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420 Anticoagulation Therapy
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extracorporeal membrane oxygenation. ASAIO J. 2013;59(1):63-68.
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with axial-flow left ventricular assist devices. Circ Heart Fail. 2011;4(6):779-784.
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product utilization with left ventricular assist device implantation. Ann Thorac Surg.
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31. Demirozu ZT, Radovancevic R, Hochman LF, et al. Arteriovenous malformation and
gastrointestinal bleeding in patients with the HeartMate II left ventricular assist device.
J Heart Lung Transplant. 2011;30(8):849-853.
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gastrointestinal bleeding in patients supported on rotary left ventricular assist devices: a
single-center experience. Artif Organs. 2010;34(9):703-706.
33. Kamdar F, Eckman P, John R. Safety of discontinuation of anti-coagulation in patients
with continuous-flow left ventricular assist devices. J Heart Lung Transplant. Mar
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suspected pump thrombus. J Heart Lung Transplant. 2013;32(7):667-670.
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*35. Hohner E, Crow J, Moranville MP. Medication management for left ventricular assist
device thrombosis. Am J Health-Syst Pharm. 2015;72(13):1104-1113.
36. Bellumkonda L, Subrahmanyan L, Jacoby D, et al. Left ventricular assist device
pump thrombosis: is there a role for glycoprotein IIb/IIIa inhibitors? ASAIO J.
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of HeartMate II left ventricular assist device thrombosis. Circ Heart Fail.
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thrombus or thrombosis in patients with left ventricular assist devices. J Heart Lung
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in patients in the HeartWare ADVANCE bridge to transplant and continued access
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argatroban on fibrin- or clot-incorporated thrombin: comparison with heparin and
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thrombosis in patients with continuous flow centrifugal left ventricular assist device.
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thrombosis and hemolysis. Ann Cardiothorac Surg. 2014;3(5):490-495.
18
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Chapter
HEPARIN-INDUCED
THROMBOCYTOPENIA
William E. Dager
INTRODUCTION
Heparin-induced thrombocytopenia (HIT) is an immune-mediated process triggered
by exposure to unfractionated heparin (UFH) or low molecular weight heparin
(LMWH) that can create the paradox of increased thrombosis risk with concurrent
thrombocytopenia. It is important to recognize and promptly initiate appropriate
management when present. No gold standard test currently exists; thus, diagnosis
typically combines signs and symptoms with laboratory observations. Stopping
the heparin agent alone will not prevent the potential risk for thrombosis, limb
ischemia (which can lead to amputation), or death.
Identification of HIT
See Table 18-1.
TABLE 18-1: Characteristics of Heparin-Related Nonimmune- and
1
Immune-Mediated Thrombocytopenia
Observation Nonimmune-Mediated
Heparin-Associated
Thrombocytopenia (HAT)
Frequency 10–30% <1–3%
Timing of onset 1–4 days Typical 5–10 days
Decrease in platelets Slight Moderate/large
Antibody mediated No Yes
Thrombosis No 30–75%
Hemorrhage None Rare
Management Observe Discontinue all heparin/LMWH products,
LMWH: low molecular weight heparin
Immune-Mediated Heparin-Induced
Thrombocytopenia (HIT)
Acute: Immediate if recent exposure
Delayed: Up to 40 days after last exposure
to the heparin compound
flushes, coated lines, and rinses.
Start alternate parenteral anticoagulant.
423
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Immune-mediated HIT is transient with the risk for recurrence highest from
re-exposure to heparin products lasting approximately 100 days.
HIT Terminology
See Table 18-2.
TABLE 18-2: HIT Terminology
Term Description Treatment Duration
Acute HIT Period of thrombocytopenia
Isolated HIT Presence of HIT without
HIT-related thrombosis
syndrome (HITTS)
History of HIT Previous history of HIT,
HIT: heparin-induced thrombocytopenia
associated with current or recent
exposure to heparin prior to
platelet count recovery.
thrombosis related to heparin.
Includes pre-existing thrombosis
and subsequent HIT.
Presence of thrombosis that
formed as a result of HIT.
but not acute, or related
thrombocytopenia.
HIT-Related Disorders (Not Common)
•
Adrenal infarct
•
Cardiovascular/anaphylactoid reactions on reexposure
•
Skin lesions at heparin injection sites
•
Venous limb gangrene (VLG) with excessive initial warfarin exposure
•
Warfarin-induced skin necrosis
2
Continue anticoagulation until
recovery of platelet counts to a
stable plateau if no thrombosis.
Continue anticoagulation until
recovery of platelet counts to a
stable plateau if no thrombosis.
3–6 months unless other factors
require longer anticoagulation.
NA—may receive anticoagulation
for other reasons (i.e., DVT
prophylaxis); consider using
fondaparinux.
2
Phases of HIT
See Table 18-3.
HEPARIN-INDUCED THROMBOCYTOPENIA 425
DTI: direct thrombin inhibitor, HIT: heparin-induced thrombocytopenia, VTE: venous thromboembolism
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Patient with history of HIT no
longer on treatment for HIT
Timing: Over 100 days out from
HIT onset
HIT with platelet count
recovery
Timing: Week/months
Normal Normal
Negative
Evaluate assay date and if true
HIT occurred vs. documentation
of suspicion only. Evaluate
anticoagulation needs based on
risk and if >100 days since initial
HIT event. For VTE prophylaxis,
~85 days)
Reassess anticoagulation
need unless secondary
reason to continue
anticoagulation; for
treatment durations, see
Table 18-2.
fondaparinux 2.5 mg/day may
be an easy option.
HIT with clear platelet count
HIT diagnosis made
3
Suspected HIT Acute HIT Subacute HIT Recent HIT History of HIT
TABLE 18-3: Phases of HIT
Definition Timing:
recovery
Timing: Days/weeks
Timing: Hours to days
Immediate: Hours
Typical: 5–10 days
Delayed: Typically up to
~40 days
Decreasing to normal after
~30 days
Increased—highest risk
in first 5–7 days
Use pre-test probability
score to estimate risk; see
Table 18-7
Platelet count Declining or declined Decreased Rising or recovered Recovered/baseline Baseline
Thrombotic
risk
Consider transition to
Remove all heparin-
NA Positive Positive Negative (after ~50 days) Negative
Functional
assay
Immunoassay NA Positive Positive −/+ (often negative after
Consideration Assess risk, evaluate need
longer-term anticoagulant if
on a parenteral continuous
infusion DTI; if warfarin
used, see considerations in
Table 18-19.
related triggers.
Initiate alternative
anticoagulant if not
already done.
for alternative management;
laboratory testing and
alternative management
typically instituted in those
considered intermediate-to-
high risk of HIT, including
removing heparin sources.
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• Initiating warfarin monotherapy, especially in
higher doses potentially leading to international
normalized ratio (INR) values >4, can increase
the risk for venous limb gangrene due to protein
C depletion.
Disorders That Can Mimic HIT
See Table 18-4.
TABLE 18-4: Pseudo-HIT Disorders That Can Mimic HIT,
Including Thrombocytopenia and Thrombosis
Early Onset Late Onset
Antiphospholipid disorder
Diabetic ketoacidosis
GP IIb/IIIa inhibitors
Infective endocarditis
Paroxysmal nocturnal hemoglobinuria
Postsurgical thrombotic thrombocytopenic
purpura
Pulmonary embolism
Septicemia-related purpura fulminans
Thrombolytic therapy
GP: glycoprotein, HIT: heparin-induced thrombocytopenia
Adenocarcinoma
Drug-induced thrombocytopenia (other than
HIT)
Postsurgical thrombotic thrombocytopenic
purpura
Post-transfusion purpura
Pulmonary embolism
4
Factors Associated with the Development of HIT
See Table 18-5.
TABLE 18-5: Factors Associated with the Development of HIT
Factor Importance Hierarchy
Type of heparin Major UFH >LMWH >fondaparinux
Duration of heparin Major 11–14 days
Higher risk with more recent exposure
a
>5–10 days >4 (or fewer) days
5–7
Type of patient Moderate Postsurgery >medical >pregnancy or neonate
Dose of heparin Moderate Therapeutic ≥prophylaxis >“flushes”
Gender of patient Minor Female >male
a
Minimal additional risk if heparin continued beyond 14 days.
>: greater than, ≥ : greater than or similar to, HIT: heparin-induced thrombocytopenia, LMWH:
low molecular weight heparin, UFH: unfractionated heparin
HEPARIN-INDUCED THROMBOCYTOPENIA 427
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Recommended Platelet Count Monitoring
See Table 18-6.
TABLE 18-6: ACCP Recommendations for Platelet Count
Monitoring to Recognize HIT
Situation Platelet Count Monitoring ACCP Recommendation
Heparin or LMWH administered
with risk of HIT >1%
Heparin or LMWH administered
with risk of HIT <1%
UFH or LMWH administered when
patient had UFH exposure within
100 days
UFH bolus given and acute
inflammatory reaction within 30
minutes of UFH bolus
ACCP: American College of Chest Physicians, D/C: discontinued, HIT: heparin-induced
thrombocytopenia, hr: hours, LMWH: low molecular weight heparin, NA: not applicable, UFH:
unfractionated heparin
Note: Daily platelet count monitoring for the first 10 days may be a consideration in the setting of
recent (or history of HIT) and re-exposure to UFH, LMWH, or fondaparinux.
5
Grade
Every 2–3 days (days 4–14
or until D/C)
No platelet monitoring 2C
Baseline, repeat within 24 hr
if feasible
Immediate and compare to
prior count
2C
NA
NA
Estimating the Probability a Patient Has HIT
See Tables 18-7, 18-8, and 18-9.
428 Anticoagulation Therapy
Thrombocytopenia
Compare the highest platelet count
within the sequence of declining
platelet counts with the lowest
count to determine the percent of
(Select only 1 option)
Timing of platelet count fall or other
Day 0 = first day of most recent
heparin exposure. (Select only 1
Thrombosis or other sequelae
(Select only 1 option)
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2
• <30% fall
• platelet nadir <10 K/mm
2,5
)
2
without exposure to heparin past 100 days
Platelet count fall within 4 days of initiation
•
• No related thrombosis suspected
(continued)
• 50% platelet fall but surgery
2
• >50% platelet fall and nadir
Indicator 2 Points 1 Point No Points
TABLE 18-7: Proposed Modified Pretest Probability Scoring (4Ts) for HIT
within preceding 3 days or
fall and nadir that does not fit
criteria for Score 2 or Score 0
(e.g., 30–50% fall, or platelet
nadir 10–19 K/mm
day 5–10 but not clear (e.g.,
missing counts)
• Any combination of platelet
• Consistent with platelet fall
• Platelet fall within 1 day of
AND no surgery
within preceding 3 days
≥20 K/mm
platelet fall.
exposure to heparin
start of heparin and exposure
Clear onset 5–10 days after
•
• Platelet fall within 1 day of
sequelae*
start of heparin and exposure
to heparin in past 31–100 days
to heparin within past 5–30
days
option)
a patient receiving therapeutic
anticoagulants
confirmation with imaging)
Recurrent venous thrombosis in
• Platelet fall after 10 days
•
• Confirmed new thromboses
Suspected thrombosis (awaiting
•
(venous or arterial)
heparin bolus
Anaphylactic reaction to IV
• Skin necrosis at injection site
•
heparin injection sites
Erythematous skin lesions at
•
Adrenal hemorrhage
•
Other causes of
thrombocytopenia**
(Select only 1 option)
• Within 72 hours of surgery
Pretest Probability
4–5 Intermediate
Some facilities classify patients with a score of 3 as an intermediate risk.
*In some circumstances, it may be appropriate to judge timing based on clinical sequelae, such as onset of heparin-induced skin lesions.
**Usually, “oTher” scores “0 points” if thrombocytopenia is not present. However, it may be appropriate to judge oTher based on clinical sequelae, such as whether
heparin-induced skin lesions are necrotizing (2 points, i.e., a non-HIT explanation is unlikely) or non-necrotizing (0 points, i.e., a non-HIT explanation is likely [see text]).
This is a more recent version of the 4Ts scoring system proposed in the 2012 CHEST Guidelines.
See Appendix J for drug-related causes of thrombocytopenia.
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• Definite other causes present
HEPARIN-INDUCED THROMBOCYTOPENIA 429
in causing D-ITP (see list)
sites (presumed DTH)
• Confirmed bacteremia/fungemia
• Chemotherapy or radiation within past 20 days
• DIC due to non-HIT cause
• Posttransfusion purpura (PTP)
• Thrombotic thrombocytopenic purpura (TTP)
• Platelet count <20 AND given a drug implicated
• Non-necrotizing skin lesions at LMWH injection
without proved microbial
source
• Possible causes evident. Sepsis
count fall evident
• No other cause for platelet
Indicator 2 Points 1 Point No Points
TABLE 18-7: (Continued)
with initiation of ventilator
• Thrombocytopenia associated
6–8 High
Low
b
0–3
4 Ts: Thrombocytopenia, Timing, Thrombosis, Other
a
b
DIC: disseminated intravascular coagulation, DTH: delayed-type hypersensitivity, HIT: heparin-induced thrombocytopenia, IV: intravenous, LMWH: low molecular weight
heparin
Note:
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