Seven-year follow-up atherosclerotic plaque progression in patients with antiphospholipid syndrome versus diabetes mellitus and healthy controls

Challenges of anticoagulation in patients with systemic lupus erythematosus

INTRODUCTION

Anticoagulation is frequently required for patients with systemic lupus erythematosus (SLE), given their high prevalence of cardiovascular disease and thrombosis, due to the complexity of disease pathophysiology, some overlap with antiphospholipid syndrome (APS), comorbidities, prevalent cardiovascular risk factors and treatment complications.

AREAS COVERED

This article outlines the epidemiology and pathophysiology of cardiovascular disease and arterial and/or venous thrombosis in SLE, with/without APS. We discuss common cardiovascular comorbidities and thrombotic disorders that may present as a complication of SLE and/or APS and highlight recommendations in current guidelines for anticoagulation management, alongside relevant disease-specific considerations. We specifically comment on the use of direct oral anticoagulants (DOACs) for venous thromboembolism (VTE) in these patients.

EXPERT OPINION

Assessment of cardiovascular risk and aPL profile is paramount in SLE patients. While warfarin is preferred in high-risk APS patients, DOACs can be used in a selected group of SLE and/or APS patients with VTE and no prior history of arterial thrombosis. Initiating anticoagulation in the setting of Catastrophic APS (CAPS) can be extremely challenging. Knowledge gaps remain regarding the management of patients with recurrent arterial and/or venous thrombosis despite anticoagulation. Research is needed to optimize strategies to reduce thrombotic events in APS patients.

Thrombotic antiphospholipid syndrome: From guidelines to clinical management

Thrombotic manifestations, mainly venous thromboembolism (VTE) and stroke, are the most common and potentially life-threatening presentations of antiphospholipid syndrome (APS). The management of APS requires the assessment of the antiphospholipid antibodies (aPL) profile, of concurrent systemic lupus erythematosus or other systemic autoimmune diseases and the presence of risk factors for cardiovascular disease and bleeding. Anticoagulation with vitamin K antagonists (VKA) remains the cornerstone of therapy for thrombotic APS. As platelets play a central role in APS, low-dose aspirin is the first option for primary thromboprophylaxis in asymptomatic aPL carriers, and also plays a role as combination therapy with VKAs in arterial thrombosis. Treatment with direct oral anticoagulants (DOACs) could be considered in certain low-risk situations, although they are not recommended in patients with arterial thrombosis or triple positive aPL. Adjuvant therapies such as hydroxychloroquine and statins may be useful in complex settings such as thrombotic recurrences or high risk of bleeding. In this article, we review the evidence and the recommendations of the guidelines for the treatment of APS, and provide a critical and practical approach of its management from our clinical perspective.

Antiphospholipid Syndrome: Insights into Molecular Mechanisms and Clinical Manifestations

Antiphospholipid syndrome (APS) is a complex systemic autoimmune disorder characterized by a hypercoagulable state, leading to severe vascular thrombosis and obstetric complications. The 2023 ACR/EULAR guidelines have revolutionized the classification and understanding of APS, introducing broader diagnostic criteria that encompass previously overlooked cardiac, renal, and hematologic manifestations. Despite these advancements, diagnosing APS remains particularly challenging in seronegative patients, where traditional tests fail, yet clinical symptoms persist. Emerging non-criteria antiphospholipid antibodies offer promising new diagnostic and management avenues for these patients. Managing APS involves a strategic balance of cardiovascular risk mitigation and long-term anticoagulation therapy, though the use of direct oral anticoagulants remains contentious due to varying efficacy and safety profiles. This article delves into the intricate pathogenesis of APS, explores the latest classification criteria, and evaluates cutting-edge diagnostic tools and therapeutic strategies.

T cell involvement in antiphospholipid syndrome

Antiphospholipid syndrome (APS) is a systemic autoimmune disorder characterized by arterial and venous thrombosis, and obstetric complications in the presence of antiphospholipid antibodies (aPL), including lupus anticoagulant, anticardiolipin and anti-β2-glycoprotein I antibodies. APS manifests as single, often as recurrent events, and rarely as a catastrophic condition. Most studies of APS pathogenesis to date have focused on the prothrombotic role of aPL, while innate immune responses such as monocyte, complement and neutrophil activation have been also recognized as part of the thrombo-inflammatory cascade in APS. While the presence of autoreactive T cells against β2-glycoprotein I has been long known, less data are available on their pathogenetic role in APS. In this review, we summarize current knowledge on the involvement of T cells in APS pathophysiology, alterations of T cell subsets in peripheral blood, and clinical associations. We also highlight potential therapeutic opportunities by targeting T helper-B cell interactions in these patients.