Residual Thrombogenic Substrate After Rupture of a Lipid-Rich Plaque

A 63-year-old man with hypertension and hyperlipidemia presented to the emergency department with an inferoposterior ST-segment elevation myocardial infarction. The patient was treated with aspirin 325 mg, clopidogrel 600 mg, and intravenous heparin and was transferred for primary percutaneous coronary intervention. The coronary angiogram revealed an occluded proximal right coronary artery. Heparin was switched to bivalirudin. Aspiration thrombectomy retrieved white thrombus and established TIMI (Thrombolysis In Myocardial Infarction) grade 3 flow (Figure 1A). A 3.5×23-mm bare-metal stent was placed (Figure 1B), which was postdilated to 4.0 mm. There was no angiographic evidence of dissection or filling defect (Figure 1C) with resolution of ST-segment changes on ECG. Bivalirudin was stopped at the end …