Role of heparin in the inactivation of thrombin, factor Xa, and plasmin by antithrombin III

Venous thrombosis epidemiology, pathophysiology, and anticoagulant therapies and trials in severe acute respiratory syndrome coronavirus 2 infection

OBJECTIVE

Infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus confers a risk of significant coagulopathy, with the resulting development of venous thromboembolism (VTE), potentially contributing to the morbidity and mortality. The purpose of the present review was to evaluate the potential mechanisms that contribute to this increased risk of coagulopathy and the role of anticoagulants in treatment.

METHODS

A literature review of coronavirus disease 2019 (COVID-19) and/or SARS-CoV-2 and cell-mediated inflammation, clinical coagulation abnormalities, hypercoagulability, pulmonary intravascular coagulopathy, and anticoagulation was performed. The National Clinical Trials database was queried for ongoing studies of anticoagulation and/or antithrombotic treatment or the incidence or prevalence of thrombotic events in patients with SARS-CoV-2 infection.

RESULTS

The reported rate of VTE among critically ill patients infected with SARS-CoV-2 has been 21% to 69%. The phenomenon of breakthrough VTE, or the acute development of VTE despite adequate chemoprophylaxis or treatment dose anticoagulation, has been shown to occur with severe infection. The pathophysiology of overt hypercoagulability and the development of VTE is likely multifactorial, with evidence supporting the role of significant cell-mediated responses, including neutrophils and monocytes/macrophages, endothelialitis, cytokine release syndrome, and dysregulation of fibrinolysis. Collectively, this inflammatory process contributes to the severe pulmonary pathology experienced by patients with COVID-19. As the infection worsens, extreme D-dimer elevations, significant thrombocytopenia, decreasing fibrinogen, and prolongation of prothrombin time and partial thromboplastin time occur, often associated with deep vein thrombosis, in situ pulmonary thrombi, and/or pulmonary embolism. A new phenomenon, termed pulmonary intravascular coagulopathy, has been associated with morbidity in patients with severe infection. Heparin, both unfractionated heparin and low-molecular-weight heparin, have emerged as agents that can address the viral infection, inflammation, and thrombosis in this syndrome.

CONCLUSIONS

The overwhelming inflammatory response in patients with SARS-CoV-2 infection can lead to a hypercoagulable state, microthrombosis, large vessel thrombosis, and, ultimately, death. Early VTE prophylaxis should be provided to all admitted patients. Therapeutic anticoagulation therapy might be beneficial for critically ill patients and is the focus of 39 ongoing trials. Close monitoring for thrombotic complications is imperative, and, if confirmed, early transition from prophylactic to therapeutic anticoagulation should be instituted. The interplay between inflammation and thrombosis has been shown to be a hallmark of the SARS-CoV-2 viral infection.

Fatal Ovarian Hemorrhage Associated With Anticoagulation Therapy in a Yucatan Mini-Pig Following Venous Stent Implantation

Swine models are commonly utilized in endovascular research for development of intravascular interventions and medical device development. As part of a pilot study for a venous vascular stent device, a 5-year-old female Yucatan mini-pig underwent bilateral external iliac vein stent placement under general anesthesia. To reduce thrombotic complications by reduction of thrombus formation on wires, sheaths, and catheters, the pig was heparinized with a total of 300 IU/kg of heparin, establishing an activated clotting time (ACT) of 436 s. The ACT had returned to below 200 s by the end of the procedure. To prevent postoperative thrombosis, the pig received an anticoagulation therapy protocol consisting of enoxaparin, clopidogrel, and aspirin. There were no complications during the immediate postoperative period. However, the pig died 4 days after surgery. Necropsy established the cause of death as abdominal exsanguination due to severe, acute, intra-ovarian hemorrhage, most likely related to ovulation. Life-threatening ovarian hemorrhage is occasionally seen in women with congenital or acquired bleeding disorders; to our knowledge this is the first report of fatal ovarian hemorrhage in an animal enrolled in a pre-clinical research trial.

Procoagulant control strategies for the human blood clotting process

This paper describes the comparison between two drug control strategies to hemophilia A. To emulate blood clotting and the pathological condition of hemophilia, a mathematical model composed by 14 ordinary differential equations is considered. We adopt a variable structure non-linear PID approach and a Model Predictive Control in order to control the dosage of procoagulant factor used in the treatment of hemophiliac patient. The two control actions are sampled for a practical application. Finally, we discuss and compare the results of the two control approaches, introducing a suited control index (eINR).

Mechanism of heparin action

Heparin catalysis of clotting proteinase inactivation occurs most efficiently through the reaction of the proteinase with the antithrombin-heparin complex. The efficiency of a heparin molecule in this reaction depends on the presence of a specific pentasaccharide sequence in it, and its molecular weight. The mechanism by which such high affinity heparin acts when antithrombin III is the inhibitor is promotion of the formation of an intermediate proteinase-heparin-antithrombin complex. Heparin promotion of thrombin inactivation by heparin cofactor II may occur by a similar mechanism. The requirement for a specific oligosaccharide sequence within the heparin molecule does not, however, exist for heparin cofactor II. Binding of heparin to both thrombin and antithrombin III interferes with thrombin inactivation. This binding is very dependent on the ionic strength of the reaction mixture and may explain some of the discordant results and interpretations from early studies on the mechanism of heparin action. Low ionic strength in in vitro reactions also results in cleavage of antithrombin III by thrombin in the presence of heparin and effectively converts antithrombin III from an inhibitor to a substrate.

Theory and experimental method for determining individual kinetic constants of fast-acting, irreversible proteinase inhibitors

A theory and experimental method are presented to characterize the kinetics of fast-acting, irreversible proteinase inhibitors. The theory is based upon formal analysis of the case of an irreversible inhibitor competing with a substrate for the active-site of a proteinase. From this theory, an experimental method is described by which the individual microscopic kinetic constants for the interaction of the inhibitor with the proteinase can be determined. These are, for a two-step inhibition reaction sequence, the equilibrium dissociation constant and the first-order rate constant for inhibition, and, for a one-step inhibition reaction sequence, the second-order rate constant for inhibition. The theory and experimental method were validated by an analysis of the inhibition of trypsin by the two-step synthetic inhibitor p-nitrophenyl p-guanidinobenzoate and the one-step protein inhibitor bovine pancreatic trypsin inhibitor. The substrate used in these experiments is a new, fluorogenic substrate for trypsin-like serine proteinases (Cbz-Ile-Pro-Arg-NH)2-Rhodamine, the synthesis and properties of which are described.

Interaction of plasmin with endothelial cells

Interaction of human plasmin with a monolayer culture of mini-pig aortic endothelial cells was studied by using the 125I-labelled enzyme. The binding of plasmin was time- and concentration-dependent. Equilibrium between bound and free enzyme was obtained within 90s, and Scatchard analysis indicated a high- and a low-affinity population of binding sites of approx. 1.24 X 10(4) sites/cell having a Kd of 1.4 X 10(-9) M and 7.2 X 10(4) sites/cell with a Kd of 2 X 10(-8) M respectively. Plasmin, bound to cell, was spontaneously released within 2 min, suggesting a rapid equilibrium. Chemical modification of the enzyme with phenylmethanesulphonyl fluoride or pyridoxal 5'-phosphate revealed that neither the active centre nor the heparin-binding site of plasmin was involved in the interaction with the endothelial cell. In terms of endothelial-cell receptors, the binding sites of cells for plasmin and thrombin were different: the two enzymes did not compete with each other, and the pretreatment of cells with neuraminidase or chondroitin ABC lyase resulted in a 50% decrease of thrombin or plasmin binding respectively. Arachidonic acid incorporated into phospholipids of the cell was released by plasmin, but a change in the rate of prostacyclin formation was not measurable. The interaction of plasmin with endothelial cells seems to be specific in the fibrinolytic system, since plasminogen did not bind to these cells under similar conditions.

Adaptation of acyl-enzyme kinetic theory and an experimental method for evaluating the kinetics of fast-acting, irreversible protease inhibitors

The theory of acyl-enzyme kinetics (Bender, M.L., Kézdy, F.J. and Wedler, F.C. (1967) J. Chem. Educ. 44, 84-88) has been adapted for use in evaluating the kinetics of inhibition of serine proteases by both natural and synthetic irreversible inhibitors. The new theory is based upon formal analysis of the case of an irreversible, active-site-directed inhibitor competing with an irreversible, active-site-directed substrate for the active site of a serine protease. From this theory, an experimentally simple and accurate method is described to obtain a second-order rate constant that is characteristic of the efficiency with which an irreversible inhibitor reacts. The experimental method is particularly useful for characterizing fast-acting, irreversible inhibitors. The theory and method which are applicable to a wide variety of enzymes are verified by analysis of the inhibition of bovine trypsin by three model inhibitors, p-nitrophenyl p'-guanidinobenzoate, soybean trypsin inhibitor and alpha-1-proteinase inhibitor as well as by human antithrombin III in the presence of heparin and by bovine pancreatic trypsin inhibitor.

The interaction of heparin with human plasmin

1. The interaction of heparin with human plasmin was investigated measuring plasmin activity and enzyme inactivation in the presence of heparin. Hydrolysis of synthetic substrates (H-D-Val-Leu-Lys-pNA, H-D-Val-Phe-Lys-pNA and H-D-Pro-Phe-Lys-pNA) by plasmin was enhanced by heparin through an increase in kcat values. 2. This effect was the consequence of a change of Vmax since Km values were not altered in the presence of heparin. The polysaccharide also enhanced the rate of enzyme inactivation using TLCK as an active site blocking reagent. 3. Furthermore, heparin increased the heat sensitivity of plasmin, when synthetic substrate H-D-Val-Leu-Lys-pNA was used but it did not affect enzyme activity towards N-benzoyl-L-arginine-ethylester substrate. 4. The data show that microenvironmental conformation around the active center of plasmin is influenced by heparin.

Specific binding of thrombin-antithrombin III complex to hepatocytes

Thrombin-antithrombin III complex binds selectively to isolated hepatocytes, whereas antithrombin III alone does not. The binding is time and concentration dependent at 37 degrees C: the apparent Km value is 0.8/microM. The rate of binding is approximately 1.6 X 10(5) molecules h-1 cell-1 at this concentration. At 4 degrees C there is no measurable interaction between the complex and the hepatocytes. The binding is also prevented by pretreatment of cells with trypsin. On the other hand, about 80% of the thrombin-antithrombin III complex bound to hepatocytes is releasable by trypsin digestion. NaF or carboxyatractyloside does not inhibit the process. The interaction of thrombin-antithrombin III complex with hepatocytes seems to be specific, since the complexes of antithrombin III with other proteinases, like trypsin or plasmin, are not bound at the concentrations used. Based on these data, a mechanism for the binding of the inactive complexed form of thrombin to hepatocytes is suggested.

Heparin and the progressive anti-thrombin activity of alpha 2-macroglobulin

Interactions between alpha 2-macroglobulin (alpha 2M) and thrombin have been studied by spectroscopic, isotopic and electrophoretic methods in presence or in absence of heparin. It is shown that thrombin binds to alpha 2M in a 1:1 ratio. Fluorescamin labelled heparin of Mr 7 000 interacts with thrombin to form a 2:1 molar complex. This complex does not bind to alpha 2M and is unable to achieve any proteolytic cleavage of this protein. In contrast the interaction of alpha 2M with chymotrypsin is not significantly affected by the mucopolysaccharide. Moreover, heparin is unable to react with alpha 2M bound thrombin.

Kinetic analysis of the heparin-enhanced plasmin--antithrombin III reaction. Apparent catalytic role of heparin

Inactivation of plasmin by a 3-4-fold molar excess of antithrombin III follows pseudo-first-order kinetics and the apparent rate constants are proportional to the concentration of the inhibitor. Heparin accelerates the inactivation reaction without changing its pseudo-first-order character, and the apparent rate constants are also proportional to the concentration of the polysaccharide. Heparin results in a minimum 20-fold rate enhancement of the reaction between plasmin and antithrombin III when the concentrations of heparin and plasmin are approx. 0.5mum and 1mum respectively. Heparin at a molar concentration well below that of plasmin still accelerates the reaction: one molecule of the polysaccharide is able to facilitate the inactivation of about 100 molecules of plasmin. Heparin must bind to plasmin to accelerate the plasmin-antithrombin III reaction, since the modification of four to five lysine residues of the enzyme inhibits the rate-enhancement effect of heparin and the dissociation of heparin-plasmin complex decreases the inactivation rate of plasmin. Increasing the concentration of antithrombin III, at a constant amount of heparin, results in increase of the inactivation rate. By contrast, the effect of increasing the amount of plasmin in the presence of constant amount of heparin and antithrombin III is such that higher plasmin-to-heparin ratios are associated with lower rates of inactivation. It seems, therefore, that to obtain ;optimal' conditions for fast enzyme inactivation, the amount of heparin should be matched to plasmin rather than to antithrombin III. Arrhenius plots of the plasmin-antithrombin III reaction are linear both in the absence and presence of heparin, at concentrations of 1 or 2mug/ml, over a range of 26K. Under these experimental conditions, heparin increases activation entropy. The findings show that heparin seems to fulfil some criteria that are characteristic for biological catalysis: binding, reaction-rate enhancement (increasing activation entropy), recycling of heparin (effectiveness of non-stoichiometric amounts of the polysaccharide) and specificity.

Enzymatic inactivation of human antithrombin III. Limited proteolysis of the inhibitor by snake venom proteinases in the presence of heparin

Incubation of human plasma antithrombin III with Crotalid, Viperid and Colubrid snake venoms resulted in the enzymatic inactivation of the inhibitor, as evidenced by a gradual loss of inhibitory activity against trypsin and thrombin. This indicates that proteinases which selectively inactivate antithrombin III are widespread among the families of poisonous snakes. The inactivation was due to metalloproteinases present in the venoms, since the reaction could be terminated by the addition of EDTA. Elapid venoms were tested and shown to be devoid of activity on antithrombin III. Preincubation of the anthrombin III with heparin accelerated the reaction, and less venom was required to achieve total inactivation. Several venoms had very little effect on antithrombin III in the absence of heparin, but inactivated the inhibitor completely within 2 h when heparin was present. Optimal rates of inactivation were observed with antithrombin III: heparin ratios of approx. 3 : 1. When heparin was present in excess, the inactivation was retarded. Sodium dodecyl sulfate (SDS)-polyacrylamide gel electrophoresis of the antithrombin III/venom proteinase reaction mixtures indicated that intact antithrombin III (63 000 daltons) was converted to an inactive form (57 500 daltons) by limited proteolysis. No complex formation between antithrombin III and venom proteinases was detectable. The inactivating cleavage occurred within a disulfide loop of the antithrombin III molecule, since the lower molecular weight species was detected only under reducing conditions.

Antithrombin III contribution to cholestasis differential diagnosis: its correlation with one stage prothrombin time and factor V

Levels of antithrombin III (AT III) measured by two different methods, Factor V (FV) and One Stage Prothrombin Time, have been studied in two groups of patients: 55 with chronic liver disease and 22 with extra hepatic cholestasis. Results show a statistically significant correlation between the decrease of AT III and FV in the first group, and the normality of these parameters (unrelated to One Stage Prothrombin Time) in the second group. Levels at AT III and FV correlate directly with the functional integrity of hepatic parenchyma, so they may help in the differential diagnosis of different types of cholestasis.

Reaction of antithrombin with proteases. Evidence for a specific reaction with papain

Experiments were performed to determine if the sulfhydryl protease, papain (EC 3.4.22.2), reacts with the plasma protease inhibitor antithrombin (antithrombin III, heparin cofactor) on a specific manner analogous to the reaction of thrombin (EC 3.4.21.5) and other serine proteases with this inhibitor. The esterolytic activity of papain is blocked by the addition of antithrombin, but not by antithrombin-thrombin complex or by protein substrates such as bovine serum albumin. Likewise, in the presence of papain, antithrombin was unable to displace the active site dye proflavine from thrombin, or to inhibit thrombin-catalysed hydrolysis of an anilide substrate. The reaction of antithrombin and papain was not accelerated by low concentrations of heparin. Approximately stoichiometric amounts of heparin completely inhibited the reaction of papain with antithrombin. The mutual inhibition indicates that plasma antithrombin does react with papain but the reaction differs from the interaction with coagulation factors, particularly in the heparin effect.

Heparinized styrene-butadiene-styrene elastomers

A heparinized high-strength elastomer has been developed which is potentially useful as a nonthrombogenic vascular prosthesis. A surface hydroxylated styrene-butadiene-styrene (SBS) block copolymer with at least 40% extent of reaction after glow-discharge cleaning was coated with a 20% acetylated polyvinyl alcohol/heparin mixture containing glutaraldehyde and magnesium chloride. After curing at 80 degrees C for 100 min, the polyvinyl alcohol, heparin, and hydroxylated SBS were covalently bound to each other by acetal bridges. The effects of the various substrate and coating parameters were optimized to achieve very strong adhesion between the coating layer and the surface hydroxylated SBS. Heparin was not leached from the surface of the new material using 3M saline at pH 7.4 despite a detection limit of 10(-5) micrograms heparin/cm2 min. Prolonged partial thromboplastin times of greater than 1200 sec were observed (control: PTT = 120 sec). Preliminary ex vivo testing using a simple arteriovenous shunt in the leg of a rabbit showed good thromboresistance. The heparinized SBS shunt chamber remained patent for more than two hours without desorption of heparin. It was concluded that surface hydroxylated SBS heparinized by acetal coupling owed its thromboresistance to the heparin covalently bound to the surface and not to a microenvironment of heparin in solution at the blood/material interface.

Inhibition of esterase and amidase activities of alpha- and beta-thrombin in the presence of antithrombin III and heparin

Inhibition of the esterase and amidase activities of bovine alpha- and beta-thrombin in the presence of antithrombin III and heparin has been studied. It was found that both the esterase and amidase activities of alpha-thrombin were inhibited by antithrombin III and the reactions were accelerated by heparin. The inhibition of amidase and esterase activities of beta-thrombin by antithrombin III has also been demonstrated. Heparin however did not increase the rate of inactivation of the enzyme.