Stent Thrombosis May Be Presenting Feature of COVID-19

Stent thrombosis may be another hallmark presentation of COVID-19, Spanish investigators say, warning that any suspected cases require intracoronary imaging and intensive antiplatelet therapy.

In a case series published online ahead of print in JACC: Case Reports late last month, Alicia Prieto-Lobato, MD (Complejo Hospitalario Universitario de Albacete, Spain), and colleagues describe four patients from their institution who presented with stent thrombosis.

Prior studies have established a link between the cytokine storm that occurs with SARS-CoV-2 infection and hypercoagulability and thrombosis, so it’s not a big leap to imagine that COVID-19 might adversely affect stents even years after implantation, the investigators say.

“We had the subjective feeling that presentation of patients with stent thrombosis was higher than expected according with our experience in normal conditions,” senior author Juan Córdoba-Soriano, MD (Complejo Hospitalario Universitario de Albacete), told TCTMD in an email. “We decided to share our experience in order to highlight some interesting points: the prothrombotic state created by the infection, the need to be demanding with the result of the angioplasty in patients at higher risk for stent thrombosis, and the use [of] potent antiplatelet [therapy] over drugs without robust evidence for COVID treatment.”

Once a more common complication, stent thrombosis now affects less than 1% of patients within 30 days, and the annual incidence of late and very late events is 0.5% to 1% and 0.2% to 2%, respectively.

“We don´t want to create alarm,” Córdoba-Soriano said. “The risk is low, we think. In our center we had near 2,000 COVID-19 patients and only four cases of stent thrombosis, but it is certain that it is a higher incidence than expected.”

Four Cases

Investigators describe in detail both the cardiovascular disease history and COVID-19-related symptoms of four patients who presented with stent thrombosis—one acute and three very late.

• Following primary PCI in a 49-year-old man, acute stent thrombosis in the circumflex artery was confirmed by repeat angiography and he was treated with intracoronary tirofiban as well as with proximal stent overexpansion. The patient received aspirin, ticagrelor, and a continuous infusion of tirofiban, but was not tested in the hospital for COVID-19 despite a dry cough and indicative chest X-ray. He was sent home after 4 days and was confirmed positive for SARS-CoV-2 at 23 days based on serology testing.
• A 71-year-old man, who had been implanted with a DES in his right coronary artery in 2007 following a STEMI, was admitted with symptoms of NSTEMI due to stent thrombosis. He was successfully treated with thrombectomy, tirofiban, and two additional DES. The patient was not tested for COVID-19 but had clinical symptoms, chest X-ray findings, and subsequent serology testing compatible with COVID-19 infection.
• After left anterior descending artery DES implantation for NSTEMI in 2018, an 86-year-old man presented with stent thrombosis and a new DES was successfully put in place. He was asymptomatic but was confirmed to have COVID-19 through a preadmission polymerase chain reaction (PCR) test and was discharged after 5 days.
• An 85-year-old man who underwent PCI with DES implantation in 2005 presented with chest pain, LVEF 30%, and anterior ST-segment elevation with prior Q waves. Despite being asymptomatic, the patient had a positive IgM blood test. The stent thrombosis found on angiography was treated with balloon angioplasty, thrombectomy, and tirofiban. After treatment with lopinavir-ritonavir, aspirin, prasugrel (replaced with clopidogrel after 10 days), and antivirals, the patient was discharged.

Toward the beginning of the pandemic, protocols were put in place to switch or withdraw P2Y12 inhibitors in COVID-19 patients treated with some antivirals due to possible drug-drug interactions, Córdoba-Soriano said. “Our aim with this paper is to highlight the need to be more precise in detecting patients with higher risk for stent thrombosis and to be demanding with the result of the angioplasty, with greater use of intracoronary imaging techniques and potent antiplatelet regimen, for example, and to [prescribe] antiplatelet therapy over drugs without robust evidence for the virus treatment,” he continued.

While patients with COVID-19 and stent thrombosis today should not be managed any differently than uninfected patients, Córdoba-Soriano advised that “intracoronary imaging must be mandatory in all stent thrombosis cases to know the cause, but probably more intensive or aggressive antiplatelet therapy [is needed] despite mechanical risk factors detected or in case of doubt due to bleeding risk.”

An ongoing Spanish multicenter registry will help answer more immediate questions about stent thrombosis and COVID-19, but “an international multicenter registry will be useful” as well, he said.