Inhibitory signaling of 17β-estradiol in platelet activation: the pivotal role of cyclic AMP-mediated nitric oxide synthase activation

Hormones, age, and sex affect platelet responsiveness in vitro

BACKGROUND

Female sex confers a survival advantage following severe injury in the setting of trauma-induced coagulopathy, with female platelets having heightened responsiveness likely due to estrogen. The effects of testosterone on platelet biology are unknown, and platelets express both estradiol and androgen receptors on the plasma membrane. We hypothesize testosterone decreases platelet responses in vitro, and there are baseline differences in platelet function and metabolism stratified by sex/age.

STUDY DESIGN AND METHODS

Apheresis platelets were collected from: older males (OM) ≥45 years, younger males (YM) <45 years, older females (OF) ≥54 years, and younger females (YF) <54 years, and testosterone and estradiol were measured. Platelets were incubated with testosterone (5.31 ng/ml), estradiol (105 pg/ml) or vehicle and stimulated with buffer, adenosine diphosphate (20 μM), platelet activating factor (2 μM), or thrombin (0.3 U/ml). Aggregation, CD62P surface expression, fibrinogen receptor surface expression, and platelet mitochondrial metabolism were measured.

RESULTS

Testosterone significantly inhibited aggregation in OF and OM (p < .05), inhibited CD41a expression in YF, YM, and OM (p < .05), and affected a few of the baseline amounts of CD62P surface expression but not platelet activation to platelet-activating factor and adenosine diphosphate, and variably changed platelet metabolism.

DISCUSSION

Platelets have sex- and age-specific aggregation, receptor expression, and metabolism. Testosterone decreases platelet function dependent on the stimulus, age, and sex. Similarly, platelet metabolism has varying responses to sex hormones with baseline metabolic differences dependent upon sex and age.

Female platelets have distinct functional activity compared with male platelets: Implications in transfusion practice and treatment of trauma-induced coagulopathy

BACKGROUND

Females are hypercoagulable and have survival benefit in trauma-induced coagulopathy (TIC). The mechanism for this sex-specific hypercoagulability is unknown. Platelets and platelet function are central in providing hemostatic potential and are the largest contributor to clot strength. Ligands (adenosine diphosphate [ADP] and platelet-activating factor [PAF]) bind distinct platelet receptors to potentiate activation and aggregation. We hypothesize that female platelets have a differential response to ADP and PAF, resulting in greater aggregation and activation compared to males, and that estradiol pretreatment of male or female platelets enhances this activity.

METHODS

Platelets were collected from healthy volunteers: premenopausal/postmenopausal females (≤54 years, >54 years) and similarly aged males. Platelet aggregometry and flow cytometry (fibrinogen binding capacity) were examined. After treatment with ADP or PAF, platelet aggregation was assessed with Chronolog and activation assessed by CD41 receptor surface expression using flow cytometry. Aggregation and activation were again assessed after platelet pretreatment with estradiol.

RESULTS

Healthy volunteers included 12 premenopausal and 13 postmenopausal females and 18 similarly aged males. Female platelets (combined premenopausal and postmenopausal) had increased aggregation with ADP stimulation, as compared to male platelets. Male and female platelets had differential fibrinogen receptor expression, with female platelets (combined premenopausal and postmenopausal) demonstrating robust activation with ADP versus male platelets with PAF. In the presence of estradiol incubation, male platelets' activation with PAF approximated that of females (combined premenopausal and postmenopausal) and activation with PAF was enhanced in both male and female platelets.

CONCLUSION

Male and female platelets have differential response to stimuli, suggesting sex-dependent signaling and cellular activation. Female platelets have both increased aggregation and activation potential, and estradiol pretreatment feminizes male platelets to approximate female platelet activation with PAF. These findings offer potential explanation for sex-based differences in hemostatic potential in TIC and question whether donor sex of transfused platelets should be considered in resuscitation. Estradiol may also serve as a novel therapeutic adjunct in TIC.

Platelet Function in Aging

Aging is associated with an increased incidence of cardiovascular disease and thrombosis. Platelets play a major role in maintaining hemostasis and in thrombus formation, making them a key player in thrombotic disorders. Whereas it is well-known that platelet aggregability is increased in vascular diseases, the contribution of age-related changes in platelet biology to cardiovascular risk is not well-understood. Several lines of evidence support that platelets from older subjects differ in their function and structure, making platelets more prone to activation and less sensitive to inhibition. These age-related changes could lead to platelet hyperactivity and to the development of a prothrombotic state in advanced age. This review will focus on platelet biochemical modifications during aging and on the mechanisms by which these alterations could lead to thrombotic disease.

Role of Gender in Dual Antiplatelet Therapy After Acute Coronary Syndrome

PURPOSE OF REVIEW

The effect of gender on use of dual antiplatelet therapy (DAPT) in treatment of acute coronary syndrome (ACS) is not well established. The purpose of this review is to understand gender-based differences in response to DAPT, so that treatment of ACS can be optimized in women to prevent ischemic events while minimizing bleeding risk.

RECENT FINDINGS

There are innate gender differences in platelet reactivity and response. However, it is unknown if this translates into differences in clinical outcomes. In all major studies evaluating the effect of DAPT in ACS, women are underrepresented. Hence, the results from the existing trials cannot be generalizable to women. There is a significant knowledge gap regarding how to balance the bleeding and ischemic risk profile among women with ACS. Currently, there is no recommendation to consider gender as covariate in choosing the type of antiplatelet drug or duration. The existing clinical evidence is limited by under representation of women in DAPT trials. The current literature does not strongly support considering gender in decision making regarding type or duration of DAPT after ACS. Future dedicated trial designs with adequate representation from women and gender specific analysis from large registry data are warranted to enhance our understanding of the interaction of gender with DAPT after ACS.

Aerobic exercise training lowers platelet reactivity and improves platelet sensitivity to prostacyclin in pre- and postmenopausal women

Essentials It is unknown how regular exercise affects platelet function after menopause. We studied the effect of 3-months of high-intensity exercise in pre- and postmenopausal women. Platelet sensitivity to the inhibitory effect of arterially infused prostacyclin was increased. Reduced basal platelet reactivity was seen in the premenopausal women only.

SUMMARY

Background The risk of atherothrombotic events increases after the menopause. Regular physical activity has been shown to reduce platelet reactivity in younger women, but it is unknown how regular exercise affects platelet function after the menopause. Objectives To examine the effects of regular aerobic exercise in late premenopausal and recent postmenopausal women by testing basal platelet reactivity and platelet sensitivity to prostacyclin and nitric oxide. Methods Twenty-five sedentary, but healthy, late premenopausal and 24 matched recently postmenopausal women, mean (95% confidence interval) 49.1 (48.2-49.9) and 53.7 (52.5-55.0) years old, participated in an intervention study: 3-month high-intensity supervised aerobic spinning-cycle training (1 h, × 3/week). Basal platelet reactivity was analyzed in platelet-rich plasma from venous blood as agonist-induced % aggregation. In a subgroup of 13 premenopausal and 14 postmenopausal women, platelet reactivity was tested ex vivo after femoral arterial infusion of prostacyclin, acetylcholine, a cyclooxygenase inhibitor, and after acute one-leg knee extensor exercise. Results Basal platelet reactivity (%aggregation) to TRAP-6 (1 μm) was higher in the postmenopausal, 59% (50-68), than the premenopausal women, 45% (35-55). Exercise training reduced basal platelet reactivity to collagen (1 μg mL-1 ) in the premenopausal women only: from 63% (55-71%) to 51% (41-62%). After the training intervention, platelet aggregation was more inhibited by the arterial prostacyclin infusion and the acute exercise in both premenopausal and postmenopausal women. Conclusions These results highlight previously unknown cardioprotective aspects of regular aerobic exercise in premenopausal and postmenopausal women, improving their regulation of platelet reactivity through an increased platelet sensitivity to prostacyclin, which may counterbalance the increased atherothrombotic risk associated with the menopause.

A review and discussion of platelet nitric oxide and nitric oxide synthase: do blood platelets produce nitric oxide from L-arginine or nitrite?

The NO/sGC/cGMP/PKG system is one of the most powerful mechanisms responsible for platelet inhibition. In numerous publications, expression of functional NO synthase (NOS) in human and mouse platelets has been reported. Constitutive and inducible NOS isoforms convert L-arginine to NO and L-citrulline. The importance of this pathway in platelets and in endothelial cells for the regulation of platelet function is discussed since decades. However, there are serious doubts in the literature concerning both expression and functionality of NOS in platelets. In this review, we aim to present and critically evaluate recent data concerning NOS expression and function in platelets, and to especially emphasise potential pitfalls of detection of NOS proteins and measurement of NOS activity. Prevailing analytical problems are probably the main sources of contradictory data on occurrence, activity and function of NOS in platelets. In this review we also address issues of how these problems can be resolved. NO donors including organic nitrites (RONO) and organic nitrate (RONO2) are inhibitors of platelet activation. Endogenous inorganic nitrite (NO2 (-)), the product of NO autoxidation, and exogenous inorganic nitrite are increasingly investigated as NO donors in the circulation. The role of platelets in the generation of NO from nitrite is also discussed.

Influence of race and sex on thrombogenicity in a large cohort of coronary artery disease patients

Background

It is uncertain whether sex and race affect thrombogenicity in patients with coronary artery disease. We evaluated the effects of sex and race on thrombogenicity in patients with coronary artery disease treated with aspirin.

Methods and Results

Patients on aspirin therapy for 1 week or longer with known or suspected coronary artery disease undergoing nonurgent cardiac catheterization (n=1172), of whom 924 were on aspirin and clopidogrel therapy, were studied. The primary end point was thrombin‐induced platelet‐fibrin clot strength (MA_KH) measured by thrombelastography. Secondary end points included coagulation index, a measure of overall coagulation; G, another measure of clot strength; and maximal platelet aggregation. Women had greater MA_KH, G, and coagulation index than men, both with and without clopidogrel therapy (with clopidogrel: 68.3±6 versus 65.8±6 mm, P<0.0001; 11.4±3 versus 9.5±4 dyne/cm², P<0.0001; and 0.12±3 versus −0.7±3, P=0.003, respectively). Platelet aggregation (induced by ADP, thrombin receptor activating peptide, or collagen) did not differ between sexes. Black patients had greater MA_KH and G than white patients (with clopidogrel: 67.8±7 versus 66.4±6 mm, P=0.005; 11±4 versus 10±3 dyne/cm², P=0.02, respectively). Black women had the highest MA_KH levels. By multivariate analysis, sex, race, diabetes, platelet count, and hemoglobin level were independently associated with MA_KH. Sex, but not race, was also associated with the frequency of MA_KH ≥72 mm (a threshold related to ischemic event occurrence in patients undergoing coronary intervention).

Conclusions

Sex and race independently influence platelet‐fibrin clot strength. Black women appear to have the highest thrombogenicity profile, potentially conferring a high‐risk phenotype for thrombotic event occurrence.

Metabolism of Dehydroepiandrosterone Sulfate and Estrone-Sulfate by Human Platelets

The aim of the present research was to study the uptake of DHEAS, and to establish the intracrine capacity of human platelets to produce sex steroid hormones. The DHEAS transport was evaluated through the uptake of [3H]-DHEAS in the presence or absence of different substrates through the organic anion transporting polypeptide (OATP) family. The activity of sulfatase enzyme was evaluated, and the metabolism of DHEAS was measured by the conversion of [3H]-DHEAS to [3H]-androstenedione, [3H]-testosterone, [3H]-estrone and [3H]-17β-estradiol. Results indicated the existence in the plasma membrane of an OATP with high affinity for DHEAS and estrone sulphate (E1S). The platelets showed the capacity to convert DHEAS to active DHEA by the steroid-sulfatase activity. The cells resulted to be a potential site for androgens production, since they have the capacity to produce androstenedione and testosterone; in addition, they reduced [3H]-estrone to [3H]-17β-estradiol. This is the first demonstration that human platelets are able to import DHEAS and E1S using the OATP family and to convert DHEAS to active DHEA, and to transform E1S to 17β-estradiol.

Platelet biology and response to antiplatelet therapy in women: implications for the development and use of antiplatelet pharmacotherapies for cardiovascular disease

Women are underrepresented in cardiovascular studies, even as their preponderance in the aging population steadily increases. Although concerns have been raised about the differential benefit of antiplatelet medications for women, the propensity for increased bleeding among women has also been recognized. A better understanding of the factors contributing to the observed sex-related differences in platelet biology is warranted. These factors include differences in the frequency and expression of genetic polymorphisms affecting platelet responsiveness to agonists (with and without antiplatelet therapies), which might be obtained through population-based studies and in large controlled clinical trials; inflammatory marker levels and their influence on atherothrombotic risk, and the role of specific hormones in mediating platelet activation and function. Knowledge gained about these mechanistic factors might inform the development of sex-specific antithrombotic treatment regimens that confer optimized safety and efficacy.

The structures and inhibitory effects of Buame [N-(3-hydroxy-1,3,5(10)-estratrien-17β-yl)-butylamine] and Diebud [N,N'-bis-(3-hydroxy-1,3,5(10)-estratrien-17β-yl)-1,4-butanediamine] on platelet aggregation

Compounds with estrogenic effects that also inhibit platelet aggregation might be useful in reducing thrombotic events associated with estrogenic therapy. In this study, two aminoestrogens, Buame [N-(3-hydroxy-1,3,5(10)-estratrien-17β-yl)-butylamine] and Diebud [N,N'-bis-(3-hydroxy-1,3,5(10)-estratrien-17β-yl)-1,4-butanediamine], were synthesized and characterized using common analytical methods and spectrophotometric analyses. The location and orientation of these molecules on the estrogenic receptor α (ERα) were also evaluated. Platelet inhibitory effects were elucidated ADP-induced platelet aggregation and ADP- and collagen-induced ATP release. Molecular docking demonstrated that Buame can reach and bind to the ERα in the ligand binding domain (LBD) similar to 17β-estradiol (co-crystallized ligand). On the other hand, Diebud binds only to the surface of ERα due to its high molecular volume compared to 17β-estradiol and Buame.

Inducible nitric oxide synthase provides protection against injury-induced thrombosis in female mice

Nitric oxide (NO) is an important vasoactive molecule produced by three NO synthase (NOS) enzymes: neuronal (nNOS), inducible (iNOS), and endothelial NOS (eNOS). While eNOS contributes to blood vessel dilation that protects against the development of hypertension, iNOS has been primarily implicated as a disease-promoting isoform during atherogenesis. Despite this, iNOS may play a physiological role via the modulation of cyclooxygenase and thromboregulatory eicosanoid production. Herein, we examined the role of iNOS in a murine model of thrombosis. Blood flow was measured in carotid arteries of male and female wild-type (WT) and iNOS-deficient mice following ferric chloride-induced thrombosis. Female WT mice were more resistant to thrombotic occlusion than male counterparts but became more susceptible upon iNOS deletion. In contrast, male mice (with and without iNOS deletion) were equally susceptible to thrombosis. Deletion of iNOS was not associated with a change in the balance of thromboxane A(2) (TxA(2)) or antithrombotic prostacyclin (PGI(2)). Compared with male counterparts, female WT mice exhibited increased urinary nitrite and nitrate levels and enhanced ex vivo induction of iNOS in hearts and aortas. Our findings suggest that iNOS-derived NO in female WT mice may attenuate the effects of vascular injury. Thus, although iNOS is detrimental during atherogenesis, physiological iNOS levels may contribute to providing protection against thrombotic occlusion, a phenomenon that may be enhanced in female mice.