Abstract
In-stent restenosis (ISR) is a common complication following stent implantation and can lead to acute coronary syndrome (ACS), particularly in patients with multiple comorbidities. This condition increases the risk of recurrent angina, myocardial infarction (MI), and the need for repeat revascularization. Although advancements in drug-eluting stents (DES), particularly second- and third-generation models, have significantly decreased the incidence of ISR to about 1-2%, it is still a major concern for high-risk individuals. Managing ACS in the presence of ISR is a complex clinical challenge, requiring careful assessment and intervention. This case report details the presentation, diagnostic challenges, and management of a 61-year-old male with a complex medical history, including atrial fibrillation, chronic obstructive pulmonary disease (COPD), prior MI, and symptomatic bradyarrhythmias treated with a permanent pacemaker. The patient presented with severe chest pain consistent with ST-elevation myocardial infarction (STEMI), later confirmed to result from ISR involving the left anterior descending (LAD) and diagonal arteries. The report highlights the critical role of emergent intervention and advanced diagnostic techniques in managing ISR-related ACS. A key aspect of this case was the use of Sgarbossa criteria to diagnose STEMI in the presence of an atrial-ventricular paced rhythm. The patient's EKG demonstrated a perfect score of 10 on the Sgarbossa scale, a rare finding indicative of a high-risk ischemic event. Emergent percutaneous coronary intervention (PCI) was performed, guided by intravascular ultrasound (IVUS), revealing near-complete ISR of the LAD and total occlusion of the first and second diagonal arteries. Successful revascularization was achieved with balloon angioplasty, stent placement, and post-dilation. Post-procedural management required a delicate balance between antithrombotic therapy and bleeding risk, leading to the initiation of dual antiplatelet therapy (DAPT) (It is not specified how long the Cardiology team was going to continue the DAPT in the records). This report underscores the importance of maintaining vigilance when encountering patients with a history of ISR and prior coronary interventions, emphasizing the need for close monitoring and aggressive management of recurrent ischemic symptoms. Furthermore, it demonstrates the diagnostic value of Sgarbossa criteria in patients with ventricular-paced rhythms and the role of multimodal imaging in guiding optimal PCI strategies. By detailing this patient's course, this report contributes to the understanding and management of ISR in complex cardiovascular cases, offering insights into optimizing outcomes for high-risk populations.