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Cogan JC, McFarland MM, May JE, Lim MY. Quality improvement approaches to heparin-induced thrombocytopenia: a scoping review. Res Pract Thromb Haemost 2023; 7:102219. [PMID: 38077807 PMCID: PMC10704520 DOI: 10.1016/j.rpth.2023.102219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 02/12/2024] Open
Abstract
Background Heparin-induced thrombocytopenia (HIT) is a relatively uncommon condition characterized by 2 exceedingly common phenomena in hospitalized patients: thrombocytopenia and heparin exposure. Consequently, HIT is frequently overdiagnosed and inappropriately treated. These issues are the focus of many quality improvement (QI) initiatives. Objectives In this scoping review, we identified and characterized all published QI studies on improving the diagnosis and management of HIT. Methods We conducted a systematic literature search through April 2022 for studies reporting on QI interventions regarding the diagnosis, treatment, and/or prevention of HIT. Results Thirty studies were included in the final review. Studies were separated into 5 groups based on the focus of the interventions: increasing HIT recognition, reducing HIT incidence, reducing HIT overdiagnosis, promoting safer HIT management, and creating HIT task forces. Nine studies focused on the implementation of 4Ts score calculator into electronic medical record orders for HIT testing, while only 1 evaluated the impact of reducing unfractionated heparin use in favor of low-molecular-weight heparin. Six studies focused on the implementation of direct thrombin inhibitor management protocols, while none evaluated the use of alternative anticoagulants in HIT management. Conclusion The bulk of published HIT QI research focused on reducing overdiagnosis and promoting safer direct thrombin inhibitor therapy, while minimal attention has been devoted to HIT prevention and the use of evidence-based alternative HIT therapies.
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Affiliation(s)
- Jacob C. Cogan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mary M. McFarland
- Spencer S. Eccles Health Sciences Library, University of Utah, Salt Lake City, Utah, USA
| | - Jori E. May
- University of Alabama at Birmingham Medicine Birmingham, Alabama, USA
| | - Ming Y. Lim
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
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Li B, Sursal T, Martinez E, Karimov Z, Feldstein E, Stein A, Cooper J, Hosein-Woodley R, Liu A, McIntyre M, Bowers C, Hanft S, Hafeez Z, Pisapia J, Muh C, Tyagi R, Mayer SA, Gandhi CD, Al-Mufti F. An institutional report of heparin induced thrombocytopenia type II in aneurysmal subarachnoid hemorrhage patients. Interv Neuroradiol 2023; 29:363-370. [PMID: 35354315 PMCID: PMC10399499 DOI: 10.1177/15910199221091643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/09/2022] [Accepted: 03/16/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Heparin induced thrombocytopenia Type II (HIT-II) is a dangerous thromboembolic complication of heparin therapy. The current literature on incidence and outcomes of HIT-II in aneurysmal subarachnoid hemorrhage (aSAH) patients remains sparse. OBJECTIVE We report our institution's incidence and outcomes of HIT-II in aSAH patients. METHODS We performed a retrospective cohort study at an academic medical center between June 2014 and July 2018. All patients had aSAH confirmed by digital subtraction angiography. Diagnosis of HIT-II was determined by positive results on both heparin PF4-platelet antibody ELISA (anti-PF4) and serotonin release assay (SRA). RESULTS 204 patients met inclusion criteria. Seven patients (7/204, 3.5%) underwent laboratory testing, three of whom met clinical criteria. HIT-II incidence was confirmed in two of these seven patients (2/204, 0.98%), who had high BMI and T4 scores. CONCLUSION Our institution's report of HIT-II incidence in aSAH patients is lower than previously reported in this population and more closely parallels HIT-II incidence in the general and surgical ICU setting. Widely-accepted American College of Chest Physicians (ACCP) clinical diagnostic criteria in conjunction with anti-PF4 and SRA testing is the gold standard of clinical diagnosis of HIT-II in aSAH patients.
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Affiliation(s)
- Boyi Li
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
| | - Tolga Sursal
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
| | - Erick Martinez
- School of Medicine, New York Medical College, Valhalla, NY 10595, United States
| | - Zafar Karimov
- School of Medicine, New York Medical College, Valhalla, NY 10595, United States
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
| | - Alan Stein
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
| | | | - Aiden Liu
- School of Medicine, New York Medical College, Valhalla, NY 10595, United States
| | - Matthew McIntyre
- Department of Neurosurgery, Oregon Health and Sciences University, Portland, Oregon 97239, United States
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico 87131, United States
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
| | - Zeeshan Hafeez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
| | - Carrie Muh
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
| | - Rachana Tyagi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
| | - Stephan A. Mayer
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
| | - Chirag D. Gandhi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, United States
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3
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Grewal US, Gaddam SJ, Thotamgari SR, Brown T, Beedupalli K, Mills GM. Hospitalized patients are needlessly over-tested for heparin induced thrombocytopenia. Eur J Intern Med 2022; 102:128-130. [PMID: 35422372 DOI: 10.1016/j.ejim.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/03/2022] [Accepted: 04/05/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Udhayvir Singh Grewal
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, United States
| | - Shiva Jashwanth Gaddam
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, United States
| | - Sahith Reddy Thotamgari
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, United States
| | - Tyiesha Brown
- Department of Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, United States
| | - Kavitha Beedupalli
- Department of Medicine, Section of Hematology and Oncology, Louisiana State University Health Sciences Center, Shreveport, LA, United States; Feist Weiller Cancer Center, 1501, Kings Highway, Shreveport, LA 71103, United States
| | - Glenn Morris Mills
- Department of Medicine, Section of Hematology and Oncology, Louisiana State University Health Sciences Center, Shreveport, LA, United States; Feist Weiller Cancer Center, 1501, Kings Highway, Shreveport, LA 71103, United States.
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4
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Obadina M, McRae HL, Lawal R, Refaai MA, Akwaa F. Impact of electronic medical record-based calculation of 4Ts on heparin-induced thrombocytopenia (HIT) testing: A single center experience. Int J Lab Hematol 2021; 44:e60-e63. [PMID: 34559473 DOI: 10.1111/ijlh.13708] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/24/2021] [Accepted: 09/07/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Mofiyin Obadina
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Hannah L McRae
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division; Hemostasis and Thrombosis Unit, University of Rochester Medical Center, Rochester, NY, USA
| | - Rialnat Lawal
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division; Hemostasis and Thrombosis Unit, University of Rochester Medical Center, Rochester, NY, USA
| | - Frank Akwaa
- Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
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5
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May JE, Irelan PC, Boedeker K, Cahill E, Fein S, Garcia DA, Hicks LK, Lawson J, Lim MY, Morton CT, Rajasekhar A, Shanbhag S, Zumberg MS, Plovnick RM, Connell NT. Systems-based hematology: highlighting successes and next steps. Blood Adv 2020; 4:4574-4583. [PMID: 32960959 PMCID: PMC7509880 DOI: 10.1182/bloodadvances.2020002947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/10/2020] [Indexed: 12/21/2022] Open
Abstract
Systems-based hematology is dedicated to improving care delivery for patients with blood disorders. First defined by the American Society of Hematology in 2015, the idea of a systems-based hematologist arose from evolving pressures in the health care system and increasing recognition of opportunities to optimize the quality and cost effectiveness of hematologic care. In this review, we begin with a proposed framework to formalize the discussion of the range of initiatives within systems-based hematology. Classification by 2 criteria, project scope and method of intervention, facilitates comparison between initiatives and supports dialogue for future efforts. Next, we present published examples of successful systems-based initiatives in the field of hematology, including efforts to improve stewardship in the diagnosis and management of complex hematologic disorders (eg, heparin-induced thrombocytopenia and thrombophilias), the development of programs to promote appropriate use of hematologic therapies (eg, blood products, inferior vena cava filters, and anticoagulation), changes in care delivery infrastructure to improve access to hematologic expertise (eg, electronic consultation and disorder-specific care pathways), and others. The range of projects illustrates the broad potential for interventions and highlights different metrics used to quantify improvements in care delivery. We conclude with a discussion about future directions for the field of systems-based hematology, including extension to malignant disorders and the need to define, expand, and support career pathways.
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Affiliation(s)
- Jori E May
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | - David A Garcia
- Division of Hematology, University of Washington, Seattle, WA
| | - Lisa K Hicks
- Division of Hematology/Oncology, Department of Medicine, St. Michael's Hospital and University of Toronto, Toronto, ON, Canada
| | | | - Ming Y Lim
- Division of Hematology and Hematological Malignancies, University of Utah, Salt Lake City, UT
| | - Colleen T Morton
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Anita Rajasekhar
- Division of Hematology and Oncology, University of Florida, Gainesville, FL
| | - Satish Shanbhag
- Cancer Specialists of North Florida, Fleming Island, FL; and
| | - Marc S Zumberg
- Division of Hematology and Oncology, University of Florida, Gainesville, FL
| | | | - Nathan T Connell
- Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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6
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Jali AGP, Nkambule BB. Prevalence and aetiology of moderate and severe thrombocytopenia in a tertiary and quaternary centre in KwaZulu-Natal. Afr J Lab Med 2020; 9:799. [PMID: 32934907 PMCID: PMC7479432 DOI: 10.4102/ajlm.v9i1.799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 06/02/2020] [Indexed: 11/12/2022] Open
Abstract
Background Thrombocytopenia is a common haematological disorder, characterised by platelet counts below 150 × 109/L. The aetiology of thrombocytopenia is multifactorial; notably, in a misdiagnosis this condition may be due to pre-analytical laboratory artefacts. Knowledge about the common aetiology of thrombocytopenia will assist clinicians in decision-making and interpretation of laboratory tests and this may lead to prompt, adequate patient management and cost-saving measures. Objective This study determined the prevalence and aetiology of moderate and severe thrombocytopenia in a tertiary or quaternary laboratory in Durban, KwaZulu-Natal, South Africa. Methods We conducted a retrospective study at the Inkosi Albert Luthuli Central Hospital haematology laboratory between October 2015 and April 2016. A total of 2076 full blood count results with a platelet count of less than 100 × 109/L were retrieved from the Inkosi Albert Luthuli Academic Hospital database. Laboratory data were extracted and matched with clinical data and used to identify the potential aetiology of thrombocytopenia. Results The prevalence of thrombocytopenia was 14.9% within the selected study period. The haematology or oncology wards and clinic accounted for 55.2% of thrombocytopenia cases, whereas the adult and paediatric intensive care units accounted for 29.3%. Notably, 15.5% of thrombocytopenia cases were reported in non-haematology wards and clinics. The most common cause of thrombocytopenia was chemotherapy which accounted for 38.5% of all causes. Conclusion In our tertiary and quaternary setting, thrombocytopenia in adults was most common in patients admitted to haematology and oncology wards. Moreover, chemotherapy-induced thrombocytopenia accounted for more than a third of all these cases.
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Affiliation(s)
- Ayanda G P Jali
- Department of Haematology, Health King Edward VIII Hospital, University of Kwa-Zulu Natal, Durban, South Africa.,Department of Haematology, National Health Laboratory service, Inkosi Albert Luthuli Academic Hospital, Durban, South Africa
| | - Bongani B Nkambule
- Department of Human Physiology, School of Laboratory Medicine and Medical Sciences, University of KwaZulu-Natal, Durban, South Africa
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7
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Safdar A. Cytopenias in Transplant Patients. PRINCIPLES AND PRACTICE OF TRANSPLANT INFECTIOUS DISEASES 2019. [PMCID: PMC7120766 DOI: 10.1007/978-1-4939-9034-4_10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Amar Safdar
- Clinical Associate Professor of Medicine, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX USA
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8
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Bashover EM, Stefaniuk CM, Harding CV, Maitta RW. Use of a whole-cell ELISA to detect additional antibodies in setting of suspected heparin-induced thrombocytopenia. Eur J Haematol 2019; 103:99-106. [PMID: 31107976 DOI: 10.1111/ejh.13263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 01/13/2023]
Abstract
OBJECTIVES Type II heparin-induced thrombocytopenia (HIT) is mediated by formation of antibodies to platelet factor 4 (PF4)-heparin complexes. We evaluated anti-PF4-heparin-negative samples for the presence of additional anti-platelet and anti-red blood cell (RBC) antibodies using whole-cell platelet/ RBC ELISAs we developed. METHODS Seventy-three samples tested for anti-PF4-heparin by ELISA were included: 62 tested negative, 9 tested positive, and 2 had equivocal results. Plasma specimens from healthy donors were used as controls. RESULTS 100% (9/9) anti-PF4-positive samples had anti-platelet antibodies detected by whole-cell platelet ELISA. 42.2% (27/64) anti-PF4-heparin-negative samples were negative for anti-platelet and anti-RBC antibodies. 32.8% (21/64) negative samples showed reactivity to both platelets and RBC; 12.5% (8/64) negative samples were each reactive with either platelet or RBC ELISA, respectively. Additionally, two samples that tested equivocal by anti-PF4-heparin ELISA had antibodies to both platelets and RBC by whole-cell ELISA. CONCLUSIONS Our study suggests that patients with thrombocytopenia testing negative for anti-PF4-heparin may still harbor antibodies to platelets. However, additional research is needed to determine the significance of these antibodies. Nevertheless, these findings may encourage clinicians to further investigate patients with possible immune-mediated etiologies of thrombocytopenia and anemia.
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Affiliation(s)
- Eva M Bashover
- Department of Pathology, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Catherine M Stefaniuk
- Department of Pathology, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Clifford V Harding
- Department of Pathology, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Robert W Maitta
- Department of Pathology, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
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9
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Platelet response to direct thrombin inhibitor or fondaparinux treatment in patients with suspected heparin-induced thrombocytopenia. J Thromb Thrombolysis 2018; 45:536-542. [PMID: 29574610 DOI: 10.1007/s11239-018-1646-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Making a definitive diagnosis of heparin-induced thrombocytopenia (HIT) can be problematic. A prompt platelet rise following treatment has been proposed as a "post-test" criterion for diagnosis. However, the platelet response following discontinuation of heparin and initiation of a recommended alternative anticoagulant remains largely undefined and unstudied. This study aimed to characterize platelet response to initial treatment in patients with a low, intermediate, or high likelihood of having HIT. This was a multicenter retrospective cohort study. Patients were over 18 years in age, underwent serologic testing for HIT, and received alternative anticoagulation treatment for HIT. Classification of each patient's likelihood of having HIT was based on an empiric, pre-hoc combination of the 4T score and serology results. The primary outcome for this study was a platelet count response after initiation of direct thrombin inhibitor (DTI) or fondaparinux therapy within 48 h. 124 patients were analyzed. The sensitivity and specificity of having an immediate platelet rise of at least 10,000/µL by day 2 after starting treatment among high-likelihood for HIT patients were 0.71 (95% CI 0.55-0.84) and 0.64 (95% CI 0.5-0.76), respectively. The negative predictive value of no platelet rise was 75.5% (95% CI 0.61-0.86). A prompt platelet count rise may be appropriate to consider along with other known criteria for the clinical diagnosis of HIT. The rise should be immediate following discontinuation of heparin and initiation of recommended treatment, with an upward rise within 48 h.
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10
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Chen W, Ha JP, Hong H, Maitta RW. Absolute immature platelet counts in the setting of suspected heparin-induced thrombocytopenia may predict anti-PF4-heparin immunoassay testing results. Transfus Apher Sci 2018; 57:507-511. [DOI: 10.1016/j.transci.2018.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/30/2018] [Accepted: 04/01/2018] [Indexed: 12/15/2022]
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Fenelus M, Peerschke EIB. HITTING the Diagnosis: Testing for Heparin-Induced Thrombocytopenia in Cancer Patients. Am J Clin Pathol 2018; 150:116-120. [PMID: 29901688 DOI: 10.1093/ajcp/aqy040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To evaluate the use of a pretest probability score (4Ts score) in cancer patients to guide ordering of laboratory screening tests for heparin-induced thrombocytopenia (HIT). METHODS A retrospective chart review was conducted for patients (n = 140) in whom laboratory testing for HIT was requested. 4Ts scores were calculated and correlated with heparin-endogenous platelet factor 4 antibody enzyme-linked immunosorbent assay (ELISA) test results. RESULTS All patients with a high pretest probability of HIT (4Ts score = 6-7) had positive ELISA results, compared to 26.1% of patients with intermediate (4Ts score = 4-5) and 4.3% of patients with low (4Ts score ≤3) pretest probability. No patients with 4Ts scores of 2 or less had positive ELISA results. CONCLUSIONS HIT can be ruled out in cancer patients (negative predictive value and sensitivity = 100%) with low pretest probability, defined by 4Ts scores of 2 or less, significantly reducing the need for laboratory testing in this patient population.
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Affiliation(s)
- Maly Fenelus
- Department of Laboratory Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Ellinor I B Peerschke
- Department of Laboratory Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY
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12
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Williams JS, Autori PJ, Kidd SK, Piazza G, Connors MC, Czeisler CA, Scheuermaier KD, Duffy J, Klerman EB, Scheer FA, Kozak M, Driscoll SM, Goldhaber SZ. Heparin-Induced Thrombocytopenia in Healthy Individuals with Continuous Heparin Infusion. TH OPEN 2018; 2:e49-e53. [PMID: 31249929 PMCID: PMC6524859 DOI: 10.1055/s-0038-1624565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 12/05/2017] [Indexed: 10/26/2022] Open
Abstract
The risk for developing heparin-induced thrombocytopenia in healthy individuals is thought to be low, but monitoring recommendations remain controversial. Therefore, a retrospective cohort study was conducted to identify the incidence of thrombocytopenic events in a healthy research population exposed and re-exposed to continuous intravenous (IV) unfractionated heparin. The Division of Sleep Medicine and the Centre for Clinical Investigations at Brigham and Women's Hospital, Boston, Massachusetts, United States, instituted a standardized platelet monitoring procedure for all research protocols that involved heparin to detect platelet count decreases. Protocol-related frequent blood sampling required use of continuous IV unfractionated heparin infusion (5,000 unit/L in 0.45% saline at 40 mL/h) to maintain line patency over extended periods of IV access. From the years 2009 to 2012, a total of 273 healthy volunteers enrolled in Sleep Medicine research protocols met study criteria as having been exposed and/or re-exposed to continuously infused intravenous heparin for at least 4 hours. The mean continuous heparin exposure time was 88 ± 82 SD hours with a total of 397 heparin exposure and re-exposure events. Platelet count measurements were obtained on 629 occasions, representing a range from 2 to 9 draws per participant. No platelet count decrease of more than 50% was detected. There were no detected adverse bleeding or thrombotic events. In this retrospective study of healthy volunteers involved in a rigorously applied inpatient platelet monitoring protocol, heparin exposure and re-exposure did not lower platelet concentration and, therefore, does not appear to be associated with increased risk of HIT in this population.
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Affiliation(s)
- Jonathan S Williams
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Paula J Autori
- Center for Clinical Investigations, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Stephen K Kidd
- Department of Cardiology, Northwestern Memorial Hospital, Chicago, Illinois, United States
| | - Gregory Piazza
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Molly C Connors
- Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Charles A Czeisler
- Division of Sleep Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Karine D Scheuermaier
- Wits Sleep Laboratory, University of the Witwatersrand, Johannesburg, Braamfontein, South Africa
| | - Jeanne Duffy
- Division of Sleep Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Elizabeth B Klerman
- Division of Sleep Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Frank A Scheer
- Division of Sleep Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Marjorie Kozak
- Center for Clinical Investigations, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Sheila M Driscoll
- Center for Clinical Investigations, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Samuel Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, United States
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13
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize recent findings on heparin-induced thrombocytopenia (HIT), a prothrombotic disorder caused by platelet-activating IgG targeting platelet factor 4 (PF4)/polyanion complexes. RECENT FINDINGS HIT can explain unusual clinical events, including adrenal hemorrhages, arterial/intracardiac thrombosis, skin necrosis, anaphylactoid reactions, and disseminated intravascular coagulation. Sometimes, HIT begins/worsens after stopping heparin ('delayed-onset' HIT). Various HIT-mimicking disorders are recognized (e.g., acute disseminated intravascular coagulation/'shock liver' with limb ischemia). HIT has features of both B-cell and T-cell immune responses; uptake of PF4/heparin complexes into macrophages ('macropinocytosis') facilitates the anti-PF4/heparin immune response. Antibody-induced activation of monocytes and platelets via their FcγIIA receptors triggers an intense procoagulant response. Sometimes, HIT antibodies recognize PF4 bound to (platelet-associated) chondroitin sulfate, explaining how HIT might occur without concurrent or recent heparin (delayed-onset HIT, 'spontaneous HIT syndrome'). The molecular structure of HIT antigen(s) has been characterized, providing a rationale for future drug design to avoid HIT and improve its treatment. The poor correlation between partial thromboplastin time and plasma argatroban levels (risking subtherapeutic anticoagulation) and need for intravenous administration of argatroban have led to increasing 'off-label' treatment with fondaparinux or one of the direct oral anticoagulants. SUMMARY Understanding the molecular mechanisms and unusual clinical features of HIT will improve its management.
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14
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Markovic I, Debeljak Z, Bosnjak B, Marijanovic M. False positive immunoassay for heparin-induced thrombocytopenia in the presence of monoclonal gammopathy: a case report. Biochem Med (Zagreb) 2017; 27:030801. [PMID: 29180919 PMCID: PMC5696753 DOI: 10.11613/bm.2017.030801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 09/19/2017] [Indexed: 11/09/2022] Open
Abstract
Heparin induced thrombocytopenia (HIT) is a life-threatening disorder which diagnosis depends on laboratory evaluation. The objective of this report is to present the impact of different laboratory methods for HIT detection on the diagnostic evaluation process. In this case, a 78-year old female patient previously diagnosed with monoclonal gammopathy of undetermined significance (MGUS) was administered with heparin for pulmonary embolism treatment. Patient’s initial diagnostic work-up (determination of platelet count and prothrombin time measurement for monitoring of pharmacotherapy) was followed by the clinical estimation of HIT likelihood by “4Ts” score, two immunoassays (ID-PaGIA Heparin/PF4 Antibody Test and ELISA PF4 IgG assay) and one functional test called high-performance liquid chromatography serotonin release assay (HPLC-SRA). The result of “4Ts” score indicated a low likelihood of HIT but persistent thrombocytopenia that appeared days after discontinuation of heparin therapy suggested delayed-onset HIT. Both immunoassays were positive for presence of HIT-autoantibodies, while the functional HPLC-SRA was negative. Since different methods gave opposing results, their interpretation required great attention. In comparison to the HPLC-SRA, immunoassays are prone to the analytical interferences associated with the presence of non-specific antibodies, which may lead to false positive results. In this case, where the patient is known to produce antibodies of undetermined significance, HIT was ruled out as the possible cause of persistent thrombocytopenia primarily due to the negative result of HPLC-SRA, which is not prone to this type of interferences, but also due to the low “4Ts” clinical score.
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Affiliation(s)
- Ivana Markovic
- Institute of Clinical Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Zeljko Debeljak
- Institute of Clinical Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Bojana Bosnjak
- Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia.,Institute of Transfusion Medicine, Osijek University Hospital, Osijek, Croatia
| | - Maja Marijanovic
- Institute of Transfusion Medicine, Osijek University Hospital, Osijek, Croatia
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15
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Bain J, Flannery AH, Flynn J, Dager W. Heparin induced thrombocytopenia with mechanical circulatory support devices: review of the literature and management considerations. J Thromb Thrombolysis 2017; 44:76-87. [DOI: 10.1007/s11239-017-1494-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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16
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Novel method using rotational thromboelastography analysis for intraoperative management of device patient with heparin-induced thrombocytopenia. Blood Coagul Fibrinolysis 2016; 27:943-947. [PMID: 26757013 DOI: 10.1097/mbc.0000000000000516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic disease in response to previous heparin exposure. Direct thrombin inhibitors are suitable candidates for the prophylaxis of thrombosis in patients with HIT. Currently activated clotting time and activated partial thromboplastin time are used to guide dosing and monitor anticoagulation. These assays provide a measure of clot initiation and only account for a small fraction of the coagulation pathway. In this case study we performed rotational thromboelastography (ROTEM) analysis on a patient with HIT implanted with a continuous-flow CentriMag device for left ventricular support. ROTEM evaluation confirmed a decline in activated clotting time values and provided further information regarding intrinsic and extrinsic clotting times. Monitoring ROTEM parameters aided in the detection of coagulopathies and the decision to administer platelet or fresh frozen plasma products. Utilizing ROTEM can guide clinical decisions in transfusions, particularly in patients with HIT, where platelet and fibrinogen levels can be safely maintained to prevent thrombosis.
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17
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Hasan M, Malalur P, Agastya M, Malik AO, Dawod Y, Jaradat M, Yoo JW, Makar R. A high-value cost conscious approach to minimize heparin induced thrombocytopenia antibody (HITAb) testing using the 4T score. J Thromb Thrombolysis 2016; 42:441-6. [DOI: 10.1007/s11239-016-1396-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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18
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Sampat HN, Brandão LR, Tamburro RF, Kees-Folts D, Dandekar S. HIT or Miss: The Sequential Diagnostic Approach to Heparin-Induced Thrombocytopenia Illustrated in a Child With Acute Post-Streptococcal Glomerulonephritis. Clin Pediatr (Phila) 2016; 55:294-7. [PMID: 25963179 DOI: 10.1177/0009922815586055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Hemal N Sampat
- Penn State Milton S. Hershey Medical Center, Hershey, PA, USA Penn State Hershey Children's Hospital, Hershey, PA, USA
| | | | - Robert F Tamburro
- Penn State Hershey Children's Hospital, Hershey, PA, USA National Institute of Child Health and Human Development, Bethesda, MD, USA
| | | | - Smita Dandekar
- Penn State Hershey Children's Hospital, Hershey, PA, USA
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19
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Samuelson BT, Glynn E, Holmes M, White AA, Martin DB, Garcia D. Use of a computer-based provider order entry (CPOE) intervention to optimize laboratory testing in patients with suspected heparin-induced thrombocytopenia. Thromb Res 2015; 136:928-31. [DOI: 10.1016/j.thromres.2015.09.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/03/2015] [Accepted: 09/04/2015] [Indexed: 12/14/2022]
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