Arthur Kavanaugh, MD

Disclosures

November 22, 2000

Question

I have two questions regarding anticardiolipin:

(1) What would be the recommendation for an asymptomatic patient with high titer of anticardiolipin (IgM and IgG)?

(2) A young woman with 1 early spontanous abortion with positive results for VDRL, a negative test for anticardiolipin IgG, and borderline results for IgM -- 4.29 IU\mL. Do you recommend treatment?

Ron Nissimov, MD

Response from Arthur Kavanaugh, MD

The first question raises the issue of an asymptomatic person who has high titers of both IgM and IgG anticardiolipin antibodies. This is certainly a tough problem when it arises in the clinic. In general, the old clinical maxim that physicians treat patients and their diseases but not isolated results of laboratory tests would seem to apply in this instance. However, a number of clinical characteristics may be relevant in such a situation. How old is this patient, and are there any comorbid conditions? For example, if the patient was an older man with several risk factors for the development of atherosclerotic disease, might low-dose aspirin be indicated? Although I do not believe there are definitive data to support it, I think many clinicians might factor in the anticardiolipin antibodies in their decision to use low-dose aspirin.

Several other questions are relevant. Are the test results certain? As with any test, there is the potential for false-positive results. Were other supporting tests also abnormal? For example, the presence of the lupus anticoagulant, as evidenced by an elevated partial thromboplastin time that does not correct with 1:1 dilution, or a dilute Russel viper venom time? If these tests are also abnormal, more credence might be given to the anticardiolipin antibodies. Why did the clinician order the test? Was there something in the patient's history that prompted him/her to do so? Even in the absence of clinical symptoms of anticardiolipin syndrome, it is prudent to observe the patient for signs and symptoms of thrombotic events or other manifestations of the anticardiolipin antibodies, and also to minimize other factors that might amplify the risk of thrombosis (eg, controlling hypertension and not smoking cigarettes).

The second question raises a particular case of a woman with 1 early spontaneous abortion, positive VDRL, negative IgG anticardiolipin but borderline IgM cardiolipin. Without knowing more of the particulars, it would be hard to give a definitive opinion, but several points can be made that would contribute to the decision. Have there been any other symptoms consistent with cardiolipin syndrome? When was the spontaneous abortion? First trimester abortions may result from genetic abnormalities and not necessarily from cardiolipin syndrome. In general, IgG anticardiolipin antibodies are of greater relevance than IgM and higher titers are more significant than lower titers.

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