Subacute Stent Thrombosis Revealing High On-Treatment Platelet Reactivity to Clopidogrel: A Case Report

Stent thrombosis (ST) is a severe complication of percutaneous coronary intervention (PCI), often presenting as acute myocardial infarction or sudden death. We present a case of a 51-year-old male patient with a history of hypertension and dyslipidemia who underwent elective PCI with stent implantation in the first marginal branch for the management of exertional angina. Five days post-procedure, he presented with an inferior ST-segment elevation myocardial infarction (STEMI). Urgent coronary angiography demonstrated subacute thrombosis of the circumflex artery and the ostium of the first marginal at the stent site. Platelet function testing using the vasodilator-stimulated phosphoprotein (VASP) index demonstrated high on-treatment platelet reactivity (HPR) to clopidogrel, which guided the decision to switch antiplatelet therapy to ticagrelor. The patient was successfully treated with glycoprotein IIb/IIIa inhibitors and with a switch from clopidogrel to ticagrelor as the P2Y12 receptor inhibitor. Follow-up angiography after 48 hours of glycoprotein IIb/IIIa inhibitor infusion showed complete thrombus resolution with restoration of normal blood flow. This case illustrates that a VASP index exceeding the 60% poor-response threshold may contribute to early ST, and that prompt platelet function testing should guide escalation to more potent P2Y12 receptor inhibitors in patients presenting with unexplained subacute ST.