Ticagrelor-induced Angioedema After Percutaneous Coronary Intervention in a Patient with a History of Ischemic Stroke and Low Response to Clopidogrel: A Rare Dilemma

Abstract

Dual antiplatelet therapy (DAPT) is widely recognized as the mainstay of treatment after percutaneous coronary intervention (PCI). Premature discontinuation may pose a risk of in-stent thrombosis, acute myocardial infarction, and death. With the increased usage of antiplatelet agents, increased attention has been drawn to their potential allergic reactions.A 66-year-old male with a history of coronary artery disease and ischemic stroke was admitted with worsening severity angina for cardiac catheterization. He was on dual antiplatelet agents, clopidogrel, and aspirin prior to admission. He had PCI and a drug-eluting stent deployment to the culprit vessel. Due to low responsiveness to clopidogrel, he was started on ticagrelor, as prasugrel was contraindicated due to the history of ischemic stroke. A few hours after ticagrelor initiation, he developed shortness of breath, swelling of the throat and tongue, and was diagnosed with angioedema. He didn't have any prior reported history of allergy to any medications to the contrast medium or heparin. The offending medication, ticagrelor, was discontinued. He was managed with intravenous steroids and antihistamines. After the resolution of angioedema, he was discharged with double the dose of clopidogrel in addition to aspirin. The patient did not have any ischemic symptoms or coronary events for the following six-month period of follow-up.The case highlights a relatively rare side effect of ticagrelor. Health care providers should be vigilant about the angioedema following ticagrelor administration. In our patient, it was effectively managed by discontinuing the offending medication and the administration of steroids and histamine blockers. The recovery was prompt, without any serious untoward effects. The DAPT was changed to clopidogrel, double the conventional dose, in addition to aspirin.

Ticagrelor Induced Angioedema Following Carotid Artery Stenting

“…In our review of the literature there have been only 2 published cases implicating Ticagrelor as the underlying cause of angioedema. 8,9 In both cases, angioedema occurred within 72 hours of exposure, as was the case for the patient described here.…”

Ticagrelor: A Rare, Delayed Case of Angioedema

“…The incidence of drug-induced angioedema is estimated to be less than 1%, and it most commonly occurs in association with ACE inhibitors [ 7 ]. According to the U.S. National Library of Medicine (NLM), hypersensitivity reactions to ticagrelor are uncommon, and 34 cases were reported to have an adverse effect with rashes by the U.S. Food and Drug Administration [ 8 ].…”

Factors Influencing 1st and 2nd Generation Drug-Eluting Stent Performance: Understanding the Basic Pharmaceutical Drug-in-Polymer Formulation Factors Contributing to Stent Thrombosis Do We Really Need to Eliminate the Polymer?

“…A possible reason for stent thrombosis is delayed endothelial and wound healing, as the therapeutic agents in DES also inhibit endothelial cell (EC) proliferation and migration in addition to inhibiting SM cell proliferation [7][8][9][10][11]. Stent thrombosis is associated with high rates of morbidity and mortality, often leading to major adverse events of cardiac death and myocardial infarction (MI) [12][13][14].…”