shujuan cheng,md; hongbing yan,md beijing anzhen hospital
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Shujuan Cheng,MD; Hongbing Yan,MD
Beijing Anzhen Hospital Capital Medical University, Beijing China
Argatroban for Severe Thrombocytopnia after Primary PCI
— case report
male , 64 yrs old Paroxysmal chest pain for 1 year with syncope one
time 1 day ago BP 90/40mmHg , HR 90 bpm
ECG: ST segment elevation 0.1-0.3mV in I 、 aVL 、 V2-6
WBC 9.5 G/L, PLT 130 G/L, RBC 4.6 T/L TnI 22.6ng/ml Diagnosis : STEMI
cardiogenic shock Antithrombotic therapy: UFH 5000u IV, clopidogrel
300mg, ASA 300mg
Case
Sub-occlusion in pLAD Heavy thrombus
burden
Primary PCI
Thrombus aspiration IC Tirofiban 500ug NTG 400ug pLAD (Endeavor30*30)
dLAD( Excel25*14)
IABP support, 24 hrs IV Tirofiban, 15 hrs ( 300ug/h , B/W 75kg) Enoxaparin 60mg q12h, 7 days WBC 8.5G/L, PLT 150G/L (Day 2) TnI: 16.3ng/ml (Day 2), 7.15ng/ml (Day 4),
3.36ng/ml (Day 7) LVEDD/LVEF: 60/40% (Day 2), 58/47% (Day 6)
Management after pPCI
2nd PCI (day 8)
In-stent thrombosis with total occlusion in LAD.
• Balloon angiography and stenting in mLAD
PCI in LCX
• Stenting in LCX• Thrombosis in LAD
• Balloon angiography in LAD
• IC Tirofiban 500ug
Intensive antithrombotic therapy: oral clopidogrel
150mg QD, ASA 300mg QD, cilostazol 50mg BID, IV tirofiban 300ug/h, enoxaparin 30mg q12h SC
The next day: WBC 6.5G/L , PLT 3.0G/L petechia on the legs, no other hemorrhagic sign
Antithrombotic therapy was interrupted
Argatroban: 1.2~1.4ug/kg/min
aPTT: monitored every 2 hours, maintained 1.5~2 times of baseline
Management after 2nd PCI
• 4 days later, PLT count reached 230G/L.
• 10 days later, another angiography showed normal coronary artery
• F/U: quite stable CAG on discharge (Day 17)
Follow up
Discussion
Any mistakes during pPCI and 2nd PCI? Causes of thrombosis Causes of severe thrombocytopnia Management for thrombocytopnia in this
patient
Indication for PCI
Indication for primary PCI Stenting in dLAD, yes or no ? Inappropriate stenting in LCX ?
Causes of thrombocytopnia
HIT GIT Pseudo-thrombocytopnia Others: associated with
IABP , clopidogrel
Pseudo-thrombocytopnia
Satellite phenomenon
HIT
thrombocytopnia Immune-related: IgG-PF4/heparin Within 5 to 14 days of treatment and within a
few hours of reexposure Thromboembolytic events Diagnosis based on both clinical and serologic
grounds: Anti-heparin/PF4 positive
GIT
Within a few hours after beginning of treatment Immune-related Bleeding complications: generally harmless,
sometimes associated with seriously bleeding Responding readily to thrombocyte transfusion A follow-up diagnosis
HIT was strongly suspected for this patient:
thrombosis
thrombocytopnia
heparin exposure
no serologic evidence available
Diagnosis
Management
Stop heparin (including LMWH) (Grade 1B) and GPIIb/IIIa inhibitor
Change to other nonheparin anticoagulants
Avoid platelet administration without active bleeding (Grade 2C)
Chest 2008,133 ACCP guidlines
I II IIIDanaparoid
Lepirudin
argatroban
I II III
fondaparinux
bivalirudin
Chest 2008,133
Argatroban
Chest 2008,133
Conclusions
Remember appropriateness criteria for coronary revascularization
platelet count monitoring at least every 2 or 3 days from day 4 to day 14
Argatroban was a direct thrombin inhibitor that is a safe and effective antithrombotic therapy for patients with HIT.
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