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Letter to the Editor
Massive coronary thrombosis: An atypical presentation of antiphospholipid syndrome
Trombosis coronaria masiva: una presentación atípica del síndrome antifosfolipídico
Pablo Vadillo Martína,
Corresponding author
pablovadillomartin@gmail.com

Corresponding author.
, Pablo Pastor Pueyob, Kristian Riverab
a Servicio de Cardiología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
b Servicio de Cardiología, Hospital Universitari Arnau de Vilanova, Institut de Reserca Biomèdica de Lleida (IRBLleida), Lleida, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Antiphospholipid syndrome &#40;APS&#41; is an autoimmune disorder characterised by recurrent vascular thrombosis in patients with persistently positive antiphospholipid antibodies &#40;APA&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> Thrombosis&#44; the defining feature of this disease&#44; occurs in any vascular site&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> and may occur in the coronary arteries in a minority of cases&#46; However&#44; acute myocardial infarction as the first manifestation of this syndrome and&#44; moreover&#44; simultaneous thrombosis of all three coronary arteries is a rare event&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 60-year-old male&#44; obese and an ex-smoker&#59; with a history of positive lupus anticoagulant antibodies in two determinations separated by more than 12 months &#40;strongly positive lupus anticoagulant&#59; anti-beta2-GP Ab &#40;IgG&#41; 138 - 99 U&#47;ml&#41;&#44; following screening for a diagnosis of pulmonary thromboembolism in a first-degree relative&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">He attended the emergency department for chest pain suggestive of angina&#44; with an electrocardiogram documenting ST-segment elevation in inferior leads and specular decrease in lateral leads &#40;Image 1A&#41;&#46; Dual antiplatelet therapy &#40;DAPT&#41; with acetylsalicylic acid &#40;ASA&#41; and prasugrel was initiated&#46; Emergency coronary angiography showed atherosclerotic disease with lesions of mild-moderate severity in the middle anterior descending coronary artery&#44; first obtuse marginal branch and in the middle right coronary artery &#40;RCA&#41;&#44; with significant thrombotic burden in all three arteries&#44; although more abundant in the RCA&#44; which was partially occluded &#40;Image 1B&#8211;D&#41;&#46; Percutaneous coronary intervention was performed on the RCA with manual thrombus aspiration and implantation of a sirolimus-eluting stent&#44; with normal electrocardiogram and resolution of symptoms&#46; Subsequently&#44; he was admitted to the Cardiac Critical Care Unit with DAPT and enoxaparin at therapeutic doses&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Six hours after admission&#44; he experienced a new episode of chest pain with ST-segment elevation in inferior leads&#44; with incipient signs of cardiogenic shock&#46; A new coronary angiography revealed acute stent thrombosis &#40;AST&#41;&#44; and mechanical aspiration thrombectomy was performed&#44; resulting in a significant thrombotic load &#40;Image 1E&#41; and intracoronary fibrinolysis with Tenecteplase &#40;25<span class="elsevierStyleHsp" style=""></span>mg&#41; due to persistence of the thrombotic load&#44; with normal RCA flow &#40;Image 1F&#41;&#44; with no evidence of technical causes related to AST and with very distal embolisation of the posterolateral branch&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In view of the thrombotic event&#44; in addition to the history of persistently positive lupus anticoagulant&#44; in conjunction with Internal Medicine and Haematology&#44; a diagnosis of definite APS was made&#44; classified as primary when its association with other autoimmune diseases was ruled out&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Due to the severity of the patient&#39;s condition and early thrombotic recurrence it was decided to manage as a catastrophic APS &#40;CAPS&#41;&#44; despite not fulfilling the diagnostic criteria&#46; Therefore&#44; treatment was started with unfractionated heparin&#44; high doses of glucocorticoids &#40;methylprednisone 500<span class="elsevierStyleHsp" style=""></span>mg for three days with subsequent de-escalation to oral prednisone 60<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#41;&#44; plasmapheresis &#40;six sessions&#41; with administration of immunoglobulins &#40;180<span class="elsevierStyleHsp" style=""></span>mg divided into five doses interspersed with the plasma exchanges&#41; and cyclophosphamide &#40;1<span class="elsevierStyleHsp" style=""></span>g&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient had a favourable outcome&#44; with no new thrombotic events&#46; Once treatment was completed&#44; he was discharged with chronic oral vitamin K antagonist anticoagulants and temporary dual antiplatelet therapy with ASA and clopidogrel&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">APS is a prothrombotic disease for which the optimal treatment has not yet been fully established&#46; One of the most morbid and fatal presentations of this syndrome is CAPS&#46; There are cases of APS that do not meet the criteria for definite or probable APS&#44; but due to their presentation and need for aggressive treatment&#44; they are considered to be similar to CAPS&#44; such as the case reported&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Simultaneous multiple coronary artery thrombosis as an initial presentation of APS is rare&#46; Depending on the clinical presentation&#44; the diagnosis can be complex and a high degree of suspicion is required&#46; In cases of diagnostic uncertainty&#44; intracoronary imaging techniques may provide additional value in confirming the presence and extent of thrombi&#44; identifying the culprit lesion and establishing or ruling out concomitant atherosclerotic disease&#46; In case of percutaneous coronary intervention with stent implantation&#44; the addition of DAPT treatment during the first months should be considered&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Finally&#44; a multidisciplinary approach involving specialists from cardiology&#44; internal medicine&#44; rheumatology and haematology is essential due to the complexity involved in treating this serious condition&#46;</p></span>"
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