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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Antiphospholipid syndrome &#40;APS&#41; is an autoimmune disease characterised by thrombosis or foetal loss associated with the presence of specific persistent antibodies &#40;lupus anticoagulant&#44; anticardiolipin and&#47;or anti-beta2-glycoprotein&#41;&#46; The standard treatment for patients with a history of venous thromboembolic disease &#40;VTED&#41; in the acute phase is unfractionated heparin &#40;UFH&#41; or low-molecular-weight heparin &#40;LMWH&#41; followed by a vitamin K antagonist &#40;VKA&#41;&#46; If VKA fails&#44; the therapeutic range can be increased&#44; prescribing an LMWH and&#47;or combining acetylsalicylic acid &#40;especially if there is associated arterial thrombosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> We present 2 clinical cases of VTED in the context of APS where rivaroxaban was used after failing to achieve adequate control with VKA&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Observation</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical Case 1</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 30-year-old male patient&#44; with a diagnosis of primary APS due to lupus anticoagulant&#44; <span class="elsevierStyleItalic">with no other history of interest</span>&#44; who started manifestations of recurring and chronic VTED in the lower limbs at the age of 17&#46; Treatment with acenocoumarol was started&#44; and the patient had a labile international normalised ratio &#40;INR&#41;&#44; despite exhaustive controls&#46; The patient required supplementary LMWH when he did not achieve the therapeutic range&#46; At the age of 25&#44; after study of a transient ischaemic attack&#44; an intracardiac thrombus that was refractory to intravenous sodium heparin was found&#44; for which the patient was operated &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Treatment was intensified with acenocoumarol with an INR of between 2&#46;5 and 3&#46;5&#44; combined with 100<span class="elsevierStyleHsp" style=""></span>mg aspirin every 24<span class="elsevierStyleHsp" style=""></span>h&#46; A year later&#44; the patient had a stroke of the middle right cerebral artery secondary to thrombosis of the right internal carotid artery &#40;days earlier his INR was near 7&#44; and therefore his regimen was changed&#59; he had an INR of 1&#46;3 on arrival at the hospital&#41;&#46; He underwent intravenous fibrinolysis which was not successful &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; The time in therapeutic range &#40;TTR&#41;&#44; according to the Rosendaal method&#44; of the acenocoumarol over the year before the ischaemic attack was 46&#37;&#46; Subsequently&#44; having failed to achieve optimal control with acenocoumarol&#44; the patient was changed to warfarin and continued to have highly fluctuating INR levels&#44; therefore treatment was started with rivaroxaban 20<span class="elsevierStyleHsp" style=""></span>mg every 24<span class="elsevierStyleHsp" style=""></span>h as compassionate use&#46; After 3 years of follow-up of the rivaroxaban treatment&#44; the patient had had no further thrombotic events&#44; and had maintained enzyme-linked immunosorbent assay <span class="elsevierStyleSmallCaps">d</span>-Dimer levels within the normal range&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical Case 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 26-year-old male&#44; with APS due to lupus anticoagulant associated with systemic lupus erythematous &#40;SLE&#41; that had started 10 years earlier with joint&#44; skin and kidney involvement &#40;diffuse proliferative glomerulonephritis with nephrotic syndrome&#41;&#46; Under maintenance treatment with mycophenolate mofetil 1000<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#44; prednisone 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#44; aspirin 100<span class="elsevierStyleHsp" style=""></span>mg&#44; losartan 50<span class="elsevierStyleHsp" style=""></span>mg and hydroxychloroquine 200<span class="elsevierStyleHsp" style=""></span>mg every 24<span class="elsevierStyleHsp" style=""></span>h&#44; with stability of the SLE and no signs of kidney involvement&#46; The patient had an episode of pulmonary thromboembolism at the age of 19 and started treatment with acenocoumarol&#46; Three years later&#44; he had an episode of VTED in the lower left limb&#44; which was not in the therapeutic range &#40;INR 1&#46;2&#41;&#46; Subsequently he maintained more exhaustive controls of VKA and supplementary LMWH&#44; if it was necessary&#46; At the age of 24&#44; he suffered a splenic infarction secondary to thrombosis of the splenoportal axis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a><span class="elsevierStyleSmallCaps">C</span>&#41;&#44; with an INR of 3&#46;4 and TTR of 71&#37; over the year before the event&#46; In the acute phase he received treatment with LMWH at therapeutic doses &#40;enoxaparin mg&#47;kg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; and after clinical and radiological stability was achieved continued with rivaroxaban 20<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h as compassionate use&#46; Since then no further VTED event over a follow-up period of 2 years has been observed on X-rays&#44; checkups and lab tests&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">We present 2 clinical cases of thromboembolic disease for which treatment with rivaroxaban managed to stabilise APS after failure with antivitamin K&#46; Traditionally UFH or LMWH have been used in the acute phase&#44; sequenced to AVK&#46; For refractory cases&#44; in maintenance therapy with&#44; AVK the INR range of the AVK agents has been increased or LMWH used&#44; combined with anticoagulants depending on the case&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Prolonged used of low molecular weight heparin is harmful to the patient because it is administered subcutaneously&#44; it causes discomfort&#44; especially locally at the puncture site&#44; and there is the possibility of adverse effects&#44; such as reduced bone mineral density&#44; thrombocytopenia and hypertransaminasaemia&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The therapeutic target of the new oral anticoagulants &#40;NOAC&#41;&#44; such as rivaroxaban &#40;anti-Xa&#41;&#44; have a similar mechanism of action to that of LMWH&#46; Because this is a drug with a predictable action and low drug interaction rate&#44; it has a promising future for patients who have been poorly controlled with the classical anticoagulant therapy&#46; Furthermore&#44; rivaroxaban&#44; according to recent research&#44; might have the additional benefit of limiting complement activation&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> and in results of the RAPS study &#40;phase II&#41; is not inferior to warfarin for APS&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> NOACs have been used for APS&#44; usually with favourable results&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#8211;7</span></a> The series published by Malec et al&#46; is worthy of note&#44; with 56 patients &#40;49 treated with rivaroxaban&#41; with a mean follow-up of 22 months&#44; and 5&#46;8&#37; recurrence of VTED per year&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In the research studies by Haladyj and Olesinska on 23 patients and Son et al&#46; on 12 patients treated with rivaroxaban&#44; 1 and 2 cases recurred&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;7</span></a> Development of thrombotic events should also be mentioned after replacing warfarin with a NOAC&#44; as in the study published by Schaefer et al&#46; with a series of 3 patients &#40;one with dabigatran and 2 with rivaroxaban<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#41;&#44; and one case of catastrophic APS after changing warfarin for rivaroxaban&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Clinical trials are currently being developed to determine the role of the NACOs in APS&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In both clinical cases &#40;one due to poor control of anticoagulation with fluctuating INR levels&#44; and the other with thrombosis phenomena despite appropriate oral anticoagulation with AVK&#41;&#44; treatment with rivaroxaban was proposed with check-up&#44; lab test and imaging follow-up&#44; without revealing any new thrombotic phenomena&#44; and showing good control of APS&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment with rivaroxaban could be considered a therapeutic alternative for patients with APS not controlled with AVK&#46; New research studies will establish the role of the NACOs in APS&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Ethical Responsibilities</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Protection of people and animals</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that neither human nor animal testing has been carried out under this research&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Data confidentiality</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have complied with their work centre protocols for the publication of patient data&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Right to privacy and informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of the patients and&#47;or subjects referred to in the article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of Interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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            0 => "Sindrome antifosfol&#237;pido"
            1 => "Rivaroxab&#225;n"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Antiphospholipid syndrome is characterised by abortions or thrombotic phenomena associated with specific antibodies&#46; Anticoagulant therapy is based on vitamin K antagonists&#46; We present two cases in which the use of rivaroxaban achieved control of the disease after the failure of acenocoumarol&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome antifosfolip&#237;dico se caracteriza por abortos o fen&#243;menos tromb&#243;ticos asociado a anticuerpos espec&#237;ficos&#46; El tratamiento se basa en la anticoagulaci&#243;n con los antagonistas de la vitamina K&#46; Presentamos 2 casos en los que el empleo del rivaroxab&#225;n ha logrado controlar la enfermedad tras su fracaso con acenocumarol&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mateos Rodr&#237;guez JJ&#44; Bellido D&#44; Castro D&#44; Portillo S&#225;nchez J&#44; Vanegas R&#44; N&#250;&#241;ez Garc&#237;a A&#46; Rivaroxab&#225;n en s&#237;ndrome antifosfolip&#237;dico tras fracaso con acenocumarol&#58; a prop&#243;sito de 2 casos&#46; Reumatol Clin&#46; 2019&#59;15&#58;e33&#8211;e35&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Cardiac magnetic resonance with gradient-echo images of 4 chambers&#46; Intracavitary polypoid lesion 12<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>9<span class="elsevierStyleHsp" style=""></span>mm dependent on the endocardium in the apical region of the left ventricle&#44; isointense with no significant contrast enhancement&#46; &#40;B&#41; CT angiography of supra-aortic trunks with axial slice image&#46; A thrombus can be observed in the right carotid system adhering to the right internal carotid artery from its origin&#44; reducing its calibre and resulting in occlusion of the artery&#46; &#40;C&#41; Abdominal CT showing thrombosis of the splenic vein of the porta hepatis with an extensive are of splenic infarction&#46;</p>"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "14th International Congress on Antiphospholipid Antibodies&#58; task force report on antiphospholipid syndrome treatment trends"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Erkan"
                            1 => "C&#46;L&#46; Aguiar"
                            2 => "D&#46; Andrade"
                            3 => "H&#46; Cohen"
                            4 => "M&#46;J&#46; Cuadrado"
                            5 => "A&#46; Danowski"
                          ]
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                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.autrev.2014.01.053"
                      "Revista" => array:6 [
                        "tituloSerie" => "Autoimmun Rev"
                        "fecha" => "2014"
                        "volumen" => "13"
                        "paginaInicial" => "685"
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                            "web" => "Medline"
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                      ]
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                  ]
                ]
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            1 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rivaroxaban limits complement activation compared with warfarin in antiphospholipid syndrome patients with venous thromboembolism"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;R&#46; Arachchillage"
                            1 => "I&#46;J&#46; Mackie"
                            2 => "M&#46; Efthymiou"
                            3 => "A&#46; Chitolie"
                            4 => "B&#46;J&#46; Hunt"
                            5 => "D&#46;A&#46; Isenberg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/jth.13475"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Thromb Haemost"
                        "fecha" => "2016"
                        "volumen" => "14"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27541499"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rivaroxaban versus warfarin to treat patients with thrombotic antiphospholipid syndrome&#44; with or without systemic lupus erythematosus &#40;RAPS&#41;&#58; a randomised&#44; controlled&#44; open-label&#44; phase 2&#47;3&#44; non-inferiority trial"
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                        0 => array:2 [
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                          "autores" => array:6 [
                            0 => "H&#46; Cohen"
                            1 => "B&#46;J&#46; Hunt"
                            2 => "M&#46; Efthymiou"
                            3 => "D&#46;R&#46; Arachchillage"
                            4 => "I&#46;J&#46; Mackie"
                            5 => "S&#46; Clawson"
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                    0 => array:2 [
                      "doi" => "10.1016/S2352-3026(16)30079-5"
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                        "tituloSerie" => "Lancet Haematol"
                        "fecha" => "2016"
                        "volumen" => "3"
                        "paginaInicial" => "e426"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27570089"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rivaroxaban a safe therapeutic option in patients with antiphospholipid syndrome&#63; Our experience in 23 cases"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "E&#46; Haladyj"
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                    0 => array:2 [
                      "doi" => "10.5114/reum.2016.61217"
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                        "tituloSerie" => "Reumatologia"
                        "fecha" => "2016"
                        "volumen" => "54"
                        "paginaInicial" => "146"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The use of direct oral anticoagulants in 56 patients with antiphospholipid syndrome"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "K&#46; Malec"
                            1 => "T&#46; Goralczyk"
                            2 => "A&#46; Undas"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Thromb Res"
                        "fecha" => "2017"
                        "volumen" => "152"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Thrombotic events in patients with antiphospholipid syndrome treated with rivaroxaban&#58; a series of eight cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "F&#46; Signorelli"
                            1 => "F&#46; Nogueira"
                            2 => "V&#46; Domingues"
                            3 => "H&#46;A&#46; Mariz"
                            4 => "R&#46;A&#46; Levy"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s10067-015-3030-y"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Rheumatol"
                        "fecha" => "2016"
                        "volumen" => "35"
                        "paginaInicial" => "801"
                        "paginaFinal" => "805"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26219490"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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Case Report
After Failure With Acenocoumarol, Rivaroxaban in Antiphospholipid Syndrome: A Report of 2 Cases
Rivaroxabán en síndrome antifosfolipídico tras fracaso con acenocumarol: a propósito de 2 casos
Javier José Mateos Rodrígueza,
Corresponding author
jjmateosr@gmail.com

Corresponding author.
, David Bellidob, David Castroa, José Portillo Sánchezb, Raúl Vanegasc, Alicia Núñez Garcíad
a Servicio de Reumatología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
b Servicio de Medicina Interna, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
c Servicio de Hematología, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
d Medicina de Familia, Ciudad Real, Spain
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        "autoresLista" => "Javier Jos&#233; Mateos Rodr&#237;guez, David Bellido, David Castro, Jos&#233; Portillo S&#225;nchez, Ra&#250;l Vanegas, Alicia N&#250;&#241;ez Garc&#237;a"
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        "titulo" => "Rivaroxab&#225;n en s&#237;ndrome antifosfolip&#237;dico tras fracaso con acenocumarol&#58; a prop&#243;sito de 2 casos"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Cardiac magnetic resonance with gradient-echo images of 4 chambers&#46; Intracavitary polypoid lesion 12<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>9<span class="elsevierStyleHsp" style=""></span>mm dependent on the endocardium in the apical region of the left ventricle&#44; isointense with no significant contrast enhancement&#46; &#40;B&#41; CT angiography of supra-aortic trunks with axial slice image&#46; A thrombus can be observed in the right carotid system adhering to the right internal carotid artery from its origin&#44; reducing its calibre and resulting in occlusion of the artery&#46; &#40;C&#41; Abdominal CT showing thrombosis of the splenic vein of the porta hepatis with an extensive are of splenic infarction&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Antiphospholipid syndrome &#40;APS&#41; is an autoimmune disease characterised by thrombosis or foetal loss associated with the presence of specific persistent antibodies &#40;lupus anticoagulant&#44; anticardiolipin and&#47;or anti-beta2-glycoprotein&#41;&#46; The standard treatment for patients with a history of venous thromboembolic disease &#40;VTED&#41; in the acute phase is unfractionated heparin &#40;UFH&#41; or low-molecular-weight heparin &#40;LMWH&#41; followed by a vitamin K antagonist &#40;VKA&#41;&#46; If VKA fails&#44; the therapeutic range can be increased&#44; prescribing an LMWH and&#47;or combining acetylsalicylic acid &#40;especially if there is associated arterial thrombosis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> We present 2 clinical cases of VTED in the context of APS where rivaroxaban was used after failing to achieve adequate control with VKA&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Observation</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical Case 1</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 30-year-old male patient&#44; with a diagnosis of primary APS due to lupus anticoagulant&#44; <span class="elsevierStyleItalic">with no other history of interest</span>&#44; who started manifestations of recurring and chronic VTED in the lower limbs at the age of 17&#46; Treatment with acenocoumarol was started&#44; and the patient had a labile international normalised ratio &#40;INR&#41;&#44; despite exhaustive controls&#46; The patient required supplementary LMWH when he did not achieve the therapeutic range&#46; At the age of 25&#44; after study of a transient ischaemic attack&#44; an intracardiac thrombus that was refractory to intravenous sodium heparin was found&#44; for which the patient was operated &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46; Treatment was intensified with acenocoumarol with an INR of between 2&#46;5 and 3&#46;5&#44; combined with 100<span class="elsevierStyleHsp" style=""></span>mg aspirin every 24<span class="elsevierStyleHsp" style=""></span>h&#46; A year later&#44; the patient had a stroke of the middle right cerebral artery secondary to thrombosis of the right internal carotid artery &#40;days earlier his INR was near 7&#44; and therefore his regimen was changed&#59; he had an INR of 1&#46;3 on arrival at the hospital&#41;&#46; He underwent intravenous fibrinolysis which was not successful &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; The time in therapeutic range &#40;TTR&#41;&#44; according to the Rosendaal method&#44; of the acenocoumarol over the year before the ischaemic attack was 46&#37;&#46; Subsequently&#44; having failed to achieve optimal control with acenocoumarol&#44; the patient was changed to warfarin and continued to have highly fluctuating INR levels&#44; therefore treatment was started with rivaroxaban 20<span class="elsevierStyleHsp" style=""></span>mg every 24<span class="elsevierStyleHsp" style=""></span>h as compassionate use&#46; After 3 years of follow-up of the rivaroxaban treatment&#44; the patient had had no further thrombotic events&#44; and had maintained enzyme-linked immunosorbent assay <span class="elsevierStyleSmallCaps">d</span>-Dimer levels within the normal range&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical Case 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 26-year-old male&#44; with APS due to lupus anticoagulant associated with systemic lupus erythematous &#40;SLE&#41; that had started 10 years earlier with joint&#44; skin and kidney involvement &#40;diffuse proliferative glomerulonephritis with nephrotic syndrome&#41;&#46; Under maintenance treatment with mycophenolate mofetil 1000<span class="elsevierStyleHsp" style=""></span>mg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#44; prednisone 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#44; aspirin 100<span class="elsevierStyleHsp" style=""></span>mg&#44; losartan 50<span class="elsevierStyleHsp" style=""></span>mg and hydroxychloroquine 200<span class="elsevierStyleHsp" style=""></span>mg every 24<span class="elsevierStyleHsp" style=""></span>h&#44; with stability of the SLE and no signs of kidney involvement&#46; The patient had an episode of pulmonary thromboembolism at the age of 19 and started treatment with acenocoumarol&#46; Three years later&#44; he had an episode of VTED in the lower left limb&#44; which was not in the therapeutic range &#40;INR 1&#46;2&#41;&#46; Subsequently he maintained more exhaustive controls of VKA and supplementary LMWH&#44; if it was necessary&#46; At the age of 24&#44; he suffered a splenic infarction secondary to thrombosis of the splenoportal axis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a><span class="elsevierStyleSmallCaps">C</span>&#41;&#44; with an INR of 3&#46;4 and TTR of 71&#37; over the year before the event&#46; In the acute phase he received treatment with LMWH at therapeutic doses &#40;enoxaparin mg&#47;kg&#47;12<span class="elsevierStyleHsp" style=""></span>h&#41;&#44; and after clinical and radiological stability was achieved continued with rivaroxaban 20<span class="elsevierStyleHsp" style=""></span>mg&#47;24<span class="elsevierStyleHsp" style=""></span>h as compassionate use&#46; Since then no further VTED event over a follow-up period of 2 years has been observed on X-rays&#44; checkups and lab tests&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">We present 2 clinical cases of thromboembolic disease for which treatment with rivaroxaban managed to stabilise APS after failure with antivitamin K&#46; Traditionally UFH or LMWH have been used in the acute phase&#44; sequenced to AVK&#46; For refractory cases&#44; in maintenance therapy with&#44; AVK the INR range of the AVK agents has been increased or LMWH used&#44; combined with anticoagulants depending on the case&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Prolonged used of low molecular weight heparin is harmful to the patient because it is administered subcutaneously&#44; it causes discomfort&#44; especially locally at the puncture site&#44; and there is the possibility of adverse effects&#44; such as reduced bone mineral density&#44; thrombocytopenia and hypertransaminasaemia&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The therapeutic target of the new oral anticoagulants &#40;NOAC&#41;&#44; such as rivaroxaban &#40;anti-Xa&#41;&#44; have a similar mechanism of action to that of LMWH&#46; Because this is a drug with a predictable action and low drug interaction rate&#44; it has a promising future for patients who have been poorly controlled with the classical anticoagulant therapy&#46; Furthermore&#44; rivaroxaban&#44; according to recent research&#44; might have the additional benefit of limiting complement activation&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> and in results of the RAPS study &#40;phase II&#41; is not inferior to warfarin for APS&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> NOACs have been used for APS&#44; usually with favourable results&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#8211;7</span></a> The series published by Malec et al&#46; is worthy of note&#44; with 56 patients &#40;49 treated with rivaroxaban&#41; with a mean follow-up of 22 months&#44; and 5&#46;8&#37; recurrence of VTED per year&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In the research studies by Haladyj and Olesinska on 23 patients and Son et al&#46; on 12 patients treated with rivaroxaban&#44; 1 and 2 cases recurred&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#44;7</span></a> Development of thrombotic events should also be mentioned after replacing warfarin with a NOAC&#44; as in the study published by Schaefer et al&#46; with a series of 3 patients &#40;one with dabigatran and 2 with rivaroxaban<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a>&#41;&#44; and one case of catastrophic APS after changing warfarin for rivaroxaban&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Clinical trials are currently being developed to determine the role of the NACOs in APS&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In both clinical cases &#40;one due to poor control of anticoagulation with fluctuating INR levels&#44; and the other with thrombosis phenomena despite appropriate oral anticoagulation with AVK&#41;&#44; treatment with rivaroxaban was proposed with check-up&#44; lab test and imaging follow-up&#44; without revealing any new thrombotic phenomena&#44; and showing good control of APS&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Treatment with rivaroxaban could be considered a therapeutic alternative for patients with APS not controlled with AVK&#46; New research studies will establish the role of the NACOs in APS&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Ethical Responsibilities</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Protection of people and animals</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that neither human nor animal testing has been carried out under this research&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Data confidentiality</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have complied with their work centre protocols for the publication of patient data&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Right to privacy and informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have obtained the informed consent of the patients and&#47;or subjects referred to in the article&#46; This document is held by the corresponding author&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of Interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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            0 => "Sindrome antifosfol&#237;pido"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Antiphospholipid syndrome is characterised by abortions or thrombotic phenomena associated with specific antibodies&#46; Anticoagulant therapy is based on vitamin K antagonists&#46; We present two cases in which the use of rivaroxaban achieved control of the disease after the failure of acenocoumarol&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El s&#237;ndrome antifosfolip&#237;dico se caracteriza por abortos o fen&#243;menos tromb&#243;ticos asociado a anticuerpos espec&#237;ficos&#46; El tratamiento se basa en la anticoagulaci&#243;n con los antagonistas de la vitamina K&#46; Presentamos 2 casos en los que el empleo del rivaroxab&#225;n ha logrado controlar la enfermedad tras su fracaso con acenocumarol&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mateos Rodr&#237;guez JJ&#44; Bellido D&#44; Castro D&#44; Portillo S&#225;nchez J&#44; Vanegas R&#44; N&#250;&#241;ez Garc&#237;a A&#46; Rivaroxab&#225;n en s&#237;ndrome antifosfolip&#237;dico tras fracaso con acenocumarol&#58; a prop&#243;sito de 2 casos&#46; Reumatol Clin&#46; 2019&#59;15&#58;e33&#8211;e35&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Cardiac magnetic resonance with gradient-echo images of 4 chambers&#46; Intracavitary polypoid lesion 12<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>9<span class="elsevierStyleHsp" style=""></span>mm dependent on the endocardium in the apical region of the left ventricle&#44; isointense with no significant contrast enhancement&#46; &#40;B&#41; CT angiography of supra-aortic trunks with axial slice image&#46; A thrombus can be observed in the right carotid system adhering to the right internal carotid artery from its origin&#44; reducing its calibre and resulting in occlusion of the artery&#46; &#40;C&#41; Abdominal CT showing thrombosis of the splenic vein of the porta hepatis with an extensive are of splenic infarction&#46;</p>"
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                      "titulo" => "14th International Congress on Antiphospholipid Antibodies&#58; task force report on antiphospholipid syndrome treatment trends"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46; Erkan"
                            1 => "C&#46;L&#46; Aguiar"
                            2 => "D&#46; Andrade"
                            3 => "H&#46; Cohen"
                            4 => "M&#46;J&#46; Cuadrado"
                            5 => "A&#46; Danowski"
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                      "doi" => "10.1016/j.autrev.2014.01.053"
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                        "tituloSerie" => "Autoimmun Rev"
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                      "titulo" => "Rivaroxaban limits complement activation compared with warfarin in antiphospholipid syndrome patients with venous thromboembolism"
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                            0 => "D&#46;R&#46; Arachchillage"
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                            2 => "M&#46; Efthymiou"
                            3 => "A&#46; Chitolie"
                            4 => "B&#46;J&#46; Hunt"
                            5 => "D&#46;A&#46; Isenberg"
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                    0 => array:2 [
                      "doi" => "10.1111/jth.13475"
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                        "tituloSerie" => "J Thromb Haemost"
                        "fecha" => "2016"
                        "volumen" => "14"
                        "paginaInicial" => "2177"
                        "paginaFinal" => "2186"
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Article information
ISSN: 21735743
Original language: English
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