Myocardial Infarction Type 4b in Human Immunodeficiency Virus-Infected Patient
A 52-year-old male with HIV infection, asthma and varicose veins presented to the hospital with first-ever chest pain. The patient had no history of diabetes mellitus, kidney disease or smoking. Initial 12-lead electrocardiography (ECG) revealed ST-segment elevation in V 2-5 leads, and ST-segment depression in II, III and aVF. The patient was immediately transferred to a catheterization laboratory, where coronary angiography was performed, which showed a dominant right coronary artery with no significant stenosis, acute occlusion of the left anterior descending artery and chronic occlusion of the intermediate branch. Primary percutaneous coronary intervention (PCI) with implantation of an Integrity bare metallic stent (Medtronic Cardiovascular, Santa Rosa, CA, USA) 3.0×1.2 mm into the left anterior descending artery was performed, resulting in complete reperfusion {Thrombolysis in Myocardial Infarction (TIMI) 3 flow}. Intravascular ultrasound was not performed during the procedure. Initial echocardiography revealed a 1.65×1.55 cm blood clot, fixed in an area near the apical part of the left ventricle (LV). His total cholesterol was 4.29 mmol/L, low density lipoproteincholesterol (LDL-C) 2.7 mmol/L and triglycerides 1.37 mmol/L and estimated glomerular filtration rate was >60 mL/min/1.73. The patient was prescribed aspirin 75 mg, clopidogrel 75 mg, enoxaparin 60 mg, ramipril 2.5 mg, nebivolol 2.5 mg and atorvastatin 40 mg. Because of the retroviral infection, he had been receiving combined antiretroviral therapy (cART) for 6 years. The cART regiment consistied of 2 nucleoside reverse transcriptase inhibitors (emtricitabine and tenofovir), and protease inhibitor lopinavir boosted with ritonavir (lopinavir/r). His plasma HIV ribonucleic acid (RNA) levels, measured by real-time polymerase chain reaction were undetectable. The counts of T lymphocytes CD4 and CD8 were 625 cells/µL (norm, 410-1590 cells/µL) and 818 cells/µL (norm, 190-1140 cells/µL), respectively. The CD4/CD8 ratio was 0.76. After 5 days of hospitalization, he was discharged and instructed to continue the prescribed medications.\nTwo weeks after discharge, the patient was readmitted to the hospital because of general fatigue and malaise. Full examination did not reveal any abnormalities other than the previously described blood clot in LV. The patient was discharged and referred for ambulatory surveillance by a cardiologist when his coagulation parameters including the activated partial thromboplastin time (aPTT) were in the normal range. After 10 days (37 days from the first hospitalization), the patient again presented to the hospital with acute chest pain. His troponin I level was 4.74 ng/mL, and in the ECG, a QS complex was seen in leads V 1-3, with new ST-segment elevation. With an initial diagnosis of type 4b myocardial infarction (MI) (), the patient again underwent coronary angiography, which showed acute occlusion of the left anterior descending artery because of in-stent thrombosis. After a bolus of eptifibatide, the thrombus was aspirated with good hemodynamic results (TIMI 3 flow). Follow up echocardiography showed a change in the diameter of the clot in the LV (from 1.65×1.55 cm to 2.2×1.2 cm), and akinesis of the apex, a part of the intraventricular septum, and the anterior wall, with an ejection fraction of 33%. Due to the thrombosis, platelet function tests were performed. The aspirin reaction unit was 394, and the P2Y12 reaction unit was 155. At this time, his total cholesterol was 2.8 mmol/L, LDL-C 1.4 mmol/L and triglycerides 1.7 mmol/L. The patient was prescribed aspirin 75 mg, prasugrel 10 mg, carvedilol 25 mg, torasemide 5 mg, ramipril 2.5 mg, spironolactone 12.5 mg, atorvastatin 40 mg and warfarin (to keep the INR at 2.5). A modification of the cART regimen was introduced. The patient still received the combination of emtricitabine and tenofovir, but the protease inhibitor was changed from lopinavir/r to darunavir/r. After 6 months of follow-up, the patient is in good general condition, with undetectable HIV RNA levels and no drop of T helper lymphocytes CD4.