Chest
SupplementAntithrombotic and Thrombolytic Therapy, 8th ED: ACCP GuidelinesTreatment and Prevention of Heparin-Induced Thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)
Section snippets
SUMMARY OF RECOMMENDATIONS
1.0 Recognition of HIT
Management of Direct Thrombin Inhibitor-VKA Overlap
2.2.1. For patients with strongly suspected or confirmed HIT, we recommend against the use of VKA (coumarin) therapy until after the platelet count has substantially recovered (ie, usually to at least 150 x 109/L) over starting VKA therapy at a lower platelet count (Grade 1B) ; that VKA therapy be started only with low, maintenance doses (maximum, 5 mg of warfarin or 6 mg of phenprocoumon) rather than with higher initial doses (Grade 1B) ; and that the nonheparin anticoagulant (eg, lepirudin,
LMWH for HIT
2.3.1. For patients with strongly suspected HIT, whether or not complicated by thrombosis, we recommend against use of LMWH (Grade 1B).
Prophylactic Platelet Transfusions for HIT
2.4.1. For patients with strongly suspected or confirmed HIT who do not have active bleeding, we suggest that prophylactic platelet transfusions should not be given (Grade 2C).
3.0 Special Patient Populations
Patients With Previous HIT Undergoing Cardiac or Vascular Surgery
3.1.1. For patients with a history of HIT who are HIT antibody negative and require cardiac surgery, we recommend the use of UFH over a nonheparin anticoagulant (Grade 1B). 3.1.2. For patients with a history of HIT who are antibody positive by platelet factor 4 (PF4)-dependent enzyme immunoassay (EIA) but antibody negative by washed platelet activation assay, we recommend the use of UFH over a nonheparin anticoagulant (Grade 2C).
Remark: Preoperative and postoperative anticoagulation, if
Patients With Acute or Subacute HIT Undergoing Cardiac Surgery
3.2.1. For patients with acute HIT (thrombocytopenic, HIT antibody positive) who require cardiac surgery, we recommend one of the following alternative anticoagulant approaches (in descending order of preference): delaying surgery (if possible) until HIT has resolved and antibodies are negative (then see Recommendation 3.1.1.) or weakly positive (then see Recommendation 3.1.2.) [Grade 1B] ; using bivalirudin for intraoperative anticoagulation during cardiopulmonary bypass (if techniques of
Percutaneous Coronary Interventions
3.3.1. For patients with strongly suspected (or confirmed) acute HIT who require cardiac catheterization or percutaneous coronary intervention (PCI), we recommend a nonheparin anticoagulant (bivalirudin [Grade 1B] , argatroban [Grade 1C] , lepirudin [Grade 1C] , or danaparoid [Grade 1C]) over UFH or LMWH (Grade 1B).
3.3.2. For patients with previous HIT (who are antibody negative) who require cardiac catheterization or PCI, we suggest use of a nonheparin anticoagulant (see Recommendation 3.3.1.)
Platelet Count Monitoring for HIT
HIT occurs most commonly in certain patient populations, such as postoperative patients who receive standard, unfractionated heparin (UFH) for ≥ 1 week (for review, see Lee and Warkentin6). One definition classifies an adverse reaction as “common” if its incidence is > 1%.30 In other clinical settings, the estimated risk of HIT can be described as “uncommon” (0.1 to 1%) or “rare” (< 0.1%).30 As described later, there is evidence that initial isolated HIT has a substantial risk of evolving to
TREATMENT OF HIT
HIT is a prothrombotic condition that is associated with increased in vivo thrombin generation (as evidenced by the presence of elevated levels of thrombin-antithrombin complexes105) and thus can be considered an acquired, hypercoagulability syndrome.13 However, unlike other acquired hypercoagulability syndromes (eg, antiphospholipid antibody syndrome, malignancy-associated thrombosis), HIT is transient, with recovery of platelet counts to normal levels within days or weeks, and disappearance
Patients With Previous HIT Undergoing Cardiac or Vascular Surgery
In general, one is reluctant to expose a patient with a history of known (or strongly suspected) drug hypersensitivity to the drug in question. However, there are several reasons why HIT is an important exception to this general rule. First, among patients with typical-onset HIT, there is no trend to earlier onset of HIT in those patients with a history of previous heparin exposure.31 Second, among patients with rapid-onset HIT preexisting HIT antibodies can be detected in patient blood
UFH vs LMWH
A metaanalysis40 of five studies (two RCTs) of postoperative thromboprophylaxis (post-orthopedic, n = 4; post-cardiac, n = 1) that examined the frequency of serologically confirmed HIT found a marked reduction in the risk of HIT with LMWH compared with UFH (common OR = 0.10 [95% CI, 0.03-0.33]; p < 0.001). A more recent metaanalysis41 confirmed the lower risk of HIT with LMWH in postsurgical thromboprophylaxis (OR = 0.072 [95% CI, 0.02-0.23]; p < 0.0001). Further evidence supporting a lower
CONLICT OF INTEREST DISCLOSURES
Dr. Warkentin discloses that he has received grant monies from the Heart & Stroke Foundation of Ontario, as well as industry-related sources of Organon and GlaxoSmithKline. Dr. Warkentin also received consultant fees from Organon, GlaxoSmithKline, and GTI, Inc, and has served on the speakers bureaus of Organon, GlaxoSmithKline, Sanofi-Aventis.
Professor Greinacher discloses that he has received grant monies from projects funded by Graduiertenkolleg, BMBF, Krupp-Kolleg, and EFRE, and has been
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