Incidence and clinical relevance of anti-platelet factor 4/heparin antibodies before cardiac surgery

Background Heparin-induced thrombocytopenia (HIT) is caused by anti-platelet factor 4/heparin (PF4/H) immunoglobulin (Ig) G antibodies, which activate platelets. In some patients, anti-PF4/H antibodies are already detectable before cardiac surgery. Whether preoperative presence of antibodies confers adverse prognosis and which particular antibody classes (IgG, IgA, IgM) might be implicated are unknown. Methods We prospectively screened 591 patients undergoing cardiopulmonary bypass surgery for heparin-dependent antibodies by PF4/H immunoassay (separately for IgG, IgA, and IgM) and platelet activation test at preoperative baseline and at days 6 and 10. All patients received heparin or low-molecular-weight heparin postsurgery regardless of antibody status and were followed for postoperative complications, frequency of HIT, length of hospital stay, and 30-day mortality. Results Anti-PF4/H antibodies of any class were detected at preoperative baseline in 128 (21.7%) of 591 patients: IgG n = 44 (7.4%), IgA n = 36 (6.1%), and IgM n = 79 (13.4%); some patients had >1 antibody class. Neither IgG nor IgA was a risk factor for any adverse outcome parameter. However, preoperative presence of IgM antibodies was associated with an increased risk for nonthromboembolic complications (all complications combined: hazard ratio 1.73, 95% CI 1.15-2.61) and a longer in-hospital stay (P = .02), but without evidence for increased risk of thrombotic complications or subsequent HIT. Conclusions Patients with preoperative anti-PF4/H antibodies of IgG and IgA class are not at increased risk for thrombotic or nonthrombotic adverse events, whereas those with baseline anti-PF4/H IgM had an increased risk of nonthrombotic adverse outcomes but not of subsequent HIT or thrombosis. Because IgM antibodies do not cause HIT, they could represent a surrogate marker for other heparin-independent risk factors. (Am Heart J 2010;160:362-9.)