ST segment elevation myocardial infarction as a presenting feature of thrombotic thrombocytopenic purpura

Abstract

Myocardial infarction with ST segment elevation (STE) on electrocardiography (ECG) is a common presentation in emergency rooms across the world. Myocardial injury and necrosis are infrequently the initial presentation in patients with thrombotic thrombocytopenic purpura (TTP). A 48-year-old woman presented with STE myocardial infarction from outside hospital for primary percutaneous coronary intervention. However, her clinical picture was not consistent. Rapid evaluation revealed symptoms associated with microangiopathic hemolytic anemia, thrombocytopenia, acute kidney injury with waxing and waning mental status. A diagnosis of TTP was made with low ADAMST-13 activity. Plasmapheresis was initiated along with intravenous steroid therapy. The patient had a full recovery and went home after full recovery of left ventricular ejection fraction and normal myocardial perfusion studies. Rapid evaluation is needed to identify infrequent causes of STE myocardial infarction. As swift protocols are activated in the emergency room and catheterization laboratories to ensure quality control, it is equally important to integrate all aspects of the patient's clinical and objective data to detect unusual disease entities.

Acute myocardial infarction in a patient with thrombotic thrombocytopenic purpura: a case report and literature review

“…AMI has been associated with TTP, with reported incidence rate varying between 15% and 41% [6,8] . Reported cases of AMI induced by TTP [4,[9][10][11][12][13][14][15][16][17][18][19][20] are summarized in Table 3. A large national database of 4,032 patients with TTP [21] reported 11.1% in-hospital mortality and 5.7% AMI rate.…”

Myocardial Infarction as an Early Presentation in Thrombotic Thrombocytopenic Purpura: A Rare Case Series

“… 3 - 5 However, MI as a presenting or early feature of TTP is rarely seen, with a reported incidence for any cardiac involvement in TTP being 10% to 40% in a few limited clinical cohorts. 7 - 14 This discrepancy between clinical and autopsy findings may account for sudden death resulting from unrecognized cardiac events.…”

“… 11 , 16 Early initiation of plasmapheresis, which involves removing large volume of the patient’s plasma containing any ADAMTS-13 antibody and replacing it with donor plasma with normal ADAMTS-13 activity, is essential to prevent further myocardial damage and associated mortality. 14 , 17 - 20 Furthermore, as evidenced by the above-mentioned cases, continuous cardiac monitoring is vital in patients with TTP given their propensity for developing fatal arrhythmias. Relapsing and refractory cases of TTP like our first case have been effectively treated with rituximab, a monoclonal antibody against CD20 receptors on memory B cells.…”

Severe Thrombotic Thrombocytopenic Purpura (TTP) with Organ Failure in Critically Ill Patients

“…In the case of typical acute coronary syndrome, coronary angiography should at least be discussed. A significant number of patients with TTP and acute coronary syndrome have a detectable thrombus on coronary angiography [50][51][52][53][54]. Angioplasty must then be discussed in the case of coronary involvement (Figure 1).…”