Can antiphospholipid antibodies cause coronary artery dissection?

Antiphospholipid Antibodies and Coronary Artery Dissection

Yes, antiphospholipid antibodies can cause coronary artery dissection, though this is a relatively uncommon manifestation of antiphospholipid syndrome (APS). The evidence supports a relationship between antiphospholipid antibodies and various cardiac manifestations, including coronary artery complications.

Pathophysiological Relationship

Antiphospholipid antibodies are associated with several cardiac manifestations:

• Thrombotic events: The primary mechanism of injury in APS is thrombosis, which can affect both arterial and venous circulation 1
• Coronary artery involvement: Antiphospholipid antibodies have been implicated in:
  • Premature myocardial infarction 2
  • Coronary artery disease 3
  • Coronary artery bypass graft occlusion 2
  • Spontaneous coronary artery dissection 4

Evidence for Coronary Artery Dissection

The relationship between antiphospholipid antibodies and coronary artery dissection is supported by case reports and clinical observations:

• A documented case of a 52-year-old man with antiphospholipid syndrome who developed chronic spontaneous coronary artery dissection presenting as stable angina 4
• Multiple reports of cardiac manifestations of APS affecting coronary circulation 2

Risk Assessment

The risk of thrombotic events, including coronary complications, varies according to antibody profile:

• Highest risk: Triple positivity (lupus anticoagulant, anticardiolipin, and anti-β2 glycoprotein-I) 5
• Intermediate risk: Double positivity 5
• Lowest risk: Single antibody positivity 5

Clinical Implications and Management

For patients with antiphospholipid antibodies and coronary manifestations:

1. Anticoagulation therapy:

   • For confirmed thrombotic APS, long-term anticoagulation with vitamin K antagonists (warfarin) targeting an INR of 2.0-3.0 for venous thrombosis 5
   • For arterial thrombosis, consider warfarin with target INR 2.0-3.0 plus low-dose aspirin, or higher intensity warfarin (INR 3.0-4.0) 5

2. Avoid direct oral anticoagulants (DOACs):

   • Rivaroxaban is not recommended for APS with history of thrombosis and triple-positive antibodies due to excess thrombotic events compared with warfarin 1

3. Antiplatelet therapy:

   • For patients with isolated antiphospholipid antibody (not meeting full APS criteria), antiplatelet therapy alone is recommended 1

4. Risk factor modification:

   • Aggressive management of traditional cardiovascular risk factors 5
   • Avoidance of estrogen-containing contraceptives in women 5

Diagnostic Considerations

When evaluating young patients with myocardial infarction or coronary artery dissection without traditional atherosclerotic risk factors:

• Consider testing for antiphospholipid antibodies 6
• Diagnostic criteria require persistent antibodies (confirmed at least 12 weeks apart) 5
• First-line testing should include all three antibodies: lupus anticoagulant, anticardiolipin antibodies, and anti-β2 glycoprotein I antibodies 5

Key Pitfalls to Avoid

1. Missing the diagnosis: Young patients with MI and normal coronary arteries should be evaluated for APS 6
2. Inappropriate anticoagulation: Patients with APS-related coronary events may require higher intensity anticoagulation (INR 3-4) rather than standard antiplatelet therapy 6
3. Using DOACs: Avoid rivaroxaban in APS patients with triple-positive antibodies due to increased thrombotic risk 1
4. Inadequate follow-up: Regular monitoring of antibody titers and reassessment of vascular risk factors is essential 5

In summary, while not the most common manifestation of APS, coronary artery dissection can occur in patients with antiphospholipid antibodies, particularly in those without traditional cardiovascular risk factors. Proper diagnosis and anticoagulation therapy are crucial for preventing recurrent thrombotic events.