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Al-Ewaidat OA, Naffaa MM. Deciphering Mechanisms, Prevention Strategies, Management Plans, Medications, and Research Techniques for Strokes in Systemic Lupus Erythematosus. MEDICINES (BASEL, SWITZERLAND) 2024; 11:15. [PMID: 39189161 PMCID: PMC11348055 DOI: 10.3390/medicines11070015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/30/2024] [Accepted: 07/26/2024] [Indexed: 08/28/2024]
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune rheumatic condition characterized by an unpredictable course and a wide spectrum of manifestations varying in severity. Individuals with SLE are at an increased risk of cerebrovascular events, particularly strokes. These strokes manifest with a diverse range of symptoms that cannot be solely attributed to conventional risk factors, underscoring their significance among the atypical risk factors in the context of SLE. This complexity complicates the identification of optimal management plans and the selection of medication combinations for individual patients. This susceptibility is further complicated by the nuances of neuropsychiatric SLE, which reveals a diverse array of neurological symptoms, particularly those associated with ischemic and hemorrhagic strokes. Given the broad range of clinical presentations and associated risks linking strokes to SLE, ongoing research and comprehensive care strategies are essential. These efforts are critical for improving patient outcomes by optimizing management strategies and discovering new medications. This review aims to elucidate the pathological connection between SLE and strokes by examining neurological manifestations, risk factors, mechanisms, prediction and prevention strategies, management plans, and available research tools and animal models. It seeks to explore this medical correlation and discover new medication options that can be tailored to individual SLE patients at risk of stroke.
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Affiliation(s)
- Ola A. Al-Ewaidat
- Department of Internal Medicine, Ascension Saint Francis Hospital, Evanston, IL 60202, USA;
| | - Moawiah M. Naffaa
- Department of Cell Biology, Duke University School of Medicine, Durham, NC 27710, USA
- Department of Psychology and Neuroscience, Duke University, Durham, NC 27708, USA
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Hubben A, McCrae KR. How to diagnose and manage antiphospholipid syndrome. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:606-613. [PMID: 38066904 PMCID: PMC10727028 DOI: 10.1182/hematology.2023000493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Antiphospholipid antibodies (aPL) are autoimmune antibodies directed toward phospholipids or phospholipid-protein complexes, particularly those containing β2-glycoprotein I (β2GPI). Persistently positive aPL accompanied by arterial or venous thrombosis, or recurrent pregnancy loss, constitutes the antiphospholipid syndrome (APS). Several types of aPL with different specificities have been defined and may be detected in the clinical lab, including lupus anticoagulants (detected using clotting assays) and anticardiolipin, anti-β2GPI and anti-prothrombin/phosphatidylserine antibodies (detected by ELISA); each of the last 3 aPL may be either IgG, IgM, or IgA, though IgA antibodies are not included in criteria for APS. Due to the relative rarity of APS and the heterogeneity of aPL, thrombosis risk stratification is challenging, and randomized clinical trials for thrombosis treatment and prevention have been limited. This lack of high-quality data has made the clinical management of APS difficult, and existing guidelines are few and could not possibly cover many of the scenarios encountered in managing patients with APS. In this review, we present 3 patients with aPL and/or APS who highlight treatment dilemmas, and we discuss background information that may help guide clinical judgment in developing individualized treatment plans for patients with these enigmatic antibodies.
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Affiliation(s)
- Anne Hubben
- Taussig Cancer and Lerner Research Institutes, Cleveland Clinic, Cleveland, OH
| | - Keith R McCrae
- Taussig Cancer and Lerner Research Institutes, Cleveland Clinic, Cleveland, OH
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Pontara E, Bison E, Cattini MG, Tonello M, Denas G, Pengo V. Close link between antiphosphatidylserine/prothrombin antibodies, lupus anticoagulant, and activated protein C resistance in tetra antiphospholipid antibody-positive subjects. J Thromb Haemost 2023; 21:3138-3144. [PMID: 37422199 DOI: 10.1016/j.jtha.2023.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND Most of the carriers/patients triple-positive for antiphospholipid antibodies (lupus anticoagulant [LAC], immunoglobulin G [IgG]/immunoglobulin M [IgM] anticardiolipin, and anti-β2-glycoprotein I antibodies) are tetra-positive, being positive for antiphosphatidylserine/prothrombin (aPS/PT) antibodies. The relationship between aPS/PT titer, LAC potency, and resistance to activated protein C (aPC-R) has not been investigated. OBJECTIVES The aim of this study was to clarify the mutual interdependence of these parameters in tetra-positive subjects. METHODS Twenty-three carriers and 30 patients with antiphospholipid syndrome, none of whom were being treated with anticoagulants, and 30 age- and sex-matched controls were studied. Detection of aPS/PT, LAC, and aPC-R in each individual was performed with established methods in our laboratory. Carriers and patients were positive for IgG or IgM aPS/PT or for both isotypes without significant difference. Since both IgG and IgM aPS/PT have anticoagulant activity, we used the sum of their titers (total aPS/PT) for the correlation studies. RESULTS Total aPS/PT in all individuals studied exceeded that in controls. There was no difference in total aPS/PT titers (P = .72), LAC potency (P = .56), and aPC-R (P = .82) between antiphospholipid antibody-carriers and patients with antiphospholipid syndrome. There was a significant correlation between total aPS/PT and LAC potency (r = 0.78; P < .0001) and between total aPS/PT titers and aPC-R (r = 0.80; P < .0001). LAC potency also was correlated significantly with aPC-R (r = 0.72; P < .0001). CONCLUSION This study shows that there is interdependence between aPS/PT, LAC potency, and aPC-R.
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Affiliation(s)
- Elena Pontara
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Elisa Bison
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | | | - Marta Tonello
- Department of Medicine, Rheumatology Section, University of Padua, Padova, Italy
| | - Gentian Denas
- Thrombosis Research Laboratory, University of Padova, Padova, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, University of Padova, Padova, Italy; Arianna Foundation on Anticoagulation, Bologna, Italy.
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Cohen H, Werring DJ, Chandratheva A, Mittal P, Devreese KMJ, Isenberg DA. Survey on antiphospholipid syndrome diagnosis and antithrombotic treatment in patients with ischemic stroke, other brain ischemic injury, or arterial thromboembolism in other sites: communication from ISTH SSC Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. J Thromb Haemost 2023; 21:2963-2976. [PMID: 37391096 DOI: 10.1016/j.jtha.2023.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/05/2023] [Accepted: 06/15/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND The optimal strategy for diagnosis and antithrombotic treatment of patients with antiphospholipid syndrome (APS)-associated acute ischemic stroke (AIS), transient ischemic attack (TIA), or other brain ischemic injury is poorly defined. OBJECTIVES The survey goal was to capture variations in diagnosis and antithrombotic treatment of APS-associated ischemic stroke and related disorders to inform guidance and clinical trials to define optimal management. METHODS Professional colleagues, including key opinion leaders, were invited to complete a REDCap survey questionnaire initiated by the International Society on Thrombosis and Haemostasis Scientific and Standardisation Committee Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. The survey data were tallied using simple descriptive statistics. RESULTS There was generally good agreement on several aspects, including which patients to test for antiphospholipid antibodies (aPL), use of a lifelong vitamin K antagonist for AIS or recurrent TIA, and formal cognitive assessment for suspected cognitive impairment. There was less agreement on other aspects, including aPL testing for brain ischemic injury other than AIS/TIA or if an alternative cause for AIS or TIA exists; choice of aPL tests, their timing, and age cutoff; the aPL phenotype to trigger antithrombotic treatment; management for patent foramen ovale; antithrombotic treatment for first TIA or white matter hyperintensities; head magnetic resonance imaging specifications; and low-molecular-weight heparin dosing/anti-Xa monitoring in pregnancy. The survey highlighted that approximately 25% practice at dedicated APS clinics and <50% have a multidisciplinary team structure for patients with APS. CONCLUSION Much of the variation in practice reflects the lack of evidence-based recommendations. The survey results should inform the development of a more uniform multidisciplinary consensus approach to diagnosis and antithrombotic treatment.
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Affiliation(s)
- Hannah Cohen
- Department of Haematology, Cancer Institute, University College London, London, UK; Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK.
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, Queen Square University College Hospitals NHS Foundation Trust, London, UK
| | - Arvind Chandratheva
- National Hospital for Neurology and Neurosurgery, Queen Square University College Hospitals NHS Foundation Trust, London, UK
| | - Prabal Mittal
- Department of Haematology, Cancer Institute, University College London, London, UK; Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Katrien M J Devreese
- Coagulation Laboratory, Ghent University Hospital, Ghent, Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - David A Isenberg
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK; Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Mittal P, Quattrocchi G, Tohidi-Esfahani I, Sayar Z, Chandratheva A, Cohen H. Antiphospholipid syndrome, antiphospholipid antibodies, and stroke. Int J Stroke 2023; 18:383-391. [PMID: 36571450 DOI: 10.1177/17474930221150349] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Antiphospholipid syndrome (APS) is a prothrombotic autoimmune disease with heterogeneous clinicopathological manifestations and is a well-established cause of acute ischemic stroke (AIS) and transient ischemic attack (TIA), particularly in younger patients. There is growing recognition of a wider spectrum of APS-associated cerebrovascular lesions, including white matter hyperintensities, cortical atrophy, and infarcts, which may have clinically important neurocognitive sequalae. Diagnosis of APS-associated AIS/TIA requires expert review of clinical and laboratory information. Management poses challenges, given the potential for substantial morbidity and recurrent thrombosis, additional risk conferred by conventional cardiovascular risk factors, and limited evidence base regarding optimal antithrombotic therapy for secondary prevention. In this review, we summarize key features of APS-associated cerebrovascular disorders, with focus on clinical and laboratory aspects of diagnostic evaluation. The current status of prognostic markers is considered. We review the evidence base for antithrombotic treatment in APS-associated stroke and discuss uncertainties, including the optimal intensity of anticoagulation and efficacy of direct oral anticoagulants. Clinical practice recommendations are provided, covering antithrombotic treatment, supportive management, and options for anticoagulant-refractory cases, and we highlight the benefits of adopting a considered, multidisciplinary team approach.
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Affiliation(s)
- Prabal Mittal
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Graziella Quattrocchi
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Neurology, North Middlesex NHS Trust, London, UK
| | - Ibrahim Tohidi-Esfahani
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Zara Sayar
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Haematology, Whittington Health NHS Trust, London, UK
| | - Arvind Chandratheva
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
- UCL Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
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Abstract
Cerebrovascular accidents (CVAs) or strokes are part of the common thrombotic manifestations of Systemic Lupus Erythematosus (SLEs) and Antiphospholipid syndrome (APS). Such neurological thrombotic events tend to occur in patients with SLE at a higher frequency when Antiphospholipid antibodies (aPLs) are present, and tend to involve the large cerebral vessels. The mechanism of stroke in SLE can be driven by complement deposition and neuroinflammation involving the blood-brain barrier although the traditional cardiovascular risk factors remain major contributing factors. Primary prevention with antiplatelet therapy and disease activity controlling agent is the basis of the management. Anticoagulation via warfarin had been a tool for secondary prevention, especially in stroke recurrence, although the debate continues regarding the target international normalized ratio (INR). The presence of either of the three criteria antiphospholipid antibodies (aPLs) and certain non-criteria aPL can be an independent risk factor for stroke. The exact mechanism for the involvement of the large cerebral arteries, especially in lupus anticoagulant (LAC) positive cases, is still to be deciphered. The data on the role of non-criteria aPL remain very limited and heterogenous, but IgA antibodies against β2GPI and the D4/5 subunit as well as aPS/PT IgG might have a contribution. Anticoagulation with warfarin has been recommended although the optimal dosing or the utility of combination with antiplatelet agents is still unknown. Minimal data is available for direct oral anticoagulants (DOACs).
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Affiliation(s)
- Georges El Hasbani
- Department of Internal Medicine, St Vincent's Medical Center, Bridgeport, CT, USA
| | - Imad Uthman
- Department of Internal Medicine, 11238American University of Beirut Medical Center, Beirut, Lebanon
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Arachchillage DJ, Mackillop L, Chandratheva A, Motawani J, MacCallum P, Laffan M. Guidelines for thrombophilia testing: A British Society for Haematology guideline. Br J Haematol 2022; 198:443-458. [PMID: 35645034 PMCID: PMC9542828 DOI: 10.1111/bjh.18239] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/24/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Deepa J Arachchillage
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Lucy Mackillop
- Women's Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Jayashree Motawani
- Department of Haematology, Birmingham Children's Hospital, Birmingham, UK
| | - Peter MacCallum
- Department of Haematology, Barts Health NHS Trust, London, UK.,Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Mike Laffan
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
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Niznik S, Rapoport MJ, Avnery O, Lubetsky A, Haj Yahia S, Ellis MH, Agmon-Levin N. Patterns of Recurrent Thrombosis in Primary Antiphospholipid Syndrome-Multicenter, Real-Life Long-Term Follow-Up. Front Immunol 2022; 13:843718. [PMID: 35514968 PMCID: PMC9063725 DOI: 10.3389/fimmu.2022.843718] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 03/15/2022] [Indexed: 11/29/2022] Open
Abstract
Background Antiphospholipid syndrome (APS) is an acquired hypercoagulable condition associated with antiphospholipid antibody (aPL) presence. Data on re-thrombosis following APS-diagnosis are limited. Methods This is a retrospective analysis of new thrombotic events among primary APS (pAPS) patients followed for up to 15 years in three medical centers in Israel. Results Among 312 primary-APS patients, 143 (46%) had new thrombotic event classified to three patterns: (1) Arterial—associated with heart valve disease (OR 7.24, 95% C.I. 2.26–24.6), hypertension (OR 3, 95% C.I. 1.44–6.25), elevated anti-B2-GPI IgM (OR 1.04, 95% C.I. 0.996–1.08), arterial thrombosis at presentation (OR 1.74 95% C.I. 0.992–3.26), and older age (41 vs. 34 years, p < 0.001). (2) Venous—linked with venous thrombosis at presentation (OR 12.9, 95% C.I. 5.27–31.6, p < 0.001), heart valve disease (OR 9.81 95% C.I. 1.82–52.9, p = 0.018), aGAPSS (OR 1.15 95% C.I. 1.02–1.29), and younger age (31 vs. 36.5 years, p = 0.001); and (3) Combined pattern—associated with heart valve disease (OR 40.5 95% C.I. 7.7–212) and pulmonary embolism (OR 7.47 95% C.I. 1.96–28.5). A 4th variant “the Breakthrough pattern” defined by re-thrombosis despite prophylactic therapy was observed in 100/143 (70%) patients and linked with heart valve disease (OR 8. 95% C.I. 2.43–26.3), venous thrombosis at presentation (OR 2.61 95% C.I. 1.47–4.66), leg ulcers (OR 12.2, 95% C.I. 1.4–107), hypertension (OR 1.99, 95% C.I. 0.92–4.34), and higher aGAPSS (OR 1.08, 95% C.I. 0.99–1.18). Conclusion In this real-life observation, re-thrombosis was common among pAPS patients including in those recommended to receive prophylactic therapy. Different patterns of recurrence were identified and linked with presenting symptoms, specific serological markers, APS manifestations, and comorbidities. Studies that will address interventions to prevent recurrences of APS-related events are needed.
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Affiliation(s)
- Stanley Niznik
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel
| | - Micha J Rapoport
- Department of Internal Medicine "C", Shamir Medical Center, Zerifin, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Avnery
- Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Aharon Lubetsky
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,The National Hemophilia Center and Thrombosis Unit, Amalia Biron Research Institute of Thrombosis and Hemostasis, Sheba Medical Center, Ramat Gan, Israel
| | - Soad Haj Yahia
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Martin H Ellis
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Hematology Institute and Blood Bank, Meir Medical Center, Kfar Saba, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Demir S, Li J, Magder LS, Petri M. Antiphospholipid patterns predict risk of thrombosis in systemic lupus erythematosus. Rheumatology (Oxford) 2021; 60:3770-3777. [PMID: 33331921 DOI: 10.1093/rheumatology/keaa857] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 11/09/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE We evaluated which aPL combinations increase the risk of future thrombosis in patients with SLE. METHODS This prospective cohort study consisted of SLE patients who had been tested for all seven aPL (LA, aCL isotypes IgM, IgG and IgA, and anti-β2-glycoprotein I isotypes IgM, IgG and IgA). Pooled logistic regression was used to assess the relationship between aPL and thrombosis. RESULTS There were 821 SLE patients with a total of 75 048 person-months of follow-up. During the follow-up we observed 88 incident cases of thrombosis: 48 patients with arterial, 37 with venous and 3 with both arterial and venous thrombosis. In individual models, LA was the most predictive of any [age-adjusted rate ratio 3.56 (95% CI 2.01, 6.30), P < 0.0001], venous [4.89 (2.25, 10.64), P < 0.0001] and arterial [3.14 (1.41, 6.97), P = 0.005] thrombosis. Anti-β2-glycoprotein I IgA positivity was a significant risk factor for any [2.00 (1.22, 3.3), P = 0.0065] and venous [2.8 (1.42, 5.51), P = 0.0029] thrombosis. Only anti-β2-glycoprotein I IgA appeared to add significant risk to any [1.73 (1.04, 2.88), P = 0.0362] and venous [2.27 (1.13, 4.59), P = 0.0218] thrombosis among those with LA. We created an interaction model with four categories based on combinations of LA and other aPL to look at the relationships between combinations and the risk of thrombosis. In this model LA remained the best predictor of thrombosis. CONCLUSION Our study demonstrated that in SLE, LA remained the best predictor of thrombosis and adding additional aPL did not add to the risk, with the exception of anti-β2-glycoprotein I IgA.
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Affiliation(s)
- Selcan Demir
- Department of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Pediatric Rheumatology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Jessica Li
- Department of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Laurence S Magder
- Division of Biostatistics and Bioinformatics, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michelle Petri
- Department of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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VWF, Platelets and the Antiphospholipid Syndrome. Int J Mol Sci 2021; 22:ijms22084200. [PMID: 33919627 PMCID: PMC8074042 DOI: 10.3390/ijms22084200] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 12/11/2022] Open
Abstract
The antiphospholipid syndrome (APS) is characterized by thrombosis and/or pregnancy morbidity with the persistent presence of antiphospholipid antibodies (aPLs). Laboratory criteria for the classification of APS include the detection of lupus anticoagulant (LAC), anti-cardiolipin (aCL) antibodies and anti-β2glycoprotein I (aβ2GPI) antibodies. Clinical criteria for the classification of thrombotic APS include venous and arterial thrombosis, along with microvascular thrombosis. Several aPLs, including LAC, aβ2GPI and anti-phosphatidylserine/prothrombin antibodies (aPS/PT) have been associated with arterial thrombosis. The Von Willebrand Factor (VWF) plays an important role in arterial thrombosis by mediating platelet adhesion and aggregation. Studies have shown that aPLs antibodies present in APS patients are able to increase the risk of arterial thrombosis by upregulating the plasma levels of active VWF and by promoting platelet activation. Inflammatory reactions induced by APS may also provide a suitable condition for arterial thrombosis, mostly ischemic stroke and myocardial infarction. The presence of other cardiovascular risk factors can enhance the effect of aPLs and increase the risk for thrombosis even more. These factors should therefore be taken into account when investigating APS-related arterial thrombosis. Nevertheless, the exact mechanism by which aPLs can cause thrombosis remains to be elucidated.
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11
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Cheng C, Cheng GY, Denas G, Pengo V. Arterial thrombosis in antiphospholipid syndrome (APS): Clinical approach and treatment. A systematic review. Blood Rev 2020; 48:100788. [PMID: 33341301 DOI: 10.1016/j.blre.2020.100788] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 11/17/2020] [Accepted: 12/08/2020] [Indexed: 12/17/2022]
Abstract
Thrombotic Antiphospholipid Syndrome (APS) is a condition affecting young individuals in whom a thromboembolic event occurs in the presence of circulating antiphospholipid antibodies (aPL). An extensive body of literature has covered the most common clinical presentation of the syndrome, venous thromboembolism. Arterial thrombosis in APS, a lesser clinical expression, is less studied. This review will concentrate on the body of literature concerning pathogenesis, clinical presentation and management of arterial thrombosis in APS.
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Affiliation(s)
- Chunyan Cheng
- Thrombosis Research Laboratory, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Gang-Yi Cheng
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Gentian Denas
- Thrombosis Research Laboratory, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padova, Padua, Italy; Arianna Foundation on Anticoagulation, Bologna, Italy.
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12
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Pisano TJ, Hakkinen I, Rybinnik I. Large Vessel Occlusion Secondary to COVID-19 Hypercoagulability in a Young Patient: A Case Report and Literature Review. J Stroke Cerebrovasc Dis 2020; 29:105307. [PMID: 32992201 PMCID: PMC7832635 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105307] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 09/02/2020] [Accepted: 09/05/2020] [Indexed: 12/11/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) initially most appreciated for its pulmonary symptoms, is now increasingly recognized for causing multi-organ disease and stroke in the setting of a hypercoagulable state. We report a case of 33-year-old African American woman with COVID-19 who developed acute malignant middle cerebral artery infarction due to thromboembolic occlusion of the left terminal internal carotid artery and middle cerebral artery stem. Mechanical thrombectomy was challenging and ultimately unsuccessful resulting in limited reperfusion of <67% of the affected vascular territory, and thrombectomized clot was over 50 mm in length, at least three times the average clot length. The final stroke size was estimated at 224 cubic centimeters. On admission her D-dimer level was 94,589 ng/mL (normal 0-500 ng/ml). Throughout the hospitalization D-dimer decreased but never reached normal values while fibrinogen trended upward. Hypercoagulability panel was remarkable for mildly elevated anticardiolipin IgM of 16.3 MPL/mL (normal: 0-11.0 MPL/mL). With respect to remaining stroke workup, there was no evidence of clinically significant stenosis or dissection in the proximal internal carotid artery or significant cardioembolic source including cardiomyopathy, atrial fibrillation, cardiac thrombus, cardiac tumor, valvular abnormality, aortic arch atheroma, or patent foramen ovale. She developed malignant cytotoxic cerebral edema and succumbed to complications. This case underscores the importance of recognizing hypercoagulability as a cause of severe stroke and poor outcome in young patients with COVID-19 and highlights the need for further studies to define correlation between markers of coagulopathy in patients with COVID-19 infection and outcome post stroke.
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Affiliation(s)
- Thomas John Pisano
- Rutgers-Robert Wood Johnson Medical School-Princeton University MD/PhD Program, New Brunswick, NJ 08854, United States.
| | - Ian Hakkinen
- Rutgers Robert Wood Johnson Medical School, Department of Neurology, New Brunswick, NJ 08854, United States.
| | - Igor Rybinnik
- Rutgers Robert Wood Johnson Medical School, Department of Neurology, New Brunswick, NJ 08854, United States.
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Mu F, Jiang Y, Ao F, Wu H, You Q, Chen Z. RapaLink-1 plays an antithrombotic role in antiphospholipid syndrome by improving autophagy both in vivo and vitro. Biochem Biophys Res Commun 2020; 525:384-391. [DOI: 10.1016/j.bbrc.2020.02.084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 02/12/2020] [Indexed: 12/20/2022]
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