Pulmonary embolism and heparin-induced thrombocytopenia successfully treated with tissue plasminogen activator and argatroban Zachary Hourmouzis MD, Mary Colleen Bhalla MD, Jennifer A. Frey PhD, Sharhabeel Jwayyed MD, MS PII: DOI: Reference:
S0735-6757(14)00862-6 doi: 10.1016/j.ajem.2014.11.027 YAJEM 54629
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
6 October 2014 15 November 2014
Please cite this article as: Hourmouzis Zachary, Bhalla Mary Colleen, Frey Jennifer A., Jwayyed Sharhabeel, Pulmonary embolism and heparin-induced thrombocytopenia successfully treated with tissue plasminogen activator and argatroban, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.11.027
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Pulmonary embolism and heparin-induced thrombocytopenia successfully treated with tissue plasminogen activator and argatroban
NU
SC
RI P
T
Corresponding author, requests for reprints Mary Colleen Bhalla, MD Department of Emergency Medicine Summa Akron City Hospital 525 East Market St. Akron, OH 44304-1619 Office 330-375-7530 Fax 330-375-7564 Email [email protected]
MA
Authors Zachary Hourmouzis, MD1
ED
Mary Colleen Bhalla, MD 1, 2
PT
Jennifer A. Frey, PhD 1
Sharhabeel Jwayyed, MD, MS 1, 2 1
2
CE
Summa Akron City Hospital, Department of Emergency Medicine, Akron, OH
AC
Northeast Ohio Medical University, Rootstown, OH
No outside funding used
Previously presented as a poster at the Summa Akron City and St. Thomas Hospitals Annual Postgraduate Day, June, 21014.
Key words: Pulmonary embolism, heparin-induced thrombocytopenia
Short Running Head: PE and HIT treated with argatroban and tPA
ACCEPTED MANUSCRIPT Abstract
RI P
T
Heparin-induced thrombocytopenia (HIT) is a disorder characterized by antibodies formed against the heparin-platelet factor 4 (PF4) complex that results in thrombosis and platelet consumption. It can lead to extensive thromboembolic disease and coagulopathy. Diagnosis remains a challenge, but there are now assays that can be used for confirmation.
ED
MA
NU
SC
A 56 year old female presented to the emergency department with a complaint of shortness of breath. She had been hospitalized five weeks prior for a laparatomy, which was complicated by pneumonia requiring intubation, and deep vein thrombosis. Initial platelet level was 63 x 109/L after being 275 upon discharge. Computed tomography angiography revealed massive bilateral saddle pulmonary emboli. She was hemodynamically stable when she was started on a heparin bolus and drip, but it was then revealed that she had received low molecular weight heparin (LMWH) as an outpatient. Her blood pressure dropped and the heparin was discontinued. She was given 100 mg of tissue plasminogen activator (tPA) over one hour rather than two, with symptomatic improvement. She was treated with argatroban and later tested positive for antibodies against the heparin-PF4 complex which confirmed the diagnosis of HIT. She was converted to and discharged on warfarin and has done well.
AC
Manuscript
CE
PT
This case demonstrates the proper diagnosis and workup for pulmonary embolism caused by HIT, with successful treatment of both the underlying disease and its life-threatening complications. It demonstrates that, though the risk of HIT is less with LMWH than for heparin, it is not zero.
Heparin-induced thrombocytopenia (HIT) is a thrombotic and coagulopathic disorder caused by use of heparin or low molecular weight heparin (LMWH) or fondaprinux, the latter two being less associated with causing the disorder. Typically, platelets will fall to
S0735-6757(14)00862-6 doi: 10.1016/j.ajem.2014.11.027 YAJEM 54629
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
6 October 2014 15 November 2014
Please cite this article as: Hourmouzis Zachary, Bhalla Mary Colleen, Frey Jennifer A., Jwayyed Sharhabeel, Pulmonary embolism and heparin-induced thrombocytopenia successfully treated with tissue plasminogen activator and argatroban, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.11.027
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Pulmonary embolism and heparin-induced thrombocytopenia successfully treated with tissue plasminogen activator and argatroban
NU
SC
RI P
T
Corresponding author, requests for reprints Mary Colleen Bhalla, MD Department of Emergency Medicine Summa Akron City Hospital 525 East Market St. Akron, OH 44304-1619 Office 330-375-7530 Fax 330-375-7564 Email [email protected]
MA
Authors Zachary Hourmouzis, MD1
ED
Mary Colleen Bhalla, MD 1, 2
PT
Jennifer A. Frey, PhD 1
Sharhabeel Jwayyed, MD, MS 1, 2 1
2
CE
Summa Akron City Hospital, Department of Emergency Medicine, Akron, OH
AC
Northeast Ohio Medical University, Rootstown, OH
No outside funding used
Previously presented as a poster at the Summa Akron City and St. Thomas Hospitals Annual Postgraduate Day, June, 21014.
Key words: Pulmonary embolism, heparin-induced thrombocytopenia
Short Running Head: PE and HIT treated with argatroban and tPA
ACCEPTED MANUSCRIPT Abstract
RI P
T
Heparin-induced thrombocytopenia (HIT) is a disorder characterized by antibodies formed against the heparin-platelet factor 4 (PF4) complex that results in thrombosis and platelet consumption. It can lead to extensive thromboembolic disease and coagulopathy. Diagnosis remains a challenge, but there are now assays that can be used for confirmation.
ED
MA
NU
SC
A 56 year old female presented to the emergency department with a complaint of shortness of breath. She had been hospitalized five weeks prior for a laparatomy, which was complicated by pneumonia requiring intubation, and deep vein thrombosis. Initial platelet level was 63 x 109/L after being 275 upon discharge. Computed tomography angiography revealed massive bilateral saddle pulmonary emboli. She was hemodynamically stable when she was started on a heparin bolus and drip, but it was then revealed that she had received low molecular weight heparin (LMWH) as an outpatient. Her blood pressure dropped and the heparin was discontinued. She was given 100 mg of tissue plasminogen activator (tPA) over one hour rather than two, with symptomatic improvement. She was treated with argatroban and later tested positive for antibodies against the heparin-PF4 complex which confirmed the diagnosis of HIT. She was converted to and discharged on warfarin and has done well.
AC
Manuscript
CE
PT
This case demonstrates the proper diagnosis and workup for pulmonary embolism caused by HIT, with successful treatment of both the underlying disease and its life-threatening complications. It demonstrates that, though the risk of HIT is less with LMWH than for heparin, it is not zero.
Heparin-induced thrombocytopenia (HIT) is a thrombotic and coagulopathic disorder caused by use of heparin or low molecular weight heparin (LMWH) or fondaprinux, the latter two being less associated with causing the disorder. Typically, platelets will fall to
