Enoxaparin Anticoagulation Monitoring in the Catheterization Laboratory Using a New Bedside Test
Johanne Silvain, MD*,
Farzin Beygui, MD, PhD*,
Annick Ankri, MD ,
Anne Bellemain-Appaix, MD*,
Ana Pena, PhD*,
Olivier Barthelemy, MD*,
Guillaume Cayla, MD*,
Vanessa Gallois, BS*,
Sophie Galier, BS*,
Dominique Costagliola, PhD ,
Jean-Philippe Collet, MD, PhD* and
Gilles Montalescot, MD, PhD*,*
* Institut de Cardiologie, Institut National de la Santé et de la Recherche Médicale (INSERM) CMR937, Pitié-Salpêtrière Hospital (AP-HP), Université Paris 6, Paris, France
Institut de Cardiologie, INSERM U720, Pitié-Salpêtrière Hospital (AP-HP), Université Paris 6, Paris, France
Service d'Hématologie Biologique, Pitié-Salpêtrière Hospital (AP-HP), Université Paris 6, Paris, France
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Figure 1 Flow Chart Representing Operation Clinical Events
The majority of patients (71.3%) received intravenous (IV) enoxaparin at the dose of 0.5 mg/kg, 21.6% received subcutaneous (SQ) enoxaparin only at the dose of 1 mg/kg/12 h (0.65 mg/kg/12 h in the case of renal impairment), and 7.1% received an additional 0.25 mg/kg IV dose in addition to SQ enoxaparin (last injection between 8 and 12 h). vit-K = vitamin K.
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Figure 2 Study Design
The first blood sample (T1) was drawn immediately after sheath insertion, and the second draw (T2) was obtained 10 min after the IV enoxaparin (Enox) bolus, if needed, according to the anticoagulation protocol. Patients previously treated with SQ enoxaparin and presenting within 8 h from the last injection had 1 draw (T2) just before percutaneous coronary intervention (PCI), as no additional anticoagulation therapy was administered to these patients. ACS = acute coronary syndrome; aPTT = activated partial thromboplastin time; Axa = anti-Xa activity; Cl Creat = renal clearance of creatinine; CT = clotting time; other abbreviations as in Figure 1.
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Figure 3 Biological Data
(Left) Hemonox clotting time distribution at time 1 (T1) and time 2 (T2). Horizontal red bars represent median and interquartile range. Out-of-range high (n = 36) and out-of-range low values (n = 4) were not represented on the graph. (Right) Anti-Xa activity level at T1 and T2. Horizontal red bars represent median and 75th and 25th percentiles (interquartile range). The bottom red line represents 0.5 IU/ml, and the top red line represents 1.8 IU/ml.
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Figure 4 ROC Curves
Receiver-operating characteristic (ROC) curves for Hemonox clotting time in red and activated partial thromboplastin time (aPTT) in blue for detection of patients with anti-Xa level <0.5 IU/ml using the Chromogenic assay as reference.
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Figure 5 Distribution of Hemonox CT
The blue line indicates a threshold of 120 s, identifying patients with anti-Xa activity <0.5 IU/ml with a sensitivity of 94.9% and a specificity of 73.9% when the Hemonox clotting time is <120 s (positive test to identify patient with inadequate level of anticoagulation). The horizontal red bars indicate median and interquartile range.
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