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Song D, Jin Y, Zhang Y, Zhou Z. Heparin-induced thrombocytopenia in extracorporeal membrane oxygenation-supported patients: a systematic review and meta-analysis. Thromb J 2024; 22:55. [PMID: 38937784 PMCID: PMC11212165 DOI: 10.1186/s12959-024-00624-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/17/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND In recent years, extracorporeal membrane oxygenation (ECMO) has been increasingly used in critically ill patients with respiratory or cardiac failure. Heparin is usually used as anticoagulation therapy during ECMO support. However, heparin-induced thrombocytopenia (HIT) in ECMO-supported patients, which results in considerable morbidity and mortality, has not yet been well described. This meta-analysis and systematic review aimed to thoroughly report the incidence of HIT on ECMO, as well as the characteristics and outcomes of HIT patients. METHODS We searched the PubMed, Embase, Cochrane Library, and Scopus databases for studies investigating HIT in adult patients supported by ECMO. All studies conforming to the inclusion criteria were screened from 1975 to August 2023. Nineteen studies from a total of 1,625 abstracts were selected. The primary outcomes were the incidence of HIT and suspected HIT. RESULTS The pooled incidence of HIT in ECMO-supported patients was 4.2% (95% CI: 2.7-5.6; 18 studies). A total of 15.9% (95% CI: 9.0-22.8; 12 studies) of patients on ECMO were suspected of having HIT. Enzyme-linked immunosorbent assay (ELISA) is the most commonly used immunoassay. The median optical density (OD) of the ELISA in HIT-confirmed patients ranged from 1.08 to 2.10. In most studies, the serotonin release assay (SRA) was performed as a HIT-confirming test. According to the subgroup analysis, the pooled incidence of HIT in ECMO patients was 2.7% in studies whose diagnostic mode was functional assays, which is significantly lower than the incidence in studies in which the patients were diagnosed by immunoassay (14.5%). Argatroban was most commonly used as an alternative anticoagulation agent after the withdrawal of heparin. Among confirmed HIT patients, 45.5% (95% CI: 28.8-62.6) experienced thrombotic events, while 50.1% (95% CI: 24.9-75.4) experienced bleeding events. Overall, 46.6% (95% CI: 30.4-63.1) of patients on ECMO with HIT died. CONCLUSION According to our study, the pooled incidence of HIT in ECMO-supported patients is 4.2%, and it contributes to adverse outcomes. Inappropriate diagnostic methods can easily lead to misdiagnosis of HIT. Further research and development of diagnostic algorithms and laboratory assays are warranted.
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Affiliation(s)
- Danyu Song
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Yu Jin
- Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Beijing, China
| | - Yang Zhang
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Zhou Zhou
- Department of Laboratory Medicine, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College Fuwai Hospital, Fuwai Hospital, No. 167 Beilishi Road, Xicheng District, Beijing, 100037, China.
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Bevilacqua S, Stefàno P, Berteotti M, Del Pace S, Pieri M, Mandarano R, Rogolino A, Cesari F, Gori AM, Giusti B, Marcucci R. Heparin-induced thrombocytopenia after cardiac surgery. A single-center, retrospective cohort study. Res Pract Thromb Haemost 2024; 8:102465. [PMID: 39036670 PMCID: PMC11260323 DOI: 10.1016/j.rpth.2024.102465] [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: 04/16/2024] [Accepted: 05/17/2024] [Indexed: 07/23/2024] Open
Abstract
Background Cardiac surgery is a high-risk setting for heparin-induced thrombocytopenia (HIT). However, large differences in its incidence, rate of thrombotic complications, and mortality have been reported in this context. Few studies address the pharmacologic management of HIT specifically in this setting. Objectives To describe the incidence, outcomes, and management of patients with HIT in our cohort and to compare them with patients presenting platelet factor 4/heparin antibodies but without platelet-activating capacity. Methods A retrospective observational study was conducted over a period of 10 years and 6 months on 13,178 cardiac operations in a single high-volume cardiac surgery center. Results HIT was diagnosed in 0.22% of patients. HIT with associated thromboembolic complications occurred in 0.04% of cases. Two deaths at 30 days were registered, both in patients with associated thrombosis. The 4T score showed a 99.9% negative predictive value. The immunoglobulin G-specific chemiluminescence test positivity rate was highly predictive of HIT. Warfarin was often started early after surgery, and although it was rarely stopped when the diagnosis of HIT was made, no new thromboembolic complications subsequently occurred. Thrombocytopenia appeared to be a poor prognostic sign, whatever the cause. Conclusion Although rare, HIT is characterized by high mortality in this setting, especially if thrombotic complications occur. Large multicentric studies or an international registry should be created to enhance the scientific evidence on HIT diagnosis and management in this context.
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Affiliation(s)
- Sergio Bevilacqua
- Department of Anesthesia and Intensive Care, University Hospital Careggi, Firenze, Italy
| | - Pierluigi Stefàno
- Department of Cardiothoracic and Vascular Surgery, University Hospital Careggi, Firenze, Italy
| | - Martina Berteotti
- Department of Experimental and Clinical Medicine, Atherothrombotic Diseases Center, University Hospital Careggi, Firenze, Italy
| | - Stefano Del Pace
- Department of Cardiothoracic and Vascular Surgery, University Hospital Careggi, Firenze, Italy
| | - Matteo Pieri
- Department of Anesthesia and Intensive Care, University Hospital Careggi, Firenze, Italy
| | - Raffaele Mandarano
- Department of Anesthesia and Intensive Care, University Hospital Careggi, Firenze, Italy
| | - Angela Rogolino
- Department of Experimental and Clinical Medicine, Atherothrombotic Diseases Center, University Hospital Careggi, Firenze, Italy
| | - Francesca Cesari
- Department of Experimental and Clinical Medicine, Atherothrombotic Diseases Center, University Hospital Careggi, Firenze, Italy
| | - Anna Maria Gori
- Department of Experimental and Clinical Medicine, Atherothrombotic Diseases Center, University Hospital Careggi, Firenze, Italy
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, Atherothrombotic Diseases Center, University Hospital Careggi, Firenze, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, Atherothrombotic Diseases Center, University Hospital Careggi, Firenze, Italy
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Habibi K, Lhuaire M, Privé S, Le Beller C, Garrido I, Helley D, Gendron N, Lantieri L. Intraoperative argatroban vessel irrigation during microsurgical anastomosis in heparin-induced thrombocytopenia patients: About two cases. J Plast Reconstr Aesthet Surg 2024; 88:245-247. [PMID: 38006712 DOI: 10.1016/j.bjps.2023.10.142] [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: 09/21/2023] [Accepted: 10/08/2023] [Indexed: 11/27/2023]
Abstract
Patients with heparin-induced thrombocytopenia or confirmed allergies to heparin have a contraindication to heparin therapy, which poses a problem for intraoperative free flap irrigation in reconstruction. The use of argatroban as an alternative to heparin allowed us to perform a free flap for leg salvage and a deep inferior epigastric perforator flap for breast reconstruction without microvascular complication, with a 0.01 mg/mL solution. We reported two cases of using an alternative treatment to heparin in an emergency and planned surgeries for vessel irrigation during microsurgical anastomosis reconstruction without microvascular complications, suggesting the reliability and effectiveness of its use in case of contraindication to heparin.
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Affiliation(s)
- Koohyar Habibi
- Department of Plastic, Reconstructive and Aesthetic Surgery, AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Paris 75015, France; Université Paris Cité, 12 Rue de l'École de Médecine, Paris 75006, France.
| | - Martin Lhuaire
- Department of Plastic, Reconstructive and Aesthetic Surgery, AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Paris 75015, France; Université Paris Cité, 12 Rue de l'École de Médecine, Paris 75006, France
| | - Samuel Privé
- Department of Plastic, Reconstructive and Aesthetic Surgery, AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Paris 75015, France
| | - Christine Le Beller
- Department of Pharmacovigilance, Hôpital Européen Georges Pompidou, AP-HP, Centre - Université Paris Cité, Paris 75015, France; Paris Cité University, Innovative Therapies in Haemostasis, INSERM, Paris 75006, France
| | - Ignacio Garrido
- Department of Plastic, Reconstructive and Aesthetic Surgery, AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Paris 75015, France
| | - Dominique Helley
- Hematology Department, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris (APHP,CUP), Paris 75015, France; Université Paris Cité, PARCC, INSERM, Paris 75015, France
| | - Nicolas Gendron
- Paris Cité University, Innovative Therapies in Haemostasis, INSERM, Paris 75006, France; Hematology Department, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris (APHP,CUP), Paris 75015, France
| | - Laurent Lantieri
- Department of Plastic, Reconstructive and Aesthetic Surgery, AP-HP, Hôpital Européen Georges Pompidou, 20 Rue Leblanc, Paris 75015, France; Université Paris Cité, 12 Rue de l'École de Médecine, Paris 75006, France
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Pong T, Cyr K, Aparicio-Valenzuela J, Carlton C, Lee AM. A Modified 4Ts Score for Heparin-Induced Thrombocytopenia in the Mechanical Circulatory Support Population. J Cardiothorac Vasc Anesth 2023; 37:2499-2507. [PMID: 37407329 DOI: 10.1053/j.jvca.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/16/2023] [Accepted: 06/21/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVE To identify risk factors and develop a pretest scoring system to differentiate patients with heparin-induced thrombocytopenia (HIT) in the mechanical circulatory support (MCS) population. The authors present a modified "4TMCS" scoring system, which considers the "type of mechanical circulatory support" that may help identify patients at risk for developing postoperative HIT. DESIGN A retrospective cohort study. Patients who underwent cardiac surgery were categorized into 3 groups: (1) normal platelet count, (2) thrombocytopenia with a negative HIT test, and (3) thrombocytopenia with a positive HIT test. A comparison of diagnostic accuracy between the 4Ts and 4TMCS probability scores was performed. SETTING At a single adult tertiary-care center. PARTICIPANTS A total of 5,314 patients who underwent cardiac surgery between May 1, 2008 and December 31, 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 125 out of 5,314 patients (2.4%) were diagnosed with HIT, of whom 75 out of 5,314 (1.4%) had clinical evidence of thrombosis. Overall, in-hospital mortality was 25.6%, 11.7%, and 1.5% in the HIT(+), HIT(-), and control groups, respectively (p < 0.001). Mechanical circulatory support was associated with a significantly increased risk for HIT, with an incidence of 5.9% in patients receiving MCS versus 1.9% in those without (p < 0.001). Area under the receiver operator curve (AUC) analysis demonstrated improved diagnostic accuracy of the 4TMCS score compared with the 4Ts (AUC = 0.83 v 0.77, p < 0.044). The 4TMCS score had higher sensitivity than the 4Ts, using the guideline-recommended score cutoff of ≥4 (95.2% v 85.7%). CONCLUSION Heparin-induced thrombocytopenia is associated with worse outcomes and increased morbidity and mortality in the MCS population. Awareness of patient risk factors and the application of a modified 4TMCS probability score may allow for more accurate screening and treatment of HIT in the MCS population.
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Affiliation(s)
- Terrence Pong
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Kevin Cyr
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Joy Aparicio-Valenzuela
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Cody Carlton
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA
| | - Anson M Lee
- Department of Cardiothoracic Surgery, School of Medicine, Stanford University, Stanford, Stanford, CA.
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5
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Dager WE, Trujillo TC, Gilbert BW. Approaches to Precision-based Anticoagulation management in the critically Ill. Pharmacotherapy 2023; 43:1221-1236. [PMID: 37604646 DOI: 10.1002/phar.2868] [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: 01/30/2023] [Revised: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 08/23/2023]
Abstract
Anticoagulant therapy is commonly associated with a high incidence of avoidable adverse events, especially in the acute care setting. This has led to several initiatives by key national health care stakeholders, including specific attention to The Joint Commission's National Patient Safety Goals, to improve anticoagulation management. The subject of special populations has long been identified as challenging by clinicians with the use of anticoagulants. This is driven in part by numerous variables that can contribute to hard outcomes such as bleeding, thrombosis, length of stay, hospital re-admission, morbidity, and mortality. Despite the notable effort to improve the use of anticoagulants with numerous clinical trials, guidelines, guidance statements, and other sources of published evidence, notable difficulties continue to challenge practitioners in managing this class of medications. This is especially the case with very diverse critically ill populations where countless variables exist, many of which were never explored in trials or have historically been frequently excluded. Trials evaluating anticoagulation therapy often can only account for small portions of variables that may affect thrombosis and hemostasis, and study methods often do not reflect the constantly changing dynamic conditions seen in unique critically ill patients. Clinicians providing care to the numerous critically ill populations are faced with conditions that lead to relatively small therapeutic windows, which makes designing safe optimal anticoagulation management plans difficult when dealing with complex patients and mechanical support devices. The approach to crafting a successful management plan for anticoagulant therapy must incorporate the numerous variables that are continuously assessed and revised during the patient's time in the intensive care unit. We explore considerations and approaches when developing, assessing, and implementing an individualized or precision-based management plan that involves the use of anticoagulants in the critically ill. The skills and thought process provided will assist clinicians in managing this unique, variable, and challenging population.
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Affiliation(s)
- William E Dager
- University of California, Davis Medical Center, Sacramento, California, USA
- University of California San Francisco School of Pharmacy, San Francisco, California, USA
- University of California School of Medicine, Sacramento, California, USA
| | - Toby C Trujillo
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
- Anticoagulation/Cardiology, University of Colorado Hospital, Aurora, Colorado, USA
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May J, Westbrook B, Cuker A. Heparin-induced thrombocytopenia: An illustrated review. Res Pract Thromb Haemost 2023; 7:100283. [PMID: 37601013 PMCID: PMC10439402 DOI: 10.1016/j.rpth.2023.100283] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse drug effect from unfractionated or low-molecular-weight heparin that results in thrombocytopenia and potentially catastrophic thrombosis. HIT occurs due to the development of platelet-activating antibodies against multimolecular complexes of platelet factor 4 and heparin. Given the frequency of thrombocytopenia and heparin use among hospitalized patients, calculation of the 4Ts Score is recommended to identify patients at increased likelihood of HIT and direct further evaluation. In patients with an intermediate or high probability 4Ts Score, an immunoassay and functional assay are recommended to confirm or refute the diagnosis of HIT. Heparin avoidance and initiation of nonheparin anticoagulation are the mainstays of acute HIT management. In this illustrated review, we provide visual summaries of the diagnosis and management of HIT, highlighting connections between pathophysiology and clinical care as well as summarizing efforts in quality improvement in the field. We further emphasize common pitfalls and pearls in diagnosis and management to encourage evidence-based care. We include graphical representation of the unique challenges of HIT with cardiopulmonary bypass and also delineate autoimmune HIT and its subtypes.
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Affiliation(s)
- Jori May
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brian Westbrook
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Nilius H, Cuker A, Haug S, Nakas C, Studt JD, Tsakiris DA, Greinacher A, Mendez A, Schmidt A, Wuillemin WA, Gerber B, Kremer Hovinga JA, Vishnu P, Graf L, Kashev A, Sznitman R, Bakchoul T, Nagler M. A machine-learning model for reducing misdiagnosis in heparin-induced thrombocytopenia: A prospective, multicenter, observational study. EClinicalMedicine 2023; 55:101745. [PMID: 36457646 PMCID: PMC9706528 DOI: 10.1016/j.eclinm.2022.101745] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Diagnosing heparin-induced thrombocytopenia (HIT) at the bedside remains challenging, exposing a significant number of patients at risk of delayed diagnosis or overtreatment. We hypothesized that machine-learning algorithms could be utilized to develop a more accurate and user-friendly diagnostic tool that integrates diverse clinical and laboratory information and accounts for complex interactions. METHODS We conducted a prospective cohort study including 1393 patients with suspected HIT between 2018 and 2021 from 10 study centers. Detailed clinical information and laboratory data were collected, and various immunoassays were conducted. The washed platelet heparin-induced platelet activation assay (HIPA) served as the reference standard. FINDINGS HIPA diagnosed HIT in 119 patients (prevalence 8.5%). The feature selection process in the training dataset (75% of patients) yielded the following predictor variables: (1) immunoassay test result, (2) platelet nadir, (3) unfractionated heparin use, (4) CRP, (5) timing of thrombocytopenia, and (6) other causes of thrombocytopenia. The best performing models were a support vector machine in case of the chemiluminescent immunoassay (CLIA) and the ELISA, as well as a gradient boosting machine in particle-gel immunoassay (PaGIA). In the validation dataset (25% of patients), the AUROC of all models was 0.99 (95% CI: 0.97, 1.00). Compared to the currently recommended diagnostic algorithm (4Ts score, immunoassay), the numbers of false-negative patients were reduced from 12 to 6 (-50.0%; ELISA), 9 to 3 (-66.7%, PaGIA) and 14 to 5 (-64.3%; CLIA). The numbers of false-positive individuals were reduced from 87 to 61 (-29.8%; ELISA), 200 to 63 (-68.5%; PaGIA) and increased from 50 to 63 (+29.0%) for the CLIA. INTERPRETATION Our user-friendly machine-learning algorithm for the diagnosis of HIT (https://toradi-hit.org) was substantially more accurate than the currently recommended diagnostic algorithm. It has the potential to reduce delayed diagnosis and overtreatment in clinical practice. Future studies shall validate this model in wider settings. FUNDING Swiss National Science Foundation (SNSF), and International Society on Thrombosis and Haemostasis (ISTH).
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Affiliation(s)
- Henning Nilius
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sigve Haug
- Mathematical Institute, University of Bern, Bern, Switzerland
- Albert Einstein Center for Fundamental Physics and Laboratory for High Energy Physics, University of Bern, Bern, Switzerland
| | - Christos Nakas
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Laboratory of Biometry, School of Agriculture, University of Thessaly, Volos, Greece
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Adriana Mendez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Adrian Schmidt
- Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Walter A. Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Prakash Vishnu
- Division of Hematology, CHI Franciscan Medical Group, Seattle, United States
| | - Lukas Graf
- Cantonal Hospital of St Gallen, Switzerland
| | | | - Raphael Sznitman
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Corresponding author. Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
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8
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Warkentin TE, Sheppard JI, Whitlock RP. Temporal presentations of heparin-induced thrombocytopenia following cardiac surgery: A single-center, retrospective cohort study. J Thromb Haemost 2022; 20:2601-2616. [PMID: 35869817 PMCID: PMC9805231 DOI: 10.1111/jth.15826] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/05/2022] [Accepted: 07/18/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an important adverse drug reaction that can occur postcardiac surgery. Preoperative exposure to unfractionated heparin (UFH) is common, raising the issue of how frequently cardiac surgery-associated HIT occurs after immunizing preoperative exposure to heparin. OBJECTIVE To determine the frequency and clinical picture of HIT occurring within 4 days of cardiac surgery (early presentation) versus later presentations (typical, delayed). METHODS We identified patients with laboratory-confirmed HIT following cardiac surgery over 30 years in a single cardiac surgery center. Three different clinical presentations of HIT were identified: typical (HIT-related platelet count fall beginning between postoperative days [PODs] 5-10), delayed (patients with falls after POD10 or who presented following hospital discharge), and early (established before POD5, including during cardiac surgery [acute intraoperative HIT]). RESULTS Of 129 patients identified with HIT complicating cardiac surgery, 100 had typical and 16 had delayed presentation of HIT; only 13 patients (10.1%) presented with early HIT, all of whom had received exposure to UFH during the 10 days before cardiac surgery. No patient was identified in whom remote preoperative UFH exposure was implicated in explaining early HIT. Notably, five patients appeared to have had acute intraoperative HIT, without immediate adverse consequences. CONCLUSIONS Approximately 90% of patients with HIT after cardiac surgery appear to develop this complication due to immunization triggered by cardiac surgery; however, in approximately 10% of patients, early presentation during the first four PODs (or intraoperatively) can be explained by recent immunizing exposure to heparin.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonOntarioCanada
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
- Transfusion MedicineHamilton Regional Laboratory Medicine ProgramHamiltonOntarioCanada
- Service of Benign HematologyHamilton Health SciencesHamiltonOntarioCanada
| | - Jo‐Ann I. Sheppard
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Richard P. Whitlock
- Department of Surgery, Division of Cardiac SurgeryMcMaster UniversityHamiltonOntarioCanada
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9
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Hanna DJ, Torbic H, Militello M, Strnad K, Krishnan S, Hohlfelder B. Evaluation of anticoagulation with bivalirudin for heparin-induced thrombocytopenia during extracorporeal membrane oxygenation. Int J Artif Organs 2022; 45:688-694. [PMID: 35708334 DOI: 10.1177/03913988221106225] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Unfractionated heparin is the most commonly utilized anticoagulant in extracorporeal membrane oxygenation (ECMO) due to clinician familiarity, ease of reversal, and low cost compared to alternative agents. However, heparin's anticoagulant effect can be unpredictable and its use accompanies a risk of heparin induced thrombocytopenia (HIT). Successful use of bivalirudin as an alternative to heparin in non-HIT ECMO patients has previously been described. However, there is a paucity of data regarding its utilization in patients with confirmed HIT on ECMO. METHODS This single-center retrospective chart review at Cleveland Clinic Main Campus included 12 ECMO patients who were managed with bivalirudin for a new diagnosis of HIT. Descriptive statistical analyses were performed utilizing median with interquartile range and number with percent as appropriate. RESULTS Of the 12 patients included, median ECMO duration was 328.5 (218.8-502.1) h and venoarterial ECMO was the most common configuration. No patients experienced the primary outcome of in-circuit thrombosis while on bivalirudin. One patient developed a deep vein thrombosis 22.5 h after switching from heparin to bivalirudin. Major bleeding occurred during bivalirudin therapy in 8 (66.7%) patients. CONCLUSIONS Overall, our study results suggest that bivalirudin is effective for the management of HIT and did not show evidence of in-circuit thrombosis. A high incidence of major bleeding was observed with bivalirudin use within this study. Clinicians should view bivalirudin as an acceptable agent for the treatment of HIT in the ECMO population, but must consider bleeding risk given the lack of effective reversal agents.
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Affiliation(s)
- Dylan J Hanna
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Mike Militello
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Kyle Strnad
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | | | - Ben Hohlfelder
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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10
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Bolliger D, Santer D, Tanaka KA. Heparin-Induced Thrombocytopenia in Patients with Mechanical Circulatory Support. J Cardiothorac Vasc Anesth 2022; 36:1880-1882. [DOI: 10.1053/j.jvca.2022.03.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/11/2022]
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Brokmeier HM, Wieruszewski ED, Nei SD, Loftsgard TO, Wieruszewski PM. Hemostatic Management in Extracorporeal Membrane Oxygenation. Crit Care Nurs Q 2022; 45:132-143. [PMID: 35212653 DOI: 10.1097/cnq.0000000000000396] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) for acute cardiac and/or respiratory failure has grown exponentially in the past several decades. Systemic anticoagulation is a fundamental element of caring for ECMO patients. Hemostatic management during ECMO walks a fine line to balance the risk of safe and effective anticoagulant delivery to mitigate thromboembolic complications and minimizing hemorrhagic sequelae. This review discusses the pharmacology, monitoring parameters, and special considerations for anticoagulation in patients requiring ECMO.
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Affiliation(s)
- Hannah M Brokmeier
- Departments of Pharmacy (Drs Brokmeier, E. D. Wieruszewski, Nei, and P. M. Wieruszewski), Cardiovascular Surgery (Mr Loftsgard), and Anesthesiology (Dr P. M. Wieruszewski), Mayo Clinic, Rochester, Minnesota
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12
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Cutler NS, Marchant BE. Comparison of screening scores for heparin induced thrombocytopenia after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2022; 36:3570-3575. [DOI: 10.1053/j.jvca.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/21/2022] [Accepted: 04/06/2022] [Indexed: 11/11/2022]
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13
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Kram SJ, Hamidi A, Kram BL, Arepally G, Levy JH. The Predictive Value of the 4Ts and HEP Score at Recommended Cutoffs in Patients with Mechanical Circulatory Support Devices. J Cardiothorac Vasc Anesth 2022; 36:1873-1879. [DOI: 10.1053/j.jvca.2022.02.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/13/2022] [Accepted: 02/21/2022] [Indexed: 11/11/2022]
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Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening adverse drug reaction that relies on quick assessment and treatment by the health care team to prevent poor outcomes. Nurses can play a critical role in recognizing disease, advocating for patients, and facilitating treatment by being familiar with current guideline recommendations and risk stratification approaches. The purpose of this article is to review management of HIT including pathogenesis, clinical presentation, current guideline recommendations for risk assessment, laboratory testing, and treatment, as well as discuss nonheparin anticoagulation options that may be ordered when HIT is suspected.
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Affiliation(s)
- Raymond Smith
- Novant Health New Hanover Regional Medical Center, Wilmington, North Carolina
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15
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Pishko AM. Heparin-induced thrombocytopenia and cardiovascular surgery. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:536-544. [PMID: 34889428 PMCID: PMC8791147 DOI: 10.1182/hematology.2021000289] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Clinicians generally counsel patients with a history of heparin-induced thrombocytopenia (HIT) to avoid heparin products lifelong. Although there are now many alternative (nonheparin) anticoagulants available, heparin avoidance remains challenging for cardiac surgery. Heparin is often preferred in the cardiac surgery setting based on the vast experience with the agent, ease of monitoring, and reversibility. To "clear" a patient with a history of HIT for cardiac surgery, hematologists must first confirm the diagnosis of HIT, which can be challenging due to the ubiquity of heparin exposure and frequency of thrombocytopenia in patients in the cardiac intensive care unit. Next, the "phase of HIT" (acute HIT, subacute HIT A/B, or remote HIT) should be established based on platelet count, immunoassay for antibodies to platelet factor 4/heparin complexes, and a functional assay (eg, serotonin release assay). As long as the HIT functional assay remains positive (acute HIT or subacute HIT A), cardiac surgery should be delayed if possible. If surgery cannot be delayed, an alternative anticoagulant (preferably bivalirudin) may be used. Alternatively, heparin may be used with either preoperative/intraoperative plasma exchange or together with a potent antiplatelet agent. The optimal strategy among these options is not known, and the choice depends on institutional experience and availability of alternative anticoagulants. In the later phases of HIT (subacute HIT B or remote HIT), brief intraoperative exposure to heparin followed by an alternative anticoagulant as needed in the postoperative setting is recommended.
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Affiliation(s)
- Allyson M. Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Correspondence Allyson M. Pishko, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, 3rd Floor Dulles, Philadelphia, PA 19104; e-mail:
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Stewart JJ, Turgeon R, Parker A, Koshman S, Omar MA. Comparison of risk-scoring systems for heparin-induced thrombocytopenia in cardiac surgery patients. Pharmacotherapy 2021; 41:1033-1040. [PMID: 34665467 DOI: 10.1002/phar.2636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 09/16/2021] [Accepted: 10/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Several risk-scoring tools have been developed to exclude heparin-induced thrombocytopenia (HIT) in patients with thrombocytopenia, but these scores have not been reproduced or compared in the cardiac surgery population. The objective of this study was to validate and compare the modified 4T's (m4T) and Lillo-Le Louet (LLL) scores for HIT screening in the cardiac surgery population. METHODS In this nested case-control study, we retrospectively calculated the m4T and the cardiac surgery-specific score by LLL for 18 cases (HIT-positive) and 54 matched controls (HIT-negative) using characteristics known at the time the HIT assay was ordered post-cardiac surgery and compared their performances by their c-statistic (area under the receiver operating characteristic curve), sensitivity and specificity. RESULTS The median time from surgery to HIT assay order was 9.5 days (IQR 3.75-11.0) in the HIT-positive group and 2 days (IQR 2.0-3.0) in the HIT-negative group (p < 0.0001). The c-statistics for the m4T and the LLL scores were 0.76 (95% CI 0.64-0.85) and 0.63 (95% CI 0.51-0.74), respectively (p = 0.051). Sensitivity and specificity were 61% and 91% for the m4T, and 94% and 32% for the LLL score. CONCLUSION Performance of the m4T and LLL scores in discriminating HIT-positive from HIT-negative patients was modest among patients post-cardiac surgery. However, differences between the sensitivities of these scores suggest that the LLL score may be a safer tool for ruling out HIT in this population.
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Affiliation(s)
- Jackson J Stewart
- Pharmacy Services, Alberta Health Services, University of Alberta Hospital, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Ricky Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Arabesque Parker
- Department of Critical Care, Division of Hematology Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sheri Koshman
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Mohamed A Omar
- Pharmacy Services, Alberta Health Services, University of Alberta Hospital, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
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Cheng Y, Chen C, Yang J, Yang H, Fu M, Zhong X, Wang B, He M, Hu Z, Zhang Z, Jin X, Kang Y, Wu Q. Using Machine Learning Algorithms to Predict Hospital Acquired Thrombocytopenia after Operation in the Intensive Care Unit: A Retrospective Cohort Study. Diagnostics (Basel) 2021; 11:diagnostics11091614. [PMID: 34573956 PMCID: PMC8466367 DOI: 10.3390/diagnostics11091614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/25/2021] [Accepted: 09/01/2021] [Indexed: 02/05/2023] Open
Abstract
Hospital acquired thrombocytopenia (HAT) is a common hematological complication after surgery. This research aimed to develop and compare the performance of seven machine learning (ML) algorithms for predicting patients that are at risk of HAT after surgery. We conducted a retrospective cohort study which enrolled adult patients transferred to the intensive care unit (ICU) after surgery in West China Hospital of Sichuan University from January 2016 to December 2018. All subjects were randomly divided into a derivation set (70%) and test set (30%). ten-fold cross-validation was used to estimate the hyperparameters of ML algorithms during the training process in the derivation set. After ML models were developed, the sensitivity, specificity, area under the curve (AUC), and net benefit (decision analysis curve, DCA) were calculated to evaluate the performances of ML models in the test set. A total of 10,369 patients were included and in 1354 (13.1%) HAT occurred. The AUC of all seven ML models exceeded 0.7, the two highest were Gradient Boosting (GB) (0.834, 0.814-0.853, p < 0.001) and Random Forest (RF) (0.828, 0.807-0.848, p < 0.001). There was no difference between GB and RF (0.834 vs. 0.828, p = 0.293); however, these two were better than the remaining five models (p < 0.001). The DCA revealed that all ML models had high net benefits with a threshold probability approximately less than 0.6. In conclusion, we found that ML models constructed by multiple preoperative variables can predict HAT in patients transferred to ICU after surgery, which can improve risk stratification and guide management in clinical practice.
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Affiliation(s)
- Yisong Cheng
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Chaoyue Chen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, China;
| | - Jie Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Hao Yang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Min Fu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Xi Zhong
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Bo Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Min He
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Zhi Hu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Zhongwei Zhang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Xiaodong Jin
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Yan Kang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
| | - Qin Wu
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu 610041, China; (Y.C.); (J.Y.); (H.Y.); (M.F.); (X.Z.); (B.W.); (M.H.); (Z.H.); (Z.Z.); (X.J.); (Y.K.)
- Correspondence: ; Tel.: +86-028-8542-2506
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Pishko AM, Cuker A. Diagnosing heparin-induced thrombocytopenia: The need for accuracy and speed. Int J Lab Hematol 2021; 43 Suppl 1:96-102. [PMID: 34288442 DOI: 10.1111/ijlh.13564] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/06/2021] [Accepted: 04/14/2021] [Indexed: 01/15/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic condition resulting from pathogenic antibodies to complexes of heparin and platelet factor 4 (PF4). The diagnosis of HIT can be challenging due to the widespread use of heparin and the frequency of thrombocytopenia in hospitalized patients. Laboratory testing for HIT typically includes an immunoassay to detect antibodies to PF4-heparin and a functional assay. Current HIT diagnostic algorithms recommend using the 4Ts score to determine the need for HIT laboratory testing. Automated calculation of HIT clinical prediction scores in the electronic health record may improve the identification of patients who should undergo HIT testing. Another challenge in the management of patients with suspected HIT is the turnaround time of the laboratory testing needed to confirm the diagnosis. Due to the high daily thrombotic risk of HIT, clinicians must treat patients with intermediate to high pretest likelihood of HIT empirically while awaiting the test results. Treatment for HIT often involves alternative anticoagulants that lack reversal agents, which may increase bleeding risk, prolong hospital stays, and increase costs for patients suspected of having HIT. Rapid immunoassays hold promise to improve the speed of HIT diagnosis. These assays must retain a very high sensitivity for this "can't miss" diagnosis, yet have sufficient specificity to be of diagnostic value. A Bayesian approach has been proposed using two rapid immunoassays in succession, which decreased analytic turnaround time to 60 minutes. Such an approach has the potential to be a much-needed clinical advance in improving accuracy and speed in the diagnosis of HIT.
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Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Tardy-Poncet B, de Maistre E, Pouplard C, Presles E, Alhenc-Gelas M, Lasne D, Horellou MH, Mouton C, Serre-Sapin A, Bauters A, Nguyen P, Mullier F, Perrin J, Le Gal G, Morange PE, Grunebaum L, Lillo-Le Louet A, Elalamy I, Gruel Y, Greinacher A, Lecompte T, Tardy B. Heparin-induced thrombocytopenia: Construction of a pretest diagnostic score derived from the analysis of a prospective multinational database, with internal validation. J Thromb Haemost 2021; 19:1959-1972. [PMID: 33872452 DOI: 10.1111/jth.15344] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 04/09/2021] [Accepted: 04/09/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Diagnosis of heparin-induced thrombocytopenia (HIT) requires pretest probability assessment and dedicated laboratory assays. OBJECTIVE To develop a pretest score for HIT. DESIGN Observational; analysis of prospectively collected data of hospitalized patients suspected with HIT (ClinicalTrials.gov NCT00748839). SETTING Thirty-one tertiary hospitals in France, Switzerland, and Belgium. PATIENTS Patients tested for HIT antibodies (2280 evaluable), randomly allocated to derivation and validation cohorts. MEASUREMENTS Independent adjudicators diagnosed HIT based on the prospectively collected data and serotonin release assay results. RESULTS Heparin-induced thrombocytopenia was diagnosed in 234 (14.7%) and 99 (14.5%) patients in the two cohorts. Eight features were associated with HIT (in brackets, points assigned for score calculation of the score): unfractionated heparin (1); therapeutic-dose heparin (1); cardiopulmonary bypass (cardiac surgery) (2); major trauma (3); 5- to 21-day interval from anticoagulation initiation to suspicion of HIT (4); ≥40% decrease in platelet count over ≤6 days (3); thrombotic event, arterial (3) or venous (3). The C-statistic was 0.79 (95% CI, 0.76-0.82). In the validation cohort, the area under the receiver operating characteristic curve was 0.77 (95% CI, 0.74-0.80). Three groups of scores were defined; HIT prevalence reached almost 30% in the high-probability group. LIMITATION The performance of the score may depend on settings and practices. CONCLUSION The objective, easy-to-collect, clinical features of HIT we evidenced were incorporated into a pretest score, which may guide clinical decisions regarding diagnostic testing and anticoagulation.
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Affiliation(s)
- Brigitte Tardy-Poncet
- CIC 1408, Inserm U1059 SAINBIOSE, F-Crin INNOVTE, Université de Lyon, Saint-Etienne, France
| | | | - Claire Pouplard
- Division of Hematology - Hemostasis, University Hospital of Tours, Tours, France
| | - Emilie Presles
- CIC 1408, Inserm U1059 SAINBIOSE, F-Crin INNOVTE, Université de Lyon, Saint-Etienne, France
| | | | - Dominique Lasne
- Hemostasis Unit, Hôpital Necker, AP-HP, Paris, France
- Université Paris Sud Paris Saclay, Inserm U1176, Le Kremlin-Bicêtre, France
| | | | | | | | | | | | - François Mullier
- Namur Thrombosis and Hemostasis Center, Hematology Laboratory, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | | | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, ON, Canada
| | - Pierre-Emmanuel Morange
- C2VN, Aix Marseille University, INSERM, INRA; Laboratory of Hematology, La Timone Hospital, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Lélia Grunebaum
- Laboratory of Hematology, CHU Strasbourg, Strasbourg, France
| | - Agnès Lillo-Le Louet
- Pharmacovigilance Center, Georges Pompidou European Hospital, AP-HP, Paris, France
| | - Ismail Elalamy
- Hematology and Thrombosis Center, Tenon University Hospital, INSERM UMRS 938, Sorbonne University, Paris, France
| | - Yves Gruel
- Division of Hematology - Hemostasis, University Hospital of Tours, Tours, France
| | - Andreas Greinacher
- Institut fuer Immunologie und Transfusionsmedizin, Universitaetsmedizin Greifswald, Greifswald, Germany
| | - Thomas Lecompte
- Department of Medicine, Geneva University Hospitals, and Geneva Platelet Group (GpG), Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Bernard Tardy
- CIC 1408, Inserm U1059 SAINBIOSE, F-Crin INNOVTE, Université de Lyon, Saint-Etienne, France
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20
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Bérezné A, Bougon D, Blanc‐Jouvan F, Gendron N, Janssen C, Muller M, Bertil S, Desvard F, Presot I, Terrier B, Chocron R, Sanchez O, Helley D, Smadja DM. Deterioration of vaccine-induced immune thrombotic thrombocytopenia treated by heparin and platelet transfusion: Insight from functional cytometry and serotonin release assay. Res Pract Thromb Haemost 2021; 5:e12572. [PMID: 34485807 PMCID: PMC8410951 DOI: 10.1002/rth2.12572] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/30/2021] [Accepted: 07/07/2021] [Indexed: 01/28/2023] Open
Abstract
We report a case of a 62-year-old man who developed cerebral venous sinus thrombosis with subarachnoid hemorrhage and concomitant thrombocytopenia, which occurred 13 days after ChAdOx1 nCov-19 injection. The patient died in the intensive care unit after heparin infusion and platelet transfusion. The key clinical purpose of this case report is to better understand how to confirm vaccine-induced immune thrombotic thrombocytopenia (VITT). VITT diagnosis was made using 14C-serotonin release and flow cytometry evaluating activation and platelet microvesicles on washed platelets. Four control patients were examined: a patient with heparin-induced thrombocytopenia (HIT), two patients with thrombotic events without thrombocytopenia after ChAdOx1 nCov-19 or BNT162b2, and a patient with suspected HIT and an excluded diagnosis. We evidenced in the VITT case a high level of IgG anti-platelet factor 4-heparin antibodies associated with a high level of platelet activation in the absence of heparin. Conversely, the functional assays were negative in the patients with thrombosis without thrombocytopenia.
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Affiliation(s)
- Alice Bérezné
- Department of Internal Medicine and Infectious DiseasesCHR Annecy‐GenevoisAnnecyFrance
| | - David Bougon
- Department of Intensive CareCHR Annecy‐GenevoisAnnecyFrance
| | | | - Nicolas Gendron
- Hematology DepartmentUniversité de ParisAssistance Publique Hôpitaux de Paris‐Centre (AP‐HP.CUP)ParisFrance
- Université de ParisInnovative Therapies in HemostasisINSERMParisFrance
- Biosurgical Research Lab (Carpentier Foundation)Assistance Publique Hôpitaux de Paris‐Centre (AP‐HP.CUP)ParisFrance
| | - Cecile Janssen
- Department of Internal Medicine and Infectious DiseasesCHR Annecy‐GenevoisAnnecyFrance
| | - Michel Muller
- Department of Intensive CareCHR Annecy‐GenevoisAnnecyFrance
| | - Sébastien Bertil
- Hematology DepartmentUniversité de ParisAssistance Publique Hôpitaux de Paris‐Centre (AP‐HP.CUP)ParisFrance
| | - Florence Desvard
- Hematology DepartmentUniversité de ParisAssistance Publique Hôpitaux de Paris‐Centre (AP‐HP.CUP)ParisFrance
| | - Isabelle Presot
- Hematology DepartmentUniversité de ParisAssistance Publique Hôpitaux de Paris‐Centre (AP‐HP.CUP)ParisFrance
| | - Benjamin Terrier
- Université de ParisPARCCINSERMParisFrance
- Internal Medicine DepartmentUniversité de ParisAssistance Publique Hôpitaux de Paris‐Centre (AP‐HP.CUP)ParisFrance
| | - Richard Chocron
- Université de ParisPARCCINSERMParisFrance
- Emergency DepartmentUniversité de ParisAssistance Publique Hôpitaux de Paris‐Centre (AP‐HP.CUP)ParisFrance
| | - Olivier Sanchez
- Université de ParisInnovative Therapies in HemostasisINSERMParisFrance
- Biosurgical Research Lab (Carpentier Foundation)Assistance Publique Hôpitaux de Paris‐Centre (AP‐HP.CUP)ParisFrance
- Pneumology DepartmentUniversité de ParisAssistance Publique Hôpitaux de Paris‐Centre (AP‐HP.CUP)ParisFrance
| | - Dominique Helley
- Hematology DepartmentUniversité de ParisAssistance Publique Hôpitaux de Paris‐Centre (AP‐HP.CUP)ParisFrance
- Université de ParisPARCCINSERMParisFrance
| | - David M. Smadja
- Hematology DepartmentUniversité de ParisAssistance Publique Hôpitaux de Paris‐Centre (AP‐HP.CUP)ParisFrance
- Université de ParisInnovative Therapies in HemostasisINSERMParisFrance
- Biosurgical Research Lab (Carpentier Foundation)Assistance Publique Hôpitaux de Paris‐Centre (AP‐HP.CUP)ParisFrance
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21
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Moran HRM, Arora RC, Manji RA. Commentary: The A-B-C's of H-I-T. Semin Thorac Cardiovasc Surg 2021; 34:581-582. [PMID: 34098116 DOI: 10.1053/j.semtcvs.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 05/26/2021] [Indexed: 01/10/2023]
Affiliation(s)
- Hellmuth R Muller Moran
- Division of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Division of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Rizwan A Manji
- Division of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada.
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Abstract
Background: Heparin-induced thrombocytopenia (HIT) is a rare autoimmune reaction that involves a decrease in platelet count following heparin exposure and can be associated with life-threatening thrombosis. Because of their prolonged heparin exposure, patients undergoing cardiac surgery are at risk of HIT, with an incidence of 0.1% to 3%. Case Report: A 65-year-old male with severe mitral regurgitation and preoperative ejection fraction of 20% to 25% underwent mitral valve bioprosthetic replacement with coronary artery bypass graft surgery. Heparin anticoagulation was started on postoperative day (POD) 1. Respiratory failure resulted in prolonged mechanical ventilation and heparinization without the ability to initiate warfarin. While the patient was on heparin, his platelet count declined on POD 2 and then steadily increased to above the preoperative level on POD 7. On POD 10, the patient's platelet count dramatically decreased, and on POD 13 he developed acute common femoral artery occlusion necessitating embolectomy. Intraoperative transesophageal echocardiography revealed heavy thrombus burden across the mitral bioprosthesis. HIT was confirmed with a positive heparin-induced platelet antibody and serotonin release assay. Heparin was stopped and argatroban initiated. The patient underwent reoperative bioprosthetic mitral valve replacement on POD 18 using bivalirudin intraoperatively. Despite resolution of HIT, the patient developed sepsis and died on POD 59. Conclusion: The diagnosis of HIT is challenging in patients who undergo cardiopulmonary bypass. Platelet counts often decrease 40% to 60% during the first 72 hours postoperatively, and the frequency of nonspecific anti-platelet factor 4/heparin antibody formation is high. These findings can mask early signs of HIT and delay diagnosis.
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23
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Allan KA, Crow JR, Chasler JE, Athale J, Lindsley JP, Shermock KM, Streiff M, Whitman GJR, Dane KE. Comparison of Clinical Scoring Tools to Predict Heparin-Induced Thrombocytopenia in Cardiac Surgery. Semin Thorac Cardiovasc Surg 2021; 34:570-580. [PMID: 34102291 DOI: 10.1053/j.semtcvs.2021.04.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 12/11/2022]
Abstract
The 4Ts and HIT-Expert Probability (HEP) scoring tools for heparin-induced thrombocytopenia (HIT) have not been validated in cardiac surgery patients, and the reported sensitivity and specificity of the Post-Cardiopulmonary Bypass (CPB) scoring tool vary widely in the 2 available analyses. It remains unclear which of the available scoring tools most accurately predicts HIT in this population. Forty-nine HIT-positive patients who underwent on-pump cardiac surgery within a 6-year period were loosely matched to 98 HIT-negative patients in a 1:2 case-control design. The 4Ts, HEP, and CPB scores were calculated for each patient. Sensitivity and specificity of each tool were calculated using standard cut-offs. The Youden method was utilized to determine optimal cut-offs within receiver operating characteristic (ROC) curves of each score, after which sensitivities and specificities were recalculated. Using standard cut-offs, the sensitivities for the CPB, HEP, and 4Ts scores were 100%, 93.9%, and 69.4%, respectively. Specificities were 51%, 49%, and 71.4%, respectively. The AUC of the scoring tool ROC curves were 0.961 for the CPB score, 0.773 for the HEP score, and 0.805 for the 4Ts score. Using the Youden method-derived optimal cut-off of ≥3 points on the CPB score, sensitivity remained 100% with improved specificity to 88.9%. The CPB score is the preferred HIT clinical scoring tool in adult cardiac surgery patients, whereas the 4Ts score performed less effectively. A cut-off of ≥ 3 points on the CPB score could increase specificity while preserving high sensitivity, which should be validated in a prospective evaluation.
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Affiliation(s)
- Kari A Allan
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland.
| | - Jessica R Crow
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Jessica E Chasler
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Janhavi Athale
- Department of Medicine, Division of Hematology, The Johns Hopkins University School of Medicine, Baltimore, Maryland; Critical Care Medicine Department, Clinical Center, National Institute of Health, Bethesda, Maryland
| | - John P Lindsley
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Michael Streiff
- Department of Medicine, Division of Hematology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn J R Whitman
- Department of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Kathryn E Dane
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland
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Hvas AM, Favaloro EJ, Hellfritzsch M. Heparin-induced thrombocytopenia: pathophysiology, diagnosis and treatment. Expert Rev Hematol 2021; 14:335-346. [PMID: 33736552 DOI: 10.1080/17474086.2021.1905512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Immune-mediated heparin-induced thrombocytopenia (HIT) is an infrequent complication following heparin exposure but with potentially fatal outcome due to thrombotic complications. Prompt suspension of heparin is necessary if HIT is suspected, followed by initiation of non-heparin anticoagulant therapy.Areas covered: In this review, the pathophysiology and challenges in diagnosing HIT are elucidated. Current and emerging treatment options are discussed with special focus on parenteral thrombin inhibitors (argatroban, bivalirudin), parenteral factor Xa inhibitors (danaparoid, fondaparinux) and direct oral anticoagulants (DOACs [rivaroxaban, apixaban, dabigatran]) including dosing strategies for DOACs. The database PubMed was employed without time boundaries.Expert opinion: Only argatroban holds regulatory approval for HIT treatment in both U.S. and Europe. This treatment is, however, challenged by the need for close monitoring and high costs. Fondaparinux has been increasingly used for off-label treatment and during recent years, evidence for the use of DOACs has emerged. Preliminary results from observational studies hold promise for future use of DOACs in the acute and subacute phase of HIT. However, so far, the use of DOACs in acute HIT should be reserved for clinically stable patients without severe thrombotic complications. Importantly, both fondaparinux and DOAC use is contraindicated in severe renal insufficiency.
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Affiliation(s)
- Anne-Mette Hvas
- Department of Clinical Biochemistry, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University. Address: Palle Juul-Jensens Boulevard 99, Aarhus N, Denmark
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, Australia
| | - Maja Hellfritzsch
- Department of Cardiology, Herning Regional Hospital, Herning, Denmark
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Moreno-Duarte I, Cooter M, Onwuemene OA, Ghadimi K, Welsby IJ. Clinical outcomes of cardiac surgery patients undergoing therapeutic plasma exchange for heparin-induced thrombocytopenia. Vox Sang 2021; 116:217-224. [PMID: 32965049 PMCID: PMC10308265 DOI: 10.1111/vox.13008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 07/29/2020] [Accepted: 08/31/2020] [Indexed: 10/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Heparin-induced thrombocytopenia (HIT) is an antibody-mediated condition that leads to thrombocytopenia and possible thrombosis. Patients with HIT who require cardiac surgery pose a challenge as high doses of heparin or heparin alternatives are required to permit cardiopulmonary bypass (CPB). Intraoperative therapeutic plasma exchange (TPE) is a valuable adjunct in the management of antibody-mediated syndromes including HIT. The clinical impact of TPE on thromboembolic events, bleeding and mortality after heparin re-exposure is not well established. We hypothesized that TPE with heparin re-exposure will not lead to HIT-related thromboembolic events, bleeding or increased mortality after cardiac surgery with CPB. MATERIALS AND METHODS We reviewed 330 patients who received perioperative TPE between September 2012 and September 2017. RESULTS Twenty four patients received TPE for HIT before anticipated heparin use for CPB. Most patients were males (79%) scheduled for advanced heart failure therapies. Three patients (12·5%) died within 30 days after surgery but none of the deaths were considered HIT-related. Thromboembolic events (TE) occurred in 3 patients within 7 days of surgery; of those, two were possibly HIT-related. CONCLUSION Therapeutic plasma exchange with heparin re-exposure was not strongly associated with HIT-related thrombosis/death after cardiac surgery with CPB.
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Affiliation(s)
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Oluwatoyosi A Onwuemene
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Ian J Welsby
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Ferry J, Youssef S, Wu P, Hegerova L. Heparin-induced thrombocytopenia presenting as splenic hemorrhage following cardiac surgery: a case report. Thromb J 2021; 19:4. [PMID: 33468150 PMCID: PMC7816498 DOI: 10.1186/s12959-021-00257-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 01/11/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia with thrombosis (HITT) is a paradoxical prothrombotic complication of anticoagulant therapy. As many as 3% of patients undergoing cardiac surgery develop clinical HIT presenting as thrombocytopenia with or without thrombosis within 5-10 days of heparin exposure. Thrombotic complications associated with HIT carry a mortality rate of 5-10%. CASE PRESENTATION We report a case of atraumatic splenic hemorrhage due to splenic vein thrombosis as the main indicator of HIT following cardiac surgery in a 62-year-old woman. She presented to the emergency department on day nine following coronary artery bypass graft surgery with acute weakness, dizziness, and malaise. Her evaluation in the emergency department found anemia and thrombocytopenia. A coagulation profile revealed a markedly elevated d-dimer. She underwent a computed tomography scan of the chest, abdomen and pelvis for suspected bleed and was found to have splenic vein thrombosis, right atrial filling defects consistent with atrial thrombus and mild to moderate hemoperitoneum. Surgical consultation was obtained due to splenic hemorrhage. Hematology was consulted on post-operative day 10, however, she unfortunately developed left sided weakness concerning for stroke. A magnetic resonance imaging scan of the brain demonstrated infarct involving distribution of the right anterior cerebral artery. A transesophageal echocardiogram demonstrated a large immobile thrombus within the right atrium with a second, mobile thrombus arising from the left tricuspid valve annulus. Due to a 4Ts score of 7 and markedly positive platelet factor 4 (PF4) IgG antibody a serotonin release assay was not performed given the high probability of HIT. She was cautiously treated with bivalirudin and was transitioned to warfarin anticoagulation. In the following days her platelet count recovered and 3 months later a transthoracic echocardiogram revealed solution of the intracardiac thrombi. CONCLUSIONS Atraumatic splenic hemorrhage is an unusual presentation of HIT that is reminiscent of the rare bilateral adrenal hemorrhage due to adrenal necrosis that also occurs in HIT. Alternative anticoagulation is the mainstay of therapy for HIT despite hemorrhage, given the underlying acquired hypercoagulability. Despite similarities of the presentation between splenic hemorrhage and bilateral adrenal hemorrhage, splenic hemorrhage is rarely described in the literature. HIT should be considered in patients presenting with thrombocytopenia following cardiac surgery.
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Affiliation(s)
- Joseph Ferry
- Department of Hematology and Oncology, Swedish Medical Center, 747 Broadway 12th Fl. East Tower, Seattle, WA, 98122, USA.
| | - Samuel Youssef
- Swedish Heart and Vascular - Cardiac Surgery, Seattle, WA, USA
| | - Pierce Wu
- Swedish Heart and Vascular - Cardiac Surgery, Seattle, WA, USA
| | - Livia Hegerova
- Swedish Center for Blood Disorders and Stem Cell Transplantation, Seattle, WA, USA
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Marashi-Sabouni Z, Vayne C, Ibrahim-Kosta M, Guidon C, Loundou A, Guery EA, Morange PE, Camoin-Jau L. Clinical validation of immunoassay HemosIL® AcuStar HIT-IgG (PF4-H) in the diagnosis of Heparin-induced thrombocytopenia. J Thromb Thrombolysis 2021; 52:601-609. [PMID: 33386560 DOI: 10.1007/s11239-020-02349-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 11/25/2022]
Abstract
Heparin induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. The misdiagnosis of this disease can have major consequences on the patients. The objective of this study was to evaluate a diagnostic strategy that combines the 4Ts score with the result of HemosIL® AcuStar HIT-IgG (PF4-H) to confirm the diagnosis of HIT. Citrated plasmas from 1300 patients with suspicion of HIT were analyzed with a fully automated quantitative chemiluminescent immunoassay (HemosIL® AcuStar HIT-IgG (PF4/H)). If the IgG anti-PF4/H antibodies were positive (cut-off, 1 U/mL), HIT diagnosis was confirmed using functional tests. In total, 1300 samples of consecutive patients were enrolled, 94 (7.2%) of which gave positive results in HemosIL® AcuStar-IgG. HIT was diagnosed in 65 out of these patients, corresponding to a prevalence of 5%. Using ROC curve analysis, patients were divided into three groups according to their titer of antibodies. Higher values of the IgG (PF4-H) were associated with increased probability of HIT, and the diagnostic specificity was greatly increased using the combination of a 4Ts score > 3 and a positive titer ≥ 3.25 U/mL. Importantly, the diagnostic specificity is 100% when the titer is > 12.40 U/mL. We demonstrated that higher values of Anti PF4/H Antibodies were associated with a high probability of having HIT. A titer of HemosIL® IgG (PF4-H) > 12.40 U/mL has a specificity of 100% which should no require a functional test to confirm the diagnosis of HIT.
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Affiliation(s)
- Zeina Marashi-Sabouni
- Laboratoire d'Hématologie, La Timone Hospital, APHM, Boulevard Jean- Moulin, 13005, Marseille, France
| | - Caroline Vayne
- Service d'Hématologie Hémostase, Hôpital Trousseau, CHU de Tours, 37044, Tours, France
- EA7501 GICC, Université de Tours, Tours, France
| | - Manal Ibrahim-Kosta
- Laboratoire d'Hématologie, La Timone Hospital, APHM, Boulevard Jean- Moulin, 13005, Marseille, France
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - Catherine Guidon
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Marseille, France
| | - Anderson Loundou
- Biostatistic and Public Health Department, La Timone Hospital, Marseille, France
| | - Eve Anne Guery
- Service d'Hématologie Hémostase, Hôpital Trousseau, CHU de Tours, 37044, Tours, France
| | - Pierre-Emmanuel Morange
- Laboratoire d'Hématologie, La Timone Hospital, APHM, Boulevard Jean- Moulin, 13005, Marseille, France
- Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - Laurence Camoin-Jau
- Laboratoire d'Hématologie, La Timone Hospital, APHM, Boulevard Jean- Moulin, 13005, Marseille, France.
- Aix Marseille Univ, IRD, APHM, MEPHI, IHU Méditerranée Infection, Marseille, France.
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Ezelsoy M, Saracoglu KT, Oral K, Saracoglu A, Akpinar B. Positive Heparin/PF4 Antibodies and High Mortality Rate: a Retrospective Case-Series Analysis. Braz J Cardiovasc Surg 2020; 35:950-957. [PMID: 33306320 PMCID: PMC7731847 DOI: 10.21470/1678-9741-2019-0360] [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] [Indexed: 11/24/2022] Open
Abstract
Introduction Heparin-induced thrombocytopenia (HIT) is a potentially lethal complication of unfractionated or low-molecular weight heparin therapy. We aimed to determine the incidence and mortality rate of patients with positive heparin/platelet factor 4 (PF4) antibodies, which is a rapid detection test of HIT. Methods Coronary artery bypass grafting and mitral and aortic valve surgeries were evaluated. Cardiopulmonary bypass was employed in all patients. The diagnosis of HIT was based on immunological assays. Postoperative complications, mortality rates, and the causes of death were specified in patients with positive heparin/PF4 antibodies. Results Postoperative thrombocytopenia was detected in 257 patients. Twenty of these patients undergoing open heart surgery were included in the final analysis. Antibodies against heparin/PF4 complex were positive in 20 patients. The mean body mass index was 28.8±2.3 kg/m2, mean value of left ventricular ejection fraction was 48.3±6.7%, cardiopulmonary bypass time was 113.0±35.0 min, aortic cross-clamping time was 88.0±32.7 min, mean intensive care unit length of stay was 10.9±4.9 days, mean preoperative platelet count was 307.250±88528 platelets/microliter, and mean postoperative platelet count was 243.050±89.354 platelets/microliter. The mean duration of heparin exposure was 6.9±2.9 days. The mortality rate was 45% (nine patients) and 1.2% (three patients) in heparin/PF4 complex positive and negative patients, respectively. Conclusion Although the incidence of HIT was low in patients undergoing open heart surgery, an increased rate of early mortality was observed in patients with positive heparin/PF4 antibodies.
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Affiliation(s)
- Mehmet Ezelsoy
- Department of Cardiovascular Surgery, Istanbul Demiroglu Bilim University Medical School, Istanbul, Turkey
| | - Kemal Tolga Saracoglu
- Department of Anesthesiology and Intensive Care, Health Sciences University Medical School, Istanbul, Turkey
| | - Kerem Oral
- Department of Cardiovascular Surgery, Istanbul Demiroglu Bilim University Medical School, Istanbul, Turkey
| | - Ayten Saracoglu
- Department of Anesthesiology and Intensive Care, Istanbul Marmara University Medical School, Istanbul, Turkey
| | - Belhan Akpinar
- Department of Cardiovascular Surgery, Istanbul Demiroglu Bilim University Medical School, Istanbul, Turkey
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Avila L, Amiri N, Yenson P, Khan S, Zavareh ZT, Chan AKC, Williams S, Brandão LR. Heparin-Induced Thrombocytopenia in a Pediatric Population: Implications for Clinical Probability Scores and Testing. J Pediatr 2020; 226:167-172.e2. [PMID: 32640269 DOI: 10.1016/j.jpeds.2020.06.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/23/2020] [Accepted: 06/25/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine the applicability of the 4Ts score and the Heparin-Induced Thrombocytopenia (HIT) Expert Probability (HEP) score in children with suspected HIT and to estimate the number of children potentially at risk of HIT. STUDY DESIGN We retrospectively estimated 4Ts and HEP scores in a cohort of 50 children referred for laboratory screening with enzyme immunoassay. In addition, minor modifications were introduced to the 4Ts score (modified 4Ts score) to adapt it for use in the pediatric setting. All patients with positive enzyme immunoassays were tested with serotonin release assay. We also extracted the number of patients started on heparins in a similar period of time. RESULTS The median age at the time of testing was 4 years (25th-75th percentile, 8.7 months to 13.5 years); 78% of patients had low and 22% had intermediate risk pretest probability scores using the original 4Ts score; 86% had low risk and 14% had intermediate risk scores using the modified 4Ts score; 54% of children had a HEP score of ≥2. Six patients (12%) had a positive (≥0.40 optical density units) enzyme immunoassay, but none had a positive serotonin release assay. Based on anticoagulation dose, there were 1-2 new daily potentially high-risk exposures to heparinoids at our institution. CONCLUSIONS The modified 4Ts and original 4Ts scores may be more adequate than the HEP score to determine HIT pretest probability in children. Despite the number of patients potentially at risk, HIT is rare in pediatrics.
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Affiliation(s)
- Laura Avila
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nour Amiri
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul Yenson
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Shirin Khan
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; G. Raymond Chang School of Continuing Education, Ryerson University, Toronto, Ontario, Canada
| | - Zahra Tofighi Zavareh
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; G. Raymond Chang School of Continuing Education, Ryerson University, Toronto, Ontario, Canada
| | - Anthony K C Chan
- Division of Hematology/Oncology, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Suzan Williams
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Leonardo R Brandão
- Division of Hematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Abstract
Purpose of Review This review will illustrate the importance of heparin-induced thrombocytopenia in the intraoperative and critical care settings. Recent Findings Heparin-induced thrombocytopenia (HIT) occurs more frequently in surgical patients compared with medical patients due to the inflammatory release of platelet factor 4 and perioperative heparin exposure. Recognition of this disease requires a high index of suspicion. Diagnostic tools and therapeutic strategies have been expanded and refined in recent years. Summary HIT is a condition where antibodies against the heparin/platelet factor 4 complex interact with platelet receptors to promote platelet activation, aggregation, and thrombus formation. Our review will focus on intraoperative and postoperative considerations related to HIT to help the clinician better manage this rare but often devastating hypercoagulable disease process.
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Sahu KK, Jindal V, Anderson J, Siddiqui AD, Jaiyesimi IA. Current Perspectives on Diagnostic Assays and Anti-PF4 Antibodies for the Diagnosis of Heparin-Induced Thrombocytopenia. J Blood Med 2020; 11:267-277. [PMID: 32884385 PMCID: PMC7443028 DOI: 10.2147/jbm.s232648] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a recognized clinical entity in patients receiving unfractionated heparin and low–molecular weight heparin. Currently, diagnosing HIT includes the combination of a physician’s clinical suspicion based on a clinical scoring system and a series of laboratory tests. In the present article, we discuss challenges in suspecting and diagnosing HIT in consideration of the turnaround time of available tests and recent advances in techniques and methodologies of newer immunoassays and functional assays.
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Affiliation(s)
- Kamal K Sahu
- Hemato-oncology Division, Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, USA
| | - Vishal Jindal
- Department of Hematology and Oncology, Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, USA
| | - Joseph Anderson
- Department of Hematology and Oncology, Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, USA
| | - Ahmad D Siddiqui
- Hemato-oncology Division, Department of Internal Medicine, Saint Vincent Hospital, Worcester, MA 01608, USA
| | - Ishmael A Jaiyesimi
- Department of Hematology and Oncology, Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, USA
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Dufendach KA, Seese L, Stearns B, Hickey G, Mathier M, Keebler M, Chen S, Sciortino CM, Thoma FW, Kilic A. Outcomes of left ventricular assist device implantation in hypercoagulable patients. J Card Surg 2020; 35:2201-2207. [PMID: 32720362 DOI: 10.1111/jocs.14710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to evaluate outcomes of left ventricular assist devices (LVADs) in patients who tested positive for hypercoagulable hematologic disorders. METHODS Adults undergoing continuous-flow LVAD implantation with preoperative hypercoagulability testing between 2004 and 2018 at a single center were reviewed. Hypercoagulability was defined as testing positive for antiphospholipid antibody, anticardiolipin antibody, lupus anticoagulant, protein C, protein S, factor V Leiden, and/or heparin-induced thrombocytopenia. The primary outcome was survival on the original LVAD. Secondary outcomes included rates of thromboembolic complications and readmission for intravenous heparin treatment. RESULTS A total of 270 LVAD patients with pre-implant hypercoagulability testing were included, and 157 (58%) tested positive for a hypercoagulable disorder. Of those testing positive, 10 (6.4%) had a clinical pre-LVAD history of thromboembolic events. Survival was comparable between hypercoagulable and non-hypercoagulable patients (1 year: 73.3% vs 78.9%, P = .2195, 2-year: 60.7% vs 62.8%, P = .3627). Rates of pump thrombosis (14.0% vs 13.3%, P = .8618), hemolysis (4.5% vs 3.5%, P = .3536), stroke (18.5% vs 14.2%, P = .3483) and readmission for IV heparin therapy (87.3% (n = 137) vs 77.9% (n = 88), P = .7560) were similar. Outcomes were comparable in patients with positive hypercoagulable tests when stratified by pre-implant clinical history of hypercoagulability as well as stratified by recent preoperative exposure to heparin or warfarin. CONCLUSIONS In this series, positive laboratory tests for hypercoagulability were common amongst patients undergoing LVAD implantation although few had positive clinical histories. Survival and freedom from thromboembolic complications were comparable to non-hypercoagulable patients. Hypercoagulability alone should therefore not serve as a contraindication to LVAD implantation.
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Affiliation(s)
- Keith A Dufendach
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Laura Seese
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Blaise Stearns
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gavin Hickey
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Michael Mathier
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Mary Keebler
- Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Shangzhen Chen
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Christopher M Sciortino
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Floyd W Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Arman Kilic
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.,Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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34
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Hogan M, Berger JS. Heparin-induced thrombocytopenia (HIT): Review of incidence, diagnosis, and management. Vasc Med 2020; 25:160-173. [PMID: 32195628 DOI: 10.1177/1358863x19898253] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. Here, we review the pathogenesis, incidence, diagnosis, and management of HIT. The first step in thwarting devastating complications from this entity is to maintain a high index of clinical suspicion, followed by an accurate clinical scoring assessment using the 4Ts. Next, appropriate stepwise laboratory testing must be undertaken in order to rule out HIT or establish the diagnosis. In the interim, all heparin must be stopped immediately, and the patient administered alternative anticoagulation. Here we review alternative anticoagulation choice, therapy alternatives in the difficult-to-manage patient with HIT, and the problem of overdiagnosis.
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Affiliation(s)
- Marie Hogan
- Department of Pediatrics, Division of Hematology Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology and Hematology, New York University School of Medicine, New York, NY, USA
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Small BL, Gomes MP, McCurry KR, Han X, Ataya A, Akindipe O, Lane CR, Budev M. A Novel Diagnostic Algorithm for Heparin-Induced Thrombocytopenia in a Retrospective Cohort of Lung Transplant Recipients. Prog Transplant 2019; 30:4-12. [PMID: 31838929 DOI: 10.1177/1526924819892918] [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] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Heparin-induced thrombocytopenia (HIT) is characterized by thrombocytopenia and potential for thromboembolism. Lung transplant recipients are at risk of developing HIT due to heparin exposure peritransplant. We describe the incidence and impact of HIT in lung transplant recipient index hospital length of stay and survival. DESIGN A retrospective cohort was obtained from electronic medical records which were queried for all recipients treated with bivalirudin (institutional treatment of choice for HIT) between January 1, 2005, and February 16, 2017 (N = 1171). Patients who developed HIT >30 days after transplant or after their index transplant admission were excluded. A diagnostic algorithm was used retrospectively to determine clinical HIT with an intermediate or high pretest clinical suspicion ("4T" score ≥4) and either (1) positive anti-heparin-platelet-factor 4 (HPF4) assay and a positive functional platelet assay or (2) a positive HPF4 assay only, in patients who did not undergo cardiopulmonary bypass. RESULTS Among all lung transplant recipients, 2.1% were found to develop HIT in the peritransplant period (N = 25, mean = 88%) with a mean lung allocation score of 50.8 and an incidence of venous thromboembolism of 72%, most upper extremity in location. When matched with historical controls, patients with HIT had a longer overall index hospital length of stay of 43 days (P = .008). There was no difference in short- or long-term survival posttransplant. CONCLUSION Vigilance for the development of HIT in lung transplant recipients is necessary to prevent further morbidity from thromboembolic events. In our cohort, HIT increased hospital length of stay but did not appear to affect recipient survival.
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Affiliation(s)
- Bronwyn Larissa Small
- Pulmonary, Critical Care and Allergy Department, University of Nebraska Medical Center, Omaha, NE, USA
| | - Marcelo P Gomes
- Department of Vascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kenneth R McCurry
- Department of Cardiothoracic Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaozhen Han
- Biostatistics Core, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ali Ataya
- Department of Pulmonary, Critical Care and Allergy, University of Florida, Gainesville, FL, USA
| | - Olufemi Akindipe
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - C Randall Lane
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marie Budev
- Department of Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Sullivan J, Bak E, Sullivan MJ, Gurnani PK. Predictive value of scoring tools in determining heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation. Perfusion 2019; 35:378-383. [DOI: 10.1177/0267659119881266] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There are currently no scoring tools validated for use in predicting heparin-induced thrombocytopenia in patients receiving extracorporeal membrane oxygenation. This study aims to determine the predictive value of the Warkentin 4T score, Lilo-Le Louet score, and the heparin-induced thrombocytopenia expert probability score in detecting heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation. This was a single center, retrospective, observational cohort study of patients at Rush University Medical Center. Heparin-induced thrombocytopenia–positive patients were defined as those with an optical density greater than or equal to 0.4, consistent with a positive anti-platelet 4 heparin antibody. Out of 39 patients on extracorporeal membrane oxygenation with suspected heparin-induced thrombocytopenia, six (15.4%) were found to be anti-platelet 4–positive. A heparin-induced thrombocytopenia diagnosis was confirmed by serotonin-release assay in two patients (5.1%). The 4T, heparin-induced thrombocytopenia expert probability, and Lilo-Le Louet scoring tools all demonstrated a low positive predictive value (21.4%, 16.7%, and 6.7%, respectively), with the 4T and heparin-induced thrombocytopenia expert probability scores demonstrating the highest specificity (66.7% and 84.8%, respectively) and lowest sensitivity (50% and 16.7%, respectively). The Lilo-Le Louet score had high sensitivity (100%) and low specificity (12.5%) in post-cardiopulmonary bypass patients. Based on the findings of this study, all three scoring tools have limited utility for predicting heparin-induced thrombocytopenia in patients on extracorporeal membrane oxygenation.
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Affiliation(s)
- Jaclyn Sullivan
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Erica Bak
- Department of Nursing, Rush University Medical Center, Chicago, IL, USA
| | - Mary Jane Sullivan
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
| | - Payal K. Gurnani
- Department of Pharmacy, Rush University Medical Center, Chicago, IL, USA
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Samuel S, McGuire MF, Cortes J, Escobar M, Weeks P, Nguyen A. Comparison of polyspecific versus IgG specific ELISA in predominately cardiac patients with suspected heparin induced thrombocytopenia. J Thromb Thrombolysis 2019; 49:27-33. [PMID: 31552545 DOI: 10.1007/s11239-019-01957-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A diagnosis of heparin induced thrombocytopenia (HIT) must often be made based on clinical and laboratory evidence. This was a quasi-experimental study of patients admitted from June 2016 to October 2017. The primary endpoint was the incidence of false positive results in polyspecific and IgG specific enzyme-linked immunosorbent assay (ELISA); then we compared the sensitivity and specificity of each assays in predominately cardiac patients with suspected HIT. A sensitivity/specificity analysis was conducted using serotonin release assay (SRA) as the 'gold standard'. The secondary outcome measures included length of hospital stay. We identified a total of 155 patients who met the inclusion criteria. Confirmatory tests with SRA on both groups were completed; false positive result was higher in the polyspecific group when compared to the IgG group [60% vs. 5%]. The IgG specific ELISA test yielded a sensitivity of 100% and a specificity of 95% however, the polyspecific ELISA had a low yield for specificity of 24% but maintained 100% sensitivity. In the IgG specific group with HIT-, their median length of stay was halved compared to those who were HIT + ; hospital LOS in days, IQR [30 (27-81) vs. 15 (7-33) p = 0.023] and a shorter median LOS in the ICU, IQR [24 (5-47) vs. 6 (2-14); p = 0.079]. Hospital or ICU LOS was the same in both (HIT+ and HIT-) groups managed with polyspecific ELISA. The IgG specific test had few false positive results and a high sensitivity score. Ensuring appropriate testing can bring a substantial decrease in drug expenditure, reduced length of stay and prevent unnecessary anticoagulation.
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Affiliation(s)
- Sophie Samuel
- Department of Pharmacy, Neuroscience Intensive Care Unit, Memorial Hermann - Texas Medical Center, 6411 Fannin Street, Houston, TX, 77030, USA.
| | - Mary F McGuire
- Department of Neurosurgery and Neurology, The University of Texas McGovern Medical School, Houston, TX, USA
| | - Jennifer Cortes
- Department of Pharmacy, Medical Intensive Care Unit, Memorial Hermann - Texas Medical Center, Houston, TX, USA
| | - Miguel Escobar
- Department of Hematology, The University of Texas McGovern Medical School, Houston, TX, USA
| | - Phillip Weeks
- Department of Pharmacy, Heart and Vascular Institute, Memorial Hermann - Texas Medical Center, Houston, TX, USA
| | - Andy Nguyen
- Department of Pathology and Laboratory Medicine, The University of Texas McGovern Medical School, Houston, TX, USA
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Prospective comparison of the HEP score and 4Ts score for the diagnosis of heparin-induced thrombocytopenia. Blood Adv 2019; 2:3155-3162. [PMID: 30463915 DOI: 10.1182/bloodadvances.2018023077] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/23/2018] [Indexed: 12/31/2022] Open
Abstract
The HIT Expert Probability (HEP) score compared favorably with the 4Ts score in a retrospective study. We assessed the diagnostic accuracy of the HEP score compared with the 4Ts score in a prospective cohort of 310 patients with suspected heparin-induced thrombocytopenia (HIT). A member of the clinical team calculated the HEP score and 4Ts score. An independent panel adjudicated HIT status based on a clinical summary as well as the results of HIT laboratory testing. The prevalence of HIT in the study population was 14.7%. At a cutoff of ≥3, the HEP score was 95.3% sensitive (95% confidence interval [CI], 84.2-99.4) and 35.7% specific (95% CI, 29.8-42.0) for HIT. A 4Ts score of ≥4 had a sensitivity of 97.7% (95% CI, 86.2-99.8) and specificity of 32.9% (95% CI, 27.2-39.1). The areas under the receiver operating characteristic (ROC) curves (AUCs) for the HEP score and 4Ts score were similar (0.81 [95% CI, 0.74-0.87] vs 0.76 [95% CI, 0.69-0.83]; P = .12). The HEP score exhibited a significantly higher AUC than the 4Ts score in patients in the intensive care unit (ICU) (0.86 vs 0.79; P = .03). Among trainee scorers, the HEP score performed significantly better than the 4Ts score (AUC, 0.80 vs 0.73; P = .03). Our data suggest that either the 4Ts score or the HEP score may be used in clinical practice. The HEP score may be preferable in ICU patients and among less experienced clinicians.
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Joseph J, Rabbolini D, Enjeti AK, Favaloro E, Kopp M, McRae S, Pasalic L, Tan CW, Ward CM, Chong BH. Diagnosis and management of heparin‐induced thrombocytopenia: a consensus statement from the Thrombosis and Haemostasis Society of Australia and New ZealandHITWriting Group. Med J Aust 2019; 210:509-516. [DOI: 10.5694/mja2.50213] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Joanne Joseph
- St Vincent's Hospital Sydney NSW
- St Vincent's Clinical SchoolUniversity of New South Wales Sydney NSW
| | - David Rabbolini
- Royal North Shore Hospital Sydney NSW
- Northern Blood Research CentreKolling Institute of Medical Research Sydney NSW
| | | | - Emmanuel Favaloro
- Institute of Clinical Pathology and Medical Research Sydney NSW
- Westmead Hospital Sydney NSW
| | | | | | - Leonardo Pasalic
- Institute of Clinical Pathology and Medical Research Sydney NSW
- Westmead Hospital Sydney NSW
| | | | - Christopher M Ward
- Royal North Shore Hospital Sydney NSW
- Northern Blood Research CentreKolling Institute of Medical Research Sydney NSW
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Ivascu NS, Fitzgerald M, Ghadimi K, Patel P, Evans AS, Goeddel LA, Shaefi S, Klick J, Johnson A, Raiten J, Horak J, Gutsche J. Heparin-Induced Thrombocytopenia: A Review for Cardiac Anesthesiologists and Intensivists. J Cardiothorac Vasc Anesth 2019; 33:511-520. [DOI: 10.1053/j.jvca.2018.10.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Indexed: 01/02/2023]
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41
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Solanki J, Shenoy S, Downs E, Palkimas S, Goldman S, Sharma AM. Heparin-Induced Thrombocytopenia and Cardiac Surgery. Semin Thorac Cardiovasc Surg 2019; 31:335-344. [DOI: 10.1053/j.semtcvs.2018.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/16/2018] [Indexed: 12/16/2022]
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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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Witten A, Bolbrinker J, Barysenka A, Huber M, Rühle F, Nowak-Göttl U, Garbe E, Kreutz R, Stoll M. Targeted resequencing of a locus for heparin-induced thrombocytopenia on chromosome 5 identified in a genome-wide association study. J Mol Med (Berl) 2018; 96:765-775. [PMID: 29934777 DOI: 10.1007/s00109-018-1661-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 06/05/2018] [Accepted: 06/12/2018] [Indexed: 12/18/2022]
Abstract
Immune-mediated heparin-induced thrombocytopenia (HIT) is the clinically most important adverse drug reaction (ADR) in response to heparin therapy characterized by a prothrombotic state despite a decrease in platelet count. We conducted a genome-wide association study in 96 suspected HIT cases and 96 controls to explore the genetic predisposition for HIT within a case-control pharmacovigilance study followed by replication in additional 86 cases and 86 controls from the same study. One single nucleotide polymorphism (SNP, rs1433265, P = 6.5 × 10-5, odds ratio (OR) 2.79) from 16 identified SNPs was successfully replicated (P = 1.5 × 10-4, OR 2.77; combined data set P = 2.7 × 10-8, OR 2.77) and remained the most strongly associated SNP after imputing locus genotypes. Fine mapping revealed a significantly associated risk-conferring haplotype (P = 4.9 × 10-6, OR 2.41). In order to find rare variants contributing to the association signals, we applied a targeted resequencing approach in a subgroup of 73 HIT patients and 23 controls for the regions with the 16 most strongly HIT-associated SNPs. C-alpha testing was applied to test for the impact of rare variants and we detected two candidate genes, the discoidin domain receptor tyrosine kinase 1 (DDR1, P = 3.6 × 10-2) and the multiple C2 and transmembrane domain containing 2 (MCTP2, P = 4.5 × 10-2). For the genes interactor of little elongation complex ELL subunit 1 (ICE1) and a disintegrin-like and metalloproteinase with thrombospondin type 1 motif, 16 (ADAMTS16) nearby rs1433265, we identified several missense variants. Although replication in an independent population is warranted, these findings provide a basis for future studies aiming to identify and characterize genetic susceptibility factors for HIT. KEY MESSAGES: We identified and validated a HIT-associated locus on chromosome 5. Targeted NGS analysis for rare variants identifies DDR1 and MCTP2 as novel candidates. In addition, missense variants for ADAMTS16 and ICE1 were identified in the locus.
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Affiliation(s)
- Anika Witten
- Department of Genetic Epidemiology, Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Juliane Bolbrinker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Andrei Barysenka
- Department of Genetic Epidemiology, Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Matthias Huber
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Frank Rühle
- Department of Genetic Epidemiology, Institute of Human Genetics, University Hospital Münster, Münster, Germany
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Department of Clinical Chemistry, University Hospital of Kiel and Lübeck, Kiel, Germany
| | - Edeltraut Garbe
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany.,Department of Clinical Epidemiology, Leibniz Institute for Prevention Research and Epidemiology - BIPS, Bremen, Germany
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Monika Stoll
- Department of Genetic Epidemiology, Institute of Human Genetics, University Hospital Münster, Münster, Germany. .,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands.
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The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines ∗ —Anticoagulation During Cardiopulmonary Bypass. Ann Thorac Surg 2018; 105:650-662. [DOI: 10.1016/j.athoracsur.2017.09.061] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/09/2017] [Indexed: 01/01/2023]
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Shore-Lesserson L, Baker RA, Ferraris VA, Greilich PE, Fitzgerald D, Roman P, Hammon JW. The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology. Anesth Analg 2018; 126:413-424. [DOI: 10.1213/ane.0000000000002613] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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46
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Lee Y, Weeks P, Gass J, Sieg A. Evaluation of 4T's scoring system in the identification of heparin-induced thrombocytopenia in patients with mechanical circulatory support. Thromb Res 2017; 160:66-68. [DOI: 10.1016/j.thromres.2017.10.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/12/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
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Nagler M, Bakchoul T. Clinical and laboratory tests for the diagnosis of heparin-induced thrombocytopenia. Thromb Haemost 2017; 116:823-834. [DOI: 10.1160/th16-03-0240] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 08/16/2016] [Indexed: 12/27/2022]
Abstract
SummaryA rapid diagnostic work-up is required in patients with suspected heparin-induced thrombocytopenia (HIT). However, diagnosis of HIT is challenging due to a number of practical issues and methodological limitations. Many laboratory tests and a few clinical scoring systems are available but the individual characteristics and the diagnostic accuracy of these are hard to appraise. The 4Ts score is a well evaluated clinical assessment tool with the potential to rule out HIT in many patients. Still, it requires experience and is subject to a relevant inter-observer variability. Immunoassays such as enzyme-linked immunosorbent assays or recently developed rapid assays are able to exclude HIT in a number of patients. But, accuracy of immunoassays differs depending on type of assay, threshold, antibody specificity and even manufacturer. Due to a comparatively low positive predictive value, HIT cannot be confirmed by immunoassays alone. In addition, only some of them are immediately accessible, particularly in small laboratories. While functional assays such as the serotonin release assay (SRA) and the heparin-induced platelet activation assay (HIPA) are considered as gold standard for diagnosis of HIT, they require a highly specialised laboratory. In addition, some of them are not adequately evaluated. In clinical practice, we recommend an integrated diagnostic approach combining not only clinical assessment (the 4Ts score) but immunoassays and functional assays as well. We propose a clear diagnostic algorithm supporting clinical decision-making. Furthermore, we provide an overview of all current laboratory techniques for HIT and discuss diagnostic pathways and strategies to reduce diagnostic errors, and future perspectives.
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48
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Joseph L, Gomes M, Al Solaiman F, Miro-Casas E, St John J, Ozaki A, Raju M, Dhariwal M, Kim E. External validation of the HIT Expert Probability (HEP) score. Thromb Haemost 2017; 113:633-40. [DOI: 10.1160/th14-05-0472] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 10/22/2014] [Indexed: 11/05/2022]
Abstract
SummaryThe diagnosis of heparin-induced thrombocytopenia (HIT) can be challenging. The HIT Expert Probability (HEP) Score has recently been proposed to aid in the diagnosis of HIT. We sought to externally and prospectively validate the HEP score. We prospectively assessed pretest probability of HIT for 51 consecutive patients referred to our Consultative Service for evaluation of possible HIT between August 1, 2012 and February 1, 2013. Two Vascular Medicine fellows independently applied the 4T and HEP scores for each patient. Two independent HIT expert adjudicators rendered a diagnosis of HIT likely or unlikely. The median (interquartile range) of 4T and HEP scores were 4.5 (3.0, 6.0) and 5 (3.0, 8.5), respectively. There were no significant differences between area under receiver-operating characteristic curves of 4T and HEP scores against the gold standard, confirmed HIT [defined as positive serotonin release assay and positive anti-PF4/heparin ELISA] (0.74 vs 0.73, p = 0.97). HEP score ≥ 2 was 100 % sensitive and 16 % specific for determining the presence of confirmed HIT while a 4T score > 3 was 93 % sensitive and 35 % specific. In conclusion, the HEP and 4T scores are excellent screening pretest probability models for HIT, however, in this prospective validation study, test characteristics for the diagnosis of HIT based on confirmatory laboratory testing and expert opinion are similar. Given the complexity of the HEP scoring model compared to that of the 4T score, further validation of the HEP score is warranted prior to widespread clinical acceptance.
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Motohashi S, Matsuo T, Inoue H, Kaneko M, Shindo S. Clinical Significance of the Serotonin Release Assay and Platelet Count Monitoring After Cardiac Surgery. Clin Appl Thromb Hemost 2017; 24:944-949. [PMID: 29046071 PMCID: PMC6714719 DOI: 10.1177/1076029617734308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is one of the serious complications in patients who undergo cardiac surgery. However, there remains a major problem in diagnosing HIT because the current immunological assays for detection of HIT antibody have limitations. Furthermore, the clinical course of thrombocytopenia in this surgery makes it increasingly difficult to diagnose HIT. We investigated the relationship between platelet count and HIT antibody in 59 patients who underwent cardiac surgery using cardiopulmonary bypass (CPB). The number of postoperative HIT antibody-positive patients evaluated using enzyme-linked immunosorbent assay kit (polyanion IgG/IgA/IgM complex antibodies/antiplatelet factor 4 enhanced) was 37 (62.7%). In contrast, platelet activation by HIT antibody was evaluated using the serotonin release assay (SRA). More than 20% and 50% release of serotonin was obtained from 12 patients (20.3%) and 8 patients (13.6%), respectively. The levels of d-dimer were significantly different on postoperative day 14 between SRA-positive and SRA-negative groups; however, postoperative thrombus complication was not detected using sonography in the patients with positive serotonin release at all. After being decreased by the operation, their platelet count recovered within 2 weeks in both groups equally. In our study, although the patients were positive in the platelet activating HIT antibody assay, they remained free from thrombosis and their platelet count recovered after early postoperative platelet decrease. Therefore, in addition to the SRA, monitoring of platelet count might be still considered an indispensable factor to facilitate the prediction of HIT thrombosis prior to manifestation in the patients undergoing cardiac surgery using CPB.
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Affiliation(s)
- Shinya Motohashi
- 1 Department of Cardiovascular Surgery, Hachioji Medical Center, Tokyo Medical University, Hachioji, Japan
| | | | - Hidenori Inoue
- 1 Department of Cardiovascular Surgery, Hachioji Medical Center, Tokyo Medical University, Hachioji, Japan
| | - Makoto Kaneko
- 3 Division of Transfusion Medicine and Cell Therapy, University of Yamanashi Hospital, Chuo, Japan
| | - Shunya Shindo
- 1 Department of Cardiovascular Surgery, Hachioji Medical Center, Tokyo Medical University, Hachioji, Japan
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Pishko AM, Cuker A. Heparin-Induced Thrombocytopenia in Cardiac Surgery Patients. Semin Thromb Hemost 2017; 43:691-698. [PMID: 28597462 DOI: 10.1055/s-0037-1602664] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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