High intensity anticoagulation in the prevention of the recurrence of arterial thrombosis in antiphospholipid syndrome: ‘PROS’ and ‘CONS’

The use of high intensity anticoagulation in the prevention of recurrence of arterial thrombosis related to the Antiphospholipid Syndrome (APS) is still controversial. This paper reports a debate that took place at the CORA meeting (Controversies in Rheumatology and Autoimmunity), held in Florence in March 2011. Major points of discussion were: 1) the paucity of prospective randomized clinical trials; retrospective studies were the main source supporting the use of high intensity anticoagulation; 2) heterogeneity in antiphospholipid antibodies (aPL) definition, due to the lack of standardization of aPL assays and to the failure to distinguish patients with a high risk profile (“triple positive”) from those a low risk profile; 3) bleeding is a major concern about high intensity anticoagulation; however, studies are not concordant in reporting an increased risk compared to the standard regimen; 4) practical issues consist of difficulties in keeping a stable PT-INR over 3 and the possibility for interference by aPL on the thromboplastins used for PT-INR measurement. In conclusion, there is currently a lack of consensus on the use of high intensity anticoagulation for the secondary prophylaxis of arterial thrombosis. However, such a treatment may be particularly recommended in those APS patients who have a high risk aPL profile and other concomitant cardiovascular risk factors, provided that the potential benefit outweighs the risk of bleeding.