CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 6, November/December 2022 332 AFRICA ST is an uncommon complication following percutaneous coronary intervention (PCI), affecting less than 1% of implants at 30 days.5 The low incidence is in contrast to the extremely high 30-day mortality rates, approaching 45%, in those affected.6 COVID-19 has modified the usual presentation of many diseases and ST is increasingly being recognised as a feature. In all reported cases, standard PCI protocols had been adhered to, but it appears that the hypercoagulable state still places patients at higher risk.7 To our knowledge, this is the first reported case of two stents thrombosing simultaneously. No published guidelines advise on the management of anticoagulant therapy in the setting of ST or COVID-19. A recent publication reviewed some aspects of antithrombotic therapy in acute coronary syndrome/COVID-19 but no specific reference to ST was made.8 Our recommendation would be: PCI results should be optimised with the liberal use of intravascular imaging techniques to mitigate any modifiable factors that are considered risk factors for ST. Additionally, drugs that induce the CYP3A4 system should be avoided. High-potency P2Y12 inhibitors (preferably prasugrel) should be favoured over clopidogrel because of less-frequent genetically acquired resistance and lower risk for drug interaction.9 Additional technologies to monitor haemostatic abnormalities, including visco-elastic haemostasis assays, P2Y12 reactivity tests, heparin-induced thrombocytopaenia (HIT) assays and anti-Xa level monitoring should be utilised as clinically indicated.10 The acute management of ST is similar to its management in COVID-19-negative patients, including early angiography, continuation of high-potency antiplatelet therapy, and a case-bycase consideration for thrombus aspiration, intracoronary tissue plasminogen activator, and the use of GPIIbIIIa as a bail-out strategy. Depending on local availability, left ventricular assist devices or left ventricular venting can be considered to provide haemodynamic support in the case of cardiogenic shock. Conclusion This case report highlights some of the limitations of real-world practice where access to intravascular imaging was limited due to COVID-19 hospital protocols and advanced haematological assays may not be readily available. The opportunity to collect specimens for HIT assays, P2Y12-resistance assays and antiphospholipid antibodies was missed due to the patient’s demise so shortly after the ST. Although not confirmative by way of exhaustive exclusion, we propose that this report of dual ST decreases the probability of local lesion/stent factors responsible for ST and adds credence to the already described pro-thrombotic state in COVID-19 infection. It is important for cardiologists to be aware of the emerging association that may present, even in non-fulminant presentations of COVID-19 infection. Further studies are warranted to guide on the management of this devastating complication. References 1. Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost 2020; 18: 844–847. 2. Rodriguez-Leor O, Alvarez ABC, de Prado AP, Rossello X, Ojeda A, Serrador A, et al. In-hospital outcomes of COVID-19 ST-elevation myocardial infarction patients. EuroIntervention 2021; 16: 1426–1433. 3. Schulman S. Prothrombotic factors, and venous thromboembolism. Semin Thromb Hemost 2020. Online published 11 May 2020. 4. Kwaan H. Coronavirus disease 2019: The role of the fibrinolytic system from transmission to organ injury and sequelae. Semin Thromb Hemostasis 2020. Published online 5 May 2020. 5. Gori T, Polimeni A, Indolfi C, et al. Predictors of stent thrombosis and their implications for clinical practice. Nat Rev Cardiol 2019; 16: 143–256. 6. Mauri L, Hsieh WH, Massaro JM, et al. Stent thrombosis in randomized clinical trials of drug-eluting stents. N Engl J Med 2007; 356: 1020–1029. 7. Lacour T, Semaan C, Genet T, Ivanes F. Insights for increased risk of failed fibrinolytic therapy and stent thrombosis associated with COVID19 in ST-segment elevation myocardial infarction patients. Catheter Cardiovasc Interv 2020; 241–243. 8. Bikdeli B, Madhaven M, Jiminez D, Chuich T, Dreyfus I, Driggin E, et al. COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up: JACC state-ofthe-art review. J Am Coll Cardiol 2020; 75(23): 2950–2973. 9. Wallentin L, Becker RC, Budaj A, et al. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med 2009; 361: 1045–1057. 10. Dutt T, Simcox D, Downey C, McLenaghan D, King C, Gautam M, et al. Thromboprophylaxis in COVID-19: anti-FXa – the missing factor? Am J Respir Crit Care Med 2020; 202(3): 455–457.
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