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PP-004 Tirofiban Induced Anemia without Thyrombocytopenia
MARCH 26e29, 2015
- PP-003 Acute Coronary Syndrome among Diabetic Patients in Invasive Versus Non-invasive Hospitals. Abdulhalim Jamal Kinsara1, Faisal A. Batwa1, Ibtesam O. Alzain2, Waeil A. Batwa2, Hattan J. Moeminkhan3, Jamal A. Kensara4, Zuhoor S. Almansouri5. 1King Saud bin Abdulaziz University for Health Sciences, COM. King Abdul Aziz Medical City- WR. King Faisal Cardiac Center, Jeddah, Saudi Arabia; 2King Abdulaziz University Hospital, Jeddah, Saudi Arabia; 3King fahd Armed forces hospital, Jeddah, Saudi Arabia; 4Ministry of Health- Makkah region, Saudi Arabia; 5King Faisal Specialist Hospital &Research Center, Jeddah, Saudi Arabia. The current guidelines recommend that patients with unstable angina/non-ST-segment elevation, acute coronary syndromes (UA/NSTEMI- ACS) be transferred to centers with cardiac catheterization facilities very early on if the risk profile is high. Although the outcome is distinctly different, whether the patient’s characteristics or referral bias to invasive hospital, influences the outcome, is an issue that needs to be looked at. Aims: We present the TIMI risk profile of NSTEMI- ACS in diabetic patients in King Abdulaziz Medical City National Guard Hospital (KAMC) in Jeddah, a non-invasive facility and compared with 4 other hospitals in the Kingdom of Saudi Arabia with cath facilities. These hospitals were involved in a Multicenter International Diabetes e Acute Coronary Syndromes study. In addition, we compared the characterization of two therapeutic modalities, Glycoprotein IIb/IIIa inhibitors and coronary angiogram. Settings and Design: The characterization of the risk profile of 35 diabetic patients from KAMC, non-invasive hospital were compared with 142 patients from four hospitals in KSA, and 3,624 patients from the international hospitals who had cath facility admitted with UA/NSTEMI- ACS. Results: The distributions of TIMI scores were similar among the three groups. The odds ratios were also comparable across the three groups. When Glycoprotein IIb/IIIa inhibitors usages were compared, the usage for a particular group was not different. The high risk factors were similar in patientswho underwent coronary angiogram in the centers of KSA who had cardiac cath in comparison to those international centers. Conclusions: The non-availability of cath facilities does not cause referral bias, with risk factors being similar and treatment approach was matching. Immediate triage and risk stratification e.g. TIMI score will affect the outcome of cardiovascular mortality and might explain some similarity in the outcome between invasive and non-invasive hospitals.
Figure. The distribution of TIMI score among three groups.
Figure. Glycoprotein IIb/IIIa inhibitors usage among three groups for the different variables of TIMI score
Figure. The utilization of coronary angiogram among three groups for the different variables of TIMI score
- PP-004 Tirofiban Induced Anemia without Thyrombocytopenia. Hüseyin Ede1, Mustafa Fatih Erkoç2, Halit Alüzüm3, Zeynep Tugba Özdemir4, Ali Rıza Erbay1. 1 Bozok University, the Faculty of Medicine, Department of Cardiology, Yozgat, Turkey; 2Bozok University, the Faculty of Medicine, Department of Radiology, Yozgat, Turke y; 3Private Sevgi Hospital, Cardiology Clinic, Kayseri, Turkey; 4Bozok University, the Faculty of Medicine, Department of Internal Medicine, Yozgat, Turkey. Objective: Here, we presented a case of tirofiban-induced anemia (without any bleeding or hemorrhage) without thrombocytopenia following tirofiban usage. Case: A 69-year-old man applied for elective CAG. He had only hyperlipidemia without diabetes or hypertension. In the elective CAG of six years ago, one bare metal stent was implanted into proximal segment of OM1 branch of the LCX without any hematological deterioration. CAG of three years later revealed that the stent was patent without any additional new obstructive lesion. At admission, the patient had been taking acetylsalicylic acid of 100 mg/day, metaprolol of 50 mg/day, atorvastatin of 20 mg/day for the last six years. He had normal hematological parameters (Tab. 1). He was taken to the angiography laboratory after receiving 100 mg of acetylsalicylic acid. The CAG revealed 20% stenosis in the LAD, proximal 90% narrowing in the LCX and 90% stenosis in the
The American Journal of Cardiologyâ MARCH 26e29, 2015 11th INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND CARDIOVASCULAR SURGERY ABSTRACTS / Poster
S95
P O S T E R A B S T R A C T S
MARCH 26e29, 2015
- PP-005 A Main Coronary Thrombus Resolves with Tirofiban in a Patient Presenting with Non-ST Elevation Myocardial Infarction. Alper Bugra Nacar, Mehmet Fatih Karakas¸, Ali Erayman, Eyüp Büyükkaya, Mustafa Kurt, Adnan Burak Akçay, Nihat S¸en. Department of Cardiology, Mustafa Kemal University, Hatay, Turkey.
Figure. Microscopic examination of the blood film (a) shows single large thrombocytes implying antiaggregant use (red arrow), acanthocytes (white arrows), and (b) the sagittal CT view of abdomen on the catheterized side demonstrates that there is no finding of retro-intra peritoneal hemorrhage.
Table
Baseline First hour Sixth hour 12th hour 18th hour 24th hour 36th hour 48th hour 72th hour 7th day
P O S T E R A B S T R A C T S
Hgb
RBC
HTC
Platelet
WBC
12.0 11.6 10.4 10.2 9.1 8.6 8.2 8.4 10.2 10.6
3.92 3.38 3.43 3.29 2.95 2.75 2.73 2.70 3.48 3.44
36.4 35.9 31.7 30.2 27.4 25.6 24.9 24.2 31.7 32.4
277 291 295 321 289 271 296 319 282 313
8.14 14.40 10.90 14.80 19.40 16.00 12.60 6.30 9.50 6.49
The complete blood count results on follow up studies. [Hgb: Hemoglobin (g/dl); RBC: Red blood cell (K/mL); HTC: Hematocrit (%); Platelet (K/mL); WBC:White blood cell (K/mL).
rudimentary RCA. One bare metal stent was implanted into the LCX following a loading dose of 300 mg clopidogrel and a bolus administration of 8,000 IU of unfractionated heparin. Three hours later, the patient developed severe chest pain without obvious electrocardiographic deviation. Second CAG showed thrombus material filling stent lumen in proximal LCX creating 99% obtruction in the luminal diameter. Thus, tirofiban was started at a bolus administration of 25 mg/kg over 3 minutes and then 0.15 mg/kg/min continuous infusion intravenously. In the follow-up, we observed progressively decreasing hemoglobin without any thrombocytopenia. Hemoglobin level had fallen from 12.0 g/dl to 8.6 g/dl at the end of 24th hour while platelet counts were stable. Tirofiban was ceased immediately at 24th hour. During 24-hour tirofiban infusion, the patient didn’t reveal any clinical signs or symptoms related to hemorrhage except fever of 38.9 C started approximately four hours after tirofiban infusion. Neurological examination was normal. Computed tomography with intravenous contrast agent revealed negative result for retroperitoneal hematoma or any other source of internal bleeding (Fig. 1a). Microscopic examination of the blood film showed hemolytic anemia findings with single large thrombocytes implying antiaggregant use (Fig. 1b). Both direct and indirect Coombs tests were negative. 24 hours after stopping tirofiban infusion, anemia started to recover without any other intervention. One week later he had hematocrit of 32.4% and obvious recovery on the blood film examination. Conclusion: Here, a case of acutely developed anemia without thrombocytopenia following tirofiban infusion used for a coronary artery intervention in an acute setting was reported.
Coronary thrombus is frequently detected during angiographic imaging in patients presenting with acute coronary syndrome. It usually accompanies a ST-elevation myocardial infarction, but also seen with non-ST elevation myocardial infarction. While it may occur in all coronary arteries, it is uncommon in the main coronary artery. We here present our approach and treatment modality for a patient who presented with a non-ST elevation myocardial infarction with an intense thrombus in the main coronary artery. Case: A 84 year-old female patient had a history of prior permanent pacemaker, diabetes mellitus and hypertension. She presented to our emergency department following a night-time onset of chest pain. Physical examination showed a blood pressure of 150/90 mmHg, and a pulse rate of 60 beats/min. Rhythm of pacemaker beats was monitored by ECG. After pacemaker was turned off, ECG showed no ST elevation, and cardiac troponin I was 1,2 ng/ml. Patient was transferred to the catheterization laboratory with a diagnosis of nonST elevation myocardial infarction, during which she received nitrolingual nitrate 5 mg, acetylsalicylic acid 300 mg and unfractionated heparin 5000 U. Coronary angiography demonstrated thrombus in the main coronary artery (figure-1). Due to TIMI 3 flow, and a stable hemodynamic profile the patient was initiated on IV infusion of tirofiban. Then, she was taken to the catheterization laboratory again following 24-hour administration of tirofiban. Coronary angiography revealed that the thrombus in the main coronary artery has resolved (figure-2). With no complaints of chest pain and an additional problem during monitoring, she was discharged from the hospital with recommendations after arrangement of her medical treatment. In conclusion, we here presented a case report to show that patients presenting with a non-ST elevation myocardial infarction may also have thrombotic lesion in the main coronary artery, and it can be conservatively treated with tirofiban infusion by avoiding emergency intervention if they have a stable hemodynamic profile and TIMI 3 flow.
Figure 1. Before tirofiban infusion treatment. Figure 2: Aftertirofiban infusion treatment
S96 The American Journal of Cardiologyâ MARCH 26e29, 2015 11th INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND CARDIOVASCULAR SURGERY ABSTRACTS / Poster
- PP-003 Acute Coronary Syndrome among Diabetic Patients in Invasive Versus Non-invasive Hospitals. Abdulhalim Jamal Kinsara1, Faisal A. Batwa1, Ibtesam O. Alzain2, Waeil A. Batwa2, Hattan J. Moeminkhan3, Jamal A. Kensara4, Zuhoor S. Almansouri5. 1King Saud bin Abdulaziz University for Health Sciences, COM. King Abdul Aziz Medical City- WR. King Faisal Cardiac Center, Jeddah, Saudi Arabia; 2King Abdulaziz University Hospital, Jeddah, Saudi Arabia; 3King fahd Armed forces hospital, Jeddah, Saudi Arabia; 4Ministry of Health- Makkah region, Saudi Arabia; 5King Faisal Specialist Hospital &Research Center, Jeddah, Saudi Arabia. The current guidelines recommend that patients with unstable angina/non-ST-segment elevation, acute coronary syndromes (UA/NSTEMI- ACS) be transferred to centers with cardiac catheterization facilities very early on if the risk profile is high. Although the outcome is distinctly different, whether the patient’s characteristics or referral bias to invasive hospital, influences the outcome, is an issue that needs to be looked at. Aims: We present the TIMI risk profile of NSTEMI- ACS in diabetic patients in King Abdulaziz Medical City National Guard Hospital (KAMC) in Jeddah, a non-invasive facility and compared with 4 other hospitals in the Kingdom of Saudi Arabia with cath facilities. These hospitals were involved in a Multicenter International Diabetes e Acute Coronary Syndromes study. In addition, we compared the characterization of two therapeutic modalities, Glycoprotein IIb/IIIa inhibitors and coronary angiogram. Settings and Design: The characterization of the risk profile of 35 diabetic patients from KAMC, non-invasive hospital were compared with 142 patients from four hospitals in KSA, and 3,624 patients from the international hospitals who had cath facility admitted with UA/NSTEMI- ACS. Results: The distributions of TIMI scores were similar among the three groups. The odds ratios were also comparable across the three groups. When Glycoprotein IIb/IIIa inhibitors usages were compared, the usage for a particular group was not different. The high risk factors were similar in patientswho underwent coronary angiogram in the centers of KSA who had cardiac cath in comparison to those international centers. Conclusions: The non-availability of cath facilities does not cause referral bias, with risk factors being similar and treatment approach was matching. Immediate triage and risk stratification e.g. TIMI score will affect the outcome of cardiovascular mortality and might explain some similarity in the outcome between invasive and non-invasive hospitals.
Figure. The distribution of TIMI score among three groups.
Figure. Glycoprotein IIb/IIIa inhibitors usage among three groups for the different variables of TIMI score
Figure. The utilization of coronary angiogram among three groups for the different variables of TIMI score
- PP-004 Tirofiban Induced Anemia without Thyrombocytopenia. Hüseyin Ede1, Mustafa Fatih Erkoç2, Halit Alüzüm3, Zeynep Tugba Özdemir4, Ali Rıza Erbay1. 1 Bozok University, the Faculty of Medicine, Department of Cardiology, Yozgat, Turkey; 2Bozok University, the Faculty of Medicine, Department of Radiology, Yozgat, Turke y; 3Private Sevgi Hospital, Cardiology Clinic, Kayseri, Turkey; 4Bozok University, the Faculty of Medicine, Department of Internal Medicine, Yozgat, Turkey. Objective: Here, we presented a case of tirofiban-induced anemia (without any bleeding or hemorrhage) without thrombocytopenia following tirofiban usage. Case: A 69-year-old man applied for elective CAG. He had only hyperlipidemia without diabetes or hypertension. In the elective CAG of six years ago, one bare metal stent was implanted into proximal segment of OM1 branch of the LCX without any hematological deterioration. CAG of three years later revealed that the stent was patent without any additional new obstructive lesion. At admission, the patient had been taking acetylsalicylic acid of 100 mg/day, metaprolol of 50 mg/day, atorvastatin of 20 mg/day for the last six years. He had normal hematological parameters (Tab. 1). He was taken to the angiography laboratory after receiving 100 mg of acetylsalicylic acid. The CAG revealed 20% stenosis in the LAD, proximal 90% narrowing in the LCX and 90% stenosis in the
The American Journal of Cardiologyâ MARCH 26e29, 2015 11th INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND CARDIOVASCULAR SURGERY ABSTRACTS / Poster
S95
P O S T E R A B S T R A C T S
MARCH 26e29, 2015
- PP-005 A Main Coronary Thrombus Resolves with Tirofiban in a Patient Presenting with Non-ST Elevation Myocardial Infarction. Alper Bugra Nacar, Mehmet Fatih Karakas¸, Ali Erayman, Eyüp Büyükkaya, Mustafa Kurt, Adnan Burak Akçay, Nihat S¸en. Department of Cardiology, Mustafa Kemal University, Hatay, Turkey.
Figure. Microscopic examination of the blood film (a) shows single large thrombocytes implying antiaggregant use (red arrow), acanthocytes (white arrows), and (b) the sagittal CT view of abdomen on the catheterized side demonstrates that there is no finding of retro-intra peritoneal hemorrhage.
Table
Baseline First hour Sixth hour 12th hour 18th hour 24th hour 36th hour 48th hour 72th hour 7th day
P O S T E R A B S T R A C T S
Hgb
RBC
HTC
Platelet
WBC
12.0 11.6 10.4 10.2 9.1 8.6 8.2 8.4 10.2 10.6
3.92 3.38 3.43 3.29 2.95 2.75 2.73 2.70 3.48 3.44
36.4 35.9 31.7 30.2 27.4 25.6 24.9 24.2 31.7 32.4
277 291 295 321 289 271 296 319 282 313
8.14 14.40 10.90 14.80 19.40 16.00 12.60 6.30 9.50 6.49
The complete blood count results on follow up studies. [Hgb: Hemoglobin (g/dl); RBC: Red blood cell (K/mL); HTC: Hematocrit (%); Platelet (K/mL); WBC:White blood cell (K/mL).
rudimentary RCA. One bare metal stent was implanted into the LCX following a loading dose of 300 mg clopidogrel and a bolus administration of 8,000 IU of unfractionated heparin. Three hours later, the patient developed severe chest pain without obvious electrocardiographic deviation. Second CAG showed thrombus material filling stent lumen in proximal LCX creating 99% obtruction in the luminal diameter. Thus, tirofiban was started at a bolus administration of 25 mg/kg over 3 minutes and then 0.15 mg/kg/min continuous infusion intravenously. In the follow-up, we observed progressively decreasing hemoglobin without any thrombocytopenia. Hemoglobin level had fallen from 12.0 g/dl to 8.6 g/dl at the end of 24th hour while platelet counts were stable. Tirofiban was ceased immediately at 24th hour. During 24-hour tirofiban infusion, the patient didn’t reveal any clinical signs or symptoms related to hemorrhage except fever of 38.9 C started approximately four hours after tirofiban infusion. Neurological examination was normal. Computed tomography with intravenous contrast agent revealed negative result for retroperitoneal hematoma or any other source of internal bleeding (Fig. 1a). Microscopic examination of the blood film showed hemolytic anemia findings with single large thrombocytes implying antiaggregant use (Fig. 1b). Both direct and indirect Coombs tests were negative. 24 hours after stopping tirofiban infusion, anemia started to recover without any other intervention. One week later he had hematocrit of 32.4% and obvious recovery on the blood film examination. Conclusion: Here, a case of acutely developed anemia without thrombocytopenia following tirofiban infusion used for a coronary artery intervention in an acute setting was reported.
Coronary thrombus is frequently detected during angiographic imaging in patients presenting with acute coronary syndrome. It usually accompanies a ST-elevation myocardial infarction, but also seen with non-ST elevation myocardial infarction. While it may occur in all coronary arteries, it is uncommon in the main coronary artery. We here present our approach and treatment modality for a patient who presented with a non-ST elevation myocardial infarction with an intense thrombus in the main coronary artery. Case: A 84 year-old female patient had a history of prior permanent pacemaker, diabetes mellitus and hypertension. She presented to our emergency department following a night-time onset of chest pain. Physical examination showed a blood pressure of 150/90 mmHg, and a pulse rate of 60 beats/min. Rhythm of pacemaker beats was monitored by ECG. After pacemaker was turned off, ECG showed no ST elevation, and cardiac troponin I was 1,2 ng/ml. Patient was transferred to the catheterization laboratory with a diagnosis of nonST elevation myocardial infarction, during which she received nitrolingual nitrate 5 mg, acetylsalicylic acid 300 mg and unfractionated heparin 5000 U. Coronary angiography demonstrated thrombus in the main coronary artery (figure-1). Due to TIMI 3 flow, and a stable hemodynamic profile the patient was initiated on IV infusion of tirofiban. Then, she was taken to the catheterization laboratory again following 24-hour administration of tirofiban. Coronary angiography revealed that the thrombus in the main coronary artery has resolved (figure-2). With no complaints of chest pain and an additional problem during monitoring, she was discharged from the hospital with recommendations after arrangement of her medical treatment. In conclusion, we here presented a case report to show that patients presenting with a non-ST elevation myocardial infarction may also have thrombotic lesion in the main coronary artery, and it can be conservatively treated with tirofiban infusion by avoiding emergency intervention if they have a stable hemodynamic profile and TIMI 3 flow.
Figure 1. Before tirofiban infusion treatment. Figure 2: Aftertirofiban infusion treatment
S96 The American Journal of Cardiologyâ MARCH 26e29, 2015 11th INTERNATIONAL CONGRESS OF UPDATE IN CARDIOLOGY AND CARDIOVASCULAR SURGERY ABSTRACTS / Poster