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Hypercoagulable state

Last reviewed: 6 Nov 2023
Last updated: 10 Feb 2023



History and exam

Key diagnostic factors

  • calf swelling
  • pain or tenderness along deep venous system
  • chest pain
  • tachypnea
  • breathlessness
  • hypotension
  • tachycardia
More key diagnostic factors

Other diagnostic factors

  • family history of venous thromboembolism (VTE)
Other diagnostic factors

Risk factors

  • history of unprovoked venous thromboembolism
  • increasing age
  • pregnancy/postpartum
  • obesity
  • smoking
  • malignancy
  • acute inflammatory state
  • antiphospholipid antibodies (aPLs)
  • myeloproliferative disorders
  • nephrotic syndrome
  • Behcet disease
  • HIV infection
  • disseminated intravascular coagulation
  • paroxysmal nocturnal hemoglobinuria
  • heparin-induced thrombocytopenia
  • estrogen-containing oral birth control pill/hormone replacement therapy/selective estrogen receptor modulator therapy
  • chemotherapy
  • surgery
  • long-haul flight (>4 hours)
  • antithrombin deficiency
  • protein C deficiency
  • protein S deficiency
  • plasminogen deficiency
  • elevated fibrinogen
  • dysfibrinogenemia
  • factor V Leiden
  • prothrombin gene mutation (G-20210-A; also referred to as F2 c.*97G>A variant)
  • elevated factor VIII levels (>150 U/L)
  • elevated levels of factor IX or XI
  • hyperhomocysteinemia
  • sickle cell disease
  • elevated levels of thrombin-activatable fibrinolysis inhibitor (TAFI)
More risk factors

Diagnostic investigations

1st investigations to order

  • CBC
  • peripheral blood smear
  • activated partial thromboplastin time (aPTT)
  • fibrinogen
  • prothrombin time (PT)
  • D-dimer
  • serum albumin
  • serum creatinine
  • serum cholesterol
  • serum triglycerides
More 1st investigations to order

Investigations to consider

  • heritable thrombophilia test
  • polymerase chain reaction (PCR) for factor V Leiden
  • antiphospholipid antibodies (lupus anticoagulant, anticardiolipin antibodies, anti-beta-2 glycoprotein 1 antibodies)
  • homocysteine level
  • factor VIII level
  • myeloproliferative neoplasm panel
  • flow cytometry for paroxysmal nocturnal hemoglobinuria
  • heparin-induced thrombocytopenia (HIT) test
  • chest x-ray
  • abdominal CT
  • abdominal ultrasound
  • tumor markers
  • 24-hour urine collection for protein, or spot urine for protein/creatinine ratio
More investigations to consider

Treatment algorithm


nonpregnant: no cancer and with an acute medical illness

nonpregnant: with cancer

nonpregnant: undergoing nonorthopedic surgery

nonpregnant: undergoing orthopedic surgery

nonpregnant with major trauma




Lara N. Roberts, MBBS, MD (Res), FRCP, FRCPath
Lara N. Roberts

Consultant Haematologist

King's Thrombosis Centre

King's College Hospital




LNR declares that she has no competing interests.

Roopen Arya, BMBCh (Oxon), MA, PhD, FRCP, FRCPath
Roopen Arya

Professor of Thrombosis and Haemostasis

King's Thrombosis Centre

King's College NHS Foundation Trust




RA declares that he has no competing interests.

Peer reviewers

Beverly Hunt, FRCP, FRCPath, MD

Professor of Thrombosis & Haemostasis

King's College


Departments of Haematology, Pathology & Rheumatology

Lead in Blood Sciences

Guy's & St Thomas' NHS Foundation Trust




BH declares that she has no competing interests.

Per Morten Sandset, MD, PhD

Senior Consultant and Head of Department

Oslo University Hospital Ullevål

Department of Hematology

Professor in Hematology

University of Oslo




PMS declares that he has no competing interests.

Michael Bromberg, MD, PhD

Associate Professor

Director of Hematologic Malignancies

Medicine and Pharmacology

Temple University School of Medicine




MB declares that he has no competing interests.

  • Hypercoagulable state images
  • Guidelines

    • 2022 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer, including patients with COVID-19
    • NCCN clinical practice guidelines in oncology: cancer-associated venous thromboembolic disease
    More Guidelines
  • Patient leaflets

    Deep vein thrombosis

    Sickle cell disease

    More Patient leaflets
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