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·Antithrombotic Therapy

·The manuscript of this volume uas auarded
HONORABLE MENTION
in the first Modern Medical Monographs Competition

·MODERN MEDICAL MONOGRAPHS
20
Editor in Chef IRVIM S WRIGIIT VD
Consulting Editor RICITARD II ORR NID
Antithrombotic Therapy
By PAUL W BOILES, MD
Instructor in Medicine University of Man School of
Medicine Jackson Vemorial Hospital Viami Florida
and Dir ctor Coagulation Research Laboratory Miami
Heart Institute Miami Beach Florida
GRUME & STPATTON
.
1959
NEV TOP AND LONDON

·Copyright 0 1959 by Grune and Stratton Inc
381 Park Avenue South New York 16 New York
Library of Congress catalog card number 59-13741
Printed and bound in the United States of America
(B)

·Contents
PRFFACE
111
1
1 THF MECHANISM OR BLOOD COAGULATION
2 CLOTTING TESTS
8
3 ANTITHROVIBOTIC REACTIONS
15
4 CLINICAL USF OF ANTITHROMBOTIC AGENTS
21
5 PRFSENT STATUS OF ANTICOAGULANT THERAPY
40
6 LONG TERY ANTICOAGUI ANT THERAI Y
50
7 THROVIBOLYTIC THERAP!
55
BIBLIOGRAPHY
80
95
ADDENDUN
SYNONYVS TOR Bioop COAGULATION FACTORS
1 FCHNIC OF BLOOD COAGULATION TESTS
95
99
SOLUTIONS
122
INDEX
127

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·Preface TO INVADE No such controversial fields of medicine as the mechanism of blood clotting and the treatment of thromboem bolic diseases would seemn presumptuous However rapid prog ress has been made in both these fields in the last 10 years Increased understanding of the complex mechanisms involved in blood coagulation has been made possible through the study of purified coagulation proteins with this technical advance in the purification of these various factors a new era in the direct treatment of thromboembolic diseases is not possible through the clinical utilization of streptokinase and fibrinolysin These agents combined with anticoagulants offer a rational approach to the treatment of intravascular clotting This monograph has been prepared to provide the clinician mth a practical under standing of the normal mechanisins of blood coagulation and coagulation defects produced by antithrombotic therapy Per haps in no other field of medicine is the practical application of basic research and laboratory studies so vital to the patient as in the present use of antithrombotic agents in thromboembolic diseases The encouragement and suggestions of my colleagues and friends I gratefully acknowledge Doctors ES Nichol Ralph Jones Jr Franz H Stewart and John H Ferguson Also I gratefully acknowledge the assistance of Mrs Catherine Ashley Florence Wey Tracy Channing Fox and Lillian Gong PAUL W BOYLES MD

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·Το Chris, Pat an Marc

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·TO Chris, Past and Marc

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·1 The Mechanism of Blood Coagulation THE LITERATURE on blood congulation contributes little because of conflicting clums superfluous hypotheses and varied ter minology The basic facts hoveier are relatively simple Blood coagulation is essentially the conversion of a soluble plasma protein (fibrinogen) into an insoluble colloidal gel (fibrın) This is specifically influenced by an enzyme (thrombın) which is formed from an inactive plasma protein (prothrombın) The activation of prothrombin is catalyzed by thromboplastın an agent whose chemical nature is still unknown Substances having thromboplastic activity are present in various tissues particu larly brain lung uterus and endothelium Plasma or intrinsic thromboplastın is produced by an interaction of coagulation proteins with phospholipids derived from platelets or from crude extracts of animal or vegetable origin 34 Initiating the corgulation process is injury to the endothe lium which then fornis 1 foreign surface that activates intrinsic thromboplastin Also if rupture of vessels occurs tissue throm boplastin enters the blood to initiate the process further Local factors such as stasis 76 narrowing of vessels from atherosclerosis or tissue damage determine the progression of clotting since the copulation factors which are locally activated are also rapidly diluted in the circulating blood and quickly inaceu ated Blood does not clot in normal vessels therefore intravascular clotting usually indicates some locul pathologic condition After its initiation the congulation process can be divided into three major reartions numely the generation of thromboplastin thrombin und fibrin respectively The over all time required for these reactions is called the clotting cime clinical test commonly used for the velocity ·2 ANTITHROMBOTIC THERAPY of the last tio reactions thrombin and fibrin is called the prothrombin time Naturally occurring inlubitors and the dilutory effects of circulating blood tend to limit the clot locally This may trien be dissolved by an enzyme (fibrinolysın) which is present in the plasma in an inactive state The three coigula tion rcactions the various deficiencies and laboratory tests are discussed individually STAGE I THROMBOPLASTIN GENERATION Since calcium ions are necessary for coagulation blood can be rendered incongulable by the addition of sodium citrite or potassium oxalate which bind the calcuum When excess calcium is then added to either citrated or oxalated blood the clotting mechanism is gun restored This process is known as recalcifi cition However platelet free plasma prepared by centrifuging citrated or oxalated blood in order to remove the formed ele ments (red blood cells white blood cells and platelets) still will not coagulate when recalcified This demonstrates the importance of an additional factor in the hemostatic mechanism which has been proved to be the platelets In fact diathetic bleeding (thrombocytopenic pur pura) is scen clinically in patients with a markedly reduced platelet count (below 50 000 per cu mm) Recent studies however have shown that phospholipids contuning phos phatidyl ethanolamines can be substituted for platelets both in vitro and in vivo 160 Nevertheless with incrcasing purifica tion of the phospholipid fractions there is a decrease in the efficacy of phospholipids to replace platelets indiciung thu existence of 1 cofactor or alteration of the phospholipid in the purification process which is yet has not been clearly defined Furthermore platelet free plasma nged for several days it 37 C (body temperature) will not clot eren with the addition of both platelets and calcium ions This can be correctal loncier by freshly dran platelet free plasmi indicating there is able factor present in blood necessary for norin al hemostasis llemo ·THE MECHANISM OF BLOOD COAGULATION 3 philia is a bleeding disorder in which there is a congenital absence of tlus factor called antihemophilic globulın (AGH Factor VIII) 19 Concentrates of either antihemophilic globulin or fresh normal plasını will correct the abnormal clotting of hemophilic plasma in viso and in vitro Anthemopbılıc globu lin is consumed in the clotting process This loss is substan tiated by the fulure of fresh normal serum to correct the abnor mal clotting of hemoplulic blood Until 1933 liemophılıı was generally considered to be a specific disease clinically diagnosed because of a familial tend ency in males tonard frequent episodes of bleeding notably into the joints following minor trauma ind also because of prolonged bleeding after tooth extraction or minor bruises Bleeding ceases following the intravenous administration of fresh plasma In 1953 several patients were described with clinical bustories typical of lemophilia but the admixture of their blood with other hemophilic blood samples resulted in the mutual correction of abnormal clotting of both simples Since these bloods correct each other it is apparent that the factors deficient in the mixed bloods are not the same Further more the serum from a normal person corrects the abnormal ciotting in one type of lemophilia but not in the other type Thus it is clear that the clinical syndrome called hemophulia is not a single diserse but at least two entities manifested in similar clinical pictures Hemophiln corrected with normal serum is called Christmas disease or plasma thromboplastın component deficiency (PTC Factor IV) 3 AHG and PTC differ in that antılıemoplulic globulin is labile and consumed in the clotting process uliereas PTC is stable and present in the serum Other diseases have been described in which the clinical pic ture is basically similar to classic hemophilia and Christmas disease but in which additional different factors are absent Aguin these factors lave been demonstrated by the mutual cor rection of abnormal clotting by blood from pitients known to have either classic hemophilia or Christmas disease with blood from patients with congenital deficiency of these different factors ·4 ANTITHROMBOTIC THERAPY These findings have given rise to the concept that henlopiulia ſorms a group of conditions aith related clinical picture and specific deficiences of coagulation factors The names applied to these various factors are plasma thromboplastin intecedent (PTA Fultor Y) 03 Hageman factor and Stuart factor 10 They zre similar to the Christinas factor in that they are stable and present in normal serum A characteristic they show with antı hernoplulic globulin is that they are all involved in the first stage of coagulacion Thus is demonstrated by the correcting cffect of the clotting time with thromboplasıın added to any of thic deficient bloods Thromboplastın derived from either tissue extracts or from plasnia requires two factors normally present in blood in order to be actre 10 One is labile and present in the plasma (Acceler dator Globulin 4c6 Fictor V Pro accelerın Labile Factor) the other factor is stable and is principally in the serum (Tactor VII Serum Prothrombin Conversion SPCA Convertin Stable Factor) * ACG is comierted to a more actre form during the process of coagulation (Seruin Accelerator Globulin Tactor VI Accelerın) Congenital deficiencies of either AcG or SPCA result in hemorrhagic diatlieses Thromboplastin cxtructed from tissues contains varying amounts of the accelerators Act and SPCA As thrombolplastın ages Act is destroyed and thromboplastin loses some of its original activity The activity retuned hou ever is due to the presence of the stable SPCA Anticonzulant therapy with Dicum arol and related compounds causes a depres sion in the level of SPCA ind prothrombin wluch prolongs tlie one stige prothrombin tinc 171 This occurs regirdless of the level of ACG because tissue thromboplastın does not have suff cient adherenc SPG 4 to activate thromboplistin with cnouglı rapidity to give i normal prothrombin time The amount of contaminating SPC4 is virible in different preparitions of tissue throinboplastin This varjation is commonly overlooked in the determination of the one stige prothrombin time in pr tients geen Dicumirol and may account for some episodes of ·THE MECHANISM OF BLOOD COAGULATION 5 bleeding when the protlırombin time is not exceedingly pro longed Tlus suggests that the thromboplastin used in the deter mination of the one stage prothrombin tine in patients recen ing anticongulants should be free of all contaminating acceler ator activity in order to reflect accurately the true level of the coagulation factors as measured by the one stage pro thrombin test Accelerator globulin is not affected by Dicu marol and thus is not variable in prothrombin determinations from patients on Dicumarol (See DIAGRAU I for the formation of active thromboplastin) TPTC PIA + Kg PLASMA 1 ROMEOPL 571 TISSUE THROMBOPLAST1 + SPC + st ACTIVE T ROMBO ST! DIAGRAY -Format on of actise thromboplastin STAGE 11 THROMBIN FORMATION Thrombin is formed from prothrombin a protein produced by the liver requiring utumin k lor its synthesis 8 13 Under physiologic conditions both calcium ions and active thrombo plastin 91 are requured for the conversion which involves the brealdoun essentially of prothromlin into several protein moieties 119 One of these proteins is thrombin The formation of thrombin is also catalyzed by at least two dditional factors ucelerator lobulin (Ic libile factor fictor V) and serum prothrombin conversion rccelerator (SPCI stible factor I ac toi VII) is stated before ACC und SPCA have similar functions but differ in that Ac is labile und Sic is stable Botlı arc present in the plasia in relzthely inctive forms and in the ·6 ANTITHROMBOTIC THERAPY serum in actile states The actise serum forin of Ac is called serum AcG Hemorrhagic diathesis occurs when congenital deficiencies exist in prothrombin ACG or SPCA Thromboplastin ACG ACTIVE THROMBOPLASTIN SPCA Stuart Factor PROTHRCMB IN THROMB IN Ca + DIAGRAM 2-Stage iso riction in thrombin formation Indirectly lonever another factor involved in conversion of prothrombın to clirombın is the Stuart frtor which func tions with Ace and SPCA in the activation of thromboplastin The Stuart factor is remarkably similar to SPCA but the exist ence of two separate factors has been proved by diseases in which there is i congenital absence of cither factor (See Dia GRAM 2 for the stage to reaction ) STAGE II FIBRIN FORMATION 1) Purified fibrinogen solutions wil not clot on standing or on simple recilcification However trice amounts of thrombin wall convert fibrinogen to fibrin Ile speed of this comersion in all enzymnically catalyzed reutions is directly related to the thrombin concentration 36 ! Thrombın alters fibrinogen inolecules with subsequent polymerization to librın ind the THROMSIN FIBRINOGEN — FIBRIN + SOLUBLE POLYPEPTIDE DICRAV 3-Stage three recliori in film for nation ·THE MECHANISM OF BLOOD COAGULATION 7 release of soluble polypeptides Patients congenitally deficient in fibrinogen line been reported and their episodes of bleeding are effectively treated with concentrates of either fibrinogen or normal plasma Dicumirol or hepırın does not alter the level of circulating fibrinogen (See DIAGRAV 3 for the stage three reaction ) SUMMARY Intravascular clot formation represents a disturbance in the normal licmostatic mechanism and is caused by local conditions sluch initiate congulation The first phase of clotting results from the interaction of several factors present in the plasma with entlier platelets or tissue thromboplastın in order to activate thromboplastın Active thromboplastin catalyzes the conversion of prothrombin to thrombin Thrombin then enzymatically acts on the soluble plasma protein fibrinogen to form the in soluble fibrin clot Progressive coagulation of the circulating blood is presented by naturally occurring inhubitors and by the diluting effects of the blood rhe final removal of the fibrın clot by the dissolung action of fibrinolysın is fully discussed in a later chapter ·6 ANTITHROMBOTIC THERAPY serum in ictise states The active scrum form of Acc is called serum Acg Hemorrhagic dızthesis occurs when congenital deficiencies exist in prothrombin AcG or SPCA Thromboplastin ACG ACTIVE THROMBOPLASTIN SPCA + Stuart Factor PROTHRCMB IN THROMBIN Ca++ DIACRAY 2-Stage 11 o reaction in thrombin formation Indirectly however another factor involved in conversion of protlırombin to thrombin is the Stuart factor much func tions with Acg and SPCA in the actuation of thromboplastın The Stuart factor is remarkably similar to SPCA but the exist ence of the separate factors has been proved by discases in which there is a congenital absence of either factor (Sec DIA GRAU 2 for the stage tno reaction) STAGE III FIBRIN FORMATION as Purified fibrinogen solutions will not clot on standing or on simple recalcification However trace amounts of thrombin will convert fibrinogen to fibrin The speed of this conversion in all cnzymatically catalyzed reactions is directly related to the thrombin concentration 36 1 Thrombin alters librinogen molecules with subsequent polymerizition to fibrin and the I ROBIN FIBRINOGEN + FIBRIN + SOLUBLE POLYPEPTIDE DIAGRAY 3–Stage three reaction in fibrin formatın ·THE MECHANISM OF BLOOD COAGULATION 7 release of soluble polypeptides Patients congenitally deficient in fibrinogen have been reported and their episodes of bleeding are effectively treated with concentrates of either fibrinogen or normal plasmi Dıcumarol or heparin does not alter the level of circulating fibrinogen (See DiAGRAV S for the stage three reaction ) SUMMARY Intravascular clot form uion represents a disturbance in the normal liemostatic mechanism and is caused by local conditions which initiate congulation The first phase of clotting results from the interaction of several factors present in the plastna With either platelets or tissue thromboplastin in order to activate thromboplastin Active thromboplastın catalyzes the conversion of prothrombin to thrombin Thrombin then enzymatically acts on the soluble plasma protein fibrinogen to form the in soluble fibrın clot Progressive coagulation of the circulating blood is prevented by naturally occurring inhibitors and by the diluting effects of the blood The final removal of the fibrin clot by the dissolving action of fibrinolysin is fully discussed in a later chapter ·2 Clotting Tests* 1 THE BASIS OI COACUIATION STUDIFs lies in the accurate ineasure ment of clotting under controlled in vitro conditions All infor mation regarding these leactions is inferred from the clotting time or the visible presence of the insoluble fibrin clot Because of the indirect nature of this information interpretation of congulation tests may be complex Particulır attention inust be pud to scemingly trivial details in technic certain conditions (ie temperature ionic strength and pH) ind regents Only the tests commonly used as screening procedures in the diagnosis of coagulation defects and those itsts which are affected by anti thrombotic agents are discussed The principal laboratory tests used to determine detects in the three stages of coagulation are listed in TABLE 1 However it should be noted at thus time that two of these tests are of special significance in demonstrating the coagulation defects produced by oral anticon,ulınts The first is the thromboplastin Generation test wluch me isures the evolution of intrinsic plasma thromboplastın Shrec serum factors PTG Stuart ind Hage man are reduced to less than 10 per cent of normal is measured by this test Secondly the one stage prothrombin test is pro longed by the combined depression of the normal levels of prothrombin und SPC 4 when onl anticoagulants have been administered Heparin wluch is administered parenterally inhibits all coagulation reactions and its effects are mesured by the whole blood clotting time which reflects the over all coagulability of the blood Tibrinulvsin (auses i depression in the normal level of fibrinogen ind i rise in the fibrinolytit activity of the blood This is determined by ss1y of fibrin produced from len Sce Addendum fcr dtals of thc tets 8 ·CLOITING TESTS 9 quantity of the patients plasma und by the lysis time of the fibrin clot produced respectively 1 Tourniquet Test This test mesures capillary fragility by applying positive pressure with a blood pressure (uff on the upper arm and inflating the cuff to the midpoint between systolic and diastolic pressure for a period of five minutes After release of the pressure the number of petecluze (ruptured capillaries) are noted on the arm The test is frequently positive in patients who have been gien Dicunrrol and who have other vitumın Tapre l-7 ests for Coagulatio i D fects Tests in Sta el Tests in Sta_c2 One stage prothrombin Ti o stage prothromb n Specific one stage tests Tests in Sta. 3 Clotting time Fibrinogen Clotting time Thrombopla lin generation Clot retraction I rothrombin consumption Tourniquet test deficiencies such as vitamins Cand D The reason for this reac tion is related to vessel wall integrity 2 Platelet Count The importance of platelets in blood clot ting is illustrated by a bleeding dirthesis which occurs when the platelet count falls below 50 000 (thrombocytopenia) or rises above 500 000 (thrombocytosis) In either case ftulty blood thromboplastin generation results It should be noted that the platelets may be present in normal ringe (100 000 to 350 000) und bleeding may occur due to qualitatively defective platelets (thrombocytopathun) This condition is demonstried by an abnormal prothrombin consumption test or a thromboplastin generation test 3 Bleeding Time The bleeding time is ascertained normally by making a small puncture in the shin and noting the time of clot formation Honever excessive tissue damage can result in the release of increased amounts of tissue thromboplastin thus causing a falsely shortened bleeding time Conditions are diffi cult to standardue with this test therefore quantitative duti ·10 ANTITHROMBOTIC THERAPY (innot be obtained In general Holejet i prolonged bleeding time usually indicates 1 congulation anomaly platelet deficiency or vascular defect 4 Cloring Time Thus is n general screening test performed with 1 chous simplc of blood in a Lee Wlute tube The time necessary for clot formation is then noted In general i pro longed clotting time reflects a disturbince due to a plina delect of any congulation factor the increased titer of an inhibitor or ? platelet deficiency Technicıl errors (poor vein puncture air TABLE 3-Coagulation Factors & Borbrl from Tormal Ili ma and Formal Verunth Baruri Sulfite Adsorbed Factors vonadsorbed Factors Prothrombin Fibrinogen SIC 1HG Vormil 1 lasmi PIC Stunt ITI Ingeman Serum 10 III IIC Hagem in Voimal Serum SICI Stuart bubbles and excessive agitation) may nevertheless lead to nor mal findings even in the presence of a cod, nation defect 5 Clot Retraction I simple of clotted blood in 1 Lee White tube begins to pull away from the sliss surface within one hour I huis is called clot retraction and normally is at its maximum within 24 hours after the simple is taken Clot retraction is related to the platelets concentrition and function 6 Preparation of Deſicunt Plasma Certain compounds like chelating agents act specifically to remove some of the factors involved in coagulation As a group they are called prothrombin adsorbints and the more widely used compounds ure byrum sultate and aluminum hydroxide in the formation of normal serum fibrinogen prothrombin ind AHO ire consumed by the clotting reactions The factors which can be adsorbed from ·CLOTTING TESTS normal plasma und normal serum are listed in TABLE 2 Serum and plasma adsorbed Tith barium sulfite are convenient sources of specific factor deficient solutions which are useful in differ cnulating congulzon defects when the thromboplastın gener sion and modified one stage prothrombin tests are performed 7 Thromboplastın Ceneration Test Under certain condi cions factors in plasa combine with platelets (or phospho lipids) to form a complex with thromboplastic activity This combination is called plasma or intrinsic thromboplastı It differs from tissue thromboplastın in that it is extremely labile due to instability or inlubiors normally present in the blood The shromboplastın generītion test is an 755 7y of this intrinsic thromboplastia and is performed by doing serial one stage pro crombin determinations at one minte intervals A thrombo plastın incubation mixture consisting of birtum sulfate adsorbed plasmi serum placelets and calcium is used The plasma is prorlirombin free but contains AHG the serum supa phes PTA PTC Suurrt fictor Hagemın factor Ach and SPCA ? the platelets (or phospholipids) and calcum are the reagenis necessary for the formation of thromboplasın This test demonstrates that patients with hemophia fail to generate thromboplusun normally By using either normal plasm or normal serum one can determine if the faulty generr tion of thromboplastın is due to a defect in either plusmr or seruin Classic hemophilia is due to defective plasma (1 e AHC) Only ruely are the placelets thrombocytoprihu This is deter mined by comparing platelets from a normal subject tith those of the pruent Defects in serum tre recognized by the mixture of various serums esther congenitally defective or made so muth barium sale in 7 specific factor id noting if there is mutual correttion of the tho serumus This type of correction indicates that the factor deficient in one serum is present in the other thus the selects in the two serums are different If the tso serums des fut cotreci cuh other tire factor deficient in loth 27t similar For en imple TIC deficient serum will conicct serun deficient PT Start factor Higemın futor ud AHG but will not ·12 ANTITHROMBOTIC THERAPY correct any serum deficient in POC Studies from this test hale guien further proof that liemoplnız is a heterogenic group of diseases In effect produced by Dicunnol and clated drugs is 7 depres sion of PIC Stuzt ſnctoi and 111 min factor which are not nieisured by the one stige prothrombin time Thus fict may be mothcı evplanation for the frequent clinical observations of purpura and blecdmg in patients on long term anticoagulant therapy when the prochrombin time is within the therapeutic range 8 Prothromum Consumption The clotting of norinal blood results in the formuion of plzsına thromboplastin wath the subscquent conversion of prothrombm to thrombin The latter is partially absorbed by the fibrın clot in the final stage of coigulation what remuns is neutralized in the serum by anti thrombin 11 hen there is a defect in the formation of intrinsic thromboplastin the prothrombin is not fully utilized and re mains in the serum If a one stage prothrombin determination is done on the serum by adding fibrinogen in esunrate of the prothrombm remuning in the serum can be obtained Thurs test is called prothrombin consumption and can be expressed in percentage of protlirombın used or iemuning 11 the serum Since the conversion of prothrombin to thrombin is a rel? tuvely slow leaction the tinie alter clotting for performance of thc prothrombin consumption test is usually one hour Thus test is useful in indicating defects in the first stage of clotting but is of little value in patients gien Dicumarol The aduc tion in plasma prothrombin resulting from such therapy leaves the titer of serum piothombin beyond the sensitivity of the test This is true because the piothrombin consumption test is subject to the same teclinical errors is the one stige prothrom hin tine Prothrombın time. The test known as the one stive pro thrombin time is simple reproducible and his worldwide applı cation in cimical medicine Tlus test mesures the clocity of fibrin formation following thic addition of cilcun to 1 solution ·GLOTTING TESTS 13 of active tissue thromboplastin usd the plasma to be tested The most important inables affectin, the test vre factors u luch aid or inhibit the formation of thrombin The contersion of fibrinogen to fibrın in the presence of thromb is most in stantaneous She time interval (rom the addition of culcum to the formation of the clot is the prothrombisz time (PT) Dependent upon the reagents used and the technician perform inz the test the PT 15 tisually 12 seconds with normal plasma If the thiromboplastın accelerator factors clcum or prothrom bir are progressively reduced the P'T is increased A normal prothrombin time generally meus that all factors other than those necessary for the lormation of thromboplastın are present in normal concentrations However a prolonged prothrombin time is difficult to interpret since the result was menn a reduction from the normal level of one or several of the Colloning prothrombin ACG SPC 1 Stuart factor or fibrino gen In addition an abnormal prothrombin time may mean ar increase in either the level of naturlly occurring or acquired inhibkors to any of these factors or un inhibitor to the acme agent produced from the interaction of these factors Dicumarol produces depression of prothrombin SPCI and the Stuart fac for Therefore a prolonged prothrombin tinc un patsents on thus therapy represents a combined defect produced by the decreased level of these proteins Heparin inhibits all coagula tion reactions thereby giung a prolonged protlırombin time The one stage prothrombin test can be modified by the addı tion of prothrombin free plasma This modification usi rellect the prothrombin level more accurately since csery thing except the frctor tested for will then be present in the reaction mixture 10 One Stage de Determination Specific determination of Ich is done by adding aged normal plasma to the plasma to be tested and then performing a one stage prothrombin test Tormal plasmi aged in the refrigerator for 14 days is deficient in Acc because of its labılıty Therefore all the factors neces sary for clouing are present in the incubation mixture except Ico the facror being tested in the sample plasma ·ANTITHROMBOTIC THERAPY 11 SPCA Determination The 1557y of the level of SPCA 18 determined with 1 one stige prothrombin test modified by adding an SPCA free plasma to the test plasmi A variable in tlus test is the mount of SPC4 contaminating the tissue throm bopl istin used thus is especially truc in patients gren Dicu mirol when the level of SPCA is depressed to 10 per cent or less of normal 12 Tuo Stage Prothrombin Determination Specific assay of prothrombin is accomplished with the tuo stije prothrombin test The basis for this test is not clocity but rather the measure ment of the amount of thrombin generated It is performed by activating plasma with optimal amounts of calcium throm boplastin and the ucelerators (AC SPCA and Stuart factor) Thus the plasın prothombın is cited to thrombin and serial alıquots are tested with purified fibrinogen Applying the principle that a shorter clotting timc mews more thrombin one on ise this technic to obirini semua quantitatie meistre ment of the thrombin present in the simple One unit of throm bin is defined as the amount of thrombin nuch will clot I cc of fibrinogen in L, seconds 1+ 29 ( One unit of thrombin 15 equal to one unit of prothrombin This techını has not been used generally is 1 gude in the control of anticon, ulant therapy because of the technical difficulty invoked and uso because the test measures only one factor depressed by oral intr corgulints 19 Fibrinogen Determinanon Fibrinogen is determined by adding thrombin to a measured quantity of citrated plasma and winding the cloc on a glass stirring rod The fibrın 1x digested from the glass rod with buuret solution and the amount of protein is determined by noting the color dinge in the biuret solution with a colojimeter und by compiring the reading to a stindardized curve 14 Fibrinolzsın Delermination The fibrinolytic activity in serum is determined by noting the lysis time of 1 stundard fibrin clot uitha measured amount of serum ·3 Antithrombotic Reactions As MENTIONED EARLIER the body has natural defense mecha nisms to prevent limit and dissolve intravascular clotting This is accomplished by inhibitors that suppress the prinıcpal coagulation reactions ind by fibrinolysin which dissolves the fibrin clot In addition a liy pocoagulable state may be induced by anticoagulants which are of two main types (1) those (such as heparin) which prolong the over all clotting time and (2) those (such as Dicumarol) which indirectly suppress the syn thesis of certain coagulation factors Fibrinolytic agents such as streptokinase 18 trypsin 109 and fibrinolysın *146 have been introduced more recently into clinical medicine The mecha nisms of these natural and therapeutic defenses against intra vascular clotting are detailed in this chapter their clinical appli cations are discussed later 0 Naturally occurring Anticoagulants i Inhubition of Stage 1 Specific antibodies may develop in plasma which inhibit AHG PTC or Acc respectively 73 74 Antibodies have also been described which destroy the platelets thereby leading to a hemorrhagic diathesis In addition plasma contains an inhibitor of thromboplastın 188 191 but it is still uncertain whether this material differs from heparin 2 Inhibitors of Stage II A specific antibody inhibitor of AcG exists but specific inhibitors of SPCA or the Stuart factor lave not been reported However in normal serum a factor (or fic tors) called untithrombin 37 11 is present which progressively inactivites thrombin forining 1 complex called metatlırom bin in the older literature This is partually reversed in vitro by the udition of acids alkalies or chloroform Antithrombin is the body defense qunst (culating thrombin The action of antithrombin is sinergtstic with heparin 15 ·18 ANTITHROMBOTIC THERAPY 3 Inhibitors of Stage III The natural defense agunist fibrin is thic lysis of the insoluble clot into soluble fragments by fibrin olysin (plasmin) Thus cnzyme is normally present in the blood as an incine precursor (profibrinolysin plasminogen) which forms fibrinolysın imder the influence of in activator Tlus activator is produced from a proactutor present in plismi in combination with i factor derned from damaged tissues foreign bacterial products or idiopathicilly Presumably the 700 for is also formed by the combi won of the proscisator with 1 tissue fictos It then (117ymatically converts profibryols sın to its active form fibrmolysisThe latter is as a protcolytic cnzyme that splits lxxxl fibiino,en ud fibrm in SITO und in ustro into protein fragments that do not clot with the addition of thrombin Clinical conditions custan wluch 1 hemorrhagic dinthesis is associated within increasing circulating titer of fibrinolysın 190 Sincc fibrinolysın is not only al pliysiolo,lc vescorer of hemo $tists but uso i therapeutic vent it is discussed further in the concluding section of this chapter Therapeutic Antithrombotic Agents The problem seguding the therapeutic approach to intra vascular clotun, makes the methods (1) the indirect prophy Tactic piciention of co, ulition ind (2) direct lysis of the clot Hepirin and Diuumirol 11e examples of 7-ents represenung the first method and fibi nolysin the sccond method 1 Heparin The more of action of thepirin is inhibitory in all three major clottin, je u tions ind its effect is mosted by the prolon, ition of the clotung time Heparin plus a postu lated cofactor in the pluma forms an immedi 10 tuhombın Thich inbuibuts fibun formation pnuculul Olreri itaon of the scactions impolung ferrin 144(115 that it combines with pro teins alterius, then (lecture de momel collord u properties I{cpırın aiuse lie romunistuied puentu illy and the preferred route is incru enous Its action is fast but its potency is ripidly ·ANTITHROMBOTIC REACTIONS 17 destroyed This is the major disucli antage to it therapeutic use since repeated injections ue ncressors Clinical application of Heparin is thus limited to the initiation of inticoagulant therapy At present there are no te quitc synthetic substitutes for heparin although several 1,ents mic bcen mestigated 2 Oral Anticoagulants Oral anticoazulants such as Dicu marol and related drugs inhibit the synthesis of prothrombin SPCA PTC Hageman and the Stuart factors 141 1 which are produced by the liver in the presence of vitimin k Apparently Dicumarol functions is a competitive inhibitor of the utilization of vitamın h by the liver A number of drugs functioning simi larly to Dicumarol are used clinically These drugs may be divided into two groups coumarins (Dicumtrol Sintrom Tromexin Murcumar Coumadın and Cumopyran) and (2) indandione derivatives (Hedulin Dipoxin and Mırdon) The major differences in these drugs are in the speed und duration of action these are dependent upon the rate of absorption into the blood Chose which tre rapidly absorbed are quich to act but of short duration Tlie converse is also true as is clearly illustrated by the one stage prothrombin test Dicumarol is eliminated cluefly by the hidneys therefore renal disease can cause 7 more sensitiie response to inocoagul lants Still other factors influencing the response to Dicumarol are both the vitamin h intake and tlie amount of vitamin produced by intestinal bacteria Anubiotics which destroy the intestinal flora ire synergistic with oral anticoagulants Aspirin also lias a mild Dicumuol like action and acts synergistically when administered with inticorgulints An eximple of this cffect is shown in FICURF ) Recent studies have demonstrated a fall in protlırombin SPC I rrc ind fibrinogen in patients after hepitic lobectomy for neoplastic diseases Liver disease when severe causes 1 reduced level of the various congulation factors and is associated clinically with an increased sensitivity to Dicumarol The congulation defects produced by Drumarol are decreased levels of SPG 1 prothombin PTC Stuart ind Hageman fac ·18 ANTITHROMBOTIC THERAPY tors in that order The rapidity in the fall of these izriots factors is related to the dose of the ticorgulant and the turn over rates of the coagulation factors The action of Dicumarol and related drugs may be rcversed by the intrusenous admims tration of utmın h, ? The effects are noted on the one stige prothrombin time within 10 to six liours Vilunin k deficiency of various types (e stertorrhez ud malnutrition) 15 7560 11 401 COAGULATION TIME SZINNIN NI 20 MARWAL RANGE 70 60 50 PROTHROMBIN TIME IN SECONDS 40 THERAPEUTIC RANGE JO 20 1a THROMBIN UNITS Y SERUM IN TGT 326 314 PLATELETS $000 270 350 236 350 390 330 300 DICUMAROL 2001 ASPIRIN Y 46! 100 B 6 V 16 18 0 v 10 12 14 DAYS OF TREATMENT HEPARIN 200 100 LC 1-1 he prolongation of Dicumarol action by aspirin in 1 patient i Ith cute myocreland infarction It shoull be note that not enou > administeret vitamiah hu Jittle effect on the prothrombin lime until t ca prin * 1s topped ·ANTITHROMBOTIC REACTIONS 19 ciated with reduction in SPCA prothrombin PIC Stuart and Hageman factors 3 Thrombolytic Agents Agents which promote the dissolu tion of the fibrin clot have been investigated extenszely in the last fes years ind are classified under the general term of fibrin olytic agents They act directly on the forned clot and as such present i direct approach to intravasculır clotting The first agent with fibrinolytic activity studied was streptokinase This material was found in the filtrates of beta hemolytic strepto- COccic cultures by Tillett and Garner in 1933 * Streptolinase combines with the proactu ator in the plasma 39 to forin an enzyme which activates profibrinolvsın wuch subsequently acts on both fibrinogen and fibrin (See DIAGRAV 4 for this reaction) TREPTOK INASE PROFIBRINOLYSIN Activator Proncti ato FIBRINOLYSIN FIBRIN LYSIS or PRODUCTS FIBRINOGEN DIAPRAV Fibrinolytic reactions The actity of streptokinase therefore depends upon the concentration of several inhibitors Varying concentrations of circulacing antistreptolinase and inuifibrinolysin result in a marledly individual response to an injection of streptokinase 24 Inother problem with this therapy is that once an active circu Jaung fibrinolytic system is induced there is no specific method avulable (or reversin, the active enzyme Concentrates of fibrinogen can be administered but these are usually con caminated with profibrinolysın ind proteinator wburli tend to propel the reaction further and thus increase the fibrinolitic activity in delition to this even the purest preparations of ·20 ANTITHROMBOTIC THERAPY 10 streptokmise 11e associated with systemic reactions which pre clude its general cimical use at the present time Trypsin was explored as 1 thrombolytic agent in prtients but because of the protein nature of its activity and the presence of antitrypsin factors in the plasma 3 luge parenteral dosages had to be administered Tlus bons proved to be chimically inad visible because of the shoch syndrome 7ssociated with intra venous injections More recently with the advent of technical adı ances in the puriſicition of human fibrinolysın * the use of intrucnois fibrinolysin las been tested in inuils and mun 34 35 11 40 An ndı antage of this enzyme is its specific protcolytic iction on fibrinogen and fibrin The level of fibrinolytic activity induced is variable depending on the level of intifibrinolysın in the plasma but levels of fibrinolysın can be injected to overcome this variation The fibrinolytic activity can either be main tained by continuous infusion or reduced by slowing or stopping the infusion Preliminary clinical reports in man have slionn that fibrinolysın is effective and practical 150 30 Toxic resc tions 3 indicate cautious administration of this ngent until further clinical evaluation is obtuned In combination with anticoagulants fibrinolysın seemingly offers in ideal approrch to the treatment of intru sculu thrombosis The tests 21 ulable for controlling ſibrinolysin therapy are the determination of fibrinogen and the lysis time of standard fibrin clots ·4 Clinical Use of Antithrombotic Agents f TIIL AIN OF AVTITTIROVIBOTIC THERAI I is to rei erse the orclu sion of a vessel by distintegration of the clot and the prevention of subsequent thrombotic formation Fibrinolysin wall dissolve an existing fibrın clot anticoagulants wall inhibit further clot ting E9 79 The limiting factor in the use of this therapy is the risk of liemorrhage Fibrinolzsın has not been used extensuely and cruition is indicated unul further evalu tion has been performed in this chapter an outline of the usual effective doses of anticonyulants and a discussion of the creat ment of hemorrhage will be presenter? Preparation of the Patient When anticoagulant therapy is to be usrd the patients should be selected carefully wath regard to personality and living con ditions luch may present close cooperation betueen patient ind physician The patient should fully understand the pur posc and possible dangers of anticoagulant therapy and in addi tron should be gren uritien instructions and dosage schedules is a precaution against unexpected bleeding the patient should Lyc prouded with vitamin h, tablets and be instructed to carry them with hu at all times Heparin Heparin is a mixopolysaccharide which is practically non tonic The preferred route of administration is unitas enous Oral lı puin is inactile ! ind the rate of absorption is quite Tartable when the drug is used intramusculsrly or subcuti ricously therefore contioł is difficult Hepatin sodium is avail Slixcut in 1 tupai inn i wts ( nudle ) as leci (51 essfitt as n p kt alth it the V12932 Hicant la stitite 21 ·22 ANTITHROMBOTIC THERAPY able in sterile aqueous solutions in strengths that contain 1000 5 000 10 000 or 20 000 USP units in 1 ml The usual initial dose is 50 mg (5 000 units) If the clotting time wluch is done four hours later is less than twice the control clotting time the second dose should be increased 50 per cent If the clotting time is triple the control clotting time further injection of heparın should be withlıeld until the clotting time returns to the desired ringe Rare instances of hypersensitivity urticaria asthma ind allergic rhinitis have occurred from the administration of hepirin Contrundications to the use of hepirin are the follow ing bleeding tendency or purpura subicture bacterial endo carditis ulcerative lesions of the gastrointestinal tract intra crunil hemorrhage threatened abortion in hypersensitivity to heparin Should it be necessary to terminate heparin therapy rapidly or should bleeding develop the activity of heparin cin be quichly ncutralized by slowly administering 50 mg of protamine sulfate intravenously In ddition whole blood or plısma may be given if the bleeding becomes life threatening Hepirin therapy is usually maintained for 24 to 48 hours until the oral anticoagulants have become effectue is demonstrated by pro lon, tion of the prothrombin time nunely tno ind one half times longer in the control prothrombin tine in seconds Oral Anticoagulants Dicumarol was the first oral anticoagulant 16 " to be used clinically and has an indirect action on the clotting factors by suppressing the synthesis of prothrombin SPCA PTC Stuart and Hageman factors Becouse of the indirect nature of its activity 24 to 48 hours or longer are required before the cir culating level of these various factors is depressed to inhibit coagulation effectively FIGURE 2 illustrates the effect of Dicu marol on the various coagulation factors It antagonizes the action of vitamin h in the liver which is 1 necessary vitamin for th formation of clotting proteins ·CLINICAL USE OF ANTITHROMBOTIC AGENTS 73 $COT 220 8€ 23 20 COAGULATION TIME IMINUTES) NORMAL RANGE 27 30 PR THROMBIN TIME ISECONDS) THERAPEUTIC RANGE 30 10 Home UNITS * SERUK SHROMON 251 322 45 670 460 570 490 PLATELETS 1000 DICUMAROL 200 100 WC Om pon N2 14 Y& KEPARIN X00 700 8 0 12 DAYS OF TREATMENT Cu-Rate of depresion n the tatous congu127309 Lests from Dicu narol therap Juicht vith nisocardial infattion The prothro ubin time is : econds up the third day of treatment and thromboplastın generalion «s nearls of the ninth day of treatment 7 The neses on anticoagulants function like Dicuinarol The tffecin eness of the drugs is directly related to the blood levels thus factors of absorption from the gut and excretion ta the kidney are important considerations in therapy Drar shea voiniting aspının antibiotics diuretics and the vitamin content in the diet 141 are some of the various factors altering ·22 ANTITHROMBOTIC THERAPY able in sterile aqueous solutions in strengths tlıt contain 1 000 5 000 10 000 or 20 000 USP units in 1 ml The usual initial dose is 50 mg (5 000 units) If the clotting time which is clone four hours later is less than twice the control clotting time the second dose should be increased 50 per cent If the clotting time is triple the control clotting time furtlier injection of lieparin should be withheld until the clotting time returns to the desired ringe Rare instances of lypersensitivity urticırıı isthma and allergic rhunitis have occurred from the administration of hepırın Contrundications to the use of heparin are the follow ing bleeding tendency or purpuri subrcture bacterial endocarditis ulceratie lesions of the 87strointestinal tract intra crinal hemorrhage threatened abortion and liypersensitivity to heparin Should it be necessary to terminate hiepirin therapy rapidly or should bleeding develop the activity of hcpırın cın be quchly neutralized by slowly administering 50 m, of protimine sulfate intravenously In addition whole blood or plasma may be given if the bleeding becomes life thrertening Jicparın therapy is usually muntained for 21 to 19 hours until the oral anticoigulants have become effective is demonstrated by pro longation of the prothrombin time nimely the ind one half nimes longer than the control prothrombin time in seconds Oral Anticoagulants Dıcumarol » as the first oral anticongulint' "1 to be used clinically and has an indirect action on the dotting factors by suppressing the synthesis of protlırombin SPCA PTC Stuart and Hagemın factors Because of the indirect nature of its activity 21 to 48 hours or longer tre required before the cir culating level of these various factors is depressed to inhibit congulation effectively FIGURE 2 illustrates the effect of Dicu marol on the various congulation factors It mtngonizes tlie action of vitamin k in the liver which is 7 nccessary uitimin for the formation of clotting proteins ·CLINICAL USE OF ANTITHROMBOTIC AGENTS 25 1 mole protracted elfect It is ?luble in intravenous form which speeds up its initial effects to within 24 liours thereby reducing the need for lieparin tlierapy except for the first day The intruenous dose is 75 mg ind maintenince is usually obtuned with 10 mg orally cach day This drug has proven to be a useful anticoagulant by ses er il different observers 17 Cumopyran (methiopyranorin) is about three times as potent as Dicumarol and has 1 slightly more rapid onset of action than Dicum rol ind a prolonged therapeutic effect Marcumır (phenprocoumon) 3 189 is 1 more potent drug than Dicumarol and becomes effectie uithin 36 hours and its elicacy lasts from two to three days Several reports have indı cated that Vacumar is an effective inticoagulant and it is interesting to note that this drug will depress the serum throm boplastic factors 37 despite i report suggesting no depression of PTC11 114 Sintrom (acenocoumırın) is also more potent than Dictimarol and becomes effective within 36 hours with a duration of action lasting 48 to 60 hours this drug has been used successfully in many patients and the dosage necessary is relatively constant Hedulin or Dinilonc (2 phenyl I 3 indandione) *% is one of the indindione dernatives the dug produces a depression of prothrombin time within 48 hours and the effect of the initi closage is dissipated within anothei 48 hours There are prob ably fener bleeding episodes with thus drug However a number of drawbacks to its lise ire the frequent resistance to its action and discoloration of the urine which may be confused with bleedling There have also been 1 fest reports of bone inntok depression urtici and derinatitis Dipaxın (2 diphenylacety! 1 3 incandione) is more potent than Hedulin and also has a more prolonged effect Honeer like all the indindione dertitties it impits in orange color to the urine which can cause confusion in regard to tirinary bleeding Viridon anısındonor ? pintsyl indandione 1 3) becomes effective within 36 to 19 liours ind muntains a fairly stable ·24 ANTITHROMBOTIC THERAPY sensitivity to Dicumirol It luas been given to patients for many years without any cvidence of toxic effects Bleeding oc curs in a small percentage of patients and will be discussed later in the chapter Some patients live toxic manifestations such as nausea vomiting and diarrhla tien with therapeutic dosiges Contraindications to Dicumirol are the sime is heparin Hon cier additional contraindications are recent operations on the brain or spinal cord regional anesthesia and Itumbar bloch vitamin k deficiency and scieic hiepuc? or renal disease TABLE 3 - 47 erage Dosage of Oral entre 1 ulants L sual Maintenaren (mg) Anticoagulant Dicumarol I romexan Coumadın Cumopyran Marcumar Sintrom Hledulin Dupaxın Varadon +0) 10 20 During First 48 (I)s (mg) 400-00 TR0X0-2 100 J0-100 100-200 21-30 18-21 200-100 21-30 600-900 100 3 J The drug should be used with caution in patients with severe hypertension active pulmonary tuberculosis and general debili tating diseases Tive other coumarin deri tiles and three indindione prepi rations are 11 zilable und line been used clinically is cffccule oral anticoagulants 55 8 65 31 1 The usual dosages of tliese 1771 ous oral anticongulants are summırıcd in 14on 3 Tromexin (cthyl biscoumacetate) 14 is less potent than Dicumarol but lias the di antage of 1 more rapid therapeutic effect (24 to 36 hours) Honeer is disadı antages are a rapid dissipation of effect variability in maintenince dosige ud frequent episodes of escape from therapeutic cffects Coumadın (sodium sarfırın)' is 1 water soluble coumarin which is about five times more potent than Dicum rol but lurs ·CLINICAL USE OF ANTITHROMBOTIC AGENTS 25 1 more protracted elfect li 18 71311able in intraenous foruı which speeds up its mitral effects to itun 24 hours thereby redning the need for kiepirin t'serap} except for the first day The intravenous diose is 75 mg und snuntenance is usually obtuned with 10 mg orally each day This drug has prosen to be a useful muconyulut by several different observers 17 Cumopyron (metliopyi inorin) is about three times as potent na Dicumarol and 1135 ? slightly more rapid onset of action du Dicumurol and a prolonged therapeutic effect Mercumar (phenprocoumon) 3 189 is 1 more potcnt drus than Dicumol und becomes effectue unhin 36 liours and its cfficacy lasts from tllo to three days Several reports have inclı crted that Mucumar is in effective anticoagulant ind it is interesting to note that this clrug will clepress the serum throm boplastic factors 17 despite i report suggesting no depression of PTC 13 14 Sitron (acenocoumar) is also more potent than Dicmarol and becomes effectue sthin 36 hours with a duration of action lasting 48 10 60 hous This drug has been used successfully in many patients and the closige necessary is relatively constant Hedalın or Danilone (2 phenyl I 3 indandione) is one of the inclandionc dernatives The drug produces 1 depression of prothrombin time withm 18 hours and the effect of the initni dorige is dissipated within mother 48 hours There te prob ally feuer bleeding episodes itseb this drug However a number of drawbacks to its use me the frequent resistance to its utton and discoloration ol the urine which may be confused with bleeding There hate 7lso been a feu reports of bone marrow depression urticaria und dermus Dipaxın (2 diphens lacetyl ! 3 417 indione) is more polene than Hedulin and also los 7 more prolonged effect However like 231 the indidiont dernitnes it imparts an orange color to the urine which can cause confusion in regard to trın ary ulceding Miradon anısındonoi pmisyl adandıone 13) becomes effective within 36 to 49 tours ind muntains furly stable ·24 ANTITHROMBOTIC THERAPY sensitivity to Dicumirol It has been giien to pruents for many years without any evidence of toxic effects Bleeding oc curs in a small percentage of patients and null be discussed later in the chapter Some patients lue toxic manifestations such as nuusea vomiting and diarrher even with therapeutic dosages Contraindications to Dicumarol are the same is heparin Honever additional contraindications are recent operations on the brain or spinal cord regional anesthesia and lumbar block vitamin h deficiency and severe liepatic or renal disease TABLE 3 ---Arerage Dosage of Oral Anticon, ulanis L sual Alamtenance D se (mg) Anticoagulant Dıcumarol Tromexan Coumadın Cumopyran Marcumar Sintrom Hedulin Dipaxın Mradon During First 15 His (ing) 400-000 1800-2400 50-100 100-900 21-30 18-24 250-400 21-30 600-900 +0 10 9) 3 4 100 3 13 5 The drug should be used with caution in patients with severe hypertension active pulmonary tuberculosis and general debılı tating diseases Five other coumarın derivatives and three indandione prepa rations are available and have been used clinically as effective oral anticoagulants 5 G71 * The usual dosages of these vari ous oral anticongulants are summarized in TALLE 3 Tromexin (ethyl biscuumacetate) 194 is less potent than Dicumarol but has the adı intage of a more rapid therapeutic effect (24 to 36 hours) However its disadvantages are a rapid dissipation of effect variability in maintenance dosage and frequent episodes of escape from therapeutic effects Coumadın (sodium warfarın)' is a water soluble coumarin which is about five times more potent than Dicumarol but has ·CLINICAL USE OF ANTITHROMBOTIC AGENTS 27 do exccur and the use of anticor,alınts carries a certain risk the estimated mortality rue is 04 per cent to Excessuels prolonged prothrombin times ire generlk the result of improper use of the drugs although bleeding does occur in the presence of therapeutsc prothromlin levels The Futter is especially true in patients on long terin therapy The medence of hemorrhage appears to be similar for the various counarın drugs but it is somewhat less then the indandione dernatives are used The most frequent <spe of hemortliige is gross or microscopic hest 3 A $ 11 and Bloemmon maalestation froma anti ogutaot therapy } 31 alxeriar ent #th test de mani culane therapy ·26 ANTITHROMBOTIC THERAPY anticoagulant effect Honeser it offers no special advantage over the previously mentioned drugs Management of Oral Anticoagulant Therapy When the need for anticongulant therapy luas been established und it can be determined that the patient has no contraindica tion to the use of anticoagulants therapy should be started immediately Hepırın is administered in combination with an oral anticoagulant The heparin is continued until the pro thrombin timc his reached a level tio and one half times the control prothroinbın in seconds This is generally 25 to 30 seconds The blood for the prothrombin determination should not be obtained within four hours after the lieparın adminis tration Heparın causes prolongation in the prothrombin time determination Anticoagulant therapy is maintained by a duly dose gren at the same time each day The daily dosage required to maintain a therapeutic prothrombin time is fairly constant in a patient If the prothrombin time is greater than 40 seconds the drug is reduced or withheld unul the prothrombin time returns to the range of 25 to 10 seconds After the patients response to a particular drug lias been determined prothrombin cimes can be done it progressively longer intervals of time namely weekly or at tro wech intervals Some authors have re ported on the use of an intermittent dosage schedule but this method has the disīdu intage of wide siings in protlırombin times which means long periods without adequate anticorgulant activity Complications of Anticoagulant Therapy The most important complication of inticoagulant therapy is hemorrhage 16 Hemorrhage is rarely i problem in patients treated for acute episodes such as myocardial infarction but about ninc per cent of the patients have significant hemorrhage In patients treated with long term anticoagulints the incidence of hemorrhage is 20 per cent or luglier if treatment is continued for seierıl years Tlie bleeding is larely serious but fatalities

·CLINICAL USE OF ANTITHROMBOTIC AGENTS
79
intrucnously * Tlus 1:}} bring the prothrombin time to a
safe les ci within four to six hours If necessary sitamin h, can
be repcued in several hours although 7 second tose is seldom
required The prothrombin time can be corrected quickly by
transfusions of fresh blood or plasma nhen dangerous bleeding
ensues
in the treatment of patients with cute myocardnl infarction
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·28 ANTITHROMBOTIC THERAPY For 313--) noient with sul conjunctival hemorrhinge trom anticoagulant therapy curii and petechie Fcchymosis hemitemesis or inclunt and epist axis occur less frequently ind in women menorrhagia is 7 common occurrence (See II UFS und 4 ) Gross hemorihinge following heparin is generally due to soin local pathologic condition when this occurs transfusion of 500 cc of fresh whole blood or plasına should be given immedi itely It may be necessary to conunue or repeat the transfusion af blecding does not stop Occisionally intruenous protimine sulfate or foludine blue ire given Honever this is seldom necessary when hepirin is administered intravenously since its activity is quickly dissipated in low to six lours Should the bleeding be due to prolonged protlırombin time the patient can be treated by reducing the dose of the anticoagulant or by administering 5 to jom, of vitamin , (Veplıyton*) orally or Merck Sh trp in Dal nc ·CLINICAL USE OF ANTITHROMBOTIC AGENTS 31 present recurrent chest pain without electrocardiographic eudence of extension of the recent myocardial infarction persistent pericardial friction rub sudden shock hepatomegaly distention of neck reins sudden anemia or x ray evidence of pericırdial effusion The presence of hemopericardium is an indication for the stoppage of anticoagulant therapy Several reports have indicated an increased incidence of myocardial rupture in patients treated with anticoagulants as compared to untreated patients with acute myocardial infarction " However an analysis of autopsy data reveals that the incidence of myocardial rupture is similar for a group of patients over a five Sear period prior to anticoagulant therapy and for a comparable group over a five year period during anticoagulant therapy Although myocardırl rupture was more common in patients treated with anticoagulants no significant over all increase in the incidence of myocardial rupture was found since the advent of anticoagulant therapy 150 Cerebral hemorrhage is a serious complication of anticoagu Jant therapy ind is an indication for its discontinuance The presence of severe hypertension is considered to be an impor tant factor predisposing patients to cerebral hemorrhage from anticoagulant therapy 19 In patients on long term anticoagulant therapy there are fre quent episodes of bruising and purpura without gross bleeding This relatively frequent occurrence has led some investigators to suggest that perhaps the same degree of clinical effectiveness might be obtained with less depression of the coagulation fac tors The danger of not maintaining a sufficiently prolonged prothrombin time is illustrated in TABLE 4 The patient described in TABLE 4 had been on Dicumarol therapy for tho years folloss ing a myocardial infarction without any evidence of recurrent thromboembolism During a six month period his prothrombin time fell 17 seconds or below for tio separate to neel periods During the second period of the weeks when his prothrombin time was 17 seconds he developed a cerebral vascular accident which was clinically ·30 ANTITHROMBOTIC THERAPY there are two complications that deserve special attention liemo pericardium and myocardial rupture Hemopericardium should be suspected when one or more of the following findings are R FIG 4B-Spinal cord block secondary to hemorrhage and clot formation (Re production of the myelort?m bv permi si n of Tieder ch I i oppe D Coral Gables Fla ) ·CLINICAL USE OF ANTITHROMBOTIC AGENTS 16 therapeutic ringe represenus a problein (or further im cstigation The importance of this problem is illustrued by several cuse ieports of unsuspected cerelyal licmorrlage 1 TARIE ius crates the effect of vitamin A, on bleeding in two patients get en Dicumarol over 1 long period of time Recent sturlies huse shown that then is 7 serum defect in these patients which can be demonstrakd by the thromboplastın generuon test but TOLE-Effect of I lewe on Blued sdt đưa Irlea me Jeru Thom < plastı facto Dale ?! Ieteks 1 93 M2 F 10 Blced nc 108 31 1 R 3 $ 11 NO) 1 12 100 100 Saint cal on 1 ,0 11 ) 56 >> 3 10 60 & ir 13 Bleeding geica O as tºnian A 3) 6/19 hich is not measured by the prodhisombın time Several in estu gutors are reported that this serum factor is similar to PTC 141 233 Our studies hne shoun that the defect is PTC Stuart and Hageman futur depression This is shown in TICLRE » The defect is produced by all the oral anticorgulants This serum defect cannot explain ill the bluedun., episocles Precause most patints on lon, tom ak Ozgulant therapy line 1 marked depression of the serum thrombxplasec factors (*I RF 6) however ferier than a per cent of the ponents have climcal evidence of any type of bleeding Tucation of the different factors is presented 21 FICE RE 7 Suse et al huse recently reported that the important factor in recurrent thrombosis or hemortlaige is the level of circulung ·32 ANTITHROMBOTIC THERAPY dingnosed is thrombosis or embolism Other patients occasion ally develop thromboembolic complicitions when their pio thrombin times are in therapeutic ringes but usually there is some underlying complication such as a hidden neoplasm Therefore if effective anticoagulant therapy is to be muntuned I ABLF 4 - current Thromboembolism in a Patient on Dici marol Date dierage Duly Dose (ms) Iemarks Prothroinbri Tue (sec) 0 26 93 3/18 32) 11 + 8 13 (8 2 (9 12 1/ 9 13 /20 197 2 13 lus 19 8 I10 6/17 691 31 3. 1 8 69 68 69 18 2) (crebralcular isci lent en oli mu 1 1/29 . 3 R 84 + 3 8/1. nir 1 p oth mb tme-1 ds the patients prothrombin time must be held in the therapeutic range of 25 to 10 seconds (control prothrombin time is uselio seconds) Bleeding from Long Term Anticoagulants When the prothrombin time is prolon,ed excessively bleed ing is easily expluned on the basis of the greatly denied º Honever bleeding in pitients on long term anticongulint therapy in whom the prothrombin time is in the clotting 59 65 181 ·CLINICAL USE OF ANTITHROMBOTIC AGENTS 35 TABLE 6-Coagulation Djects from long term Decumarul Hlest ry of lonbleed in patie is! Ilision of Bleeding (+9 falents) 20 & 7 este for Coagulanon D fecti Trothrombin time (*) (one stage mesh nd) SPC) Prothrombin fint stage noethod Sesum delect 11 thrombx pas tia gmeration (est) 307 39 < 50 tients with no luistory of bleeding as compared to 19 patients sath past episodes of frequent bleeding A summary of these data is shown TABI F G Studies by Verstraete et al "11314 shown that one fretur com monly overlooked in the performance of the one stage pro thrombm test is the difference in SPC I like activity s various nor Wutt WOWO 17 wout OM W OF NAONG TAZIOCD NOSPHO MMD $ ED CE an 90 10! 10 70' 20 20 20 F: £fferus of long term Anikoagulant therapy in the armus coagulation factors the shade) arcas represent the normal range for the warious tests The foss terres at the actual value oasped the various tests Fron Boules cial Mlonxel H P 14 9 rep odu edo perma in of the publier ·34 ANTITHROMBOTIC THERAPY prothrombin In a series of 86 patients grien Dicumarol foi a period of one to 10 years we have been unable to demonstrate iny significant difference in tlic coagulation defects in 37 pa DICUMAROL COUMADIN MARCUMAR HEPARIN HEDULIN SINTRON PTC 40 H100 PTA STUART F60 -20 HAGEMAN 40 CIRRHOSIS 30 PERCENTAGE THROMBOPLASTIN GENERATED SALINE HEATED SEAUM AGED SERUM DEPRO SERUM 30 AMMONIUN SULFATE SERUM 20 Tic 5-Percentage of thromboplastin gener icd from a mixture of 0 per cent serum (rom patients treated with various long term anticoagulants 1 ith Oper cent scrum congenitally deficient in a specifc factor sera from a patient sith sesere liver disease and normal serum treated with physical or chemical agents It will be noted that the defects in thromboplast in generation caused by the 1arious anticoagulants are simular namels depresion in the normal fesels of I TC Stuart and Hageman factors ·CLINICAL USE OF ANTITHROMBOTIC AGENTS 37 Frequently prothrombin times done with thromboplastın con tyining no SPC i like actisity ire prolonged beyond 40 seconds whereas the test is situn the therapeutic range and belou 40 seconds when performed with other thromboplastin prepara tions which contun trice SPCA lihe activity The modified one stage prothrombin test of Ouren llare Stragnell mesures prothrombin primarily 1 3) 75 does also 40 30 % PROTHROMBIN 20 ILI I STAGE OWS 2 STAGE MANCHESTER PROTHROMBIN METHODS FC 8-The arius prothrombin levels in patients on long term anticoagulant thei P (00 patients) The amount of pothumbın assayed by the ti o stane method al no t twce the amount saved by the Quick one stage prothromt n true the two sta, e method of llue and Setgers However the one stage test measures the relative depression of prothrombin SPCA and Stuart factor in patients on inticoagulant therapy Another method which is not used generally is the simple bedside test of Vanchester 133 Compartson of these methods in patients on long term anticoagulants is shown in FICURE 8 Discontinuance of Anticoagulant Therapy One major disidi inta,e of anticoagulant therapy is the danger of interruption for any reason such 75 hemorrhage ·36 ANTITHROMBOTIC THERAPY thuomboplastis lle mie confirmed these findings but the clinical importance of this factor in bleeding when prothrombin times are in the therapeutic lciet las not been determined 50, 401 CLOTTING TIME MINUTES 30- 20 60 SECONDS 407 PROTHROMBIN TIME 20 100 AC GLOBULIN 50 30 SPCA SECONDS 20- 10 100 50 THROMBOPLASTIN GENERATION (SERUM O 150 757 DICUMAROL VITAMIN K 10 mg po 5 10 15 20 25 30 DAYS OF OBSERVATION TIC-Tlie relative and endence of the variou (gulation til na itient on long term Dicumarol therapy of particular interest is dic disas ociation between the prothrombin time ind thrombopla tin generation curve Jim Posles et 1! Blood 14/81 19 reprelucell CTM on th pull !

·CLINICAL USE OF ANTITHROMBOTIC AGENTS 39 but a secent report of prolonged bleeding from dental extrac fton }ias indicted the danger of such procedures Therefore in patients in whom dental or surgical procedures ase planned anticoagulant therapy should be discontinued three (lays prior to the operation After the procedure reinstitution of anticoagulants should be carried out with heparin and oral antı coagulants If discontinuation of anticoagulants is planned the therapy should be reduced gradurlly over a period of several weeks in order to reduce the danger of the rebound phenomenon ·38 ANTITHROMBOTIC THERAPY operation or dental extraction The discontinuance of therapy not only restores the risk of thromboembolisin but there is also rebound phenomenon with a return of the corgulation factor back to normal or above normal levels for a temporary period as sugggested in several case reports Carter et alhave 50 GROSS NEMATURIA PROTHROMBIN TIME {SONOSIS) JO PROTHROWBIN TIME TO 100 OF NORMAL 50 SPCA PROTHROWBIN TOO 50 THROMBOPLASTIN GENERATED THROMBOPLASTIN GENERATED 0 30 DICUMAROL img] penanaman 20 40 60 30 DAYS Fic 9-The relative levels of the various a azulation factors in a patient bice1 ing from long term Dicumarol therapy The rapid (rebound) of SPC 4 and pro thrombin (tno stage method) are in marked contra t to the stugas h return i the thromboplastin generation test to normal recently presented statistical data that indicate that the tendemos toward recurrent thromboembolism is greatest during a six siech period folloning such an episode or the discontinuation of anticoagulant therapy in pzients without a recent thromboem bolic attach (See FIGL RE 9 ) Several reports hase indicated that dental extraction can be carried out while a patient is undergoing anticoagulint therapy ·PRESENT STATUS OF ANTICOAGULANT THERAPY 41 patients treated conseri unely compared to 0 to per cent in 900 patients treated with either heparın or Dicumarol In the prophylactic use of Dicumirol postoperatively the incidence of fuel pulmonary cinbolism was reduced from 6 to 0 per cent in a total of 1 332 patients These studies 16 3 "I love convinc ingly established the value of anticorulant therapy in these conditions Acute Myocardial infarction Anticoagulant therapy for acute myocardial infarction has been the subject of much controversy As ezrly as 1939 inimal TAMIE-Fflert of Indic agulant Teraps on the Vortal from doute Wora dial Infation con ol Crop Tanent Hortalily (lo) (OP) 10 2 3 45 1 Author T tei (1J10) 184 Nichol and Page 114)16 I urher and Barker (191) I eters (1918) 84 (riesman and laicus (1918) (11 (1919) Wright et al (1918) Ielon and Taylor (1920) + Holion (1930) 10 11 uff and Field (190) 9 Tullochard G. Ichr 1930) Slull (190) Tulloch and Ich st (10) Rhkoft (19 her n (1993) Tuuman (1933) Schnur (13) Beauniont (1) 3) Luin (1.3) 8 le ter (191) 3 ghi WH 1 Study (11! 100 or 100 4+ 369 1 6 100 81 60 161 36 40 40 40 # Teated Crop Patients Mortalit (۱) () 4 18 0 10 110 11 3 9 41 MO 43 15 4 00 1/4 80 10 93 60 1 1) 21 14° 18 32 18 100) 18 81 10 10 7) 10 19 89 16 160 211 190 96 99 S 30+ 3 11 28 03 1 10 Hoxp al nd App i uuted by Z1 in Fell tsa ·5 Present Status of Anticoagulant Therapy > 1031 1+ 381 84 88 103 110 118 163 187 ID 73 DURING TIF rast lu venis anticoagulant therapy has been used lor vrious tlırombotic and thromboembolic disorders + 40 ! Despite numerous investig? tions on the effectiveness of anticoagulant therapy its use is still luglily controversial Tlie reil alue of anticoagulant therapy emains unknown because there are no conclusie therapeutic studies Statistical data are 11 zılıble on patients with acute thrombotic and recurrent thromboembolic episodes Admit tedly thus type of information is not conclusive but it does gne some indication of the general clinical effects of anticoagulant therapy 04 It present there is no satisfactory liboi ntory nid to predict which patients when subjected to operation or bed rest will develop thromboembolic complutions The follouing prtients hne been found on the basis of clinical observations to be benefited by anticoagulant therapy (1) Ill patients who have 1 past hustory of iny tlıromboembolic or occlusive Treul dis ense (2) ill patients following acute coronary occlusion (3) patients over 10 years of age (without any specific contrundica tion) and (d) patients in congestne licirt flure or auricula librillation obese debılınted polycythenuc or unemic In this chapter in analysis will be made of the current status of anticorulant therapy in various thrombotic disorders Thrombophlebitis and Pulmonary Embolism Il right 3 has reported on the effectii eness of inticoagulant therapy in thrombophlebitis and pulmon iry enibolism Total embolisin was reduced from 57 to 0) per cent in the former and from 18 3 to 03 per cent in the latter Total pulmonziy inforctions were reduced from 16 per cent in 7 series of 13 40 ·PRESENT STATUS OF ANTICOAGULANT THERAPY 43 lar fibrillation or flutice ventricular tachycardia or intraventric ular block and (8) dibelic acidosis obesity previous pulmo nary embolisin varicosities of the lower extremities and thrombophlebitis As a background for the discussion of good and poor risk patients it is wortliis inle to reven the literature on cute myocardial infarctions prior to the use of anticoagulant therapy TABLE 8 summarizes the mortality from acute myocardial infarc tion during the first four weeks after the diagnosis in a total 1 ABLE 9 --Effect of Anticoa ulant Therapy in Patients with truie Vyocardial Infarction Good Risks Autho Control Group Patients Vorially (lo) 1 5 611 34 Treated Group Patients Mortality (lo) 114 18 bs Wright AH A Study 3 Rusch 201 Poo Resks 5 Il right All A Study Russel 07 194 3 ,0 97 60 of 3 008 patients The mortality rate varies from 16 to as high 1878 per cent Russel presents data from a study of 1 318 patients in whom anticoagulant therapy was not used Com parison of the series by Russel with the results obtained in the cooperative study of the American Heart Association is shown in TABLE 9 Ths comparison clearly demonstrates that anti coagulant therapy is most effective in poor risk patients Russels mortality rate is higher than that of Wright in the poor risl non treated patients because of the older ages of patients in Russels study Ilierefore some tiation in the poor risk patients in previous reports probably accounts for the difference in mor tality rates shown in TABLE 8 Evans 79 has presented data on 1 series of patients (1 000) who suffered an acute myocardial infarction and who were observed ·42 ANTITHROMBOTIC THERAPY studies suggested the effectiveness of hepirin and more recent studies 118 indicate that infarction does not necessarily lead to scar formation Clinic ıl reports 31 subsequently suggest that anticoagulant therapy has ? favorable effect in acute myocardial infarction Accordingly a cooperative study was made by the American Heart Association Thuis study revealed that the mortality and thromboembolic complications were reduced by approximately 50 per cent in patients with acute myocardial TABLE 8- Mortality from Acute lyocardial Infarctions (Durs in the First Four Il eeks) after Diagnosis Palients (Vo) Vortality for) 53 16 281 148 26: 1 Authors I evine and Lronn (1928)1 1 Connors and Holt (1930) 43 Harrington and Wright (1993) Master (1936) 135 Vaster (1937)134 Bland and I\hite (1941) Levine and Rosenbaum (1941) Woods and Barnes (1971) 68 Newman (1946) 161 Vintz and Katz (1941)16 Yater (1918) 281 140 900 19 33 908 128 1 50 5. 866 18+ 22 52 Ft my d) fct #lou & ad Its for w ek fl! P TIBLE infarctions in whom anticoagulant therapy was used ? 7 summarizes the effect of anticoagulant therapy on the mortality rate in acute myocardial infarction 5 6 41 Subsequently it has been pointed out by Russek et al 04 that patients with myocardial infarction run a variable course and on the basis of retrospective studies these patients can be divided into good and poor risks The following criteria for the recognition of poor rish cases have been established (1) previous myocardial infarction (2) intractable pain (3) extreme degree or persistence of shock (1) significant enlargement of the heart (5) gallop rhythm (6) congestive heart fulure (7) auricu ·PRESENT STATUS OF ANTICOAGULANT THERAPY 45 Fre 10_Vural thrombt in the heart fa patient i ho dce from cauda e arrithm and i ho had been on long term Dicumarol therapy for nunc 31 (Reproduce! Tycrmis on of D 1 Sterling Schol Viami Flr) 1 recognized recurrence of thromboembolism while on unti congulant therapy Acute Arterial Embolization or Occlusion The use of anticoagulants in arterial occlusions (other than coronary and cerebral) is indicated and the pro_nosis depends to a large extent on the promptness with which therapy is started 185 64 21 Hepirin for immediate antithrombotic effect fibrinolysın to lyse the clot ind oral anticoagulants to prevent re formation of the clot represent the ideal medical approach ·44 ANTITHROMBOTIC THERAPY for varying periods of tho to 10 years Ile presents a total mor tality rate of only 19 per cent in these patients all of whom were not treated with anticoagulants Reclassification of his dat? on the basis of good and poor risks reveals that 206 of his patients 1 cre in the poor rish category and that the mortality rate in these patients was 40 per cent This agun emplızsizes the good prognosis for good risk patients even without inticongulint therapy One remuning question about good ud poor risk classifica tion is Can patients be grouped accurately at the onset of an acute myocardul infuction. One study" by 1 group of суретт inced cardiologists indicates that 56 per cent of the patients required 1 revision of their classification from good to poor risk The percentage of error by a general physicrın would prob ably be somewhat higher therefore it is questionable whether in accurate classification can be made within the first 18 hous of an acute attich A recent report on liospital words "indi cited a mortality of 47 per cent in both tested and nontre sted patients with acute myocardial infiction This suggests the importance of factors other than anticoagulants in the treat ment of this disorder 3 99 1 1 134 296 Another approach to the evaluation of anticoagulant therapy is from postmortem data on patients dying shortly aftei tlie onset of clinically diagnosed myocardial infarction These studies reveal that only 50 per cent of patients who dic from acute myocardial infarction have thrombi in their coronus arteries and that many have hemorrhage into ricriosclerotic plaques crusing the thrombosis 8 1 7 In a recent study 1 º mural thrombi were found in 4 1 per cent of the patients treated with anticoagulants and the data indi cated that therapy was not effective unless started within thiec days of onset of infarction It is interesting to note that a patient ulio liad been treated with Dicumirol for nine years following myocardııl infarction had a large mural thrombus (Sce fictire 10) However he died from cardiac arrhythmir und never lid 68 180 ·PRESENT STATUS OF ANTICOAGULANT THERAPY TABLE 10 CO Binge! Cerebral Thrombosis Cerebral Embolus Cerebral Hernartha, Incidence FORO Per Cent) {5-'Per Cent (8-1 Per Cent Seldon Raze Common Cheyne Stokes or tabored respir3 tion Seldo12 Rare Conjugate dessa tion of eyes Trquent Quadriplegia Rarc Rare Rare except an thrombosis of bus 1}at artery Stuft sech Rare Rare Frequent Rare Rare Frequent Bilateral extensor plantar response (posstyse Babinsk) Leukocytosts Lncorim n Uncommon unless embolus an fected More than o per cent of potsents have over 12 000 Sculocytes per cu mm often greater than 20 000 Cerebrospssal flurd Fissid usaa 11 clear pressure slightly increased but not above 0 cm of water Flusd may be clear or xantho chronic Usually bloody and under IST rcased pressure There may be slight pleocytosis and ast 15crease in prolein content There may be moderate pleocz tosis and increase in protein concete especially dem bolus as septic Bloocty huid dag Rostic of hernar 2 hane nto 1022 153cutar or sub arachn> pace Flurd xanthochra mc if hemorrhage is old rarely way te clear { hemos Thage is deep an brain tissue Or walled off ·46 ANTITHROMBOTIC THERAPY TABLE 10-Differential Diagnosis of Cerebral Thrombosis Cerebral Embolus and Intracerebral Hemorrhage Cerebral Cerebral Cerebral Thrombosis Embolus Hemorrhage Incidence (10-80 I er Cent) (1-22 Per Cent) (8-15 Per Cent) Ige groups Same as for hem As majority of Same as for arteri orrhage cases occur from osclerosis (increas rheumatic hearts most patients are ade over 50) young adults or early middle aged ing with each dec History and gen eral physical ex amination Same as for hem orhage but blood pressure normal in majority of cases may be eleinted Rheumatic heart disease with matral stenosis bacterial endocarditis au ricular fibrilla tron recent myocardial infarction embolelsewhere as in lungs arms legs kidneys or mesentery usually at least one of these pathologic states can be found Evidence of arteri osclerosis 11 ret inal or peripheral vessels or other es idence of disease of cardiovascular systern blood pres sure often ele vated the syscolic pressure usually above 200 mm Hg On et Very sudden ab rupt development of neurologic signs Difficulty in speak ing and weakness of arm or Jeg are the usual first symptoms onset mas le gradual or sudden Severe headache nausea and vomit ing frequently oc cur at onset fol los ed by cona Coma Often none at all if present usually les than 24 hours Coma not usual unless embolus 15 large If com2 persists more than 94 hours hemorrhage more likely Convulsions Vay occur Occur in per cent of patients at onset Occur in 14 per cent of patients at onset Co PL I RICET IS Strokes D OS d mod I Ca asc la Duese S 519 1959 Rp odt t tm t by pe m I Dagnost Vod pblish ·PRESENT STATUS OF ANTICOAGULANT THERAPY 49 established but seient case reports eniphasize that i curious approicli xs indicated 19 18 The basic question relate to the general effectueness of atticoagulant therapy in strokes is currently under cooperative shid, Prelomnirs dria indicate thai fatal hemorrhages occur nuore frequently in strokes than in other thromboric conditions ulun anticoagulants 114 employed further studies will deter mme of the risk of this therapy is grerter than its benefits ·48 ANTITHROMBOTIC THERAPY at the present time 150 The question of therapy to prevent recur rent thrombosis or embolism till be discussed further in the chapter on long term anticoagulint therapy Patients with rheu initic heart disease in ho nie zuricular fibrillation have fre quent embolic episodes and Inve been slioun to benefit from long term anticoagulant therapy There were 55 embolic cpisodes in a group of 51 patients wlule on anticongulant therapy and 197 episodes during a similar period when inticoagulant therapy 175 withdran These findings Ine been con firmned 9 10 Cerebral Vascular Disease The use of anticongulint therapy in cerebral vascular disease demınds an accurate clinical dignosis since its rise in patients with intracrınıal hemorrhage may be quickly faul The fear of gross intracerebral bleeding has resulted in a slow and cau tious use of anticoagulants 80 0 1 1 76 The differential ding nosis of cerebral thrombosis embolism or hemorrhage can be determined in most instances by utilizing the data presented in TABI F 10 Anticoagulant therapy has been shown to be effective in prtients with intermittent insufficiency of the vertebral basılır arterial system or carotid arterial system thrombosis of the vertebral basılar system with infarction and actrely adı inc ing occlusion of the carotid artery Atracks of intermittent in sufficiency rent controlled in 9 per cent of 179 patients and the rate of mortality from thrombosis was reduced from 50 per cent in 48 control patients and to 7 per cent in 139 patients treated with anticoagulants 11 McDevitt et al 138 Inne presented data on the frequency of cerebril emboli in patients with various types of licart disease They found 122 cerebral emboli in 90 patients not given inti congulants during 2812 patient months and only 16 cerebral emboli during 2 291 patient months when anticoagulant thierapy nas used The decision as to whether severe hypertension is ? contraindication to anticoagulant therapy has not been definitely ·PRESENT STATUS OF ANNICOAGULANT THERAPY +9 established but several case reports emphasize that a cautious approach is indicated 1316 The basic question rune to the gemrl effectneness of anticoagulant therapy in strokes is currently under cooperative study Preliminars du sndicate tht final liemorrhinges occur inore frequently in strohes than sa other thrombotic conditions when anticoagulants 35€ employed Further studies will deter me of the risk of the therapy is greater in its benefits ·6 Long Term Anticoagulant Therapy THE VAJOR EFFECT of anticoagulant therapy in patients with acute myocordial infarction is a reduction in the incidence of mortality and thromboembolic complications in poor risk pa tients This effect is probably due to the pretention of reelli rent thrombosis or mural thrombı or at least to the prevention of mobilization of localized thrombı These results emphasize the fact that anticoagulant therapy is prophylactic and not cura tive Therefore it is not surprising that this type of therapy has been tried in patients with recurrent episodes of thromboem bolism 17 O 50 51 55 8 79 100 117 130 1 164 167 184 11 17 183 00 10 16 17 6 8 33 31 38 41 1 58 67 RESULTS OF OTHER STUDIES In 1941 Nichol started long term anticoagulant therapy in a patient who had had three serious myocardial infarctions in Is months In a series of 5 patients Nichol reported that long term anticoagulants were of definite benefit 168 Peters et al also suggested that anticoagulant therapy was of some ard in preventing recurrent coronary thrombosis Since these preliminary reports many publications have up peared which tend to support the belief that long term anti coagulant therapy is effective and practical The problem of evaluation of this therapy however is more difficult than that involved in the use of anticoagulants in acute thrombotic episodes because the factors licated in long term experi ments are innumerable Again no conclusive therapeutic in Testigations have been reported but some indication of the effectiveness of long term anticoagulant therapy can be obtumed from a review of some of the larger series discussed in this chapter TABLE 11 summarizes the effects of long term anti coagulant therapy in arteriosclerotic heart disease 7 6 11 13 1 113 -3 55 In a small series of patients who had clinical evidence of 50 ·LONG TERM ANTICOAGULANT THERAPY $1 congestie heirt friluft the use of long term anticoigulants 11 25 found to reduce the mortality rate from 13 to 75 per cent and some decrease in the incidence of thromboembolic complications Tas noted Ouren 173 folloned 106 patients wlio irid surved an attack of acute myocardni infarction for at least eight weels and Tiit Results of Long Term Anticoagulant Therapy it frteriosclerotic Neart Discare Antkcc 161/int Control Crop Goup Author D sease Cases Vortality Cases Mortality (lo (lo) Anderson (1930)7 CHF 150 75 Owren (1953)111 o controls) 106 113aler (1951) Ingina (ho controls) 260 124 Suzman (1935) 89 SS 82 73 Aches (1996) 114 MI 231 43 121 Bjerkelund (19; } . NET 118 119 03 Vanct ester (1927) 131 St "D Vichol(19.9245 signa 10 40 96 6! 111 407 313 99. 1° 5 Pecherang (19.93386 V3 1837 17 19.) 21 CILE & 34 heart fail 16 Domy oc alatel At Low dosar of ant & rapy ses td as the controle 90 1 treated these patients with anticoagulanes for approximately tho and six tenths scars He noted a yearly mortality rate of per cent or a toul mortality rate of 85 per cent He had no controls but indicated that this is about one half the mortality rate one would expect from a review of the iterature Waaler reported 2 careſul study of 266 patients with angina pectoris who were treated with anticoagulants for two and one half years "The mortality rate in these patients was 12 4 per cent however he hnd no controls The study indicated that patients with a short history of angin7 were benefited most by the treat ment In a controlled investigation Suzmın et al ' reported on the effect of anticoagulant therapy carried on for three to 70 months ·57 ANTITHROMBOTIC THERAPY in a series of patients who lnd been given inticoagulant therapy during the acute phase of their myocardial infarction In 82 patients treated with long term anticoagulints there was ? mortality of 73 per cent in 49 controls the mortality was 33 per cent in comparing both groups of patients with severe acute attacks the mortality 11 25 9 per cent in the group treated and 46 7 per cent in the control group heges et 2] 117 11 line presented data on a series of 121 p? tients who were treated and 234 control patients after myocardial infarcuion The mortality was 99 per cent and 18 per cent respectively A fen patients observed for four yeirs in whom there is a lustory of a single attack had z mortality of 8 + per cent in the group treated and 41 per cent in the control group in patients with multiple myocardial infarctions who were observed for tour years there was a mortality of 12 per cent in the group treated and 62 per cent in the control group Manchester 131 his folloned 7 controlled series of patients after acute myocardial infarction for a period of one to 10 and found a mortality rate of 14 per cent in those trented com pared to 3-4 per cent in the control group Nichol et 1] 16 have presented the combined results of 10 different cardiologists ti ho used long term anticoagulant therapy in private patients The mortality rate in 993 patients treated 175 12 5 per cent compared to a control group of 407 patients with a 37 per cent mortality Anticoagulant therapy 175 used for less than one year in 12 per cent of the pitients treated and the mortality rate it is 28 per cent in 319 patients who stopped anticorgulant therapy Bjerkelund * has presented his findings in 1 cirefully con trolled series of 237 piuents u ho were followed for 66 months There was a mortality of 20 per cent in those trented and 33 6 per cent in the control group The statistical analysis of the dari revealed 1 rather interesting finding namely that 2011 coagulant therapy \ 75 of greater benefit to patients who were good risks than to those who were This lias recently been confirmed in the cooperatne study 189 from Fng years poor risks ·LONG TERM ANTICOAGULANT THERAPY 53 land but contrasts with the findings in acute myocardial infarc tion when anticongulints nicre used RISK OF HEMORRHAGE The major criticisin agrist anticoagulant therapy is the possi bility of liemorrhinge Its occurrence is reported in every series in which the patients niele lept on long term therapy The risk of hemorrlinge increases with the length of treatment and the level of depression of coagulation factors An nccurite estimate of the risk is not possible from publislied reports Bjerkelund his summarized the data from the liternture and found 22 dentlıs MW SGOT 93 OS B0 13 83 PURPURA 40 COAGUL TION TIME M NUTES) MORVAL PROTHROMEIN TINE (SONOSIS) THERAPEUTIC RANGE T ROMBIN UNITS SERUM TGT 164 122 124 200 250 200 250 PLATELETS 1000 200 300 100 . 9 12 200 D CUMAROL Soya PL 25 mg 780 mg IV 4 2 . 10 EPAR N 300 DYS OF TREATMENT Tic 11-Cects of vitam n h and intra enoui si bean phospholipid on the arious corgi lation te is on a patient 1 th purpu a from Dicumarol therapy From Boyles et al Bloo 1 14 1 199 1 poluced by permi son of the publisher

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·LONG TERM ANTICOAGULANT THERAPY 53 land but contrasts with the findings in acute myocardul infarc tion when anticongulants were used RISK OF HEMORRHAGE The major criticism against anticoagulant therapy is the possi bility of hemarrlinge Its occurrence is reported in every series in which the patients were kept on long term therapy The rish of hemorrlage increases with the length of treatment and the level of depression of coigulation factors in accurate estimate of the risk is not possible from published reports Bjerkelund has summarized the data from the literature and found 22 denths SGOT 3 OS DO 15 PURPURA 101 MORIAL PROTHROHEN TIME [SECONDS) Motor TWERUCUTKC RANGE N BOSALE UNITS * SERUM IGT 164 PLATELETS 1000 122 124 200 20 200 250 100 TUMAROL 300 2007 100 1K 25 mg Soya PL 780 mg tv 3 MEPANN 300 2 200 $ 6 9 10 12 4 S OF TREATNENT Fir ]]—[ffects of amu and intravenous soy bean phospholipit on the a los congulat on te is on a patient i Ith purpura fron D cumarol therap From Boules et al Blood 14 L 19 9 reproduced by perm 3101) of the publisher ·52 ANTITHROMBOTIC THERAPY in a series of patients who had been guen anticoagulant therapy during the acute phase of their myocardial infarction In 82 patients treated with long term inticoagulants there was a mortality of 7 3 per cent in 89 controls tle mortality was 31 per cent in compırıng both groups of patients with severe acute attacks the mortality was 9 per cent in the group treated and 46 7 per cent in the control group heyes et 2 116 117 hate presented data on a series of 141 pa tients who were treated and 234 control patients after myocardial infarction The mortality isas 99 per cent and 18 per cent respectively A few patients observed for four years in whom there was a history of 1 single attack had a mortality of 84 per cent in the group treated and 11 per cent in the control froup In patients tith multiple myocardial infarctions who here obserıcd for four years there *75 7 mortality of 1.2 per cent in the group treated and 62 per cent in the control group Vanchester 131 has followed a controlled series of parents after acute myocardial infarction for a period of one to 10 years and found a mortality rate of 11 per cent in those treated com pared to 31 per cent in the control group Vichol et al ' have presented the combined results of 10) different cardiologists is ho used long term anticoagulant therapy in private parents The mortality rate in 99, paricnis trented was 12 5 per cent compared to a control group of 407 patients with a 37 per cent mortality Inticoagulant theraps as used for less than one year in 1? per cent of the patients treated and the mortality rate was 28 per cent in 319 patients who stopped anticoagulant therapy Bjerkelund a las presented his findings in a carefully con trolled series of 237 patients who were follosed for 66 months There was a mortalıtı of 20 per cent in those treated and 37h per cent in the control group The statistical analysis of the data revealed a rather interesting finding namely that anar coagulant therapy 1135 of greater benefit in patients who were This has good risks than to those who were recently been confirmed in the cooperaille study " from Fng poor risks ·7 Thrombolytic Therapy I LOOD clors are teniporary stiuctures in the normal process of hemostasis The clot series as 1 frumen ork for nes tissue formation and the fibrin us gridually replaced by dissolution Intru ascular thrombı are morphologically different in arteries and veins Those in arteries ire generally crescent in shape and relatively acellular with very little tendency toward retrograde progression which is thought to be related to the higher pres sure in the arter Venous clots are usunily filled with entripped cellular elements especially platelets and there is a marhed tendency toward retrograde progression Arterial occlusion is 1 much more serious disorder than venous thrombosis therefore the need for an agent to restore circulation quickly is more im portunt in this condition The enzyme responsible for normal lysis of the clot is called ſilvrinolysın Methods of activation of fibrinolysin its clinical implication and therapeutic use ure discussed in this chapter The physiologic activation of fibrinolysin is almost as coinplex as the clotting reactions and the exact mechanisms involved are unknown However the nature of the reactions intolved can be summarized briefly into three general reactions (1) Tibrino lysin is in enzyme which will act specifically on fibrinogen or fibrın so that the fibrinogen will not clot upon the addition of thrombin and the fibrın will become soluble (2) Tibrinolysın is formed from its inutne precursor profibrinolysın by the enzymatic action of an activator (3) Thus activator can be formed by many diverse methods In general activation of the activator can be classified into either in vitro or in vivo methods One of the earliest observations in blood coagulation was the demonstration of proteolytic activity in serum after the addition of chloroform ethier or thymo!! Later Tillert and Garner 44 found that human plasm clots dissolved rapidly in tlie presence of certain strains of beta hemolytic streptococci In 1941 Mil 55 ·54 ANTITHROMBOTIC THERAPY (006 per cent) from long term anticoagulant therapy in 3 773 patients treated The over all cstimated mortality from all types of anticoagulants is 02 per cent while the incidence of major bleeding is bets een 5 to 20 per cent in most of the larger series reported Daily capsules of vitamins C and P are beneficial for the many patients on long term anticoagulants in whom hruising is ob served 39 Effects of phospholipid administered intravenously on Dicumirol induced purpura is shonn in FIGURE 11 1 743 47-19 BLOOD COAGULATION AND CORONARY ARTERIOSCLEROSIS Vany authois live reported considerable differences in the prognosis of patients with coronary heart disease 1 66 The cause of coronary artery disease is generally considered to be arterio sclerosis the etiology of which is unknown An interesting theory postulates that coronary arteriosclerosis is secondary to repeated intramural coronary thrombı 3 CO 6 69 97 98 139 14 57 63 SI 104 1 138 143 1 7 176 1 8 103 3 19 58 57 61 117 170 110 RO 81 43 29 1 ac Histologic studies have shown a relationship between intimal hemorrhage and fatty changes in the arterial wall 149 Several recent obsert itions tend to support this old theory Diets low in ſat in Norway and Russia during World War 2 were associated with the reduced incidence of thromboembolic diseases 153 1 * Fatty meals hue been reported to accelerate clotting 160 170 and also inhibit fibrinolysis *9 Decreased fibrinolysın 10 celerated 140 clotting and delayed heparin clotting times 18 have been observed in patients with acute myocardial infarctions The common factor related to these findings is not known but if these studies have any merit anticoagulant therapy may in some indirect manner inhibit the progressive development of coronary arteriosclerosis These observations may also explain the beneficial effect of intermittent heparin on patients with angina pectoris 67 68 In any event these findings are of interest and deserve further investigation ·THROMBOLYTIC THERAPY 57 either streptokinase or staphylokinase depending on the bacte ral source of the kinase Other studies demonstrated inexplicable species differ cnces 1 415 when fibrinolysın was activated with streptokinase namely human prepirations of profibrinolysin were rapıdly ctn nted with streptokinase whereas bovine profibrinolysin was not These findings have been explained by the suggestive evidence that a proactivator exists in human plasma which combines stoichiometrically with streptokinase The activator then enzymatically catalyzes profibrinolysın from any species into fibrinolysin The fibrinolysın in turn acts as a proteolytic enzyme on fibrinogen and fibrın ? The reaction products have similar clectrophoretic patterns (Set FIGURE 12) The various body fluids ie urine salny tears and milk also contain an activa tor which functions like the activator found in human blood In addition to the activation of profibrinolysın loy the method just described many studies liave shown that tissue extracts 3 13 83 can activate a proteolytic system in the blood Tlus tissue ex tract acts directly Plıysical characteristics of the activators from tissit extracts and from blood or body fluids indicate that the tuo agents are of different chemical structures However tech nual difficulties in obtaining tissue extract free from trace iniounts of blood oi serum render 1 definite statement impossi ble (See DiagRAN 5 for the activation of fibrinolysın ) Under certain conditions the circulating blood becomes capa ble of rapidly liquify mg fibrin It is not clear if the mechanism is the same in each condition but the result appears to be an in vivo activation of profibrinolysin to fibrinolysin These con ditions are accidental death drowning trauma ischemia fear electroslioch prolonged bleeding pyrogen reactions and cer tain neoplastic diseases especially carcinoma of the prostate In addition there are certain clinical situations in which hemor rhage occurs with low levels of fibrinogen in the circulatin. blood such as takes place with infusion of amniotic fluid into the circulation and extensive pulmonary surgical procedures One explanation offered is that the accumulation of thromho 1Jr

·56
ANTITHROMBOTIC THERAPY
stone 146 showed that purified fibrin resisted the lyric action of
streptococcal culture filtrites but the addition of small amounts
of human globulin resulted in rapid lysis Subsequent studies
suggested that the factor in human globulin fraction was a
proteolytic enzyme precursor which was actitated by the addı
tion of bacterni filtrite The agent in the filtrate was called
+
FIBRINOLYSIN
FIBRINOGEN
FIBRINOGEN DERIVATIVES
B)
a
+
FIBRINOLYSIN
FIBRIN
FIBRIN DERIVATIVES
116 19–Electrophoretic patterns of fibrinolysin fibrinogen and fibrin and the
Teacion products of the enzyme fibrinolysin on either fibrinogen or fibrin

·THROMBOLYTIC THERAPY 59 pancreas forms utach most proteins Streptokinase and brcterul polysaccharides ctnatc profibrinolysın and ure effective in the actuation of librinolysin an enzyme which specially attacks fibrinogen and librin Clinical studies of these rrions agents we discussel indu dually Trypsin Trypsın is one of the pancreatic enzymes which catalyzes the hydrolysis of proteins in the intestinal tract The the inert precursor trypsinogen which is actnated by the intes total enzyme enterokinase to trypsin with subsequent ruto catalytic activation of the remaining trypsinogen by trypsin The enzyme can be prepared in crystallıe form and studies with synthetic substrates indicate that its action is specifically for peptide bonds with a free carboxyl group and either arginine or lysine at the site of hydrolysis In addition trypsın is able to spist certain specific umides and amino acids winch have been used to assay the enzyme unity In vitro studies hie slon n ilne trypsin in los concentrations scclerates blood clotting and in higher concentrations inhibits clorong and catalyzes the activation of profibrmolysin to fibrino lysis is so studies by Varshy ind Freis 18 demonstrated that trypsın administered innenously caused laser and kidney dam age with extensne intramuscular clotting Theories on the mechanism of trypsin in accelerating closing indicate that the enzyme accelerated the formation of thrombm from prothom bin cither directly or by the activition of plasma thromboplastin In any event this is an important contraindication to the use of sntru enous trypsin in the treatment of intrinscular thrombi Other studies have shown that high doses of intravenous trypun produce ? shock syndrome wluch in many respects is similar to the intravenous administration of thrombin These toxicity reictions can be reduced by sloning the rate of the infusion of trypsin boncier no free enzyme activity could be demonstrated presumably due to the rapid inactivation of tryp sin by antitrypsin inluibutors in the plasma Despite these find ·58 ANTITHROMBOTIC THERAPY plastic tissue 197 119 materials in the blood Icads to activation of the circulating profibrinolysin and slow progressive intravascu lar clotting hence the circulating fibrinogen is depleted Inhibitors in the blood tend to inactivate circulating fibrino lysin thus a relative increase in fibrinolytic activity can occur with a decreased level of unuifibrinolysin' This substance and other inhubitors to the activation of profibrinolysın limit the level to which an increase in fibrinolytic activity may rise in Proactivator (in blood urine milk etc) Kinase (Streptokinase Staphylokinase) PROFIBRINOLYSIN ACTIVATOR Tiss . Activator Chloroform Trypsin FIBRINOLYSIN DIAGRAM 5— Activation of brinolyse the blood but they also complicitc iny attempt at quantitative estimation or study of fibrinolytic reactions Therefore evalu? tion of the effectiveness of the enzyme is difficult in addition the inhibitors complicate the problem of purification of fibrino lysin and the actuator The inictisation of fibrinolysin 15 considered to occur by the formation of a complex with anti libriolysin which can be partially split with an agent such as chloroform THROMBOLYSIS BY VARIOUS ENZYMES Iuve agents have been shown to have an invio dissolving action on fibrın 131 14 141 1 37 These are trypsin chymotrypsin streptokinase pyrogen free bacterial polysaccharide and fibrino lysin Trypsin and chymotrypsin are proteolytic enzymes which ·THROMBOLYTIC THERAPY 61 due to the reaction of the orga11333 to the breakdona products of rapidly destroyed protems Chnical studies with chymotrypsin hare indicated that its activity is similar to trypsin The toxicity produced also appears suslar watii generalized urticant and prin at the injection sites tending to limit its usefulness Pyragen free Polysaccharide The mode of action of brcterial lipopolysaccharides is pre sumed due to its ability to actitate profibrinolysın to fibrinolysın by in vivo febrile reaction it Although this type of therapy does not appear useful in most instances of intravascular clotting it does gne some indication of one method by whach fibrinolysın may be acırated physiologically Interestingly the increased fibrinolyuc activity is not blocked by prednisolone or by control of feser with aspirin ** Streptokinase Streptokinase is interesting because of its ability to produce fibrinolytic activity both in vitro and in 1110 112 Other bacteria such as staphylococci can also produce this action but because the mechanism of scuon is apparently similar and because strep tolinise has been most extensively investigated this discussion *ill center on this agent Studies by Tilett et al 246 brave shown that beta struns of streptococcus produce the most effectue kbrinolytic agen: Numerous experiments hile been made to purify the actie igent ind small quantities of rather pure prepa rations lase been studied The mechanism of action is not definitely established but reports indicate that streptokinase is not fibrinolytic in itsell A proacinator is considered to be chemically combined with streptokinase forming an actor sluch enzymatically converts profibrinolysin into fibrinolssin Studies have shoun some species difference Panified preparuions of filmu prolibrino Issia pre rapidly actuated uith streptokinase while bovine prepi ·60 ANTITHROMBOTIC THERAPY ings Innerfeld 108 reported in 1952 that intravenously admin istered trypsin would lyse experimentally produced clots in animals These findings were not confirmed by subsequent investigations from several different labomtories In addition intravenous trypsin in animals caused changes in the electrocardiogram Thus these contraindications and the nonspecific nature of the proteolytic action of trypsin las resulted in its abandonment generally for the treatment for intravascular clotting Chymotrypsin Chymotrypsin like trypsin is a pancreatic enzyme which is activated by trypsin into veral forms which differ in their relative proteolytic and hydrolytic activity The active enzymes are all formed from inert chymotrypsinogen which is produced in this state by the pancreas The outstanding differences in activity from those of trypsın are its ability to clot milk but not to clot blood Chymotrypsin requires the presence of an aroma tic ring containing tyrosine or phenylalaninc residue for its hydrolytic activity but it will attack 1 uude range of synthetic substrates and proteins the latter being acted upon at different linkages from those attached by trypsin Tagnon 40 has shown that intravenous chymotrypsin will not cause intravascular clotting but will produce 1 shock syndrome similar to that produced by trypsin His studies demonstrated a fall in fibrinogen and a prolongation of the prothrombin time which he considered to be a direct attack on these congulation proteins Jensen et al 1l found that chymotrypsını loners the antifibrinolytic titer of the blood which may explain the action on fibrinogen Later studies have confirmed the in vio action on fibrinogen and some thrombolytic activity but a rapı rise in inhibitor activity suggested that tlus enzyme had little poten tial use in intravascular thrombi Another difference in chymo trypsin from trypsin is that the shoch phenomenon cannot be inlubited by heparin which may indicate that tius toxicity is ·THROMBOLYTIC THERAPY 63 siderably in different prrents esen if the amount of profibrı nolysin is similar this is related to variation in the levels of antfibrinolysın Fictre 13 zilustrates the electroploretic pattern of the interaction of purified fibrinolysın and antfibrinolysin In addition streptococcal inſections result in an inhibitor to streptokinase which is ? ruher frequent excurrence In some patients the level of this inhsbitor is sufficient to require er tremely high doses of streptokinase in order to obtain an effec the level of this agent for the activation of prohbrinolysin Since even the purest preparations of streptokinase produce toxicity in a significant number of patients the amount that can be infused is limited Chills lever lıypotension and allergic phenomena are the most frequently observed toxic reactions Honeer another theoretic danger is hemorrlige for once the fibrinolasc system has been activated in mo there is no knonn specific method which will reserse the 100111y If very active fibrinolyesc system ss present it will lyse all of the circulating fibrinogen which could be treated with human Fraction 1 but tlus preparation is contaminated with proenzyme which would further increase the lyric actuss At the present time the best therapy is plasma ishich contains fibrinogen and profibrinolsın but plasma also contains the inhibitor inefibrinolysın Despite these dran hacks streptokinase has been used success fully in many patients suith various thrombotic conditions II preparations of streptokinase can be made in which the acaruty is retained and the toxic reactions are elimmated it would undoubtedly be used more dels in the treatment of all types of intraiascular cloring Fibrinolysin Fibrinolysın is the naturally occurring enzyme formed from plasma profibrinolysın Recent advances in the purification of human profibrinolysin live resulted in the successful applıca tion of in vitro acii tted enzyme for the sus of arterial and venous thrambi in animals ind man " + 15) FIGI RE 14 demon ·62 ANTITHROMBOTIC THERAPY rations are not affected The addition of small quantities of human globulin or profibrinolysın however results in the rapid activation of the mixture of streptokinase and bovine profibrino lysin This is thought to be due to a proicti ator in human plasma which is missing from the blood of other species It has also been suggested that human profibrinolysin combines with streptokinase more readily and this is the actit ator of prolibrino lysın in any species Other in vtro studies lave shown that fibrinolysın attacks fibrinogen and fibrın at an equal rate wlule in uno studies have + FIBRINOLYSIN ANTIFIBRINOLYSIN INACTIVE COMPLEX FIC 13--Electrophoretic pattern of fibrinolysin antifibrinolysın and the inactive complex formed from their interaction shown that fibrın appears to be destroyed more selectively than fibrinogen These studies however are complicated by inhibi tors in the plasma hich limit the value of any in vitro estimate of circulating fibrinolytic activity and the rapid turnover rate of fibrinogen in the intact animal This difference in the rate of attack is probably explained by some adsorption of fibrino lysin onto the fibrin clot and by the rapid replacement of the destroyed circulating fibrinogen In the clincal use of streptokinase the lesel of circulating profibrinolysin and the intifibrinolysın are limiting factors in the quintity of active fibrinolysin produced in the circulation The activation of profibrinolysin occurs tuithin one half hour and within one hour nearly all of the circulating profibrinolysin is converted to fibrinolysın This is revealed by the failure of additional quantities of streptokinase to produce further fibrino lytic activity The level of fibrinolytic activity may vary con ·THROMBOLYTIC THERAPY 65 tint se mental injection of fibrinolisin is necessary to achieve effectne in polysis of coronary tlirombi FIGURE 21 illustrates the effect of innvenous fibrinalysın on the corgulation factors in a woman with cerebral thrombosis However all fibrinoly sin prepinitions oue been associated with systemic reactions such 25 fever culls and lıypotension in a significant percentage of the patients In addition skin reac tions Inse been noted in some instances with repeated admin 301 MINUTES CLOTTING TIME 10- 30- PROTHROMBIN CONSUMPTION SECONDS PROTHROMBIN TIME 104 250 TWO STAGE PROTHROMAIN UNITS 150 900 FIBRINOGEN 800 700 201 YAME UNITS/CC 500 000 U FIBRINOLYSIN DOG 38 WI IO & XO 2 4 TIME N HOURS 15-ritect of intravenous fibrinolint therapy on the coagulation factors in dar af et an inducer: 1 lood clou ·64 ANTITHROMBOTIC THERAPY strates the in vitro inactisation of the esterise activity (fibrino lyuc) with v zrious plasinis Animal studies and preliminary studies in man indicate that fibrinolysın is a specific and effective agent for the lysis of intra enous clots FIGURES 15 and 16 stion the effect of intravenous DOG HUMAN HUMAN PLASMA CONTROL LOG OF BAME UNITS PER ML PLASMA DOG AND BOVINE PLASMA CONTROLS BOVINE 20 40 60 ao 100 120 INCUBATION TIME IN MINUTES AT 25 C FIG 14-In vitro inactivation of fibunolysin by normal plasma as determined by mersurements of the synthetic substrate BAVE fibrinolysin on the coagulation factors and the accelerated lysis of radio-opaque venous clot 33 in dogs The gross appearance of an induced radio opaque coronary thrombus in i dosis illustrated in FIGURE 17 Serial ry eximinations in TIGURE 18 illustrate the failure of large amounts of intravenous human fibrinolysin to accelerate the lysis of this induced clot The amount of fibrinolysın used in this experiment was much larger than could be used clinically as illustrated by the marked effects on the blood factors shown in FICURE 19 These findings suggest ·THROMOLYTIC THERAPY 57 Ircind cel raciso oprette blood clol nr bra b of the left le cond >> OTA Pr* artera at surgers 1501ation of the enzyme librinolysın has been shoun to be ffective in the lysis of clors esen without endence of a marked zase in mersurible fbrmolux activity This may be due to the absorption of the enzyme onto the fibrın clots Another explan. (10n may be the difficulty of measuring hibrinolytic actuals 1xcrust of the inlubitor muhibrinolysin lt 1$ important to note that the enzyme is ineffective once the clot has been covered 11th endothelium wluch occurs a athin three to seven days This fimus the use of fibrinoly sins to only recent thrombotic episodes Thi enzyme can be diministered in conjunction tuth oral antı coagulints and it seems likely that fibrinolysin combined with tarkoigulants will be prescribed for all types of acute throm

·66
ANTITHROMBOTIC THERAPY
3
tir 10–L) is of aduced rali 1 KR 1») duna dug ven after s tem
fibriol;sm aclmudi tritt a From Bk II Vel (in pres) to reduced
b) permiston of the pull hei
49891

·THROMBOLYTIC THERAPY
69
tension which wahlırje doses trat must be used »sh minive
nous therapy Preliminary obserı acions indicate that fibrinoly
sın administered under pressure mto the root of the porta or
into the carotid artery is the most effective method for the lists
thrombi sn the coronary or cerebral arteries
TA
Tic 180--After closure of the chest all and jut befo e the adminsitat on of
intravenous fibrinolysin sherapy

·68 ANTITHROMBOTIC THERAPY bouc episodes when a nontoxic prepu uuion becomes ar zilable FICURF 2 demonsantes the serial changes in the xray examina tions of a patient with pulmonary embolism who was treated with intiavenous fibrinolysm and anticongulant therapy It the present ume however its use is limited by the frequency of systemic reactions such as fever clulls and occasional lupo AY hu Ti 181-C Serial vrny appearance of 1 rada opique induced coronarit clot in a dog 11 184 {abo c)- It the time of urgery

·THROMBOLYTIC THERAPY
69
tension which its large doses diu must be used uuh unrise
nous therapy Preluntry observations indicate that fibrinoly
sin administered under pressure into the root of the forta or
into the caroud artery is the most effective method for the lusta
thromb: in the coronins or cerebral arteris
Fxc 1814fter insure of the chest all and a stel je de roma traio
Blravenoza fibrinolis a therapy
of

·70
ANTITHROMBOTIC THERAPY
Tre 18C-Twenty hours following intruenous fibrinolysın therapy

·THROMBOLYTIC THERAPY PROTHROMBIN TIME 20 300 PROTHROMBIN TIME ISEC 1 2 STAGE PROTHROMBIN 2 STAGE PADTHAON BM UNITS 10 200 100 4 800 TAME FIBRINOGEN 400 TAME UNTS/ FIBRINOGEN 0 40 Loos 20 SGOT LYSIS TIME 4 MR$ 22 KAS >> DAYS 30HRS 350 000 UNITS FIBRINOLYSIN INTRAVENOUSLY 0 1 2 3 4 TIME IN MOURS DOG 54 WT 181D tre 39-Efects of a large intravenous inson of branofs in on the coagulat on acrors in a dogh an induced coronani thrombosis Increased on the pro Thrombin time fit molytic Coy (TIV) Iss time and transaminase activity are nored al ng with a der case of cu utaling level of fibrinogen 20 zero From Boyles INVITE 4) seproduced is ne sau of che pullisher

·72
ANTITHROMBOTIC THERAPY
FMETRIC,
namestitutunum.
Fioru)
Fic 20--Partl lysis of a radio or aque coronars blood clot in n dag uith dis
semination of the clot to the terminal branches of the artery

·THROMBOLYTIC THERAPY
73
zor
PROTHROWBIN TIME
TIME IN
SECONDS
2. STAGE
UNITS
PROTHROMBIN
300+
500
FIBRINOGEN
300
24.
200
MINUTES
CLOT LYSIS
TIME
100F
ol
SKIN RASM
M
LEFT FORE ARM
20D OOO
FIBRINOLYSIN
6
DAYS
Il 21-ElTects of repeated intri enous infu tons of human fibrinolysin on the
various coagulation factors in a patients ith cerebral thrombosis From Bmles
I FITIM I on pres ) reproduced 1 crmus son of the publisher

·74 ANTITHROMBOTIC THERAPY Fic 2A-F-Series of x rays of a patients ith a pulmonin çmbolus bo i 15 suc cessfully treated with intravenous fibrinolyson therapy For 291 (above)-Im taken five days before the on ct of cute chest

·THROMBOLYTIC THERAPY
75
Tc13-\rzy 11 the t me of acute chest pain

·76
ANTITHROMBOTIC THERAPY
C
Fic 29C-Right lateral at the time of acute chest pain

·THROMBOLYTIC THERAPY
17
Fic-Tartable ras siken hours after the first fusion of matsavenous
Shrinolysen

·78
ANTITHROMBOTIC THERAPY
Hur 1-1 orable x ryuken 'I hours after the aun 1 imtu i ne intraren is
Glorinolysin

·THROMBOLYTIC THERAPY
Fac ray taken nine dats after the onset of acute chest pain the patient
appeared completely recareted clinicall

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Ved & Surg 1,119 113 - The use of anticoagulants in acute coronary insufficiency or impending myocardial infarction South Y J 43 62 19,0 AND BORG I F Long term dicumarol therapy k preient recurrent (trony artery thrombo is Circulation 1 1097 1900 10 KEYLS J N BORG J F COOGAV TJ BOFIIRER J J VELUSI SCOTTI PAGE R GRIFFITH G C AD ASSIE Long term anticoagu Int therapy in coronary atherosclerosis im Heart J 1914 1998 1611 AND PACE S 11 Documarol therapy in acute coronini thomh results in Gfts attacks ) florida 13 sf 1910 Plut Lit's 11 CAND JENANNS I L Inticongulints in coronary bonn dascase Med Clin Amer 39 999 19 4 174 41115 FTT D 11 In attempt fore tall acuilc coronary thromb):

·BIBLIOGRAPHY 99 1 Preliminary note on tfic continuous use of difumarol South M 5 0 31 1937 167 O BRIO JR Fat gestion blood coagulation and atherosclerosis 4m I VSC 934 3.3 (Oct ) 19 10 The cfiect of some fatty acids and phospholipds on blood coagulation Brit J Exper Path 38 5 3 19.3" 11 OLSEN OC KANT ROYCE O AD LINGJARPE P Long term prognosis of myocardial infarction Inal $15 in relation to Russels Classe [cation of good and poor" risk cases Icta med scandinat Supp! 319 1. 196 !! OLI ) Il Centrol of d cumarol therapy im SSC 217 427 1919 13 0 arv I Long term ducumarol treatment in cardiovascular disease technique and results Proc 1 Internat Cont on Thromboss and Embolism Basel 1954 Basel B nno Schwalxe 19 PP 109 {--- long term escumarol therapy in cardiovascular diseases Acta mert candinav Suppl S, {8 19,3 AND A The control of dicumarol therapy and the quantitate determination of prothrombin and procomertint Scandinay J Clin & Lab Iniest 01 19,1 16 I ALMER J 1 The prognosis following reco ery from coronary thrombosts wah special reference to the influence of hyperien 10h ind cardiac er Largeness Quart J Med 6 49 193, 1 7 TARKER RL AND RARAER NW Use of anticoagulants to management of acute myocardial infarction Ireliminary report Proc Scan Veer Vasa Clinic *1 IBS 1941 1 8 1 APRINSON) AND BEDFORD DE Cardinc infarction and coronary throm bosis Iance 1 + 1998 1 9 PATERSOV JC Vascularization and tiemorrhage of the intr13 of Brleri selerotic coronary arteries Arch I ath > 13 1936 180 Capıllary rupture with intimal hepsorriuge as causatne factor 1 co onary thrombosis Arch Pastı 25 1939 141 I LARSON SC AV MACKENZIE RJ Intestinal obstruction due to bushcrosscoumarin poisoning JAVA 16. 4. 199 18 PEFLIAI Sel ctxn for anticoagulant therapy in Curdiac infarco us ng the fiepatin retardeci cagulation time Brre Heart ) 18 V8 19 6 383 PETERS H R DOENTES } P AND BRA 1881 C F Further experiences with dicumarol therapy in coror ary tt rombosys South M | 4150 1943 GEYSKER ) R AND BRAMBEL CE Dicumarol in acute corot ar thrombosis JANA 130 593 1916 JA PELAY J I AND Jound yr Diagnosis of ser pheral arterial embolii the extremilies JAVA 168 1939 11,8 18G PICKERING GARVATT IM Bices R FLUERTO 11 GIUCHIRIST IR FILTER P B REID D D Wood I ll Rigur J I A DOUCLAS AS 41 as essment of lang term anticoagulant a tministration after car sia infarction Br 31 $ 803 1919 IN/ lworz V The presente aspects of chronar disea e and myocardial in farction New York J Med 44 12 7 1944 184 ·8B ANTITHROMBOTIC THERAPY Ictt med fine hundred and ses cits to cases IV Arch Int Veu 80-00-31 1917 148 V1RSY I 1 AND FREE I 1) Renil and hepatic injury in trypsin shock I roc Soc Typer Biol & Ved 5, 2,8-2,9 1911 119 VORCIY 4D The Jathogenesis of Coronery Occlusion Springfiel 1 Charles Thomas 1906 150 VOIR AM Thrombolysis with fibrinoly in (plasmın)-new therapeutic upprorch te thromboembolism JAV 16, 169-1,01 19,8 151 Voirs P D VILLIKAN C I HATA KG SAYRE GP AND WHISNAST JI Infuence of anticuagulants on cyperimental caninc cerebral infarct I roc Staff Vice Mayo Clen } 121-130 19.7 152 MULIER Tanthomata hypercholesterinemia angina pecton candınav Suppl 89 1938 Ingina pectoris in fiereduars vanthomatosis IVA Irch Int Ved (1 675 1939 151 Ver ] Long (erm treatment with clicumarol in myocardial infarcen Ict med scandina: 153 363 1906 J NAE RI Plasma tromboplastin component Influence of cottmarin compounds and remain has its custy in serum Proc Sac Exper Biol & Med 01 101 1916 1,6 ATTINSOY V CR41OTO ! I\D (Ole B Subdural homem clite to anticoagulation therapy inn Int ved +7 1368 19,8 1 MATITISO VI Disease of the monary irterics clinical and pathe logical feature Im J N S 10 210 199 18 FT T C VOOS RX AND spre EER J B Chanical evaluation of 1 nen aral anticoagulant 1110cm Circulation 15 13 1907 19 NELSOS VC Intimal (OIONATY neri hemerrliage as a factor in the (usation fcinary occlusion J Iith & Bict 53 10. 1911 160 VENTANDS VJ AND WILD T Source of platelet factor for the il romi plastin generation test attire 1 689 19 ) 11 ۱۴۱۱۱۱۱۱۱ Coronary occlusion in Foung adults Revies of Occin tlie en vice Iancet 109 1910 169 Nou L S The risk of hemorrhage in anticoagulant therapy Inn Wol Ved & Surg + J 1990 103 - The use of inticoagulants in acute coronars insufficiency or impen ling 111 ocardial infarction South M J 43 G, 19,0 16 AND Okt J F Long term dicumarol therapy to present recinco c ronary artery thrombo s Circulation 1 1097 19 0 ir AFYES I BORC J F COOCA r J BOETIRER J J VLIN " I Sort T PAGF R GRIFFIN (CAD Masser r Long tim antic gu fint tertpi in coronari atherosclero w im Heart J >5 14" 1929 16C 410 P4F S 11 Dicumarol therapy in acute coronars thromb results in fifts attacks J Florida VI 3 3/3 1916 1 DILLIPS CAD FINS I C inticoagulants in coronary he disease Ved Clin \ Amer 35 994 1904 nt 1 168 AND IS FTT D 1 In attempt to forestall child coronary the ·818LIOGRAPHY 90 AD- In (saluation of antkoagulant therapy in the treatment of acute myocardial infarct10 im Ileart J 43 871 197 04 AND Anticoagulant theraps in acute myocar fial infarction sures of specialist's punions mncething in lictions results and dangers Im J V Sc 795 8 1933 AND - Selection of patients or anticongulant therapy in acute myocardial infarction im Sc $ 133 191 19 SAMPSON J J AND FUKSER VI Ile diagnosis of inpending acute coronary artery occlusion im lloart J 1961 193. "11 SAT111R O PRIEST 1 S 11 IVALRCER AND LAT IN Coronary arterinsclero i coronars thromlxxis and the resulting myocardial chances Im Ilean J 10,67 an 1,69 1933 IWCHILLINFJ inuicongulants m myocardial urlaretion JAVA 14378) 190 "13 SCINEK S Viralsts and other studies questioning the evidence for and value of nuutine anticoagulant them in acute myc cardial infarction Circulation R 193 The current dispute concerning tincoagulants in acute myocardial Infarction JI156 11., 1991 1, SCOTT RF AND THOFAS ! Methods for comparing effects of arious Cats on fbrinalysis I roc Soc fuper Bot & Ved 96 24 1927 "1€ Srivar o Coronars (1«chacmic) bicart disease in patients with arterio sclerosis obliterans Atta med scan Isnas Suppl 319 59 1956 91 St APIRO CVLISHER RICHTAAN AY AND JOSFEROV IV Com parative clinical study of cumadın sodium an dicumarol in patients with thromboembolic diseases Am Heart J 55 66 19 8 218 SILPRY S FLETCHER IP AND ALKJAER IT Dclopments in fibrinolic therapy for thromiso enlolic di esse Am Int Ved 50 60 19 9 *19 - TUTCUTNER A GOTTESVIAN LWASSERMAN P AND TROLLI The enzymatic dissolution of experimental arterial thrombi in the doll bas trypsin chymotrypsin and į lasınınogen açtı alors J Clin Invest 3i 194 AND ALKJAFRSIC Stud es oi the fibrinolytic enzyme of human plasmas Thromb Dirth Haemat 1 261 1997 TROLL AND GLLECK IT Thrombin as a proteolytic enzyme Ihysiol Rey 34 79G 1954 my StelEY WA MORLEME J HAND LATIHAN L N Fxpeririental cerebral infarction The effect of dicumarol Am J V Sc 34 663 19) *3 StFT EL M AND CLIFFTON E E Mechanism of in vitro of human fbrinolytic system Differential turation of the components J Appl Physioł 10 289 1997 + SICLIR I H Prognosis of angina pectoris and coronary aclusion }AMA 11 998 193] Sist 11S Adin D * KIVBALL D Studies on the anticoagulant pfenindione Its mult phas effect on the coagulation mechanism J Lab & Cun Med 19 69 1957 KIMBALL DM AD AD4415 D Plasma thromboplastin component MO ·90 ANTITHROMBOTIC THERAPY 188 Post CR DES OITOLANDER GJ H AD H0011 EG 1 G carc of hemorrhagic diathesis due to 7 circulating antwoagulant Acta hacmat 18 290 1957 189 PRIEST EM AND PAUL HIG Phenprocouinon (marcumar) 1 An agent for short term anticoagulant therapy Im J Cardiol 2 61 1998 190 PROUT GRS1FGEL 1 CLIFFTOY CE AND THJEITMORE F Hemor rhagic deathesis in patients with carcinoma of prostate JAMA 160 810 19.G 191 QUICK I J DANIELS E R AND HUSSEX 1 icquired antithrombo plastınogenemia (hemophilia like disease) with special reference to its diagnosis J Lab & Clin Invest 44 91 1924 192 Hemophilia and hemophiliacs Bull v Library A 43 151 193 193 RAWE 1 AND DEGLID ) B The pathogenesis of cholesterol arteria sclerosis in the rabbit J I ath & Bact 66 39) 1933 194 RASHIKOFF J 1 AND GILCIERIST AR Tromexan in treatment of coronars thrombosis Im Heart J 4? 861 19,1 195 - SCHAEFFER LE VAGIDA VG AVDILY H Fialuation of di cumarol creatment in °81 cases of acute insocardial mfarction J V Sma: Hosp 18 350 19,2 196 RATHIE HI VIyocardial infarction Clinical features and prognosis JAMII O 99 1942 19 REID DE TEINERAL AND ROBY CCI Intravascular clotting and afibrinogenemia the presumptive Icthal factors in the syndrome of amniotic fluid embolisin im J Obst & Gynec 66 16) 1933 198 AVD - II Incoagulablc blood in severe premature separation of the placenta 1 method of management Im J Obst & Gynec 664 1953 199 AVD DIAMOND IK III Vaternal afibrinogenemia asso ciated with long standing intrauterine fetal derth Am J Obst & Cincc 66 500 19.3 200 RICE R L ACKTRYAN J S ASD SACHER R Long term dicumurol therapy Ann Int Med 3973) 19.0 201 RICHARDS RK AND LORTELL R Studies on anticoagulant 39 methylenc bis (4 hydroxycoumarın) Proc Soc Exper Biol & Med 50 237 194" 20. ROSENBERG BA AND VALACHI M Icute myocardial infarction in a city hospital Am J Cardiol 1 11 19,8 203 ROSENTIAL RL DRESKIY OH AND ROSENTIAL A Plasma thronito plastın antecedent (PTA) deficiency Clinical coagulation therapeutic and hereditary aspects of a new hemophilia like disease Blood 10 1.0 19 204 RUSSEK HIZOWMAN BLITE I GAD DOFRVER 4 1 Indications for bishydroxycoumarın (dicumarol) in acute myocardial infarction JAMA 145 390 1991 205 DOERVER A ARUSSEK AS AND VIITE LG Age and survival in cases of acute myocardial infarction J.AMA 147 1731 19,1 206 - Indications for bihydroxicoumarin (di cumarol) Circulation 0,19,2 AD ·P18LIOGRAPHY 93 AND The occurrence of antſ brinolytic properlies in the blool of palients with acute hemolytic streptococcus infections } Cha Iniest 14 15 191 Fibrinolytic activity of hemolytic streptococct Bact Res IC 1999 ?TOCANTINS L.M The Corgulation of Blool \ew lock Crune ani Sirifton 1955 18 THE WAY ) B Factors buencing teliate surnal full iming ( TONJIV thrombor s with myocar lal infarctun lennsyl anta V1 ) - 191, 19 fluxu J 1 AND GCIIKIST IR Anticongulants in the treatment of coronary thrombosis Brit VI 3tys 19,0 Tromexan 111 Iteatment of care 110 thn Heart J 21 1921 O AND IRIGRE IS Long ternt artic agutzat eri 1921) (171 ences Circulation 98 $ 10 SERSTRAETE VE AND SANDF\BROICHE S Occurrence 11 no «chion { endogenous circulating anticuagulants J Lab & Chin Tel +86 3 1936 13 ---AND- The thronboplastın generatu n iest Some practical modifica 11 and study of the role of factors I an! Ill on the imation of plasma thromboplastin Ida med scr dinay 155 37 19,8 - CLARK PA AND WRITISI col different li sul th amb pfitins in the control of an icoagulant therapy Circulation 16 213 1991 >> WALER B A Its effect of permanent anticoagulant therapy on symptoms and mortality ir angina pect ris cia me! scan lingi 15 247 19,7 f 141.19OY PA AN COISTABLE 11 Myocardial actres more liv study frans 45 Tiſc ins Ved! Directors of America 31 09 10 257 WANG CH BLAND FF AND WATE PD note on coron4T OL fu son and myocardial infarction fou nil niem 1 tl Mas achu eit Ceneral Ho puial during the twiny ver yer xl ou 147 111111 Uusae Am} int Ved 601 1918 29 WAKE A CAND S1RATNELL R inicuagulant the 11 LAU 1 commonly occurring pitfalls in Int Vect 10 19 7 3) WARTOK N 1 CLIRASO 1 AND SIE VIR Cifect of bloot coagulation time in therosclerosas de ster lict (Dehorel Circulation 5 4,8 19 GO WAPINAY 1 B Occluse 21 tu (0 arter le bletil L 29111 their walls im ffeart J 154 1 1938 6 AND ITELLERSTEIN II 1 he ir cider esfhent diea c m 2 (con secutive autop les Am J Int Vled 841 1948 Thrombosis of th coro1141) alter Hint 1 10 I the heart Am MSc J65.0 19.5 963 WELLS BB VEARVIS IN *10 14 ALDI OX CL 11 1) Wr NU? 11 tryptic activity in l uman plasa: 4m } Ch 11 1 118 1919 + 11 FSSC ER S SIETS SC GILBER1 N AND SHE VIC L luation fliera peutic procedures for acute arterial occlusion Cuculation 17 ! 13.8 5 BALLOY JD AVD KATE J 1 Siud es in the intr vascular coagula ton V A distinction between the It o gulant and anush ombx u effects of d curparol New England ) Med 256 1 23 19.7 t ۱ " EARN JT ·92 ANTITHROMBOTIC THERAPY (PTC) deficiency produced by prolonged administration of prothromb) penic anticoagulants Proc Soc Exper Biol & Med 89 81 1935 22. LAVELLE SM AD4A11$ D AND BECKER R Relation of hemorrhage and thrombosis to prothrombin during treatment with coumarin type anticoagulants New England J Ved 259 967 1938 778 MOLOVEYTIC AND GUTTAS CG Studics on the anticoagulant phenindione II Details regarding its administration in tuo lun ired cases Im Heart ] 53 139 1934 O SVITU C Length of survival after myocardul infarction JINA 11 16 1993 *30 SMITH FAND SCHELUNG I I clinical compar son of laboratory method used in controlling oral anticoagulant therap Throinb and Fmbol 1 Inter Conf Basel 1954 815 1935 131 SOLANDT DY AND BEST CH Heparin and coronary thrombosis in the experimental animal Lancet 235 130 1938 23' —- Nassin R AND BEST CH Production and prevention of cardiac mural thrombi in dogs Lincet 3, 59' 1939 933 SITTEL J A AND SIEKERT R G Anticoagulant therapy of a patient sath aortic arch syndrome Proc Staff Meet Mayo Clin 39 723 1914 31 STEITENS CAL JR Anticongulant therapy prasate practice Cusculats a 0 682 1994 93 STRAGNILLOR AND WARE A 6 Mephyton (emulsified Vitamin (1) in the treatment of excessive therapeutic hypoprothrombinomir Vel Clin N Amer 38 413 1954 996 SUSSMAN B J AND FITCH TSI Thrombolysts with fibrinolysin in celebrul arterial occluston JIM 4 167 1/0 1958 23. SUZMAN MM RLSKIY HD AND GOLDBERG B un cvaluation of the effect of continuous long term anticoagulant therapy on the prognosi ol myocardial infarction A report of 8? Cases Circulation 1? 3.38 19 238 SI EDBERG B Dikumarol vid migrerande tromboser ord med 1 m 19.3 39 TAGER V Studies on the nature and the purif cation of the clubul 1eacting factor and its relation to prothrombm J Exper Vedt nie 1956 210 TAG ON HJ \ature of mechanism of shock produce 1 1x inject 11 trypsin and thrombin J Clin Insest 4 1. 1917 211 TANZI F AND lav \ESS IL Long term anticoagulant therapy of th ambulatory pauent follos ing myocardial infarction Med Chin A 1125 1957 949 THL CJ STAFFORD 1 T STOOVER VAD VEYEK Oo llemorthagic agent 35 methylenebis (4 hydror coumarin) | Its cffect in prevention of experimental thrombosis Proc Soc Exper Biol & Med 54 333 1913 213 TILDEN J HAND SIUPLEY RF Fstimation (f clotting accelerator actinely in plasma after ingestion of fat (irculation 5 998 19,7 911 TILLETT W S AND GARVER RL Fibrinolitic activity of hemol 11c streptococci ) Exper Ved 58 18 1933 ·Addendum The most important factors in the study of blood coagulation are the attainment of (1) A carefully obtained blood simple one which is uncontaminated with tissue thromboplastin with out air bubbles and with prompt efficient admixture of inti coagulant (2) clean glassi are (3) daily standardızation of reagents and (t) attention to seemingly truunal details The methods described in this section ne not original but SYNOVI VS FOR BLOOD CO IGULATION FACTORS + Tactor 1 Fibrinogen Factor II Prothrombin Prothrombase 1 hrombozy me Factor III Thrombin Thromba e Factor IV Ti ve thromboplastin Thrombohincase Cyrozyme Thrombohinase Factor V Ac Globulin (plastda accelerator globulin) Labile factor Proaccelerın Thrombokinase Accelerator factor Component A of prothrombin Co factor of thromboplastin Prothrombinokinase Proprothrombinase Prothrombogenase Plasma prothrombin conversion facto Factor VI Serum 4c Globulin Accelerın Serum accelerator Thrombokinase Thrombogenase Prothrombinas 95 ·94 ANTITHROMBOTIC THERAPY AND 273 266 VESTLUND K AND HOI GEN A Vyocardial infarction An epidemiologic and prognostic study of patients from five departments of internal medicine in Oslo 1933-1949 Acta med scandinav Suppl 315 1936 96/ WOOD MTV AND SVEN HJ Stepwise mechanical occlusion of the common carotid artery under dicumarol and heparin therapy Proc Staff Veet Mayo Clin 3. 366-369 1957 268 loops RV410 BARVES IR Tactors influencing immediate mortality rate following icute coronary occlusion Proc Staff Afeet Mayo Clin 16 311 1911 26.) TRICHT HI KUBIK VI MAND HAYDEN M Influence of anticoagulant administritton on the rate of recanalization of experimentally thrombosed eins Brit J Surg 10 163 1992-1993 2.0 - Recanalization of thrombosed artertes under anticoagulant therapy Brit VJ 1 1021 19,3 271 TRIGHT IS Early use of anticoagulants in the treatment of myocardial mfarction J IV 163 918 19 Experience with dicumarol (3 3 methylenebis (+ hydroxycoumarin) in the treatment of coronars thrombosis with myocardial infarction Am Heart J 3 O 1916 The use of the anticoagulants in the treatment of diseases of the heart and blood vessels Ann Int Med 30 80 1919 214 AND LLCKEY CH Cerebral lascular Diseases New York Grune and Stratton 19 2,5 - MARPLE CD AVD BECK DF Myocardial infarction Its clinical manifestation and treatment with anticoagulants A study in 1031 case New York Crune and Stratton 1994 AND OVERWAV R S New blood inhibitor J Biol Chero 1 4 159 1948 AND TOLEX 1 Q Use of anticoagulants in treatment of heart disease ith special reference to coronary thromb! RHD with thromboembolk complications and subacute bacterial endocardius Am J Med 3.18 191/ 18 -- AND STROKCS Diagnosis and modern treatment I Diagnosis Modern concepts of cardiovascular disease 8 u19 19.9 219 WRICHT IT AND ROTHYAN M Deaths from dicumarol Irch Surg 69 23 1951 -80 WRICHT-SMITH RJ Coronary obsti uction Roy Melbourne Hosp Clin Rep.1 1936 981 YATER T M TRAUM 4 M BROWW G FITZGERALD RP GEISLER VA AND WILCOX B B Coronary artery disease in men eighteen to thirty nine years of age Report of eight hundred sixty six cases four hundred fifty with necrops examinations Im Heart J 36 334 481 and 689 1948 289 ZELEIFF G AND FIELD 1 Anticoagulants in treatment of coronary occlusion ith myocardial infuction Study of 80 cases New York J Med 50 1737 19.0 983 ZIFFER AV SCOPP I W BECK J BAUM ] AVD BERGER A R Profound bleeding after dental extractions during dicumarol th rapy New England J Med 56 951 19 ·ADDENDUM 97 SH\OV WS FOR BLOOD COAGULATION TICTORS Continued + Factor PTI (Plasma thrombo 1 135m3 thromboplastic factor CITA plastic antecedente) Platelet throm? oplas Thromboplastinogena e tic factor Plaisiet activator Thromboplastic cellular component TCC a) Cette 17t of Bloer CI { F ton 5&gest dame by fast At omistu ved brok At ng nily wil tam Calctura sons are needed for all teactions of blood coagulation Other Factor Thorght to be Concerned with Plasma Thromboplastan fo matro Factor Plasma thromboplastic factor D PTE- Sparis i factor of thromboplast Platelet factors 1 2 3 4 11F (1/ageman factor) Stuart factor (Prower factar) Car facror Inhibutors of Coagulat di lleparin Intathrombin-thrombin inhibitor-Aninhrombin I II II and I) Innhornb nco factor Profibrinoly sin plasminogen--tryptogen---pralyssn Fibrinoli simplasmin---sprasevimlyetc factor Troantifibrinolysin Antil bruohsin Ctrcularıng anikoagulants antithromboplastins (antibodies) thromboplasın Ibuprantuthtombokinase--heparin like substances--heparın co factor represent slight modification of previously described methods hich have proved to be reliable These methods have been compiled in this simplified form for contenience Paper electrophoresis has proved to be a convenient method for determining the effectiveness of various coagulation protein purification procedures This is illustrated in FIGURE 23 ·96 ANTITHROMBOTIC THERAPY SYNONYMS FOR BLOOD COAGUL ITIO FACTORS Continued t Pro SPCA pro conicrtin Factor VII SIC 1 (Scrum pro Stable factor thrombin conversion Autoprothrombin I accelerator) Coni crtin Co factor Component B of prothrombin Serum accelerator I rothrombin accelerator Prothrombin conversion factor Prothrombin converting factor Serozyme Co thromboplastin Prothrombinogen kappa fictor (chicken) Tactor VIII AHG (Antihemophilic intihemophilic globulin A globulin) HF-intihemophilic factor Prothrimbokinase Plasmahının Thromboplastinogen Thrombocytolysin Thrombe katılysin Thromboplastic plasma component- TPC Plasma thromboplastic factor I lrsma thromboplastic factor-PTF-A 11pha prothromboplastin I Jatelet co factor I PTF-plasma thromboplastic factor Tacteur antihemophilique A T'actor IX PTC (Plasma thrombo plastic component) Tacteur antihemophılıquc B Plasma factor Chnstmas factor Beta prothromboplastın I latelet co factor II Tutoprothrombin II Thromboplastın B Intihemophilic globulin B plasma thrombo plastic factor B-PTF_B ·ADDENDUM by the administration of large doses of ACTH und less effectuels ith Cortisone BLEEDING TIME Purpose To establish an inden of platelet function and tissue factors in olied to hemostasis Veihod Cleanse the car lobe sath alcohol and allow to dr Vale a 537!! puncture through the skin with a lancet Bard Parker blade or needle Do not touch the skin or apply an external pressure It 30 second inten als blot all the blood sbuch fas flowed usth a piece of filter paper Interpretation Normal bleeding time is one to three minutes Then the platelets are reduced or the fibrinogen content of the blood is los bleeding mat continue for an hour or more Then bleeding 15 prolonged the aventieth bloc mas be fully as large 75 the first Comments Prolonged bleeding time is observed in primar usualls congenual defects of the vascular wall (pseudohemophilia) and when there is a qualitne or quan sative plateler deficiena The mechanssm by which thrombocitopenia pro stuces prolonged breeding ume ss nor completels understood This is usualls attributed to a lack of asoconstrictor substance (serotonın) from the platelets agglutinaung at the site of vascu Injury and to a lach of mechanical plugging Du the plarelers The prolonged bleeding time of thrombocytopenia may be corrected partially by the continued administration of ACTH and temporarily corrected by the administration of platelets Par CLOTTING TIME Purpose Clutuing time is used as a general index of the sum of the various corpulation reactions which the place when blood clots Method Place la of whole blood into each of three tubes and note the clotting time Tilt rube lo I every 60 seconds unul 2 solid en form Then ult tube lo ? and after the blood ·98 ANTITHROMBOTIC THERAPY THROMBIN PROTHROMBIN JIC 23-Correlation between the electrophoretu. pattern and the specific activity of purified prothrombin and thrombin as determined with electrophoretic technics TOURNIQUET TEST Purpose To measure capillary fragility Method Outline an area 5 cm in duzmeter on the interior aspect of the arm Place 1 sphygotometer cuff around the pa tients orm and inflate the cuff to a pressure half way between systolic and diastolic or at least 100 mm pressure Vuntun this pressure for five minutes after which time release the pres sure and remove the cuff Wait a fets ininutes and then inspect the arm for petechiae Interpretation In normals 0 to 10 petechuae may be found If more are present abnormal capillary fragility is indicated Comments This test is positive in pitients with increased vascular fragility which occurs in suurvy vascular purpuri of undetermined origin senile purpuri etc In all of these condi tions the positivity of the test indicates only the inability of the vessel wall to resist stress The test is also positive in thrombocytopenic purpura The mechanism is unknoun but the defect can be corrected by the administration of platelets It can also be corrected promptly ·ADDENDUM 101 stable platelets Physical factors also like the weight of the clot nature of the surface etc wall influence clot retraction WHOLE BLOOD LYSIS TIME Purpose To test for possible increase in fibrinolync activity in a blood sample Vetkol The clots in {est tubes used for testing clotting tonie and clot retraction may be obseried for 24 hours in a water bath at 37 C Lysis of clots faster than 12 hours is significant of increased fibrinolyure activity or poor clot formann chased by a defecunse coagulation process or a reduced fibrinogen con tent Abnormal results cin be ex alunted by more quantitatile methods described later to PLATELET COUNT Purpose To quantitate circulating platelets Materials i Pitelet ud Sequesterene 12 (recrystallized 3 x) 10 Cm Sodrum chloride 17 Gm Distilled titer 300 cc The solution is filtered shrough filter paper and stored in the refrigerator The solution should be filtered each time before using 2 Bard Parker blide loll 3 U ceruhed hemocytotrets and pipets Method Isth this method blood can be collected from the finger tip or from a vein les based on the use of an anticoagulat ing solution which has the ability of preser ing the usability of platelets to the maximum The method employed is essentially similar (o that used for the determination of the red cell count Count from Finger Tip Blood Cleanse the finger tip of the patient woh alcohol and wipe dry Puncture the finger tıp and discard the first drop of blood Dra's blood into the hemacy tometer pipes to che 0 0o mark and aspirate platelet fluid to the 1 Ol mark (as for a red blood cell count) Vix the concept ·100 ANTITHROMBOTIC THERAPY has clotted tilt tube No 3 The clotting time of tube No 3 is taken as the significant time Marhed variation in the clotting time of the three tubes usually indicates poor technic Interpretation Normal clotting time ranges between 10 and 15 minutes Prolonged clotting time is found when the following conditions exist hemophilic diseases (AHG PTC PTA) severe hepirinemia fibrinogenopenia or severe prothrombinemia decrease in accelerators of prothrombin conversion decreased platelet concentration pseudohemophula and circulating inti coagulants CLOT RETRACTION OF WHOLE BLOOD Purpose To determine the function of platelets in regard to clot retraction Method Collect blood sith the tho syringe technic dis carding the blood in the first syringe Remove the needle from the second syringe and transfer 2 cc of blood to a glass test tube whuch should be hept in a water bath at 37 C Examine the test tube at the end of one hour after completion of clothing Interpretation The clot from normal blood will retract and serum will collect betueen the clot and wall of the test tube The serum can be poured off and mcasured The olume of serum obtained multiplied by 50 represents the clot retraction in per cent Direct visual observation however is usually suffi cient to distinguish betu een normal and abnormal clot retrac tion Normal clot retraction of whole blood is 20 to 65 per cent This retraction is generally a direct function of the number of actie platelets present No clot retraction is observed in blood and plasma of patients sath severe thrombocytopenia or throm boasthenia Clot retraction can be restored to normal tempo rarily in these patients by the administration of viable platelets Comments The degree of clot retraction is influenced by a number of factors (1) the fibrinogen content of the blood (2) the volume of plasma and most important (3) the number of ·ADDENDUM 103 Method Place 02 cc oxilated plasmi ud 0 ? cc of 02 VI Cicl in a test tulx Let thuis initure stand in the water bath at 37 C for 60 seconds and olsserie eiey 15 seconds theiealter The end point is the time librin strids appeir ind i ciot forms Interpretation The normal for the test is 90 to 120 seconds with platelet rich plam? ind 120 to 2 10 seconds with platelet poor plasmi? If the test is prolonged it is supplemented by ? titration of unknoun plısmı gunst normal plısma to deter mine whether the normal plasmas clotting time is prolonged by the addition of unknown plasma The prolongation of the clotting time of normal plasma by the unknoun plusmı kould indicate a circulating anticoagulant ONE STAGE PROTHROMBIN TIME Purpose To estimate prothrombin in plasmi Method Collect 45 cc whole blood and add to 0 5 cc of 0 I V potassium oxalate Spin at 3000 x G for 10 minutes to obtun platelet poor plasma Aspirite plasma from the cells then nda the following in Lee White iubes in the order given 01 cc plasma Ol cc thromboplastin and O 1 cc CaCl (025 M) Test clotting time from the addition of CaCl Place the tube in the water bath at 37 C for 10 seconds tlien tilt tube until a clot forms Do this procedure in duplicite Interpretation Normal prothrombin time meins the pro thrombin Ac globulin SPCA ind fibrinogen are of normal content in the plasma Jt there is a reduction in any or all of these factors the clotting time is prolonged The 100 per cent prothrombin time is 11 0 to 130 seconds When the one stige prothrombin time reaches 1 level of 25 per cent or less hemor rhage may occur A prothrombin percentage curre can be made up with pro thrombin free plasma or salıne alues are different especially in the 0 to 20 per cent ringe therefore the shape of the trio dilution curies is different This is done as follois ·102 ANTITHROMBOTIC THERAPY the pipet wel by reported inession an charge and ordinary red blood cell counting chamber is for a red blood cell count After charging set the chamber aside for 15 to 20 minutes so that platelets can settle To prevent evaporation cover the chamber with a Petrı dısl containing 1 piece of moistened filter paper Count the platelets under lugh dry magnification with a 10 x cyepiece Count all platelets in 25 squares (ench square is duuded into 16 individual squares) To obtain the absolute number of platelets per cu mm multiply the number of plate lets counted by 2000 (the figure of 2 000 is the result of a multiplication of the dilution 200 x the depth of the chamber 1 min) Count from Venous Blood Aspirite sterile platelet fluid into 1 tuberculin syringe to the 01 cc mark through 1 23 gauge needle Then dran venous blood to the 10 cc mark Transfer the mixture to siliconized test tube Collect blood from the test tube into the pipet The rest of the procedure is identical 10 that described for the finger op method In calculating the absolute number of platelets an additional correction factor should be introduced nimely 5/3 (166) which indicates the dilution of venous blood with platelet flud during its collection Comment for more precise counts the use of phase micros copy is advised 4 43 x phase objective with a long working distance condenser and 10 x eyepiece can be used This method is very useful in recognizing the platelets clearly It is necessary to count the platelets within one hour after charging the cham ber in order to prevent formation of platelet clumps This for mation greatly reduces the accuracy of the method The normal platelet count is 200 000 to 300 000 per cu mm Tith the method described RECALCIFICATION TIME OF OXALATED PLASMA Purpose This is in exclusion test for circulating anu coagulants provided defects in platelets and plasma thrombo plistin formation ure excluded ·ADDENDUM 105 BEDSIDE PROTHROMBIN TIME (MANCHESTER) Purpose To deterinine prothrombin comerting factors in whole blood Materials Thromboplistin (0 15 cm dried rabbit brun) microscopy slide with z nell and 1 stop 1 ach Method Add thrombopi istin to 1 cc of salıne incubate the solution it 10 for 20 ininutes and centrifuge Plue 20 cu mm of thronboplastin solution on a clenn microscope slide and then add 20 cu mm of liolc blood from finger tip prick Mix and start stop watch Interpretation Clotting time is indicated by a thick viscous clot Mornial clotting time is 15 to 18 seconds Room tempera there is a important variable in this test and 1 control determina cion must be done each time this test is performed Dilution curies can be done but are only gross estimates of the relative percentages of prothrombin converting factors PROTHROMBIN CONSUMPTION Purpose To measure the prothiombın rernung in serum one hour after clouting Alethod Place 1 cc whole blood in 1 test tube and after clotting put the tube in a wher bath (37 C) for one hour In a second tube add the following in the order guen 01 cc fibrinogen solution 01 cc thromboplastın 01 cc 107 ind 01 cc serum from the clotted biood (free of red cells as they contain thromboplastın) Time is chieched with the addition of the serum Place in the water bath for 10 seconds tilt unti) a clor is formed The clot is the end point Interpretation Prothrombin should be utilized when blood clots If there is a defect in the clotting mechanism the clotting time of this test is short indicating an abnormal amount of prochirumban iemainin, in the seruin A shortened clotting time occuts then there are decreases in platelet number or func tion hemoplulic diseases or circul iting anticoagulants This serum prothrombin time is compared to the plasma ·104 ANTITHROMBOTIC THERAPY O STICE I ROTIROVBI DILUTION CURIE Tormal Plasini Prothrombin Deprothromboni ed Plasma or Salme (cc) 05 013 04 +0 0 +0 10 0 33 100 90 80 0 60 50 10 30 0 30 0. 020 013 () 10 0 0 00) +00 +0 2 +0 30 +03) +0 10 +O4 +0 JJ 10 5 n U olce 1 abo e di Rp th mł 1 + 01c tb mboplat +01 ccc d perl mal kre OWREN WARE STRAGNELL PROTHROMBIN TEST Purpose To determine prothrombin Vaterials Anticoagulant–01 M of potassium oxalate with 100 microgrims of liepzun percc Method Add 45 a of blood to 0 5 cc of the anticoagulant Centrifuge the mixture for 10 minutes and then remove the plasmı Dilute the plasma 1 10 (1 cc to 9 cc of distilled water) All reagents should be warmed to 37 C Add 0 1 cc of prothrom bin free beef plasm7 * or 05 per cent boune librinogen (friction I) † to 01 vc of diluted test plasma in a small test tube (10 mm x 75 mm) Then add 0 1 cc of 7 thromboplastin calcium mix turc (potent thromboplastin mixed with an equal volume of 025 M calcium chloride) Interpretation The 100 per cent standard clotting time is 2) seconds the 20 per cent standırd clotting time is 45 seconds Rend from log paper the plot of clotting time und per cent of standard Hyland Laboratory froduct + Irmour product ·ADDENDUM 107 intervals unul clotting occurs in the reaction tristure and 30 seconds thereaſter pipet 0 1 cc of plasma saline-calcium chloride mixture into the fibrinogen solution and record the clothing time Interprelahon In hemoplulo there is prolon,ed latent penod but the total amount is unaffected thrombocytopenic curve goes up and down in various perks Blood from 1 patient on oral anticonqulants lias a prolonged latent period and the total amount of thrombın generited is reduced The normal range is 3 to 12 unus of prothrombin generated within 300 seconds THIROVBI VI15 CT Units CT Inits ст lnits inits of + 6 4 19 J) 19. 14 10%) 0 38 0 3 6 5 89 9) 99 9944 16 93 100-3 10+ 10 10 19 10 6 10 53 10 10 > 10 4 10 $ 102 102 10 is Z b 291 +0 10 58 9 60 61 62 63 60 6 66 30 31 3. 19 233 136 SH 19 28 10) 66 b + 63 6. G) 60 9 5) 38 1 30 31 38 36 $ 960 6 6 16 10 0 10 0 95 94 90 380 I 63 69 71 3 112 Il 120 12, 12 10 138 119 14) 133 160 163 166 310 971) 26 4 2 $1 30 8 6 1 + 13 81 80 49 78 9 SO 81 89-3 2 8 62 50 51 59 3 5 0 10 49 18 47 $60 11? +36 160 799 300 301 26 11 1 0 10 10 00 #6 83 18 Clotning time is gien in seconds ·106 ANTITHROMBOTIC THERAPY prothrombin time and the difference is expressed in seconds Normally the difference is always greater than 20 seconds ie at least 80 per cent of the prothrombin is consumed 25 meas ured with the prothrombin curve used in calculating the one stage prothrombin activity The normal value is usually 27 seconds and above when there is a relatively normal amount of prothrombin present in the plasma Comment In patients with hernophilia or hemopluılın like disease and idiopathuc thrombocytopenic purpuri (ITP) the prothrombin activity of scrum is high (ie 1 rapid pro thrombin time) Abnormal prothrombin consumption in ITP is not corrected by the administration of ACTH or Cor tisone nor by the infusion of bank blood It is corrected tem porarily by the administration of concentrated platelets In this condition as in liemophilia the test is useful in evaluating the clinical status of the patient ind the effectiveness of therapy This test is of little value in patients who are on oril inti coagulants because the prothrombin in the plasma is greatly reduced and the amount remaining in the serum is small and below the sensitivity of this method # per 10 cc of GENERATION OF THROMBIN IN RECALCIFIED PLASMA Purpose To ineasure the time required for the peak of gen eration and the total amount of thrombin generated Solution One hundred my of fibrinogen borite buffer Method Centrifuge 45 cc of blood and 05cc of citrate it 1 000 r p in for tuo minutes or allon mixture to settle in order to obtain platelet rich plasmı Place 0 4 cc of fibrinogen solu tion in each of 20 tubes which should be kept in 7 ulter bath 7t 37 C In another tube place the following 10 cc of patients platelet rich plasma 10 cc of 0 85 per cent N1C? ind 10 cc of Chci Start to time the reaction (If patient s recalcification time is prolonged use twice the strength of C7C! ) At 60 second Bovine Fibrinogen Fraction I Armour Lalvoratories ·ADDENDUM 109 tors Temperature All dilutions ind undiluted reagents should be lept refrigerated unul ready for tise Method The test is performed at 37 C Into ench of 6 test tubes is placed 0 1 cc of normal substrite plasma (oxilated) A thromboplastın generating mixture is made adding 03 cc of LOG OF 7 SERUM 5 30 35 10 15 20 25 MINIMUM CLOT TING TIME IN SECONDS A Thomboplast n ge erat o with added thrombin to sho to log phose B Thomboplastin ge e aton (control & lutos) TC "L--Effc is of progressi e dulution of normal serum in the thromboplastin generation test hich jn be us ! to determine the relat e percentage of Chroniboplasi n generated cach of the follown, (1) prothrombin free plasma (2) serum (3) platelet suspension or phospholipid substitute ind (4) 002) M Caci At one minute intervals after the addition of the calcium solution 0 1 cc aliquots of the thromboplistin generat ing mixtwe is added simultaneously with 01 cc of 0 025 M Clinto one of the tubes containin, 01 cc of tlie plasını suyunte it 376 (luiting times ire determined by the visual one stage prothnombın techmque normal control must be performed with each preparation of reagents ·108 ANTITHROMBOTIC THERAPY THROMBOPLASTIN GENERATION TEST Purpose To incisure intrinsic plasma thromboplastin Materials (13) Preparation of platelets Utilizing siliconized quipment 20 << oſcitiated blood is quickly challel to 5 cand centrifuged at 1000 x ( for five minutes and spirite the platelet rich plasını This plasma is centrifuged at 3000 G for 30 ininutes then one half of the supernatunt is removed ind replaced with siline Thus procedure is repeated three times with fifteen minute periods of centrifugation The platelets are suspended in sılıne to 1 final volume of 2 cc (or at least one fourth of the original plasma volume) (1b) Platelet substitutes for thromboplastın generation test Bruin phospholipid Three hundred mg of bruin phospliolipid gum is homogenized in 50 cc of 0 85 per cent NaCl This is the stock solution for thromboplastın generation the stock solu tion is diluted i 50 with saline Soy bein phospholipid * The stoch solution is 50 mg per cc For the thromboplastın generation test 0025 mg per cc is used Both brain or soy bein phospholipids may be substituted for platelets in the thromboplastin generation test To replace platelet suspension 0 } rc of either brain or soy bein pliosplio lipid is used (2) Prothrombin free pluma One cc of 7 0 15 M Baso, sus pension is centrifuged 1 3 000 rpm for 15 minutes the supernatant fund is discarded One cc of oxal ned plasma 15 mixed with the Baso, sediment and is incubated at 37 ( for 10 minutes The supernutant from the BaSO, plasma mixture is diluted 1 5 with saline just before being used in tlus test (3) Serum Serum iged at 37 C for six bours is diluted 1 10 Tith saline (4) Substrate Plasma Plasnii used as substrate sliould be sitlun the normal range for prothrombin content In addition it should contain at least adequate unounts of accelerator lac Glıd len and Coinpany Chicag Illmoi ·ADOENDUM oxrlated plasin? (15 to 23 shtys olch) loscs its content of Ac globulin Ilus is added to supply the fibrinogen and protliron bin if 7 small amount of Ac lobulin is added to the unknown plasma the test reuls longer than the one singe prothrombin determination and indicates 7 deficiency of Acc SPCA Purpose To see if there is a deficiency of SPCA when the result of the one stage prothroinkın test is abnormal Method Mix the following in the order guen 001 cc of aged stored serum 009 cc of patient s plisma O 1 cc of turom boplastin ind 0 1 cc of Call Test the clotung time and con tinue as a regular one stave procedure Interpretation If the serum redures the prothrombin time to withun normal lumits (60 to 100 per cent) there is probably a deficiency of SPCA SPCA (PROCONVERTIN) ASSAY Purpose to determine SPCA (proconvertin) Materials 1 Proconiertn free beef plasma Collect nine parts of whole bouine blood in one part potassium oxalate monohy drate 25 per cent Separate plasia by centrifugation Place five ordinary filter pads 123 cm in diameter in the bottom of a glass Buchner funnel of the sime diameter Above them put 15 Cm of powdered soud charcoal and bore thus put another filter paper or a layer of gauze to prevent admixture of clinconi with plasma This Hiltering layer is pretreated by allowing 20 (c of 0 85 per cent salıme to pass through under suction in order to pack the layer of the charcoal Ilen place 50 cc of bovine plasma in the funnel and allow to filter by ,tauity only Two or three passages of the same plasmi through the same carbon are sufficient to produce essentially proconvertin free plastia After the last filtration suction is used for removal of a relatisely large amount of plasma soaked in the churcoal All procedures are done at 46 The prothrombin content is determined by the ·110 ANTITHROMBOTIC THERAPY Interpretation If thic clotting time of the patients factors falls in the normal range (9 to 12 seconds) after six minutes in cubition it can be assumed that the patient s AHG and serum factors are normal If the clotting time is in the doubtful or abnormal ringe (16 to 18 seconds) the test procedure should be carried out substitutiny one at a tiine the patients factors in place of the reagent actors When the patient s AHG is substituted for reagent AHC and the clotting time is those 18 seconds after six minutes incub? tion in IIIG deficiency can be assumed When the patient s scrum is substituted for reagent seru and the clotting time is bove 18 seconds after six minutes incubation 1 serum factor deficiency can be assumed (ie PTC PTA Stunt Prower Hagemın or Car factor) The specific serum defect can be identified by mutual correction studies with hnoun congenital deficient serun and patients serum If the patients plasma and serum are both doubtfully abnormal this suggests 7 cnculnun, anticoagulant or antithromboplastin The effects of progressive serum dilutions on the thrombolplastın scncration is illustrated in FI URF 2 1 ACCELERATOR GLOBULIN (STEFANINIS METHOD) Purpose To incasure the amount of Ac globulin in oxulated plasma Method Iran 15 (c of whole blood and add it to 05cc of 025 M oxalate Spın donn at full peed for 10 minutes (platelet poor plasmı) and aspirate plasma using 1 ee White tubes Mix the following in the order given 00} a of unknown plism? 0 09 cc of stored plasma (15 to 25 days old at 5 C) 01 cc of thromboplastin und 0 1 «c of C7C1 Test clotting tine from the addition of the (Plict in the water bath at 37 C for 10 seconds Tilt tube until a clot forms Interpretation A short clottin, time means the plasını con tuins an adequate imount of Irlobulin lihen the amount reaches 25 per cent or less licmorilc may occur Stored ·ADDENDUM centrifuged the supernatunt is discarded Ten cc of the librino gen salıne solution is added to eich of the 20 tubes The mixture is incubated with stirring at 37 C for 10 minutes and then cen trifuged Tifty cc of cold (3C) 100 per cent saturated (NH) SO. are added to the supernatant Tlie tubes are centrifuged 15 C and the supernatunt is discardel The precipitate is dissolved in salıne solution This (NII) SO, purification process is repented thisce times The final solution is clılyzed for sex hours-ching ing the salınc solution after the first lour 2 Reaction Mixture This mixture is prepared by adding the following 09 cc regular thromboplastin Olcc beef serum diluted 1 10 th salıne 20cc acacia buffer mixture Any active thromboplastın norks well The acacia buffer mix ture is prepared by adding 20 cc of 15 per cent crude acacia 5 cc of imidazole buffer and 39 cc of 0 85 per cent Naci This mixture is stable indefinitely in the deep freeze 3 Thrombin One ampul of Topical Thrombin (1 000 units) * is dissolved in 5 cc of distilled water and 5 cc of glycerol is added to stabilize the solution This mixture should be stored in the refrigerator 4 Defibrinated plasma Plasma is defibrinated by placing the following in a test tube 05cc fresh oxulated plasma 04 cc 085 per cent Vaci 01 cc thrombin (100 units) The clot is collected on a rod 75 soon as it appears The deſibrı nited plasma is allowed to stand for at least 10 minutes to let tlie antithrombin initiate the added thrombin 5 Defibrinited plasma dilution Dilutions are estimated by the results from the one stage prothrombin time ie plasma with a prothrombin tiine of 12 seconds is tisually diluted I 50 Parke Da 1 and Company product ·112 ANTITHROMBOTIC THERAPY tko stage 18517 ind should be greater than 75 per cent of the original concentration 2 Testing plasmi Collect liumun blood with ordinary glass syringes and needles and add 45 cc to 1 tube containing 05 cc of 0 1 M sodium oxalate Separate plasına by centrifuging at 4 000 rpm for five minutes in a small angle centrifuge 3 Diluting solution Mahe diluting solution with 800 cc of 0 85 NaCl solution ndd 200 cc of veronil buffer and 700 mg potassium oxalate monohydrate 4 Buffer Mike veronil buffer by adding to 570 cc of 0 1 M sodium dicthylbırbitrate 430 cc of 0 I M HCl and 5 67 Cm NICI The pH is measured and adjusted to 7 35 to 740 Method Add the following in the order listed and note the clotting time 02 cc proconi ertin free beef plasma 02 cc of 1 10 dilution of the test plasma (01 cc plusmı + 09 cc diluting solution) 02 cc of rabbit brain thromboplastin and 0 2 cc of Caci (003M) Do control with normal plasma in the same minner described above and compare with prepared dilution curie The percentage of SPC I can be issayed with this method from 1 dilution curve prepared in 7 similir minner to that described for the one stage prothrombın test using dilutions of normal serum Interpretation The sources of errors are in the dilution of the test plasmi and detorution of the prothrombin in the procon vertin free beef plasına The percentage of SPC 4 is determined on the normil control done with the sime reagents TWO STAGE PROTHROMBIN TIME Purpose To determine prothrombin quintitatively Materials 1 Purified librinogen Solution Six Cm oſ com merical fibrinogen (Bovine) * is dissolved in 200 cc of saline solution at 5 C Twenty centrifuge tubes (15 a tubes) each containing 2 cc of B250, solution (500 mg Paso,, ) are Boune fibrinogen Traction I Irmour I aborures Clucige Illinos ·ADDENDUM 115 BIURET METHOD OF FIBRINOGEN Purpose To quintitate fibrinogen Solution Mehls biuret solution is propued by mixing thic following 100 cc of ethylene glycol 40 cc of 60 per cent NOH and 50 cc of 4 per cent CuSO, 5H O Dilute mixture to 100 > FIBRINOGFY CURIE 510 WAVE LE\GTH-BIURCT METHOD Optical De stts Fibri kogen ( ng 0 025 50 0 080 100 000 10 0 060 00 DONO 90 0 09 300 0 110 300 01 400 014 40 160 00 0 17 5.0 0 190 600 0 0 60 020 700 0 30 10 0 250 800 090 80 098) 900 0 300 90 0 310 1003 cc with distilled water and heat until precipitation is complete then filter Add sufficient NaOH to make a 10 to 11 per cent solution Method Place 1 cc of citrated plasma (05 cc citrate per 45 cc blood) in a 100 cc beaker and add 20 cc of distilled water To this solution add 1 0 cc of 025 M CaCl and I 0 cc of throm bın (100 units per cc) Remove the fibrın clot by winding on a glass rod Wash the clot three times with distilled water and then place it in 40 cc of Mehls biulet solution Allow clot to digest in the biuret solution for 12 hours Then dilute the solu ·114 ANTITHROMBOTIC THERAPY with salınc and n plasma with a prothrombin time of 25 seconds as diluted 1 10 Method One cc of diluted plasma and 3 cc of reaction mix ture are combined Zero point fou cc of this combination is added to 01 cc of fibrinogen solution This test is usually done nt 29 C Clotting time is tested every 30 seconds until optimum time has been reached wluch must be between 12 to 18 seconds or the test must be repeated at 1 diſferens dilution Daily con trol is performed in order to determine the activity of the reagents The percentage normal is determined from the duly control Calculation THROVIBIN UNITS CI Units CT Units 12 0 12 5 19 0 19 5 14 0 14 u 1 31 1 26 1 20 1 14 1 09 1 01 1,0 15 5 16 0 16 5 1,0 17 180 100 076 092 O R9 O R6 089 0 80 CT 18 lott gim e nds Total Thrombin units = Thrombın units of asszy plasma dilution X 5+ \inticoigulant dilution +1 dilution because 0 4 (c of the reaction mixture is added to 0 1 fibrinogen solution Interpretation Since prothrombın is rapidly activated to thrombin in the presence of optimal amounts of ccclerators the tuo stige test measures prim trily the quantity of thrombin (protlırombın) in allen solution This is in marhed contrast to the one stage prothrombin time determination which primi rily measures the velocity of the prothrombin actuation Nor mal plasını contains 300 to 100 units of protlırombın ·ADDENDUM 117 One unit of fibrinolysın is tlie zimount necessary to digest ? 03 per cent fibrın clot in two minutes at 37 C in an indazole buffered system nt p!1 72 Thus tcst not only measures fibrino lysın but also includes 2 partul estimation of the rate of activity If 1 dilution is used correct for it by means of the following calculation Units of fibrinolysin per cc = 5 x C D (D = dilution CF =- correction factor for clevntion from 120 seconds in the lysis time) Comment The souces of error ure fibrinogen and tlırombin contamination bounc fibrinogen is the most suitable regent I ess difficulty will be encountered if purified fibrinogen similar to that used in the two stage prothrombin assay is used Human fibrinogen prepirations 11c contaminated with fibrinolysın to 1 much greater degret If human fibrinogen must be uscd 7 0 15 per cent clot instead of the 03 per cent bosine clot will give a unit approximately cqual to the defined unit Fibrino lysın or profibrinolvsin containinites thrombın" but since bovine profibrinolysın actn ites poorly with streptokinase the only source of error to be considered is the active proteolytic enzyme ESTIMATION OF FIBRINOLYTIC ACTIVITY (FIBRIN PLATE METHOD OF ASTRUP AND MULLERTZ) Purpose To determine fibrinolytic activity giving in accurate 25S iy with a wide variety of materials Materials (1) Petri dishes--10 cm duimeter with uniforin and level surfaces (2) Fibrinogen---diluted with 0 85 per cent NaCl to i concentration of 0 2 or 04 per cent Use purified fibrinogen + preparation of 80 to 90 per cent clottible protein 16 11 hro 111 (Parke Davis and CD) can be ad urbed wth baru ulfat 514 that to dsoul pla ma 1 1ll result n a relati ely Pire (Llecti 11 ten) frepinaison til < 1 Ige threint ? IV 1 2 Tenient liric 1el fit gn t ·116 ANTITHROMBOTIC THERAPY tion to 10cc with distilled water Rend on the Coleman photom cter (540 m) ind compire to a standard curie Standard Fibrinogen Curvi Weigh out boune fibrinogen (20 mg per cc) and make dilutions of the fibrinogen Determine tlie amount of protein by the method described abost To determine the mount of clottable protein perform the following steps Add Icc of fibrinogen solution to 01 cc of thrombin (10 units per cc) Weigh glass rod ind mind clot out on rod Place rod with clot in in oven at 85 C and dry oser night or desiccate Then weigh the clot Interpretation (1) II eight of the cloi — by 20 = per cent of clottable protein (b) Per cent of clottable protein x weight of protein in the various dilutions = mg of fibrinogen Use optıcıl density ob tained with various dilutions and plot curse as illustrated below Normal ringe is 300-600 mg per cent FIBRINOLYSIN ACTIVITY OF SERUM Purpose To determine the mount of fibrinolysın in fiuman serum Materials (1) Human serum (2) boune fibrino, en (pınıfıed) 06 per cent clottable in imidazole buffered salınc solution (3) bouine thrombin 75 U per uc in 50 per cent olycerol (1) open ended capillary tubes (5) test tubes 10 x 75 mm (0) pipets (7) water bath at 37 C (8) stopu itch Method If plasını is to be tested convert the plasma to scrum by recalcification or the ddwon of thrombin Aspirate the serun from the fibrın clot and test Place 02 cc of thrombin and 02 cc of serum or suitable dilu tion into a 10 x 75 mm test tube Quickly add 0 5 cc of 0 6 per cent bouine fibrinogen and imun dutely start a stopwatch Tilt or slzke the test tube to bisten the mixing of the reagents Wilien a clot forms insert 1 capillary tube to the bottom of the clot and place in a water both at 37 C The instint the liquid level in the capıllary cube is parallel to the clot level in the test tube the end point has been resched ·ADDENDUM 119 sin may be used as a standard of reference As small an amount as 002 vs can be detected The method is especially adapted for plasmin (fibrinolysın) but may be used as a practical tool in the study of other fibrinolytic enzymes ANTITHROMBIN TITER Purpose To assay antithrombin Vethod Incubate 3 cc of serum or plasma for 10 minutes at 56 C Dilute the serum (normally 1 10 to 1 60 with saline) and add 1 cc of diluted serum to 1 cc of thrombin † (4 units per cc) Incubate this mixture it 28 C for exactly four minutes and then add 0 5 cc of the mixture to 05 cc fibrinogen Note clot ting time Normal serum control is determined in the same manner Interpretation One antithrombin unit (ATU) is defined as that amount which will neutralize one unit of thrombin in four minutes at 28 C The normal range is 74 to 115 ATU and the averige is 90 ATU PROTAMINE TITRATION Purpose To estimate the amount of heparin activity in a blood sample Materals Protamine I (50 mg) dissolved in 50 ct of distilled water This contains 1 000 gamma per cc The solution is stable for six days Heparin Sodium 1000 USP 8 units per cc or 10 000 gamma per cc (Resulting heparınızed blood contains in added 2 000 gamma per05cc) Method Draw 5 cc of blood into a syringe containing 0 1 cc heparin Add this to a tube with 01 a heparin and mix well Place 05 cc of this heparınızed blood into each of 10 test tubes I u ified hum nibrinolys n (Acta tho I harmaceut cal Corporation and Thrombolys n-Verck Shp and Dohme) +P ke Dir and Co Eli L lly product Io luct of Upjohn Laboral e ·18 ANTITHROMBOTIC THERAPY (3) Buffer-add 338 cc of O 1 M HCl to 662 cc of 0 1 1 Sodium diethyl barbiturate and then dilute with 320 cc water (resulting solution pH 78 ionic strength = 005) (4) Thrombin puri fied thrombin * in a final concentration of 100 units per cc in 0 85 per cent NaCl solution (5) Incubator-temperature of 37 C (6) Pipets-5 cc and 0 1 cc graduated in 0 001 cc Method Using the buffer as diluent (fibrinogen concentra tion 02 or 01 per cent) place 90 cc of the diluted fibrinogen solution in each Petri dish Then put the Petri dishes on a horizontal surface and clot by adding 02 cc thrombin A clot forms it should be even and homogeneous throughout Add exactly 003 cc of the solution to be tested onto the clotted sur face in the form of a drop Usually three single determinations are carried out on a plate Then incubate the plates 18 to 20 hours at 37 C and calculate the product of tho perpendicular diameters (square mm) of the digested area Convert the areas into concentrations by interpolation on a reference cure Calculations Purified enzymes produce a straight line when the logarithm of the product of the area is plotted against the logarithm of the concentrations as expressed in units The fol lou ing equation applies to this straight line relationship or log A = a log c + b where A = area or product of two prependicular diameters c is the relative enzyme concentration a is a constant denoting the slope of the cure and k and b are constants It is possible to compare tho solutions only when the curves have identical slopes solution differing in concentrations produce parallel dilution curves in a logarithmic = log graph By means of such curies the concentration of the unknown solutions can be esti mated by interpolation on a dilution cure of a solution used as a standard of reference Comments In estimating the reproducibility and the sensi tivity of the method crystalline trypsin or purified fibrinoly Ith birium alfate pe Thromt in (1 arke Days an unpany) dx bed! vides a purified preparation of thrombin ·ADDENDUM 1 X3 ** Tatt 7 lat dl 11 In 31 s latot 0 idutin <C WC % ACI to II 1X) tutan 1 cc (6) 4 ure Vact 1 0 Its of 1 10 0 dibuatan ac Cacs 2 Vaci I 100 W for of 1 10100 dluaon uc Car 15 cc \ac Interpretation if there is an anısthromboplastın present it will be neutralized as recaled by prolongation of the clotting time in the patient s plasma is compired 11th normal plasti? CIRCULATING ANTICOAGULANT Purpose To show the presence of a circulating anticoagulant Vethod In order to minimize the surface effects silikonized Sessels and equipment are used for collecting blood simples Blood is collected from the prient in sequesterene Plitelet poor plasma is made by centrsfugation (20 000 G lor 10 minutes) and stored in the relrigerator Platelet poor plasmr or 08u per cent laC) is added to b) test tubes as follows (1) 01 cc salıne (2)05cc salıne (3) 0 1 cc plasma (1) 02 cc plasia (5) 0 5 C plasma (6) 05 ec plasnia (102cc plasma (8) 01 cc plasma (9) 05 £¢ salıne (10) 03 cc salme (3]) 0 1 « salme (12) 05 cc salıne (13) Ol«c phasma (14) 02 « plasma (15) 05 cc plasma Blood Solinned from 1 sormal a stopatch is started from the instant of successful senipuncture One o of the normal blood is added to esch of the 15 test tubes fter careful mixing the tubes afl observed for clotting at 370 Interpretation Significant prolongzhon of the cloiting times with plzeler pour plasma indicates abnormal anticoagulant 20811 sty fos result with platelet poor plasma greater than the salinc consrols hy at least seven ininutes is in the abnormal range ·120 ANTITHROMBOTIC THERAPY containing the follow ing amounts of 1 per cent protamine solution Tube 3 Prolammc (cc) 0 08 0 10 012 014 016 0 18 0 20 07 0 21 0 26 6 8 9 10 After setting up the tubes sluike well and allon to stand for one lour Read the first clotted test tube as the end point Interpretation The normal ringe is between the 0 10 and 0 14 tubes Control normal blood should be run with the same reagents daily Betrieen 100 to 140 gummi of prorumine will neutralize 200 gimma of heparin ANTITHROMBOPLASTIN TEST Purpose To see if there is a circulating antithrombolplastin Method Male dilutions of thromboplastin with salıne and CaCl Add 02 uc of the diluted thromboplastin caterum mixture to 0 1 cc of unknown plasma ind run a one stige decer mination Control normal plasaiz should be performed with the same dilutions rest Thromboplast dilutt 1rxture 1 100 c Ca 1 Joc lac! 0 cc thromboplastin 1 200 lucan 100 dilution CC (act C Mac 1 1 000 lic of I (X) CC Caci cc laci 9 #3 ·ADDENDUM 123 3 Add about 250 cc of chloroform 4 Let this solution sit for 30 minutes stirring occasionally with applicator stick 5 Then filter through a Buchner funnel with suction using double filter paper (Whatman #1) 6 Evaporate on a mild hot plate until a gummy residue forms 7 Reweigh bealer to determine the amount of active mite rial 8 Homogenize in salıne (300 mg /50 cc 0 85 per cent NaCl) PREPARATION OF BRAIN PHOSPHOLIPID I Fresh brain stripped of meninges and blood vessels and minus the corpus callosum 2 Hunks of brain are put into acetone in the Waring Blender and blended for 4 to 5 minutes 3 Let the solution settle and decant off the acetone 4 Add more acetone and repeat this procedure about six to 10 times 5 Then filter through a Buchner funnel and wash about six times until cholesterol free 6 Put in a desiccator to dry 7 Store powder in the deep freeze PREPARATION OF THROMBOPLASTIN SOLUTION Afaterials 1 Acetone brain extract 2 Saline (0 85 per cent) solution 3 Phenol (25 mg/10 cc thromboplastin solution) 4 01 M potassium oxalate Vethod 1 Weigh out 200 to 350 mg dried acetone brun extract 2 Add 10 cc 0 85 per cent saline 3 Incubate at 50 to 54 C for 15 minutes inverting every two minutes once 4 Centrifuge at full speed for five minutes using the super natant as solution ·122 ANTITHROMBOTIC THERAPY Possible errors in this test would tend to make an abnormally shortened clotting time due to possible contaminating tissite thromboplastın or surface effect SOLUTIONS 1 0 025 M CICI 1 387 Gm in 500 cc distilled 11 der 201 M Potassium Oxalate 18 i Gm in 1000 cc distilled 14 ntcr 3 38 per cent Sodium Citrate 76 Cm in 200 cc distilled Water 1 Sequesterene (used as platelet fluid) 175 Gm in 100 cc saline Add 1 feu crystals of brilliant cresyl blue 5 Phosphate Buffer A M/15 KH PO, 9 078 Gm in ) 000CC BM/15 Na HPO, (Anhydrous) 9 17 Gm in 1 000 cc for pH 6 1 M/15 5 pirts of A I part of B for pH 7 8 M/15 I part of A 10 parts of B 6 Tibrinogen Buffer (Borite) Lachliter contuns 11 25 Gm H,BO, 225 Gm NaCl 40 Gm Na B,0, 101 This solution has a pH of 7 75 7 Protimine i per cent (Eli Lilly Co ) 50 mg /50cc distilled water (Stable for six days) 8 librinogen solution (fibrinogen--Bounc from Armour Lab Chicago III) 20 mg /2 cc Borate buffer 9 Heparin sodium 1000 USP units/CC (Upjohn) 10 Sequesterene (Alrose Chemical Compiny) for platelet preparation 1 75 Gm /100cc distilled is iter PHOSPHOLIPID SOLUTION 1 Weigh beaker ? Weigh 5 Gm of powdered brun phospholipid

·Addendum
Bibliography
I D141 D SIE IS AND KINI ! 11 The contin tosi ) Lat and
Clin Vcl 17 3 19 6
Bicos RO ENARY AND CHARLAYE RC Human Blood Coagulatını ed ?
Sprinofeld Ill Charles G. The las 19
3 VIALE J Lab srate ry Vedicine-llematology St Louis The Vosby
Co 19%
# TOCANTINS 1 11 The Coagulation ct Blool--feit ods of Study \ Jork
Gruine and Stratton 19
175

·124 ANTITHROMBOTIC THERAPY 5 Add plienol to prevent growth of bacteria 6 Add 0 2 potassium oxalate for each 10 cc to neutralıze any calcium Dried material is potent indefinitely in the frozen state Solu tion is stable for six 11 cels or more THROMBOPLASTIN Materials 1 Normal brun stripped of vessels and meninges ? Buchner funnel and flashs 3 Waring Blender and jars 4 At least 30 lbs of acetone Two large glass cylinders 6 Several pieces of large filter paper Procedure 1 hnead by hand small pieces of brain in three times the volume of acetone Decant acetone repeat the proce dure tivo more times Tissue will feel dry to the hand After decanting the acetone place brain tissue in Waring Blender with three times the volume of acetone (Cup should be one half full) 3 Turn on the blender rapidly for about 1 minute Allow the tissue to settle decant acetone and repeat three more times 4 After decinting wish material in Buchner funnel with acetone and let dry Repeat izslungs with acetone unul material is completely dry (About 6 11 ishings are needed ) 5 Spread the dried material on 1 large sheet of filter paper and make into a ponder When odor of acetone is completely pichage with pirafin und screw top wal (Storc in the deep freeze this is good for at least a year) go ·Index (lote In addition to regular index entries particularly tests sce also technical deta is indexed under Ad lendum) Accelerator globulin 4 recalcification time of oxalated determination one stage 13 plama 102 and Documarol 5 SI C1 11 Accelerin SPC1 (proconvertin) as ay 111 Addendum 9.-)) thromboplastın generation 108 blood coagulation factors synonyms fournsquet 98 for 95-97 two stage prethrombin time 119 electrophoresis paper 91 1 hole blood lysis time 101 solutions 1 9-12 Ingina pectoris long term anticoagu brain phosphol put 13 lant therapy in 51 phospholipid 129 Inticoagutart therapy thrombopla tin 124 in cerebral vascular d sease 49 thrombor lastin solution 123 complications of 1 Synonyms for blood congulation fac discontinuance of 37 tors 9-9 effect of on myocar lal infarct on tests 95-12 41 43 accelerator globulin (Stefanını s evaluat on of 50 toethod) 110 long term 50-54 ant thrombin titer 119 in angina pectoris 51 antithromboplastia 190 in arteri clerotic heart di ease 51 bedside prothrombin time (Van bleeding from yo che fer) 105 1 myocardial sofarction! buret method of fibrinogen 115 previous studies in 50-33 bleeding time 99 11 h of hemorrhage th3 circulating ant coagulant 1'1 oral management of 26 clot retraction of whole blood 100 pre ent status of 40-49 clotting time 99 prophylactic not curative Po fibrinolysın act ty of serum 116 in tccurrent thromboembolism 50 fibr nolyt c activity (fibrın plate and se ere hyperten 1on 48 method of Astrup and Multertz) in strokes 49 117 in thrombotic d o ders 40 generation of thrombin in reculai Ant coagulants fied plasma 106 gradual reduction of 39 one stage proth Ombat me 103 natu ally occurring 15-16 Owren Ware Stragnell prothrom oral 2 -26 bin te t 104 aver ge dosage of platelet count 101 coagulation lefects with 8 protamine titration 119 inh hition of prothromt n synthe proth nbin consumption 10 SIS th 17 127 1

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·INDEX 129 Specific fcd ulat n facta s + tamin Dental extraction with rolnnge 11 lecil ing 39 1) ugne ferential in cati brala cular traxe 164 11 cumarol + 91 111. 31 11 and accelerator glotulin action of on dtting factors ? mith vitamin h 18 (agulat n delects caused by I contrain i calions to effect of on circulating fibrın gen on Vitamin in the Iver 2 climination of 1 I ng term coagulation lefects he cause of 3 recurrent thromtemlo! m be cause of 3 sens (isits to 1 21 to ic man festations of 2 Diprin 17 24 ) Bit rin lisan 120 s) action of on fibrin on furin gen 20 etisation of leprescant in hibrin gen * letermination 14 electrophoretic patterns of u human 2) inactilation of us in intra art tar throulxm ) I vol cints with f3 ) reaction offbrin to b) of fibrinogen to 53 systemat c reactions to 6 68 toxic reactions of Fibrinolytic agents 19 Fibrinolyt ctcactions 19 Hageman factor 4 12 1 33 Hedulin 124 depression of prothrombin time with Fmbol sm arterial 4.8 pulmonarı 40 41 anticoagulant therapin 40 disadvantages of Hemoper card um in myocardial n farction 50 Hemos hila - clotting 3 thrombopla in generation in 11 Hemorrhage cerebral due to ant coagulant ther p 31 incidence of with ant coagulants 1 of 53-51 in antithrombotic therap 21 with long term ant coagulant ther Factor dep ex on 33 Fibrin action of fit runvolsson con er on of fibrin yen to 6 13 electrophoretic patterns of 5 formar on for tage three reaction in 6 velocity of l. reaction of to fiboly in 5 Fibrinogen action of fit Nol in on " < culating eff ct of Dici marol on effect of heparin on con et on of to fhrn 13 defic encin letem nation 1 electrophoreta ptices of 6 level depres lonR react not to fih pol apy 33 use of protamine sulfate in 24 tolu d ne blue in 28 Hepar n 8 13 16 21 28 41 action of 16 administrat on of 16 contraind cat ons to 22 disad antages of 1 dosage 2 effect of on Circulat ng fibrinogen ·128 INDEX (lessufication of patients with myoca1 dial infarction 43-41 Clot use of in arterial occlusion + Intifibrinolysin 19 Intihemophilic globulin un clothing 3 Intistreptohınase 19 Intithrombin inactivation of thrombin with lo Synergistic action with heparin 15 Intithrombolic agents clinical use of 21-39 therapeutic 16-20 Intithrombotic reactions 15-20 Intithrombotic therapy aim of 21 Intitrypsin factors in plasma 20 Irterial occlusion 5) Steniosclerosis coronary and blood coagulation 54 Irteriosclerotic heart disease long term anticorgulant therapy in 51 Aspirin action of with anticoagulants 17 lysis of 16 retraction 10 Glotting abnormal correction of 3 antihemophilic globulin in $ delayed with prolonged prothrombin time 3? factors action of Dicumarol on of hemophilic blood 3 intravascular mechanism of 10 tests 8-14 tune 30 screening test for 10 Coagulation and coronary arterio clerosis of defects caused by oral anticoagulants 8 from long term Dicumarol 3 factors congenital deficiency of 3 after hepatic Jobcctomy 11 plasma defect in 10 reduction of in luser clise ili specific deficiencies of 4 prophylactic prevention of 16 reactions, inhibitors (f 1-16 Consertin + artcrio cIosis and blod coagulation ut Cotimadın 1, 21 effect of 21 Coumaris 1 Cumopsran 1. 21 therapeutic effect of Bleeding due to long term anticoagu Iants 39 effect of vitamin kon 33 prolonged from dental extraction 39 time 9 test for 9 Blood hemophilic clotting of 3 Blood clot defnition of 5 cffect of tryp in on 59 see als Clot Clotting Blood coagulation and coronary arteri sclerosis ut mechanism of 1- see also Coagulation Coronary 1 4 (apıllary fragilets test for 9 Cerebral hemorrhage due to anticoagu Jant therapy 31 (crebral vascular di eas 18 19 anticoagulant therapy in 18 differential diagnosi n 46 48 (hristmas disease 3 (hymn typen 8 061 Ictuation of Go contrainde ttions t u e of 10 Dantone - Del ciencie (ingenital 1 magn) shirt 11 rotlumbin Dit mogen Ima throm ili 113 e Dime 1 Itclct 10 ·INDEX 131 Scruin accelerator globulin 4 defects in 11 fibrinolytic activity in 14 normal coagulation factors ad orbed from 10 plasma thromt oplastın comp nent in S prothrombin conversion nccelerator 4 5 determmat on It thromboplastic fictors depressi n of 33 Slock syndrome th try in injections 20 Sintrom 17 24 Src determination 14 Staphylokinase 5 Steatorrhea 18 Streptokinase 1o 1990 59 61-63 activation with 61 clinical use of 62 contraindications to use of 63 Strokes anticoagulant therapy in 49 Stuart factor 4 6 1 17 93 I hromboplastin active 6 formation of activity loss of 4 formation reagents for 11 generation - In hemophilia 11 test 11 intrinsic 11 1 plasma » 11 12 formation of 12 tissue I i II 13 1 hrombosis intrava cular fibrinolysın in " chous . 11 he thromboplastin 1 + 11 13 Toludine blue in hemorrhage 8 Tourniquet test 9 98 Toucts IIth Dicumarol 94 with fibrtholysın 20 Tromexan 17 4 disadvantages of 94 therapeutic effect of 1 Trypsin l20 8 9-60 contrain lications to u c of 59 effect of on blod clotting 59 injections shock syndrome ath 90 Chrombi intravascular 53 Thrombin con ersion of prothromi in to 1 definition of 14 formation of stage to eaction in 6 13 gener ition a nount of 14 Inactisation with antithromb n 13 Thrombocytopathia 9 Thrombocytopenia 9 Thrombocytosis 9 Tl romboembolism recurrent ant coagulant therapy in 50 in patient on Dicim rol S. tendency tol ar 1 39 Thromboly uy trious enzymes 8-9 Thrombolytic agents 19 Tombolytic therapy 9 Thrombophlebiti 40-41 anticongulant therapy n 40 las ular disea cerel ral 4949 Vitamin deficiencies 9 der ciency 18 n liver effect of Dictinarol on 92 in synthess of prothrombin use of by liser 17 h action of Duct marol with 18 effect of on bleed ng 33 tablets 21 i se of in hemorrhage 78 Vitamins and P effect of on bruis ing 11 are and Seegers ti o stage prothrom bin test 37 112 Irfari i Sodium 94 ·130 INDEX oral inactivity of 21 I lasma snergistic action of antithrombin antitrypsin factors in 20 with lj clefect of coagulation factor 10 therapy terminition of a deficient preparation of 10 Hypertension severe me antico igu normal coagulation factors ad orbeel lunt therapy 48 from 10 plateict free 1 Indandione derivatives 17 21 27 prothrombin actilation of 11 Infarction myocardial acute 41-4) thromboplastin 5 11 19 component deficiency 3 I cr formation of 12 disease reduction of coagulation fac intrinsic 8 tors in 1 I lasminogen 16 use of vitamin by 17 Platelets I obectomy hepatic coagulation fac count 9 tors after 17 deficiency 10 Lysis of clots 16 substitution of pho pholipid for ? with fibrinolysin 63-19 thrombocytopathic 11 1 olysaccharide bacterial pyrogen (rec Walnutrition 18 58 GI Manchester bedsude test for prothrom I ro accelerın 4 bin 37 10 Profibrinolysin Varcumar 11 94 activation of 5) 7 cfficacy of 2) consersion of 16 Mephyton use of in hemorrhage 28 Protamine sulfate in hemorrhage 8 Miradon 1942 Prothrombin Vyocardial infarction congenital deficiencies in ncute 41-. consumption 12 classification of patients sith 43-44 conversion of to thrombin 1 complications in 29 determination to stage 14 effect of anticoagulant therapy on Jes els during long term anticoagulant 41 43 therap 37 hemopericardium in 30 synthesis inhibition of 17 with vitamin ku long term antic gulant therapy in test of Owren Jarc Stragnell 37 101 test of llare and Scegers 37 112 myocardial rupture in 31 time 19 depression of th Hedulin 9, Occlu ion arterial 42-48 50 normal 13 use of anticoagulants in 4) prolonged 13 Oi ren Ware Stragnell onc stage pro and delayed cloting 3 thrombin test 3, 101 test for 12 Pulmonary embolism 40-41 Phospholipids 11 anticoagulant therapy in 40 effect of on Dicumirol induced pur Re ctions congulation substitution of for platelets 2 Recalcifcatan 9 ol pura 51 ·INDEX 131 Scrum 2ccelerator glabu ni delects $21 librinoliek activity 14 torial corgulacan (actars act orded from 10 plasma thromlag lastin cams neue prothrombin isserska 3cceleratit determination 14 Chromloplastı ! klou depresion Shock syndrorse with trysin injections 3 hromboplassen atinse 6 formation of act11th to so furminn reugenis for !! generating in hemophilus text mmc 33 19 pla ma l firmon tf !! 1 uc 1 4 5 1 13 1hre also untraiascular fibrinolin chos 5 17 ne thronix lasi If 31 13 Colui une ble on hemor hage 8 Tourniquet est 9 98 Τονιειιι with Moumarol with hormohsın 9 romexan 1,94 disadvantages of 21 therapeutic effect of 91 frypsan? O 8 9 0 contraindication to s cofu? effect of n bod cl 11 g 5.) mjecur n shock rosie i sth U ntrom SPC1 detesinatson 34 Staphylokinase 7 Steatorrhea 38 Streptokinase lo 19 20 ) 5R 61-63 activation ith G! chun cal use of 62 contraindications to use < 63 Strokes anticoagu156 theraps sa 49 Stuart Cactor 61 33 Thrombi intravascular 5 Thrombin conversion of prothrestben co! definition of 11 formata in 36 stage in o reaction in 6 13 generalion amount of 14 +8441+ a11Dn 1 th antithroub n 15 Thromboeyropathua Thrombocytopenia 2 9 'Thro aboc) 20515 9 Thro nboembol sm recurrent ant coagulant therapy »» 50 in patient on D cumaro! 3? tendency tot ax! 98 Thrombolysis by various enzymes 8-59 Thrombolyt c agents 19 Thrombolytic therapy 9 Thromix phlebius 10-1 anticdaoulant therapy in 40 ascular ce cerebral 48-4) 10min deficien se 9 h defic ency 18 un Isser cilact of Delmar Son ? 553shes of pi t) tomhr of by liter 1 action of Documarol with 18 effect af on bleeding 33 tallets > uc of in hemorrhage 28 I samns ran 1 p effect of on baru ng 54 11 ere an 1 Sergers o stage prothrom bro test %31 Haft nodom

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