Recurrent intraventricular thrombus six months after ST-elevation myocardial infarction in a diabetic man: a case report

BMC Research Notes

Ignacio Laynez¹  Alejandro de la Rosa¹  Alejandro Sánchez-Grande¹  María Manuela Izquierdo¹  Belén Marí¹  Juan Lacalzada¹ 

[1] Department of Cardiology, Cardiac Imaging Laboratory, University Hospital of the Canary Islands, Ofra s/n. La Cuesta, La Laguna, Tenerife, 38320, Spain

关键词: Oral anticoagulation;    Dual antiplatelet therapy;    Intraventricular thrombus;    Echocardiography;    Drug-eluting stent;    Percutaneous coronary intervention;    Acute myocardial infarction;   

Others  :  1141752
DOI  :  10.1186/1756-0500-6-348

 received in 2013-05-20, accepted in 2013-08-29,  发布年份 2013

【 摘 要 】

Background

Percutaneous coronary intervention with placement of a drug-eluting stent in a diabetic patient with ST-elevation myocardial infarction is a relatively common procedure, and always requires subsequent treatment with dual antiplatelet therapy. It is sometimes necessary to add oral anticoagulation therapy because of individual clinical circumstances, which further increases the risk of bleeding.

Case presentation

A 66-year-old hypertensive diabetic man with a history of gastrointestinal bleeding was admitted with an ST-elevation inferior myocardial infarction that had been evolving over 72 h. Electrocardiography showed ST segment elevation in the inferior leads and Q waves in the inferior and anterior leads. He reported a similar episode of chest pain 1 month previously, for which he had not sought medical treatment. Coronary angiography showed chronic occlusion of the mid-left anterior descending coronary artery, and acute occlusion of the mid-right coronary artery. He was treated by percutaneous coronary intervention, with placement of a drug-eluting stent in the right coronary artery. Soon after admission, transthoracic echocardiography showed abnormal left ventricular contractility and a large left intraventricular thrombus. Three weeks after admission, the patient was discharged on dual antiplatelet therapy (clopidogrel and aspirin) and oral anticoagulation therapy (acenocoumarol). Four months after discharge, transthoracic echocardiography showed absence of left ventricular thrombus and resolution of the abnormal contractility in the area supplied by the revascularized right coronary artery. Given the high risk of bleeding, oral anticoagulation therapy was stopped. Six months later, transthoracic echocardiography showed recurrent left ventricular apical thrombus, and an underlying hypercoagulable state was ruled out. Oral anticoagulation therapy was restarted on an indefinite basis, and dual antiplatelet therapy was continued.

Conclusions

The present case illustrates the need for repeat transthoracic echocardiography following the withdrawal of oral anticoagulation therapy in patients with ST-elevation myocardial infarction, both to monitor thrombus status and to assess left ventricular segmental contraction. In patients who require anticoagulation, avoidance of a drug-eluting stent is strongly preferred and second-generation stents are recommended. The alternative regimen of oral anticoagulation and clopidogrel may be considered in this scenario. In patients with recurrent intraventricular thrombus an underlying hypercoagulable state should be ruled out.

【 授权许可】

   
2013 Lacalzada et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

【 参考文献 】

• [1]Stettler C, Allemann S, Wandel S, Kastrati A, Morice MC, Schomig A, Pfisterer ME, Stone GW, Leon MB, de Lezo JS, Goy JJ, Park SJ, Sabate M, Suttorp MJ, Kelbaek H, Spaulding C, Menichelli M, Vermeersch P, Dirksen MT, Cervinka P, De Carlo M, Erglis A, Chechi T, Ortolani P, Schalij MJ, Diem P, Meier B, Windecker S, Juni P, et al.: Drug eluting and bare metal stents in people with and without diabetes: collaborative network meta-analysis. BMJ 2008, 337:a1331.
• [2]Steg G, James SK, Atar D, Badano L, Blömstrom-Lundqvist C, Borger MA, Di Mario C, Dickstein K, Ducrocq G, Fernandez-Aviles F, Gershlick AH, Giannuzzi P, Halvorsen S, Huber K, Juni P, Kastrati A, Knuuti J, Lenzen MJ, Mahaffey K, Valgimigli M, van’t Hof A, Widimsky P, Zahger D: ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012, 33:2569-2619.
• [3]O’Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW: 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. J Am Coll Cardiol 2013, 61(4):e78-140.
• [4]You JJ, Singer DE, Howard PA, Lane DA, Eckman MH, Fang MC, Hylek EM, Schulman S, Go AS, Hughes M, Spencer FA, Manning WJ, Halperin JL, Lip GY: Antithrombotic therapy for atrial fibrillation: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest 2012, 141:e531S-e575S.
• [5]Vandvik PO, Lincoff AM, Gore JM, Gutterman DD, Sonnenberg FA, Alonso-Coello P, Akl EA, Lansberg MG, Guyatt GH, Spencer FA: Primary and secondary prevention of cardiovascular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American college of chest physicians evidence-based clinical practice guidelines. Chest 2012, 141:1129. Chest 2012; 141: e637 S–68 S. Erratum in: Chest
• [6]Douglas PS, Garcia MJ, Haines DE, Lai WW, Manning WJ, Patel AR, Picard MH, Polk DM, Ragosta M, Ward RP, Weiner RB: ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR2011. American college of cardiology foundation appropriate Use criteria for echocardiography task force. J Am Coll Cardiol 2011, 57(9):1126-66.
• [7]Kolh P, Wijns W, Di Danchin N, Mario C, Falk V, Folliguet T, Garg S, Huber K, James S, Knuuti J, Lopez-Sendon J, Marco J, Menicanti L, Ostojic M, Piepoli MF, Pirlet C, Pomar JL, Reifart N, Ribichini FL, Schalij MJ, Sergeant P, Serruys PW, Silber S, Sousa Uva M, Taggart D: Guidelines on myocardial revascularization. Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS); European Association for Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg 2010, 38(Suppl):S1-S52.
• [8]Shireman TI, Mahnken JD, Howard PA, Kresowik TF, Hou Q, Ellerbeck EF: Development of a contemporary bleeding risk model for elderly warfarin recipients. Chest 2006, 130(5):1390-1396.
• [9]Huret JF, Gebuhrer V, Shibli H, Fichter P, Grand A: Cerebral embolism disclosing a left intraventricular thrombus 6 years after atypical infarction. Ann Cardiol Angeiol (Paris) 1992, 41(3):137-40.
• [10]Kwiecień-Sobstel A, Zabojszcz M, Owsiak M, Bartuś S, Dudek D, Kawecka-Jaszcz K, Mirek-Bryniarska E, Bryniarski L: Patient with left ventricular aneurysm and thrombus after myocardial infarction— long-term observation. Kardiol Pol 2011, 69(4):373-6.
• [11]Berny-Lang MA, Jakubowski JA, Sugidachi A, Barnard MR, Michelson AD, Frelinger AL: P2Y12 Receptor blockade augments glycoprotein IIb-IIIa antagonist inhibition of platelet activation, aggregation, and procoagulant activity. J Am Heart Assoc 2013, 2(3):e000026.
• [12]Lanni F, Santulli G, Izzo R, Rubattu S, Zanda B, Volpe M, Iaccarino G, Trimarco B: The Pl (A1/A2) polymorphism of glycoprotein IIIa and cerebrovascular events in hypertension: increased risk of ischemic stroke in high-risk patients. J Hypertens 2007, 25(3):551-6.
• [13]Santulli G, Cipolletta E, Sorriento D, Del Giudice C, Anastasio A, Monaco S, Maione AS, Condorelli G, Puca A, Trimarco B, Illario M, Iaccarino G: CaMK4 Gene deletion induces hypertension. J Am Heart Assoc 2012, 1(4):e001081.
• [14]Faxon DP, Eikelboom JW, Berger PB, Holmes DR, Bhatt DL, Moliterno DJ, Becker RC, Angiolillo DJ: Consensus document: antithrombotic therapy in patients with atrial fibrillation undergoing coronary stenting. A North-American perspective. Thromb Haemost 2011, 106(4):572-84.
• [15]Leon MB, Kandzari DE, Eisenstein EL, Anstrom KJ, Mauri L, Cutlip DE, Nikolsky E, O’Shaughnessy C, Overlie PA, Kirtane AJ, McLaurin BT, Solomon SL, Douglas JS Jr, Popma JJ, ENDEAVOR IV Investigators: Late safety, efficacy, and cost-effectiveness of a zotarolimus-eluting stent compared with a paclitaxel-eluting stent in patients with de novo coronary lesions: 2-year follow-up from the ENDEAVOR IV trial (randomized, controlled trial of the Medtronic endeavor drug [ABT-578] eluting coronary stent system versus the taxus paclitaxel-eluting coronary stent system in De novo native coronary artery lesions). JACC Cardiovasc Interv 2009, 2:1208-1218.
• [16]Caixeta A, Lansky AJ, Serruys PW, Hermiller JB, Ruygrok P, Onuma Y, Gordon P, Yaqub M, Miquel-Hebert K, Veldhof S, Sood P, Su X, Jonnavithula L, Sudhir K, Stone GW, SPIRIT II and III Investigators: Clinical follow-up 3 years after everolimus-and paclitaxel-eluting stents: a pooled analysis from the SPIRIT II (A clinical evaluation of the XIENCE V everolimus eluting coronary stent system in the treatment of patients with de novo native coronary artery lesions) and SPIRIT III (A clinical evaluation of the investigational device XIENCE V Everolimus Eluting Coronary Stent System [EECSS] in the treatment of subjects with de novo native coronary artery lesions) randomized trials. JACC Cardiovasc Interv 2010, 3:1220-1228.
• [17]Park KW, Yoon JH, Kim JS, Hahn JY, Cho YS, Chae IH, Gwon HC, Ahn T, Oh BH, Park JE, Shim WH, Shin EK, Jang YS, Kim HS: Efficacy of Xience/promus versus Cypher in rEducing Late Loss after stENTing (EXCELLENT) trial: study design and rationale of a Korean multicenter prospective randomized trial. Am Heart J 2009, 157:811-817 e1.
• [18]Dewilde WJ, Oirbans T, Verheugt FW, Kelder JC, De Smet BJ, Herrman JP, Adriaenssens T, Vrolix M, Heestermans AA, Vis MM, Tijsen JG, van ’t Hof AW, ten Berg JM, WOEST study investigators: Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: an open-label, randomised, controlled trial. Lancet 2013, 381(9872):1107-15.