Abstract Number: PO117
Meeting: ISTH 2021 Congress
Background: Factor V Leiden (FVL) or resistance to activated Protein C (aPC) results from a single-point mutation in the Factor V gene, which renders activated Factor V (FVa) enzymatically active but resistant to deactivation by activated protein C (aPC), leading to a hypercoagulable state. FVL confers a 4 to 5-fold risk for venous thromboembolism, however its contribution to arterial thrombosis remains controversial.
Aims: Discuss the risk of arterial atherothrombotic events in heterozygous FVL individuals.
Methods: We report a case of a 71-year-old heterozygous FVL man who presented with recurrent acute myocardial infarction (AMI) prompted by interruptions in antiplatelet and anticoagulation therapy.
Results: This patient was diagnosed with heterozygous FVL at 58 years of age when he presented with post-operative pulmonary embolism following a biceps repair. He had no other comorbidities and never smoked. However, within 12 months from his hypercoagulable workup, patient was diagnosed with intermediate grade prostate cancer and was treated with surgery and chemoradiation, achieving complete remission. At 66 years old, he had his first AMI resulting from complete right coronary artery (RCA) occlusion, for which he was placed on dual-antiplatelet therapy and warfarin. After six months of treatment, warfarin was switched to rivaroxaban. The following year, he had another AMI secondary to acute RCA thrombosis, approximately one month after discontinuing rivaroxaban. He had two subsequent AMIs in the following four years, both soon after stopping therapeutic anticoagulation (Tables 1 and 2). Ultimate management was determined to be a combination of low-dose rivaroxaban and clopidogrel.
|Angiographic Findings||100% occlusion of RCA||Thrombosis of RCA||Acute thrombus; severe in-stent-restenosis at the previous distal stent at bifurcation of rPDA & rPLV||Acute thrombus of RCA|
|Treatment||Thrombectomy + DESx1 to RCA; DAPT + warfarin. Warfarin switched to rivaroxaban after 6 months||Thrombectomy + DESx3 to RCA; DAPT + warfarin||Angioplasty to rPLV + DESx1; DAPT + therapeutic enoxaparin||Intravascular aspiration; clopidogrel + rivaroxaban|
|Comorbid VTE||Right common femoral vein DVT||Left gastrocnemius vein DVT||None||None|
|Preceding Anticoagulation||None||Rivaroxaban stopped due to financial burden 1 month prior||Warfarin stopped 1 week prior for colonoscopy||Therapeutic enoxaparin stopped 10 days prior due to expanding gluteal hematoma with lower extremity paresthesia and acute anemia|
|Comorbid Malignancy||Gleason 7 T3bN1M0 prostate cancer||Bone metastatic prostate cancer||None (PSA undetectable, not on active treatment)||None (PSA undetectable, not on active treatment)|
|AMI = acute myocardial infarction; STEMI = ST-elevation myocardial infarction; RCA = right coronary artery
rPDA = right posterior descending artery; rPLV = right posterior-lateral ventricular branch
DES = drug-eluting stent; DAPT = dual-antiplatelet therapy; VTE = venous thromboembolism
DVT = deep vein thrombosis; PSA = prostate-specific antigen
|Hemoglobin A1c (%)||5.1||5.5||5.4||5.6|
|Blood Pressure (mmHg)||100/65||110/80||107/70||94/59|
Conclusions: This case illustrates that FVL may interact with certain genetic and environmental risk factors to promote arterial thrombosis. Therefore, in select patient groups with established cardiovascular disease, a concomitant diagnosis of FVL carrier state may warrant aggressive escalation of therapy for secondary prevention of arterial thrombotic events.
To cite this abstract in AMA style:Grinsztejn E, Dugan JP, Stavrou EX. A Case of Recurrent Myocardial Infarction and Heterozygous Factor V Leiden [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 1). https://abstracts.isth.org/abstract/a-case-of-recurrent-myocardial-infarction-and-heterozygous-factor-v-leiden/. Accessed September 25, 2021.
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