PMC9874025_01
ASA, acetylsalicylic acid; CRP, C-reactive protein; CT, computed tomography; DAPT, dual antiplatelet therapy; DES, drug-eluting stent; IABP, intra-aortic balloon pump; LAD, left anterior descending artery; LDH, lactate dehydrogenase; PCI, percutaneous coronary intervention; PEx, plasma exchange; PLT, platelet count; STEMI, ST-elevation myocardial infarction.
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ST-segment elevation myocardial infarction in anterolateral leads (Figure 1). She received 250 mg intravenous lysine acetylsalicylate according to local standard and soon underwent emergent coronary angiography showing proximal left anterior descending (LAD) artery occlusion.
Electrocardiogram showing ST-segment elevation myocardial infarction in anterolateral leads.
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A drug-eluting stent (DES) was implanted with final angiographic evidence of slow-flow and only partial symptom relief and ST-segment elevation reduction on ECG despite good stent position on angiography (see Supplementary material online, Video S1, Figure 2).
Electrocardiogram after primary percutaneous coronary intervention showing partial ST-segment elevation reduction.
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A few hours later, the patient developed severe thrombocytopenia (platelet count 35 000/uL) (Figure 3).
Graphical representation of platelet levels before and after stent thrombosis and the second tirofiban infusion on day 8.
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After repeated consultation with a nephrologist, the need for a diagnosis for such a rapid increase in creatinine levels prompted a subsequent thoraco-abdominal contrast-enhanced CT scan that showed signs of cortical ischaemia of the left kidney (Figure 4) and apical left ventricular thrombosis (Figure 5).
Computed tomography scan demonstrating left cortical kidney ischaemia.
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After repeated consultation with a nephrologist, the need for a diagnosis for such a rapid increase in creatinine levels prompted a subsequent thoraco-abdominal contrast-enhanced CT scan that showed signs of cortical ischaemia of the left kidney (Figure 4) and apical left ventricular thrombosis (Figure 5). The patient remained anuric and developed both clinical and radiological signs of pulmonary congestion (Figure 5), without signs of respiratory distress nor hypoxaemia upon oxygen therapy.
Computed tomography scan showing apical left ventricular thrombosis.
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Finding of schistocytes (>1%) on peripheral blood smear (Figure 6), together with signs of haemolysis (rapid increase of serum lactate dehydrogenase and reduced haptoglobin) and compatible coagulation parameters (normal prothrombin time, partial thromboplastin time, and fibrinogen, see Table 1) lead to suspect thrombotic thrombocytopenic purpura.