A practical guide to the management of immune thrombocytopenia co-existing with acute coronary syndrome

Introduction

Immune thrombocytopenia (ITP) management with co-existing acute coronary syndrome (ACS) remains challenging as it requires a clinically relevant balance between the risk and outcomes of thrombosis and the risk of bleeding. However, the literature evaluating the treatment approaches in this high-risk population is scarce.

Methods and Results

In this review, we aimed to summarize the available literature on the safety of ITP first- and second-line therapies to provide a practical guide on the management of ITP co-existing with ACS. We recommend holding antithrombotic therapy, including antiplatelet agents and anticoagulation, in severe thrombocytopenia with a platelet count < 30 × 109/L and using a single antiplatelet agent when the platelet count falls between 30 and 50 × 109/L. We provide a stepwise approach according to platelet count and response to initial therapy, starting with corticosteroids, with or without intravenous immunoglobulin (IVIG) with a dose limit of 35 g, followed by thrombopoietin receptor agonists (TPO-RAs) to a target platelet count of 200 × 109/L and then rituximab.

Conclusion

Our review may serve as a practical guide for clinicians in the management of ITP co-existing with ACS.

Percutaneous coronary intervention can be safely performed with left ventricular thrombus without increasing stroke risk: A 5-year retrospective review using real-world data

INTRODUCTION

Left ventricular thrombus (LVT) increases the risk of ischemic stroke. However, it remains uncertain if the percutaneous coronary intervention (PCI) in the confirmed LVT setting further augments the stroke risk. Therefore, in this study, we evaluated the risk of stroke among patients with LVT undergoing CAG +/- PCI.

METHODS

This retrospective observational cohort study included all the patients encountered with LVT from 1st of April 2015, to 31st of March 2020. The study population was divided into two groups: Longobardo et al. (2018) [1] patients with LVT who underwent CAG +/- PCI; Solheim et al. (2010) [2] patients with LVT who did not undergo CAG +/- PCI. The primary outcome evaluated was stroke during the index admission, and the secondary outcomes included in-hospital mortality, all-cause mortality, and stroke at 12 months post-discharge. Logistic regression was used to determine the risk of stroke associated with PCI among patients with LVT, and a p-value<0.05 indicated statistical significance.

RESULTS

Of the 210 patients included, 119 underwent CAG +/- PCI, while 91 patients did not undergo CAG +/- PCI. Most of the patients were Asian (67%), male (96%), with a mean age of 56 years. Ischemic cardiomyopathy was the primary etiology of LVT in both groups (96% in the CAG +/- PCI group and 80% in non CAG +/- PCI group). During the index admission, stroke among patients with LVT did not differ between the CAG +/- PCI and non CAG +/- PCI groups (5% versus 3.3%; odds ratio (OR) 1.6, 95% confidence interval (CI) 0.34-6.4, p = 0.539; adjusted OR 0.9, 95% CI 0.09-10.6, p = 0.968). Similarly, in-hospital mortality, all-cause mortality, and stroke at 12 months did not differ between the study groups.

CONCLUSION

Performing CAG +/- PCI among patients with LVT was not associated with an increased risk of stroke during admission or within 12 months in comparison to patients who did not undergo CAG +/- PCI, which may reassure cardiologists to perform CAG +/- PCI among patients with LVT safely.

Concurrent coronary artery disease and immune thrombocytopenia: a systematic review

Introduction

Coronary artery disease (CAD) management in the setting of immune thrombocytopenia (ITP) remains very challenging to clinicians as a reasonable balance between bleeding and thrombosis risks needs to be achieved, and the evidence guiding such management is scarce.

Methods

We conducted a systematic review following the PRISMA guidelines to summarize the available literature on the management and outcomes of CAD coexisting with ITP. We searched PubMed and Embase for studies published in English exploring CAD and ITP management until 05 October 2022. Two independent reviewers screened and assessed the articles for inclusion. Patients' characteristics, CAD treatment modalities, ITP treatment, and complications were reported.

Results

We identified 32 CAD cases, among which 18 cases were revascularized with percutaneous coronary intervention (PCI), 12 cases underwent coronary artery bypass graft surgery (CABG), and two cases were managed conservatively. More than 50% were men, with a mean age of 61 ± 13 years and a mean baseline platelet count of 52 ± 59 × 109/L. Irrespective of the revascularization modality, most patients were treated with either corticosteroids alone, intravenous immunoglobulins (IVIG) alone, or in combination. Among those who underwent PCI, two patients had bleeding events, and one patient died. Similarly, among those with CABG, one patient developed bleeding, and one patient died.

Conclusion

We found that revascularization with either PCI or CABG with the concurrent use of corticosteroids and/or IVIG for ITP was feasible, with an existing non-negligible risk of bleeding and mortality.

One-year unplanned readmission after percutaneous coronary intervention in ST-elevation myocardial infarction: rates, causes and predictors

Introduction and aim

Unplanned readmission after percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) has a significant impact on the healthcare system. Nevertheless, most of the previous literature evaluated readmission within one month only post PCI without assessing the long-term readmission rates and predictors post-PCI. Therefore, we conducted a retrospective observational study to determine the rates, causes, and predictors of readmission post PCI among patients with STEMI over 1-year follow-up.

Methods

We conducted a single-center retrospective observation cohort study. Study population included all patients who were admitted to the hospital with diagnosis of STEMI and underwent PCI during the same admission (index admission) and discharged alive in the period between Jan 1st, 2016 and Sep 30th, 2018. Patients were divided into two groups: those who had one or more unplanned readmission within one year after PCI and those who were not readmitted. Rates and causes of readmission within one year following PCI were reported. Predictors of readmission post-PCI were assessed using multivariate logistic regression and reported as odds ratio (OR) with p&lt;0.05 indicating statistical significance.

Results

A total of 1257 patients were included in our retrospective analysis. Most of the patients were male (95.9%). The mean age of the study population was 51±10. The most frequent culprit vessel was left anterior descending artery (LAD) in 56.3%. The median troponin T upon presentation was 47 ng/L [interquartile range: 171], with 25th percentile of 17 ng/L and 75th percentile of 2197 ng/L. Although around 70% of patients had reduced ejection fraction during the index admission, only 13.4% of the study population had clinical heart failure (HF). The unplanned readmission rate within one year post PCI was 11.5%, with 8.2% due to cardiac readmission while the remaining 3.3% due to non-cardiac causes. The most common cardiac causes for readmission were acute coronary syndrome and HF as shown in Table 1. As demonstrated in Table 2, positive predictors for all-cause readmission within one year after PCI among patients with STEMI were female gender (aOR= 4.14, 95% CI 2.10–8.18; p-value&lt;0.001), chronic kidney disease (aOR= 2.76, 95% CI 1.07–7.08; p-value= 0.035), PCI using more than one stent (aOR= 1.66, 95% CI 1.09–2.55; p-value= 0.019) and clinical HF during index admission (aOR= 2.36, 95% CI 1.49–3.74; p-value&lt;0.001).

Conclusion

The rate of one-year unplanned readmissions after PCI among patients with STEMI was 11.5%, with acute coronary syndrome and HF as most common causes of cardiac readmission. We found that female gender, chronic kidney disease, PCI with more than one stent and clinical HF were associated with a significantly increased likelihood of readmission after PCI among patients with STEMI which may warrant close and frequent follow-up for these populations.

Funding Acknowledgement

Type of funding sources: None.

Mitral regurgitation increases readmission due to heart failure after percutaneous coronary intervention among patients with ST-elevation myocardial infarction: a retrospective data review

Introduction

Post-ST elevation myocardial infarction (STEMI) course can be complicated with mitral regurgitation (MR) which has significant impact on in-patient outcomes and post-discharge course. MR in the setting of STEMI can be due to left ventricular dilatation, papillary muscle rupture or chordal rupture.

Purpose

In this retrospective study, we aimed to evaluate the impact of MR on readmission within one year after percutaneous coronary intervention (PCI) in STEMI patients.

Methods

We conducted a single-center retrospective observation cohort study. We included all patients admitted to the hospital with diagnosis of STEMI, underwent PCI during the same admission (index admission) and discharged alive in the period between Jan 1st, 2016 and Sep 30th, 2018. Factors associated with readmission due to heart failure within 1 year of discharge were evaluated using multivariate logistic regression and results were reported as odds ratio (OR) with p-value &lt;0.05 indicating statistical significance.

Results

A total of 1257 patients were included in our retrospective analysis. The mean age of the study population was 51±10 years. Around 16% (n=206) of the study population had mitral regurgitation (MR) during their admission for STEMI. Among them, 195 patients had newly discovered MR. MR severity was mild in 196 (95%) patients with MR. Unplanned readmission due to cardiac reasons within 1 year of discharge occurred in 103 (8.2%) patients. Among them, 37 (3%) were readmitted due to heart failure. MR was found to increase the likelihood of readmission due to heart failure within one year after PCI among patients with STEMI by three times (aOR=3.13, 95% CI 1.39–7.03; p-value 0.006). As demonstrated in table 1, other positive predictors for readmission due to heart failure were female gender (aOR=3.80, 95% CI 1.22–11.86; p-value 0.021), chronic kidney disease (aOR=4.56, 95% CI 1.22–17.03; p-value 0.024), and clinical heart failure during the index admission (aOR=4.82, 95% CI 1.53–15.15; p-value 0.007). Interestingly, reduced left ventricular ejection fraction was not a significant predictor of heart failure readmission.

Conclusion

Mitral regurgitation is relatively common in STEMI and most frequently presents with mild severity. In our study, MR was found to be a strong predictor for readmission due to heart failure within one year after PCI among patients with STEMI, which may warrant frequent follow-up for these patients and proper initiation of and titration of guideline-directed medical therapy (GDMT).

Funding Acknowledgement

Type of funding sources: None.