Measurement of heparin in plasma: influence of inter-subject and circadian variability in heparin sensitivity according to method.

Heparin was measured, with respect to standard curves prepared with normal pooled plasma, by five methods (APTT, thrombin time, one and two stage coagulation, anti-factor Xa and chromogenic anti-factor Xa) after addition at three concentrations to plasmaprepared from normal young volunteers, hospitalized patients with malignancy and geriatric patients. By the APTT and TT, differences in sensitivity were observed at 0.4iu heparin/ml corresponding to an apparent difference in heparin level of 10 and 14 fold between high and low responding individuals. Such large differences were not apparent by anti-factor Xa assay. A circadian difference in sensitivity was also observed in the patient group such that in samples taken at night, heparin levels were 30-50% higher on average when measured in the APTT and TT. Again, such large differences were not apparent by anti-factor Xa methods. In light of recent findings about the usefulness of anti-factor Xa methods for efficient monitoring of heparin, it is suggested that this conclusion may arise from the tendency for anti-factor Xa methods to determine actual concentrations of heparin.

Circadian changes in anticoagulant effect of heparin infused at a constant rate.

Six patients with venous thromboembolism were treated with heparin, administered intravenously by a constant infusion pump. The initial daily dose of heparin was adjusted to keep the activated partial thromboplastin time, sampled at 0800, between 1.5 and 2.5 times the control level. Once that level was obtained, this dose was kept constant. Anticoagulation was thereafter measured, every four hours for 48 hours, by activated partial thromboplastin time, thrombin time, and coagulation factor Xa inhibition assay. The results of all three coagulation tests showed a circadian variation in the six patients. Maximum values were achieved at night and minimum values in the morning. These circadian variations were reproduced for two consecutive days. Differences between night and morning values reached almost 50% for activated partial thromboplastin time, 60% for thrombin time, and 40% for factor Xa inhibition assay. This circadian variation resulted from two rhythms, a circadian rhythm lasting 24 hours and an ultradian rhythm lasting 12 hours, which were detected by cosinor analysis for each coagulation test (p less than 0.01). A circadian rhythm was detected individually in most of the patients for each coagulation test (p less than 0.05). All patients had a nocturnal peak in activated partial thromboplastin time on both days. In four patients this peak exceeded the upper desired limit of activated partial thromboplastin time. These rhythms should be taken into account when evaluating the dosage of heparin to be administered.