|
THE MOSAIC OF APS
Additional interesting aspects of APS raised by presenters included:
1. High titers of aCL in advanced coronary atherosclerosis (I. Stankulov).
2. The appearance of aCL often with myocardial infarction.
3. The 5% to 10% incidence of epilepsy in APS, related to the effect of aCL on the central nervous system.
4. The 29% of aCL positivity in sera of patients (I. Kokareshkov) with multiple sclerosis.
All the above indicates that indeed APS is a multi-disciplinary disease. Precipitating factors in 80 patients with catastrophic APS
| |
No. |
(%) |
| |
|
|
Infections |
12 |
(5) |
Respiratory tract |
6 |
(8) |
Cutanous |
5 |
(6) |
Urinary tract |
2 |
(3) |
Spesis |
1 |
(1) |
Gastrointestinal |
7 |
(9) |
Other |
10 |
(13) |
Surgery, trauma, and invasive procedures |
6 |
(8) |
Neoplasia |
6 |
(8) |
Anticoagulation withdrawal/low INR |
5 |
(6) |
Obstetric complications |
4 |
(5) |
SLE flares |
2 |
(3) |
Oral contraceptives |
28 |
(35) |
No factor identified |
|
|
Criteria for the Diagnosis of Antiphospholipid Antibody Syndrome
Clinical
|
Laboratory |
· Recurrent venous thrombosis ·
Recurrent arterial thrombosis · Recurrent fetal loss+ · Persistent thrombocytopenia ·
Livedo reticularis
|
- IgG or IgM anticardiolipin (anti-B2-glycoprotein-I dependent) antibody (> 20 IU) ++
- Lupus anticoagulant*
|
Patients must have at least one clinical and 1 laboratory finding and laboratory test result must be
positive on at least 2 occasions more than 3 months apart.
+ As defined by Branch and Silver. (At least 3 spontaneous abortions, fetal death,or early neonatal
death due to preterm delivery required because of fetal distress. )1
This may soon be supplanted by a direct test for antibody to B2-glycoprotein-I.
*Phospholipid-dependent screening test, such as activated partial thromboplastin time, must be abnormal. Treatment For recurrent manifestations of APS anticoagulation is the treatment of choice. For treatment of recurrent fetal
loss heparin and aspirin increases survival from 40% to 80% 25. Recent Treatment Studies in Antiphospholipid Antibody Syndrome*
Condition |
Study |
Type |
Comparison |
Conclusion |
Comment |
Clot (all) |
Khamashta et al11 |
Retrospective |
Aspirin vs warfarin |
INR> 3 protective |
INR may be an invalid test |
Clot (stroke) |
Brey and Levine29 |
RCT |
Aspirin vs warfarin sodium, different warfarin doses |
In progress |
... |
Clot (venous) |
Ginsberg et al |
RCT |
Different warfarin doses |
Moderate dose sufficient |
15% recurrence at 6 mo after discontinuation |
Pregnancy |
Cowchock et al |
RCT |
Aspirin + heparin vs Aspirin + Prednisone |
Aspirin + heparin better |
Small study |
Pregnancy |
Pregnancy Loss Study Group |
RCT |
Aspirin + heparin vs IVIG |
In progress |
... |
Pregnancy |
Kutteh |
RCT |
Aspirin vs heparin, different heparin doses |
Heparin better, low dose as effective as high dose |
Small study |
INR indicates international normalized ratio;RCT, randomized controlled trial; and IVIG, intravenous immunoglobulin. |
