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Suspicion of heparin-induced thrombocytopenia in internal medicine: How appropriate is the ordering of anti-PF4/heparin antibody testing?
[heparin-induced thrombocytopenia]
Abstract
Thrombocytopenia
is
frequent
in
hospitalized
patients
,
and
heparin-induced
thrombocytopenia
(
HIT
)
is
often
suspected
when
a
decrease
in
platelet
count
is
concomitant
with
heparin
treatment
.
ELISA
tests
used
for
anti-
PF
4
/
heparin
antibodies
detection
usually
have
high
sensitivity
but
only
fair
specificity
for
HIT
.
Pre-test
probability
scores
(
such
as
4
Ts
or
HEP
scores
)
have
been
validated
and
a
low
probability
score
rules
out
HIT
without
anti-
PF
4
/
heparin
testing
.
The
aims
of
this
study
are
to
evaluate
the
appropriateness
of
anti-
PF
4
/
heparin
testing
according
to
pre-test
probabilities
of
HIT
and
to
compare
the
abilities
of
the
4
Ts
and
HEP
scores
to
avoid
inappropriate
anti-
PF
4
/
heparin
testing
.
This
retrospective
observational
study
included
74
consecutive
patients
hospitalized
in
a
general
internal
medicine
division
who
had
anti-
PF
4
/
heparin
testing
for
suspicion
of
HIT
.
4
Ts
and
HEP
scores
were
computed
retrospectively
.
About
73
%
of
patients
who
had
ordering
of
an
anti-
PF
4
/
heparin
were
at
low
risk
according
to
the
4
Ts
score
,
and
46
%
according
to
the
HEP
score
.
Heparin
was
discontinued
in
61
%
and
62
%
of
low
-risk
patients
according
to
4
Ts
and
HEP
scores
and
switched
to
alternative
anticoagulant
in
31
%
and
32
%
of
them
,
respectively
.
No
case
of
HIT
was
diagnosed
in
patients
with
a
low
-risk
score
.
One
major
bleeding
and
no
thrombosis
were
observed
.
For
the
4
Ts
score
,
the
sensitivity
was
100
%
,
the
negative
predictive
value
(
NPV
)
was
100
%
,
the
specificity
was
77
%
,
and
the
positive
predictive
value
(
PPV
)
was
20
%
(
95
%
CI
:
7
-
44
)
.
For
the
HEP
score
,
the
sensitivity
was
100
%
,
the
NPV
was
100
%
,
the
specificity
was
49
%
,
and
the
PPV
was
10
%
.
In
conclusion
,
pre-test
probability
scores
were
vastly
underused
in
this
internal
medicine
population
despite
their
ability
to
rule
out
HIT
without
laboratory
testing
in
a
large
proportion
of
patients
.
Appropriate
use
of
those
instruments
should
be
actively
promoted
.
Diseases
Validation
Diseases presenting
"positive predictive value"
symptom
22q11.2 deletion syndrome
acute rheumatic fever
carcinoma of the gallbladder
cholangiocarcinoma
congenital adrenal hyperplasia
congenital diaphragmatic hernia
congenital toxoplasmosis
cushing syndrome
esophageal adenocarcinoma
esophageal carcinoma
familial mediterranean fever
heparin-induced thrombocytopenia
hodgkin lymphoma, classical
phenylketonuria
thoracic outlet syndrome
typhoid
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