1 / 18

Shujuan Cheng,MD; Hongbing Yan,MD Beijing Anzhen Hospital

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

avari
Download Presentation

Shujuan Cheng,MD; Hongbing Yan,MD Beijing Anzhen Hospital

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


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

  2. 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

  3. Primary PCI Sub-occlusion in pLAD Heavy thrombus burden Thrombus aspiration IC Tirofiban 500ug NTG 400ug pLAD (Endeavor30*30) dLAD( Excel25*14)

  4. 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)

  5. 2nd 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. 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

  8. 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

  9. Discussion • Any mistakes during pPCI and 2nd 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. Diagnosis • HIT was strongly suspected for this patient: thrombosis thrombocytopnia heparin exposure no serologic evidence available

  16. 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

  17. Argatroban Chest 2008,133

  18. 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

More Related