Antiplatelet therapy – ClinCaseQuest https://clincasequest.hospital Medical education in clinical cases Thu, 06 Jan 2022 22:59:29 +0000 en-US hourly 1 https://wordpress.org/?v=6.2.13 https://clincasequest.hospital/wp-content/uploads/sites/7/2020/02/logo-ru-project-90x90.png Antiplatelet therapy – ClinCaseQuest https://clincasequest.hospital 32 32 HEMORR₂HAGES Score for Major Bleeding Risk On-line calculator https://clincasequest.hospital/hemorr2hages/ Tue, 27 Jul 2021 11:54:00 +0000 https://clincasequest.hospital/?p=29903 The HEMORR2HAGES score was developed to quantify the risk of hemorrhage in patients with atrial fibrillation on anticoagulation and to aid in the management of…

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]]> The HEMORR2HAGES score was developed to quantify the risk of hemorrhage in patients with atrial fibrillation on anticoagulation and to aid in the management of antithrombotic therapy. For patients on warfarin found that HEMORR2HAGES was more discriminatory compared to the other scores systems.

Hepatic or Renal Disease:
No
Yes

Ethanol (Alcohol) Abuse:
No
Yes

Malignancy History:
No
Yes

Older (Age > 75):
No
Yes

Reduced Platelet Count or Function
Includes aspirin use, any thrombocytopenia or blood dyscrasia, like hemophilia:
No
Yes

Rebleeding Risk (history of past bleeding):
No
Yes

Hypertension (Uncontrolled):
No
Yes

Anemia (Hgb<13 g/dL for Men; Hgb <12 g/dL for Women):
No
Yes

Genetic Factors (CYP 2C9 single-nucleotide polymorphisms):
No
Yes

Excessive Fall Risk, dementia, Parkinson’s disease, or psychiatric disease:
No
Yes

Stroke History:
No
Yes



Patient’s score Points Risk of bleeding
0 0 0

The HEMORR2HAGES scoring system consists of eleven criteria, one of which (history of prior bleeding) is worth 2 points, while the other ten are worth 1 point each.

The HEMORR2HAGES scoring system combines components from several other previously validated bleeding risk scores into one.

Addition of the selected points, see below:

CriteriaPoints
Hepatic or renal disease+1
Ethanol abuse+1
Malignancy+1
Older (age > 75)+1
Reduced platelet count or function+1
Rebleeding (Prior Bleed)+2
Hypertension (uncontrolled)+1
Anemia+1
Genetic factors (CYP 2C9 single-nucleotide polymorphisms)+1
Excessive fall risk, dementia, Parkinson’s disease, or psychiatric disease+1
Stroke+1

Results interpretation:

PointsRisk of bleeding
0-1Low-risk group
2-3Intermediate-risk group
≥4High-risk group

Risk of bleeding in patients on warfarin:

PointsRisk of bleedingRecommendation
0 points  1.9% risk of bleeding per 100 patient-years of warfarin.  Consider initiation of warfarin therapy if clinically indicated as risk of thrombotic events likely outweighs the risk of bleeding.  
1 points  2.5% risk of bleeding per 100 patient-years of warfarin.  Consider initiation of warfarin therapy if clinically indicated as risk of thrombotic events likely outweighs the risk of bleeding.    
2 points  5.3% risk of bleeding per 100 patient-years of warfarin.  Consider alternatives to anticoagulation unless strong indications for warfarin therapies exist.    
3 points  8.4% risk of bleeding per 100 patient-years of warfarin.Consider alternatives to anticoagulation unless strong indications for warfarin therapies exist.  
4 points  10.4% risk of bleeding per 100 patient-years of warfarin.  Alternative options should often be considered in patients with high-risk of major bleeding events in need of anticoagulation.  
5-12 points  12.3% risk of bleeding per 100 patient-years of warfarin.  Alternative options should often be considered in patients with high-risk of major bleeding events in need of anticoagulation.  

Study found that the number of bleeds per 100 patient-years of warfarin increased as their HEMORR2HAGES score increased. A subsequent systemic review and meta-analysis comparing the performance of HAS-BLED, ATRIA and HEMORR2HAGES recommended HAS-BLED for the assessment of atrial fibrillation patients’ major bleeding risk. The analysis found that HEMORR2HAGES had a higher diagnostic accuracy, but considered it difficult to use due to its complexity.

The genetic risk factor was included in their score, but not actually tested in their cohort of patients.

HAS-BLED Score compare with the HEMORR2HAGES Score has greater sensitivity,  HEMORR2HAGES Score has greater specificity then HAS-BLED Score.

Risks and benefits of anticoagulation should be carefully considered in all patients with atrial fibrillation prior to initiating therapy.

Other risk stratification scores such as HAS-BLED or ATRIA should also be taken into consideration prior to starting anticoagulation.

 

Literature:
Gage BF, Yan Y, Milligan PE, et al. Clinical classification schemes for predicting hemorrhage: results from the National Registry of Atrial Fibrillation. Am Heart J 2006; 151:713-9. https://pubmed.ncbi.nlm.nih.gov/16504638/
Stavros Apostolakis, MD, PhD, Deirdre A. Lane, PhD, Yutao Guo, MD, Harry Buller, MD, PhD, Gregory Y.H. Lip, MD Performance of the HEMORR https://www.jacc.org/doi/10.1016/j.jacc.2012.06.019?articleid=1305797&
Caldera D, Costa J, Fernandes RM, et al. Performance of the HAS-BLED high bleeding-risk category, compared to ATRIA and HEMORR https://pubmed.ncbi.nlm.nih.gov/25012972/

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]]> 4Ts Score System for Heparin-Induced Thrombocytopenia https://clincasequest.hospital/4ts-score-for-hit/ Fri, 16 Jul 2021 08:31:00 +0000 https://clincasequest.hospital/?p=29788 4Ts Score System assessment for Heparin-Induced Thrombocytopenia is an alternative evaluation tool prior to time-consuming antibody testing for HIT or empiric substitution of heparin for…

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]]> 4Ts Score System assessment for Heparin-Induced Thrombocytopenia is an alternative evaluation tool prior to time-consuming antibody testing for HIT or empiric substitution of heparin for another anti-coagulant.

Thrombocytopenia:
Platelet count fall 30–50% OR platelet nadir 10–19×109/l
Platelet count fall <30% OR platelet nadir <10×109/l

Timing of platelet count fall:
Clear onset between days 5–10 OR platelet fall ≤1 day (prior heparin exposure within 30 days)
Consistent with days 5–10 fall, but not clear; onset after day 10 OR fall ≤1 day (prior heparin exposure 30–100 days ago)
Platelet count fall <4 days without recent exposure

Thrombosis or other sequelae:
New thrombosis OR skin necrosis; acute systemic reaction post-IV heparin bolus
Progressive OR recurrent thrombosis; non-necrotizing skin lesions; suspected thrombosis (not proven)
None

Other causes for thrombocytopenia:
None apparent
Possible
Definite



Patient’s score Range Risk stratification Probability of HIT Recommendation
0 0 0 0 0

Consider using the 4Ts scoring system 4Ts Score for Heparin-Induced Thrombocytopenia for:

  • Differential diagnostic HIT and other causes of thrombocytopenia;
  • Patients’ risk stratification for HIT in patients with thrombocytopenia who are currently or were recently on heparin derived agents.
ThrombocytopeniaPlatelet count fall >50% AND platelet nadir ≥20×109/l+2
 Platelet count fall 30–50% OR platelet nadir 10–19×109/l+1
 Platelet count fall <30% OR platelet nadir <10×109/l0
Timing of platelet count fallClear onset between days 5–10 OR platelet fall ≤1 day (prior heparin exposure within 30 days)+2
 Consistent with days 5–10 fall, but not clear; onset after day 10 OR fall ≤1 day (prior heparin exposure 30–100 days ago)+1
 Platelet count fall <4 days without recent exposure0
Thrombosis or other sequelaeNew thrombosis OR skin necrosis; acute systemic reaction post-IV heparin bolus+2
 Progressive OR recurrent thrombosis; non-necrotizing skin lesions; suspected thrombosis (not proven)+1
 None0
Other causes for thrombocytopeniaNone apparent+2
 Possible+1
 Definite0

Results evaluation:

4Ts Score System for Heparin-Induced Thrombocytopenia consisted of four criteria, each of which was worth 0, 1, or 2 points. To carry out stratification on the scale, it is necessary to summarize the obtained points.

ScoreRisk stratificationProbability of HIT
≤3 pointslow probability for HIT≤5% in original study, <1% in meta-analysis
4-5 pointsintermediate probability for HIT~14%
6-8 pointshigh probability for HIT~64%

Patients from the low-risk category frequently do not need further testing for HIT based on the assessment with 4Ts Score for Heparin-Induced Thrombocytopenia. Patients from the intermediate or high-risk groups require further laboratory evaluation for HIT or switching to a non-heparin-derived anti-coagulant.

Detailed parameters evaluation:

Category2 points1 point0 points
ThrombocytopeniaPlatelet count fall > 50% AND platelet nadir ≥ 20 ×109/lPlatelet count fall 30%–50% OR platelet nadir 10–19 ×109/lPlatelet count fall < 30% OR platelet nadir < 10 ×109/l
Timing of platelet count fallClear onset between days 5 and 10 OR platelet fall ≤ 1 day (prior heparin exposure within 30 days)Consistent with days 5–10 fall, but not clear (e.g. missing platelet counts) OR onset after day 10 OR fall ≤ 1 day (prior heparin exposure 30–100 days ago)Platelet count fall < 4 days without recent heparin exposure
Thrombosis or other sequelaeNew thrombosis (confirmed) OR skin necrosis at heparin injection sites OR acute systemic reaction after intravenous heparin bolusProgressive or recurrent thrombosis OR nonnecrotizing (erythematous) skin lesions OR suspected thrombosis (not proven)None
Other causes for thrombocytopeniaNone apparentPossibleDefinite

Gold standard for diagnosis of HIT was either:

  • A platelet serotonin release assay (SRA) and a PF4/polyanion-enzyme immunoassay (EIA) with ≥ 50% serotonin release and positive EIA, OR
  • A positive heparin-induced platelet activation (HIPA) test in at least three of four donor platelets.

4Ts Score for Heparin-Induced Thrombocytopenia was developed based on the prospective studies in patients being evaluated for thrombocytopenia or suspected HIT in two clinical settings: inpatients at Hamilton General Hospital in Canada and various clinicians in a variety of healthcare settings in Germany and Austria. A subsequent review and meta-analysis of the 4Ts scoring system for HIT revealed that patients in the low-risk group had a negative predictive value of 0.998, irrespective of type of clinician, prevalence of HIT, or patient population. However, one of the four components of their scoring system, other causes for thrombocytopenia, is subjective.

Literature:
Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A. Evaluation of pretest clinical score (4 Ts) for the diagnosis of heparin-induced thrombocytopenia in two clinical settings. J Thromb Haemost 2006; 4: 759–65. https://pubmed.ncbi.nlm.nih.gov/16634744/
Vatanparast R, Lantz S, Ward K, Crilley PA, Styler M. Evaluation of a pretest scoring system (4Ts) for the diagnosis of heparin-induced thrombocytopenia in a university hospital setting. Postgrad Med. 2012 Nov;124(6):36-42. https://pubmed.ncbi.nlm.nih.gov/23322137/

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