A comparison of red blood cell transfusion utilization between anti‐activated factor X and activated partial thromboplastin monitoring in patients receiving unfractionated heparin

Abstract

Anti‐activated factor X (Anti‐Xa) monitoring is more precise than activated partial thromboplastin (aPTT). 20 804 hospitalized cardiovascular patients monitored with Anti‐Xa or aPTT were analyzed. Adjusted transfusion rates were significantly lower for patients monitored with Anti‐Xa. Adoption of Anti‐Xa protocols could reduce transfusions among cardiovascular patients in the US. Summary BackgroundAnticoagulant activated factor X protein (Anti‐Xa) has been shown to be a more precise monitoring tool than activated partial thromboplastin time (aPTT) for patients receiving unfractionated heparin (UFH) anticoagulation therapy. ObjectivesTo compare red blood cell (RBC) transfusions between patients receiving UFH who are monitored with Anti‐Xa and those monitored with aPTT. Patients/MethodsA retrospective cohort study was conducted on patients diagnosed with acute coronary syndrome (ACS) (N = 14 822), diagnosed with ischemic stroke (STK) (N = 1568) or with a principal diagnosis of venous thromboembolism (VTE) (N = 4414) in the MedAssets data from January 2009 to December 2013. Anti‐Xa and aPTT groups were identified from hospital billing details, with both brand and generic name as search criteria. Propensity score techniques were used to match Anti‐Xa cases to aPTT controls. RBC transfusions were identified from hospital billing data. Multivariable logistic regression was used to identify significant drivers of transfusions. ResultsAnti‐Xa patients had fewer RBC transfusions than aPTT patients in the ACS population (difference 17.5%; 95% confidence interval [CI] 16.4–18.7%), the STK population (difference 8.2%; 95% CI 4.4–11.9%), and the VTE population (difference 4.7%; 95% CI 3.3–6.1%). After controlling for patient age and gender, diagnostic risks (e.g. anemia, renal insufficiency, and trauma), and invasive procedures (e.g. cardiac catheterization, hemodialysis, and coronary artery bypass graft), Anti‐Xa patients were less likely to have a transfusion while hospitalized for ACS (odds ratio [OR] 0.16, 95% CI 0.14–0.18), STK (OR 0.41, 95% CI 0.29–0.57), and VTE (OR 0.35, 95% CI 0.26–0.48). ConclusionAnti‐Xa monitoring was associated with a significant reduction in RBC transfusions as compared with aPTT monitoring alone.

The Burden of Hypoxic Respiratory Failure in Preterm and Term/Near-term Infants in the United States 2011-2015

“…Vizient is an administrative patient-level database which includes inpatient and hospital-based outpatient information from more than 400 hospitals across 42 US states (59% Southern, 17% Western, 13% Midwestern, 12% Northeastern region). 12 Hospitals included large and small facilities in urban (87%) and rural (13%) locations. Inpatient and outpatient data are submitted by ~98% of providers, and data are updated twice monthly with a 30-to-45-day lag from month-end.…”

Monitoring unfractionated heparin therapy: Lack of standardization of anti‐Xa activity reagents

“…These studies, which included a small number of patients, were often retrospectively designed, 30‐35 except one single‐center prospective randomized management study aimed at comparing the two monitoring strategies with clinical end‐points in a cohort of 131 patients with VTE 36 . By evaluating various criteria such as the rate of recurrence of thrombosis, the rate of bleeding complication, the time‐to‐therapeutic range, the number of dosage change, the total UFH dosage, the duration or the cost of hospital stay, or even the need for red blood cells transfusion, 37 all concluded that anti‐Xa had at least similar safety/efficacy/efficiency in UFH monitoring when compared to aPTT, even though differences were not always significant partly because of their lack of statistical power.…”

Traditional and non-traditional anticoagulation management during extracorporeal membrane oxygenation

“…In a large retrospective analysis of more than 22,000 adult medical patients, anti-Xa-based heparin management significantly reduced transfusions when compared to an aPTT-based strategy (23). In a retrospective study of 100 ECMO and non-ECMO children, therapeutic anti-Xa levels were associated with a 66% reduction in the thrombosis rate, while 11% of patients experienced bleeding, particularly when aPTT values were excessive (24).…”

“…Results from pediatric patients are promising, and discounting how far these results can be translated to the adult wards, the fundamental limitations of the observational and single-center nature of these studies have to be clearly considered. Moreover, in ECMO patients with an impaired overall coagulation system, particularly after major surgery, such a strategy may be associated with an increased risk of bleeding (23).…”