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 mV in I 、 aVL 、 V 2-6  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 300 mg, ASA 300 mg Case

Sub-occlusion in pLAD Heavy thrombus burden Primary PCI Thrombus aspiration IC Tirofiban 500ug NTG 400ug pLAD (Endeavor 30*30 ) d LAD ( Excel 25*14 )

 IABP support, 24 hrs  IV Tirofiban, 15 hrs （ 300ug /h ， B/W 75 kg)  Enoxaparin 60 mg q 12 h, 7 days  WBC 8.5 G/L, PLT 150 G/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

2 nd 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 150 mg QD, ASA 300 mg QD, cilostazol 50 mg BID, IV tirofiban 300ug /h, enoxaparin 30 mg q 12 h SC  The next day: WBC 6.5 G/L ， PLT 3.0 G/L  petechia on the legs, no other hemorrhagic sign  Antithrombotic therapy was interrupted  Argatroban: 1.2~1.4 ug/kg/min  aPTT: monitored every 2 hours, maintained 1.5~2 times of baseline Management after 2 nd PCI

4 days later, PLT count reached 230 G/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 2 nd 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 1 B) and GPIIb/IIIa inhibitor  Change to other nonheparin anticoagulants  Avoid platelet administration without active bleeding (Grade 2 C) Chest 2008,133 ACCP guidlines I II III Danaparoid 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.