Primary Percutaneous Coronary Intervention by a Stentless Technique for Acute Myocardial Infarction with Idiopathic Thrombocytopenic Purpura: A Case Report and Review of the Literature

The presence of idiopathic thrombocytopenic purpura and incidence of acute non-ST elevation myocardial infarction

Platelets play an integral role in the pathogenesis of acute coronary syndrome (ACS). The purpose of this study was to investigate any correlation between immune thrombocytopenia (ITP) and non-ST segment elevation myocardial infarction (NTSEMI), a common presentation of ACS. Using the large Nationwide Inpatient Sample (NIS) database, we studied any correlation between NSTEMI and ITP utilizing ICD-9 codes. We performed uni- and multivariate analysis adjusting for risk factors from the years 2002-2011. Data was extracted from 106,653 ITP patients and 79,636,090 controls. In multiple years of the study period (2002-2011), NSTEMI incidence was significantly higher in ITP patients when compared with non-ITP patients in the univariate analysis (odds ratio average 1.226). However, no significant association was found after adjusting for additional risk factors in multivariate analysis. Based on our large database study, ITP is not independently associated with NSTEMI incidence after adjusting for comorbidity.

The presence of idiopathic thrombocytopenic purpura correlates with lower rate of acute ST-elevation myocardial infarction

Background: Platelets are important in the pathogenesis of myocardial infarction (MI). We hypothesize that patients with acquired thrombocytopenia such as idiopathic thrombocytopenic purpura (ITP) may have lower MI rate. Materials & method: The Nationwide Inpatient Sample was used for this study. We analyzed the correlation between ST-elevation MI (STEMI) and ITP utilizing ICD-9 codes. Results: STEMI rate was lower in patients with ITP. We found that, in 2002, STEMI occurred in 0.64% of patients with ITP versus 0.89 (p < 0.007) and for 2011 0.30 versus 0.48 (p < 0.005). After adjusting for tobacco use, diabetes, hypertension, hyperlipidemia, gender and age, STEMI rate remained lower in ITP patients. Conclusion: ITP appears to be associated with lower STEMI rate suggesting low platelet count may exert protective effect from STEMI.

Management of acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura, the value of optical coherence tomography: a case report

BACKGROUND

Treating myocardial infarction in the setting of immune thrombocytopenic purpura (ITP) is always a challenge especially if the platelet count is labile. Cardiologists dealing with such patients should keep a delicate balance between thrombotic and bleeding complications.

CASE SUMMARY

A 50-year-old gentleman with treatment-challenging ITP presented with acute inferior ST elevation myocardial infarction after receiving recent intravenous immunoglobulin. Using optical coherence tomography (OCT) guidance, it was decided to treat him with percutaneous old balloon angioplasty especially with the labile nature of his platelet count. Subsequently, dual antiplatelet therapy was a challenge and he remained on clopidogrel for a period of only 10 weeks.

CONCLUSION

This case highlights the rare presentation of patients with ITP with thrombotic complications and the usefulness of OCT in formulating a management plan.

Recurrent Acute Coronary Syndromes in a Patient with Idiopathic Thrombocytopenic Purpura

A 53-year-old man was admitted to a peripheral hospital with the diagnosis of acute myocardial infarction without ST elevation. Due to the concomitant presence of first-diagnosed thrombocytopenia (platelet count 50.000/μL), it was decided to be treated conservatively with clopidogrel. Five days later, he developed an acute myocardial infarction with ST elevation (STEMI) and was transferred to our department for primary percutaneous coronary intervention (PCI). Coronary angiography revealed three-vessel disease. The left anterior descending lesion was considered culprit, and PCI was successfully performed using a drug-eluting balloon. This approach was considered safer due to the risk of intolerance of prolonged dual antiplatelet therapy in case of stent implantation. Indeed, four days later, aspirin was discontinued, and the patient remained only on clopidogrel due to a platelet fall. Meanwhile, idiopathic thrombocytopenic purpura (ITP) was diagnosed by hematology consultation, and specific ITP treatment was initiated. Seven days following the procedure, the patient was transferred to the Hematology clinic, where a continuous rise of platelet count up to 115.000/μL while on clopidogrel was observed, and he was discharged from the hospital asymptomatic. Unfortunately, twenty days later, the patient died of a lung infection. In ITP patients with STEMI, primary PCI with drug-eluting balloon angioplasty may be a reasonable approach.

Impact of immune thrombocytopenic purpura on clinical outcomes in patients with acute myocardial infarction

Background

Patients with immune thrombocytopenic purpura (ITP) admitted with acute myocardial infarction (AMI) may be challenging to manage given their increased risk of bleeding complications. There is limited evidence in the literature guiding appropriate interventions in this population. The objective of this study is to determine the difference in clinical outcomes in AMI patients with and without ITP.

Methods

Using the United States national inpatient sample database, adults aged ≥18 years, who were hospitalized between 2007 and 2014 for AMI, were identified. Among those, patients with ITP were selected. A propensity‐matched cohort analysis was performed. The primary outcome was in‐hospital mortality. Secondary outcomes were coronary revascularization procedures, bleeding and cardiovascular complications, and length of stay (LOS).

Results

The propensity‐matched cohort included 851 ITP and 851 non‐ITP hospitalizations for AMI. There was no difference in mortality between ITP and non‐ITP patients with AMI (6% vs7.3%, OR:0.81; 95% CI:0.55‐1.19; P = .3). When compared to non‐ITP patients, ITP patients with AMI underwent fewer revascularization procedures (40.9% vs 45.9%, OR:0.81; 95% CI:0.67‐0.98; P = .03), but had a higher use of bare metal stents (15.4% vs 11.3%, OR:1.43; 95% CI:1.08‐1.90; P = .01), increased risk of bleeding complications (OR:1.80; CI:1.36‐2.38; P < .0001) and increased length of hospital stay (6.14 vs 5.4 days; mean ratio: 1.14; CI:1.05‐1.23; P = .002). More cardiovascular complications were observed in patients requiring transfusions.

Conclusions

Patients with ITP admitted for AMI had a similar in‐hospital mortality risk, but a significantly higher risk of bleeding complications and a longer LOS compared to those without ITP. Further studies are needed to assess optimal management strategies of AMI that minimize complications while improving outcomes in this population.

Successful Treatment of Idiopathic Thrombocytopenic Purpura After Liver Transplant: A Case Report

Idiopathic thrombocytopenic purpura, a common acquired bleeding disorder in pediatric patients, is an autoimmune disorder characterized by a low platelet count. Organ transplant can transfer such diseases, but the occurrence of idiopathic thrombocytopenic purpura after liver transplant is rare. Here, we report a 17-month-old girl who was diagnosed with idiopathic thrombocytopenic purpura and who had a history of liver transplant 11 months earlier. Treatment of cytomegalovirus and Epstein-Barr virus infection led to a successful outcome.

Acute Coronary Syndromes in Patients with Hematological Disorders

Hematological conditions can lead to serious disturbances in blood rheology, being frequently associated with increased systemic inflammation and increased risk of bleeding. The imbalance between coagulation and thrombolytic factors in patients with acute coronary syndromes may lead to undesirable outcomes, and the success of emergency coronary angioplasty or by-pass grafting may be altered by increased bleeding in coagulopathies such as hemophilia. This paper intends to review the present knowledge in the field of acute coronary syndromes in subjects with hematological and onco-hematological disorders such as thrombotic thrombocytopenic purpura, immune thrombocytopenic purpura, von Willebrand disease, hemophilia, polycythemia vera, erythrocyte disorders, myelodysplastic syndrome, leukemia, lymphoma or myeloma.