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Machhi R, Lindholm PF, Cooke D, Groth M, Martin KA. Improving Judicious Use of Heparin-Induced Thrombocytopenia Testing Through Electronic Health Record-Based Intervention. Jt Comm J Qual Patient Saf 2023; 49:648-654. [PMID: 37479590 PMCID: PMC10615670 DOI: 10.1016/j.jcjq.2023.06.015] [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: 04/14/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia (HIT) is an immune-mediated drug reaction that can cause thromboembolism in the setting of thrombocytopenia. An enzyme-linked immunosorbent assay (ELISA)-based assay to screen for HIT antibodies (HAb) is available but has relatively low specificity and a correspondingly high false positive rate. The 4Ts score has been validated to determine the pretest probability of HIT. The authors hypothesized that an electronic health record (EHR)-based clinical decision support (CDS) tool incorporating the 4Ts score would reduce the volume of HAb orders. METHODS After implementing a CDS tool into the EHR, the researchers retrospectively evaluated the impact from November 2019 to October 2021, compared to a preintervention period (January to October 2019). The primary outcome was average tests per month. Secondary outcomes included rates of tests ordered per total inpatient encounters and proportion of HAb sent despite low 4Ts score in the postintervention study period. RESULTS Of 1,833 HAb sent during the study period, 1,217 occurred in the postintervention period. In the postintervention period compared with the preintervention period, the average orders per month was 50.5 (standard deviation [SD] 9.7) vs. 61.6 (SD 7.2) (p = 0.003), and the order incidence rate was 8.0 per 1,000 patient encounters postintervention vs. 9.2 per 1,000 patient encounters preintervention (rate ratio [RR] 0.87, 95% confidence interval [CI] 0.79-0.96, p = 0.002). Postintervention, 252 (20.7%) had a 4Ts score calculated as low probability, 759 (62.4%) as intermediate probability, and 131 (10.8%) as high probability, and 75 had no associated 4Ts score. CONCLUSION Implementation of a simple CDS tool reduced the rate of HAb orders, reducing unnecessary HAb testing.
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Patell R, Khan AM, Bogue T, Merrill M, Koshy A, Bindal P, Joyce R, Aird WC, Neuberg D, Bauer KA, Zwicker JI. Heparin induced thrombocytopenia antibodies in Covid-19. Am J Hematol 2020; 95:E295-E296. [PMID: 32658337 PMCID: PMC7405086 DOI: 10.1002/ajh.25935] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Rushad Patell
- Division of HematologyBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusetts
| | - Adeel M Khan
- Division of HematologyBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusetts
| | - Thomas Bogue
- Division of HematologyBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusetts
| | - Mwanasha Merrill
- Department of MedicineBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusetts
| | - Anita Koshy
- Division of HematologyBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusetts
| | - Poorva Bindal
- Division of HematologyBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusetts
| | - Robin Joyce
- Division of HematologyBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusetts
| | - William C Aird
- Division of HematologyBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusetts
| | - Donna Neuberg
- Department of Data SciencesDana‐Farber Cancer InstituteBostonMassachusetts
| | - Kenneth A Bauer
- Division of HematologyBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusetts
| | - Jeffrey I Zwicker
- Division of HematologyBeth Israel Deaconess Medical Center, Harvard Medical SchoolBostonMassachusetts
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3
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Patell R, Zwicker JI. Inpatient prophylaxis in cancer patients: where is the evidence? Thromb Res 2020; 191 Suppl 1:S85-S90. [PMID: 32736785 DOI: 10.1016/s0049-3848(20)30403-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 10/23/2022]
Abstract
Venous thromboembolism (VTE) is a leading cause of preventable in-hospital mortality. Cancer is associated with an increased risk of VTE which is further compounded by acute hospitalization for medical illness. The absolute incidence of VTE of hospitalized cancer patients ranges between 2% and 17% but the rates vary considerably depending on the type of study, method of VTE surveillance and whether pharmacologic thromboprophylaxis is administered. Complicating the interpretation of thromboprophylaxis trials is the paucity of reported data on the relative benefit of thromboprophylaxis relative to an increased risk of hemorrhage inherent to cancer patients. Efforts over the last decade have improved the rates of adherence to in-hospital pharmacologic thromboprophylaxis regimens. Whether these efforts also improve outcomes continues to be debated. In this review, the prevalence of VTE and hemorrhage in hospitalized cancer patients is presented in the context of pharmacologic thromboprophylaxis data along with a discussion of emerging approaches towards VTE risk-adapted prescription of antithrombotics during hospitalization.
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Affiliation(s)
- Rushad Patell
- Department of Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Jeffrey I Zwicker
- Department of Hematology/Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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Hogan M, Berger JS. Heparin-induced thrombocytopenia (HIT): Review of incidence, diagnosis, and management. Vasc Med 2020; 25:160-173. [PMID: 32195628 DOI: 10.1177/1358863x19898253] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is a life and limb-threatening complication of heparin exposure. Here, we review the pathogenesis, incidence, diagnosis, and management of HIT. The first step in thwarting devastating complications from this entity is to maintain a high index of clinical suspicion, followed by an accurate clinical scoring assessment using the 4Ts. Next, appropriate stepwise laboratory testing must be undertaken in order to rule out HIT or establish the diagnosis. In the interim, all heparin must be stopped immediately, and the patient administered alternative anticoagulation. Here we review alternative anticoagulation choice, therapy alternatives in the difficult-to-manage patient with HIT, and the problem of overdiagnosis.
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Affiliation(s)
- Marie Hogan
- Department of Pediatrics, Division of Hematology Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Jeffrey S Berger
- Department of Medicine, Division of Cardiology and Hematology, New York University School of Medicine, New York, NY, USA
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5
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Fondaparinux and Direct Oral Anticoagulants. J Am Coll Cardiol 2018; 71:1710. [DOI: 10.1016/j.jacc.2017.12.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/26/2017] [Indexed: 11/17/2022]
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6
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Wong M, Oo TH, Qiao W, Garg N, Rojas-Hernandez CM. Performance of 4T score and heparin-platelet factor 4 antibody in the diagnosis of heparin-induced thrombocytopenia (HIT) in cancer. J Thromb Thrombolysis 2017; 44:261-266. [PMID: 28677022 DOI: 10.1007/s11239-017-1523-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Cancer patients have characteristics which significantly influence the 4T score and heparin-platelet factor 4 antibody (H-PF4 ab). Our aim was to determine among cancer patients the correlation of the 4T score and H-PF4 ab with the serotonin release assay (SRA). We performed a retrospective analysis of records of cancer patients in whom H-PF4 polyclonal (IgG, IgM and IgA) enzyme-linked immunosorbent assay (ELISA) and SRA were evaluated. Cases were defined as heparin induced thrombocytopenia (HIT) when SRA confirmed the diagnosis. Logistic regression model and the receiver operating characteristic curves were conducted to identify the optimal cutting point for the optical density (OD) and 4T score to discriminate the SRA status. Among 246 patients, the optimal cutoff of 4T score for HIT diagnosis was 5 (sensitivity 90.0%, specificity 73.6%), and the optimal cutoff of H-PF4 polyclonal ELISA OD was 1.004 (sensitivity 81.8%, specificity 97.0%). Our findings suggest that cancer patients may need higher cutoff values for the 4T score. Conventional H-PF4 ab testing seem to perform similarly for the diagnosis of HIT when compared to published data from non-cancer cohorts. Additional studies are necessary to confirm our findings.
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Affiliation(s)
- Myra Wong
- Department of Pathology and Immunology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
| | - Thein Hlaing Oo
- Section of Benign Hematology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Wei Qiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Naveen Garg
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Cristhiam M Rojas-Hernandez
- Section of Benign Hematology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA.
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Abstract
Heparin-induced thrombocytopenia (HIT) is an immune complication of heparin therapy caused by antibodies to complexes of platelet factor 4 (PF4) and heparin. Pathogenic antibodies to PF4/heparin bind and activate cellular FcγRIIA on platelets and monocytes to propagate a hypercoagulable state culminating in life-threatening thrombosis. It is now recognized that anti-PF4/heparin antibodies develop commonly after heparin exposure, but only a subset of sensitized patients progress to life-threatening complications of thrombocytopenia and thrombosis. Recent scientific developments have clarified mechanisms underlying PF4/heparin immunogenicity, disease susceptibility, and clinical manifestations of disease. Insights from clinical and laboratory findings have also been recently harnessed for disease prevention. This review will summarize our current understanding of HIT by reviewing pathogenesis, essential clinical and laboratory features, and management.
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Al-Eidan FAS. Pharmacotherapy of heparin-induced thrombocytopenia: therapeutic options and challenges in the clinical practices. JOURNAL OF VASCULAR NURSING 2016; 33:10-20. [PMID: 25700733 DOI: 10.1016/j.jvn.2014.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 07/28/2014] [Accepted: 07/28/2014] [Indexed: 12/20/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is an immune response to heparin associated with significant morbidity and mortality in hospitalized patients if unidentified as soon as possible, owing to thromboembolic complications involving both arterial and venous systems. Early diagnoses based on a comprehensive interpretation of clinical and laboratory information improves clinical outcomes. Management principles of strongly suspected HIT should not be delayed for laboratory result confirmation. Treatment strategies have been introduced including new, safe, and effective agents. This review summarizes the clinical therapeutic options for HIT addressing the use of parenteral direct thrombin inhibitors and indirect factor Xa inhibitors as well as the potential non-vitamin K antagonist oral anticoagulants.
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Affiliation(s)
- Fahad A S Al-Eidan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
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Erratum. Clin Appl Thromb Hemost 2013; 19:344-9. [DOI: 10.1177/1076029613491346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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10
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Zhao D, Sun X, Yao L, Lin H, Li J, Zhao J, Zhang Z, Lun L, Zhang J, Li M, Huang Q, Yang Y, Jiang S, Wang Y, Zhu H, Chen X. The clinical significance and risk factors of anti-platelet factor 4/heparin antibody on maintenance hemodialysis patients: a two-year prospective follow-up. PLoS One 2013; 8:e62239. [PMID: 23646121 PMCID: PMC3639940 DOI: 10.1371/journal.pone.0062239] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 03/19/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Heparin-induced thrombocytopenia is an immune response mediated by anti-PF4/heparin antibody, which is clinically characterized by thrombocytopenia and thromboembolic events. In this study, a prospective and multi-center clinical investigation 1) determined the positive rate of anti-PF4/heparin antibody in maintenance hemodialysis patients in China, 2) identified the related risk factors, and 3) further explored the effect of the anti-PF4/heparin antibody on bleeding, thromboembolic events, and risk of death in the patients. METHODS The serum anti-PF4/heparin antibody was measured in 661 patients from nine hemodialysis centers, detected by IgG-specific ELISA and followed by confirmation with excess heparin. Risk factors of these patients were analyzed. Based on a two-year follow-up, the association between the anti-PF4/heparin antibody and bleeding, thromboembolic events, and risk of death in the patients was investigated. RESULTS 1) The positivity rate of the anti-PF4/heparin antibody in maintenance hemodialysis patients was 5.6%. With diabetes as an independent risk factor, the positivity rate of the anti-PF4/heparin antibody decreased in the patients undergoing weekly dialyses ≥3 times. 2) The positivity rate of the anti-PF4/heparin antibody was not related to the occurrence of clinical thromboembolic events and was not a risk factor for death within two years in maintenance hemodialysis patients. 3) Negativity for the anti-PF4/heparin antibody combined with a reduction of the platelet count or combined with the administration of antiplatelet drugs yielded a significant increase in bleeding events. However, the composite determination of the anti-PF4/heparin antibody and thrombocytopenia, as well as the administration of antiplatelet drugs, was not predictive for the risk of thromboembolic events in the maintenance hemodialysis patients. CONCLUSIONS A single detection of the anti-PF4/heparin antibody did not predict the occurrence of clinical bleeding, thromboembolic events, or risk of death in the maintenance hemodialysis patients.
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Affiliation(s)
- Delong Zhao
- Department of Nephrology, Chinese PLA General Hospital, State Key Laboratory of Kidney Disease (2011DAV00088), Beijing, China
| | - Xuefeng Sun
- Department of Nephrology, Chinese PLA General Hospital, State Key Laboratory of Kidney Disease (2011DAV00088), Beijing, China
- * E-mail: (XS); (XC)
| | - Li Yao
- Department of Nephrology, The First Affiliated Hospital, Chinese Medical University, Shenyang, China
| | - Hongli Lin
- Department of Nephrology, The First Affiliated Hospital, Dalian Medical College, Dalian, China
| | - Jijun Li
- Department of Nephrology, The First Affiliated Hospital, General Hospital of PLA, Beijing, China
| | - Jiuyang Zhao
- Department of Nephrology, The Second Affiliated Hospital, Dalian Medical College, Dalian, China
| | - Zhimin Zhang
- Department of Nephrology, General Hospital of the General Headquarters, Beijing, China
| | - Lide Lun
- Department of Nephrology, General Hospital of the Air Force, Beijing, China
| | - Jianrong Zhang
- Department of Nephrology, General Hospital of the Force Police Army, Beijing, China
| | - Mingxu Li
- Department of Nephrology, General Hospital of the Navy, Beijing, China
| | - Qi Huang
- Department of Nephrology, Chinese PLA General Hospital, State Key Laboratory of Kidney Disease (2011DAV00088), Beijing, China
| | - Yang Yang
- Department of Nephrology, Chinese PLA General Hospital, State Key Laboratory of Kidney Disease (2011DAV00088), Beijing, China
| | - Shimin Jiang
- Department of Nephrology, Chinese PLA General Hospital, State Key Laboratory of Kidney Disease (2011DAV00088), Beijing, China
| | - Yong Wang
- Department of Nephrology, Chinese PLA General Hospital, State Key Laboratory of Kidney Disease (2011DAV00088), Beijing, China
| | - Hanyu Zhu
- Department of Nephrology, Chinese PLA General Hospital, State Key Laboratory of Kidney Disease (2011DAV00088), Beijing, China
| | - Xiangmei Chen
- Department of Nephrology, Chinese PLA General Hospital, State Key Laboratory of Kidney Disease (2011DAV00088), Beijing, China
- * E-mail: (XS); (XC)
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11
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Lee GM, Arepally GM. Diagnosis and management of heparin-induced thrombocytopenia. Hematol Oncol Clin North Am 2013; 27:541-63. [PMID: 23714311 DOI: 10.1016/j.hoc.2013.02.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is a prothrombotic disorder caused by antibodies to platelet factor 4/heparin (PF4/H) complexes. It presents with declining platelet counts 5 to 14 days after heparin administration and results in a predisposition to arterial and venous thrombosis. Establishing the diagnosis of HIT can be extremely challenging. It is essential to conduct a thorough clinical evaluation in addition to laboratory testing to confirm the presence of PF4/H antibodies. Multiple clinical algorithms have been developed to aid the clinician in predicting the likelihood of HIT. Once HIT is recognized, an alternative anticoagulant should be initiated to prevent further complications.
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Affiliation(s)
- Grace M Lee
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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12
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Nicolaides A, Fareed J, Kakkar AK, Comerota AJ, Goldhaber SZ, Hull R, Myers K, Samama M, Fletcher J, Kalodiki E, Bergqvist D, Bonnar J, Caprini JA, Carter C, Conard J, Eklof B, Elalamy I, Gerotziafas G, Geroulakos G, Giannoukas A, Greer I, Griffin M, Kakkos S, Lassen MR, Lowe GDO, Markel A, Prandoni P, Raskob G, Spyropoulos AC, Turpie AG, Walenga JM, Warwick D. Heparin-Induced Thrombocytopenia. Clin Appl Thromb Hemost 2013; 19:208-13. [DOI: 10.1177/1076029612474840s] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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13
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Antithrombotic therapy in heparin-induced thrombocytopenia: guidelines translated for the clinician. J Thromb Thrombolysis 2013; 34:552-61. [PMID: 22843169 DOI: 10.1007/s11239-012-0785-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Heparin-induced thrombocytopenia (HIT) is a clinicopathologic syndrome initiated by heparin exposure and characterized by thrombocytopenia and paradoxical thrombophilia. HIT is mediated by the formation of antibodies against the platelet factor 4/heparin complex, which leads to platelet activation, thrombin generation, and potentially fatal thrombotic sequelae. The clinical presentation of HIT is variable and can be easily overlooked. Although a number of functional and antigen-based immunoassays have been developed to detect the presence of HIT antibodies, initial diagnosis is often based on recognition of thrombocytopenia in the appropriate clinical context and later confirmed with immunologic testing. Given the serious clinical consequences of HIT, immediate cessation of heparin products and administration of non-heparin anticoagulants are crucial components of treatment. We provide a review of the clinical syndrome and practical summary of treatment recommendations from the most recent 2012 American College of Chest Physicians evidence-based guidelines for the treatment and prevention of HIT.
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Abstract
Platelet factor 4 (CXCL4-PF4) is a chemokine that binds to and neutralizes heparin and other negatively charged proteoglycans, but is also involved in angiogenesis and cancer development. In some patients exposed to heparin, antibodies are generated against the CXCL-PF4/heparin complex that may activate platelets and coagulation and lead to thrombocytopenia and arterial or venous thrombosis, a condition commonly named heparin induced thrombocytopenia (HIT). HIT has been investigated in numerous clinical settings, but there is limited data on the epidemiology and phenotype of HIT in cancer patients. The present review describes the role of CXCL4-PF4 in cancer, the immunobiology, clinical presentation and diagnosis of HIT, and the specific problems faced in cancer patients.
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Affiliation(s)
- Per Morten Sandset
- Oslo University Hospital Rikshospitalet, Department of Haematology and Research Institute of Internal Medicine, and University of Oslo, Institute of Clinical Medicine, Oslo, Norway.
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15
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Zhou A, Winkler A, Emamifar A, Gartland B, Duncan A, Antun A, Arellano M, Tindol GA, Levy JH, Bornstein WA, Horowitz IR, Khoury HJ. Is the Incidence of Heparin-Induced Thrombocytopenia Affected by the Increased Use of Heparin for VTE Prophylaxis? Chest 2012; 142:1175-1178. [DOI: 10.1378/chest.11-2926] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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16
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Jenkins I, Helmons PJ, Martin-Armstrong LM, Montazeri ME, Renvall M. High Rates of Venous Thromboembolism Prophylaxis Did Not Increase the Incidence of Heparin-Induced Thrombocytopenia. Jt Comm J Qual Patient Saf 2011; 37:163-9. [DOI: 10.1016/s1553-7250(11)37020-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Augoustides JGT. Update in hematology: heparin-induced thrombocytopenia and bivalirudin. J Cardiothorac Vasc Anesth 2011; 25:371-5. [PMID: 21316987 DOI: 10.1053/j.jvca.2010.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Indexed: 01/19/2023]
Abstract
Heparin-induced thrombocytopenia (HIT) is important because it is common, and it significantly increases mortality after cardiac surgery. Although thrombocytopenia after cardiac surgery is common, it predicts serious adverse outcome when it is severe. Despite the high prevalence of heparin/platelet factor 4 antibodies in cardiac surgical patients, they typically do not indicate a higher perioperative risk. Recent evidence suggests, however, that when these antibodies are in the immunoglobulin M class, there is an increased risk of nonthrombotic adverse outcomes after cardiac surgery. According to the guidelines from the American College of Chest Physicians, patients with HIT require parenteral anticoagulation with a direct thrombin inhibitor such as lepirudin, argatroban, or bivalirudin. The transition to oral anticoagulation must be undertaken cautiously and only after the platelet count has recovered. Patients with a remote history of HIT can have cardiac surgery safely with unfractionated heparin. Patients with clinically active HIT who require cardiac surgery before the resolution of the HIT preferably should be anticoagulated with bivalirudin, dosed according to body weight and the goal-activated coagulation time. Given that bivalirudin is an established alternative to heparin as a thrombin inhibitor for cardiac surgery, it is likely that future trials will investigate which anticoagulant confers better outcomes after cardiac surgery, as is the case in percutaneous coronary intervention.
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Affiliation(s)
- John G T Augoustides
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-4283, USA.
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Kim J, Park NH, Choi SY. The Management of Heparin-induced Thrombocytopenia with Thrombosis That Developed after Aortic Dissection Surgery. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2010. [DOI: 10.5090/kjtcs.2010.43.5.538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- JaeBum Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Keimyung University
| | - Nam-Hee Park
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Keimyung University
| | - Sae-Young Choi
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Keimyung University
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19
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Abstract
Heparin-induced thrombocytopenia (HIT) is an immune-mediated hypercoagulable disorder caused by antibodies to platelet factor 4 (PF4) and heparin. HIT develops in temporal association with heparin therapy and manifests either as an unexplained thrombocytopenia or thrombocytopenia complicated by thrombosis. The propensity for thrombosis distinguishes HIT from other common drug-induced thrombocytopenias. Diagnosing HIT in hospitalized patients is often challenging because of the frequency of heparin use, occurrence of thrombocytopenia from other causes, and development of asymptomatic PF4/heparin antibodies in patients treated with heparin. This review summarizes our current understanding of the pathogenesis, clinical features, diagnostic criteria, and management approaches in HIT.
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Affiliation(s)
- Gowthami M Arepally
- Division of Hematology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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20
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2010. [DOI: 10.1002/pds.1847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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