Objectives
New oral anticoagulants have been used in non-valvular atrial fibrillation (AF), deep vein thrombosis (DVT), pulmonary thromboembolism (PTE) and their prophylaxis. However, their benefits have not been investigated in thromboembolic complication of concomitant myocardial infarction. Here, we introduced a case of peripheral embolism in a 81-year-old female patient under dual antiplatelet and dabigatran treatment.
Case
A 81-years-old female patient was admitted to the emergency room with left leg pain lasting for five hours. The patient was 157 cm in height and 62 kg in weight. Fifteen days ago, the patient was performed primary percutaneous coronary intervention to LAD because of acute anterior wall STEMI following the loading dose of 300 mg clopidogrel and 300 mg acetylsalicylic acid. She had newly diagnosed diabetes mellitus and AF at index hospitalization period in same center. Creatinine clearance was normal. The patient was given anticoagulation with subcutaneous enoxaparin twice a day adjusted according to the weight during index hospitalization. At discharge, the patient was prescribed to take consisting of acetylsalicylic acid 100 mg per day, clopidogrel 75 mg per day, ramipril 5 mg per day, metoprolol 50 mg per day, atorvastatin 40 mg per day and dabigatran 150 mg bid. The patient had used the drugs for 15 days without interruption. The physical examination upon arrival revealed an irregular pulse rate of 86 beats/minute, a blood pressure of 145/95 mmHg and absence of left popliteal artery and dorsalis pedis artery pulses. Initial twelwe lead electrocardiogram revealed AF with 1 mm elevated ST segment and biphasic T wave in leads V1 to V6 implying subacute phase of anterior wall infarction. Upon emergency, bedside transthoracic echocardiographic examination revealed abnormalities of anterior and septal wall motions, apical aneurysm with image of fresh thrombus formation (Figure 1). The patient was referred promptly to Doppler examination for the left lower extremity followed by computed tomographic angiography of peripheral vasculature. It confirmed the diagnosis of acute arterial thromboembolism. Thrombotic subtotal occlusion was located at the proximal part of left superficial femoral artery (SFA). The patient transferred to the surgery. Following the percutaneous mechanical thrombectomy, blood flow of SFA was restored successfully. The patient was discharged with warfarin therapy.
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