Acute Stent Thrombosis Joo Heung Yoon, MD Sammy Elmariah, MD, MPH - - PowerPoint PPT Presentation

Acute Stent Thrombosis

Joo Heung Yoon, MD Sammy Elmariah, MD, MPH Ik-Kyung Jang, MD, PhD Di i i f C di l D t t f M di i Division of Cardiology, Department of Medicine Massachusetts General Hospital Harvard Medical School Boston MA Boston, MA

Disclosures Disclosures

N

• None

Clinical presentation Clinical presentation

• 68 yo Caucasian female with h/o hypertension presented complaining of new
• 68 yo Caucasian female with h/o hypertension presented, complaining of new
• nset left-sided chest pressure. The discomfort woke her from sleep at 3 am.

Symptoms improved with aspirin 325 mg, so she returned to bed.

• However, one hour later she awoke again with same sub-sternal chest

pressure and nausea. She decided to visit EW as the pain persisted more than a few hours.

• She denied having dyspnea, palpitations, lightheadedness, fever, chills, or low

extremity swelling.

PMH HTN h h id ti / RML l h t ti 2004 PMH: HTN, hemorrhoids, vertigo, s/p RML lung hamartoma resection 2004, scoliosis, *Normal ETT 9/2009 All: NKDA Medications: flurazepam 30 mg QHS li i PRN meclizine PRN SH: Distant tobacco use (5 pack-years), 1-2 alcohol drinks nightly, no illicit drug ( p y ) g y g use FH: Father - hypertension no other cardiovascular disease FH: Father hypertension, no other cardiovascular disease

EW - Physical examination EW Physical examination

• V/S:
• V/S:

T = 98.2 HR = 104 BP = 171/98 RR = 18 POX = 100% on RA

• GEN: Not in acute distress
• HEENT: no JVD, 2+ bilateral carotid pulses with normal upstroke
• COR: non-displaced, discrete PMI with RRR, no m/g/r

p g

• RESP: CTA bilaterally
• ABD: soft NT ND no hepatosplenomegaly

ABD: soft, NT, ND, no hepatosplenomegaly

• EXT: warm, 2+ distal pulses, no edema
• NEURO: A&O x3 grossly intact motor and sensory functions
• NEURO: A&O x3, grossly intact motor and sensory functions

Laboratory Values Laboratory Values

15.2 135 96 17 11.0 44.3 442 3.6 24 0.83 118 Trop I: positive Trop T: 0.08 CK: 79 PT: 12.2 INR: 1.0 PTT: 23 4 CK: 79 CKMB: 6.9 M 1 8 PTT: 23.4 Total Chol: 165 T i 62 Mg: 1.8 Trig: 62 HDL: 68 LDL: 85

ECG ECG

EW assessment and plan EW assessment and plan

With h t i d iti di bi k d i i l ECG h

• With chest pain and positive cardiac biomarkers, and minimal ECG changes.
• EW treatment:

Aspirin 325 mg Metoprolol 25 mg Q8h Atorvastatin 80 mg QHS Atorvastatin 80 mg QHS IV Heparin infusion

Cardiac catheterization Cardiac catheterization

50% proximal LAD stenosis and 95% mid LAD stenosis 50% proximal LAD stenosis and 95% mid LAD stenosis

Cardiac catheterization Cardiac catheterization

• Bivalirudin initiated
• Predilatation: Sprinter Legend RX 2.00x12 mm at 10 ATM

Cardiac catheterization Cardiac catheterization

• Stent: Xience 2.50x18 mm DES at 14 ATM

Stent: Xience 2.50x18 mm DES at 14 ATM

• Postdilatation: DuraStar RX 2.5x15 mm at 16 ATM

Hospital Course Hospital Course

C di th t i ti l t d t 11 58 ith t li ti

• Cardiac catheterization completed at 11:58 am without complications
• About an hour later, (around 12:56 pm), patient reported severe, crushing type

( p ) p p g yp

• f chest pain. 12-lead EKG was obtained immediately.

ECG ECG

Cardiac catheterization: Acute stent thrombosis Cardiac catheterization: Acute stent thrombosis

Etiology of early stent thrombosis Etiology of early stent thrombosis

Technical:

• Technical:

– Poor stent apposition – Stent under-expansion – Small stent diameter and/or long stent length – Small stent diameter and/or long stent length – Coronary artery dissection – Inflow or outflow stenosis

• Pharmacologic:

– Aspirin/clopidogrel resistance – Inadequate antithrombotic therapy

• Other

– Diffuse disease – Polycythemia

• Circulation. 2009;119:687-98.

Cardiac catheterization: Acute stent thrombosis Cardiac catheterization: Acute stent thrombosis

• Heparin and Integrilin initiated

Heparin and Integrilin initiated

• Thrombectomy catheter would not cross the lesion
• Angioplasty was performed using a Sprinter

Legend 2.5x12 mm balloon at 12 ATM

Optical Coherence Tomography Optical Coherence Tomography

Optical Coherence Tomography: Stent th b i thrombosis

White thrombus

Management: Cardiac catheterization Management: Cardiac catheterization

• PTCA using DuraStar RX 2.5x15 mm balloon at 20 ATM

PTCA using DuraStar RX 2.5x15 mm balloon at 20 ATM

Etiology of stent thrombosis in our patient?

Technical:

Etiology of stent thrombosis in our patient?

• Technical:

– Poor stent apposition – Stent under-expansion – Small stent diameter and/or long stent length ✓ 2 50x18 mm stent Slight proximal malapposition – Small stent diameter and/or long stent length – Coronary artery dissection – Inflow or outflow stenosis ✓ 2.50x18 mm stent

• Pharmacologic:

– Aspirin/clopidogrel resistance – Inadequate antithrombotic therapy Unclear (turned out to be negative) ✓✓

• Other

– Diffuse disease – Polycythemia ✓ 15.2

• Circulation. 2009;119:687-98.

Review of Pharmacotherapy Review of Pharmacotherapy

P i t di th t i ti

• Prior to cardiac catheterization:

– Aspirin 325mg – Heparin infusion – held prior to catheterization p p

• Within catheterization laboratory
• Within catheterization laboratory

– Bivalirudin bolus (0.75 mg/kg) and infusion (1.75 mg/kg/hr) – Clopidogrel 600 mg load at the end of the procedure – Bivalirudin stopped at time of clopidogrel load

Pharmacotherapy Pharmacotherapy

Bi li di

• Bivalirudin:

– Immediate onset of action – Short half-life (25 minutes) ( ) – Duration of effect ~1 hour after discontinuation of infusion

• Clopidogrel (Plavix):
• Clopidogrel (Plavix):

– Onset of action detected ~2 hours after 300-600 mg bolus

A i i d k Cath begins Chest pain with ST elevation Bivalirudin

• ff

Anticipated peak Clopidogrel effect

10:30 am 11:00 am 11:30 am 12:00 pm 12:30 pm 1:00 pm 1:30 pm

Bivalirudin initiated 2nd cath begins Clopidogrel load Anticipated end

• f bivalirudin

10:30 am 11:00 am 11:30 am 12:00 pm 12:30 pm 1:00 pm 1:30 pm

• 1. Expert Rev Cardiovasc Ther. 2010;8:1673-81.
• 2. www.merckmanuals.com

g

• f bivalirudin

effect

ACUITY Trial: Bivalirudin in ACS ACUITY Trial: Bivalirudin in ACS

ACUITY Trial. NEJM. 2006;355:2203-16.

ACUITY Trial: Bivalirudin in ACS ACUITY Trial: Bivalirudin in ACS

ACUITY Trial. NEJM. 2006;355:2203-16.

Can we ensure adequate antithrombotic therapy ith bi li di ? with bivalirudin?

O l id l i t th t i ti

• On clopidogrel prior to catheterization:

– Usual care

• Options for clopidogrel-naïve patients with bolus in the cath lab:

– Clopidogrel loading immediately after diagnostic angiogram Continue bivalirudin infusion more than 1 hour post catheterization – Continue bivalirudin infusion more than 1-hour post-catheterization – Prasugrel -*max effect in < 1 hour after bolus

• 1. Am Heart J. 2008;156:S16-22.
• 2. J Thromb Thrombolysis. 2010 Nov 25.
• 3. Coron Artery Dos. 2009;20:348-53.

Management Management

T f d t CCU f b ti d t

• Transferred to CCU for observation and management
• Heparin and eptifibatide infusions continued for 12 hours post-catheterization
• Plavix 150 mg daily for 7 days then 75 mg thereafter

g y y g

• Aggressive risk factor modification

Outcome Outcome

E h di (POD#3) Echocardiogram (POD#3)

• Small area of akinesis in anteroseptum
• Preserved LV function with LVEF = 81%

Preserved LV function with LVEF = 81%

• Discharged to home in stable condition