Recurrent intraventricular thrombus six months after ST-elevation myocardial infarction in a diabetic man: a case report

Abstract

BackgroundPercutaneous coronary intervention with placement of a drug-eluting stent in a diabetic patient with ST-elevation myocardial infarction is a relatively common procedure, and always requires subsequent treatment with dual antiplatelet therapy. It is sometimes necessary to add oral anticoagulation therapy because of individual clinical circumstances, which further increases the risk of bleeding.Case presentationA 66-year-old hypertensive diabetic man with a history of gastrointestinal bleeding was admitted with an ST-elevation inferior myocardial infarction that had been evolving over 72 h. Electrocardiography showed ST segment elevation in the inferior leads and Q waves in the inferior and anterior leads. He reported a similar episode of chest pain 1 month previously, for which he had not sought medical treatment. Coronary angiography showed chronic occlusion of the mid-left anterior descending coronary artery, and acute occlusion of the mid-right coronary artery. He was treated by percutaneous coronary intervention, with placement of a drug-eluting stent in the right coronary artery. Soon after admission, transthoracic echocardiography showed abnormal left ventricular contractility and a large left intraventricular thrombus. Three weeks after admission, the patient was discharged on dual antiplatelet therapy (clopidogrel and aspirin) and oral anticoagulation therapy (acenocoumarol). Four months after discharge, transthoracic echocardiography showed absence of left ventricular thrombus and resolution of the abnormal contractility in the area supplied by the revascularized right coronary artery. Given the high risk of bleeding, oral anticoagulation therapy was stopped. Six months later, transthoracic echocardiography showed recurrent left ventricular apical thrombus, and an underlying hypercoagulable state was ruled out. Oral anticoagulation therapy was restarted on an indefinite basis, and dual antiplatelet therapy was continued.ConclusionsThe present case illustrates the need for repeat transthoracic echocardiography following the withdrawal of oral anticoagulation therapy in patients with ST-elevation myocardial infarction, both to monitor thrombus status and to assess left ventricular segmental contraction. In patients who require anticoagulation, avoidance of a drug-eluting stent is strongly preferred and second-generation stents are recommended. The alternative regimen of oral anticoagulation and clopidogrel may be considered in this scenario. In patients with recurrent intraventricular thrombus an underlying hypercoagulable state should be ruled out.

Cocaine-Induced Delayed Myocardial Infarction Complicated by Apical Thrombus

“…In terms of managing these patients post-intervention, the choice of treatment requires a combination of therapies bearing in mind risk of bleeding, patient’s age, and many other risk factors. The current consensus in patients with mural thrombi is the use of an oral anticoagulant therapy with a vitamin K antagonist for up to 6 months [ 8 ]. This consensus however has yet to be revised since the implementation of stenting and dual anti-platelet therapy.…”

Dissolution of an apical thrombus by apixaban in a patient with old anteroseptal myocardial infarction

“…Guidelines recommend using oral anticoagulants for at least 3 months after STEMI in case of LVT ( 2 ). Despite the fact that trials of long-term anticoagulation of these patients do not exist, late LVT reports in literature emphasize that the duration of anticoagulation may be individualized in certain conditions ( 3 , 4 ). Recently, NOACs were shown to be effective in thromboembolism prevention, and their safety was shown to be superior to VKAs in AF ( 5 ).…”