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Two Types:
Primary Disorders usually inherited
Secondary Disorders more common
o Usually associated with more than one hemostatic abnormality
PATHOPHYSIOLOGY
Three natural anticoagulant mechanisms that control thrombus
formation
Antithrombin-III (AT-III) - neutralizes thrombin and the other activated
serine proteases in the coagulation cascade
o Heparin accelerates the formation of antithrombin-thrombin
complexes and neutralization of thrombin activity.
Protein C pathway
o Protein C - converted by thrombin to activated protein C (pCa)
o The rate of activation is greatly increased by Thrombomodulin
Fibrinolytic system
o Activates plasmin, which lyses the fibrin clot into fibrin
degradation products (FDP)
1.
Clinical Findings
Recurrent lower-extremity thrombophlebitis
Pulmonary embolism
Thromboembolic events may occur at other anatomic sites
2. Protein C Deficiency
Vitamin K-dependent glycoprotein that inactivates factors Va and VIIIa,
Discovered in 1960
Initial report of a clinical deficiency was not made until 1981
Autosomal dominant trait
Homozygous deficiencies have been reported in infants with severe
thrombosis who have almost no measurable plasma protein
Heterozygous state is associated with venous thrombotic disease and
immunologic protein C levels of 40% to 50% of normal
Two Types of Hereditary Protein C Deficiency
Type I - both the antigen and the activity are below the normal range
o Incidence is about 5% in patients with venous thrombosis under
40
Type II - only the activity is below normal
Clinical Findings
Recurrent superficial or deep vein thrombophlebitis
Frequent pulmonary emboli
Approximately 50% experience a thromboembolic episode before 30
years of age
Laboratory Findings
Immunologic and functional assays
70% to 125% - normal reference for both assays
Both assays should be performed to distinguish type I from type II
deficiency
Because protein C is a vitamin K-dependent protein, levels will be low in
patients receiving warfarin
Congenitally deficient individuals will have a disproportionately low level
of protein C.
Treatment
Long-term warfarin therapy
Protein C supplementation appears to be useful
Factor IX concentrates are rich in protein C and have been effective in a
number of cases
3. Protein S Deficiency
Discovered in 1980
Cofactor that enhanced the in vitro inactivation of factor Va by Protein
Ca.
Clinical Findings
Heterozygous deficient individuals - recurrent venous thrombosis
together with immunologic protein S levels of 30% to 60% of reference
levels.
Laboratory Findings
levels,
5. Dysfibrinogenemia
Congenital disorders with clinically significant functional abnormalities of
fibrinogen (dysfibrinogenemia) have been reported occasionally in conjunction
with increased thrombosis. The functionally abnormal fibrinogen molecule
forms a rigid fibrin gel that is resistant to the fibrinolytic enzyme system.
6. Homocystinuria
Rare autosomal recessive disorder
Associated with a high incidence of arterial and venous thrombosis early
in life, resulting in a high morbidity and mortality rate
Endothelial cell injury apparently is responsible for the abnormal
platelet-vessel wall interaction.
1. Lupus Anticoagulant
Acquired immunoglobulin directed against phospholipids
Associated with an increased risk of thrombosis, possibly secondary to
prostacyclin inhibition
Can be present in Patients with systemic lupus erythematosus, other
autoimmune disorders, or neoplasms; during certain drug therapy
Can cause prolonged APTT and occasionally, a prolonged PT
b. Malignancy
Related to the release of coagulation activating factors by the neoplastic
cells
Trousseaus report more than a century ago
5% to 15% generally and as high as 50% in certain malignancies
incidence of thrombosis in cancer patients
Patients with adenocarcinomas seem to be especially susceptible to
thrombosis
Typically, hemostatic abnormalities are corrected by elimination of the
malignancy
c. Pregnancy
e.
Other Causes
Nephrotic syndrome
Coronary artery disease
Stroke
In addition to plasma protein abnormalities, these patients frequently
exhibit hyperactive platelet function and elevated levels of von
Willebrand factor
Decreased levels of AT-III in morbidly obese or severely burned
3.
Platelet Abnormalities
Elevated numbers
Increased aggregation response to ADP, collagen, and epinephrine
Increased levels of beta-thromboglobulin and platelet factor