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Bavinck AP, Heerde WV, Schols SEM. Point-of-Care Testing in Patients with Hereditary Disorders of Primary Hemostasis: A Narrative Review. Semin Thromb Hemost 2024. [PMID: 38950596 DOI: 10.1055/s-0044-1787976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Inherited disorders of primary hemostasis, such as von Willebrand disease and congenital platelet disorders, can cause extensive, typically mucocutaneous bleeding. Assays to diagnose and monitor these disorders, such as von Willebrand factor activity assays and light transmission aggregometry, are performed in specialized hemostasis laboratories but are commonly not available in local hospitals. Due to the complexity and relative scarcity of these conventional assays, point-of-care tests (POCT) might be an attractive alternative in patients with hereditary bleeding disorders. POCTs, such as thromboelastography, are increasingly used to assess hemostasis in patients with acquired hemostatic defects, aiding clinical decision-making in critical situations, such as during surgery or childbirth. In comparison, the use of these assays in patients with hereditary hemostasis defects remains relatively unexplored. This review aims to give an overview of point-of-care hemostasis tests in patients with hereditary disorders of primary hemostasis. A summary of the literature reporting on the performance of currently available and experimental POCTs in these disorders is given, and the potential utility of the assays in various use scenarios is discussed. Altogether, the studies included in this review reveal that several POCTs are capable of identifying and monitoring severe defects in the primary hemostasis, while a POCT that can reliably detect milder defects of primary hemostasis is currently lacking. A better understanding of the strengths and limitations of POCTs in assessing hereditary defects of primary hemostasis is needed, after which these tests may become available for clinical practice, potentially targeting a large group of patients with milder defects of primary hemostasis.
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Affiliation(s)
- Aernoud P Bavinck
- Department of Hematology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Waander van Heerde
- Department of Hematology, Radboud University Medical Centre, Hemophilia Treatment Centre Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands
| | - Saskia E M Schols
- Department of Hematology, Radboud University Medical Centre, Hemophilia Treatment Centre Nijmegen-Eindhoven-Maastricht, Nijmegen, The Netherlands
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2
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Russo I, Brookles CG, Barale C, Melchionda E, Mousavi AH, Biolè C, Chinaglia A, Bianco M. Current Strategies to Guide the Antiplatelet Therapy in Acute Coronary Syndromes. Int J Mol Sci 2024; 25:3981. [PMID: 38612792 PMCID: PMC11011739 DOI: 10.3390/ijms25073981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/14/2024] Open
Abstract
The role of antiplatelet therapy in patients with acute coronary syndromes is a moving target with considerable novelty in the last few years. The pathophysiological basis of the treatment depends on platelet biology and physiology, and the interplay between these aspects and clinical practice must guide the physician in determining the best therapeutic options for patients with acute coronary syndromes. In the present narrative review, we discuss the latest novelties in the antiplatelet therapy of patients with acute coronary syndromes. We start with a description of platelet biology and the role of the main platelet signal pathways involved in platelet aggregation during an acute coronary syndrome. Then, we present the latest evidence on the evaluation of platelet function, focusing on the strengths and weaknesses of each platelet's function test. We continue our review by describing the role of aspirin and P2Y12 inhibitors in the treatment of acute coronary syndromes, critically appraising the available evidence from clinical trials, and providing current international guidelines and recommendations. Finally, we describe alternative therapeutic regimens to standard dual antiplatelet therapy, in particular for patients at high bleeding risk. The aim of our review is to give a comprehensive representation of current data on antiplatelet therapy in patients with acute coronary syndromes that could be useful both for clinicians and basic science researchers to be up-to-date on this complex topic.
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Affiliation(s)
- Isabella Russo
- Department of Clinical and Biological Sciences, University of Turin, I-10043 Turin, Italy; (I.R.); (C.B.); (E.M.)
| | - Carola Griffith Brookles
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
- Department of Medical Sciences, University of Turin, I-10124 Turin, Italy
| | - Cristina Barale
- Department of Clinical and Biological Sciences, University of Turin, I-10043 Turin, Italy; (I.R.); (C.B.); (E.M.)
| | - Elena Melchionda
- Department of Clinical and Biological Sciences, University of Turin, I-10043 Turin, Italy; (I.R.); (C.B.); (E.M.)
| | - Amir Hassan Mousavi
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
- Department of Medical Sciences, University of Turin, I-10124 Turin, Italy
| | - Carloalberto Biolè
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
| | - Alessandra Chinaglia
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
| | - Matteo Bianco
- Cardiology Division, San Luigi Gonzaga University Hospital, I-10043 Orbassano, Italy; (C.G.B.); (A.H.M.); (C.B.); (A.C.)
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3
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Pikta M, Banys V, Szanto T, Joutsi-Korhonen L, Vaide I, Varik M, Lehtinen AE, Giangrande P, Laane E. Von Willebrand Factor Multimeric Assay in Acquired von Willebrand Disease Diagnosis: A Report of Experience from North Estonia Medical Centre. J Lab Physicians 2021; 13:195-201. [PMID: 34602781 PMCID: PMC8478502 DOI: 10.1055/s-0041-1730818] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Objectives
Acquired von Willebrand syndrome (AVWS) is a rare and frequently underdiagnosed bleeding disorder with an unknown prevalence. The diagnosis of AVWS is made based on laboratory investigations and the presence of clinical symptoms. Evaluation and management of affected patients are complex due to the need for multiple laboratory assays.
Materials and Methods
Here, we describe the clinical and laboratory data of seven patients with a diagnosis of AVWS. All patients met the criteria for AVWS based on laboratory findings, bleeding symptoms, and the absence of any previous history of a bleeding disorder.
Results
In all cases, the laboratory findings, lack of bleeding anamnesis, and family history suggested the presence of AVWS. Von Willebrand factor multimeric analysis showed decreased high-molecular weight (HMW) multimers in six cases. Patients with lower HMW multimers experienced more severe bleeding complications.
Conclusions
The diagnosis of AVWS is complex and requires extensive laboratory evaluation. Interdisciplinary collaboration and complex laboratory evaluations are of paramount importance for the early recognition of AVWS and optimal AVWS diagnosis as well as successful clinical management.
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Affiliation(s)
- Marika Pikta
- Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia.,Department of Laboratory Medicine, North Estonia Medical Centre, Tallinn, Estonia
| | - Valdas Banys
- Department of Physiology, Biochemistry, Microbiology and Laboratory Medicine, Faculty of Medicine, Institute of Biomedical Sciences, Vilnius University, Vilnius, Lithuania
| | - Timea Szanto
- Research Program Unit of Systems Oncology, Helsinki University Hospital, Unit of Coagulation Disorders, Helsinki, Finland
| | - Lotta Joutsi-Korhonen
- Department of Clinical Chemistry, Unit of Coagulation Disorders, HUSLAB Laboratory Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ines Vaide
- Hemato-Oncology Clinic, Institute of Clinical Medicine, Tartu University, Tartu, Estonia
| | - Mirja Varik
- Hematology Department, North Estonia Medical Centre, Tallinn, Estonia
| | - Anna-Elina Lehtinen
- Department of Hematology, Unit of Coagulation Disorders, Helsinki University Hospital Comprehensive Cancer Center and University of Helsinki, Helsinki, Finland
| | - Paul Giangrande
- Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Edward Laane
- Hemato-Oncology Clinic, Institute of Clinical Medicine, Tartu University, Tartu, Estonia
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4
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Nakajima Y, Yada K, Ogiwara K, Furukawa S, Shimonishi N, Shima M, Nogami K. A microchip flow-chamber assay screens congenital primary hemostasis disorders. Pediatr Int 2021; 63:160-167. [PMID: 32640065 DOI: 10.1111/ped.14378] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/04/2020] [Accepted: 07/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Von Willebrand disease (VWD) and platelet function disorders (PFDs) are congenital bleeding disorders caused by primary hemostasis defects. Platelet function tests are time-consuming and require considerable amounts of blood sample, and there have been no easy-to-use assays for assessing platelet function quickly and sensitively. We report the usefulness of a microchip flow-chamber system (T-TAS® ) for detecting and/or predicting clinical severity in patients with VWD type 1 and type 2N and platelet storage pool disease. Here, we developed an application of a screening assay for primary hemostasis disorders. METHODS Microchips coated with collagen (PL-chip) and collagen/thromboplastin (AR-chip) were utilized to evaluate platelet thrombus formation (PTF) at high shear and fibrin-rich PTF at low shear, respectively, in whole blood samples from 22 patients with VWD (16 type 2A, four type 2B, two type 3) and four patients with PFDs (two BSS, two Glanzmann thrombasthenia). The time-to-increase by 10 kPa (T10 ) was calculated from flow pressure curves. Also, whole blood-induced platelet aggregation was assessed using Multiplate® analysis. RESULTS PL-chip T10 values ≥10 min successfully distinguished patients with all types of VWD and PFDs from healthy controls, irrespective of age, bleeding scores, and von Willebrand factor levels. However, AR-chip assay incompletely distinguished between type 2A patients and healthy ones. Multiplate analysis permitted screening of PFDs and type 3 VWD, but values in type 2A partially overlapped with those in controls. PL-chip assay did not reflect the clinical severity in these patients. CONCLUSIONS T-TAS with PL-chip could be a quick screening tool for congenital primary hemostasis disorder, VWD, and PFDs.
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Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Koji Yada
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Hemophilia Education, Nara Medical University, Kashihara, Nara, Japan
| | - Kenichi Ogiwara
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Shoko Furukawa
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan.,The Course of Thrombosis and Hemostasis Molecular Pathology, Nara Medical University, Kashihara, Nara, Japan
| | - Naruto Shimonishi
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Nara, Japan
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5
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Zhu S, Gilbert JC, Liang Z, Kang D, Li M, Tarantino PM, Jilma B. Potent and rapid reversal of the von Willebrand factor inhibitor aptamer BT200. J Thromb Haemost 2020; 18:1695-1704. [PMID: 32275107 PMCID: PMC7384040 DOI: 10.1111/jth.14822] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/26/2020] [Accepted: 03/31/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND BT200, a pegylated form of the aptamer BT100, inhibits binding of von Willebrand factor (VWF) to platelet glycoprotein GPIb, preventing arterial thrombosis in cynomolgus monkeys. It is being developed for secondary prevention of arterial thrombosis such as stroke or myocardial infarction. Inhibition of thrombogenesis by BT200 is expected to provide a therapeutic benefit. However, there may be unexpected bleeding (eg, incidental trauma) in which a reversal agent is required. To address this need, BT101, a complementary aptamer, has been developed to specifically inhibit BT100 and BT200 function. OBJECTIVES To characterize the effects of BT101 both in vitro and in vivo. METHODS The direct interaction between BT101 and the core aptamer BT100 was evaluated using polyacrylamide gel electrophoresis. The binding of BT200 to purified human VWF and inhibition of VWF activity was further characterized using enzyme-linked immunosorbent assay. VWF-dependent platelet function was measured by the platelet function analyzer and aggregometry in whole blood. In addition, both the in vivo pharmacokinetic profile of BT101 as well as its ability to reverse BT200 activity, were evaluated in cynomolgus monkeys. RESULTS BT101 bound to the core aptamer BT100 at a 1:1 ratio, inhibited BT200 binding to purified human VWF, and reversed BT200-induced inhibition of both VWF activity and VWF-dependent platelet function in vitro. After intravenous injection to monkeys, BT101 reversed BT200-induced effects on VWF activity and platelet function within minutes, without causing any adverse effects. CONCLUSIONS The results of this study demonstrate that BT101 is an effective reversal agent for BT200.
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Affiliation(s)
| | | | - Zicai Liang
- Suzhou Ribo Life Science Co., LtdKunshan CityChina
| | - Daiwu Kang
- Suzhou Ribo Life Science Co., LtdKunshan CityChina
| | - Ming Li
- Shanghai Institute of Materia MedicaChinese Academy of SciencesShanghaiChina
| | | | - Bernd Jilma
- Department of Clinical PharmacologyMedical University of ViennaViennaAustria
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6
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Nakajima Y, Nogami K, Yada K, Ogiwara K, Furukawa S, Shimonishi N, Shima M. Whole blood ristocetin‐induced platelet impedance aggregometry does not reflect clinical severity in patients with type 1 von Willebrand disease. Haemophilia 2019; 25:e174-e179. [DOI: 10.1111/hae.13725] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 02/12/2019] [Accepted: 02/12/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Yuto Nakajima
- Department of Pediatrics Nara Medical University Kashihara Nara Japan
| | - Keiji Nogami
- Department of Pediatrics Nara Medical University Kashihara Nara Japan
| | - Koji Yada
- Department of Pediatrics Nara Medical University Kashihara Nara Japan
- The Course of Hemophilia Education Nara Medical University Kashihara Nara Japan
| | - Kenichi Ogiwara
- Department of Pediatrics Nara Medical University Kashihara Nara Japan
| | - Shoko Furukawa
- Department of Pediatrics Nara Medical University Kashihara Nara Japan
- The Course of Thrombosis and Hemostasis Molecular Pathology Nara Medical University Kashihara Nara Japan
| | - Naruto Shimonishi
- Department of Pediatrics Nara Medical University Kashihara Nara Japan
| | - Midori Shima
- Department of Pediatrics Nara Medical University Kashihara Nara Japan
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7
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Lordkipanidzé M, Hvas AM, Harrison P. Clinical Tests of Platelet Function. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00033-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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8
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Pagliari MT, Baronciani L, Stufano F, Colpani P, Siboni SM, Peyvandi F. Differential diagnosis between type 2A and 2B von Willebrand disease in a child with a previously undescribed de novo mutation. Haemophilia 2018; 24:e263-e266. [PMID: 30044032 DOI: 10.1111/hae.13532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2018] [Indexed: 11/30/2022]
Affiliation(s)
- M T Pagliari
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Luigi Villa Foundation, Milan, Italy
| | - L Baronciani
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Luigi Villa Foundation, Milan, Italy
| | - F Stufano
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Luigi Villa Foundation, Milan, Italy
| | - P Colpani
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Luigi Villa Foundation, Milan, Italy
| | - S M Siboni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Luigi Villa Foundation, Milan, Italy
| | - F Peyvandi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico and Luigi Villa Foundation, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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9
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Haas T, Cushing MM, Varga S, Gilloz S, Schmugge M. Usefulness of multiple electrode aggregometry as a screening tool for bleeding disorders in a pediatric hospital. Platelets 2018; 30:498-505. [DOI: 10.1080/09537104.2018.1475631] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Thorsten Haas
- Department of Anesthesia, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Melissa M. Cushing
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Stephanie Varga
- Department of Anesthesia, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Séverine Gilloz
- Department of Hematology, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Markus Schmugge
- Department of Hematology, University Children’s Hospital Zurich, Zurich, Switzerland
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10
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Nummi V, Lassila R, Joutsi-Korhonen L, Armstrong E, Szanto T. Comprehensive re-evaluation of historical von Willebrand disease diagnosis in association with whole blood platelet aggregation and function. Int J Lab Hematol 2018; 40:304-311. [PMID: 29427305 DOI: 10.1111/ijlh.12785] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 01/11/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Diagnosis of von Willebrand disease (VWD) is challenging, particularly for type 1. The current diagnostic guidelines emphasize simultaneous bleeding symptoms and von Willebrand factor (VWF) levels of <30-40 IU/dL. Historical diagnoses require updated evaluation. We assessed the accuracy of past VWD diagnoses in our comprehensive care center with the standardized bleeding score (BS) and central laboratory analysis, focusing on VWF-dependent platelet functions in whole blood. METHODS Our study comprised 83 adults with prior VWD who were diagnosed a median of 20 years ago. We assessed BS, VWF antigen and activity (minimum of 3 measurements), FVIII, PFA-100® , and platelet aggregation via Multiplate® . Genetic testing was targeted to types 3, 2N, 2B, and equivocal cases. RESULTS All 13/13 (100%) type 3 and 29/32 (90%) type 2, but only 10/38 (26%) of type 1 (overall 52/83 (63%)) patients met the current criteria for VWD. All confirmed cases had abnormal BS, impaired PFA-100® , and decreased or absent ristocetin-induced platelet aggregation (RIPA), except subtype 2B. VWF, FVIII, RIPA, and PFA correlated with BS including all study subjects. Ten of the 38 patients with previous type 1 had low VWF (35-50 IU/dL) and variable VWF-dependent platelet function. Altogether, 21/83 patients (25%) had repeatedly normal VWF:RCo (>50 IU/dL). CONCLUSION von Willebrand disease is associated with impaired VWF-dependent whole blood platelet functions that match traditional VWF measurements. We detected normal VWF in 25% of historically diagnosed patients, mainly type 1 patients, implying that there is a need to systematically re-evaluate historical VWD diagnoses.
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Affiliation(s)
- V Nummi
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Coagulation Disorders Unit, Department of Hematology and Comprehensive Cancer, Helsinki University Hospital, Helsinki, Finland
| | - R Lassila
- Faculty of Medicine, University of Helsinki, Helsinki, Finland.,Coagulation Disorders Unit, Department of Hematology and Comprehensive Cancer, Helsinki University Hospital, Helsinki, Finland
| | - L Joutsi-Korhonen
- Coagulation Disorders Unit, Department of Clinical Chemistry, HUSLAB Laboratory Services, Helsinki University Hospital, Helsinki, Finland
| | - E Armstrong
- Coagulation Disorders Unit, Department of Hematology and Comprehensive Cancer, Helsinki University Hospital, Helsinki, Finland
| | - T Szanto
- Coagulation Disorders Unit, Department of Clinical Chemistry, HUSLAB Laboratory Services, Helsinki University Hospital, Helsinki, Finland
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11
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Holmström M, Schmidt DE, Hosokawa K, Blombäck M, Hjemdahl P, Ågren A. Monitoring of coagulation factor therapy in patients with von Willebrand disease type 3 using a microchip flow chamber system. Thromb Haemost 2017; 117:75-85. [DOI: 10.1160/th16-06-0430] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 09/23/2016] [Indexed: 01/22/2023]
Abstract
SummaryPatients with type 3 von Willebrand disease (VWD-3) have no measurable levels of VW factor (VWF) and usually require treatment with VWF-FVIII concentrate to prevent and/or stop bleeding. Even though the patients are treated prophylactically, they may experience bleeding symptoms. The aim of this study was to evaluate the effect of VWF-FVIII concentrate treatment in VWD-3 patients with the Total Thrombus Analysis System (T-TAS®), which measures thrombus formation under flow conditions. Coagulation profiles of 10 VWD-3 patients were analysed using T-TAS before and 30 minutes after VWF-FVIII concentrate (Haemate®) injection. Results were compared to VWF- and FVIII activity in plasma, and results with thromboelastometry and ris-tocetin-activated platelet impedance aggregometry (Multiplate®) in whole blood. For comparison, 10 healthy controls were also analysed with T-TAS. A median dose of 27 (range 15–35) IU/kg of VWF-FVIII concentrate increased VWF- and FVIII activity as expected. T-TAS thrombus formation was enhanced when a tissue factor/collagen-coated flow chamber was used at low shear, but treatment effects at high shear using a collagen-coated flow chamber were minimal. Whole blood coagulation assessed by thromboelastometry was normal and did not change (p > 0.05) but ristocetin-induced platelet aggregation improved (p < 0.001). In conclusion, T-TAS detects effects of VWF-FVIII concentrate treatment on coagulation-dependent thrombus formation at low shear, but minor effects are observed on platelet-dependent thrombus formation at high shear. The poor prediction of bleeding by conventional laboratory monitoring in VWD-3 patients might be related to insufficient restoration of platelet-dependent thrombus formation.
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12
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Schmidt DE, Bruzelius M, Majeed A, Odeberg J, Holmström M, Ågren A. Whole blood ristocetin-activated platelet impedance aggregometry (Multiplate) for the rapid detection of Von Willebrand disease. Thromb Haemost 2017; 117:1528-1533. [PMID: 28692107 DOI: 10.1160/th17-02-0129] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/09/2017] [Indexed: 12/22/2022]
Abstract
Von Willebrand disease (VWD) is the most common bleeding disorder, but no bedside tests specific for Von Willebrand factor are available. The objective of this study was to evaluate the diagnostic accuracy of whole blood ristocetin-induced platelet aggregometry (WB-RIPA) in VWD. WB-RIPA was performed in VWD patients (n=100) and healthy controls (n=17) using the Multiplate® platelet impedance aggregometry platform. The diagnostic properties of the test were described as sensitivity/specificity, positive and negative predictive value, and ROC area under the curve (AUC). Patients with VWD had impaired platelet aggregation by WB-RIPA. At a cut-off of 98 U, the test sensitivity and specificity of WB-RIPA for VWD was 0.95 and 0.53. A cut-off of 60 U provided a specificity of 1.00 with reduced sensitivity of 0.76. All patients with type 3 VWD and >90 % of patients with type 2 VWD were accurately distinguished from the controls. Incorrect classifications were attributable to patients with type 1 VWD, showing partly overlapping WB-RIPA results with healthy controls. Remarkably, these patients had lower bleeding scores and higher VWF activity than other type 1 VWD patients. Overall, WB-RIPA discriminated VWD patients from healthy controls accurately with a ROC AUC of 0.94. These results show that WB-RIPA is a promising diagnostic test for VWD, especially when timely results are required. Depending on the chosen test threshold, WB-RIPA could be clinically used as a rule out test, or to suggest patients in whom further testing for VWD is warranted.
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Affiliation(s)
| | | | | | | | | | - Anna Ågren
- Anna Ågren, MD, PhD, Coagulation Unit, Hematology Center, Karolinska University Hospital, 171 76 Stockholm, Sweden, Tel.: +46 8 51773373, Fax: +46 8 51775084, E-mail:
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13
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Venkatesh K, Nair PS, Hoechter DJ, Buscher H. Current Limitations of the Assessment of Haemostasis in Adult Extracorporeal Membrane Oxygenation Patients and the Role of Point-of-Care Testing. Anaesth Intensive Care 2016; 44:669-680. [DOI: 10.1177/0310057x1604400601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Haemostatic perturbations are commonly seen in extracorporeal membrane oxygenation (ECMO) patients and remain a clinical challenge, contributing significantly to morbidity and mortality. The approach to anticoagulation monitoring and the management of bleeding varies considerably across ECMO centres. Routine laboratory tests have their limitations in terms of turnaround time and specificity of information provided. Newer point-of-care testing (POCT) for coagulation may overcome these issues, as it provides information about the entire coagulation pathway from clot initiation to lysis. It is also possible to obtain qualitative information on platelet function from these tests. Furthermore, the ability to incorporate these results into a goal-directed algorithm to manage bleeding with targeted transfusion strategies appears particularly attractive and cost effective. Further studies are required to evaluate the utility of POCT to optimise bleeding and anticoagulation management in these complex patients.
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Affiliation(s)
- K. Venkatesh
- Prince of Wales Hospital, Conjoint Associate Lecturer, University of New South Wales, Sydney, New South Wales
| | - P. S. Nair
- Intensive Care Unit, St Vincent's Hospital, Conjoint Senior Lecturer, University of New South Wales, Sydney, New South Wales
| | - D. J. Hoechter
- Department of Anaesthesiology, University of Munich (LMU), Munich, Germany
| | - H. Buscher
- Intensive Care Unit, St Vincent's Hospital, Conjoint Senior Lecturer, University of New South Wales, Sydney, New South Wales
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15
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Mannu GS, Macartney A, Lambert JRA, Bettencourt-Silva JH, Lawn M, Lyall H, Metcalf AK, Potter JF, Wood J, Clark A, Baglin T, Myint PK, Bowles KM. The clinical utility of Multiplate analyser measurement in platelet function testing following stroke and transient ischaemic attack. Eur J Haematol 2014; 94:138-44. [PMID: 24981148 DOI: 10.1111/ejh.12406] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Platelet responsiveness to aspirin in people with cerebrovascular disease is poorly understood. OBJECTIVES To determine: (i) normal reference range, imprecision and reproducibility of the Multiplate instrument in healthy volunteers naive to aspirin; (ii) imprecision and reproducibility of the Multiplate instrument in acute stroke and transient ischaemic attack (TIA); (iii) the relationship between aspirin responsiveness and clinical outcome. MATERIALS AND METHODS We evaluated platelet function response to three agonists [Adenosine Diphosphate (ADP), Arachidonic Acid (AA), Collagen (Col)] using the Mulitplate platelet function analyser in a two-phase pilot study. In phase 1, we recruited healthy volunteers to determine the normal reference range and imprecision of the Multiplate instrument. In phase 2, we assessed platelet function in acute stroke or TIA patients presenting to hospital. These patients were bled within 24 h of presentation and between 12 and 24 h after ≥75 mg dose of Aspirin. Patients were followed up to 1 yr to assess mortality and recurrent cardiovascular event. RESULTS Overall, 29 healthy volunteers and 81 stroke/TIA patients were recruited. On assessing components of variance, Multiplate testing is reproducible and precise in volunteers and stroke/TIA patients. In stroke patients receiving aspirin, Bland-Altman plots show initial day 1 measurement provided a reliable measure of continuing response to aspirin at day 3. We defined one-third of patients as aspirin resistant [31.8% (95% CI: 22.1%-42.8%)] using cut off mean aggregation of ≥23.08% for AA and mean aggregation of ≥80.76% for ADP. CONCLUSION The Multiplate device gives reproducible, precise results in volunteers and stroke/TIA patients.
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Affiliation(s)
- Gurdeep S Mannu
- Oxford University Hospitals NHS Trust, Oxford, UK; Norfolk and Norwich University Hospital, Norfolk, UK
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Abstract
Platelet function tests have been traditionally used to aid in the diagnosis and management of patients with bleeding problems. Given the role of platelets in atherothrombosis, several dedicated platelet function instruments are now available that are simple to use and can be used as point-of-care assays. These can provide rapid assessment of platelet function within whole blood without the requirement of sample processing. Some tests can be used to monitor antiplatelet therapy and assess risk of bleeding and thrombosis, although current guidelines advise against this. This article discusses the potential utility of tests/instruments that are available.
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Affiliation(s)
- Paul Harrison
- School of Immunity and Infection, University of Birmingham Medical School, Birmingham, UK.
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Lawrie AS, Kobayashi K, Lane PJ, Mackie IJ, Machin SJ. The automation of routine light transmission platelet aggregation. Int J Lab Hematol 2013; 36:431-8. [PMID: 24237750 PMCID: PMC4298021 DOI: 10.1111/ijlh.12161] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 10/01/2013] [Indexed: 11/30/2022]
Abstract
Introduction The investigation of platelet function by aggregometry requires specialist equipment and is labour intensive. We have developed an automated platelet aggregation method on a routine coagulation analyser. Methods We used a CS-2000i (Sysmex) with prototype software to perform aggregation in platelet-rich plasma (PRP), using the following agonists: ADP (0.5–10 μm), epinephrine (0.5–10 μm), collagen (0.5–10 mg/μL), ristocetin (0.75–1.25 mg/mL) and arachidonic acid (0.12–1.0 mm). Platelet agonists were from Hyphen Biomed, and an AggRAM aggregometer (Helena Biosciences) was used as the reference instrument. Results CS-2000i reaction cuvette stirrer speed was found to influence reaction sensitivity and was optimized to 800 rpm. There were no clinically significant changes in aggregation response when the PRP platelet count was 150–480 x 109/L, but below this there were changes in the maximum amplitude (MA) and slope (rate). Dose response with each of the agonists was comparable between CS-2000i and an AggRAM aggregometer and normal subjects receiving antiplatelet drugs. Aggregation imprecision was similar on both the CS-2000i and AggRAM systems, with a cv for 2–5 μm ADP MA and slope varying between 3–12%. Conclusion Our preliminary studies indicated that optimal sensitivity using the CS-2000i was obtained with a reaction cuvette stirrer speed of 800 rpm and a PRP platelet count of 200–300 x 109/L; aggregation with a PRP count <100 x 109/L showed poor sensitivity. Imprecision and detection of antiplatelet drug effects was similar between the CS-2000i and AggRAM. These data demonstrate that CS-2000i is comparable to a stand-alone aggregometer, although CS-2000i has the advantages of walk-away technology and also required a smaller sample volume than the AggRAM (44% less).
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Affiliation(s)
- A S Lawrie
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
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Glas M, Mauer D, Kassas H, Volk T, Kreuer S. Sample transport by pneumatic tube system alters results of multiple electrode aggregometry but not rotational thromboelastometry. Platelets 2012; 24:454-61. [PMID: 22931353 DOI: 10.3109/09537104.2012.718383] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pneumatic tube systems (PTS) present a convenient way for blood sample transport in medical facilities. Associated preanalytical interference in various tests is largely unknown. Implementing point-of-care coagulation management at our institution, we investigated multiple electrode aggregometry (MEA) and rotational thromboelastometry (ROTEM) after PTS transportation. Whole blood samples from patients undergoing general or trauma surgery were analysed by MEA after collection (baseline, '0 × PTS') and sent on a predefined PTS track (n = 12). MEA was repeated after samples travelled the track 4 ('4 × PTS'), 8 ('8 × PTS') and 12 times ('12 × PTS') and compared with stationary controls analysed at the same time. Samples for ROTEM (n = 6) were analysed after collection and travelling the track 12 times. An acceleration detector recorded g-forces on the PTS track. At '0 × PTS' no significant differences in MEA results were detected. Values were significantly lower for transported samples compared with controls ('4 × PTS' to '12 × PTS', p < 0.001). Furthermore, MEA results of PTS samples were significantly decreased for '4 × PTS' to '12 × PTS' compared to baseline (p < 0.001). Except for the clotting time in EXTEM PTS transport did not significantly alter results for investigated ROTEM parameters, compared with baseline and stationary controls. Acceleration detector readout revealed alternating g-forces between -6.3 and +5.9 during transport. PTS transport caused invalid results in MEA while only one ROTEM parameter was found to be affected in this study. Variable acceleration during transport provides a potential reason for platelet activation. The authors recommend sample transport by hand or the device to be placed patient-side when MEA is performed.
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Affiliation(s)
- Michael Glas
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Hospital , Kirrberger Strasse, D-66421 Homburg (Saar) , Germany.
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Johansson PI, Sølbeck S, Genet G, Stensballe J, Ostrowski SR. Coagulopathy and hemostatic monitoring in cardiac surgery: an update. SCAND CARDIOVASC J 2012; 46:194-202. [PMID: 22375889 DOI: 10.3109/14017431.2012.671487] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Cardiac surgery with cardiopulmonary bypass (CPB) causes severe derangements in the hemostatic system, which in turn puts the patient at risks of microvascular bleeding. Excessive transfusion and surgical re-exploration after cardiac surgery are potentially associated with a number of adverse outcomes including increased mortality. DESIGN This review describes coagulopathies occurring in cardiac surgery and the monitoring of these. Viscoelastic hemostatic assays (VHA) have routinely been used in cardiac surgery for more than 25 years and at least 16 studies (involving more than 3250 patients, including three randomized controlled trials) have compared VHA to routine coagulation tests (RCoT) with regards to their ability to predict bleeding and re-do surgery and also with regards to transfusion requirements secondary to hemostatic therapy based on VHA vs. RCoT. RESULTS All 16 studies demonstrated superiority with VHA as compared to RCoT both in predicting bleeding and need for re-do surgery and in reducing the total amount of blood transfusions by employing goal-directed administration of blood products based on VHA as compared RCoT based therapy or at the clinicians discretion. CONCLUSIONS The different types of coagulopathies observed in patients undergoing cardiac surgery requires adequate and timely hemostatic therapy and real-time monitoring with WHA such as TEG/ROTEM and whole blood platelet aggregometry.
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Affiliation(s)
- Pär I Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen, Denmark.
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Bolliger D, Dell-Kuster S, Seeberger MD, Tanaka KA, Gregor M, Zenklusen U, Tsakiris DA, Filipovic M. Impact of loss of high-molecular-weight von Willebrand factor multimers on blood loss after aortic valve replacement. Br J Anaesth 2012; 108:754-62. [PMID: 22311365 DOI: 10.1093/bja/aer512] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Severe aortic stenosis is associated with loss of the largest von Willebrand factor (vWF) multimers, which could affect primary haemostasis. We hypothesized that the altered multimer structure with the loss of the largest multimers increases postoperative bleeding in patients undergoing aortic valve replacement. METHODS We prospectively included 60 subjects with severe aortic stenosis. Before and after aortic valve replacement, vWF antigen, activity, and multimer structure were determined and platelet function was measured by impedance aggregometry. Blood loss from mediastinal drainage and the use of blood and haemostatic products were evaluated perioperatively. RESULTS Before operation, the altered multimer structure was present in 48 subjects (80%). Baseline characteristics and laboratory data were similar in all subjects. The median blood loss after 6 h was 250 (105-400) and 145 (85-240) ml in the groups with the altered and normal multimer structures, respectively (P=0.182). After 24 h, the cumulative loss was 495 (270-650) and 375 (310-600) ml in the groups with the altered and normal multimer structures, respectively (P=0.713). Multivariable analysis revealed no significant influence of multimer structure and platelet function on bleeding volumes after 6 and 24 h. After 24 h, there was no obvious difference in vWF antigen, activity, and multimer structure in subjects with and without the altered multimer structure before operation or in subjects with and without perioperative plasma transfusion. CONCLUSIONS The altered vWF multimer structure before operation was not associated with increased bleeding after aortic valve replacement. Our findings might be explained by perioperative release of vWF and rapid recovery of the largest vWF multimers.
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Affiliation(s)
- D Bolliger
- Department of Anaesthesia and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland.
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