Critical Care Medicine-Neurologic Disorders>>>>>Acute Coronary Syndrome
Question 1#

A 46-year-old man with atrial fibrillation, hypertension, hyperlipidemia, and diabetes is admitted with unstable angina. He undergoes coronary angiography which demonstrates a 90% stenosis of the mid left circumflex in a left dominant system. A single drug-eluting stent is deployed with an excellent angiographic result, and the patient is given aspirin and ticagrelor. The patient is admitted to the cardiac service and shortly after arriving to the floor reports new onset chest pain. A 12-lead electrocardiogram is performed: 

Which of the following is the next BEST step in management?

a. Intravenous nitroglycerin
b. Observation
c. Urgent repeat coronary angiography
d. Transthoracic echocardiogram (TTE)

Correct Answer is C

Comment:

Correct Answer: C

The 12-lead electrocardiogram demonstrates an inferoposteroapical ST segment elevation myocardial infarction (STEMI) in the context of a recently deployed stent. Stent thrombosis is an uncommon but serious complication that accounts for less than 10% of cardiac deaths following stent placement. Most cases occur within the first 30 days of placement and are independent of the stent type. The presentation is often with myocardial injury, usually with ST segment elevation (mimicking the acute coronary syndrome), or death. Treatment includes urgent coronary angiography with repeat revascularization.

Although the most common cause for stent thrombosis is P2Y12 discontinuation, other risk factors include acute coronary syndrome presentation, diabetes mellitus, side-branch stenting, greater stent length, suboptimal stent apposition. The cumulative rate of stent thrombosis is approximately 2% at 2 years and is similar for both bare metal stents and first-generation drug-eluting stents. A high index of suspicion is key for successful recognition and management.

References:

  1. Stone GW, Moses JW, Ellis SG, et al. Safety and efficacy of sirolimus- and paclitaxel-eluting coronary stents. N Engl J Med. 2007;356(10):998-1008.
  2. Palmerini T, Kirtane AJ, Serruys PW, et al. Stent thrombosis with everolimus-eluting stents: meta-analysis of comparative randomized controlled trials. Circ Cardiovasc Interv. 2012;5(3):357-364.
  3. Werkum JW, van Heestermans AA, Zomer AC, et al. Predictors of coronary stent thrombosis: the dutch stent thrombosis registry. J Am Coll Cardiol. 2009;53(16):1399-1409.