Abstract
A 74-year old Japanese male was admitted for acute myocardial infarction and underwent implantation of a bare metal stent for total occlusion of the right coronary artery (RCA). He developed acute stent thrombosis (ST) at the implantation site, and was re-treated using balloon angioplasty. Two weeks after discharge he presented to the emergency department with a sore throat and was admitted for treatment of agranulocytosis and esophageal candidiasis. During the first night of hospitalization, his vital signs indicated that he was experiencing cardiogenic shock. An electrocardiogram revealed a junctional rhythm with ST-segment elevations in the inferior leads. An emergency coronary angiography showed total occlusion of the RCA at the site of stent placement. Late ST was diagnosed, and intra-aortic balloon pumping was performed, followed by another thrombectomy and balloon angioplasty. Drug-induced agranulocytosis was highly suspected, and all drugs prescribed to the patient with the exception of aspirin were discontinued. He experienced a smooth recovery and a regimen of sarpogrelate and cilostazol was begun on Day 4 of hospitalization. On Day 7, he presented melena complicating hemorrhagic shock. Therefore, all drugs including aspirin were discontinued. The decision was made to replace clopidogrel with another antithrombotic agent in order to obtain adequate platelet inhibition. Thus while unfractionated heparin continued to be administered, aspirin was begun on Day 19 and sarpogrelate on Day 27. The patient was discharged on Day 34 and his treatment course was good. Thus far the patient has been free of chest pain and has had no need of further hospitalization.
