Heparin-induced thrombocytopenia resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Karol Gema Hernandez, M.D. [2]

Definition

This section provides a short and straight to the point definition of the disease or symptom in one sentence.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Life threatening cause 1
• Life threatening cause 2
• Life threatening cause 3

Common Causes

• Common cause 1
• Common cause 2
• Common cause 3
• Common cause 4
• Common cause 5

Management

Shown below is an algorithm summarizing the approach to heparin induced thrombocytopenia.

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Thrombocytopenia: ❑ Platelet count <150,000/mm3 or ❑ >50% decrease from highest level before initiation of heparin therapy ❑ Making sure patient has received heparin or LMWH in the previous 5- 14 days ❑ And after ruling out other causes of thrombocytopenia

High or intermediate clinical suspicion of HIT ❑ Venous/arterial thrombosis ❑ Unusual manifestations: Skin necrosis at SC heparin injection sites Transient global amnesia ❑ Abscence of petechiae and/or significant bleeding

Discontinue heparin

Lepirudin

Measure aPTT 2 hrs after therapy and after each dose adjustment. Optimal aPTT<65 sec. Check baseline before starting warfarin.

Direct thrombin inhibitors

Argatroban

Measure aPTT 2 hrs after therapy and after each dose adjustment. Switching to warfarin complicated due to prolonged PT.

Bivalirudin

Measure ACT 5 min after completing IV bolus

Initiate alternative anticoagulant therapy for at least 2-3 months

Danaparoid

Monitoring not needed. If needed maintain anti-factor Xa 0.5-0.8 U/mL

Anti-factor Xa therapy

Fondaparinux

Proceed to serologic testing

Positive + high clinical suspicion of HIT

Positive + intermediate suspicion of HIT

Negative + high clinical suspicion of HIT

Negative + intermediate clinical suspicion of HIT

Confirmed HIT

Proceed to functional testing

Indeterminate HIT

Can restart heparin

C-Serotonin Release Assay (SRA)

Heparin induced platelet-activation assays (HIPA)

Rule out other causes of thrombocytopenia

Rule out other causes of thrombocytopenia