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Gue YX, Memtsas V, Kanji R, Wellsted DM, Busby A, Smith M, Vilar E, Ryding A, Arachchillage DJ, Gorog DA. Impact of very low dose rivaroxaban in addition to dual antiplatelet therapy on endogenous fibrinolysis in acute coronary syndrome: The VaLiDate-R study. Thromb Res 2024; 236:144-154. [PMID: 38447421 DOI: 10.1016/j.thromres.2024.02.030] [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: 09/22/2023] [Revised: 02/16/2024] [Accepted: 02/29/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND Impaired endogenous fibrinolysis is adverse cardiovascular risk factor in acute coronary syndrome (ACS) patients. Addition of very low dose rivaroxaban (VLDR) to dual antiplatelet therapy (DAPT) reduces cardiovascular events but increases bleeding. OBJECTIVE We aimed to assess whether addition of VLDR to DAPT can enhance endogenous fibrinolysis. METHODS In a prospective, open-label trial, we assessed endogenous fibrinolysis in whole blood, in 549 patients with ACS using the Global Thrombosis Test (GTT) and Thromboelastography (TEG). Patients (n = 180) who demonstrated impaired endogenous fibrinolysis (lysis time [LT] >2000s with the GTT) were randomised 1:1:1 to (i) clopidogrel 75 mg daily; (ii) clopidogrel 75 mg daily plus rivaroxaban 2.5 mg twice daily; or (iii) ticagrelor 90 mg twice daily, for 30 days, in addition to aspirin. Fibrinolytic status was assessed at 0, 2, 4 and 8 weeks. The primary outcome was the change in LT from admission to week 4. We also measured thrombotic occlusion time (OT) at high shear, and rivaroxaban level. RESULTS There was no difference between the groups with respect to LT or clot lysis with TEG, and no change in these parameters compared to baseline during study drug allocation. In the rivaroxaban plus clopidogrel group, OT was prolonged compared to the other groups, although rivaroxaban levels were low, suggesting non-compliance. CONCLUSION Addition of rivaroxaban 2.5 mg twice daily to DAPT does not affect endogenous fibrinolysis of thrombus formed at either high or low shear. Further studies are needed to determine whether higher doses of rivaroxaban can favourably modulate fibrinolysis. CONDENSED ABSTRACT Impaired endogenous fibrinolysis is a strong risk factor in ACS. We aimed to assess whether adding very low dose rivaroxaban (VLDR) to DAPT can enhance fibrinolysis. Fibrin and clot lysis were assessed in whole blood. ACS patients with impaired fibrinolysis were randomised 1:1:1 to clopidogrel 75 mg daily; clopidogrel 75 mg plus VLDR; or ticagrelor 90 mg twice daily, in addition to aspirin. At 30-days, there was no difference in lysis time between the groups, nor change from baseline. VLDR does not improve fibrinolysis at high or low shear. Further studies are needed to determine whether alternative antithrombotic regimens can enhance endogenous fibrinolysis.
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Affiliation(s)
- Ying X Gue
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom; Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Vassilios Memtsas
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom; Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Rahim Kanji
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom; Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - David M Wellsted
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Amanda Busby
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Megan Smith
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom
| | - Enric Vilar
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom; Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom
| | - Alisdair Ryding
- Cardiology Department, Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | - Deepa J Arachchillage
- Department of Haematology, Royal Brompton Hospital, London, United Kingdom; Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Diana A Gorog
- Centre for Health Services and Clinical Research, School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, Hertfordshire, United Kingdom; Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, United Kingdom; Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom.
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Al Said S, Kaier K, Sumaya W, Alsaid D, Duerschmied D, Storey RF, Gibson CM, Westermann D, Alabed S. Non-vitamin-K-antagonist oral anticoagulants (NOACs) after acute myocardial infarction: a network meta-analysis. Cochrane Database Syst Rev 2024; 1:CD014678. [PMID: 38264795 PMCID: PMC10806408 DOI: 10.1002/14651858.cd014678.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
BACKGROUND Balancing the risk of bleeding and thrombosis after acute myocardial infarction (AMI) is challenging, and the optimal antithrombotic therapy remains uncertain. The potential of non-vitamin K antagonist oral anticoagulants (NOACs) to prevent ischaemic cardiovascular events is promising, but the evidence remains limited. OBJECTIVES To evaluate the efficacy and safety of non-vitamin-K-antagonist oral anticoagulants (NOACs) in addition to background antiplatelet therapy, compared with placebo, antiplatelet therapy, or both, after acute myocardial infarction (AMI) in people without an indication for anticoagulation (i.e. atrial fibrillation or venous thromboembolism). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, the Conference Proceedings Citation Index - Science, and two clinical trial registers in September 2022 with no language restrictions. We checked the reference lists of included studies for any additional trials. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) that evaluated NOACs plus antiplatelet therapy versus placebo, antiplatelet therapy, or both, in people without an indication for anticoagulation after an AMI. DATA COLLECTION AND ANALYSIS Two review authors independently checked the results of searches to identify relevant studies, assessed each included study, and extracted study data. We conducted random-effects pairwise analyses using Review Manager Web, and network meta-analysis using the R package 'netmeta'. We ranked competing treatments by P scores, which are derived from the P values of all pairwise comparisons and allow ranking of treatments on a continuous 0-to-1 scale. MAIN RESULTS We identified seven eligible RCTs, including an ongoing trial that we could not include in the analysis. Of the six RCTs involving 33,039 participants, three RCTs compared rivaroxaban with placebo, two RCTs compared apixaban with placebo, and one RCT compared dabigatran with placebo. All participants in the six RCTs received concomitant antiplatelet therapy. The available evidence suggests that rivaroxaban compared with placebo reduces the rate of all-cause mortality (risk ratio (RR) 0.82, 95% confidence interval (CI) 0.69 to 0.98; number needed to treat for an additional beneficial outcome (NNTB) 250; 3 studies, 21,870 participants; high certainty) and probably reduces cardiovascular mortality (RR 0.83, 95% CI 0.69 to 1.01; NNTB 250; 3 studies, 21,870 participants; moderate certainty). There is probably little or no difference between apixaban and placebo in all-cause mortality (RR 1.09, 95% CI 0.88 to 1.35; number needed to treat for an additional harmful outcome (NNTH) 334; 2 studies, 8638 participants; moderate certainty) and cardiovascular mortality (RR 0.99, 95% CI 0.77 to 1.27; number needed to treat not applicable; 2 studies, 8638 participants; moderate certainty). Dabigatran may reduce the rate of all-cause mortality compared with placebo (RR 0.57, 95% CI 0.31 to 1.06; NNTB 63; 1 study, 1861 participants; low certainty). Dabigatran compared with placebo may have little or no effect on cardiovascular mortality, although the point estimate suggests benefit (RR 0.72, 95% CI 0.34 to 1.52; NNTB 143; 1 study, 1861 participants; low certainty). Two of the investigated NOACs were associated with an increased risk of major bleeding compared to placebo: apixaban (RR 2.41, 95% CI 1.44 to 4.06; NNTH 143; 2 studies, 8544 participants; high certainty) and rivaroxaban (RR 3.31, 95% CI 1.12 to 9.77; NNTH 125; 3 studies, 21,870 participants; high certainty). There may be little or no difference between dabigatran and placebo in the risk of major bleeding (RR 1.74, 95% CI 0.22 to 14.12; NNTH 500; 1 study, 1861 participants; low certainty). The results of the network meta-analysis were inconclusive between the different NOACs at all individual doses for all primary outcomes. However, low-certainty evidence suggests that apixaban (combined dose) may be less effective than rivaroxaban and dabigatran for preventing all-cause mortality after AMI in people without an indication for anticoagulation. AUTHORS' CONCLUSIONS Compared with placebo, rivaroxaban reduces all-cause mortality and probably reduces cardiovascular mortality after AMI in people without an indication for anticoagulation. Dabigatran may reduce the rate of all-cause mortality and may have little or no effect on cardiovascular mortality. There is probably no meaningful difference in the rate of all-cause mortality and cardiovascular mortality between apixaban and placebo. Moreover, we found no meaningful benefit in efficacy outcomes for specific therapy doses of any investigated NOACs following AMI in people without an indication for anticoagulation. Evidence from the included studies suggests that rivaroxaban and apixaban increase the risk of major bleeding compared with placebo. There may be little or no difference between dabigatran and placebo in the risk of major bleeding. Network meta-analysis did not show any superiority of one NOAC over another for our prespecified primary outcomes. Although the evidence suggests that NOACs reduce mortality, the effect size or impact is small; moreover, NOACs may increase major bleeding. Head-to-head trials, comparing NOACs against each other, are required to provide more solid evidence.
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Affiliation(s)
- Samer Al Said
- Department of Cardiology and Angiology, University Heart Center Freiburg Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Institute for Medical Biometry and Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Wael Sumaya
- Department of Medicine, Faculty of Medicine, Dalhousie University, QE II Health Sciences Centre, Halifax Infirmary, Halifax, Canada
| | - Dima Alsaid
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) partner site Heidelberg/Mannheim, Mannheim, Germany, Mannheim, Germany
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - C Michael Gibson
- Cardiology Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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Shaw JR, Castellucci LA, Siegal D, Carrier M. DOAC-associated bleeding, hemostatic strategies, and thrombin generation assays - a review of the literature. J Thromb Haemost 2023; 21:433-452. [PMID: 36696204 DOI: 10.1016/j.jtha.2022.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/24/2022] [Accepted: 11/15/2022] [Indexed: 01/26/2023]
Abstract
Direct oral anticoagulants (DOACs) account for most oral anticoagulant use. DOAC-associated bleeding events are commonly encountered in clinical practice and are associated with substantial morbidity and mortality. Both specific reversal agents and nonspecific hemostatic therapies, such as prothrombin complex concentrates, are used in the management of DOAC-associated bleeding. Measuring hemostatic efficacy and demonstrating a clinical impact from these therapies among studies of bleeding patients is challenging. Thrombin generation assays provide information on the total hemostatic potential of plasma, and have emerged as a promising modality to both measure the impact of DOACs on coagulation and to evaluate the effects of hemostatic therapies among patients with DOAC-associated bleeding. The mechanisms by which nonspecific hemostatic agents impact coagulation and thrombin generation in the context of DOAC therapy are unclear. As a result, we undertook a review of the literature using a systematic search strategy with the goal of summarizing the effects of DOACs on thrombin generation and the effects of both specific reversal agents and nonspecific hemostatic therapies on DOAC-altered thrombin generation parameters. We sought to identify clinical studies focusing on whether altered thrombin generation is associated with clinical bleeding and whether correction of altered thrombin generation parameters predicts improvements in clinical hemostasis. Lastly, we sought to outline future directions for the application of thrombin generation assays toward anticoagulation therapies and the question of anticoagulation reversal.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Lana A Castellucci
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Deborah Siegal
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
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Schiffer S, Schwers S, Heitmeier S. The effect of rivaroxaban on biomarkers in blood and plasma: a review of preclinical and clinical evidence. J Thromb Thrombolysis 2023; 55:449-463. [PMID: 36746885 PMCID: PMC10110699 DOI: 10.1007/s11239-023-02776-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 02/08/2023]
Abstract
Rivaroxaban is a direct, oral factor Xa inhibitor that is used for the prevention and treatment of various thromboembolic disorders. Several preclinical and clinical studies have utilized specific molecules as biomarkers to investigate the potential role of rivaroxaban beyond its anticoagulant activity and across a range of biological processes. The aim of this review is to summarize the existing evidence regarding the use of blood-based biomarkers to characterize the effects of rivaroxaban on coagulation and other pathways, including platelet activation, inflammation and endothelial effects. After a literature search using PubMed, almost 100 preclinical and clinical studies were identified that investigated the effects of rivaroxaban using molecular biomarkers. In agreement with the preclinical data, clinical studies reported a trend for reduction in the blood concentrations of D-dimers, thrombin-antithrombin complex and prothrombin fragment 1 + 2 following treatment with rivaroxaban in both healthy individuals and those with various chronic conditions. Preclinical and also some clinical studies have also reported a potential impact of rivaroxaban on the concentrations of platelet activation biomarkers (von Willebrand factor, P-selectin and thrombomodulin), endothelial activation biomarkers (matrix metalloproteinase-9, intercellular adhesion molecule-1 and vascular cell adhesion molecule-1) and inflammation biomarkers (interleukin-6, tumor necrosis factor-α and monocyte chemoattractant protein-1). Based on the results of biomarker studies, molecular biomarkers can be used in addition to traditional coagulation assays to increase the understanding of the anticoagulation effects of rivaroxaban. Moreover, there is preliminary evidence to suggest that rivaroxaban may have an impact on the biological pathways of platelet activation, endothelial activation and inflammation; however, owing to paucity of clinical data to investigate the trends reported in preclinical studies, further investigation is required to clarify these observations.
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Affiliation(s)
- Sonja Schiffer
- Bayer AG, Pharmaceuticals, R&D, 42113 Wuppertal, Germany
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Galli M, Franchi F, Rollini F, Ortega-Paz L, D'Amario D, De Caterina R, Mehran R, Gibson CM, Angiolillo DJ. Dual pathway inhibition in patients with atherosclerotic disease: pharmacodynamic considerations and clinical implications. Expert Rev Clin Pharmacol 2023; 16:27-38. [PMID: 36455906 DOI: 10.1080/17512433.2023.2154651] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
INTRODUCTION The persistence of elevated rates of ischemic recurrences despite the use of antiplatelet therapy among patients with atherosclerotic disease together with the understanding of the pivotal role of coagulation in the thrombo-inflammatory processes involved in the pathogenesis of atherosclerosis and its complications has fostered the development of treatments targeting both platelets and coagulation, a strategy known as dual-pathway inhibition (DPI). AREAS COVERED In this review we discuss the recent advancements in the understanding of the interplay between coagulation, platelets and inflammation involved in the pathophysiology of atherosclerosis and atherothrombosis, as the rationale for the implementation of a DPI strategy. We also discuss the available pharmacodynamic (PD) evidence and clinical implications with the use of DPI in patients with atherosclerotic disease. EXPERT OPINION The implementation of a DPI by adding the so-called 'vascular dose of rivaroxaban' (i.e. 2.5 mg bis in die), on top of antiplatelet therapy has consistently been associated with reduced levels of thrombin generation in PD studies and with reduced ischemic event rates at the cost of increased bleeding compared to antiplatelet therapy alone. Further research is warranted to best define patients in whom a DPI regimen has the best safety and efficacy profile.
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Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Domenico D'Amario
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Raffaele De Caterina
- University of Pisa and University Cardiology Division, Pisa University Hospital, Pisa, Italy.,Fondazione VillaSerena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - C Michael Gibson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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Thrombelastography Compared with Multiple Impedance Aggregometry to Assess High On-Clopidogrel Reactivity in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention. J Clin Med 2022; 11:jcm11144237. [PMID: 35888001 PMCID: PMC9320091 DOI: 10.3390/jcm11144237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/11/2022] [Accepted: 07/13/2022] [Indexed: 02/04/2023] Open
Abstract
Background: High on-clopidogrel platelet reactivity (HPR) following percutaneous coronary intervention (PCI) is associated with increased ischemic risk. It is unclear whether conventional definitions of HPR apply to patients with concomitant oral anticoagulation (OAC). This study aimed to compare the performance of multiple platelet aggregometry (MEA) and thrombelastography (TEG) to detect HPR in patients with atrial fibrillation (AF) and indication for an OAC. Methods: In this observational single-center cohort study, MEA and TEG were performed in patients with AF with an indication for OAC on day 1 to 3 after PCI. The primary outcome was HPR as assessed by MEA (ADP area under the curve ≥ 46 units [U]) or TEG (MAADP ≥ 47 mm), respectively. The secondary exploratory outcomes were a composite of all-cause death, myocardial infarction (MI) or stroke and bleeding, as defined by the International Society on Thrombosis and Hemostasis, at 6 months. Results: Platelet function of 39 patients was analyzed. The median age was 78 (interquartile range [IQR] was 72−82) years. 25 (64%) patients were male, and 19 (49%) presented with acute coronary syndrome. All patients received acetylsalicylic acid and clopidogrel prior to PCI. Median (IQR) ADP-induced aggregation, MAADP, TRAP-induced aggregation, and MAthrombin were 9 (6−15) U, 50 (43−60) mm, 54 (35−77) U and 65 (60−67) mm, respectively. The rate of HPR was significantly higher if assessed by TEG compared with MEA (25 [64%] vs. 1 [3%]; p < 0.001). Within 6 months, four (10%) deaths, one (3%) MI and nine (23%) bleeding events occurred. Conclusion: In patients with AF undergoing PCI, the rates of HPR detected by TEG were significantly higher compared with MEA. Conventional cut-off values for HPR as proposed by consensus documents may need to be re-evaluated for this population at high ischemic and bleeding risk. Further studies are needed to assess the association with outcomes.
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Jurk K, Rothenaicher KF, Groß K, Rossmann H, Weißer G, Schmidtmann I, Münzel T, Espinola-Klein C. Differential Inhibition of Platelet Reactivity by Dual Therapy With Aspirin and Low-Dose Rivaroxaban in Peripheral Arterial Disease: A Pilot Study. Front Cardiovasc Med 2022; 9:865166. [PMID: 35600474 PMCID: PMC9120432 DOI: 10.3389/fcvm.2022.865166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/28/2022] [Indexed: 01/22/2023] Open
Abstract
Patients with peripheral arterial disease (PAD) benefit from combination therapy with acetylsalicylic acid (ASA, 100 mg, one time per day) plus low-dose rivaroxaban (2.5 mg, two times per day) compared to ASA monotherapy. In particular, major adverse cardiac and limb events were significantly reduced after peripheral endovascular revascularization (EVR). In this pilot study, the platelet activation status in vivo and platelet reactivity in vitro were longitudinally analyzed by flow cytometric assays and calibrated automated thrombography in platelet-rich plasma (PRP) from 10 patients with PAD receiving ASA (100 mg, one time per day) before EVR, ASA plus clopidogrel (75 mg, one time per day) after EVR, and ASA plus rivaroxaban (2.5 mg, two times per day) during a long-term follow-up. Platelet responsiveness to clopidogrel was compared to additional 10 patients with stable PAD and clopidogrel (75 mg, one time per day) monotherapy. ASA plus rivaroxaban treatment resulted in a significantly decreased thrombin peak in PRP for two triggers, namely, low concentration of tissue factor (TF) and thrombin, compared to ASA monotherapy. TF-controlled thrombin generation was additionally characterized by a significantly prolonged lag time in PRP and platelet-free plasma during ASA plus rivaroxaban combination therapy. In comparison, ASA plus clopidogrel treatment presented a significant reduction of the thrombin peak in PRP, which was less pronounced than during subsequent ASA plus rivaroxaban therapy. Platelet responsiveness to clopidogrel was observed for 60% of patients receiving ASA plus clopidogrel and clopidogrel monotherapy, respectively. Blocking of CD36 on the platelet surface further reduced the thrombin peak in PRP induced by TF for all three therapy regimes. Platelet activation in vivo and in response to the GPVI-agonist convulxin or thrombin in vitro was similar, whereas integrin αIIbβ3 activation and α-granule release induced by the PAR-1 activating peptide TRAP-6 were significantly diminished during ASA plus rivaroxaban treatment compared to ASA monotherapy. In conclusion, the data of this pilot study indicate an inhibitory effect of rivaroxaban on the thrombin propagation phase of CD36-sensitive platelet thrombin formation in patients with PAD treated with ASA plus rivaroxaban combination therapy, which is associated with decreased PAR-1 but not thrombin-mediated platelet activation.
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Affiliation(s)
- Kerstin Jurk
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Korbinian F. Rothenaicher
- Center for Cardiology, Cardiology III—Angiology, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Kathrin Groß
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Heidi Rossmann
- Institute for Clinical and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Gerhard Weißer
- Center for Cardiology, Cardiology III—Angiology, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Irene Schmidtmann
- Institute for Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Thomas Münzel
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
- Center for Cardiology, Cardiology I—General and Interventional Cardiology and Intensive Care, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Christine Espinola-Klein
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
- Center for Cardiology, Cardiology III—Angiology, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
- *Correspondence: Christine Espinola-Klein,
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Berkowitz SD, Bauersachs RM, Szarek M, Nehler M, Debus ES, Patel MR, Anand S, Capell WH, Hess CN, Hsia J, Leeper NJ, Brasil D, Mátyás L, Diaz R, Brodmann M, Muehlhofer E, Haskell LP, Bonaca MP. Prevention of arterial and venous thrombotic events in symptomatic peripheral arterial disease patients after lower extremity revascularization in the VOYAGER PAD trial: Dual anticoagulant/antiplatelet regimen vs antiplatelet therapy alone. J Thromb Haemost 2022; 20:1193-1205. [PMID: 35170216 PMCID: PMC9314576 DOI: 10.1111/jth.15673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/10/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Vascular disease burden after lower extremity revascularization (LER) comprises more than the first event, more vascular beds than the local arteries, and more than one clinical event type. OBJECTIVES Assess total arterial and venous thrombotic burden after LER for symptomatic peripheral artery disease (PAD) and effect of low-dose anticoagulation added to low-dose antiplatelet therapy. PATIENTS/METHODS VOYAGER PAD randomized 6564 symptomatic PAD patients undergoing LER to rivaroxaban 2.5 mg twice-daily or placebo on aspirin background. Marginal proportional-hazards models used to generate treatment hazard ratios and associated 95% CIs for first and total events; non-thrombotic deaths treated as competing terminal events. Incidence rates calculated as number of events per 100 patient-years follow-up. RESULTS Over 2.5 years (median), first and total thrombotic event rates: 7.1 and 10.3 events/100 patient-years, respectively, in placebo group. Two-thirds (925/1372) of total thrombotic events (arterial 95%, venous 5%) were nonfatal first events. Nearly one-third of patients with first event had a second arterial or venous thrombotic event. Rivaroxaban plus aspirin reduced first and total arterial and venous thrombotic events to 5.4 and 7.9 events/100 patient-years, respectively, a reduction in total thrombotic events over aspirin of 23% (HR: 0.77, 95%CI: 0.67-0.89, p = .0005), preventing 6.1 total arterial and venous thrombotic events at 3 years. CONCLUSIONS Assessing total arterial and venous thrombotic events, not just first events, provides more complete information about disease burden and absolute on-treatment impact. Following LER, judicious modulation of more than one coagulation pathway can provide broader benefit than intensifying inhibition of one hemostatic system component.
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Affiliation(s)
- Scott D. Berkowitz
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Divisions of Cardiology and HematologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Rupert M. Bauersachs
- Cardiovascular Center Bethanien CCBFrankfurtGermany
- Center of Thrombosis and HemostasisUniversity of MainzMainzGermany
| | - Michael Szarek
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Division of CardiologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- State University of New York Downstate Health Sciences UniversityBrooklynNew YorkUSA
| | - Mark R. Nehler
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Division of Vascular SurgeryDepartment of SurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - E. Sebastian Debus
- Department of Vascular Medicine, Vascular Surgery–Angiology–Endovascular TherapyUniversity of Hamburg‐EppendorfHamburgGermany
| | - Manesh R. Patel
- Duke Clinical Research InstituteDurhamNorth CarolinaUSA
- Division of CardiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Sonia S. Anand
- Department of Medicine & EpidemiologyMcMaster UniversityHamiltonOntarioCanada
- Population Health Research InstituteHamilton Health Sciences and McMaster UniversityHamiltonOntarioCanada
| | - Warren H. Capell
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Division of EndocrinologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Connie N. Hess
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Division of CardiologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Judy Hsia
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Division of CardiologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Nicholas J. Leeper
- Division of Vascular SurgeryDepartment of SurgeryStanford UniversityStanfordCaliforniaUSA
| | - David Brasil
- FELUMA‐Faculdade de Ciencias Medicas de Minas Gerais School of MedicineBelo HorizonteBrazil
| | - Lajos Mátyás
- B‐A‐Z Central University Teaching County Hospital Vascular and Endovascular SurgeryMiskolcHungary
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica ‐ Instituto Cardiovascular de RosarioRosarioArgentina
| | | | | | | | - Marc P. Bonaca
- Colorado Prevention Center Clinical ResearchAuroraColoradoUSA
- Division of CardiologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
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CRACking the Molecular Regulatory Mechanism of SOCE during Platelet Activation in Thrombo-Occlusive Diseases. Cells 2022; 11:cells11040619. [PMID: 35203269 PMCID: PMC8870035 DOI: 10.3390/cells11040619] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/31/2022] [Accepted: 02/09/2022] [Indexed: 11/16/2022] Open
Abstract
Thrombo-occlusive diseases such as myocardial infarction, ischemic stroke and deep vein thrombosis with subsequent pulmonary embolism still represent a major health burden worldwide. Besides the cells of the vasculature or other hematopoietic cells, platelets are primarily responsible for the development and progression of an occluding thrombus. The activation and function of platelets crucially depend on free cytosolic calcium (Ca2+) as second messenger, which modulates platelet secretion, aggregation and thrombus formation. Ca2+ is elevated upon platelet activation by release of Ca2+ from intracellular stores thus triggering of the subsequent store-operated Ca2+ entry (SOCE), which is facilitated by Ca2+ release-activated channels (CRACs). In general, CRACs are assembled by the pore-forming unit Orai in the plasma membrane and the Ca2+-sensing stromal interaction molecule (STIM) in the endoplasmic reticulum after the depletion of internal Ca2+ stores. In the last few years, there is a growing body of the literature demonstrating the importance of STIM and Orai-mediated mechanism in thrombo-occlusive disorders. Thus, this review provides an overview of the recent understanding of STIM and Orai signaling in platelet function and its implication in the development and progression of ischemic thrombo-occlusive disorders. Moreover, potential pharmacological implications of STIM and Orai signaling in platelets are anticipated and discussed in the end.
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Galli M, Franchi F, Rollini F, Been L, Abou Jaoude P, Rivas A, Zhou X, Sida J, Maaliki N, Hoon Lee C, Pineda Maldonado AM, Suryadevara S, Soffer D, Zenni MM, Geisler T, Jennings LK, Bass TA, Angiolillo D. Pharmacodynamic profiles of dual-pathway inhibition with or without clopidogrel vs dual antiplatelet therapy in patients with atherosclerotic disease. Thromb Haemost 2022; 122:1341-1351. [PMID: 34983074 DOI: 10.1055/a-1730-8725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIM Inhibition of thrombin-mediated signaling processes using a vascular dose of rivaroxaban in adjunct to antiplatelet therapy, known as dual-pathway inhibition (DPI), reduces atherothrombotic events in patients with stable atherosclerotic disease. However, there are limited data on the pharmacodynamic (PD) effects of this strategy. METHODS AND RESULTS This investigation was conducted in selected cohorts of patients (n=40) with stable atherosclerotic disease enrolled within a larger prospective PD study who were treated with either aspirin plus clopidogrel (DAPT), aspirin plus rivaroxaban 2.5 mg/bid (DPI) or DAPT plus rivaroxaban 2.5 mg/bid. Multiple PD assays assessing of markers of thrombosis were used. PD endpoints included platelet-mediated global thrombogenicity measured by light transmittance aggregometry (LTA) following stimuli with CATF [collagen-related peptide +adenosine diphosphate (ADP) +tissue factor (TF)], markers of P2Y12 reactivity, markers of platelet aggregation using LTA following several stimuli (arachidonic acid, ADP, collagen, TF, and TRAP), thrombin generation and thrombus formation. There was no difference in platelet-mediated global thrombogenicity between groups. Rivaroxaban significantly reduced thrombin generation and was associated with a trend towards reduced TF-induced platelet aggregation. Clopidogrel-based treatments reduced markers of P2Y12 signaling and TRAP-induced platelet aggregation. There were no differences between groups on markers of cyclooxygenase-1 mediated activity. CONCLUSIONS Compared with DAPT, DPI does not result in any differences in platelet-mediated global thrombogenicity, but reduces thrombin generation. These PD observations support that modulating thrombin generation by means of factor Xa inhibition in adjunct to antiplatelet therapy provides effective antithrombotic effects, supporting the efficacy and safety findings of DPI observed in clinical.
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Affiliation(s)
- Mattia Galli
- Policlinico Universitario Agostino Gemelli, Rome, Italy
| | - Francesco Franchi
- University of Florida College of Medicine-Jacksonville, Division of Cardiology, Jacksonville, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida, Jacksonville, United States
| | - Latonya Been
- University of Florida College of Medicine-Jacksonville, Division of Cardiology, Jacksonville, United States
| | - Patrick Abou Jaoude
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, United States
| | - Andrea Rivas
- University of Florida College of Medicine-Jacksonville, Division of Cardiology, Jacksonville, United States
| | - Xuan Zhou
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, United States
| | - Jia Sida
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, United States
| | - Naji Maaliki
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, United States
| | - Chang Hoon Lee
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, United States
| | - Andres M Pineda Maldonado
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, United States
| | - Siva Suryadevara
- Division of Cardiology, University of Florida, Jacksonville, United States
| | - Daniel Soffer
- University of Florida College of Medicine-Jacksonville, Division of Cardiology, Jacksonville, United States
| | - Martin M Zenni
- Division of Cardiology, University of Florida, Jacksonville, United States
| | - Tobias Geisler
- Cardiology and Angiology, Eberhard Karls University Tübingen Faculty of Medicine, Tubingen, Germany
| | - Lisa K Jennings
- University of Tennessee Health Science Center, Memphis, United States.,CirQuest Labs, Memphis, United States
| | - Theodore A Bass
- Division of Cardiology, University of Florida, Jacksonville, United States
| | - Dominick Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, Jacksonville, United States
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Moll MA, Zwerger D, Grassl KJ, Westreicher W, Neururer SB, Moll CW, Wipper SH, Klocker J. Prevalence of VOYAGER PAD trial exclusion criteria in unselected patients undergoing lower limb revascularisation. INT ANGIOL 2021; 41:56-62. [PMID: 34913631 DOI: 10.23736/s0392-9590.21.04816-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The VOYAGER PAD trial investigated data on dual pathway inhibition after lower limb revascularisation for peripheral arterial disease (PAD). Multiple exclusion criteria were applied. However, neither data on the prevalence of exclusion criteria nor on the total number of patients screened for inclusion was discussed. METHODS We performed a single-center prospective observational study in unselected PAD patients undergoing lower limb revascularisation. Demographic and disease-specific data was collected. RESULTS 150 patients were included with only 29 patients (19.3%) as potential candidates for the VOYAGER PAD study medication. Poorly controlled diabetes or severe uncontrolled hypertension (33.3%), major tissue loss (18.7%), acute limb ischaemia within prior 2 weeks (17.3%) and a history of intracranial haemorrhage, stroke or TIA (16%) were amongst the exclusion criteria most frequently met. Compared to VOYAGER PAD study patients, significant differences regarding sex (36.7% female vs. 25.8%), renal insufficiency (29.0% vs. 20.1%), previous myocardial infarction (16.7% vs. 11.1%) and known carotid artery disease (18.7% vs. 8.6%) revealed. Patients presented significantly more frequently with critical limb ischemia (56.7% vs. 30.4%) and a history of previous peripheral revascularisation (72.0% vs. 35.9%). Fewer endovascular interventions (52% vs. 65.5%) and more surgeries (58% vs. 34.5%) were performed. CONCLUSIONS In unselected patients undergoing revascularisation for peripheral arterial disease, the majority presents with characteristics that, at present, preclude prescription of rivaroxaban in addition to aspirin. This patient cohort represents a population with higher rates of comorbidities and more complex vascular interventions, but might also benefit from dual pathway inhibition strategy.
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Affiliation(s)
- Maria A Moll
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniela Zwerger
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Kristina J Grassl
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Werner Westreicher
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sabrina B Neururer
- Department of Clinical Epidemiology, Tyrolean Federal Institute for Integrated Care, Tirol Kliniken GmbH, Innsbruck, Austria
| | - Clemens Wi Moll
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Sabine H Wipper
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Josef Klocker
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria -
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12
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Platelet ACKR3/CXCR7 Favors Anti-Platelet Lipids over an Atherothrombotic Lipidome and Regulates Thrombo-inflammation. Blood 2021; 139:1722-1742. [PMID: 34905596 DOI: 10.1182/blood.2021013097] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 11/30/2021] [Indexed: 11/20/2022] Open
Abstract
Platelet ACKR3/CXCR7 surface expression is enhanced and influences prognosis in coronary artery disease-(CAD) patients, who exhibit a distinct atherothrombotic platelet lipidome. Current investigation validates the potential of ACKR3/CXCR7 in regulating thrombo-inflammatory response, through its impact on the platelet lipidome. CAD patients-(n=230) with enhanced platelet-ACKR3/CXCR7 expression exhibited reduced aggregation. Pharmacological CXCR7-agonist-(VUF11207) significantly reduced pro-thrombotic platelet response in blood from ACS patients-(n=11) ex vivo. CXCR7-agonist administration reduced thrombotic functions and thrombo-inflammatory platelet-leukocyte interactions post myocardial infarction-(MI) and arterial injury in vivo. ACKR3/CXCR7-ligation did not affect surface availability of GPIbα, GPV, GPVI, GPIX, αv-integrin, β3-integrin, coagulation profile-(APTT, PT), bleeding time, plasma-dependent thrombin generation-(thrombinoscopy) or clot formation-(thromboelastography), but counteracted activation-induced phosphatidylserine exposure and procoagulant platelet-assisted thrombin generation. Targeted-(micro-UHPLC-ESI-QTrap-MS/MS) and untargeted-(UHPLC-ESI-QTOF-MS/MS) lipidomics analysis revealed that ACKR3/CXCR7-ligation favored generation of anti-thrombotic lipids-(dihomo-γ-linolenic acid-DGLA, 12-hydroxyeicosatrienoic acid-12-HETrE) over cyclooxygenase-COX-1-(thromboxane-TxA2), or 12-lipoxygenase-LOX-(12-HETE) metabolized pro-thrombotic, and phospholipase derived atherogenic-(lysophosphatidylcholine-LPC) lipids, in healthy subjects and CAD patients, contrary to anti-platelet therapy. Through 12-HETrE, ACKR3/CXCR7-ligation coordinated with Gαs-coupled prostacyclin receptor-(IP) to trigger cAMP-PKA mediated platelet inhibition. ACKR3/CXCR7-ligation reduced generation of lipid agonists-(arachidonic acid-AA,TxA2), lipid signaling intermediates-(lyophosphatidylinositol-LPI, diacylglycerol-DG), which affected calcium mobilization, intracellular signaling, consequently platelet interaction with physiological matrices and thrombo-inflammatory secretion-(IL1β,IFN-γ,TGF-β,IL-8), emphasizing its functional dichotomy from pro-thrombotic CXCR4. Moreover, CXCR7-agonist regulated heparin-induced thrombocytopenia-(HIT)-sera/IgG-induced platelet and neutrophil activation, heparin induced platelet aggregation-(HIPA), generation of COX-1-(TxA2), 12-LOX-(12-HETE) derived thrombo-inflammatory lipids, platelet-neutrophil aggregate formation, and thrombo-inflammatory secretion (sCD40L, IL-1β, IFN-γ, TNF-α, sP-selectin, IL-8, tissue factor-TF) ex vivo. Therefore, ACKR3/CXCR7 may offer a novel therapeutic strategy in acute/chronic thrombo-inflammation exaggerated cardiovascular pathologies, and CAD.
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13
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Platelet-Derived PCSK9 Is Associated with LDL Metabolism and Modulates Atherothrombotic Mechanisms in Coronary Artery Disease. Int J Mol Sci 2021; 22:ijms222011179. [PMID: 34681838 PMCID: PMC8538687 DOI: 10.3390/ijms222011179] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 01/03/2023] Open
Abstract
Platelets play a significant role in atherothrombosis. Proprotein convertase subtilisin/kexin type 9 (PCSK9) is critically involved in the regulation of LDL metabolism and interacts with platelet function. The effect of PCSK9 in platelet function is poorly understood. The authors of this article sought to characterize platelets as a major source of PCSK9 and PCSK9's role in atherothrombosis. In a large cohort of patients with coronary artery disease (CAD), platelet count, platelet reactivity, and platelet-derived PCSK9 release were analyzed. The role of platelet PCSK9 on platelet and monocyte function was investigated in vitro. Platelet count and hyper-reactivity correlated with plasma LDL in CAD. The circulating platelets express on their surface and release substantial amounts of PCSK9. Release of PCSK9 augmented platelet-dependent thrombosis, monocyte migration, and differentiation into macrophages/foam cells. Platelets and PCSK9 accumulated in tissue derived from atherosclerotic carotid arteries in areas of macrophages. PCSK9 inhibition reduced platelet activation and platelet-dependent thrombo-inflammation. The authors identified platelets as a source of PCSK9 in CAD, which may have an impact on LDL metabolism. Furthermore, platelet-derived PCSK9 contributes to atherothrombosis, and inhibition of PCSK9 attenuates thrombo-inflammation, which may contribute to the reported beneficial clinical effects.
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14
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Weiss L, Keaney J, Szklanna PB, Prendiville T, Uhrig W, Wynne K, Kelliher S, Ewins K, Comer SP, Egan K, O'Rourke E, Moran E, Petrov G, Patel A, Lennon Á, Blanco A, Kevane B, Murphy S, Ní Áinle F, Maguire PB. Nonvalvular atrial fibrillation patients anticoagulated with rivaroxaban compared with warfarin exhibit reduced circulating extracellular vesicles with attenuated pro-inflammatory protein signatures. J Thromb Haemost 2021; 19:2583-2595. [PMID: 34161660 DOI: 10.1111/jth.15434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 06/02/2021] [Accepted: 06/22/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Rivaroxaban, a direct oral factor Xa inhibitor, mediates anti-inflammatory and cardiovascular-protective effects besides its well-established anticoagulant properties; however, these remain poorly characterized. Extracellular vesicles (EVs) are important circulating messengers regulating a myriad of biological and pathological processes and may be highly relevant to the pathophysiology of atrial fibrillation as they reflect alterations in platelet and endothelial biology. However, the effects of rivaroxaban on circulating pro-inflammatory EVs remain unknown. OBJECTIVES We hypothesized that rivaroxaban's anti-inflammatory properties are reflected upon differential molecular profiles of circulating EVs. METHODS Differences in circulating EV profiles were assessed using a combination of single vesicle analysis by Nanoparticle Tracking Analysis and flow cytometry, and proteomics. RESULTS We demonstrate, for the first time, that rivaroxaban-treated non-valvular atrial fibrillation (NVAF) patients (n=8) exhibit attenuated inflammation compared with matched warfarin controls (n=15). Circulating EV profiles were fundamentally altered. Moreover, quantitative proteomic analysis of enriched plasma EVs from six pooled biological donors per treatment group revealed a profound decrease in highly pro-inflammatory protein expression and complement factors, together with increased expression of negative regulators of inflammatory pathways. Crucially, a reduction in circulating levels of soluble P-selectin was observed in rivaroxaban-treated patients (compared with warfarin controls), which negatively correlated with the patient's time on treatment. CONCLUSION Collectively, these data demonstrate that NVAF patients anticoagulated with rivaroxaban (compared with warfarin) exhibit both a reduced pro-inflammatory state and evidence of reduced endothelial activation. These findings are of translational relevance toward characterizing the anti-inflammatory and cardiovascular-protective mechanisms associated with rivaroxaban therapy.
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Affiliation(s)
- Luisa Weiss
- UCD Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John Keaney
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Cardiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Paulina B Szklanna
- UCD Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tadhg Prendiville
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Wido Uhrig
- UCD Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
| | - Kieran Wynne
- Systems Biology Ireland, University College Dublin, Dublin, Ireland
| | - Sarah Kelliher
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Karl Ewins
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Shane P Comer
- UCD Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | - Karl Egan
- UCD Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Ellen O'Rourke
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Eric Moran
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Georgi Petrov
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ashish Patel
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Áine Lennon
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Alfonso Blanco
- Flow Cytometry Core, Conway Institute, University College Dublin, Dublin, Ireland
| | - Barry Kevane
- UCD Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Murphy
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Stroke Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fionnuala Ní Áinle
- UCD Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Patricia B Maguire
- UCD Conway SPHERE Research Group, Conway Institute, University College Dublin, Dublin, Ireland
- School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
- Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland, Dublin, Ireland
- UCD Institute for Discovery, O'Brien Centre for Science, University College Dublin, Dublin, Ireland
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15
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Nekrasov AA, Timoshchenko ES, Nekrasova TA, Timoshchenko MV, Suleimanova AV. The effect of rivaroxaban low doses on the stable angina of the II-III functional class clinical manifestations and the quality of life in patients with ischemic heart disease. KARDIOLOGIYA 2021; 61:47-51. [PMID: 34713785 DOI: 10.18087/cardio.2021.9.n1696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/15/2021] [Indexed: 11/18/2022]
Abstract
Aim To evaluate the effect of low-dose rivaroxaban on quality of life of patients and clinical manifestations of functional class (FC) II-III stable angina.Material and methods 26 patients with ischemic heart disease (IHD) with FC II-III stable angina, who were newly prescribed rivaroxaban 2.5 mg twice a day in combination with acetylsalicylic acid 75-100 mg, were followed for 10 weeks. During the first (before the beginning of treatment) and the last weeks of study, patients kept diaries, in which they reported angina attacks and short-acting nitrate intake, filled in an angina questionnaire (SAQ), and underwent electrocardiogram (ECG) Holter monitoring (HM).Results The treatment was associated with decreases in the frequency of angina attacks (by 19.5 %; р=0.027) and the number of taken short-acting nitrate pills (by 17.1 %; р=0.021) and an improvement of quality of life according to stability scales (р=0.042). Data from ECG HM showed decreases in the number and duration of ischemic episodes (p≤0.05).Conclusion The treatment of IHD patients with rivaroxaban 2.5 mg twice a day in combination with acetylsalicylic acid 75-100 mg for 2 mos. was associated with decreased frequency of angina attacks, reduced requirement for short-acting nitrate, and with improvement of quality of life.
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Affiliation(s)
- A A Nekrasov
- Privolzhsky Research Medical University, Nizhny Novgorod
| | | | - T A Nekrasova
- Privolzhsky Research Medical University, Nizhny Novgorod
| | | | - A V Suleimanova
- I. I. Mechnikov North-Western State Medical University, St. Petersburg
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16
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Characteristics of atherosclerosis in femoropopliteal artery and its clinical relevance. Atherosclerosis 2021; 335:31-40. [PMID: 34547588 DOI: 10.1016/j.atherosclerosis.2021.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/28/2021] [Accepted: 09/09/2021] [Indexed: 12/12/2022]
Abstract
Atherosclerosis is a systemic disease with different faces. Despite identical or similar pathogenetic mechanisms, atherosclerotic lesions and their clinical manifestations vary in different parts of the vascular system. Peripheral arterial disease (PAD) represents one of the most frequent clinical manifestations of atherosclerosis with predominant location in the superficial femoral artery (SFA). Morphological characteristics of atherosclerotic plaques in peripheral arteries differ from lesions in the coronary and carotid arteries. Plaques in SFA have more fibrotic components, less lipids and inflammatory cells, which makes them more stable and less prone to rupture. Factors that determine the different structure of plaques in SFA compared to coronary arteries include hemodynamic forces, vasa vasorum and calcification. Low shear stress in SFA in the adductor canal is one of the factors which determines frequent atherosclerotic lesions in this region. Lower lipid content and fewer inflammatory cells explain higher stability of SFA plaques. The specific structure of SFA plaques may require preventive and therapeutic measures, which to some extent differ from prevention of coronary atherosclerosis and may include inhibition of fibrotic proliferation in SFA plaques and calcification. Revascularization of PAD differs from procedures used in coronary arteries and requires specific technical expertise and devices.
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Хрыщанович В. Dual Pathway of Inhibition and Vascular Protection in Patients with Atherosclerotic Disease. КАРДИОЛОГИЯ В БЕЛАРУСИ 2021. [DOI: 10.34883/pi.2021.13.2.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Несмотря на широкое внедрение в клиническую практику современной антитромботической стратегии (моно- или двойной антитромбоцитарной терапии), резидуальный риск неблагоприятных сердечно-сосудистых событий у пациентов с ишемической болезнью сердца (ИБС) и заболеваниями периферических артерий (ЗПА) по-прежнему остается высоким. До настоящего времени двойная антитромбоцитарная терапия является «золотым стандартом» вторичной профилактики при остром коронарном синдроме (ОКС), а монотерапия рекомендована пациентам с симптоматическим течением ЗПА, стабильной ИБС и цереброваскулярной болезнью. Вместе с тем разрыв атеросклеротической бляшки приводит не только к активации тромбоцитов, но также, вследствие экспозиции тканевого фактора, потенцирует образование тромбина. Поэтому терапевтическая стратегия, направленная на одновременное подавление генерации тромбина и активации тромбоцитов и называемая «двойной путь ингибирования», представляется более эффективной, чем известные варианты лечения, связанные с торможением только одного из двух путей. Как показали результаты исследования COMPASS, комбинация 2,5 мг ривароксабана дважды в сутки со 100 мг/сутки аспирина оказалась более эффективной по сравнению с монотерапией 100 мг/сутки аспирина в части снижения риска серьезных сердечно-сосудистых событий, незапланированных госпитализаций и летальности без увеличения количества фатальных и интракраниальных геморрагических осложнений. Преимущества режима двойного ингибирования, апробированного в исследовании COMPASS, были продемонстрированы в популяции пациентов с недавним ОКС, стабильной ИБС и ЗПА, а также после реваскуляризации нижних конечностей. На сегодняшний день ривароксабан является единственным антикоагулянтом, подтвердившим безусловные преимущества в сочетании с антитромбоцитарной терапией в указанных группах пациентов. Комбинированная терапия низкими дозами ривароксабана (2,5 мг/дважды/сутки) и аспирином (100 мг/сутки) уже включена в последние международные рекомендации как вариант вторичной профилактики у пациентов с патологией коронарных и периферических артерий.
Patients with cardiovascular (CV) disease are at high residual risk of CV events (including peripheral ischemic events), even when they receive the current antithrombotic strategies (single/dual antiplatelet therapy). Until now, dual antiplatelet therapy is the standard of care for the secondary prevention in patients with acute coronary syndrome (ACS), whereas the single antiplatelet therapy, generally with aspirin, is the standard of care for the secondary prevention in stable patients with coronary artery disease (CAD), peripheral artery disease (PAD), or cerebrovascular disease. Meanwhile, atherosclerotic plaque disruption not only induces the platelet activation, but also results in thrombin generation because of tissue factor exposure. Therefore, interrupting both pathways by combining antiplatelet therapy with an anticoagulant (dual pathway inhibition [DPI]), has the potential to be more effective than inhibiting either pathway alone. The COMPASS trial showed that in comparison with aspirin 100 mg, rivaroxaban 2.5 mg twice a day plus aspirin 100 mg reduced the risk of major cardiac events, CV hospitalization, and mortality, without the increase of intracranial or fatal bleedings. The benefit of DPI using the COMPASS regimen was demonstrated in patients with the recent ACS, in chronic CAD and PAD patients, and after the lower extremity revascularization. So far, rivaroxaban is the only anticoagulant, which is effective in combination with antiplatelet therapies in the mentioned groups. The combination of low-dose rivaroxaban (2.5 mg twice daily) and aspirin (100 mg once daily) has been included recently into the latest international recommendations for the secondary prevention in patients with coronary or peripheral artery disease.
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18
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Clifford CR, Jung RG, Hibbert B, Chong AY, Lordkipanidzé M, Tanguay JF, So DYF. Dual antiplatelet therapy (PEGASUS) vs. dual pathway (COMPASS): a head-to-head in vitro comparison. Platelets 2021; 33:298-303. [PMID: 33856269 DOI: 10.1080/09537104.2021.1904134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Dual antiplatelet therapy (DAPT) with aspirin and a P2Y12 inhibitor is prescribed for 1-year after myocardial infarction. Two clinical strategies are considered at 1-year: continuation of DAPT or "Dual Pathway" (DP), using aspirin and rivaroxaban. No head-to-head comparative studies exist. In our in-vitro study, 24 samples of donor blood were treated with clinically proven concentrations of 5 antithrombotic regimens: aspirin, ticagrelor, rivaroxaban, DAPT, and DP. Thrombosis was analyzed using the Total Thrombus Analysis System (T-TAS) to measure both antiplatelet and anticoagulant effects. Flow cytometry was performed to quantify platelet activation. DAPT was the most potent antiplatelet regimen, delaying thrombus onset (p < .0001) and reducing thrombogenicity (p < .0001), relative to control. DP did not delay thrombus formation relative to aspirin alone (p = .69). DP was the most potent anticoagulant regimen, delaying thrombus onset (p < .0001) and reducing thrombogenicity (p < .0001), relative to control. DP showed synergistic antithrombotic effects by delaying thrombus onset (p < .0001) and reducing thrombogenicity (p = .0003), relative to rivaroxaban alone. Flow cytometry showed only DAPT (p = .0023) reduced platelet activation. DP treatment demonstrated synergistic antithrombotic effects over rivaroxaban alone, but no additional antiplatelet synergism over aspirin alone.
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Affiliation(s)
- Cole R Clifford
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Richard G Jung
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Benjamin Hibbert
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Aun Yeong Chong
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marie Lordkipanidzé
- Montreal Heart Institute Research Center, Montreal, Qc, Canada.,Faculty of Pharmacy, Université De Montréal, Montreal, Qc, Canada
| | - Jean-Francois Tanguay
- Montreal Heart Institute Research Center, Montreal, Qc, Canada.,Faculty of Medicine, Université De Montréal, Montreal, Qc, Canada
| | - Derek Y F So
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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González-Juanatey JR, Almendro-Delia M, Cosín-Sales J, Bellmunt-Montoya S, Gómez-Doblas JJ, Riambau V, García-Moll X, García-Alegría J, Hernández JL, Lozano FS, Suarez Fernández C. Residual risk reduction opportunities in patients with chronic coronary syndrome. Role of dual pathway inhibition. Expert Rev Clin Pharmacol 2021; 13:695-706. [PMID: 32434452 DOI: 10.1080/17512433.2020.1772056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION In this review, the role of the rivaroxaban-plus-aspirin approach (dual pathway inhibition - DPI) in patients with chronic coronary syndrome (CCS) and to perform practical recommendations about its use was updated. AREAS COVERED The contents of this review were proposed in an expert meeting. To identify relevant articles, a systematic search of Medline/Embase was performed (to July 2019), using the key words 'rivaroxaban', 'vascular dose', 'COMPASS' and 'coronary artery disease' in the search strategy. EXPERT OPINION Despite current antithrombotic strategies (single/dual antiplatelet therapy) have decreased rates of recurrent cardiovascular events among patients with CCS, residual risk remains unacceptably high. The COMPASS trial showed in CCS patients that compared with aspirin 100 mg rivaroxaban 2.5 mg bid plus aspirin 100 mg reduced the risk of major cardiac events, cardiovascular hospitalization and mortality, without an increase of intracranial or fatal bleedings. Importantly, residual risk with the rivaroxaban plus aspirin approach was lower than with different dual antiplatelet therapy regimens. The rivaroxaban plus aspirin strategy is of particular benefit in patients with CCS and high-risk cardiovascular feature (i.e. ≥2 vascular beds, heart failure, renal insufficiency, peripheral artery disease, previous stroke or diabetes) and should be considered in these populations.
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Affiliation(s)
- José R González-Juanatey
- Cardiology and Intensive Cardiac Care Department, CIBERCV, University Hospital Santiago de Compostela , Santiago de Compostela, Spain
| | - Manuel Almendro-Delia
- Intensive Cardiovascular Care Unit, Cardiovascular Clinical Trials & Translational Research Unit, Cardiology and Cardiovascular Surgery Division, Virgen Macarena University Hospital , Seville, Spain
| | - Juan Cosín-Sales
- Cardiology Department, Hospital Arnau de Vilanova, Facultad de Medicina, Universidad CEU-Cardenal Herrena , Valencia, Spain
| | - Sergi Bellmunt-Montoya
- Vascular Surgery Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona , Barcelona, Spain
| | | | - Vincent Riambau
- Vascular Surgery Division, CardioVascular Institute Hospital Clinic University of Barcelona , Barcelona, Spain
| | | | | | - José Luis Hernández
- Internal Medicine Department, Hospital Marqués de Valdecilla-IDIVAL, Universidad de Cantabria , Santander, Spain
| | - Francisco S Lozano
- Department of Vascular Surgery, Hospital Clínico de Salamanca , Salamanca, Spain
| | - Carmen Suarez Fernández
- Internal Medicine Department, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid , Madrid, Spain
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Spinthakis N, Gue Y, Farag M, Srinivasan M, Wellsted D, Arachchillage DRJ, Lip GYH, Gorog DA. Apixaban enhances endogenous fibrinolysis in patients with atrial fibrillation. Europace 2020; 21:1297-1306. [PMID: 31505618 PMCID: PMC6735819 DOI: 10.1093/europace/euz176] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 05/30/2019] [Indexed: 12/14/2022] Open
Abstract
Aims Approximately 20% of ischaemic stroke patients exhibit spontaneous arterial recanalization, attributable to endogenous fibrinolysis, which strongly relates to improved functional outcome. The impact of oral anticoagulants on endogenous fibrinolysis is unknown. Our aim was to test the hypothesis that apixaban enhances endogenous fibrinolysis in non-valvular atrial fibrillation (NVAF). Methods and results In a prospective cross-sectional analysis, we compared endogenous fibrinolysis in NVAF patients (n = 180) taking aspirin, warfarin, or apixaban. In a prospective longitudinal study, patients were tested before and after apixaban (n = 80). Endogenous fibrinolysis was assessed using the Global Thrombosis Test (GTT) and thromboelastography (TEG). Endogenous fibrinolysis [measured by GTT lysis time (LT)] was shorter on apixaban compared with warfarin or aspirin [median 1850 (IQR 1591–2300) vs. 2758 (2014–3502) vs. 2135 (1752–2463) s, P < 0.0001]. Among TEG indices, a small but significant difference in clot lysis time (CLT) was observed [apixaban 60.0 (45.0–61.0) vs. warfarin 61.0 (57.0–62.0) vs. aspirin 61.0 (59.0–61.0) min, P = 0.036]. Apixaban improved endogenous fibrinolysis measured using the GTT [LT pre-treatment 2204 (1779–2738) vs. on-treatment 1882 (1607–2374) s, P = 0.0003], but not by using TEG. Change in LT (ΔLT) with apixaban correlated with baseline LT (r = 0.77, P < 0.0001). There was weak correlation between ΔLT and ΔCLT in response to apixaban (r = 0.28, P = 0.02) and between on-apixaban LT and CLT (r = 0.25, P = 0.022). Conclusion Apixaban enhances endogenous fibrinolysis, with maximal effect in those with impaired fibrinolysis pre-treatment. Apixaban-treated patients exhibit more favourable fibrinolysis profiles than those taking warfarin or aspirin. Whether apixaban may confer additional thrombotic risk reduction in NVAF patients with impaired fibrinolysis, compared to warfarin, merits further study.
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Affiliation(s)
- Nikolaos Spinthakis
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK.,Department of Cardiology, East and North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Ying Gue
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK.,Department of Cardiology, East and North Hertfordshire NHS Trust, Hertfordshire, UK
| | - Mohamed Farag
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK.,Department of Cardiology, East and North Hertfordshire NHS Trust, Hertfordshire, UK
| | | | - David Wellsted
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK
| | - Deepa R J Arachchillage
- Department of Haematology, Royal Brompton Hospital, London, UK.,Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, UK.,Department of Cardiology, East and North Hertfordshire NHS Trust, Hertfordshire, UK.,Faculty of Medicine, National Heart & Lung Institute, Imperial College, Dovehouse Street, London, London, UK
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21
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Mastenbroek TG, Karel MFA, Nagy M, Chayoua W, Korsten EIJ, Coenen DM, Debets J, Konings J, Brouns AE, Leenders PJA, van Essen H, van Oerle R, Heitmeier S, Spronk HM, Kuijpers MJE, Cosemans JMEM. Vascular protective effect of aspirin and rivaroxaban upon endothelial denudation of the mouse carotid artery. Sci Rep 2020; 10:19360. [PMID: 33168914 PMCID: PMC7653917 DOI: 10.1038/s41598-020-76377-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/27/2020] [Indexed: 11/08/2022] Open
Abstract
While in recent trials the dual pathway inhibition with aspirin plus rivaroxaban has shown to be efficacious in patients with atherosclerotic cardiovascular disease, little is known about the effects of this combination treatment on thrombus formation and vascular remodelling upon vascular damage. The aim of this study was to examine the effects of aspirin and/or rivaroxaban on injury-induced murine arterial thrombus formation in vivo and in vitro, vessel-wall remodelling, and platelet-leukocyte aggregates. Temporary ligation of the carotid artery of C57BL/6 mice, fed a western type diet, led to endothelial denudation and sub-occlusive thrombus formation. At the site of ligation, the vessel wall stiffened and the intima-media thickened. Aspirin treatment antagonized vascular stiffening and rivaroxaban treatment led to a positive trend towards reduced stiffening. Local intima-media thickening was antagonized by both aspirin or rivaroxaban treatment. Platelet-leukocyte aggregates and the number of platelets per leukocyte were reduced in aspirin and/or rivaroxaban treatment groups. Furthermore, rivaroxaban restricted thrombus growth and height in vitro. In sum, this study shows vascular protective effects of aspirin and rivaroxaban, upon vascular injury of the mouse artery.
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Affiliation(s)
- T G Mastenbroek
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Complex Tissue Regeneration, MERLN Institute for Technology-Inspired Regenerative Medicine, Maastricht, The Netherlands
| | - M F A Karel
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - M Nagy
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - W Chayoua
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Synapse Research Institute, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - E I J Korsten
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - D M Coenen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J Debets
- Department of Pharmacology & Toxicology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J Konings
- Synapse Research Institute, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - A E Brouns
- Department of Pharmacology & Toxicology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - P J A Leenders
- Department of Pharmacology & Toxicology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - H van Essen
- Department of Pharmacology & Toxicology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - R van Oerle
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - S Heitmeier
- Cardiovascular Research Institute, Bayer AG, Wuppertal, Germany
| | - H M Spronk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - M J E Kuijpers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - J M E M Cosemans
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
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22
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Weitz JI, Angiolillo DJ, Geisler T, Heitmeier S. Dual Pathway Inhibition for Vascular Protection in Patients with Atherosclerotic Disease: Rationale and Review of the Evidence. Thromb Haemost 2020; 120:1147-1158. [DOI: 10.1055/s-0040-1713376] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
AbstractDespite advances in secondary prevention strategies in patients with cardiovascular disease, the residual risk of recurrent atherothrombotic events remains high. Dual-antiplatelet therapy is the standard of care for secondary prevention in patients with acute coronary syndrome (ACS), whereas single antiplatelet therapy, generally with aspirin, is the standard of care for secondary prevention in stable patients with coronary artery disease (CAD), peripheral artery disease (PAD), or cerebrovascular disease. However, atherosclerotic plaque disruption not only triggers platelet activation but also results in thrombin generation because of tissue factor exposure. Therefore, blocking both pathways by combining antiplatelet therapy with an anticoagulant, or dual pathway inhibition (DPI), has the potential to be more effective than inhibiting either pathway alone. The benefit of DPI has been demonstrated in the ATLAS ACS 2-TIMI 51, COMPASS, and VOYAGER PAD trials, where the combination of rivaroxaban vascular dose (2.5 mg twice daily) plus aspirin significantly reduced the risk of atherothrombotic events compared with aspirin across a broad range of patients, including those with recent ACS, those with chronic CAD and/or PAD, and patients with PAD who have undergone peripheral revascularization. This article provides the rationale for this regimen in more detail, including why the DPI regimen with the rivaroxaban vascular dose was developed for vascular protection in a broad spectrum of patients with atherosclerotic disease.
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Affiliation(s)
- Jeffrey Ian Weitz
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Ontario, Canada
| | - Dominick J. Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Tobias Geisler
- Department of Cardiology and Angiology, University Hospital Tübingen, Tübingen, Germany
| | - Stefan Heitmeier
- Research and Development Pharmaceuticals, Bayer AG, Wuppertal, Germany
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23
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Ciprandi G, Bellussi LM, Passali GC, Damiani V, Passali D. HMGB1 in nasal inflammatory diseases: a reappraisal 30 years after its discovery. Expert Rev Clin Immunol 2020; 16:457-463. [PMID: 32252560 DOI: 10.1080/1744666x.2020.1752668] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
| | | | | | - Valerio Damiani
- Medical Department, Drugs Minerals and Generics, Pomezia, Italy
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24
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Franchi F, Rollini F, Faz G, Rivas JR, Rivas A, Agarwal M, Briceno M, Wali M, Nawaz A, Silva G, Shaikh Z, Maaliki N, Fahmi K, Been L, Pineda AM, Suryadevara S, Soffer D, Zenni MM, Baber U, Mehran R, Jennings LK, Bass TA, Angiolillo DJ. Pharmacodynamic Effects of Vorapaxar in Prior Myocardial Infarction Patients Treated With Potent Oral P2Y 12 Receptor Inhibitors With and Without Aspirin: Results of the VORA-PRATIC Study. J Am Heart Assoc 2020; 9:e015865. [PMID: 32306797 PMCID: PMC7428520 DOI: 10.1161/jaha.120.015865] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/18/2020] [Indexed: 11/16/2022]
Abstract
Background Vorapaxar as an adjunct to dual antiplatelet therapy (DAPT) reduces thrombotic events in patients with prior myocardial infarction at the expense of increased bleeding. Withdrawal of aspirin has emerged as a bleeding reduction strategy. The pharmacodynamic effects of vorapaxar with potent P2Y12 inhibitors as well as the impact of dropping aspirin is unexplored and represented the aim of the VORA-PRATIC (Vorapaxar Therapy in Patients With Prior Myocardial Infarction Treated With Newer Generation P2Y12 Receptor Inhibitors Prasugrel and Ticagrelor) study. Methods and Results Post-myocardial infarction patients (n=130) on standard DAPT (aspirin+prasugrel or ticagrelor) were randomized to 1 of 3 arms: (1) triple therapy: aspirin+prasugrel/ticagrelor+vorapaxar; (2) dual therapy (drop aspirin): prasugrel/ticagrelor+vorapaxar; (3) DAPT: aspirin+prasugrel/ticagrelor. Pharmacodynamic assessments were performed at 3 time points (baseline and 7 and 30 days). Vorapaxar reduced CAT (collagen-ADP-TRAP)-induced platelet aggregation, a marker of platelet-mediated global thrombogenicity (triple therapy versus DAPT at 30 days: mean difference=-27; 95% CI,-35 to -19; P<0.001; primary end point). This effect was attenuated but still significant in the absence of aspirin (dual therapy versus DAPT at 30 days: mean difference=-15; 95% CI,-23 to -7; P<0.001; between-group comparisons, P<0.05). Vorapaxar abolished TRAP-induced aggregation (P<0.001), without affecting thrombin generation and clot strength. There were no differences in markers of P2Y12 reactivity. Markers sensitive to aspirin-induced effects increased (P<0.001) in the dual-therapy arm. Conclusions In post-myocardial infarction patients treated with potent P2Y12 inhibitors, vorapaxar reduces platelet-driven global thrombogenicity, an effect that persisted, albeit attenuated, in the absence of aspirin and without affecting markers of P2Y12 reactivity or clot kinetics. The clinical implications of these PD observations warrant future investigation. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02545933.
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Affiliation(s)
| | | | - Gabriel Faz
- University of Florida College of Medicine–JacksonvilleFL
| | | | - Andrea Rivas
- University of Florida College of Medicine–JacksonvilleFL
| | - Malhar Agarwal
- University of Florida College of Medicine–JacksonvilleFL
| | | | - Mustafa Wali
- University of Florida College of Medicine–JacksonvilleFL
| | - Ahmed Nawaz
- University of Florida College of Medicine–JacksonvilleFL
| | - Gabriel Silva
- University of Florida College of Medicine–JacksonvilleFL
| | - Zubair Shaikh
- University of Florida College of Medicine–JacksonvilleFL
| | - Naji Maaliki
- University of Florida College of Medicine–JacksonvilleFL
| | - Kerolos Fahmi
- University of Florida College of Medicine–JacksonvilleFL
| | - Latonya Been
- University of Florida College of Medicine–JacksonvilleFL
| | | | | | - Daniel Soffer
- University of Florida College of Medicine–JacksonvilleFL
| | | | - Usman Baber
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNY
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Borst O. Letter by Borst Regarding Article, "Rivaroxaban Reduces Arterial Thrombosis by Inhibition of FXa Driven Platelet Activation via Protease Activated Receptor-1". Circ Res 2020; 126:e53. [PMID: 32271683 DOI: 10.1161/circresaha.120.316777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Oliver Borst
- From the Department of Cardiology, Angiology and Cardiovascular Medicine, University of Tübingen, Germany
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Petzold T, Thienel M, Dannenberg L, Mourikis P, Helten C, Ayhan A, M'Pembele R, Achilles A, Trojovky K, Zhang Z, Regenauer R, Pircher J, Ehrlich A, Lüsebrink E, Nicolai L, Stocker TJ, Brandl R, Röschenthaler F, Strecker J, Saleh I, Spannagl M, Mayr CH, Schiller HB, Jung C, Gerdes N, Hoffmann T, Levkau B, Hohlfeld T, Zeus T, Schulz C, Kelm M, Polzin A. Response by Petzold et al to Letter Regarding Article, "Rivaroxaban Reduces Arterial Thrombosis by Inhibition of FXa-Driven Platelet Activation via Protease Activated Receptor-1". Circ Res 2020; 126:e54-e55. [PMID: 32271680 DOI: 10.1161/circresaha.120.316786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tobias Petzold
- German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.).,Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Manuela Thienel
- German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.).,Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Lisa Dannenberg
- From the Department of Cardiology, Pulmonology and Vascular Medicine (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.), Medical Faculty of the Heinrich Heine University Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Germany (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.)
| | - Philipp Mourikis
- From the Department of Cardiology, Pulmonology and Vascular Medicine (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.), Medical Faculty of the Heinrich Heine University Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Germany (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.)
| | - Carolin Helten
- From the Department of Cardiology, Pulmonology and Vascular Medicine (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.), Medical Faculty of the Heinrich Heine University Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Germany (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.)
| | - Aysel Ayhan
- From the Department of Cardiology, Pulmonology and Vascular Medicine (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.), Medical Faculty of the Heinrich Heine University Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Germany (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.)
| | - René M'Pembele
- From the Department of Cardiology, Pulmonology and Vascular Medicine (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.), Medical Faculty of the Heinrich Heine University Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Germany (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.)
| | - Alina Achilles
- From the Department of Cardiology, Pulmonology and Vascular Medicine (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.), Medical Faculty of the Heinrich Heine University Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Germany (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.)
| | - Kajetan Trojovky
- From the Department of Cardiology, Pulmonology and Vascular Medicine (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.), Medical Faculty of the Heinrich Heine University Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Germany (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.)
| | - Zhe Zhang
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Ron Regenauer
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Joachim Pircher
- German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.).,Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Andreas Ehrlich
- German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.).,Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Enzo Lüsebrink
- German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.).,Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Leo Nicolai
- German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.).,Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Thomas J Stocker
- German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.).,Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Richard Brandl
- St. Mary's Square Institute for Vascular Surgery and Phlebology, Munich, Germany (R.B.)
| | - Franz Röschenthaler
- German Heart Center, Institute for Laboratory Medicine, Technical University Munich (F.R.)
| | - Jan Strecker
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Inas Saleh
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Michael Spannagl
- Department of Anesthesiology, Cell Therapeutics and Hemostaseology (M.S.), Ludwig-Maximilians-University, Munich, Germany.,Department of Transfusion Medicine, Cell Therapeutics and Hemostaseology (M.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Christoph H Mayr
- Helmholtz Zentrum München, Institute of Lung Biology and Disease, Group Systems Medicine of Chronic Lung Disease, Member of the German Center for Lung Research, Munich, Germany (C.H.M., H.B.S.)
| | - Herbert B Schiller
- Helmholtz Zentrum München, Institute of Lung Biology and Disease, Group Systems Medicine of Chronic Lung Disease, Member of the German Center for Lung Research, Munich, Germany (C.H.M., H.B.S.)
| | - Christian Jung
- From the Department of Cardiology, Pulmonology and Vascular Medicine (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.), Medical Faculty of the Heinrich Heine University Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Germany (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.)
| | - Norbert Gerdes
- From the Department of Cardiology, Pulmonology and Vascular Medicine (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.), Medical Faculty of the Heinrich Heine University Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Germany (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.)
| | - Till Hoffmann
- Institute of Transplantation Diagnostics and Cell Therapeutics, Heinrich Heine University Medical Center Düsseldorf, Germany (T. Hoffmann)
| | - Bodo Levkau
- Institute of Pathophysiology, West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen, Germany (B.L.)
| | - Thomas Hohlfeld
- Institute of Pharmacology and Clinical Pharmacology (T. Hohlfeld), Medical Faculty of the Heinrich Heine University Düsseldorf, Germany
| | - Tobias Zeus
- Cardiovascular Research Institute Düsseldorf, Germany (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.)
| | - Christian Schulz
- German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.).,Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University, Munich, Germany
| | - Malte Kelm
- From the Department of Cardiology, Pulmonology and Vascular Medicine (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.), Medical Faculty of the Heinrich Heine University Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Germany (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.)
| | - Amin Polzin
- From the Department of Cardiology, Pulmonology and Vascular Medicine (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.), Medical Faculty of the Heinrich Heine University Düsseldorf, Germany.,Cardiovascular Research Institute Düsseldorf, Germany (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., C.J., N.G., T.Z., M.K., A.P.)
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27
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Gurbel PA, Fox KAA, Tantry US, Ten Cate H, Weitz JI. Combination Antiplatelet and Oral Anticoagulant Therapy in Patients With Coronary and Peripheral Artery Disease. Circulation 2020; 139:2170-2185. [PMID: 31034291 DOI: 10.1161/circulationaha.118.033580] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Antiplatelet therapy is the mainstay for the treatment of acute and chronic arterial disease involving the coronary and peripheral beds. However, questions remain about optimal antithrombotic therapy for long-term treatment of chronic vascular disease. The observation that dual antiplatelet therapy with acetylsalicylic acid and clopidogrel was associated with lower thrombotic event rates than acetylsalicylic acid monotherapy in patients with acute coronary syndromes and those undergoing percutaneous coronary intervention changed the treatment paradigm. Moreover, the demonstration that more pharmacodynamically potent P2Y12 inhibitors than clopidogrel were associated with fewer thrombotic event occurrences further solidified the dual antiplatelet therapy approach. However, recurrent thrombotic events occur in ≈1 in 10 patients in the first year following an acute coronary syndrome event, despite treatment with the most potent P2Y12 inhibitors, a limitation that has stimulated interest in exploring the efficacy and safety of approaches using anticoagulants on top of antiplatelet therapy. These investigations have included treatment with very-low-dose oral anticoagulation, and even its replacement of acetylsalicylic acid in the presence of a P2Y12 inhibitor, in patients stabilized after an acute coronary syndrome event. Recent basic and translational studies have suggested noncanonical effects of coagulation factor inhibition that may further modulate clinical benefits. This in-depth review will discuss developments in our understanding of the roles that platelets and coagulation factors play in atherothrombosis and review the rationale and clinical evidence for combining antiplatelet and oral anticoagulant therapy in patients with coronary and peripheral artery disease.
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Affiliation(s)
- Paul A Gurbel
- Inova Center for Thrombosis Research and Drug Development, Inova Heart and Vascular Institute, Falls Church, VA (P.A.G.)
| | - Keith A A Fox
- British Heart Foundation Centre for Cardiovascular Sciences, University of Edinburgh, United Kingdom (K.A.A.F.)
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, MD (U.S.T.)
| | - Hugo Ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Netherlands (H.t.C.)
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute and McMaster University, Hamilton, Canada (J.I.W.)
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28
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Petzold T, Thienel M, Dannenberg L, Mourikis P, Helten C, Ayhan A, M'Pembele R, Achilles A, Trojovky K, Konsek D, Zhang Z, Regenauer R, Pircher J, Ehrlich A, Lüsebrink E, Nicolai L, Stocker TJ, Brandl R, Röschenthaler F, Strecker J, Saleh I, Spannagl M, Mayr CH, Schiller HB, Jung C, Gerdes N, Hoffmann T, Levkau B, Hohlfeld T, Zeus T, Schulz C, Kelm M, Polzin A. Rivaroxaban Reduces Arterial Thrombosis by Inhibition of FXa-Driven Platelet Activation via Protease Activated Receptor-1. Circ Res 2019; 126:486-500. [PMID: 31859592 DOI: 10.1161/circresaha.119.315099] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
RATIONALE A reduced rate of myocardial infarction has been reported in patients with atrial fibrillation treated with FXa (factor Xa) inhibitors including rivaroxaban compared with vitamin K antagonists. At the same time, low-dose rivaroxaban has been shown to reduce mortality and atherothrombotic events in patients with coronary artery disease. Yet, the mechanisms underlying this reduction remain unknown. OBJECTIVE In this study, we hypothesized that rivaroxaban's antithrombotic potential is linked to a hitherto unknown rivaroxaban effect that impacts on platelet reactivity and arterial thrombosis. METHODS AND RESULTS In this study, we identified FXa as potent, direct agonist of the PAR-1 (protease-activated receptor 1), leading to platelet activation and thrombus formation, which can be inhibited by rivaroxaban. We found that rivaroxaban reduced arterial thrombus stability in a mouse model of arterial thrombosis using intravital microscopy. For in vitro studies, atrial fibrillation patients on permanent rivaroxaban treatment for stroke prevention, respective controls, and patients with new-onset atrial fibrillation before and after first intake of rivaroxaban (time series analysis) were recruited. Platelet aggregation responses, as well as thrombus formation under arterial flow conditions on collagen and atherosclerotic plaque material, were attenuated by rivaroxaban. We show that rivaroxaban's antiplatelet effect is plasma dependent but independent of thrombin and rivaroxaban's anticoagulatory capacity. CONCLUSIONS Here, we identified FXa as potent platelet agonist that acts through PAR-1. Therefore, rivaroxaban exerts an antiplatelet effect that together with its well-known potent anticoagulatory capacity might lead to reduced frequency of atherothrombotic events and improved outcome in patients.
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Affiliation(s)
- Tobias Petzold
- From the Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.)
| | - Manuela Thienel
- From the Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.)
| | - Lisa Dannenberg
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
| | - Philipp Mourikis
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
| | - Carolin Helten
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
| | - Aysel Ayhan
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
| | - René M'Pembele
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
| | - Alina Achilles
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
| | - Kajetan Trojovky
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
| | - Daniel Konsek
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
| | - Zhe Zhang
- From the Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University Munich, Germany
| | - Ron Regenauer
- From the Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University Munich, Germany
| | - Joachim Pircher
- From the Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.)
| | - Andreas Ehrlich
- From the Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.)
| | - Enzo Lüsebrink
- From the Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.)
| | - Leo Nicolai
- From the Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.)
| | - Thomas J Stocker
- From the Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.)
| | - Richard Brandl
- St Mary's Square Institute for Vascular Surgery and Phlebology, Munich (R.B.)
| | - Franz Röschenthaler
- German Heart Center, Institute for Laboratory Medicine, Technical University Munich (F.R.)
| | - Jan Strecker
- From the Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University Munich, Germany
| | - Inas Saleh
- From the Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University Munich, Germany
| | - Michael Spannagl
- Anesthesiology and Transfusion Medicine, Cell Therapeutics and Hemostaseology (M.S.), Ludwig-Maximilians-University Munich, Germany
| | - Christoph H Mayr
- Helmholtz Zentrum München, Institute of Lung Biology and Disease, Group Systems Medicine of Chronic Lung Disease, Munich, Germany, Member of the German Center for Lung Research (DZL) (C.H.M., H.B.S.)
| | - Herbert B Schiller
- Helmholtz Zentrum München, Institute of Lung Biology and Disease, Group Systems Medicine of Chronic Lung Disease, Munich, Germany, Member of the German Center for Lung Research (DZL) (C.H.M., H.B.S.)
| | - Christian Jung
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
| | - Norbert Gerdes
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
| | - Till Hoffmann
- Institute of Transplantation Diagnostics and Cell Therapeutics, Heinrich Heine University Medical Center Düsseldorf (T. Hoffmann)
| | - Bodo Levkau
- Institute of Pathophysiology, West German Heart and Vascular Center, University Hospital Essen, University of Duisburg-Essen (B.L.)
| | - Thomas Hohlfeld
- Cardiovascular Research Institute Düsseldorf (CARID), Institute of Pharmacology and Clinical Pharmacology, Medical Faculty of the Heinrich Heine University Düsseldorf (T. Hohlfeld)
| | - Tobias Zeus
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
| | - Christian Schulz
- From the Medizinische Klinik und Poliklinik I, Klinikum der Universität München (T.P., M.T., Z.Z., R.R., J.P., A.E., E.L., L.N., T.J.S., J.S., I.S., C.S.), Ludwig-Maximilians-University Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Germany (T.P., M.T., J.P., A.E., E.L., L.N., T.J.S., C.S.)
| | - Malte Kelm
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
| | - Amin Polzin
- Cardiology, Pulmonology and Vascular Medicine, Medical Faculty of the Heinrich Heine University Düsseldorf, Düsseldorf (L.D., P.M., C.H., A. Ayhan, R.M., A. Achilles, K.T., D.K., C.J., N.G., T.Z., M.K., A.P.)
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Rivaroxaban Effects Illustrate the Underestimated Importance of Activated Platelets in Thrombin Generation Assessed by Calibrated Automated Thrombography. J Clin Med 2019; 8:jcm8111990. [PMID: 31731710 PMCID: PMC6912513 DOI: 10.3390/jcm8111990] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/04/2019] [Accepted: 11/12/2019] [Indexed: 12/28/2022] Open
Abstract
Background: The direct oral anticoagulant rivaroxaban inhibiting specifically activated factor X (FXa) causes delayed thrombin generation (TG) as measured by calibrated automated thrombography (CAT). The implications of these changes for assessing bleeding or residual prothrombotic risks of patients are unclear in the absence of a better understanding of the underlying mechanism. Methods: We compared platelet rich plasma (PRP) without or with prior collagen-induced platelet aggregation (agPRP) in the CAT assay to better characterize TG in the presence of rivaroxaban. Results: In the presence of rivaroxaban, TG curves in agPRP showed a distinct profile with a rapidly ascending phase followed with a protracted phase. Inhibition of tissue factor pathway inhibitor amplified the first phase of the curve which was also modulated by procoagulant phospholipids. Inhibition of FXIIa-dependent FXI activation revealed that aggregated platelets influenced the first phase by a combination of extrinsic and intrinsic coagulation pathway initiations. Thrombin-dependent amplification of TG (even prior collagen activation) was responsible for the second phase of the TG curve. Conclusions: AgPRP fully includes platelet ability to support TG and reveal distinct TG phases in the presence of direct FXa inhibitors highlighting its potential use in an anticoagulated setting.
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Pharmacodynamic Effects of Vorapaxar in Patients With and Without Diabetes Mellitus: Results of the OPTIMUS-5 Study. JACC Basic Transl Sci 2019; 4:763-775. [PMID: 31998847 PMCID: PMC6978557 DOI: 10.1016/j.jacbts.2019.07.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 07/31/2019] [Accepted: 07/31/2019] [Indexed: 12/18/2022]
Abstract
Vorapaxar reduces thrombotic cardiovascular events in patients with atherosclerotic disease, with enhanced effects in those with DM. Adjunctive vorapaxar therapy reduces platelet-mediated thrombogenicity without affecting clot kinetics in both patients with and those without DM having prior MI/PAD on dual antiplatelet therapy with aspirin and clopidogrel. The pharmacodynamic effects of vorapaxar occur via selective blockade of the PAR-1 on the platelet membrane without apparent interplay with other platelet signaling pathways. Aspirin withdrawal, which leaves patients on a background of clopidogrel and vorapaxar, increases markers specific to COX-1–mediated blockade, leading to an increase in platelet-mediated global thrombogenicity, particularly among patients with DM.
Vorapaxar reduces thrombotic cardiovascular events at the expense of increased bleeding. However, the differential pharmacodynamic (PD) effects of vorapaxar according to diabetes mellitus (DM) status are unknown. Moreover, although withdrawal of aspirin has emerged as a bleeding reduction strategy, the PD effects of stopping aspirin in patients treated with vorapaxar also are unknown. In this prospective PD investigation, vorapaxar was associated with reduced platelet-mediated thrombogenicity without affecting clot kinetics irrespective of DM status. However, platelet-mediated thrombogenicity increased after aspirin withdrawal, particularly among patients with DM. (Optimizing anti-Platelet Therapy In diabetes MellitUS-5 Study [OPTIMUS-5]; NCT02548650)
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Key Words
- ADP, adenosine diphosphate
- CAT, collagen-related peptide + adenosine diphosphate + thrombin receptor activating peptide
- CI, confidence interval
- COX, cyclooxygenase
- DAPT, dual antiplatelet therapy
- DM, diabetes mellitus
- LTA, light transmittance aggregometry
- MI, myocardial infarction
- MPA, maximum platelet aggregation
- PAD, peripheral arterial disease
- PAR, protease-activated receptor
- PD, pharmacodynamic
- TRAP, thrombin receptor activating peptide
- TXB2, thromboxane B2
- VASP, vasodilator-stimulated phosphoprotein
- dual antiplatelet therapy
- o.d., once daily
- pharmacodynamics
- platelets
- thrombin
- vorapaxar
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Sanmartín M, Bellmunt S, Cosín-Sales J, García-Moll X, Riera-Mestre A, Almendro-Delia M, Hernández JL, Lozano F, Mazón P, Suarez Fernández C. Role of rivaroxaban in the prevention of atherosclerotic events. Expert Rev Clin Pharmacol 2019; 12:771-780. [DOI: 10.1080/17512433.2019.1637732] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | - Sergi Bellmunt
- Vascular Surgery Department, Hospital General Vall d´Hebron, Barcelona, Spain
| | - Juan Cosín-Sales
- Cardiology Department, Hospital Arnau de Vilanova, Valencia, Spain
| | | | - Antoni Riera-Mestre
- Internal Medicine Department, Hospital Universitari de Bellvitge-IDIBELL, Universitat de Barcelona, Barcelona, Spain
| | | | - José Luis Hernández
- Internal Medicine Department, Hospital Marqués de Valdecilla-IDIVAL, Universidad de Cantabria, Santander, Spain
| | - Francisco Lozano
- Department of Surgery, Hospital Clinico de Salamanca, Salamanca, Spain
| | - Pilar Mazón
- Cardiology Department, Hospital Clinico Universitario de Santiago de Compostela, CIBERCV, Santiago de Compostela, Spain
| | - Carmen Suarez Fernández
- Internal Medicine Department, Hospital Universitario de la Princesa, Universidad Autónoma de Madrid, Madrid, Spain
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Kremers BMM, Ten Cate H, Spronk HMH. Pleiotropic effects of the hemostatic system. J Thromb Haemost 2018; 16:S1538-7836(22)02208-5. [PMID: 29851288 DOI: 10.1111/jth.14161] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Indexed: 01/19/2023]
Abstract
Atherothrombosis is characterized by the inflammatory process of atherosclerosis combined with a hypercoagulable state leading to superimposed thrombus formation. In atherosclerotic plaques, cell signaling can occur via protease-activated receptors (PARs), four of which have been identified so far (PAR1-PAR4). Proteases that are able to activate PARs can be produced systemically, but also at the sites of lesions, and they include thrombin and activated factor X. After PAR activation, downstream signaling can lead to both proinflammatory effects and a hypercoagulable state. Which specific effect occurs depends on the type of protease and activated PAR, and the site of activation. Hypercoagulable effects are mainly exerted through PAR1 and PAR4, whereas proinflammatory responses are mostly seen after PAR1 and PAR2 activation. PAR signaling pathways contribute to atherothrombosis, suggesting that inhibition of these pathways possibly prevents cardiovascular events based on this pathophysiological mechanism. In this review, we highlight the pathways by which PAR activation leads to proinflammatory responses and a hypercoagulable state. Furthermore, we give an overview of potential pharmacological treatment targets that promote vascular protection.
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Affiliation(s)
- B M M Kremers
- Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - H Ten Cate
- Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - H M H Spronk
- Departments of Internal Medicine and Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
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