Coagulation Testing

What is it?
Why do we need it POC?

Marcia L. Zucker, Ph.D.

Director of Clinical Research

Educational Services,
Edison, NJ
Coagulation Testing
 Monitoring hemostasis

Bleeding Clotting
 Anticoagulants
Monitor with PT
In
t ri

H
ns

Monitor EP Extrinsic Pathway

ic

A
Pa

with aPTT R
IN
th

or ACT
wa
y

WARFARIN
DXaI
X Xa
Common Pathway II IIa LMWH
Monitor with (thrombin) Hirudin &
????? DTI
CLOT
 Coagulation is Complex

Picture from
DiaPharma.com
Common(?) Coagulation Tests
 Laboratory  Point of Care
PT..
aPTT
TT..
Fib.
– ACT
– Anti Xa » Celite®
– Anti IIa » Kaolin
– Factor Assays » Glass beads
» Silica
» thromboplastin
Differences in test methods
 Standard Laboratory  Point of Care
– Platelet Poor Plasma – Whole Blood
– Sodium Citrate – No Added
Anticoagulant Anticoagulant
– 1:9 Dilution – No Dilution
– Variable Preanalytical – No Preanalytical
Delay Delay
POC Coagulation Analyzers
 HEMOCHRON 401 / 801 / Response
 HEMOCHRON Jr. Signature / Signature +
 ProTime / 3
 Medtronic HMS/HMS+/ HemoTec ACT II / ACTPlus
 CoaguChek / S / Pro / Pro DM
 i-STAT
 Helena Actalyke
 Hemosense INRatio
 Others?
POC Coag Analyzers Differ
 Test methodology
– Sample size and application
» Microliters to milliliters
– Sample measurement
» Manual vs automated
– Clot detection method
» Enzyme detection method
 Thrombin generation
– Reagent composition
– Results
Clinical Applications
Operating Room
– Cardiac Surgery
– Interventional Cardiology and Radiology
 Critical Care
 Satellite Sites
– Dialysis
– ECMO
– Emergency Room
– Anticoagulation Clinic
History of the ACT
 Lee-White clotting time
– Manual
– No activator
– Very slow
 1966 –Hattersley- Activated Clotting Time
– Diatomaceous earth activator
– Operator defined mixing and clot detection
– Global assay - Contact activation of cascade
Activated
Clotting
Time
Particulate Contact Activation
 Initiation of intrinsic coagulation cascade
– Factor XII (Hageman factor)
– Prekallikrein (Fletcher factor)
 Dramatically shortens contact activation
period over Lee-White time
 Proposed as both screening assay for
coagulation defects and for heparin
monitoring
ACT Automation - 1969
 HEMOCHRON introduced
– semi-automated
– less operator dependence
– two assays
» CA510 (later FTCA510)
diatomaceous earth
activated
» P214 glass bead activated
2 assays for separate applications
700

600
C-ACT
500
Clotting Time (sec)

P214
400

300

200

100 CATH
ECMO PTCA CPB
0
0
Dialysis 1 2 3 4 5
Heparin (units/ml)
1980’s HemoTec ACT
 Liquid kaolin activator
 Different technology
– Different results
ACT Differences
 Recognized in literature >20 years
– Clinical evaluations of Hemochron
appeared in journals mid 1970’s
– By 1981, papers appeared showing little
correlation between ACT and heparin level
– By 1988, papers clearly showed clinically
different results between Hemochron and
HemoTec
 Differences ignored by clinicians
Why are there so many different ACTs?
700
C-ACT
600 K-ACT
500 ACT+
Clotting Time (sec)

P214
400 ACT-LR
300

200

100 CATH
CCU PTCA CPB
0
Dialysis
0 1 2 3 4 5
Heparin (units/ml)
Monitoring - ACT
 Benefits
– Industry Standard Since 1970s
– Recommended as primary method in
AmSECT guidelines (perfusion)
– Easy to run
 Disadvantages
– Each system yields different numbers
– High sensitivity to hypothermia and
hemodilution (with exceptions)
– Little or no correlation to heparin level
» especially true for pediatric patients
Heparinized ACT - CPB
700
675
650
625 Hemochron
600 Hemotec
Seconds

575 TAS
550 HMS
525
500
475

Pre 15 30 45 60 75 90 105
CPB min min min min min min min

Data from Huffman, et.al. 1998 AmSECT meeting

Pharmaceutical Intervention
 Amicar or Tranexamic Acid
– No effect on standard celite ACT
 Aprotinin
– Significant elevation of celite ACT
– Two dosing regimens
» Full or Half Hammersmith
» Both independent of patient size
ACT Monitoring-Aprotinin Treatment
 Celite ACT
– Not recommended
– Still used with target times of >750 seconds
 Kaolin ACT
– Unaffected by moderate doses of aprotinin
– Used with target times of > 480 seconds
 ACT+
– Unaffected by ALL doses of aprotinin
– Used with target times of > 400 seconds
 Monitoring in CPB - Aprotinin
C-ACT ACT+
1200
1200
Trasylol 1000
1000 Trasylol
Placebo
Placebo
800
800
600
600
400
400
200
200
0
0

Baseline

PostBolus

PostBolus2

OnPump

OnPump2

OnPump3

PostProt.
Baseline

PostBolus

PostBolus2

OnPump

OnPump2

OnPump3

PostProt.

 Data from clinical evaluation, on file, ITC

Other POC Coag in the OR
 aPTT / PT
– Pre- and post-procedural screening
 Fibrinogen
– Pre- and post-procedural screening
 Dosing Assays
– Customize heparin and protamine for each patient
» HEMOCHRON HRT / PRT
» Hepcon HMS
– Measure heparin level
» Relationship to coagulation status unclear
Other POC Coag in the OR
 Heparin neutralization verification
– Ensure complete removal of circulating
heparin
» aPTT
» PDA-O - ACT based
» TT / HNTT - Thrombin Time based
» heparinase ACT
Outcome studies - POC in OR
 Reduced Blood Loss/Transfusion
– Use of HRT and PRT (RxDx System)
 Reduced Cost Resulting from Use of POC Assays
– RxDx combined with TT / HNTT
 Reduced Complication Rates
– TT / HNTT
– Re-Exploration for Bleeding Reduced from 2.5% to
1.1%
– Re-Exploration for Coagulopathy Reduced from
1.0% to 0.0.
Clinical Applications
Operating Room
– Cardiac Surgery
– Interventional Cardiology and Radiology
 Critical Care
 Satellite Sites
– Dialysis
– ECMO
– Emergency Room
– Anticoagulation Clinic
Procedures
 Diagnostic
– Catheterization
» locate and map vessel blockage(s)
» determine need for interventional procedures
– Electrophysiology
– Interventional Radiology
 Interventional
– Balloon angioplasty
– Atherectomy (roto-rooter)
Diagnostic – Low dose heparin
 Catheterization and Electrophysiology
– 2500 - 5000 unit bolus dose
– frequently not monitored
– if monitored –
» ACT
» aPTT
Interventional – Moderate dose
 Angioplasty and Atherectomy
– Heparin
» 10,000 unit bolus dose or
» 2 - 2.5 mg/kg
» target ACT 300 - 350 seconds
 200 – 300 in presence of ReoPro
– Angiomax (bivalirudin)
» ACT >300
 Hemochron (ACT-LR or FTCA510) trials
» Measure post-bolus to ensure drug on board
» Required in patients with renal impairment
Why use platelet inhibitors?
 Angioplasty promotes aggregation
Adhesion
•shape change
• release 3 sec
ADP release

Aggregation

10 sec

Coagulation
•Fibrin
formation 5 min
Need to inhibit restenosis / reocclusion
Platelet Inhibitors
 ReoPro
– elevates ACTs
– target time = 250 sec with ReoPro
» determined using FTCA510 tube
 Integrelin
– No reported clinically significant
effects on ACT
 Aggrastat
– No reported effects on ACT
Clinical Applications
Operating Room
– Cardiac Surgery
– Interventional Cardiology and Radiology
 Critical Care
 Satellite Sites
– Dialysis
– ECMO
– Emergency Room
– Anticoagulation Clinic
ACT or aPTT
 Determine when to pull the femoral sheath
– Premature sheath pull can lead to bleeding.
– Delayed removal can increase time in CCU.
– Target set at each site.
» ACT targets range from 150 – 220 seconds
» aPTT targets range from 40 – 70 seconds
 Must be linked to heparin sensitivity of reagent used
ACT vs aPTT
120
110 y = 0.57x - 28.44
100 R = 0.896
aPTT (J103) (sec)

90
80
70
60
50
40
30
20
50 100 150 200 250
FTCA510 (sec)

Single site comparison, ACT tube vs HE Jr Sig aPTT

ACT or aPTT
 Monitor heparin therapy
– Target times determined by each facility
– APTT outcome study
» Reduce time to result (112 vs <5 minute)
» Reduce time to stabilization
» Reduce dose adjustments
» Reduce length of stay
» By using POC aPTT instead of lab
 Poster at AACC 2000 – Staikos, et.al.
Activated Partial Thromboplastin Time
In
t ri
ns

AP Extrinsic Pathway
ic

TT
Pa
th
wa
y

Common Pathway

CLOT
Activated Partial Thromboplastin Time
 NOT a PTT
– PTT is the predecessor of the aPTT
– Not used anymore
 Laboratory or Point of Care
 High APTT values
– presence of heparin
» treat by giving protamine
– underlying coagulopathy
» treat by giving FFP
 Monitor heparin / Coumadin® cross-over
Heparin versus Warfarin
Mechan- Moni-
Drug Action Effective
ism toring

Direct
ATIII APTT
Heparin Inhibition of Immediate
cofactor ACT
Thrombin
Decreases
Delay
Warfarin Production Vitamin K PT
3-5 days
of factors
Prothrombin Time
In
tri
ns
ic Extrinsic Pathway
Pa
th
wa
PT
y

Common Pathway

CLOT
 Prothrombin Time
 Monitor warfarin therapy
 Monitor heparin/warfarin crossover ISI
 PTpatient 
 Target times are set by INR   
 PTmeannormal 
International Normalized Ratio (INR)
ISI = international Sensitivity Index
– INR target ranges are specified by patient populations
» DVT, Afib, Atrial MHV: INR= 2.0 - 3.0
» Mitral mechanical heart valve: INR= 2.5 – 3.5
» Hypercoagulable disorders: INR= 1.5 – 2.5?
Will POC Results Match the Lab?

(Probably Not)
but it WILL Correlate
Correlate Does Not Mean Match

140 y = 0.737x + 22.2

R = 0.920
120
Signature APTT

100

80

60

40

20

0
0 50 Lab APTT 100 150
Coag is NOT Chemistry
Dade Actin / MLA Organon Technika / MDA
70 70
y = 0.72x + 11.5 y = 1.02x + 4.1
60 R = 0.883 60 R = 0.942
Signature

Signature
50 50
40 40
30 30

20 20
20 30 40 lab 50 60 70 20 30 40 lab 50 60 70

150.0 IL aPTT C / ACL #3 IL aPTT SP / ACL #2

150.0
y = 0.44x + 22.2
130.0 130.0 y = 0.59x + 16.0
R = 0.9533
110.0 110.0 R = 0.961
Signature

Signature
90.0 90.0
70.0 70.0
50.0 50.0
30.0 30.0
10.0 10.0
10 30 50 70 90 110 130 150 10 30 50 70lab 90 110 130 150
lab
 IL aPTT C /ACL #1 IL aPTT SP / ACL #1
100.0 100.0
y = 0.45x + 17.9 y = 0.35x + 22.1
80.0 80.0

S ig n a tu re
S ig n a tu re
Compare
R = 0.929 R = 0.928
60.0 60.0

40.0 40.0

for your
20.0 20.0
0.0 0.0
0 50 lab 100 150 0 50 lab 100 150

site. 100.0
IL aPTT C / ACL #2

y = 0.47x + 20.2
100.0
IL aPTT SP / ACL #2

y = 0.59x + 16.0
80.0
S ig n a tu re
80.0

S ig n a tu re
R = 0.942 R = 0.961
60.0 60.0

Same 40.0
20.0
40.0
20.0

System /
0.0 0.0
0 50 lab 100 150 0 50 lab 100 150

IL aPTT C / ACL #3 IL aPTT SP / ACL #3

Multiple 100.0
y = 0.44x + 22.2
100.0
80.0
y = 0.40x + 23.3

S ig n a tu re
80.0 R = 0.912
S ig n a tu re

R = 0.953
60.0

Sites
60.0
40.0 40.0

20.0 20.0

0.0 0.0
0 50 0 50 100 150
lab 100 150 lab
Are differences important?
 Sometimes no - aPTT C
Signature site 1 site 2 site 3
30 27 21 18
40 49 42 41
50 71 63 64
60 94 84 87
70 116 105 109
80 138 127 132
90 160 148 155
  Sometimes VERY - aPTT SP
Signature site 1 site 2 site 3
30 23 24 33
40 51 41 82
50 80 57 130
60 109 74 179
70 138 91 >200
80 167 108 >200
90 196 125 >200
Lot to Lot Reproducibility
Cuvette Lot a
80 Signature Lot a Lot b
70 y = 1.35x - 14.2 30 26 29
R=.909
60 40 40 43
Lab

50 50 53 57
40
60 67 70
30
70 80 84
20
20 40 60 80
80 93 98
Signature 90 107 112
Cuvette Lot b
80
y = 1.39x - 12.8
70 R=0.934
60
La b

50
40
30
20
20 40 60 80
Signature
Clinical Applications
Operating Room
– Cardiac Surgery
– Interventional Cardiology and Radiology
 Critical Care
 Satellite Sites
– Dialysis
– ECMO
– Emergency Room
– Anticoagulation Clinic
Dialysis / ECMO
 ACT (or nothing in dialysis)
– Majority use P214 glass activated ACT
– Some use ACT-LR; HemoTec LR ACT
 Better Control of Anticoagulation Leads to
Increased Dialyzer Reuse
– Potential for Long Term Cost Savings
– No Compromise in Dialysis Efficacy (Kt/V)
» Ouseph, R. et.al. Am J Kidney Dis 35:89-94; 2000
Emergency Room
 ACT; aPTT; PT; Fibrinogen
 Immediate Identification of Coagulopathies
– Optimization of Critical Decision Pathways
 ACT Allows Early Detection of Traumatic
Coagulopathy
– Allows Early Treatment Decisions
– Aids Damage Control Decisions
» Aucar, J. et.al. 1998 SW Surgeons Congress
 Optimize Staffing During Off Hours
Anticoagulation Clinics
 Results Available While Patient is Present
– Improved Anticoagulation Management
– Improved Standard of Care
– Staff Efficiency
 Immediate Retesting (if needed)
– Fingerstick Sampling
 Same System for Clinic and Home Bound
Patients
– Standardized ISI / PT normal
» Test System Specific
Anticoagulation Clinics
 Potential for Self-Testing
– High Risk Patients
– Patients Who Travel Frequently
– Home-Bound
– Patients in Rural Areas Far from Clinic
 Improved Outcomes Through More
Frequent Testing
Will POC Results Match the Lab?

(It will be a lot closer than for aPTT)

but it WILL Correlate
How to Compare INR Results

 Lower dose?
 Keep same dose?
 Raise Dose?

 Test Again?
 Test more often?
Lab to Lab Comparison
1.5
Mean difference = 0.3 INR
1
Difference (TPC - INN)

0.5

0
0 1 2 3 4 5 6 7
-0.5

-1

-1.5
Mean Innovin and TPC INR
INR Expectations
INR within 0.4 of lab > 80%
INR within 0.7 of lab > 90%
INR within 1.0 of lab > 95%

(values shown Pairs within Pairs within

are ranges)
AACC 2002
0.4 INR 0.7 INR
Lab to Lab 85.4 – 97.9 % 94.8 – 99.0 %
POC to Lab 74.7 – 89.9 % 87.9 – 99.0 %
POC to POC 89.9 – 94.9 % 97.0 – 99.5 %
Why Bother with POC Coag?
 Improved TAT - Turn Around Time
– Defined from the Clinician, not Lab view
– When is Turn Around Important
» Emergency Room
» ICU/CCU Dose Adjustments
» Operating Room / Cath Lab
– STAT Testing Turn Around
STAT Testing TAT
Lab (min) CPB (N=40) PVS (N=45)
Median 90.0 90.0
Mean 78.5 74.0
Minimum 38.0 21.0
POC (min) All Groups
Median 2.23
Minimum 0.33
Maximum 6.97

Fitch, et.al, J. Clin Monit & Comput. 1999. 15:197-204

Standardized Clinical Interpretation
 Defined Assay Sensitivity
– Requires Lot to Lot Reproducibility
 Defined Reagent Variability
– Identical Instrumentation and Reagents at All
Testing Sites
 Defined Critical Clinical Decision Points
– No Change of Normal Ranges or Target Times
Between Lots of Test Reagents or Testing
Locations
What’s the catch?

1. Regulatory compliance
2. Connectivity
Regulatory compliance - Who sets the rules?
– JCAHO
» Joint Commission on Accreditation of Health Care Orgs
– CAP
» College of American Pathologists
– FDA
» Food and Drug Administration
» CDRH
 Center for Devices and Radiological Health
– CMS
» Centers for Medicare and Medicaid Services
– CDC
» Centers for Disease Control
CLIA Applies to ALL Testing Areas
 Central Laboratory
 Satellite Labs
– Critical Care
– Surgical Suite
 Clinics
 Bedside testing
 Doctor’s office
CLIA Regulations for Coagulation
 Central Laboratory can hold the CLIA license
– Satellites can have independent licensure
 Moderately Complex tests
– Except – ProTime, Coaguchek, INRatio are waived
 Requires
– Certified Laboratory Director
– Record Keeping
– Training
– Quality Policy
Implementing POC coag requires:
 Method Validation - accuracy
– Comparison to current standard
» NCCLS Guideline EP-09 recommends 40 samples
– Linearity may be used if no current standard
– Is assay performance appropriate to clinical needs?
 Precision
– Controls may be used to establish within and between run
variability
 Training
– Document training of all personnel
» high school equivalence or higher education level
– competency evaluations at predetermined intervals
Implementing POC coag requires:
 Linearity NOT required for coag
 Calibration “does not apply to unit test systems that
cannot be adjusted”
 Calibration verification
• Current assumption:
– Equivalent to CAP POC.05450
» If the laboratory has more than one method-system for performing
tests for a given analyte, are they checked against each other at least
twice a year for correlation of patient results?
– CLIA requires at least 3 point check
New CLIA Regulations
 Work in progress
– New rules published January 2003
– Rules in effect March 23, 2003
– Interpretive guidelines published Jan 2004
– Inspections using new regulations now
» 2 year grace period to adapt new rules
» Ends Jan 2005
 Quality Assessment Program - Lab Responsibilities
– Establish & follow policies/procedures addressing ongoing
QA activity.
– Take corrective actions as necessary.
» Review their effectiveness.
» Revise policies/procedures as necessary to prevent recurrence.
– Communicate to staff.
– Document all assessment activities.
New CLIA Regulations
 Proficiency testing
– Changed consensus for PT program grading from 90% to 80%.
 Quality Assessment replaces Quality Assurance.
– Quality Assessment is interspersed throughout the regulation.
– Creates one set of nonwaived QC requirements.
 Subpart K - Quality System for Nonwaived Testing
– Laboratory is ultimately responsible for ensuring that all
components of the analytic process are monitored.
– Each laboratory that performs nonwaived testing must meet
the applicable analytic systems requirements; unless HHS
approves a procedure, specified in the Interpretive Guidelines,
that provides equivalent quality testing
Equivalent Quality Testing
 Traditional:
– Testing two levels of external control materials
each day of testing
– Except coag and blood gases
» every 8 hours of use
 Equivalent QC Options
– #2 -Test systems with internal/procedural
controls that monitor a portion of the analytic
components, and if the lab successfully
completes a thirty day evaluation process, the
lab may reduce the frequency of external quality
control materials to once per calendar week.
Equivalent Quality Testing
 Option #2
– Perform the test system’s internal control procedure(s) in
accordance with the manufacturer’s instructions (but not
less frequently than once each day of testing) and test two
levels of external control material daily for 30 consecutive
days of testing.
 EQC AND LQC daily (NOT every 8 hours) for 30 days
– Then OK to use EQC daily, LQC weekly
» Unless manufacturer requires more
– Send comments to: Judith Yost
» Director, Division of Laboratory Services, CMS
» JYost@cms.hhs.gov
» (410) 786-3407
Routine Quality Control
 Instrument Performance Verification
– Electronic Quality Control with Numeric Output
– Two levels per 8 hour shift (CLIA reg)
 Assay Performance Verification
– Wet QC as per Manufacturer’s Recommendation
» Varies by system
 No external QC required for ProTime / INRatio in
most States
» Within system may vary by waived or moderate
complexity licensure
Ensuring Compliance
 Required identification
– Mandatory operator ID
» Password control
» Reuse IDs for some applications
– Mandatory patient ID
» Reuse IDs for some applications
 Lockout
– Force QC at specific times
» QC must pass to run patient samples
– Lockout non-compliant or untrained operators
– Disallow specific assays
Connectivity
 Multiple definitions
– Download to computer
» To LIS or to HIS or to both or to data
management software
» Real time and / or batch
» QC data, patient data, or both
Connectivity
 Bidirectional communication
– Send data to instrument
» Reset lockouts
» Load configurations
 Operator tables
 QC frequency
 QC ranges
 Reuse availability
» Vary configuration by clinical setting
Solutions
 System specific configuration
– e.g. HCM for Signature+
HRDM for Response
 System specific data management
– e.g. ReportMaker for Signature / +
HRDM for Response
RapidLink for Bayer RapidPoint
DataCare for Roche CoaguChek / S / DM / Pro
 Link to systems designed for glucose
– Abbott and Roche state they will connect with any POC
instrumentation
Solutions
 Manufacturer neutral interface
– MAS RALS-plus
– Telcor Quick Serv
– Manufacturer works with interface supplier to
ensure compatibility
– Interface supplier works with LIS / HIS
supplier to ensure compatibility
– Likely more options as CIC guidelines
implemented (NCCLS POCT1-A)
Why Bother with POC Coag?

 Oncecompliance issues
addressed –
– Improved Clinical Outcome
– Reduced LOS – Length of Stay
– Improved, timely patient care