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Barbati ME, Avgerinos ED, Baccellieri D, Doganci S, Lichtenberg M, Jalaie H. Interventional treatment for post-thrombotic chronic venous obstruction: Progress and challenges. J Vasc Surg Venous Lymphat Disord 2024; 12:101910. [PMID: 38777042 DOI: 10.1016/j.jvsv.2024.101910] [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: 01/11/2024] [Revised: 04/28/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
Chronic venous obstruction, including nonthrombotic iliac vein lesions and post-thrombotic syndrome, presents a significant burden on patients' quality of life and health care systems. Venous recanalization and stenting have emerged as promising minimally invasive approaches, yet challenges in patient selection, procedural techniques, and long-term outcomes persist. This review synthesizes current knowledge on the interventional treatment of post-thrombotic syndrome, focusing on the evolution of endovascular techniques and stenting. Patient selection criteria, procedural details, and the characteristics of dedicated venous stents are discussed. Particular emphasis is given to the role of inflow and other anatomical considerations, along with postoperative management protocols for an optimal long-term outcome.
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Affiliation(s)
- Mohammad E Barbati
- Clinic of Vascular and Endovascular Surgery, RWTH Aachen University Hospital, Aachen, Germany.
| | | | | | - Suat Doganci
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara, Turkey
| | | | - Houman Jalaie
- Clinic of Vascular and Endovascular Surgery, RWTH Aachen University Hospital, Aachen, Germany
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2
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Gurnari C, Awada H, Pagliuca S, Dima D, Ullah F, Kawashima N, Kubota Y, Colak C, Visconte V, Patel BJ, Dhillon V, Marneni N, Balasubramanian SK, Kishtagari A, Bat T, Maciejewski JP. Paroxysmal nocturnal hemoglobinuria-related thrombosis in the era of novel therapies: a 2043-patient-year analysis. Blood 2024; 144:145-155. [PMID: 38513233 DOI: 10.1182/blood.2024023988] [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: 01/18/2024] [Revised: 02/27/2024] [Accepted: 03/12/2024] [Indexed: 03/23/2024] Open
Abstract
ABSTRACT Thrombophilia is one of the principal features of paroxysmal nocturnal hemoglobinuria (PNH) and constitutes the main cause of disease morbidity/mortality. Anticomplement treatment has revolutionized the natural history of PNH, with control of the hemolytic process and abolition of thrombotic events (TEs). However, no guidelines exist for the management of thromboembolic complications in this setting, with type and duration of anticoagulation depending on individual practices. Besides, a scarcity of data is present on the efficacy of direct oral anticoagulants (DOACs). Herein, we accrued a large real-world cohort of patients with PNH from 4 US centers to explore features, predictors of TE, and anticoagulation strategies. Among 267 patients followed up for a total of 2043 patient-years, 56 (21%) developed TEs. These occurred at disease onset in 43% of cases, involving more frequently the venous system, typically as Budd-Chiari syndrome. Rate of TEs was halved in patients receiving complement inhibitors (21 vs 40 TEs per 1000 patient-years in untreated cases, with a 2-year cumulative incidence of thrombosis of 3.9% vs 18.3%, respectively), and varied according to PNH granulocytes and erythrocytes clone size, type, disease activity parameters, as well as number (≥2 mutations, or less) and variant allelic frequency of PIGA mutations. Anticoagulation with warfarin (39%), DOACs (37%), and low-molecular weight heparin (16%) was administered for a median of 29 months (interquartile range [IQR], 9-61.8). No thrombotic recurrence was observed in 19 patients treated with DOACs at a median observation of 17.1 months (IQR, 8.9-45) whereas 14 cases discontinued anticoagulation without TE recurrence at a median time of 51.4 months (IQR, 29.9-86.8).
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Affiliation(s)
- Carmelo Gurnari
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Hussein Awada
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Simona Pagliuca
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
- Department of Clinical Hematology, Centre Hospitalier Régional Universitaire Nancy and Unité Mixte de Recherche 7635, University of Lorraine, Vandoeuvre-lès-Nancy, France
| | - Danai Dima
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Fauzia Ullah
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Naomi Kawashima
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Yasuo Kubota
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Ceylan Colak
- Imaging Institute, Cleveland Clinic, Cleveland, OH
| | - Valeria Visconte
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Bhumika J Patel
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
| | - Vikram Dhillon
- Department of Oncology, Karmanos Cancer Institute/Wayne State University, Detroit, MI
| | - Naimisha Marneni
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | | | - Ashwin Kishtagari
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Taha Bat
- Division of Hematology and Oncology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jaroslaw P Maciejewski
- Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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Sikorska M, Chmiel J, Papuga-Szela E, Broniatowska E, Undas A. Apixaban Versus Vitamin K Antagonists in Patients With Antiphospholipid Syndrome: A Cohort Study. J Cardiovasc Pharmacol 2024; 84:36-44. [PMID: 38922590 DOI: 10.1097/fjc.0000000000001578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/27/2024] [Indexed: 06/27/2024]
Abstract
ABSTRACT Current guidelines recommend that direct anticoagulants should not be used in prevention of recurrent thrombosis in patients with antiphospholipid syndrome (APS). However, except for triple-positive APS and rivaroxaban use, little evidence supports such recommendation. In a real-life cohort study, we evaluated the risk of thromboembolism and bleeding in patients with APS on apixaban versus vitamin K antagonists (VKA). We enrolled 152 patients with APS (aged 44 years [interquartile range 36-56], 83% women), including 66 patients treated with apixaban 5 mg bid and 86 with warfarin (target international normalized ratio [INR] 2-3). During a median follow-up of 53 months, we recorded venous thromboembolism, ischemic stroke, or myocardial infarction, along with major bleeding. We observed 4 thrombotic events (6.1%, 3 venous thromboembolism and 1 ischemic stroke) in patients on apixaban and 12 events (14%, 9 venous thromboembolism, 2 ischemic strokes and 1 myocardial infarction) in VKA patients. Patients with APS on apixaban had similar risk of recurrent thromboembolism compared with those on warfarin (hazard ratio [HR] = 0.327, 95% confidence interval [CI]: 0.104-1.035). Thromboembolic events occurred less commonly in statin users (8% vs. 50%, P = 0.01) and more frequently in triple-positive APS (50% vs. 22.1%, P = 0.028) and in patients with higher D-dimer at baseline ( P = 0.023); the latter difference was present in the apixaban group ( P = 0.02). Patients on apixaban had similar risk of major bleeding compared with warfarin (HR = 0.54, 95% CI: 0.201-1.448). In real-life patients with APS, apixaban appears to be similar to VKA for the prevention of thromboembolism and risk of bleeding, which might suggest that some patients with APS could be treated with apixaban.
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Affiliation(s)
- Martyna Sikorska
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- John Paul II Hospital, Krakow, Poland
| | - Jakub Chmiel
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, Krakow, Poland
- John Paul II Hospital, Krakow, Poland
| | | | - Elzbieta Broniatowska
- Faculty of Medicine and Health Science, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland ; and
| | - Anetta Undas
- John Paul II Hospital, Krakow, Poland
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University, Medical College, Krakow, Poland
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4
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Zhang Z, Chi J, Duensing I, Qureshi H, Cui Q. Risks Following Total Knee Arthroplasty in Patients Who Have Antiphospholipid Syndrome. J Arthroplasty 2024; 39:1500-1504. [PMID: 38056723 DOI: 10.1016/j.arth.2023.11.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 11/22/2023] [Accepted: 11/29/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Antiphospholipid syndrome (APS) is recognized as a thrombophilic autoimmune condition characterized by a tendency to develop venous thromboembolism. Total knee arthroplasty (TKA) is a prevalent procedure in patients who have advanced knee arthritis. Notably, TKA is unequivocally considered a thrombotic risk factor. However, outcomes of APS patients after TKA are still poorly documented in literature. The purpose of this study was to evaluate APS as a potential risk factor for complications after TKA. METHODS Using the PearlDiver Mariner database from 2010 to 2022, APS patients undergoing primary TKA were identified and compared to 10:1 matched control based on age, sex, and relevant comorbidities. A total of 7,478 patients undergoing primary TKA were analyzed, of which 683 had APS. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications including revision up to 2 years. Ninety-day emergency department visit and inpatient readmission were also documented. RESULTS Within 90 days after TKA, patients who have APS exhibited higher rates of cerebrovascular accident (adjusted odds ratio 2.04, 95% confidence interval 1.12 to 3.57; P = .014) and deep vein thrombosis (adjusted odds ratio 2.87, 95% confidence interval 1.99 to 4.06; P < .001) as compared to matched controls. No difference in surgical or nonthrombotic medical complications was observed between 2 cohorts. CONCLUSIONS There were significantly higher rates of stroke and deep vein thrombosis in APS patients. Our study did not find statistical differences in other surgical complications or readmissions between the 2 groups. Orthopaedic surgeons should consider appropriate prophylaxis of thrombosis in this patient population undergoing TKA perioperatively.
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Affiliation(s)
- Zhichang Zhang
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia; Department of Orthopaedic Surgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui, Henan, China
| | - Jialun Chi
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Ian Duensing
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Huzaifah Qureshi
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Quanjun Cui
- Department of Orthopaedic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
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Moore GW, Platton S, Yartey N, Foxton E, White D, MacDonald SG. Taipan snake venom time has high sensitivity for lupus anticoagulants in non-anticoagulated, triple positive antiphospholipid syndrome patients. Int J Lab Hematol 2024; 46:538-545. [PMID: 38303489 DOI: 10.1111/ijlh.14240] [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: 11/21/2023] [Accepted: 01/05/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Dilute Russell's viper venom time (dRVVT) and activated partial thromboplastin time (APTT) are the mainstay assays in lupus anticoagulant (LA) detection yet they have limitations, particularly in relation to interferences and specificity. The recently validated Taipan snake venom time (TSVT) screening with ecarin time (ET) confirmatory assays overcome many of those limitations due to the innate specificity engendered from direct prothrombin activation, and insensitivity to the effects of vitamin K antagonists (VKA). The present study aimed to further evidence diagnostic utility of TSVT/ET by performing them in samples from 116 nonanticoagulated patients with established triple-positive antiphospholipid syndrome (APS). METHODS Samples were identified in three expert centres who performed dRVVT, APTT and solid phase antiphospholipid antibody assays with reagents from a variety of manufacturers. All samples additionally received TSVT/ET analysis using standardised reagents. RESULTS Ninety seven of 116 (83.6%) were dRVVT- and APTT-positive, 85/97 (87.6%) of which were TSVT/ET-positive, 9/116 (7.8%) were dRVVT-positive only, 6 of which were TSVT/ET-positive, and 10/116 (8.6%) were APTT-positive only, 5 of which were TSVT/ET-positive. 96/116 TSVT/ET-positivity returned a high sensitivity for LA of 82.8%. Low coefficients of determination revealed weak relationships between LA potency and anticardiolipin and anti-β2-glycoprotein I antibody titres for all three LA assays. CONCLUSIONS TSVT/ET has high sensitivity for the clinically significant LA found in triple positive APS patients. TSVT/ET can establish multiple LA assay positivity in nonanticoagulated patients negative for one of dRVVT or APTT, and is the only assay pairing insensitive to VKAs, the recommended anticoagulation for APS.
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Affiliation(s)
- Gary W Moore
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Natural Sciences, Faculty of Science and Technology, Middlesex University, London, UK
| | - Sean Platton
- The Royal London Hospital Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Nada Yartey
- East and South East London NHS Pathology Partnership, Barts Health NHS Trust, London, UK
| | - Eleanor Foxton
- Synnovis Haemostasis and Thrombosis Laboratory, St. Thomas' Hospital, London, UK
| | - Danielle White
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Stephen G MacDonald
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Bernardi M, Spadafora L, Andaloro S, Piscitelli A, Fornaci G, Intonti C, Fratta AE, Hsu CE, Kaziròd-Wolski K, Metsovitis T, Biondi-Zoccai G, Sabouret P, Marzetti E, Cacciatore S. Management of Cardiovascular Complications in Antiphospholipid Syndrome: A Narrative Review with a Focus on Older Adults. J Clin Med 2024; 13:3064. [PMID: 38892776 PMCID: PMC11173304 DOI: 10.3390/jcm13113064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 05/19/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Antiphospholipid syndrome (APS), also known as Hughes syndrome, is an acquired autoimmune and procoagulant condition that predisposes individuals to recurrent thrombotic events and obstetric complications. Central is the role of three types of antiphospholipid antibodies that target phospholipid-binding proteins: lupus anticoagulant (LAC), anti-β2-glycoprotein I (β2-GPI-Ab), and anti-cardiolipin (aCL). Together with clinical data, these antibodies are the diagnostic standard. However, the diagnosis of APS in older adults may be challenging and, in the diagnostic workup of thromboembolic complications, it is an underestimated etiology. The therapeutic management of APS requires distinguishing two groups with differential risks of thromboembolic complications. The standard therapy is based on low-dose aspirin in the low-risk group and vitamin K antagonists in the high-risk group. The value of direct oral anticoagulants is currently controversial. The potential role of monoclonal antibodies is investigated. For example, rituximab is currently recommended in catastrophic antiphospholipid antibody syndrome. Research is ongoing on other monoclonal antibodies, such as daratumumab and obinutuzumab. This narrative review illustrates the pathophysiological mechanisms of APS, with a particular emphasis on cardiovascular complications and their impact in older adults. This article also highlights advancements in the diagnosis, risk stratification, and management of APS.
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Affiliation(s)
- Marco Bernardi
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Piazzale A. Moro 5, 00185 Rome, Italy; (L.S.); (G.F.); (C.I.)
| | - Luigi Spadafora
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Piazzale A. Moro 5, 00185 Rome, Italy; (L.S.); (G.F.); (C.I.)
| | - Silvia Andaloro
- Department of Translational Medicine and Surgery, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy;
| | - Alessandra Piscitelli
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy; (A.P.); (A.E.F.); (C.-E.H.); (T.M.)
| | - Giovanni Fornaci
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Piazzale A. Moro 5, 00185 Rome, Italy; (L.S.); (G.F.); (C.I.)
| | - Chiara Intonti
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Piazzale A. Moro 5, 00185 Rome, Italy; (L.S.); (G.F.); (C.I.)
| | - Alberto Emanuele Fratta
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy; (A.P.); (A.E.F.); (C.-E.H.); (T.M.)
| | - Chieh-En Hsu
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy; (A.P.); (A.E.F.); (C.-E.H.); (T.M.)
| | - Karol Kaziròd-Wolski
- Institute of Medical Sciences, Collegium Medicum, Jan Kochanowski University, Al. IX Wieków Kielc 19A, 25-317 Kielce, Poland;
| | - Theodora Metsovitis
- Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy; (A.P.); (A.E.F.); (C.-E.H.); (T.M.)
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Via XXIV Maggio 7, 04100 Latina, Italy;
- Cardiology Unit, Santa Maria Goretti Hospital, Via L. Scaravelli, 04100 Latina, Italy
| | - Pierre Sabouret
- Heart Institute, Pitié-Salpétrière Hospital, Sorbonne University, 47-83 Bd. de l’Hôpital, 75013 Paris, France;
- National College of French Cardiologists, 13 Niepce, 75014 Paris, France
| | - Emanuele Marzetti
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy;
- Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Stefano Cacciatore
- Department of Geriatrics, Orthopedics, and Rheumatology, Università Cattolica del Sacro Cuore, Largo F. Vito 1, 00168 Rome, Italy;
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Mohtashim A, Azhar A, Mazhar S, Devi D, Danial M, Patel D, Khan O, Andani A, Khan MM, Samad S, Qureshi A, Ali H, Ejaz U, Jawad S. Factor Xa inhibitors vs. warfarin in patients with Hughes syndrome: a systematic review and meta-analysis of randomized controlled trials. Ann Med Surg (Lond) 2024; 86:2992-3000. [PMID: 38694373 PMCID: PMC11060306 DOI: 10.1097/ms9.0000000000001999] [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] [Received: 12/01/2023] [Accepted: 03/14/2024] [Indexed: 05/04/2024] Open
Abstract
Background The optimal treatment regimen for patients with Hughes syndrome remains unclear. Therefore, the authors sought to compare the outcomes of warfarin vs. factor Xa inhibitors in patients with Hughes syndrome. Methods MEDLINE, Embase, and Cochrane Central databases were searched for randomized controlled trials (RCTs) comparing 8 efficacy and safety of warfarin and factor Xa inhibitors in patients with Hughes syndrome. Recurrent thrombosis, all-cause mortality, stroke, adverse reactions, and bleeding were among 10 outcomes of interest. Mantel-Haenszel weighted random-effects model was used to calculate 11 relative risks (RRs) with 95% CIs. Results The analysis included 625 patients from four RCTs and one post-hoc analysis. Meta-analysis showed a statistically non-significant difference between factor Xa inhibitors and warfarin in the recurrent thrombosis risk (arterial or venous) [RR 2.77 (95%, CI 0.79, 9.65); P=0.11, I2=50%]. Consistent results were revealed among patients with a previous history of arterial thrombosis [RR 2.76 (95% CI 0.93, 8.16); P=0.75, I2=0%], venous thrombosis [RR 1.71 (95% CI 0.60, 4.84); P=0.31, I2=15%] and patients who were triple antiphospholipid antibodies (aPL) positive [RR 4.12 (95% CI 0.46, 37.10); 21 P=0.21, I2=58%]. Factor Xa inhibitors were significantly associated with an increased risk of stroke [RR 8.51 (95% CI 2.35, 13.82); P=0.47, I2=0%]. Conclusion Factor Xa inhibitors exhibited an increased risk of stroke among patients with Hughes syndrome. In addition, although not significant, the higher RRs among patients on factor Xa inhibitors may indicate a higher risk of thrombotic events associated with factor Xa inhibitors.
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Affiliation(s)
- Ali Mohtashim
- Department of Medicine, Allama Iqbal Medical College
| | - Aima Azhar
- Department of Medicine, Fatima Jinnah Medical University
| | - Saad Mazhar
- Department of Medicine, King Edward Medical University, Lahore
| | - Deepa Devi
- Department of Medicine, Ziadduddin University
| | | | - Dhruvilkumar Patel
- Department of Medicine, DY Patil University School of Medicine, Navi Mumbai, Maharashtra, India
| | - Owais Khan
- Department of Medicine, Dow Medical College
| | | | | | - Shahzaib Samad
- Department of Medicine, Jinnah Sindh Medical University, Karachi
| | - Aena Qureshi
- Department of Medicine, Liaqat National Medical College
| | - Hafsa Ali
- Department of Medicine, Jinnah Sindh Medical University, Karachi
| | - Umer Ejaz
- Department of Medicine, Rawalpindi Medical College, Rawalpindi, Pakistan
| | - Sayed Jawad
- Department of Medicine, Kabul University of Medical Sciences, Kabul, Afghanistan
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8
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Gailani D, Gruber A. Targeting factor XI and factor XIa to prevent thrombosis. Blood 2024; 143:1465-1475. [PMID: 38142404 PMCID: PMC11033593 DOI: 10.1182/blood.2023020722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 11/22/2023] [Accepted: 12/07/2023] [Indexed: 12/26/2023] Open
Abstract
ABSTRACT Direct oral anticoagulants (DOACs) that inhibit the coagulation proteases thrombin or factor Xa (FXa) have replaced warfarin and other vitamin K antagonists (VKAs) for most indications requiring long-term anticoagulation. In many clinical situations, DOACs are as effective as VKAs, cause less bleeding, and do not require laboratory monitoring. However, because DOACs target proteases that are required for hemostasis, their use increases the risk of serious bleeding. Concerns over therapy-related bleeding undoubtedly contribute to undertreatment of many patients who would benefit from anticoagulation therapy. There is considerable interest in the plasma zymogen factor XI (FXI) and its protease form factor XIa (FXIa) as drug targets for treating and preventing thrombosis. Laboratory and epidemiologic studies support the conclusion that FXI contributes to venous and arterial thrombosis. Based on 70 years of clinical observations of patients lacking FXI, it is anticipated that drugs targeting this protein will cause less severe bleeding than warfarin or DOACs. In phase 2 studies, drugs that inhibit FXI or FXIa prevent venous thromboembolism after total knee arthroplasty as well as, or better than, low molecular weight heparin. Patients with heart disease on FXI or FXIa inhibitors experienced less bleeding than patients taking DOACs. Based on these early results, phase 3 trials have been initiated that compare drugs targeting FXI and FXIa to standard treatments or placebo. Here, we review the contributions of FXI to normal and abnormal coagulation and discuss results from preclinical, nonclinical, and clinical studies of FXI and FXIa inhibitors.
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Affiliation(s)
- David Gailani
- The Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
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Netha A, Mazhar S, Azhar A, Moeez A, Choradia A, Mohtashim A, Anees U, Ejaz U, Tariq MU, Jawad S. Effectiveness of rivaroxaban in preventing cerebral venous thromboembolism: a systematic review and meta-analysis. Ann Med Surg (Lond) 2024; 86:2098-2104. [PMID: 38576935 PMCID: PMC10990339 DOI: 10.1097/ms9.0000000000001689] [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] [Received: 08/26/2023] [Accepted: 12/27/2023] [Indexed: 04/06/2024] Open
Abstract
Background Cerebral venous thromboembolism (CVT) poses a significant risk of venous infarction and haemorrhage, which can lead to neurological deficits and, in severe cases, even death. The optimal treatment regimen for patients with CVT remains unclear. Methods MEDLINE, Embase, Google Scholar, Web of Science (WoS), and Cochrane Central databases were searched for randomized controlled trials (RCTs) and observational studies assessing the efficacy and safety of rivaroxaban in patients with CVT. All-site venous thromboembolism (VTE), risk of clinically relevant non-major bleeding, incidence of partial recanalization, complete recanalization and major haemorrhage were among outcomes of interest. Mantel-Haenszel weighted random-effects model was used to calculate relative risks (RRs) with 95% CIs. Results The analysis included 1 RCT and 3 observational studies containing 211 patients. Compared to vitamin K antagonists (VKAs), rivaroxaban did not significantly decrease the all-site VTE [RR 0.31 (95% CI 0.01, 8.43); P=0.49, I2=0%]. Compared with VKAs, patients on rivaroxaban did not show a significantly reduced risk of recurrent cerebral venous thrombosis. In terms of incidence of partial recanalization, there was no discernible difference between rivaroxaban and VKAs [RR 0.90 (95% CI 0.66, 1.22); P=0.49, I2=0%]. There was no discernible difference in incidence of complete recanalization [RR 0.98 (95% CI 0.32, 3.03); P=0.97, I2=28%] and incidence of major haemorrhage [RR 0.19 (95% CI 0.01, 4.54); P=0.30]. Conclusion Rivaroxaban was found to have similar efficacy to VKAs. Due to its lower risk of severe bleeding and no need for INR monitoring, rivaroxaban may be a preferable treatment option for CVT.
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Affiliation(s)
- Aadarsh Netha
- Department of Medicine, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Tamilnadu, India
| | - Saad Mazhar
- Department of Medicine, King Edward Medical University
| | - Aima Azhar
- Department of Medicine, Fatima Jinnah Medical University
| | - Abdul Moeez
- Department of Medicine, Services Institute of Medical Sciences
| | - Aakash Choradia
- Department of Medicine, Tribhuwan University, Kathmandu, Nepal
| | - Ali Mohtashim
- Department of Medicine, Allama Iqbal Medical College, Lahore
| | - Usama Anees
- Department of Medicine, Quaid-e-Azam Medical College, Bahawalpur
| | - Umer Ejaz
- Department of Medicine, Rawalpindi Medical College, Rawalpindi
| | | | - Sayed Jawad
- Department of Medicine, Kabul University of Medical Sciences, Kabul, Afghanistan
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10
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Sabina M, Barakat Z, Costa Guerra B, Lurie A, Khan Z. Vintage Victory: Warfarin Versus Apixaban in the Antiphospholipid Arena. Cureus 2024; 16:e57040. [PMID: 38681463 PMCID: PMC11046336 DOI: 10.7759/cureus.57040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2024] [Indexed: 05/01/2024] Open
Abstract
This case report explores the efficacy of warfarin compared to apixaban in managing antiphospholipid syndrome (APS), an autoimmune disorder characterized by recurrent thrombosis. We emphasize the constraints of direct oral anticoagulants (DOACs) such as apixaban in APS management. This case discusses a 41-year-old female patient with APS who did not respond to apixaban therapy. The report details her transition to warfarin, resulting in symptom resolution and no further complications, thus alluding to warfarin's effectiveness in APS management over apixaban. The case contributes to the ongoing debate on the suitability of modern DOACs in APS treatment.
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Affiliation(s)
- Michael Sabina
- Internal Medicine, Lakeland Regional Health Medical Center, Lakeland, USA
| | - Zein Barakat
- Internal Medicine, Lakeland Regional Health Medical Center, Lakeland, USA
| | | | - Andrew Lurie
- Research, Nova Southeastern University Dr. Kiran C. Patel College of Osteopathic Medicine, Davie, USA
| | - Zoya Khan
- Research, Lakeland Regional Health Medical Center, Lakeland, USA
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11
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Bhat RV, Young G, Sharathkumar AA. How I treat pediatric venous thromboembolism in the DOAC era. Blood 2024; 143:389-403. [PMID: 37390311 PMCID: PMC10862368 DOI: 10.1182/blood.2022018966] [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: 02/14/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 07/02/2023] Open
Abstract
ABSTRACT The direct oral anticoagulants (DOACs) rivaroxaban and dabigatran are newly licensed for the treatment and prevention of venous thromboembolism (VTE) in children and mark a renaissance in pediatric anticoagulation management. They provide a convenient option over standard-of-care anticoagulants (heparins, fondaparinux, and vitamin K antagonists) because of their oral route of administration, child-friendly formulations, and significant reduction in monitoring. However, limitations related to therapeutic monitoring when needed and the lack of approved reversal agents for DOACs in children raise some safety concerns. There is accumulating experience of safety and efficacy of DOACs in adults for a broad scope of indications; however, the cumulative experience of using DOACs in pediatrics, specifically for those with coexisting chronic illnesses, is sparse. Consequently, clinicians must often rely on their experience for treating VTE and extrapolate from data in adults while using DOACs in children. In this article, the authors share their experience of managing 4 scenarios that hematologists are likely to encounter in their day-to-day practice. Topics addressed include (1) appropriateness of indication; (2) use for special populations of children; (3) considerations for laboratory monitoring; (4) transition between anticoagulants; (5) major drug interactions; (6) perioperative management; and (7) anticoagulation reversal.
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Affiliation(s)
- Rukhmi V. Bhat
- Center for Cancer and Blood Disorders, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Guy Young
- Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Anjali A. Sharathkumar
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
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12
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Marongiu F, Ruberto MF, Marongiu S, Mameli A, Barcellona D. Do we need more guidance on thrombophilia testing? Challenges and special considerations. Expert Rev Hematol 2024; 17:27-37. [PMID: 38228491 DOI: 10.1080/17474086.2024.2306821] [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: 11/23/2023] [Accepted: 01/15/2024] [Indexed: 01/18/2024]
Abstract
INTRODUCTION Thrombophilia testing (TT) is a laboratory procedure designed to detect the risk factors involved in the pathogenesis of vascular occlusions. The role of TT is also controversial because it has a limited impact on the choice and duration of antithrombotic treatments. AREAS COVERED We reviewed, by examining MEDLINE up to October 2023. Accepted and not accepted thrombophilia markers are discussed along with the appropriateness or not of prescribing TT in several conditions such as: provoked and unprovoked venous thromboembolism (VTE), women who are planning a pregnancy whose relatives had VTE or have a hereditary thrombophilia, before assumption of estro-progestins, after multiple pregnant loss, arterial thrombosis, retinal vein occlusion, and splanchnic vein thrombosis. EXPERT OPINION TT is not essential in the management of VTE, but it may be useful for limiting adverse events in case of thrombophilia. We expose our criticism of items afforded by other guidelines by presenting our opinion based on both the scientific evidence and clinical practice. We also deal with common mistakes in prescribing and interpretations of TT hoping to purpose an educational approach on this topic. Finally, we emphasize the creation of the expert in hemostasis and thrombosis who should be present in every hospital.
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Affiliation(s)
- Francesco Marongiu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Haemostasis and Thrombosis Unit, Azienda Ospedaliera Universitaria of Cagliari, Cagliari, Italy
| | - Maria Filomena Ruberto
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Silvia Marongiu
- Internal Medicine department, SS Trinità Hospital, ASL, Cagliari, Italy
| | - Antonella Mameli
- Haemostasis and Thrombosis Unit, Azienda Ospedaliera Universitaria of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Haemostasis and Thrombosis Unit, Azienda Ospedaliera Universitaria of Cagliari, Cagliari, Italy
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13
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Hubben A, McCrae KR. How to diagnose and manage antiphospholipid syndrome. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:606-613. [PMID: 38066904 PMCID: PMC10727028 DOI: 10.1182/hematology.2023000493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Antiphospholipid antibodies (aPL) are autoimmune antibodies directed toward phospholipids or phospholipid-protein complexes, particularly those containing β2-glycoprotein I (β2GPI). Persistently positive aPL accompanied by arterial or venous thrombosis, or recurrent pregnancy loss, constitutes the antiphospholipid syndrome (APS). Several types of aPL with different specificities have been defined and may be detected in the clinical lab, including lupus anticoagulants (detected using clotting assays) and anticardiolipin, anti-β2GPI and anti-prothrombin/phosphatidylserine antibodies (detected by ELISA); each of the last 3 aPL may be either IgG, IgM, or IgA, though IgA antibodies are not included in criteria for APS. Due to the relative rarity of APS and the heterogeneity of aPL, thrombosis risk stratification is challenging, and randomized clinical trials for thrombosis treatment and prevention have been limited. This lack of high-quality data has made the clinical management of APS difficult, and existing guidelines are few and could not possibly cover many of the scenarios encountered in managing patients with APS. In this review, we present 3 patients with aPL and/or APS who highlight treatment dilemmas, and we discuss background information that may help guide clinical judgment in developing individualized treatment plans for patients with these enigmatic antibodies.
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Affiliation(s)
- Anne Hubben
- Taussig Cancer and Lerner Research Institutes, Cleveland Clinic, Cleveland, OH
| | - Keith R McCrae
- Taussig Cancer and Lerner Research Institutes, Cleveland Clinic, Cleveland, OH
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14
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Benevolo G, Marchetti M, Melchio R, Beggiato E, Sartori C, Biolé CA, Rapezzi D, Bruno B, Milan A. Diagnosis and Management of Cardiovascular Risk in Patients with Polycythemia Vera. Vasc Health Risk Manag 2023; 19:765-778. [PMID: 38025519 PMCID: PMC10676644 DOI: 10.2147/vhrm.s429995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/04/2023] [Indexed: 12/01/2023] Open
Abstract
Polycythemia vera (PV) is a myeloproliferative neoplasm characterized by aberrant myeloid lineage hematopoiesis with excessive red blood cell and pro-inflammatory cytokine production. Patients with PV present with a range of thrombotic and hemorrhagic symptoms that affect quality of life and reduce overall survival expectancy. Thrombotic events, transformation into acute myeloid leukemia, and myelofibrosis are largely responsible for the observed mortality. Treatment of PV is thus primarily focused on symptom control and survival extension through the prevention of thrombosis and leukemic transformation. Patients with PV frequently experience thrombotic events and have elevated cardiovascular risk, including hypertension, dyslipidemias, obesity, and smoking, all of which negatively affect survival. To reduce the risk of thrombotic complications, PV therapy should aim to normalize hemoglobin, hematocrit, and leukocytosis and, in addition, identify and modify cardiovascular risk factors. Herein, we review what is currently known about the associated cardiovascular risk and propose strategies for diagnosing and managing patients with PV.
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Affiliation(s)
- Giulia Benevolo
- University Hematology Division, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Monia Marchetti
- Hematology and Transplant Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Remo Melchio
- Division of Internal Medicine, A.O. S. Croce E Carle, Cuneo, Italy
| | - Eloise Beggiato
- University Hematology Division, Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chiara Sartori
- Cardiology, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | | | | | - Benedetto Bruno
- University Hematology Division, Città della Salute e della Scienza di Torino, Turin, Italy
- Department of Molecular Biotechnolgies and Medical Sciences, University of Turin, Turin, Italy
| | - Alberto Milan
- Department of Medical Sciences, University of Turin, Città della Salute e della Scienza di Torino, Turin, Italy
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Menichelli D, Cormaci VM, Marucci S, Franchino G, Del Sole F, Capozza A, Fallarino A, Valeriani E, Violi F, Pignatelli P, Pastori D. Risk of venous thromboembolism in autoimmune diseases: A comprehensive review. Autoimmun Rev 2023; 22:103447. [PMID: 37714419 DOI: 10.1016/j.autrev.2023.103447] [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: 05/30/2023] [Revised: 09/04/2023] [Accepted: 09/12/2023] [Indexed: 09/17/2023]
Abstract
Autoimmune diseases have specific pathophysiologic mechanisms leading to an increased risk of arterial and venous thrombosis. The risk of venous thromboembolism (VTE) varies according to the type and stage of the disease, and to concomitant treatments. In this review, we revise the most common autoimmune disease such as antiphospholipid syndrome, inflammatory myositis, polymyositis and dermatomyositis, rheumatoid arthritis, sarcoidosis, Sjogren syndrome, autoimmune haemolytic anaemia, systemic lupus erythematosus, systemic sclerosis, vasculitis and inflammatory bowel disease. We also provide an overview of pathophysiology responsible for the risk of VTE in each autoimmune disorder, and report current indications to anticoagulant treatment for primary and secondary prevention of VTE.
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Affiliation(s)
- Danilo Menichelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; Department of General Surgery and Surgical Specialty Paride Stefanini, Sapienza University of Rome, 00161 Rome, Italy
| | - Vito Maria Cormaci
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Silvia Marucci
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Giovanni Franchino
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Francesco Del Sole
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Alessandro Capozza
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Alessia Fallarino
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Emanuele Valeriani
- Department of General Surgery and Surgical Specialty Paride Stefanini, Sapienza University of Rome, 00161 Rome, Italy
| | - Francesco Violi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Pasquale Pignatelli
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - Daniele Pastori
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
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16
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Agbayani E, Doig C, Noutsos T. Antiphospholipid syndrome in rural, remote, and First Nations peoples in the Top End of the Northern Territory, Australia. Res Pract Thromb Haemost 2023; 7:102227. [PMID: 38193060 PMCID: PMC10772872 DOI: 10.1016/j.rpth.2023.102227] [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] [Received: 06/01/2023] [Revised: 09/10/2023] [Accepted: 09/24/2023] [Indexed: 01/10/2024] Open
Abstract
Background The Northern Territory of Australia has a high proportion of First Nations peoples living in remote communities and a high burden of chronic autoimmune diseases. The epidemiology and clinical outcomes of antiphospholipid syndrome (APS) in First Nations Australians are poorly characterized. Objectives To determine the epidemiology, presenting features, and outcomes of patients with APS using an 18-year retrospective cohort of newly diagnosed patients presenting to Royal Darwin Hospital (2002-2020). Methods Patients admitted to Royal Darwin Hospital with a new incident diagnosis of APS between January 2002 and December 2020 were identified and followed until December 2022, with data on baseline demographics, clinical and laboratory features, and overall survival extracted from electronic and paper medical records. Results Fifty-three patients with APS were included, of whom 40 (75%) were First Nations and 46 (87%) were female. Thirty (75%) of First Nations patients with APS resided in very remote Australia vs 0 (0%) non-First Nations patients. Eighteen cases (34%) had primary APS, and 35 cases (66%) had secondary APS, most in association with lupus. Eight (15%) cases developed catastrophic APS (CAPS), all in First Nations patients. There were 13 deaths (of which 11 were among First Nations patients). Patients with CAPS had significantly shorter median overall survival (8.3 years from diagnosis), with median survival in non-CAPS patients not reached (P = .003). Conclusion There is a high prevalence of APS in First Nations patients living in very remote Australia admitted for tertiary care in the tropical north of the Northern Territory, Australia. The rate of CAPS in First Nations patients was high, and CAPS was associated with significantly shorter survival. Larger prospective studies are required to inform improved models of care for First Nations and remote Australians living with APS.
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Affiliation(s)
- Evangeline Agbayani
- Northern Territory Medical Program, College of Medicine and Public Health, Flinders University, Darwin, Australia
| | - Chris Doig
- Department of Haematology, Royal Darwin Hospital, Darwin, Australia
| | - Tina Noutsos
- Department of Haematology, Royal Darwin Hospital, Darwin, Australia
- Division of Global and Tropical Health, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
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17
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Marco-Rico A, Marco-Vera P. Thrombotic Antiphospholipid Syndrome and Direct Oral Anticoagulants: Unmet Needs and Review of the Literature. Semin Thromb Hemost 2023; 49:736-743. [PMID: 36996874 DOI: 10.1055/s-0043-1767728] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
Patients with thrombotic antiphospholipid syndrome (APS) require long-term anticoagulation due to the high-thrombotic recurrence risk. Vitamin K antagonists (VKA) have been traditionally considered the standard of care in thrombotic APS. Nevertheless, the risk of recurrence persists with VKA. There are publications considering different intensities of anticoagulation with VKA; however, the standard-intensity anticoagulation (international normalized ratio between 2.0 and 3.0) is the most recommended. Furthermore, there is no consensus on the role of antiplatelet treatment in thrombotic APS. Nonvitamin K antagonist oral anticoagulants (NOACs) have emerged as an alternative to VKA for many indications. There are, however, discrepancies regarding the management with NOACs in thrombotic APS. In this review, we update the different clinical trials with NOACs in venous, arterial, and microvascular thrombosis and suggest how these patients should be managed in agreement with the expert panels. Although scarce data are published regarding the current role of NOACs in thrombotic APS, the clinical trials failed to demonstrate noninferiority of NOACs compared with VKA, especially in patients with triple antiphospholipid antibodies positivity and/or arterial thrombosis. Single or double antiphospholipid positivity should be analyzed on a case-by-case basis. In addition, we focus on different areas of uncertainty that still remain in thrombotic APS and NOACs. To summarize, emerging clinical trials are needed to provide robust data on the management of thrombotic APS.
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Affiliation(s)
- Ana Marco-Rico
- Department of Thrombosis and Hemostasis, Hematology Service, University General Hospital Dr. Balmis, Alicante, Spain
- Biomedical Health Research Institute (ISABIAL), University General Hospital Dr. Balmis, Alicante, Spain
| | - Pascual Marco-Vera
- Biomedical Health Research Institute (ISABIAL), University General Hospital Dr. Balmis, Alicante, Spain
- Department of Clinical Medicine, Miguel Hernández University, Alicante, Spain
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18
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El Hasbani G, Del Pilar Morel M, Tandoh B, Vargas JF, Crusio R. Adrenal hemorrhage and non-ST elevation myocardial infarction: an antiphospholipid syndrome dilemma. Reumatismo 2023; 75. [PMID: 37721347 DOI: 10.4081/reumatismo.2023.1584] [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: 04/13/2023] [Accepted: 07/12/2023] [Indexed: 09/19/2023] Open
Abstract
Antiphospholipid syndrome (APS) can affect different organ systems, including the heart and adrenal glands. Despite being known for its prothrombotic characteristics, APS can have serious bleeding complications. Occasionally, thrombotic and bleeding episodes can present simultaneously in an APS patient. Whenever these events co-occur, resuming anticoagulation becomes a topic of debate. As such, we present the case of a 43-year-old male with triple positive antiphospholipid antibodies, indicating APS, who presented with chest pain. Anticoagulants were switched one month before presentation from warfarin to a direct oral anticoagulant, rivaroxaban. Non-ST elevation myocardial infarction, as well as new-onset left-sided adrenal hemorrhage, were diagnosed. The patient developed adrenal insufficiency; therefore, corticosteroids were administered, and warfarin was resumed to prevent further thrombotic episodes.
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Affiliation(s)
- G El Hasbani
- Department of Medicine, Hartford Healthcare, St Vincent's Medical Center, Bridgeport, Connecticut.
| | - M Del Pilar Morel
- Department of Medicine, Hartford Healthcare, St Vincent's Medical Center, Bridgeport, Connecticut.
| | - B Tandoh
- Department of Medicine, Hartford Healthcare, St Vincent's Medical Center, Bridgeport, Connecticut.
| | - J F Vargas
- Department of Radiology, Hartford Healthcare, St Vincent's Medical Center, Bridgeport, Connecticut.
| | - R Crusio
- Department of Medicine, Hartford Healthcare, St Vincent's Medical Center, Bridgeport, Connecticut.
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19
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Tonutti A, Scarfò I, La Canna G, Selmi C, De Santis M. Diagnostic Work-Up in Patients with Nonbacterial Thrombotic Endocarditis. J Clin Med 2023; 12:5819. [PMID: 37762758 PMCID: PMC10532023 DOI: 10.3390/jcm12185819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/23/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Nonbacterial thrombotic endocarditis (NBTE) is a form of endocarditis that occurs in patients with predisposing conditions, including malignancies, autoimmune diseases (particularly antiphospholipid antibody syndrome, which accounts for the majority of lupus-associated cases), and coagulation disturbances for which the correlation with classical determinants is unclear. The condition is commonly referred to as "marantic", "verrucous", or Libman-Sacks endocarditis, although these are not synonymous, representing clinical-pathological nuances. The clinical presentation of NBTE involves embolic events, while local valvular complications, generally regurgitation, are typically less frequent and milder compared to infective forms of endocarditis. In the past, the diagnosis of NBTE relied on post mortem examinations, while at present, the diagnosis is primarily based on echocardiography, with the priority of excluding infective endocarditis through comprehensive microbiological and serological tests. As in other forms of endocarditis, besides pathology, transesophageal echocardiography remains the diagnostic standard, while other imaging techniques hold promise as adjunctive tools for early diagnosis and differentiation from infective vegetations. These include cardiac MRI and 18FDG-PET/CT, which already represents a major diagnostic criterion of infective endocarditis in specific settings. We will herein provide a comprehensive review of the current knowledge on the clinics and therapeutics of NBTE, with a specific focus on the diagnostic tools.
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Affiliation(s)
- Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (A.T.); (C.S.)
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Iside Scarfò
- Applied Diagnostic Echocardiography Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (I.S.); (G.L.C.)
| | - Giovanni La Canna
- Applied Diagnostic Echocardiography Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (I.S.); (G.L.C.)
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (A.T.); (C.S.)
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Maria De Santis
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (A.T.); (C.S.)
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
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20
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Windisch S, Ash JY, Frishman WH. Antiphospholipid Syndrome: Thrombotic and Vascular Complications. Cardiol Rev 2023:00045415-990000000-00143. [PMID: 37607079 DOI: 10.1097/crd.0000000000000590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Antiphospholipid syndrome is a rare, autoimmune thrombophilia defined by vascular thrombosis and pregnancy morbidity, in the setting of documented persistent antiphospholipid antibodies including the lupus anticoagulant, anticardiolipin antibodies, or anti-β2 glycoprotein I antibodies. The presence of antiphospholipid antibodies can be completely asymptomatic, or they can lead to clinical manifestations as severe as catastrophic antiphospholipid syndrome, which involves widespread coagulopathy over a very short period of time. The degree of risk associated with antiphospholipid syndrome depends on the characteristics of the antiphospholipid antibody profile and on the presence of additional thrombotic risk factors. The current standard treatment for unprovoked thrombosis is long-term warfarin. Treatment to prevent recurrent obstetric complications is low-dose aspirin and prophylactic heparin in pregnant patients. The use of direct oral anticoagulants in patients with antiphospholipid syndrome is still being debated. Their use is generally contraindicated, especially in high-risk patients, such as those with all 3 antiphospholipid antibodies present, but they may potentially be of some use in some low-risk patients.
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Affiliation(s)
- Stephen Windisch
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - Julia Y Ash
- From the Department of Medicine, New York Medical College, Valhalla, NY
| | - William H Frishman
- Departments of Medicine and Cardiology, New York Medical College/Westchester Medical Center, Valhalla, NY
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21
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Depietri L, Veropalumbo MR, Leone MC, Ghirarduzzi A. Antiphospholipid Syndrome: State of the Art of Clinical Management. Cardiovasc Drugs Ther 2023:10.1007/s10557-023-07496-3. [PMID: 37572208 DOI: 10.1007/s10557-023-07496-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2023] [Indexed: 08/14/2023]
Abstract
Antiphospholipid syndrome (APS) is a systemic autoimmune disorder clinically characterized by recurrent arterial and venous thrombosis and/or pregnancy morbidity in the presence of antiphospholipid antibodies. Currently, treatment is mainly focused on anticoagulation, but therapies targeting mechanisms involved in APS autoimmune pathogenesis could play an important role in specific settings. An evidence-based therapeutic approach is limited by the broad clinical spectrum of the syndrome and the nature of a "rare disease" that makes it difficult to carry out well-designed prospective studies. Vitamin K antagonists (AVK), notably warfarin, are the standard treatment for preventing recurrent venous thrombosis and perhaps also arterial thrombosis. Direct oral anticoagulants (DOACs) are not recommended at least in patients with triple positivity APS. Treatment options for the prevention of pregnancy complications in obstetric APS, as combined use of aspirin and heparin, low-dose prednisolone, hydroxychloroquine, intravenous immunoglobulin (IVIG), may improve pregnancy outcome. The catastrophic antiphospholipid syndrome (CAPS) is the most severe form of APS with acute multiple organ involvement and small vessel thrombosis. Glucocorticoids, heparin, plasma exchange or IVIG, rituximab, or eculizumab must be added to concurrent treatment of precipitating factors (e.g. infections) as rescue therapies. Finally, it has been observed that SARS COV2 infection may produce vascular complications mimicking the clinical and pathophysiological features of APS and particularly of CAPS. From this point of view, attention has been focused on the "protective" role of anticoagulant therapy in preventing thrombotic complication when these clinical conditions coexist.
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Affiliation(s)
- Luca Depietri
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy.
| | - Maria Rosaria Veropalumbo
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Maria Cristina Leone
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Angelo Ghirarduzzi
- Cardiovascular Medicine - Angiology Unit and Haemostasis and Thrombosis Centre, AUSL-IRCCS Di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
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22
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Nekooghadam SM, Ebrahimi‐Dehkordi S, Paraandavaji E, Pishgahi M, Ghadirzadeh E, Charkazi E, Ghorbani P. Heparin induced thrombocytopenia in pregnancy: A therapeutic challenge case report and literature review. Clin Case Rep 2023; 11:e7839. [PMID: 37614288 PMCID: PMC10442474 DOI: 10.1002/ccr3.7839] [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] [Received: 04/27/2023] [Revised: 07/12/2023] [Accepted: 08/11/2023] [Indexed: 08/25/2023] Open
Abstract
The anticoagulants of choice for the prevention and treatment of venous thromboembolic disease during pregnancy are unfractionated heparin and low-molecular-weight heparin. Heparin-induced thrombocytopenia (HIT) is introduced as a rare but critical side effect of heparin products raising the thromboembolic event paradoxically. Here, we present a case of HIT in pregnancy with challenging management due to coincidence of lupus anticoagulant (LA) and limited anticoagulant options in the pharmaceutical market of our country of residence. We describe a 6-week pregnant patient with deep venous thrombosis (DVT) and pulmonary thromboembolism (PTE), which developed HIT during antenatal care. Therapeutic anticoagulation was initiated with argatroban, then switched to apixaban due to limited access to argatroban. Another therapeutic challenge was the concurrent incidence of LA. The interdisciplinary care team decided on adding up warfarin and scheduled termination at 12 weeks regarding the hazardous condition of the patient. We also reviewed related case literature to convey a new insight into managing pregnancy-related HIT. HIT is a pro-coagulatory and lethal complication associated with heparin therapy that can be diagnosed by clinical suspicion, the 4T score system, and confirmatory laboratory analyses. Alternative anticoagulation is the cornerstone of the treatment and an interdisciplinary plan will be worthwhile to make the best clinical decision regarding the critical situation and least the thromboembolic events mortality during pregnancy.
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Affiliation(s)
- Seyyed Mojtaba Nekooghadam
- Department of Internal MedicineSchool of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | | | - Elham Paraandavaji
- Skull Base Research CenterLoghman Hakim HospitalShahid Beheshti University of Medical SciencesTehranIran
| | - Mehdi Pishgahi
- Department of CardiologySchool of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | - Erfan Ghadirzadeh
- Cardiovascular Research CenterMazandaran University of Medical SciencesSariIran
| | | | - Parastoo Ghorbani
- Cardiovascular Research CenterMazandaran University of Medical SciencesSariIran
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23
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Bakow BR, Phung Q, Rabinovich D, Olszewski AJ, Reagan JL. Choice of anticoagulation in patients with low risk antiphospholipid syndrome. J Thromb Thrombolysis 2023:10.1007/s11239-023-02826-6. [PMID: 37219825 DOI: 10.1007/s11239-023-02826-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 05/24/2023]
Abstract
Antiphospholipid syndrome (APS) is an acquired hypercoagulable state necessitating long-term anticoagulation for secondary thrombosis prevention. Anticoagulation guidelines are predominantly based on data in high risk, triple positive patients, and favor Vitamin K antagonists over other forms of anticoagulation. The efficacy of alternative anticoagulants for secondary thrombosis prevention in low risk, single and double positive APS remains uncertain. This study aimed to assess the incidence of recurrent thrombosis and major bleeding for patient with low risk APS on long-term anticoagulation. We performed a retrospective cohort study of patients who met revised criteria for thrombotic APS between January, 2001 and April, 2021 and received care through the Lifespan Health System. Primary outcomes included recurrent thrombosis and WHO Grades 3 and 4 major bleeding. A total of 190 patients were followed over a median duration of 3.1 years. At time of APS diagnosis, 89 patients were treated with warfarin and 59 patients with a direct oral anticoagulant (DOAC). There were similar rates of recurrent thrombosis in low risk patients on warfarin versus DOACs (adjusted IRR 6.91; 95% CI 0.90-53.40, p = 0.064). Major bleeding events only occurred in low risk patients on warfarin (n = 8, log-rank p = 0.13). In conclusion, despite the choice of anticoagulation, patients with low risk APS had similar rates of recurrent thrombosis suggesting DOACs may be a potential treatment option for this cohort. There was a non-significant increase in major bleeding rates in low risk patients on warfarin versus DOACs. Study limitations include a retrospective study design and small event numbers.
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Affiliation(s)
- Brianna R Bakow
- Warren Alpert Medical School of Brown University, Providence, RI, USA.
- Division of Hematology/Oncology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence, RI, 02903, USA.
| | - Quan Phung
- Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Medicine, Rhode Island Hospital, Providence, RI, USA
| | | | - Adam J Olszewski
- Warren Alpert Medical School of Brown University, Providence, RI, USA
- Division of Hematology/Oncology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence, RI, 02903, USA
| | - John L Reagan
- Warren Alpert Medical School of Brown University, Providence, RI, USA
- Division of Hematology/Oncology, Warren Alpert Medical School of Brown University, Rhode Island Hospital, 593 Eddy St, Providence, RI, 02903, USA
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24
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Ambati A, Knight JS, Zuo Y. Antiphospholipid syndrome management: a 2023 update and practical algorithm-based approach. Curr Opin Rheumatol 2023; 35:149-160. [PMID: 36866678 PMCID: PMC10364614 DOI: 10.1097/bor.0000000000000932] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
PURPOSE OF REVIEW Antiphospholipid syndrome (APS) is an acquired thrombo-inflammatory disease that has morbid and sometimes devastating effects on patients and their families. This review will discuss the most recent international societal treatment guidelines and propose practical management algorithms for various APS sub-types. RECENT FINDINGS APS represents a disease spectrum. Although thrombosis and pregnancy morbidities are traditional hallmarks of APS, a variety of extra-criteria clinical phenotypes can often be seen, which makes clinical management more challenging. Primary APS thrombosis prophylaxis should take a risk-stratified approach. Although vitamin K antagonists (VKAs) or heparin/low molecular weight heparin (LMWH) remain the preferred treatment for secondary APS thrombosis prophylaxis, some international society guidelines support the use of direct oral anticoagulants (DOACs) in certain circumstances. Careful monitoring and individualized obstetric care with the use of aspirin and heparin/LMWH will improve pregnancy outcomes among pregnant individuals with APS. Treatment of microvascular and catastrophic APS remains challenging. While the addition of various immunosuppressive agents is often utilized, further systemic evaluations of their use are warranted before definitive recommendations can be made. Several new therapeutic strategies are on the horizon that might enable more personalized and targeted APS management in the near future. SUMMARY Although the knowledge of APS pathogenesis has grown in recent years, the management principles and strategies are largely unchanged. There is an unmet need for evaluating pharmacological agents, beyond anticoagulants, that target diverse thromboinflammatory pathways.
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Affiliation(s)
- Amala Ambati
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason S. Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Yu Zuo
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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25
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Porta SV, de Andrade DCO, Erkan D, Gómez- Puerta JA, Jara LJ, Alba Moreyra P, Pons-Estel GJ. Controversies in the Management of Antiphospholipid Syndrome. J Clin Rheumatol 2023. [PMID: 37478021 DOI: 10.1097/rhu.0000000000001961] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
ABSTRACT Strategies to prevent thrombosis in antiphospholipid antibody (aPL)-positive patients are of the utmost importance. The risk of thrombosis in patients with aPLs varies, depending on additional venous thrombosis and cardiovascular risk factors, as well as associated comorbidities. Recurrent thrombosis despite treatment with vitamin K antagonists is relatively common in daily practice. In this context, the effectiveness of the new direct oral anticoagulants in antiphospholipid syndrome is debated, as well as that of low-dose aspirin for primary thromboprophylaxis. There is an urgent unmet need to recognize the subgroup of patients that may benefit from low-dose aspirin use. Here we also discuss different points of view on primary and secondary thrombosis preventions in aPL-positive patients, which were presented as a debate during the 2021 PANLAR Congress (Pan-American League of the Association of Rheumatology) and that was organized by GESAF (Argentine Society of Rheumatology APS Study Group). It is the intention of this article to provide a useful discussion to aid treatment decision-making in daily clinical practice.
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26
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Novelli C, Pradella P, Papandrea M, Montaruli B. Direct oral anticoagulant adsorption and laboratory detection of lupus anticoagulant. Blood Coagul Fibrinolysis 2023; 34:199-205. [PMID: 37017015 DOI: 10.1097/mbc.0000000000001214] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
Direct oral anticoagulants (DOACs) interfere with many coagulation assays, mostly in lupus anticoagulant (LA) detection, causing false positive and negative results. Despite guidelines recommendations, LA testing may be important during anticoagulation when the clinician has to decide whether to prolong or discontinue the drug. OBJECTIVES In this study, the effect of activated charcoal (DOAC-Stop, DS) as a DOAC-adsorbent was investigated on samples from DOACs treated and untreated patients. BASIC METHODS 165 plasma samples with a LA request were collected in three laboratories: 105 were from patients receiving DOACs and 60 were from nonanticoagulated patients with 30 LA negative and 30 LA positive. All coagulation screening assays and LA assays were evaluated before and after DS treatment. RESULTS The adsorption technique reduced DOACs concentration below the Lower Limit of Quantification. For nonanticoagulated patients: no significant difference in ratio results of coagulation screening (prothrombin time, activated partial thromboplastin time and thrombin time) and LA tests were observed before and after addition of DS in LA positive and negative patients. Every LA was correctly classified. For anticoagulated patients: a statistically significant difference was found for coagulation screening assays and LA assays. Final LA conclusions changed after DS addition from positive to negative in 58.9% of patients (more frequently with Rivaroxaban) and from negative to positive in 8% of patients (more frequently with Apixaban). CONCLUSIONS Our study suggests that DOAC-Stop can be used in daily laboratory practice to remove DOACs interference for a more accurate assessment of LA that is essential for diagnosis and management of APS patients.
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Affiliation(s)
- Chiara Novelli
- Transfusion Center and Haematology Laboratory, ASST Ovest Milanese, Legnano Hospital, Legnano
| | - Paola Pradella
- Transfusion Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina, University Hospital, Trieste
| | - Maria Papandrea
- Laboratory Analysis, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| | - Barbara Montaruli
- Laboratory Analysis, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
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27
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Guo G, Liang S, Guan Z, Zhu K. Effect of direct oral anticoagulants in patients with atrial fibrillation with mitral or aortic stenosis: A review. Front Cardiovasc Med 2022; 9:1070806. [DOI: 10.3389/fcvm.2022.1070806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 10/31/2022] [Indexed: 11/18/2022] Open
Abstract
BackgroundSeveral studies have summarized the clinical performance of direct oral anticoagulants (DOACs) in atrial fibrillation (AF) patients with mitral stenosis or aortic stenosis. The significance of this review was to provide clinicians the latest update of the clinical application of DOACs in managing this specific population.MethodsLiteratures from the PubMed database up to July 2022 were screened for inclusion. Studies on the effect of DOACs in patients suffering from AF with mitral or aortic stenosis were assessed for further selection.ResultsResults from four studies were gathered: the RISE MS trial, the DAVID-MS study, and two observational studies. In the Korean observational study with a 27-month follow-up duration and a sample population consisted of patients with mitral stenosis and AF, the thromboembolic events happened at a rate of 2.22%/ year in the DOAC group and 4.19%/year in the warfarin group (adjusted hazard ratio: 0.28; 95% CI: 0.18–0.45). Intracranial hemorrhage occurred at rates of 0.49% and 0.93% in the DOAC and the warfarin groups, respectively (adjusted hazard ratio: 0.53; 95% CI: 0.22–1.26). In the Danish observational study, which had a sample pool with AF patients with aortic stenosis, reported that the adjusted hazard ratios for thromboembolism and major bleeding were 1.62 (95% CI, 1.08–2.45) and 0.73 (95% CI, 0.59–0.91) for DOACs compared with warfarin during 3 years of follow-up. In the RISE-MS trial involving AF patients with mitral stenosis, there were no differences in ischemic stroke, systemic embolic events, or major bleeding between the rivaroxaban vs. warfarin groups during a 1-year follow-up as well as equal rate of increased thrombogenicity in the left atrial appendage at 6 months. The rate of silent cerebral ischemia at 12 months was higher in the warfarin group (17.6%) than that in the rivaroxaban group (13.3%).ConclusionsCurrent published studies supported DOACs' effectiveness in preventing thromboembolism in patients of AF with mitral or aortic stenosis. Further clinical trials could confirm these findings.
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28
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Comparing the efficacy and safety of direct oral anticoagulants versus Vitamin K antagonists in patients with antiphospholipid syndrome: a systematic review and meta-analysis. Blood Coagul Fibrinolysis 2022; 33:389-401. [PMID: 35867933 PMCID: PMC9594143 DOI: 10.1097/mbc.0000000000001153] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Thromboprophylaxis is the cornerstone strategy for thrombotic antiphospholipid syndrome (APS). Data comparing direct oral anticoagulants (DOACs) to Vitamin K antagonists (VKAs) in the secondary prevention of thrombosis in APS patients remain contentious. We aim to review and analyse literature on the efficacy and safety of DOACs compared with VKAs in treating patients with APS. A literature search was performed from inception to 31 December 2021. Subgroups were analysed based on the risk stratification of APS profiles and different DOAC types. A total of nine studies with 1131 patients were included in the meta-analysis. High-risk APS patients (triple positive APS) who used DOACs displayed an increased risk of recurrent thrombosis [risk ratio = 3.65, 95% confidence interval (95% CI): 1.49-8.93; I2 = 29%, P = 0.005] compared with those taking VKAs. Similar risk of recurrent thrombosis or major bleeding was noted in low-risk APS patients (single or double antibody-positive) upon administering DOACs or VKAs. The utilization of Rivaroxaban was associated with a high risk of recurrent thromboses (RR = 2.63; 95% CI: 1.56-4.42; I2 = 0, P = 0.0003), particularly recurrent arterial thromboses (RR = 4.52; 95% CI: 1.99-10.29; I2 = 0, P = 0.18) in overall APS patients. Comparisons of the rate of recurrent thrombosis events and major bleeding events when using dabigatran or apixaban versus VKAs yielded no statistical differences. In the absence of contraindications, this meta-analysis suggests that VKAs remain the first-choice treatment for high-risk APS patients, with DOACs a more appropriate option for low-risk APS patients. Different DOACs may exhibit different levels of efficacy and safety for thromboprophylaxis in APS patients and require further exploration.
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29
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Gullapalli K, Prasad RM, Al-Abcha A, Hussain Z, Alsouqi A, Mosalem O, Hrinczenko B. Efficacy and Safety of Direct Oral Anticoagulants in Patients With Antiphospholipid Syndrome: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e29449. [PMID: 36299971 PMCID: PMC9587712 DOI: 10.7759/cureus.29449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2022] [Indexed: 11/23/2022] Open
Abstract
Due to a high risk of recurrent thromboembolism in patients with antiphospholipid syndrome (APS), long-term anticoagulation is recommended. For decades, vitamin K antagonists (VKAs) have been the gold standard for thromboprophylaxis in these patients. Due to the widespread use of direct oral anticoagulants (DOACs) in various thromboembolic conditions and their potential advantages compared to VKAs, several studies have been conducted to evaluate their safety and efficacy in APS. We performed a literature search using PubMed, Embase, and Cochrane databases for studies comparing DOACs to VKAs in patients with APS. Relative risk (RR) and the corresponding 95% confidence intervals (95% CI) were estimated for recurrent thromboembolic events, bleeding, and mortality. A total of 1437 patients pooled from 12 studies were analyzed. The risk of recurrent thrombosis, especially arterial thrombosis, doubled with DOACs compared to VKAs (RR 2.61, 95% CI 1.44-4.71; p=0.001). The risk further increased in patients with a triple-positive antiphospholipid antibody profile (RR 4.50, 95% CI 1.91-10.63; p=0.0006) and with the use of rivaroxaban (RR 1.95, 95% CI 1.10-3.45; p=0.02). The risk of major bleeding and mortality were not significantly different between the two arms. A trend favoring DOACs compared to VKAs was observed for all bleeding events. This meta-analysis comes in agreement with previous studies and supports the use of VKAs in APS. Our study revealed that VKAs remain the gold standard for the management of APS, especially triple-positive APS. DOACs, particularly rivaroxaban, are not as effective in preventing recurrent thromboembolism in high-risk APS patients. Further studies are needed to evaluate the role of DOACs apart from rivaroxaban with a focus on their efficacy in the management of isolated or double-positive APS.
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Affiliation(s)
- Keerthi Gullapalli
- Internal Medicine, Michigan State University-Sparrow Hospital, Lansing, USA
| | - Rohan M Prasad
- Internal Medicine, Michigan State University-Sparrow Hospital, Lansing, USA
| | - Abdullah Al-Abcha
- Internal Medicine, Michigan State University-Sparrow Hospital, Lansing, USA
| | - Zahin Hussain
- Internal Medicine, Michigan State University College of Human Medicine, Lansing, USA
| | - Aseel Alsouqi
- Hematology and Oncology, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Osama Mosalem
- Internal Medicine, Michigan State University-Sparrow Hospital, Lansing, USA
| | - Borys Hrinczenko
- Hematology and Oncology, Michigan State University, Lansing, USA
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30
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Liu A, Rupani KV, Naymagon L. Direct oral anticoagulants versus warfarin in patients with single antibody-positive anti-phospholipid syndrome. Eur J Haematol 2022; 109:69-74. [PMID: 35305281 DOI: 10.1111/ejh.13770] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 03/12/2022] [Accepted: 03/16/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND The role of direct oral anticoagulants (DOACs) among patients with antiphospholipid syndrome (APLS) remains unclear. Warfarin has been shown to be superior to DOACs among high-risk APLS patients (particularly those with triple-positive APLS). However, it remains unknown whether DOACs may be appropriate for lower-risk patients such as those with single-positive APLS. METHODS We conducted a retrospective study comparing the risk of recurrent thrombosis among single-positive APLS patients treated with DOACs (apixaban or rivaroxaban), and those treated with warfarin. RESULTS One-hundred-forty-three single-positive APLS patients, newly started on anticoagulation following a first thrombotic event, were included. Median follow-up was 54 months (IQR 29-73 months). Ninety-one patients (64%) received warfarin and 52 patients (36%) received a DOAC. Six patients (6.6%) who received warfarin experienced a recurrent thrombotic event compared with 3 of 52 (5.8%) patients who received a DOAC (p = .845). There was no difference in event-free survival between groups (HR DOAC:Warfarin = 0.952, 95% CI 0.232 - 3.908). Major bleeding was similar in both groups. CONCLUSIONS These findings suggest that DOACs may be a safe and effective option for patients with single-positive APLS. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Angela Liu
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York, USA
| | - Karishma Vijay Rupani
- Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel Hospital, New York, New York, USA
| | - Leonard Naymagon
- Icahn School of Medicine at Mount Sinai, Tisch Cancer Institute, New York, New York, USA
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31
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Imazeki A, Miyachi H, Nakamura Y, Sugiura T, Matsue H. Development of venous thromboembolism in an elderly man with plaque psoriasis and antiphospholipid syndrome: A case report. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2022. [DOI: 10.1002/cia2.12246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Azusa Imazeki
- Department of Dermatology Graduate School of Medicine Chiba University Chiba Japan
- Division of Dermatology Funabashi Municipal Medical Center Chiba Japan
| | - Hideaki Miyachi
- Department of Dermatology Graduate School of Medicine Chiba University Chiba Japan
| | - Yuumi Nakamura
- Department of Dermatology Graduate School of Medicine Chiba University Chiba Japan
| | - Toshihiko Sugiura
- Department of Respirology Graduate School of Medicine Chiba University Chiba Japan
| | - Hiroyuki Matsue
- Department of Dermatology Graduate School of Medicine Chiba University Chiba Japan
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32
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Ciprian G. Adverse Reaction to COVID-19 mRNA Vaccination in a Patient With VEXAS Syndrome. Cureus 2022; 14:e23456. [PMID: 35481304 PMCID: PMC9034849 DOI: 10.7759/cureus.23456] [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: 03/24/2022] [Indexed: 11/05/2022] Open
Abstract
VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a rare genetic disorder originating from a somatic mutation in the hematopoietic stem cells. This syndrome was first described in 2020 and carries many clinical features that other conditions cannot explain. Widespread autoinflammation is the primary process the disease presents, with high morbidity and mortality in those who show signs of bone marrow failure. Treatment is complex, and response to current therapies is poor. Long-term prognosis carries a mortality of 50%. In addition, the advancement of new-generation messenger ribonucleic acid (mRNA) vaccines raises concerns about their safety in this population since it could trigger a vaccine-related autoimmune response. This case describes the hospital course of a male in his 50s exhibiting an unexplained cutaneous reaction to an mRNA COVID-19 vaccine. He was later diagnosed with VEXAS syndrome based on symptoms presentation and diagnostic workup.
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33
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Direct oral anticoagulants for use in paediatrics. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:207-214. [PMID: 35033222 DOI: 10.1016/s2352-4642(21)00343-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/28/2021] [Accepted: 10/28/2021] [Indexed: 12/12/2022]
Abstract
With the increasing incidence of thromboembolism in children and improvement in management for patients with medically complex diseases, expanded availability of safe and effective anticoagulant medications is needed. Traditionally, the most common anticoagulants used for the treatment or prevention of venous thromboembolism or embolic stroke in children were either unfractionated heparin or the low-molecular-weight heparins. These medications require either intravenous access or daily subcutaneous injections, in addition to multiple venepunctures to monitor drug concentrations. Direct oral anticoagulants provide an alternative, and potentially safer, choice for children, as they are available in oral formulations and do not require drug monitoring. With the approval of the direct factor Xa inhibitor, rivaroxaban (by the European Medicines Agency and Health Canada), and the direct thrombin inhibitor, dabigatran (by the European Medicines Agency and US Food and Drug Administration), the field of paediatric anticoagulation is changing. In this Review, we provide an overview of the four direct oral anticoagulants approved in adults for the treatment and prevention of thrombosis and the completed and ongoing paediatric trials.
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34
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Anderson M, Belmont M. Severe thrombotic events associated with pre-procedural interruption of anticoagulation in systemic lupus erythematosus with secondary antiphospholipid syndrome: Cases and literature review. Lupus 2022; 31:261-267. [PMID: 35041558 DOI: 10.1177/09612033221074920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The American College of Chest Physicians (ACCP) and National Institutes for health and care Excellence in the United Kingdom (NICE) recommend that patients who are high risk for thrombotic events but require cessation of oral anticoagulation with warfarin, due to bleeding risk of a planned procedure, undergo bridging therapy with heparin. However, those conditions which are considered high risk are not universal, nor do guidelines differentiate between low molecular weight heparin (LMWH) and unfractionated heparin. Triple positive antiphospholipid syndrome (APS) is a thrombophilic state with a very high risk for thrombotic events during periods of anticoagulation cessation. Patients with secondary antiphospholipid syndrome in the setting of SLE may be at an even greater risk of thrombotic events during the perioperative period. PURPOSE Along with a review of the literature for perioperative management in APS we present three cases of triple positive secondary APS in systemic lupus erythematosus (SLE) patients who had severe thrombotic complications after cessation of their oral anticoagulation despite being bridged with LWMH. CONCLUSION Given the severity and rapidity of thrombotic complications with low molecular weight heparin bridging, we propose that all patients with triple positive APS, especially secondary APS with SLE should undergo bridging therapy with intravenous UFH to reduce time without anticoagulation and minimize risk of thrombotic complications. Furthermore, we propose that NICE include APS in the list of medical conditions which are high risk for thrombotic complications and require bridging therapy.
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Affiliation(s)
- Meghan Anderson
- 12297Department of Rheumatology at NYU Langone Health, New York, NY, USA.,12297Department of Rheumatology at NYU Langone Health and Hospital for Joint Disease, New York, NY, USA
| | - Michael Belmont
- 12297Department of Rheumatology at NYU Langone Health, New York, NY, USA.,12297Department of Rheumatology at NYU Langone Health and Hospital for Joint Disease, New York, NY, USA
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35
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Buliková A, Penka M. Venous thromboembolism in antiphosholipid syndrome. VNITRNI LEKARSTVI 2022; 68:493-497. [PMID: 36575066 DOI: 10.36290/vnl.2022.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Antiphosholipid syndrome (APS) is defined by the presence of clinical and laboratory criteria, it means by presence of antiphospholipid antibodies. Venous thromboembolism belongs to the most frequent clinical manifestation of this syndrome. Here we summarised basic pathophysiological mechanisms of venous thrombosis and lung embolism development, epidemiology of APS, and also the situations when this syndrome should be considered. The possible difficulties of laboratory diagnosis and their therapy involvement are mentioned.
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36
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Otsuka R, Saito S, Yamamoto T, Ohno T, Koyama A, Morimae H, Matsushita M, Yokota K, Miyahara K, Matsuura A. Recurrent Mural Thrombosis of the Ascending Aorta in a Patient with Antiphospholipid Syndrome. Ann Vasc Dis 2022; 15:77-80. [PMID: 35432651 PMCID: PMC8958407 DOI: 10.3400/avd.cr.21-00138] [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: 11/24/2021] [Accepted: 02/01/2022] [Indexed: 11/13/2022] Open
Abstract
A 38-year-old man presented with embolic occlusion of the brachial artery. As per his computed tomography results, a pedunculated mass in the proximal ascending aorta was detected. Since discrimination between a thrombus and a tumor was deemed difficult, the patient underwent replacement of the ascending aorta. Histopathology revealed the mass to be a thrombus. The diagnosis of antiphospholipid syndrome was then confirmed postoperatively. Six months post-surgery, a new thrombus was detected in the vascular prosthesis. The thrombus resolved after treatment with edoxaban and aspirin. To the best of our knowledge, this is the first report on graft thrombosis in antiphospholipid syndrome, highlighting the importance of seamless anticoagulation therapy.
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Affiliation(s)
- Ryohei Otsuka
- Division of Cardiovascular Surgery, Ichinomiya Municipal Hospital
| | - Shunei Saito
- Division of Cardiovascular Surgery, Ichinomiya Municipal Hospital
| | | | - Tsukasa Ohno
- Division of Cardiovascular Surgery, Ichinomiya Municipal Hospital
| | - Akio Koyama
- Division of Vascular Surgery, Ichinomiya Municipal Hospital
| | | | | | - Kaori Yokota
- Division of Rheumatology and Collagen Diseases, Ichinomiya Municipal Hospital
| | - Ken Miyahara
- Division of Cardiovascular Surgery, Ichinomiya Municipal Hospital
| | - Akio Matsuura
- Division of Cardiovascular Surgery, Ichinomiya Municipal Hospital
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