From the Guidelines
Anticoagulation with a target INR of 2 to 3 is reasonable for patients with APLA valve disease who meet the criteria for the APL antibody syndrome with venous and arterial occlusive disease in multiple organs, miscarriages, and livedo reticularis (Class IIa, Level of Evidence B) 1. When managing APLA valve disease, it's crucial to consider the patient's overall clinical presentation and history of thrombotic events.
- For patients with valve lesions but no history of thrombosis, anticoagulation therapy with warfarin, maintaining an INR of 2.0-3.0, may be considered.
- For those with previous thrombotic events, a higher INR target of 2.5-3.5 may be necessary.
- Low-dose aspirin (81-100 mg daily) is often added to the regimen for its antiplatelet effects.
- Regular echocardiographic monitoring is recommended every 1-2 years for patients with known valve lesions to assess progression. The pathophysiology of APLA valve disease involves antibody-mediated inflammation and thrombosis on valve surfaces, leading to valve thickening, vegetations, and regurgitation, most commonly affecting the mitral valve 1. In terms of management, a multidisciplinary team including rheumatology and cardiology specialists is essential, with particular attention to anticoagulation management during pregnancy or perioperative periods when thrombotic risk increases.
- Hydroxychloroquine (200-400 mg daily) may be beneficial in some patients as it has antithrombotic properties and may reduce antibody levels.
- Surgical valve repair or replacement may be necessary for patients with significant valve dysfunction causing hemodynamic compromise.
From the Research
APLA Valve Disease
- APLA valve disease is associated with an increased risk of recurrent arterial or venous thromboembolism (VTE) despite anticoagulation therapy 2.
- The optimal anticoagulant therapy for preventing recurrent thromboembolic events (TE) in patients with antiphospholipid antibodies (APLA) is still a topic of debate.
- Studies have shown that patients with APLA and TE have an acceptable rate of recurrent TE if they are treated with usual-intensity warfarin 2.
- However, the use of rivaroxaban in high-risk patients with antiphospholipid syndrome was associated with an increased rate of events compared with warfarin, showing no benefit and excess risk 3.
Treatment Options
- Warfarin is commonly used for the prevention of recurrent TE in patients with APLA, with a target international normalized ratio (INR) of 2.0 to 3.0 2, 4.
- Aspirin may be used in combination with warfarin for patients with APLA and arterial TE, but the addition of aspirin may increase the risk of hemorrhagic complications 4.
- Direct oral anticoagulants, such as rivaroxaban, may be considered as an alternative to warfarin in some patients, but their use in high-risk patients with antiphospholipid syndrome is not recommended due to the increased risk of events 3, 5.
Valve Replacement Patients
- Patients with mechanical heart valves require anticoagulation therapy to prevent stroke, with warfarin being the most commonly used anticoagulant 6.
- The target INR range for patients with mechanical heart valves varies depending on the type and position of the valve, as well as other risk factors for stroke 6.
- Patients with a history of systemic embolization may require a higher INR range and the addition of low-dose aspirin to their anticoagulation regimen 6.