ACT

The ACT test is used to monitor the effect of high dose heparin before, during, and shortly after surgeries that require intense anticoagulation measures, such as cardiac bypass surgery, cardiac angioplasty, and dialysis. It is ordered in situations where the PTT test is not clinically useful or takes too long. The ACT is sometimes used, along with the prothrombin time (PT) to help determine whether a bleeding episode is due to excessive anticoagulation or to depletion of coagulation factors.

The ACT is ordered after someone has received an initial dose (bolus) of heparin and before the start of an open heart surgery or other procedure that requires a high level of anticoagulation. During surgery, the ACT is measured at intervals to achieve and maintain a steady level of heparin anticoagulation. After surgery the ACT is monitored until the patient has stabilized and the heparin dosage has been reduced and/or neutralized with a counter agent.

Occasionally, the ACT may be measured during a bleeding episode or used as part of a bedside evaluation of a patient’s heparin anticoagulation level.

The ACT is measured in seconds: the higher it is the higher the degree of clotting inhibition. During surgery, the ACT is kept above a lower limit, a limit at which most people will not form blood clots. There is not widespread agreement of exactly what this lower limit should be. It will vary from hospital to hospital and depends to some degree on the method used to determine ACT. It is important to evaluate how the patient is responding to this ACT lower limit and to the amount of heparin they are being given. The amount of heparin needed to reach and maintain a certain ACT (for instance, 300 seconds) will vary as will the body’s clotting potential at that ACT. If there are clotting or bleeding problems, the dosages and ACT may need to be adjusted accordingly. After surgery, the ACT may be maintained within a narrow range (for instance, 175 – 225 seconds) until the patient has stabilized.

ACT and PTT results are not interchangeable. In the area where they overlap (upper measurements of PTT and lower levels of ACT), they have poor correlation. ACT and PTT results should be evaluated independently. It is better to determine a patient’s heparin anticoagulant requirements, stabilize them, and then change the monitoring tool.

The ACT may be influenced by a patient’s platelet count and platelet function. Platelets that are activated during surgery often become dysfunctional, and both surgery and heparin can cause thrombocytopenia. The temperature of the blood may also affect ACT results – the blood tends to cool during surgery as it is mechanically filtered and oxygenated. Acquired and inherited conditions such as lupus antibodies and coagulation factor deficiencies may also affect ACT results.