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Meenakshi
1. MEENATCHI 66 /F
Admitted on 04.06.19 with complaints of Chest pain for 2 days
Resting pain
Retrosternal , compressive , radiating to left arm , associated with sweating .
Unstable angina , class III b
Cardiac enzymes - negative
Risk factors : Age
Grace score – 106
Vitals :
Pulse rate : 73/ min
BP: 110/ 80 mm Hg in right upper limb in sitting position
JVP : not elevated
CVS : S1S2 Heard , no gallop rhythm , no murmurs
RS : NVBS + ; no creps , wheeze
2. Ecg showed
• Sinus rate 73 / min
• Normal axis
• Sinus rhythm
• PR interval : 170 msec
• Qrs 80 msec
• No ST segment changes
• QS in v1, v2
• T inversion in leads V1 – V5.
3.
4. • ECHO :
• Hypokinesia of distal 2/3rd of IVS , anterior ,
antero septal and antero lateral segments of LV
at apical , mid and basal levels and LV apex.
• Segment involved ( 1,2,6,7,8,12,13,14,16,17 )
• LV EF 48 %.
• GRADE I LV DD
• NO VSR/ MR/ TR.
• NO PERICARDIAL EFFUSION.
16. • PATIENT HAD UNEVENTFUL PERIOD FOLLOWING PCI
• WAS DISCHARGED 2 DAYS LATER
• WITH ASA 150 mg OD & CLOPIDOGREL 75 mg BD
17. • Patient admitted one week later with anterior wall
myocardial infarction on 29.02.19
• Window period : 5 hrs
• Ecg showed st elevation in v1 - v6
• Echo showed hypokinesia of anteroseptal ,
anterolateral and anterior wall of lv at apical , mid
and basal levels.
• Patient was thrombolysed with SK.
• Taken for CAG next day.
32. • PATIENT WAS DISCHARGED 2 DAYS LATER
• NO SYMPTOMS OF CHEST PAIN FOLLOWING PCI
• PATIENT WAS PUT ON T.ASPIRIN 150 mg OD & T. TICAGRELOR 90 mg 1-0-1 .
33. STENT THROMBOSIS
• INCIDENCE : 0.5 - 1 %.
• USUALLY PRESENTS AS MI 50 – 70 %.
• MORTALITY RATES ARE REPORTED FROM 25 - 40 %
• REPEAT REVASCULARISATION – 20 – 40 %
• 20 % OF PATIENTS WITH A FIRST STENT THROMBOSIS EXPERIENCE A
RECURRENT STENT THROMBOSIS EPISODE WITHIN 2 YRS.
EARLY STENT
THROMBOSIS
INCIDENCE
HORIZON AMI
TRIAL
ACUTE MI 2.5 %
ACUITY TRIAL STABLE ANGINA 0.1 – 0.6 %
ACUITY TRIAL NSTEMI 1.4 %
34. • WHILE PRESENTING AS MI:-
• ASSOCIATED WITH HIGH THROMBUS LOAD
• EXTENSIVE DISTAL EMBOLISATION
• LOWER RATE OF SUCCESSFUL CATHETER BASED PCI REPERFUSION
35. CLASSIFICATION
• BASED ON DURATION:
ACUTE AND SUBACUTE THROMBOSIS COMMON IN BOTH BMS & DES
LATE AND VERY LATE THROMOSIS COMMON IN FIRST GENERATION
DES ( DUE TO INCOMPLETE ENDOTHELIALIZATION.
ACUTE <24 HRS
SUBACUTE 1 DAY TO 1 MONTH
LATE 1 MONTH TO 1 YR
VERY LATE > 1 YR
36. PRIMARY STENT THROMBOSIS : DIRECTLTY RELATED TO STENT
SECONDARY : THROMOSIS OCCURING AT THE STENT
SITE AFTER AN INTERVENING TLR
EVENT.
37. DEFINTION CRITERIA
DEFINITE ACUTE CORONARY SYNDROME WITH
ANGIOGRAPHIC OR AUTOPSY EVIDENCE
OF THROMBUS OR OCCLUSION WITH IN
OR ADJACENT TO A STENT
PROBABLE UNEXPLAINED DEATH WITHIN 30 DAYS
AFTER STENT IMPLANTATION OR ACUTE
MYOCARDIAL INFARCTION INVOLVING
THE TARGET VESSEL TERRITORY WITHOUT
ANGIOGRAPHIC CONFIRMATION
POSSIBLE UNEXPLAINED DEATH OCCURING MORE
THAN 30 DAYS AFTER THE INDEX
PROCEDURE
ACADEMIC RESEARCH CONSORTIUM -- CRITERIA FOR STENT THROMBOSIS
DEFINTION
38. • TYPE 4 MI:
-MI RELATED TO PCI
- ELEVATION OF cTn VALUES ABOVE 5 TIMES THE 99TH PERCENTILE , IF BASELINE VALUES ARE
NORMAL
- OR ELEVATION > 20 % , IF THE BASELINE VALUES ARE ELEVATED .
IN ADDITION EITHER
1. SYMPTOMS SUGGESTIVE OF MYOCARDIAL ISCHEMIA
2. NEW ISCHEMIC CHANGES IN ECG OR NEW LBBB
3. ANGIOGRAPHIC LOSS OF PATENCY OF A MAJOR CORONARY ARTERY OR A SIDE BRANCH OR
PERSISTENT SLOW FLOW OR NO FLOW OR EMBOLISATION.
4. IMAGING DEMONSTRATION OF NEW LOSS OF VIABLE MYOCARDIUM OR NEW RWMA ON
ECHO.
39. TYPE 4 b
• Rise and / or fall in cardiac biomarkers values
with atleast one value above the 99th
percentile URL.
40. POST HOC ANALYSIS OF HORIZON AMI TRIAL
• FOLLOWED PTS FOR 3 YRS:-
• AMONG INHOSPITAL MORTALITY GROUPS:
• SUCCESSIVE LOSS OF VIABLE MYOCARDIUM OVER A PERIOD
OF 30 DAYS.
IN HOSPITAL MORTALITY 27.8%
OUT OF HOSPITAL MORTALITY 10.8% P < 0.01
ACUTE ST 7.1%
SUBACUTE ST 50%
42. LESION BASED FACTORS:
1. Diffuse disease.
2. Long stent.
3. Multiple stents.
4. Small vessel disease.
5. Bifurcation disease.
6. Thrombus containing lesion.
7. Significant lesion proximal and distal to the stented
segment.
43. STENT RELATED FACTORS:
1. Poor stent expansion
2. Edge dissection
3. Delayed or absent endothelialization of stent struts
4. Thicker stent struts
5. Hypersensitivity to specific DES polymer
6. Strut fractures
44. INDEPENDENT PREDICTORS IN EMERGENT DES/
ELECTIVE DES
I. STENTING IN ACS
II. PRESTENTATION AS ST ELEVATED MI
III. RENAL FAILURE
IV. STENT IN LAD
V. STENT LENGTH
VI. DIABETES.
45. HORIZON TRIAL
FACTORS PROMOTING ST
• ANGIOGRAPHIC ULCERATION
• IMPAIRED BASELINE FLOW
• INSULIN TREATED DIABETES
FACTORS REDUCES THE ST :
. CLOPIDOGREL 600 mg LOADING DOSE
. EARLY TREATMENT WITH HEPARIN
STRONGEST PREDICTORS IN IVUS:
• MINIMUM LUMINAL CSA
• INFLOW / OUTFLOW DISEASE ( RESIDUAL DISSECTION , STENOSIS )
46. PREVENTION OF STENT THROMBOSIS
1. Usage of stents with proven lower stent thrombosis
2. Selecting the correct size of stent
3. High pressure stent deployment and post dilation.
4. Ensuring the absence of edge dissection
5. Ensuring the adequate inflow and outflow
6. Avoiding the use of 2 stents in bifurcation lesions if possible
47. PERI AND POST PROCEDURE CARE:
• More potent oral antiplatelet regimens ( prasugrel and ticagrelor ) .
• Continuation of DAPT without interruption .
48. TREATMENT
• THROMBOLYSIS
• Treated with emergent thrombectomy ( mechanical or aspiration) .
• Balloon angioplasty / PTCA along with administration of gp iib / iiia
inhibitors.
• Usage of ivus or oct cause of stent thrombosis like stent
underexpansion , malapposition , residual dissection , significant inflow
or outflow stenosis.
• Has to be done following thrombectomy.
49.
50. • 4 patients
• May 2005 – dec 2006
• 2 patients had acute ST & other 2 had subacute ST.
• Window period - < 1 hr
• 2 patients discontinued DAPT / 1 – only on ASA / 1 – DAPT
• Lysed with TNK & UFH / ASA – given.
• Successful st segment settling in ecg and complete resolution of thrombus
in cag.
