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.