Case Report and Brief Review

Reversal of Recurrent Thrombocytopenia Due to Abciximab

Vibhavasu Sharma, MD and Dan Mascarenhas, MD, FSCAI
Vibhavasu Sharma, MD and Dan Mascarenhas, MD, FSCAI
Case Report. A 75-year-old male with a history of coronary artery disease, percutaneous coronary angioplasty and stent placement of the right coronary artery (RCA), primary wall stent of the saphenous vein graft (SVG) to the left anterior descending artery (LAD), 2-vessel coronary artery bypass grafting and hypertension, was admitted to our hospital with epigastric pain and hypotension. The ECG revealed ST-segment elevation in leads V3 to V6 (Figure 1) and the myocardial enzymes were elevated (Figure 2). The patient was given enoxaparin and aspirin, and since he was in cardiogenic shock, he was taken emergently for cardiac catheterization, having an intra-aortic balloon pump (IABP) placed prior to coronary angiography. Coronary angiography revealed a completely occluded vein graft to the LAD (Figure 3) and a 60–70% proximal RCA stenosis. The left main coronary artery and the vein graft to the circumflex artery were both totally occluded. Since the patient was in cardiogenic shock, he was given an intracoronary abciximab bolus, as the vein graft to the LAD was thrombus-laden. The patient underwent a wall stent placement in the vein graft to the LAD subsequent to the intracoronary bolus, with complete reperfusion of the occluded vessel (Figures 4A and 4B). Following the procedure, his blood pressure stabilized and he was transferred to the intensive care unit with the IABP in place. He also received standard intravenous abciximab infusion post-procedure. Laboratory Data Hemoglobin: 14.8 G/DL Hematocrit: 43.2% MCV: 84.4 fl Platelet count: 218 ,000 /mL MPV: 7.3 FL INR: 1.1 APTT: 23 seconds CK-MB: 592 NG/ML Troponin-I: 943.5 NG/ML BUN: 26 MG/DL Creatinine: 1.3 MG/DL Figure 2. Laboratory data on admission revealing elevated myocardial enzymes. Within six hours of starting the abciximab, the patient developed profound thrombocytopenia with the platelet count falling from 212,000 per to 12,000 per (Figure 5). There was no clumping of platelets on the peripheral smear. However, he did not develop any overt muco-cutaneous bleeding or bleeding from the sites of vascular access. Abciximab, clopidogrel and aspirin were withheld and the patient was given intravenous hydrocortisone 200 mg every six hours. Six units of apheresed multi-donor platelets were transfused. Within the first 24 hours from the first dose of steroids, the platelet count had increased to 80,000 per, and there was a sustained increase to a normal level over the next two days (Figure 5). The steroids were discontinued on the third day since the platelet count was 100,000 per; hence, aspirin and clopidogrel were restarted. The patient was discharged home after an uneventful recovery on the sixth day of his admission. Two years prior to this admission, the patient was admitted to another hospital with unstable angina where he received a complete dose of abciximab complicated by thrombocytopenia. This condition was reversed by intravenous steroids and platelet infusions. Coronary angiography during that admission revealed a critical lesion in the SVG to the LAD. The patient was successfully treated with eptifibatide and stent placement in the above-mentioned graft. Discussion. Abciximab is a glycoprotein IIb/ IIIa inhibitor. It binds to the platelet GP IIb/IIIa receptor and inhibits platelet aggregation by preventing the binding of fibrinogen to this receptor. Abciximab is used in the prevention of acute cardiac ischemic complications in patients at high risk for abrupt closure of the treated coronary vessel. It has also been shown to decrease the rates of urgent repeat target vessel revascularization.2–5 However, the use of this agent is associated with bleeding complications and thrombocytopenia (platelet count Acknowledgment. The authors wish to thank Ms. Patricia Roblin for her assistance with photography.
1. Lewis B. Thrombocytopenia and outcome in invasive cardiology. J Invas Cardiol 2002;14(Suppl B):38B–47B. 2. The EPIC Investigators. Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. N Engl J Med 1994;330:956–961. 3. The CAPTURE Investigators. Randomized placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina: The CAPTURE Study. Lancet 1997;349:1429–1435. 4. The EPILOG Investigators. Platelet glycoprotein IIb/IIIA receptor blockade and low dose heparin during percutaneous coronary revascularization. N Engl J Med 1997;336:1689–1696. 5. The EPISTENT Investigators. Randomized placebo-controlled and balloon angioplasty-controlled trial to assess safety of coronary stenting with use of platelet glycoprotein IIb/IIIa blockade. Lancet 1998;352:87–92. 6. Blankenship J, Menapace F, Demko L. Incidence of thrombocytopenia complicating treatment with glycoprotein IIb/IIIa receptor inhibitors. J Am Coll Cardiol 1999;33:255A. 7. Sane DC, Damaraju LV, Topol EJ,et al. Occurrence and clinical significance of pseudothrombocytopeniaduring abciximab therapy. J Am Coll Cardiol 2000;36:75–83. 8. Tcheng JE. Clinical challenges of platelet glycoprotein IIb/IIIa receptor inhibitor therapy: Bleeding, reversal, thrombocytopenia and retreatment. Am Heart J 2000;139,S38–S45. 9. Harker L and Thompson W. Manual of Hemostasisand Thrombosis. Philadelphia: F.A Davis and Co. 1983,p60. 10. Tcheng JE, Kereiakes DJ, Lincoff AM, et al. Abciximab readministartion. Results of the ReoPro Readministartion Registry. Circulation 2001;104:870–875. 11. Nguyen N, Salib H, Mascarenhas DAN. Acute profound thrombocytopenia without bleeding complications after re-administartion of abciximab. J Invas Cardiol 2001;13:56–58. 12. Rao J, Mascarenhas DAN. Successful use of eptifibatide as an adjunct to coronary stenting in a patient with abciximab associated acute profound thrombocytopenia. J Invas Cardiol 2001;13:471–473. 13. Desai M, Lucore C. Uneventful use of tirofiban as an adjunctto coronary stenting in a patient with a history of abciximab associated thrombocytopenia 10 months earlier. J Invas Cardiol 2000;12:109–112. 14. Berkowitz S, Sane DC, Sigmon, et al. for the EPIC Study Group. Occurance and clinical significance of thrombocytopenia in a population undergoing high-risk percutaneous coronary revascularization. J Am Coll Cardiol 1998;32:387–392.