Platelet Function Testing
PFA-100® System
Clinical Indications
Mag. Herbert Maier
Overview of the PFA-100® Test System
Overview
Introduction
Overview of the Test System
Test Principle
Intended Use and Clinical Performance
PFA-100® compared to Bleeding Time
VWD and DDAVP
Acetyl Salicylic Acid (ASA, Aspirin® - Bayer)
Use of PFA in:
Pre-surgical screening and Bleeding Risk management
Risk Stratification of CVD patients
Transfusion medicine
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PFA-100® Platelet Function Analyzer
Built-In Printer
LCD screen
Soft keys
Trigger solution container
Test Cartridge
Cassette
Carousel
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PFA-100® Test Principle
before
after
p = -40 mBar
cup
aperture
Ø150 µM
800 µl
blood
Filter
+
epinephrine
or ADP
collagen
capillary
Ø 200 µM
flash
membrane
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Platelet
plug
PFA-100® Test Principle
PFA-100®
In Vivo Haemostasis
high shear rate
>5000 /s
endothelial cell
Epinephrine
or
ADP
collagen fibrils
membrane with
collagen coating
von Willebrand Factor
von Willebrand Factor
erythrocyte
fibrinogen
platelet
platelet
FLOW
erythrocyte
capillary 200µm
lumen
To: Poujol, Nurden, Paponneau, et al.
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PFA-100® Test Principle - summary
Simulates in-vivo conditions; high shear such as
present in small arteries (CVD)
High shear increases the sensitivity to vWF
abnormalities
Assesses the effect of anti-platelet agents under
physiological conditions*
*also recommendation of subcommittee on Biorheology - ISTH 1999
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Expected Normal Ranges
Expected Values
3.8% (129mM) buffered Sodium citrate;
90% Central Interval (sec)**:
Col/Epi
Col/ADP
85 - 165
71 - 118
** : data based on testing of 127 samples with normal platelet function in Germany
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** Dade® PFA-100® System
Package Insert
PFA-100® Clinical Performance
Comparison of the PFA-100® with skin Bleeding Time test
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Populations:
206 normals
176 abnormals
Sensitivity
PFA-100®
Bleeding Time test
PFA-100®
Area Under Curve
Error
0
0
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1
8
To : Mammen, Comp, Gosselin, et al..
0.98
0.01
Bleeding
Time test
0.70
0.04
Sensitivity of PFA-100® System for Platelet Dysfunction
Sensitivity for Platelet Dysfunction
Cases
Sensitivity (%)
GT
BSS
SPD
HPS
ASA
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2
16
11
127
100%
100%
75%
91%
95%
Overall sensitivity for platelet disorders:
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* with Dade® PFA-100® Col/Epi Cartridge
91%
(based on meta-analysis of 15 studies)
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E.J. Favoloro. Haemophilia 2001; 7:170-179
Sensitivity of PFA-100® System for vWD
Sensitivity for von Willebrand Disease Type
1
2A
2B
2M
3
Acquired
Cases
174*
33
36
12
31
8/8
Sensitivity (%)
88%
100%
92%
100%
100%
100%
Overall sensitivity for VWD:
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92%
VWD patient management with DDAVP
Correction of Primary Hemostasis in vWD patients
Fressinaud et al. British Journal of Haematology 1999;106(3):777-783.
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PFA-100® and ASA resistance
Cardiac Population
Review of the literature on 1,105 patients on ASA
frequency of normal Col/Epi result:
23% of 283 ACS patients
Poulsen et al; ESC 2003
38% of 129 post-AMI patients
Andersen et al., 2003
10% of 325 patients with CVD
Gum et al., 2001
27% of 89 patients with CVD, CAD
Santos et al; ISTH 2001
42% of 31 pts. with stable angina
Crowe et al; ISTH 2001
25% of 105 pts. with CAD
von Pape et al; ASH 2000
58% of 43 pts. undergoing PTCA
von Pape et al; ASH 2000
45% of 100 pts. with ACS
Sambola et al; ISTH 2001
= 25% of low-responders or non-compliants!
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PFA-100® and ASA resistance
Stroke Population
Review of the literature on 300 patients on ASA
frequency of normal Col/Epi result:
• 33% of 118 cerebral ischemia patients
• 37% of 129 cerebrovascular patients
• 23% of 53 cerebrovascular patients
Hanswillemenke et al; GTH 2002
Alberts et al., 2004
Grundmann et al., 2003
= 33% of low-responders or non-compliants!
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PFA-100® and ASA resistance
Review of the literature on 552 patients with clinical data
Patients with AMI had 38% ASA non-responders compared to 18% for non
AMI patients
Poulsen et al., 2003
The event rates was 36% in the post-AMI group of ASA non-reponders,
compared to 24% for the responders
Andersen et al., 2003
Patients with recurrent cerebral ischemia attacks had 30% ASA non
responders, compared to 15% for patients with stable clinic
Hanswillemenke et al; GTH 2002
Symptomatic cerebral ischemia patients had 34% ASA non-responders,
compared to 0% for the asymptomatic group
Grundmann et al., 2003
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There is a correlation between ASA nonresponsiveness measured by PFA-100® and
clinical events!
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Conclusion: aspirin non-responders
Poor response to aspirin has been found in
1.
2.
3.
Acute coronary syndromes, where it predicted deaths
Late venous graft occlusion after bypass
Recurrent TIA
ACS patients with aspirin home therapy could also profit from
additional aspirin infusion (Fuchs & Jilma)
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ASA-containing Medication in Germany (1)
Acesal Tbl., 500 mg
Acetylin Tbl., 500 mg
Acetylsalicylsäure Tbl. Michallik, 500 mg
Alka-Seltzer Brausetbl., 325 mg
Asasantin Tbl., 330 mg
Aspirin direkt Kautbl., 500 mg
Aspirin protect, 100 und 300 mg
Aspro Tbl., 320 mg
ASS Bonfal Infarktschutz Tbl., 75 mg
ASS dura Tbl., 500 mg
ASS 100 Tbl. Lichtenstein
ASS Kombi ratiopharm Brausetbl., 300 mg
ASS ratiopharm Tbl., 100, 300, 500 mg
ASS Stada 100/500 Tbl.-Boxazin plus C Br.-tbl., 500mg
Acesal-Calcium, 250 mg
Acetylsalicylsäure 500 PB, 500 mg
Alacetan N Tbl., 250 mg
Antineuralgie Tbl. Scheurich, 250 mg
Aspirin Tbl., 500 mg, 300 mg, 100 mg
Aspirin plus C Brausetbl., 400 mg
Aspisol Amp., 500 mg
ASS-AbZ Tbl.
ASS 100/500 Hexal Tbl.
ASS Kreuz, 500 Tbl.
ASS light 100 Azupharma
ASS mini Tbl., von CT, 50 mg
ASS +C Braustbl. 500 mg
ASS opt. Tbl., 500 mg
Boxonal Tbl., 210 mg
CC-ASS-500 Tbl., 500 mg
CC-Cor Tbl., 30 mg
Cebion Erkältungsbrausetbl., 50 mg
Coffalon Tbl., 200 mg (Calicylamid)
CC-forte Tbl., 250 mg
Chephapyrin N Tbl., 250 mg
Coffetylin Tbl., 450 mg
Contradol Pastillen-Dolomo TN Tbl., 250 mg
Doppel-Spalt compact Tbl., 500 mg
Dolviran N Tbl., 500 mg
Dorocoff-ASS plus Tbl., 400 mg
*All medications are listed registered trade marks from various companies
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(Koscnielny, personal communication)
ASA-containing Medication in Germany (2)
Gelonida NA supp. für Ki/Erw., 125 mg/500 mg
Godamed 100/500 Tbl., 100 /500 mg
Herz ASS ratiopharm 50/100 Tbl., 50 mg/ 100 mg
Glutidal Tbl., 400 mg (Salicylamid)
Godasal Tbl., 500 mg-HA-Tbl.N., 250 mg
Hermes ASS plus Tbl., 400 mg
Malinert Tbl., 325 mg
Melanbon+C Brausetbl., 500 mg
Mentopin Vit. C+ASS Brausetbl., 500 mg
Miniasal Tbl., 30 mg
Neuranidal Tbl., 300 mg
Ortoton Plus Tbl., 400 mg
Praecineural Tbl., 350 mg und supp. 500 mg
Quadronal ASS comp. Tbl., 460 mg
Rio-Josipyrin N Tbl., 250 mg
Melabon K Tbl., 250 mg
Menostabil-ASS Tbl.
Micristin Tbl., 500 mg
Neuralgin Tbl., 250 mg
Neuranidal Duo Brausetbl., 400 mg
Pono-ASS Kaps.
Pyracil N Tbl.
Ring N Tbl., 300 mg
Romigal ASS 500 Tbl., 500 mg
Santasal N Tbl., 500 mg
Spalt A+P Tbl., 300 mg
Spalt ASS Tbl., 600 mg
Spalt plus Tbl., 250 mg
Temagin ASS 600 Tbl., 600 mg
Tempil N Kaps., 250 mg
Thomapyrin C Brausetbl., 300 mg
Togal Kopfschmerzbrause + Vit.C, 500 mg
Temagin PAC Tbl., 250 mg
Thomapyrin Tbl., 250 mg
Togal Tbl., 250 mg
Togal ASS Tbl., 400 mg
Werodon-ASS Tbl.
*All medications are listed registered trade marks from various companies
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(Koscnielny, personal communication)
PFA-100® in Preoperative Screening
The Berlin Experience* - Set Up
During 2000, 5649 patients, filled in a questionnaire dedicated to bleeding
observations
• Results
pos.resp.
pred.value
– prolonged bleeding
5.7%
8.2%
– high frequency of “blue spots”
5.1%
65.4%
– NSAID’s
3.6%
83.9%
– Menorrhagia
4,5%
• All patients were tested with a panel of screening tests:
Platelet Count, APTT, PT, PFA-100 (Col/Epi and Col/ADP)
Patients, with a positive bleeding history (11.2%), were tested with two
additional tests; BT (Surgicutt®), VWF:Ag.
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* Koscielny J, et al. Clin Appl Thrombosis/Hemostasis 2004; 10(3): 195-204
PFA-100® in Preoperative Screening
The Berlin Experience* - Results
Negative Bleeding History
n=5.021 (88.8%)
All Patients
n=5.649
Abnormal Screening Tests
n=9 (0.2%)
APTT
Platelet Count
Abnormal Screening Tests
n=256 (40.8%)
PFA-100® (C/Epi) n = 250 (97.7%)
PFA-100® (C/ADP) n = 199 (77.7%) ‡
BT
n = 188 (73.4%)
VWF:Ag
n = 39 (15.2%) §
APTT
n = 24 (9.4%) #
PT
n = 10 (3.9%) ¶
Platelet Count
n = 2 (0.8%)
n = 9 (0.2%) *
n = 0 (0.0%) †
Not detected with PFA-100® (Col/Epi):
‡ 2 patients with hereditary thrombopathy
§ 2 patients with VWD
# 2 patients with VWD
¶ 1 pat. w. dysfibrinogenaemia, 1 w. F VII-deficiency
* all 9 patients had lupus inhibitors
† 1 patient had pseudothrombocytopenia
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Positive Bleeding History
n=628 (11.2%)
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* Koscielny J, et al. Clin Appl Thrombosis/Hemostasis 2004; 10(3): 195-204
PFA-100® in Preoperative Screening
Patients with impaired hemostasisis n=256
Results 2 *
Secondary haemostatic
disorders; n = 2 (0.8%)
Congenital dysfibrinogenaemia
n=1
Hereditary F VII deficiency n = 1
Primary haemostatic
disorders; n = 187 (73.0%)
Acquired
thrombocytopathies
Von Willebrand disease
uremia associated
drug induced
acetylsalicylic acid
diclofenac
ibuprofen
piroxicam
ticlopidine
clopidogrel
valproic acid
ciprofloxacin
cefotaxin
azlocillin
benzylpenicillin
VWD:type 1
n = 40
VWF:Ag(%):
38 (27-49)
VWD: possible type 1 n = 12
VWF:Ag(%):
57 (50-65)
VWD:type 2a
n=2
VWF:Ag(%):
55 (35-62)
n=7
n = 87
n = 29
n=7
n=5
n = 17
n=2
n=5
n=3
n=2
n=2
n=3
Hereditary
thrombocytopathies
Glanzmann Thromb.
Bernard-Soulier S.
Secretion Defects
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Combined haemostatic
disorders; n = 67 (26.2%)
n=1
n=1
n = 16
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* Koscielny J, et al. Clin Appl Thrombosis/Hemostasis 2004; 10(3): 195-204
Liver cirrhosis
VWD:type 1
n = 13
PFA-100® in Preoperative Screening
Conclusions*
The vast majority of these patients could not be identified by routine
screening for PT, APTT and Platelet Count
250 of these patients (256) are detected with the PFA-100® (Col/Epi)
A combination of all tests, without PFA-100® would miss up to 30% of the
patients at risk for bleeding!
The PFA-100® (Col/Epi) demonstrated a PPV of 81.8% and NPV of 93.4% for
impaired hemostasis
The PFA-100® system is clearly superior to the bleeding time.
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* Koscielny J, et al. Clin Appl Thrombosis/Hemostasis 2004; 10(3): 195-204
PFA-100® in Preoperative Screening
Recommendations*
For patients needing a pre-surgical work-up, a test panel without the PFA100® (Col/Epi) is insufficient.
Patients with increased risk for bleeding complications can be identified
using a standardized questionnaire and a test panel comprised of PFA100® (Col/Epi), VWF-Ag, PT and APTT.
The PFA-100® (col/Epi) is important also for assessing the therapeutic
efficacy of drugs such as aspirin and desmopressin acetate (DDAVP)
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* Koscielny J, et al. Clin Appl Thrombosis/Hemostasis 2004; 10(3): 195-204
Preoperative management of patients with impaired hemostasis
The Berlin Experience* - Results
The administration of DDAVP led to a correction of platelet dysfunction
in 229 of the 254 patients treated (90.2%).
In patients with corrected impaired hemostasis the number of blood
transfusions was non-significantly lower (9.4% vs. 12.2%; p = 0.202),
than in patients without impaired hemostasis.
In a retrospective group of patients with non-corrected impaired
hemostasis, the number of blood transfusions was significantly higher
(89.3% vs. 11.3%; p < 0.001) than in patients without impaired
hemostasis.
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* Koscielny J, et al. Clin Appl Thrombosis/Hemostasis 2004; 10(2): 155-166
Preoperative management of patients with impaired hemostasis
Results *
Retrospective study
n=5102
Elective
operations
Prospective study
n=5649
Non-corrected normals
Non-corrected Impaired
Non-corrected normals
n=4785
n=317
n=5393
transfused
n=541 (11,3%)
Transfused (%)
100
transfused
n=283 (89,3%)
Corrected Impaired
n=256
transfused
n=660 (12,2%)
p < 0.001
80
60
p = 0.202
40
20
0
1999 retrospective
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2000 prospective
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* Koscielny J, et al. Clin Appl Thrombosis/Hemostasis 2004; 10(2): 155-166
transfused
n=24 (9,4%)
Platelet Function in Patients with Acute MI*
Set-up
Patients with acute chest pain or symptoms suggestive of acute coronary
syndromes (n=216) were prospectively examined at an emergency unit.
Results
COL/ADP-CT was significantly shorter in MI patients, than in other patient
groups (unstable angina, stable coronary artery disease), or controls.
Furthermore, COL/ADP-CT and COL/EPI–CT at presentation were
independent predictors of myocardial damage as measured by CK-MB or
TnT.
Patients with MI whose COL/ADP-CT values fell in the first quartile had
3-fold higher CK-MB and TnT levels than those in the fourth quartile.
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* Frossard M, et al. Circulation. 2004;110:1392-1397
Potential applications for PFA-100 in transfusion medicine
Quality control of platelet concentrates
– Collection (van der Boehlen et al. 2001, Feuring et al. 2001)
– Storage (Beck et al. 2002, Borzini et al. 1999)
– Cryo-Preservation (Borzini et al. 1999, 2000)
Therapeutic monitoring (e.g. DDAVP)
» Eriksson et al. Vox Sang 1996
Peri-operative transfusion management
– Platelet concentrates (Raman et al. 2001)
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Conclusion
INDICATIONS FOR PFA-100
BLEEDING
Screening for VWD and platelet dysfunction
Transfusion medicine: donor screening, transfusion efficacy
Menorrhagia: screening for platelet defect / VWD
Surgery: patients with high risk for platelet dysfunction or vWD
THROMBOSIS
Detection of aspirin non-responsiveness and platelet hyperactivity
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The End
Thank you for your attention!
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