Shujuan cheng md hongbing yan md beijing anzhen hospital capital medical university beijing china
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Argatroban for Severe Thrombocytopnia after Primary PCI — case report. Shujuan Cheng,MD; Hongbing Yan,MD Beijing Anzhen Hospital Capital Medical University, Beijing China. Case. male, 64 yrs old Paroxysmal chest pain for 1 year with syncope one time 1 day ago

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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

Shujuan Cheng,MD; Hongbing Yan,MD

Beijing Anzhen Hospital

Capital Medical University, Beijing China


Case

  • 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


Primary PCI

Sub-occlusion in pLAD

Heavy thrombus burden

Thrombus aspiration

IC Tirofiban 500ug

NTG 400ug

pLAD (Endeavor30*30) dLAD( Excel25*14)


Management after pPCI

  • 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)


2 nd pci day 8
2nd PCI (day 8)

  • In-stent thrombosis with total occlusion in LAD.

  • Balloon angiography and stenting in mLAD


Pci in lcx
PCI in LCX

  • Stenting in LCX

  • Thrombosis in LAD

  • Balloon angiography in LAD

  • IC Tirofiban 500ug


Management after 2nd PCI

  • 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


Cag on discharge day 17

Follow up

CAG on discharge (Day 17)

  • 4 days later, PLT count reached 230G/L.

  • 10 days later, another angiography showed normal coronary artery

  • F/U: quite stable


Discussion
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 PCI

  • Indication for primary PCI

  • Stenting in dLAD, yes or no ?

  • Inappropriate stenting in LCX ?


Causes of thrombocytopnia
Causes of thrombocytopnia

  • HIT

  • GIT

  • Pseudo-thrombocytopnia

  • Others: associated with IABP,clopidogrel


Pseudo thrombocytopnia
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


Diagnosis

  • HIT was strongly suspected for this patient:

    thrombosis

    thrombocytopnia

    heparin exposure

    no serologic evidence available


Management

I II III

I II III

C

C

B

C

C

Management

  • Stop heparin (including LMWH) (Grade 1B) and GPIIb/IIIa inhibitor

  • Change to other nonheparin anticoagulants

  • Avoid platelet administration without active bleeding (Grade 2C)

Danaparoid

Lepirudin

argatroban

fondaparinux

bivalirudin

Chest 2008,133 ACCP guidlines


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.

Chest 2008,133


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