The withdrawal of abciximab last year left a treatment gap in the management of intracoronary thrombus however a local case report has shown a combination of tirofiban, heparin, aspirin and prasugrel can be effective.

The case, published in the Journal of Thrombosis and Thrombolysis, involved a 77 year-old male presenting to Orange Base Hospital with chest pain shown to be secondary to an occluded right coronary artery on emergency angiography after administration of aspirin and clopidogrel.

A relook angiogram after 48 hours of IV heparin revealed a large residual thrombus.

The patient was then treated with a 48 hour tirofiban infusion and heparin, the clopidogrel was changed to prasugrel, and the patient transferred to a metropolitan hospital.

Follow-up angiography showed complete dissolution of the thrombus and the patient received a stent at the site of the lesion.

Associate Professor Harry Lowe, a cardiologist at Orange Base Hospital and head of coronary intervention at Concord Repatriation General Hospital, told the limbic abciximab had been quite commonly used throughout Australia and elsewhere before its withdrawal.

“Following the withdrawal of abciximab, treatment of significant intracoronary thrombus has become somewhat empiric.”

He said tirofiban was a similar agent but has not been used widely for treatment of intracoronary thrombus or where there were thrombotic complications following stenting.

“Tirofiban was used in different situations – one large trial was with heparin after people presented with ACS, with or without early angiography, that showed benefit. It has not been trialled in the cath lab for intracoronary thrombus in any randomized manner.”

He said the reason for writing the case report was that “it was a case of significant intracoronary thrombus that did seem to get better with the treatment described”.

“That combination, which has not been trialled to any significant degree for this problem, was very effective in this particular patient.”

He also noted that antiplatelet drugs have evolved over the last few years.

“We do use tirofaban with different antiplatelets depending on the patient’s perceived risk. Tirofiban might also be used alone in patients where the thrombus burden is not particularly high and bleeding risk is assessed as moderate.”

“It is something we are doing on a case by case basis because these patients are really difficult to manage otherwise.”

He said experience of such cases was growing. Orange Base Hospital, with a large catchment area of western NSW, sees a lot of acute infarcts many of which haven’t been reperfused.

Associate Professor Lowe also said that extraction devices and distal protection devices have been trialled and not shown to be universally effective in this situation.

The case report was written by Dr Daniel McGhie with co-authors Dr David Amos, Dr Alexander Elder, Professor David Brieger and Associate Professor Harry Lowe.