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 Division of Cardiology, Department of Medicine f C di l D t t f M di i Massachusetts General Hospital Harvard Medical School Boston MA Boston, MA

Disclosures Disclosures None N •

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 • • onset 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 PMH: HTN, hemorrhoids, vertigo, s/p RML lung hamartoma resection 2004, h id ti / RML l h t ti 2004 scoliosis, *Normal ETT 9/2009 All: NKDA Medications: flurazepam 30 mg QHS meclizine PRN li i 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 135 96 17 15.2 118 11.0 442 3.6 24 0.83 44.3 Trop I: positive PT: 12.2 Trop T: 0.08 INR: 1.0 CK: 79 CK: 79 PTT: 23 4 PTT: 23.4 CKMB: 6.9 Total Chol: 165 M Mg: 1.8 1 8 T i Trig: 62 62 HDL: 68 LDL: 85

ECG ECG

EW assessment and plan EW assessment and plan With chest pain and positive cardiac biomarkers, and minimal ECG changes. With h t i d iti di bi k d i i l ECG h • 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 Cardiac catheterization completed at 11:58 am without complications C di th t i ti l t d t 11 58 ith t li ti • About an hour later, (around 12:56 pm), patient reported severe, crushing type ( p ) p p g yp • of 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 thrombosis b i 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? Etiology of stent thrombosis in our patient? Technical: Technical: • – Poor stent apposition Slight proximal malapposition – Stent under-expansion Small stent diameter and/or long stent length ✓ 2 50x18 mm stent ✓ 2.50x18 mm stent – – Small stent diameter and/or long stent length – Coronary artery dissection – Inflow or outflow stenosis Pharmacologic: • – Aspirin/clopidogrel resistance Unclear (turned out to be negative) ✓✓ – Inadequate antithrombotic therapy Other • – Diffuse disease Polycythemia ✓ 15.2 – Circulation. 2009;119:687-98.

Review of Pharmacotherapy Review of Pharmacotherapy P i Prior to cardiac catheterization: t di th t i ti • – 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 Bivalirudin: li di • – 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 Anticipated peak A i i d k Clopidogrel Cath Bivalirudin Chest pain with effect begins ST elevation off 10:30 am 10:30 am 11:00 am 11:00 am 11:30 am 11:30 am 12:00 pm 12:00 pm 12:30 pm 12:30 pm 1:00 pm 1:00 pm 1:30 pm 1:30 pm Clopidogrel load 2 nd cath Bivalirudin Anticipated end initiated begins g of bivalirudin of bivalirudin effect 1. Expert Rev Cardiovasc Ther. 2010;8:1673-81. 2. www.merckmanuals.com

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 with bivalirudin? ith bi li di ? On clopidogrel prior to catheterization: O l id l i t th t i ti • – 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 Transferred to CCU for observation and management T f d t CCU f b ti d t • 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 Echocardiogram (POD#3) di (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 •