# ST-Elevation Myocardial Infarction Despite Adequate Anticoagulation in a Patient With Triple-Positive Antiphospholipid Syndrome: A Therapeutic Dilemma in a Resource-Limited Setting

## TL;DR

A 40-year-old woman with antiphospholipid syndrome had a heart attack despite being on blood thinners, highlighting treatment challenges in resource-limited areas.

## Contribution

Presents a rare case of ST-elevation myocardial infarction in anticoagulated antiphospholipid syndrome managed in a resource-limited setting.

## Key findings

- Therapeutic warfarin failed to prevent ST-elevation myocardial infarction in a triple-positive antiphospholipid syndrome patient.
- Conservative management with enoxaparin and antiplatelet therapy led to functional recovery after delayed intervention.
- Multidisciplinary team input was crucial in determining an individualized antithrombotic regimen post-recovery.

## Abstract

Antiphospholipid syndrome is a prothrombotic autoimmune disorder that can lead to arterial thrombotic events such as acute myocardial infarction. We report a case of a 40-year-old female with triple-positive antiphospholipid syndrome on therapeutic warfarin who presented with anterior ST-elevation myocardial infarction. With an international normalized ratio of 2.3, thrombolysis was contraindicated, and primary percutaneous coronary intervention was unavailable due to resource limitations. She was managed conservatively with enoxaparin, dual antiplatelet therapy, and supportive care. Elective angiography revealed complete occlusion of the left anterior descending artery, and viability testing guided subsequent percutaneous coronary intervention, resulting in good functional recovery. An individualized antithrombotic regimen with a clear timeline was offered after a multidisciplinary team discussion. This case highlights the therapeutic challenges of ST-elevation myocardial infarction in patients with anticoagulated antiphospholipid syndrome, particularly in settings without primary percutaneous coronary intervention.