Heparin-induced thrombocytopenia (HIT) is a severe complication that can occur in patients exposed to any form or amount of heparin products. A fall in platelet counts and a hypercoagulable state characterize HIT. Patients who experience HIT may also develop thromboembolic complications that are associated with morbidity and mortality. This is a significant burden since heparin is widely used for treatment and prophylaxis of thromboembolism, for line flushes, and in heparin-coated catheters. This review will discuss the pathophysiology, diagnosis, and management of patients with HIT.
Types of Thrombocytopenia (occur secondary to heparin use)
Type I HIT, also known as Heparin-associated thrombocytopenia (HAT), is a non-immune mediated reaction. Type I HIT is much more common than type II and can occur as early as day 1 of therapy. This is a mild reaction, it is not associated with any complications, and platelet counts will spontaneously normalize even if heparin is continued.
Type II HIT is an immune, antibody-mediated reaction. Because it takes time for the antibodies to form, this reaction usually occurs after 5 to 14 days of receiving heparin. However, if a patient has been exposed to heparin within the last 100 days, antibodies may remain in the system, causing this reaction to manifest as soon as day one of heparin therapy. This is a very serious reaction that causes a hypercoagulable state and can lead to life-threatening complications. The rest of this review will focus on type II HIT and its management.
A HIT can occur in up to 5% of patients exposed to heparin products. HIT causes an extremely hypercoagulable state, where up to 50% of patients develop thromboembolic complications, associated with a mortality rate up to 30%.
There are several medication-related as well as patient-related factors that can increase the risk of a HIT. Because of the difference in structure and function, HIT is more likely to occur with unfractionated heparin (UFH) than with low molecular weight heparin (LMWH). Fondaparinux is a heparin-like drug that does not cause HIT. UFH is a heterogeneous product that consists of long saccharide chains of varying lengths and molecular weights; the average UFH molecule is 45 saccharide units long. LMWH is also a heterogeneous product; however, LMWH is, on average, 15 saccharide units long. Fondaparinux is a synthetic pentasaccharide, consisting of only the 5 sugars. The shorter the saccharide chain and the smaller the molecular weight, the less likely the drug is to bind to plasma proteins and cells. Therefore, there is a reduced risk of a HIT with LMWH compared to UFH, whereas fondaparinux does not cause HIT, and can be safely utilized in patients with a history of HIT and potentially in the treatment of acute HIT.
Although no amount of heparin is too small to cause this reaction, HIT is more likely to occur in patients exposed to higher doses of the drug; and the longer the duration of therapy, the higher the risk. Furthermore, females and elderly patients appear to be at an increased risk. The incidence of HIT is also higher among surgical patients, and this may be due to increased platelet activation and PF4 activity due to mechanical intervention and injury.
Under normal physiological conditions, PF4 is stored in alpha-granules of the platelets and is released upon platelet activation. PF4 is positively charged and can, therefore, bind to the negatively charged heparan (a heparin-like substance normally present on the endothelial cell surface); PF4 can also bind to exogenous heparin with much higher affinity than heparin.
PF4 binding to heparin may trigger the formation of IgG, IgA, or IgM antibodies specific to the heparin-PF4 complex. A HIT can only occur if IgG, while attached to the heparin-PF4 complex, binds to the FC receptor on the platelet surface and leads to platelet activation. Activated platelets then release pro-thrombotic substances (such as thrombin) and PF4. As IgG activates more platelets, more PF4 is released forming more complexes with heparin, thus activating more platelets. This creates a severely hypercoagulable state and a continuous cycle that can only be broken when heparin is discontinued, and appropriate treatment is initiated.
The most characteristic clinical feature of HIT is the thrombocytopenia. Platelet counts fall because macrophages consume the IgG-coated platelets and the removed by the reticuloendothelial system removes them. Simultaneously, as platelets become activated, they aggregate, and the platelet count drops as thrombus forms.
Because HIT causes a hypercoagulable state, venous and/or arterial thrombosis can occur. The most common complications are DVT, PE or skin necrosis. The latter is particularly a risk if warfarin is administered in the acute phase. The risk of these complications is highest within the first 10 days, but the pro-thrombotic state persists up to 30 days after stopping heparin.
HIT should be suspected when there is an unexplained drop in platelet counts in a patient currently on heparin or recently exposed to heparin products. HIT typically presents as a steady drop in platelet counts (no fluctuations), while hemoglobin and hematocrit counts remain relatively stable.
The first step in the diagnosis of HIT is the calculation of the 4T score. This is a scoring system used to determine the likelihood of a patient having HIT based on the presence or absence of certain parameters. The score may be calculated using the following table.
A 4T score of 0 to 3 points means a HIT is unlikely, and heparin therapy may continue while the clinician looks for other causes of thrombocytopenia. A score of 4 to 5 corresponds to intermediate probability and a score of 6 to 8 means high probability. All forms of heparin, including line flushes, should be immediately discontinued and treatment with an alternative anticoagulant should be pursued in any patient who scores 4 or more. In addition, the clinical diagnosis with the 4T score should be confirmed with the PF4 ELISA and the Serotonin Release Assay (SRA).
The PF4 ELISA detects the presence of antibodies. This test is highly sensitive and has a high negative predictive value; HIT can be ruled out if this test is negative. However, if the PF4 ELISA is positive, the result should be confirmed with the SRA, a more specific test that is also more costly and takes several days for the result to be reported. The PF4 ELISA detects not only IgG but also IgA and/or IgM, leading to false positives.
The SRA is the gold standard test for confirming HIT with high sensitivity and specificity. Unlike ELISA, which detects the presence of antibodies, the SRA is a functional test, which detects the activation of platelets in the presence of antibodies. A donor platelet that becomes activated in the presence of heparin and a sample of the patient’s blood (containing IgG) will release serotonin. A positive SRA confirms the diagnosis of HIT, and a negative SRA rules out HIT, even in the setting of a positive ELISA.
The treatment of HIT should start as soon as a 4T score of 4 or more is calculated. The first step in the treatment is the discontinuation of all forms of heparin. Next, an alternative anticoagulant must be initiated to prevent or treat any HIT-induced thrombosis. In patients recently started on warfarin, warfarin should be held, and phytonadione (vitamin K) should be administered to replete protein C and S stores. The PF4 ELISA an SRA should be sent to confirm the diagnosis.
The anticoagulant of choice in an acute HIT is argatroban. Argatroban is a direct thrombin inhibitor that does not interact with PF4 or heparin-induced antibodies. Argatroban has a short half-life of about 50 minutes; it is given as a continuous infusion and requires aPTT monitoring, similar to heparin. This drug is hepatically metabolized and requires adjustment to the starting rate in patients with hepatic dysfunction, heart failure and/or multi-organ failure. Argatroban can profoundly increase INR; however, no therapeutic range for INR has been established for patients on argatroban. Argatroban’s effect on the INR must be considered when bridging a patient to warfarin.
Bivalirudin is another direct thrombin inhibitor that may safely be used in this patient population; however, this agent is usually reserved for use during cardiac catheterization procedures as an alternative to heparin. It is FDA approved for patients undergoing percutaneous coronary intervention with or without a HIT. It is more expensive than argatroban.
Another anticoagulant that may be used in a HIT is fondaparinux, although not FDA-approved for this indication. Fondaparinux is given as a once-daily subcutaneous injection. Unlike UFH and LMWH, fondaparinux does not interact with PF4 or heparin-induced antibodies.
Other conditions to be considered on the differential when diagnosing HIT include, but are not limited to: type I HIT (HAT), disseminated intravascular coagulation (DIC), liver disease, bleeding, hemodilution, Immune thrombocytopenia (ITP), myelosuppression, as well as other drug-induced causes.
Absolute contraindications during the acute period include the use of UFH, LMWH, warfarin and platelet transfusions.
When warfarin is first initiated, the natural anticoagulants, protein C and S, whose synthesis is vitamin K-dependent, will be depleted first, while the vitamin-K dependent clotting factors remain in circulation, leading to a hypercoagulable state. If warfarin is administered at the onset of a HIT, protein C and S depletion can severely worsen coagulation and increase the risk of thromboembolic complications, particularly skin necrosis. If recently started, warfarin must be stopped and reversed with phytonadione to replete protein C and S stores.
Warfarin can be started once 2 criteria have been met. First, the platelet count has made a substantial resolution and reached a stable plateau, ideally a platelet count of at least 150 or the patient’s baseline, if baseline was below 150. Second, the patient must be therapeutically anticoagulated with argatroban or fondaparinux before the initiation of warfarin and the two agents must overlap for at least 5 days before monotherapy with warfarin.
Platelet transfusions are contraindicated during this acute phase, as transfused platelets can bind to IgG, become activated and release PF4, thus worsening the hypercoagulable state.
The risk of thromboembolic complications persists for up to 30 days after stopping heparin. Therefore, in patients with HIT and no thrombosis, anticoagulation for 1 month should be considered. Warfarin may be used for that purpose once the 2 criteria mentioned above are met.
Following an episode of HIT, IgG antibodies may remain in the system for up to 100 days; if the patient receives any amount of UFH or LMWH during this period, platelet counts can drop in as little as 12 hours. If this 100-day period has passed, heparin products can be used with caution if necessary, at the lowest dose and for the least amount of time possible. Ideally, and if time permits, an SRA should be obtained before using heparin to confirm the absence of IgG in the patient’s blood. If unable to obtain the SRA, then the use of a direct thrombin inhibitor or fondaparinux should be considered.