Table of Contents Background knowledgeCoagulation testsPT and INR = EXTRINSICAPTT = INTRINSICBleeding time = PLATELET FUNCTIONFibrinogen Important conditionsDifferentiating common bleeding disordersTest yourself with a scenario Background knowledge Haemostasis process: Coagulation cascade: Clot dissolution: Other things to know Natural anticoagulants: proteins C and S (inactivate factors V and VIII); antithrombin (inactivates many clotting factors)Vitamin K dependent clotting factors: II, VII, IX, X (+ proteins C and S)Most coagulation factors are synthesised by the liver NB: when an ‘a’ is placed after the clotting factor number (e.g. ‘factor Xa’), it means it is in its activated form. Coagulation tests Basic tests PT and INR = EXTRINSIC Tissue factor is added to blood in the laboratory to activate the extrinsic pathway. Clotting time (PT) is measured in seconds (normal usually = 12-13). However, the PT may vary depending on the reagent used, so the laboratory can use the PT to calculate the INR to standardise results (normal = 0.8-1.2).WEPT – Warfarin Extrinsic Prothrombin TimeOnly factor VII is involved in the extrinsic pathway, before the common pathway. Isolated factor VII deficiencies are rare, so PT/INR is only really affected by globally reduced clotting factor synthesis or increased consumption: Warfarin/vitamin K deficiencyLiver diseaseDisseminated intravascular coagulation APTT = INTRINSIC A contact activator is added to blood in the laboratory to activate the intrinsic pathway. Clotting time (APTT) is measured in seconds (normal usually = 30-50). The APTT can be divided by the mean normal value to calculate the APTT ratio if required.The APTT involves similar clotting factors to the extrinsic pathway PLUS others (VIII, IX, XI) so is affected by:Warfarin/vitamin K deficiencyLiver diseaseDisseminated intravascular coagulationPLUS anything which affects factor VIII (haemophilia A/von Willebrand disease), factor IX (haemophilia B), or factor XI (haemophilia C) NB: factor XII is also involved in the intrinsic pathway but isolated deficiencies are rare. NB: antiphospholipid syndrome is a common cause of a misleadingly prolonged APTT, due to antibody-mediated inactivation of the phospholipid added in the laboratory to activate the intrinsic pathway. Bleeding time = PLATELET FUNCTION Involves making an incision in the patient’s skin and timing how long it takes to stop bleedingMeasures platelet plug formation so only affected by conditions involving platelet quantity/functionRarely used in practice Fibrinogen Fibrinogen is a clotting factor involved in the final stage of coagulationThe fibrinogen level reflects the blood’s clotting ability (low = increased bleeding risk; high = may increase clotting)Low levels are due to: increased consumption (e.g. disseminated intravascular coagulation) or decreased production (e.g. liver disease, malnutrition)Fibrinogen is an acute phase protein and high levels may be due to: inflammation, malignancy, trauma, or infection Other relevant tests Full blood count: to check platelet count and other haematological abnormalitiesLiver function tests: to exclude liver function abnormalities as a cause for clotting problemsD-dimer/fibrin degradation products: tests the level of fibrin degradation products suggesting recent clot formation (e.g. DVT, PE, disseminated intravascular coagulation etc.) Advanced tests Antiphospholipid antibodies (e.g. lupus anticoagulant, anticardiolipin antibodies, anti-β2 glycoprotein I antibodies) – to look for antiphospholipid syndromeFactor assays ± factor inhibitor antibodies (e.g. factors VIII, IX, XI) – the level of individual clotting factors may be tested to look for common deficiencies (e.g. haemophilia A, B, C respectively) Important conditions Factor synthesis problems Vitamin K deficiency Vitamin K is a fat-soluble vitamin so may be deficient if there is fat malabsorption (e.g. in biliary obstruction – check LFTs) or a simple dietary deficiencyDeficiency leads to reduced synthesis of vitamin K dependent clotting factors (2, 7, 9, 10) and so affects both intrinsic and extrinsic pathwaysIf due to dietary deficiency, treat with oral vitamin K (phytomenadione) 5-10mg OD for 3 days; if due to fat malabsorption, give IV vitamin K or oral menadiol (a water-soluble vitamin K derivative) Liver disease The liver synthesises most clotting factors so liver disease can result in a global deficiency, affecting both intrinsic and extrinsic pathwaysPlatelets may also be reduced due to hypersplenismLiver-related coagulopathy is difficult to manage and is mainly supportive (e.g. FFP, cryoprecipitate, platelet transfusions as required). Vitamin K may be given if deficiency is suspected. Consumption Disseminated intravascular coagulation In severe systemic illness, dying cells release procoagulants, resulting in fibrin generation, which can occlude small vesselsThis process consumes platelets and clotting factors, resulting in bleeding elsewhereBlood tests reveal thrombocytopenia; increased PT/INR and APTT; low fibrinogen; and raised D-dimer and fibrin degradation productsTreat the cause and give supportive therapies (e.g. blood, platelets, FFP, cryoprecipitate) Drugs Warfarin (vitamin K antagonist) Reduces synthesis of vitamin K dependent clotting factors (II, VII, IX, X) and so affects both intrinsic and extrinsic pathwaysIts effect is monitored using INR, which is a measure of the extrinsic pathwayIt can be reversed using prothrombin complex concentrate and vitamin K Heparin Heparin is an anticoagulant that increases antithrombin activity by enhancing its binding to factor Xa and thrombin. Types of heparin that are commonly used include: Subcutaneous LMWH (e.g. enoxaparin): most commonly used for prophylactic and therapeutic anticoagulation. LMWH consists of only short chain heparins, so most of its activity is mediated by inhibition of factor Xa. Its effects are therefore more predictable than those of standard (unfractionated) heparin. Monitoring is not routinely required, but its effect can be measured by anti-factor Xa assay.IV or subcutaneous unfractionated (standard) heparin: consists of heparin chains with a variety of molecular lengths. Its effect on the coagulation cascade is therefore more wide-ranging and less predictable.Subcutaneous therapy may be used for prophylactic anticoagulation in patients with reduced renal function, since unfractionated heparin is predominately cleared by the liver, whereas LMWH is not. IV heparin has a short half life and stops working after 4 hours. It can therefore be used for therapeutic anticoagulation peri-operatively, or if there is significant risk of bleeding. It must be monitored regularly, using the APTT ratio, and dose-adjusted according to hospital guidelines. Both types of heparin can be reversed with protamine sulphate if required. Deficiencies Haemophilia Haemophilia A = factor VIII deficiencyHaemophilia B = factor IX deficiencyHaemophilia C = factor XI deficiency Clinical features depend on levels of affected factor but characteristically include haemarthroses and muscle haematomas. Von Willebrand disease Deficiency of von Willebrand factor, which is involved in platelet aggregation and adhesion, and binds to factor VIII to prevent its destructionVon Willebrand disease produces a platelet disorder picture of bleeding (petechiae, menorrhagia, contact bleeding, e.g. from gums) Autoimmune Antiphospholipid syndrome Antiphospholipid antibodies react against proteins that bind to plasma membrane phospholipids, resulting in arterial and venous thrombosisAntiphospholipid syndrome misleadingly causes a prolonged APTT because the antibodies inactivate the phospholipid added to activate the intrinsic pathway during the laboratory measurement of APTTAntiphospholipid antibody testing:Lupus anticoagulant assayAnticardiolipin antibodiesAnti-β2 glycoprotein I antibodies Differentiating common bleeding disorders Test yourself with a scenario A 34 year old male who was previously fit and well is referred by his GP to the Same Day Emergency Care unit with bilateral leg swelling and breathlessness. Blood tests are undertaken and are unremarkable other than a coagulation screen that reveals a significantly raised APTT (with a normal INR and fibrinogen). This is repeated and the results are the same. A CTPA confirms bilateral PEs and Dopplers of the lower limbs confirm bilateral extensive DVTs. Based on the blood test, which clotting pathway is affected? Oops! This section is restricted to members. Which clotting factors unique to this pathway? Oops! This section is restricted to members. Which conditions may cause a raised APTT? Oops! This section is restricted to members. Haematology are contacted and undertake a 50/50 mix study. Why did they do this test and how is it performed? Oops! This section is restricted to members. Haematology confirm that the APTT cannot be corrected by mixing studies. What is the likely diagnosis? Which additional tests would you send? Oops! This section is restricted to members. How would you treat this patent? Oops! 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