medicina Case Report How to Manage a Patient with Haemophilia and ACS Requiring PCI: A Battle between Bleeding and Thrombosis Konstantinos C. Theodoropoulos 1,2 , Sofia Vakalopoulou 3, Maria Oikonomou 1, George Stavropoulos 1, Antonios Ziakas 2, Ioannis Kanonidis 1 and George Kassimis 1,* 1 Second Cardiology Department, Hippokration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; [email protected] (K.C.T.); [email protected] (M.O.); [email protected] (G.S.); [email protected] (I.K.) 2 First Cardiology Department, University General Hospital AHEPA, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; [email protected] 3 Haemophilia Centre of Northern Greece, Second Propaedeutic Department of Internal Medicine, Medical School, Hippokration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; [email protected] * Correspondence: [email protected]; Tel.: +30-2310892349 Abstract: We present the case of a 70-year-old man with a history of haemophilia B, who presented to our hospital with a non-ST-elevation myocardial infarction. The patient, following consultation by a haemophilia expert, was revascularized with percutaneous coronary intervention (PCI) under adequate clotting factor administration. Patients with haemophilia and acute coronary syndrome, are susceptible to periprocedural bleeding and thrombotic events during PCI, and therefore a balanced management plan should always be implemented by a multidisciplinary team. Citation: Theodoropoulos, K.C.; Vakalopoulou, S.; Oikonomou, M.; Keywords: Haemophilia B; factor IX; coagulation factors; bleeding; thrombosis; PCI; NSTE-ACS Stavropoulos, G.; Ziakas, A.; Kanonidis, I.; Kassimis, G. How to Manage a Patient with Haemophilia and ACS Requiring PCI: A Battle 1. Introduction between Bleeding and Thrombosis. Coronary artery disease (CAD) is the most common type of cardiac disease with the Medicina 2021, 57, 352. https:// highest mortality globally [1]. Non-ST-elevation acute coronary syndromes (NSTE-ACS) doi.org/10.3390/medicina57040352 represent 70% of all ACSs, while patients with NSTE-ACS tend to be older and have more comorbidities than patients with ST-elevation myocardial infarction (STEMI) [2]. Invasive Academic Editor: Pierpaolo Di Micco strategy with a coronary angiogram and possible percutaneous coronary intervention (PCI) along with dual antiplatelet therapy (DAPT) and anticoagulation is the standard of care Received: 24 February 2021 for patients with NSTE-ACS according to current guidelines [2,3]. However, periproce- Accepted: 2 April 2021 Published: 7 April 2021 dural bleeding is one of the most frequent complications of PCI and is associated with an increased risk of both short- and long-term mortality [4]. A high incidence of bleed- Publisher’s Note: MDPI stays neutral ing events occurs in patients with various haematological disorders such as anaemia, with regard to jurisdictional claims in thrombocytopenia, or haemophilia who undergo PCI. published maps and institutional affil- Haemophilia A (HA) and haemophilia B (HB) are recessive, X-linked inherited blood iations. disorders caused by a deficiency of coagulation factor VIII (FVIII) and factor IX (FIX) respectively [5]. They affect mainly males and their clinical manifestations are similar, however it is generally considered that bleeding episodes in patients with HA are more severe and occur at higher frequency than in patients with HB [5]. HB was first reported in 1952 and was called “Christmas disease” after the name of the patient, a 10-year-old Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. boy named Stephen Christmas [6]. The severity of haemophilia is inversely related to the This article is an open access article level of functional FVIII or FIX present and is categorized into mild, moderate, and severe distributed under the terms and disease, as follows: severe (factor level < 1% of normal), moderate (factor level 1–5% of conditions of the Creative Commons normal) and mild (factor level > 5% and <40% of normal) [7]. However, current stratification Attribution (CC BY) license (https:// based on factor VII or IX levels is not always reflecting the clinical severity of the disease. creativecommons.org/licenses/by/ Haemophilia patients are usually well known to their haemophilia centres, which often 4.0/). have specialized treatment protocols. Bleeding episodes can range from minor/moderate Medicina 2021, 57, 352. https://doi.org/10.3390/medicina57040352 https://www.mdpi.com/journal/medicina Medicina 2021, 57, 352 2 of 7 (haemarthrosis, epistaxis) to severe (intracerebral bleed or limp muscle bleeds leading to compartment syndrome). Treatment of haemophilia has evolved dramatically in the last decades, transforming haemophilia from an often-fatal hereditary bleeding disease to one with available, safe and effective, treatment. Haemophilia treatment is based on missing factor replacement with FVIII or FIX concentrates. These concentrates can be used as either prophylaxis or treatment of bleeding episodes [8]. 2. Case Presentation A 70-year-old man developed sudden onset severe central chest pain lasting in total 2 h. Cardiovascular risk factors included only hypertension and the patient had a history of mild haemophilia B and chronic obstructive pulmonary disease (COPD). He presented to our institute some hours later, where a 12-lead electrocardiogram demonstrated T wave inversion in leads III and V1-V6 (Figure1) and hs-TnI was mildly elevated (120 ng/L, nor- mal < 14 ng/L), therefore a NSTE-ACS was diagnosed. Blood pressure was 160/90 mmHg. Baseline Factor IX activity was 24.9% (Figure2), activated Partial Thromboplastin Time [aPTT] was 37.9 s and international normalized ratio (INR) 0.98 (INR is normal and aPTT Medicina 2021, 57, x FOR PEER REVIEW 3 of 7 is prolonged in haemophilia patients). Haemogram and biochemical parameters were all within normal ranges. FigureFigure 1. 1.1212 lead lead electrocardiogram electrocardiogram (ECG)(ECG) showing showing T waveT wave inversion inversion in leads in leads III and III V1–V6. and V1–V6. As we adopted an early intervention strategy, the patient was referred to haematology for consultation and joined management. The patient was loaded with dual antiplatelet therapy (aspirin and clopidogrel), b-blocker and lansoprazole. The coronary angiogram was performed the next day and periprocedural intravenous unfractionated heparin (UFH) was used, guided by the ACT (activated clotting time) levels. Although ACT is prolonged in patients with haemophilia, replacement of the deficient FVIII or FIX suppress this phenomenon. Despite this, ACT remains a useful point-of-care test in order to monitor co- agulation during PCI and to guide unfractionated heparin (UFH) treatment. Recombinant Figure 2. Plasma Factor IX activity before, during and after percutaneous coronary intervention (PCI). Medicina 2021, 57, x FOR PEER REVIEW 3 of 7 Medicina 2021, 57, 352 3 of 7 factor IX (with a periprocedural level target of >80%) was also administered (Figure2). Given the baseline level (24.9%), the patient received 5000 units of recombinant factor IX (Benefix, Pfizer, Philadelelphia, PA, USA) intravenously two hours before coronary angiog- raphy (CAG). CAG was performed using the left radial artery access and demonstrated unobstructed right and left circumflex coronary arteries. The left anterior descending artery (LAD) had proximally a severe non-calcified lesion causing 99% stenosis (Figure3A) . The culprit lesion was treated with a 2.75 mm × 18 mm zotarolimus eluting stent and post-dilated with a non-compliant balloon 3.0 mm × 15 mm at 18 atm with a good final angiographic result (Figure3B). Three hours later, the TR BAND ® Radial Compression Device was removed and neither bleeding nor haematoma was observed. The patient had an uneventful recovery and was discharged the following day with recommendation for DAPT (aspirin and clopidogrel) for 1 month. He continued to receive prophylaxis therapy with regular administration of FIX concentrates to keep trough levels around ≥30% while on DAPT (Figure2). He was completely asymptomatic in a follow-up appoint- ment one month later, with preserved left ventricular systolic function on transthoracic echocardiography.Figure 1. 12 lead electrocardiogram (ECG) showing T wave inversion in leads III and V1–V6. Medicina 2021, 57, x FOR PEER REVIEW 4 of 7 Figure 2. Plasma Factor IX activity before, during and after percutaneous coronary intervention Figure 2. Plasma Factor IX activity before, during and after percutaneous coronary intervention (PCI). (PCI). FigureFigure 3.3. ((AA)) CoronaryCoronary angiogramangiogram showingshowing severesevere proximalproximal left anterior descending (LAD) lesion. (B) Coronary angiogram showing good angiographic result post-PCI. (B) Coronary angiogram showing good angiographic result post-PCI. 3. Discussion 3.1. Haemophilia and Coronary Artery Disease Haemophilia is an inherited blood disorder due to deficiency of coagulation factors VIII or IX. Patients with haemophilia suffer from minor or major bleeding events. Alt- hough haemophilia patients appear to have lower mortality due to ischemic heart disease compared to the general population, the prevalence of cardiovascular risk factors in hae- mophilia patients is similar to the prevalence in the general population, and hypertension is even more common [9,10]. Lower mortality of haemophiliacs due to ischaemic heart disease can be attributed to their hypocoagulable