101
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Schotte H, Becker H, Domschke W, Gaubitz M. [Cardiovascular monitoring of patients with systemic lupus erythematosus]. Z Rheumatol 2005; 64:564-75. [PMID: 16328762 DOI: 10.1007/s00393-005-0668-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2004] [Accepted: 10/05/2004] [Indexed: 11/28/2022]
Abstract
Accelerated atherosclerotic cardiovascular disease is increasingly recognized as a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Cardiac manifestations of SLE are frequent and can involve almost all components of the heart. Pulmonary hypertension often develops during the course of SLE. The high incidence of cardiovascular complications may justify a screening of SLE patients in order to ensure early diagnosis and therapy. Results of diagnostic procedures that detect coronary insufficiency, surrogates of atherosclerotic burden and echocardiographic findings are often abnormal in SLE. However, evidence to support a routine screening for cardiovascular disease is currently not available. Therefore, based on the recommendations that have been proposed for other conditions associated with cardiovascular disease, we suggest assessment of risk factors and the performance of echocardiography at least annually in asymptomatic SLE patients. If two or more risk factors are present, an exercise ECG is recommended. The benefit, however, of screening SLE patients for cardiovascular disease has to be confirmed in prospective studies.
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Affiliation(s)
- H Schotte
- Medizinische Klinik und Poliklinik B, Universitätsklinikum Münster, Albert-Schweitzer-Str. 33, 48129 Münster, Germany.
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102
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Amigo-Castañeda MC. [Antiphospholipid syndrome treatment, to whom, when and how long?]. REUMATOLOGIA CLINICA 2005; 1 Suppl 2:S52-S58. [PMID: 21794291 DOI: 10.1016/s1699-258x(05)72773-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- M C Amigo-Castañeda
- Reumatóloga. Instituto Nacional de Cardiología Ignacio Chávez. Profesora de curso de posgrado. Universidad Nacional Autónoma de México. Investigadora Nacional. Miembro de la Academia Nacional de Medicina. México DF. México
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103
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Cederholm A, Frostegård J. Annexin A5 in cardiovascular disease and systemic lupus erythematosus. Immunobiology 2005; 210:761-8. [PMID: 16325495 DOI: 10.1016/j.imbio.2005.10.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2005] [Accepted: 08/30/2005] [Indexed: 11/18/2022]
Abstract
Atherosclerosis, a major cause of disease and death from cardiovascular disease (CVD), is an inflammatory disease characterized by T cell and monocyte/macrophage infiltration in the intima of large arteries. During recent years and with improved treatment of acute disease manifestations, it has become clear that the risk of CVD is very high in systemic lupus erythematosus (SLE), often considered a prototypic autoimmune disease. A combination of traditional and non-traditional risk factors, including dyslipidemia, inflammation, antiphospholipid antibodies (aPL) and lipid oxidation are related to CVD in SLE. aPL are highly thrombogenic, and possible mechanisms include direct effects of aPL on endothelial and other cells, and interference with coagulation reactions. More than a thousand proteins of the annexin-superfamily are expressed in eukaryotes. Annexins are ubiquitous, highly conserved, predominantly intracellular proteins, widely distributed in tissues. Annexin A5 (ANXA5) is an important member of the annexin family due to its antithrombotic properties. These are believed to be caused by it forming a two-dimensional protective shield, covering exposed potentially thrombogenic cell surfaces. Recently, ANXA5 has been implicated in SLE since aPL interfere with ANXA5 binding to placental trophoblasts, causing microthrombosis and miscarriage, a rather common complication in SLE. We recently demonstrated that ANXA5 may play a role in CVD and is abundant in late-stage atherosclerotic lesions. Sera from SLE-patients with a history of CVD inhibited ANXA5 binding to endothelium, caused by IgG antibodies, to a significant degree aPL. This review will focus on potential involvement of ANXA5 in pathogenesis of CVD, particularly caused by underlying atherosclerosis and atherothrombosis.
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Affiliation(s)
- Anna Cederholm
- Center for Infectious Medicine and Unit of Rheumatology, F59, Department of Medicine, Karolinska University Hospital, Huddinge, S-141 86 Stockholm, Sweden.
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104
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Bruce IN. ‘Not only…but also’: factors that contribute to accelerated atherosclerosis and premature coronary heart disease in systemic lupus erythematosus. Rheumatology (Oxford) 2005; 44:1492-502. [PMID: 16234277 DOI: 10.1093/rheumatology/kei142] [Citation(s) in RCA: 191] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Premature coronary heart disease (CHD) has emerged as a major cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Overall SLE patients have a 5-6-fold increased risk of CHD and this excess risk is especially pronounced in younger women where the excess risk may be >50-fold. Studies from our group and others have also demonstrated that SLE patients have a higher prevalence of subclinical atherosclerosis compared with controls, with approximately 30% having evidence of subclinical involvement. It is important to consider what factors may underlie this excess risk. We have found that certain 'classic' risk factors, i.e. hypertension and diabetes mellitus, are more prevalent in SLE and that persistent hypercholesterolaemia independently predicts patients who will develop CHD. These risk factors alone do not completely explain the excess risk observed, and after adjusting for classic risk factors SLE remains independently associated with both clinical and subclinical outcomes. Certain other metabolic changes also occur more frequently in SLE, namely premature menopause, renal impairment, high triglycerides and higher plasma homocysteine. In addition, insulin resistance is more pronounced in patients with SLE, and approximately 18% have the metabolic syndrome. It is also increasingly accepted that atherosclerosis is a chronic inflammatory condition, and in SLE systemic complement activation as well as immune complex formation can result in changes that promote the development of atheroma. Similarly, autoantibody production, especially antibodies directed against lipoprotein subtypes and those in the antiphospholipid (APLA) family, are gaining increasing attention. The role of the latter are particularly controversial as different subtypes have been shown to both promote and protect against atherogenesis. In a study looking at carotid plaque in SLE, we found that APLA was independently associated with the presence of plaque; this study also found that patients with plaque had higher white cell counts, suggesting ongoing chronic inflammation. We have also noted a negative correlation between activation of transforming growth factor beta-1 and carotid intima-medial thickness. This cytokine, which is known to be a potent anti-inflammatory molecule, has also been shown to be protective against atherogenesis. With regard to therapy, steroids may be a true double-edged sword, with low doses exerting a beneficial anti-inflammatory role whereas higher doses may be detrimental through exacerbation of metabolic risk factors. In contrast, we have found that antimalarials have a beneficial effect on lipids especially when co-prescribed with steroids, and this, along with anti-inflammatory and proposed antiplatelet effects, may confer protection against CHD in lupus. The risk of premature CHD in SLE is therefore mediated by a number of factors that involve not only classic risk factors but also a range of factors associated with SLE itself. Preventative strategies will therefore need to address all potential risk factors of relevance. A more through understanding of the interplay between autoimmunity and atherogenesis should be possible by the study of SLE, and this may not only benefit lupus patients but also may have implications for our understanding of atherosclerosis in general.
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Affiliation(s)
- I N Bruce
- The University of Manchester, Rheumatism Research Centre, Central Manchester and Manchester Children's University Hospital Trust, Oxford Road, Manchester M13 9WL, UK.
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105
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Mattu A, Petrini J, Swencki S, Chaudhari C, Brady WJ. Premature atherosclerosis and acute coronary syndrome in systemic lupus erythematosus. Am J Emerg Med 2005; 23:696-703. [PMID: 16140181 DOI: 10.1016/j.ajem.2004.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2004] [Accepted: 12/22/2004] [Indexed: 10/25/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a vasculitic disorder with potential for multisystem organ dysfunction. Among the organ systems affected is the cardiovascular system. Patients with SLE are prone to premature atherosclerosis; this premature atherosclerosis places the patient at risk for myocardial infarction with onset at a relatively young age. We present 4 patients with SLE who experienced myocardial infarction; these patients also experienced diagnostic and treatment delays because of their relatively young age at presentation. Relevant pathophysiology and diagnostic strategies are discussed.
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Affiliation(s)
- Amal Mattu
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
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106
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Haque S, Bruce IN. Therapy Insight: systemic lupus erythematosus as a risk factor for cardiovascular disease. ACTA ACUST UNITED AC 2005; 2:423-30. [PMID: 16119705 DOI: 10.1038/ncpcardio0270] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease with a strong female predilection. Cardiovascular morbidity and mortality is a frequent complication, particularly in females aged 35-44 years, in whom the risk of myocardial infarction is raised 50-fold. The mechanisms underlying this increased risk are not fully understood. Certain traditional risk factors, such as hypertension and diabetes mellitus, are more common in SLE patients than in the general population. These factors do not, however, completely account for the increased cardiovascular risk; factors such as renal impairment, increased homocysteine levels and early menopause probably have a role. In addition, several factors more specifically related to lupus are proposed to be of importance, including chronic inflammation, antiphospholipid antibodies and therapy, especially corticosteroid use. Thus, we need to be proactive in our approach to risk-factor management in SLE patients. Here, we propose that, like diabetes mellitus, SLE should be considered a coronary heart disease equivalent condition for baseline risk and that assessment of cardiovascular risk should be done routinely. In addition to lifestyle modifications, blood pressure and cholesterol levels should be stringently controlled, and administration of aspirin should be considered in selected patients. The increased use of certain interventions, such as statins, also needs to be more widely investigated in this population.
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Affiliation(s)
- Sahena Haque
- North-West England Deanery Rheumatology Training Programme, UK
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107
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Wahbi K, Salengro E, Galicier L, Guillevin L, Spaulding C, Weber S, Meune C. [Acute myocardial infarction complicating primary antiphospholipid syndrome after aspirin and steroids withdrawal]. Ann Cardiol Angeiol (Paris) 2005; 54:212-5. [PMID: 16104622 DOI: 10.1016/j.ancard.2005.05.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
A 24-year-old woman, with known antiphospholid antibodies (APS), presented with an acute myocardial infarction (AMI) that occurred three months after delivery. No risk factors for arteriosclerosis and no past history of arterial/venous thrombosis were noted. During pregnancy, aspirin prophylaxis was prescribed and followed by steroids after caesarian section. Steroids withdrawal was followed by AMI. Immediate coronary angiography revealed thrombotic occlusion of the left descending coronary artery; PTCA was successfully performed. She was discharged with an antiplatelet and anticoagulant regimen. No recurrent coronary event occurred during follow-up.
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Affiliation(s)
- K Wahbi
- Service de cardiologie, hôpital Cochin, université René-Descartes, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
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108
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Montes R, Hurtado V, Alonso A, Foco L, Zonzin P, Mannucci PM, Hermida J. Autoantibodies against the endothelial receptor of protein C are associated with acute myocardial infarction in young women. J Thromb Haemost 2005; 3:1454-8. [PMID: 15978102 DOI: 10.1111/j.1538-7836.2005.01297.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute myocardial infarction (AMI) is rare among young women. The search for unknown risk factors is warranted. Endothelial protein C receptor (EPCR) is largely present at the endothelial surface of large arteries. No studies about association of anti-EPCR autoantibodies (anti-EPCR) with AMI are available. METHODS Plasma IgA, IgM and IgG anti-EPCR levels were measured by enzyme-linked immunosorbent assay in 165 women younger than 45 years who survived a first AMI and 165 healthy women, matched by age and geographical origin. RESULTS Using the 90th percentile of IgA anti-EPCR in the control group, IgA anti-EPCR were independently associated with AMI after adjustment for cardiovascular risk factors (OR 5.1; 95% CI 1.7-15.6; P = 0.004). The risk apparently conferred by IgA anti-EPCR increased dose-dependently (P for trend =0.0002). IgM anti-EPCR were less consistently associated with AMI: a significant increase in the risk was found when women above the 90th percentile were compared with those in the lowest quartile (OR 3.6; 95% CI 1.2-11.5; P = 0.03). IgG anti-EPCR were similar in patients and controls. A total of 145 patients underwent coronary arteriography. IgA or IgM anti-EPCR were not different among patients with different degrees of atherosclerotic lesion (anova, P = 0.77 and 0.24, respectively). CONCLUSIONS High levels of IgA and, to a lesser extent, IgM anti-EPCR, are associated with AMI in young women.
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Affiliation(s)
- R Montes
- Haematology Department and the Division of Cardiovascular Pathophysiology, Laboratory of Thrombosis and Haemostasis, Clínica Universitaria/School of Medicine, Applied Medical Research Centre, Pamplona, Spain.
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109
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Zampieri S, Iaccarino L, Ghirardello A, Tarricone E, Arienti S, Sarzi-Puttini P, Gambari P, Doria A. Systemic Lupus Erythematosus, Atherosclerosis, and Autoantibodies. Ann N Y Acad Sci 2005; 1051:351-61. [PMID: 16126977 DOI: 10.1196/annals.1361.077] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Over the past number of years numerous data have been published regarding increased atherosclerosis in patients with systemic lupus erythematosus (SLE), and it has been shown that premature or accelerated atherosclerosis is an important cause of morbidity and mortality in these patients. Besides the traditional risk factors for cardiovascular disease, the association between SLE and atherosclerosis can be attributed to additional risk factors closely related to inflammation and autoimmunity. In particular, several autoantibodies and their respective autoantigens have been identified as possible factors in the development and progression of the atherosclerotic process in SLE. The understanding of SLE-related risk factors for enhanced atherosclerosis could shed more light on disease mechanisms, leading to new therapeutic strategies for the treatment of cardiovascular diseases in SLE patients. In the present paper, the biological characteristics and possible pathogenetic role of the oxidized low-density lipoprotein (oxLDL) and anti-oxLDL, beta(2)-glycoprotein I (beta(2)GPI) and anti-beta(2)GPI, and heat-shock protein 60/65 (HSP60/65) and anti-HSP60/65 autoantibody systems are summarized.
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Affiliation(s)
- Sandra Zampieri
- Division of Rheumatology, University of Padova, Via Giustiniani 2, I-35128 Padua, Italy
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110
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Abstract
Antiphospholipid syndrome spans many medical disciplines. Classic criteria include the presence of anticardiolipin antibody or lupus anticoagulant with typical complications of thrombosis or pregnancy loss. Other common associated manifestations include livedo reticularis, thrombocytopenia, valvular heart disease, and nephropathy with renal insufficiency, hypertension, and proteinuria. Treatment of serious complications with anticoagulation is standard; generally warfarin for thrombosis and aspirin/heparin for pregnancy prophylaxis. Detailed recommendations regarding precise intensity and duration of anticoagulation are still a subject of debate.
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Affiliation(s)
- Lisa R Sammaritano
- Weill Medical College of Cornell University, Hospital of Special Surgery, New York, NY 10021, USA.
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111
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Abstract
Atherosclerosis is an inflammatory disease and the major cause of cardiovascular disease (CVD) in general. Atherosclerotic plaques are characterized by the presence of activated immune competent cells, but antigens and underlying mechanisms causing this immune activation are not well defined. During recent years and with improved treatment of acute disease manifestations, it has become clear that the risk of CVD is very high in a prototypic autoimmune disease, systemic lupus erythematosus (SLE). SLE-related CVD and atherosclerosis are important clinical problems but may in addition also shed light on how immune reactions are related to premature atherosclerosis and atherothrombosis. A combination of traditional and nontraditional risk factors, including dyslipidaemia (and to a varying degree hypertension, diabetes and smoking), inflammation, antiphospholipid antibodies (aPL) and lipid oxidation are related to CVD in SLE. Premature atherosclerosis in some form leading to atherothrombosis is likely to be a major underlying mechanism, though distinctive features if any, of SLE-related atherosclerosis when compared with 'normal' atherosclerosis are not clear. One interesting possibility is that factors such as inflammation or aPL make atherosclerotic lesions in autoimmune disease more prone to rupture than in 'normal' atherosclerosis. Whether premature atherosclerosis is a general feature of SLE or only affects a subgroup of patients remains to be demonstrated. Treatment of SLE patients should also include a close monitoring of traditional risk factors for CVD. In addition, attention should also be paid to nontraditional risk factors such as inflammation and SLE-related factors such as aPL. Hopefully novel therapeutic principles will be developed that target the causes of the inflammation and immune reactions present in atherosclerotic lesions.
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Affiliation(s)
- J Frostegård
- Department of Medicine, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden.
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112
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Forastiero R, Martinuzzo M, Pombo G, Puente D, Rossi A, Celebrin L, Bonaccorso S, Aversa L. A prospective study of antibodies to beta2-glycoprotein I and prothrombin, and risk of thrombosis. J Thromb Haemost 2005; 3:1231-8. [PMID: 15946213 DOI: 10.1111/j.1538-7836.2005.01295.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Antiphospholipid syndrome (APS) is a clinical autoimmune disorder characterized by thrombosis/pregnancy morbidity associated with the persistence of lupus anticoagulant (LA) and/or anticardiolipin (aCL) antibodies. We assessed the contribution of antibodies to beta2-glycoprotein I (anti-beta2GPI) and prothrombin (anti-PT) to the thrombotic risk in a cohort of 194 consecutive patients with persistent LA and/or aCL. Median follow-up was 45 months. A total of 39 patients (20.1%) had one documented episode of thrombosis during follow-up. Eleven of these patients had no previous thrombosis before enrollment in the study and 28 had recurrences of thrombosis. There were 21 venous and 18 arterial thrombotic events and the overall incidence of thrombosis was 5.6% per patient-year. After multivariate analysis, the male sex (P = 0.025), a previous thrombosis (P < 0.01), the presence of anti-beta2GPI (P = 0.001), and the presence of anti-PT (P = 0.03) remained as independent risk factors for recurrent thrombosis. Only IgG anti-beta2GPI and anti-PT were associated with an increased risk of thrombosis (P < 0.01 and P = 0.005). Patients testing positive for anti-beta2GPI had a higher rate of thrombosis than did antiphospholipid patients without anti-beta2GPI (8.0% vs. 3.1% per patient-year). Similarly, a higher rate of thrombosis was found in patients with positive anti-PT compared with patients without anti-PT (8.6% vs. 3.5% per patient-year). Considering only the group of 142 LA positive patients, the highest incidence of thrombosis was found in LA patients positive for both anti-beta2GPI and anti-PT (8.4% per patient-year). In conclusion, the presence of IgG anti-beta2GPI and anti-PT in patients with LA and/or aCL and mainly in those with LA predicts a higher risk of thromboembolic events.
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Affiliation(s)
- R Forastiero
- Division of Hematology, Thrombosis and Hemostasis, Institute of Cardiology and Cardiovascular Surgery, Favaloro Foundation, Favaloro University, Buenos Aires, Argentina.
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113
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Kahles T, Humpich M, Steinmetz H, Sitzer M, Lindhoff-Last E. Phosphatidylserine IgG and beta-2-glycoprotein I IgA antibodies may be a risk factor for ischaemic stroke. Rheumatology (Oxford) 2005; 44:1161-5. [PMID: 15927998 DOI: 10.1093/rheumatology/keh698] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Antiphospholipid antibodies (APLA) are established risk factors for venous thrombosis but their role in the pathogenesis of cerebral ischaemia is unclear. The purpose of the present study was to evaluate the relevance of various APLA in patients with cryptogenic stroke (group A, n = 21) and determined causes of stroke (group B, n = 104) according to the TOAST classification in comparison with healthy volunteers without any thrombotic or ischaemic event in their history (group C, n = 84). METHODS Median ages were 52 yr (A), 60 yr (B) and 51 yr (C). Blood samples were tested for lupus anticoagulant (LA) using phospholipid-dependent coagulation tests (activated partial thromboplastin time, diluted Russell viper venom time). Confirmatory tests were performed if necessary. Furthermore, we assessed the presence of specific APLA and their antibody subclasses against cardiolipin (AclA), phosphatidylserine (ApsA), phosphatidylinositol (ApiA) and beta-2-glycoprotein I (Abeta2A) using enzyme-linked immunosorbent assay. RESULTS For ApsA IgG we found a significantly higher prevalence in stroke patients (57.7%) compared with normal subjects (4.8%; P < 0.001). Similarly, Abeta2A IgA was significantly more prevalent in stroke patients (20.8%) in comparison with normals (3.6%; P < 0.001). For all other APLAs tested, no significant differences emerged after adjustment for multiple comparisons. We did not find significant differences between stroke subtypes for any APLA. CONCLUSION The results of this study suggest a relevant role for antiphosphatidylserine IgG and anti-beta2-glycoprotein I IgA in stroke aetiology.
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Affiliation(s)
- T Kahles
- Department of Neurology, University Hospital, JW Goethe University Frankfurt, Germany.
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114
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Jiménez S, García-Criado MA, Tàssies D, Reverter JC, Cervera R, Gilabert MR, Zambón D, Ros E, Bru C, Font J. Preclinical vascular disease in systemic lupus erythematosus and primary antiphospholipid syndrome. Rheumatology (Oxford) 2005; 44:756-61. [PMID: 15757967 DOI: 10.1093/rheumatology/keh581] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To determine the prevalence of preclinical vascular disease and associated risk factors in patients with systemic lupus erythematosus (SLE) or primary antiphospholipid syndrome (APS). METHODS We consecutively studied 70 SLE patients and 25 primary APS patients without clinical coronary artery disease. The control group included 40 healthy women. Carotid ultrasound was performed and the intima-media wall thickness (IMT) and presence of plaque was investigated in all patients and controls. Traditional vascular risk factors and SLE-disease and treatment related factors were also analysed. RESULTS SLE patients had a higher prevalence of traditional atherosclerosis risk factors: hypertension (P<0.005) and dyslipidaemia (P<0.05) and higher levels of total cholesterol (P = 0.03), triglycerides (P = 0.004) and apolipoprotein B (P = 0.04). The prevalence of carotid plaque was higher and appeared earlier in SLE patients than in the primary APS patients or controls (P<0.001). The IMT was similar in the three groups. SLE patients with secondary APS had a higher prevalence of carotid plaque than patients with primary APS (37.5% vs 8%, P = 0.03). The presence of plaque in SLE patients was associated with a higher SLICC score (2.40 +/- 1.78 vs 1.02 +/- 1.18, P = 0.002), higher ECLAM score (3.10 +/- 2.32 vs 1.84 +/- 1.59, P = 0.02) and older age (47.3 +/- 8.44 vs 37.38 +/- 11.28, P = 0.003) at the time of carotid ultrasound study. CONCLUSION Plaque prevalence in patients with primary APS is similar to that of controls and inferior to that of SLE patients with secondary APS. SLE patients have a high prevalence of early carotid atherosclerosis that is associated with cumulative disease damage and disease activity.
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Affiliation(s)
- Sònia Jiménez
- Servicio de Enfermedades Autoinmunes, ICMiD, Hospital Clínic, C/Villaroel 170, 08036 Barcelona, Spain
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115
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Napoli C, Palinski W. Neurodegenerative diseases: insights into pathogenic mechanisms from atherosclerosis. Neurobiol Aging 2005; 26:293-302. [PMID: 15639306 DOI: 10.1016/j.neurobiolaging.2004.02.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2003] [Accepted: 02/23/2004] [Indexed: 10/26/2022]
Abstract
Increasing evidence indicates that several pathogenic mechanisms promoting atherosclerosis are also involved in neurodegenerative diseases, and that insight into the factors determining the susceptibility to, and long-term progression of, atherosclerosis may be of interest for the evolution of diseases such as Alzheimer's. Furthermore, atherosclerosis of intracranial arteries or thromboembolic consequences of atherosclerotic extracranial arteries are responsible for most ischemic events in the brain. Age-related changes of cerebrovascular atherosclerosis, and atherosclerosis in general, may therefore be important for stroke and neurodegenerative diseases affecting the elderly. In the following, pathogenic mechanism involving increased lipid peroxidation, oxidative stress, inflammation and immune responses, and fetal programming will be discussed in the context of cerebrovascular disease and aging.
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Affiliation(s)
- Claudio Napoli
- Department of Medicine 0682, University of California San Diego, 9500 Gilman Drive, MTF 110, La Jolla, CA 92093-0682, USA.
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116
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Frostegård J, Svenungsson E, Wu R, Gunnarsson I, Lundberg IE, Klareskog L, Hörkkö S, Witztum JL. Lipid peroxidation is enhanced in patients with systemic lupus erythematosus and is associated with arterial and renal disease manifestations. ACTA ACUST UNITED AC 2005; 52:192-200. [PMID: 15641060 DOI: 10.1002/art.20780] [Citation(s) in RCA: 178] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Cardiovascular disease with premature atherosclerosis is common in patients with systemic lupus erythematosus (SLE). We previously identified elevated levels of oxidized low-density lipoprotein (OxLDL) together with elevated levels of autoantibodies related to OxLDL as risk factors for cardiovascular disease in female patients with SLE. Autoantibodies to OxLDL are common in SLE and cross-react with anticardiolipin antibodies (aCL). We therefore hypothesized that lipid peroxidation is enhanced in patients with SLE in general. METHODS One hundred forty-seven female patients with SLE and 60 age- and sex-matched controls were compared. A monoclonal antibody to oxidized phospholipids, EO6, was used to determine oxidation epitopes on LDL. Anti-OxLDL and autoantibodies to malondialdehyde (MDA)-modified LDL, cardiolipin, and oxidized aCL were determined by chemiluminescence technique. RESULTS As determined by binding of EO6, patients with SLE had a higher level of oxidized phospholipids on LDL (P = 0.005) compared with controls. The level of OxLDL (e.g., oxidized phospholipid/apolipoprotein B) was associated with arterial disease (P = 0.006) and renal manifestations (P = 0.04). As reported previously, levels of aCL, autoantibodies to OxLDL, and autoantibodies to MDA-modified LDL were enhanced and were closely correlated in SLE. Anticardiolipin antibodies from these SLE patients recognized mainly oxidized forms of cardiolipin, indicating that antigenic epitopes on cardiolipin are related to lipid peroxidation in patients with SLE. CONCLUSION In general, patients with SLE (particularly those with cardiovascular disease) had more oxidized epitopes on LDL compared with controls. Furthermore, aCL in these patients recognized epitopes generated during lipid peroxidation. Thus, "neo" self antigens on lipoproteins, generated during oxidation, are present in SLE and may be of importance for the development of premature cardiovascular disease and possibly also for other autoimmune phenomena observed in SLE.
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Affiliation(s)
- Johan Frostegård
- Center for Infectious Medicine and Center for Metabolism and Endocrinology, Department of Medicine, Karolinska University Hospital, Huddinge, S-141 86 Stockholm, Sweden.
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117
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Segev A, Ellis MH, Segev F, Friedman Z, Reshef T, Sparkes JD, Tetro J, Pauzner H, David D. High prevalence of thrombophilia among young patients with myocardial infarction and few conventional risk factors. Int J Cardiol 2005; 98:421-4. [PMID: 15708174 DOI: 10.1016/j.ijcard.2003.10.057] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2003] [Revised: 10/15/2003] [Accepted: 10/25/2003] [Indexed: 11/17/2022]
Abstract
BACKGROUND Thrombophilia refers to series of acquired and inherited conditions that confer a tendency to thrombus formation. The exact relationship between thrombophilia and MI is not well established. OBJECTIVES To determine the prevalence of thrombophilia in young patients with their first MI and few conventional risk factors. METHODS We evaluated the baseline characteristics and the thrombophilia profile, including anti-cardiolipin antibodies, activated protein C resistance (APCR) with the factor V Leiden mutation, prothrombin G20210A mutation, protein C, protein S, and antithrombin-III levels, among 85 consecutive patients (<50 year old) who were admitted to CCU with their first MI. Patients were divided into two groups: group A-patients with < or =1 risk factor and group B-patients with > or =2 risk factors. RESULTS 92% were male and 55% with anterior wall MI. Overall, the risk factor profile was: smoking in 60%, hyperlipidemia in 42%, positive family history in 29%, hypertension in 18%, diabetes mellitus in 13%, and obesity in 8%. Forty-seven percent of patients had < or =1 risk factor (n=40, group A) and 53% had > or =2 risk factors (n=45, group B). The prevalence of the prothrombin mutation was 15% in group A compared to 7% in group B (p=0.12). APCR secondary to a heterozygous genotype of factor V Leiden mutation was found in 20% in group A compared to 2% in group B (p<0.01). Anti-cardiolipin antibodies were found in 16% in group A compared to 22% in group B (p=ns). Finally, we have found that the likelihood of identifying at least one thrombophilia marker was 50% in group A compared to 29% in group B (p=0.046). CONCLUSIONS The likelihood to detect at least one thrombophilia marker in young patients with MI and few conventional risk factors is significantly high. Thrombophilia may contribute to the development of MI in this specific group of young patients.
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Affiliation(s)
- Amit Segev
- Department of Cardiology, Meir General Hospital, Kfar-Saba, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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118
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Musuraca G, Imperadore F, Terraneo C, De Girolamo P, Cemin C, Bonmassari R, Vergara G. Successful treatment of post-exertion acute myocardial infarction by primary angioplasty and stenting in a patient with antiphospholipid antibody syndrome. Blood Coagul Fibrinolysis 2005; 15:95-8. [PMID: 15166950 DOI: 10.1097/00001721-200401000-00015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Antiphospholipid syndrome is a disorder characterized by arterial and venous thromboses, thrombocytopaenia and stroke. Acute myocardial infarction is rarely associated with this syndrome. The treatment of these patients is a clinical challenge. This report is about a patient with antiphospholipid syndrome presenting with an acute myocardial infarction after an exercise test. The infarct-related coronary artery was successfully revascularized by primary angioplasty and stenting without any major bleeding complications. We think that the physical exertion could have favoured acute coronary thrombosis in this particular setting.
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Affiliation(s)
- Gerardo Musuraca
- Division of Cardiology, S. Maria del Carmine Hospital, Rovereto (Trento), Italy.
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119
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Meroni PL, Riboldi P. Pathogenic mechanisms of antiphospholipid syndrome: a new autoimmune disease. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/j.ddmec.2004.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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120
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Oztürk MA, Haznedaroğlu IC, Turgut M, Göker H. Current debates in antiphospholipid syndrome: the acquired antibody-mediated thrombophilia. Clin Appl Thromb Hemost 2004; 10:89-126. [PMID: 15094931 DOI: 10.1177/107602960401000201] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Antiphospholipid (APL) syndrome is the most common form of acquired thrombophilia. It can cause significant morbidity and even mortality. The term "APL antibodies" represents a heterogeneous group of antibodies associated with this disorder. Currently no single assay can identify every APL antibody. Clinically relevant APL antibodies are mainly anticardiolipin antibodies (ACA) detected by solid phase enzyme-linked immunosorbent assay (ELISA) and lupus anticoagulants (LA) demonstrated by in vitro coagulation assay. However, there are some other antibodies associated with the APL syndrome (i.e., subgroup APL antibodies). ACAs, LAs, and subgroup APL antibodies represent intersecting, but non-identical, subsets of autoantibodies. Thus, those autoantibodies may coexist or may occur independently. Any organ system and any size of vessel can be affected during the clinical course of the disease. Therefore, the APL syndrome can manifest itself in a wide variety of clinical thrombotic features. Fetal loss and pregnancy morbidity represent a specific challenge. Despite tremendous advances in the understanding of the pathogenesis of APL syndrome during the past decade, the mainstay of management is still anticoagulation. However, there is no general agreement regarding the duration and intensity of anti-coagulant therapy. In this review, we focused on the current dilemmas and their present clarifications in the wide clinicopathologic spectrum of APL syndrome and APL antibody-related distinct pathologic conditions.
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Affiliation(s)
- M Akif Oztürk
- Gazi University School of Medicine Department of Rheumatology, Ankara, Turkey.
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121
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Ishikura K, Wada H, Kamikura Y, Hattori K, Fukuzawa T, Yamada N, Nakamura M, Nobori T, Nakano T. High prevalence of anti-prothrombin antibody in patients with deep vein thrombosis. Am J Hematol 2004; 76:338-42. [PMID: 15282665 DOI: 10.1002/ajh.20124] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The present study was designed to determine the prevalence of lupus anticoagulant (LA) antibody and several antibodies for antiphospholipid syndrome (APS) in patients with deep vein thrombosis (DVT)/pulmonary embolism (PE) (n = 48), cerebral thrombosis (CT, n = 30), systemic lupus erythematosus (SLE, n = 22), and idiopathic thrombocytopenic purpura (ITP, n = 30). The presence of antibodies was examined by using the respective ELISA kits. LA was positive in 38.6% of patients with DVT/PE, suggesting that LA is one of the most important risk factors in DVT/PE. The highest prevalence of anti-beta(2) glycoprotein I (beta(2)GPI) IgG was in CT and SLE, followed by DVT, and none in ITP and healthy volunteers (control, n = 40), suggesting that it is related to thrombosis, particularly arterial thrombosis. The highest prevalence of anti-prothrombin (aPT) IgG antibody was in DVT, followed by CT and SLE, and none in ITP and the control, suggesting that it is related to thrombosis, especially venous thrombosis. The highest prevalence of antiphospholipid (aPL) IgG was in DVT, CT, and SLE, but 0% in ITP and control. On the other hand, aPL IgM, anti-annexin V IgG, and anti-annexin V IgM were positive in patients both with and without thrombosis, suggesting that they are not related to thrombosis. Our results indicated that among the anti-phospholipid antibodies, LA is the most sensitive marker for APS while anti-beta(2)GPI IgG, aPT IgG, and aPL IgG are risk factors for thrombosis. In particular, aPT IgG is a significant marker for DVT/PE.
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Affiliation(s)
- Ken Ishikura
- First Department of Internal Medicine, Mie University School of Medicine, Tsu, Mie, Japan
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122
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Aydin Z, Bruijn JA, Vleming LJ. ARF and cerebral infarcts in a young woman. Am J Kidney Dis 2004; 44:179-83. [PMID: 15211451 DOI: 10.1053/j.ajkd.2003.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Zeynep Aydin
- Department of Internal Medicine, Leiden University Medical Centre, Leiden, The Netherlands.
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123
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Praticò D, Rokach J, Lawson J, FitzGerald GA. F2-isoprostanes as indices of lipid peroxidation in inflammatory diseases. Chem Phys Lipids 2004; 128:165-71. [PMID: 15037161 DOI: 10.1016/j.chemphyslip.2003.09.012] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Isoprostanes are a new class of lipids, isomers of conventional enzymatically derived prostaglandins, which are produced in vivo primarily by a free radical-catalyzed peroxidation of polyunsaturated fatty acids. F2-isoprostanes, isomers of the enzyme-derived prostaglandin F2alpha, are the most studied species. Because of their mechanisms of formation, specific structural features that distinguish them from other free radical-generated products and chemical stability, they provide a reliable index of the oxidative component of several diseases in vivo. Consistent data suggest that formation of F2-isoprostanes is indeed altered in a variety of clinical settings associated with inflammation and oxidant stress. Moreover, measurement of F2-isoprostanes might provide a sensitive biochemical basis of dose-selection in studies of natural and synthetic antioxidants.
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Affiliation(s)
- Domenico Praticò
- Center for Experimental Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, USA
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124
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Abstract
Antiphospholipid antibodies are associated with venous and arterial thrombo-occlusive events, including stroke. They are a heterogeneous family of antibodies that react to negatively charged membrane-bound phospholipids or phospholipid-protein complexes. Despite much progress in the past decade, the precise mechanisms by which they promote thrombosis remain unknown. Increased risk of initial, but perhaps not recurrent, stroke has been associated with their presence. Antithrombotic regimens have been the mainstay of treatment, but the ideal therapeutic approach remains to be defined. This paper reviews the history, definition, associations, and treatment of this complex entity.
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Affiliation(s)
- Stanley Tuhrim
- Department of Neurology, Box 1137, Mt. Sinai School of Medicine, 1 Gustave Levy Place, New York, NY 10029, USA.
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125
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Armitage JD, Homer-Vanniasinkam S, Lindsey NJ. The role of endothelial cell reactive antibodies in peripheral vascular disease. Autoimmun Rev 2004; 3:39-44. [PMID: 15003186 DOI: 10.1016/s1568-9972(03)00087-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2003] [Accepted: 06/24/2003] [Indexed: 11/25/2022]
Abstract
The mechanism by which a small but significant proportion of patients with peripheral vascular disease (PVD) rapidly progress to critical ischaemia is unclear. Both experimental and clinical data suggest a role for autoantibodies in the pathogenesis of atherosclerotic disease, particularly in the accelerated atherosclerosis seen in patients with systemic lupus erythematosus and the anti-phospholipid syndrome. This review examines the evidence for a role for endothelial cell reactive autoantibodies in PVD and the potential mechanisms by which these autoantibodies could contribute to the acceleration of atherosclerosis in a proportion of patients. The identification of such markers could lead to the identification of patients with PVD who are at risk of developing critical ischaemia and may warrant early and aggressive intervention.
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Affiliation(s)
- J D Armitage
- Vascular Surgical Unit, Leeds General Infirmary, Leeds LS1 3EX, UK
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126
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Wisløff F, Crowther M. Evidence-based treatment of the antiphospholipid syndrome. Thromb Res 2004; 114:75-81. [PMID: 15306148 DOI: 10.1016/j.thromres.2004.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2004] [Revised: 05/12/2004] [Accepted: 05/12/2004] [Indexed: 10/26/2022]
Affiliation(s)
- Finn Wisløff
- Hematological Research Laboratory, Department of Hematology, Ullevål University Hospital, Kirkeveien 166, 0407 Oslo, Norway.
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127
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Cockerill KA, Iverson GM, Jones DS, Linnik MD. Therapeutic Potential of Toleragens in the Management of Antiphospholipid Syndrome. BioDrugs 2004; 18:297-305. [PMID: 15377172 DOI: 10.2165/00063030-200418050-00002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Autoantibodies to beta2-glycoprotein I (beta2GPI) are believed to be the primary cause of coagulation abnormalities in patients with antiphospholipid syndrome (APS). Clinical features include a range of life-threatening thrombotic events and microangiopathies affecting multiple organ systems. Current standard of care relies on long-term, high-intensity anticoagulation and is associated with a high risk for serious bleeding events. The relation between autoantibodies and the pathophysiology of APS is not clearly understood, but numerous in vitro studies have characterized the effects of antiphospholipid autoantibodies on various components of the coagulation cascade, including tissue factor and the protein C pathway. The fine specificity of autoantibodies to beta2GPI is a subject of considerable debate; however, a body of evidence may offer resolution by integrating concepts of antibody affinity and assay sensitivity with carefully designed molecular studies. An investigational new therapy for APS is based on the approach that pathogenic antibodies may be reduced via depletion of circulating autoantibodies and induction of immune tolerance at the B-cell level. Preliminary results from a phase I/II clinical trial with LJP 1082, a B-cell toleragen, indicate the drug was well tolerated and may warrant further development for reduction of thrombotic events in patients with APS.
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128
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McClain MT, Arbuckle MR, Heinlen LD, Dennis GJ, Roebuck J, Rubertone MV, Harley JB, James JA. The prevalence, onset, and clinical significance of antiphospholipid antibodies prior to diagnosis of systemic lupus erythematosus. ACTA ACUST UNITED AC 2004; 50:1226-32. [PMID: 15077305 DOI: 10.1002/art.20120] [Citation(s) in RCA: 134] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine whether antiphospholipid antibodies (aPL) occur before the diagnosis of systemic lupus erythematosus (SLE) and before initial clotting events, and whether their presence early in the disease course influences clinical outcome. METHODS Serum samples obtained from 130 lupus patients before and after SLE diagnosis were screened for IgG and IgM aPL using an anticardiolipin (aCL) enzyme-linked immunosorbent assay. Medical records of all patients were carefully reviewed for data on the time of onset of SLE features meeting clinical criteria and on disease manifestations. RESULTS Twenty-four patients (18.5%) were positive for IgG and/or IgM aCL prior to SLE diagnosis. Anticardiolipin antibodies appeared from 7.6 years prior to SLE diagnosis to within the same month as SLE diagnosis, with a mean onset occurring 3.0 years before SLE diagnosis. Additionally, aCL presence early in the disease process seemed to predict a more severe clinical outcome; these patients eventually met an average of 6.1 of the 11 classification criteria for SLE, compared with 4.9 criteria for other patients (P < 0.001). The early aCL-positive population also had more frequent renal disease, central nervous system disease, thrombocytopenia, and clotting events. In this population, aCL preceded initial thrombotic events by a mean of 3.1 years. CONCLUSION Anticardiolipin antibodies in SLE patients tend to precede initial clotting events by several years. Furthermore, the presence of early, prediagnosis aPL seems to herald a more varied, severe clinical course with earlier onset in patients with SLE.
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Affiliation(s)
- Micah T McClain
- Oklahoma Medical Research Foundation and University of Oklahoma Health Sciences Center, Oklahoma City 73104, USA
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129
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Cervera R. Coronary and valvular syndromes and antiphospholipid antibodies. Thromb Res 2004; 114:501-7. [PMID: 15507284 DOI: 10.1016/j.thromres.2004.06.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2004] [Revised: 06/16/2004] [Accepted: 06/23/2004] [Indexed: 10/26/2022]
Abstract
Since the recognition of the antiphospholipid syndrome (APS), a large number of cardiac manifestations have been reported in association with these antibodies, including coronary artery and valvular disease, cardiomyopathy, and intracardiac thrombosis. Most of these manifestations are explicable on the basis of thrombotic lesions either in the coronary circulation or on the valves and may mimic other similar conditions, such as rheumatic fever or infectious endocarditis. The APS coagulopathy in these patients requires the careful and judicious use of appropriate antiaggregant and anticoagulant therapy. In this review article, the focus will be on the main cardiac features related to the presence of antiphospholipid antibodies (aPLs), which may be of interest to clinicians.
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Affiliation(s)
- Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Villarroel, 170, 08036 Barcelona, Catalonia, Spain.
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130
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Gottenberg JE, Roux S, Assayag P, Clerc D, Mariette X. Specific cardiomyopathy in lupus patients: report of three cases. Joint Bone Spine 2004; 71:66-9. [PMID: 14769525 DOI: 10.1016/s1297-319x(03)00101-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2002] [Accepted: 01/15/2003] [Indexed: 11/17/2022]
Abstract
Clinically important myocarditis is an unusual feature in patients with systemic lupus erythematosus (SLE). We report three consecutive lupus patients over a 1 year period who developed severe left ventricular dysfunction in the absence of coronary artery disease or hypertensive cardiomyopathy. Two of them had clinical and biological flare of the disease whereas the lupus was quiescent in the latter. Two of them had positive IgG anticardiolipin antibodies. High dose steroids were given in two patients; one of them also required cyclophosphamide on account of diffuse proliferative glomerulonephritis. Left ventricular function improved quickly and markedly in these two patients; one of them had recurrence of severe myocarditis at intervals of 6 years and was each time responsive to steroids. Lupus cardiomyopathy, a rare event in the course of SLE, can be related to the disease even in the absence of coronary artery disease or hypertensive cardiomyopathy. It may be improved by steroids and immunosuppressive therapy. Literature concerning this cardiac manifestation in lupus is reviewed.
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Affiliation(s)
- Jacques-Eric Gottenberg
- Rheumatology department, Hôpital de Bicêtre, (Assistance Publique-Hôpitaux de Paris [AP-HP]), 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre cedex, France
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131
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Brey RL, Chapman J, Levine SR, Ruiz-Irastorza G, Derksen RHWM, Khamashta M, Shoenfeld Y. Stroke and the antiphospholipid syndrome: consensus meeting Taormina 2002. Lupus 2003; 12:508-13. [PMID: 12892389 DOI: 10.1191/0961203303lu390oa] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ischaemic stroke is the only neurological manifestation accepted as a clinical diagnostic criterion for the antiphospholipid syndrome (APS). This association is reasonably well established in patients first diagnosed with APS but is less clear in randomly selected stroke patients who test positive on one occasion for antiphospholipid antibodies and who have no other evidence of systemic autoimmune disease. We propose a grading system that posits stroke to be definitely, likely or possibly associated with antiphospholipid antibodies (aPL). Further, there are limited prospective data to determine appropriate treatment. There is controversy as to whether the presence of aPL even increases risk of a recurrent stroke or other thromboembolic event, although data point to persistent medium-high titre aCL and/or LA as risk factors for recurrence. In the absence of data to guide clinicians on the best treatment, we cannot make strong recommnendations as to optimal therapy, nor can we propose clear consensus treatment guidelines.
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Affiliation(s)
- R L Brey
- Department of Medicine, Division of Neurology, University of Texas Health Science Center-San Antonio, Texas 78229-3900, USA.
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132
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Abstract
Recommendations for the management of thrombosis in the antiphospholipid antibody syndrome have been based largely on retrospective case series. Several clinical trials have been recently published on the management of thrombosis in general. Two clinical trials have specifically addressed thrombosis in antiphospholipid antibody syndrome, and one is underway. These new clinical trials have challenged the previous dogma of a target International Normalized Ratio of 3 to 4 ("high-intensity" warfarin).
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Affiliation(s)
- Michelle Petri
- Department of Medicine: Rheumatology, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7500, Baltimore, MD 21205, USA.
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133
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Sherer Y, Shoenfeld Y. Antiphospholipid antibodies: are they pro-atherogenic or an epiphenomenon of atherosclerosis? Immunobiology 2003; 207:13-6. [PMID: 12638897 DOI: 10.1078/0171-2985-00212] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Antiphospholipid antibodies are the hallmark of the antiphospholipid syndrome which is characterized by thrombosis. There are currently data supporting an association between these autoantibodies and atherosclerosis as well. Human studies suggest that anti-cardiolipin and anti-beta2-glycoprotein-I antibodies are elevated in patients having coronary artery disease compared with controls. Anti-cardiolipin antibodies are also associated with typical chest pain, significant coronary artery stenosis on angiography and prediction of myocardial infarction. Laboratory studies and murine models support the pro-atherogenic role of these autoantibodies, as they are involved in uptake of oxidized LDL into macrophages, and immunization of mice with them results in enhanced atherosclerosis. There is some evidence that high anti-beta2-glycoprotein-I antibodies can present a risk factor for atherosclerosis, but more epidemiological data are required in order to confirm whether the pro-atherogenic properties of anti-phospholipid antibodies signifies an independent risk factor for atherosclerosis and its complications.
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Affiliation(s)
- Yaniv Sherer
- Department of Medicine 'B' and Center of Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
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134
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Ducloux D, Bourrinet E, Motte G, Chalopin JM. Antiphospholipid antibodies as a risk factor for atherosclerotic events in renal transplant recipients. Kidney Int 2003; 64:1065-70. [PMID: 12911558 DOI: 10.1046/j.1523-1755.2003.00155.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Epidemiologic studies reported that antiphospholipid antibodies (APAs) were independent predictors of atherosclerotic events. We recently reported a high prevalence of APAs in renal transplant recipients. Nevertheless, the role of APAs on atherosclerotic events has not been prospectively studied in this high-risk population. METHODS Participants in the study were 324 consecutive renal transplant recipients. Patients were enrolled between January 1996 and May 1998 and followed up until June 2002. RESULTS The patients were followed for a mean duration of 62 +/- 26 months. Eighty seven (26.8%) patients exhibited APAs. We found a slight, but significant, correlation between total plasma homocysteine (tHcy) concentration and anticardiolipin (ACA) titers (r = 0.26; P = 0.036). Fifty six athersclerotic events (17.2%) occurred in 54 patients. Atherosclerotic events occurred more frequently in patients with APAs (33% vs. 9%; P = 0.0003) and ACAs levels were higher in patients who experienced atherosclerotic events (23.7 +/- 13.1 IU vs. 13.9 +/- 9.4 IU; P = 0.003). APAs were associated with an increased risk of atherosclerotic events (RR, 2.82; 95% CI, 1.17 to 5.31). Cox regression analysis also revealed that age above the median (RR, 5.21; 95% CI, 1.67 to 17.13), a previous history of cardiovascular disease (RR, 3.54; 95% CI, 1.57 to 10.43), hyperhomocysteinemia (RR, 4.01; 95% CI, 1.22 to 14.61), and current smoking (RR, 2.17; 95% CI, 1.01 to 6.72) were risk factors for atherosclerotic events. CONCLUSION The presence of APAs is an independent cardiovascular risk factor in renal transplant recipients. Prevention trials are necessary to assess the efficacy and safety of anticoagulation therapy in transplant patients with APAs.
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Affiliation(s)
- Didier Ducloux
- Department of Nephrology, Dialysis, and Renal Transplantation, University Hospital, Besançon, France.
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135
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136
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Abstract
An acute coronary syndrome (ACS) is the clinical manifestation of a thrombotic event occurring within a coronary artery narrowed by atherosclerosis. This atherothrombotic event is thought to occur following destabilizing changes within the atherosclerotic plaque, rendering it a surface on which thrombus can develop. The development and progression of this thrombus are determined by deleterious perturbations in the hemostatic equilibrium within the local environment of the plaque that favor thrombosis. Major risk factors for the development of atherosclerotic disease have been clearly established and are targets of aggressive modification in an effort to impede the development or slow the progression of disease. While conferring an increased risk for plaque development, these and other risk factors also establish a prothrombotic milieu within the microenvironment of the atherosclerotic plaque that favors thrombosis. This review seeks to address these traditional and emerging risk factors from the context of their pathologic effects on local hemostatic balance. Aggressive risk factor modification not only reduces atherosclerotic disease development and progression, but also ameliorates the prothrombotic state, and ultimately serves to reduce atherothrombotic events.
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Affiliation(s)
- Frederick L Ruberg
- Evans Department of Medicine, Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
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137
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Barshack I, Keren P, Goldberg I, Kopolovic J, Keren G, George J. Relation of preexisting anti-beta2GPI antibodies to infarct size in a rat model. Cardiovasc Pathol 2003; 12:195-201. [PMID: 12826288 DOI: 10.1016/s1054-8807(03)00056-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Anti-beta2-glycoprotein I (beta2GPI) antibodies (a subpopulation of antiphospholipid (aPL) antibodies) are associated with a procoagulant state in humans and with enhanced atherosclerosis in experimental animal models. Moreover, the presence of high titers of aPL antibodies in relatively young patients is associated with higher incidence of subsequent myocardial infarction. Herein, we evaluated the role of preexisting high levels of aPL antibodies in determining the size of the infarct induced by permanent ligation of the left anterior descending artery (LAD) in a rat model. METHODS AND RESULTS A total of 11 Wistar rats were immunized and boosted with 10 microg of the phospholipid binding protein -beta2GPI (a method commonly applied for induction of aPL antibodies). Rats in the control group (n=9) were immunized and boosted with a Freund's adjuvant. Upon development of high anti-beta2GPI antibodies levels, myocardial infarction was induced by ligation of the LAD coronary artery. Rats were sacrificed 7 days later, their lymph nodes were collected for evaluation of cellular immunity to beta2GPI and their hearts were removed for assessment of infarct size and for immunohistochemical stains for iNOS and TGF-beta. beta2GPI-immunized rats exhibited high levels of aPL antibodies (mean optical density of 1.3+/-0.3) as compared with the control group (mean optical density of 0.12+/-0.03; P<.0001). Cellular immunity to beta2GPI was also pronounced as evident by an increased thymidine uptake and by increased interferon gamma secretion by the lymph node cells from beta2GPI-immunized rats. Myocardial infarct size has shown a tendency to be increased in rats induced to develop anti-beta2GPI antibodies (mean size 23+/-9%) as compared with controls (17+/-12%; P<.23). iNOS positive cells in the infarct area of beta2GPI-immunized rats were significantly increased in comparison to the control group (P<.01). Similarly, TGF-beta cell expression was significantly increased in the infarct area of the immunized rats in comparison to the control group (22.6+/-5.1 and 7+/-2.1 per 100 mononuclear inflammatory cells, respectively; P=.01). CONCLUSION The presence of high levels of aPL antibodies is associated with higher expression of iNOS and TGF-beta and may contribute to myocardial damage.
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Affiliation(s)
- I Barshack
- Department of Pathology, Sheba Medical Center, Tel-Hashomer 52621, Israel.
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138
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Brizzi P, Isaja T, D'Agata A, Malaguarnera L, Malaguarnera M, Musumeci S. Oxidized LDL antibodies (OLAB) in patients with beta-thalassemia major. J Atheroscler Thromb 2003; 9:139-44. [PMID: 12226555 DOI: 10.5551/jat.9.139] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Thalassemic (TM) patients are subjected to peroxidative tissue injury because of continuous blood transfusions. It has been documented that circulating LDL from TM patients show marked oxidative modification, that could represent an event leading to atherogenesis. We investigated in 75 beta-TM patients the levels of oxidized LDL antibody (OLAB) to asses their correlation with total cholesterol, LDL and HDL cholesterol, triglycerides Apo A-1 and Apo B. OLAB/mg chol-LDL is greater in TM patients than healthy controls (p<0.001). No correlation was found between OLAB and age, sex of patients, mean blood consumption, mean serum ferritin, mean transaminases, PT, PTT, and fibrinogen. A significant positive correlation was found between OLAB and triglycerides in TM patients (p<0.001). Also a significant correlation was found between OLAB/mg chol-LDL and level of triglycerides in TM patients, but not with total cholesterol, LDL and HDL chols, Apo A-1 and Apo B. On the contrary in the healthy controls this correlation between OLAB and OLAB/mg chol-LDL versus triglycerides was negative and not significant. High levels of OLAB/mg chol-LDL in patients with beta-thalassemia, in absence of evident signs of atherosclerosis, suggest some regulatory mechanisms on the lipid peroxidation which modulate the deposition of ox-LDL in the macrophages and support the hypothesis that both serum iron and triglycerides are involved in the pathogenesis of LDL oxidation.
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Affiliation(s)
- Patrizia Brizzi
- Department of Internal Medicine, University of Sassari, Sassari, Italy
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139
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Bulckaen HG, Puisieux FL, Bulckaen ED, Di Pompeo C, Bouillanne OM, Watel AA, Fauchais ALM, De Groote P, Millaire A. Antiphospholipid antibodies and the risk of thromboembolic events in valvular heart disease. Mayo Clin Proc 2003; 78:294-8. [PMID: 12630582 DOI: 10.4065/78.3.294] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To investigate the role of antiphospholipid antibodies (aPLs) in subsequent thromboembolic events and mortality in a prospective follow-up of 89 patients with severe, nonspecific valvular heart disease. PATIENTS AND METHODS Between November 1, 1993, and March 31, 1994, 89 patients with valvular heart disease were assessed for the presence of anticardiolipin antibodies and lupus anticoagulant. The primary end point was thromboembolic events, and the secondary end points were cardiovascular mortality and overall mortality. RESULTS All patients were followed up for a mean of 59 months; 1 patient (without aPLs) was lost to follow-up. Nineteen patients had increased titers of aPLs. Thromboembolic events were significantly more frequent in the aPL-positive group than in the aPL-negative group (7/19 [37%] vs 8/70 [11%]; P=.01). Cardiovascular mortality tended to be higher in the aPL-positive group than in the aPL-negative group (3 [16%] vs 6 [9%]; P = .40). However, in multivariate Cox analysis, presence of aPLs was not an independent risk factor for thromboembolic events. CONCLUSION Our results suggest that patients with severe valvular heart disease and aPLs have an increased risk for developing thromboembolic events.
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Affiliation(s)
- Hélène G Bulckaen
- Service de Médecine Interne et Gériatrie, Hôpital Gériatrique les Bateliers, Centre Hospitalier Régional et Universitaire de Lille, 59037 Lille, France
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140
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Ferro D, Saliola M, Meroni PL, Valesini G, Caroselli C, Praticò D, Fitzgerald GA, Shoenfeld Y, Violi F. Enhanced monocyte expression of tissue factor by oxidative stress in patients with antiphospholipid antibodies: effect of antioxidant treatment. J Thromb Haemost 2003; 1:523-31. [PMID: 12871461 DOI: 10.1046/j.1538-7836.2003.00108.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In a first study, we performed a cross-sectional analysis of urinary excretion of isoprostanes, IPF(2alpha-III) and (VI), and monocyte tissue factor (TF) antigen and activity between 11 antiphospholipid (APL) antibody-positive patients and 13 APL negative subjects. In a second study, 11 APL positive patients were randomly supplemented either with (n = 6) or without (n = 5) antioxidants (vitamin E at 900 IU day(-1), vitamin C at 2000 mg day(-1)) for 6 weeks. In a third study, TF and superoxide anion were measured in human monocytes incubated with anti-beta(2) glycoprotein 1 (beta(2)GP(1)) or control IgG, either with or without vitamin E. APL-positive patients had higher values of isoprostanes (P < 0.05) and monocyte TF antigen (P = 0.001) and activity (P = 0.0001) than APL-negative subjects. Only in APL positive patients did monocyte TF antigen correlate significantly with IPF(2alpha-III) (rho 0.79; P < 0.003) and IPF(2alpha-VI) (rho = 0.87; P < 0.0001). In patients who received antioxidant supplementation, we found a significant decrease of isoprostanes (P < 0.05) and monocyte TF antigen (P < 0.01) and activity (P < 0.007). In vitro experiments demonstrated that anti-beta(2)GP(1) antibodies dose-dependently enhanced the monocyte production of the superoxide anion and TF, which were significantly inhibited by vitamin E. This study demonstrates that in APL-positive patients, oxidative stress contributes to activate the clotting system via over-expression of monocyte TF. We suggest that anti-beta(2)GP(1) antibodies could play a pivotal role by enhancing the monocyte production of oxygen free radicals.
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Affiliation(s)
- D Ferro
- Institute of Clinical Medicine I, University 'La Sapienza' Rome, Italy
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141
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Galli M, Luciani D, Bertolini G, Barbui T. Lupus anticoagulants are stronger risk factors for thrombosis than anticardiolipin antibodies in the antiphospholipid syndrome: a systematic review of the literature. Blood 2003; 101:1827-32. [PMID: 12393574 DOI: 10.1182/blood-2002-02-0441] [Citation(s) in RCA: 633] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
To formally establish the risk of lupus anticoagulants and anticardiolipin antibodies for arterial and venous thrombosis, we ran a MEDLINE search of the literature from 1988 to 2000. Studies were selected for their case-control (11), prospective (9), cross-sectional (3), and ambispective (2) design. They provided or enabled us to calculate the odds ratio with 95% confidence interval (CI) of lupus anticoagulants and/or anticardiolipin antibodies for thrombosis in 4184 patients and 3151 controls. Studies were grouped according to the antibody investigated. Five studies compared lupus anticoagulants with anticardiolipin antibodies: the odds ratio with 95% CI of lupus anticoagulants for thrombosis was always significant. None of them found anticardiolipin antibodies were associated with thrombosis. Four studies analyzed only lupus anticoagulants: the odds ratio with 95% CI was always significant. The risk of lupus anticoagulants was independent of the site and type of thrombosis, the presence of systemic lupus erythematosus, and the coagulation tests employed to detect them. Sixteen studies served to assess 28 associations between anticardiolipin antibodies and thrombosis: the odds ratio with 95% CI was significant in 15 cases. Anticardiolipin titer correlated with the odds ratio of thrombosis. In conclusion, the detection of lupus anticoagulants and, possibly, of immunoglobulin G (IgG) anticardiolipin antibodies at medium or high titers helps to identify patients at risk for thrombosis. However, to take full advantage of the conclusions provided by the available evidence, there is an urgent need to harmonize investigational methods.
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Affiliation(s)
- Monica Galli
- Division of Hematology, Ospedali Riuniti, Bergamo, Italy.
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142
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Affiliation(s)
- Finn Wisløff
- Department of Hematology, Hematological Research Laboratory, Ullevål University Hospital, NO-0407, Oslo, Norway.
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143
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Affiliation(s)
- Sònia Jiménez
- Servei de Malalties Autoimmunes. Institut Clínic d'Infeccions i Immunologia. Hospital Clínic. Barcelona. España
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144
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Van Cott EM, Laposata M, Prins MH. Laboratory evaluation of hypercoagulability with venous or arterial thrombosis. Arch Pathol Lab Med 2002; 126:1281-95. [PMID: 12421136 DOI: 10.5858/2002-126-1281-leohwv] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To provide recommendations for hypercoagulation testing for patients with venous, arterial, or neurovascular thrombosis, as reflected in the medical literature and the consensus opinion of recognized experts in the field. DATA SOURCES, EXTRACTION, AND SYNTHESIS The authors extensively examined the literature and current practices, and prepared a draft manuscript with preliminary recommendations. The draft manuscript was circulated to each of the expert participants (n = 30) in the consensus conference prior to the convening of the conference. The manuscript and recommendations were then presented at the conference for discussion. Recommendations were accepted if a consensus of the 28 experts attending the conference was reached. The discussions were also used to revise the manuscript into its final form. CONCLUSIONS The resulting article provides 17 recommendations for hypercoagulation testing in the setting of venous, arterial, or neurovascular thrombosis. The supporting evidence for test selection is analyzed and cited, and consensus recommendations for test selection are presented. Issues for which a consensus was not reached at the conference are also discussed.
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145
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Pai JK, Curhan GC, Cannuscio CC, Rifai N, Ridker PM, Rimm EB. Stability of Novel Plasma Markers Associated with Cardiovascular Disease: Processing within 36 Hours of Specimen Collection. Clin Chem 2002. [DOI: 10.1093/clinchem/48.10.1781] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jennifer K Pai
- Departments of Epidemiology and
- Divisions of Preventive Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115
| | - Gary C Curhan
- Departments of Epidemiology and
- Divisions of Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115
| | | | - Nader Rifai
- Center for Cardiovascular Disease Prevention, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115
- Department of Pathology, Children’s Hospital Medical Center and Harvard Medical School, Boston, MA 02115
| | - Paul M Ridker
- Divisions of Preventive Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115
- Divisions of Cardiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115
- Center for Cardiovascular Disease Prevention, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115
| | - Eric B Rimm
- Departments of Epidemiology and
- Nutrition, Harvard School of Public Health, Boston, MA 02115
- Divisions of Channing Laboratory, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA 02115
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146
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Cuadrado MJ. Treatment and monitoring of patients with antiphospholipid antibodies and thrombotic history (Hughes syndrome). Curr Rheumatol Rep 2002; 4:392-8. [PMID: 12217243 DOI: 10.1007/s11926-002-0083-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Patients with Hughes (antiphospholipid) syndrome who develop an initial thrombosis have an increased risk of subsequent thrombotic events. Current therapy to prevent recurrent thrombosis is controversial. While it seems clear that anticoagulant treatment is a better option than anti-aggregants alone, there is no consensus regarding the duration and intensity of oral anticoagulation. The risk of bleeding, the main complication of anticoagulant treatment, and the need for frequent monitoring of the International Normalized Ratio to measure the anticoagulant effect of warfarin concern patients and physicians. In addition, there is some debate about the validity of the International Normalized Ratio in patients with lupus anticoagulant activity. The development of new therapies that target more specific pathogenic mechanisms is highly warranted.
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Affiliation(s)
- Maria J Cuadrado
- St. Thomas' Hospital, Lupus Research Unit, London SE1 7EH, United Kingdom.
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147
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Su Z, Izumi T, Thames EH, Lawson JH, Ortel TL. Antiphospholipid antibodies after surgical exposure to topical bovine thrombin. THE JOURNAL OF LABORATORY AND CLINICAL MEDICINE 2002; 139:349-56. [PMID: 12066133 DOI: 10.1067/mlc.2002.123950] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Exposure to topical bovine thrombin during surgery frequently results in the development of antibodies to multiple protein and carbohydrate antigens. We investigated the frequency of increased levels of antibodies to cardiolipin and beta(2)-glycoprotein I (beta(2)-GPI) in two groups of patients, one exposed to bovine thrombin during cardiovascular surgery (n = 151) and a "control" group undergoing cardiovascular surgery but without exposure to bovine thrombin (n = 11). Anticardiolipin antibody levels were increased before surgery in 10 of the 151 patients exposed to topical thrombin (6.6%). Four to 8 weeks after surgery, 84 patients (55.6%) had increased anticardiolipin antibody levels (P <.0001). In the control group, an increased anticardiolipin antibody level was present in a single patient before and after surgery (9%). Increased levels of antibodies to bovine and human beta(2)-GPI were also observed after surgery in the patients exposed to topical thrombin (37.7% and 38.2%, respectively). Increased anticardiolipin levels correlated with higher levels of antibody to bovine, but not human, beta(2)-GPI. In addition, increased levels of anticardiolipin antibody were associated with higher levels of antibodies to bovine factor V and prothrombin, as well as human factor V. Antibody binding on an enzyme-linked immunosorbent assay conducted to detect anticardiolipin antibody was dependent on the presence of anionic phospholipid, indicating that binding was not linked to the fetal bovine serum in the blocking buffer alone. Seven of 8 patients with delayed thromboembolic complications had increased anticardiolipin IgG antibody levels after surgery, but this association was not statistically significant. Nevertheless, our findings support the recommendation that the clinical safety of these commonly used hemostatic agents should be reassessed.
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Affiliation(s)
- Zuowei Su
- Department of Medicine, Division of Hematology, Duke University Medical Center, Durham, NC 27710, USA
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148
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Durrani OM, Gordon C, Murray PI. Primary anti-phospholipid antibody syndrome (APS): current concepts. Surv Ophthalmol 2002; 47:215-38. [PMID: 12052409 DOI: 10.1016/s0039-6257(02)00289-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Primary anti-phospholipid syndrome (APS) is a thrombophilic state characterized by recurrent arterial and venous thrombosis, recurrent pregnancy loss, and the presence of circulating anti-phospholipid antibodies that may be responsible for thrombophilia and pregnancy morbidity. Ophthalmologic features are present in 15-88% of the patients with primary APS, thus ophthalmologists are one of the first physicians to whom the patient will present. An accurate diagnosis may save the patient from recurrent, potentially life-threatening thrombosis. In the U.S.A., an estimated 35,000 new cases of APS-related venous thrombosis occur each year in a population that is several decades younger than the patient population typically affected by thrombosis. Clinical features, such as chorea, transverse myelitis, cardiac valvular lesions, and accelerated atherosclerosis, are hypothesized to be due to a direct tissue-antibody interaction and cannot be explained purely by thrombosis. The use of recently proposed, well-defined diagnostic criteria, and better standardization of laboratory assays for the anti-phospholipid antibodies should help enable epidemiological surveys to establish the prevalence of these antibodies in patients with thrombosis and in the general population. Diagnosis of APS should be considered in all patients with recurrent systemic or ocular thrombosis in the absence of known risk factors. Several well-designed prospective studies show an increased risk of thrombosis in the presence of medium to high antibody level. With ocular involvement in as many as 88% of APS patients, an ophthalmic assessment should be an integral part of the clinical work-up of any patient with suspected or confirmed APS. The presence of isolated ocular thrombophilia with persistently elevated anti-phospholipid antibodies or lupus coagulant should confirm the diagnosis of APS. Management of these patients must be a multi-disciplinary effort with either a rheumatologist or a hematologist having the overall responsibility for coordinating treatment and monitoring the patient's immune status and anticoagulation. Treatment of isolated ocular thrombophilia in the presence of moderate to high titers of antiphospholipid antibodies should be on the same principles as patients with APS to prevent recurrent ocular or cerebral thrombosis.
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Affiliation(s)
- Omar M Durrani
- Academic Unit of Ophthalmology, University of Birmingham, Birmingham, United Kingdom
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149
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Nagappan R, Lodge RS. Acute autoimmune cardiomyopathy in primary antiphospholipid antibody syndrome. Anaesth Intensive Care 2002; 30:226-9. [PMID: 12002935 DOI: 10.1177/0310057x0203000219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We present a case of acute pulmonary oedema as the first presentation of autoimmune cardiomyopathy in primary antiphospholipid antibody syndrome in a patient who had no previous cardiac history. Five days of methylprednisolone at 500 mg/day followed by 100 mg/day for 10 days and then a weaning course of oral prednisone resulted in effective resolution of the acute diffuse cardiomyopathy. Her cardiac status became clinically and echocardiographically normal. We illustrate the effectiveness of immunosuppressive therapy as an adjunct to standard anti-failure measures in such presentations and we outline the association between antiphospholipid antibodies and cardiac dysfunction.
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Affiliation(s)
- R Nagappan
- Intensive Care Unit, St Vincent's Hospital, Melbourne, Victoria
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150
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Affiliation(s)
- Jerrold S Levine
- Department of Medicine, Section of Nephrology, University of Chicago, USA
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