Anticoagulation with Warfarin is Required for CVA in APLA Syndrome
For patients with antiphospholipid syndrome (APLA) who have experienced a cerebrovascular accident (CVA/stroke), oral anticoagulation with warfarin targeting an INR of 2.0-3.0 is the recommended treatment, not aspirin alone. 1
Treatment Recommendation for Arterial Thrombosis in APLA
Patients with ischemic stroke or TIA who meet criteria for APLA syndrome should receive oral anticoagulation with warfarin (target INR 2.0-3.0) rather than aspirin monotherapy 1
The 2011 AHA/ASA guidelines specifically state this is a Class IIa recommendation with Level of Evidence B for secondary stroke prevention in APLA syndrome 1
Some evidence suggests warfarin plus low-dose aspirin may be optimal for arterial thrombotic events in APLA, though warfarin alone at moderate intensity (INR 2.0-3.0) is the standard approach 2
Why Aspirin Alone is Insufficient
The WARSS/APASS trial compared warfarin (INR 1.4-2.8) versus aspirin (325 mg) in APLA-positive stroke patients and found no significant difference in recurrence rates, but this does not support aspirin as adequate therapy—rather it suggests the warfarin intensity tested was subtherapeutic 1
For cryptogenic stroke with APLA antibodies detected but not meeting full APLA syndrome criteria, antiplatelet therapy alone is reasonable (Class IIa), but this is a different clinical scenario than established APLA syndrome 1
Critical Distinction: Primary vs Secondary Prevention
Aspirin has NO role in primary prevention of thrombosis in asymptomatic APLA-positive patients—the APLASA trial definitively showed no benefit (HR 1.04,95% CI 0.69-1.56, P=0.83) 1, 3, 4
However, once a thrombotic event like CVA has occurred, the patient has transitioned from primary to secondary prevention, where anticoagulation is required 3, 5
Practical Management Algorithm
For confirmed APLA syndrome with prior CVA:
- Initiate warfarin with target INR 2.0-3.0 1, 5
- Continue indefinitely as long as APLA antibodies persist 3, 5
- Consider adding low-dose aspirin (75-100 mg) in high-risk cases, particularly with triple-positive antibodies or recurrent events despite adequate anticoagulation 2, 5
Avoid DOACs in arterial APLA: Direct oral anticoagulants should NOT be used in patients with arterial thrombosis (including stroke) or triple-positive antibodies—warfarin remains first-line 6
Common Pitfall to Avoid
Do not treat APLA-associated stroke with aspirin alone simply because the WARSS/APASS trial showed equivalence—that trial used subtherapeutic warfarin dosing (target INR 1.4-2.8) and included patients with any APLA positivity, not just those meeting full syndrome criteria 1. The current standard for established APLA syndrome with arterial thrombosis is therapeutic anticoagulation with warfarin 1, 3, 5.