CME INDIA Case Presentation by Dr Ritesh Kumar, DM, Cardiology, Ranchi.
CME INDIA Case Study:
Acute Inferior wall MI, PCI done. Later, developed COVID-19 and Stent Thrombosis.
A 45 yrs. old diabetic lady of 50 kg came to me 15 days back with acute chest pain for 5 hours. Her vitals were stable. Her ECG revealed ST elevation in lead 2,3 and AVF suggestive of Acute Inferior wall MI. Her echo showed RWMA in RCA territory with EF of 45%.
Video No. 1: After loading with 300 mg aspirin and 180 mg of ticagrelor patient was taken to cathlab. Her Coronary Angio showed normal LMCA, 50% lesion of mid LAD, normal LCX and 95% stenosis of proximal RCA with thrombus.
Video No. 2 and 3: PCI to RCA was done with good result.
Dr Ritesh Kumar, DM Card., Ranchi:
- On 2nd day her COVID report came to be positive, shifted to COVID-19 ICU, managed accordingly. I personally ensured that aspirin and ticagrelor was given uninterruptedly
- Patient was discharged after 7 days uneventfully.
- 10 days after discharge patient, i.e. 17 day after primary PCI, patient came again with continuous chest pain and sweating. ECG showed re elevation of ST segment in inferior leads
- Diagnosis was Sub acute stent thrombosis. Patient was taken to Cath lab immediately, Angio was done.
ECG of Stent thrombosis
Video No. 4: Despite ticagrelor and aspirin, stent was thrombosed with no distal flow
Video No. 5 and 6: Showing Final Results /Rescue pci done with thrombosuction and putting another stent.
ECG: Post PCI, Final result as shown above was satisfactory with setelling of ecg
Cause of stent thrombosis is probably post COVID-19 high thrombotic status as her d dimer and crp are still high.
Q. Now which anti-platelet should be continued. Any point in giving oral anticoagulants
Dr Prashant Kumar, DM Card., RIMS, Ranchi:
- Nice result. If D dimer and CRP is raised, then NOAC should be added for 1-3 months with monitoring of inflammatory markers.
- For DAPT plus NOAC, clopidogrel is safer than ticagrelor and after 1-3 months ticagrelor may be restarted in place of clopidogrel as second drug DAPT.
Dr Ritesh Kumar, DM Card., Ranchi:
- As patient had SAT with ticagrelor I am sceptical in switching to clopidogrel.
- 2nd – whether patient will tolerate triple therapy with body weight of less than 50 kg. There is financial constrain too.
Dr Deepak Gupta, DM Card., Pulse Hosp., Ranchi:
Better choice, clopidogrel Plus NOAC for 3 months.
Dr P G Sarkar, DM Card., Ranchi.
- Very good result. If the stent thrombosis has occurred after 10 days of discharge, isn’t it likely that the patient may have inadvertently missed a dose of ticagrelor?
- Being a reversible p2y12 inhibitor we know that even missing a single dose can cause rebound increase in thrombosis rates. In that case clopidogrel, being an irreversible inhibitor, is safer even if the patients miss a dose.
Dr Ritesh Kumar, Ranchi:
Now further plan is to put her on triple therapy of aspirin, clopidogrel and NOAC for at least 3 months.
Dr Satish Kumar, CSI President – Jharkhand, Bokaro:
Very interesting real-life case with learning points.
CME INDIA Learning Points
- COVID-19 hypercoagulable state may lead to a stent thrombosis trigger in the presence of other mechanical and biological risk factors.
- Recommendations on antithrombotic treatment and PCI for acute coronary syndromes should be maintained during COVID-19 treatment.
- Stent Thrombosis may be presenting feature of COVID-19.
- Other points to remember: The mechanisms of underlying sent thrombosis are multifactorial; like, patient-related factors (diabetes mellitus, renal failure), procedural factors (the complexity of the lesion, bifurcating lesions and poor stent expansion and apposition to vessel wall) and post-procedural factors (type and duration of antiplatelet therapy).
- ST is an uncommon but most dreaded complication of coronary artery stenting, usually presents as acute STEMI and carries a 30-day mortality rate of 20% to 45%.
- Insufficient antiplatelet, along with ACS presentation, is cardinal risk factor for ST.
- Prevalence of clopidogrel resistance is to be kept in mind, may vary 4 to 44%.
- The PLATO study showed a 33% reduction in the 1-year incidence of definite ST with ticagrelor vs. clopidogrel, which was later confirmed in the SWEDEHEART registry.
- In the TRITON study, the 15-month incidence of definite ST was 2.2% in the clopidogrel group but 1.1% in the prasugrel group.
- Once all contraindication for ticagrelor or prasugrel are ruled out, one should have low threshold for using one of them and avoid clopidogrel altogether, particularly when PCI is performed in ACS settings.
- Ticagrelor, like all P2Y12 inhibitors, reduce platelet leukocyte aggregates and release of platelet-derived pro-inflammatory cytokines from α-granules, but additionally also inhibit cellular adenosine uptake by inhibiting nucleoside transporter (NT). Therefore, in comparison to clopidogrel and prasugrel, this unique property of dual inhibition of platelet P2Y12 receptor and NT, ticagrelor confers more potent anti-inflammatory properties.
- Furthermore, evidence regarding clinical benefit of ticagrelor in the management of pneumonia by preventing the septic complications and reducing lung injury, were provided by the Targeting Platelet-Leukocyte Aggregates in Pneumonia with Ticagrelor trial and post-hoc analyses of PLATO study
- Although in the current circumstances, literature favours ticagrelor over other P2Y12 inhibitors in view of its potent, rapid, and reversible antiplatelet action along with its optimistic effect in pneumonia, in this case discussion, experts agree on switching to Clopidogrel. One important factor can be missing of dose with Ticagrelor which can be disastrous.