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PubMed1982

Syndrome of hemolysis, elevated liver enzymes, and low platelet count: a severe consequence of hypertension in pregnancy.

Data are presented to define a unique group of preeclamptic/eclamptic patients with the finding of hemolysis (H), elevated liver enzymes (EL), and a low platelet count (LP). This entity has been termed the HELLP syndrome and may occur when the usual clinical findings to diagnose severe preeclampsia are absent. Often the patient is given a nonobstetric diagnosis and treatment is withheld or modified. The possible pathophysiology of this syndrome, the management of the patient, and the maternal and neonatal outcomes are presented. Recognition of the clinical and laboratory findings of the HELLP syndrome is important if early, aggressive therapy is to be initiated to prevent maternal and neonatal death. The practicing obstetrician must be knowledgeable about this severe consequence of hypertension in pregnancy.

Adolescent↗
PubMed1979

Bleeding time in uremia: a useful test to assess clinical bleeding.

Modified Ivy bleeding time (template) and platelet aggregation to ADP, epinephrine, and collagen were studied in 26 uremic patients who had not recently ingested anti-platelet drugs. Regardless of the aggregating agent used, the abnormalities in platelet aggregation were often mild, even with advanced uremia, and frequently less severe than the effects of common anti-platelet drugs. The inhibition of collagen-induced aggregation was significantly correlated with both increased bleeding time and blood urea nitrogen. Platelet aggregation was not discriminative between clinically bleeding and non-bleeding groups of patients, but the bleeding time was helpful in this regard. In certain cases, the aggregometric patterns differed between drug-induced and uremic thrombocytopathies. Platelet aggregometry appears to be of little help clinically in assessing the severity of the uremic bleeding diathesis.

Adenosine Diphosphate↗
PubMed1986

"Haemostasis time", a modified bleeding time test and its comparison with the Duke and Ivy/template bleeding times. I. Normal values, application in thrombocytopenic patients and evaluation of heparin and aspirin effects.

The occlusion time ("haemostasis time" - HT) of a thin, short cannula inserted into the cubital vein, was compared with the skin bleeding times of the Duke and Ivy/template techniques. 25 male and 25 female volunteers without a history of bleeding were divided into 5 equally large age groups ranging from 10 to over 50 years of age. They exhibited a range of 46 s-6 min 38 s (95% tolerance interval), while the Duke and Ivy/template bleeding times, which were simultaneously determined, corresponded to values given by other authors. HT is different from the skin bleeding times in that endothelium is replaced by a standard foreign surface which allows better standardization of the method. Similar results were obtained with HT compared to the skin bleeding times. These and a similar, non-significant heparin response with all three techniques suggest that HT is not more influenced by clotting factors than the Duke and Ivy/template bleeding times and, indeed, may be regarded as a bleeding time modification. HT, like both of the skin bleeding times, reflected lowered platelet counts and is even more sensitive in this respect. As tested in a group of 20 male and 20 female volunteers, HT showed a significant prolongation two hours after ingestion of 1 g aspirin. While male individuals exhibited longer bleeding times than females with the Ivy/template technique (sex-related difference p = 0.01), no male to female differences were found both with HT and the Duke bleeding time. HT is easy to perform, inexpensive, leaves no scars and is safe even for the patient with severe bleeding. Moreover, compared to the skin bleeding times, it permits a differential evaluation of vessel wall and tissue effects.

Adolescent↗
PubMed2001

Thromboagglutination by anticardiolipin antibody complex in the antiphospholipid syndrome: a possible mechanism of immune-mediated thrombosis.

The tendency for patients with antiphospholipid syndrome (APLS) to thromboembolism and the criteria for its detection are well established, whereas the mechanism of this thrombophilic syndrome is still obscure. Using immunofluorescent techniques and a microscopic spontaneous platelet aggregation test (mSPAT), we have previously demonstrated platelet binding by antibody followed by aggregation in patients with lupus anticoagulant. In the present study, we investigated 18 anticardiolipin antibody-positive (ACLA pos.) patients, comprised of 12 primary APLS and 6 secondary APLS lupus patients. We demonstrated direct platelet microaggregate formation in 16/18 cases, whereas this finding was not present in 20 ACLA-negative (ACLA neg.) subjects (P<.001). Indirect testing revealed 10/12 cases of platelet microaggregation and none in the ACLA neg. subjects. In addition, immunofluorescent studies showed that platelet antibody complex binding occurred in 8/12 cases tested directly and in 11/12 cases in indirect testing, as compared to 1 out of 20 binding in ACLA neg. subjects (P<.001). Antibody complex binding was inhibited in two cases by prior extraction of phospholipids. Platelet aggregation could be demonstrated in two ACLA neg. individuals by the addition of exogenous ACLA to platelets in EDTA-plasma. We therefore propose a mechanism for immune-mediated thrombosis in APLS in which calcium-independent platelet aggregation, or thromboagglutination, is initiated by an ACLA-phospholipid complex present in the patients' plasma. Following the antibody complex-induced platelet agglutination, thrombosis proceeds by release, recruitment, and fibrin formation. The mechanism should have important implications in the diagnosis, management, and monitoring of APLS.

Adolescent↗
PubMed1996

Smoking and plasma fibrinogen, lipoprotein (a) and serotonin are markers for postoperative infrainguinal graft stenosis.

OBJECTIVES: A number of systemic variables are associated with infrainguinal graft failure and also with experimental smooth muscle hyperplasia. Stenosis is the most common cause of infrainguinal graft thrombosis but it is not known if systemic variables are associated with stenosis. DESIGN, MATERIALS, AND METHODS: In this study, clinical and serological factors were measured and correlated with stenosis development in 81 infrainguinal bypass grafts (52 vein, 29 PTFE; 28 with stenosis) in prospective (n=46) and retrospective (n=35) groups. Pre-existing stenosis was excluded by perioperative graft assessment. RESULTS: There was a significantly greater proportion of smokers in the patients who developed stenosis (11/18; 61%) compared with those who did not (6/28; 21%, p=0.006; chi 2). Patients who developed stenosis also had significantly (Mann Whitney U-tests), higher circulating levels of [median (interquartile range)] fibrinogen (412.5 (356-484.5) vs. 339 (300-397.7) mg/100ml, p=0.003), Lipoprotein (a) (0.20 (0.05-0.45) vs. 0.085 (0.05-0.23) g/l, p=0.03) and 5-hydroxytryptamine (14.1 (6.6-45) vs. 4.41 (3-8.39) nmol/l, p=0.005), than those without stenosis. By logistic regression, these associations were independent of graft material and whether grafts were studied prospectively or retrospectively. CONCLUSIONS: Smoking and plasma fibrinogen, Lp(a) and 5-hydroxytryptamine are markers for postoperative infrainguinal graft stenosis.

Blood Vessel Prosthesis↗
PubMed1994

Effect of inhaled terbutaline on platelet activity in bronchial asthma.

Thirty five young subjects with long standing bronchial asthma were studied for the effects of terbutaline misthaler (500 micrograms) during acute asthma. Bronchodilators were omitted for a day before the test. Ten matched controls were also studied. In all subjects, basal IgE level (ELISA), pulmonary parameters (FVC, FEV, PEFR, FEF 25-75 and FEF 75-85) and platelet activity, (platelet clumping/150 WBC on smear, platelet adhesiveness, blood recalcification time and kaolin clotting time for platelet factor3) were compared. During acute asthma, the subjects displayed IgE levels > or = 500 IU/ml (n = 33), activation of clotting (n = 30) and eosinophilia > or = 450/cmm (n = 28). These changes were not seen in normal controls. Terbutaline resulted in a reversal of airway obstruction, mainly of small airways, while the platelet hyperactivity and blood hypercoagulability were rectified (P < 0.001). It is concluded that platelet activity increases in acute asthma and is corrected by inhaled terbutaline concomittant with the relief of bronchospasm.

Adult↗
PubMed2005

Aspirin resistance in ischaemic heart disease.

BACKGROUND: In spite of the usage of acetylsalicylic acid (aspirin) in the secondary prevention of ischaemic heart disease (IHD), new thrombo-embolic events occur in more than half of patients. Aspirin resistance may be partially responsible for this phenomenon. AIM: To assess the prevalence of aspirin resistance in patients with IHD and to correlate this phenomenon with the progression of atherosclerosis, concomitant diseases and other medication. METHODS: The study group consisted of 205 patients (mean age 65.8 years, 95 females) with stable angina, recent coronary angiography and positive result of non-invasive stress tests, treated with 75 mg of aspirin for at least one week. Platelet aggregation was measured using the optical aggregation method. Aspirin resistance was defined as a mean collagen and ATP-induced platelet aggregation >70%. RESULTS: Aspirin resistance was found in 41 (20%) patients and was significantly associated with previous coronary artery bypass grafting (CABG) (p<0.01) and three-vessel disease (p<0.05). Previous CABG was the only independent risk factor for the presence of aspirin resistance (OR 5.6; 95% CI 2.0-15.4; p<0.01). CONCLUSIONS: Aspirin resistance is present in 20% of patients with stable angina. Previous CABG is an independent risk factor of this phenomenon.

Aged↗
PubMed2004

Two-stage total hepatectomy and liver transplantation for acute deterioration of chronic liver disease: a new bridge to transplantation.

Two-stage total hepatectomy and liver transplantation has been reported for acute liver disease such as fulminant hepatic failure, primary graft failure, severe hepatic trauma, and spontaneous hepatic rupture secondary to hemolysis, elevated liver function tests, low platelets syndrome, and preeclampsia. This is the first report of patients with cirrhosis to undergo a 2-stage total hepatectomy and liver transplantation. From 1984 to 2002, our institution performed 2008 orthotopic liver transplantations. We identified 4 patients with chronic liver disease who underwent a 2-stage hepatectomy and liver transplantation. This is a retrospective review of these 4 patients and a review of the literature on this procedure. All 4 patients were young men with an age range of 29-31 years and had underlying cirrhosis as well as a previous transjugular intrahepatic portosystemic shunt (TIPS)procedure. Acute decompensation fulfilling Ringes' criteria for toxic liver syndrome secondary to an upper gastrointestinal bleed occurred in all patients. The approximate average time between hepatectomy and liver transplantation was 20 hours (range: 8-42 hours). In all cases, the explanted liver showed histological changes of acute hepatic necrosis within the background of cirrhosis. After hepatectomy, vasopressor requirements were well documented in 2 patients. For 1 patient, there was a clear improvement in their hemodynamic status. The mean hospital stay of the 4 patients was 63 days. All patients were discharged from the hospital and are alive and well with adequate liver function at 6 to 37 months follow-up. Two-stage total hepatectomy and liver transplantation may be a life-saving procedure in highly selected cirrhotic patients with acute hepatic decompensation and multiorgan dysfunction.

Adult↗
PubMed2006

The management of heparin-induced thrombocytopenia.

The Haemostasis and Thrombosis Task Force of the British Committee for Standards in Haematology has produced a concise practical guideline to highlight the key issues in the management of heparin-induced thrombocytopenia (HIT) for the practicing physician in the UK. The guideline is evidence-based and levels of evidence are included in the body of the article. All patients who are to receive heparin of any sort should have a platelet count on the day of starting treatment. For patients who have been exposed to heparin in the last 100 d, a baseline platelet count and a platelet count 24 h after starting heparin should be obtained. For all patients receiving unfractionated heparin (UFH), alternate day platelet counts should be performed from days 4 to 14. For surgical and medical patients receiving low-molecular-weight heparin (LMWH) platelet counts should be performed every 2-4 d from days 4 to 14. Obstetric patients receiving treatment doses of LMWH should have platelet counts performed every 2-4 d from days 4 to 14. Obstetric patients receiving prophylactic LMWH are at low risk and do not need routine platelet monitoring. If the platelet count falls by 50% or more, or falls below the laboratory normal range and/or the patient develops new thrombosis or skin allergy between days 4 and 14 of heparin administration HIT should be considered and a clinical assessment made. If the pretest probability of HIT is high, heparin should be stopped and an alternative anticoagulant started at full dosage unless there are significant contraindications while laboratory tests are performed. Platelet activation assays using washed platelets have a higher sensitivity than platelet aggregation assays but are technically demanding and their use should be restricted to laboratories experienced in the technique. Non-expert laboratories should use an antigen-based assay of high sensitivity. Only IgG class antibodies need to be measured. Useful information is gained by reporting the actual optical density, inhibition by high concentrations of heparin, and the cut-off value for a positive test rather than simply reporting the test as positive or negative. In making a diagnosis of HIT the clinician's estimate of the pretest probability of HIT together with the type of assay used and its quantitative result (enzyme-linked immunosorbent assay, ELISA, only) should be used to determine the overall probability of HIT. Clinical decisions should be made following consideration of the risks and benefits of treatment with an alternative anticoagulant. For patients with strongly suspected or confirmed HIT, heparin should be stopped and full-dose anticoagulation with an alternative, such as lepirudin or danaparoid, commenced (in the absence of a significant contraindication). Warfarin should not be used until the platelet count has recovered. When introduced in combination with warfarin, an alternative anticoagulant must be continued until the International Normalised Ratio (INR) is therapeutic for two consecutive days. Platelets should not be given for prophylaxis. Lepirudin, at doses adjusted to achieve an activated partial thromboplastin time (APTT) ratio of 1.5-2.5, reduces the risk of reaching the composite endpoint of limb amputation, death or new thrombosis in patients with HIT and HIT with thrombosis (HITT). The risk of major haemorrhage is directly related to the APTT ratio, lepirudin levels and serum creatinine levels. The patient's renal function needs to be taken into careful consideration before treatment with lepirudin is commenced. Severe anaphylaxis occurs rarely in recipients of lepirudin and is more common in previously exposed patients. Danaparoid in a high-dose regimen is equivalent to lepirudin in the treatment of HIT and HITT. Danaparoid at prophylactic doses is not recommended for the treatment of HIT or HITT. Patients with previous HIT who are antibody negative (usually so after >100 d) who require cardiac surgery should receive intraoperative UFH in preference to other anticoagulants that are less validated for this purpose. Pre- and postoperative anticoagulation should be with an anticoagulant other than UFH or LMWH. Patients with recent or active HIT should have the need for surgery reviewed and delayed until the patient is antibody negative if possible. They should then proceed as above. If deemed appropriate early surgery should be carried out with an alternative anticoagulant. We recommend discussion of these complex cases requiring surgery with an experienced centre. The diagnosis must be clearly recorded in the patient's medical record.

Anticoagulants↗
PubMed1984

[Changes in spontaneous platelet aggregation induced by the ambient temperature].

The diagnostic meaning of the functional platelets modifications (particularly those of spontaneous platelet aggregation = P.A.) in cardiovascular pathology has been recalled. It is emphasized that, in order to have significantly predictable data on eventual pathological alterations in case of deviations of values considered normal, one has to use methods that do not differ from the real haemorheological conditions. A research has therefore been made with the purpose to evaluate the influence that variations of temperature may have on the samples collected and left to sediment (for the separation of the PRP) and the subsequent modifications of P.A. The research has been made in double on plasma sedimented at 37 degrees C and at room-temperature on 731 subjects, 289 of which were the casuistic groups for the subsequent statistic elaboration. With similar modalities in other 8 patients the eventual variations in excretion of beta-TG were looked for. The results have shown that there are important variations of the spontaneous P.A. rates, that the difference is always statistically very significant and that lowering the temperature of the samples favors an increase in beta-TG excretion . The Authors think therefore that only the sedimentation at 37 degrees C issues a plasma usefull for the further performing of platelets tests, while in the plasma obtained with sedimentation at room-temperature the platelets are perhaps already stimulated to an activation (and subsequently an aggregation) higher than the real one. Data obtained from a homogeneous group of subjects, healthy from a clinical point of view, allowed to fix the new range of normal values within 3% of aggregability . The mechanisms that lead to such different results are discussed. Emphasis is put on the fact that the spontaneous P.A. determined by the means mentioned seems satisfactorily near to the real clinical conditions. That's why the hypothesis arises that also other tests concerning platelet functions could be negatively influenced if they have room-temperature as a condition for plasma separation.

Adult↗
PubMed2006

Critical pathways using platelet testing to potentially optimize the use of oral antiplatelet therapy.

Although monitoring anticoagulation is standard practice, monitoring antiplatelet therapy has not yet widely been adopted as a means of assessing antithrombotic response. However, bedside devices have recently become available that facilitate more rapid assessment of antithrombotic response, allowing this information to be developed into a critical pathway. Three major opportunities exist for oral antiplatelet therapy: (1) optimizing the dose of aspirin for long-term therapy; (2) optimizing the dose of clopidogrel, especially in percutaneous coronary intervention, acutely and during long-term therapy; and (3) evaluating the level of platelet inhibition before coronary artery bypass grafting or other major surgery. Several critical pathways are proposed that may assist clinicians in trying to ensure adequate platelet inhibition in these important clinical situations.

Administration, Oral↗
PubMed2000

Defective von willebrand factor activity detected by the filterometer in three clinical conditions.

When exposed to high levels of shear in a filterometer, platelets bind to von Willebrand factor (vWF) via receptors Ib and IIb/IIIa, forming aggregates that block the filteromer. In this study we used the filterometer to explore the mechanisms by which abnormal vWF-platelet interaction might occur. In the first phase of the study, the global vWF-platelet interaction in native blood was investigated. In the second phase, to eliminate the difference that platelets might contribute, samples of platelet-poor plasma from test individuals were added to normal control blood and the mixtures were investigated by the filterometer. The filterometer results were adjusted for the antigen concentrations to obtain vWF potency ratios. Sodium dodecyl sulphate (SDS) agarose gel electrophoresis and SDS-Polyacylamide gel electrophoresis (PAGE) were used to analyze multimeric size and proteolytic profiles of vWF. Pregnancy was associated with high platelet retention, high vWF antigen concentration, normal multimeric size distribution, but decreased vWF potency ratios. The plasma samples of pregnancy contained one 183-kDa fragment not detected in normal plasma. These results suggested that in pregnancy, platelets were highly active. However, presumably due to abnormal proteolytic cleavage, vWF potency was decreased. This decrease in vWF potency might minimize the risk of thrombosis in association with highly active platelets. Renal transplant patients had normal platelet retention but high vWF levels. The plasma vWF contained normal multimers. A decrease in vWF potency, presumably caused by toxic inhibitors in the plasma, was detected. Aortic valve stenosis patients had decreased platelet retention, normal or slightly increased vWF antigen concentration and a decrease in large multimers. As a result, the vWF potency was markedly decreased. However, the results obtained with the filterometer became normal when the studies were repeated 3 months postpartum, when renal function had improved after transplantation, and when the aortic valves were corrected by surgery. These results indicate that the filterometer is a useful tool for elucidating the mechanisms by which vWF-platelet interaction might be impaired in various clinical conditions.

Adult↗
PubMed1998

Effect of the antioxidants selenium and beta-carotene on HIV-related endothelium dysfunction.

Patients infected with HIV are at increased risk of atherosclerosis, and have evidence of endothelium dysfunction. The hypothesis was tested that HIV-related endothelium dysfunction is related to loss of antioxidants. This was done by the supplementation of the antioxidants selenium and beta-carotene. We supplemented the diet of 10 HIV-seropositive subjects with 100 microg selenium daily, 11 subjects with 30 mg beta-carotene twice daily while 15 subjects were not supplemented. Plasma was obtained at outset and after a year, and tested by ELISA for endothelial cell, platelet and inflammatory markers. The non-supplemented patients experienced increases in von Willebrand factor and soluble thrombomodulin (both p <0.01). There were no changes in any of the indices in the patients taking selenium or beta-carotene. Increased von Willebrand factor and soluble thrombomodulin in the non-supplemented patients imply increased damage to the endothelium over the year of the study. Therefore we interpret the lack of increase in the patients taking antioxidants as evidence of the protection of the endothelium by these agents.

Antioxidants↗
PubMed1982

Sulfinpyrazone decreases epinephrine-induced platelet aggregation after myocardial infarction.

Platelet studies were performed during a controlled double-blind randomized clinical trial of sulfinpyrazone (Anturane Reinfarction Trial) in 41 patients who had recent myocardial infarction. Aggregation of platelet-rich plasma by thrombin (0.185, 0.246 U/ml), collagen, adenosine diphosphate, and adrenaline (0.23, 0.46, and 0.91 microgram/ml) was estimated after a 12 hour fast including abstinence from drugs and cigarette smoking. The tests were carried out 2 weeks after myocardial infarction and 6, 12, and 24 months later. At the last visit, washed platelet suspensions were also tested for aggregation to thrombin (0.03, 0.015 U/ml) +/- epinephrine (0.55 microgram/ml) and their production of malonyldialdehyde was estimated. A significant (p less than 0.02) reduction (50%) of the aggregation response of platelet-rich plasma to epinephrine was found in the group treated with sulfinpyrazone (n = 21) as compared with the placebo group (n = 20). Also, adrenaline evoked a milder (p less than 0.01) potentiation of aggregation by thrombin of the washed platelet suspensions in the sulfinpyrazone versus the placebo group. Other assays including platelet coagulant activity were not useful in discriminating between the 2 groups. It is concluded that sulfinpyrazone (200 mg 4 times daily) normalizes the platelet response to epinephrine; a relation with the drug-reported reduction of sudden death after myocardial infarction is suggested.

Clinical Trials as Topic↗
PubMed1984

Platelet activation caused by cardiac catheter blood collection, and its prevention.

The study of platelet changes occurring across the coronary circulation is important in the investigation of the platelet's role in ischemic heart disease. It requires blood sampling through cardiac catheters. This could activate platelets and alter the results of tests of platelet activation and reactivity. This study was designed to examine this problem and to devise satisfactory methods for obtaining blood for platelet studies through long catheters. Blood collected through catheters introduced with a guide-wire had a much higher plasma heparin neutralising activity (HNA), platelet factor 4(PF4) and beta-thromboglobulin (beta TG) than peripheral venous blood, and lower platelet count(PC). Blood collected through catheters introduced via a sheath, and kept filled with anticoagulant/antiplatelet solution until blood sampling, gave results similar to peripheral venous blood for the PC, platelet aggregate ratio, platelet fluorescent granule count, and for plasma HNA, PF4 and beta TG. It is concluded that platelets are activated during blood collection through cardiac catheters; however, with appropriate precautions, blood which is satisfactory for platelet studies can be obtained.

Adolescent↗
PubMed1984

The bleeding time: current practice in the UK.

A questionnaire survey of current practice in the bleeding time test has been undertaken by the UK External Quality Assessment Scheme in blood coagulation. Completed returns have been received from 358 centres. Most centres (88.5%) perform bleeding times and of these the Ivy test is the most commonly performed. Only 13.6% perform the Duke method. Templates are used to control the procedure by approximately half of the hospitals. There is considerable variability in the type and depth of incision and interpretation of the endpoint. The upper limit of normality not unexpectedly differs considerably between the centres with both Ivy and Duke methods. The use of a commercial template method, 'Simplate', provides a measure of agreement amongst the group of hospitals using this instrument but it remains to be established whether this is the most reliable procedure. In the interim, gross discrepancies in technique or interpretation should be corrected in the light of the findings of the survey.

Bleeding Time↗
PubMed1988

[Disorders of liver function, thrombopenia and hemolysis in a special clinical form of hypertension in pregnancy (the so-called HELLP syndrome)].

The so called HELLP syndrome is a severe complication of pregnancy-induced hypertension, characterized by haemolysis (H), elevated liver enzymes (EL) and low platelet counts (LP). The data of 37 patients with a HELLP syndrome are presented. In addition to the clinical symptoms of pregnancy-induced hypertension, 21 patients suffered from abdominal pain and 5 patients from icterus. Thrombocytopenia, haemolysis and elevated liver enzymes were observed in every case. In 28 of the patients a Caesarean section was performed to prevent further deterioration of the disease. Three patients died post partum as a consequence of severe complications. In five pregnancies intrauterine deaths were observed. The results of this retrospective study confirm the great risk for both the mother and the foetus, if pregnancy-induced hypertension is complicated by a so called HELLP syndrome.

Adult↗
PubMedDate not supplied

Platelet aggregometric study on whole blood of patients with ischaemic heart disease.

Platelet aggregation is an important in vitro test to assess platelet aggregation response in IHD. The present prospective case control study was undertaken to evaluate the platelet aggregation response in IHD and the effects of aspirin therapy on it. Platelet aggregation was conducted on whole blood by the Chrono- Log whole blood Aggrometer model 540-VS. Various agonists used for platelet aggregation were collagen, ADP, Epinephrine and Thrombin. High platelet aggregation was observed in-patients of IHD as compared to controls by few or all of the reagents used. Platelet aggregation was high in both MI and angina as compared to control cases. However, cases of MI showed higher response than those of angina. Aspirin intake was associated with a decrease in platelet aggregation in patients of IHD. The platelet aggregation response was higher in PRP as compared to whole blood with similar concentration of reagents, however whole blood was equally effective as PRP in detecting hyper-responsive platelets in--patients of IHD.

Adult↗