P213 a complicated stemi : poised between thrombosis and hemorrhage

Abstract The introduction of more effective and powerful antithrombotic therapies has allowed the progressive reduction of ischemic events associated however with an increase in haemorrhagic events. What we are describing is an example of how iatrogenic and non–iatrogenic complications can add up, making routine therapeutic management difficult during and after hospital stay.We are talking about a 50–year–old male patient, a smoker and with a history of dyslipidemia under treatment, who arrived at our cath–lab with a diagnosis of anterior SCA–STEMI, after loading ticagrelor 180 mg from the spoke center where he had gone for chest pain. At coronary angiography, evidence of critical disease of the median anterior interventricular artery treated by primary angioplasty and for the high thrombotic load by thromboaspiration, DES and Tirofiban bolus and 18–hour continuous infusion. Approximately 15 hours after the event, the patient appeared confused and aphasic. A brain CT scan with and without contrast agent was performed which documented the presence of a hemorrhagic focus in the atypical left temporal site, in the absence of arteriovenous malformations not susceptible to surgical therapy (BARC–3). Therefore, in view of the high risk of bleeding, de–escalation therapy with cardioaspirin and clopidogrel was practiced. Five days after the event, the clinical picture was complicated again by the finding of apical thrombosis on the transthoracic ultrasound. For this reason, given the stability of the haemorrhagic lesion on CT scans and control MRIs, Enoxaparin sodium 4000 IU was introduced in therapy once, with resolution of the formation in the imaging control after one month. The patient was then discharged with indication for short–DAPT in consideration of the high PRECISE–DAPT score. The arduous task of managing this case led us to reflect on the importance of the pre– and post–PCI clinical picture of the patient in order to seek the appropriate antithrombotic treatment by dynamically balancing the ischemic and haemorrhagic risk during hospitalization through numerous standardized tools at our disposal.