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

Trends and Outcomes Following Percutaneous Coronary Intervention in Patients With Myeloproliferative Neoplasms: Insights From National Database

BACKGROUND

Myeloproliferative neoplasms (MPN) are associated with an increased cardiovascular risk including acute coronary syndrome. However, there is a lack of comprehensive data regarding the rate of percutaneous coronary intervention (PCI), as well as the in-hospital characteristics and outcomes for MPN patients.

AIMS

We aimed to evaluate the temporal trends and outcomes of PCI among patients with MPN.

METHODS AND RESULTS

The National Inpatient Sample database from 2016 to 2020 was queried to identify all PCI hospitalizations. Temporal trends and outcomes of patients with and without MPN following PCI were analyzed. Propensity score matching (PSM) was implemented to compare outcomes between MPN and non-MPN groups. 2,237,210 PCI hospitalizations with 7560 (0.27%) patients with MPN were included in this study. Throughout the study period, the prevalence of MPN among PCI admissions remained stable (p-value for trend = 0.12). Within the MPN subgroup, essential thrombocythemia (ET) was the predominant condition (53.2). Patients with MPN had higher prevalence of cardiovascular comorbidities than non-MPN patients. Following PSM, MPNs were significantly associated with a higher risk of blood transfusions (OR: 1.66, 95% CI: 1.22-2.24, p = 0.001) and AKI (OR: 1.39, 95% CI: 1.17-1.65, p < 0.001). In contrast, the risk of in-hospital mortality (OR: 1.18, 95% CI: 0.83-1.69, p = 0.354 and bleeding (OR: 1.43, 95% CI: 0.90-2.27, p = 0.127) did not significantly differ between the two groups.

CONCLUSIONS

Our study demonstrated that while the prevalence of MPN among patients undergoing PCI remained stable, those with MPN faced higher risks of bleeding, blood transfusion and acute kidney injury. Further research is warranted to explore the underlying reasons for these increased risks and to improve outcomes in this high-risk group.

ST-Segment Elevation Myocardial Infarction With Acute Stent Thrombosis as the Initial Presentation of Essential Thrombocythemia

This paper presents a patient with acute coronary syndrome and 100% mid-left anterior descending artery occlusion, complicated by acute stent thrombosis. Subsequent work-up revealed essential thrombocythemia. This case highlights the increased risk of acute coronary syndrome and stent thrombosis in essential thrombocythemia, emphasizing the need for multidisciplinary management.

Secondary thrombocythemia with ST-segment elevation myocardial infarction as the first manifestation: a case report

Secondary thrombocythemia (ST), also called reactive thrombocytosis, is caused by a disorder that triggers increased production by normal platelet-forming cells and is characterized by the abnormally increased number of platelet and megakaryocytes in the bone marrow. Previous reports have found complications from malignant tumors, chronic inflammation, acute inflammation, acute hemorrhage, splenectomy, etc. to be the common causes of ST. However, reports of secondary thrombocytosis caused by antibiotics are limited and there are no reports of secondary thrombocytosis with acute myocardial infarction as the first presentation. If the patient is at high risk of thrombosis, intensive antithrombotic therapy is required. To raise clinicians' awareness of drug-induced secondary thrombocytosis and to enhance antithrombotic therapy for high-risk patients, this article presented a case of drug-induced secondary thrombocytosis with acute ST-segment elevation myocardial infarction as the primary manifestation.

CASE PRESENTATION

An 80-year-old woman was admitted with cardiogenic shock due to post-activity chest pain. She was started on aspirin and clopidogrel antiplatelet therapy, then replaced aspirin with indolibuprofen, which has relatively few side effects. There was no significant decrease in platelet counts during treatment.

CLINICAL DISCUSSION

Secondary thrombocythemia, characterized by nonspecific symptoms, is difficult to diagnose. Secondary thrombocytosis with acute myocardial infarction as the first symptom is uncommon, but is very urgent and associated with a poor prognosis. What's more, cause-specific treatment counts for secondary thrombocythemia. Therefore it is important to search for the causal factor of secondary thrombocytosis. Secondary thrombocytosis caused by cephalosporins is rare. There is a need to arouse the attention of clinicians to the ST caused by cephalosporins and to provide a guide of treatment to these patients.

CONCLUSION

After a thorough analysis of the pertinent literature, we discovered that several retrospective studies demonstrated the effectiveness of cytoreductive therapy in significantly reducing platelet counts. Based on this finding, we prescribed hydroxyurea to our patient, which led to a gradual decrease in platelet count and ultimately resulted in a return to normal levels.

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.

In-Hospital Outcomes of Acute Myocardial Infarction With Essential Thrombocythemia and Polycythemia Vera: Insights From the National Inpatient Sample

Background Acute myocardial infarction (AMI) with essential thrombocythemia (ET) or polycythemia vera is rare, and there are scarce real-world data on its management and impact on in-hospital outcomes. Methods and Results Dates of current retrospective cohort study were obtained from the US National Inpatient Sample from October 2015 to 2019 for hospitalizations with AMI. The primary outcome was in-hospital mortality, and the secondary outcome was major adverse cardiac or cerebrovascular events, stroke, and bleeding; major adverse cardiac or cerebrovascular event was defined by a composite of all-cause mortality, stroke, and cardiac complications. Of the 2 871 934 weighted AMI hospitalizations, 0.27% were with ET and 0.1% were with polycythemia vera. Before propensity matching, AMI hospitalization with ET was associated with increased risk of in-hospital mortality (7.1% versus 5.7%; odds ratio [OR], 1.14 [95% CI, 1.04-1.24]), major adverse cardiac or cerebrovascular events (12.6% versus 9%; OR, 1.36 [95% CI, 1.26-1.45]), bleeding (12.7% versus 5.8%; OR, 2.28 [95% CI, 2.13-2.44]), and stroke (3.1% versus 1.8%; OR, 1.66 [95% CI, 1.46-1.89]). Polycythemia vera was associated with an increased risk of in-hospital mortality (7.8% versus 5.7%; OR, 1.21 [95% CI, 1.04-1.39]) and major adverse cardiac or cerebrovascular events (12.0% versus 9%; OR, 1.18 [95% CI, 1.05-1.33]). After propensity matching, ET was associated with increased risk of bleeding (12.6% versus 6.1%; OR, 2.22 [95% CI, 1.70-2.90]), and AMI with polycythemia vera was not associated with worse in-hospital outcomes. Conclusions AMI hospitalization with ET is associated with high bleeding risk before and after propensity score matching, particularly for hospitalizations treated with percutaneous coronary intervention. The management of AMI requires a multidisciplinary and patient-centered approach to ensure safety and improve outcomes.

Cardiovascular Disease in Myeloproliferative Neoplasms: JACC: CardioOncology State-of-the-Art Review

Myeloproliferative neoplasms are associated with increased risk for thrombotic complications. These conditions most commonly involve somatic mutations in genes that lead to constitutive activation of the Janus-associated kinase signaling pathway (eg, Janus kinase 2, calreticulin, myeloproliferative leukemia protein). Acquired gain-of-function mutations in these genes, particularly Janus kinase 2, can cause a spectrum of disorders, ranging from clonal hematopoiesis of indeterminate potential, a recently recognized age-related promoter of cardiovascular disease, to frank hematologic malignancy. Beyond thrombosis, patients with myeloproliferative neoplasms can develop other cardiovascular conditions, including heart failure and pulmonary hypertension. The authors review the pathophysiologic mechanisms of cardiovascular complications of myeloproliferative neoplasms, which involve inflammation, prothrombotic and profibrotic factors (including transforming growth factor-beta and lysyl oxidase), and abnormal function of circulating clones of mutated leukocytes and platelets from affected individuals. Anti-inflammatory therapies may provide cardiovascular benefit in patients with myeloproliferative neoplasms, a hypothesis that requires rigorous evaluation in clinical trials.

Clinical Study on Characteristics and Risk Factors of Coronary Artery Lesions in Young Patients with Acute Myocardial Infarction

Epidemiological evidence suggests that the incidence of acute myocardial infarction (AMI) among people under 40 years of age has an increasing trend in recent years. Smoking, hypertension, diabetes mellitus, family history, and gender (male) are considered as classic risk factors for CHD, but the pathogenesis of CHD in young people is not exactly the same. Moreover, the relationship between the pattern of coronary artery disease and risk factors in young patients with acute myocardial infarction is inconclusive. In this study, we retrospectively studied the clinical data of 150 AMI patients treated in our hospital from January 2020 to May 2021. The patients were divided into the young group and elderly group according to the difference in age. The number of coronary artery lesions, the degree of coronary artery stenosis, the distribution dominance typing, the position of the lesions, and the presence of collateral circulation were observed and compared between the two groups. Multivariate logistic regression analysis was used to investigate the risk factors affecting coronary artery lesions in young patients with AMI. The results showed that the number of coronary lesions in young patients with AMI was mainly single-vessel, and the dominant type of distribution was mainly right dominant type. The stenosis degree is lighter than that of elderly patients, and the incidence of collateral circulation is lower than that of elderly patients, but the position of the lesions has no obvious regular. Smoking, staying up late, HDL-C, and LDL-C/ApoB were independent factors affecting the number of coronary artery lesions, and the changes of HDL-C and LDL-C/ApoB had an important influence on the degree of coronary stenosis in young patients. This provides a new idea for clinical treatment.

The Assessment of the Platelet Function During the Acute Phase of ST-segment Elevation Myocardial Infarction in Essential Thrombocythemia

We encountered a case of ST-segment elevation myocardial infarction (STEMI) as the first clinical manifestation of essential thrombocythemia (ET). Platelet function tests revealed high thrombogenicity during primary percutaneous coronary intervention compared with general cardiovascular patients, whereas the platelet function two weeks after admission was effectively suppressed by dual antiplatelet therapy. The patient, who lacked cytoreduction, suffered from recurrent STEMI because of poor compliance with antiplatelet drugs. The risk of acute coronary occlusion may be high during the acute phase of STEMI in ET patients because of high thrombogenicity. Insufficient antiplatelet therapy and no cytoreduction are also risk factors for recurrent coronary events.

Percutaneous coronary intervention in a patient with heparin resistance due to essential thrombocythaemia: a case report

Background 

Coronary artery disease is uncommon in patients with essential thrombocythaemia (ET); therefore, no treatment strategies have been established.

Case summary 

A 68-year-old man visited our hospital with worsening effort angina complicated with ET. Coronary angiography (CAG) revealed moderate stenosis of the left main trunk and left anterior descending artery (LAD). We planned to perform percutaneous coronary intervention (PCI) only after the patient’s platelet count had fallen below 600 000/μL. Platelet factor 4 levels were markedly elevated (355.0 ng/mL; the normal range is <20 ng/mL). We observed a de novo lesion in the proximal left circumflex artery and stenosis progression in the LAD at the time of the PCI, neither of which had been detected at the previous CAG. During the PCI procedure, argatroban was infused to maintain the activated clotting time (ACT) above 250 s. The PCI was performed successfully without any complications. Follow-up CAG showed no restenosis, and no bleeding complications were observed during the course.

Discussion 

In patients with ET, it may be useful to measure platelet factor 4 before PCI and to monitor ACT during the procedure. When heparin resistance is suspected based on blood coagulation tests, infusion of direct thrombin inhibitor during PCI may be considered, with anticoagulation monitoring by ACT.

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

Percutaneous coronary intervention in patients with essential thrombocythemia: case reports and literature review

Essential thrombocythemia (ET) can cause systemic vascular thrombosis, but the involvement of coronary arteries is rare. This study is aimed to analyze the characteristics, treatment, and prognosis during follow-up in patients with ET after percutaneous coronary intervention (PCI). A total of eight patients with ET who had coronary heart disease and treated with PCI in our hospital from 2012 to 2018 were retrospectively studied. The basic clinical information with clinical data, data of coronary intervention, application of anti-platelet and platelet reducing drugs, and the results of long-term follow-up were recorded. There were five males and three females with a median age of 67 years. Clinical presentation was unstable angina in four cases, stable angina in one case, ST-elevation myocardial infarction in two cases, and non-ST elevation myocardial infarction in one case. The average platelet count was 722 × 10⁹/L in admission, and hydroxyurea was used in seven cases. Coronary angiography suggested that all eight cases were single-vessel lesion. All the patients received PCI treatment, and Drug-eluting stent (DES) was used in all cases. Six were treated with one stent, one was treated with two stents and one was treated with three stents. After PCI, aspirin, and clopidogrel (or ticagrelor) were used in all cases. During the follow-up, one developed stent thrombus 2 months later, two developed stent restenosis 1 year later. In conclusion, PCI is an effective method of revascularization in patients with ET; but it may be associated with a higher rate of complications including stent thrombus and restenosis.

The Role of Autophagy in Acute Myocardial Infarction

Acute myocardial infarction refers to a sudden death of cardiomyocytes, which leads to a large mortality worldwide. To attenuate acute myocardial infarction, strategies should be made to increase cardiomyocyte survival, improve postinfarcted cardiac function, and reverse the process of cardiac remodeling. Autophagy, a pivotal cellular response, has been widely studied and is known to be involved in various kinds of diseases. In the recent few years, the role of autophagy in diseases has been drawn increasing attention to by researchers. Here in this review, we mainly focus on the discussion of the effect of autophagy on the pathogenesis and progression of acute myocardial infarction under ischemic and ischemia/reperfusion injuries. Furthermore, several popular therapeutic agents and strategies taking advantage of autophagy will be described.