Abstract
Introduction Immune thrombocytopenia (ITP) is an autoimmune disorder causing low platelet counts and bleeding tendencies; however, paradoxically, ITP and its therapies can increase thrombotic risk. ITP patients presenting with acute coronary syndrome (ACS) pose a clinical dilemma: they have high hemorrhagic risk but require antithrombotic therapy for ACS and are also at a greater risk of thrombotic events. Managing ACS in the setting of ITP is therefore challenging. Evidence to guide treatment is limited; such patients are rare and are largely excluded from major ACS trials, leaving guidelines ambiguous. We conducted a retrospective study to characterize real-world management strategies and outcomes in patients with ITP who developed ACS.
Methods We identified 59 adults with confirmed ITP who presented with ACS in our center. The cohort included 15 ST-elevation MI (STEMI) patients, 20 non-STEMI patients, and 24 unstable angina patients. We collected data on ACS management (percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), or medical management without revascularization) and ITP-directed therapies (platelet transfusion, intravenous immunoglobulin (IVIG), and thrombopoietin receptor agonist (TPO-RA) used during hospitalization. In-hospital outcomes were assessed, with bleeding events graded by the Bleeding Academic Research Consortium (BARC) criteria and ischemic events defined as major adverse cardiovascular events (MACEs: composites of death, recurrent MI, stroke, or stent thrombosis). We compared in-hospital outcomes across treatment modalities (PCI vs. CABG vs. medical management) and according to the use of thrombocytopenia-directed interventions.
Results Among the 59 ITP patients with ACS, approximately 70% underwent coronary revascularization (PCI in 30%, CABG in 40%), whereas the remaining 30% were managed medically without invasive intervention. This revascularization rate is somewhat lower than that in general ACS populations, reflecting a cautious approach due to bleeding concerns. Most patients (over 80%) received ITP-directed therapy to increase platelet counts. IVIG was administered in 40% of the patients and platelet transfusions in 25% (typically for platelet counts <30×10^9/L or preprocedurally), and approximately 15% of the patients received a TPO-RA during hospitalization. Corticosteroids were used as first-line ITP treatment in the majority of patients. These practices are consistent with reported case series in which the majority of ACS patients with ITP required immunosuppressive therapy or transfusions to enable safe cardiac care. Overall, bleeding events occurred in ~17% of patients (any BARC ≥2), with 8% experiencing major bleeding (BARC grade 3–5). One CABG patient experienced severe bleeding requiring surgical re-exploration (BARC 4), and no intracranial or fatal hemorrhages occurred. MACEs occurred in approximately 15% of patients. The in-hospital mortality rate was 5%, which was consistent with prior analyses, and we observed recurrent MI in 7%, ischemic stroke in 3%, and definite stent thrombosis in 5% of the patients. The outcome patterns varied with management strategy. Patients managed conservatively (medical therapy only) had no major bleeds (0% BARC ≥3) but a higher incidence of recurrent ischemia, whereas invasively treated patients (PCI or CABG) achieved prompt revascularization at the cost of increased bleeding risk. The rate of major bleeding was highest in the CABG subgroup (~10%), whereas the incidence of major bleeding was moderate in patients treated with PCI (8%), and there was one case of stent thrombosis (notably in a patient who required early discontinuation of dual antiplatelet therapy). Patients requiring platelet transfusions for severe thrombocytopenia experienced higher complication rates than those not requiring transfusions did, in line with prior reports linking transfusions to increased cardiovascular complications.
Conclusion Our study demonstrates that, with appropriate platelet count management, standard ACS interventions (PCI or CABG) are feasible in many ITP patients, with in-hospital mortality rates similar to those in ACS patients without ITP. Improved multidisciplinary strategies are needed to minimize bleeding while preventing ischemic events in this high-risk population.
