Abstract
BackgroundThromboelastography® (TEG) utilizes kaolin, an intrinsic pathway activator, to assess clotting function. Recent published studies suggest that TEG results are commonly normal in patients receiving warfarin, despite an increased International Normalized Ratio (INR). Because RapidTEG™ includes tissue factor, an extrinsic pathway activator, as well as kaolin, we hypothesized that RapidTEG would be more sensitive in detecting a warfarin-effect.MethodsIncluded in this prospective study were 22 consecutive patients undergoing elective cardioversion and receiving warfarin. Prior to cardioversion, blood was collected to assess INR, Prothrombin Time, TEG, and RapidTEG.ResultsINR Results: 2.8 ± 0.5 (1.6 to 4.2). Prothrombin Time Results: 19.1 ± 2.2 (13.9. to 24.3).TEG Results (Reference Range): R-Time: 8.3 ± 2.7 (2–8); K-Time: 2.1 ± 1.4 (1–3); Angle: 62.5 ± 10.3 (55–78); MA: 63.2 ± 10.3 (51–69); G: 9.4 ± 3.5 (4.6-10.9); R-Time within normal range: 10 (45.5%) with INR 2.9 ± 0.3; Correlation coefficients for INR and each of the 5 TEG variables were insignificant (P > 0.05).RapidTEG Results (Reference Range): ACT: 132 ± 58 (86–118); K-Time: 1.2 ± 0.5 (1–2); Angle: 75.4 ± 5.2 (64–80); MA: 63.4 ± 5.1 (52–71); G: 8.9 ± 2.0 (5.0-11.6); ACT within normal range: 9 (40.9%) with INR 2.7 ± 0.5; Correlation coefficients for INR and each of the 5 RapidTEG variables were insignificant (P > 0.05).ConclusionsTEG, using kaolin activation, and RapidTEG, with kaolin and tissue factor activation, were normal in a substantial percent of warfarin patients, despite an increased INR. The false-negative rate for detecting warfarin coagulopathy with either test is unacceptable. The lack of correlation between INR and all TEG and RapidTEG components further indicates that these methodologies are insensitive to warfarin effects. Findings suggest that intrinsic pathway activation may mitigate detection of an extrinsic pathway coagulopathy.
Highlights
Thromboelastography® (TEG) utilizes kaolin, an intrinsic pathway activator, to assess clotting function
The lack of correlation between International Normalized Ratio (INR) and all TEG and RapidTEG components further indicates that these methodologies are insensitive to warfarin effects
Findings suggest that intrinsic pathway activation may mitigate detection of an extrinsic pathway coagulopathy
Summary
Thromboelastography® (TEG) utilizes kaolin, an intrinsic pathway activator, to assess clotting function. Recent published studies suggest that TEG results are commonly normal in patients receiving warfarin, despite an increased International Normalized Ratio (INR). Because RapidTEGTM includes tissue factor, an extrinsic pathway activator, as well as kaolin, we hypothesized that RapidTEG would be more sensitive in detecting a warfarin-effect. A publication by Dossett indicates that warfarin use is common among injured patients and its prevalence has increased each year since 2002 [2]. It is important to recognize that with the TEG assay, kaolin or celite, as factor XII activators, or tissue factor may be used to enhance clot formation [3,7]. Several review articles emphasized the importance of knowing the “assay variant” (clotting activator) utilized in a given set of studies [4,5,6]. Kaolin is an intrinsic activator; coagulation time (R-Time) is sensitive to heparin [4]
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