PB0014 - Do antiphospholipid antibodies inform the choice of anticoagulant agents in patients with atrial fibrillation?

Sunday, June 25, 2023

18:30 – 19:30 ET

Room: Exhibition

Presenting Author(s)

Behnood Bikdeli

Associate Physician, Section of Cardiovascular Medicine
Brigham and Women's Hospital, Harvard Medical School
Boston, Massachusetts, United States

Co-Author(s)

AB

Antoine Bejjani

Research fellow
Brigham and Women's Hospital
Boston, Massachusetts, United States
CK

Candrika Dini Khairani

Research fellow
Brigham and Women's Hospital
Boston, Massachusetts, United States
David Jimenez, PhD

Professor
Hospital Ramon y Cajal
Madrid, Madrid, Spain
Manuel Monreal, PhD, MD

Senior consultant
Universidad Catolica de Murcia
Barcelona, Catalonia, Spain
Deborah M. Siegal, MD MSc FRCPC

Associate Professor/Associate Scientist
The Ottawa Hospital
Ottawa, Ontario, Canada
Yogen Kanthi, MD

Chief, Section of Vascular Thrombosis and Inflammation
National Heart, Lung, and Blood Institute
Bethesda, Maryland, United States
Geoffrey Barnes, MD, MSc (he/him/his)

Cardiologist and Vascular Medicine Specialist
Michigan Medicine
Ann Arbor, Michigan, United States
MO

Michelle O'Donoghue

Associate Professor
Brigham and Women's Hospital
Boston, Massachusetts, United States
CR

Christian Ruff

Associate Professor
Brigham and Women's Hospital
Boston, Massachusetts, United States
Saskia Middeldorp, MD PhD

Professor
Department of Internal Medicine, Radboud university medical center, Nijmegen, The Netherlands
Nijmegen, Gelderland, Netherlands
RL

Renato Lopes

Professor of Medicine
Duke University
Durham, North Carolina, United States
SG

Samuel Goldhaber

Professor of Medicine
Brigham and Women's Hospital
Boston, Massachusetts, United States
JW

Jeffrey I. Weitz, MD

Principal Investigator
McMaster University | Thrombosis and Atherosclerosis Research Institute (TaARI)
Hamilton, Ontario, Canada
Mary Cushman, MD, MSc (she/her/hers)

Professor
Department of Medicine, Larner College of Medicine at the University of Vermont, USA
Colchester, Vermont, United States
HK

Harlan Krumholz

Professor of Medicine
Yale University
New Haven, Connecticut, United States
GL

Gregory Lip

Professor of Medicine
University of Liverpool
Liverpool, England, United Kingdom
Gregory Piazza, MD, MS

Associate Professor
Brigham and Women's Hospital
Boston, Massachusetts, United States

Background: Although direct oral anticoagulants (DOACs) are convenient and safe in many scenarios, our recent analysis for patients with thrombotic antiphospholipid syndrome (APS; prior vascular thrombosis with positive antiphospholipid antibodies [aPL]), revealed a higher risk of arterial thrombosis with DOACs vs vitamin-K antagonists (VKAs), including a 10 (95% CI 2.2-50)-fold increase in the risk of stroke. It is unknown whether VKAs are more effective than DOACs in patients with atrial fibrillation (AF) who have APS/positive aPL.

Aims: To assess the frequency of APS/aPL in patients with AF, and to investigate the treatment effect of DOACs vs VKAs in pivotal randomized trials

Methods: We searched PubMed for studies reporting APS/aPL in patients with AF (last search 01/09/2023). We assessed the efficacy and safety of DOACs vs VKAs. Reports from pivotal randomized trials were manually reviewed for subgroup-specific results in patients with APS/aPL.

Results: A search of PubMed identified 34 studies, of which only a single study (N=67) of DOAC-treated patients with AF suggested that on-treatment testing for a lupus anticoagulant might yield false positive results. Another study of 1,913 AF patients treated with DOACs showed that among 53 with excessively prolonged coagulation tests (>2 SD over the median), 15 had aPL. No studies compared DOACs with VKAs in AF patients with concomitant APS/aPL. A manual review of the pivotal DOAC trials showed that the presence of APS/aPL was not an exclusion criterion. Nonetheless, subgroup-specific results for APS/aPL have not been reported (Figure).

Conclusion(s): Although APS/aPL may be infrequent in patients with AF, considering prior data on the markedly elevated risk of arterial thrombosis in patients with APS who receive DOACs vs VKAs, additional investigations are needed about: 1) Frequency of APS/+aPL and their association with outcomes in patients with AF, 2) Treatment effect of DOACs vs VKAs in patients with AF and APS/+aPL.