Elevated factor VIII levels and arterial stroke: a review of literature with a case report

Assessing cardiovascular disease: looking beyond cholesterol

PURPOSE OF REVIEW

The low-density lipoprotein (LDL)-cholesterol level is a weak predictor of developing cardiovascular (CV) disease and can only explain a small proportion of CV risk. It is not used to determine CV risk on either the atherosclerotic cardiovascular disease (ASCVD) calculator in the United States, or the Qrisk3 in the UK.A study in JAMA in 2022 suggested that ' the absolute benefits of statins are modest and may not be strongly mediated through the degree of LDL reduction '. Perhaps it is time to look beyond cholesterol to a different causal model - the 'thrombogenic' model of ASCVD.

RECENT FINDINGS

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) pandemic demonstrated that infectious agents damage the endothelium and the glycocalyx - the glycoprotein layer protecting underlying endothelial cells. There are numerous other conditions leading to this kind of damage, which can trigger thrombus formation, causing strokes and myocardial infarctions.Although these are acute events, they highlight a mechanism for the development of ASCVD which centres on endothelial damage and thrombus formation as both the primary causal mechanism for acute events, and the driver behind progression towards atherosclerotic plaque development.

SUMMARY

The cholesterol hypothesis, that a raised LDL is directly causal for ASCVD, does not adequately explain cardiovascular risk in individuals, or populations. An alternative 'thrombogenic' hypothesis is proposed as a more valid causal model.

Arterial Thrombosis of Unknown Etiology in a 10-Year-Old Male

Arterial thrombotic events are exceedingly rare occurrences in pediatric populations. The incidence of childhood thrombosis is extremely low and the majority of cases are venous in origin. There are several well-known etiologies and genetic risk factors with an underlying predisposition to venous thrombosis, however, there have been few identified etiologies of arterial thrombotic events in pediatric patients. The most common include factor V Leiden mutation, trauma, neoplasm, and inherited metabolic disorders. This case report involves a 10-year-old male with no predisposing factors or significant medical or surgical history, who presents with a cerebral vascular accident secondary to a peripheral arterial clot of the basilar artery. The patient's only identifiable risk factor was an elevated factor VIII level. Elevated factor VIII levels are a risk factor for thrombotic events, with a greater impact on venous than on arterial thrombosis. However, due to a lack of international consensus on methods for the laboratory testing of factor VIII levels in plasma, it is not currently recommended that the measurement of factor VIII levels be part of routine thrombophilia screening in pediatric populations.