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Heparin-induced thrombocytopenia

Key sources
The following summarized guidelines for the evaluation and management of heparin-induced thrombocytopenia are prepared by our editorial team based on guidelines from the Society for Cardiovascular Angiography and Interventions (SCAI/AHA/ACC 2022), the French Working Group on Perioperative Hemostasis (GIHP 2020), the Canadian Association of Interventional Cardiology (CAIC 2019), the European Society of Cardiology (ESC/EACTS 2019), the American Society of Hematology (ASH 2018), the European Society of Cardiology (ESC 2018), the Society for Vascular Surgery (SVS 2018), the Canadian Consensus Group on Venous Thromboembolism in Cancer (CCG-VTEC 2015), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2014), the British Committee for Standards In Haematology (BCSH 2012), the American College of Chest Physicians (ACCP 2012), and the Kidney Disease: Improving Global Outcomes Foundation (KDIGO 2012).
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Guidelines

1.Screening and diagnosis

Indications for monitoring, baseline platelet count, GIHP: obtain baseline measurement of platelet count before initiating heparin (or alternatively as soon as possible after the first injection, before day 4), whether UFH or LMWH.
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  • Indications for monitoring (low risk)

  • Indications for monitoring (moderate-to-high risk)

  • Indications for monitoring (after surgery)

  • Indications for monitoring (recent heparin exposure)

  • Indications for testing (low pretest probability)

  • Indications for testing (moderate-to-high pretest probability)

  • Indications for testing (acute systemic reaction)

  • Diagnosis

2.Classification and risk stratification

Pretest probability
As per GIHP 2020 guidelines:
Use the 4T score (outside a cardiac surgery context) to determine the clinical probability of HIT in patients with suspected HIT.
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Consider classifying the risk of HIT during heparin administration into three groups:
Situation
Guidance
Low (< 0.1%)
Treatment with LMWH in medicine (except cancer), obstetrics (except surgery including C-section), or in the course of minor trauma
Treatment with fondaparinux
Isolated UFH injection for an endovascular procedure or simple surgery
Treatment with UFH or LMWH lasting > 1 month
Intermediate (0.1-1%)
Prophylactic treatment with UFH in medicine/obstetrics
Prophylactic treatment with LMWH in patients with cancer or severe trauma or in postoperative care (including cardiac surgery)
High (> 1%)
Prophylactic treatment with UFH in surgery (including circulatory assistance) or for RRT
All curative treatments with UFH in medicine/surgery/obstetrics
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  • Classification

3.Diagnostic investigations

Immunoassays
As per GIHP 2020 guidelines:
Consider obtaining anti-PF4 antibodies as soon as possible in patients with suspected HIT with intermediate or high clinical probability.
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Obtain biological tests to detect anti-PF4 antibodies in patients with intermediate (4T = 4-5) or high (4T ≥ 6) pretest probability.
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  • Platelet function tests

  • Screening for asymptomatic DVT

4.Medical management

Continuation of heparin: as per GIHP 2020 guidelines, consider continuing or resuming heparin therapy, with close monitoring of platelet count, after the exclusion of HIT based on the absence of anti-PF4 antibodies in patients with intermediate clinical probability.
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  • Discontinuation of heparin

  • Initiation of non-heparin anticoagulants, HIT without thrombosis (general principles)

  • Initiation of non-heparin anticoagulants, HIT without thrombosis (direct thrombin and factor Xa inhibitors)

  • Initiation of non-heparin anticoagulants, HIT without thrombosis (DOACs)

  • Initiation of non-heparin anticoagulants, HIT without thrombosis (VKAs)

  • Initiation of non-heparin anticoagulants, HIT with thrombosis (general principles)

  • Initiation of non-heparin anticoagulants, HIT with thrombosis (direct thrombin and factor Xa inhibitors)

  • Initiation of non-heparin anticoagulants, HIT with thrombosis (VKAs)

  • Duration of anticoagulation

  • Antiplatelet therapy

  • IVIG

5.Therapeutic procedures

Platelet transfusion: as per GIHP 2020 guidelines, do not administer platelet transfusion in the acute phase of HIT in the absence of life-threatening or functional bleeding.
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  • IVC filter placement

6.Specific circumstances

Pediatric patients
Consider using the same procedures for monitoring platelet counts in pediatric patients treated with heparin as in adult patients.
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Initiate sodium danaparoid or argatroban, with rigorous dose adjustment based on weight and bioassay results, in pediatric patients with HIT.
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  • Pregnant patients (management)

  • Pregnant patients (diagnosis)

  • Patients with hepatic impairment

  • Patients with renal impairment

  • Patients requiring RRT

  • Patients requiring PCI

  • Patients requiring cardiac surgery

  • Patients requiring non-cardiac surgery

  • Patients with non-HIT-related thrombosis

7.Preventative measures

Secondary prevention: as per GIHP 2020 guidelines, consider initiating an OAC (VKA or DOAC) or fondaparinux in patients with a history of HIT requiring prophylactic or curative anticoagulation. Consider initiating argatroban, bivalirudin, or danaparoid only when OACs and fondaparinux are contraindicated.
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8.Quality improvement

Documentation: consider obtaining a hemostasis consultation within 3 months of the diagnosis of HIT and provide a card attesting this complication, specifying the results of the biological tests, and recommending the exclusion of all heparin treatment to the patient.
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  • Medical alert bracelet