Purpose: Coronary artery aneurysm/ectasia (CAA/CAE) in the setting of acute coronary syndrome (ACS) remains an uncommon but significant finding during percutaneous coronary intervention (PCI). Presence of CAA/CAE has been suggested to increase risk of recurrent thrombotic events and procedural complications. We currently lack an established consensus on optimal treatment strategies for this subset of patients. The use of triple therapy – consisting of dual antiplatelet therapy (DAPT) plus a direct oral anticoagulant (DOAC) – has been reported in ACS patients who have an additional indication for oral anticoagulation, but no large-scale or prospective studies have included patients with CAA/CAE. The purpose of our case series was to describe the safety of prolonged triple therapy for secondary prevention of ACS in four patients with CAA/CAE in order to provide insight on potential future treatment regimens for this patient population.

Cases: Retrospective chart analysis on four patients with ACS in the setting of CAA/CAE who were started on a prolonged duration triple therapy (≥1 mos). Patients were between the ages of 28 and 67, and triple therapy consisted of DAPT (aspirin 81 mg qday and clopidogrel 75 mg qday) and a DOAC (apixaban 5 mg BID).

Discussion: For the four patients analyzed in our case review, triple therapy with DAPT plus a DOAC was well-tolerated with no adverse bleeding events and no recurrence of MI at one-year follow-up. Our study adds to the growing body of evidence utilizing chronic anticoagulation in CAA/CAE patients following MI. Despite known increased risks of bleeding with triple therapy, these cases highlight the feasibility of prolonged triple therapy post-ACS in patients with CAA/CAE. There are also very few studies discussing the use of DOACs for triple therapy as traditional regimens involve use of warfarin, so our treatment regimen is rather novel. Additional research is needed to determine the optimal treatment strategies for this unique patient population along with the duration of triple therapy before transitioning to regimens with lower bleeding risk such as single antiplatelet agents with anticoagulation or anticoagulation alone.

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