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

The antiphospholipid syndrome (APS) is an autoimmune systemic disease characterized by a hypercoagulable state secondary to the presence of antiphospholipid antibodies (aPL) and associated to vascular thromboses and/or pregnancy complications. Although ≈60% of thrombotic manifestations is represented by venous thrombosis, also cardiovascular (CV) manifestations can occur in APS patients, comprising coronary and/or non-coronary complications. Moreover, several studies consistently showed a more significant atherosclerosis in APS patients than controls. Thus, a stratification of thrombotic and CV 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 anti-thrombotic treatment, a 50% recurrence rate is reported in APS patients over a 5-year follow-up. Vitamin K antagonists (VKA) still remain the mainstay treatment to prevent recurrent event in APS subjects. The use of non-vitamin-K oral anticoagulants (NOACs) in APS patients is still controversial, and identification of specific APS patients who could benefit from this therapy is still an open issue. Use of low-dose aspirin should be considered in arterial APS in addition to VKA in high-risk subset, or alone for primary prophylaxis in high-risk aPL carriers. Furthermore, statins and immunomodulation therapies have an emerging role in APS patients treatment. Overall, ad hoc designed high-quality studies are needed to definitely define optimal therapeutic strategies for arterial APS.