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Prasugrel an Alternative to Clopidogrel; In Patients with Diffuse Alveolar Hemorrhage and Coronary Artery Disease
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A6633 - Prasugrel an Alternative to Clopidogrel; In Patients with Diffuse Alveolar Hemorrhage and Coronary Artery Disease
Author Block: A. Goldstein, S. Siddiqui, T. Vo; Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, United States.
Introduction: Diffuse alveolar hemorrhage is a syndrome characterized by bleeding into the alveolar spaces. In general, the causes of pulmonary alveolar hemorrhage are Wegener's granulomatosis, microscopic polyangitis, Goodpasture's syndrome, antiphospholipid antibody syndrome, infection, toxin, pulmonary embolism, mitral stenosis, and malignancy. Diffuse alveolar hemorrhage associated with antiplatelet drugs is a very rare and serious complication
Case: We present a case of 47-year-old Caucasian male who suffered cardiac arrest post knee surgery. He underwent left heart catheterization for STEMI necessitating placement of drug eluting stent. He was started on aspirin and clopidogrel post stenting. Multiple attempts for weaning and extubation off ventilator following procedure failed as patient developed respiratory distress secondary to diffuse alveolar hemorrhage. Subsequently percutaneous tracheostomy was performed followed by repeat bronchoscopy which showed persistent DAH. Aspirin and Clopidogrel were held as patient was developing critical anemia requiring transfusions. He was empirically started on steroids which was later stopped as work up for vasculitis was negative. Aspirin was resumed with no issue but re-initiation of Clopidogrel resulted in symptoms again. Because of the importance of dual-antiplatelet therapy for prevention of in-stent thrombosis, we opted for a combination of aspirin and Prasugrel. Patient tolerated the combination with no issues and was eventually weaned off vent with subsequent discharge. He was able to complete 3 months of dual antiplatelet therapy with no further incidents of alveolar hemorrhage.
Discussion: Dual antiplatelet therapy is an essential component of care following vascular stenting to avoid complications with in-stent thrombosis. Unfortunately, it predisposes patients to an increased incidence of bleeding. Studies comparing Prasugrel and Clopidogrel show similar incidences of bleeding yet our patient had resolution of bleeding when switched to Prasugrel. Our case, therefore, argues that a trial of a different thienopyridine anti-platelet agent should be attempted before abandoning dual-antiplatelet therapy all together.
Author Block: A. Goldstein, S. Siddiqui, T. Vo; Internal Medicine, Texas Tech University Health Sciences Center, Amarillo, TX, United States.
Introduction: Diffuse alveolar hemorrhage is a syndrome characterized by bleeding into the alveolar spaces. In general, the causes of pulmonary alveolar hemorrhage are Wegener's granulomatosis, microscopic polyangitis, Goodpasture's syndrome, antiphospholipid antibody syndrome, infection, toxin, pulmonary embolism, mitral stenosis, and malignancy. Diffuse alveolar hemorrhage associated with antiplatelet drugs is a very rare and serious complication
Case: We present a case of 47-year-old Caucasian male who suffered cardiac arrest post knee surgery. He underwent left heart catheterization for STEMI necessitating placement of drug eluting stent. He was started on aspirin and clopidogrel post stenting. Multiple attempts for weaning and extubation off ventilator following procedure failed as patient developed respiratory distress secondary to diffuse alveolar hemorrhage. Subsequently percutaneous tracheostomy was performed followed by repeat bronchoscopy which showed persistent DAH. Aspirin and Clopidogrel were held as patient was developing critical anemia requiring transfusions. He was empirically started on steroids which was later stopped as work up for vasculitis was negative. Aspirin was resumed with no issue but re-initiation of Clopidogrel resulted in symptoms again. Because of the importance of dual-antiplatelet therapy for prevention of in-stent thrombosis, we opted for a combination of aspirin and Prasugrel. Patient tolerated the combination with no issues and was eventually weaned off vent with subsequent discharge. He was able to complete 3 months of dual antiplatelet therapy with no further incidents of alveolar hemorrhage.
Discussion: Dual antiplatelet therapy is an essential component of care following vascular stenting to avoid complications with in-stent thrombosis. Unfortunately, it predisposes patients to an increased incidence of bleeding. Studies comparing Prasugrel and Clopidogrel show similar incidences of bleeding yet our patient had resolution of bleeding when switched to Prasugrel. Our case, therefore, argues that a trial of a different thienopyridine anti-platelet agent should be attempted before abandoning dual-antiplatelet therapy all together.
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