Case Presentation: Stent thrombosis

Chonnam Nat. Univ. Hosp.

Case Presentation:

Stent thrombosis

TCTAP 2013 [Breakfast Meetings]

Youngkeun Ahn, MD, PhD

Department of Cardiology, Cardiovascular Center

Chonnam National University Hospital, Gwangju, Korea

The Heart Center of Chonnam National University Hospital

Mr. Kim (50/M)

The patient had AMI and underwent PCI 3 years previously. Recently

he had discontinued antiplatelet therapy (aspirin, clopidogrel, and

pletaal) in preparation for his dental procedure for the past 3 days.

On the night of presentation, he developed sudden chest pain, which

was refractory to sublingual nitroglycerin. He presented to his local

hospital and was subsequently transferred to our center.

C/C Chest pain at rest (onset : 1 hour ago)

P/H NC

S/H 26 PYS, current smoker

Vital sign : BP 84/46 mmHg, HR 62 bpm


Mr. Kim (50/M)

P/E Inspiratory and expiratory crackles in both lung fields

CBC 8800 / 13.5 / 208,000

Na/K 137/3.5 mEq/L

BUN/Cr 15.0/0.8 mg/dL

CK-MB/ Troponin-I 13.7 U/L / 0.01 ng/mL

T-Chol/HDL/LDL/TG 145/44/75/114 mg/dL

Clinical Impression

: Acute myocardial infartion (Killip class IV)


12-lead EKG on local hospital

Not relieved by sublingual NTG


12-lead EKG on admission


Chest PA


Previous CAG and PCI

2007. 3.12 p-RCA (cypher® )

3.16 p-LAD (cypher® )

2007. 3.18 POBA in stent thrombosis lesions

(LAD, RCA)

2007. 3.24 patent stent in RCA and LAD

2007.11.14 no ISR


Previous clinical course

1st CAG

Aspirin 300mg

Clopidogrel 600mg

Cilazapril 2.5mg

Carvedilol 6.25mg

Rosuvastatin 60mg

IV heparin

IV NTG

2007.3.12


(On

addmission)

(Post-angio)


1st CAG (2007.3.12)

3.5 x 18 mm Cypher



1st CAG

Aspirin 300mg

Clopidogrel 600mg

Cilazapril 2.5mg

Carvedilol 6.25mg

Rosuvastatin 60mg

IV heparin

IV NTG

2007.3.12

2nd CAG

Aspirin 200mg

Clopidogrel 150mg

Pletaal 200mg

Perindopril 4mg

Carvediol 6.25mg

Rosuvastatin 60mg

IV heparin

2007.3.16


2nd CAG (2007.3.16)

3.0 x 28 mm Cypher 2.5 x 20 mm

3.0 x 28mm



1st CAG

Aspirin 300mg

Clopidogrel 600mg

Cilazapril 2.5mg

Carvedilol 6.25mg

Rosuvastatin 60mg

IV heparin

IV NTG

2007.3.12

2nd CAG

Aspirin 200mg

Clopidogrel 150mg

Pletaal 200mg

Perindopril 4mg

Carvedilol 6.25mg

Rosuvastatin 60mg

IV heparin

2007.3.16 CPR

2007.3.18

Emergent CAG


(Pre-angio)

(Post-angio)


3rd CAG (2007.3.18)

2.0, 3.0 mm

2.0, 3.0 mm



1st CAG

Aspirin 300mg

Clopidogrel 600mg

Cilazapril 2.5mg

Carvedilol 6.25mg

Rosuvastatin 60mg

IV heparin

IV NTG

2007.3.12

2nd CAG

Aspirin 200mg

Clopidogrel 150mg

Pletaal 200mg

Perindopril 4mg

Carvedilol 6.25mg

Rosuvastatin 60mg

IV heparin

2007.3.16 CPR

2007.3.18

Emergent CAG

Aspirin 300mg

Clopidogrel 75mg

Pletaal 200mg

Warfarin 3mg

Ramipril 2.5mg

Carvedilol 6.25mg

Atrovastatin 10mg

Amiodarone 100mg


F/U CAG (2007.3.24)

2.0, 3.0 mm

2.0, 3.0 mm


F/U CAG (2007.11.14)

2.0, 3.0 mm

2.0, 3.0 mm



1st

PCI2nd

PCI

3.16 5.31

3rd

PCI

2007.3.12 3.18

f/u CAG

Aspirin 200mg

Clopidogrel 75mg

Pletaal 200mg

Ramipril 2.5mg

Carvedilol 6.25mg

Atrovastatin 10mg

Aspirin 200mg

Clopidogrel 75mg

Sarpogrelate 100mg

Candesartan 8mg

Carvedilol 6.25mg

Atrovastatin 10mg

2009.9.22 11.14

Aspirin 300mg

Clopidogrel 75mg

Pletaal 200mg

Warfarin 3mg

Ramipril 2.5mg

Carvedilol 6.25mg

Atrovastatin 10mg

Amiodarone 100mg


CAG (2011.1.9)

2.0, 3.0 mm

2.0, 3.0 mm


Multiple stepwise POBA for p-LAD

2.0, 3.0 mm

2.0, 3.0 mm

3.0 x 15 mm


Multiple stepwise POBA for p-LAD

2.0, 3.0 mm


Final CAG

2.0, 3.0 mm


Critical pathway for MI patient

2.0, 3.0 mm

Symptom onset : 00:30

Patient arrived in ER : 01:40

Patient arrived in cath Lab : 02:30

Time of PTCA start : 02:45

Door to Balloon time : 65 min


F/U EKG

2.0, 3.0 mm


2D-Echocardiography

2.0, 3.0 mm


f/u CAG (2011.1.14)

2.0, 3.0 mm


IVUS (2011.1.14)

2.0, 3.0 mm



1st

PCI2nd

PCI

3.16 5.31

3rd

PCI

2007.3.12 3.18

f/u CAG

Aspirin 200mg

Clopidogrel 75mg

Pletaal 200mg

Ramipril 2.5mg

Carvedilol 6.25mg

Atrovastatin 10mg

Aspirin 300mg

Clopidogrel 75mg

Pletaal 200mg

Candesartan 8mg

Carvedilol 6.25mg

Atrovastatin 10mg

2009.9.22 11.14

Platelet drug response

Aspirin : 410 ARU

P2Y12 : 237 PRU

4th

PCI

2011.1.9

APT hold d/t

dental care


Hospital course

63.48

22.76 15.47 10.4 10.52 5.57 1.24 0.94 0.48

020406080

Tn-I

Discharge

STEMI medication

(Aspirin 300mg, Clopidogrel 75mg, Pletaal 200mg) + iv heparin

ER visit

2DE

CAG/PCI

f/u CAG

Hypercoargulability test

Homocystein 17.16 umol/L


Discussion point

1. What is the cause of recurrent ST in this patient?

2. What is the optimal antiplatelet treatment in this patient?

3. How to manage this patient during perioperative period in

the future?

Case Presentation: Stent thrombosis

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