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Suh JW, Memtsas V, Gue YX, Cho HW, Lee W, Kang SH, Gorog DA. Ethnic Differences in Thrombotic Profiles of Acute Coronary Syndrome Patients and Relationship to Cardiovascular Outcomes: A Comparison of East Asian and White subjects. Thromb Haemost 2024; 124:501-516. [PMID: 38158199 PMCID: PMC11126334 DOI: 10.1055/s-0043-1777794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/27/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND East Asians (EAs), compared to white Caucasians (W), have a lower risk of ischemic heart disease and a higher risk of bleeding with antithrombotic medications. The underlying mechanisms are incompletely understood. OBJECTIVES We sought to compare thrombotic profiles of EA and W patients with myocardial infarction (MI) and relate these to cardiovascular outcomes. METHODS In a prospective study in the United Kingdom and Korea, blood samples from patients (n = 515) with ST- or non-ST-elevation MI (STEMI and NSTEMI) were assessed using the Global Thrombosis Test, measuring thrombotic occlusion (OT) and endogenous fibrinolysis (lysis time [LT]). Patients were followed for 1 year for major adverse cardiovascular events (MACE) and bleeding. RESULTS EA patients showed reduced OT (longer OT) compared to W (646 seconds [470-818] vs. 436 seconds [320-580], p < 0.001), with similar LT. In STEMI, OT (588 seconds [440-759] vs. 361 seconds [274-462], p < 0.001) and LT (1,854 seconds [1,389-2,729] vs. 1,338 seconds [1,104-1,788], p < 0.001) were longer in EA than W. In NSTEMI, OT was longer (OT: 734 seconds [541-866] vs. 580 seconds [474-712], p < 0.001) and LT shorter (1519 seconds [1,058-2,508] vs. 1,898 seconds [1,614-2,806], p = 0.004) in EA than W patients. MACE was more frequent in W than EA (6.3 vs. 1.9%, p = 0.014) and bleeding infrequent. While OT was unrelated, LT was a strong independent predictor of MACE event after adjustment for risk factors (hazard ratio: 3.70, 95% confidence interval: 1.43-9.57, p = 0.007), predominantly in W patients, and more so in STEMI than NSTEMI patients. CONCLUSION EA patients exhibit different global thrombotic profiles to W, associated with a lower rate of cardiovascular events.
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Affiliation(s)
- Jung-Won Suh
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Vassilios Memtsas
- Cardiovascular Division, Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Hyoung-Won Cho
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Wonjae Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Si-Hyuck Kang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Diana A. Gorog
- Cardiovascular Division, Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
- Centre for Health Services and Clinical Research, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom
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Wilschut JM, Vogel RF, Elscot JJ, Delewi R, Lemmert ME, van der Waarden NWPL, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Smits PC, Vlachojannis GJ, Van Mieghem NM, Diletti R. Prehospital crushed versus integral prasugrel loading dose in STEMI patients with a large myocardial area. EUROINTERVENTION 2024; 20:e436-e444. [PMID: 38562070 PMCID: PMC10979386 DOI: 10.4244/eij-d-23-00618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 01/15/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND The effect of administering a crushed prasugrel loading dose is uncertain in patients presenting with a large myocardial infarction and ST-segment elevation myocardial infarction (STEMI). AIMS The aim of this study was to investigate if patients with a large myocardial infarction may benefit from prehospital administration of a crushed prasugrel loading dose. METHODS Patients from the CompareCrush trial with an available ambulance electrocardiography (ECG) were included in the study. An independent core laboratory confirmed a prehospital large myocardial area. We compared pre- and postprocedural angiographic markers, including Thrombolysis in Myocardial Infarction (TIMI) 3 flow in the infarct-related artery, high thrombus burden, and myocardial blush grade 3, in STEMI patients with and without a prehospital large myocardial area. RESULTS Ambulance ECG was available for 532 patients, of whom 331 patients were identified with a prehospital large myocardial area at risk. Crushed prasugrel significantly improved postprocedural TIMI 3 flow rates in STEMI patients with a prehospital large myocardial area at risk (92% vs 79%, odds ratio [OR] 3.00, 95% confidence interval [CI]: 1.50-6.00) but not in STEMI patients without a prehospital large myocardial area at risk (91% vs 95%, OR 0.47, 95% CI: 0.14-1.57; pinteraction=0.009). CONCLUSIONS Administration of crushed prasugrel may improve postprocedural TIMI 3 flow in STEMI patients with signs of a large myocardial area at risk on the ambulance ECG. The practice of crushing tablets of prasugrel loading dose might, therefore, represent a safe, fast and cost-effective strategy to improve myocardial reperfusion in this high-risk STEMI subgroup undergoing primary percutaneous coronary intervention.
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Affiliation(s)
| | - Rosanne F Vogel
- University Medical Center Utrecht, Utrecht, the Netherlands
- Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Jacob J Elscot
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ronak Delewi
- Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Miguel E Lemmert
- Erasmus University Medical Center, Rotterdam, the Netherlands
- Isala Hospital, Zwolle, the Netherlands
| | | | - Rutger-Jan Nuis
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Dimitrios Alexopoulos
- National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Felix Zijlstra
- Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Gilles Montalescot
- Sorbonne University, ACTION group, Groupe Hospitalier Pitié Salpêtrière (AP-HP), Paris, France
| | | | | | | | | | | | - Roberto Diletti
- Erasmus University Medical Center, Rotterdam, the Netherlands
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3
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Gue YX, Memtsas V, Kanji R, Wellsted DM, Busby A, Smith M, Vilar E, Ryding A, Arachchillage DJ, Gorog DA. Impact of very low dose rivaroxaban in addition to dual antiplatelet therapy on endogenous fibrinolysis in acute coronary syndrome: The VaLiDate-R study. Thromb Res 2024; 236:144-154. [PMID: 38447421 DOI: 10.1016/j.thromres.2024.02.030] [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: 09/22/2023] [Revised: 02/16/2024] [Accepted: 02/29/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Impaired endogenous fibrinolysis is adverse cardiovascular risk factor in acute coronary syndrome (ACS) patients. Addition of very low dose rivaroxaban (VLDR) to dual antiplatelet therapy (DAPT) reduces cardiovascular events but increases bleeding. OBJECTIVE We aimed to assess whether addition of VLDR to DAPT can enhance endogenous fibrinolysis. METHODS In a prospective, open-label trial, we assessed endogenous fibrinolysis in whole blood, in 549 patients with ACS using the Global Thrombosis Test (GTT) and Thromboelastography (TEG). Patients (n = 180) who demonstrated impaired endogenous fibrinolysis (lysis time [LT] >2000s with the GTT) were randomised 1:1:1 to (i) clopidogrel 75 mg daily; (ii) clopidogrel 75 mg daily plus rivaroxaban 2.5 mg twice daily; or (iii) ticagrelor 90 mg twice daily, for 30 days, in addition to aspirin. Fibrinolytic status was assessed at 0, 2, 4 and 8 weeks. The primary outcome was the change in LT from admission to week 4. We also measured thrombotic occlusion time (OT) at high shear, and rivaroxaban level. RESULTS There was no difference between the groups with respect to LT or clot lysis with TEG, and no change in these parameters compared to baseline during study drug allocation. In the rivaroxaban plus clopidogrel group, OT was prolonged compared to the other groups, although rivaroxaban levels were low, suggesting non-compliance. CONCLUSION Addition of rivaroxaban 2.5 mg twice daily to DAPT does not affect endogenous fibrinolysis of thrombus formed at either high or low shear. Further studies are needed to determine whether higher doses of rivaroxaban can favourably modulate fibrinolysis. CONDENSED ABSTRACT Impaired endogenous fibrinolysis is a strong risk factor in ACS. We aimed to assess whether adding very low dose rivaroxaban (VLDR) to DAPT can enhance fibrinolysis. Fibrin and clot lysis were assessed in whole blood. ACS patients with impaired fibrinolysis were randomised 1:1:1 to clopidogrel 75 mg daily; clopidogrel 75 mg plus VLDR; or ticagrelor 90 mg twice daily, in addition to aspirin. At 30-days, there was no difference in lysis time between the groups, nor change from baseline. VLDR does not improve fibrinolysis at high or low shear. Further studies are needed to determine whether alternative antithrombotic regimens can enhance endogenous fibrinolysis.
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Affiliation(s)
- Ying X Gue
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Vassilios Memtsas
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom; Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Rahim Kanji
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom; Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - David M Wellsted
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Amanda Busby
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Megan Smith
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Enric Vilar
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom; Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom
| | - Alisdair Ryding
- Cardiology Department, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Deepa J Arachchillage
- Department of Haematology, Royal Brompton Hospital, London, United Kingdom; Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Diana A Gorog
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom; Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom; Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom.
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4
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Kanji R, Gue YX, Memtsas V, Spencer NH, Gorog DA. Biomarkers of Thrombotic Status Predict Spontaneous Reperfusion in Patients With ST-Segment Elevation Myocardial Infarction. J Am Coll Cardiol 2023; 81:1918-1932. [PMID: 37164525 DOI: 10.1016/j.jacc.2023.03.388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/01/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Spontaneous reperfusion, seen in ∼20% of patients with ST-segment elevation myocardial infarction (STEMI), manifests as normal epicardial flow in the infarct-related artery, with or without ST-segment resolution, before percutaneous coronary intervention (PCI). The drivers mediating this are unknown. OBJECTIVES The authors sought to relate spontaneous reperfusion to the thrombotic profile. METHODS In a prospective study, blood from STEMI patients (n = 801) was tested pre-PCI to assess in vitro, point-of-care, occlusion times (OT) and endogenous lysis times (LT). Spontaneous reperfusion was defined as infarct-related artery Thrombolysis In Myocardial Infarction flow grade 3 before PCI. Patients were followed for major cardiovascular events (death, myocardial infarction, or stroke). RESULTS Spontaneous reperfusion was associated with a longer OT (435 seconds vs 366 seconds; P < 0.001) and a shorter LT (1,257 seconds vs 1,616 seconds; P < 0.001), lower troponin, and better left ventricular function. LT was superior to OT for predicting spontaneous reperfusion (area under the curve for LT: 0.707; 95% CI: 0.661-0.753; area under the curve for OT: 0.629; 95% CI: 0.581-0.677). Among patients with spontaneous reperfusion, those with complete, vs partial ST-segment resolution, had a longer OT (P = 0.002) and a shorter LT (P < 0.001). Spontaneous reperfusion was unrelated to clinical characteristics or pain-to-angiography times. Over 4 years, patients with spontaneous reperfusion experienced fewer major adverse cardiovascular events than those without (4.1% vs 10.6%; P = 0.013), especially in those with both spontaneous reperfusion and complete ST-segment resolution (1.5% vs 10.1%; P = 0.029). CONCLUSIONS We demonstrate a novel hematological signature in STEMI patients with spontaneous reperfusion, namely, decreased platelet reactivity and faster endogenous fibrinolysis, relating to smaller infarcts and improved survival. This finding indicates a role for modulating thrombotic status early after STEMI onset, to facilitate spontaneous reperfusion and improve outcomes.
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Affiliation(s)
- Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom; Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom
| | - Ying X Gue
- Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Vassilios Memtsas
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom; Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom
| | - Neil H Spencer
- University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom; Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom; Centre for Health Services Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom.
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5
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Kanji R, Gue YX, Farag MF, Spencer NH, Mutch NJ, Gorog DA. Determinants of Endogenous Fibrinolysis in Whole Blood Under High Shear in Patients With Myocardial Infarction. JACC Basic Transl Sci 2022; 7:1069-1082. [PMID: 36687271 PMCID: PMC9849272 DOI: 10.1016/j.jacbts.2022.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/24/2022] [Accepted: 05/24/2022] [Indexed: 01/25/2023]
Abstract
Hypofibrinolysis is a recently-recognized risk factor for recurrent cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI), but the mechanistic determinants of this are not well understood. In patients with STEMI, we show that the effectiveness of endogenous fibrinolysis in whole blood is determined in part by fibrinogen level, high sensitivity C-reactive protein, and shear-induced platelet reactivity, the latter directly related to the speed of thrombin generation. Our findings strengthen the evidence for the role of cellular components and bidirectional crosstalk between coagulatory and inflammatory pathways as determinants of hypofibrinolysis.
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Affiliation(s)
- Rahim Kanji
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom
| | - Ying X. Gue
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Mohamed F. Farag
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Neil H. Spencer
- Statistical Services and Consultancy Unit, Hertfordshire Business School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Nicola J. Mutch
- Aberdeen Cardiovascular and Diabetes Centre, Institute of Medical Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Diana A. Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom,Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom,School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom,Address for correspondence: Prof Diana A. Gorog, Faculty of Medicine, National Heart and Lung Institute, Imperial College, Dovehouse Street, London SW3 6LY, United Kingdom.
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Lim HY, Donnan G, Nandurkar H, Ho P. Global coagulation assays in hypercoagulable states. J Thromb Thrombolysis 2022; 54:132-144. [PMID: 34997471 DOI: 10.1007/s11239-021-02621-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/26/2022]
Abstract
Thrombosis is one of the major global causes of morbidity and mortality, and predicting the risk of thrombotic and cardiovascular complications remains one of the key challenges in modern medicine. Conventional coagulation testing does not provide sufficient information, primarily because they measure the time to start of blood clotting and do not evaluate total thrombin generation. Possible adjunctive tools that may be helpful are global coagulation assays, which includes the assessment of the final products of the coagulation cascade, namely thrombin and fibrin. Whilst these assays have been more widely investigated in bleeding states, their role in thrombotic disorders is less established. We have previously investigated the use of assays such as thromboelastography, calibrated automated thrombogram and overall haemostatic potential assay in several hypercoagulable states including cardiovascular disease, haematological disorders and influence of hormone status as well as healthy controls. We provide a review of the use and limitations of global coagulation assays in healthy controls as well as hypercoagulable conditions.
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Affiliation(s)
- Hui Yin Lim
- Department of Haematology, Northern Pathology Victoria, Northern Health, Northern Hospital, 185 Cooper St, Epping, VIC, 3076, Australia.
- Australian Centre for Blood Diseases, Monash University - Monash AMREP Building, Level 1 Walkway via the Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia.
- Department of Medicine, Northern Health, University of Melbourne, Studley Road, Heidelberg, VIC, 3084, Australia.
| | - Geoffrey Donnan
- The Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, 4/300 Grattan St, Parkville, VIC, 3050, Australia
| | - Harshal Nandurkar
- Australian Centre for Blood Diseases, Monash University - Monash AMREP Building, Level 1 Walkway via the Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Prahlad Ho
- Department of Haematology, Northern Pathology Victoria, Northern Health, Northern Hospital, 185 Cooper St, Epping, VIC, 3076, Australia
- Australian Centre for Blood Diseases, Monash University - Monash AMREP Building, Level 1 Walkway via the Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
- Department of Medicine, Northern Health, University of Melbourne, Studley Road, Heidelberg, VIC, 3084, Australia
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7
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Gorog DA, Yamamoto J. Global Thrombosis Test: Occlusion Is Attributable to Shear-Induced Platelet Thrombus Formation. TH OPEN 2022; 5:e591-e597. [PMID: 34984319 DOI: 10.1055/s-0041-1741108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/16/2021] [Indexed: 10/19/2022] Open
Affiliation(s)
- Diana A Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom.,Clinical Pharmaceutical and Biological Science, School of Life and Medical Science, University of Hertfordshire, United Kingdom
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8
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Gorog DA, Yamamoto J. Global Thrombosis Test: Occlusion Is Attributable to Shear-Induced Platelet Thrombus Formation. TH OPEN 2021. [PMID: 34984319 PMCID: PMC8847114 DOI: 10.1055/a-1704-1022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Diana A. Gorog
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
- Clinical Pharmaceutical and Biological Science, School of Life and Medical Science, University of Hertfordshire, United Kingdom
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Clavería V, Yang PJ, Griffin MT, Ku DN. Global Thrombosis Test: Occlusion by Coagulation or SIPA? TH OPEN 2021; 5:e400-e410. [PMID: 34553123 PMCID: PMC8450046 DOI: 10.1055/s-0041-1732341] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/16/2021] [Indexed: 01/04/2023] Open
Abstract
The global thrombosis test (GTT) is a point of care device that tests thrombotic and thrombolytic status. The device exposes whole blood flow to a combination of both high and low shear stress past and between ball bearings potentially causing thrombin and fibrin formation. The question arises as to whether thrombosis in the GTT is dominated by coagulation-triggered red clot or high shear-induced white clot. We investigated the nature of the thrombus formed in the GTT, the device efficacy, human factors use, and limitations. The GTT formed clots that were histologically fibrin-rich with trapped red blood cells. The occlusion time (OT) was more consistent with coagulation than high shear white clot and was strongly lengthened by heparin and citrate, two common anticoagulants. The clot was lysed by tissue plasminogen activator (tPA), also consistent with a fibrin-rich red clot. Changing the bead to a collagen-coated surface and eliminating the low shear zone between the beads induced a rapid OT consistent with a platelet-rich thrombus that was relatively resistant to heparin or tPA. The evidence points to the GTT as occluding primarily due to fibrin-rich red clot from coagulation rather than high shear platelet aggregation and occlusion associated with arterial thrombosis.
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Affiliation(s)
- Viviana Clavería
- GWW School of Mechanical Engineering, Institute for Bioengineering and Biosciences, Georgia Institute of Technology, Atlanta, Georgia, United States
| | - Patricia J. Yang
- GWW School of Mechanical Engineering, Institute for Bioengineering and Biosciences, Georgia Institute of Technology, Atlanta, Georgia, United States
| | - Michael T. Griffin
- GWW School of Mechanical Engineering, Institute for Bioengineering and Biosciences, Georgia Institute of Technology, Atlanta, Georgia, United States
| | - David N. Ku
- GWW School of Mechanical Engineering, Institute for Bioengineering and Biosciences, Georgia Institute of Technology, Atlanta, Georgia, United States
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10
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Fibrinolysis in Platelet Thrombi. Int J Mol Sci 2021; 22:ijms22105135. [PMID: 34066261 PMCID: PMC8152010 DOI: 10.3390/ijms22105135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/08/2021] [Accepted: 05/09/2021] [Indexed: 12/17/2022] Open
Abstract
The extent and duration of occlusive thrombus formation following an arterial atherothrombotic plaque disruption may be determined by the effectiveness of endogenous fibrinolysis. The determinants of endogenous fibrinolysis are the subject of much research, and it is now broadly accepted that clot composition as well as the environment in which the thrombus was formed play a significant role. Thrombi with a high platelet content demonstrate significant resistance to fibrinolysis, and this may be attributable to an augmented ability for thrombin generation and the release of fibrinolysis inhibitors, resulting in a fibrin-dense, stable thrombus. Additional platelet activators may augment thrombin generation further, and in the case of coronary stenosis, high shear has been shown to strengthen the attachment of the thrombus to the vessel wall. Neutrophil extracellular traps contribute to fibrinolysis resistance. Additionally, platelet-mediated clot retraction, release of Factor XIII and resultant crosslinking with fibrinolysis inhibitors impart structural stability to the thrombus against dislodgment by flow. Further work is needed in this rapidly evolving field, and efforts to mimic the pathophysiological environment in vitro are essential to further elucidate the mechanism of fibrinolysis resistance and in providing models to assess the effects of pharmacotherapy.
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11
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Gue YX, Jeong YH, Farag M, Spinthakis N, Gorog DA. Precision Treatment in ACS-Role of Assessing Fibrinolysis. J Clin Med 2021; 10:jcm10050929. [PMID: 33804303 PMCID: PMC7957496 DOI: 10.3390/jcm10050929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 11/24/2022] Open
Abstract
Despite advancements in pharmacotherapy and interventional strategies, patients with acute coronary syndrome (ACS) remain at risk of recurrent thrombotic events. In addition to an enhanced tendency to thrombus formation, impairment in the ability to naturally dissolve or lyse a developing thrombus, namely impaired endogenous fibrinolysis, is responsible for a major part of this residual risk regardless of optimal antiplatelet medication. Global assessment of endogenous fibrinolysis, including a point-of-care assay, can identify patients with ACS at persistent high cardiovascular risk and might play an important role in allowing the personalisation of potent antithrombotic therapy to enhance fibrinolytic status, providing precision treatment of ACS to improve long-term outcome.
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Affiliation(s)
- Ying X. Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK;
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (M.F.); (N.S.)
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon 51472, Korea;
| | - Mohamed Farag
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (M.F.); (N.S.)
| | - Nikolaos Spinthakis
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (M.F.); (N.S.)
| | - Diana A. Gorog
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (M.F.); (N.S.)
- National Heart and Lung Institute, Imperial College, London SW3 6LY, UK
- Correspondence:
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12
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Gue YX, Kanji R, Wellsted DM, Srinivasan M, Wyatt S, Gorog DA. Rationale and design of "Can Very Low Dose Rivaroxaban (VLDR) in addition to dual antiplatelet therapy improve thrombotic status in acute coronary syndrome (VaLiDate-R)" study : A randomised trial modulating endogenous fibrinolysis in patients with acute coronary syndrome. J Thromb Thrombolysis 2020; 49:192-198. [PMID: 31872349 PMCID: PMC6969858 DOI: 10.1007/s11239-019-02014-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Impaired endogenous fibrinolysis is novel biomarker that can identify patients with ACS at increased cardiovascular risk. The addition of Very Low Dose Rivaroxaban (VLDR) to dual antiplatelet therapy has been shown to reduce cardiovascular events but at a cost of increased bleeding and is therefore not suitable for all-comers. Targeted additional pharmacotherapy with VLDR to improve endogenous fibrinolysis may improve outcomes in high-risk patients, whilst avoiding unnecessary bleeding in low-risk individuals. The VaLiDate-R study (ClinicalTrials.gov Identifier: NCT03775746, EudraCT: 2018-003299-11) is an investigator-initiated, randomised, open-label, single centre trial comparing the effect of 3 antithrombotic regimens on endogenous fibrinolysis in 150 patients with ACS. Subjects whose screening blood test shows impaired fibrinolytic status (lysis time > 2000s), will be randomised to one of 3 treatment arms in a 1:1:1 ratio: clopidogrel 75 mg daily (Group 1); clopidogrel 75 mg daily plus rivaroxaban 2.5 mg twice daily (Group 2); ticagrelor 90 mg twice daily (Group 3), in addition to aspirin 75 mg daily. Rivaroxaban will be given for 30 days. Fibrinolytic status will be assessed during admission and at 2, 4 and 8 weeks. The primary outcome measure is the change in fibrinolysis time from admission to 4 weeks follow-up, using the Global Thrombosis Test. If VLDR can improve endogenous fibrinolysis in ACS, future large-scale studies would be required to assess whether targeted use of VLDR in patients with ACS and impaired fibrinolysis can translate into improved clinical outcomes, with reduction in major adverse cardiovascular events in this high-risk cohort.
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Affiliation(s)
- Ying X Gue
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
- Cardiology Department, East and North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Rahim Kanji
- Cardiology Department, East and North Hertfordshire NHS Trust, Hertfordshire, UK
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, UK
| | - David M Wellsted
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | | | - Solange Wyatt
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK
| | - Diana A Gorog
- Department of Postgraduate Medicine, University of Hertfordshire, Hatfield, UK.
- Cardiology Department, East and North Hertfordshire NHS Trust, Hertfordshire, UK.
- National Heart and Lung Institute, Imperial College, Dovehouse Street, London, SW3 6LY, UK.
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Gorog DA, Lip GYH. Impaired Spontaneous/Endogenous Fibrinolytic Status as New Cardiovascular Risk Factor?: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 74:1366-1375. [PMID: 31488274 DOI: 10.1016/j.jacc.2019.07.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Revised: 06/17/2019] [Accepted: 07/19/2019] [Indexed: 12/27/2022]
Abstract
Endogenous fibrinolysis is a powerful natural defense mechanism against lasting arterial thrombotic occlusion. Recent prospective studies have shown that impaired endogenous fibrinolysis (or hypofibrinolysis) can be detected in a significant number of patients with acute coronary syndrome (ACS) using global assays and is a strong marker of future cardiovascular risk. This novel risk biomarker is independent of traditional cardiovascular risk factors and unaffected by antiplatelet therapy. Most prospective prognostic data have been obtained using a global assay using native whole blood at high shear or plasma turbidimetric assays, which are described herein. Tests of endogenous fibrinolysis could be used to identify patients with ACS who, despite antiplatelet therapy, remain at high cardiovascular risk. This review discusses the impact of currently available medications and those in development that favorably modulate fibrinolytic status and may offer a potential new avenue to improve outcomes in ACS.
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Affiliation(s)
- Diana A Gorog
- National Heart and Lung Institute, Imperial College, London, United Kingdom; Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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14
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Optimal Timing of Invasive Coronary Angiography following NSTEMI. J Interv Cardiol 2020; 2020:8513257. [PMID: 32206045 PMCID: PMC7073472 DOI: 10.1155/2020/8513257] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/17/2020] [Indexed: 11/18/2022] Open
Abstract
Objective To obtain a real-world perspective of the optimal timing of angiography performed within 24 hours of admission with non-ST elevation myocardial infarction (NSTEMI). Background Current guidelines recommend angiography within 24 hours of hospitalisation with NSTEMI. The recent VERDICT trial found that angiography within 12 hours of admission with NSTEMI was associated with improved cardiovascular outcomes among high-risk patients. We compared the outcomes of real-world NSTEMI patients undergoing angiography within 12 hours of admission with those of patients undergoing angiography 12 to 24 hours after admission. Methods NSTEMI patients without life-threatening features who received angiography within 24 hours of admission were obtained from the SPUM-ACS registry, a cohort of consecutive patients admitted with acute coronary syndromes to four university hospitals in Switzerland. Cox models assessed for an association between door-to-catheter time and one-year major adverse cardiovascular events (MACE: cardiovascular mortality, myocardial infarction, and stroke). Results Of 2672 NSTEMI patients, 1832 met the inclusion criteria. Among them, 1464 patients underwent angiography within 12 hours (12 h group) compared with 368 patients between 12 and 24 hours (12-24 h group). Multiple logistic regression identified out-of-hours admission as the only factor associated with delayed angiography. After 2 : 1 propensity score matching, 736 patients from the 12 h group and 368 patients from the 12-24 h group demonstrated no significant difference in rates of one-year MACE (7.7% vs. 7.3%, HR: 1.050, 95% CI 0.637-1.733, p=0.847). Stratification by GRACE score (>140 vs. ≤140) found no significant reduction in MACE among high-risk patients in the 12 h group (p=0.847). Stratification by GRACE score (>140 vs. ≤140) found no significant reduction in MACE among high-risk patients in the 12 h group (. Conclusions In an unselected real-world cohort of NSTEMI patients, angiography within 12 hours of admission was not associated with improved one-year cardiovascular outcomes when compared with angiography 12 and 24 hours after admission, even among high-risk patients.
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Graßler A, Bauernschmitt R, Guthoff I, Kunert A, Hoenicka M, Albrecht G, Liebold A. Effects of pulsatile minimal invasive extracorporeal circulation on fibrinolysis and organ protection in adult cardiac surgery-a prospective randomized trial. J Thorac Dis 2019; 11:S1453-S1463. [PMID: 31293794 DOI: 10.21037/jtd.2019.02.66] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Minimal invasive extracorporeal circulation (MiECC) reduces the impact of cardiopulmonary bypass during cardiac surgery on inflammation and hemostasis. Pulsatile perfusion may enhance organ perfusion and help to prevent renal and neuronal damage. The present study investigated the impact of pulsatile MiECC in low-risk coronary artery bypass grafting (CABG) patients. Methods CABG patients were prospectively randomized for non-pulsatile (np: n=19) and pulsatile (p: n=21) MiECC. Blood and urine samples were collected at several time points until 72 h post-operative and analyzed for biochemical markers of fibrinolytic capacity, renal damage, and neuronal damage. Results Although intraoperative tissue plasminogen activator (tPA) levels tended to be higher in the p group, none of the fibrinolysis markers including plasminogen activator inhibitor (PAI-1) and the PAI-1/tPA ratio were significantly affected by pulsation. Hemolysis and markers of renal and neuronal damage were comparable between groups. Intraoperative urinary excretion [np: 400 mL (355 to 680) vs. p: 530 mL (360 to 900)] and cumulative 24 h volume intake [np: 7,090 mL (5,492 to 7,544) vs. p: 7,155 mL (6,682 to 8,710)] were increased by pulsation whereas blood losses up to 12 h post-operative [np: 365 mL (270 to 515) vs. p: 310 mL (225 to 470)] and up to 24 h post-operative [np: 760 mL (555 to 870) vs. p: 520 mL (460 to 670)] were attenuated. Conclusions The present study did not find evidence for a beneficial effect of pulsation on markers of fibrinolysis, renal damage, and neuronal damage. However, pulsatile perfusion increased intraoperative urinary secretion and reduced post-operative blood losses.
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Affiliation(s)
- Angelika Graßler
- Department of Cardiothoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany.,RoMed Clinical Center Rosenheim, Department of Internal Medicine III, Rosenheim, Germany
| | - Robert Bauernschmitt
- Department of Cardiothoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany.,MediClin Herzzentrum, Department of Cardiothoracic and Vascular Surgery, Lahr, Germany
| | - Irene Guthoff
- Department of Cardiothoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - Andreas Kunert
- Department of Cardiothoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - Markus Hoenicka
- Department of Cardiothoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - Günter Albrecht
- Department of Cardiothoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, University of Ulm Medical Center, Ulm, Germany
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A point-of-care global thrombosis test measuring occlusion time and endogenous lysis time may indicate thrombotic status. Future Sci OA 2019; 5:FSO402. [PMID: 31285845 PMCID: PMC6609900 DOI: 10.2144/fsoa-2019-0052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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