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Chen Y, Gue Y, McDowell G, Gorog DA, Lip GYH. Impaired endogenous fibrinolysis status: a potential prognostic predictor in ischemic stroke. Minerva Med 2024; 115:364-379. [PMID: 38727704 DOI: 10.23736/s0026-4806.24.09133-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
Stroke confers a severe global healthcare burden, hence exploring risk factors for stroke occurrence and prognosis is important for stroke prevention and post-stroke management strategies. Endogenous fibrinolysis is a spontaneous physiological protective mechanism that dissolves thrombus to maintain vascular patency. Recently, impaired endogenous fibrinolysis has been considered as a potential novel cardiovascular risk factor, but its link with ischaemic stroke in the past has been underappreciated. In this review, we summarize the latest mechanisms of endogenous fibrinolysis, review the current evidence and data on endogenous fibrinolysis in ischemic stroke. It includes the structure of thrombus in ischemic stroke patients, the effect of fibrin structure on the endogenous fibrinolytic efficiency, and the association between intravenous thrombolytic therapy and endogenous fibrinolysis in ischemic stroke. It also includes the single factors (tissue plasminogen activator, urokinase plasminogen activator, plasminogen activator inhibitor-1, thrombin activatable fibrinolysis inhibitor, complement component 3, complement component 5, alpha-2-antiplasmin, plasmin-alpha-2-antiplasmin complex, and lipoprotein[a]), and the global assessments of endogenous fibrinolysis status (thromboelastography, rotational thromboelastometry, and global thrombosis test), and their potential as predictors to identify occurrence or unfavorable functional outcomes of ischemic stroke. All of these assessments present advantages and limitations, and we suggest that the global thrombosis test may be more appropriate for detecting impaired endogenous fibrinolysis status in ischemic stroke patients.
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Affiliation(s)
- Yang Chen
- Liverpool Center for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Ying Gue
- Liverpool Center for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool Heart and Chest Hospital, Liverpool, UK -
| | - Garry McDowell
- Liverpool Center for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool Heart and Chest Hospital, Liverpool, UK
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, UK
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, UK
| | - Gregory Y H Lip
- Liverpool Center for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Paszek E, Malinowski KP, Ząbczyk M, Butenas S, Undas A. Elevated factor XIa as a modulator of plasma fibrin clot properties in coronary artery disease. Eur J Clin Invest 2023; 53:e14007. [PMID: 37042848 DOI: 10.1111/eci.14007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/12/2023] [Accepted: 04/11/2023] [Indexed: 04/13/2023]
Abstract
INTRODUCTION Patients with coronary artery disease (CAD) display a prothrombotic fibrin clot phenotype, involving low permeability and resistance to lysis. The determinants of this phenotype remain elusive. Circulating tissue factor (TF) and activated factor XI (FXIa) are linked to arterial thromboembolism. We investigated whether detectable active TF and FXIa influence fibrin clot properties in CAD. METHODS In 118 CAD patients (median age 65 years, 78% men), we assessed Ks, an indicator of clot permeability, and clot lysis time (CLT) in plasma-based assays, along with the presence of active TF and FXIa. We also analysed proteins involved in clotting and thrombolysis, including fibrinogen, plasminogen activator inhibitor-1 (PAI-1) and thrombin activatable thrombolysis inhibitor (TAFI). During a median 106 month (interquartile range 95-119) follow-up, myocardial infarction (MI), stroke, systemic thromboembolism (SE) and cardiovascular (CV) death were recorded. RESULTS Circulating TF and FXIa, detected in 20.3% and 39.8% of patients, respectively, were associated with low Ks and prolonged CLT. Solely FXIa remained an independent predictor of low Ks and high CLT on multivariable analysis. Additionally, fibrinogen and PAI-1 were associated with low Ks, while PAI-1 and TAFI-with prolonged CLT. During follow-up low Ks and prolonged CLT increased the risk of MI and the latter also a composite endpoint of MI, stroke/SE or CV death. CONCLUSIONS To our knowledge, this study is the first to show that circulating FXIa is associated with prothrombotic fibrin clot properties in CAD, suggesting additional mechanisms through which FXIa inhibitors could act as novel antithrombotic agents in CAD.
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Affiliation(s)
- Elżbieta Paszek
- Clinical Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof P Malinowski
- Department of Bioinformatics and Telemedicine, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
- Center for Digital Medicine and Robotics, Jagiellonian University Medical College, Krakow, Poland
| | - Michał Ząbczyk
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Krakow Center for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
| | - Saulius Butenas
- Department of Biochemistry, University of Vermont, Burlington, Vermont, USA
| | - Anetta Undas
- Department of Thromboembolic Disorders, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Krakow Center for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
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Wang YL, Zhang HX, Chen YQ, Yang LL, Li ZJ, Zhao M, Li WL, Bian YY, Zeng L. Research on Mechanisms of Chinese Medicines in Prevention and Treatment of Postoperative Adhesion. Chin J Integr Med 2023; 29:556-565. [PMID: 37052766 DOI: 10.1007/s11655-023-3735-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 04/14/2023]
Abstract
Postoperative adhesion (PA) is currently one of the most unpleasant complications following surgical procedures. Researchers have developed several new strategies to alleviate the formation of PA to a great extent, but so far, no single measure or treatment can meet the expectations and requirements of clinical patients needing complete PA prevention. Chinese medicine (CM) has been widely used for thousands of years based on its remarkable efficacy and indispensable advantages CM treatments are gradually being accepted by modern medicine. Therefore, this review summarizes the formating process of PA and the efficacy and action mechanism of CM treatments, including their pharmacological effects, therapeutic mechanisms and advantages in PA prevention. We aim to improve the understanding of clinicians and researchers on CM prevention in the development of PA and promote the in-depth development and industrialization process of related drugs.
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Affiliation(s)
- Ya-Li Wang
- School of First Clinical Medicine, Nanjing University of Chinese Medicine, Nanjing, 210023, China
- Jiangsu Provincial Engineering Center of Traditional Chinese Medicine External Medication Researching and Industrializing, Nanjing University of Chinese Medicine, Nanjing, 210023, China
| | - Hui-Xiang Zhang
- School of First Clinical Medicine, Nanjing University of Chinese Medicine, Nanjing, 210023, China
| | - Yan-Qi Chen
- School of First Clinical Medicine, Nanjing University of Chinese Medicine, Nanjing, 210023, China
- Jiangsu Provincial Engineering Center of Traditional Chinese Medicine External Medication Researching and Industrializing, Nanjing University of Chinese Medicine, Nanjing, 210023, China
| | - Li-Li Yang
- School of First Clinical Medicine, Nanjing University of Chinese Medicine, Nanjing, 210023, China
- Jiangsu Provincial Engineering Center of Traditional Chinese Medicine External Medication Researching and Industrializing, Nanjing University of Chinese Medicine, Nanjing, 210023, China
- Jingwen Library, Nanjing University of Chinese Medicine, Nanjing, 210023, China
| | - Zheng-Jun Li
- College of Health Economics Management, Nanjing University of Chinese Medicine, Nanjing, 210023, China
| | - Min Zhao
- School of Chinese Medicine, School of Integrated Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, 210023, China
| | - Wen-Lin Li
- Jingwen Library, Nanjing University of Chinese Medicine, Nanjing, 210023, China
| | - Yao-Yao Bian
- Jiangsu Provincial Engineering Center of Traditional Chinese Medicine External Medication Researching and Industrializing, Nanjing University of Chinese Medicine, Nanjing, 210023, China
- School of Second Clinical Medicine, Nanjing University of Chinese Medicine, Nanjing, 210023, China
| | - Li Zeng
- School of First Clinical Medicine, Nanjing University of Chinese Medicine, Nanjing, 210023, China.
- Jiangsu Provincial Engineering Center of Traditional Chinese Medicine External Medication Researching and Industrializing, Nanjing University of Chinese Medicine, Nanjing, 210023, China.
- Jingwen Library, Nanjing University of Chinese Medicine, Nanjing, 210023, China.
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Ząbczyk M, Ariëns RAS, Undas A. Fibrin clot properties in cardiovascular disease: from basic mechanisms to clinical practice. Cardiovasc Res 2023; 119:94-111. [PMID: 36662542 PMCID: PMC10377755 DOI: 10.1093/cvr/cvad017] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/28/2022] [Accepted: 11/14/2022] [Indexed: 01/21/2023] Open
Abstract
Fibrinogen conversion into insoluble fibrin and the formation of a stable clot is the final step of the coagulation cascade. Fibrin clot porosity and its susceptibility to plasmin-mediated lysis are the key fibrin measures, describing the properties of clots prepared ex vivo from citrated plasma. Cardiovascular disease (CVD), referring to coronary heart disease, heart failure, stroke, and hypertension, has been shown to be associated with the formation of dense fibrin networks that are relatively resistant to lysis. Denser fibrin mesh characterized acute patients at the onset of myocardial infarction or ischaemic stroke, while hypofibrinolysis has been identified as a persistent fibrin feature in patients following thrombotic events or in those with stable coronary artery disease. Traditional cardiovascular risk factors, such as smoking, diabetes mellitus, hyperlipidaemia, obesity, and hypertension, have also been linked with unfavourably altered fibrin clot properties, while some lifestyle modifications and pharmacological treatment, in particular statins and anticoagulants, may improve fibrin structure and function. Prospective studies have suggested that prothrombotic fibrin clot phenotype can predict cardiovascular events in short- and long-term follow-ups. Mutations and splice variants of the fibrinogen molecule that have been proved to be associated with thrombophilia or increased cardiovascular risk, along with fibrinogen post-translational modifications, prothrombotic state, inflammation, platelet activation, and neutrophil extracellular traps formation, contribute also to prothrombotic fibrin clot phenotype. Moreover, about 500 clot-bound proteins have been identified within plasma fibrin clots, including fibronectin, α2-antiplasmin, factor XIII, complement component C3, and histidine-rich glycoprotein. This review summarizes the current knowledge on the mechanisms underlying unfavourable fibrin clot properties and their implications in CVD and its thrombo-embolic manifestations.
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Affiliation(s)
- Michał Ząbczyk
- Thromboembolic Disorders Department, Institute of Cardiology, Jagiellonian University Medical College, 80 Pradnicka St, 31-202 Krakow, Poland
- Krakow Center for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
| | - Robert A S Ariëns
- Discovery and Translational Science Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Anetta Undas
- Thromboembolic Disorders Department, Institute of Cardiology, Jagiellonian University Medical College, 80 Pradnicka St, 31-202 Krakow, Poland
- Krakow Center for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
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Accelerated fibrin clot degradation is associated with arterial thromboembolism in patients following venous thrombosis: a cohort study. Sci Rep 2021; 11:21003. [PMID: 34702844 PMCID: PMC8548328 DOI: 10.1038/s41598-021-00411-6] [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: 02/19/2021] [Accepted: 09/24/2021] [Indexed: 11/08/2022] Open
Abstract
Several lines of evidence have suggested that patients following venous thromboembolism (VTE) are at higher risk of arterial thromboembolism (ATE). Prothrombotic fibrin clot characteristics were reported in individuals with cardiovascular risk factors. We investigated whether specific fibrin clot properties measured after 3-4 months of anticoagulation characterize VTE patients with subsequent ATE. We enrolled 320 patients following VTE aged below 70 years (median age, 46). Ten patients were lost to follow-up. ATE occurred in 21 individuals after a median 54 (31-68) months during a follow-up of 87.5 months (incidence 0.94%; 95% confidence interval [CI], 0.59-1.4 per patient-year). Patients with ATE had faster fibrin clot degradation, reflected by maximum rate of D-dimer increase during plasma clot lysis induced by tissue-type plasminogen activator (D-Drate) at baseline. Clot permeability, turbidimetric variables, clot lysis time, and thrombin generation were unrelated to ATE. Univariable Cox proportional hazards analysis showed that age, diabetes, and D-Drate were risk factors for subsequent ATE. Increased D-Drate (by 0.001 mg/L/min; hazard ratio, 1.08; 95% CI 1.02-1.14) was an independent predictor of ATE after adjustment for potential confounders. Faster fibrin clot degradation at 3 months since VTE may increase the risk of ATE among VTE patients during follow-up.
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Fibrin Clot Properties in Atherosclerotic Vascular Disease: From Pathophysiology to Clinical Outcomes. J Clin Med 2021; 10:jcm10132999. [PMID: 34279484 PMCID: PMC8268932 DOI: 10.3390/jcm10132999] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/29/2021] [Indexed: 01/15/2023] Open
Abstract
Fibrin is a major component of thrombi formed on the surface of atherosclerotic plaques. Fibrin accumulation as a consequence of local blood coagulation activation takes place inside atherosclerotic lesions and contributes to their growth. The imbalance between thrombin-mediated fibrin formation and fibrin degradation might enhance atherosclerosis in relation to inflammatory states reflected by increased fibrinogen concentrations, the key determinant of fibrin characteristics. There are large interindividual differences in fibrin clot structure and function measured in plasma-based assays and in purified fibrinogen-based systems. Several observational studies have demonstrated that subjects who tend to generate denser fibrin networks displaying impaired clot lysis are at an increased risk of developing advanced atherosclerosis and arterial thromboembolic events. Moreover, the majority of cardiovascular risk factors are also associated with unfavorably altered fibrin clot properties, with their improvement following effective therapy, in particular with aspirin, statins, and anticoagulant agents. The prothrombotic fibrin clot phenotype has been reported to have a predictive value in terms of myocardial infarction, ischemic stroke, and acute limb ischemia. This review article summarizes available data on the association of fibrin clot characteristics with atherosclerotic vascular disease and its potential practical implications.
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Kietsiriroje N, Ariëns RAS, Ajjan RA. Fibrinolysis in Acute and Chronic Cardiovascular Disease. Semin Thromb Hemost 2021; 47:490-505. [PMID: 33878782 DOI: 10.1055/s-0040-1718923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The formation of an obstructive thrombus within an artery remains a major cause of mortality and morbidity worldwide. Despite effective inhibition of platelet function by modern antiplatelet therapies, these agents fail to fully eliminate atherothrombotic risk. This may well be related to extensive vascular disease, beyond the protective abilities of the treatment agents used. However, recent evidence suggests that residual vascular risk in those treated with modern antiplatelet therapies is related, at least in part, to impaired fibrin clot lysis. In this review, we attempt to shed more light on the role of hypofibrinolysis in predisposition to arterial vascular events. We provide a brief overview of the coagulation system followed by addressing the role of impaired fibrin clot lysis in acute and chronic vascular conditions, including coronary artery, cerebrovascular, and peripheral vascular disease. We also discuss the role of combined anticoagulant and antiplatelet therapies to reduce the risk of arterial thrombotic events, addressing both efficacy and safety of such an approach. We conclude that impaired fibrin clot lysis appears to contribute to residual thrombosis risk in individuals with arterial disease on antiplatelet therapy, and targeting proteins in the fibrinolytic system represents a viable strategy to improve outcome in this population. Future work is required to refine the antithrombotic approach by modulating pathological abnormalities in the fibrinolytic system and tailoring therapy according to the need of each individual.
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Affiliation(s)
- Noppadol Kietsiriroje
- Department of Metabolic Medicine, Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom.,Endocrinology and Metabolism Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
| | - Robert A S Ariëns
- Department of Metabolic Medicine, Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Ramzi A Ajjan
- Department of Metabolic Medicine, Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
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