If the prothrombin time (PT) and activated partial thromboplastin time (APTT) are both abnormally prolonged, the

deficiency is likely to involve factors II, V, or X.

If the PT is abnormal, but the APTT is normal, factor VII may be deficient. If the PT is normal, but the APTT is abnormal, the deficient factor(s) may
be from among those in the intrinsic pathway (VIII, IX, XI, XII).

Partial Thromboplastin Time

(PTT, Activated Partial Thromboplastin Time [APTT])
Test Description
The process of hemostasis involves numerous steps and the proper functioning of a variety of coagulating factors and other substances. The partial thromboplastin time (PTT) or activated partial thromboplastin time (APTT) is used to evaluate how well the coagulation process is functioning. This test is useful for detecting bleeding disorders caused by either deficient or defective coagulation factors that compose the intrinsic system. These factors include I, II, V, VIII, IX, X, XI, and XII. Normal APTTs may reflect normal clotting function but moderate single factor deficiencies may still exist. They will not be reflected in the APTT until they have decreased to 30% to 40% of normal. The PTT is also used to monitor heparin therapy. Heparin inactivates prothrombin and prevents the formation of thromboplastin. Thus, in conditions in which prevention of thrombus formation is essential, heparin is given, usually in the form of a continuous intravenous infusion. It is important that the patients response to this anticoagulant therapy be appropriate; that is, enough for prevention of clot formation, but not so much as to cause spontaneous bleeding. This delicate balance can be monitored through use of the PTT. The PTT involves measuring the amount of time it takes for a clot to form in a plasma sample to which calcium and partial thromboplastin have been added. If additional chemicals are added to standardize and accelerate the test, the result is reported as an activated partial thromboplastin time, or APTT. A normal range for PTT is 60 to 90 seconds, whereas for APTT the normal range is 25 to 35 seconds. Laboratories report the actual PTT or APTT values along with the control value for reference. The therapeutic level for a patient receiving heparin is 1.5 to 2.5 times the control value. If the value falls below the therapeutic level for a patient on heparin, an increase in anticoagulation, and thus, dosage is needed. If the APTT is greater than 100 seconds, the patient is at high risk for spontaneous bleeding. In the case of heparin overdose with resultant hemorrhage, the antidote is protamine sulfate, with each 1 mg reversing 100 units of heparin.

Normal Values APTT: 2535 seconds PTT: 6090 seconds Therapeutic level for anticoagulant therapy: 1.52.5 times the control value

Prothrombin Time (PT, INR, Pro Time)

Test Description
The process of hemostasis involves numerous steps and the proper functioning of a variety of coagulating factors and other substances. The prothrombin time (PT) is used to evaluate how well the coagulation process is functioning. This test is useful for detecting bleeding disorders caused by either deficient or defective coagulation factors that compose the extrinsic system. These factors include fibrinogen (I), prothrombin (II), V, VII, and X. If the patients blood is deficient in one of these factors, the patients PT in seconds will be higher than the control PT in seconds (or less than the control if using percentages). The PT is also used to monitor the effectiveness of anticoagulant therapy with warfarin sodium (Coumadin). This drug interferes with the production of vitamin K-dependent clotting factors, such as prothrombin. The PT involves measuring the amount of time it takes for a clot to form in a plasma sample to which calcium and tissue thromboplastin have been added. A normal range for PT is 8.8 to 11.6 seconds, but varies according to the norms established by individual laboratories. Laboratories report the actual PT value along with the control value for reference. The goal of oral anticoagulant therapy is to maintain

the PT at 1.5 to 2 times the control value (in seconds). Thus, a therapeutic goal, if receiving Coumadin, would be a PT of 24 seconds, or 25% of normal activity. If the value falls below the therapeutic level for a patient on an oral anticoagulant, an increase in anticoagulation, and thus, dosage is needed. If the PT is greater than 30 seconds, the patient is at high risk for spontaneous bleeding. In the case of warfarin overdose with resultant hemorrhage, the antidote is vitamin K, which reverses the action of warfarin in 12 to 24 hours. To provide standardization of PT reporting among different laboratories, the World Health Organization recommends the use of the International Normalized Ratio (INR) to express the intensity of therapy. Most laboratories now report both the PT and the INR. Maintaining an INR of 2.0 to 3.0 is recommended for prophylaxis/treatment of venous thrombosis and thromboembolic complications associated with atrial fibrillation, for pulmonary embolism, for prophylaxis of systemic embolism after myocardial infarction, and for bioprosthetic cardiac valves. A higher INR of 2.5 to 3.5 is recommended for cardiac valve replacement which involves mechanical valves and antiphospholipid antibody syndrome. The frequency of testing to reach and maintain the recommended INR level is based upon the individual patients clinical status.

Normal Values 8.811.6 seconds; 60140% (varies according to laboratory) Therapeutic level for anticoagulant therapy: 1.52 times the control value INR for DVT prophylaxis and atrial fibrillation: 2.03.0 INR for mechanical valve: 2.53.5

Bleeding Time (Ivy Bleeding Time, Template Bleeding Time)

Test Description
Bleeding time measures the duration of bleeding after a standardized skin incision has been made. Bleeding time is a screening test for detecting disorders involving platelet function and for vascular (i.e., capillary) defects that interfere with the clotting process. Prolonged bleeding time in the absence of a low platelet count indicates that a qualitative platelet disorder exists. The test is indicated when there is a personal or family history of bleeding tendencies and as a screening test for preoperative patients when a hemostatic defect is suspected.

Normal Values 19 minutes (Ivy method)

Thrombin Clotting Time (TCT, Thrombin Time [TT])

Test Description
During the process of hemostasis, intrinsic and extrinsic pathways lead to the activation of coagulation factor X. This leads to the conversion of prothrombin to thrombin. Thrombin then stimulates the formation of fibrin from fibrinogen. This fibrin, with the addition of fibrin stabilizing factor, forms a stable fibrin clot at the site of injury. Thrombin clotting time (TCT) measures the time it takes for a blood sample to clot when thrombin is added to the sample. TCT is longer than normal when there is an abnormality in the conversion of fibrinogen to fibrin. The test is used to assess for bleeding disorders, such as disseminated intravascular coagulation (DIC), and liver disease, and to monitor patients receiving fibrinolytic therapy.

Normal Values 1520 seconds (varies with laboratory)