Review High intensity anticoagulation in the prevention of the recurrence of arterial thrombosis in antiphospholipid syndrome: ‘PROS’ and ‘CONS’ ☆ Vittorio Pengo a , Guillermo Ruiz-Irastorza b , Gentian Denas a , Laura Andreoli c , Munther Khamashta d , Angela Tincani c, ⁎ a Clinical Cardiology, Thrombosis Centre, University Hospital, Padova, Italy b Autoimmune Diseases Research Unit, Department of Internal Medicine, Hospital De Cruces, University of the Basque Country, Bizkaia, Spain c Rheumatology and Clinical Immunology, Spedali Civili and University of Brescia, Brescia, Italy d Lupus Research Unit, The Rayne Institute, St. Thomas'Hospital, King's College, London, United Kingdom abstract article info Available online 22 October 2011 Keywords: Antiphospholipid syndrome Antiphospholipid antibodies Arterial thrombosis Stroke Vitamin K antagonists 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 pa- tients 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 com- pared 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 ben- efit outweighs the risk of bleeding. © 2011 Elsevier B.V. All rights reserved. Contents 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 577 2. High intensity anticoagulation in prevention of arterial thrombosis: “pro” view . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 578 3. High intensity anticoagulation in prevention of arterial thrombosis: “con” view . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579 4. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 579 . Take-home messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 580 1. Introduction Antiphospholipid Antibody Syndrome (APS) has been defined as the occurrence of vascular thrombosis (venous or arterial) and/or pregnancy losses in the presence of well defined antiphospholipid antibodies (aPL) [1]. This term currently includes antibodies detected by the three tests recommended in the revised classification criteria that are lupus anticoagulant (LA), anticardiolipin and anti beta2gly- coprotein I antibodies assays (aCL, antib2GPI); at least one of these tests must be positive at the time of the clinical event (or no more than 5 years apart) and has to remain positive over time. Therefore, Autoimmunity Reviews 11 (2012) 577–580 ☆ Grants: Dr. Ruiz-Irastorza is supported by the Department of Education, Universi- ties and Research of the Basque Government. Dr. Andreoli is supported by the project “Dote Ricercatore e Dote Ricerca Applicata ai sensi dell'accordo regionale per lo svi- luppo del capitale umano nel sistema universitario Lombardo sottoscritto tra Regione Lombardia e Università Lombarde il 20-10-2009” (Università degli Studi di Brescia). ⁎ Corresponding author at: Rheumatology and Clinical Immunology, A.O. Spedali Civili, Piazzale Spedali Civili, 1, 25123 Brescia, Italy. Tel.: +39 030 3995487; fax: +39 030 3995085. E-mail address: tincani@bresciareumatologia.it (A. Tincani). Take-home messages . . . 1568-9972/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.autrev.2011.10.016 Contents lists available at SciVerse ScienceDirect Autoimmunity Reviews journal homepage: www.elsevier.com/locate/autrev