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DOI: 10.1111/ijlh.12993
REVIEW
Theodore E. Warkentin1,2,3,4
1
Department of Pathology and Molecular
Medicine, Michael G. DeGroote School of Abstract
Medicine, McMaster University, Hamilton, Heparin‐induced thrombocytopenia (HIT) is a clinical‐pathological disorder; thus,
Ontario, Canada
2 laboratory testing for the pathogenic platelet‐activating antiplatelet factor 4 (PF4)/
Department of Medicine, Michael G.
DeGroote School of Medicine, McMaster heparin antibodies is central for diagnosis. The “iceberg” model summarizes the inter‐
University, Hamilton, Ontario, Canada
relationship between platelet activation assays and PF4‐dependent immunoassays,
3
Hamilton Regional Laboratory
Medicine Program, Hamilton Health
with platelet‐activating antibodies comprising a subset of anti‐PF4/heparin antibod‐
Sciences, Hamilton General Hospital, ies. The platelet serotonin‐release assay (SRA), performed by reference laboratories,
Hamilton, Ontario, Canada
4
has high sensitivity and specificity for HIT (~95% each), and is especially suited for
McMaster Centre for Transfusion Research,
Hamilton, Ontario, Canada detecting highly pathogenic HIT sera containing both heparin‐dependent and hepa‐
rin‐independent platelet‐activating antibodies; this latter subgroup of antibodies ex‐
Correspondence
Theodore E. Warkentin, Hamilton Regional plains “autoimmune HIT” disorders (delayed‐onset, persisting, spontaneous, heparin
Laboratory Medicine Program, Room “flush,” fondaparinux‐associated). Recently, SRA‐negative HIT has become recog‐
1-270B, Hamilton General Hospital, 237
Barton St. East, Hamilton, Ontario L8L 2X2 nized, in which serum from some HIT patients contains subthreshold levels of plate‐
Canada let‐activating antibodies (by SRA) that become detectable using a PF4‐enhanced
Email: twarken@mcmaster.ca
platelet activation assay. Unusual immunologic features of HIT include early antibody
detectability (at onset of platelet count fall) and antibody transience (seroreversion).
Widely available PF4‐dependent enzyme immunoassays (EIAs) have high sensitivity
but poor specificity for HIT, although specificity is enhanced with IgG‐specific EIAs
and strong positive results; unfortunately, EIA results are usually not available in real
time. Automated rapid immunoassays, such as the chemiluminescence immunoassay
(CLIA) and latex immunoturbidimetric assay (LIA), facilitate real‐time laboratory diag‐
nosis. Recently available likelihood ratio (LR) data for positive (LR+) and negative (LR−)
test results allow clinicians to adjust their pretest probabilities for HIT, using Bayesian
analysis, into real‐time posttest probabilities that are dramatically increased (test
positive) or decreased (test negative). Moreover, (semi‐)quantitative CLIA‐ and LIA‐
positive results (weak, moderate, strong positive) can further refine the posttest
probability of HIT.
KEYWORDS
(autoimmune) heparin‐induced thrombocytopenia, Bayesian analysis, chemiluminescence
immunoassay, latex immunoturbidimetric assay, rapid immunoassays, serotonin‐release assay
Int J Lab Hematol. 2019;41(Suppl. 1):15–25. © 2019 John Wiley & Sons Ltd | 15
wileyonlinelibrary.com/journal/ijlh
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16 WARKENTIN
3 | TE M P O R A L FE AT U R E S O F H IT
at pharmacologic heparin concentrations (0.1‐0.3 U/mL UFH) that is presence of various concentrations of heparin. Recently, it has been
19,20
inhibited at high heparin (100 U/mL). However, the assay is tech‐ shown that addition of increasing concentrations of PF4—rather
nically demanding (platelet washing) and requires selected (pedigree) than heparin—can be used to perform the SRA. 26 Moreover, this
platelet donors whose platelets react well to HIT antibodies, 21 and so maneuver appears to increase sensitivity for detection of heparin‐
laboratories that offer the SRA may not necessarily have good per‐ dependent platelet‐activating antibodies (although impact on test
formance. Moreover, the usual platelet activation end‐point—release specificity vis‐à‐vis the SRA remains unclear). Our laboratory has
from platelet dense granules of radioactive serotonin—limits testing found that up to one‐third of sera that test SRA‐negative/EIA‐posi‐
to laboratories permitted to use radiolabels. Recent controversies re‐ tive will yield a positive result in a PF4‐enhanced SRA, which we call
garding SRA sensitivity are discussed in Section 5.5. the “PF4‐SRA”; however, case review suggested the patients were
unlikely to have had HIT. 26
Padmanabhan and colleagues have also developed a PF4‐en‐
4.2 | Heparin‐induced platelet activation assay
hanced platelet activation assay, named the PF4‐dependent P‐se‐
(HIPA)
lectin expression assay (PEA). 27 In this assay, 62.5 μg/mL PF4 is
The HIPA is another washed platelet activation assay (primar‐ added to isolated donor platelets prior to addition of patient serum,
ily used in Europe) that uses platelet aggregation, judged visually, measuring platelet activation through flow cytometric detection of
as the platelet activation end‐point.18 Whereas the SRA is usually P‐selectin expression. This assay reportedly detects HIT antibodies
performed testing platelets in a shaker (reacted for 60 minutes), the 1 to 2 days prior to the SRA. 28 Whereas the PF4‐SRA and the PEA
HIPA is performed using stirred platelets, and read visually in 5‐min‐ perform the assays at one or more concentrations of PF4 (without
ute intervals (up to 45 minutes). Like the SRA, the HIPA can be used use of heparin), Vayne and colleagues29 have recently developed a
to recognize aHIT. Recently, it has been observed that the HIPA is hybrid assay in which addition of PF4 is used to enhance reactivity
more sensitive for detecting platelet‐activating antibodies than the in the SRA (which is otherwise performed using heparin as per the
22
SRA; however, it is unclear whether this improves sensitivity for usual fashion). To date, the utility of these various PF4‐enhanced
true HIT or rather results in detection of nonpathogenic antibodies assays in improving the sensitivity‐specificity profiles of platelet ac‐
(decreased diagnostic specificity). tivation assays for HIT remains uncertain.
These five autoimmune HIT (aHIT) disorders feature HIT antibodies that activate platelets in the
absence of heparin both in vitro and in vivo. Thus, strong platelet activation is seen in platelet activa‐
tion assays (e.g, SRA, HIPA) even at 0 U/mL heparin, with greater platelet activation, using either
neat or diluted patient serum/plasma, in the presence of pharmacologic heparin concentrations
(0.1‐0.3 U/mL UFH). As with conventional HIT sera, platelet activation is inhibited in the presence of
high heparin concentrations (100 U/mL).
molecules with (nonheparin) platelet‐associated polyanions (chon‐ High‐dose intravenous gamma globulin (IVIG) interrupts HIT anti‐
droitin sulfate, polyphosphates) or even in the absence of polyanion body‐induced platelet activation, resulting in rapid platelet count
altogether. Table 1 lists various presentations of HIT in which most recovery.31,40
32-38
(or all) patients have aHIT antibodies.
Platelet activation assays performed both in the presence and
5.3 | Spontaneous HIT syndrome
absence of heparin are important in supporting a diagnosis of aHIT:
Strong platelet activation at 0 U/mL heparin, which is enhanced in This increasingly recognized aHIT disorder is clinically and serologi‐
the presence of pharmacological concentrations of heparin (0.1‐0.5 cally indistinguishable from HIT, but occurs in the absence of a prox‐
U/mL UFH)—either using neat or diluted serum/plasma—with in‐ imate immunizing heparin exposure.34-36 Precipitating events have
31,38,39
hibition at 100 U/mL heparin, is the serological picture. The included bacterial infection and knee replacement surgery (the latter
major U.S. reference laboratories that perform the SRA do not despite postoperative nonheparin thromboprophylaxis). A large pro‐
perform the test in the absence of heparin,36 contributing to aHIT portion (~70%) of patients with post‐knee replacement spontaneous
underrecognition. HIT syndrome evince adrenal hemorrhagic necrosis.36
5.5 | Fondaparinux‐associated HIT
5.2 | Persisting HIT
An advantage of fondaparinux—a sulfated pentasaccharide anti‐
Persisting HIT refers to patients with prolonged time to plate‐ coagulant modeled after the antithrombin‐binding region of hepa‐
let count recovery. For example, well‐documented cases of HIT rin—is its low frequency (versus UFH and LMWH) of promoting
have been reported where the platelet count takes more than one platelet activation in the presence of HIT antibodies.4 However,
month to recover.32,33,39 Interestingly, there is an inverse relation‐ HIT has been described in patients who have only received post‐
ship between the severity of thrombocytopenia and the degree of operative fondaparinux thromboprophylaxis. 38 In these cases,
heparin‐independent platelet activation induced by patient serum.39 aHIT antibodies have been observed where platelet activation
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20 WARKENTIN
F I G U R E 3 Schematic representation of the latex immunoturbidimetric assay (LIA) for detection of HIT antibodies. Latex nanoparticles
coated with a HIT‐like monoclonal antibody (KKO), upon addition of PF4/PVS complexes, will become maximally agglutinated if tested
with a blood sample that contains no PF4/heparin‐reactive antibodies (upper‐third of figure). In contrast, inhibition of particle agglutination
occurs if free KKO (positive calibrator [used to define the calibration curve, expressed in arbitrary U/mL] or positive control) is added
before PF4/PVS (middle‐third). HIT antibodies within patient plasma will also inhibit (to varying degrees) particle agglutination triggered by
PF4/PVS (lower‐third). The instrument automatically interpolates delta (Δ) absorbance with the calibration curve where the concentration of
antibodies in the sample is inversely proportional to the degree of agglutination.
*Positive control can be KKO or another HIT‐like monoclonal antibody. Δ, delta (change); HIT, heparin‐induced thrombocytopenia; HIT Abs,
HIT antibodies; IgGAM, antibodies of any of the immunoglobulin classes, IgG, IgA, and IgM; KKO, name of HIT‐like monoclonal antibody
used in the LIA; MAb, monoclonal antibody; PF4/PVS, platelet factor 4/polyvinyl sulfonate. Reprinted, with permission49
next section, the semi‐quantitative reporting of the LIA, permitting treatment decisions based on either the 4Ts score or an empiric esti‐
graded classification of positive results (weak, moderate, strong), al‐ mation of HIT likelihood, with subsequent treatment changes based
lows for nuanced, real‐time diagnostic evaluation of HIT. upon subsequent laboratory results (EIAs, platelet activation tests),
as they become available (perhaps several days later). However,
rapid, on‐demand immunoassays allow for real‐time incorporation
7 | BAY E S I A N A N A LYS I S FO R H IT of HIT laboratory test results into the initial diagnostic evaluation.
D I AG N OS I S Moreover, as some assays (eg, CLIA, LIA) provide (semi‐)quantita‐
tive data, fine‐tuning of clinical probability estimates is achievable.
Clinical tools such as the 4Ts scoring system47 are helpful in esti‐ Potentially, if the posttest probability for HIT (per combination of
mating the pretest probability of HIT. The 4Ts evaluates parameters clinical probability and results of a validated rapid assay) is very low
typically sought during clinical evaluation, for example, the timing of or very high, further diagnostic testing with traditional HIT tests
onset and magnitude of the platelet count fall (in relation to hepa‐ (EIA, SRA) might not necessarily be required.
rin exposure), thrombosis occurrence, and other clinical features In Bayesian analysis, pretest probability is modified by the test
arguing for or against HIT. Traditionally, the clinician would make result(s) to yield a revised posttest probability.46,48,50 The test result
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22
(A) CLIA
Posttest probability of HIT (based on 4Ts pretest probability and CLIA test result)
Pretest probability CLIA‐neg (<1.0 U/ CLIA‐positive (any pos result, CLIA‐positive (weak) (1.0‐4.99 CLIA‐positive (moderate) CLIA‐positive (strong)
4Ts score of HITa mL) LR− = 0.031 i.e, ≥1.0 U/mL) LR+ = 65.9 U/mL) SSLR+ = 12.0 (5.0‐19.99 U/mL) SSLR+ = 144 (≥20.0 U/mL) SSLR+ = ∞
(B) LIA
Posttest probability of HIT (based on 4Ts pretest probability and LIA test result)
LIA‐positive (strong)
Pretest probability LIA‐negative (<1.0 LIA‐positive (any pos result, i.e, LIA‐positive (weak) (1.0‐4.9 LIA‐positive (moderate) (≥16.0 U/mL)
4Ts score of HITa U/mL) LR− = 0.034 ≥1.0 U/mL) LR+ = 16.0 U/mL) SSLR+ = 5.7 (5.0‐15.9 U/mL) SSLR+ = 31 SSLR+ = 128
4Ts, Four Ts scoring system; CLIA, chemiluminescence‐based immunoassay (IgG‐specific); HIT, heparin‐induced thrombocytopenia; LIA, latex immunoturbidimetric assay; LR−, negative likelihood ratio; LR+,
positive likelihood ratio; SSLR+, stratum‐specific likelihood ratio (for the positive result range shown); U, units.
Data shown are obtained from published sources.48,49 CLIA testing was performed in most cases using sera, whereas LIA testing was performed using citrated plasma. Data for the CLIA and LIA are based
on 509 and 429 subjects, respectively; the discrepancy relates to fewer patients having plasma samples available for testing in the LIA.
a
The pretest probabilities shown are based upon the frequency of SRA‐positive status for the three 4Ts scoring groups (low, intermediate, and high), per the clinician who performed the score at time of
enrollment into the 4Ts clinical trial. 4Ts score for pretest probability of HIT is based on the following 3 risk categories: 0 to 3 points, low probability; 4‐5 points, intermediate probability; and 6‐8 points,
high probability.
WARKENTIN
WARKENTIN |
23
can be considered either as dichotomous (positive or negative), with quantitative instrument‐based immunoassays such as the CLIA and
corresponding positive or negative likelihood ratios (LR+ or LR−, re‐ LIA is ideally suited for real‐time diagnostic evaluation of HIT.
spectively), or the result can be considered in the context of a par‐
ticular “stratum,” for example, weak, moderate, or strong positive
AC K N OW L E D G E M E N T S
results, with various associated stratum‐specific likelihood ratios
(SSLRs) that progressively increase to reflect the greater probabil‐ I thank Jo‐Ann I. Sheppard and other members of the McMaster
ity of HIT associated with a stronger test result. Table 2 summarizes Platelet Immunology Laboratory for performing much of the work
data from our institution that illustrates the power of Bayesian anal‐ described in this review.
ysis when using the CLIA (Table 2A) or LIA (Table 2B), based upon the
approximate pretest probabilities of HIT found in our 4Ts study.46
C O N FL I C T O F I N T E R E S T
To illustrate, consider a patient judged to have a 30% proba‐
bility of HIT on clinical grounds; the corresponding “odds” of this Dr. Warkentin reports having received consulting fees from Aspen
patient having HIT is 3 to 7 (ie, 3:7). Now, further consider that Global and Octapharma; research support and consulting fees from
the actual test result obtained was positive and of a magnitude W.L. Gore and Instrumentation Laboratory; royalties from Informa
that corresponded to an SSLR+ of 31. (Per Table 2B, a moderate (Taylor & Francis); and consulting fees related to medical‐legal
positive LIA yields an SSLR+ of 31.) In this scenario, the posttest testimony.
odds can be easily calculated as (3 × 31):7, which is 93:7, that is,
a 93% probability for HIT. In contrast, if the test result was nega‐
ORCID
tive, which corresponds to a low LR− value of 0.034 (ie, 1/0.034
or a 29‐fold decrease in odds of having HIT), that negative test Theodore E. Warkentin https://orcid.
result would reduce the posttest probability of HIT as follows: org/0000-0002-8046-7588
3:(7 × 29), or 3:203, which corresponds to a small possibility of
HIT of only 3/(203 + 3), or ~1.5%. This is a striking difference
REFERENCES
in posttest probability (93% vs. 1.5%) and is based upon real‐
world data. 49 In other words, in the example shown, the differ‐ 1. Warkentin TE, Greinacher A, Gruel Y, Aster RH, Chong BH; Scientific
and Standardization Committee of the International Society on
ence between a moderate positive result obtained with the LIA,
Thrombosis and Haemostasis. Laboratory testing for heparin‐in‐
versus a negative result, corresponds to a ~900‐fold (!) change duced thrombocytopenia: a conceptual framework and implications
in diagnostic probability (from 31‐fold higher to 29‐fold lower), for diagnosis. J Thromb Haemost. 2011;9(12): 2498‐2500.
which in the context of a pretest probability for HIT of ~30% 2. Warkentin TE. Drug‐induced immune‐mediated thrombocyto‐
penia—from purpura to thrombosis. N Engl J Med. 2007;356(9):
corresponds to a major shift in posttest probability of HIT, from
891‐893.
93% vs. 1.5%. 3. Warkentin TE. How I diagnose and manage HIT. Hematology Am Soc
With such a rapid test result (assuming local availability of the Hematol Educ Program. 2011;2011:143‐149.
CLIA or LIA), the physician can order the blood test while performing 4. Warkentin TE, Davidson BL, Büller HR, et al. Prevalence and risk
of preexisting heparin‐induced thrombocytopenia antibodies in pa‐
the usual diagnostic workup for HIT (review heparin exposures, as‐
tients with acute VTE. Chest. 2011;140(2):366‐373.
sess timing of platelet count changes, examine the blood film, order 5. Warkentin TE, Sheppard JI, Chu FV, Kapoor A, Crowther MA,
duplex ultrasound for deep‐vein thrombosis, etc.), and have the HIT Gangji A. Plasma exchange to remove HIT antibodies: dissociation
test result back in time to impact diagnostic reasoning. Thus, cru‐ between enzyme‐immunoassay and platelet activation test reactiv‐
ities. Blood. 2015;125(1):195‐198.
cial therapeutic decisions, such as whether to stop heparin and/or
6. Warkentin TE, Climans TH, Morin PA. Intravenous immune glob‐
commence alternative anticoagulation in prophylactic or therapeu‐ ulin to prevent heparin‐induced thrombocytopenia. N Engl J Med.
tic dosing, can be made—in most situations—in the context of much 2018;378(19):1845‐1848.
greater clinician confidence as to whether HIT is likely to be present 7. Warkentin TE, Levine MN, Hirsh J, et al. Heparin‐induced thrombo‐
or not. cytopenia in patients treated with low‐molecular‐weight heparin or
unfractionated heparin. N Engl J Med. 1995;332(20):1330‐1335.
8. Warkentin TE, Roberts RS, Hirsh J, Kelton JG. An improved defi‐
nition of immune heparin‐induced thrombocytopenia in post‐
8 | CO N C LU S I O N operative orthopedic patients. Arch Intern Med. 2003;163(20):
2518‐2524.
9. Warkentin TE, Sheppard JI, Moore JC, Moore KM, Sigouin CS,
The fundamental paradigm of HIT as an antibody‐mediated plate‐
Kelton JG. Laboratory testing for the antibodies that cause hepa‐
let activation disorder accounts for the importance of the SRA and rin‐induced thrombocytopenia: how much class do we need? J Lab
other platelet activation assays in diagnosing HIT with high confi‐ Clin Med. 2005;146(6):341‐346.
dence. Moreover, platelet activation assays uniquely are able to 10. Husseinzadeh HD, Gimotty PA, Pishko AM, Buckley M, Warkentin
TE, Cuker A. Diagnostic accuracy of IgG‐specific versus polyspe‐
identify the heparin‐independent antibodies responsible for aHIT.
cific enzyme‐linked immunoassays in heparin‐induced thrombocy‐
There are growing interest and availability of rapid immunoassays topenia: a systematic review and meta‐analysis. J Thromb Haemost.
that allow for real‐time diagnosis of HIT. Bayesian analysis of (semi‐) 2017;15(6):1203‐1212.
|
24 WARKENTIN
11. Warkentin TE, Sheppard JI, Heels‐Ansdell D, et al. Heparin‐in‐ 3 0. Pandya KA, Johnson EG, Davis GA, Padmanabhan A. Serotonin re‐
duced thrombocytopenia in medical surgical critical illness. Chest. lease assay (SRA)‐negative HIT: a newly recognized entity: implica‐
2013;144(3):848‐858. tions for diagnosis and management. Thromb Res. 2018;172:169‐171.
12. Warkentin TE, Sheppard JI, Sigouin CS, Kohlmann T, Eichler P, 31. Greinacher A, Selleng K, Warkentin TE. Autoimmune hep‐
Greinacher A. Gender imbalance and risk factor interactions in hep‐ arin‐induced thrombocytopenia. J Thromb Haemost.
arin‐induced thrombocytopenia. Blood. 2006;108(9):2937‐2941. 2017;15(11):2099‐2114.
13. Warkentin TE, Kelton JG. Temporal aspects of heparin‐induced 32. Warkentin TE, Kelton JG. Delayed‐onset heparin‐induced thrombo‐
thrombocytopenia. N Engl J Med. 2001;344(17):1286‐1292. cytopenia and thrombosis. Ann Intern Med. 2001;135(7):502‐506.
14. Shih AW, Sheppard JI, Warkentin TE. Platelet count recovery 33. Warkentin TE. Clinical picture of heparin‐induced thrombocytope‐
and seroreversion in immune HIT despite continuation of hepa‐ nia (HIT) and its differentiation from non‐HIT thrombocytopenia.
rin: further observations and literature review. Thromb Haemost. Thromb Haemost. 2016;116(5):813‐822.
2017;117(10):1868‐1874. 3 4. Warkentin TE, Makris M, Jay RM, Kelton JG. A spontaneous pro‐
15. Warkentin TE, Sheppard JI, Moore JC, Cook RJ, Kelton JG. Studies thrombotic disorder resembling heparin‐induced thrombocytope‐
of the immune response in heparin‐induced thrombocytopenia. nia. Am J Med. 2008;121(7):632‐636.
Blood. 2009;113(20):4963‐4969. 35. Warkentin TE, Basciano PA, Knopman J, Bernstein RA. Spontaneous
16. Warkentin TE, Arnold DM, Kelton JG, Sheppard JI, Smith JW, Nazy heparin‐induced thrombocytopenia syndrome: 2 new cases and a
I. Platelet‐activating antibodies are detectable at the earliest onset proposal for defining this disorder. Blood. 2014;123(23):3651‐3654.
of heparin‐induced thrombocytopenia, with implications for the 36. Poudel DR, Ghimire S, Dhital R, Forman D, Warkentin TE.
operating characteristics of the serotonin‐release assay. Chest. Spontaneous HIT syndrome post‐knee replacement surgery with
2018;153(6):1396‐1404. delayed recovery of thrombocytopenia: a case report and literature
17. Newman PM, Chong BH. Heparin‐induced thrombocytopenia: new review. Platelets. 2017;28(6):614‐620.
evidence for the dynamic binding of purified anti‐PF4‐heparin an‐ 37. Mian H, Warkentin TE, Sheppard JI, et al. Autoimmune HIT due to
tibodies to platelets and the resultant platelet activation. Blood. apheresis catheter heparin flushes for stem cell harvesting before
2000;96(1):182‐187. autotransplantation for myeloma. Blood. 2017;130(14):1679‐1682.
18. Warkentin TE, Greinacher A. Laboratory testing for heparin‐in‐ 38. Warkentin TE, Sheppard JI, Manheim JC. HIT complicating
duced thrombocytopenia. In: Warkentin TE, Greinacher A, eds. fondaparinux prophylaxis: fondaparinux‐dependent platelet activa‐
Heparin‐Induced Thrombocytopenia, 5th edn. Boca Raton, FL: CRC tion as a marker for fondaparinux‐induced HIT. Thromb Haemost.
Press; 2013:272‐314. 2014;112(6):1319‐1322.
19. Warkentin TE, Arnold DM, Nazi I, Kelton JG. The platelet serotonin‐ 39. Kopolovic I, Warkentin TE. Progressive thrombocytopenia after
release assay. Am J Hematol. 2015;90(6):564‐572. c ardiac surgery in a 67‐year‐old man. CMAJ. 2014;186(12):
20. Sheridan D, Carter C, Kelton JG. A diagnostic test for heparin‐in‐ 929‐933.
duced thrombocytopenia. Blood. 1986;67(1):27‐30. 4 0. Padmanabhan A, Jones CG, Pechauer SM, et al. IVIg for treatment
21. Warkentin TE, Hayward CPM, Smith CA, Kelly PM, Kelton JG. of severe refractory heparin‐induced thrombocytopenia. Chest.
Determinants of donor platelet variability when testing for heparin‐ 2017;152(3):478‐485.
induced thrombocytopenia. J Lab Clin Med. 1992;120(3):371‐379. 41. Warkentin TE, Sheppard JI, Moore JC, Kelton JG. The use of
22. Eekels JJM, Althaus K, Bakchoul T, et al. An international external well‐characterized sera for the assessment of new diagnostic en‐
quality assessment for laboratory diagnosis of heparin‐induced zyme‐immunoassays for the diagnosis of heparin‐induced throm‐
thrombocytopenia. J Thromb Haemost. 2019;17(3):525-531. bocytopenia. J Thromb Haemost. 2010;8(1):216‐218.
23. Chong BH, Burgess J, Ismail F. The clinical usefulness of the platelet 42. Sun L, Gimotty PA, Lakshmanan S, Cuker A. Diagnostic accu‐
aggregation test for the diagnosis of heparin‐induced thrombocy‐ racy of rapid immunoassays for heparin‐induced thrombocyto‐
topenia. Thromb Haemost. 1993;69(4):344‐350. penia. A systematic review and meta‐analysis. Thromb Haemost
24. Galea V, Khaterchi A, Robert F, Gerotziafas G, Hatmi M, Elalamy 2016;115(5):1044‐1055.
I. Heparin‐induced multiple electrode aggregometry is a prom‐ 43. Warkentin TE, Sheppard JI, Moore JC, Sigouin CS, Kelton JG.
ising and useful functional tool for heparin‐induced thrombocy‐ Quantitative interpretation of optical density measurements
topenia diagnosis: confirmation in a prospective study. Platelets. using PF4‐dependent enzyme‐immunoassays. J Thromb Haemost.
2013;24(6):441‐447. 2008;6(8):1304‐1312.
25. Favaloro EJ, McCaughan G, Mohammed S, et al. HIT or miss? 4 4. Warkentin TE, Sheppard JI, Raschke R, Greinacher A. Performance
A comprehensive contemporary investigation of labora‐ characteristics of a rapid assay for anti‐PF4/heparin antibod‐
tory tests for heparin‐induced thrombocytopenia. Pathology. ies, the Particle ImmunoFiltration Assay. J Thromb Haemost.
2018;50(4):426‐436. 2007;5(11):2308‐2310.
26. Nazi I, Arnold DM, Warkentin TE, Smith JW, Staibano P, Kelton JG. 45. Compton FB, Alrabeh R, Nguyen LQ, Nedelcu E, Wahed A, Nguyen
Distinguishing between anti‐platelet factor 4/heparin antibodies ND. PIFA PLUSS P4 assay for screening of heparin‐induced
that can and cannot cause heparin‐induced thrombocytopenia. J thrombocytopenia. Lab Med. 2019;50(1):73‐77.
Thromb Haemost. 2015;13(10):1900‐1907. 46. Linkins LA, Bates SM, Lee AYY, Heddle NM, Wang G, Warkentin
27. Padmanabhan A, Jones CG, Curtis BR, et al. A novel PF4‐dependent TE. Combination of 4Ts score and PF4/H‐PaGIA for diagnosis and
platelet activation assay identifies patients likely to have heparin‐in‐ management of heparin‐induced thrombocytopenia: prospective
duced thrombocytopenia/thrombosis. Chest. 2016;150(3):506‐515. cohort study. Blood. 2015;126(5):597‐603.
28. Jones CG, Pechauer SM, Curtis BR, et al. A platelet factor 4‐de‐ 47. Lo GK, Juhl D, Warkentin TE, Sigouin CS, Eichler P, Greinacher A.
pendent platelet activation assay facilitates early detection of Evaluation of pretest clinical score (4 T's) for the diagnosis of hep‐
pathogenic heparin‐induced thrombocytopenia antibodies. Chest. arin‐induced thrombocytopenia in two clinical settings. J Thromb
2017;152(4):e77‐e80. Haemost. 2006;4(4):759‐765.
29. Vayne C, Guery EA, Kizlik‐Masson C, et al. Beneficial effect 48. Warkentin TE, Sheppard JI, Linkins LA, Arnold DM, Nazy I.
of exogenous platelet factor 4 for detecting pathogenic hep‐ High sensitivity and specificity of an automated IgG‐specific
arin‐induced thrombocytopenia antibodies. Br J Haematol. chemiluminescence immunoassay for diagnosis of HIT. Blood.
2017;179(5):811‐819. 2018;132(12):1345‐1349.
WARKENTIN 25|
49. Warkentin TE, Sheppard JI, Linkins LA, Arnold DM, Nazy I. analysis, stratum‐specific likelihood ratios, and Bayes theorem.
Performance characteristics of an automated latex immuno‐ Chest. 2013;144(4):1269‐1275.
turbidimetric assay [HemosIL® HIT‐Ab(PF4‐H)] for the diagno‐
sis of immune heparin‐induced thrombocytopenia. Thromb Res.
2017;153:108‐117.
How to cite this article: Warkentin TE. Laboratory diagnosis
50. Raschke RA, Curry SC, Warkentin TE, Gerkin RD. Improved clinical
of heparin‐induced thrombocytopenia. Int J Lab Hematol.
interpretation of the anti‐platelet factor 4/heparin enzyme‐linked
immunosorbent assay for the diagnosis of heparin‐induced throm‐ 2019;41(Suppl. 1):15‐25. https://doi.org/10.1111/ijlh.12993
bocytopenia through the use of receiver operating characteristic