The clinical application of a new specific functional assay to detect the factor V(Leiden) mutation associated with activated protein C resistance.

Abstract

Resistance to activated protein C (APC) is the most common defect found in patients who have venous thromboembolism. The molecular basis of APC resistance is a single-point mutation (arginine506-glutamine) in the gene that encodes for coagulation factor V. This mutation results in a factor V molecule (factor V(Leiden)) that is less effectively downregulated by APC than is normal factor V. The gold standard for the detection of this defect is DNA analysis. Several functional tests, which are based on activated partial thromboplastin time clotting assays, are also commercially available for the detection of APC resistance. These tests, however, have not been satisfactory. Compared with the results of DNA analysis, the results of these tests are frequently discordant. Further, in some patients (eg, those who have lupus anticoagulant or have been receiving heparin), these tests cannot be performed at all. DNA analysis is therefore required in most patients to distinguish congenital APC resistance (factor V(Leiden)) from other causes of abnormal response in functional APC-resistance tests. The purpose of this study was to investigate the clinical use of a new chromogenic APC-resistance assay that is based on direct measurement of the effect of APC on factor Va cofactor activity in highly diluted, thrombin-activated plasma specimens. All individuals who provided plasma samples for the study underwent DNA analysis to detect the presence of the factor V mutation. In all patient subgroups, including patients who had lupus anticoagulant and those who were receiving unfractionated heparin or coumarin derivatives, the chromogenic test showed excellent discrimination between normal individuals and those who were heterozygous or homozygous for the factor V(Leiden) mutation. No discordant results with DNA analysis were found in 150 cases. The new test easily can be incorporated in any laboratory that has an automated coagulation apparatus with an option for chromogenic measurements. All reagents are commercially available at low cost, and the test is easy to perform and is not time-consuming. This new, sensitive, and specific test allows large-scale screening for the factor V(Leiden) mutation without the need for DNA analysis.