BACK

A Case Series of Stent Thrombosis During the COVID-19 Pandemic

Background:

  • Stent Thrombosis has become an infrequent complication in recent years given improved stents, polymers and antiplatelet options.
  • The authors note an increased potential risk of stent thrombosis based on the COVID – 19 inflammatory induced hypercoagulable state.

Key Points:

The authors report 4 cases to support their concerns for an increased risk of stent thrombosis.

  • Case 1 is a 49-y. o. male with a 6-hour delayed presentation of a lateral wall STEMI treated with 2 overlapping DES stents. Thirty minutes later patient had recurrent symptoms with In stent thrombosis (ISR) potentially related to modest proximal stent underinflation and/or a minor distal stent edge dissection. The patient was treated with IC tirofiban and proximal stent overexpansion. He has continued on dual antiplatelet therapy with aspirin and ticagrelor. The patient had a cough and follow up serology was positive for COVID – 19 Infection.
  • COVID infected patients comprising cases 2-4 all represent very late ST with myocardial infarction. Elderly age (71-86) was a consistent risk factor. All patients had guideline appropriate antiplatelet treatment but were on agents to treat Coronavirus that might interfere with the CYP3A4 metabolism of antiplatelet treatment.
  • Given less frequent PCI during the COVID – 19 period, the incidence of ST in this center has been 13% compared to 1.2% the year before. Thus, a registry has been initiated in Spain to assess the relationship between ST and COVID infection.
  • All 4 patients showed D-dimer elevations, as well as significant elevations in CRP, high sensitivity peak troponin as well as peak CK values, consistent with an inflammatory and prothrombotic state.
  • The authors note that decisions unproven anti-viral regimens for COVID – 19 patients with prior stents might favor greater emphasis on the importance of antiplatelet therapy and/or use prasugrel (provided no contraindication of age > 75, prior stroke or weight < 60kg.) as the acute antiplatelet agent.
  • This is an interesting report. If confirmed it potentially emphasizes the previously unrecognized risk of late stent thrombosis in the setting of the intense coagulopathy associated with COVID – 19.

Prieto-Lobato A, Ramos-Martínez R, Vallejo-Calcerrada N, Corbí-Pascual M, Córdoba-Soriano JG, A Case Series of Stent Thrombosis During the COVID-19 Pandemic, JACC Case Reports (2020), doi: https://doi.org/10.1016/j.jaccas.2020.05.024.