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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

slide2
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
slide3
Primary PCI

Sub-occlusion in pLAD

Heavy thrombus burden

Thrombus aspiration

IC Tirofiban 500ug

NTG 400ug

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

slide4
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
slide7
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 upCAG 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

slide13
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
slide14
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
slide15
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

slide17
Argatroban

Chest 2008,133

slide18
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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