Chest
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Online Only ArticlesTreatment and Prevention of Heparin-Induced Thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Section snippets
Summary of Recommendations
Note on Shaded Text: Throughout this guideline, shading is used within the summary of recommendations sections to indicate recommendations that are newly added or have been changed since the publication of Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Recommendations that remain unchanged are not shaded.
2.1.1. For patients receiving heparin in whom clinicians consider the risk of HIT to be > 1%, we
Methods and Overview of HIT
We adhered to the general approach to developing recommendations described in the methodology article of these guidelines.1 We searched the PubMed English language literature from January 1976 to June 2010 using the following search terms: “heparin-induced thrombocytopenia,” “clinical trial,” “cohort,” “randomized clinical trial,” “argatroban,” “lepirudin,” “hirudin,” “bivalirudin,” “fondaparinux”, “diagnosis,” “laboratory assay,” “clinical prediction rule,” “platelet count monitoring,”
Platelet Count Monitoring Combined With the 4Ts Score for Patients Receiving Heparin/LMWH
Platelet count monitoring is warranted when the benefits of early diagnosis and treatment of HIT exceed the potential harms of frequent platelet count monitoring, including cost, unnecessary anxiety and additional testing, unnecessary withdrawal of heparin, and the use of nonheparin anticoagulants with a higher bleeding risk. No studies have directly addressed the issue of whether advantages of platelet monitoring outweigh the disadvantages in patients receiving UFH/LMWH. Three retrospective
Discontinue Heparin or Initiate VKA vs Treatment With Nonheparin Anticoagulants
The first step in the treatment of HIT complicated by thrombosis (HITT) is discontinuation of all forms of heparin and LMWH (including heparin flushes and heparin-coated catheters). Whether taking this step alone is enough to prevent further thrombotic complications secondary to HITT has been evaluated in pooled analyses of prospective cohort studies with historical controls.76, 78 DTIs lepirudin and argatroban have each been compared with historical controls who received the best available
Discontinue Heparin or Initiate VKA vs Treatment With Nonheparin Anticoagulants
The first step in the treatment of HIT is discontinuation of all forms of heparin and LMWH (including heparin flushes and heparin-coated catheters). Whether taking this step alone is enough to prevent the development of thrombotic complications in patients who have isolated HIT has been evaluated in pooled analyses of prospective cohort studies with historical controls76, 78 and in three retrospective case series.6, 42, 70 The prospective studies compared DTIs lepirudin and argatroban with
Patients Who Require Urgent Cardiac Surgery
During cardiac surgery, heparin is commonly used to maintain patency in the CPB apparatus and to prevent coagulation in the tissue factor-rich operative field. Heparin is ideally suited for this role because it has a rapid onset of action, has a short half-life, is reversible with protamine sulfate, and has a point-of-care assay (activated clotting time [ACT]). Substituting a nonheparin anticoagulant, such as bivalirudin, lepirudin, or argatroban, for heparin is one strategy that has been used
Management of Patients With a Past History of HIT
With certain procedures (eg, surgery requiring CPB, hemodialysis), the properties of heparin make it preferable to alternative nonheparin anticoagulants (eg, short half-life, reversibility, readily available assays for monitoring the anticoagulant effect, low cost). The risk of giving heparin to patients with acute or subacute HIT is too high (ie, risk of fatal thrombosis); hence, our recommendations for management of patients who require these procedures are given in section 5.0. This section
Conclusions
The diagnosis and treatment of HIT is an ongoing challenge. Studies evaluating the efficacy and safety of fondaparinux and new anticoagulants in the treatment of HIT would be of tremendous value to the medical community.
Acknowledgments
Author Contributions: As Topic Editor, Dr Linkins oversaw the development of this article, including the data analysis and subsequent development of the recommendations contained herein.
Dr Linkins: contributed as Topic Editor.
Dr Dans: contributed as panelist.
COL Moores: contributed as panelist.
Dr Bona: contributed as frontline clinician.
Dr Davidson: contributed as panelist.
Dr Schulman: contributed as panelist.
Dr Crowther: contributed as panelist.
Financial/nonfinancial disclosures: The authors
References (182)
- et al.
Methodology for the development of antithrombotic therapy and prevention of thrombosis guidelines: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2012) - et al.
Patient values and preferences in decision making for antithrombotic therapy: a systematic review: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
Chest
(2012) - et al.
A 14-year study of heparin-induced thrombocytopenia
Am J Med
(1996) - et al.
Immunoglobulin G from patients with heparin-induced thrombocytopenia binds to a complex of heparin and platelet factor 4
Blood
(1994) - et al.
Sera from patients with heparin-induced thrombocytopenia generate platelet-derived microparticles with procoagulant activity: an explanation for the thrombotic complications of heparin-induced thrombocytopenia
Blood
(1994) - et al.
Risk for heparin-induced thrombocytopenia with unfractionated and low-molecular-weight heparin thromboprophylaxis: a meta-analysis
Blood
(2005) - et al.
Impact of the patient population on the risk for heparin-induced thrombocytopenia
Blood
(2000) - et al.
Laboratory testing for the antibodies that cause heparin-induced thrombocytopenia: how much class do we need?
J Lab Clin Med
(2005) - et al.
The severity of trauma determines the immune response to PF4/heparin and the frequency of heparin-induced thrombocytopenia
Blood
(2010) - et al.
Gender imbalance and risk factor interactions in heparin-induced thrombocytopenia
Blood
(2006)
Heparin-induced thrombocytopenia: a stoichiometry-based model to explain the differing immunogenicities of unfractionated heparin, low-molecular-weight heparin, and fondaparinux in different clinical settings
Thromb Res
Anti-PF4/heparin antibody formation postorthopedic surgery thromboprophylaxis: the role of non-drug risk factors and evidence for a stoichiometry-based model of immunization
J Thromb Haemost
Venous thromboembolism during pregnancy: a retrospective study of enoxaparin safety in 624 pregnancies
BJOG
Heparin-induced thrombocytopenia is rare in pregnancy
Am J Obstet Gynecol
The incidence of heparin-induced thrombocytopenia in hospitalized medical patients treated with subcutaneous unfractionated heparin: a prospective cohort study
Blood
Replacement of unfractionated heparin by low-molecular-weight heparin for postorthopedic surgery antithrombotic prophylaxis lowers the overall risk of symptomatic thrombosis because of a lower frequency of heparin-induced thrombocytopenia
Blood
Incidence of thrombocytopenia in hospitalized patients with venous thromboembolism
Am J Med
Incidence and clinical relevance of anti-platelet factor 4/heparin antibodies before cardiac surgery
Am Heart J
The incidence of heparin-induced thrombocytopenia in medical patients treated with low-molecular-weight heparin: a prospective cohort study
Blood
Cancer, thrombosis and heparin-induced thrombocytopenia
Thromb Res
The 4Ts scoring system for heparin-induced thrombocytopenia in medical-surgical intensive care unit patients
J Crit Care
Low-molecular-weight heparins for thromboprophylaxis and treatment of venous thromboembolism in pregnancy: a systematic review of safety and efficacy
Blood
Heparin-induced thrombocytopenia: temporal pattern of thrombocytopenia in relation to initial use or reexposure to heparin
Chest
Blood product use in cardiac revascularization: comparison of on- and off-pump techniques
Ann Thorac Surg
Towards a diagnosis of heparin-induced thrombocytopenia after cardiopulmonary bypass
J Thromb Haemost
Diagnostic score for heparin-induced thrombocytopenia after cardiopulmonary bypass
J Thromb Haemost
Failure of early heparin cessation as treatment for heparin-induced thrombocytopenia
Am J Med
Complications from heparin-induced thrombocytopenia in patients undergoing cardiopulmonary bypass
Chest
Heparin-induced skin lesions and other unusual sequelae of the heparin-induced thrombocytopenia syndrome: a nested cohort study
Chest
Evaluation of pretest clinical score (4 T's) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings [see comment]
J Thromb Haemost
The HIT Expert Probability (HEP) Score: a novel pre-test probability model for heparin-induced thrombocytopenia based on broad expert opinion
J Thromb Haemost
Prospective evaluation of the ‘4Ts’ score and particle gel immunoassay specific to heparin/PF4 for the diagnosis of heparin-induced thrombocytopenia [see comment]
J Thromb Haemost
A clinical-laboratory approach contributing to a rapid and reliable diagnosis of heparin-induced thrombocytopenia
Thromb Res
Non-necrotizing heparin-induced skin lesions and the 4Ts score
J Thromb Haemost
Lepirudin in patients with heparin-induced thrombocytopenia - results of the third prospective study (HAT-3) and a combined analysis of HAT-1, HAT-2, and HAT-3
J Thromb Haemost
Heparin-induced thrombocytopenia: a prospective study on the incidence, platelet-activating capacity and clinical significance of antiplatelet factor 4/heparin antibodies of the IgG, IgM, and IgA classes
J Thromb Haemost
Rapid detection of heparin-induced platelet antibodies with particle gel immunoassay (ID-HPF4)
Lancet
Prospective evaluation of PF4/heparin immunoassays for the diagnosis of heparin-induced thrombocytopenia
J Thromb Haemost
Quantitative interpretation of optical density measurements using PF4-dependent enzyme-immunoassays
J Thromb Haemost
Thrombosis and ELISA optical density values in hospitalized patients with heparin-induced thrombocytopenia
J Thromb Haemost
Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition)
Chest
Effects of argatroban therapy, demographic variables, and platelet count on thrombotic risks in heparin-induced thrombocytopenia [see comment]
Chest
Lepirudin for prophylaxis of thrombosis in patients with acute isolated heparin-induced thrombocytopenia: an analysis of 3 prospective studies
Blood
A multicenter, randomized study of argatroban versus heparin as adjunct to tissue plasminogen activator (TPA) in acute myocardial infarction: myocardial infarction with novastan and TPA (MINT) study
J Am Coll Cardiol
Management of heparin-induced thrombocytopenia: a critical comparison of lepirudin and argatroban
Thromb Res
Results of a systematic evaluation of treatment outcomes for heparin-induced thrombocytopenia in patients receiving danaparoid, ancrod, and/or coumarin explain the rapid shift in clinical practice during the 1990s
Thromb Res
Heparin-induced thrombocytopenia in patients treated with low-molecular-weight heparin or unfractionated heparin
N Engl J Med
An improved definition of immune heparin-induced thrombocytopenia in postoperative orthopedic patients
Arch Intern Med
Clinical features of heparin-induced thrombocytopenia including risk factors for thrombosis. A retrospective analysis of 408 patients
Thromb Haemost
Heparin-associated thrombocytopenia: isolation of the antibody and characterization of a multimolecular PF4-heparin complex as the major antigen
Thromb Haemost
Cited by (787)
The therapeutic effects of marine sulfated polysaccharides on diabetic nephropathy
2024, International Journal of Biological MacromoleculesA Modified 4Ts Score for Heparin-Induced Thrombocytopenia in the Mechanical Circulatory Support Population
2023, Journal of Cardiothoracic and Vascular AnesthesiaImproving Judicious Use of Heparin-Induced Thrombocytopenia Testing Through Electronic Health Record–Based Intervention
2023, Joint Commission Journal on Quality and Patient SafetyCangrelor for cardiopulmonary bypass in delayed-onset heparin-induced thrombocytopenia: a case report
2023, Research and Practice in Thrombosis and Haemostasis
Funding/Support: The Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines received support from the National Heart, Lung, and Blood Institute [R13 HL104758] and Bayer Schering Pharma AG. Support in the form of educational grants was also provided by Bristol-Myers Squibb; Pfizer, Inc; Canyon Pharmaceuticals; and sanofi-aventis US.
Disclaimer: American College of Chest Physician guidelines are intended for general information only, are not medical advice, and do not replace professional medical care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this guideline can be accessed at http://chestjournal.chestpubs.org/content/141/2_suppl/1S.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).