From the Guidelines
A full hypercoagulable workup for deep vein thrombosis (DVT) is not routinely recommended for all patients, but rather should be considered on a case-by-case basis, taking into account individual risk factors and clinical presentation, as suggested by the most recent guidelines 1. When considering a hypercoagulable workup, it is essential to weigh the potential benefits against the risks and costs of testing. The workup may include testing for both inherited and acquired thrombophilias, such as:
- Factor V Leiden mutation
- Prothrombin G20210A mutation
- Protein C deficiency
- Protein S deficiency
- Antithrombin deficiency
- Antiphospholipid antibodies (including lupus anticoagulant, anticardiolipin antibodies, and anti-beta2 glycoprotein I antibodies)
- Homocysteine levels
- JAK2 V617F mutation testing if polycythemia vera is suspected Timing of testing is crucial, and ideally, blood samples should be collected before initiating anticoagulation therapy, as warfarin and direct oral anticoagulants can affect protein C and S levels, as noted in the guidelines 1. If testing must be done while on anticoagulation, results should be interpreted cautiously. For antiphospholipid syndrome diagnosis, positive tests should be confirmed after 12 weeks. Consider testing for paroxysmal nocturnal hemoglobinuria and myeloproliferative disorders in cases of unusual thrombosis sites like hepatic or portal veins. Family history of thrombosis, young age at onset (under 50), recurrent thrombosis, unusual thrombosis locations, or thrombosis without clear precipitating factors are all indications for comprehensive testing, as suggested by the guidelines 1. The results of this workup may influence treatment duration, with some conditions requiring indefinite anticoagulation rather than the standard 3-6 months for provoked DVT, as recommended by the guidelines 1.
From the Research
Full Hypercoagulable Workup for DVT
A full hypercoagulable workup for Deep Vein Thrombosis (DVT) involves testing for various inherited and acquired thrombophilias. The following are some of the key components of this workup:
- Testing for Factor V Leiden mutation, which is a common cause of hereditary thrombophilia 2
- Testing for Protein C and Protein S deficiency, which are also associated with an increased risk of thrombosis 2, 3
- Testing for Antithrombin deficiency, which can increase the risk of thrombosis 2, 3
- Testing for Prothrombin gene mutation, which can also increase the risk of thrombosis 4, 3
Approach to Thrombophilia Testing
The approach to thrombophilia testing should be guided by the clinical presentation, suspected pathophysiology, and an understanding of how the results may affect patient care 5. The testing should be strategic and not reflexively performed without a clear appreciation of the clinical implications of the results.
Risk Factors for DVT
There are several risk factors associated with DVT, including:
- Prolonged immobility
- Malignancy
- Recent surgery
- Family history 6
- Factor V Leiden mutation 2, 4
- Protein C and Protein S deficiency 2, 3
- Antithrombin deficiency 2, 3
- Prothrombin gene mutation 4, 3
Diagnosis and Treatment of DVT
The diagnosis and treatment of DVT should be prompt and effective to prevent complications such as pulmonary embolism 6. Specialist services and diagnostic pathways have been developed to speed up the diagnosis and treatment of DVT, many of which are now nurse-led 6.