1999 Resident Poster Competition
Heidi M. Crane M.D.
Washington University
Acute Myocardial Infarction as an Unusual Presentation of Chronic Myelogenous Leukemia
Introduction: Chronic myelogenous leukemia is a rare hematological neoplasm ( less than 15% of leukemias). Patients typically present with fatigue, headache, weight loss or are diagnosed from routine leukocyte counts obtained for other reasons. This is an unusual case of a young woman with no cardiac risk factors who presented with an acute myocardial infarction.
Case: A 48-year-old female with no significant past medical history was admitted to the hospital after one week of chest pain. Pain typically began at night, usually at rest, often would wake patient from sleep. Initially pain did not radiate nor was it associated with nausea, vomiting, or diaphoresis. On night of admit pain was more severe than previously, it radiated to her left arm, and she vomited two times. At that point she went to the hospital. After receiving aspirin and nitrates patient had substantial reduction in pain. Initial laboratory studies showed a troponin level of 4.1, a white blood cell count of 88,000, a platelet count of 2.4 million, and a hematocrit of 36. An EKG revealed a sinus tachycardia with T wave inversions in V2 and V3, an echocardiogram showed apical akinesis and anteroseptal hypokinesis. A cardiac catheterization demonstrated a 90% LAD lesion which was treated with percutaneous tranSt. Louis University minal coronary angioplasty as well as a stent, in addition, spasm was present at other sites, No reoccurrence of chest pain occurred after the cardiac catheterization. Patient's treatment included platelet phoresis, aspirin, plavix, calcium channel blockers, and initially hydroxyurea myelogenous leukemia. Patient recovered uneventfully from the acute event.
Discussion: Acute myocardial infarctions can be due to a number of pathologic hematologic abnormalities including polycythemia vera, acute myelocytic leukemia, and others. An acute myocardial infarction as a presenting symptom for chronic myelogenous leukemia is exceeding rare especially in the setting of no cardiac risk factors. This case has value in not only its unusual presentation, but also the treatment questions that arise. As an example, one could suspect that this patient would have benefited from a glycoprotein IIb/IIIa inhibitor but there is no data. This leads to a number of other questions such as dosing (standard versus dosing until a percentage of platelets are affected), safety, etc. These issues then have implications about treatments for more standard acute myocardial infarctions.
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Alan D Forker, MD MACP
Missouri Chapter Governor
Patrick Mills
Missouri Chapter Executive Director
