PO154 | CORONARY REVASCULARIZATION IN ACUTE CORONARY SYNDROME IN PATIENT WITH MILD HEMOPHILIA B: A CASE REPORT

D. Fumarulo, R. Corrado, M. Canfora, M. Mazzetti, M. Littera, D. Prisco, C. Tamburini | Internal Medicine, Careggi Hospital, University of Florence, Firenze, Italy

Background. Coronary angiography in patients with Hemophilia requires careful multidisciplinary management to prevent bleeding complications.
Case report. A 84-year-old man with mild hemophilia B (FIX 20%) was admitted to our Hospital for management of bleeding in recent placement of percutaneous endoscopic gastrostomy (PEG). His past medical history was significant for hypertension, hyperlipidemia, permanent atrial fibrillation (AF) on therapy with Vitamin K Antagonist (VKA) at a reduced range of INR (1.5-1.8) and a history of previous acute myocardial infarction (AMI), udergone to percutaneous coronary intervention (PCI) and placement of drug-eluting stent (DES) on left anterior descending (LAD) in 2013. During his hospital stay, the patient experienced recurrent chest tightness lasting less than 30 minutes, unaccompanied by autonomic symptoms and/or radiation always with complete spontaneous resolution. The patient had been reporting these symptoms as frequent in the last 3 months, even at home. Serial electrocardiograms showed bradycardic fibrillo-flutter associated with left anterior hemiblock (unclear whether new onset) in the absence of obvious ST-T segment alterations. However, a myocardial necrosis enzyme curve appeared abnormal and warranting further diagnostic testing. Therefore, considering the patient's cardiovascular history, clinical findings and laboratory abnormalities, despite the absence of dys/akinesia detected by cardiac echocolor doppler, the need for coronary angiography (CAG) was evident. CAG was performed using the left radial artery access and with an adequate peri-interventional factor substitution. It showed a critical left main (LM) ostial stenosis and stent restenosis on the LAD. Given the clinical complexity and the severity of the Coronary Artery Disease (CAD), the patient was evaluated by the local Heart team, along with the Hemophilia experts. Although the operative surgical risk was low (EuroSCORE II = 1.6%), taking into account the relevant comorbidities, the Heart team established PCI to be more appropriate than surgical approach in this case. The serum FIX dosage before the procedure was around 10%, so, as the guidelines suggest, the patient was prepared with rFIX maintaining a minimum level >50% within 24h after PCI and >20% during Dual Antiplatelet Therapy (DAPT)¹. The final result was satisfactory, in absence of postprocedural complications. The patient was discharged with the recommendation to continue FIX prophylaxis therapy, keeping levels >20% during DAPT. Nevertheless, our patient had an additional factor that made management of antithrombotic therapy more difficult: AF requiring anticoagulation. Given the extremely high bleeding risk of triple antithrombotic therapy, the high thrombotic risk associated with the stenting site (LM) and the not extremely high thromboembolic risk (CHADsVA 4), it was decided to maintain DAPT after the procedure with subsequent reevaluation of anticoagulation after at least 3 months.
Conclusions. This complex clinical case highlights the delicate balance between thrombotic and bleeding risks in the management of hemophilic patients with AMI. The presence of hemophilia B, combined with multiple cardiovascular risk factors, further complicates decision-making regarding revascularization strategies and antithrombotic therapy. A multidisciplinary approach is essential to optimize short- and long-term outcomes. ¹https://pmc.ncbi.nlm.nih.gov/articles/PMC10256340/