Hypercoagulable State: An Overview

What Is a Hypercoagulable State?

A hypercoagulable state is also known as thrombophilia. It is a condition characterized by an increased tendency of the body to form blood clots (thrombosis) due to one or more predisposing factors. These factors can either be inherited or acquired. In a normal state, clot formation is a good thing. It ensures that the body can cope with injuries and heal independently.

However, blood clots can become dangerous when developing within the blood vessels. Therefore, individuals in a hypercoagulable state are at an increased risk of developing thrombus formation within the veins, such as deep vein thrombosis or pulmonary embolism. Deep vein thrombosis is characterized by developing a clot in a deep vein of the upper and lower extremities, which usually presents with swollen and painful limbs. Pulmonary embolism occurs when parts of these blood clots from the vein break off and reach the lungs. On the other hand, arterial clots can travel to other organs like the brain, bones, heart, kidneys, and liver, thereby cutting off blood supply to these organs. This leads to infarction (local death of the tissue).

What Causes Hypercoagulability?

Blood clotting occurs due to the interaction between blood vessels, platelets, and clotting factors. Clotting factors circulate in their inactive form in the blood to prevent coagulation from occurring when it is not required. When an injury occurs, clotting factor VII binds to the exposed vessel wall cells, triggering the coagulation cascade's activation. This often leads to subsequent activation of the other clotting factors, ultimately forming thrombin (factor II). Thrombin, in turn, converts fibrinogen into fibrin, thereby forming a mesh to stabilize the platelet plug.

To limit clot formation at the injury site and prevent it from growing very big, the coagulation cascade is mediated by different anticoagulant mechanisms. Any condition that strikes an imbalance between thrombogenic and anti-thrombogenic mechanisms makes the person susceptible to an increased risk of bleeding (state of hypercoagulability).

What Is a Primary Hypercoagulable State?

The primary hypercoagulable state is an inherited type of clotting disorder in which the natural anticoagulant mechanism is defective.

What Is a Secondary Hypercoagulable State?

A secondary hypercoagulable state develops when clot formation is caused by acquired factors that can increase the chance of clot formation. These factors include neoplasms, smoking, excessive fat deposition, pregnancy, major injury or surgery, autoimmune disorders, and consumption of certain medicines like oral contraceptives. Cancer leads to an increased generation of procoagulant factors and cytokines, causing hypercoagulation. Other conditions like smoking, surgery, or severe injury cause damage to the blood vessels, thereby activating the coagulation cascade.

Is Pregnancy a Hypercoagulable State?

During pregnancy, there is a higher risk of venous thromboembolism (blood clots in the veins). This occurs due to hormonal and physical changes occurring during pregnancy. Increased clotting factors and womb pressure reduce the venous return into the heart. This makes the blood clot more easily.

What Are the Symptoms of a Hypercoagulable State?

The symptoms of a hypercoagulable state depend on blood clots in the body. Symptoms may include:

• Swelling of the legs.

• Tenderness in the legs.

• Pain in the legs.

• Chest pain.

• Breathlessness.

• Heart attack.

• Stroke (damage to the brain due to disruption in the blood supply).

How to Diagnose a Hypercoagulability State?

The diagnostic tests for blood clotting include

• Prothrombin Time: This test helps the healthcare provider monitor the condition if the patient is on Warfarin. PT test helps to determine the time taken for a clot formation in a blood sample.

• Activated Partial Thromboplastin Time (aPTT): It measures the time the blood takes to clot. The healthcare provider may monitor the situation well.

• Fibrinogen Test: This test helps determine the blood's fibrinogen levels. Fibrinogen is a protein that helps in blood clotting.

• Complete Blood Count (CBC): This test helps determine the different blood features.

Some tests that help to diagnose inherited coagulation disorders include

• Genetic Mutation Tests- These include prothrombin gene mutation and activated protein C resistance.

• Antithrombin Activity- Antithrombin acts to thin the blood slightly, so it does not clot easily.

• Protein C Activity- Protein C helps to control blood coagulation.

• Protein S Activity- This protein blocks the activity of certain proteins that promote blood clot formation.

• Homocysteine Test- This test measures the amount of homocysteine, an amino acid, in the body. Higher levels suggest a high risk of heart disease.

How to Manage a Hypercoagulable State?

Treatment of a hypercoagulability state is usually recommended after a thromboembolic event has occurred in individuals with a known clotting disorder.

Short-term anticoagulant therapy with medications such as low molecular weight Heparin, Warfarin, or direct anticoagulants is preferred in acute thromboembolic situations. In severe conditions, the clot is surgically removed through thrombectomy (clot removal surgery from a vein or artery) or dissolved with fibrinolytic medications like urokinase or streptokinase. Long-term anticoagulant therapy is prescribed in such individuals to inhibit the clotting cascade and prevent the formation of clots. These medications may also be prescribed in high-risk people, such as during pregnancy or after major surgery or trauma.

It is also important to avoid risk factors that may lead to developing a hypercoagulable state when possible. These preventive measures include substituting oral contraceptive pills for another birth control method and cessation of smoking.

Conclusion

To conclude, staying in touch with the healthcare provider is crucial if a patient suffers from a blood clotting disorder. The patient should not miss the follow-up appointments. No over-the-counter medicines should be purchased without a doctor’s prescription. If the blood clotting disorder is inherited, the condition may remain life-long. Still, if it is acquired, the patient's condition might improve after eliminating the underlying pathology.