Chest
Volume 141, Issue 2, Supplement, February 2012, Pages e495S-e530S
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Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physician Evidence-Based Clinical Practice Guidelines Online Only Articles
Treatment and Prevention of Heparin-Induced Thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

https://doi.org/10.1378/chest.11-2303Get rights and content

Background

Heparin-induced thrombocytopenia (HIT) is an antibody-mediated adverse drug reaction that can lead to devastating thromboembolic complications, including pulmonary embolism, ischemic limb necrosis necessitating limb amputation, acute myocardial infarction, and stroke.

Methods

The methods of this guideline follow the 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 in this supplement.

Results

Among the key recommendations for this article are the following: For patients receiving heparin in whom clinicians consider the risk of HIT to be > 1%, we suggest that platelet count monitoring be performed every 2 or 3 days from day 4 to day 14 (or until heparin is stopped, whichever occurs first) (Grade 2C). For patients receiving heparin in whom clinicians consider the risk of HIT to be < 1%, we suggest that platelet counts not be monitored (Grade 2C). In patients with HIT with thrombosis (HITT) or isolated HIT who have normal renal function, we suggest the use of argatroban or lepirudin or danaparoid over other nonheparin anticoagulants (Grade 2C). In patients with HITT and renal insufficiency, we suggest the use of argatroban over other nonheparin anticoagulants (Grade 2C). In patients with acute HIT or subacute HIT who require urgent cardiac surgery, we suggest the use of bivalirudin over other nonheparin anticoagulants or heparin plus antiplatelet agents (Grade 2C).

Conclusions

Further studies evaluating the role of fondaparinux and the new oral anticoagulants in the treatment of HIT are needed.

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

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    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).

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