Probable trombosis de stent, resistencia al clopidogrel y fibrinólisis exitosa / Probable stent thrombosis, nonresponsiveness to clopidogrel and successful fibrinolysis

RESUMEN

La doble terapia antiagregante plaquetaria con ácido acetilsalicílico y clopidogrel es uno de los tratamientos utilizados en la intervención coronaria percutánea (ICP) con colocación de stent. La trombosis del stent (TS) puede ocurrir por diversas causas, una de ellas es la falta de respuesta al clopidogrel. La incidencia de la TS es aparentemente baja (0,5%-2%), pero no tiene un impacto clínico mayor, debido al alto riesgo de infarto de miocardio y muerte. Se reporta una mortalidad hasta de 45%. Se presenta el caso de un paciente que ingresó con diagnóstico de infarto de miocardio agudo sin elevación del segmento ST, que fue revascularizado exitosamente mediante ICP, con implante de tres stents metálicos y tratado inicialmente con ácido acetilsalicílico y ticagrelor, durante su hospitalización, hasta su alta, cuando se pasó a clopidogrel. Reingresó con reinfarto agudo de miocardio y elevación del segmento ST, y se le sometió a fibrinólisis exitosamente. No hubo evidencia de trombosis en la coronariografía de control y se reinició ticagrelor.

ABSTRACT

Dual antiplatelet therapy with aspirin and clopidogrel is the standard treatment for patients who undergo a percutaneous coronary intervention (PCI) with stent placement. Stent thrombosis, however, also can occur in patients treated with aspirin and clopidogrel, suggesting that platelet aggregation non responsiveness to clopidogrel could be one of the causes. The incidence of stent thrombosis is apparently low to 0,5-2,0%, but stent thrombosis has a major clinical impact owing to a high risk of myocardial infarction and death. Mortality due to stent thrombosis has bee reported to be as high as 45%. We report a patient, diagnosed with acute myocardial infarction without ST-segment elevation that was revascularized successfully with PCI and three bare metal stents. He was initially treated with ticagrelor and aspirin during hospitalization until discharge when he was switched to clopidogrel. The patient was readmitted with a new myocardial reinfarction and ST elevation, he received fibrinolysis successfully. There was no evidence of thrombosis in coronary angiography follow up and ticagrelor was restarted.