Primary antiphospholipid syndrome: absence of premature atherosclerosis in patients without traditional coronary artery disease risk factors

Risk factors for thrombotic events in systemic lupus erythematosus patients with antiphospholipid antibodies: insights from morphometric measurements of carotid arteries

Objective

To identify the correlation between thrombosis and atherosclerosis in systemic lupus erythematosus (SLE) patients with antiphospholipid antibodies (aPLs) (SLE/aPLs) through high-resolution magnetic resonance imaging (HR-MRI) of the carotid artery.

Methods

A single-center, cross-sectional study was conducted. We collected consecutive patients with SLE/aPLs and healthy controls who underwent carotid HR-MRI examinations. The morphometric characteristics of the common carotid artery (CCA), internal carotid artery (ICA), external carotid artery (ECA), and carotid bulb (Sinus) were measured, and the differences in morphometric parameters between different groups were analyzed.

Results

A total of 144 carotid arteries were analyzed. Compared with the control group, the wall area, wall thickness (WT and WTmax), and normalized wall index of CCA, ICA, ECA, and Sinus were increased in patients with SLE/aPLs, and the total vascular area (TVA) of CCA, ICA, and Sinus, and the bifurcation angle (BIFA) of ICA-ECA were also increased. A negative lupus anticoagulant (LAC) (with or without positive anticardiolipin antibody (aCL) or anti-β2glycoprotein antibody (aβ2GPI)) contributed to illustrating lower increased TVA and thickened vessel walls of CCA and ICA in SLE/aPLs patients without thrombotic events. Logistic regression analysis showed that WTmaxSinus and WTmaxGlobal were independent risk factors for thrombotic events in SLE/aPLs patients. The receiver operator characteristic curve showed that the cut-off value of WTmaxSinus was 2.855 mm, and WTmaxGlobal was 3.370 mm.

Conclusion

HR-MRI ensures the complete and accurate measurement of carotid morphometric parameters. Compared with the control group, the carotid artery in patients with SLE/aPLs is mainly characterized by diffusely thickened vessel walls, and the patients with thrombotic events showed additional higher vascular area of CCA and ICA, and BIFA of ICA-ECA without significant change in lumen area. The carotid arteries of SLE/aPLs patients with thrombotic events exhibited significant vessel wall thickening in all segments except ECA compared to those without thrombotic events. LAC-negative and non-thrombotic events distinguish relatively early atherosclerosis in the carotid arteries in patients with SLE/aPLs. Patients with SLE/aPLs that possess circumscribed thickened carotid vessel walls (>3.370 mm), particularly thickened at the Sinus (>2.855 mm), may require management strategies for the risk of thrombotic events.

Arterial stiffness tested by pulse wave velocity and augmentation index for cardiovascular risk stratification in antiphospholipid syndrome

OBJECTIVES

Cardiovascular disease is a major cause of morbidity and mortality in Antiphospholipid syndrome (APS). Arterial stiffness (ArS) has emerged as a predictor of future cardiovascular events in the general population. We aimed to assess ArS in patients with thrombotic APS versus diabetes mellitus (DM) and healthy controls (HC) and identify predictors of increased ArS in APS.

METHODS

ArS was evaluated by carotid-femoral pulse wave velocity (cfPWV) and augmentation index normalized to 75 beats/min (AIx@75) using the SphygmoCor device. Participants also underwent carotid/femoral ultrasound for atherosclerotic plaque detection. We used linear regression to compare ArS measures among groups and assess ArS determinants in the APS group.

RESULTS

We included 110 patients with APS (70.9% female, mean age 45.4 years), 110 DM patients and 110 HC, all age/sex matched. After adjustment for age, sex, cardiovascular risk factors and plaque presence, APS patients exhibited similar cfPWV [β = -0.142 (95% CI -0.514, 0.230), p = 0.454] but increased AIx@75 [β = 4.525 (95% CI 1.372, 7.677), p = 0.005] compared with HC and lower cfPWV (p < 0.001) but similar AIx@75 (p = 0.193) versus DM patients. In the APS group, cfPWV was independently associated with age [β = 0.056 (95% CI 0.034, 0.078), p < 0.001], mean arterial pressure (MAP) [β = 0.070 (95% CI 0.043, 0.097), p < 0.001], atherosclerotic femoral plaques [β = 0.732 (95% CI 0.053, 1.411), p = 0.035] and anti-β2-glycoprotein I IgM positivity [β = 0.696 (95% CI 0.201, 1.191), p = 0.006]. AIx@75 was associated with age [β = 0.334 (95% CI 0.117, 0.551), p = 0.003], female sex [β = 7.447 (95% CI 2.312, 12.581), p = 0.005] and MAP [β = 0.425 (95% CI 0.187, 0.663), p = 0.001].

CONCLUSION

APS patients exhibit elevated AIx@75 vs HC and similar to DM patients, indicating enhanced arterial stiffening in APS. Given its prognostic value, ArS evaluation may help to improve cardiovascular risk stratification in APS.

Non-invasive imaging in antiphospholipid syndrome to assess subclinical coronary artery disease

Antiphospholipid antibody syndrome (usually named antiphospholipid syndrome, APS) is an autoimmune disorder seen mainly in young people. Clinically, APS is described by pregnancy complications and/or a hypercoagulable state, including the venous or arterial vasculature, and strongly related to antiphospholipid antibodies. Although several cardiac manifestations have been involved with APS, and accelerated atherosclerosis is present in this condition, little is known about cardiovascular (CV) risk and the relation between APS. Several studies have used imaging markers to associate them with the main clinical features of patients with APS and the probability of having subclinical atherosclerosis. However, it has not yet been established which markers are most related to the risk of developing CV diseases (CVD) in these patients. In this narrative review, we focus on non-invasive imaging markers that can predict CVD, including carotid intima-media thickness and carotid plaques assessed by carotid ultrasonography or coronary artery calcium score, which usually by computed tomography. We also examine the evidence about vascular function markers used in APS, such as arterial flow-mediated brachial dilation and artery stiffness measured by the velocity of the pulse wave. We present the current status of non-invasive imaging markers, which suggest the existence of subclinical atherosclerosis in patients with APS. However, new prospective research is required to identify the predictive value of these findings and their modification by current treatments for APS.

Risk of Subclinical Atherosclerosis in Patients with Antiphospholipid Syndrome and Subjects With Antiphospholipid Antibody Positivity: A Systematic Review and Meta-analysis

Currently, the guidelines for the prevention of atherosclerosis in patients with antiphospholipid syndrome (APS) do not differ substantially from those in the general population. We aimed to assess the risk of subclinical atherosclerosis in patients with APS and subjects with antiphospholipid antibody (aPL) positivity. Systematic literature search was conducted through Medline and Scopus until January 2023. Random effects meta-analyses were performed to examine the differences in markers of subclinical atherosclerosis between APS patients, subjects positive for aPLs and healthy controls. Patients with APS had significantly higher values of common carotid artery (CCA) intima-media thickness (IMT) (MD = 0.07 mm; P < 0.0001), internal carotid artery IMT (MD = 0.06 mm; P < 0.01), carotid bifurcation IMT (MD = 0.14 mm; P < 0.01) and were more frequently diagnosed with atherosclerotic plaques compared to controls (OR = 3.73; P < 0.01). Similarly, APS patients showed a decreased flow and nitrate-mediated dilation (MD = -4.52 %; <0.01, MD = -1.25 %; P < 0.05, respectively). Interestingly, comparable were the results for subjects with aPL positivity, who had higher CCA-IMT (MD = 0.06 mm; P < 0.01) and higher prevalence of atherosclerotic plaques (OR = 2.59; P = 0.08) compared to controls. Sensitivity analysis conducted on primary APS patients revealed that the risk of atherosclerosis is associated with APS per se and is not exclusively driven by other underlying conditions. Patients with APS and subjects with aPLs have an increased risk of subclinical atherosclerosis and require early and disease-specific prevention of atherosclerosis.

Cardiovascular disease risk in antiphospholipid syndrome: Thrombo-inflammation and atherothrombosis

Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by the presence of antiphospholipid antibodies (aPL) (lupus anticoagulant, anticardiolipin antibodies and anti-beta2glycoprotein I (anti-β2GPI) antibodies) and a plethora of macro- and micro-vascular manifestations, affecting predominantly young adults. Cardiovascular events are the leading causes of morbidity and mortality in APS. APL-mediated thrombo-inflammation and atherothrombosis are emerging pathogenetic mechanisms of cardiovascular disease (CVD) in APS, involving endothelial cell and monocyte activation, cytokines and adhesion molecules expression, complement and neutrophils activation, neutrophil extracellular traps formation, platelet cell activation and aggregation, and subsequent thrombin generation, in parallel with an oxidized low-density lipoprotein (oxLDL)-β2GPI complex induced macrophage differentiation to foam cells. High risk aPL profile, especially the presence of lupus anticoagulant and triple aPL positivity (all three aPL subtypes), co-existence with Systemic Lupus Erythematosus (SLE), as well as traditional risk factors such as smoking, hypertension, hyperlipemia and obesity are associated with both subclinical atherosclerosis and cardiovascular events in APS. Increased awareness of CVD risk by the physicians and patients, regular assessment and strict control of traditional risk factors, and lifestyle modifications are recommended. Use of low-dose aspirin should be considered for cardiovascular prevention in asymptomatic aPL carriers or SLE patients with high-risk aPL profile. The role of older agents such as hydroxychloroquine and statins or new potential targeted treatments against immuno- and athero-thrombosis has been demonstrated by experimental and some clinical studies and needs to be further evaluated by randomized controlled studies. This review summarizes the available evidence about the pathogenetic mechanisms and prevalence of cardiovascular events and subclinical atherosclerosis, the interrelationship between traditional and disease-related CVD risk factors, and the cardiovascular risk assessment and management in APS.

Antiphospholipid antibodies in patients with myocardial infarction with and without obstructive coronary arteries

BACKGROUND

Recent studies demonstrate that prothrombotic antiphospholipid antibodies (aPL) are overrepresented in patients with myocardial infarction (MI) due to coronary artery disease (MICAD). However, it is not known whether aPL differ between the two subsets of MI: MICAD and MI with nonobstructive coronary arteries (MINOCA).

OBJECTIVES

To determine whether aPL are associated with MINOCA or MICAD, or with hypercoagulability as assessed by activated protein C-protein C inhibitor (APC-PCI) complex.

METHODS

Well-characterized patients with MINOCA (n = 98), age- and gender-matched patients with MICAD (n = 99), and healthy controls (n = 100) were included in a cross-sectional case-control study. Autoantibodies (IgA/G/M) targeting cardiolipin and β₂ glycoprotein-I and specific nuclear antigens were analyzed by multiplexed bead technology. The concentration of APC-PCI was determined as a measure of hypercoagulability by an immunofluorometric sandwich assay.

RESULTS

Both prevalence and titers of aPL of the IgG isotype (anti-cardiolipin and/or anti-β₂ glycoprotein-I) were higher in patients with MINOCA and MICAD than in controls. aPL IgG positivity was twice as frequent among patients with MICAD than MINOCA (11% vs. 6%, nonsignificant). We observed no group differences regarding aPL IgA/M or antibodies targeting specific nuclear antigens. Levels of APC-PCI were elevated in aPL IgG-positive compared to aPL IgG-negative MICAD patients.

CONCLUSIONS

aPL IgG, but not IgA/M, are enriched particularly in patients with MICAD but also in patients with MINOCA, as compared to controls. Interestingly, signs of hypercoagulability-measured by increased levels of the APC-PCI complex-were present in aPL IgG-positive MICAD patients, indicating an association with functional disturbances of the coagulation system.

Description of damage in different clusters of patients with antiphospholipid syndrome

OBJECTIVE

To identify the different clinical phenotypes of antiphospholipid syndrome (APS) by using cluster analysis and describe cumulative damage of disease clusters.

METHODS

This retrospective study includes patients with APS (±systemic lupus erythematosus (SLE)). Two-step cluster analysis was applied by considering clinical data. Damage was calculated for all patients by applying damage index for APS (DIAPS).

RESULTS

A total of 237 patients (198 females; median age of 43 years; median follow-up of 9.5 years) were classified into four clusters. Cluster 1 (n = 74) consisted of older patients with arterial-predominant thrombosis, livedo reticularis, and increased cardiovascular risk; cluster 2 (n = 70) of SLE+APS patients with thrombocytopenia and heart valve disease; cluster 3 (n = 59) of patients with venous-predominant thrombosis, less extra-criteria manifestations; and cluster 4 (n = 34) of patients with only pregnancy morbidity with lower frequency of extra-criteria features and cardiovascular risk. Patients with SLE+APS (n = 123) had the highest mean DIAPS. Regarding clusters, 1 and 2 had high cumulative damage. While cumulative survival rates of clusters did not differ, cluster 2 and 3 had lower survival rates at further years. There was no correlation between DIAPS and mortality.

CONCLUSION

SLE+APS patients with extra-criteria manifestations and older APS patients with arterial thrombosis and increased cardiovascular risk have higher cumulative damage. Effective treatment of SLE disease activity and control of cardiovascular risk may help to reduce cumulative damage in these patients.

Extrinsic and Intrinsic Responses in the Development and Progression of Atherosclerosis

Atherosclerosis is a multifactorial disease that is thought to be primarily inflammatory in origin. Given the contribution of inflammation to the development and progression of atherosclerosis, other conditions that are characterised by a dysregulated inflammatory response have also been proposed to play a role. The purpose of this review is to organise and present the various inflammatory processes that can affect atherosclerosis into two broad categories: extrinsic or host-independent and intrinsic or host-dependent. Within these two categories, we will discuss various processes that may contribute to the development and progression of atherosclerosis and the clinical studies describing these associations. Although the clinical trials investigating anti-inflammatory therapies have to date provided mixed results, further studies, particularly in conjunction with lipid-lowering and blood pressure lowering therapies should be considered.

Validation of the adjusted global antiphospholipid syndrome score in a single centre cohort of APS patients from Turkey

The adjusted global antiphospholipid syndrome score (aGAPSS) is a recently developed thrombotic risk assessment score that considers the antiphospholipid antibody (aPL) profile and conventional cardiovascular risk factors. In this retrospective study, we aimed to evaluate the validity of the aGAPSS in predicting clinical manifestations (criteria and extra-criteria) of antiphospholipid syndrome (APS) in a single centre cohort of patients. Ninety-eight patients with APS ± systemic lupus erythematosus (SLE) were classified according to clinical manifestations as vascular thrombosis (VT), pregnancy morbidity (PM) or both (VT + PM). The aGAPSS was calculated for each patient as previously defined. Mean aGAPSS of the cohort was calculated as 10.2 ± 3.8. Significantly higher aGAPSS values were seen in VT (n = 58) and VT + PM (n = 29) groups when compared to PM (n = 11) group (10.6 ± 3.7 vs 7.4 ± 2.9, P = 0.005; 10.7 ± 4 vs 7.4 ± 2.9, P = 0.008, respectively), mainly due to lower frequencies of cardiovascular risk factors in PM. Higher aGAPPS values were also associated with recurrent thrombosis (11.6 ± 3.7 vs 9.9 ± 3.6, P = 0.04). Regarding extra-criteria manifestations, patients with livedo reticularis (n = 11) and APS nephropathy (n = 9) had significantly higher aGAPSS values (12.9 ± 3.4 vs 9.9 ± 3.7, P = 0.02; 12.4 ± 2.9 vs 10 ± 3.8, P = 0.04, respectively). The computed AUC demonstrated that aGAPSS values ≥10 had the best diagnostic accuracy for thrombosis. Our results suggest that patients with higher aGAPSS values are at higher risk for developing vascular thrombosis (either first event or recurrence) and extra-criteria manifestations, especially livedo reticularis and APS nephropathy.

Effects of β2/aβ2 on oxLDL-induced CD36 activation in THP-1 macrophages

AIMS

β2-glycoprotein I/anti-β2-glycoprotein I antibody complex (β2/aβ2) could promote oxLDL-induced endothelial inflammation through Toll-like receptor 4 (TLR4), therefore accelerates atherosclerosis in patients with anti-phospholipid syndrome (APS). However, effects of β2/aβ2 and TLR4 on oxLDL-induced CD36 activation in macrophages remain to be elucidated and are currently under investigation.

MATERIALS AND METHODS

THP-1 macrophages with or without the pre-treatment of TAK-242, a TLR4 inhibitor, were treated with RPMI 1640, oxLDL, oxLDL+β2/aβ2 or oxLDL + LPS.CD36 expression and subsequent intracellular lipid accumulation, cholesterol-transportation-related proteins (ACAT1, ABCG1 and ABCA1) expression, inflammatory cytokines (IL-1β, TNF-α and IL-6) secretion, focal adhesion kinases (FAK) activation and matrix metalloproteinases (MMP-2 and MMP-9) expression by these THP-1 macrophages were evaluated. Moreover, effects of TLR4 on oxLDL+β2/aβ2-induced peroxisome proliferators-activated receptor-γ (PPAR-γ) expression and CD36 translocation have also been observed.

KEY FINDINGS

Compared with oxLDL-treated ones, CD36 expression, intracellular lipid accumulation and FAK activation were inhibited, whereas the levels of inflammatory cytokines and MMPs were upregulated in THP-1 macrophages treated with oxLDL+β2/aβ2 (p < 0.05). Moreover, observed differences between oxLDL-treated and oxLDL+β2/aβ2-treated THP-1 macrophages could be reversed by TAK-242 pre-treatment (p < 0.05). Furthermore, oxLDL+β2/aβ2 promoted PPAR-γ expression and CD36 cytoplasmic translocation in THP-1 macrophages, these effects could also be attenuated by TAK-242 (p < 0.05).

SIGNIFICANCE

Through a TLR4 dependent manner, β2/aβ2 inhibited oxLDL-induced CD36 expression, lipid accumulation and FAK activation, while promoted inflammatory cytokines and MMPs expression in THP-1 macrophages, indicating the novel dual roles played by β2/aβ2 in APS-related atherosclerosis.

Cardiac Manifestations of Antiphospholipid Syndrome With Focus on Its Primary Form

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.

The frequency of anti-phospholipid antibody syndrome in patients with premature coronary artery disease

Introduction: Coronary Artery Disease (CAD) is known as the major cause of morbidity and mortality in the world with a growing trend, especially in some developing countries. CAD commonly observed in elderly cases, however; recently it is usually found in young adults. In this study, we aimed to evaluate the prevalence of anti-phospholipid antibody syndrome (APS) in patients with premature CAD.

Methods: The cross-sectional study was conducted in Baqiyatallah hospital from April 2012 to April 2016. Patients with premature CAD were included in the study. The data regarding the laboratory tests, echocardiography, and angiography were obtained from all cases.

Results: Overall 133 eligible patients were included in the study. In the first set of the laboratory test, 18 patients were recognized to have APS (13.53%). The second confirmatory APA test was showing 3 of 18 patients were considered to have APS (2.25%).

Conclusion: The results showed there is an association between the risk of developing Premature CAD and APS could potentially. The APS may have significant effects on the risk of coronary heart disease, especially in young adults.

Plasma levels of high-mobility group box 1 and soluble receptor for advanced glycation end products in primary antiphospholipid antibody syndrome patients

Introduction

Many studies have demonstrated elevated circulating levels of high-mobility group box 1 (HMGB1) and decreased circulating levels of soluble receptor for advanced glycation end products (sRAGE) in patients with autoimmune diseases. In the present study, we investigated plasma levels of both HMGB1 and sRAGE in primary antiphospholipid syndrome (pAPS) patients.

Methods

We prospectively recruited 11 pAPS patients, 17 antiphospholipid antibody (APA)-positive SLE patients without APS manifestations (APA⁺SLE) and 12 SLE patients with secondary APS (APS⁺SLE). We also recruited 10 healthy controls (HCs). Plasma levels of HMGB1 and sRAGE were determined using sandwich ELISA kits. In addition, plasma levels of HMGB1 were also determined using Western blot in 6 pAPS patients and 6 HCs.

Results

There was no significant difference in plasma levels of HMGB1 measured by ELISA among subgroups of the enrolled subjects. In addition, there was no significant difference in plasma levels of HMGB1 measured by Western blot between pAPS patients and HCs. On the other hand, we observed a trend toward lower plasma levels of sRAGE in APA⁺SLE or APS⁺SLE patients when compared with HCs. However, there was no significant difference in plasma levels of sRAGE between pAPS patients and HCs, or between APA⁺SLE patients and APS⁺SLE patients.

Conclusion

There was no significant difference in plasma levels of sRAGE or HMGB1 between pAPS patients and HCs. Plasma levels of sRAGE/HMGB1 could not be utilized to differentiate between APA⁺SLE and APS⁺SLE patients.

Prevalence and associated factors of resting electrocardiogram abnormalities among systemic lupus erythematosus patients without cardiovascular disease

Background

Electrocardiogram (ECG) cardiovascular disease (CVD) abnormalities (ECG-CVD) are predictive of subsequent CVD events in the general population. Systemic lupus erythematosus (SLE) patients are vulnerable to CVD. We aimed to determine the prevalence of ECG-CVD in SLE patients and to examine the risk factors associated with ECG-CVD.

Methods

A 12-lead resting supine ECG was performed on consecutive adult patients attending the clinic. One cardiologist interpreted the ECGs. ECG-CVD were defined as the presence of one or more of the following 4 elements (ECG-4): ST-segment and/or T-wave abnormalities, left ventricular hypertrophy (LVH), left axis deviation (LAD), left bundle branch block (LBBB) and right bundle branch block (RBBB). ECG-5 included the same elements as ECG-4 and the Q-wave. Repeated measurement data were created and the associations between ECG-4/ECG-5 and demographics were evaluated with univariate and multivariate Cox regression models.

Results

Of 487 SLE patients, 104 (21.4%) and 118 (24.2%) patients had one or more of the ECG-4 and ECG-5 elements, respectively. A higher prevalence of ECG-CVD was found in patients with a longer SLE disease duration, and the burden of ECG-CVD elements increased with age. Increased age, active SLE disease, and damage were associated with ECG4 and ECG-5, while treatment of hyperlipidemia was protective.

Conclusion

A high prevalence of ECG-4 (21.4%) and ECG-5 (24.2%) was found in this SLE cohort. Controlling SLE disease activity is important since it was associated with ECG-4 and ECG-5. Early identification of ECG-4 and ECG-5 in SLE patients might allow for better stratification and risk management.