Coronary artery disease in severe haemophilia

Thrombosis in Hemophiliacs with Prothrombotic Molecular Defect

Thrombosis in hemophiliacs is a very unusual event mostly reported in patients treated with concentrates containing large quantities of activated coagulation factors. A patient with hemophilia A is reported who had an acute myocardial infarction and in whom investigation for hereditary thrombophilia showed a prothrombotic molecular defect, the G20210A prothrombin mutation.

Cardiovascular disease prevalence and relevance in haemophilia: a scoping review

The prevalence of cardiovascular disease (CVD) risk and events in patients with haemophilia (PWH) is expected to increase as the longevity of this cohort increases due to treatment advances since the 1950s. The aims of this study were to assess publications of CVD and haemophilia for robustness, determine if the increasing longevity of PWH and associated age-related CVD risk factors result in CVD events; assess the need for an extension of the circle of care for ageing PWH due to the shift in comorbidities. A scoping review was conducted, resulting in a final pool of 30 articles which were organized based on publication dates. A matrix was created to illustrate which articles cited articles published prior to its own publication. This led to the identification of the primary articles, receiving the highest number of citations by other publications, which drive the research pertaining to the study of age-related risk factors of CVD in PWH. The scoping review revealed 14 original articles, four of which indicated a protective effect of haemophilia toward CVD. Twelve articles demonstrated a similar prevalence of CVD in PWH compared to the general population while seven articles concluded a difference in the prevalence of CVD in the ageing haemophilia population. The existing literature presented conflicting evidence regarding the possibility of a protective effect of haemophilia against CVD. The scoping review was not able to finalize whether the longevity of PWH and their associated age-related CVD risk factors result in CVD events because the articles assessed reported conflicting results.

Challenges in treating elderly patients with haemophilia: a focus on cardiology

Seventy years ago, the average life expectancy for patients with severe haemophilia A was less than 17 years. Today, due to the availability of safe and effective clotting factor concentrates, life expectancy is nearly normal, at least in patients without viral infections. More individuals are living into their 70s and 80s, acquiring a range of diseases that are common in elderly persons. One of the most important challenges includes the treatment of comorbidities, especially cardiovascular diseases. Although most evidence suggests that haemophilia, at least the severe manifestation, partially protects against myocardial infarction, stroke and venous thromboembolism, typical cardiovascular risk factors can still be present despite the clotting defect. Patients with haemophilia are equally or even more prone to obesity, hypertension, diabetes, and dyslipidaemia, and this is especially true for HIV-infected individuals using highly active antiretroviral therapy. The management of elderly haemophilia patients with cardiovascular comorbidities is hampered by a lack of evidence-based guidelines. Nevertheless, experience in treating cardiovascular disease is growing amongst the haemophilia community, and several authors have published their own recommendations for managing a variety of commonly encountered cardiovascular scenarios in haemophilia patients. Basic recommendations exist for risk-factor management, the adaptation of factor replacement therapy in the at-risk elderly, management of coronary revascularization, the management of acute coronary syndrome and atrial fibrillation. This review outlines our current knowledge about cardiovascular risk in elderly haemophilia patients, recommendations for clinical decision making, and our own experiences of managing individuals with coronary heart disease and atrial fibrillation.

Challenges and controversies in haemophilia care in adulthood

Overall life expectancy and quality of life among persons with haemophilia have increased in recent years, primarily because of the advances in factor replacement therapy and better treatment of infectious diseases. Older haemophilic patients now face aging co-morbidities that are common in the general male population, such as cardiovascular or metabolic diseases, prostate hypertrophy and hepatic, prostate and other cancers. The prevalence of cardiovascular disease and incidence of vascular events among older haemophilic patients can be expected to increase and haemophilic patients may become prone to some cardiovascular risk factors, warranting preventative measures. The treatment of long-term complications of hepatitis C virus infection such as liver cirrhosis and hepatic cancer can be expected to be required in a large portion of the older haemophilia population for some years to come. Appropriate antiviral treatment and close monitoring for possible disease advancement will constitute an important part of routine medical care, and special considerations may be appropriate in conjunction with invasive procedures, chemo- or radiotherapy. At the moment, hard data on which to base the management of these conditions are largely lacking, but can be expected to increase dramatically in the coming decades. In the meantime, the ageing population of haemophilia patients should be offered the same comprehensive health care offered to the general population, which may require a restructuring of health care delivery.

Myocardial infarction and other arterial occlusions in hemophilia a patients. A cardiological evaluation of all 42 cases reported in the literature

Myocardial infarction and other arterial occlusions are considered to be rare in hemophilia A. However, a systematic study of the subject has never been attempted. All case reports of myocardial infarction or other arterial occlusions have been now gathered and properly evaluated from a cardiological point of view. Thirty-six patients with myocardial infarction and 6 patients with documented cerebrovascular event were retrieved from the literature. The age of the patients varied between 7 and 79 years, with a mean of 44 years. In 16 cases, the arterial occlusion occurred in men <40 years of age. The majority of myocardial infarctions (MIs) were anterolateral (12 cases). Posterior-inferior MI was present in 6 cases whereas it was of the non-Q type in 4 patients. It was multiple in 6 cases, and in the remaining patients the type of infarction could not be determined. In 26 cases, the thrombotic event (22 myocardial infarctions and 4 ischemic cerebrovascular accidents) occurred during or after the infusion of factor VIII concentrates and, more frequently, after prothrombin complex concentrates (activated or non-activated ones) or recombinant factor VIIa preparations. In 3 cases, the vascular complication occurred after intravenous desmopressin administration. MI was fatal in 7 instances. After the event, signs and symptoms of heart failure were seen as sequels in 7 patients. One patient had to undergo cardiac transplant 5 months after the MI. No death occurred after ischemic cerebrovascular accidents. Since not all hemophilia patients develop inhibitors and therefore are not usually treated with activated concentrates, this series of patients is somewhat biased and does not allow general conclusions. The high prevalence of MI and other arterial complications which occurred after transfusion therapy, usually in patients with inhibitors, clearly indicates the need for a careful evaluation of the appropriate therapeutic approach in each single patient.

Hemophilia A, von Willebrand disease, and atherosclerosis of abdominal aorta and leg arteries: factor VIII and von Willebrand factor defects appear to protect abdominal aorta and leg arteries from atherosclerosis

We hypothesized that patients with hemophilia or von Willebrand disease might be protected from atherosclerosis because of their coagulation defect. We studied 40 subjects affected by these two coagulation diseases using echocolor Doppler of the abdominal aorta and leg arteries, and compared the results with those obtained in 40 control patients who were homogenous with study patients in terms of sex, age, and risk factors for atherosclerosis. The probands presented a lower number of plaques than the 40 control subjects in the aorta and in the leg arteries. The most serious hemophilic patients had fewer plaques than controls or than patients with mild hemophilia. Both hemophilia and von Willebrand disease seem to protect against atherosclerosis.

Do hemophilia A and von Willebrand disease protect against carotid atherosclerosis? A comparative study between coagulopathics and normal subjects by means of carotid echo-color Doppler scan

Atherosclerosis is a multifactorial disease caused by genetic and environmental factors with important clinical sequelae. The aim of this study was to evaluate the degree of carotid atherosclerosis by echo-color Doppler scan in a group of patients affected by hemophilia A and von Willebrand disease versus a group of normal subjects apparently free of atherosclerotic risk factors. All coagulopathics and normal patients who came to our Internal Medicine Department (Padua Hospital) underwent physical exam, blood analysis, standard electrocardiogram, chest x-ray, echo-color Doppler scan, and a thorough history. We examined 156 subjects, 76 coagulopathics (46 men, 30 women) and 77 normals (37 men, 40 women). Coagulopathics were affected by hypertension in 28.9% of cases, diabetes mellitus in 6.5%, dislipidemia in 17.1%, smoke in 39.4%, and obesity in 36.8% (p < .05). Echo-color Doppler scan revealed carotid plaques in 27.2% of control patients versus 13.1% of coagulopathics (p < .05). Hemophilics and subjects with von Willebrand disease with a more serious illness had fewer plaques than those with lighter defects. Coagulopathics showed 23.6% of the plaques we revealed on the whole, versus 76.3% of control subjects (p < .01), with a lighter degree of stenosis (p < .01). Our data demonstrate that patients with hemophilia A and von Willebrand disease have fewer carotid plaques and a smaller degree of carotid stenosis than normal subjects of the same sex and age. These data seem to strengthen the hypothesis that blood coagulation defects may allow protection against carotid atherosclerosis and its sequelae.

Mortality and causes of death in Dutch haemophiliacs, 1973-86

Mortality figures were calculated for a group of 717 Dutch haemophiliacs over the period 1973-86. Follow-up was on average 10.9 years; no patients were lost to follow-up. The data were compared to the general male population by actuarial methods and patient-year analysis. Forty-three patients died, while 20 deaths were expected in a hypothetical group of non-haemophiliacs of the same age distribution. Hence, overall mortality was 2.1 times higher than in the general population. This leads to a calculated life expectancy of 66 years, as compared to 74 years in the general male population. Mortality did not differ much by severity of haemophilia. A possibly beneficial effect of prophylaxis on longevity was observed. Haemorrhage occurred in half of all deaths and among these traumatic bleeding was the most prevalent. The number of deaths due to ischaemic heart disease was significantly lower (80% reduction) than expected and therefore the authors conclude that haemophilia offers protection against ischaemic heart disease. Cancer mortality was significantly higher (2.5 times) than expected.

Cause of death in hemophilia A patients in the United States from 1968 to 1979

Death data on 949 hemophiliacs for the years 1968-1979 have been analyzed. The median age at death has increased from 33 to 55 years. There was no evidence of new diseases caused by the more intensive therapy during this time interval. The leading infectious disease was hepatitis, accounting for eight deaths. Only one acute hepatitis death was listed after 1974, when sensitive tests for hepatitis B antigen screening of plasma were implemented. Cirrhosis was a primary or associated cause of death in 76 cases (8%) and pneumonia was a primary or associated cause of death in 62 deaths (6.5%). The types of malignancies in hemophiliacs were similar to those in the male US population with no evidence of excessive retrovirus malignancies prior to infection with HIV-1.