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Gusev VV, Lvova OA, Shamalov NA. Problems of selecting an anticoagulant for secondary stroke prevention in patients with atrial fibrillation. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-3044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The article describes the urgent problem of ischemic stroke prevention in patients with atrial fibrillation. It is proved that ischemic stroke in combination with AF is the most severe in terms of developing stable motor and speech disorders and disability. The frail older patients, as well as patients with swallowing disorders and reduced medical adherence present a special problem from this point of view. The most famous clinical studies on secondary prevention of cardioembolic stroke are RE-LY, ROCKET-AF, and ARISTOTLE. Based on subanalyses of randomized controlled trials, direct oral anticoagulants demonstrated a favorable efficacy profile in patients with atrial fibrillation and stroke/ transient ischemic attack, but the level of knowledge on each of them remained different. A number of advantages of rivaroxaban for primary and secondary prevention of stroke in patients with atrial fibrillation, including the elderly and patients with cognitive impairments and swallowing disorders, have been demonstrated.
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Affiliation(s)
- V. V. Gusev
- Central City Clinical Hospital № 23; Ural Federal University named after the First President of Russia B.N. Yeltsin; Ural State Medical University
| | - O. A. Lvova
- Ural Federal University named after the First President of Russia B.N. Yeltsin; Ural State Medical University
| | - N. A. Shamalov
- Institute of Cerebrovascular Pathology and Stroke, Federal Center of Brain Research and Neurotechnologies
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Kaesler N, Schurgers LJ, Floege J. Vitamin K and cardiovascular complications in CKD patients. Kidney Int 2021; 100:1023-1036. [PMID: 34310988 DOI: 10.1016/j.kint.2021.06.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/08/2021] [Accepted: 06/11/2021] [Indexed: 01/07/2023]
Abstract
Vitamin K, well known for its role in coagulation, encompasses two major subgroups: Vitamin K1 is exclusively synthesized by plants, whereas vitamin K2 mostly originates from bacterial synthesis. Vitamin K serves as a cofactor for the enzyme γ-glutamyl carboxylase, which carboxylates and thereby activates various vitamin K dependent proteins. Several vitamin K-dependent proteins are synthesized in bone but the role of vitamin K for bone health in CKD patients, in particular the prevention of osteoporosis is still not firmly established. Here we focus on another prominent action of vitamin K, in particular vitamin K2, namely the activation of matrix Gla protein (MGP), the most potent inhibitor of cardiovascular calcifications. Multiple observational studies link relative vitamin K deficiency or low intake to cardiovascular calcification progress, morbidity and mortality. Patients with advanced chronic kidney disease (CKD) are particularly vitamin K deficient, in part because of dietary restrictions but possibly also due to impaired endogenous recycling of vitamin K. At the same time this population is characterized by markedly accelerated cardiovascular calcifications and mortality. High dose dietary supplementation with vitamin K2, in particular the most potent form menaquinone-7 (MK7), can potently reduce circulating levels of dephosphorylated uncarboxylated, i.e. inactive MGP in patients with end stage kidney disease. However, despite this compelling data basis, several randomized controlled trials with high dose MK7 supplements in patients with advanced CKD have failed to confirm cardiovascular benefits. Here we discuss potential reasons and solutions for this.
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Affiliation(s)
- Nadine Kaesler
- Division of Nephrology and Rheumatology, University Hospital, Rheinisch Westfälische Technische Hochschule, Aachen, Germany
| | - Leon J Schurgers
- Department of Biochemistry and Cardiovascular Research Institute Maastricht, School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands; Institute of Experimental Medicine and Systems Biology, Rheinisch Westfälische Technische Hochschule, Aachen University, Aachen, Germany
| | - Jürgen Floege
- Division of Nephrology and Rheumatology, University Hospital, Rheinisch Westfälische Technische Hochschule, Aachen, Germany.
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CYP4F2 and VKORC1 Polymorphisms Amplify the Risk of Carotid Plaque Formation. Genes (Basel) 2020; 11:genes11070822. [PMID: 32698322 PMCID: PMC7396977 DOI: 10.3390/genes11070822] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/11/2020] [Accepted: 07/17/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction: Atherosclerosis represents the process by which fibrous plaques are formed in the arterial wall, increasing its rigidity with a subsequent decrease in blood flow which can lead to several cardiovascular events. Seeing as vitamin K antagonists are involved in the pathogenesis of atherosclerosis, we decided to investigate whether polymorphisms in genes that influence vitamin K metabolism might have an impact in modulating the risk of plaque formation. Patients and Methods: In the current study we included adult patients admitted in the Clinical Municipal Hospital of Cluj-Napoca without any carotid or femoral plaques clinically visible at the initial investigation, and a five year follow-up was subsequently performed. We recorded the following patient characteristics: age at inclusion, gender, area of living, smoking, presence of carotid and/or femoral plaques at five years, ischemic heart disease, arterial hypertension, atrial fibrillation, heart failure, diabetes mellitus, obesity, dyslipidemia, drug (oral anticoagulants, antihypertensives, hypolipidemic, anti-diabetic) use and status for the following gene polymorphisms: VKORC1 1639 G>A, CYP4F2 1347 G>T and GGCX 12970 C>G. Results: We observed that the major predictor of both carotid and femoral plaque formation is represented by ischemic cardiac disease. VKORC1 and CYP4F2 polymorphisms did not predict plaque formation, except for VKORC1 homozygous mutants. Nonetheless, both VKORC1 and CYP4F2 interacted with ischemic cardiac disease, increasing the risk of developing a carotid plaque, while only CYP4F2, but not VKORC1, interacted with ischemic cardiac disease to increase the risk of femoral plaque formation. Conclusions: We documented that CYP4F2 and VKORC1 polymorphisms boost the proinflammatory plaque environment (observed indirectly through the presence of ischemic heart disease), increasing the risk of plaque development.
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Abstract
Ca2+ binding proteins (CBP) are of key importance for calcium to play its role as a pivotal second messenger. CBP bind Ca2+ in specific domains, contributing to the regulation of its concentration at the cytosol and intracellular stores. They also participate in numerous cellular functions by acting as Ca2+ transporters across cell membranes or as Ca2+-modulated sensors, i.e. decoding Ca2+ signals. Since CBP are integral to normal physiological processes, possible roles for them in a variety of diseases has attracted growing interest in recent years. In addition, research on CBP has been reinforced with advances in the structural characterization of new CBP family members. In this chapter we have updated a previous review on CBP, covering in more depth potential participation in physiopathological processes and candidacy for pharmacological targets in many diseases. We review intracellular CBP that contain the structural EF-hand domain: parvalbumin, calmodulin, S100 proteins, calcineurin and neuronal Ca2+ sensor proteins (NCS). We also address intracellular CBP lacking the EF-hand domain: annexins, CBP within intracellular Ca2+ stores (paying special attention to calreticulin and calsequestrin), proteins that contain a C2 domain (such as protein kinase C (PKC) or synaptotagmin) and other proteins of interest, such as regucalcin or proprotein convertase subtisilin kexins (PCSK). Finally, we summarise the latest findings on extracellular CBP, classified according to their Ca2+ binding structures: (i) EF-hand domains; (ii) EGF-like domains; (iii) ɣ-carboxyl glutamic acid (GLA)-rich domains; (iv) cadherin domains; (v) Ca2+-dependent (C)-type lectin-like domains; (vi) Ca2+-binding pockets of family C G-protein-coupled receptors.
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Chirinos JA, Sardana M, Syed AA, Koppula MR, Varakantam S, Vasim I, Oldland HG, Phan TS, Drummen NEA, Vermeer C, Townsend RR, Akers SR, Wei W, Lakatta EG, Fedorova OV. Aldosterone, inactive matrix gla-protein, and large artery stiffness in hypertension. JOURNAL OF THE AMERICAN SOCIETY OF HYPERTENSION : JASH 2018; 12:681-689. [PMID: 30033123 PMCID: PMC6139275 DOI: 10.1016/j.jash.2018.06.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 05/09/2018] [Accepted: 06/26/2018] [Indexed: 01/07/2023]
Abstract
Vascular calcification leads to increased large artery stiffness. Matrix gla-protein (MGP) is a vitamin K-dependent protein that inhibits arterial calcification. Aldosterone promotes vascular calcification and stiffness, but the relationships between aldosterone, MGP, and arterial stiffness are unknown. We studied 199 adults (predominantly older men) with hypertension. We assessed the relationship between levels of dephospho-uncarboxylated MGP (dp-ucMGP), aldosterone, and carotid-femoral pulse wave velocity (CF-PWV) using standard regression and mediation analyses. Plasma aldosterone was measured in a subgroup of subjects (n = 106). Aldosterone was strongly associated with dp-ucMGP (standardized β = 0.50, P < .001), which was independent of potential confounders (β = 0.37, P < .001). Levels of dp-ucMGP were significantly associated with CF-PWV (β = 0.30; P < .001), which persisted after adjustment for potential confounders (β = 0.25; P = .004). Plasma aldosterone was also significantly associated with CF-PWV (standardized β = 0.21; P = .035). However, in a model that included aldosterone and dp-ucMGP, only the latter was associated with CF-PWV. Mediation analyses demonstrated a significant dp-ucMGP-mediated effect of aldosterone on CF-PWV, without a significant direct (dp-ucMGP independent) effect. Our study demonstrates a novel independent association between high aldosterone levels and dp-ucMGP, suggesting that aldosterone may influence the MGP pathway. This relationship appears to underlie the previously documented relationship between aldosterone and increased arterial stiffness.
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Affiliation(s)
- Julio A Chirinos
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA; Cardiology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine and Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Mayank Sardana
- Cardiology Division, Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA
| | - Amer Ahmed Syed
- Cardiology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine and Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Maheshwara R Koppula
- Cardiology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine and Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Swapna Varakantam
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA; Cardiology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine and Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Izzah Vasim
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA; Cardiology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine and Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Harold G Oldland
- Cardiology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine and Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy S Phan
- Cardiology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine and Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Nadja E A Drummen
- R&D Group, VitaK, Maastricht University, Maastricht, The Netherlands
| | - Cees Vermeer
- R&D Group, VitaK, Maastricht University, Maastricht, The Netherlands
| | - Raymond R Townsend
- Cardiology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine and Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott R Akers
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
| | - Wen Wei
- National Institute of Aging, Baltimore, MD, USA
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Ruderman I, Holt SG, Hewitson TD, Smith ER, Toussaint ND. Current and potential therapeutic strategies for the management of vascular calcification in patients with chronic kidney disease including those on dialysis. Semin Dial 2018; 31:487-499. [PMID: 29733462 DOI: 10.1111/sdi.12710] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with CKD have accelerated vascular stiffening contributing significantly to excess cardiovascular morbidity and mortality. Much of the arterial stiffening is thought to involve vascular calcification (VC), but the pathogenesis of this phenomenon is complex, resulting from a disruption of the balance between promoters and inhibitors of calcification in a uremic milieu, along with derangements in calcium and phosphate metabolic pathways. Management of traditional cardiovascular risk factors to reduce VC may be influential but has not been shown to significantly improve mortality. Control of mineral metabolism may potentially reduce the burden of VC, although using conventional approaches of restricting dietary phosphate, administering phosphate binders, and use of active vitamin D and calcimimetics, remains controversial because recommended biochemical targets are hard to achieve and clinical relevance hard to define. Increasing time on dialysis is perhaps another therapy with potential effectiveness in this area. Despite current treatments, cardiovascular morbidity and mortality remain high in this group. Novel therapies for addressing VC include magnesium and vitamin K supplementation, which are currently being investigated in large randomized control trials. Other therapeutic targets include crystallization inhibitors, ligand trap for activin receptors and BMP-7. This review summarizes current treatment strategies and therapeutic targets for the future management of VC in patients with CKD.
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Affiliation(s)
- Irene Ruderman
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Tim D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Vic., Australia
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Siltari A, Vapaatalo H. Vascular Calcification, Vitamin K and Warfarin Therapy - Possible or Plausible Connection? Basic Clin Pharmacol Toxicol 2017. [PMID: 28639365 DOI: 10.1111/bcpt.12834] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Atherosclerosis is a pathological process underpinning many cardiovascular diseases; it is the main cause of global mortality. Atherosclerosis is characterized by an invasion of inflammatory cells, accumulation of lipids and the formation of fatty streaks (plaques) which subsequently allow accumulation of calcium and other minerals leading to a disturbance in the vascular endothelium and its regulatory role in arterial function. Vascular calcification is a different process, stringently regulated mainly by local factors, in which osteoblast-like cells accumulate in the muscular layer of arteries ultimately taking on the physiological appearance of bone. The elevated stiffness of the arteries leads to severe vascular complications in brain, heart and kidneys. Recently, evidence from animal experiments as well as clinical and epidemiological results suggests that long-term treatment with warfarin, but not with the novel direct anticoagulants, can increase the risk or even induce vascular calcification in some individuals. Gamma-carboxylation is an enzymatic process not only needed for activation of vitamin K but also other proteins which participate in bone formation and vascular calcification. Thus, reduced expression of the vitamin K-dependent proteins which physiologically inhibit calcification of cellular matrix could be postulated to lead to vascular calcification. Published clinical data, describing at present a few thousand patients, need to be supplemented with controlled studies to confirm this interesting hypothesis.
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Affiliation(s)
- Aino Siltari
- Faculty of Medicine, Pharmacology, University of Helsinki, Helsinki, Finland
| | - Heikki Vapaatalo
- Faculty of Medicine, Pharmacology, University of Helsinki, Helsinki, Finland
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Wuyts J, Dhondt A. The role of vitamin K in vascular calcification of patients with chronic kidney disease. Acta Clin Belg 2016; 71:462-467. [PMID: 27254816 DOI: 10.1080/17843286.2016.1180770] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Patients with chronic kidney disease (CKD) are prone to vascular calcification. Pathogenetic mechanisms of vascular calcifications have been broadly studied and discussed such as the role of hyperphosphatemia, hypercalcemia, parathormone, and vitamin D. In recent years, new insights have been gained pointing to vitamin K as a main actor. It has been discovered that vitamin K is an essential cofactor for the activation of matrix Gla protein (MGP), a calcification inhibitor in the vessel wall. Patients with CKD often suffer from vitamin K deficiency, resulting in low active MGP and eventually a lack of inhibition of vascular calcification. Vitamin K supplementation and switching warfarin to new oral anticoagulants are potential treatments. In addition, MGP may have a role as a non-invasive biomarker for vascular calcification.
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Caluwé R, Pyfferoen L, De Boeck K, De Vriese AS. The effects of vitamin K supplementation and vitamin K antagonists on progression of vascular calcification: ongoing randomized controlled trials. Clin Kidney J 2015; 9:273-9. [PMID: 26985380 PMCID: PMC4792621 DOI: 10.1093/ckj/sfv146] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 11/30/2015] [Indexed: 01/02/2023] Open
Abstract
Background The extent and the progression of vascular calcification (VC) are independent predictors of cardiovascular risk in the haemodialysis population. Vitamin K is essential for the activation of matrix gla protein (MGP), a powerful inhibitor of tissue calcification. Functional vitamin K deficiency may contribute to the high VC burden in haemodialysis patients. In addition, haemodialysis patients are frequently treated with vitamin K antagonists, mainly to prevent stroke in atrial fibrillation, potentially compounding the cardiovascular risk in these already vulnerable patients. New oral anticoagulants (NOACs) are valuable alternatives to vitamin K antagonists in the general population, but their use in dialysis has been encumbered by substantial renal clearance. However, a recent pharmacokinetic study provided information on how to use rivaroxaban in haemodialysis patients. Methods We conduct a randomized, prospective, multicentre, open-label interventional clinical trial that will include 117 chronic haemodialysis patients with non-valvular atrial fibrillation, treated with or candidates for treatment with vitamin K antagonists. Patients will be randomized to a vitamin K antagonist titrated weekly to an international normalized ratio between 2 and 3, a daily dose of rivaroxaban of 10 mg, or a daily dose of rivaroxaban 10 mg with a thrice weekly supplement of 2000 µg vitamin K2. Cardiac computed tomography, pulse wave velocity (PWV) measurements and MGP sampling will be performed at baseline, 6 months, 12 months and 18 months. Primary endpoints include progression of coronary artery and thoracic aorta calcification and changes in PWV. Secondary endpoints are progression of aortic and mitral valve calcification, all-cause mortality, major adverse cardiovascular events, stroke and bleeding. The ClinicalTrials.gov database was searched to retrieve related trials. Results Seven trials, three of which are performed in the haemodialysis population, evaluate whether pharmacological doses of vitamin K1 or K2 retard progression of VC. Five studies compare the effect of warfarin and NOACs on progression of VC, the present study being the only conducted in the dialysis population. Conclusion Vitamin K deficiency may be a modifiable cardiovascular risk factor in the haemodialysis population. Conversely, vitamin K antagonists may aggravate VC burden in haemodialysis patients. Several ongoing trials may provide an answer to these questions in the near future.
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Affiliation(s)
| | - Lotte Pyfferoen
- Department of Medical Imaging , AZ Sint-Jan Brugge , Brugge , Belgium
| | - Koen De Boeck
- Division of Nephrology , ZNA Hospital , Antwerp , Belgium
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases , AZ Sint-Jan Brugge , Brugge , Belgium
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De Vriese AS, Caluwé R, Bailleul E, De Bacquer D, Borrey D, Van Vlem B, Vandecasteele SJ, Emmerechts J. Dose-Finding Study of Rivaroxaban in Hemodialysis Patients. Am J Kidney Dis 2015; 66:91-8. [DOI: 10.1053/j.ajkd.2015.01.022] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 01/22/2015] [Indexed: 11/11/2022]
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Vogel T, Geny B, Kaltenbach G, Lang PO. L’anticoagulation dans la fibrillation atriale du sujet âgé : point de vue du gériatre avec un focus sur les anticoagulants oraux directs. Rev Med Interne 2015; 36:22-30. [DOI: 10.1016/j.revmed.2014.08.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 05/19/2014] [Accepted: 08/13/2014] [Indexed: 12/16/2022]
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Bansal N. The debate on warfarin use in dialysis patients with atrial fibrillation: more fuel for the fire. Am J Kidney Dis 2014; 64:677-80. [PMID: 24833202 PMCID: PMC4209313 DOI: 10.1053/j.ajkd.2014.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 04/22/2014] [Indexed: 11/11/2022]
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Helin TA, Wickholm N, Kautiainen H, Vapaatalo H. Possible Correlation between INR and Serum Calcium. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/pp.2014.513129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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