Vascular Medicine 2003; 8: 33–46

Hypercoagulable state testing and malignancy screening

following venous thromboembolic events
Steven R Deitchera and Marcelo PV Gomesb

Abstract: Mounting interest in hypercoagulability, increased availability of hypercoagulable

state test ‘panels’ and enhanced ability to identify abnormalities in tested patients have
prompted widespread testing. Testing for acquired and inherited hypercoagulable states
uncovers an abnormality in over 50% of patients presenting with an initial venous thromboem-
bolic event (VTE) but may have minimal actual impact on management in most of these
patients. Such laboratory screening should be reserved for patients in whom the results of
individual tests will signiŽ cantly impact the choice of anticoagulant agent, intensity of antico-
agulant therapy, therapeutic monitoring, family screening, family planning, prognosis determi-
nation, and most of all duration of therapy. Testing ‘just to know’ is neither cost-effective nor
clinically appropriate. The most important testing in patients following acute VTE may be age-
and gender-speciŽ c cancer screening. Cancer screening following VTE seems most prudent in
older individuals and in those with idiopathic VTE and no laboratory evidence for an inherited
hypercoagulable state. Cancer screening should focus on identiŽ cation of treatable cancers and
those where diagnosis in an early stage favorably impacts patient survival. Extensive searches
for occult malignancy employing whole-body computed tomography and serum tumor markers
may identify more cancers but without affecting patient outcome. We advocate that physicians
should focus their attention more on VTE prophylaxis and proper treatment and less on costly
and, at times, invasive testing of questionable value.

Key words: cancer; diagnosis; hypercoagulable states; laboratory testing; screening; venous
thrombosis

Introduction by a natural anticoagulant (e.g., factor V G1691A, also

Venous thromboembolic disease, including deep venous
thrombosis (DVT) and pulmonary embolism, constitutes
the third most common cardiovascular disease, after athero-
sclerotic heart disease and stroke. Risk factors for venous
thromboembolic events (VTE) can be divided into three
categories: situational, inherited and acquired.1 – 4 Situational
risk factors represent well-deŽ ned, transient clinical cir-
cumstances that are associated with greater VTE risk both
while they are present and for a short period after they have
resolved. Examples include surgery, prolonged immobiliz-
ation, use of oral contraceptive pills (OCP), hormone
replacement therapy (HRT), pregnancy, cancer chemo-
therapy and heparin-induced thrombocytopenia. Inherited
risk factors represent genetic mutations and polymorphisms
that result in deŽ ciency of a natural anticoagulant (e.g., pro-
tein C, protein S or antithrombin), procoagulant factor
accumulation (e.g., prothrombin G20210A, the thermolab-
ile variant of the enzyme methylenetetrahydrofolate
reductase) or coagulation factor resistance to inactivation
a
Departments of Hematology and Medical Oncology and Cardiovascular
Medicine and bDepartment of Cardiovascular Medicine, The Cleveland
Clinic Foundation, Cleveland, OH, USA
Address for correspondence: Steven R Deitcher, The Cleveland Clinic
Foundation, 9500 Euclid Avenue, Desk R-35, Cleveland, OH 44195, USA.
Tel: +1 216 445 9275; Fax: +1 216 444 9464; E-mail: deitchs@ccf.org
Note: Marcelo PV Gomes is currently a Research Associate in the Section
of Hematology and Coagulation Medicine, Department of Hematology and
Medical Oncology at The Cleveland Clinic Foundation.
known as factor V Leiden). These conditions are charac-
terized by a disruption in the normally highly regulated
coagulation homeostasis, resulting in greater thrombin gen-
eration and an increased risk of clinical VTE. Acquired risk
factors result either from medical conditions or from non-
familial hematologic abnormalities that interfere with nor-
mal hemostasis or blood rheology. Examples include can-
cer, in ammatory bowel disease, nephrotic syndrome,
vasculitis, antiphospholipid antibodies, myeloproliferative
and hyperviscosity syndromes, as well as paroxysmal noc-
turnal hemoglobinuria. These acquired risk factors are dis-
tinct from situational risk factors by the fact that they rep-
resent alterations in hemostatic homeostasis as a result of
disease or, for the most part, nonreversible processes. In
contrast, most situational risk factors result either from a
therapeutic intervention or an adverse reaction from such
intervention.
Hyperhomocysteinemia and increased factor VIII func-
tional activity are examples of VTE risk factors that can
be acquired in nature or have a genetic predisposition.5 ,6
Age deŽ es categorization but remains the single most pre-
dictable risk factor for VTE. The estimated baseline age-
associated risk of VTE is one in 10 000 persons per year
before age 40, increasing to one in 100 persons per year
over the age of 75.7 – 9
Patients with any of the previously mentioned risk fac-
tors for VTE should be viewed as ‘hypercoagulable’, even
if only transiently so. But the term ‘hypercoagulable state’
(also known as ‘thrombophilia’) has been traditionally used
in reference to the inherited and acquired predispositions

Ó Arnold 2003 10.1191/1358863x03vm461ra

34 SR Deitcher and MPV Gomes
to hypercoagulability for which speciŽ c testing is available.
Although patients deemed to have a ‘hypercoagulable state’
are at a greater baseline risk for developing VTE than indi-
viduals without such conditions, most VTE appear to occur
as a result of a combination of risk factors. An underlying
inherited or acquired risk factor may provide a background
predisposition towards VTE and a situational risk factor
(’trigger’) may immediately precede and precipitate the
actual VTE. This is illustrated by the fact that 50–70% of
all VTE affecting patients with an inherited predisposition
to hypercoagulability are not ‘idiopathic’ (i.e., do not occur
spontaneously), but are rather triggered by a situational cir-
cumstance.1 0 – 1 6
Mounting interest in hypercoagulability, increasingly
available hypercoagulable state test ‘panels’, and enhanced
ability to identify both inherited and acquired disorders in
tested patients have led to an apparent increase in the utiliz-
ation of hypercoagulable state testing. While testing
uncovers a laboratory abnormality in over 50% of patients
presenting with VTE, it may not be in the patient’s best
interest.4 ,1 0 ,1 7 ,1 8 Such specialized testing is costly, and
results are frequently interpreted with exaggerated or insuf-
Ž cient concern. Assignment of excessive importance to a
test result may lead to a nonevidence-based use of
antithrombotic therapy and inappropriate justiŽ cation for
‘lifetime’ therapy.4 Inadequate attention to an abnormal
result, such as mild fasting hyperhomocysteinemia, may
result in avoidable risk. Nevertheless, hypercoagulable state
testing may be considered in selected patients provided that
the results will meaningfully impact management.
Emphasis on hypercoagulable state testing may also
undermine the pursuit of appropriate age- and gender-spe-
ciŽ c cancer screening. Such screening should be strongly
considered in older individuals and even in young patients,
particularly those with idiopathic VTE and unrevealing lab-
oratory screening for hypercoagulability.
In this article, the impact of selected hypercoagulable
states and cancer on VTE risk and VTE recurrence rates
will be brie y reviewed. A rational approach to hypercoag-
ulable state testing and cancer screening following VTE,
with emphasis on how such practice may impact manage-
ment, will be discussed.
Hypercoagulable states and venous
thrombosis
Appreciation for the prevalence of various hypercoagulable
states and the magnitude of VTE risk associated with them
is necessary to interpret the signiŽ cance of a positive test
result and to help predict the natural history and prognosis
of a thrombotic event in a given patient. Prevalence is pre-
dictably lowest in the general population, greater in individ-
uals with a single thrombotic event, and greatest in those
with recurrent VTE or from a thrombophilic family
(Table 1).1 9
The increased VTE risk associated with hypercoagulable
states can be expressed as absolute risk or, more commonly,
relative risk (RR). Although the RR is useful in comparing
the rates of VTE between a speciŽ ed group with a particular
disorder and the rates of VTE in normal controls, the absol-
ute risk is probably a better measure to assess the impor-
tance of a given risk for an individual patient.3 ,4
Vascular Medicine 2003; 8: 33–46
Activated protein C resistance (APC-R) and factor V
Leiden
APC-R due to the factor V Leiden mutation is the most
common inherited predisposition to hypercoagulability in
Caucasian populations of European ancestry.4 The highest
prevalence of the mutation is found in northern and western
Europe, but high prevalence is also found in the Americas,
Australia, the Middle East and the Indian region.2 0 Factor
V Leiden accounts for more than 90% of cases of APC-R,
with the remaining 10% of cases being due to pregnancy,
OCP use, other factor V point mutations, plasma glucosyl-
ceramide deŽ ciency, and selected antiphospholipid anti-
bodies such as anti-b2 -glycoprotein I and anti-phosphatidy-
lethanolamine antibodies.4 ,2 1 – 2 3 Even in the absence of
factor V Leiden, APC-R is an independent risk factor for
VTE.2 4 Heterozygous carriers of factor V Leiden have a
two to 10-fold increased lifetime RR of developing
VTE.1 0 ,1 1 ,1 5 ,2 5 – 2 9 The RR is further increased in combination
with pregnancy (ninefold), OCP use (36-fold) and HRT
(13- to 16-fold).3 0 – 3 4
There are con icting data on the role of factor V Leiden
heterozygosity as an independent risk factor for VTE recur-
rence. Two studies (‘positive studies’) have found an
increased risk of VTE recurrence compared with control
subjects, with RR of 4.1 and 2.4, respectively.3 5 ,3 6 Six other
studies (‘negative studies’) have found no such associ-
ation.3 7 – 4 2 The ‘positive studies’ by Ridker et al and
Simioni et al were prospective, but included a small number
of patients with factor V Leiden heterozygosity (14 and 41,
respectively).3 5 ,3 6 The Physician’s Health Study (by Ridker
et al) included only men.3 5 Among the ‘negative studies’,
four were prospective and two were retrospective.3 7 – 4 2
Three of the prospective studies and the large retrospective
cohort study by De Stefano et al included 80–112 patients
a piece with factor V Leiden heterozygosity.3 7 ,3 8 ,4 0 ,4 2 The
two ‘positive studies’ and three of the ‘negative studies’
had a patient follow-up period of four or more
years.3 5 ,3 6 ,3 8 ,4 0 ,4 2 The study by Simioni et al and two of the
‘negative studies’ did include some patients in whom the
diagnosis of VTE recurrence was made on clinical grounds
alone, without objective imaging assessment.3 6 ,3 8 ,4 2 When
only objectively conŽ rmed cases of VTE recurrence were
analyzed, the ‘negative study’ by Lindmarker et al showed
a nonstatistically signiŽ cant trend towards more VTE recur-
rence in individuals heterozygous for factor V Leiden com-
pared with noncarriers (16.1% versus 12.4%).3 8 One ‘posi-
tive study’ and three of the ‘negative studies’ also included
patients with upper extremity and distal lower extremity
(calf) DVT,3 5 ,3 7 ,3 8 ,4 1 while the ‘positive study’ by Simioni
et al had the greatest proportion of patients with proximal
lower extremity DVT (>90%).3 6 A recent re-evaluation of
the study by Simioni et al did conŽ rm the original study
Ž ndings of increased RR of recurrent VTE in heterozygous
carriers of factor V Leiden.4 3 The recently published PRE-
VENT trial revealed no difference in rate of recurrent VTE
in patients with factor V Leiden compared to patients with
only normal factor V alleles.1 4 9
Homozygous carriers of the factor V Leiden mutation
are estimated to have a 80-fold increased lifetime RR of
VTE.2 6 A more recent estimate, derived from a pooled
analysis of a larger population, has conŽ rmed an increased
risk of VTE but of lower magnitude (10-fold).2 9 The dis-
crepancy is likely due to the very low prevalence of factor

Table 1 Prevalence of selected inherited and acquired hypercoagulable states in different patient populations.
Hypercoagulable state General population
Factor V Leiden1 9 ,2 0,45 ,1 4 3,14 4 3–7%a
Prothrombin G20210A4 5 ,4 6 1–3%
Protein C deŽ ciency4 5 ,5 9,61 ,1 4 5 0.2–0.4%
Protein S deŽ ciency4 5 ,6 1,14 5 N/A
Antithrombin deŽ ciency4 5 ,6 1,14 5 ,1 46 0.02%
Mild hyperhomocysteinemia7 2 –7 4 5–10%
Elevated factor VIII7 5 11%
Lupus anticoagulant8 1 ,8 2,14 7 0–3%
Elevated anticardiolipin antibodies8 2 ,1 47 ,1 4 8 2–7%
a
Prevalence as high as 15% in northern Europe.
N/A, not available or unknown.
V Leiden homozygosity found in the healthy controls from
the general population.2 6 ,2 9 Most homozygous carriers
present with VTE before age 40, but some can live throm-
bosis free until the sixth or seventh decades of life, or even
remain asymptomatic for life.1 6 ,1 9 The majority of VTE are
situational, and women appear more likely to develop VTE
than men, suggesting an important role of OCP use and
pregnancy in triggering the events.1 6 ,1 9 ,4 4 Based on data
from the Ž rst prospective Duration of Anticoagulation
(DURAC-I) Trial, the risk of VTE recurrence is signiŽ -
cantly increased in homozygous factor V Leiden carriers
(36.4% at 48 months) when compared with heterozygous
carriers (16.1%) and controls (12.4%).3 8
Prothrombin G20210A
The prothrombin G20210A mutation (PT G20210A)
appears to result in elevated plasma prothrombin (factor
II) levels.4 5 In fact, the VTE risk increases as the plasma
prothrombin level increases, with levels greater than
115 IU/dl leading to a 2.1-fold increased RR of VTE.4 5 The
mutation also appears to follow a geographic and ethnic
distribution, with the highest prevalence occurring, unlike
factor V Leiden, in Caucasians from southern Europe
(3%).4 6 This prevalence is nearly twice the one observed
in northern Europe (1.7%).4 6 Similar to factor V Leiden, the
PT G20210A mutation is also found in Caucasians living in
North and South America, the Middle East and the Indian
region, and is virtually absent in individuals with Asian and
African backgrounds.2 0 ,4 6
Heterozygous PT G20210A is associated with a two to
sixfold increased lifetime RR of VTE.3 ,1 9 ,4 5 ,4 7 The risk
appears to be further increased in combination with preg-
nancy (15-fold) and OCP use (16-fold).3 0 ,4 8 The RR of cer-
ebral vein thrombosis is increased 10-fold in women with
this mutation who are not on OCP, as opposed to 150-fold
in OCP users.4 9 Homozygosity for PT G20210A has an
estimated populational prevalence of 0.014%,4 5 and homo-
zygous carriers appear to have greater predisposition to
develop early (before age 40) idiopathic recurrent VTE
than heterozygotes.5 0 ,5 1
The role of PT G20210A as a risk factor for VTE recur-
rence is less controversial than it is for factor V Leiden,
but data are also somewhat con icting. Simioni et al, re-
evaluating a prospective study from 1997, retrospectively
determined the patients’ PT G20210A mutation status and
Vascular Medicine 2003; 8: 33–46
Hypercoagulable state testing after VTE 35
Patients with Ž rst VTE Thrombophilic families
20% 50%
6% 18%
3% 6–8%
1–2% 3–13%
1% 4–8%
10–25% N/A
25% N/A
5–15% N/A
14% N/A
found that the hazard ratio of VTE recurrence was 2.4.4 3
However, three prospective studies, which included 28–52
patients a piece, showed no increased risk of recurrent VTE
in heterozygous PT G20210A carriers.3 8 ,5 2 ,5 3
More recently, a novel single-point mutation of the pro-
thrombin gene at position 20209 has been reported in four
unrelated patients, two of whom had a history of VTE and
one other had a history of stroke.5 4 Although the clinical
signiŽ cance of the PT C20209T mutation is unknown, it
may be underrecognized because it is not detected by the
polymerase chain reaction (PCR)/digestion assay com-
monly used for prothrombin gene mutation testing.4 5 ,5 4
Interestingly, all four individuals with PT C20209T were
African Americans.5 4 Two additional patients with this
mutation have been identiŽ ed by the same group of investi-
gators.
Natural anticoagulant deŽ ciency
A deŽ ciency of protein C, protein S or antithrombin is
present in a minority (5–15%) of patients with VTE.4 ,1 7 – 1 9
In family studies, VTE occurred in 50% of protein C-
deŽ cient relatives of affected probands before age 40, in
100% of protein S-deŽ cient relatives by age 70, and in 85%
of antithrombin deŽ cient relatives before the age of 55.55– 5 7
The estimated increased lifetime RR of VTE has been
reported to be up to 31-fold, 36-fold and 40-fold for protein
C, protein S and antithrombin deŽ ciency, respectively.1 0 ,1 2
However, recent studies have cast doubt on the real VTE
risk associated with these disorders. These include: the
Leiden Thrombophilia Study, which reported a lack of an
increased VTE risk in carriers of protein S deŽ ciency;5 8 the
study by Miletich et al, which failed to detect an increased
VTE risk in carriers of protein C deŽ ciency;5 9 and the study
by Koeleman et al, which demonstrated that the highest
VTE rates seen in families with protein C deŽ ciency were
actually reported in those relatives with double heteroz-
ygosity for protein C deŽ ciency and factor V Leiden, and
not in those with protein C deŽ ciency alone.6 0 Differences
in risk between family- and population-based studies can be
explained in part by greater difŽ culty in obtaining reliable
population-based estimates due to the overall low preva-
lence of these disorders. It is also possible that event rates
were overestimated in early familial studies.1 1 ,1 2 It has also
been hypothesized that both autosomal recessive and auto-
somal dominant clinical forms of protein C deŽ ciency exist,
36 SR Deitcher and MPV Gomes
the latter resulting from coinheritance of another throm-
bophilic defect, most commonly APC-R due to factor V
Leiden.5 9 ,6 0 Nevertheless, in studies of unselected patients
with VTE, the RR does appear to be increased, albeit not
as markedly as in family studies, by six to ninefold, Ž vefold
and twofold for protein C, antithrombin and protein S
deŽ ciency, respectively.3 ,5 5 ,5 8 ,6 1 An annual absolute risk of
VTE of 4.3% has been reported in women carriers of a
natural anticoagulant deŽ ciency who also use OCP, with
the highest risk seen in antithrombin deŽ cient women
(27.5% per year).1 1 ,6 2 Although early studies reported very
high incidences of pregnancy-related VTE (17%, 33% and
70% for protein S, protein C and antithrombin-deŽ cient
women, respectively), two recent reports showed VTE inci-
dence of 4.1% per pregnancy (including the postpartum
period), with an eightfold increased RR of VTE compared
with pregnant noncarriers.1 1 ,6 3 ,6 4
The risk of VTE recurrence associated with any of the
natural anticoagulant deŽ ciencies is difŽ cult to ascertain
due to the lack of prospective studies with long-term fol-
low-up, but it appears to be high.6 5 – 6 7 The rare homozygous
protein C or protein S deŽ ciency is associated with neonatal
purpura fulminans, whereas the extremely rare homozygous
type I antithrombin deŽ ciency is believed to be fatal in
utero.1 9 ,6 8 ,6 9
Hyperhomocysteinemia
The amino acid homocysteine is normally metabolized via
the trans-sulfuration pathway by the enzyme cystathionine-
b-synthase (CBS), which requires vitamin B6 as cofactor,
and via the remethylation pathway by the enzymes methyl-
enetetrahydrofolate reductase (MTHFR), which is folate
dependent, and methionine synthase, which requires vit-
amin B12 as cofactor.5 ,7 0 Inherited severe hyperhomocyste-
inemia (plasma level >100 mmol/l), as seen in classic
homocystinuria, may result from homozygous MTHFR and
CBS deŽ ciencies and, more rarely, from inherited errors
of cobalamin metabolism.5 ,7 0 ,7 1 Inherited mild to moderate
hyperhomocysteinemia (plasma level >15–100 mmol/l)
may result from heterozygous MTHFR and CBS
deŽ ciencies, but most commonly it results from the thermo-
labile variant of MTHFR (tlMTHFR) that is encoded by
the C677T gene polymorphism.5 ,7 0 ,7 1 Acquired hyperhomo-
cysteinemia may be caused by folate deŽ ciency, vitamins
B6 and B12 deŽ ciencies, renal insufŽ ciency, hypothyroid-
ism, diabetes mellitus, pernicious anemia, in ammatory
bowel disease, carcinoma (particularly involving breast,
ovaries or pancreas), acute lymphoblastic leukemia, as well
as methotrexate, theophylline and phenytoin therapy.5 ,7 0 ,7 1
Heterozygous carriers of the tlMTHFR mutation have
normal plasma homocysteine levels.7 1 More importantly,
the majority of case–control studies have failed to demon-
strate an increased VTE risk in homozygous carriers of the
tlMTHFR, and the majority of individuals with hyperhomo-
cysteinemia do not have the tlMTHFR polymorphism.7 1
Thus, characterization of the tlMTHFR polymorphism is
not useful to determine an individual’s VTE risk. VTE risk
is most closely related to elevated fasting plasma homocys-
teine levels, regardless of etiology. Hyperhomocysteinemia
(plasma level >18.5 mmol/l) has been associated with a two
to fourfold increased VTE risk.7 2 ,7 3 Interestingly, in the
Physician’s Health Study, hyperhomocysteinemia (plasma
level above the 95th percentile- 17.2 mmol/l) did increase
Vascular Medicine 2003; 8: 33–46
the risk of idiopathic VTE (RR=3.4) but not the risk of all
(situational and idiopathic) VTE.2 8 The cumulative prob-
ability of VTE recurrence two years after discontinuation
of anticoagulation has been shown to be higher in patients
with persistent hyperhomocysteinemia (plasma levels
above the 95th percentile) than in controls (19.2% versus
6.3%, RR 2.7, p = 0.009).7 4
Elevated factor VIII activity
It is now appreciated that elevated levels of procoagulant
coagulation factors, in addition to deŽ ciencies of natural
anticoagulant proteins, are risk factors for VTE. Of all
coagulation factors implicated as potential risk factors for
VTE, evidence supporting the role of factor VIII is the
strongest. Factor VIII activity levels greater than 1.5 IU/ml
(150%) are associated with a threefold and a sixfold greater
RR of VTE when compared with levels below 1.5 IU/ml
(150%) and below 1.0 IU/ml (100%), respectively.7 5 VTE
risk is increased 11-fold with factor VIII levels greater than
200%, but does not appear to be accentuated by concomi-
tant OCP use.7 6 ,7 7 Elevated activity levels of factor VIII
associated with VTE risk seem to be persistent and not
solely attributable to acute phase response.7 8 Transiently
elevated factor VIII levels associated with acute phase pro-
tein release, though, may in part explain the hypercoagul-
ability associated with in ammatory disorders such as
in ammatory bowel disease and cancer. Individuals with
plasma factor VIII activity greater than 234% (above the
90th percentile cut-off point for the study population) have
a 6.7-fold increased RR of recurrent VTE compared to
those with activity levels of less than 120%.6
Because factor VIII is indeed an acute phase reactant and
its levels can be affected by many factors, including blood
type and von Willebrand factor concentration, determi-
nation of the true meaning of an elevated factor VIII level
in an individual patient with VTE is challenging. In the
study by Koster et al, where blood samples for factor VIII
activity were obtained a minimum of six months after the
VTE, it was impossible to completely differentiate between
inherited elevation and post-thrombotic transient elevation
of factor VIII.1 9 ,7 5 Nonetheless, the fact that an increased
factor VIII is prevalent in persons with VTE (see Table 1)
may, in fact, imply that elevated factor VIII is not only
frequent but also an important risk factor for VTE.1 9
Antiphospholipid antibodies
Antiphospholipid antibodies consist of two major sub-
groups: the lupus anticoagulants and the anticardiolipin
antibodies. It is difŽ cult to determine the exact prevalence
of antiphospholipid antibodies in the general population
because anticardiolipin antibodies do not follow a Gaussian
distribution in normal individuals, lupus anticoagulants
detection can depend on the test or combination of tests
employed, and the titers of both types of antibodies may
 uctuate over time.7 9 The prevalence of antiphospholipid
antibodies in patients with systemic lupus erythematosus
(SLE) is as high as 60% (‘secondary antiphospholipid
antibodies’), but data on the incidence of VTE in this spe-
ciŽ c population cannot be extrapolated to patients without
SLE (‘primary antiphospholipid antibodies’).7 9 – 8 2 In indi-
viduals with primary antiphospholipid antibodies, the pres-
ence of lupus anticoagulants appears to be more strongly
associated with the risk of VTE, with increased RR of nine

to 11-fold as opposed to 3.2-fold and 1.6-fold for high and
low anticardiolipin antibody titers, respectively.8 1 – 8 3 The
presence of lupus anticoagulants or persistently elevated tit-
ers of IgG anticardiolipin antibodies (measured after six
months of anticoagulant therapy) have both been found to
be associated with signiŽ cantly higher rates of VTE recur-
rence.3 9 ,6 7 ,7 9 ,8 4 ,8 5
Combined defects
Compound heterozygosity for two different natural antico-
agulant deŽ ciencies is extremely rare due to the low preva-
lence of each individual defect. The phenotypic presen-
tation of such compound heterozygotes does not appear to
be as severe as it is for the homozygous forms of each
deŽ ciency, with the rarely reported patient presenting with
VTE of early onset (in the teenage years).1 0 ,1 9 Because fac-
tor V Leiden is the most common inherited thombophilia,
double heterozygosity for factor V Leiden and a natural
anticoagulant deŽ ciency has been described in some famil-
ies.6 0 ,8 6 In families harboring factor V Leiden and protein
C deŽ ciency, 73% of compound heterozygotes reported a
history of VTE, compared with 31% and 13% of relatives
with protein C deŽ ciency only and factor V Leiden only,
respectively.6 0 In families with factor V Leiden and
antithrombin deŽ ciency, 92% of double-heterozygous car-
riers had a history of VTE, as opposed to 57% and 20%
of individuals with antithrombin deŽ ciency only and factor
V Leiden only, respectively.8 6
Although it is clear that VTE are more frequent in dou-
ble-heterozygous carriers from thrombophilic families as
described above, evaluation of a true interaction and esti-
mation of VTE risk cannot be determined due to lack of
power.1 9 ,2 9 However, combined heterozygosity for both fac-
tor V Leiden and prothrombin G20210A mutations, which
is estimated to occur in one in 1000 persons, does appear
to be associated with an increased RR of both Ž rst and
recurrent VTE.2 9 ,4 2 ,6 7 In a pooled analysis of eight case–
control studies including over 2000 patients with VTE, a
2.2% prevalence for the combined mutations was found in
patients.2 9 Twelve per cent of patients with factor V Leiden
were also heterozygous for PT G20210A, and 23% of
patients with PT G20210A were also heterozygous for fac-
tor V Leiden.2 9 Double heterozygosity was associated with
a 20-fold increased RR of VTE.2 9 The risk of recurrent
VTE for heterozygous carriers of both factor V Leiden and
PT G20210A also appears to be increased (RR = 2.6).4 2
The prevalence of factor V Leiden carriership in combi-
nation with acquired hypercoagulable states has also been
studied. Factor V Leiden appears to increase the risk of
VTE in patients with antiphospholipid antibodies, but is not
a prerequisite for the development of VTE in those
patients.1 9 ,8 7 The interaction between factor V Leiden and
hyperhomocysteinemia has been a matter of interest since
the observation, not corroborated by further studies, that
factor V Leiden appeared to be a prerequisite for VTE in
individuals from families with classic homocystinuria.8 8
Nonetheless, two studies on the interaction between mild to
moderate hyperhomocysteinemia and factor V Leiden have
yielded somewhat different Ž ndings. Den Heijer et al found
that the RR of VTE associated with the combination of
conditions (RR = 2.0) did not exceed the RR associated
with each condition alone (RR=9.5 for factor V Leiden,
RR = 2.2 for hyperhomocysteinemia).7 2 However, in the
Vascular Medicine 2003; 8: 33–46
Hypercoagulable state testing after VTE 37
large Physician’s Health Study, the concomitant presence
of both conditions did appear to be synergistic.2 8 The rela-
tive risks of 21.8 and 9.7 for idiopathic VTE and all VTE
(situational and idiopathic), respectively, far exceeded the
RR of VTE associated with each condition alone.2 8 Thus,
it is uncertain whether the interaction between factor V
Leiden and hyperhomocysteinemia is, in fact, synergistic.
Because both studies used the 95th percentile cut-off point
for plasma homocysteine levels, the discrepancies in the
reported relative risks (2.0 and 21.8 in the Dutch and the
American study, respectively) could have resulted from the
small number of patients with both conditions.1 9 ,2 8 ,7 2 In the
Physician’s Health Study, only four patients and two con-
trols had the combined defects.2 8
Cancer and venous thrombosis
The incidence of symptomatic VTE in cancer patients has
been reported to be as high as 15%, but prevalence as high
as 50% has been reported in postmortem studies.8 9 Cancer
patients have higher rates of postoperative VTE than
patients without malignancy, and are three times more
likely to die within the Ž rst six months of an initial VTE
event than patients without cancer.9 0 ,9 1 Moreover, for any
given international normalized ratio (INR) range (within,
below or above the target 2.0–3.0), cancer patients are more
likely to develop recurrent VTE while on oral anticoagul-
ation than patients without cancer.9 2 The VTE risk varies
between different histologic types of malignancy, and is
markedly increased when selected chemotherapeutic agents
are administered (Table 2).9 1 ,9 3 VTE may also be the
presenting feature of occult malignancy, and several studies
have shown that patients presenting with idiopathic VTE
will be more frequently diagnosed with cancer in follow-
up than controls or those presenting with situational VTE
(Table 3).9 4 – 9 8 The majority of new cancers are diagnosed
during the index hospitalization for VTE.9 7 ,9 8 In addition,
two large studies from the Swedish and Danish Registries
showed that patients with idiopathic VTE had a higher rate
of cancer diagnosis than expected for the general popu-
lation, particularly during the Ž rst six months following the
VTE event.9 9 ,1 0 0
Whether patients with idiopathic VTE should undergo
any speciŽ c form of cancer screening is debatable. Whether
patients who undergo cancer screening should have a lim-
ited or extensive evaluation is also a matter of debate. A
limited clinical evaluation typically consists of four compo-
Table 2 Relative risk of deep venous thrombosis in noncancer
and cancer patients.
Patient population Relative risk
of VTE
Hospitalized, noncancer, 60–70 years of age 1
Hospitalized, noncancer, 70–80 years of age 2
Breast cancer 4
Lung cancer 90
Breast cancer on chemotherapy 140
Pancreatic cancer 150
Gastrointestinal cancer 150
Data from ref. 93.
38 SR Deitcher and MPV Gomes
Table 3 Subsequent cancer diagnosis in patients with idiopathic VTE compared with control patients and patients with situational
VTE.
Reference Follow-up period Idiopathic VTE
Nordström et al9 4 7 years 11%
Prandoni et al9 5 24 monthsa 10.5%
Bastounis et al9 6 24 months 25%
Monreal et al9 7 5 yearsb 12.4%
Monreal et al9 8 24 monthsc 22.4%
a
All new cancers diagnosed within 18 months of follow-up.
b
Most new cancers diagnosed within 12 months of the index VTE.
c
Majority of new cancers diagnosed during index hospitalization for VTE.
nents: comprehensive history, physical examination includ-
ing digital rectal examination, basic laboratory testing, and
chest radiography.9 5 ,1 0 1 In a retrospective cohort study of
986 patients who underwent duplex ultrasound for sus-
pected idiopathic DVT, Cornuz et al found that all patients
conŽ rmed to have a DVT and diagnosed with cancer at
the time of the initial VTE presentation had one or more
abnormalities on at least one of the four components of
the limited clinical evaluation.1 0 1 No patient with a normal
limited clinical evaluation was diagnosed with cancer dur-
ing follow-up. The probability of cancer-free survival in
patients with DVT and no cancer was similar to those with-
out conŽ rmed DVT, thus supporting the conclusion that
additional testing should be guided by abnormalities
detected on the initial limited work-up.1 0 1 In contrast, in a
retrospective study of 674 patients hospitalized with idio-
pathic or situational DVT, Monreal et al reported that 15
of 674 patients were diagnosed with occult cancers during
admission, but the diagnosis of cancer in those 15 patients
would not have been possible had an initial extensive work-
up not been performed.9 7 Extensive work-up includes com-
puted tomography, tumor markers and, in some cases,
abdominal ultrasound, colonoscopy, upper endoscopy and
biopsies.9 6 – 9 8 Although nine of the 15 patients with occult
cancer reported by Monreal et al had early stage disease
and underwent curative surgery (seven cases of prostate
cancer, two cases of colon cancer),9 7 the fact that an exten-
sive cancer screening may indeed detect more cancers at
VTE presentation does not imply that malignancies will be
diagnosed at early stages. In the study from the Danish
Registry, 44% of patients with cancer had distant metastasis
at the time of VTE presentation.1 0 2 To date, there are no
studies demonstrating that the diagnosis of more cancers
at the time of VTE presentation translates into prolonged
patient survival.
Hypercoagulable state testing
A rational approach to hypercoagulable state testing in
patients with VTE should focus on the identiŽ cation of the
individuals most likely to beneŽ t from testing and the per-
formance of tests that will yield useful data.
Who should be tested?
Thirty to 50% of all venous thrombotic events in patients
with known hypercoagulability occur without a clear trig-
ger (i.e., idiopathic).1 0 – 1 6 Idiopathic VTE is probably the
Vascular Medicine 2003; 8: 33–46
Situational VTE Controls
– 7%
1.9% –
4% –
1.8% –
6.1% –
most common reason physicians order hypercoagulable
state tests. Other traditional indications for testing include
VTE in unusual sites, recurrent VTE, venous thrombosis at
a young age (<45 years), venous thrombosis in the setting
of a strong family history of VTE, and unexplained recur-
rent pregnancy loss.4 ,1 9 ,1 0 3 Selected testing should also be
considered in relatives of patients with known inherited
hypercoagulability, provided that the results will either
affect one’s decision to undergo elective surgery based on
an excessive postoperative VTE risk or help women to
make an informed decision about OCP use, HRT or preg-
nancy.4
While it is true that an abnormality is more likely to be
found in the setting of recurrent VTE and VTE in unusual
sites, testing may still not be necessary in these settings. We
feel that testing should be strongly considered in patients
presenting with VTE and a combination (two or more) of
the indications listed above. Because the majority of VTE
events are made up of situational and idiopathic events in
individuals with only one indication for testing, we actually
advocate testing in a minority of patients with VTE. Careful
selection of the patient population to be tested increases the
likelihood not only of Ž nding an abnormality but most of
all of Ž nding an abnormality that is likely to be playing a
causative role in the patients’ VTE.
Why should testing be performed?
Even if a patient falls into one or more of the groups at
high risk for harboring a hypercoagulable state, testing
should only be performed if a deŽ ned beneŽ t can be ident-
iŽ ed a priori. Hypercoagulable state testing may impact
management by guiding the duration of anticoagulant ther-
apy, the intensity of such therapy as well as therapeutic
monitoring strategies. In addition, testing may impact
patient prognosis determination, family screening, family
planning, and the use of concomitant medications.
Duration of therapy
Determination of the optimal length of therapy would be
an ideal goal of hypercoagulable state testing. To date,
however, conclusive evidence from prospective, ran-
domized controlled trials comparing different durations of
treatment in individuals with speciŽ c hypercoagulable
states is lacking. Thus, in reality, the decision-making pro-
cess needs to be tailored to each patient based on the avail-
able estimates of VTE recurrence, the nature of the VTE,
and the risk of bleeding associated with oral anticoagul-
ation. Current guidelines recommend oral anticoagulation

therapy for a minimum of six months in patients presenting
with idiopathic VTE.1 0 4 The longer the duration of therapy
the lower the VTE recurrence rates, but this beneŽ t is par-
tially offset by annual major bleeding rates of approxi-
mately 3–4% (as high as 7–9% in the elderly).3 9 ,1 0 4 – 1 0 6 In
addition, the beneŽ t of lower VTE recurrence is not sus-
tained once anticoagulant therapy is stopped and the cumu-
lative recurrence rate catches up with time.1 0 5 Based on
available data, a decision to prolong warfarin therapy in
patients with either heterozygous factor V Leiden or PT
G20210A does not seem justiŽ ed because there is no con-
clusive evidence that these mutations increase the risk of
VTE recurrence. In fact, the Sixth American College of
Chest Physicians (ACCP) Consensus Guidelines on
Antithrombotic Therapy do not recommend prolonging oral
anticoagulation beyond three to six months for patients with
factor V Leiden or PT G20210A heterozygosity.1 0 4 But
patients with combined inherited defects, homozygous fac-
tor V Leiden, documented antiphospholipid antibodies six
months following index VTE, and deŽ ciencies of natural
anticoagulants do appear to have increased VTE recurrence
rates.3 9 ,4 2 ,6 5 – 6 7 ,8 4 ,8 5 Hence testing for these disorders may
help deŽ ne the need for long-term therapy. Unfortunately,
the ideal duration of therapy is unknown because the bal-
ance between the beneŽ ts and risks of long-term anticoag-
ulation is likely to shift as the patient ages.3 9 ,1 0 4 – 1 0 7
Moreover, it must be emphasized that an increased RR
of VTE recurrence, regardless of magnitude, should not
singularly mandate the prescription of long-term (nor
‘lifetime’) anticoagulation. This is particularly true for con-
ditions that have been shown to increase the RR of recur-
rent VTE by a factor of 1 to 3. In this scenario, long-term
anticoagulation may not be prudent if the patient belongs
to a high-risk group for oral anticoagulation-related major
bleeding. At what level of increased RR of recurrence one
should always prescribe long-term anticoagulation therapy
is not known. Therefore, given the available evidence to
date, it is impossible to avoid individualization of duration
of therapy recommendations.
Because the only study demonstrating an association
between hyperhomocysteinemia and VTE recurrence did
not use vitamin supplementation, it is not clear whether
plasma homocysteine level normalization reduces the risk
of recurrent VTE.7 4 Further studies are required before any
recommendations on long-term anticoagulation therapy can
be made based on elevated factor VIII levels alone.
Intensity of therapy and therapeutic monitoring
Testing for lupus anticoagulants may signiŽ cantly impact
management in two distinct ways. First, lupus anticoagu-
lants can cause a prolongation of the activated partial
thromboplastin time (aPTT), making therapeutic monitor-
ing and determination of a target treatment intensity of
unfractionated heparin a challenge. Options in this setting
include monitoring by heparin assay (protamine titration or
anti-factor Xa activity assay) instead of the aPTT and treat-
ment with an anticoagulant that does not require monitor-
ing, such as a low-molecular-weight heparin.
Secondly, 26.8–53% of patients with lupus anticoagu-
lants have a baseline prolonged prothrombin time, and in
many of these patients the corresponding INR is already
greater than 2.0 prior to initiation of warfarin therapy.1 0 8
In this situation, warfarin monitoring with an alternative
Vascular Medicine 2003; 8: 33–46
Hypercoagulable state testing after VTE 39
assay such as a chromogenic factor X activity assay is rec-
ommended.1 0 8 Even if the baseline prothrombin time is nor-
mal, the INR may still be unreliable for monitoring warfa-
rin therapy.1 0 8 Although one trial suggested that
maintaining an INR >3.0 in patients with VTE and antipho-
spholipid antibodies was advisable due to higher recurrent
VTE rates seen in those with INR <3.0, it is unclear
whether the INR was reliable for monitoring warfarin ther-
apy in all subjects included in the study.8 5 Because no
further studies have addressed this issue, the ideal target
INR range for patients with lupus anticoagulants remains
unclear.1 0 9 In the study by Schulman et al, no VTE recur-
rence was observed in patients with documented anticardi-
olipin antibodies maintained at a target INR of 2.0–3.0,
which appears to be adequate in this patient population.8 4
Need for additional speciŽ c therapy
Hyperhomocysteinemia is a risk factor for both VTE and
premature atherosclerotic disease, and plasma homocys-
teine levels can be lowered in many by folic acid supple-
mentation.5 ,1 1 0 IdentiŽ cation of a deŽ ciency in a natural
anticoagulant may prompt replacement therapy prior to
high-risk situations such as pregnancy, delivery and major
surgery. Fresh frozen plasma (FFP) contains protein S, pro-
tein C and antithrombin at a concentration of 1.0 IU/ml,
but replacement therapy with FFP may require large trans-
fusion volumes that can precipitate congestive heart failure
and lead to exposure to viral antigens. Plasma-derived and
recombinant antithrombin concentrates exist, and activated
protein C (APC) concentrate may theoretically be useful in
protein C-deŽ cient patients.
Family screening
Because of the low overall absolute risk of idiopathic VTE
associated with most of the hypercoagulable states, testing
of asymptomatic family members for any hypercoagulable
state with the sole purpose of initiating long-term prophy-
lactic therapy is not advised.1 1 – 1 5 ,1 7 ,1 8 ,5 5 ,1 0 3 ,1 0 9 Consideration
for oral anticoagulation (target INR 1.5–2.0) of asymptom-
atic antithrombin-deŽ cient relatives between the ages of 15
and 40 years was suggested in the past due to the very
high rates of VTE occurring at a young age.5 7 However,
the reliability of those rates is highly questionable, for early
family studies were likely biased reports that overestimated
VTE risk.1 2 ,1 1 1 Furthermore, recent studies of antithrombin
deŽ cient families have reported that asymptomatic carriers
have a low risk of fatal VTE and no excess mortality com-
pared with the general population, hence making oral antic-
oagulation of asymptomatic individuals with antithrombin
deŽ ciency less appealing.1 1 2 ,1 1 3
The most common reasons for screening asymptomatic
relatives of VTE patients are related to OCP use, HRT and
pregnancy. Both OCP and HRT are associated with a two
to sixfold increased RR of VTE in women with no known
hypercoagulable states.1 1 4 We believe that this risk of VTE
should be discussed with any women who plan to use OCP
or HRT. After being informed of the OCP-related VTE risk,
some women may choose to avoid these drugs regardless
of any test result. Others may indicate an unwillingness to
discontinue these drugs regardless of any identiŽ ed con-
comitant hypercoagulable state. If testing is desired and will
impact the woman’s informed decision about using these
medications, it is reasonable to screen for the common
40 SR Deitcher and MPV Gomes
inherited disorders. Testing all women, regardless of per-
sonal or family history of VTE, prior to starting OCP use
is not currently recommended mainly because of cost-effec-
tiveness concerns.1 1 5 ,1 1 6
More extensive testing should be offered to asymptom-
atic women who plan to use OCP or HRT and are relatives
of VTE patients known to have a deŽ ciency of a natural
anticoagulant. It is prudent that estrogen-containing OCP
and HRT be avoided in women with a natural anticoagulant
deŽ ciency, especially antithrombin and protein C, because
of the high (4%) annual absolute risk of VTE reported in
this group.1 1 ,6 2 ,1 1 6 Such recommendations – testing and
avoidance of OCP and HRT – do not necessarily apply to
women with heterozygous factor V Leiden or PT
G20210A mutation.
In women on estrogen-containing OCP who are hetero-
zygous for factor V Leiden, an increased RR of VTE of
approximately 35-fold has been reported.3 1 Although data
are not as abundant for PT G20210A, carriers who are OCP
users appear to not only have a greater risk of DVT but
also have a worrisome 150-fold increased RR of cerebral
vein thrombosis.4 8 ,4 9 However, caution must be taken when
interpreting these epidemiological data because the calcu-
lated RRs are derived from studies that included small num-
bers of controls (i.e., hormone users with the mutation but
without VTE) and the conŽ dence intervals around each RR
are wide.3 1 – 3 4 ,4 8 ,4 9 In addition, because women on OCP
belong to a young age group, with an estimated baseline
absolute risk of VTE of one per 10 000 persons per year,
a 35-fold increased RR of DVT translates into an absolute
risk that is still fairly low.3 1 ,1 1 6 Furthermore, OCP remains
the most efŽ cacious form of prescribed contraception.3 1 ,1 1 6
While it appears reasonable to recommend avoidance of
OCP use in women with or without a personal history of
VTE who carry either factor V Leiden or PT G20210A
heterozygosity, this approach may lead to unwanted preg-
nancy with its attendant VTE risk. Therefore, Ž rm rec-
ommendations regarding allowance or avoidance of OCP
in women with factor V Leiden or PT G20210A mutation
cannot be made in light of current data.
In contrast, because women on HRT usually belong to
an older age group, with an estimated annual baseline VTE
risk between one per 1000 and one per 100, a 15-fold
increased RR of VTE in those with heterozygous factor V
Leiden may have a signiŽ cantly larger impact on women’s
health.3 2 ,3 3 Some authors have suggested that, in women
with established coronary disease who carry factor V
Leiden heterozygosity but have no personal history of VTE,
the risks (of VTE) associated with HRT outweigh the bene-
Ž ts.3 3 The same lack of a favorable beneŽ t-to-risk ratio
exists for postmenopausal women without coronary disease
based on the Women’s Health Initiative trial that failed to
prove that combination HRT is effective for the primary
prevention of coronary events.1 5 0
In women with a personal history of recent VTE, we
advocate strict avoidance of estrogen-containing OCP for
at least one year following the event regardless of any test-
ing result. Although there are no studies showing that OCP
are independent risk factors for VTE recurrence, the inci-
dence of OCP-related VTE is higher during the Ž rst year of
OCP use.1 1 6 During that Ž rst year post-VTE, and probably
beyond the Ž rst year, an effective and safe form of non-
estrogen-containing contraception should be prescribed.
Vascular Medicine 2003; 8: 33–46
Progesterone-only pills or injections do not appear to
increase the VTE risk to the same extent as estrogen-con-
taining OCP (at least in women without a previous history
of VTE),1 1 6 – 1 1 8 and are a potential alternative to estrogen-
containing OCP. It is unknown whether progestin-only for-
mulations are safer than estrogen-containing OCP in car-
riers of factor V Leiden or PT G20210A mutation. Because
HRT has been shown to signiŽ cantly increase the risk of
recurrent VTE, HRT should be avoided in women with a
personal history of VTE regardless of the results of any
testing.1 1 9 ,1 2 0
The VTE risk in OCP users needs to be counterbalanced
with the pregnancy-related risk of VTE. VTE are reported
to occur in 0.1–0.2% of all pregnancies, and the risk is
increased in women with any of the inherited hypercoagul-
able states.1 1 ,3 0 ,6 3 ,6 4 In general, pregnant asymptomatic
women with a family history of VTE should not undergo
hypercoagulable state testing, unless their relatives are
known to have protein C, protein S or antithrombin
deŽ ciency. This is because: (a) the predictive value of fac-
tor V Leiden and PT G20210A for the occurrence of VTE
during pregnancy is low (except for combined defects);3 0
(b) Postpartum anticoagulation with heparin followed by
conversion to warfarin (target INR 2.0–3.0) has been rec-
ommended for women with protein C or protein S
deŽ ciency;1 0 3 (c) VTE prophylaxis during pregnancy fol-
lowed by anticoagulation for the six weeks postpartum has
been recommended for women carriers of antithrombin
deŽ ciency;6 3 ,1 0 3 ,1 2 1 and (d) APC or antithrombin concen-
trates could be made readily available at the time of deliv-
ery. We do not advocate hypercoagulable state testing in
women with prior history of idiopathic VTE who want to
become pregnant, because VTE prophylaxis during preg-
nancy may be indicated regardless of the results of test-
ing.4 ,6 3 ,1 0 3 ,1 2 1 The exception may be antithrombin
deŽ ciency: while some authors have recommended VTE
prophylaxis during pregnancy followed by anticoagulation
with warfarin postpartum,1 0 3 others have recommended
treatment (not prophylaxis) with subcutaneous unfraction-
ated heparin to prolong the aPTT to 1.5–2.0 times the con-
trol throughout pregnancy and postpartum period.6 3 Brill-
Edwards et al, though, found a low (2.4%) risk of antepar-
tum recurrent VTE in pregnant women with single previous
episode of VTE.1 2 2 Three of 125 women (2.4%) with recur-
rent VTE had a history of idiopathic VTE (two women)
and of situational VTE in the setting of OCP use and factor
V Leiden heterozygosity.1 2 2 Based on these Ž ndings, the
authors concluded, as did the Sixth ACCP Consensus
Guidelines for Antithrombotic Therapy, that routine ante-
partum prophylaxis for VTE is not warranted for pregnant
women with prior history of VTE, but that postpartum (six
weeks) treatment-intensity anticoagulation is recommended
to all pregnant women with previous VTE (idiopathic and
situational) because of the ‘safety, convenience and low
cost’ associated with such therapy.1 2 1 ,1 2 2 Therefore, testing
for antithrombin, protein C and protein S deŽ ciencies are
the only ones that can impact management for pregnant
women with or without a personal history of VTE who are
relatives of patients with VTE. In addition, because the sim-
ple presence of factor V Leiden or PT G20210A heteroz-
ygosity does not appear to identify women at markedly high
absolute risk for VTE during pregnancy (even though they
are associated with an increased RR),3 0 testing for these

two common conditions should be reserved for women who
will base their decision to become pregnant or not on the
results of testing.
Antiphospholipid antibody testing should be considered
in women with at least three consecutive Ž rst-trimester
spontaneous miscarriages or in those with at least one
second- or third-trimester unexplained death of a morpho-
logically normal fetus.1 2 3 ,1 2 4 In this scenario, a positive test
result may prompt the decision to use some form of
additional therapy with any following pregnancy attempt.
Aspirin alone, unfractionated heparin (or low-molecular-
weight heparin) alone, or a combination of low-dose aspirin
with prophylactic heparin have all been reported to lead
to successful pregnancy outcomes.7 9 However, more recent
studies have shown that low-dose aspirin was not superior
to placebo and that a regimen of heparin plus low-dose
aspirin was more effective than aspirin alone for achieving
live births among women with APA.1 0 9 ,1 2 1 ,1 2 5
What tests should be performed?
If testing is deemed appropriate in a carefully selected
patient, proper selection of the speciŽ c tests to be perfor-
med should be individualized and based on the patient’s
age, thrombotic presentation, family history and how each
test will impact management. For example, elderly patients
with no family history of VTE are unlikely to have congeni-
tal deŽ ciency of a natural anticoagulant, but have a high
prevalence of factor V Leiden and hyperhomocysteine-
mia.1 2 6 In general, we recommend avoidance of test
‘panels’ because it is likely that only selected assays will
be useful for a given patient. Moreover, different hospitals
may include different tests in their ‘panels’, and it is poss-
ible that a given ‘panel’ will comprise tests that are
unnecessary for some patients while not including other
tests that will be appropriate for other patients.
Laboratory testing for hypercoagulable states is best per-
formed in stages, with initial testing made up of the highest
yield assays (Table 4).6 9 We recommend performing APC-
R testing initially for the two following reasons: (a) if nega-
tive, testing for the factor V Leiden mutation is unnecess-
ary; and (b) the presence of APC-R may interfere with pro-
tein S assays.1 2 7 Even though carriers of the PT G20210A
mutation are known to have higher prothrombin activity
levels than noncarriers, measurement of prothrombin
activity is not recommended because, by itself and in an
individual patient, it does not sufŽ ciently differentiate car-
riers from noncarriers.4 ,4 5 We prefer activity assays for pro-
tein C, protein S and antithrombin initially because activity
will be reduced both in quantitative (type I) and qualitative
Table 4 Screening laboratory evaluation for patients sus-
pected of having a hypercoagulable state.
1) Activated protein C-resistance (diluting patient plasma
with factor V-deŽ cient plasma)
2) Prothrombin G20210A mutation testing by PCR
3) Activity assays for antithrombin, protein C and protein S
4) Activated PTT, aPTT mixing studies and dilute Russel viper
venom time (dRVVT)
5) Fasting total plasma homocysteine level
6) Anticardiolipin antibody testing by enzyme-linked
immunosorbent assays (ELISA)
7) Factor VIII activity
Vascular Medicine 2003; 8: 33–46
Hypercoagulable state testing after VTE 41
(type II) disorders, whereas antigenic assays are usually
normal in type II disorders.6 9 Genotyping for the tlMTHFR
is not indicated because, unlike measurement of plasma
homocysteine levels, it is not useful to identify individuals
at higher VTE risk.7 1 Factor VIII activity testing may also
be prudent, particularly in individuals with suspected pro-
tein S deŽ ciency, because activity >250% can interfere with
protein S activity testing.1 2 7 Initial testing for antiphosphol-
ipid antibodies should follow the guidelines set by the Inter-
national Society on Thrombosis and Haemostasis, con-
sisting of two distinct LA assays and ACA testing by
enzyme-linked immunosorbent assay (ELISA). 1 2 8
If any initial assays are abnormal, pertinent conŽ rmatory
tests including polymerase chain reaction (PCR) for factor
V Leiden, antigenic assays for protein C, protein S and
antithrombin (including free and total antigen for protein
S), as well as conŽ rmatory tests for LA, such as the platelet
neutralization procedure, should be performed.6 9 ,1 2 8
VTE in unusual sites occurs more frequently in, and can
be suggestive of certain hypercoagulable disorders
(Table 5).4 9 ,5 7 ,1 0 9 ,1 2 9 – 1 3 3 Paroxysmal nocturnal hemoglobin-
uria (PNH) and the myeloproliferative syndromes are com-
monly associated with VTE in unusual sites.1 2 9 – 1 3 3 PNH
should be suspected in the setting of leukopenia, throm-
bocytopenia and hemolytic anemia in association with
VTE. VTE occurs in up to 40% of PNH patients, and the
intra-abdominal veins are commonly involved.1 2 9 ,1 3 0 Flow
cytometry for CD-55 and CD-59 are the diagnostic tests of
choice for PNH, whereas a complete blood count is the
initial screening test for the myeloproliferative syndromes.
When should patients be tested?
It is important to note that a number of conditions may
interfere with the laboratory tests used to identify hyper-
coagulable states. These interferences most often lead to
false-positive identiŽ cation of a hypercoagulable state, and
may be particularly important by hampering one’s ability
to conŽ rm or refute the true presence of an inherited VTE
predisposition.6 9 Acute illness may cause elevation of acute
phase proteins such as factor VIII, Ž brinogen, C4b-binding
protein (C4b-BP) and IgM ACA. Elevated C4b-BP can
shift the balance between free (active) protein S and bound
(inactive) protein S resulting in both free and functional
protein S deŽ ciency.6 9 Factor VIII activity greater 250%,
APA, and APC-R also can cause an apparent protein S
deŽ ciency.6 9 ,1 2 7 In fact, many families with APC-R were
misdiagnosed as having type II protein S deŽ ciency in the
past.1 3 4 Low protein C, protein S and antithrombin activity
levels may be seen in disseminated intravascular coagu-
lation (DIC), liver disease, OCP use or l-asparaginase ther-
apy.6 9 Protein C and protein S activity levels may be
reduced due to warfarin therapy, whereas a low antithrom-
bin activity may occur due to heparin therapy, nephrotic
syndrome and active colitis.6 9 Low protein S activity has
also been reported in human immunodeŽ ciency virus
(HIV)-infected patients.6 6 9 ,1 3 5 Therapy with unfractionated
or low-molecular-weight heparin will also interfere with
LA assays. Plasma homocysteine levels may be falsely
elevated if testing is not performed in a fasting state.6 9
Finally, OCP use, HRT and selected LA may cause APC-
R that is not due to the factor V Leiden mutation.4 ,2 2 ,2 3
In general, it is probably best that any testing be avoided
during acute illness, for the aforementioned reasons. Prefer-
42 SR Deitcher and MPV Gomes

Table 5 Clinical presentations of venous thromboembolism that may be suggestive of certain hypercoagulable states.

VTE presentation Hypercoagulable state References

Cerebral vein thrombosis in women using OCP PT G20210A 49

Cerebral vein thrombosis in general
Intra-abdominal vein thrombosis
(inferior vena cava, renal vein, portal vein, mesenteric
and hepatic veins)
Warfarin skin necrosis
Unexplained recurrent fetal loss
Recurrent superŽ cial thrombophlebitis
Migratory superŽ cial thrombophlebitis
(‘Trousseau’s syndrome’)
Neonatal purpura fulminans
Paroxysmal nocturnal hemoglobinuria, 49,109,129,130,133
essential thrombocythemia, antiphospholipid
antibodies, antithrombin deŽ ciency, PT
G20210A
Antiphospholipid antibodies, paroxysmal 57,109,129–133
nocturnal hemoglobinuria, myeloproliferative
syndromes, cancer, antithrombin deŽ ciency
Protein C, protein S deŽ ciencies 68
Antiphospholipid antibodies 79,109,124
Factor V Leiden, polycythemia vera, protein C, 10,131,132
protein S or antithrombin deŽ ciency
Adenocarcinoma (particularly of the 89
gastrointestinal tract)
Homozygous protein C or protein S deŽ ciency 68

ably, testing should be performed in the outpatient setting,
at least four to six weeks after the VTE diagnosis. It must
be remembered that testing for most hypercoagulable states
rarely, if ever, impacts acute VTE management. Thus, test-
ing does not need to be obtained during hemostatically
compromised times. Although protein C activity less than
0.68 U/ml, measured at the time of patients’ presentation
with Ž rst VTE, has been associated with increased rates of
recurrent VTE,1 3 6 we do not advocate measurement of pro-
tein C activity early after VTE.1 3 6
Malignancy screening
Malignancy screening following VTE is best pursued in the
elderly, in those with idiopathic VTE or VTE in unusual
sites (see Table 5), and in younger patients (<45 years old)
with these VTE presentations but without laboratory evi-
dence for a hypercoagulable state. Best current evidence
suggests that, for patients presenting with idiopathic VTE,
a limited cancer work-up is appropriate initially.1 0 1 Such
work-up includes a comprehensive history, physical exam-
ination including digital rectal examination, basic labora-
tory testing (sedimentation rate, urinalysis, complete blood
count, liver function tests, serum creatinine, fecal occult
blood testing) and chest radiography. Additional testing
should be guided by abnormalities identiŽ ed during the
initial work-up.1 0 1 In addition, we advocate appropriate
age- and gender-speciŽ c cancer screening, which includes:
(a) mammography and pelvic examination with PAP smear
in women, (b) prostate, testicular examination and prostate-
speciŽ c antigen (PSA) in men, (c) colonoscopy in patients
greater than 50 years of age, and (d) serum protein electro-
phoresis in elderly patients. Guidelines for the early detec-
tion of cancer have recently been updated by the American
Cancer Society.1 3 7
The Ž rst and foremost reason to pursue cancer screening
in patients with or without VTE is to prevent or reduce
cancer-related mortality. In the setting of acute VTE, cancer
screening may also impact the duration of therapy, the
choice of anticoagulant agent to be used and the need for
additional speciŽ c therapies. It is recommended that, in
cancer patients with VTE, anticoagulant therapy should be
continued for a minimum of six months, as long as the
malignancy is active, and for as long as chemotherapy, radi-
ation or hormonal therapy are ongoing.1 0 4 ,1 3 8 Active malig-
nancy implies cancer with evidence of disease in the form
of lesions on imaging studies, elevated tumor markers
and/or continued anticancer treatment.
Cancer screening may also affect the choice of antico-
agulant agent. Several meta-analyses have demonstrated
survival advantage for cancer patients with VTE who were
treated with initial low-molecular-weight heparin instead of
unfractionated heparin.1 3 9 ,1 4 2 Three recently presented pro-
spective clinical trials (CLOT, LITE and ONCENOX) have
demonstrated lower VTE recurrence rates in cancer patients
with acute VTE treated with low-molecular weight heparin
(dalteparin, tinzaparin, and enoxaparin, respectively) for up
to six months in place of oral warfarin with a target INR
of 2.0 to 3.0.1 5 1 – 1 5 3
Conclusion
Although testing for conditions that predispose to hyper-
coagulability is unlikely to beneŽ t most patients with VTE,
testing may be indicated in selected cases. The goals of
testing should be clearly deŽ ned in order to guide the
choice of tests to be obtained. In addition, the complex
implications of testing for each particular patient make it
virtually impossible for physicians to avoid individualiz-
ation, which is preferred instead of generalizing testing rec-
ommendations.
Conclusive evidence as to the best duration of therapy
based on the presence or absence of hypercoagulable states
is lacking. Long-term therapy seems prudent in patients
with LA, persistently elevated IgG ACA, antithrombin
deŽ ciency, homozygous factor V Leiden and, possibly, in
those with protein C and protein S deŽ ciencies. Screening
for inherited hypercoagulable states may impact a woman’s
decision to proceed with OCP use, HRT and planned preg-
nancy. APA screening may impact the need to monitor
unfractionated heparin and warfarin therapy differently, the
choice to use a low-molecular-weight heparin instead of
unfractionated heparin in the acute VTE setting, and the use
of aspirin and/or low-dose heparin in women with recurrent

Vascular Medicine 2003; 8: 33–46


spontaneous miscarriages. Measurement of fasting total
plasma homocysteine and, in rare circumstances, of protein
C and antithrombin activity may impact the need to employ
additional speciŽ c therapies.
Screening for cancer in males or females, young or old,
should be pursued in persons with or without a VTE his-
tory, according to published guidelines. Until conclusive
evidence from prospective studies is available to demon-
strate that an extensive initial cancer work-up favorably
impacts patient survival, we recommend a limited work-up
at the time of VTE presentation. This work-up consists of
a comprehensive history and physical examination, basic
laboratory screening and chest radiography. In addition to
the limited initial work-up, we also recommend an age- and
gender-appropriate cancer screening.
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