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Dual antiplatelet resistance – tiptoeing through thrombosis, bleeding and arrhythmic risk.
Session:
Casos Clínicos: Cardiologia de Intervenção
Speaker:
Rita Almeida Carvalho
Congress:
CPC 2024
Topic:
H. Interventional Cardiology and Cardiovascular Surgery
Theme:
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Subtheme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Rita Almeida Carvalho; Catarina Brízido; Samuel Azevedo; Miguel Sobral Domingues; Mariana Sousa Paiva; Pedro Lopes; Joana Silva Ferreira; Nuno Fonseca; Raquel Lopes; Joaquim Varandas; António Tralhão; Marisa Trabulo
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">Introduction: Dual antiplatelet therapy (DAPT) is the cornerstone treatment to prevent stent thrombosis, a life-threatening complication of PCI. Early stent thrombosis despite effective antiplatelet therapy should prompt investigation. </span></span></span></p> <p style="text-align:justify"><br /> <span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">Case report: A 46-year-old smoker and diabetic male was admitted for anterior STEMI. Primary PCI of the occluded mid LAD and first diagonal branch was performed, achieving TIMI 3 flow. DAPT with acetylsalicylic acid (ASA) and ticagrelor was started. Despite evolving in Killip class I, echocardiogram revealed a LVEF of 35% with akinesia of the LAD territory.<br /> Eight days after admission, the patient presented with in-hospital ventricular fibrillation (VF). Post-arrest ECG showed anterior ST-segment elevation, and emergent coronary angiography (CA) revealed acute stent thrombosis with high thrombotic burden. During PCI, multiple VF episodes prompted admission to the ICU. Eptifibatide was administered for 24 hours while maintaining previous DAPT. For the following 48 hours, the patient evolved into electrical storm owing to multiple VF episodes and was transferred to a tertiary care center for mechanical circulatory support. On arrival, repeat CA for persistent anterior ST-segment elevation showed residual thrombus of the distal LAD and severe distal RCA stenosis, treated with PCI. The patient was initially stabilized but had repeat FV episodes after another 48 hours.<br /> Antiplatelet therapy resistance was suspected given early stent thrombosis, although no intra-coronary imaging had been performed. Whole blood impedance aggregometry (ROTEM</span></span></span><span style="font-size:10.0pt"><span style="font-family:Symbol">Ò</span></span> <span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">platelet) and light transmission aggregometry showed resistance to both ASA and ticagrelor. Eptifibatide perfusion was restarted and antiplatelet activity testing for triflusal and prasugrel revealed good performance. Cardiac MRI after clinical stabilization showed extensive scar tissue in the LAD territory with a LVEF of 39%. Additionally, LV septal asymmetric hypertrophy, apically implanted papillary muscles and LV/RV junctional late gadolinium enhancement were consistent with hypertrophic cardiomyopathy (HCM) diagnosis, adding up to the estimated arrhythmic risk. A secondary prevention ICD was implanted, under triflusal and eptifibatide bridging, with no thrombotic complications. After ICD implantation, the patient was re-loaded with prasugrel, and discharged on triflusal and prasugrel, with no device-related bleeding complications.</span></span></span></p> <p style="text-align:justify"><br /> <span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="font-size:10.0pt">Conclusion: We describe a case of early stent thrombosis owing to resistance to both ASA and ticagrelor. Besides timely revascularization, prompt investigation of antiplatelet resistance is key to tailor antithrombotic therapy. For this patient, secondary prevention ICD was implanted owing to late FV, borderline LVEF and HCM diagnosis, and peri-procedural antiplatelet management was crucial to prevent thrombotic and bleeding complications.</span></span></span></p>
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