1
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Ripoll JG, Klompas AM, Smith BB, Smith MM. Contemporary Perioperative Management of Direct Oral Anticoagulants. Adv Anesth 2022; 40:93-109. [PMID: 36333054 DOI: 10.1016/j.aan.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Direct oral anticoagulants (DOACs) have rapidly emerged as popular alternatives to warfarin in the setting of nonvalvular atrial fibrillation, prevention and treatment of venous thromboembolism, and secondary prevention of arterial thrombosis. It is now estimated that more patients in the United States take DOACs than warfarin for approved indications. Studies to date have shown that these drugs are similarly efficacious with perhaps a lower bleeding risk than warfarin. The purpose of this review is to provide insight into the currently available DOACs and discuss the management and reversal strategies for patients in the perioperative period.
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Affiliation(s)
- Juan G Ripoll
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Allan M Klompas
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA.
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2
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Cortesi V, Raffaeli G, Amelio GS, Amodeo I, Gulden S, Manzoni F, Cervellini G, Tomaselli A, Colombo M, Araimo G, Artoni A, Ghirardello S, Mosca F, Cavallaro G. Hemostasis in neonatal ECMO. Front Pediatr 2022; 10:988681. [PMID: 36090551 PMCID: PMC9458915 DOI: 10.3389/fped.2022.988681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/12/2022] [Indexed: 12/14/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving support for cardio-respiratory function. Over the last 50 years, the extracorporeal field has faced huge technological progress. However, despite the improvements in technique and materials, coagulation problems are still the main contributor to morbidity and mortality of ECMO patients. Indeed, the incidence and survival rates of the main hemorrhagic and thrombotic complications in neonatal respiratory ECMO are relevant. The main culprit is related to the intrinsic nature of ECMO: the contact phase activation. The exposure of the human blood to the non-endothelial surface triggers a systemic inflammatory response syndrome, which chronically activates the thrombin generation and ultimately leads to coagulative derangements. Pre-existing illness-related hemostatic dysfunction and the peculiarity of the neonatal clotting balance further complicate the picture. Systemic anticoagulation is the management's mainstay, aiming to prevent thrombosis within the circuit and bleeding complications in the patient. Although other agents (i.e., direct thrombin inhibitors) have been recently introduced, unfractionated heparin (UFH) is the standard of care worldwide. Currently, there are multiple tests exploring ECMO-induced coagulopathy. A combination of the parameters mentioned above and the evaluation of the patient's underlying clinical context should be used to provide a goal-directed antithrombotic strategy. However, the ideal algorithm for monitoring anticoagulation is currently unknown, resulting in a large inter-institutional diagnostic variability. In this review, we face the features of the available monitoring tests and approaches, mainly focusing on the role of point-of-care (POC) viscoelastic assays in neonatal ECMO. Current gaps in knowledge and areas that warrant further study will also be addressed.
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Affiliation(s)
- Valeria Cortesi
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Genny Raffaeli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo S Amelio
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ilaria Amodeo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Gulden
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesca Manzoni
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gaia Cervellini
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Andrea Tomaselli
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Marta Colombo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Gabriella Araimo
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Artoni
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ghirardello
- Neonatal Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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3
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Yang Z, Wan Y, E J, Luo Z, Guan S, Wang S, Zhang H. Structural basis of different surface-modified fullerene derivatives as novel thrombin inhibitors: insight into the inhibitory mechanism through molecular modelling studies. Mol Phys 2021. [DOI: 10.1080/00268976.2021.1943028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Zhijie Yang
- Laboratory of Theoretical and Computational Chemistry, Institute of Theoretical Chemistry, College of Chemistry, Jilin University, Changchun, People’s Republic of China
| | - Yongfeng Wan
- Institute of Atomic and Molecular Physics, Jilin University, Changchun, People’s Republic of China
| | - Jingwen E
- Laboratory of Theoretical and Computational Chemistry, Institute of Theoretical Chemistry, College of Chemistry, Jilin University, Changchun, People’s Republic of China
| | - Zhijian Luo
- Laboratory of Theoretical and Computational Chemistry, Institute of Theoretical Chemistry, College of Chemistry, Jilin University, Changchun, People’s Republic of China
| | - Shanshan Guan
- College of Biology and Food Engineering, Jilin Engineering Normal University, Changchun, People’s Republic of China
| | - Song Wang
- Laboratory of Theoretical and Computational Chemistry, Institute of Theoretical Chemistry, College of Chemistry, Jilin University, Changchun, People’s Republic of China
| | - Hao Zhang
- Laboratory of Theoretical and Computational Chemistry, Institute of Theoretical Chemistry, College of Chemistry, Jilin University, Changchun, People’s Republic of China
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4
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Fabrizio C, Levito MN, Rivosecchi R, Bashline M, Slocum B, Kilic A, Toma C, Murray H, Ramanan R, Fowler J, Hickey GW, Horn ET. Outcomes of systemic anticoagulation with bivalirudin for Impella 5.0. Int J Artif Organs 2021; 44:681-686. [PMID: 34250827 DOI: 10.1177/03913988211032238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Temporary mechanical circulatory support (tMCS) devices are used for the management of cardiogenic shock. The Impella 5.0 (Abiomed; Danvers, MA) (IMP5) is a commonly used, surgically implanted, tMCS device that requires systemic anticoagulation and purge solution to avoid pump failure. To avoid heparin-induced thrombocytopenia (HIT) from unfractionated heparin (UFH) use, our program has explored the utility of bivalirudin (BIV) for systemic anticoagulation in IMP5. This single center, retrospective study included patients supported on IMP5 with BIV based AC. The efficacy and safety end points were recovery, bridge to left ventricular assist device (LVAD), cardiac transplant (HTX), or death as well as clinically significant bleeding, incidence of Tissue Plasminogen Activator (tPA) use for suspected pump thrombosis, stroke, and device failure. There were 31 patients included, and 26 (84%) received BIV purge solutions. The median duration of IMP5 was 6 (IQR 4-10) days. Most patients were bridged to LVAD (39%, 12); 16% (5) were bridged to HTX, 16% (5) recovered, and 29% (9) died. One patient (3%) suffered from ischemic stroke and 12% (4) patients developed clinically significant bleeding. tPA was administered to 8 (26%) patients. Logistic regression analysis demonstrated that duration of IMP5 was a significant predictor of tPA use (OR 1.28; 95% Confidence Interval 1.04-1.56). There were no cases of pump failure. Our experience highlights the feasibility of utilizing BIV for routine AC use in IMP5.
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Affiliation(s)
- Carly Fabrizio
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Marissa N Levito
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ryan Rivosecchi
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael Bashline
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brittany Slocum
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arman Kilic
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Catalin Toma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Holt Murray
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jeffrey Fowler
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gavin W Hickey
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Edward T Horn
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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5
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Zhao S, Tian R, Wu J, Liu S, Wang Y, Wen M, Shang Y, Liu Q, Li Y, Guo Y, Wang Z, Wang T, Zhao Y, Zhao H, Cao H, Su Y, Sun J, Jiang Q, Ding B. A DNA origami-based aptamer nanoarray for potent and reversible anticoagulation in hemodialysis. Nat Commun 2021; 12:358. [PMID: 33441565 PMCID: PMC7807036 DOI: 10.1038/s41467-020-20638-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 12/08/2020] [Indexed: 12/30/2022] Open
Abstract
Effective and safe hemodialysis is essential for patients with acute kidney injury and chronic renal failures. However, the development of effective anticoagulant agents with safe antidotes for use during hemodialysis has proven challenging. Here, we describe DNA origami-based assemblies that enable the inhibition of thrombin activity and thrombus formation. Two different thrombin-binding aptamers decorated DNA origami initiates protein recognition and inhibition, exhibiting enhanced anticoagulation in human plasma, fresh whole blood and a murine model. In a dialyzer-containing extracorporeal circuit that mimicked clinical hemodialysis, the origami-based aptamer nanoarray effectively prevented thrombosis formation. Oligonucleotides containing sequences complementary to the thrombin-binding aptamers can efficiently neutralize the anticoagulant effects. The nanoarray is safe and immunologically inert in healthy mice, eliciting no detectable changes in liver and kidney functions or serum cytokine concentration. This DNA origami-based nanoagent represents a promising anticoagulant platform for the hemodialysis treatment of renal diseases.
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Affiliation(s)
- Shuai Zhao
- CAS Key Laboratory of Nanosystem and Hierarchical Fabrication, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, 100190, Beijing, China
- University of Chinese Academy of Sciences, 100049, Beijing, China
- Sino-Danish College, Sino-Danish Center for Education and Research, University of Chinese Academy of Sciences, 100049, Beijing, China
| | - Run Tian
- CAS Key Laboratory of Nanosystem and Hierarchical Fabrication, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, 100190, Beijing, China
- University of Chinese Academy of Sciences, 100049, Beijing, China
| | - Jun Wu
- Beijing Jishuitan Hospital, Department of Laboratory Medicine, Peking University Fourth School of Clinical Medicine, 100035, Beijing, China
| | - Shaoli Liu
- CAS Key Laboratory of Nanosystem and Hierarchical Fabrication, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, 100190, Beijing, China
- University of Chinese Academy of Sciences, 100049, Beijing, China
| | - Yuanning Wang
- CAS Key Laboratory of Nanosystem and Hierarchical Fabrication, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, 100190, Beijing, China
| | - Meng Wen
- Beijing Jishuitan Hospital, Department of Laboratory Medicine, Peking University Fourth School of Clinical Medicine, 100035, Beijing, China
| | - Yingxu Shang
- CAS Key Laboratory of Nanosystem and Hierarchical Fabrication, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, 100190, Beijing, China
- University of Chinese Academy of Sciences, 100049, Beijing, China
| | - Qing Liu
- CAS Key Laboratory of Nanosystem and Hierarchical Fabrication, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, 100190, Beijing, China
| | - Yan Li
- CAS Key Laboratory of Nanosystem and Hierarchical Fabrication, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, 100190, Beijing, China
| | - Ying Guo
- National & Local Joint Engineering Research Center of Biodiagnosis and Biotherapy, The Second Affiliated Hospital of Xi'an Jiaotong University, 710004, Xi'an, China
| | - Zhaoran Wang
- CAS Key Laboratory of Nanosystem and Hierarchical Fabrication, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, 100190, Beijing, China
- University of Chinese Academy of Sciences, 100049, Beijing, China
| | - Ting Wang
- CAS Key Laboratory of Nanosystem and Hierarchical Fabrication, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, 100190, Beijing, China
| | - Yujing Zhao
- Beijing Jishuitan Hospital, Department of Laboratory Medicine, Peking University Fourth School of Clinical Medicine, 100035, Beijing, China
| | - Huiru Zhao
- Beijing Jishuitan Hospital, Department of Laboratory Medicine, Peking University Fourth School of Clinical Medicine, 100035, Beijing, China
| | - Hui Cao
- Beijing Jishuitan Hospital, Department of Laboratory Medicine, Peking University Fourth School of Clinical Medicine, 100035, Beijing, China
| | - Yu Su
- Beijing Jishuitan Hospital, Department of Laboratory Medicine, Peking University Fourth School of Clinical Medicine, 100035, Beijing, China
| | - Jiashu Sun
- CAS Key Laboratory of Nanosystem and Hierarchical Fabrication, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, 100190, Beijing, China
- University of Chinese Academy of Sciences, 100049, Beijing, China
| | - Qiao Jiang
- CAS Key Laboratory of Nanosystem and Hierarchical Fabrication, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, 100190, Beijing, China.
- University of Chinese Academy of Sciences, 100049, Beijing, China.
| | - Baoquan Ding
- CAS Key Laboratory of Nanosystem and Hierarchical Fabrication, CAS Center for Excellence in Nanoscience, National Center for Nanoscience and Technology, 100190, Beijing, China.
- University of Chinese Academy of Sciences, 100049, Beijing, China.
- School of Materials Science and Engineering, Zhengzhou University, 450001, Zhengzhou, China.
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6
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Bates A, Buchholz H, Freed D, MacArthur R, PiDBorochynski T, Conway J. Bivalirudin Experience in a Heterogeneous Ventricular Assist Device Population. ASAIO J 2021; 66:677-682. [PMID: 31567418 DOI: 10.1097/mat.0000000000001062] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Ventricular assist devices (VADs) are an increasingly common therapy for end-stage heart failure across all ages as a bridge to recovery or transplant and more recently as destination therapy. With increasing experience and difficulties with establishing therapeutic heparin levels, we have begun to explore the effectiveness of direct thrombin inhibitors in this patient population. This is a retrospective review of all long-term VAD patients, both adult and pediatric, who were anticoagulated with bivalirudin between January 2009 and January 2016. The starting dose was 0.3 mg/kg/hr, and dose was titrated for a goal partial thromboplastin time (PTT) of 70-100. There were 14 patients (13 males, 5 ≤18 years) with 17 episodes of bivalirudin therapy. The median age on initiation was 45 years (range, 15 days-67 years) with 10 episodes associated with a HeartWare HVAD, five a HeartMate II, and two with a Berlin Heart EXCOR. The predominant indication of bivalirudin therapy was suspected pump thrombosis (13/17). The median time from VAD insertion to initiation of bivalirudin was 116 days (range, 3-1,870) with the median duration of therapy being 21 days (range, 3-113). In patients with pump thrombosis, the mean baseline lactate dehydrogenase (LDH) was 229 ± 64 U/L, peak 690 ± 380 U/L, and decreased to 330 ± 243 U/L when bivalirudin was stopped. The outcomes following suspected pump thrombosis included: transitioned to warfarin (n = 7), death in two destination therapy patients who did not undergo pump exchange, transplantation (n = 2), and pump exchange (n = 2). A major bleeding complication occurred in only one patient. Our experience highlights the potential use of bivalirudin in a heterogenous VAD population. Although these initial results suggest some potential role for direct thrombin inhibitors for use in long-term VADs, larger prospective studies are required to support these preliminary observations and to determine who may benefit from direct thrombin inhibitors (DTIs) and the side effect profile in this patient population.
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Affiliation(s)
- Angela Bates
- From the Division of Pediatric Cardiac Critical Care Medicine
| | | | | | | | - Tara PiDBorochynski
- Division of Pediatric Cardiology at the University of Alberta in Edmonton, Alberta, Canada
| | - Jennifer Conway
- Division of Pediatric Cardiology at the University of Alberta in Edmonton, Alberta, Canada
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7
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Roberts TR, Garren M, Handa H, Batchinsky AI. Toward an artificial endothelium: Development of blood-compatible surfaces for extracorporeal life support. J Trauma Acute Care Surg 2020; 89:S59-S68. [PMID: 32251267 PMCID: PMC7398848 DOI: 10.1097/ta.0000000000002700] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
A new generation of extracorporeal artificial organ support technologies, collectively known as extracorporeal life support (ECLS) devices, is being developed for diverse applications to include acute support for trauma-induced organ failure, transitional support for bridge to organ transplant, and terminal support for chronic diseases. Across applications, one significant complication limits the use of these life-saving devices: thrombosis, bleeding, and inflammation caused by foreign surface-induced blood interactions. To address this challenge, transdisciplinary scientists and clinicians look to the vascular endothelium as inspiration for development of new biocompatible materials for ECLS. Here, we describe clinically approved and new investigational biomaterial solutions for thrombosis, such as immobilized heparin, nitric oxide-functionalized polymers, "slippery" nonadhesive coatings, and surface endothelialization. We describe how hemocompatible materials could abrogate the use of anticoagulant drugs during ECLS and by doing so radically change treatments in critical care. Additionally, we examine several special considerations for the design of biomaterials for ECLS, including: (1) preserving function of the artificial organ, (2) longevity of use, and (3) multifaceted approaches for the diversity of device functions and applications.
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Affiliation(s)
- Teryn R. Roberts
- Autonomous Reanimation and Evacuation Program, San Antonio, TX, USA
- The Geneva Foundation, Tacoma, WA, USA
- U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - Mark Garren
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Hitesh Handa
- School of Chemical, Materials and Biomedical Engineering, College of Engineering, University of Georgia, Athens, GA, USA
| | - Andriy I. Batchinsky
- Autonomous Reanimation and Evacuation Program, San Antonio, TX, USA
- The Geneva Foundation, Tacoma, WA, USA
- U.S. Army Institute of Surgical Research, Fort Sam Houston, TX, USA
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8
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The blood compatibility challenge. Part 1: Blood-contacting medical devices: The scope of the problem. Acta Biomater 2019; 94:2-10. [PMID: 31226480 DOI: 10.1016/j.actbio.2019.06.021] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 02/07/2023]
Abstract
Blood-contacting medical devices are an integral part of modern medicine. Such devices may be used for only a few hours or may be implanted for life. Despite advances in biomaterial science, clotting on medical devices remains a common problem. Systemic administration of antiplatelet drugs or anticoagulants is often needed to reduce the risk of clotting. Although effective, such therapy increases the risk of bleeding, which can be fatal. This chapter (a) describes some of the commonly used blood-contacting devices and their potential complications, (b) provides an overview of the mechanisms that drive device-associated clotting, and (c) reviews the strategies employed to attenuate clotting on blood-contacting medical devices. STATEMENT OF SIGNIFICANCE: This paper is part 1 of a series of 4 reviews discussing the problem of biomaterial associated thrombogenicity. The objective was to highlight features of broad agreement and provide commentary on those aspects of the problem that were subject to dispute. We hope that future investigators will update these reviews as new scholarship resolves the uncertainties of today.
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9
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Roberts TR, Leslie DC, Cap AP, Cancio LC, Batchinsky AI. Tethered-liquid omniphobic surface coating reduces surface thrombogenicity, delays clot formation and decreases clot strength ex vivo. J Biomed Mater Res B Appl Biomater 2019; 108:496-502. [PMID: 31069955 DOI: 10.1002/jbm.b.34406] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 03/12/2019] [Accepted: 04/25/2019] [Indexed: 12/16/2022]
Abstract
Hemocompatible materials for extracorporeal life support (ECLS) technology are investigated to mitigate thrombotic complications associated with this therapy. A promising solution is an omniphobic bilayer coating, tethered liquid perfluorocarbon (TLP), which utilizes an immobilized tether to anchor a mobile, liquid surface lubricant that prevents adhesion of blood components to the substrate. In this study, we investigated the effects of TLP on real-time clot formation using thromboelastography (TEG). TLP was applied to TEG cups, utilizing perfluorodecalin (PFD) or FluorLube63 as the liquid layer, and compared to uncoated cups. Human blood (n = 10) was added to cups; and TEG parameters (R, K, α-angle, MA, LY30, LY60) and adherent thrombus weight were assessed. TLP decreased clot amplification (α-angle), clot strength (MA), and adherent clot weight (p < .0001). These effects were greater with FluorLube63 versus PFD (α-angle p < .0001; MA p = .0019; clot weight p < .0001). Reaction time (R) was longer in TLP-coated cups versus control cups with liquid lubricant added (p = .0377). Percent fibrinolysis (LY30 and LY60) was greater in the TLP versus controls at LY30 (p < .0001), and in FluoroLube63 versus controls at LY60 (p = .0021). TLP significantly altered clot formation, exerting antithrombogenic effects. This reduction in surface thrombogenicity supports TLP as a candidate for improved biocompatibility of ECLS materials, pending further validation with exposure to shear stress.
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Affiliation(s)
- Teryn R Roberts
- Multi-Organ Support Technology, U.S. Army Institute of Surgical Research, San Antonio, Texas.,The Geneva Foundation, Tacoma, Washington.,Morsani College of Medicine, University of South Florida, Tampa, Florida
| | | | - Andrew P Cap
- Multi-Organ Support Technology, U.S. Army Institute of Surgical Research, San Antonio, Texas
| | - Leopoldo C Cancio
- Multi-Organ Support Technology, U.S. Army Institute of Surgical Research, San Antonio, Texas
| | - Andriy I Batchinsky
- Multi-Organ Support Technology, U.S. Army Institute of Surgical Research, San Antonio, Texas.,The Geneva Foundation, Tacoma, Washington.,Morsani College of Medicine, University of South Florida, Tampa, Florida.,Department of Translational Medicine, University of the Incarnate Word, San Antonio, Texas
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10
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Wang J, Song M, Hu C, Wu K. Portable, Self-Powered, and Light-Addressable Photoelectrochemical Sensing Platforms Using pH Meter Readouts for High-Throughput Screening of Thrombin Inhibitor Drugs. Anal Chem 2018; 90:9366-9373. [DOI: 10.1021/acs.analchem.8b01979] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Juan Wang
- Key Laboratory for Material Chemistry of Energy Conversion and Storage, Ministry of Education, School of Chemistry and Chemical Engineering, Huazhong University of Science and Technology, Wuhan 430074, China
| | - Mengmeng Song
- Key Laboratory of Analytical Chemistry for Biology and Medicine, Ministry of Education, College of Chemistry and Molecular Sciences, Wuhan University, Wuhan 430072, China
| | - Chengguo Hu
- Key Laboratory of Analytical Chemistry for Biology and Medicine, Ministry of Education, College of Chemistry and Molecular Sciences, Wuhan University, Wuhan 430072, China
| | - Kangbing Wu
- Key Laboratory for Material Chemistry of Energy Conversion and Storage, Ministry of Education, School of Chemistry and Chemical Engineering, Huazhong University of Science and Technology, Wuhan 430074, China
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11
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Sun J, Wu Y, Dong S, Li X, Gao W. Influence of the drying method on the bioactive compounds and pharmacological activities of rhubarb. JOURNAL OF THE SCIENCE OF FOOD AND AGRICULTURE 2018; 98:3551-3562. [PMID: 29315599 DOI: 10.1002/jsfa.8871] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 01/02/2018] [Indexed: 06/07/2023]
Abstract
BACKGROUND Raw rhubarb samples that have been subjected to different drying procedures will have different therapeutic effects, possibly due to processing-induced variations in the chemical composition. In the present work, the fresh materials were processed by smoking, sun-drying, shade-drying and oven-drying at low, moderate and high temperatures. To facilitate the selection of a suitable drying method for rhubarb, the quality of rhubarb processed under various drying conditions was evaluated based on the simultaneous determination of multiple bioactive constituents in combination with bioactivity assays. RESULTS The total concentrations of 12 compounds in smoked rhubarb were higher than the concentrations of the same components in raw rhubarb and rhubarb products processed using other drying techniques. Smoked rhubarb was found to substantially inhibit Na+ /K+ -ATPase and thrombin. In addition, higher content of anthraquinones led to higher Na+ /K+ -ATPase inhibitory activities, and higher gallic acid content increased the antithrombin capacity. CONCLUSION The results confirmed that post-harvest fresh plant materials, especially roots, were still physiologically active organs that could undergo series of anti-dehydration mechanisms, including the production of related secondary metabolites during the early stages of dehydration. Therefore, the proper design of drying processes could enhance the quality of rhubarb as well as other similar medicinal plants. © 2018 Society of Chemical Industry.
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Affiliation(s)
- Jiachen Sun
- Tianjin University of Traditional Chinese Medicine, Tianjin, 300193, PR China
| | - Yueting Wu
- Tianjin University of Traditional Chinese Medicine, Tianjin, 300193, PR China
| | - Shengjie Dong
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, 300072, PR China
| | - Xia Li
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, 300072, PR China
| | - Wenyuan Gao
- Tianjin University of Traditional Chinese Medicine, Tianjin, 300193, PR China
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, 300072, PR China
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12
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Li QQ, Yang YX, Qv JW, Hu G, Hu YJ, Xia ZN, Yang FQ. Investigation of Interactions between Thrombin and Ten Phenolic Compounds by Affinity Capillary Electrophoresis and Molecular Docking. JOURNAL OF ANALYTICAL METHODS IN CHEMISTRY 2018; 2018:4707609. [PMID: 29744232 PMCID: PMC5884136 DOI: 10.1155/2018/4707609] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/30/2017] [Accepted: 12/31/2017] [Indexed: 06/08/2023]
Abstract
Thrombin plays a vital role in blood coagulation, which is a key process involved in thrombosis by promoting platelet aggregation and converting fibrinogen to form the fibrin clot. In the receptor concept, drugs produce their therapeutic effects via interactions with the targets. Therefore, investigation of interaction between thrombin and small molecules is important to find out the potential thrombin inhibitor. In this study, affinity capillary electrophoresis (ACE) and in silico molecular docking methods were developed to study the interaction between thrombin and ten phenolic compounds (p-hydroxybenzoic acid, protocatechuic acid, vanillic acid, gallic acid, catechin, epicatechin, dihydroquercetin, naringenin, apigenin, and baicalein). The ACE results showed that gallic acids and six flavonoid compounds had relative strong interactions with thrombin. In addition, the docking results indicated that all of optimal conformations of the six flavonoid compounds were positioned into the thrombin activity centre and had interaction with the HIS57 or SER195 which was the key residue to bind thrombin inhibitors such as argatroban. Herein, these six flavonoid compounds might have the potential of thrombin inhibition activity. In addition, the developed method in this study can be further applied to study the interactions of other molecules with thrombin.
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Affiliation(s)
- Qiao-Qiao Li
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China
| | - Yu-Xiu Yang
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China
| | - Jing-Wen Qv
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China
| | - Guang Hu
- School of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing 400054, China
| | - Yuan-Jia Hu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macau, China
| | - Zhi-Ning Xia
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China
| | - Feng-Qing Yang
- School of Chemistry and Chemical Engineering, Chongqing University, Chongqing 401331, China
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13
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Nahain AA, Ignjatovic V, Monagle P, Tsanaktsidis J, Ferro V. Heparin mimetics with anticoagulant activity. Med Res Rev 2018; 38:1582-1613. [PMID: 29446104 DOI: 10.1002/med.21489] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 12/16/2017] [Accepted: 01/12/2018] [Indexed: 01/10/2023]
Abstract
Heparin, a sulfated polysaccharide belonging to the glycosaminoglycan family, has been widely used as an anticoagulant drug for decades and remains the most commonly used parenteral anticoagulant in adults and children. However, heparin has important clinical limitations and is derived from animal sources which pose significant safety and supply problems. The ever growing shortage of the raw material for heparin manufacturing may become a very significant issue in the future. These global limitations have prompted much research, especially following the recent well-publicized contamination scandal, into the development of alternative anticoagulants derived from non-animal and/or totally synthetic sources that mimic the structural features and properties of heparin. Such compounds, termed heparin mimetics, are also needed as anticoagulant materials for use in biomedical applications (e.g., stents, grafts, implants etc.). This review encompasses the development of heparin mimetics of various structural classes, including synthetic polymers and non-carbohydrate small molecules as well as sulfated oligo- and polysaccharides, and fondaparinux derivatives and conjugates, with a focus on developments in the past 10 years.
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Affiliation(s)
- Abdullah Al Nahain
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Vera Ignjatovic
- Haematology Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Paul Monagle
- Haematology Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia.,Department of Clinical Haematology, Royal Children's Hospital, Parkville, Victoria, Australia
| | - John Tsanaktsidis
- CSIRO Materials Science and Engineering, Clayton South, Victoria, Australia
| | - Vito Ferro
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, Queensland, Australia
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14
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Zeng X, Lincoff AM, Schulz-Schüpke S, Steg PG, Elbez Y, Mehran R, Stone GW, McAndrew T, Lin J, Zhang X, Shi W, Lei H, Jing Z, Huang W. Efficacy and safety of bivalirudin in coronary artery disease patients with mild to moderate chronic kidney disease: Meta-analysis. J Cardiol 2017; 71:494-504. [PMID: 29191630 DOI: 10.1016/j.jjcc.2017.10.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 09/28/2017] [Accepted: 10/14/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) have elevated bleeding and ischemic outcomes. We aim to assess the short- and long-term efficacy and safety of bivalirudin compared to heparin plus glycoprotein IIb/IIIa inhibitors (GPIs) in coronary artery disease (CAD) patients with CKD. METHODS Randomized trials were searched in PubMed, Cochrane, and Embase databases up to January 2017. Among the trials retrieved, efficacy endpoints were defined as mortality, myocardial infarction (MI), repeat revascularization, stent thrombosis, and major adverse cardiac events (MACEs). Safety endpoints were reported as non-coronary artery bypass grafting (CABG) related major bleeding and thrombolysis in myocardial infarction (TIMI) major bleeding. Risk ratio (RR) and 95% confidence interval (CI) were calculated for each outcome using a fixed effect model. RESULTS Five studies with a total of 3796 patients were included. In short-term follow up (30 days), bivalirudin significantly reduced non-CABG related major bleeding (p=0.0004) and TIMI major bleeding (p=0.007) compared to heparin plus GPIs. No significant differences were observed in rates of mortality, MI, repeat revascularization, stent thrombosis, and MACEs between the two groups in short- and long-term follow up (6 months to 3 years). In patients with ST elevated myocardial infarction (STEMI) with concurrent CKD, the decreased non-CABG related major bleeding (p=0.04) without increasing ischemic events was also observed after short-term follow up. CONCLUSIONS (1) Bivalirudin is safer than and as effective as heparin plus GPIs in CAD patients with CKD. (2) Impaired renal function does not affect the safety benefits of bivalirudin. (3) Similar efficacy profiles were identified between the two groups after both short- and long-term follow up in the CAD patients with CKD.
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Affiliation(s)
- Xiaofang Zeng
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | | | - Stefanie Schulz-Schüpke
- ISA Research Center, Deutsches Herzzentrum, Technische Universität, Munich, Germany and German Center for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance
| | - Philippe Gabriel Steg
- French Alliance for Cardiovascular Clinical Trials (FACT), DHU-FIRE, Hôpital Bichat (Assistance Publique-Hôpitaux de Paris), Université Paris-Diderot, Sorbonne-Paris Cité and INSERM U-1148, Paris, France
| | - Yedid Elbez
- French Alliance for Cardiovascular Clinical Trials (FACT), DHU-FIRE, Hôpital Bichat (Assistance Publique-Hôpitaux de Paris), Université Paris-Diderot, Sorbonne-Paris Cité and INSERM U-1148, Paris, France
| | - Roxana Mehran
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Gregg W Stone
- Department of Cardiology, New York-Presbyterian Hospital/Columbia University Medical Center, New York, USA
| | - Thomas McAndrew
- Clinical Trials Center, Cardiovascular Research Foundation, New York, USA
| | - Jianhui Lin
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield Medical School, Sheffield, UK
| | - Xindan Zhang
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Wenhai Shi
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Han Lei
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Zhicheng Jing
- State Key Laboratory of Cardiovascular Disease, Fu Wai Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Huang
- Department of Cardiology, The First Affiliated Hospital, Chongqing Medical University, Chongqing, China.
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15
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Popular naturally occurring antioxidants as potential anticoagulant drugs. Chem Biol Interact 2016; 257:35-45. [PMID: 27475864 DOI: 10.1016/j.cbi.2016.07.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 07/05/2016] [Accepted: 07/18/2016] [Indexed: 01/11/2023]
Abstract
Blood coagulation is a physiological process whose main task is prevention of blood loss from injured vessels. This process consists of a series of zymogens proteolytic activation leading to the generation of the main coagulation enzyme - thrombin. Besides its important role in blood coagulation process, thrombin is involved in many cardiovascular diseases, which are responsible for almost half of fatalities in economically developed countries. The evidence for the increased generation and in vivo activity of thrombin was observed in the plasma of individuals at high risk for clinically significant venous and arterial thromboembolic complications. Antioxidants activity of plants extracts has been well known for many years and was confirmed by many publications. However, during the last decade many research centers presented results suggesting anticoagulant potential of various plant extracts. Many researchers have also provided evidence that polyphenol compounds are able to inhibit the activity of many enzymes, including serine proteases. All research described in this review clearly indicate that polyphenols and polyphenol-rich extracts possess not only antioxidative but also anticoagulant properties and may be useful in creation of new therapeutic agents or dietary supplements. Based on described properties polyphenols would be very helpful with both prevention and treatment of thromboembolic complications associated with multiple failures of haemostasis, because the available therapeutic agents do not offer such double-effects (antioxidant and anticoagulant).
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16
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The Quest for Nonthrombotic Surface Modifications to Achieve Hemocompatibility of Implantable Devices. ASAIO J 2016; 61:623-34. [PMID: 26366685 DOI: 10.1097/mat.0000000000000283] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The use of blood-contacting implantable devices is limited by surface-induced thrombosis, which has led to the development of thromboresistant surfaces. Multidisciplinary efforts have promoted the development of surface modifications to minimize thrombosis by targeting surface-induced coagulation. To this date, no material has been identified that remains irrevocably hemocompatible with time but many options are now available with their own limitations. Essential to this review is the understanding of some of the challenges in this field and newer opportunities for hemocompatibility research. This report will also briefly review many of the achievements in the development of hemocompatible biomaterial coating, including surface modifications against protein adsorption and platelet adhesion, biomimetism, and endothelialization.
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17
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Ebrahimi R, Lincoff AM, Bittl JA, Chew D, Wolski K, Wadhan N, Toggart EJ, Topol EJ. Bivalirudin vs Heparin in Percutaneous Coronary Intervention: A Pooled Analysis. J Cardiovasc Pharmacol Ther 2016; 10:209-16. [PMID: 16382257 DOI: 10.1177/107424840501000401] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: This study evaluates outcomes with bivalirudin vs heparin in various patient subgroups and the overall population during percutaneous coronary interventions (PCI). Background: Recent data suggest that bivalirudin, a reversible direct thrombin inhibitor, provides ischemic protection superior to heparin and comparable to heparin plus glycoprotein (GP) IIb/IIIa inhibitors but with significantly fewer bleeding complications. Whether this advantage persists in different subgroups has not been fully defined. To our knowledge, this is the largest pooled analysis of bivalirudin to date. Methods: Four randomized controlled trials were identified that compared bivalirudin to heparin (with or without GP IIb/IIIa inhibitors) in PCI. The incidence of death, myocardial infarction (MI), revascularization, and major bleeding at 48 hours was compared between these two agents overall and in patients with and without diabetes mellitus, hypertension, renal insufficiency, and advanced age. Results: The trials consisted of 11,638 patients (bivalirudin, 5,861; heparin, 5,777). There were no significant differences in patient characteristics between the two groups. At 48 hours, the incidence of death, MI, revascularization, and major bleeding was significantly reduced in the bivalirudin group (7.8% vs 1.08%, P < .001); individual ischemic end points were significantly reduced for death (0.01% vs 0.02%, P = .049) and revascularization (2.0% vs 2.7%, P = .02), with similar reductions for major bleeding (2.7% vs 5.8%, P < .001). Subgroup analysis was generally consistent with the overall findings. Conclusion: This analysis further supports the superiority of bivalirudin compared with heparin. Bivalirudin provides excellent ischemic protection with a significant reduction of bleeding complications, even in high-risk subgroups.
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Affiliation(s)
- Ramin Ebrahimi
- University of California, Los Angeles School of Medicine, West Los Angeles VA, Los Angeles, USA.
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18
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Taslakian B, Sebaaly MG, Al-Kutoubi A. Patient Evaluation and Preparation in Vascular and Interventional Radiology: What Every Interventional Radiologist Should Know (Part 2: Patient Preparation and Medications). Cardiovasc Intervent Radiol 2015; 39:489-99. [PMID: 26606917 DOI: 10.1007/s00270-015-1239-4] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 11/04/2015] [Indexed: 01/17/2023]
Abstract
Performing an interventional procedure imposes a commitment on interventional radiologists to conduct the initial patient assessment, determine the best course of therapy, and provide long-term care. Patient care before and after an interventional procedure, identification, and management of early and delayed complications of various procedures are equal in importance to the procedure itself. In this second part, we complete the comprehensive, methodical review of pre-procedural care and patient preparation before vascular and interventional radiology procedures.
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Affiliation(s)
- Bedros Taslakian
- Department of Radiology, NYU Langone Medical Center, 660 First Avenue, New York, NY, 10016, USA.
| | - Mikhael Georges Sebaaly
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Riad El-Solh, Beirut, 1107 2020, PO Box: 11-0236, Lebanon.
| | - Aghiad Al-Kutoubi
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Riad El-Solh, Beirut, 1107 2020, PO Box: 11-0236, Lebanon.
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19
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Abstract
Coagulation and anticoagulation system is kept in balance by the orchestrated action of a variety of biological factors, and the disruption of this balance leads to the risk of hemorrhage or thrombosis. Oligonucleotide aptamers are single-stranded DNA (ssDNA) or RNA ligands that are synthesized in vitro and bind to target molecules through dimensional structure with high specificity and affinity, and thus represent attractive candidates for the development of agents to maintain the balance of coagulation and anticoagulation. In this review, we summarize recent progress in aptamer-based application in the modulation of coagulation. The aptamers with specific chemical and biological characteristics have great potential to be explored as agents for the treatment of blood coagulation abnormalities.
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20
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Salazar CA, Malaga G, Malasquez G, Bernardo R. Direct factor Xa inhibitors versus low molecular weight heparins or vitamin K antagonists for prevention of venous thromboembolism in elective primary hip or knee replacement or hip fracture repair. Hippokratia 2015. [DOI: 10.1002/14651858.cd011762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Carlos A Salazar
- Universidad Peruana Cayetano Heredia; Department of Medicine; Avenida Honorio Delgado 430 San Martin de Porres Lima Peru
| | - German Malaga
- Universidad Peruana Cayetano Heredia; Avenida Honorio Delgado 430 San Martin de Porres Lima Peru 33
| | - Giuliana Malasquez
- Universidad Peruana Cayetano Heredia; Avenida Honorio Delgado 430 San Martin de Porres Lima Peru 33
| | - Roberto Bernardo
- British American Hospital; Medicine Service; 350 Alfredo Salazar Street Lima Peru Lima 27
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21
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She ZG, Liu X, Kotamraju VR, Ruoslahti E. Clot-targeted micellar formulation improves anticoagulation efficacy of bivalirudin. ACS NANO 2014; 8:10139-49. [PMID: 25270510 DOI: 10.1021/nn502947b] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Application of anticoagulants remains the primary strategy for prevention and treatment of thrombosis. However, high rate of bleeding complications limits their use. The peptide anticoagulant bivalirudin has been reported to exhibit a lower rate of bleeding complications than heparin, and it also has the advantage of not causing thrombocytopenia, which is a problem with heparin. Nonetheless, hemorrhage is the most common complication of bivalirudin therapy, and there is no effective antidote. Here we use a thrombus-binding peptide, CR(NMe)EKA, to accomplish selective delivery of the bivalirudin-carrying micellar nanocarrier to sites of thrombosis. Bivalirudin and CR(NMe)EKA, each with a PEG-lipid tail, spontaneously assembled into 30 nm micelles, which almost completely retained the anticoagulant activity of bivalirudin. The micellar formulations exhibited high stability both in vitro and in vivo. In a thromboplastin-induced mouse thrombosis model, the targeted micelles accumulated in lung thrombi 10-fold more than nontargeted micelles. Moreover, the micellar formulation significantly prolonged the half-life and thereby increased the bioavailability of bivalirudin. The micellar bivalirudin had significantly higher anticoagulant activity than free bivalirudin in both the lung thrombosis model and a ferric chloride-induced carotid artery thrombosis model. The specific targeting of thrombi demonstrated here makes it possible to increase the efficacy of bivalirudin as an anticoagulant. Alternatively, the dose could be reduced without loss of efficacy to lower the systemic exposure and improve safety.
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Affiliation(s)
- Zhi-Gang She
- Cancer Research Center, Sanford-Burnham Medical Research Institute , La Jolla, California 92037, United States
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22
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The characteristics of thrombin in osteoarthritic pathogenesis and treatment. BIOMED RESEARCH INTERNATIONAL 2014; 2014:407518. [PMID: 25313362 PMCID: PMC4182002 DOI: 10.1155/2014/407518] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Accepted: 09/01/2014] [Indexed: 01/08/2023]
Abstract
Osteoarthritis (OA) is a mechanical abnormality associated with degradation of joints. It is characterized by chronic, progressive degeneration of articular cartilage, abnormalities of bone, and synovial change. The most common symptom of OA is local inflammation resulting from exogenous stress or endogenous abnormal cytokines. Additionally, OA is associated with local and/or systemic activation of coagulation and anticoagulation pathways. Thrombin plays an important role in the stimulation of fibrin deposition and the proinflammatory processes in OA. Thrombin mediates hemostatic and inflammatory responses and guides the immune response to tissue damage. Thrombin activates intracellular signaling pathways by interacting with transmembrane domain G protein coupled receptors (GPCRs), known as protease-activated receptors (PARs). In pathogenic mechanisms, PARs have been implicated in the development of acute and chronic inflammatory responses in OA. Therefore, discovery of thrombin signaling pathways would help us to understand the mechanism of OA pathogenesis and lead us to develop therapeutic drugs in the future.
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23
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Saini A, Spinella PC. Management of Anticoagulation and Hemostasis for Pediatric Extracorporeal Membrane Oxygenation. Clin Lab Med 2014; 34:655-73. [DOI: 10.1016/j.cll.2014.06.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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24
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Sidhu TS, French SL, Hamilton JR. Differential signaling by protease-activated receptors: implications for therapeutic targeting. Int J Mol Sci 2014; 15:6169-83. [PMID: 24733067 PMCID: PMC4013622 DOI: 10.3390/ijms15046169] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 03/14/2014] [Accepted: 04/03/2014] [Indexed: 12/29/2022] Open
Abstract
Protease-activated receptors (PARs) are a family of four G protein-coupled receptors that exhibit increasingly appreciated differences in signaling and regulation both within and between the receptor class. By nature of their proteolytic self-activation mechanism, PARs have unique processes of receptor activation, "ligand" binding, and desensitization/resensitization. These distinctive aspects have presented both challenges and opportunities in the targeting of PARs for therapeutic benefit-the most notable example of which is inhibition of PAR1 on platelets for the prevention of arterial thrombosis. However, more recent studies have uncovered further distinguishing features of PAR-mediated signaling, revealing mechanisms by which identical proteases elicit distinct effects in the same cell, as well as how distinct proteases produce different cellular consequences via the same receptor. Here we review this differential signaling by PARs, highlight how important distinctions between PAR1 and PAR4 are impacting on the progress of a new class of anti-thrombotic drugs, and discuss how these more recent insights into PAR signaling may present further opportunities for manipulating PAR activation and signaling in the development of novel therapies.
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Affiliation(s)
- Tejminder S Sidhu
- Australian Centre for Blood Diseases & Department of Clinical Haematology, Monash University, Melbourne 3004, Australia.
| | - Shauna L French
- Australian Centre for Blood Diseases & Department of Clinical Haematology, Monash University, Melbourne 3004, Australia.
| | - Justin R Hamilton
- Australian Centre for Blood Diseases & Department of Clinical Haematology, Monash University, Melbourne 3004, Australia.
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25
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Abstract
Thromboembolic disorders continue to be a major cause of morbidity and mortality, resulting in an increased need for anticoagulant therapy. In recent years, new anticoagulant drugs have been developed at a rapid pace, prompted by the recognition of many undesirable properties of currently used agents, and by a greater knowledge of the active enzymatic sites of clotting factors. Furthermore, the structure of a thrombus is better understood, so that newer drugs can inhibit thrombin or Factor Xa not only on the surface of a thrombus, as in the case of heparin, but also the fibrin-bound thrombin or Factor Xa within the thrombus. These agents are usually small molecules synthesized on the basis of their inhibition of specific active sites in the respective coagulation factors. They possess many improved characteristics, such as greater efficacy and safety, oral administration, reliable pharmacokinetics, less need for laboratory monitoring and minimal interactions with other drugs and diet. Prominent among these are lepuridin (Refludan, Pfizer), fondaparinux (Arixtra, Sanofi-Synthelabo) and ximelagatran (Exanta, Astra Zeneca). However, these new drugs are still far from fulfilling the desired objectives. Most of them possess some but not all of the needed properties. Furthermore, many do not have specific antidotes for immediate reversal of their pharmacologic actions, and all are much more costly than conventional agents. Development of newer agents with properties closer to that of the ideal drug remains a challenge.
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Affiliation(s)
- Hau C Kwaan
- Division of Hematology/Oncology, Northwestern University, Feinberg School of Medicine, 333 East Huron Street, Chicago, IL 60011-3008, USA.
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26
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de Candia M, Fiorella F, Lopopolo G, Carotti A, Romano MR, Lograno MD, Martel S, Carrupt PA, Belviso BD, Caliandro R, Altomare C. Synthesis and biological evaluation of direct thrombin inhibitors bearing 4-(piperidin-1-yl)pyridine at the P1 position with potent anticoagulant activity. J Med Chem 2013; 56:8696-711. [PMID: 24102612 DOI: 10.1021/jm401169a] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The design and synthesis of a new class of nonpeptide direct thrombin inhibitors, built on the structure of 1-(pyridin-4-yl)piperidine-4-carboxamide, are described. Starting from a strongly basic 1-amidinopiperidine derivative (6) showing poor thrombin (fIIa) and factor Xa (fXa) inhibition activities, anti-fIIa activity and artificial membrane permeability were considerably improved by optimizing the basic P1 and the X-substituted phenyl P4 binding moieties. Structure-activity relationship studies, usefully complemented with molecular modeling results, led us to identify compound 13b, which showed excellent fIIa inhibition (Ki = 6 nM), weak anti-Xa activity (Ki = 5.64 μM), and remarkable selectivity over other serine proteases (e.g., trypsin). Compound 13b showed in vitro anticoagulant activity in the low micromolar range and significant membrane permeability. In mice (ex vivo), 13b demonstrated anticoagulant effects at 2 h after oral dosing (100 mg·kg(-1)), with a significant 43% prolongation of the activated partial thromboplastin time (aPTT), over controls (P < 0.05).
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Affiliation(s)
- Modesto de Candia
- Dipartimento di Farmacia-Scienze del Farmaco, University of Bari "Aldo Moro" , Via E. Orabona 4, 70125 Bari, Italy
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27
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De Servi S, Mariani G, Mariani M, D’Urbano M. The bivalirudin paradox. J Cardiovasc Med (Hagerstown) 2013; 14:334-41. [DOI: 10.2459/jcm.0b013e32835f1915] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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28
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Martin JA, Parekh P, Kim Y, Morey TE, Sefah K, Gravenstein N, Dennis DM, Tan W. Selection of an aptamer antidote to the anticoagulant drug bivalirudin. PLoS One 2013; 8:e57341. [PMID: 23483901 PMCID: PMC3590194 DOI: 10.1371/journal.pone.0057341] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 01/21/2013] [Indexed: 11/18/2022] Open
Abstract
Adverse drug reactions, including severe patient bleeding, may occur following the administration of anticoagulant drugs. Bivalirudin is a synthetic anticoagulant drug sometimes employed as a substitute for heparin, a commonly used anticoagulant that can cause a condition called heparin-induced thrombocytopenia (HIT). Although bivalrudin has the advantage of not causing HIT, a major concern is lack of an antidote for this drug. In contrast, medical professionals can quickly reverse the effects of heparin using protamine. This report details the selection of an aptamer to bivalirudin that functions as an antidote in buffer. This was accomplished by immobilizing the drug on a monolithic column to partition binding sequences from nonbinding sequences using a low-pressure chromatography system and salt gradient elution. The elution profile of binding sequences was compared to that of a blank column (no drug), and fractions with a chromatographic difference were analyzed via real-time PCR (polymerase chain reaction) and used for further selection. Sequences were identified by 454 sequencing and demonstrated low micromolar dissociation constants through fluorescence anisotropy after only two rounds of selection. One aptamer, JPB5, displayed a dose-dependent reduction of the clotting time in buffer, with a 20 µM aptamer achieving a nearly complete antidote effect. This work is expected to result in a superior safety profile for bivalirudin, resulting in enhanced patient care.
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Affiliation(s)
- Jennifer A. Martin
- Department of Chemistry and Department of Physiology and Functional Genomics, Shands Cancer Center and Center for Research at the Bio/nano Interface, University of Florida, Gainesville, Florida, United States of America
| | - Parag Parekh
- Department of Chemistry and Department of Physiology and Functional Genomics, Shands Cancer Center and Center for Research at the Bio/nano Interface, University of Florida, Gainesville, Florida, United States of America
| | - Youngmi Kim
- Department of Chemistry and Department of Physiology and Functional Genomics, Shands Cancer Center and Center for Research at the Bio/nano Interface, University of Florida, Gainesville, Florida, United States of America
| | - Timothy E. Morey
- Department of Anesthesiology and Pharmacology, University of Florida, Gainesville, Florida, United States of America
| | - Kwame Sefah
- Department of Chemistry and Department of Physiology and Functional Genomics, Shands Cancer Center and Center for Research at the Bio/nano Interface, University of Florida, Gainesville, Florida, United States of America
| | - Nikolaus Gravenstein
- Department of Anesthesiology and Pharmacology, University of Florida, Gainesville, Florida, United States of America
| | - Donn M. Dennis
- Department of Anesthesiology and Pharmacology, University of Florida, Gainesville, Florida, United States of America
| | - Weihong Tan
- Department of Chemistry and Department of Physiology and Functional Genomics, Shands Cancer Center and Center for Research at the Bio/nano Interface, University of Florida, Gainesville, Florida, United States of America
- * E-mail:
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Bioengineered surfaces to improve the blood compatibility of biomaterials through direct thrombin inactivation. Acta Biomater 2012; 8:4101-10. [PMID: 22846590 DOI: 10.1016/j.actbio.2012.07.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 07/05/2012] [Accepted: 07/16/2012] [Indexed: 11/21/2022]
Abstract
Thrombus formation, due to thrombin generation, is a major problem affecting blood-contacting medical devices. This work aimed to develop a new strategy to improve the hemocompatibility of such devices by the immobilization of a naturally occurring thrombin inhibitor into a nanostructured surface. Boophilin, a direct thrombin inhibitor from the cattle tick Rhipicephalus microplus, was produced as a recombinant protein in Pichia pastoris. Boophilin was biotinylated and immobilized on biotin-terminated self-assembled monolayers (SAM) via neutravidin. In order to maintain its proteinase inhibitory capacity after surface immobilization, boophilin was biotinylated after the formation of a boophilin-thrombin complex to minimize the biotinylation of the residues involved in thrombin-boophilin interaction. The extent of boophilin biotinylation was determined using matrix-assisted laser desorption/ionization-time of flight/time of flight mass spectrometry. Boophilin immobilization and thrombin adsorption were quantified using quartz crystal microbalance with dissipation. Thrombin competitive adsorption from human serum was assessed using ¹²⁵I-thrombin. Thrombin inhibition and plasma clotting time were determined using spectrophotometric techniques. Boophilin-coated SAM were able to promote thrombin adsorption in a selective way, inhibiting most of its activity and delaying plasma coagulation in comparison with boophilin-free surfaces, demonstrating boophilin's potential to improve the hemocompatibility of biomaterials used in the production of blood-contacting devices.
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30
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Iqbal Z, Rana G, Cohen M. Appropriate anti-thrombotic/anti-thrombin therapy for thrombotic lesions. Curr Cardiol Rev 2012; 8:181-91. [PMID: 22920489 PMCID: PMC3465822 DOI: 10.2174/157340312803217175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 03/16/2012] [Accepted: 04/10/2012] [Indexed: 11/22/2022] Open
Abstract
Managing coronary thrombus is a challenging task and requires adequate knowledge of the various antithrombotic
agents available. In this article, we will briefly analyze the risk-benefit profile of antithrombotic agents, with critical
analysis of the scientific evidence available to support their use. Since thrombus consists of platelets and coagulation cofactors,
an effective antithrombotic strategy involves using one anticoagulant with two or more antiplatelet agents.
Unfractionated heparin traditionally has been the most commonly used anticoagulant but is fast being replaced by relatively
newer agents like LMWH, direct thrombin inhibitors, and Factor Xa inhibitors. In recent years, the antiplatelet landscape has changed significantly with the availability of more potent and rapidly acting
agents, like prasugrel and ticagrelor. These agents have demonstrated a sizeable reduction in ischemic outcomes in patients
with ACS, who are treated invasively or otherwise, with some concern for an increased bleeding risk. Glycoprotein
IIb/IIIa inhibitors have an established role in high risk NSTE ACS patients pretreated with dual antiplatelets, but its role in
STEMI patients, treated with invasive approach and dual antiplatelets, has not been supported consistently across the studies.
Additionally, in recent years, its place as a directly injected therapy into coronaries has been looked into with mixed
results. In conclusion, a well-tailored antithrombotic strategy requires taking into account each patient’s individual risk
factors and clinical presentation, with an effort to strike balance between not only preventing ischemic outcomes but also
reducing bleeding complications.
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Affiliation(s)
- Zafar Iqbal
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, NJ 07112, USA
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31
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Baldwin AD, Robinson KG, Militar J, Derby CD, Kiick KL, Akins RE. In situ crosslinkable heparin-containing poly(ethylene glycol) hydrogels for sustained anticoagulant release. J Biomed Mater Res A 2012; 100:2106-18. [PMID: 22615105 PMCID: PMC4096162 DOI: 10.1002/jbm.a.34050] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2011] [Accepted: 11/29/2011] [Indexed: 11/08/2022]
Abstract
Low-molecular weight heparin (LMWH) is widely used in anticoagulation therapies and for the prevention of thrombosis. LMWH is administered by subcutaneous injection usually once or twice per day. This frequent and invasive delivery modality leads to compliance issues for individuals on prolonged therapeutic courses, particularly pediatric patients. Here, we report a long-term delivery method for LMWH via subcutaneous injection of long-lasting hydrogels. LMWH is modified with reactive maleimide groups so that it can be crosslinked into continuous networks with four-arm thiolated poly(ethylene glycol) (PEG-SH). Maleimide-modified LMWH (Mal-LMWH) retains bioactivity as indicated by prolonged coagulation time. Hydrogels comprising PEG-SH and Mal-LMWH degrade via hydrolysis, releasing bioactive LMWH by first-order kinetics with little initial burst release. Separately dissolved Mal-LMWH and PEG-SH solutions were co-injected subcutaneously in New Zealand White rabbits. The injected solutions successfully formed hydrogels in situ and released LMWH as measured via chromogenic assays on plasma samples, with accumulation of LMWH occurring at day 2 and rising to near-therapeutic dose equivalency by day 5. These results demonstrate the feasibility of using LMWH-containing, crosslinked hydrogels for sustained and controlled release of anticoagulants.
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Affiliation(s)
- Aaron D. Baldwin
- Department of Materials Science and Engineering, 201 DuPont Hall, University of Delaware, Newark, DE 19716, USA
| | - Karyn G. Robinson
- Tissue Engineering and Regenerative Medicine Laboratory, Nemours Biomedical Research, Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA
| | - Jaimee Militar
- Tissue Engineering and Regenerative Medicine Laboratory, Nemours Biomedical Research, Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA
| | - Christopher D. Derby
- Tissue Engineering and Regenerative Medicine Laboratory, Nemours Biomedical Research, Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA
| | - Kristi L. Kiick
- Department of Materials Science and Engineering, 201 DuPont Hall, University of Delaware, Newark, DE 19716, USA
- Tissue Engineering and Regenerative Medicine Laboratory, Nemours Biomedical Research, Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA
- Delaware Biotechnology Institute, 15 Innovation Way, Newark, DE 19716, USA
| | - Robert E. Akins
- Tissue Engineering and Regenerative Medicine Laboratory, Nemours Biomedical Research, Alfred I. duPont Hospital for Children, Wilmington, DE 19803, USA
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32
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Shi ZH, Li NG, Tang YP, Wei-Li, Lian-Yin, Yang JP, Hao-Tang, Duan JA. Metabolism-based synthesis, biologic evaluation and SARs analysis of O-methylated analogs of quercetin as thrombin inhibitors. Eur J Med Chem 2012; 54:210-22. [PMID: 22647223 DOI: 10.1016/j.ejmech.2012.04.044] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Revised: 04/26/2012] [Accepted: 04/30/2012] [Indexed: 11/29/2022]
Abstract
In blood, quercetin is mainly found in metabolized forms. In order to study the activities of these quercetin metabolites in cardiovascular disease, 17 methylquercetin derivatives were synthesized based on metabolism in vivo, their thrombin inhibition activity were evaluated through the analyzation of prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT) and fibrinogen (FIB). The results showed that 6 methylquercetin derivatives had stronger inhibitory activities than that of quercetin. Preliminary SARs analysis showed that hydroxyl groups at C-3' and C-4' position in the B-ring and hydroxyl group at C-3 position in the C-ring played key roles in the thrombin inhibitory activity. The findings of this study would provide information for the exploitation and utilization of quercetin as thrombin inhibitor for thrombotic disease treatment.
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Affiliation(s)
- Zhi-Hao Shi
- Jiangsu Key Laboratory for High Technology Research of TCM Formulae, Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210046, China
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Lu L, Li QL, Maitz MF, Chen JL, Huang N. Immobilization of the direct thrombin inhibitor-bivalirudin on 316L stainless steel via polydopamine and the resulting effects on hemocompatibility in vitro. J Biomed Mater Res A 2012; 100:2421-30. [PMID: 22566466 DOI: 10.1002/jbm.a.34143] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Revised: 02/12/2012] [Accepted: 02/22/2012] [Indexed: 11/09/2022]
Abstract
Bivalirudin (BV), a peptidic direct thrombin inhibitor, derived from hirudin, has gained increasing interest in clinical anticoagulant therapy in the recent years. In this work, a hemocompatible surface was prepared by immobilization of BV on 316L stainless steel (SS) using a bonding layer of polydopamine (DA). X-ray photoelectron spectroscopy (XPS) was used to determine the chemical composition of the surfaces to characterize polydopamine intermediate layer and the immobilized BV. The quantity of bound BV was measured by quartz crystal microbalance (QCM). The hemocompatibility in vitro was evaluated by coagulating time of activated partial thromboplastin time (aPTT) and prothrombin time (PT) assay, platelet adhesion and activation, fibrinogen adsorption, and activation and whole blood test. The effect of sterilizing method on the bioactivity of immobilized BV was also evaluated. The results showed that BVs were successfully immobilized on SS surface with the DA interlayer at a density of 98 ng/cm(2) . BV coating surface prolonged aPTT and PT, inhibited the activation of platelet and fibrinogen significantly. Sterilization by ultraviolet radiation was possible with only marginal loss of activity. Thus, the approach described here may provide a basis for the preparation of 316L SS surface modification for use in cardiovascular implants.
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Affiliation(s)
- Lei Lu
- Key Laboratory of Advanced Technologies of Materials, Ministry of Education, Southwest Jiaotong University, Chengdu, China
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34
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Weitz JI, Eikelboom JW, Samama MM. New antithrombotic drugs: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e120S-e151S. [PMID: 22315258 DOI: 10.1378/chest.11-2294] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
This article focuses on new antithrombotic drugs that are in or are entering phase 3 clinical testing. Development of these new agents was prompted by the limitations of existing antiplatelet, anticoagulant, or fibrinolytic drugs. Addressing these unmet needs, this article (1) outlines the rationale for development of new antithrombotic agents; (2) describes the new antiplatelet, anticoagulant, and fibrinolytic drugs; and (3) provides clinical perspectives on the opportunities and challenges faced by these novel agents.
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Affiliation(s)
- Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute and Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada.
| | - John W Eikelboom
- Thrombosis and Atherosclerosis Research Institute and Department of Medicine, McMaster University, Hamilton, ON, Canada
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35
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Wiggins NB, Granger CB, Alexander JH. Novel oral anticoagulants after acute coronary syndromes. Cardiovasc Drugs Ther 2012; 26:265-71. [PMID: 22434545 DOI: 10.1007/s10557-012-6386-0] [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] [Indexed: 11/27/2022]
Abstract
PURPOSE A number of novel oral anticoagulants, including direct thrombin inhibitors and direct factor Xa inhibitors, have been developed. This review discusses these agents and their respective clinical trials in patients with acute coronary syndromes. METHODS This review discusses the results of phase 2 and 3 clinical trials with novel oral anticoagulants. RESULTS Phase 2 clinical trials demonstrated that novel oral anticoagulants increase the risk of bleeding in a dose-related fashion, particularly when used in addition to dual antiplatelet therapy. What was less clear is their impact on recurrent ischemic events. In phase 3 trials, rivaroxaban was found to have a benefit on ischemic events and perhaps a greater benefit at the lower dose. The phase 3 trial with apixaban was stopped early due to increased bleeding without a meaningful reduction in ischemic events. CONCLUSIONS Novel oral anticoagulants represent a promising, potentially beneficial treatment for patients with a recent acute coronary syndrome but come with a risk of bleeding. The benefits and risks of these agents will need to be carefully weighed and may depend on both patient risk and concomitant therapy. Additional research is needed to determine how to best integrate these medications into the care of patients with acute coronary syndromes.
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36
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Tao WW, Duan JA, Yang NY, Tang YP, Liu MZ, Qian YF. Antithrombotic phenolic compounds from Glycyrrhiza uralensis. Fitoterapia 2011; 83:422-5. [PMID: 22197642 DOI: 10.1016/j.fitote.2011.12.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 12/05/2011] [Accepted: 12/06/2011] [Indexed: 10/14/2022]
Abstract
A new coumestan, named glycyrurol, and nine phenolic compounds were isolated from the ethyl acetate extract of the roots and rhizomes of Glycyrrhiza uralensis. Their structures were elucidated based on spectroscopic analysis and literature data, and anticoagulative assay found significant antithrombotic activity of compounds 4, 8 and 10.
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Affiliation(s)
- Wei-Wei Tao
- School of Traditional Chinese Medicine, China Pharmaceutical University, Nanjing, China
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37
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Abstract
Although currently available anticoagulants are effective for the prevention and treatment of thromboembolic disorders, they have several drawbacks. Low molecular weight heparin and fondaparinux produce a predictable level of anticoagulation that obviates the need for coagulation monitoring, but they must be given parenterally, which renders them inconvenient for long-term use. Vitamin K antagonists, such as warfarin, are administered orally, but produce a variable anticoagulant response because genetic polymorphisms, dietary vitamin K intake and multiple drug-drug interactions affect their metabolism. Consequently, coagulation monitoring and frequent dose adjustments are needed to ensure that a therapeutic level of anticoagulation is achieved. This is burdensome for patients and physicians, and costly for the healthcare system. These limitations have prompted the development of new oral anticoagulants that target thrombin or factor Xa. The new agents produce such a predictable anticoagulant response that they can be given in fixed doses without monitoring. This paper focuses on the new oral anticoagulants in the most advanced stages of development.
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Affiliation(s)
- Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.
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38
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Madala PK, Tyndall JDA, Nall T, Fairlie DP. Update 1 of: Proteases Universally Recognize Beta Strands In Their Active Sites. Chem Rev 2011; 110:PR1-31. [DOI: 10.1021/cr900368a] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Praveen K. Madala
- Centre for Drug Design and Development, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Qld 4072, Australia This is a Chemical Reviews Perennial Review. The root paper of this title was published in Chem. Rev. 2005, 105 (3), 973−1000; Published (Web) Feb. 16, 2005. Updates to the text appear in red type
| | - Joel D. A. Tyndall
- Centre for Drug Design and Development, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Qld 4072, Australia This is a Chemical Reviews Perennial Review. The root paper of this title was published in Chem. Rev. 2005, 105 (3), 973−1000; Published (Web) Feb. 16, 2005. Updates to the text appear in red type
| | - Tessa Nall
- Centre for Drug Design and Development, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Qld 4072, Australia This is a Chemical Reviews Perennial Review. The root paper of this title was published in Chem. Rev. 2005, 105 (3), 973−1000; Published (Web) Feb. 16, 2005. Updates to the text appear in red type
| | - David P. Fairlie
- Centre for Drug Design and Development, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Qld 4072, Australia This is a Chemical Reviews Perennial Review. The root paper of this title was published in Chem. Rev. 2005, 105 (3), 973−1000; Published (Web) Feb. 16, 2005. Updates to the text appear in red type
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39
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Affiliation(s)
- P. Joshua O’Brien
- Department of Surgery, Section of Vascular Surgery, Duke University Medical Center, Durham, NC, USA
| | - Leila Mureebe
- Department of Surgery, Section of Vascular Surgery, Duke University Medical Center, Durham, NC, USA
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40
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Modifying the substrate specificity of Carcinoscorpius rotundicauda serine protease inhibitor domain 1 to target thrombin. PLoS One 2010; 5:e15258. [PMID: 21188150 PMCID: PMC3004852 DOI: 10.1371/journal.pone.0015258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 11/01/2010] [Indexed: 01/08/2023] Open
Abstract
Protease inhibitors play a decisive role in maintaining homeostasis and eliciting antimicrobial activities. Invertebrates like the horseshoe crab have developed unique modalities with serine protease inhibitors to detect and respond to microbial and host proteases. Two isoforms of an immunomodulatory two-domain Kazal-like serine protease inhibitor, CrSPI-1 and CrSPI-2, have been recently identified in the hepatopancreas of the horseshoe crab, Carcinoscorpius rotundicauda. Full length and domain 2 of CrSPI-1 display powerful inhibitory activities against subtilisin. However, the structure and function of CrSPI-1 domain-1 (D1) remain unknown. Here, we report the crystal structure of CrSPI-1-D1 refined up to 2.0 Å resolution. Despite the close structural homology of CrSPI-1-D1 to rhodniin-D1 (a known thrombin inhibitor), the CrSPI-1-D1 does not inhibit thrombin. This prompted us to modify the selectivity of CrSPI-1-D1 specifically towards thrombin. We illustrate the use of structural information of CrSPI-1-D1 to modify this domain into a potent thrombin inhibitor with IC50 of 26.3 nM. In addition, these studies demonstrate that, besides the rigid conformation of the reactive site loop of the inhibitor, the sequence is the most important determinant of the specificity of the inhibitor. This study will lead to the significant application to modify a multi-domain inhibitor protein to target several proteases.
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41
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Anand SX, Viles-Gonzalez JF, Mahboobi SK, Heerdt PM. Bivalirudin utilization in cardiac surgery: shifting anticoagulation from indirect to direct thrombin inhibition. Can J Anaesth 2010; 58:296-311. [DOI: 10.1007/s12630-010-9423-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Accepted: 11/03/2010] [Indexed: 01/19/2023] Open
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42
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Thompson KA, Philip KJ, Schwarz ER. Clinical Applications of Bivalirudin in the Cardiac Catheterization Laboratory. J Cardiovasc Pharmacol Ther 2010; 16:140-9. [DOI: 10.1177/1074248410385682] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Heparin has been used in the catheterization laboratory to prevent ischemic complications of percutaneous coronary intervention (PCI). Bivalirudin, a direct thrombin inhibitor, is an anticoagulant that has several pharmacologic advantages over heparin, and it has been proposed that bivalirudin is superior to heparin in its ability to prevent bleeding complications of PCI. As such, there have been a variety of large prospective clinical trials comparing bivalirudin and heparin over the past 13 years. The results of these trials have prompted the general acceptance of bivalirudin as a safe alternative to heparin use during PCI, and bivalirudin has been given a class 1 recommendation by the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for a variety of clinical indications. This article will review the data supporting the use of bivalirudin in the cardiac catheterization laboratory and describe several advantages of bivalirudin over traditional heparin use. We also include a discussion of the use of bivalirudin in conjunction with other medications that are frequently used in the catheterization laboratory. We end with an analysis of the economic differences between bivalirudin and heparin and the impact that financial factors may have on the choice of anticoagulant.
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Affiliation(s)
- Keith A. Thompson
- Division of Cardiology, Department of Medicine, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Kiran J. Philip
- Division of Cardiology, Department of Medicine, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | - Ernst R. Schwarz
- Division of Cardiology, Department of Medicine, Cedars Sinai Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA,
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Singh M, Adigopula S, Patel P, Kiran K, Khosla S. Recent advances in oral anticoagulation for atrial fibrillation. Ther Adv Cardiovasc Dis 2010; 4:395-407. [DOI: 10.1177/1753944710386844] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Atrial fibrillation is the most common sustained rhythm disturbance. Thromboembolic events related to atrial fibrillation result in significant morbidity, mortality and increases in the cost of healthcare. Anticoagulants are pivotal agents for the prevention and treatment of thromboembolic disorders. The latest American College of Cardiology/American Heart Association guidelines recommend antithrombotic therapy to prevent thromboembolism for all patients with atrial fibrillation, except those with lone atrial fibrillation or contraindications. Vitamin K antagonists were first synthesized in 1948 and for the past six decades they have been the only agents used for long-term oral anticoagulant therapy. Although these drugs are effective, they have numerous limitations, which have led to the development of newer anticoagulant therapies. The emerging oral anticoagulant agents are target selective. They have predictable pharmacokinetic and pharmacodynamic parameters and do not require routine monitoring. They are not associated with significant food and drug interactions, and can be administered in simple fixed daily or twice daily doses. This article reviews the current literature on various targets for anticoagulant therapy and newer oral anticoagulants for atrial fibrillation.
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Affiliation(s)
- Mukesh Singh
- Department of Cardiology, Mount Sinai Hospital, 1500 California Avenue, Chicago, IL 60608, USA,
| | | | - Pawan Patel
- Department of Cardiology, Mount Sinai Hospital, Chicago, IL, USA
| | - Kranti Kiran
- Department of Cardiology, Mount Sinai Hospital, Chicago, IL, USA
| | - Sandeep Khosla
- Department of Cardiology, Mount Sinai Hospital, Chicago, IL, USA
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Liu L, Ma H, Yang N, Tang Y, Guo J, Tao W, Duan J. A series of natural flavonoids as thrombin inhibitors: structure-activity relationships. Thromb Res 2010; 126:e365-78. [PMID: 20828797 DOI: 10.1016/j.thromres.2010.08.006] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 08/09/2010] [Accepted: 08/11/2010] [Indexed: 11/15/2022]
Abstract
A series of natural flavonoids has been evaluated as potential inhibitors of thrombin using the optimized method of thrombin time. Myricetin and quercetin have shown to be the best thrombin inhibitors tested. In order to investigate the thrombin recognition of the most active and selective compounds, a molecular modeling study has been performed using available Protein Data Bank (PDB) structures as receptor models for docking experiments. Structure-activity relationships of flavonoids (SARs) on thrombin would facilitate the design of chemical compounds with higher potency to serve as potential thrombin inhibitors, and provide information for the exploitation and utilization of flavonoids as thrombin inhibitors for thrombotic disease treatment.
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Affiliation(s)
- Li Liu
- Jiangsu Key Laboratory for TCM Formulae Research, Nanjing University of Chinese Medicine, Nanjing 210046, China
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45
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Gracher AHP, Cipriani TR, Carbonero ER, Gorin PA, Iacomini M. Antithrombin and heparin cofactor II-mediated inactivation of α-thrombin by a synthetic, sulfated mannogalactan. Thromb Res 2010; 126:e180-7. [DOI: 10.1016/j.thromres.2010.04.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 04/14/2010] [Accepted: 04/20/2010] [Indexed: 11/26/2022]
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46
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Trautmann A, Seitz CS. The complex clinical picture of side effects to anticoagulation. Med Clin North Am 2010; 94:821-34, xii-iii. [PMID: 20609865 DOI: 10.1016/j.mcna.2010.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Inflammatory plaques at injection sites are frequent side effects of heparin treatment and a clinical symptom of delayed-type hypersensitivity (DTH) to heparin. In most cases, changing the subcutaneous therapy from unfractionated to low-molecular-weight heparin or treatment with heparinoids does not provide improvement because of extensive cross-reactivity. Because of their completely different chemical structure, hirudins are a safe alternative for anticoagulation. Despite DTH to subcutaneously injected heparins, patients tolerate heparin intravenously. Therefore, in case of therapeutic necessity and DTH to heparins, the simple shift from subcutaneous to intravenous heparin administration is justified. Skin necrosis is a rare complication of anticoagulation. Heparin-induced skin necrosis is 1 of the symptoms of immune-mediated heparin-induced thrombocytopenia and should result in the immediate cessation of heparin therapy to prevent potentially fatal thrombotic events. This is in contrast to coumarin-induced skin necrosis, where therapy may be continued or restarted at a lower dose.
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Affiliation(s)
- Axel Trautmann
- Allergy Unit, Department of Dermatology, University of Würzburg, Josef Schneider Strasse 2, 97080 Würzburg, Germany.
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47
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Lu WF, Mo W, Liu Z, Fu WG, Guo DQ, Wang YQ, Song HY. The antithrombotic effect of a novel hirudin derivative after reconstruction of carotid artery in rabbits. Thromb Res 2010; 126:e339-43. [PMID: 20483158 DOI: 10.1016/j.thromres.2010.03.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Revised: 03/29/2010] [Accepted: 03/30/2010] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Hirudin is a direct thrombin inhibitor that has potential mechanistic advantages over indirect inhibitors. Peptides containing the RGD motif competitively inhibit binding of fibrinogen to glycoprotein IIb/IIIa on platelets, thus inhibiting platelet aggregation. A novel hirudin derivative, recombinant RGD-hirudin (r-RGD-hirudin), was engineered by fusing the tripeptide RGD sequence to the native hirudin. We tested the antithrombotic effect of r-RGD-hirudin using a carotid artery reconstruction model in rabbits. MATERIALS AND METHODS A fusion gene encoding r-RGD-hirudin was constructed and expressed at high levels in Pichia pastoris. Following traumatic injury and anastomosis, 42 New Zealand White rabbits were randomized to receive normal saline, abciximab, wild-type hirudin, or r-RGD-hirudin. Fibrinogen concentration, aPTT, TT, PT, and PAGm were measured prior to and following the operation. Carotid angiography and pathological examination of the anastomotic site were performed to compare patency rates among the groups. RESULTS The r-RGD-hirudin significantly prolonged aPTT, TT, PT and inhibited PAGm following carotid anastomosis in rabbits. The median dose of r-RGD-hirudin (0.5 mg/kg) had a therapeutic effect equal to that of wild-type hirudin (1.0 mg/kg) and higher than that of abciximab (0.2 mg/kg) with regard to patency rates. CONCLUSIONS Compared to wild-type hirudin or antiplatelet agent, the novel anticoagulant, r-RGD-hirudin was capable of inhibiting both thrombin activity and platelet aggregation, and was demonstrated to be effective in the prevention of thrombosis.
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Affiliation(s)
- Wei Feng Lu
- Department of Vascular Surgery, Zhongshan Hospital of Xiamen University, Xiamen 361000, China
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Freitas SC, Barbosa MA, Martins MCL. The effect of immobilization of thrombin inhibitors onto self-assembled monolayers on the adsorption and activity of thrombin. Biomaterials 2010; 31:3772-80. [DOI: 10.1016/j.biomaterials.2010.01.097] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Accepted: 01/15/2010] [Indexed: 12/01/2022]
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Salazar CA, Malaga G, Malasquez G. Direct thrombin inhibitors versus vitamin K antagonists or low molecular weight heparins for prevention of venous thromboembolism following total hip or knee replacement. Cochrane Database Syst Rev 2010; 2010:CD005981. [PMID: 20393944 PMCID: PMC6486302 DOI: 10.1002/14651858.cd005981.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Patients who have undergone total hip or knee replacement (THR, TKR) have a high risk of developing venous thromboembolism (VTE) following surgery, despite appropriate anticoagulation with warfarin or low molecular weight heparin (LMWH). New anticoagulants are under investigation. OBJECTIVES To examine the efficacy and safety of prophylactic anticoagulation with direct thrombin inhibitors (DTIs) versus LMWH or vitamin K antagonists in the prevention of VTE in patients undergoing THR or TKR. SEARCH STRATEGY The Cochrane Peripheral Vascular Disease Group searched their Specialized Register (last searched 12 March 2010) and CENTRAL (last searched 2010, Issue 2). SELECTION CRITERIA Randomised controlled trials. DATA COLLECTION AND ANALYSIS Three reviewers independently assessed methodological quality and extracted data in pre-designed tables. The reported follow-up events were included MAIN RESULTS We included 14 studies included involving 21,642 patients evaluated for efficacy and 27,360 for safety. No difference was observed in major VTE in DTIs compared with LMWH in both types of operations (odds ratio (OR) 0.91; 95% confidence interval (CI) 0.69 to 1.19), with high heterogeneity (I(2) 71%). No difference was observed with warfarin (OR 0.85; 95% CI 0.63 to 1.15) in TKR, with no heterogeneity (I(2) 0%).More total bleeding events were observed in the DTI group (in ximelagatran and dabigatran but not in desirudin) in patients subjected to THR (OR 1.40; 95% CI 1.06, 1.85; I(2) 41%) compared with LMWH. No difference was observed with warfarin in TKR (OR 1.76; 95% CI 0.91 to 3.38; I(2) 0%). All-cause mortality was higher in the DTI group when the reported follow-up events were included (OR 2.06; 95% CI 1.10 to 3.87).Studies that initiated anticoagulation before surgery showed less VTE events; those that began anticoagulation after surgery showed more VTE events in comparison with LMWH. Therefore, the effect of the DTIs compared with LMWH appears to be influenced by the time of initiation of coagulation more than the effect of the drug itself.The results obtained from sensitivity analysis, did not differ from the analysed results; this strengthens the value of the results. AUTHORS' CONCLUSIONS Direct thrombin inhibitors are as effective in the prevention of major venous thromboembolism in THR or TKR as LMWH and vitamin K antagonists. However, they show higher mortality and cause more bleeding than LMWH. No severe hepatic complications were reported in the analysed studies. Use of ximelagatran is not recommended for VTE prevention in patients who have undergone orthopedic surgery. More studies are necessary regarding dabigatran.
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Key Words
- humans
- anticoagulants
- anticoagulants/therapeutic use
- antifibrinolytic agents
- antifibrinolytic agents/therapeutic use
- arthroplasty, replacement, hip
- arthroplasty, replacement, hip/adverse effects
- arthroplasty, replacement, knee
- arthroplasty, replacement, knee/adverse effects
- azetidines
- benzimidazoles
- benzimidazoles/therapeutic use
- benzylamines
- contraindications
- dabigatran
- heparin, low‐molecular‐weight
- heparin, low‐molecular‐weight/therapeutic use
- pyridines
- pyridines/therapeutic use
- randomized controlled trials as topic
- thrombin
- thrombin/antagonists & inhibitors
- venous thromboembolism
- venous thromboembolism/etiology
- venous thromboembolism/prevention & control
- vitamin k
- vitamin k/antagonists & inhibitors
- warfarin
- warfarin/therapeutic use
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Affiliation(s)
- Carlos A Salazar
- Universidad Peruana Cayetano HerediaDepartment of MedicineAvenida Honorio Delgado 430San Martin de PorresLimaPeru
| | - German Malaga
- Universidad Peruana Cayetano HerediaAvenida Honorio Delgado 430San Martin de PorresLimaPeru33
| | - Giuliana Malasquez
- Universidad Peruana Cayetano HerediaAvenida Honorio Delgado 430San Martin de PorresLimaPeru33
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Cohen M. The thrombin hypothesis in ACS: a disappointing disconnect between bench data and bedside clinical trials. Am J Med 2010; 123:103-10. [PMID: 20103015 DOI: 10.1016/j.amjmed.2009.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Studies have demonstrated the efficacy and safety of unfractionated heparin and low-molecular-weight heparin in the management of patients with acute coronary syndrome. However, a common limitation of unfractionated heparin and low-molecular-weight heparin is that neither can neutralize clot-bound thrombin. To overcome this limitation of the broad heparin-based anticoagulants, novel anticoagulants targeted for both the free and clot-bound forms of thrombin (direct thrombin inhibitors), or other individual components of the coagulation cascade (eg, direct and indirect factor Xa inhibitors), were developed. These targeted anticoagulation agents showed promising results in preclinical testing and have been evaluated in large-scale clinical acute coronary syndrome trials. This review discusses the disconnect between the excellent preclinical findings obtained with these novel, targeted agents and the efficacy and safety data observed in patients with acute coronary syndrome, compared with the broader-range heparin-based anticoagulants.
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Affiliation(s)
- Marc Cohen
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, NJ; Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA.
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