1
|
Kelleher ST, Regan IE, Cox D, Shaw K, Franklin O, Kenny DP, Walsh KP, McMahon CJ. Aspirin Responsiveness in a Cohort of Pediatric Patients with Right Ventricle to Pulmonary Artery Conduits and Transcatheter Valve Replacement Systems. Pediatr Cardiol 2024:10.1007/s00246-024-03449-1. [PMID: 38489091 DOI: 10.1007/s00246-024-03449-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/10/2024] [Indexed: 03/17/2024]
Abstract
The aim of this study was to determine the rate of aspirin responsiveness in a cohort of pediatric patients with in situ xenograft valved right ventricle to pulmonary artery (RV-PA) conduits and/or transcatheter valve replacements (TVR). Aspirin is routinely prescribed to these patients. Optimizing anti-platelet therapy could promote valve longevity and reduce the risk of infective endocarditis in this at-risk group. This was a prospective, observational study. Patients were recruited from both ward and outpatient settings. Patients were eligible if under 18 years and taking aspirin. Non-response to aspirin was defined as > 20% platelet aggregation using light transmission platelet aggregometry (LTA) and < 50% platelet inhibition by thromboelastography with platelet mapping (TEGPM). Participants were invited to provide a confirmatory sample in cases of aspirin resistance and dose adjustments were made. Thirty patients participated. Median age was 9 years (2 months to 18 years). The majority (93%) had complex right ventricular outflow tract pathology. 13 (43%) had an RV-PA conduit and 24 (80%) had a TVR, with valve situated in conduit in 7 (23%) cases. Rate of aspirin non-response on initial testing was 23% (n = 7/30) with median LTA 74.55% (60-76%) and TEG 13.25% (0-44%) in non-responders. Non-responders were more likely to be under 1 year. Two patients required dose increases and one patient non-adherence to dose was identified. Four patients on repeat testing were responsive to aspirin by laboratory tests. The rate of aspirin non-response on laboratory testing in this cohort of patients was 23% and resulted in therapeutic intervention in 10%.
Collapse
Affiliation(s)
- Sean T Kelleher
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Irene E Regan
- Department of Coagulation/Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- National Children's Research Centre, Children's Health Ireland, Dublin, Ireland
| | - Dermot Cox
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons Ireland, Dublin, Ireland
| | - Kathryn Shaw
- Department of Paediatric Pharmacy, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Damien P Kenny
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Kevin P Walsh
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Colin J McMahon
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland.
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland.
- School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands.
- National Children's Research Centre, Children's Health Ireland, Dublin, Ireland.
| |
Collapse
|
2
|
Chen D, Pruthi R. A Brief History of Hemostasis and Thrombosis at the Mayo Clinic. Semin Thromb Hemost 2024; 50:26-33. [PMID: 36940712 DOI: 10.1055/s-0043-1764470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
Coagulation is a crucial biological mechanism in human bodies to prevent blood loss. Abnormal coagulation can cause bleeding diathesis or thrombosis, common pathologic conditions in our clinical practice. Many individuals and organizations have dedicated their efforts in the past decades to understanding the biological and pathological mechanisms of coagulation and developing laboratory testing tools and treatment options to help patients with bleeding or thrombotic conditions. Since 1926, the Mayo Clinic coagulation group has made significant contributions to the clinical and laboratory practice, basic and translational research on various hemostatic and thrombotic disorders, and the education and collaboration to share and advance our knowledge in coagulation through a highly integrated team and practice model. We would like to use this review to share our history and inspire medical professionals and trainees to join the efforts to advance our understanding of coagulation pathophysiology and improve our care for patients with coagulation disorders.
Collapse
Affiliation(s)
- Dong Chen
- Division of Hematopathology, Mayo Clinic, Rochester, Minnesota
| | - Rajiv Pruthi
- Division of Hematopathology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
3
|
Gao H, Yang N, Yang L, Wang H, Zhang G, Ma X, Deng N. Advances and Perspectives in methods for identifying high platelet reactivity. Heliyon 2023; 9:e22214. [PMID: 38107326 PMCID: PMC10724541 DOI: 10.1016/j.heliyon.2023.e22214] [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: 05/08/2023] [Revised: 11/06/2023] [Accepted: 11/07/2023] [Indexed: 12/19/2023] Open
Abstract
Antiplatelet therapy is the foundational treatment for the prevention and treatment of coronary and cerebrovascular ischemic events in patients with coronary heart disease, ischemic stroke, and transient ischemic attack (TIA). However, with more and more studies reporting an increased risk of thrombosis in some patients due to poor response to therapeutic agents, the selection of appropriate P2Y12 inhibitors has become a major challenge that needs to be addressed urgently. Currently, commonly used oral P2Y12 inhibitors include clopidogrel, ticagrelor, and prasugrel. Assessing patients' risk factors before the development of treatment regimens by effectively predicting the risk of high platelet reactivity with specific P2Y12 inhibitors in advance to avert the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) is the key point to the problem. Up to now, methods available for predicting platelet reactivity include genetic testing, platelet function testing, and risk scores. This review provides a summarization of the existent available identification methods and analyzes the advantages and drawbacks of different methods in specific clinical settings, intending to guide the rational clinical application of P2Y12 receptor inhibitors.
Collapse
Affiliation(s)
- Hua Gao
- Department of Pharmacy, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
- School of Pharmacy, Ningxia Medical University, Yinchuan, 750004, China
| | - Nan Yang
- School of Pharmacy, Ningxia Medical University, Yinchuan, 750004, China
| | - Libo Yang
- Heart Centre and Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Hui Wang
- Department of Pharmacy, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Guoshan Zhang
- Heart Centre and Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Xueping Ma
- Heart Centre and Department of Cardiovascular Diseases, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Ning Deng
- Office of Drug Clinical Trial Organization, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| |
Collapse
|
4
|
Carll T. Viscoelastic Testing Methods. Adv Clin Chem 2023; 117:1-52. [PMID: 37973317 DOI: 10.1016/bs.acc.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Viscoelastic testing methods examine the real-time formation of a clot in a whole blood sample, and include thromboelastography (TEG), rotational thromboelastometry (ROTEM), and several other testing platforms. They allow for concurrent assessment of multiple aspects of clotting, including plasmatic coagulation factors, platelets, fibrinogen, and the fibrinolytic pathway. This testing is rapid and may be performed at the point-of-care, allowing for prompt identification of coagulopathies to guide focused and rational administration of blood products as well as the identification of anticoagulant effect. With recent industry progression towards user-friendly, cartridge-based, portable instruments, viscoelastic testing has emerged in the 21st century as a powerful tool to guide blood transfusions in the bleeding patient, and to identify and treat both bleeding and thrombotic conditions in many operative settings, including trauma surgery, liver transplant surgery, cardiac surgery, and obstetrics. In these settings, the use of transfusion algorithms guided by viscoelastic testing data has resulted in widespread improvements in patient blood management as well as modest improvements in select patient outcomes. To address the increasingly wide adoption of viscoelastic methods and the growing number of medical and laboratory personnel tasked with implementing, performing, and interpreting these methods, this chapter provides an overview of the history, physiology, and technology behind viscoelastic testing, as well as a practical review of its clinical utility and current evidence supporting its use. Also included is a review of testing limitations and the contextual role played by viscoelastic methods among all coagulation laboratory testing.
Collapse
Affiliation(s)
- Timothy Carll
- Department of Pathology, University of Chicago, Chicago, IL, United States.
| |
Collapse
|
5
|
Wool GD, Carll T. Viscoelastic testing: Critical appraisal of new methodologies and current literature. Int J Lab Hematol 2023; 45:643-658. [PMID: 37559473 DOI: 10.1111/ijlh.14144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/25/2023] [Indexed: 08/11/2023]
Abstract
United States Food and Drug Administration (FDA)-approved viscoelastic testing (VET) methodologies have significantly changed in the last 10 years, with the availability of cartridge-based VET. Some of these cartridge-based methodologies use harmonic resonance-based clot detection. While VET has always allowed for the evaluation of real-time clot formation, cartridge-based VET provides increased ease of use as well as greater portability and robustness of results in out-of-laboratory environments. Here we review the use of VET in a variety of clinical contexts, including cardiac surgery, trauma, liver transplant, obstetrics, and hypercoagulable states such as COVID-19. As of now, high quality randomized trial evidence for new generation VET (TEG 6s, HemoSonics Quantra, ROTEM sigma) is limited. Nevertheless, the use of VET-guided transfusion algorithms appears to result in reduced blood usage without worsening of patient outcomes. Future work comparing the new generation VET instruments and continuing to validate clinically important cut-offs will help move the field of point-of-care coagulation monitoring forward and increase the quality of transfusion management in bleeding patients.
Collapse
Affiliation(s)
- Geoffrey D Wool
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Timothy Carll
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
6
|
Hall R, Majumdar M, Cassidy R, Feldman Z, Suarez S, Goudot G, Bellomo T, Jessula S, Kirshkaln A, Dua A. Use of Thromboelastography with Platelet Mapping to Identify Prothrombotic Coagulation Profiles in Patients with History of Cardiac Intervention Undergoing Lower Extremity Revascularization. J Am Coll Surg 2023; 236:495-504. [PMID: 36729802 DOI: 10.1097/xcs.0000000000000497] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients with concomitant coronary and peripheral artery disease (CAD and PAD) are at significant risk for major adverse limb events (MALEs). Prevention of thrombosis in this population is of paramount importance. Identifying prothrombotic coagulation profiles in this cohort may facilitate targeted thromboprophylaxis. We compared coagulation profiles of those with CAD and PAD to those with PAD alone during the perioperative period of lower extremity revascularization. STUDY DESIGN Patients undergoing lower extremity revascularization underwent thromboelastography-platelet mapping (TEG-PM) analysis preoperatively and at serial intervals for up to 6 months. Coagulation profiles of patients with significant CAD (defined as history of coronary artery bypass graft or percutaneous coronary intervention) and PAD were compared with those with PAD alone. MALE in the postoperative period was recorded. RESULTS Four hundred seventy-seven TEG-PM samples from 114 patients were analyzed; 28.1% had a history of significant CAD. The incidence of atrial fibrillation was higher in this group. The significant CAD group had lower ADP-platelet inhibition, higher ADP-platelet aggregation, and greater maximum clot strength compared with patients with PAD alone. Patients with significant CAD were more frequently on full-dose anticoagulation, but less frequently on dual antiplatelet therapy; 28.1% of patients with significant CAD developed postoperative MALE compared with 22.9% of patients with PAD alone (p = 0.40). For both groups, patients who developed postoperative MALE demonstrated greater ADP-platelet aggregation and lower ADP-platelet inhibition. CONCLUSIONS Patients with a history of significant CAD undergoing lower extremity revascularization demonstrated prothrombotic TEG-PM profiles, less frequent use of dual antiplatelet therapy, and greater rates of full-dose anticoagulation. Decreased platelet inhibition was also associated with postoperative MALE. This study underscores the potential utility of viscoelastic assays for coagulation profiling in complex cardiovascular patients.
Collapse
Affiliation(s)
- Ryan Hall
- From the Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA (Hall, Majumdar, Feldman, Suarez, Goudot, Bellomo, Jessula, Kirshkaln, Dua)
| | - Monica Majumdar
- From the Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA (Hall, Majumdar, Feldman, Suarez, Goudot, Bellomo, Jessula, Kirshkaln, Dua)
| | - Ryan Cassidy
- Hackensack Meridian School of Medicine, Nutley, NJ (Cassidy)
| | - Zachary Feldman
- From the Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA (Hall, Majumdar, Feldman, Suarez, Goudot, Bellomo, Jessula, Kirshkaln, Dua)
| | - Sasha Suarez
- From the Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA (Hall, Majumdar, Feldman, Suarez, Goudot, Bellomo, Jessula, Kirshkaln, Dua)
| | - Guillaume Goudot
- From the Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA (Hall, Majumdar, Feldman, Suarez, Goudot, Bellomo, Jessula, Kirshkaln, Dua)
| | - Tiffany Bellomo
- From the Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA (Hall, Majumdar, Feldman, Suarez, Goudot, Bellomo, Jessula, Kirshkaln, Dua)
| | - Samuel Jessula
- From the Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA (Hall, Majumdar, Feldman, Suarez, Goudot, Bellomo, Jessula, Kirshkaln, Dua)
| | - Amanda Kirshkaln
- From the Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA (Hall, Majumdar, Feldman, Suarez, Goudot, Bellomo, Jessula, Kirshkaln, Dua)
| | - Anahita Dua
- From the Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA (Hall, Majumdar, Feldman, Suarez, Goudot, Bellomo, Jessula, Kirshkaln, Dua)
| |
Collapse
|
7
|
Coleman JR, Moore EE, Schmitt L, Hansen K, Dow N, Freeman K, Cohen MJ, Silliman CC. Estradiol provokes hypercoagulability and affects fibrin biology: A mechanistic exploration of sex dimorphisms in coagulation. J Trauma Acute Care Surg 2023; 94:179-186. [PMID: 36694329 PMCID: PMC9881840 DOI: 10.1097/ta.0000000000003822] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Sex dimorphisms in coagulation are well established, with female-specific hypercoagulability conferring a survival benefit in the setting of trauma-induced coagulopathy (TIC). The mechanism behind these phenomena remains to be elucidated. We hypothesize that estradiol provokes a hypercoagulable profile and alters clot proteomics and fibrin crosslinking. METHODS Whole blood was collected from healthy adult volunteers (n = 30). A battery of thrombelastography (TEG) assays (native, kaolin, platelet-mapping, functional fibrinogen), whole blood thrombin generation, proteomics, and clot structure architecture (via analysis of fibrin crosslinks and fluorescent fibrinogen-visualized clots) were performed after pre-treatment of the blood with physiologic concentrations of beta-estradiol. In addition, a prospective study of coagulation through the menstrual cycle was conducted by collecting blood from women on peak and nadir estrogen days in the standard 28-day menstrual cycle. RESULTS On TEG, in females, estradiol provoked a hypercoagulable phenotype, specifically a shorter time to clot formation and greater thrombin generation, greater rate of clot propagation and functional fibrinogen, higher clot strength, and diminished clot fibrinolysis. In both males and females, estradiol increased platelet hyperactivity. Similar changes were seen in time to clot formation and clot strength in vivo during peak estrus of the menstrual cycle. On proteomic analysis, in both males and females, estradiol was associated with increases in abundance of several procoagulant and antifibrinolytic proteins. Crosslinking mass spectrometry analysis showed addition of estradiol increased the abundance of several FXIII crosslinks within the FIBA alpha chain in both sexes. Fluorescent fibrinogen analysis revealed a trend toward increased fiber resolvability index after addition of estradiol. CONCLUSION Estradiol provokes a hypercoagulable phenotype, affecting time to clot formation, clot propagation, clot strength, clot fibrinolysis, and clot structure. In sum, these data highlight the role of estradiol is driving female-specific hypercoagulability and highlights its potential role as a therapeutic adjunct in resuscitation of TIC.
Collapse
Affiliation(s)
- Julia R Coleman
- The Ohio State University, Department of Surgery, Columbus, OH
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, Department of Surgery, Denver, CO
| | - Lauren Schmitt
- University of Colorado, Department of Biochemistry and Molecular Genetics, Aurora, CO
| | - Kirk Hansen
- University of Colorado, Department of Biochemistry and Molecular Genetics, Aurora, CO
| | - Nathan Dow
- University of Vermont, Department of Emergency Medicine, Burlington, VT
| | - Kalev Freeman
- University of Vermont, Department of Emergency Medicine, Burlington, VT
| | | | - Christopher C Silliman
- Vitalant Research Institute, Denver, CO
- University of Colorado, Department of Pediatrics, Aurora, CO
| |
Collapse
|
8
|
Majumdar M, Waller D, Poyant J, McElroy I, Lella S, Feldman ZM, Levine E, Kim Y, Nuzzolo K, Kirshkaln A, DeCarlo C, Dua A. Variability of antiplatelet response in patients with peripheral artery disease. J Vasc Surg 2023; 77:208-215.e3. [PMID: 36028157 DOI: 10.1016/j.jvs.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/09/2022] [Accepted: 08/17/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Antiplatelet therapy has been a pillar of management for peripheral artery disease (PAD). However, a significant subset of patients with PAD will be resistant to certain antiplatelet medications and, therefore, have an increased risk of graft and/or stent thrombosis unknown to the surgeon. At present, no point-of-care testing to identity which patients will experience benefit from these medications has been incorporated into the treatment guidelines. Thromboelastography with platelet mapping affords an opportunity to evaluate real-time coagulation dynamics and platelet function. In the present prospective, observational study, we aimed to delineate the variation in response to antiplatelet therapy in patients with PAD undergoing revascularization. METHODS All patients who were undergoing named vessel revascularization during December 2020 through April 2022 were prospectively enrolled. Platelet mapping assays were performed in three clinical phases: preoperative, postoperative inpatient, and postoperative outpatient. The distribution of platelet reactivity within patients receiving mono- vs dual antiplatelet therapy was assessed, and a between-group inferential analysis was performed. The effect of comorbidities and intervention subtype on platelet inhibition was also analyzed. RESULTS A total of 521 platelet mapping samples from 143 individual patients were analyzed using thromboelastography with platelet mapping. We found wide variability in the distribution of platelet inhibition, with a range of 0 to 100 and an interquartile range of 37.6. Although platelet inhibition with clopidogrel 75 mg was higher on average (44.8 ± 30.2) than that with aspirin 81 mg (24.6 ± 23.7) or aspirin 325 mg (27.1 ± 26.4; P = .001), clopidogrel at 75 mg demonstrated the highest variability in response. CONCLUSIONS These data have demonstrated significant variability in the response to both mono- and dual antiplatelet therapy in PAD patients undergoing lower extremity revascularization. Future research on the effect of this variability in response on the clinical outcomes could provide invaluable understanding of the perioperative thrombotic risk.
Collapse
Affiliation(s)
- Monica Majumdar
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Davis Waller
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Janelle Poyant
- Department of Pharmacy, Tufts Medical Center, Boston, MA
| | - Imani McElroy
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Srihari Lella
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Zach M Feldman
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Emma Levine
- Larner College of Medicine, University of Vermont Medical Center, Burlington, VT
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Kathryn Nuzzolo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Amanda Kirshkaln
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital/Harvard Medical School, Boston, MA.
| |
Collapse
|
9
|
Hartmann J, Curzen N. Modified Thromboelastography for Peri-interventional Assessment of Platelet Function in Cardiology Patients: A Narrative Review. Semin Thromb Hemost 2022; 49:192-200. [PMID: 36252602 PMCID: PMC9894686 DOI: 10.1055/s-0042-1757545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Viscoelastic testing (VET), such as thromboelastography, can measure whole blood coagulation dynamics in real time and is used across a range of clinical settings, including cardiac surgery, liver transplant, and trauma. The use of modified thromboelastography with platelet function assessment (TEG(R) PlateletMapping(R) Assay) can provide an analysis of platelet contribution to hemostasis, including the contribution of the P2Y12 receptor and thromboxane pathway to platelet function. The TEG PlateletMapping Assay has shown high correlation with the current gold standard test of platelet function, light transmission aggregometry, to measure arachidonic acid and adenosine diphosphate agonist-induced platelet activation. Studies have also shown comparable results with other whole blood platelet function tests. In this review, we explore the clinical applications of modified thromboelastography with platelet function assessment. This includes guiding dual antiplatelet therapy in relation to cardiac procedures, such as percutaneous coronary interventions, transcatheter aortic valve replacement, and left atrial appendage closure. We also explore the developing use of thromboelastography in the emergency care setting of coronavirus disease 2019, which is commonly associated with a hypercoagulable and hypofibrinolytic state. Despite a general lack of high-quality, grade 1 evidence regarding the use of modified thromboelastography with platelet function assessment in these disease areas, the ability of the TEG PlateletMapping Assay to measure global hemostasis and platelet reactivity rapidly and to view and evaluate results at the point of care makes it a promising area for further study for managing patient treatment and optimizing hemostatic therapy.
Collapse
Affiliation(s)
- Jan Hartmann
- Haemonetics Corp., Boston, Massachusetts,Address for correspondence Jan Hartmann, MD Haemonetics Corp, 125 Summer Street, Boston, MA 02110
| | - Nick Curzen
- Faculty of Medicine, University of Southampton & Cardiothoracic Department, University Hospital Southampton, United Kingdom
| |
Collapse
|
10
|
Matkovic E, Lindholm PF. Role of Viscoelastic and Conventional Coagulation Tests for Management of Blood Product Replacement in the Bleeding Patient. Semin Thromb Hemost 2022; 48:785-795. [PMID: 36174609 DOI: 10.1055/s-0042-1756192] [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
An important aim of viscoelastic testing (VET) is to implement transfusion algorithms based on coagulation test results to help reduce transfusion rates and improve patient outcomes. Establishing a rapid diagnosis and providing timely treatment of coagulopathy is the cornerstone of management of severely bleeding patients in trauma, postpartum hemorrhage, and major surgery. As the nature of acute bleeding and trauma leads to an unstable and tenuous physiologic state, conventional coagulation tests (CCTs) are too slow to diagnose, manage, and also course correct any hemostatic abnormalities that accompany an acute critical illness. Viscoelastic point-of-care tests strongly correlate with results from standard laboratory tests but are designed to enable clinicians to make timely, informed bleeding management decisions when time to intervene is critical. These assays provide an individualized and goal-oriented approach to patient blood management and are increasingly becoming involved in transfusion algorithms. The scope of this review aims to evaluate the current literature on VETs and their impact on actionable outputs in clinical decision making and their relationship to CCT.
Collapse
Affiliation(s)
- Eduard Matkovic
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Paul F Lindholm
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
11
|
Volod O, Wegner J. Viscoelastic Testing in the Management of Adult Patients on Mechanical Circulatory Support Devices with Focus on Extracorporeal Membrane Oxygenation. Semin Thromb Hemost 2022; 48:814-827. [DOI: 10.1055/s-0042-1756303] [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
AbstractThromboembolic and hemorrhagic complications continue to remain frequent complications that significantly impact the morbidity and mortality of patients implanted with mechanical circulatory support devices (MCSDs). The severe acute respiratory syndrome caused by coronavirus 2 (SARS-CoV-2) has resulted in a number of COVID-19 patients being supported by MCSDs, specifically extracorporeal membrane oxygenation (ECMO), which in turn has created a crucial need for rapid assessment of hemostatic status in these patients to avoid bleeding and thrombotic complications. Currently, conventional plasma-based coagulation assays such as prothrombin time and activated partial thromboplastin time (aPTT) are used to assess hemostasis, and the activated clotting time (ACT) and aPTT are the most common tests used to monitor heparin anticoagulation in patients on ECMO. Unfractionated heparin remains the mainstay anticoagulation therapy for patients on ECMO. Extracorporeal Life Support Organization (ELSO) offers little guidance on the subject but does state that each institution should create its internal anticoagulation protocols. Viscoelastic assays (VEAs) are increasingly recognized by ELSO and ECMO community for their potential to assess hemostatic derangements in patients implanted with MCSDs as well as guidance for appropriate hemostatic therapy. This review focuses on the evidence for the use of viscoelastic assays to assess overall hemostasis and to guide the treatment of adult patients connected to an ECMO circuit. Limitations of the use of conventional assays, ACT, and VEA are also discussed.
Collapse
Affiliation(s)
- Oksana Volod
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Julie Wegner
- College of Health Professions, South University Online, Savannah, Georgia
| |
Collapse
|
12
|
Thrombelastography Compared with Multiple Impedance Aggregometry to Assess High On-Clopidogrel Reactivity in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. J Clin Med 2022; 11:jcm11144237. [PMID: 35888001 PMCID: PMC9320091 DOI: 10.3390/jcm11144237] [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: 05/31/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 02/04/2023] Open
Abstract
Background: High on-clopidogrel platelet reactivity (HPR) following percutaneous coronary intervention (PCI) is associated with increased ischemic risk. It is unclear whether conventional definitions of HPR apply to patients with concomitant oral anticoagulation (OAC). This study aimed to compare the performance of multiple platelet aggregometry (MEA) and thrombelastography (TEG) to detect HPR in patients with atrial fibrillation (AF) and indication for an OAC. Methods: In this observational single-center cohort study, MEA and TEG were performed in patients with AF with an indication for OAC on day 1 to 3 after PCI. The primary outcome was HPR as assessed by MEA (ADP area under the curve ≥ 46 units [U]) or TEG (MAADP ≥ 47 mm), respectively. The secondary exploratory outcomes were a composite of all-cause death, myocardial infarction (MI) or stroke and bleeding, as defined by the International Society on Thrombosis and Hemostasis, at 6 months. Results: Platelet function of 39 patients was analyzed. The median age was 78 (interquartile range [IQR] was 72−82) years. 25 (64%) patients were male, and 19 (49%) presented with acute coronary syndrome. All patients received acetylsalicylic acid and clopidogrel prior to PCI. Median (IQR) ADP-induced aggregation, MAADP, TRAP-induced aggregation, and MAthrombin were 9 (6−15) U, 50 (43−60) mm, 54 (35−77) U and 65 (60−67) mm, respectively. The rate of HPR was significantly higher if assessed by TEG compared with MEA (25 [64%] vs. 1 [3%]; p < 0.001). Within 6 months, four (10%) deaths, one (3%) MI and nine (23%) bleeding events occurred. Conclusion: In patients with AF undergoing PCI, the rates of HPR detected by TEG were significantly higher compared with MEA. Conventional cut-off values for HPR as proposed by consensus documents may need to be re-evaluated for this population at high ischemic and bleeding risk. Further studies are needed to assess the association with outcomes.
Collapse
|
13
|
Nellis ME, Remy KE, Lacroix J, Cholette JM, Bembea MM, Russell RT, Steiner ME, Goobie SM, Vogel AM, Crighton G, Valentine SL, Delaney M, Parker RI. Research Priorities for Plasma and Platelet Transfusion Strategies in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e63-e73. [PMID: 34989706 PMCID: PMC8769351 DOI: 10.1097/pcc.0000000000002859] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present a list of high-priority research initiatives for the study of plasma and platelet transfusions in critically ill children from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 13 experts developed research priorities for the study of plasma and platelet transfusions in critically ill children which were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. The specific priorities focused on the following subpopulations: severe trauma, traumatic brain injury, intracranial hemorrhage, cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, oncologic diagnosis or stem cell transplantation, acute liver failure and/or liver transplantation, noncardiac surgery, invasive procedures outside of the operating room, and sepsis and/or disseminated intravascular coagulation. In addition, tests to guide plasma and platelet transfusion, as well as component selection and processing, were addressed. We developed four general overarching themes and 14 specific research priorities using modified Research and Development/University of California, Los Angeles methodology. CONCLUSIONS Studies are needed to focus on the efficacy/harm, dosing, timing, and outcomes of critically ill children who receive plasma and/or platelet transfusions. The completion of these studies will facilitate the development of evidence-based recommendations.
Collapse
Affiliation(s)
- Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Kenneth E Remy
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Jill M Cholette
- Division of Pediatric Critical Care Medicine, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert T Russell
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Marie E Steiner
- Divisions of Critical Care and Hematology, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam M Vogel
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Gemma Crighton
- Department of Haematology, Royal Children's Hospital, Melbourne, Australia
| | - Stacey L Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Hospital; Department of Pathology and Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Robert I Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
| |
Collapse
|
14
|
OUP accepted manuscript. Lab Med 2022; 53:349-359. [DOI: 10.1093/labmed/lmac005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Racine-Brzostek SE, Asmis LM. Assessment of platelet function utilizing viscoelastic testing. Transfusion 2021; 60 Suppl 6:S10-S20. [PMID: 33089932 DOI: 10.1111/trf.16081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/29/2020] [Accepted: 08/29/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Sabrina E Racine-Brzostek
- Department of Pathology and Laboratory Medicine, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, New York, USA
| | - Lars M Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
| |
Collapse
|
17
|
Carll T, Wool GD. Basic principles of viscoelastic testing. Transfusion 2021; 60 Suppl 6:S1-S9. [PMID: 33089939 DOI: 10.1111/trf.16071] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Viscoelastic testing is a method of hemostatic analysis that provides a real-time, holistic view of ex vivo clotting. It allows for examination of both cellular and plasma protein contributions to clotting including platelet number and function, fibrin(ogen) function, and coagulation factor function. The method assesses physical clot properties during the transition of blood from a liquid to a gel state, either by measurement of clot shear modulus using physical force transduction or by measurement of clot resonance frequency using sonometric interrogation. Results are reported in a live trace, with different trace parameters reflecting different contributors to hemostasis. These reported parameters vary between testing platforms. RESULTS In the United States, there are several commonly used Food and Drug Administration (FDA)-approved viscoelastic instruments available on the market. Those instruments that use sonometric clot assessment are more recently available and allow for improved portability for use near the patient's bedside. These instruments generally feature different reagent kits that allow more specific interrogation of different hemostatic pathways. Viscoelastic testing can predict the results of traditional plasma-based coagulation assays and has the added benefit of detecting hypercoagulability and severe hyperfibrinolysis. Implementation of viscoelastic testing in many clinical settings is becoming widespread and has proven to be efficacious in reducing blood transfusion rates in many settings. An impact on overall mortality and morbidity has not yet been demonstrated. CONCLUSION This article provides a narrative review of the basic principles of viscoelastic testing, including the science and technology behind the method, as well as currently available testing platforms and reagents.
Collapse
Affiliation(s)
- Timothy Carll
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| | - Geoffrey D Wool
- Department of Pathology, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
18
|
Transcatheter aortic valve implantation induces transient drop in platelet reactivity. J Cardiovasc Pharmacol 2021; 78:263-268. [PMID: 34029272 DOI: 10.1097/fjc.0000000000001056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 04/27/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT Although recent studies described platelet reactivity (PR) changes in days following transcatheter aortic valve implantation (TAVI), precise time course and duration of these changes have not been fully investigated. The aim of this study was to investigate PR pattern during and after TAVI in multiple time points. Study included 40 consecutive patients undergoing TAVI. All patients underwent the procedure on dual antiplatelet therapy. PR was measured in seven time points: before induction of anaesthesia (T1), after heparin administration (T2), 10 minutes after initial valve implantation (T3), at the end of procedure (T4), and on 3rd, 6th and 30th postoperative day (T 5-7). PR was measured using impedance aggregometer using three different platelet aggregation agonists (arachidonic acid in ASPItest, adenosine diphosphate in ADPtest and thrombin receptor activating peptide 6 in TRAPtest). All patients underwent successful TAVI procedure. Mean PR on T1 was 22.9±23.0 U for ASPItest, 40.5±23.7 U for ADPtest and 91.7±32.5 U for TRAPtest. There was no significant difference in PR on T2. On T3, significant reduction of PR in all three tests was observed (ASPI 10.4±11.6 U (p=0.001), ADP 24.2±14.1 U (p<0.001) and TRAP 69.3±26.6 U (p<0.001)). PR nadir for all tests was reached on T5, with subsequent PR incline. PR values in all tests returned to baseline levels on T7. Our results show that successful TAVI procedure induces transient decrease in PR regardless of the platelet activation pathway.
Collapse
|
19
|
Karagöz IK, Karagöz A, Özkalaycı F, Doğan C, Kocabay G, Elbay A. Relation Between Platelet Reactivity Levels and Diabetic Retinopathy Stage in Patient with Type 2 Diabetes Mellitus by Using Multiplate Whole Blood Aggregometry. Semin Ophthalmol 2021; 36:392-399. [PMID: 33755523 DOI: 10.1080/08820538.2021.1893759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: To test the hypothesis of a possible association between platelet reactivity and the severity of diabetic retinopathy using Multiplate whole blood aggregometry in type 2 diabetes mellitus patients. Methods: Of 157 patients were divided to three groups based on the severity of diabetic retinopathy (normal, non-proliferative and proliferative [ordinal among group 1-2-3]). Platelet reactivity was measured using arachidonic acid response to the ASPI and ADP platelet test. The association between DR stage and the degree of platelet reactivity (predictor variable) ASPI, ADP, systolic blood pressure, age, hypertension, body mass index (BMI), HbA1c, creatinine, Microalbumin, platelet, triglyceride/HDL and Hscrp variables were evaluated using ordinal logistic regression models (Model 1). The association between DR presence (outcome variable (group 1 vs group 2 and 3)) and the presence of variables was evaluated using binary logistic regression models (Model 2). Results: A comparison of the laboratory parameters of the three groups revealed that the ASPI, ADP, glucose and HbA1c values were significantly higher in Group-3 than Group-1. ASPI (odds-ratio OR: 1.044[1.021-1.09], p < .001], ADP (OR: 1.033[1.010-1.10], p: 0.002] and HbA1c (OR: 2.42(1.22, 4.94), p < .001) were demonstrated to be associated with stage of DR while the other variables were not. In binary logistic regression (model-2) analysis; ASPI (OR: 1.061[1.031-1.1], p < .001], ADP (OR: 1.03(1.01, 1.06), p: 0.045] and HbA1c (OR: 4.37 (1.67, 11.36)], p: 0.002) were associated with DR while the other variables were not. Conclusion: Herewith, we demonstrated that higher platelet reactivity measured by multiplate ASPI and ADP was significantly associated with stages of DR. Therefore, these measurements may be useful to predict the severity of DR in the clinical practice of physicians.
Collapse
Affiliation(s)
- Işıl Kutlutürk Karagöz
- Health and Science University, Ümraniye Training Research and Education Hospital, Eye Clinic, Istanbul, Turkey
| | - Ali Karagöz
- Health Science University Kartal Kosuyolu High Training Research and Education Hospital. Kartal, Istanbul, Turkey
| | - Flora Özkalaycı
- Health Science University Kartal Kosuyolu High Training Research and Education Hospital. Kartal, Istanbul, Turkey
| | - Cem Doğan
- Health Science University Kartal Kosuyolu High Training Research and Education Hospital. Kartal, Istanbul, Turkey
| | - Gonenc Kocabay
- Health Science University Kartal Kosuyolu High Training Research and Education Hospital. Kartal, Istanbul, Turkey
| | - Ahmet Elbay
- Bezmialem University. Fatih Eye Clinic,Istanbul,Turkey
| |
Collapse
|
20
|
Viscoelastic Hemostatic Assays and Platelet Function Testing in Patients with Atherosclerotic Vascular Diseases. Diagnostics (Basel) 2021; 11:diagnostics11010143. [PMID: 33478051 PMCID: PMC7835760 DOI: 10.3390/diagnostics11010143] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/14/2021] [Accepted: 01/18/2021] [Indexed: 11/16/2022] Open
Abstract
Platelets play crucial role in acute vascular atherosclerotic diseases, including myocardial infarction and stroke. Additionally, platelet aggregation is a key target of antiplatelet agents, forming the keystone of pharmacotherapy of various atherosclerotic cardiovascular diseases. Thromboelastography and thromboelastometry, representing currently available viscoelastic hemostatic assays (VHA), are designed as whole blood, real-time analyzers of clot formation and clot resolution. These assays could, in theory, overcome some limitations of currently available platelet function testing assays. This article reviews the current experience with the use of VHA for platelet function testing and for monitoring of the response to antiplatelet therapy.
Collapse
|
21
|
Riojas CM, Ekaney ML, Ross SW, Cunningham KW, Furay EJ, Brown CVR, Evans SL. Platelet Dysfunction after Traumatic Brain Injury: A Review. J Neurotrauma 2021; 38:819-829. [PMID: 33143502 DOI: 10.1089/neu.2020.7301] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Coagulopathy is a known sequela of traumatic brain injury (TBI) and can lead to increased morbidity and mortality. Platelet dysfunction has been identified as one of several etiologies of coagulopathy following TBI and has been associated with poor outcomes. Regardless of whether the platelet dysfunction occurs as a direct consequence of the injury or because of pre-existing medical comorbidities or medication use, accurate detection and monitoring of response to therapy is key to optimal patient care. Platelet transfusion has been proposed as a potential therapeutic intervention to treat platelet dysfunction, with several studies using platelet function assays to monitor response. The development of increasingly precise diagnostic testing is providing enhanced understanding of the specific derangement in the hemostatic process, allowing clinicians to provide patient-specific treatment plans. There is wide variability in the currently available literature on the incidence and clinical significance of platelet dysfunction following TBI, which creates challenges with developing evidence-based management guidelines. The relatively high prevalence of platelet inhibitor therapy serves as an additional confounding factor. In addition, the data are largely retrospective in nature. We performed a literature review to provide clarity on this clinical issue. We reviewed 348 abstracts, and included 97 manuscripts in our final literature review. Based on the currently available research, platelet dysfunction has been consistently demonstrated in patients with moderate-severe TBI. We recommend the use of platelet functional assays to evaluate patients with TBI. Platelet transfusion directed at platelet dysfunction may lead to improved clinical outcome. A randomized trial guided by implementation science could improve the applicability of these practices.
Collapse
Affiliation(s)
- Christina M Riojas
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Michael L Ekaney
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Samuel W Ross
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Kyle W Cunningham
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Elisa J Furay
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Carlos V R Brown
- Dell Medical School, University of Texas at Austin, Austin, Texas, USA
| | - Susan L Evans
- FH "Sammy" Ross Trauma Center, Department of Surgery, Carolinas Medical Center, Charlotte, North Carolina, USA
| |
Collapse
|
22
|
Alvitigala BY, Gooneratne LV, Constantine GR, Wijesinghe RANK, Arawwawala LDAM. Pharmacokinetic, pharmacodynamic, and pharmacogenetic assays to monitor clopidogrel therapy. Pharmacol Res Perspect 2020; 8:e00686. [PMID: 33200888 PMCID: PMC7670852 DOI: 10.1002/prp2.686] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 12/11/2022] Open
Abstract
Clopidogrel is the most common and widely used antiplatelet agent for patients with coronary artery disease following confirmation by electrocardiographic studies. The nonresponsiveness of patients to clopidogrel and the possibility of testing for clopidogrel resistance by platelet function assays (PFA) are contentious issues. Light transmission aggregometry (LTA) is considered as the gold standard test among all PFA. In this review, the most commonly used PFA used for monitoring the effect of clopidogrel, LTA, vasodilator-stimulated phosphoprotein assay phosphorylation, rotational thromboelastometry (ROTEM) delta and ROTEM platelet, thromboelastography, PFA-100, VerifyNow P2Y12 assay, Multiplate analyzer, Plateletworks assay and pharmacogenetic studies, are comparatively discussed including their principles of action, advantages, and disadvantages. VerifyNow P2Y12 assay can be accepted as the ideal point of care test out of the discussed assays. However, modified assays are required which could overcome the limitations associated with currently available assays.
Collapse
Affiliation(s)
- Bhawani Yasassri Alvitigala
- Department of Medical Laboratory ScienceFaculty of Health SciencesThe Open University of Sri LankaNugegodaSri Lanka
| | | | | | | | | |
Collapse
|
23
|
Shao T, Cheng Y, Jin J, Huang L, Yang D, Luo C, Han Z, Wang Z, Ge W, Xu Y. A comparison of three platelet function tests in ischemic stroke patients with antiplatelet therapy. J Clin Neurosci 2020; 78:91-96. [PMID: 32624366 DOI: 10.1016/j.jocn.2020.06.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 04/20/2020] [Accepted: 06/06/2020] [Indexed: 12/31/2022]
Abstract
Predicting the effectiveness of antiplatelet drugs is critical to precision antiplatelet therapy. However, there is a lack of an acceptable method, although there are a variety of methods for detecting platelet function. In this study, we compared three major platelet function tests to assess their performance and found better methods for platelet function evaluation after aspirin or clopidogrel treatment in ischemic stroke patients by comparative study. A total of 249 ischemic stroke patients were enrolled who were treated with aspirin or clopidogrel or both. Three platelet function tests including light transmittance aggregometry (LTA), thromboelastography (TEG), platelet function analyzer (PFA) were performed as well as CYP2C19 genotype determination. Correlation analyses and kappa statistics were used. All three methods were effective in evaluating aspirin function. However, only LTA and TEG had good correlation and consistency (r = -0.37, kappa = 0.634). TEG-ADP was the least sensitive for clopidogrel, as the platelet inhibition ratio did not differ between the clopidogrel-user group and the control (P = 0.074), while LTA and PFA were sensitive (P < 0.001). Correlations between platelet assays were poor for clopidogrel (the absolute value of r range from 0.13 to 0.35) and so was the agreement (Kappa from 0.232 to 0.314). LTA and PFA have a good correlation with CYP2C19 genotyping (P = 0.034 and 0.014). In conclusion, all three tests were able to evaluate aspirin effect, LTA-AA and TEG-AA had a good correlation. TEG perform badly for clopidogrel effect detection. The fair-to-modest agreement among assays indicated further study was indispensable.
Collapse
Affiliation(s)
- Tengfei Shao
- Department of Pharmacy, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yue Cheng
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Jiali Jin
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Lili Huang
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Dan Yang
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Caimei Luo
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Zhou Han
- Department of Pharmacy, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Zhongyuan Wang
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Weihong Ge
- Department of Pharmacy, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Yun Xu
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, Jiangsu, China.
| |
Collapse
|
24
|
Wirtz MM, Schirmer CM, Goren O, Bohan CO, Dalal S, Weiner G, Foreman PM, Griessenauer CJ. Utility of platelet function testing in stent-assisted coiling of cerebral aneurysms. Interv Neuroradiol 2020; 26:275-282. [PMID: 31856647 PMCID: PMC7254623 DOI: 10.1177/1591019919894140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/18/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Thromboembolic complications are the primary risks of stent-coiling of cerebral aneurysms. The utility of platelet function testing in stent-assisted aneurysm coiling remains controversial. This study aimed to assess a pharmacy-mediated antiplatelet management protocol for stent-assisted coiling. METHODS Stent-coiled aneurysms at an academic institution in the United States between 2015 and 2018 were retrospectively reviewed. All patients were managed using a pharmacy-mediated antiplatelet protocol, which required repeated platelet function testing and subsequent dose adjustments. Medication dosage, number of adjustments, aspirin reaction units (ARU) and P2Y12 reaction units (PRU), as well as complication rates, angiographic and functional outcome were analyzed. RESULTS A total of 56 aneurysms (median size 5 mm, range 2.6-14.0 mm) in 54 patients (median age 58.5 years) were treated with stent-assisted coil embolization. Most aneurysms were located at the basilar tip (28.6%). Median pre-procedure ARU and PRU were 442.5 (range 363-594) and 123.5 (range 1-252), respectively. Approximately two-thirds of all procedures required at least one aspirin dose adjustment and 88.5% of procedures required at least one clopidogrel dose adjustment. There were two (3.6%) thromboembolic complications. One of the thromboembolic complications occurred in a patient where the pharmacy-mediated protocol was violated. There were no hemorrhagic complications. Last imaging follow-up demonstrated complete aneurysm occlusion in 83.9%. CONCLUSION In patients where the pharmacy-mediated antiplatelet protocol was followed, the thromboembolic complication rate was 1.8%. This complication rate compares favorably to those reported in large contemporary series. Nevertheless, the pharmacy-mediated protocol places a significant burden on both the patient and healthcare system.
Collapse
Affiliation(s)
- Mirja M Wirtz
- Department of Neurosurgery, Geisinger, Danville, PA, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger, Danville, PA, USA
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Oded Goren
- Department of Neurosurgery, Geisinger, Danville, PA, USA
| | | | - Shamsher Dalal
- Department of Neurosurgery, Geisinger, Danville, PA, USA
- Department of Radiology, Geisinger, Danville, PA, USA
| | - Gregory Weiner
- Department of Neurosurgery, Geisinger, Danville, PA, USA
| | - Paul M Foreman
- Department of Neurosurgery, Geisinger, Danville, PA, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger, Danville, PA, USA
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| |
Collapse
|
25
|
Platelet Mapping by Thromboelastography and Whole Blood Aggregometry in Adult Patients Supported by Mechanical Circulatory Support Device on Aspirin Therapy. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:13-21. [PMID: 32280140 DOI: 10.1182/ject-1900029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Accepted: 02/24/2020] [Indexed: 11/20/2022]
Abstract
Patients on mechanical circulatory support (MCS) devices are placed on aspirin and may require platelet function testing (PFT) to monitor the adequacy of therapy. Routine laboratory PFT is performed using whole blood aggregation (WBA) which typically has a long turnaround time (4-5 hours) and may not be readily available. By contrast, platelet mapping by thromboelastography (TPM) can provide results within 45 minutes. The objective of this study was to compare the results of TPM with WBA. We compared platelet mapping maximal amplitude (MA) by TPM with that of arachidonic acid (AA) to WBA with AA by impedance. We analyzed paired samples where both TPM and WBA were available. Of 45 paired samples, 34 were from 29 MCS patients and 11 were from non-MCS patients. When applying institutional interpretation guidelines with an MAActivator cutoff of ≤40 mm, WBAAA vs TPM MAAA in non-MCS and MCS patients correlated well with an accuracy of 100 and 94.4%, respectively. MAActivator >40 had poor correlation with an accuracy of 37.5%. Irrespective of MAActivator value, TPM AA inhibition expressed in percent of inhibition had poor accuracy. When used with proper guidelines for interpretation, specifically when MAActivator ≤ 40 mm, TPM is a suitable and reliable test to use for MCS patients on aspirin.
Collapse
|
26
|
Ranucci M, Baryshnikova E. Sensitivity of Viscoelastic Tests to Platelet Function. J Clin Med 2020; 9:E189. [PMID: 32284512 PMCID: PMC7019879 DOI: 10.3390/jcm9010189] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 12/28/2019] [Accepted: 01/07/2020] [Indexed: 12/02/2022] Open
Abstract
Viscoelastic tests provide a dynamic assessment of coagulation, by exploring the time to clot formation and the clot strength. Using specific activators or inhibitors, additional factors can be explored, like the fibrinogen contribution to clot strength. Since the early days, various attempts have been done to measure platelet function with viscoelastic test. In general, the difference between the maximum clot strength and the fibrinogen contribution is considered an index of platelet contribution. However, this parameter does not clearly split platelet count from function; additionally, the extensive thrombin generation of standard activated viscoelastic tests activates platelet through the protease activated receptors, bypassing the other pathways. For this reason, standard viscoelastic tests cannot be used to assess platelet reactivity under the effects of aspirin or P2Y12 inhibitors. To overcome this limitation, a specific test was developed (thromboelastography platelet mapping). This test has been compared with the gold standard of light transmission aggregometry and with other point-of-care tests, with conflicting results. In general, the use of viscoelastic tests to assess the effects of antiplatelet agents is still limited. Conversely, platelet contribution to clot strength in the setting of coagulopathic bleeding is considered an important parameter to trigger platelet transfusion or desmopressin.
Collapse
Affiliation(s)
- Marco Ranucci
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, 20097 Milan, Italy;
| | | |
Collapse
|
27
|
Katzman BM, Wockenfus AM, Scott RJ, Bryant SC, Jaffe AS, Karon BS. Estimating short- and long-term reference change values and index of individuality for tests of platelet function. Clin Biochem 2019; 74:54-59. [PMID: 31669512 DOI: 10.1016/j.clinbiochem.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/30/2019] [Accepted: 10/07/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND In order to manage risks of bleeding and thrombosis after some surgical procedures, platelet function is often measured repeatedly over days or weeks using laboratory tests of platelet function. To interpret test results in the perioperative period, it is necessary to understand analytical, biological and between-person variation. METHODS We collected three separate blood specimens from 16 healthy volunteers on the first study day, and one additional specimen from each volunteer 1, 2, and 3 months later. Arachidonic acid-induced and adenosine diphosphate (ADP)-induced platelet function were measured in duplicate by whole blood impedance aggregometry using Multiplate (ASPI/ADP tests) and VerifyNow (Aspirin Reaction Units [ARU] and P2Y12 Reaction Units [PRU]). The analytical variation (CVA), within-subject variation (CVI), between-subject variation (CVG), index of individuality (II), and reference change values (RCV) were calculated. RESULTS VerifyNow ARU demonstrated the smallest short-term and long-term variability (CVA, CVI, and CVG ~1%), resulting in short- and long-term RCV values <5%. II was also higher (1.92) for VerifyNow ARU than other platelet function tests. Multiplate ASPI and ADP tests had the highest RCV both short-(19.0% and 25.2%, respectively) and long-term (32.1% and 39.6%, respectively) due to increased CVA (>5%) and CVI (3.9-13.1%). VerifyNow PRU had a lower RCV than Multiplate ADP; but was the only test with II <0.6. CONCLUSIONS VerifyNow ARU results can be interpreted relative to a fixed cut-off or population-based reference interval; or relative to small changes in an individual's previous values. VerifyNow PRU and Multiplate ASPI and ADP tests should only be interpreted based upon relative change; and can only distinguish relatively large (>23%) changes over several weeks.
Collapse
Affiliation(s)
- Brooke M Katzman
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Amy M Wockenfus
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Renee J Scott
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Sandra C Bryant
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Allan S Jaffe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States; Department of Cardiology, Mayo Clinic, Rochester, MN, United States
| | - Brad S Karon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States.
| |
Collapse
|
28
|
Görlinger K, Pérez-Ferrer A, Dirkmann D, Saner F, Maegele M, Calatayud ÁAP, Kim TY. The role of evidence-based algorithms for rotational thromboelastometry-guided bleeding management. Korean J Anesthesiol 2019; 72:297-322. [PMID: 31096732 PMCID: PMC6676023 DOI: 10.4097/kja.19169] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 05/08/2019] [Indexed: 02/07/2023] Open
Abstract
Rotational thromboelastometry (ROTEM) is a point-of-care viscoelastic method and enables to assess viscoelastic profiles of whole blood in various clinical settings. ROTEM-guided bleeding management has become an essential part of patient blood management (PBM) which is an important concept in improving patient safety. Here, ROTEM testing and hemostatic interventions should be linked by evidence-based, setting-specific algorithms adapted to the specific patient population of the hospitals and the local availability of hemostatic interventions. Accordingly, ROTEM-guided algorithms implement the concept of personalized or precision medicine in perioperative bleeding management (‘theranostic’ approach). ROTEM-guided PBM has been shown to be effective in reducing bleeding, transfusion requirements, complication rates, and health care costs. Accordingly, several randomized-controlled trials, meta-analyses, and health technology assessments provided evidence that using ROTEM-guided algorithms in bleeding patients resulted in improved patient’s safety and outcomes including perioperative morbidity and mortality. However, the implementation of ROTEM in the PBM concept requires adequate technical and interpretation training, education and logistics, as well as interdisciplinary communication and collaboration.
Collapse
Affiliation(s)
- Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.,Tem Innovations, Munich, Germany
| | - Antonio Pérez-Ferrer
- Department of Anesthesiology, Infanta Sofia University Hospital, San Sebastián de los Reyes, Madrid, Spain
| | - Daniel Dirkmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Fuat Saner
- Department of General, Visceral and Transplant Surgery, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Marc Maegele
- Department for Trauma and Orthopedic Surgery, CologneMerheim Medical Center (CMMC), Cologne, Germany.,Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke (UW/H), Campus Cologne-Merheim, Cologne, Germany
| | - Ángel Augusto Pérez Calatayud
- Terapia Intensiva Adultos, Hospital de Especialidades del Niño y la Mujer, Coordinador Grupo Mexicano para el Estudio de la Medicina Intensiva, Colegio Mexicano de Especialistas en Obstetrica Critica (COMEOC), Queretarco, Mexico
| | - Tae-Yop Kim
- Department of Anesthesiology, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| |
Collapse
|
29
|
Huang HL, Chen CH, Kung CT, Li YC, Sung PH, You HL, Lin YH, Huang WT. Clinical utility of mean platelet volume and immature platelet fraction in acute coronary syndrome. Biomed J 2019; 42:107-115. [PMID: 31130246 PMCID: PMC6541877 DOI: 10.1016/j.bj.2018.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 10/16/2018] [Accepted: 12/17/2018] [Indexed: 01/30/2023] Open
Abstract
Background Platelets play an important role in the pathogenesis of acute coronary syndrome (ACS). Patients with ACS have an increased mean platelet volume (MPV) and immature platelet fraction (IPF) resulting in elevation of thrombotic ability. In this study, we evaluated the diagnostic performance of MPV and IPF in identifying suspected ACS patients at emergency department. Moreover, we investigated the correlation between MPV or IPF with initial troponin I (TnI), one of the current ACS biomarkers. Methods This was a single-center study recruiting suspected ACS patients who had acute chest pain at the emergency department. Whole blood samples were obtained from all participants and MPV and IPF were measured by Sysmex XE-5000 hematology analyzer within 20 min of blood sampling. The diagnostic values of MPV and IPF in identifying ACS were analyzed retrospectively. Result In this study, 63 in 104 suspected ACS patients were diagnosed as ACS (65.3%). MPV and IPF were higher in ACS patients compared to non-ACS patients (MPV: 10.7 ± 0.80 fL vs 10.0 ± 0.64 fL, p < 0.001; IPF: 3.7 ± 2.64% vs 3.1 ± 2.69%, p = 0.030). MPV and IPF were similar in unstable angina and acute myocardial infarction patients. We showed that elevation of MPV could be an independent predictive factor of ACS (odds ratio: 5.038). At the optimal cut-off value of 10.55 fL (AUC 95% CI: 0.637–0.836), the diagnostic performance of MPV in predicting ACS had an area under a receiver operating characteristic curve (AUC) of 0.736 with sensitivity and specificity of 54.2% and 82.8%, respectively. Patients with both of initial TnI and MPV higher than the established cut-off value had increased incidence (3.792 fold) for ACS development compared to patients with TnI below the cut-off value. Furthermore, diagnosing ACS with both MPV and initial TnI increased the positive predictive value from 84.2% to 86.7%. No correlation was observed between MPV or IPF and the mortality rate of ACS patients (MPV: 3.8% vs 11.1%, p = 0.300; IPF: 12.0% vs 37.5%, p = 0.054). Conclusion Here we show that ACS patients have higher MPV and IPF compared to non-ACS patients. We further demonstrate that MPV can be utilized as an independent predictor for early diagnosis of low-risk ACS patients who have acute chest pain.
Collapse
Affiliation(s)
- Hsien-Li Huang
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Hung Chen
- Divisions of General Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
| | - Chia-Te Kung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chen Li
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Pei-Hsun Sung
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Huey-Ling You
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Medical Laboratory Sciences and Biotechnology, Fooyin University, Kaohsiung, Taiwan
| | - Yu-Hung Lin
- Department of Medical Research, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wan-Ting Huang
- Department of Laboratory Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; Department of Medical Laboratory Sciences and Biotechnology, Fooyin University, Kaohsiung, Taiwan; Department of Pathology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| |
Collapse
|
30
|
Abstract
Platelet contraction provides a minimally invasive source for physiologic information. In this article, we describe a device that directly measures the kinetics of platelet contraction. Whole blood is injected between acrylic plates and an adherent clot forms. The bottom plate is fixed, and the top plate is attached to a wire cantilever. Platelet contraction drives deflection of the wire cantilever which is captured by a camera. Force generated by the clot with time is derived using beam equations. Force derivations were verified using a microelectromechanical (MEMS) force sensor. Kinetics of clot contraction were defined, including maximum contraction force (FMAX), lift-off time (TLIFTOFF), and contraction rate (CR). Metrics were compared with optical aggregometry and thromboelastography. FMAX correlates with optical aggregometry maximal amplitude with a Spearman's rho of 0.7904 and p = 0.0195 and thromboelastography maximal amplitude with a Spearman's rho of 0.8857 and p = 0.0188. Lift-off time correlates with optical aggregometry lag time with a Spearman's rho of 0.9048 and p = 0.002. This preliminary study demonstrates the repeatability of a useful platelet contraction device and its correlation with thromboelastography and optical aggregometry, the gold standard platelet function test.
Collapse
|
31
|
Binderup HG, Houlind K, Brasen CL, Madsen JS. Identification of aspirin resistance using a PDW-miR92a-score: Validation in an intermittent claudication cohort. Clin Biochem 2019; 64:30-36. [DOI: 10.1016/j.clinbiochem.2018.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/23/2018] [Accepted: 12/21/2018] [Indexed: 01/09/2023]
|
32
|
Anders M, Rock P, Cartron A, Chow J, Henderson R, Martz D, Tanaka K, Mazzeffi M. Isolated platelet concentrate transfusion during surgery: a single‐center observational cohort study. Transfusion 2019; 59:1661-1666. [DOI: 10.1111/trf.15156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 12/20/2018] [Accepted: 12/29/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Megan Anders
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Peter Rock
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Alex Cartron
- University of Maryland School of Medicine Baltimore Maryland
| | - Jonathan Chow
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Reney Henderson
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Douglas Martz
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Kenichi Tanaka
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| | - Michael Mazzeffi
- Department of AnesthesiologyUniversity of Maryland School of Medicine Baltimore Maryland
| |
Collapse
|
33
|
Monitoring Platelet Function in Children With Ventricular Assist Devices: The Devil Is in the Details. ASAIO J 2019; 65:104-105. [PMID: 30640186 DOI: 10.1097/mat.0000000000000948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
34
|
Ramström S. Arachidonic acid causes lysis of blood cells and ADP-dependent platelet activation responses in platelet function tests. Platelets 2018; 30:1001-1007. [PMID: 30580677 DOI: 10.1080/09537104.2018.1557614] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The use of arachidonic acid (AA) to stimulate platelets is considered as a specific approach to study aspirin treatment efficacy. However, very high concentrations of AA are used, and it has been previously reported that AA can induce cell lysis in other settings. Several clinical studies have reported decreased responses to AA in whole blood tests in the presence of clopidogrel. Our aim was to investigate whether unspecific effects contribute to AA-induced aggregation and platelet activation in light transmission aggregometry (LTA) in platelet-rich plasma (PRP), and in assays using whole blood, multiple electrode aggregometry (MEA, Multiplate®), and flow cytometry. We report that cell lysis, especially of red blood cells, does occur at concentrations of AA used in the clinical tests and that ADP is very important for the AA-induced platelet activation responses. In flow cytometry, very limited platelet activation was detected before reaching AA concentrations in the millimolar range, where cell lysis also occurred, making it problematic to develop a reliable flow cytometry assay using AA as reagent. We conclude that cell lysis and ADP release contribute to AA-induced platelet responses, most markedly in whole blood assays. This finding could potentially explain some differences between studies comparing methods using whole blood and PRP and also how clopidogrel treatment could influence AA-induced aggregation results in previously published studies. Our findings highlight some issues with AA as reagent for platelet activation, which also have an impact on how platelet activation assays using AA should be interpreted.
Collapse
Affiliation(s)
- Sofia Ramström
- Department of Clinical Chemistry and Department of Clinical and Experimental Medicine, Linköping University , Linköping , Sweden.,Cardiovascular Research Centre, School of Medical Sciences, Örebro University , Örebro , Sweden
| |
Collapse
|
35
|
Chandler WL, Brown AF, Chen D, Moser K, Olson JD, Pham HP, Smock KJ, Volod O, Higgins RA. External Quality Assurance of Platelet Function Assays: Results of the College of American Pathologists Proficiency Testing Program. Arch Pathol Lab Med 2018; 143:472-482. [DOI: 10.5858/arpa.2017-0556-cp] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—The College of American Pathologists (CAP) developed proficiency testing for platelet function assays by using blood collected by the participant added to challenge tubes containing either saline (normal) or tirofiban (abnormal).Objective.—To analyze platelet function proficiency testing for Platelet Function Analyzer PFA-100, platelet aggregation, PlateletWorks, and PlateletMapping.Design.—Proficiency testing data from 2012–2016 were analyzed.Results.—For PFA-100, a total of 1200 laboratories participated; the coefficient variation (CV) of cartridge closure times was 22% (saline); 44,952 of 45,616 survey responses (99%) provided an interpretation, and 42,934 of 44,952 (96%) were correct. For optical platelet aggregation, 190 laboratories participated; the CV was 17% (saline), 7444 of 7813 survey responses (95%) provided an interpretation, and 7015 of 7444 (94%) were correct. For PlateletWorks, 60 laboratories participated; the CV was 3% to 11% (saline); 2412 of 2454 survey responses (98%) provided an interpretation, and 1207 of 1276 (95%) were correct for adenosine diphosphate (ADP) and 936 of 1136 (82%) for collagen. For PlateletMapping, 200 laboratories participated. For ADP, 1128 of 2697 survey responses (42%) provided an interpretation, but only 927 of 1128 (82%) were correct. For arachidonic acid, 1139 of 2604 survey responses (44%) provided an interpretation and 964 of 1139 (85%) were correct.Conclusions.—CAP is the first to provide proficiency testing for platelet aggregation, PlateletWorks, and PlateletMapping. Platelet aggregation, PFA-100, and PlateletWorks using ADP as an agonist performed well with more than 90% of laboratories providing an interpretation and a similar number providing correct results. PlateletWorks using collagen and PlateletMapping showed worse interpretive accuracy than the other methods.
Collapse
Affiliation(s)
- Wayne L. Chandler
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Chandler); the Department of Pathology, University of Utah, Salt Lake City (Drs Brown and Smock); Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota (Dr Chen); the Department of Pathology, St. Louis University School of Medicine, St Louis, Missouri (Dr Moser); the Department of Pathology, Univ
| | - Alan F. Brown
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Chandler); the Department of Pathology, University of Utah, Salt Lake City (Drs Brown and Smock); Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota (Dr Chen); the Department of Pathology, St. Louis University School of Medicine, St Louis, Missouri (Dr Moser); the Department of Pathology, Univ
| | - Dong Chen
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Chandler); the Department of Pathology, University of Utah, Salt Lake City (Drs Brown and Smock); Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota (Dr Chen); the Department of Pathology, St. Louis University School of Medicine, St Louis, Missouri (Dr Moser); the Department of Pathology, Univ
| | - Karen Moser
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Chandler); the Department of Pathology, University of Utah, Salt Lake City (Drs Brown and Smock); Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota (Dr Chen); the Department of Pathology, St. Louis University School of Medicine, St Louis, Missouri (Dr Moser); the Department of Pathology, Univ
| | - John D. Olson
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Chandler); the Department of Pathology, University of Utah, Salt Lake City (Drs Brown and Smock); Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota (Dr Chen); the Department of Pathology, St. Louis University School of Medicine, St Louis, Missouri (Dr Moser); the Department of Pathology, Univ
| | - Huy Phu Pham
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Chandler); the Department of Pathology, University of Utah, Salt Lake City (Drs Brown and Smock); Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota (Dr Chen); the Department of Pathology, St. Louis University School of Medicine, St Louis, Missouri (Dr Moser); the Department of Pathology, Univ
| | - Kristi J. Smock
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Chandler); the Department of Pathology, University of Utah, Salt Lake City (Drs Brown and Smock); Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota (Dr Chen); the Department of Pathology, St. Louis University School of Medicine, St Louis, Missouri (Dr Moser); the Department of Pathology, Univ
| | - Oksana Volod
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Chandler); the Department of Pathology, University of Utah, Salt Lake City (Drs Brown and Smock); Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota (Dr Chen); the Department of Pathology, St. Louis University School of Medicine, St Louis, Missouri (Dr Moser); the Department of Pathology, Univ
| | - Russell A. Higgins
- From the Department of Laboratories, Seattle Children's Hospital, Seattle, Washington (Dr Chandler); the Department of Pathology, University of Utah, Salt Lake City (Drs Brown and Smock); Special Coagulation Laboratory, Mayo Clinic, Rochester, Minnesota (Dr Chen); the Department of Pathology, St. Louis University School of Medicine, St Louis, Missouri (Dr Moser); the Department of Pathology, Univ
| |
Collapse
|
36
|
Baumann Kreuziger L, Karkouti K, Tweddell J, Massicotte MP. Antithrombotic therapy management of adult and pediatric cardiac surgery patients. J Thromb Haemost 2018; 16:2133-2146. [PMID: 30153372 DOI: 10.1111/jth.14276] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Indexed: 12/16/2022]
Abstract
Despite the development of catheter-based interventions for ischemic and valvular heart disease, hundreds of thousands of people undergo open heart surgery annually for coronary artery bypass graft (CABG), valve replacement or cardiac assist device implantation. Cardiac surgery patients are unique because therapeutic anticoagulation is required during cardiopulmonary bypass. Developmental hemostasis and altered drug metabolism affect management in children. This narrative review summarizes the current evidence-based and consensus guidelines regarding perioperative, intraoperative and postoperative antithrombotic therapy in patients undergoing cardiac surgery. Anticoagulation preoperatively is required in the setting of cardiac arrhythmias, prior valve replacement or history of venous thromboembolism. In patients with ischemic heart disease, aspirin is continued in the perioperative period, whereas oral P2Y12 antagonists are withheld for 5-7 days to reduce the risk of perioperative bleeding. Intraoperative management of cardiopulmonary bypass in adults and children includes anticoagulation with unfractionated heparin. Variability in dose-response to heparin and influence of other medical conditions on dosing and reversal of heparin make intraoperative anticoagulation challenging. Vitamin K antagonist therapy is the standard anticoagulant after mechanical heart valve or left ventricular assist device (LVAD) implantation. Longer duration of dual antiplatelet therapy is recommended after CABG if patients undergo surgery because of acute coronary syndrome. Antiplatelet therapy after LVAD implantation includes aspirin, dipyridamole and/or clopidogrel in children and aspirin in adults. A coordinated approach between hematology, cardiology, anesthesiology, critical care and cardiothoracic surgery can assist to balance the risk of thrombosis and bleeding in patients undergoing cardiac surgery.
Collapse
Affiliation(s)
- L Baumann Kreuziger
- BloodCenter of Wisconsin, Blood Research Institute, Milwaukee, WI, USA
- Medical College of Wisconsin, Department of Medicine, Division of Hematology and Oncology, Milwaukee, WI, USA
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - J Tweddell
- Department of Surgery and Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - M P Massicotte
- University of Alberta, Department of Pediatrics, Edmonton, Alberta, Canada
| |
Collapse
|
37
|
Gestion des agents antiplaquettaires pour une procédure invasive programmée. Propositions du Groupe d’intérêt en hémostase périopératoire (GIHP) et du Groupe français d’études sur l’hémostase et la thrombose (GFHT) en collaboration avec la Société française d’anesthésie-réanimation (SFAR). ANESTHÉSIE & RÉANIMATION 2018. [DOI: 10.1016/j.anrea.2018.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
38
|
Bender MT, Zarrin DA, Campos JK, Jiang B, Chandra A, Vo CD, Caplan JM, Huang J, Tamargo RJ, Lin LM, Colby GP, Coon AL. Precision of VerifyNow P2Y12 Assessment of Clopidogrel Response in Patients Undergoing Cerebral Aneurysm Flow Diversion. Neurosurgery 2018; 85:543-549. [DOI: 10.1093/neuros/nyy395] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/30/2018] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Dual antiplatelet therapy (DAT), most commonly with aspirin and Clopidogrel, is the standard of care for intracranial stenting, including flow diversion. Clopidogrel response varies by individual.
Objective
To investigate the real-world precision of VerifyNow P2Y12 assessment (Accumetrics, San Diego, California) of Clopidogrel response.
Methods
Using a prospectively-collected, IRB-approved cerebral aneurysm database 643 patients were identified who were treated with the Pipeline embolization device from 2011 to 2017. Patients with multiple P2Y12 assays drawn within a 24-h window were identified. A single patient could contribute multiple, independent sets. Levels drawn before a 5-d course of DAT and patients who received alternative antiplatelet agents were excluded. Therapeutic range was defined as platelet reaction units (PRU) 60–200.
Results
A total of 1586 P2Y12 measurements were recorded; 293 (46%) patients had more than one assay. One hundred forty (22%) patients had multiple P2Y12 measurements within 24 h. These patients accounted for 230 independent 24-h sets. The average P2Y12 fluctuation across all sets was 35 points; the 25th, 50th, and 75th percentiles were 12, 26, and 48 points, respectively. Of the 230 24-h sets of P2Y12 assays, 76% remained within their original therapeutic category: 100 (43%) all therapeutic, 54 (23%) all hypo-responsive, and 21 (9%) all hyper-responsive. Twenty-four percent of patients fluctuated between therapeutic categories when multiple P2Y12 assessments were drawn within a 24-h period: 29 (13%) between hypo-response and therapeutic, 23 (10%) between hyper-response and therapeutic, and 3 (1%) between hypo-response and hyper-response.
CONCLUSION
Our experience suggests P2Y12 is an often-imprecise measure, and this should be considered when utilizing P2Y12 levels for clinical decisions.
Collapse
Affiliation(s)
- Matthew T Bender
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David A Zarrin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jessica K Campos
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bowen Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Arun Chandra
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Chau D Vo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Li-Mei Lin
- Department of Neurosurgery, University of California Irvine, Orange, California
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California
| | - Alexander L Coon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
39
|
Yang Z, Xie Z, Pei X, Quan X, Feng D. Effect of thrombelastography on timing of coronary artery bypass grafting. Exp Ther Med 2018; 16:579-584. [PMID: 30116315 PMCID: PMC6090235 DOI: 10.3892/etm.2018.6202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 03/28/2018] [Indexed: 01/30/2023] Open
Abstract
The guiding value of thrombelastography (TEG) on the selection of surgical timing for patients scheduled for coronary artery bypass grafting (CABG) was investigated. A total of 90 subjects with acute coronary syndrome (ACS) treated between February 2014 and December 2016 in Henan Provincial People's Hospital were recruited. The patients received dual antiplatelet therapy (DAPT) and were scheduled for CABG. Subjects were randomly allocated into two groups, TEG group (n=45) and non-TEG group (n=45). Patients in the TEG group withheld medications at 24 h prior to surgery and received TEG examination. Based on maximum amplitude of adenosine diphosphate (MAADP), subjects were further grouped into three sub-groups with MAADP <35 mm, 35–50 mm, and >50 mm, and accordingly received CABG within 1 day, 3–5 days and 5 days later, respectively. Subjects in the control group (non-TEG group) received CABG 5–7 days after medication withdrawal. Chest drainage volume within 24 h after surgery and red blood cell transfusion during perioperative period were compared. Other recorded parameters were incubation period, intensive care unit length of stay, hospital stay, incidence of 30-day adverse events and readmission rate. The average waiting time before CABG for patients of TEG group was shorter compared with the commonly recommended time. The red blood cell transfusions during perioperative period of subjects in TEG group and non-TEG group were significantly different (P=0.23). The median hospital stay of subjects in TEG group was shorter than that of non-TEG group (P=0.037). The bleeding amount of patients in TEG group was 220.16±80.56 ml, which was significantly lower than that of non-TEG group (435.29±90.16). The difference was statistically significant (P=0.032). The results suggested that TEG assay-based evaluation of platelet function for patients scheduled for CABG reasonably guides surgeons with appropriate surgical timing and reduces the amount of time patients wait to be treated.
Collapse
Affiliation(s)
- Zhiyuan Yang
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Zhouliang Xie
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Xueliang Pei
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Xiaoqiang Quan
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| | - Deguang Feng
- Department of Cardiovascular Surgery, Henan Provincial People's Hospital, Zhengzhou, Henan 450003, P.R. China
| |
Collapse
|
40
|
Roullet S, Labrouche S, Carrie C, Auque H, Berard X, Freyburger G. Multiplate ® evaluation of acetylsalicylic acid efficacy in carotid surgery: routine and genetic influencing factors. J Thromb Haemost 2018; 16:583-591. [PMID: 29314596 DOI: 10.1111/jth.13943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Indexed: 11/30/2022]
Abstract
Essentials Acetylsalicylic acid (ASA) is prescribed to patients scheduled for carotid endarterectomy (CEA). We measured ASA efficacy during CEA by Multiplate® and searched for influencing factors. Most patients scheduled for CEA and treated by ASA are sensitive to this therapy. Influencing genomic factors are involved in ASA metabolism and in platelet function modulations. SUMMARY Background Acetylsalicylic acid (ASA) is recommended before, during and after carotid endarterectomy (CEA). The efficacy of ASA is influenced by numerous biological and genotypic factors. Objectives To determine the biological efficacy of ASA by using the Multiplate® method, and to explore the biological parameters and genomic factors influencing this efficacy. Methods This descriptive cross-sectional study included all patients scheduled for CEA between January 2012 and April 2013. Multiplate® tests were performed at day 0 and day 30. A set of 66 single-nucleotide polymorphisms (SNPs) from 38 genes or DNA regions were selected and studied along with phenotypic parameters by the use of hierarchical clustering (HC) for multidimensional data management. Results Fifty-five patients receiving ASA were analyzed. Of the patients, 95% were found to be sensitive to ASA, with values under the threshold of normality (400 AU min-1 ). However, there were notable differences in residual aggregation among subjects over a wide range. HC revealed four subclusters comprising three categories of parameters: (i) routine and functional parameters - in ASA-treated patients, the ASPItest was highly linked to the ADPtest, to platelet count, and, to a lesser extent, to fibrinogen and hematocrit; (ii) polymorphisms in genes involved in ASA absorption and in the arachidonic acid pathway (ABCB1 and COX-1); and (iii) polymorphisms in genes modulating basal platelet function, i.e. TBXA2R, ADRA2A, PEAR1, ITGA2 and ITGB1. Conclusion Most patients treated with ASA before CEA were sensitive to it, according to Multiplate® ASPItest results. Genomic factors influencing this efficacy are SNPs involved in ASA absorption and metabolic pathway, and in modulations in basal platelet function.
Collapse
MESH Headings
- ATP Binding Cassette Transporter, Subfamily B/genetics
- Aged
- Aged, 80 and over
- Aspirin/therapeutic use
- Carotid Arteries/surgery
- Cluster Analysis
- Cyclooxygenase 1/genetics
- Endarterectomy, Carotid/methods
- Female
- Fibrinogen/analysis
- Genomics
- Hematocrit
- Humans
- Integrin alpha2/genetics
- Integrin beta1/genetics
- Male
- Middle Aged
- Platelet Aggregation/drug effects
- Platelet Aggregation Inhibitors/therapeutic use
- Platelet Count
- Platelet Function Tests
- Polymorphism, Genetic
- Polymorphism, Single Nucleotide
- Receptors, Adrenergic, alpha-2/genetics
- Receptors, Cell Surface/genetics
- Receptors, Thromboxane A2, Prostaglandin H2/genetics
- Sequence Analysis, DNA
Collapse
Affiliation(s)
- S Roullet
- CHU Bordeaux, Service Anesthésie Réanimation I, Bordeaux, France
- Université Bordeaux, Inserm U 12-11, Bordeaux, France
| | - S Labrouche
- CHU Bordeaux, Laboratoire Hématologie-PTRR, Bordeaux, France
- Université Bordeaux, Inserm U 10-34, Bordeaux, France
| | - C Carrie
- CHU Bordeaux, Service Anesthésie Réanimation I, Bordeaux, France
| | - H Auque
- CHU Bordeaux, Service de chirurgie vasculaire, Bordeaux, France
| | - X Berard
- CHU Bordeaux, Service de chirurgie vasculaire, Bordeaux, France
- Université Bordeaux, Inserm U 10-26, Bordeaux, France
| | - G Freyburger
- CHU Bordeaux, Laboratoire Hématologie-PTRR, Bordeaux, France
| |
Collapse
|
41
|
Fox SC, May JA, Dovlatova N, Glenn JR, Johnson A, White AE, Radhakrishnan A, Heptinstall S. How does measurement of platelet P-selectin compare with other methods of measuring platelet function as a means of determining the effectiveness of antiplatelet therapy? Platelets 2018; 30:290-295. [PMID: 29461906 DOI: 10.1080/09537104.2018.1434311] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Measurement of P-selectin on activated platelets as a means of measuring platelet function utilizing the technology described here has the advantage of not requiring immediate access to specialist equipment and expertise. Blood samples are activated, fixed, stored, and transported to a central laboratory for flow cytometric analysis. Here we have compared P-selectin with other more traditional approaches to measuring platelet function in blood and/or platelet-rich plasma (PRP) from patients with acute coronary syndromes on treatment for at least 1 month with either aspirin and clopidogrel or aspirin with prasugrel. The comparators were light transmission aggregometry (LTA), VerifyNow and Multiplate aggregometry (for determining the effects of aspirin) and LTA, VerifyNow and Multiplate together with the BioCytex VASP phosphorylation assay (for the P2Y12 antagonists). The P-selectin Aspirin Test revealed substantial inhibition of platelet function in all but three of 96 patients receiving aspirin with clopidogrel and in none of 51 patients receiving aspirin and prasugrel. The results were very similar to those obtained using LTA. There was only one patient with high residual platelet aggregation and low P-selectin expression. The same patients identified as "non-responders" to aspirin also presented with the highest residual platelet activity as measured using the VerifyNow system, although not quite as well separated from the other values. With the Multiplate test only one of these patients clearly stood out from the others. The results obtained using the P-selectin P2Y12 Test in 102 patients taking aspirin and clopidogrel were similar to the more traditional approaches in that a wide scatter of results was obtained. Generally, high values seen with the P-selectin P2Y12 Test were also high with the LTA, VerifyNow, Multiplate, and BioCytex VASP P2Y12 Tests. Similarly, low residual platelet function using the P2Y12 test was seen irrespective of the testing procedure used. However, there were differences in some patients. Prasugrel was always more effective than clopidogrel in inhibiting platelet function with none of 56 patients (P-selectin and VerifyNow), only 2 of 56 patients (Multiplate) and only 3 of 56 patients (Biocytex VASP) demonstrating high on-treatment residual platelet reactivity (HRPR) defined using previously published cut-off values. The exception was LTA where there were 11 of 56 patients with HRPR. It remains to be seen which experimental approach provides the most useful information regarding outcomes after adjusting therapies in treated patients.
Collapse
Affiliation(s)
- Susan C Fox
- a Division of Clinical Neuroscience, School of Medicine , University of Nottingham, Queen's Medical Centre , Nottingham , England
| | - Jane A May
- a Division of Clinical Neuroscience, School of Medicine , University of Nottingham, Queen's Medical Centre , Nottingham , England
| | - Natalia Dovlatova
- a Division of Clinical Neuroscience, School of Medicine , University of Nottingham, Queen's Medical Centre , Nottingham , England
| | - Jackie R Glenn
- a Division of Clinical Neuroscience, School of Medicine , University of Nottingham, Queen's Medical Centre , Nottingham , England
| | - Andrew Johnson
- a Division of Clinical Neuroscience, School of Medicine , University of Nottingham, Queen's Medical Centre , Nottingham , England
| | - Ann E White
- a Division of Clinical Neuroscience, School of Medicine , University of Nottingham, Queen's Medical Centre , Nottingham , England
| | - Ashwin Radhakrishnan
- a Division of Clinical Neuroscience, School of Medicine , University of Nottingham, Queen's Medical Centre , Nottingham , England
| | - Stan Heptinstall
- a Division of Clinical Neuroscience, School of Medicine , University of Nottingham, Queen's Medical Centre , Nottingham , England
| |
Collapse
|
42
|
Management of antiplatelet therapy in patients undergoing elective invasive procedures: Proposals from the French Working Group on perioperative hemostasis (GIHP) and the French Study Group on thrombosis and hemostasis (GFHT). In collaboration with the French Society for Anesthesia and Intensive Care (SFAR). Arch Cardiovasc Dis 2018; 111:210-223. [PMID: 29402671 DOI: 10.1016/j.acvd.2017.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/21/2017] [Indexed: 01/02/2023]
|
43
|
Godier A, Fontana P, Motte S, Steib A, Bonhomme F, Schlumberger S, Lecompte T, Rosencher N, Susen S, Vincentelli A, Gruel Y, Albaladejo P, Collet JP. Management of antiplatelet therapy in patients undergoing elective invasive procedures. Proposals from the French Working Group on perioperative haemostasis (GIHP) and the French Study Group on thrombosis and haemostasis (GFHT). In collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR). Anaesth Crit Care Pain Med 2018; 37:379-389. [PMID: 29309950 DOI: 10.1016/j.accpm.2017.12.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 12/28/2017] [Accepted: 12/28/2017] [Indexed: 10/18/2022]
Abstract
The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT) in collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR) drafted up-to-date proposals for the management of antiplatelet therapy in patients undergoing elective invasive procedures. The proposals were discussed and validated by a vote; all proposals but one could be assigned with a high strength. The management of antiplatelet therapy is based on their indication and the procedure. The risk of bleeding related to the procedure can be divided into high, moderate and low categories depending on the possibility of performing the procedure in patients receiving antiplatelet agents (none, monotherapy and dual antiplatelet therapy respectively). If discontinuation of antiplatelet therapy is indicated before the procedure, a last intake of aspirin, clopidogrel, ticagrelor and prasugrel 3, 5, 5 and 7 days before surgery respectively is proposed. The thrombotic risk associated with discontinuation should be assessed according to each specific indication of antiplatelet therapy and is higher for patients receiving dual therapy for coronary artery disease (with further refinements based on a few well-accepted items) than for those receiving monotherapy for cardiovascular prevention, for secondary stroke prevention or for lower extremity arterial disease. These proposals also address the issue of the potential role of platelet functional tests and consider management of antiplatelet therapy for regional anaesthesia, including central neuraxial anaesthesia and peripheral nerve blocks, and for coronary artery surgery.
Collapse
Affiliation(s)
- Anne Godier
- Department of Anaesthesiology and Intensive Care, Fondation Rothschild, and Inserm UMR-S1140, Paris Descartes university, 75006 Paris, France.
| | - Pierre Fontana
- Division of angiology and haemostasis and Geneva Platelet Group, University hospitals of Geneva, 1205 Geneva, Switzerland
| | - Serge Motte
- Department of Vascular Diseases, Erasme University Hospital, Université Libre de Bruxelles, 1050 Brussels, Belgium
| | - Annick Steib
- Department of Anaesthesiology and Intensive Care, NHC, University Hospital-Federation de Medecine Translationnelle, 67000 Strasbourg, France
| | - Fanny Bonhomme
- Department of Anaesthesiology, Pharmacology, and Intensive Care, Geneva University Hospitals, 1205 Geneva, Switzerland
| | | | - Thomas Lecompte
- Geneva Platelet Group (GpG), Department of Medical Specialties, Faculty of Medicine, Geneva University Hospitals, University of Geneva, 1205 Geneva, Switzerland
| | - Nadia Rosencher
- Cochin Hospital, Paris Descartes University, AP-HP, 75014 Paris, France
| | - Sophie Susen
- U1011 - EGID, Inserm, Institute of haematology-transfusion, université de Lille, CHU de Lille, 59000 Lille, France
| | - André Vincentelli
- Department of cardiac surgery, Centre hospitalier régional universitaire de Lille, Lille, France
| | - Yves Gruel
- Department of Haematology-Haemostasis, University-Hospital of Tours, 37044 Tours cedex, France
| | - Pierre Albaladejo
- Department of Anaesthesiology and Critical Care, Grenoble-Alpes University Hospital, Grenoble, ThEMAS, TIMC, UMR CNRS 5525, Université Grenoble-Alpes, 38700 Grenoble, France
| | - Jean-Philippe Collet
- ACTION Study Group, Inserm UMR_S 1166, department of cardiology, institut de cardiologie, Pitié-Salpêtrière Hospital, Sorbonne Universités_Univ Paris 06 (UPMC), AP-HP, 75013 Paris, France
| | | |
Collapse
|
44
|
|
45
|
Bordet JC, Negrier C, Dargaud Y, Quellec SL. Comparison of current platelet functional tests for the assessment of aspirin and clopidogrel response. Thromb Haemost 2017; 116:638-50. [DOI: 10.1160/th15-11-0870] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 06/29/2016] [Indexed: 12/18/2022]
Abstract
SummaryThe two most widely used antiplatelet drugs in the world are aspirin and clopidogrel. However, some patients on aspirin and/or clopidogrel therapy do not respond appropriately to either aspirin or clopidogrel. This phenomenon is usually called “aspirin/clopidogrel resistance”. Several platelet function tests have been used in various studies for the assessment of aspirin and clopidogrel resistance in healthy individuals and patients admitted in cardiology departments. An accurate assessment of platelet response to aspirin/clopidogrel could benefit patients by proposing tailored-antiplatelet therapy based on test results. However, there is a clear lack of standardisation of such techniques and their analytical variability may induce misinterpretation. After a quick report of the mechanisms responsible for aspirin/clopidogrel resistance, we describe the pre-analytical aspects and the analytical performances of current platelet function tests (Light-transmission aggregometry, whole-blood aggregometry, VerifyNow®, Platelet Function Analyzer®, thromboelastography, VASP assay) that are used for the assessment of aspirin/clopidogrel resistance in clinical studies. Considering the different variables that have to be taken into account with each of the platelet function tests, a particular attention should be paid when interpreting results.
Collapse
|
46
|
Giorni C, Costopoulos M, Bachelot‐Loza C, Belleville‐Rolland T, Pouard P, Raisky O, Pascreau T, Borgel D, Lasne D. Platelet-mapping assay for monitoring antiplatelet therapy during mechanical circulatory support in children: A retrospective observational study. Res Pract Thromb Haemost 2017; 1:120-127. [PMID: 30046680 PMCID: PMC6058205 DOI: 10.1002/rth2.12010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/26/2017] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION The complex hemostatic changes associated with Berlin Heart (BH) implantation in children require a challenging antithrombotic treatment. The aim of this retrospective analysis was to evaluate the thromboelastography (TEG)-platelet mapping (PM) assay to monitor antiplatelet therapy in children implanted with a BH. METHODS TEG-PM was performed in 4 BH-implanted patients receiving dipyridamole and aspirin, and 9 healthy volunteers. Patients' antiplatelet therapy was adjusted to TEG-PM results. Light transmission aggregometry (LTA) was also available for 2 of these patients. RESULTS Between 2009 and 2014, 4 BH-implanted patients received a dual antiplatelet therapy monitored by TEG-PM. In 2 patients, 18 of 34 tracings were atypical, because the maximum amplitude due to fibrin never stabilized, which made difficult antiplatelet therapy adjustment as recommended by BH's guidelines. To overcome this difficulty, TEG-PM and LTA were next performed in parallel. However, both methods led to different decisions to adjust antiplatelet therapy in 57% of the cases. In order to better understand this atypical tracing, TEG-PM was also performed in 9 volunteers and surprisingly 3 of them had the same atypical tracing. This atypical tracing was corrected by adding apyrase, suggesting that adenosine diphosphate (ADP) participates to spontaneous platelet activation in heparinized samples. In addition, we evidenced a high variability in the responses of TEG-PM with ADP in volunteers. CONCLUSIONS Antiplatelet therapy monitoring in BH-implanted children remains challenging, as TEG-PM is sensitive to several preanalytical and analytical conditions.
Collapse
Affiliation(s)
- Chiara Giorni
- Pediatric Intensive CareCardiac Surgery and Perfusion UnitParisFrance
| | - Myrto Costopoulos
- Laboratoire d'HématologieAP‐HPHôpital Universitaire Necker‐Enfants MaladesParisFrance
| | | | - Tiphaine Belleville‐Rolland
- Laboratoire d'HématologieAP‐HPHôpital Universitaire Necker‐Enfants MaladesParisFrance
- INSERM UMR‐S1140ParisFrance
- Paris Descartes UniversitySorbonne Paris CitéParisFrance
| | - Philippe Pouard
- Pediatric Intensive CareCardiac Surgery and Perfusion UnitParisFrance
| | - Olivier Raisky
- Pediatric Intensive CareCardiac Surgery and Perfusion UnitParisFrance
| | - Tiffany Pascreau
- Laboratoire d'HématologieAP‐HPHôpital Universitaire Necker‐Enfants MaladesParisFrance
- INSERM UMR‐S1176University Paris‐SudUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | - Delphine Borgel
- Laboratoire d'HématologieAP‐HPHôpital Universitaire Necker‐Enfants MaladesParisFrance
- INSERM UMR‐S1176University Paris‐SudUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| | - Dominique Lasne
- Laboratoire d'HématologieAP‐HPHôpital Universitaire Necker‐Enfants MaladesParisFrance
- INSERM UMR‐S1176University Paris‐SudUniversité Paris‐SaclayLe Kremlin‐BicêtreFrance
| |
Collapse
|
47
|
Winearls J, Reade M, Miles H, Bulmer A, Campbell D, Görlinger K, Fraser JF. Targeted Coagulation Management in Severe Trauma: The Controversies and the Evidence. Anesth Analg 2017; 123:910-24. [PMID: 27636575 DOI: 10.1213/ane.0000000000001516] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Hemorrhage in the setting of severe trauma is a leading cause of death worldwide. The pathophysiology of hemorrhage and coagulopathy in severe trauma is complex and remains poorly understood. Most clinicians currently treating trauma patients acknowledge the presence of a coagulopathy unique to trauma patients-trauma-induced coagulopathy (TIC)-independently associated with increased mortality. The complexity and incomplete understanding of TIC has resulted in significant controversy regarding optimum management. Although the majority of trauma centers utilize fixed-ratio massive transfusion protocols in severe traumatic hemorrhage, a widely accepted "ideal" transfusion ratio of blood to blood products remains elusive. The recent use of viscoelastic hemostatic assays (VHAs) to guide blood product replacement has further provoked debate as to the optimum transfusion strategy. The use of VHA to quantify the functional contributions of individual components of the coagulation system may permit targeted treatment of TIC but remains controversial and is unlikely to demonstrate a mortality benefit in light of the heterogeneity of the trauma population. Thus, VHA-guided algorithms as an alternative to fixed product ratios in trauma are not universally accepted, and a hybrid strategy starting with fixed-ratio transfusion and incorporating VHA data as they become available is favored by some institutions. We review the current evidence for the management of coagulopathy in trauma, the rationale behind the use of targeted and fixed-ratio approaches and explore future directions.
Collapse
Affiliation(s)
- James Winearls
- From the *Intensive Care Unit, Gold Coast University Hospital, Southport, Queensland, Australia; †Gold Coast University Hospital Critical Care Research Group, Queensland, Australia; ‡Joint Health Command, Australian Defence Force and Burns, Trauma and Critical Care Research Centre, University of Queensland, Brisbane, Queensland, Australia; §Heart Foundation Research Centre, School of Medicine, Griffith University, Gold Coast, Queensland, Australia; ∥Trauma Department, Gold Coast University Hospital, Queensland, Australia; ¶Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany; #Tem International GmbH, Munich, Germany; and **Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
| | | | | | | | | | | | | |
Collapse
|
48
|
Perez Botero J, Warad DM, He R, Uhl CB, Tian S, Otteson GE, Barness RL, Olson MC, Gossman SC, Charlesworth JE, Nichols WL, Pruthi RK, Chen D. Comprehensive Platelet Phenotypic Laboratory Testing and Bleeding History Scoring for Diagnosis of Suspected Hereditary Platelet Disorders. Am J Clin Pathol 2017; 148:23-32. [DOI: 10.1093/ajcp/aqx038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
|
49
|
Nagao Y, Masuda R, Ando A, Nonaka M, Nishimura A, Goto K, Maruoka Y, Iijima T. Whole Blood Platelet Aggregation Test and Prediction of Hemostatic Difficulty After Tooth Extraction in Patients Receiving Antiplatelet Therapy. Clin Appl Thromb Hemost 2017; 24:151-156. [PMID: 28511553 DOI: 10.1177/1076029617709086] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
When patients on antiplatelet therapy (APT) require minor invasive surgery, APT is usually continued to limit the risk of thrombosis. However, the possibility of hemostatic difficulties necessitates the monitoring of platelet aggregation to prevent unexpected bleeding. We examined whether whole blood aggregometry as a point-of-care testing (POCT) could be useful as a tool for predicting hemostatic difficulties. Sixty-five patients receiving APT and 15 patients who were not receiving APT were enrolled in the present study; all patients were scheduled to undergo a tooth extraction. Whole blood samples were obtained and were examined using multiple electrode aggregometry. The aggregometry was performed using arachidonic acid (AA), adenosine diphosphate (ADP), and thrombin receptor activating peptide. Hemostatic difficulty was defined as a need for more than 10 minutes of compression to achieve hemostasis. The AA test results were significantly lower in patients treated with aspirin (control: 97.7 [29.0] U, aspirin: 14.5 [7.2] U, P < .001). The ADP test results were also significantly lower in patients treated with a P2Y12 inhibitor (control: 77.7 [21.7] U, P2Y12 inhibitor: 37.3 [20.4] U, P < .01). Six of the examined cases exhibited hemostatic difficulties. The cutoff values for the prediction of hemostatic difficulty were 16.5 U for the AA test (sensitivity, 0.833; specificity, 0.508) and 21 U for the ADP test (sensitivity, 0.847; specificity, 0.500). Our study showed that whole blood aggregometry was useful as a POCT for the prediction of hemostatic difficulties after tooth extraction in patients receiving APT.
Collapse
Affiliation(s)
- Yasushi Nagao
- 1 Division of Community-Based Comprehensive Dentistry, Department of Special Needs Dentistry, Showa University, Shinagawa, Japan
| | - Rikuo Masuda
- 2 Division of Anesthesiology, Department of Perioperative Medicine, School of Dentistry, Showa University, Shinagawa, Japan
| | - Akane Ando
- 2 Division of Anesthesiology, Department of Perioperative Medicine, School of Dentistry, Showa University, Shinagawa, Japan
| | - Mutsumi Nonaka
- 2 Division of Anesthesiology, Department of Perioperative Medicine, School of Dentistry, Showa University, Shinagawa, Japan
| | - Akiko Nishimura
- 2 Division of Anesthesiology, Department of Perioperative Medicine, School of Dentistry, Showa University, Shinagawa, Japan
| | - Kinuko Goto
- 2 Division of Anesthesiology, Department of Perioperative Medicine, School of Dentistry, Showa University, Shinagawa, Japan
| | - Yasubumi Maruoka
- 1 Division of Community-Based Comprehensive Dentistry, Department of Special Needs Dentistry, Showa University, Shinagawa, Japan
| | - Takehiko Iijima
- 2 Division of Anesthesiology, Department of Perioperative Medicine, School of Dentistry, Showa University, Shinagawa, Japan
| |
Collapse
|
50
|
Kirmani BH, Johnson RI, Agarwal S. Platelet function testing in cardiac surgery: A comparative study of electrical impedance aggregometry and thromboelastography. Platelets 2017; 28:550-554. [DOI: 10.1080/09537104.2016.1237626] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Bilal H. Kirmani
- Departments of Perfusion, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool, UK
| | - Robert Ian Johnson
- Departments of Surgery, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool, UK
| | - Seema Agarwal
- Departments of Anaesthesia, Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool, UK
| |
Collapse
|