What is the role of stroke anticoagulation and prophylaxis in patients with antiphospholipid antibodies?

Updated: Dec 18, 2018
  • Author: Salvador Cruz-Flores, MD, MPH, FAHA, FCCM, FAAN, FACP, FANA; Chief Editor: Helmi L Lutsep, MD  more...
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Answer

Several studies have addressed secondary prevention of stroke in patients with antiphospholipid antibodies. This group includes patients with medium or high-titer anticardiolipin antibodies or the presence of lupus anticoagulants.

In the Antiphospholipid Antibodies and Stroke Study (APASS), a prospective cohort study within the randomized double-blind WARSS that compared warfarin (INR 1.4-2.8) and aspirin (325 mg/d) for prevention of recurrent stroke or death, patients were classified into 2 groups based on the presence or absence of antiphospholipid antibodies. Among the 1770 patients included in APASS, no difference was reported in the risk of thrombotic events in patients treated with warfarin compared with aspirin and no difference was reported in the risk of bleeding. [50]

Based on the APASS data, patients with first ischemic stroke and a single positive antiphospholipid antibody test result who do not have another indication for anticoagulation may be treated with aspirin (325 mg/d) or warfarin (INR 1.4-2.8). Aspirin is likely to be preferred because of its ease of use and lack of need for laboratory monitoring.

Patients with ischemic stroke due to cerebral arterial thrombosis and a positive antiphospholipid antibody test who have a history of venous thrombosis but were not receiving anticoagulant drugs when suffering the stroke should be treated with moderate-intensity warfarin (target INR 2.5, range 2-3).

In 2 prospective randomized studies, high-intensity warfarin (target INR 3.5, range 3-4) was not superior to moderate-intensity warfarin (target INR 2.5, range 2-3) in preventing recurrent thrombosis and was associated with an increased rate of minor hemorrhagic complications. [51, 52]


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