Thromb Haemost 2001; 85: 584-95
Hemostdtic Rssk Factors and Arterlal TTuombotic Disease
Alexander R Reiner1
, David S. Siscovick1
, Frits R. Rosendaal2
'Cardiovascular Health Research Unit, Departmenls of Medidno and
University of Washington, Seattle, WA, USA;2
The Hemostasis and Thrombosis Research Center <
Department of Clinical Epidemiology, University Hospital Leiden, The Netl
The pathogenesis of arterial thrombotic disease involves multiple
genetic and environmental factors related to atherosclerosis and
throm-bosis. Acute thrombosis at the site of a ruptured, lipid-rich
atheroscle-rotic plaque is the usual precipitating event in the transition from stable
or subclinical atherosclerotic disease to acute myocardial infarction
(MI), stroke, or peripheral arterial occlusion (1). Pathologie studies of
coronary arteries in acute MI suggest that the acute thrombosis likely
involves activation of both platelets and the coagulation System.
Following atherosclerotic plaque rupture, platelets initially adhere to
exposed subendothelial von Willebrand factor (vWF) and Collagen
through the glycoprotein Ib/IX receptor complex and the glycoprotein
la/IIa receptor complex, respectively. The attachment of platelets to the
vascular subendothelium (platelet adhesion) induces a series of
intra-cellular signaling events that result in platelet activation. The binding of
fibrinogen and vWF to the conformationally active form of the
glyco-protein Hb/IIIa receptor results in platelet cohesion or aggregation, and
further propagation of the platelet thrombus, Plaque rupture also results
in exposure of subendothelial tissue factor, which initiales the
coagula-tion cascade, and leads to the generacoagula-tion of thrombin and formacoagula-tion of
a fibrin clot. While arterial thrombi traditionally are considered to be
composed predominantly of platelets, accumulating evidence suggests
that certain arterial thrombotic disorders (e.g., transmural or "Q-wave"
MI) are associated with greater activation of the coagulation system,
which results in occlusive thrombi that are relatively rieh in fibrin (2).^
Prevention of arterial thrombotic diseases, such äs myocardial
in-farction and ischemic stroke, has focused on identification and
mod-ification of traditional cardiovascular risk factors, such äs Smoking,
hyperlipidemia, hypertension, and obesity, that are related: to
athero-sclerosis. However, approximately 30% of MI occur in individuals
without traditional cardiovascular risk factors (3). Since antithrombotic
agents such äs aspirin have been shown to be beneficial in primary and
secondary prevention of arterial thrombosis (4), attention has shifted in
recent years to the characterization and evaluation of novel phenotypic
markers of cardiovascular disease, involving lipoprotein metabolism,
the coagulation and fibrinolytic Systems, and inflammation (5, 6). In
addition, the identification of molecular variants within the genes
en-coding proteins involved in the pathogenesis of thrombosis has led to
their evaluation äs genetic ^usceptibility markers in epidemiologic
studies of arterial thrombotic disease. In this review, we briefly discuss
some general issues related to the studies that examine the associations
-Correspondence to: Alexander P. Reiner, M. D., Harborview Medical
Center, 325 9th
Avenue, Box 359756, Seattle, Washington 98104,
USA - Tel.: +1206-731-3291; Fax: +1206-341-5312; E-mail: apreiner@u.
of both genetic susccpiibiliiy markers and inlcrmcdiaic hemostadcffc:
notypes with arterial Ihroinhotic disease. \Ve then review thet
pertaining to the roie of specilic genetic markers and hemostaticpjfcjji1
types in arterial thromhosis.
General Issues Related to Study Design and Interpretation of Results
Case-control und cross-scctional studies assess the rclaticmlip.'p
between phenotjpic markers (c.ü., plasiua coagulation facffif fe|jd$j
and the occurrence of arterial thrombutic disease. However;!
studies cannot esiablish a temporal order, und thercforecaoaote
the possibility thal a hemostalic phenotype is a c
disorder (e.g., due to aecompanying tissue injur>' or in
Even in prospectivc cohort sludics, the obscrved associatiöwi
confounded by subclinical atherosclerosis. which may <
both the hemostalic phenoiypes äs well äs the clinical ι
addition, plasma Icvels öl' hcmosuitic fuclors are sometimesc
with each other and-also are inlluenced by other<
factors (e.g., obesily, hyperlipidemia, smoking), that may tatet
found an apparenl relaiionship betwcen the hemostatic
of disease. Forthcsc rcasons, ine most convincing evidenceofae
relationship between a hemostatic phcnolypc and the ι
arterial thrombotic disease is inicrred from clinical
strate that alterin!! l he phenotype (e.g., lowering
hemostatic factor) reduces disease.
Another means of circiiinventing somc of the spurious (
that can result from Ihc use of inlermediate hemostatic
to analyze genetic variants that are known to be related tof
Variation. T h e advamage o f studying genetic varianls i s t
"fixed at birth", and thcrel'ore clearly preccde disease .onsetnijWj!^
confounded by oiher behavioral and environmental (
factors or subclinical atherosdcrosis. However, raolecutar fl
ologic studies evaluaiing potential genetic susce
their own set of limiuuions. and diftcrent studies
genetic marker ollen yield conflicting results. Con
among studies is liampcred by differences in sti
terisücs of case paiiems and control subjecls, Variation ofl
quencies among dift'erent populations, äs well äs ihe
heterogeneityof Ihe clinical endpoinisof coronary heart
and peripheral anerial occlusion. These complex
effect^ of multiple genes interacting wilhthe*Wj!
The effect of any single «enetic susceplibility factor riffjgj
thrombotic disease is likely lo hc rnodest, but may
importance in the presence of udditional genetic *.^
exposures (i.e., gene-gene or gene-cnvironment i
Reiner et al.: Hemostatic Risk Factors and Arterial Thrombotic Disease
Äabetween a putative genctic suscepiibiliiy marker and
arte-pdisease may only he dcmoiisirablc wilhin a certain
a result, large sample si/cs ma\ be ro(|uired to
demon-• stable esümaie of el'fcct. pariicularly for alleles or
; tlial arc uncommon within l ho population. >
ib'ootsnbject to conl'ouriding by olhcr behavioral and
envi-il risk factors, populalion siudics of «eneiic variants are subject
> by ethnicily, i.e.. population admixlure or "population
i". Thus, a spurious associalion may arise if the frequency
c.raarker and the frcquency öl anerial tlirombolic disease
»jccording to genetic anccstry. Thi.i is inosi likely to be the
jljtbuically hetcrogencous populalions, and tan be accounted for
i that asscss genetic linkage äs well äs association.
; reason for a positive association in some studies but
i is thal the genetic marker of inierest is not directly
in-idisease susceptibiliiy. bul radier is in linkage disequilibrium
Ifteactual causalive mutation locaied in the sanic gene or another
y. Depending on the populalion hisiory and the
recombina-ilinction, the genetie marker may be associatcd with the causative
i in some populalions bul not in olliers. Therefore, it is
prefer-iioassess genetic markers that. are wcll-characicri/ed with respect
fe ftfflctional consequences of the molecular defeci and that
con-tSgnificantly to phenotypic Variation uiiliin Ihe population.
FactorVII is a vitamin-K dependent coagulation protein, which
upon activation, binds to tissue factor present in damaged vascular
sub-endothelium and initiales coagulation. In Ihe Northwick Park Heart
Study, a prospective sludy of over 1,300 middle-aged men, plasma
factor, VII aclivity levels were associaled with fatal, but not non-fatal,
ischemic heart disease (20). However, seveVal subsequent prospective
studies have failed to confirm Ihe associalion between faclor VII levels
and risk of coronary heart disease (21-23). Factor VII is also unrelated
to risk of venous Ihrombotic disease (24). Plasma factor VII levels are
determined by multiple environmental faclors, including age, gender,
body mass index, dielary fal, and triglyceride level (25). In addilion,
several intragenic faclor VII polymorphisms which influence plasma
factor VII levels have been described. These include an Arg353GIn
Substitution that is associated with decreased factor VII secretion
in vitro and lower factor VII levels (26). An Italian case-control sludy
of youn'g adulls wilh familial MI observed an inverse associalion wilh
homozygosity of Ihe faclor VII Gln353 allele (OR = 0.08, 95% CI =
0.01-0.9) (27). In conlrasl, several olher case-control studies involving
either young men (28) or a broader age ränge (29-31) found no
associ-alion belween Ihe Arg353Gln polymorphism and risk of MI or stroke.
Thus; the evidence to date does not support faclor VII at eilher the
phenotypic or genotypic level äs an importanl risk factor for arterial
fibrinogen levels have been consisieniK ancf independenlly
"l.an increased risk öl' MI and Mroke in prospective
idiapparently hcallhy persons and paiienis with preexisting
:disease (7-9). Subjccts with plasma fibrinogen levels
t tertile have ~2-fold increased risk compared lo Ihöse in
ftftätile. Fibrinogen may conlribuie lo arterial thrombotic
|iaanurnber of mechanisms. including increased fibrin
viscosiiy, platelel aggregaiion, and \ascularendolhelial
imuscle proliferalion (7). On tlie olher band, fibrinogen is an
: reactant, and the associalion of clevatcd fibrinogen and
W protein levels wilh risk of arterial thrombolic disease
sug-jl'diatthe inflammation thal acconipanies alherosclcrosis may
con-ito increased fibrinogen levels (10). Plasma fibrinogen levels are
correlated with olher cardiovascular risk tactors, such äs
, diabetes, and cslrogens (7.11). Be/afi brate, an agent that
sboth.fibrinogcn-lowcring and lipid-modilying properties, was
l with an overall rcduction ofarterial thrombotic events in
HfClinical trial of palients with coronary heart disease (12).
ι fibrinogen is composed of 3 pairs of pol\ peplide chains, et,
i encoded by 3 separale genes clusiered on chromosome 4q.
S.Öie synthesis of the fibrinogen ß-chain is raie-limiting (13),
i ß-chain polymnrphisnis have been associaled wilh
inter-R( Variation in plasma fibrinogen levels. The 455 G/A
substi-i the promoler regsubsti-iorsubsti-i of ι he fsubsti-ibrsubsti-inogen ß-chasubsti-in has been
texlensivcly. The -455A allele is present in about 20% of
, who have ~l()9r higher fibrinogen level> compared to
ι the GG genotypc (14). The relaiionship between the -455
(finogcn variant and risk of anerial thrombolic disease is
il. with sorne case-eonirol studies obsemng an association
fc'and other large siudies finding no associntion 118,19). These
nt finding cast doubl on ;i direct cause-and-efl'ect
relalion-wccn llbrinoüen le\els and anerial Ihrombotic disorders.
Factor VIII and von Willebrand Factor
Increased plasma levels of faclor VIII aclivily, von Willebrand
fac-lor (vWF) anligen, and vWF aclivity have been associated with incident
falal and non-falal arterial thrombotic events in prospective siudies
involving heallhy middle-aged (22,23,32,33) and elderly (34)
popula-tions. In some studies, the associations were independent of other
cardiovascular risk factors. In most prospective studies of patients
with underlying atherosclerolic disease, vWF levels have been
indepen-dently associated wilh risk of acule Ihrombotic events (10, 35, 36).
Factor VIII and vWF circulate äs a complex, and plasma levels of these
two factors are highly correlated wilh each olher. Thus, elevated
fac-tor VIII/vWF levels may be either a marker of atherosclerosis (i.e.,
endothelial dysfunction and vascular injury) or contribute directly lo
fibrin formation (factor VIII) or shear-induced platelet adhesion and
aggregaiion (vWF). The demonslralion lhat congenilal factor VIII
defi-ciency.is associated wilh decreased mortalily from ischemic heart
dis-ease (37, 38), äs well äs the association of elevated factor VIII levels
with venous thrombolic disease (39), support the hypothesis of a direct
effecl of faclor VIII concenlration on Ihe occurrence of thrombolic
events. Factor VIII levels are also influenced by ABO blood group, and
individuals with blood group non-0 have both higher factor VIII levels
and higher incidence of coronary heart disease compared to individuals
with blood group 0 (32, 40). Further evaluation of factor VIII and
cardiovascular risk awaits elucidalion of other genetic delerminanls of
increased faclor VIII levels (41).
Faclor XIII is a Iransglulaminase lhal forms covalenl bonds between
adjacent fibrin monomers, and Ihus slabilizes a fibrin clol. Factor XIII
circulates äs a zymogen composed of 2 catalytic A subunits and 2
car-rier B subunits. Thrombin cleavage of a 37-amino-acid N-terminal
peptide results in activation of the catalytic subunit. A Val34Leu
Thromb H;HMW>>I 2 ' Ν ΐ ί : so: 58-1
moφhisnι ol'lhe caialyiic M.ibiinii i.·« locaied 3 ainino acid roiidues Iroiii
the thrombiii olca\ age site. and ihe los·« coinmon l.eu34 allcle h;i> Iven
associated uiih incroascd plasma lacior XIII acii\ity le\ds (42, 131.
Paradoxically. sevcral rcccnt smdies suggosi Ihm l ho "high acii\iiy"
Leu34 allclo may he associalod wiili a decreased ri.ik öl' MI (44. 45i.
ischemic ancrial siroko (46). and vonons ihromboiic disoasc (47l, äs
well äs an incrcascd risk öl' hemorrhauic siroke i4Si. Tho niochanism
for the apparent aniiihronihoiic effccl οΓ ιΐιο lacior XI11 Vall.L-u34
Substitution may involve an increased raie of convorsion οΓ lacior XIII
to activalcd lacior XIII by thrombin lhai resuli* in an aliered
cross-linkedfibrin clol simciure (49l.
Levels of oilicr (.'»amiltitiini l'aciim
Recenily. clcvaicd levels of lacior \'. bin not i'aclor X or
proihrorn-bin, were associated w ilh occurrence οΓ Ml aller adjusting l'or oihcr risk
factors (SOi. liocausc ol'the reirospeclive naiure oflhi.s siudy, onc can
not distiniiuish whoihor increased lacior V acii viiy is a caiise ralhcrihan
a consequence of Ml. To our knowlcdgc. Ihc a>socialions of lovcls of
coagulation laciors XI. X. and IX. V. and proihronibin with arlerial
thrombotic disease have noi heen assc.ised in pro^peciive Mudics.
Inherited Thrombophilic Disorders
Protein (', Protein S. Antiihroinhin Deßriency
It is \\cll-osiahlishod lhai congenital det'iciencics of protein (.'..
pro-tein S, and anliilirombin are associalecl wilh an increased ri.ik of venous
thrombotic disease. \Vhelhcr congeniial deficiencies of thesc
naturally-occurrin» coagulalion inhibitors are associalecl \\iih increaied risk of
arterial thromhoiic di.scasc is less clear öl. 52 i. In a pooled analysis
of 8 small series of anorial cerebral infarclion in predominanily young
patients i n = 3l 1 1. deficiencies of proiein S. proioin ('. and
anlithrom-bin were noied in 1 1.')' i. 2. 2' i. and 2.2'.'·; of cases. respecli\d\ (53 1.
However. in niaiiy -of ilu.se siudies. inicrpretalion of rcsuhs is limited
due to small mimhcr< of subjeeis. lack of controk lack of follou-up or
family siudic.i lo docinnenl inherilcd v>. acquiroil ddicicncy. and
pop-ulation adini.Miire. Morc recenl smdies of unselecied young adiills with
acute cerebral ischemia suggoit lhai aciile. iransioni or acquired
defi-ciencies of the naiurally-occurring anticoa.suilimis are noi iincommon.
but that iruo congoniial deticiencies are rare (54-.Ϊ6). Several recent
pediatric SCIUN siiajjcsi ι hat prolein C" or proioin S deficiency may be
present in äs many a*. 5-15'ί ofchildren wilh ischemic siroke (57-591.
However. in Mime case> inie con«enilal deficiency has not been clcarly
documeniod. and oilior |»xliairic siudies ha\c not confirmed these
asso-dations 1 60. 6l l. Taken logether. l ho evidena: suggests ι hat
deficien-cies of natural anticoaüulanls are likoly 10 be assoeiaied wilh arlerial
thromboiic disease. panicularly in very younu indiviüuals with acule
cerebral ischemia. Ho\vc\er. since ihe prevalences of theso deficicMicies
are low even amon;j younc palienls. ihey accouni for a small proporlion
ActivatetI Protein (' Kevxmnre and l-'ucior \ ' Leiden
Resistance lo ihe anticoaguluni effect of acli\ated prolein C! is mosi
commonlj due lo a nucleoiide (Ί 1 69 1 Λ nunaiion in the szene encodinu
factor V (hat resulis in an .-\rs5()6(iln iiuiuiiion (factor V Leiden), "l'his
mutation occurs al Ihe initial acli\aled protein C cleava»e site wilhin
the factor Va heavy chain and rc.siilis in a prothn>mbotic siate becaibe
of a roducod MIO of facior \'a inaciivaiion. l-'acior V l .eiden is themojt
coiniDon iionoiio facior as.ioc.kned with risk of venous ihroinboenüxiBt;
disease, and is foinid in approximaiely 3-5'.i öl the Caucasian ρρρ&,«
A relaiionship betwecn factor V Leiden and arlerial ihr
ease was first suggosiod by Hohn öl al. (64). who rcponed twoyöj
women lagos 33 and 34 years) with Ml and homo/ygosily forf
Gln5()6. However. nu>sl subscquenl siudies have failed to.-j
associalion boiween factor V Leiden and coronary disease on,
MI (65-71), even among patienls who dcveloped acutc coromey.'^
dromes al a young age (72-74). In contrasl, Roscndaal et al. (
öd a higher risk of non-falal Ml among young female cariieisoi
torV Leiden (OR 2.4, 95<i Cl 1.0-5.9) lhat was particulalyü
among smokers (32-fold increased risk comparcd lo nonsi
women withoul ihe facior V muiation). In a largc. casc-controlsta
middle-aged-to-elderly Duich men, Doggen el al. (76) alsore
inercased risk of MI assoeiaied with hetcro/ygosity for factor Vi
(OR l .4:95Ύ Cl 0.8 2.2) ihai was mosi pronounced in men wjtb.oj^v
cardiovascular risk faclors. ... .yi:y$
\Vhile facior V Leiden is noi a risk facior for ischemic sbobJll
middlo-agod lo elderly patienls. (66. 68. 71, 77), some studkti
youngor adults (<45-50 years) indicale a higher prevalenceoffkliirl
Leiden in siroke cases ihan conlrols (56), bul mosl shuwnoi
(78-80). In an Italian siudy (56). the risk of siroke associaledS
lacior V Leiden mutalion was sinniger in women Ihan men, j
smaller North American study of exclusively young womenί
association (80). In children. recent data suggesLs that i
may accouni for approximaiely 2()'.i. (if cases of is
The relaiionship beiwecn lacior V Leiden and
occlusixc disease has been examined in thrcc case-cpnöol-S
two siudies, Ihe fiequcncy of facior V Leiden carriershiJMiii
among eases. whiclns higher than the population ]
In conlrasl. a larger AuMrian siudy of 336 patients. with']
arterial occlusion and 300 conlrols observcd a similar f
facior V Leiden mulalion betwecn cases (8%) and controb(
Takcn together. ihe cumulaiive resulis of studiesexaminjflgl
tionship of facior V Leiden and incident arterial throrabotic'i
suggest lhat facior V Leiden is noi a major cardiovascülar.lill
but may assumc increased imponancc in cenain patienti
panicularly children wrih ancrial siroke and young womeiM
cardiovascular risk factors. Allernatively. the positive findingl»
only a l'ew of Ihe puhlished siudies suggesls the possibilityofi
positive associalion due lo population admixture. AddiöofHll
tion siudies involving larger numbers of subjects i
siudies lhat assess geoelic linkago will bc required to ί
Thcre is some ovidcncc lhat aclivaied proiein Cfesislaeeil
ence the risk of arlerial ihroinboiic disease even in!
factor V Leiden mutalion (85, 86). In a cross-!
men and women. carolid and feinoral artcry atherosderasBi
prevalent athero-ihromhoiic disease were associated '
response lo APC (86). In ihis study. less than 50% of tbe«
APC resislance were carriers of the factor V Leiden i
ing lhai oihcr gcnelic and environmental factors raay <
APC resislance phenolype äs well äs to Ihc riskof art«?W<
disease (86.87). I Iowever. the e\ aluation of a phenotypcr"
contexl of a cross-seclional study raises Ihe issue of *
resislance is a consequence rather Ihan a cause of ί
Kcincr ci al.: l liimosiaiic Ri^k I-adors and Ancrial Throinhoiic
i is.the circulating precursor öl' ihronibin. which pliiys ;i
sinfibrin fonnalion and ihrombosis. A G to A iransition in
520210 »ithin ihe .V untranslaled region of ihe proihromhin
l with elcvalcd circulating prothronibin levcK, and
identified äs a risk lacior l'or venous thromboembolic
fe(88)..This mutalion is presem in about 2'i of Caucasians. (>ιιι
— i;--«increases froni Nonhcrn lo Southern F.nmpc (89).
leiden, the rclationship bclween ihe prothrombin
fc Imitation and risk of arlerial ihronibolic (iisease is
conirover-jiiost of the published studies. ihcre was no as.iociation beiween
!0f the 202ΙΟΛ allele and risk of acuie MI or coronary
: (90-94). Whilc ihcsc rcsults suggest llial ihi; prothrombin
W is not a major risk facior for coronary hcarl discase. llic sial is ·
rof many of ihcse studies lo deiect an association
flriatively Iow frequcncy of ihe imnalion in ihc gencral
popula-I pooled analysis of 1.115 palicnis and 1.888 conirols l'roin
[.Franco et al. nolcd a significani association in l he Mudies lhat
to patients wilh MI (OR = 2.5: 95',?· CI l .5 4..?). bin no
ι in die pooled analysis of Mudies lhat iricludcd eases wiih a
f ränge of athero-thrombolic disease (95). In the: largest single
ii'icase-control study of patienls with MI (560 paticnis under
the prothrombin 202 1 OA allele was associalcd wiih a
6) incrcascd risk of MI (hat incrcascd substaniially 10
e-pfesencc of tradiiional cardiovascular risk factors such äs
Jhypertension (76). Similarlv. in a small case-conirol siudv
|:<45 years old with acute MI, Roscndaal et al. reponed a
l risk of MI associatcd wilh prothrombin 202 1 ΟΛ thai
'enhanced in the presencc of smokin» or other meiabolie
of studies examining the rclalionship bciween
pro-»;"620210A and ischemic artcrial siroke in young adults (56.
dolder subjccts (90, 94) have bcen negali\ e. The exceplion is
öl sludy of 72 Italian young inen and womcn (<5() \ears
h ischemic arlerial strokc u ho did not have tradilional
cardio-rrisk factors (OR = 5.1. 95';;. CI = 1.6-16.3) (78). In a
casc-istudy of 148 pediairic palicnis. the prolhrombin 202 IOA allele
with a 5-fold increased risk of sponlaneons ischemic
oke (58), but iwo srnallcr pediairic siudies found no
8l). A recenl case-control study found no association of ihe
1 2021 OA allele with risk of periphcral arlerial occlusion in
f patient population (84).
i-together. the resulis of these studies suggest lhat the
pro-ΪΪ20210Α mulalion may bc associaied with a modesily
in-trisk of arterial thronibotic disease thal may as.Miine (tanicular
in certain subgroups. such äs young wornen wilh MI or
vascular events in children.
itein llb/llla (integrin «nißi) is the plalelei surlace receplor
in. von \Villebrand facior (vWK). and scvcral other
adhe-ands. The glvcoprolein lila subunil consisis of iwo common
ns,PI.A: ( I I P A - l a ) a n d ΡΙΛ' (IIPA-lb). Thisdimorphism isdue
C niicleoiide .siibMilution involving niicleoiide 1565 witliin
l2 of ihc glvcoprotein l i l a gene. and rcsiilh in a I.cu33/Pro33
substilution thal is associaied wilh a confonnational chan.ue in die
N-ienninal disulfide loop öl 'glwoprolcin lila relatixe to ihe llbrinotien
binding sile (98). The allele l'reqiiency ol'ihe ΙΊ.Λ:
variani ranges l'roin
~l() 10 18 perceni in (..'auca^ian populatioib. ~8'·ί in African
po|)i:la-lions. and is viriually abscnl in A>ian popnlaiions.
In 1996. V\'eiss et al. rcponcd lhat ihe fre(|iiency of carr\ing al Ica1
one copy ol'ihe ΙΊ.Λ:
allele was iwice äs hish in 7l hospiuili/.ed paiienis
wiih MI or unsiablc anüina 1 39.4'. r l compared wiih 68 lios|)iiali/ed
conirol subjecls 1 1 9. l '"t ) (OR = 2.8: 95 '·ί (Ί = l
6.4) (99i. \Vhen the
analysis was resiricied lo ihe subgronp of paiienis under Ihe agc of 60.
ihe relaiive risk of acnto coronarj disease associaied \vilh Ihe I'I..N:
allele increased 10 6.2 (95'. ί (Ί = 1.8-22.4). Since ihis initial repon.
liiere have been over 20 addilional observaiional siudies ihat have
c.xamincd ihc relaiionship bciwecn ihe ΡΙ.Λ'/ΙΊ.Χ·' polymorphi^ni of
cKcoproiein l i l a and risk öl acnie or Mahle coronary arlerv disease.
\\hile- a leu ofihese siudies have confinned ihe a>Miciation beiween
Ihe ΙΊΛ! allele and increased risk of early-iMixei coronury hcan disease
(73. l (K)- 1 02). ihe majoriiv have nol. The noüaii\e \iudie> include ihe
5 iinoKing al leasi 300 cases ( 1 03- 1 07 1. Iknvever. cornparison öl ihe
resulis among studies is complicaied by differences in definilion öl
coronary disease. selection of conirol siibjecis. and study de>ij;n. Thu.v
neüalive reMilts obserxed in some siudies mi»lii he e.xpected if ihe
;ΙΛ·>Ο-eiaiion is confined 10 younger paiients \\illi MI and/or to specific sub
jiroups. such äs womcn l l()2i. eiuarcnc smoker«. (73 1. individuals wiih
pre-cxisiing coronary atherosclerosis (10h. or indi\iduals wiih
addi-lional geneiic prcdisposiiioris
Of ihe published siudies ihai have asse.ssed Ihe rclalionship beiween
ΡΙ.Λ- and ischemic siroke. one (109) observcd an associaiion only
in subgroups of paiienis under ihe age öl 50 (OR ~ 1.68: 95r
1.00- 2^X2 1 and in non-smokers ι OK = 137: 95'·ί (Ί 1.Ι94.74.Ι. and
anoiher only in a small subgronp of womcn (n = 18) who wcre whiie
and had an identillable ciiology ( l 10). In contra.·.!. IWO other siudies
involving a broaderage ränge ol'both men and womcn ( I I I . 112). and
a siudj of male physicians ( 1 06) found no a>sociation beiween ihe l'l .Λ"
variant and risk of ischemic siroke.
The assessmem ol'ihe relaiionship between ihe l'l.·'1 geneiic variani
ofgKcopmiein lila and risk of arlerial ihronibolic disease is aNo
ham-pcred by the lack of a clearlv del'ined el'feci on plaielet fuiiciioii. \\ hile
some studies ha\e deinonsiraicd Ihai Pl/^-posilivc plaielcls displav
in-creased in \iiro platclcl reaciiviiy compared to ΡΙΛ'-negaiive plaielets
(1 13. 1 14). oihers have not ( 1 15. 1 16). The associaiion beiween Pl..':
and an increased ihronibolic icndcncy is also tupponcd by experiments
usin» stähle eell lines overexpressin« ihe ΙΊ.υ and Ρ Ι Λ · polxmorphic
fornis ol'glvcoproicin llb/llla ( 1 1 7i. äs well äs a recenl auiopsy sludy in
which the presencc ol'ihe ΡΙ.Λ
· allek· was associaied wilh an increased
l'rec|ueucy (>f aeuie coronary Ihrombo.iis and complicaied
aiherosclerot-ic plaques in men wilh fatal M i d i 8).
In summary. both ihe clinical and experimcnial data assessing ihe
role ol'ihe PLC variani of ghcoprotein lila in arterial Ihronibolic
dis-ease have yiclded conlliciing resulis. Addilional moleculargcneiic and
l'unciional analysis of ihe plalelei glycoproiein llb/llla recepior. äs well
äs \iudics iuvolving larger nnnibcr> of subjeeis that allow straiilicalion
by 01 her cardiovascular risk l'aclors. w i l l be recjuired lo resolve ihese
Thromb Haernost 2001: 85: 584-95
glycoprotem la (a, integrin) subunit of the glycoprotein ia/IIa receptor have been described. T wo silent single nucleotide polymorphisms. C807T and G873A are in complete linkage disequilibrium with each other, äs well äs with several other single nucleotide polymorphisms located in the adjoining introns ( l 19. 120). Among normal individuals. there is a 5-10 fold Variation in the surface level of glycoprotein Ia/IIa that correlates with collagen-induced platelet adhesion and aggregation in vitro. The nucleotide 807T variant of glycoprotein Ja is associated with increased platelet glycoprotein Ia/IIa receptor levels and in-creased collagen-induced platelet adhesion compared to the 807C allele (l 19-121). The mechanism of the association between the 807T allele and increased receptor density is unknown. The 807T allele may be linked to another polymorphism within the glycoprotein la gene in-volving a regulatory element that controls gene transcription levels or mRNA stability.
The prothrombotic tendency of the glycoprotein la 807T allele is supported by four recent case-control studies. In a study of 2,237 con-secutive German men undergoing coronary angiography, Santoso et al. (122) reported a higher frequency of the 807T allele in individuals who had suffered an MI compared to those without MI (OR 1.57; 95% CI 1.14-2.13) that was most pronounced in obese men under the age of 49 (OR 4.92; 95% CI 1.71-14.2). In a smaller case-control study, Moshfegh et al. reported a 3-fold increased risk of MI in individuals who carried two copies of the 807T allele compared to individuals who possessed the CC or CT genotype (OR 3.3; 95% CI 1.23-8.83) (123). Similarly, the 807T allele was associated with a 2-3 fold increased risk of ischemic stroke in men under the age of 50 (124) and women under the age of 45 (125). In contrast to these 4 positive studies, Croft et al. reported no association between glycoprotein C807T and risk of MI. either overall (OR 0.88. 95% CI 0.74-1.05). in younger individuals, or in subgroups defined by other risk factors (126). Corral et al. also re-ported no association between the 807T allele and risk of either acute coronary heart disease or ischemic stroke in a middle-aged to elderly study population (121). Furthermore, it should be noted that the fre-quency of 807TT homozygotes among the control group of one of the positive studies (5.6%) was considerably lower than other published population studies (123). In summary, preliminary results suggest that the 807T variant of glycoprotein la may be a genetic risk factor for early-onset arterial thrombotic disease, but further studies involving larger numbers of subjects, äs well äs further characterization of the mechanism responsible for increased receptor levels, are required to settle this issue.
Glycoprotein Ib/IX receptor is the major platelet receptor for von Willebrand factor. Two polymorphisms that affect the amino acid se-quence of the glycoprotein Ib heavy chain (glycoprotein Iba) have been described. The first, an ACG to ATG Substitution at codon 145, results in a Thr/Met dimorphism that is responsible for the human platelet anti-gen (HPA)-2 System. The second is a size polymorphism that results from a variable number of tandem repeats (VNTR) of a 13-amino-acid sequence (Ser399-Thr411) that is present in either one (D), two (C), three (B), or four (A) copies (127). The HPA-2 and VNTR polymor-phisms are in strong linkage disequilibrium with each other. The HPA-2 Thrl45Met dimorphism results in a protein conformational change in a region adjacent to the vWF binding region of glycopro-tein Iba, but an effect on in vitro platelet function or von Willbebrand factor binding has not been demonstrated (128, 129). The VNTR poly-morphism involves the macroglycopeptide region of glycoprotein Iba,
with the addition of each repeat resulting in an increased distan^· between the ligand binding region and the platelet surface. While it hj. been hypothesized that this distance Variation may affect platelet \IK ceptibility to shear-induced activation (127), this has yet to be demon-strated experimentally.
Despite the lack of an associated prothrombotic phenotype, se\erai case-control studies have noted a 2-3 fold increased risk of coro-nary heart disease or stroke associated with the Met 145 (HPA-2bi or VNTR-B allele. particularly in younger patients (130-132). In contra^ Ardissino et al. did not find an association between the HPA-2 pol\-morphism and premature MI in a case-control study involvins pre-dominantly men (73). Two other studies did not observe an association between HPA-2 or VNTR genotypes and risk of ischemic stroke in older patient populations (109, 112).
Other Hemostatic Factors
The fibrinolytic System consists of the circulating proen/\mc plasminogen, which is converted to plasmin by the plasminogen acuu tors, tPA and urokinase. Plasminogen activator inhibitor-1 (PA1-111> j major inhibitor of the fibrinolytic system, and is synthesi/ed h\ j variety of cell types, including platelets, endothelial cells. and \avcuL· smooth muscle cells. Data from several prospective studies indicaie r association between plasma levels of various fibrinolytic markers 11 c tPA antigen, PAI-1 activity and antigen levels, and fibrin degradamM· products) and risk of arterial thrombotic disease (133-137). Thi· pre* ence of increased levels of PAI-1 mRNA in atherosclerotic plaqui· (138) and the association of elevated plasma PAI-1 levels uith ^ clinical atherosclerosis (139) also suggest a role for impaired fihnno!» sis in the occurrence of athero-thrombotic disease. However. ihh ro; is complex; Inhibition of fibrinolysis may promote thrombosi·,. h.< also may inhibit matrix metalloendopeptidase activation and xascui;· smooth muscle proliferation. which may alter atherosderolic plaqu: stability (140).
The Interpretation of cardiovascular epidemiologic Studie1· <>t fit".'
olytic markers is complicated by several other factors. Plasma ιΡ·\ jn1
gen and PAI-1 activity levels are highly correlated. m pari hecaux.· '* tPA antigen assay measures both free tPA and tPA complcvii · PAI-1. which increases in patients with high PAI-1 le\els du.· i··* layed clearance (141). Measurement and Interpretation öl pb"·· PAI-1 activity levels are particularly problematic due to dmmai >-·'» tion, spontaneous transformation of PAI-1 to an inaclhe or 'sj'Z' form at neutral pH, and the potential for release of PAI-1 from pbicsf·
these necessitate special measures during blood collection and Μ"Ϊ'
processing (142). PAI-1 is also an acute phase reactant. and cirniU'·?·· levels are influenced by a number of hormones and c>tokinev 114"· Λ
creased PAI-1 levels are also correlated with obesit\. hNpenrwfe-"--· and hypertriglyceridemia, (i.e., the "insulin resistancc s)mlf« Thus, in most epidemiologic studies, the association between Γ V tPA levels and risk of arterial thrombotic disease ma\ ho c> >«<''·-"'*'' by these other cardiovascular risk factors.
The 4G allele of the 4G/5G polymorphism located »nhin :rc ^ moter region of the PAI-1 gene has been associated w ü h m·"*'^ cytokine-induced gene transcription in vitro (143) due ditlerenta · *· ing of a transcriptional repressor (144), and increased pl^nu l
levels m most studies (140). While several case-conirolxluJli*'^''
Reiner et al.: Hemostatic Risk Faclors and Aricnal Thromholic Disease
l allele (144-146), these findings have not been con- Lipoprotein (a)
' , m xjieral larger studies (147-149). A meta-analysis of nine '". -vh:! mcluded 1.521 cases and 2,120 controls indicated an
over-<S'*-fcih increased risk of MI associated with the 40 allele (OR l .23,
1' Π |'|t4-l.45) (150). However, the increased risk was confined to *. ,-ί-wtJp of case-control studies in which both cases and controls
trom "high-risk" populations.
a sulfur-containing amino acid that is formed äs an Λ compound during methionine metabolism. Congenital >, ,·-.ν> ^timiria. a rare autosomal recessive metabolic disorder, is asso-„' min *ery high levels (>100μηιο1/ί) of fasting plasma total
Sl r. o>ieini. and is often accompanied by premature thrombotic
jiv·-^' imohing the coronary, cerebral, and peripheral arteries. Mild ι.,-rtiiniocweinemia (i.e., >15μηιο1/ί) is not uncommon in the
•,',:r.u popukition. and is associated with a variety of acquired and :'i\ uiors. including increasing age, male sex, cigarette smoking, r.ivaK'i'iMiniption of nutritional factors (folate, vitamin B6, vitamin
» . , rcnal failure. and heterozygous deficiencies of enzymes involved ,; ΜΙΗΚΛsteine metabolism (151, 152). The adverse effects of sfvoivteine include vascular endothelial injury, smooth muscle yiitiraiion. oxidation of low-density lipoprotein cholesterol, and in-Aition of a prothrombotic vascular endothelial microenvironment
>iincc the very high levels of plasma homocysteine that accompany iejenital homocystinuria are strongly related to risk of arterial
throm-\& disease, some degree of association with mildly elevated levels i.s
tut plausible. There have been a number of case-control and cross-ctiunal studies that indicate that mild hyperhomocysteinemia is
asso-ίαά ttith an increased risk of coronary heart disease, cerebrovascular käse, and peripheral vascular disease (153-155). However, it should *soted that homocysteine levels may increase following acute arte-•al thrombosis (156, 157), which complicates the Interpretation of in which levels are measured retrospectively. Prospective assessmg the risk of arterial thrombotic disease associated with »oied homocysteine levels have yielded mixed results with most showing a weak or no association (154. 155). The strengest \\iaiions have tended to occur in studies involving subjects with wxisling cardiovascular disease. This raises the issue of whether the wied homocysteine levels are a consequence rather than a cause of Winical atherosclerosis.
•Mild hyperhomocysteinemia has been associated with a thermola-wriant of MTHFR that is due to a C to T transition at nucleotide Homozygosity for the C677T MTHFR variant is present in 5% fo ofCaucasians. A recent meta-analysis of 23 case-control studies ling over 12,000 subjects concluded that homozygosity for the 'labile MTHFR variant is not associated with risk of cardiovas-disease (158). This absence of an association raises doubt about •'role of mild hyperhomocysteinemia äs a cause of arterial
throm-: disease. However. based on the association of MTHFR and
κΐίίι Dcysteine levels, the predicted relative risk of the thermolabile genotype is small (possibly no more than a 20-percent risk
,· pr*. öse), and even a meta-analysis may have insufficient power to
Ö a risk of this magnitude. Ongoing randomized clinical trials of and B vitamin supplementation to reduce plasma homocysteine Should provide more definitive answers to the public health
(ns surroundins homocvsteine and risk of athero-thrombotic
Lp(a) is a complex serum lipoprotein composed of an LDL particle linked by its surface apolipoprotein (apo) B-100 via a disulfide bond to a unique and highly polymorphic glycoprotein, apo(a) (159). Apo(a) shares extensive structural homology with plasminogen, and consists of a ηοπ-functional serine protease domain, a variable number of multiple repeats of kringle IV, and a single copy of kringle V. The variable number of kringle IV repeats is due to varying number of copies within the apo(a) gene. and results in at least 35 different molecular weight isoforms.
Plasma Lp(a) levels are largely genetically determined (160). and vary inversely with apo(a) isoform size. Levels increase in patients with renal disease, and are lower m white populations compared to African Americans (161). In contrast to plasma LDL levels, Lp(a) levels are unaffected by diet. physical activity, and most lipid-lowenng agents. On the other band, estrogen replacement therapy and high-dose niacin can lower plasma Lp(a) levels.
Experimental evidence suggests that Lp(a) may contribute to the occurrence of arterial thrombotic disease through effects on both atherosclerosis and thrombosis (159). Oxidized Lp(a) can be internal-ized by macrophages and contribute to delivery of cholesterol to sites of vessel injury. Because of its structural similarity to plasminogen. Lp(a) inhibits plasminogen binding to fibrin and endothelial cells (162). and thereby inteiferes with fibrinolysis and promotes thrombosis (163). Lp(a) accumulates in atherosclerotic lesions, and has been impli-cated in the progression of coronary atherosclerosis (164). Lp(a) may also impair endothelial function and induce smooth muscle prolifera-tion.
Despite these experimental data. clinical data supporting the
role of Lp(a) äs a cardiovascular risk factor are controversial.
A number of studies have shown an association between elevated Lp(a) levels and mcreased risk of coronary. cerebrovascular, and peripheral arterial disease (161, 165, 166). However, like homo-cysteine, Lp(a) levels increase following an acute thrombotic event. Thus. retrospective .studies may not be able to discern whether elevated Lp(a) levels are the cause or consequence of cardiovascular disease, and prospective studies have yielded conflicting results (167-174). Based on the cumulative epidemiologic data. if an associa-tion between Lp(a) levels and cardiovascular exists, the effect is likely to be small and confined to a small proportion of the popula-tion with the very highest serum levels (175), onset at a young age (170) or those with additional dyslipidemias (167, 174, 176. 177). Further evaluation of the significance of apo(a) isoform size on the occurrence of athero-thrombotic disease (171. 177) äs well äs other genetic mechanisms that underlie Lp(a) heterogeneity (178) may lead to improvements in the use of Lp(a) äs a determinant of cardiovascular risk.
Thrombomodulin is an endothelial cell surface receptor for thrombin that functions äs an anticoagulant by greatly accelerating thrombin-induced activation of protein C. A soluble, truncated form of thrombo-modulin circulates in plasma, but its significance is unknown. In a large prospective case-cohort study. decreased plasma thrombomodulin levels were associated with an increased risk of MI (179). Some reports have suggested that several rare polymorphisms within the thrombo-modulin promoter and coding sequence may be related to risk of MI (180-182).
inioinn Macniosi ζυυι. fo. j
Recommendations for Screening
Despite the proliferation of epidemiologic studies. increased fibrino-gen level remains the only hemostatic biomarker that has been clearly
identified äs a risk factor for arterial thrombotic disease. And even for fibrinogen one may question the causality of the association. The deci-sion whether to perform screening for a hemostatic marker, however, should be based on whether screening offers a cost-effective way of identifying individuals who would benefit from treatment. Therefore, screening of plasma fibrinogen is generally not advocated because levels are favorably affected by modification of other risk factors (e. g., smoking cessation, exercise, and post-menopausal hormone replace-ment therapy) and because a beneficial effect of lowering fibrinogen level on cardiovascular risk has yet to be demonstrated. There is some epidemiologic and biologic evidence that elevated plasma levels of factor VIII. homocysteine, and Lp(a). äs well äs several genetic hemo-static variants (factor V Leiden, factor XIII Leu34, prothrombin
G20210A, the PLA: variant of glycoprotein lila, and glycoprotein la
807T) are related to the occurrence of arterial thrombosis. However, there is currently no evidence that screening for any of the above hemo-static markers either within the general population or among subgroups, such äs individuals who develop arterial thrombotic disease at a young age, would have any prognostic or therapeutic consequences. Several inherited conditions associated with venous thrombosis (deficiencies of protein C. protein S or antithrombin, factor V Leiden, and prothrombin G20210A) are not äs important in the overall occurrence of arterial thrombosis. except possibly in subgroups such äs the very young or pre-menopausal women. Thus, evaluation of these disorders in the setting of arterial thrombosis may be considered in young patients once more likely candidates (lipid disorders, hyperhomocystenemia, lupus anti-coagulant/antiphospholipid antibody syndrome) have been excluded, or in MI patients without significant coronary atherosclerosis (183). In addition, a thrombin time and fibrinogen level should be obtained in these young patients to exclude congenital dysfibrinogenemia, another rare cause of both venous and arterial thrombophilia (184).
With the progression of the human genome project and the recent focus on identification of inter-individual genetic Variation, the poten-tial for evaluating the relationship between functional variants of candi-date genes, associated prothrombotic phenotypes. and risk of arterial thrombotic disease will greatly increase. Several guidelines for future studies that evaluate novel hemostatic markers should be considered. First, molecular epidemiologic studies should focus on genetic muta-tions that are associated with clearly defined effects on hemostatic function and that contribute significantly to inter-individual phenotypic Variation. Second. examination of homogenous populations and pre-cise. well-defined clinical outcomes should enhance the ability to detect associations. For example, hereditary determination by äs yet unidenti-fied genetic factors may be particularly important in MI that occurs at younger ages and in women (185). Furthermore, restriction to ethnical-ly homogeneous populations or eliciting detailed Information regarding genetic ancestry from study subjects should minimize the problem of false positive associations arising from population admixture. In addi-tion, any preliminary associations observed in population-based studies should be complemented with family-based studies that provide evi-dence that the marker of interest is genetically linked to the disease (186). Third, large sample sizes will be required to provide enough statistical power to assess the interaction of genetic susceptibility
ers with other genetic and environmental risk factors. UndoubtedK
other candidate genes and associated functional polymoφhisms m
volved in arterial thrombotic disease will continue to be ideniiile^ Integration of knowledge involving novel hemostatic biomarkers at iht genetic, biochemical, and clinical-epidemiologic levels should lead i, significant developments in understanding the pathophysiology of arte rial thrombotic disease, the assessment of cardiovascular risk, and thc targeting of specific antithrombotic therapies to high-risk individuaN
1. Davies MJ. Stability and instability: two faces of coronary atheiwclerm,. Circulation 1996:94:2013-20.
2. Rentrop KP. Thrombi in acute coronary syndromes. Revisted and rcMv\: Circulation 2000: 101: 1619-26.
3. Grover SA. Coupal L. Hu XP. Identifying adults at mcreascd rw, . coronary disease. How well do the current cholesterol guideline^ u^i JAMA 1995: 274: 801-6.
4. Hebert PR. Ridkcr PM. Fuster V, Hennekens CH. Antithrombmu .n.· in the secondary and pnmary prevention of cardiovascular diseave·. m", .·
and usual risk individuals. In: Cardiovascular Thrombosis: ThrnmKx.j·: ology and Thromboncurology. Verstraete M, Fuster V. Topol ES. .·; Philadelphia: Lippmcott-Raven Pubhshers 1998:461-70.
5. Ridker PM. Novel risk factors and markers for coronary discjsc \ ·
Intern Med 2000: 45: 391-417.
6. Kullo U, Gau GT, Tajik AJ. Novel risk factors for atheroscleroMs M.. Clin Proc 2000: 75: 369-80.
7. Ernst E. Resch KL. Fibrinogen äs a cardiovascular risk factor a '.κ,
analysis and review of the literature. Ann Intern Med 1993: l IS: 9M·;·' 8. Danesh J, Collins R, Appleby P, Peto R. Association of fibrinosen. ( ·.
active prolem. albumin. or leukocyte count with coronar) hcan ϋκ·.\ Meta-analysis of prospeclive studies. JAMA 1998; 279: 1477-82 9. Maresca G. Di Blasio A, Marchioli R, Di Minno G. Ivteunnc ,"'>".
fibrinogen to predict stroke and myocardial infarction An u^." Artenoscler Thromb Vase Biol 1999; 19: 1368-77.
10. Thompson SG, Kienast J, Pyke SDM, Haverkate F, van de Lw h« Hemostatic raetors and the risk of myocardial infarction or sudik-n .v: in patients with angina pectoris. N Engl J Med 1995: 332.635-41 11. Folsom AR. Fibrinogen and cardiovascular risk markers. BlouJ ( -,
Fibrinol 1999: 10:S13-S15.
12. BeharS. Lowering fibrinogen levels: clinical Update. Blond du:. Ί ' nol 1999: 10: S41-S43.
13. Roy SN. Mukhopadhyay G. Redman CM. Regulalion öl ff-r'.,-assembly. Transtection of hepG2 cells with Bß cDNA spcoK- ' hancessynlhesisofthethreecomponentchainsoffihrinosion ) B « 1990:265:6389-93.
14. Humphrics SE, Henry JA. Montgomery HE. Gene-cn\ircn''vr tion in the determination of levels of haemostatic variable1· i\ >
-thrombosis and fibrinolysis. Blood Coagul Fibrinol l W): 10 s
15. Behague I. Poirier 0. Nicaud V, Evans A, Aneiler D. Lut i> «··"'*"
J-P. Scarabin P-Y, Bara L. Green F, Cambien F. ß-lihnnos« ix« '" morphisms are associated with plasma fibrinogen and coronar; Λ" ease in patients with myocardial infarction: the ECTIM MUJ; < . · · · ' 1996:93:440-9.
16. Carter AM, Catto AJ, Bamford JM, Grant PJ. Gendcr-rvU.. -'-«" tions of the fibrinogen Bß 448 polymorphism. fibrim'.^'i .^ acutc coronary disease. Arterioscler Thromh Vase Biol l1'1'
17. Nishiuma S, Kario K. Yakushijm K. Maeda M. Murai R. \l-U. Shimada K. Matsuo M. Genetic Variation in ihc prom.'icT ß-fibrmogen gene is associated with ischcmic stroke m J ^ lation. Blood Coagul Fibrinol 1998; 9: 373-9.
18. Tybjaerg-Hansen A, Agerholm-Larsen B, Humphni"· sl""
Reiner et al.: Hcmostaüc Risk Faciors and Arterial Thromhotic Discasc
.. «>-γπ ^ri>mi>ter is an indepcndcnt prcdiclor of plasma fibrinogen, •\ IMIIII' heart discasc. A siudy of 9.127 individuals bascd on "!, Γ.νπ^η üu Hcan Sludy. J Clin Invcst 1997; 99: 3034-9.
"... ;.Λ \ Schwan/ 0. Habcrbosch W. Kalz N, Weiss T. Tillmanns
* .... [·\\. \Vaax \V. Ebcrbach A. Positive associalion of thc β fi-.·,- Hi H- -L'ni-' \ariation to basal fibrinogen levels and to increasc /~-.·.νη amcemration during acute phase reaction but not to coro--,-. JivMM.1 and mvocardial infarction. Thromb Haemost 1997: 77:
• n »i: Π\ Ruddock V. Stirling Y. Chakrabati R. Miller GJ. Fibrinolytic i. ^.iiiiins! Kictorx. and long-term incidence of ischaemic heart dis-".. · i.v \orrlnuck Park Heart Study. Lancet 1993: 342: 1076-9.
..(.- K Heinrich J. Schulte H. van de Loo J, Assmann G. Coagulation - \ il j'id thc lisk of coronary heart disease in heallhy mcn.
Arlcri-[ : · !,·,:, wh Vase Biol 1997:17: 1539-44.
·, - ί H IM M. Fowkes FGR. Price JF. Rumley A. Löwe GDO. Hcmo-,; . '..*ii>r> ,1·. prediclorx of Lschemie heart disease and stroke in the Edin-v„· Vk-o Suid\. Anenoscler Thromb Vase Biol 1997; 17:3321-5. > .,·;·, \K. V, u KK. Rosamond WD. Sharrett AR. Chambless LE.
Pros-,· · ,.· -iüiK of hcmostalic factors and incidence of coronary heart dis-,-x Ihi Mherosclcrosis Risk in Communities (ARIC) study. Circulation
, >, .-.i l, Rou-ndaal FR. Rcitsma PH, van der Vcldcn PA. Briet E. Van-?r,l-;,'ikke JP. Facior VII and fibrinogen levels äs risk factors for \ enous
T-.'.xniVMv A case-control study of plasma levels and DNA
polymor-*:·πι» - thc Leiden Thrombophilia Study (LETS). Thromb Haemost
• Μ.τ.ϋοη 1.1. Schonten EG. Grobbee DE. Kluft C. Coagulation factor VII. Ji'jr) tüi and blood lipids: a review. Thromb Haemost 1996: 76: 492-9. Hunauli M. Arbini AA. Lopaciuk S. Carew JA. Bauer KA. The
VJi.'Gln pohmorphism reduccs the level of coagulalion factor VII. !·- mo and in vitro studies. Arterioscler Thromb Vase Biol 1997: 17:
"' ΙκοιιιΊΙο L. Di Castelnuovo A. de Knijff P. D'Orazio A. Amorc C. Arbo-~«i K. Kluft C. Donati MB. Polymorphisms in the coagulalion factor VII ,·.·ικ· >md thc nsk of myocardial infarction. N Engl J Mcd 1998; 338:
* \livr t. Siheira A, van't Hooft F. Suontaka AM. Eriksson P, Blombäck M Haimien A. Coagulation factor VII mass and aclivity in young men »ith imocardial infarction at a young age. Rolc of plasma lipoproteins and
'Λ.ΊΟΓ VII genotype. Arterioscler Thromb Vase Biol 1995: 15: 655-64. '· l Jitf Λ. Green F. Scarabin PY. Nicaud V, Bara L, Humphries S. Evans A.
U ü. Camhou JP. Arveiler D, Cambie F. Factor VII Arg/Gln353 poly-''!i>rphism dciermines factor VII coagulant activity in patients with myo-v-irdiül infarction (MI) and control subjects in Belfast and France but is not •i 'ironc indicator of MI risk in the ECTIM study. Atherosclerosis 1996: Hl. 119-27.
' tV'ssen CJM. Mangcr Cats V. Bertina RM. Reitsma PH. Vandenbroucke 'P. Rosendaal FR. A genetic propensity to high factor VII is not
associal-Λ! with the risk of myocardial infarction in men. Thromb Haemost 1998: *): 2X1-5.
Heuood DM. Carter AM, Catto AJ. Bamford JM. Grant PJ. Polymor-phwns of the factor VII gene and circulating FVIIC levels in relation to •Miie ccrcbrovascular disease and post stroke mortality. Stroke 1997: 28: M6-21.
: Mcado TW, Cooper JA, Stirling Y. Howarth DJ. Ruddock V, Miller GJ. fcfciur VIII, ABO blood group, and the incidence of ischaemic heart dis-«w.BrJHaematol 1994; 88: 601-7.
; Rumle\ A. Löwe GDO. Sweetnam PM. Yarnell JWG. Ford RP. Fac-!or VIII. von Willebrand factor and the risk of major ischaemic heart
Jl^Jsc in the Caerphilly Heart Study. Br J Hacmatol 1999; 105: 110-6.
' ΤΓ» RP. Arnold AM. Ettingcr W. Fried L. Meilahn E. Savage P. The re-'•ilionship of fibrinogen and factors VII and VIII to incident cardiovascu-ar disease and death in the clderly. Results from thc Cardiovascular 'blih Study. Arterioscler Thromb Vase Biol 1999: 19: 1776-83.
35. Jansson JH. Nilsson TK. Johnson 0. von Willebrand faclor in plasma: a novel risk factor for recurrent myocardial infarclion and dcath. Br Hcarl .1 1991:66:351-5.
36. Blann AD. McCollum CN. Von Willchrand faclor and solublc ihrombo-modulin äs prcdictors of adversc evcnts among subjects wilh periphcral or coronary athcrosclcrosis. Blood Coagul Fibrinol 1999: 10: 375-80. 37. Rosendaal FR. Varckamp I. Brocker-Vriends AH. \an Dijck H.
Vanden-broucke JP. Hcrmans J. Suurmeijer TPBM. Briet E. Mortality and causcs of dcath in Dulch haemophiliacs. 1973-1986. Br J Haematol 1989: 71: 71-6.
38. Triemstra M. Rosendaal FR. Smit C. Van der Ploeg HM. Briet E. Mortal-ity in palients wilh hcmophilia. Charmes in a Dmch population from 1986 to 1992 and 1973 lo 1986, Ann Intern Med 1995: 123: 823-7.
39. Kostcr T. Blann AD. Briet E. Vandenbroucke JP. Rosendaal FR. Rolc of clotting faclor VIII in effect of von Willebrand factor on occurrence of dcep-venous ihrombosis. Lancet 1995: 345: 152-5.
40. Medalie JH. Levcnc C. Papier C. Goldboun U. Dreyfus F. Oron D. Neu-leid H. Riss E. Blood groups. myocardial infarction and angina pectoris among 10.000 adult males. N Engl J Med 1971: 285: 1348-53,
41. Kamphuiscn PW. Houwing-Duistermaat JJ. \an Houwelingen HC. Eiken-boom JCJ. Bcrtina RM. Rosendaal FR. Familial clustering of factor VIII and von Willebrand factor levels. Thromb Haemost 1998: 79: 323-7. 42. Kangsadalampai S, Board PG. The Val34Lcu polymorphism in the A
sub-unil of coagulation factor XIII contributes to the largc normal ränge in ac-tivity and dcmonstrates that Ihe activation pcplide plays a rolc in catalytic activity. Blood 1998:8:2766-70.
43. Köhler HP. Ariens RAS. Whitaker P. Grant PJ. A common coding poly-morphism in thc FXIII A-subunit gcne (FXIIIVAL34Lcu) affects cross-linking activity. Thromb Haemost 1998: 80: 704.
44. Köhler HP. Slickland MH. Ossci-Gcrning N. Carter A. Mikkola H. Granl PJ. Association of a common polymorphism in Ihe factor XIII gene with myocardial infarction. Thromb Haemost 1998; 79: 8-13.
45. Warliovaara U. Perola M. Mikkola H. Tötterman K. Savolainen V. Penttilä A. Grant PJ. Tikkanen MJ, Vartiainen E. Karhunen PJ. Pcltonen L. Palotic A. Association of FXIII Val34Lcu with dccreased risk of myocardial infarction in Finnish males. Atherosclerosis 1999: 142: 295-300.
46. Elba/. A. Poiricr 0. Canaple S. Chcdru F. Cambicn F. Amarcnco P. The association belween the Val34Lcu polymorphism in the factor XIII gcnc and brain infarclion. Blood 2000: 95: 586-91.
47. Catto AJ. Kohler HP, Coore J. Mansfield MW. Stickland MH. Grant PJ. Associalion of a common polymorphism in the factor XIII gene with vc-nous thrombosis. Blood 1999: 93: 906.
48. Callo AJ. Kohler HP. Bannan S. Slickland M. Carlcr A. Grant PJ. Fac-lor XIII Val34Leu: a novcl associalion wilh primary intracercbral hemor-rhage. Slrokc 1998: 29: 813-816.
49. Ariens RAS. Phillippou H, Nagaswami C. Weisel JW. Lane DA. Granl PJ. The faclor XIII V34L polymorphism accclerates thrombin activation of factor XIII and affects cross-linked fibrin strueture. Blood 2000; 96: 988-95.
50. Rcdondo M. Watzkc HH. Stucki B. Sulzcr I. Dcmarmcls Biasiutti F. Binder BR. Furlan M. Lämmle B, Wuillermin. Coagulation factors II. V, VII. and X. prothrombin gene 20210G->A transition. and factor V Leiden in coronary ariery disease. Arterioscler Thromb Vase Biol 1999: 19:
51. De Stefano V. Leone G. Maslrangelo S. Tripodi A. Rodeghiero F. Casta-man G. Barbui T. Finazzi G. Bizzi B. Mannucci PM. Clinical Casta- manifesia-tions and managcmenl of inherilcd thrombophilia: retrospektive analysis and follow-up aftcr diagnosis of 238 palients with congenital dcficiency of aniithrombin III. protcin C. prolein S. Thromb Haemosi 1994: 72: 352-8.
53. Barinagarremenlcria F. Cantu-Brito C. De La Pcna A. I/aguirrc R. Pro-ihromhoiic slales in \oung peoplc vvilh idiopathic slroke. A prospecthe study. Stroke 1994:25:287-90.
54. Douav X. Lucas C. Caron C. Goudemand J. Lcys D. Anlithrombin. protcin C. and protein S levels in 127 conseeutive young adults with ischemic stroke. Ada Neurol Scand 1998: 98: 124-7.
55. Munis AG. van Gcnderen PJJ. Dippel DWJ, \an Konten F. Koudslaal PJ. Coagulation disorders in young adults with acute eerebral ischcmia. J Neurol 1998:245:21-5.
56. Margaglione M. D'Andrea G. Giuliani N. Brancaceio V. De Lucia D. Grandone E. De Stefane V. Tonali PA. Di Minno G. Inherited prothrom-botic conditions and prcmaturc ischemic slroke. Sex differences in the association with factor V Leiden. Artcriosclcr Thromh Vase Biol 1999: 19: 1751-6.
57. Bonduel M. Sciuccati G, Hepner M. Torrcs AF. Picroni G. Frontroth JP. Prethrombotic disorders in children with arterial ischemic stroke and sinovcnous thrombosis. Arch Neurol 1999: 56: 967-71.
58. Nowak-Gölll U. Slräter R. Heinecke A. Junker R. Koch HG. Schuiercr G. von Eckardslein. Lipoprolcin (a) and genetic polymorphisms of clotting faeior V, prothrombin. and mclhylcnctetrahuliOfolatc reductase are risk l'actors of spontaneous ischemic slroke in childhood. Blood 1999: 94: 3678-82.
59. Kenct G. Sadetzki S. Murad H. Martinowiiz U. Roscnbcrg N. Gilcl S. Re-chavi G. Inbal A. Factor V Leiden and antiphospholipid antibodies are sig-nificain risk l'actors l'or ischemic stroke in children. Slroke 2000; 31:1283-8. 60. Ganesan V. McShane MA. Liesner R. Cookson J. Hann I. Kirkham FJ. In-herited prothromboiic staies and ischaemic slroke in childhood. J Neurol Ncurosurg Psychialry 1998: 65: 508-11.
61. McColl MD. Chalmers EA. Thomas A. Sproul A. Hcalcy C, Raffcrty I, McWilliam R. Euson P. Factor V Leiden, prothrombin 20210 G-»A and the MTHFR C677T mutations in childhood stroke. Thromb Haemost
62. Koster T. Rosendaai F. de Ronde H. Briet E. Vandenbroukc J. Bertina R. Venous ihrombosis duc lo poor antieoagulant responsc to activalcd pro-tein C: Leiden Thrombophilia Study. Lancct 1993: 342: 1503-6. 63. Bertina RM, Koeleman BPC. Kostet T. Rosendaai FR. Dirvcn RJ. de
Ronde H. um der Veiden PA, Reitsma PH. Muiaiion in blood coagulalion factor V associated with resistance lo aclivated protein C. Nature 1994: 369: 64-7.
64. Hohn J. Zöller B. Svensson PJ. Bernlorp E. Erhard! L. Dahlbäck B. Myo-cardial infarction associaied with homozygous resistance lo aclivaled pro-lein C. Lancet 1994: 344: 952-3.
65. Emmerich J. Poirier 0. Evans A. Marques-vidal P, Aneiier D. Luc G. Aiach M. Cambien F. Myocardial infarclion. Arg506 to Gin factor V mu-lalion. and activaled protein C resistance. Lancel 1995: 345: 321. 66. Kontula K. Yiikorkala A. Mieuinen H. Vuorio A. Kauppinen-Mäkelin R.
Hämäläinen L. Paloma'ki H. Kaste M. Arg506Gln faciot V Imitation in pa-licnts with ischaemic cerebrovasculardisea.se and sur\ivors of myocardial infarclion. Thromb Haemost 1995: 73: 558-60.
67. Prohaska W. Mannebach H. Schmidt M. Gleichmann U, Kleesiek K. Evi-dence against heterozygous coagulalion factor V 1691 GA mutation for coronary arlery disease and myocardial infarction. J Molec Med 1995: 73: 521-4. '
68. Cushman M. Rosendaai FR. Psaty BM. Cook EF. Valliere J. Kuller LH. Traey RP. Faclor V Leiden is nol a risk l'aclor l'or arterial vascular discasc in the clderly: results l'rom the Cardiovascular Heallh Study. Thromb Haemost 1998: 79: 912-5.
69. Dünn ST. Roberts CR. Scheeler E. Moore WE, Lee ET. Eichner JE. Rolc of factor V Leiden mutation in patients with angiographically demonstral-ed coronary artery disease. Thromb Res 1998: 91:91-9.
70. Gardemann A. Arsic T. Kalz N. Tillmanns H. Hehrlein FW, Haberbosch W. The l'aclor 11G2021OA and factor V G1691A gene transitions and cor-onary heart disease. Thromb Haemost 1999; 81: 208-13.
71. Ridkcr PM. Hennekens CH. Lindpaintner K. Stampfer MJ, Eisenberg PR. Miletich JP. Mutation in the gene coding l'or coagulation l'aclor V and the
risk of myocardial infarction. stroke. and\cnous thrombosis in apparen; heallhy men. N Engl J Med 1995; 332: 912-7.
72. Van Bockxmeer FM. Baker Rl. Tavlor RR. Premalure ischaemic !\v discasc and the gene l'or coagulalion l'aclor V. Nat Med 1995; l: l S5. 73. Ardissino D. Mannucci PM. Merlini PA, Duca F. Feti\eau R. Tagliahiv i
Tubaro M. Galvani M. Otlani F. Ferrario M. Corral J. Margaglione M Prothrombotic gcnctic risk factors in young sur\ivors of myocardul · farction. Blood 1999: 94: 46-51.
74. Vargas M. Solo I. Pinto CR. Urgelles MF. Batalla A. Rodriquez-Reiir J. Corlina A. Alvarez V. Coto E. The prothrombin 2021 OA alleleandi·· factor V Leiden are associated wilh \enous ihrombosis but not \\iih out coronary artery disease. Blood Coagul Fibrinol 1999; 10: 39-41. 75. Rosendaai FR. Siscovick DS. Schwanz SM, Beverly RK. Psat\ B\|
Longsireth WT. Jr. Raghunathan TE, Koepsell TD, Reitsma PH. Fact« \ Leiden (resistance to aclivated protein C) increases the risk of injocaro,, infarction in young women. Blood 1997: 89: 2817-21.
76. Doggen CJM. Manger Cats V. Bertina RM. Rosendaai FR. Interaciior. coagulalion defecls and cardiovascular risk factors: increased risk oi'im,. cardial infarction associated wilh factor V Leiden or prothrombin 202 !'·Α Circulationl998;97: 1037-41.
77. Catlo A. Carler A. Ireland H. Bayston TA. Phillippou H. Barren J. l ..·, DA. Gram PJ. Faclor V Leiden gene mutalion and thrombin generjiu·' -relation lo development of stroke. Arterioscler Thromb Vase Biol l1'-·*
78. De Stefane V. Chiusolo P. Paciaroni K. Casorelli I. Rossi E. Mohnjr \' Servidei S. Tonali.PA. Leone G. Prothrombin G20210A mutani i:em» ·· is a risk factor for cerebrovascular ischemic disease in \ouns p.c.· Blood 1998; 91: 3562-5.
79. Voetsch B. Damasceno BP. Camargo ECS. Massaro A. Bachevhi l i Scaff M, Anniehino-Bizzachi JM, Arruda VR. Inherited thromhophih. a risk factor for the development of ischemic stroke in jouna nki:
Thromb Haemost 2000; 83: 229-33.
80. Longsireth WT Jr. Rosendaai FR. Siscovick DS. Vos HL. Sdnun,· Ά· Psaty BM. Raghunathan TE, Koepsell TD. Reitsma PH. Risk of ^ira: · young women and two prothrombotic mutations: factor V Leiden jr,J .1· thrombin gene variant (G20210A). Stroke 1998; 29: 577-80. 81. Zenz W. Bodo Z. Plolho J. Streif W. Male C. Bernerl G. RÄ"
Ebetsbergcr G. Kaltenbrunner K, Kurnik P. Lischka A. Pak\ F. K*.·: > Kotier G, Mannhaller C. Muntean W. Factor V Leiden and prnthi.'.' gene G2021 OA variant in children with ischemic stroke. Thromh HJ.' -1998; 80: 763-6.
82. Foley PWX, Irvine CD. Standen GR. Morse C. Smith Ff. \Uiv Baird RN. Lamont PM. Activaled protein C resistanee. lacto; \ '· and peripheral vascular disease. Cardiovasc Surg 1997:5. b •hl1
83. Sampram ESK, Lindblad B, Dahlbäck B. Activaled prolein C ι:>·>ϋ'· ' patients with peripheral vascular disease. J Vase Surg 19*. > '-'· 84. Renner W, Koppel H. Brodmann M. Pabst E, SchallmoxT K T>c .
Wäscher TC. Pilger E. Faclor II G20210A and l'aclor \ (iί""' * ' mutations and peripheral arterial occlusive disease. Thi>'·:''· K. "· 2000: 83: 20-2.
85. Van der Born JG. Bots ML. Haverkate F. Slaghoom P!·. <'«·**'· '
Kluft C. Rcduced response to activated protein C i·. J^'-' · increased risk for cerebrovascular disease. Ann Intern MeJ **" 265-9.
86. Kiechl S. Muigg A, Sanier P. Mitlerer M. Eggcr G. OK""·1 Oberhollenzer F, Mayr A. Gasperi A. Poewe W. Willen J l'»' 'Γ'Λ''' to activaled protein C äs a prominent risk prediclor öl aJ^"-' ·' sclerosis and arterial disease. Circulation 1999:99:614-4 87. Soufo JC. Almasy L, Borrell M. Gari M. Martine/ E. M.iti.'''J v Λ *
Blangero J. Fontcuberla J. Genetic determinantsofhenuM.i^ ·<'- '
in Spanish families. Circulation 2000: 101: 1546-51.