Severe thrombotic events associated with pre-procedural interruption of anticoagulation in systemic lupus erythematosus with secondary antiphospholipid syndrome: Cases and literature review

Abstract

Background The American College of Chest Physicians (ACCP) and National Institutes for health and care Excellence in the United Kingdom (NICE) recommend that patients who are high risk for thrombotic events but require cessation of oral anticoagulation with warfarin, due to bleeding risk of a planned procedure, undergo bridging therapy with heparin. However, those conditions which are considered high risk are not universal, nor do guidelines differentiate between low molecular weight heparin (LMWH) and unfractionated heparin. Triple positive antiphospholipid syndrome (APS) is a thrombophilic state with a very high risk for thrombotic events during periods of anticoagulation cessation. Patients with secondary antiphospholipid syndrome in the setting of SLE may be at an even greater risk of thrombotic events during the perioperative period. Purpose Along with a review of the literature for perioperative management in APS we present three cases of triple positive secondary APS in systemic lupus erythematosus (SLE) patients who had severe thrombotic complications after cessation of their oral anticoagulation despite being bridged with LWMH. Conclusion Given the severity and rapidity of thrombotic complications with low molecular weight heparin bridging, we propose that all patients with triple positive APS, especially secondary APS with SLE should undergo bridging therapy with intravenous UFH to reduce time without anticoagulation and minimize risk of thrombotic complications. Furthermore, we propose that NICE include APS in the list of medical conditions which are high risk for thrombotic complications and require bridging therapy.

Antiphospholipid Syndrome in Patients with Venous Thromboembolism

“…However, this practice may be dangerous in high-risk patients as it could precipitate a catastrophic APS. 10,11 In the case of treatment with direct oral anticoagulants (DOACs), the dilute Russell's viper venom time is the test that is most influenced, 12 while the Taipan/Ecarin assay is not affected. 13 If needed, LA detection in patients receiving DOACs could be performed at trough level, or if doubts persist, the determination of DOACs' concentration at trough is indicated.…”