Relationship Between Inflammation and Venous Thromboembolism as Studied by Microparticle Assessment in Plasma**Editorials published in the Journal of the American College of Cardiologyreflect the views of the authors and do not necessarily represent the views of JACCor the American College of Cardiology

Trauma magnitude of the meta-epyphyseal cancellous affects the incidence of deep vein thrombosis. A prospective cohort study on the dynamic of Collagen I, Collagen IV, Tissue factor, P-Selectin and Nitric Oxide in the thrombus formation following hip and knee surgeries

INTRODUCTION

The purpose of this study was to analyze the traumatization degree of meta-epiphyseal cancellous of hip and knee joints in major orthopedic surgery that affects the incident of deep vein thrombosis (DVT) event through the dynamics expression of pro-thrombogenic biomarkers (Collagen I, Collagen IV, Tissue Factor, P-selectin) and anti-thrombogenic (Nitric Oxide).

METHODS

In this cohort prospective study, there were sixty-nine (69) subjects that were divided into three (3) groups, with twenty-three (23) subjects that were treated with total arthroplasty (TA), twenty-two (22) subjects were treated with hemiarthroplasty (HA), twenty-four (24) subjects were treated with open reduction internal fixation (ORIF). Subjects from May 2010 to September 2011 who met the inclusion criteria were included in this study. All patients were treated without thromboprophylaxis. Blood samples were taken in three different periods, before surgery, 72 h, and 144 h after surgery, for examination of pro-thrombogenic biomarkers (Collagen I, Collagen IV, Tissue Factor, P-selectin) and anti-thrombogenic (Nitric Oxide), which are the components involved in the hemostasis.

RESULTS

DVTs were proven by venography (or Doppler ultrasound in 8 cases) done at 144 h after the surgeries. Eighteen (18) subjects had DVT (26.1%), with ten (10) subjects from the TA group (43.5%), five (5) subjects from the HA group (22.7%), and three (3) subjects from ORIF groups (12.5) %). The risk for experiencing DVT on TA is 3.5 times more than the ORIF group, while in HA group is 2.1 times more than ORIF group. The role of biomarker levels on DVT incidence was found in Col I (p < 0.1) and NO (p < 0.05) at 72 h after surgery.

CONCLUSION

This research confirms that trauma magnitude of the meta-epiphyseal cancellous of hip and knee joints in major orthopedic surgery influences the incidence of DVTs, through the elevation of Col I and NO. An estimated 72 h after surgery is a useful period to examine these biomarkers to help predict the diagnose of DVT. The involvement of the other biomarkers studied (Col IV, TF, and Ps) could not be proven. Future studies are needed to evaluate other biomarkers in the complex process of hemostasis to establish the diagnose of DVT.

In patients with superficial vein thrombosis the inflammatory response is increased and related to the recanalization rate

INTRODUCTION

Little is known about pathogenetic mechanisms of superficial venous thrombosis (SVT). We aimed to investigate the systemic inflammatory response in the acute phase of SVT, the time course of inflammatory markers and involvement of inflammation in resolution of thrombus in SVT.

MATERIAL AND METHODS

The circulatory inflammatory parameters high-sensitivity C-reactive protein (hsCRP), tumor necrosis factor α (TNF-α), interleukins 6, 8 and 10 (IL-6, IL-8, IL-10), and markers of fibrinolytic activity tissue plasminogen activator (t-PA), plasminogen activator inhibitor-1 (PAI-1) and fibrinogen were determined in 68 patients with acute SVT of lower limbs, who were allocated to two groups, dalteparin 5000 IU once daily or 10 000 IU once daily. Recanalization of occluded veins was monitored by ultrasonography at regular intervals. Blood was drawn in the acute phase and after 12 weeks.

RESULTS

In the acute phase a majority of the measured inflammatory markers were increased, while after 12 weeks most of them significantly dropped: hsCRP: 13.6 ±11.9 vs. 7.4 ±4.4, p < 0.001; IL-6: 3.8 ±3.1 vs. 2.6 ±1.9, p = 0.007. Significant changes in endogenic fibrinolytic parameters were also observed: t-PA activity decreased (0.81 ±0.35 vs. 0.68 ±0.34, p = 0.003), while PAI-1 levels increased (5.6 ±5.1 vs. 8.8 ±8.5, p < 0.001). Levels of inflammatory markers at inclusion and after 12 weeks were related to less effective thrombus resolution: CRP: r = 0.386, p = 0.001; IL-6: r = 0.384; TNF-α: r = 0.255, p = 0.037.

CONCLUSIONS

In the acute phase of SVT, most of the circulating inflammatory markers were increased and most of their levels decreased after 12 weeks. Levels of inflammatory markers were negatively correlated with the recanalization rate.

Patients With a History of Idiopathic Deep Venous Thrombosis Have Long-Term Increased Levels of Inflammatory Markers and Markers of Endothelial Damage

INTRODUCTION

Although the role of inflammation in DVT has been investigated in different studies, there is no definite answer as to whether increased systemic inflammation is the cause or the consequence of DVT.

AIM

To follow inflammatory parameters in a cohort of patients with idiopathic DVT.

METHODS

Out of 49 patients with an acute idiopathic DVT, which were investigated four months after an acute episode (DEVTA 1), 43 patients were included in the follow-up study investigating inflammatory markers and hemostatic markers of endothelial damage five years after an acute DVT (DEVTA 2). A control group consisted of 43 sex and age matched healthy subjects (CONTROLS).

RESULTS

The levels of inflammatory markers were significantly higher in DEVTA 2 in comparison to CONTROLS: tumor necrosis factor alpha 2.0 pg/mL (1.1-2.3) vs 1.3 pg/mL (0.8-1.9), p < .001, high sensitivity C-reactive protein 3.2 mg/L (1.5-5.2) vs 1.7 mg/L (0.9-3.0), p = .008, interleukin-6 (IL-6) 2.7 pg/mL (2.0-3.5) vs 2.1 pg/mL (1.5-2.6), p = .025, IL-8 5.0 pg/mL (3.6-7.3) vs 2.4 pg/mL (1.8-2.8), p < .001. IL-10 was significantly decreased (0.9 pg/mL (0.7-1.8) vs 1.8 (1.5-2.2), p < .001. Most of the proinflammatory markers remained elevated in the DEVTA 2 in comparison to DEVTA 1. Markers of endothelial damage were higher in DEVTA 2 in comparison to CONTROLS and higher than in DEVTA 1.

CONCLUSION

Patients with idiopathic DVT have long-term increased inflammatory markers and markers of endothelial damage. These findings favor the hypothesis that inflammation is a cause and not merely a consequence of acute DVT.

Microvesicles at the crossroads between infection and cardiovascular diseases

Observational and experimental studies continue to support the association of infection and infection-stimulated inflammation with development of cardiovascular disease (CVD) including atherosclerosis and thrombosis. Microvesicles (MV) are heterogeneous populations of sealed membrane-derived vesicles shed into circulation by activated mammalian cells and/or pathogenic microbes that may represent an interface between bacterial/microbial infection and increased risk of CVD. This review evaluates how MV act to modulate and intersect immunological and inflammatory responses to infection with particular attention to progression of CVD. Although infection-related stimuli provoke release of MV from blood and vascular cells, MV express phosphatidylserine and other procoagulant factors on their surface, which initiate and amplify blood coagulation. In addition, MV mediate cell-cell adhesion, which may stimulate production of pro-inflammatory cytokines in vascular cells, which in turn aggravate progression of CVD and propagate atherothrombosis. MV transfer membrane receptors, RNA and proteins among cells, and present auto-antigens from their cells of origin to proximal or remote target cells. Because MV harbor cell surface proteins and contain cytoplasmic components of the parent cell, they mediate biological messages and play a pivotal role in the crossroad between infection-stimulated inflammation and CVDs.

Increased platelet, leukocyte and endothelial microparticles predict enhanced coagulation and vascular inflammation in pulmonary hypertension

Pulmonary hypertension (PH) is associated with platelet activation, vascular inflammation and endothelial dysfunction leading to often life threatening thrombo-embolic complications. Microparticles (MPs) are cell vesicles with strong coagulatory and inflammatory effects being released during cell activation and apoptosis. As there are currently no established surrogate markers predicting platelet activation and pro-coagulation in PH patients, the aim of the study was to analyze different pro-coagulatory MP populations that might be related to thrombo-embolic complications in PH patients. Circulating MPs from platelet- (PMP, CD31(+)/61(+)), leukocyte- (LMP, CD11b(+)) and endothelial- (EMP, CD62E(+)) origin were measured by flow cytometry in 19 PH patients and were compared to 16 controls. PH patients had increased levels of PMP (PH vs. control 1,016 ± 201 vs. 527 ± 59 counts per min [cpm], P = 0.032), LMP (PH vs. control 31 ± 3 cpm vs. 18 ± 2 cpm, P = 0.001) and EMP (PH vs. control 99 ± 14 cpm vs. 46 ± 6 cpm, P = 0.001). Furthermore, PMP correlated to LMP (PMP vs. LMP: r = 0.75, P < 0.001) and LMP correlated to EMP levels (LMP vs. EMP, r = 0.74, P < 0.001) indicating a functional interaction between the different types of MP. In comparison to non-embolic PH patients, patients with a thrombo-embolic PH suffered from enhanced endothelial cell dysfunction as represented by significantly increased EMP levels (thrombo-embolic PH vs. non-embolic PH 137 ± 27 vs. 72 ± 10, P = 0.02). PH patients have increased levels of platelet-, leukocyte- and endothelial MP indicating an increased vascular pro-coagulation and inflammation which might be related to thrombo-embolic complications as well as PH progression.

D-dimers, thrombin-antithrombin complexes, and risk factors for thromboembolism in hospitalized patient

INTRODUCTION

There is lack of data about the correlation between hemostatic markers and the clinical and biological risk factors (RFs) for venous thromboembolism (VTE) in medical inpatients without suspicion of acute VTE.

MATERIAL AND METHODS

To evaluate the coagulation activation status in patients with current known RFs for VTE, the authors measured 2 markers of hypercoagulability, thrombin antithrombin (TAT) complexes and D-dimers, at day 1 in 165 patients hospitalized in internal medicine wards without suspected acute VTE. All known RFs for VTE were systematically assessed at admission and classified in a chronological way as permanent or transient.

RESULTS

Surprisingly, TAT values followed a multimodal distribution. D-dimers showed a normal distribution after a logarithmic transformation (P = .34, Shapiro-Wilk test). Interestingly, a significant progression in D-dimer levels was found according to the chronological classification of RFs. D-dimer variations on multivariate analysis (not applicable for TAT because of the multimodal distribution) correlated independently with a recent inability to walk and an increase in C reactive protein level more than 10 mg/L.

CONCLUSIONS

(a) this study is the first to describe the variations of hypercoagulability markers according to a systematic screening of RFs for VTE in inpatients without suspicion of acute VTE, (b) TAT appeared as a less relevant marker of hypercoagulability than D-dimers in internal medicine inpatients, (d) the chronological classification of RFs identified clearly groups at risk for the prethrombotic state, and (d) an increased hypercoagulability state was demonstrated in patients with an association between a recent immobility and increased inflammatory markers.

[Risk of venous thromboembolism in the course of acute medical illness. Part 1: Basic research, clinical models, descriptive and analytic epidemiology]

PURPOSE

Some acute medical illnesses are associated with an increased risk of venous thromboembolism. This risk is difficult to assess in medical patients on account of the multiplicity of their pathologies, leading to potential interactions between numerous risk factors.

CURRENT KNOWLEDGE AND KEY POINTS

A rational analysis of the risk of venous thrombosis in acute medical setting may be derived from pathogenic models and be based on elementary risk factors for venous thromboembolism classified as transient, permanent, major and intermediate factors. The systematic study of pathophysiological mechanisms in process, in each medical patient could guide the physician attitude toward still non-evaluated situations.

FUTURE PROSPECTS AND PROJECTS

A synthesis of the last epidemiological and pathophysiological data is developed in the first part of this literature review, whereas the risk linked to specific situations in ambulatory, hospital or internal medicine settings will be described in the second part.

Proteomics and transfusion medicine: Future perspectives

Limited number of important discoveries have greatly contributed to the progresses achieved in the blood transfusion; ABO histo-blood groups, citrate as anticoagulant, fractionation of plasma proteins, plastic bags and apheresis machines. Three major types of blood products are transfused to patients: red cell concentrates, platelet concentrates and fresh frozen plasma. Several parameters of these products change during storage process and they have been well studied over the years. However, several aspects have completely been ignored; in particular those related to peptide and protein changes. This review presents what has been done using proteomic tools and the potentials of proteomics for transfusion medicine.

The pivotal role of the endothelium in haemostasis and thrombosis

The endothelium plays a pivotal role in the regulation of the haemostatic balance. The function of endothelial cells exceeds far beyond providing a non-thrombogenic inner layer of the vascular wall which maintains the blood fluidity. In physiological circumstances endothelial cells carefully prevent thrombosis by different anticoagulant and antiplatelet mechanisms. Endothelial cells are involved in all major haemostatic pathways upon vascular injury and limit clot formation to the areas where haemostasis is needed to restore vascular integrity. Failure of this complex balance between pro- and anticoagulant systems because of genetic or acquired disturbances may result in bleeding or thrombosis. Endothelial heterogeneity assures adequate homeostasis in the different organs and parts of the vascular tree. The local environment induces heterogeneous endothelial cell phenotypes determined by local needs. This heterogeneity also explains the diverse pathological responses upon disturbed vascular integrity. Localised manifestation of thrombosis in spite of systemic procoagulant disturbances depends on vascular bed-specific properties. Endothelial dysfunction not only precedes atherogenesis but may also predispose to arterial thrombosis. The potential role of the endothelium in venous thrombosis with and without overt vessel wall injury is discussed. The vast majority of endothelial cells are located in the microvessels. Therefore, it is no surprise that endothelial cells play a key role in microcirculatory diseases such as thrombotic microangiopathies and diffuse intravascular coagulation. Microcirculatory endothelial cell activation is an important feature in all thrombotic microangiopathies. In diffuse intravascular coagulation, the endothelium is the interface between inflammation and inappropriate activation of the coagulation system.