How to manage elevated fibrinogen levels?

Management of Elevated Fibrinogen Levels

Elevated fibrinogen levels should be managed based on the underlying cause, with treatment focused on addressing the primary condition rather than the fibrinogen level itself, as fibrinogen is an acute phase reactant that increases during inflammatory processes. 1

Understanding Elevated Fibrinogen

• Fibrinogen functions as an acute phase reactant protein that increases during inflammatory processes, often rising alongside C-reactive protein (CRP) during inflammatory responses 1
• Elevated fibrinogen is a significant independent risk marker in acute coronary syndromes and is associated with both short-term and long-term risk of death and subsequent myocardial infarction 1, 2
• Increased fibrinogen levels are linked to reduced fibrinolytic capacity, increasing risk of thrombotic events 1, 3
• Normal fibrinogen levels typically range from 2.0-4.0 g/L, with levels above this considered elevated 2

Causes of Elevated Fibrinogen

Inflammatory Conditions

• Acute and chronic inflammatory diseases trigger fibrinogen elevation as part of the acute phase response 1
• Cardiovascular diseases, particularly acute coronary syndromes, are associated with elevated fibrinogen 2, 3
• Trauma and tissue injury lead to increased fibrinogen production 2, 1

Cardiovascular Risk

• In the FRISC trial, elevated fibrinogen was associated with both short and long-term risk of death and subsequent myocardial infarction 2, 1
• Fibrinogen-mediated erythrocyte aggregation contributes to spontaneous echo contrast in atrial fibrillation, indicating stasis and increased thrombotic risk 1
• Both persistent and paroxysmal atrial fibrillation are associated with increased systemic fibrinogen levels, indicating active intravascular thrombogenesis 1, 4

Management Approach

Assessment

• Measure fibrinogen levels using the Clauss method, recognizing that artificial colloids like hydroxyethyl starch can cause overestimation 2
• Consider viscoelastic monitoring (thromboelastometry/TEG) for more accurate assessment of fibrinogen function in critical care settings 2

Treatment of Underlying Causes

• Primary management should focus on treating the underlying inflammatory condition or disease process causing the elevated fibrinogen 1, 5
• For cardiovascular disease-related elevation:
  • Address traditional cardiovascular risk factors (hypertension, hypercholesterolemia, diabetes) 3
  • Consider lipid-lowering therapy, particularly fibrates which can reduce elevated fibrinogen by up to 40% 5
  • Antiplatelet therapy may be indicated based on cardiovascular risk 3

Lifestyle Modifications

• Smoking cessation is the most effective lifestyle intervention for lowering fibrinogen levels 5
• Weight reduction and increased physical activity may have moderate effects on lowering fibrinogen 5
• Regular, moderate alcohol consumption may result in small reductions in fibrinogen levels 5

Pharmacological Options

• Fibrates (e.g., bezafibrate) can reduce elevated fibrinogen by up to 40% 5
• Ticlopidine may induce a reduction of about 15% if fibrinogen was elevated at baseline 5
• In cases of extreme hyperfibrinogenemia causing symptoms, therapeutic plasma exchange may be considered in specialized settings 5

Special Considerations

Pregnancy

• Fibrinogen levels physiologically increase during pregnancy 2
• In pregnant women with congenital fibrinogen disorders, management differs significantly and requires specialized care 2

Trauma and Critical Care

• In trauma patients, fibrinogen levels should be maintained above 1.5-2.0 g/L to prevent bleeding complications 2
• For ongoing bleeding in trauma, target fibrinogen levels of ≥1.5 g/L 2
• In cases of hypofibrinogenemia in trauma, fibrinogen concentrate (3-4g) or cryoprecipitate (50 mg/kg) may be administered 2

Monitoring

• Regular monitoring of fibrinogen levels is recommended when treating conditions associated with elevated fibrinogen 2
• Goal-directed strategies using standard laboratory coagulation values, including fibrinogen, are recommended for managing bleeding in trauma patients 2, 1

Caution

• Aggressive lowering of fibrinogen without addressing the underlying cause is not recommended 5
• Interventions to lower fibrinogen have multiple effects on cardiovascular function and should be carefully considered 5, 3
• The risk-benefit ratio of fibrinogen-lowering therapies should be evaluated on an individual basis 5