Arterial Thrombosis in Patients with Antiphospholipid Syndrome: A Review and Meta-Analysis

Abstract

There is a scarcity of high-quality randomized controlled trials (RCTs) comparing antithrombotic regimens for secondary prevention of arterial thrombosis (AT) in antiphospholipid syndrome (APS). We reviewed different antithrombotic regimens used for this purpose. We searched for studies on management of AT in APS on PubMed and Web of Science. Eleven studies (5 RCTs, 3 prospective, and 3 retrospective cohort studies) comparing different regimens and reporting outcomes specifically for patients with index AT events were identified. Treatments were vitamin K antagonists (VKA; 9 studies), non-VKA oral anticoagulant (NOAC; 3 studies), single antiplatelet therapy (SAPT; 7 studies), dual antiplatelet therapy (DAPT; 2 studies), and VKA combined with SAPT (4 studies). We performed a meta-analysis for the outcomes: recurrent AT, any (arterial or venous) recurrent thromboembolism, and major bleeding. Recurrent AT was reduced with VKA plus SAPT versus VKA (risk ratio [RR]: 0.43; 95% confidence interval [CI]: 0.22–0.85) and with DAPT versus SAPT (RR: 0.29; 95% CI: 0.09–0.99). Any recurrent thromboembolism was reduced with VKA plus SAPT versus VKA alone (RR: 0.41; 95% CI: 0.24–0.69) and versus SAPT alone (RR: 0.36; 95% CI: 0.13–0.96). There were no significant differences between other treatments for thromboembolism and for none of the comparisons regarding major bleeding. In a sensitivity analysis, excluding low-quality studies, VKA was more effective than NOAC to prevent recurrent AT (RR: 0.25; 95% CI: 0.07–0.93). Combined antithrombotic therapy might be more effective than single agents as secondary prophylaxis in APS with AT, and does not seem to compromise with safety, but the quality of evidence is generally low. NOACs should be avoided for patients with APS and AT.

Antiphospholipid syndrome, antiphospholipid antibodies, and stroke

“…A meta-analysis reported greater efficacy of DAPT versus single antiplatelet therapy and combined VKA-antiplatelet versus VKA alone, albeit with limitations in the number and quality of its constituent studies. 54…”

“…A meta-analysis reported greater efficacy of DAPT versus single antiplatelet therapy and combined VKA-antiplatelet versus VKA alone, albeit with limitations in the number and quality of its constituent studies. 54 Optimal intensity of anticoagulation: The optimal INR range for APS patients with arterial thrombosis is undefined. Two randomized controlled trials (RCT) concluded that the optimal target INR after first thrombosis in APS is 2.5 (range: 2.0-3.0) 55,56 although patients with arterial thrombosis were under-represented in both studies.…”

Antiphospholipid Syndrome in Renal Allograft Recipients—A Long-Term Multicenter Analysis

“…In three patients, anticoagulation treatment was suboptimal due to bleeding complications, which seems to be the major obstacle in maintaining the treatment. Novel oral agents such as rivaroxaban gave conflicting results due to scarce data in APS [ 27 , 28 ] and currently remain contraindicated in triple positive APS and in arterial thrombosis [ 29 ].…”

TaSER: Combining forces to stop the clot

“…Patients suffering from the antiphospholipid syndrome (APS) can be affected by either arterial or venous thrombosis, or both. 13,14 In addition, there are unmet medical needs in APS and some patients are refractory to current antithrombotic agents. This dual-action TaSER could therefore serve as a tool to address both sides of the coin, the arterial and venous thrombotic aspects.…”

“…Perhaps it could be of relevance to highlight the antiphospholipid syndrome in this regard. Patients suffering from the antiphospholipid syndrome (APS) can be affected by either arterial or venous thrombosis, or both 13,14 . In addition, there are unmet medical needs in APS and some patients are refractory to current antithrombotic agents.…”