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

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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


Shujuan cheng md hongbing yan md beijing anzhen hospital

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


Shujuan cheng md hongbing yan md beijing anzhen hospital

Primary PCI

Sub-occlusion in pLAD

Heavy thrombus burden

Thrombus aspiration

IC Tirofiban 500ug

NTG 400ug

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


Shujuan cheng md hongbing yan md beijing anzhen hospital

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


Shujuan cheng md hongbing yan md beijing anzhen hospital

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


Shujuan cheng md hongbing yan md beijing anzhen hospital

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


Shujuan cheng md hongbing yan md beijing anzhen hospital

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


Shujuan cheng md hongbing yan md beijing anzhen hospital

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


Shujuan cheng md hongbing yan md beijing anzhen hospital

Argatroban

Chest 2008,133


Shujuan cheng md hongbing yan md beijing anzhen hospital

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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