in stent thrombosis

[Ethan]

Hello all, how would you manage a 50 years old man with a recent PCI (DES to prox. LAD 2 weeks ago) with a 2 days chest pain (sound ischemic) with no ECG changes and no troponin? what is the chance for an in-stent thrombosis without ECG changes? thanks.

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[muscles]

Hello all, how would you manage a 50 years old man with a recent PCI (DES to prox. LAD 2 weeks ago) with a 2 days chest pain (sound ischemic) with no ECG changes and no troponin? what is the chance for an in-stent thrombosis without ECG changes? thanks.

If he had in-stent thrombosis causing occlusion of the proximal LAD, this would likely be a catastrophic event, resulting in infarction of tissue distal to the proximal LAD, which is a large territory. You would see EKG/Tn changes.

Concerning management, you're obligated to do the workup and treat empirically as ACS pending a rule-out, following which clinical judgment should dictate further management.

 

[dragonfly99]

Agree w/above.
Stent thrombosis is pretty much a catastrophic event. And you WOULD have ST elevations. Maybe the chest pain is noncardiac, or maybe he has another lesion that is now acting up; did you review the cath report to see whether there were other coronary lesions not intervened on at that time of the LAD stenting? Also, a lot of patients get anxious after this type of event. If he has chest pain but clinically looks well and doesn't look that uncomfortable, this could be noncardiac (like anxiety, etc.). Still would treat as r/o ACS, though, as mentioned above.