Antiphospholipid Antibodies and Heart Failure with Preserved Ejection Fraction. The Multicenter ATHERO-APS Study

The prognostic value of HFA-PEFF score in connective tissue disease-associated PAH: evidence from a cohort study

BACKGROUND

Connective tissue disease-associated pulmonary arterial hypertension (CTD-PAH) patients with left heart dysfunction may have worse prognosis. This study was to investigate the prognostic value of HFA-PEFF score in connective tissue disease-associated PAH.

METHODS

This single-center retrospective cohort study enrolled 147 CTD-PAH patients diagnosed via right heart catheterization (RHC), divided into two groups based on their HFA-PEFF scores: < 5 (n = 74) and ≥ 5 (n = 73). The clinical characteristics were compared between the two groups. The primary end point was all-cause mortality, and the secondary end point was clinical worsening events. Survival was analyzed using Kaplan-Meier analysis and Cox proportional hazards models.

RESULTS

Compared to the HFA-PEFF score < 5 group, the ≥ 5 group exhibited significantly higher levels of N-terminal pro-brain natriuretic peptide (NT-proBNP), a greater proportion of WHO functional class III-IV, shorter 6-min walk distance (6MWD), larger right ventricular (RV) volume, worse RV function, smaller left ventricular (LV) volume, and higher native T1 values. An HFA-PEFF score ≥ 5 was a predictor for all-cause mortality in CTD-PAH (HR 5.022, P = 0.020) and for clinical worsening events (HR 2.670, P = 0.020). At follow-up, 17.9% of CTD-PAH had an HFA-PEFF score ≥ 5. Patients with follow-up HFA-PEFF scores ≥ 5 had a significantly lower event-free survival rate (P < 0.001).

CONCLUSION

An HFA-PEFF score ≥ 5 was associated with all-cause mortality and clinical worsening events in CTD-PAH patients.

TRIAL REGISTRATION

NCT05980728. Connective Tissue Disease Patients With Pulmonary Hypertension. Oct 17, 2023.

Statins as an Adjunctive Antithrombotic Agent in Thrombotic Antiphospholipid Syndrome: Mechanisms and Clinical Implications

The thrombotic physiopathology of antiphospholipid syndrome (APS) is complex, heterogeneous, and dynamic. While venous thromboembolism (VTE) is the most common initial presentation, arterial thrombotic events (ATE) become more frequent in advanced stages and are associated with high morbidity and mortality. Despite the use of oral anticoagulants (OACs), thrombotic APS remains associated with a high risk of recurrent thrombosis. Given their potential antithrombotic effects capable of reducing the risk of both VTE and ATE, statins have been proposed as an adjunctive therapy to OACs for patients with APS and recurrent thrombosis. However, this recommendation is primarily based on studies not specifically conducted in APS populations, with only preclinical data or evidence from retrospective observational studies available from APS patients cohorts. For these reasons, this narrative review aims to synthesise the studies evaluating the potential antithrombotic effects of statins in patients with APS, highlighting the progress made and identifying areas for future research.

Heart valve disease in primary antiphospholipid syndrome

OBJECTIVES

APS-associated heart valve disease (HVD) is well described. Nonetheless, limited data exist on clinical parameters associated with the course of primary APS (pAPS) patients with HVD. The goal of this study was to assess clinical features and related outcomes in patients with APS-associated HVD.

METHODS

In this multicentre retrospective study, we identified 33 pAPS patients with HVD (pAPS-HVD group) and compared their clinical course with 128 pAPS patients with normal heart valves on echocardiography (pAPS-control group).

RESULTS

pAPS-HVD patients had more cerebrovascular events (56.3% vs 25%, P = 0.005) and livedo reticularis (24.2% vs 7.8%, P = 0.013) than pAPS-controls. Furthermore, catastrophic-APS (CAPS) (12.1% vs 2.4%, P = 0.034), recurrent thrombosis (33.3% vs 4.7%, P < 0.001) and need for advanced therapy (i.e. IVIG, plasmapheresis or rituximab) were more frequent in pAPS-HVD patients. Anti-β2-glycoprotein 1 IgG (84.8% vs 63.2%, P = 0.034), anti-cardiolipin IgG (90.9% vs 64.8%, P = 0.005) and triple positive aPL (75.8% vs 56.5%, P = 0.047) were commoner in pAPS-HVD patients vs pAPS-controls. Ten of the 33 patients with pAPS-HVD underwent valve surgery, which was associated with male gender, smoking, arterial limb ischaemia and livedo reticularis.

CONCLUSION

pAPS-HVD patients had a more severe APS clinical course including CAPS and thrombotic events as well as a specific serology, namely IgG isotype aPL antibodies and triple positivity. Our data suggest that pAPS-HVD represents a high-risk subgroup of APS patients.

Due Diligence of a Diastolic Index as a Prognostic Factor in Heart Failure with Preserved Ejection Fraction

Of the existing non-invasive diastolic indices, none consider arterial load. This article reveals points of caution for determining the diastolic prognostic index using a novel index of vascular resistance-integrated diastolic function in old, real-world patients with heart failure with preserved ejection fraction (HFpEF) in Japan. This index represents the ratio of left ventricular diastolic elastance (Ed) to arterial elastance (Ea), where Ed/Ea = (E/e')/(0.9 × systolic blood pressure), showing a relative ratio of left atrial filling pressure to left ventricular end-systolic pressure. The role of hemodynamic prognostic factors related to diastolic function, such as Ed/Ea, may differ according to the clinical endpoint, follow-up duration, and sex. In HFpEF patients with heterogenous cardiac structure and function, an assessment using a serial echocardiographic diastolic index in clinical care can provide an accurate prognosis.

Oxidative Stress as a Regulatory Checkpoint in the Production of Antiphospholipid Autoantibodies: The Protective Role of NRF2 Pathway

Oxidative stress is a well-known hallmark of Antiphospholipid Antibody Syndrome (APS), a systemic autoimmune disease characterized by arterial and venous thrombosis and/or pregnancy morbidity. Oxidative stress may affect various signaling pathways and biological processes, promoting dysfunctional immune responses and inflammation, inducing apoptosis, deregulating autophagy and impairing mitochondrial function. The chronic oxidative stress and the dysregulation of the immune system leads to the loss of tolerance, which drives autoantibody production and inflammation with the development of endothelial dysfunction. In particular, anti-phospholipid antibodies (aPL), which target phospholipids and/or phospholipid binding proteins, mainly β-glycoprotein I (β-GPI), play a functional role in the cell signal transduction pathway(s), thus contributing to oxidative stress and thrombotic events. An oxidation-antioxidant imbalance may be detected in the blood of patients with APS as a reflection of disease progression. This review focuses on functional evidence highlighting the role of oxidative stress in the initiation and progression of APS. The protective role of food supplements and Nuclear Factor Erythroid 2-Related Factor 2 (NRF2) activators in APS patients will be summarized to point out the potential of these therapeutic approaches to reduce APS-related clinical complications.

Alshamaa S. Evaluation of ejection fraction in patients with Acute Myocardial Infarction in Mosul City, Iraq

Between 1 January 2021 and 1 July 2021, 120 blood samples from acute myocardial infarction (AMI) patients—60 as controls and 60 patients—of both sexes who were accepted to the cardiac surgery unit at AL- Salam teaching hospital, the intensive cardiac care unit, and outpatient clinics in Mosul City/Iraq, were taken. In the presented research, the ejection fraction regarding patients with AMI was evaluated by echocardiography, and the blood-liver enzyme levels (ALP and AST \ ALT ratio) were examined in those patients. The findings indicate that patients with AMI in the age range of 35 to 45 years have a (52.41) % ejection fraction (EF) rate, which is closer to (51.344%) than it is in samples from healthy controls. In addition to that, findings indicate that patients in an age range of 46 to 56 years have heart failure with a mid-range EF (HFmrEF), with a (48.13%) percentage, whereas this heart failure type in healthy controls has been preserved ejection fraction (HFpEF) with (53.368 %). In the case of the comparison of the AST/ALT ratio and EF across all of the age groups that have been tested, the results suggest a significant level (P ≤ 0.050) relation between the ALP enzyme and EF for the patients within the (35-45 years) age group additionally, as there has been a positive and weak linear connection (r = 0.10650) and a nominal p-value (p = 0.47240) at a threshold of probability ≤ P 0.050, the link and correlation between the AST/ALT ratio and cardiac EF have been investigated. Keywords: ALP enzyme, AMI patients, Ejection Fraction, AST \ ALT ratio.

The trends in the incidence and thrombosis-related comorbidities of antiphospholipid syndrome: a 14-year nationwide population-based study

Background

This study aims to provide 14-year nationwide epidemiology data to evaluate the incidence ratio of APS in Taiwan and the condition of comorbidities by analyzing the National Health Insurance Research Database.

Methods

Nineteen thousand one hundred sixty-three patients newly diagnosed as having APS during the 2000–2013 period and 76,652 controls (with similar distributions of age and sex) were analyzed.

Results

The incidence of APS increased from 4.87 to 6.49 per 10,000 person-years in the Taiwan population during 2000–2013. The incidence of APS increased with age after 20 years old, especially in the female population, and it rose rapidly after age over 60 years old. In addition, APS cohorts presented a higher proportion of diabetes mellitus, hypertension, hyperlipidemia, stroke, heart failure, atrial fibrillation, myocardial infarction, PAOD, chronic kidney disease, COPD, deep vein thrombosis, pulmonary embolism, SLE, rheumatoid arthritis, Sjogren’s syndrome, and polymyositis.

Conclusions

Our study indicated an increasing trend in APS incidence among the Taiwanese population and a relationship between APS and potential comorbidities. This large national study found that the APS risk is heavily influenced by sex and age. Thus, the distinctive sex and age patterns might be constructive given exploring potential causal mechanisms. Furthermore, our findings indicate that clinicians should have a heightened awareness of the probability of APS, especially in women in certain age groups presenting with symptoms of APS.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) levels in primary antiphospholipid syndrome. The multicenter ATHERO-APS study

BACKGROUND

The proprotein convertase subtilisin/kexin type 9 (PCSK9) is emerging as a novel cardiovascular risk factor. Levels of PCSK9 in thrombotic primary antiphospholipid syndrome (PAPS) have never been investigated.

METHODS

Cross sectional comparison of baseline characteristics of 91 PAPS patients enrolled in the multicenter prospective ATHERO-APS cohort study. PCSK9 levels were categorized into tertiles and the association with arterial and recurrent thrombosis were assessed by univariable and multivariable logistic regression analysis.

RESULTS

Median age was 51 years and 71.4% (n = 65) were women. Overall, 33% (n = 30) experienced an arterial event while 31% (n = 28) had recurrent thrombotic events. Median PCSK9 levels were 1243 (1100-1650) pg/ml. Patients in the third PCSK9 tertile (>1458 pg/ml) showed a higher prevalence of dyslipidemia, lupus anticoagulant positivity and a history of previous arterial and recurrent thrombosis than patients in the first and second tertile. PCSK9 levels were higher in arterial than venous thrombosis (1502 vs. 1180 pg/ml, p = 0.002), and in patients with recurrent vs isolated thrombosis (1680 vs. 1150 pg/m, p < 0.001). High plasma PCSK9 levels were associated with a 4-fold increase risk for arterial events and with a 10-fold increase risk for recurrent thrombosis after adjustment for confounding factors.

CONCLUSION

These preliminary data suggest that PCSK9 levels are increased in PAPS patients with arterial and recurrent thrombosis. Its role as a possible therapeutic target in PAPS needs further studies.

Cardiac and vascular features of arterial and venous primary antiphospholipid syndrome. The multicenter ATHERO-APS study

BACKGROUND

Patients with primary antiphospholipid syndrome (PAPS) may suffer from venous and/or arterial thrombosis, but studies addressing eventual clinical and laboratory features that may discriminate between arterial thromboembolism (ATE) from venous thromboembolism (VTE) have been poorly addressed.

METHODS

Cross sectional comparison of baseline characteristics of 100 patients enrolled in the multi center ATHERO-APS cohort study; patients with previous ATE and VTE were compared with regards to clinical and biochemical variables as well as to echocardiographic features and ankle-brachial index (ABI) measured at enrolment.

RESULTS

Mean age of patients was 51 years, 72 were women. 60 patients suffered VTE and 40 ATE. Compared to VTE, ATE patients displayed a higher prevalence of hypertension (43.3% vs. 65%, p = 0.034) and diabetes (3.3% vs. 17.5%, p = 0.015). Mean concentration of inflammation and complement activation markers were similar between the two groups as well as autoantibodies titres; mean D-dimer concentration was greater in VTE patients (184 ng/ml vs. 347 ng/ml; p = 0.024) whereas mean platelet count was greater in ATE patients (263 × 10⁹/L vs 216 × 10⁹/L, p = 0.044). By multivariable logistic regression analysis, adjusted for age, sex, hypertension and diabetes, ABI ≤ 0.9 (OR: 3.4; p = 0.041) and left atrial enlargement (OR: 3.5; p = 0.035) were associated with a history of ATE. ATE patients had a higher prevalence of ABI <0.9 (32.5% vs 10% p = 0.005) than VTE patients. At logistic regression analysis, IgG aCL >120 GPL U/ml was associated with an ABI ≤0.9 (OR: 5; p = 0.023) after adjustment for age and sex.

CONCLUSION

Clinical, laboratory and cardiovascular variables distinguish arterial from venous APS patients, amongst which the ABI and left atrial enlargement. Implications for these two distinct clinical phenotypes of APS patients need further investigation.

Oxidative Stress in the Pathogenesis of Antiphospholipid Syndrome: Implications for the Atherothrombotic Process

Atherothrombosis is a frequent complication of the clinical history of patients with antiphospholipid syndrome (APS). Both atherothrombosis and APS are characterized by increased oxidative stress. Oxidative modifications are implicated in the formation of antiphospholipid antibodies, which in turn may favour the oxidative imbalance by increasing the production of reactive oxidant species (ROS) or by a direct interaction with pro-oxidant/antioxidant enzymes. As a result of these processes, APS patients suffer from an oxidative imbalance that may contribute to the progression of the atherosclerotic process and to the onset of ischemic thrombotic complications. The aim of this review is to describe mechanisms implicated in the formation of ROS in APS patients and their involvement in the atherothrombotic process. We also provide an overview of potential therapeutic approaches to blunt oxidative stress and to prevent atherothrombotic complications in these patients.