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PubMed1979

[Does low-dosage heparin treatment require serial haematological controls? (author's transl)].

Blanket serial controls are not necessary in low-dosage heparin treatment. It would, in any case, be difficult under normal clinical conditions and would run counter to the whole conception of low-dose heparin treatment. However, in problem cases with an increased thrombo-embolic risk, sensitive methods for monitoring the heparin effect are recommended. A study on 150 patients has indicated that the most sensitive method is the use of chromogenic substrates. Thrombin time, using low-concentration thrombin solution of 1.5 NIH units/ml, thrombelastogram and activated partial thromboplastin time are less sensitive. Antithrombin III levels should be determined in all cases of increased heparin tolerance. With reduced antithrombin III levels and higher body weight an increase of the standard dose from 5000 U.S.P. units heparin t. i. d. subcutaneously to 7500 U.S.P. units t. i. d. should be considered.

Antithrombins↗
PubMed1995

Perspectives on thromboelastography.

The knowledge of these sources of error together with strict methodology assure reliable results and avoid what some authors consider limitations of the test. These so-called limitations are actually due to incomplete information or insufficient experience. It is our opinion that the key for success when using TEG is to use the test in those cases for which it has been indicated. Also, the fact that TEG is a global test of coagulation should be kept in mind and therefore the need for additional hemostatic tests should be evaluated when applicable (Fig.3). According to this review, the established applications of TEG are as follows: (1) detection of hypercoagulable states, particularly in the postoperative period and for patients with malignancies; (2) management of patients who are administered intravenous heparin; (3) monitoring the coagulation state during liver transplantation; (4) monitoring the coagulation state and management of patients during cardiopulmonary bypass; and (5) diagnosis and treatment of hematologic dysfunctions, particularly hemophilia. Management of patients under warfarin administration, as well as monitoring of the adjustment of subcutaneous heparin prophylaxis in several surgical procedures, should probably belong to this list, but further studies are needed to confirm these roles. Used by experienced hands, TEG is a valuable hemostatic test, the future of which is already present.

Artifacts↗
PubMed2000

Comparative efficacy of different low-molecular-weight heparins (LMWHs) and drug interactions with LMWH: implications for management of vascular disorders.

The low-molecular-weight heparins (LMWHs) are more efficacious and safer than unfractionated heparin (UFH) in the prevention and treatment of venous thrombosis and to a certain extent in the treatment of acute ischemic syndromes. Because of their predictable pharmacokinetics and bioavailability after subcutaneous administration, LMWHs can be more convenient for outpatient use than UFH. Differences in the manufacturing process of LMWHs result in significant structural and molecular weight differences; thus, LMWHs have individual biochemical and pharmacological profiles and are not interchangeable on the basis of either mass or anti-Xa activity. Using thromboelastograph (TEG) and platelet aggregometry, this investigation compared the in vitro efficacy among various LMWHs and examined the interactions between LMWHs and platelet glycoprotein (GP) IIb/IIIa antagonists. TEG was used to determine the ability of platelet and fibrin interactions to augment blood clots, an effect measured under conditions of maximal platelet activation during clot formation accelerated by recombinant human tissue factor (TF). The comparative efficacy of LMWHs on different mediator-induced clot retraction in human blood was assessed by TEG, which demonstrated the potency of different LMWHs to inhibit various mediator-induced clot formations under shear. Tinzaparin was relatively more effective in inhibiting TF-, lipopolysaccharide-, factor (f) Xa-, and thrombin-induced clot formation under shear. Under these conditions, platelets significantly enhance clot strength (eightfold vs. platelet-free fibrin clots). LMWHs appear to have broader efficacy than other anticoagulants. Abciximab and roxifiban further inhibited clot strength by affecting the transmission of platelet contractile force to fibrin by platelet GPIIb/IIIa receptors. Subtherapeutic doses of tinzaparin combined with abciximab or roxifiban resulted in a distinct synergy that improved anticoagulant and antiplatelet efficacy mediated by TF, fXa, or thrombin. As these data suggest, the combination of low-dose tinzaparin with low-dose GPIIb/IIIa antagonists (abciximab, roxifiban) may be efficacious in the prevention and treatment of various thromboembolic disorders.

Amidines↗