Hypercoagulable state in COVID blocks two coronary stents simultaneously, EHJ report.

Coronavirus disease 2019 (COVID-19) is associated with hypercoagulability and a high rate of thrombosis. Authors Mareau et al have reported an interesting case of very late dual coronary stent thrombosis in a patient recently infected with COVID-19. Dual stent thrombosis is an exceptional event highlighting the high procoagulant state promoted by coronavirus 19.

A 65-year-old man with a history of coronary artery disease (CAD) was admitted following an out-of-hospital cardiac arrest in 2020, related to an ST-segment elevation myocardial infarction revealing a very late dual coronary stent thrombosis of the left anterior descending and posterior descending arteries. Ten days prior to admission, he was diagnosed with COVID-19 pneumonia and treated with dexamethasone, which led to rapid clinical improvement.

Left ventricular ejection fraction (LVEF) was normal. The patient was compliant with his treatment including aspirin, etanercept, methotrexate, enalapril, hydrochlorothiazide, ezetimib, atorvastatin, and verapamil. His stents were implanted in 2010 and 2018.

One day before the OHCA, he was discharged without any change in cardiovascular treatment. He had fully recovered from COVID-19, the D-dimer level was normal for his age [630 ng/mL (N < 650 ng/mL)], whereas fibrinogen was still high [3.9 g/L (N < 3.5 g/L)] at discharge.

At admission, immediately following an ECG that showed ST elevation in anterior leads, patient developed recurrent VF episodes which were cardioverted and patient was rushed to catheterization lab. Coronary angiography revealed an acute thrombotic occlusion in the LAD DES and an acute thrombotic occlusion in the PDA DES. (Figure)

Coronary flow was rapidly restored by percutaneous coronary intervention (PCI) resulting in two DES implanted in mid-LAD and PDA with a resolution of chest pain and ST-segment elevation. No thrombus aspiration was performed according to current ESC guidelines since the vessel was open after guide wire insertion.

Laboratory tests indicated a decrease in previous inflammatory markers: fibrinogen (3.8 g/L), C-reactive protein (2 mg/L), and D-dimer (630 ng/mL)

Intravenous antiplatelet therapy was initiated during PCI with cangrelor, replaced by ticagrelor after PCI, whereas aspirin was continued without interruption. During hospitalization, anticoagulant therapy was initiated, initially with unfractionated heparin, then with enoxaparin, and finally with apixaban because of atrial fibrillation onset. Ticagrelor was switched to clopidogrel as triple anticoagulant therapy with ticagrelor is not recommended.

A sustained prothrombotic state with high prevalence of both venous and arterial thrombotic events has been described during COVID-19. This is the first case highlighting very late dual stent thrombosis in a COVID infected patient.

The addition of extended antithrombotic treatment at discharge in patients with COVID-19 and previous coronary disease is not currently recommended. This case emphasizes the high procoagulant state related to COVID-19 and thus raises the issue of an extended (post-discharge) antithrombotic treatment, which could reduce the risk of ischaemic events, at the cost of increase in bleeding events.

"This case emphasizes the high thrombotic risk in COVID-19 patients and suggests that strengthening of antithrombotic therapy in CAD patients presenting with COVID-19 should be discussed", concluded the authors.

Source: European Heart Journal Case Reports: European Heart Journal - Case Reports, Volume 5, Issue 6, June 2021, ytab114, https://doi.org/10.1093/ehjcr/ytab114