CONGRESS ABSTRACT

Background In the concomitant management of coronary artery disease and atrial fibrillation, the choice of an antithrombotic strategy balancing ischemic and bleeding risks represents a therapeutic dilemma. Current guidelines recommend triple antithrombotic therapy followed by dual antithrombotic therapy, in which clopidogrel is the P2Y12 inhibitor of choice, discouraging the use of more potent agents such as ticagrelor or prasugrel due to excessive bleeding risk. However, the guidelines do not provide standardized decision-making pathways that consider clopidogrel resistance and in-stent thrombosis. Case summary We report the case of a 70-year-old dyslipidemic patient who presented with extertional dyspnea and severe left ventricular dysfunction (LVEF 22%). Coronary angiography revealed a significant bifurcation lesion involving the left anterior descending artery (LAD) and the second diagonal branch (D2). After initiation of dual antiplatelet therapy with aspirin and clopidogrel, the patient underwent PCI with two drug-eluting stent (DES) implantation by step mini-crush technique, intraprocedurally complicated by endoluminal thrombosis, resolved by DES post-dilatation and implantation of an additional DES in the mid-LAD. Given the high thrombotic risk related to procedural complexity, tirofiban infusion was started. However, the patient developed recurrent chest pain with ST-segment elevation a few hours later. Repeat coronary angiography documented recurrent acute in-stent thrombosis, successfully treated by re-PCI with plain old balloon angioplasty (POBA). Suspecting clopidogrel resistance, therapy was switched to prasugrel. The clinical course was further complicated by the onset of atrial fibrillation. Given the patient’s high thrombotic risk and low bleeding risk, triple antithrombotic therapy with unfractionated heparin, aspirin and prasugrel was chosen, with no further events during hospitalization. Conclusions This case falls within an evidence gap: the need for triple antithrombotic therapy in the presence of suspected clopidogrel failure. Although guidelines recommend clopidogrel in triple therapy to reduce bleeding risk, suspected clopidogrel resistance associated with very high ischemic risk and low bleeding risk prompted the use of triple therapy with aspirin and prasugrel. This case highlights how, in selected patients, the use of prasugrel within triple antithrombotic therapy may represent a necessary rescue strategy.