1
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Luo JQ, Mao SS, Chen JY, Ke XY, Zhu YF, Huang W, Sun HM, Liu ZJ. Antithrombin III deficiency in a patient with recurrent venous thromboembolism: A case report. World J Clin Cases 2023; 11:4956-4960. [PMID: 37583989 PMCID: PMC10424044 DOI: 10.12998/wjcc.v11.i20.4956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 05/19/2023] [Accepted: 06/26/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Antithrombin III (AT3) deficiency, an autosomal dominant disease, increases the likelihood of an individual developing venous thromboembolism (VTE). Long-term anticoagulation treatment is required for those suffering from AT3 deficiency. CASE SUMMARY A man aged 23, who had a history of deep venous thrombosis (DVT), experienced recurrent pain and swelling in his right lower extremity for three days following withdrawal of Rivaroxaban. He was diagnosed with DVT and antithrombin III deficiency as genetic testing revealed a single nucleotide variant in SERPINC1 (c.667T>C, p.S223P). The patient was advised to accept long-term anticoagulant therapy. CONCLUSION Inherited AT3 deficiency due to SERPINC1 mutations results in recurrent VTE. Patients may benefit from long-term anticoagulant therapy.
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Affiliation(s)
- Jia-Qing Luo
- Department of Vascular Surgery, Changxing People's Hospital, Changxing 313100, Zhejiang Province, China
| | - Shuai-Shuai Mao
- Department of Endocrinology, Changxing People's Hospital, Changxing 313100, Zhejiang Province, China
| | - Jin-Yi Chen
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Xue-Ying Ke
- Department of Vascular Surgery, Sir Runrun Shaw Hospital of Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Yue-Feng Zhu
- Department of Vascular Surgery, Sir Runrun Shaw Hospital of Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Wei Huang
- Department of General Surgery, Changxing People's Hospital, Changxing 313100, Zhejiang Province, China
| | - Hai-Ming Sun
- Department of Vascular Surgery, Changxing People's Hospital, Changxing 313100, Zhejiang Province, China
| | - Zhen-Jie Liu
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
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2
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Detection of Unknown and Rare Pathogenic Variants in Antithrombin, Protein C and Protein S Deficiency Using High-Throughput Targeted Sequencing. Diagnostics (Basel) 2022; 12:diagnostics12051060. [PMID: 35626216 PMCID: PMC9139221 DOI: 10.3390/diagnostics12051060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 02/01/2023] Open
Abstract
The deficiency of natural anticoagulants—antithrombin (AT), protein C (PC), and protein S (PS)—is a highly predisposing factor for thrombosis, which is still underdiagnosed at the genetic level. We aimed to establish and evaluate an optimal diagnostic approach based on a high-throughput sequencing platform suitable for testing a small number of genes. A fast, flexible, and efficient method involving automated amplicon library preparation and target sequencing on the Ion Torrent platform was optimized. The cohort consisted of a group of 31 unrelated patients selected for sequencing due to repeatedly low levels of one of the anticoagulant proteins (11 AT-deficient, 13 PC-deficient, and 7 PS-deficient patients). The overall mutation detection rate was 67.7%, highest in PC deficiency (76.9%), and six variants were newly detected—SERPINC1 c.398A > T (p.Gln133Leu), PROC c.450C > A (p.Tyr150Ter), c.715G > C (p.Gly239Arg) and c.866C > G (p.Pro289Arg), and PROS1 c.1468delA (p.Ile490fs) and c.1931T > A (p.Ile644Asn). Our data are consistent with those of previous studies, which mostly used time-consuming Sanger sequencing for genotyping, and the indication criteria for molecular genetic testing were adapted to this process in the past. Our promising results allow for a wider application of the described methodology in clinical practice, which will enable a suitable expansion of the group of indicated patients to include individuals with severe clinical findings of thrombosis at a young age. Moreover, this approach is flexible and applicable to other oligogenic panels.
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3
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Weronska A, Potaczek DP, Oto J, Medina P, Undas A, Wypasek E. A Series of 14 Polish Patients with Thrombotic Events and PC Deficiency-Novel c.401-1G>A PROC Gene Splice Site Mutation in a Patient with Aneurysms. Genes (Basel) 2022; 13:genes13050733. [PMID: 35627118 PMCID: PMC9141864 DOI: 10.3390/genes13050733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/16/2022] [Accepted: 04/18/2022] [Indexed: 12/04/2022] Open
Abstract
Objectives: Protein C (PC) deficiency is an inherited thrombophilia with a prevalence of 0.5% in the general population and 3% in subjects with a first-time deep vein thrombosis (DVT). Here we report a series of 14 PC-deficient Polish patients with comprehensive clinical and molecular characteristics, including long-term follow-up data and a deep mutational analysis of the PROC gene. Patients and Methods: Fourteen unrelated probands (mean ± SD age 43.8 ± 13.0 years) with suspicion of PC deficiency, who experienced thromboembolic events and a majority of whom received anticoagulants (92.8%), were screened for PROC mutations by sequencing the nine PROC exons and their flanking intron regions. Results: Ten probands (71.4%) had missense mutations, two patients (14.3%) carried nonsense variants, and the other two subjects (14.3%) had splice-site mutations, the latter including the c.401-1G>A variant, reported here for the very first time. The proband carrying the c.401-1A allele had a hepatic artery aneurysm with a highly positive family history of aneurysms and the absence of any mutations known to predispose to this vascular anomaly. Conclusion: A novel detrimental PROC mutation was identified in a family with aneurysms, which might suggest yet unclear links of thrombophilia to vascular anomalies, including aneurysms at atypical locations in women. The present case series also supports data indicating that novel oral anticoagulants (NOACs) are effective in PC deficient patients.
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Affiliation(s)
- Anna Weronska
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland;
| | - Daniel P. Potaczek
- Translational Inflammation Research Division & Core Facility for Single Cell Multiomics, Medical Faculty, Biochemical Pharmacological Center (BPC), Philipps University of Marburg, 35043 Marburg, Germany;
| | - Julia Oto
- Haemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe, 46026 Valencia, Spain; (J.O.); (P.M.)
| | - Pilar Medina
- Haemostasis, Thrombosis, Arteriosclerosis and Vascular Biology Research Group, Medical Research Institute Hospital La Fe, 46026 Valencia, Spain; (J.O.); (P.M.)
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University School of Medicine, 31-202 Krakow, Poland;
- John Paul II Hospital, 80 Prądnicka Street, 31-202 Krakow, Poland
| | - Ewa Wypasek
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland;
- John Paul II Hospital, 80 Prądnicka Street, 31-202 Krakow, Poland
- Correspondence: ; Tel./Fax: +48-12-6143145
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4
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Larsen OH, Kjaergaard AD, Hvas AM, Nissen PH. Genetic Variants in the Protein S ( PROS1 ) Gene and Protein S Deficiency in a Danish Population. TH OPEN 2021; 5:e479-e488. [PMID: 34729451 PMCID: PMC8553426 DOI: 10.1055/s-0041-1736636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/08/2021] [Indexed: 12/01/2022] Open
Abstract
Protein S (PS) deficiency is a risk factor for venous thromboembolism (VTE) and can be caused by variants of the gene encoding PS (
PROS1
). This study aimed to evaluate the clinical value of molecular analysis of the
PROS1
gene in PS-deficient participants. We performed Sanger sequencing of the coding region of the
PROS1
gene and multiplex ligation-dependent probe amplification to exclude large structural rearrangements. Free PS was measured by a particle-enhanced immunoassay, while PS activity was assessed by a clotting method.
A total of 87 PS-deficient participants and family members were included. In 22 index participants, we identified 13
PROS1
coding variants. Five variants were novel. In 21 index participants, no coding sequence variants or structural rearrangements were identified. The free PS level was lower in index participants carrying a
PROS1
variant compared with index participants with no variant (0.51 [0.32–0.61] vs. 0.62 [0.57–0.73] × 10
3
IU/L;
p
< 0.05). The p.(Thr78Met) variant was associated with only slightly decreased free PS levels (0.59 [0.53–0.66] × 10
3
IU/L) compared with the p.(Glu390Lys) variant (0.27 [0.24–0.37] × 10
3
IU/L,
p
< 0.01). The frequency of VTE in participants with a coding
PROS1
variant was 43 and 17% in the group with normal
PROS1
gene (
p
= 0.05).
In conclusion, we report 13
PROS1
coding variants including five novel variants. PS levels differ by
PROS1
variant and the frequency of VTE was higher when a coding
PROS1
variant was present. Hence, molecular analysis of the
PROS1
gene may add clinical value in the diagnostic work-up of PS deficiency.
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Affiliation(s)
- Ole Halfdan Larsen
- Department of Molecular Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Alisa D Kjaergaard
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Peter H Nissen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
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5
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Wang B, Xu P, Shu Q, Yan S, Xu H. Combined Effect of MTHFR C677T and PAI-1 4G/5G Polymorphisms on the Risk of Venous Thromboembolism in Chinese Lung Cancer Patients. Clin Appl Thromb Hemost 2021; 27:10760296211031291. [PMID: 34325549 PMCID: PMC8327007 DOI: 10.1177/10760296211031291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolism (VTE) is a common and potentially fatal complication in
cancer patients. Although several genetic risk factors related to thrombophilia
have been identified, their contributions for the occurrence of VTE in cancer
patients have conflicting results. The aim of this study was to evaluated the
gene polymorphisms of methylenetetrahydrofolate reductase (MTHFR) C677T and
plasminogen activator inhibitor-1 (PAI-1) 4G/5G in lung cancer patients, with
and without VTE, and the combined effect on the risk of VTE. 92 lung cancer
patients diagnosed with VTE (VTE group) and 122 lung cancer patients without VTE
(non-VTE group) were enrolled in the study. The gene polymorphisms were analyzed
by the method of polymerase chain reaction-restriction fragment length
polymorphism. Gene mutation of factor V Leiden was not detected both in non-VTE
group and VTE group. The frequency of MTHFR C677T homozygous mutation in VTE
group was 25.00%, higher than that in the non-VTE group without statistical
difference. It was found that the PAI-1 4G4G genotype is associated with a
higher risk of VTE (OR: 2.62, 95%CI: 1.19-5.75). Interestingly, the interaction
between MTHFR C677T and PAI-1 4G/5G polymorphisms showed that the coexistence of
the 2 homozygous mutation could further increase the risk of VTE. In conclusion,
PAI-1 4G/5G polymorphism may be an increased risk factor for VTE among lung
cancer patients in Chinese population. The homozygous MTHFR C677T mutation may
be not a risk factor for VTE but increases the risk, accompanied with PAI-1 4G5G
genotype.
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Affiliation(s)
- Baoyan Wang
- Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Peijuan Xu
- Nanjing Tongren Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Qing Shu
- Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Simin Yan
- Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Hang Xu
- Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
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6
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Ząbczyk M, Natorska J, Kopytek M, Malinowski KP, Undas A. The Effect of Direct Oral Anticoagulants on Antithrombin Activity Testing Is Abolished by DOAC-Stop in Venous Thromboembolism Patients. Arch Pathol Lab Med 2021; 145:99-104. [PMID: 33367661 DOI: 10.5858/arpa.2020-0021-oa] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Direct oral anticoagulants (DOACs) may cause false negative results of antithrombin (AT) deficiency screening. OBJECTIVE.— To evaluate the impact of DOAC-Stop, an agent reversing in vitro effects of DOACs, on AT testing in anticoagulated patients. DESIGN.— We assessed 130 venous thromboembolism patients aged 46.7 ± 13.5 years. Blood samples were collected 2 to 27 hours after DOAC intake from 49 patients on rivaroxaban, 54 on apixaban, and 27 on dabigatran. Antithrombin activity was assessed using the activated factor X (FXa)-based and the activated factor II (FIIa)-based method twice, before and after DOAC-Stop treatment, together with plasma DOAC levels using coagulometric assays. RESULTS.— The use of DOAC-Stop did not influence AT activity measured using the FIIa-based assay, whereas there was a marked decrease in AT activity determined using the FXa-based assay (ΔAT = 16.9%; 95% CI, 12.9%-19.1%). The AT-FIIa assay revealed decreased AT level (<79%) in all 10 (7.7%) genetically confirmed AT-deficient patients treated with rivaroxaban or apixaban (n = 5 each), whereas the AT-FXa assay showed decreased AT activity (<83%) in 2 subjects on rivaroxaban and 1 on apixaban with low plasma DOAC concentrations (<90 ng/mL). After DOAC-Stop median AT-FXa activity lowered from 83.5% (interquartile range, 66%-143%) to 65.5% (interquartile range, 57%-75%; P = .005; ΔAT = 18%) in AT-deficient patients, without any false negative results. The ΔAT in the FXa-based assay correlated with rivaroxaban and apixaban concentrations in the AT-deficient patients (r = 0.99, P < .001). CONCLUSIONS.— Application of DOAC-Stop enables reliable evaluation of AT deficiency screening in patients taking rivaroxaban or apixaban and tested using the FXa-based method.
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Affiliation(s)
- Michał Ząbczyk
- From the Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Kraków, Poland (Ząbczyk, Natorska, Kopytek, Undas)
| | - Joanna Natorska
- From the Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Kraków, Poland (Ząbczyk, Natorska, Kopytek, Undas)
| | - Magdalena Kopytek
- From the Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Kraków, Poland (Ząbczyk, Natorska, Kopytek, Undas)
| | - Krzysztof P Malinowski
- Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland (Malinowski)
| | - Anetta Undas
- From the Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Kraków, Poland (Ząbczyk, Natorska, Kopytek, Undas)
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7
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Direct oral anticoagulants in patients with severe inherited thrombophilia: a single-center cohort study. Int J Hematol 2020; 113:190-198. [PMID: 33040276 DOI: 10.1007/s12185-020-03012-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 10/23/2022]
Abstract
We investigated the safety and efficacy of direct oral anticoagulants (DOACs) in patients with venous thromboembolism (VTE) associated with severe inherited thrombophilia. In this single-center cohort study, we enrolled 56 consecutive VTE patients with severe inherited thrombophilia, defined as the presence of antithrombin (n = 18), protein C (n = 12) and protein S (n = 12) deficiencies, homozygous Factor V Leiden (n = 3) and prothrombin G20210AA (n = 4) mutations, or combined defects (n = 7). During a median follow-up of 44.5 (IQR 30-52.5) months, rivaroxaban was used in 30 (53.6%), apixabanin 14 (25%), and dabigatran in 12 (21.4%) subjects. Recurrent nonfatal VTE was observed in 5 (8.9%) patients (2.4 per 100 patient-years), treated with rivaroxaban (n = 4) and apixaban (n = 1). Major bleeding and clinically relevant non-major bleeding (CRNMB) occurred in 2 (3.5%) and 4 (7%) subjects, respectively (0.96 per 100 patient-years and 1.92 per 100 patient-years, respectively), including 4 patients on rivaroxaban. The event-free survival analysis showed that the use of rivaroxaban was associated with increased risk of recurrent VTE or bleeding, compared with apixaban or dabigatran (HR 2.76, 95% CI 1.26-3.92, p = 0.039). In conclusion, the results of our cohort study indicate that full-dose dabigatran or apixaban are effective and safe in patients with severe inherited thrombophilia.
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8
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Mrożek M, Wypasek E, Alhenc-Gelas M, Potaczek DP, Undas A. Novel Splice Site Mutation in the PROS1 Gene in a Polish Patient with Venous Thromboembolism: c.602-2delA, Splice Acceptor Site of Exon 7. ACTA ACUST UNITED AC 2020; 56:medicina56090485. [PMID: 32971918 PMCID: PMC7558706 DOI: 10.3390/medicina56090485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 12/16/2022]
Abstract
We identified a novel splice site mutation of the PROS1 gene in a Polish family with protein S (PS) deficiency and explored the molecular pathogenesis of this previously undescribed variant. A novel mutation was detected in a 26-year-old woman with a history of venous thromboembolism (VTE) provoked by oral contraceptives. Her family history of VTE was positive. The sequence analysis of the PROS1 gene was performed in the proband and the proband’s family. The proband and their asymptomatic father had lower free PS levels (45% and 50%, respectively) and PS activity (48% and 44%, respectively). Total PS levels were normal (65.6% and 62.4%, respectively). The sequence analysis of the PROS1 gene revealed the presence of heterozygous deletion at the nucleotide position c.602-2 in intron 6, just upstream of exon 7, detected in the proband and her father. This variant alters the splice acceptor site of exon 7, and, according to the in silico prediction, it is highly likely to cause in-frame exon 7 skipping. We also presented follow-up data of two other Polish patients with PS deficiency associated with splice site mutations in PROS1 gene.
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Affiliation(s)
- Magdalena Mrożek
- The John Paul II Hospital, 80 Prądnicka Street, 31-202 Krakow, Poland; (M.M.); (E.W.); (A.U.)
| | - Ewa Wypasek
- The John Paul II Hospital, 80 Prądnicka Street, 31-202 Krakow, Poland; (M.M.); (E.W.); (A.U.)
- Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland
| | - Martine Alhenc-Gelas
- Laboratoire d’Hémostase, Service de Médecine Vasculaire, Centre Claude Bernard de Recherche sur les Maladies Vasculaires, Hôpital Broussais–AP-HP, 75116 Paris, France;
- Société Serbio, 92230 Gennevilliers, France
| | - Daniel P. Potaczek
- The John Paul II Hospital, 80 Prądnicka Street, 31-202 Krakow, Poland; (M.M.); (E.W.); (A.U.)
- Institute of Laboratory Medicine and Translational Inflammation Research Division & Core Facility for Single Cell Multiomics Members of the German Center for Lung Research (DZL) and Universities of Giessen and Marburg Lung Center (UGMLC), Philipps-University Marburg, 35043 Marburg, Germany
- Correspondence: ; Tel.: +49-151-2050-9812
| | - Anetta Undas
- The John Paul II Hospital, 80 Prądnicka Street, 31-202 Krakow, Poland; (M.M.); (E.W.); (A.U.)
- Institute of Cardiology, Jagiellonian University Medical College, 30-705 Krakow, Poland
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9
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Gunasekaran K, Rajasurya V, Devasahayam J, Singh Rahi M, Chandran A, Elango K, Talari G. A Review of the Incidence Diagnosis and Treatment of Spontaneous Hemorrhage in Patients Treated with Direct Oral Anticoagulants. J Clin Med 2020; 9:E2984. [PMID: 32942757 PMCID: PMC7563837 DOI: 10.3390/jcm9092984] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 12/25/2022] Open
Abstract
Anticoagulation carries a tremendous therapeutic advantage in reducing morbidity and mortality with venous thromboembolism and atrial fibrillation. For over six decades, traditional anticoagulants like low molecular weight heparin and vitamin K antagonists like warfarin have been used to achieve therapeutic anticoagulation. In the past decade, multiple new direct oral anticoagulants have emerged and been approved for clinical use. Since their introduction, direct oral anticoagulants have changed the landscape of anticoagulants. With increasing indications and use in various patients, they have become the mainstay of treatment in venous thromboembolic diseases. The safety profile of direct oral anticoagulants is better or at least similar to warfarin, but several recent reports are focusing on spontaneous hemorrhages with direct oral anticoagulants. This narrative review aims to summarize the incidence of spontaneous hemorrhage in patients treated with direct oral anticoagulants and also offers practical management strategies for clinicians when patients receiving direct oral anticoagulants present with bleeding complications.
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Affiliation(s)
- Kulothungan Gunasekaran
- Division of Pulmonary Diseases and Critical Care, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT 06610, USA;
| | - Venkat Rajasurya
- Division of Pulmonary Diseases and Critical Care, Multi-Care Pulmonary Specialists, Puyallup, WA 98372, USA;
| | - Joe Devasahayam
- Division of Pulmonary Diseases and Critical Care, Avera Medical Group, Sioux Falls, SD 57105, USA;
| | - Mandeep Singh Rahi
- Division of Pulmonary Diseases and Critical Care, Yale-New Haven Health Bridgeport Hospital, Bridgeport, CT 06610, USA;
| | - Arul Chandran
- Division of Pulmonary Diseases and Critical Care, Hurley Medical Center, Flint, MI 48532, USA;
| | - Kalaimani Elango
- Division of Cardiology, University of Nevada, Las Vegas, NV 89154, USA;
| | - Goutham Talari
- Division of Hospital Medicine, Henry Ford Hospital, Detroit, MI 48202, USA;
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10
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Delayed Thrombin Generation Is Associated with Minor Bleedings in Venous Thromboembolism Patients on Rivaroxaban: Usefulness of Calibrated Automated Thrombography. J Clin Med 2020; 9:jcm9072018. [PMID: 32605001 PMCID: PMC7409038 DOI: 10.3390/jcm9072018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/12/2020] [Accepted: 06/22/2020] [Indexed: 11/30/2022] Open
Abstract
Bleeding is the most feared and difficult to predict adverse event of anticoagulation. We sought to investigate whether calibrated automated thrombography (CAT) parameters are associated with minor bleeding (MB) in anticoagulated patients following venous thromboembolism (VTE). Enrolled were 132 patients on rivaroxaban, 145 on vitamin K antagonists (VKA) and 31 controls who stopped anticoagulation. Prior to the next dose of the anticoagulant, we measured CAT parameters, along with rivaroxaban concentration and INR. During a median follow-up of 10 months, we recorded minor and major bleedings. On rivaroxaban, 27 (20.5%) patients with MB had longer time to start thrombin generation, lower peak thrombin generation and lower endogenous thrombin potential compared with subjects without MB (all p < 0.001). All CAT parameters, except for peak thrombin generation (p = 0.049), were similar in VKA patients with (n = 25, 17.2%) vs. without MBs. By logistic regression, time to start thrombin generation (p = 0.007) and unprovoked VTE (p = 0.041) independently predicted MBs on rivaroxaban. Major bleedings were more frequent in patients with MBs (17.3% vs. 1.8%, p < 0.001). Abnormal CAT parameters characterize VTE patients prone to MBs on rivaroxaban, but not on VKA. Time to start thrombin generation measured about 24 h since the last rivaroxaban dose might help predict MBs.
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11
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Reznik EV, Shcherbakova ES, Borisovskaya SV, Gavrilov YV, Pajeva TM, Lepkov SV, Mironkov AB, Dzhobava EM, Nikitin IG. ST-elevation myocardial infarction, pulmonary embolism, and cerebral ischemic stroke in a patient with critically low levels of natural anticoagulants. J Cardiol Cases 2020; 21:106-109. [PMID: 32153685 DOI: 10.1016/j.jccase.2019.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 10/10/2019] [Accepted: 10/31/2019] [Indexed: 11/17/2022] Open
Abstract
This clinical case report describes the simultaneous development of an acute myocardial infarction, stroke, and a massive pulmonary thromboembolism in a 44-year-old patient - a carrier of the thrombophilia gene polymorphisms: MTHFR C677T, А1298C, PAI-1 4G/5G, ITGA2 C807T. Multifocal thrombosis was probably due to the initial congenital deficiency of anticoagulants, accompanied by a decrease in antithrombin III and protein C, against the background of their critical consumption in cascade thrombosis, in combination with the carrier of polymorphisms of moderate and low thrombogenic risk. This case is unique in that there is usually a tendency toward clinical thrombosis when the level of antithrombin III is less than 70%. Such patients develop thrombosis at a younger age, and by the age of 35-40 years usually have a verified diagnosis of extremely high-risk hereditary thrombophilia. In this case, multifocal thrombosis was accompanied by critically low values of anticoagulants: antithrombin III - 3.4%, and protein C - 36.8%. The patient had suffered from epilepsy since childhood and took anticonvulsant drugs that increase the deficit of active folic acid and can lead to hyperhomocysteinemia, which in this case, against the background of an innate decrease in the activity of methyltetrahydrofolate reductase, could have aggravated the situation. <Learning objective: To focus on the possibility of the manifestation of multifocal thrombosis in congenital thrombophilia in adulthood against the background of critically low values of anticoagulants - antithrombin III and protein C.>.
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Affiliation(s)
- Elena Vladimirovna Reznik
- Department No 2, Medical Faculty of the N.I. Pirogov National Research Medical University, Moscow, Russia.,V.M. Buyanov's Moscow City Clinical Hospital, Moscow, Russia
| | | | - Svetlana Vasilievna Borisovskaya
- Department No 2, Medical Faculty of the N.I. Pirogov National Research Medical University, Moscow, Russia.,V.M. Buyanov's Moscow City Clinical Hospital, Moscow, Russia
| | | | | | | | | | | | - Igor Gennadievich Nikitin
- Department No 2, Medical Faculty of the N.I. Pirogov National Research Medical University, Moscow, Russia.,Federal State Autonomous Institution Treatment and Rehabilitation Center Ministry of Health of Russia, Moscow, Russia
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A prothrombotic state and denser clot formation in patients following acute limb ischemia of unknown cause. Thromb Res 2020; 187:32-38. [PMID: 31951936 DOI: 10.1016/j.thromres.2020.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/09/2019] [Accepted: 01/08/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Fibrin clot structure differs between healthy individuals and those following thromboembolic events. Dense and poorly lysable fibrin clots have also been reported in peripheral artery disease. We studied fibrin clot properties and its determinants in individuals with a history of acute lower limb ischemia (ALI) of unknown cause. MATERIALS AND METHODS In this case-control study, we enrolled 43 patients who experienced ALI of unknown cause, and two age-and sex-matched reference groups: (1) patients with cryptogenic non-lacunar stroke (n = 43) and (2) individuals without any history of thromboembolism (n = 43, control group). Plasma fibrin clot properties, along with thrombin generation and fibrinolysis markers were assessed following ≥3 months of anticoagulation. RESULTS Compared with the control group, the ALI group exhibited more compact plasma fibrin clots (13.4% lower permeability [Ks], p = .001), decreased formed clot lysis (12.5% lower D-Drate, p = .001) and unaltered clot lysis potential, along with enhanced thrombin generation potential (49% higher peak thrombin concentration, p < .0001). There were no differences in these variables between ALI and stroke patients. Patients with ALI had slightly higher α2-antiplasmin and lower plasminogen activator inhibitor 1 levels compared with the stroke and control groups (all p < .01). CONCLUSIONS Patients who experienced ALI of unknown cause display a prothrombotic fibrin clot phenotype, including increased clot density and hypofibrinolysis associated with higher thrombin generation, which might suggest potential benefits from prolonged anticoagulation in this disease.
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Xu J, Peng G, Ouyang Y. A novel mutation Gly222Arg in PROS1 causing protein S deficiency in a patient with pulmonary embolism. J Clin Lab Anal 2019; 34:e23111. [PMID: 31743498 PMCID: PMC7171343 DOI: 10.1002/jcla.23111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/26/2019] [Accepted: 09/26/2019] [Indexed: 11/29/2022] Open
Abstract
Background Thrombophilia is becoming a more frequently reported disorder these years. Hereditary protein S deficiency is one of the anticoagulant deficiencies that eventually results in thrombophilia. Case presentation A 24‐year‐old male patient was suffering from unexplained thrombosis for the second time with a family history of deep venous thrombosis. Screening tests for anticoagulant proteins found the activity of protein S markedly lowered (5.0%). The patient was discharged after anticoagulation treatment. Four years later, the review still showed the activity of protein S in his plasma decreased (16.0%). Molecular genetic analysis revealed him homozygous for a missense mutation, c.664G>A, in the exon7 of PROS1. The mutation discovered here is the first mutation affecting the codon 222 of PROS1. This mutation results in the replacement of the glycine at the codon 222 of protein S with arginine, leading to a reduction of protein S function. Conclusions The finding of this mutation may help with the understanding of the mechanism of protein S deficiency, especially in the Chinese population.
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Affiliation(s)
- Jingqing Xu
- Tongji Medical College of Huangzhong University of Science and Technology, Hankou City, China
| | - Gehong Peng
- Department of Ultrasound, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Yao Ouyang
- Department of Respiratory, Affiliated Hospital of Zunyi Medical University, Zunyi, China
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de la Morena-Barrio ME, Wypasek E, Owczarek D, Miñano A, Vicente V, Corral J, Undas A. MPI-CDG with transient hypoglycosylation and antithrombin deficiency. Haematologica 2018; 104:e79-e82. [PMID: 30545931 DOI: 10.3324/haematol.2018.211326] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- María Eugenia de la Morena-Barrio
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER, Spain
| | - Ewa Wypasek
- John Paul II Hospital, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, and the Institute of Cardiology, Jagiellonian University Medical College, Poland
| | - Danuta Owczarek
- Department of Gastroenterology, Hepatology and Infectious Diseases, Jagiellonian University Medical College, Kraków, Poland
| | - Antonia Miñano
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER, Spain
| | - Vicente Vicente
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER, Spain
| | - Javier Corral
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER, Spain
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, Kraków, Poland
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Venous thromboembolism associated with protein S deficiency due to Arg451* mutation in PROS1 gene: a case report and a literature review. J Genet 2018; 96:1047-1051. [PMID: 29321366 DOI: 10.1007/s12041-017-0865-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Protein S (PS) is a vitaminK-dependent glycoproteinwhich plays an important role in the regulation of blood coagulation. PS deficiency has been found in 1.5-7% of thrombophilic patients. Here, we report the first Polish case with PS deficiency caused by the p.Arg451* in the PROS1 gene detected in a 21-year-old man with trauma-induced venous thromboembolism. To our knowledge, we provided the review of all the available data on this mutation (a total of 56 cases). The proband, his mother and his sister were screened for thrombophilia. To elucidate genetic background of PS deficiency, all PROS1 genes were subjected to direct sequencing. The free PS levels were 35% in the proband, 21% in the proband's mother and 28% in the proband's sister and their PS total levels were 37.1, 47.5 and 55.1%, respectively. Type I PS deficiency was diagnosed. In all patients, genetic analysis revealed the presence of heterozygous nonsense mutation (c.1351C>T; p.Arg451*) located in exon 12 of PROS1 gene. This mutation interrupts the reading frame by premature termination codon at position 451 and may lead to the production of truncated protein. The present case combined with the review of the literature suggests that p.Arg451* in the PROS1 gene mainly leads to clinically evident thrombosis following trauma, surgery or serious comorbidities especially malignancy.
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