1. Basic Clinician Training Module 5
Hypercoagulable states

2. Introduction
A prothrombotic or hypercoagulable state can be the result of:
Hyperactive platelet function and/or
Hyperactive coagulation cascade function
Proper assessment of the factor(s) contributing to a hypercoagulable state is necessary to determine proper pharmacological intervention to prevent the development of a thrombotic event.

3. Importance of assessing the hypercoagulable state
Percentage of Patients with a Thrombotic Complication
By Quartiles of MA Value
MA range
% with Thrombotic complication
McGrath DJ et al.
Anesth Analg 96:
SCA1-141, 2003

4. Insert graph from Sinai study

5. Assessing hypercoagulability with the TEG
TEG analysis can demonstrate hypercoagulable as well as hypocoagulable states
TEG analysis can differentiate between platelet hypercoagulability and enzymatic hypercoagulability.

7. Hypercoagulable states Platelet vs. enzymatic
Hyperactive platelet function is characterized by rapid clot development and abnormally high clot strength.
Hyper enzymatic pathway activity is characterized by rapid fibrin formation with subsequent clot formation.

8. Platelet hypercoagulability
Characterized by rapid clot development with higher than normal clot strength due to hyperactive platelet function.
Probable causes:
Diminished endogenous platelet inhibitory mechanisms
High platelet numbers
Abnormal generation of platelet activators
Inflammatory mediators

9. Platelet hypercoagulability Common conditions
Antithrombin III deficiency
Thrombomodulin-Protein C dysfunction or APC resistance
Diminished nitric oxide synthesis/release
Dysplasminogenemia
High plasminogen activator inhibitor
Hyperhomocysteinemia
Malignancy
DIC

10. Platelet hypercoagulability As shown by TEG
Patient status: high risk for thrombotic event
Probable cause: Rapid clot formation and strong clot development
Common treatment: Platelet inhibitor

11. Platelet hypercoagulability Treatment considerations
Step 1: Identify and quantify prothrombotic state
Step 2: Determine therapeutic response of anti-platelet therapies
WHY?: Patient resistance to aspirin and clopidogrel has been documented in the literature
HOW?: TEG analysis combined with PlateletMapping assay (Module 6).
Assesses platelet inhibition against total platelet function
Provides personalized treatment regimen

12. Platelet hypercoagulability Common therapy algorithm

13. Enzymatic hypercoagulability
Characterized by rapid fibrin generation with subsequent clot formation
Probable cause(s):
Loss of antithrombotic protective mechanisms
APC resistance (Factor V Leiden)
ATIII deficiency
Dysfibrinogenemia

14. Enzymatic hypercoagulability As shown by TEG analysis
Patient status: high risk for thrombotic event
Probable cause: Rapid thrombin generation and subsequent clot formation
Common treatment: Anticoagulation

15. Enzymatic hypercoagulability Special considerations
Treatment ultimately depends on clinical situation
Goal is to prevent clot formation
Common inpatient treatment: heparin, LMWH, APC (activate protein C)
Common outpatient treatment: LMWH or Coumadin to maintain INR > 2.0
If clots have already formed - may require fibrinolytic agent before anticoagulation

16. Platelet & enzymatic hypercoagulability Common conditions
Heart assist device
Lupus anticoagulant
Cancer
Orthopedic surgery
Pregnancy
Trauma
Burns
Sepsis

17. Platelet & enzymatic hypercoagulability As shown by TEG analysis
Patient status: high risk for thrombotic event
Probable cause(s):
Rapid thrombin generation
Excessive platelet function
Common treatment(s):
Anticoagulation and/or
Platelet inhibitor

18. Interpretation Exercises
Prothrombotic states

19. Exercise 1
Using the TEG Decision Tree, what is your interpretation of this tracing?
(select all that apply)
Platelet hypercoagulability
Enzymatic hypercoagulability
Platelet and enzymatic hypercoagulability
Secondary fibrinolysis
What would be an appropriate treatment, if any for this patient?
Answer
Next

20. Exercise 2
Using the TEG Decision Tree, what is your interpretation of this tracing?
(select all that apply)
Platelet hypercoagulability
Enzymatic hypercoagulability
Platelet and enzymatic hypercoagulability
Secondary fibrinolysis
What would be an appropriate treatment, if any for this patient?
Answer
Next

21. Exercise 3: Off-pump CABG patient
Kaolin with heparinase
Green: Pre-op
Black: Before protamine
The above are tracings from a patient who has undergone an off-pump
CABG. What is this patient’s current hemostatic state (black tracing)?
Platelet hypercoagulability
Enzymatic hypercoagulability
Platelet and enzymatic hypercoagulability
Secondary fibrinolysis
What would be an appropriate treatment, if any for this patient?
Answer
Next

22. Exercise 4
Using the TEG Decision Tree, what is your interpretation of this tracing?
(select all that apply)
Platelet hypercoagulability
Enzymatic hypercoagulability
Platelet and enzymatic hypercoagulability
Secondary fibrinolysis
What would be an appropriate treatment, if any for this patient?
Answer
Next

23. Exercise 5
Using the TEG Decision Tree, what is your interpretation of this tracing?
(select all that apply)
Platelet hypercoagulability
Enzymatic hypercoagulability
Platelet and enzymatic hypercoagulability
Secondary fibrinolysis
What would be an appropriate treatment, if any, for this patient?
Answer
Next

24. Exercise 6
Using the TEG Decision Tree, what is your interpretation of this tracing?
(select all that apply)
Platelet hypercoagulability
Enzymatic hypercoagulability
Platelet and enzymatic hypercoagulability
Secondary fibrinolysis
If this was a tracing from a pre-bypass cardiac surgical patient,
what type of antifibrinolytic treatment would you consider?
Answer
Next

25. Exercise 1
Using the TEG Decision Tree, what is your interpretation of this tracing?
(select all that apply)
Platelet hypercoagulability
Enzymatic hypercoagulability
Platelet and enzymatic hypercoagulability
Secondary fibrinolysis
What would be an appropriate treatment, if any for this patient?
Consider an anti-platelet agent.
Back
Next

26. Exercise 2
Using the TEG Decision Tree, what is your interpretation of this tracing?
(select all that apply)
Platelet hypercoagulability
Enzymatic hypercoagulability
Platelet and enzymatic hypercoagulability
Secondary fibrinolysis
What would be an appropriate treatment, if any for this patient?
Consider treatment with both an anticoagulant and anti-platelet
agent.
Back
Next

27. Exercise 3: Off-pump CABG patient
Kaolin with heparinase
Green: Pre-op
Black: Before protamine
The above are tracings from a patient who has undergone an off-pump
CABG. What is this patient’s current hemostatic state (black tracing)?
Platelet hypercoagulability
Enzymatic hypercoagulability
Platelet and enzymatic hypercoagulability
Secondary fibrinolysis
What would be an appropriate treatment, if any for this patient?
Although the R value is within normal range, the pre-op value was
lower than normal. Consider half the normal protamine dose plus
an anti-platelet agent.
Back
Next

28. Exercise 4
Using the TEG Decision Tree, what is your interpretation of this tracing?
(select all that apply)
Platelet hypercoagulability
Enzymatic hypercoagulability
Platelet and enzymatic hypercoagulability
Secondary fibrinolysis
What would be an appropriate treatment, if any for this patient?
Consider treatment with an anticoagulant.
Back
Next

29. Exercise 5
Using the TEG Decision Tree, what is your interpretation of this tracing?
(select all that apply)
Platelet hypercoagulability
Enzymatic hypercoagulability
Platelet and enzymatic hypercoagulability
Secondary fibrinolysis
What would be an appropriate treatment, if any, for this patient?
Consider an anticoagulant plus an anti-platelet agent.
Back
Next

30. Exercise 6
Using the TEG Decision Tree, what is your interpretation of this tracing?
(select all that apply)
Platelet hypercoagulability
Enzymatic hypercoagulability
Platelet and enzymatic hypercoagulability
Secondary fibrinolysis
If this was a tracing from a pre-bypass cardiac surgical patient,
what type of antifibrinolytic treatment would you consider? Since the patient
is hypercoagulable, treatment with an antifibrinolytic agent may be contra-
indicated at this phase in the surgery. Repeat a TEG during CPB to determine
if fibrinolysis has developed and treat accordingly.
Back
Next

31. End of Module 5