0
Correspondence |

American College of Chest Physicians Guidelines for Heparin-Induced ThrombocytopeniaRisk Assessment of Heparin-Induced Thrombocytopenia: A Need for Evidence-Based Assessment of the Baseline Risk of Heparin-induced Thrombocytopenia FREE TO VIEW

Daniela R. G. Junqueira, PhD
Author and Funding Information

From the Centro de Estudos do Medicamento (Cemed), Faculdade de Farmácia, Universidade Federal de Minas Gerais; Faculty of Health Sciences, The University of Sydney (Sydney, NSW, Australia).

Correspondence to: Daniela R. G. Junqueira, PhD, Rua Camapuã 700 apto 102, Grajaú, Cep: 30431-236, Belo Horizonte, Minas Gerais, Brazil; e-mail: danijunqueira@gmail.com


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;143(4):1190-1191. doi:10.1378/chest.12-2926
Text Size: A A A
Published online
To the Editor:

The ninth edition of the American College of Chest Physicians (ACCP) Antithrombotic Therapy and Prevention of Thrombosis Guidelines presented summary recommendations addressing a number of clinical problems in the form of evidence-based clinical practice guidelines. These guidelines advocate a rigorous methodology1 for collating and interpreting data obtained from a comprehensive and systematic literature review. The guidelines are respected worldwide and play an invaluable role in determining medical care and offering physician advice.

The most recent ACCP guidelines were published as a supplementary volume of CHEST (February 2012), which also included an article by Linkins et al2 focusing on the treatment and prevention of heparin-induced thrombocytopenia (HIT). I read with great interest the guideline regarding HIT, which based the key recommendations for its treatment and prevention on the risk (incidence) of this adverse drug reaction. The incidence of HIT can vary considerably, and Table 2 of the guidelines presents its incidence in various patient populations according to type of heparin. A careful analysis of the references presented in Table 2 reveals, however, that the incidence of HIT is not assessed according to standard methodology for grading the quality of evidence. For example, determining the incidence of HIT in postoperative patients who received standard heparin (prophylactic dose) vs low-molecular-weight heparin (prophylactic or treatment doses) was based on four papers (one, a letter to the editor [comparing two series of cases] and three, reports with overlapping cohorts of patients). Similarly, determining the incidence of HIT in patients exposed to therapeutic treatment with heparin was supported by a paper reporting a retrospective study assessing the incidence of secondary thrombocytopenia recorded in the discharge boards of patients who were referred for a short stay in nonfederal US hospitals with a diagnostic code for thromboembolism and related outcomes. Beside the fact that the meta-analysis reported in this paper did not focus on HIT, it lacked most quality parameters.3,4

Although high-quality evidence from randomized controlled trials regarding the incidence of HIT in postoperative patients has, to date, been sparse,5 I believe the previous examples indicate that there is a need to explore this issue more carefully in the ACCP Guideline to prevent this dangerous, adverse drug reaction.

References

Guyatt GH, Norris SL, Schulman S, et al. Methodology for the development of antithrombotic therapy and prevention of thrombosis guidelines: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(suppl 2):53S-70S. [CrossRef] [PubMed]
 
Linkins LA, Dans AL, Moores LK, et al. Treatment and prevention of heparin-induced thrombocytopenia: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(suppl 2):e495S-530S. [CrossRef] [PubMed]
 
Higgins J, Green S., eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [updated March 2011]: The Cochrane Collaboration, 2011.http://www.cochrane-handbook.org. Accessed June 19, 2012.
 
Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. [CrossRef] [PubMed]
 
Junqueira DR, Perini E, Penholati RR, Carvalho MG. Unfractionated heparin versus low molecular weight heparin for avoiding heparin-induced thrombocytopenia in postoperative patients. Cochrane Database Syst Rev. 2012;9:CD007557. [PubMed]
 

Figures

Tables

References

Guyatt GH, Norris SL, Schulman S, et al. Methodology for the development of antithrombotic therapy and prevention of thrombosis guidelines: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(suppl 2):53S-70S. [CrossRef] [PubMed]
 
Linkins LA, Dans AL, Moores LK, et al. Treatment and prevention of heparin-induced thrombocytopenia: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(suppl 2):e495S-530S. [CrossRef] [PubMed]
 
Higgins J, Green S., eds. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [updated March 2011]: The Cochrane Collaboration, 2011.http://www.cochrane-handbook.org. Accessed June 19, 2012.
 
Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. [CrossRef] [PubMed]
 
Junqueira DR, Perini E, Penholati RR, Carvalho MG. Unfractionated heparin versus low molecular weight heparin for avoiding heparin-induced thrombocytopenia in postoperative patients. Cochrane Database Syst Rev. 2012;9:CD007557. [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543