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A 35 year old female patient with symptoms of unstable angina and a positive troponin I test was admitted to our hospital three days after coloscopic biopsy was performed elsewhere. Immediate coronary angiography revealed a coronary thrombus in the bifurcation of the main stem of the left coronary artery with involvement of the origin of the circumflex artery as well as the proximal segments of the marginal and intermediate branches. A flap of the thrombus extended into the LAD, giving rise to systolic/diastolic oscillations (A1 and A2). In order to spare the young patient with severe symptoms an aortocoronary bypass operation, we decided to administer the glycoprotein IIb/IIIa receptor blocker tirofiban. In view of the recent coloscopic biopsy and the increased risk of bleeding, only half the normal initial bolus (0.2 μg/kg/min for 30 minutes) and half the normal maintenance dose (0.05 μg/kg/min) were given. As no intestinal bleeding occurred, the dose was increased after 24 hours to the normal maintenance dose (0.1 μg/kg/min) so as to achieve the maximum effect of the drug. Following three days' tirofiban administration and initiation of antiplatelet treatment with 75 mg clopidogrel and 300 mg aspirin daily, plus low molecular weight heparin twice daily, control coronary angiography showed complete regression with no coronary thrombi present (B).
Aggressive antiplatelet treatment with tirofiban, a potent inhibitor of glycoprotein IIb/IIIa receptors on the surface of platelets, in combination with low molecular weight heparin, led to complete thrombolysis in the affected coronary vessels of this patient with unstable angina.