Possible interaction of platelets and adrenaline in the early phase of myocardial infarction

The receptor EP3 to PGE2: A rational target to prevent atherothrombosis without inducing bleeding

The prostanoid E2 (PGE2) is known to modulate the aggregative response of platelets to their conventional agonists such as ADP, TXA2, thrombin or collagen. Through the activation of its receptor EP3, PGE2 sensitizes platelets to their agonists but also inhibits them through its two other receptors, EP2 and EP4. In mice, the net result of these opposed actions is the EP3-mediated potentiation of platelet aggregation and the in vivo aggravation of murine atherothrombosis. Since the pathway PGE2/EP3 is not involved in murine hemostasis, we propose a "platelet EP3 paradigm" to describe this apparently paradoxical association between the facilitating impact on atherothrombosis and the unaltered hemostasis. Consistent with this paradigm, a drug blocking EP3 dramatically decreased atherothrombosis without inducing bleeding in mice. In humans, several studies did not agree on the effect of PGE2 on platelets. Reinterpreting these data with the notion of "potentiation window" and taking the platelet initial cAMP level into account reconciled these inconsistent results. Thereby, the in vitro potentiating effect of PGE2 on human platelets becomes clear. In addition, the EP3 blocking drug DG-041 abrogated the potentiating effect of PGE2 in whole human blood but did not prolong bleeding times in volunteers. Thus, the murine "platelet EP3 paradigm" would apply to humans if the aggravating role of PGE2 on atherothrombosis is shown in patients. Therefore, testing an EP3 blocker in a phase III trial would be of high interest to fulfill the unmet medical need which is to control atherothrombosis without impacting hemostasis and thus to improve the prevention of myocardial infarction.

Influence of Adrenergic Receptor Blockade on Aspirin-induced Inhibition of Platelet Function

Studies from our laboratory have demonstrated that epinephrine via alpha(2)-adrenoreceptor modulation can restore the sensitivity of aspirin-treated platelets to the action of agonists independent of secretion of granule contents or synthesis of prostanoids. The present study has evaluated the effects of full strength aspirin (take on alternate days) and low dose aspirin (taken daily) and sought to determine whether agents which antagonise alpha or beta adrenergic receptors can prevent the corrective influence of epinephrine on aspirin-treated platelets. Adult volunteers were given 325 mg aspirin every other day or 80 mg aspirin daily. After confirming the inhibitory effect of aspirin, these individuals were given yohimbine (5 mg), atenolol (100 mg), verapamil (160 mg) or ethanol (white wine 8 oz). Two hours later, blood was drawn for platelet studies. Cells exposed to aspirin did not aggregate when stirred with arachidonate (0.45 mM) or epinephrine (5 M) alone. Addition of epinephrine to aspirin treated platelets restored the sensitivity to the action of arachidonate and resulted in irreversible aggregation. Ethanol and verapamil at the concentrations tested did not potentiate the action of aspirin. Ingestion of yohimbine, an alpha(2)-adrenergic antagonist, or atenolol, a beta blocker, prevented the corrective influence of epinephrine on aspirin-treated refractory platelets. Results suggest that alpha and beta blockers may serve a useful role in reinforcing the antithrombotic influence of aspirin in vivo.

Time course of platelet alpha granule release in acute myocardial infarction treated with streptokinase

OBJECTIVE

To determine the time course of platelet alpha granule release in patients with acute myocardial infarction treated with streptokinase.

DESIGN

A prospective study.

SETTING

Coronary care unit.

PATIENTS

Nine with myocardial infarction treated with both streptokinase and aspirin, and nine with acute chest pain but without myocardial infarction, who were treated with aspirin only.

METHODS

All patients received 250 mg aspirin on admission and 150 mg once daily thereafter. All patients who fulfilled the indications for streptokinase received 1.5 megaunits, in a single infusion. After the initial medication, serial measurements of plasma beta thromboglobulin and plasma platelet factor 4 were performed at fixed intervals after the onset of chest pain. The primary endpoint sought was the peak value of beta thromboglobulin and platelet factor 4 in each individual.

RESULTS

The median peak plasma beta thromboglobulin in the infarction group was substantially higher than in those without infarction, at 37 (range 12 to 210) v 15 (9 to 36) mg/litre, P < 0.01. The corresponding values for plasma platelet factor 4 were 4.6 (2.4 to 60.0) v 2.2 (< 2 to 8.5) mg/litre, P < 0.01. Increased values were seen only within the first 12 h after onset of chest pain, and after 12 h there was no difference between the patients with myocardial infarction and those without. Aspirin treatment did not abolish alpha granule release.

CONCLUSIONS

In patients with acute myocardial infarction treated with streptokinase the content of the alpha granules is released within the first 12 h after the onset of chest pain. Aspirin apparently does not abolish this release.