Background: Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by venous or arterial thrombosis. Myocardial infarction occurs in about 7% of APS patients, and data on optimal anticoagulation therapy after percutaneous coronary intervention (PCI) in these patients is insufficient. (1, 2)

Case report: 35-years-old male with APS was admitted with ST-segment elevation myocardial infarction. He was on warfarin due to secondary prevention of DVT with an average INR of 2.1. Urgent angiography showed severe thrombotic stenosis of the proximal LAD (Figure 1). Successful PCI with implantation of everolimus eluting stent was performed without complications (Figure 2). Dual antiplatelet therapy (DAPT) consisted of aspirin 300 mg and ticagrelor 180 mg that were continued as per protocol, whereas unfractionated heparin 100 U/kg IV was used before and during PCI. After PCI and during hospitalization, enoxaparine 1 mg/kg subcutaneously BID was added to DAPT. On hospital discharge ticagrelor was switched to clopidogrel (300 mg on the first day, 75 mg in continuation), whereas enoxaparine was switched to rivaroxaban 20 mg, and aspirin 100 mg was continued.

Conclusion: Guidelines for the treatment of patients with APS who have had arterial thrombosis suggest a target INR of 3 or more. Although being off label, we believed novel oral anticoagulants (NOAC) would achieve better anticoagulant effect and lower the risk of bleeding compared to warfarin with high target INR together with DAPT. In addition, rivaroxaban is currently the only novel anticoagulant being tested to treat venous thrombosis in APS (RAPS study). Studies on triple therapy after stenting in APS, or similar syndromes, are needed.