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Leveraging Turbidity and Thromboelastography for Complementary Clot Characterization
Published on: June 4, 2020
Use of Thromboelastography (TEG) for Detection of New Oral Anticoagulants
João D Dias1, Katherine Norem, Derek D Doorneweerd
1From Clinical Marketing, Haemonetics SA, Signy, Switzerland (Dr Dias); Operations Department (Ms Norem) and Scientific Research & Biomedical (Dr Doorneweerd), Haemonetics Corporation, Rosemont, and Medical Affairs, Haemonetics Corporation, Chicago (Dr Omert), Illinois; Hospital Division (Dr Thurer) and Medical Affairs (Dr Popovsky), Haemonetics Corporation, Braintree, Massachusetts; and Department of Surgery, Einstein Medical Center, Philadelphia, Pennsylvania (Dr Omert). Dr Omert is now with Acquired Bleeding, CSL Behring, King of Prussia, Pennsylvania.
Context:
The clinical introduction of new oral anticoagulants (NOACs) has stimulated the development of tests to quantify the effects of these drugs and manage complications associated with their use. Until recently, the only treatment choices for the prevention of venous thromboembolism in orthopedic surgical patients, as well as for stroke and systemic embolism in patients with atrial fibrillation, were vitamin K antagonists, antiplatelet drugs, and unfractionated and low-molecular-weight heparins. With the approval of NOACs, treatment options and consequent diagnostic challenges have expanded.
Objective:
To study the utility of thromboelastography (TEG) in monitoring and differentiating between 2 currently approved classes of NOACs, direct thrombin inhibitors (dabigatran) and factor Xa inhibitors (rivaroxaban and apixaban).
Design:
Blood samples from healthy volunteers were spiked with each NOAC in both the presence and absence of ecarin, and the effects on TEG were evaluated.
Results:
Both the kaolin test reaction time (R time) and the time to maximum rate of thrombus generation were prolonged versus control samples and demonstrated a dose response for apixaban (R time within the normal range) and dabigatran. The RapidTEG activated clotting time test allowed the creation of a dose-response curve for all 3 NOACs. In the presence of anti-Xa inhibitors, the ecarin test promoted significant shortening of kaolin R times to the hypercoagulable range, while in the presence of the direct thrombin inhibitor only small and dose-proportional R time shortening was observed.
Conclusions:
The RapidTEG activated clotting time test and the kaolin test appear to be capable of detecting and monitoring NOACs. The ecarin test may be used to differentiate between Xa inhibitors and direct thrombin inhibitors. Therefore, TEG may be a valuable tool to investigate hemostasis and the effectiveness of reversal strategies for patients receiving NOACs.
Insights
Thromboelastography (TEG) can monitor new oral anticoagulants (NOACs) and differentiate between direct thrombin and factor Xa inhibitors. This diagnostic tool aids in managing NOAC therapy and potential complications.
Area of Science:
- Clinical Chemistry
- Hematology
- Pharmacology
Background:
- New oral anticoagulants (NOACs) have expanded treatment options but present diagnostic challenges.
- Traditional anticoagulants include vitamin K antagonists and heparins.
- Monitoring NOACs requires novel diagnostic approaches.
Purpose of the Study:
- To evaluate the utility of thromboelastography (TEG) for monitoring new oral anticoagulants (NOACs).
- To assess TEG's ability to differentiate between direct thrombin inhibitors (e.g., dabigatran) and factor Xa inhibitors (e.g., rivaroxaban, apixaban).
Main Methods:
- Blood samples from healthy volunteers were treated with NOACs and ecarin.
- Thromboelastography (TEG) parameters were analyzed.
- Dose-response effects of NOACs on TEG were evaluated.
Main Results:
- TEG parameters, including R time, were prolonged by NOACs in a dose-dependent manner.
- RapidTEG activated clotting time created dose-response curves for all tested NOACs.
- The ecarin test differentiated between factor Xa inhibitors and direct thrombin inhibitors based on R time changes.
Conclusions:
- TEG, specifically RapidTEG activated clotting time and kaolin tests, can detect and monitor NOACs.
- The ecarin test shows potential for distinguishing between different classes of NOACs.
- TEG may serve as a valuable tool for investigating hemostasis and guiding reversal strategies in patients on NOACs.
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