Beyond Clotting Time Clot Waveform Analysis (CWA)
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1 Beyond Clotting Time Clot Waveform Analysis (CWA) DR CHUEN WEN TAN CONSULTANT DEPARTMENT OF HAEMATOLOGY SINGAPORE GENERAL HOSPITAL FELLOW ANZAC RESEARCH INSTITUTE HAEMATOLOGY, CONCORD HOSPITAL
2 Outline Background Clinical pplications of CWA
3 Photo Optical Method of Clotting Time Measurement Activator Phospholipids Calcium Plasma Detector (Transmittance / Absorbance) CLOT
4 New Utility of An Old Test Addition of activator and calcium Transmittance (%) Data NOT utilized! CWA provides the solution Clotting Time (aptt) Time (s)
5 Understanding CWA
6
7 CWA Parameters CWA Parameters Coagulability
8 Growing List of Analyzers with CWA Function Table S 1 Coagulation analyzers and APTT reagents for Clot Waveform Analysis Coagulation analyzer CA 7000 Sysmex CS 5100 Sysmex CS 2000i, CS 2100i Sysmex CA 1500 Sysmex BCS Siemens BCT Siemens ACL Top 700 IL ACL Top 500 CTS IL ACL Top 300 CTS IL ACL Advance IL ACL FUTURA IL ACL ELITE pro IL ACL 7000 IL CD X Dia Med MDA II Trinity Coapresta2000 Shimazu Shima et al 2013
9 Applications of CWA
10 Early Disseminated Intravascular Coagulation (DIC) marker Biphasic Waveform Normal waveform Biphasic waveform (BPW) 1187 patients admitted to ICU BPW preceded DIC diagnosis by 18hours BPW is due to formation of a precipitate containing VLDL and CRP in the presence of Ca++ changes turbidity on recalcification of plasma Toh et al (Blood 2002)
11 APTT BASED CLOT WAVEFORM ANALYSIS IN VARIOUS INFECTIONS Retrospective study Subjects: Controls subject: Patients admitted for elective orthopedic, urology surgery with pre operative screening aptt Infection subject: Patients admitted with various infection (proven by cultures/molecular tests) who had aptt done within 48 hours of admission: 1. Patients with bacterial infection 2. Patients with dengue infection 3. Patients with viral respiratory tract infection Exclusion criteria: Subjects on anticoagulant, with active thrombosis and cancer, DIC
12 Different infections, different CWA parameters: Increased CWA results in bacterial infection and reduced CWA results in dengue infection P>0.05 P<0.05 P>0.05 P<0.05 P<0.05 P<0.05 Bacterial infection (n= 52) Dengue infection (n= 36) Other viral infection (n= 13) Control (n= 112) A B C EHA way Anova with Bonferoni correction Adjusted for age/gender/race
13 Application of CWA in Bleeding Disorders
14 Application of CWA in Bleeding Disorders
15 Application in Bleeding Disorders Detection of low levels of factor VIII and IX activities Management of haemophilia Factor replacement Bypassing agents including emicizumab
16 Application of CWA in Thrombotic Disorders
17 THE ASSOCIATION OF CWA PARAMETERS WITH ACUTE VENOUS THROMBOEMOBLISM (VTE) Retrospective study Subjects: Controls subject: Patients admitted for elective orthopedic, urology surgery with pre operative screening aptt Patients with acute VTE: Patients with acute VTE prior to initiation of anticoagulants
18 CWA parameters are significantly elevated in acute venous thromboembolism a b Min2 1.2 * p< c d 0.8 Patients Controls Patients (n) = 45 Controls (n) =111 aptt results similar between the groups EHA sample independent T test Adjusted for age/gender/race
19 Elevated CWA are strongly associated with venous thromboembolism Parameter Unadjusted Adjusted (for age, gender, ethnicity) Odds ratio 95% CI p value Odds ratio 95% CI p value APTT ratio Min1 >reference interval * < * <0.001 Min2 >reference interval * < * <0.001 Max2 >reference interval * < * <0.001 Delta change >reference interval * < * <0.001 EHA 2018 CWA as potential markers for hypercoagulability Ruberto et al (2018)
20 Comparability of CWA Results
21 Multicentre Study of Normal Controls 6 centres (at least 40 samples from each centre) 3 reagents: Actin FS, Actin FSL, Pathromtin SL (approximately 200 samples for each reagent) Analyzer: Sysmex CS2100i 3 rd Asia Pacific CWA Meeting (2018)
22 ACTIN FS: Normal ranges of CWA comparable across the labs
23 ACTIN FSL: Normal ranges of CWA parameters are comparable between the labs
24 Different aptt Reagents: CWA data are dissimilar
25 Possibility of combining CWA data and future multicentre studies Combine CWA data from different labs Coagulation analyser aptt reagents Standardised
26 CWA: Advantages vs Disadvantages Advantages Disadvantages Easily performed/automated Widely available Routine reagents Low cost Whole blood/platelet rich plasma samples not suitable Data on influence of preanalytical variables lacking
27 Conclusions Global haemostatic assay Wide availability Automated Cheap Potential applications in: Bleeding disorders Thrombotic disorders Infection/Sepsis
28 Acknowledgement Singapore General Hospital Department of Haematology Dr Heng Joo Ng Dr Lai Heng Lee Haematology Laboratory Dr Wan Hui Wong Thank You All the patients and blood donors
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