Diagnosis of hemostatic system disorders in patients with chronic heart failure using classical and integral methods

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BACKGROUND

Chronic heart failure (CHF) develops as a result of impaired filling and/or emptying ability of the heart. This occurs under conditions of imbalance of vasoconstrictor and vasodilating neurohormonal systems, accompanied by insufficient perfusion of organs and tissues [1]. CHF is the most urgent socio-economic problem and one of the main issues in clinical medicine [2, 3].

Studies on the functional state of the hemostasis system in patients with CHF are limited, and most of these studies date back to the early 2000s. These studies considered platelet properties, endothelial factors, coagulogram parameters, level of thrombosis risk, and bleeding in patients with CHF. Moreover, studies on platelet properties reported that platelet aggregation is increased in CHF patients [5–8]. In the studies by Shmeleva and Malchevsky, the values of screening indicators of the coagulogram did not deviate from the reference values [9, 10]. Moreover, in a study by Medvedeva, certain coagulogram parameters (i.e., prothrombin index [PTI], international normalized ratio [INR]) exhibited hypocoagulation, whereas other parameters (e.g., activated partial thromboplastin time, APTT) and Quick’s prothrombin test demonstrated hypercoagulability [11]. The study of endothelial factors affecting hemostasis in patients with CHF demonstrated that nitric oxide synthesis inhibition is a viable mechanism. Furthermore, in patients exhibiting CHF symptoms, the von Willebrand factor expression was increased, indicating a reduction in anticoagulant properties of the endothelium in these patients [12–14]. The findings of these studies show that the hemostatic potential in patients with CHF may be inclined towards hypercoagulation. However, studies on thrombosis and bleeding risks in these patients did not provide definitive insights for understanding of the problem. Thrombosis and bleeding risks increased approximately equally and correlated with disease severity [15–19]. Furthermore, attempts to use direct oral anticoagulants to prevent venous thromboembolic complications in patients with CHF significantly increased hemorrhagic risks [20]. Hence, more sensitive methods should be used to study the hemostasis system in patients with CHF. Recent studies have shown that low-frequency piezoelectric thromboelastography (LFPTEG) can be used for the integral analysis of the hemostasis system, which allows a cumulative assessment of the interaction of all links of hemostasis [21].

This study is relevant owing to the need for frequent prescription of antiaggregant and anticoagulant therapy for coronary heart disease (CHD) in 60 % of patients with CHF [4] and atrial fibrillation (AF) in 40 % [22].

This study aimed to evaluate the state of hemostasis system in patients with CHF by classical (coagulogram) and integral (LEPTEG) methods.

MATERIALS AND METHODS

Study design

Two main groups of patients were recruited: group 1 with CHF stage I–IIa (30 patients) and group 2 with CHF stage IIb–III (60 patients). The control group included healthy individuals (30 patients without CHF).

The mean age of the patients with CHF was 70 years, and that of controls was 68 years. Among the patients with CHF, 26 had hypertension, 16 had CHD, and 48 had a combination of hypertension and CHD. AF was noted in 43 patients, 11 of whom were in sinus rhythm at the time of the study.

The study included patients who, for one reason or another, had not taken anticoagulant and antiaggregant therapy for at least 10 days prior to hospitalization (commonly because of poor compliance) to exclude the effect on the hemostasis system. At least a day after admission, patients were rigorously screened before administration of antiaggregant and anticoagulant therapy.

Eligibility criteria

Inclusion criteria:

1. Age 50–75 years
2. Diagnosis of CHF confirmed by laboratory and instrumental studies
3. Presence of CHD, hypertension, or their combination (according to medical history and laboratory tests)

Exclusion criteria:

1. Acute coronary syndrome within 2 months prior to the examination
2. Coronavirus infection (or vaccination) within the last 6 months
3. Autoimmune diseases, cancer, acute inflammatory diseases, and chronic inflammatory diseases in acute stage
4. Chronic liver disease
5. Chronic pulmonary and bronchial diseases
6. Hereditary and acquired coagulopathies and thrombocytopathies and chronic hematologic diseases.

Setting

The study was conducted in 2021–2023 at the Vishnevsky Central Military Clinical Hospital of the Russian Ministry of Defense (Moscow Region, Novy Village) and Bauman State Clinical Hospital No. 29 of the Moscow City Health Department.

Study duration

The study lasted 36 months. Patients were enrolled upon admission to the hospital and followed throughout their stay.

Methods for recording outcomes

Verification of the diagnosis of CHF and assessment of the stage of the disease were based on complaints, data from the patient’s objective examination, laboratory data (e.g., NT-proBNP level), instrumental studies (e.g., ECHO-CG, ECG), and functional exercise tests (e.g., 6-minute walk test).

The hemostasis system was assessed by standard laboratory (i.e., INR, APTT, PTT, PTI, fibrinogen, D-dimer, antithrombin-III) and instrumental (i.e., LFPTEG) methods. LFPTEG allows for the comprehensive assessment of the hemostasis system, including the process of fibrinogenesis. In the present study, whole unstabilized blood was collected without the use of a tourniquet using a disposable three-component siliconized syringe with a volume of 1 ml. Subsequently, the obtained sample was positioned within a disposable cuvette of 0.45 ml (Mednord, Russia), situated within the thermostat of the MEDNORD hardware–software complex (piezoelectric thromboelastograph).

LFPTEG is a standardized test based on the observation of changes in the studied aliquot of whole, unstabilized venous blood during its transformation from a pre-gel (liquid) to a post-gel (solid-elastic) state. The kinetics of hemocoagulation is determined by changes in the aggregate state of the studied aliquot, as illustrated in the integrated curve shown in Figure 1. Each point (Аi) on the curve represents the state of the system at a specific time point (ti).

 

Fig. 1. Dynamics of the wound process in the study groups. A₀ is the initial amplitude value at time t₀, min; A₁ — max decrease in amplitude during time t₁ (reaction period), min.; t₂ — time to reach amplitude A₂ NPTEG, min; A₃ is the amplitude of the NPTEG at the gelation point, r.u.; A₄ is the value of the NPTEG amplitude 10 minutes after reaching the gelation point, r.u.; A₅ — maximum amplitude of NPTEG recorded for 10 min, r.u.; t₅ — time to reach the maximum amplitude of NPTEG (A₅) (time of formation of the fibrin-platelet structure of the clot), min; A₆ — value of the amplitude of the NPTEG 10 minutes after reaching the maximum amplitude, r.u.

 

Statistical analysis

The sample size was not pre-calculated.

Statistical analysis was performed using Microsoft Excel and Statistica 10.0. Based on the formalized examination maps, summary tables were generated in Microsoft Excel. The obtained variation series were subjected to a series of tests to ascertain their normality of distribution. These tests included the calculation of asymmetry and kurtosis and Shapiro–Wilk test. All data are presented as mean with standard error (M ± m) or median with 25 % and 75 % quartiles, depending on the normality of the distribution of random variables. The Mann–Whitney U test was used to examine the differences between groups. The differences were considered reliable at a significance level of p < 0.05.

Ethical review

On December 29, 2021, the Ethics Committee of Vishnevsky Central Military Clinical Hospital of the Russian Ministry of Defense approved the submitted documents and authorized the research involving human participants.

RESULTS

Comparison of platelet levels between patients with CHF and controls

In patients with CHF who were experiencing disease progression, no notable decline was observed in platelet levels. A significant difference was found between the groups under investigation (p < 0.05). A comparison of the studied groups with the control group revealed significant differences (p < 0.05), thereby confirming the relationship between an increase in the functional class of CHF and the degree of platelet count reduction (Fig. 2).

 

Fig. 2. Platelet count in patients with CHF and individuals in the control group

 

Coagulation parameters in patients with CHF and in controls

In patients with CHF, hypocoagulation tendency was noted in both studied groups, which was expressed as decreased prothrombin and antithrombin-III and increased INR, correlated with the severity of heart failure manifestations and statistical differences among themselves (p < 0.05) and with the control group (p < 0.05) (Fig. 3; Table 1).

 

Fig. 3. Prothrombin concentration in patients with CHF and individuals in the control group

 

Table 1. Coagulogram parameters (INR, antithrombin III) in patients with CHF and in the control group Таблица 1. Показатели коагулограммы (МНО, антитромбин III) у пациентов с ХСН и в контрольной группе
Indices (group)	Ме	Lower quartile	Upper quartile	р
INR in group 1	1.03	1.0	1.07	<0.05#*
INR in group 2	1.12	1.05	1.20	<0.05#*
INR in the control group	1.01	0.96	1.02	<0.05
Antithrombin-III in group 1	76.5	73	81	<0.05#*
Antithrombin-III in group 2	73	69	76	<0.05#*
Antithrombin-III in the control group	91	88	93	<0.05
Note: *, when comparing between groups 1 and 2; #, when comparing with the control group. Примечание. * — при сравнении между 1 и 2 группой; # — при сравнении с группой контроля.

 

The increase of indicators such as the prothrombin time and APTT was observed in the studied groups compared to the control group (p < 0.05); no differences were found between the studied groups (p > 0.05). Regarding fibrinogen and D-dimer levels, a difference was observed between group 2 and controls and group 1 (p < 0.05). No significant differences were found between group 1 and the control group (p > 0.05) (Table 2).

 

Table 2. Indicators of coagulogram and fibrinolysis system (Fibrinogen, PTT, APTT, D-Dimer) in patients with CHF and in the control group Таблица 2. Показатели коагулограммы и системы фибринолиза (фибриноген, ПТВ, АЧТВ, D-Димера) у пациентов с ХСН и в контрольной группе
Indices (group)	Ме	Lower quartile	Upper quartile	р
Fibrinogen in group 1	3.25	2.8	3.6	>0.05* <0.05#
Fibrinogen in group 2	3.4	3.05	3.7	>0.05#*
Fibrinogen in the control group	3.5	3.5	3.8	<0.05 >0.05
Prothrombin time in group 1	11.9	10.9	12.3	>0.05* <0.05#
Prothrombin time in group 2	12.1	11.25	12.8	>0.05* <0.05#
Prothrombin time in the control group	10.6	10.1	11	<0.05
APTT in group 1	29.6	26.2	32.3	>0.05* <0.05#
APTT in group 2	29	27.35	31.15	>0.05* <0.05#
APTT in the control group	27	26.4	27.8	<0.05
D-dimer in group 1	139	112	210	<0.05* >0.05#
D-dimer in group 2	284	222	432	<0.05#*
D-dimer in the control group	135	110	183	>0.05 <0.05
Note: *, when comparing between groups 1 and 2; #, when comparing with the control group. Примечание. * — при сравнении между 1 и 2 группой; # — при сравнении с группой контроля.

 

LEPTEG parameters in patients with CHF and in controls

In patients with CHF in both study groups, no differences were observed in some LFPTEG parameters compared to the control group and to each other (p > 0.05): T1 time (time from the beginning of the study to the attainment of the minimum amplitude of the LFPTEG curve), thrombin activity constant, contact phase coagulation intensity (characterizing the activity of the proliferation and amplification phases of fibrinogenesis); T3 time (transition from liquid state (sol) to elastic-solid state (gel)), T5 time (indicator evaluating the time of clot formation of maximum density), and clot lysis retraction intensity (indicator evaluating clot lysis) (Table 3).

 

Table 3. Indicators of low-frequency piezothromboelastography Таблица 3. Показатели НПТЭГ
Indices (group)	Ме	Q1	Q3	р
T1 time in group 1	0.85	0.1	1.2	>0.05#*
T1 time in group 2	0.9	0.3	1.55	>0.05#*
T1 time in the control group	0.75	0.1	1.3	>0.05
Contact phase coagulation intensity (CCI) in group 1	8.2	0.0	13.8	>0.05#*
CCI in group 2	8.4	2.9	19.45	>0.05#*
CCI) in the control group	4	0.0	20.0	>0.05
Thrombin activity constant (TAC) in group 1	43.6	33.3	66.7	>0.05* <0.05#
TAC in group 2	42.65	21.5	55.6	>0.05#*
TAC in the control group	32.8	27	40.0	<0.05 >0.05
T3 time in group 1	7.3	3.5	8.4	>0.05#*
T3 time in group 2	7.65	5.2	10.8	>0.05#*
T3 time in the control group	6.95	5.7	8.8	>0.05
T5 time in group 1	31.0	26.7	38.0	>0.05#*
T5 time in group 2	30.6	26.1	35.25	>0.05#*
T5 time in the control group	28.25	25.8	36.8	>0.05
Clot lysis retraction intensity (CLRI) in group 1	0.67	0.28	0.88	>0.05#*
CLRI in group 2	0.69	0.29	1.5	>0.05#*
CLRI in the control group	0.65	0.44	1.37	>0.05
Note: *, when comparing between groups 1 and 2; #, when comparing with the control group. Примечание. * — при сравнении между 1 и 2 группой; # — при сравнении с группой контроля.

 

However, the most crucial LFPTEG indicators for assessing the hemostasis system are clot polymerization intensity (CPI) and maximum amplitude (MA). CPI evaluates the polymerization stage of the hemocoagulation phase III and rate of cross-linked fibrin formation, whereas MA characterizes the maximum clot density resulting from platelet activity; the qualitative characteristics of cross-linked fibrin exhibited significant differences (p < 0.05) between the studied groups (groups 1 and 2) and control group. These differences were more pronounced when comparing group 2 to the control group (p < 0.01) (Figs. 4 and 5).

 

Fig. 4. The indicator of low-frequency piezothromboelastography is the intensity of clot polymerization (IPS)

 

Fig. 5. The indicator of low-frequency piezothromboelastography is maximum amplitude (MA)

 

A comparison of the coagulogram parameters to those of LFPTEG (Table 4) reveals that, despite significant differences between the groups, the coagulogram parameters do not exceed the reference values and thus are of minimal clinical significance.

 

Table 4. Comparison of coagulogram and NPTEG parameters Таблица 4. Сравнение показателей коагулограммы и НПТЭГ
Indices (reference values)	Groups
	Group 1 (median)	Group 2 (median)	Control group (median)
Coagulation indices
INR (0.8–1.2).	1.03	1.12	1.01
Prothrombin (70%–120%)	89	86	101
Prothrombin time (10–15 s)	11.9	12.1	10.6
APTT (25.4–36.9 s)	29.6	29	27
Fibrinogen (2.0–4.0 g/L)	3.25	3.4	3.5
Antithrombin-III (66%–124%)	76.5	73	91
D-dimer (<243 ng/mL)	139	284	135
LFPTEG indicators
CPI (15.4–22.5 RU)	12.25	10.75	14.5
MA (450–650 RU)	419	393	470
TCR (14–18.1 RU)	12.8	12.7	16

 

In turn, LFPTEG parameters exhibit significant differences between the groups, with values exceeding the reference range in patients with CHF. These deviations are more pronounced in patients with stage IIb–III of the disease. Therefore, the LFPTEG method can be regarded as a more sensitive diagnostic tool for hemostasis system disorders in patients with CHF.

Adverse events

No adverse events were noted.

DISCUSSION

In patients with CHF, changes in hemostasis system characterized by a hypocoagulation tendency are observed. This phenomenon is directly correlated with the CHF stage and affects the platelet and plasma components of the coagulation system. A reduction in platelet levels has been observed during CHF progression. This may be attributed to splenomegaly, which can lead to hypersplenism and stasis in the great circle of blood circulation [23]. Additionally, according to some studies, a possible cause of platelet count reduction may be a decrease in thrombopoietin production due to liver and kidney damage in patients with CHF [24].

Furthermore, the study on standard coagulogram parameters showed a hypocoagulation tendency in patients with CHF, apparently due to congestion in the systemic circulation, which leads to impaired hepatic microcirculation, involving the processes of hepatic fibrosis [25–27], and impaired synthesis of plasma coagulation factors.

In this case, the changes in the hemostatic system in patients with CHF are confirmed by an integral research method, namely, LFPTEG, which allows for the assessment of the patient’s hemostatic potential considering the interaction of all parts of the coagulation system. Indicators assessing clot density, rate of clot formation, and qualitative characteristics of cross-linked fibrin significantly change in the direction of decrease of hemostatic potential in patients transitioning to more severe stages of heart failure.

CONCLUSIONS

1. In patients with CHF, changes in the hemostasis system are evident, manifesting as hypocoagulation tendency.
2. Changes in the coagulation system are associated with disease severity and are most pronounced in patients with CHF stage IIb–III.
3. LFPTEG confirms hemostasis disorders detected by standard laboratory methods (e.g., platelet count, coagulogram indices) and may be considered a more sensitive method for use in clinical practice in patients with CHF.

ADDITIONAL INFORMATION

Funding source: No funding was provided for this study.

Conflict of interest: The authors declare that there are no obvious and potential conflicts of interest related to the publication of this article.

Ethical review: The study was approved by the Ethical Committee Vishnevsky Central Military Clinical Hospital of the Russian Ministry of Defense on December 29, 2021.

Authors’ contribution: M.A. Lebedev, primary collection of materials, analysis of scientific data, writing the text; M.B. Patsenko, author of the idea and objectives of the study; M.I. Pugachev, methodological control over the processing of scientific data, writing the text; Y.V. Ovchinnikov, concept and design of the study; L.I. Melnichenko, collection, systematization and analysis of scientific data; M.V. Palchenkova, collection and processing of materials, literature review, translation of foreign articles. All authors made a significant contribution to the research and preparation of the article and read and approved the final version before publication.

About the authors

Maxim A. Lebedev

Military Medical Academy

Author for correspondence.
Email: vmeda-nio@mail.ru
ORCID iD: 0000-0002-9536-6683
SPIN-code: 4775-9499
Russian Federation, Moscow

Mikhail B. Patsenko

Military Medical Academy

Email: vmeda-nio@mail.ru
ORCID iD: 0000-0001-8391-1691
SPIN-code: 5681-3603

MD, Cand. Sci. (Medicine), Associate Professor

Russian Federation, Moscow

Maxim I. Pugachev

Military Medical Academy

Email: vmeda-nio@mail.ru
ORCID iD: 0000-0001-5523-8233
SPIN-code: 1549-6552

MD, Cand. Sci. (Medicine)

Russian Federation, Moscow

Yury V. Ovchinnikov

Military Medical Academy; Industry Clinical Diagnostic Center of the Public Joint Stock Company “Gazprom”

Email: vmeda-nio@mail.ru
ORCID iD: 0000-0003-1843-087X
SPIN-code: 6965-6407

MD, Dr. Sci. (Medicine), Professor

Russian Federation, Moscow; Moscow

Larisa I. Melnichenko

N.E. Bauman City Clinical Hospital N. 29

Email: vmeda-nio@mail.ru
ORCID iD: 0009-0004-8275-9009

MD, Cardiologist

Russian Federation, Moscow

Marina V. Palchenkova

Military Medical Academy

Email: vmeda-nio@mail.ru
ORCID iD: 0000-0001-6885-9610
SPIN-code: 7567-9650

MD, Cand. Sci. (Medicine), Associate Professor

Russian Federation, Moscow

References

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