From: Elizabeth M. Van Cott, M.D., and Michael Laposata, M.D., Ph.D., "Coagulation." In: Jacobs DS et al, ed. The Laboratory Test Handbook, 5th Edition. Lexi-Comp, Cleveland, 2001; 327-358.
Index of Tests
Activated Partial Thromboplastin Time [CO003400]
Synonyms APTT; aPTT; Partial Thromboplastin Time; PTT
Applies to Argatroban; Common Pathway; Extrinsic Pathway;
Heparin; Heparin Resistance; High Molecular Weight Kininogen; Hirudin;
Intrinsic Pathway; Prekallikrein
Abstract The activated partial thromboplastin time (PTT)
measures the clotting time from the activation of factor XII, through
the formation of fibrin clot (see figure). This measures the integrity
of the intrinsic and common pathways of coagulation, whereas the
prothrombin time (PT) measures the integrity of the extrinsic and
common pathways of coagulation. PTT prolongations are caused by
either factor deficiencies (especially of factors VIII, IX, XI,
and/or XII), or inhibitors (most commonly, lupus anticoagulants,
or therapeutic anticoagulants such as heparin, hirudin, or argatroban).
(SEE GRAPHIC IN BOOK)
Container One blue top (citrate) tube; 3.2% citrate tubes
are now recommended instead of 3.8% citrate tubes.1
Sampling Time See Additional Information for sampling times
with the various anticoagulant therapies.
Collection Routine venipuncture. If multiple tests are being
drawn, draw blue top tubes after any red top tubes but before any
lavender top (EDTA), green top (heparin), or gray top (oxalate/fluoride)
tubes. Recent data suggest that an initial discard tube is not necessary.2 Immediately invert tube gently at least 4 times to mix. Tubes must
be appropriately filled. Deliver tubes immediately to the laboratory,
otherwise factor VIII may degrade thereby falsely raising the PTT,
or falsely low values may occur in heparinized samples as platelets
release platelet factor 4 (PF4) which neutralizes heparin.
Specimens drawn from a heparinized line are easily contaminated
with heparin, even when the initial volume drawn is discarded. Therefore,
coagulation tests are best drawn directly from a peripheral vein,
avoiding the arm in which heparin, hirudin, or argatroban is being
infused (if relevant).
Storage Instructions Separate plasma from cells as soon as
possible, preferably within 1 hour if the PTT is used to monitor
heparin, otherwise, PF4 released from platelets neutralizes heparin
and can falsely lower the PTT value. To minimize the amount of PF4
in specimens, laboratories should ensure that the plasma contains
<10 x 109/L platelets. With or without heparin, plasma
may be stored on ice for up to 4 hours, otherwise, store frozen.
Causes for Rejection Specimen received more than 4 hours
after collection, tubes not filled, clotted specimens, visible hemolysis
Turnaround Time Less than 1 day; often less than 1 hour if
requested stat. The PT and PTT are the most readily available coagulation
Reference Interval Varies significantly among different reagent-instrument
combinations. The approximate lower limit of normal is 20-25 seconds;
the approximate upper limit of normal is 32-39 seconds. Newborns
normally have prolonged PTTs in comparison with adults. The PTT
is up to 55 seconds at birth, and the PTT gradually decreases into
the adult normal range by the age of 6 months.3 However,
newborns and infants do not normally experience bleeding, because
a balance between procoagulants and natural anticoagulants is maintained.
Critical Values >100-150 seconds (varies depending on
reagent-instrument combination and laboratory policies)
Use To screen the integrity of the intrinsic pathway of coagulation
(factors VIII, IX, XI, and XII) and to a lesser extent the common
pathway (fibrinogen and factors II, V, and X). May detect lupus
anticoagulants, but the PTT should not be used to screen for lupus
anticoagulants because the PTT may or may not be prolonged (depending
on the reagents). Also used to monitor therapeutic heparin, hirudin,
or argatroban anticoagulation.
Limitations With single factor deficiencies, the deficient
factor has to be below 15% to 45% before the PTT becomes prolonged,
depending on the reagent and the deficient factor. The PTT is more
sensitive to intrinsic pathway factor deficiencies than to common
pathway factor deficiencies. With multiple factor deficiencies,
the PTT becomes prolonged with less severe decreases in factor levels.4 Factor VIII elevations shorten the PTT. Factor VIII elevations are
common because they occur during acute phase reactions.
Factors VII and XIII do not affect the PTT. The PT can screen for
factor VII (and common pathway factor) deficiencies and a specific
factor XIII assay can screen for factor XIII deficiencies.
Lupus anticoagulants and deficiencies of certain factors (eg, factor
XII) may prolong the baseline PTT and/or accentuate the prolongation
of the PTT when heparin is added. Therefore, in these situations,
an alternative assay, such as the Heparin
Antifactor Xa Assay, should be used rather than the PTT to monitor
heparin. If the heparin anti-Xa assay demonstrates that the heparinized
PTT is not affected by the lupus anticoagulant, cautious use of
the PTT may be considered in that patient.
With very high doses of heparin, as used in cardiac bypass surgery,
the PTT is unclottable (>150 seconds) and therefore not useful.
The activated coagulation time (ACT) is typically used instead in
Methodology PTT reagent (phospholipid with an intrinsic pathway
activator such as silica, celite, kaolin, ellagic acid) and calcium
are added to patient plasma, and the time until clot formation is
measured in seconds. Phospholipid in the PTT assay is called "partial
thromboplastin" because tissue factor is not present. Tissue factor
is present with phospholipid in (complete) thromboplastin reagents
that are used for PT assays. Tissue factor activates the extrinsic
pathway of coagulation, which is not measured in PTT assays. Phospholipid
and calcium are required cofactors in the coagulation cascade. Citrate
in the blue top tube prevents clotting by chelating calcium. When
the PTT test is ready to be performed, excess calcium is added to
More recently point-of-care PTT test methods have become available
which use a single drop of whole blood, and these methods are undergoing
Additional Information To determine the etiology of an unexplained
PTT prolongation, the first step is usually to determine if heparin
contamination is the cause (see Heparin
Neutralization). If this demonstrates that heparin is not present,
a mixing study is usually the next step (see Mixing
Studies). Mixing studies can predict whether the cause of the
PTT prolongation is a factor deficiency or an inhibitor.
Factor deficiencies that prolong PTT: The PTT is more sensitive
to deficiencies of the intrinsic pathway (factors VIII, IX, XI,
XII, prekallikrein, HMWK) than it is to deficiencies of the common
pathway (fibrinogen, and factors II, V, and X). If a mixing study
suggests a factor deficiency, assays for factors VIII, IX, XI, and
XII can be performed. If the PT is also prolonged, assays for fibrinogen
and factors II, V, VII, and X can also be performed. Prekallikrein
and HMWK are often not assayed because deficiencies of these two
factors are rare and do not cause bleeding, despite causing a prolonged
PTT. Factor XII deficiencies also do not cause bleeding, but factor
XII deficiencies are relatively common. If the factor assays are
all normal, lupus anticoagulant tests can be considered, because
occasionally the mixing study will not detect the presence of a
The effects of hereditary or acquired factor deficiencies on PT
and PTT are shown in Tables 1 and 2 in Coagulation
Inhibitors that prolong PTT: Inhibitors are usually antibodies
(lupus anticoagulants or specific factor inhibitors) or anticoagulants
such as heparin, hirudin, or argatroban. Lupus anticoagulants bind
to phospholipid and interfere with phospholipid's role as an essential
cofactor in the coagulation cascade, thereby prolonging various
clotting times such as the PTT. Despite the PTT prolongation, lupus
anticoagulants are associated with thrombosis rather than bleeding.
Specific factor inhibitors are antibodies directed against a specific
coagulation factor, such as a factor VIII inhibitor. PTT mixing
studies have a characteristic pattern when a factor VIII inhibitor
is present. In such cases, factor VIII inhibitor tests should be
performed (see Mixing Studies and Factor Inhibitors). When
a PTT mixing study suggests the presence of an inhibitor other than
a factor VIII inhibitor, lupus anticoagulant tests may be performed,
as lupus anticoagulants are by far the most common inhibitor. If
the lupus anticoagulant tests are negative, factor assays may be
performed as described above. If one factor is significantly decreased,
specific factor inhibitor assays may be performed to determine if
there is an inhibitor against that factor (see Factor Inhibitors).
Specific factor inhibitors are rare.
Acquired causes of PTT prolongations are much more common than
hereditary causes, especially among inpatients (see following list).
The liver synthesizes all of the coagulation factors. Therefore,
with liver disease, multiple factor deficiencies can develop which
prolong the PT earlier and more than the PTT. Coumadin® or vitamin
K deficiency impairs the function of factors II, VII, IX, and X,
leading to PT and eventually PTT prolongations. In disseminated
intravascular coagulation (DIC), multiple factor deficiencies may
arise due to activation and consumption of factors, prolonging the
PT more often than the PTT.6 Heparin inhibits activated
factors II, X, IX, XI, XII, and kallikrein by enhancing antithrombin
activity. Hirudin and argatroban inhibit only activated factor II
Causes of PTT Prolongations
* Deficiency of factor VIII, IX, XI, XII, prekallikrein,
or HMWK (PT is normal)
* Deficiency of fibrinogen or factor II, V, or X (PT is
* Lupus anticoagulants (PT usually normal)
* Heparin (PT less affected than PTT, PT may be normal)
* Hirudin or argatroban (PT usually also prolonged)
* Liver dysfunction (PT affected earlier and more than
* Vitamin K deficiency (PT affected earlier and more than
* Coumadin®(PT affected earlier and more than PTT)
* Disseminated intravascular coagulation (DIC) (PT affected
earlier and more than PTT)
* Specific factor inhibitors (PT normal except in the
rare cases of an inhibitor against fibrinogen, factor II,
V, or X)
Monitoring heparin: Low-dose, subcutaneous, prophylactic
unfractionated heparin (eg, 5000 units two or three times daily)
is typically not monitored with coagulation tests. Platelet counts
should be followed to ensure that if heparin-induced thrombocytopenia
develops, the diagnosis will be made promptly. These low levels
of unfractionated heparin usually do not affect the PTT. Full-dose,
therapeutic levels of unfractionated heparin should be monitored,
and the platelet count also followed. The PTT is the most commonly
used assay for unfractionated heparin monitoring because it is inexpensive,
automated, and usually available 24 hours a day. The therapeutic
range is the PTT range that corresponds to an antifactor Xa level
of 0.3-0.7 units/mL. Each laboratory determines its own therapeutic
range, but it is often a PTT range that is about 1.5-2.5 times the
mean of normal PTT. Therapeutic levels of heparin are most often
administered as an initial intravenous bolus followed by a continuous
intravenous infusion. The PTT is measured every 6 hours during the
first day of unfractionated heparin therapy and 6 hours after any
dosage change. If the PTT is therapeutic, it can be checked once
daily while patients are on heparin. A less common approach is to
administer therapeutic unfractionated heparin doses subcutaneously
twice daily, drawing the PTT 6 hours after injection.7,8 Peak levels are reached 2-4 hours after subcutaneous injection,
although this is variable. If patients on unfractionated heparin
are started on Coumadin,® heparin is continued until the INR
is therapeutic for 2 days. With some PT reagents, heparin can prolong
the PT (and therefore the INR) to some extent. Conversely, the PTT
can be prolonged somewhat by Coumadin.® Low-molecular weight
heparin (LMWH) usually does not significantly prolong the PTT, therefore,
the PTT is not used to monitor LMWH. Antifactor Xa assays can be
used to monitor LMWH, when indicated.
Heparin resistance is a condition in which the PTT does
not prolong as much as expected despite high doses of heparin. This
is commonly due to an acute phase reaction, because many acute phase
reactant proteins bind and neutralize heparin. Additionally, factor
VIII becomes elevated during acute phase reactions, which shorten
the PTT. Rarely, heparin resistance is due to antithrombin deficiency.
Mild decreases of antithrombin commonly occur as a result of heparin
therapy, but mild decreases do not cause significant heparin resistance.
Thus, if a patient has heparin resistance, indices of an acute phase
reaction may be ordered (eg, fibrinogen, factor VIII), and a heparin
assay (antifactor Xa assay) may be helpful.
Monitoring hirudin (lepirudin, RefludanTM): Hirudin
is a direct thrombin inhibitor that is commonly used as an anticoagulant
for the treatment of thrombosis in patients with heparin-induced
thrombocytopenia. Hirudin treatment should be monitored with the
PTT. The usual therapeutic dose of hirudin in patients with normal
kidney function is 0.4 mg/kg intravenous bolus followed by 0.15
mg/kg/hour continuous intravenous infusion. The dose has to be significantly
reduced when the creatinine is >1.6 mg/dL. The PTT is performed
4 hours after starting hirudin and 4 hours after any dosage change.
If the PTT is in the desired therapeutic range (1.5-2.5 times mean
of normal PTT), the PTT can be checked once daily while on hirudin. Note: See Coagulation Factor
Assays for the use of chromogenic factor X assays to monitor
Coumadin® in patients receiving hirudin or argatroban.
1. National Committee for Clinical Laboratory Standards (NCCLS),
"Collection, Transport, and Processing of Blood Specimens for Coagulation
Testing and General Performance of Coagulation Assays: Approved
Guideline 3rd edition," NCCLS document H21-A3, NCCLS, 940 West Valley
Road, Wayne, Pennsylvania 19087, USA, 1998.
2. Gottfried EL and Adachi MM, "Prothrombin Time and Activated
Partial Thromboplastin Time Can Be Performed on the First Tube,"Am
J Clin Pathol, 1997, 107(6):681-3.
3. Andrew M, Paes B, and Johnston M, "Development of the Hemostatic
System in the Neonate and Young Infant,"Am J Pediatr Hematol
Oncol, 1990, 12(1)95-104.
4. Burns ER, Goldberg SN, and Wenz B, "Paradoxic Effect of Multiple
Mild Coagulation Factor Deficiencies on the Prothrombin Time and
Activated Partial Thromboplastin Time,"Am J Clin Pathol,
5. Solomon HM, Mullins RE, Lyden P, et al, "The Diagnostic Accuracy
of Bedside and Laboratory Coagulation: Procedures Used to Monitor
the Anticoagulation Status of Patients Treated With Heparin,"Am
J Clin Pathol, 1998, 109(4):371-8.
6. Spero JA, Lewis JH, and Hasiba U, "Disseminated Intravascular
Coagulation: Findings in 346 Patients,"Thromb Haemost, 1980,
7. Prandoni P, Bagatella P, Bernardi E, et al, "Use of an Algorithm
for Administering Subcutaneous Heparin in the Treatment of Deep
Venous Thrombosis,"Ann Intern Med, 1998, 129(4):299-302.
8. Kearon C, Harrison L, Crowther M, et al, "Optimal Dosing of
Subcutaneous Unfractionated Heparin for the Treatment of Deep Vein
Thrombosis,"Thromb Res, 2000, 97(6):395-403.
Bajaj SP and Joist JH, "New Insights Into How Blood Clots: Implications
for the Use of APTT and PT as Coagulation Screening Tests and in
Monitoring of Anticoagulant Therapy,"Semin Thromb Hemost,
Hyers TM, Agnelli G, Hull RD, et al, "Antithrombotic Therapy for
Venous Thrombotic Disease,"Chest, 1998, 114(5 Suppl):561S-78S.
Laposata M, Green D, Van Cott EM et al, "College of American Pathologists
Conference XXXI on Laboratory Monitoring of Anticoagulant Therapy.
The Clinical Use and Laboratory Monitoring of Low-Molecular Weight
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Pathol Lab Med, 1998, 122(9):799-807.
Olson JD, Arkin CF, Brandt JT, et al, "College of American Pathologists
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