ASH 2018: HIT Flashcards Preview

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Flashcards in ASH 2018: HIT Deck (32)
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1

If risk of HIT is low for patient receiving heparin, don't do

Platelet count monitoring to screen for HIT

2

If risk of HIT is 0.1% - 100%, do

Platelet count monitoring to screen for HIT

3

For platelet count monitoring, when to start
A. If patient has had heparin in the 30 days prior
B. If patient is heparin naive
C. If patient is high risk (frequency)
D. If patient is intermediate risk (frequency)

A. Day 0
B. Day 4 - 14 or until heparin is stopped
C. Every other day
D. Every 2 - 3 days

4

If suspected HIT and 4T score shows intermediate or high probability, strong recommendation for

Immunoassay
If immunoassay is positive, conditional recommendation to follow up with a functional assay

5

If suspected HIT and low 4T score, don't do (2 things)

1. HIT laboratory testing
2. Empiric HIT therapy

Strong recommendations

6

If suspected HIT and intermediate 4T score, regardless of whether or not they have an indication for therapeutic anticoagulation, strong recommendation to

Discontinue heparin

7

If suspected HIT, intermediate 4T score, no Other indication for therapeutic anticoagulation, conditional recommendation for (incl if high bleeding risk or no high bleeding risk)

Non-heparin anticoagulation at therapeutic dosing if not at high risk for bleeding
Non-heparin anticoagulation at prophylactic dosing if at high risk for bleeding

8

If suspected HIT, intermediate 4T score, and Another indication for therapeutic anticoagulation, conditional recommendation for

Therapeutic dosing of non-heparin anticoagulant

9

If suspected HIT, high 4T score, strong recommendation for

Discontinuation of heparin and initiation of non-heparin anticoagulant

10

If suspected HIT, high 4T score and negative immunoassay, strong recommendation to

Stop non-heparin anticoagulant and restart heparin

11

If suspected HIT, intermediate 4T score and positive immunoassay, strong recommendation to

Continue avoiding heparin
Administer therapeutic doses of non-heparin anticoagulant

12

In acute HITT (HIT + Thrombosis) or HIT patients, strong recommendation to

Discontinue heparin and start non-heparin anticoagulant

13

Preferred drugs for acute HIT if critical illness, increased bleed risk, life or limb threatening thromboembolism, or increased need for urgent procedures

Vs.

Reasonable options in clinically stable patients at average bleeding risks

Argatroban or Bivalirudin

Vs.

Fondaparinux or DOACs

14

If DOAC for acute HITT, most published option (with dose)

If acute, isolated HIT (with dose)

Rivaroxaban 15 mg BID x 3 weeks, then 20 mg daily

Rivaroxaban 15 mg BID until platelet count recovery, then 20 mg daily

15

Routine insertion of IVC filter in acute HIT or HITT?

No

16

When to start warfarin in acute HITT or HIT

After platelet count recovery (150 x 10^9)

17

If on warfarin and diagnosed with HIT or HITT

Stop warfarin, give vitamin K and start non-heparin anticoagulant

18

Routine platelet transfusion for acute HIT or HITT?

No

19

If acute isolated HIT, to screen for asymptomatic proximal DVT, conditional recommendation to do

Bilateral lower extremity compression ultrasonography

20

If acute isolated HIT and upper extremity central venous catheter, conditional recommendation to do... And to not do...

(Do) upper extremity ultrasonography in the limb with the catheter to screen for asymptomatic DVT

(Don't) upper extremity ultrasonography in limbs without the catheter

21

How long to anticoagulate in acute isolated HIT with no DVT found?

Until platelet count recovery

22

If subacute HIT A, which is preferred between DOACs or warfarin

DOACs

23

What is Suspected vs.
Acute vs.
subacute HIT A vs.
subacute HIT B vs.
Remote

Suspected: low platelets
Acute: positive immunoassay and if possible functional assay
Subacute A: platelet count recovery
Subacute B: functional assay recovery
Remote: immunoassay recovery

24

If acute HIT or subacute HIT A and requiring cardiovascular surgery

Delay surgery until functional assay recovery (subacute B) or immunoassay recovery (remote HIT)

25

If cannot delay surgery while acute HIT or subacute HIT A

Intraoperative Bivalirudin or plasma exchange and then intraoperative heparin or intraoperative heparin with a potent antiplatelet like tirofiban

26

If cardiovascular surgery needed in a patient with subacute HIT B or remote HIT

Intraoperative heparin

27

If subacute HIT A or acute HIT and need PCI

Bivalirudin
If Bivalirudin is not available, can use Argatroban

28

If subacute HIT B or remote HIT and need PCI

Bivalirudin
Heparin is an acceptable alternative if no other anticoag can be used

29

If acute HIT on dialysis

Argatroban, Danaparoid, or Bivalirudin

30

In subacute HIT A, subacute HIT B, or remote HIT and on dialysis and not otherwise receiving anticoagulation

Regional Citrate