HIT: more than just heparin

A rare case of intracerebral hemorrhage complicating heparin-induced thrombocytopenia in a COVID-19 patient

Introduction

Heparin-induced thrombocytopenia is a rare complication of heparin therapy associated with thrombocytopenia and mainly thrombotic complications.

Case report

we herein describe a case of a woman hospitalized for management of a severe case of COVID-19 treated with low molecular weight heparin, who developed heparin-induced thrombocytopenia complicated by intracerebral hemorrhage with no thrombotic complications.

Conclusion

Discontinuation of heparin was effective without the use of other non-heparin anticoagulants, platelet transfusion or plasmapheresis.

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HIT is a rare complication of LMWH, it is associated with thrombocytopenia and mainly thrombotic complications.

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In this paper we will report a rare complication of HIT : ICH in a 63 years old woman admitted for covid 19-infection.

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Discontinuation of heparin was effective without the use of other non-heparin anticoagulants, platelet transfusion or plasmapheresis.

Platelet transfusions in platelet consumptive disorders are associated with arterial thrombosis and in-hospital mortality

While platelets are primary mediators of hemostasis, there is emerging evidence to show that they may also mediate pathologic thrombogenesis. Little data are available on risks and benefits associated with platelet transfusions in thrombotic thrombocytopenic purpura (TTP), heparin-induced thrombocytopenia (HIT) and immune thrombocytopenic purpura (ITP). This study utilized the Nationwide Inpatient Sample to evaluate the current in-hospital platelet transfusion practices and their association with arterial/venous thrombosis, acute myocardial infarction (AMI), stroke, and in-hospital mortality over 5 years (2007-2011). Age and gender-adjusted odds ratios (adjOR) associated with platelet transfusions were calculated. There were 10 624 hospitalizations with TTP; 6332 with HIT and 79 980 with ITP. Platelet transfusions were reported in 10.1% TTP, 7.1% HIT, and 25.8% ITP admissions. Platelet transfusions in TTP were associated with higher odds of arterial thrombosis (adjOR = 5.8, 95%CI = 1.3-26.6), AMI (adjOR = 2.0, 95%CI = 1.2-3.3) and mortality (adjOR = 2.0,95%CI = 1.3-3.0), but not venous thrombosis. Platelet transfusions in HIT were associated with higher odds of arterial thrombosis (adjOR = 3.4, 95%CI = 1.2-9.5) and mortality (adjOR = 5.2, 95%CI = 2.6-10.5) but not venous thrombosis. Except for AMI, all relationships remained significant after adjusting for clinical severity and acuity. No associations were significant for ITP. Platelet transfusions are associated with higher odds of arterial thrombosis and mortality among TTP and HIT patients.

The use of novel oral anticoagulants for thromboprophylaxis after elective major orthopedic surgery

Venous thromboembolism is a common cause of morbidity and mortality among patients undergoing elective orthopedic surgery. Due to the high incidence of venous thromboembolism in this setting, perioperative anticoagulation is the recommended approach for thromboprophylaxis. Low molecular weight heparin (LMWH), fondaparinux and warfarin are the agents commonly used for thromboprophylaxis. The well-recognized limitations of warfarin and the inconvenience and discomfort associated with the subcutaneous administration of low molecular weight heparin and fondaparinux inspired intense investigation to develop novel oral anticoagulants (NOACs) with more predictable pharmacokinetics, fewer drug interactions and no need for regular laboratory monitoring. Three NOACs have been demonstrated to be effective for thromboprophylaxis after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in large randomized controlled trials. Here we review the pharmacology of rivaroxaban, dabigatran, and apixaban, summarize the major clinical trials of these agents in thromboprophylaxis after THA and TKA, and discuss the clinical factors to be considered by providers when selecting a NOAC for their patients.