Heparin-induced thrombocytopenia diagnostic criteria: Difference between revisions
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{{Heparin-induced thrombocytopenia}} | {{Heparin-induced thrombocytopenia}} | ||
{{CMG}}; {{shyam}} | {{CMG}}; {{shyam}} | ||
==overview== | |||
The diagnostic workup for HIT begins with calculation of the pre-test probability of HIT. The 4T score can be used to determine the likelihood of HIT and whether to proceed with further diagnostic evaluation. The 4T score includes factors such as [[thrombocytopenia]], timing, [[thrombosis]], and other explanations. If the 4T score is intermediate or high, further diagnostic workup should be pursed and includes assessment for clinical and laboratory criteria, including the anti-PF4 IgG optical density. A high titer of antibodies to PF4-heparin is suggestive of a diagnosis of HIT. | |||
== | |||
==Diagnostic Criteria== | ==Diagnostic Criteria== | ||
===The 4T score=== | ===The 4T score=== | ||
The current diagnostic algorithm for HIT involves calculation of the pre-test probability using the 4T score.<ref name="pmid16634744">{{cite journal| author=Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A| title=Evaluation of pretest clinical score (4 T's) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. | journal=J Thromb Haemost | year= 2006 | volume= 4 | issue= 4 | pages= 759-65 | pmid=16634744 | doi=10.1111/j.1538-7836.2006.01787.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16634744 }} </ref> <ref name="pmid22990018">{{cite journal| author=Cuker A, Gimotty PA, Crowther MA, Warkentin TE| title=Predictive value of the 4Ts scoring system for heparin-induced thrombocytopenia: a systematic review and meta-analysis. | journal=Blood | year= 2012 | volume= 120 | issue= 20 | pages= 4160-7 | pmid=22990018 | doi=10.1182/blood-2012-07-443051 | pmc=3501714 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22990018 }} </ref> This scoring system is used when a patient is found to have thrombocytopenia or thrombosis after heparin exposure. It is calculated before the heparin-PF4 IgG antibody is ordered, and it offers a cost-effective and efficient way for determining the likelihood of HIT.<ref name="pmid24824208">{{cite journal| author=Gardiner EE, Andrews RK, Cuker A| title=DiagnoSTic assays for heparin-induced thrombocytopenia. | journal=Br J Haematol | year= 2014 | volume= 166 | issue= 5 | pages= 631-3 | pmid=24824208 | doi=10.1111/bjh.12940 | pmc=4134688 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24824208 }} </ref> | The current diagnostic algorithm for HIT involves calculation of the pre-test probability using the 4T score.<ref name="pmid16634744">{{cite journal| author=Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A| title=Evaluation of pretest clinical score (4 T's) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. | journal=J Thromb Haemost | year= 2006 | volume= 4 | issue= 4 | pages= 759-65 | pmid=16634744 | doi=10.1111/j.1538-7836.2006.01787.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16634744 }} </ref> <ref name="pmid22990018">{{cite journal| author=Cuker A, Gimotty PA, Crowther MA, Warkentin TE| title=Predictive value of the 4Ts scoring system for heparin-induced thrombocytopenia: a systematic review and meta-analysis. | journal=Blood | year= 2012 | volume= 120 | issue= 20 | pages= 4160-7 | pmid=22990018 | doi=10.1182/blood-2012-07-443051 | pmc=3501714 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22990018 }} </ref> This scoring system is used when a patient is found to have [[thrombocytopenia]] or [[thrombosis]] after heparin exposure. It is calculated before the heparin-PF4 IgG antibody is ordered, and it offers a cost-effective and efficient way for determining the likelihood of HIT.<ref name="pmid24824208">{{cite journal| author=Gardiner EE, Andrews RK, Cuker A| title=DiagnoSTic assays for heparin-induced thrombocytopenia. | journal=Br J Haematol | year= 2014 | volume= 166 | issue= 5 | pages= 631-3 | pmid=24824208 | doi=10.1111/bjh.12940 | pmc=4134688 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24824208 }} </ref> | ||
* '''T'''hrombocytopenia: 2 points are assigned to platelet count fall greater than 50% and platelet nadir greater than 20,000 per microliter. 1 point is assigned to platelet count fall 30-50% or platelet nadir 10,000-19,000 per microliter. No points are assigned to platelet count fall less than 30% or [[platelet]] nadir less than 10,000 per microliter. | |||
* '''T'''hrombosis: 2 points are assigned to new confirmed [[thrombosis]] or skin necrosis at injection sites or acute systemic reaction after IV heparin bolus. 1 point is assigned to progressive or recurrent [[Skin lesion|skin lesions]] or suspected [[thrombosis]] (without proof of thrombosis. No points are assigned if there is no thrombosis. | |||
* '''T'''iming: 2 points are assigned if the [[platelet]] count fall clearly occurs between days 5 and 10, or if the [[platelet count]] fall occurs in less than 1 day if a patient had recent [[heparin]] exposure within the past 30 days. 1 point is assigned if the platelet count is likely to have fallen between days 5-10 (there may be missing platelet count checks), or platelet count fall after day 10, or platelet count fall within 1 day in the setting of prior heparin exposure 30-100 days ago. No points are assigned if platelet count fall occurs within 4 days in the setting of no heparin exposure. | |||
* o'''T'''her: 2 points are assigned if there is no apparent alternative explanation of [[thrombocytopenia]]. 1 point is assigned if there is a possible alternative explanation of [[thrombocytopenia]]. No points are assigned if there is a definite alternative explanation of [[thrombocytopenia]]. | |||
* 0 to 3 points: low probability | The range of scores is from 0 to 8. The points from each of the 4 categories is summed in order to obtain the final score, as follows: | ||
* 4 to 5 points: intermediate probability | * '''0 to 3 points:''' low probability of HIT | ||
* 6 to 8 points: high probability | * '''4 to 5 points:''' intermediate probability of HIT | ||
* '''6 to 8 points:''' high probability of HIT | |||
The American Society of Hematology, as part of the [http://www.choosingwisely.org/ Choosing Wisely] program, states<ref>The American Society of Hematology. [http://www.choosingwisely.org/clinician-lists/american-society-hematology-testing-treating-suspected-heparin-induced-thrombocytopenia/Don’t test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT.]. 2014</ref>: | The American Society of Hematology, as part of the [http://www.choosingwisely.org/ Choosing Wisely] program, states<ref>The American Society of Hematology. [http://www.choosingwisely.org/clinician-lists/american-society-hematology-testing-treating-suspected-heparin-induced-thrombocytopenia/Don’t test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT.]. 2014</ref>: | ||
: "Don’t test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT." | : "Don’t test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT." | ||
===Clinical and Laboratory Criteria=== | |||
There are no well-established formal criteria for the diagnosis of HIT. However, there are clinical and laboratory criteria which can strongly suggest a diagnosis of HIT. | |||
'''Clinical criteria''' for a diagnosis of HIT include<ref name="pmid20059332">{{cite journal| author=Arepally GM, Ortel TL| title=Heparin-induced thrombocytopenia. | journal=Annu Rev Med | year= 2010 | volume= 61 | issue= | pages= 77-90 | pmid=20059332 | doi=10.1146/annurev.med.042808.171814 | pmc=4153429 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20059332 }} </ref>: | |||
* Development of [[thrombocytopenia]] and/or [[Thrombosis|thrombosi]]<nowiki/>s in the setting of recent heparin exposure | |||
* Absence of other causes of [[thrombocytopenia]] | |||
* Timing of [[thrombocytopenia]] (i.e. 5-14 days is most suggestive) | |||
'''Laboratory criteria''' for diagnosis of HIT include<ref name="pmid20059332">{{cite journal| author=Arepally GM, Ortel TL| title=Heparin-induced thrombocytopenia. | journal=Annu Rev Med | year= 2010 | volume= 61 | issue= | pages= 77-90 | pmid=20059332 | doi=10.1146/annurev.med.042808.171814 | pmc=4153429 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20059332 }} </ref>: | |||
* [[Thrombocytopenia]] (i.e. a platelet count drop by > 50% with nadir > 20,000 per microliter is most suggestive) | |||
* Presence of heparin-PF4 IgG antibodies via enzyme-linked immunoassay: A high PF4 IgG optical density is more suggestive of HIT than a low optical density. If the optical density is more than 2, a diagnosis of HIT is very likely. This should be confirmed via the functional assay. | |||
* Presence of a positive functional assay (i.e. C14-serotonin release assay or heparin-induced platelet aggregation assay) | |||
==Reference== | ==Reference== | ||
Latest revision as of 15:16, 8 August 2018
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Heparin-induced thrombocytopenia |
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Differentiating Heparin-induced thrombocytopenia from other Diseases |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Shyam Patel [2]
overview
The diagnostic workup for HIT begins with calculation of the pre-test probability of HIT. The 4T score can be used to determine the likelihood of HIT and whether to proceed with further diagnostic evaluation. The 4T score includes factors such as thrombocytopenia, timing, thrombosis, and other explanations. If the 4T score is intermediate or high, further diagnostic workup should be pursed and includes assessment for clinical and laboratory criteria, including the anti-PF4 IgG optical density. A high titer of antibodies to PF4-heparin is suggestive of a diagnosis of HIT.
Diagnostic Criteria
The 4T score
The current diagnostic algorithm for HIT involves calculation of the pre-test probability using the 4T score.[1] [2] This scoring system is used when a patient is found to have thrombocytopenia or thrombosis after heparin exposure. It is calculated before the heparin-PF4 IgG antibody is ordered, and it offers a cost-effective and efficient way for determining the likelihood of HIT.[3]
- Thrombocytopenia: 2 points are assigned to platelet count fall greater than 50% and platelet nadir greater than 20,000 per microliter. 1 point is assigned to platelet count fall 30-50% or platelet nadir 10,000-19,000 per microliter. No points are assigned to platelet count fall less than 30% or platelet nadir less than 10,000 per microliter.
- Thrombosis: 2 points are assigned to new confirmed thrombosis or skin necrosis at injection sites or acute systemic reaction after IV heparin bolus. 1 point is assigned to progressive or recurrent skin lesions or suspected thrombosis (without proof of thrombosis. No points are assigned if there is no thrombosis.
- Timing: 2 points are assigned if the platelet count fall clearly occurs between days 5 and 10, or if the platelet count fall occurs in less than 1 day if a patient had recent heparin exposure within the past 30 days. 1 point is assigned if the platelet count is likely to have fallen between days 5-10 (there may be missing platelet count checks), or platelet count fall after day 10, or platelet count fall within 1 day in the setting of prior heparin exposure 30-100 days ago. No points are assigned if platelet count fall occurs within 4 days in the setting of no heparin exposure.
- oTher: 2 points are assigned if there is no apparent alternative explanation of thrombocytopenia. 1 point is assigned if there is a possible alternative explanation of thrombocytopenia. No points are assigned if there is a definite alternative explanation of thrombocytopenia.
The range of scores is from 0 to 8. The points from each of the 4 categories is summed in order to obtain the final score, as follows:
- 0 to 3 points: low probability of HIT
- 4 to 5 points: intermediate probability of HIT
- 6 to 8 points: high probability of HIT
The American Society of Hematology, as part of the Choosing Wisely program, states[4]:
- "Don’t test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT."
Clinical and Laboratory Criteria
There are no well-established formal criteria for the diagnosis of HIT. However, there are clinical and laboratory criteria which can strongly suggest a diagnosis of HIT.
Clinical criteria for a diagnosis of HIT include[5]:
- Development of thrombocytopenia and/or thrombosis in the setting of recent heparin exposure
- Absence of other causes of thrombocytopenia
- Timing of thrombocytopenia (i.e. 5-14 days is most suggestive)
Laboratory criteria for diagnosis of HIT include[5]:
- Thrombocytopenia (i.e. a platelet count drop by > 50% with nadir > 20,000 per microliter is most suggestive)
- Presence of heparin-PF4 IgG antibodies via enzyme-linked immunoassay: A high PF4 IgG optical density is more suggestive of HIT than a low optical density. If the optical density is more than 2, a diagnosis of HIT is very likely. This should be confirmed via the functional assay.
- Presence of a positive functional assay (i.e. C14-serotonin release assay or heparin-induced platelet aggregation assay)
Reference
- ↑ Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A (2006). "Evaluation of pretest clinical score (4 T's) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings". J Thromb Haemost. 4 (4): 759–65. doi:10.1111/j.1538-7836.2006.01787.x. PMID 16634744.
- ↑ Cuker A, Gimotty PA, Crowther MA, Warkentin TE (2012). "Predictive value of the 4Ts scoring system for heparin-induced thrombocytopenia: a systematic review and meta-analysis". Blood. 120 (20): 4160–7. doi:10.1182/blood-2012-07-443051. PMC 3501714. PMID 22990018.
- ↑ Gardiner EE, Andrews RK, Cuker A (2014). "DiagnoSTic assays for heparin-induced thrombocytopenia". Br J Haematol. 166 (5): 631–3. doi:10.1111/bjh.12940. PMC 4134688. PMID 24824208.
- ↑ The American Society of Hematology. test or treat for suspected heparin-induced thrombocytopenia (HIT) in patients with a low pre-test probability of HIT.. 2014
- ↑ 5.0 5.1 Arepally GM, Ortel TL (2010). "Heparin-induced thrombocytopenia". Annu Rev Med. 61: 77–90. doi:10.1146/annurev.med.042808.171814. PMC 4153429. PMID 20059332.