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History of the Prothrombin Time and Development of the INR
Leon Poller
European Concerted Action on Anticoagulation
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Mean results with different thromboplastins in 30 patients
Poller L. Acta Haemat. 32:292-298 (1964)
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Mean doses of warfarin from different geographical locations.
Striped boxes indicate rabbit reagent.
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Bleeding events with Simplastin (ISI 2.5) and Manchester Reagent (ISI 1.0) control.
Hull et al (1982). Prothrombin Ratio 2.0 Simplastin = 4.7 INR.
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Figure 1 Figure 2
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ACCP Consensus Meeting
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An example of the orthogonal regression line
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Calibration lines from the seventeen participant centres
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The hierarchical structure of thromboplastin calibration
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IRP = International Reference Preparation. *Now discontinued.
IRR = International Reference Reagent. IS = International Standard.
International reference preparations for thromboplastins 2003
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INR = Prothrombin Ratio (PR)ISI
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Causes of Erroneous INRs (1)
• Pretest variablesErroneous prothrombin ratio determination
Variations in manual techniqueCoagulometer effects
• Incorrect normal value due to: Failure to use MNPT Error in MNPT due to: (a) unrepresentative selection; (b) technical faults; (c) non-use of geometric mean.
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Causes of Erroneous INRs (2)
• Incorrect ISI calibration • Drift of ISI • Poor distribution of coumarin test samples,
inadequate numbers of test samples• Incorrect choice of IRP • Incorrect transformation of PR to INR
• ‘Rogue’ plasmas (outliers)
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Errors in PT Determination • Pretest variables • blood collection • citrate • container • storage time • temperature • evacuated and non-evaculated tubes • variations in manual technique • coagulometers The overall trend of coagulometers is to accelerate the normal PT
with the PR distorted.System-related ISI of limited value.
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Coagulometer Effects of ACL and MLA
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The ISI of thromboplastins and effect of ISI on the width of therapeutic range in prothrombin ratios.
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Percentage deviation of mean INR from the IRP value with various thromboplastin reagents during the
induction phase
Reagent C
Reagent B
Reagent A
Reagent D
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Reliability of monitor INR on CoaguChek Mini and TAS PT-NC at 10
centres
No. of samples
Displayed INR
“true” INR
% difference
Mean displayed
INR difference
TAS PT-NC 536 2.91 2.52 +15.2
21.3
CoaguChek Mini
536 2.40 2.59 -7.1
Br Med J 2003;327:30-34
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DAILY TELEGRAPH 23 SEPTEMBER 2003
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Proportion of time in INR ranges
*INR results for all weeks, including first 3 weeks
Lancet 1998;352:1505-9