1
|
Hanarz M, Ząbczyk M, Natorska J, Baran M, Undas A. Positive antiphospholipid antibodies increase the risk of ischemic stroke in patients with atrial fibrillation. J Thromb Haemost 2024; 22:2797-2809. [PMID: 38944242 DOI: 10.1016/j.jtha.2024.05.038] [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: 01/23/2024] [Revised: 05/27/2024] [Accepted: 05/30/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Antiphospholipid antibodies (aPL), including lupus anticoagulant, antibodies against β2 glycoprotein I (anti-β2GPI), and anticardiolipin (aCL) antibodies are associated with ischemic stroke (IS). Their prevalence and clinical relevance in atrial fibrillation (AF) remain unclear. OBJECTIVES To assess whether aPL are associated with increased risk of IS in AF patients despite anticoagulation. METHODS We conducted a post hoc analysis of aPL using blood samples from 243 consecutive AF patients enrolled in a cohort study. Markers of a prothrombotic state, including endogenous thrombin potential, fibrin clot permeability, and lysis time, were measured at baseline. During a median follow-up of 52 months, IS/transient ischemic attack and major bleeding were recorded. RESULTS We observed aPL at a moderate or high titer in 51 (21%) patients, including 17 (7%) with anti-β2GPI, 19 (7.8%) with aCL antibodies, and 37 (15.2%) with lupus anticoagulant. aPL-positive patients were more likely to have prior stroke (P = .01) and be active smokers (P = .03), along with increased endogenous thrombin potential (P = .02), without any changes in fibrin clot properties. Anti-β2GPI (hazard ratio, 4.38; 95% CI, 1.58-12.19) and aCL (hazard ratio, 4.70; 95% CI, 1.80-12.30) at a moderate or high titer were associated with IS during follow-up (n = 20; 1.9% per year). There were 23 major bleedings (2.1% per year) and 20 deaths (1.9% per year), which were not associated with aPLs. CONCLUSION Our study showed a relatively high prevalence of aPL positivity in AF patients, which was linked to an increased risk of IS/transient ischemic attack. This suggests that screening for aPL might help optimize anticoagulant therapy in such patients.
Collapse
Affiliation(s)
- Maksymilian Hanarz
- Department of Thromboembolic Diseases, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Michał Ząbczyk
- Department of Thromboembolic Diseases, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; Krakow Centre for Medical Research and Technologies, St. John Paul II Hospital, Krakow, Poland
| | - Joanna Natorska
- Department of Thromboembolic Diseases, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; Krakow Centre for Medical Research and Technologies, St. John Paul II Hospital, Krakow, Poland
| | - Mateusz Baran
- Faculty of Electrical Engineering, Automatics, Computer Science and Biomedical Engineering, AGH University of Science and Technology, Krakow, Poland
| | - Anetta Undas
- Department of Thromboembolic Diseases, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; Krakow Centre for Medical Research and Technologies, St. John Paul II Hospital, Krakow, Poland.
| |
Collapse
|
2
|
Wei J, Zhang M, Wang X, Yang K, Xiao Q, Zhu X, Pan X. Role of cardiolipin in regulating and treating atherosclerotic cardiovascular diseases. Eur J Pharmacol 2024; 979:176853. [PMID: 39067567 DOI: 10.1016/j.ejphar.2024.176853] [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: 05/06/2024] [Revised: 07/10/2024] [Accepted: 07/24/2024] [Indexed: 07/30/2024]
Abstract
Cardiovascular diseases, mainly caused by atherosclerosis, are the leading causes of morbidity and mortality worldwide. Despite the discrepancies in clinical manifestations between different abnormalities, atherosclerosis shares similar pathophysiological processes, such as mitochondrial dysfunction. Cardiolipin (CL) is a conserved mitochondria-specific lipid that contributes to the cristae structure of the inner mitochondrial membrane (IMM). Alterations in the CL, including oxidative modification, reduced quantity, and abnormal localization, contribute to the onset and progression of atherosclerosis. In this review, we summarize the knowledge that CL is involved in the pathogenesis of atherosclerosis. On the one hand, CL and its oxidative modification promote the progression of atherosclerosis via several mechanisms, including oxidative stress, apoptosis, and inflammation in response to stress. On the other hand, CL externalizes to the outer mitochondrial membrane (OMM) and acts as the pivotal "eat-me" signal in mitophagy, removing dysfunctional mitochondria and safeguarding against the progression of atherosclerosis. Given the imbalance between proatherogenic and antiatherogenic effects, we provide our understanding of the roles of the CL and its oxidative modification in atherosclerotic cardiovascular diseases, in addition to potential therapeutic strategies aimed at restoring the CL. Briefly, CL is far more than a structural IMM lipid; broader significances of the evolutionarily conserved lipid need to be explored.
Collapse
Affiliation(s)
- Jin Wei
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Meng Zhang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xia Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Kaiying Yang
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qi Xiao
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China.
| | - Xiaoyan Zhu
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China.
| | - Xudong Pan
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China.
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Wang Q, Han G, Sha Y, Tang M, Pan Z, Zhu Y, Zhou L, Ni J. Current status and value of testing antiphospholipid antibody in patients with acute ischemic stroke: a retrospective single-center study in China. Neurol Sci 2024; 45:1121-1128. [PMID: 37707604 DOI: 10.1007/s10072-023-07054-7] [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: 05/06/2023] [Accepted: 09/01/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND AND PURPOSE Testing for antiphospholipid antibodies (aPL) is useful to determine the cause of ischemic stroke in young and female patients. However, the clinical relevance of aPL in older patients with ischemic stroke remains unclear. We aimed to explore the status and diagnostic value of initial aPL testing in all patients with acute ischemic stroke. METHODS We retrospectively analyzed patients with acute ischemic stroke who were consecutively hospitalized in our hospital between June 2012 and January 2022 and investigated the factors associated with performing aPL screening in real-world clinical practice. Furthermore, factors associated with initial aPL positivity were evaluated by comparing the demographic, etiological, and therapeutic characteristics. RESULTS Of 1209 patients, 287 (23.7%) were tested for aPL and 58 (20.2%) tested positive. Physicians tended to conduct aPL testing on female patients (P<0.001), younger patients (P<0.001), patients with fewer vascular risk factors (P<0.001), and multiple infarctions in the multivascular blood supply area (P<0.001). Multivariate logistic regression analysis showed that only stroke of other determined etiology type was a significant influencing factor for positive aPL results (OR 2.97, 95% CI 1.137, 7.774, P=0.026), adjusting for sex, age, and causes of stroke, etc. CONCLUSION: Approximately one-quarter of the patients with acute ischemic stroke were tested for aPL. Age, sex, number of vascular risk factors, and neuroimaging features affected the discretion in performing aPL testing. aPL testing may be appropriate in older patients with no identified cause of ischemic stroke and may provide additional diagnostic opportunities for acute ischemic stroke.
Collapse
Affiliation(s)
- Qiqi Wang
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Guangsong Han
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yuhui Sha
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Mingyu Tang
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Ziang Pan
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Yicheng Zhu
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Lixin Zhou
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Jun Ni
- Department of Neurology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| |
Collapse
|
5
|
Gaspar P, Sciascia S, Tektonidou MG. Epidemiology of antiphospholipid syndrome: macro- and microvascular manifestations. Rheumatology (Oxford) 2024; 63:SI24-SI36. [PMID: 38320589 PMCID: PMC10846913 DOI: 10.1093/rheumatology/kead571] [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: 08/16/2023] [Accepted: 10/08/2023] [Indexed: 02/08/2024] Open
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized by thrombotic and non-thrombotic macro- and microvascular manifestations and pregnancy complications in the setting of persistent antiphospholipid antibodies (aPL), namely anticardiolipin antibodies, anti-β2 glycoprotein-I antibodies and lupus anticoagulant. Four decades after its first description, APS prevalence and incidence are still not completely understood due to the limited number of well-designed, population-based multi-ethnic studies. Furthermore, despite decades of efforts to standardise aPL immunoassays, considerable intraassay and interlaboratory variances in aPL measures still exist. Large multicentre APS cohorts have shown a 10-year survival of ∼91% and the presence of catastrophic APS occurs in about 1% of the entire population, associated with a 50% mortality rate. Clinically, any organ can be affected in the context of large, medium or small vessel (artery and/or vein) thrombosis. Macrovascular thrombosis is the hallmark of the disease and veins are more frequently affected than arteries. Deep vein thrombosis/pulmonary embolism thromboembolic disease is the most common APS manifestation, while stroke and transient ischaemic attack are the most frequent arterial thrombosis events. Myocardial infarction can also occur and contributes to increased mortality in APS. A minority of patients present with thrombosis affecting the intraabdominal organs, including the liver, spleen, small and large bowel, and the kidneys. Microvascular thrombosis, including APS nephropathy, chronic skin ulcers and livedoid vasculopathy represent a diagnostic challenge requiring histologic confirmation. In this narrative review we summarize the available evidence on APS epidemiology, focusing on the description of the prevalence of macro- and microvascular manifestations of the disease.
Collapse
Affiliation(s)
- Pedro Gaspar
- Internal Medicine Department, Hospital Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
- Instituto de Medicina Molecular João Lobo Antunes, Centro Académico de Medicina de Lisboa, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Savino Sciascia
- Department of Clinical and Biological Sciences, University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-ReConnect and RITA-ERN Member) with Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), ASL Città Di Torino and University of Turin, Turin, Italy
| | - Maria G Tektonidou
- First Department of Propaedeutic and Internal Medicine, Joint Academic Rheumatology Program, EULAR Centre of Excellence, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| |
Collapse
|
6
|
Dong J, Zhao L, Pan L, Wang H, Wang L. Belimumab therapy for refractory immune thrombocytopenia in systemic lupus erythematosus patients with anti-phospholipid antibodies. Scand J Rheumatol 2024; 53:59-62. [PMID: 37650252 DOI: 10.1080/03009742.2023.2247881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 08/11/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE To observe the effect of belimumab treatment in refractory anti-phospholipid antibody-associated immune thrombocytopenia with systemic lupus erythematosus (SLE). METHOD Four SLE patients with refractory anti-phospholipid antibody-associated immune thrombocytopenia were included in this one-arm observational study. Inclusion criteria were a diagnosis of SLE according to 1997 American College of Rheumatology criteria, severe immune thrombocytopenia (platelets <30 × 109/L), no bleeding symptoms, lack of satisfactory response to traditional treatment, and high-titre anti-phospholipid antibodies. All patients received belimumab (Benlysta®) for 6 months. RESULTS The mean platelet count was 21.8 × 109 cells/L, ranging between 16 and 29 × 109/L at baseline, 123.3 × 109/L at 1 month, and 172.5 × 109/L at the end of 6 months after belimumab treatment. No bleeding complications occurred during the entire follow-up period. CONCLUSION In this study, belimumab reduced the anti-phospholipid antibodies while increasing the platelet count in SLE patients with anti-phospholipid antibody-associated immune thrombocytopenia.
Collapse
Affiliation(s)
- J Dong
- Rheumatology and Clinical Immunology Department, The Affiliated Hospital of Qingdao University, Qingdao, P.R. China
| | - L Zhao
- Rheumatology and Clinical Immunology Department, The Affiliated Hospital of Qingdao University, Qingdao, P.R. China
| | - L Pan
- Rheumatology and Clinical Immunology Department, The Affiliated Hospital of Qingdao University, Qingdao, P.R. China
| | - H Wang
- Rheumatology and Clinical Immunology Department, The Affiliated Hospital of Qingdao University, Qingdao, P.R. China
| | - L Wang
- Rheumatology and Clinical Immunology Department, The Affiliated Hospital of Qingdao University, Qingdao, P.R. China
| |
Collapse
|
7
|
Sarkar S, Karmakar S, Basu M, Ghosh P, Ghosh MK. Neurological damages in COVID-19 patients: Mechanisms and preventive interventions. MedComm (Beijing) 2023; 4:e247. [PMID: 37035134 PMCID: PMC10080216 DOI: 10.1002/mco2.247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/14/2023] [Accepted: 03/01/2023] [Indexed: 04/11/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus, causes coronavirus disease 2019 (COVID-19) which led to neurological damage and increased mortality worldwide in its second and third waves. It is associated with systemic inflammation, myocardial infarction, neurological illness including ischemic strokes (e.g., cardiac and cerebral ischemia), and even death through multi-organ failure. At the early stage, the virus infects the lung epithelial cells and is slowly transmitted to the other organs including the gastrointestinal tract, blood vessels, kidneys, heart, and brain. The neurological effect of the virus is mainly due to hypoxia-driven reactive oxygen species (ROS) and generated cytokine storm. Internalization of SARS-CoV-2 triggers ROS production and modulation of the immunological cascade which ultimately initiates the hypercoagulable state and vascular thrombosis. Suppression of immunological machinery and inhibition of ROS play an important role in neurological disturbances. So, COVID-19 associated damage to the central nervous system, patients need special care to prevent multi-organ failure at later stages of disease progression. Here in this review, we are selectively discussing these issues and possible antioxidant-based prevention therapies for COVID-19-associated neurological damage that leads to multi-organ failure.
Collapse
Affiliation(s)
- Sibani Sarkar
- Division of Cancer Biology and Inflammatory DisorderSignal Transduction in Cancer and Stem Cells LaboratoryCouncil of Scientific and Industrial Research‐Indian Institute of Chemical Biology (CSIR‐IICB)KolkataIndia
| | - Subhajit Karmakar
- Division of Cancer Biology and Inflammatory DisorderSignal Transduction in Cancer and Stem Cells LaboratoryCouncil of Scientific and Industrial Research‐Indian Institute of Chemical Biology (CSIR‐IICB)KolkataIndia
| | - Malini Basu
- Department of MicrobiologyDhruba Chand Halder College, University of CalcuttaDakshin BarasatWBIndia
| | - Pratyasha Ghosh
- Department of EconomicsBethune CollegeUniversity of CalcuttaKolkataIndia
| | - Mrinal K Ghosh
- Division of Cancer Biology and Inflammatory DisorderSignal Transduction in Cancer and Stem Cells LaboratoryCouncil of Scientific and Industrial Research‐Indian Institute of Chemical Biology (CSIR‐IICB)KolkataIndia
| |
Collapse
|
8
|
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).
Collapse
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
| |
Collapse
|
9
|
Serrano M, Espinosa G, Serrano A, Cervera R. COVID-19 and the antiphospholipid syndrome. Autoimmun Rev 2022; 21:103206. [PMID: 36195247 PMCID: PMC9527199 DOI: 10.1016/j.autrev.2022.103206] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/28/2022] [Indexed: 01/08/2023]
Abstract
Coronavirus disease 2019 (COVID-19) has resulted in a global pandemic. Most COVID-19 patients are asymptomatic or have flu-like symptoms. However, around 15% of the patients may have severe disease, including unilateral or bilateral pneumonia with acute respiratory distress syndrome and progressive hypoxemia that may require mechanical ventilation assistance. A systemic inflammatory response syndrome occurs in the most severe forms of COVID-19, with multiorgan involvement which can be life threatening caused by a cytokine storm. Although what best characterizes COVID-19 are the manifestations of the respiratory system, it has been shown that it also acts at the cardiovascular level, producing coagulation abnormalities, which causes thrombotic events mainly in the arteries/arterioles, microcirculation and venous system, and potentially increased mortality risk. This multiorgan vascular disease overlaps with other known microangiopathies, such as thrombotic microangiopathy or paroxysmal nocturnal hemoglobinuria, where complement overactivation plays an important role in the pathophysiology of thrombosis. Furthermore, coagulopathy secondary to COVID-19 occurs in the context of an uncontrolled inflammatory response, reminiscent of APS, especially in its catastrophic form. This review summarizes the current knowledge regarding the relationship between COVID-19 and the APS.
Collapse
Affiliation(s)
- Manuel Serrano
- Department of Immunology, Healthcare Research Institute I+12, Hospital 12 de Octubre, Madrid, Spain
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Insititut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Antonio Serrano
- Department of Immunology, Healthcare Research Institute I+12, Hospital 12 de Octubre, Madrid, Spain
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Insititut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Catalonia, Spain,Corresponding author at: Servei de Malalties Autoimmunes, Hospital Clínic, Villarroel, 170, 08036 Barcelona, Catalonia, Spain
| |
Collapse
|
10
|
Su L, Qi Z, Guan S, Wei L, Zhao Y. Exploring the risk factors for ischemic cerebrovascular disease in systemic lupus erythematosus: A single-center case-control study. Front Immunol 2022; 13:978910. [PMID: 36238309 PMCID: PMC9552613 DOI: 10.3389/fimmu.2022.978910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesIschemic cerebrovascular disease (ICVD) is one of the most common and severe complications in systemic lupus erythematosus (SLE). We aim to explore the risk factors for ICVD in SLE and to assess their associated clinical characteristics.MethodsIn this study, 44 lupus patients with ICVD (ICVD-SLE) and 80 age- and sex-matched lupus patients without ICVD (non-ICVD-SLE) who were hospitalized in our center between 2014 and 2021 were enrolled. A comprehensive set of clinical and socio-demographic data was recorded. In the ICVD-SLE group, the modified Rankin score (mRS) at 90 days after the occurrence of ICVD, the brain MRI, and arterial ultrasonography findings were collected. Group comparisons were made with continuous variables using an independent t-test or the Mann–Whitney test, and with categorical variables using the chi-square test or Fisher exact test. Multivariate logistic regression analysis was performed to identify the risk factors for ICVD in SLE. Patients with ICVD-SLE were divided into three subgroups according to the gradations of intracranial arterial stenosis (ICAS). The subgroup comparisons were performed by one-way ANOVA test or Kruskal–Wallis test.ResultsOf the 44 patients with ICVD, 45% had a large-vessel ischemic stroke, 50% had a symptomatic lacunar stroke, and 9% had a transient ischemic attack. 2 (4.5%) had both large-vessel ischemic stroke and symptomatic lacunar stroke. Multivariate logistic regression analysis showed that cutaneous vasculitis (OR=7.36, 95% CI=2.11–25.65), anticardiolipin antibody (aCL) (OR=4.38, 95% CI=1.435–13.350), and lupus anticoagulant (LA) (OR=7.543,95% CI=1.789–31.808) were the risk factors, and hydroxychloroquine (HCQ) therapy (OR=0.198, 95% CI=0.078–0.502) was the protective factor, after controlling for confounders. During the analysis of the subgroups, no significant difference was observed between the patients in the group without internal carotid arterial occlusion (ICAS) and those with severe ICAS except for diagnostic delay. However, patients in the moderate ICAS group were older when SLE occurred (P<0.01), had a longer diagnostic delay (P<0.01), a lower percentage of hypocomplementemia (P=0.05) and steroids and HCQ therapy (P=0.01, P=0.05, respectively), a trend toward lower mRS score, but a higher incidence of carotid atherosclerotic plaque (P<0.01), when compared with the other two subgroups.ConclusionCutaneous vasculitis and antiphospholipid antibodies (aPLs) are associated with an increased risk of ICVD, while HCQ therapy may provide protection against ICVD in SLE. The ICVD in younger lupus patients is associated with complement-mediated inflammation and poorer outcome, and require immunosuppressive therapy, whereas the ICVD in elderly patients are characterized by moderate ICAS and carotid atherosclerotic plaques.
Collapse
Affiliation(s)
- Li Su
- Department of Rheumatology and Allergy, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhigang Qi
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shaochen Guan
- Evidence-Based Medical Center, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Lian Wei
- Department of Rheumatology and Allergy, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yi Zhao
- Department of Rheumatology and Allergy, Xuanwu Hospital, Capital Medical University, Beijing, China
- *Correspondence: Yi Zhao,
| |
Collapse
|
11
|
Chen L, Zhang P, Zhu X, Zhang M, Deng B. A Cryptogenic Stroke Associated With Infective Endocarditis and Antiphospholipid Antibody Syndrome: Case Report and Literature Review. Front Neurol 2022; 13:872279. [PMID: 35959388 PMCID: PMC9358978 DOI: 10.3389/fneur.2022.872279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/22/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Accurate definition of stroke etiology is crucial, as this will guide effective targets for treatment. Both antiphospholipid antibody syndrome (APS) and infective endocarditis (IE) can be independent risk factors for ischemic stroke in young adults. When an embolic stroke occurs with IE and APS simultaneously, the origin of the embolic source is difficult to identify. Case Report A 19-year-old man was admitted to the hospital for the onset of stroke. A diagnosis of APS accompanied by IE was made after a series of examinations. We identified aortic valve vegetation as the embolic source. Although both APS and IE can induce valve vegetation, we considered IE to be the primary cause according to the infective clues. Despite treatment with ampicillin, the patient's fever persisted, and surgical aortic valve replacement was performed urgently. The patient recovered without recurrence of stroke during the 1-year follow-up. Conclusion A considerable challenge for physicians is evaluating all the signs suggestive of embolic sources in acute stroke and identifying the primary etiology when there are multiple causes. Early diagnosis and surgical intervention for bicuspid aortic valve (BAV) vegetation complicated by acute stroke may yield favorable clinical results.
Collapse
|
12
|
Serrano M, Espinosa G, Serrano A, Cervera R. Antigens and Antibodies of the Antiphospholipid Syndrome as New Allies in the Pathogenesis of COVID-19 Coagulopathy. Int J Mol Sci 2022; 23:ijms23094946. [PMID: 35563337 PMCID: PMC9102661 DOI: 10.3390/ijms23094946] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 01/27/2023] Open
Abstract
High prevalence of both criteria and extra-criteria antiphospholipid antibodies (aPL) has been reported in COVID-19 patients. However, the differences in aPL prevalence decreased when an age-matched control group was included. The association of aPL with thrombotic events in COVID-19 is very heterogeneous. This could be influenced by the fact that most of the studies carried out were conducted on small populations enriched with elderly patients in which aPL was measured only at a single point and they were performed with non-standardized assays. The few studies that confirmed aPL in a second measurement showed that aPL levels hardly changed, with the exception of the lupus anticoagulant that commonly reduced. COVID-19 coagulopathy is an aPL-independent phenomenon closely associated with the onset of the disease. Thrombosis occurs later in patients with aPL presence, which is likely an additional prothrombotic factor. B2-glycoprotein deficiency (mainly aPL antigen caused both by low production and consumption) is very common during the SARS-CoV2 infection and has been associated with a greater predisposition to COVID-19 complications. This could be a new prothrombotic mechanism that may be caused by the blockage of its physiological functions, the anticoagulant state being the most important.
Collapse
Affiliation(s)
- Manuel Serrano
- Department of Immunology, Healthcare Research Institute I+12, Hospital 12 de Octubre, 28041 Madrid, Spain;
| | - Gerard Espinosa
- Department of Autoimmune Diseases, Hospital Clínic, Insititut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, 08036 Barcelona, Spain; (G.E.); (R.C.)
| | - Antonio Serrano
- Department of Immunology, Healthcare Research Institute I+12, Hospital 12 de Octubre, 28041 Madrid, Spain;
- Correspondence: or
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic, Insititut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, 08036 Barcelona, Spain; (G.E.); (R.C.)
| |
Collapse
|
13
|
Yacoub MS, Khine J, Najar A, Yadlapalli S. Evidence of Thrombogenesis Recurrence Induced by IgA Antiphospholipid Antibody β2 Glycoprotein I-Dependent in Early Adulthood. Cureus 2022; 14:e23535. [PMID: 35495019 PMCID: PMC9045554 DOI: 10.7759/cureus.23535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2022] [Indexed: 11/10/2022] Open
Abstract
Antiphospholipid antibodies (aPLs) against Beta-2 glycoprotein-I (β2GPI) are considered to be the center of pathogenesis of antiphospholipid syndrome (APS). Autoimmune aPLs are pathogenic as patients are at increased risk of enhancing thrombin generation at a young age. There are only three aPLs considered as diagnostic laboratory markers for APS - IgM, IgG, and IgA isotypes. However, the association of the IgA isotypes with clinical thrombosis remains highly controversial. A 30-year-old male with a past medical history of childhood asthma initially presented to the hospital with acute left middle cerebral artery ischemic stroke, which did not get resolved with tissue plasminogen activator (tPA) but was successfully resolved with thromboembolectomy. It was speculated to be associated with a clot from mitral valve prolapse found subsequently on echocardiogram. Twenty-eight days later, the patient presented again with a high-grade luminal narrowing of his mid- and distal left internal carotid artery with 80% narrowing and an acute dissection of his left internal carotid artery. The recurrence of thrombosis was evaluated through hypercoagulable state workup, which demonstrated evidence of antiphospholipid syndrome with elevated beta-2 glycoprotein IgA antibody titers of more than 150 U/mL. This is one of the first cases reported nationwide as evidence of thrombogenesis recurrence induced by IgA antiphospholipid antibody β2 glycoprotein I-dependent in early adulthood. IgA anti- β2GPI antibodies are found to have an association with many clinical manifestations of antiphospholipid syndrome and thrombotic events, particularly arterial thrombosis. To determine the link between the IgA-aβ2GPI antibodies and APS-events in asymptomatic individuals before recommending preventive treatments, there needs to be a broader intention to standardize IgA-aβ2GPI assays as a diagnostic criterion for APS.
Collapse
|
14
|
Killian M, van Mens TE. Risk of Thrombosis, Pregnancy Morbidity or Death in Antiphospholipid Syndrome. Front Cardiovasc Med 2022; 9:852777. [PMID: 35299976 PMCID: PMC8921454 DOI: 10.3389/fcvm.2022.852777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 02/07/2022] [Indexed: 12/12/2022] Open
Abstract
The antiphospholipid syndrome is an autoimmune disease characterized by thrombosis and pregnancy morbidity. The manifestations are caused by antibodies targeting cell membrane phospholipids and/or associated proteins. The triggers leading to these antibodies' production are unknown but recent work suggests cross-reactivity between the autoantigens and peptides produced by the intestinal microbiome. Work on how the autoantibodies could cause clinical manifestations implicates different mechanisms. Binding to surface proteins of different cell types can induce intracellular signaling leading to cell activation and tissue factor expression. Complement activation and neutrophil extracellular-traps are also involved, and recent evidence implicates endothelial protein C receptor-lysobisphosphatidic acid complex. Pregnancy is a high-risk situation for antiphospholipid syndrome patients due to the increased risk of thrombosis and obstetric complications. Epidemiological and clinical research on APS is hampered by heterogeneity in populations, testing and treatment strategies. About one in 10 to one in fifty APS pregnancies is complicated by thrombosis, despite treatment. Pregnant patients with prior thrombosis are prescribed therapeutic dose heparins and low dose aspirin. Without prior thrombosis a prophylactic dose is used. The most frequent obstetrical manifestation is recurrent early pregnancy loss. The association of APS antibodies with late pregnancy loss is stronger, however. Prevention of recurrence is achieved with aspirin and prophylactic dose heparin, although the evidence is of low certainty. The third obstetrical classifying manifestation comprises preterm delivery due to placenta-mediated complications and is treated in subsequent pregnancies with aspirin with or without prophylactic dose heparin, again based on low quality evidence. New therapies are under investigation.
Collapse
Affiliation(s)
- Martin Killian
- CIRI - Centre International de Recherche en Infectiologie, Team GIMAP, Université de Lyon, Université Jean Monnet, Université Claude Bernard Lyon 1, Inserm, U1111, CNRS, UMR530, Saint-Étienne, France.,Internal Medicine Department, Saint-Etienne University Hospital, Saint-Étienne, France
| | - Thijs E van Mens
- Amsterdam UMC, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam Reproduction and Development, University of Amsterdam, Amsterdam, Netherlands
| |
Collapse
|
15
|
Gil-Etayo FJ, Garcinuño S, Lalueza A, Díaz-Simón R, García-Reyne A, Pleguezuelo DE, Cabrera-Marante O, Rodriguez-Frias EA, Perez-Rivilla A, Serrano M, Serrano A. Anti-Phospholipid Antibodies and COVID-19 Thrombosis: A Co-Star, Not a Supporting Actor. Biomedicines 2021; 9:biomedicines9080899. [PMID: 34440103 PMCID: PMC8389622 DOI: 10.3390/biomedicines9080899] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/19/2021] [Accepted: 07/23/2021] [Indexed: 12/25/2022] Open
Abstract
Background: COVID-19 clinical features include a hypercoagulable state that resembles the antiphospholipid syndrome (APS), a disease characterized by thrombosis and presence of antiphospholipid antibodies (aPL). The relationship between aPL-presence and the appearance of thrombi as well as the transience or permanence of aPL in COVID-19 patients is not sufficiently clear. Methods: A group of 360 COVID-19 patients were followed-up for 6 months. Classic aPL, anti-B2GPI IgA, anti-phosphatidylserine/prothrombin IgG/M and anti-SARS-CoV-2 antibodies were determined at acute phase and >12 weeks later. The reference group included 143 healthy volunteers of the same age-range distribution. Results: aPL prevalence was similar in COVID-19 patients and the reference population. aPL presence in both determinations was significantly associated with thrombosis (OR: 2.33 and 3.71), strong agreement being found for classic aPL and anti-B2GPI IgA (Weighted kappa: 0.85–0.91). Thrombosis-associated aPL occurred a median of 17 days after hospital admission (IQR: 6–28) vs. 4 days for the rest (IQR: 3–7). Although anti-SARS-CoV-2 antibodies levels increased during convalescence, aPL hardly changed. Conclusions: Most COVID-19 patients would carry these aPL before the infection. At least two mechanisms could be behind thrombosis, early immune-dysregulation-mediated thrombosis after infection and belated-aPL-mediated thrombosis, with SARS-CoV-2 behaving as a second hit.
Collapse
Affiliation(s)
- Francisco Javier Gil-Etayo
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (F.J.G.-E.); (D.E.P.); (O.C.-M.); (E.A.R.-F.)
| | - Sara Garcinuño
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
| | - Antonio Lalueza
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (A.L.); (R.D.-S.); (A.G.-R.)
| | - Raquel Díaz-Simón
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (A.L.); (R.D.-S.); (A.G.-R.)
| | - Ana García-Reyne
- Department of Internal Medicine, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (A.L.); (R.D.-S.); (A.G.-R.)
| | - Daniel Enrique Pleguezuelo
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (F.J.G.-E.); (D.E.P.); (O.C.-M.); (E.A.R.-F.)
| | - Oscar Cabrera-Marante
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (F.J.G.-E.); (D.E.P.); (O.C.-M.); (E.A.R.-F.)
| | - Edgard Alfonso Rodriguez-Frias
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (F.J.G.-E.); (D.E.P.); (O.C.-M.); (E.A.R.-F.)
| | - Alfredo Perez-Rivilla
- Department of Microbiology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain;
| | - Manuel Serrano
- Department of Immunology, Hospital Universitario Clínico San Carlos, 28041 Madrid, Spain;
| | - Antonio Serrano
- Department of Immunology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain; (F.J.G.-E.); (D.E.P.); (O.C.-M.); (E.A.R.-F.)
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), 28041 Madrid, Spain;
- Department of Epidemiology, Biomedical Research Centre Network for Epidemiology and Public Health (CIBERESP), 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-659-496-544
| |
Collapse
|