MANAGEMENT OF ACUTE CORONARY SYNDROME AND SUBACUTE IN-STENT THROMBOSIS IN SETTING OF FACTOR V LEIDEN MUTATION

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Factor V Leiden (FVL) results from mutation in the F5 gene resulting in hypercoagulable state. Although, venous thromboembolism (VTE) is frequently reported with FVL, cases of arterial thrombosis, especially MI in setting of FVL are rare. CASE PRESENTATION: 55-year-old Caucasian woman, diagnosed with FVL (heterozygous) 3 weeks ago in setting of unprovoked right lower extremity DVT, presented with substernal chest pain radiating to left arm. Past medical history was insignificant. She was up to date on cancer screening. Home medication was recently initiated rivaroxaban. No family history of premature CAD or thrombophilia and no smoking, alcohol, or drug use reported. Of note, the patient presented 1 week prior to this visit with chest pain, peak troponin I of 1.99 ng/ml, without ST changes on EKG. CT arteriogram at that time showed no occlusions, calcified or non-calcified coronary plaques. Echocardiogram at that time was normal. EKG on this visit showed ST-elevations in leads II, III, aVF, V3-V6. Emergent coronary angiography revealed 80% focal mid LAD stenosis due to thrombus, and distal showering of thrombus in the apical region. Left ventriculography showed apical dyskinesis with normal EF. Remaining coronary vessels were 100% patent. She was treated with DES to mid LAD, aspirin, ticagrelor, beta-blocker and statin. Hematology was consulted for possible anticoagulation failure given acute LAD thrombus and recommended heparin to warfarin bridge with INR goal of 2-3. 5 days later, patient had chest pain again and left heart catheterization this time showed subacute in-stent thrombosis, treated with manual aspiration and balloon angioplasty. She was switched to therapeutic enoxaparin and remains asymptomatic to date. DISCUSSION: Hereditary thrombophilias are associated with increased risk of thromboembolic events. Association of FVL with VTE is well established, but its role in arterial thrombotic events is controversial. While the patient received dual anti-platelet therapy following stent implantation, the subacute in-stent thrombosis likely resulted from her underlying hypercoagulable state. We can possibly infer that the dual anti-platelet therapy alone may not be effective for the carriers of FVL. Also, the role of NOACs to prevent coronary artery thrombosis is questionable. Higher INR goal on warfarin or therapeutic doses of LMWH may be necessary to prevent coronary thrombus in setting of FVL. CONCLUSIONS: More studies are needed to establish the role of thrombophilic disorders and coronary artery and stent thrombosis. Higher INR goal on warfarin or therapeutic LMWH may be required to prevent future coronary thrombotic events. In patients with acute or subacute stent thrombosis, hypercoagulable workup should be pursued, and such patients can potentially benefit from anticoagulation therapy on top of dual antiplatelet therapy. Reference #1: J Cardiovasc Med (Hagerstown). 2008;9(4):410–413. DISCLOSURES: No relevant relationships by Mohammad Hamza, source=Web Response No relevant relationships by Usman Naseer, source=Web Response No relevant relationships by Sheikh Raza Shahzad, source=Web Response Speaker/Speaker's Bureau relationship with Amgen Please note: $5001 - $20000 Added 06/01/2020 by Ira Zackon, source=Web Response, value=Honoraria Speaker/Speaker's Bureau relationship with Takeda Please note: $1001 - $5000 Added 06/01/2020 by Ira Zackon, source=Web Response, value=Honoraria Consultant relationship with G1 Therapeutics Please note: $1-$1000 Added 06/01/2020 by Ira Zackon, source=Web Response, value=Consulting fee