Antiphospholipid Antibody

Syndrome
Thomas L. Ortel, M.D., Ph.D.
Duke Hemostasis & Thrombosis Center
30 September 2006

Patient History
59 yr old man admitted locally with chest pain,
found to have a non-Q-wave MI.
Remote history of DVT and PE, on chronic oral
anticoagulant therapy (target INR?).
Warfarin discontinued, and cardiac
catheterization performed.

Patient History
Complex LAD stenosis treated by angioplasty
and stent placement.
Recurrent chest pain during same admission.
Repeat catheterization found thrombus in stent.
LAD and 1st diagonal branch restented.
Recurrent chest pain one week later resulted in
2-vessel CABG.

Patient History
Re-admit one week later with fever, new CHF,
and elevated liver function enzymes.
Echocardiogram revealed severe
cardiomyopathy.
CT scan revealed multiple liver lesions, felt to be
either cysts or abscesses.
Transfer to Duke because of coagulopathy and
need to biopsy

Patient Laboratory Data

PT
TCT
Factor VIII

20.6 sec
8.8 sec
Inhibitory

Factor XI

<1.6%

Platelets

120,000/ml

aPTT
DRVVT
Factor IX
Bethesda titer
Factor X

100.3 sec
No clot
<1.6%
2.8 U
68%

Mixing Studies

aPTT (Time = 0 min)

Normal
Donor
(sec)
26.9

Patient +
Normal Donor
(sec)
85.4

aPTT (Time = 60 min)

26.7

85.7

PT

12.9

18.6

Antiphospholipid Syndrome
A clinicopathologic diagnosis

Sapporo Criteria (Updated)

International Consensus Statement on
Classification Criteria for APS (2006).
Clinical criteria.
Vascular thrombosis.
Pregnancy morbidity.

Laboratory criteria.
Lupus anticoagulant.
Anticardiolipin IgG or IgM antibody.
Anti-b2glycoprotein I IgG or IgM antibody.
-- Miyakis, et al., J.Thromb.Haemost., 2006; 4: 295-306.

Clinical criteria for APS

Vascular thrombosis*.
Venous thromboembolic disease (DVT, PE).
Arterial thromboembolic disease.
Small vessel thrombosis.
* Coexisting inherited or acquired thrombotic risk
factors are not reasons for excluding patients
from a diagnosis of APS trials.
-- Miyakis, et al., J.Thromb.Haemost., 2006; 4: 295-306.

Clinical criteria for APS

Pregnancy morbidity.
One or more unexplained deaths of a
morphologically normal fetus at or beyond10th
week of gestation.
Three or more unexplained spontaneous abortions
at or prior to 10th week of gestation.
One or more premature births at or before the 34th
week of gestation due to eclampsia or placental
insufficiency.
-- Miyakis, et al., J.Thromb.Haemost., 2006; 4: 295-306.

Laboratory criteria for APS

Lupus anticoagulant: defined by a
functional, clot-based assay using the ISTH
guidelines.
Anticardiolipin IgG or IgM antibody.
Anti-b2glycoprotein I IgG or IgM antibody.
--Measured on 2 or more occasions at
least 12 weeks apart.
-- Miyakis, et al., J.Thromb.Haemost., 2006; 4: 295-306.

ISTH criteria for lupus

anticoagulants
Prolongation of a phospholipid-dependent
screening assay;
Evidence of inhibitory activity;
Evidence that inhibitory activity is phospholipiddependent; and,
Distinction from other coagulopathies

Non-criteria APS findings

Thrombocytopenia and/or hemolytic anemia.

Transverse myelopathy or myelitis.
Livido reticularis.
Cardiac valve disease.
Nephropathy.
Non-thrombotic neurologic manifestations,
including multiple sclerosis-like syndrome,
chorea, or migraine headaches.
-- Miyakis, et al., J.Thromb.Haemost., 2006; 4: 295-306.

Did our patient meet clinical

criteria for APS?
Major criteria:
Deep venous thrombosis & pulmonary
embolism.
Myocardial infarction and stent thrombosis (age
< 60 yrs.).

Non-criteria APS-associated parameters:

Thrombocytopenia.

Did our patient meet clinical

criteria for APS?
Major criteria:
Deep venous thrombosis & pulmonary
embolism.
Myocardial infarction and stent thrombosis (age
< 60 yrs.).

Non-criteria APS-associated parameters:

Thrombocytopenia.

Yes.

Did our patient meet laboratory

criteria for APS?
Initial assessment:
Prolonged PT and aPTT that did not correct with
mixing studies.
Decreased factor VIII, IX, and XI levels.
A detectable factor VIII inhibitor by Bethesda assay.
Prolonged DRVVT but could not complete the
CONFIRM portion of the assay.

Did our patient meet laboratory

criteria for APS?
Initial assessment:
Prolonged PT and aPTT that did not correct with
mixing studies.
Decreased factor VIII, IX, and XI levels.
A detectable factor VIII inhibitor by Bethesda assay.
Prolonged DRVVT but could not complete the
CONFIRM portion of the assay.

No... but

Alternative strategies to
identify a lupus anticoagulant
Platelet neutralization procedure (PNP; uses
platelet membranes).
Hexagonal phase phospholipid assay
(StaClot LA; uses PE in a hexagonal phase
conformation).
Textarin/Ecarin clot time.
Factor V analysis by PT and aPTT-based
assays.

Additional Laboratory Data

Factor V (aPTT)
Factor V (PT)
Factor II
Fibrinogen
D-dimer

Inhibitory
115%
38%
795.6 mg/dl
>4.37 mcg FEU/ml

Repeat DRVVT (ratio)

3.23

DRVVT Confirm (ratio)

2.17

Assessment of
Coagulation Tests
Lupus anticoagulant detected and confirmed.
Multiple factor deficiencies in aPTT pathway
reflect high-titer lupus anticoagulant.
Prolonged PT reflects mild factor II deficiency
and lupus anticoagulant effect.
Elevated D-dimer reflects recent thrombosis.
Elevated inhibitor titer due to lupus anticoagulant.

What are the clinical implications

of an elevated antiphospholipid
antibody level?

Frequency of antiphospholipid
antibodies in different populations
Population

aCL

LAC

Normal individuals:

2-5%

0-1%

Normal pregnancy:

1-10%

Elderly (>70 years of age):

>50%

Patients with SLE:

17-86%

7-65%

Family members of patients with APS:

8-31%

Risk of thrombosis in patients with

antiphospholipid antibodies
Odds Ratios for VTE
SLE with lupus anticoagulant

6.32 (3.80-8.27)*

Non-SLE with lupus anticoagulant

11.1 (3.81-32.3)**

Incidence of thrombosis: ~2-2.5%.

Coincident risk factors for thrombosis: up to 50%.
Lupus (1997) 6: 467.
Am J Med (1996) 100: 530.

** Lupus (1998) 7: 15.

J Rheumatol (2004) 31: 1560.

Antiphospholipid antibodies in patients

with venous thromboembolism
Study

VTE Patients

aPL positive

Ginsberg, et al. (1995)

65

14%*

Simioni, et al. (1996)

59

8.5%*

Mateo, et al. (1997)

2,132

4.1%

92

28.3%

Palomo, et al. (2004)

* LAC only.

Anticardiolipin & LAC.

Anticardiolipin only.

Do any of the clinical laboratory

tests identify patients at risk for
thromboembolic problems?

Lupus anticoagulants, anticardiolipin

antibodies, and thrombosis

-- Galli, et al., Blood, 2003; 101: 1827.

Anticardiolipin antibody titer

and thrombosis

-- Galli, et al.,
Blood, 2003; 101:
1827.

What is the optimal antithrombotic

therapy for a patient with APS and
thromboembolism?

Target INR in patients with APS and

venous thrombosis
Retrospective studies.
Prospective studies investigating oral
anticoagulant therapy that included patients
subsequently found to have antiphospholipid
antibodies.
Prospective randomized clinical trials.

Target INR in patients with APS and

venous thrombosis

Retrospective studies.
1. Rosove & Brewer (1992): 70 patients with APS
and thrombosis. No thrombosis when INR 3.0.
2. Khamashta, et al. (1995): 147 patients with APS
and thrombosis. Of 42 recurrent events on
warfarin, 3 occurred with an INR 3, compared to
39 with INR < 3.

Recurrent Thrombosis in APS

Warfarin, INR 3.0

Warfarin, INR < 3.0

ASA
None

-- Khamashta, et al., N Eng J Med, 1995; 332: 993.

Caveats about the

retrospective studies
Retrospective study design.
Heterogenous management of anticoagulant
therapy.
Many patients had secondary APS.
Most of the patients had recurrent thrombosis.
Hemorrhagic complications relatively common.

Target INR in patients with APS and

venous thrombosis

Prospective studies.
1. Schulman, et al. (1998): 412 patients with a first
episode of venous thromboembolism treated for 6
months with oral anticoagulants with a target INR
of 2.0 to 2.85.
68 patients (16.5%) had an anticardiolipin
antibody detected at the time anticoagulation was
stopped.

Target INR in patients with APS and

venous thrombosis

Prospective randomized trials.

1. Crowther, et al. (2003): 114 patients with APS
and thrombosis. Higher target INR (3.1 to 4) was
not superior to standard target INR (2 to 3).
2. Finazzi, et al. (2005): 109 patients with APS and
thrombosis. Higher target INR (3 to 4.5) was not
superior to standard target INR (2 to 3).

Patients with Recurrent

Thrombosis (%)

Recurrent Thrombosis
0.25
0.20
INR 3.1-4.0

0.15
0.10

INR 2.0-3.0

0.05
0.00

Time since Randomization (yr)

-- Crowther, et al., N Eng J Med, 2003; 349: 1133.

Caveats about the

prospective randomized trials
Patients with previous thrombotic recurrence
were excluded.
Few patients with secondary APS.
Few patients with arterial thromboembolism.
Patients in the high-intensity group more
frequently subtherapeutic than those in the
standard intensity group.

ACCP Guidelines
Treatment of venous thromboembolism in
patients with antiphospholipid antibodies.
We recommend a target INR of 2.5 (INR range,
2.0 and 3.0) (Grade 1A). We recommend against
high-intensity VKA therapy (Grade 1A).

-- Buller, et al., Chest, 2004; 126 (Supplement): 401S.

How long should patients with APS

and venous thrombosis be treated
with warfarin?
Schulman, et al., 1998.
Prospective study.
412 patients with 1st episode of venous thromboembolism treated for 6 months with warfarin.
68 patients (17%) with elevated antibody levels
when warfarin therapy stopped.

Cumulative Probability of
Recurrence

Anticardiolipin Antibodies and

Recurrent Venous Thromboembolism
0.3

ACLA positive

0.2

0.1

ACLA negative
0.0
0

12

18

24

30

36

42

48

Months
-- Schulman, et al., Am J Med, 1998; 104: 332.

ACCP Guidelines
Treatment of venous thromboembolism in
patients with antiphospholipid antibodies.
We recommend a target INR of 2.5 (INR range,
2.0 and 3.0) (Grade 1A). We recommend against
high-intensity VKA therapy (Grade 1A).
We recommend treatment for 12 months (Grade
1C+).
We suggest indefinite anticoagulant therapy for
these patients (Grade 2C).
-- Buller, et al., Chest, 2004; 126 (Supplement): 401S.

British Society of Haematology

Guidelines
For patients with APS and venous thrombosis,
treatment for 6 months with a target INR of 2.5
is reasonable.
Recurrent venous thrombosis should be treated
by long-term oral anticoagulation.
Recurrence while the INR is between 2.0 and
3.0 should lead to more intensive warfarin
therapy, target INR 3.5, but this is uncommon.
-- Greaves, et al., Br.J.Haematol., 2000; 109: 704-15.

How do I treat venous

thromboembolism in APS?
Confirm baseline PT is normal.
For an initial event, oral anticoagulation with a
target INR of 2.5 for 12 months. Consider
longer pending clinical course.
Address additional prothrombotic risk factors.
For recurrent events, consider more aggressive
or alternative anticoagulation, or other strategy.

What about patients with APS and

arterial thromboembolism?
Retrospective studies suggest target INR > 3.0.
Rosove & Brewer (1992).
Khamashta, et al. (1995).

Prospective randomized trials suggest target

INR of 2 to 3.
Crowther, et al. (2003).
Finazzi, et al. (2005).

Antiphospholipid Antibodies and

Recurrent Stroke
The APASS Investigators, 2004.
Prospective cohort study.
Conducted within the WARSS study.
Compared warfarin (target INR 1.4 to 2.8) vs.
ASA.
Analyzed antiphospholipid status after stroke.
Composite outcome measure including death,
ischemic stroke, or other thromboembolic events.

APASS Study Outcomes

Proportion with
Event at 2 Years

30

20

10
aPL +
aPL -

0
Warfarin

Aspirin

Treatment Group
-- APASS Investigators, JAMA, 2004; 291: 576.

Caveats about the APASS study

Patients were stratified according to a single
determination of anticardiolipin antibody
status.
Patients in this study were older than most
patients with APS.
Target INR was lower than what is frequently
used to prevent recurrent thromboembolic
events.

What about antiplatelet therapy

alone in patients with APS and
stroke/TIA?

Aspirin for APS with ischemic stroke

Eight patients with ischemic stroke as the initial
thrombotic presentation of APS.
All were women, mean age of 35.5 years
(range, 26-47 years).
Two patients sustained a recurrent stroke during
8.9 years of follow-up (recurrence rate of 3.5 per
100 patient-years). One sustained a DVT.
-- Derksen, et al., Neurology, 2003; 61: 111-4.

ACCP Guidelines
Prevention of noncardioembolic cerebral
ischemic events.
For most patients, we recommend antiplatelet
agents over oral anticoagulation (Grade 1A).
For patients with well-documented prothrombotic
disorders, we suggest oral anticoagulation over
antiplatelet agents (Grade 2C).

-- Albers, et al., Chest, 2004; 126 (Supplement): 483S.

British Society of Haematology

Guidelines
Because of the high risk of recurrence and
likelihood of consequent permanent disability or
death, stroke due to cerebral infarction in APS
should be treated with long-term oral
anticoagulant therapy, target INR 2.5 (optimal
range 2.0-3.0) (level III evidence, grade B
recommendation).
-- Greaves, et al., Br.J.Haematol., 2000; 109: 704-15.

How do I treat arterial

thromboembolism in APS?
Confirm baseline PT is normal.
For an initial event, oral anticoagulation with a
target INR of 3.0 for 12 months. Consider
longer pending clinical course.
Address additional prothrombotic risk factors.
For recurrent events, consider more aggressive
or alternative anticoagulation, or other strategy.

What about our patient?

Arterial and venous thromboembolism
necessitate anticoagulant therapy.
But what are the hepatic lesions?
And what is going on with his prothrombin
time and factor II?

Subsequent course
Maintained on therapeutic enoxaparin.
Follow-up CT scan confirmed resolving
infarcts.
Follow-up factor II consistently low, and
antiprothrombin antibodies detected
have therefore avoided warfarin.

Antiprothrombin Antibodies
Anti-prothrombin antibodies are relatively
common in patients with APS (prevalence of
50-90%, dependent on assay).
These antibodies may be associated with an
increased thrombotic risk.
Typically, factor II levels are not decreased.

Hypoprothrombinemia
Hypoprothrombinemia due to clearing
antiprothrombin antibodies is an uncommon
complication.
Low factor II levels associated with increased
bleeding risk.
Treatment typically targets control of bleeding
(PCCs, factor VIIa) and elimination of the
antiprothrombin antibody (immunosuppression).

Is the INR accurate in all

patients with APS?

Antiphospholipid antibodies and the INR

Study

Patients Reagents

Inaccurate INR

Robert, 1998

43

14% with Innovin

Sanfelippo, 2000

123

6.5%*

Tripodi, 2001

58

67% with Thromborel R

Rosborough, 2004

68

11%*

Perry, 2005

59

8% non-measurable

* Compared to chromogenic factor X results.

Do point-of-care INR meters work in

patients with APS on warfarin?

POC INR Measurements in APS

Patients followed by the Duke Anticoagulation
Management Service with the diagnosis of
either APS (n=52) or atrial fibrillation (n=46).
Stable warfarin therapy.
Capillary and citrated venous blood checked
on two different point-of-care PT meters,
compared to plasma-based INR and
chromogenic factor X assay.
Perry, et al, Thromb Haemost, 2005; 94:1196-202.

Non-measurable INR results

Five APS patients (8.8%) had non-measurable
results with the ProTime monitor.
All five had:
Elevated anti-b2GPI antibody levels (38-338 units).
Elevated anticardiolipin antibody levels (19-286 units).
Lupus anticoagulants.

Error message indicated lack of correction with

control level I.
Perry, et al, Thromb Haemost, 2005; 94:1196-202.

Difference Plot for Plasma & ProTime INR in Atrial Fibrillation Patients
1.6

AF

1.2

Plasma-ProTime INR

Difference plots
for INR results
with the ProTime
and plasmabased assays

0.8
0.4
0
-0.4
-0.8
-1.2
-1.6
0

Mean INR (Plasma and ProTime INR)

Difference Plot for Plasma & ProTime INR in APS Patients

1.6

APS

1.2

Plasma-ProTime INR

Mean absolute differences

between the INR results for the
ProTime and the plasma based
assays were generally small, but
overall significantly different.

0.8
0.4
0
-0.4
-0.8
-1.2
-1.6
0

Mean INR (Plasma and ProTime INR)

Perry, et al, Thromb Haemost, 2005; 94:1196-202.

POC INR Testing in APS

For most patients with APS, the ProTime meter
provided INR results comparable to the plasmabased INR results.
However, variation between the INR results
obtained by the ProTime meter and the plasma
method were greater for APS patients than AF.
For a subset of APS patients (8.8%), the INR
could not be determined with the ProTime
meter.
Perry, et al, Thromb Haemost, 2005; 94:1196-202.

What about patients with recurrent

thromboembolism despite
therapeutic warfarin?

Therapeutic options for recurrent

thromboembolism in APS
Warfarin with a higher target INR (> 3.0).
Addition of an antiplatelet agent to warfarin.
Change to an alternative anticoagulant (e.g.,
low molecular weight heparin).
Immunomodulatory therapy.

What options are there for

prevention or treatment of
thromboembolism during
pregnancy?

ACCP Guidelines: Pregnancy and aPL

Manifestation
Antiphospholipid
antibody; no prior
VTE or pregnancy
loss.
Antiphospholipid
antibody; prior
thrombotic event.

Recommendation

Grade

Surveillance, or mini-dose
heparin, or prophylactic
LMWH, &/or aspirin

2C

Adjusted dose UFH or

LMWH, plus low-dose
aspirin.

1C

-- Bates, et al., Chest, 2004; 126: 627S-644S.

What about the asymptomatic

individual with an antiphospholipid
antibody?

Preventive Therapy with aPL

Patients: 77 with APS and non-gravid
thrombosis; 56 asymptomatic aPL-positive.
Study periods:
For patients with thrombosis, 6 months prior to
thrombotic event.
For asymptomatic individuals, 6 months prior to
most recent clinic visit.

Study variables included use of aspirin,

hydroxychloroquine, and corticosteroids.
-- Erkan, et al., Rheumatology, 2002; 41: 924.

Preventive Therapy with aPL

Characteristic

APS

aPL

Age at event (yr)

34.9 13.4

46.0 13.8

<0.001

aPL with no CTD

65%

18%

<0.001

aPL with CTD

31%

78%

<0.001

-- Erkan, et al., Rheumatology, 2002; 41: 924.

Preventive therapy with aPL

Prior
thrombosis

No prior
thrombosis

Aspirin

1/77 (1%)

18/56 (32%)

<0.001

Hydroxychloroquine

4/77 (5%)

21/56 (38%)

<0.001

14/77
(18%)

25/56 (45%)

0.002

Steroids

-- Erkan, et al., Rheumatology, 2002; 41: 924.

Recommendations for the

asymptomatic individual with aPL
a low threshold for the use of
thromboprophylaxis at times of high risk is
indicated.
Greaves, et al. Br.J.Haematol.,2000; 109: 704.

In most instances there was consensus in

adding low dose aspirin
Alarcon-Segovia, et al. Lupus,2003; 12: 499.

And what lies ahead?

Future Directions
Can we predict which patients with
antiphospholipid antibodies will develop
thromboembolic complications?

Genomic strategy
Whole blood RNA prepared using PAXgene
system from patients with APS and selected
control populations.
RNA extracted and validated.
Oligonucleotide arrays printed at the Duke
Microarray Facility, using the Operon Human
Genome Oligo Set Version 3.0 (Operon,
Huntsville, AL).
-- Potti, et al., Blood, 2006; 107: In press.

Discovery Mode
Preliminary data with patients and controls

Controls with VTE

APS

Up regulated

aPLA

Normal

Down regulated

-- Potti, et al., Blood, 2006; 107: 1391.

Future Directions
Can we predict which patients with
antiphospholipid antibodies will develop
thromboembolic complications?
Is there an inherited predisposition to developing
antiphospholipid antibody syndrome?

Family history
Mother developed arterial
thrombosis and thrombocytopenia
prior to her death.

Asymptomatic
daughter tests
positive for a lupus
anticoagulant.

Familial Antiphospholipid Syndrome

Family members of patients with APS have an
increased incidence of autoimmune disorders.
Genetics of APS is a clinical trial being
developed by the Rare Thrombotic Diseases
Clinical Research Consortium.
For more information:
http://rarediseasesnetwork.epi.usf.edu/rtdc/