1. Approach to the Patients with Bleeding Tendency Hwi-Joong Yoon, MD Department of Hematology/Oncology Kyung Hee University School of Medicine

2. 2 Bleeding through a lesion/defect in the vascular wall I. Primary Hemostasis I. Primary Hemostasis platelets adhere to the margins of the lesion platelets aggregate forming a primary platelet plug II. Secondary Hemostasis a secondary hemostatic plug is formed further bleeding from the lesion is prevented repair of the vessel lesion by the fibrinolytic system is facilitated Hemostasis

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11. 11 Nichols WL et al: Guidelines. Haemophilia 2008

12. 12 Approach to the Bleeding Tendency Clinical Assessment Clinical Assessment Laboratory Assessment Laboratory Assessment

13. 13 Clinical Assessment: Major issues to be determined, principally from the medical history Is a bleeding tendency present? Is a bleeding tendency present? Is the condition familial or acquired? Is the condition familial or acquired? Is the disorder one affecting primary hemostasis (platelet or vessel wall dependent) or one affecting fibrin formation and stability (dependent on the fluid phase of coagulation)? Is the disorder one affecting primary hemostasis (platelet or vessel wall dependent) or one affecting fibrin formation and stability (dependent on the fluid phase of coagulation)? Is there another disorder present that could be the cause of or might exacerbate any bleeding tendency? Is there another disorder present that could be the cause of or might exacerbate any bleeding tendency? Is the increased bleeding pharmacologically induced? Is the increased bleeding pharmacologically induced?

14. 14 Is a Bleeding Disorder Present? Easy bruising: Easy bruising: large lesion, on the trunk, without trauma Mucosal Bleeding: Mucosal Bleeding: epistaxis, gingival bleeding, blood blister hematuria, hemoptysis, hematemesis, melena, rectal bldg Menorrhagia: Menorrhagia: > 7 days, heavy losses > 3 days, causing IDA Surgical Hemorrhage: Surgical Hemorrhage: dental extraction, tonsillectomy, delayed wound healing, unusual transfusion Postpartum Hemorrhage Postpartum Hemorrhage Joint and Muscle Bleeds Joint and Muscle Bleeds

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18. 18 Is There Underlying Systemic Disease Causing or Exacerbating the Bleeding Tendency? Liver disease, severe renal impairment, hyothyroidism, bone marow failure Liver disease, severe renal impairment, hyothyroidism, bone marow failure Paraproteinemia, amyloidosis Paraproteinemia, amyloidosis DIC DIC Drug: NSAID, steroid, quinidine, hearin (thrombocytopenia) Drug: NSAID, steroid, quinidine, hearin (thrombocytopenia)

19. 19 Herbs with Potential Anti- Platelet Activity Ginkgo ( 은행 ) Garlic ( 마늘 ) Bilberry ( 월귤나무열매 ) Ginger ( 생강 ) Dong quai Feverfew ( 흰꽃여름 국화 ) Asian Ginseng American Ginseng Siberian ginseng/eleuthero Tumeric Meadowsweet ( 조팝나무속 ) Willow ( 버드나무 ) Table 59-2 Herbal Supplements Associated with Increased Bleeding Coumarin-Containing Herbs Motherworth Chamomile Horse chestnut ( 마로니에 ) Red clover Fenugreek ( 호로파 )

20. 20 “The application of the basic clinical skills of history taking and clinical examination are essential components in the assessment of bleeding risk. The use of laboratory tests of coagulation and hemostasis can in no way act as a substitute for clinical assessment.”

21. 21 Laboratory Assessment Four screening test: Prothrombin Time (PT) Activated Partial Thromboplastin Time (aPTT) Platelet count Bleeding time (BT) Four screening test: Prothrombin Time (PT) Activated Partial Thromboplastin Time (aPTT) Platelet count Bleeding time (BT) Others: Thrombin Clotting Time (TCT) / Reptilase Time, Specific Clotting Factor Assays, Test of Platelet Function, etc. Others: Thrombin Clotting Time (TCT) / Reptilase Time, Specific Clotting Factor Assays, Test of Platelet Function, etc.

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23. 23 Prothrombin Time (PT) recalcifying citrated plasma in the presence of thromboplastin (rabbit brain or lung, recombinant thromboplastin with phospholipid) recalcifying citrated plasma in the presence of thromboplastin (rabbit brain or lung, recombinant thromboplastin with phospholipid) careful venipuncture through a No. 21 to No. 19 gauge needle careful venipuncture through a No. 21 to No. 19 gauge needle citrate anticoagulant : blood 1:9 citrate anticoagulant : blood 1:9 avoid contamination of other tissue avoid contamination of other tissue

24. 24 PTR (PT ratio) PTR (PT ratio) INR (International Normalized Ratio): therapeutic monitoring of oral anticoagulant drugs “correct” PT to the values of reference thromboplastin INR (International Normalized Ratio): therapeutic monitoring of oral anticoagulant drugs “correct” PT to the values of reference thromboplastin WHO IRP (International Reference Preparation) WHO IRP (International Reference Preparation) ISI (Internatinal Sensitivity Index) ISI (Internatinal Sensitivity Index) INR = PTR ISI INR = PTR ISI Prothrombin Time (PT)

25. 25 False Prolongation : small amount of sample, Hct > 55%, diluted blood False Prolongation : small amount of sample, Hct > 55%, diluted blood Inherited deficiency of II, V, VII, X Liver disease, vitamin K deficiency, DIC Inherited deficiency of II, V, VII, X Liver disease, vitamin K deficiency, DIC Heparin : no effect on PT at therapeutic concentration Heparin : no effect on PT at therapeutic concentration  PT may be prolonged shortly after bolus heparin  heparin can increase the prolonged PT of a patient taking wafarin Prothrombin Time (PT)

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27. 27 Activated Partial Thromboplastin Time calcifying plasma with “activator” and phospholipid without thromboplastin -> “partial thromboplastin” calcifying plasma with “activator” and phospholipid without thromboplastin -> “partial thromboplastin” activation : preincubation with negative charged substance e.g., kaolin, celite, ellagic acid, silica, sulfatide, dextran sulfate activation : preincubation with negative charged substance e.g., kaolin, celite, ellagic acid, silica, sulfatide, dextran sulfate Reference range : 4-6s around a mean aPTT of about 30s. Reference range : 4-6s around a mean aPTT of about 30s. Same errors in sample collection in PT Same errors in sample collection in PT Inhibitor vs. Deficiency ---> 50:50 mix with normal plasma Inhibitor vs. Deficiency ---> 50:50 mix with normal plasma

28. 28 screening VIII, IX, XI (XII, HMWK, PK) deficiency or inhibitor (I, II, V, X : PT is more sensitive) screening VIII, IX, XI (XII, HMWK, PK) deficiency or inhibitor (I, II, V, X : PT is more sensitive) monitor heparin : range 1.5-2.5 times the control (45 - 75s) monitor heparin : range 1.5-2.5 times the control (45 - 75s) screening for lupus anticoagulant screening for lupus anticoagulant Contamination of samples with heparin : fail to correct on mixing Contamination of samples with heparin : fail to correct on mixing Normal aPTT does not exclude a clinically significant hemostatic defect (late preg, oral contraceptive, postop, etc.)  factor assay Normal aPTT does not exclude a clinically significant hemostatic defect (late preg, oral contraceptive, postop, etc.)  factor assay Activated Partial Thromboplastin Time

29. 29 Activated Clotting Time monitor heparin anticoagulation monitor heparin anticoagulation W/B + activator W/B + activator less reproducible than aPTT no mixing dilutional study complicates quatlity control less reproducible than aPTT no mixing dilutional study complicates quatlity control 70 - 120s 70 - 120s normal with lupus anticoagulant normal with lupus anticoagulant

30. 30 Coagulation Factor Assay diagnose coagulation factor deficiency diagnose coagulation factor deficiency clarify the cause of abnormal PT/aPTT clarify the cause of abnormal PT/aPTT diluted test with specific factor-deficient plasma diluted test with specific factor-deficient plasma One-stage bioassay : aPTT Two-stage bioasay : thromboplastin generation time Chromogenic substrate assay One-stage bioassay : aPTT Two-stage bioasay : thromboplastin generation time Chromogenic substrate assay VIII -- labile protein --> fresh or quick-frozen at -40 o C VIII -- labile protein --> fresh or quick-frozen at -40 o C

31. 31 Plasma Thrombin Time Plasma Thrombin Time Plasma Concentration of Fibrinogen Plasma Concentration of Fibrinogen Factor XIII Factor XIII Fibrinolysis (  2-antiplasmin, etc.) Fibrinolysis (  2-antiplasmin, etc.) Factor VIII Inhibitor Assay Factor VIII Inhibitor Assay Protein C, Protein S, AT III, FDP, D-dimer Protein C, Protein S, AT III, FDP, D-dimer Other tests

32. 32 Skin Bleeding Time Ivy method : carefully trained personnel, 2.5-10 min Ivy method : carefully trained personnel, 2.5-10 min Influenced by platelet number, function, hematocrit, medication, renal impairment, macroglobulinemia, myelomatosis, hypo- or dysfibrinogenemia, factor V deficiency, von Willebrand disease Influenced by platelet number, function, hematocrit, medication, renal impairment, macroglobulinemia, myelomatosis, hypo- or dysfibrinogenemia, factor V deficiency, von Willebrand disease

33. 33 Platelet Aggregation Test Turbidometric platelet aggregometry Turbidometric platelet aggregometry Other methods Other methods

34. 34 Plasma and platelet von Willebrand factor assessment antigen antigen multimeric analysis multimeric analysis ristocetin cofactor activity ristocetin cofactor activity

35. 35 Quantitation of plasma coagulation factors 1.Functional assay (bioasssay) 2.Antigenic assay: CRM (cross-reacting material) CRM-positive = qualitative disorder = variant

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44. 44 Fresh Frozen Plasma (FFP) 160 mL (400 mL + 56 mL CPDA-1) 160 mL (400 mL + 56 mL CPDA-1) Fibrinogen : 230 - 240 mg/dL Fibrinogen : 230 - 240 mg/dL Factor V : 119 U/dL Factor V : 119 U/dL Factor VII : 89 - 94 U/dL Factor VII : 89 - 94 U/dL Factor VIII : 49 - 94 U/dL Factor VIII : 49 - 94 U/dL Factor IX : 84 - 125 U/dL Factor IX : 84 - 125 U/dL Other factors : 100 U/dL Other factors : 100 U/dL  Antithrombin, albumin, protein C, S