Platelet-monocyte aggregates: molecular mediators of thromboinflammation.

Platelets, key facilitators of primary hemostasis and thrombosis, have emerged as crucial cellular mediators of innate immunity and inflammation. Exemplified by their ability to alter the phenotype and function of monocytes, activated platelets bind to circulating monocytes to form monocyte-platelet aggregates (MPA). The platelet-monocyte axis has emerged as a key mechanism connecting thrombosis and inflammation. MPA are elevated across the spectrum of inflammatory and autoimmune disorders, including cardiovascular disease, systemic lupus erythematosus (SLE), and COVID-19, and are positively associated with disease severity. These clinical disorders are all characterized by an increased risk of thromboembolic complications. Intriguingly, monocytes in contact with platelets become proinflammatory and procoagulant, highlighting that this interaction is a central element of thromboinflammation.

Racial and ethnic differences in pharmacotherapy to prevent coronary artery disease and thrombotic events.

Awareness of racial/ethnic disparities represents a key challenge for healthcare systems that attempt to provide effective healthcare and to reduce existing inequalities in the use of and adherence to guideline-recommended cardiovascular drugs to improve clinical outcomes for cardiovascular disease (CVD). In this review, we describe important racial/ethnic differences between and within ethnic groups in the prevalence, risk factors, haemostatic factors, anti-inflammatory and endothelial markers, recurrence, and outcomes of CVD. We discuss important differences in the selection, doses, and response [efficacy and adverse drug reactions (ADRs)] in ethnically diverse patients treated with antithrombotics or lipid-lowering drugs. Differences in drug response are mainly related to racial/ethnic differences in the frequency of polymorphisms in genes encoding drug-metabolizing enzymes (DMEs) and drug transporters. These polymorphisms markedly influence the pharmacokinetics, dose requirements, and safety of warfarin, clopidogrel, and statins. This review aims to support a better understanding of the genetic differences between and among populations to identify patients who may experience an ADR or a lack of drug response, thus optimizing therapy and improving outcomes. The greater the understanding of the differences in the genetic variants of DMEs and transporters that determine the differences in the exposure, efficacy, and safety of cardiovascular drugs between races/ethnicities, the greater the probability that personalized medicine will become a reality.

Application of a Novel Swallowable Telemetric Device for Real Time Luminal Blood Detection to Guide Timing of Enteroscopy in a Patient with Obscure-Occult Gastrointestinal Bleeding: A Case Report

Background and aim: Gastrointestinal (GI) bleeding is deemed "obscure" when upper and lower GI endoscopy reveal no bleeding site. While the term "overt" is used in cases where visible blood passage is observed or reported, cases without macroscopic bleeding stigmata are defined "occult". Although small bowel origin accounts for only about 5% of all GI bleedings, it makes up the majority of obscure GI bleedings. Diagnostic work-up and treatment of small bowel GI bleedings can be challenging, especially when overt bleeding symptoms are absent. Material(s) and Method(s): We report the case of a frail patient with multiple comorbidities and evidence of bleeding small bowel angiodysplastic lesions on videocapsule assisted enteroscopy (VCE). Device assisted enteroscopy (DAE), planned in order to treat the bleeding lesions, was delayed after the patient contracted SARSCoV- 2 infection. Eight weeks after, in the absence of clinical signs of bleeding, a device for real time luminal blood detection (HemoPillR acute, Ovesco) was applied to guide timing of enteroscopy. Result(s): The 71 year old male patient was on dual anti platelet therapy and had persistent clinical features of iron deficiency anemia (Hemoglobin 8,0g/dl). Upper and lower GI endoscopy were negative for potential bleeding sources. VCE showed three small lesions suspect for angiodysplasia within 1 to 13 minutes after pylorus passage. Upon recovery from SARS-CoV-2 infection and congestive heart failure with respiratory insufficiency, we administered HemoPillRacute orally, without previous bowel preparation. The measurement showed a peak HemoPillR-Index (HI max) at 1h 47min after capsule administration (Fig. 1) and was therefore indicative of a small bowel bleeding site, best approachable by antegrade oral route, in keeping with the prior VCE findings. On subsequent DAE, performed through spiral enteroscopy, the small bowel angiodysplastic lesions were successfully treated. [Figure presented] Conclusion(s): Our case report illustrates how a novel telemetric blood detection measurement was able to confirm luminal blood presence and successfully guide timing of therapeutic DAE in a patient with obscure-occult GI bleeding, without the need for repetition of VCE.Copyright © 2023. Editrice Gastroenterologica Italiana S.r.l.

Superior Cerebellar Artery Dissection in a Patient Diagnosed with Reversible Cerebral Vasoconstriction Syndrome: A Case Report

Arterial dissection is an uncommon complication of reversible cerebral vasocon-striction syndrome (RCVS). We describe the case of a 35-year-old woman with a migraine history who presented with recurrent thunderclap headache and focal neurological signs, including right hemiataxia. She had been diagnosed with COVID-19 disease two weeks earlier. Neuroimaging revealed multifocal stenosis of the posterior circulation arteries and dissection of the right superior cerebellar artery. She improved significantly throughout her one-week hospitalization and maintained only mild ataxia. The interplay between COVID-19 disease, RCVS, and arterial dissection requires further investigation.Copyright © Author(s) (or their employer(s)) and Sinapse 2022.

The Signaling Pathway of the ADP Receptor P2Y12 in the Immune System: Recent Discoveries and New Challenges.

P2Y12 is a G-protein-coupled receptor that is activated upon ADP binding. Considering its well-established role in platelet activation, blocking P2Y12 has been used as a therapeutic strategy for antiplatelet aggregation in cardiovascular disease patients. However, receptor studies have shown that P2Y12 is functionally expressed not only in platelets and the microglia but also in other cells of the immune system, such as in monocytes, dendritic cells, and T lymphocytes. As a result, studies were carried out investigating whether therapies targeting P2Y12 could also ameliorate inflammatory conditions, such as sepsis, rheumatoid arthritis, neuroinflammation, cancer, COVID-19, atherosclerosis, and diabetes-associated inflammation in animal models and human subjects. This review reports what is known about the expression of P2Y12 in the cells of the immune system and the effect of P2Y12 activation and/or inhibition in inflammatory conditions. Lastly, we will discuss the major problems and challenges in studying this receptor and provide insights on how they can be overcome.

COVID-19 and the Response to Antiplatelet Therapy.

The coronavirus SARS-CoV2 disease (COVID-19) is connected with significant morbidity and mortality (3.4%), disorders in hemostasis, including coagulopathy, activation of platelets, vascular injury, and changes in fibrinolysis, which may be responsible for an increased risk of thromboembolism. Many studies demonstrated relatively high rates of venous and arterial thrombosis related to COVID-19. The incidence of arterial thrombosis in severe/critically ill intensive care unit-admitted COVID-19 patients appears to be around 1%. There are several ways for the activation of platelets and coagulation that may lead to the formation of thrombi, so it is challenging to make a decision about optimal antithrombotic strategy in patients with COVID-19. This article reviews the current knowledge about the role of antiplatelet therapy in patients with COVID-19.

Antiplatelet therapy for patients with COVID-19: Systematic review and meta-analysis of observational studies and randomized controlled trials.

Background: Hyperinflammation and coagulopathy are hallmarks of COVID-19 and synergistically contribute to illness progression. Antiplatelet agents have been proposed as candidate drugs for COVID-19 treatment on the basis of their antithrombotic and anti-inflammatory properties. A systematic review and meta-analysis that included early observational studies and recent randomized controlled trials (RCTs) was performed to summarize and compare evidence on this issue. Methods: PubMed, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify studies published up to Nov 7, 2021, and the results of registered clinical trials were followed up to Mar 30, 2022. We included RCTs and observational studies assessing the effect of antiplatelet therapy in adult patients with COVID-19. Data on baseline patient characteristics, interventions, controls, and outcomes were extracted by two independent reviewers. The primary outcome was mortality. Data were pooled using a random-effects model. Results: Twenty-seven studies were included, of which 23 observational studies were pooled in a meta-analysis, and the remaining four RCTs (ACTIV-4B, RECOVERY, ACTIV-4a, and REMAP-CAP) were narratively synthesized. Based on 23 observational studies of 87,824 COVID-19 patients, antiplatelet treatment favors a lower risk of mortality [odds ratio (OR) 0.72, 95% confidence interval (CI) 0.61-0.85; I 2 = 87.0%, P < 0.01]. The narrative synthesis of RCTs showed conflicting evidence, which did not support adding antiplatelet therapy to the standard care, regardless of the baseline illness severity and concomitant anticoagulation intensity. Conclusion: While the rationale for using antiplatelet treatment in COVID-19 patients is compelling and was supported by the combined result of early observational studies, evidence from RCTs did not confirm this approach. Several factors that could explain this inconsistency were highlighted alongside perspectives on future research directions.

Lower Gastrointestinal Bleeding Management as Per British Society Gastroenterology Guidelines: A Departmental Audit, Pilgrim Hospital

Aim: In 2019, the British Society of Gastroenterology (BSG) published the first United Kingdom national guidelines for acute lower gastrointestinal bleeding (LGIB),(1) following inadequacies in LGIB emergency service provision.(1,2) Method: We performed a retrospective cohort study (January 2019 to September 2020), using paper and electronic notes through coded data, for all LGIB emergency surgical admissions for LGIB. Paper and electronic notes were used, in retrieving data. Primary outcome end-points: evaluate our standards as per BSG guidelines. Result(s): 48 patients were identified as matching the inclusion criteria, with a median age of 64.75 and diverticular diseases accounting for the majority of cases. None of the patients were categorised in the group of being stable/unstable or had their Oakland scores calculated. 62.5% of patients were offered outpatient investigations versus 6.25% for inpatient investigations. 0% of unstable patients were offered a CT angiogram (as no patients were stratified as unstable). 75% of patients achieved haemoglobin target levels post-transfusion. 100% of patients taking warfarin and dual antiplatelets followed guidelines versus 50% on clopidogrel, 80% on dual antiplatelet therapy and 63.6% on aspirin alone. Conclusion(s): This study found that our department did not adhere to the BSG guidelines. This can be improved through the routine calculation of the Oakland score and shock index, which will stratify clinical risk. Additionally creating an agreed trust management pathway and assigning a gastrointestinal bleed lead will allow for earlier detection and encourage better clinical practice. Whilst there were limitations due to restricted data collection, as a result of the coronavirus, further research will identify how these implementations can be amended and if the changes are effective in local practice.

Managing Low and Intermediate Risk Transient Ischemic Attacks in the Time of a Pandemic

Background: Transient Ischemic Attacks (TIA) are both a harbinger of acute ischemic stroke and warrant urgent evaluation and management to reduce stroke risk. Recently, there has been increasing acceptance to evaluate low-risk (ABCD2 score 0-3) patients in an outpatient setting, but there is limited data on management of intermediate (ABCD2 score 4-5) risk patients. We hypothesized that intermediate risk TIA patients being treated according to protocolized medical management and diagnostic testing would have similar clinic follow-up and re- admission rates to low-risk patients. Method(s): An interdisciplinary team developed a standardized emergency department (ED) TIA protocol using ABCD2 scores, vascular/brain imaging, and neurology consultation to identify low and intermediate risk patients safe for discharge (DC) to the outpatient neurology TIA Clinic. Providers were encouraged to start patients on 7 days of dual anti-platelet therapy (Aspirin 81 mg, Plavix 75mg) and high dose statin (Atorvastatin 80 mg) unless contraindicated. A retrospective review of all patient records with a TIA Clinic referral order was performed to determine the number of days from ED discharge to clinic follow-up while trending 30-day readmission rates to any of our facilities during calendar year 2021. The same datapoints were reviewed and compared using Mann-Whitney U, SPSS version 22 for both low and intermediate risk patient populations for the same time interval. Result(s): Following the January 2021 expansion of ABCD2 score criteria from 0 to 5, there were 324 total patients referred to the TIA Clinic. There were 198 low risk patients with ABCD2 scores from 0-3, 78% were seen in clinic, and 22% did not schedule an appointment. There were 126 intermediate risk patients with scores from 4-5, 69% were seen in clinic, and 31% did not schedule an appointment. There was no difference in outpatient follow up rates between low and intermediate groups (p value of 0.616). Only 1% of all referred patients were re-admitted and there was no difference in readmission rates between low and intermediate risk groups. None of the readmissions had acute infarcts on MRI. Conclusion(s): Our multidisciplinary team created a novel emergency-based TIA evaluation protocol with close TIA Clinic follow up which allowed us to risk stratify both low and intermediate risk patients who could be managed in an outpatient setting. There was no significant difference in readmission rates while achieving similar rates of follow up for both low and intermediate risk patients. And with dwindling bed availability during the COVID pandemic, avoiding hospital admission could preserve precious bed space. [Formula presented] No, authors do not have interests to disclose Copyright © 2022

Double Trouble: Interrupting DAPT and COVID-19

Cardiovascular disorders have been described as relevant risk factor for severe COVID infection. Stent thrombosis is a life-threatening complication that may occur subacutely. We present an interesting case of a middle-aged woman who developed acute stent thrombosis while interrupting dual antiplatelet therapy (DAPT) ticagrelor, during an episode of coronavirus disease (COVID-19). In our case, the patient's not-compliance to DAPT, associated with COVID-19 infection and a hyperinflammatory and hypercoagulable state associated with it played a major role in the development of stent thrombosis. The hypercoagulable and hyperinflammatory state associated with COVID-19 has important implications for cardiac patients, especially those undergoing complex coronary intervention, predisposing them to an increased risk of post-PCI complications.

WHEN ST-ELEVATION MYOCARDIAL INFARCTION (STEMI) IS JUST THE BEGINNING: DISSEMINATED INTRAVASCULAR COAGULATION (DIC) FROM COVID-19 INFECTION PRESENTING AS ACUTE MYOCARDIAL INFARCTION

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: COVID-19 is associated with a hypercoagulable state and has been linked with Disseminated Intravascular Coagulation (DIC) [1]. DIC causes systemic thrombosis in micro- and macro- vasculature and in rare instances can involve coronary arteries [2]. In this case report, we present a patient who presented as an ST-segment elevation myocardial infarction (STEMI) and DIC in the setting of severe COVID-19 disease. CASE PRESENTATION: A 46-year-old lady with a history of hypertension presented with acute onset of typical chest pain. She tested positive for COVID-19 infection. Emergency room EKG showed anterior STEMI, and the patient underwent cardiac catheterization via a femoral approach which revealed a 99% stenosis in the proximal LAD, with filling defects consistent with a thrombus. Thrombectomy was performed and three drug-eluting stents were placed in the left anterior descending artery. Following stent placement, the patient went into ventricular fibrillation cardiac arrest followed by PEA. ROSC was attained after 3 rounds of CPR. Labs showed an acute drop in hemoglobin from 14 gm/dL to 5 gm/dL with CT evidence of extensive retroperitoneal bleed, extraperitoneal bleed, and large abdominal aorta thrombus proximal to the bifurcation. Labs were significant for prolonged INR (2.1), PT (23.4 seconds), PTT (106.7 seconds), elevated D-dimer (>4.0), decreased platelets (101K/μl), and increased fibrin split products (80uG/mL) consistent with DIC. The acute aortoiliac occlusive thrombus resulted in acute limb ischemia, rhabdomyolysis causing renal failure, and compartment syndrome requiring bedside fasciotomy. She was treated with triple therapy and demonstrated gradual clinical improvement. DISCUSSION: DIC was a possible precipitant of STEMI in this patient with evidence of thrombotic occlusion of LAD. DIC is a life-threatening coagulopathy characterized by mixed hypo- and hypercoagulation. This often leads to a systemic distribution of clots, evidenced by thrombi present in the coronary and aortoiliac arteries. Historically, bacterial sepsis was more strongly linked with DIC than viral causes;however, there has been an increasing amount of evidence linking COVID-19 with DIC, likely due to the severity of the illness. In this patient with recent stent placement, large aortic thrombus, and extensive retroperitoneal bleed, management was complicated by need for dual antiplatelet therapy for drug-eluting stents as well as anticoagulation for acute limb ischemia. Another diagnosis to keep in the differential includes heparin-induced thrombocytopenia, characterized by similar findings to DIC, but is associated with antibodies against platelet factor 4, which was not found in our patient. CONCLUSIONS: In this case, a young female patient without traditional cardiac risk factors was found to have an anterior STEMI, likely precipitated by DIC as a complication of COVID-19 infection. Reference #1: Asakura, Hidesaku, and Haruhiko Ogawa. "COVID-19-associated coagulopathy and disseminated intravascular coagulation.” International journal of hematology vol. 113,1 (2021): 45-57. doi:10.1007/s12185-020-03029-y Reference #2: M. Sugiura, K. Hiraoka, and S. Ohkawa, "A clinicopathological study on cardiac lesions in 64 cases of disseminated intravascular coagulation,” Japanese Heart Journal, vol. 18, no. 1, pp. 57–69, 1977. DISCLOSURES: No relevant relationships by radhika deshpande No relevant relationships by Shruti Hegde No relevant relationships by Robert Kropp No relevant relationships by Prashanth Singanallur

Incidence and Outcomes of Clinically Significant Bleeding Events in Critically Ill Covid-19 Patients Receiving Therapeutic Dose Anticoagulants: A Retrospective Cohort Study (Interact Study)

Aim and background: The high mortality associated with the thrombotic events in hospitalised COVID-19 patients resulted in the usage of anticoagulants in varying doses. Whether the high-dose anticoagulants have led to better outcomes or higher incidence of clinically significant bleeding events is still debatable. Objectives: To find the incidence of clinically significant bleeding events in moderate to severe COVID-19 patients on therapeutic anticoagulation and the factors influencing these events. Materials and methods: In our retrospective, single-centre, cohort study of 155 critically ill COVID-19 patients we observed the incidence of clinically significant bleeding. Multivariate regression models were used to evaluate the association between anticoagulant regimen, coagulation, and inflammatory markers with the incidence of bleeding and thrombotic events. Results: The incidence of Clinically Relevant Non-Major Bleeding (CRNMB) was 33.5% (26.17-41.46%,) and major bleeding was 9.03% (5.02-14.69%). The anticoagulation intensity at baseline had a very high odds of major bleeding when Enoxaparin and dual antiplatelet therapy were used together (adjusted OR of 434.09 [3.81-49502.95], p < 0.05). At admission, bleeders had a poorer P/F ratio with more patients on invasive ventilation. At the time of bleeding, the bleeders had a higher d-dimer, ferritin, CRP, and procalcitonin. The subhazard ratio (SHR) for death in bleeders was 3.35 (95% CI, 1.97-5.65;p < 0.001). Conclusion: The incidence of bleeding in critically ill COVID-19 patients on therapeutic anticoagulation increases with the severity of the disease as well as with concurrent use of dual antiplatelets. Major bleeding may also contribute to higher mortality.

Severe Hypertriglyceridemia as a Cause of Arterial Thrombosis with Peripheral Embolic Complications

Lead Author's Financial Disclosures: Nothing to disclose. Study Funding: None. Background/Synopsis: Extensive evidence exists in support of a causal association of elevated triglyceride-rich lipoprotein (TRL) levels with the risk of atherosclerosis progression. Hypertriglyceridemia has been established as a risk factor for venous thrombosis, including a 2- fold increase in the risk of venous thrombosis in postmenopausal women. However, there is limited data on the role of hypertriglyceridemia in the arterial thrombosis. Objective/Purpose: Not Applicable. Methods: Case description: A 51-year-old white female with hypertension and type 2 diabetes (hemoglobin A1C, 7.4%) was transferred for further management of newly diagnosed bilateral renal and splenic infarcts. No risky habits were elicited except for the use of combined hormonal contraceptives over the past two years to control menorrhagia. Family history was significant for hypertriglyceridemia. Her physical exam was unremarkable. Testing for COVID-19 was negative. An extensive hypercoagulable and autoimmune work-up was unremarkable. Fasting lipid profile was significant for elevated levels of triglycerides, 1,274 mg/dL (replicated on two separate occasions), very low-density lipoprotein-cholesterol, 255 mg/dL, and non-high-density lipoprotein-cholesterol, 214 mg/dL, directly measured low-density lipoprotein cholesterol, 39 mg/dL and lipoprotein(a), 6 mg/dL. There was no structural pathology on the echocardiogram, including no interatrial shunt or intracardiac thrombus. Her whole-body computed tomography angiography revealed a focal calcified protruding thrombus in the distal thoracic aorta. No significant plaque was seen elsewhere in the aorta. Results: Decision-making. The posterior thrombus in the distal thoracic and proximal abdominal aorta was determined as a culprit for the visceral organ infarcts. Over the course of the hospital stay her abdominal pain gradually resolved. Treatment with low dose aspirin and therapeutic dose of low-molecular weight heparin was initiated followed by apixaban and aspirin on discharge. She was started on atorvastatin 40 mg, fenofibrate 145 mg, icosapent ethyl 4 g, resulting in a 70% reduction in the triglycerides levels (306 mg/dL). In 3 months, her repeat CT angiography showed significant resolution of the aortic atherothrombosis with no signs of aortic wall inflammation. At the 6-month follow-up visit she was switched to dual antiplatelet therapy with a plan to repeat imaging in 6 months. Conclusions: This case illustrates challenges in managing patients with arterial thrombosis in the setting of familial hypertriglyceridemia. Apart from severely elevated triglycerides no other etiology was evident. We propose further investigation of the prothrombotic properties of TRL and the role of targeted triglyceride-lowering therapies on atherothrombotic outcomes.

Retroperitoneal Hemorrhage in Patients with COVID-19 Undergoing Hemodialysis: Three Case Reports.

A 73-year-old man receiving hemodialysis and antiplatelets was admitted with a mild case of COVID-19. Heparin was added, and iliopsoas hemorrhage developed. He was successfully treated by interventional radiology. A 76-year-old man receiving hemodialysis and antiplatelets was admitted with mild COVID-19. Heparin was added, and iliacus hemorrhage developed. Despite heparin discontinuation, he died of worsening pneumonia. A 74-year-old man undergoing hemodialysis was admitted with severe COVID-19. Gastrointestinal bleeding developed during continuous hemodiafiltration with heparin. Upon switching to nafamostat and increasing the dose, iliopsoas hemorrhage developed. Despite interventional radiology, he died of infectious complications. Attention to hemorrhagic complications is therefore needed in patients with COVID-19.

Aspirin Therapy on Prophylactic Anticoagulation for Patients Hospitalized With COVID-19: A Propensity Score-Matched Cohort Analysis of the HOPE-COVID-19 Registry.

Background COVID-19 is an infectious illness, featured by an increased risk of thromboembolism. However, no standard antithrombotic therapy is currently recommended for patients hospitalized with COVID-19. The aim of this study was to evaluate safety and efficacy of additional therapy with aspirin over prophylactic anticoagulation (PAC) in patients hospitalized with COVID-19 and its impact on survival. Methods and Results A total of 8168 patients hospitalized for COVID-19 were enrolled in a multicenter-international prospective registry (HOPE COVID-19). Clinical data and in-hospital complications, including mortality, were recorded. Study population included patients treated with PAC or with PAC and aspirin. A comparison of clinical outcomes between patients treated with PAC versus PAC and aspirin was performed using an adjusted analysis with propensity score matching. Of 7824 patients with complete data, 360 (4.6%) received PAC and aspirin and 2949 (37.6%) PAC. Propensity-score matching yielded 298 patients from each group. In the propensity score-matched population, cumulative incidence of in-hospital mortality was lower in patients treated with PAC and aspirin versus PAC (15% versus 21%, Log Rank P=0.01). At multivariable analysis in propensity matched population of patients with COVID-19, including age, sex, hypertension, diabetes, kidney failure, and invasive ventilation, aspirin treatment was associated with lower risk of in-hospital mortality (hazard ratio [HR], 0.62; [95% CI 0.42-0.92], P=0.018). Conclusions Combination PAC and aspirin was associated with lower mortality risk among patients hospitalized with COVID-19 in a propensity score matched population compared to PAC alone.

Endovascular Procedure in Patient with Ruptured Abdominal Aortic Aneurysm after High-Risk Early Percutaneous Coronary Intervention

Purpose The aim of the study is to present the success of an endovascular procedure for ruptured abdominal aortic aneurysm (AAA) patient with high-risk non-ST elevation myocardial infarct (NSTEMI) after early percutaneous coronary intervention (PCI). Case Report A 56-year-old man came to our emergency room with a history of early PCI in the previous hospital and received dual antiplatelet therapy (DAPT). His COVID-19 test result was unknown. This patient was then being re-examined and was diagnosed with ruptured AAA. Despite his pending COVID-19 laboratory results, we decided to perform an urgent endovascular aortic repair (EVAR) in this patient, considering his DAPT consumption history. The procedure was successful and the patient's condition after EVAR showed improvements. Conclusion In patients with ruptured AAA with high-risk NSTEMI who just underwent early PCI and recently received DAPT, endovascular procedure can be considered as the treatment of choice since open surgery repair is contraindicated.

VERY LATE STENT THROMBOSIS AFTER JOHNSON & JOHNSON/JANSSEN VACCINATION

Background: Stent thrombosis (ST) is a dreaded complication of percutaneous coronary intervention (PCI), however incidence has been declining with improvement in stent design and pharmacological treatments. While ST can occur at any time after placement of a stent, the rate of ST declines as time from implantation progresses. Case: A 54 year-old man with a history of hypertension, hyperlipidemia, type two diabetes mellitus and coronary artery disease status PCI to the left anterior descending artery (LAD) six years prior presented with substernal chest discomfort for three hours. Vital signs were within normal limits, and his electrocardiogram showed two-to-three-millimeter ST elevation across the precordial leads with reciprocal ST depressions. He was brought emergently to the cardiac catheterization lab where coronary angiography revealed a large thrombus within the previously placed LAD stent. The patient underwent aspiration thrombectomy, balloon angioplasty and stenting of the LAD. The patient was discharged in good condition on dual-antiplatelet therapy three days after his presentation. Decision-making: Since the beginning of the COVID-19 pandemic, physicians on the front lines have been learning more and more about the virus including prevention and treatment. In a stunning collaboration of science and enterprise, several vaccines were created including the Johnson & Johnson/Janssen (J&J) single dose COVID-19 immunization. However, although effective at preventing serious COVID-19 infections, anecdotal evidence of thrombotic events has been reported. Given this patient's thrombotic event, a hypercoagulable workup was undertaken but unrevealing. Conclusion: We describe a case of very late ST of a six year-old drug eluting stent occurring three weeks after the patient received a J&J COVID-19 vaccine. While temporally the timing of the stent thrombosis is surprising and possibly related, this is yet another case to add to the body of evidence as we learn more about the 2019 Novel Coronavirus and the COVID-19 vaccines as we navigate this pandemic together.

Double Whammy: Subacute Stent Thrombosis While Being Adherent to Dual Antiplatelet Therapy Including Ticagrelor, Followed by Multiple Coronary Artery Aneurysms in a COVID-19 Patient.

Coronavirus disease 2019 (COVID-19), although predominantly a respiratory illness, can have important cardiovascular implications, which include the development of myocardial injury/myocarditis, acute coronary syndromes, arrhythmias, pericarditis, and the occurrence of arterial and venous thrombosis. We describe a rare case of a middle-aged COVID-19 patient who developed sub-acute stent thrombosis after implantation of second-generation drug-eluting stents (DES) despite being adherent to dual antiplatelet therapy including ticagrelor and who subsequently developed multiple coronary artery aneurysms within a few weeks of the DES implantation.

An uncommon cause of ischemic strokeintracranial internal carotid artery dissection

Background Intracranial internal carotid artery (ICA) dissection is a spontaneous or trauma-induced cause of stroke. Intracranial dissections, less common than extracranial, affect younger age groups and cause larger strokes. Case presentation 47-year-old female with a past medical history of poorly controlled type two diabetes, hypertension, and nicotine dependence presented to the emergency department with over twelve hours of left-sided weakness. With no known trauma, she woke up from a nap the day prior with weakness that has progressed, prompting her visit to the hospital. She denied paresthesia, dysarthria, shortness of breath, or chest pain but had bifrontal headache. On examination, she had left-sided hemiparesis with a right-sided gaze preference. Initial CT without contrast demonstrated evolving infarct. MRI revealed multifocal infarcts involving right parietal cortex, deep white matter and basal ganglia. Carotid Doppler showed 100% occlusion of the right ICA. CTA of head revealed asymmetric narrowing of the right cervical ICA thought to represent proximal propagation of the dissection into cavernous sinus without visible dissection flap. Attempts to transfer to a higher center in surrounding area hospitals for neuroradiological intervention were unsuccessful because of lack of ICU beds due to occupation with high numbers of COVID 19. Anticoagulation therapy was withheld due to large area of acute stroke and risk of hemorrhagic conversion. Dual antiplatelet therapy with aspirin and clopidogrel was started and high dose statin. Frequent neurological examinations were performed throughout her hospital stay;however, she remained stable and was discharged with home health and outpatient physical therapy. Workup for genetic risk factors for dissection remained negative. The patient was counseled on the importance of smoking cessation and chronic care management to reduce her risk of future events. Discussion ICA dissection accounts for 2.5% of all strokes and 20% of strokes in patients under 40. Most notably, over 80% of dissection cases are due to trauma, connective tissue, or vascular disorders. Other risk factors associated with dissection include, but are not limited to, recent infection, hypertension, and smoking. Dissections result in separation between arterial wall layers creating an intramural hematoma. Enlarged thrombus formation may lead to TIA or ischemic stroke. Rupture of the hematoma may lead to subarachnoid hemorrhage. Non-contrast head CT with CTA of the head and neck is the high sensitivity imaging modality of choice. Standard approach to stroke treatment is followed for patients presenting with ischemic stroke or TIA. Antithrombotic or anticoagulation treatment is acceptable for extracranial dissection. Antiplatelet therapy and/or surgical interventions are preferred for intracranial dissections. Repeat neurovascular imaging is recommended three to six months after initial event to assess the status of dissection.

Antiplatelet therapy and covid-19 outcomes in patients with stable coronary artery disease

Introduction: Severe COVID-19 can cause acute respiratory distress syndrome (ARDS), with pulmonary pathology composed of platelet microthrombi. Antiplatelet agents have been investigated as a treatment in ARDS, but without clear evidence of benefit. The decision on antiplatelet use in patients with COVID-19 and coronary artery disease (CAD) is key. Hypothesis: We assessed the hypothesis that increased use of antiplatelet therapy was associated with no worse clinical outcomes in COVID-19 among adults with stable CAD. Methods: We performed a retrospective cohort study of patients who presented with COVID-19 to two New York City hospitals from March 3 to May 15, 2020. Patients were separated into groups based on antiplatelet use, including no outpatient antiplatelet use, monotherapy, and dual antiplatelet therapy (DAPT). Outcomes and complications were compared among the groups, using propensity scoring with inverse probability of treatment weighting. Results: This study included 315 patients with stable CAD and COVID-19. Patients on no outpatient antiplatelet therapy were significantly older and more likely to be taking anticoagulation, while patients on DAPT had the highest rates of diabetes and chronic kidney disease. The most prescribed antiplatelet in the cohort was aspirin (72.1%) followed by clopidogrel (22.5%). There was no difference in COVID-19 admission mortality between the DAPT and monotherapy groups (DAPT 27.9%, monotherapy 27.2%, p=NS). Patients on DAPT had decreased rates of venous thromboembolism compared to monotherapy (DAPT 0.0%, monotherapy 6.4%, p=0.01), and bleeding rates were similar. The rate of home monotherapy continuation in hospital was 79.9%, with the most common reasons for discontinuation being hemorrhage, anemia, and thrombocytopenia. No outpatient antiplatelet use was a high-risk group, with the highest rates of intensive care admissions, intubations and mortality. Conclusions: In conclusion, we found no difference in COVID-19 outcomes for CAD patients on DAPT compared to those on monotherapy. There were decreased clotting complications in patients on more antiplatelet therapy, while bleeding rates were similar. No outpatient antiplatelet use was found to be a high-risk group in COVID-19.