The Routine Determination of the Endogenous Thrombin Potential, First Results in Different Forms of Hyper- and Hypocoagulability

Summary

The area under the thrombin generation curve (the endogenous thrombin potential; ETP) has been proposed as a parameter for plasma-based hypercoagulability and to monitor anticoagulant treatment. We present an ETP assay for the routine laboratory using a centrifugal analyser. Throughput is 30 samples/h, within and between run imprecision is 4-5.6%. Suitable substrates were developed for the ranges of 10-500% and 2-100% of normal.

Independent of tissue factor concentration (if >4 pM), the normal value of the extrinsic ETP is 384.8 ±51.7 nM.min. The intrinsic ETP, triggered by ellagic acid, is 414 ± 41 nM.min.

The ETP is decreased to 15 and 35% of normal by oral anticoagulation (INR 2.5-4.0) and by heparin administration (APTT 1.5-2.5 X control).

The ETP is increased in untreated subjects with congenital antithrombin deficiency and in women using oral contraceptives. In deep vein thrombosis (phlebographically confirmed), it is increased by 29.4% (extrinsic) and 53% (intrinsic). In (angiographically assessed) coronary artery disease the increase is by 10% and 17% respectively.

• References

• 1 Virchow R. Gesammelte Abhandlungen zur Wissenschaftlichen Medizin. Berlin: Max Hirsch Verlag; 1962. pp 294
• 2 Biggs R, Macfarlane RG. Human Blood Coagulation and its Disorders. Oxford: Blackwell Scientific Publications. 1967 pp 67
• 3 Hemker HC. Thrombin Generation an Essential Step in Haemostasis and Thrombosis. In: Bloom AL, Forbes CD, Thomas DP, Tuddenham EGD. (eds). Haemostasis and Thrombosis. Edinburgh: Churchill Livingstone; 1993. pp 477-490
• 4 Hemker HC, Wielders SJH, Kessels H, Béguin S. Continuous registration of thrombin generation in plasma, Its use for the determination of the thrombin potential. Thromb Haemost 1993; 70: 617-624
• 5 Hemker HC, Béguin S. Thrombin generation in plasma: its assessment via the endogenous thrombin potential. Thromb Haemost 1995; 74: 134-138
• 6 Hemker HC, Willems GM, Béguin S. A computer assisted method to obtain the prothrombin activation velocity in whole plasma independent of thrombin decay processes. Thromb Haemost 1986; 56: 09-17
• 7 Jochmans K, Lissens W, Ting Yin, Michiels JJ, Van derLuit L, Peerlinck K, De WaeleM, Liebaers I. Molecular basis for type 1 antithrombin deficiency: Identification of two novel point mutations and evidence for a de novo splice site mutation. Blood 1994; 84: 3742-3748
• 8 Michiels JJ, Van derLuit L, Van VlietHHDM, Jochmans K, Lissens W. Nonsense mutation Arg 197 stop in a dutch family with type 1 hereditary antithrombin deficiency causing thrombophylia. Thromb Res 1994; 78: 251-256
• 9 Engel H, Zwang L, Van VlietHHDM, Michiels JJ, Stibbe J, Lindemans J. Phenotyping and genotyping of coagulation factor V Leiden. Thromb Haemost 1996; 75: 267-268
• 10 Rijkers DTS, Adams HPHM, Hemker HC, Tesser GI. A convenient synthesis of amino acid p-nitroanilides, synthons in the synthesis of protease substrates. Tetrahedron 1995; 51: 11235-11250
• 11 Rijkers DTS, Wielders SJH, Tesser GI, Hemker HC. Design and synthesis of thrombin substrates with modified kinetic parameters. Thromb Res 1995; 79: 491-499
• 12 Chan KE, Rizza CR, Henderson MP. A study on the coagulant properties of Malayan pit-viper venom. Br J Haemat 1965; 11: 646-657
• 13 Davey MG, Luscher EF. Actions of some coagulant snake venoms on blood platelets. Nature 1965; 207: 730
• 14 Bendetowicz AV, Béguin S, Caplain H, Hemker HC. Pharmacokinetics and pharmacodynamics of a low molecular weight heparin (Enoxaparin) after subcutaneous injection, comparison with unfractionated heparin. A three way cross over study in human volunteers. Thromb Haemost 1994; 71: 305-313
• 15 Svoboda P, Meier J, Freyvogel TA. Purification and characterisation of the a₂-antiplasmin and α₂-macroglobulin inactivating enzymes from the venom of the mexican west coast rattlesnake(Crotalus basilicas). Toxicon 1995; 33: 1331-1346
• 16 Lindhout T, Blezer R, Hemker HC. The anticoagulant mechanism of action of recombinant hirudin (CGP 39393) in plasma. Thromb Haemost 1990; 64: 464-468
• 17 Nemerson Y. Tissue factor, then and now. Thromb Haemost 1995; 74: 180-184
• 18 Morissey JH. Tissue factor modulation of factor VII avtivity. Thromb Haemost 1995; 74: 185-188
• 19 Béguin S, Lindhout T, Hemker HC. The mode of action of heparin in plasma. Thromb Haemost 1988; 60: 457-462
• 20 Von demBorne PAKr, Meijers JCM, Bouma BM. Feedback activation of Factor XI in plasma results in additional formation of thrombin that protects fibrin clots from fibrinolysis. Blood 1995; 86: 3035-3042
• 21 Bajzàr L, Manuel R, Nesheim ME. Purification and characterization of TAFI, a thrombin-activatable fibrinolysis inhibitor. J Biol Chem 1995; 270: 14477-14484
• 22 Barrowcliffe TW, Johnson EJ, Thomas DP. Low Molecular Weight Heparin. Chichester: John Wiley & Sons. 1992 pp 135
• 23 Levine NM, Hirsh J, Gent M, Turpie AG, Cruickshank M, Weitz J, Anderson D, Johnson M. A randomized trial comparing activated thromboplastin time with heparin assay in patients with acute venoembolism requiring large daily doses of heparin. Arch Intern Med 1994; 154: 49-56
• 24 Hull RD, Raskob GE, Rosenbloom D, Lemaire J, Pineo GF, Bayliss B, Ginsberg JS, Panju AA, Brill-Edwards P, Brant R. Optimal therapeutic level of heparin therapy in patients with venous thrombosis. Arch Intern Med 1992; 152: 1589-1595
• 25 Bums ER, Goldberg SN, Wenz B. Paradoxic effect of multiple mild coagulation factor deficiencies on the prothrombin time and activated partial thromboplastin time. Am J Clin Path 1993; 100: 94-98
• 26 Van derVelde EA, Poller L. The APTT monitoring of heparin – The ISTH/ ICSH Collaborative study. Thromb Haemost 1995; 73: 73-81
• 27 Sandset PM, Abildgaard U, Larsen ML. Heparin induces release of extrinsic coagulation pathway inhibitor (EPI). Thromb Res 1988; 50: 803-813
• 28 Sandset PM, Abildgaard U. Extrinsic pathway inhibitor – the key to feedback control of blood coagulation initiated by tissue thromboplastin. Haemostasis 1991; 21: 219-239
• 29 Hemker HC, Béguin S. Standardand Method Independent Units for Heparin Anticoagulant Activities. Thromb Haemost 1993; 70: 724-728
• 30 Hemker HC, Béguin S. The Activity of Heparin in the Presence and Absence of Ca⁺⁺Ions; why the Anti-Xa Activity of LMW Heparins Is about two Times Overestimated. Thromb Haemost 1993; 70: 717-718
• 31 Van denBesselaar AMHP. Recommended method for reporting therapeutic control of oral anticoagulant therapy. Thromb Haemost 1990; 63: 316-317
• 32 Hirsh J. Optimal Therapeutic Ranges for Unfractionated Heparin and Low Molecular Weight Heparins. In: Fuster V, Verstraete M. (eds). Thrombosis in Cardiovascular Disorders. Philadelphia: W. B. Saunders; 1992. pp 147
• 33 AÏach M, Michaud A, Capron L, Fiessinger JN. Determination of factor X and heparin with chromogenic substrate. Acta Chir Scand Suppl 1982; 509: 109-113
• 34 Rotteveel RC, Roozendaal KJ, Eijsman L, Hemker HC. The influence of oral contraceptives on the time-integral of thrombin generation (Thrombin Potential). Thromb Haemost 1993; 70: 959-962
• 35 Berends F, Morriën-Salomons WM, Van EnkA, Béguin S, Van denEnde A. Oral contraceptives induce the prethrombotic state. Thromb Haemost 1995; 73: 959 (abstr).