Frequency of Abnormal Biphasic aPTT Clot Waveforms in Patients with Underlying Disorders Associated with Disseminated Intravascular Coagulation

Abstract

Abnormal biphasic waveform (BPW) patterns were previously reported when the activated partial thromboplastin time (aPTT) was performed in plasma from patients with disseminated intravascular coagulation (DIC). In this study, the prevalence of the BPW was examined in a cohort of 508 hospitalized patients with elevated fibrinogen degradation products (FDP) levels (>10 microg/mL). The presence of a BPW was automatically flagged by the MDA analyzer when the slope of the precoagulation phase in the waveform exceeded a threshold value of -0.25%T/sec. In our cohort, 76 patients (15%) were diagnosed with overt DIC according to the criteria recently proposed by the International Society of Thrombosis and Haemostasis (ISTH), whereas 96 patients (18.9%) were diagnosed with DIC following the criteria of the Japanese Ministry of Health and Welfare (JMHW). The JMHW and ISTH criteria agreed in 93% of cases (kappa coefficient 0.76). The concordance between both scoring systems was high in patients with infection but low in solid cancer. The BPW appeared in 65 patients (12.8%), with the highest prevalence (23.6%) in patients with infection. The BPW was more prevalent in the subgroup of patients with DIC: 59.2% and 47.9% for DIC diagnosed by ISTH and JMWH scores, respectively. The prevalence of the BPW was particularly high in patients with DIC and infection: 86.4% and 75.0% for DIC diagnosed by ISTH and JMWH scores, respectively. For the total cohort, the presence of the BPW was significantly associated with DIC. Odds ratios were 29.9 and 19.0 for ISTH and JMWH scores, respectively (p<0.0001). The BPW showed a moderate sensitivity (59.2% for the ISTH score; 47.9% for the JMWH score), but a high specificity (95.4% for both scores). Waveform analysis of the aPTT potentially provides a practical tool in risk assessment of critical care patients, in whom development of DIC is known to worsen the prognosis.

The scoring system of the Scientific and Standardisation Committee on Disseminated Intravascular Coagulation of the International Society on Thrombosis and Haemostasis: a 5‐year overview

“…Discordance was primarily in the JMHW sensitivity to DIC in hematologic malignancies with high fibrinolytic activity. Without such patients, a further comparative study showed 93% concordance [4]. Although these were mainly in patients with infection, Gando et al found mortality to be also high in the DIC of non-infected patients diagnosed using ISTH criteria [5].…”

Elevated plasma CL-K1 level is associated with a risk of developing disseminated intravascular coagulation (DIC)

“…The waveform represents the change in light transmittance through a plasma specimen as the aPTT reaction takes place. The biphasic waveform is characterized by an initial steep negative slope, which is not seen in a normal waveform and is caused, in part, by precipitation of a C-reactive protein (CRP) complex [17, 18, 20]. The abnormal biphasic waveform was predictive of approximately half of fully developed DIC 18 h prior to the diagnosis provided by a battery of several other clinical tests that are currently regarded as definitive of DIC [21].…”

DIC Score: Statistical Relationship with PT, APTT, and Simplified Scoring Systems with Combinations of PT and APTT

“…A biphasic clot waveform of APTT has been reported by some observers as an early event in DIC and noted to have an adverse outcome by others [8, 9]. …”