Antithrombotic therapy in a patient with stent thrombosis and hemorrhagic syndrome after percutaneous coronary intervention for acute coronary syndrome and atrial fibrillation: a case study

Abstract

Summary. The 2023 guidelines of the European Society of Cardiology (ESC) for the management of acute coronary syndrome (ACS) provide for the adjustment of dual antiplatelet therapy (DAPT), including de-escalation, based on individual clinical assessment. In patients with atrial fibrillation (AF) who are taking direct oral anticoagulants (DOACs) in combination with the P2Y12 receptor inhibitor clopidogrel, the situation is challenged in the presence of CYP2C19 gene polymorphism. In such cases, patients are often required to switch to a more potent P2Y12 inhibitor (e. g., ticagrelor), which is not recommended due to a high risk of bleeding complications. Optimizing antithrombotic therapy in patients with AF remains a major challenge and requires careful balancing of hemorrhagic and ischemic risks. This paper presents a clinical case of a patient with ACS and AF who was prescribed antithrombotic therapy with a DOAC and clopidogrel after percutaneous coronary intervention (PCI). The patient developed subacute stent thrombosis, likely determined by heterozygous carriage of the CYP2C19*2 poly- morphism. As a result, clopidogrel was replaced with ticagrelor, which, when used in combination with a DOAC, is not recommended as a first-line antiplatelet agent. The development of bleeding while on ticagrelor therapy required de-escalation via dose reduction.

For citation: Mansurova J.A., Kozhabayeva A.D., Karazhanova L.K., Kassymova A.A. Antithrombotic therapy in a patient with stent thrombosis and hemorrhagic syndrome after percutaneous coronary intervention for acute coronary syndrome and atrial fibrillation: a case study. Tromboz, gemostaz i reologiya. 2025;(4):101–107. (In Russ.).

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