Heparin-induced thrombocytopenia in patients requiring prolonged intensive care unit treatment after cardiopulmonary bypass

BACKGROUND: The diagnosis of heparin-induced thrombocytopenia (HIT) is problematic in postcardiac surgery (CS) intensive care unit (ICU) patients, as there are multiple potential explanations for thrombocytopenia and the presence of anti-platelet factor 4/heparin antibodies is not highly specific for HIT. Two platelet count profiles for HIT - a 40% or greater fall in platelet count beginning on or after day 5 (pattern 1) and persisting thrombocytopenia (< 100 x 10(9) L(-1)) beyond day 7 (pattern 2) - have been described in post-CS patients. METHODS AND RESULTS: We examined the platelet count profiles of 329 consecutive post-CS patients who required ICU treatment beyond 7 days. Although 70 patients (21.3%) developed thrombocytopenia (57.1% pattern 1, 42.9% pattern 2), the overall incidence of HIT was only 1.8% [6/329; 95% confidence interval (95% CI) 0.7-3.9%] in these ICU patients, with more HIT patients showing a pattern 2 than a pattern 1 platelet count decrease (four vs. two patients). Notably, pattern 2 patients with HIT also showed a new proportional fall of > 30% in platelet count between postoperative days 5 and 10. Among the remaining 2242 post-CS patients without a prolonged ICU stay, only three (0.1%; 95% CI 0.03-0.4%) developed symptomatic HIT (OR 0.07; 95% CI 0.01-0.3; P = 0.0002 vs. ICU patients), all presenting with pattern 1. CONCLUSIONS: Among post-CS ICU patients, a postoperative platelet count fall between days 5 and 10 increases diagnostic specificity for HIT, irrespective of whether this platelet count fall occurs after postoperative platelet count recovery (pattern 1) or is superimposed upon persisting postoperative thrombocytopenia (pattern 2). A prospective study is required in order to validate the findings of this retrospective analysis.