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 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.

Figure 1

A total occlusion of the left anterior descending coronary artery (LAD), high-grade proximal stenosis in the first diagonal branch (90%), and a diffuse atherosclerotic left circumflex coronary artery (LCx) are depicted in RAO caudal (a, b), RAO cranial (c), LAO cranial (d), and LAO caudal (e) projections. RAO = right anterior oblique; LAO = left anterior oblique.

Figure 2

A moderate-severe stenosis (70%) in the middle dominant right coronary artery (RCA) is shown in LAO caudal (a) and RAO cranial (b) projections. RAO = right anterior oblique; LAO = left anterior oblique.

Figure 3

Left coronary angiogram in a RAO cranial projection showing (a) dilatation of the LAD culprit lesion with drug-eluting balloon, (b) post predilatation of the lesion using a SC Artimes balloon, and (c, d) successful drug-eluting balloon angioplasty with a TIMI grade II flow. TIMI = thrombolysis in myocardial infarction study group; RAO = right anterior oblique.