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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 74-77

Eptifibatide-induced acute profound thrombocytopenia in a patient with left main artery plaque rupture complicated by cardiogenic shock and gastrointestinal bleeding


1 Department of Cardiology, The Northern Hospital, Melbourne, VIC, Australia
2 Department of Cardiology, The Northern Hospital; Department of Cardiology, The University of Melbourne, Melbourne, VIC, Australia

Date of Submission09-Nov-2020
Date of Decision31-Jan-2021
Date of Acceptance07-May-2021
Date of Web Publication22-Jun-2021

Correspondence Address:
Dr. Savvy Nandal
The Northern Hospital, 185 Cooper Street, Epping, Melbourne, VIC
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcpc.jcpc_67_20

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  Abstract 


Eptifibatide inhibits platelet aggregation by reversibly binding to the platelet receptor glycoprotein (GP) IIb/IIIa of human platelets, thus preventing the binding of fibrinogen and adhesion proteins such as fibronectin, vitronectin, and von Willebrand factor to form cross bridges with adjacent platelets. There are two other GP IIb/IIIa inhibitors, namely abciximab and tirofiban, available for clinical use. Profound thrombocytopenia is an uncommon but clinically important complication of GP IIb/IIIa inhibitors. This case discusses a 64-year-old male patient who developed profound thrombocytopenia within 4 h of first administration of eptifibatide. This report adds a case of eptifibatide-induced thrombocytopenia complicated by gastrointestinal bleeding to the medical literature. It highlights the need for complex decision-making regarding cessation of antiplatelet therapy in patients with recent percutaneous coronary intervention and the lack of robust evidence for the benefit of GP IIb/IIIa inhibitors in the ticagrelor era when compared to clopidogrel and aspirin.

Keywords: Eptifibatide, myocardial infarction, thrombocytopenia


How to cite this article:
Nandal S, Van Gaal W, Ponnuthurai FA. Eptifibatide-induced acute profound thrombocytopenia in a patient with left main artery plaque rupture complicated by cardiogenic shock and gastrointestinal bleeding. J Clin Prev Cardiol 2021;10:74-7

How to cite this URL:
Nandal S, Van Gaal W, Ponnuthurai FA. Eptifibatide-induced acute profound thrombocytopenia in a patient with left main artery plaque rupture complicated by cardiogenic shock and gastrointestinal bleeding. J Clin Prev Cardiol [serial online] 2021 [cited 2021 Jul 28];10:74-7. Available from: https://www.jcpconline.org/text.asp?2021/10/2/74/319047




  Introduction Top


Eptifibatide inhibits platelet aggregation by competitive antagonism of the platelet receptor glycoprotein (GP) IIb/IIIa of human platelets, preventing fibrinogen and adhesion proteins such as fibronectin, vitronectin, and von Willebrand factor to form cross bridges with adjacent platelets.[1] Inhibition of platelet aggregation occurs in a dose- and concentration-dependent manner. There are two other GP IIb/IIIa inhibitors, namely abciximab and tirofiban, available for clinical use.

Concomitant administration of eptifibatide has been shown to improve outcomes in clinical studies in patients undergoing percutaneous coronary intervention (PCI). Profound thrombocytopenia is an uncommon but clinically important complication of GP IIb/IIIa inhibitors. In clinical trials, 0.7%–2% of patients developed thrombocytopenia after initial exposure and up to 4.6% in patients after re-exposure.[2]

This case discusses a 64-year-old male patient who developed profound thrombocytopenia within 4 h of first administration of eptifibatide, complicated by gastrointestinal bleeding and cardiogenic shock.


  Case Report Top


A 64-year-old male with no previous history of cardiovascular disease presented with acute retrosternal chest pain with associated nausea, vomiting, and diaphoresis. There was no previous history of blood dyscrasia, thrombocytopenia, or any cardiovascular risk factors. In addition, he had no prior history of hospitalization where he may have received heparin or eptifibatide.

Initial electrocardiogram with ambulance showed diffuse ST elevation in V1–6 and I, II, and aVL [Figure 1], therefore, he was diagnosed with anterolateral ST-elevation myocardial infarction. This was complicated by ventricular fibrillation cardiac arrest requiring 1x direct cardioversion with return of spontaneous circulation during transit to a PCI capable hospital. Upon arrival to a tertiary center, he was given aspirin 300 mg, ticagrelor 180 mg, and intravenous (IV) heparin 5000 units.
Figure 1: Electrocardiogram showing diffuse ST elevation in V1–6 and I, II, and aVL

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Emergent coronary angiography showed a ruptured plaque in the mid left main stem artery extending into the ostial left anterior descending (LAD) artery with subtotal occlusion of the proximal LAD secondary to thrombus, TIMI 1 flow in the LAD [Figure 2]. The left circumflex artery was the dominant vessel with ostial 40% stenosis, proximal 30% stenosis, and mid 20% stenosis. The right coronary artery was small and nondominant. Two IV eptifibatide boluses of 6.8 ml each were administered; 8 min apart prior to stent deployment for thrombus management, however, infusion therapy was not commenced. A 4.0 mm × 26 mm Resolute Onyx drug-eluting stent was deployed at 14 atm from the proximal left main into proximal LAD with pre and post dilatation resulting in TIMI III flow [Figure 3].
Figure 2: Coronary angiogram demonstrating left main plaque rupture with subtotal occlusion of the left anterior descending artery due to thrombus

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Figure 3: Coronary angiogram demonstrating successful percutaneous coronary intervention to left main-left anterior descending artery with flow restoration

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During the PCI procedure, the patient developed cardiogenic shock and large hematemesis with worsening hemodynamic instability, requiring inotropic support, intubation for airway protection, and transfer to the intensive care unit (ICU).

Initial blood testing at presentation showed a platelet count of 249 × 109/L. Repeat bloods which were performed in ICU approximately 4 h post eptifibatide initiation, the patient was noted to have developed profound thrombocytopenia with platelet count reduction by >90% to 6 × 109/L. All other complete blood count parameters remained stable.

All antiplatelet or anticoagulant products including aspirin and ticagrelor were withheld for 24 h due to the significant risk of spontaneous bleeding such as intracranial bleeding which outweighed the risk of in-stent thrombosis. Other causes of acute thrombocytopenia including heparin-induced thrombocytopenia (HIT) using the 4T score, disseminated intravascular coagulopathy, and pseudothrombocytopenia were excluded based on temporal relationship and blood testing. The patient was given 1 unit of platelets with recovery of his platelet count, as shown in [Figure 4]. Proton-pump inhibitor therapy was administered, however, there was no further hematemesis or melena during recovery in ICU, therefore, immediate upper gastrointestinal endoscopy was delayed until clinical recovery.

Dual antiplatelet therapy (aspirin and ticagrelor) was recommenced the following day, and he continued recovery in the ward without any further complications [Figure 4]. He was discharged home on day 7 of admission on antiplatelets and proton-pump inhibitor therapy. Upper gastrointestinal endoscopy was performed a few months later that showed evidence of duodenitis, which was managed with proton-pump inhibitor therapy.
Figure 4: Chart presenting the development of profound thrombocytopenia and its recovery

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  Discussion Top


GP IIb–IIIa inhibitors are commonly used in patients undergoing PCI, especially among those presenting with acute coronary syndrome.[3] Eptifibatide, one of the three GP IIb/IIIa inhibitors, is a derivative of the naturally occurring rattlesnake venom protein known as barbourin.[4] Eptifibatide has linear, dose-proportional pharmacokinetics, and steady state is achieved within 4–6 h. It is approximately 25% bound to human plasma protein and has elimination half-life in patients undergoing PCI of 2.71 h.[2]

GP IIb/IIIa inhibitors are known to cause thrombocytopenia in 0.7%–2% of patients after initial exposure and up to 4.6% in patients after re-exposure.[5] Clinical trials with eptifibatide include the PURSUIT trial and ESPRIT trial that report acute profound thrombocytopenia at 0.1%–0.2%[3],[6] which is defined as platelet count <20,000/mm3[7] usually within 24 h of drug administration.

The pathophysiology of acute profound thrombocytopenia secondary to GP IIb/IIIa inhibitors is speculated by several mechanisms. Preexisting drug antibodies to platelet surface are present in some patients with prior exposure to the drug. However, in patients with no previous exposure, GP IIb/IIIa inhibitors may induce conformational change in their receptor leading to expression of neoepitopes that may be recognized by preformed antibodies. This neoepitope formation creates the possibility of thrombocytopenia arising within a few hours as evident in our case.[8],[9]

In this case, there was a precipitous platelet count drop leading to upper gastrointestinal bleeding within few hours of eptifibatide infusion. GP IIb/IIIa inhibitor therapies have low rates of life-threatening bleeding and intracranial hemorrhage (<0.2%).[10] However, this risk increases significantly with concomitant development of thrombocytopenia. Therefore, it became imperative in our case to cease all antiplatelet and anticoagulant therapies until the platelet count recovery was established. With resolution of thrombocytopenia, gastrointestinal bleeding self-resolved and the patient underwent gastrointestinal endoscopy at a later stage post clinical recovery.

Other differentials for thrombocytopenia were also considered and thought to be unlikely for the following reasons. Pseudothrombocytopenia and disseminated intravascular coagulopathy were excluded with blood testing including repeat blood count, prothrombin time, activated partial thromboplastin time, and fibrinogen level. HIT types 1 and 2 present days to weeks post heparin exposure usually leading to mild reduction in platelet count.[11] The lack of temporal relationship and history of previous exposure with heparin, the precipitous drop as well as patient's 4T score made HIT unlikely. There have been few case reports of ticagrelor-induced thrombocytopenia since its usage in acute coronary syndrome.[12],[13],[14] Two of the case reports describe thrombotic thrombocytopenic purpura occurring months after exposure to ticagrelor with the presence of microangiopathic hemolytic anemia and thrombocytopenia. However, this has not been well characterized in the literature with clinical course and mechanism of action still unclear. In our patient, there was no evidence of hemolytic anemia and re-exposure to ticagrelor did not induce thrombocytopenia again making this drug an unlikely culprit.

This report adds a case of eptifibatide-induced profound thrombocytopenia complicated by gastrointestinal bleeding to the medical literature and highlights the lack of robust evidence for the benefit of GP IIb/IIIa inhibitors in the ticagrelor era when compared to clopidogrel and aspirin.[15],[16] Therefore, judicious usage of GP IIb/IIIa inhibitors is advised with the more potent antiplatelets.


  Conclusion Top


Early and regular platelet count monitoring is imperative with GP IIb/IIIa inhibitor administration. Profound thrombocytopenia can lead to life-threatening hemorrhagic complications which subsequently needs complex decision-making regarding cessation of antiplatelet therapy in patients with recent PCI. There is limited evidence of the utility of GP IIb/IIIa inhibitors in patients with concomitant ticagrelor.

Consent

The author/s confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Graidis C, Golias C, Dimitriadis D, Dimitriadis G, Bitsis T, Dimitrelos I, et al. Eptifibatide-induced acute profound thrombocytopenia: A case report. BMC Res Notes 2014;7:107.  Back to cited text no. 1
    
2.
Curran MP, Keating GM. Eptifibatide: A review of its use in patients with acute coronary syndromes and/or undergoing percutaneous coronary intervention. Drugs 2005;65:2009-35.  Back to cited text no. 2
    
3.
O'Shea JC, Hafley GE, Greenberg S, Hasselblad V, Lorenz TJ, Kitt MM, et al. Platelet glycoprotein IIb/IIIa integrin blockade with eptifibatide in coronary stent intervention: The ESPRIT trial: A randomized controlled trial. JAMA 2001;285:2468-73.  Back to cited text no. 3
    
4.
Phillips DR, Scarborough RM. Clinical pharmacology of eptifibatide. Am J Cardiol 1997;80:11B-20B.  Back to cited text no. 4
    
5.
Fahdi IE, Saucedo JF, Hennebry T, Ghani M, Sadanandan S, Garza-Arreola L. Incidence and time course of thrombocytopenia with abciximab and eptifibatide in patients undergoing percutaneous coronary intervention. Am J Cardiol 2004;93:453-5.  Back to cited text no. 5
    
6.
Platelet Glycoprotein IIb/IIIa in Unstable Angina; Receptor Suppression Using Integrilin Therapy (PURSUIT) Trial Investigators. Inhibition of platelet glycoprotein IIb/IIIa with eptifibatide in patients with acute coronary syndromes. N Engl J Med 1998;339:436-43.  Back to cited text no. 6
    
7.
Williamson DR, Albert M, Heels-Ansdell D, Arnold DM, Lauzier F, Zarychanski R, et al. Thrombocytopenia in critically ill patients receiving thromboprophylaxis: Frequency, risk factors, and outcomes. Chest 2013;144:1207-15.  Back to cited text no. 7
    
8.
Aster RH, Bougie DW. Drug-induced immune thrombocytopenia. N Engl J Med 2007;357:580-7.  Back to cited text no. 8
    
9.
Bougie DW, Wilker PR, Wuitschick ED, Curtis BR, Malik M, Levine S, et al. Acute thrombocytopenia after treatment with tirofiban or eptifibatide is associated with antibodies specific for ligand-occupied GPIIb/IIIa. Blood 2002;100:2071-6.  Back to cited text no. 9
    
10.
Tcheng JE. Clinical challenges of platelet glycoprotein IIb/IIIa receptor inhibitor therapy: Bleeding, reversal, thrombocytopenia, and retreatment. Am Heart J 2000;139:S38-45.  Back to cited text no. 10
    
11.
Linkins LA, Dans AL, Moores LK, Bona R, Davidson BL, Schulman S, et al. Treatment and prevention of heparin-induced thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:S495-530.  Back to cited text no. 11
    
12.
Siao WZ, Chuang WY, Su CH, Huang SF, Tu WK, Chan KC. A rare case of ticagrelor-induced profound isolated thrombocytopenia. Acta Cardiol Sin 2017;33:556-8.  Back to cited text no. 12
    
13.
Wang X, Zhang S, Li L, Hua J, Zhu L, Li L, et al. Ticagrelor-induced thrombotic thrombocytopenic purpura: A case report and review of the literature. Medicine (Baltimore) 2018;97:e11206.  Back to cited text no. 13
    
14.
Doğan A, Özdemir B, Bal H, Özdemir E, Kurtoğlu N. Ticagrelor-associated thrombotic thrombocytopenic purpura. Anatol J Cardiol 2017;17:73-4.  Back to cited text no. 14
    
15.
Rubboli A, Patti G. What is the role for glycoprotein IIb/IIIa inhibitor use in the catheterization laboratory in the current era? Curr Vasc Pharmacol 2018;16:451-8.  Back to cited text no. 15
    
16.
Shimada YJ, Bansilal S, Wiviott SD, Becker RC, Harrington RA, Himmelmann A, et al. Impact of glycoprotein IIb/IIIa inhibitors on the efficacy and safety of ticagrelor compared with clopidogrel in patients with acute coronary syndromes: Analysis from the Platelet Inhibition and Patient Outcomes (PLATO) Trial. Am Heart J 2016;177:1-8.  Back to cited text no. 16
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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