TITLE:
One Case of Primary Thrombocythemia with Concealed Hypokalemia Complicated by Acute Myocardial Infarction
AUTHORS:
Huiling Liang, Tingting Zheng, Yuanhong Zhuo
KEYWORDS:
Primary Thrombocythemia, Acute ST-Segment Elevation Myocardial Infarction, Concealed Hypokalemia, Thrombosis, Bleeding
JOURNAL NAME:
World Journal of Cardiovascular Diseases,
Vol.14 No.1,
January
18,
2024
ABSTRACT: Medical history summary: Male, 47 years old, was admitted to the hospital due to “dizziness accompanied
by chest tightness and pain for more than 8 days”. One week ago, the patient
experienced chest tightness, chest pain accompanied by profuse sweating for 3
hours and underwent emergency percutaneous
coronary intervention (PCI) at a local hospital. The procedure revealed left
main stem occlusion with subsequent left main stem to left anterior
descending artery percutaneous transluminal coronary angioplasty (PTCA). After
the procedure, the patient experienced hemodynamic instability, recurrent
ventricular fibrillation, and critical condition, thus transferred to our
hospital for further treatment. Symptoms and signs: The
patient is in a comatose state, unresponsive to stimuli, with bilateral dilated
pupils measuring 2.0 mm, exhibiting reduced sensitivity to light reflex, and
recurrent fever. Coarse breath sounds can be
heard in both lungs, with audible moist rales. Irregular breathing pattern is observed, and heart sounds vary
in intensity. No pathological murmurs are auscultated in any valve auscultation
area. Diagnostic methods: Coronary angiography
results at the local hospital showed complete occlusion of the left main stem,
and left main stem to left anterior descending artery percutaneous transluminal
coronary angioplasty (PTCA) was performed. However, the distal guidewire did
not pass through. After admission, blood tests showed a Troponin T level of
1.44 ng/ml and a Myoglobin level of 312 ng/ml. The platelet count was 1390 × 109/L.
Von Willebrand factor (vWF) activity was measured at 201.9%. Bone marrow
aspiration biopsy showed active bone marrow proliferation and platelet
clustering. The peripheral blood smear also showed platelet clustering. JAK-2
gene testing was positive, confirming the diagnosis of primary thrombocytosis. Treatment methods: The patient is assisted with mechanical ventilation and
intra-aortic balloon counterpulsation to improve coronary blood flow.
Electrolyte levels are closely monitored, especially maintaining plasma
potassium levels between 4.0 and 4.5 mmol/l.
Hydroxyurea 500 mg is administered for platelet reduction. Anticoagulants and
antiplatelet agents are used rationally to prevent further infarction or
bleeding. Antiarrhythmic, lipid-lowering, gastroprotective, hepatoprotective,
and heart failure treatment are also provided. Clinical outcome: The family members chose to withdraw treatment and signed for discharge due to
a combination of reasons, including economic constraints and uncertainty about
the prognosis due to the long disease course. Acute myocardial infarction has
gradually become one of the leading causes of death in our country. As a “green
channel” disease, corresponding diagnostic and treatment protocols have been
established in China, and significant progress has been made in emergency care.
There are strict regulations for the time taken from the catheterization lab to
the cardiac intensive care unit, and standardized treatments are provided to
patients once they enter the intensive care unit. Research results show that
the incidence of acute myocardial infarction in patients with primary
thrombocythemia within 10 years is 9.4%. This type of disease is rare and
difficult to cure, posing significant challenges to medical and nursing
professionals. In order to benefit future patients, we have documented
individual cases of treatment and nursing care for these patients. The research
results show that these patients exhibit resistance to traditional oral
anticoagulant drugs and require alternative anticoagulants. Additionally, there
are significant differences in serum and plasma potassium levels among
patients. Therefore, when making clinical diagnoses, it is necessary to
carefully distinguish between the two. Particularly, nursing personnel should
possess dialectical thinking when supplementing potassium levels in patients in
order to reduce the incidence of malignant arrhythmias and mortality rates.