idiopathic thrombocytopenic purpura ( itp ) is an autoimmune disorder with a low platelet count characterized by premature platelet destruction and suppression of platelet production mediated by autoantibodies , which may predispose to bleeding.1 ) since severe bleeding is uncommon when the platelet count exceeds 30000/ul , treatment is usually indicated when a platelet count is less.2 ) considering the crucial role of platelets in thrombotic events , the prevalence of coronary artery disease ( cad ) in patients with itp seems to be uncommon , especially when the platelet count is low .
patients with itp have increased risks for thrombosis and atherosclerosis associated with larger and more adhesive platelets , direct endothelial damage,3 ) and negative effects of therapy with steroids4 ) or intravenous immunoglobulin ( ivig).5 ) since relatively few case reports have been reported , no recommendations have been issued regarding the management of thrombocytopenic patients with cad . moreover , considering the high bleeding risk , a careful balance must be achieved between the prevention of thrombosis and hemorrhagic risk .
we present two patients with itp and cad who were successfully treated using different therapeutic strategies .
a 65-year - old man was transferred to our emergency room ( er ) with epigastric pain .
the patient had taken oral steroids for itp ( prednisolone 55 mg / day ) , which had increased the platelet count from 8000 to 73000/ul . at er
electrocardiography ( ecg ) showed st segment elevation in leads v 1 - 3 , which was consistent with an anterior wall acute myocardial infarction .
cardiac enzyme ( troponin i ) was elevated ( 7.61 ng / ml , normal range : 0.0 - 0.1 ng / ml ) .
blood coagulation tests showed a prothrombin time ( pt ) of 13.4 seconds { international normalized ratio ( inr ) 1.15 } and an activated partial thromboplastin time ( aptt ) of 35.1 seconds .
primary percutaneous coronary intervention ( pci ) with loading dose clopidogrel 300 mg and aspirin ( asa ) 500 mg was performed .
coronary angiography ( cag ) revealed nearly total occlusion with the thrombolysis in myocardial infarction ( timi ) grade 2 in the proximal left anterior descending coronary artery ( lad ) ( fig .
after balloon angioplasty , one drug eluting stent ( des , 3.028 mm , coroflex please ; b. braun melsungen ag , germany ) was implanted in the proximal lad , and achieved an optimal angiographic result and timi grade 3 flow in the lad ( fig .
1b ) . after removing the sheath introducer , careful manual compression of the femoral puncture site was performed and no bleeding complication occurred .
daily treatment with asa 100 mg and clopidogrel 75 mg was continued and no symptoms or bleeding complication were noted after discharge . a 67-year - old man with a 10-year history of treatment resistant itp was admitted with effort - induced chest pain ( canadian cardiovascular society class iii ) .
ten years previously , a splenectomy was performed but it was ineffective in increasing platelet count . on admission ,
blood coagulation tests showed a pt of 11.2 seconds ( inr 1.04 ) and an aptt of 30.2 seconds .
concerning about bleeding due to a low platelet count and gastrointestinal disturbance , antiplatelet medication maintained on a single antiplatelet regimen ( clopidogrel 75 mg / day ) . on hospital
he was administered two consecutive courses of ivig and subsequent platelet transfusion and intravenous ( iv ) steroid ( methylprednisolone 500 mg ) .
cag revealed 60% stenosis in the left main trunk , total occlusion of the proximal lad ( timi grade 0 distal flow ) with collateral flow timi grade 2 from the rca to the lad , and 50% luminal stenosis in the middle rca ( fig .
after careful discussion with the patient , a coronary artery bypass graft ( cabg ) strategy was chosen .
after sheath removal , the perclose proglide 6 f device ( abbott vascular , usa ) was applied at the femoral puncture site without bleeding complication . while preparing for cabg , the platelet count dropped again to 14000/ul .
after 2 days of ivig , iv steroid , and platelet transfusion , the platelet count increased to 189000/ul .
cabg was performed using off - pump techniques , and the lima was connected to the lad . to minimize the operation time
initial activated clotting time was 136 seconds , iv unfractionated heparin 6000 iu ( 100 iu / kg ) was administered .
a 65-year - old man was transferred to our emergency room ( er ) with epigastric pain .
the patient had taken oral steroids for itp ( prednisolone 55 mg / day ) , which had increased the platelet count from 8000 to 73000/ul . at er
electrocardiography ( ecg ) showed st segment elevation in leads v 1 - 3 , which was consistent with an anterior wall acute myocardial infarction .
cardiac enzyme ( troponin i ) was elevated ( 7.61 ng / ml , normal range : 0.0 - 0.1 ng / ml ) .
blood coagulation tests showed a prothrombin time ( pt ) of 13.4 seconds { international normalized ratio ( inr ) 1.15 } and an activated partial thromboplastin time ( aptt ) of 35.1 seconds .
primary percutaneous coronary intervention ( pci ) with loading dose clopidogrel 300 mg and aspirin ( asa ) 500 mg was performed .
coronary angiography ( cag ) revealed nearly total occlusion with the thrombolysis in myocardial infarction ( timi ) grade 2 in the proximal left anterior descending coronary artery ( lad ) ( fig .
after balloon angioplasty , one drug eluting stent ( des , 3.028 mm , coroflex please ; b. braun melsungen ag , germany ) was implanted in the proximal lad , and achieved an optimal angiographic result and timi grade 3 flow in the lad ( fig .
1b ) . after removing the sheath introducer , careful manual compression of the femoral puncture site was performed and no bleeding complication occurred .
daily treatment with asa 100 mg and clopidogrel 75 mg was continued and no symptoms or bleeding complication were noted after discharge .
a 67-year - old man with a 10-year history of treatment resistant itp was admitted with effort - induced chest pain ( canadian cardiovascular society class iii ) .
ten years previously , a splenectomy was performed but it was ineffective in increasing platelet count . on admission ,
blood coagulation tests showed a pt of 11.2 seconds ( inr 1.04 ) and an aptt of 30.2 seconds .
concerning about bleeding due to a low platelet count and gastrointestinal disturbance , antiplatelet medication maintained on a single antiplatelet regimen ( clopidogrel 75 mg / day ) . on hospital
he was administered two consecutive courses of ivig and subsequent platelet transfusion and intravenous ( iv ) steroid ( methylprednisolone 500 mg ) .
cag revealed 60% stenosis in the left main trunk , total occlusion of the proximal lad ( timi grade 0 distal flow ) with collateral flow timi grade 2 from the rca to the lad , and 50% luminal stenosis in the middle rca ( fig .
after careful discussion with the patient , a coronary artery bypass graft ( cabg ) strategy was chosen .
after sheath removal , the perclose proglide 6 f device ( abbott vascular , usa ) was applied at the femoral puncture site without bleeding complication . while preparing for cabg , the platelet count dropped again to 14000/ul .
after 2 days of ivig , iv steroid , and platelet transfusion , the platelet count increased to 189000/ul .
cabg was performed using off - pump techniques , and the lima was connected to the lad . to minimize the operation time , a single graft to the lad was made rather than multivessel grafting .
initial activated clotting time was 136 seconds , iv unfractionated heparin 6000 iu ( 100 iu / kg ) was administered .
although the prevalence of cad in patients with itp seems to be rare , considering the crucial role of platelets , the coexistence of itp and cad is not unusual .
if a patient with chronic thrombocytopenia has cad , then the presence of known cardiovascular risk factors , such as a relevant family history , hypertension , diabetes mellitus , dyslipidemia , chronic kidney disease , and cigarette smoking should be considered .
bleeding tendency is one of the most important problems of itp and cad , especially in patients with des , because of long - term dual antiplatelet therapy .
thus , the appropriate use of periprocedural support treatment to increase platelet numbers probably minimized bleeding . in itp , thrombocytopenia itself does not protect against thrombosis , and cases of acute coronary syndrome have been reported.3 ) accordingly it appears that some factors other than platelet number are involved .
patients with itp may be predisposed to coronary thrombosis because their platelets are larger and more adhesive to vascular surfaces.6 ) furthermore , an antigenic mimicry between platelets and endothelial cells may also lead to endothelial damage by autoantibodies directed against platelet surface antigens.3 ) in addition , steroid and ivig treatment may be related to an increased risk of cad and thrombosis in itp.4)5 ) steroids induce metabolic changes as well as a hypercoagulable state , both of which may promote atherosclerosis.7 ) infusion of ivig may induce expansion of plasma volume with subsequent hypertensive reactions , increased oxygen demand , and cardiac decompensation,8 ) and also increase in plasma and blood viscosity.9 ) in case 1 , steroid therapy appeared to play a role as a precipitating agent with another factor , such as hyperglycemia .
percutaneous coronary intervention has been successfully performed in itp despite markedly different platelets counts ( range from 3000/ul10 ) to 200000/ul11 ) ) without major bleeding . however
, performance of pci in a patient with itp presents a particular problem that requires sufficient inhibition of platelet function to prevent stent thrombosis ( st ) , but not enough to cause bleeding . because des requires long - term maintenance with dual antiplatelet agents to prevent st , bare metal stents ( bms ) are generally implanted during pci in order to use the dual antiplatelet therapy in as less time as possible .
however , like our case 1 , des can be safely implanted in a background of itp and cad without any serious bleeding complications.11)12 ) although neskovic et al.13 ) proposed a management algorithm of bms placement followed by lifelong asa and short termed clopidogrel , we believe that des can be applied safely in this subset of patients if platelet number and bleeding tendency are careful monitored . regarding the vascular approach , a radial artery is preferred due to evidence of a lower risk of bleeding , as well as easy hemostatic compression , early ambulation , and patient comfort.10)12)14 ) however , a vascular approach
should be decided on having considered platelet count , degree of emergency , characteristics of coronary lesions , and vascular integrity . as described for our patients , both transfemoral and transradial approaches were successfully used for cag or pci without any bleeding complication.15 ) in addition , arterial sealing and closing devices have been demonstrated to be effective at achieving immediate hemostasis after sheath removal and to allow early ambulation , reduce local complications , and provide patient comfort.16 ) such hemostatic devices may be especially helpful in patients with a high risk of bleeding and with performing through transfemoral route . historically ,
cabg is generally preferred to pci in these itp patients because it produces better results for all types of lesion and facilitates the management of antiplatelet therapy after the procedure.17 ) despite the low platelet count , cabg was successfully carried out with a moderate increase in bleeding risk compared to cabg in the general population .
the risk of significant bleeding was higher in the itp population , 12.5% , compared to 5.4% in the general population.18 ) perioperative treatments , such as prophylactic splenectomy , steroid treatment , ivig , and platelet transfusion , may reduce complication rates by increasing platelet counts . in particular , some authors have suggested preoperative ivig as a treatment of choice,18 ) especially when a rapid increase in platelet count is needed ( as occurred in case 2 ) . however , as mentioned above , associations have been reported between cad and perioperative management , such as ivig , steroid , and platelet transfusion .
case 2 underwent cabg using an off - pump technique and a lima conduit . an off - pump cabg technique may be a safer strategy , because it avoids the use of an extracorporeal circuit and , thus , minimizes platelet dysfunction.19 ) one of the benefits of using off - pump cabg rather than conventional cabg is the significant reduction in blood loss and the reduced need for transfusion of platelets and other blood products.20 ) moreover , given the minimal bleeding rate , extending conduit use including internal mammary arteries appears appropriate.18 ) we present two patients with itp and cad , who were treated differently , using pci and cabg .
although the optimal management of thrombocytopenic patients with cad remains uncertain , our experiences of the two described cases suggest that both coronary revascularization techniques can be a useful strategy in these patients , even when thrombocytopenia is severe .
we conclude that various revascularization strategies are possible in itp patients with cad and that treatment should be individualized after taking into consideration initial diagnosis and patient variables , such as platelet count and bleeding tendency .
 idiopathic thrombocytopenic purpura ( itp ) is an autoimmune disorder with a low platelet count characterized by premature platelet destruction and suppression of platelet production mediated by autoantibodies , which may predispose to bleeding . 
 although the prevalence of coronary artery disease ( cad ) in itp seems to be rare , their co - occurrence is not unusual . 
 patients with itp have increased risks for thrombosis and atherosclerosis associated with hemostatic factors , endothelial damage , and the negative effects of steroid and immunoglobulin therapies . 
 thus , the coexistence of itp and cad presents complex problems requiring a balance between hemorrhagic risk and prevention of thrombosis . here , the authors present two patients with itp , who were revascularized in different ways for cad . 
 although the optimal management of thrombocytopenic patients with cad is uncertain , individualized treatment modalities can be useful in patients with itp and cad . 
Introduction
Cases
Case 1
Case 2
Discussion