Heparin Concentration–Based Anticoagulation for Cardiac Surgery Fails to Reliably Predict Heparin Bolus Dose Requirements

Garvin, Sean; FitzGerald, Daniel C.; Despotis, George J.; Shekar, Prem; Body, Simon C.

doi:10.1213/ane.0b013e3181b79d09

Cited by 53 publications

(49 citation statements)

References 26 publications

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“…2B-D). Although 0.92 U mL -1 UFH represents a $ 25-fold higher concentration than the EC 50 value for inhibition of thrombin generation (not 1200-to 1600-fold as stated in the letter), it is only modestly higher than the therapeutic range for UFH in venous thromboembolic disease (0.3-0.7 U mL -1 ), and substantially lower than levels expected during cardiopulmonary bypass (> 2.0 U mL -1 ) [4]. Thus, the findings in Fig.…”

mentioning

confidence: 83%

“…The basis for our suggestion to abstain from reversal with vitamin K of asymptomatic INRs between 4.5 and 10 is derived from four randomized controlled trials [3][4][5][6]. In three of those, the population studied had INRs of 4.5-10.0, whereas the smallest study included patients with INRs between 6.0 and 12.0 [4].…”

Section: Disclosure Of Conflicts Of Interestmentioning

confidence: 99%

“…In three of those, the population studied had INRs of 4.5-10.0, whereas the smallest study included patients with INRs between 6.0 and 12.0 [4]. The negative results are driven by the largest trial [5].…”

Section: Disclosure Of Conflicts Of Interestmentioning

confidence: 99%

See 2 more Smart Citations

Low-molecular-weight heparin inhibits plasma thrombin generation via direct targeting of factor IXa: a reply to rebuttal

Buyue

Misenheimer

Sheehan

2013

Journal of Thrombosis and Haemostasis

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mentioning

confidence: 83%

Section: Disclosure Of Conflicts Of Interestmentioning

confidence: 99%

See 1 more Smart Citation

Low-molecular-weight heparin inhibits plasma thrombin generation via direct targeting of factor IXa: a reply to rebuttal

Buyue

Misenheimer

Sheehan

2013

Journal of Thrombosis and Haemostasis

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“…73 As with other devices, some studies showed good agreement between whole blood heparin concentration and either ACT 74 or plasma anti-Xa levels 75 whereas, other studies showed no significant correlation. 76 An important feature of the HMS device is an in vitro individualized heparin dose-response assay. It is the Medtronic equivalent of the Hemochron RxDx system, but it assesses heparin concentration instead of ACT.…”

Section: Hms Plus Hemostasis Management System (Previously Hepcon)mentioning

confidence: 99%

Point-of-Care Testing for Anticoagulation Monitoring in Neuroendovascular Procedures

Hussein

Georgiadis

Qureshi

2011

AJNR Am J Neuroradiol

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SUMMARY: POC testing is defined as diagnostic testing at or near the site of patient care. Rapid measurement of the intensity of anticoagulation and, more recently, platelet inhibition allows dose titration of adjuvant medications such a heparin and antiplatelet agents during neuroendovascular procedures. However, knowledge among practicing physicians regarding the pathophysiologic basis of these measurements and variations in knowledge about the differences among devices is often limited. This review discusses the role of anticoagulation in endovascular procedures and the currently available POC tests for anticoagulation monitoring. ABBREVIATIONS:ACT ϭ activated clotting time; Anti-Xa ϭ quantitative chromogenic heparin assay; aPTT ϭ activated partial thromboplastin time; AT ϭ antithrombin; CI ϭ confidence interval; GP IIb/IIIa ϭ glycoprotein IIb/IIIa; Hemonox-CT ϭ Hemonox clotting time; HIT ϭ heparin-induced thrombocytopenia; HMT ϭ Heparin Management Test; IV ϭ intravenous; LMWH ϭ low-molecularweight heparin; MI ϭ myocardial infarction; OR ϭ odds ratio; PCI ϭ percutaneous coronary intervention; POC ϭ point of care; UFH ϭ unfractionated heparin T hromboembolism ensues from activation of platelets and the coagulation cascade and is a major source of complications during endovascular procedures. Multiple studies have demonstrated accelerated platelet activation during coronary and cerebral angioplasty.1,2 The coagulation cascade (Fig 1) consists of a sequential conversion of a series of proenzymes, or inactive precursor proteins (zymogens) to active enzymes, resulting in the formation of thrombus. It can be divided into 3 pathways: the extrinsic pathway (tissue factor and factor VIIa), which is the primary activator of the cascade; the intrinsic pathway (factors XIIa, XIa, IXa, and VIIIa), which amplifies the cascade; and the common pathway (factor Xa, factor Va, and thrombin), which generates thrombin and fibrin.Vessel injury and the introduction of foreign bodies set off the coagulation cascade.3 Catheters and wires used in endovascular procedures are thrombogenic, independent of intimal injury.3 Traversing atherosclerotic lesions with guidewires and catheters can dislodge plaque or thrombus. Inflation of balloons can produce intimal cracks, flaps, or dissections, all of which act as thrombogenic surfaces.3 In vivo studies have demonstrated that platelets rapidly accumulate on the stent surface after placement, especially if the underlying artery is injured. 4 The role of fibrin and platelets in stent-related thrombosis has been confirmed in pathologic studies. 5Anticoagulants and antiplatelet agents are, therefore, essential for reducing the rate of thromboembolic complications. On the other hand, their use may increase the risk of bleeding complications. In this review, we will focus on anticoagulants and available POC devices that measure anticoagulation. Brief Overview of Anticoagulant MedicationsAnticoagulants reduce the activity of proteases in the coagulation cascade. On the basis of their mechanism of ac...

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“…11 This inaccuracy is a source of error and a potential reason for the inter-patient variability observed in heparin dose responses indexed by activated clotting time (ACT) or serum heparin levels. [12][13][14][15] The magnitude of error in TBV estimation in patients undergoing cardiac surgery has not been systematically evaluated. Moreover, the severity and nature of cardiac disease may lead to substantial variation in TBV and, thereby, contribute to possible imprecisions of point-of-care anticoagulation management instruments.…”

Section: Introductionmentioning

confidence: 99%

Blood volume measurement by hemodilution: association with valve disease and re-evaluation of the Allen Formula

et al. 2014

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Blood volume assessment via the Allen Formula or bodyweight overestimated TBV in cardiac surgical patients, with potential implications on their management. The assumption that MR frequently presents with increased intravascular volume was confirmed whereas AS patients with coronary disease had a relatively smaller TBV. Lastly, a modified Allen Formula to better reflect today's patient population was derived to reproducibly improve accuracy in mathematical estimates of TBV.

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Heparin Concentration–Based Anticoagulation for Cardiac Surgery Fails to Reliably Predict Heparin Bolus Dose Requirements

Cited by 53 publications

References 26 publications

Low-molecular-weight heparin inhibits plasma thrombin generation via direct targeting of factor IXa: a reply to rebuttal

Low-molecular-weight heparin inhibits plasma thrombin generation via direct targeting of factor IXa: a reply to rebuttal

Point-of-Care Testing for Anticoagulation Monitoring in Neuroendovascular Procedures

Blood volume measurement by hemodilution: association with valve disease and re-evaluation of the Allen Formula

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