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Coleman JR, Gumina R, Hund T, Cohen M, Neal MD, Townsend K, Kerlin BA. Sex dimorphisms in coagulation: Implications in trauma-induced coagulopathy and trauma resuscitation. Am J Hematol 2024; 99 Suppl 1:S28-S35. [PMID: 38567625 DOI: 10.1002/ajh.27296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 02/17/2024] [Accepted: 03/04/2024] [Indexed: 04/04/2024]
Abstract
Trauma-induced coagulopathy (TIC) is one of the leading causes of preventable death in injured patients. Consequently, it is imperative to understand the mechanisms underlying TIC and how to mitigate this mortality. An opportunity for advancement stems from the awareness that coagulation demonstrates a strong sex-dependent effect. Females exhibit a relative hypercoagulability compared to males, which persists after injury and confers improved outcomes. The mechanisms underlying sex dimorphisms in coagulation and its protective effect after injury have yet to be elucidated. This review explores sex dimorphisms in enzymatic hemostasis, fibrinogen, platelets, and fibrinolysis, with implications for resuscitation of patients with TIC.
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Affiliation(s)
- Julia R Coleman
- Division of Trauma, Critical Care, and Burn, Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Division of Interventional Cardiology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Richard Gumina
- Division of Interventional Cardiology, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Thomas Hund
- Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Mitchell Cohen
- Department of Surgery, University of Colorado Medical Center, Aurora, Colorado, USA
| | - Matthew D Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kristy Townsend
- Department of Neurosurgery, The Ohio State University, Columbus, Ohio, USA
| | - Bryce A Kerlin
- Department of Neurosurgery, The Ohio State University, Columbus, Ohio, USA
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio, USA
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Natorska J, Corral J, de la Morena-Barrio ME, Bravo-Pérez C, Bagoly Z, Bereczky Z, Treliński J, Witkowski M, Klajmon A, Undas A, Ząbczyk M. Antithrombin Deficiency Is Associated with Prothrombotic Plasma Fibrin Clot Phenotype. Thromb Haemost 2023; 123:880-891. [PMID: 37201530 PMCID: PMC10460956 DOI: 10.1055/s-0043-1768712] [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: 12/09/2022] [Accepted: 03/26/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Deficiency of antithrombin increases risk of venous thromboembolism. We hypothesized that antithrombin deficiency affects fibrin clot structure and function. METHODS We evaluated 148 patients (age: 38 [32-50] years; 70% women) with genetically confirmed antithrombin deficiency and 50 healthy controls. Fibrin clot permeability (Ks) and clot lysis time (CLT) along with thrombin generation capacity were assessed before and after antithrombin activity normalization in vitro. RESULTS Antithrombin-deficient patients had lower antithrombin activity (-39%) and antigen levels (-23%) compared with controls (both p < 0.01). Prothrombin fragment 1 + 2 levels were 26.5% higher in patients with antithrombin deficiency than in controls along with 94% increased endogenous thrombin potential (ETP) and 108% higher peak thrombin (all p < 0.01). Antithrombin deficiency was associated with 18% reduced Ks and 35% prolonged CLT (both p < 0.001). Patients with type I (n = 65; 43.9%) compared with type II antithrombin deficiency (n = 83; 56.1%) had 22.5% lower antithrombin activity (p < 0.001) and despite similar fibrinogen levels, 8.4% reduced Ks, 18% prolonged CLT, and 30% higher ETP (all p < 0.01). Reduced Ks was associated with lower antithrombin antigen level (β = - 6.1, 95% confidence interval [CI]: -1.7 to -10.5), while prolonged CLT was associated with lower antithrombin antigen (β = - 69.6, 95% CI: -9.6 to -129.7), activity (β = - 2.4, 95% CI: -0.3 to -4.5), higher PAI-1 (β = 12.1, 95% CI: 7.7-16.5), and thrombin-activatable fibrinolysis inhibitor levels (β = 3.8, 95% CI: 1.9-5.7). Addition of exogenous antithrombin reduced ETP (-42%) and peak thrombin (-21%), and improved Ks (+8%) and CLT (-12%; all p < 0.01). CONCLUSION Our study suggests that enhanced thrombin generation and prothrombotic plasma fibrin clot phenotype can contribute to increased risk of thrombosis in patients with antithrombin deficiency.
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Affiliation(s)
- Joanna Natorska
- Department of Experimental Cardiac Surgery, Anesthesiology and Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
- Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Kraków, Poland
| | - Javier Corral
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER-ISCIII, Universidad de Murcia, Murcia, Spain
| | - Maria Eugenia de la Morena-Barrio
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER-ISCIII, Universidad de Murcia, Murcia, Spain
| | - Carlos Bravo-Pérez
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, IMIB, CIBERER-ISCIII, Universidad de Murcia, Murcia, Spain
| | - Zsuzsa Bagoly
- Division of Clinical Laboratory Sciences, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zsuzsanna Bereczky
- Division of Clinical Laboratory Sciences, Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Jacek Treliński
- Department of Haemostasis Disorders, Medical University of Lodz, Łódź, Poland
- Department of Haematology, Copernicus Memorial Hospital, Łódź, Poland
| | - Michał Witkowski
- Department of Haematology, Copernicus Memorial Hospital, Łódź, Poland
| | - Adrianna Klajmon
- Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Kraków, Poland
| | - Anetta Undas
- Department of Experimental Cardiac Surgery, Anesthesiology and Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
- Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Kraków, Poland
| | - Michał Ząbczyk
- Department of Experimental Cardiac Surgery, Anesthesiology and Cardiology, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
- Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Kraków, Poland
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Sikora M, Skrzydlewski P, Perła-Kaján J, Jakubowski H. Homocysteine thiolactone contributes to the prognostic value of fibrin clot structure/function in coronary artery disease. PLoS One 2022; 17:e0275956. [PMID: 36301961 PMCID: PMC9612472 DOI: 10.1371/journal.pone.0275956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 09/11/2022] [Indexed: 11/04/2022] Open
Abstract
Fibrin clot structure/function contributes to cardiovascular disease. We examined sulfur-containing metabolites as determinants of fibrin clot lysis time (CLT) and maximum absorbance (Absmax) in relation to outcomes in coronary artery disease (CAD) patients. Effects of B-vitamin/folate therapy on CLT and Absmax were studied. Plasma samples were collected from 1,952 CAD patients randomized in a 2 x 2 factorial design to (i) folic acid, vitamins B12, B6; (ii) folic acid, vitamin B12; (iii) vitamin B6; (iv) placebo for 3.8 years in the Western Norway B-Vitamin Intervention Trial. Clot lysis time (CLT) and maximum absorbance (Absmax) were determined using a validated turbidimetric assay. Acute myocardial infarction (AMI) and mortality were assessed during a 7-year follow-up. Data were analyzed using bivariate and multiple regression. Survival free of events was studied using Kaplan Mayer plots. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox proportional hazards models. Baseline urinary homocysteine (uHcy)-thiolactone and plasma cysteine (Cys) were significantly associated with CLT while plasma total Hcy was significantly associated with Absmax, independently of fibrinogen, triglycerides, vitamin E, glomerular filtration rate, body mass index, age, sex plasma creatinine, CRP, HDL-C, ApoA1, and previous diseases. B-vitamins/folate did not affect CLT and Absmax. Kaplan-Meier analysis showed associations of increased baseline CLT and Absmax with worse outcomes. In Cox regression analysis, baseline CLT and Absmax (>cutoff) predicted AMI (CLT: HR 1.58, 95% CI 1.10-2.28; P = 0.013. Absmax: HR 3.22, CI 1.19-8.69; P = 0.021) and mortality (CLT: HR 2.54, 95% CI 1.40-4.63; P = 0.002. Absmax: 2.39, 95% CI 1.17-4.92; P = 0.017). After adjustments for other prognostic biomarkers these associations remained significant. Cys and uHcy-thiolactone, but not tHcy, were significant predictors of AMI in Cox regression models that included CLT. Conclusions uHcy-thiolactone and plasma Cys are novel determinants of CLT, an important predictor of adverse CAD outcomes. CLT and Absmax were not affected by B-vitamin/folate therapy, which could account for the lack of efficacy of such therapy in CAD. Trial registration: URL: http://clinicaltrials.gov. Identifier: NCT00354081.
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Affiliation(s)
- Marta Sikora
- European Center for Bioinformatics and Genomics, Institute of Bioorganic Chemistry, Poznań, Poland
| | - Paweł Skrzydlewski
- Department of Biochemistry and Biotechnology, University of Life Sciences, Poznań, Poland
| | - Joanna Perła-Kaján
- Department of Biochemistry and Biotechnology, University of Life Sciences, Poznań, Poland
| | - Hieronim Jakubowski
- Department of Biochemistry and Biotechnology, University of Life Sciences, Poznań, Poland
- Department of Microbiology, Biochemistry and Molecular Genetics, Rutgers-New Jersey Medical School, International Center for Public Health, Newark, NJ, United States of America
- * E-mail:
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Abstract
Fibrinolysis is of paramount importance in maintaining or regaining the patency of veins and pulmonary arteries obstructed by thrombi. Growing experimental and clinical evidence indicates that impaired fibrinolysis mediated by multiple complex mechanisms is involved in venous thromboembolism (VTE). Global plasma fibrin clot lysis markers, especially clot lysis time, have been reported to predict recurrent deep-vein thrombosis and pulmonary embolism. The current overview summarizes available data linking fibrinolysis to VTE and its long-term sequelae.
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Affiliation(s)
- Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
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Plasma Fibrin Clot Properties Are Unfavorably Altered in Women following Venous Thromboembolism Associated with Combined Hormonal Contraception. DISEASE MARKERS 2019; 2019:4923535. [PMID: 31827635 PMCID: PMC6885764 DOI: 10.1155/2019/4923535] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/22/2019] [Indexed: 11/17/2022]
Abstract
The use of hormonal contraception is associated with an increased risk of venous thromboembolism (VTE). Unfavorably altered fibrin clot phenotype has been reported in patients following unprovoked VTE who are at risk of recurrences. It remains unknown whether fibrin clot characteristics in women with contraception-related VTE differ from those in unprovoked VTE. We studied three age-matched groups of women: (1) after contraception-related VTE, (n = 48) (2) after unprovoked VTE (n = 48), and (3) controls (n = 48). Plasma fibrin clot permeability (K s), turbidity of clot formation, efficiency of fibrinolysis using clot lysis time (CLT), and rate of increase in D-dimer during lytic clot degradation (D-Drate), along with thrombin generation and fibrinolysis proteins were determined. Compared with the controls, patients following contraception-related and unprovoked VTE formed faster (lag phase, -8.8% and -20.4%, respectively) fibrin clots of increased density (K s , -8.6% and -13.4%, respectively) displaying impaired fibrinolysis as evidenced by prolonged CLT (+11.5% and +14.5%, respectively) and lower D-Drate (-7.1% and -5.6%, respectively), accompanied with higher plasminogen activator inhibitor-1 (PAI-1, +14.9% and +17.8%, respectively) and elevated peak thrombin generation (+63.8% and +36.7%, respectively). The only differences between women with unprovoked and contraception-related VTE were lower fibrin mass in plasma clots (D-Dmax, -8.6%), along with higher peak thrombin generation (+19.8%) and shorter lag phase (-6.8%) in the latter group. This study suggests that women after contraception-related VTE, similar to those following unprovoked VTE, have denser fibrin clot formation and impaired clot lysis. These findings might imply higher risk of VTE recurrence in women with the prothrombotic clot phenotype.
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Undas A, Natorska J. Improving fibrinolysis in venous thromboembolism: impact of fibrin structure. Expert Rev Hematol 2019; 12:597-607. [PMID: 31159611 DOI: 10.1080/17474086.2019.1627193] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction. Fibrinolysis is of key importance in maintaining vessel patency. Impaired fibrinolysis associated with more compact fibrin structure has been shown in patients with venous thromboembolism (VTE), including deep-vein thrombosis and pulmonary embolism (PE). Currently, recombinant or modified plasminogen activators are the only commonly available thrombolytic agents. However, they are fraught with side effects and suboptimal effectiveness. Areas covered. Based on the available literature, the current evidence linking fibrinolysis with VTE and potential therapeutic targets among fibrinolysis proteins are presented. Expert opinion. Prolonged clot lysis time has been reported as a new predictor of first-time and recurrent VTE, including PE. Anticoagulant therapy, including non-vitamin K antagonist oral anticoagulants, has a favorable impact on fibrinolysis in VTE patients. Several VTE risk factors are also related to lower efficiency of fibrinolysis and their treatment improve fibrinolysis, in part by alterations to fibrin properties. There is an increasing number of studies aiming at developing novel profibrinolytic therapeutic agents for treatment of VTE patients, mostly targeting the antifibrinolytic proteins, i.e. antiplasmin, plasminogen activator inhibitor-1 and thrombin-activatable fibrinolysis inhibitor.
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Affiliation(s)
- Anetta Undas
- a Institute of Cardiology, Jagiellonian University Medical College , Kraków , Poland
| | - Joanna Natorska
- a Institute of Cardiology, Jagiellonian University Medical College , Kraków , Poland
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Undas A. Fibrin clot properties and their modulation in thrombotic disorders. Thromb Haemost 2017; 112:32-42. [DOI: 10.1160/th14-01-0032] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 02/19/2014] [Indexed: 11/05/2022]
Abstract
SummaryAccumulating evidence indicates that accelerated formation of fibrin clots composed of compact, highly-branched networks with thin fibres which are relatively resistant to plasmin-mediated lysis can be commonly observed in patients with venous or arterial thrombosis. This review discusses characteristics of fibrin clot structure and function in patients with various thromboembolic manifestations, in particular myocardial infarction, ischaemic stroke and venous thromboembolism, based on the publications till December 2013. Moreover, factors will be presented that in vivo unfavourably determine altered fibrin clot properties in thrombotic disorders and modalities that can improve clot phenotype.
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Undas A. Prothrombotic Fibrin Clot Phenotype in Patients with Deep Vein Thrombosis and Pulmonary Embolism: A New Risk Factor for Recurrence. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8196256. [PMID: 28740853 PMCID: PMC5504927 DOI: 10.1155/2017/8196256] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/27/2017] [Accepted: 05/04/2017] [Indexed: 11/23/2022]
Abstract
Prothrombotic fibrin clot phenotype, involving faster formation of dense meshwork composed of thinner and highly branched fibers that are relatively resistant to plasmin-induced lysis, has been reported in patients with not only myocardial infarction or stroke, but also venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT), and/or pulmonary embolism (PE). Prothrombotic fibrin clot phenotype, in particular prolonged clot lysis time, is considered a novel risk factor for VTE as well as venous thrombosis at unusual location, for example, cerebral sinus venous thrombosis, retinal vein obstruction, and Budd-Chiari syndrome. Growing evidence from observational studies indicates that abnormal fibrin clot properties can predict recurrent DVT and PE and they are involved in serious complications of VTE, for example, thromboembolic pulmonary hypertension and postthrombotic syndrome. The purpose of this article is to review our current understanding of the role of fibrin clot structure and function in venous thrombosis with emphasis on clinical issues ranging from prognosis to therapy.
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Affiliation(s)
- Anetta Undas
- Institute of Cardiology, Jagiellonian University School of Medicine and The John Paul II Hospital, Krakow, Poland
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Meus R, Son M, Sobczyk D, Undas A. Prothrombotic State in Patients With a Left Atrial Appendage Thrombus of Unknown Origin and Cerebrovascular Events. Stroke 2016; 47:1872-8. [PMID: 27301942 DOI: 10.1161/strokeaha.116.012856] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 05/19/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We hypothesized that formation of left atrial appendage (LAA) thrombi of unknown origin is associated with altered fibrin clot properties and blood hypercoagulability. METHODS In a case-control study, we investigated 32 patients with a history of LAA thrombus after successful anticoagulant treatment versus 32 control subjects matched for age, sex, and diabetes mellitus. All subjects had previous ischemic stroke, transient ischemic attack, or migraine associated with patent foramen ovale. Patients with documented atrial fibrillation were excluded. We determined plasma fibrin clot permeability, fibrinolytic efficiency, thrombin generation, platelet and endothelial markers. Stroke or transient ischemic attack were assessed during a median follow-up of 74 (range 19-98) months. RESULTS Compared with controls, patients with LAA thrombus more frequently were smokers (43.8% versus 18.8%) and had 20% prolonged clot lysis time, lower plasminogen (-14%), and higher plasminogen activator inhibitor-1 (+17%), thrombin-antithrombin complexes (+17%), CD40 ligand (+30%), P-selectin (+29%), and von Willebrand factor (+30%, all P<0.05). Occurrence of LAA thrombus was predicted by von Willebrand factor (β=0.038, P=0.004), plasminogen (β=-0.048, P=0.01), plasminogen activator inhibitor-1 (β=-0.161, P=0.03), and clot permeability (β=-1.076, P=0.03). During follow-up, cerebrovascular events occurred in 10 (33.33%) of the 30 available patients in the LAA thrombus group, including 7 (23.3%) with recurrent LAA thrombus and 4 (13.33%) with documented atrial fibrillation. Recurrent LAA thrombus was associated with lower baseline Ks and higher thrombin generation, fibrinogen, plasminogen activator inhibitor-1, and soluble CD40 ligand (all P<0.05). CONCLUSIONS Prothrombotic blood alterations could be involved in the LAA thrombus formation in patients without documented atrial fibrillation and are associated with increased risk of stroke or transient ischemic attack during follow-up.
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Affiliation(s)
- Rafal Meus
- From the Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland (R.M., M.S., A.U.); and John Paul II Hospital, Cracow, Poland (D.S., A.U.)
| | - Maksim Son
- From the Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland (R.M., M.S., A.U.); and John Paul II Hospital, Cracow, Poland (D.S., A.U.)
| | - Dorota Sobczyk
- From the Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland (R.M., M.S., A.U.); and John Paul II Hospital, Cracow, Poland (D.S., A.U.)
| | - Anetta Undas
- From the Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland (R.M., M.S., A.U.); and John Paul II Hospital, Cracow, Poland (D.S., A.U.).
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Bouman A, McPherson H, Cheung Y, ten Wolde M, ten Cate H, Ariëns R, ten Cate-Hoek A. Clot structure and fibrinolytic potential in patients with post thrombotic syndrome. Thromb Res 2016; 137:85-91. [DOI: 10.1016/j.thromres.2015.11.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 11/01/2015] [Accepted: 11/08/2015] [Indexed: 11/17/2022]
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Abstract
The fibrin clot permeability coefficient (Ks) is a useful measure of porosity of the fibrin network, which is determined by a number of genetic and environmental factors. Currently available methods to evaluate Ks are time-consuming, require constant supervision and provide only one parameter. We present an automated method in which drops are weighed individually, buffer is dosed by the pump and well defined clot washing is controlled by the software. The presence of a straight association between drop mass and their dripping time allows to shorten the measurement time twice. In 40 healthy individuals, Ks, the number of drops required to reach the plateau (DTP), the time to achieve the plateau (TTP) and the DTP/TTP ratio (DTR) were calculated. There was a positive association between Ks (r = 0.69, P < 0.0001) evaluated by using the manual [median of 4.17 (3.60-5.18) ·10⁻⁹ cm²) and the automated method [median of 4.35 (3.74-5.38) ·10⁻⁹ cm²]. The correlation was stronger (r = 0.85, P < 0.001) in clots with DTP of 7 or less (n = 12). DTP was associated with total homocysteine (tHcy) (r = 0.35, P < 0.05) and activated partial thromboplastin time (APTT) (r = -0.34, P < 0.05), TTP with Ks (r = -0.55, P < 0.01 for the manual method and r = -0.44, P < 0.01 for the automated method) and DTP (r = 0.75, P < 0.0001), and DTR with Ks (r = 0.70, P < 0.0001 for the manual method and r = 0.76, P < 0.0001 for the automated method), fibrinogen (r = -0.58, P < 0.0001) and C-reactive protein (CRP) (r = -0.47, P < 0.01). The automated method might be a suitable tool for research and clinical use and may offer more additional parameters describing fibrin clot structure.
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