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Sargin M, Erdogan SB, Bastopcu M, Arslanhan G, Tasdemir MM, Orhan G. Cost of Healthcare Associated With Deep Vein Thrombosis in Patients Treated With Warfarin in Turkey: 2010-2013 Database Analysis of a Tertiary Care Center. Value Health Reg Issues 2019; 19:81-86. [PMID: 31254969 DOI: 10.1016/j.vhri.2019.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/22/2019] [Accepted: 03/08/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To evaluate the cost of healthcare with respect to the quality of anticoagulation in patients with deep vein thrombosis (DVT) treated with warfarin in daily practice via the database analysis of a tertiary care center in the period 2010 to 2013. METHODS Of 258 307 records in total, 42 582 unique patients with DVT and 32 012 patients with international normalized ratio (INR) measurements were included. Overall, 6720 unique patients with DVT diagnosis and one or more INR measurements were identified, and the records of 4377 out of 6720 unique patients were validated and included in the analysis data set. The cost analysis was based on direct medical costs from the payer's perspective. Cost items were related to healthcare resource utilization (inpatient and outpatient services) during the study period, which provided a basis for calculation of per-patient, outpatient, inpatient, and total direct medical costs. RESULTS Mean outpatient, inpatient, and total hospital admission costs were $578, $2195, and $2785, respectively, for patients with time in the therapeutic range of 70% or more, whereas the same costs were $571, $2163, and $3192, respectively, for patients with time in the therapeutic range of less than 70%. CONCLUSIONS Our findings for a retrospective cohort of patients with DVT undergoing warfarin therapy reveal that patients spent 70% or more, as opposed to less than 70%, of follow-up time within the therapeutic INR range and that outpatient care, as opposed to inpatient care, was associated with lower healthcare costs. Given the significant contribution that hospital stay makes to the cost burden of DVT, our findings also highlight the association between poor warfarin anticoagulant control and increased hospitalization costs.
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Affiliation(s)
- Murat Sargin
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey.
| | - Sevinc Bayer Erdogan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Bastopcu
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gokhan Arslanhan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Muge Mete Tasdemir
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gokcen Orhan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Sargin M, Tasdemir MM, Kuplay H, Erdogan SB, Tandogar N, Akansel S, Kurc E, Orhan G, Aka SA. Retrospective cohort study for evaluating the INR monitoring patterns in patients with deep vein thrombosis in daily practice: Analysis of 2010-2013 database of a tertiary care center. Phlebology 2018; 34:317-323. [PMID: 30336760 DOI: 10.1177/0268355518806117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the international normalized ratio (INR) monitoring patterns in patients with deep vein thrombosis. METHODS Of 32,012 patients with ≥1 outpatient INR measurement and 42,582 patients with confirmed deep vein thrombosis diagnosis registered to our hospital between 1 January 2010 and 31 December 2013, 6720 records were identified to have both deep vein thrombosis and international normalized ratio measurement, and 4.377 out of 6.720 single patient records were determined to be statistically analyzable. RESULTS Median INR measurement frequency was 6.47 times/year and patients had INR levels of 2-3 in 34.3% of follow-up time. Having ≥70% vs. <70% of follow-up time within therapeutic range was associated with lower hospital admission frequency (9.7 vs. 10.3 times/year). CONCLUSION Our study revealed only one-third of the follow-up time to be spent within therapeutic INR, association of INR therapeutic range with lesser number of hospital admissions and INR monitoring frequency of 6.47 times/year despite lack of stable INR control in most of the deep vein thrombosis patients.
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Affiliation(s)
- Murat Sargin
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Muge Mete Tasdemir
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Huseyin Kuplay
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sevinc Bayer Erdogan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Nehir Tandogar
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Serdar Akansel
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Erol Kurc
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Gokcen Orhan
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Serap Aykut Aka
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Abstract
SummaryAn overview is given on the method and the applications of thrombin generation assays. Thrombin generation assays provide a tool which can be used to trace the entire thrombin formation and inactivation of a plasma sample. Therefore they are principally different from traditional global assays like PT and aPTT and promise new opportunities for the assessment of bleeding or thrombotic risks.
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de Koning MLY, Fischer K, de Laat B, Huisman A, Ninivaggi M, Schutgens REG. Comparing thrombin generation in patients with hemophilia A and patients on vitamin K antagonists. J Thromb Haemost 2017; 15:868-875. [PMID: 28296129 DOI: 10.1111/jth.13674] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Indexed: 08/31/2023]
Abstract
Essentials It is unknown if hemophilia patients with atrial fibrillation need anticoagulation. Endogenous thrombin potentials (ETP) in hemophilia patients and patients on coumarins were compared. Severe hemophilia patients had comparable ETP to therapeutic international normalized ratio (INR). In non-severe hemophilia, 33% had higher ETP than therapeutic INR and may need anticoagulation. Click to hear Dr Negrier's perspective on global assays for assessing coagulation SUMMARY: Background It is unknown whether patients with hemophilia A with atrial fibrillation require treatment with vitamin K antagonists (VKAs) to the same extent as the normal population. Objective To compare hemostatic potential in hemophilia patients and patients on VKAs using thrombin generation (TG). Methods In this cross-sectional study, TG, initiated with 1pM tissue factor, was measured in 133 patients with severe (FVIII < 1%, n = 15) and non-severe (FVIII 1-50%, n = 118) hemophilia A, 97 patients on a VKA with an international normalized ratio (INR) ≥ 1.5 and healthy controls. Endogenous thrombin potential (ETP) (nm*min) was compared according to FVIII level (< 1%, 1-19% and 20-50%) with healthy controls and patients with sub-therapeutic INR (1.5-1.9) and therapeutic INR (≥ 2.0). Medians and interquartile ranges (IQRs) were calculated. Results Compared with healthy controls (898 [IQR 803-1004]), both hemophilia patients and patients on VKAs had lower median ETPs at 304 (196-449) and 176 (100-250), respectively. ETP was quite similar in severe hemophilia patients (185 [116-307]) and patients with a therapeutic INR (156 [90-225]). Compared with patients with therapeutic INR, ETP in patients with FVIII 1-19% and patients with FVIII 20-50% was higher at 296 (203-430) and 397 (219-632), respectively. All patients with therapeutic INR had an ETP < 400. Considering this threshold, 93% of severe hemophilia patients, 70% of patients with FVIII 1-19% and 52% of patients with FVIII 20-50% had an ETP < 400. Conclusion In severe hemophilia patients, TG was comparable to that in patients with a therapeutic INR. In one-third of non-severe hemophilia patients, TG was higher. These results suggest that anticoagulation therapy should be considered in a substantial proportion of non-severe hemophilia patients.
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Affiliation(s)
- M L Y de Koning
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, the Netherlands
| | - K Fischer
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, the Netherlands
| | - B de Laat
- Synapse, Maastricht, the Netherlands
| | - A Huisman
- Department of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - R E G Schutgens
- Van Creveldkliniek, University Medical Center Utrecht, Utrecht, the Netherlands
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Berezovskaya G, Smirnova O, Malev E, Khromov-Borisov N, Klokova E, Karpenko M, Papayan L, Petrishchev N. Thrombin generation test for evaluation of antiplatelet treatment in patients with coronary artery disease after percutaneous coronary intervention. Platelets 2017; 29:185-191. [PMID: 28374620 DOI: 10.1080/09537104.2017.1294680] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
To study the possibility of using thrombin generation tests in platelet-rich and platelet-poor plasma for evaluation of dual antiplatelet therapy efficacy in patients with coronary artery disease (CAD), following percutaneous coronary intervention. Venous blood was analyzed from CAD patients aged 53-75 years who had undergone percutaneous coronary intervention with stenting within one year and had been receiving standard doses of clopidogrel and aspirin (75 and 75-100 mg per day, respectively). The control group comprised age- and sex-matched subjects without clinical signs of CAD who were not receiving these drugs. Thrombin generation tests were performed in platelet-rich and platelet-poor plasma. Intravascular platelet activation, induced platelet aggregation, and routine coagulation were evaluated. Antiplatelet treatment did not influence results of routine coagulation tests or intravascular platelet activation. The dual antiplatelet therapy affects collagen-induced platelet aggregation (44 ± 2.5 vs. 7.9 ± 2.6%, р = 10-7) and leads to decreases in endogenous thrombin potential (1900 ± 85 vs. 1740 ± 95 nM∙min, p = 0.0045), maximum thrombin concentration (134 ± 9.5 vs. 106 ± 6.5 nM, p = 4∙10-6), and increases in time to peak thrombin (27 ± 1.5 vs. 31 ± 2 min, p = 0.0012). Decreases in thrombin generation rate showed the highest statistical significance (13 ± 2 vs. 7.9 ± 0.8 nM/min, p = 10-8). Antiplatelet treatment did not alter thrombogram parameters for platelet-poor plasma.
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Affiliation(s)
- Gelena Berezovskaya
- a Department of Faculty Therapy , Pavlov First Saint-Petersburg State Medical University , Saint-Petersburg , Russia.,b Department of Acute Coronary Syndrome , Federal Almazov North-West Medical Research Centre , Saint-Petersburg , Russia
| | - Olga Smirnova
- c Department of Blood Coagulation , Russian Research Institute of Hematology and Transfusiology , Saint-Petersburg , Russia
| | - Eduard Malev
- d Department of Connective Tissue Disorders , Federal Almazov North-West Medical Research Centre , Saint-Petersburg , Russia
| | - Nikita Khromov-Borisov
- e Department of Physics, Mathematics and Computer Science , Pavlov First Saint-Petersburg State Medical University , Saint-Petersburg , Russia
| | - Elena Klokova
- f Department of Ultrasound Diagnostics , Federal Almazov North-West Medical Research Centre , Saint-Petersburg , Russia
| | - Mikhail Karpenko
- g Department of Clinical Angiology , Federal Almazov North-West Medical Research Centre , Saint-Petersburg , Russia
| | - Lyudmila Papayan
- c Department of Blood Coagulation , Russian Research Institute of Hematology and Transfusiology , Saint-Petersburg , Russia
| | - Nikolay Petrishchev
- h Department of Pathological Physiology , Pavlov First Saint-Petersburg State Medical University , Saint-Petersburg , Russia
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Wendl-Soeldner M, Moll C, Kammerlander C, Gosch M, Roth T. Algorithm for anticoagulation management in geriatric hip fracture patients—Surgeons save Blood. Z Gerontol Geriatr 2014; 47:95-104. [DOI: 10.1007/s00391-013-0595-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Choi Q, Kim JE, Hyun J, Han KS, Kim HK. Contributions of procoagulants and anticoagulants to the international normalized ratio and thrombin generation assay in patients treated with warfarin: potential role of protein Z as a powerful determinant of coagulation assays. Thromb Res 2013; 132:e70-5. [PMID: 23769659 DOI: 10.1016/j.thromres.2013.05.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Revised: 05/20/2013] [Accepted: 05/21/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND The effects of warfarin are measured with the international normalized ratio (INR). However, the thrombin generation assay (TGA) may offer more information about global coagulation. We analyzed the monitoring performance of the TGA and INR and investigated the impact of procoagulants (fibrinogen, factor (F)II, FVII, FIX, and FX) and anticoagulants (proteins C, S, and Z) on them. METHODS The TGA was performed on a calibrated automated thrombogram, producing lag time, endogenous thrombin potential (ETP), and peak thrombin in 239 patients treated with warfarin. Pro- and anticoagulant levels were also measured. RESULTS The INR was significantly and inversely correlated with ETP. The therapeutic range of ETP comparable to an INR range of 2.0-3.0 was 290.1-494.6. ETP showed comparable performance to the INR as a warfarin-monitoring parameter with respect to clinical complication rate. The median levels of FII, FVII, FIX, and FX and proteins C and Z tended to decrease gradually with increasing anticoagulation intensity according to the INR or ETP. Of note, protein Z levels decreased dramatically with increasing anticoagulation status. INRs were significantly determined by FII, FVII, and protein Z. ETP was significantly dependent on FVII, and proteins C and Z concentration. Protein Z significantly reduced the total amount of thrombin generation and prolonged PT value in vitro. CONCLUSIONS The INR and ETP exhibit similar efficacy for warfarin monitoring according to the clinical complication rate. Protein Z is considered to be a significant determinant of INR and ETP in patients on warfarin therapy.
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Affiliation(s)
- Qute Choi
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
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Budak YU, Huysal K, Polat M, Tarakçi G, Uçar H. Evaluation of the Steelex M600H coagulometer prothrombin time-international normalized ratio assay with Steelex test reagents. Biochem Med (Zagreb) 2012; 22:121-6. [PMID: 22384527 PMCID: PMC4062317 DOI: 10.11613/bm.2012.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Accepted: 12/28/2011] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The aim of the present study was to validate prothrombin time (PT) international normalized ratio (INR) results obtained using Steelex test reagents and a Steelex coagulometer (Steelex Scientific Instrument Company, Beijing, China), in comparison with use of a well-established standard test employing Pacific Hemostasis reagents (Fisher Diagnostics, Middletown, VA, USA) and Teco Coatron A4 coagulometer (Teco Medical Instruments GmbH, Neufahrn, Germany). MATERIALS AND METHODS Between- and within-day coefficients of variation (CVs) of both assays were calculated using control samples provided by the test manufacturers. Samples from 90 subjects were collected and INR values were determined in a double-blind parallel manner employing both systems. RESULTS The within-day coefficients of variation (CVs) in INR estimates ranged from 2.6% (INR = 1.12) to 3.1% (INR = 2.51) for the Steelex system and from 2.1% (INR = 1.09) to 1.8% (INR = 2.8) for the Pacific test; the between-day values ran from 3.4% (INR = 1.16) to 7.9% (INR = 2.64) and from 3.3% (INR = 1.1) to 2.3% (INR = 2.7), respectively. Passing-Bablok fit of the of the Steelex and Pacific methods yielded the equation: Steelex INR = 0.85 (0.79-0.91) x Pacific INR + 0.12 (-0.02-0.21), whereas the CUSUM linearity P value was < 0.01. The mean bias as determined by the Bland-Altman test was -0.156 (-0.912-0.600). CONCLUSION The results obtained using Steelex reagents and the M600H coagulometer are not equivalent to those obtained using Pacific Hemostasis reagents and a Teco Coatron A4 coagulometer, at least in the therapeutic range.
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Affiliation(s)
- Yasemin U Budak
- Department of Clinical Laboratory, Sevket Yilmaz Education and Training Hospital, Bursa, Turkey.
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Sølvik UØ, Petersen PH, Monsen G, Stavelin AV, Sandberg S. Discrepancies in International Normalized Ratio Results between Instruments: A Model to Split the Variation into Subcomponents. Clin Chem 2010; 56:1618-26. [DOI: 10.1373/clinchem.2010.146233] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Observed differences between results obtained from comparison of instruments used to measure international normalized ratio (INR) have been higher than expected from the imprecision of the instruments. In this study the variation of these differences was divided into subcomponents, and each of the subcomponents was estimated.
METHODS
Blood samples were collected at 4 different patient visits from each of 36 outpatients who were receiving warfarin treatment and were included in the study. INR was determined on 1 laboratory instrument (STA Compact®) and 3 point-of-care instruments (Simple Simon®PT, CoaguChek®XS, and INRatio™). All 4 INR instruments were compared in pairs. Linear regression was used to correct for systematic deviations. The remaining variation of the differences was subdivided into between-subject, within-subject, and analytical variation in an ANOVA nested design.
RESULTS
The mean difference between instruments varied between 1.0% and 14.3%. Between-subject variation of the differences (expressed as CV) varied between 3.3% and 7.4%, whereas within-subject variation of the differences was approximately 5% for all 6 comparisons. The analytical imprecision of the differences varied between 3.8% and 8.6%.
CONCLUSIONS
The differences in INR between instruments were subdivided into calibration differences, between- and within-subject variation, and analytical imprecision. The magnitude of each subcomponent was estimated. Within results for individual patients the difference in INR between 2 instruments varied over time. The reasons for the between- and within-subject variations of the differences can probably be ascribed to different patient-specific effects in the patient plasma. To minimize this variation in a monitoring situation, each site and patient should use results from only 1 type of instrument.
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Affiliation(s)
- Una Ø Sølvik
- Department of Public Health and Primary Health Care, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Per H Petersen
- Department of Public Health and Primary Health Care, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Grete Monsen
- Norwegian Quality Improvement of Primary Care Laboratories (NOKLUS), Haraldsplass Hospital, Bergen, Norway
| | - Anne V Stavelin
- Department of Public Health and Primary Health Care, Faculty of Medicine and Dentistry, University of Bergen, Norway
- Norwegian Quality Improvement of Primary Care Laboratories (NOKLUS), Haraldsplass Hospital, Bergen, Norway
| | - Sverre Sandberg
- Department of Public Health and Primary Health Care, Faculty of Medicine and Dentistry, University of Bergen, Norway
- Haukeland University Hospital, Bergen, Norway
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Davidson SJ, Turner N, Tillyer L. Anticoagulation of a patient with hypertrophic cardiomyopathy and factor VII deficiency. Blood Coagul Fibrinolysis 2010; 21:707-8. [DOI: 10.1097/mbc.0b013e32833e47ad] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Miot S, Marteau AT, Simard G, Lavigne C. Accident hémorragique sous antagonistes de la vitamine K: adaptation de la détermination de l’International Normalized Ratio (INR) dans les hypertriglycéridémies majeures. Rev Med Interne 2010; 31:60-2. [DOI: 10.1016/j.revmed.2008.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2008] [Accepted: 12/08/2008] [Indexed: 11/29/2022]
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Gatt A, Riddell A, van Veen JJ, Kitchen S, Tuddenham EG, Makris M. Optimizing warfarin reversal--an ex vivo study. J Thromb Haemost 2009; 7:1123-7. [PMID: 19575759 DOI: 10.1111/j.1538-7836.2009.03435.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Warfarin reversal is a common clinical situation. This is commonly performed using vitamin K and, depending on the urgency, fresh frozen plasma (FFP), prothrombin complex concentrates (PCCs), or activated factor VII. Even though PCCs are widely used, the ideal dosing regimen is far from established. OBJECTIVES To verify differences in warfarin reversal patterns using FFP, recombinant FVIIa (rFVIIa), and PCC; and to test the hypothesis that supratherapeutic International Normalized Ratios (INRs) might not correlate with thrombin generation (TG) and identify the ideal concentrations of PCC required to reverse various INR thresholds. METHODS We studied the effects of FFP, rFVIIa and Beriplex P/N on the INR and TG, using the calibrated automated thrombography assay in ex vivo warfarinized plasma. Plasmas with different INRs were spiked with different concentrations of Beriplex P/N. RESULTS Beriplex P/N was the only agent that completely normalized TG and the INR. The endogenous thrombin potential (ETP) and the peak thrombin showed a significant negative correlation with all INRs. The ETP and velocity of TG reached a plateau at an INR of approximately 4.0. A concentration equivalent to a dose of 30 IU kg(-1) Beriplex P/N normalized the ETP, the INR, FII, FVII, FIX and FX of samples with INRs > or = 4.0. Higher doses resulted in hypercoagulable TG patterns. A concentration equivalent to a dose of 20 IU kg(-1) was sufficient to reverse warfarin at an INR range of 2.0-3.9, as judged by the same tests. CONCLUSIONS Warfarin reversal algorithms could be simplified with the adoption of this strategy utilizing two doses of PCC, depending on the INR of the patient. This would also lead to cost reductions and, possibly, a reduction in thrombotic risk.
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Affiliation(s)
- A Gatt
- The Royal Free Hospital Haemophilia Centre & Thrombosis Unit, Hampstead, London, UK.
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13
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Osman A, Lindahl TL. Plasma predilution with addition of depleted plasma in a prothrombin time reagent improves the agreement between different prothrombin time methods. Scand J Clin Lab Invest 2009; 69:395-400. [PMID: 19191068 DOI: 10.1080/00365510802706637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND The Quick (plain thromboplastins) and Owren (combined thromboplastins, with the addition of bovine plasma with vitamin K-dependent factors depleted) prothrombin time (PT) methods are used for measuring prothrombin time; for instance, in monitoring anticoagulation therapy with vitamin K antagonists. In most Quick PT methods, the final plasma dilution is 1/3 compared to Owren methods, which have a final dilution of 1/21. The Quick PT methods are associated with larger inter-laboratory variations than the Owren PT methods. OBJECTIVES We investigated whether dilution of the sample or thromboplastin has any impact on the correlation between the different PT methods. MATERIAL AND METHODS Plasma samples were analysed undiluted and prediluted in buffer, with adsorbed bovine plasma added, and by using rabbit brain or human placenta thromboplastins. Bootstrapping (re-sampling) was utilized to estimate the difference in correlations between PT of different reagents at different dilutions of plasma. RESULTS AND CONCLUSIONS We found the best correlations for combined reagents when the sample was prediluted 7-fold (r = 0.95) or more, and lowest when the sample was undiluted (r = 0.67). The source of thromboplastin had only a minor impact, if any, on the PT results. It was impossible to test whether predilution of plasma samples improved the correlation between Quick PT methods due to absence of clotting in many samples. We suggest that the Owren-style sample predilution is preferable for the harmonization of PT results and to overcome the large inter-laboratory variations that are associated with Quick PT methods to the benefit of patients on oral anticoagulation.
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Affiliation(s)
- Abdmajid Osman
- Department of Clinical Chemistry, Laboratory Medicine, University Hospital, Linkoping, Sweden
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Gatt A, van Veen JJ, Bowyer A, Woolley AM, Cooper P, Kitchen S, Makris M. Wide variation in thrombin generation in patients with atrial fibrillation and therapeutic International Normalized Ratio is not due to inflammation. Br J Haematol 2008; 142:946-52. [DOI: 10.1111/j.1365-2141.2008.07279.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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van Veen JJ, Gatt A, Makris M. Thrombin generation testing in routine clinical practice: are we there yet? Br J Haematol 2008; 142:889-903. [PMID: 18564356 DOI: 10.1111/j.1365-2141.2008.07267.x] [Citation(s) in RCA: 160] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Thrombin is the central enzyme in the coagulation cascade. Estimation of an individual's potential to generate thrombin may correlate more closely with a hyper- or hypo-coagulable phenotype, compared to traditional coagulation tests. The possible correlation and recent technical advances in thrombin generation measurement has caused a significant interest in the method and the development of commercial assays. Several variations of the assay exist depending on the defect to be investigated. Fluorogenic thrombin generation assays have acceptable intra-laboratory variation but a higher inter-laboratory variation. Variation in preanalytical variables makes comparisons between studies difficult. Thrombin generation is highly variable between individuals and there are suggestions that this may allow individualized treatment based on global haemostatic response in patients with bleeding disorders or on anticoagulant therapy. In patients with thrombotic disorders it may be possible to identify those at higher risk of recurrent thrombosis. For both scenarios, however, data from large prospective studies are lacking or inconclusive and a good relationship between thrombin generation and phenotype remains to be established. Further standardization of the assay is needed before large multicentre studies can be conducted and until then thrombin generation in routine clinical practice is not yet a reality.
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Affiliation(s)
- J J van Veen
- Leicester Haemophilia Comprehensive Care Centre & Haemostasis and Thrombosis Unit, Leicester, UK.
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Dargaud Y, Desmurs-Clavel H, Marin S, Bordet JC, Poplavsky JL, Negrier C. Comparison of the capacities of two prothrombin complex concentrates to restore thrombin generation in plasma from orally anticoagulated patients: an in vitro study. J Thromb Haemost 2008; 6:962-8. [PMID: 18373620 DOI: 10.1111/j.1538-7836.2008.02964.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Human prothrombin complex concentrates (PCCs) are used for prevention and treatment of bleeding episodes in patients under warfarin therapy. PCCs contain human factor (F) II, FVII, FIX, FX, protein C and protein S. The concentrations of these coagulation factors contained in PCCs are variable and do not reflect entirely the capacity of these drugs to correct hemostasis. Furthermore, commercially available PCCs do not have exactly the same composition, though they are all labelled and prescribed in units per kg of FIX (10-40 IU of FIX/kg). As the final product generated by PCCs is thrombin, a thrombin generation (TG) test could theoretically be used for monitoring the hemostatic correction. METHODS TG was measured in platelet free plasma in the presence of tissue factor 5 pm and phospholipids 4 microM with a final concentration of PCC of 0-0.1-0.2-0.3-0.4-0.5-0.75-1 IU ml(-1). The activity of vitamin K-dependent coagulation factors (i.e. FII, FVII, FIX, FX, protein C and protein S) were determined for each concentration of two different PCCs available on the French market. RESULTS AND DISCUSSION Our results showed that the addition of two different PCCs dose-dependently increased the TG capacity in patients with INR of 2-2.5-3-4 and >7 (n = 15 subjects) that reached the normal values. We also found a significant correlation between endogenous thrombin potential (ETP) and INR (Pearson test, P < 0.0001). The two PCCs improved the TG parameters differently with increasing concentrations. The difference in the correction of TG capacity observed between the two drugs could be explained by a variable increase in FX, FVII and protein C with similar doses. These results strongly suggest that TG assay could be used for monitoring the clinical efficacy of PCC and for optimizing the therapeutic regimen towards a more individualized therapy involving the type of the bleeding complications, the level of inhibition of the coagulation system and the molecule content of the PCC.
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Affiliation(s)
- Y Dargaud
- Laboratoire d'Hémostase, Hôpital Edouard Herriot, Lyon, and EA 4174, IFR 62, Université Lyon 1, Lyon, France.
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Al Dieri R, Alban S, Béguin S, Hemker HC. Fixed dosage of low-molecular-weight heparins causes large individual variation in coagulability, only partly correlated to body weight. J Thromb Haemost 2006; 4:83-9. [PMID: 16409456 DOI: 10.1111/j.1538-7836.2005.01672.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Low-molecular-weight heparins (LMWHs) are routinely given without the control of their effect on coagulation. The endogenous thrombin potential (ETP) is a sensitive detector of the heparin effect. QUESTION What is the interindividual variation in TG after a fixed dose of LMWH in normal volunteers, is it explained by variation in weight? METHODS Subcutaneous (s.c.) injection, in 12 healthy volunteers, of 9000 aXa-units of unfractionated heparin (UFH) and of three heparins with narrow MW distribution around 10.5, 6.0 and 4.5 kD. Measurement of anti-thrombin (aIIa) and antifactor Xa (aXa)-activities and ETP at 11 time points over 24 h. RESULTS The coefficient of variation (CV) of the AUCs of aXa- and aIIa-activities is 50% for UFH and 22-37% for LMWHs. Because of the hyperbolic form of the dose-response curve, the CV of the inhibition of the ETP is lower: 32% for UFH and 13-21% for the LMWHs. Fixed dosage of LMWH caused under-dosage in 10-13% of the samples and over-dosage in 5-11%. High or low response is an individual property independent of the type of heparin injected and only partially explained by variation in body weight. CONCLUSION Optimized individual dosage of LMWH is possible through recognition of high and low responders, which requires one measurement of the heparin concentration or, preferably, the heparin effect on the ETP, 2-5 h after a first injection.
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Affiliation(s)
- R Al Dieri
- Synapse BV, Cardiovascular Research Institute, Maastricht, The Netherlands.
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Steiner T, Rosand J, Diringer M. Intracerebral hemorrhage associated with oral anticoagulant therapy: current practices and unresolved questions. Stroke 2005; 37:256-62. [PMID: 16339459 DOI: 10.1161/01.str.0000196989.09900.f8] [Citation(s) in RCA: 200] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Life-threatening intracranial hemorrhage, predominantly intracerebral hemorrhage (ICH), is the most serious complication of oral anticoagulant therapy (OAT), with mortality in excess of 50%. Early intervention focuses on rapid correction of coagulopathy in order to prevent continued bleeding. SUMMARY OF REVIEW This article reviews the epidemiology of OAT-associated ICH (OAT-ICH), and current treatment options, with the aim of providing a framework for future studies of unresolved questions. A number of acute treatments are available, but all have a significant risk of inducing thrombosis and other side effects, and vary in their rapidity of effect: vitamin K (very slow response time), fresh frozen plasma (slow response time, large volume of fluid required, transfusion-related acute lung injury), prothrombin complex concentrates, and recombinant activated factor VII. Current practice is to administer a combination of vitamin K and either fresh frozen plasma or prothrombin complex concentrates; the occasional use of recombinant activated factor VII has been reported. No prospective study has addressed the efficacy of, or outcomes from, the use of these practices. CONCLUSIONS Current management of OAT-ICH is varied and not based on evidence from randomized controlled trials. Well-designed clinical trials are essential if we are to identify the effective acute treatments for OAT-ICH that are urgently needed.
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Horsti J, Uppa H, Vilpo JA. Poor agreement among prothrombin time international normalized ratio methods: comparison of seven commercial reagents. Clin Chem 2005; 51:553-60. [PMID: 15665046 DOI: 10.1373/clinchem.2004.043836] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Prothrombin time (PT) has long been the most popular test for monitoring oral anticoagulation therapy. The International Normalized Ratio (INR) was introduced to overcome the problem of marked variation in PT results among laboratories and the various recommendations for patient care. According to this principle, all reagents should be calibrated to give identical results and the same patient care globally. This is necessary for monitoring of single patients and for application of the results of anticoagulation trials and guidelines to clinical practice. METHODS We took blood samples from 150 patients for whom oral anticoagulation had been prescribed. Plasmas were separated and PTs determined by use of seven commercial reagents and four calibrator sets. The differences in results were assessed by plotting, for each possible pair of methods, the differences in INR values for each sample against the mean INR value (Bland-Altman difference plots). RESULTS Mean results differed significantly (P <0.001) for 17 of 21 possible paired comparisons of methods. Only two pairs of methods produced very similar results when assessed for problems of substantial differences in INR values; a significant, systematic increase in the difference with INR; and a significant systematic increase in the variation in difference with increasing INR values. CONCLUSIONS The agreement among several (and perhaps most) commercial INR methods is poor. The failure of current calibration strategies may severely compromise both the monitoring of individual patients and the application of oral anticoagulation guidelines and trial results to clinical practice.
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Affiliation(s)
- Juha Horsti
- Department of Clinical Chemistry, Laboratory Centre, Tampere University Hospital and University of Tampere, Tampere, Finland.
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