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HIT Risks in Cancer Patients

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Heparin-Induced Thrombocytopenia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
DVT in a Breast Cancer Patient ,[object Object],[object Object],[object Object],[object Object]
HIT With Cancer
Some Lessons from this Case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
There are more than 100 HIT stories in the Medical Center every year

Frequency of HIT Perspectives ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Some Paradoxes of HIT ,[object Object],[object Object],[object Object],[object Object],[object Object]
Heparin-Induced Thrombocytopenia (HIT): Pathophysiology 1 *Places patient at greater risk from primary thrombotic problem. 1. Adapted from Aster RH. N Engl J Med . 1995;332(20):1374-1376. Formation of PF4-heparin complexes IgG antibody Formation of immune complexes (PF4-heparin-IgG) EC injury PF4 release Platelet activation* Microparticle release Fc receptor Platelet Heparin-like molecules Blood vessel PF4 Heparin
Heparin-Induced Thrombocytopenia (HIT): Clinical Consequences if Untreated ,[object Object],[object Object],[object Object],[object Object],[object Object],1. Warkentin TE, Kelton JG. Am J Med. 2. King DJ, Kelton JG. Ann Intern Med.
Risk of Thrombosis with HIT After Heparin is Stopped (if an effective alternative is not begun) Warkentin and Kelton. Am J Med 1996;101. Days after isolated HIT recognized 100 90 80 70 60 50 40 30 20 10 0 52.8% 0 2 4 6 10 12 14 16 8 18 22 26 28 30 24 20 Cumulative frequency of thrombosis (%)
HIT is a Clinico-Pathologic Syndrome ,[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Suspicion for HIT The 4 T’s (Warkentin, 2003) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
HIT Temporal Variants Courtesy of Dr Ahjad AlMahameed Cleveland Clinic, OH. Day 1 Day 4 Day 14 Day 30 Delayed-onset HIT (9 – 40 days) Rapid-onset HIT (hours – days) Typical HIT Mean Day 9 (4 – 14 days) Heparin (re) Exposure THROMBOCYTOPENIA (± THROMBOSIS)
Distribution of Platelet Count Warkentin. Semin Hematol 1998;35(4):9-16.
Laboratory Tests for Heparin-PF4 Antibodies ,[object Object],[object Object],[object Object],[object Object],[object Object]
ACCP Antithrombotic Guidelines Chest supplement, Sept. 2004, Chapter on HIT: Monitoring, Dx and Rx ,[object Object],[object Object],[object Object]
Treatment of Other Drug-Induced Thrombocytopenias ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Treatment of Heparin-Induced Thrombocytopenia Rice L. Arch Intern Med. 2004;164:1961-1964.
Alternative Anticoagulants Approved for HIT in Canada, Europe, Aust. Danaparoid Prophylaxis and Rx of VTE Fondaparinux (pentasac.) PCI (including HIT patients) Bivalirudin FDA-approved for HIT Lepirudin FDA-approved for HIT (also for PCI) Argatroban Indications Drug
The Key to Avoiding Catastrophes from HIT is Awareness, Vigilance, High Degree of Suspicion ,[object Object],[object Object],[object Object],Consider HIT during/soon after heparin exposure* * Heparin exposure may be through virtually any preparation (including LMWH), any dose, or any route of heparin (including flushes and coated lines)
HIT Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Proposed ICD-9 CM ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Proposed ICD-9 CM ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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HIT Risks in Cancer Patients

  • 1.
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  • 5. There are more than 100 HIT stories in the Medical Center every year

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  • 8. Heparin-Induced Thrombocytopenia (HIT): Pathophysiology 1 *Places patient at greater risk from primary thrombotic problem. 1. Adapted from Aster RH. N Engl J Med . 1995;332(20):1374-1376. Formation of PF4-heparin complexes IgG antibody Formation of immune complexes (PF4-heparin-IgG) EC injury PF4 release Platelet activation* Microparticle release Fc receptor Platelet Heparin-like molecules Blood vessel PF4 Heparin
  • 9.
  • 10. Risk of Thrombosis with HIT After Heparin is Stopped (if an effective alternative is not begun) Warkentin and Kelton. Am J Med 1996;101. Days after isolated HIT recognized 100 90 80 70 60 50 40 30 20 10 0 52.8% 0 2 4 6 10 12 14 16 8 18 22 26 28 30 24 20 Cumulative frequency of thrombosis (%)
  • 11.
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  • 13. HIT Temporal Variants Courtesy of Dr Ahjad AlMahameed Cleveland Clinic, OH. Day 1 Day 4 Day 14 Day 30 Delayed-onset HIT (9 – 40 days) Rapid-onset HIT (hours – days) Typical HIT Mean Day 9 (4 – 14 days) Heparin (re) Exposure THROMBOCYTOPENIA (± THROMBOSIS)
  • 14. Distribution of Platelet Count Warkentin. Semin Hematol 1998;35(4):9-16.
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  • 18. Alternative Anticoagulants Approved for HIT in Canada, Europe, Aust. Danaparoid Prophylaxis and Rx of VTE Fondaparinux (pentasac.) PCI (including HIT patients) Bivalirudin FDA-approved for HIT Lepirudin FDA-approved for HIT (also for PCI) Argatroban Indications Drug
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  • 22.