Understanding Heparin Induced Thrombocytopenia (HIT) / Test 3/3 Flashcards Preview

CVPR 330 Blood > Understanding Heparin Induced Thrombocytopenia (HIT) / Test 3/3 > Flashcards

Flashcards in Understanding Heparin Induced Thrombocytopenia (HIT) / Test 3/3 Deck (82):
1

Heparin was discovered by

1916 Dr. Maclean

2

Heparin is a member of heterogeneous family of

glycosaminoglycans

3

Molecular weight of Heparin ?

3,000 - 30,000 daltons

4

Heparin is negatively charged, binds to a variety of ?

Plasma Proteins

5

Synthesized endogeneously and stored in basophilic granules of __________ cells. (High concentrations in lung & intestines)

Mast

6

Product Sources:
Porcine ?
Bovine ?

Porcine = Intestines
Bovine = Lungs

7

Does renal nor hepatic dysfunction have any significant effect on heparin elimination?

No

8

Heparins primary action is to bind reversibly to natural circulating ?

ATIII
1,000-4,000 fold acceleration

9

What happens Following the blockade and inactivation of thrombin ?

heparin is released

10

Heparins Limited anticoagulant action is that it is unable to dissolve an ?

Existing thrombus directly

11

Heparins Effectiveness occurs immediately, how long after the heparin bolus do we test ?

3 min

12

Heparin is associated with what ?

Deranged platelet function

13

HIT is a result of what ?

Immune and non-Immune responses.

14

In regards to heparin and inflammation, heparin can bind to what ?

chemokines,
cytotoxic peptides, &
tissue destructive enzymes

15

In regards to heparin and malignancy ?

Heparin contains Anti metastatic action

16

Inhibition of adrenal aldosterone which is generated by heparin may produce what?

hyperkalemia

17

In regards to heparin and metabolism, Heparin activates what ?

lipoprotein lipase

18

Abnormal thyroid function tests may occur with

heparin admistration

19

Long-term heparin therapy can cause the development of what?

osteoporosis

20

Studies find that this heparin preparation is more likely to yield immune HIT.

Bovine Lung

21

Many cases of HIT could be avoided simply by using what?

porcine GUT UFH

22

Prophylactic dose
Therapeutic dose
Flushes
Heparin-coated devices

Fall under what type of heparin ?

Associated Incidence of HIT?

Unfractionated Heparin

Highest

23

Prophylactic dose
Therapeutic dose

Fall under what type of heparin ?

Associated Incidence of HIT?

Low Molecular Weight Heparin

Medium

24

Pentosan polysulfate
Hypersulfated chondroitin sulfate
PI-88 (anti-angiogenic drug)

Fall under what type of heparin ?

Associated Incidence of HIT?

Highly sulfated polysaccharides

Low

25

Clinical events associated with HIT include:

-Venous thromboembolism
-Arterial thromboembolism
-Skin lesions
-Disseminated Coagulation
(DIC)

26

DVT and pulmonary embolism are strongly associated with ?

HIT (1,2,)

27

Arterial thromboembolic events include ?

peripheral arterial occlusion, acute myocardial infarction, and stroke.

28

The ratio of venous to arterial thrombotic events in a large retrospective study of serologically confirmed HIT was approximately

4:1

29

Pulmonary embolism occurred in about ___ of all patients diagnosed with HIT, which was more frequent than all arterial thrombotic events combined

25%

30

Skin lesions associated with HIT include?

Skin necrosis and/or erythematous plaques

31

Acute Systemic reactions associated with HIT include?

Acute inflammatory – fevers, chills
Cardiorespiratory – hypertension, tachycardia

32

For the last 60 years, heparin has been widely used as an anticoagulant drug for the treatment and prevention of thromboembolic disorders
during CPB & Cath Lab procedures. Heparin may cause what?

Immune thrombocytopenia (a reduction in platelet count), or HIT

33

HIT can cause ___ threatening thromboses

Life or Limb

34

HIT Type 2 also known as ?

-White Clot Syndrome &
-Heparin-associated thrombocytopenia (HAT)

35

If heparin-dependent antibodies are detectable, this tell the perfusionist what?

HIT Type 2

We need to dig a little further to see if this will be a problem .

36

Non-immune heparin-associated thrombocytopenia
Also known as what ?

HIT Type 1
(non-immune) HAT

37

Denotes absence of heparin-dependent antibodies and the potential role for other factors in causing thrombocytopenia

non-immune HAT
AKA
HIT Type 1

38

Denotes demonstrable role of heparin in “inducing” thrombocytopenia (ie, heparin-dependent antibodies are detectable)

HIT Type 2 patient

39

Clinical Conditions/Causes of Non-immune
Thrombocytopenia (HIT Type 1 )?

-Septicemia/Inflammation
-Disseminated intravascular
coagulation
-Thrombotic thrombocytopenic purpura

40

Clinical Conditions/Causes of Immune
Thrombocytopenia (HIT Type 2 )?

Alloimune:
- post-transfusion purpura
Drug-induced:
-Prothrombic (heparin),
-Prohemorrhagic (quinine, quinidine, gold, sulfa antibiotics, rifampin, vancomycin, NSAIDs, many others)

41

HIT Type 1 Characteristics:

Frequency:
Timing of onset:
Nadir platelet count:
Antibody mediated:
Thromboembolic sequelae:
Treatment:

Frequency: 10 - 20%
Timing of onset: 2 - 3 days
Nadir Platelet count: 100,000
Antibody mediated: No
Thromboembolic sequelae: none
Treatment: Observe patient

42

HIT Type 2 Characteristics:

Frequency:
Timing of onset:
Nadir platelet count:
Antibody mediated:
Thromboembolic sequelae:

Frequency: 1 - 3 %
Timing of onset: 5 - 10 days
Nadir Platelet count: 10,000 - 20,000
Antibody mediated: yes
Thromboembolic sequelae: 30-80%

43

Treatment for HIT Type 2 ?

Discontinue heparin by all routes, select other anticoagulation, adjunctive therapy.

44

What to do During HIT Type I and Cardiopulmonary Bypass ?

-Continue Heparin if indicated.
-Patients with non-immune HAT are asymptomatic; platelet counts should return to normal during continuation of heparin therapy.
-No additional risk of thrombosis

45

Frequency of HIT related to Bovine Lung?

1.9 - 30.8%

46

Frequency of HIT related to Porcine intestines?

1.3 - 8%

47

Frequency of HIT related to full dose heparin?

0 - 30%

48

5 T’s …. Approach to diagnose HIT

1.) Thrombocytopenia = >50%
2.) Timing = 5-14 days after
starting heparin
3.) Thrombosis (unusual thromboembolism, skin lesions, anaphylaxis)
4.) OTher cause not apparent
5.) Test for HIT antibodies is
positive

49

HIT is a clinicopathologic syndrome, i.e. the diagnosis is based on both

clinical and laboratory prerequisites:

50

HIT antibody seroconversion occurs as a result of

heparin exposure

51

Recent exposure to heparin (within ~100 days) may be associated with a more rapid response and is usually associated with ?

persistence of the HIT antibodies

52

HIT antibodies may develop in patients who do not develop the HIT Syndrome, i.e.

thrombocytopenia +/- thrombosis

53

Patients with HIT seroconversion without thrombocytopenia or other clinical sequelae should

not be diagnosed as having HIT

54

Although in occurs much less frequently in patients receiving low molecular weight heparins (LMWH) the possibility of the diagnosis must always be considered particularly in those patients who may have received ?

unfractionated heparin in the past

55

What must we monitor in all patients receiving heparin ?

Platelet counts.

Changes in platelet count should increase the level of suspicion and the intensity of observation for evidence of occult thrombosis increased

56

Extension or failure of the thrombotic to respond during prescribed heparin therapy should also raise the possibility of ?

HIT

57

It is essential that the diagnosis is confirmed early in the process by specific HIT serology if possible but the management decision to suspend heparin therapy and institute substitution antithrombotic therapy should ?

not be delayed for this if there is strong clinical confirmation of the diagnosis

58

5 Clinical events associated with HIT:

Venous Thrombosis ?

30 - 70%

- (DVT)
- (PE)
- Adrenal necrosis (adrenal
vein thrombosis)
- Cerebral venous (sinus)
thrombosis
- Venous limb gangrene (VKA
associated)

59

3 Clinical events associated with HIT:

Arterial Thrombosis ?

15-30%
- Limb artery thrombosis
- Stroke
-Myocardial infarction

60

Clinical events associated with HIT:

Skin lesions at heparin injection sites ?

10%

Skin necrosis
Erythematous plaques

61

Clinical events associated with HIT:
Acute reactions after i.v. heparin bolus ?

10%

62

Clinical events associated with HIT:
Disseminated intravascular coagulation (DIC) ?

10%

63

The following Acute Systemic Reactions can occur in patients sensitized to heparin within 5–30 minutes:

Fever, chills
Tachycardia, hypertension
Flushing, headache
Chest pain, dyspnea
Nausea, vomiting, large-volume diarrhea
Sudden Anaphylactic shock
Transient global amnesia

64

Heparin interacts (mild activation) with platelets causing release of proteins (chemokines) including ______from alpha granules

PF4

65

PF4 & heparin form an antigen complex which induces the formation of anti-heparin-PF4 complex IgG antibodies that bind to

FcIIa (gamma) receptors on platelet surface membrane

66

Binding causes strong platelet activation and release of
______ that promotes thrombin formation.

Microparticles

67

Microparticles are

intensely procoagulant

68

HIT antibodies also bind to endogenous PF4-endothelial
heparan-sulfate complexes (endo activation) which leads to what ?

Increased amounts of Thrombin

69

Thrombin = platelet aggregation =

cross linking w/fibrinogen

70

14C-serotonin-release assay (SRA) &
The Heparin-induced Platelet Aggregation Assay (HIPAA)

Sensitivity % ?

Early Thrombocytopenia Specificity %
Late Thrombocytopenia Specificity %

Sensitivity: 90%
Specificity (%)
Early Thrombocytopenia: > 95%
Late Thrombocytopenia: 80-95%

71

Platelet-rich plasma (PRP) aggregation

Sensitivity % ?
Early Thrombocytopenia Specificity %
Late Thrombocytopenia Specificity %

Sensitivity: 35-85%
Specificity (%)
Early Thrombocytopenia: 90%
Late Thrombocytopenia: 82%

72

PF4 Antigen Assays

Sensitivity % ?
Early Thrombocytopenia Specificity %
Late Thrombocytopenia Specificity %

Sensitivity: > 90%
Specificity (%)
Early Thrombocytopenia: > 95
Late Thrombocytopenia: 50-93%

73

This assay can detect IgG, IgM, and IgA antibodies with a sensitivity of approximately 80-90% (5,6).
Sensitivity is less than 100% because the test does not recognize antigens other than

PF4 Antigen Assays


heparin-PF4 complex

74

Combination of:
Heparin-induced platelet activation assay &
PF4 antigen EIA

Sensitivity:
Early Thrombocytopenia:
Late Thrombocytopenia:

Sensitivity: 100%
Early Thrombocytopenia: > 95%
Late Thrombocytopenia: 80-97%

75

How should Cardiac surgery in patients with previous HIT episode be addressed ?

-Delay surgery until the (transient) antibodies are undetectable. (usually decline to zero in 100 days.
- Use UFH, but avoid pre-operative heparin completely.
- Remove any heparin-coated products from circuitry

76

Bypass pharmacology options while pumping a patient with HIT ?

- Argatroban : Dorect thrombin
inhibitor
- Iloprost : prostacyclin analog,
reversibly inhibits platelet
aggregation.
- Lepirudin: leach saliva;
Monitor ECT

77

defibrinogenating agent (pit viper venom)

Ancrod

78

Danaparoid sodium

(hepariniod)

79

Prostacyclin Analogues

Act as natural vasodilators
Inhibit platelet aggregation

80

Advantages of Prostacyclin Analogues ?

-Platelet activation blocked in
patients with HIT
-Short half-life (15–30 minutes)
permits ease of control

81

Disadvantage of Prostacyclin Analogues ?

Adverse reactions, such as hypotension, may limit usefulness

82

Treatment of HIT should be initiated before?

laboratory confirmation