Theophylline adenosine dipyridamole (CTAD) and citrate evaluation to survey unfractionated heparin treatment: a delayed centrifugation validation for anti-Xa measurement?

Unfractionated heparin (UFH) is the main anticoagulante used in intensive care unit. The anticoagulant effect is monitored by activated partial thrombin time (aPTT) and anti-Xa activity (anti-Xa) measurement. However, delayed centrifugation induces platelet factor 4 (PF4) release and anti-Xa decrease. Several studies have concluded that aPTT and anti-Xa measurement should be performed within 2 hours in citrated anticoagulant but may be delayed longer in citrate theophylline adenosine and dypiridamol (CTAD) anticoagulant. The objective of this study was to compare the stability of both aPTT and anti-Xa in citrate and CTAD samples, and to determine the effect of delayed centrifugation on both aPTT, anti-Xa results, and PF4 release in citrate samples only. Methods. aPTT and anti-Xa were measured in citrate and CTAD anticoagulant samples from 93 patients. Delayed centrifugation was performed in citrate samples from 31 additional patients, with hourly aPTT and antiXa measurement from 1 to 6 hours. In 14 of these last patients, PF4 release was also evaluated with Human CXCL4/PF4 Quantikine ELISA Kit. Results. We observed a significant correlation between citrate and CTAD anticoagulant for aPTT (r(2)=0.94) and anti-Xa (r(2)=0.95). With Bland-Altman correlation, a minor bias was observed for anti-Xa (-0.025 +/- 0.041). Delayed centrifugation in citrated anticoagulant showed an excellent concordance from 1 to 4 hours for aPTT (-4.0 +/- 5.3 s) and anti-Xa (1.10(-9)+/- 0.058 UI/mL) measurements. Moreover, PF4 release was not different between 1 hour (31.5 +/- 14.7 ng/mL) and 4 hours (33.8 +/- 11.8 ng/mL). Conclusion. We have demonstrated that anti-Xa measurement for unfractionated heparin should be done 4 hours in citrated plasma and thatCTADwas not better than citrate. However, these initial findings require confirmation using other aPTT and calibrated anti-Xa assays.