Practical Aspects of Monitoring of Antiplatelet Therapy.

Despite the application of new antiplatelet drugs (prasugrel and ticagrelor), dual antiplatelet therapy with clopidogrel and aspirin remains the standard for patients with acute coronary syndrome undergoing percutaneous coronary intervention, especially in countries of low socioeconomic status. Regardless of the proven benefits, numerous studies have shown that certain groups of patients who receive standard doses of clopidogrel and aspirin do not respond adequately, and many of them also exhibit adverse cardiovascular events. Studies have shown that the risk of stent thrombosis and ischemic complications is higher in patients with: acute coronary syndrome, diabetes mellitus, thrombocytosis, reduced systolic function of the left ventricle with ejection fraction less than 30%, presence of multiple stents, longer and thinner stents, and renal failure. In these patients it is particularly important to assess the response to clopidogrel and selecting adequate antiplatelet therapy; this provides an impetus for platelet function tests. The second especially significant group to target for laboratory evaluation includes patients with increased risk of bleeding, such as elderly patients, patients with low body weight, anemia, thrombocytopenia, renal failure, past or current ventricular or duodenal ulcer, coagulopathy, or liver disease. The third important application of platelet function tests entails the preparation and evaluation of the time for surgical interventions or invasive diagnostic procedures in patients on antiplatelet therapy. These tests can also be helpful for monitoring the effects of therapy of bleeding due to platelet dysfunction. For high-risk patients the careful selection of optimal antiplatelet drug(s) on the basis of estimated individual risk of thrombosis and bleeding, pharmacodynamic characteristics of each drug, and patient̀s comorbidity remains essential.

[Thrombocytopenia induced by type II heparin and myocardial infarct: 2 case reports]. / Trombocitopenija indukovana heparinom tip II i infarkt miokarda: prikazi dva bolesnika.

Heparin-induced thrombocytopenia (HIT) type II is an acquired thrombophylic state and life-threatening immune complication of a heparin treatment mainly clinically manifested by marked thrombocytopenia, frequently by arterial and venous thrombosis, and sometimes by skin changes. Functional assay as heparin aggregation test and 14C-serotonin release assays are used in diagnostics as well as antigen assays of which detection tests for heparin-platelet factor 4 antibodies are most frequently used. Considering the fact that there is no single reliable assays for HIT II detection available, sometimes it is necessary to combine both of the above-mentioned types of assays. We present the case of a 57-year-old patient with an acute anterior myocardial infarction with cardiac insufficiency of III and IV degree according to Killip, recurrent ventricular fibrillation and diabetes mellitus type II developing thrombocytopenia to 37 x 10(9)/l accompanied with typical skin changes. The diagnosis was confirmed by the heparin aggregation test. The second patient aged 70 undergoing the treatment for anteroseptal myocardial infarction and reinfarction of the inferior wall complicated by a cardiogenic shock and acute right bundle branch block developed thrombocytopenia 59 x 10(9)/l on the third day of the heparin therapy, with the remark that he had received a heparin therapy during the first infarction as well. Antibodies against heparin-platelet factor 4 were detected by particle gel ID-HPF4 immuno-assay. In both patients, the disease had a lethal outcome despite all then available therapeutic measures applied. Further on we discuss advantages of certain types of tests, a therapy doctrine, need for urgent therapeutic measures, inclusive of the administration of antithrombins, avoidance of harmful procedures like low-molecular-weight heparins administration and prophylactic platelet transfusion as well as preventive measures.

[Heparin-induced type II thrombocytopenia--new views on diagnosis and therapy]. / Heparinom indukovana trombocitopenija tip II--novine u dijagnostici i lecenju.

HEPARIN-INDUCED THROMBOCYTOPENIA (HIT): Management of heparin-induced thrombocytopenia (HIT) and treatment options have significantly changed recently. Heparin may induce two types of thrombocytopenia. Type I, occurring earlier with a much higher rate of incidence (5-30%), is characterized by mild thrombocytopenia without significant clinical manifestations. Type II, is less frequent (0.5-2%), life threatening immune type, develops following a period of minimum 5-7 days upon introduction of heparin therapy (patients earlier treated with heparin are excluded). Type II heparin-induced thrombocytopenia with severely reduced platelet count may be clinically manifested by thrombosis in 20-50% cases within the period of 30 days. HIT is suspected in persons resistant to heparin with relatively reduced platelet count, though HIT is described in person with normal platelet counts, as well. None of available assays used for HIT detection is completely reliable. Sensitivity of a highly specific platelet aggregation assay is only 36%, sensitivity and specificity of 14C-serotonin release assays amounts to 95%, while ELISA using a heparin/platelet factor-4 target has a sensitivity of 85%. Thus, it is sometimes necessary to combine functional and antigen assays. Furthermore, new classes of antigen assays, like antibody detection tests of complexes between heparin and neutrophil-activating peptide-2 as well as those between heparin and interleukin-8, have been used. CURRENT THERAPY OPTIONS: Current therapy options exclude formerly applied low-molecular-weight heparins due to the existing cross-reactivity of 80-100%. Danaparoid sodium exhibits in vitro cross-reactivity of 10-61%, clinically manifested in less than 5% of patients. Two drugs are drugs of choice in HIT type II treatment: lepirudin, especially in patients without renal failure, and argatroban, particularly in patients with renal failure. The following procedures and agents are also efficient: asmapheresis in the first four days, high-dose intravenous gammaglobulin, antiaggregans, especially ADP antagonists, aspirin, dipirydamole, dextran, prostacyclin analagoues, thrombolytic therapy as well as thromboembolectomy. Oral anticoagulants are not administered in active HIT type II, in deep vein thrombosis with high international normalized ratio (INR) and thrombin-antithrombin complexes, and low protein C levels to avoid the possibility of venous limb gangrene development. They can be administered in a stable phase, when the thrombin generation is controlled by previous administration of one of the above-mentioned alternative anticoagulants.

Condylomata gigantea in anal and perianal region: surgical and CO2 laser treatment.

CASE REPORT: We present a case of 28-year-old female patient with condylomata gigantea (Buschke-Lowenstein tumor) in anal and perianal region with propagation on vulva and vagina. The local surgical excision and CO(2) laser treatment were performed. Histological examination showed presence of HPV type 11 without malignant potential. RESULT: Three months later, there was no recurrence.