Cardiovascular disease and antiphospholipid syndrome: how to predict and how to treat?

Antiphospholipid syndrome (APS) is an autoimmune systemic disease characterized by a hypercoagulable state secondary to the presence of antiphospholipid antibodies and associated with vascular thromboses and / or pregnancy complications. Although venous thrombosis represents approximately 60% of thrombotic manifestations, also cardiovascular events can occur in patients with APS, including coronary and / or noncoronary complications. Moreover, several studies consistently showed a more significant atherosclerosis in patients with APS than controls. Thus, a stratification of thrombotic and cardiovascular risk according to clinical and immunologic features is mandatory in order to prevent APS-related vascular events. The most appropriate antithrombotic treatment of patients with arterial APS still represents an open issue, mainly in primary prevention settings. After a thrombotic event, in the absence of an adequate antithrombotic treatment, a 50% recurrence rate is reported in APS patients over a 5-year follow-up. Vitamin K antagonists still remain the mainstay treatment to prevent a recurrent event in patients with APS. The use of non–vitamin K oral anticoagulants in those with APS is still controversial, and identification of patients who could benefit from this therapy is still an open issue. Low-dose aspirin should be considered in arterial APS in addition to vitamin K antagonists in a high-risk subset, or alone for primary prophylaxis in high-risk antiphospholipid antibodies carriers. Furthermore, statins and immunomodulation therapies have an emerging role in the treatment of APS. Overall, ad hoc designed high-quality studies are needed to definitely determine optimal therapeutic strategies for arterial APS.