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Zhou X, Li Z, Liu H, Li Y, Zhao D, Yang Q. Antithrombotic therapy and bleeding risk in the era of aggressive lipid-lowering: current evidence, clinical implications, and future perspectives. Chin Med J (Engl) 2023; 136:645-652. [PMID: 36806078 PMCID: PMC10129148 DOI: 10.1097/cm9.0000000000002057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Indexed: 02/23/2023] Open
Abstract
ABSTRACT The clinical efficacy of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) in reducing major cardiovascular adverse events related to atherosclerotic cardiovascular disease (ASCVD) has been well established in recent large randomized outcome trials. Although the cardiovascular and all-cause mortality benefit of PCSK9i remains inconclusive, current cholesterol management guidelines have been modified toward more aggressive goals for lowering low-density lipoprotein cholesterol (LDL-C). Consequently, the emerging concept of "the lower the better" has become the paradigm of ASCVD prevention. However, there is evidence from observational studies of a U-shaped association between baseline LDL-C levels and all-cause mortality in population-based cohorts. Among East Asian populations, low LDL-C was associated with an increased risk for hemorrhagic stroke in patients not on antithrombotic therapy. Accumulating evidence showed that low LDL-C was associated with an enhanced bleeding risk in patients on dual antiplatelet therapy following percutaneous coronary intervention. Additionally, low LDL-C was associated with a higher risk for incident atrial fibrillation and thereby, a possible increase in the risk for intracranial hemorrhage after initiation of anticoagulation therapy. The mechanism of low-LDL-C-related bleeding risk has not been fully elucidated. This review summarizes recent evidence of low-LDL-C-related bleeding risk in patients on antithrombotic therapy and discusses potential measures for reducing this risk, underscoring the importance of carefully weighing the pros and cons of aggressive LDL-C lowering in patients on antithrombotic therapy.
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Affiliation(s)
- Xin Zhou
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Ziping Li
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Hangkuan Liu
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Yongle Li
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin 300052, China
| | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, Institute of Heart, Lung and Blood Vessel Diseases, Beijing 100029, China
| | - Qing Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin 300052, China
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Venugopal J, Wang J, Guo C, Eitzman DT. Amiodarone improves anemia in a murine model of sickle cell disease and is associated with increased erythrocyte bis(monoacylglycerol) phosphate. Sci Rep 2022; 12:16437. [PMID: 36180774 PMCID: PMC9525675 DOI: 10.1038/s41598-022-20955-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 09/21/2022] [Indexed: 11/26/2022] Open
Abstract
Sickle cell disease (SCD) is associated with altered plasma and erythrocyte lipid profiles. In a previous study, SCD mice with deficiency of proprotein convertase subtilisin/kexin type 9 (PCSK9) were observed to have more severe anemia and increased sickling compared to control SCD mice. Although PCSK9 affects circulating low density lipoprotein (LDL) by regulation of the LDL receptor, the effect of PCSK9 on anemia was independent of LDL receptor expression. In the current study, erythrocyte metabolomics were performed and revealed altered erythrocyte lipid species between SCD mice with and without PCSK9. Of particular interest, the late endosome-specific lipid bis(mono)acylglycerol phosphate (BMP) 44:12 was markedly decreased in erythrocytes from SCD mice deficient in PCSK9 mice relative to control SCD mice. Incubation of sickle erythrocytes with a neutralizing antibody to BMP increased erythrocyte sickling in vitro. In vitro treatment of SCD erythrocytes with amiodarone (1.5 μM) or medroxyprogesterone (6.75 μM), two pharmacologic compounds known to increase BMP, resulted in reduced erythrocyte sickling. Treatment of SCD mice with amiodarone (10 mg/kg) for 2 weeks resulted in increased BMP, improvement in anemia with reduced reticulocytosis, and decreased ex vivo sickling. In conclusion, severity of anemia in SCD is improved with amiodarone treatment, an effect which may be mediated through increased erythrocyte BMP.
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Affiliation(s)
- Jessica Venugopal
- Cardiovascular Research Center, University of Michigan Internal Medicine-Cardiology Division, 7301A MSRB III, 1150 West Medical Center Drive, Ann Arbor, MI, 48109-0644, USA
| | - Jintao Wang
- Cardiovascular Research Center, University of Michigan Internal Medicine-Cardiology Division, 7301A MSRB III, 1150 West Medical Center Drive, Ann Arbor, MI, 48109-0644, USA
| | - Chiao Guo
- Cardiovascular Research Center, University of Michigan Internal Medicine-Cardiology Division, 7301A MSRB III, 1150 West Medical Center Drive, Ann Arbor, MI, 48109-0644, USA
| | - Daniel T Eitzman
- Cardiovascular Research Center, University of Michigan Internal Medicine-Cardiology Division, 7301A MSRB III, 1150 West Medical Center Drive, Ann Arbor, MI, 48109-0644, USA.
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Venugopal J, Wang J, Guo C, Eitzman DT. Interleukin-1 receptor antagonism leads to improved anaemia in a murine model of sickle cell disease and is associated with reduced ex vivo platelet-mediated erythrocyte sickling. Br J Haematol 2021; 196:1040-1051. [PMID: 34786709 DOI: 10.1111/bjh.17941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 10/01/2021] [Accepted: 10/21/2021] [Indexed: 11/29/2022]
Abstract
Sickle cell disease (SCD) is associated with haemolytic anaemia and secondary activation of leucocytes and platelets, which in turn may further exacerbate haemolysis. As cytokine signalling pathways may participate in this cycle, the present study investigated whether pharmacological blockade of the interleukin-1 receptor (IL-1R) would mitigate anaemia in a murine model of SCD. Within 2 weeks of treatment, reduced markers of haemolysis were observed in anakinra-treated mice compared to vehicle-treated mice. After 4 weeks of anakinra treatment, mice showed increased numbers of erythrocytes, haemoglobin, and haematocrit, along with reduced reticulocytes. Blood from anakinra-treated mice was less susceptible to ex vivo erythrocyte sickling and was resistant to exogenous IL-1β-mediated sickling. Supernatant generated from IL-1β-treated platelets was sufficient to promote erythrocyte sickling, an effect not observed with platelet supernatant generated from IL-1R-/- mice. The sickling effect of IL-1β-treated platelet supernatant was inhibited by a transforming growth factor-β (TGF-β) neutralising antibody, nicotinamide adenine dinucleotide phosphate (NADPH) oxidase inhibition, and superoxide scavengers, but replicated by recombinant TGF-β. In conclusion, pharmacological IL-1R antagonism leads to improved anaemia in a murine SCD model. IL-1β stimulation of platelets promotes erythrocyte sickling. This effect may be mediated by platelet-derived TGF-β-induced reactive oxygen species generation though erythrocyte NADPH oxidase.
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Affiliation(s)
- Jessica Venugopal
- University of Michigan Internal Medicine - Cardiology Division, Ann Arbor, MI, USA
| | - Jintao Wang
- University of Michigan Internal Medicine - Cardiology Division, Ann Arbor, MI, USA
| | - Chiao Guo
- University of Michigan Internal Medicine - Cardiology Division, Ann Arbor, MI, USA
| | - Daniel T Eitzman
- University of Michigan Internal Medicine - Cardiology Division, Ann Arbor, MI, USA
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Jacome Sanz D, Saralahti AK, Pekkarinen M, Kesseli J, Nykter M, Rämet M, Ojanen MJT, Pesu M. Proprotein convertase subtilisin/kexin type 9 regulates the production of acute-phase reactants from the liver. Liver Int 2021; 41:2511-2522. [PMID: 34174143 DOI: 10.1111/liv.14993] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/07/2021] [Accepted: 06/24/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Proprotein convertase subtilisin/kexin type 9 (PCSK9) controls blood cholesterol levels by fostering the LDL receptor (LDLR) degradation in hepatocytes. Additionally, PCSK9 has been suggested to participate in immunoregulation by modulating cytokine production. We studied the immunological role of PCSK9 in Streptococcus pneumoniae bacteraemia in vivo and in a human hepatocyte cell line. METHODS CRISPR/Cas9 mutagenesis was utilized to create pcsk9 knock-out (KO) zebrafish, which were infected with S pneumoniae to assess the role of PCSK9 for the survival of the fish and in the transcriptomic response of the liver. The direct effects of PCSK9 on the expression of acute-phase reaction (APR) genes were studied in HepG2 cells. RESULTS The pcsk9 KO zebrafish lines (pcsk9tpu-13 and pcsk9tpu-2,+15 ) did not show developmental defects or gross phenotypical differences. In the S pneumoniae infected zebrafish, the mortality of pcsk9 KOs was similar to the controls. A liver-specific gene expression analysis revealed that a pneumococcal challenge upregulated pcsk9, and that the pcsk9 deletion reduced the expression of APR genes, including hepcidin antimicrobial peptide (hamp) and complement component 7b (c7b). Accordingly, silencing PCSK9 in vitro in HepG2 cells using small interfering RNAs (siRNAs) decreased HAMP expression. CONCLUSIONS We demonstrate that PCSK9 is not critical for zebrafish survival in a systemic pneumococcal infection. However, PCSK9 deficiency was associated with the lower expression of APR genes in zebrafish and altered the expression of innate immunity genes in a human hepatocyte cell line. Overall, our data suggest an evolutionarily conserved function for PCSK9 in APR in the liver.
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Affiliation(s)
- Dafne Jacome Sanz
- Laboratory of Immunoregulation, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Anni K Saralahti
- Laboratory of Experimental Immunology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Meeri Pekkarinen
- Laboratory of Computational Biology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Juha Kesseli
- Laboratory of Computational Biology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Matti Nykter
- Laboratory of Computational Biology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Mika Rämet
- Laboratory of Experimental Immunology, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Vaccine Research Center, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland.,Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Markus J T Ojanen
- Laboratory of Immunoregulation, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Marko Pesu
- Laboratory of Immunoregulation, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Fimlab laboratories Ltd, Tampere, Finland
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Yang Q, Sun D, Pei C, Zeng Y, Wang Z, Li Z, Hao Y, Song X, Li Y, Liu G, Tang Y, Smith SC, Han Y, Huo Y, Ge J, Ma C, Fonarow GC, Morgan L, Liu J, Liu J, Zhou M, Zhao D, Zhou Y, Zhou X. LDL cholesterol levels and in-hospital bleeding in patients on high-intensity antithrombotic therapy: findings from the CCC-ACS project. Eur Heart J 2021; 42:3175-3186. [PMID: 34347859 DOI: 10.1093/eurheartj/ehab418] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/29/2020] [Accepted: 06/17/2021] [Indexed: 11/12/2022] Open
Abstract
AIMS Emerging evidence has linked cholesterol metabolism with platelet responsiveness. We sought to examine the dose-response relationship between low-density lipoprotein cholesterol (LDL-C) and major in-hospital bleeds in acute coronary syndrome (ACS) patients. METHODS AND RESULTS Among 42 378 ACS patients treated with percutaneous coronary intervention (PCI) enrolled in 240 hospitals in the Improving Care for Cardiovascular Disease in China-ACS project from 2014 to 2019, a total of 615 major bleeds, 218 ischaemic events, and 337 deaths were recorded. After controlling for baseline variables, a non-linear relationship was observed for major bleeds, with the higher risk at lower LDL-C levels. No dose-response relationship was identified for ischaemic events and mortality. A threshold value of LDL-C <70 mg/dL was associated with an increased risk for major bleeds (adjusted odds ratio: 1.49; 95% confidence interval: 1.21-1.84) in multivariable-adjusted logistic regression models and in propensity score-matched cohorts. The results were consistent in multiple sensitivity analyses. Among ticagrelor-treated patients, the LDL-C threshold for increased bleeding risk was observed at <88 mg/dL, whereas for clopidogrel-treated patients, the threshold was <54 mg/dL. Across a full spectrum of LDL-C levels, the treatment effect size associated with ticagrelor vs. clopidogrel on major bleeds favoured clopidogrel at lower LDL-C levels, but no difference at higher LDL-C levels. CONCLUSIONS In a nationwide ACS registry, a non-linear association was identified between LDL-C levels and major in-hospital bleeds following PCI, with the higher risk at lower levels. As the potential for confounding may exist, further studies are warranted. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02306616.
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Affiliation(s)
- Qing Yang
- Department of Cardiology, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin 300052, China
| | - Dongdong Sun
- Department of Cardiology, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin 300052, China
| | - Chongzhe Pei
- Department of Cardiology, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin 300052, China
| | - Yuhong Zeng
- Departments of Epidemiology and Cardiology, Beijing Anzhen Hospital, Capital Medical University, the Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No.2 Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Zhuoqun Wang
- Department of Cardiology, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin 300052, China
| | - Ziping Li
- Department of Cardiology, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin 300052, China
| | - Yongchen Hao
- Departments of Epidemiology and Cardiology, Beijing Anzhen Hospital, Capital Medical University, the Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No.2 Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Xiwen Song
- Department of Cardiology, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin 300052, China
| | - Yongle Li
- Department of Cardiology, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin 300052, China
| | - Gang Liu
- Heart Center, the First Hospital of Hebei Medical University, 89 Donggang Road, Shijiazhuang 050000, Hebei, China
| | - Yida Tang
- Department of Cardiology, Peking University Third Hospital, 49 Huayuanbei Road, Haidian District, Beijing 100191, China
| | - Sidney C Smith
- Division of Cardiology, University of North Carolina at Chapel Hill, 6031 Burnett-Womack Building, Chapel Hill, NC 27599-7075, USA
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, 83 Wenhua Road, Shenhe District, Shenyang 110801, Liaoning, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, 8 Xishiku Street, Xicheng District, 100034 Beijing, China
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, 180 Fenglin Road, 200032 Shanghai, China
| | - Changsheng Ma
- Departments of Epidemiology and Cardiology, Beijing Anzhen Hospital, Capital Medical University, the Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No.2 Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at University of California, Los Angeles, 100 UCLA Medical Plaza, Los Angeles, CA 90095, USA
| | - Louise Morgan
- International Quality Improvement Department, American Heart Association, 7272 Greenville Ave, Dallas, TX 75231, USA
| | - Jing Liu
- Departments of Epidemiology and Cardiology, Beijing Anzhen Hospital, Capital Medical University, the Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No.2 Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Jun Liu
- Departments of Epidemiology and Cardiology, Beijing Anzhen Hospital, Capital Medical University, the Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No.2 Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Mengge Zhou
- Departments of Epidemiology and Cardiology, Beijing Anzhen Hospital, Capital Medical University, the Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No.2 Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Dong Zhao
- Departments of Epidemiology and Cardiology, Beijing Anzhen Hospital, Capital Medical University, the Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No.2 Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Yujie Zhou
- Departments of Epidemiology and Cardiology, Beijing Anzhen Hospital, Capital Medical University, the Key Laboratory of Remodeling-Related Cardiovascular Diseases, Ministry of Education, Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing Institute of Heart, Lung and Blood Vessel Diseases, No.2 Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Xin Zhou
- Department of Cardiology, Tianjin Medical University General Hospital, 154 Anshan Road, Heping District, Tianjin 300052, China
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