70-year-old female with no Aprevious cardiac history resented with complaints of severe chest and back pain lasting for 20 minutes. She had a past history of type 2 diabetes mellitus for five years and hypertension fo...70-year-old female with no Aprevious cardiac history resented with complaints of severe chest and back pain lasting for 20 minutes. She had a past history of type 2 diabetes mellitus for five years and hypertension for twenty years, but denied a history of hyperlipidemia, smoking or hemorrhagic disorder. There was no family history of coronary artery or hematologic disease. On physical examination, the blood pressure was 145/90 mmHg and the heart rate was 102 beats/rain. Cardiac examination revealed normal S1 and $2 sounds. There were no murmors or clicks. The lungs were clear on auscultation. Hepatosplenomegaly or lymphadenopathy was not detected. Her electrocardiogram showed ST elevations in lead V1-V6, consistent with acute anterior MI and echocardiogram supported the diagnosis with a slight reduction in wall motion in the anterior region. Complete blood count revealed a white blood cell count of 9 000/mm3 with a normal differential, red blood cell count of 3.5×106/mm3, hematocrit of 40.2%, and platelet count of 238 000/mm3. Emergent coronary angiography demonstrated proximal thrombotic occlusion of the left anterior descending artery （LAD） （Figure 1A）. A loading dose of 600 mg clopidogrel and 300 mg acetylsalicylic asid （ASA） was given immediately. After administration of 10 000 U intravenous heparin, angioplasty was performed and a 3.0 mm×20.0 mm bare metal stent （BMS） was deployed to the LAD. Repeat angiogram revealed TIMI III flow in the LAD （Figure 1B）. Five days later, the patient was discharged without any bleeding or thrombotic complications. She was receiving dual antiplatelet therapy with ASA and clopidogrel 150 mg daily. However, she was admitted to our hospital again with severe chest pain just one day after dischargement. Her platelet count of 487 000/mm3 was remarkable in comparison with her previous complete blood count. Electrocardiogram showed ST elevations in leads V1-V6, suggestive of an acute anterior reinfarction. Coronary angiography revealed in- stent thrombosis in the LAD （Figure 1C）. After balloon angioplasty （Figure 1D）, TIMI III flow was achieved and no residual stenosis was seen. During her follow-up, complete blood cell counts showed gradually increasing platelets up to 818 000/ram3, on the fourth day of sub- acute stent thrombosis. Peripheral blood smear examination was performed and showed markedly increased large thrombocytes with anisothrombia, consistent with essential thrombocythemia （ET）. Soon after, platelet-loweringtherapy with hydroxyurea （500 mg/d） was initiated, One week after the initiation of hydroxyurea, the platelet count was decreased to 220 000/ram3. The patient remained on hydroxyurea and dual antiplatelet therapy. She was free of symptoms for three months during the follow-up period and her platelet counts remained within the normal range.展开更多
文摘70-year-old female with no Aprevious cardiac history resented with complaints of severe chest and back pain lasting for 20 minutes. She had a past history of type 2 diabetes mellitus for five years and hypertension for twenty years, but denied a history of hyperlipidemia, smoking or hemorrhagic disorder. There was no family history of coronary artery or hematologic disease. On physical examination, the blood pressure was 145/90 mmHg and the heart rate was 102 beats/rain. Cardiac examination revealed normal S1 and $2 sounds. There were no murmors or clicks. The lungs were clear on auscultation. Hepatosplenomegaly or lymphadenopathy was not detected. Her electrocardiogram showed ST elevations in lead V1-V6, consistent with acute anterior MI and echocardiogram supported the diagnosis with a slight reduction in wall motion in the anterior region. Complete blood count revealed a white blood cell count of 9 000/mm3 with a normal differential, red blood cell count of 3.5×106/mm3, hematocrit of 40.2%, and platelet count of 238 000/mm3. Emergent coronary angiography demonstrated proximal thrombotic occlusion of the left anterior descending artery （LAD） （Figure 1A）. A loading dose of 600 mg clopidogrel and 300 mg acetylsalicylic asid （ASA） was given immediately. After administration of 10 000 U intravenous heparin, angioplasty was performed and a 3.0 mm×20.0 mm bare metal stent （BMS） was deployed to the LAD. Repeat angiogram revealed TIMI III flow in the LAD （Figure 1B）. Five days later, the patient was discharged without any bleeding or thrombotic complications. She was receiving dual antiplatelet therapy with ASA and clopidogrel 150 mg daily. However, she was admitted to our hospital again with severe chest pain just one day after dischargement. Her platelet count of 487 000/mm3 was remarkable in comparison with her previous complete blood count. Electrocardiogram showed ST elevations in leads V1-V6, suggestive of an acute anterior reinfarction. Coronary angiography revealed in- stent thrombosis in the LAD （Figure 1C）. After balloon angioplasty （Figure 1D）, TIMI III flow was achieved and no residual stenosis was seen. During her follow-up, complete blood cell counts showed gradually increasing platelets up to 818 000/ram3, on the fourth day of sub- acute stent thrombosis. Peripheral blood smear examination was performed and showed markedly increased large thrombocytes with anisothrombia, consistent with essential thrombocythemia （ET）. Soon after, platelet-loweringtherapy with hydroxyurea （500 mg/d） was initiated, One week after the initiation of hydroxyurea, the platelet count was decreased to 220 000/ram3. The patient remained on hydroxyurea and dual antiplatelet therapy. She was free of symptoms for three months during the follow-up period and her platelet counts remained within the normal range.
