How to improve the management of a patient with heparin-induced thrombocytopenia?

Heparin-induced thrombocytopenia (HIT) is an adverse drug reaction caused by immunoglobulin G platelet-activating antibodies against platelet factor 4 (PF4)/heparin complexes, leading to venous and arterial thromboembolism (1). I read with keen interest the case report describing a fatal case of probable HIT in a young man who experienced pulmonary embolism (PE) and concomitant deep vein thrombosis (2). The case of this patient with intracardiac thrombus formation and severe ischemic stroke highlights the high risk of thromboembolic events in patients with HIT despite anticoagulant treatment with fondaparinux (5 mg/d), which was ineffective in case of the patient even when the platelet count increased to 150.000/uL. However, without any description of the patient’s weight, it remains unclear whether the dosage of fondaparinux was appropriate. The use of vitamin K antagonist (VKA) after normalization of the platelet count, along with the administration of low-molecular-weight heparins or non-VKA oral anticoagulants immediately after the diagnosis of PE in a hemodynamically stable patient could lower the risk of HIT development and significantly improve the prognosis (1, 3). The rationale for choosing unfractionated heparin (UFH), the most common cause of HIT, in the patient was not presented.