Heparin-Induced Thrombocytopenia in Severe COVID-19
2020; Lippincott Williams & Wilkins; Volume: 142; Issue: 19 Linguagem: Inglês
10.1161/circulationaha.120.049015
ISSN1524-4539
AutoresFlorence Daviet, Christophe Guervilly, Olivier Baldési, Fanny Bernard-Guervilly, Estelle Pilarczyk, Adrien Genin, Laurent Lefèbvre, Jean Marie Forel, Laurent Papazian, Laurence Camoin‐Jau,
Tópico(s)Intramuscular injections and effects
ResumoHomeCirculationVol. 142, No. 19Heparin-Induced Thrombocytopenia in Severe COVID-19 Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBHeparin-Induced Thrombocytopenia in Severe COVID-19 Florence Daviet, Christophe Guervilly, Olivier Baldesi, Fanny Bernard-Guervilly, Estelle Pilarczyk, Adrien Genin, Laurent Lefebvre, Jean Marie Forel, Laurent Papazian and Laurence Camoin-Jau Florence DavietFlorence Daviet Florence Daviet, MD, Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Chemin des Bourrely, 13015 Marseille, France. Email E-mail Address: [email protected] https://orcid.org/0000-0002-6703-5481 Médecine Intensive Réanimation (F.D., C.G., E.P., J.M.F., L.P.), Assistance Publique-Hôpitaux de Marseille, France. Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Faculté de Médecine, Aix-Marseille Université, Marseille, France (F.D., C.G., J.M.F., L.P.). , Christophe GuervillyChristophe Guervilly Médecine Intensive Réanimation (F.D., C.G., E.P., J.M.F., L.P.), Assistance Publique-Hôpitaux de Marseille, France. Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Faculté de Médecine, Aix-Marseille Université, Marseille, France (F.D., C.G., J.M.F., L.P.). , Olivier BaldesiOlivier Baldesi Réanimation et Surveillance Continue Médico-Chirurgicales Polyvalentes (O.B., L.L.), Centre Hospitalier du Pays d'Aix, Aix-en-Provence, France. , Fanny Bernard-GuervillyFanny Bernard-Guervilly Service de Médecine Interne (F.B.-G.), Assistance Publique-Hôpitaux de Marseille, France. , Estelle PilarczykEstelle Pilarczyk Médecine Intensive Réanimation (F.D., C.G., E.P., J.M.F., L.P.), Assistance Publique-Hôpitaux de Marseille, France. Service d'Accueil des Urgences (E.P.), Assistance Publique-Hôpitaux de Marseille, France. , Adrien GeninAdrien Genin Laboratoire d'Hématologie et d'Immunologie (A.G.), Centre Hospitalier du Pays d'Aix, Aix-en-Provence, France. , Laurent LefebvreLaurent Lefebvre Réanimation et Surveillance Continue Médico-Chirurgicales Polyvalentes (O.B., L.L.), Centre Hospitalier du Pays d'Aix, Aix-en-Provence, France. , Jean Marie ForelJean Marie Forel Médecine Intensive Réanimation (F.D., C.G., E.P., J.M.F., L.P.), Assistance Publique-Hôpitaux de Marseille, France. Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Faculté de Médecine, Aix-Marseille Université, Marseille, France (F.D., C.G., J.M.F., L.P.). , Laurent PapazianLaurent Papazian Médecine Intensive Réanimation (F.D., C.G., E.P., J.M.F., L.P.), Assistance Publique-Hôpitaux de Marseille, France. Centre d'Etudes et de Recherches sur les Services de Santé et Qualité de Vie EA 3279, Faculté de Médecine, Aix-Marseille Université, Marseille, France (F.D., C.G., J.M.F., L.P.). and Laurence Camoin-JauLaurence Camoin-Jau https://orcid.org/0000-0003-4681-626X Aix-Marseille Université, Hôpital Nord, and Laboratoire d'Hématologie, Hôpital de la Timone (L.C.-J.), Assistance Publique-Hôpitaux de Marseille, France. Originally published29 Sep 2020https://doi.org/10.1161/CIRCULATIONAHA.120.049015Circulation. 2020;142:1875–1877Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: September 29, 2020: Ahead of Print As the coronavirus disease 2019 (COVID-19) pandemic has spread throughout the world, important efforts have been made to describe its physiopathology and complications. In critically ill patients with COVID-19, a systemic inflammatory response associated with endothelial activation is observed.1 A high rate of thrombotic complications has been described, including deep vein thrombosis.2 Although the mechanisms of thrombosis are unclear, anticoagulation with high doses of heparin has been proposed for these patients.Heparin-induced thrombocytopenia (HIT) is a severe, life-threatening drug reaction associated with a decrease in platelet count and a high risk of thrombosis caused by platelet-activating antibodies against PF4/heparin complexes.3 The atypical clinical and therapeutic context of the COVID-19 pandemic, with a broader indication of curative anticoagulation, could lead to a higher prevalence of HIT.In this context, we retrospectively reviewed all cases of HIT among patients presenting with COVID-19 acute respiratory distress syndrome (ARDS) in 2 intensive care units in southern France. We described 7 consecutive cases of HIT associated with COVID-19 ARDS between March 30 and April 18, 2020 (Table). Patients or their relatives received information and signed a nonopposition form, according to French law, to be enrolled in COAG-COVID (Coagulopathy of COVID-19: A Pragmatic Randomized Controlled Trial of Therapeutic Anticoagulation Versus Standard Care). The study was approved by an ethics committee.Table 1. Characteristics of 7 Patients With Severe COVID-19 Hospitalized in the ICU With HITVariablePatient 1Patient 2Patient 3Patient 4Patient 5Patient 6Patient 7Age, y46504363595769SexMaleMaleFemaleMaleMaleMaleMaleBody mass index27254721332627Medical historyNoneNoneSevere obesity, asthmaNoneSleep apnea syndromeBurnoutDiabetes type 2, hypertensionMedicationsNoneNoneBronchodilatorNoneNoneParoxetineRepaglinide, zofenoprilDelay between onset of symptoms of COVID-19 and admission to ICU, d27713979Invasive mechanical ventilationYesYesYesYesYesNoYesVenovenous ECMOYesYesYesNoNoNoNoAntiviral treatmentHydroxychloroquineHydroxychloroquineLopinavir/ritonavirHydroxychloroquineNoneHydroxychloroquineHydroxychloroquineHeparin type during ICU stayLMWH, then UHLMWH, then UHLMWH, then UHLMWH, then UHLMWH, then UHUHUHDuration of heparin exposition before HIT diagnosis, d16131514911164T score6664554Platelet count at admission, G/L61243160191161159215Platelet count at HIT diagnosis337348566239107Drop in platelet count, %46707075697653WBC count at diagnosis, G/L87.29.48.610.44.4915.5Lymphocytes at diagnosis of HIT, G/L0.690.640.780.710.690.750.76CRP, mg/L19825420115313525378Anti-PF4 levels, URL/mL (normal value <1 U/ml)461139604212Alternative anticoagulation after HIT diagnosisArgatrobanArgatrobanArgatrobanDanaparoidDanaparoidDanaparoidDanaparoidClinical thrombotic eventsMultiple deep vein thrombosisIntracardiac thrombosis, ECMO membrane thrombosisMultiple deep vein thrombosis, ECMO pump thrombosisStrokeDeep vein thrombosisNoneNoneOutcome status at day 28Discharged from ICUStill in ICUStill in ICUDischarged from hospitalDischarged from ICUDischarged from hospitalDischarged from hospital4T score indicates thrombocytopenia, timing of thrombocytopenia relative to heparin exposure, thrombosis or other sequelae of heparin-induced thrombocytopenia, likelihood of other causes of thrombocytopenia; COVID-19, coronavirus disease 2019; CRP, C-reactive protein; ECMO, extracorporeal membrane oxygenation; HIT, heparin-induced thrombocytopenia; ICU, intensive care unit; LMWH, low-molecular-weight heparin; UH, unfractionated heparin; and WBC, white blood cell.All patients presented antibodies to PF4/heparin, as detected by a quantitative chemiluminescent immunoassay (HemosIL AcuStar HIT immunoglobulin G, PF4-H, normal value 10 days for 6 patients. All patients presented a severe drop in platelet count. Five patients experienced at least 1 severe clinical thromboembolic event. Alternative anticoagulation was pursued with either danaparoid or argatroban. All platelet counts returned to normal values after the anticoagulation therapy was switched. At the observation period end point, 5 patients were discharged from the intensive care unit, including 3 from the hospital, and the remaining 2 were still in the intensive care unit.During the COVID-19 pandemic period, we admitted 86 patients with severe COVID-19 in 2 intensive care units, which represents an incidence of HIT of 8%. Although thrombocytopenia is frequent in critically ill patients, the incidence of HIT is relatively rare (<1%3; up to 3.7% in patients supported by extracorporeal membrane oxygenation).4 In a previously published cohort of 105 patients supported by venovenous extracorporeal membrane oxygenation, we reported an incidence of HIT of 2%5 compared with 3 among 14 patients (21%) during the COVID-19 pandemic. We compared this cohort with a control cohort of patients in the intensive care units of our centers during a 6-month period from January 1 to June 1, 2019: 447 patients were admitted to our centers, with 58.8% of patients requiring mechanical ventilation and 13 patients (5%) supported by extracorporeal membrane oxygenation. During this period, 19 patients (4.2%) were tested for HIT, and 4 were ultimately positive, representing 0.89% of the cohort. The median rate of anti-PF4 among patients with HIT was 22.6, compared with 0.045 in HIT-negative patients. Regarding our results, we observed a nearly 10-fold higher occurrence of HIT during severe COVID-19 in our centers. This increased incidence could be explained by the higher doses of heparin used for treatment of patients with COVID-19 and by specific features of severe COVID-19 disease. Whereas obesity is associated with an increased risk of developing HIT, only 2 patients were obese in our observation.The pathophysiology of an increased thrombosis risk or a potential increased HIT risk in the context of COVID-19 is not yet clearly understood. The higher prevalence of HIT in these patients could be explained by exacerbated immune reactions and probably by an increased release of PF4 linked to platelet activation.Critically ill patients with COVID-19 develop life-threatening coagulopathy and thromboembolic complications that justify aggressive anticoagulation with close monitoring. However, the occurrence of HIT increases the risk of severe thrombotic events and could alter the risk–benefit balance of anticoagulation. In this context, clinicians should be aware of a possible higher incidence of HIT. Achieving a 4T score (thrombocytopenia, timing of thrombocytopenia relative to heparin exposure, thrombosis or other sequelae of HIT, likelihood of other causes of thrombocytopenia) in patients with COVID-19 is complex. Thrombocytopenia and thrombosis are commonly observed, and patients present with other causes of thrombocytopenia. Rapid detection of antibodies to PF4/heparin is necessary in patients with COVID-19 to avoid a misdiagnosis of HIT. Immune dysregulation observed during acute COVID-19 may contribute to HIT occurrence. Further larger investigations are warranted to confirm this increased incidence of HIT and to understand its physiopathology.DisclosuresNone.Footnotes*Drs Daviet and Guervilly contributed equally.https://www.ahajournals.org/journal/circFlorence Daviet, MD, Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Chemin des Bourrely, 13015 Marseille, France. Email florence.daviet@ap-hm.frReferences1. Varga Z, Flammer AJ, Steiger P, Haberecker M, Andermatt R, Zinkernagel AS, Mehra MR, Schuepbach RA, Ruschitzka F, Moch H. Endothelial cell infection and endothelitis in COVID-19Lancet. 2020; 395:1417–1418. doi: 10.1016/S0140-6736(20)30937-5CrossrefMedlineGoogle Scholar2. Ren B, Yan F, Deng Z, Zhang S, Xiao L, Wu M, Cai L. Extremely high incidence of lower extremity deep venous thrombosis in 48 patients with severe COVID-19 in Wuhan.Circulation. 2020; 142:181–183. doi: 10.1161/CIRCULATIONAHA.120.047407LinkGoogle Scholar3. Warkentin TE. Heparin-induced thrombocytopenia in critically ill patients.Semin Thromb Hemost. 2015; 41:49–60. doi: 10.1055/s-0034-1398381CrossrefMedlineGoogle Scholar4. Jiritano F, Serraino GF, Ten Cate H, Fina D, Matteucci M, Mastroroberto P, Lorusso R. Platelets and extra-corporeal membrane oxygenation in adult patients: a systematic review and meta-analysis.Intensive Care Med. 2020; 46:1154–1169. doi: 10.1007/s00134-020-06031-4CrossrefMedlineGoogle Scholar5. Parzy G, Daviet F, Persico N, Rambaud R, Scemama U, Adda M, Guervilly C, Hraiech S, Chaumoitre K, Roch A, et al. Prevalence and risk factors for thrombotic complications following venovenous extracorporeal membrane oxygenation: a CT scan study.Crit Care Med. 2020; 48:192–199. doi: 10.1097/CCM.0000000000004129CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. 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