Activated protein C resistance test

Activated protein C resistance test
SynonymsAPC resistance test; Activated protein C resistance assay; APC resistance assay; APCR test; APCR assay
Test ofActivated protein C resistance, coagulation, hypercoagulability

The activated protein C resistance (APCR) test is a coagulation test used in the evaluation and diagnosis of activated protein C (APC) resistance, a form of hypercoagulability.[1][2] Hereditary APC resistance is usually caused by the factor V Leiden mutation, whereas acquired APC resistance has been linked to antiphospholipid antibodies, pregnancy, and estrogen therapy.[3][4][5][6] APC resistance can be measured using either an activated partial thromboplastin time (aPTT)-based test or an endogenous thrombin potential (ETP)-based test.[5][4][2]

Methodology

The aPTT-based APC resistance test involves a modified aPTT test performed in the presence and absence of activated protein C (APC).[1][5] The ratio of these aPTT values is calculated and is called the APC sensitivity ratio (APCsr) or simply APC ratio (APCr).[1][5] This ratio is inversely related to the degree of APC resistance.[7] The ETP-based APC resistance test involves the addition of APC to a thrombin generation assay (TGA).[5] This results in an inhibition of thrombin generation as measured by reduction of the endogenous thrombin potential (ETP; area under the thrombin generation curve).[5] The result is expressed as a normalized APC sensitivity ratio (nAPCsr), which corresponds to the ratio of the ETP measured in the presence and absence of APC divided by the same ratio in reference plasma.[5] nAPCsr values range from 0 to 10.[5] Opposite to the case of the APCsr with the aPTT-based APC resistance test, higher nAPCsr values indicate greater APC resistance.[5][8] This is the result of the fact that APC prolongs the aPTT but inhibits thrombin generation.[8]

Whereas the aPTT-based APC resistance test only measures the initiation phase of coagulation, the ETP-based test is a global assay and measures the initiation, propagation, and termination phases of coagulation.[5][9] The initiation phase accounts for less than 5% of total thrombin generation, making aPTT-based tests poorly indicative of hypercoagulability in general.[10][11] The aPTT-based assay is more sensitive to levels of prothrombin and factor VIII, whereas the ETP-based test is more sensitive to levels of tissue factor pathway inhibitor (TFPI) and protein S.[5] The ETP-based test has traditionally been performed using methods such as the calibrated automated thrombogram (CAT) and has been limitedly available due to its technical difficulty.[2] Recently however, a fully automated commercial test system called the ST Genesia has been introduced, and it has been said that this should allow for adoption of TGAs and ETP-based APC resistance tests in routine clinical settings.[2][12]

Influences

Thrombin generation curves in the absence (HPP -APC) and presence (HPP +APC) of activated protein C (APC) in healthy pooled plasma and in plasma of women on various combined oral contraceptives.[5] The contraceptives are estetrol/drospirenone (E4/DRSP), ethinylestradiol/levonorgestrel (EE/LNG), ethinylestradiol/desogestrel (EE/DSG), and ethinylestradiol/drospirenone (EE/DRSP).[5]

Estrogens are well known to increase APC resistance, which has been described as acquired APC resistance.[2][5][4][13][14] However, the aPTT-based APC resistance test is much less sensitive to the procoagulatory effects of estrogens than is the ETP-based test.[13][14][5][4][2][15] Pregnancy[7] and ethinylestradiol (EE)-containing combined birth control pills increase APC resistance as measured by either the aPTT- or ETP-based test.[4][5][15] EE-containing birth control pills show different degrees of influence on the ETP-based test depending on the progestin, which may be due to varying degrees of androgenic antagonism of ethinylestradiol-mediated procoagulation.[5][4] In contrast to EE-containing birth control pills, studies have not found increased APC resistance with menopausal hormone therapy or with estetrol- or estradiol-containing birth control pills using the aPTT-based test, though increased APC resistance has been shown with the ETP-based test.[14] The increase in APC resistance is much greater with oral estrogens than with transdermal estradiol.[14] Increased APC resistance with both the aPTT-based and ETP-based tests has been observed with feminizing hormone therapy in transgender women, which involves higher doses of estradiol than are used in other contexts.[16][17] EE produces a much stronger increase in APC resistance than does estradiol.[18][17] In relation to this, ethinylestradiol is associated with a higher risk of venous thromboembolism (VTE) than is estradiol.[18][19][20]

History

The aPTT-based APC resistance test was developed in 1993, while the ETP-based test was developed in 1997.[5] For many years, the ETP-based APC resistance test suffered from a lack of standardization which hampered study-to-study comparison.[21] By 2020 however, a validated methodology was developed aiming to propose a standardized and harmonized scale for ETP-based APC resistance, the normalized activated protein C sensitivity ratio (nAPCsr).[21]

References

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  2. 1 2 3 4 5 6 Reda S, Morimont L, Douxfils J, Rühl H (August 2020). "Can We Measure the Individual Prothrombotic or Prohemorrhagic Tendency by Global Coagulation Tests?". Hamostaseologie. 40 (3): 364–378. doi:10.1055/a-1153-5824. PMID 32726831. S2CID 220878363.
  3. Kujovich JL (January 2011). "Factor V Leiden thrombophilia". Genet Med. 13 (1): 1–16. doi:10.1097/GIM.0b013e3181faa0f2. PMID 21116184. S2CID 220861191.
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  12. Favaloro EJ, Lippi G (April 2019). "Recent Advances in Mainstream Hemostasis Diagnostics and Coagulation Testing". Semin Thromb Hemost. 45 (3): 228–246. doi:10.1055/s-0038-1676579. PMID 30912101. S2CID 85517668.
  13. 1 2 Tchaikovski SN, Rosing J (July 2010). "Mechanisms of estrogen-induced venous thromboembolism". Thromb Res. 126 (1): 5–11. doi:10.1016/j.thromres.2010.01.045. PMID 20163835.
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  16. Scheres LJ, Selier NL, Nota NM, van Diemen JJ, Cannegieter SC, den Heijer M (April 2021). "Effect of gender-affirming hormone use on coagulation profiles in transmen and transwomen". J Thromb Haemost. 19 (4): 1029–1037. doi:10.1111/jth.15256. PMC 8048491. PMID 33527671.
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  20. Grandi G, Facchinetti F, Bitzer J (February 2022). "Confirmation of the safety of combined oral contraceptives containing oestradiol on the risk of venous thromboembolism". Eur J Contracept Reprod Health Care. 27 (2): 83–84. doi:10.1080/13625187.2022.2029397. PMID 35133236. S2CID 246651102.
  21. 1 2 Douxfils, Jonathan; Morimont, Laure; Delvigne, Anne-Sophie; Devel, Philippe; Masereel, Bernard; Haguet, Hélène; Bouvy, Céline; Dogné, Jean-Michel (2020-01-28). "Validation and standardization of the ETP-based activated protein C resistance test for the clinical investigation of steroid contraceptives in women: an unmet clinical and regulatory need". Clinical Chemistry and Laboratory Medicine. 58 (2): 294–305. doi:10.1515/cclm-2019-0471. ISSN 1437-4331. PMID 31444961. S2CID 201644826.
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