SPC365

From thrombus to hemorrhage: difficult decisions in disturbing situations

Session: Sessão Speaker’s Corner - Casos clínicos desafiantes… em Cardiologia - 1
Speaker: Inês Sofia Pereira Oliveira

Congress: CPC 2022
Topic: P. Other
Theme: 37. Miscellanea
Subtheme: ---
Session Type: Sessão de Casos Clínicos
FP Number: ---
Authors: Inês Pereira Oliveira; Rafaela Lopes; Isabel Cruz; Ana Neto; Bruno Bragança; Joel Ponte Monteiro; João Azevedo; Aurora Andrade
<p style="text-align:justify"><span style="font-size:medium"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="color:#000000"><span style="background-color:white"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">A 43-year-old man with past smoking habits and previous&nbsp;embolic myocardial infarction in the setting of coronary artery ectasia presented to the hospital for retrosternal chest pain. He was medicated with&nbsp;rivaroxaban and admitted taking an additional dose one hour earlier when the pain started. ECG showed sinus rhythm with inferior ST-elevation.&nbsp;ST-elevation myocardial infarction (STEMI) was diagnosed and he was given 250mg of acetylsalicylic acid and 600mg of clopidogrel. Echocardiogram (echo) depicted a normal sized left ventricle (LV) with preserved function. Before completing the echo, the patient evolved to ventricular fibrillation (VF). Cardiopulmonary resuscitation maneuvers were started. After multiple cycles in refractory VF, non-shockable rhythm ensued. No signs of cardiac mechanical complications. It was decided to perform fibrinolysis with&nbsp;50&nbsp;mg of tenecteplase. After 55 minutes there was recovery of spontaneous circulation (ROSC). Mechanical ventilation, noradrenaline and dobutamine were initiated. Coronary angiography showed diffuse coronary artery dilation with epicardial aneurysms, slow blood flow but no occluded segments. An intra-aortic balloon (IAB) was inserted and unfractionated heparin begun. On the following day, active hemorrhage from the femoral access&nbsp;requiring blood transfusion was documented. Heparin was suspended and the IAB support stopped. Favorable clinical evolution on inotropes with preserved LV function&nbsp;and no neurological&nbsp;complications. He was discharged home on day 10&nbsp;anticoagulated with apixaban&nbsp;with therapeutic anti-factor Xa levels, contrary to&nbsp;admission. </span></span></span></span></span></span></span></p>

<p style="text-align:justify">&nbsp;</p>

<p style="text-align:justify"><span style="font-size:medium"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="color:#000000"><span style="background-color:white"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">STEMI is a medical emergency with high risk of fatal arrythmias. Though coronary angiography is the treatment of choice, thrombolysis is a reasonable alternative when angiography is not an immediate option or in life-threatening situations when emergent reperfusion is paramount. Anticoagulation and prolonged resuscitation are relative contra-indications to thrombolysis due to the risk of major hemorrhage. </span></span></span></span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:medium"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="color:#000000"><span style="background-color:white"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">Our patient had taken an extra dose of anticoagulant increasing the risk of fibrinolysis. Nonetheless, it was a life-saving strategy in the setting of refractory cardiopulmonary arrest which proved successful considering ROSC and the absence of coronary occlusion on angiography. However, the risks should not be belittled as shown by the development of hemorrhage on the femoral access. </span></span></span></span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:medium"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="color:#000000"><span style="background-color:white"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">The use of an IAB was also debatable in the setting of diffuse dilated coronary arteries with slow blood flow, based on the rationale that it would boost coronary flow in a cardiogenic shock scenario. Despite the hemorrhagic complication, there was no left ventricular disfunction and the patient evolved favorably. </span></span></span></span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:medium"><span style="font-family:&quot;Times New Roman&quot;,serif"><span style="color:#000000"><span style="background-color:white"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:black">The purpose of this case is to highlight the need to perform difficult decisions in non-linear situations and to consider the advantages and drawbacks of available therapies. </span></span></span></span></span></span></span></p>