Predictive Genetic Variants for

Venous Thrombosis: What’s New?

Irene D. Bezemera and Frits R. Rosendaala,b

Various pathways lead to the development of venous thrombosis. Risk factors are common
and can be genetic or acquired. Since the identification of factor V Leiden and prothrombin
20210 G¡A, the field of genetic epidemiology has developed rapidly and many new genetic
variants have been described in the past decade. However, the association with venous
thrombosis is often unclear and conflicting results have been reported in various studies.
The aim of this review is to describe these candidate predictors of venous thrombosis and
to put these in perspective.
Semin Hematol 44:85-92 © 2007 Elsevier Inc. All rights reserved.

V enous thrombosis is a complex condition in which genes

and environment both contribute to the risk of disease.
Many risk factors for venous thrombosis are common, and
often, if not always, the coincidence of two or more risk
factors is required to develop thrombosis. Heritable defects in
factors that control the hemostatic balance have been identi-
fied since 1965 (for a comprehensive review, see Mannucci1).
In that year, Egeberg described a family in which the inci-
dence of venous thrombosis was higher and at a younger age
than expected. It appeared that the affected family members
had about 50% lower antithrombin levels than the non-af-
fected family members. Deficiencies of protein C and protein
S were identified in a similar manner during the 1980s. Fam-
ilies with a history of recurring venous thrombosis but no
known hereditary abnormalities were studied to determine
the role of plasma protein deficiencies. It appeared that af-
fected family members had severely reduced protein levels of
protein C or S. Today, numerous loss-of function mutations
have been described in the genes encoding antithrombin,
protein C, and protein S that lead to reduced plasma levels. In
the heterozygous state these mutations lead to about half-
normal plasma levels. Homozygous mutations, especially in
the antithrombin gene, are assumed to be incompatible with
life.
In addition to these relatively rare protein deficiencies, two
much more common genetic defects were described during
aDepartment of Clinical Epidemiology, Leiden University Medical Center,
Leiden, the Netherlands.
bHemostasis and Thrombosis Research Center, Department of Hematology,
Leiden University Medical Center, Leiden, The Netherlands.
Address correspondence to Frits R. Rosendaal, MD, Department of Clinical
Epidemiology, C9-P, Leiden University Medical Center, PO Box 9600,
2300 RC Leiden, the Netherlands. E-mail: f.r.rosendaal@lumc.nl
the 1990s. Activated protein C (APC) resistance was identi-
fied as a risk factor for venous thrombosis in 1993. In 1994,
Bertina et al found that factor V was involved in APC resis-
tance. Subsequently, the factor V Leiden mutation was found
by searching the factor V gene of APC resistant patients for
mutations in APC binding- and cleavage sites. The second
common genetic factor, prothrombin 20210 G¡A, was
identified in 1996 through screening the prothrombin gene
for abnormalities among patients with a personal and family
history of venous thrombosis.
At present, the three plasma protein deficiencies and the
two mutations are the main genetic risk factors for venous
thrombosis. However, they still explain only part of venous
thrombotic events.1 The failure to identify a risk factor in
many patients and the belief that genetic factors play an im-
portant role in the development of venous thrombosis stim-
ulate the search for novel predictive genetic variants.
Since the identification of prothrombin 20210 G¡A in
1996, the field of genetic epidemiology has evolved rapidly
and many genetic variants have been described that might
influence the risk of venous thrombosis. In this review we
will give an overview of the main genetic factors described in
the past decade and put the findings in perspective. The main
features are presented in Table 1.
Novel Genetic Variants
Fibrinogen
Fibrinogen is the precursor of fibrin, the fundamental con-
stituent of the thrombus. The fibrinogen molecule consists of
three chains: alpha (FGA), beta (FGB), and gamma (FGG),
each encoded by a separate gene. High levels of fibrinogen
increase the risk of venous thrombosis, mainly in elderly

0037-1963/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. 85

doi:10.1053/j.seminhematol.2007.01.007
86 I.D. Bezemer and F.R. Rosendaal

Table 1 Candidate Predictors of Venous Thrombosis

Amino Allele
Gene Nucleotide Acid Frequency* Phenotype Odds Ratio†
Procoagulant
proteins
FGA 4266 A¡G Thr312 Ala 0,26 (G) Reduced clot strength 1,85
FGG 10034 C¡T (FGG-H2) 0,26 (T) Alternatively spliced protein 2,46
Prothrombin 19911 A¡G 0,49 (G)11 Higher protein level 1,411
FV 6755 A¡G (HR2) Asp2194Gly 0,07 (G) Decreased FV cofactor activity 1,215 (carriers)
FVIII 94901 C¡G Asp1241Glu 0,15 (G) Lower protein level 0,620 (carriers)
FVIII HTI 0,14 (HT1)21 Lower protein level 0,421 (men)
FXII 46 C¡T 0,15 (T) Lower protein level Not replicated
FXIII G¡T Val34Leu 0,24 (T)29 Higher protein activity 0,629
FXIII 8259 A¡G His95Arg 0,08 (T)31 Higher protein activity 1,531 (carriers)
TF 1208 I/D 0,52 (D)32 Lower protein level 0,732
FSAP 1601 G¡A Gly511Gly 0,04 (A) Impaired fibrinolysis inhibition Not replicated
ACE I/D 0,51 (D)49 Higher protein level Not clear
Anticoagulant
proteins
TFPI 536 C¡T Pro151Leu <0,01 (D)52 Not known Not replicated
TFPI ⴚ33 T¡C 0,36 (C) Higher protein level 0,659
EPCR 4600 A¡G Ser219Gly 0,08 (G) Higher sEPCR level Not clear
EPCR 4678 G¡C 0,34 (C) Higher APC level Not clear
Antifibrinolytic
proteins
PAI-1 4G/5G (D/I) 0,54 (5G)74 Lower protein level Not clear
TAFI 505 G¡A Ala147Thr 0,30 (T) Higher protein level 0,776
Other
Blood group O 0,43 (O)39 Lower FVIII level 0,639
ZPI 728 C¡T Arg67Stop <0,01 (T) Lower protein level 3,383 (carriers)
MTHFR 677 C¡T Ala222Val 0,24 (T) Lower protein activity Not clear
*Allele frequencies as calculated in the study population referred to. When no reference is given, the allele frequency for Caucasian populations
(applies to almost all studies) was obtained from dbSNP.
†By default, the odds ratio for homozygous carriers. For FV HR2, FVIII Asp1241Glu, FXIII His95Arg, and ZPI Arg69Stop, the odds ratio for all
carriers (heterozygous and homozygous) is given.

people (for a review on coagulation factor levels and venous
thrombosis, see Nossent et al in this issue). The most fre-
quently studied polymorphism is a G¡A substitution at nu-
cleotide -455 in the FGB gene. This genetic variant is associ-
ated with slightly increased fibrinogen levels but appears not
to increase the risk of venous thrombosis,2,3 Another, less
frequently studied, polymorphism in the FGA gene, 4266
A¡G (Thr312Ala), is associated with the risk of pulmonary
embolism (PE) and is postulated to influence fibrin cross-
linking.4 The 312Ala genotype leads to reduced clot strength
and a higher risk of embolization. Ko et al found an FGA
haplotype, covering the Thr312Ala variant, to be related to
both PE and deep vein thrombosis (DVT) in a Taiwanese
population.5 In another study that analyzed the association of
haplotypes of the alpha, beta, and gamma genes and the risk
of DVT, the only haplotype associated with DVT was a hap-
lotype of the FGG gene, tagged by 10034 C¡T (FGG-H2).6
This polymorphism is located in a consensus sequence that is
involved in cleavage and splicing of the FGG pre-mRNA. The
FGG-H2 haplotype is associated with decreased levels of fi-
brinogen gamma’ (FGG’) and decreased FGG’/total fibrino-
gen ratios. Interestingly, the FGA Thr312Ala polymorphism
is strongly linked to this haplotype. Whether FGA Thr312Ala
is a functional variant itself or only reflects the effect of the
10034C¡T variation in FGG-H2 remains to be elucidated.
Prothrombin
Prothrombin is the inactive precursor of thrombin. A princi-
pal role of thrombin is to cleave fibrinogen to form fibrin. In
addition, thrombin gives positive feedback to the coagulation
cascade by activating other coagulation factors and negative
feedback by activating protein C in a complex with throm-
bomodulin. It influences fibrinolysis also, through thrombin
activatable fibrinolysis inhibitor (TAFI). The 20210 G¡A
mutation in the prothrombin gene increases the risk of ve-
nous thrombosis by increasing plasma prothrombin levels
(first described by Poort et al7). Around the 20210 position
several additional variants were described, but there is no
clear evidence that these rare variants contribute to the risk of
venous thrombosis.8 Another common variant in the pro-
thrombin gene, 19911 A¡G, is also associated with slightly
higher prothrombin levels.9-11 Initially, two studies reported
that 19911 A¡G modulates the risk in 20210A carriers.9,12
Recently, two larger studies reported an increased risk asso-
ciated with 19911 A¡G, independently of other genetic risk
factors.10,11
Predictive genetic variants
Factor V
Activated factor V (FVa) is a cofactor for factor Xa in the
conversion of prothrombin to thrombin. In addition, FV is a
cofactor of APC-mediated FVIII degradation. Factor V Leiden
(1691 G¡A, Arg506Gln) is a mutation in the major cleavage
site of FVa by APC, which makes FVa more resistant to inac-
tivation. Recently, all known FV missense mutations that are
relatively common were reviewed by Vos.13 The most impor-
tant variant, apart from factor V Leiden, is a common haplo-
type including several polymorphisms throughout the FV
gene, first described by Lunghi et al.14 This haplotype, FV
HR2, is associated with decreased cofactor activity in FVIII
inactivation and a more procoagulant isoform of FV. The
variant responsible for the FV HR2 phenotype is probably
6755 A¡G (Asp2194Gly).13 Whether the FV HR2 haplotype
affects the risk of venous thrombosis is not clear. Individual
studies reported conflicting results and in a meta-analysis a
pooled odds ratio of 1.15 (95% confidence interval [CI], 0.98
to 1.36) was calculated.15
Factor VIII
The factor VIII (FVIII) gene has been studied extensively
because there is a clear association between FVIII levels and
the risk of venous thrombosis. Several studies screened cleav-
age sites, promoter and polyadenylation regions of the FVIII
gene but found no mutation that corresponded with either
FVIII levels or thrombosis.16-18 However, two other studies
reported lower FVIII levels associated with a 94901 C¡G
(Asp1241Glu) polymorphism that was therefore possibly
protective for venous thrombosis.19,20 In a recent study of the
haplotypes carrying the 1241Glu variant (HT1, HT3, HT5),
the protective effect of 1241Glu and lower levels of FVIII
were confirmed, but seemed limited to male carriers of
HT1.21 This indicates that Asp1241Glu is not likely to be
functional but is probably linked to a functional variant. In
addition, the risk reduction was only partially dependent on
the lower levels of FVIII, which suggests that not only FVIII
levels influence risk but also protein function may contrib-
ute.
Factor XII
Factor XII (FXII) is involved in both the intrinsic coagulation
pathway and the fibrinolytic pathway. Although it has been
suggested that deficiency of FXII may lead to an increased
risk of thrombosis, there is not enough evidence to confirm
an association. In 1998, Kanaji et al22 described the FXII 46
C¡T polymorphism that was associated with decreased
plasma FXII levels. After finding FXII 46 C¡T associated
with FXII levels and venous thrombosis in a linkage study,
Tirado et al reported an odds ratio of 4.8 (95% CI, 1.5 to
15.6) for the TT genotype.23 However, other studies could
not confirm this finding.24-26
Factor XIII
Factor XIII (FXIII) stabilizes the fibrin clot by cross-linking
fibrin monomers. A genetic variant that interferes with clot
stabilization is the FXIII Val34Leu polymorphism. The FXIII
87
34Leu variant is more rapidly activated and thus more rap-
idly cross-links fibrin fibers. However, these fibers are thin-
ner and the fibrin clots are more solid.27 The 34Leu variant
was found to be protective when first studied in relation to
venous thrombosis.28 Subsequent studies mostly failed to
confirm this finding, perhaps due to small study sizes, but in
a meta-analysis a pooled odds ratio of 0.63 (95% CI, 0.46 to
0.86) was computed.29 Recently, this protective effect was
shown to depend on fibrinogen levels.30 High levels of fibrin-
ogen also lead to less porous fibrin clots, and seem to act
synergistically with FXIII 34Leu, being protective against ve-
nous thrombosis. Another polymorphism was reported in
the FXIII B-subunit. This is a carrier protein for FXIII and
dissociates upon activation of FXIII. The 8259 A¡G
(His95Arg) variant leads to increased dissociation and mod-
erately increases the risk of venous thrombosis.31
Tissue Factor
Tissue factor (TF) initiates coagulation by activating factor
VII. TF is expressed by most cells and organs and a soluble
form of TF might also circulate in plasma. The relationship
between circulating TF levels and venous thrombosis is not
clear. Arnaud et al32 screened the promoter region of the TF
gene in blood donors and identified a deletion/insertion
polymorphism, 1208 D/I, of which the 1208 D variant was
associated with lower circulating TF levels and a lower risk of
venous thrombosis in a subsequent case-control study. The
coding region of the TF gene was screened in a case-control
setting by Zawadzki et al.33 They found a C¡T (Arg200Trp)
variant that might lower monocyte TF concentrations, but
the variant was too rare to study its effect on the risk of
thrombosis.
Factor VII–Activating Protease
Factor VII-activating protease (FSAP) stimulates coagulation
by activating FVII. It also stimulates fibrinolysis by activating
urokinase precursor. The Marburg I polymorphism (1601
G¡A, Gly511Gly) impairs the profibrinolytic activity of
FSAP but has no effect on its FVII-activating function.34 Ini-
tially, an increased risk of venous thrombosis was reported
for carriers of the Marburg I polymorphism, mainly for idio-
pathic cases.35 However, this finding could not be confirmed
by others.36,37
Blood Group
ABO blood group is associated with both FVIII and von Wil-
lebrand factor (VWF) levels, and a reduced risk of venous
thrombosis for phenotypic blood group O was already rec-
ognized by Jick et al38 in 1969. The protective effect of blood
group O is mainly explained by FVIII levels.39,40 In 2005,
several investigators reported on the association between
blood group genotype and venous thrombosis.39,41-43 All
studies confirmed the lower risk for blood group O (geno-
types O1O1 and O1O2), and the highest risk for carriers of the
A1 allele. Blood group O genotypes were associated with
lower FVIII and VWF levels.42,43 The protective effect is re-
stricted to homozygous carriers of O alleles; hence individu-
88
als with phenotypic blood group O.41 There is some evidence
that the risk for non-OO genotypes is higher in carriers of
factor V Leiden.39
Angiotensin-Converting Enzyme
Angiotensin-converting enzyme (ACE) stimulates platelet ac-
tivation and regulates fibrinolysis. The relationship between
ACE levels and the risk of venous thrombosis is, however, not
clear. Variation in ACE levels is largely explained by a 287-bp
insertion/deletion (I/D) polymorphism in the ACE gene. In-
dividuals with the DD genotype have higher plasma ACE
than individuals with the II genotype.44 Initially, the DD ge-
notype was reported to increase the risk of venous thrombo-
sis.45,46 Subsequent studies reported varying associations be-
tween the I/D variant and venous thrombosis, as summarized
by Okumus et al47 and Ekim et al.48 An important conclusion
from both reviews was that studies were heterogeneous in
patient selection, with regard to etiology and ethnicity. The
most recent and largest study found a slightly protective ef-
fect of the DD genotype, which was restricted to women.
However, the authors concluded that the I/D polymorphism
itself is unlikely to be functional.49
Tissue Factor Pathway Inhibitor
The first step in the extrinsic coagulation pathway is inhibited
by tissue factor pathway inhibitor (TFPI). Low TFPI levels are
associated with an increased risk of venous thrombosis.50
Five polymorphisms have been described in the TPFI gene.
The -399 C¡T polymorphism, reported by Miyata et al,51
was not associated with TFPI concentrations or with venous
thrombosis. Kleesiek et al52 screened the coding region of the
gene and found a 536 C¡T (Pro151Leu) variant that was
associated with an increased risk of venous thrombosis but
not with TFPI plasma activity and concentration. The asso-
ciation with venous thrombosis was not confirmed by oth-
ers.53-55 Three other polymorphisms were reported by Moatti
et al.56,57 The 874 G¡A (Val264Met) variant might influence
TFPI levels, but it was not associated with venous thrombo-
sis.50,58 The intron variant -33 T¡C and the promoter poly-
morphism -287 T¡C were both associated with higher TFPI
levels.57,59 Accordingly, -33C was found to be protective for
venous thrombosis.59 The -287 T¡C variant has not yet been
studied in venous thrombosis patients.
Endothelial Protein C Receptor
The endothelial protein C receptor (EPCR) is expressed on
the endothelium of large vessels. Binding of protein C stim-
ulates protein C activation by the thrombin–thrombomodu-
lin complex. A soluble form of EPCR (sEPCR) also binds
protein C but inhibits protein C activity. Low levels of sEPCR
have been found to reduce the risk of venous thrombosis.60
Biguzzi et al screened the EPCR gene in venous thrombosis
patients and found a 23-bp insertion (4031ins23) that im-
paired EPCR function, and four promoter polymorphisms
that did not affect transcription in vitro.61,62 These variants
were rare in both patients and control subjects and therefore
the effect on thrombosis risk could not be established.63-65
I.D. Bezemer and F.R. Rosendaal
España et al66 reported more common polymorphisms in
exon 4 (4600 A¡G, Ser219Gly) and in the 3=UTR (4678
G¡C). The 4600G genotype was associated with increased
sEPCR levels and the 4678C genotype was associated with
increased APC levels. Conflicting results were published
about the association with venous thrombosis.60,67-69 Two
studies constructed haplotypes of the EPCR gene. Saposnik
et al70 found three haplotypes of which the haplotype corre-
sponding to the 4600G genotype (H3) was associated with
increased sEPCR levels and an increased risk of venous
thrombosis. Uitte de Willige et al60 identified an additional
haplotype (H4) that also contained 4600G and was part of
H3 in the study of Saposnik et al. In this study, carriers of H4
(not H3) had a slightly increased risk of venous thrombosis,
which suggests that 4600G itself is not a functional variant.
Plasminogen Activator Inhibitor-1
Plasminogen activator inhibitor-1 (PAI-1) indirectly inhibits
the fibrinolytic activity of plasminogen. There is no clear
relationship between PAI-levels and venous thrombosis.71
Dawson et al72 described a guanine deletion/insertion (4G/
5G) upstream of the PAI-1 gene that influences PAI-1 activity.
A literature review regarding 4G/5G and venous thrombosis
by Francis71 showed that although most studies find higher
plasma levels of PAI-1 in individuals with 4G/4G, the effect
on the risk of venous thrombosis is not clear. There is some
evidence that 4G/4G increases the risk of venous thrombosis
in subgroups with additional genetic risk factors,73,74 but
these findings need to be confirmed. The fact that the 4G/5G
variant is associated with PAI-I levels but not with venous
thrombosis suggests that PAI-I levels have no major effect on
the risk of venous thrombosis.
Thrombin-Activatable Fibrinolysis Inhibitor
During fibrinolysis, partially degraded fibrin is a cofactor for
plasminogen activation. Thrombin-activatable fibrinolysis
inhibitor (TAFI) inhibits fibrinolysis by suppressing this co-
factor activity. Increased TAFI levels were found to be asso-
ciated with a slightly increased risk of venous thrombosis.
Zhao et al75 described the 505 G¡A polymorphism
(Ala147Thr) that was associated with higher TAFI concen-
trations. In addition, several promoter polymorphisms (-438
A¡G, 1102 T¡G, 1690 G¡A) and an additional polymor-
phism in the coding region (1040 C¡T, Thr325Ile) were
described that influenced TAFI levels and possibly the risk of
venous thrombosis, but these variants were strongly linked to
the 505 polymorphism.76,77 Martini et al76 analyzed haplo-
types constructed of -438 G¡A, 505 G¡A and 1040 C¡T
and found that only 505A was associated with a reduced risk
of venous thrombosis. This was an unexpected finding be-
cause 505A is the variant associated with higher TAFI levels.
Further research is needed to unravel the relationship be-
tween TAFI and venous thrombosis.
5,10-Methylenetetrahydrofolate Reductase
Increased homocysteine has been associated with venous
thrombosis in many studies but the mechanism by which
Predictive genetic variants
homocysteine affects coagulation is not clear. The common
677 C¡T (Ala222Val) polymorphism in the 5,10-methyl-
enetetrahydrofolate reductase (MTHFR) gene, leading to a
thermolabile variant of the enzyme, slightly increases plasma
homocysteine levels and has been studied extensively. Odds
ratios computed from a large meta-analysis indicate that
MTHFR 677 C¡T is a weak risk factor for venous thrombo-
sis.78 However, we have recently studied MTHFR 677 C¡T
in a large case-control study but found no evidence of an
association with venous thrombosis.79
Protein Z–Dependent Protease Inhibitor
Although in vitro studies suggest that protein Z– dependent
protease inhibitor (ZPI) might influence coagulation by in-
hibiting FXa and FXIa,80 ZPI plasma levels do not seem to
affect the risk of venous thrombosis.81 Van de Water et al80
screened the coding region of the ZPI gene for mutations and
identified two premature stop codons at Arg67 and Trp303
that were associated with venous thrombosis. However,
in subsequent studies, the Trp303 stop codon was not de-
tected82 or the presence of either Arg67Stop or Trp303Stop
was not associated with venous thrombosis.83 Recently, how-
ever, Corral et al84 studied haplotypes of the ZPI gene and
found the haplotype covering Arg67Stop to be associated
with venous thrombosis with a 3.3-fold increased risk. Since
Arg67Stop is a rare mutation, large studies are needed to
confirm this finding.
Factors VII, IX, X, XI, von
Willebrand Factor, and Thrombomodulin
Despite a clear association between plasma levels and the
occurrence of venous thrombosis, no predictive genetic vari-
ants are known in the genes encoding factor IX and factor XI.
The promoter region of the FXI gene has been screened and
two single-nucleotide polymorphisms (SNPs) were identi-
fied,85 but the association with plasma concentrations of FXI
and venous thrombosis has not yet been studied. Plasma
levels of factor X and von Willebrand factor are also related to
the risk of venous thrombosis, but the association is depen-
dent on levels of other coagulation factors.39,40,86 For both
factors, gene variants were studied in relation to plasma con-
centrations and the risk of venous thrombosis, but no asso-
ciation was found.16,86
Plasma concentrations of factor VII and thrombomodulin
are not related to the risk of venous thrombosis. Some genetic
variants were identified that were related to levels but not to
the risk of venous thrombosis.2,3,87-90
Future Perspectives
Research Goals
All variants that were initially found to be associated with
venous thrombosis are listed in Table 1. For each factor, the
magnitude of the association with venous thrombosis is given
in the right column. However, most of these findings have
not yet been replicated, and others have failed to replicate.
Failure of replication may occur for several reasons.
89
First, many genetic variants of modest effect are expected
to contribute to the risk of venous thrombosis. To detect
these modest effects large sample sizes are needed. All of the
genetic variants discussed above are at most weak risk factors
and were studied in samples of at most several hundreds of
study subjects.
Another obstacle for replication is phenotype definition.
Venous thrombosis is a multicausal disease and genetic vari-
ants that influence the risk of disease are expected to affect
only one of the causal pathways. The intermediate phenotype
of that causal pathway (for example, protein levels) will be
more strongly correlated to the genetic variant. On the other
hand, when the intermediate phenotype is not associated
with venous thrombosis, which is the case with FVII, FX,
FXII, von Willebrand factor, and thrombomodulin, finding
an association between venous thrombosis and the genetic
variant is less likely.
Alternatively, the initial finding may have been a false-
positive result. As the amount of genetic variants tested in-
creases, the possibility of finding false-positive results also
increases when multiple testing is not correctly accounted
for. The problem of false-positive findings probably accounts
for many of the non-replicated associations.
Once a finding is replicated, the knowledge from previous
studies can be used to further explore the relationship be-
tween the replicated variant and disease. This can be done by
constructing haplotypes in the genes where association was
found, as was the case in relation to the fibrinogen,6 FVIII,21
and EPCR70 genes. In these studies, haplotypes were identi-
fied that increased the risk of thrombosis and probably ex-
plained the association observed before with a single nucle-
otide polymorphism. Knowledge from previous research can
further be used to study interaction of genetic variants that
seem to affect the same causal pathway. The synergistic effect
of the FXIII Val34Leu variant and fibrinogen levels observed
by Vossen et al30 is an example of this approach.
Clinical Implications
The ultimate goal of genetic epidemiologic research is to be
able to predict each individual’s risk of disease on the basis of
genetic and acquired factors. With a genetic profile it would
then be possible to give lifestyle recommendations or pro-
phylaxis in high-risk situations to maximally reduce the risk
of disease.
However, venous thrombosis is a complex disease and
prediction requires an extensive model including many ac-
quired and genetic factors. To be clinically useful, the genetic
variants described above should be evaluated together with
many other, as yet unknown, risk factors. In addition, the
outcome of testing the genetic variant should influence treat-
ment or preventive measures. The various possible or weak
genetic risk factors for venous thrombosis that have been
identified in the past years are not of clinical importance.
Conclusion
In the past decade, many factors have been described that
might influence the risk of venous thrombosis. Some of these,
90
like ABO blood group, FXIII Val34Leu, or haplotypes of fi-
brinogen, FV, and FVIII, are possible novel predictive vari-
ants. Others have failed to replicate in subsequent studies.
More well-designed, large studies are needed to unravel the
various pathways that lead to the development of venous
thrombosis.
References
1. Mannucci PM: Laboratory detection of inherited thrombophilia: A his-
torical perspective. Semin Thromb Hemost 31:5-10, 2005
2. Austin H, Hooper WC, Lally C, Dilley A, Ellingsen D, Wideman C, et al:
Venous thrombosis in relation to fibrinogen and factor VII genes among
African-Americans. J Clin Epidemiol 53:997-1001, 2000
3. Koster T, Rosendaal FR, Reitsma PH, van der Velden PA, Briet E, Van-
denbroucke JP: Factor VII and fibrinogen levels as risk factors for ve-
nous thrombosis. A case-control study of plasma levels and DNA poly-
morphisms—The Leiden Thrombophilia Study (LETS). Thromb
Haemost 71:719-722, 1994
4. Carter AM, Catto AJ, Kohler HP, Ariens RA, Stickland MH, Grant PJ:
Alpha-fibrinogen Thr312Ala polymorphism and venous thromboem-
bolism. Blood 96:1177-1179, 2000
5. Ko YL, Hsu LA, Hsu TS, Tsai CT, Teng MS, Wu S, et al: Functional
polymorphisms of FGA, encoding alpha fibrinogen, are associated with
susceptibility to venous thromboembolism in a Taiwanese population.
Hum Genet 119:84-91, 2006
6. Uitte de Willige S, de Visser MC, Houwing-Duistermaat JJ, Rosendaal
FR, Vos HL, Bertina RM: Genetic variation in the fibrinogen gamma
gene increases the risk for deep venous thrombosis by reducing plasma
fibrinogen gamma’ levels. Blood 106:4176-4183, 2005
7. Poort SR, Rosendaal FR, Reitsma PH, Bertina RM: A common genetic
variation in the 3=-untranslated region of the prothrombin gene is as-
sociated with elevated plasma prothrombin levels and an increase in
venous thrombosis. Blood 88:3698-3703, 1996
8. Ceelie H, Spaargaren-van Riel, CC, Lyon E, Bertina RM, Vos HL: Func-
tional analysis of two polymorphisms in the 3=-UTR of the human
prothrombin gene. J Thromb Haemost 3:806-808, 2005
9. Ceelie H, Bertina RM, van Hylckama Vlieg A, Rosendaal FR, Vos HL:
Polymorphisms in the prothrombin gene and their association with
plasma prothrombin levels. Thromb Haemost 85:1066-1070, 2001
10. Martinelli I, Battaglioli T, Tosetto A, Legnani C, Sottile L, Ghiotto R,
et al: Prothrombin 19911 A⬎G polymorphism and the risk of venous
thromboembolism. J Thromb Haemost 4:2582-2586, 2006
11. Chinthammitr Y, Vos HL, Rosendaal FR, Doggen CJM: The association
of prothrombin A19911G polymorphism with plasma prothrombin
activity and venous thrombosis: Results of the MEGA study, a large
population-based case-control study. J Thromb Haemost 4:2587-
2592, 2006
12. Perez-Ceballos E, Corral J, Alberca I, Vaya A, Llamas P, Montes R, et al:
Prothrombin A19911G and G20210A polymorphisms’ role in throm-
bosis. Br J Haematol 118:610-614, 2002
13. Vos HL: Inherited defects of coagulation Factor V: The thrombotic side.
J Thromb Haemost 4:35-40, 2006
14. Lunghi B, Iacoviello L, Gemmati D, Dilasio MG, Castoldi E, Pinotti M,
et al: Detection of new polymorphic markers in the factor V gene:
Association with factor V levels in plasma. Thromb Haemost 75:45-48,
1996
15. Castaman G, Faioni EM, Tosetto A, Bernardi F: The factor V HR2
haplotype and the risk of venous thrombosis: A meta-analysis. Haema-
tologica 88:1182-1189, 2003
16. Kamphuisen PW, Eikenboom JC, Rosendaal FR, Koster T, Blann AD,
Vos HL, et al: High factor VIII antigen levels increase the risk of venous
thrombosis but are not associated with polymorphisms in the von
Willebrand factor and factor VIII gene. Br J Haematol 115:156-158,
2001
17. Mansvelt EP, Laffan M, McVey JH, Tuddenham EG: Analysis of the F8
gene in individuals with high plasma factor VIII:C levels and associated
venous thrombosis. Thromb Haemost 80:561-565, 1998
I.D. Bezemer and F.R. Rosendaal
18. Roelse JC, Koopman MM, Buller HR, ten Cate JW, Montaruli B, van
Mourik JA, et al: Absence of mutations at the activated protein C cleav-
age sites of factor VIII in 125 patients with venous thrombosis. Br J
Haematol 92:740-743, 1996
19. Machiah DK, Viel K, Almasy L, Soria JM, Porter S, Souto JC, et al:
A common SNP in the factor VIII (f-VIII) gene encodes a conservative
aspartate to glutamate substitution (Asp1241Glu) in the B-domain that
influences f-VIII activity levels. Blood 102:181, 2003 (abstr)
20. Scanavini D, Legnani C, Lunghi B, Mingozzi F, Palareti G, Bernardi F:
The factor VIII D1241E polymorphism is associated with decreased
factor VIII activity and not with activated protein C resistance levels.
Thromb Haemost 93:453-456, 2005
21. Nossent AY, Eikenboom JC, Vos HL, Bakker E, Tanis BC, Doggen CJM,
et al: Haplotypes encoding the factor VIII 1241 Glu variation, factor
VIII levels and the risk of venous thrombosis. Thromb Haemost 95:
942-948, 2006
22. Kanaji T, Okamura T, Osaki K, Kuroiwa M, Shimoda K, Hamasaki N,
et al: A common genetic polymorphism (46 C to T substitution) in the
5=-untranslated region of the coagulation factor XII gene is associated
with low translation efficiency and decrease in plasma factor XII level.
Blood 91:2010-2014, 1998
23. Tirado I, Soria JM, Mateo J, Oliver A, Souto JC, Santamaria A, et al:
Association after linkage analysis indicates that homozygosity for the
46C¡T polymorphism in the F12 gene is a genetic risk factor for
venous thrombosis. Thromb Haemost 91:899-904, 2004
24. Grunbacher G, Marx-Neuhold E, Pilger E, Koppel H, Renner W: The
functional -4C⬎T polymorphism of the coagulation factor XII gene is
not associated with deep venous thrombosis. J Thromb Haemost
3:2815-2817, 2005
25. Bertina RM, Poort SR, Vos HL, Rosendaal FR: The 46C¡T polymor-
phism in the factor XII gene (F12) and the risk of venous thrombosis.
J Thromb Haemost 3:597-599, 2005
26. Franco RF, Reitsma PH, Lourenco D, Maffei FH, Morelli V, Tavella MH,
et al: Factor XIII Val34Leu is a genetic factor involved in the etiology of
venous thrombosis. Thromb Haemost 81:676-679, 1999
27. Ariens RA, Philippou H, Nagaswami C, Weisel JW, Lane DA, Grant PJ:
The factor XIII V34L polymorphism accelerates thrombin activation of
factor XIII and affects cross-linked fibrin structure. Blood 96:988-995,
2000
28. Catto AJ, Kohler HP, Coore J, Mansfield MW, Stickland MH, Grant PJ:
Association of a common polymorphism in the factor XIII gene with
venous thrombosis. Blood 93:906-908, 1999
29. Wells PS, Anderson JL, Scarvelis DK, Doucette SP, Gagnon F: Factor
XIII Val34Leu variant is protective against venous thromboembolism:
A HuGE review and meta-analysis. Am J Epidemiol 164:101-109, 2006
30. Vossen CY, Rosendaal FR: The protective effect of the factor XIII
Val34Leu mutation on the risk of deep venous thrombosis is dependent
on the fibrinogen level. J Thromb Haemost 3:1102-1103, 2005
31. Komanasin N, Catto AJ, Futers TS, van Hylckama Vlieg A, Rosendaal
FR, Ariens RA: A novel polymorphism in the factor XIII B-subunit
(His95Arg): relationship to subunit dissociation and venous thrombo-
sis. J Thromb Haemost 3:2487-2496, 2005
32. Arnaud E, Barbalat V, Nicaud V, Cambien F, Evans A, Morrison C, et al:
Polymorphisms in the 5= regulatory region of the tissue factor gene and
the risk of myocardial infarction and venous thromboembolism: The
ECTIM and PATHROS studies. Etude Cas-Temoins de l’Infarctus du
Myocarde. Paris thrombosis case-control study. Arterioscler Thromb
Vasc Biol 20:892-898, 2000
33. Zawadzki C, Preudhomme C, Gaveriaux V, Amouyel P, Jude B: The
Arg200Trp mutation in the human tissue factor gene. Thromb Hae-
most 87:540-541, 2002
34. Roemisch J, Feussner A, Nerlich C, Stoehr HA, Weimer T: The frequent
Marburg I polymorphism impairs the pro-urokinase activating potency
of the factor VII activating protease (FSAP). Blood Coagul Fibrinolysis
13:433-441, 2002
35. Hoppe B, Tolou F, Radtke H, Kiesewetter H, Dorner T, Salama A:
Marburg I polymorphism of factor VII-activating protease is associated
with idiopathic venous thromboembolism. Blood 105:1549-1551,
2005
Predictive genetic variants
36. Franchi F, Martinelli I, Biguzzi E, Bucciarelli P, Mannucci PM: Marburg
I polymorphism of factor VII-activating protease and risk of venous
thromboembolism. Blood 107:1731, 2006
37. Van Minkelen R, de Visser MC, Vos HL, Bertina RM, Rosendaal FR: The
Marburg I polymorphism of factor VII-activating protease is not asso-
ciated with venous thrombosis. Blood 105:4898, 2005
38. Jick H, Slone D, Westerholm B, Inman WH, Vessey MP, Shapiro S, et al:
Venous thromboembolic disease and ABO blood type. A cooperative
study. Lancet 1:539-542, 1969
39. Morelli VM, de Visser MC, Vos HL, Bertina RM, Rosendaal FR: ABO
blood group genotypes and the risk of venous thrombosis: Effect of
factor V Leiden. J Thromb Haemost 3:183-185, 2005
40. Koster T, Blann AD, Briet E, Vandenbroucke JP, Rosendaal FR: Role of
clotting factor VIII in effect of von Willebrand factor on occurrence of
deep-vein thrombosis. Lancet 345:152-155, 1995
41. Mercier B, Oger E, Le Gal G, Mottier D, Ferec C: Phenotypic but not
allelic ABO blood group association with risk of venous thrombosis.
Thromb Haemost 93:388-389, 2005
42. Schleef M, Strobel E, Dick A, Frank J, Schramm W, Spannagl M: Rela-
tionship between ABO and Secretor genotype with plasma levels of
factor VIII and von Willebrand factor in thrombosis patients and con-
trol individuals. Br J Haematol 128:100-107, 2005
43. Tirado I, Mateo J, Soria JM, Oliver A, Martinez-Sanchez E, Vallve C,
et al: The ABO blood group genotype and factor VIII levels as indepen-
dent risk factors for venous thromboembolism. Thromb Haemost 93:
468-474, 2005
44. Rigat B, Hubert C, Alhenc-Gelas F, Cambien F, Corvol P, Soubrier F:
An insertion/deletion polymorphism in the angiotensin I-converting
enzyme gene accounting for half the variance of serum enzyme levels.
J Clin Invest 86:1343-1346, 1990
45. Dilley A, Austin H, Hooper WC, Lally C, Ribeiro MJ, Wenger NK, et al:
Relation of three genetic traits to venous thrombosis in an African-
American population. Am J Epidemiol 147:30-35, 1998
46. Philipp CS, Dilley A, Saidi P, Evatt B, Austin H, Zawadsky J, et al:
Deletion polymorphism in the angiotensin-converting enzyme gene as
a thrombophilic risk factor after hip arthroplasty. Thromb Haemost
80:869-873, 1998
47. Okumus G, Arseven O: Insertion/deletion polymorphism of the angio-
tensin-converting enzyme gene: Really a risk factor for venous throm-
boembolism? Thromb Haemost 90:766-767, 2003
48. Ekim N, Oguzulgen IK, Demir N, Altinok B, Akar N: The role of
angiotensin-converting enzyme gene polymorphism in pulmonary
thromboembolism. Thromb Haemost 92:432-433, 2004
49. Buddingh EP, van Hylckama Vlieg A, Rosendaal FR: The angiotensin-
converting enzyme gene insertion/deletion polymorphism: Insufficient
evidence for a role in deep venous thrombosis. J Thromb Haemost
3:403-404, 2005
50. Amini-Nekoo A, Futers TS, Moia M, Mannucci PM, Grant PJ, Ariens
RA: Analysis of the tissue factor pathway inhibitor gene and antigen
levels in relation to venous thrombosis. Br J Haematol 113:537-543,
2001
51. Miyata T, Sakata T, Kumeda K, Uchida K, Tsushima M, Fujimura H,
et al: C-399T polymorphism in the promoter region of human tissue
factor pathway inhibitor (TFPI) gene does not change the plasma TFPI
antigen level and does not cause venous thrombosis. Thromb Haemost
80:345-346, 1998
52. Kleesiek K, Schmidt M, Gotting C, Schwenz B, Lange S, Muller-
Berghaus G, et al: The 536C¡T transition in the human tissue factor
pathway inhibitor (TFPI) gene is statistically associated with a higher
risk for venous thrombosis. Thromb Haemost 82:1-5, 1999
53. Gonzalez-Conejero R, Lozano ML, Corral J, Martinez C, Vicente V: The
TFPI 536C¡T mutation is not associated with increased risk for ve-
nous or arterial thrombosis. Thromb Haemost 83:787-788, 2000
54. Hessner MJ, Luhm RA: The C536T transition in the tissue factor path-
way inhibitor (TFPI) gene does not contribute to risk of venous throm-
bosis among carriers of factor V Leiden. Thromb Haemost 84:724-725,
2000
55. Paciaroni K, Rossi E, Bazzan M, Ireland H, De Stefano V: Prevalence of
the C536T mutation in the tissue factor pathway inhibitor (TFPI) gene
91
among patients with venous thromboembolic disease. Thromb
Haemost 85:938-939, 2001
56. Moatti D, Seknadji P, Galand C, Poirier O, Fumeron F, Desprez S, et al:
Polymorphisms of the tissue factor pathway inhibitor (TFPI) gene in
patients with acute coronary syndromes and in healthy subjects: Im-
pact of the V264M substitution on plasma levels of TFPI. Arterioscler
Thromb Vasc Biol 19:862-869, 1999
57. Moatti D, Haidar B, Fumeron F, Gauci L, Boudvillain O, Seknadji P,
et al: A new T-287C polymorphism in the 5= regulatory region of the
tissue factor pathway inhibitor gene. Association study of the T-287C
and C-399T polymorphisms with coronary artery disease and plasma
TFPI levels. Thromb Haemost 84:244-249, 2000
58. Arnaud E, Moatti D, Emmerich J, Aiach M, de Prost D: No link between
the TFPI V264M mutation and venous thromboembolic disease.
Thromb Haemost 82:159-160, 1999
59. Ameziane N, Seguin C, Borgel D, Fumeron F, Moatti D, Alhenc-Gelas
M, et al: The -33T¡C polymorphism in intron 7 of the TFPI gene
influences the risk of venous thromboembolism, independently of the
factor V Leiden and prothrombin mutations. Thromb Haemost 88:195-
199, 2002
60. Uitte de Willige S, van Marion V, Rosendaal FR, Vos HL, de Visser MC,
Bertina RM: Haplotypes of the EPCR gene, plasma sEPCR levels and the
risk of deep venous thrombosis. J Thromb Haemost 2:1305-1310,
2004
61. Biguzzi E, Merati G, Liaw PC, Bucciarelli P, Oganesyan N, Qu D, et al:
A 23bp insertion in the endothelial protein C receptor (EPCR) gene
impairs EPCR function. Thromb Haemost 86:945-948, 2001
62. Biguzzi E, Gu JM, Merati G, Esmon NL, Esmon CT: Point mutations in
the endothelial protein C receptor (EPCR) promoter. Thromb Haemost
87:1085-1086, 2002
63. Grossmann R, Schwender S, Geisen U, Schambeck C, Merati G, Walter
U: CBS 844ins68, MTHFR TT677 and EPCR 4031ins23 genotypes in
patients with deep-vein thrombosis. Thromb Res 107:13-15, 2002
64. Poort SR, Vos HL, Rosendaal FR, Bertina RM: The endothelial protein C
receptor (EPCR) 23 bp insert mutation and the risk of venous throm-
bosis. Thromb Haemost 88:160-162, 2002
65. von Depka M, Czwalinna A, Eisert R, Wermes C, Scharrer I, Ganser A,
Ehrenforth S: Prevalence of a 23bp insertion in exon 3 of the endothe-
lial cell protein C receptor gene in venous thrombophilia. Thromb
Haemost 86:1360-1362, 2001
66. España F: A new polymorphism in the 3=UTR region of the endothelial
protein C receptor associated with increased levels of circulating acti-
vated protein c and decreased risk of venous thrombosis. Thromb
Haemost 1:885, 2001 (suppl 1, abstr)
67. Galligan L, Powell C, Livingstone W, Mynett-Johnston L, Smith OP:
The G7763C endothelial protein C receptor (EPCR) gene mutation:
Prevalence and association with DVT in the Irish population. Thromb
Haemost 88:163-165, 2002
68. Medina P, Navarro S, Estelles A, Vaya A, Bertina RM, España F: Influ-
ence of the 4600A/G and 4678G/C polymorphisms in the endothelial
protein C receptor (EPCR) gene on the risk of venous thromboembo-
lism in carriers of factor V Leiden. Thromb Haemost 94:389-394, 2005
69. Medina P, Navarro S, Estelles A, Vaya A, Woodhams B, Mira Y, et al:
Contribution of polymorphisms in the endothelial protein C receptor
gene to soluble endothelial protein C receptor and circulating activated
protein C levels, thrombotic risk. Thromb Haemost 91:905-911, 2004
70. Saposnik B, Reny JL, Gaussem P, Emmerich J, Aiach M, Gandrille S: A
haplotype of the EPCR gene is associated with increased plasma levels
of sEPCR and is a candidate risk factor for thrombosis. Blood 103:
1311-1318, 2004
71. Francis CW: Plasminogen activator inhibitor-1 levels and polymor-
phisms. Arch Pathol Lab Med 126:1401-1404, 2002
72. Dawson S, Hamsten A, Wiman B, Henney A, Humphries S: Genetic
variation at the plasminogen activator inhibitor-1 locus is associated
with altered levels of plasma plasminogen activator inhibitor-1 activity.
Arterioscler Thromb 11:183-190, 1991
73. Segui R, Estelles A, Mira Y, España F, Villa P, Falco C, et al: PAI-1
promoter 4G/5G genotype as an additional risk factor for venous
92
thrombosis in subjects with genetic thrombophilic defects. Br J
Haematol 111:122-128, 2000
74. Barcellona D, Fenu L, Cauli C, Pisu G, Marongiu F: Allele 4G of gene
PAI-1 associated with prothrombin mutation G20210A increases the
risk for venous thrombosis. Thromb Haemost 90:1061-1064, 2003
75. Zhao L, Morser J, Bajzar L, Nesheim M, Nagashima M: Identification
and characterization of two thrombin-activatable fibrinolysis inhibitor
isoforms. Thromb Haemost 80:949-955, 1998
76. Martini CH, Brandts A, de Bruijne EL, van Hylckama Vlieg A, Leebeek
FW, Lisman T, Rosendaal FR: The effect of genetic variants in the
thrombin activatable fibrinolysis inhibitor (TAFI) gene on TAFI-anti-
gen levels, clot lysis time and the risk of venous thrombosis. Br J
Haematol 134:92-94, 2006
77. Henry M, Aubert H, Morange PE, Nanni I, Alessi MC, Tiret L, et al:
Identification of polymorphisms in the promoter and the 3= region of
the TAFI gene: evidence that plasma TAFI antigen levels are strongly
genetically controlled. Blood 97:2053-2058, 2001
78. den Heijer M, Lewington S, Clarke R: Homocysteine, MTHFR and risk
of venous thrombosis: A meta-analysis of published epidemiological
studies. J Thromb Haemost 3:292-299, 2005
79. Bezemer ID, Doggen CJM, Vos HL, Rosendaal FR: No association be-
tween the common MTHFR 677C¡T polymorphism and venous
thrombosis: Results from the MEGA study. Arch Intern Med 167:497-
501, 2007
80. Water N, Tan T, Ashton F, O’grady A, Day T, Browett P, et al: Mutations
within the protein Z-dependent protease inhibitor gene are associated
with venous thromboembolic disease: A new form of thrombophilia.
Br J Haematol 127:190-194, 2004
81. Al Shanqeeti A, van Hylckama Vlieg A, Berntorp E, Rosendaal FR, Broze
GJ: Protein Z and protein Z-dependent protease inhibitor. Determi-
nants of levels and risk of venous thrombosis. Thromb Haemost 93:
411-413, 2005
I.D. Bezemer and F.R. Rosendaal
82. Gonzalez-Conejero R, Perez-Ceballos E, Vicente V, Corral J: Protein
Z-dependent protease inhibitor W303X mutation in venous thrombo-
sis. Br J Haematol 129:561-562, 2005
83. Razzari C, Martinelli I, Bucciarelli P, Viscardi Y, Biguzzi E: Polymor-
phisms of the protein Z-dependent protease inhibitor (ZPI) gene and the
risk of venous thromboembolism. Thromb Haemost 95:909-910, 2006
84. Corral J, Gonzalez-Conejero R, Soria JM, Gonzalez-Porras JR, Perez-
Ceballos E, Lecumberri R, et al: A nonsense polymorphism in the
protein Z-dependent protease inhibitor increases the risk for venous
thrombosis. Blood 108:177-183, 2006
85. Tarumi T, Kravtsov DV, Moore JH, Williams SM, Gailani D: Common
single nucleotide polymorphisms in the promoter region of the human
factor XI gene. J Thromb Haemost 1:1854-1856, 2003
86. De Visser MC, Poort SR, Vos HL, Rosendaal FR, Bertina RM: Factor
X levels, polymorphisms in the promoter region of factor X, the risk
of venous thrombosis. Thromb Haemost 85:1011-1017, 2001
87. Le Flem L, Picard V, Emmerich J, Gandrille S, Fiessinger JN, Aiach M,
et al: Mutations in promoter region of thrombomodulin and venous
thromboembolic disease. Arterioscler Thromb Vasc Biol 19:1098-
1104, 1999
88. Le Flem L, Mennen L, Aubry ML, Aiach M, Scarabin PY, Emmerich J,
et al: Thrombomodulin promoter mutations, venous thrombosis,
and varicose veins. Arterioscler Thromb Vasc Biol 21:445-451,
2001
89. Thude H, Wilkens A, Anders O, Barz D: Analysis of the thrombomodu-
lin gene in patients with venous thrombosis. Thromb Res 107:109-114,
2002
90. Heit JA, Petterson TM, Owen WG, Burke JP, de Andrade M, Melton LJ,
III: Thrombomodulin gene polymorphisms or haplotypes as potential
risk factors for venous thromboembolism: A population-based case-
control study. J Thromb Haemost 3:710-717, 2005