Thrombophilia screen (profile)

The complex orchestration of cellular and molecular participants of haemostasis achieves a crucial yet fine balance of procoagulant and anticoagulant mechanisms. Deficiencies of natural anticoagulant regulators of secondary haemostasis, such as antithrombin, protein C and protein S, and gain of function mutations in genes for FII and FV, are heritable disorders that can shift this balance and increase the risk of venous thromboembolic disease. First line phenotypic screening for heritable thrombophilia includes a coagulation screen with fibrinogen, antithrombin activity, protein C activity, free protein S antigen and activated protein C resistance screening. Antithrombin (AT) is a serine protease inhibitor whose main target enzymes are thrombin and FXa, although it also possesses activity against FIXa, FXIa and TF:FVIIa. It is more efficient at inhibiting free thrombin and FXa than when they are contained within activation assemblies on clot surfaces, thus acting as a scavenger of potentially lethal enzymes that would otherwise diffuse away and cause unnecessary fibrin formation elsewhere. This serves to localise clot formation to the site of injury and limit coagulation. Hereditary AT deficiency can manifest as a reduced concentration of normally functioning AT, (type I defect), or a deficiency of function, (type II defect).Protein C (PC) is the vitamin K dependent zymogen of the serine protease activated protein C (APC), which functions as a regulator of secondary haemostasis by inactivating FVa & FVIIIa within a forming clot. PC attaches to vessel endothelium via a specific receptor, endothelial PC receptor (EPCR) and then migrates across the endothelial surface 'in search' of its activator. If a clot is being formed, some of the thrombin leaks onto the endothelial surface and encounters membrane-bound thrombomodulin (TM), whereupon they form a complex that induces a conformational change in thrombin such that it loses procoagulant activity and instead adopts an anticoagulant role by activating PC. The APC/EPCR complex then dissociates from the TM-throbmin complex and the APC is released to migrate onto the surface of an activated platelet. PC & its non-enzymatic cofactor protein S (PS) are vitamin K dependent and so bind to surface phospholipid and PS orientates the active site of PC above the platelet surface to facilitate inactivation of substrates by cleavage of a small number of peptide bonds. Inactivation of FVIIIa additionally requires zymogen FV to operate synergistically with PS in a cofactor role.Deficiency of PC can be qualitative or quantitative and reduces the effectiveness of haemostasis regulation, thus tipping the balance towards an increased risk of venous thromboembolism. Approximately 60% of PS circulates bound to C4b-binding protein and is largely unavailable for functioning as a cofactor for APC. The remainder is termed free protein S (FPS) and is directly available for APC cofactor function. PS also operates as a cofactor for tissue factor pathway inhibitor. Deficiency of PS also tips the haemostatic balance towards an increased risk of venous thromboembolism.Activated protein C resistance (APCR) is defined as a poor anticoagulant response of plasma to APC and has both hereditary and acquired causes. More than 90% of hereditary cases are due to the FV Leiden (FVL) point mutation which results in an impaired inactivation rate of FVa due to alteration of a protein C cleavage site. Native FVa is an important procoagulant co-factor to FXa in the prothrombinase complex and the result of the mutation is that thrombin formation will not be stopped as efficiently as in the case of inactivation of native FVa. Compared to individuals with a normal FV genotype, heterozygosity for the mutation confers about a 5 – 10 fold higher thrombotic risk. Other FV mutations conferring at least in vitro APCR include FV Cambridge and FV Hong Kong. No mutations in the FVIII gene conferring APCR have been described. Acquired APCR has been described in association with pregnancy, high FVIII levels, antiphospholipid antibodies and use of the oral contraceptive pill.