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AMBULATORY CARE

Anticoagulation Monitoring Part 2: Unfractionated Heparin and Low-Molecular-Weight Heparin

Professor of Clinical Pharmacy, Adjunct Associate Professor of Pharmacy in Medicine, Cardiovascular Division, Department of Medicine, Philadelphia College of Pharmacy, University of Pennsylvania, Philadelphia, PA

Ann K Wittkowsky, PharmD CACP FASHP

Professor of Clinical Pharmacy, School of Pharmacy, University of Washington; Director, Anticoagulation Services, University of Washington Medical Center, Seattle, WA

Edith A Nutescu, PharmD

Clinical Associate Professor, Director, Antithrombosis Services, Department of Pharmacy Practice, College of Pharmacy, The University of Illinois at Chicago, Chicago, IL

Maureen A Smythe, PharmD FCCP BCPS

Clinical Care Pharmacist, Department of Pharmaceutical Services, William Beaumont Hospital, Royal Oak, MI; Professor of Pharmacy Practice, Wayne State University, Detroit, MI

Reprints: Dr. Spinler, 600 S. 43rd St., Philadelphia, PA 19104-4495, fax 215/596-8586, s.spinle{at}usip.edu

OBJECTIVE: To review the availability, mechanisms, limitations, and clinical application of point-of-care (POC) devices used in monitoring anticoagulation with unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs).

DATA SOURCES: Articles were identified through a MEDLINE search (1966–August 2004), device manufacturer Web sites, additional references listed in articles and Web sites, and abstracts from scientific meetings.

STUDY SELECTION AND DATA EXTRACTION: English-language literature from clinical trials was reviewed to evaluate the accuracy, reliability, and clinical application of POC monitoring devices.

DATA SYNTHESIS: The activated partial thromboplastin time (aPTT) and activated clotting time (ACT) are common tests for monitoring anticoagulation with UFH. Multiple devices are available for POC aPTT, ACT, and heparin concentration testing. The aPTT therapeutic range for UFH will vary depending upon the reagent and instrument employed. Although recommended by the American College of Chest Physicians Seventh Conference on Antithrombotic and Thrombolytic Therapy, establishing a heparin concentration–derived therapeutic range for UFH is rarely performed. Additional research evaluating anti-factor Xa monitoring of LMWHs using POC testing is necessary.

CONCLUSIONS: Multiple POC devices are available to monitor anticoagulation with UFH. For each test, there is some variability in results between devices and between reagents used in the same device. Despite these limitations, POC anticoagulation monitoring of UFH using aPTT and, more often, ACT is common in clinical practice, particularly when evaluating anticoagulation associated with interventional cardiology procedures and cardiopulmonary bypass surgery.

Key Words: point-of-care testing: anticoagulation, heparin, low-molecular-weight heparin, warfarin, activated partial thromboplastin time, activated clotting time, anti-factor Xa

Published Online, June 14, 2005. www.theannals.com, DOI 10.1345/aph.1E524

THIS ARTICLE IS APPROVED FOR CONTINUING EDUCATION CREDIT
ACPE UNIVERSAL PROGRAM NUMBER: 407-000-05-022-H01

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