A survey of heparin monitoring in Australasia

Evolution of Hemostasis Testing: A Personal Reflection Covering over 40 Years of History

There is no certainty in change, other than change is certain. As Seminars in Thrombosis and Hemostasis celebrates 50 years of publication, I felt it appropriate to reflect on my own 40-year plus scientific career. My career in the thrombosis and hemostasis field did not start until 1987, but the subsequent 35 years reflected a period of significant change in associated disease diagnostics. I started in the Westmead Hospital "coagulation laboratory" when staff were still performing manual clotting tests, using stopwatches, pipettes, test tubes, and a water bath, which we transported to the hospital outpatient department to run our weekly warfarin clinic. Several hemostasis instruments have come and gone, including the Coag-A-Mate X2, the ACL-300R, the MDA-180, the BCS XP, and several StaR Evolution analyzers. Some instruments remain, including the PFA-100, PFA-200, the AggRAM, the CS-5100, an AcuStar, a Hydrasys gel system, and two ACL-TOP 750s. We still have a water bath, but this is primarily used to defrost frozen samples, and manual clotting tests are only used to teach visiting medical students. We have migrated across several methodologies in the 45-year history of the local laboratory. Laurel gel rockets, used for several assays in the 1980s, were replaced with enzyme-linked immunosorbent assay assays and most assays were eventually placed on automated instruments. Radio-isotopic assays, used in the 1980s, were replaced by an alternate safer method or else abandoned. Test numbers have increased markedly over time. The approximately 31,000 hemostasis assays performed at the Westmead-based laboratory in 1983 had become approximately 200,000 in 2022, a sixfold increase. Some 90,000 prothrombin times and activated partial thromboplastic times are now performed at this laboratory per year. Thrombophilia assays were added to the test repertoires over time, as were the tests to measure several anticoagulant drugs, most recently the direct oral anticoagulants. I hope my personal history, reflecting on the changes in hemostasis testing over my career to date in the field, is found to be of interest to the readership, and I hope they forgive any inaccuracies I have introduced in this reflection of the past.

How useful is the monitoring of (low molecular weight) heparin therapy by anti-Xa assay? A laboratory perspective

We have conducted a series of laboratory-based surveys to assess variability in assay results utilized to monitor heparin anticoagulant therapy. These surveys involved laboratories participating in the Haematology component of the Royal College of Pathologists of Australasia Quality Assurance Program (RCPA QAP). Thirty five of 646 laboratories that were sent a preliminary questionnaire indicated that they performed anti-Xa assays and these laboratories were sent a panel of four plasma samples. These plasma samples contained respectively: (i) no added heparin, (ii) low molecular weight heparin (LMWH), enoxaparin, added to a level of approximately .5 U/mL, (iii) unfractionated heparin added to a level of approximately .5 U/mL, and (iv) LMWH added to a level of approximately 1.0 U/mL. Tests to be performed were the activated partial thromboplastin time (APTT), the thrombin time (TT), fibrinogen, and anti-Xa. As expected, returned results for APTT and TT showed some elevation in heparinized samples while fibrinogen assays were not affected. Anti-Xa assays yielded the following results (median [range]): (i) .01 [0-.11], (ii) .43 [.33-.80], (iii) .23 [.10-.49], and (iv) .90 [.60-1.30]. Thus, although median values were close to those anticipated, there was a wide variation in returned results. In a repeat exercise a few months later laboratories were also asked about their therapeutic ranges (TRs) and provided with an additional vial of LMWH-spiked (1.0 U/mL) plasma labeled as 'heparin-standard' to be used as an assay calibrant. TRs varied substantially between laboratories, from low ranges of .2-.4 to high ranges of .8-1.2. Anti-Xa assay results were similar to those of the first survey: (median [range]): (a) repeat testing: (i) .02 [0-.28], (ii) .47 [.34-.80], (iii) .25 [.14-.58], (iv) .95 [.65-1.31]; (b) repeat testing using survey provided 'heparin-standard': (i) .02 [0-.24], (ii) .55 [.4-.83], (iii) .28 [.10-.63], (iv) 1.00 [.9-1.16]. Thus using the provided 'heparin-standard' yielded lower variability in results for LMWH. In conclusion, the high variability of anti-Xa assay results coupled with the widely variable TRs suggests that therapeutic heparin monitoring is poorly standardized, and this raises some concerns over the clinical value of such monitoring.

An international survey of current practice in the laboratory assessment of anticoagulant therapy with heparin

AIMS

We conducted a survey of laboratory practice for assessment of heparin anticoagulant therapy by participants of the Royal College of Pathologists of Australasia Quality Assurance Program (RCPA QAP).

METHODS

A questionnaire was sent to 646 laboratories enrolled in the Haematology component of the QAP, requesting details of tests used for monitoring heparin therapy.

RESULTS

Seventy laboratories (10.8%) returned results that indicated that they performed laboratory monitoring of heparin therapy. Most laboratories (69/70 = 98.6%) use the activated partial thromboplastin time (APTT) to monitor unfractionated heparin, with eight (11.4%) also using the APTT for monitoring low molecular weight (LMW) heparin. Five (7.1%) laboratories use the thrombin time (TT) test to help monitor heparin therapy and 37 (52.9%) laboratories use an anti-Xa assay to monitor heparin (either LMW or unfractionated). Normal reference ranges (NRR) for APTT differed considerably between laboratories, even those using the same reagent. Therapeutic ranges (TR) also differed considerably between laboratories, for both APTT and the anti-Xa assay. Laboratory differences in NRR and TR using the same reagents could only be partly explained by the use of different instrumentation.

CONCLUSIONS

There is a large variation in current laboratory practice relating to monitoring of heparin anticoagulant therapy. This finding is similar to that of a similar survey conducted by the RCPA QAP almost a decade ago. This study suggests that better standardisation is still required for laboratory monitoring of heparin therapy.

Results of a Survey of Hospital Coagulation Laboratories in the United States, 2001

Context.—Coagulation and bleeding problems are associated with substantial morbidity and mortality, and inappropriate testing practices may lead to bleeding or thrombotic complications.

Objective.—To evaluate practices reported by hospital coagulation laboratories in the United States and to determine if the number of beds in a hospital was associated with different practices.

Design.—From a sampling frame of institutions listed in the 1999 directory of the American Hospital Association, stratified into hospitals with 200 or more beds (“large hospitals”) and those with fewer than 200 beds (“small hospitals”), we randomly selected 425 large hospitals (sampling rate, 25.6%) and 375 small hospitals (sampling rate, 8.8%) and sent a survey to them between June and October 2001. Of these, 321 large hospitals (75.5%) and 311 small hospitals (82.9%) responded.

Results.—An estimated 97.1% of respondents reported performing some coagulation laboratory tests. Of these, 71.6% reported using 3.2% sodium citrate as the specimen anticoagulant to determine prothrombin time (81.3% of large vs 67.7% of small hospitals, P < .001). Of the same respondents, 45.3% reported selecting thromboplastins insensitive to heparin in the therapeutic range when measuring prothrombin time (59.4% of large vs 39.8% of small hospitals, P < .001), and 58.8% reported having a therapeutic range for heparin (72.9% of large vs 53.2% of small hospitals, P < .001). An estimated 96.3% of respondents assayed specimens for activated partial thromboplastin time within 4 hours after phlebotomy, and 89.4% of respondents centrifuged specimens within 1 hour of collection. An estimated 12.1% reported monitoring low-molecular-weight heparin therapy, and to do so, 79% used an assay for activated partial thromboplastin time (58% of large vs 96% of small hospitals, P = .001), whereas 38% used an antifactor Xa assay (65% of large vs 18% of small hospitals, P = .001).

Conclusions.—Substantial variability in certain laboratory practices was evident. Where significant differences existed between the hospital groups, usually large hospitals adhered to accepted practice guidelines to a greater extent. Some reported practices are not consistent with current recommendations, showing a need to understand the reasons for noncompliance so that better adherence to accepted standards of laboratory practice can be promoted.

A survey of aPTT reporting in Canadian medical laboratories. The need for increased standardization. Thrombosis Interest Group of Canada

A survey of all licensed medical laboratories performing activated partial thromboplastin time (aPTT) testing in Canada was undertaken; the response rate was 50.7%. Preanalytic phase of testing seemed generally satisfactory, although 46% of laboratories were still using 3.8% or a 129-mmol/L concentration of citrate, and only 59% of institutions routinely performed testing to verify the platelet-poor status of the plasma used for aPTT testing. There were also concerns relating to the speed and duration of centrifugation for specimen preparation. While more than 67% of institutions had established an individual therapeutic range for aPTT testing, only 47% of laboratories verified this range with heparinized samples. Approximately 67% of the institutions that had verified the range had done this by spiking heparin concentrations into pooled plasma rather than using ex vivo specimens from patients receiving heparin therapy. There seemed to be a need for increased education about circumstances under which the therapeutic range should be rechecked and current standards for screening for the lupus anticoagulant. More than 71% of Canadian institutions surveyed used low-molecular-weight heparin, which may obviate many of the issues surrounding aPTT testing. Overall performance as documented by survey results seemed similar to that reported for the United States and Australasia.