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Kwon O, Ahn JH, Koh JS, Park Y, Hwang SJ, Tantry US, Gurbel PA, Hwang JY, Jeong YH. Platelet-fibrin clot strength and platelet reactivity predicting cardiovascular events after percutaneous coronary interventions. Eur Heart J 2024; 45:2217-2231. [PMID: 38804262 DOI: 10.1093/eurheartj/ehae296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 03/26/2024] [Accepted: 04/30/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND AND AIMS Platelet-fibrin clot strength (PFCS) is linked to major adverse cardiovascular event (MACE) risk. However, the association between PFCS and platelet reactivity and their prognostic implication remains uncertain in patients undergoing percutaneous coronary intervention (PCI). METHODS In PCI-treated patients (n = 2512) from registry data from January 2010 to November 2018 in South Korea, PFCS using thromboelastography and platelet reactivity using VerifyNow were measured. High PFCS (PFCSHigh) was defined as thromboelastography maximal amplitude ≥ 68 mm, and high platelet reactivity (HPR) was defined as >208 P2Y12 reaction units. Patients were stratified into four groups according to maximal amplitude and P2Y12 reaction unit levels: (i) normal platelet reactivity (NPR)-PFCSNormal (31.8%), (ii) HPR-PFCSNormal (29.0%), (iii) NPR-PFCSHigh (18.1%), and (iv) HPR-PFCSHigh (21.1%). Major adverse cardiovascular event (all-cause death, myocardial infarction, or stroke) and major bleeding were followed up to 4 years. RESULTS High platelet reactivity and PFCSHigh showed an additive effect for clinical outcomes (log-rank test, P < .001). Individuals with NPR-PFCSNormal, NPR-PFCSHigh, HPR-PFCSNormal, and HPR-PFCSHigh demonstrated MACE incidences of 7.5%, 12.6%, 13.4%, and 19.3%, respectively. The HPR-PFCSHigh group showed significantly higher risks of MACE compared with the NPR-PFCSNormal group [adjusted hazard ratio (HRadj) 1.89; 95% confidence interval (CI) 1.23-2.91; P = .004] and the HPR-PFCSNormal group (HRadj 1.60; 95% CI 1.12-2.27; P = .009). Similar results were observed for all-cause death. Compared with HPR-PFCSNormal phenotype, NPR-PFCSNormal phenotype was associated with a higher risk of major bleeding (HRadj 3.12; 95% CI 1.30-7.69; P = .010). CONCLUSIONS In PCI patients, PFCS and platelet reactivity demonstrated important relationships in predicting clinical prognosis. Their combined assessment may enhance post-PCI risk stratification for personalized antithrombotic therapy.
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Affiliation(s)
- Osung Kwon
- Division of Cardiology, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Cardiovascular Research Institute for Intractable Disease, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong-Hwa Ahn
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Jin-Sin Koh
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 79, Gangnam-ro, Jinju 52727, Republic of Korea
| | - Yongwhi Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Seok Jae Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 79, Gangnam-ro, Jinju 52727, Republic of Korea
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Jin-Yong Hwang
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 79, Gangnam-ro, Jinju 52727, Republic of Korea
| | - Young-Hoon Jeong
- CAU Thrombosis and Biomarker Center, Chung-Ang University Gwangmyeong Hospital, 110, Deokan-ro, Gwangmyeong 14353, Republic of Korea
- Department of Internal Medicine, Chung-Ang University College of Medicine, 84, Heukseok-ro, Seoul 06974, Republic of Korea
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2
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Bunch CM, Berquist M, Ansari A, McCoy ML, Langford JH, Brenner TJ, Aboukhaled M, Thomas SJ, Peck E, Patel S, Cancel E, Al-Fadhl MD, Zackariya N, Thomas AV, Aversa JG, Greene RB, Seder CW, Speybroeck J, Miller JB, Kwaan HC, Walsh MM. The Choice between Plasma-Based Common Coagulation Tests and Cell-Based Viscoelastic Tests in Monitoring Hemostatic Competence: Not an either-or Proposition. Semin Thromb Hemost 2022; 48:769-784. [PMID: 36174601 DOI: 10.1055/s-0042-1756302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There has been a significant interest in the last decade in the use of viscoelastic tests (VETs) to determine the hemostatic competence of bleeding patients. Previously, common coagulation tests (CCTs) such as the prothrombin time (PT) and partial thromboplastin time (PTT) were used to assist in the guidance of blood component and hemostatic adjunctive therapy for these patients. However, the experience of decades of VET use in liver failure with transplantation, cardiac surgery, and trauma has now spread to obstetrical hemorrhage and congenital and acquired coagulopathies. Since CCTs measure only 5 to 10% of the lifespan of a clot, these assays have been found to be of limited use for acute surgical and medical conditions, whereby rapid results are required. However, there are medical indications for the PT/PTT that cannot be supplanted by VETs. Therefore, the choice of whether to use a CCT or a VET to guide blood component therapy or hemostatic adjunctive therapy may often require consideration of both methodologies. In this review, we provide examples of the relative indications for CCTs and VETs in monitoring hemostatic competence of bleeding patients.
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Affiliation(s)
- Connor M Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Margaret Berquist
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Aida Ansari
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Max L McCoy
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Jack H Langford
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Toby J Brenner
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Michael Aboukhaled
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Samuel J Thomas
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Ethan Peck
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Shivani Patel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Emily Cancel
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana
| | - Mahmoud D Al-Fadhl
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Nuha Zackariya
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - Anthony V Thomas
- Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
| | - John G Aversa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan B Greene
- Department of Interventional Radiology, St. Joseph Regional Medical Center, Mishawaka, Indiana
| | - Christopher W Seder
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Jacob Speybroeck
- Department of Orthopedic Surgery, Case Western Medical Center, Cleveland, Ohio
| | - Joseph B Miller
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Hau C Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark M Walsh
- Department of Emergency Medicine, Saint Joseph Regional Medical Center, Mishawaka, Indiana.,Indiana University School of Medicine, Notre Dame Campus, South Bend, Indiana
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3
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Sayce AC, Neal MD, Leeper CM. Viscoelastic monitoring in trauma resuscitation. Transfusion 2021; 60 Suppl 6:S33-S51. [PMID: 33089933 DOI: 10.1111/trf.16074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/13/2020] [Accepted: 06/14/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Traumatic injury results in both physical and physiologic insult. Successful care of the trauma patient depends upon timely correction of both physical and biochemical injury. Trauma-induced coagulopathy is a derangement of hemostasis and thrombosis that develops rapidly and can be fatal if not corrected. Viscoelastic monitoring (VEM) assays have been developed to provide rapid, accurate, and relatively comprehensive depictions of an individual's coagulation profile. VEM are increasingly being integrated into trauma resuscitation guidelines to provide dynamic and individualized guidance to correct coagulopathy. STUDY DESIGN AND METHODS We performed a narrative review of the search terms viscoelastic, thromboelastography, thromboelastometry, TEG, ROTEM, trauma, injury, resuscitation, and coagulopathy using PubMed. Particular focus was directed to articles describing algorithms for management of traumatic coagulopathy based on VEM assay parameters. RESULTS Our search identified 16 papers with VEM-guided resuscitation strategies in adult patients based on TEG, 12 such protocols in adults based on ROTEM, 1 protocol for children based on TEG, and 2 protocols for children based on ROTEM. CONCLUSIONS This review presents evidence to support VEM use to detect traumatic coagulopathy, discusses the role of VEM in trauma resuscitation, provides a summary of proposed treatment algorithms, and discusses pending questions in the field.
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Affiliation(s)
- Andrew C Sayce
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christine M Leeper
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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4
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Myers SP, Dyer MR, Hassoune A, Brown JB, Sperry JL, Meyer MP, Rosengart MR, Neal MD. Correlation of Thromboelastography with Apparent Rivaroxaban Concentration: Has Point-of-Care Testing Improved? Anesthesiology 2020; 132:280-290. [PMID: 31939843 DOI: 10.1097/aln.0000000000003061] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Concern remains over reliable point-of-care testing to guide reversal of rivaroxaban, a commonly used factor Xa inhibitor, in high-acuity settings. Thromboelastography (TEG), a point-of-care viscoelastic assay, may have the ability to detect the anticoagulant effect of rivaroxaban. The authors ascertained the association of apparent rivaroxaban concentration with thromboelastography reaction time, i.e., time elapsed from blood sample placement in analyzer until beginning of clot formation, as measured using TEG and TEG6S instruments (Haemonetics Corporation, USA), hypothesizing that reaction time would correlate to degree of functional factor Xa impairment. METHODS The authors prospectively performed a diagnostic accuracy study comparing coagulation assays to apparent (i.e., indirectly assessed) rivaroxaban concentration in trauma patients with and without preinjury rivaroxaban presenting to a single center between April 2016 and July 2018. Blood samples at admission and after reversal or 24 h postadmission underwent TEG, TEG6S, thrombin generation assay, anti-factor Xa chromogenic assay, prothrombin time (PT), and ecarin chromogenic assay testing. The authors determined correlation of kaolin TEG, TEG6S, and prothrombin time to apparent rivaroxaban concentration. Receiver operating characteristic curve compared capacity to distinguish therapeutic rivaroxaban concentration (i.e., greater than or equal to 50 ng/ml) from nontherapeutic concentrations. RESULTS Eighty rivaroxaban patients were compared to 20 controls. Significant strong correlations existed between rivaroxaban concentration and TEG reaction time (ρ = 0.67; P < 0.001), TEG6S reaction time (ρ = 0.68; P < 0.001), and prothrombin time (ρ = 0.73; P < 0.001), however reaction time remained within the defined normal range for the assay. Rivaroxaban concentration demonstrated strong but not significant association with coagulation assays postreversal (n = 9; TEG reaction time ρ = 0.62; P = 0.101; TEG6S reaction time ρ = 0.57; P = 0.112) and small nonsignificant association for controls (TEG reaction time: ρ = -0.04; P = 0.845; TEG6S reaction time: ρ = -0.09; P = 0.667; PT-neoplastine: ρ = 0.19; P = 0.301). Rivaroxaban concentration (area under the curve, 0.91) and TEG6S reaction time (area under the curve, 0.84) best predicted therapeutic rivaroxaban concentration and exhibited similar receiver operating characteristic curves (P = 0.180). CONCLUSIONS Although TEG6S demonstrates significant strong correlation with rivaroxaban concentration, values within normal range limit clinical utility rendering rivaroxaban concentration the gold standard in measuring anticoagulant effect.
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Affiliation(s)
- Sara P Myers
- From the Department of General Surgery, The University of Pittsburgh Medical Center (S.P.M., M.R.D., A.H., J.B.B., J.L.S., M.R.R., M.D.N.) the Institute for Transfusion Medicine (M.P.M.) the Pittsburgh Surgical Outcomes Research Center, University of Pittsburgh (M.R.R.), Pittsburgh, Pennsylvania
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5
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Schmidt AE, Israel AK, Refaai MA. The Utility of Thromboelastography to Guide Blood Product Transfusion. Am J Clin Pathol 2019; 152:407-422. [PMID: 31263903 DOI: 10.1093/ajcp/aqz074] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To provide an overview of the clot viscoelastic testing technology and to describe its utility in guiding blood product transfusions. METHODS A case scenario will be discussed as well as interpretation of thromboelastography (TEG) tracings. In addition, literature examining the utility of viscoelastic testing in guiding patient management and blood product transfusions will be reviewed. RESULTS TEG/rotational thromboelastometry (ROTEM) is useful in evaluating clot kinetics in trauma and acutely bleeding patients. TEG/ROTEM parameters are reflective of values measured using standard coagulation assays; however, TEG/ROTEM parameters are more rapidly available and more costly. TEG and ROTEM are used in three main settings: cardiac surgery, liver transplantation, and trauma to assess global hemostasis and administration of blood products. CONCLUSIONS TEG/ROTEM can be helpful in guiding resuscitation and blood product transfusion. Several studies have demonstrated a reduction in transfusion of blood components with TEG/ROTEM; however, other studies have suggested that TEG/ROTEM is not clinically effective in guiding transfusion.
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Affiliation(s)
- Amy E Schmidt
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Anna Karolina Israel
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY
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6
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Taune V, Skeppholm M, Ågren A, Gryfelt G, Malmström RE, Wikman A, Van Ryn J, Wallén H. Rapid determination of anticoagulating effects of dabigatran in whole blood with rotational thromboelastometry and a thrombin-based trigger. J Thromb Haemost 2018; 16:2462-2470. [PMID: 30288934 DOI: 10.1111/jth.14308] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Indexed: 01/16/2023]
Abstract
Essentials A rapid test to detect thrombin inhibition by dabigatran would be valuable in acute situations. A thrombin-based trigger was applied in whole blood using rotation thromboelastometry. Effects of dabigatran were assessed in vitro and in samples from patients on dabigatran. The test produced data rapidly and was sensitive to dabigatran concentrations from 20 to 500 ng mL-1 . SUMMARY: Background Rapid determination of the anticoagulant effect of dabigatran is essential in emergency situations. Objective To study a viscoelastic test (rotational thromboelastometry [ROTEM]) for rapid determination of dabigatran effects in whole blood samples. Method ROTEM measurements were performed with comparison of two triggers (thrombin-based versus the commercial tissue factor-based trigger Ex-tem) in samples from 10 healthy donors spiked with dabigatran (20-500 ng mL-1 ) and in samples from 35 patients receiving dabigatran treatment; 10 healthy subjects served as controls. Clotting time (CT) and the difference in CT without versus with addition of the dabigatran antidote idarucizumab (CTdiff ) were measured. Addition of idarucizumab reveals the contribution of dabigatran to ROTEM measurements and its potential reversibility. Results In vitro studies showed that thrombin CT and thrombin CTdiff were more sensitive than Ex-tem CT and Ex-tem CTdiff in detecting dabigatran in whole blood samples. In patient samples, when thrombin CT and thrombin CTdiff were used, it was possible to detect dabigatran with a cut-off of dabigatran at 20 ng mL-1 , whereas, when Ex-tem CT and Ex-tem CTdiff were used, the method was less sensitive. Data from patient samples were obtained within 15 min of blood sampling. Conclusions ROTEM CT with a thrombin-based trigger is more sensitive to dabigatran effects than Ex-tem CT, and detects anticoagulant effects of drug concentrations in the low-very low therapeutic range. Analysis with idarucizumab (CTdiff ) reveals dabigatran-specific effects. As data are rapidly obtained, this method could, with further development and validation of its performance, be suitable for detecting clinically significant dabigatran effects in emergency situations.
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Affiliation(s)
- V Taune
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - M Skeppholm
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - A Ågren
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - G Gryfelt
- Department of Laboratory Medicine, Division of Clinical Immunology and Transfusion Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - R E Malmström
- Department of Medicine Solna, Karolinska Institutet & Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - A Wikman
- Department of Laboratory Medicine, Division of Clinical Immunology and Transfusion Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - J Van Ryn
- Department of Medicine, Boehringer Ingelheim International GmbH, Biberach an der Riss, Germany
| | - H Wallén
- Department of Clinical Sciences, Division of Cardiovascular Medicine, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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7
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Franchi F, Rollini F, Cho JR, King R, Phoenix F, Bhatti M, DeGroat C, Tello-Montoliu A, Zenni MM, Guzman LA, Bass TA, Ajjan RA, Angiolillo DJ. Effects of dabigatran on the cellular and protein phase of coagulation in patients with coronary artery disease on dual antiplatelet therapy with aspirin and clopidogrel. Thromb Haemost 2018; 115:622-31. [DOI: 10.1160/th15-06-0467] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 10/29/2015] [Indexed: 01/12/2023]
Abstract
SummaryThere is growing interest in understanding the effects of adding an oral anticoagulant in patients on dual antiplatelet therapy (DAPT). Vitamin K antagonists (VKAs) and clopidogrel represent the most broadly utilised oral anticoagulant and P2Y12 receptor inhibitor, respectively. However, VKAs can interfere with clopidogrel metabolism via the cytochrome P450 (CYP) system which in turn may result in an increase in platelet reactivity. Dabigatran is a direct acting (anti-II) oral anticoagulant which does not interfere with CYP and has favourable safety and efficacy profiles compared with VKAs. The pharmacodynamic (PD) effects on platelet reactivity and clot kinetic of adjunctive dabigatran therapy in patients on DAPT are poorly explored. In this prospective, randomised, double-blind, placebo-controlled PD study, patients (n=30) on maintenance DAPT with aspirin and clopidogrel were randomised to either dabigatran 150 mg bid or placebo for seven days. PD testing was performed before and after treatment using four different assays exploring multiple pathways of platelet aggregation and fibrin clot kinetics: light transmittance aggregometry (LTA), multiple electrode aggregometry (MEA), kaolin-activated thromboelastography (TEG) and turbidimetric assays. There were no differences in multiple measures of platelet reactivity investigating purinergic and non-purinergic signaling pathways assessed by LTA, MEA and TEG platelet mapping. Dabigatran significantly increased parameters related to thrombin activity and thrombus generation, and delayed fibrin clot formation, without affecting clot structure or fibrinolysis. In conclusion, in patients on DAPT with aspirin and clopidogrel, adjunctive dabigatran therapy is not associated with modulation of profiles of platelet reactivity as determined by several assays assessing multiple platelet signalling pathways. However, dabigatran significantly interferes with parameters related to thrombin activity and delays fibrin clot formation.
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Abstract
Direct oral anticoagulants are becoming increasingly popular in outpatient use. These medications have lacked specific reversal agents. However, this is changing. The Federal Food and Drug Administration approved idarucizumab for reversal of dabigatran in 2016, and another agent, andexanet alfa, is currently in clinical trials for reversal of rivaroxaban and apixaban. This article examines the efficacy and safety of these emerging reversal agents, as well as other historical agents for reversal of direct oral anticoagulants.
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9
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Solbeck S, Jensen AS, Maschmann C, Stensballe J, Ostrowski SR, Johansson PI. The anticoagulant effect of therapeutic levels of dabigatran in atrial fibrillation evaluated by thrombelastography (TEG ®), Hemoclot Thrombin Inhibitor (HTI) assay and Ecarin Clotting Time (ECT). Scandinavian Journal of Clinical and Laboratory Investigation 2018; 78:25-30. [PMID: 29304563 DOI: 10.1080/00365513.2017.1408138] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Monitoring the effect of dabigatran (Pradaxa®) is challenging. The aim of this study was to evaluate if thrombelastography reaction time (TEG® R) could detect the anticoagulant effect of dabigatran showing a correlation between TEG® R, Hemoclot Thrombin Inhibitor (HTI) assay and Ecarin Clotting Time (ECT) in patients with non-valvular atrial fibrillation (NVAF). Blood samples from 35 AF patients receiving either 110 mg (n 19) or 150 mg (n 16) dabigatran twice daily were analyzed with TEG®, HTI and ECT 2-3 h after dabigatran intake. All patients had prolonged TEG® R. The patients receiving dabigatran 110 mg ×2 had a TEG® R mean 14.2 min (range 9.1-25), a mean dabigatran concentration measured by HTI of 268.5 ng/mL (range 54-837 ng/mL) and by ECT of 355.7 ng/mL (range 40-1020 ng/mL). The corresponding numbers for patients receiving dabigatran 150 mg ×2 were TEG® R mean of 12.5 min (range 9.2-23.2 min), mean dabigatran concentration of 179.2 ng/mL by HTI (range 26-687 ng/mL) and by ECT 225.1 ng/mL (range 42-1020 ng/mL). The two dosage groups had comparable anticoagulation demonstrated by equally prolonged TEG® R (p = .909), HTI (p = .707) and ECT (p = .567). No difference in creatinine levels in the two dosage groups was observed (p = .204) though patients with dabigatran concentration >400 ng/mL had significantly higher creatinine levels (p = .001). Large individual variation of the anticoagulant response was observed. Some patients had TEG® R values up to three times upper normal limit with immediate risk of bleeding. Our data indicate that TEG® R reflected dabigatran levels in NVAF patients and that TEG® R correlated to HTI and ECT.
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Affiliation(s)
- Sacha Solbeck
- a Section for Transfusion Medicine, Capital Region Blood Bank , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark
| | | | - Christian Maschmann
- c Emergency Department & Department of Anesthesia and Intensive Care , Copenhagen University Hospital Bispebjerg , Copenhagen , Denmark
| | - Jakob Stensballe
- a Section for Transfusion Medicine, Capital Region Blood Bank , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark.,d Department of Anaesthesiology, Centre of Head and Orthopaedics , Copenhagen University Hospital, Rigshospitalet , Copenhagen , Denmark
| | - Sisse Rye Ostrowski
- a Section for Transfusion Medicine, Capital Region Blood Bank , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark
| | - Pär I Johansson
- a Section for Transfusion Medicine, Capital Region Blood Bank , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark.,e Department of Surgery , University of Texas Health Medical School , Houston , TX , USA
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10
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Jeong YH, Bliden K, Shuldiner A, Tantry U, Gurbel P. Thrombin-induced platelet-fibrin clot strength: Relation to high on-clopidogrel platelet reactivity, genotype, and post-percutaneous coronary intervention outcomes. Thromb Haemost 2017; 111:713-24. [DOI: 10.1160/th13-08-0643] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 11/03/2013] [Indexed: 01/01/2023]
Abstract
SummaryThe relationship between thrombin-induced platelet-fibrin clot strength (MATHROMBIN), genotype and high on-treatment platelet reactivity (HPR) is unknown. The aim of this study is to assess the influence of MATHROMBIN measured by thrombelastography on HPR and long-term major adverse cardiovascular events (MACE) in percutaneous coronary intervention (PCI)-treated patients during aspirin and clopidogrel therapy. MATHROMBIN, platelet aggregation, genotype, and two-year MACE were assessed in 197 PCI-treated patients. HPR was defined as 5 µM ADP-induced PR46% measured by conventional aggregometry. Both high MATHROMBIN ( 68 mm) and CYP2C19*2 allele carriage were independently associated with ADP-induced platelet aggregation ([uni03B2] coefficient: 8.3% and 12.0%, respectively). The combination of CYP2C19*2 allele carriage and high MATHROMBIN increased the predictive value for the risk of HPR (odds ratio: 13.89; 95% confidence interval: 3.41 to 55.56; p < 0.001). MACE occurred in 25 patients (12.7%). HPR and high MATHROMBIN were both associated with MACE (hazard ratio: 3.09 and 2.24, respectively), and patients with both HPR and high MATHROMBIN showed an increased risk for MACE (adjusted hazard ratio: 5.56; 95% confidence interval: 1.85 to 16.67; p = 0.002). In conclusion, this is the first study to demonstrate that high platelet-fibrin clot strength is an independent determinant of HPR in PCI-treated patients. Combining the measurements of platelet aggregation and platelet-fibrin clot strength may enhance post-PCI risk stratification and deserves further study.
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11
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In-vitro assessment of the effect of dabigatran on thrombosis of adult and neonatal plasma. Blood Coagul Fibrinolysis 2017; 28:551-557. [DOI: 10.1097/mbc.0000000000000639] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Walsh M, Fritz S, Hake D, Son M, Greve S, Jbara M, Chitta S, Fritz B, Miller A, Bader MK, McCollester J, Binz S, Liew-Spilger A, Thomas S, Crepinsek A, Shariff F, Ploplis V, Castellino FJ. Targeted Thromboelastographic (TEG) Blood Component and Pharmacologic Hemostatic Therapy in Traumatic and Acquired Coagulopathy. Curr Drug Targets 2017; 17:954-70. [PMID: 26960340 PMCID: PMC5374842 DOI: 10.2174/1389450117666160310153211] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 10/13/2015] [Accepted: 12/15/2015] [Indexed: 12/17/2022]
Abstract
Trauma-induced coagulopathy (TIC) is a recently described condition which traditionally has been diagnosed by the common coagulation tests (CCTs) such as prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), platelet count, and fibrinogen levels. The varying sensitivity and specificity of these CCTs have led trauma coagulation researchers and clinicians to use Viscoelastic Tests (VET) such as Thromboelastography (TEG) to provide Targeted Thromboelastographic Hemostatic and Adjunctive Therapy (TTHAT) in a goal directed fashion to those trauma patients in need of hemostatic resuscitation. This review describes the utility of VETs, in particular, TEG, to provide TTHAT in trauma and acquired non-trauma-induced coagulopathy.
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Affiliation(s)
- Mark Walsh
- Memorial Hospital of South Bend, South Bend, Indiana 46601, USA.
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13
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Körber MK, Langer E, Köhr M, Wernecke KD, Korte W, von Heymann C. In vitro and ex vivo Measurement of Prophylactic Dabigatran Concentrations with a New Ecarin-Based Thromboelastometry Test. Transfus Med Hemother 2017; 44:100-105. [PMID: 28503126 DOI: 10.1159/000470622] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 03/16/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND An increasing number of oral anticoagulants has been approved, including dabigatran etexilate (DE). DE is a direct thrombin inhibitor that requires no routine monitoring, but, if necessary (e.g. urgent surgery etc.), the diluted thrombin time measured with Hemoclot® has shown reliable results. So far, no point-of-care (PoC) assay is available to measure DE effects. The EcaTEM assay uses ecarin to initiate the coagulation cascade at the step of thrombin generation and measures the clotting time (CT) by thromboelastometry. METHODS This study investigated the correlation of the EcaTEM with standard laboratory assays in dabigatran-treated patients. Ten patients undergoing total hip or knee arthroplasty were included in the study. DE for thromboprophylaxis was started 4 h after surgery. Blood samples were taken before surgery as well as 2, 6 and 12 h after ingestion on the 3rd postoperative day. Dabigatran concentration (Hemoclot), activated partial thromboplastin time, thrombin time and CT EcaTEM were measured. RESULTS Only CT EcaTEM and Hemoclot showed a correlation > 0.75 for all measurements. CONCLUSION CT EcaTEM appears a valid PoC method parameter to detect thrombin inhibition and thus the presence of dabigatran beside diluted thrombin time at different concentration levels. This may represent an opportunity to identify the presence of dabigatran, e.g., in emergency situations.
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Affiliation(s)
- Mareike Kristina Körber
- Department of Anesthesiology and Intensive Care Medicine, Charité -Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Elisabeth Langer
- Labor Berlin - Charite Vivantes GmbH Berlin, Berlin, Germany.,Institute for Laboratory Medicine, Clinical Chemistry and Pathobiochemistry, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Martin Köhr
- Department of Anesthesiology and Intensive Care Medicine, Charité -Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | | | - Wolfgang Korte
- Center for Laboratory Medicine; and Hemostasis and Hemophilia Center St. Gallen, Switzerland
| | - Christian von Heymann
- Department of Anesthesiology and Intensive Care Medicine, Charité -Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany.,Department of Anesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Netzwerk für Gesundheit GmbH, Klinikum im Friedrichshain, Berlin, Germany
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14
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Thrombelastography detects dabigatran at therapeutic concentrations in vitro to the same extent as gold-standard tests. Int J Cardiol 2016; 208:14-8. [DOI: 10.1016/j.ijcard.2016.01.148] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 11/21/2022]
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15
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Dale BJ, Chan NC, Eikelboom JW. Laboratory measurement of the direct oral anticoagulants. Br J Haematol 2015; 172:315-36. [DOI: 10.1111/bjh.13810] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Brian J. Dale
- School of Pharmacy and Medical Sciences; University of South Australia; Adelaide South Australia Australia
| | - Noel C. Chan
- Population Health Research Institute; Hamilton Ontario Canada
| | - John W. Eikelboom
- Population Health Research Institute; Hamilton Ontario Canada
- Department of Medicine; McMaster University; Hamilton Ontario Canada
- Thrombosis and Atherosclerosis Research Institute; Hamilton Ontario Canada
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16
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More efficient reversal of dabigatran inhibition of coagulation by activated prothrombin complex concentrate or recombinant factor VIIa than by four-factor prothrombin complex concentrate. Thromb Res 2015; 135:544-7. [DOI: 10.1016/j.thromres.2014.12.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 12/05/2014] [Accepted: 12/23/2014] [Indexed: 11/24/2022]
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17
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Monitoring of dabigatran anticoagulation and its reversal in vitro by thrombelastography. Int J Cardiol 2014; 176:794-9. [DOI: 10.1016/j.ijcard.2014.07.084] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 06/26/2014] [Accepted: 07/26/2014] [Indexed: 11/18/2022]
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18
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Emergency surgery and trauma in patients treated with the new oral anticoagulants. J Trauma Acute Care Surg 2014; 77:486-94; quiz 486-94. [DOI: 10.1097/ta.0000000000000360] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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van Ryn J, Grottke O, Spronk H. Measurement of dabigatran in standardly used clinical assays, whole blood viscoelastic coagulation, and thrombin generation assays. Clin Lab Med 2014; 34:479-501. [PMID: 25168938 DOI: 10.1016/j.cll.2014.06.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Dabigatran, a direct thrombin inhibitor, is increasingly used clinically as one of the new oral anticoagulants. This review summarizes the assays available to measure its activity and includes the relative sensitivity of the different assays for this agent. In addition to plasma-based clotting tests, assays commonly used in surgical/emergency settings, such as activated clotting time and thromboelastometry/thromboelastography, are reviewed. In addition, the thrombin generation assay is discussed as an important method to determine the potential risk of thrombosis or bleeding and its relevance to the measurement of direct thrombin inhibitors.
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Affiliation(s)
- Joanne van Ryn
- Department of CardioMetabolic Disease Research, Boehringer Ingelheim Pharma GmbH & Co KG, Birkendorfer Street 65, Biberach 88397, Germany.
| | - Oliver Grottke
- Department of Anesthesiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, Aachen 52074, Germany
| | - Henri Spronk
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, PO Box 616, Maastricht 6200 MD, The Netherlands
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20
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Sølbeck S, Nilsson CU, Engström M, Ostrowski SR, Johansson PI. Dabigatran and its reversal with recombinant factor VIIa and prothrombin complex concentrate: A Sonoclot in vitro study. Scandinavian Journal of Clinical and Laboratory Investigation 2014; 74:591-8. [DOI: 10.3109/00365513.2014.921930] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Sacha Sølbeck
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen,
Copenhagen, Denmark
| | | | - Martin Engström
- Department of Anaesthesia and Intensive Care, Lund University,
Lund, Sweden
| | - Sisse R. Ostrowski
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen,
Copenhagen, Denmark
| | - Pär I. Johansson
- Section for Transfusion Medicine, Capital Region Blood Bank, Rigshospitalet, University of Copenhagen,
Copenhagen, Denmark
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21
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STEIN P, BOSSHART M, BRAND B, SCHLICKER A, SPAHN DR, BETTEX D. Dabigatran anticoagulation and Stanford type A aortic dissection: lethal coincidence: Case report with literature review. Acta Anaesthesiol Scand 2014; 58:630-7. [PMID: 24601892 DOI: 10.1111/aas.12303] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND Novel oral anticoagulants are now encountered in patients needing emergency surgery. Knowledge and treatment options are limited. METHODS AND RESULT We present the case of a 76-year-old patient who suffered from an acute Stanford type A aortic dissection, needing emergency surgical aortic repair. He was anticoagulated with dabigatran due to past atrial fibrillation. Despite haemodiafiltration, surgical revision and massive transfusion of packed red blood cells, fresh frozen plasma, platelets, coagulation factors, and recombinant factor VIIa, the patient died from intractable bleeding with sustained therapeutic levels of dabigatran. CONCLUSION After reviewing the literature, we summarize the limited treatment options and show possible approaches for patients treated with dabigatran needing emergency surgery.
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Affiliation(s)
- P. STEIN
- Institute of Anaesthesiology; University and University Hospital of Zurich; Zurich Switzerland
| | - M. BOSSHART
- Division of Cardiovascular Anaesthesia and Intensive Care; University and University Hospital of Zurich; Zurich Switzerland
| | - B. BRAND
- Division of Haematology; University and University Hospital of Zurich; Zurich Switzerland
| | - A. SCHLICKER
- Institute of Anaesthesiology; University and University Hospital of Zurich; Zurich Switzerland
| | - D. R. SPAHN
- Institute of Anaesthesiology; University and University Hospital of Zurich; Zurich Switzerland
| | - D. BETTEX
- Division of Cardiovascular Anaesthesia and Intensive Care; University and University Hospital of Zurich; Zurich Switzerland
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23
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Sarma A, Rossi JE, Connors JM, Giugliano RP. Dabigatran excess: case report and review of the literature. Cardiol Ther 2013; 2:111-24. [PMID: 25135294 PMCID: PMC4107435 DOI: 10.1007/s40119-013-0016-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Novel oral anticoagulants are increasingly used for stroke prophylaxis in patients with non-valvular atrial fibrillation. While these agents offer a more predictable pharmacokinetic profile, the lack of readily available laboratory tests to monitor the level of anticoagulation and absence of an antidote or established therapies to reverse the anticoagulant effect make management of cases of over-anticoagulation challenging. CASE REPORT In this case report an 87-year-old man with a history of atrial fibrillation presented with dabigatran excess in the setting of life-threatening, acute renal and hepatic failure. The authors review the use of dabigatran in elderly patients, the available data on management of patients with excess anticoagulation, and the potential options for reversal of the anticoagulation effect. CONCLUSION Further investigation into reliable means of monitoring and reversing the anticoagulant effect of dabigatran is crucial to the management of such patients.
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Affiliation(s)
- Amy Sarma
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Jeffrey E. Rossi
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Jean M. Connors
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Hematology Division, Brigham and Women’s Hospital, Boston, MA USA
| | - Robert P. Giugliano
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA USA
- TIMI Study Office, 350 Longwood Avenue, 1st Floor Offices, Boston, MA 02115 USA
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Aron JL, Gosselin R, Moll S, Arkin CF, Mantha S. Effects of recombinant factor VIIa on thrombin generation and thromboelastography in a patient with dabigatran-associated intracranial hemorrhage. J Thromb Thrombolysis 2013; 37:76-9. [DOI: 10.1007/s11239-013-0913-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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