Unusual Presentation of Thrombotic Thrombocytopenic Purpura With Non-ST-Elevation Myocardial Infarction

Abstract

Thrombotic thrombocytopenic purpura (TTP) is a multisystem disease characterized by disseminated thrombus formation in the arterioles and capillaries. Patients usually present with weakness, subtle mental changes, fever, and acute kidney injury. Cardiac symptoms, such as chest pain or arrhythmia, have been reported but were rarely the sole presenting symptom. We report the case of a 68-year-old woman with acute non-ST-elevation myocardial infarction who was found to have TTP. Prompt diagnosis of TTP is essential because traditional approaches to manage an acute coronary event, inclusive of dual antiplatelet therapy and percutaneous coronary intervention, might be contraindicated due to an increased risk of bleeding. Early administration of steroids and urgent initiation of plasmapheresis to improve platelet count would be crucial initial steps in the management of these patients.

A Case of Thrombotic Thrombocytopenic Purpura and ST-Elevation Myocardial Infarction: An Unusual Correlation

“…Early diagnosis and management are mandatory to prevent high mortality from TTP-induced cardiac morbidity. Severe morbidity and mortality are reported to be higher in TTP patients with high levels of positive cardiac biomarkers [ 9 ]. It has been reported that the mortality risk increases threefold in patients with TTP who have serum troponin levels greater than 0.25 ug/ml [ 10 ].…”

Non-ST-Segment Elevation Myocardial Infarction As Initial Thrombotic Event of Thrombotic Thrombocytopenic Purpura: A Rare Challenging Case

“…However, TTP-induced MI as presenting event of TTP is extremely rare [ 5 ]. We have tabulated the reported cases of TTP-induced cardiac events in Table 2 [ 4 - 8 ].…”

“…Without enough ADAMTS13, vWF can build up in the bloodstream, leading to the formation of micro-clots [ 3 ]. In TTP, the patient commonly manifests renal and neurological symptoms; however, cardiovascular involvement is not widely reported in the literature [ 4 ]. Herein, we present a case of myocardial infarction (MI) as an initial thrombotic event of TTP, masking other symptoms.…”

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

“…Timely identification and management are imperative but difficult. Notably, TTP patients with elevated levels of positive cardiac biomarkers have morbidity and increased mortality [4] . Elevated serum troponin (>0.25 g/mL) has been associated with markedly higher risk of mortality and refractory risk in patients diagnosed with TTP [5] .…”

“…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.…”