Incidence of factor V Leiden in patients with acute myocardial infarction

Acute Myocardial Infarction in Patients with Hereditary Thrombophilia-A Focus on Factor V Leiden and Prothrombin G20210A

Factor V (FV) Leiden and prothrombin G20210A are the most common hereditary thrombophilias. While their role in venous thromboembolism is well known, there are still uncertainties regarding their relationship with arterial thrombotic events, especially coronary ones. Our research, based on an in-depth analysis of the available literature, provides up-to-date information on the relationship between FV Leiden and prothrombin G20210A and acute myocardial infarction. FV Leiden and prothrombin G20210A screening should be implemented only in select cases, such as acute coronary syndrome in young individuals and/or in the absence of traditional cardiovascular risk factors and/or in the absence of significant coronary artery stenosis at angiography. Their identification should be followed by the implementation of optimal control of modifiable traditional cardiovascular risk factors to reduce the risk of recurrent events and genotyping and genetic counseling of all family members of affected cases for proper prophylaxis. An extended dual antiplatelet therapy (DAPT) may be considered, given the lower risk of bleeding under DAPT conferred by FV Leiden.

Factor V Leiden but not the factor II 20210G>A mutation is a risk factor for premature coronary artery disease: a case-control study in Iran

Background

Factor V Leiden (FVL) and factor II c.∗97G>A (rs1799963) are genetic risk factors for venous thromboembolism. Their contribution to coronary artery disease (CAD) is less clear.

Objectives

This study aimed to investigate the association between FVL, rs1799963, and premature CAD in Iranians.

Methods

We performed a genetic case-control study of 944 cases and 1081 controls from the premature CAD Milano-Iran study, including patients aged 18-55 (female) and 18-45 years (male) who underwent coronary angiography at the Tehran Heart Centre (Iran) in 2004-2011. Cases had luminal stenosis ≥50% in at least 1 main coronary artery or branch. Controls were age- and sex-matched with no CAD history. FVL and rs1799963 were genotyped using TaqMan SNP genotyping assays. Association was tested by logistic regression adjusted for matching factors and ethnicity. Effect modification by sex and cardiovascular risk factors (metabolic [obesity, hypertension, hyperlipidemia, and diabetes], and smoking) was assessed.

Results

The risk of premature CAD was increased by 50% in FVL carriers (adjusted odds ratio [adjOR] 1.54 [95% CI, 0.95-2.48]) and slightly reduced in rs1799963 carriers (adjOR 0.71 [95% CI, 0.40-1.27]). These effects were more pronounced in women than men (FVL, adjOR 1.66 vs 1.25; rs1799963, adjOR 0.60 vs 1.07). The risk of premature CAD was substantially increased in carriers of FVL with at least 1 metabolic risk factor compared with noncarriers without metabolic risk factors (adjOR 25.14 [95% CI, 12.51-50.52]).

Conclusion

FVL but not FII rs1799963 was associated with an increased risk of CAD in young Iranians. This risk increased considerably when combined with metabolic cardiovascular risk factors.

The Association of Hereditary Prothrombotic Risk Factors with ST-Elevation Myocardial Infarction

Objective

The ST- elevation myocardial infarction (STEMI), a serious health care problem, is commonly a thrombotic complication of coronary artery disease. We compare the STEMI patients and control group in terms of the possible causes of inherited thrombophilia including FactorV Cambridge G1091C, FactorV Leiden G1691A, MTHFRC677T, MTHFR A1298C, FactorII G20210A, Factor XIII (V34L), PAI-1, FGB, ITGB3, APOB, FVHR2, ACE gene variants.

Methods

Fifty-three patients with STEMI and 47 individuals without diagnosis of acute coronary syndrome were included in the study. Percutaneous coronary intervention was performed for patients with STEMI. Echocardiography was performed and inherited thrombophilia genes were evaluated in all subjects.

Results

The MTHFR A1298C, Factor XIII (V34L), ITGB, ACE and homozygous or compound heterozygous gene varations of inherited thrombophilia are significantly related with STEMI (p<0.05). Also significantly higher MTHFR A1298C, FactorV Leiden G1691A, PAI and ACE gene variations in MI patients who were smokers; Factor XIII (V34L), PAI and ACE gene variations in MI patients with HT; PAI and ACE gene variation in MI patients with FH and PAI gene variations in MI patients with HL were detected when compared with the control groups with all of the same risk factors (p<0.05).

Conclusion

Hereditary thrombophilia factors may show promise in the prevention and management of STEMI when supported studies with larger case series.

[ST elevation myocardial infarction in young adults: Is there an interest for thrombophilia screening?]

BACKGROUND

Coronary lesions characteristics as well as patient thrombogenicity can explain coronary events manifestation. In young patient, local conditions are usually less important and thrombogenicity could play a significant role. Assessing thrombophilia could be justified in young patients and may induce an adapted therapeutic management.

PURPOSE

We aimed to assess the prevalence of thrombophilia and therapeutic modification in young adults aged≤55 years admitted in our department for ST elevation myocardial infarction (STEMI).

METHODS

From January 2013 to January 2017, data on all patients aged≤55 years with STEMI admitted in emergency were retrospectively retrieved from our database. Thrombophilia investigation was made regarding clinical (with or without cardiovascular risk factors [CVRF]), biological and/or angiographic evaluation.

RESULTS

A total of 133 patients aged≤55 years with STEMI were included. Cardiac arrest occurred in 15 patients (11%). One or less CVRF were found in 47 patients (35%). Smoking was reported in 93 patients (70%) and drug addiction (cannabis, cocaine) in 19 patients (14%). A subset of 51 patients (38%) were screened for thrombophilia. Patients with thrombophilia assessment were younger, less active smokers and presented less CVRF than patients without investigation (P<0.001). Single vessel diseased was found in 88 patients (66%). No differences regarding coronary procedural characteristic were found between the two groups. The most frequently encountered aetiology, found in 122 patients (92%), was de novo intra-arterial thrombosis related to atherosclerosis. In patients with thrombophilia assessment (n=51), one or more abnormal biological results was found in 22 patients (43%) and a therapeutic adjustment was made in 6 patients (12%).

CONCLUSION

Thrombophilia screening in young STEMI adults showed an abnormality in 43% of cases. Antithrombotic treatment can be modified after its demonstration.

Hypereosinophilic Syndrome Associated with Heterozygous Factor V Gene Mutation: An Unusual Combination Resulting in an Acute Coronary Syndrome and Recurrent Cerebral Stroke

The authors report the first case of a patient with a hypereosinophilic syndrome associated with heterozygous factor V gene mutation, resulting in an acute coronary syndrome and recurrent cerebral stroke despite effective anticoagulation. A 40-year-old man presented with an acute coronary syndrome accompanied by a brachiofacial right-sided hemiparesis and dysarthria. Diagnosis of a hypereosinophilic syndrome was established by blood testing, myocardial biopsy, and bone marrow analysis. Eosinophilic infiltration was present in the myocardium, accompanied by proliferation in the endomyocardium and a pneumonic infiltrate. Although effective anticoagulation with heparin was administered, a recurrent stroke occurred while blood eosinophils were being normalized by corticosteroid treatment. A coexisting heterozygosity of the factor V mutation was demonstrated, and it is hypothesized that this might have contributed to the recurrent thromboembolic episodes. In patients with hypereosinophilic syndrome and recurrent thromboembolic episodes, other thrombophilic diseases, including factor V mutations, should be considered, and long-term coagulation should be contemplated.

Increase in the risk of ST elevation myocardial infarction is associated with homocysteine level

BACKGROUND AND AIMS

The present study aimed to investigate the relationship between coagulation defects and ST elevation myocardial infarction (STEMI) in patients without any known coronary artery risk factors and considered low risk according to the Framingham risk classification.

METHODS

This study included 76 (73.6% male) STEMI patients without any known risk factors for coronary artery disease and 56 healthy controls (67.8% male) with similar characteristics.

RESULTS

Factor V Leiden mutation was noted in two patients and in one control. There were no significant differences in protein C, protein S, or antithrombin 3 values between the patient and control groups (p = 0.405, p = 0.476, and p = 0.221, respectively). None of the participants had antiphospholipid syndrome, factor V deficiency, or factor VII deficiency. Plasma homocysteine level was significantly higher in the patient group (19.0 ± 3.6) μmol/L than in the control group (15.8 ± 4.2) μmol/L (p = 0.008). Homocysteine levels in both groups were higher in males without a statistically significant difference. Vitamin B12 and folate levels, which are directly related to homocysteine metabolism, did not differ significantly between groups. Correlation analysis showed that the homocysteine level was not correlated with lipid parameters, folate, or vitamin B12.

CONCLUSION

Homocysteine level was significantly higher in acute MI in patients without any risk factors and were considered low risk according to the Framingham risk score. The findings support the hypothesis that homocysteine level may be an independent risk factor for coronary artery disease.

Association between factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T mutations and events of the arterial circulatory system: a meta-analysis of published studies

BACKGROUND

The association between the inherited gene mutations of factor V, prothrombin, and homocysteine metabolism and venous thromboembolic events is accepted widely; however, their influence on the arterial circulatory system remains controversial.

METHODS

We performed a MEDLINE search to identify published case-control and cohort studies correlating the factor V Leiden, prothrombin (PT) G20210A, and methylenetetrahydrofolate reductase (MTHFR) C677T (TT genotype) mutations with myocardial infarction, ischemic stroke, or peripheral vascular disease. Studies were included only when they adhered to specific diagnostic criteria for ischemic events and met the published methodological criteria. Odds ratios (ORs) with accompanying 95% CIs were calculated for each mutation and clinical end points with a random-effects model (DerSimonian and Laird method).

RESULTS

The association between inherited gene mutations and arterial ischemic events was modest: factor V Leiden mutation (OR, 1.21; 95% CI, 0.99-1.49), PT G20210A mutation (OR, 1.32; 95% CI, 1.03-1.69), and MTHFR TT mutation (OR, 1.20; 95% CI, 1.02-1.41). Subgroup analyses of younger patients (<55 years old) and of women revealed slightly stronger associations overall.

CONCLUSIONS

Genetic abnormalities specific to factor V, prothrombin,and homocysteine metabolism increase the risk for myocardial infarction and ischemic stroke, particularly among younger patients and women. Because the overall association is only modest, screening studies should be limited to carefully selected patient populations. The individual propensity for arterial and venous thrombosis is likely influenced by differing local mechanisms, systemic mechanisms, or both.

Factor V Leiden mutation and its relation to left atrial thrombus in chronic nonrheumatic atrial fibrillation

The genetic defect of coagulation factor V, known as factor V Leiden, produces a resistance to degradation by activated protein C and increased venous thrombosis. However, the role of factor V Leiden in the formation of left atrial thrombus with nonrheumatic atrial fibrillation has not been studied. We investigated whether factor V Leiden is a risk factor for left atrial thrombus in patients with nonrheumatic atrial fibrillation. We analyzed clinical, echocardiographic, and biochemical data in 105 consecutive patients with nonrheumatic atrial fibrillation. These patients were divided into two groups: group A (n = 37) with left atrial thrombus and group B (n = 68) without left atrial thrombus. The study also included 42 control subjects. Left atrial thrombus was investigated by using both transthoracic echocardiography and transesophageal echocardiography. Blood samples from the patients and controls were analyzed for the factor V Leiden mutation by DNA analysis, using the polymerase chain reaction. There was no significant difference in the prevalence of factor V Leiden between the patients and control subjects. The prevalence of factor V Leiden mutation was 8.1% (3/37) in patients with left atrial thrombus, and 8.8% (6/68) in patients without left atrial thrombus. The prevalence of factor V Leiden was 7.1% (3/42) in control subjects. The prevalance of factor V Leiden was 10% (2/20) in patients with spontaneous echo contrast and 8% (7/85) in patients without spontaneous echo contrast. Multivariate analyses showed that left ventricular ejection fraction was an independent predictor of left atrial thrombus. Factor V Leiden mutation is not a risk factor for left atrial thrombus formation and spontaneous echo contrast in patients with nonrheumatic atrial fibrillation.

[Factor V Leiden and myocardial infarction: a case, review of the literature with a meta-analysis]

Mutation in blood coagulation factor V Leiden is the most frequently genetic polymorphism implied in venous thrombosis. A 57 year old man was hospitalised for acute myocardial infarction (MI). An emergency coronary angiography was performed, and no significant stenosis was observed. The haematologic check-up showed an heterozygous Leiden mutation of factor V. We report all publications about the relation between factor V Leiden and coronary thrombosis, and we performed a meta-analysis. We analysed the relation in general population and in subgroups, such as, younger and older, and patient with or without coronary stenosis. In global population, the meta-analysis did not found significant association between Factor V Leiden and myocardial infarction (OR = 1.25; IC = 0.97-1.58). In contrast, in patients less than < 55 years old after MI, Factor V Leiden prevalence was significantly higher than in control group (OR = 1.48; IC = 1.05-2.08). In addition, after MI without significant coronary stenosis Factor V Leiden prevalence was significantly higher than in normal patients (OR = 2.84; IC = 1.46-5.51). After MI, in patients without significant coronary stenosis, Factor V Leiden prevalence was significantly higher than in patients with significant coronary stenosis (OR = 3.26; IC = 1.67-6.36). Our study suggests that Factor V Leiden could be search after MI in young subjects and/or without significant stenosis.

Detection of factor V leiden and prothrombin gene mutations in patients who died with thrombotic events

CONTEXT

Individuals with factor V or prothrombin gene mutations are at increased risk for thrombotic events. Furthermore, the risk of recurrent deep venous thrombosis in heterozygous carriers of both factor V Leiden and prothrombin gene mutations is high enough that some investigators suggest lifelong warfarin prophylaxis for these individuals, even with a single spontaneous thrombotic event.

OBJECTIVES

To assess the incidence of factor V Leiden and prothrombin gene mutations in an autopsy population and to determine if these tests can prove useful in identification of at-risk family members.

DESIGN

We analyzed factor V Leiden and prothrombin gene mutations in 45 patients who died with or of thrombotic events, using archival tissue and multiplex allele-specific polymerase chain reaction amplification. The wild-type factor V gene was amplified in all 45 patients, whereas the wild-type prothrombin gene was amplified in 29 patients.

RESULTS

Two patients (4.4%) who died with thrombotic events at the ages of 35 and 92 years were heterozygous for factor V gene mutation. Two additional patients (6.7%), who died with thrombotic events at the ages of 26 and 39 years, were heterozygous for prothrombin gene mutation. Patients homozygous for either factor V or prothrombin gene or simultaneously heterozygous for both genes were not detected in our study.

CONCLUSIONS

Our findings suggest that screening the relatives of elderly patients who die with thrombotic events would not be cost-effective because of the low incidence of these mutations in the autopsy population. However, because the incidence of these mutations appeared significantly more frequently among individuals who died at 39 years or younger, testing the relatives of this subset of patients may prove useful for detection of at-risk individuals who would benefit from preventive anticoagulation therapy.

Laboratory evaluation of hypercoagulability with venous or arterial thrombosis

OBJECTIVE

To provide recommendations for hypercoagulation testing for patients with venous, arterial, or neurovascular thrombosis, as reflected in the medical literature and the consensus opinion of recognized experts in the field.

DATA SOURCES, EXTRACTION, AND SYNTHESIS

The authors extensively examined the literature and current practices, and prepared a draft manuscript with preliminary recommendations. The draft manuscript was circulated to each of the expert participants (n = 30) in the consensus conference prior to the convening of the conference. The manuscript and recommendations were then presented at the conference for discussion. Recommendations were accepted if a consensus of the 28 experts attending the conference was reached. The discussions were also used to revise the manuscript into its final form.

CONCLUSIONS

The resulting article provides 17 recommendations for hypercoagulation testing in the setting of venous, arterial, or neurovascular thrombosis. The supporting evidence for test selection is analyzed and cited, and consensus recommendations for test selection are presented. Issues for which a consensus was not reached at the conference are also discussed.

Factor V Leiden: The Copenhagen City Heart Study and 2 meta-analyses

Factor V Leiden (FVL) is associated with venous thrombosis; however, an association between FVL and arterial thrombosis remains controversial. We investigated FVL as a risk factor for myocardial infarction (MI), ischemic stroke (IS), or non-MI ischemic heart disease (non-MI-IHD). The design was 3 case-control studies and 3 prospective studies with 21 years' follow-up. The setting was the general population in Copenhagen, Denmark. The participants for The Copenhagen City Heart Study were 20- to 95-year-old participants without cardiovascular disease (control population, n = 7907) or participants diagnosed with MI (n = 469), IS (n = 231), or non-MI-IHD (n = 365). In addition, 3 independent patient populations from Copenhagen University Hospital with MI (n = 493), IS (n = 231), or non-MI-IHD (n = 448) were included. We measured FVL genotype; major cardiovascular risk factors; and MI, IS, and non-MI-IHD incidence and prevalence. Prevalences of FVL heterozygotes and homozygotes in control subjects from the general population were 7.7% and 0.2%. Odds ratios and relative risks of MI in FVL carriers (heterozygotes + homozygotes) versus noncarriers were 1.24 (95% confidence interval [CI], 0.91-1.69) and 0.83 (0.58-1.20) in case-control and prospective studies, respectively. Corresponding risks for IS were 0.92 (95% CI, 0.56-1.53) and 0.68 (0.45-1.04), and for non-MI-IHD 1.01 (95% CI, 0.71-1.44) and 0.97 (0.66-1.42). Findings from The Copenhagen City Heart Study suggest that FVL is not associated with MI, IS, or non-MI-IHD.

Genetic variation in coagulation and fibrinolytic proteins and their relation with acute myocardial infarction: a systematic review

BACKGROUND

It is pathophysiologically conceivable that genetic variations in coagulation and fibrinolytic proteins are associated with the risk of myocardial infarction. Methods and Results- We performed a literature search to identify published case-control studies correlating the factor V Leiden or prothrombin G20210A mutations or fibrinogen G-455A or plasminogen activator inhibitor-1 (PAI-1) 4G/5G polymorphisms with the risk of myocardial infarction. Studies were included only if they used solid diagnostic criteria and complied with published methodological criteria. A common OR with corresponding 95% CI was calculated for the risk of myocardial infarction in a fixed-effect model according to Mantel-Haenszel. The factor V Leiden and prothrombin G20201A mutations did not significantly correlate with myocardial infarction (OR 1.26, 95% CI 0.94 to 1.67, P=0.12 and OR 0.89, 95% CI 0.59 to 1.35, P=0.6, respectively). Inclusion of the studies that investigated young patients (<55 years) made the association significant for factor V Leiden (OR 1.29, 95% CI 1.03 to 1.61, P=0.02). Homozygosity for the fibrinogen -455A allele was significantly associated with a decreased risk of myocardial infarction (OR 0.66, 95% CI 0.44 to 0.99, P=0.04), whereas the PAI-1 4G4G genotype was significantly associated with increased risk (OR 1.20, 95% CI 1.04 to 1.39, P=0.04).

CONCLUSIONS

Associations between these genetic variations and myocardial infarction were weak or absent. In the absence of clinical implications, our results indicate that screening of patients with myocardial infarction for these genetic variations is not warranted.

Factor V Leiden: a clinical review

Factor V Leiden is the most prevalent genetic thrombophilia in people of European descent. Since its discovery, much clinical information has been gathered regarding the distribution and prevalence of the genetic mutation, the mechanism of thrombophilia, and its association with clinical thromboembolic events. Although its association with venous thromboembolism is clear, the role of Factor V Leiden in other disease states is not clear. A review of the literature regarding the mechanism of hypercoagulability, genetic versus functional diagnostic tests, screening issues, relationship to arterial thromboses, pregnancy and pregnancy complications, and treatment are discussed.