PTT

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Also known as: Activated Partial Thromboplastin Time; aPTT; APTT Formal name: Partial Thromboplastin Time Related tests: Prothrombin Time (PT); Fibrinogen; Thrombin Time; Lupus Anticoagulant;Activated Clotting Time (ACT); Coagulation Factors; Platelet Count; Heparin Anti-Xa; von Willebrand Factor;Antiphospholipid Antibodies; Dilute Russell Viper Venom Time (DRVVT)

At a Glance Test Sample The Test Common Questions Ask Us Related Pages

The Test
1. 2. 3. 4. How is it used? When is it ordered? What does the test result mean? Is there anything else I should know?

How is it used?
The PTT test is used to investigate unexplained bleeding or clotting. It may be ordered along with a PT (Prothrombin Time) test to evaluate hemostasis, the process that the body uses to form blood clots to help stop bleeding. The PTT evaluates the coagulation factors XII, XI, IX, VIII, X, V, II (prothrombin), and I (fibrinogen) as well as prekallikrein (PK) and high molecular weight kininogen (HK). A PT test evaluates the coagulation factors VII, X, V, II, and I (fibrinogen). By evaluating the results of the two tests together, a doctor can gain clues as to what bleeding or clotting disorder may be present. A PTT is often used to monitor standard (unfractionated, UF) heparin anticoagulant therapy. Heparin is a drug that is givenintravenously (IV) or by injection to prevent and to treat thromboemboli. When it is administered for therapeutic purposes, it must be closely monitored. If too much is given, the treated person may bleed excessively; with too little, the treated person may continue to clot.

If the PTT is prolonged and the cause is not anticoagulant therapy or heparin contamination, then a second PTT test is performed by mixing the patient's plasma with pooled normal plasma (a collection of plasma from a number of normal donors). If the PTT time returns to normal ("corrects"), it suggests a deficiency of one or more of the coagulation factors in the patient's plasma. If the time remains prolonged, then the problem may be due to the presence of an abnormal factorinhibitor (autoantibody). Further studies can then be performed to identify what factors may be deficient or determine if an inhibitor is present in the blood. Nonspecific inhibitors, such as lupus anticoagulant and anticardiolipin antibodies, are associated with clotting episodes and with recurrent miscarriages, especially those that occur in the second or third trimester. For this reason, PTT testing may be performed to help investigate recurrent miscarriages. Based on carefully obtained patient histories, the PTT and PT tests are sometimes selectively performed as pre-surgical procedures to screen for potential bleeding tendencies. Other testing that may be done along with a PTT includes:

Platelet counts should always be monitored during heparin therapy to promptly detect any heparin-inducedthrombocytopenia

Thrombin time testing sometimes ordered to help rule out heparin contamination Fibrinogen testing may be done to rule out hypofibrinogenemia as a cause of PTT prolongation ^ Back to top

When is it ordered?
The PTT may be ordered along with other tests such as a PT when a person presents with unexplained bleeding or bruising, a thromboembolism, an acute condition such as disseminated intravascular coagulation (DIC) that may cause both bleeding and clotting as factors are used up at a rapid rate, or with a chronic condition such as liver disease. When someone has had a thrombotic episode or recurrent miscarriages, the PTT may be ordered as part of an evaluation forlupus anticoagulant or anticardiolipin antibodies. When a person is on intravenous (IV) or injection heparin therapy, the PTT is often ordered at regular intervals to monitor the degree of anticoagulation. When someone is switched from

heparin therapy to longer-term warfarin (COUMADIN) therapy, the two are overlapped and both the PTT and PT are monitored until the person has stabilized. A PTT may be ordered as part of a pre-surgical evaluation for bleeding tendencies, especially if the surgery carries an increased risk of blood loss and/or if the person has a clinical history of bleeding, such as frequent or excessive nosebleeds and easy bruising, which may indicate the presence of a clotting disorder. ^ Back to top

What does the test result mean?

PTT results that fall within the reference interval as established by each laboratory usually indicate normal clotting function; however, mild to moderate deficiencies of a single coagulation factor may still exist. The PTT may not be prolonged until the factor levels have decreased to 30% to 40% of normal. Also lupus anticoagulant may be present but may not prolong the PTT result. If the lupus anticoagulant (LA) is suspected, an LA-sensitive PTT or a Dilute Russell Viper Venom Time can be used to test for it. A prolonged PTT means that clotting is taking longer to occur than expected and may be due to a variety of causes. Often, this suggests that there may be a coagulation factor deficiency or a specific or nonspecific inhibitor affecting the body's clotting ability. Coagulation factor deficiencies may be acquired or inherited. Prolonged PTT tests may be due to:

Inherited or acquired factor deficiencies. Prolonged PTTs due to a factor deficiency usually "correct" after being mixed with pooled normal plasma. The PTT may be prolonged in von Willebrand disease, the most common, inheritedbleeding disorder, which affects platelet function due to decreased von Willebrand factor. Hemophilia A and Hemophilia B (Christmas disease) are two other inherited bleeding disorders resulting from a decrease in factors VIII and IX, respectively. Deficiencies of other coagulation factors are rare but may also adversely impact PTT results. An example of an acquired deficiency is one due to lack of vitamin K. Vitamin K, found in various leafy green vegetables and produced by certain gastrointestinal bacteria, is a key component to proper blood coagulation. Vitamin K deficiencies are rare but can occur due to an extremely poor diet, malabsorption disorders, or prolonged use of certain antibiotics. Most coagulation factors, including the vitamin K-dependent ones, are manufactured by the

liver, thus liver disease may cause prolonged PT and PTT. With liver disease and vitamin K deficiency, PT is more likely to be prolonged than is PTT.

A nonspecific inhibitor. Nonspecific inhibitors, such as the lupus anticoagulant (LA) and cardiolipin antibodies, bind to chemicals called phospholipids found on the surface of platelets. Since phospholipids assist in the clotting process, and since the PTT test reagents contain phospholipids, such antibodies may prolong the PTT, suggesting a bleeding problem. In fact, the presence of these inhibitors is usually associated with thrombosis instead of bleeding in the body. If the lupus anticoagulant does prolong the PTT or LA sensitive PTT, it will not correct with normal plasma mixing, but it will usually correct if an excess of phospholipid is added to the sample. The Dilute Russell Viper Venom Time (dRVVT) is more sensitive than the PTT in detecting lupus anticoagulants.

A specific inhibitor. Although relatively rare, these are antibodies that specifically target certain coagulation factors, such as Factor VIII antibodies. They may develop in someone with a bleeding disorder who is receiving factor replacements (such as Factor VIII, which is used to treat hemophilia A) or spontaneously as an autoantibody. The specific inhibitor will prolong the PTT and it will not correct with mixing studies. Factor-specific inhibitors can cause severe bleeding.

Heparin. Will prolong a PTT, either as a contaminant of the sample or as part of anticoagulation therapy. For anticoagulant therapy, the target PTT is often about 1.5 to 2.5 times longer than a person's pretreatment level.

Warfarin (COUMADIN) anticoagulation therapy. The PTT is not used to monitor warfarin therapy, but it may be affected by it. Typically, the PT is used to monitor warfarin therapy.

Prolonged PTT levels may also be seen with leukemia, excessive bleeding in pregnant women prior to or after giving birth, or recurrent miscarriages.

Results of the PTT are often interpreted with that of the PT in determining what condition may be present.

Interpretation of PT and PTT in Patients with a Bleeding or Clotting Syndrome

PT RESULT

PTT RESULT

COMMON CONDITION PRESENT

PT RESULT
Prolonged

PTT RESULT

COMMON CONDITION PRESENT

Normal

Liver disease, decreased vitamin K, decreased or defective factor VII

Normal

Prolonged

Decreased or defective factor VIII, IX, or XI, von Willebrand disease, or lupus anticoagulant present

Prolonged Prolonged

Decreased or defective factor I, II, V or X, severe liver disease, disseminated intravascular coagulation (DIC)

Normal

Normal or slightly prolonged

May indicate normal hemostasis; however PT and PTT can be normal in conditions such as mild deficiencies in other factors and mild form of von Willebrand disease. Further testing may be required to diagnose these conditions.

A shortened PTT may result when coagulation factor VIII is elevated. This may occur during an acute phase reaction, a condition causing pronounced tissue inflammation or trauma. This is usually a temporary change that is not monitored with a PTT test. When the condition causing the acute phase reaction is resolved, the PTT will return to normal. ^ Back to top

Is there anything else I should know?

Two anticoagulants often used, low molecular weight heparin (LMWH) and danaparoid, may not prolong the PTT and, if indicated, should be monitored using the heparin anti-factor Xa assay. Several factors can affect results of a PTT and the interpretation of test results:

Insufficient sample there must be enough blood collected. The anticoagulant-to-blood ratio must be 9:1 in the collection tube.

People with high hematocrit levels may have prolonged PTTs. Heparin contamination this is the most common problem, especially when blood is collected from intravenous lines that are being kept "open" with heparin washes.

Clotted blood samples the clotting process uses up some of the factors. People should avoid high-fat meals prior to having their blood drawn for a PTT.

In some cases, heparin can unintentionally decrease a person's platelet count in a complication called heparin-induced thrombocytopenia. When this occurs, substitute anticoagulants such as hirudin or argatroban may be given. The PTT test is also used to monitor these therapies. It does not directly measure the anticoagulants used but measures their effect on blood clotting.

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