Severe atherosclerotic changes, including aortic occlusion, associated with hyperhomocysteinaemia and antiphospholipid antibodies

Abstract

Three patients are described with severe systemic atherosclerosis, including aortic occlusion, in the presence of a spectrum of risk factors, including hypercholesterolaemia, hypertension, a positive family history of cardiovascular problems, and hyperhomocysteinaemia. In all three patients high levels of anticardiolipin antibodies were found. The possible pathogenic role of antiphospholipid antibodies in atherosclerosis in the context of hyperhomocysteinaemia in these patients is discussed. (Ann Rheum Dis 2001;60:699-701) We describe three patients with severe systemic atherosclerosis including one with aortic occlusion. High levels of antiphospholipid antibodies (aPLs) and hyperhomocysteinaemia were present in all three patients, who were also heavy smokers. To our knowledge, this is the first report in which the relation between severe atherosclerosis, aPLs, and hyperhomocysteinaemia is discussed. There has been much debate about the possible pathophysiological role of aPLs in atherosclerosis. The presence of these autoantibodies and other known atherogenic factors in our patients is discussed. Case reportsPATIENT 1 A 41 year old man was seen at our outclinic because of hypertension. He smoked 10 cigarettes a day with a history of 25 pack years. His father also had had hypertension and angina pectoris. Apart from the hypertension (blood pressure 220/110 mm Hg), a physical examination was unremarkable. In particular, no bruits were heard over the renal arteries. The patient was taking amlodipine 5 mg/day and atenolol 100 mg/day. Ultrasound examination of his abdomen showed a smaller left kidney (12.7 cm right side; 9.2 cm left side), which had shrunk since a similar investigation one year previously (12.3 cm). As renal artery stenosis was suspected, angiography was performed.Injection of contrast into the descending thoracic aorta showed that the aorta was occluded. Huge intercostal arteries feeding collaterals over the abdominal wall to the pelvic and leg arteries were found. Severe atheromatous plaques, an occluded left renal artery, a partially (70%) occluded right renal artery, an occluded coeliac trunk, and partially (50%) occluded superior mesenteric artery were found (fig 1).In view of these findings, additional laboratory tests were carried out (table 1). Homocysteine levels were very high, and folate levels were slightly decreased. After folate treatment (5 mg once a day), homocysteine levels normalised (although still in the higher range) as measured by the methionine loading test. Anticardiolipin antibodies of both IgM and IgG class were present at high levels (repeated testing), whereas lupus anticoagulant and Venereal Disease Research Laboratory results were negative. High density lipoprotein (HDL) cholesterol concentration was decreased and triglycerides were increased. Treatment with coumarins was started.The risk of complications during or after extensive vascular surgery were explained to the patient. He declined the oVer of surgical intervention. So far (one year later), he is doin...

Increased carotid artery intima-media thickness may be associated with stroke in primary antiphospholipid syndrome

“…20 Spronk et al reported on three patients with severe systemic atherosclerosis in the presence of high levels of aCL and other factors such as hyperhomocysteinaemia without other features of SLE and primary APS. 21 Recently, Ames et al, showed that IgG aCL independently predict IMT of carotid arteries in subjects with idiopathic aPL, lending support to the concept of atherosclerosis development in primary APS. 22 All these studies strongly support an atherogenic role for aCL in patients with APS.…”

Accelerated Atherosclerosis in Autoimmune Rheumatic Diseases

“…43 Three patients were described with severe systemic atherosclerosis, including aortic occlusion, associated with high levels of aCL and hyperhomocysteinemia and other risk factors without other features of SLE or primary APS. 44 A prospective study of 116 consecutive new patients with intermittent claudication has been performed to determine the prevalence of prothrombotic factors in that setting. Some kind of thrombophilia was demonstrated in almost one quarter of patients; more than half of those affected had a raised aPL level compatible with APS.…”

Autoimmune aspects of accelerated atherosclerosis in rheumatology

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