Coagulation Activation Parameters Research Articles

“TEG” talks: technology worth spreading?

“TEG” talks: technology worth spreading?

Correlation of Inflammation and Coagulation Markers with the Incidence of Deep Vein Thrombosis in Cancer Patients with High Risk of Thrombosis.

BackgroundDeep vein thrombosis (DVT) is a common complication and the second leading cause of death in cancer patients. Pro-inflammatory stimuli in the cancer microenvironment induce nuclear factor kappa B (NF-κB) signaling pathway that plays an integral role in immunothrombosis mechanism.ObjectiveTo investigate the role of inflammatory and coagulation biomarkers in the development of DVT in cancer patients with high risk of thrombosis (Khorana score ≥2).Subjects and methodsThis study was a cross-sectional study at Dr. Kariadi General Hospital. The serum levels of proinflammatory cytokines, ie, NF-κB, interleukin-6 (IL-6), C-reactive protein (CRP), tumor necrosis factor-alpha (TNF-α), and coagulation biomarkers, ie, tissue factor (TF), prothrombin fragment F1+2 (F1+2), fibrinogen and D-dimer were measured in newlydiagnosed cancer patients with a highrisk of thrombosis. Color duplex sonography was used for DVT screening.ResultsFrom January to November 2021, there were 83 eligible patients. DVT was confirmed in 8 subjects (9.63%). Univariate analysis revealed a significant difference between the median age of patients with DVT compared to non-DVT patients, 49.5 years (range: 23–60 years) and 42 years (range: 19–60 years), with p=0.046. D-dimer level was higher in DVT patients [(6.020 µg/L, range 2.090–20.000) vs (1.940 µg/L, range 270–20.000), p=0.005]. Multivariate analysis revealed age and D-dimer were significantly correlated with DVT incidence. In all patients, there were significant positive correlations between several inflammatory and coagulation activation parameters, which were IL-6 with D-dimer and F1+2, CRP with F1+2 and D-dimer as well as TNF-α with F1+2. However, these findings were not shown in DVT patients.ConclusionIn cancer patients with a high risk of thrombosis, age and D-dimer level are the significant variables towards the incidence of DVT. In patients with DVT, there was no significant correlation between inflammatory and coagulation activation parameters.

Coagulation activation after discontinuation of VTE treatment with different oral anticoagulants and impact on 12-month clinical outcomes

Increasing D-dimer (DD) levels after discontinuation of vitamin K antagonist (VKA) therapy indicate an increased risk of recurrence of venous thromboembolism (VTE). However, after discontinuation of direct-acting non-VKA oral anticoagulants (DOACs or NOACs) the extent of coagulation activation and its clinical impact is unknown. Blood samples were collected from consenting patients with proximal VTE at the end of anticoagulation treatment with apixaban (n=37), dabigatran (n=17), rivaroxaban (n=9) or VKA (n=184) and 4weeks later. DD, prothrombin fragments F1+2 (F1+2) and thrombin–antithrombin complexes (TAT) were measured. All patients underwent follow-up at 12months to establish recurrent VTE or death from any cause. Irrespective of the treatment, DD and F1+2 but not TAT demonstrated a similar increase between baseline and week 4. At 12months, 18 patients (7.3%) had recurrent VTE and two (0.8%) had died. For all patients and subgroups of VKA and DOAC, positive likelihood ratios were numerically higher for baseline values but only TAT values at 4weeks were found to be related to a small increase of outcome event likelihood (2.6; 95%CI 1.23-5.50), which was driven by VKA patients (3.1; 95%CI 1.32-7.30) and not by DOAC patients (2.27; 95%CI 0.52-9.95). For all parameters, negative likelihood ratios were not predictive.In logistic regression analysis, only ΔTAT (optimal cut-off >178% from baseline demonstrated a significant risk increase for VTE/death (odds ratio 3.76; 95% confidence interval 1.46-9.68; p=0.006). In conclusion, the concept of testing coagulation activation parameters may also be transferred to VTE patients at the end of DOAC therapy. For patients with an increase of TAT levels within 4weeks after treatment discontinuation (>178% from baseline) is associated with an increased risk for VTE recurrence or death at 12months.

Endovascular treatment of chronic cerebro spinal venous insufficiency in patients with multiple sclerosis modifies circulating markers of endothelial dysfunction and coagulation activation: a prospective study.

We performed a monocentric observational prospective study to evaluate coagulation activation and endothelial dysfunction parameters in patients with multiple sclerosis undergoing endovascular treatment for cerebro-spinal-venous insufficiency. Between February 2011 and July 2012, 144 endovascular procedures in 110 patients with multiple sclerosis and chronical cerebro-spinal venous insufficiency were performed and they were prospectively analyzed. Each patient was included in the study according to previously published criteria, assessed by the investigators before enrollment. Endothelial dysfunction and coagulation activation parameters were determined before the procedure and during follow-up at 1, 3, 6, 9, 12, 15 and 18 months after treatment, respectively. After the endovascular procedure, patients were treated with standard therapies, with the addition of mesoglycan. Fifty-five percent of patients experienced a favorable outcome of multiple sclerosis within 1 month after treatment, 25% regressed in the following 3 months, 24.9% did not experience any benefit. In only 0.1% patients, acute recurrence was observed and it was treated with high-dose immunosuppressive therapy. No major complications were observed. Coagulation activation and endothelial dysfunction parameters were shown to be reduced at 1 month and stable up to 12-month follow-up, and they were furthermore associated with a good clinical outcome. Endovascular procedures performed by a qualified staff are well tolerated; they can be associated with other currently adopted treatments. Correlations between inflammation, coagulation activation and neurodegenerative disorders are here supported by the observed variations in plasma levels of markers of coagulation activation and endothelial dysfunction.

Changes Of Coagulation Activation Parameters After Discontinuation Of VTE Treatment With Vitamin-K Antagonists, Apixaban, Rivaroxaban Or Dabigatran and Impact On Clinical Outcome After 12 Months

BackgroundAt the end of VTE treatment, increasing D-Dimer levels after discontinuation of Vitamin-K antagonists (VKA) have been shown to indicate coagulation activation and increased risk of VTE recurrence. However, it is unknown if changes of coagulation activation parameters will be similar after discontinuation of direct oral anticoagulants (DOAC) such as apixaban, rivaroxaban and dabigatran. Furthermore, the clinical impact of these changes is still unclear. ObjectivesTo quantify changes of coagulation activation parameters at the end of VTE treatment with VKA or DOAC and to evaluate their positive predictive value for VTE recurrence at 12 months. Patients and MethodsBlood samples for coagulation tests were collected from consenting patients with proximal VTE who discontinued anticoagulation treatment at the end of apixaban, dabigatran or rivaroxaban phase-III VTE treatment trials. Furthermore, similar samples were obtained from VKA patients at the end of treatment.From all patients, samples for D-dimer (DD), prothrombin fragments (F1+2) and thrombin-antithrombin complexes (TAT) measurements were collected at the end of treatment and 4 weeks later. Samples were analysed by blinded lab personnel and statistically evaluated for differences between VKA and DOAC regarding changes between both samples as well as absolute values at 4 weeks. Finally, all patients underwent 12 months follow-up by phone calls to establish rates of recurrent VTE or death from any cause. ResultsBlood samples were obtained from patients discontinuing apixaban (A; n=37), dabigatran (D; n=17), rivaroxaban (R; n=9) and VKA (n=184), respectively.Absolute values and relative changes of DD, F1+2 and TAT at baseline and 4 weeks were not significantly different between VKA or the DOAC cohorts. Irrespective of the anticoagulant treatment, DD and F1+2 but not TAT demonstrated a significant increase between baseline and week 4 (figure 1). [Display omitted] At 12 months, 18 patients (7.3%) had recurrent VTE and 2 patients (0.8%) were dead. Regarding clinical outcomes at 12 months, the negative predictive values (NPV) of DD, F1+2 and TAT were highest for patients after VKA treatment (at least 0.93) and systematically lower for DOAC patients (ranging between 0.86 and 0.91).In contrast, positive predictive values (PPV) of DD, F1+2 and TAT were systematically higher in DOAC patients (0.19 to 0.43) compared to VKA patients (0.03-0.16) with highest values for TAT-complexes > 200% baseline (PPV VKA 0.14; PPV DOAC 0.43), which was also seen in logistic regression analysis with a significant risk increase for VTE/death (Odds ratio for TAT > 200% baseline 5.0; p=0.006). None of the other parameters showed a correlation to the risk of recurrent VTE or death. ConclusionChanges of DD, F1+2 and TAT values post treatment are not different between patients discontinuing VTE treatment with VKA, apixaban, dabigatran or rivaroxaban. NPV of DD, F1+2 and TAT for recurrent VTE/death are higher in VKA than DOAC patients, while PPV are higher in DOAC patients.At 4 weeks, a TAT increase over 200% of baseline value was found to be associated with a 5-fold increase of recurrent VTE or death with a PPV of 0.14 for VKA patients and of 0.43 for DOAC patients. Disclosures:Werth:Bayer Healthcare: Honoraria. Beyer-Westendorf:Bayer Healthcare: Research Funding, Speakers Bureau; Boehringer Ingelheim: Research Funding, Speakers Bureau; Pfizer: Research Funding, Speakers Bureau.

Cardiac catheterization: haemostatic changes in pediatric versus adult patients

Thrombophilic or haemorrhagic complications are possible adverse events following cardiac catheterization particularly in pediatric patients. It was therefore the aim of our study to compare the cardiac catheterization-related haemostatic changes in children with that in adults. The total of 50 patients was subdivided into Gr I (1-6years), Gr II (7-18years), and Gr III (19-58years). Parameters of coagulation activation, plasma levels of various clotting factors and heparinase-modified thrombelastometry parameters were determined prior and immediately after cardiac catheterization. The haemostatic system of pediatric patients was markedly more affected by the procedure than that of adults. Levels of thrombin/antithrombin complex and prothrombin fragment 1+2 in the post-catheter plasma samples were significantly increased in Grs I and II, not in Gr III. The catheter-related decrease in fibrinogen and F II levels was higher in Gr I than in Grs II and III. F VII levels were significantly decreased in Grs I and II, not in Gr III. The catheter-related prolongation of Coagulation times was highest in Gr I, followed by Gr II and finally Gr III. A significant catheter-related decrease of maximum clot firmness was observed solely in Gr I. Our results show that cardiac catheterisation perturbs the haemostatic system of adults, and, even more pronounced, that of pediatric patients. Thus, our results indicate that children might be at a higher risk for either thrombotic complications or post-operative bleeding events than adults.

The creation of an antithrombotic surface by apyrase immobilization

Blood incompatibility reactions caused by surfaces often involve platelet activation and subsequent platelet-initiated activation of the coagulation and complement cascades. The goal of this study was to immobilize apyrase on a biomaterial surface in order to develop an enzymatically active surface that would have the capacity to inhibit platelet activation by degrading ADP. We were able to immobilize apyrase on a polystyrene surface with preservation of the enzymatic activity. We then analyzed the hemocompatibility of the apyrase surface and of control surfaces by incubation with platelet-rich plasma (PRP) or whole blood. Monitoring of markers of platelet, coagulation, and complement activation and staining of the surfaces revealed decreased levels of platelet and coagulation activation parameters on the apyrase surface. The formation of antithrombin-thrombin and antithrombin-factor XIa complexes and the extent of platelet consumption were significantly lower on the apyrase surface than on any of the control surfaces. No significant differences were seen in complement activation (C3a levels). Staining of the apyrase surface revealed low platelet adherence and no formation of granulocyte–platelet complexes. These results demonstrate that it is possible to create an antithrombotic surface targeting the ADP amplification of platelet activation by immobilizing apyrase.

Pneumonectomy due to lung cancer results in a more pronounced activation of coagulation system than lobectomy

Surgical treatment of lung cancer is associated with an elevated risk of thrombo-embolic complications. The question is whether the extent of pulmonary resection influences the concentration of serum coagulation system proteins. This study aims to compare the blood coagulation activation parameters among patients undergoing pneumonectomy and lobectomy due to primary lung cancer. A prospective study was carried out in 40 patients. Of whom, 30 underwent lobectomy and 10 treated with pneumonectomy. Serum concentrations of tissue factor (TF), tissue factor pathway inhibitor (TFPI), tissue factor pathway inhibitor-activated factor X complex (TFPI/Xa), thrombin-antithrombin complex (TAT), L-selectin, E-selectin and P-selectin were measured on the first and seventh postoperative days. On the first postoperative day, the results of selected proteins concentrations were similar in both groups. However, on the seventh postoperative day, significantly higher concentrations of TF, TAT complex and E-selectin were found in patients who underwent pneumonectomy (median values: TF: 182.4 pg ml(-1) vs 116.6 pg ml(-1), P=0.031; TAT: 6.2 mg ml(-1) vs 3.9 mg ml(-1), P=0.048; E-selectin 40.24 ng ml(-1) vs 26.54 ng ml(-1), P=0.049). Pneumonectomy was associated with significantly higher activation of coagulation system on the seventh postoperative day than lobectomy. TAT complex, TF and E-selectin are promising markers of extensive postoperative activation of coagulation and efficacy of antithrombotic prophylaxis.

Increased platelet activation markers in rheumatoid arthritis: Are they related with subclinical atherosclerosis?

Atherosclerotic cardiovascular mortality is increased in rheumatoid arthritis (RA) patients. We evaluated the association of inflammatory response with platelet, endothelial, coagulation activation parameters; and subclinical atherosclerosis in RA patients. We included 27 RA patients (21 female; six male) and 19 healthy subjects (14 female; five male). Disease activity score (DAS28) in RA patients was calculated; and patients were divided into two groups as active and inactive. Flow cytometry was used to determine platelet CD62P expression, platelet microparticles (PMP), platelet-monocyte (PMC) and platelet-neutrophil complexes (PNC). Plasma E-selectin, thrombin-antithrombin (TAT) complex, and serum sCD40L levels were determined by ELISA. The intima-media thickness (IMT) of carotid arteries was determined by B-mode ultrasonography. In RA patients, platelet CD62P expression (p < 0.001), PMC (p = 0.037) and sCD40L (p < 0.001) levels were increased when compared to the control group. PNC (p = 0.07) and TAT levels (p = 0.1) were non-significantly higher, and PMP level (p = 0.075) was nonsignificantly lower in RA patients. Soluble E-selectin level was significantly higher in the active RA group than in the inactive RA group (p = 0.009). There was no correlation between carotid IMT and activity markers, the evaluated parameters (p > 0.05).The increase in markers of active platelets, CD62P and sCD40L, and PMC levels might be associated with the increased cardiovascular mortality in RA. Nevertheless, none of these parameters were associated with carotid IMT: this suggests that one cross-sectional value might not be a good marker for atherosclerosis.

Effects of Recombinant Factor VIIa (NovoSeven®) on Restoring Thrombin Generation in Patients with Hemophilia A and Antibodies to Factor VIII.

Introduction: Development of antibodies (ab) against factor VIII (FVIII) is a serious complication of replacement therapy in patients with hemophilia A. In case of bleeding patients with FVIII ab are treated with agents that induce hemostasis independently of FVIII. Recombinant activated factor VIIa (rVIIa) shows clinical efficacy, but its effects on hemostatic system need still to be fully elucidated.Methods: In an open controlled study, we investigated thrombin generation (peak thrombin) and parameters of coagulation activation [D-Dimer, prothrombin fragment F1+2 (F1+2)] in 5 patients with hemophilia A and FVIII ab, and in 5 healthy age-matched controls before and after intravenous bolus infusion of rVIIa (90 μg/kg bodyweight NovoSeven®, NovoNordisk, Denmark) (in hemophiliacs only). All parameters were measured in plasma before and 0.5, 1, 2, 3, and 4 hours after rVIIa infusion by use of commercially available assays (Technothrombin®TGA, Technoclone, Austria; Asserachrom®D-Di, Diagnostica Stago, France; Enzygnost F1+2, Dade Behring, Germany).Results: At baseline, hemophilia A patients had markedly lower mean (min-max) peak thrombin levels than controls [0.12 (0.0–0.6) nM vs. 186.9 (116.0–254.4) nM]. Mean (min-max) F1+2 levels did not significantly differ between patients and controls [160.7 (89.8–331.3) pmol/l vs. 160.8 (104.4–242.3) pmol/l]. Notably, D-Dimer levels were significantly higher in hemophiliacs than controls [1087.5 (174.8–3882.4) ng/ml vs. 146.3 (87.2–289.8) ng/mL]. FVIIa levels reached a mean (min-max) maximum of 28 (24–32) U/ml after 0.5 hours in all patients. After infusion, a considerable increase in mean (min-max) peak thrombin levels to 40.7 (28.3–51.6) nM was seen. Time to maximum levels was 30 minutes in three patients and 60 minutes in two. For each of the five patients the peak thrombin level was substracted from the level of its matched control at the same time point. The mean of these differences was 168.7 nM (95% CI 82.6–254.8), which translates into 80.2% (95% CI 65.4% – 88.6%) lower peak thrombin levels in haemophiliacs with FVIII ab. F1+2 significantly increased in all patients [mean (min-max) maximum levels 292.5 (175.1–464.3) pmol/l]; time to maximum levels varied from 2 to 4 hours. D-Dimer levels remained almost unchanged in all patients.Conclusion: Patients with hemophilia A and FVIII ab have low in vitro thrombin generation and F1+2 levels. After rVIIa infusion, coagulation activation as measured by F1+2 levels is slightly increased, and thrombin generation capacity is restored by 20% compared to healthy controls. Measurement of peak thrombin could be useful to monitor procoagulant treatment of patients with hemophilia A and FVIII ab.

The immediate effect of aerobic exercise on haemostatic parameters in patients with recently diagnosed mild to moderate essential hypertension

Exercise is frequently recommended for the treatment of patients with arterial hypertension. Previous studies have shown an enhanced coagulation state after exercise. Our study investigates the alterations observed after a single session of submaximal aerobic exercise concerning coagulation, fibrinolysis, platelet activation as well as endothelial function in patients with recently diagnosed essential hypertension. Twenty non-diabetic patients with recently diagnosed essential hypertension participated in a 45 min submaximal exercise test on a bicycle ergometer. Blood samples were drawn before and after exercise in order to determine parameters of coagulation activation (Prothrombin time [PT], activated Partial Thromboplastin time [aPTT], fibrinogen, D-Dimers, prothrombin fragments 1 + 2 [PF1+2], thrombin-antithrombin III complex [TAT] and factors VII, VIII and XII), platelet activation (Platelet count, Platelet factor 4 [PF4] and beta-thromboglobulin [beta-TG]), fibrinolysis activation (Plasmin-a(2) antiplasmin complex, PAP) and endothelial function (soluble Thrombomodulin [sTM] and von Willebrand factor [vWf]). Soluble P-selectin served as a marker for endothelial and platelet activation. All patients completed the exercise test. aPTT (P < 0.001) and factor VII (P = 0.01) significantly decreased while PT (P = 0.04), fibrinogen (P = 0.008), factor VIII (P < 0.001), platelet count (P = 0.002) and beta-TG levels (P = 0.01) significantly increased as a result of exercise. Compared to baseline there was an 11% increase in TAT (P = 0.04) and a 28% increase in PAP (P < 0.001) at peak exercise. One hour post exercise, there was a 43% increase in PAP whereas TAT levels became similar to those at baseline. Additionally vWf (P = 0.01) and sP-selectin (P = 0.02) levels significantly increased throughout the exercise protocol. Patients with recently diagnosed and never treated mild to moderate essential hypertension undergoing submaximal aerobic exercise present evidence of enhanced fibrinolysis compared with a mild increase of coagulation indices. However, whether there is a favourable effect of exercise on fibrinolysis over coagulation and/or endothelial involvement during exercise needs to be further investigated.

Diagnosis and prognosis of overt disseminated intravascular coagulation in a general hospital—Meaning of the ISTH score system, fibrin monomers, and lipoprotein–C-reactive protein complex formation

The meaning, the utility, and the prognostic significance of the International Society of Thrombosis and Hemostasis overt disseminated intravascular coagulation (DIC) score and other parameters of coagulation activation including soluble fibrin monomer complexes (SFMC), antithrombin and protein C consumption, and formation of lipoprotein-C-reactive protein (LP-CRP) complexes (MDA slope 1 and flag A2) were evaluated in 165 inpatients from a general hospital for whom DIC testing was required by the attending physicians. Of these 165 patients, 148 had an underlying disease that clearly justified the laboratory request from our systematic post hoc review of the clinical charts. Of these 148 patients, 28 had a positive overt DIC score, 19 had an A2 flag, and 4 had both. The DIC score was strongly related to several major markers of coagulation activation such as D-dimers, thrombin-antithrombin complexes, and soluble fibrin and was inversely related to antithrombin and protein C levels, which began to fall from DIC score 4 or higher. The formation of LP-CRP complexes was only related to Gram-negative sepsis and these patients had a strong inflammatory reaction. Independent risk factors for death were high creatininemia, positive overt DIC score, and/or presence of SFMC. In patients with positive DIC score, SFMC positivity and low levels of antithrombin and/or protein C were additional risk factors. The ISTH overt DIC score proves useful and adequate as a marker for clinically significant DIC. Illness severity is further defined by SFMC, antithrombin, and protein C levels. LP-CRP complexes are related to sepsis but not to actual overt DIC and lethal prognosis.

Expression of beta-2-integrins and L-selectin by leukocytes and changes in acute-phase reactants in total hip replacement surgery.

The aim of this study was to characterize the changes in the quantitative expression of beta 2-integrins and L-selectin detected by means of fluorochrome-conjugated monoclonal antibodies and flow cytometry on leukocytes in the systemic circulation after a major musculoskeletal trauma, i.e. hip replacement surgery, and to relate these changes to parameters of the acute-phase response [plasma acute-phase reactants (C-reactive protein, CRP, and interleukin-6, IL-6) and parameters of coagulation activation (thrombin-antithrombin III complexes, TAT)]. Eight patients with either primary or secondary osteoarthritis of the hip received uncemented total hip prostheses. LFA-1 (CD11a/CD18) was upregulated on granulocytes during the operation. MAC-1 (CD11b/CD18) expression on monocytes increased to peak levels 20 h after surgery, whereas the L-selectin (CD62L) expression on monocytes and granulocytes reached peak values at the end of surgery. The changes in expression of LFA-1 on monocytes, MAC-1 on granulocytes and p150,95 (CD11c/CD18) on monocytes and granulocytes during and after the operation did not reach statistical significance. TAT and IL-6 increased during surgery and reached peak values at the end of the operation and 20 h after surgery, respectively. In contrast, CPR concentrations increased after surgery with peak levels 44 h postoperatively. Significant upregulation of LFA-1 on granulocytes and L-selectin on monocytes and granulocytes preceded the increase in IL-6 which again preceded the increase in CRP. However, the up- or downregulation of leukocyte beta 2-integrins and L-selectin during and after surgery was not significantly correlated with the increase in IL-6. The increases in TAT correlated well with the upregulation of L-selectin on monocytes, but not with the beta 2-integrins known to participate in the coagulation process in vitro. The rise in CRP was inversely correlated with the maximal increase in expression of MAC-1 on monocytes. In conclusion, the changes in leukocyte adhesion molecules during and after surgery indicate changes in critical leukocyte functions. The lack of correlation between quantitative up- and downregulation of leukocyte beta 2-integrins and parameters of the acute phase response suggests that these processes are regulated through independent pathways or that functional up- and downregulation of adhesion molecules, shedding, leukocyte-endothelial adhesion and mobilization of new unactivated cells may result in a net estimate of leukocyte activation not suspected to be positively correlated to acute-phase reactants.