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Choi PYI, Uzun G, Bakchoul T. Results of an international survey of opinions on the definitions and treatments for heparin-induced thrombocytopenia: communication from the ISTH SSC Subcommittee on Platelet Immunology. J Thromb Haemost 2024; 22:1772-1778. [PMID: 38301999 DOI: 10.1016/j.jtha.2024.01.014] [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: 10/17/2023] [Revised: 01/08/2024] [Accepted: 01/20/2024] [Indexed: 02/03/2024]
Abstract
Heparin-induced thrombocytopenia (HIT) is rare, affecting fewer than 1 in 1500 hospital admissions. Despite the increasing adoption of new therapies in HIT, such as direct oral anticoagulants and pooled immunoglobulins, there is limited high-quality evidence to guide clinicians. Numerous uncommon presentations of HIT and HIT-like entities have recently been recognized, and a harmonized approach to their classification is required to study them better. We present the results of an international survey of opinions from experts and practitioners in the field of platelet immunology regarding the role of direct oral anticoagulants in HIT, novel definitions of subclassifications of HIT-like platelet factor 4 immune conditions (spontaneous autoimmune HIT, persistent autoimmune HIT, and treatment-refractory HIT), and the role for intravenous immunoglobulins in the treatment paradigm of HIT and these HIT-like conditions. From 102 survey responses, there was broad acceptance of rivaroxaban (74.5%) and apixaban (73.5%) even before platelet recovery, as well as for intravenous immunoglobulin in the management of spontaneous (85.6%), persistent (83.7%), and treatment-refractory HIT (87.4%). With this mandate for harmonizing terminologies and treatment approaches in special situations without robust clinical data owing to their rarity, we plan to conduct a robust survey, establish international consensus, and draft management guidelines for HIT and platelet factor 4 immune diseases in the near future.
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MESH Headings
- Humans
- Heparin/adverse effects
- Heparin/immunology
- Immunoglobulins, Intravenous/therapeutic use
- Immunoglobulins, Intravenous/adverse effects
- Thrombocytopenia/chemically induced
- Thrombocytopenia/immunology
- Thrombocytopenia/diagnosis
- Anticoagulants/adverse effects
- Platelet Factor 4/immunology
- Surveys and Questionnaires
- Pyrazoles/adverse effects
- Pyrazoles/therapeutic use
- Blood Platelets/immunology
- Blood Platelets/drug effects
- Blood Platelets/metabolism
- Pyridones/adverse effects
- Pyridones/therapeutic use
- Rivaroxaban/adverse effects
- Purpura, Thrombocytopenic, Idiopathic/chemically induced
- Purpura, Thrombocytopenic, Idiopathic/immunology
- Purpura, Thrombocytopenic, Idiopathic/diagnosis
- Purpura, Thrombocytopenic, Idiopathic/blood
- Purpura, Thrombocytopenic, Idiopathic/drug therapy
- Health Care Surveys
- Terminology as Topic
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Affiliation(s)
- Philip Young-Ill Choi
- Haematology Department, the Canberra Hospital, Garran, Canberra, Australian Capital Territory, Australia; John Curtin School of Medical Research, Australian National University, Acton, Canberra, Australian Capital Territory, Australia
| | - Günalp Uzun
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany
| | - Tamam Bakchoul
- Institute for Clinical and Experimental Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany; Centre for Clinical Transfusion Medicine, Tübingen, Germany.
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2
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Sugraliyev AB. [Heparin-Induced Thrombocytopenia]. KARDIOLOGIIA 2024; 64:18-25. [PMID: 38841785 DOI: 10.18087/cardio.2024.5.n2186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 10/28/2022] [Indexed: 06/07/2024]
Abstract
The extensive use of therapeutic doses of heparin to prevent thrombosis in critically ill patients with COVID-19 during the pandemic has led to an increased incidence of bleeding and heparin-induced thrombocytopenia (HIT). In addition, the introduction of the AstraZeneca and Johnson&Johnson vaccines against COVID-19 into clinical practice was associated with the development of a rare but very severe, adverse thrombotic complication, vaccine-induced immune thrombotic thrombocytopenia (VITT). Thrombotic complications of VITT turned out to be similar to HIT both clinically and pathophysiologically. HIT is a potentially fatal immune-mediated adverse drug response that results in emergence of antibodies that activate platelets in the presence of heparin. HIT is characterized by a high incidence of venous and arterial thromboses, often with fatal outcomes. Currently, there are clearly defined international guidelines for the diagnosis, treatment and prevention of HIT. In case of thrombotic complications, non-heparin anticoagulants should be used.
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Warkentin TE. A career in solving clinical-pathological conundrums: Heyde syndrome, anti-platelet factor 4 disorders, and microvascular limb ischemic necrosis. Int J Lab Hematol 2024; 46 Suppl 1:12-26. [PMID: 38432651 DOI: 10.1111/ijlh.14261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/14/2024] [Indexed: 03/05/2024]
Abstract
Hematology is a clinical specialty with strong roots in the laboratory; accordingly, the lab can help solve perplexing clinical problems. This review highlights clinical-pathological conundrums addressed during my 35-year hematology career at McMaster University. Heyde syndrome is the association between aortic stenosis and bleeding gastrointestinal (GI) angiodysplasia where the bleeding is usually cured by aortic valve replacement; the chance reading of a neonatal study showing reversible deficiency of high-molecular-weight (HMW) multimers of von Willebrand factor (vWF) following surgical correction of congenital heart disease provided the key insight that a subtle deficiency of HMW multimers of vWF explains Heyde syndrome. The unusual immunobiology of heparin-induced thrombocytopenia (HIT)-a highly prothrombotic, antibody-mediated, anti-platelet factor 4 (PF4) disorder featuring rapid appearance and then disappearance (seroreversion) of the pathological heparin-dependent platelet-activating antibodies-permitted identification of key clinical features that informed development of a scoring system (4Ts) to aid in HIT diagnosis. Atypical clinical presentations of HIT prompted identification of heparin-independent anti-PF4 antibodies, now recognized as the explanation for vaccine-induced immune thrombotic thrombocytopenia (VITT), as well as VITT-like disorders triggered by adenovirus infection. Another unusual feature of HIT is its strong association with limb ischemia, including limb necrosis secondary to deep-vein/microvascular thrombosis (venous limb gangrene). The remarkable observation that supratherapeutic warfarin anticoagulation predisposes to HIT- and cancer-associated venous limb gangrene provided insight into disturbed procoagulant/anticoagulant balance; these concepts are relevant to microvascular thrombosis in critical illness (symmetrical peripheral gangrene), including a pathophysiological role for proximate "shock liver" (impaired hepatic synthesis of natural anticoagulants).
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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4
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Arachchillage DJ, Thachil J, Anderson JAM, Baker P, Poles A, Kitchen S, Laffan M. Diagnosis and management of heparin-induced thrombocytopenia: Third edition. Br J Haematol 2024; 204:459-475. [PMID: 38153164 DOI: 10.1111/bjh.19180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 12/29/2023]
Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Jecko Thachil
- Department of Haematology, Manchester Royal Infirmary, Manchester, UK
| | - Julia A M Anderson
- Department of Haematology, Edinburgh Royal Infirmary, Edinburgh, Scotland
| | - Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Anthony Poles
- Bristol NHS Blood and Transplant Centre, Bristol, UK
| | - Steve Kitchen
- Department of Haematology, Royal Hallamshire Hospital, Sheffield, UK
| | - Mike Laffan
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
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5
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Müller L, Dabbiru VAS, Schönborn L, Greinacher A. Therapeutic strategies in FcγIIA receptor-dependent thrombosis and thromboinflammation as seen in heparin-induced thrombocytopenia (HIT) and vaccine-induced immune thrombocytopenia and thrombosis (VITT). Expert Opin Pharmacother 2024; 25:281-294. [PMID: 38465524 DOI: 10.1080/14656566.2024.2328241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/05/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Fcγ-receptors (FcγR) are membrane receptors expressed on a variety of immune cells, specialized in recognition of the Fc part of immunoglobulin G (IgG) antibodies. FcγRIIA-dependent platelet activation in platelet factor 4 (PF4) antibody-related disorders have gained major attention, when these antibodies were identified as the cause of the adverse vaccination event termed vaccine-induced immune thrombocytopenia and thrombosis (VITT) during the COVID-19 vaccination campaign. With the recognition of anti-PF4 antibodies as cause for severe spontaneous and sometimes recurrent thromboses independent of vaccination, their clinical relevance extended far beyond heparin-induced thrombocytopenia (HIT) and VITT. AREAS COVERED Patients developing these disorders show life-threatening thromboses, and the outcome is highly dependent on effective treatment. This narrative literature review summarizes treatment options for HIT and VITT that are currently available for clinical application and provides the perspective toward new developments. EXPERT OPINION Nearly all these novel approaches are based on in vitro, preclinical observations, or case reports with only limited implementation in clinical practice. The therapeutic potential of these approaches still needs to be proven in larger cohort studies to ensure treatment efficacy and long-term patient safety.
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Affiliation(s)
- Luisa Müller
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Venkata A S Dabbiru
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Linda Schönborn
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Andreas Greinacher
- Institut für Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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Porres-Aguilar M, Najera C, Mares AC, Benzidia I, Prakash S, Crichi B. Successful Treatment With the Oral Factor Xa Inhibitor Edoxaban in Heparin-Induced Thrombocytopenia With Thrombosis. Angiology 2023:33197231225291. [PMID: 38153027 DOI: 10.1177/00033197231225291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Heparin-induced thrombocytopenia with thrombosis (HITT) is a rare immune reaction to the drug heparin that causes increased blood clotting, putting patients at risk for arterial and venous thromboembolism which can have severe consequences. We present a case of HITT successfully treated with the direct oral anticoagulant (DOAC), edoxaban. A 56-year-old man had surgery to remove a colorectal mass. After discharge, he developed chest discomfort, shortness of breath, and low oxygen levels and was diagnosed with a right-sided lobar pulmonary embolism. His platelet count dropped, his tests confirmed a diagnosis of HITT, and he was initially treated with fondaparinux. After showing clinical and laboratory improvement, he was switched to edoxaban. Despite being diagnosed with colonic adenocarcinoma during follow-up, the patient's platelet count returned to normal, and he did not experience any more blood clots or serious bleeding events. The use of DOACs like edoxaban as potential therapies for HITT is promising; further research is being conducted to evaluate their effectiveness, safety, and potential benefits for treating this acquired high-risk thrombophilia.
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Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Carolina Najera
- Department of Internal Medicine, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, TX, USA
| | | | - Ilham Benzidia
- Vascular Medicine Unit, Department of Thoracic, Cardiovascular Surgery and Vascular Medicine, CHU Reunion-Site Nord, Saint Denis, France
| | - Swathi Prakash
- Department of Internal Medicine, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Benjamin Crichi
- Department of Internal Medicine, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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7
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Warkentin TE. Autoimmune Heparin-Induced Thrombocytopenia. J Clin Med 2023; 12:6921. [PMID: 37959386 PMCID: PMC10649402 DOI: 10.3390/jcm12216921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 10/27/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
Autoimmune thrombocytopenia (aHIT) is a severe subtype of heparin-induced thrombocytopenia (HIT) with atypical clinical features caused by highly pathological IgG antibodies ("aHIT antibodies") that activate platelets even in the absence of heparin. The clinical features of aHIT include: the onset or worsening of thrombocytopenia despite stopping heparin ("delayed-onset HIT"), thrombocytopenia persistence despite stopping heparin ("persisting" or "refractory HIT"), or triggered by small amounts of heparin (heparin "flush" HIT), most cases of fondaparinux-induced HIT, and patients with unusually severe HIT (e.g., multi-site or microvascular thrombosis, overt disseminated intravascular coagulation [DIC]). Special treatment approaches are required. For example, unlike classic HIT, heparin cessation does not result in de-escalation of antibody-induced hemostasis activation, and thus high-dose intravenous immunoglobulin (IVIG) may be indicated to interrupt aHIT-induced platelet activation; therapeutic plasma exchange may be required if high-dose IVIG is ineffective. Also, aHIT patients are at risk for treatment failure with (activated partial thromboplastin time [APTT]-adjusted) direct thrombin inhibitor (DTI) therapy (argatroban, bivalirudin), either because of APTT confounding (where aHIT-associated DIC and resulting APTT prolongation lead to systematic underdosing/interruption of DTI therapy) or because DTI inhibits thrombin-induced protein C activation. Most HIT laboratories do not test for aHIT antibodies, contributing to aHIT under-recognition.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular Medicine and Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON L8N 3Z5, Canada; ; Tel.: +1-(905)-527-0271 (ext. 46139)
- Service of Benign Hematology, Hamilton Health Sciences (General Site), Hamilton, ON L8L 2X2, Canada
- Transfusion Medicine, Hamilton Regional Laboratory Medicine Program, Hamilton, ON L8L 2X2, Canada
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8
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Howick V JF, Harmon DM, McBane RD. 44-Year-Old Woman With Cough and Shortness of Breath. Mayo Clin Proc 2023; 98:1557-1563. [PMID: 37793730 DOI: 10.1016/j.mayocp.2023.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 10/06/2023]
Affiliation(s)
- James F Howick V
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - David M Harmon
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Robert D McBane
- Advisor to residents and Consultant in Vascular Cardiology, Mayo Clinic, Rochester, MN.
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9
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Lv FF, Li MY, Qu W, Jiang ZS. Rivaroxaban for the treatment of heparin-induced thrombocytopenia with thrombosis in a patient undergoing artificial hip arthroplasty: A case report. World J Clin Cases 2023; 11:6147-6153. [PMID: 37731576 PMCID: PMC10507566 DOI: 10.12998/wjcc.v11.i26.6147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Anticoagulation treatment after lower limb surgery is one of the key methods to avoid thrombosis, and low-molecular-weight heparin is the treatment that is most frequently used in clinical practice. But one uncommon side effect of low-molecular-weight heparin is heparin-induced thrombocytopenia (HIT), which can develop into thrombosis if not caught early or managed incorrectly. CASE SUMMARY We present a case of a patient who underwent hip arthroplasty and experienced thrombocytopenia due to HIT on the 9th d following the application of low-molecular-weight heparin anticoagulation. We did not diagnose HIT in time and applied 1 unit of platelets to the patient, which led to thrombosis. Luckily, the patient recovered following effective and timely surgery and treatment with rivaroxaban. CONCLUSION Patients using low-molecular-weight heparin after lower limb surgery need to have their platelet counts regularly checked. If HIT develops, platelet treatment should be given with caution.
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Affiliation(s)
- Fang-Fang Lv
- Department of Endocrinology, 960th Hospital of PLA, Jinan 250014, Shandong Province, China
| | - Mei-Ye Li
- Department of Endocrinology, 960th Hospital of PLA, Jinan 250014, Shandong Province, China
| | - Wei Qu
- Department of Endocrinology, 960th Hospital of PLA, Jinan 250014, Shandong Province, China
| | - Zhao-Shun Jiang
- Department of Endocrinology, 960th Hospital of PLA, Jinan 250014, Shandong Province, China
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10
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Gbadamosi S, Feick KL. Update on the Treatment of Heparin-Induced Thrombocytopenia. AACN Adv Crit Care 2023; 34:173-178. [PMID: 37644631 DOI: 10.4037/aacnacc2023462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Affiliation(s)
- Sheriff Gbadamosi
- Sheriff Gbadamosi is Clinical Pharmacy Specialist-Critical Care, Temple University Hospital Main Campus, 3401 N Broad Street, Philadelphia, PA 19140
| | - Kristin L Feick
- Kristin L. Feick is Clinical Pharmacy Specialist-Critical Care, University of Pittsburgh Medical Center Central Pennsylvania Region
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11
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Sarkar A, Khandelwal S, Koma GT, Kim H, Gruel Y, Rollin J, Passam F, Wool GD, Arepally GM, Cines DB, Rauova L, Poncz M. Treatment of thrombocytopenia and thrombosis in HIT in mice using deglycosylated KKO: a novel therapeutic? Blood Adv 2023; 7:4112-4123. [PMID: 37196641 PMCID: PMC10388731 DOI: 10.1182/bloodadvances.2023009661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/19/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is characterized by thrombocytopenia associated with a highly prothrombotic state due to the development of pathogenic antibodies that recognize human platelet factor 4 (hPF4) complexed with various polyanions. Although nonheparin anticoagulants are the mainstay of care in HIT, subsequent bleeding may develop, and the risk of developing new thromboembolic events remain. We previously described a mouse immunoglobulin G2bκ (IgG2bκ) antibody KKO that mimics the sentinel features of pathogenic HIT antibodies, including binding to the same neoepitope on hPF4-polyanion complexes. KKO, like HIT IgGs, activates platelets through FcγRIIA and induces complement activation. We then questioned whether Fc-modified KKO could be used as a novel therapeutic to prevent or treat HIT. Using the endoglycosidase EndoS, we created deglycosylated KKO (DGKKO). Although DGKKO retained binding to PF4-polyanion complexes, it inhibited FcγRIIA-dependent activation of PF4-treated platelets triggered by unmodified KKO, 5B9 (another HIT-like monoclonal antibody), and IgGs isolated from patients with HIT. DGKKO also decreased complement activation and deposition of C3c on platelets. Unlike the anticoagulant fondaparinux, injection of DGKKO into HIT mice lacking mouse PF4, but transgenic for hPF4 and FcγRIIA, prevented and reversed thrombocytopenia when injected before or after unmodified KKO, 5B9, or HIT IgG. DGKKO also reversed antibody-induced thrombus growth in HIT mice. In contrast, DGKKO was ineffective in preventing thrombosis induced by IgG from patients with the HIT-related anti-PF4 prothrombotic disorder, vaccine-induced immune thrombotic thrombocytopenia. Thus, DGKKO may represent a new class of therapeutics for targeted treatment of patients with HIT.
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Affiliation(s)
- Amrita Sarkar
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Gavin T. Koma
- Department of Bioengineering, Temple University, Philadelphia, PA
| | - Hyunjun Kim
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Yves Gruel
- Department of Hemostasis, University Hospital Center of Tours, and EA4245 T2i, University of Tours, Tours, France
| | - Jerome Rollin
- Department of Hemostasis, University Hospital Center of Tours, and EA4245 T2i, University of Tours, Tours, France
| | - Freda Passam
- Central Clinical School, Faculty Medicine Health, University of Sydney, Sydney, Australia
| | | | | | - Douglas B. Cines
- Department of Pathology and Clinical Laboratories, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lubica Rauova
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mortimer Poncz
- Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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12
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Karki S, Aryal B, Mainali A, Uprety N, Panigrahi K, Adhikari S. Type II Heparin-Induced Thrombocytopenia: An Underrecognized Cause of Dialysis Catheter Dysfunction - A Case Report. Cureus 2023; 15:e41812. [PMID: 37575780 PMCID: PMC10422934 DOI: 10.7759/cureus.41812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/15/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is categorized into type 1 and type 2. It causes a decrease in platelet count during or shortly after exposure to heparin. Type 1 is mild and has a non-immune mechanism. Type 2 is a hypercoagulable state resulting from anti-heparin platelet factor 4 (PF4) IgG antibodies. These antibodies cause the activation of endothelium and thrombin generation. Type 2 HIT is complicated by life-threatening thromboembolic events such as deep venous thrombosis, pulmonary embolism, and myocardial infarction. HIT remains an under-recognized cause of dialysis catheter dysfunction and thrombosis. We present a case of a 66-year-old male with recurrent dialysis catheter thrombosis secondary to Type 2 HIT. Avoiding heparin-based dialysis or switching to non-heparin-based anticoagulation or peritoneal dialysis are the possible management strategies for such patients.
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Affiliation(s)
- Sailesh Karki
- Internal Medicine, Interfaith Medical Center, Brooklyn, USA
| | - Binit Aryal
- Internal Medicine, Interfaith Medical Center, Brooklyn, USA
| | - Arjun Mainali
- Internal Medicine, Interfaith Medical Center, Brooklyn, USA
| | | | - Kalpana Panigrahi
- Internal Medicine, One Brooklyn Health, Interfaith Medical Center, Brooklyn, USA
| | - Samaj Adhikari
- Internal Medicine, Interfaith Medical Center, Brooklyn, USA
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13
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Shah NB, Sharedalal P, Shafi I, Tang A, Zhao H, Lakhter V, Kolluri R, Rao AK, Bashir R. Prevalence and outcomes of heparin-induced thrombocytopenia in hospitalized patients with venous thromboembolic disease: Insight from national inpatient sample. J Vasc Surg Venous Lymphat Disord 2023; 11:723-730. [PMID: 36893884 DOI: 10.1016/j.jvsv.2023.02.001] [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: 10/19/2022] [Revised: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVE The mainstay of therapy for patients with venous thromboembolic disease (VTE) is anticoagulation. In the inpatient setting, majority of these patients are treated with heparin or low molecular weight heparin. The prevalence and outcomes of heparin-induced thrombocytopenia (HIT) in hospitalized patients with venous thromboembolic disease (VTE) is unknown. METHODS This nationwide study identified patients with VTE from the National Inpatient Sample database between January 2009 and December 2013. Among these patients, we compared in-hospital outcomes of patients with and without HIT using a propensity score-matching algorithm. The primary outcome was in-hospital mortality. Secondary outcomes included rates of blood transfusions, intracranial hemorrhage, gastrointestinal bleed, length of hospital stay, and total hospital charges. RESULTS Among 791,932 hospitalized patients with VTE, 4948 patients (0.6%) were noted to have HIT (mean age, 62.9 ±16.2 years; 50.1% female). Propensity-matched comparison showed higher rates of in-hospital mortality (11.01% vs 8.97%; P < .001) and blood transfusions (27.20% vs 20.23%; P < .001) in patients with HIT compared with those without HIT. No significant differences were noted in intracranial hemorrhage rates (0.71% vs 0.51%; P > .05), gastrointestinal bleed (2.00% vs 2.22%; P > .05), length of hospital stay (median, 6.0 days; interquartile range [IQR], 3.0-11.0 vs median, 6.0 days; IQR, 3.0-10.0 days; P > .05), and total hospital charges (median, $36,325; IQR, $17,798-$80,907 vs median, $34,808; IQR, $17,654-$75,624; P > .05). CONCLUSIONS This nationwide observational study showed that 0.6% of hospitalized patients with VTE in the United States have HIT. The presence of HIT was associated with higher in-hospital mortality and blood transfusion rates compared with those without HIT.
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Affiliation(s)
- Neal B Shah
- Department of Internal Medicine, New York Medical College, Valhalla, NY
| | - Parija Sharedalal
- Department of Cardiovascular Disease, New York Medical College, Valhalla, NY
| | - Irfan Shafi
- Department of Internal Medicine, Wayne State University, Detroit, MI
| | - Alice Tang
- Department of Internal Medicine, Boston Medical Center, Boston, MA
| | - Huaqing Zhao
- Department of Clinical Sciences, Temple University Hospital, Philadelphia, PA
| | - Vladimir Lakhter
- Department of Cardiovascular Diseases, Temple University Hospital, Philadelphia, PA
| | - Raghu Kolluri
- Department of Cardiovascular Medicine, OhioHealth/Riverside Methodist Hospital, Columbus, OH
| | - A Koneti Rao
- Hematology Section and Sol Sherry Thrombosis Research Center, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Riyaz Bashir
- Department of Cardiovascular Diseases, Temple University Hospital, Philadelphia, PA.
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14
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Abstract
Acute thrombosis and thrombocytopenia pose challenges to the clinician. Thrombocytopenia is naturally viewed as a risk factor for bleeding, and an association with acute thrombosis appears paradoxical. It presents typically as a medical emergency and requires treatment to be started before having confirmatory results. This review supports the attending clinician to recognise and manage conditions that are part of the thrombotic thrombocytopenic syndrome through four illustrative clinical cases. Common themes linking the underlying pathology and treatment are explored to highlight the continued relevance of this rare, but often devastating, presentation.
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Affiliation(s)
| | - Cheng-Hock Toh
- University of Liverpool, Liverpool, UK, and consultant in haematology, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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15
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Heart Lung Transplant 2023; 42:e1-e64. [PMID: 36805198 DOI: 10.1016/j.healun.2022.10.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/28/2022] [Indexed: 02/08/2023] Open
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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16
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Bernhardt AM, Copeland H, Deswal A, Gluck J, Givertz MM. The International Society for Heart and Lung Transplantation/Heart Failure Society of America Guideline on Acute Mechanical Circulatory Support. J Card Fail 2023; 29:304-374. [PMID: 36754750 DOI: 10.1016/j.cardfail.2022.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany.
| | - Hannah Copeland
- Department of Cardiac Surgery, Lutheran Health Physicians, Fort Wayne, Indiana
| | - Anita Deswal
- Department of Cardiology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jason Gluck
- Heart and Vascular Institute, Hartford Hospital, Hartford, Connecticut
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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17
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Mirzamohammadi F, Nnamani Silva ON, Leaf RK, Eberlin KR, Valerio IL. Chemoprophylaxis and Management of Venous Thromboembolism in Microvascular Surgery. Semin Plast Surg 2023; 37:57-72. [PMID: 36776808 PMCID: PMC9911223 DOI: 10.1055/s-0042-1760381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
This review aims to highlight the common pharmacological and nonpharmacological interventions utilized for thromboprophylaxis as well as flap salvage in microsurgery. A literature review was conducted in PubMed/National Center for Biotechnology Information, Scopus, Web of Science, and MEDLINE databases. Articles with a focus on thromboprophylaxis in microsurgical procedures spanning head and neck surgery, breast and extremity microvascular reconstruction, deep venous thrombosis/pulmonary embolus in microvascular surgery, and flap thrombosis and salvage were included in this review. The majority of available evidence supports mechanical venous thromboembolism (VTE) prophylaxis in all patients undergoing microsurgery given the presence of multiple risk factors for VTE within this particular patient population. Based on the literature review, addition of VTE chemoprophylactic agents is beneficial and an algorithmic approach to thromboprophylaxis in microsurgery patients and management of patients with thrombosis based on literature review and senior authors' experience is recommended and outlined.
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Affiliation(s)
- Fatemeh Mirzamohammadi
- Wright State University Plastic Surgery Residency Program, Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | | | - Rebecca K. Leaf
- Division of Hematology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Kyle R. Eberlin
- Division of Plastic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ian L. Valerio
- Division of Plastic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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18
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Warkentin TE, Sheppard JI, Whitlock RP. Temporal presentations of heparin-induced thrombocytopenia following cardiac surgery: A single-center, retrospective cohort study. J Thromb Haemost 2022; 20:2601-2616. [PMID: 35869817 PMCID: PMC9805231 DOI: 10.1111/jth.15826] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/05/2022] [Accepted: 07/18/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an important adverse drug reaction that can occur postcardiac surgery. Preoperative exposure to unfractionated heparin (UFH) is common, raising the issue of how frequently cardiac surgery-associated HIT occurs after immunizing preoperative exposure to heparin. OBJECTIVE To determine the frequency and clinical picture of HIT occurring within 4 days of cardiac surgery (early presentation) versus later presentations (typical, delayed). METHODS We identified patients with laboratory-confirmed HIT following cardiac surgery over 30 years in a single cardiac surgery center. Three different clinical presentations of HIT were identified: typical (HIT-related platelet count fall beginning between postoperative days [PODs] 5-10), delayed (patients with falls after POD10 or who presented following hospital discharge), and early (established before POD5, including during cardiac surgery [acute intraoperative HIT]). RESULTS Of 129 patients identified with HIT complicating cardiac surgery, 100 had typical and 16 had delayed presentation of HIT; only 13 patients (10.1%) presented with early HIT, all of whom had received exposure to UFH during the 10 days before cardiac surgery. No patient was identified in whom remote preoperative UFH exposure was implicated in explaining early HIT. Notably, five patients appeared to have had acute intraoperative HIT, without immediate adverse consequences. CONCLUSIONS Approximately 90% of patients with HIT after cardiac surgery appear to develop this complication due to immunization triggered by cardiac surgery; however, in approximately 10% of patients, early presentation during the first four PODs (or intraoperatively) can be explained by recent immunizing exposure to heparin.
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Affiliation(s)
- Theodore E. Warkentin
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonOntarioCanada
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
- Transfusion MedicineHamilton Regional Laboratory Medicine ProgramHamiltonOntarioCanada
- Service of Benign HematologyHamilton Health SciencesHamiltonOntarioCanada
| | - Jo‐Ann I. Sheppard
- Department of Pathology and Molecular MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Richard P. Whitlock
- Department of Surgery, Division of Cardiac SurgeryMcMaster UniversityHamiltonOntarioCanada
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19
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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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20
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Shiuan E, Sharma D, Ely EW, Moodabagil N, Tillman BF. Limb ischemia due to spontaneous heparin-induced thrombocytopenia as the primary presentation of acute COVID-19 infection. J Thromb Thrombolysis 2022; 54:367-371. [PMID: 35763168 PMCID: PMC9243831 DOI: 10.1007/s11239-022-02676-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/30/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) occurs with the development of IgG antibodies that bind complexes of heparin and platelet factor 4 (PF4), which activate platelets and result in a profoundly prothrombotic condition. In rare instances, this syndrome develops in the absence of proximate heparin administration, referred to as spontaneous HIT, for which less than three dozen cases have been reported. Spontaneous HIT is considered a subtype of "autoimmune HIT" (aHIT), characterized by platelet activation in the serotonin release assay (SRA) without the addition of exogenous heparin. Here, we report spontaneous HIT as the presenting feature in a patient with 2019 coronavirus disease infection (COVID-19).A 66-year-old male presented with progressive leg pain and was found to have a platelet count of 39 × 109/L and multiple lower extremity arterial thromboses requiring fasciotomy and thrombectomy. He had no recent hospitalization, heparin exposure, vaccinations, or known thrombophilia. He had a strongly positive IgG-specific enzyme-linked immunosorbent assay for heparin-PF4 antibodies, and the SRA was strongly positive both with and without the addition of heparin. He was treated successfully with bivalirudin, intravenous immunoglobulin, and apixaban.
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Affiliation(s)
- Eileen Shiuan
- Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, TN, USA
- Department of Internal Medicine, UCLA Medical Center, Los Angeles, CA, USA
| | - Deva Sharma
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Pathology, Microbiology and Immunology, Division of Transfusion Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - E Wesley Ely
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Brain Dysfunction, and Survivorship (CIBS) Center, Critical Illness, Nashville, TN, USA
- Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Nikil Moodabagil
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Benjamin F Tillman
- Department of Medicine, Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN, USA.
- Division of Laboratory Medicine, Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Medicine, VA Tennessee Valley Healthcare System, Nashville, TN, USA.
- Hematology/Oncology Division, Vanderbilt University Medical Center, 777 Preston Research Building, 2220 Pierce Avenue, 37232-5310, Nashville, TN, USA.
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21
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Farasatinasab M, Baloochzehi S, Moghamddam OM, Ansarinejad N, Mohammadi M, Nasiripour S. An Open-Label, Single-Arm, Pilot Intervention Study to Assess the Efficacy and Safety of Apixaban in Heparin-Induced Thrombocytopenia. J Clin Pharmacol 2022; 62:1379-1384. [PMID: 35656855 DOI: 10.1002/jcph.2096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/31/2022] [Indexed: 11/05/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is a serious adverse drug reaction due to its related risk of life- and limb-threatening thrombosis. Apixaban is a direct factor Xa inhibitor that may be intended as an ideal alternative for the management of HIT. In this open-label, single-arm, pilot intervention study, the efficacy and safety of apixaban were evaluated in 30 patients over the age of 18 with clinically suspected HIT (4Ts score 4 points or greater). Patients with mechanical heart valves, chronic kidney disease, hepatic impairment, and active bleeding were excluded. In all patients with inclusion criteria, heparin or enoxaparin was discontinued and apixaban was started. The dose of apixaban for HIT suspected patients were defined based on the reason for anticoagulant therapy. Endpoints included confirmed thrombosis, mortality, and adverse treatment-related events. After Apixaban therapy, platelet counts normalized in all patients, none of the 30 subjects developed new, progressive, or recurrent thrombosis, and only 1/30 patients developed hemorrhagic events. Five patients (16.7%) died, but the reason for death was not linked to thrombosis, hemorrhage, or adverse effects of apixaban. Along with the available emerging data, our results propose that apixaban could be a safe and effective drug for the management of suspected HIT in clinically stable patients. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Maryam Farasatinasab
- Department of Clinical Pharmacy, Firoozgar Clinical Research Development Center (FCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Saeedeh Baloochzehi
- School of Pharmacy-International Campus, Iran University of Medical Sciences, Tehran, Iran
| | - Omid Moradi Moghamddam
- Department of Critical Care Medicine, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Nafiseh Ansarinejad
- Department of Haematology and Oncology, Hazrat-e Rasool Akram University Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mahmonir Mohammadi
- Department of Cardiology, Azad University of Medical Sciences, Tehran, Iran
| | - Somayyeh Nasiripour
- Department of Clinical Pharmacy, Rasool Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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22
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Bendapudi PK. When Is It Preferable to Use Warfarin? NEJM EVIDENCE 2022; 1:EVIDccon2100011. [PMID: 38319225 DOI: 10.1056/evidccon2100011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Warfarin Versus Direct Oral AnticoagulantsDespite the growing popularity of DOACs, data in specific populations have provided a stark reminder that the equivalence (or superiority) of DOACs to warfarin cannot be assumed across the board. These results have raised an increasingly common clinical question: When is it preferable to use warfarin?
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Affiliation(s)
- Pavan K Bendapudi
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Boston
- Harvard Medical School, Boston
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23
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Marchetti M, Barelli S, Gleich T, Gomez FJ, Goodyer M, Grandoni F, Alberio L. Managing argatroban in heparin-induced thrombocytopenia: A retrospective analysis of 729 treatment days in 32 patients with confirmed heparin-induced thrombocytopenia. Br J Haematol 2022; 197:766-790. [PMID: 35358358 PMCID: PMC9324832 DOI: 10.1111/bjh.18120] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Matteo Marchetti
- Division of Hematology and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, UNIL, University of Lausanne, Lausanne, Switzerland
| | - Stefano Barelli
- Division of Hematology and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Tobias Gleich
- Division of Transfusion Medicine and Immunohematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Francisco J Gomez
- Division of Hematology and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Matthew Goodyer
- Division of Hematology and Laboratory of Hematology, Institut Central des Hôpitaux Valaisans, Sion, Switzerland
| | - Francesco Grandoni
- Division of Hematology and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Lorenzo Alberio
- Division of Hematology and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, UNIL, University of Lausanne, Lausanne, Switzerland
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24
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Kwan C, Reimers J, o'Gorman C, Bird R, Brown H. Multiterritorial strokes in the setting of spontaneous heparin-induced thrombocytopaenia syndrome. BMJ Case Rep 2022; 15:15/2/e244143. [PMID: 35228213 PMCID: PMC8886379 DOI: 10.1136/bcr-2021-244143] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
We present a case study of a 38-year-old man who developed arterial and venous thrombi, resulting in multiterritorial strokes, a pulmonary embolus and a cerebral venous sinus thrombosis in the setting of spontaneous heparin-induced thrombocytopaenia syndrome.
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Affiliation(s)
- Christopher Kwan
- Neurology, Princess Alexandra Hospital Health Service District, Brisbane, Queensland, Australia
| | - Jon Reimers
- Neurology, Princess Alexandra Hospital Health Service District, Brisbane, Queensland, Australia
| | - Cullen o'Gorman
- Neurology, Princess Alexandra Hospital Health Service District, Brisbane, Queensland, Australia
| | - Robert Bird
- Haematology, Princess Alexandra Hospital Health Service District, Woolloongabba, Queensland, Australia
| | - Helen Brown
- Neurology, Princess Alexandra Hospital Health Service District, Brisbane, Queensland, Australia
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25
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Cost-effectiveness analysis of alternative anticoagulation in suspected heparin-induced thrombocytopenia. Blood Adv 2022; 6:3114-3125. [PMID: 35147675 PMCID: PMC9131923 DOI: 10.1182/bloodadvances.2022007017] [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] [Received: 01/10/2022] [Accepted: 02/08/2022] [Indexed: 11/20/2022] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a life-threatening complication associated with high medical costs. Factor Xa inhibitors have gradually replace approved treatment with intravenous direct thrombin inhibitors despite their off-label indication, because of easier management and favorable economic profile.Whether they are cost-effective remains unclear. We evaluated the cost-effectiveness of approved and off-label anticoagulants in patients with suspected HIT, based on census data from the largest Swiss hospital between 2015 and 2018. We constructed a decision tree model that reflects important clinical events associated with HIT. Relevant cost data were obtained from the finance department or estimated based on the Swiss-wide cost tariff. We estimated averted adverse events (AE) and incremental cost-effectiveness ratio as primary outcome parameters. We performed deterministic and probabilistic sensitivity analyses with 2000 simulations to assess the robustness of our results. In the base-case analysis, the total cost of averting one AE was 49,565 CHF for argatroban; 30,380 CHF for fondaparinux, and 30,610 CHF for rivaroxaban; after adjusting for 4Ts score: 41,152 CHF (argatroban); 27,710 CHF (fondaparinux) and 37,699 CHF (rivaroxaban). Fondaparinux and rivaroxaban were more clinically-effective than argatroban with AE averted of 0.820; 0.834 and 0.917 for argatroban, fondaparinux and rivaroxaban, respectively. Treatment with fondaparinux resulted in less cost and more AE averted, hence dominating argatroban. Results were most sensitive to AE rates and prolongation of stay. Monte Carlo simulations affirmed our base-case analysis. This is the first cost-effectiveness analysis comparing argatroban with fondaparinux and rivaroxaban using primary data. Fondaparinux and rivaroxaban resulted in more averted AE but fondaparinux had greater cost savings. Fondaparinux could be a viable alternative to argatroban.
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26
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Hsu SY, Lin CY, Cheng MH. Heparin-induced thrombocytopenia and thrombosis in primary lymphedema patients who underwent vascularized lymph node transplantations. J Surg Oncol 2022; 125:958-967. [PMID: 35107827 DOI: 10.1002/jso.26811] [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: 12/28/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Heparin-induced thrombocytopenia and thrombosis (HITT) may result in microsurgical flap failure. This study investigated the outcomes of HITT in primary lymphedema patients who underwent vascularized lymph node transplantations (VLNT). METHODS Between 2012 and 2019, primary lymphedema patients who underwent VLNTs were retrospectively included. The 4Ts score was used to categorize patients into HITT (scores of 5-7) and non-HITT (score < 5) groups. Outcome evaluations included the re-exploration rate, success rate, circumferential differences, cellulitis episodes, and Lymphedema Specific Quality of Life Questionnaire (LYMQoL) scores. RESULTS Twenty-six and 15 patients with 31 and 16 VLNTs were included in the HITT and non-HITT groups, respectively. The HITT group had significantly greater first, second and third re-exploration rates of 38.7% (12/31), 25.7% (8/31), and 6.5% (2/31) than the non-HITT group (6.3%, 0%, and 0%, all p < 0.01), respectively. The platelet counts significantly decreased by 21.0% in the HITT group compared with the non-HITT group (14%) on postoperative Day one (p < 0.01) with a cutoff value of 17% and AUC = 0.88. CONCLUSIONS HITT may cause a high re-exploration rate of VLNTs in primary lymphedema patients. The 17% reduction in platelets on postoperative day one was an early sign for detecting HITT.
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Affiliation(s)
- Shao-Yun Hsu
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chia-Yu Lin
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Huei Cheng
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Center for Lymphedema Microsurgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Section of Plastic Surgery, The University of Michigan, Ann Arbor, Michigan, USA
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27
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Warkentin TE. Platelet-activating anti-PF4 disorders: an overview. Semin Hematol 2022; 59:59-71. [DOI: 10.1053/j.seminhematol.2022.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 11/11/2022]
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28
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A Multicenter Retrospective Evaluation of Direct Oral Anticoagulants for the Treatment of Heparin-Induced Thrombocytopenia. Am J Cardiovasc Drugs 2022; 22:417-424. [PMID: 35040095 DOI: 10.1007/s40256-021-00519-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) represent an off-label but potential alternative to traditional therapies for heparin-induced thrombocytopenia (HIT). OBJECTIVE The objective of this study was to evaluate the efficacy and safety of DOACs in patients with a diagnosis of laboratory-confirmed HIT. METHODS A multicenter retrospective cohort study of adult patients with HIT treated with apixaban, rivaroxaban, or dabigatran between 1 January 2013 and 1 January 2020 was performed. Patients with an intermediate or high pre-test probability for HIT and a positive antiplatelet factor 4/heparin complex assay, latex immunoturbidimetric assay, or serotonin release assay were included for analysis. The primary outcome was the composite of newly diagnosed venous or arterial thromboembolism, gangrene, or severe limb ischemia requiring amputation at 3 months following DOAC initiation. This study was approved by local institutional review boards, and the requirement for informed consent was waived. RESULTS A total of 77 patients from four health systems were included. The median 4Ts score was 5 (interquartile range 4.5-6), and 38 patients (49.4%) had a diagnosis of HIT with thrombosis. The most frequently used DOAC was apixaban (n = 51), followed by rivaroxaban (n = 24) and dabigatran (n = 2). In total, 63 (81.8%) patients received parenteral non-heparin anticoagulation prior to DOAC initiation. Nine patients (11.7%) experienced the primary outcome of HIT-related thrombotic events. Of the 14 patients who exclusively received DOAC therapy, none experienced the primary outcome. Major bleeding occurred in five (6.5%) patients. CONCLUSION In this retrospective cohort study, DOACs were associated with rates of thrombotic and hemorrhagic events similar to those with other therapies currently used in the treatment of HIT.
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29
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A challenging case of heparin-induced skin necrosis without thrombocytopenia. Blood Coagul Fibrinolysis 2022; 33:134-137. [DOI: 10.1097/mbc.0000000000001112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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30
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Malinauskiene L, Aleksandraviciute L, Kryzauskaite L, Savlan I. Rare complication of nadroparin injections: Skin necrosis and heparin-induced thrombocytopenia syndrome. Clin Case Rep 2022; 10:e05297. [PMID: 35079393 PMCID: PMC8765090 DOI: 10.1002/ccr3.5297] [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: 09/28/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 11/08/2022] Open
Abstract
We described a rare case of nadroparin-induced skin necrosis with thrombocytopenia. LMWH therapy is used in thrombosis prophylaxis, it is important to recognize that skin necrosis can be a part of HIT early in its course and change heparin or LMWH to non-heparin anticoagulants such as direct thrombin III inhibitors or anti-Xa anticoagulants.
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Affiliation(s)
- Laura Malinauskiene
- Vilnius UniversityInstitute of Clinical MedicineClinic of Chest Diseases, Immunology and AllergologyVilniusLithuania
- Vilnius University Hospital Santaros KlinikosVilniusLithuania
| | | | | | - Ilona Savlan
- Vilnius University Hospital Santaros KlinikosVilniusLithuania
- Vilnius UniversityInstitute of Clinical MedicineClinic of Gastroenterology, Nephrourology and SurgeryCentre of Hepatology, Gastroenterology and DieteticsVilniusLithuania
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31
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Abstract
OBJECTIVES Vaccine-induced immune thrombotic thrombocytopenia is an unexpected consequence of the coronavirus disease 2019 pandemic era. We reviewed the pathogenesis, clinical presentation, diagnosis, and treatment of this rare side effect. DATA SOURCES Online search of published medical literature through PubMed, Scopus, Web of Science, and Google Scholar using the terms "COVID-19," "vaccine," "thrombosis" was performed. STUDY SELECTION Articles were chosen for inclusion based on their relevance to coronavirus disease 2019, vaccine, and thrombosis. DATA SYNTHESIS Vaccine-induced immune thrombotic thrombocytopenia manifests most often as unusual thromboses (cerebral venous sinus thrombosis, splanchnic vein thrombosis) but sometimes also "usual" thromboses (arterial stroke, pulmonary embolism, deep-vein thrombosis), with oftentimes severe thrombocytopenia, that becomes clinically evident 5-30 days after adenovirus-vectored coronavirus disease 2019 vaccine administration. Most patients have disseminated intravascular coagulation. These features are the result of vaccine-triggered formation of anti-platelet factor 4 immunoglobulin G that activate platelets, clinically mimicking autoimmune heparin-induced thrombocytopenia. Early recognition based on thrombosis (sometimes, hemorrhage), thrombocytopenia, and d-dimer elevation within the day 5-30 postvaccine "window" is important given treatment with high-dose IV immunoglobulin plus nonheparin anticoagulation. CONCLUSIONS Vaccine-induced immune thrombotic thrombocytopenia is a serious complication of vaccination that is not feasible to anticipate or prevent. When the patient presents with sustained headache, neurologic symptoms/signs, abdominal pain, dyspnea, or limb pain/swelling beginning 5-30 days post vaccination, platelet count and d-dimer must be measured, and imaging for thrombosis performed. Confirmation of vaccine-induced immune thrombotic thrombocytopenia diagnosis should be ordered (platelet factor 4/polyanion enzyme-linked immunosorbent assay; platelet factor 4-enhanced platelet activation testing) as treatment is initiated (nonheparin anticoagulation, IV immunoglobulin).
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC
| | - Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, Hamilton, ON, Canada
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Carré J, Jourdi G, Gendron N, Helley D, Gaussem P, Darnige L. Recent Advances in Anticoagulant Treatment of Immune Thrombosis: A Focus on Direct Oral Anticoagulants in Heparin-Induced Thrombocytopenia and Anti-Phospholipid Syndrome. Int J Mol Sci 2021; 23:ijms23010093. [PMID: 35008518 PMCID: PMC8744910 DOI: 10.3390/ijms23010093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/17/2021] [Accepted: 12/17/2021] [Indexed: 12/25/2022] Open
Abstract
For more than 10 years, direct oral anticoagulants (DOACs) have been increasingly prescribed for the prevention and treatment of thrombotic events. However, their use in immunothrombotic disorders, namely heparin-induced thrombocytopenia (HIT) and antiphospholipid syndrome (APS), is still under investigation. The prothrombotic state resulting from the autoimmune mechanism, multicellular activation, and platelet count decrease, constitutes similarities between HIT and APS. Moreover, they both share the complexity of the biological diagnosis. Current treatment of HIT firstly relies on parenteral non-heparin therapies, but DOACs have been included in American and French guidelines for a few years, providing the advantage of limiting the need for treatment monitoring. In APS, vitamin K antagonists are conversely the main treatment (+/− anti-platelet agents), and the use of DOACs is either subject to precautionary recommendations or is not recommended in severe APS. While some randomized controlled trials have been conducted regarding the use of DOACs in APS, only retrospective studies have examined HIT. In addition, vaccine-induced immune thrombotic thrombocytopenia (VITT) is now a part of immunothrombotic disorders, and guidelines have been created concerning an anticoagulant strategy in this case. This literature review aims to summarize available data on HIT, APS, and VITT treatments and define the use of DOACs in therapeutic strategies.
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Affiliation(s)
- Julie Carré
- Hematology Department, CHU de Poitiers, 86021 Poitiers, France
- Correspondence:
| | - Georges Jourdi
- Research Center, Montreal Heart Institute, Montreal, QC H1T 1C8, Canada;
- Faculty of Pharmacy, Université de Montréal, Montreal, QC H3T 1J4, Canada
| | - Nicolas Gendron
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, University of Paris, 75006 Paris, France; (N.G.); (P.G.); (L.D.)
- Biosurgical Research Lab (Carpentier Foundation), AP-HP, 75015 Paris, France
- Biological Hematology Department, Assistance Publique-Hôpitaux de Paris-Centre (AP-HP.CUP), 75015 Paris, France;
| | - Dominique Helley
- Biological Hematology Department, Assistance Publique-Hôpitaux de Paris-Centre (AP-HP.CUP), 75015 Paris, France;
- Paris Cardiovascular Research Center, INSERM UMR-S970, 75015 Paris, France
| | - Pascale Gaussem
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, University of Paris, 75006 Paris, France; (N.G.); (P.G.); (L.D.)
- Biological Hematology Department, Assistance Publique-Hôpitaux de Paris-Centre (AP-HP.CUP), 75015 Paris, France;
| | - Luc Darnige
- Innovative Therapies in Haemostasis, INSERM UMR-S1140, University of Paris, 75006 Paris, France; (N.G.); (P.G.); (L.D.)
- Biological Hematology Department, Assistance Publique-Hôpitaux de Paris-Centre (AP-HP.CUP), 75015 Paris, France;
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Voigtlaender M, Langer F. Management of Vascular Thrombosis in Patients with Thrombocytopenia. Hamostaseologie 2021; 42:19-28. [PMID: 34933376 DOI: 10.1055/a-1675-7824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Platelets play critical roles in hemostasis and thrombosis. While low platelet counts increase the risk of bleeding, antithrombotic drugs, including anticoagulants and antiplatelet agents, are used to treat thromboembolic events. Thus, the management of thrombosis in patients with low platelet counts is challenging with hardly any evidence available to guide treatment. Recognition of the underlying cause of thrombocytopenia is essential for assessing the bleeding risk and tailoring therapeutic options. A typical clinical scenario is the occurrence of venous thromboembolism (VTE) in cancer patients experiencing transient thrombocytopenia during myelosuppressive chemotherapy. In such patients, the severity of thrombocytopenia, thrombus burden, clinical symptoms, and the timing of VTE relative to thrombocytopenia must be considered. In clinical practice, distinct hematological disorders characterized by low platelet counts and a thrombogenic state require specific diagnostics and treatment. These include the antiphospholipid syndrome, heparin-induced thrombocytopenia (HIT) and (spontaneous) HIT syndromes, disseminated intravascular coagulation, and paroxysmal nocturnal hemoglobinuria.
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Affiliation(s)
- Minna Voigtlaender
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
| | - Florian Langer
- II. Medizinische Klinik und Poliklinik, Hubertus Wald Tumorzentrum - Universitäres Cancer Center Hamburg (UCCH), Universitätsklinikum Eppendorf, Hamburg, Germany
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Swan D, Enright H, Desmond R, Le G, El Hassadi E, Hennessy B, Lynott F, O'Keeffe D, Crowley M, Smyth L, Perera K, Jennings C, Ni Ainle F, Coll J, Ryan K, O'Donnell J, Lavin M, O'Connell N. Vaccine-induced thrombosis and thrombocytopenia (VITT) in Ireland: A review of cases and current practices. THROMBOSIS UPDATE 2021; 5:100086. [PMID: 38620810 PMCID: PMC8578028 DOI: 10.1016/j.tru.2021.100086] [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] [Received: 09/28/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
Since the beginning of the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS CoV-2) virus pandemic, several highly effective and safe vaccines have been produced at remarkable speed. Following global implementation of vaccination programmes, cases of thrombosis with thrombocytopenia following administration of adenoviral vector-based vaccines started being reported. In this review we discuss the known pathogenesis and epidemiology of so-called vaccine induced thrombocytopenia and thrombosis (VITT). We consider the available guidelines, diagnostic laboratory tests and management options for these patients. Finally, we discuss important unanswered questions and areas for future research in this novel pathoclinical entity.
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Affiliation(s)
- D Swan
- National Coagulation Centre, St James' Hospital, Dublin, Ireland
| | - H Enright
- Tallaght University Hospital, Dublin, Ireland
| | - R Desmond
- Tallaght University Hospital, Dublin, Ireland
| | - G Le
- Tallaght University Hospital, Dublin, Ireland
| | - E El Hassadi
- Waterford University Hospital, Waterford, Ireland
| | - B Hennessy
- Waterford University Hospital, Waterford, Ireland
| | - F Lynott
- Waterford University Hospital, Waterford, Ireland
| | - D O'Keeffe
- University Hospital Limerick, Limerick, Ireland
| | - M Crowley
- Cork University Hospital, Cork, Ireland
| | - L Smyth
- St Vincent's University Hospital, Dublin, Ireland
| | - K Perera
- Midland Regional Hospital Tullamore, Tullamore, Ireland
| | - C Jennings
- Midland Regional Hospital Tullamore, Tullamore, Ireland
| | - F Ni Ainle
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - J Coll
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - K Ryan
- National Coagulation Centre, St James' Hospital, Dublin, Ireland
| | - J O'Donnell
- National Coagulation Centre, St James' Hospital, Dublin, Ireland
| | - M Lavin
- National Coagulation Centre, St James' Hospital, Dublin, Ireland
| | - N O'Connell
- National Coagulation Centre, St James' Hospital, Dublin, Ireland
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35
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Saengboon S, Chinthammitr Y, Kanitsap N. Spontaneous heparin-induced thrombocytopaenia with adrenal haemorrhage following orthopaedic surgery: a case report and literature review. BMJ Case Rep 2021; 14:e245385. [PMID: 34844962 PMCID: PMC8634289 DOI: 10.1136/bcr-2021-245385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 11/03/2022] Open
Abstract
A 68-year-old woman was admitted to the hospital for elective total knee arthroplasty in both knees without preceding heparin exposure. She developed adrenal haemorrhage and thrombocytopaenia on postoperative day 12, followed by right leg arterial occlusion and multiple venous intra-abdominal sites thrombosis. After given unfractionated heparin to treat arterial occlusion, platelet count was gradually declined. Spontaneous heparin-induced thrombocytopaenia was diagnosed by heparin-induced platelet activation test with light transmission aggregometry. The patient was successfully treated with fondaparinux and intravenous immunoglobulin. Apixaban was given after recovery of platelet count. Resolution of both thrombus along aorta and adrenal haemorrhage were shown by CT of whole abdomen after 2 months of treatment. Our case demonstrates that this serious complication is important but seldom recognised early.
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Affiliation(s)
- Supawee Saengboon
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Yingyong Chinthammitr
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nonglak Kanitsap
- Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
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36
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Tucker M, Padarti A. Thrombocytopenia Due to Direct Oral Anticoagulation and Low-Molecular-Weight Heparin. Cureus 2021; 13:e18757. [PMID: 34804643 PMCID: PMC8592300 DOI: 10.7759/cureus.18757] [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] [Accepted: 10/13/2021] [Indexed: 11/05/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are becoming increasingly prevalent in the general population for anticoagulation. However, rare adverse effects from these medications are still being discovered. Thrombocytopenia has previously been reported with these medications, but its clinical significance is still unknown. We present a patient who developed thrombocytopenia from apixaban and who subsequently developed a severe presentation of heparin-induced thrombocytopenia (HIT) from enoxaparin. This raises the possibility that thrombocytopenia from oral anticoagulants increases the likelihood of the development of heparin-induced thrombocytopenia.
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Affiliation(s)
- Madeline Tucker
- Neurology, University of South Alabama College of Medicine, Mobile, USA
| | - Akhil Padarti
- Neurology, University of South Alabama College of Medicine, Mobile, USA
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37
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Doppler ultrasound screening in patients with newly diagnosed heparin-induced thrombocytopenia. Blood Adv 2021; 5:4575-4577. [PMID: 34619754 PMCID: PMC8759129 DOI: 10.1182/bloodadvances.2021005254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/07/2021] [Indexed: 11/24/2022] Open
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Cirbus K, Simone P, Austin Szwak J. Rivaroxaban and apixaban for the treatment of suspected or confirmed heparin-induced thrombocytopenia. J Clin Pharm Ther 2021; 47:112-118. [PMID: 34704283 DOI: 10.1111/jcpt.13537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/09/2021] [Accepted: 09/22/2021] [Indexed: 01/04/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Heparin-induced thrombocytopenia (HIT) is an adverse hematologic drug reaction that results in thrombocytopenia. This potentially life-threatening event is due to the administration of heparin products, such as unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH). The incidence of HIT occurs in <0.1%-7% of hospitalized patients treated with heparin products, with a risk of thrombosis as high as 50%. In 2018, the American Society of Hematology (ASH) recommended the utilization of direct oral anticoagulants (DOACs) in clinically stable patients at average bleeding risk with HIT. The objective of this study was to evaluate the prescribing patterns of rivaroxaban and apixaban for the treatment of suspected or confirmed HIT. METHODS This was a retrospective chart review from January 2013 through October 2019 at the University of Chicago Medicine. Twelve patients were identified to have received a DOAC for suspected or confirmed HIT. RESULTS Rivaroxaban was utilized in seven (58%) patients, six of whom received argatroban prior to starting rivaroxaban. Five (71%) of these patients were started on the recommended dose of rivaroxaban for VTE. Apixaban was utilized in five (42%) patients; four patients were started on argatroban and transitioned to apixaban. One patient was started on the suggested dose of apixaban for VTE. WHAT IS NEW AND CONCLUSION After starting DOACs for suspected HIT, no patients had new thrombosis during hospitalization. Eight patients (67%) followed up at our institution within 6 months of their discharge date. No subsequent thrombi formation were identified for any of these patients. The results of this study add to the expanding literature regarding the safety and efficacy of DOAC use in HIT, and indicate DOACs are being increasingly utilized for the treatment of confirmed or suspected HIT.
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Affiliation(s)
- Kristen Cirbus
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, Illinois, USA
| | - Pamela Simone
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jennifer Austin Szwak
- Department of Pharmacy Services, University of Chicago Medicine, Chicago, Illinois, USA
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39
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(Thrombosis of temporary caval filter in a patient with subacute heparin-induced thrombocytopenia). COR ET VASA 2021. [DOI: 10.33678/cor.2021.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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40
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Sulakshana S, Nayak SS, Perumal S, Das BP. Heparin-Induced Thrombocytopenia in COVID-19: A Systematic Review. Anesth Essays Res 2021; 15:341-347. [PMID: 35422550 PMCID: PMC9004278 DOI: 10.4103/aer.aer_151_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 12/22/2022] Open
Abstract
Background: It has been more than a year since the whole world is struggling with COVID-19 pandemic and may experience resurgences in the near future. Along with severe pneumonia, this disease is notorious for extensive thromboembolic manifestations. That is why experts advocated aggressive anticoagulation as a part of the therapy since the beginning. However, from May 2020 onwards, cases of heparin-induced thrombocytopenia (HIT) are being reported. HIT in itself is an autoimmune entity leading to life-threatening thrombosis in the setting of thrombocytopenia. Continuation of heparin can have disastrous consequences in case of unrecognized HIT. Hence, timely recognition of HIT is of utmost value to modify the anticoagulation strategy and salvaging lives. We performed a systemic review trying to find all reported cases of HIT in COVID-19. Methods: It involved extensive search of the databases including PubMed, Google Scholar, Scopus, and Embase in an attempt to find all reported literature in the last 1 year (November 1, 2019–December 25, 2020) using keywords in various combinations. Literature search resulted in a total of 27 articles and 12 articles were finally selected based on the study design and their relevance pertaining to the intervention done and the outcome of interest. Results: A total of 35 patients were included (mean age 56.7 ± 12.8 years, male-to-female ratio = 2:1). The most frequent comorbidity was hypertension. Fifty-seven percent of cases were with low-molecular weight heparin and the rest with unfractionated heparin. Confirmatory functional assay was done in 85.7% of cases (67% by serotonin-release assay [SRA] and 33% by heparin-induced platelet aggregation [HIPA]). All cases tested with HIPA were positive, while with SRA, only 30% were positive. The most common alternate anticoagulation used was argatroban infusion. The new arterial thrombotic event was seen in only 5.7% of cases as repeat myocardial infarction, stroke, and splenic infarction, while clinically significant bleeding was seen in 17.1% of cases. Fifty percent of bleeding episodes were seen where conventional doses of argatroban were used, while no mortality was seen with low-dose argatroban infusion. However, only 45.7% of patients were discharged, 31.4% of patients died, while the outcome was pending for 23% of patients. Conclusion: Severe endotheliitis and immune dysregulation giving rise to HIT antibodies and antiphospholipid antibodies have been demonstrated in COVID-19 and modifying our therapy becomes indispensable when it is pathogenic with potentially fatal consequences. In the light of interim results of REMAP-CAP study in severe COVID-19 cases where heparin does not improve the outcome, the present anticoagulation strategy needs re-evaluation. Unrecognized HIT can be catastrophic and close clinical monitoring is required for patients on heparin therapy.
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Affiliation(s)
- Sulakshana Sulakshana
- Department of Anaesthesiology and Critical Care, Heritage Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
| | | | - Siva Perumal
- Department of Anaesthesiology and Critical Care, SVMCH and RC, Puducherry, India
| | - Badri Prasad Das
- Department of Anaesthesiology and Critical Care, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
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Carré J, Guérineau H, Le Beller C, Mauge L, Huynh B, Nili R, Planquette B, Clauser S, Smadja DM, Helley D, Lillo-Le Louet A, Gendron N, Calmette L. Direct Oral Anticoagulants as Successful Treatment of Heparin-Induced Thrombocytopenia: A Parisian Retrospective Case Series. Front Med (Lausanne) 2021; 8:713649. [PMID: 34422867 PMCID: PMC8374891 DOI: 10.3389/fmed.2021.713649] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/08/2021] [Indexed: 02/02/2023] Open
Abstract
Background: Heparin-induced thrombocytopenia (HIT) is a prothrombotic life-threatening disorder caused by an adverse reaction to heparin exposure. In this context, it is imperative to stop heparin immediately and to replace it by a non-heparin anticoagulant therapy. Despite their advantages, the use of direct oral anticoagulants (DOACs) is only emerging for HIT treatment, and their use remains rare. Objective: To improve our knowledge on the emerging role of DOACs as treatment of HIT and give an overview of our local practices in this context. Patients/Methods: This is a multi-centric retrospective case series of HIT patients referred to our Parisian pharmacovigilance network and treated with DOACs. Results: We report the cases of seven patients from four healthcare centers, diagnosed with HIT (4T score ≥ 4, positive anti-PF4/heparin immunoassay and positive serotonin-release assay) and treated with DOACs. After a few days on substitutive parenteral treatment (n = 6) or directly at HIT diagnosis (n = 1), these patients were treated with either rivaroxaban (n = 6) or apixaban (n = 1) during acute HIT phase. Mean time to platelet count recovery after heparin discontinuation was 3.3 days (range 3-5). No patient experienced major or clinically relevant non-major bleeding or thrombosis that could be related to DOAC treatment during follow-up. Conclusions: Our cases studies are consistent with recent guidelines credit to the potential and safe use of DOAC during acute HIT in clinically stable patients.
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Affiliation(s)
- Julie Carré
- Innovative Therapies in Haemostasis, INSERM, Université de Paris, Paris, France.,Hematology Department, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris, Paris, France
| | - Hippolyte Guérineau
- Hematology-Immunology-Transfusion Department, Hôpitaux Universitaires Paris Ile De France Ouest, Université Versailles Saint Quentin, Boulogne, France
| | - Christine Le Beller
- Innovative Therapies in Haemostasis, INSERM, Université de Paris, Paris, France.,Pharmacovigilance Department, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris, Paris, France
| | - Laëtitia Mauge
- Hematology Department, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris, Paris, France.,INSERM UMR-S970, Centre de Recherche Cardiovasculaire de Paris, Paris, France
| | - Benoit Huynh
- Hematology Department, Institut Mutualiste Montsouris, Paris, France
| | - Roya Nili
- Innovative Therapies in Haemostasis, INSERM, Université de Paris, Paris, France.,Pharmacovigilance Department, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris, Paris, France
| | - Benjamin Planquette
- Innovative Therapies in Haemostasis, INSERM, Université de Paris, Paris, France.,Respiratory Medicine Department and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris, Centre-Université de Paris, Paris, France
| | - Sylvain Clauser
- Hematology-Immunology-Transfusion Department, Hôpitaux Universitaires Paris Ile De France Ouest, Université Versailles Saint Quentin, Boulogne, France
| | - David M Smadja
- Innovative Therapies in Haemostasis, INSERM, Université de Paris, Paris, France.,Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris, Centre-Université de Paris, Paris, France
| | - Dominique Helley
- Hematology Department, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris, Paris, France.,INSERM UMR-S970, Centre de Recherche Cardiovasculaire de Paris, Paris, France
| | - Agnès Lillo-Le Louet
- Innovative Therapies in Haemostasis, INSERM, Université de Paris, Paris, France.,Pharmacovigilance Department, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris, Paris, France
| | - Nicolas Gendron
- Innovative Therapies in Haemostasis, INSERM, Université de Paris, Paris, France.,Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance Publique Hôpitaux de Paris, Centre-Université de Paris, Paris, France
| | - Leyla Calmette
- Hematology-Immunology-Transfusion Department, Hôpitaux Universitaires Paris Ile De France Ouest, Université Versailles Saint Quentin, Boulogne, France
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42
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Rizk JG, Gupta A, Sardar P, Henry BM, Lewin JC, Lippi G, Lavie CJ. Clinical Characteristics and Pharmacological Management of COVID-19 Vaccine-Induced Immune Thrombotic Thrombocytopenia With Cerebral Venous Sinus Thrombosis: A Review. JAMA Cardiol 2021; 6:1451-1460. [PMID: 34374713 DOI: 10.1001/jamacardio.2021.3444] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance The COVID-19 pandemic saw one of the fastest developments of vaccines in an effort to combat an out-of-control pandemic. The 2 most common COVID-19 vaccine platforms currently in use, messenger RNA (mRNA) and adenovirus vector, were developed on the basis of previous research in use of this technology. Postauthorization surveillance of COVID-19 vaccines has identified safety signals, including unusual cases of thrombocytopenia with thrombosis reported in recipients of adenoviral vector vaccines. One of the devastating manifestations of this syndrome, termed vaccine-induced immune thrombotic thrombocytopenia (VITT), is cerebral venous sinus thrombosis (CVST). This review summarizes the current evidence and indications regarding biology, clinical characteristics, and pharmacological management of VITT with CVST. Observations VITT appears to be similar to heparin-induced thrombocytopenia (HIT), with both disorders associated with thrombocytopenia, thrombosis, and presence of autoantibodies to platelet factor 4 (PF4). Unlike VITT, HIT is triggered by recent exposure to heparin. Owing to similarities between these 2 conditions and lack of high-quality evidence, interim recommendations suggest avoiding heparin and heparin analogues in patients with VITT. Based on initial reports, female sex and age younger than 60 years were identified as possible risk factors for VITT. Treatment consists of therapeutic anticoagulation with nonheparin anticoagulants and prevention of formation of autoantibody-PF4 complexes, the latter being achieved by administration of high-dose intravenous immunoglobin (IVIG). Steroids, which can theoretically inhibit the production of new antibodies, have been used in combination with IVIG. In severe cases, plasma exchange should be used for clearing autoantibodies. Monoclonal antibodies, such as rituximab and eculizumab, can be considered when other therapies fail. Routine platelet transfusions, aspirin, and warfarin should be avoided because of the possibility of worsening thrombosis and magnifying bleeding risk. Conclusions and Relevance Adverse events like VITT, while uncommon, have been described despite vaccination remaining the most essential component in the fight against the COVID-19 pandemic. While it seems logical to consider the use of types of vaccines (eg, mRNA-based administration) in individuals at high risk, treatment should consist of therapeutic anticoagulation mostly with nonheparin products and IVIG.
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Affiliation(s)
- John G Rizk
- Arizona State University, Edson College, Phoenix, Arizona
| | - Aashish Gupta
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Partha Sardar
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana
| | - Brandon Michael Henry
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John C Lewin
- National Coalition on Health Care, Washington, DC
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Carl J Lavie
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, Louisiana
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43
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Páramo JA, Lozano ML, González-Porras JR, Mateo J. Current status of diagnosis and treatment of heparin-induced thrombocytopenia (HIT). Med Clin (Barc) 2021; 158:82-89. [PMID: 34311973 DOI: 10.1016/j.medcli.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 12/01/2022]
Affiliation(s)
- José A Páramo
- Servicio de Hematología Clínica, Universidad de Navarra, Pamplona, España; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, España; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, España.
| | - Mª Luisa Lozano
- Departmento de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Murcia, España; Universidad de Murcia, IMIB-Arrixaca, CB15/00055-CIBERER, Murcia, España
| | | | - José Mateo
- Unidad de Hemostasia y Trombosis, Servicio de Hematología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
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Nilius H, Kaufmann J, Cuker A, Nagler M. Comparative effectiveness and safety of anticoagulants for the treatment of heparin-induced thrombocytopenia. Am J Hematol 2021; 96:805-815. [PMID: 33857342 PMCID: PMC8252596 DOI: 10.1002/ajh.26194] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The effectiveness and safety of non-heparin anticoagulants for the treatment of heparin-induced thrombocytopenia (HIT) are not fully established, and the optimal treatment strategy is unknown. In a systematic review and meta-analysis, we aimed to determine precise rates of platelet recovery, new or progressive thromboembolism (TE), major bleeding, and death for all non-heparin anticoagulants and to study potential sources of variability. METHODS Following a detailed protocol (PROSPERO: CRD42020219027), EMBASE and Medline were searched for all studies reporting clinical outcomes of patients treated with non-heparin anticoagulants (argatroban, danaparoid, fondaparinux, direct oral anticoagulants [DOAC], bivalirudin, and other hirudins) for acute HIT. Proportions of patients with the outcomes of interest were pooled using a random-effects model for each drug. The influence of the patient population, the diagnostic test used, the study design, and the type of article was assessed. RESULTS Out of 3194 articles screened, 92 studies with 119 treatment groups describing 4698 patients were included. The pooled rates of platelet recovery ranged from 74% (bivalirudin) to 99% (fondaparinux), TE from 1% (fondaparinux) to 7% (danaparoid), major bleeding from 1% (DOAC) to 14% (bivalirudin), and death from 7% (fondaparinux) to 19% (bivalirudin). Confidence intervals were mostly overlapping, and results were not influenced by patient population, diagnostic test used, study design, or type of article. DISCUSSION Effectiveness and safety outcomes were similar among various anticoagulants, and significant factors affecting these outcomes were not identified. These findings support fondaparinux and DOACs as viable alternatives to conventional anticoagulants for treatment of acute HIT in clinical practice.
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Affiliation(s)
- Henning Nilius
- Department of Clinical ChemistryInselspital, Bern University HospitalBernSwitzerland
| | - Jonas Kaufmann
- Department of Clinical ChemistryInselspital, Bern University HospitalBernSwitzerland
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Michael Nagler
- Department of Clinical ChemistryInselspital, Bern University HospitalBernSwitzerland
- University of BernBernSwitzerland
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45
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Warkentin TE, Greinacher A. Spontaneous HIT syndrome: Knee replacement, infection, and parallels with vaccine-induced immune thrombotic thrombocytopenia. Thromb Res 2021; 204:40-51. [PMID: 34144250 DOI: 10.1016/j.thromres.2021.05.018] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/26/2021] [Accepted: 05/28/2021] [Indexed: 12/21/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is characterized clinically by thrombocytopenia, hypercoagulability, and increased thrombosis risk, and serologically by platelet-activating anti-platelet factor 4 (PF4)/heparin antibodies. Heparin-"induced" acknowledges that HIT is usually triggered by a proximate immunizing exposure to heparin. However, certain non-heparin medications (pentosan polysulfate, hypersulfated chondroitin sulfate, fondaparinux) can trigger "HIT". Further, naturally-occurring polyanions (bacterial lipopolysaccharide, DNA/RNA) can interact with PF4 to recapitulate HIT antigens. Indeed, immunologic presensitization to naturally-occurring polyanions could explain why HIT more closely resembles a secondary, rather than a primary, immune response. In 2008 it was first reported that a HIT-mimicking disorder can occur without any preceding exposure to heparin or polyanionic medications. Termed "spontaneous HIT syndrome", two subtypes are recognized: (a) surgical (post-orthopedic, especially post-total knee arthroplasty, and (b) medical (usually post-infectious). Recently, COVID-19 adenoviral vector vaccination has been associated with a thrombotic thrombocytopenic disorder associated with positive PF4-dependent enzyme-immunoassays and serum-induced platelet activation that is maximal when PF4 is added. Vaccine-induced immune thrombotic thrombocytopenia (VITT) features unusual thromboses (cerebral venous thrombosis, splanchnic vein thrombosis) similar to those seen in spontaneous HIT syndrome. The emerging concept is that classic HIT reflects platelet-activating anti-PF4/heparin antibodies whereas spontaneous HIT syndrome and other atypical "autoimmune HIT" presentations (delayed-onset HIT, persisting HIT, heparin "flush" HIT) reflect heparin-independent platelet-activating anti-PF4 antibodies-although the precise relationships between PF4 epitope targets and the clinical syndromes remain to be determined. Treatment of spontaneous HIT syndrome includes non-heparin anticoagulation (direct oral Xa inhibitors favored over direct thrombin inhibitors) and high-dose immunoglobulin.
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Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, and Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Hamilton Regional Laboratory Medicine Program (Transfusion Medicine), Hamilton, Ontario, Canada; Service of Benign Hematology, Hamilton Health Sciences (Hamilton General Hospital), Canada.
| | - Andreas Greinacher
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
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46
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Greinacher A, Thiele T, Warkentin TE, Weisser K, Kyrle PA, Eichinger S. Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination. N Engl J Med 2021; 384:2092-2101. [PMID: 33835769 PMCID: PMC8095372 DOI: 10.1056/nejmoa2104840] [Citation(s) in RCA: 1534] [Impact Index Per Article: 511.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Several cases of unusual thrombotic events and thrombocytopenia have developed after vaccination with the recombinant adenoviral vector encoding the spike protein antigen of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (ChAdOx1 nCov-19, AstraZeneca). More data were needed on the pathogenesis of this unusual clotting disorder. METHODS We assessed the clinical and laboratory features of 11 patients in Germany and Austria in whom thrombosis or thrombocytopenia had developed after vaccination with ChAdOx1 nCov-19. We used a standard enzyme-linked immunosorbent assay to detect platelet factor 4 (PF4)-heparin antibodies and a modified (PF4-enhanced) platelet-activation test to detect platelet-activating antibodies under various reaction conditions. Included in this testing were samples from patients who had blood samples referred for investigation of vaccine-associated thrombotic events, with 28 testing positive on a screening PF4-heparin immunoassay. RESULTS Of the 11 original patients, 9 were women, with a median age of 36 years (range, 22 to 49). Beginning 5 to 16 days after vaccination, the patients presented with one or more thrombotic events, with the exception of 1 patient, who presented with fatal intracranial hemorrhage. Of the patients with one or more thrombotic events, 9 had cerebral venous thrombosis, 3 had splanchnic-vein thrombosis, 3 had pulmonary embolism, and 4 had other thromboses; of these patients, 6 died. Five patients had disseminated intravascular coagulation. None of the patients had received heparin before symptom onset. All 28 patients who tested positive for antibodies against PF4-heparin tested positive on the platelet-activation assay in the presence of PF4 independent of heparin. Platelet activation was inhibited by high levels of heparin, Fc receptor-blocking monoclonal antibody, and immune globulin (10 mg per milliliter). Additional studies with PF4 or PF4-heparin affinity purified antibodies in 2 patients confirmed PF4-dependent platelet activation. CONCLUSIONS Vaccination with ChAdOx1 nCov-19 can result in the rare development of immune thrombotic thrombocytopenia mediated by platelet-activating antibodies against PF4, which clinically mimics autoimmune heparin-induced thrombocytopenia. (Funded by the German Research Foundation.).
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Affiliation(s)
- Andreas Greinacher
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Thomas Thiele
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Theodore E Warkentin
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Karin Weisser
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Paul A Kyrle
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
| | - Sabine Eichinger
- From Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald (A.G., T.T.), and the Division of Safety of Medicinal Products and Medical Devices, Paul-Ehrlich-Institut (Federal Institute for Vaccines and Biomedicines), Langen (K.W.) - both in Germany; the Departments of Pathology and Molecular Medicine and of Medicine, McMaster University, Hamilton, ON, Canada (T.E.W.); and the Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna (P.A.K., S.E.)
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47
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Management of heparin-induced thrombocytopenia: systematic reviews and meta-analyses. Blood Adv 2021; 4:5184-5193. [PMID: 33095876 DOI: 10.1182/bloodadvances.2020002963] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/22/2020] [Indexed: 01/01/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic adverse drug reaction occurring in <0.1% to 7% of patients receiving heparin products depending on the patient population and type of heparin. Management of HIT is highly dependent on a sequence of tests for which clinicians may or may not have the results when care decisions need to be made. We conducted systematic reviews of the effects of management strategies in persons with acute HIT, subacute HIT A or B, and remote HIT. We searched Medline, EMBASE, and the Cochrane Database through July 2019 for previously published systematic reviews and primary studies. Two investigators independently screened and extracted data and assessed the certainty of the evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. We found primarily noncomparative studies and case series assessing effects of treatments, which led to low to very low certainty evidence. There may be little to no difference in the effects between nonheparin parenteral anticoagulants and direct oral anticoagulants in acute HIT. The benefits of therapeutic-intensity may be greater than prophylactic-intensity anticoagulation. Using inferior vena cava filters or platelet transfusion may result in greater harm than not using these approaches. Evidence for management in special situations, such as for patients undergoing cardiovascular interventions or renal replacement therapy, was also low to very low certainty. Additional research to evaluate nonheparin anticoagulants is urgently needed, and the development of novel treatments that reduce thrombosis without increasing hemorrhage should be a priority.
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48
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Costache RS, Dragomirică AS, Dumitraș EA, Mariana J, Căruntu A, Popescu A, Costache DO. Portal vein thrombosis: A concise review (Review). Exp Ther Med 2021; 22:759. [PMID: 34035856 DOI: 10.3892/etm.2021.10191] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/19/2021] [Indexed: 12/14/2022] Open
Abstract
Portal vein thrombosis (PVT) is a frequent complication in cirrhotic patients, but it may also exist as a basic vascular condition even without any liver damage. Local and systemic factors play a significant role in the pathogenesis of PVT; yet, in practice, more than one factor may be identified. PVT can be considered a result of liver fibrosis and hepatic insufficiency. The JAK2 mutation has been accepted as a factor producing PVT. In general, the anticoagulants are recommended but this therapy should be used carefully in treating patients that associate coagulopathy or thrombocytopenia and esophageal varices. Acute PVT without bowel infarction has a good prognosis. In liver cirrhosis, the mortality due to hemorrhage is higher than in chronic PVT. Therefore, for the patients with PVT, the survival rate is decreased by 55% in two years, due to hepatic insufficiency. Regarding the treatment, LMWH (low molecular weight heparine) is the most utilized in patients with cirrhosis, non-malignancies, infections, or those who are awaiting a liver transplant. DOACs (direct-acting oral anticoagulants) may be used in the rest of the medical conditions, being safe and equal to LMWH.
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Affiliation(s)
- Raluca S Costache
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania.,5th Clinical Department, Gastroenterology and Internal Medicine Discipline, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Andreea S Dragomirică
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania
| | - Elena A Dumitraș
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania
| | - Jinga Mariana
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania.,5th Clinical Department, Gastroenterology and Internal Medicine Discipline, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ana Căruntu
- Department of Maxillofacial Surgery, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania
| | - Andrada Popescu
- Department of Gastroenterology, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania.,5th Clinical Department, Gastroenterology and Internal Medicine Discipline, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Daniel O Costache
- Department of Research, 'Carol Davila' University Central Emergency Military Hospital, 010825 Bucharest, Romania
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Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H, Lip GYH, Deneke T, Dagres N, Boriani G, Chao TF, Choi EK, Hills MT, Santos IDS, Lane DA, Atar D, Joung B, Cole OM, Field M. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23:1612-1676. [PMID: 33895845 DOI: 10.1093/europace/euab065] [Citation(s) in RCA: 423] [Impact Index Per Article: 141.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, Division of Electrophysiology, University Heart Center Zurich, Switzerland
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital / Department of Gerontology Trinity College, Dublin, Ireland
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Braunschweig, Germany
| | - Pieter Cornu
- Faculty of Medicine and Pharmacy, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Desteghe
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK
| | - Hein Heidbüchel
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan & Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Boyoung Joung
- Yonsei University College of Medicine, Cardiology Department, Seoul, Republic of Korea
| | - Oana Maria Cole
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
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50
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Lai CMB, Smith T, Lee AYY. Treatment and outcomes of heparin-induced thrombocytopenia (HIT) in patients with neoplasm, a case series. J Thromb Thrombolysis 2021; 51:725-733. [PMID: 33582956 DOI: 10.1007/s11239-020-02320-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/21/2020] [Indexed: 11/28/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is a highly thrombogenic condition. Cancer patients are already at high risk of thrombosis. The treatment and outcomes of HIT in cancer patients are not well established. We retrospectively identified patients with active cancer who were diagnosed with HIT at our institution. Only patients with a positive HIT assay and intermediate to high 4Ts score were included. We assessed patients for baseline characteristics, HIT characteristics, non-heparin agent usage, and outcomes (recurrent thrombosis, bleeding, and death) up to 180 days after diagnosis of HIT. Between November 1, 2006 and December 31, 2016, 39 patients with active cancer received a diagnosis of HIT. Of these, 35.9% had thrombotic complications at diagnosis. Gastrointestinal cancer was the most common solid organ malignancy while myeloproliferative neoplasm (MPN) was the most common hematological malignancy. Fondaparinux was the most often used parenteral agent at any point of follow-up (87.2%), followed by argatroban (41.0%). Less than half the patients transitioned to an oral agent. The recurrent thrombosis rate was 17.9%, the bleeding rate was 20.5%, the major bleeding rate was 10.3%, and the mortality rate was 15.4% in the entire cohort. HIT in cancer patients is associated with poor outcomes.
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Affiliation(s)
| | - Tyler Smith
- Department of Pathology & Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Agnes Yuet Ying Lee
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada. .,BC Cancer, Vancouver, BC, Canada.
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