Acute stent thrombosis associated with exercise testing after successful percutaneous transluminal coronary angioplasty

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Acute stent thrombosis associated with exercise testing after successful percutaneous transluminal coronary angioplasty Bruce Samuels, MD, John Schumann, MD, Hosen Kiat, MD, FRACP, John Friedman, MD, and Daniel S. Berman, MD Los Angeles, Calif.

Exercise testing is often used to noninvasively assess the functional result of percutaneous transluminal coronary angioplasty (PTCA). 1 However, debate exists regarding the proper timing of stress testing in these patients. Several reports of acute thrombotic occlusion associated with exercise testing shortly after successful PTCA have been described. 27 In this article we present the first described case of acute coronary occlusion after exercise testing in a patient 5 days after successful intracoronary stent placement. A 37-year-old man was referred for a rest/stress myocardial perfusion study 14 days after having a non-Q-wave anteroseptal myocardial infarction (MI). The patient was admitted for observation and started on intravenous heparin and aspirin. Cardiac catheterization revealed 100% occlusion of the left anterior descending (LAD) coronary artery immediately after the first diagonal branch. PTCA was performed successfully and resulted in less than a 20% residual stenosis. A moderate localized dissection was noted at the site of PTCA. The patient underwent anticoagulation with coumadin. Three days later the patient had typical angina with ischemic anterior electrocardiographic changes and transient hypotension. The patient underwent repeat angiography that revealed 80% occlusion of the LAD at the site ofPTCA. A 3 mm Cook stent was placed at the site of the dissection with an excellent angiographic result. The patient was placed on calcium-channel blockers, and coumadin was continued. Four days later the patient had nonanginal chest pain and was referred for stress technetium-99m sestamibi (MIBI)/rest thallium (TI-201) separate acquisition dual-isotope myocardial perfusion SPECT. The patient exercised for 8 minutes of a Bruce protocol to a peak heart rate of 156 (85% of age-predicted maximum) with no chest discomfort or other anginal symptoms during the study. The resting blood pressure was 110/66, and the peak blood pressure was 184/78. From the Departments of Imaging(Division of Nuclear Medicine) and Medicine(DivisionofCardiology),Cedars-SinaiMedicalCenter,LosAngeles; and the Department OfMedicine, UCLASchoolof Medicine. Dr. Kiat was supportedby a Tjahjadi FamilyFoundationResearchgrant. Reprint requests: Hosen Kiat, MD, Cedars-Sinai Medical Center, 8700 BeverlyBlvd., Los Angeles,CA90048. AMHEARTJ 1995;130:1120-2. Copyright© 1995by Mosby-YearBook,Inc. 0002-8703/95/$5.00+ 0 4/4/66528

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Fig. 1. LAO angiographic View demonstrates completely occluded proximal left anterior descending coronary artery (open arrow) without flow through coronary stent (closed

arrows).

Resting electrocardiogram (ECG) showed baseline anterolateral ST-T wave abnormalities, and stress ECG did not reveal any additional ischemic ST-segment changes. The nuclear perfusion images demonstrated a nonreversible defect of the mid to distal anterior wall and left ventricular apex and a small amount of periinfarct ischemia. The left ventricle was not enlarged at rest, and no transient dilation of the left ventricle occurred with exercise. Two hours after the stress test the patient had severe chest pain with concomitant ST-segment elevations on the anterior and lateral ECG leads. A minimal response to sublingual nitroglycerin was seen. He was taken immediately for cardiac catheterization, and coronary angiography revealed complete stent thrombosis without any distal runoff (Fig. 1). Repeat balloon angioplasty and intracoronary thrombolysis were performed with suboptimal results. Two episodes ofventricular fibrillation responded to cardioversion. The patient was taken immediately to surgery, and the left internal mammary artery was grafted to the LAD. The patient did well and was discharged in stable condition on the fourth postoperative day. Exercise stress testing of patients who have undergone PTCA has been an accepted standard of practice since the inception of this revascularization procedure almost 2 decades ago. In their first report on PTCA, Gruentzig et al.1 administered exercise testing within the first 2 days after successful angioplasty, and a large body of the medical literature supports similar testing to evaluate the functional status of the patient. 81° Carlier et al.ll studied the results of exercise testing performed within 3 days of successful

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Table I. P a t i e n t demographics from published data Stenosis No. min

No.

Authors (Reference)

Age Sex (yr)

Before PTCA (%)

After PTCA (%)

Stenosis after PTCA

days Dissec- after tion PTCA

CP with Ex

ST-dep with Ex

%Pred HR achieved

to isch after stress

Dash 2

M

41

LAD

80

30

N

2

N

N

"Stage 4"

30

Przybojewski 3 Nygaard4

M M

37 31

RCA LAD

95 90

35 30

N Y

3 5

N N

Y N

85 96

30 20

Mitsuo5 Mitsuo5 Bedogni 6 Goodman7 Samuels

M M M M M

54 68 55 41 37

NA NA 25 25 20

--N Y Y

8 18 7 42 5

N N N N N

N N N N N

103 102 -100 85

"Few" 10 20 45 120

95 8

34 37

Mean _+SD

46 12

RCA/Cx 99, 90 LAD 99 LAD 90 LAD 90 LAD 100 92 7

28 5

11 13

Disposition

Thrombolysis/ CABG Thrombolysis Thrombolysis/ PTCA/CABG Repeat PTCA Repeat PTCA Thrombolysis Thrombolysis/PTCA Thrombolysis/ PTCA/CABG

cP, Chest Pain;Ex, exercise;ST~dep, ST-segmentdepression;Pred HR, predictedheart rate; Min to Isch, minutesto ischemicevent;CABG, coronaryartery bypass graft surgery.

PTCA in 351 consecutive patients a n d reported no cardiac complications. Several case reports have been published, however, t h a t question the safety of this practice. 27 These reported patients all had postexercise test coronary occlusion at the site of previous PTCA. Table I lists the relevant clinical data contained in each of these reports, including our case. All patients were male and had a m e a n age of 45.5 years. I n all the patients a n initial high-grade stenosis with a n acceptable post-PTCA result (mean residual stenosis = 27.5%) was present. Half (three of six) of the patients for whom data were available had dissection at the site of PTCA. Six of the eight p a t i e n t s performed stress testing within 8 days of PTCA with a range of 2 days to 6 weeks. All of the patients performed a m a x i m a l exercise test, achieving a m e a n of 95.2% of their m a x i m a l predicted heart rate. None of the patients had chest pain during testing, a n d only one p a t i e n t had a n ischemic electrocardiographic response. All b u t one had ischemia within 1 hour of exercise testing. The m e c h a n i s m for acute coronary occlusion occurring after exercise testing performed after a successful angioplasty is unclear. K u m p u r i s et al. (2) found t h a t patients with coronary artery disease (CAD) had higher levels of platelet aggregation d u r i n g exercise testing t h a n did patients in a n o r m a l control group. This finding was elaborated by Mehta et al., ]3 who documented a n increase i n thromboxane A2 levels d u r i n g exercise testing in patients with k n o w n CAD. Platelet activation and hyperreactivity increased d u r i n g exercise testing in a study by Kestin et al. 14 b u t only in those subjects who were sedentary. Others have suggested t h a t the increased arterial wall stress associated With increased coronary blood flow a n d blood pressure t h a t occurs d u r i n g exercise m a y t r a u m a t i z e a n already disrupted intima, 2 b u t no data currently exist to support this contention. This report is the first description of a n acute coronary thrombosis d u r i n g exercise testing performed 5 days after

successful placement of a n intracoronary stent. I n spite of the case reports noted i n Table I, h u n d r e d s of thousands of PTCA procedures are performed annually, and therefore a n y complication related to early stress testing m u s t be considered to be a n exceedingly rare event. However, intracoronary stent placement is a relatively new procedure without such large n u m b e r s to date; therefore we believe our case w a r r a n t s a degree of caution. I n particular, because both acute a n d subacute thrombosis after intracoronary stent placement is far more common t h a n after balloon angioplasty, 15 the potential for increased complications d u r i n g exercise testing related to increased thrombogenicity m a y exist. I n addition, stents are often placed to treat t h r e a t e n e d or acute closure caused by dissection after PTCA, and several authors have hypothesized t h a t a significant l u m i n a l disruption m a y act as a n aggravating factor for the propensity to platelet aggregation and vasomotor tone seen d u r i n g exercise. 4, 6-7 U n t i l further data become available, we would recommend caution in performance of stress testing during the first week after intracoronary stent placement, especially if a significant underlying coronary dissection is present. If stress testing is clinically indicated during the early poststent period, vasodilator pharmacologic stress with adenosine or dipyridamole m a y be preferable to avoid the catecholamine elevations (and associated thrombogenicity) and the increased blood pressure associated with exercise. REFERENCES

1. GruentzigAR, SenningA, SiegenthalerWE. Nonoperativedilatation of coronaryartery stenosis:percutaneoustransluminalcoronaryangioplasty. N Engl J Med 1979;301:61-8. 2. Dash H. Delayed coronary occlusionafter successful percutaneous transluminal coronaryangioplasty:associationwith exercise testing. Am J Cardiol 1982;52:1143-4. 3. PrzybojewskiJZ, WeichHFH. Acute coronarythrombusformationafter stress testing followingpercutaneoustransluminal coronaryangioplasty: a case report. S AfTMed J 1985;67:378-82. 4. NygaardTW,BellerGA,MentzerRM, GibsonRS, MoenerCM,Burwell LR. Acute coronaryocclusionwith exercise testing after initially suc-

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cessful coronary angioplasty for acute myocardial infarction. Am J Cardiol 1986;57:687-8. 5. Mitsuo K, Degawa T, Tohma M, Nakamura M, Yoshimura H, Watanabe S, Hase H, NinomiyaK. [Twocases of acute coronaryocclusion after successfulcoronary angioplastyassociated with a treadmill stress testing.] Kokyu to Junkan 1990;38:805-10. [Japan] 6. Bedogni F, LaVecchia L, Arfiero S, Castellani A, Vincenzi M. Acute coronary occlusionafter recent coronary angioplasty: associationwith exercise and successful treatment with intracoronary thrombolysis. Chest 1990;98:505-7. 7. GoodmanSG, HollowayRM, Adelman,AG. Acutecoronarythrombotic occlusionfollowingexercisetesting 6 weeks after percutaneous transluminal-coronary angioplasty. Cath Cardiovasc Diag 1992;27:40-4. 8. Task Force Members on ExerciseTesting. Guidelinesfor exercisetesting. A report of the American Collegeof Cardiology/AmericanHeart Association Task Force on Assessment of Cardiovascular Procedures (Subcommitteeon ExerciseTesting). J Am CollCardio11986;8:725-38. 9. SheffieldLT. Exercise stress testing. In: Braunwald E, editor. Heart disease: a textbook of cardiovascular medicine.4th ed. Philadelphia: WB Saunders, 1992:161-79. 10. ESC Working Group on Exercise Physiology, Physiopathology and Electrocardiography. Guidelinesfor cardiac exercisetesting. Eur Heart J 1993;14:969-88. 11. Carlier M~MeierB, FinciL, Karpuz H, Nukta E, RighettA. Early stress tests after successfulcoronaryangioplasty. Cardiology1993;83:339-44. 12. Kumpuris AG, Luchi RJ, WaddellCC, MillerRR. Production for circulating platelet aggregatesby exercisein coronarypatients. Circulation 1980;61:62-5. 13. Mehta J, Mehta P, Horalek C. The significanceof platelet-vesselwall prostaglandin equilibriumduring exercise-inducedstress. AMHEARTJ 1983;105:895-904. 14. Kestin AS, Ellis PA, Barnard MR, ErrichettiA, Rosner BA, Michelson AD. Effectsof strenuous exerciseon platelet activationstate and reactivity. Circulation 1993;88:1502:11. 15. Nath FC, Muller DW, Ellis SG, Rosenschein U, Chapekis A, Quain L, Zimmerman C, Topol EJ. J Am CoUCardiol 1993;21:622-7.

Takayasu's arteritis with unstable angina and aortic insufficiency Salvatore Trazzera, MD, J o s e p h Colasacco, MD, and Lawrence Ong, MD Manhasset, N.Y.

Takayasu's arteritis (TA) is a chronic large-vessel vasculitis affecting young w o m e n more frequently t h a n young men. Although the cause of this i n f l a m m a t o r y disease is unknown, the patients frequently h a v e signs and symptoms of peripheral v a s c u l a r insufficiency caused by arterial l u m i n a l obliteration or narrowing. 1' 2 This narrowing is often preceded by a systemic i n f l a m m a t o r y phase characterized by fever, malaise, and arthralgias. We describe a unique presentation of TA in a young w o m a n w i t h pro-

From North Shore University Hospital-CorneU University Medical Center, Division of Cardiology. Reprint requests: Lawrence Ong, MD, North Shore University Hospital, Division of Cardiology, 300 Community Dr., Manhasset, NY 11030. AM HEARTJ 1995;130:1122-4. Copyright © 1995 by Mosby-Year Book, Inc. 0002-8703/95/$5.00 + 0 414166523

American Heart Journal

Fig. 1. Aortogram demonstrates irregular ascending aorta with s e v e r e aortic insufficiency. Right coronary ostium is occluded, and left coronary ostium is severely diseased (arrows).

gressive angina and dyspnea caused by involvement of the coronary ostia and the aortic valve. A 39-year-old w o m a n had a 5-month history of progressive exertional chest pain and dyspnea. She had recently begun to h a v e chest pain at rest relieved by sublingual nitroglycerin. She also gave a 1-year history of easy fatiguability, malaise, arthralgias, and headaches. No history of syncope, ocular disturbances, neurologic deficits, or claudication was present. No history of coronary disease or family history of p r e m a t u r e coronary or cerebrovascular events was reported. The p a t i e n t gave a 15-year history of smoking cigarettes but denied a history of hypertension, diabetes, hyperlipidemia, or p r e m a t u r e menopause. The patient was a former Air Force technician who h a d lived in J a p a n w i t h tours of duty in G u a m and the Phillipines. Physical examination revealed t h a t the w o m a n had no musculoskeletal deformities but was afebrile. Blood pressure was 130/60 and equal in both arms. The h e a r t r a t e was 80 beats/min and regular. Carotid, brachial, radial, femoral, and dorsalis pedis pulses were bounding. Cardiac examination revealed n o r m a l first and second h e a r t sounds without gallops. A harsh, 3/6 systolic m u r m u r was heard over the aortic area, and a long, high-pitched, 3/6 decrescendo diastolic m u r m u r was heard best at the upper left sternal border. The results of the r e m a i n d e r of the physical examination were normal. Laboratory values were rem a r k a b l e only for an elevated erythrocyte sedimentation r a t e of 40 mm/hr. The chest x-ray film d e m o n s t r a t e d the absence of cardiomegaly or mediastinal widening. The electrocardiograph d e m o n s t r a t e d normal sinus r h y t h m and nonspecific ST s e g m e n t changes. Cardiac catheterization was performed. The left ventricular end-diastolic