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Dai Y, Kretz CA, Kim PY, Gross PL. A specific fluorescence resonance energy quenching-based biosensor for measuring thrombin activity in whole blood. J Thromb Haemost 2024; 22:1627-1639. [PMID: 38382740 DOI: 10.1016/j.jtha.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/06/2024] [Accepted: 02/09/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND At sites of vessel injury, thrombin acts as the central mediator of coagulation by catalyzing fibrin clot formation and platelet activation. Thrombin generation is most frequently measured in plasma samples using small-molecule substrates; however, these have low specificity for thrombin and limited utility in whole blood. Plasma assays are limited because they ignore the hemostatic contributions of blood cells and require anticoagulation and the addition of supraphysiological concentrations of calcium. OBJECTIVES To overcome these limitations, we designed and characterized a fluorescence resonance energy quenching-based thrombin sensor (FTS) protein. METHODS The fluorescence resonance energy quenching pair of mAmetrine and tTomato, separated by a thrombin recognition sequence, was developed. The protein was expressed using Escherichia coli, and purity was assessed using sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The cleavage of FTS was monitored by fluorescence using excitation at 406 nm and emission at 526 nm and 581 nm. RESULTS Compared with small-molecule substrates, the FTS demonstrated high specificity for thrombin; it is not cleaved by thrombin or inhibited by α2-macroglobulin and interacts with thrombin's anion-binding exosite I. The FTS can effectively measure thrombin generation in plasma and in finger-prick whole blood, which allows it to be developed into a point-of-care test of thrombin generation. The FTS does not inhibit standard thrombin-generation assays. Lastly, FTS-based thrombin generation in nonanticoagulated finger-prick blood was delayed but enhanced compared with that in citrated plasma. CONCLUSION The FTS will broaden our understanding of thrombin generation in ways that are not attainable with current methods.
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Affiliation(s)
- Ying Dai
- Hamilton Health Sciences and Departments of Medicine and Medical Sciences, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Colin A Kretz
- Hamilton Health Sciences and Departments of Medicine and Medical Sciences, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Paul Y Kim
- Hamilton Health Sciences and Departments of Medicine and Medical Sciences, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Peter L Gross
- Hamilton Health Sciences and Departments of Medicine and Medical Sciences, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.
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Makedonov I, Kahn S, Abdulrehman J, Schulman S, Delluc A, Gross PL, Galanaud JP. TILE pilot trial study protocol: Tinzaparin Lead-in to Prevent the Post-Thrombotic syndrome study protocol. BMJ Open 2023; 13:e064715. [PMID: 37907305 PMCID: PMC10618981 DOI: 10.1136/bmjopen-2022-064715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/11/2023] [Indexed: 11/02/2023] Open
Abstract
INTRODUCTION The post-thrombotic syndrome (PTS) is a form of chronic venous insufficiency due to a prior ipsilateral deep venous thrombosis (DVT). This is a frequent complication that develops in 20%-50% of patients after a proximal DVT and is associated with significant healthcare, economic and societal consequences. In the absence of effective and well-tolerated treatment options for established PTS, effective preventative measures are needed. Anticoagulation itself reduces the risk of PTS, and low-molecular-weight heparin may reduce this further through anti-inflammatory properties targeting the initial acute inflammatory phase of DVT. METHODS AND ANALYSIS The Tinzaparin Lead-In to Prevent the Post-Thrombotic syndrome pilot trial is an investigator-initiated, multicentre, open-label assessor-blinded trial that will randomise patients with first acute symptomatic common femoral or iliac DVT to receive either a 3-week lead-in course of tinzaparin, followed by rivaroxaban (experimental arm) or rivaroxaban alone (control arm). Its primary objectives are to assess: (1) proportion of PTS at 6 months using the Villalta scale and (2) study feasibility, which consists of (a) the proportion of screened patients eligible for the study, (2) the proportion of eligible patients recruited and (c) the proportion of recruited patients adherent to treatment (defined as at least 80% of drug taken). This study will determine the feasibility of a subsequent larger definitive trial. Secondary outcomes include change of quality of life scores, PTS severity, global improvement, patient satisfaction, bleeding, recurrent venous thromboembolism, leg pain, death and lost to follow-up. Target recruitment will be a total of 60 participants, recruited at 5-6 centres. ETHICS AND DISSEMINATION Primary ethics approval was received from the Sunnybrook Health Sciences Center Research Ethics Board (approval ID 3315). Results of the study will be disseminated via peer-reviewed presentation at scientific conferences and open access publication. TRIAL REGISTRATION NUMBER NCT04794569.
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Affiliation(s)
- Ilia Makedonov
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Susan Kahn
- Department of Medicine, Jewish General Hospital, Montreal, Quebec, Canada
| | - Jameel Abdulrehman
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aurelien Delluc
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter L Gross
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Rodenas MC, Peñas-Martínez J, Pardo-Sánchez I, Zaragoza-Huesca D, Ortega-Sabater C, Peña-García J, Espín S, Ricote G, Montenegro S, Ayala-De La Peña F, Luengo-Gil G, Nieto A, García-Molina F, Vicente V, Bernardi F, Lozano ML, Mulero V, Pérez-Sánchez H, Carmona-Bayonas A, Martínez-Martínez I. Venetoclax is a potent hepsin inhibitor that reduces the metastatic and prothrombotic phenotypes of hepsin-expressing colorectal cancer cells. Front Mol Biosci 2023; 10:1182925. [PMID: 37275957 PMCID: PMC10235687 DOI: 10.3389/fmolb.2023.1182925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/08/2023] [Indexed: 06/07/2023] Open
Abstract
Introduction: Hepsin is a type II transmembrane serine protease and its expression has been linked to greater tumorigenicity and worse prognosis in different tumors. Recently, our group demonstrated that high hepsin levels from primary tumor were associated with a higher risk of metastasis and thrombosis in localized colorectal cancer patients. This study aims to explore the molecular role of hepsin in colorectal cancer. Methods: Hepsin levels in plasma from resected and metastatic colorectal cancer patients were analyzed by ELISA. The effect of hepsin levels on cell migration, invasion, and proliferation, as well as on the activation of crucial cancer signaling pathways, was performed in vitro using colorectal cancer cells. A thrombin generation assay determined the procoagulant function of hepsin from these cells. A virtual screening of a database containing more than 2000 FDA-approved compounds was performed to screen hepsin inhibitors, and selected compounds were tested in vitro for their ability to suppress hepsin effects in colorectal cancer cells. Xenotransplantation assays were done in zebrafish larvae to study the impact of venetoclax on invasion promoted by hepsin. Results: Our results showed higher plasma hepsin levels in metastatic patients, among which, hepsin was higher in those suffering thrombosis. Hepsin overexpression increased colorectal cancer cell invasion, Erk1/2 and STAT3 phosphorylation, and thrombin generation in plasma. In addition, we identified venetoclax as a potent hepsin inhibitor that reduced the metastatic and prothrombotic phenotypes of hepsin-expressing colorectal cancer cells. Interestingly, pretreatment with Venetoclax of cells overexpressing hepsin reduced their invasiveness in vivo. Discussion: Our results demonstrate that hepsin overexpression correlates with a more aggressive and prothrombotic tumor phenotype. Likewise, they demonstrate the antitumor role of venetoclax as a hepsin inhibitor, laying the groundwork for molecular-targeted therapy for colorectal cancer.
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Affiliation(s)
- Maria Carmen Rodenas
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Julia Peñas-Martínez
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Irene Pardo-Sánchez
- Department of Cell Biology, Faculty of Biology, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - David Zaragoza-Huesca
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Carmen Ortega-Sabater
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Jorge Peña-García
- Computer Engineering Department, Structural Bioinformatics and High Performance Computing Research Group (BIO-HPC), UCAM Universidad Católica de Murcia, Guadalupe, Spain
| | - Salvador Espín
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Guillermo Ricote
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Sofía Montenegro
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Francisco Ayala-De La Peña
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Ginés Luengo-Gil
- Clinical Analysis and Pathology Department, Group of Molecular Pathology and Pharmacogenetics, IMIB-Pascual Parrilla, Hospital Universitario Santa Lucía, Cartagena, Spain
| | - Andrés Nieto
- Department of Pathology, Hospital Universitario Morales Meseguer, Murcia, Spain
| | | | - Vicente Vicente
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Francesco Bernardi
- Department of Life Sciences and Biotechnology, University of Ferrara, Ferrara, Italy
| | - María Luisa Lozano
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Victoriano Mulero
- Department of Cell Biology, Faculty of Biology, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Horacio Pérez-Sánchez
- Computer Engineering Department, Structural Bioinformatics and High Performance Computing Research Group (BIO-HPC), UCAM Universidad Católica de Murcia, Guadalupe, Spain
| | - Alberto Carmona-Bayonas
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
| | - Irene Martínez-Martínez
- Department of Hematology and Medical Oncology, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Centro de Investigación Biomédica en Red de Enfermedades Raras, IMIB-Pascual Parrilla, Universidad de Murcia, Murcia, Spain
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Shaw JR, Castellucci LA, Siegal D, Carrier M. DOAC-associated bleeding, hemostatic strategies, and thrombin generation assays - a review of the literature. J Thromb Haemost 2023; 21:433-452. [PMID: 36696204 DOI: 10.1016/j.jtha.2022.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/24/2022] [Accepted: 11/15/2022] [Indexed: 01/26/2023]
Abstract
Direct oral anticoagulants (DOACs) account for most oral anticoagulant use. DOAC-associated bleeding events are commonly encountered in clinical practice and are associated with substantial morbidity and mortality. Both specific reversal agents and nonspecific hemostatic therapies, such as prothrombin complex concentrates, are used in the management of DOAC-associated bleeding. Measuring hemostatic efficacy and demonstrating a clinical impact from these therapies among studies of bleeding patients is challenging. Thrombin generation assays provide information on the total hemostatic potential of plasma, and have emerged as a promising modality to both measure the impact of DOACs on coagulation and to evaluate the effects of hemostatic therapies among patients with DOAC-associated bleeding. The mechanisms by which nonspecific hemostatic agents impact coagulation and thrombin generation in the context of DOAC therapy are unclear. As a result, we undertook a review of the literature using a systematic search strategy with the goal of summarizing the effects of DOACs on thrombin generation and the effects of both specific reversal agents and nonspecific hemostatic therapies on DOAC-altered thrombin generation parameters. We sought to identify clinical studies focusing on whether altered thrombin generation is associated with clinical bleeding and whether correction of altered thrombin generation parameters predicts improvements in clinical hemostasis. Lastly, we sought to outline future directions for the application of thrombin generation assays toward anticoagulation therapies and the question of anticoagulation reversal.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Lana A Castellucci
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Deborah Siegal
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
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Spiegelburg DT, Mannes M, Schultze A, Scheibenberger F, Müller F, Klitzing A, Messerer DAC, Nilsson Ekdahl K, Nilsson B, Huber-Lang M, Braun CK. Impact of surface coating and systemic anticoagulants on hemostasis and inflammation in a human whole blood model. PLoS One 2023; 18:e0280069. [PMID: 36634087 PMCID: PMC9836312 DOI: 10.1371/journal.pone.0280069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Surface compatibility with blood is critical both for scientific investigations on hemostasis and clinical applications. Regarding in vitro and ex vivo investigations, minimal alteration in physiological hemostasis is of particular importance to draw reliable conclusions on the human coagulation system. At the same time, artificial coagulation activation must be avoided, which is relevant for the patient, for example to prevent stent graft occlusion. The aim was to evaluate the advantages and disadvantages of antithrombotic and antifouling surface coatings in the context of their suitability for ex vivo incubation and the study of coagulation properties. METHODS We investigated the impact of different protocols for surface coating of synthetic material and different anticoagulants on hemostasis and platelet activation in ex vivo human whole blood. Blood samples from healthy donors were incubated in coated microtubes on a rotating wheel at 37°C. Two protocols for surface coating were analyzed for hemostatic parameters and metabolic status, a heparin-based coating (CHC, Corline Heparin Conjugate) without further anticoagulation and a passivating coating (MPC, 2-methacryloyloxethyl phosphorylcholine) with added anticoagulants (enoxaparin, ENOX; or fondaparinux, FPX). Employing the MPC-based coating, the anticoagulants enoxaparin and fondaparinux were compared regarding their differential effects on plasmatic coagulation by thrombelastometry and on platelet activation by flowcytometry and platelet function assays. RESULTS Using the CHC coating, significant coagulation cascade activation was observed, whereas parameters remained mostly unchanged with MPC-based protocols. Extended incubation caused significantly elevated levels of the soluble membrane attack complex. Neither ENOX nor FPX caused a relevant impairment of platelet function or activation capacity and thrombelastometric parameters remained unchanged with both protocols. For translational purposes, we additionally modeled endotoxemia with the MPC-based protocols by incubating with lipopolysaccharide plus/minus thrombin. While coagulation parameters remained unchanged, elevated Interleukin 8 and Matrix Metalloproteinase 9 demonstrated preserved immune cell responsiveness. CONCLUSIONS The MPC-based protocols demonstrated better hemocompatibility compared to CHC, and ENOX and FPX proved useful for additional anticoagulation. Furthermore, this simple-to-use whole blood model may be useful for experimental analyses of the early coagulatory and immunological response without decalcification.
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Affiliation(s)
- Doreen Tabea Spiegelburg
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Marco Mannes
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Anke Schultze
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Frieder Scheibenberger
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Frederik Müller
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Amadeo Klitzing
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - David Alexander Christian Messerer
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
- Department of Transfusion Medicine and Hemostaseology, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Kristina Nilsson Ekdahl
- Centre of Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
- Rudbeck Laboratory, Department of Immunology, Genetics and Pathology, Uppsala, Sweden
| | - Bo Nilsson
- Rudbeck Laboratory, Department of Immunology, Genetics and Pathology, Uppsala, Sweden
| | - Markus Huber-Lang
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Christian Karl Braun
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
- * E-mail:
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Makedonov I, Kahn SR, Abdulrehman J, Schulman S, Delluc A, Gross PL, Galanaud JP. Prevention of the post thrombotic syndrome with anticoagulation: a narrative review. Thromb Haemost 2021; 122:1255-1264. [PMID: 34852380 DOI: 10.1055/a-1711-1263] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The post thrombotic syndrome (PTS) is chronic venous insufficiency secondary to a prior deep vein thrombosis (DVT). It is the most common complication of VTE and, while not fatal, it can lead to chronic, unremitting symptoms as well as societal and economic consequences. The cornerstone of PTS treatment lies in its prevention after DVT. Specific PTS preventative measures include the use of elastic compression stockings (ECS) and pharmacomechanical catheter directed thrombolysis (PCDT). However, the efficacy of these treatments has been questioned by large RCTs. So far, anticoagulation, primarily prescribed to prevent DVT extension and recurrence, appears to be the only unquestionably effective treatment for the prevention of PTS. In this literature review we present pathophysiological, biological, radiological and clinical data supporting the efficacy of anticoagulants to prevent PTS and the possible differential efficacy among available classes of anticoagulants (vitamin K antagonists (VKA), low molecular weight heparins (LMWHs) and direct oral anticoagulants (DOACs)). Data suggest that LMWHs and DOACs are superior to VKAs, but no head-to-head comparison is available between DOACs and LMWHs. Owing to their potentially greater anti-inflammatory properties, LMWHs could be superior to DOACs. This finding may be of interest particularly in patients with extensive DVT at high risk of moderate to severe PTS, but needs to be confirmed by a dedicated RCT.
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Affiliation(s)
- Ilia Makedonov
- Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | | | | | | | - Peter L Gross
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Canada
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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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Poredos P, Antignani PL, Blinc A, Fras Z, Jezovnik MK, Fareed J, Mansilha A. Do we have a unified consensus on antithrombotic management of PAD? INT ANGIOL 2021; 40:229-239. [PMID: 33739074 DOI: 10.23736/s0392-9590.21.04597-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Peripheral artery disease (PAD) is one of the most frequent manifestations of atherosclerosis with high rates of morbidity and mortality. Platelets and coagulation are involved in the progression of atherosclerosis and thromboembolic complications. PAD patients have increased prothrombotic potential, which includes platelet hyperaggregability and increased pro-coagulant state. Therefore, antithrombotic treatment is of utmost importance for the prevention of cardiovascular events in this group of patients. Aspirin is the basic antiplatelet drug, but with limited efficacy in PAD. In contrast to coronary artery disease, its effect on the prevention of cardiovascular events in PAD has been limited proven. Particularly in asymptomatic PAD, there is no evidence for risk reduction with aspirin. Clopidogrel and ticagrelor are more effective than aspirin. Clopidogrel is thus an effective alternative to aspirin for prevention of cardiovascular events in symptomatic PAD. In patients who are non-responders to clopidogrel, ticagrelor is indicated. Dual antiplatelet treatment (DAPT) with aspirin and ticagrelor in patients with coronary artery disease and concomitant PAD significantly decreased the rate of major adverse cardiovascular events, including adverse limb events. However, in the CHARISMA Trial, aspirin and clopidogrel were not more effective than aspirin alone and increased bleeding complications. Therefore, DAPT seems effective only in PAD accompanied by coronary artery disease. Anticoagulant treatment for symptomatic PAD with vitamin K antagonists alone or in combination with aspirin is not more effective than single antiplatelet treatment but increases the rate of major bleeding. Low dose rivaroxaban combined with aspirin in PAD patients significantly reduces cardiovascular events, including limb-threatening ischemia and limb amputations. Anticoagulation and antiplatelet treatment after percutaneous or surgical revascularization of PAD improve the patency of treated vessels. Aspirin with or without dipyridamole improved patency of infra-inguinal by-pass grafts at one year. The combination of clopidogrel with aspirin was more effective than aspirin alone in the prevention of prosthetic graft occlusions in patients undergoing below-knee by-pass-grafting. Oral vitamin K antagonists were not more effective than aspirin in the prevention of infra-inguinal by-pass occlusion. The combination of low dose rivaroxaban and aspirin was effective in preventing major adverse cardiovascular events and adverse limb events after infrainguinal endovascular or surgical revascularization in patients with intermittent claudication. However, the data on antithrombotic treatment after revascularization for limb-threatening ischemia is scanty and inconclusive. In conclusion: Antithrombotic treatment of PAD is a cornerstone for the management of these patients. Antiplatelet drugs prevent the initiation and progression of atherosclerosis and are effective also in the prevention of thromboembolic events. Simultaneous use of antiplatelet and anticoagulation drugs is accompanied by an increased risk of bleeding. However, combined treatment with aspirin and low-dose rivaroxaban is more effective than single antithrombotic treatment and safer than full-dose combined treatment.
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Affiliation(s)
- Pavel Poredos
- Department of Vascular Disease, University Medical Center Ljubljana, Ljubljana, Slovenia
| | | | - Ales Blinc
- Department of Vascular Disease, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Zlatko Fras
- Department of Vascular Disease, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Health Science Center, University of Texas, Houston, TX, USA
| | - Jawed Fareed
- Loyola University Medical Center, Maywood, IL, USA
| | - Armando Mansilha
- Department of Angiology and Vascular Surgery, Hospital CUF Porto, Porto, Portugal
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9
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Gerotziafas GT, Catalano M, Colgan MP, Pecsvarady Z, Wautrecht JC, Fazeli B, Olinic DM, Farkas K, Elalamy I, Falanga A, Fareed J, Papageorgiou C, Arellano RS, Agathagelou P, Antic D, Auad L, Banfic L, Bartolomew JR, Benczur B, Bernardo MB, Boccardo F, Cifkova R, Cosmi B, De Marchi S, Dimakakos E, Dimopoulos MA, Dimitrov G, Durand-Zaleski I, Edmonds M, El Nazar EA, Erer D, Esponda OL, Gresele P, Gschwandtner M, Gu Y, Heinzmann M, Hamburg NM, Hamadé A, Jatoi NA, Karahan O, Karetova D, Karplus T, Klein-Weigel P, Kolossvary E, Kozak M, Lefkou E, Lessiani G, Liew A, Marcoccia A, Marshang P, Marakomichelakis G, Matuska J, Moraglia L, Pillon S, Poredos P, Prior M, Salvador DRK, Schlager O, Schernthaner G, Sieron A, Spaak J, Spyropoulos A, Sprynger M, Suput D, Stanek A, Stvrtinova V, Szuba A, Tafur A, Vandreden P, Vardas PE, Vasic D, Vikkula M, Wennberg P, Zhai Z. Guidance for the Management of Patients with Vascular Disease or Cardiovascular Risk Factors and COVID-19: Position Paper from VAS-European Independent Foundation in Angiology/Vascular Medicine. Thromb Haemost 2020; 120:1597-1628. [PMID: 32920811 PMCID: PMC7869052 DOI: 10.1055/s-0040-1715798] [Citation(s) in RCA: 105] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023]
Abstract
COVID-19 is also manifested with hypercoagulability, pulmonary intravascular coagulation, microangiopathy, and venous thromboembolism (VTE) or arterial thrombosis. Predisposing risk factors to severe COVID-19 are male sex, underlying cardiovascular disease, or cardiovascular risk factors including noncontrolled diabetes mellitus or arterial hypertension, obesity, and advanced age. The VAS-European Independent Foundation in Angiology/Vascular Medicine draws attention to patients with vascular disease (VD) and presents an integral strategy for the management of patients with VD or cardiovascular risk factors (VD-CVR) and COVID-19. VAS recommends (1) a COVID-19-oriented primary health care network for patients with VD-CVR for identification of patients with VD-CVR in the community and patients' education for disease symptoms, use of eHealth technology, adherence to the antithrombotic and vascular regulating treatments, and (2) close medical follow-up for efficacious control of VD progression and prompt application of physical and social distancing measures in case of new epidemic waves. For patients with VD-CVR who receive home treatment for COVID-19, VAS recommends assessment for (1) disease worsening risk and prioritized hospitalization of those at high risk and (2) VTE risk assessment and thromboprophylaxis with rivaroxaban, betrixaban, or low-molecular-weight heparin (LMWH) for those at high risk. For hospitalized patients with VD-CVR and COVID-19, VAS recommends (1) routine thromboprophylaxis with weight-adjusted intermediate doses of LMWH (unless contraindication); (2) LMWH as the drug of choice over unfractionated heparin or direct oral anticoagulants for the treatment of VTE or hypercoagulability; (3) careful evaluation of the risk for disease worsening and prompt application of targeted antiviral or convalescence treatments; (4) monitoring of D-dimer for optimization of the antithrombotic treatment; and (5) evaluation of the risk of VTE before hospital discharge using the IMPROVE-D-dimer score and prolonged post-discharge thromboprophylaxis with rivaroxaban, betrixaban, or LMWH.
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Affiliation(s)
- Grigoris T. Gerotziafas
- Hematology and Thrombosis Center, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine, Sorbonne Université, Paris, France
- Research Group Cancer, Haemostasis and Angiogenesis,” INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France
| | - Mariella Catalano
- Research Center on Vascular Disease & Angiology Unit, Department of Biomedical Science, L Sacco Hospital, University of Milan, Milan, Italy
| | - Mary-Paula Colgan
- Department of Vascular Surgery, St. James's Hospital/Trinity College Dublin, Dublin, Ireland
| | - Zsolt Pecsvarady
- Department of Vascular Medicine, Flor Ferenc Teaching Hospital, Kistarcsa, Hungary
| | - Jean Claude Wautrecht
- Service de Pathologie Vasculaire, Hôpital ERASME, Université Libre de Bruxelle, Brussels, Belgium
| | - Bahare Fazeli
- Immunology Department, Avicenna (Bu-Ali) Research Institute, Mashhad University of Medical Sciences, Iran
| | - Dan-Mircea Olinic
- Medical Clinic No. 1, University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Katalin Farkas
- Department of Angiology, St. Imre University Teaching Hospital, Budapest, Hungary
| | - Ismail Elalamy
- Hematology and Thrombosis Center, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine, Sorbonne Université, Paris, France
- Research Group Cancer, Haemostasis and Angiogenesis,” INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France
- Department of Obstetrics and Gynecology, I.M.Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, & the Thrombosis and Hemostasis Center, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Jawed Fareed
- Department of Pathology, Loyola University Medical Center, Maywood, Illinois, United States
| | - Chryssa Papageorgiou
- Service Anesthésie, Réanimation et Médecine Périopératoire, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de médecine, Sorbonne Université, Paris, France
| | | | - Petros Agathagelou
- Department of Inrterventional Cardiology, American Heart Institute of Cyprus, Nicosia, Cyprus
| | - Darco Antic
- Clinic for Hematology, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Luciana Auad
- Medicina Vascular, Sanatorio Allende Córdoba, Ciencias Médicas, Universidad Católica de Córdoba, Argentina
| | - Ljiljana Banfic
- University Hospital Center, School of Medicine University of Zagreb, Croatia
| | | | - Bela Benczur
- Balassa Janos County Hospital, University Medical School, Szeged, Hungary
| | | | - Francesco Boccardo
- Department of Cardio-Thoracic-Vascular and Endovascular Surgery, Unit of Lymphatic Surgery, IRCCS S. Martino Hospital, University of Genoa, Italy
| | - Renate Cifkova
- Department of Preventive Cardiology, Thomayer Teaching Hospital, Prague, Czech Republic
| | - Benilde Cosmi
- Angiology and Blood Coagulation, Department of Specialty, Diagnostic and Experimental Medicine, S. Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Sergio De Marchi
- Angiology Unit, Cardiovascular and Thoracic and Medicine Department, Verona University Hospital, Verona, Italy
| | - Evangelos Dimakakos
- Vascular Unit of 3rd Department of Internal Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A. Dimopoulos
- Hellenic Society of Hematology, Athens, Greece
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Gabriel Dimitrov
- Research Center on Vascular Disease & Angiology Unit, Department of Biomedical Science, L Sacco Hospital, University of Milan, Milan, Italy
| | - Isabelle Durand-Zaleski
- Université de Paris, CRESS, INSERM, INRA, URCEco, AP-HP, Hôpital de l'Hôtel Dieu, Paris, France
| | - Michael Edmonds
- Diabetic Foot Clinic, King's College Hospital, London, United Kingdom
| | | | - Dilek Erer
- Department of Cardiovascular Surgery, Faculty of Medicine, Gazi University, Besevler/Ankara, Turkey
| | - Omar L. Esponda
- Internal Medicine Department, Hospital Perea, Mayaguez, Puerto Rico, United States
| | - Paolo Gresele
- Section of Internal and Cardiovascular Medicine, Department of Medicine, -University of Perugia, Perugia, Italy
| | - Michael Gschwandtner
- MedizinischeUniverstiät Wien, Universitätsklinik für Innere Medizin II, Klinische Abteilung für Angiologie, Vienna, Austria
| | - Yongquan Gu
- Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing China
| | - Mónica Heinzmann
- Medicina Vascular, Sanatorio Allende Córdoba, Ciencias Médicas, Universidad Católica de Córdoba, Argentina
| | - Naomi M. Hamburg
- The Whitaker Cardiovascular Institute Department of Medicine Boston University School of Medicine, Boston, Massachusetts, United States
| | - Amer Hamadé
- Vascular Medicine Unit, Internal Medicine Department, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Noor-Ahmed Jatoi
- Department Vascular Medicine, Mulhouse Hospital Center, Mulhouse, France
| | - Oguz Karahan
- Department of Cardiovascular Surgery, Medical School of Alaaddin Keykubat University, Alanya/Antalya, Turkey
| | - Debora Karetova
- Second Department of Medicine, Department of Cardiovascular Medicine, Charles University in Prague, Prague, Czech Republic
| | - Thomas Karplus
- Department of Vascular Medicine, Concord Repatriation General Hospital, Sydney, Australia
| | - Peter Klein-Weigel
- Klinik für Angiologie, Zentrum für Innere Medizin II, Ernst von Bergmann Klinikum, Potsdam, Germany
| | - Endre Kolossvary
- Department of Angiology, St. Imre University Teaching Hospital, Budapest, Hungary
| | - Matija Kozak
- Department for Vascular Diseases, Medical Faculty of Ljubljana, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Eleftheria Lefkou
- Board member of the Institute for the Study and Education on Thrombosis and Antithrombotic Therapy, Athens, Greece
| | - Gianfranco Lessiani
- Angiology Unit, Internal Medicine Department., Città Sant' Angelo Hospital, AUSL 03, Pescara, Italy
| | - Aaron Liew
- Portiuncula University Hospital, Soalta University Health Care Group, National University of Ireland Galway (NUIG), Galway, Ireland
| | - Antonella Marcoccia
- Unità di Medicina Vascolare e Autoimmunità, CRIIS-Centro di riferimento interdisciplinare per la Sclerosi Sistemica, Rome, Italy
| | - Peter Marshang
- Department of Internal Medicine, Central Hospital of Bolzano, Bolzano, Italy
| | | | - Jiri Matuska
- MATMED s.r.o., Private Angiology Facility, Hodonin, Czech Republic
| | - Luc Moraglia
- Angiologie Centre Cours du Médoc, Médecine Vasculaire Travail, Bordeaux, France
| | - Sergio Pillon
- UOSD Angiology, San Camillo-Forlanini Hospital, National Health Institute ISS, Rome, Italy
| | - Pavel Poredos
- Medical Association of Slovenia and SMA, Slovenia Academic Research Centre, Slovenian Medical Academy, Ljubljana, Slovenia
| | - Manlio Prior
- Angiology Unit, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy
| | | | - Oliver Schlager
- Division of Angiology, Department of Internal Medicine 2, Medical University of Vienna, Vienna, Austria
| | - Gerit Schernthaner
- Division of Angiology, Department of Internal Medicine 2, Medical University of Vienna, Vienna, Austria
| | - Alexander Sieron
- Department of Internal Medicine, Angiology and Physical Medicine, Medical University of Silesia, Katowice, Poland
- Specialist Hospital, Bytom, Jan Długosz University in Częstochowa, Częstochowa, Poland
| | - Jonas Spaak
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Stockholm County, Sweden
| | - Alex Spyropoulos
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Feinstein Institute for Medical Research, New York, New York, United States
| | - Muriel Sprynger
- Cardiology Department, University Hospital Sart Tilman, Liege, Belgium
| | - Dusan Suput
- Center for Clinical Physiology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Agata Stanek
- Department of Internal Medicine, Angiology and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Bytom, Poland
| | - Viera Stvrtinova
- Faculty of Medicine, Comenius University, Bratislava, Slovak Republic
| | - Andrzej Szuba
- Department of Angiology, Hypertension and Diabetology, Wroclaw Medical University, Wroclaw, Poland
| | - Alfonso Tafur
- Vascular Medicine University of Chicago, Northshore Cardiovascular Institute, Skokie, Illinois, US Army
| | - Patrick Vandreden
- Research Group Cancer, Haemostasis and Angiogenesis,” INSERM U938, Centre de Recherche Saint-Antoine, Institut Universitaire de Cancérologie, Faculty of Medicine, Sorbonne University, Paris, France
| | - Panagiotis E. Vardas
- Medical School of Crete, University of Crete and Heart Sector, Hellenic Healthcare Group, Athens, Greece
| | - Dragan Vasic
- Department of Noninvasive vascular laboratory, Clinic of Vascular and Endovascular Surgery, Clinical Centre of Serbia, Belgrade, Serbia
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Paul Wennberg
- Department of Cardiovascular Medicine, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, United States
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Peking University Health Science Center, Capital Medical University, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
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10
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Gauer JS, Riva N, Page EM, Philippou H, Makris M, Gatt A, Ariëns RAS. Effect of anticoagulants on fibrin clot structure: A comparison between vitamin K antagonists and factor Xa inhibitors. Res Pract Thromb Haemost 2020; 4:1269-1281. [PMID: 33313466 PMCID: PMC7695561 DOI: 10.1002/rth2.12443] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/01/2020] [Accepted: 09/12/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Abnormal clot structure has been identified in patients with thrombotic disorders. Anticoagulant therapy offers clear benefits for thrombosis prevention and treatment by reducing blood clot formation and size; nevertheless, there are limited data on the effects of different anticoagulants, where clotting is initiated with different triggers, on clot structure. OBJECTIVES Our aim was to investigate the effects of vitamin K antagonists and factor Xa inhibitors on clot structure. METHODS Clots from pooled plasma spiked with rivaroxaban, apixaban, or enoxaparin, as well as plasma from patients on warfarin, were compared to plasma without anticoagulation. The kinetic profile of polymerizing clots was obtained by turbidity, fiber density was determined by confocal microscopy, clot pore size was investigated by permeation, and fiber size was analyzed using scanning electron microscopy. Clotting agonist was either tissue factor or thrombin. RESULTS Following clotting with tissue factor, all anticoagulated clots had a significantly increased lag time, with the exception of enoxaparin. Rivaroxaban additionally led to significantly less dense and more permeable clots, with thicker fibers. In contrast, turbidity analysis following initiation with thrombin showed few effects of anticoagulation, with only enoxaparin leading to a prolonged lag time. Enoxaparin clots made with thrombin were less dense and more permeable. CONCLUSION Our results show that anticoagulants modulate clot structure particularly when induced by tissue factor, most likely due to reduction of thrombin generation. We propose that the effects of different anticoagulants could be assessed with a global clot structure measurement such as permeation or turbidity, providing information on clot phenotype.
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Affiliation(s)
- Julia S. Gauer
- Discovery and Translational Science DepartmentInstitute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
| | - Nicoletta Riva
- Department of PathologyFaculty of Medicine & SurgeryUniversity of MaltaMsidaMalta
| | - Eden M. Page
- Discovery and Translational Science DepartmentInstitute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
| | - Helen Philippou
- Discovery and Translational Science DepartmentInstitute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
| | - Michael Makris
- Sheffield Haemophilia and Thrombosis CentreUniversity of SheffieldSheffieldUK
| | - Alex Gatt
- Department of PathologyFaculty of Medicine & SurgeryUniversity of MaltaMsidaMalta
| | - Robert A. S. Ariëns
- Discovery and Translational Science DepartmentInstitute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
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11
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Wakui M, Fujimori Y, Nakamura S, Oka S, Ozaki Y, Kondo Y, Nakagawa T, Katagiri H, Murata M. Characterisation of antithrombin-dependent anticoagulants through clot waveform analysis to potentially distinguish them from antithrombin-independent inhibitors targeting activated coagulation factors. J Clin Pathol 2020; 74:251-256. [PMID: 32796051 DOI: 10.1136/jclinpath-2020-206835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/26/2020] [Accepted: 06/30/2020] [Indexed: 11/04/2022]
Abstract
AIMS While antithrombin (AT)-independent inhibitors targeting thrombin or activated factor X have been assessed through clot waveform (CWA), there are no reports on assessment with respect to AT-dependent anticoagulants. The present study aims to characterise AT-dependent anticoagulants through CWA to distinguish them from AT-independent inhibitors. METHODS CWA was applied to the activated partial thromboplastin time (APTT) assay of plasma samples spiked with each of AT-dependent drugs (unfractionated heparin, enoxaparin and fondaparinux) and AT-independent drugs (rivaroxaban, apixaban, edoxaban, dabigatran, argatroban, hirudin and bivalirudin), which was performed using the CS-5100 or CN-6000 (Sysmex). The APTT-CWA data were automatically gained by the analyser program. The positive mode of clotting reaction curves was defined as the direction towards fibrin generation. RESULTS Regarding dose-response curves in AT-dependent anticoagulants, the maximum positive values of the first and secondary derivatives (Max1 and Maxp2, respectively) and the maximum negative values of the secondary derivative (Maxn2) seemed to drop to zero without making an asymptotic line, consistent with the irreversibility. Such a feature was observed also in hirudin, as reported previously. Notably, the symmetric property of Max1 peaks in the waveforms was distorted dose dependently in AT independent but not AT-dependent drugs. A plot of Maxp2 logarithm versus Maxn2 logarithm was linear. The slope was about 1 in AT-dependent drugs while that was more than 1 in AT-independent drugs. These features made it possible to distinguish AT-dependent and AT-independent drugs. CONCLUSIONS The results aid in further understanding of the pharmacological aspects of anticoagulation and in screening of candidates for novel anticoagulants.
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Affiliation(s)
- Masatoshi Wakui
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuta Fujimori
- Office of Clinical Laboratory Technology, Keio University Hospital, Tokyo, Japan
| | - Shoko Nakamura
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Shusaku Oka
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Yuko Ozaki
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Yoshino Kondo
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | | | | | - Mitsuru Murata
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
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12
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Aptamer-modified FXa generation assays to investigate hypercoagulability in plasma from patients with ischemic heart disease. Thromb Res 2020; 189:140-146. [PMID: 32224381 DOI: 10.1016/j.thromres.2020.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/29/2020] [Accepted: 03/09/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND High plasma levels of activated Factor VII-Antithrombin complex (FVIIa-AT) have been associated with an increased risk of cardiovascular mortality in patients with stable coronary artery disease (CAD). OBJECTIVES To investigate if FVIIa-AT levels are associated with activated factor X generation (FXaG) in modified assays. PATIENTS/METHODS Forty CAD patients were characterized for FVIIa-AT levels by ELISA and for FXaG in plasma. Novel fluorogenic FXaG assays, based on aptamers inhibiting thrombin and/or tissue factor pathway inhibitor (TFPI), were set up. RESULTS FXaG correlated with FVIIa-AT levels (RAUC = 0.393, P = 0.012). The combination of thrombin inhibition and FXaG potentiation by using anti-thrombin and anti-TFPI aptamers, respectively, favors the study of time parameters. The progressive decrease in lag time from the lowest to the highest FVIIa-AT quartile was magnified by combining TFPI and thrombin inhibitory aptamers, thus supporting increased FXaG activity in the coagulation initiation phase. By exploring FXaG rates across FVIIa-AT quartiles, the largest relative differences were detectable at the early times (the highest versus the lowest quartile; 5.0-fold, P = 0.005 at 45 s; 3.5-fold, P = 0.001 at 55 s), and progressively decreased over time (2.3-fold, P = 0.002 at 75 s; 1.8-fold, P = 0.008 at 95 s; 1.6-fold, P = 0.022 at 115 s). Association between high FVIIa-AT levels and increased FXaG was independent of F7 -323 A1/A2 polymorphism influencing FVIIa-AT levels. CONCLUSIONS High FVIIa-AT plasma levels were associated with increased FXaG. Hypercoagulability features were specifically detectable in the coagulation initiation phase, which may have implications for cardiovascular risk prediction by either FVIIa-AT complex measurement or modified FXaG assays.
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