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Neuropsychiatric Manifestations of Antiphospholipid Syndrome—A Narrative Review. Brain Sci 2022; 12:brainsci12010091. [PMID: 35053834 PMCID: PMC8773877 DOI: 10.3390/brainsci12010091] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 01/05/2022] [Accepted: 01/07/2022] [Indexed: 12/24/2022] Open
Abstract
Antiphospholipid syndrome (APS) is a common autoimmune pro-thrombotic condition characterised by thrombosis and pregnancy morbidity. There are a broad range of neuropsychiatric manifestations associated with APS, from focal symptoms to more global dysfunction. Patients commonly present with transient ischaemic attacks and ischaemic strokes, with identifiable lesions on brain imaging. However, the underlying pathogenesis remains uncertain in other manifestations, such as cognitive dysfunction, seizures, headache and chorea. The aim is to provide a comprehensive review of the various neuropsychiatric manifestations associated with APS. A detailed literature search was applied to PubMed, including citations from 1983 to December 2021.
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Cerdà P, Becattini C, Iriarte A, Hernández JC, Corbella X, Riera-Mestre A. Direct oral anticoagulants versus vitamin K antagonists in antiphospholipid syndrome: A meta-analysis. Eur J Intern Med 2020; 79:43-50. [PMID: 32482595 DOI: 10.1016/j.ejim.2020.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 05/03/2020] [Accepted: 05/06/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Anticoagulant treatment is recommended in patients with thrombosis and antiphospholipid syndrome (APS). Conflicting results have been reported on the role of direct oral anticoagulants (DOACs) in these patients. We performed a meta-analysis of randomized controlled trials (RCTs) focused on this issue. METHODS We searched MEDLINE and EMBASE for RCTs comparing DOACs and vitamin K antagonists (VKAs) for secondary thromboprophylaxis in patients with thrombotic APS. The primary objective was to assess the efficacy of DOACs compared to VKAs to prevent recurrence of thromboembolic events. Risk difference (RD) was reported as weighted RD according to Mantel-Haenszel random-effect method. RESULTS Three RCTs (426 patients) were included, all comparing rivaroxaban with VKAs. The proportion of recurrences (either arterial or venous) was higher among rivaroxaban patients when compared with those receiving VKAs (9.5% vs 2.8%; RD 6%, 95% CI, -0.05 - 0.18, p=0.29), although non-statistically significant. In patients with an arterial index event, thromboembolic recurrences were more frequent in those treated with rivaroxaban compared to those treated with VKAs (25% vs 6.2%; RD 19%, 95% CI, 0.04 - 0.33; p =0.01; I2 49%). In triple aPL positive patients, rivaroxaban showed higher rates of thromboembolic recurrences compared with VKAs (12% vs 3%; RD 9%, 95% CI, 0.02 - 0.15; p= 0.01; I2 13%). Non-statistically significant differences were observed in major bleeding events or mortality. CONCLUSIONS The use of rivaroxaban in APS patients is associated with an increased rate of thromboembolic recurrences compared to VKAs, at least in those with arterial index event or triple aPL positivity.
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Affiliation(s)
- Pau Cerdà
- Internal Medicine Department, Hospital Universitari Bellvitge - IDIBELL, Barcelona, Spain
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Adriana Iriarte
- Internal Medicine Department, Hospital Universitari Bellvitge - IDIBELL, Barcelona, Spain
| | - Josefina Cortés Hernández
- Internal Medicine Department. Rheumatology Research Group. Vall d´Hebrón University Hospital Research Institute, Barcelona, Spain
| | - Xavier Corbella
- Internal Medicine Department, Hospital Universitari Bellvitge - IDIBELL, Barcelona, Spain; Faculty of Medicine and Health Sciences. Universitat Internacional de Catalunya, Barcelona, Spain
| | - Antoni Riera-Mestre
- Internal Medicine Department, Hospital Universitari Bellvitge - IDIBELL, Barcelona, Spain; Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona, Spain.
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Kolitz T, Shiber S, Sharabi I, Winder A, Zandman-Goddard G. Cardiac Manifestations of Antiphospholipid Syndrome With Focus on Its Primary Form. Front Immunol 2019; 10:941. [PMID: 31134062 PMCID: PMC6522847 DOI: 10.3389/fimmu.2019.00941] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 04/11/2019] [Indexed: 01/09/2023] Open
Abstract
Antiphospholipid syndrome (APS) is a multisystem autoimmune disease most commonly associated with recurrent arterial and venous thromboembolism and recurrent fetal loss. Other possible antiphospholipid antibody (aPL)-related clinical manifestations include cardiac involvement. The heart can be involved through immune mediated and /or thrombotic mechanisms. Mortality due to cardiovascular problems is elevated in APS. However, the cardiovascular risk in patients with primary APS (PAPS) compared with lupus-related APS is yet to be established. Cardiac symptoms of APS include valve abnormalities (thickening and vegetations), coronary artery disease (CAD), myocardial dysfunction, pulmonary hypertension, and intracardiac thrombi. Heart valve lesions are the most common cardiac manifestation, observed in approximately one third of PAPS patients and usually do not cause hemodynamic significance. Deposits of immunoglobulins including anticardiolipin (aCL), and of complement components, are commonly observed in affected heart valves from these patients. This suggests that an inflammatory process is initiated by aPL deposition, eventually resulting in the formation of valvular lesion. aPL may have a direct role in the atherosclerotic process via induction of endothelial activation. Multiple traditional and autoimmune-inflammatory risk factors are involved in triggering an expedited atherosclerotic arterial disease evident in APS. It is imperative to increase the efforts in early diagnosis, control of risk factors and close follow-up, in the attempt to minimize cardiovascular risk in APS. Clinicians should bear in mind that a multidisciplinary therapeutic approach is of paramount importance in these patients. This article reviews the cardiac detriments of APS, including treatment recommendations for each cardiac complication.
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Affiliation(s)
- Tamara Kolitz
- Department of Medicine C, Wolfson Medical Center, Holon, Israel
| | - Shachaf Shiber
- Department of Rheumatology, Rabin Medical Center, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itzhak Sharabi
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Cardiology, Wolfson Medical Center, Holon, Israel
| | - Asher Winder
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Hematology, Wolfson Medical Center, Holon, Israel
| | - Gisele Zandman-Goddard
- Department of Medicine C, Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Santos TDS, Ieque AL, de Carvalho HC, Sell AM, Lonardoni MVC, Demarchi IG, de Lima Neto QA, Teixeira JJV. Antiphospholipid syndrome and recurrent miscarriage: A systematic review and meta-analysis. J Reprod Immunol 2017; 123:78-87. [PMID: 28985591 DOI: 10.1016/j.jri.2017.09.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 09/15/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune condition that is associated with thrombosis and morbidity in pregnancy. The exact mechanisms by which these associations occur appear to be heterogeneous and are not yet well understood. The aim of this study was to identify and analyze publications in recent years to better understand the diagnosis and its contribution to monitoring APS among women with recurrent miscarriage (RM). This systematic review and meta-analysis was conducted using the PubMed and Web of Knowledge databases, with articles published between 2010 and 2014, according to the PRISMA statement. Of the 85 identified studies, nine were selected. Most of the studies reported an association between recurrent miscarriage and specific antiphospholipid antibodies, as anticardiolipin antibodies (aCL), lupus anticoagulant (LA), anti-β2-glycoprotein I antibodies (aβ2GPI) and antiphosphatidylserine (aPS), which showed a relationship with RM. The main result of the meta-analysis revealed association between antiphospholipid antibodies (aPLs) and/or APS compared to the patients with RM (OR: 0.279; 95% CI: 0.212-0.366) and APS cases compared to the patients with RM (OR: 0.083; 95% CI: 0.036-0.189). High heterogeneity among these studies (I2=100.0%, p <0.001) was observed. In addition, there was no significant publication bias across studies according to Begg's test (p=0.230), although Egger's test (p=0.037) suggests significant publication bias. The funnel plot was slightly asymmetrical. Systematic review and meta-analysis demonstrated a positive association between antiphospholipid antibodies and/or antiphospholipid syndrome in patients with recurrent miscarriage.
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Affiliation(s)
- Thaís da Silva Santos
- Postgraduate Program in Biosciences and Physiopathology, State University Maringa, 5790 Colombo Avenue, 87020-900, Maringa, Brazil
| | - Andressa Lorena Ieque
- Postgraduate Program in Health Sciences, State University Maringa, 5790 Colombo Avenue, 87020-900 Maringa, Brazil
| | - Hayalla Corrêa de Carvalho
- Postgraduate Program in Biosciences and Physiopathology, State University Maringa, 5790 Colombo Avenue, 87020-900, Maringa, Brazil
| | - Ana Maria Sell
- Department of Cell Biology and Genetics, Center of Biological Sciences, State University Maringa,5790 Colombo Avenue, 87020-900 Maringa, Brazil
| | | | - Izabel Galhardo Demarchi
- Department of Clinical Analyses and Biomedicine, State University Maringa, 5790 Colombo Avenue, 87020-900 Maringa, Brazil
| | - Quirino Alves de Lima Neto
- Department of Basic Health Sciences, State University Maringa,5790 Colombo Avenue, 87020-900 Maringa, Brazil
| | - Jorge Juarez Vieira Teixeira
- Postgraduate Program in Biosciences and Physiopathology, Department of Clinical Analyses and Biomedicine, State University Maringa, 5790 Colombo Avenue, 87020-900 Maringa, Brazil.
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Reshetnyak TM, Seredavkina NV, Satybaldyeva MA, Nasonov EL, Reshetnyak VI. Liver transplantation in a patient with primary antiphospholipid syndrome and Budd-Chiari syndrome. World J Hepatol 2015; 7:2229-2236. [PMID: 26380049 PMCID: PMC4561778 DOI: 10.4254/wjh.v7.i19.2229] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 07/06/2015] [Accepted: 08/21/2015] [Indexed: 02/06/2023] Open
Abstract
The antiphospholipid syndrome (APS) is an acquired thrombophilic disorder in which autoantibodies are produced to a variety of phospholipids determinants of cell membranes or phospholipid binding proteins. There are few reports about association between antiphospholipid antibodies and development of Budd-Chiari syndrome (BCS). We report the case of BCS development in young Russian male with primary APS. The patient underwent orthotopic liver transplantation on August 26, 2012. At present time his state is good, the blood flow in the liver restored and its function is not impaired. We report about the first time the successful use of dabigatran etexilate for prolonged anticoagulation therapy in APS patient with BCS. In addition patient is managed with immunosuppressive drugs.
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Cutting-edge issues in coronary disease and the primary antiphospholipid syndrome. Clin Rev Allergy Immunol 2013; 44:51-6. [PMID: 21403998 DOI: 10.1007/s12016-011-8268-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Antiphospholipid syndrome (APS) is the most frequent cause of venous and arterial thrombotic events in young patients. The brain arterial tree is primarily affected, but coronary ischemic manifestations are also relatively frequent. Coronary involvement was suggested to be closely related to the accelerated atherosclerosis linked to the underlying disease in APS associated to systemic autoimmune diseases, in particular, systemic lupus erythematosus. However, arterial ischemic events can occur in primary APS--with no other systemic disorders--even in the absence of traditional cardiovascular risk factors and overt atherosclerosis. From a biological point of view, this finding speaks in favor for a pro-coagulant activity of anti-phospholipid antibodies rather than for their role in atherosclerotic plaque formation. On the other hand, the clinical challenge is to avoid the risk to misdiagnose young patients with potentially life-threatening symptoms, such as myocardial infarction (MI). In fact, the occurrence of nonspecific symptoms related to coronary ischemic events is frequently misdiagnosed because of its rarity in young patients. This issue is well illuminated by two cases of MI in young patients reported in the manuscript together with a systematic review of the associations and implications of coronary ischemic events in APS.
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Abstract
Ischemic stroke is one of the most common complications of the antiphospholipid syndrome (APS). Because of the relative lack of definitive prospective studies, there is still some debate as to whether the persistent presence of antiphospholipid antibodies (aPLs) increases the risk of recurrent stroke. There is more evidence for aPLs as a risk factor for first stroke. The mechanisms of ischemic stroke are considered to be thrombotic and embolic. APS patients with thrombotic stroke frequently have other, often conventional vascular risk factors. Transesophageal echocardiogram is strongly recommended in APS patients with ischemic stroke because of the high yield of valvular abnormalities. The appropriate management of thrombosis in patients with APS is still controversial because of limited randomized clinical trial data. This review discusses the current evidence for antithrombotic therapy in patients who are aPL positive but do not fulfill criteria for APS, and in APS patients. Alternative and emerging therapies including low molecular weight heparin, new oral anticoagulants (including direct thrombin inhibitors), hydroxychloroquine, statins, and rituximab, are also addressed.
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Affiliation(s)
- Kessarin Panichpisal
- Department of Neurology, SUNY Downstate Medical Center, Brooklyn, NY 11203-2098, USA.
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Ugarte A, Villar I, Ruiz-Irastorza G. [Management of pregnancy in patients with systemic lupus erythematosus]. Rev Clin Esp 2012; 212:491-8. [PMID: 22245369 DOI: 10.1016/j.rce.2011.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 10/02/2011] [Accepted: 11/07/2011] [Indexed: 11/15/2022]
Abstract
Patients with systemic lupus erythematosus are exposed to a remarkably high number of maternal-fetal complications during pregnancy. Knowledge regarding the reciprocal influence between lupus and pregnancy is the starting point to assure that these patients are correctly monitored. It is also important to carry out comprehensive preconception evaluation to individually evaluate the risk of each patient. The immunological profile, history of nephritis, presence of chronic damage and disease activity are the basic data that will determine the specific individual risk profile. Finally, correct drug management must be assured during this period, based on the safety profile of the different treatments during pregnancy and lactation.
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Affiliation(s)
- A Ugarte
- Unidad de Investigación de Enfermedades Autoinmunes, Servicio de Medicina Interna, Hospital de Cruces, Barakaldo, Bizkaia, Spain
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Rodríguez-Fernández S, Saavedra Ramírez P, Espinosa Garriga G, Cervera Segura R. [Suspension of anticoagulation in patients with primary antiphospholipid syndrome in which a negative antibody antiphospholipid]. Rev Clin Esp 2009; 209:357-8. [PMID: 19709543 DOI: 10.1016/s0014-2565(09)71823-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Carvalho JF, Freitas CAEW, Lima IVS, Leite CC, Lage LV. Primary antiphospholipid syndrome with thrombotic thrombocytopenic purpura: a very unusual association. Lupus 2009; 18:841-844. [DOI: 10.1177/0961203308101958] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
This report considers the rare situation in which primary antiphospholipid syndrome (PAPS) is linked with thrombotic thrombocytopenic purpura (TTP). It describes the case of a young lady with PAPS, characterized by recurring cerebro-vascular abnormalities and marked livedo reticularis, combined with circulating anticardiolipin and lupus anticoagulant antibodies. On follow-up, while on oral anticoagulation, she developed severe thrombocytopenia associated with hematuria, microangiophatic anaemia and neurological manifestations consistent with a diagnosis of TTP. The patient was treated with pulses of methylprednisolone and plasmapheresis with plasma exchange. The result was a favourable outcome. To our knowledge, this is the seventh report on this rare association in the English-language literature of this field.
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Affiliation(s)
- JF Carvalho
- Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo e Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
| | - CAEW Freitas
- Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo e Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
| | - IVS Lima
- Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo e Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
| | - CC Leite
- Radiology Department, Faculdade de Medicina da Universidade de São Paulo e Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
| | - LV Lage
- Rheumatology Division, Faculdade de Medicina da Universidade de São Paulo e Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo
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Oliver-Miñarro D, Gil J, Aguaron A, Rodríguez-Mahou M, Fernandez-Cruz E, Sanchez-Ramon S. NK cell expansion in obstetrical antiphospholipid syndrome: guilty by association? Eur J Obstet Gynecol Reprod Biol 2009; 145:227. [PMID: 19482406 DOI: 10.1016/j.ejogrb.2009.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 03/23/2009] [Accepted: 05/01/2009] [Indexed: 10/20/2022]
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Gómez-Puerta JA, Sanin-Blair J, Galarza-Maldonado C. Pregnancy and catastrophic antiphospholipid syndrome. Clin Rev Allergy Immunol 2009; 36:85-90. [PMID: 19052924 DOI: 10.1007/s12016-008-8100-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Antiphospholipid syndrome (APS) is clearly related to maternal morbidity. The most characteristic feature is pregnancy loss; however, several other serious complications had been reported including fetal growth restriction, uteroplacental insufficiency, fetal distress, pre-eclampsia, and HELLP syndrome. Herein, we review the different aspects of obstetric APS features, with special emphasis on its life-threatening variant known as catastrophic APS (Asherson's syndrome) and its relationship with a thrombotic microangiopathy such as HELLP syndrome.
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Espinosa G, Cervera R. Thromboprophylaxis and obstetric management of the antiphospholipid syndrome. Expert Opin Pharmacother 2009; 10:601-14. [DOI: 10.1517/14656560902772302] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Antiphospholipid syndrome is diagnosed when arterial or venous thrombosis or recurrent miscarriages occur in a person in whom laboratory tests for antiphospholipid antibodies (anticardiolipin antibodies and/or lupus anticoagulant and/or anti-beta 2-glycoprotein I) are positive. Despite the strong association between antiphospho-lipid antibodies and thrombosis, their pathogenic role in the development of thrombosis has not been fully elucidated. Novel mechanisms involving both the complement pathway and micro-particles have been described. The knowledge of these new pathogenic approaches might identify novel therapeutic targets and therefore may improve the management of these patients.
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Affiliation(s)
- Gerard Espinosa
- Department of Autoimmune Diseases, Institut Clínic de Medicina i Dermatologia, Hospital Clínic, Barcelona, Catalonia, Spain.
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