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Prolonged intravenous eptifibatide infusion for prevention of coronary stent thrombosis
International Journal of Cardiology 114 (2007) 409 – 411 www.elsevier.com/locate/ijcard
Letter to the Editor
Prolonged intravenous eptifibatide infusion for prevention of coronary stent thrombosis Ronen Jaffe a,*, David A. Halon a, Judith Carmeli b, Basil S. Lewis a b
a Department of Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel Department of Anesthesiology, Lady Davis Carmel Medical Center, Haifa, Israel
Received 28 October 2005; accepted 15 November 2005 Available online 3 April 2006
Abstract Coronary bare-metal stent thrombosis usually occurs within a week of angioplasty, and may result in myocardial infarction and death. Thrombosis is effectively prevented by antiplatelet therapy with aspirin and clopidogrel. We describe a patient who was unable to ingest oral medication after angioplasty due to gastrointestinal surgery, and was therefore at risk for stent thrombosis. Intravenous eptifibatide was infused for 8 days in order to achieve parentreal platelet inhibition. We suggest a role for long-term intravenous administration of glycoprotein IIb/IIIa inhibitors for prevention of stent thrombosis in patients unable to take oral antiplatelet therapy. D 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Stent; Thrombosis; Eptifibatide
We describe a 73-year-old hypertensive man who was admitted to our hospital with non ST-elevation myocardial infarction and was treated with aspirin, clopidogrel and enoxaparine. Myocardial scintigraphy indicated anterior and inferior myocardial ischemia. Coronary angiography revealed significant stenoses of the proximal right coronary artery (Fig. 1A), mid-portion of the left anterior descending artery (Fig. 1B), and the obtuse-marginal branch of the left circumflex artery (Fig. 1C). The patient underwent triple vessel angioplasty with bare-metal stents, with satisfactory angiographic result (Fig. 1D – F). He was discharged the following day on aspirin and clopidogrel. The patient was re-admitted 5days later with anterior wall myocardial infarction. Intravenous eptifibatide was administered immediately. Urgent coronary angiography revealed patency of the right coronary artery and obtusemarginal branch, and critical stenosis within the stent in the left anterior descending artery (Fig. 2A) due to subacute stent thrombosis. The artery was reperfused successfully by * Corresponding author. Cardiology Department, St Michael’s Hospital, 30 Bond St. Toronto, ON, Canada M5B 1W8. Tel.: +1 416 788 9803. E-mail address: [email protected] (R. Jaffe). 0167-5273/$ - see front matter D 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.11.089
coronary balloon angioplasty (Fig. 2B). One hour later the patient vomited repeatedly and then developed hematemesis. Gastroscopy revealed massive hemorrhage at the gastro-esophageal junction due to Mallory –Weiss tears, which persisted despite local injections of epinephrine. He underwent abdominal surgery with truncal vagotomy and gastroenterostomy. Following surgery a gastric drain was placed and the patient received parenteral nutrition. Inability to administer oral antiplatelet therapy predisposed the patient to recurrent stent thrombosis. Potential occlusion of the stent in the proximal right coronary artery was perceived to be especially dangerous due to the large viable myocardial territory subtended by this artery. After active bleeding was ruled out, parenteral antiplatelet therapy with intravenous eptifibatide was administered for 8 days. The patient was hemodynamically stable during this period with no evidence of myocardial ischemia or bleeding. On day 13 after the original intervention (day 8 after the repeat angioplasty) the patient had recurrent upper gastrointestinal hemorrhage. Eptifibatide infusion was necessarily stopped, and 4h later the patient sustained anterior wall myocardial re-infarction, presumably due to recurrent stent thrombosis in the left anterior descending artery. He was treated
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R. Jaffe et al. / International Journal of Cardiology 114 (2007) 409 – 411
Fig. 1. Coronary angiography revealed stenosis of right coronary artery (A), left anterior descending coronary artery (B) and obtuse marginal branch (C). Results of coronary angioplasty: right coronary artery (D), left anterior descending coronary artery (E) and obtuse marginal branch (F).
conservatively at this point and remained hemodynamically stable. The patient was discharged to his home 31days after the initial angioplasty. Echocardiography at discharge revealed anterior wall akinesis with a left ventricular ejection fraction of 45%.
1. Discussion Subacute stent thrombosis usually presents as myocardial infarction within 1 week after bare-metal stent implantation, and is associated with high mortality [1]. Occurrence of stent thrombosis is influenced by patient, lesion and procedural characteristics [2], and is effectively prevented by combination oral antiplatelet therapy with aspirin and the thienopyridine derivatives ticlopidine and clopidogrel [3]. This therapy prevents platelet adhesion and aggregation on the luminal surface of the stent until endothelization has occurred, and is recommended for a minimum period of 2– 4 weeks. Eptifibatide selectively inhibits the platelet glycoprotein IIb/IIIa receptor and reduces ischemic complications following coronary intervention [4,5]. Eptifibatide is usually administered intravenously for 12– 24 h; however, we are
unaware of any previous report of long-term treatment for prevention of stent thrombosis. In our patient subacute stent thrombosis occurred despite combination oral antiplatelet therapy, and manifested as myocardial infarction on the fifth day after intervention. Primary angioplasty to the occluded artery was complicated by massive gastrointestinal hemorrhage. Subsequent inability of the patient to ingest oral clopidogel and aspirin exposed him to the risk of repeat stent thrombosis. To prevent these occurrences, intravenous eptifibatide was administered for 8days. This approach achieved continuous antiplatelet therapy for a total of 13 days after the initial intervention, during which the stent in the right coronary artery may have undergone endothelization. After eptifibatide administration was stopped due to renewed bleeding, there was clinical evidence of left anterior descending artery re-occlusion within 4h, which is in accordance with the drug’s half-life and elimination curve [5]. The resulting anterior wall myocardial re-infarction was well tolerated by the patient due to the limited amount of viable myocardium subtended by this artery. The main benefit of eptifibatide treatment was prevention of stent thrombosis in the proximal right coronary artery, which supplied a large
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myocardial territory vital for maintaining left-ventricular function following anterior infarction.
2. Conclusion Long-term intravenous treatment with platelet glycoprotein IIb/IIIa inhibitor following coronary angioplasty may prevent stent thrombosis in patients in whom oral antiplatelet therapy is contraindicated.
References [1] Malenka DJ, O’Rourke D, Miller MA, et al. Cause of in-hospital death in 12,232 consecutive patients undergoing percutaneous transluminal coronary angioplasty. The Northern New England cardiovascular disease study group. Am Heart J 1999;137:632 – 8. [2] Cheneau E, Leborgne L, Mintz GS, et al. Predictors of subacute stent thrombosis: results of a systematic intravascular ultrasound study. Circulation 2003;108:43 – 7. [3] Leon MB, Baim DS, Popma JJ, et al. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent anticoagulation restenosis study investigators. N Engl J Med 1998;339: 1665 – 71. [4] Scarborough RM. Development of eptifibatide. Am Heart J 1999;138: 1093 – 104. [5] Granada JF, Kleiman NS. Therapeutic use of intravenous eptifibatide in patients undergoing percutaneous coronary intervention: acute coronary syndromes and elective stenting. Am J Cardiovasc Drugs 2004;4: 31 – 41.
Fig. 2. Urgent coronary angiography following left anterior descending coronary artery stent occlusion: stent thrombosis (A) and following repeat angioplasty (B).
Letter to the Editor
Prolonged intravenous eptifibatide infusion for prevention of coronary stent thrombosis Ronen Jaffe a,*, David A. Halon a, Judith Carmeli b, Basil S. Lewis a b
a Department of Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel Department of Anesthesiology, Lady Davis Carmel Medical Center, Haifa, Israel
Received 28 October 2005; accepted 15 November 2005 Available online 3 April 2006
Abstract Coronary bare-metal stent thrombosis usually occurs within a week of angioplasty, and may result in myocardial infarction and death. Thrombosis is effectively prevented by antiplatelet therapy with aspirin and clopidogrel. We describe a patient who was unable to ingest oral medication after angioplasty due to gastrointestinal surgery, and was therefore at risk for stent thrombosis. Intravenous eptifibatide was infused for 8 days in order to achieve parentreal platelet inhibition. We suggest a role for long-term intravenous administration of glycoprotein IIb/IIIa inhibitors for prevention of stent thrombosis in patients unable to take oral antiplatelet therapy. D 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Stent; Thrombosis; Eptifibatide
We describe a 73-year-old hypertensive man who was admitted to our hospital with non ST-elevation myocardial infarction and was treated with aspirin, clopidogrel and enoxaparine. Myocardial scintigraphy indicated anterior and inferior myocardial ischemia. Coronary angiography revealed significant stenoses of the proximal right coronary artery (Fig. 1A), mid-portion of the left anterior descending artery (Fig. 1B), and the obtuse-marginal branch of the left circumflex artery (Fig. 1C). The patient underwent triple vessel angioplasty with bare-metal stents, with satisfactory angiographic result (Fig. 1D – F). He was discharged the following day on aspirin and clopidogrel. The patient was re-admitted 5days later with anterior wall myocardial infarction. Intravenous eptifibatide was administered immediately. Urgent coronary angiography revealed patency of the right coronary artery and obtusemarginal branch, and critical stenosis within the stent in the left anterior descending artery (Fig. 2A) due to subacute stent thrombosis. The artery was reperfused successfully by * Corresponding author. Cardiology Department, St Michael’s Hospital, 30 Bond St. Toronto, ON, Canada M5B 1W8. Tel.: +1 416 788 9803. E-mail address: [email protected] (R. Jaffe). 0167-5273/$ - see front matter D 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2005.11.089
coronary balloon angioplasty (Fig. 2B). One hour later the patient vomited repeatedly and then developed hematemesis. Gastroscopy revealed massive hemorrhage at the gastro-esophageal junction due to Mallory –Weiss tears, which persisted despite local injections of epinephrine. He underwent abdominal surgery with truncal vagotomy and gastroenterostomy. Following surgery a gastric drain was placed and the patient received parenteral nutrition. Inability to administer oral antiplatelet therapy predisposed the patient to recurrent stent thrombosis. Potential occlusion of the stent in the proximal right coronary artery was perceived to be especially dangerous due to the large viable myocardial territory subtended by this artery. After active bleeding was ruled out, parenteral antiplatelet therapy with intravenous eptifibatide was administered for 8 days. The patient was hemodynamically stable during this period with no evidence of myocardial ischemia or bleeding. On day 13 after the original intervention (day 8 after the repeat angioplasty) the patient had recurrent upper gastrointestinal hemorrhage. Eptifibatide infusion was necessarily stopped, and 4h later the patient sustained anterior wall myocardial re-infarction, presumably due to recurrent stent thrombosis in the left anterior descending artery. He was treated
410
R. Jaffe et al. / International Journal of Cardiology 114 (2007) 409 – 411
Fig. 1. Coronary angiography revealed stenosis of right coronary artery (A), left anterior descending coronary artery (B) and obtuse marginal branch (C). Results of coronary angioplasty: right coronary artery (D), left anterior descending coronary artery (E) and obtuse marginal branch (F).
conservatively at this point and remained hemodynamically stable. The patient was discharged to his home 31days after the initial angioplasty. Echocardiography at discharge revealed anterior wall akinesis with a left ventricular ejection fraction of 45%.
1. Discussion Subacute stent thrombosis usually presents as myocardial infarction within 1 week after bare-metal stent implantation, and is associated with high mortality [1]. Occurrence of stent thrombosis is influenced by patient, lesion and procedural characteristics [2], and is effectively prevented by combination oral antiplatelet therapy with aspirin and the thienopyridine derivatives ticlopidine and clopidogrel [3]. This therapy prevents platelet adhesion and aggregation on the luminal surface of the stent until endothelization has occurred, and is recommended for a minimum period of 2– 4 weeks. Eptifibatide selectively inhibits the platelet glycoprotein IIb/IIIa receptor and reduces ischemic complications following coronary intervention [4,5]. Eptifibatide is usually administered intravenously for 12– 24 h; however, we are
unaware of any previous report of long-term treatment for prevention of stent thrombosis. In our patient subacute stent thrombosis occurred despite combination oral antiplatelet therapy, and manifested as myocardial infarction on the fifth day after intervention. Primary angioplasty to the occluded artery was complicated by massive gastrointestinal hemorrhage. Subsequent inability of the patient to ingest oral clopidogel and aspirin exposed him to the risk of repeat stent thrombosis. To prevent these occurrences, intravenous eptifibatide was administered for 8days. This approach achieved continuous antiplatelet therapy for a total of 13 days after the initial intervention, during which the stent in the right coronary artery may have undergone endothelization. After eptifibatide administration was stopped due to renewed bleeding, there was clinical evidence of left anterior descending artery re-occlusion within 4h, which is in accordance with the drug’s half-life and elimination curve [5]. The resulting anterior wall myocardial re-infarction was well tolerated by the patient due to the limited amount of viable myocardium subtended by this artery. The main benefit of eptifibatide treatment was prevention of stent thrombosis in the proximal right coronary artery, which supplied a large
R. Jaffe et al. / International Journal of Cardiology 114 (2007) 409 – 411
411
myocardial territory vital for maintaining left-ventricular function following anterior infarction.
2. Conclusion Long-term intravenous treatment with platelet glycoprotein IIb/IIIa inhibitor following coronary angioplasty may prevent stent thrombosis in patients in whom oral antiplatelet therapy is contraindicated.
References [1] Malenka DJ, O’Rourke D, Miller MA, et al. Cause of in-hospital death in 12,232 consecutive patients undergoing percutaneous transluminal coronary angioplasty. The Northern New England cardiovascular disease study group. Am Heart J 1999;137:632 – 8. [2] Cheneau E, Leborgne L, Mintz GS, et al. Predictors of subacute stent thrombosis: results of a systematic intravascular ultrasound study. Circulation 2003;108:43 – 7. [3] Leon MB, Baim DS, Popma JJ, et al. A clinical trial comparing three antithrombotic-drug regimens after coronary-artery stenting. Stent anticoagulation restenosis study investigators. N Engl J Med 1998;339: 1665 – 71. [4] Scarborough RM. Development of eptifibatide. Am Heart J 1999;138: 1093 – 104. [5] Granada JF, Kleiman NS. Therapeutic use of intravenous eptifibatide in patients undergoing percutaneous coronary intervention: acute coronary syndromes and elective stenting. Am J Cardiovasc Drugs 2004;4: 31 – 41.
Fig. 2. Urgent coronary angiography following left anterior descending coronary artery stent occlusion: stent thrombosis (A) and following repeat angioplasty (B).