Palacios et al1 presented a 52-year-old man with systemic lupus erythematosus (SLE) and likely antiphospholipid syndrome (APS) reactivation who developed acute myocardial infarction, successfully managed with immediate PCI followed by elective CABG.
We would like to highlight important considerations regarding the initial revascularization strategy in such patients, particularly when TIMI flow grade 3 is achieved after thrombolysis with minimal residual ST-segment elevation. In this specific scenario, immediate stent implantation may not be the optimal approach.
In the DEFER-STEMI trial, delaying stenting 4 to 16 hours after initial TIMI-3 reperfusion allowing for thrombus stabilization reduced no-reflow from 29% to 6% and improved the myocardial-salvage index.2
For SLE patients with positive antiphospholipid antibodies, the risks of immediate stenting are even more pronounced. Perl et al3 showed that APS patients undergoing PCI have significantly higher rates of target vessel revascularization and major adverse cardiac events.3 The prothrombotic state in these patients, combined with the inflammatory response to stent implantation, creates a particularly high-risk scenario for stent thrombosis and restenosis.
The case described achieved TIMI flow grade 3 after thrombolysis with only persistent T-wave changes, suggesting successful reperfusion. In this setting, a pharmacoinvasive strategy with intensive antithrombotic therapy and delayed reassessment would have been preferable. This approach allows time for: 1) stabilization of the prothrombotic state through optimized anticoagulation; 2) control of inflammatory response with immunosuppressive therapy; and 3) assessment of the true underlying lesion versus residual thrombus.
The reported case ultimately required CABG despite successful PCI, suggesting that immediate stenting may have been avoidable. A delayed strategy could have potentially reduced the high-risk perioperative scenario of combined immunosuppression and anticoagulation management.
We propose that in SLE patients with APS and STEMI achieving TIMI flow grade 3 after thrombolysis, initial medical management with intensive antithrombotic therapy followed by delayed reassessment for revascularization represents a safer paradigm.
Footnotes
This work was supported by the Shenzhen Guangming District Program for Introducing High-Level Medical Teams (Grant No. szgmtd2025004). The author has reported that he has no relationships relevant to the contents of this paper to disclose.
The author attests they are in compliance with human studies committees and animal welfare regulations of the author’s institution and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
- 1.Palacios R.U., Garibaldi S., Castillo Mendoza E.S., et al. Challenges in revascularization in patients with systemic lupus erythematosus. JACC Case Rep. 2026;31(5) doi: 10.1016/j.jaccas.2025.106251. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Carrick D., Oldroyd K.G., McEntegart M., et al. A randomized trial of deferred stenting versus immediate stenting to prevent no- or slow-reflow in acute ST-segment elevation myocardial infarction (DEFER-STEMI) J Am Coll Cardiol. 2014;63(20):2088–2098. doi: 10.1016/j.jacc.2014.02.530. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Perl L., Netzer A., Rechavia E., et al. Long-term outcome of patients with antiphospholipid syndrome who undergo percutaneous coronary intervention. Cardiology. 2012;122(2):76–82. doi: 10.1159/000338347. [DOI] [PubMed] [Google Scholar]