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Published on: September 9, 2012
Prediction of survival in patients suspected of disseminated intravascular coagulation
E Hjorleifsson1, M I Sigurdsson2,3, B R Gudmundsdottir4
1University of Iceland School of Health Sciences, Landspitali National University Hospital, Reykjavik, Iceland.
Insights
Low levels of antithrombin (AT) and protein C (PC) predict mortality in patients suspected of disseminated intravascular coagulation (DIC). Mortality risk increases with lower protein levels and higher ISTH DIC scores, even before overt DIC criteria are met.
Area of Science:
- Hematology
- Critical Care Medicine
- Clinical Chemistry
Background:
- Disseminated intravascular coagulation (DIC) involves consumption of key coagulation proteins like antithrombin (AT), protein C (PC), and antiplasmin (AP).
- The prognostic value of these protein levels in patients initially suspected of acute DIC, regardless of overt diagnostic criteria, remains unclear.
- Understanding these associations is crucial for risk stratification in critically ill patients.
Purpose of the Study:
- To investigate the association between plasma levels of AT, PC, and AP and mortality in patients suspected of acute DIC.
- To determine if these protein levels and the International Society of Thrombosis and Haemostasis (ISTH) DIC score predict mortality across the spectrum of suspected DIC.
- To evaluate the prognostic significance of these markers in patients who do and do not fulfill overt DIC criteria.
Main Methods:
- A 5-year prospective study of consecutive patients clinically suspected of acute DIC at a tertiary referral hospital.
- Patients were scored using the overt ISTH DIC criteria.
- Plasma levels of AT, PC, and AP were measured, and their correlation with ISTH DIC score and mortality (28-day and 1-year) was assessed.
Main Results:
- Of 1814 patients, 91 met overt ISTH DIC criteria (score ≥5).
- Lower levels of AT and particularly PC were significantly associated with increased 28-day and 1-year mortality.
- Both AT and PC levels correlated inversely with the ISTH DIC score, and AP decreased with higher scores (≥4).
- Mortality risk increased progressively with decreasing ISTH scores, highlighting risk even below the overt DIC threshold.
Conclusions:
- Reduced antithrombin and protein C activity are significant predictors of mortality in critically ill patients with suspected acute DIC.
- Mortality risk escalates across the entire spectrum of the ISTH DIC score, not solely in patients meeting overt DIC criteria.
- These findings underscore the importance of monitoring AT and PC levels for early risk assessment in suspected DIC.
Background:
Although antithrombin (AT), protein C (PC), and antiplasmin (AP) are consumed during disseminated intravascular coagulation (DIC), their association with mortality in patients initially suspected of acute DIC is unknown. We examined how these proteins associate with mortality in consecutive patients initially suspected of DIC, fulfilling or not fulfilling overt DIC criteria.
Methods:
All consecutive patients clinically suspected of acute DIC during 5 years at a tertiary referral hospital were scored according to overt International Society of Thrombosis and Haemostasis (ISTH) DIC criteria. The influence of ISTH DIC score and measurements of AT, PC, and AP measured in all on mortality was assessed.
Results:
During 1825 occurrences in 1814 patients, 91 fulfilled ISTH criteria for overt DIC (score ≥ 5). Both 28-day and 1-year mortality increased progressively as AT and in particular PC decreased. AT and PC correlated inversely with ISTH score (AT: R(2 ) = 0.14, P < 0.001, PC: R(2 ) = 0.21, P < 0.001). AP decreased when ISTH score of > 3 was reached. The 28-day mortality was 3%, 11%, 16%, 23%, 35%, and 52% and 1-year mortality 5%, 18%, 24%, 36%, 54%, and 63%, respectively for patients with an ISTH score of 0, 1, 2, 3, 4, and ≥5 (P < 0.001 for all).
Conclusions:
Lowered AT and in particular PC activity was predictive of mortality risk upfront in critically ill patients suspected of acute DIC. Mortality in patients suspected of acute DIC increased progressively across the spectrum of the overt ISTH score and not only in those fulfilling overt DIC criteria.
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