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Santana-Otero A, Harper A, Telling N, Ortega D, Cabrera D. Magnetic coagulometry: towards a new nanotechnological tool for ex vivo monitoring coagulation in human whole blood. NANOSCALE 2024; 16:3534-3548. [PMID: 38285061 PMCID: PMC10868660 DOI: 10.1039/d3nr02593d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 12/19/2023] [Indexed: 01/30/2024]
Abstract
Blood clotting disorders consisting of unwanted blood clot formation or excessive bleeding are some of the main causes of death worldwide. However, there are significant limitations in the current methods used to clinically monitor the dynamics of clot formation in human whole blood ex vivo. Here a new magnetic coagulometry platform for testing ex vivo coagulation is described. This platform exploits the sensitivity of the out-of-phase component of alternating current (AC) magnetic susceptibility (χ'') to variations in mobility and agglomeration of magnetic nanoparticles when trapped during blood clot formation. By labelling human whole blood with magnetic nanoparticles, the out-of-phase component of AC magnetic susceptibility shows that the dynamics of blood clot formation correlates with a decrease in the out-of-phase component χ'' over time activation of coagulation. This is caused by a rapid immobilisation of nanoparticles upon blood coagulation and compaction. In contrast, this rapid fall in the out-of-phase component χ'' is significantly slowed down when blood is pre-treated with three different anticoagulant drugs. Remarkably, the system showed sensitivity towards the effect of clinically used direct oral anticoagulation (DOAC) drugs in whole blood coagulation, in contrast to the inability of clinical routine tests prothrombin time (PT) and partial thromboplastin time (PTT) to efficiently monitor this effect. Translation of this nanomagnetic approach into clinic can provide a superior method for monitoring blood coagulation and improve the efficiency of the current diagnostic techniques.
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Affiliation(s)
- Antonio Santana-Otero
- Condensed Matter Physics Department, Faculty of Sciences, University of Cádiz, Campus Universitario Rio San Pedro s/n, 11510 Puerto Real, Cádiz, Spain.
| | - Alan Harper
- School of Medicine, Keele University, Newcastle-under-Lyme, Staffordshire. ST5 5BG, UK
| | - Neil Telling
- School of Pharmacy and Bioengineering, Keele University, Guy Hilton Research Centre, Thronburrow Drive, Hartshill, Stoke on Trent, ST47QB, UK.
| | - Daniel Ortega
- Condensed Matter Physics Department, Faculty of Sciences, University of Cádiz, Campus Universitario Rio San Pedro s/n, 11510 Puerto Real, Cádiz, Spain.
- iMdea Nanociencia, Campus Universitario de Cantoblanco. C/Faraday, 9, 28049, Madrid, Spain
- Institute of Research and Innovation in Biomedical Sciences of Cádiz (INiBICA), University of Cádiz, 11002, Cádiz, Spain
| | - David Cabrera
- School of Pharmacy and Bioengineering, Keele University, Guy Hilton Research Centre, Thronburrow Drive, Hartshill, Stoke on Trent, ST47QB, UK.
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Lasica R, Asanin M, Djukanovic L, Radovanovic N, Savic L, Polovina M, Stankovic S, Ristic A, Zdravkovic M, Lasica A, Kravic J, Perunicic J. Dilemmas in the Choice of Adequate Therapeutic Treatment in Patients with Acute Pulmonary Embolism—From Modern Recommendations to Clinical Application. Pharmaceuticals (Basel) 2022; 15:ph15091146. [PMID: 36145366 PMCID: PMC9501350 DOI: 10.3390/ph15091146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 11/24/2022] Open
Abstract
Pulmonary thromboembolism is a very common cardiovascular disease, with a high mortality rate. Despite the clear guidelines, this disease still represents a great challenge both in diagnosis and treatment. The heterogeneous clinical picture, often without pathognomonic signs and symptoms, represents a huge differential diagnostic problem even for experienced doctors. The decisions surrounding this therapeutic regimen also represent a major dilemma in the group of patients who are hemodynamically stable at initial presentation and have signs of right ventricular (RV) dysfunction proven by echocardiography and positive biomarker values (pulmonary embolism of intermediate–high risk). Studies have shown conflicting results about the benefit of using fibrinolytic therapy in this group of patients until hemodynamic decompensation, due to the risk of major bleeding. The latest recommendations give preference to new oral anticoagulants (NOACs) compared to vitamin K antagonists (VKA), except for certain categories of patients (patients with antiphospholipid syndrome, mechanical valves, pregnancy). When using oral anticoagulant therapy, special attention should be paid to drug–drug interactions, which can lead to many complications, even to the death of the patient. Special population groups such as pregnant women, obese patients, patients with antiphospholipid syndrome and the incidence of cancer represent a great therapeutic challenge in the application of anticoagulant therapy. In these patients, not only must the effectiveness of the drugs be taken into account, but great attention must be paid to their safety and possible side effects, which is why a multidisciplinary approach is emphasized in order to provide the best therapeutic option.
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Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Correspondence:
| | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Nebojsa Radovanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Lidija Savic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Marija Polovina
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Sanja Stankovic
- Center for Medical Biochemistry, University Clinical Center of Serbia, 11000 Belgrade, Serbia
- Faculty of Medical Sciences, University of Kragujevac, 34000 Kragujevac, Serbia
| | - Arsen Ristic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | | | | | - Jelena Kravic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jovan Perunicic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Abstract
During sepsis, an initial prothrombotic shift takes place, in which coagulatory acute-phase proteins are increased, while anticoagulatory factors and platelet count decrease. Further on, the fibrinolytic system becomes impaired, which contributes to disease severity. At a later stage in sepsis, coagulation factors may become depleted, and sepsis patients may shift into a hypo-coagulable state with an increased bleeding risk. During the pro-coagulatory shift, critically ill patients have an increased thrombosis risk that ranges from developing micro-thromboses that impair organ function to life-threatening thromboembolic events. Here, thrombin plays a key role in coagulation as well as in inflammation. For thromboprophylaxis, low molecular weight heparins (LMWH) and unfractionated heparins (UFHs) are recommended. Nevertheless, there are conditions such as heparin resistance or heparin-induced thrombocytopenia (HIT), wherein heparin becomes ineffective or even puts the patient at an increased prothrombotic risk. In these cases, argatroban, a direct thrombin inhibitor (DTI), might be a potential alternative anticoagulatory strategy. Yet, caution is advised with regard to dosing of argatroban especially in sepsis. Therefore, the starting dose of argatroban is recommended to be low and should be titrated to the targeted anticoagulation level and be closely monitored in the further course of treatment. The authors of this review recommend using DTIs such as argatroban as an alternative anticoagulant in critically ill patients suffering from sepsis or COVID-19 with suspected or confirmed HIT, HIT-like conditions, impaired fibrinolysis, in patients on extracorporeal circuits and patients with heparin resistance, when closely monitored.
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Argatroban for Anticoagulation in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation in Coronavirus Disease 2019. Crit Care Explor 2021; 3:e0530. [PMID: 34514426 DOI: 10.1097/cce.0000000000000530] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A significant proportion of patients with coronavirus disease 2019 requiring venovenous extracorporeal membrane oxygenation at our institution demonstrated heparin resistance, which in combination with a heparin shortage resulted in the transition to argatroban with or without aspirin as an alternative anticoagulation strategy. The optimal anticoagulation strategy for coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation is unknown, and therefore, we sought to evaluate the efficacy and safety of argatroban with or without aspirin as an alternative anticoagulation strategy in this patient population. DESIGN Retrospective cohort. SETTING Single-center tertiary-care facility in Fort Sam Houston, TX, from 2020 to 2021. PATIENTS Twenty-four patients who were cannulated for venovenous extracorporeal membrane oxygenation due to respiratory failure secondary to coronavirus disease 2019. INTERVENTIONS Argatroban, with or without aspirin, was substituted for heparin in coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation. MEASUREMENTS AND MAIN RESULTS Eighty percent of our coronavirus disease 2019 patients requiring venovenous extracorporeal membrane oxygenation demonstrated heparin resistance, and patients who were initially started on heparin were significantly more likely to require a change to argatroban than vice versa due to difficulty achieving or maintaining therapeutic anticoagulation goals (93.4% vs 11.1%; p < 0.0001). The time to reach the therapeutic anticoagulation goal was significantly longer for patients who were initially started on heparin in comparison with argatroban (24 vs 6 hr; p = 0.0173). Bleeding and thrombotic complications were not significantly different between the two cohorts. CONCLUSIONS Argatroban, with or without aspirin, is an effective anticoagulation strategy for patients who require venovenous extracorporeal membrane oxygenation support secondary to coronavirus disease 2019. In comparison with heparin, this anticoagulation strategy was not associated with a significant difference in bleeding or thrombotic complications, and was associated with a significantly decreased time to therapeutic anticoagulation goal, likely as a result of high rates of heparin resistance observed in this patient population.
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Nilius H, Kaufmann J, Cuker A, Nagler M. Comparative effectiveness and safety of anticoagulants for the treatment of heparin-induced thrombocytopenia. Am J Hematol 2021; 96:805-815. [PMID: 33857342 PMCID: PMC8252596 DOI: 10.1002/ajh.26194] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND The effectiveness and safety of non-heparin anticoagulants for the treatment of heparin-induced thrombocytopenia (HIT) are not fully established, and the optimal treatment strategy is unknown. In a systematic review and meta-analysis, we aimed to determine precise rates of platelet recovery, new or progressive thromboembolism (TE), major bleeding, and death for all non-heparin anticoagulants and to study potential sources of variability. METHODS Following a detailed protocol (PROSPERO: CRD42020219027), EMBASE and Medline were searched for all studies reporting clinical outcomes of patients treated with non-heparin anticoagulants (argatroban, danaparoid, fondaparinux, direct oral anticoagulants [DOAC], bivalirudin, and other hirudins) for acute HIT. Proportions of patients with the outcomes of interest were pooled using a random-effects model for each drug. The influence of the patient population, the diagnostic test used, the study design, and the type of article was assessed. RESULTS Out of 3194 articles screened, 92 studies with 119 treatment groups describing 4698 patients were included. The pooled rates of platelet recovery ranged from 74% (bivalirudin) to 99% (fondaparinux), TE from 1% (fondaparinux) to 7% (danaparoid), major bleeding from 1% (DOAC) to 14% (bivalirudin), and death from 7% (fondaparinux) to 19% (bivalirudin). Confidence intervals were mostly overlapping, and results were not influenced by patient population, diagnostic test used, study design, or type of article. DISCUSSION Effectiveness and safety outcomes were similar among various anticoagulants, and significant factors affecting these outcomes were not identified. These findings support fondaparinux and DOACs as viable alternatives to conventional anticoagulants for treatment of acute HIT in clinical practice.
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Affiliation(s)
- Henning Nilius
- Department of Clinical ChemistryInselspital, Bern University HospitalBernSwitzerland
| | - Jonas Kaufmann
- Department of Clinical ChemistryInselspital, Bern University HospitalBernSwitzerland
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Michael Nagler
- Department of Clinical ChemistryInselspital, Bern University HospitalBernSwitzerland
- University of BernBernSwitzerland
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Colarossi G, Maffulli N, Trivellas A, Schnöring H, Hatam N, Tingart M, Migliorini F. Superior outcomes with Argatroban for heparin-induced thrombocytopenia: a Bayesian network meta-analysis. Int J Clin Pharm 2021; 43:825-838. [PMID: 33774764 PMCID: PMC8352815 DOI: 10.1007/s11096-021-01260-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 03/15/2021] [Indexed: 12/20/2022]
Abstract
Background Argatroban, lepirudin, desirudin, bivalirudin, and danaparoid are commonly used to manage heparin-induced thrombocytopenia related complications. However, the most suitable drug for this condition still remains controversial. Aim of the review This Bayesian network meta-analysis study compared the most common anticoagulant drugs used in the management of heparin-induced thrombocytopenia. Method All clinical trials comparing two or more anticoagulant therapies for suspected or confirmed heparin-induced thrombocytopenia were considered for inclusion. Studies concerning the use of heparins or oral anticoagulants were not considered. Data concerning hospitalisation length, thromboembolic, major, and minor haemorrhagic events, and mortality rate were collected. The network analyses were made through the STATA routine for Bayesian hierarchical random-effects model analysis with standardised mean difference (SMD) and log odd ratio (LOR) effect measures. Results Data from a total of 4338 patients were analysed. The overall mean age was 62.31 ± 6.6 years old. Hospitalization length was considerably shorter in favour of the argatroban group (SMD: − 1.70). Argatroban evidenced the lowest rate of major (LOR: − 1.51) and minor (LOR: − 0.57) haemorrhagic events. Argatroban demonstrated the lowest rate of thromboembolic events (LOR: 0.62), and mortality rate (LOR: − 1.16). Conclusion Argatroban performed better overall for selected patients with HIT. Argatroban demonstrated the shortest hospitalization, and lowest rate of haemorrhages, thromboembolisms, and mortality compared to bivalirudin, lepirudin, desirudin, and danaparoid.
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Affiliation(s)
- Giorgia Colarossi
- Department of Cardiac and Thoracic Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, 275 Bancroft Road, London, E1 4DG, England
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine At UCLA, Los Angeles, CA, USA
| | - Heike Schnöring
- Department of Cardiac and Thoracic Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Nima Hatam
- Department of Cardiac and Thoracic Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany
| | - Markus Tingart
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Filippo Migliorini
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Pauwelsstraße 30, 52074, Aachen, Germany.
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Colbaugh Z, Watts TE, Ahmed MI, Addis DR. Bivalirudin as a Systemic Anticoagulant and Flush Solution Additive for Sequential Mitral and Tricuspid Valve Percutaneous Edge-to-Edge Repair in a Patient With Heparin-Induced Thrombocytopenia. J Cardiothorac Vasc Anesth 2021; 36:1709-1714. [PMID: 33836962 DOI: 10.1053/j.jvca.2021.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/23/2021] [Accepted: 03/02/2021] [Indexed: 11/11/2022]
Abstract
Herein the case of a patient with a prior history of heparin-induced thrombocytopenia who underwent percutaneous mitral valve edge-to-edge repair that was followed by a tricuspid edge-to-edge repair two months later is presented. Recommendations exist for systemic anticoagulant alternatives for percutaneous mitral valve edge-to-edge repair with the MitraClip device (Abbott, Chicago, IL), but minimal guidance and experience are present regarding alternative systemic anticoagulation during the performance of right-sided interventions, including tricuspid edge-to-edge repair (TriClip; Abbott). Notably, there is no clear consensus regarding the use of an alternative anticoagulant in the catheter flush solution for the delivery systems used during these procedures, particularly for right-sided interventions.
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Affiliation(s)
- Zachary Colbaugh
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Thomas Evans Watts
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Mustafa I Ahmed
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Dylan R Addis
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL; Division of Molecular and Translational Biomedicine, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL; University of Alabama at Birmingham Comprehensive Cardiovascular Center, Birmingham, AL.
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Colarossi G, Schnöring H, Trivellas A, Betsch M, Hatam N, Eschweiler J, Tingart M, Migliorini F. Prognostic factors for patients with heparin-induced thrombocytopenia: a systematic review. Int J Clin Pharm 2020; 43:449-460. [PMID: 33044680 DOI: 10.1007/s11096-020-01166-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/23/2020] [Indexed: 10/23/2022]
Abstract
Background Little is known with regards to the prognostic factors for patients with suspected or diagnosed Heparin-Induced Thromobocytopenia (HIT). The role of patient and therapy characteristics may play a role in predicting the outcome. Aim of the review To investigate the role of patient and therapy characteristics as potential prognostic factors for HIT-related complications (haemorrhagic and thromboembolic events), and mortality. Method The present systematic review was conducted according to the PRISMA statement. In September 2020, the main online databases were accessed: Pubmed, EMBASE, Scopus, Google Scholar. All the clinical trials concerning the management of patients with suspected or confirmed HIT were eligible. Studies evaluating the use of oral anticoagulants (e.g. vitamin K antagonists, Apixaban) were not considered, along with those comparing the use of heparin. For pairwise correlation, the Pearson Product-Moment Correlation Coefficient (r) was used. The final effect was evaluated according to the Cauchy-Schwarz inequality.Results Data from 33 clinical studies (4338 patients) were retrieved. The overall mean age was 62.3 ± 6.6 years old. Patients with HIT-related thromboembolism at the moment of diagnosis were associated with greater rate of haemorrhages (P > 0.0001), thromboembolism (P > 0.0001) and mortality (P = 0.001). Patients with more comorbidities at diagnosis were associated with a greater risk of haemorrhages (P = 0.07), thromboembolism (P = 0.002) and mortality (P = 0.002). Patients with longer duration of the therapy were associated with lower rate of mortality (P = 0.04). ConclusionsPatient comorbidities, presence of HIT-related thromboembolism on admission and shorter anticoagulant therapy were found to be negative prognostic factors. Thrombocythemia on admission, patients age and gender did not influence the overall outcome.
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Affiliation(s)
- Giorgia Colarossi
- Department of Cardiac and Thoracic Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Heike Schnöring
- Department of Cardiac and Thoracic Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Andromahi Trivellas
- Department of Orthopaedics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Marcel Betsch
- Women´s College Hospital, University of Toronto Orthopaedic Sports Medicine Program (UTOSM), Toronto, ON, Canada
| | - Nima Hatam
- Department of Cardiac and Thoracic Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Jörg Eschweiler
- Department of Orthopaedics Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Markus Tingart
- Department of Orthopaedics Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany
| | - Filippo Migliorini
- Department of Orthopaedics Surgery, RWTH Aachen University Clinic, Pauwelstr. 31, Aachen, 52074, Germany.
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