Case Series Hints at Excess Stent Thrombosis During COVID-19

Debra L. Beck

June 09, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

A group of interventional cardiologists from Spain have published details on a series of four cases of stent thrombosis (ST) in patients with COVID-19 seen at their hospital.

One case was an acute ST and the other three were very late ST cases. Ages ranged from 49 to 86 years, and all four patients were male. The three late ST cases initially received stents in 2005, 2007, and 2018, respectively.

One patient tested positive for SARS-CoV-2, one was presumed positive based on symptoms and chest x-ray findings, and the last two tested positive for antibodies.

"In 2019, we performed 899 PCIs (percutaneous coronary interventions) with 11 being due to stent thrombosis — 3 were acute ST and 8 were very late ST. This incidence is much lower than what we have seen during the COVID-19 outbreak," said Juan G. Córdoba Soriano, MD, in an email exchange with theheart.org | Medscape Cardiology.

"The patients had some risk factors for ST, but not too much, so we think that taking into consideration that this infection generates a prothrombotic state, it could play a role of trigger in some predisposed patients," said Córdoba Soriano.

The paper was published online May 28 in JACC Case Reports.

The researchers, including first author Alicia Prieto-Lobato, MD, are from the Complejo Hospitalario Universitario de Albacete. The hospital is a public hospital located in the Spanish city ​​of Albacete and a primary referral center for the region.

The authors suggest that these cases are related to virus-related hypercoagulability triggering thrombotic complications. "Pathophysiologically, the cytokine storm that occurs 5-7 days after the onset of symptoms promotes the coagulation cascade, as well as platelet activation mediated by interleukin-6 and tissue factors," Córdoba Soriano et al write.

As well, endothelial damaged possibly caused by viral binding to the angiotensin converting enzyme receptor and blood stasis promoted by inflammation, might complete the Virchow's triad predisposing to thrombotic complications.

A Signal, Not a Reason to Panic

"We only describe our experience, and we do not want to create alarm," Córdoba Soriano stressed in emailed comments.

He added that a case series is weak evidence, but can highlight a need for higher-level data. His group is participating in a multicenter registry of ST in COVID-19 patients, results from which he hopes will be published soon.

"I'm not surprised by these cases, but I don't think the numbers are there to say that stent thrombosis is increased out of proportion in COVID-19," said George Dangas, MD, PhD, from the Icahn School of Medicine at Mount Sinai, New York City.

"Stent thrombosis is traditionally a very rare event, so it's hard to systematically study, so a cluster report like this one from Spain is useful. Maybe if we see other cluster reports are popping up, we can say more at that time," he added.

Dangas said that in his hospital they are being more vigilant with thromboprophylaxis and checking for clotting risk in patients with COVID-19 and others coming in to the hospital over the past month or so.

For his part, Córdoba Soriano said this about how he's changed his management of patients during the pandemic:

"At the beginning of the pandemic, protocols called for switching or withdrawal of P2Y12 inhibitors in COVID-19 patients treated with some antivirals due to the possible interactions. Our aim with this paper is to highlight the need to be more precise in detecting patients with a higher risk of ST and to be demanding with the result of the angioplasty, with greater use of intracoronary imaging techniques and a potent antiplatelet regimen, which in the setting of acute coronary syndrome should be prioritized over antiviral treatments against SARS-CoV-2 that have questionable effectiveness."

The acute case was in a 49-year-old who presented with a lateral ST-segment elevation myocardial infarction 6 hours after symptom onset. To decrease hospital length of stay, ad hoc PCI was performed in the circumflex artery with two overlapped drug-eluting stents.

Thirty minutes later, there was new onset chest pain with marked ST-segment depression and an acute circumflex artery ST was confirmed by repeat angiography. Imaging demonstrated in-stent mixed thrombus and mild stent under-expansion. The patient was treated with tirofiban and proximal overexpansion of the stent was performed.

The authors have disclosed no relevant financial relationships.

JACC Case Rep. Published online May 28, 2020. Article

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