Severe Thrombocytopenia in a Patient with Submassive Pulmonary Embolism and Heparin-Induced Thrombocytopenia: to Lyse or
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MEDICINE
Severe Thrombocytopenia in a Patient with Submassive Pulmonary Embolism and Heparin-Induced Thrombocytopenia: to Lyse or Not to Lyse? Chirag Sheth 1 & Chompunut Asava-Aree 2 & Mandeep Singh Randhawa 3 & John R. Bartholomew 1 Accepted: 9 October 2020 # Springer Nature Switzerland AG 2020
Abstract Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse reaction to heparin which can cause life-threatening venous as well as arterial thrombosis. HIT-driven thrombosis is associated with very high morbidity and mortality. Patients with HIT are also at increased risk of bleeding due to concomitant use of non-heparin anticoagulant, especially in patients with profound thrombocytopenia. We present a case of a 69-year-old female who developed heparin-induced thrombocytopenia complicated by acute submassive pulmonary embolism 1 week after total knee replacement surgery. Despite treatment with a direct thrombin inhibitor, her hemodynamic status deteriorated. She was given half-dose (50 mg) systemic thrombolysis resulting in hemodynamic and respiratory status improvement without any bleeding complications. This case represents successful thrombolysis of a submassive pulmonary embolism in a patient with severe thrombocytopenia resulting from heparin-induced thrombocytopenia. Keywords Heparin-induced thrombocytopenia . Pulmonary embolism . Thrombolysis . Direct thrombin inhibitor
Background Heparin-induced thrombocytopenia (HIT) is an antibodymediated adverse reaction to heparin or heparin-related products including low molecular weight heparin (LMWH) that can result in both arterial and/or venous thrombosis [1].
Treatment consists of discontinuing heparin products and initiating a non-heparin anticoagulant. In the USA, there are only two agents approved for HIT, argatroban and bivalirudin. Argatroban is authorized by the Food and Drug Administration (FDA) for treatment of HIT, while bivalirudin is approved for HIT patients undergoing percutaneous
Highlights • Thrombosis associated with heparin-induced thrombocytopenia (HIT) carries very high morbidity and mortality. • Treatment of HIT involves cessation of heparin and heparin-related products and initiating non-heparin anticoagulant, preferably direct thrombin inhibitor. • We report a case of submassive pulmonary embolism (PE) in a patient with HIT-associated severe thrombocytopenia treated with systemic thrombolysis in conjunction with bivalirudin. • Half dose of systemic thrombolytic therapy (50-mg tissue plasminogen activator) can be safely administered in a patient with submassive PE with HIT despite severe thrombocytopenia. This article is part of the Topical Collection on Medicine * Chirag Sheth [email protected]; [email protected] 1
Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Desk J3-5, 9500 Euclid Avenue, Cleveland, OH 44195, USA
2
Department of Vascular Medicine, Southeastern Regional Medical Center, 300 W 27th St., Lumberton, NC 28358, USA
3
Department of Internal Medicine, Division o
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