Activated protein C resistance--a major risk factor for thrombosis

Resistance to activated protein C is a recently detected phenomenon that has gained a rapid acceptance as a major risk factor for venous thromboembolism. The phenotypic expression of resistance to activated protein C is characterized by a poor response to the anticoagulant activity of activated protein C, a key enzyme in the down-regulation of blood coagulation, which causes a disposition for a hypercoagulable state. At least 90% of the cases with resistance to activated protein C are explained by a point mutation in the gene for coagulation factor V, resulting in replacement of an Arg to Gln at position 506 (factor V:Q506, often denoted factor V Leiden), one of the three activated protein C cleavage sites in activated factor V. The mutation is inherited as an autosomally dominant trait and has a prevalence of 2% to more than 10% in the general Caucasian population. A number of clinical studies, using different inclusion criteria, show a prevalence of activated protein C resistance of 20-60% among patients with venous thromboembolism. The actual thrombotic risk is moderate with an odds ratio of 5-7 but its high prevalence makes it by far the most important inherited risk factor known today, even higher than the sum of contributions from inherited deficiencies of antithrombin, protein C and protein S. Recent data suggest that activated protein C resistance, which is not due to factor V:Q506 and which appears to be acquired, is also a risk factor for venous thrombosis and for cerebral ischaemic disease. A decreased response to activated protein C is common during pregnancy and during use of oral contraceptives, but the clinical relevance of these findings have yet to be determined. The activated protein C resistance phenotype is typically diagnosed with an activated partial thromboplastin time-based assay, which detects factor V:Q506-dependent as well as acquired activated protein C resistance. However, the sensitivity and specificity for the factor V mutation are usually below 90%. Coagulation instruments with a turbidimetric or photometric clot detection principle generally provide a better performance as compared to electromechanical instruments. The activated partial thromboplastin time test requires careful control of preanalytical variables and platelet contamination should be below 1% since otherwise a falsely low activated protein C response will be obtained. A sensitivity and specificity of close to 100% for factor V:Q506 is obtained in a modified activated partial thromboplastin time test using predilution of sample plasma with factor V deficient plasma. The influence of preanalytical variables in this assay is minor. A number of polymerase chain reaction-based methods, some of them allele-specific, have been published, which provide convenient and objective confirmation of the factor V mutation. Thrombotic events are often triggered through the presence of a combination of inherited and circumstantial risk factors. The high prevalence of activated protein C resistance raises the issue whether it would be cost-beneficial to screen for this trait in connection with surgery, pregnancy and oral contraceptives. Some data already support this, but prospective studies will be necessary to delineate under which circumstances this might be implicated.