Factor V Leiden Deficiency


Article Author:
Sara Albagoush


Article Editor:
Amy Schmidt


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Richard Sue
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Sandeep Sekhon


Updated:
3/19/2019 5:28:50 PM

Introduction

Factor V Leiden (FVL) is a point mutation of factor V resulting in an elimination of cleavage site in factor V and factor Va. This genetic defect leads to an increased risk of thrombosis especially in homozygous or pseudo-homozygous FVL mutations. Many individuals with the mutation will never develop a venous thrombotic event (VTE). The decision about VTE risk reduction (both primary and secondary and prevention of recurrence) requires a great deal of clinical acumen, given that most of the people who carry the mutation will never have VTE.

Etiology

Normally, factor V synthesis principally occurs in the liver. Thrombin activates factor V and once activated, it will convert prothrombin to thrombin.

Activated protein C, one of the principal physiologic inhibitor of coagulation degrades factor V. In the presence of what is called thrombomodulin; thrombin acts to decrease clotting by activating protein C; therefore, the concentration and the action of protein C are important determinants in the negative feedback loop through which thrombin limits its activation.

Factor V Leiden is an autosomal dominant genetic condition which exhibits incomplete penetrance, meaning that not every person who has the mutation will develop the disease. 

FVL, also known as factor VR506Q and factor V Arg506 Gln, results from a single-point mutation in the factor V gene (guanine to adenine at nucleotide 1691), which leads to a single amino acid change (replacement of arginine with glutamine at amino acid 506). This abolishes the Arg506 cleavage site for aPC in Factor V and Va.[1]

Epidemiology

Heterozygosity for the FVL mutation is the most common inherited thrombophilia in the unselected Caucasian population (prevalence, approximately 1% to 5%) and is considered the most common inherited thrombophilia in individuals with venous thromboembolism (prevalence approximately 10% to 20%). [2] Heterozygosity of this gene increases the lifetime risk of thrombosis 7-fold, while homozygosity (which is rare) increases the risk 20- to 80-fold.

Despite the increase in the risk of VTE, there is no clinical evidence that heterozygosity to FVL increases the overall mortality.

Pathophysiology

Factor V Leiden (FVL) results from a single-point mutation in the factor V gene (guanine to adenine at nucleotide 1691) that would lead to the replacement of arginine with glutamine at amino acid 506. This abolishes the Arg506 cleavage site at aPC in factor V and factor Va. The consequences are enhancing the procoagulant role of factor Va and the reduced anticoagulant role of factor V.[1]

History and Physical

The main clinical manifestation of the FVL (heterozygous) mutation is a risk for venous thromboembolism (VTE). However, the most common finding in individuals with FVL is a laboratory-only abnormality. Only a small percentage of individuals with FVL will develop VTE in their lifetime, with an approximate risk of 5% for FVL heterozygotes in the general population and up to 20% in thrombophilic families.

Venous Thromboembolism

  • The most common site of VTE is a deep vein thrombosis and pulmonary embolism (PE), but other sites including superficial veins of the legs and cerebral, portal, and hepatic veins may be involved.[3]
  • Isolated PE: Less common presentation. Without evidence of DVT, FVL patient can still present with PE. But this is a less common presentation of VTE in individuals with FVL compared with the general population, a phenomenon called FVL paradox.[4]  
  • Cerebral vein thrombosis can occur in FVC individuals, especially in patients using oral contraceptive pills. Studies have shown that FVL to be associated with an increased risk of Budd-Chiari syndrome.

Arterial Thromboembolism

  • Association between FVL and arterial thromboembolism remains controversial, and it is likely to be small if present.
  • Myocardial infarction: Studies have shown a modest increase in the risk of coronary artery disease in patients with FVL. It has been observed that the FVL mutation is associated with an increased risk of stroke especially in women, smokers, and younger individuals.[5]

Evaluation

Testing for FVL is indicated for individuals with venous thromboembolism, especially if VTE occurs at a young age and if the VTE occurs in an unusual location such as a portal vein or cerebral vein. It is also indicated in a member of a thrombophilic family.

Testing usually is not performed in individuals with a first episode especially if it is provoked or if it occurs in people who are older than 50 years of age.

FVL can be diagnosed by mutation analysis (DNA testing) or a functional coagulation test for aPC resistance.

  • Genetic testing is indicated for those with a family history of FVL. It is also preferred for members of a thrombophilic family, patients with an antiphospholipid syndrome or those who need to be on an anticoagulant. Individuals with a positive functional assay for aPC resistance should have genetic testing to confirm a diagnosis.[6]
  • Mutation testing: Polymerase chain reaction methods can detect FVL mutation.  The DNA from individuals without the mutation would be 'cut' by a restriction enzyme. In contrast, it will not cut DNA in patients with FVL mutation resulting in a different banding pattern on a DNA gel.[7]
  • Functional aPC resistance assays: These tests cost less than genetic testing, but in rare cases, they can give a misleading falsely normal result especially in individuals on therapy with direct thrombin inhibitors or factor Xa inhibitor, as well as in presence of a lupus anticoagulant.

Treatment / Management

Management of venous thromboembolism in people with FVL mutation is the same as that of the general population, and FVL mutation will not affect the decision about which anticoagulant one should use. The choice of anticoagulant is based on some factors like patient preference, adherence to therapy, the severity of thrombosis and drug interactions. 

Generally, direct oral anticoagulant (DOAC) are usually used for patients with typical VTE presentation. Warfarin is preferred if there is a concern about adherence or those who present with a submissive/massive pulmonary embolism who would benefit from maintaining INR at the high end of the therapeutic range.

The duration of VTE treatment is not different between FVL and the general population, and it depends on the risk of recurrent VTE. It is highly recommended that one continue indefinite anticoagulation for unprovoked, life-threatening venous thromboembolism, VTE at an unusual location or if it is recurrent.[8]

Individuals with FVL heterozygous mutation who undergo surgery should be treated as a high-risk group and receive prophylactic anticoagulation.

Differential Diagnosis

The differential diagnosis for deep vein thrombosis (DVT) includes the following:

Inherited Thrombophilia

  • Prothrombin G20210A mutation
  • Protein S deficiency 
  • Protein C deficiency
  • Antithrombin (AT) deficiency

Others

  • Malignancy
  • Trauma/surgery
  • Pregnancy, oral contraceptives
  • Immobilization/obesity
  • Nephrotic syndrome
  • Antiphospholipid syndrome 
  • Paroxysmal nocturnal hemoglobinuria
  • Myeloproliferative disorder
  • Heart failure 
  • Severe liver disease
  • Medications like tamoxifen, thalidomide, lenalidomide

Prognosis

A proportion of the population with Factor V Leiden will suffer venous thrombosis. Thromboembolism, including pulmonary embolism, carries significant morbidity and mortality. 

However, despite the increase in the risk of VTE, there is no evidence that heterozygosity to FVL increases overall mortality.

Enhancing Healthcare Team Outcomes

Factor V Leiden deficiency is not a common disorder, but because there is a potential risk of developing VTE, healthcare workers should be aware of this disorder. Patients may present with either venous or arterial thrombotic events, both of which are associated with a high morbidity and mortality. The condition is best managed by a multidisciplinary team that includes a hematologist, internist, nurse practitioner, a pharmacist, and the primary care provider. The key reason for such a team is that even when a diagnosis is made, many patients with only a laboratory finding of the defect may not require therapy. Only patients with VTE require treatment. The other difficulty in managing these patients is the duration of therapy. At the moment, data indicate that VTE in factor Leiden deficiency should be managed in the same manner as the normal population, but those with recurrent VTE or thrombosis of vessels in unusual locations may require long-term therapy. The outcomes in most patients with factor V Leiden deficiency are good but the outcomes in pregnant families with the disorder are guarded, because the risk of anticoagulation can adversely affect the fetus.[9][10]


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Factor V Leiden Deficiency - Questions

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What is the most common genetic defect in whites associated with a hypercoagulable state?



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A 23-year-old female on oral contraceptive pills develops a deep venous thrombosis and pulmonary embolism. She is a nonsmoker. Select the most probable predisposing factor.



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A 28 year old female with migraines with aura has an embolic event and is found by TEE to have a patent foramen ovale and atrial septal aneurysm. Ultrasound imaging of the leg veins and MRI imaging of the pelvic veins were unremarkable. Factor V Leiden mutation is present. Which of the following would be least appropriate?



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A 23-year-old woman presents for follow-up evaluation after hospitalization for deep venous thrombosis last week. She denies recent travel, surgery, or immobilization. She has a brother who was diagnosed with an unprovoked deep venous thrombosis 2 years ago at 40 years of age. The patient has a history of hypothyroidism. Her only medications are rivaroxaban and levothyroxine. Her vital signs are normal, and the physical examination is unremarkable. The possibility of an inherited thrombophilia is discussed with the patient. After reviewing the risks and benefits of additional testing, she agrees to further evaluation for a possible thrombophilia. Which of the following is the most appropriate step?



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A 28-year-old male was admitted last week for cerebral vein thrombosis. His brother has a history of massive pulmonary embolism and left iliofemoral deep vein thrombosis at 31 years of age. The workup during hospitalization revealed a factor V Leiden heterozygous mutation. His only medications are rivaroxaban and as needed acetaminophen. Today at the clinic he reports feeling good. His vital signs are normal, and the physical examination is unremarkable. How long should he continue anticoagulant therapy?



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All of the following are considered an inherited thrombophilia except which one?



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Factor V Leiden Deficiency - References

References

Dzimiri N,Meyer B, World distribution of factor V Leiden. Lancet (London, England). 1996 Feb 17     [PubMed]
Thorelli E,Kaufman RJ,Dahlbäck B, Cleavage of factor V at Arg 506 by activated protein C and the expression of anticoagulant activity of factor V. Blood. 1999 Apr 15     [PubMed]
Stolz E,Kemkes-Matthes B,Pötzsch B,Hahn M,Kraus J,Wirbartz A,Kaps M, Screening for thrombophilic risk factors among 25 German patients with cerebral venous thrombosis. Acta neurologica Scandinavica. 2000 Jul     [PubMed]
de Moerloose P,Reber G,Perrier A,Perneger T,Bounameaux H, Prevalence of factor V Leiden and prothrombin G20210A mutations in unselected patients with venous thromboembolism. British journal of haematology. 2000 Jul     [PubMed]
Juul K,Tybjaerg-Hansen A,Steffensen R,Kofoed S,Jensen G,Nordestgaard BG, Factor V Leiden: The Copenhagen City Heart Study and 2 meta-analyses. Blood. 2002 Jul 1     [PubMed]
Perez Botero J,Majerus JA,Strege AK,Johnson RD,Chen D,Pruthi RK, Diagnostic Testing Approaches for Activated Protein C Resistance and Factor V Leiden: A Comparison of Institutional and National Provider Practices. American journal of clinical pathology. 2017 Jun 1     [PubMed]
Amiral J,Vissac AM,Seghatchian J, Laboratory assessment of Activated Protein C Resistance/Factor V-Leiden and performance characteristics of a new quantitative assay. Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis. 2017 Dec     [PubMed]
Tritschler T,Kraaijpoel N,Le Gal G,Wells PS, Venous Thromboembolism: Advances in Diagnosis and Treatment. JAMA. 2018 Oct 16     [PubMed]
Khalafallah AA,Ibraheem AR,Teo QY,Albarzan AM,Parameswaran R,Hooper E,Pavlov T,Dennis AE,Hannan T, Review of Management and Outcomes in Women with Thrombophilia Risk during Pregnancy at a Single Institution. ISRN obstetrics and gynecology. 2014     [PubMed]
Ilonczai P,Oláh Z,Selmeczi A,Kerényi A,Bereczky Z,Póka R,Schlammadinger Á,Boda Z, Management and outcome of pregnancies in women with antithrombin deficiency: a single-center experience and review of literature. Blood coagulation & fibrinolysis : an international journal in haemostasis and thrombosis. 2015 Oct     [PubMed]

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