Coronary artery disease
Impact of In-Hospital Acquired Thrombocytopenia in Patients Undergoing Primary Angioplasty for Acute Myocardial Infarction

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Thrombocytopenia that develops after percutaneous coronary intervention (PCI) may result in hemorrhagic complications, requirement for blood product transfusions, and potentially thrombotic or ischemic complications. The incidence and prognostic significance of thrombocytopenia, in patients with acute myocardial infarction (AMI) who undergo primary PCI have not been evaluated. In the CADILLAC trial 2,082 patients who had AMI within 12 hours of onset without shock were prospectively randomized to receive balloon angioplasty with or without abciximab versus stenting with or without abciximab. Acquired thrombocytopenia, defined as a nadir platelet count <100 × 109/L in patients who did not have baseline thrombocytopenia, developed in 50 of 1,975 qualifying patients (2.5%) after primary PCI. By multivariate analysis, acquired thrombocytopenia developed more frequently in patients who had non-insulin-requiring diabetes mellitus (odds ratio 3.88 [OR], p = 0.0002), previous statin administration (OR 3.28, p = 0.002), and use of abciximab (OR 2.06, p = 0.02) and less frequently in patients who had previous aspirin use (OR 0.26, p = 0.002), a higher baseline platelet count (OR 1.20, p < 0.0001), and greater body mass index (OR 0.90, p = 0.006). Patients who developed thrombocytopenia versus those who did not had higher in-hospital rates of major hemorrhagic complications (10.0% vs 2.7%, p = 0.01), greater requirement for blood transfusions (10.0% vs 3.9%, p = 0.05), longer hospital stay (median 4.8 vs 3.6 days, p = 0.008), and increased costs (median $14,466 vs $11,629, p = 0.001). All-cause mortality was markedly increased at 30 days (8.0% vs 1.6%, p = 0.0008) and at 1 year (10.0% vs 3.9%, p = 0.03) in patients who developed thrombocytopenia. In conclusion, thrombocytopenia that develops after primary PCI for AMI, although uncommon, is associated with increased hemorrhagic complications and decreased survival.

Section snippets

Patient population and study design

In the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial, 2,082 patients of any age who developed AMI within 12 hours of onset and underwent primary PCI in a native coronary artery that was eligible for stent implantation were randomized to 1 of 4 mechanical reperfusion strategies: percutaneous transluminal coronary balloon angioplasty with or without abciximab (Centocor, Malvern, Pennsylvania) versus stenting with the Multilink stent

Incidence of acquired thrombocytopenia after primary angioplasty

Of the 2,082 randomized patients, 1,975 (94.8%) had a platelet count >100 × 109/L on admission and ≥2 measured values after PCI. From this group, 50 patients (2.5%) developed thrombocytopenia before hospital discharge. Among these patients, the median platelet count decreased from 179 × 109/L (interquartile range 144 to 228) to 84 × 109/L (interquartile range 50 to 93, p < 0.0001). Thrombocytopenia was classified as mild in 36 patients (72%), severe in 12 patients (24%), and profound in 2

Discussion

The major results of this report are: (1) thrombocytopenia that developed after hospital admission occurred in 2.5% of patients who underwent contemporary mechanical reperfusion strategies for AMI; (2) the occurrence of thrombocytopenia was most strongly predicted by non-insulin-requiring diabetes mellitus, use of statin medications before admission, lower body mass index, lower platelet count at admission, and treatment with abciximab; (3) development of thrombocytopenia was associated with

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    The primary goal of our study was to evaluate the outcomes in nTP versus aTP populations and report the effects for in-hospital, 30-day follow up and the outcomes reported at longest follow up. These outcomes were defined as follows: aTP after PCI was defined as a decline in absolute platelet count to <150 × 109/L [16,19,20], or a >50% decline from the baseline platelet count or a decline to <100 × 109/L in some studies [15,17,18,21]. Baseline thrombocytopenia was defined as a platelet count of <150,000 in CAD patients on presentation to the hospital.

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    In this regard, AC-induced major bleeding (most of which occurred within the first 5 days after procedure) may have led to early discontinuation of antiplatelet therapy, which in the present and previous studies has been strongly linked to ischemic events and death after primary PCI.16,17 In-hospital acquired thrombocytopenia also developed more frequently in the specific indication AC group and has also been strongly associated with subsequent recurrent ischemic and hemorrhagic events.18–20 In terms of specific pharmacotherapy, post-PCI AC with unfractionated heparin was associated with significantly higher rates of 30-day adverse ischemic and hemorrhagic events compared with other agents.

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