1Stroke Cerebrovasc Dis 1991;1:9-20 © 1991 Demos Publications
Prevention of Recurrent Stroke in Patients with Systemic Lupus Erythematosus or Lupus Anticoagulant Nancy Futrell, M.D., and Clark H. Millikan, M.D.
Patients with systemic lupus erythematosus (SLE) or lupus anticoagulant (LA) may have antibodies, including anticardiolipin antibodies (aCL), which may be associated with stroke and a high risk of recurrent stroke. Optimum preventive treatment is uncertain. We report and analyze experience with 26 patients with SLE or LA, some of whom also had aCL, who were treated with heparin and/or warfarin, often after failure of aspirin and/or steroids to prevent cerebral ischemia. Representative summaries of cases are included. Potential mechanisms of the thrombotic tendency in these patients are reviewed. Complications of anticoagulant therapy can be serious; contraindications to this treatment are discussed. Patients with either SLE or LA who have a history of a cerebral ischemic event have a high risk of recurrent stroke, which may be ameliorated by administering anticoagulants if there are no contraindications. Key Words: Lupus-StrokeAntibodies.
Systemic lupus erythematosus (SLE) and lupus anticoagulant (LA), which are often associated with anticardiolipin antibodies (aCL), are being recognized as potential risk factors for stroke (1-17) and are associated with a high incidence of recurrent stroke (7,18-26). Optimum preventive treatment is not known (7,10,25-28), and neither antiplatelet agents (6) nor corticosteriods (10,29) have prevented stroke in these patients. There may be a reluctance to use anticoagulant therapy in these patients, possibly (a) because the term "lupus anticoagulant" is a misnomer that has implied that these patients are already anticoagulated or that they may have an increased risk of bleeding from anticoagulant therapy, (b) because of the practical problems of managing anticoagulant therapy in patients who already have a prolonged
From the Department of Neurology, Henry Ford Hospital, Detroit, MI, U.S.A. Address correspondence and reprint requests to Dr. N. Futrell at Department of Neurology, K-ll, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, MI 48202, U.S.A.
partial thromboplastin time (PIT) (30), and (c) because many of these patients have a serious systemic disease that may lead to increased complications of treatment with anticoagulants. We have previously suggested that anticoagulants may be beneficial in preventing recurrent stroke in patients with SLE (26). We now report our experience with heparin and warfarin in these patients, including the results and complications of treatment, along with reviewing potential mechanisms of abnormal thrombosis in these patients and the rationale for the use of anticoagulant.
Methods We identified 26 patients with SLE and/or LA (19 SLE,3 SLE + LA, 4 LA alone) who were anticoagulated with heparin or warfarin at Henry Ford Hospital (8 patients), the University of Miami (2 patients) ,and the University of Utah (16 patients). Twenty of these patients were referred to the authors for evaluation of strokes or transient ischemic attacks (TIAs), and the other six patients were located in a retrospective chart
J STROKE CEREBROVASC
DIS, VOL. 1, NO.1, 1991
9
N. FlIfRELL AND C. H. MILLIKAN Table 1.
Patient
1 2 3
Sex
Stroke
LA
aCL
W/H
Duration
Indication
2WK 10D
DVT,PE PE DVT PE PE Orthopedic surgery Embolus to leg (amputation) TlAs on aspirin DVT Strokes Strokes
N
H
+ +
N
H W
F
8 9 10 11
F F F F
12
F
13
F F F
+
M
++
16 17 18
SLE
+
7
15
TIA
F
5 6
14
Events on anticoagulant
F F F F F
4
Age at stroke (or TIA)
Anticoagulant therapy
F F
N
+
+
++ ++
+ +
N
+ +
N N
W W W
N
w
+
29
+
+
28
++
24
++
+
71 28
+
32
++
+
+
W W W H W W
50 59 16
+ + +
+ + +
+ +
H H W
6M 7D
W
1.5Y
30 30
+ +
+ + +
N
W
N
W
6M 4M 6M
+
33
32 35
+ +
+ +
+
N
+ +
+ +
N N
W
F
20
F
+
21
F
22
++
F
++
32 33
++
23 24
F
+
28
+
+
N
25
F M
+ + +
N N
26
+
+
3Y
N N
++
++ ++
15M
+ + +
19
F
3Y 3M 3M 8WK
16
30 52
+
+
6WK
3Y 9D 4WK
3M
IY
W W
6M
W H W W W W H W
4Y 10D
3Y
3Y IBM 6M 3M 50 8M
Subclavian occlusion TIAs
Stroke
TIA
?
+
TrA
Stroke Stroke, DVT, PE Strokes, TlAs TIAs Strokes, clotted fistula TIAs Strokes, cardiac source PE, DVT PE PE TIA, stroke Stroke Strokes, lIAs Strokes Strokes
-
Abbreviations: M, male; F, female; ++, multiple strokes or frequent lIAs; N, not tested or not known; W, warfarin; H, heparin; D, day; WI 150
Prevention of Recurrent Stroke in Patients with Systemic Lupus Erythematosus or Lupus Anticoagulant Nancy Futrell, M.D., and Clark H. Millikan, M.D.
Patients with systemic lupus erythematosus (SLE) or lupus anticoagulant (LA) may have antibodies, including anticardiolipin antibodies (aCL), which may be associated with stroke and a high risk of recurrent stroke. Optimum preventive treatment is uncertain. We report and analyze experience with 26 patients with SLE or LA, some of whom also had aCL, who were treated with heparin and/or warfarin, often after failure of aspirin and/or steroids to prevent cerebral ischemia. Representative summaries of cases are included. Potential mechanisms of the thrombotic tendency in these patients are reviewed. Complications of anticoagulant therapy can be serious; contraindications to this treatment are discussed. Patients with either SLE or LA who have a history of a cerebral ischemic event have a high risk of recurrent stroke, which may be ameliorated by administering anticoagulants if there are no contraindications. Key Words: Lupus-StrokeAntibodies.
Systemic lupus erythematosus (SLE) and lupus anticoagulant (LA), which are often associated with anticardiolipin antibodies (aCL), are being recognized as potential risk factors for stroke (1-17) and are associated with a high incidence of recurrent stroke (7,18-26). Optimum preventive treatment is not known (7,10,25-28), and neither antiplatelet agents (6) nor corticosteriods (10,29) have prevented stroke in these patients. There may be a reluctance to use anticoagulant therapy in these patients, possibly (a) because the term "lupus anticoagulant" is a misnomer that has implied that these patients are already anticoagulated or that they may have an increased risk of bleeding from anticoagulant therapy, (b) because of the practical problems of managing anticoagulant therapy in patients who already have a prolonged
From the Department of Neurology, Henry Ford Hospital, Detroit, MI, U.S.A. Address correspondence and reprint requests to Dr. N. Futrell at Department of Neurology, K-ll, Henry Ford Hospital, 2799 W. Grand Boulevard, Detroit, MI 48202, U.S.A.
partial thromboplastin time (PIT) (30), and (c) because many of these patients have a serious systemic disease that may lead to increased complications of treatment with anticoagulants. We have previously suggested that anticoagulants may be beneficial in preventing recurrent stroke in patients with SLE (26). We now report our experience with heparin and warfarin in these patients, including the results and complications of treatment, along with reviewing potential mechanisms of abnormal thrombosis in these patients and the rationale for the use of anticoagulant.
Methods We identified 26 patients with SLE and/or LA (19 SLE,3 SLE + LA, 4 LA alone) who were anticoagulated with heparin or warfarin at Henry Ford Hospital (8 patients), the University of Miami (2 patients) ,and the University of Utah (16 patients). Twenty of these patients were referred to the authors for evaluation of strokes or transient ischemic attacks (TIAs), and the other six patients were located in a retrospective chart
J STROKE CEREBROVASC
DIS, VOL. 1, NO.1, 1991
9
N. FlIfRELL AND C. H. MILLIKAN Table 1.
Patient
1 2 3
Sex
Stroke
LA
aCL
W/H
Duration
Indication
2WK 10D
DVT,PE PE DVT PE PE Orthopedic surgery Embolus to leg (amputation) TlAs on aspirin DVT Strokes Strokes
N
H
+ +
N
H W
F
8 9 10 11
F F F F
12
F
13
F F F
+
M
++
16 17 18
SLE
+
7
15
TIA
F
5 6
14
Events on anticoagulant
F F F F F
4
Age at stroke (or TIA)
Anticoagulant therapy
F F
N
+
+
++ ++
+ +
N
+ +
N N
W W W
N
w
+
29
+
+
28
++
24
++
+
71 28
+
32
++
+
+
W W W H W W
50 59 16
+ + +
+ + +
+ +
H H W
6M 7D
W
1.5Y
30 30
+ +
+ + +
N
W
N
W
6M 4M 6M
+
33
32 35
+ +
+ +
+
N
+ +
+ +
N N
W
F
20
F
+
21
F
22
++
F
++
32 33
++
23 24
F
+
28
+
+
N
25
F M
+ + +
N N
26
+
+
3Y
N N
++
++ ++
15M
+ + +
19
F
3Y 3M 3M 8WK
16
30 52
+
+
6WK
3Y 9D 4WK
3M
IY
W W
6M
W H W W W W H W
4Y 10D
3Y
3Y IBM 6M 3M 50 8M
Subclavian occlusion TIAs
Stroke
TIA
?
+
TrA
Stroke Stroke, DVT, PE Strokes, TlAs TIAs Strokes, clotted fistula TIAs Strokes, cardiac source PE, DVT PE PE TIA, stroke Stroke Strokes, lIAs Strokes Strokes
-
Abbreviations: M, male; F, female; ++, multiple strokes or frequent lIAs; N, not tested or not known; W, warfarin; H, heparin; D, day; WI 150
