From the Guidelines
For patients with recurring cerebrovascular accidents (CVAs) and positive Anticardiolipin (ACL) antibodies, the recommended treatment is lifelong anticoagulation therapy with warfarin, targeting an INR of 2.0-3.0, as suggested by the American Heart Association/American Stroke Association guidelines 1. This diagnosis suggests antiphospholipid syndrome (APS), which increases the risk of both arterial and venous thrombosis.
Key Considerations
- Treatment should begin immediately after diagnosis and stroke stabilization.
- In addition to warfarin, patients should take low-dose aspirin (81-100 mg daily) for added protection against arterial thrombosis.
- Regular INR monitoring is essential, initially weekly until stable, then monthly.
- Patients should avoid vitamin K-rich foods that can interfere with warfarin efficacy.
- Direct oral anticoagulants (DOACs) like apixaban or rivaroxaban are not recommended for APS with arterial thrombosis as they've shown inferior protection compared to warfarin 1.
Lifestyle Modifications and Special Considerations
- Lifestyle modifications including smoking cessation, regular exercise, and blood pressure control are crucial.
- Women of childbearing age should receive counseling about pregnancy risks and may require specialized management with low-molecular-weight heparin during pregnancy.
- The pathophysiology involves autoantibodies binding to phospholipids and proteins, activating platelets, endothelial cells, and the coagulation cascade, creating a hypercoagulable state that leads to recurrent thrombotic events.
Guideline Recommendations
- The American College of Rheumatology guideline for the management of reproductive health in rheumatic and musculoskeletal diseases also supports the use of anticoagulation therapy in patients with APS 1.
- The guidelines emphasize the importance of testing for aPL in patients with SLE or SLE-like disease and in patients with suggestive histories or physical findings.
- The presence of aPL modifies the recommendations in many circumstances, and therefore is considered separately.
From the Research
Diagnosis of Cerebrovascular Accident (CVA) with Positive Anticardiolipin (ACL) Antibodies
- The presence of anticardiolipin antibodies is a key factor in diagnosing antiphospholipid syndrome (APS) 2, 3.
- APS is an autoimmune prothrombotic disorder mediated by a heterogeneous group of autoantibodies, including lupus anticoagulant, IgG and IgM anticardiolipin antibodies, and anti-β2-glycoprotein I antibodies 2.
- The diagnosis of APS is based on the presence of persistent increased titres of antiphospholipid antibodies and thromboembolic complications and/or pregnancy morbidity 4.
Treatment of Cerebrovascular Accident (CVA) with Positive Anticardiolipin (ACL) Antibodies
- Anticoagulation therapy is pivotal and beneficial for achieving recanalization and prevention of recurrence in patients with APS 5.
- Continuous and adequate anticoagulant therapy can increase the vascular recanalization rate and reduce thrombosis recurrence 5.
- Warfarin has been recommended for secondary prevention of thrombosis in APS patients, although the optimal dosing or the utility of combination with antiplatelet agents is still unknown 3.
- The use of direct-acting oral anticoagulants (DOACs) in thrombotic APS is still being explored, and their safety and efficacy are being assessed 2.
Risk Factors and Clinical Characteristics
- The presence of anticardiolipin antibodies can be an independent risk factor for stroke 3.
- APS patients with cerebral venous sinus thrombosis (CVST) often have special risk factors, including pregnancy, intracranial infection, oral contraceptives, and tumors 5.
- CVST should be considered in APS patients who experience sudden onset headaches, particularly those with thrombotic risk factors 5.