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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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Santos JD, Dawson S, Conefrey C, Isaacs T, Khanum M, Faisal S, Paramasivan S. Most UK cardiovascular disease trial protocols feature criteria that exclude ethnic minority participants: a systematic review. J Clin Epidemiol 2024; 167:111259. [PMID: 38215800 DOI: 10.1016/j.jclinepi.2024.111259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 12/12/2023] [Accepted: 01/08/2024] [Indexed: 01/14/2024]
Abstract
OBJECTIVES We systematically reviewed UK cardiovascular disease (CVD) randomized controlled trial (RCT) protocols to identify the proportion featuring eligibility criteria that may disproportionately exclude ethnic minority (EM) participants. METHODS We searched MEDLINE, Embase, and Cochrane Library databases, January 2014-June 2022, to identify UK CVD RCT protocols. We extracted nonclinical eligibility criteria from trial protocols and inductively categorized the trials by their language, consent, and broad (ambiguous) criteria. Findings are narratively reported. RESULTS Of the seventy included RCT protocols, most (87.1%; 61/70) mentioned consent within the eligibility criteria, with more than two-thirds (68.9%; 42/61) indicating a requirement for 'written' consent. Alternative consent pathways that can aid EM participation were absent. English language requirement was present in 22.9% (16/70) of the studies and 37.1% (26/70) featured broad criteria that are open to interpretation and subject to recruiter bias. Only 4.3% (3/70) protocols mentioned the provision of translation services. CONCLUSION Most UK CVD trial protocols feature eligibility criteria that potentially exclude EM groups. Trial eligibility criteria must be situated within a larger inclusive recruitment framework, where ethnicity is considered alongside other intersecting and disadvantaging identities.
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Affiliation(s)
- Jhulia Dos Santos
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Shoba Dawson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Carmel Conefrey
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Talia Isaacs
- UCL Centre for Applied Linguistics, IOE, UCL's Faculty of Education and Society, University College London, London, UK
| | - Mahwar Khanum
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Saba Faisal
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sangeetha Paramasivan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
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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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Global thrombosis test for assessing thrombotic status and efficacy of antithrombotic diet and other conditions. Future Sci OA 2022; 8:FSO788. [PMID: 35251699 PMCID: PMC8890116 DOI: 10.2144/fsoa-2021-0086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 01/10/2022] [Indexed: 11/23/2022] Open
Abstract
Because of the high mortality from myocardial infarction and stroke, there is a great demand for finding novel methods of diagnosis, prevention and treatment of these diseases. Most of the current tests measure important determinants of thrombosis such as platelet function, coagulation and fibrinolysis in isolation; therefore, a global test measuring the actual thrombotic status would be more useful in clinical conditions. We obtained considerable experience by using the global thrombosis test, which determines the actual thrombotic status by taking into account the measured platelet reactivity, coagulation and fibrinolytic activities. In animal experiments, we found significant correlation between the ex vivo global thrombosis test measurements and the in vivo thrombotic status. The published evidence for the benefit of an antithrombotic diet with regular physical exercise is also described. There is a great concern in the general population how to detect the risk of thrombotic events and prevent the high mortality from stroke, myocardial infarction, sudden death and cancer-associated thrombosis. Our experience on antithrombotic fruits and vegetables intake and regular exercise assessed by the global thrombosis test suggested a potentially unique way of preventing these life-threatening diseases. In addition, global thrombosis testing may offer some benefit in detecting risk of thrombotic of forthcoming thrombotic events in cancer and COVID-19 virus-infected patients.
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Kietsiriroje N, Ariëns RAS, Ajjan RA. Fibrinolysis in Acute and Chronic Cardiovascular Disease. Semin Thromb Hemost 2021; 47:490-505. [PMID: 33878782 DOI: 10.1055/s-0040-1718923] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The 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.
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Affiliation(s)
- Noppadol Kietsiriroje
- Department of Metabolic Medicine, Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom.,Endocrinology and Metabolism Unit, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla, Thailand
| | - Robert A S Ariëns
- Department of Metabolic Medicine, Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
| | - Ramzi A Ajjan
- Department of Metabolic Medicine, Leeds Institute of Cardiovascular and Metabolic Medicine, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom
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Gue YX, Jeong YH, Farag M, Spinthakis N, Gorog DA. Precision Treatment in ACS-Role of Assessing Fibrinolysis. J Clin Med 2021; 10:jcm10050929. [PMID: 33804303 PMCID: PMC7957496 DOI: 10.3390/jcm10050929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 11/24/2022] Open
Abstract
Despite advancements in pharmacotherapy and interventional strategies, patients with acute coronary syndrome (ACS) remain at risk of recurrent thrombotic events. In addition to an enhanced tendency to thrombus formation, impairment in the ability to naturally dissolve or lyse a developing thrombus, namely impaired endogenous fibrinolysis, is responsible for a major part of this residual risk regardless of optimal antiplatelet medication. Global assessment of endogenous fibrinolysis, including a point-of-care assay, can identify patients with ACS at persistent high cardiovascular risk and might play an important role in allowing the personalisation of potent antithrombotic therapy to enhance fibrinolytic status, providing precision treatment of ACS to improve long-term outcome.
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Affiliation(s)
- Ying X. Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK;
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (M.F.); (N.S.)
| | - Young-Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon 51472, Korea;
| | - Mohamed Farag
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (M.F.); (N.S.)
| | - Nikolaos Spinthakis
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (M.F.); (N.S.)
| | - Diana A. Gorog
- Department of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (M.F.); (N.S.)
- National Heart and Lung Institute, Imperial College, London SW3 6LY, UK
- Correspondence:
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