1. Shujuan Cheng,MD; Hongbing Yan,MD Beijing Anzhen Hospital Capital Medical University, Beijing China Argatroban for Severe Thrombocytopnia after Primary PCI — case report

2.  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 0.1-0.3 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

3. 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 )

4.  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

5. 2 nd PCI (day 8)  In-stent thrombosis with total occlusion in LAD. Balloon angiography and stenting in mLAD

6. PCI in LCX Stenting in LCX Thrombosis in LAD Balloon angiography in LAD IC Tirofiban 500ug

7.  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

8. 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

9. Discussion  Any mistakes during pPCI and 2 nd PCI?  Causes of thrombosis  Causes of severe thrombocytopnia  Management for thrombocytopnia in this patient

10. Indication for PCI  Indication for primary PCI  Stenting in dLAD, yes or no ?  Inappropriate stenting in LCX ?

11. Causes of thrombocytopnia  HIT  GIT  Pseudo-thrombocytopnia  Others: associated with IABP ， clopidogrel

12. Pseudo-thrombocytopnia Satellite phenomenon

13. 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

14. 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

15.  HIT was strongly suspected for this patient: thrombosis thrombocytopnia heparin exposure no serologic evidence available Diagnosis

16. 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

17. Chest 2008,133 Argatroban

18. 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.