shujuan cheng,md; hongbing yan,md beijing anzhen hospital capital medical university, beijing china...
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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
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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
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Sub-occlusion in pLAD Heavy thrombus
burden
Primary PCI
Thrombus aspiration IC Tirofiban 500ug NTG 400ug pLAD (Endeavor30*30)
dLAD( Excel25*14)
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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
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2nd PCI (day 8)
In-stent thrombosis with total occlusion in LAD.
• Balloon angiography and stenting in mLAD
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PCI in LCX
• Stenting in LCX• Thrombosis in LAD
• Balloon angiography in LAD
• IC Tirofiban 500ug
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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
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• 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
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Discussion
Any mistakes during pPCI and 2nd PCI? Causes of thrombosis Causes of severe thrombocytopnia Management for thrombocytopnia in this
patient
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Indication for PCI
Indication for primary PCI Stenting in dLAD, yes or no ? Inappropriate stenting in LCX ?
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Causes of thrombocytopnia
HIT GIT Pseudo-thrombocytopnia Others: associated with
IABP , clopidogrel
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Pseudo-thrombocytopnia
Satellite phenomenon
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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
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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
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HIT was strongly suspected for this patient:
thrombosis
thrombocytopnia
heparin exposure
no serologic evidence available
Diagnosis
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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
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Chest 2008,133
Argatroban
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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.