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

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