From the Guidelines
High PT and high PTT indicate a potential bleeding risk, and immediate medical evaluation is necessary to determine the underlying cause and appropriate treatment. The combination of high PT and high PTT suggests a deficiency in multiple coagulation factors or the presence of anticoagulant medications, which can increase the risk of bleeding 1. Common causes of these abnormalities include liver disease, vitamin K deficiency, disseminated intravascular coagulation (DIC), or anticoagulant therapy with medications like warfarin or heparin.
Key Considerations
- The presence of high PT and high PTT does not necessarily predict bleeding, as patients with liver disease may be in a 'rebalanced' haemostatic state 1.
- Treatment depends on the underlying cause and may include vitamin K supplementation, fresh frozen plasma, or adjusting anticoagulant dosages if medication-induced.
- Patients should avoid activities with high bleeding risk, limit alcohol consumption, and ensure adequate intake of vitamin K through leafy greens.
Management Approach
- For patients with ongoing bleeding and/or hemodynamic instability, local measures to control bleeding and volume resuscitation with intravenous isotonic crystalloids are recommended 1.
- Supportive measures should include blood product transfusion when appropriate, with a restrictive transfusion strategy to improve survival and reduce the risk of recurrent bleeding 1.
- The goal of treatment should be to restore hemodynamic stability and correct any underlying coagulopathy, while also addressing the underlying cause of the high PT and high PTT.
Important Laboratory Tests
- PT and PTT are essential laboratory tests to evaluate the coagulation pathways, with prolonged PT suggesting on-therapy or above on-therapy levels of anticoagulants, and prolonged PTT suggesting the same 1.
- However, normal PT and PTT do not exclude on-therapy levels, particularly if relatively insensitive reagents are used 1.
From the FDA Drug Label
Warfarin sodium tablets may increase the activated partial thromboplastin time (aPTT) test, even in the absence of heparin A severe elevation (>50 seconds) in activated partial thromboplastin time (aPTT) with a PT/INR in the desired range has been identified as an indication of increased risk of postoperative hemorrhage.
High PT and high PTT may be associated with an increased risk of bleeding, especially if the PTT is severely elevated (>50 seconds) even if the PT/INR is within the desired range.
- Key points:
- Warfarin can increase PTT even without heparin.
- Severe elevation of PTT (>50 seconds) may indicate increased risk of hemorrhage.
- Monitoring of PT/INR and PTT is crucial in patients on warfarin therapy 2.
From the Research
High PT and High PTT
- High PT (Prothrombin Time) and high PTT (Partial Thromboplastin Time) can be indicative of bleeding disorders or anticoagulant therapy 3.
- Patients on anticoagulants, such as warfarin, may experience bleeding complications, and the management of these complications depends on the severity of the bleed and the patient's overall health 3.
- The reversal of anticoagulation can be achieved through various methods, including the use of vitamin K, fresh frozen plasma (FFP), or prothrombin complex concentrates (PCC) 3, 4, 5.
Reversal of Anticoagulation
- Vitamin K can reverse the effects of warfarin within 24 to 48 hours, but it may not be sufficient in cases of major bleeding 3.
- FFP and PCC are commonly used for urgent warfarin reversal, with PCC being associated with a significant reduction in all-cause mortality and more rapid INR reduction compared to FFP 4, 5.
- However, the use of PCC has been linked to a higher risk of thromboembolic events compared to FFP in some studies 6.
Management of Bleeding
- The management of bleeding in patients on anticoagulants requires a multidisciplinary approach, taking into account the patient's overall health, the severity of the bleed, and the need for urgent reversal of anticoagulation 3.
- The choice of reversal agent and the timing of administration depend on the specific clinical scenario and the availability of resources 3, 4, 5, 6.