Thrombocytopenia and Thromboses in Myocardial Infarction Associated with Eptifibatide-Dependent Activating Antiplatelet Antibodies

Introduction

Eptifibitide and other glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors are commonly used with dual antiplatelet therapy for high-risk percutaneous coronary interventions (PCI) in the treatment of acute coronary syndromes. Although initial clinical trials did not identify a significant incidence of thrombocytopenia following eptifibatide treatment,[1] this complication has become more recognized over time in clinical practice. We report the case of a 60-year-old man with an ST-elevation myocardial infarction (STEMI), who developed profound thrombocytopenia as well as multiple venous and arterial thromboses after exposure to eptifibatide during high-risk PCI. We demonstrate the presence and activity of eptifibatide-dependent anti-platelet antibodies in this patient and present clinical data that supports a causal link between eptifibatide and this patient’s hematologic sequelae.

^* Authors contributed equally.

• References

• 1 Dasgupta H, Blankenship JC, Wood GC, Frey CM, Demko SL, Menapace FJ. Thrombocytopenia complicating treatment with intravenous glycoprotein IIb/IIIa receptor inhibitors: a pooled analysis. Am Heart J 2000; 140 (02) 206-211
• 2 Curtis BR, McFarland JG, Wu GG, Visentin GP, Aster RH. Antibodies in sulfonamide-induced immune thrombocytopenia recognize calcium-dependent epitopes on the glycoprotein IIb/IIIa complex. Blood 1994; 84 (01) 176-183
• 3 Sheridan D, Carter C, Kelton JG. A diagnostic test for heparin-induced thrombocytopenia. Blood 1986; 67 (01) 27-30
• 4 Moser M, Bertram U, Peter K, Bode C, Ruef J. Abciximab, eptifibatide, and tirofiban exhibit dose-dependent potencies to dissolve platelet aggregates. J Cardiovasc Pharmacol 2003; 41 (04) 586-592
• 5 Hongo RH, Brent BN. Association of eptifibatide and acute profound thrombocytopenia. Am J Cardiol 2001; 88 (04) 428-431
• 6 Epelman S, Nair D, Downey R, Militello M, Askari AT. Eptifibatide-induced thrombocytopenia and thrombosis. J Thromb Thrombolysis 2006; 22 (02) 151-154
• 7 Gao C, Boylan B, Bougie D. , et al. Eptifibatide-induced thrombocytopenia and thrombosis in humans require FcgammaRIIa and the integrin β3 cytoplasmic domain. J Clin Invest 2009; 119 (03) 504-511
• 8 Giuliano C, Edwin SB, Kador H, Mooney M. Eptifibatide-induced thrombocytopenia and subsequent thrombosis. J Pharm Technol 2012; 28: 146-150
• 9 Tempelhof MW, Benzuly KH, Fintel D, Krichavsky MZ. Eptifibatide-induced thrombocytopenia: with thrombosis and disseminated intravascular coagulation immediately after left main coronary artery percutaneous coronary angioplasty. Tex Heart Inst J 2012; 39 (01) 86-91
• 10 Bougie DW, Wilker PR, Wuitschick ED. , et al. Acute thrombocytopenia after treatment with tirofiban or eptifibatide is associated with antibodies specific for ligand-occupied GPIIb/IIIa. Blood 2002; 100 (06) 2071-2076
• 11 Goel R, Ness PM, Takemoto CM, Krishnamurti L, King KE, Tobian AA. Platelet transfusions in platelet consumptive disorders are associated with arterial thrombosis and in-hospital mortality. Blood 2015; 125 (09) 1470-1476