Recurrent Acute Coronary Syndromes in a Patient with Idiopathic Thrombocytopenic Purpura

Abstract

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 threevessel disease. The left anterior descending lesion was considered culprit, and PCI was successfully performed using a drugeluting 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.

Invasive management of non-ST elevation myocardial infarction (NSTEMI) in a patient with severe thrombocytopenia secondary to adult-onset immune thrombocytopenic purpura

“…In our case, we adopted a stepwise method and were successful in achieving target platelet levels with prednisolone alone and did not result in acute stent thrombosis in the immediate term. Although medical management with single antiplatelet therapy is an option, there is the risk of further ischaemic event and conversion into STEMI, which may further compromise cardiac function and predispose to arrhythmias 6. Therefore, invasive management should be considered if deemed suitable for the patient.…”

“…On the other hand, Al-Lawati et al showed in their case report that obstructive coronary lesions presenting as STEMI in patients with ITP may be successfully treated with OCT-guided plain old balloon angioplasty only 5. Similarly, Iakovis et al opted for a drug-eluting balloon in addition to standard semicompliant balloons 6. These approaches avoid implantation of a stent and therefore DAPT may be stopped earlier than 1 month if needed.…”