Gettysburg Medical Center
The Clinical View
by P.E. Hoffsten, MD
28 February 2007

PLATELET PROBLEMS

            Platelets are tiny particles that circulate in our blood and play a pivotal role in the ability to form a blood clot.  From an evolutionary standpoint, platelets were critical to stop bleeding when injuries occurred such as cuts or severe bruises.  Platelets work by finding raw spots where blood vessels have been damaged.  This damage can come from a bruise or an infection or a cut.

When rough spots are found in the blood vessels, platelets stick to these.  They then have the magical property of attracting other platelets to stick to each other to form a plug of a blood clot to stop the bleeding from occurring.  This prevents hemorrhage and extensive bleeding problems. 

            In today’s world, platelets are the leading cause of death in our society.  Specifically, our blood vessels develop rough spots secondary to high blood cholesterols, hypertension, cigarette smoking, or infections.  When this occurs, blood vessels in the heart have platelets stick to the inside of the blood vessel and block the vessel causing a heart attack.  The same type of problem causes strokes, or peripheral vascular disease.  Thus, methods of inhibiting platelet function have been sought over many years time.  One of the best products that we have to inhibit platelet function is aspirin which is one of the best preventions for stroke and heart attack.  Another more potent agent is called clopidogrel (Plavix) and these two products have been used together in extreme cases where patients have a marked tendency to form a stroke or heart attack.

            I have said before that medicine is relatively simple.  There are only two things that can go wrong.  Disease can come from platelets being too effective or not being effective enough.  If they are too effective, blood clots form and heart attack or strokes occur.  If platelets are not effective enough, the person can develop hemorrhage that can be very severe and even fatal.  The two ladies below illustrate how difficult these problems can be. 

            The first lady was 72 years old and developed chest pain that was beneath the sternum, felt like a “weighty ache”, lasted about 15-20 minutes and then seemed to go away for a brief period.  The pain would recur at a later time and recur if she did any exertion at all.  On one occasion when she finally came to the hospital, she broke out in a sweat, became very nauseated and vomited.  The pain persisted over more than an hour.  On arrival at the hospital, it was quite apparent that she was developing a heart attack.  She was given a medicine to prevent platelets from forming blood clots in her heart and got much better over the course of the next day.  She was transferred to the heart doctors who put a “stent” in the blocked place in her heart artery.  This was one of those new classy “drug eluting” stents that are said to be better at preventing a block from forming in the same coronary artery in the future.

            She was told to take her aspirin and Plavix for three months and then discontinue the product because it was no longer necessary.  Unfortunately, the chemicals in her “drug eluting” stent washed out in the course of about 12-18 months.  It was about two years and one month from the time that she had had her stent put in, that she returned to the emergency room again with very severe chest pain and an obvious recurrence of the blockage in her heart artery that had been treated previously.  She was again taken to the heart doctors and a “rotor router” procedure was carried out to clean out clot and plaque that had reoccurred at the site of her drug eluting stent.  On this occasion, she was told that she should take the aspirin and Plavix forever to prevent recurrence of this type of problem.  Hopefully, the Plavix and aspirin will prevent platelets from sticking to irritated spots near the stent and new blockage of her heart arteries at that site.  She is now taking these two drugs and we hope for the best in the future. 

            Those individuals who have had a “drug eluting” stent placed in their heart need to be aware that there is a significant danger period beginning one year after their stent is placed and unless they continue the aspirin and Plavix, they are at a significant risk of having a blood clot reform at the site of their stent. 

            The second lady to be concerned about had quite a different problem.  She came to the clinic because she was bruising everywhere.  When she took off her blouse, it was apparent that there must have been thirty bruises on her arms, her back, her stomach, and her legs.  She indicated that she had no specific injury that she was aware of. She simply indicated that almost anything she touched caused a bruise.  When we ran blood tests, we found that her blood platelet count was very, very low and she couldn’t really form a blood clot.  This is a very dangerous situation and can lead to hemorrhage into the central nervous system and a major hemorrhagic stroke. 

            Like all simple things in medicine, her low platelet count was the result of either breaking them up too quickly or not making them quickly enough.  What we found was she had become allergic to her own platelets, a very rare condition called idiopathic thrombocytopenic purpura.  Idiopathic means that we don’t really know why.  Thrombocytopenic means that she doesn’t have many platelets.  Purpura means that she is forming bruises everywhere so the name idiopathic thrombocytopenic purpura means that this lady was having bruises everywhere because her platelet count was low but we didn’t know why. 

            The first step in caring for her was to give her very large doses of cortisone.  Initially, this seemed to help but then her platelet count dropped again and she began to bruise.

            Now unfortunately, she also had all those side effects of too much cortisone.  She was referred to the hematologist for recommendations on what should be done next and it was elected to have her spleen taken out because it was trapping too many platelets and ridding the body of them.  When this was done, her platelet count came up quickly to normal levels on small doses of cortisone.  Her condition stabilized and she didn’t have any more bruising for about six months and then the platelet count began to drop slowly again.  A second drug was added to suppress her allergy to her own platelets.  With the second drug, her platelet count has come up to normal and all bruising has stopped.  But now she will remain on two drugs to prevent this problem from reoccurring over a long period of time. 

            The healthcare providers at your local clinics are aware of the nature of these problems and steps that should be taken to help deal with them.  Most specifically at this time, we are looking for individuals who have drug eluting stents in place and are not remaining on Plavix and aspirin.  They need to get on those drugs very quickly to prevent recurrence of their heart problems.  When low platelet counts are formed such as in the second lady above, specialized care is required but that can be directed from your local clinics where all basic care should begin.