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Tohidi-Esfahani I, Mittal P, Isenberg D, Cohen H, Efthymiou M. Platelets and Thrombotic Antiphospholipid Syndrome. J Clin Med 2024; 13:741. [PMID: 38337435 PMCID: PMC10856779 DOI: 10.3390/jcm13030741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Antiphospholipid antibody syndrome (APS) is an autoimmune disorder characterised by thrombosis and the presence of antiphospholipid antibodies (aPL): lupus anticoagulant and/or IgG/IgM anti-β2-glycoprotein I and anticardiolipin antibodies. APS carries significant morbidity for a relatively young patient population from recurrent thrombosis in any vascular bed (arterial, venous, or microvascular), often despite current standard of care, which is anticoagulation with vitamin K antagonists (VKA). Platelets have established roles in thrombosis at any site, and platelet hyperreactivity is clearly demonstrated in the pathophysiology of APS. Together with excess thrombin generation, platelet activation and aggregation are the common end result of all the pathophysiological pathways leading to thrombosis in APS. However, antiplatelet therapies play little role in APS, reserved as a possible option of low dose aspirin in addition to VKA in arterial or refractory thrombosis. This review outlines the current evidence and mechanisms for excessive platelet activation in APS, how it plays a central role in APS-related thrombosis, what evidence for antiplatelets is available in clinical outcomes studies, and potential future avenues to define how to target platelet hyperreactivity better with minimal impact on haemostasis.
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Affiliation(s)
- Ibrahim Tohidi-Esfahani
- Haematology Department, Concord Repatriation General Hospital, Sydney, NSW 2139, Australia
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2050, Australia
| | - Prabal Mittal
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London WC1E 6DD, UK;
| | - David Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London WC1E 6JF, UK
| | - Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK
- Haemostasis Research Unit, Department of Haematology, University College London, London WC1E 6DD, UK;
| | - Maria Efthymiou
- Haemostasis Research Unit, Department of Haematology, University College London, London WC1E 6DD, UK;
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Nasonov EL, Reshetnyak TM, Solovyev SK, Popkova TV. [Systemic lupus erythematosus and antiphospholipid syndrome: past, present, future]. TERAPEVT ARKH 2023; 95:365-374. [PMID: 38158987 DOI: 10.26442/00403660.2023.05.202246] [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: 07/16/2023] [Accepted: 07/16/2023] [Indexed: 01/03/2024]
Abstract
Immune-inflammatory (autoimmune and autoinflammatory) rheumatic diseases are widespread severe chronic inflammatory diseases and also "models" for studying the fundamental mechanisms of pathogenesis and approach to pharmacotherapy of other diseases associated with autoimmunity and/or autoinflammation. Uncontrolled inflammation leading to hypercoagulation forms the basis of "thromboinflammation", which is considered a universal pathogenetic mechanism of organ involvement in immune-inflammatory rheumatic diseases, as well as in COVID-19 and atherosclerotic vascular lesions (atherothrombosis). Thrombo-inflammatory mechanisms play a crucial role in systemic lupus erythematosus and antiphospholipid syndrome. Russian rheumatology, under the leadership of academician Valentina Alexandrovna Nasonova, greatly contributed to the research of these disorders. This article addresses the current view about the overlapping pathogenetic mechanisms of thrombosis in systemic lupus erythematosus and antiphospholipid syndrome, the relevance of these studies during the COVID-19 pandemic, and the prospects for antithrombotic and anti-inflammatory therapy.
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Affiliation(s)
- E L Nasonov
- Nasonova Research Institute of Rheumatology
- Sechenov First Moscow State Medical University (Sechenov University)
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3
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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
Antiphospholipid syndrome (APS) is a thrombo-inflammatory disease propelled by circulating autoantibodies that recognize cell surface phospholipids and phospholipid binding proteins. The result is an increased risk of thrombotic events, pregnancy morbidity, and various other autoimmune and inflammatory complications. Although antiphospholipid syndrome was first recognized in patients with lupus, the stand alone presentation of antiphospholipid syndrome is at least equally common. Overall, the diagnosis appears to affect at least one in 2000 people. Studies of antiphospholipid syndrome pathogenesis have long focused on logical candidates such as coagulation factors, endothelial cells, and platelets. Recent work has shed light on additional potential therapeutic targets within the innate immune system, including the complement system and neutrophil extracellular traps. Vitamin K antagonists remain the mainstay of treatment for most patients with thrombotic antiphospholipid syndrome and, based on current data, appear superior to the more targeted direct oral anticoagulants. The potential role of immunomodulatory treatments in antiphospholipid syndrome management is receiving increased attention. As for many systemic autoimmune diseases, the most important future direction is to more precisely identify mechanistic drivers of disease heterogeneity in pursuit of unlocking personalized and proactive treatments for patients.
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Affiliation(s)
- Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - D Ware Branch
- James R. and Jo Scott Research Chair, Department of Obstetrics and Gynecology, University of Utah Health and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas L Ortel
- Division of Hematology, Departments of Medicine and Pathology, Duke University, Durham, North Carolina, USA
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Wu T, Huang W, Qi J, Li Y, Zhang Y, Jiang H, Wang J, Zhang J, Jiang Z, Chen L, Ying Z. Research trends and frontiers on antiphospholipid syndrome: A 10-year bibliometric analysis (2012-2021). Front Pharmacol 2022; 13:1035229. [PMID: 36386238 PMCID: PMC9664156 DOI: 10.3389/fphar.2022.1035229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 10/13/2022] [Indexed: 01/24/2023] Open
Abstract
Objectives: A growing body of studies related to antiphospholipid syndrome (APS) have been published in recent years. Nevertheless, there is a lack of visualized and systematic analysis in the literature on APS. Hence, this study sought to conduct a bibliometric analysis to identify research status and discover frontiers in the field. Methods: Articles and reviews concerning APS were acquired from the Web of Science Core Collection (WoSCC) database. CiteSpace, VOSviewer and a bibliometric online analysis platform were employed to conduct a visualization and knowledge-map analysis. Results: A total of 1,390 publications regarding APS were identified. Globally, Italy contributed the most publications. The University of Padua was the most productive institution. Lupus ranked first in both the most published and most co-cited journals. Savino Sciascia and Spiros Miyakis were the most prolific and most co-cited authors, respectively. "Vitamin K antagonists (VKA)" and "immunoglobulin A (IgA)" were current research foci. Burst analysis of keywords suggested that "neutrophil extracellular trap (NET)," "direct oral anticoagulant (DOAC)," "open label," "outcome," "hydroxychloroquine (HCQ)," and "arterial thrombosis (AT)" were significant future research frontiers. Conclusion: The scientific literature on APS has increased steadily in the past 10 years. The clinical studies on the treatment and mechanism research of APS are recognized as promising research hotspots in the domain of APS. The research status and trends of APS publications from the bibliometric perspective can provide a practical guide and important reference for subsequent studies by researchers and physicians in the domain.
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Affiliation(s)
- Teng Wu
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China,Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Wei Huang
- Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China,Qingdao University, Qingdao, China
| | - Jiaping Qi
- Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China,Bengbu Medical College, Bengbu, China
| | - Yixuan Li
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China,Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Yuan Zhang
- Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China,Bengbu Medical College, Bengbu, China
| | - Huan Jiang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China,Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Jing Wang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China,Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Ju Zhang
- Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Zhaoyu Jiang
- Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Lin Chen
- Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China
| | - Zhenhua Ying
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China,Zhejiang Provincial People’s Hospital, Hangzhou Medical College Affiliated People’s Hospital, Rheumatism and Immunity Research Institute, Hangzhou, China,Qingdao University, Qingdao, China,Bengbu Medical College, Bengbu, China,*Correspondence: Zhenhua Ying,
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Sayar Z, Burke S, Mittal P, Cohen H. The use of fondaparinux and rituximab for recurrent thrombotic events in antiphospholipid syndrome. Lupus 2022; 31:1485-1490. [PMID: 36074077 PMCID: PMC9580031 DOI: 10.1177/09612033221122147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Limited evidence exists to guide the management of recurrent thrombosis occurring despite therapeutic anticoagulation in patients with thrombotic antiphospholipid syndrome (APS). In this case series, fondaparinux, with or without an antiplatelet agent, provided an effective and safe option in three patients with thrombotic APS, all two triple and one single positive for antiphospholipid antibodies, who had recurrent venous and/or arterial thromboembolism. Rituximab was also used in all patients. Recurrent events occurred despite therapeutic anticoagulation, including at high-intensity, with warfarin and subsequent low-molecular-weight heparin. There were no major bleeding events. Adjunctive therapies used for thrombosis included catheter-directed thrombolysis and rituximab.
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Affiliation(s)
- Zara Sayar
- Department of Haematology, 4919University College London Hospitals NHS Foundation Trust, London, UK.,Department of Haematology, Whittington Health NHS Trust, London, UK
| | - Shoshana Burke
- Department of Haematology, 4919University College London Hospitals NHS Foundation Trust, London, UK
| | - Prabal Mittal
- Department of Haematology, 4919University College London Hospitals NHS Foundation Trust, London, UK.,Haemostasis Research Unit, Department of Haematology, 4919University College London, London, UK
| | - Hannah Cohen
- Department of Haematology, 4919University College London Hospitals NHS Foundation Trust, London, UK.,Haemostasis Research Unit, Department of Haematology, 4919University College London, London, UK
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Tumian NR, Hunt BJ. Clinical Management of Thrombotic Antiphospholipid Syndrome. J Clin Med 2022; 11:jcm11030735. [PMID: 35160188 PMCID: PMC8836580 DOI: 10.3390/jcm11030735] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 12/19/2022] Open
Abstract
Thrombotic manifestations of antiphospholipid syndrome are often a therapeutic dilemma and challenge. Despite our increasing knowledge of this relatively new disease, many issues remain widely unknown and controversial. In this review, we summarise the latest literature and guidelines on the management of thrombotic antiphospholipid syndrome. These include the laboratory assays involved in antiphospholipid antibodies (aPL) testing, the use of direct oral anticoagulants in secondary prevention, management of recurrent thrombosis, individuals with isolated aPL, and catastrophic antiphospholipid syndrome. Treatment aims to prevent the potentially fatal and often disabling complications of APS with antithrombotic and cardiovascular risks prevention strategies. Some insights and updates on topical issues in APS are provided. We also include our current practice, which we believe is the pragmatic approach based on the currently available evidence.
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Affiliation(s)
- Nor Rafeah Tumian
- Haemostasis & Thrombosis Centre, Guy’s and St Thomas’ Hospital NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK;
- Clinical Haematology Unit, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Malaysia
| | - Beverley J. Hunt
- Haemostasis & Thrombosis Centre, Guy’s and St Thomas’ Hospital NHS Foundation Trust, Westminster Bridge Road, London SE1 7EH, UK;
- Correspondence:
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8
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Abstract
PURPOSE OF REVIEW To review the recent available evidence on epidemiology, pathogenesis, clinical phenotypes, and management of antiphospholipid syndrome (APS) and summarize potential future research perspectives. RECENT FINDINGS Accumulating evidence has further expanded our understanding of the disease, including new data about the incidence and prevalence of APS, novel pathways supporting the role of thrombo-inflammation in APS including platelet, monocyte and endothelial cell activation, pro-inflammatory cytokine and chemokine production, complement activation, neutrophil extracellular trap release, and type I interferon gene expression that could yield to new potential treatment targets, better identification of criteria and non-criteria clinical phenotypes, antiphospholipid antibody profiles and their associations with clinical outcomes, prognostic tools, and treatment strategies based on recent evidence-based recommendations for patients with thrombotic and obstetric APS, with or without systemic lupus erythematosus. Ongoing research efforts and international collaborations enhance our knowledge of this rare and often devastating syndrome and help improve patient care and health outcomes.
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Affiliation(s)
- Eleni Xourgia
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria G Tektonidou
- Department of Propaedeutic Internal Medicine, Medical School, Rheumatology UnitJoint Academic Rheumatology Program - EULAR Centre of Excellence'Laiko' Hospital, National and Kapodistrian University of Athens, 17 Agiou Thoma str, 11527, FirstAthens, Greece.
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9
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Selby R, Abdulrehman J. Antiphospholipid Antibodies and the Antiphospholipid Syndrome: From Coagulation to the Clinic. J Appl Lab Med 2022; 7:373-378. [PMID: 34996086 PMCID: PMC8741326 DOI: 10.1093/jalm/jfab134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 10/04/2021] [Indexed: 01/07/2023]
Affiliation(s)
- Rita Selby
- Department of Laboratory Medicine & Pathobiology & Department of Medicine, University of Toronto, Toronto, ON, Canada,Address correspondence to this author at: University Health Network Laboratory Medicine Program, Room 3EB 359C, Toronto General Hospital, 200 Elizabeth St, Toronto, ON, M5G 2C4 Canada. Fax 416 340 5544; e-mail:
| | - Jameel Abdulrehman
- Division of Hematology & Medical Oncology, Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
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Croles FN, Te Boekhorst PAW, Leebeek FWG, Jansen AJG. Therapeutic plasma exchange for anticoagulant-refractory antiphospholipid syndrome with severe ischemic and necrotic skin lesions: A case series. Transfus Apher Sci 2021; 60:103192. [PMID: 34226147 DOI: 10.1016/j.transci.2021.103192] [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: 03/17/2021] [Revised: 06/01/2021] [Accepted: 06/11/2021] [Indexed: 11/17/2022]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by clinical findings including thrombosis and/or obstetric complication and laboratory findings, e.g. ≥1 positive antiphospholipid antibodies (aPL) (lupus anticoagulant, anticardiolipin IgG/IgM and/or anti-β2-glycoprotein IgG/IgM). A rare APS clinical entity is severe necrosis which is difficult to treat and often does not respond to anticoagulant therapy. Three consecutive patients with primary or secondary APS who presented with necrotic skin lesions secondary to APS were treated with therapeutic plasma exchange (TPE), glucocorticoids and low-molecular-weight heparin. All patients had a rapid-onset, either full or significant recovery of their APS-related necrotic lesions. Upon treatment, one patients showed resolution of lupus anticoagulant. Two patients had a decrease of at least 88 % in aPL titers after the initial treatment, and were kept on TPE maintenance every 5-6 weeks. None of the patients experienced significant side effects of the TPE. This is the first case series showing the clinical benefits of TPE in patients with ischemic and necrotic skin lesions due to severe anticoagulant-refractory vascular APS.
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Affiliation(s)
- F Nanne Croles
- Department of Hematology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Peter A W Te Boekhorst
- Department of Hematology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Frank W G Leebeek
- Department of Hematology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - A J Gerard Jansen
- Department of Hematology, Erasmus MC University Medical Center, Rotterdam, the Netherlands.
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Erkan D. Expert Perspective: Management of Microvascular and Catastrophic Antiphospholipid Syndrome. Arthritis Rheumatol 2021; 73:1780-1790. [PMID: 34114366 DOI: 10.1002/art.41891] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/01/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Doruk Erkan
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
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12
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Management of Antiphospholipid Syndrome. Biomedicines 2020; 8:biomedicines8110508. [PMID: 33212808 PMCID: PMC7696303 DOI: 10.3390/biomedicines8110508] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/09/2020] [Accepted: 11/14/2020] [Indexed: 02/07/2023] Open
Abstract
Antiphospholipid syndrome (APS), is an acquired autoimmune disorder characterised by thrombosis, pregnancy morbidity, and the presence of antiphospholipid antibodies (aPL). Although venous thromboembolism is the most common manifestation, thrombotic events in APS may also occur in virtually any vascular bed, with cerebral circulation being the arterial territory most commonly affected. As APS is a heterogeneous condition, its management should be tailored with a patient-centred approach based on individual risk assessment, which includes the aPL profile, concomitant auto-immune diseases, and traditional cardiovascular risk factors. Although literature data are conflicting regarding primary prophylaxis, there is some evidence indicating that antiplatelet agents may reduce the risk of a first thrombotic event in individuals with a high-risk profile. In patients with thrombotic APS, current evidence-based guidelines recommend lifelong vitamin K antagonists (VKAs), preferably warfarin. The optimal intensity of anticoagulation following arterial thrombosis remains controversial. Arterial thrombosis should be treated either with high-intensity warfarin at a target INR > 3.0, or low-dose aspirin (LDA) combined with moderate-intensity warfarin (INR 2.0-3.0). It is recommended to avoid direct oral anticoagulants (DOACs) in patients with high-risk APS, mainly those with triple-positive PL and previous arterial events. They would only be used exceptionally in selected patients with low-risk venous thromboembolism (VTE). In low-risk VTE patients currently treated with a DOAC due to warfarin intolerance or a previous unstable International Normalized Ratio on warfarin, the decision of continuing DOACs would be taken in carefully selected patients. In women with obstetric APS, the combination therapy with LDA plus heparin remains the conventional strategy.
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