Question of the Week # 61

 24 year old woman presents to the Emergency Room with complaints of  left sided weakness and slurred speech. The patient has history of Systemic Lupus Erythematosus. Her SLE was diagnosed 2 years ago when she had malar rash and abnormal blood counts. She reports that she has not received any treatment for it since her physician felt this was not needed at that time. She denies any history of kidney involvement. She denies any joint pains or rash. Physical examination revealed left hemiparesis consistent with cerebrovascular accident. A CT of the head reveals right parietal infarct with out any bleed. An EKG is obtained and is normal.  Anti-cardiolipin antibody is +ve which was also positive 1 year ago as per her old records . The patient is started on adequate therapy and follows up in your office 1 month later. Which of the following interventions is most appropriate to prevent recurrent stroke in her case?

a)        Aspirin  for life

b)       Warfarin for 1 year

c)        Warfarin for 6 months

d)       Warfarin for life

e)        Hydroxychloroquine

9 Responses

  1. D
    Antiphospholipid Syndrome
    Ref-(National institute of Neurological disorders & Stroke)

    Primary Prevention-Low dose Aspirin
    Secondary Prevention -Warfarin for life

  2. Thanks good one !

  3. Answer D

    In patients with SLE, consider hydroxychloroquine, which may have intrinsic antithrombotic properties.

    The antithrombotic properties of hydroxychloroquine have long been recognized and may be considered in the prophylactic treatment of a patient with SLE and a positive aPL antibody test result.

    Low-dose aspirin is used widely in this setting; however, the effectiveness of low-dose aspirin as primary prevention for APS remains unproven. Clopidogrel has anecdotally been reported to be helpful in persons with APS and may be useful in patients allergic to aspirin

    If Thrombosis like this case:
    Perform full anticoagulation with intravenous or subcutaneous heparin followed by warfarin therapy. Based on the most recent evidence, a reasonable target for the international normalized ratio (INR) is 2.0-3.0 for venous thrombosis and 3.0 for arterial thrombosis. Patients with recurrent thrombotic events, while well maintained on the above regimens, may require an INR of 3.0-4.0. For severe or refractory cases, a combination of warfarin and aspirin may be used. Treatment for significant thrombotic events in patients with APS is generally lifelong.

  4. Dr Red is it aaaaaa ?????? please let us know ….

    • It is not A, patient has sle with positive aPl (antiphpspholipid antibodies) aspirin is not adequate post thrombotic event here a parietal infarct. Rx with heparin and then lifelong warfarin indicated.

  5. Answer D
    The patient has anti-phospholipid antibody syndrome by definition and needs anticoagulation for life. She is now presenting with arterial thrombotic event. APLA should be repeated to confirm the positivity.
    Full explanation to follow.

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