Acute Stent Thrombosis Due to Absence Without Leave (AWOL)

Case report

A 55-year-old male with risk factors of diabetes, hypertension and smoking presented to the emergency department with severe retrosternal chest pain of 6 hours duration. A 12-lead electrocardiogram (ECG) performed revealed an acute inferior wall ST elevation myocardial infarction (STEMI). Primary percutanoeus coronary intervention was performed after counselling about the costs (there is no health insurance system in Nepal) and the need for dual antiplatelet therapy (DAPT). The mid right coronary artery (RCA) had a subtotal occlusion which was recanalised with a drug-eluting stent (Figure 1). The patient had an uneventful recovery and was transferred to the ward form the coronary care unit. On the third day the patient absconded from the hospital without paying for the treatment and stopped all his medications. He presented 11 days later with chest pain for 3 hours with dizziness and two episodes of syncope. A 12-lead ECG revealed an acute inferior wall STEMI with complete heart block. Temporary pacing was performed immediately and a coronary angiogram revealed an acute stent thrombosis of the RCA stent. Balloon angioplasty was performed successfully with a drug-eluting balloon establishing a TIMI III flow and sinus rhythm was restored (Figure 2).

Causes of acute stent thrombosis are multifactorial, but in resource-poor settings we must consider the economics, patient literacy and, above all, the need to comply with the DAPT regime prescribed. The patient was discharged home after 3 days, after clearing his bills for both the interventional procedures, and remains symptom-free on follow-up.