肝素诱导的血小板减少症(HIT)是由血小板活化抗体介导的药物不良反应,该抗体靶向血小板因子4和肝素的复合物。患者的血栓栓塞风险明显增加。
美国血液学会(ASH)的这些循证指南旨在支持患者,临床医生,和其他医疗保健专业人员在他们关于HIT诊断和管理的决定中。
ASH成立了一个多学科指南小组,以平衡最大程度地减少利益冲突的潜在偏见。麦克马斯特大学成绩中心支持指导方针制定过程,包括更新或执行系统的证据审查。小组根据临床医生和患者的重要性,优先考虑临床问题和结果。建议评估的分级,开发和评估(等级)方法用于评估证据并提出建议,受到公众的评论。
专家组同意了33项建议。这些建议涉及对无症状患者进行HIT筛查,疑似HIT患者的诊断和初步治疗,急性HIT的治疗,以及急性HIT或HIT病史患者的特殊情况,包括心血管手术,经皮心血管介入治疗,肾脏替代疗法,和静脉血栓栓塞的预防。
强有力的建议包括使用4Ts评分而不是格式塔方法来估计HIT的预测试概率,并避免HIT实验室测试和对4Ts评分较低的患者进行HIT的经验性治疗。有条件的建议包括选择非肝素抗凝剂(阿加曲班,bivalirudin,danapoid,磺达肝素,直接口服抗凝剂)用于治疗急性HIT。
Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction mediated by platelet-activating antibodies that target complexes of platelet factor 4 and heparin. Patients are at markedly increased risk of thromboembolism.
These evidence-based
guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about diagnosis and management of HIT.
ASH formed a multidisciplinary
guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the
guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment.
The panel agreed on 33 recommendations. The recommendations address screening of asymptomatic patients for HIT, diagnosis and initial management of patients with suspected HIT, treatment of acute HIT, and special situations in patients with acute HIT or a history of HIT, including cardiovascular surgery, percutaneous cardiovascular intervention, renal replacement therapy, and venous thromboembolism prophylaxis.
Strong recommendations include use of the 4Ts score rather than a gestalt approach for estimating the pretest probability of HIT and avoidance of HIT laboratory testing and empiric treatment of HIT in patients with a low-probability 4Ts score. Conditional recommendations include the choice among non-heparin anticoagulants (argatroban, bivalirudin, danaparoid, fondaparinux, direct oral anticoagulants) for treatment of acute HIT.