Acute Myocardial Infarction Managed with Thrombolysis in Polycythemia Vera Patient: May 2023, IHJ (CVCR) Finds

The case report findings were published in May 2023 in the Indian Heart Journal, Cardiovascular Case Reports, by Narra Lavanya and her cardiology team.

Clinical Case Overview

A 59-year-old diabetic and hypertensive male presented with epigastric pain and was diagnosed with an inferoposterior wall myocardial infarction (IPWMI) accompanied by junctional bradycardia. Significant laboratory findings included elevated hemoglobin (18 g/dL) and hematocrit (58%), while imaging confirmed a 99% thrombotic occlusion in the left circumflex artery. Pharmacological thrombolysis with tenecteplase successfully resolved the massive thrombus within 48 hours, though subsequent balloon angioplasty of a distal occlusion was unsuccessful. Following stabilization with respiratory and heart failure support, the patient was confirmed to have polycythemia vera via JAK2 V617F mutation testing. He was discharged on hydroxyurea and febuxostat to manage this myeloproliferative neoplasm and mitigate the risk of future life-threatening arterial events.

Mechanistic Insights

The management of acute coronary syndrome in polycythemia vera balances immediate reperfusion with long-term hematologic stability. Weight-adjusted thrombolysis with tenecteplase is utilized to enzymatically resolve massive coronary thrombi, providing a safer alternative to primary percutaneous intervention, which carries a high risk of acute stent-related thrombosis and poor outcomes in hyperviscous environments. Following acute stabilization, cytoreductive therapy with agents like hydroxyurea or ruxolitinib is initiated to suppress bone marrow panmyelosis. By reducing the overproduction of erythroid, leucocytic, and megakaryocytic lineages, these medications lower blood viscosity and platelet counts, thereby addressing the underlying prothrombotic mechanism and preventing recurrent life-threatening vascular events

Potential Clinical Implications

Practicing cardiologists should consider polycythemia vera as a potential underlying cause of acute myocardial infarction, as prompt diagnosis is vital for accurate prognosis and effective risk management. For patients presenting with a high coronary thrombus burden, pharmacological thrombolysis may serve as a more favorable intervention than mechanical stenting to minimize the specific risk of acute stent-related complications in a hyperviscous environment. Furthermore, identifying this myeloproliferative neoplasm allows for the early implementation of essential cytoreductive treatments, such as hydroxyurea or ruxolitinib, to stabilize hematologic parameters and prevent recurrent life-threatening arterial events.

Reference

Lavanya, N., Srinivasan, K. N., Sathyamurthy, I., & Manodaya. (2023). Acute myocardial infarction due to Polycythemia Vera - Stenting or lysis? – A case report. IHJ Cardiovascular Case Reports (CVCR), 7, 43–45.