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Assessment of endogenous fibrinolysis in clinical practice using novel tests: ready for clinical roll-out? SN APPLIED SCIENCES 2021. [DOI: 10.1007/s42452-021-04517-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
AbstractThe occurrence of thrombotic complications, which can result in excess mortality and morbidity, represent an imbalance between the pro-thrombotic and fibrinolytic equilibrium. The mainstay treatment of these complications involves the use of antithrombotic agents but despite advances in pharmacotherapy, there remains a significant proportion of patients who continue to remain at risk. Endogenous fibrinolysis is a physiological counter-measure against lasting thrombosis and may be measured using several techniques to identify higher risk patients who may benefit from more aggressive pharmacotherapy. However, the assessment of the fibrinolytic system is not yet accepted into routine clinical practice. In this review, we will revisit the different methods of assessing endogenous fibrinolysis (factorial assays, turbidimetric lysis assays, viscoelastic and the global thrombosis tests), including the strengths, limitations, correlation to clinical outcomes of each method and how we might integrate the assessment of endogenous fibrinolysis into clinical practice in the future.
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52
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Zhang L, Hailati J, Ma X, Liu J, Liu Z, Yang Y, He P, Wulasihan M. Analysis of risk factors for different subtypes of acute coronary syndrome. J Int Med Res 2021; 49:3000605211008326. [PMID: 33969735 PMCID: PMC8113931 DOI: 10.1177/03000605211008326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/15/2021] [Indexed: 11/17/2022] Open
Abstract
AIMS To investigate the different risk factors among different subtypes of patients with acute coronary syndrome (ACS). METHODS A total of 296 patients who had ACS were retrospectively enrolled. Blood and echocardiographic indices were assessed within 24 hours after admission. Differences in risk factors and Gensini scores of coronary lesions among three groups were analyzed. RESULTS Univariate analysis of risk factors for ACS subtypes showed that age, and levels of fasting plasma glucose, amino-terminal pro-brain natriuretic peptide, and creatine kinase isoenzyme were significantly higher in patients with non-ST-segment elevation myocardial infarction (NSTEMI) than in those with unstable angina pectoris (UAP). Logistic multivariate regression analysis showed that amino-terminal pro-brain natriuretic peptide and the left ventricular ejection fraction (LVEF) were related to ACS subtypes. The left ventricular end-diastolic diameter was an independent risk factor for UAP and ST-segment elevation myocardial infarction (STEMI) subtypes. The severity of coronary stenosis was significantly higher in NSTEMI and STEMI than in UAP. Gensini scores in the STEMI group were positively correlated with D-dimer levels (r = 0.429) and negatively correlated with the LVEF (r = -0.602). CONCLUSION Different subtypes of ACS have different risk factors. Our findings may have important guiding significance for ACS subtype risk assessment and clinical treatment.
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Affiliation(s)
- Lei Zhang
- Department of Comprehensive Cardiology, The First
Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province,
China
| | - Juledezi Hailati
- Department of Comprehensive Cardiology, The First
Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province,
China
| | - Xiaoyun Ma
- Department of Comprehensive Cardiology, The First
Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province,
China
| | - Jiangping Liu
- Department of Comprehensive Cardiology, The First
Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province,
China
| | - Zhiqiang Liu
- Department of Comprehensive Cardiology, The First
Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province,
China
| | - Yuchun Yang
- Department of Comprehensive Cardiology, The First
Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province,
China
| | - Pengyi He
- Department of Comprehensive Cardiology, The First
Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province,
China
| | - Muhuyati Wulasihan
- Department of Comprehensive Cardiology, The First
Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Province,
China
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53
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Rivaroxaban versus warfarin for the management of left ventricle thrombus. Egypt Heart J 2021; 73:41. [PMID: 33932172 PMCID: PMC8088413 DOI: 10.1186/s43044-021-00164-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/16/2021] [Indexed: 12/31/2022] Open
Abstract
Background Rivaroxaban has been recently introduced for the management of non-valvular intra-cardiac thrombosis with variable results. We aimed to compare the results of the off-label use of rivaroxaban versus warfarin in the management of patients with left ventricle (LV) thrombus. This research is a retrospective study conducted on 63 patients who had LV thrombus from January to December 2016. We compared patients treated with warfarin (n=35) to patients who had rivaroxaban (n=28), and study outcomes were time to thrombus resolution, bleeding, stroke, and mortality. Results The median duration of treatment was 9.5 (25th-75th percentiles: 6-32.5) months for rivaroxaban and 14 (3-41) months for warfarin. Thrombus resolution occurred in 24 patients in the warfarin group (68.6%) and 20 patients in the rivaroxaban group (71.4%). The median time to resolution in the warfarin group was 9 (4-20) months and 3 (2-11.5) months in the rivaroxaban group. Thrombus resolution was significantly faster in patients on rivaroxaban (p= 0.019). Predictors of thrombus resolution were thrombus surface area (HR: 1.21; CI 95% (1.0-1.46); p= .048) and the use of rivaroxaban (HR: 1.92; CI 95% (1.01-3.65); p= 0.048). There was no difference in stroke, bleeding, and mortality between both groups. Conclusion Rivaroxaban was as effective and safe as warfarin in managing patients with left ventricle thrombus. Larger randomized clinical trials are recommended to confirm our findings.
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Swanepoel AC, de Lange-Loots Z, Cockeran M, Pieters M. Lifestyle Influences Changes in Fibrin Clot Properties Over a 10-Year Period on a Population Level. Thromb Haemost 2021; 122:67-79. [PMID: 33906245 DOI: 10.1055/a-1492-6143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Case-control and observational studies have provided a plausible mechanistic link between clot structure and thrombosis. We aimed to identify lifestyle, demographic, biochemical, and genetic factors that influence changes in total fibrinogen concentration and clot properties over a 10-year period in 2,010 black South Africans. Clot properties were assessed with turbidimetry and included lag time, slope, maximum absorbance, and clot lysis time. Linear mixed models with restricted maximum likelihood were used to determine whether (1) outcome variables changed over the 10-year period; (2) demographic and lifestyle variables, biochemical variables, and fibrinogen single-nucleotide polymorphisms influenced the change in outcome variables over the 10-year period; and (3) there was an interaction between the exposures and time in predicting the outcomes. A procoagulant risk score was furthermore created, and multinomial logistic regression was used to determine the exposures that were associated with the different risk score categories. In this population setting, female gender, obesity, poor glycemic control, increased low-density lipoprotein cholesterol, and decreased high-density lipoprotein cholesterol contributed to the enhanced progression to prothrombotic clot properties with increasing age. Alcohol consumption on the other hand, offered a protective effect. The above evidence suggest that the appropriate lifestyle changes can improve fibrin clot properties on a population level, decreasing cardiovascular disease risk and thus alleviate the strain on the medical health care system.
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Affiliation(s)
- Albe Carina Swanepoel
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Zelda de Lange-Loots
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa.,Medical Research Council Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa
| | - Marike Cockeran
- School of Mathematical and Statistical Sciences, Faculty of Natural and Agricultural Sciences, North-West University, Potchefstroom, South Africa
| | - Marlien Pieters
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa.,Medical Research Council Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa
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55
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Hernández-Fernández F, Ramos-Araque ME, Barbella-Aponte R, Molina-Nuevo JD, García-García J, Ayo-Martin O, Pedrosa-Jiménez MJ, López-Martinez L, Serrano-Heras G, Julia-Molla E, Segura T. Fibrin-Platelet Clots in Acute Ischemic Stroke. Predictors and Clinical Significance in a Mechanical Thrombectomy Series. Front Neurol 2021; 12:631343. [PMID: 33959088 PMCID: PMC8093432 DOI: 10.3389/fneur.2021.631343] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 03/09/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction: The histological composition of the clot influences its mechanical properties, affects the efficacy of endovascular treatment (EVT), and could determine the clinical outcome of patients with acute ischemic stroke (AIS). Insights into clot composition may guide therapeutic decision-making prior to EVT and facilitate revascularization therapies. Material and Methods: Consecutive patients with AIS recorded in a prospective single-center reperfusion registry from December 2015 to December 2019 and treated with EVT were included. Baseline, laboratory [including post-procedural C-reactive protein (CRP)], radiological, and angiographic variables were analyzed. We aimed to study the relationship between histological composition of the clot with basal neuroimaging, laboratory markers, and recanalization technique. The secondary outcome was to analyze the correlation between clot composition and functional outcome at 3 months assessed by the modified Rankin scale (mRS). Results: From the study period, 360 AIS patients treated with EVT were included, of whom 189 (53%) fulfilled the inclusion criteria. One hundred (53%) cases of fibrin-predominant clot (FPC) were recorded. Full recanalization in FPC cases was achieved with higher probability when stent retrievers (SR) were selected as the first-line device (68.2%, p = 0.039). Patients with FPC had higher levels of CRP (p = 0.02), lower frequency of the hyperdense middle cerebral artery (HMCA) in baseline imaging (p = 0.039), and higher rates of mortality (p = 0.012). The multivariate analysis showed that the absence of HMCA (OR = 0.420; 95% CI 0.197-0.898; p = 0.025) and higher levels of CRP (OR = 1.01; 95% CI 1.003-1.019; p = 0.008) were predictors of FPC. Leukocytes and platelet counts were not associated with clot histology. Conclusions: The absence of HMCA and higher levels of CRP were markers of FPC. In patients with FPC, complete recanalization was most likely to be achieved when a SR was selected as first line of treatment. Mortality was higher in patients within this histologic group.
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Affiliation(s)
| | - María E. Ramos-Araque
- Department of Neurology, University Hospital of Salamanca, Biomedical Research Institute of Salamanca, Salamanca, Spain
- Department of Neurology, University Hospital of Valladolid, Valladolid, Spain
| | - Rosa Barbella-Aponte
- Department of Surgical Pathology, Hospital General Universitario de Albacete, Albacete, Spain
| | | | - Jorge García-García
- Department of Neurology, Hospital General Universitario de Albacete, Albacete, Spain
| | - Oscar Ayo-Martin
- Department of Neurology, Hospital General Universitario de Albacete, Albacete, Spain
| | | | - Lorena López-Martinez
- Department of Radiology, Hospital General Universitario de Albacete, Albacete, Spain
| | | | - Enrique Julia-Molla
- Department of Radiology, Hospital General Universitario de Albacete, Albacete, Spain
| | - Tomás Segura
- Department of Neurology, Hospital General Universitario de Albacete, Albacete, Spain
- Instituto de Investigación en Discapacidades Neurológicas (IDINE), Facultad de Medicina, Universidad de Castilla-La Mancha, Albacete, Spain
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Kietsiriroje N, Ariëns RAS, Ajjan RA. Fibrinolysis in Acute and Chronic Cardiovascular Disease. Semin Thromb Hemost 2021; 47:490-505. [PMID: 33878782 DOI: 10.1055/s-0040-1718923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The formation of an obstructive thrombus within an artery remains a major cause of mortality and morbidity worldwide. Despite effective inhibition of platelet function by modern antiplatelet therapies, these agents fail to fully eliminate atherothrombotic risk. This may well be related to extensive vascular disease, beyond the protective abilities of the treatment agents used. However, recent evidence suggests that residual vascular risk in those treated with modern antiplatelet therapies is related, at least in part, to impaired fibrin clot lysis. In this review, we attempt to shed more light on the role of hypofibrinolysis in predisposition to arterial vascular events. We provide a brief overview of the coagulation system followed by addressing the role of impaired fibrin clot lysis in acute and chronic vascular conditions, including coronary artery, cerebrovascular, and peripheral vascular disease. We also discuss the role of combined anticoagulant and antiplatelet therapies to reduce the risk of arterial thrombotic events, addressing both efficacy and safety of such an approach. We conclude that impaired fibrin clot lysis appears to contribute to residual thrombosis risk in individuals with arterial disease on antiplatelet therapy, and targeting proteins in the fibrinolytic system represents a viable strategy to improve outcome in this population. Future work is required to refine the antithrombotic approach by modulating pathological abnormalities in the fibrinolytic system and tailoring therapy according to the need of each individual.
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Affiliation(s)
- Noppadol Kietsiriroje
- Department of Metabolic Medicine, Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom.,Endocrinology and Metabolism Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
| | - Robert A S Ariëns
- Department of Metabolic Medicine, Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Ramzi A Ajjan
- Department of Metabolic Medicine, Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
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57
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Kanji R, Kubica J, Navarese EP, Gorog DA. Endogenous fibrinolysis-Relevance to clinical thrombosis risk assessment. Eur J Clin Invest 2021; 51:e13471. [PMID: 33296082 DOI: 10.1111/eci.13471] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/05/2020] [Accepted: 12/06/2020] [Indexed: 12/11/2022]
Abstract
The development of an obstructive luminal thrombus is pathological and considered a failure of endogenous fibrinolysis. The consequences may be fatal, or result in lasting downstream organ damage. Therefore, assessment of endogenous fibrinolytic status in an individual may identify those at risk of occlusive thrombus formation and provide prognostic information. Arterial thrombi are more platelet rich and more resistant to fibrinolysis than venous thrombi. Several recent studies using global tests of fibrinolysis in patients with acute coronary syndromes (ACS) have shown that despite dual antiplatelet therapy, patients with impaired fibrinolytic status have an increased risk of adverse cardiovascular events, compared with those with effective fibrinolytic function. Such data add significantly to the predictive value of established cardiovascular risk factors and conventional biomarkers. Most data reported have been obtained with the Global Thrombosis Test and the turbidimetric plasma clot lysis assay. A few small studies in patients with ischaemic stroke suggest a similar predictive role of fibrinolytic status assessment in these patients. Studies reporting an association between impaired fibrinolysis and future venous thrombotic events are limited, and in the form of case-control studies. Viscoelastic assays may have a role in the prediction of venous thromboembolic risk. Assays of fibrinolytic function should be used to obtain a more accurate risk of future thrombotic events, particularly in the setting of ACS. The availability of point-of-care tests helps facilitate this and should encourage future studies to assess personalised antithrombotic treatment combinations to optimise fibrinolytic status and reduce thrombosis risk.
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Affiliation(s)
- Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Eliano P Navarese
- Department of Cardiology and Internal Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland.,Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK.,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, UK.,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Stevenage, UK
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58
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Kim HK, Tantry US, Park HW, Shin ES, Geisler T, Gorog DA, Gurbel PA, Jeong YH. Ethnic Difference of Thrombogenicity in Patients with Cardiovascular Disease: a Pandora Box to Explain Prognostic Differences. Korean Circ J 2021; 51:202-221. [PMID: 33655720 PMCID: PMC7925962 DOI: 10.4070/kcj.2020.0537] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 12/24/2020] [Indexed: 01/07/2023] Open
Abstract
Arterial and venous atherothrombotic events are finely regulated processes involving a complex interplay between vulnerable blood, vulnerable vessel, and blood stasis. Vulnerable blood ('thrombogenicity') comprises complex interactions between cellular components and plasma factors (inflammatory, procoagulant, anticoagulant, and fibrinolytic factors). The extent of thrombogenicity may determine the progression of atheroma and the clinical manifestation of atherothrombotic events, with the highest thrombogenicity in African Americans and lowest in East Asians. Inherent thrombogenicity may influence clinical efficacy and safety of specific antithrombotic treatments in high-risk patients, which may in part explain the observation that East Asian patients have reduced anti-ischemic benefits and elevated bleeding risk with antithrombotic therapy compared to Caucasian patients. In this review, we discuss available evidence regarding the racial differences in thrombogenicity and its impact on clinical outcomes among patients with atherosclerotic cardiovascular disease.
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Affiliation(s)
- Hyun Kuk Kim
- Department of Cardiology, Chosun University Hospital, Gwangju, Korea
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Hyun Woong Park
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Division of Cardiology, Gyeongsang National University Hospital, Jinju, Korea
| | - Eun Seok Shin
- Division of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital of Tübingen, Tübingen, Germany
| | - Diana A Gorog
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, MD, USA
| | - Young Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine, Jinju, Korea
- Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Korea
- Institute of the Health Sciences, Gyeongsang National University, Jinju, Korea.
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59
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Gue YX, Jeong YH, Farag M, Spinthakis N, Gorog DA. Precision Treatment in ACS-Role of Assessing Fibrinolysis. J Clin Med 2021; 10:jcm10050929. [PMID: 33804303 PMCID: PMC7957496 DOI: 10.3390/jcm10050929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 11/24/2022] Open
Abstract
Despite advancements in pharmacotherapy and interventional strategies, patients with acute coronary syndrome (ACS) remain at risk of recurrent thrombotic events. In addition to an enhanced tendency to thrombus formation, impairment in the ability to naturally dissolve or lyse a developing thrombus, namely impaired endogenous fibrinolysis, is responsible for a major part of this residual risk regardless of optimal antiplatelet medication. Global assessment of endogenous fibrinolysis, including a point-of-care assay, can identify patients with ACS at persistent high cardiovascular risk and might play an important role in allowing the personalisation of potent antithrombotic therapy to enhance fibrinolytic status, providing precision treatment of ACS to improve long-term outcome.
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Affiliation(s)
- Ying X. Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK;
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (M.F.); (N.S.)
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon 51472, Korea;
| | - Mohamed Farag
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (M.F.); (N.S.)
| | - Nikolaos Spinthakis
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (M.F.); (N.S.)
| | - Diana A. Gorog
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (M.F.); (N.S.)
- National Heart and Lung Institute, Imperial College, London SW3 6LY, UK
- Correspondence:
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60
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Memtsas VP, Arachchillage DRJ, Gorog DA. Role, Laboratory Assessment and Clinical Relevance of Fibrin, Factor XIII and Endogenous Fibrinolysis in Arterial and Venous Thrombosis. Int J Mol Sci 2021; 22:ijms22031472. [PMID: 33540604 PMCID: PMC7867291 DOI: 10.3390/ijms22031472] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
Diseases such as myocardial infarction, ischaemic stroke, peripheral vascular disease and venous thromboembolism are major contributors to morbidity and mortality. Procoagulant, anticoagulant and fibrinolytic pathways are finely regulated in healthy individuals and dysregulated procoagulant, anticoagulant and fibrinolytic pathways lead to arterial and venous thrombosis. In this review article, we discuss the (patho)physiological role and laboratory assessment of fibrin, factor XIII and endogenous fibrinolysis, which are key players in the terminal phase of the coagulation cascade and fibrinolysis. Finally, we present the most up-to-date evidence for their involvement in various disease states and assessment of cardiovascular risk.
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Affiliation(s)
- Vassilios P. Memtsas
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire SG1 4AB, UK;
| | - Deepa R. J. Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London SW7 2AZ, UK;
- Department of Haematology, Imperial College Healthcare NHS Trust, London W2 1NY, UK
- Department of Haematology, Royal Brompton Hospital, London SW3 6NP, UK
| | - Diana A. Gorog
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire SG1 4AB, UK;
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire AL10 9AB, UK
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London SW3 6LY, UK
- Correspondence: ; Tel.: +44-207-0348841
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61
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Impact of epicatechin on fibrin clot structure. Eur J Pharmacol 2021; 893:173830. [PMID: 33347819 DOI: 10.1016/j.ejphar.2020.173830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 12/15/2020] [Accepted: 12/16/2020] [Indexed: 11/21/2022]
Abstract
Fibrin clot structure and function are major determinants of thromboembolic diseases. The study aim was to determine the impact of epicatechin (a flavonoid with cardiovascular protective effects) on fibrin clot structure and permeability. Plasma samples from 12 healthy subjects were incubated with increasing concentrations of epicatechin. Turbidity of fibrin clot was analyzed by absorbance measurement at 405 nm. The fibrin clot nanostructure was determined by scanning spectrometry (wavelength from 500 to 800 nm) and fibrin fiber size by electron microscopy. Permeability was analyzed to assess the fibrin clot functional properties. Epicatechin addition increased the maximum absorbance from 0.34 ± 0.066 (vehicle) to 0.35 ± 0.077 (P = 0.1), 0.35 ± 0.072 (P < 0.05) and 0.34 ± 0.065 (P = 0.5) for 1, 10 and 100 μM epicatechin, respectively. Epicatechin increased the fibrin clot fiber radius (nm) from 109.2 ± 3.2 (vehicle) to 108.9 ± 4.3 (P = 0.9), 110.0 ± 3.6 (P < 0.05) and 109.5 ± 3.3 (P = 0.4), and the distance between protofibrils (nm) from 22.2 ± 1.5 (vehicle) to 22.1 ± 2.3 (P = 0.9), 22.6 ± 1.8 (P < 0.05) and 22.3 ± 1.8 (P = 0.9) for 1, 10 and 100 μM epicatechin respectively. Electron microscopy confirmed these changes. Fibrin clot permeability, expressed as Darcy's constant (Ks, cm2), increased from 2.97 ± 1.17 (vehicle) to 3.36 ± 1.21 (P < 0.05), 3.81 ± 1.41 (P < 0.01) and 3.38 ± 1.33 (P = 0.9). Upon epicatechin addition, the fibrin clot structure became less dense and more permeable.
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62
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Abstract
Fibrinogen is a large glycoprotein, synthesized primarily in the liver. With a normal plasma concentration of 1.5-3.5 g/L, fibrinogen is the most abundant blood coagulation factor. The final stage of blood clot formation is the conversion of soluble fibrinogen to insoluble fibrin, the polymeric scaffold for blood clots that stop bleeding (a protective reaction called hemostasis) or obstruct blood vessels (pathological thrombosis). Fibrin is a viscoelastic polymer and the structural and mechanical properties of the fibrin scaffold determine its effectiveness in hemostasis and the development and outcome of thrombotic complications. Fibrin polymerization comprises a number of consecutive reactions, each affecting the ultimate 3D porous network structure. The physical properties of fibrin clots are determined by structural features at the individual fibrin molecule, fibrin fiber, network, and whole clot levels and are among the most important functional characteristics, enabling the blood clot to withstand arterial blood flow, platelet-driven clot contraction, and other dynamic forces. This chapter describes the molecular structure of fibrinogen, the conversion of fibrinogen to fibrin, the mechanical properties of fibrin as well as its structural origins and lastly provides evidence for the role of altered fibrin clot properties in both thrombosis and bleeding.
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63
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Pieters M, Ferreira M, de Maat MPM, Ricci C. Biomarker association with cardiovascular disease and mortality - The role of fibrinogen. A report from the NHANES study. Thromb Res 2020; 198:182-189. [PMID: 33360152 DOI: 10.1016/j.thromres.2020.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/26/2020] [Accepted: 12/09/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND While fibrinogen is a known cardiovascular disease (CVD) risk marker, its quantitative input to mortality risk is a topic of debate. METHODS We investigated the contribution of fibrinogen, among that of other biomarkers, to prevalent CVD and incident CVD mortality in 4487 participants of the US National Health and Nutrition Examination Survey (NHANES). Participants were observed for a median period of 14 years, resulting in more than 58,000 person-years. RESULTS At baseline 551 participants had CVD and during follow up, 1339 all-cause deaths occurred, 321 (24%) of which were due to CVD. Hierarchical cluster analysis and principal component analysis (PCA) were performed to derive clusters of association between biomarkers. Next, structural equation modelling was performed to investigate the association of these clusters with baseline CVD and all-cause and CVD mortality during follow-up. Mediation analysis was used to determine which biomarkers played a mediatory role between prevalent CVD and future mortality. Fibrinogen clustered with C-reactive protein only and was associated with CVD at baseline (p < 0.0001) and with all-cause (p < 0.001) and CVD (p < 0.001) mortality at follow-up. Only fibrinogen (4.7%), followed by gamma-glutamyl transferase (GGT) (3.5%) and uric acid (2.3%) were identified as possible mediators between CVD status and all-cause mortality, with fibrinogen (3.2%) and GGT (3.1%) the only mediators between CVD status and CVD mortality. CONCLUSION This data shows that fibrinogen is not only cross-sectionally associated with CVD, but also contributes to all-cause and CVD mortality at follow-up. It furthermore appears to mediate the association between prevalent CVD and both all-cause and CVD mortality.
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Affiliation(s)
- Marlien Pieters
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa; Medical Research Council Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa.
| | - Maylene Ferreira
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Moniek P M de Maat
- Department of Hematology, Erasmus University Medical Centre, Rotterdam, the Netherlands
| | - Cristian Ricci
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa; Pediatric Epidemiology, Department of Pediatrics, University Medicine Leipzig, Leipzig, Germany
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64
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Krychtiuk KA, Speidl WS, Giannitsis E, Gigante B, Gorog DA, Jaffe AS, Mair J, Möckel M, Mueller C, Storey RF, Vilahur G, Wojta J, Huber K, Halvorsen S, Geisler T, Morais J, Lindahl B, Thygesen K. Biomarkers of coagulation and fibrinolysis in acute myocardial infarction: a joint position paper of the Association for Acute CardioVascular Care and the European Society of Cardiology Working Group on Thrombosis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 10:343-355. [PMID: 33620437 DOI: 10.1093/ehjacc/zuaa025] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 12/19/2022]
Abstract
The formation of a thrombus in an epicardial artery may result in an acute myocardial infarction (AMI). Despite major advances in acute treatment using network approaches to allocate patients to timely reperfusion and optimal antithrombotic treatment, patients remain at high risk for thrombotic complications. Ongoing activation of the coagulation system as well as thrombin-mediated platelet activation may both play a crucial role in this context. Whether measurement of circulating biomarkers of coagulation and fibrinolysis could be useful for risk stratification in secondary prevention is currently not fully understood. In addition, measurement of such biomarkers could be helpful to identify thrombus formation as the leading mechanism for AMI. The introduction of biomarkers of myocardial injury such as high-sensitivity cardiac troponins made rule-out of AMI even more precise. However, elevated markers of myocardial injury cannot provide proof of a type 1 AMI, let alone thrombus formation. The combined measurement of markers of myocardial injury with biomarkers reflecting ongoing thrombus formation might be helpful for the fast and correct diagnosis of an atherothrombotic type 1 AMI. This position paper gives an overview of the current knowledge and possible role of biomarkers of coagulation and fibrinolysis for the diagnosis of AMI, risk stratification, and individualized treatment strategies in patients with AMI.
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Affiliation(s)
- Konstantin A Krychtiuk
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Walter S Speidl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Cardiology, Angiology, Pulmonology, Medical University of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Bruna Gigante
- Unit of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solnavägen 1, 171 77 Solna, Sweden.,Department of Clinical Science, Danderyds Hospital, Entrévägen 2, 182 57 Danderyd, Sweden
| | - Diana A Gorog
- Department of Medicine, National Heart & Lung Institute, Imperial College, Guy Scadding Building, Dovehouse St, Chelsea, London SW3 6LY, UK.,Postgraduate Medical School, University of Hertfordshire, Hatfield, UK
| | - Allan S Jaffe
- Department of Cardiology, Mayo Clinic, 1216 2nd St SW Rochester, MN 55902, USA.,Department of Laboratory Medicine and Pathology, Mayo Clinic, 1216 2nd St SW Rochester, MN 55902, USA
| | - Johannes Mair
- Department of Internal Medicine III - Cardiology and Angiology, Medical University Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Martin Möckel
- Division of Emergency and Acute Medicine and Chest Pain Units, Charite - Universitätsmedizin Berlin, Campus Mitte and Virchow, Augustenburger Pl. 1, 13353 Berlin, Germany
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Spitalstrasse 2, 4056 Basel, Switzerland
| | - Robert F Storey
- Cardiovascular Research Unit, Department of Infection Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Beech Hill Rd, Sheffield S10 2RX, UK
| | - Gemma Vilahur
- Cardiovascular Program ICCC - Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Carrer de Sant Quintí, 89, 08041 Barcelona, Spain.,Centro de Investigación Biomédica en Red Cardiovascular (CIBERCV), Instituto de Salud Carlos III, Calle de Melchor Fernández Almagro, 3, 28029 Madrid, Spain
| | - Johann Wojta
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Kurt Huber
- Ludwig Boltzmann Institute for Cardiovascular Research, Waehringer Guertel 18-20, 1090 Vienna, Austria.,3rd Medical Department of Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstraße 37, 1160 Vienna, Austria
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, University of Oslo, Kirkeveien 166, 0450 Oslo, Norway
| | - Tobias Geisler
- University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076 Tübingen, Germany
| | - Joao Morais
- Division of Cardiology, Santo Andre's Hospital, R. de Santo André, 2410-197 Leiria, Portugal
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala Clinical Research Center, Dag Hammarskjölds Väg 38, 751 85 Uppsala University, Uppsala, Sweden
| | - Kristian Thygesen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Blvd. 161, 8200 Aarhus N, Denmark
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65
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Siudut J, Iwaniec T, Plens K, Pieters M, Undas A. Determinants of plasma fibrin clot lysis measured using three different assays in healthy subjects. Thromb Res 2020; 197:1-7. [PMID: 33157491 DOI: 10.1016/j.thromres.2020.10.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 08/26/2020] [Accepted: 10/10/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Several methods for measuring fibrinolytic capacity in plasma have been developed yielding frequently inconsistent results. We investigated which factors determine fibrinolytic capacity in three plasma-based assays. MATERIAL AND METHODS In 80 apparently healthy controls (aged 43 ± 10 years, 50 women [62.5%]) we evaluated fibrinolysis using three assays: (1) by Pieters et al. (CLT2018), (2) by Lisman et al. (CLT), and (3) by Carter et al. (Lys50). Coagulation factors and fibrinolytic proteins, including histidine-rich glycoprotein (HRG) and γ'-fibrinogen, were determined. Regression models were performed to identify determinants of lysis times. RESULTS Positive correlations were observed between CLT2018 and both CLT (r = 0.73) and Lys50 (r = 0.61), as well as between CLT and Lys50 (r = 0.46, all p < 0.001). The main determinants of both CLT2018 and CLT were plasminogen activator inhibitor-1 (PAI-1), followed by thrombin-activatable fibrinolysis inhibitor (TAFI) and α2-antiplasmin. Histidine-rich glycoprotein was a predictor of the longest-normal CLT2018 alone (OR 1.04, 95% CI 1.02-1.06). α2-Antiplasmin and fibrinogen levels, followed by PAI-1 and TAFI determined Lys50. After adjustment for age, sex, and body mass index, C-reactive protein (CRP) was an independent predictor of the top quartiles of the three lysis times. CONCLUSIONS We showed that apart from PAI-1, TAFI, and α2-antiplasmin, several other factors, in particular CRP, can affect the results of global fibrinolysis tests used in research. Our findings may help understand why the choice of a specific fibrinolysis assay can affect the presence and/or magnitude of intergroup differences in fibrinolytic capacity in a given disease state.
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Affiliation(s)
- Jakub Siudut
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; Krakow Center for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
| | - Teresa Iwaniec
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | | | - Marlien Pieters
- Centre of Excellence for Nutrition, North-West University, Potchefstroom, South Africa
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland; Krakow Center for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland.
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66
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Larsen JB, Hvas AM. Fibrin Clot Formation and Lysis in Plasma. Methods Protoc 2020; 3:mps3040067. [PMID: 32993011 PMCID: PMC7712220 DOI: 10.3390/mps3040067] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022] Open
Abstract
Disturbance in the balance between fibrin formation and fibrinolysis can lead to either bleeding or thrombosis; however, our current routine coagulation assays are not sensitive to altered fibrinolysis. The clot formation and lysis assay is a dynamic plasma-based analysis that assesses the patient’s capacity for fibrin formation and fibrinolysis by adding an activator of coagulation as well as fibrinolysis to plasma and measuring ex vivo fibrin clot formation and breakdown over time. This assay provides detailed information on the fibrinolytic activity but is currently used for research only, as the assay is prone to inter-laboratory variation and as it demands experienced laboratory technicians as well as specialized personnel to validate and interpret the results. Here, we describe a protocol for the clot formation and lysis assay used at our research laboratory.
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Affiliation(s)
- Julie Brogaard Larsen
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark;
- Correspondence: ; Tel.: +45-4046-5766
| | - Anne-Mette Hvas
- Thrombosis and Haemostasis Research Unit, Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark;
- Department of Clinical Medicine, Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus, Denmark
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67
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Widimsky P, Crea F, Binder RK, Lüscher TF. The year in cardiology 2018: acute coronary syndromes. Eur Heart J 2020; 40:271-282. [PMID: 30601993 DOI: 10.1093/eurheartj/ehy904] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/26/2018] [Indexed: 01/05/2023] Open
Affiliation(s)
- Petr Widimsky
- Cardiocenter, Third Faculty of Medicine, Charles University, Hospital Kralovske Vinohrady, Ruska 87, Prague 10, Czech Republic
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Policlinico A. Gemelli-IRCCS, Catholic University, Roma, Italy
| | - Ronald K Binder
- Cardiology and Intensive Care, University Teaching Hospital Klinikum Wels Grieskirchen, A-4600 Wels, Austria
| | - Thomas F Lüscher
- Royal Brompton and Harefield Hospitals and Imperial College, London, UK.,Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
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68
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Prothrombotic fibrin clot properties associated with NETs formation characterize acute pulmonary embolism patients with higher mortality risk. Sci Rep 2020; 10:11433. [PMID: 32651425 PMCID: PMC7351737 DOI: 10.1038/s41598-020-68375-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/12/2020] [Indexed: 11/09/2022] Open
Abstract
Venous thromboembolism is associated with formation of denser fibrin clots resistant to lysis. We investigated whether prothrombotic plasma clot properties are associated with the severity of acute pulmonary embolism (PE). We enrolled 126 normotensive acute PE patients (aged 58 ± 14 years) and 25 age- and sex-matched healthy controls. Plasma fibrin clot permeability (Ks), clot lysis time (CLT), endogenous thrombin potential (ETP), plasminogen activator inhibitor-1 (PAI-1), and citrullinated histone H3 (citH3) were evaluated on admission. PE patients compared to controls had 370% higher citH3 levels, 41% higher ETP, 16.5% reduced Ks, and 25.6% prolonged CLT. Patients with intermediate-high (n = 29) and intermediate-low (n = 77) PE mortality risk had reduced Ks and prolonged CLT, increased PAI-1 and ETP as compared to low-risk PE (n = 20) patients. Prolonged CLT was predicted by PAI-1 and citH3, while low Ks by C-reactive protein. During a 12-month follow-up 9 (7.1%) patients who had 24% higher ETP, 45% higher citH3 levels, and 18% prolonged CLT at baseline died. High ETP combined with elevated citH3 levels and prolonged CLT was associated with eightfold increased risk of PE-related death. Prothrombotic fibrin clot properties and enhanced neutrophil extracellular traps formation are associated with higher early mortality risk in acute PE patients, which suggests a prognostic role of these biomarkers.
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69
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Impaired Fibrinolysis in Patients with Isolated Aortic Stenosis is Associated with Enhanced Oxidative Stress. J Clin Med 2020; 9:jcm9062002. [PMID: 32630544 PMCID: PMC7355626 DOI: 10.3390/jcm9062002] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 11/17/2022] Open
Abstract
Aortic stenosis (AS) has been associated with impaired fibrinolysis and increased oxidative stress. This study aimed to investigate whether oxidative stress could alter fibrin clot properties in AS. We studied 173 non-diabetic patients, aged 51–79 years, with isolated AS. We measured plasma protein carbonylation (PC) and thiobarbituric acid reactive substances (TBARS), along with plasma clot permeability (Ks), thrombin generation, and fibrinolytic efficiency, which were evaluated by two assays: clot lysis time (CLT) and lysis time (Lys50). Coagulation factors and fibrinolytic proteins were also determined. Plasma PC showed an association with AS severity, reflected by the aortic valve area and the mean and maximum aortic gradients. Plasma PC was positively correlated with CLT, Lys50, plasminogen activator inhibitor-1 (PAI-1), and tissue factor (TF) antigens. TBARS were positively correlated with maximum aortic gradient, Lys50, and TF antigen. Regression analysis showed that PC predicted prolonged CLT (>104 min; odds ratio (OR) 6.41, 95% confidence interval (CI) 2.58–17.83, p < 0.001) and Lys50 (>565 s; OR 5.83, 95% CI 2.23–15.21, p < 0.001). Multivariate regression analysis showed that mean aortic gradient, PC, α2-antiplasmin, PAI-1, and triglycerides were predictors of prolonged CLT, while PC, α2-antiplasmin, and fibrinogen were predictors of Lys50. Our findings suggest that elevated oxidative stress contributes to impaired fibrinolysis in AS and is associated with AS severity.
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70
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Abstract
Studies using whole blood platelet aggregometry as a laboratory research tool, provided important insights into the mechanism and modulators of platelet aggregation. Subsequently, a number of point-of-care (POC) platelet function tests (PFTs) were developed for clinical use, based on the concept that an individual’s thrombotic profile could be assessed in vitro by assessing the response to stimulation of platelet aggregation by specific, usually solo agonists such as adenosine diphosphate (ADP), collagen and thrombin. However, adjusting antiplatelet medication in order to improve the results of such POC PFTs has not translated into a meaningful reduction in cardiovascular events, which may be attributable to important differences between the POC PFT techniques and in vivo conditions, including patient-to-patient variability. Important limitations of most tests include the use of citrate-anticoagulated blood. Citrate directly and irreversibly diminishes platelet function and even after recalcification, it may result in altered platelet aggregation in response to ADP, epinephrine or collagen, and interfere with thrombin generation from activated platelets. Furthermore, most tests do not employ flowing blood and therefore do not assess the effect of high shear forces on platelets that initiate, propagate and stabilize arterial thrombi. Finally, the effect of endogenous thrombolysis, due to fibrinolysis and dislodgement, which ultimately determines the outcome of a thrombotic stimulus, is mostly not assessed. In order to accurately reflect an individual’s predisposition to arterial thrombosis, future tests of thrombotic status which overcome these limitations should be used, to improve cardiovascular risk prediction and to guide pharmacotherapy.
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Affiliation(s)
- Diana A Gorog
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, UK.
- University of Hertfordshire, Hertfordshire, UK.
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71
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Gorog DA, Lip GYH. Impaired Spontaneous/Endogenous Fibrinolytic Status as New Cardiovascular Risk Factor?: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 74:1366-1375. [PMID: 31488274 DOI: 10.1016/j.jacc.2019.07.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/17/2019] [Accepted: 07/19/2019] [Indexed: 12/27/2022]
Abstract
Endogenous fibrinolysis is a powerful natural defense mechanism against lasting arterial thrombotic occlusion. Recent prospective studies have shown that impaired endogenous fibrinolysis (or hypofibrinolysis) can be detected in a significant number of patients with acute coronary syndrome (ACS) using global assays and is a strong marker of future cardiovascular risk. This novel risk biomarker is independent of traditional cardiovascular risk factors and unaffected by antiplatelet therapy. Most prospective prognostic data have been obtained using a global assay using native whole blood at high shear or plasma turbidimetric assays, which are described herein. Tests of endogenous fibrinolysis could be used to identify patients with ACS who, despite antiplatelet therapy, remain at high cardiovascular risk. This review discusses the impact of currently available medications and those in development that favorably modulate fibrinolytic status and may offer a potential new avenue to improve outcomes in ACS.
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Affiliation(s)
- Diana A Gorog
- National Heart and Lung Institute, Imperial College, London, United Kingdom; Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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72
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Sagar RC, Naseem KM, Ajjan RA. Antiplatelet therapies in diabetes. Diabet Med 2020; 37:726-734. [PMID: 32141628 DOI: 10.1111/dme.14291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
Abstract
Cardiovascular complications remain the main cause of mortality and morbidity in diabetes. This is related to advanced vascular pathology in this population, together with an enhanced thrombotic environment. The increased risk in thrombosis is secondary to platelet hyper-reactivity and increased levels and/or altered activity of coagulation factors. The current review is focused on the role of antiplatelet agents in modulating the thrombotic milieu in diabetes and improving vascular outcome in this high-risk population. We review the latest evidence for the use of aspirin in primary vascular prevention together with long-term treatment with this agent for secondary prevention. We also discuss the effects of the various P2Y12 inhibitors, including clopidogrel, prasugrel and ticagrelor, on both short- and long-term secondary vascular prevention. Moreover, we briefly review antiplatelet therapies in special groups of people including those intolerant to aspirin, individuals with peripheral vascular disease and those with cerebrovascular pathology. The overall aim of this review is to provide the healthcare professional with a pragmatic guide for the management of thrombotic risk using established antiplatelet therapies to improve vascular outcome in persons with diabetes.
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Affiliation(s)
- R C Sagar
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - K M Naseem
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - R A Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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73
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Sinnaeve PR, Van de Werf F. Endogenous fibrinolysis in STEMI: important before and after primary PCI. Eur Heart J 2020; 40:306-308. [PMID: 30496395 DOI: 10.1093/eurheartj/ehy760] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- Peter R Sinnaeve
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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74
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Pernicova I, Kelly S, Ajodha S, Sahdev A, Bestwick JP, Gabrovska P, Akanle O, Ajjan R, Kola B, Stadler M, Fraser W, Christ-Crain M, Grossman AB, Pitzalis C, Korbonits M. Metformin to reduce metabolic complications and inflammation in patients on systemic glucocorticoid therapy: a randomised, double-blind, placebo-controlled, proof-of-concept, phase 2 trial. Lancet Diabetes Endocrinol 2020; 8:278-291. [PMID: 32109422 DOI: 10.1016/s2213-8587(20)30021-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND An urgent need to reduce the metabolic side-effects of glucocorticoid overexposure has been recognised, as glucocorticoid excess can lead to Cushing's syndrome, which is associated with high morbidity. We aimed to evaluate the potential of metformin to reverse such effects while sparing the anti-inflammatory benefits of glucocorticoids. METHODS We did a randomised, double-blind, placebo-controlled, proof-of-concept, phase 2 trial involving four hospitals in the UK. Patients without diabetes were eligible if they were between the ages of 18 and 75 years with an inflammatory disease treated with continuous prednisolone (≥20 mg/day for ≥4 weeks and remaining on ≥10 mg/day for the subsequent 12 weeks, or its cumulative dose-equivalent). Eligible patients were randomly allocated (1:1) to either the metformin or placebo groups, using a computer-generated randomisation table stratified according to age and BMI. Metformin and placebo were administered orally for 12 weeks in escalating doses: 850 mg/day for the first 5 days, 850 mg twice a day for the next 5 days, and 850 mg three times a day subsequently. The primary outcome was the between-group difference in visceral-to-subcutaneous fat area ratio over 12 weeks, assessed by CT. Secondary outcomes included changes in metabolic, bone, cardiovascular, and inflammatory parameters over 12 weeks. Our analysis followed a modified intention-to-treat principle for the primary outcome. This study is registered with ClinicalTrials.gov, NCT01319994. FINDINGS Between July 17, 2012, and Jan 14, 2014, 849 patients were assessed for study eligibility, of which 53 were randomly assigned to receive either metformin (n=26) or placebo (n=27) for 12 weeks. 19 patients in the metformin group and 21 in the placebo group were eligible for the primary outcome analysis. Both groups received an equivalent cumulative dose of glucocorticoids (1860 mg prednisolone-equivalent [IQR 1060-2810] in the metformin group vs 1770 mg [1020-2356] in the placebo group); p=0·76). No change in the visceral-to-subcutaneous fat area ratio between the treatment groups was observed (0·11, 95% CI -0·02 to 0·24; p=0·09), but patients in the metformin group lost truncal subcutaneous fat compared with the placebo group (-3835 mm2, 95% CI -6781 to -888; p=0·01). Improvements in markers of carbohydrate, lipid, liver, and bone metabolism were observed in the metformin group compared with the placebo group. Additionally, those in the metformin group had improved fibrinolysis, carotid intima-media thickness, inflammatory parameters, and clinical markers of disease activity. The frequency of pneumonia (one event in the metformin group vs seven in the placebo group; p=0·01), overall rate of moderate-to-severe infections (two vs 11; p=0·001), and all-cause hospital admissions due to adverse events (one vs nine; p=0·001) were lower in the metformin group than in the placebo group. Patients in the metformin group had more events of diarrhoea than the placebo group (18 events vs eight; p=0·01). INTERPRETATION No significant changes in the visceral-to-subcutaneous fat area ratio between the treatment groups were observed; however, metformin administration did improve some of the metabolic profile and clinical outcomes for glucocorticoid-treated patients with inflammatory disease, which warrants further investigation. FUNDING Barts Charity and Merck Serono.
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Affiliation(s)
- Ida Pernicova
- Centre for Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK; Endocrinology and Metabolic Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Stephen Kelly
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Sharon Ajodha
- Centre for Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Anju Sahdev
- Department of Radiology, Barts Health NHS Trust, London, UK
| | - Jonathan P Bestwick
- Wolfson Institute of Preventive Medicine, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Plamena Gabrovska
- Centre for Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Ramzi Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Blerina Kola
- Centre for Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Marietta Stadler
- Centre for Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK; Faculty of Life Sciences and Medicine, Department of Diabetes, King's College London, London, UK
| | - William Fraser
- Department of Medicine, University of East Anglia, Norwich, UK
| | - Mirjam Christ-Crain
- Centre for Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK; Division of Endocrinology, Diabetes & Metabolism, Department of Internal Medicine and Department of Clinical Research, University Hospital, University of Basel, Basel, Switzerland
| | - Ashley B Grossman
- Centre for Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Costantino Pitzalis
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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75
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Otamas A, Grant PJ, Ajjan RA. Diabetes and atherothrombosis: The circadian rhythm and role of melatonin in vascular protection. Diab Vasc Dis Res 2020; 17:1479164120920582. [PMID: 32506946 PMCID: PMC7607413 DOI: 10.1177/1479164120920582] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Obesity-related euglycaemic insulin resistance clusters with cardiometabolic risk factors, contributing to the development of both type 2 diabetes and cardiovascular disease. An increased thrombotic tendency in diabetes stems from platelet hyperactivity, enhanced activity of prothrombotic coagulation factors and impaired fibrinolysis. Furthermore, a low-grade inflammatory response and increased oxidative stress accelerate the atherosclerotic process and, together with an enhanced thrombotic environment, result in premature and more severe cardiovascular disease. The disruption of circadian cycles in man secondary to chronic obesity and loss of circadian cues is implicated in the increased risk of developing diabetes and cardiovascular disease. Levels of melatonin, the endogenous synchronizer of circadian rhythm, are reduced in individuals with vascular disease and those with deranged glucose metabolism. The anti-inflammatory, antihypertensive, antioxidative and antithrombotic activities of melatonin make it a potential therapeutic agent to reduce the risk of vascular occlusive disease in diabetes. The mechanisms behind melatonin-associated reduction in procoagulant response are not fully known. Current evidence suggests that melatonin inhibits platelet aggregation and might affect the coagulation cascade, altering fibrin clot structure and/or resistance to fibrinolysis. Large-scale clinical trials are warranted to investigate the effects of modulating the circadian clock on insulin resistance, glycaemia and cardiovascular outcome.
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Affiliation(s)
- Anastasia Otamas
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine and Leeds Teaching Hospitals Trust, University of Leeds, Leeds, UK
| | - Peter J Grant
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine and Leeds Teaching Hospitals Trust, University of Leeds, Leeds, UK
| | - Ramzi A Ajjan
- The LIGHT Laboratories, Leeds Institute of Cardiovascular and Metabolic Medicine and Leeds Teaching Hospitals Trust, University of Leeds, Leeds, UK
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76
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Gue YX, Kanji R, Wellsted DM, Srinivasan M, Wyatt S, Gorog DA. Rationale and design of "Can Very Low Dose Rivaroxaban (VLDR) in addition to dual antiplatelet therapy improve thrombotic status in acute coronary syndrome (VaLiDate-R)" study : A randomised trial modulating endogenous fibrinolysis in patients with acute coronary syndrome. J Thromb Thrombolysis 2020; 49:192-198. [PMID: 31872349 PMCID: PMC6969858 DOI: 10.1007/s11239-019-02014-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Impaired endogenous fibrinolysis is novel biomarker that can identify patients with ACS at increased cardiovascular risk. The addition of Very Low Dose Rivaroxaban (VLDR) to dual antiplatelet therapy has been shown to reduce cardiovascular events but at a cost of increased bleeding and is therefore not suitable for all-comers. Targeted additional pharmacotherapy with VLDR to improve endogenous fibrinolysis may improve outcomes in high-risk patients, whilst avoiding unnecessary bleeding in low-risk individuals. The VaLiDate-R study (ClinicalTrials.gov Identifier: NCT03775746, EudraCT: 2018-003299-11) is an investigator-initiated, randomised, open-label, single centre trial comparing the effect of 3 antithrombotic regimens on endogenous fibrinolysis in 150 patients with ACS. Subjects whose screening blood test shows impaired fibrinolytic status (lysis time > 2000s), will be randomised to one of 3 treatment arms in a 1:1:1 ratio: clopidogrel 75 mg daily (Group 1); clopidogrel 75 mg daily plus rivaroxaban 2.5 mg twice daily (Group 2); ticagrelor 90 mg twice daily (Group 3), in addition to aspirin 75 mg daily. Rivaroxaban will be given for 30 days. Fibrinolytic status will be assessed during admission and at 2, 4 and 8 weeks. The primary outcome measure is the change in fibrinolysis time from admission to 4 weeks follow-up, using the Global Thrombosis Test. If VLDR can improve endogenous fibrinolysis in ACS, future large-scale studies would be required to assess whether targeted use of VLDR in patients with ACS and impaired fibrinolysis can translate into improved clinical outcomes, with reduction in major adverse cardiovascular events in this high-risk cohort.
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Affiliation(s)
- Ying X Gue
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
- Cardiology Department, East and North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Rahim Kanji
- Cardiology Department, East and North Hertfordshire NHS Trust, Hertfordshire, UK
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, UK
| | - David M Wellsted
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | | | - Solange Wyatt
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Diana A Gorog
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK.
- Cardiology Department, East and North Hertfordshire NHS Trust, Hertfordshire, UK.
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, UK.
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77
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Shavadia JS, Granger CB, Alemayehu W, Westerhout CM, Povsic TJ, Brener SJ, van Diepen S, Defilippi C, Armstrong PW. High-throughput targeted proteomics discovery approach and spontaneous reperfusion in ST-segment elevation myocardial infarction. Am Heart J 2020; 220:137-144. [PMID: 31812755 DOI: 10.1016/j.ahj.2019.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 09/20/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Although spontaneous reperfusion (SR) prior to primary percutaneous coronary intervention (pPCI) is associated with improved outcomes, its pathophysiology remains unclear. The objective of the study was to explore associations between SR in ST-segment elevation myocardial infarction (STEMI) using a multimarker cardiovascular proteins strategy METHODS: We evaluated STEMI patients from the Assessment of Pexelizumab in Acute Myocardial Infarction trial treated with pPCI within 6 hours from symptom onset. SR was core laboratory-defined as pre-PCI Thrombolysis in Myocardial Infarction flow 2 or 3. Ninety-one cardiovascular disease-related serum biomarkers drawn prior to PCI were analyzed using a high-throughput "targeted discovery" panel. Expression levels for individual biomarkers were compared between patients with/without SR. A hierarchical clustering method of biomarkers identified clusters of biomarkers that differentiated the 2 groups. Associations between individual biomarkers and clusters with SR were further evaluated by multivariable logistic regression. RESULTS Of 683 patients studied, 290 had spontaneous reperfusion; those with compared to without SR were more likely noninferior STEMI and had lower clinical acuity and lower baseline levels of troponin and creatine kinase. SR was associated with a lower occurrence of 90-day composite of death, heart failure, or cardiogenic shock. Fifty-two of 91 individual biomarkers were significantly univariably associated with SR. Forty-five remained significant with adjustment for false discovery rate. Using cluster analysis, 26 biomarkers clusters were identified, explaining 72% of total covariance, and 13 biomarker clusters were significantly associated with SR after multivariable adjustment. SR was associated with higher mean expression levels of proteins in all 13 clusters. The cluster most strongly associated with SR consisted of novel proteins across various distinct, yet interlinked, pathobiological processes (kallikrein-6, matrix extracellular phosphoglycoprotein, matrix mettaloproteinaise-3, and elafin). CONCLUSIONS Spontaneous reperfusion prior to pPCI in STEMI was associated with a lower risk of adverse clinical events. These exploratory data from a targeted discovery proteomics platform identifies novel proteins across diverse, yet complementary, pathobiological axes that show promise in providing mechanistic insights into spontaneous reperfusion in STEMI. CONDENSED ABSTRACT Spontaneous reperfusion has been established with improved STEMI outcomes, yet its pathobiology is unclear and appears to involve diverse physiological processes. Using a 91-biomarker high-throughput proteomics platform, we studied 683 STEMI patients in the APEX AMI trial (290 had core laboratory-adjudicated pre-PCI TIMI 2/3 flow) and identified 52 proteins that univariably associate with spontaneous reperfusion. Cluster analysis identified 26 biomarker clusters (explaining 72% of total variance), 13 of which, after multivariable adjustment, were significantly associated with spontaneous reperfusion. Four proteins (kallikrein-6, matrix extracellular phosphoglycoprotein, matrix mettaloproteinaise-3, and elafin) across diverse, yet complementary, pathways appear to be associated most strongly with spontaneous reperfusion.
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Affiliation(s)
- Jay S Shavadia
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Duke Clinical Research Institute, Durham, NC, USA.
| | | | | | | | | | - Sorin J Brener
- Department of Medicine, Cardiac Catheterization Laboratory, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Sean van Diepen
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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78
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The association of body mass index with long-term clinical outcomes after ticagrelor monotherapy following abbreviated dual antiplatelet therapy in patients undergoing percutaneous coronary intervention: a prespecified sub-analysis of the GLOBAL LEADERS Trial. Clin Res Cardiol 2020; 109:1125-1139. [PMID: 32006156 PMCID: PMC7449952 DOI: 10.1007/s00392-020-01604-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 01/16/2020] [Indexed: 12/18/2022]
Abstract
Background The efficacy of antiplatelet therapies following percutaneous coronary intervention (PCI) may be affected by body mass index (BMI). Methods and results This is a prespecified subgroup analysis of the GLOBAL LEADERS trial, a prospective, multicenter, open-label, randomized controlled trial in an all-comer population undergoing PCI, comparing the experimental strategy (23-month ticagrelor monotherapy following 1-month dual antiplatelet therapy [DAPT]) with a reference regimen (12-month aspirin monotherapy following 12-month DAPT). A total of 15,968 patients were stratified by baseline BMI with prespecified threshold of 27 kg/m2. Of those, 6973 (43.7%) patients with a BMI < 27 kg/m2 had a higher risk of all-cause mortality at 2 years than those with BMI ≥ 27 kg/m2 (adjusted HR 1.24, 95% CI 1.02–1.49). At 2 years, the rates of the primary endpoint (all-cause mortality or new Q-wave myocardial infarction) were similar between treatment strategies in either BMI group (pinteraction = 0.51). In acute coronary syndrome, however, the experimental strategy was associated with significant reduction of the primary endpoint compared to the reference strategy in patients with BMI < 27 kg/m2 (HR 0.69, 95% CI 0.51–0.94), but not in the ones with BMI ≥ 27 kg/m2 (pinteraction = 0.047). In chronic coronary syndrome, there was no between-group difference in the efficacy and safety of the two antiplatelet strategies. Conclusions Overall, BMI did not influence the treatment effect seen with ticagrelor monotherapy; however, a beneficial effect of ticagrelor monotherapy was seen in ACS patients with BMI < 27 kg/m2. Trial registration The trial has been registered with ClinicalTrials.gov, Number NCT01813435. Graphic abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s00392-020-01604-1) contains supplementary material, which is available to authorized users.
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79
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Xu RG, Ariëns RAS. Insights into the composition of stroke thrombi: heterogeneity and distinct clot areas impact treatment. Haematologica 2020; 105:257-259. [PMID: 32005654 DOI: 10.3324/haematol.2019.238816] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- Rui-Gang Xu
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Robert A S Ariëns
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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80
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Sumaya W, Wallentin L, James SK, Siegbahn A, Gabrysch K, Himmelmann A, Ajjan RA, Storey RF. Impaired Fibrinolysis Predicts Adverse Outcome in Acute Coronary Syndrome Patients with Diabetes: A PLATO Sub-Study. Thromb Haemost 2020; 120:412-422. [PMID: 31975352 PMCID: PMC7286125 DOI: 10.1055/s-0039-1701011] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Hypofibrinolysis is a key abnormality in diabetes but the role of impaired clot lysis in predicting vascular events and mortality in this population is yet to be determined. We aimed to investigate the relationship between fibrin clot properties and clinical outcomes in patients with diabetes and recent acute coronary syndrome (ACS). Plasma samples were collected at hospital discharge from 974 ACS patients with diabetes randomised to clopidogrel or ticagrelor in the PLATO trial. A validated turbidimetric assay was employed to study fibrin clot lysis and maximum turbidity. One-year rates of cardiovascular (CV) death, spontaneous myocardial infarction (MI) and PLATO-defined major bleeding events were assessed after sample collection. Hazard ratios (HRs) were determined using Cox proportional analysis. After adjusting for CV risk factors, each 50% increase in lysis time was associated with increased risk of CV death/MI (HR 1.21; 95% confidence interval [CI] 1.02–1.44;
p
= 0.026) and CV death alone (HR 1.38; 1.08–1.76;
p
= 0.01). Similarly, each 50% increase in maximum turbidity was associated with increased risk of CV death/MI (HR 1.25; 1.02–1.53;
p
= 0.031) and CV death alone (HR 1.49; 1.08–2.04;
p
= 0.014). The relationship between lysis time and the combined outcome of CV death and MI remained significant after adjusting for multiple prognostic vascular biomarkers (
p
= 0.034). Neither lysis time nor maximum turbidity was associated with major bleeding events. Impaired fibrin clot lysis predicts 1-year CV death and MI in diabetes patients following ACS.
Clinical Trial Registration
URL:
http://www.clinicaltrials.gov
. Unique identifier NCT00391872.
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Affiliation(s)
- Wael Sumaya
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.,Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Katja Gabrysch
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Ramzi A Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
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81
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Sex-specific alteration to α2-antiplasmin incorporation in patients with type 2 diabetes. Thromb Res 2020; 185:55-62. [DOI: 10.1016/j.thromres.2019.09.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/12/2019] [Accepted: 09/24/2019] [Indexed: 01/06/2023]
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82
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Polak MW, Siudut J, Plens K, Undas A. Prothrombotic clot properties can predict venous ulcers in patients following deep vein thrombosis: a cohort study. J Thromb Thrombolysis 2019; 48:603-609. [PMID: 31432450 PMCID: PMC6800839 DOI: 10.1007/s11239-019-01914-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
Abstract
Venous ulcers are the most severe manifestation of post-thrombotic syndrome (PTS). We have previously demonstrated that formation of compact fibrin clots resistant to lysis is observed in patients following deep-vein thrombosis (DVT) who developed PTS. The current study investigated whether unfavourable fibrin clot properties can predict post-thrombotic venous ulcers. In a cohort study on 186 consecutive patients following DVT, we determined plasma fibrin clot characteristics, including clot permeability and lysability, inflammatory markers, thrombin generation, fibrinolysis proteins at 3 months since the index event. Occurrence of PTS and venous ulcers was recorded during follow-up (median, 53; range 24 to 76 months). Fifty-seven DVT patients (30.6%) developed PTS, including 12 subjects (6.45%) with a venous ulcer (4 individuals with recurrent ulcers). Patients who developed ulcers compared with the remainder had at enrolment 13.0% lower clot permeability (Ks), 17.4% longer clot lysis time (CLT), 13.1% longer lag phase of clot formation, and 5.0% higher maximum absorbance, with no difference in fibrinogen, C-reactive protein, and thrombin generation. The baseline prothrombotic fibrin clot phenotype (Ks ≤ 6.5 × 10-9 cm2 and CLT > 100 min) was associated with a higher risk of ulcers [hazard ratio (HR), 5.37; 95% confidence interval (CI), 1.3-21.5]. A multivariate model adjusted for age, sex, and fibrinogen showed that independent predictors of the ulcer occurrence were body mass index (HR 1.53; 95% CI 1.30-1.86), CLT (HR 1.43; 95% CI 1.04-2.05), and α2-antiplasmin (HR 0.95; 95% CI 0.90-0.99). This study suggests that formation of denser fibrin clots with impaired fibrinolysis predisposes to post-thrombotic venous ulcers.
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Affiliation(s)
- Maciej Wiktor Polak
- Institute of Cardiology, Jagiellonian University Medical College, 80 Pradnicka St, 31-202, Krakow, Poland
| | - Jakub Siudut
- Institute of Cardiology, Jagiellonian University Medical College, 80 Pradnicka St, 31-202, Krakow, Poland
- Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
| | | | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, 80 Pradnicka St, 31-202, Krakow, Poland.
- Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland.
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83
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Winzap P, Davies A, Klingenberg R, Obeid S, Roffi M, Mach F, Räber L, Windecker S, Templin C, Nietlispach F, Nanchen D, Gencer B, Muller O, Matter CM, von Eckardstein A, Lüscher TF. Diabetes and baseline glucose are associated with inflammation, left ventricular function and short- and long-term outcome in acute coronary syndromes: role of the novel biomarker Cyr 61. Cardiovasc Diabetol 2019; 18:142. [PMID: 31672144 PMCID: PMC6824030 DOI: 10.1186/s12933-019-0946-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 10/11/2019] [Indexed: 02/07/2023] Open
Abstract
Background Hyperglycemia in the setting of an acute coronary syndrome (ACS) impacts short term outcomes, but little is known about longer term effects. We therefore designed this study to firstly determine the association between hyperglycemia and short term and longer term outcomes in patients presenting with ACS and secondly evaluate the prognostic role of diabetes, body mass index (BMI) and the novel biomarker Cyr61 on outcomes. Methods The prospective Special Program University Medicine-Acute Coronary Syndrome (SPUM-ACS) cohort enrolled 2168 patients with ACS between December 2009 and October 2012, of which 2034 underwent PCI (93.8%). Patients were followed up for 12 months. Events were independently adjudicated by three experienced cardiologists. Participants were recruited from four tertiary hospitals in Switzerland: Zurich, Geneva, Lausanne and Bern. Participants presenting with acute coronary syndromes and who underwent coronary angiography were included in the analysis. Patients were grouped according to history of diabetes (or HbA1c greater than 6%), baseline blood sugar level (BSL; < 6, 6–11.1 and > 11.1 mmol/L) and body mass index (BMI). The primary outcome was major adverse cardiac events (MACE) which was a composite of myocardial infarction, stroke and all-cause death. Secondary outcomes included the individual components of the primary endpoint, revascularisations, bleeding events (BARC classification) and cerebrovascular events (ischaemic or haemorrhagic stroke or TIA). Results Patients with hyperglycemia, i.e. BSL ≥ 11.1 mmol/L, had higher levels of C-reactive protein (CRP), white blood cell count (WBC), creatinine kinase (CK), higher heart rates and lower left ventricular ejection fraction (LVEF) and increased N-terminal pro-brain natriuretic peptide. At 30 days and 12 months, those with BSL ≥ 11.1 mmol/L had more MACE and death compared to those with BSL < 6.0 mmol/L or 6.0–11.1 mmol/L (HR-ratio 4.78 and 6.6; p < 0.001). The novel biomarker Cyr61 strongly associated with high BSL and STEMI and was independently associated with 1 year outcomes (HR 2.22; 95% CI 1.33–3.72; Tertile 3 vs. Tertile 1). Conclusions and relevance In this large, prospective, independently adjudicated cohort of in all comers ACS patients undergoing PCI, both a history of diabetes and elevated entry glucose was associated with inflammation and increased risk of MACE both at short and long-term. The mediators might involve increased sympathetic activation, inflammation and ischemia as reflected by elevated Cyr61 levels leading to larger levels of troponin and lower LVEF. Trial registration Clinical Trial Registration Number: NCT01000701. Registered October 23, 2009
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Affiliation(s)
- Patric Winzap
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Allan Davies
- Royal Brompton and Harefield Hospitals and Imperial College, Sydney Street, London, SW3 6NP, UK
| | - Roland Klingenberg
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Slayman Obeid
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Marco Roffi
- Department of Cardiology, Hopital Universitaire de Geneve, Geneva, Switzerland
| | - François Mach
- Department of Cardiology, Hopital Universitaire de Geneve, Geneva, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Swiss Heart Centre, Inselspital, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Swiss Heart Centre, Inselspital, Bern, Switzerland
| | - Christian Templin
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Fabian Nietlispach
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | - David Nanchen
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Baris Gencer
- Department of Cardiology, Hopital Universitaire de Geneve, Geneva, Switzerland
| | - Olivier Muller
- Service of Cardiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Christian M Matter
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland.,Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Zurich, Switzerland
| | | | - Thomas F Lüscher
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland. .,Royal Brompton and Harefield Hospitals and Imperial College, Sydney Street, London, SW3 6NP, UK.
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84
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Lüscher TF. Lumpers and splitters: the bumpy road to precision medicine. Eur Heart J 2019; 40:3292-3296. [DOI: 10.1093/eurheartj/ehz644] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 08/18/2019] [Accepted: 08/19/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas F Lüscher
- The Royal Brompton & Harefield Hospitals and Imperial College, Guy Scadding Building, Cale Street, London, UK
- Center for Molecular Cardiology, University of Zürich, Switzerland
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85
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Drabik L, Konieczyńska M, Undas A. Clot Lysis Time Predicts Stroke During Anticoagulant Therapy in Patients with Atrial Fibrillation. Can J Cardiol 2019; 36:119-126. [PMID: 31740169 DOI: 10.1016/j.cjca.2019.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 07/26/2019] [Accepted: 08/04/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Formation of dense fibrin clots has been reported in both atrial fibrillation (AF) and ischemic stroke. We have previously demonstrated that such clot properties can predict thromboembolism and major bleeding in AF patients treated with vitamin K antagonists (VKAs). In this longitudinal cohort study, we evaluated whether impaired fibrinolysis is associated with clinical outcomes in AF. METHODS In 236 patients with AF receiving VKAs, we measured ex vivo plasma clot lysis time (CLT), a measure of global fibrinolysis along, with von Willebrand factor antigen (vWF), plasminogen activator inhibitor 1 antigen (PAI-1), and other fibrinolysis modulators. The primary outcome were ischemic cerebrovascular events. Secondary end points were death and major bleeding. RESULTS During a median follow-up time of 4.3 (interquartile range 3.7-4.8) years, annual rates of death, ischemic cerebrovascular events, and major bleeding were 1.48%, 2.96%, and 3.45%, respectively. Patients with CLT in the fourth quartile (> 115 min) had 8-fold higher stroke or transient ischemic attack (TIA) rates compared with the other patients (8.67% vs 1.1%; P < 0.0001). CLT correlated with PAI-1 and vWF (r = 0.59; P < 0.0001 for both). In the multivariate Cox regression analysis adjusted for potential confounders, the independent predictors of stroke or TIA were CLT > 115 minutes (hazard ratio [HR] 7.67, 95% confidence interval [CI] 2.78-21.17; P < 0.0001), PAI-1 (HR 1.16, 95% 1.05-1.28; P = 0.003), and CHA2DS2-VASc score ≥3 (HR 5.18, 95% 1.76-15.29; P = 0.003). CLT was not associated with death or major and minor bleeding events. CONCLUSIONS Impaired fibrinolysis may predict thromboembolic events in AF patients receiving VKA.
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Affiliation(s)
- Leszek Drabik
- John Paul II Hospital, Krakow, Poland; Department of Pharmacology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Anetta Undas
- John Paul II Hospital, Krakow, Poland; Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.
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86
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Spinthakis N, Gue Y, Farag M, Ren G, Srinivasan M, Baydoun A, Gorog DA. Impaired endogenous fibrinolysis at high shear using a point-of-care test in STEMI is associated with alterations in clot architecture. J Thromb Thrombolysis 2019; 47:392-395. [PMID: 30739303 PMCID: PMC6439169 DOI: 10.1007/s11239-018-01799-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Impaired endogenous fibrinolysis is an adverse prognostic biomarker in acute coronary syndrome (ACS). Abnormally dense in vitro fibrin thrombi have been demonstrated in ACS patients and related to hypofibrinolysis using cumbersome, laboratory-based methods. We aimed to assess endogenous fibrinolysis using a point-of-care technique and relate this to clot architecture. From patients with ST-segment elevation myocardial infarction (STEMI), venous blood was drawn immediately on arrival to assess thrombotic status. Blood was assessed using the point-of-care Global Thrombosis Test which measures occlusive thrombus formation under high shear and subsequently endogenous fibrinolysis (lysis time, LT). Two samples per patient were run in parallel. In one channel, the measurement was allowed to proceed as normal. In the other, after occlusion, thrombus was extracted, washed, fixed in glutaraldehyde, dried, sputter-coated, and assessed using scanning electron microscope. Endogenous fibrinolysis was strongly associated fibrin fibre thickness (p = 0.0001). As LT increased (less efficient fibrinolysis), the fibrin network of the thrombus was significantly more compact and dense, with thinner fibrin fibres and smaller gaps. Fibrin fibre thickness correlated inversely with LT (r = − 0.89, p = 0.001). Adverse clot architecture in vitro is directly related to impaired endogenous fibrinolysis using a relatively new point-of-care technique in patients with STEMI. This may transform the relevance of fibrin clot architecture from an off-line laboratory association to being directly relevant to endogenous fibrinolysis at the patient bedside, which could be used as a near-patient test to guide prognosis and assess the effect of treatment.
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Affiliation(s)
- Nikolaos Spinthakis
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK.,Department of Cardiology, East and North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Ying Gue
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK.,Department of Cardiology, East and North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Mohamed Farag
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK.,Department of Cardiology, East and North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Guogang Ren
- School of Engineering and Technology, University of Hertfordshire, Hertfordshire, UK
| | | | - Anwar Baydoun
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK
| | - Diana A Gorog
- Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK. .,Department of Cardiology, East and North Hertfordshire NHS Trust, Hertfordshire, UK. .,National Heart & Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LR, UK.
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87
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Thålin C, Hisada Y, Lundström S, Mackman N, Wallén H. Neutrophil Extracellular Traps: Villains and Targets in Arterial, Venous, and Cancer-Associated Thrombosis. Arterioscler Thromb Vasc Biol 2019; 39:1724-1738. [PMID: 31315434 DOI: 10.1161/atvbaha.119.312463] [Citation(s) in RCA: 251] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recent studies have demonstrated a role of neutrophils in both venous and arterial thrombosis. A key prothrombotic feature of neutrophils is their ability to release web-like structures composed of DNA filaments coated with histones and granule proteins referred to as neutrophil extracellular traps (NETs). NETs were discovered over a decade ago as part of our first line of host defense against invading microorganisms. Although NETs have a protective role against pathogens, recent data suggest that an uncontrolled and excessive NET formation within the vasculature may contribute to pathological thrombotic disorders. In vitro studies suggest that NETs promote vessel occlusion by providing a scaffold for platelets, red blood cells, extracellular vesicles, and procoagulant molecules, such as von Willebrand factor and tissue factor. In addition, NET components enhance coagulation by both activating the intrinsic pathway and degrading an inhibitor of the extrinsic pathway (tissue factor pathway inhibitor). NET formation has, therefore, been proposed to contribute to thrombus formation and propagation in arterial, venous, and cancer-associated thrombosis. This review will describe animal and human studies suggesting a role of NETs in the pathogenesis of various thrombotic disorders. Targeting NETs may be a novel approach to reduce thrombosis without affecting hemostasis.
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Affiliation(s)
- Charlotte Thålin
- From the Division of Internal Medicine, Department of Clinical Sciences, Danderyd Hospital (C.T.), Karolinska Institutet, Stockholm, Sweden
| | - Yohei Hisada
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill (Y.H., N.M.)
| | - Staffan Lundström
- Department of Oncology-Pathology (S.L.), Karolinska Institutet, Stockholm, Sweden.,Palliative Care Services and R&D-Unit, Stockholms Sjukhem Foundation, Sweden (S.L.)
| | - Nigel Mackman
- Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill (Y.H., N.M.)
| | - Håkan Wallén
- Division of Cardiovascular Medicine (H.W.), Karolinska Institutet, Stockholm, Sweden
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88
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The Influence of Inflammation on Fibrinogen Turnover and Redistribution of the Hemostatic Balance to a Prothrombotic State in High On-Treatment Platelet Reactivity-Dual Poor Responder (HTPR-DPR) Patients. Mediators Inflamm 2019; 2019:3767128. [PMID: 31396017 PMCID: PMC6664506 DOI: 10.1155/2019/3767128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/11/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022] Open
Abstract
Knowledge about the influence of inflammation on platelet function and relocation of hemostatic balance to hypercoagulable state is still unclear. We compared two groups of patients who suffer from acute vs. chronic inflammatory process and additionally present high on-treatment platelet reactivity-dual platelet resistance. We did not found any differences in platelet aggregation between both investigated groups, but patients who suffer from chronic inflammation presented stronger relocation of the hemostatic balance to the hypercoagulability. A high concentration of prothrombin fragment F1+2 together with higher activity of von Willebrand factor in critical limb ischemia shows more exaggerated fibrinogen turnover although the blood concentration of this factor was in normal range. We concluded that high on-treatment platelet reactivity-dual platelet resistance and intensified inflammation are linked with elevated platelet and fibrinogen turnover to counteract proper hemostatic balance in favor of a prothrombotic state.
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89
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Matusik PT, Małecka B, Lelakowski J, Undas A. Association of NT-proBNP and GDF-15 with markers of a prothrombotic state in patients with atrial fibrillation off anticoagulation. Clin Res Cardiol 2019; 109:426-434. [PMID: 31280356 PMCID: PMC7098929 DOI: 10.1007/s00392-019-01522-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 06/26/2019] [Indexed: 12/23/2022]
Abstract
Abstract We investigated whether growth differentiation factor-15 (GDF-15), also known as macrophage inhibitory cytokine-1 (MIC-1), levels are associated with a prothrombotic state in atrial fibrillation (AF) as compared to N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin I (cTnI-hs). In 103 patients with AF assessed off anticoagulation (age: 71.0 [65.0–76.0] years; CHA2DS2-VASc score: 4.6 ± 1.7), we measured endogenous thrombin potential (ETP), plasma fibrin clot permeability (Ks, a measure of clot density) and clot lysis time (CLT) and other hemostatic parameters, along with GDF-15, NT-proBNP, and cTnI-hs. GDF-15 positively correlated with ETP and CLT (r = 0.25, P = 0.01 and R = 0.56, P < 0.0001, respectively) but not with Ks, von Willebrand factor, thrombin-activatable fibrinolysis inhibitor, plasminogen, antiplasmin or tissue-type plasminogen activator antigen. NT-proBNP showed a stronger association with ETP (r = 0.60, P < 0.0001) and a similar correlation with CLT (R = 0.53, P < 0.0001), while cTnI-hs correlated solely with CLT (R = 0.25, P = 0.01). After adjustment for clinical and laboratory parameters, GDF-15 was a better independent predictor of CLT (unstandardized coefficient B 0.009; 95% confidence interval [CI] 0.006–0.012) than NT-proBNP (B 0.007; 95% CI 0.004–0.010, R (2) = 0.51; P < 0.0001); while among the three biomarkers, only NT-proBNP was an independent predictor of ETP. Elevated GDF-15 and NT-proBNP independently predict impaired fibrin clot lysability, while NT-proBNP is a key predictor of heightened thrombin formation in AF. Our findings suggest that a predictive value of NT-proBNP and GDF-15 in AF could be in part attributed to their association with prothrombotic blood alterations. Graphic Abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s00392-019-01522-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Paweł T Matusik
- Department of Electrocardiology, The John Paul II Hospital, Kraków, Poland.,Institute of Cardiology, Jagiellonian University Medical College, 80 Prądnicka Street, 31-202, Kraków, Poland
| | - Barbara Małecka
- Department of Electrocardiology, The John Paul II Hospital, Kraków, Poland.,Institute of Cardiology, Jagiellonian University Medical College, 80 Prądnicka Street, 31-202, Kraków, Poland
| | - Jacek Lelakowski
- Department of Electrocardiology, The John Paul II Hospital, Kraków, Poland.,Institute of Cardiology, Jagiellonian University Medical College, 80 Prądnicka Street, 31-202, Kraków, Poland
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, 80 Prądnicka Street, 31-202, Kraków, Poland. .,Krakow Center for Medical Research and Technology, The John Paul II Hospital, Kraków, Poland.
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90
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Alkhalil M. Mechanistic Insights to Target Atherosclerosis Residual Risk. Curr Probl Cardiol 2019; 46:100432. [PMID: 31285037 DOI: 10.1016/j.cpcardiol.2019.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 06/05/2019] [Indexed: 12/11/2022]
Abstract
Current pharmacological and mechanical therapies have reduced future cardiovascular risk. Nonetheless, a significant proportion of patients remained at high risk of recurrent events despite achieving guideline-directed therapeutic targets. This residual risk poses challenges despite tackling 'traditional' risk factors. Targeting the residual risk has been the focus of numerous pharmacotherapies which were associated with variable success. Incomplete understanding of the mechanistic nature combined with the lack of tools to precisely quantify the residual risk contributed to the relatively high residual risk after 'optimal' medical therapy. The development of atherosclerotic plaque is derived from lipid retention within arterial intima that triggers an inflammatory cascade accelerating atherosclerosis progression and rendering plaque more prone to rupture. The exposed subendothelial space with activated platelets causes arterial occlusion leading to potential fatality. Therefore, a distinctive approach to characterize these features may offer the opportunity to tailor novel antiatherosclerotic to reduce the residual risk. The traditional approach of measuring risk factors is beneficial at population-level but maybe less informative upon quantifying risk at an individual-basis. This review will discuss lipid accumulation, thrombosis, and inflammation as therapeutic targets of atherosclerosis. Additionally, we will summarize previous challenges of antiatherosclerosis therapies and the future role to tackle the residual risk.
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91
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Ten Cate H, Kontny F, Nilsen DW. Editorial: Novel and potential markers for prediction of outcome in patients with acute and chronic coronary heart disease. Front Cardiovasc Med 2019; 6:66. [PMID: 31192230 PMCID: PMC6540587 DOI: 10.3389/fcvm.2019.00066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/03/2019] [Indexed: 11/21/2022] Open
Affiliation(s)
- Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Frederic Kontny
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway.,Drammen Heart Center, Drammen, Norway
| | - Dennis W Nilsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway.,Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
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92
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Sumaya W, Storey RF. Does Risk of Premature Discontinuation of Dual-Antiplatelet Therapy Following PCI Attenuate With Increasing Age? JACC Cardiovasc Interv 2019; 12:993-994. [PMID: 31122355 DOI: 10.1016/j.jcin.2019.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/26/2019] [Indexed: 11/27/2022]
Affiliation(s)
- Wael Sumaya
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.
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93
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Lüscher TF. Frontiers in today's chronic coronary syndromes: detecting obstructive disease, role of beta-blockers and of anticoagulants. Eur Heart J 2019; 40:1387-1390. [PMID: 33215662 DOI: 10.1093/eurheartj/ehz293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Professor of Cardiology, Imperial College and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals London, UK.,Professor and Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland.,Editor-in-Chief, EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, 8032 Zurich, Switzerland
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94
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Shavadia JS, Sharma A, Gu X, Neaton J, DeLeve L, Holmes D, Home P, Eckel RH, Watkins PB, Granger CB. Determination of fasiglifam-induced liver toxicity: Insights from the data monitoring committee of the fasiglifam clinical trials program. Clin Trials 2019; 16:253-262. [DOI: 10.1177/1740774519836766] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Different approaches to safety event collection influence the determination of liver toxicity within drug development programs. Herein, a description of how fasiglifam-induced liver injury was detected is provided. Methods This eight-trial drug development program was intended to evaluate fasiglifam (25 mg, 50 mg) against placebo or active comparators (glimepiride, sitagliptin) in approximately 11,000 suboptimally controlled patients with type 2 diabetes (terminated Dec 2013 due to liver toxicity). Liver safety had been pre-identified as a concern, and within the phase 3 trials, was measured through (1) adverse event reporting, (2) central predefined liver monitoring schedule with various thresholds for potential drug-induced liver injury, and (3) blinded adjudication of serious liver toxicity by a panel of experts in drug-induced liver injury. A single data monitoring committee provided safety oversight across all trials within the program. Findings Prior to program termination, 7595 of 7602 (99.9%) randomized participants across the eight trials received at least one dose of the study drug (fasiglifam, placebo, or active control). No concerning trends were noted in adverse or serious adverse event frequency, suspected unexpected serious adverse reaction, alanine or aspartate transaminase elevations, or hepatobiliary or gastrointestinal adverse events as reported by local site investigators. However, the predefined central liver safety measurements revealed a greater frequency of possible Hy’s Law cases (5 vs 2) and a 3- to 7-fold greater relative risk in alanine or aspartate transaminase elevation (with respect to upper limit of normal) within fasiglifam recipients compared with placebo/active control: alanine or aspartate transaminase > 3×: relative risk 3.34 (95% confidence interval 2.29–4.90), alanine or aspartate transaminase > 5×: relative risk 6.60 (95% confidence interval 3.03–14.38), alanine or aspartate transaminase > 8×: relative risk 6.14 (95% confidence interval 2.18–17.27), and alanine or aspartate transaminase > 10×: relative risk 6.74 (95% confidence interval 2.05, 22.14). All elevations resolved on study drug discontinuation. Drug-induced liver injury was adjudicated as highly likely or probably related in 0.64% of fasiglifam-treated versus 0.06% placebo or active control-treated patients. Conclusion In spite of clear liver toxicity detected with a systematic surveillance program, liver safety signals were not identified from investigator adverse event reporting alone. By integrating key safety monitoring processes within the randomized design of adequately sized clinical trials, the rare but serious liver toxicity signal became clear, leading to timely program termination.
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Affiliation(s)
- Jay S Shavadia
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Department of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | | | | | - James Neaton
- School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Laurie DeLeve
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Phillip Home
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Robert H Eckel
- Division of Endocrinology, Metabolism & Diabetes, University of Colorado, Boulder, CO, USA
| | - Paul B Watkins
- Institute for Drug Safety Sciences, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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95
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Pieters M, Wolberg AS. Fibrinogen and fibrin: An illustrated review. Res Pract Thromb Haemost 2019; 3:161-172. [PMID: 31011700 PMCID: PMC6462751 DOI: 10.1002/rth2.12191] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 01/30/2019] [Indexed: 12/19/2022] Open
Abstract
Since its discovery over 350 years ago, studies of fibrinogen have revealed remarkable characteristics. Its complex structure as a large (340 kDa) hexameric homodimer supports complex roles in hemostasis and homeostasis. Fibrinogen synthesis is regulated at the transcriptional and translational levels, undergoing both constitutive (basal) secretion from liver, and inducible upregulation in response to inflammatory events. In addition, alternative splicing yields fibrinogen variants with unique properties and contributions to coagulation biochemistry. During coagulation, fibrinogen conversion to fibrin occurs via thrombin‐mediated proteolytic cleavage that produces intermediate protofibrils and then mature fibers that provide remarkable biochemical and mechanical stability to clots. Fibrin formation, structure, and stability are regulated by various genetic, biochemical, and environmental factors, allowing for dynamic kinetics of fibrin formation and structure. Interactions between fibrinogen and/or fibrin and plasma proteins and receptors on platelets, leukocytes, endothelial cells, and other cells enable complex functions in hemostasis, thrombosis, pregnancy, inflammation, infection, cancer, and other pathologies. Disorders in fibrinogen concentration and/or function increase risk of bleeding, thrombosis, and infection. This illustrated review covers fundamental aspects of fibrinogen and fibrin biology, biochemistry, biophysics, epidemiology, and clinical applications. Continued efforts to enhance our understanding of fibrinogen and fibrin in these processes are likely to advance treatment and prevention of many human diseases.
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Affiliation(s)
- Marlien Pieters
- Center of Excellence for Nutrition North-West University Potchefstroom South Africa
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine University of North Carolina Chapel Hill North Carolina
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96
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Parker WA, Orme RC, Hanson J, Stokes HM, Bridge CM, Shaw PA, Sumaya W, Thorneycroft K, Petrucci G, Porro B, Judge HM, Ajjan RA, Rocca B, Storey RF. Very-low-dose twice-daily aspirin maintains platelet inhibition and improves haemostasis during dual-antiplatelet therapy for acute coronary syndrome. Platelets 2019; 30:148-157. [PMID: 30759035 PMCID: PMC6425913 DOI: 10.1080/09537104.2019.1572880] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 01/04/2019] [Accepted: 01/11/2019] [Indexed: 01/11/2023]
Abstract
Higher aspirin doses may be inferior in ticagrelor-treated acute coronary syndrome (ACS) patients and reducing bleeding risk whilst maintaining antithrombotic benefits could improve outcomes. We characterized the pharmacodynamics of a novel dual-antiplatelet-therapy regimen consisting of very-low-dose twice-daily (BD) aspirin with standard-dose ticagrelor. A total of 20 ticagrelor-treated ACS patients entered a randomized crossover to take aspirin 20 mg BD (12-hourly) during one 14-day period and 75 mg once-daily (OD) in the other. After 14 days of treatment, serum thromboxane (TX)B2 and light-transmittance aggregometry were assessed pre- and 2 h post-morning-dose, bleeding time was measured post-dose, and TXA2 and prostacyclin stable metabolites were measured in urine collected 2 h post-morning-dose. Data are expressed as mean ± SD. After 14 days treatment, serum TXB2 levels were significantly greater 2 h post-dosing with aspirin 20 mg BD vs. 75 mg OD (3.0 ± 3.6 ng/mL vs. 0.8 ± 1.9 ng/mL; p = 0.018) whereas pre-dosing levels were not significantly different (3.5 ± 4.1 ng/mL vs. 2.5 ± 3.1 ng/mL, p = 0.23). 1-mmol/L arachidonic acid-induced platelet aggregation was similarly inhibited by both regimens pre-dose (8.5 ± 14.3% vs. 5.1 ± 3.6%, p = 0.24) and post-dose (8.7 ± 14.2% vs. 6.6 ± 5.3%; p = 0.41). Post-dose bleeding time was shorter with 20 mg BD (680 ± 306 s vs. 834 ± 386 s, p = 0.02). Urinary prostacyclin and TX metabolite excretion were not significantly different. In conclusion, compared to aspirin 75 mg OD, aspirin 20 mg BD provided consistent inhibition of platelet TXA2 release and aggregation, and improved post-dose hemostasis, in ticagrelor-treated ACS patients. Further studies are warranted to assess whether this regimen improves the balance of clinical efficacy and safety.
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Affiliation(s)
- William A.E. Parker
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rachel C. Orme
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jessica Hanson
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Hannah M. Stokes
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Claire M. Bridge
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Patricia A. Shaw
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Wael Sumaya
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Kirstie Thorneycroft
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Giovanna Petrucci
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Benedetta Porro
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico Cardiologico Monzino, Milan, Italy
| | - Heather M. Judge
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Ramzi A. Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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97
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Abstract
Circulating levels of Brain Derived Neurotrophic Factor (BDNF) are lower in coronary heart disease (CHD) than in healthy subjects and are associated with coronary events and mortality. However, the mechanism(s) underling this association is not fully understood. We hypothesize that BDNF may influence fibrin fiber structure and clot stability, favoring clot lysis and thrombus resolution. We showed that recombinant BDNF (rh-BDNF) influenced with clot formation in a concentration-dependent manner in both purified fibrinogen and plasma from healthy subjects. In particular, rh-BDNF reduced the density of fibrin fibers, the maximum clot firmness (MCF) and the maximum clot turbidity, and affected the lysis of clot. In addition, both thrombin and reptilase clotting time were prolonged by rh-BDNF, despite the amount of thrombin formed was greater. Intriguingly, CHD patients had lower levels of BDNF, greater fibrin fibers density, higher MCF than control subjects, and a negative correlation between BDNF and MCF was found. Of note, rh-BDNF markedly modified fibrin clot profile restoring physiological clot morphology in CHD plasma. In conclusion, we provide evidence that low levels of BDNF correlate with the formation of bigger thrombi (in vitro) and that this effect is mediated, at least partially, by the alteration of fibrin fibers formation.
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98
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Lüscher TF. Myocardial injury and myocardial infarction: the various ways of losing myocytes and their prognostic impact. Eur Heart J 2019; 40:223-225. [PMID: 33215663 DOI: 10.1093/eurheartj/ehy909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Thomas F Lüscher
- Professor of Cardiology, Imperial College and Director of Research, Education & Development, Royal Brompton and Harefield Hospitals London, UK.,Professor and Chairman, Center for Molecular Cardiology, University of Zurich, Switzerland.,Editor-in-Chief, EHJ Editorial Office, Zurich Heart House, Hottingerstreet 14, Zurich, Switzerland
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99
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Affimer proteins as a tool to modulate fibrinolysis, stabilize the blood clot, and reduce bleeding complications. Blood 2018; 133:1233-1244. [PMID: 30545831 DOI: 10.1182/blood-2018-06-856195] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 12/02/2018] [Indexed: 12/17/2022] Open
Abstract
Bleeding complications secondary to surgery, trauma, or coagulation disorders are important causes of morbidity and mortality. Although fibrin sealants are considered to minimize blood loss, this is not widely adopted because of its high cost and/or risk for infection. We present a novel methodology employing nonantibody fibrinogen-binding proteins, termed Affimers, to stabilize fibrin networks with the potential to control excessive bleeding. Two fibrinogen-specific Affimer proteins, F5 and G2, were identified and characterized for their effects on clot structure/fibrinolysis, using turbidimetric and permeation analyses and confocal and electron microscopy. Binding studies and molecular modeling identified interaction sites, whereas plasmin generation assays determined effects on plasminogen activation. In human plasma, F5 and G2 prolonged clot lysis time from 9.8 ± 1.1 minutes in the absence of Affimers to 172.6 ± 7.4 and more than 180 minutes (P < .0001), respectively, and from 7.6 ± 0.2 to 28.7 ± 5.8 (P < .05) and 149.3 ± 9.7 (P < .0001) minutes in clots made from purified fibrinogen. Prolongation in fibrinolysis was consistent across plasma samples from healthy control patients and individuals at high bleeding risk. F5 and G2 had a differential effect on clot structure and G2 profoundly altered fibrin fiber arrangement, whereas F5 maintained physiological clot structure. Affimer F5 reduced fibrin-dependent plasmin generation and was predicted to bind fibrinogen D fragment close to tissue plasminogen activator (tPA; residues γ312-324) and plasminogen (α148-160) binding sites, thus interfering with tPA-plasminogen interaction and representing 1 potential mechanism for modulation of fibrinolysis. Our Affimer proteins provide a novel methodology for stabilizing fibrin networks with potential future clinical implications to reduce bleeding risk.
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100
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Ajjan RA. Primary vascular prevention: The end of the road for aspirin? Diab Vasc Dis Res 2018; 15:475-476. [PMID: 30415566 DOI: 10.1177/1479164118807988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- R A Ajjan
- Leeds Institute of Cardiovascular and Metabolic Medicine, LIGHT Laboratories, University of Leeds, Leeds, UK
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