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Safety of Warfarin Anticoagulation in Patients With Heparin-Induced Thrombocytopenia^*

^* From Midwest Heart Specialists, Ltd. (Dr. Wallis), Downers Grove, IL; and Loyola University Medical Center (Drs. Quintos, Wehrmacher, and Messmore), Maywood, IL.

Correspondence to: Diane E. Wallis, MD, FCCP, Midwest Heart Research Foundation, 2340 Highland Ave, Suite 310, Lombard, IL 60148

Objectives: Venous limb gangrene has been reported to occur after high warfarin doses in heparin-induced thrombocytopenia (HIT), and this observation has been used to exclude warfarin management in this condition. The outcome of patients receiving modest doses of warfarin was studied.

Design: Retrospective study of 114 consecutive HIT patients who received diagnoses by platelet aggregometry; 51 of the 114 patients received warfarin.

Setting: Tertiary-care medical center.

Results: Thirty-five patients received warfarin for non-HIT indications, and 16 received warfarin for heparin-associated thrombosis. Warfarin was given to 23 patients (47%) 2.4 ± 0.4 days prior to the onset of HIT, in 19 while receiving IV heparin for an overlap of 2.7 ± 0.4 days. Twenty-eight patients (53%) received warfarin 2.8 ± 1.0 days after the diagnosis of HIT. Patients received 11 ± 1 doses of warfarin over 16 ± 2 days, with a mean daily dose of 3.5 ± 0.5 and a maximum dose of 9 ± 0.5 mg. Prothrombin time at discharge was 17.3 ± 0.4 s with a maximum of 22.8 ± 0.8. The final international normalized ratio was 2.9 ± 0.3, and the maximum was 7.5 ± 1.4. The minimum therapeutic range was reached in 59% of determinations. When compared to the 63 patients who did not receive warfarin, warfarin patients received more IV heparin (86% vs 41%; p < 0.001), open heart surgery (78% vs 43%; p < 0.001), and had a lower mortality (8% vs 43%; p < 0.001), but had no differences in thrombosis.

Conclusions: Modest doses of warfarin were not associated with a worse outcome in patients with HIT.

Key Words: heparin-induced thrombocytopenia • heparin-induced thrombosis • treatment of heparin-induced thrombocytopenia

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