Activated protein C resistance and factor V Leiden

INTRODUCTION — Factor V Leiden is the most common cause of inherited

thrombophilia in Caucasian populations, accounting for 40 to 50 percent of cases. The
prothrombin gene mutation, deficiencies in protein S, protein C, and antithrombin
account for most of the remaining cases, while rare causes include the
dysfibrinogenemias. The total incidence of an inherited thrombophilia in subjects with a
deep vein thrombosis ranges from 24 to 37 percent overall, compared with about 10
percent in controls.

PHYSIOLOGY — Factor V circulates in plasma as an inactive cofactor. Activation by

thrombin results in the formation of factor Va, which then serves as a cofactor in the
conversion of prothrombin to thrombin.

Factor Va is enzymatically inactivated by proteolytic cleavages in its heavy chain. The

mechanism of factor Va inactivation is an ordered event. Factor Va is first cleaved at
Arg506 and then at Arg306 and Arg679 by activated protein C. The peptide bond
cleavage at Arg506 facilitates the exposure of cleavage sites at Arg306 and Arg679 [ 4 ].

In 1993, a group of individuals with unexplained venous thromboembolism were reported

whose plasmas exhibited a poor response to activated protein C (APC) in an activated
partial thromboplastin time (aPTT) assay. Recognized mechanisms for APC resistance,
such as functional protein S deficiency or inhibitors of APC, were excluded. Other
clinically affected relatives of the probands demonstrated APC resistance in the aPTT-
based test, suggesting that the abnormality was inherited.

The molecular basis for the laboratory phenotype of resistance to APC was found to be a
mutation in the gene coding for coagulation factor V [ 5 ]. A transition (guanine to
adenine) at nucleotide 1691 (G1691) resulted in the replacement of arginine at position
506 in factor V by glutamine. The gene product, factor V Leiden (factor V Q506,
Arg506Gln) is not susceptible to cleavage at position 506 by activated protein C and is
therefore inactivated more slowly.

Dual defect leading to hypercoagulable state — The factor V Leiden mutation leads
to a hypercoagulable state for two reasons, due to the critical position of factor V in both
the coagulant and anticoagulant pathways [ 6 ]. (See "Overview of hemostasis", section
on 'Multicomponent complexes' .)

 Increased coagulation — The activated form of Factor V Leiden is inactivated

more slowly by APC than is normal Factor Va. Accordingly, more factor Va is
available within the prothrombinase complex, increasing coagulation via the
increased generation of thrombin.
 Decreased anticoagulation — Factor V cleaved at position 506 is also thought
to be a cofactor, along with protein S, in supporting the role of activated protein
C in the degradation of factor VIIIa (in the tenase complex) as well as factor Va
(in the prothrombinase complex) [ 7-9 ]. Lack of this cleavage product in
patients with factor V Leiden thus decreases the anticoagulant activity of
activated protein C.
The poor susceptibility to cleavage by APC as well as impaired APC cofactor activity
appear to contribute equally to the phenomenon of Factor V Leiden-associated APC
resistance and the ensuing hypercoagulable state [ 8,10 ].

The dual nature of factor V also helps to explain why the risk of thrombosis is greater in
patients homozygous or pseudohomozygous (ie, compound heterozygosity for factor V
Leiden and type I factor V deficiency) for factor V Leiden than in heterozygotes [ 8,11 ].
The blood of heterozygotes, unlike the situation in homozygotes and
pseudohomozygotes, contains both factor V Leiden and normal factor V. Presence of the
normal factor V molecule allows for the inactivation of factor VIIIa by APC, via the second
of the two pathways noted above, affording some protection against thrombosis.
(See 'Factor V Leiden plus factor V deficiency' below.)

CAUSES AND PREVALENCE — The causes for APC resistance are genetic or acquired
[ 3 ]:

 Genetic — Heterozygosity for the factor V Leiden mutation accounts for 90 to 95

percent of cases of the hereditary APC resistance. A much smaller number of
homozygotes exist. In rare cases, genetic abnormalities other than the factor V
Q506 mutation produce the APC resistance phenotype or modulate its
expression in factor V Q506 heterozygotes.
 Acquired — Acquired conditions that can cause APC resistance in first generation
APC resistance assays include elevated factor VIII levels, pregnancy, use of oral
contraceptives, and the presence of antiphospholipid antibodies. Some patients
have been described with APC resistance of unknown cause [ 12,13 ].
(See 'Acquired APC resistance' below.)

Heterozygosity for factor V Leiden — The prevalence of heterozygosity for the factor
V Leiden mutation in Caucasians, including European, Jewish, Israeli, Arab, Canadian and
Indian populations, ranges from 1 to 8.5 percent, with most European studies reporting
overall rates of 5 to 8 percent [ 14,15 ]. The prevalence has been reported to be
approximately 15 percent in some parts of Greece, Sweden, and Lebanon [ 16-18 ]. On
the other hand, the factor V Leiden mutation is apparently not present in African Blacks,
Chinese, or Japanese populations.

In a study of 4047 American men and women participating in the Physician's Health
Study and the Women's Health Study, the following carrier frequencies for factor V
Leiden were found [ 19 ]:

 Caucasians — 5.3 percent

 Hispanic Americans — 2.2 percent
 Native Americans — 1.2 percent
 African Americans — 1.2 percent
 Asian Americans — 0.45 percent

Studies using dimorphic sites in the factor V gene to do haplotype analysis have provided
evidence for the existence of a founder effect as the basis for the mutation in Caucasians
of differing ethnic backgrounds [ 20 ]. It has been estimated that the mutation originated
approximately 30,000 years ago, after the evolutionary divergence of Caucasian, African,
and Oriental populations [ 20 ]. Similar data, indicating a founder haplotype and a single
genetic origin during the same time period, have been found in studies of individuals with
the prothrombin mutation, which occurs independently in the same ethnic groups [ 21 ].
(See "Prothrombin gene mutation" .)
Homozygosity for factor V Leiden — Homozygotes account for about 1 percent of
patients with the factor V Leiden mutation but are disproportionately represented
clinically, as compared with the general population, because of a higher thrombotic risk.
(See 'Clinical manifestations' below.)

Other genetic defects in factor V — Several mutations at the Arg306 residue in factor
V, the second APC site cleavage in the activated cofactor, have been described in
patients with a history of thrombosis. These include replacement of Arg306 with
threonine (factor V Cambridge) [ 22 ] or with glycine (in Hong Kong Chinese) [ 23 ].
Thr306, albeit rare, does confer APC resistance. The clinical importance of Gly306 is
uncertain, since it may not be associated with APC resistance [ 23 ] and the mutation is
as common in healthy Chinese blood donors as in patients with thrombosis (4.5 and 4.7
percent, respectively) [ 24 ].

Factor V Liverpool (Ile359Thr) has been associated with an increased risk of thrombosis,
apparently due to both reduced APC-mediated inactivation of factor Va as well as being a
poor APC cofactor for the inactivation of factor VIIIa [ 25 ]. (See 'Physiology' above.)

HR2 haplotype — In addition to the above-noted mutations, several polymorphisms

are present in the factor V gene [ 26 ]. An extended factor V gene haplotype (HR2)
containing the R2 polymorphism (Arg1299) is in complete linkage disequilibrium with the
factor V Leiden allele and is found with increased frequency in heterozygous factor V
Leiden-positive patients with the lowest APC resistance ratios [ 27 ].

The slight increase in thrombotic risk in those with the HR2 haplotype may be due to a
reduction in its activated protein C cofactor activity [ 8 ]. However, it is controversial
whether the HR2 haplotype is associated with increased thrombotic risk in the absence of
factor V Leiden [ 8,28-34 ]. (See 'Physiology' above.)

Factor V Leiden plus factor V deficiency — Occasional patients have been described
in whom there is cosegregation of heterozygous APC resistance due to the factor V
Leiden mutation along with type I factor V deficiency [ 35-38 ]. The plasma of these
individuals manifests severe APC resistance in activated partial thromboplastin time
assays, similar to patients with homozygous factor V Leiden (ie, they are
pseudohomozygous). These patients appear to be more thrombosis prone than
heterozygous relatives with factor V Leiden alone, suggesting that the clinical phenotype
is similar to [ 11,39 ], or more severe than [ 40 ], that of patients homozygous for factor
V Leiden.

Other genetic influences

 Having a non-O blood group (eg, A, B, or AB) appears to increase the risk of
developing VTE in both heterozygotes and homozygotes for factor V Leiden by
two- to four-fold [ 41-43]. This may be explained, at least in part, by the higher
levels of factor VIII seen in non-O individuals [ 43-45 ]. (See 'Combined
inherited defects' below and "Biology and normal function of von Willebrand
factor", section on 'Plasma VWF' .)
 Studies in both mouse and man have suggested that alterations in the protein Z
gene may influence the clinical symptoms of thromboembolism in patients with
factor V Leiden. (See "Vitamin K, gamma carboxyglutamic acid, and the
function of coagulation and other proteins", section on 'Protein Z' .)
 Common single nucleotide polymorphisms in the factor V gene may reduce the
quantity of normal factor V in individuals heterozygous for factor V Leiden, and
increase the risk of venous thromboembolism [ 46 ].
Acquired APC resistance — Some patients with APC resistance without the factor V
Leiden mutation can be identified using the first generation aPTT-based assay for APC
resistance (see 'Diagnostic assays' below):

 Individuals with cerebrovascular disease have been described with APC resistance
not due to the factor V Leiden mutation [ 47,48 ]. In one study, the
investigators divided patients into five categories of responsiveness to APC, as
opposed to the usual practice of using a cutoff value for optimal separation of
carriers and noncarriers of the mutation [ 48 ]. Statistical analysis showed that
a low response to APC was associated with an increased risk of cerebrovascular
disease, which was independent of the factor V Leiden mutation.
 In the Leiden Thrombophilia Study, a case-control study including 474 patients
with a first episode of deep vein thrombosis and 474 age- and sex-matched
controls, in which all carriers of the factor V Leiden mutation were excluded, a
dose-response relationship was observed between the sensitivity for APC and
the risk of thrombosis [ 13 ]. After correcting for confounding variables, a
reduced response to APC remained a risk factor for thrombosis (odds ratio for
the lowest quartile: 2.5; 95% CI 1.5-4.2).
 In a study of over 14,000 participants in the Vicenza Thrombophilia and
Atherosclerosis Project who did not have factor V Leiden, the adjusted odds
ratio for development of VTE was 1.7 (95% CI 1.0-2.7) in those with
phenotypic resistance to APC [ 49 ].
 Significant resistance to APC has been found in patients with multiple myeloma
and other cancers [ 50,51 ], and may contribute to the thrombotic tendency in
these patients [50,52,53 ].
 Resistance to APC has also been found in some patients with systemic lupus
erythematosus and the antiphospholipid antibody syndrome in the absence of
factor V Leiden. This subject is discussed separately. (See "Pathogenesis of the
antiphospholipid syndrome", section on 'Genetic predisposition' .)

At present, the clinical importance of documenting this type of APC resistance is

uncertain [ 54,55 ]. The use of assays to identify these individuals is best restricted to
research studies [56 ].

Oral contraceptives — The use of oral contraceptives (OC), especially third generation
OCs, has been associated with acquired APC resistance. APC resistance, which can also
be acquired following use of hormone replacement therapy [ 57 ], may underlie, in part,
the supra-additive effect of exogenous estrogens on thrombotic risk in women with factor
V Leiden ( table 1 ), or in those women without factor V Leiden who have the lowest APC
resistance ratios [ 58 ]. (See "Risks and side effects associated with estrogen-progestin
contraceptives", section on 'Venous thromboembolic disease' .)

According to data from the Leiden Thrombophilia Study ( table 1 ), the annual risk of
developing a first episode of VTE for patients with varying combinations of factor V
Leiden and use of OCs, is as follows:

 Normal subjects — 1 in 12,500

 Use of OCs — 1 in 3333
 Factor V Leiden heterozygotes — 1 in 1667
 Factor V Leiden heterozygotes taking OCs — 1 in 345

CLINICAL MANIFESTATIONS — The major clinical manifestation of factor V Leiden,

the most common cause of hereditary thrombophilia, is deep vein thrombosis with or
without pulmonary embolism (ie, venous thromboembolic disease). The mutation is also
a risk factor for cerebral, mesenteric, and portal vein thrombosis [ 59-61 ]. Despite the
increase in risk of venous thrombosis, there is no evidence that heterozygosity for factor
V Leiden increases overall mortality [ 62 ].

There is evidence that the factor V Leiden mutation, presumably due to thrombosis of
placental vessels, may play a role in some cases of unexplained recurrent pregnancy loss
[ 63-66 ]. (See 'Obstetric complications' below and "Inherited thrombophilias in
pregnancy" .)

Risk of DVT — Multiple studies have evaluated the role of factor V Leiden in the risk of
venous thromboembolism ( table 1 ) [ 67-73 ]. Approximately 10 to 26 percent of such
patients have this mutation, as illustrated by the following observations:

 The Physicians' Health Study found a 12 percent incidence of heterozygosity for

the factor V Leiden mutation in patients with a first confirmed deep vein
thrombosis (DVT) or pulmonary embolism, compared with 6 percent in controls
[ 73 ]. The incidence reached 26 percent in 31 men >60 years of age with no
identifiable precipitating factors (ie, those with idiopathic/unprovoked VTE)
[ 73 ].
 The Leiden Thrombophilia Study, consisting of 471 patients under age 70 with a
first confirmed DVT and 474 healthy controls, found a 21 percent incidence of
activated protein C resistance, compared with 5 percent in controls [ 70,71 ].
The incidence of heterozygosity (18 versus 3 percent) and homozygosity for
factor V Leiden (1.5 versus zero percent) was significantly higher in the patients
with thrombosis [ 71 ]. The relative risk for DVT was increased sevenfold for
heterozygotes and 80-fold for homozygotes ( table 1 ).
 In a study of 306 family members from 50 Swedish families, 40 percent of
homozygotes for factor V Leiden had an episode of venous thrombosis by age
33, compared with 20 percent of heterozygotes and 8 percent of normal
subjects [ 12 ].

Although possibly influenced by a selection bias [ 74 ], the lifetime probability of

developing thrombosis and the severity of the thromboses are considerably less in
heterozygotes with the factor V Leiden mutation than in patients with the less common
inherited thrombophilias. This was illustrated in a report that compared the risk for
thrombosis in individuals with inherited thrombophilia due to factor V Leiden or to
antithrombin, protein C, or protein S deficiency in 150 pedigrees [ 75 ]. The lifetime
probability of developing thrombosis compared with those with no defect was 8.5 times
higher for carriers of protein S deficiency, 8.1 for antithrombin deficiency, 7.3 for protein
C deficiency, and 2.2 for factor V Leiden. (See"Overview of the causes of venous
thrombosis", section on 'Inherited thrombophilia' .)

Despite the increase in thrombotic tendency, the risk of thrombosis in homozygous factor
V Leiden is significantly less than the risk in homozygous or doubly heterozygous protein
C or protein S deficiency.

Combined inherited defects — There appears to be an increased incidence of factor V

Leiden among thrombotic patients with other thrombophilic defects, as compared with
the general population. These include deficiencies of protein C [ 76,77 ], protein S
[ 78,79 ], antithrombin [ 80 ], the prothrombin gene mutation [ 81,82 ], and elevated
levels of factor VIII [ 44 ]. As examples:
  A study of 18 unrelated thrombosis-prone families with inherited protein S
deficiency found a concomitant factor V gene mutation in 39 percent of the
study subjects [ 79 ].
 In another report which compared 113 patients with protein C deficiency and 104
healthy volunteers, the Arg506Gln mutation in factor V was much more
common in those with protein C deficiency than in controls (15 versus 1
percent) [ 77 ].

Carriers of two defects seem to be at a higher risk for thrombosis than their relatives
with a single defect. In one review of four studies, approximately 75 percent of the family
members who were carriers of two defects had experienced thrombosis compared with
10 to 30 percent of the carriers of a single defect [ 83 ]. The presence of two defects in
these studies increased the thrombotic risk three-fold above the risk of a single defect.

A pooled analysis of eight case-control studies evaluated thrombotic risks in patients

bearing factor V Leiden and/or the prothrombin G20210A mutation [ 84 ]. The following
odds ratios for the risk of VTE were found:

 Factor V Leiden heterozygotes — 4.9

 Prothrombin G20210A mutation heterozygotes — 3.8
 Both mutations (ie, double heterozygotes) — 20.0

Double heterozygosity occurred in 2.2 percent of patients with VTE overall, in 12 percent
of patients who were heterozygous for factor V Leiden, and in 23 percent of patients
heterozygous for the prothrombin G20210A mutation

This analysis also determined the additional risk posed by the use of oral contraceptives
in women aged 15 to 49 in the three case-control studies in which this information was
available. The risk of VTE was increased two- to six-fold in subjects with one "defect", 7-
to 15-fold in those with two defects, and 17-fold in those using oral contraceptives with
both genetic defects (ie, all three "defects").

In a retrospective study of first degree relatives from selected thrombophilic families (ie,
at least two symptomatic relatives in addition to the proband), factor VIII levels ≥150
international units/dL increased the risk of thrombosis threefold in carriers of factor V
Leiden [ 44 ]. In first degree relatives of unselected patients with factor V Leiden (ie,
relatives of consecutive patients with a first thrombosis), high levels of factor VIII
increased the thrombotic risk of carriers twofold.

The risk of thrombosis was also increased in patients with factor V Leiden and
hyperhomocysteinemia. In a large prospective cohort study, the relative risk for
idiopathic VTE compared with patients with neither abnormality was 3.4 with
hyperhomocysteinemia, 3.6 with the factor V Leiden mutation, and 21.8 with both
disorders [ 85 ]. (See "Overview of homocysteine".)

Risk of recurrent DVT — There are conflicting data as to whether the factor V Leiden
mutation is, or is not, associated with an increased risk of recurrent venous
thromboembolism [ 72,86-88 ], with odds ratios varying from 0.90 to 3.62 for 10 studies
included in one meta-analysis [ 89 ]. Examples of this diversity of opinion include:

 In two series, patients with factor V Leiden who had a first venous thrombotic
event were more than twice as likely to have a recurrent episode than those
without the mutation at follow-ups ranging from 5.7 to 8 years [ 72,86,90 ].
  Six studies found no difference in the incidence of recurrence between those with
and without factor V Leiden [ 87,91-95 ].
 Three different meta-analyses have reported an odds of VTE recurrence
associated with factor V Leiden of 1.30, 1.36, and 1.41 [ 89,96,97 ].
 In four studies, the risk of recurrence was increased in patients heterozygous for
factor V Leiden who were also heterozygous for the prothrombin gene mutation
or a concomitant thrombophilic disorder, particularly those in whom the first
episode of DVT was spontaneous (see below) [ 91,94,98 ]. However, a case-
control study within a large thrombophilic family cohort did not find a higher
recurrence risk in those with combined inherited defects [ 99 ]. Although the
number of events were small and the confidence limits wide, individuals with
homozygous factor V Leiden and/or homozygous prothrombin G20210A or
those doubly heterozygous for factor V Leiden and prothrombin G20210A did
not appear to have a higher risk of recurrent VTE than noncarriers.

Reports are also conflicting as to whether the risk of VTE recurrence in patients with
factor V Leiden is [ 100,101 ] or is not [ 102 ] increased over noncarriers in those
receiving anticoagulation for a shorter period of time (eg, <3 months versus >6 months).

While these different results are likely due to somewhat different patient populations and
more importantly different study population sizes, it can be concluded that
heterozygosity for factor V Leiden is only a modest risk factor for a first episode of DVT
and is most likely not associated with an increased risk for recurrent DVT [ 103 ].
(See "Treatment of lower extremity deep vein thrombosis", section on 'Recurrent VTE' .)

Further, in a follow-up study of 396 patients with a first episode of VTE, the risk of VTE
recurrence in those who were heterozygous for factor V Leiden and also had high levels
of factors VIII, IX, or XI was not increased over the risk in those without factor V Leiden
who had normal levels of these three coagulation factors (crude hazard ratio 1.4; 95% CI
0.6-3.0) [ 103].

Acquired risk factors — There is an important interaction between factor V Leiden and
other acquired risk factors for venous thrombosis (eg, oral contraceptives, hormone
replacement therapy, pregnancy) [ 104-113 ]. The magnitude of the increase in risk can
be illustrated by the following observations:

In 155 consecutive premenopausal women with deep vein thrombosis, the risk among
those with both oral contraceptive use and the factor V Leiden mutation was increased
more than 30-fold compared with women with neither risk factor; the increase in risk
was lower (four- to eightfold) with either risk factor alone ( table 1 ) [ 104 ].

A second study has provided data that might explain the increased risk for venous
thrombosis in oral contraceptives users and the interaction with factor V Leiden [ 114 ].
In this report, the effects of activated protein C on thrombin generation in the plasma of
women using oral contraceptives were compared to the response in women not using
oral contraceptives and in women heterozygous or homozygous for the factor V Leiden
mutation. Oral contraceptives induced a degree of activated protein C resistance
comparable with the resistance caused by a heterozygous factor V Leiden mutation. In
women heterozygous for factor V Leiden who used oral contraceptives, the degree of
activated protein C resistance was as high as that among women homozygous for the
factor V Leiden mutation.
The risk of venous thromboembolic disease associated with the various forms of oral
contraceptives is discussed separately. (See "Risks and side effects associated with
estrogen-progestin contraceptives", section on 'Venous thromboembolic disease' .)

A long-term study of 9253 randomly selected Danish patients found increasing risk for
venous thromboembolism (VTE) with age, smoking, increasing body mass index (BMI),
and presence of factor V Leiden [ 115 ]. (See "Overview of the causes of venous
thrombosis", section on 'Obesity' and "Overview of the causes of venous thrombosis",
section on 'Smoking'.)

As examples:

 Absolute 10-year risks for VTE were 0.7 and 3 percent among heterozygotes and
homozygotes, respectively, who were <40 years of age, did not smoke, and
were not overweight.
 The 10-year risks for VTE in heterozygotes and homozygotes >60 years of age
who smoked and were overweight (body mass index >30 kg/m 2 ) were 10 and
51 percent, respectively.

It is unclear whether the factor V Leiden mutation increases the risk of thrombosis in
patients with malignancy or following insertion of central venous catheters.
(See "Hypercoagulable disorders associated with malignancy", section on 'Venous
thromboembolism' and "Catheter-induced upper extremity venous thrombosis" .)

Obstetric complications — Obstetric complications and treatment during pregnancy in

patients with factor V Leiden are discussed separately. (See "Inherited thrombophilias in
pregnancy" .)

Isolated pulmonary emboli — The risk of developing isolated pulmonary emboli (ie,
without concomitant deep vein thrombosis) in patients with factor V Leiden has been
reported to be about one-half (odds ratio 2.5) that of the risk of developing deep vein
thrombosis with (odds ratio 5.2) or without (odds ratio 6.0) pulmonary emboli [ 116-
119 ]. The cause of this interesting “Factor V Leiden paradox” is not known
[ 117,120,121 ], but may be due to the lower incidence in patients with factor V Leiden
of deep vein thrombi affecting the large, proximal iliofemoral vessels most often
associated with the generation of symptomatic pulmonary emboli.

In one study, the incidence of severe dyspnea was significantly higher in 20 factor V
Leiden homozygotes (32 percent) than in 699 heterozygotes or 8534 non-carriers (7 and
6 percent, respectively) [ 122 ]. Homozygotes also had evidence for reduced pulmonary
function. The explanation for these differences is not known, but may reflect continuing
subclinical episodes of recurrent pulmonary embolism in the homozygotes.

Cerebral vein thrombosis — The factor V Leiden mutation occurs with increased
frequency in patients with cerebral vein thrombosis (CVT) (10 to 20 percent versus 2 to 3
percent in controls) [ 123-125 ]. As with deep vein thrombosis, CVT occurs more
frequently in young women who are taking oral contraceptives or who are pregnant or in
the postpartum state. (See "Etiology, clinical features, and diagnosis of cerebral venous
thrombosis", section on 'Etiology' .)

The use of oral contraceptives alone is a strong risk factor for CVT, and the addition of
oral contraceptives to the presence of factor V Leiden results in a risk that exceeds the
sum of the two separate risks. In a case control study, for example, the estimated odds
ratios for CVT were 10 for the use of oral contraceptives, three to four for hereditary
prothrombotic disorders, and 34 for the presence of both risk factors [ 126 ].

Superficial vein thrombosis — In one study in subjects with superficial vein

thrombosis (SVT) as the sole thrombotic manifestation, and in the absence of varicose
veins, malignancy, or autoimmune disease, the odds ratio for the development of SVT in
those heterozygous for factor V Leiden was 4.3 [ 127 ]. Other studies have demonstrated
a high prevalence of factor V Leiden in subjects with SVT on normal veins [ 128,129 ].
(See "Superficial thrombophlebitis of the lower extremity", section on 'Malignancy and
hypercoagulable states' .)

Arterial thrombosis — An association between factor V Leiden and arterial disease

remains controversial, although there appears to be a weak but significant association
between premature myocardial infarction (ie, first event before age 45) and factor V
Leiden [ 130,131 ]. There are a number of studies, including two meta-analyses, which
have generally been unable to find an increased prevalence of the mutation in patients
with myocardial infarction (MI) and stroke [ 73,132-137 ]. However, it is not clear
whether there is a small risk that is amplified considerably when there are additional
coronary risk factors present (see "Coronary heart disease and myocardial infarction in
young men and women" ):

 In a case control study in patients ≤60 years of age with

ischemic stroke/transient ischemic attack, an increase in stroke risk was
confined to female smokers with factor V Leiden (odds ratio 8.8 95% CI 2.0-38)
[ 138 ]. No such interaction was found for men.
 In a case control study in young women (18 to 44 years of age), the factor V
Leiden mutation was associated with a 2.4-fold increase in risk of MI after
adjustment for age; this increase in risk was limited to current smokers [ 139 ].
 In a third study, factor V Leiden was found in 12 percent of young patients (mean
age 44 years) with MI and normal coronary angiography, in 4.5 percent of age-
and sex-matched patients with MI and significant coronary artery disease, and
5 percent of normal controls [ 140 ].
 In a fourth report, presence of eight prothrombotic gene polymorphisms, including
factor V Leiden, was not associated with an increased or decreased risk of
premature MI [ 141 ]. However, a later publication from this group, which
included more cases, found a significant association between factor V Leiden
and premature MI [ 131 ].

Factor V Leiden may be a more important contributor to cerebral infarction in children

than in adults [ 137 ]. In one series of 26 such children, factor V Leiden was present in
six; two of these children also had protein C deficiency [ 142 ].

Settings in which thrombotic risk may not be increased — There are conflicting
data as to whether the factor V Leiden mutation increases the underlying thrombotic risk
in patients who are undergoing hip or knee replacement therapy or have pulmonary
emboli, who more frequently have preexisting medical illness, or have undergone recent
surgery [ 143-145 ]. (See "Overview of the causes of venous thrombosis" .)

 A retrospective study of 825 patients undergoing hip or knee replacement surgery

was unable to demonstrate an increased risk of venographically documented
events postoperatively among patients with the factor V Leiden mutation
[ 143 ]. The absolute incidence of deep vein thrombosis was 31 percent in
patients with the mutation and 26 percent in those without the mutation.
  A prospective study of 645 consecutive patients undergoing elective hip or knee
replacement found a fivefold increase (95 percent confidence interval: 1.9 to
12.9) in the risk of symptomatic postoperative VTE in patients with, as
compared with those without, APC resistance [ 145 ].

DIAGNOSTIC ASSAYS

First generation APC resistance assays — Activated partial thromboplastin time

(aPTT)-based assays serve as a screening test for APC resistance. The aPTT is performed
in the presence and absence of a standardized amount of APC, and the two clotting times
are converted to an APC ratio. The results can be interpreted by comparing the ratio to
the normal range or by normalizing it to the APC resistance ratio obtained using normal
pooled plasma.

Although this first generation APC resistance assay was conceptually simple and easy to
perform in a coagulation laboratory, it required careful standardization and determination
of the normal range in at least 50 controls. In addition, the level of activated protein C,
the aPTT reagent, and the instrumentation used for clot detection affected the
performance characteristics of the assay.

Some assays using this format had inadequate sensitivity and specificity for the factor V
Leiden mutation. Further, patients receiving anticoagulants or those with an abnormal
aPTT due to other coagulation defects could not be investigated with this assay, and the
test was not validated in patients with acute thrombotic events or pregnant women
[ 146 ].

Second generation APC resistance assays — Second generation coagulation tests

have been developed which, with proper standardization, can give nearly 100 percent
sensitivity and 100 percent specificity for the factor V Leiden mutation. This was achieved
by diluting patient plasma in a sufficient volume of factor V-deficient plasma and then
performing either an aPTT-based assay or a tissue factor-dependent factor V assay
[ 147,148 ]. This modification also permits the evaluation of plasma of patients receiving
anticoagulants or with abnormal aPTT results due to coagulation factor deficiencies.

Genetic testing — Since factor V Leiden is the major mutation underlying APC
resistance, this defect can be detected directly by analyzing genomic DNA in peripheral
blood mononuclear cells. This is performed by amplifying a DNA fragment containing the
factor V mutation site by polymerase chain reaction (PCR) and analyzing the cleavage
products on ethidium bromide-stained agarose gels after restriction enzyme digestion
with MnlI [ 5 ]. This approach is effective because the substitution of an A for a G at
nucleotide 1691 in the factor V cDNA (CGA to CAA) results in the Arg506Gln mutation
and loss of an MnlI cleavage site.

Other approaches using PCR with sequence-specific primers or capture probes or direct
detection of the mutation without amplification have been reported [ 149,150 ].

At present, the factor V Leiden mutation can be identified by testing for APC resistance
using a second generation coagulation assay. Patients with low APC resistance ratios
should then be genotyped for the mutation. Alternatively, only genetic testing for the
factor V Leiden mutation can be performed.

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education

materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are
written in plain language, at the 5 th to 6 th grade reading level, and they answer the four
or five key questions a patient might have about a given condition. These articles are
best for patients who want a general overview and who prefer short, easy-to-read
materials. Beyond the Basics patient education pieces are longer, more sophisticated,
and more detailed. These articles are written at the 10 th to 12 th grade reading level and
are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you
to print or e-mail these topics to your patients. (You can also locate patient education
articles on a variety of subjects by searching on “patient info” and the keyword(s) of
interest.)

 Basics topic (see "Patient information: Factor V Leiden (The Basics)" )

SUMMARY

Activated protein C resistance — Protein C, which is converted to activated protein C,

along with protein S, are natural anticoagulants that are produced within the body. Their
anticoagulant activity comes about through the enzymatic degradation of factors VIIIa
and Va. Resistance to this effect of activated protein C is called activated protein C
resistance (APC resistance).

 Heterozygosity for the factor V Leiden mutation (factor V Q506, Arg506Gln)

accounts for 90 to 95 percent of cases of hereditary APC resistance.
 The most common causes of acquired APC resistance include elevated factor VIII
levels, pregnancy, use of oral contraceptives, and the presence of
antiphospholipid antibodies. (See 'Acquired APC resistance' above.)

Factor V Leiden — The activated form of Factor V Leiden is not susceptible to cleavage
at position 506 by activated protein C and is therefore inactivated more slowly. It is the
most common cause of inherited thrombophilia in Caucasian populations, accounting for
40 to 50 percent of cases. Its incidence in most European studies is about 5 to 8 percent.
The mutation is not present in African Blacks, Chinese, or Japanese populations.
(See 'Physiology' above.)

Nature of the hypercoagulable state — Factor V Leiden is associated with

a prothrombotic/thrombophilic state through two different mechanisms.
(See 'Physiology' above and"Overview of hemostasis", section on 'Multicomponent
complexes' .)

 Increased coagulation — The activated form of Factor V Leiden is inactivated more

slowly by APC than is normal Factor Va. Accordingly, more factor Va is available
within the prothrombinase complex, increasing coagulation via the increased
generation of thrombin.
 Decreased anticoagulation — Factor V cleaved at position 506 is a cofactor, along
with protein S, in supporting the role of activated protein C in the degradation
of factors VIIIa and Va. Lack of this cleavage product decreases the
anticoagulant activity of activated protein C.

This hypercoagulable state can be exacerbated when a patient heterozygous for factor V
Leiden has one or more additional causes for hypercoagulability (eg, heterozygosity for
the prothrombin gene mutation, use of oral contraceptives).
Diagnosing factor V Leiden — The most direct way to diagnose factor V Leiden is
through genetic testing, although second generation APC resistance assays can give
nearly 100 percent sensitivity and 100 percent specificity for the factor V Leiden
mutation. (See 'Diagnostic assays' above.)

Screening for the factor V Leiden mutation — Screening for the Factor V Leiden
mutation in patients with venous thromboembolic disease, their relatives, and in the
population at large is discussed separately. (See "Evaluation of the patient with
established venous thrombosis", section on 'Screening for inherited
thrombophilia' and "Screening for inherited thrombophilia in asymptomatic
populations" .)

Management of the patient with factor V Leiden — Management of the patient with
heterozygous factor V Leiden, double heterozygosity for factor V Leiden and another
inherited thrombophilia, or homozygous factor V Leiden is discussed separately.
(See "Management of inherited thrombophilia", section on 'Factor V
Leiden' and "Screening for inherited thrombophilia in asymptomatic populations", section
on 'Homozygosity and multiple defects' and "Inherited thrombophilias in pregnancy",
section on 'Patient selection' .)

REFERENCES