A associação entre a doença arterial coronariana e a púrpura trombocitopênica é rara e implica em algumas dificuldades quando a revascularização se faz necessária. Relatamos um caso dessa associação, com importante comprometimento coronariano, tratado percutaneamente com o implante de stent.
Angioplastia transluminal coronariana em portador de púrpura trombocitopênica idiopática
São Paulo, SP
Real e Benemérita Associação Portuguesa de Beneficência - São Paulo
A associação entre a doença arterial coronariana e a púrpura trombocitopênica é rara e implica em algumas dificuldades quando a revascularização se faz necessária. Relatamos um caso dessa associação, com importante comprometimento coronariano, tratado percutaneamente com o implante de
A púrpura trombocitopênica Idiopática, também conhecida como doença de Werlhof, tem incidência rara na população geral. Ocorre em todas as faixas etárias, nas formas aguda e crônica. As crianças apresentam, predominantemente, a forma aguda, com o acometimento equalizado de ambos os sexos. Já os adultos apresentam, principalmente, a forma crônica, com maior incidência no sexo feminino (3:1)1. Ambas as formas têm como fisiopatologia a produção de anticorpos anti-plaquetas, usualmente da classe IgG, levando à destruição acelerada das plaquetas pelo sistema retículo-endotelial.
A associação da púrpura com a doença arterial coronariana também é rara. Relatamos um caso de associação entre essas duas doenças, tratado, percutaneamente, com o implante de dois
Homem de 54 anos, relatando dor precordial típica associada a dispnéia, com início há cerca de 4 meses, associada a médios esforços, com piora rápida e, a uma semana da internação, apresentando-se com dor a pequenos esforços e mesmo em repouso.
Como antecedentes relatava ser hipertenso e diabético, em uso de captopril – 75 mg/d e de glibenclamida – 10 mg/d. Referia também ser portador de púrpura trombocitopênica, sendo acompanhado, regularmente, por hematologista de sua cidade e fazendo uso de prednisona – 60 mg/d, não apresentando sangramentos patológicos nos últimos meses. Negava antecedentes familiares de doença arterial coronariana, tabagismo ou hipercolesterolemia.
Ainda em sua cidade, foi submetido a cinecoronariografia que mostrou circulação coronariana de dominância esquerda com lesões graves nas artérias descendente anterior (DA), circunflexa (CX) e no ramo primeiro marginal esquerdo (ME-1) (
O paciente foi encaminhado para a realização de cirurgia de revascularização do miocárdio. À admissão, o hemograma mostrou Hb de 10,4 g/dl, Ht de 28,8% e plaquetopenia acentuada com 8.000 plaq/mm3. Não havia outras alterações laboratoriais dignas de nota.
O caso foi avaliado pela hematologia, que tratou, primeiramente a anemia e a plaquetopenia, iniciando também a administração de metil-prednisolona e imunoglobulina e orientando a realização da cirurgia, somente após a obtenção de pelo menos 90.000 plaq/mm3. Entretanto, mesmo após várias transfusões ao longo de 20 dias, atingiu-se um máximo de 86.000 plaq/mm3 (
O eletrocardiograma prévio mostrava ritmo sinusal, com alterações difusas e inespecíficas da repolarização ventricular.
O paciente foi então submetido a dissecção da artérial braquial direita, decorrida sem incidentes. No dia do procedimento o paciente apresentava uma contagem de 15.000 plaq/mm3. Após a dissecção da artéria braquial foi administrada heparina EV na dose de 70 U/Kg e utilizado um cateter-guia modelo
Após a constatação de resultado satisfatório em ambas as artérias tratadas, encerrou-se o procedimento. A artéria braquial foi suturada com um fio prolene 6-0, não se observando a ocorrência posterior de sangramentos ou hematomas.
No seguimento intra-hospitalar, o paciente apresentou boa evolução, com melhora do quadro anginoso. A CKMB pré-ATC era de 42 U/l, havendo normalização já nas primeiras 24h (
Embora o grupo de hematologia não aconselhasse a utilização de anti-plaquetários, optou-se, em comum acordo, administrar enoxaparina por via subcutânea na dose de 1 mg/kg/dia durante o período hospitalar. Entretanto, nas primeiras 24h após o início da administração da droga houve 3 episódios de epistaxe, e nova contagem de plaquetas revelou a concentração de 11.000/mm3. A enoxaparina foi suspensa e o paciente mantido sem qualquer tipo de heparina ou anti-plaquetário. Dois dias após, recebeu alta hospitalar, evoluindo sem precordialgia ou sangramentos. Recebeu orientação de controle rigoroso com o hematologista de sua cidade, sendo-lhe solicitado a liberação de pelo menos um antiagregante, assim que se verificasse valores de concentração plaquetária que permitissem a utilização de tais drogas.
Em reavaliação telefônica recente, 4 meses após o procedimento, o paciente apresenta-se sem angina. Durante esse período não iniciou o uso de qualquer droga antiplaquetária, por recomendação de seu hematologista, devido à persistência da plaquetopenia acentuada e atingiu um máximo de 20.000 plq/mm3, sendo a maioria dos valores inferiores a 10.000; última contagem em 22/06/04 mostrava 3.000 plq/mm3. Continua sob uso de corticóides e imunoglobulinas, aguardando melhora para ser submetido a esplenectomia. Faz uso ainda de captopril - 50 mg/dl, atenolol – 100 mg/d e mononitrato de isossorbida – 30 mg/d.
A púrpura trombocitopênica idiopática tem incidência rara. Levantamento realizado no Japão mostra uma prevalência de 15,5 casos ao ano para cada 100.000 indivíduos2. A associação entre a doença arterial coronariana e a púrpura também é rara, e relatos na literatura mostram boa evolução desse quadro, quando é possível se elevar, adequadamente, a concetração plaquetária e submeter o paciente a revascularização cirúrgica3,4.
No caso descrito, observamos uma forma agressiva dessa doença, associada a grave doença coronariana obstrutiva. Uma possível explicação para a acentuada plaquetopenia, com inexpressiva resposta terapêutica, pode ser a concomitância de importantes níveis de estresse, gerados pela precordialgia e pela iminência de uma cirugia de grande porte.
Embora dispuséssemos de sistemas para a hemostasia do local de punção femoral (do tipo
Apesar do paciente apresentar-se com plaquetopenia importante, consideramos prudente a utilização, pelo menos, da enoxaparina, já que foram implantados dois
Observação importante deve ser feita com relação à introdução de algum antiagregante plaquetário assim que possível. Fuchi e cols.5 realizaram uma angioplastia transluminal coronariana primária em portador de púrpura trombocitopênica idiopática e com quadro de infarto agudo do miocárdio, onde se observou suboclusão da artéria DA no seu terço proximal e outra lesão, de 50%, no terço médio. Embora a angioplastia transluminal coronariana da lesão proximal tenha sido realizada com sucesso, a paciente desenvolveu, 9h depois, novo episódio de infarto agudo do miocárdio com oclusão no terço médio da DA junto à lesão de 50%. Os autores consideraram a possibilidade de ter havido lesão iatrogênica pela corda-guia durante a primeira angioplastia transluminal coronariana, associada a um aumento da viscosidade sangüínea causado pelo contraste e pela reposição das plaquetas. Ressaltaram a importância de se realizar as transfusões com cuidado, atendo-se ao mínimo necessário, a fim de evitar complicações trombogênicas após a angioplastia transluminal coronariana nesses portadores de púrpura trombocitopênica.
No nosso caso foi solicitado acompanhamento rigoroso pelo hemotologista, com a introdução de pelo menos alguma droga antiagregante assim que se obtivesse concentrações aceitáveis de plaquetas, mantendo-se por um período mínimo suficiente para permitir a endotelização dos
Nos casos de associação entre a púrpura trombocitopênica e a doença arterial coronariana, a angioplastia transluminal coronariana com o implante de
Murillo Kenji Furukawa Rua Haddock Lobo, 1459/102 Cep 01414-003 - São Paulo, SP E-mail:
Enviado em 30/04/2004 - Aceito em 03/08/2004
The association between coronary heart disease and thrombocytopenic purpura is rare and poses some difficulties when myocardial revascularization is necessary. We report a case with this association and significant coronary impairment, which was percutaneously treated with stent implantation.
São Paulo, SP - Brazil
Real e Benemérita Associação Portuguesa de Beneficência, São Paulo
The association between coronary heart disease and thrombocytopenic purpura is rare and poses some difficulties when myocardial revascularization is necessary. We report a case with this association and significant coronary impairment, which was percutaneously treated with stent implantation.
The incidence of idiopathic thrombocytopenic purpura, also known as Werlhof's disease, is low in the general population. It occurs in all age groups, in acute and chronic forms. Children usually have the acute form, with a similar incidence in both sexes. Adults, on the other hand, usually have the chronic form, with a higher incidence in the female sex (3:1)1. The pathophysiology of both forms is the production of anti-platelet antibodies, usually of the IgG class, that lead to accelerated destruction of platelets by the reticuloendothelial system.
The association of purpura and coronary heart disease is also rare. We report a case of that association, which was percutaneously treated with intracoronary stent implantation.
The patient is a 54-year-old male, complaining of typical precordial pain for 4 months associated with dyspnea on medium exertion, with rapid progression. He also reported that in the week preceding hospitalization, the pain was triggered by minimum exertion, appearing even at rest.
As antecedents, the patient reported hypertension and diabetes, and the use of captopril (75 mg/dL) and glibenclamide (10 mg/dL). He also reported having thrombocytopenic purpura and being on regular hematological follow-up in his city, and was being treated with prednisone (60 mg/dL), with no pathological bleeding in recent months. He denied familial antecedents of coronary heart disease, tobacco smoking, and hypercholesterolemia.
While still in his city, he underwent cine coronary angiography, which showed coronary circulation with left dominance and severe lesions in the following arteries: anterior descending (AD), circumflex (Cx), and the first left marginal branch (MB-1) (
The patient was referred for coronary artery bypass grafting. On admission, his hemogram was as follows: Hb, 10.4 g/dL; Ht, 28.8%; and very low platelet count (8,000 plat/mm3). No other laboratory alterations were observed.
The patient was assessed at the hematology unit. Initially, he had his anemia and low platelet count treated. Methylprednisolone and immunoglobulin were also administered, and the patient was indicated for surgery only after achieving a platelet count of at least 90,000 plat/mm3. However, even after several transfusions for 20 days, the maximum count achieved was 86,000 plat/mm3 (
The previous electrocardiogram showed sinus rhythm, with diffuse and unspecific alterations in ventricular repolarization.
Then the patient underwent dissection of the right brachial artery, which was uneventful. On the day of the procedure, the patient had a platelet count of 15,000 plat/mm3. After dissection of the brachial artery, intravenous heparin was administered at the dose of 70 U/kg. A 6F Wiseguide guiding catheter, FL 3.5 SH model, and a 0.014" guidewire, 182 cm, Choice PT Extra Support model (both from Boston Scientific – SCIMED), were used. Initially, the lesion in the Cx artery was approached and easily surpassed by the guidewire. Then, a Driver-RX stent, 3.5x15 mm (Medtronic AVE), was directly implanted and deployed at 12 atm. The guidewire was then redirected towards the AD artery. The lesion was, once again, surpassed without great difficulty. Another Driver-RX stent, 3.5x18 mm, was directly implanted, then deployed at 14 atm, with a good final result (
After obtaining a satisfactory result in both arteries treated, the procedure was finished. The brachial artery was sutured with a 6-0 Prolene thread, and neither instances of bleeding nor hematomas were observed.
During hospitalization, the patient evolved well, with improvement of the anginal pain. The CK-MB level before percutaneous transluminal coronary angioplasty (PTCA) was 42 U/L, with normalization within the first 24 hours (
Although the hematology team did not recommend the use of anti-platelet agents, we chose to use enoxaparin, subcutaneously, at the dosage of 1 mg/kg/day during the in-hospital period. However, within the first 24 hours of drug administration, 3 episodes of epistaxis occurred, and the new platelet count was 11,000/mm3. Enoxaparin was suspended, and the patient was maintained with no type of heparin or anti-platelet agent. After 2 days, the patient was discharged from the hospital, and evolved with no precordialgia or bleeding. He was instructed to undergo strict hematological control in his city, and advised to use at least one anti-platelet agent when his platelet count allowed it.
During recent telephone contact, 4 months after the procedure, the patient reported having no angina. During that period, he had not begun using any anti-platelet agent, due to the recommendation of his hematologist, because of a persistent significantly low platelet count, which achieved a maximum of 20,000 plat/mm3, but most values were below 10,000. The last platelet count (06/22/04) was 3,000 plat/mm3. The patient continues to use corticoids and immunoglobulins, and waits for improvement so that he can undergo a splenectomy. He is still using captopril (50 mg/dL), atenolol (100 mg/dL), and isosorbide mononitrate (30 mg/dL).
Idiopathic thrombocytopenic purpura has a low incidence. A study carried out in Japan showed a prevalence of 15.5 cases per year for each 100,000 individuals2. Its association with coronary heart disease is rare, and reports in the literature have shown that good evolution occurs when the platelet count can be adequately elevated and the patient can undergo coronary artery bypass grafting3,4.
Our patient had an aggressive form of idiopathic thrombocytopenic purpura associated with severe obstructive coronary heart disease. A possible explanation for the significantly low platelet count, with an inexpressive therapeutic response, could be the concomitance of important levels of stress, generated by precordialgia and the imminence of intricate surgery.
Although systems for local hemostasia of the femoral puncture, such as the Perclose – AbbotVascular Devices, were available, the possibility of occurrence of accidents during arterial puncture was considered, which could cause, due to the significantly low platelet count, hemorrhagic complications even before initiating the interventional procedure. The radial approach was not used because the necessary material was not available, and our professional team lacked experience with that technique. Therefore, we chose to dissect the right brachial artery, which allowed direct visualization of the artery and better control of hemostasia. Although the patient had already undergone a previous cine coronary angiography by use of that technique, his brachial artery was easily palpable above the first incision, with no decrease in the radial pulse.
Although the patient had a significantly low platelet count, we considered it prudent to use at least enoxaparin, because 2 stents were implanted in the AD and CX arteries, which were dominant. However, the occurrence of epistaxis caused the suspension of that drug, and the patient was maintained without any type of heparin or antiplatelet agent.
It is worth noting that some type of antiplatelet agent should be introduced as soon as possible. Fuchi et al 5 performed a primary percutaneous transluminal coronary angioplasty in a patient with idiopathic thrombocytopenic purpura and acute myocardial infarction, who had subocclusion of the AD artery in its proximal third and another lesion, of 50%, in its middle third. Although percutaneous transluminal coronary angioplasty of the proximal lesion was successfully performed, 9 hours later, the patient experienced a new episode of acute myocardial infarction with occlusion in the middle third of the DA artery, close to the 50% lesion. The authors considered the possibility of an iatrogenic lesion caused by the guidewire during the first percutaneous transluminal coronary angioplasty, associated with an increase in blood viscosity caused by the contrast medium and platelet replacement. They emphasized the importance of carefully performing transfusions, as less frequently as possible, to avoid thrombogenic complications after percutaneous transluminal coronary angioplasty in patients with thrombocytopenic purpura.
We recommended a careful hematological follow-up for our patient, with the introduction of at least one antiplatelet agent as soon as the platelet count was acceptable, and that agent should be maintained for a period sufficient to allow stent endothelialization
In cases in which thrombocytopenic purpura is associated with coronary heart disease, percutaneous transluminal coronary angioplasty with stent implantation is an attractive therapeutic option. In addition to being an effective method, the introduction of more recent techniques, mainly the radial approach, makes the procedure safer for patients having that association, exposing them to minimum trauma with excellent control of hemostasia. We emphasize the importance of strict hematological control to balance platelet count and use of antiplatelet agents, aiming at avoiding thrombotic complications.
Murillo Kenji Furukawa Rua Haddock Lobo, 1459/ 102 Cep 01414-003 - São Paulo, SP, Brazil E-mail:
Sent for publication: 04/30/2004
Accepted for publication: 08/03/2004
English version by Stela Maris Costalonga