Circ J 2005; 69: 1000 – 1002

Acute Myocardial Infarction in a Patient

With Essential Thrombocythemia
Successful Treatment With Percutaneous
Transluminal Coronary Recanalization

Einosuke Mizuta, MD; Shin-ichi Takeda, MD*; Norihito Sasaki, MD*;

Junichiro Miake, MD; Toshiriro Hamada, MD*; Masaki Shimoyama, MD*;
Fumihito Tajima, MD**; Osamu Igawa, MD*;
Chiaki Shigemasa, MD*; Ichiro Hisatome, MD

A 65-year-old woman with essential thrombocythemia (ET) was admitted to hospital where she was diagnosed
as acute myocardial infarction (AMI). Because of abundant thrombus of right coronary arteries, percutaneous
transluminal coronary recanalization by administration of urokinase was selected as the reperfusion therapy,
resulting in successful revascularization with Thrombolysis in Myocardial Infarction grade III coronary flow.
The maximum creatine kinase reached 507 IU/L, and left ventriculography performed at 1 month after initiation
of both anticoagulant and antiplatelet therapies revealed reduced motion in the inferior wall with an ejection
fraction of 57%. Despite good recovery of left ventricular function, bleeding complications, such as epistaxis or
ecchymoma, which did not require blood transfusion, occurred during the clinical course. Because ET causes not
only thrombus formation but also bleeding tendency, it is very important to carefully follow-up any clotting
abnormality in AMI patients with ET. (Circ J 2005; 69: 1000 – 1002)
Key Words: Acute myocardial infarction; Essential thrombocythemia; Percutaneous transluminal coronary
recanalization

E
ssential thrombocythemia (ET) is a clonal myelo-
proliferative disorder of unknown origin, charac-
terized by a persistent increase in the platelet
count. In the past, ET was described as hemorrhagic throm-
bocytosis,1–3 but recent studies have reported that thrombo-
embolic complications, especially thrombus in the cerebral,
coronary, and peripheral arteries, were more frequent than
hemorrhages in patient with ET.4,5 Pulmonary embolism
and deep-vein thrombosis were less frequent than arterial
thrombus.6 The incidence of acute coronary disease in
patients with ET was reported as 9.4% and that of acute
myocardial infarction (AMI) as more frequent in patients
older than 40 years.7 Smoking and hypertension are risk
factors of arterial ischemic complications, including AMI,
in patients with ET.
(Received December 27, 2004; revised manuscript received April 27,
2005; accepted May 25, 2005)
Divison of Genetic Medicine and Regenerative Therapeutics, Depart-
ment of Regenerative Medicine and Regenerative Therapeutics,
Institute of Regenerative Medicine and Biofunction, Tottori Graduate
School of Medical Science, Tottori University, *Department of
Molecular Medicine and Therapeutics, Division of Multidisciplinary
Internal Medicine, Division of Multidisciplinary Internal Medicine,
Tottori University Faculty of Medicine and **Department of Medi-
cine and Clinical Science, Division of Multidisciplinary Internal
Medicine, Tottori University, Tottori, Japan
Mailing address: Einosuke Mizuta, MD, Division of Genetic Medi-
cine and Regenerative Therapeutics, Department of Regenerative
Medicine and Regenerative Therapeutics, Institute of Regenerative
Medicine and Biofunction, Tottori Graduate School of Medical
Science, 86 Nishicho, Yonago 683-8503, Japan. E-mail:einosuke@
grape.med.tottori-u.ac.jp
Several agents are now available for initial treatment of
ET to prevent thrombus.8 There is evidence that hydrox-
yurea, which controls platelets, is effective in preventing
thrombus in ET patients at high risk for systemic artery
disease.9 Low-dose aspirin therapy (100 mg/day) reduces
coronary thrombosis without increasing bleeding complica-
tions in patients with elevated platelet count and common
atherosclerotic risk factors.7 There are many reports about
the efficacy of drug therapy for preventing coronary artery
disease in patients with ET, but no guidelines to treat AMI
in such patients, as ET causes the high-risk complications
of thrombosis, as well as hemorrhage, during acute treat-
ment of AMI.
We present a case of ET accompanied by AMI which
was characterized by both coronary artery thrombus and
bleeding during the clinical cause.
Case Report
A 65-year-old woman visited the Emergency Depart-
ment of Tottori University Hospital because of severe chest
pain lasting for 3 h. She was a smoker and had a past histo-
ry of hypertension, chronic renal failure, and ET, but did
not have a family history of heart disease or hemorrhagic
disorder. She had been already treated with hydroxyurea
and ticlopidine because of the previous diagnosis of ET
when her platelet count was 1,500,000 /mm3. The vital
signs on admission were as follows: blood pressure,
140/76 mmHg; pulse rate, 64 beats/min, regular; tempera-
ture, 35.4°C. Laboratory results were as follows: white
blood cell count, 13,400 /mm3; hemoglobin, 12.3 g/dl;

Circulation Journal Vol.69, August 2005

MI and Thrombocythemia
Fig 1. Angiography of the right coronary artery before PTCR.
platelet count, 469,000 /mm3; serum sodium, 143 mmol/L;
serum potassium, 4.1 mmol/L; chlorine, 102 mmol/L; blood
urea nitrogen 29 mg/dl; serum creatinine, 1.61 mg/dl; serum
glutamate oxaloacetate transaminase, 15 IU/L; serum
glutamate pyruvate transaminase, 18 IU/L; serum lactate
dehydrogenase, 458 IU/L; serum creatine kinase (CK),
173 IU/L; CK-MB, 17 IU/L; blood sugar, 144 mg/dl; C
reactive protein, 0.08 mg/dl; serum troponin T levels were
high. No pulmonary congestion was observed on chest X-
ray. Electrocardiography revealed heart rate, 52 beats/min,
sinus rhythm; ST segment elevation in leads II and III, and
augmented voltage foot (aVF); poor R progression in leads
III and aVF. Echocardiography showed that the inferior
wall motion was severely reduced. These findings were
compatible with AMI accompanied by ET, so intravenous
heparin (3,000 U), intravenous and oral nitroglycerin
(2.5 mg), and oral aspirin (200 mg) were initiated and
emergency coronary catheterization was performed. When
she arrived at the catheter laboratory, her chest pain had
entirely disappeared, and the ST segment elevation had
recovered and an inverted T wave appeared in leads II, III,
and aVF. Coronary angiography (CAG) revealed that the
mid region of the right coronary artery (RCA) was ob-
structed by abundant thrombus with Thrombolysis in Myo-
cardial Infarction (TIMI) grade II flow (Fig 1). Because the
thrombus was mainly composed of platelet and fibrin,10
percutaneous transluminal coronary recanalization (PTCR)
with intra-right coronary injection of urokinase (240,000
units) was selected as the early reperfusion therapy, result-
ing in improving RCA flow from TIMI grade II to TIMI
grade III.
Subsequently, she was treated with anticoagulant and
antiplatelet drugs, such as heparin, aspirin, ticlopidine, and
warfarin, to prevent the formation of new thrombus and to
dissolve the existing multiple thrombi. Hydroxyurea was
continued to control the platelet count. As a result, bleeding
time was prolonged to 8 min and the platelet aggregation
test showed that 10μmol/L ADP-induced secondary aggre-
gation was inhibited. The maximum concentration of CK
was 507 IU/L at 24 h after the onset of chest pain, and no
Circulation Journal Vol.69, August 2005
1001
Fig 2. Angiography of the right coronary artery after the procedure.
remarkable complications did not occur during her clinical
course other than ecchymoma at the puncture site of the
right femoral artery, which did not appear until the day
after angiography. Epistaxis occurred frequently, but was
stopped by compression of the nose for a few minutes. The
size of the ecchymoma did not increase and vascular echo
study showed extravasation of blood had already stopped.
These complications did not cause a severe anemia that re-
quired blood transfusion. Von Willebrand factor is known
to play crucial role in the onset of arterial thrombosis11–15
and her plasma von Willebrand factor was high at 184%.
One month later, the ecchymoma had disappeared, and
so a treadmill test and repeat CAG were performed. The
treadmill test showed no ischemic change under sufficient
load. Although there was still moderate stenosis in the mid
RCA (Fig 2), CAG revealed that blood flow had dra-
matically improved and the thrombus had disappeared as
expected. Left ventriculography showed that inferior wall
motion had improved. Her platelet count was kept stable at
approximately 600,000 /mm3.
Discussion
ET is a myeloproliferative disorder characterized by
abnormal proliferation of megakaryocytes and it causes
thrombus formation in systemic arteries including the coro-
nary arteries. In AMI associated with ET, the affected coro-
nary artery is often occluded with a large amount of throm-
bus, thus a careful therapeutic strategy is required for
successful revascularization. We report here that PTCR
followed by sufficient antiplatelet and anticoagulant thera-
py resulted in a good clinical course of AMI in a patient
with ET.
We selected PTCR for the early reperfusion therapy
rather than balloon angioplasty because the occlusion was
caused by abundant thrombus. In addition, we thought that
the peripheral blood circulation might recover spontane-
ously when cardiac catheterization began, because by that
time her chest pain had disappeared with recovery of ST
segment elevation.
1002
We consider that it is rational to carefully monitor of the
inhibition of platelet aggregation in patient with ET be-
cause the complications of ET are not only thrombus but
also hemorrhage. Regarding the anticoagulation therapy for
patient with ET, we treated with aspirin, ticlopidine and
warfarin and the patient’s bleeding time was increased to
8 min and ADP-induced secondary aggregation was in-
hibited.
Moreover, we treated with hydroxyurea to decrease the
platelet count. Platelets are a major source of von Willebrand
factor,11–15 which is known to play a major role in the onset
of coronary arterial thrombosis. In the present patient, von
Willebrand factor was high (184%), emphasizing the need
to control the platelet count.
It is also important to control the risk factors for prevent-
ing ischemic heart disease in patients with ET, especially
arterial blood pressure and cigarette smoking, because a
previous study has shown that they have strong relation
with the thromboembolic complications of ET.7 It has been
reported that in patients with ET who also have hyperten-
sion or who smoke, the blood platelets facilitate the
endothelial injury, which increases the possibility of throm-
bosis.16 The present patient was a habitual smoker and had
apast history of hypertension, so we persuaded her to quit
smoking immediately and monitored her blood pressure
very carefully.
In summary, a case of ET had a good clinical course
after AMI treated by PTCR followed by anticoagulant and
antiplatelet therapy. Careful follow-up of any clotting
abnormality is necessary for AMI patients with ET.
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