Bleeding associated with the management of acute coronary syndromes

Creatine kinase during non-ST-segment elevation acute coronary syndromes is associated with major bleeding

Background

It was recently reported that highly elevated plasma activity of the ADP-scavenging enzyme creatine kinase (CK), to >10 times the upper reference limit (URL), is independently associated with fatal or non-fatal bleeding during treatment for ST-segment elevation myocardial infarction (OR 2.6 (95% CI, 1.8 to 2.7)/log CK increase). Evidence indicates that CK attenuates ADP-dependent platelet aggregation. This study investigates whether moderately elevated CK in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is associated with major bleeding.

Methods

The Thrombolysis In Myocardial Ischemia (TIMI) 3B trial compared recombinant tissue-type plasminogen activator (rt-PA) (35–80 mg) with placebo and early catheterisation with conservative management in patients with NSTE-ACS. Main outcomes of the current study are the independent association of peak plasma CK (CKmax) with adjudicated fatal or non-fatal major bleeding (primary) and with combined major bleeding, stroke and hospital death (secondary), with covariables including age, sex, body mass index, systolic blood pressure, creatinine and assignment to add-on rt-PA versus placebo. Discrimination was assessed with C-statistics.

Results

The study included 1473 patients (66% men, 80% white, mean age 59 years, SE 0.3). CKmax ranged between 15 and 19 045 IU/L (mean (SE), 450 (24) IU/L; two times URL). Major bleeding occurred in 2.0% (mean age 65 (1.3) years; mean CKmax 1015 (319) IU/L; six times URL), and the combined outcome in 4.3% of the patients, adjusted OR per log CK increase, respectively, 3.1 (1.6 to 5.9) for major bleeding and 3.9 (2.5 to 6.1) for the combined outcome; C-index 0.8 for both outcomes. The association between CK and bleeding was independent of the use of thrombolytic therapy.

Discussion

The presented data add to the existing evidence that proportionate to its plasma activity, the ADP-binding enzyme CK is strongly and independently associated with non-fatal and fatal major bleeding during treatment for NSTE-ACS. CK might increase the accuracy of prediction models for major bleeding in patients with NSTE-ACS.

Trial registration number

NCT00000472.

Sparganin A alleviates blood stasis syndrome and its key targets by molecular docking

Blood stasis syndrome is implicated in the development of chronic conditions, including cardio- and cerebrovascular diseases. Cyclo-(Tyr-Leu), named Sparganin A (SA), is a compound isolated from the ethanol extract of Rhizoma Sparganii. Here, the successful extraction of SA from Rhizoma Sparganii was verified by extensive spectral analysis using 1H NMR and 13C NMR. To determine the biological effects of SA, a mouse model of acute blood stasis was established by subcutaneous injection of adrenaline hydrochloride and placing the animals in an ice water bath. In this model, the concentration of TXB2, PAI-1, FIB, ET-1 was measured by ELISA, and thymus index (TI), hepatic index (HI), and spleen index (SI) were calculated. Molecular docking by SYBYL and functional analysis of the putative targets by STRING and Cytoscape were employed to identify the key targets of SA. The accumulated results documented that SA exhibits anticoagulative activity, and its key targets are VEGFA and SERPINE1. SA may be involved in the pathological process of complement and coagulation cascades. This study demonstrates that SA may be a promising drug to control coagulation in blood stasis syndrome.