Abstract 1758: 3 Acute Coronary Syndromes, 5 Stents and 8 Antithrombotics in 12 Days in a 59-Year-Old Woman
A 59-year-old female with a history of hypertension and hyperlipidemia presented with a two day history of escalating chest pain. Her ECG revealed evolving T wave changes in leads V1–V3; troponin levels were undetectable. She was treated with aspirin 325mg and unfractionated heparin for unstable angina. Cardiac catheterization demonstrated high-grade stenoses in the proximal and mid left anterior descending artery. Two bare metal stents were deployed and she was given a 600mg loading dose of clopidogrel. She was discharged to home on hospital day 3 on a regimen that included aspirin 325mg and clopidogrel 75mg daily. Two days after discharge, the patient returned to the ED with substernal chest pain and anterior ST-segment elevations on ECG. Emergent coronary angiography demonstrated occlusive thrombus within the proximal stent. Intravascular ultrasound (IVUS) confirmed adequate stent deployment without edge dissection. Following thrombectomy, two additional bare metal stents were inserted and all stents post-dilated at high-pressure. She reported full medication compliance. She was empirically reloaded with 300mg of clopidogrel and her dose increased to 150mg daily. A hypercoagulability workup was negative. Two days after her second hospital discharge, the patient returned with chest pain and anterior ST-segment elevations on ECG. Emergent angiography confirmed recurrent stent thrombosis. Repeat IVUS showed that the stents were fully expanded and well apposed without evidence of mechanical complication. Following thrombectomy, an additional bare metal stent was inserted. She was empirically started on heparin and continued on clopidogrel 150mg daily. Following discontinuation of peri-procedural eptifibatide, platelet response to aspirin and clopidogrel were assessed with the VerifyNow™ (Accumetrics, San Diego, CA) assay. She demonstrated an appropriate response to aspirin but was found to have 0–3% platelet inhibition to clopidogrel on successive testing. Her clopidogrel was replaced with ticlopidine and coumadin. Repeat platelet testing demonstrated modest platelet inhibition (17%) with ticlopidine. Cilostazol was added as a third antiplatelet agent and her coumadin was discontinued. She has had no subsequent cardiac events.