Prothrombin Time [CO004400]

Related Information

 Activated Partial Thromboplastin Time

 Bilirubin, Total, Serum
 Blood, Urine
 Coagulation Factor Assays
 Cryoprecipitate
 Disseminated Intravascular Coagulation Screen
 Factor Inhibitors
 Fibrinogen
 Hepatitis B Core Antibody
 Hepatitis C Virus RNA Detection and Quantitation
 Liver Disease: Laboratory Assessment, Overview
 Mixing Studies
 Plasma, Fresh Frozen
 Point-of-Care Testing
 Protein C
 Protein S
 Reptilase® Time
 Thrombin Time
 Warfarin

Synonyms Protime; PT

Applies to Argatroban; Common Pathway; Coumadin®; Extrinsic

Pathway; Heparin; Hirudin; INR; International Normalized Ratio;
Intrinsic Pathway; Thromboplastin; Vitamin K

Abstract The prothrombin time (PT) measures the clotting time from
the activation of factor VII, through the formation of fibrin clot (see
figure). This test measures the integrity of the extrinsic and common
pathways of coagulation, whereas the activated partial thromboplastin
time (PTT) measures the integrity of the intrinsic and common
pathways of coagulation. PT prolongations are most commonly caused
by factor deficiencies involving fibrinogen or factors II, V, VII, or X.
Less commonly, PT prolongations are due to an inhibitor, such as
therapeutic anticoagulants including heparin, hirudin, or argatroban.
Rarely, PT prolongations are caused by lupus anticoagulants or by
specific factor inhibitors against fibrinogen or factor II, V, VII, or X.
(SEE GRAPHIC IN BOOK)
Specimen Plasma

Container Blue top (sodium citrate) tube; 3.2% citrate tubes are now
recommended instead of 3.8% citrate tubes.1

Collection Routine venipuncture. If multiple tests are being drawn,

draw blue top tubes after any red top tubes but before any lavender
top (EDTA), green top (heparin), or gray top (oxalate/fluoride) tubes.
Recent data suggest that an initial discard tube is not necessary.2
Immediately invert tube gently at least 4 times to mix. Tubes must be
appropriately filled. Deliver tubes immediately to the laboratory.

Specimens drawn from a heparinized line are easily contaminated with

heparin, even when the initial volume drawn is discarded. Although
heparin prolongs the PTT, it can also prolong the PT to a lesser extent.
Hirudin and argatroban prolong the PT and PTT. Therefore, coagulation
tests are best drawn directly from a peripheral vein, avoiding the arm
in which heparin, hirudin or argatroban is being infused (if relevant).

Storage Instructions Separate plasma from cells as soon as

possible. Plasma (or uncentrifuged specimen) may be stored at room
temperature or on ice for up to 24 hours, otherwise store frozen.1

Causes for Rejection Specimen received more than 24 hours after

collection, tube not filled, clotted specimen, visible hemolysis

Turnaround Time Less than 1 day; often less than 1 hour if

requested stat. The PT and PTT are the most readily available
coagulation tests.

Reference Interval Varies significantly among different reagent-

instrument combinations. The approximate lower limit of normal is 10-
12 seconds; the approximate upper limit of normal is 12-14 seconds.
Newborns normally have prolonged PTs in comparison with adults. The
PT is up to approximately 16 seconds at birth, and the PT gradually
shortens into the adult normal range by the age of 6 months.3
However, newborns and infants do not normally experience bleeding,
because a balance between procoagulants and natural anticoagulants
is maintained.

Critical Values Longer than 30 seconds is the most commonly used

PT panic value in specialized coagulation laboratories according to the
College of American Pathologists 1999 Survey CG2-C, but the value
varies depending on the reagent-instrument combination and
individual laboratory policies.

Use Screen the integrity of the extrinsic (factor VII) and common
(fibrinogen and factors II, V, and X) pathways of coagulation; monitor
warfarin (Coumadin®) anticoagulation

Limitations With single factor deficiencies, the deficient factor has to

be below 15% to 45% before the PT becomes prolonged, depending
on the reagent. With multiple factor deficiencies, the PT becomes
prolonged with less severe decreases in factor levels.4

Deficiencies of factors VIII, IX XI, XII, prekallikrein, or high-molecular

weight kininogen do not affect the PT, but do affect the PTT. Factor
XIII does not affect the PT nor PTT. A specific factor XIII assay can
screen for factor XIII deficiencies.

Heparin can prolong the PT, depending on the reagent. Some reagents
contain a heparin neutralizer to reduce or eliminate heparin
interference.

Lupus anticoagulants uncommonly prolong the baseline PT. Most PT

reagents contain excess phospholipid such that lupus anticoagulants
(which are antiphospholipid antibodies) do not prolong the PT.
However, with some PT reagents, lupus anticoagulants can accentuate
the prolongation of the PT when patients are on warfarin.5 In these
situations, an alternative assay such as a chromogenic factor X assay
can be used rather than (or in addition to) the PT to monitor warfarin
(see Additional Information).

Methodology PT reagent is called thromboplastin (phospholipid with

tissue factor and calcium). It is added to patient plasma, and the time
until clot formation is measured in seconds. Tissue factor activates the
extrinsic pathway of coagulation. Phospholipid and calcium are
required cofactors in the coagulation cascade. Citrate in the blue top
tube prevents clotting by chelating calcium. PT reagents contain
excess calcium to overcome the citrate. More recently, point-of-care
PT test methods have become available which use a single drop of
whole blood, and these methods are undergoing evaluation.6

Additional Information If indicated, a vitamin K trial may be

performed in a patient with an unexplained PT prolongation. If the PT
prolongation is due to vitamin K deficiency, the PT becomes normal or
significantly shorter within 12-24 hours after vitamin K administration.
To determine the etiology of an unexplained PT prolongation, a mixing
study is usually the first step (if the PTT is also prolonged, the
presence of heparin or related anticoagulants must first be excluded -
see Mixing Studies). Mixing studies can predict whether the cause of
the PT prolongation is a factor deficiency or an inhibitor. The majority
of PT prolongations are due to factor deficiencies. If the PT mixing
study suggests a factor deficiency, assays for fibrinogen and factors II,
V, VII, and X can be performed to identify the deficient factor(s).
Inhibitors that prolong the PT are rare. Factor VII inhibitors prolong
the PT but not the PTT. Factor II, V, or X inhibitors typically prolong
the PTT as well as the PT (see Coagulation Factor Assays for more
information). As mentioned above, lupus anticoagulants are inhibitors
that commonly prolong the PTT, but uncommonly prolong the PT.

In patients with both a lupus anticoagulant and a prolonged PT, a

factor II assay could be considered, because occasionally lupus
anticoagulants cause decreased factor II due to increased clearance.

Acquired causes of PT prolongations are much more common than

hereditary causes, especially among inpatients (see list below). The
liver synthesizes all of the coagulation factors. Therefore, with liver
disease, multiple factor deficiencies can develop which prolong the PT
earlier and more than the PTT. Coumadin® or vitamin K deficiency
impair the function of factors II, VII, IX, and X, leading to PT and
eventually PTT prolongations. In disseminated intravascular
coagulation (DIC), multiple factor deficiencies may arise due to
activation and consumption of factors, prolonging the PT more often
than the PTT.7 Heparin inhibits activated factors II, X, IX, XI, XII, and
kallikrein by enhancing antithrombin activity, prolonging the PTT more
than the PT. Hirudin and argatroban inhibit only activated factor II
(thrombin), prolonging the PT and PTT.

CAUSES OF PT PROLONGATIONS:

Hereditary:

* Deficiency of factor VII (PTT is normal)

* Deficiency of fibrinogen or factors II, V, or X (PTT may
also be prolonged)

Acquired:

* Liver dysfunction (PT affected earlier and more than

PTT)
 * Vitamin K deficiency (PT affected earlier and more
than PTT)
* Warfarin (PT affected earlier and more than PTT)
* Disseminated intravascular coagulation (DIC) (PT
affected earlier and more than PTT)
* Lupus anticoagulants (may or may not prolong the
PTT; PT is rarely prolonged)
* Heparin (PT less affected than PTT, PT may be
normal)
* Hirudin or argatroban (PTT also prolonged)
* Specific factor inhibitors (PTT also prolonged except in
the rare case of an inhibitor against factor VII)

The effects of hereditary or acquired factor deficiencies on PT and PTT

are shown in Tables 1 and 2 in Coagulation Factor Assays. Factor
half-lives are summarized in Table 3 in that listing.

Monitoring warfarin: Warfarin is monitored by the international

normalized ratio (INR). The usual therapeutic goal is an INR of 2-3.
The INR is calculated from the PT and is intended to allow valid
comparisons of results regardless of the type of PT reagent used
among different laboratories:

INR = [patient PT / mean normal PT]ISI

The international sensitivity index (ISI) is a measure of the sensitivity

of a particular PT reagent. Different PT reagents have different
sensitivities to factor deficiencies. For example, with an insensitive
reagent, the PT will not become prolonged until the factor levels are
very decreased, whereas with a sensitive reagent, the PT will become
prolonged with milder factor deficiencies. Insensitive reagents have
higher ISI values, up to about 3.0. Sensitive reagents have lower ISI
values, down to about 1.0. The ISI for each reagent is determined by
the manufacturer.

During warfarin initiation, the PT/INR is typically checked daily or at

least 4-5 times per week until the dose and INR are therapeutic and
stable.8 The interval between PT/INR tests can then be gradually
decreased to as infrequently as every 4 weeks, depending on the
stability of the dose and the PT/INR result.8,9 It takes 4-5 days for
warfarin's antithrombotic action to take effect, because the half-lives
of factors II and X are relatively long. For this reason, patients who
need immediate anticoagulation are treated with an immediate-acting
anticoagulant (eg, heparin) while waiting for warfarin to become
therapeutic. Heparin is typically continued until the INR is in the
desired range for two consecutive days.9

To treat warfarin overdose (bleeding), vitamin K or fresh frozen

plasma can be administered.9 If the INR is >5 without bleeding,
vitamin K administration can be considered. If large doses of vitamin K
are administered, patients can become temporarily warfarin resistant.

Warfarin (Coumadin®) and vitamin K deficiency share the same

molecular basis for their effects. Warfarin is used as a therapeutic
anticoagulant because it impairs the regeneration of active vitamin K,
thereby decreasing the amount of active vitamin K. Vitamin K in its
active form is a cofactor in a reaction which carboxylates glutamic acid
residues to form gamma carboxyglutamic acid residues on factors II,
VII, IX, and X as well as protein C and protein S. This carboxylation
step is necessary for normal activity of these proteins. As a result,
vitamin K deficiency or warfarin therapy decreases the activity of these
proteins and prolongs the PT. Patients with mild vitamin K deficiency
or low levels of warfarin anticoagulation can have a normal PTT.

In certain situations (eg, lupus anticoagulants or the concomitant use

of hirudin or argatroban with warfarin) alternative assays may be used
to monitor warfarin because the PT/INR will be elevated by hirudin,
argatroban, and occasionally by lupus anticoagulants.5 Alternative
assays (eg, chromogenic factor X assays) are not affected by these
interferences. However, alternative assays have not yet been well
studied in these settings. An INR of 2-3 corresponds approximately to
a chromogenic factor X of 20% to 40%.

Changes in dietary vitamin K (see website reference below) and many

medications (many of which are listed in reference 9) can alter the
warfarin dose requirement. Hyperthyroidism, liver failure, cancer,
fever, or vitamin K deficiency (from malabsorption, steatorrhea, poor
nutrition, certain antibiotics etc) tend to decrease the dose required to
increase the PT. Hypothyroidism or certain genetic polymorphisms
tend to increase the dose requirement.10 Some patients have
hereditary warfarin resistance, an uncommon condition in which very
high doses of warfarin are needed to maintain a therapeutic INR.

Warfarin should not be used alone in the acute setting of heparin-

induced thrombocytopenia, because paradoxical thrombosis can occur.
If warfarin is used in this setting, a rapid-acting anticoagulant (eg,
hirudin, danaparoid, or argatroban) must also be used until the INR is
therapeutic.11 A similar approach is used for patients with hereditary
protein C or protein S deficiency, to prevent Coumadin®-induced skin
necrosis.

Footnotes

1. NCCLS, "Collection, Transport, and Processing of Blood Specimens

for Coagulation Testing and General Performance of Coagulation
Assays: Approved Guideline 3rd edition," NCCLS Document H21-A3,
NCCLS, 940 West Valley Road, Wayne, Pennsylvania 19087, USA
1998.

2. Gottfried EL and Adachi MM, "Prothrombin Time and Activated

Partial Thromboplastin Time Can Be Performed on the First Tube,"Am J
Clin Pathol, 1997, 107(6):681-3.

3. Andrew M, Paes B, and Johnston M, "Development of the

Hemostatic System in the Neonate and Young Infant,"Am J Pediatr
Hematol Oncol, 1990, 12(1):95-104.

4. Burns ER, Goldberg SN, and Wenz B, "Paradoxic Effect of Multiple

Mild Coagulation Factor Deficiencies on the Prothrombin Time and
Activated Partial Thromboplastin Time,"Am J Clin Pathol, 1993,
100(2):94-8.

5. Moll S and Ortel TL, "Monitoring Warfarin Therapy in Patients With

Lupus Anticoagulants,"Ann Intern Med, 1997, 127(3):177-85.

6. Sawicki PT, Working Group for the Study of Patient Self-

Management of Oral Anticoagulation, "A Structured Teaching and Self-
Management Program for Patients Receiving Oral Anticoagulation,"J
Am Med Assoc, 1999, 281(2):145-50.

7. Spero JA, Lewis JH, and Hasiba U, "Disseminated Intravascular

Coagulation: Findings in 346 Patients,"Thromb Haemost, 1980,
43(1):28-33.

8. Fairweather RB, Ansell J, van den Besselaar AM, et al, "College of

American Pathologists Conference XXXI on Laboratory Monitoring of
Anticoagulant Therapy. Laboratory Monitoring of Oral Anticoagulant
Therapy,"Arch Pathol Lab Med, 1998, 122(9):768-81.
9. Hirsh J, Dalen JE, Anderson DR, et al, "Oral Anticoagulants.
Mechanism of Action, Clinical Effectiveness, and Optimal Therapeutic
Range,"Chest, 1998, 114(5):445-69S.

10. Taube J, Halsall D, and Baglin T, "Influence of Cytochrome P-450

CYP2C9 Polymorphisms on Warfarin Sensitivity and Risk of Over-
Anticoagulation in Patients on Long-Term Treatment,"Blood, 2000,
96(5):1816-9.

11. Warkentin TE, "Heparin-Induced Thrombocytopenia: IgG-Mediated

Platelet Activation, Platelet Microparticle Generation, and Altered
Procoagulant/Anticoagulant Balance in the Pathogenesis of Thrombosis
and Venous Limb Gangrene Complicating Heparin-Induced
Thrombocytopenia,"Transfus Med Rev, 1996, X:249-58.

References

Bajaj SP and Joist JH, "New Insights Into How Blood Clots:
Implications for the Use of APTT and PT as Coagulation Screening
Tests and in Monitoring of Anticoagulant Therapy,"Semin Thromb
Hemost, 1999, 25(4):407-18.

Hyers TM, Agnelli G, Hull RD, et al, "Antithrombotic Therapy for

Venous Thrombotic Disease,"Chest, 1998, 114(5):561-578S.

Internet Web Sites

www.nal.usda.gov (foods with vitamin K)

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%3a//www.mgh.harvard.edu/labmed/lab/coag/handbook/CO004400.htm