Fibrinolysis in Acute and Chronic Cardiovascular Disease

Author(s):  
Noppadol Kietsiriroje ◽  
Robert A.S. Ariëns ◽  
Ramzi A. Ajjan

AbstractThe formation of an obstructive thrombus within an artery remains a major cause of mortality and morbidity worldwide. Despite effective inhibition of platelet function by modern antiplatelet therapies, these agents fail to fully eliminate atherothrombotic risk. This may well be related to extensive vascular disease, beyond the protective abilities of the treatment agents used. However, recent evidence suggests that residual vascular risk in those treated with modern antiplatelet therapies is related, at least in part, to impaired fibrin clot lysis. In this review, we attempt to shed more light on the role of hypofibrinolysis in predisposition to arterial vascular events. We provide a brief overview of the coagulation system followed by addressing the role of impaired fibrin clot lysis in acute and chronic vascular conditions, including coronary artery, cerebrovascular, and peripheral vascular disease. We also discuss the role of combined anticoagulant and antiplatelet therapies to reduce the risk of arterial thrombotic events, addressing both efficacy and safety of such an approach. We conclude that impaired fibrin clot lysis appears to contribute to residual thrombosis risk in individuals with arterial disease on antiplatelet therapy, and targeting proteins in the fibrinolytic system represents a viable strategy to improve outcome in this population. Future work is required to refine the antithrombotic approach by modulating pathological abnormalities in the fibrinolytic system and tailoring therapy according to the need of each individual.

1999 ◽  
Vol 81 (04) ◽  
pp. 601-604 ◽  
Author(s):  
Hiroyuki Matsuno ◽  
Osamu Kozawa ◽  
Masayuki Niwa ◽  
Shigeru Ueshima ◽  
Osamu Matsuo ◽  
...  

SummaryThe role of fibrinolytic system components in thrombus formation and removal in vivo was investigated in groups of six mice deficient in urokinase-type plasminogen activator (u-PA), tissue-type plasminogen activator (t-PA), or plasminogen activator inhibitor-1 (PAI-1) (u-PA-/-, t-PA-/- or PAI-1-/-, respectively) or of their wild type controls (u-PA+/+, t-PA+/+ or PAI-1+/+). Thrombus was induced in the murine carotid artery by endothelial injury using the photochemical reaction between rose bengal and green light (540 nm). Blood flow was continuously monitored for 90 min on day 0 and for 20 min on days 1, 2 and 3. The times to occlusion after the initiation of endothelial injury in u-PA+/+, t-PA+/+ or PAI-1+/+ mice were 9.4 ± 1.3, 9.8 ± 1.1 or 9.7 ± 1.6 min, respectively. u-PA-/- and t-PA-/- mice were indistinguishable from controls, whereas that of PAI-1-/- mice were significantly prolonged (18.4 ± 3.7 min). Occlusion persisted for the initial 90 min observation period in 10 of 18 wild type mice and was followed by cyclic reflow and reocclusion in the remaining 8 mice. At day 1, persistent occlusion was observed in 1 wild type mouse, 8 mice had cyclic reflow and reocclusion and 9 mice had persistent reflow. At day 2, all injured arteries had persistent reflow. Persistent occlusion for 90 min on day 0 was observed in 3 u-PA-/-, in all t-PA-/- mice at day 1 and in 2 of the t-PA-/-mice at day 2 (p <0.01 versus wild type mice). Persistent patency was observed in all PAI-1-/- mice at day 1 and in 5 of the 6 u-PA-/- mice at day 2 (both p <0.05 versus wild type mice). In conclusion, t-PA increases the rate of clot lysis after endothelial injury, PAI-1 reduces the time to occlusion and delays clot lysis, whereas u-PA has little effect on thrombus formation and spontaneous lysis.


2012 ◽  
Vol 107 (04) ◽  
pp. 760-768 ◽  
Author(s):  
Edwin S. Gershom ◽  
Amanda L. Vanden Hoek ◽  
Scott C. Meixner ◽  
Michael R. Sutherland ◽  
Edward L.G. Pryzdial

SummaryThe incorporation of virus- and host-derived procoagulant factors initiates clotting directly on the surface of herpesviruses, which is an explanation for their correlation to vascular disease. The virus exploits the resulting thrombin to enhance infection by modulating the host cell through protease activated receptor (PAR) 1 signalling. Prior reports demonstrated that at least one herpesvirus expresses surface annexin A2 (A2), a cofactor for tissue plasminogen activator (tPA)-dependent activation of plasminogen to plasmin. Since plasmin is both a fibrinolytic protease and PAR agonist, we investigated whether herpesviruses enhance fibrinolysis and the effect of plasmin on cell infection. Herpes simplex virus types 1 (HSV1) and 2, and cytomegalovirus (CMV) purified from various cell lines each accelerated the proteolytic activation of plasminogen to plasmin by tPA. Ligand blots identified A2 as one of several plasminogen binding partners associated with the virus when compared to an A2-deficient virus. This was confirmed with inhibitory A2-antibodies. However, A2 was not required for virus-enhanced plasmin generation. HSV1, HSV2 and CMV accelerated tPA-dependent fibrin clot lysis by up to 2.8-fold. Modest plasmin generation and fibrinolysis was detected independent of exogenous tPA, which was inhibited by plasminogen activator inhibitor type-1 and ε-aminocaproic acid; however, the molecular basis remains speculative. Up to a ∼6-fold enhancement of infection was provided by plasmin-mediated cell infection. Inhibitory antibodies revealed that plasmin increased HSV1 infection through a mechanism involving PAR2. Thus, virus-enhanced fibrinolysis may help explain the paradox of the highly procoagulant in vitro herpesvirus surface eliciting only relatively weak independent vascular disease risk.


1967 ◽  
Vol 126 (5) ◽  
pp. 979-988 ◽  
Author(s):  
B. Lipiński ◽  
J. Hawiger ◽  
J. Jeljaszewicz

Clumping reaction, using standard suspension of Staph. aureus Newman D-2-C strain and various substrates, was quantitatively tested. It has been shown that clumping occurs in fibrin lysate containing soluble fibrin monomer complexes unclottable by thrombin. The reaction was positive with staphylococcal strains possessing clumping factor regardless of staphylocoagulase production. Clumping reaction is similar to paracoagulation reaction induced by protamine sulfate. The substrate for both reactions is stable at 56°C but is destroyed at 60°C. The kinetics of substrate formation for both reactions during fibrin clot lysis is also similar. Clumping reaction with a strain of Staph. epidermidis possessing no clumping factor was positive when these bacteria were coated with protamine sulfate. The effect of heparin, sodium citrate, urea, 2-mercaptoethanol, merthiolate, and mucin on both reactions was tested. The present findings explain the clumping reaction in serum and emphasize the role of blood clotting and fibrinolytic systems in this phenomenon.


Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 1153-1153 ◽  
Author(s):  
Edwin S Gershom ◽  
Amanda Vanden Hoek ◽  
Michael R Sutherland ◽  
Ed L.G. Pryzdial

Abstract Abstract 1153 Background: Members of the Herpesvirus family have been implicated in vascular disease. To explain the correlation on a molecular basis we have shown that the virus envelope contains anionic phospholipid derived from host cells, and proteins encoded by the host (tissue factor) as well as the viral (glycoprotein C) genomes, which initiate blood coagulation. This suggests that virus infection should be a strong independent predictor of vascular disease. Nevertheless, the clinical correlation is relatively weak, becoming more significant in combination with other risk factors. To explain this discrepancy, the current work is based on our additional report that at least one Herpesvirus (cytomegalovirus (CMV)) has host-genome-encoded annexin II on its surface. Annexin II is known to accelerate tissue plasminogen activator (tPA)-mediated activation of plasminogen to plasmin because of C-terminal lysines that interact with both plasminogen and tPA. Plasmin is the primary fibrinolytic protease, and is necessary for physiological clot dissolution. Thus, these viruses may facilitate clearance of the fibrin they generate. Hypothesis: We hypothesize that Herpesviruses enhance tPA-mediated plasmin generation and this mechanism correlates to the presence of annexin II on the virus. Methods: Purified herpes simplex virus type 1 (HSV1) and 2 (HSV2) and CMV were quantified by electron microscopy. Annexin II expression varies between cell types, therefore HSV1 was propagated in several cell lines. Virus-dependent plasmin generation was followed in the presence of purified plasminogen and tPA using a chromogenic assay. The contribution of viruses to fibrin clot lysis using purified proteins was investigated by light scattering. Plasminogen-conjugated horse radish peroxidase (plasminogen-HRP) and western blots were used to identify plasminogen-binding species and annexin II associated with the virus, respectively. The effect of plasmin-mediated signalling on virus infection was determined using cytopathic plaque assays. Results: Chromogenic experiments demonstrated that HSV1, HSV2 and CMV enhanced plasminogen activation in a dose-dependent manner by up to 5-fold, regardless of the parental cell line. Prolonged incubation confirmed the requirement for exogenous tPA. Plasminogen-HRP bound to a number of virus-associated proteins and was shown to be C-terminal lysine-dependent by complete inhibition with epsilon-aminocaproic acid (EACA). Annexin II was demonstrated to be associated with purified HSV1 cultured in different cells except when propagated in a melanoma (A7) line that did not express annexin II. An annexin II antibody inhibited binding of plasminogen-HRP to viral annexin II. HSV1, HSV2 and CMV accelerated fibrin clot lysis, which was inhibited in the presence of EACA and aprotinin, a plasmin inhibitor. However, in contrast to the chromogenic experiment for plasmin generation, each virus also exhibited a clot lysis mechanism independent of added tPA. As we have previously identified for thrombin, incubation of host cells with purified plasmin during inoculation enhanced virus infection by over 3-fold. Conclusion: Cumulatively these data demonstrate that HSV1, HSV2 and CMV accelerate tPA- mediated plasmin generation in the absence of fibrin and identify annexin II as one of several plasminogen binding partners. These viruses furthermore enhance the rate of fibrin clot lysis. However, in the presence of fibrin, purified HSV1, HSV2 and CMV are capable of facilitating clot dissolution in the absence of exogenous tPA. The molecular basis for this novel mechanism is not yet known, but requires plasminogen activation. The finding that purified plasmin enhances infection suggests these viruses may have evolved to initiate plasmin generation. Hence, the virus-mediated activation of fibrinolysis may compensate for its ability to trigger coagulation and attenuate potential contributions as an independent predictor of vascular disease. Disclosures: No relevant conflicts of interest to declare.


Immuno ◽  
2021 ◽  
Vol 1 (1) ◽  
pp. 17-29
Author(s):  
Mateusz Kudelko ◽  
Tsz Fung Yip ◽  
Grace Chun Hei Law ◽  
Suki Man Yan Lee

Prevalent coagulopathy and thromboembolism are observed in severe COVID-19 patients with 40% of COVID-19 mortality being associated with cardiovascular complications. Abnormal coagulation parameters are related to poor prognosis in COVID-19 patients. Victims also displayed presence of extensive thrombosis in infected lungs. Vitamin K is well-known to play an essential role in the coagulation system. Latest study revealed an existing correlation between vitamin K deficiency and COVID-19 severity, highlighting a role of vitamin K, probably via coagulation modulation. In agreement, other recent studies also indicated that anti-coagulant treatments can reduce mortality in severe cases. Altogether, potential mechanisms linking COVID-19 with coagulopathy in which vitamin K may exert its modulating role in coagulation related with disease pathogenesis are established. In this review, we discuss the recent evidence supporting COVID-19 as a vascular disease and explore the potential benefits of using vitamin K against COVID-19 to improve disease outcomes.


Author(s):  
Soon Jun Hong ◽  
Hong Seog Seo ◽  
Chang Gyu Park ◽  
Seung Woon Rha ◽  
Dong Joo Oh ◽  
...  

Background: Lipoprotein(a) (Lp(a)) has been regarded in some studies as an independent risk factor of atherosclerotic vascular disease. However, the use of a baseline plasma Lp(a) concentration as a screening tool for future acute vascular events (AVE) is controversial. We therefore investigated whether progressively increasing change in plasma Lp(a) concentration is associated with the development of AVE. Methods: We investigated prospective analyses of 985 participants (464 women and 521 men) who had either clinically evident vascular disease (VD group, n=443) or its risk factor(s) (RF group, n=542). Blood samples were taken from all participants every six months to measure inflammatory markers such as Lp(a) and C-reactive protein during a 10-year follow-up period. Results: During the follow-up, 223 new cases of myocardial infarction, stroke, and peripheral arterial disease were identified. In the RF group, the relative risk of positive ∆ Lp(a) for predicting AVE was 4.36 (95% confidence interval [CI] 1.76-10.85; P=0.002). In the VD group, the relative risk of positive ∆ Lp(a) for predicting AVE was 6.35 (95% CI 3.68-10.97; P<0.001). Conclusions: These results suggest that a progressively increasing change in Lp(a) concentration has a highly significant predictive value in AVE in both the VD and the RF groups.


2021 ◽  
Vol 22 (22) ◽  
pp. 12537
Author(s):  
Nikoletta Pechlivani ◽  
Katherine J. Kearney ◽  
Ramzi A. Ajjan

Thrombus formation remains a major cause of morbidity and mortality worldwide. Current antiplatelet and anticoagulant therapies have been effective at reducing vascular events, but at the expense of increased bleeding risk. Targeting proteins that interact with fibrinogen and which are involved in hypofibrinolysis represents a more specific approach for the development of effective and safe therapeutic agents. The antifibrinolytic proteins alpha-2 antiplasmin (α2AP), thrombin activatable fibrinolysis inhibitor (TAFI), complement C3 and plasminogen activator inhibitor-2 (PAI-2), can be incorporated into the fibrin clot by FXIIIa and affect fibrinolysis by different mechanisms. Therefore, these antifibrinolytic proteins are attractive targets for the development of novel therapeutics, both for the modulation of thrombosis risk, but also for potentially improving clot instability in bleeding disorders. This review summarises the main properties of fibrinogen-bound antifibrinolytic proteins, their effect on clot lysis and association with thrombotic or bleeding conditions. The role of these proteins in therapeutic strategies targeting the fibrinolytic system for thrombotic diseases or bleeding disorders is also discussed.


Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 19-20
Author(s):  
Enrica Branca ◽  
Giovanna Carrà ◽  
Isabella Russo ◽  
Massimo Terzolo ◽  
Angelo Guerrasio ◽  
...  

Background:inflammatory bowel disease (IBD) is characterized by chronic inflammation associated with an increased tendency to thrombosis and thromboembolic complications. The underlying mechanisms of VTE are not yet fully understood. Several studies reported different expressions of circulating procoagulant factors or fibrinolysis inhibitors in IBD. Others linked podoplanin overexpression with thrombosis, hypercoagulability, and increased risk of VTE. Here, we aimed to identify, among genes able to trigger thrombosis, those aberrantly expressed in IBD samples as compared with matched normal mucosa. Methods:we analyzed the transcriptome of matched normal and inflamed lesions in 168 patients with Adult Crohn Disease (CD) and 245 pediatric IBD using publicly available datasets. We intentionally assessed the expression levels of triggers and inhibitors of the coagulation system (Tissue Factor, TFI), the fibrinolytic system (PLAU, PLAT, PAI-1/2/3, TAFI, PN-1, SERPINF2, A2M, SNX1, SERPINC1) and platelets activation (podoplanin). Analyses were finally performed using additional datasets with 219 ulcerative colitis (UC) adult patients, 198 IBD patients and compared to normal colon transciptome. Results:in all datasets, when compared to matched normal mucosal transcriptome, CD and UC inflamed tissues over-expressed Podoplanin mRNA (p=2.46e-25). TF mRNA was also consistently up-regulated in inflamed mucosal of IBD patients, even if paralleled with up-regulation of TFPI as well, questioning on the functional role of TF in IBD. Among the regulators of the fibrinolytic system the urokinase-activator of the plasminogen is consistently deregulated in inflamed areas. Conclusion: our in-silico analyses on gene expression profiles, using matched normal and pathological mucosa of the same patients, suggested that IBD inflamed mucosa favors platelets activation due to podoplanin over-expression. These observations require further studies to assess the biological role of podoplanin in IBD patients and opens new insights on how to perform antithrombotic prophylaxis in IBD patients. Disclosures No relevant conflicts of interest to declare.


Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 4231-4231
Author(s):  
Manu Thomas Kalathottukaren ◽  
Rajesh A Shenoi ◽  
Lai FL Benjamin ◽  
Fred Rosell ◽  
Jayachandran N Kizhakkedathu ◽  
...  

Abstract Background and Objective Anticoagulants play a pivotal role in the treatment of thromboembolic disorders. Haemorrhage in surgical patients receiving anticoagulants is a major concern. Antidotes are administered to counteract anticoagulation and to restore normal hemostasis. To date, protamine sulphate (PS), a cationic polypeptide is the only clinically approved antidote for unfractionated heparin. PS has toxic side effects and limitations. Inability of PS to completely reverse low molecular weight heparins and fondaparinux is due to its low binding affinity to these drugs. However, PS interacts with coagulation proteins such as fibrinogen to form aggregates which leads to cardiovascular adverse effects. Recently, we developed a synthetic universal heparin reversal agent (UHRA) with high binding affinity to heparins. In vivo studies revealed that UHRA completely reverse the activity of all clinical available parenteral anticoagulants and is nontoxic. This study aims to demonstrate the nontoxic nature of UHRA by assessing its influence on fibrinogen, fibrin clot architecture, plasma clotting and clot lysis. Methods UHRA was developed by incorporating tertiary amine based heparin binding groups on a dendritic hyperbranched polyglycerol scaffold and capping it with methoxy polyethylene glycol chains. Recalcification and tissue factor (TF) initiated turbidimetric plasma clotting assays was performed to understand the impact of UHRA on coagulation system. The interaction of UHRA on fibrinogen was investigated by fibrinogen aggregation assay, fibrin polymerization assay and by spectroscopic analysis (fluorescence and circular dichroism (CD)). The influence of UHRA on fibrin clot architecture was evaluated by scanning electron microscopy (SEM).The anticoagulant neutralization (heparins) by UHRA was studied by fluorogenic thrombin generation assay (TGA) in human platelet-rich plasma (PRP). The lysis of TF-induced plasma clot containing UHRA or PS exposed to exogenous tissue plasminogen activator (t-PA) was studied by turbidimetric assay. Results and discussion Results from the plasma clotting assays showed that UHRA did not alter the clotting parameters compared to PS (TF initiated lag time and maximum absorbance, control vs UHRA 200 mcg/mL, p=0.21 and 0.16, respectively; lag time and maximum absorbance in recalcification, control vs UHRA 200mcg/mL, p=0.08 and 0.13, respectively) suggesting that UHRA has no effect on coagulation system at the concentration studied (Figure 1). Unlike protamine, the fibrinogen aggregation and fibrin polymerization assay was not influenced by UHRA over a broad range of concentrations from 0.05mg/mL to 1mg/mL. Together with tryptophan fluorescence quenching measurements (Figure 2) and fibrinogen secondary structure measurements corroborates that UHRA is not interacting with fibrinogen. The results are quite different from PS and other synthetic cationic polymers which interact with fibrinogen eliciting aggregation and conformational changes. Fibrin clots generated in presence of UHRA (even at 0.5 mg/mL) showed similar structure and fiber size remains same as normal fibrin clot (control vs UHRA 0.5 mg/mL clot, p= 0.12) (Figure 3). On the other hand, fibrin clots formed in the presence of 0.05mg/mL PS (clinical dose) increased the fiber size and changed the clot structure dramatically (control vs PS 0.05mg/mL clot, p< 0.0001). Our plasma clot lysis studies in the presence of exogenous t-PA demonstrate that UHRA did not enhance clot degradation unlike protamine. UHRA restored thrombin levels in anticoagulated PRP (heparinized) demonstrating the efficacy. Conclusion and significance Our studies demonstrate that universal heparin antidote, UHRA, has negligible impact on fibrinogen, fibrin polymerization, clot structure, clot degradation and the coagulation system revealing their excellent hemocompatibility compared to protamine. Our results support the fact that UHRA could be an ideal antidote to restore hemostasis following invasive surgical procedures and to address bleeding complications by heparin based anticoagulants. Figure 1 Figure 1. Figure 3 Figure 3. Figure 2 Figure 2. Disclosures No relevant conflicts of interest to declare.


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