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J Cardiol 2001 Dec; 38 6 : 327 335 % 1 1 1 2 2 3 4 Relationship Between Prothrombin Time International Normalized Ratio and Thrombo Test % Yuichi Yasuhiro Kenshiro Yutaka Tomio Hiroshi Hiroshi Takeshi NUMATA, MD OGATA, MD ARAO, MD MIZUMASA, MD 1 WAKITA, MD 1 HARUGUCHI, MD 1 ARAKI, MD 2 TSUJI, MD 2 Koshi MAWATARI, MD 3 Kazuyuki SHIMADA, MD, FJCC Abstract Objectives. The optimal therapeutic range for laboratory evaluation of oral anticoagulant therapy is now defined by the prothrombin time international normalized ratio PT-INR. However, the thrombo test TT, an alternative method to measure intensity of anticoagulation, is also currently used throughout Japan. The relationship between PT-INR and TT % has yet to be clarified. This study investigated the relationship between PT-INR and TT %. Methods. The PT-INR and TT % were simultaneously measured of 505 consecutive samples from patients treated with warfarin in our hospital. Fourteen functions were used for regression analyses: a fractional function Y a/x b, a square root function Y ax 0.5 b, a natural logarithmic function Y a lnx b, a power series function Y ax b, a quotient function Y ab X, and polynomial functions Y a n X n a n 1 X n 1 a 1 X 1 b, 1 n 9. The results were confirmed by the same methods in 383 samples and 296 samples from another two laboratories. Results. The power series function showed the most significant p 0.0001 and highest adjusted R 2 0.858 correlation, with a regression formula of TT % e 4.48 PT-INR 2.09 in our laboratory. Using the same analyses, the power series function also showed the most significant and highest adjusted R 2 in samples from the other two laboratories. Conclusions. This study showed that a power series function is the most appropriate for expressing the relationship between PT-INR and TT % among the 14 functions. The function between PT-INR and TT % is mainly derived from the relationship between TT % and TT sec. Both internal validity and external validity confirmed the relationship between PT-INR and TT %. J Cardiol 2001 Dec ; 38 6 : 327 335 Key Words Blood coagulation prothrombin time international normalized ratio, thrombo test Anticoagulants warfarin : 862 8520 2 1 1; 1 ; 2 ; 3 ; 4 Department of Cardiology, Japanese Red Cross Kumamoto Hospital, Kumamoto ; 1 Department of Cardiology, Taragi Municipal Hospital, Kumamoto ; 2 Department of Cardiology, Kamiamakusa General Hospital, Kumamoto ; 3 Department of Cardiology, Kagoshima Seikyo Hospital, Kagoshima ; 4 Department of Cardiology, Jichi Medical School, Tochigi Address for correspondence: NUMATA Y, MD, Department of Cardiology, Japanese Red Cross Kumamoto Hospital, Nagamineminami 2 1 1, Kumamoto, Kumamoto 862 8520 Manuscript received April 26, 2001; revised June 20 and September 12, 2001; accepted September 19, 2001 327

328 prothrombin time : PTthrombo test : TT World Health Organization WHOPT international sensitivity index : ISI international normalized ratio : INR 1,2 PT- INR 3 8 PT-INR 100 1 9 3 8 10 12 PT TT TT PT K TT protein induced by vitamin K antagonists or absence PIVKA TT PT TT 13 1999 PT 1,424 PT-INR 1,371 TT 1,072 TT INR 860 14 TT TT PT-INR TT PT-INR TT PT-INR TT % PT-INR PT-INR TT % TT % 2 PT-INR TT % 1 PT-INR TT 505 64 11 358 66 13147 63 11 PT-INR TT % S ISI 0.99 1.12 T ISI 0.87 0.96 TH CA-5000 TT % 5% TT % TT % 5% ISI 2 PT-INR TT % Y a/x b Y ax 0.5 by a lnx b Y ax b Y ab X 1 9 Y a n X n a n 1 X n 1 a 1 X 1 b 1 n 9 n : Y TT % J Cardiol 2001 Dec; 38 6 : 327 335

329 X PT-INR Stat View ver. 4.5 1 2 9 p 0.05 1 2 9 y Ax B X Y Y ax b TT % a PT-INR b ln TT % lna b ln PT-INR y ln TT % x ln PT-INR y bx lna x ln PT-INR y ln TT % b A lna B a e B TT % e PT-INR B A 3 2 PT-INR TT % 1383 PT-INR TT % C ISI 1.43 1.55 ISI 0.97 1.02 N CA-1000 2286 PT-INR TT % C ISI 1.43 1.55 CA TTO ISI 0.93 0.99 N CA-530 4 PT-INR TT % TT TT % TT % PT- INR PT TT TT TT-INR TT % TT TT-INR TT % PT TT PT-INR TT-INR PT % TT % 1 9 INR TT % Fig. 1 No. 4 Table 1 1 9 1 9 5 :TT % e 4.48 PT-INR 2.09 p : 0.858 1 2 J Cardiol 2001 Dec; 38 6 : 327 335

330 沼田 緒方 荒尾 ほか Fig. 1 Regression curves from the monomial and polynomial regression analyses of 505 samples from the Japanese Red Cross Kumamoto Hospital laboratory Each graph shows the correlation between PT-INR and TT %. Regression curves on graphs No. 1 No. 6 were derived from monomial regression analyses. The results of analyses were converted to a fractional function from graph No. 1, a square root function from No. 2, a natural logarithmic function from No. 3, a power series function from No. 4, and a quotient function from No. 5. Regression curves on No. 6 No. 14 were derived from monomial and polynomial regression analyses. TT thrombo test ; PT-INR prothrombin time international normalized ratio. J Cardiol 2001 Dec; 38 6 : 327 335

331 Table 1 Regression functions and adjusted R 2 derived from regression analyses using the 14 functions Japanese Red Cross Kumamoto Hospital, n 505 Functions Regression curves Y TT, X PT-INR p value Adjusted R 2 Fractional function Y 125.6/X 39.3 Square root function Y 88.4X 0.5 155.1 Natural logarithmic functiony 66.7 lnx 73.9 Power series function Y e 4.5 X 2.1 Quotient function Y e 5.1 e 0.9 X Monomial function Y 26.9X 86.3 Polynomial functions Y 10.7X 2 81.9X 146.5 Y 4.8X 3 56.5X 2 203.5X 239.2 Y 1.9X 4 29.2X 3 162.1X 2 384.0X 342.1 Y 0.8X 5 15.0X 4 108.7X 3 381.3X 2 658.2X 466.4 Y 0.1X 6 3.0X 5 31.9X 4 172.1X 3 505.4X 2 777.9X 510.7 Y 0.1X 7 2.1X 6 21.1X 5 118.9X 4 407.7X 3 863.5X 2 1060.0X 599.5 Y 0.1X 8 1.8X 7 21.1X 6 135.6X 5 526.8X 4 1285.0X 3 1972.0X 2 1810.4X 807.5 Y 0.04X 9 1.3X 8 17.6X 7 135.0X 6 637.7X 5 1926.6X 4 3745.2X 3 4593.0X 2 3343.4X 1182.2 0.749 0.556 0.639 0.858 0.757 0.458 0.657 0.751 0.776 0.783 0.783 0.783 0.782 0.782 Tables 2, 3 Table 4 TT TT-INR TT TT % TT TT % TT-INR PT TT INR % INR % 14 PT-INR TT % PT-INR TT % 14 PT-INR TT % 2 PT-INR TT % PT-INR TT % TT % PT-INR TT % PT-INR TT % PT-INR 15,16 1 1 PT-INR TT % X Y PT-INR TT % TT % PT-INR 0 1 TT % PT-INR Uetsuka 15 X Y TT % PT-INR TT % PT-INR J Cardiol 2001 Dec; 38 6 : 327 335

332 Table 2 Regression functions and adjusted R 2 derived from regression analyses using the 14 functions Kagoshima Seikyo Hospital, n 383 Functions Regression curves Y TT %, X PT-INR p value Adjusted R 2 Fractional function Square root function Y 98.1/X 33.3 Y X 0.5 122.8 Natural logarithmic functiony 53.0 lnx 54.6 Power series function Quotient function Monomial function Polynomial functions Y e 4.2 X 2.1 Y e 4.9 e 1.0 X Y 24.1X 69.1 Y 17.5X 2 99.8X 143.5 Y 14.1X 3 114.6X 2 303.9X 275.7 Y 10.4X 4 109.9X 3 427.7X 2 732.0X 482.0 Y 6.5X 5 86.1X 4 449.2X 3 1151.7X 2 1467.0X Y 5.3X 6 82.2X 5 518.1X 4 1712.4X 3 3143.6X 2 3070.8X 1280.4 Y 3.9X 7 69.8X 6 527.4X 5 2169.0X 4 5259.5X 3 7554.3X 2 6006.6X 2086.8 Y 2.6X 8 53.0X 7 468.2X 6 2323.3X 5 7081.7X 4 13597.8X 3 16120.8X 2 10873.5X 3257.0 Y 4.065X 9 89.8X 8 865.1X 7 4771.8X 6 16608.7X 5 37850.7X 4 56560.6X 3 53593.3X 2 29389.6X 7205.0 0.801 0.614 0.686 0.890 0.817 0.533 0.768 0.850 0.874 0.880 0.882 0.882 0.882 0.882 Table 3 Regression functions and adjusted R 2 derived from regression analyses using the 14 functions Taragi Municipal Hospital, n 296 Functions Regression curves Y TT %, X PT-INR p value Adjusted R 2 Fractional function Y 148.8/X 62.3 Square root function Y 109.8X 0.5 174.5 Natural logarithmic functiony 80.2 lnx 71.8 Power series function Y e 4.5 X 2.5 Quotient function Y e 5.4 e 1.2 X Monomial function Y 35.4X 93.7 Polynomial functions Y 23.1X 2 137.6X 192.6 Y 16.4X 3 146.9X 2 414.3X 379.2 Y 13.1X 4 155.5X 3 657.7X 2 1180.1X 777.4 Y 9.7X 5 142.9X 4 805.3X 3 2180.9X 2 2853.2X 1468.4 Y 8.0X 6 137.9X 5 952.7X 4 3398.7X 3 6612.1X 2 6683.3X 2778.6 Y 6.8X 7 432.4X 6 1069.3X 5 4669.1X 4 11921.5X 3 17842.0X 2 14557.7X 5047.4 Y 4.9X 8 109.0X 7 1026.7X 6 5389.6X 5 17259.3X 4 34566.6X 3 42379.2X 2 29201.1X 8733.8 Y 0.2X 9 8.4X 8 143.1X 7 1217.6X 6 6056.0X 5 18761.8X 4 36753.1X 3 44359.7X 2 30214.5X 8957.0 0.675 0.477 0.552 0.854 0.754 0.396 0.615 0.729 0.800 0.828 0.838 0.841 0.841 0.841 J Cardiol 2001 Dec; 38 6 : 327 335

333 Table 4 Relationships between TT sec and TT-INR, TT % and TT %, TT % and TT-INR, TT sec and PT sec, TT-INR and PT-INR, and TT % and PT % Japanese Red Cross Kumamoto Hospital Regression curves p value Adjusted R 2 PT prothrombin time. Other abbreviations as in Fig. 1. 0.990 0.960 0.959 0.949 0.917 0.816 1 TT % PT-INR PT-INR TT % TT TT TT % TT TT-INR TT- INR PT-INR 17 TT PT-INR TT % PT-INR TT % PT-INR TT TT % PT-INR TT % TT TT % TT % PT-INR 2 TT % PT-INR TT % PT-INR 0.859 PT- INR TT % 86% 14% TT-INR TT % 0.959 TT-INR TT % PT-INR TT % PT TT PT TT PT % TT % PT-INR TT-INR PT TT PT-INR TT-INR PT % TT % PT TT PT-INR TT-INR ISI PT % TT % PT-INR TT % TTTT % 2 3 % PT TTPT % TT % PT TT PT % TT % TT-INR TT ISI ISI J Cardiol 2001 Dec; 38 6 : 327 335

334 1 PT-INR TT % 14 PT-INR TT % TT % 4 TT % 2 PT-INR X TT % Y Y ax b PT- INR TT % PT-INR TT % PT-INR TT % TT % PT-INR TT % PT-INR TT % PT-INR TT % PT-INR : PT-INR TT PT- INR TT %PT-INR TT % : 505 PT-INR TT %PT-INR TT % 14 Y a/x b Y ax 0.5 b Y a lnx b Y ax b Y ab X 1 9 Y a n X n a n 1 X n 1 a 1 X 1 b 1 n 9 2 383 296 : PT-INR TT % 14 p 0.858 TT % e 4.48 PT-INR 2.09 2 : 14 PT-INR TT % TT % PT-INR TT % J Cardiol 2001 Dec; 38 6 : 327 335 J Cardiol 2001 Dec; 38 6 : 327 335

335 1 WHO Expert Committee on Biological Standardization : Thirty-third report. World Health Organ Tech Rep Ser 1983; 687: 1 184 2 International Committee for Standardization in Haematology/International Committee on Thrombosis and Haemostasis : ICSH/ICTH recommendations for reporting prothrombin time in oral anticoagulant control. Blut 1985 ; 50 : 185 187 3 Petersen P, Boysen G, Godtfredsen J, Andersen ED, Andersen B : Placebo-controlled, randomised trial of warfarin and aspirin for prevention of thromboembolic complications in chronic atrial fibrillation : The Copenhagen AFASAK study. Lancet 1989; : 175 179 4 Atrial Fibrillation Investigators: Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation : Analysis of pooled data from five randomized controlled trials. Arch Intern Med 1994; 154: 1449 1457 5 Connolly SJ, Laupacis A, Gent M, Roberts RS, Cairns JA, Joyner C : Canadian Atrial Fibrillation Anticoagulation CAFA Study. J Am Coll Cardiol 1991; 18 : 349 355 6 Stroke Prevention in Atrial Fibrillation Investigators : Stroke Prevention in Atrial Fibrillation Study : Final results. Circulation 1991; 84 :527 539 7 Stroke Prevention in Atrial Fibrillation Investigators : Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation : Stroke Prevention in Atrial Fibrillation Study. Lancet 1994; 343: 687 691 8 Stroke Prevention in Atrial Fibrillation Investigators : Adjusted-dose warfarin versus low-intensity, fixed-dose warfarin plus aspirin for high-risk patients with atrial fibrillation : Stroke Prevention in Atrial Fibrillation randomised clinical trial. Lancet 1996 ; 348: 633 638 9 Feinberg WM, Blackshear JL, Laupacis A, Kronmal R, Hart RG : Prevalence, age distribution, and gender of patients with atrial fibrillation: Analysis and implications. Arch Intern Med 1995; 155: 469 473 10 Sudlow M, Thomson R, Thwaites B, Rodgers H, Kenny RA: Prevalence of atrial fibrillation and eligibility for anticoagulants in the community. Lancet 1998 ; 352 : 1167 1171 11 Clinical Quality Improvement Network CQIN Investigators : Thromboembolic prophylaxis in 3575 hospitalized patients with atrial fibrillation. Can J Cardiol 1998 ; 14 : 695 702 12 Stafford RS, Singer DE : National patterns of warfarin use in atrial fibrillation. Arch Intern Med 1996; 156 : 2537 2541 13 Owren PA : Thrombotest a new method for controlling anticoagulant therapy. Lancet 1959; 7: 754 758 14 : : 1999; pp 471 560 15 Uetsuka Y, Hosoda S, Aosaki M, Iwade K, Koyanagi H, Ohki K, Hokari T, Inoue M, Akiyama E, Kitada M : Clinical significance of thrombotest and PT-INR in monitoring the oral anticoagulant therapy. Japanese Journal of Thrombosis and Hemostasis 1992 ; 3 : 123 130 in Jpn with Eng abstr 16 : 1994 ; 169 : 309 310 17 Uetsuka Y, Hosoda S, Kasanuki H, Aosaki M, Murasaki K, Ooki K, Inoue M, Akiyama E, Kitada M : Optimal therapeutic range for oral anticoagulants in Japanese patients with prosthetic heart valves: A preliminary report from a single institution using conversion from thrombotest to PT- INR. Heart Vessels 2000; 15 : 124 128 J Cardiol 2001 Dec; 38 6 : 327 335

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