Recent Developments in the Role of Coenzyme Q10 for Coronary Heart Disease: a Systematic Review

UPLC-MS/MS reveals the differences in lipids composition of Camellia oleifera from northern margin distribution area

The lipids accumulation characteristics in 23Camellia oleifera lines from northern margin distribution area were investigated through quantitative lipidomics. Combined lipids content-function analysis indicated that NQ1, HT1, HT2, ZA2, ZB1, ZB2, and SN2 lines had potential to develop functional foods due to abundant glycerolipids (GLs), glycerophospholipids (GPs), fatty acids (FAs), and prenol lipids (PRs). 673 lipids components were detected, and 293 differential components were identified in NQ1, ZA2, HB1, and HT1. 4 kinds free fatty acids (FFAs) were higher in NQ1, 5 triglycerides (TGs) were higher in HT1, and 2 phosphatidyl serines (PSs) and 1 phosphatidyl glycerol (PG) were higher in ZA2. GLs, GPs, and FFAs had strong relation at intra- and inter-category level. Glycerolipid metabolism, glycerophospholipid metabolism, and fatty acid biosynthesis were the significantly differential lipids pathways. Our study elucidated lipids differences of 23 C. oleifera lines, and offered valuable references for lipids biosynthesis, directional breeding, and lipids utilization.

Recommendations for nutritional supplements for dry eye disease: current advances

Dry eye disease (DED) represents a prevalent ocular surface disease. The development of effective nutritional management strategies for DED is crucial due to its association with various factors such as inflammation, oxidative stress, deficiencies in polyunsaturated fatty acids (PUFAs), imbalanced PUFA ratios, and vitamin insufficiencies. Extensive research has explored the impact of oral nutritional supplements, varying in composition and dosage, on the symptoms of DED. The main components of these supplements include fish oils (Omega-3 fatty acids), vitamins, trace elements, and phytochemical extracts. Beyond these well-known nutrients, it is necessary to explore whether novel nutrients might contribute to more effective DED management. This review provides a comprehensive update on the therapeutic potential of nutrients and presents new perspectives for combination supplements in DED treatment.

The association between ferroptosis and autophagy in cardiovascular diseases

Autophagy is a process in which cells degrade intracellular substances and play a variety of roles in cells, such as maintaining intracellular homeostasis, preventing cell overgrowth, and removing pathogens. It is highly conserved during the evolution of eukaryotic cells. So far, the study of autophagy is still a hot topic in the field of cytology. Ferroptosis is an iron-dependent form of cell death, accompanied by the accumulation of reactive oxygen species and lipid peroxides. With the deepening of research, it has been found that ferroptosis, like autophagy, is involved in the occurrence and development of cardiovascular diseases. The relationship between autophagy and ferroptosis is complex, and the association between the two in cardiovascular disease remains to be clarified. This article reviews the mechanism of autophagy and ferroptosis and their correlation, and discusses the relationship between them in cardiovascular diseases, which is expected to provide new and important treatment strategies for cardiovascular diseases.

Coenzyme Q10 as Adjunctive Therapy for Cardiovascular Disease and Hypertension: A Systematic Review

BACKGROUND

Mitochondrial ATP production requires a small electron carrier, coenzyme Q10 (CoQ10), which has been used as adjunctive therapy in patients with cardiovascular disease (CVD) and hypertension (HTN) because of its bioenergetics and antioxidant properties. Randomized controlled trials (RCTs) beyond the last 2 decades evaluating CoQ10 added to conventional therapy resulted in mixed results and were underpowered to address major clinical endpoints.

OBJECTIVES

The objective of this systematic review was to examine the impact of CoQ10 supplementation on older adults with CVD or HTN in the last 2 decades (2000-2020).

METHODS

PubMed/Medline, Cochrane Database, CINAHL, and Google Scholar databases were searched systematically, and references from selected studies were manually reviewed, to identify RCTs or crossover studies evaluating the efficacy of CoQ10 supplementation. Data extracted from selected studies included trial design and duration, treatment, dose, participant characteristics, study variables, and important findings.

RESULTS

A total of 14 studies (1067 participants) met the inclusion criteria. The effect of CoQ10 supplementation was examined among predominantly older adult males with heart failure (HF) (n = 6), HTN (n = 4), and ischemic heart disease (n = 3), and preoperatively in patients scheduled for cardiac surgery (n = 1). CoQ10 supplementation in patients with HF improved functional capacity, increased serum CoQ10 concentrations, and led to fewer major adverse cardiovascular events. CoQ10 had positive quantifiable effects on inflammatory markers in patients with ischemic heart disease. Myocardial hemodynamics improved in patients who received CoQ10 supplementation before cardiac surgery. Effects on HTN were inconclusive.

CONCLUSIONS

In predominantly older adult males with CVD or HTN, CoQ10 supplementation added to conventional therapy is safe and offers benefits clinically and at the cellular level. However, results of the trials need to be viewed with caution, and further studies are indicated before widespread usage of CoQ10 is recommended in all older adults.

Ubiquinol ameliorates endothelial dysfunction and increases expression of miRNA-34a in a rat model of pulmonary hypertension

Introduction: In this research, we evaluate the effect of intravenously administrated solubilized ubiquinol on 4-week monocrotalin-induced pulmonary hypertension (PH) in rats.

Materials and methods: To reproduce the model, some male Wistar rats were subcutaneously injected with alcohol solution of monocrotaline 60 mg/kg and the rest – with alcohol solution (Control). Those with monocrotaline (MCT) were divided into 3 groups. They underwent intravenous administration of 1% ubiquinol solution 30 mg/kg (MCT-Ubiquinol), the vehicle (MCT-Vehicle) and saline (MCT-saline) three times on days 7, 14 and 21, depending on the group. The hemodynamic parameters were measured in anesthetized rats on day 29. Right ventricle hypertrophy, pulmonary arteries reactivity and expression of miRNA-21 and miRNA-34a were estimated after euthanasia.

Results and discussion: All MCT-groups demonstrated an increase in right ventricle systolic pressure and hypertrophy in comparison with the control group. An increase in lung weight was shown in MCT-Vehicle and MCT-Saline; however, the MCT-Ubiquinol indicators did not differ from those of the Control. There was an increased vasodilatation response to acetylcholine at concentrations of 1*10-6M and 1*10-5M in MCT-Ubiquinol in contrast to the other two MCT-groups. A significantly lower level of expression of miRNA-34a was observed in MCT-Ubiquinol.

Conclusion: Our findings suggest that a triple ubiquinol injection influences pulmonary changes and endothelium-depended vasodilatation, which contributes to pulmonary vascular tone and reactivity. A decrease in miRNA-34a expression in MCT-Ubiquinol group demonstrates the ubiquinol anti-inflammatory properties.

QuinoMit Q10-Fluid attenuates hydrogen peroxide-induced irregular beating in mouse pluripotent stem cell-derived cardiomyocytes

BACKGROUND

Coenzyme Q10 (CoQ10) is a crucial component of the mitochondrial structure which is involved in producing more than 90% of cellular ATP. This study aimed to investigate the protective effects and underlying mechanisms of QuinoMit Q10-Fluid against hydrogen peroxide (H₂O₂)-induced arrhythmias on cardiomyocytes (CMs).

METHODS

Undifferentiated stem cell-derived CMs were cultured in the presence of different concentrations of QuinoMit Q10-Fluid. To investigate if CoQ10 has anti-apoptotic activity, CMs were exposed to H₂O₂ for up to 100 h with or without CoQ10. The expression levels of cardiac reference genes were determined by RT-PCR. The structural and functional properties of CMs were examined by immunofluorescence and the xCELLigence system. Caspase 3/7 assay was also performed for cell apoptosis study.

RESULTS

The study showed that QuinoMit Q10-Fluid inhibits the proliferation of pluripotent stem cells at high concentrations and had less effect on cardiomyogenesis. However, the beating rate of clusters containing CMs generated under QuinoMit Q10-Fluid (1:100) was significantly increased. This increase was accompanied by the up-regulated expression level of some important cardiac markers during differentiation. Treatment of CMs with H₂O₂ notably induced irregular beating and decreased the amplitude of the beating signal of CMs, concomitantly with increased caspase-3/7 activity. However, CMs pretreated with QuinoMit exhibited a protective effect against H₂O₂-induced arrhythmia.

CONCLUSION

Our results reveal that QuinoMit Q10-Fluid attenuates H₂O₂-induced irregular beating in mouse pluripotent stem cell-derived CMs, at least partly by reducing the generation of ROS, suggesting a protective effect against CM dysfunctions.

A Review of the Role of Statins in Heart Failure Treatment

BACKGROUND

Heart failure is a common medical problem in the world, which has a high prevalence in both developed and developing countries. Today, among the medications used for the heart failure treatment, there are many medications with a positive cardiac contraction effect (positive inotropic such as digital glycosides, adrenergic receptor stimulants, and phosphodiesterase inhibitors), a large number of cardiac diluents (such as Angiotensin-Converting Enzyme (ACE) inhibitor group), and a few other types of drugs whose final effects are still under review. Statins are valuable drugs that are broadly prescribed in hyperlipidemia and cardiovascular patients due to their multiple properties, such as cholesterol reduction, endothelial function improvement, antioxidative, anti-inflammatory, neovascularization, and immunomodulatory activities.

METHODS

There is evidence that the therapeutic role of statins in HF, due to myocardial hypertrophy, show reduction in cardiomyocyte loss in the apoptosis process, oxidative stress, inflammation, and also the return of neurohormonal imbalance. However, the fact that these drugs have no sideeffects has not been confirmed in all studies, as statins prevent the production of particular beneficial and protective factors, such as coenzyme Q10 (CoQ10), while inhibiting the production of specific proteins involved in pathologic mechanisms.

RESULTS

Recently, it has been hypothesized that, despite the positive effects reported, high doses of statins in patients with long-term heart failure lead to progress in heart failure by inhibiting CoQ10 synthesis and intensifying hypertrophy.

CONCLUSION

Thus, it can be stated that the advantage of using statins depends on factors, such as stroke fraction, and the existence of other standard indications such as atherosclerotic diseases or high Low-Density Lipoprotein-C (LDL-C).

From Mitochondria to Atherosclerosis: The Inflammation Path

Inflammation is a key process in metazoan organisms due to its relevance for innate defense against infections and tissue damage. However, inflammation is also implicated in pathological processes such as atherosclerosis. Atherosclerosis is a chronic inflammatory disease of the arterial wall where unstable atherosclerotic plaque rupture causing platelet aggregation and thrombosis may compromise the arterial lumen, leading to acute or chronic ischemic syndromes. In this review, we will focus on the role of mitochondria in atherosclerosis while keeping inflammation as a link. Mitochondria are the main source of cellular energy. Under stress, mitochondria are also capable of controlling inflammation through the production of reactive oxygen species (ROS) and the release of mitochondrial components, such as mitochondrial DNA (mtDNA), into the cytoplasm or into the extracellular matrix, where they act as danger signals when recognized by innate immune receptors. Primary or secondary mitochondrial dysfunctions are associated with the initiation and progression of atherosclerosis by elevating the production of ROS, altering mitochondrial dynamics and energy supply, as well as promoting inflammation. Knowing and understanding the pathways behind mitochondrial-based inflammation in atheroma progression is essential to discovering alternative or complementary treatments.

Stability of Reduced and Oxidized Coenzyme Q10 in Finished Products

The efficiency of coenzyme Q10 (CoQ10) supplements is closely associated with its content and stability in finished products. This study aimed to provide evidence-based information on the quality and stability of CoQ10 in dietary supplements and medicines. Therefore, ubiquinol, ubiquinone, and total CoQ10 contents were determined by a validated HPLC-UV method in 11 commercial products with defined or undefined CoQ10 form. Both forms were detected in almost all tested products, resulting in a total of CoQ10 content between 82% and 166% of the declared. Ubiquinol, ubiquinone, and total CoQ10 stability in these products were evaluated within three months of accelerated stability testing. Ubiquinol, which is recognized as the less stable form, was properly stabilized. Contrarily, ubiquinone degradation and/or reduction were observed during storage in almost all tested products. These reactions were also detected at ambient temperature within the products’ shelf-lives and confirmed in ubiquinone standard solutions. Ubiquinol, generated by ubiquinone reduction with vitamin C during soft-shell capsules’ storage, may lead to higher bioavailability and health outcomes. However, such conversion and inappropriate content in products, which specify ubiquinone, are unacceptable in terms of regulation. Therefore, proper CoQ10 stabilization through final formulations regardless of the used CoQ10 form is needed.

Coenzyme Q10 in COPD: An Unexplored Opportunity?

COPD represents a major cause of mortality and morbidity worldwide, is linked to systemic inflammation and tends to coexist with a variety of comorbidities. Inflammation, oxidative stress and protease-antiprotease imbalance represent the pathogenic triad of COPD. Even though oxidative stress and mitochondrial dysfunction is a well-studied phenomenon in COPD and there is a variety of studies that aim to counteract its effect, there is limited data available on the use of coenzyme Q10 in COPD. The aim of the current review is to analyze the current data on the use of coenzyme Q10 in the management of COPD and frequently encountered comorbidities.

Systematic Review of Nutrition Supplements in Chronic Kidney Diseases: A GRADE Approach

Chronic kidney disease (CKD) is cumulative worldwide and an increasing public health issue. Aside from the widely known protein restriction and medical therapy, less evident is the renal protection of nutrition supplements in CKD patients. This systematic review (SR), using a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, aims to summarize and quantify evidence about the prevention effects of vitamin D and analogues, omega-3 polyunsaturated fatty acid (omega-3 PUFA), dietary fiber, coenzyme Q10 (CoQ10), and biotics on CKD progression. This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to examine SRs and/or meta-analysis of clinical controlled trials identified from PubMed, Embase, and the Cochrane Library. Finally, seventeen SRs were included in the qualitative analysis. The beneficial effects of these nutrition supplements in CKD patients mostly seem to be at low to very low evidence on proteinuria, kidney function, and inflammations and did not appear to improve CKD prognosis. The recommendation of nutrition supplements in CKD patients needs to discuss with physicians and consider the benefits over the adverse effects. Longer follow-up of larger randomized trials is necessary to clarify the benefits of nutrition supplements in CKD patients.

Effects of coenzyme Q10 on health-related quality of life, clinical disease activity and blood pressure in patients with mild to moderate ulcerative colitis: a randomized clinical trial

Background: Ulcerative colitis (UC) is specified by a chronic mucosal inflammation that has a deleterious impact on the quality of life (QoL). Coenzyme Q10 (CoQ10) appears to influence disease activity by its obvious properties. Therefore, the current research intends to assess the impacts of CoQ10 on QoL, disease activity, and blood pressure in UC patients. Methods: This clinical trial performed on men and women with UC in 2017 who were attended the gastrointestinal center of Hazrat Rasool Akram Hospital and private clinic. Eighty-eight UC patients were randomly allocated to receive either CoQ10 (200 mg/day) or placebo for 8 weeks. The anthropometric parameters, blood pressure, inflammatory bowel disease questionnaire-32 (IBDQ-32) score, and the Simple Clinical Colitis Activity Index (SCCAI) score were measured pre and post-intervention. P-value <0.05 was considered to be statistically significant. All statistical analysis was done using SPSS software version 24. Results: Eighty-six UC patients (44 males) with a mean age of 39.29 (10.19) years completed the trial. The results of between- and within-group analysis revealed that the SCCAI score (p<0.001 and p<0.001, respectively), diastolic blood pressure (p=0.025 and p=0.001, respectively), and systolic blood pressure (p=0.001 and p<0.001, respectively) decremented significantly; while, the mean IBDQ-32 (p<0.001 and p=0.001, respectively) increased substantially in the CoQ10 group; whereas there was no significant difference in anthropometric indices in both groups. Conclusion: Findings suggest that CoQ10 can be used as a potential intervention for diminishing the disease severity and blood pressure and may improve QoL and UC patients. IRCT number: IRCT20090822002365N17.

Endothelial dysfunction in neuroprogressive disorders-causes and suggested treatments

BACKGROUND

Potential routes whereby systemic inflammation, oxidative stress and mitochondrial dysfunction may drive the development of endothelial dysfunction and atherosclerosis, even in an environment of low cholesterol, are examined.

MAIN TEXT

Key molecular players involved in the regulation of endothelial cell function are described, including PECAM-1, VE-cadherin, VEGFRs, SFK, Rho GEF TRIO, RAC-1, ITAM, SHP-2, MAPK/ERK, STAT-3, NF-κB, PI3K/AKT, eNOS, nitric oxide, miRNAs, KLF-4 and KLF-2. The key roles of platelet activation, xanthene oxidase and myeloperoxidase in the genesis of endothelial cell dysfunction and activation are detailed. The following roles of circulating reactive oxygen species (ROS), reactive nitrogen species and pro-inflammatory cytokines in the development of endothelial cell dysfunction are then described: paracrine signalling by circulating hydrogen peroxide, inhibition of eNOS and increased levels of mitochondrial ROS, including compromised mitochondrial dynamics, loss of calcium ion homeostasis and inactivation of SIRT-1-mediated signalling pathways. Next, loss of cellular redox homeostasis is considered, including further aspects of the roles of hydrogen peroxide signalling, the pathological consequences of elevated NF-κB, compromised S-nitrosylation and the development of hypernitrosylation and increased transcription of atherogenic miRNAs. These molecular aspects are then applied to neuroprogressive disorders by considering the following potential generators of endothelial dysfunction and activation in major depressive disorder, bipolar disorder and schizophrenia: NF-κB; platelet activation; atherogenic miRs; myeloperoxidase; xanthene oxidase and uric acid; and inflammation, oxidative stress, nitrosative stress and mitochondrial dysfunction.

CONCLUSIONS

Finally, on the basis of the above molecular mechanisms, details are given of potential treatment options for mitigating endothelial cell dysfunction and activation in neuroprogressive disorders.

Effect of Statin Therapy on the Plasma Concentrations of Retinol, Alpha-Tocopherol and Coenzyme Q10 in Children with Familial Hypercholesterolemia

Purpose

Familial hypercholesterolemia (FH) requires early treatment. However, statins, which are regarded the first-line therapy, have an influence on redox balance. Antioxidant vitamins are important for many metabolic processes in the developing body. There are few data available on the long-term safety of statin use in children. The aim of this study was to evaluate the influence of statin treatment in children with FH on plasma concentrations of antioxidant vitamins: retinol, alpha-tocopherol and coenzyme Q10.

Methods

The first study group consisted of 13 children aged 10–18 years treated with simvastatin for at least 6 months, and the second group comprised 13 age- and sex-matched children with hypercholesterolemia, in whom pharmacological treatment had not been applied yet. Analyses were performed using a high-performance liquid chromatograph coupled with a MS detector.

Results

The analysis did not reveal significant differences in the concentration of retinol, alpha-tocopherol or coenzyme Q10 between the studied groups. The adjustment of the concentrations of the vitamins to the cholesterol level also indicated no significant differences. We found no deficits in antioxidant vitamins in patients treated with statins, or any risk of adverse effects associated with an increase in their concentration.

Conclusion

There is no rationale for additional supplementation using antioxidant vitamins or modification of low-fat and low-cholesterol diet in pediatric patients treated with statins.

Electronic supplementary material

The online version of this article (10.1007/s10557-020-07091-w) contains supplementary material, which is available to authorized users.

The role of nutraceuticals in prevention and treatment of hypertension: An updated review of the literature

Hypertension (HTN) is a worldwide epidemic in both developed and developing countries. It is one of the leading causes of major health problems such as cardiovascular disease, stroke, and heart attack. In recent years, several studies have reported associations between specific dietary ingredients and improving HTN. Nutraceuticals are natural food components with pharmacological properties. Reports suggest that functional foods and nutraceutical ingredients might support patients to obtain the desired therapeutic blood pressure (BP) goals and reduce cardiovascular risks by modulating various risk factors such as oxidative stress, renin-angiotensin system hyperactivity, inflammation, hyperlipidemia, and vascular resistance. We review the recent clinical experiments that have evaluated the biological and pharmacological activities of several types of nutraceuticals, including sour tea, cocoa, common spices, vitamin C, vitamin E, lycopene, flavonoids, coenzyme Q10, milk's tripeptides, calcium, magnesium, polyunsaturated fatty acids, and prebiotics in preventing and treating HTN. This review summarizes recent knowledge about the impact of common nutraceuticals for the regulation of BP.

Effects of coenzyme Q10 intervention on diabetic kidney disease: A systematic review and meta-analysis

BACKGROUND

The diabetic kidney disease (DKD) has become a seriously kidney disease that commonly caused by diabetes mellitus (DM). Oxidative stress response plays an essential role in the genesis and worsening of DKD and Coenzyme Q10 (CoQ10) has been reported the promising clinical effectiveness on DKD treatment. However, there is lack of relative evidence-based medical evidence currently.

OBJECTIVE

The systematic review and meta-analysis was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, which conducted to evaluate the effectiveness of CoQ10 in combination with other western medicine for DKD therapy through the randomized controlled trials (RCTs) and experimental studies.

METHODS

RCTs and experimental studies were searched based on standardized searching rules in 12 medical databases from the inception up to June 2018 and a total of 8 articles (4 RCTs and 4 experimental studies) were enrolled in the meta-analysis.

RESULTS

The results revealed that CoQ10 combined with other western medicine show statistical differences in the laboratory parameters of fasting plasma glucose (FPG), Hemoglobin A1c (HbA1c), total cholesterol (TC), high density lipoprotein cholesterol (HDL-C), triglyceride (TG), and malondialdehyde (MDA) amelioration after DKD therapy compared with control group. However, LDL-C and Urea level for RCTs and Urine output and Glucose for experimental studies on DKD was not superior to control group.

CONCLUSION

We need to make conclusion cautiously for the effectiveness of CoQ10 application on DKD therapy. More standard, multicenter, double-blind RCTs, and formal experimental studies of CoQ10 treatment for DKD were urgent to be conducted for more clinical evidence providing in the future. The underlying pharmacological mechanism of CoQ10 needs to be researched and revealed for its future application on DKD therapy.

The Effects of Resveratrol in Patients with Cardiovascular Disease and Heart Failure: A Narrative Review

Cardiovascular disease (CVD) is the main cause of death globally and responsible for the second highest number of deaths in Canada. Medical advancements in the treatment of CVD have led to patients living longer with CVD but often progressing to another condition called heart failure (HF). As a result, HF has emerged in the last decade as a major medical concern. Fortunately, various “traditional” pharmacotherapies for HF exist and have shown success in reducing HF-associated mortality. However, to augment the treatment of patients with CVD and/or HF, alternative pharmacotherapies using nutraceuticals have also shown promise in the prevention and treatment of these two conditions. One of these natural compounds considered to potentially help treat HF and CVD and prevent their development is resveratrol. Herein, we review the clinical findings of resveratrol’s ability to be used as an effective treatment to potentially help treat HF and CVD. This will allow us to gain a more fulsome appreciation for the effects of resveratrol in the health outcomes of specific patient populations who have various disorders that constitute CVD.

Important drug-micronutrient interactions: A selection for clinical practice

Interactions between drugs and micronutrients have received only little or no attention in the medical and pharmaceutical world in the past. Since more and more pharmaceutics are used for the treatment of patients, this topic is increasingly relevant. As such interactions - depending on the duration of treatment and the status of micronutrients - impact the health of the patient and the action of the drugs, physicians and pharmacists should pay more attention to such interactions in the future. This review aims to sensitize physicians and pharmacists on drug micronutrient interactions with selected examples of widely pescribed drugs that can precipitate micronutrient deficiencies. In this context, the pharmacist, as a drug expert, assumes a particular role. Like no other professional in the health care sector, he is particularly predestined and called up to respond to this task. The following article intends to point out the relevance of mutual interactions between micronutrients and various examples of widely used drugs, without claiming to be exhaustive.

Clinical profiles and risk assessment in patients with antiphospholipid antibodies

INTRODUCTION

Antiphospholipid syndrome (APS) is an acquired autoimmune thrombophilia associated with the presence of persistent antiphospholipid antibodies (aPL). Owing to recent studies, not only APS patients but also incidentally-identified, asymptomatic aPL carriers are able to be stratified in terms of the risk of future thrombotic events, according to the variety and the titer of positive aPL tests and to the non-thrombotic, aPL-associated clinical manifestations. Areas covered: Here, we critically review (1) criteria manifestations of APS, (2) non-criteria manifestations of APS, (3) risk assessment in patients with APS and in aPL carriers, and (4) the potential role of primary thrombosis prophylaxis in aPL carriers. In addition, we discuss what we are currently able to do and what we need to do in the future for primary prophylaxis against a first thrombotic event. Expert commentary: We suggest a comprehensive algorithm to stratify thrombotic risk in aPL carriers, including criteria aPL, non-criteria aPL, their scoring systems, and non-criteria manifestations. However, further studies, particularly prospective randomized controlled trials, are highly warranted to establish an effective and tolerable treatment regimen for high risk aPL carriers.