• Hereditary angioedema is associated with venous thromboembolism in Swedish families with HAE.

  • A high familial risk for VTE is observed in especially younger patients with HAE.

Abstract

Hereditary angioedema (HAE), caused by C1 inhibitor protein deficiency, was recently shown to be associated with an increased risk for venous thromboembolism (VTE). To our knowledge, this is the first national family study of HAE, which aimed to determine the familial risk of VTE. The Swedish Multi-Generation Register was linked to the Swedish National Patient Register for the period of 1964 to 2018. Only patients with HAE with a validated diagnosis were included in the study and were linked to their family members. Hazard ratios (HRs) and 95% confidence intervals (CIs) for VTE were calculated for patients with HAE in comparison with relatives without HAE. Among 2006 individuals (from 276 pedigrees of 365 patients with HAE), 103 individuals were affected by VTE. In total, 35 (9.6%) patients with HAE were affected by VTE, whereas 68 (4.1%) non-HAE relatives were affected (P < .001). The adjusted HR for VTE among patients with HAE was 2.51 (95% CI, 1.67-3.77). Patients with HAE were younger at the first VTE than their non-HAE relatives (mean age, 51 years vs 63 years; P < .001). Before the age of 70 years, the HR for VTE among patients with HAE was 3.62 (95% CI, 2.26-5.80). The HR for VTE for patients with HAE born after 1964 was 8.29 (95% CI, 2.90-23.71). The HR for VTE for patients with HAE who were born in 1964 or earlier was 1.82 (95% CI, 1.14-2.91). HAE is associated with VTE among young and middle-aged individuals in Swedish families with HAE. The effect size of the association is in the order of other thrombophilias. We suggest that HAE may be considered a new rare thrombophilia.

1.
Heit
JA
.
Epidemiology of venous thromboembolism
.
Nat Rev Cardiol
.
2015
;
12
(
8
):
464
-
474
.
2.
Zöller
B
,
Li
X
,
Ohlsson
H
,
Ji
J
,
Sundquist
J
,
Sundquist
K
.
Family history of venous thromboembolism as a risk factor and genetic research tool
.
Thromb Haemost
.
2015
;
114
(
5
):
890
-
900
.
3.
Rosendaal
FR
.
Venous thrombosis: a multicausal disease
.
Lancet
.
1999
;
353
(
9159
):
1167
-
1173
.
4.
Zöller
B
,
García de Frutos
P
,
Hillarp
A
,
Dahlbäck
B
.
Thrombophilia as a multigenic disease
.
Haematologica
.
1999
;
84
(
1
):
59
-
70
.
5.
Zöller
B
,
Svensson
PJ
,
Dahlbäck
B
,
Lind-Hallden
C
,
Hallden
C
,
Elf
J
.
Genetic risk factors for venous thromboembolism
.
Expert Rev Hematol
.
2020
;
13
(
9
):
971
-
981
.
6.
Mannucci
PM
,
Franchini
M
.
Classic thrombophilic gene variants
.
Thromb Haemost
.
2015
;
114
(
5
):
885
-
889
.
7.
Morange
PE
,
Suchon
P
,
Trégouët
DA
.
Genetics of venous thrombosis: update in 2015
.
Thromb Haemost
.
2015
;
114
(
5
):
910
-
919
.
8.
Manderstedt
E
,
Lind-Halldén
C
,
Halldén
C
, et al;
Regeneron Genetics Center
.
Classic thrombophilias and thrombotic risk among middle-aged and older adults: a population-based cohort study
.
J Am Heart Assoc
.
2022
;
11
(
4
):
e023018
.
9.
Desch
KC
,
Ozel
AB
,
Halvorsen
M
, et al
.
Whole-exome sequencing identifies rare variants in STAB2 associated with venous thromboembolic disease
.
Blood
.
2020
;
136
(
5
):
533
-
541
.
10.
Morange
PE
,
Peiretti
F
,
Gourhant
L
, et al
.
A rare coding mutation in the MAST2 gene causes venous thrombosis in a French family with unexplained thrombophilia: the Breizh MAST2 Arg89Gln variant
.
PLoS Genet
.
2021
;
17
(
1
):
e1009284
.
11.
Manderstedt
E
,
Lind-Halldén
C
,
Halldén
C
, et al;
Regeneron Genetics Center
.
Genetic variation of the blood coagulation regulator tissue factor pathway inhibitor and venous thromboembolism among middle-aged and older adults: a population-based cohort study
.
Res Pract Thromb Haemost
.
2022
;
6
(
7
):
e12842
.
12.
Manderstedt
E
,
Halldén
C
,
Lind-Halldén
C
, et al
.
Thrombomodulin (THBD) gene variants and thrombotic risk in a population-based cohort study
.
J Thromb Haemost
.
2022
;
20
(
4
):
929
-
935
.
13.
Manderstedt
E
,
Halldén
C
,
Lind-Halldén
C
, et al;
Regeneron Genetics Center
.
Thrombotic risk determined by rare and common SERPINA1 variants in a population-based cohort study
.
J Thromb Haemost
.
2022
;
20
(
6
):
1421
-
1427
.
14.
Miyata
T
,
Horiuchi
T
.
Biochemistry, molecular genetics, and clinical aspects of hereditary angioedema with and without C1 inhibitor deficiency
.
Allergol Int
.
2023
;
72
(
3
):
375
-
384
.
15.
Kerr
FK
,
Thomas
AR
,
Wijeyewickrema
LC
, et al
.
Elucidation of the substrate specificity of the MASP-2 protease of the lectin complement pathway and identification of the enzyme as a major physiological target of the serpin, C1-inhibitor
.
Mol Immunol
.
2008
;
45
(
3
):
670
-
677
.
16.
Hansen
CB
,
Csuka
D
,
Munthe-Fog
L
, et al
.
The levels of the lectin pathway serine protease MASP-1 and its complex formation with C1 inhibitor are linked to the severity of hereditary angioedema
.
J Immunol
.
2015
;
195
(
8
):
3596
-
3604
.
17.
Gailani
D
.
Hereditary angioedema and thrombosis
.
Blood
.
2023
;
141
(
19
):
2295
-
2297
.
18.
Cugno
M
,
Cicardi
M
,
Bottasso
B
, et al
.
Activation of the coagulation cascade in C1-inhibitor deficiencies
.
Blood
.
1997
;
89
(
9
):
3213
-
3218
.
19.
Cugno
M
,
Zanichelli
A
,
Bellatorre
AG
,
Griffini
S
,
Cicardi
M
.
Plasma biomarkers of acute attacks in patients with angioedema due to C1-inhibitor deficiency
.
Allergy
.
2009
;
64
(
2
):
254
-
257
.
20.
Csuka
D
,
Veszeli
N
,
Imreh
É
, et al
.
Comprehensive study into the activation of the plasma enzyme systems during attacks of hereditary angioedema due to C1-inhibitor deficiency
.
Orphanet J Rare Dis
.
2015
;
10
:
132
.
21.
Bork
K
,
Witzke
G
.
Shortened activated partial thromboplastin time may help in diagnosing hereditary and acquired angioedema
.
Int Arch Allergy Immunol
.
2016
;
170
(
2
):
101
-
107
.
22.
Grover
SP
,
Kawano
T
,
Wan
J
, et al
.
C1 inhibitor deficiency enhances contact pathway-mediated activation of coagulation and venous thrombosis
.
Blood
.
2023
;
141
(
19
):
2390
-
2401
.
23.
Sundler Björkman
L
,
Persson
B
,
Aronsson
D
,
Skattum
L
,
Nordenfelt
P
,
Egesten
A
.
Comorbidities in hereditary angioedema-a population-based cohort study
.
Clin Transl Allergy
.
2022
;
12
(
3
):
e12135
.
24.
Grover
SP
,
Sundler Björkman
L
,
Egesten
A
,
Moll
S
,
Mackman
N
.
Hereditary angioedema is associated with an increased risk of venous thromboembolism
.
J Thromb Haemost
.
2022
;
20
(
11
):
2703
-
2706
.
25.
Allaart
CF
,
Poort
SR
,
Rosendaal
FR
,
Reitsma
PH
,
Bertina
RM
,
Briët
E
.
Increased risk of venous thrombosis in carriers of hereditary protein C deficiency defect
.
Lancet
.
1993
;
341
(
8838
):
134
-
138
.
26.
Zöller
B
,
Svensson
PJ
,
He
X
,
Dahlbäck
B
.
Identification of the same factor V gene mutation in 47 out of 50 thrombosis-prone families with inherited resistance to activated protein C
.
J Clin Invest
.
1994
;
94
(
6
):
2521
-
2524
.
27.
Zöller
B
,
Berntsdotter
A
,
García de Frutos
P
,
Dahlbäck
B
.
Resistance to activated protein C as an additional genetic risk factor in hereditary deficiency of protein S
.
Blood
.
1995
;
85
(
12
):
3518
-
3523
.
28.
van Boven
HH
,
Vandenbroucke
JP
,
Briët
E
,
Rosendaal
FR
.
Gene-gene and gene-environment interactions determine risk of thrombosis in families with inherited antithrombin deficiency
.
Blood
.
1999
;
94
(
8
):
2590
-
2594
.
29.
Rosen
M
,
Hakulinen
T
. Use of disease registers. In:
Ahrens
W
,
Pigeot
I
, eds.
Handbook of Epidemiology
.
Springer-Verlag
;
2005
:
231
-
252
.
30.
Ludvigsson
JF
,
Andersson
E
,
Ekbom
A
, et al
.
External review and validation of the Swedish National Inpatient Register
.
BMC Public Health
.
2011
;
11
:
450
.
31.
Ekbom
A
.
The Swedish Multi-Generation Register
.
Methods Mol Biol
.
2011
;
675
:
215
-
220
.
32.
Zöller
B
.
Nationwide family studies of cardiovascular diseases – clinical and genetic implications of family history
.
EMJ Cardiol
.
2013
;
1(1)
:
102
-
113
.
33.
Ludvigsson
JF
,
Almqvist
C
,
Bonamy
AK
, et al
.
Registers of the Swedish total population and their use in medical research
.
Eur J Epidemiol
.
2016
;
31
(
2
):
125
-
136
.
34.
Ludvigsson
JF
,
Otterblad-Olausson
P
,
Pettersson
BU
,
Ekbom
A
.
The Swedish personal identity number: possibilities and pitfalls in healthcare and medical research
.
Eur J Epidemiol
.
2009
;
24
(
11
):
659
-
667
.
35.
Ludvigsson
JF
,
Svedberg
P
,
Olén
O
,
Bruze
G
,
Neovius
M
.
The longitudinal integrated database for health insurance and labour market studies (LISA) and its use in medical research
.
Eur J Epidemiol
.
2019
;
34
(
4
):
423
-
437
.
36.
Zöller
B
,
Pirouzifard
M
,
Svensson
PJ
, et al
.
Familial segregation of venous thromboembolism in Sweden: a nationwide family study of heritability and complex segregation analysis
.
J Am Heart Assoc
.
2021
;
10
(
24
):
e020323
.
37.
Zöller
B
,
Li
X
,
Sundquist
J
,
Sundquist
K
.
Age- and gender-specific familial risks for venous thromboembolism: a nationwide epidemiological study based on hospitalizations in Sweden
.
Circulation
.
2011
;
124
(
9
):
1012
-
1020
.
38.
Zöller
B
,
Ohlsson
H
,
Sundquist
J
,
Sundquist
K
.
Familial risk of venous thromboembolism in first-second- and third-degree relatives: a nationwide family study in Sweden
.
Thromb Haemost
.
2013
;
109
(
3
):
458
-
463
.
39.
Rosendahl
A
,
Mjörnheim
B
,
Eriksson
LC
.
Autopsies and quality of cause of death diagnoses
.
SAGE Open Med
.
2021
;
9
:
20503121211037169
.
40.
Rosengren
A
,
Fredén
M
,
Hansson
P-O
,
Wilhelmsen
L
,
Wedel
H
,
Eriksson
H
.
Psychosocial factors and venous thromboembolism: a long-term follow-up study of Swedish men
.
J Thromb Haemost
.
2008
;
6
(
4
):
558
-
564
.
41.
Breslow
NE
,
Day
NE
.
Statistical methods in cancer research, volume II: the design and analysis of cohort studies
.
IARC Sci Publ
.
1987
;
82
:
1
-
406
.
42.
Zöller
B
,
Li
X
,
Sundquist
J
,
Sundquist
K
.
Neighborhood deprivation and hospitalization for venous thromboembolism in Sweden
.
J Thromb Thrombolysis
.
2012
;
34
(
3
):
374
-
382
.
43.
Zöller
B
,
Li
X
,
Sundquist
J
,
Sundquist
K
.
Neighbourhood deprivation and hospitalization for atrial fibrillation in Sweden
.
Europace
.
2013
;
15
(
8
):
1119
-
1127
.
44.
Kleinbaum
DG
,
Klein
M
. Survival Analysis, A Self-Learning Text. 2nd ed..
Springer
;
2005
.
45.
Kozarcanin
H
,
Lood
C
,
Munthe-Fog
L
, et al
.
The lectin complement pathway serine proteases (MASPs) represent a possible crossroad between the coagulation and complement systems in thromboinflammation
.
J Thromb Haemost
.
2016
;
14
(
3
):
531
-
545
.
46.
Gulla
KC
,
Gupta
K
,
Krarup
A
, et al
.
Activation of mannan-binding lectin-associated serine proteases leads to generation of a fibrin clot
.
Immunology
.
2010
;
129
(
4
):
482
-
495
.
47.
Krarup
A
,
Wallis
R
,
Presanis
JS
,
Gál
P
,
Sim
RB
.
Simultaneous activation of complement and coagulation by MBL-associated serine protease 2
.
PLoS One
.
2007
;
2
(
7
):
e623
.
48.
Jenny
L
,
Dobó
J
,
Gál
P
,
Schroeder
V
.
MASP-1 induced clotting–the first model of prothrombin activation by MASP-1
.
PLoS One
.
2015
;
10
(
12
):
e0144633
.
49.
Conway
EM
.
Reincarnation of ancient links between coagulation and complement
.
J Thromb Haemost
.
2015
;
13
(
suppl 1
):
S121
-
S132
.
50.
Zöller
B
,
Holm
J
,
Svensson
P
,
Dahlbäck
B
.
Elevated levels of prothrombin activation fragment 1 + 2 in plasma from patients with heterozygous Arg506 to Gln mutation in the factor V gene (APC-resistance) and/or inherited protein S deficiency
.
Thromb Haemost
.
1996
;
75
(
2
):
270
-
274
.
51.
Rühl
H
,
Berens
C
,
Winterhagen
FI
, et al
.
Increased activated protein C response rates reduce the thrombotic risk of Factor V Leiden carriers but not of prothrombin 20210G>A carriers
.
Circ Res
.
2019
;
125
(
5
):
523
-
534
.
52.
Martinelli
I
,
Mannucci
PM
,
De Stefano
V
, et al
.
Different risks of thrombosis in four coagulation defects associated with inherited thrombophilia: a study of 150 families
.
Blood
.
1998
;
92
(
7
):
2353
-
2358
.
53.
Segal
JB
,
Brotman
DJ
,
Necochea
AJ
, et al
.
Predictive value of factor V Leiden and prothrombin G20210A in adults with venous thromboembolism and in family members of those with a mutation: a systematic review
.
JAMA
.
2009
;
301
(
23
):
2472
-
2485
.
54.
Lindström
S
,
Wang
L
,
Smith
EN
, et al
.
Genomic and transcriptomic association studies identify 16 novel susceptibility loci for venous thromboembolism
.
Blood
.
2019
;
134
(
19
):
1645
-
1657
.
55.
Klarin
D
,
Busenkell
E
,
Judy
R
, et al
.
Genome-wide association analysis of venous thromboembolism identifies new risk loci and genetic overlap with arterial vascular disease
.
Nat Genet
.
2019
;
51
(
11
):
1574
-
1579
.
56.
Kalaria
S
,
Craig
T
.
Assessment of hereditary angioedema treatment risks
.
Allergy Asthma Proc
.
2013
;
34
(
6
):
519
-
522
.
57.
Gandhi
PK
,
Gentry
WM
,
Bottorff
MB
.
Thrombotic events associated with C1 esterase inhibitor products in patients with hereditary angioedema: investigation from the United States Food and Drug Administration adverse event reporting system database
.
Pharmacotherapy
.
2012
;
32
(
10
):
902
-
909
.
58.
Taeuber
I
,
Weibel
S
,
Herrmann
E
, et al
.
Association of intravenous tranexamic acid with thromboembolic events and mortality: a systematic review, meta-analysis, and meta-regression
.
JAMA Surg
.
2021
;
156
(
6
):
e210884
.
59.
Farkas
H
,
Kőhalmi
KV
,
Veszeli
N
,
Zotter
Z
,
Várnai
K
,
Varga
L
.
Risk of thromboembolism in patients with hereditary angioedema treated with plasma-derived C1-inhibitor
.
Allergy Asthma Proc
.
2016
;
37
(
2
):
164
-
170
.
60.
Grover
SP
,
Snir
O
,
Hindberg
K
, et al
.
High plasma levels of C1-inhibitor are associated with lower risk of future venous thromboembolism
.
J Thromb Haemost
.
2023
;
21
(
7
):
1849
-
1860
.
61.
Yuan
S
,
Xu
F
,
Zhang
H
, et al
.
Proteomic insights into modifiable risk of venous thromboembolism and cardiovascular comorbidities
.
J Thromb Haemost
.
2024;22(3):738-748
.
62.
Preis
M
,
Hirsch
J
,
Kotler
A
, et al
.
Factor XI deficiency is associated with lower risk for cardiovascular and venous thromboembolism events
.
Blood
.
2017
;
129
(
9
):
1210
-
1215
.
63.
Salomon
O
,
Steinberg
DM
,
Zucker
M
,
Varon
D
,
Zivelin
A
,
Seligsohn
U
.
Patients with severe factor XI deficiency have a reduced incidence of deep-vein thrombosis
.
Thromb Haemost
.
2011
;
105
(
2
):
269
-
273
.
64.
Meijers
JC
,
Tekelenburg
WL
,
Bouma
BN
,
Bertina
RM
,
Rosendaal
FR
.
High levels of coagulation factor XI as a risk factor for venous thrombosis
.
N Engl J Med
.
2000
;
342
(
10
):
696
-
701
.
65.
Cushman
M
,
O'Meara
ES
,
Folsom
AR
,
Heckbert
SR
.
Coagulation factors IX through XIII and the risk of future venous thrombosis: the Longitudinal Investigation of Thromboembolism Etiology
.
Blood
.
2009
;
114
(
14
):
2878
-
2883
.
66.
Elsheikh
S
,
Tidbury
N
,
Lip
GYH
.
A review of emerging factor XI inhibitors
.
Expert Opin Emerg Drugs
.
2023
;
28
(
1
):
43
-
53
.
67.
Nørgaard
I
,
Nielsen
SF
,
Nordestgaard
BG
.
Complement C3 and high risk of venous thromboembolism: 80517 individuals from the Copenhagen General Population Study
.
Clin Chem
.
2016
;
62
(
3
):
525
-
534
.
68.
Skjeflo
EW
,
Brækkan
SK
,
Ludviksen
JK
, et al
.
Elevated plasma concentration of complement factor C5 is associated with risk of future venous thromboembolism
.
Blood
.
2021
;
138
(
21
):
2129
-
2137
.
69.
Damoah
CE
,
Snir
O
,
Hindberg
K
, et al
.
High levels of complement activating enzyme MASP-2 are associated with the risk of future incident venous thromboembolism
.
Arterioscler Thromb Vasc Biol
.
2022
;
42
(
9
):
1186
-
1197
.
70.
Skjeflo
EW
,
Evensen
LH
,
Jensen
SB
, et al
.
Complement factors B, D, C3bBbP and risk of future venous thromboembolism
.
Clin Immunol
.
2023
;
249
:
109278
.
71.
Aabom
A
,
Bygum
A
,
Koch
C
.
Complement factor C4 activation in patients with hereditary angioedema
.
Clin Biochem
.
2017
;
50
(
15
):
816
-
821
.
72.
Lander
ES
,
Schork
NJ
.
Genetic dissection of complex traits
.
Science
.
1994
;
265
(
5181
):
2037
-
2048
.
73.
Patel
H
,
Sun
H
,
Hussain
AN
,
Vakde
T
.
Advances in the diagnosis of venous thromboembolism: a literature review
.
Diagnostics (Basel)
.
2020
;
10
(
6
):
365
.
74.
Zöller
B
,
Li
X
,
Sundquist
J
,
Sundquist
K
.
Socioeconomic and occupational risk factors for venous thromboembolism in Sweden: a nationwide epidemiological study
.
Thromb Res
.
2012
;
129
(
5
):
577
-
582
.
75.
Winkleby
MA
,
Jatulis
DE
,
Frank
E
,
Fortmann
SP
.
Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease
.
Am J Public Health
.
1992
;
82
(
6
):
816
-
820
.
76.
Zöller
B
,
Li
X
,
Sundquist
J
,
Sundquist
K
.
Risk of venous thromboembolism in first- and second-generation immigrants in Sweden
.
Eur J Intern Med
.
2012
;
23
(
1
):
40
-
47
.
77.
Weinstock
MA
,
Brodsky
GL
.
Bias in the assessment of family history of melanoma and its association with dysplastic nevi in a case-control study
.
J Clin Epidemiol
.
1998
;
51
(
12
):
1299
-
1303
.
78.
Wettermark
B
,
Hammar
N
,
Fored
CM
, et al
.
The new Swedish Prescribed Drug Register--opportunities for pharmacoepidemiological research and experience from the first six months
.
Pharmacoepidemiol Drug Saf
.
2007
;
16
(
7
):
726
-
735
.
You do not currently have access to this content.
Sign in via your Institution