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Resolution of a spontaneous coronary artery thrombus with a new antiplatelet agent
S Dagdelen1, S Soydinc, M Ergelen
1Kosuyolu Heart and Research Hospital, Istanbul, Turkey. sinandagdelen@hotmail.com
Insights
A large coronary artery thrombus causing myocardial infarction completely dissolved with medical management, including tirofiban and anticoagulation. This approach avoided invasive procedures in a patient with acute anterior myocardial infarction.
Area of Science:
- Cardiology
- Interventional Cardiology
- Vascular Medicine
Background:
- Acute myocardial infarction often necessitates urgent revascularization.
- Coronary artery thrombus formation can occur without underlying atherosclerosis.
Observation:
- A 47-year-old woman presented with acute anterior myocardial infarction due to a large, eccentric thrombus in the left anterior descending coronary artery.
- The coronary angiogram revealed a 22 mm long, 1.9 mm diameter thrombus, with no signs of atherosclerosis in the affected segment or the rest of the coronary tree.
Findings:
- Due to the thrombus's morphology and the patient's refusal of surgical or interventional procedures, medical management was initiated.
- Treatment included a glycoprotein IIb/IIIa inhibitor (tirofiban), acetylsalicylic acid, nitroglycerin, and warfarin, maintaining an INR of 2-2.5.
- Follow-up coronary angiography after two months demonstrated complete dissolution of the thrombus and restoration of vessel patency.
Implications:
- This case highlights the potential efficacy of aggressive medical therapy in achieving complete resolution of large coronary artery thrombi.
- It suggests that non-atherosclerotic coronary thrombi may be amenable to successful medical treatment, potentially avoiding invasive interventions.
- This approach offers a viable alternative for patients unsuitable for or refusing revascularization procedures.
Abstract:
A thrombus was observed in the left anterior descending coronary artery in a 47 year-old woman who presented with acute anterior myocardial infarction. On a coronary angiogram in the right oblique cranial position, the thrombus appeared as an eccentric, solid and homogeneous mass with a 22 mm maximal length and 1.9 mm maximal diameter. The thrombotic segment and the rest of the coronary tree was free of atherosclerosis. Due to the inappropriate coronary structure and length of the thrombus, coronary angioplasty and/or stent procedures were not performed. The patient refused coronary artery by-pass. She was given the glycoprotein IIb/IIIa inhibitor tirofiban 0.4 microg x kg(-1) x min(-1) bolus over 30 minutes followed by 0.1 microg x kg(-1) x min(-1) for 24 hours, orally acetylsalicylic acid 300 mg per day, nytroglicerin 40 mg per day and warfarine with INR being in a range of 2-2.5 times. A control coronary angiography performed two months later showed total dissolution of the coronary thrombus and clearance of the culprit vessel.