Evidence-based indications for thrombophilia screening.
Thrombophilic defects have been shown to be associated with an increased risk of venous thrombosis, fetal loss, and gestational complications. The knowledge about the clinical relevance of thrombophilic defects is increasing, and evidence-based indications for thrombophilia screening are therefore discussed in this review. Selective thrombophilia screening based on previous personal and/or family history of venous thromboembolism is more cost-effective than universal screening in all patient groups evaluated. In the majority of patients with acute venous thrombosis, the results of thrombophilia screening do not influence the duration of oral anticoagulation. The only patient population who clearly profits from thrombophilia screening in this situation are patients with a newly diagnosed antiphospholipid syndrome, because prolonged anticoagulation can avoid the high incidence of recurrence in this patient population. Because of the increased risk of venous thrombosis during pregnancy and the puerperium, thrombophilia screening is indicated in selected patients with a previous history of venous thrombosis or a positive family history. Significant associations with early and late pregnancy loss are observed for carriers of the heterozygous factor V Leiden mutation, the heterozygous prothrombin-mutation G20210A and anticardiolipin antibodies, while protein S deficiency is significantly associated with late pregnancy loss. Antithrombotic drugs like UFH, LMWH or low-dose aspirin may have a potential therapeutic benefit in patients with recurrent pregnancy loss and thrombophilia, but placebo-controlled, multicenter trials are urgently needed to clarify this issue. Although a supra-additive effect for the risk of venous thrombosis is observed between oral contraceptives and some thrombophilias, the absolute incidence of venous thromboembolism is low in premenopausal women and mass screening strategies are therefore unlikely to be effective. While antiphospholipid antibodies are known to be associated with arterial thrombosis, screening for heritable thrombophilias is not useful in arterial thrombosis, although subgroup analysis indicates that they may play a role particularly in young patients and children.
Lindhoff-Last
E
E
Department of Internal Medicine, Division of Vascular Medicine/Haemostaseology, University Hospital, Frankfurt/Main, Germany. lindhoff-last@em.uni-frankfurt.de
Luxembourg
B
B
D000022:Abortion, Spontaneous / Q000097:blood / Q000209:etiology; D000925:Anticoagulants / Q000494:pharmacology / Q000627:therapeutic use*; D001157:Arterial Occlusive Diseases / Q000097:blood / Q000209:etiology; D001777:Blood Coagulation / Q000187:drug effects*; D003278:Contraceptives, Oral, Hormonal / Q000009:adverse effects; D015914:Estrogen Replacement Therapy / Q000009:adverse effects; D019317:Evidence-Based Medicine; D005260:Female; D020022:Genetic Predisposition to Disease; D006801:Humans; D008297:Male; D008403:Mass Screening; D018579:Patient Selection; D010375:Pedigree; D011225:Pre-Eclampsia / Q000097:blood / Q000209:etiology; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000097:blood / Q000209:etiology; D012307:Risk Factors; D013923:Thromboembolism / Q000097:blood / Q000209:etiology; D019851:Thrombophilia / Q000097:blood / Q000150:complications / Q000175:diagnosis* / Q000188:drug therapy / Q000235:genetics; D020246:Venous Thrombosis / Q000097:blood / Q000209:etiology
D000925:Anticoagulants; D003278:Contraceptives, Oral, Hormonal