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Mukherjee A, Gentille C, Patel A, Ensor J, Rice L. Heparin-induced thrombocytopenia with very high antibody titer is associated with slower platelet recovery and higher risk of thrombosis. Int J Hematol 2024:10.1007/s12185-024-03811-2. [PMID: 38976179 DOI: 10.1007/s12185-024-03811-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 06/06/2024] [Accepted: 06/24/2024] [Indexed: 07/09/2024]
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic disorder mediated by platelet-activating antibodies targeting platelet factor 4 (PF4) and heparin complex. A higher antibody titer is reflected in a higher optical density (OD) by enzyme-linked immunosorbent assay for heparin-PF4 antibodies. This single-institution retrospective study of 116 HIT patients examined the effect of heparin-PF4 OD on time to platelet recovery, vascular thrombosis, and in-hospital mortality. Patients were divided into 3 cohorts based on heparin-PF4 OD: cohort 1 had an OD ≥ 2 and ≤ 2.4, cohort 2 had an OD > 2.4 and ≤ 2.8, and cohort 3 had an OD > 2.8. A higher OD titer was associated with significantly increased time to platelet recovery when compared between cohorts 1 versus 2 (HR = 0.599, p = 0.0221) and 1 versus 3 (HR = 0.515, p = 0.0014), as well as an increased risk of thrombosis (79.4%-cohort 3 vs 53.8%-cohort 2 vs 46.1%-cohort 1, p = 0.04), but had no impact on mortality (2.62-alive vs 2.65-deceased, p = 0.7432). A higher OD titer can inform risk assessment and support decision-making in HIT patients; however, prospective studies are needed to further clarify the impact of heparin-PF4 OD on outcomes.
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Affiliation(s)
- Akash Mukherjee
- Department of Hematology and Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Cesar Gentille
- Department of Hematology and Oncology, Houston Methodist Hospital, Houston, TX, USA.
| | - Asmita Patel
- Department of Hematology and Oncology, Global Cancer Research Institute, San Jose, CA, USA
| | - Joe Ensor
- Department of Hematology and Oncology, Houston Methodist Hospital, Houston, TX, USA
| | - Lawrence Rice
- Department of Hematology and Oncology, Houston Methodist Hospital, Houston, TX, USA
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Wan T, Garland SJ, Drury CT, Lambert J, Yoon J, Chan M. Anticoagulation stewardship: Improving adherence to clinical guidelines and reducing overuse of venous thromboembolism prophylaxis in hospitalized medical patients. Thromb Res 2024; 239:109036. [PMID: 38776611 DOI: 10.1016/j.thromres.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
Adherence to guideline recommendations for venous thromboembolism prophylaxis (VTE) in hospitalized medical patients is suboptimal despite national policies and institutional interventions. The aim of this quality improvement project was to improve adherence to guidelines and decrease the overuse of VTE prophylaxis in order to reduce the institutional cost for heparins. A multidisciplinary anticoagulation stewardship program (ACSP) using the audit and feedback strategy was implemented on the medicine inpatient units at a teaching hospital in Canada. The primary outcome measure was a comparison, pre and post introduction of the ACSP, of the costs per 6-month period for prophylactic dose enoxaparin and unfractionated heparin on the medicine units. The balancing measures were the 90-day VTE rate and major bleeding rate during the hospitalization. Six months after the implementation of the ACSP, the cost was decreased by >50 % without any observed negative impact on patient safety. This study demonstrates the potential for anticoagulation stewardship programs to optimize the use of VTE prophylaxis and reduce the associated costs and risks.
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Affiliation(s)
- Tony Wan
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Canada.
| | - Stephanie J Garland
- Department of Pharmacy, St. Paul's Hospital, Vancouver, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Canada
| | - Chipman Taylor Drury
- Division of General Internal Medicine, Department of Medicine, University of British Columbia, Canada
| | - Justin Lambert
- General Internal Medicine Fellowship Program, Department of Medicine, University of British Columbia, Canada
| | - Joshua Yoon
- Doctors of Medicine Undergraduate Program, Department of Medicine, University of British Columbia, Canada
| | - Melissa Chan
- Doctors of Medicine Undergraduate Program, Department of Medicine, University of British Columbia, Canada
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Darok M, Daly A, Walter V, Krawiec C. Association of medical comorbidities in obese subjects diagnosed with heparin-induced thrombocytopenia. SAGE Open Med 2024; 12:20503121241247471. [PMID: 38711468 PMCID: PMC11072068 DOI: 10.1177/20503121241247471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/28/2024] [Indexed: 05/08/2024] Open
Abstract
Objectives Heparin-induced thrombocytopenia can occur in obese subjects. The medical comorbidities associated with obesity may contribute to the pathogenesis of this disease. It is unknown, however, which specific medical comorbidities and if higher odds of thrombosis are present in obese heparin-induced thrombocytopenia patients. We sought to determine whether obese heparin-induced thrombocytopenia subjects had higher odds of both comorbidities and thrombosis, hypothesizing that this patient population would have higher odds of both these conditions. Methods This was a multi-center retrospective study utilizing TriNetX©, an electronic health record database, in subjects aged 18-99 years diagnosed with heparin-induced thrombocytopenia. The cohort was divided into two groups (1) non-obese (body mass index < 30 kg/m2) and (2) obese (body mass index ⩾ 30 kg/m2). We evaluated patient characteristics, diagnostic, laboratory, medication, and procedure codes. Results A total of 1583 subjects (696 (44.0%) non-obese and 887 (56.0%) obese) were included. Obese subjects had higher odds of diabetes with complications (OR = 1.73, 95% CI = 1.35-2.22, p < 0.001) and without complications (OR = 1.81, 95% CI = 1.47-2.22, p < 0.001). This association was still present after correcting for demographic and clinical factors. There were no increased odds of thrombosis observed in the obesity group. Conclusions Our study found that obese heparin-induced thrombocytopenia subjects had higher odds of having a diabetes mellitus comorbidity, but did not have higher odds of thrombosis. Given obesity is considered a hypercoagulable state, further study may be needed to understand why obese subjects diagnosed with heparin-induced thrombocytopenia do not have higher rates of thrombosis.
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Affiliation(s)
- Matthew Darok
- Pediatrics, Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA, USA
| | - Alexander Daly
- Hospital Pediatrics, Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA, USA
| | - Vonn Walter
- Division of Biostatistics and Bioinformatics, Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Conrad Krawiec
- Pediatric Critical Care Medicine, Department of Pediatrics, Penn State Hershey Children’s Hospital, Hershey, PA, USA
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Moghaddam OM, Ramsheh ZH, Sedighi M, Amanollahi A, Lahiji MN. Association between time of heparin exposure and platelets decline in patients with heparin induced thrombocytopenia. Hematol Transfus Cell Ther 2024:S2531-1379(24)00001-4. [PMID: 38307828 DOI: 10.1016/j.htct.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 10/29/2023] [Accepted: 11/13/2023] [Indexed: 02/04/2024] Open
Affiliation(s)
- Omid Moradi Moghaddam
- Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran; School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Mohsen Sedighi
- Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Alireza Amanollahi
- Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Niakan Lahiji
- Trauma and Injury Research Center, Iran University of Medical Sciences, Tehran, Iran; School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
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Gabarin N, Hack M, Revilla R, Arnold DM, Nazy I. Hematology in the post-COVID era: spotlight on vaccine-induced immune thrombotic thrombocytopenia and a conceptual framework (the 4P's) for anti-PF4 diseases. Expert Rev Hematol 2024; 17:39-45. [PMID: 38149432 DOI: 10.1080/17474086.2023.2298333] [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: 10/26/2023] [Accepted: 12/19/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a life-threatening prothrombotic disorder first identified following the introduction of adenoviral vector vaccines for COVID-19. The condition is characterized by anti-PF4 antibodies and clinically presents with thrombocytopenia and thrombosis often in unusual anatomical sites. AREAS COVERED In this review, we discuss the clinical presentation, diagnostic testing, and treatment of VITT. We also review VITT-like syndromes that have been described in patients without previous vaccination. We propose a conceptual framework for the mechanism of anti-PF4 diseases that includes sufficiently high levels of PF4, the presence of a Polyanion that can form immune complexes with PF4, a Pro-inflammatory milieu, and an immunological Predisposition - the 4Ps. EXPERT OPINION Significant progress has been made in understanding the characteristics of the VITT antibody and in testing methods that can confirm that diagnosis. Future work should be directed at understanding long-term outcomes, mechanisms of thrombosis, and individual risk factors for this rare but dangerous immune-thrombotic disease.
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Affiliation(s)
- Nadia Gabarin
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Michael Hack
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Ryan Revilla
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Donald M Arnold
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Ishac Nazy
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
- McMaster Center for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
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Jesudas R, Takemoto CM. Where have all the platelets gone? HIT, DIC, or something else? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:43-50. [PMID: 38066886 PMCID: PMC10727081 DOI: 10.1182/hematology.2023000465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Thrombocytopenia in ill children is common; accurately diagnosing the underlying etiology is challenging and essential for appropriate management. Triggers for accelerated consumption of platelets are numerous; common downstream mechanisms of clearance include platelet trapping in microvascular thrombi, phagocytosis, and platelet activation. Thrombocytopenia with microangiopathic hemolytic anemia (MAHA) is frequently due to disseminated intravascular coagulation. Thrombotic microangiopathy (TMA) is a subgroup of MAHA. Specific TMA syndromes include thrombotic thrombocytopenic purpura, complement-mediated TMA (CM-TMA), and Shiga toxin-mediated hemolytic uremic syndrome. Isolated thrombocytopenia is characteristic of immune thrombocytopenia; however, concomitant cytopenias are frequent in critically ill patients, making the diagnosis difficult. Immune thrombocytopenia with large vessel thrombosis is a feature of heparin-induced thrombocytopenia and antiphospholipid antibody syndrome. In addition, thrombocytopenia is common with macrophage activation, which is characteristic of hemophagocytic lymphohistiocytosis. While thrombocytopenia in ill patients can be driven by hypoproliferative processes such as myelosuppression and/or bone marrow failure, this review will focus on consumptive thrombocytopenia due to immune and nonimmune causes.
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Skornova I, Simurda T, Stanciakova L, Lauko V, Holly P, Samos M, Bolek T, Schnierer M, Drotarova M, Belakova KM, Sokol J, Stasko J, Mokan M, Gumulec J, Chrastinova L. A Functional Assay for the Determination of Heparin-Induced Thrombocytopenia via Flow Cytometry. Diagnostics (Basel) 2023; 13:3019. [PMID: 37761386 PMCID: PMC10527925 DOI: 10.3390/diagnostics13183019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening complication of heparin therapy (both unfractionated heparin and low-molecular-weight heparin). In our study, we examined a group of 122 patients with suspected HIT. The samples of all patients were analyzed in the first step using an immunoassay (ID-PaGIA Heparin/PF4, Hemos1L-Acustar HIT IgG, ZYMUTEST HIA Monostrip IgG) to detect the presence of antibodies against heparin-PF4 complexes (platelet factor 4). When the immunoassay was positive, the sample was subsequently analyzed for HIT with a functional flow cytometry assay, the HITAlert kit, the purpose of which was to demonstrate the ability of the antibodies present to activate platelets. A diagnosis of HIT can be made only after a positive functional test result. In this article, we present an overview of our practical experience with the use of the new functional method of analysis, HIT, with flow cytometry. In this work, we compared the mutual sensitivity of two functional tests, SRA and the flow cytometry HITAlert kit, in patients perceived as being at risk for HIT. This work aims to delineate the principle, procedure, advantages, pitfalls, and possibilities of the application of the functional test HITAlert using flow cytometry.
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Affiliation(s)
- Ingrid Skornova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Tomas Simurda
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Lucia Stanciakova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Viliam Lauko
- National Institute of Cardiovascular Diseases, 83348 Bratislava, Slovakia
| | - Pavol Holly
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Matej Samos
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia; (M.S.); (T.B.); (M.M.)
| | - Tomas Bolek
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia; (M.S.); (T.B.); (M.M.)
| | - Martin Schnierer
- Department of Gastroenterology Medicine, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia;
| | - Miroslava Drotarova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Kristina Maria Belakova
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Juraj Sokol
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Jan Stasko
- National Center of Hemostasis and Thrombosis, Department of Hematology and Transfusiology, Comenius University in Bratislava, Jessenius Faculty of Medicine in Martin and University Hospital in Martin, 03601 Martin, Slovakia; (I.S.); (P.H.); (M.D.); (K.M.B.); (J.S.); (J.S.)
| | - Marian Mokan
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, 03601 Martin, Slovakia; (M.S.); (T.B.); (M.M.)
| | - Jaroslav Gumulec
- Clinic of Hemato-Oncology, Faculty Hospital in Ostrava, 708 00 Ostrava, Czech Republic;
| | - Leona Chrastinova
- Institute of Hematology and Blood Transfusion in Prague, 128 20 Nove Mesto, Czech Republic;
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Abstract
Venous thromboembolism, that consists of the interrelated conditions deep-vein thrombosis and pulmonary embolism, is an under-appreciated vascular disease. In Western regions, approximately 1 in 12 individuals will be diagnosed with venous thromboembolism in their lifetime. Rates of venous thromboembolism are lower in Asia, but data from other regions are sparse. Numerous risk factors for venous thromboembolism have been identified, which can be classified as acute or subacute triggers (provoking factors that increase the risk of venous thromboembolism) and basal or acquired risk factors (which can be modifiable or static). Approximately 20% of individuals who have a venous thromboembolism event die within 1 year (although often from the provoking condition), and complications are common among survivors. Fortunately, opportunities exist for primordial prevention (prevention of the development of underlying risk factors), primary prevention (management of risk factors among individuals at high risk of the condition) and secondary prevention (prevention of recurrent events) of venous thromboembolism. In this Review, we describe the epidemiology of venous thromboembolism, including the incidence, risk factors, outcomes and opportunities for prevention. Meaningful health disparities exist in both the incidence and outcomes of venous thromboembolism. We also discuss these disparities as well as opportunities to reduce them.
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Affiliation(s)
- Pamela L Lutsey
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA.
| | - Neil A Zakai
- Division of Hematology/Oncology, Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
- Department of Pathology and Laboratory Medicine, Larner College of Medicine, University of Vermont, Burlington, VT, USA
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Valdes CA, Sharaf OM, Bleiweis MS, Jacobs JP, Mumtaz M, Sharaf RM, Jeng EI, Peek GJ. Heparin-based versus bivalirudin-based anticoagulation in pediatric extracorporeal membrane oxygenation: A systematic review. Front Med (Lausanne) 2023; 10:1137134. [PMID: 36999064 PMCID: PMC10043325 DOI: 10.3389/fmed.2023.1137134] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
IntroductionOptimal anticoagulation therapy is essential for the prevention of thrombotic and hemorrhagic complications in pediatric patients supported with extracorporeal membrane oxygenation (ECMO). Recent data have demonstrated bivalirudin has the potential to surpass and replace heparin as the anticoagulant of choice.MethodsWe conducted a systematic review comparing the outcomes of heparin-based versus bivalirudin-based anticoagulation in pediatric patients supported on ECMO to identify the preferred anticoagulant to minimize bleeding events, thrombotic complications, and associated mortality. We referenced the PubMed, Cochrane Library, and Embase databases. These databases were searched from inception through October 2022. Our initial search identified 422 studies. All records were screened by two independent reviewers using the Covidence software for adherence to our inclusion criteria, and seven retrospective cohort studies were identified as appropriate for inclusion.ResultsIn total, 196 pediatric patients were anticoagulated with heparin and 117 were anticoagulated with bivalirudin while on ECMO. Across the included studies, it was found that for patients treated with bivalirudin, trends were noted toward lower rates of bleeding, transfusion requirements, and thrombosis with no difference in mortality. Overall costs associated with bivalirudin therapy were lower. Time to therapeutic anticoagulation varied between studies though institutions had different anticoagulation targets.ConclusionBivalirudin may be a safe, cost-effective alternative to heparin in achieving anticoagulation in pediatric ECMO patients. Prospective multicenter studies and randomized control trials with standard anticoagulation targets are needed to accurately compare outcomes associated with heparin versus bivalirudin in pediatric ECMO patients.
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Albuloushi A, Rhoten M, Kelly J, Sylvester KW, Grandoni J, Connors JM. Evaluation of the use of direct oral anticoagulants for the management of heparin-induced thrombocytopenia. J Thromb Thrombolysis 2022; 54:597-604. [PMID: 36129561 DOI: 10.1007/s11239-022-02705-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 11/30/2022]
Abstract
Historically, treatment of heparin-induced thrombocytopenia (HIT) includes a non-heparin parenteral anticoagulant with bridging to warfarin once platelets recover. Data supporting the use of direct oral anticoagulants (DOACs) for HIT treatment are limited. Given the paucity of evidence for the use of DOACs in HIT, the aim of this study is to describe the prescribing patterns of DOACs for HIT at our institution. This is a single center, retrospective chart evaluation of patients admitted from January 2017 to October 2020 with a confirmed diagnosis of HIT. Twenty-six patients were identified; 21 patients (81%) received initial parenteral treatment and 5 patients (19.2%) with initial DOAC treatment. The most frequently used DOAC was apixaban at the VTE treatment dose [15 (57.7%)] followed by the reduced dose of apixaban [5 (19.2%)]. Of the patients initially treated with a parenteral agent, 11 (42.3%) were transitioned to a DOAC after platelet recovery, 7 (26.9%) transitioned as platelets were steadily increasing, and 3 (11.5%) transitioned at the time of discharge (prior to platelet recovery). Platelet recovery was achieved in 23 patients (88.5%) at a median of 5 days (IQR 2.8-8.3) after HIT diagnosis. No new thrombotic or bleeding events occurred within 30 days of HIT diagnosis. In our patients treated with a DOAC for HIT, no progression of HIT was observed. Apixaban was the most frequently utilized DOAC. Most patients received a parenteral anticoagulant prior to DOAC initiation. All patients managed with a DOAC as initial treatment achieved platelet recovery within 30 days of HIT diagnosis.
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Affiliation(s)
- Asmaa Albuloushi
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA.
| | - Megan Rhoten
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Julie Kelly
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Jessica Grandoni
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Boston, MA, USA
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Sakai T, Takemoto M, Ueno J, Nyuta E, Antoku Y, Koga T, Tsuchihashi T. Atrial Fibrillation in a Patient with Heparin-induced Thrombocytopenia Successfully Treated by Radiofrequency Catheter Ablation Using a Direct Thrombin Inhibitor. Intern Med 2022; 61:2747-2751. [PMID: 35185059 PMCID: PMC9556243 DOI: 10.2169/internalmedicine.9288-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A 74-year-old man was admitted to our hospital to undergo radiofrequency catheter ablation (RFCA) of persistent atrial fibrillation (AF). We found that he had a history of heparin-induced thrombocytopenia (HIT). Thus, a direct thrombin inhibitor, Argatroban Hydrate (Argatroban®), was used instead of heparin as anticoagulation therapy during the RFCA procedure. Finally, the AF was successfully treated by RFCA without any complications. Given these findings, the direct thrombin inhibitor Argatroban® may be effective and feasible for anticoagulation therapy during RFCA procedures for AF in patients with HIT, such as the present case.
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Affiliation(s)
- Togo Sakai
- Cardiovascular Center, Steel Memorial Yawata Hospital, Japan
| | - Masao Takemoto
- Cardiovascular Center, Steel Memorial Yawata Hospital, Japan
| | - Jiro Ueno
- Cardiovascular Center, Steel Memorial Yawata Hospital, Japan
| | - Eiji Nyuta
- Cardiovascular Center, Steel Memorial Yawata Hospital, Japan
| | | | - Tokushi Koga
- Cardiovascular Center, Steel Memorial Yawata Hospital, Japan
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Naji FS, Shafie M, Issaiy M, Zarei Jalalabadi N, Parsa S. Delayed‐onset heparin‐induced thrombocytopenia complicated with saddle embolus. Clin Case Rep 2022; 10:e6085. [PMID: 35865782 PMCID: PMC9295682 DOI: 10.1002/ccr3.6085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 06/20/2022] [Accepted: 07/04/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Faezeh Sadat Naji
- Department of Internal Medicine, Imam Khomeini Hospital Complex Tehran University of Medical Sciences Tehran Iran
| | - Mahan Shafie
- Department of Internal Medicine, Imam Khomeini Hospital Complex Tehran University of Medical Sciences Tehran Iran
- School of Medicine Tehran University of Medical Sciences Tehran Iran
| | - Mahbod Issaiy
- School of Medicine Tehran University of Medical Sciences Tehran Iran
| | - Narjes Zarei Jalalabadi
- Department of Internal Medicine, Imam Khomeini Hospital Complex Tehran University of Medical Sciences Tehran Iran
| | - Samaneh Parsa
- Department of Internal Medicine, Imam Khomeini Hospital Complex Tehran University of Medical Sciences Tehran Iran
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A case of severe COVID-19 with pulmonary thromboembolism related to heparin-induced thrombocytopenia during prophylactic anticoagulation therapy. J Infect Chemother 2022; 28:1208-1211. [PMID: 35570112 PMCID: PMC9091339 DOI: 10.1016/j.jiac.2022.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/29/2022] [Accepted: 05/06/2022] [Indexed: 12/22/2022]
Abstract
A 53-year-old male Japanese patient with COVID-19 was admitted to our hospital after his respiratory condition worsened on day 9 of the disease. With the diagnosis of severe COVID-19, treatment with remdesivir, dexamethasone, and unfractionated heparin was started for the prevention of thrombosis. Although the patient's respiratory status data improved after treatment, severe respiratory failure persisted. Thrombocytopenia and D-dimer elevation were observed on day 8 after heparin therapy initiation. Heparin-induced thrombocytopenia (HIT) antibody measured by immunological assay was positive, and contrast computed tomography showed pulmonary artery thrombus. The patient was diagnosed with HIT because the pre-test probability score (4Ts score) for HIT was 7 points. Heparin was changed to apixaban, a direct oral anticoagulant, which resulted in a reduction of the pulmonary thrombus and improvement of the respiratory failure. In patients with COVID-19, anticoagulant therapy with heparin requires careful monitoring of thrombocytopenia and elevated D-dimer as possible complications related to HIT. (151/250 words).
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14
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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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Ahmadinejad M, Shahbazi M, Chegini A. Heparin-Induced Thrombocytopenia in Iranian Cardiac Surgery Patients Using the 4Ts Clinical Scoring System and Laboratory Methods. Int J Hematol Oncol Stem Cell Res 2021; 15:230-238. [PMID: 35291665 PMCID: PMC8888360 DOI: 10.18502/ijhoscr.v15i4.7478] [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: 04/25/2020] [Accepted: 09/11/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction. HIT diagnosis needs an algorithmic approach including clinical evaluation and laboratory tests (screening and confirmatory). Few studies have been conducted on HIT in Iran, and most existing research has been general and based on clinical evaluations alone. The present study was conducted to determine the prevalence of HIT among cardiac surgery patients using an algorithmic approach. Materials and Methods: A cross-sectional study was carried out over a period of 10 months, at Modares Hospital (Tehran, Iran) on 92 patients who were candidates for cardiac surgery. For the clinical evaluation, the 4Ts scoring system was used; in cases with 4Ts scores ≥4, a laboratory evaluation of anti-PF4/heparin antibody (Ab) was performed by enzyme-linked immunosorbent assay (ELISA) and a HIPA test too as a functional confirmatory method. The patients with 4Ts scores ≥4 who were ELISA positive (OD ≥0.2) and HIPA positive were taken as a definite case of HIT. Results: Of the 92 patients who had undergone cardiac surgery, 14 (15%) had 4Ts scores ≥4. Anti- PF4/heparin Ab was detected in eight patients using the ELISA and in six patients using the HIPA. Ultimately, definite HIT was confirmed in five of the patients. Conclusion: The prevalence of HIT was 5.4% among the cardiac surgery patients assessed in the present study. To the researchers’ knowledge, this is the first time that HIT has been evaluated in Iran using a comprehensive algorithmic approach including clinical history-taking and both immunological and functional laboratory tests, and the findings showed a slightly higher HIT frequency in this single-center study in comparison with the other studies carried out in other countries.
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Affiliation(s)
- Minoo Ahmadinejad
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Massoumeh Shahbazi
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Azita Chegini
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
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16
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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: 4] [Impact Index Per Article: 1.3] [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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17
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Kelly J, Sylvester KW, Rimsans J, Bernier TD, Ting C, Connors JM. Heparin-induced thrombocytopenia in end-stage renal disease: Reliability of the PF4-heparin ELISA. Res Pract Thromb Haemost 2021; 5:e12573. [PMID: 34386689 PMCID: PMC8339384 DOI: 10.1002/rth2.12573] [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: 04/12/2021] [Revised: 07/01/2021] [Accepted: 07/13/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Diagnosing heparin-induced thrombocytopenia (HIT) in patients with end-stage renal disease (ESRD) can be difficult, as they are frequently exposed to heparin and have multiple etiologies for thrombocytopenia. OBJECTIVE To correlate 4T scores, IgG heparin-platelet factor 4 (PF4-heparin) ELISA results, and serotonin release assay (SRA) results in patients with ESRD. METHODS We performed a retrospective review of patients with ESRD (creatinine clearance < 15 mL/min or on renal replacement therapy [RRT]) who underwent PF4-heparin ELISA testing from October 2015 to September 2019. True-positive PF4s required an intermediate to high 4T score (≥4), a positive SRA, and receipt of treatment for a HIT diagnosis. False-positive PF4s were defined as a positive PF4 with a negative SRA, low 4T score (<4), or lack of treatment for HIT. Indeterminant cases were classified on the basis of clinical assessment by the treating team (eg, hematology or vascular medicine). RESULTS Of 254 patients with ESRD (92% on RRT), 29 patients (11.4%) had a positive PF4. Eleven (37.9%) had a confirmed diagnosis of HIT: 10 patients who met all of the above criteria, and one who met the 4T criteria and was treated for HIT but did not have SRA testing due to high clinical suspicion and a positive PF4 test. False-positive PF4 values occurred in 8 patients (27.5%). Of 10 (34.5%) indeterminant cases of patients with a negative SRA but intermediate to high 4T and positive PF4, only 3 patients were treated for HIT, whereas the other 7 were judged not to have HIT as assessed by the treating clinician. In patients with an intermediate to high 4T score and PF4 optical density > 0.4 but negative SRA, who were not treated for HIT, there were no adverse outcomes documented such as new or progressive thrombosis. CONCLUSION In our ESRD population, 4T scores and PF4 testing were not predictive of a clinical diagnosis of HIT.
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Affiliation(s)
- Julie Kelly
- Brigham and Women's Hospital ‐ Department of Pharmacy ServicesBostonMassachusettsUSA
| | - Katelyn W. Sylvester
- Brigham and Women's Hospital ‐ Department of Pharmacy ServicesBostonMassachusettsUSA
| | - Jessica Rimsans
- Brigham and Women's Hospital ‐ Department of Pharmacy ServicesBostonMassachusettsUSA
| | - Thomas D. Bernier
- Brigham and Women's Hospital ‐ Department of Pharmacy ServicesBostonMassachusettsUSA
| | - Clara Ting
- Brigham and Women's Hospital ‐ Department of Pharmacy ServicesBostonMassachusettsUSA
| | - Jean M. Connors
- Brigham and Women's Hospital ‐ Division of Hematology, Department of MedicineBostonMassachusettsUSA
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18
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Samuelson Bannow B, Warad DM, Jones CG, Pechauer SM, Curtis BR, Bougie DW, Sharma R, Grill DE, Redman MW, Khalighi PR, Leger RR, Pruthi RK, Chen D, Sabath DE, Aster RH, Garcia DA, Padmanabhan A. A prospective, blinded study of a PF4-dependent assay for HIT diagnosis. Blood 2021; 137:1082-1089. [PMID: 32898858 PMCID: PMC7907721 DOI: 10.1182/blood.2020008195] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/23/2020] [Indexed: 12/22/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening, prothrombotic, antibody-mediated disorder. To maximize the likelihood of recovery, early and accurate diagnosis is critical. Widely available HIT assays, such as the platelet factor 4 (PF4) heparin enzyme-linked immunosorbent assay (ELISA) lack specificity, and the gold-standard carbon 14-labeled serotonin release assay (SRA) is of limited value for early patient management because it is available only through reference laboratories. Recent studies have demonstrated that pathogenic HIT antibodies selectively activate PF4-treated platelets and that a technically simpler assay, the PF4-dependent P-selectin expression assay (PEA), may provide an option for rapid and conclusive results. Based upon predefined criteria that combined 4Ts scores and HIT ELISA results, 409 consecutive adults suspected of having HIT were classified as disease positive, negative, or indeterminate. Patients deemed HIT indeterminate were considered disease negative in the primary analysis and disease positive in a sensitivity analysis. The ability of PEA and SRA to identify patients judged to have HIT was compared using receiver operating characteristic curve statistics. Using these predefined criteria, the diagnostic accuracy of PEA was high (area under the curve [AUC], 0.94; 95% confidence interval [CI], 0.87-1.0) and similar to that of SRA (AUC, 0.91; 95% CI, 0.82-1.0). In sensitivity analysis, the AUCs of PEA and SRA were also similar at 0.88 (95% CI, 0.78-0.98) and 0.86 (95% CI, 0.77-0.96), respectively. The PEA, a technically simple nonradioactive assay that uses ∼20-fold fewer platelets compared with the SRA, had high accuracy for diagnosing HIT. Widespread use of the PEA may facilitate timely and more effective management of patients with suspected HIT.
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Affiliation(s)
| | - Deepti M Warad
- Department of Pediatric and Adolescent Medicine and
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | | | - Brian R Curtis
- Platelet and Neutrophil Immunology Laboratory, Versiti Wisconsin, Milwaukee, WI
| | | | - Ruchika Sharma
- Platelet and Neutrophil Immunology Laboratory, Versiti Wisconsin, Milwaukee, WI
| | - Diane E Grill
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - Parisa R Khalighi
- Department of Obstetrics and Gynecology, University of Colorado, Denver, CO
| | - Rachel R Leger
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Rajiv K Pruthi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
- Department of Medicine, Mayo Clinic, Rochester, MN; and
| | - Dong Chen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Daniel E Sabath
- Department of Laboratory Medicine and
- Department of Medicine, University of Washington, Seattle, WA
| | | | - David A Garcia
- Department of Medicine, University of Washington, Seattle, WA
| | - Anand Padmanabhan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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19
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Squiccimarro E, Jiritano F, Serraino GF, ten Cate H, Paparella D, Lorusso R. Quantitative and Qualitative Platelet Derangements in Cardiac Surgery and Extracorporeal Life Support. J Clin Med 2021; 10:jcm10040615. [PMID: 33561947 PMCID: PMC7914426 DOI: 10.3390/jcm10040615] [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: 12/08/2020] [Revised: 01/30/2021] [Accepted: 02/03/2021] [Indexed: 01/19/2023] Open
Abstract
Thrombocytopenia and impaired platelet function are known as intrinsic drawbacks of cardiac surgery and extracorporeal life supports (ECLS). A number of different factors influence platelet count and function including the inflammatory response to a cardiopulmonary bypass (CPB) or to ECLS, hemodilution, hypothermia, mechanical damage and preoperative treatment with platelet-inhibiting agents. Moreover, although underestimated, heparin-induced thrombocytopenia is still a hiccup in the perioperative management of cardiac surgical and, above all, ECLS patients. Moreover, recent investigations have highlighted how platelet disorders also affect patients undergoing biological prosthesis implantation. Though many hypotheses have been suggested, the mechanism underlying thrombocytopenia and platelet disorders is still to be cleared. This narrative review aims to offer clinicians a summary of their major causes in the cardiac surgery setting.
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Affiliation(s)
- Enrico Squiccimarro
- Department of Cardiac Surgery, Mater Dei Hospital, 70125 Bari, Italy;
- Department of Emergency and Organ Transplant (DETO), University of Bari, 70125 Bari, Italy
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands;
| | - Federica Jiritano
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands;
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
- Correspondence:
| | - Giuseppe Filiberto Serraino
- Cardiac Surgery Unit, Department of Experimental and Clinical Medicine, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Hugo ten Cate
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, D-55131 Mainz, Germany;
- Thrombosis Center Maastricht, Maastricht University Medical Center (MUMC), 6229HX Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), 6229HX Maastricht, The Netherlands
| | - Domenico Paparella
- Division of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, 70125 Bari, Italy;
- Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), 6229HX Maastricht, The Netherlands;
- Cardiovascular Research Institute Maastricht (CARIM), 6229HX Maastricht, The Netherlands
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20
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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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21
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Dhawan N. Beware of Warfarin-Induced Skin Necrosis in the Setting of Heparin-Induced Thrombocytopenia. Cureus 2020; 12:e8857. [PMID: 32754398 PMCID: PMC7386079 DOI: 10.7759/cureus.8857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) and thrombosis affect a small minority of patients exposed to heparin. However, given the high proportion of patients who receive heparin during hospitalization, clinicians should be mindful to keep it on their differential. This case involves a 56-year-old woman who developed HIT during a prolonged hospitalization. She was started on a direct thrombin inhibitor, argatroban, until her platelets recovered, was bridged to warfarin, and later developed warfarin-induced skin necrosis (WISN). Patients with prolonged hospitalizations may have an inherent vitamin K deficiency, leading to erratic changes in international normalized ratio (INR). Currently, there are no guidelines to address very high supratherapeutic INR levels in this setting. Prompt diagnosis and close monitoring during treatment are essential to minimize the risk of morbidity and mortality.
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22
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Thomas BR, Hambly RJ, Weisel JW, Rauova L, Badiei N, Brown MR, Thornton CA, Williams PR, Hawkins K. Abnormal clot microstructure formed in blood containing HIT-like antibodies. Thromb Res 2020; 193:25-30. [PMID: 32505081 DOI: 10.1016/j.thromres.2020.05.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 04/26/2020] [Accepted: 05/18/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Thrombosis is a severe and frequent complication of heparin-induced thrombocytopenia (HIT). However, there is currently no knowledge of the effects of HIT-like antibodies on the resulting microstructure of the formed clot, despite such information being linked to thrombotic events. We evaluate the effect of the addition of pathogenic HIT-like antibodies to blood on the resulting microstructure of the formed clot. MATERIALS AND METHODS Pathogenic HIT-like antibodies (KKO) and control antibodies (RTO) were added to samples of whole blood containing Unfractionated Heparin and Platelet Factor 4. The formed clot microstructure was investigated by rheological measurements (fractal dimension; df) and scanning electron microscopy (SEM), and platelet activation was measured by flow cytometry. RESULTS AND CONCLUSIONS Our results revealed striking effects of KKO on clot microstructure. A significant difference in df was found between samples containing KKO (df = 1.80) versus RTO (df = 1.74; p < 0.0001). This increase in df was often associated with an increase in activated platelets. SEM images of the clots formed with KKO showed a network consisting of a highly branched and compact arrangement of thin fibrin fibres, typically found in thrombotic disease. This is the first study to identify significant changes in clot microstructure formed in blood containing HIT-like antibodies. These observed alterations in clot microstructure can be potentially exploited as a much-needed biomarker for the detection, management and monitoring of HIT-associated thrombosis.
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Affiliation(s)
- Bethan R Thomas
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Rebecca J Hambly
- Swansea University Medical School, Swansea University, Swansea, UK
| | - John W Weisel
- University of Pennsylvania School of Medicine, PA, USA
| | - Lubica Rauova
- University of Pennsylvania School of Medicine, PA, USA; Children's Hospital of Philadelphia, PA, USA
| | | | - M Rowan Brown
- College of Engineering, Swansea University, Swansea, UK
| | | | | | - Karl Hawkins
- Swansea University Medical School, Swansea University, Swansea, UK.
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Patriarcheas V, Pikoulas A, Kostis M, Charpidou A, Dimakakos E. Heparin-induced Thrombocytopenia: Pathophysiology, Diagnosis and Management. Cureus 2020; 12:e7385. [PMID: 32337112 PMCID: PMC7179984 DOI: 10.7759/cureus.7385] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/24/2020] [Indexed: 01/16/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT), even rare, is a life-threatening, immune-mediated complication of heparin exposure. It is considered the most severe non-bleeding adverse reaction of heparin treatment and one of the most important adverse drug reactions. The pathophysiological basis of HIT results from the formation of an immunocomplex consisting of an auto-antibody against platelet factor 4 (PF4) - heparin complex, which binds to the surface of platelets and monocytes, provoking their activation by cross-linking FcgIIA receptors. Platelets and monocyte activation, leads to the generation of catastrophic arterial and venous thrombosis, with a mortality rate of 20%, without early recognition. The definitive diagnosis of HIT i.e., clinical and laboratory evidence, can not be done at the onset of symptoms because laboratory results may not be available for several days. Thus, the initial approach is to predict the likelihood of HIT, because in highly suspected patients immediate heparin cessation and initiation of alternative anticoagulation treatment are crucial for the prevention of the devastating thrombotic sequelae. Herein, we describe the pathophysiology, the clinical manifestations, the diagnostic approach, and the management of patients with HIT.
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Affiliation(s)
| | | | - Minas Kostis
- Internal Medicine, University Hospital of Patras, Patras, GRC
| | - Andriani Charpidou
- Internal Medicine, Thoracic Diseases General Hospital Sotiria, Athens, GRC
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24
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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: 62] [Impact Index Per Article: 15.5] [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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25
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Suljevic I, Basic S, Surkovic I, Turan M, Musija E. The Effect of Prophylactic Doses of Reviparin on the Postoperative Value of Platelets. Med Arch 2020; 73:404-407. [PMID: 32082009 PMCID: PMC7007632 DOI: 10.5455/medarh.2019.73.404-407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Introduction Low molecular weight heparin (LMWH) is used as anticoagulant in diseases characterized by possible thrombosis, as well as for thromboprophylaxis in surgery. The administration of LMWH preoperatively and postoperatively allows satisfactory thromboprophylaxis of patients undergoing surgery. Their application can reduce the number of platelets. Aim To determine what effect Reviparin has on platelet values postoperatively in patients undergoing open cholecystectomy. Methods The study was conducted at the Clinic for Anesthesia and Resuscitation of the Clinical Center of the University of Sarajevo. A retrospective study was performed that included data analysis for 33 patients undergoing open cholecystectomy over a two-year period. There were 22 male and 11 female patients out of a total of 33 patients. Platelet values from laboratory findings of patient's medical history were monitored for 5 days. The values found were recorded in a table containing the patient's first and last name, gender, age and platelet value. All patients had the same endotracheal anesthesia with Propofol, Fentanyl, and Atracurium supplemented with oxygen and nitric oxide at the appropriate dose. All of the patients received same dose of 0.25ml (1432 IU) Reviparin (Clivarin) from Abbott GmbH & Co.KG, preoperatively and postoperatively. Patients undergoing laparoscopic surgery as well as patients receiving other low-molecular-weight heparin or receiving higher doses of Reviparin were excluded from the study. Statistical analysis was performed using the MedCalc v12.7 statistical package for biomedical research. Results An analysis of gender representation in the total sample shows that there was 22 or 66.7% of males while there was 11 or 33.3% of female patients. Analysis of platelet values indicates that there is no statistically significant correlation with gender, but that there is a statistically significant correlation between platelet values between samples, ie. that patients who had higher preoperative values retained more platelet values even during postoperative measurements. Conclusion Platelet values do not change significantly postoperatively with the use of prophylactic doses of Reviparin, after an open cholecystectomy.
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Affiliation(s)
- Ismet Suljevic
- Clinic for Anesthesia and Resuscitation, Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Suad Basic
- Public Health institution, Institute for Addiction Diseases of Zenica-Doboj Canton, Zenica, Bosnia and Herzegovina
| | - Ismana Surkovic
- Clinic for Nuclear Medicine and Endocrinology, Clinical Center Sarajevo, Bosnia and Herzegovina
| | - Maida Turan
- Acibadem Health Group, Representative Office in Sarajevo, Bosnia and Herzegovina
| | - Ehlimana Musija
- Clinic for Heart and Blood vessel Diseases and Rheumatism, Clinical Center Sarajevo, Bosnia and Herzegovina
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26
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Guo Q, Lou Y, Liu L, Luo P. How Can I Manage Thrombocytopenia in Hemodialysis Patient? A Review. Ther Apher Dial 2019; 24:352-360. [PMID: 31661590 DOI: 10.1111/1744-9987.13448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/24/2019] [Accepted: 10/25/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Qiaoyan Guo
- Department of NephrologyJilin University Second Hospital Changchun China
| | - Yan Lou
- Department of NephrologyJilin University Second Hospital Changchun China
| | - Lihua Liu
- Department of NephrologyJilin University Second Hospital Changchun China
| | - Ping Luo
- Department of NephrologyJilin University Second Hospital Changchun China
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Pishko AM, Lefler DS, Gimotty P, Paydary K, Fardin S, Arepally GM, Crowther M, Rice L, Vega R, Cines DB, Guevara JP, Cuker A. The risk of major bleeding in patients with suspected heparin-induced thrombocytopenia. J Thromb Haemost 2019; 17:1956-1965. [PMID: 31350937 PMCID: PMC6913895 DOI: 10.1111/jth.14587] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 07/22/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND The presence of a hypercoagulable disorder such as heparin-induced thrombocytopenia (HIT) may protect against anticoagulant-associated bleeding. OBJECTIVES To determine the incidence of major bleeding in patients with suspected HIT. METHODS We performed a retrospective analysis of 310 patients suspected of having HIT from the Hospital of the University of Pennsylvania and an affiliated community hospital. We compared the cumulative incidence of major bleeding following suspicion for HIT by ultimate HIT status (HIT+ or HIT-) and exposure to an alternative anticoagulant (Tx+ or Tx-). Secondary outcomes included the incidence of new/progressive thrombosis and 30-day mortality. RESULTS The incidence of major bleeding was high in the HIT+Tx+, HIT- Tx+, and HIT-Tx- groups (35.7%, 44.0%, and 37.3%, respectively). The time to first major bleeding event did not differ between groups (P = .24). Factors associated with increased risk of major bleeding included intensive care unit admission (HR 2.24, 95% CI 1.44-3.47), platelet count < 25 × 109 /L (HR 2.13, 1.10-4.12), and renal dysfunction (HR 1.56, 1.06-2.27); 35.7% of HIT+Tx+, 13.8% HIT-Tx+, and 9.3% of HIT-Tx- patients experienced new or progressive thrombosis. Mortality was similar among the three groups (26.2% HIT+Tx+, 34.5% HIT-Tx+, and 26.7% of HIT-Tx- [P = .34]). CONCLUSIONS Among patients with suspected HIT, major bleeding was common regardless of HIT status. Contrary to our hypothesis, HIT+ patients were not protected from major bleeding. A better understanding of bleeding risk is needed to inform management decisions in patients with suspected HIT.
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Affiliation(s)
- Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel S Lefler
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Phyllis Gimotty
- Department of Biostatistics and Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Koosha Paydary
- Department of Internal Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Sara Fardin
- Department of Radiology, Tufts Medical Center, Boston, Massachusetts
| | - Gowthami M Arepally
- Division of Hematology, Department of Medicine, Duke University, Durham, North Carolina
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Rice
- Hematology Division, Department of Medicine, Houston Methodist Hospital, Weill Cornell Medical College, Houston, Texas
| | - Rolando Vega
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas B Cines
- 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
| | - James P Guevara
- Department of Biostatistics and Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Pediatrics, Children's Hospital of Philadelphia, 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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Li S, Fan LK, Wu W, Zhao YQ, Wang SJ. [Diagnostic value of two immunoassays for detecting heparin/PF4 complex antibodies in heparin-induced thrombocytopenia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:411-416. [PMID: 31207707 PMCID: PMC7342243 DOI: 10.3760/cma.j.issn.0253-2727.2019.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Indexed: 11/05/2022]
Abstract
Objectives: To assess the diagnostic values of latex immunoturbidimetric assay (LIA) and particle immunofiltration assay (PIFA) for heparin-induced thrombocytopenia (HIT) . Methods: Samples from 94 patients with suspected HIT from May 2016 to July 2018 in our hospital were prospectively analyzed by the two immunoassays. Their medical records and further follow-up data were also collected and analyzed by our hematologists to make the 4Ts scores and confirm the diagnosis of HIT, respectively. Performance characteristics of the two immunoassays were assessed, including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) . Their post-test probabilities (PTP) were also calculated based on the 4Ts score. Results: Among 94 cases, 15 (16.0%) had a positive HIT, including 6 of 37 (16.2%) with an intermediate, and 9 of 15 (60.0%) with a high 4Ts score. PIFA operating characteristics were: sensitivity 100.0% (15/15) , specificity 51.9% (41/80) , PPV 28.3% (15/53) , NPV 100.0% (41/41) . The positive PTP in intermediate and high 4Ts score group were 28.7% and 75.7%, respectively, while negative PTP were all 0. At manufacturers' cutoffs, LIA operating characteristics were: sensitivity 66.7% (10/15) , specificity 94.9% (75/79) , PPV 71.4% (10/14) and NPV 93.8% (75/80) . The positive and negative PTP in intermediate 4Ts score group were 71.8% and 6.3%, while 95.2% and 34.4% in high 4Ts score group, respectively. Receiver operating characteristic (ROC) analysis manifested that LIA was preferable than PIFA, and combining the 2 assays together was significantly better than single test. Conclusions: 4Ts score is still an important tool for the diagnosis of HIT. Combining clinical score with heparin/PF4 antibody assay can increase the accuracy of confirming or excluding HIT. Although PIFA is inferior to LIA in the diagnostic value, its user friendliness and 100% NPV have major advantages. Combining the 2 assays together can achieve a higher diagnostic value.
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Affiliation(s)
- S Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
| | - L K Fan
- Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
| | - W Wu
- Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
| | - Y Q Zhao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
| | - S J Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medicine Sciences, Beijing 100730, China
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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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Dhakal B, Kreuziger LB, Rein L, Kleman A, Fraser R, Aster RH, Hari P, Padmanabhan A. Disease burden, complication rates, and health-care costs of heparin-induced thrombocytopenia in the USA: a population-based study. LANCET HAEMATOLOGY 2018; 5:e220-e231. [PMID: 29703336 DOI: 10.1016/s2352-3026(18)30046-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia can be a life-threatening and limb-threatening complication of heparin therapy. Incidence and complication rates of this condition have been extrapolated from studies with modest sample sizes, and despite the availability of therapeutic interventions the outcomes of heparin-induced thrombocytopenia are not well understood. We aimed to estimate disease burden, complication rates, and costs of heparin-induced thrombocytopenia in the USA. METHODS In this population-based study we analysed data from 2009 to 2013 from the Nationwide (National) Inpatient Sample (NIS), a large, all-payer inpatient health-care database in the USA. To validate the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for heparin-induced thrombocytopenia (289.84), we defined the sensitivity and specificity of this code using patient data from 2013 from a local hospital (Froedtert Memorial Lutheran Hospital, Milwaukee, WI, USA). The primary outcomes assessed were the incidence of hospital discharges with codes for heparin-induced thrombocytopenia and of discharges for heparin-induced thrombocytopenia associated with cardiopulmonary bypass, haemodialysis, hip or knee arthroplasty, trauma or injury (or both), and gingival or periodontal disease (or both). We also assessed the incidence of thrombosis, bleeding, limb or digit amputation, mortality, length of hospital stay, and associated hospital charges. FINDINGS Between 2009 and 2013, 97 566 discharges from the NIS assigned the ICD-9-CM code for heparin-induced thrombocytopenia, and 149 911 247 discharges coded for non-heparin-induced thrombocytopenia, were analysed. Overall, heparin-induced thrombocytopenia was identified in 97 566 (0·065%; SE 0·0012) of 150 008 813 discharges, corresponding to approximately one in 1500 hospital admissions. Patients undergoing cardiopulmonary bypass had the highest rates of heparin-induced thrombocytopenia (7702 [0·63%; SE 0·03] of 1 230 362), followed by those undergoing haemodialysis (23 012 [0·47%; 0·01] of 4 908 100), those with gingival or periodontal disease, or both (106 [0·12%; 0·03] of 88 621), and those with trauma or injury, or both (541 [0·09%; 0·01] of 602 944); patients with hip (845 [0·04%; 0·004] of 1 943 353) and knee (676 [0·02%; 0·002] of 3 022 602) arthroplasty had the lowest rates of heparin-induced thrombocytopenia. Thrombosis (29 079 [29·8%; SE 0·4] of 97 566) and bleeding (6044 [6·2%; 0·2] of 97 566) were common complications in heparin-induced thrombocytopenia, and 1446 (23·9%; 1·2) of 6044 patients with heparin-induced thrombocytopenia who had haemorrhage died. 742 (0·76%; SE 0·06) of 97 566 patients with heparin-induced thrombocytopenia discharges underwent amputations compared with 173 043 (0·12%; 0·001) of 149 911 247 with non-heparin-induced thrombocytopenia discharges (adjusted odds ratio 5·095 [95% CI 4·309-6·023]; p<0·0001). Overall, in-hospital mortality was 9842 (10·1%; SE 0·2) of 97 508 in discharge summaries coded for heparin-induced thrombocytopenia compared with 3 206 700 (2·1%; 0·01) of 149 811 891 in discharges for non-heparin-induced thrombocytopenia (adjusted odds ratio 4·075 [95% CI 3·846-4·317]; p<0·0001). The median length of stay among live discharges was 8·9 days (IQR 4·6-17·1) and total hospital charges were US$83 072 (IQR 37 240-188 419) for heparin-induced thrombocytopenia discharges compared with 2·6 days (1·4-4·8) and $21 360 (11 426-41 917) for non-heparin-induced thrombocytopenia discharges (p<0·0001 for both). 333 discharges from a local hospital were analysed to assess the diagnostic sensitivity and specificity of the heparin-induced thrombocytopenia ICD-9-CM code; sensitivity was 90·9% (95% CI 57·1-99·5) and specificity was 94·4% (91·1-96·6). INTERPRETATION Complication rates for heparin-induced thrombocytopenia remain high and more effective preventive and treatment interventions are needed. FUNDING None.
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Affiliation(s)
- Binod Dhakal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Baumann Kreuziger
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ariel Kleman
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Raphael Fraser
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard H Aster
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - Parameswaran Hari
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anand Padmanabhan
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA; Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA.
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Stoll F, Gödde M, Leo A, Katus HA, Müller OJ. Characterization of hospitalized cardiovascular patients with suspected heparin-induced thrombocytopenia. Clin Cardiol 2018; 41:1521-1526. [PMID: 30144122 DOI: 10.1002/clc.23061] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 08/21/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Little is known about heparin-induced thrombocytopenia (HIT), a pro-thrombotic, potentially life-threatening immune-mediated reaction to heparin exposure, in conservative and interventional cardiovascular medicine. HYPOTHESIS The 4T score, validated for prediction of HIT in surgical patients before, is also suitable for assessing HIT probability in cardiovascular patients with unclear thrombocytopenia. METHODS A total of 403 consecutive patients from our Department of Cardiology, Angiology and Pneumology in whom a HIT screening test was performed between 2009 and 2016 were identified. All 72 patients with a positive screening test were subjected to a functional confirmation test (heparin-induced platelet activation test, HIPA), resulting in 23 patients with serologically confirmed HIT (positive screening test, positive HIPA) and 49 patients with nonconfirmed HIT (positive screening test, negative HIPA). RESULTS The 4TScore had a sensitivity of 82.6% and a specificity of 28.6% in our patients, suggesting that it might not sufficiently predict the clinical probability of HIT in cardiovascular patients. In both confirmed and nonconfirmed HIT, intrahospital mortality was high without a significant difference (30% in confirmed HIT vs 43% in nonconfirmed HIT). Bacteremia was more often found in patients with nonconfirmed HIT, suggesting infection as a frequent differential diagnosis of thrombocytopenia in these patients (49% vs 17%, P = 0.0185). CONCLUSION HIT screening should be initiated in cardiovascular patients with unclear thrombocytopenia despite a low 4Tscore in order to distinguish patients requiring alternative anticoagulants from those with other causes such as infections. Further research is needed to specify the risk profile for HIT in cardiovascular patients.
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Affiliation(s)
- Felicitas Stoll
- Heidelberg University Hospital, Internal Medicine III, DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Miriel Gödde
- Heidelberg University Hospital, Internal Medicine III, DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Albrecht Leo
- Institute for Clinical Transfusion Medicine and Cell Therapy Heidelberg gGmbH, Heidelberg, Germany
| | - Hugo A Katus
- Heidelberg University Hospital, Internal Medicine III, DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Oliver J Müller
- Heidelberg University Hospital, Internal Medicine III, DZHK (German Center for Cardiovascular Research), Mannheim, Germany.,Department of Internal Medicine III, University of Kiel, Germany
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Fathi M. Heparin-induced thrombocytopenia (HIT): Identification and treatment pathways. Glob Cardiol Sci Pract 2018; 2018:15. [PMID: 30083545 PMCID: PMC6062760 DOI: 10.21542/gcsp.2018.15] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a major health problem, especially in cardiac surgery theaters, cardiac catheterization labs, and intensive care units. Some patients with HIT develop serious thrombotic complications like limb ischemia and gangrene, while others may not develop such complications and have only mild thrombocytopenia. Current laboratory diagnostic tools incur significant time delays before confirming HIT, therefore upon clinical suspicion, treatment of HIT should start immediately while awaiting laboratory results. This is a review of the types, phases, pathophysiology, clinical presentation and diagnosis of HIT, and its current management strategies.
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33
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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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Antithrombotic Drugs. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00149-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
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35
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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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36
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Markovic I, Debeljak Z, Bosnjak B, Marijanovic M. False positive immunoassay for heparin-induced thrombocytopenia in the presence of monoclonal gammopathy: a case report. Biochem Med (Zagreb) 2017; 27:030801. [PMID: 29180919 PMCID: PMC5696753 DOI: 10.11613/bm.2017.030801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 09/19/2017] [Indexed: 11/09/2022] Open
Abstract
Heparin induced thrombocytopenia (HIT) is a life-threatening disorder which diagnosis depends on laboratory evaluation. The objective of this report is to present the impact of different laboratory methods for HIT detection on the diagnostic evaluation process. In this case, a 78-year old female patient previously diagnosed with monoclonal gammopathy of undetermined significance (MGUS) was administered with heparin for pulmonary embolism treatment. Patient’s initial diagnostic work-up (determination of platelet count and prothrombin time measurement for monitoring of pharmacotherapy) was followed by the clinical estimation of HIT likelihood by “4Ts” score, two immunoassays (ID-PaGIA Heparin/PF4 Antibody Test and ELISA PF4 IgG assay) and one functional test called high-performance liquid chromatography serotonin release assay (HPLC-SRA). The result of “4Ts” score indicated a low likelihood of HIT but persistent thrombocytopenia that appeared days after discontinuation of heparin therapy suggested delayed-onset HIT. Both immunoassays were positive for presence of HIT-autoantibodies, while the functional HPLC-SRA was negative. Since different methods gave opposing results, their interpretation required great attention. In comparison to the HPLC-SRA, immunoassays are prone to the analytical interferences associated with the presence of non-specific antibodies, which may lead to false positive results. In this case, where the patient is known to produce antibodies of undetermined significance, HIT was ruled out as the possible cause of persistent thrombocytopenia primarily due to the negative result of HPLC-SRA, which is not prone to this type of interferences, but also due to the low “4Ts” clinical score.
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Affiliation(s)
- Ivana Markovic
- Institute of Clinical Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Zeljko Debeljak
- Institute of Clinical Laboratory Diagnostics, Osijek University Hospital, Osijek, Croatia.,Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia
| | - Bojana Bosnjak
- Faculty of Medicine, JJ Strossmayer University of Osijek, Osijek, Croatia.,Institute of Transfusion Medicine, Osijek University Hospital, Osijek, Croatia
| | - Maja Marijanovic
- Institute of Transfusion Medicine, Osijek University Hospital, Osijek, Croatia
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37
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Zheng G, Streiff MB, Takemoto CM, Bynum J, Gelwan E, Jani J, Judge D, Kickler TS. The Clinical Utility of the Heparin Neutralization Assay in the Diagnosis of Heparin-Induced Thrombocytopenia. Clin Appl Thromb Hemost 2017; 24:749-754. [PMID: 28774196 DOI: 10.1177/1076029617721013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) remains diagnostically challenging. Immunoassays including PF4/heparin enzyme-linked immunosorbent assay (ELISA) have high sensitivity but low specificity. Whether the heparin neutralization assay (HNA) improves the diagnostic accuracy of the PF4/heparin ELISA for HIT is uncertain. In this study, to assess its clinical utility and evaluate whether it improves the diagnostic accuracy for HIT, we implemented HNA in conjunction with PF4/heparin ELISA over a 1-year period. A total of 1194 patient samples were submitted to the laboratory for testing from December 2015 to November 2016. Heparin neutralization assay alone is a poor predictor for HIT, but it has high negative predictive value (NPV): Cases with %inhibition <70% are always negative for serotonin release assay. It improves the diagnostic positive predictive value (PPV) of ELISA without compromising sensitivity: ELISA optical density (OD) ≥1.4 alone has a sensitivity of 88% (14/16) and a PPV of 61% (14/23); with HNA %inhibition ≥70%, the sensitivity remains 88% (14/16) and PPV is 82% (14/17). 4Ts score correlates with ELISA OD and predicts HIT; the predictive accuracy of 4Ts score is further improved by HNA. Interestingly, HNA %inhibition of <70% correlates with low 4Ts scores. Based on its high NPV, HNA has the potential to facilitate more timely and accurate HIT diagnosis.
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Affiliation(s)
- Gang Zheng
- 1 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael B Streiff
- 2 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Clifford M Takemoto
- 3 Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jennifer Bynum
- 1 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elise Gelwan
- 1 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jayesh Jani
- 1 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Danielle Judge
- 1 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Thomas S Kickler
- 1 Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,2 Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ezekwudo DE, Chacko R, Gbadamosi B, Batool S, Gaikazian S, Warkentin TE, Sheppard JAI, Jaiyesimi I. Apixaban for treatment of confirmed heparin-induced thrombocytopenia: a case report and review of literature. Exp Hematol Oncol 2017; 6:21. [PMID: 28725494 PMCID: PMC5513338 DOI: 10.1186/s40164-017-0080-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/05/2017] [Indexed: 02/08/2023] Open
Abstract
Background Heparin-induced thrombocytopenia (HIT) is a life and limb-threatening condition caused by the binding of platelet-activating antibodies (IgG) to multimolecular platelet factor 4 (PF4)/heparin complexes because of heparin exposure. The by-product of this interaction is thrombin formation which substantially increases the risk of venous and/or arterial thromboembolism. Currently, only one anticoagulant, argatroban, is United States Food and Drug Administration-approved for management of HIT; however, this agent is expensive and can only be given by intravenous infusion. Recently, several retrospective case-series, case reports, and one prospective study suggest that direct oral anticoagulants (DOACs) are also efficacious for treating HIT. We further review the literature regarding current diagnosis and clinical management of HIT. Case presentation A 66-year-old male patient developed HIT beginning on day 5 post-cardiovascular surgery; the platelet count nadir on day 10 measured 16 × 109/L. Both the PF4-dependent ELISA and Serotonin-release assay were strongly positive. Despite initial anticoagulation with argatroban (day 6), the patient developed symptomatic Doppler ultrasound-documented bilateral lower extremity deep vein thrombosis on day 14 post-surgery. The patient was transitioned to the DOAC, apixaban, while still thrombocytopenic (platelet count 108) and discharged to home, with platelet count recovery and no further thrombosis at 3-month follow-up. Conclusions We report a patient with serologically confirmed HIT who developed symptomatic bilateral lower limb deep vein thrombosis despite anticoagulation with argatroban. The patient was switched to oral apixaban and made a complete recovery. Our patient case adds to the emerging literature suggesting that DOAC therapy is safe and efficacious for management of proven HIT.
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Affiliation(s)
- Daniel E Ezekwudo
- Department of Hematology and Oncology, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, 3577 W. 13 Mile Rd., Suite 202a, Royal Oak, MI USA
| | - Rebecca Chacko
- Department of Internal Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI USA
| | - Bolanle Gbadamosi
- Department of Hematology and Oncology, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, 3577 W. 13 Mile Rd., Suite 202a, Royal Oak, MI USA
| | - Syeda Batool
- Department of Internal Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI USA
| | - Sussana Gaikazian
- Department of Hematology and Oncology, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, 3577 W. 13 Mile Rd., Suite 202a, Royal Oak, MI USA
| | - Theodore E Warkentin
- Department of Medicine, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8 Canada.,Department of Pathology & Molecular Medicine, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8 Canada
| | - Jo-Ann I Sheppard
- Department of Medicine, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8 Canada.,Department of Pathology & Molecular Medicine, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8 Canada
| | - Ishmael Jaiyesimi
- Department of Hematology and Oncology, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, 3577 W. 13 Mile Rd., Suite 202a, Royal Oak, MI USA.,Department of Internal Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI USA
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Abstract
Direct oral anticoagulants (DOACs) are attractive options for treatment of heparin-induced thrombocytopenia (HIT). We report our continuing experience in Hamilton, ON, Canada, since January 1, 2015 (when we completed our prospective study of rivaroxaban for HIT), using rivaroxaban for serologically confirmed HIT (4Ts score ≥4 points; positive platelet factor 4 [PF4]/heparin immunoassay, positive serotonin-release assay). We also performed a literature review of HIT treatment using DOACs (rivaroxaban, apixaban, dabigatran, edoxaban). We focused on patients who received DOAC therapy for acute HIT as either primary therapy (group A) or secondary therapy (group B; initial treatment using a non-DOAC/non-heparin anticoagulant with transition to a DOAC during HIT-associated thrombocytopenia). Our primary end point was occurrence of objectively documented thrombosis during DOAC therapy for acute HIT. We found that recovery without new, progressive, or recurrent thrombosis occurred in all 10 Hamilton patients with acute HIT treated with rivaroxaban. Data from the literature review plus these new data identified a thrombosis rate of 1 of 46 patients (2.2%; 95% CI, 0.4%-11.3%) in patients treated with rivaroxaban during acute HIT (group A, n = 25; group B, n = 21); major hemorrhage was seen in 0 of 46 patients. Similar outcomes in smaller numbers of patients were observed with apixaban (n = 12) and dabigatran (n = 11). DOACs offer simplified management of selected patients, as illustrated by a case of persisting (autoimmune) HIT (>2-month platelet recovery with inversely parallel waning of serum-induced heparin-independent serotonin release) with successful outpatient rivaroxaban management of HIT-associated thrombosis. Evidence supporting efficacy and safety of DOACs for acute HIT is increasing, with the most experience reported for rivaroxaban.
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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: 24] [Impact Index Per Article: 3.4] [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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Salter BS, Weiner MM, Trinh MA, Heller J, Evans AS, Adams DH, Fischer GW. Heparin-Induced Thrombocytopenia: A Comprehensive Clinical Review. J Am Coll Cardiol 2017; 67:2519-32. [PMID: 27230048 DOI: 10.1016/j.jacc.2016.02.073] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 02/03/2016] [Accepted: 02/08/2016] [Indexed: 12/13/2022]
Abstract
Heparin-induced thrombocytopenia is a profoundly dangerous, potentially lethal, immunologically mediated adverse drug reaction to unfractionated heparin or, less commonly, to low-molecular weight heparin. In this comprehensive review, the authors highlight heparin-induced thrombocytopenia's risk factors, clinical presentation, pathophysiology, diagnostic principles, and treatment. The authors place special emphasis on the management of patients requiring procedures using cardiopulmonary bypass or interventions in the catheterization laboratory. Clinical vigilance of this disease process is important to ensure its recognition, diagnosis, and treatment. Misdiagnosis of the syndrome, as well as misunderstanding of the disease process, continues to contribute to its morbidity and mortality.
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Affiliation(s)
- Benjamin S Salter
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York.
| | - Menachem M Weiner
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| | - Muoi A Trinh
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| | - Joshua Heller
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| | - Adam S Evans
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
| | - David H Adams
- Department of Cardiac Surgery, Mount Sinai Medical Center, New York, New York
| | - Gregory W Fischer
- Department of Anesthesiology, Mount Sinai Medical Center, New York, New York
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Padmanabhan A, Jones CG, Pechauer SM, Curtis BR, Bougie DW, Irani MS, Bryant BJ, Alperin JB, Deloughery TG, Mulvey KP, Dhakal B, Wen R, Wang D, Aster RH. IVIg for Treatment of Severe Refractory Heparin-Induced Thrombocytopenia. Chest 2017; 152:478-485. [PMID: 28427966 DOI: 10.1016/j.chest.2017.03.050] [Citation(s) in RCA: 87] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/29/2017] [Accepted: 03/31/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) complicated by severe thrombocytopenia and thrombosis can pose significant treatment challenges. Use of alternative anticoagulants in this setting may increase bleeding risks, especially in patients who have a protracted disease course. Additional therapies are lacking in this severely affected patient population. METHODS We describe three patients with HIT who had severe thromboembolism and prolonged thrombocytopenia refractory to standard treatment but who achieved an immediate and sustained response to IVIg therapy. The mechanism of action of IVIg was evaluated in these patients and in five additional patients with severe HIT. The impact of a common polymorphism (H/R 131) in the platelet IgG receptor FcγRIIa on IVIg-mediated inhibition of platelet activation was also examined. RESULTS At levels attained in vivo, IVIg inhibits HIT antibody-mediated platelet activation. The constant domain of IgG (Fc) but not the antigen-binding portion (Fab) is required for this effect. Consistent with this finding, IVIg had no effect on HIT antibody binding in a solid-phase HIT immunoassay (platelet factor 4 enzyme-linked immunoassay). The H/R131 polymorphism in FcγRIIa influences the susceptibility of platelets to IVIg treatment, with the HH131 genotype being most susceptible to IVIg-mediated inhibition of antibody-induced activation. However, at high doses of IVIg, activation of platelets of all FcγRIIa genotypes was significantly inhibited. All three patients did well on long-term anticoagulation therapy with direct oral anticoagulants. CONCLUSIONS These studies suggest that IVIg treatment should be considered in patients with HIT who have severe disease that is refractory to standard therapies.
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Affiliation(s)
- Anand Padmanabhan
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI.
| | - Curtis G Jones
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | | | - Brian R Curtis
- Platelet and Neutrophil Immunology Laboratory, BloodCenter of Wisconsin, Milwaukee, WI
| | - Daniel W Bougie
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Mehraboon S Irani
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Pathology, Medical College of Wisconsin, Milwaukee, WI
| | - Barbara J Bryant
- Department of Pathology, University of Texas Medical Branch, Galveston, TX
| | - Jack B Alperin
- Department of Pathology, University of Texas Medical Branch, Galveston, TX; Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | | | - Kevin P Mulvey
- Department of Medicine, Kootenai Health, Coeur d'Alene, ID
| | - Binod Dhakal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Renren Wen
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Demin Wang
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI
| | - Richard H Aster
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI; Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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Abstract
Heparin-induced thrombocytopenia (HIT) is an immune complication of heparin therapy caused by antibodies to complexes of platelet factor 4 (PF4) and heparin. Pathogenic antibodies to PF4/heparin bind and activate cellular FcγRIIA on platelets and monocytes to propagate a hypercoagulable state culminating in life-threatening thrombosis. It is now recognized that anti-PF4/heparin antibodies develop commonly after heparin exposure, but only a subset of sensitized patients progress to life-threatening complications of thrombocytopenia and thrombosis. Recent scientific developments have clarified mechanisms underlying PF4/heparin immunogenicity, disease susceptibility, and clinical manifestations of disease. Insights from clinical and laboratory findings have also been recently harnessed for disease prevention. This review will summarize our current understanding of HIT by reviewing pathogenesis, essential clinical and laboratory features, and management.
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44
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Minet V, Dogné JM, Mullier F. Functional Assays in the Diagnosis of Heparin-Induced Thrombocytopenia: A Review. Molecules 2017; 22:molecules22040617. [PMID: 28398258 PMCID: PMC6153750 DOI: 10.3390/molecules22040617] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 04/05/2017] [Accepted: 04/08/2017] [Indexed: 01/09/2023] Open
Abstract
A rapid and accurate diagnosis in patients with suspected heparin-induced thrombocytopenia (HIT) is essential for patient management but remains challenging. Current HIT diagnosis ideally relies on a combination of clinical information, immunoassay and functional assay results. Platelet activation assays or functional assays detect HIT antibodies that are more clinically significant. Several functional assays have been developed and evaluated in the literature. They differ in the activation endpoint studied; the technique or technology used; the platelet donor selection; the platelet suspension (washed platelets, platelet rich plasma or whole blood); the patient sample (serum or plasma); and the heparin used (type and concentrations). Inconsistencies in controls performed and associated results interpretation are common. Thresholds and performances are determined differently among papers. Functional assays suffer from interlaboratory variability. This lack of standardization limits the evaluation and the accessibility of functional assays in laboratories. In the present article, we review all the current activation endpoints, techniques and methodologies of functional assays developed for HIT diagnosis.
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Affiliation(s)
- Valentine Minet
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur 5000, Belgium.
| | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur 5000, Belgium.
| | - François Mullier
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Hematology Laboratory, Université catholique de Louvain, Yvoir 5530, Belgium.
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45
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Abstract
Thrombocytopenia is a commonly encountered hematologic problem in inpatient and ambulatory medicine. The many underlying mechanisms of thrombocytopenia include pseudothrombocytopenia, splenic sequestration, and marrow underproduction and destruction. This article presents the known causes of thrombocytopenia, a framework for evaluation, and brief descriptions of management in a case-based format.
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Affiliation(s)
- Eun-Ju Lee
- Division of Hematology, Weill Cornell Medical College, New York, NY, USA
| | - Alfred Ian Lee
- Section of Hematology, Yale Cancer Center, Yale University School of Medicine, 333 Cedar Street, Box 208021, New Haven, CT 06520, USA.
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46
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Tran PN, Tran MH. Emerging Role of Direct Oral Anticoagulants in the Management of Heparin-Induced Thrombocytopenia. Clin Appl Thromb Hemost 2017; 24:201-209. [PMID: 28301915 DOI: 10.1177/1076029617696582] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia with thrombosis (HITT) are rare but potentially limb- and life-threatening complications of heparin therapy. Continuation of heparin or low-molecular-weight heparin is contraindicated due to platelet activation in the presence of (heparin-dependent) HIT antibodies. Primary treatment options currently include argatroban, fondaparinux, or bivalirudin. However, the parenteral administration routes and interference of argatroban with traditional coagulation markers complicate management. The goal of this review is to assess the viability of direct oral anticoagulants as an alternative treatment option in patients with HIT/HITT. Their use in HIT/HITT is reasonable, given absent cross-reactivity preformed with HIT antibodies. Furthermore, their rapid onset of action and induction of effective anticoagulation provide a favorable basis for their use in this condition. Herein, we summarize 3 studies and 8 case reports comprising 56 patients in whom direct oral anticoagulants were used in the treatment of HIT/HITT.
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Affiliation(s)
- Phu Ngoc Tran
- 1 Division of Hematology-Oncology, Department of Medicine, Chao Family Comprehensive Cancer Center, University of California Irvine School of Medicine, Orange, CA, USA
| | - Minh-Ha Tran
- 2 Department of Pathology and Laboratory Medicine, University of California Irvine School of Medicine, Irvine, CA, USA.,3 Department of Internal Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
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47
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Welsby IJ, Krakow EF, Heit JA, Williams EC, Arepally GM, Bar-Yosef S, Kong DF, Martinelli S, Dhakal I, Liu WW, Krischer J, Ortel TL. The association of anti-platelet factor 4/heparin antibodies with early and delayed thromboembolism after cardiac surgery. J Thromb Haemost 2017; 15:57-65. [PMID: 27714919 PMCID: PMC5280211 DOI: 10.1111/jth.13533] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Indexed: 12/18/2022]
Abstract
Essentials We evaluated antibody status, thromboembolism and survival after cardiac surgery. Positive antibody tests are common - over 50% are seropositive at 30 days. Seropositivity did not increase thromboembolism or impair survival after cardiac surgery. Results show heparin induced thrombocytopenia antibody screening after surgery is not warranted. SUMMARY Background Heparin-induced thrombocytopenia (HIT) is a prothrombotic response to heparin therapy with platelet-activating, anti-platelet factor 4 (PF4)/heparin antibodies leading to thrombocytopenia associated with thromboembolism. Objective We tested the hypothesis that anti-PF4/heparin antibodies are associated with thromboembolism after cardiac surgery. Methods This multicenter, prospective cohort study collected laboratory and clinical data up to 30 days after surgery and longer-term clinical follow-up data. The primary outcome variable combined new arterial or venous thromboembolic complications (TECs) with all-cause death until 90 days after surgery. Laboratory analyses included platelet counts and anti-PF4/heparin antibody titers (GTI ELISA), with a confirmatory excess heparin step and serotonin release assay. Chi-square testing was used to test the relationship between our outcome and HIT antibody seropositivity. Results Initially, 1021 patients were enrolled between August 2006 and May 2009, and follow-up was completed in December 2014. Seropositivity defined by OD > 0.4 was common, being almost 20% preoperatively, > 30% by discharge, and > 60% by day 30. Death (1.7% within 30 days) or TECs (69 in total) were more likely if the partient was seronegative (OD < 0.4), but positivity defined by OD > 1.0 or including an excess heparin confirmatory step resulted in equal incidence of death or TECs, whether the patient was seronegative or seropositive. Incorporating the serotonin release assay for platelet-activating antibodies did not alter these findings. Conclusions Seropositivity for anti-PF4/heparin antibodies does not increase the risk of death or thromboembolism after cardiac surgery. Screening is not indicated, and seropositivity should only be interpreted in the context of clinical evidence for HIT. TRIAL REGISTRATION Duke IRB Protocol #00010736.
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Affiliation(s)
- I J Welsby
- Department of Anesthesiology and Critical Care, Durham, NC, USA
| | - E F Krakow
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - J A Heit
- Department of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Durham, NC, USA
| | - E C Williams
- Department of Medicine, Division of Hematology, University of Wisconsin, Durham, NC, USA
| | - G M Arepally
- Department of Medicine, Division of Hematology, Duke University Medical Center, Durham, NC, USA
| | - S Bar-Yosef
- Department of Anesthesiology, Durham VA Medical Center, Durham, NC, USA
| | - D F Kong
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - S Martinelli
- Department of Anesthesiology, University of North Carolina, Durham, NC, USA
| | - I Dhakal
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - W W Liu
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, NC, USA
| | - J Krischer
- Pediatric Epidemiology Center, University of South Florida Morsani College of Medicine, Durham, NC, USA
| | - T L Ortel
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
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48
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Is It HIT?*. Crit Care Med 2017; 45:132-134. [DOI: 10.1097/ccm.0000000000002096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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49
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Abstract
Platelets, or megakaryocytes, are irregular, disk-shaped cell fragments circulating in the blood. They are a primary component in maintaining hemostasis. Low platelet counts, or thrombocytopenia, leave patients at an increased risk of hemorrhage. This article discusses various etiologies of disorders of low platelets and current therapies for management.
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50
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Al-Eidan FAS. Pharmacotherapy of heparin-induced thrombocytopenia: therapeutic options and challenges in the clinical practices. JOURNAL OF VASCULAR NURSING 2016; 33:10-20. [PMID: 25700733 DOI: 10.1016/j.jvn.2014.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 07/28/2014] [Accepted: 07/28/2014] [Indexed: 12/20/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is an immune response to heparin associated with significant morbidity and mortality in hospitalized patients if unidentified as soon as possible, owing to thromboembolic complications involving both arterial and venous systems. Early diagnoses based on a comprehensive interpretation of clinical and laboratory information improves clinical outcomes. Management principles of strongly suspected HIT should not be delayed for laboratory result confirmation. Treatment strategies have been introduced including new, safe, and effective agents. This review summarizes the clinical therapeutic options for HIT addressing the use of parenteral direct thrombin inhibitors and indirect factor Xa inhibitors as well as the potential non-vitamin K antagonist oral anticoagulants.
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Affiliation(s)
- Fahad A S Al-Eidan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
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