Acute ST-segment elevation myocardial infarction as the first manifestation of essential thrombocytosis successfully treated with thrombectomy alone

Essential thrombocytosis: diagnosis, differential diagnosis, complications and treatment considerations of relevance for a cardiologist

Essential thrombocytosis (ET) is a rare haematological malignancy, with an incidence rate of 1.5-2.5/100,000 per year. For many patients with ET the first manifestation of their underlying disease is a thrombotic or haemorrhagic complication. A recent retrospective study revealed an incidence rate of at least 2.1% in people under 40 years presenting with an acute coronary syndrome, although the diagnosis was initially missed in all cases. Thus, cardiologists face a much higher than average incidence rate of ET in their daily practice, but seem insufficiently aware of the disease. The current review summarises symptoms, (differential) diagnosis, complications and treatment considerations of ET of relevance for a cardiologist. Typical symptoms, besides thrombosis and haemorrhage, include erythromelalgia and aquagenic pruritus, while platelets > 450 × 109/l are a diagnostic for ET once other myeloproliferative neoplasms, secondary and spurious thrombocytosis have been excluded. With regard to treatment, timing of revascularisation depends on the presence of ischaemia and concurrent platelet counts. In the presence of ischaemia, revascularisation should not be delayed and adequate platelet counts can be achieved by platelet apheresis. In the absence of ischaemia, revascularisation can be delayed until adequate platelet counts have been achieved by cytoreductive therapies. Cardiologists should be aware of/screen for possible ET.

Manual Thrombus Aspiration in Patients With ST-Elevation Myocardial Infarction With High Thrombus Burden and a Total Ischemic Time Greater or Equal Than 3 Hours: Mini Review

Manual Thrombus Aspiration (MTA) reduces thrombus burden and improves myocardial reperfusion markers in patients with ST-segment elevation myocardial infarction (STEMI), however its clinical benefit is controversial due to conflicting results from randomized clinical trials, which is why the benefit of its application during primary angioplasty (PA) remains uncertain. Reports such as that of Doo Sun Sim, et al. suggest that the impact of MTA may become clinically relevant in patients with a longer total ischemia time.1 We present the case of an adult male, with multiple risk factors for coronary disease, with lower STEMI, due to occlusion of the right coronary artery with a heavy thrombus load and an ischemia time of 10 hours. It was successfully treated by MTA, removing abundant intracoronary thrombus and obtaining a TIMI III flow, without requiring stent implantation. The case, the evolution and the current knowledge regarding the use of AT are discussed. Our case report and review of five cases with similar characteristics in the literature illustrate the use of MTA in patients with STEMI, high thrombus burden, and prolonged ischemia time.

Ischemic Stroke in a Young Man: Unraveling the Domain of Myeloproliferative Disorders

Ischemic stroke is a rare phenomenon in young adults. A complete workup for hypercoagulable and myeloproliferative disorders is a cornerstone of evaluation. Essential thrombocytosis is a chronic myeloproliferative disorder that primarily involves platelets. It may remain undiagnosed in patients and subsequently present in the form of ischemic stroke. The management of this disorder is complex and often involves cytoreduction therapies. The initiation of these drugs in such patients may lead to unnecessary adverse effects and complications. This case report is an attempt to highlight an underappreciated cause of stroke when assessing young individuals.

Acute ST-segment Elevation Myocardial Infarction as the First Manifestation of Essential Thrombocytosis

A 36-year-old female with no significant past medical history presented with sudden onset of crushing substernal chest pain. When the emergency medical services (EMS) arrived, she had a cardiac arrest requiring defibrillation two times in the field prior to arriving at the hospital. In the emergency department (ED), the electrocardiogram (ECG) was significant for ST-elevation that suggested acute anterolateral infarct. Her laboratory evaluation also showed a platelet count of 1095 x 10³/ul. Also, her troponin levels were at 0.16 ng/ml at the time of arrival and peaked at 42.8 ng/ml. She immediately underwent a cardiac catheterization which showed 100% occlusion of her left anterior descending (LAD) artery by a thrombus, which was then treated with a thrombectomy and a single drug-eluting stent was placed. Upon further work-up of her thrombocytosis, the patient had a bone marrow biopsy showing megakaryocytic hyperplasia which no evidence of fibrosis. She was tested for Janus kinase 2 (JAK2) mutation which was positive. The patient was diagnosed with essential thrombocytosis (ET) and was started on cytoreduction therapy with hydroxyurea. Her platelet counts responded appropriately and dropped to less than 500 x 10³ at the time of discharge.