From the Guidelines
An elevated TEG-CK angle, combined with increased cff-ma and cff-flev values, indicates hypercoagulability with excessive fibrinogen activity, and management should include anticoagulation therapy to prevent thrombotic events. This pattern suggests a patient is at increased risk for thrombotic events, as evidenced by the accelerated fibrin formation reflected by the elevated CK angle, and the excessive fibrinogen contribution to clot strength indicated by increased cff-ma and cff-flev values 1. The use of viscoelastic testing, such as TEG, in obstetrics has been reviewed and recommended by the Women's SSC of the ISTH, highlighting its importance in assessing coagulation status in high-risk patients 1.
Some key points to consider in the interpretation of these results include:
- The TEG-CK angle is a measure of the rate of fibrin formation, with elevated values indicating accelerated clotting 1.
- The cff-ma and cff-flev values provide information on the contribution of fibrinogen to clot strength, with increased values suggesting excessive fibrinogen activity 1.
- Hypercoagulability can occur in various conditions, including pregnancy, malignancy, inflammatory states, and post-surgical settings, and addressing the underlying cause is essential for preventing thrombotic complications 1.
In terms of management, anticoagulation therapy is typically recommended, with options including low molecular weight heparin (LMWH) such as enoxaparin 1mg/kg twice daily or unfractionated heparin with a target aPTT of 1.5-2.5 times normal 1. In cases of severe hypercoagulability, direct oral anticoagulants like rivaroxaban 20mg daily or apixaban 5mg twice daily may be considered. Close monitoring of the patient with repeat TEG testing every 24-48 hours is necessary to assess response to therapy and adjust treatment as needed.
From the Research
Interpretation of Elevated TEG-CK Angle and CFF-MA and CFF-FLEV
- An elevated TEG-CK angle and CFF-MA and CFF-FLEV may indicate hypercoagulability, as evidenced by a study on patients with chronic kidney disease and peripheral artery disease 2.
- The study found that patients with declining kidney function showed progressively higher values in CFF MA and CFF FLEV, suggesting a prothrombotic state.
- Another study on thromboelastography found that functional fibrinogen assay can indicate the contribution of fibrinogen to clot strength, and that fibrinogen is critical in correcting abnormal clot strength following trauma 3.
- The study suggested that fibrinogen should be addressed early in trauma patients manifesting acute coagulopathy of trauma.
- However, it is essential to consider the clinical context and other laboratory findings when interpreting these results, as the relationship between TEG parameters and clinical outcomes is complex 2, 4, 5, 6.
Clinical Implications
- Elevated TEG-CK angle and CFF-MA and CFF-FLEV may require careful consideration of anticoagulant therapy, as patients with hypercoagulability may be at increased risk of thrombotic events 4, 6.
- The choice of anticoagulant therapy should be guided by the patient's clinical condition, renal function, and other factors, such as the presence of bleeding or thrombotic complications 4, 6.
- Further studies are needed to fully understand the relationship between TEG parameters and clinical outcomes, and to develop evidence-based guidelines for the management of patients with hypercoagulability 2, 5.