Multiplate T Analyzer für die Thrombozytenfunktionstestung ...

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Multiplate T Analyzer für die Thrombozytenfunktionstestung Literaturübersicht

Transcript of Multiplate T Analyzer für die Thrombozytenfunktionstestung ...

Page 1: Multiplate T Analyzer für die Thrombozytenfunktionstestung ...

MultiplateT Analyzer für die Thrombozytenfunktionstestung Literaturübersicht

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MultiplateT AnalyzerStärkung des Hämostaseportfolios

Mit Übernahme der Verum Diagnostica GmbH stehtRoche Diagnostics mit dem Multiplate® Analyzer eine innovative und überzeugende Lösung für die Thrombozytenfunktionstestung zur Verfügung. Die hohe medizinische Wertigkeit des Systems resultiert aus seiner überzeugenden Prädiktivität für Thrombosen und Blutungen. Das ermöglicht eine patientenindividuelle aggregationshemmende Medi-kation und die Stratifizierung eines perioperativen Blutungsrisikos.

Insbesondere durch den hohen Standardisierungs-grad des Messverfahrens kann der Multiplate®

Analyzer im Bereich der primären Hämostase neueMaßstäbe bei der Patientenversorgung setzen.Das System ist daher für Roche eine ideale Ergänzung, die Vision, Innovationen mit bewahrtem medizini-schem und diagnostischem Know-how zu kombinieren, in das neue Gerinnungsportfolio zu übertragen.

Die Gerinnungsdiagnostik gehört fur Roche Diagnostics zu den wichtigsten Investitionsbereichen dernächsten Jahre. Unser Anspruch ist, unsere Kompe-tenzen und Konzepte der Klinischen Chemie,Immunologie und POC-Diagnostik hinsichtlichProduktqualität, Prozesseffizienz, Flexibilität und Bedienerfreundlichkeit auch in unserem neuenGerinnungsportfolio zu etablieren.

Neben den Systemen der cobas t Plattform für die Diagnostik der plasmatischen Gerinnung, bietet der Multiplate® Analyzer die Möglichkeit einer schnellen Bestimmung der Thrombozytenfunktion. Die Kenntnis der Thrombozytenfunktion von Patienten kann für den behandelnden Arzt ein wichtiger Baustein sein, klinische Entscheidungen zu treffen und umzusetzen, insbesondere in der Kardiologie, Chirurgie und Intensivmedizin.

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Zuverlässige Ergebnisse• Einfaches, standardisiertes und

schnelles Testverfahren aus Vollblut• Umfangreiches, CE-markiertes

Parametermenü• 5 Kanäle für hohen Durchsatz • Hohe Sensitivität• Parallelbestimmung (2 Sensoren-

paare) zur Qualitätskontrolle

Hohe Prädiktivität – für eine individuell angepasste, aggregationshemmende Therapie• Ca. 20 % der Patienten unter Clopidogrel-

Therapie zeigen keine ausreichende Medika-mentenwirkung (low-responder)

• Low-responder, die mittels der Multiplate-Testung detektiert wurden, haben ein 5–10-fach höheres Risiko für ischämische Ereignisse

• Eine Umstellung auf neuere und potentere Medikamente hat Vor- und Nachteile; sie ist mit 10–15-fach höheren Kosten verbunden

• Patienten, die überdurchschnittlich gut auf Clopidogrel ansprechen (high-responder), weisen ein 2,6-fach höheres Risiko für schwere Blutungen auf

• Viele Arbeitsgruppen berichten über die erfolgreiche Umsetzung von Multiplate-Ergebnissen in eine individuell angepasste, aggregationshemmende Therapie

Medizinischer Fokus• Mehr als 200 Publikationen

mit dem Multiplate® Analyzer in Medline

• Konsensuspapier der Arbeitsgruppe für „high on treatment platelet reactivity“ mit der Multiplate- Methode

• Richtlinien mit Empfehlungen zur Thrombozyten- Funktionstestung bei koronaren Bypass- Operationen und koronaren Interventionen für Patienten unter Clopidogrel-Therapie

Hohe Prädiktivität – zur Stratifi zierung des Blutungsrisikos• Patienten, bei denen mittels Multiplate-

Analyse eine Thrombozytenfunktionsstörung festgestellt wurde, haben ein erhöhtes Risiko für intra- und postoperative Blutungs-komplikationen und/oder Transfusionsbedarf

• Der Einsatz des Multiplate-Analyzers kann das Management von Blutungskomplika-tionen im Rahmen chirurgischer Eingriffe verbessern

MultiplateT AnalyzerStärkung des Hämostaseportfolios

Überzeugende PrädiktivitätMultiplateT Analyzer

MultiplateT Analyzer

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Prediction of early coronary stent thrombosis based on Multiplate® platelet reactivity

In Sibbing et al’s (2009) study hirudin anticoagulated blood was used for analysis. The optimal cut-off value to predict the occurrence of 30-day stent thrombosis according to ROC analysis was 47 U.

This study has been featured in an article in “www.theheart.org” 3 where Sibbing stated: “We can’t say whether the MEA assay is better than other assays or not, but we are very happy with it, and we are convinced by the results we have seen in this study. It also works out at a reasonable cost for each test. When we started this study, we were not routinely measuring platelet responsiveness in the cath lab, but now we are measuring it with this device“.

High residual platelet reactivity in patients on clopidogrel therapy undergoing percutaneous coronary intervention (PCI) is associated with an increased risk of ischemic events.1

Sibbing, Braun, Morath et al. (2009) investigated in a prospective trial if platelet reactivity to clopidogrel assessed with multiple electrode platelet aggregometry (MEA, Multiplate®) correlates with the risk of early drug-eluting stent thrombosis.2 With 1,608 CAD patients enrolled who were scheduled for drug eluting stent PCI, this study is among the largest ones conducted on this topic. The primary end point was definite ST at 30 days.

Before PCI, all patients received 600 mg clopidogrel. Blood was obtained directly before PCI and tested with the Multiplate® ADPtest more than 2 hours after clopidogrel loading. The upper 20% of patients according to MEA measurements (n = 323) were defined as clopidogrel low responders.

Low responders had an approximately 10 times higher risk of definite ST within 30 days compared to normal responders, (2.2% vs. 0.2%; odds ratio [OR]: 9.4; 95% confidence interval [CI]: 3.1 to 28.4; p < 0.0001).

Ris

k of

ST

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Odds ratio 9.495% CI, 3.1-28.4P < 0.0001

Low respondersto clopidogrel

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Odds Ratio 9.4 95% CI, 3.1-28.4 P<0.0001

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Prediction of early coronary stent thrombosis based on Multiplate® platelet reactivity

Prediction of coronary stent thrombosis based on Multiplate® platelet reactivity: 6 month results

High residual platelet reactivity in patients on clopidogrel therapy undergoing percutaneous coronary intervention (PCI) is an independent predictor of early definite stent thrombosis (ST) within 30 days.

This association was established by Sibbing, Morath, Braun et al. (2009) using the Multiplate® ADPtest to identify low responders resulting in an odds ratio of 9.4; 95% [CI]: 3.1 to 28.4; p < 0.0001) for definite stent thrombosis in low responders versus normal responders.2 Sibbing et al. (2010) also reported the six-month follow-up results of these study patients.4

The upper 20% of patients according to Multiplate® measure-ments (n = 323) were defined as clopidogrel low responders using a cut-off value of 42 U.

Low responders had an approximately 7 times higher risk of definite stent thrombosis within 6 months compared to normal responders, (2.5% vs. 0.4%; OR: 6.5; 95% [CI]: 2.4 – 17.0; p < 0.001).

When considering definite and probable stent thrombosis combined, low responders exhibited an approximate 6-fold increased risk of ST upon a 6-month follow-up (4.1% vs. 0.7%; OR: 5.8; 95% [CI]: 2.4 – 17.0; p < 0.0001).

Of note is the observation that the majority of low responders to clopidogrel identified by MEA suffer ischemic events early in the course following PCI, usually within 3 months.

Low respondersto clopidogrel

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Odds ratio 6.595% CI, 2.4-17.0P < 0.001

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Odds Ratio 6.595% CI, 2.4-17.0P<0.001

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Odds Ratio 5.895% CI, 2.8-12.3P<0.0001

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Odds Ratio 5.895% CI, 2.8–12.3P<0.0001

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Further support for variable anti-platelet drug efficacy and the clinical relevance of Multiplate® testing

Müller-Schunk, Linn, Peters, Spannagl et al. conducted the first outcome related clinical trial with the Multiplate® analyzer, published in 2008 in AJNR.5 50 neurologic patients scheduled for supra-aortic stent placement were enrolled. The aim was to determine platelet inhibition after clopidogrel treatment using the Multiplate® analyzer and correlate the results with the clini-cal outcome. Adverse ischemic events were registered in 10% of patients and a statistically significant correlation of clopidogrel non-response and adverse events has been reported.

In a prospective study from Siller-Matula, Christ, Lang et al. (2009)6 416 CAD patients scheduled for PCI were enrolled and assessed for clopidogrel response in Multiplate® and VASP assays. The rate of stent thrombosis was recorded during a 6-month follow-up. Positive predictive value for the prediction of stent thrombosis and outcome related sensitivity and speci-ficity was determined to be superior in Multiplate® testing. The authors conclude that “the assessment of the antiplatelet effect of clopidogrel by platelet aggregometry [with Multiplate] was more predictive for stent thrombosis than the VASP assay.”

3.0

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to clopidogrelresponders

to clopidogrel

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erse

ev e

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rse

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ler -

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unk,

et a

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VASPcutoff 42% PRI

Multiplatecutoff 54 U

®

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acco

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Sensitivity and Speci�cityfor de�nite ST

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atulaet

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®

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Further support for variable anti-platelet drug efficacy and the clinical relevance of Multiplate® testing

Tailoring antiplatelet therapy with Multiplateand the potential to reduce the incidence of adverse ischemic events after PCI

Twenty-four hours before PCI, all patients received either 300 mg (patients with angina pectoris) or 600 mg (patients with acute coronary syndrome) loading dose of clopidogrel. In the tailored group, platelet function was tested with the Multiplate® ADPtest 24 hours after clopidogrel loading and at indicated time points (MEA). Patients with HPR (>46 U) received an additional 600 mg loading daily dose and 150 mg daily dose of clopidogrel for 30 days. Thereafter the 75 mg daily dose was resumed for the remainder of the study. Patients in the non-tailored group received a standard daily dose of 75 mg clopidogrel for 180 days after PCI.

During 6 months of follow-up, no ischemic events occurred in the Multiplate® tailored patient group. However, 5.3% of patients undergoing uniform standard dose clopidogrel therapy suffered severe cardiac and cerebovascular complications such as cardiac death or myocardial infarction (Fig. 1).

Various medical centers use the Multiplate® analyzer to assess and monitor platelet function in patients receiving antiplatelet drug therapy, like Aspirin® or clopidogrel, to minimize the risk of on-treatment complications.

High residual platelet reactivity (HPR) in patients on clopidogrel therapy undergoing percutaneous coronary intervention (PCI) is associated with increased risk of ischemic events (e.g. stent thrombosis). Prasugrel and ticagrelor are novel potent ADP-receptor inhibiting drugs that act more consistently and significantly reduce the risk of ischemic events compared to clopidogrel therapy. However, these drugs are also associated with a risk of increased major bleeding and other side effects that negatively impact compliance and patient outcomes. Furthermore, the treatment of patients with prasugrel or ticagrelor is up to 10 – 15 x more expensive compared to clopidogrel.

Several studies support that routine tailoring of antiplatelet therapy using Multiplate® testing has the potential to significantly reduce the incidence of major adverse ischemic complications.

A study of Hazarbasanov, Velchev, Finkov et al. (2012) 7 aimed to analyze the clinical impact of a platelet function-guided antiplatelet therapy compared to standard dose clopidogrel treatment in patients after PCI. This prospective, randomized, open-label, interventional study enrolled 192 patients. The primary end point was the incidence of major adverse cardiac and cerebovascular events such as cardiac death, myocardial infarction, stent thrombosis or ischemic stroke at six months (180 days).

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Hazarbasanov et al.’s (2012) study demonstrated that a treatment strategy incorporating the Multiplate® analyzer to assess a tailored dose of clopidogrel may reduce the incidence of ischemic events in patients after PCI.

Furthermore, a study by Christ, Francesconi et al. (2011) 8 of 507 patients undergoing PCI has shown that routine tailoring of antiplatelet therapy using Multiplate® testing helps prevent early definite stent thrombosis in compliant patients. In this study patients undergoing PCI received a personalized anti-platelet treatment of either clopidogrel or prasugrel depending on the clinical status and platelet reactivity test result. STEMI patients received first line prasugrel, while all other patients received clopidogrel and were tested for their platelet response. Patients with a low response to the anti-platelet treatment (ADPtest > 50 U) were either reloaded with clopidogrel (patients with prior cerebrovascular events) or with prasugrel (all other patients) . Christ et al. (2011) reported a very low incidence of stent thrombosis in this patient cohort treated with a personalized anti-platelet therapy.

Another study by Sibbing, Mayer, Bernlocher et al. (2012) 9 aimed to investigate whether Multiplate® tailored antiplatelet therapy with prasugrel in patients displaying HPR on clopi-dogrel treatment reduces the incidence of stent thrombosis after PCI. Before PCI, all patients received a loading dose of 600 mg clopidogrel. In the study design one group of patients received a standard clopidogrel treatment whereas another cohort of patients were switched from clopidogrel to prasugrel based on Multiplate testing. The primary outcome was the incidence of stent thrombosis (ST) within 30 days after PCI.

Stent thrombosis was 4-fold higher in the patient group without antiplatelet therapy adjustment compared to the patient group with Multiplate-tailored treatment (Fig. 2). Routine platelet function testing for guidance of antiplatelet treatment markedly reduced risk of stent thrombosis in patients with HPR while on clopidogrel therapy.

96

98

94

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90Standard clopidogrel

treatment N=97Multiplate® tailoredtreatment N=97

MA

CC

E -

free

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viv a

l [%

]

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Fig.2 according to Hazarbasanov , e t al. 1.Fig.2 according to Hazarbasanov , e t al. 1.

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Log - rankp=0.02

Fig.

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azar

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inci

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Odds Ratio (adj) 0.0895% Cl, 0.01 - 0.84p=0.036

Fig.

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ibbi

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Fig.3 according to Sibbing , e t al. 2.Fig.3 according to Sibbing , e t al. 2.

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treatment N = 428Treatment adjustment

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Odds ratio (adj) 0.0895% Cl, 0.01 - 0.84P = 0.036

Survival analysis 180 days post PCI 7

Stent thrombosis incidence 30 days post PCI 9

Fig. 1

Fig. 2

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Multiplate® analysis: Prediction of bleedingand transfusion in coronary artery surgery

Reece et al. (2011) investigated the Multiplate® analyzer for determining platelet aggregation in 44 patients during coronary surgery.10 The results demonstrated that platelet aggregation was reduced during and after cardiopulmonary bypass surgery (CPB) as compared to baseline values with evidence of slight recovery in platelet function post chest closure. Patients receiv-ing transfusion products displayed lower levels of ADP and TRAP induced platelet aggregation than patients not receiving transfusions. It was concluded that the Multiplate® analyzer can detect platelet dysfunction in the setting of CPB.

Rahe-Meyer et al. (2008) showed in a study of 100 surgical patients 11 that in the case of possible Aspirin® ingestion, the Multiplate® system is a better predictor of platelet related coagulopathy or transfusion than patient self-reporting.

Ranucci et al. (2011) aimed to determine if a preoperative test of platelet function could determine postoperative risk of excessive bleeding and transfusion requirements.12 They tested 87 patients who discontinued thienopyridine treatment no more than 7 days prior to surgery.

Multivariable linear regression analysis confirmed the Multiplate® ADPtest (p = 0.007) as independently associated with postoperative bleeding. The accuracy of prediction was good with an area under the curve of 0.71, p= 0.013. Using the Youden index the best cut-off value for the ADP test was determined to be 31 U with an associated sensitivity of 72%, specificity 66%, negative predictive value 92%, and positive predictive value 29%.

The incidence of excessive bleeding was significantly higher in patients with ADPtest results below the cutpoint (31 U) in com-parison to patients with ADPtest results higher than the cutpoint (29% vs 8%).

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Platelet dysfunction and bleeding in cardiac surgery 12

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Bleeding risk and platelet function testingwith Multiplate® analysis in PCI

High residual platelet reactivity in patients on clopidogrel therapy has been associated with increased risk of thrombotic events in PCI; however, it is also recognized that enhanced response to clopidogrel carries an associated risk of increased major bleeding. Both conditions significantly increase mortality.

The association of enhanced platelet response to clopidogrel treatment in PCI as evidenced by low levels of platelet reactivity measured with the Multiplate® analyzer and its association with bleeding was first elucidated by Sibbing, Schulz, Braun, Morath et al. (2010).13

Sibbing’s group evaluated 2,533 CAD patients scheduled for drug-eluting stent PCI. All patients received a clopidogrel loading dose of 600mg. Blood was obtained directly before PCI, more than 2 hours after clopidogrel loading and tested with the Multi-plate® ADPtest.

ROC analysis identified the optimal cut-off of 19 U to identify enhanced responders. The incidence of major bleeding was significantly higher in enhanced clopidogrel responders (n = 975) as compared with the remaining patients (n = 1,558) [21 (2.2%) vs. 13 (0.8%); OR 2.6, 95% CI 1.3 –5.2; P = 0.005].

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Bleeding risk and platelet function testingwith Multiplate® analysis in PCI

Morel-Kopp et al.’s (2012) study14 demonstrated, that the Multiplate® analyzer is not only an easy-to-use and rapid test system, but its high sensitivity and specificity is comparable to those of the accepted gold standard serotonin release assay. Thus, Multiplate® analysis should be considered as a confirmatory assay for platelet activating HIT antibodies.

Another study by Valarche et al. (2011) 15 compared the MEA analyzer with the classic diagnostic method LTA (light trans-mission aggregometry) to evaluate the sensitivity of MEA for von Willebrand disease (VWD). It was shown that MEA was as sensitive as LTA in detecting VWD, with 76% correlation between the two methods. Thus, MEA is a reliable tool in association with other standard test systems, for the evaluation of VWD.

The Multiplate® analyzer has been widely used to evaluate patient responses to platelet aggregation inhibiting drugs. Moreover, its role as a reliable diagnostic tool for platelet-related disorders is becoming more obvious.

Heparin-induced thrombocytopenia (HIT) is a severe complication of anticoagulant therapy with heparin. Some patients develop abnormal antibodies of the IgG class against heparin when it is bound to a platelet protein called platelet factor 4 (PF4). This antigen-antibody complex then binds to the FcγIIa receptor on the platelet surface and leads to platelet activation and consequent formation of blood clots. Additionally, the platelet count may fall in an immune-mediated thrombocytopenia. The diagnosis of HIT is still very challenging as the functional assays are complex, long-lasting and require qualified medical staff. The 14C-serotonin release assay (SRA) is considered to be the gold standard for HIT diagnosis but is not suitable for routine use because of the difficulties mentioned above. Morel-Kopp et al. (2012)14 conducted a large study to validate Multiplate® analysis as a suitable diagnostic tool for functional assessment of HIT.

They tested 181 patient samples positive for Heparin-PF4 antibodies via MEA and SRA tests to assess the diagnosis of true HIT. Using differrent criteria for SRA-positivity (serotonin release >20% with 0.1 IU/ml heparin and <20% release with 100 IU/ml heparin/threshold of >50% serotonin release), Multiplate® analysis showed a high sensitivity and specificity for HIT.

Multiplate® analyzer in heparin-induced thrombocytopenia (HIT) and von Willebrand disease (VWD)

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Co rre lation be tw ee n the func tional SR A a ndMEA f or HIT d iagnos is

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sp ec if icit y

PP V

82

84

86

88

90

92

94

96

98

strict SRA positivity modified SRA positivity

sensitivity specificity PPV

Fig.

1 ac

cord

ing

to M

orel

-Kop

p, e

t al .

PPV

posi

tive

pred

ictiv

e va

lue.

1

Cor

rela

tion

[%

]

100

80

82

84

86

88

90

92

94

96

98

Strict SRA positivity Modified SRA positivity

Sensitivity Specificity PPV

Correlation between the functional SRA and MEA for HIT diagnosis 14

Page 12: Multiplate T Analyzer für die Thrombozytenfunktionstestung ...

Evaluation of paediatric reference values for normal platelet function based on Multiplate® impedance aggregometry

Platelet aggregation was evaluated using the ADPtest (ADP, 6.5 uM), COLtest (collagen 3.2 ug), TRAPtest (thrombin receptor-activating peptide 6; TRAP-6, 32 uM), ASPItest (arachidonic acid 0.5 mM) and RISTOtest (ristocetin 0.77 mg/ml).

Infants aged 0.1-12 months displayed significantly lower aggregation values in TRAPtest and ASPItest compared with the older age groups. Therefore adult reference values can provide a valid guidance for the evaluation of platelet function of children at age > 1 year.

Hereditary platelet disorders are rare but can lead to bleeding syndromes appearing during infancy or early childhood.

Patients with platelet dysfunction disorders possess a higher risk of bleeding complications during complex surgeries or per-cutaneous injuries. Evaluation of reference diagnostic parameters is necessary for the comparison between normal and disordered platelet function.

The study of Halimeh, de Angelis, Sander et al. (2010) 16 evaluated paediatric reference values for the Multiplate® system in infants and children from different age groups (0.1-12 months, 1.1-4 years, 5-9 years and 10- to <18 years).

60

0

40

80

100

120

140

plat

elet

agg

rega

tion

[A

UC

; U]

TRAPtestCOLtestADPtest

160

20

ASPItest RISTOtest

0.1 - 12 months 1.1 - 4 years 5 - 9 years 10 - 18 years<

****

acco

rdi n

g to

Hal

imeh

et a

l.**

P<

0 .00

1

160

0

40

80

100

120

140

Pla

tele

t ag

greg

atio

n [A

UC

; U]

TRAPtestCOLtestADPtest

160

20

ASPItest RISTOtest

0.1 - 12 months 1.1 - 4 years 5 - 9 years 10 - 18 years<

****

Aggegometry values in healthy infants, children and adoloscents 16

** P < 0.001

Page 13: Multiplate T Analyzer für die Thrombozytenfunktionstestung ...

Evaluation of paediatric reference values for normal platelet function based on Multiplate® impedance aggregometry

Glanzmann thrombasthenia is a rare hereditary disease which can lead to severe mucocutaneous bleeds. Glanzmann thrombasthenia caused by a genetic defect of the GPIIb/IIIa receptor. The platelet GPIIb/IIIa receptor binds to fibrinogen and is the most important principle receptor for platelet aggregation. Quantitative and qualitative defects in GPIIb/IIIa receptors lead to deficient platelet aggregation followed by a tendency for increased bleeding.

The detection of Glanzmann thrombasthenia using light transmis-sion aggregometry is time-consuming and weakly standardized. The study of Awidi, Maqablah, Dweik et al. (2009) 17 investigated the suitability of Multiplate® analysis using whole blood for the diagnosis of patients with Glanzmann thrombasthenia.

Blood samples were taken from patients with Glanzmann thrombasthenia who were not taking platelet function inhibiting medications for at least 7 days. Platelet aggregation in platelet-rich plasma was monitored by LTA (a), whereas platelet aggregation in whole blood was studied by Multiplate® (b) after stimulation of platelets with ADP (ADPtest), collagen (COLtest) or ristocetin (RISTOtest) . In both LTA and Multiplate® a very low level of aggregation was witnessed in response to all examined agonists. Thus, Multiplate® analysis provides comparable results to LTA.

Awidi et al.’s (2009) study demonstrated that MEA performed via the Multiplate® analyzer is a fast and standardized method to assess severe platelet function disorders like Glanzmann thrombasthenia in whole blood.

Multiple electrode aggregometry (MEA) is a reliable test device for diagnostic assessment of Glanzmann thrombasthenia

Ev al ua tion of platel et aggregation v ia LTA a fte r a ddition o fsp ec ific ac tiva tors

0

10

20

30

40

50

60

70

80

90

100

ADPt est CO Lt est RI ST Otest

%plateletag

greg

ation

80

0

70

90

100

60

50

40

30

20

10

% p

late

let

aggr

egat

ion

COLtest0.19 mg/ml

ADPtest2 X 10 M4

RIST test1.5 mg/ml

80

0

70

90

100

60

50

40

30

20

10

Pla

tele

t ag

greg

atio

n [%

]

Collagen0.19 mg/ml

ADP2 X 10 M-4

Ristocetin1.5 mg/ml

Pla

tele

t ag

greg

atio

n [A

UC

; U]]

COLtest3.2 g/mlµ

ADPtest6.4 Mµ

RISTOtest0.77 mg/ml

Ev al ua tion of platelet aggr egation v ia MEA a fte r a ddi tion ofsp ec ific ac tiva tors

0

20

40

60

80

100

ADPt est CO Lt est RI ST Otestplatelet

aggr

egation(A

UC;

U)

80

0

70

90

100

60

50

40

30

20

10

plat

elet

agg

rega

tion

[A

UC

; U]

acco

rdin

g to

Aw

idi e

t al.1

COLtest3.2 g/mlµ

ADPtest6.4 Mµ

RISTOtest0.77 mg/ml

80

0

70

90

100

60

50

40

30

20

10

Evaluation of platelet aggregation via Multiplate after addition of specific activators (b) 17

Evaluation of platelet aggregation via LTA after addition of specific activators (a)

Page 14: Multiplate T Analyzer für die Thrombozytenfunktionstestung ...

Cross validation of Multiple ElectrodeAggregometry – A prospective trial in healthy volunteers

At present dual drug therapy with Aspirin® and clopidogrel is the standard treatment of patients undergoing percutaneous coronary intervention (PCI). However, there is strong variability in the individual response to these antiplatelet drugs, that carries a high risk of bleeding by high-responders and an increased risk of stent thrombosis by low/non-responders.

There are several standard test systems which allow the deter-mination of platelet function in patients undergoing clopidogrel and Aspirin therapy. Multiplate® analysis is a fast and easy-to-use platelet function test method that analyzes whole blood.

Siller-Matula, Gouya, Wolzt and Jilma (2009)18 investigated the sensitivity of Multiplate® analysis to clopidogrel and Aspirin effects and compared it with other platelet function tests such as the Cone and Platelet Analyzer (CPA), PFA-100 and VASP phosphorylation assay. In this study design each of 9 healthy volunteers received a loading dose of 300 mg Aspirin and 300 mg clopidogrel on the first day, and a standard dose of 100 mg Aspirin and 75 mg clopidogrel on each of the three consecutive days. Blood samples were analyzed at baseline (pre Aspirin and clopidogrel intake), and 2, 4, 6 and 72 hours after drug ingestion. Clopidogrel effect was investigated by means of ADP-induced platelet aggregation, whereas Aspirin effect was measured by means of arachidonic acid-induced platelet aggregation. The effect size for the clopidogrel and Aspirin treatment was calculated as the average of the amplitude between baseline and maximal platelet inhibition at nadir for each patient. The best effect resolution for both Aspirin and clopidogrel according to the greatest signal magnitude was found for Multiplate® analysis (Tab. 1) .

Multi- plate PFA-100 VASP

assayCPA SC

CPA AS

Clopidogrel 11.3 n.d. 2.2 2.6 2.1

Aspirin 19.0 2.0 n.d. 2.3 2.2

Tab. 1 according to Siller-Matula et al. (2009) the effect size for clopidogrel

and Aspirin measured with different tests as median values. SC surface coverage;

AS average size of platelet aggregation.

Page 15: Multiplate T Analyzer für die Thrombozytenfunktionstestung ...

Cross validation of Multiple ElectrodeAggregometry – A prospective trial in healthy volunteers

Time point 0 marks the baseline of platelet aggregation in healthy volunteers without Aspirin treatment.

Aspirin caused significant platelet inhibition four hours after intake and the inhibitory effect lasted 24 hours by all study participants. Platelet aggregation returned to the baseline range (60-120 U) in 33% of volunteers by 80 hours (day 3) and in 88% of probands by 124 hours (day 5).

This study showed that Multiplate® analysis is a reliable method for the assessment of Aspirin effect.

Aspirin® is a widely used inhibitor of platelet aggregation. Due to its antiplatelet effects, Aspirin intake is associated with increased bleeding risk during and after complex surgery.

Jambor, Weber, Gerhardt et al. (2009) 19 showed that multiple electrode aggregometry (MEA) is a reliable test to assess Aspi-rin-induced platelet dysfunction.

In Jambor et al.’s (2009) study each of 24 healthy adult volunteers received a single dose of 500 mg of acetylsalicylic acid (Aspirin). Blood samples were collected at several time points after Aspirin intake and analyzed with the Multiplate® system.

Platelet aggregation was determined following stimulation by arachidonic acid (ASPItest).

Evaluation of Aspirin-induced platelet dysfunction based on Multiplate® assessed platelet reactivity

Pla

tele

t ag

greg

atio

n [A

UC

; U]]

time / h after aspirin intake

plat

elet

agg

raga

tion

(A

UC

; U) 80

100

50

20

0

120

10

30

40

60

70

90

110

ASPI test , 0 ,5 mM30 min a fte r b lood draw ing

0

10

20

30

40

50

60

70

80

90

100

110

120

0 4 24 56 80 124

time / h a fte r a sp ir in inta ke

platelet

aggr

agation(AUC;

U)

00 4 24 56 80 124

Time after Aspirin intake [h]

80

100

50

20

0

120

10

30

40

60

70

90

110

024 124805640

ASPItest 0.5 mM

Page 16: Multiplate T Analyzer für die Thrombozytenfunktionstestung ...

CLSI – guideline adopting Multiplate® analysis

Since the introduction of the Multiplate® analyzer to the market in 2005 the system has seen a great momentum in terms of adoption and medical consensus on the value of Multiplate® analysis. Since then over 200 medline listed publications with the use of Multiplate® analysis were published, supporting the growing interest and adoption of the Multiplate® system in clinical practice.

Multiplate® analysis is an improvement of traditional whole blood impedance aggregometry, which was introduced in 1979 by Cardinal et al.20

Multiplate® analysis is included in the latest Clinical and Laboratory Standards Institute guideline on platelet function testing (H58-A).21

Page 17: Multiplate T Analyzer für die Thrombozytenfunktionstestung ...

CLSI – guideline adopting Multiplate® analysis

The document also provides a consensus statement of the definition of high platelet reactivity to ADP on the Multiplate® analyzer, defined as an aggregation > 47 U (468 AU*min).

The addition of ADP receptor antagonists to Aspirin® treatment reduces ischemic events in patients with cardiovascular disease. However, recurrent ischemic events during dual antiplatelet therapy, including stent thrombosis, remains a major concern. Platelet function measurements demonstrate a highly variable inhibition of ADP induced platelet function under clopidogrel treatment. High on-treatment platelet reactivity to adenosine diphosphate (ADP) is observed in a significant proportion of clopidogrel-treated individuals. Multiple studies have demonstrated a clear association between high on-treatment platelet reactivity to ADP and the occurrence of adverse events.

This review 1 provides a consensus opinion on the definition of high on-treatment platelet reactivity to ADP based on various methods and proposes how identification of HPR may be used in patient care.

Multiplate® analysis was included in this consensus document. Table 2 of the document summarized studies linking high on-treatment platelet reactivity to ischemic events. The best prediction of ischemic events was associated with the Multiplate® analyser, with an odds ratio of 12.0, while other studies using for example the VerifyNow system showed an odds ratio of only 2-3.

Cardiology consensus paper supporting bestpredictivity of Multiplate® analysis

Multiplate LTA VerifyNow Platelet-works VASP

2.8

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

Sibbing et al.(2009)

Cuisset et al.(2009)

Gurbel et al.(2008)

Breet et al.(2010)

Marcucci et al.(2009)

Breet et al.(2010)

Breet et al.(2010)

Blindt et al.(2007)

Odd

s ra

tio

[Ris

k en

hanc

emen

t]

bette

r12.0

5.8

3.92.1

2.5 2.2

1.2

Multiplate – highest odds ratios in consensus paper.1

Supporting best predictivity for stent thrombosis

Fig.: adapted from Bonello et al. (2010) consensus paper.

Page 18: Multiplate T Analyzer für die Thrombozytenfunktionstestung ...

Guidelines are supporting platelet functiontesting

With the increasing evidence of a poor response to clopidogrel being associated with an increased risk for stent thrombosis and other adverse events, platelet function testing (PFT) has been incorporated into PCI treatment guidelines.

PFT is now supported by a 2011 Class IIb recommendation from the American College of Cardiology Foundation/American Heart Association/Society for Cardiovascular Angiography and Inter-ventions Guideline for Percutaneous Coronary Intervention.22

“CLASS IIb1. Platelet function testing may be considered in patients at high

risk for poor clinical outcomes. (Level of Evidence: C)2. In patients treated with clopidogrel with high platelet reactivity,

alternative agents, such as prasugrel or ticagrelor, might be considered. (Level of Evidence: C)”

Oral antiplatelet agents

Recommendation Evidence Level

Aspirin I B

P2Y12 Inhibitors I A

Clopidogrel I B

Prasugrel I B

Ticagrelor I B

Class IIb recommendation

1. Platelet function testing may be considered in patients at high risk for poor clinical outcomes (Level of evidence: C)

2. In patients treated with clopidogrel with high platelet reactivity, alternative agents, such as prasugrel or ticagrelor, might be considered (Level of evidence: C)

Several anti-platelet agents with level I recommendations

Relatively careful recommendation for drug selection aided by platelet function testing

2011 ACCF/AHA/SCAI guideline for PCISupporting the use of platelet function testing

Tab.: adapted from Levine et al. (2011).22

Page 19: Multiplate T Analyzer für die Thrombozytenfunktionstestung ...

Class I represents conditions or recommendations for which there is general agreement or evidence, or both, that a proce-dure is useful or effective, while class IIa and IIb recommendations represent conditions in which opinions diverge, with class IIa carrying a weight of evidence or opinion in favor of the use-fulness or effectiveness of a procedure, and class IIb carrying a weight of evidence in which the usefulness or efficacy of the procedure is less well established.23

Typically as new markers gain more evidence over time the recommendations in guidelines become stronger, which is also expected for platelet function testing.

PFT has also received a Class IIb recommendation by the Society of Thoracic Surgeons and the Society of Cardiovascular Anes-thesiologists.23

“Class IIb.Point-of-care testing for platelet ADP responsiveness might be reasonable to identify clopidogrel nonresponders who are can-didates for early operative coronary revascularization and who may not require a preoperative waiting period after clopidogrel discontinuation. (Level of evidence C).”

The guideline supports the idea of testing platelet reactivity in order to eliminate an unnecessary preoperative waiting period in patients demonstrating no effect from clopidogrel.

Such guidelines divide their advice into class I, class IIa, class IIb, or class III.

References1 Bonello, L. et al. (2010). J Am Coll Cardiol Sep 14;56(12):919-33. 2 Sibbing, D., Braun, S., Morath, T. et al. (2009). Platelet reactivity after clopidogrel treatment

assessed with point-of-care analysis and early drug-eluting stent thrombosis. J Am Coll

Cardiol;53:849–56.3 www.theheart.org/article/946661.do 4 Sibbing, D., Morath, T., Braun, S. et al. (2010). Clopidogrel response status assessed with

Multiplate point-of-care analysis and the incidence and timing of stent thrombosis. Thromb

Haemost:103 (1):151-159.5 Müller-Schunk, S., Linn, J., Peters, N., Spannagl, M., Deisenberg, M., Brückmann, H.,

Mayer, T.E. (2008). Monitoring of clopidogrel-related platelet inhibition: correlation of nonresponse with clinical outcome in supra-aortic stenting. Am J Neuroradiol.

Apr;29(4):786-91.6 Siller-Matula, J., Christ, G., Lang, I.M., Delle-Karth, G., Huber, K., Jilma, B. (2009). Multiple

Electrode Aggregometry better predicts stent thrombosis than the VASP assay. J Thromb

Haemost. Nov 23. [Epub ahead of print].7 Hazarbasanov, D., Velchev, V., Finkov, B., Postadjian, A., Kostov, E., Rifai, N., Aradi, D. (2012).

Tailoring clopidogrel dose according to multiple electrode aggregometry decreases the rate of ischemic complications after percutaneous coronary intervention. J Thromb Thrombolysis. Jan

15 (Epub ahead of print).8 Christ, G., Francesconi, M., Dechant, C., Macura, J., Ruzicka, K., Podczeck-Schweighofer,

A. (2011). Routine tailoring of antiplatelet therapy after coronary stent implantation has the potential to eradicate early definite stent thrombosis in compliant patients. Eurointerven-

tion, Vol 7;Suppl M May 17.

9 Sibbing, D., Mayer, K., Bernlochner, I. et al. (2012). Platelet function testing guided use of prasugrel in patients with high on-clopidogrel treatment platelet reactivity reduces the risk of early stent thrombosis. J. Am. Coll. Cardiol.;59;E265.

10 Reece, M. et al. (2011). Near-patient platelet function testing in patients undergoing coronary artery surgery: a pilot study. Anaesthesia, 66, pages 97–103.

11 Rahe-Meyer, N. et al. (2008). An Evaluation of Cyclooxygenase-1 Inhibition Before Coronary Artery Surgery: Aggregometry Versus Patient Self-Reporting. Anesth

Analg;107:1791–7.

12 Ranucci, M. et al. (2011). Multiple Electrode Whole-Blood Aggregometry and Bleeding in Cardiac Surgery Patients Receiving Thienopyridines. Ann Thorac Surg;91:123–30.

13 Sibbing, D., Schulz, S., Braun, S., Morath, T., Stegherr, J., Mehilli, J., Schoemig, A., von Beckerath, N., Kastrati, A. (2010). Antiplatelet effects of clopidogrel and bleeding in patients undergoing coronary stent placement. J Thromb Haemost; 8: 250–6.

14 Morel-Kopp et al. (2012). Validation of whole blood impedance aggregometry as a new diagnostic tool for HIT. J Thromb Haemost. Mar;107(3);575-583.

15 Valarche et al. (2011). Multiplate whole blood impedance aggregometry: a new tool for von Willebrand disease. J Thromb Haemost. Aug;9(8);1645-1647.

16 Halimeh, S., de Angelis, G., Sander, A., Edelbusch, C., Rott, H., Thedieck, S., Mesters, R., Schlegel, N., Nowak-Göttl, U. (2010). Multiplate whole blood impedance point of care aggregometry: preliminary reference values in healthy infants, children and adolescents. Klin Padiatr 222(3); 158—163..

17 Awidi, A., Maqablah, A., Dweik, M., Bsoul, N., Abu-Khader, A. (2009). Comparison of platelet aggregation using light transmission and multiple electrode aggregometry in Glanzmann thrombasthenia. Platelets 20(5); 297--301.

18 Siller-Matula, J., Gouya, G., Wolzt, M., Jilma B. (2009). Cross validation of the Multiple Electrode Aggregometry. A prospective trial in healthy volunteers. J Thromb Haemost.

Aug;102(2);397-403.19 Jambor, C., Weber, C., Gerhardt, K., Dietrich, W., Spannagl, M., Heindl, B., Zwissler, B.

(2009). Whole blood multiple electrode aggregometry is a reliable point-of-care test of aspirin-induced platelet dysfunction. Anesth Analg;109:25–31.

20 Cardinal DC, Flower RJ. Br J Pharmacol. 1979 May;66(1):94P-95P21 Clinical and Laboratory Standards Institute (CLSI) document H58-A. (2008). Platelet

Function Testing by Aggregometry; Approved Guideline. ISBN 1-56238-683-2.22 Levine, G.N. et al. (2011). Circulation. Dec 6;124(23):2574-609.23 Ferraris, V.A. et al. (2011). Ann Thorac Surg. Mar;91(3):944-82.

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