IIb/IIIa Receptor Antagonists for Failed Rescue Angioplasty
A46-year-old woman presented with 3 hours of severe chest pain, sweating, and nausea. The cardiac history included a small anterior wall infarction 8 years earlier, a slightly impaired left ventricle, and a successful balloon angioplasty of the left anterior descending and right coronary artery 11 months before presentation. Systolic blood pressure was 85 mm Hg, but further physical examination was normal. The ECG demonstrated an acute inferior wall infarction with extension to the right precordial leads without rhythm or conduction abnormalities.
The patient was included in the HIT-4 trial, in which heparin was compared with hirudin in combination with streptokinase for acute myocardial infarction.
Treatment per protocol was started with streptokinase 1.5 million IU in 60 minutes, aspirin 300 mg, and heparin 12 500 IU SC. No signs of reperfusion were seen; sinus bradycardia developed, blood pressure was unchanged, and diaphoresis was noted. Diuresis was absent.
Thirty minutes after streptokinase infusion, protocol angiography revealed a dominant right coronary artery with TIMI 2 flow (Thrombolysis in Myocardial Infarction flow grade 2 denotes partial perfusion) and a thrombus measuring 10 mm in length (Figure 1⇓). Because of persisting pain, hypotension, and bradycardia with hampered coronary flow, it was decided to perform balloon angioplasty.
After balloon inflation, cardiogenic shock worsened, despite intra-aortic balloon pumping and inotropics. Total AV block developed, and shortly thereafter, ventricular fibrillation. Angiography showed that the thromboembolic mass was dislodged and the thrombotic mass occluded the distal artery, not amenable to angioplasty (Figure 2⇓). Intracoronary verapamil gave no improvement.
As bailout, abciximab, a monoclonal platelet glycoprotein IIb/IIIa receptor blocker, was started, with a 0.25-mg/kg bolus and a 10-μg/min infusion. In ≈10 minutes, TIMI 3 flow (complete perfusion) was restored (Figure 3⇓), and chest pain subsided 7 hours after it had begun.
Bleeding developed in the groins. Heparin infusion was therefore stopped, but abciximab was given continuously up to 24 hours after balloon angioplasty. Cardiac recovery was uneventful. The myocardial fraction of creatinine kinase (CK-MB) peaked at 90 U/L, and echocardiography showed a global good left ventricular function with a hypokinetic inferior wall. The massive left and right leg hematomas recovered without intervention or clinical sequelae. Hemoglobin decreased to 7.4 g/dL (4.6 mmol/L), a decrease of 6.4 g/dL (4.0 mmol/L). Seven units of packed cells were given. At 1-year follow-up, our patient is in good health without cardiac complaints.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke’s Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
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