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Kanji R, Vandenbriele C, Arachchillage DRJ, Price S, Gorog DA. Optimal Tests to Minimise Bleeding and Ischaemic Complications in Patients on Extracorporeal Membrane Oxygenation. Thromb Haemost 2022; 122:480-491. [PMID: 33984868 DOI: 10.1055/a-1508-8230] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Patients supported with extracorporeal membrane oxygenation (ECMO) experience a very high frequency of bleeding and ischaemic complications, including stroke and systemic embolism. These patients require systemic anticoagulation, mainly with unfractionated heparin (UFH) to prevent clotting of the circuit and reduce the risk of arterial or venous thrombosis. Monitoring of UFH can be very challenging. While most centres routinely monitor the activated clotting time and activated partial thromboplastin time (aPTT) to assess UFH, measurement of anti-factor Xa (anti-Xa) level best correlates with heparin dose, and appears to be predictive of circuit thrombosis, although aPTT may be a better predictor of bleeding. Although monitoring of prothrombin time, platelet count and fibrinogen is routinely undertaken to assess haemostasis, there is no clear guidance available regarding the optimal test.Additional tests, including antithrombin level and thromboelastography, can be used for risk stratification of patients to try and predict the risks of thrombosis and bleeding. Each has their specific role, strengths and limitations. Increased thrombin generation may have a role in predicting thrombosis. Acquired von Willebrand syndrome is frequent with ECMO, contributing to bleeding risk and can be detected by assessing the von Willebrand factor activity-to-antigen ratio, while the platelet function analyser can be used in urgent situations to detect this, with a high negative predictive value. Tests of platelet aggregation can aid in the prediction of bleeding.To personalise management, a selection of complementary tests to collectively assess heparin-effect, coagulation, platelet function and platelet aggregation is proposed, to optimise clinical outcomes in these high-risk patients.
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Affiliation(s)
- Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.,Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
| | - Deepa R J Arachchillage
- Haematology Department, Royal Brompton Hospital, London, United Kingdom.,Centre for Haematology, Imperial College Healthcare NHS Trust & Imperial College, London, United Kingdom
| | - Susanna Price
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom.,Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
| | - Diana Adrienne Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
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2
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A pilot study evaluating the Calibrated Automated Thrombogram assay and application of plasma-thromboelastography for detection of hemostatic aberrations in horses with gastrointestinal disease. BMC Vet Res 2021; 17:346. [PMID: 34749707 PMCID: PMC8573990 DOI: 10.1186/s12917-021-03058-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/19/2021] [Indexed: 01/15/2023] Open
Abstract
Background Critically ill horses, such as horses with gastrointestinal (GI) disease, often suffer from hemostatic aberrations. Global hemostatic tests examining the initiation of coagulation, clot strength and fibrinolysis, such as the Calibrated Automated Thrombogram (CAT) and plasma-thromboelastography (TEG) have not been evaluated in horses. This study aimed to evaluate CAT and apply plasma-TEG in horses. Test performance of CAT was evaluated on equine platelet poor plasma with intra- and inter-assay variability (CV) and a heparin dilution curve. To examine clinical performance of both tests, group comparisons were assessed comparing healthy horses, horses with mild and severe GI disease with both CAT and plasma-TEG. Results For CAT, intra- and inter-assay CVs were established for lag-time (1.7, 4.7%), endogenous thrombin potential (1.6, 4.6%), peak (2.6, 3.9%) and time to peak (ttPeak) (1.9, 3.4%). Increasing heparin concentrations led to the expected decrease in thrombin generation. In the group comparison analysis, CAT showed significant higher peak (p = 0.04) and ttPeak (p = 0.008) in the severe GI disease group compared to horses with mild GI disease and healthy horses, respectively. Plasma-TEG showed an increased angle (p = 0.032), maximum amplitude (p = 0.017) and shear elastic force (G) (p = 0.017) in the severe GI disease group compared to healthy horses. Conclusions CAT performed well in horses. Both CAT and plasma-TEG identified hemostatic aberrations in horses with severe GI disease compared to healthy horses. Further studies including more horses, are needed to fully appreciate the use of CAT and plasma-TEG in this species. Supplementary Information The online version contains supplementary material available at 10.1186/s12917-021-03058-7.
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van der Bruggen MM, Kremers B, van Oerle R, van Oostenbrugge RJ, Ten Cate H. Potential value of the calibrated automated thrombogram in patients after a cerebral venous sinus thrombosis; an exploratory study. Thromb J 2021; 19:81. [PMID: 34736478 PMCID: PMC8567338 DOI: 10.1186/s12959-021-00335-1] [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: 07/28/2021] [Accepted: 10/21/2021] [Indexed: 11/24/2022] Open
Abstract
Background Cerebral venous sinus thrombosis (CVST) is a relatively rare, but potentially lethal condition. In approximately 15% of the patients, the cause of CVST remains unclear. Conventional clotting tests such as prothrombin time and activated partial thromboplastin time are not sensitive enough to detect prothrombotic conditions nor mild haemostatic abnormalities. The calibrated automated thrombogram (CAT) is a physiological function test that might be able to detect minor aberrations in haemostasis. Therefore, we aimed to detect the presence of a prothrombotic state in patients who endured idiopathic CVST with the CAT assay. Methods Five adult patients with an idiopathic, radiologically proven CVST that had been admitted during the past 3 years were included in this study. The control group consisted of five age/gender matched healthy volunteers. Exclusion criteria were known haematological disorders, malignancy (current/past) or hormonal and anticoagulant therapy recipients. We obtained venous blood samples from all participants following cessation of anticoagulation. Using the CAT assay, we determined lag time, normalized endogenous thrombin potential (ETP), ETP reduction and normalized peak height. In addition, prothrombin concentrations were determined. Results We found no significant differences in lag time (4.7 min [4.5–4.9] vs 5.3 min [3.7–5.7], p = 0.691), normalized ETP (142% [124–148] vs 124% [88–138], p = 0.222), ETP reduction (29% [26–35] vs 28% [24–58], p > 0.999), and normalized peak height (155% [153–175] vs 137 [94–154], p = 0.056) between patients and their age/gender matched controls. In addition, prothrombin concentrations did not significantly differ between patients and controls (120% [105–132] vs 127% [87–139], p > 0.999). Conclusion Reasons for absent overt hypercoagulability within this study population may be the small patient sample, long time since the event (e.g. 3 years) and avoidance of acquired risk factors like oral contraception. Given the fact that CVST is a serious condition with a more than negligible risk of venous thrombosis event recurrence, exclusion of clinically relevant hypercoagulability remains a challenging topic to further study at the acute and later time points, particularly in patients with idiopathic CVST.
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Affiliation(s)
- Myrthe M van der Bruggen
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Bram Kremers
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands
| | - Rene van Oerle
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,Clinical Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, the Netherlands
| | | | - Hugo Ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands. .,Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.
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Gerotziafas GT, Zografos T, Pantos I, Lefkou E, Carlo A, Fareed J, Van Dreden P, Katritsis D. Prospective Assessment of Biomarkers of Hypercoagulability for the Identification of Patients With Severe Coronary Artery Disease. The ROADMAP-CAD Study. Clin Appl Thromb Hemost 2021; 26:1076029620964590. [PMID: 33284037 PMCID: PMC7724406 DOI: 10.1177/1076029620964590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
In patients with stable coronary artery disease (CAD) blood hypercoagulability
figures among factors leading to thrombosis. Tissue factor (TF) exposure at
ruptured plaque initiates blood coagulation and hypercoagulability is
responsible for thrombus formation. Early identification of patients eligible
for angiography is a challenging issue for effective prevention of ACS. This
pilot study aimed to identify biomarkers of hypercoagulability that can be
prospectively used in risk assessment tools for the evaluation of CAD severity.
Biomarkers of hypercoagulability could be a used for the evaluation of CAD
severity. Platelet-poor plasma from 66 patients who were referred to coronary
angiography was assessed for thrombin generation, phospholipid-dependent
clotting time (Procoag-PPL®) and D-Dimers, and evaluated against atherosclerotic burden.
Patients with CAD, as compared to controls, showed attenuated thrombin
generation lag time: 4.7 (3.8-5.4) min versus 2.5 (2.1-2.9) min; p < 0.0001,
shorter Procoag-PPL® clotting time 55.0(32-66) s versus 62.8 (42-85)
s; p = 0.001), and higher D-Dimer levels 0.509 (0.27-2.58) μg/ml versus 0.309
(0.23-0.39) μg/ml; p = 0.038. Multivariate logistic regression model showed
excellent discriminatory value in predicting CAD severity. The ROADMAP-CAD study
showed that the Procoag-PPL® clotting time and thrombin Peak are
informative for the the burden of the coronary atherosclerotic disease. The
clinical relevance of this observation in the development of a new
clinic-biological risk assessment model for early diagnosis of severe CAD has to
be examined in a prospective study.
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Affiliation(s)
- Grigoris T Gerotziafas
- Sorbonne Université, 27102INSERM UMR_938 Cancer Biology and T, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Paris, France.,Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Paris, France.,Department of Hematology and Cell Therapy, Saint Antoine Hospital, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Theodoros Zografos
- 3 rd Cardiology Clinic, Hygeia Hospital, Hellenic Healthcare Group, Athens, Greece
| | - Ioannis Pantos
- Radiology Department, "Amalia Flemig" General Hospital, Melissia, Greece
| | - Eleftheria Lefkou
- Sorbonne Université, 27102INSERM UMR_938 Cancer Biology and T, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Paris, France
| | | | - Jawed Fareed
- Department of Pathology, Cardiovascular Institute 2456Loyola University Chicago, Maywood, IL, USA
| | - Patrick Van Dreden
- Clinical Research Department, 33289Diagnostica Stago, Gennevilliers, France
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Wang H, Rosendaal FR, Cushman M, van Hylckama Vlieg A. D-dimer, thrombin generation, and risk of a first venous thrombosis in the elderly. Res Pract Thromb Haemost 2021; 5:e12536. [PMID: 34263100 PMCID: PMC8268666 DOI: 10.1002/rth2.12536] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/14/2021] [Accepted: 04/21/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A high D-dimer level and parameters of the thrombin generation (TG) potential are associated with the risk of a first venous thrombosis (VT) in young and middle-aged populations. OBJECTIVES To investigate whether D-dimer and TG potential (lag-time, time-to-peak [ttPeak], peak thrombin, endogenous thrombin potential [ETP], and velocity index), are associated with the risk of a first VT in those aged 70 years and older. METHODS We included 215 patients with a first VT and 358 controls, all aged >70 years, from the Age and Thrombosis, Acquired and Genetic Risk Factors in the Elderly (AT-AGE) study. To assess the risk of VT, odds ratios with 95% confidence intervals (CIs) were estimated using logistic regression analysis. RESULTS D-dimer and all TG parameters except lag time were associated with an increased risk of VT in a dose-response manner. Comparing the fourth with the first quartile (for ttPeak comparing the first with the fourth quartile), risk estimates were: 7.8 (95% CI, 4.0-15.0) for peak, 2.0 (95% CI, 1.2-3.3) for ttPeak, 9.1 (95% CI, 4.4-18.9) for ETP, and 11.5 (95% CI, 5.7-23.3) for velocity index. Comparing the highest quartile of D-dimer with the lowest, the risk was 7.7-fold increased (95% CI, 4.0-14.8). Furthermore, all factors also increased the risk of VT after dichotomizing at more extreme cutoff values. The risk of VT was further increased in the presence of multiple prothrombotic TG parameters and elevated D-dimer level or in combination with prothrombotic mutations. CONCLUSIONS D-dimer and TG parameters (except lag time) are associated with the risk of first VT in elderly population.
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Affiliation(s)
- Huijie Wang
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Frits R. Rosendaal
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Mary Cushman
- Department of MedicineLarner College of Medicine at the University of VermontBurlingtonVermontUSA
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Abstract
The serine protease thrombin, a naturally derived enzyme, plays a key role in hemostasis by converting fibrinogen to fibrin and activating coagulation factor XIII whereby the fibrin clot is stabilized. Furthermore, thrombin activates platelets through protease-activated receptors on the platelet surface. Conversely, thrombin also exerts anticoagulant effects, enhancing the protein C activity while complexed with thrombomodulin. During recent years, it has become evident that thrombin has significant effects beyond hemostasis, as it contributes also to modulation of the endothelium, promotes inflammation and angiogenesis, and plays a role in tumor progression. Yet, due to the very short half-life and almost immediate inhibition in fluid phase by antithrombin, thrombin itself remains elusive, and only indirect measurement of thrombin generation is possible. This review provides a description of structure and mechanisms of action of thrombin both in physiological and pathological processes. Furthermore, it summarizes laboratory tests that measure in vivo or ex vivo thrombin generation, and presents knowledge on the value of these biomarkers in bleeding disorders, cardiopulmonary bypass surgery, and thromboembolic risk assessment in different patient populations. Finally, this review outlines further perspectives on using thrombin generation biomarkers for research purposes and in clinical practice.
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Affiliation(s)
- Julie Brogaard Larsen
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Abstract
Coronary artery disease is a leading cause of morbidity and mortality worldwide. Despite significant advances in revascularization strategies and antiplatelet therapy with aspirin and/or P2Y12 receptor antagonist, patients with acute coronary syndrome (ACS) continue to be at long-term risk of further cardiovascular events. Besides platelet activation, the role of thrombin generation (TG) in atherothrombotic complications is widely recognized. In this study, we hypothesized that there is an elevation of coagulation activation persists beyond 12 months in patients with ACS and chronic coronary syndrome (CCS) when compared with healthy controls. We measured TG profiles of patients within 72 h after percutaneous coronary intervention, at 6-month, 12-month and 24-month. Our results demonstrated that TG of patients with ACS (n = 114) and CCS (n = 40) were persistently elevated when compared to healthy individuals (n = 50) in peak thrombin (ACS 273.1 nM vs CCS 287.3 nM vs healthy 234.3 nM) and velocity index (ACS 110.2 nM/min vs CCS 111.0 nM/min vs healthy 72.9 nM/min) at 24-month of follow-up. Our results suggest a rationale for addition of anticoagulation to antiplatelet therapy in preventing long-term ischemic events after ACS. Further research could clarify whether the use of TG parameters to enable risk stratification of patients at heightened long-term procoagulant risk who may benefit most from dual pathway inhibition.
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Farm M, Antovic A, Schmidt DE, Bark N, Soutari N, Siddiqui AJ, Holmström M, Pruner I, Antovic JP. Diagnostic Accuracy in Acute Venous Thromboembolism: Comparing D-Dimer, Thrombin Generation, Overall Hemostatic Potential, and Fibrin Monomers. TH OPEN 2020; 4:e178-e188. [PMID: 32844145 PMCID: PMC7440969 DOI: 10.1055/s-0040-1714210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 06/09/2020] [Indexed: 11/13/2022] Open
Abstract
Introduction
For acute venous thromboembolism (VTE), a biomarker with higher specificity than D-dimer would be of great clinical use. Thrombin generation and overall hemostatic potential (OHP) reflect the hemostatic balance by globally assessing multiple coagulation factors and inhibitors. These tests discriminate between healthy controls and patients with a prothrombotic tendency but have yet to be established as clinical biomarkers of VTE.
Objective
This study compares endogenous thrombin potential (ETP) and OHP to D-dimer and fibrin monomers (FM) in outpatients with suspected VTE.
Methods
A cross-sectional diagnostic study where 954 patients with suspected pulmonary embolism or deep venous thrombosis were recruited consecutively from the medical emergency department at Karolinska University Hospital. D-dimer, FM, OHP, and ETP were analyzed in a subpopulation of 60 patients with VTE and 98 matched controls without VTE. VTE was verified either by ultrasonography or computed tomography and clinical data were collected from medical records.
Results
Compared with healthy controls, both VTE and non-VTE patients displayed prothrombotic profiles in OHP and ETP. D-dimer, FM, ETP area under the curve (AUC), and ETP T
lag
were significantly different between patients with VTE and non-VTE. The largest receiver-operating characteristic AUCs for discrimination between VTE and non-VTE, were found in D-dimer with 0.94, FM 0.77, and ETP AUC 0.65. No useful cutoff could be identified for the ETP or the OHP assay.
Conclusion
Compared with D-dimer, neither ETP nor OHP were clinically viable biomarkers of acute venous thrombosis. The data indicated that a large portion of the emergency patients with suspected VTE were in a prothrombotic state.
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Affiliation(s)
- Maria Farm
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Aleksandra Antovic
- Rheumatology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Academic Specialist Center, Center for Rheumatology, Stockholm Health Services, Stockholm, Sweden
| | - David E Schmidt
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden.,Coagulation Unit, Division of Haematology, Karolinska University Hospital, Stockholm, Sweden
| | - Niklas Bark
- Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Nida Soutari
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
| | - Anwar J Siddiqui
- Emergency Medicine Function, Karolinska University Hospital, Stockholm, Sweden
| | - Margareta Holmström
- Division of Diagnostics and Specialist Medicine, Unit of Internal Medicine, Medicine and Caring Sciences, Department of Health, Linköping University, Linköping, Sweden
| | - Iva Pruner
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Jovan P Antovic
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden
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Riva N, Vella K, Hickey K, Bertù L, Zammit D, Spiteri S, Kitchen S, Makris M, Ageno W, Gatt A. Biomarkers for the diagnosis of venous thromboembolism: D-dimer, thrombin generation, procoagulant phospholipid and soluble P-selectin. J Clin Pathol 2018; 71:1015-1022. [PMID: 30093507 DOI: 10.1136/jclinpath-2018-205293] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/03/2018] [Accepted: 07/16/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND The diagnostic algorithm for venous thromboembolism (VTE) currently involves a composite of pre-test probability, D-dimer and imaging. Other laboratory tests, however, may assist in the identification of patients with VTE. AIM To assess the accuracy of different coagulation tests (D-dimer, thrombin generation, phospholipid-dependent (PPL) clotting time, soluble P-selectin (sP-selectin)) as biomarkers of acute VTE. METHODS Random samples arriving at the Coagulation Laboratory at Mater Dei Hospital (Msida, Malta) from the Accident and Emergency Department with a request for D-dimer measurement were collected between August 2015 and February 2016. The following tests were performed: Innovance D-dimer (Siemens Healthcare Diagnostics), HemosIL D-dimer HS (Instrumentation Laboratory), thrombin generation (using the calibrated automated thrombogram), STA Procoag PPL (Diagnostica Stago) and sP-selectin (Affymetrix; eBioscience). VTE was objectively confirmed by compression ultrasonography, CT pulmonary angiography or ventilation/perfusion lung scan. RESULTS 100 samples were collected (33 with VTE). A strong positive linear correlation was found between the two D-dimer tests (r=0.97, p<0.001). Patients with VTE showed significantly higher sP-selectin concentrations compared with patients without VTE (75.7 ng/mL vs 53.0 ng/mL, p<0.001). In the random forest plot, the two D-dimer assays showed the highest variable importance, followed by sP-selectin. A sP-selectin cut-off of 74.8 ng/mL was associated with 72.7% sensitivity and 78.2% specificity for acute VTE in our cohort. CONCLUSION Our results confirmed D-dimer as the main biomarker of VTE and speculated a role for sP-selectin. The impact of thrombin generation was limited and no role emerged for the PPL clotting time. These observations need to be confirmed in large management studies.
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Affiliation(s)
- Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Kevin Vella
- Coagulation Medicine Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta
| | - Kieron Hickey
- Sheffield Haemophilia and Thrombosis Centre, University of Sheffield, Sheffield, UK
| | - Lorenza Bertù
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Daniel Zammit
- Coagulation Medicine Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta
| | - Silvana Spiteri
- Coagulation Medicine Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta
| | - Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre, University of Sheffield, Sheffield, UK
| | - Michael Makris
- Sheffield Haemophilia and Thrombosis Centre, University of Sheffield, Sheffield, UK
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta .,Coagulation Medicine Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta
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