Acute coronary occlusion and in-stent thrombosis in a patient with essential thrombocythemia

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.

A Review of Systemic Hematological Manifestations and Stent Thrombosis

Stent thrombosis (ST) has significant morbidity and mortality following percutaneous coronary intervention (PCI). ST is uncommon making the identification of nonprocedural predictors challenging. Numerous case reports of ST in both benign and malignant hematological conditions exist. Given ST could be a Herald event of an undiagnosed condition and condition-specific treatment may be available, it is important to consider specialist testing in an unexplained ST. This review included a case presentation of ST in previously undiagnosed paroxysmal nocturnal hemoglobinuria (PNH) and a literature review of ST in other acquired thrombophilias including myeloproliferative disorders (MPNs), antiphospholipid syndrome, hematological malignancies, and heparin-induced thrombocytopenia (HIT). Inherited thrombophilias and common pitfalls in thrombophilia and coagulation testing are also discussed. The cardiac-hematology landscape is becoming increasingly complex and there is a paucity of how to best manage ST in these patients. There is clear variability in practice and the use of multidisciplinary input between cardiologists and hematologists is essential.

Development of Alveolar Hemorrhage in a Patient with Acute Myocardial Infarction Complicated with Essential Thrombocythemia

Patient: Male, 75-year-old

Final Diagnosis: Alveolar hemorrhage

Symptoms: Hemoptysis

Medication:—

Clinical Procedure: —

Specialty: Cardiology • Hematology

In-stent Massive Thrombi Formation During Primary Percutaneous Coronary Intervention in a Patient with Acute Myocardial Infarction Complicated with Essential Thrombocythemia

A 61-year-old man with essential thrombocythemia (ET) presented with acute myocardial infarction (AMI) and underwent primary percutaneous coronary intervention. After stent deployment from the left main (LM) to the left anterior descending artery, intravascular ultrasound revealed thrombi formation in the whole stent. Two days later, optical frequency domain imaging confirmed stent malapposition and thrombi remaining in only the LM. The stent malapposition and ET might have contributed to this phenomenon. He underwent an additional stent expansion and aggressive anti-thrombotic regimen. AMI complicated with ET carries increased risks of in-stent thrombi formation and requires careful revascularization and aggressive pharmacotherapy.

Very Late Stent Thrombosis in a Drug-Eluting Stent due to Interruption of Anti-Platelet Agents in Patients With Acute Myocardial Infarction and Thrombocytosis

Stent thrombosis is a fatal complication in patients who have undergone percutaneous coronary intervention, and discontinuation of anti-platelet agent is a major risk factor of stent thrombosis. We report a rare case of very late stent thrombosis (VLST) following discontinuation of anti-platelet agents in a patient who experienced acute myocardial infarction and essential thrombocytosis. She had undergone implantation of a drug eluting stent (DES) and a bare metal stent (BMS) two and half years prior to her presentation. VLST developed in DES, not in BMS, following interruption of anti-platelet therapy.

Very late stent thrombosis after drug-eluting stent implantation in a patient with antiphospholipid syndrome

A 74-year-old woman was admitted to our hospital with chest pain and shortness of breath. Coronary arteriograms revealed occlusion of a drug-eluting stent, which had been implanted 33 months earlier, in the middle right coronary artery. During percutaneous coronary intervention, distal embolization developed and a thrombus was detected with an aspiration catheter. Serological examinations performed 1 year before and during the present hospitalization revealed positive lupus anticoagulant activity. Thrombophilic tendencies, such as antiphospholipid syndrome, are noteworthy as one of the causative factors in very late stent thrombosis.

Essential thrombocythemia: a case of acute ST-segment elevation myocardial infarction in a young female

Essential thrombocythemia (ET) is a clonal disorder of the myeloid stem cell that causes abnormal proliferation of the megakaryocytes. The main feature of the disease is arterial and venous thrombosis caused by platelet dysfunction. Coronary artery involvement leading to acute coronary syndromes is a rare complication of the ET. We report a coronary angioplasty and stenting in a 30-year-old female patient with acute ST-segment elevation myocardial infarction (MI) as the first clinical sign of essential thrombocythemia. Facilitated percutaneous coronary intervention with GPIIb/IIIa and/or thrombolytic therapy may be considered as the first treatment modality for this patient group.

Essential thrombocytemia and acute coronary syndrome: clinical profile and association with other thromboembolic events

BACKGROUND

The existence of a relationship between essential thrombocytemia (ET) and acute coronary syndromes (ACS) has been suggested.

METHOD

Data from eleven consecutive patients admitted with ET in the cardiology department were reviewed.

RESULTS

Nine patients (82%) presented with ACS and two with bradycardia. Patients with ACS had a mean age of 67+/-11 years. Risk factors, especially hypertension (6, 66.7%), and smoking (6, 66.7%) were frequent. Average platelet count was 509 778+/-282 126/mm3. Significant coronary lesions were found in five of six patients studied with coronary angiography. During hospitalization, a patient suffered a thrombotic stroke, a massive pulmonary embolism, and partial aortic thrombosis. Another patient had a transient ischemic attack. Discharge treatments were aspirin (78%), clopidogrel (56%), acenocumarol (33%), hydroxyurea (56%) and anagrelide (44%). Three patients (27%) had thromboembolic events during follow-up (median 1.6 years), 2 patients had coronary events and 1 patient had venous thrombosis. There were neither significant haemorrhages nor deaths.

CONCLUSIONS

Patients with ET and ACS have similar profiles to those of traditional ACS with frequent risk factors and significant coronary artery disease. Association with other thrombotic events can be seen during admission and follow-up while haemorrhagic complications seem to be rare.

Multiple coronary thrombosis and stent implantation to the subtotally occluded right renal artery in a patient with essential thrombocytosis: A case report with review

Essential thrombocytosis is a myeloproliferative disorder of unknown etiology manifested clinically by the overproduction of platelets in the absence of a definable cause. Platelet dysfunction in essential thrombocytosis results in both hemorrhage and thrombosis. It is one of the rare causes of ischemic cardiovascular events. Fewer than 20 cases of essential thrombocytosis with involvement of coronary arteries leading to acute coronary syndromes or myocardial infarction have been reported. We report a case of multiple coronary thrombosis involving the left anterior descending artery and circumflex artery and stent implantation to the subtotally stenotic right renal artery in a women with unstable angina pectoris, essential thrombocytosis and previous history of renal artery trombosis.

Coronary artery intervention after cytostatics treatment in unstable angina patient with essential thrombocythemia. A case report and literature review

Essential thrombocythemia (ET) is a clonal disorder of myeloid stem cells that causes thrombocytosis. As a result, ET can lead to vascular thrombosis and tissue ischemia; the association of coronary artery abnormalities such as myocardial infarction or unstable angina is rare. Here we describe a 45,-year-old male patient with essential thrombocythemia who presented with unstable angina. Elective coronary angiography showed total occlusion of mid right coronary artery and mid left anterior descending coronary artery. ET was confirmed by a bone marrow biopsy; treatment was started with antiplatelet therapy including aspirin and clopidogrel along with cytostatic therapy with hydroxyurea and anagrelide. After the initiation of the treatment, the platelet count decreased to 20 x 10(4)/microL. In addition, percutaneous coronary angioplasty was successfully performed with stent placement at the right coronary artery without hemorrhagic or thrombotic complications.

Acute myocardial infarction in a patient with essential thrombocythemia who underwent successful stenting--a case report

Essential thrombocythemia (ET) can cause systemic vascular thrombosis, but involvement of coronary arteries in the setting of ET is rare. This report describes a case of acute myocardial infarction (MI) in a patient with ET. A 67-year-old man with ET complained of severe acute chest pain. Emergent coronary angiography revealed subtotal thrombotic occlusion of the left main trunk (LMT) coronary artery. Coronary angioplasty and stenting were performed successfully. Coronary angiography 4 weeks later revealed no significant restenosis. The patient has done well after primary coronary stenting with the use of only an antiplatelet agent to treat the thrombocythemia.

Aggressive antiplatelet therapy before coronary stent implantation in acute coronary syndrome with essential thrombocythemia--a case report

A 52-year-old man was admitted to the hospital because of unstable angina pectoris. Coronary angiography revealed severe stenosis at a proximal site of the left anterior descending artery. Essential thrombocythemia (ET) was diagnosed on the basis of findings of marked thrombocytosis (106 x 10(4)/microL) and an increased number of immature megakaryocytes in the bone marrow. Because hyperaggregability of platelets was demonstrated by an ex vivo platelet aggregation assay and by elevated plasma levels of beta-thromboglobulin (beta-TG) and platelet factor 4 (PF4), antiplatelet therapy with aspirin and ticlopidine and cytoreduction therapy with hydroxyurea were started. This combination treatment resulted in a decrease in the platelet count to less than 60 x 10(4)/microL and decreases in plasma levels of both beta-TG and PF4 to almost normal values. Percutaneous coronary angioplasty and stenting were then performed successfully without thrombotic complications. These findings suggest that combination therapy with antiplatelet and cytoreduction agents before catheter intervention is useful for the prevention of thrombotic complications in patients with acute coronary syndrome associated with essential thrombocythemia.

Essential thrombocytosis causing a massive myocardial infarction

Essential thrombocytosis (ET) is an uncommon myeloproliferative disorder. This disease may have both occlusive thrombotic as well as hemorrhagic complications throughout the body. We report a young man with severe thrombocytosis, clinically thought to be unknown ET, who had massive myocardial infarction requiring bypass surgery, ventricular assist device and ultimately cardiac transplantation. ET may have devastating cardiovascular consequences and should be considered as a rare cause of myocardial infarction in the young.