Associazione Nazionale Medici Cardiologi Ospedalieri

CONGRESS ABSTRACT

CONGRESS ABSTRACT

DISCONTINUING DAPT: NOT JUST A MATTER OF SCORES BUT OF INTEGRATED EVALUATION? A KEY ROLE OF IMAGING IN A COMPLEX SCENARIO

Tamborrino Pietro Paolo Pisa(PI) – Cardiology 1, Azienda Ospedaliero Universitaria Pisana, University of Pisa | Vitale Carlo Pisa(PI) – Cardiology 1, Azienda Ospedaliero Universitaria Pisana, University of Pisa | Angelillis Marco Pisa(PI) – Interventional Cardiology, Azienda Ospedaliero Universitaria Pisana

The duration of the dual antiplatelet therapy (DAPT) is a widely debated topic within the scientific community. The latest guidelines on acute coronary syndromes have supported the possibility of different therapeutic approaches tailored to patient characteristics. However, the clinical cardiologist ‘s decisions are not always based on certain principles. The following case report is a practical example.

Discussion: A 31-years-old man came to our attention after a resuscitated cardiac arrest due to ventricular fibrillation during a motorcycle race. His history was characterized by a previous acute myocardial infarction at the age of thirteen due to a traumatic dissection of the proximal left anterior descending (LAD) coronary artery and ascending aorta treated conservatively, with residual transmural necrosis of the mid and subendocardial anterior wall on cardiac MRI. At the admission, ECG showed ST-segment elevation in the anterior leads. Coronary angiography revealed occlusion of the proximal LAD coronary artery, treated with drug-eluting stent (ONYX 5.0 mm), with evidence of dissection and aneurysmal wall of that segment. The patient started a DAPT with aspirin and prasugrel. At discharge, echocardiogram evidenced a moderate left ventricular dysfunction (ejection fraction 34%) with signs of anterior and apical necrosis. Later, the patient was admitted for a subcutaneous defibrillator implantation, due to persistent moderate ventricular dysfunction. One year after revascularization, a lifelong DAPT strategy with downgrading to clopidogrel was considered the best choice for the following considerations: the young age of the patient, the low bleeding risk (PRECISE DAPT score 8), a not elevated DAPT score (value 2), the revascularization in the aneurysmal segment without an appropriate stent apposition (due to absence of a right sizing) and the previous dissection with sign of partial thrombosis at coronary CT.

Conclusions: The anatomical complexity of angioplasty procedures and the delicate balance between ischemic and thrombotic risks have led to continuously evolving therapeutic strategies. The clinical scores currently available cannot often account for complex coronary anatomy. Thus, it ‘s essential to consider a personalized approach, individualized on clinical and imaging characteristics, that encompasses ischemic and bleeding risk and procedural data for the appropriate treatment for each patient.