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Presume J, Ferreira J, Ribeiras R. Factor XI Inhibitors: A New Horizon in Anticoagulation Therapy. Cardiol Ther 2024; 13:1-16. [PMID: 38306010 PMCID: PMC10899133 DOI: 10.1007/s40119-024-00352-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024] Open
Abstract
Anticoagulation therapy has undergone significant evolution, marked by the emergence of direct oral anticoagulants with distinct advantages. Despite these advancements, challenges persist in managing residual thrombotic and bleeding risks, particularly among vulnerable populations. The pursuit of alternative drugs has honed in on factor XI/XIa inhibitors. This comprehensive review delves into several key aspects regarding this new target: (i) the role of factor XI in the coagulation cascade; (ii) the genetic evidence and pathophysiologic rationale supporting factor XI inhibition as a therapeutic target; (iii) an exploration of the various types of factor XI/XIa inhibitors currently under investigation; (iv) potential applications of these medications, spanning thromboprophylaxis after orthopedic surgery, stroke prevention in atrial fibrillation, secondary prevention after acute coronary syndrome, non-cardioembolic stroke, thromboprophylaxis after foreign material implantation, end-stage renal disease, and patients with cancer; and (v) an overview of ongoing studies, recent findings, and the future trajectory of research into these drugs.
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Affiliation(s)
- João Presume
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo Dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
- Comprehensive Health Research Centre, NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Jorge Ferreira
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo Dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - Regina Ribeiras
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo Dos Santos, Carnaxide, 2790-134, Lisbon, Portugal.
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2
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Marongiu F, Barcellona D. Why Does Rivaroxaban Not Work in Severe Mitral Stenosis? Semin Thromb Hemost 2024; 50:303-306. [PMID: 37160162 DOI: 10.1055/s-0043-1768938] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Francesco Marongiu
- Haemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
- Fondazione Arianna Anticoagulazione, Bologna, Italy
| | - Doris Barcellona
- Haemostasis and Thrombosis Unit, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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3
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Sun F, Wang W, Li Z, Li Y, Guo W, Kong Y. Design, expression and biological evaluation of DX-88mut as a novel selective factor XIa inhibitor for antithrombosis. Bioorg Chem 2024; 142:106951. [PMID: 37924755 DOI: 10.1016/j.bioorg.2023.106951] [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: 08/29/2023] [Revised: 10/21/2023] [Accepted: 10/28/2023] [Indexed: 11/06/2023]
Abstract
Thrombotic diseases, such as myocardial infarction, stroke, and deep vein thrombosis, severely threaten human health, and anticoagulation is an effective way to prevent such illnesses. However, most anticoagulant drugs in the clinic have different bleeding risks. Previous studies have shown that coagulation factor XI is an ideal target for safe anticoagulant drug development. Here, we designed the FXIa inhibitory peptide DX-88mut by replacing Loop1 (DGPCRAAHPR) and Loop2 (IYGGC) in DX-88, which is a clinical drug targeting PKa for the treatment of hereditary angioedema, using Loop1 (TGPCRAMISR) and Loop2 (FYGGC) in the FXIa inhibitory peptide PN2KPI, respectively. DX-88mut selectively inhibited FXIa against a panel of serine proteases with an IC50 value of 14.840 ± 0.453 nM, dose-dependently prolonged APTT in mouse, rat and human plasma, and potently inhibited FeCl3-induced carotid artery thrombosis in mice at a dose of 1 µmol/kg. Additionally, DX-88mut did not show a significant bleeding risk at a dose of 5 µmol/kg. Taken together, these results show that DX-88mut is a potential candidate for the development of a novel antithrombotic agent.
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Affiliation(s)
- Feilong Sun
- School of Life Science and Technology, China Pharmaceutical University, Longmian Street 639, Nanjing 211198, China
| | - Weihao Wang
- School of Life Science and Technology, China Pharmaceutical University, Longmian Street 639, Nanjing 211198, China
| | - Zhengyang Li
- School of Life Science and Technology, China Pharmaceutical University, Longmian Street 639, Nanjing 211198, China
| | - Yitong Li
- School of Life Science and Technology, China Pharmaceutical University, Longmian Street 639, Nanjing 211198, China
| | - Wei Guo
- School of Life Science and Technology, China Pharmaceutical University, Longmian Street 639, Nanjing 211198, China.
| | - Yi Kong
- School of Life Science and Technology, China Pharmaceutical University, Longmian Street 639, Nanjing 211198, China.
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4
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Engelen MM, Verhamme P, Vanassche T. Clotting of the Extracorporeal Circuit in Hemodialysis: Beyond Contact-Activated Coagulation. Semin Nephrol 2023; 43:151473. [PMID: 38233291 DOI: 10.1016/j.semnephrol.2023.151473] [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] [Indexed: 01/19/2024]
Abstract
Thrombotic complications in patients with end-stage kidney disease are frequent. While being a lifesaving treatment for these patients, hemodialysis introduces a thromboinflammatory environment. Additionally, the extracorporeal hemodialysis circuit itself is prone to clotting because of an interaction between different activation mechanisms of the coagulation system, platelets, and the immune system. Anticoagulation of the patient and the machine is frequently complicated by bleeding. We discuss the factors important in this balancing act and touch on potential strategies that are on the horizon to target thromboinflammation.
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Affiliation(s)
- Matthias M Engelen
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium.
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
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5
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Xu LC, Siedlecki CA. FXII contact activation products have an inhibitory effect on αFXIIa. J Biomed Mater Res A 2023:10.1002/jbm.a.37612. [PMID: 37737653 PMCID: PMC10957503 DOI: 10.1002/jbm.a.37612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/24/2023] [Accepted: 09/01/2023] [Indexed: 09/23/2023]
Abstract
It is accepted that the contact activation complex of the intrinsic pathway of blood coagulation cascade produces active enzymes that lead to plasma coagulation following biomaterial contact. In this study, FXII was activated through contact with hydrophilic glass beads and hydrophobic octadecyltrichlorosilane-modified glass beads from neat buffer solutions. These FXII contact activation products generated from material interaction were found to suppress the procoagulant activity of exogenous αFXIIa, and this inhibition was dependent on surface wettability and the concentration of exogenous αFXIIa. Higher relative inhibition rates were generally observed at low concentrations of αFXIIa (1-2 μg/mL) while both hydrophobic and hydrophilic materials showed similar inhibition levels (~39%) at high concentrations of αFXIIa (20 μg/mL). The presence of prekallikrein in the activation system increased the amount of FXIIa produced during FXII contact activation, and also suppressed the apparent levels of inhibitors on hydrophilic surfaces, while having no effect on apparent levels of inhibitors on hydrophobic surface. The combination of FXII contact activation products and activator surfaces was found to dramatically increase inhibition of αFXIIa activity compared to the activation products alone, regardless of activator surface wettability and the presence of prekallikrein. This finding of inhibitors in the suite of proteins generated by contact activation provides additional knowledge into the complex series of interactions that occur when plasma comes into contact with material surfaces.
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Affiliation(s)
- Li-Chong Xu
- Department of Surgery, Pennsylvania State University College of Medicine, Hershey, PA, 17033
| | - Christopher A. Siedlecki
- Department of Surgery, Pennsylvania State University College of Medicine, Hershey, PA, 17033
- Department of Bioengineering, Pennsylvania State University College of Medicine, Hershey, PA, 17033
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6
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Xia Y, Hu Y, Tang L. Factor XIa Inhibitors as a Novel Anticoagulation Target: Recent Clinical Research Advances. Pharmaceuticals (Basel) 2023; 16:866. [PMID: 37375813 DOI: 10.3390/ph16060866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/03/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND While current clinically administered anticoagulant medications have demonstrated effectiveness, they have also precipitated significant risks: severe bleeding complications including, but not limited to, gastrointestinal hemorrhaging and intracranial and other life-threatening major bleedings. An ongoing effort is being made to identify the best targets for anticoagulant-targeted drugs. Coagulation factor XIa (FXIa) is emerging as an important target of current anticoagulant treatment. OBJECTIVE This review will summarize the development of anticoagulants and recent advances in clinical trials of experimental factor XI inhibitors from a clinical application perspective. RESULTS As of 1 January 2023, our search screening included 33 clinical trials. We summarized the research progress of FXIa inhibitors from seven clinical trials that evaluated their efficacy and safety. The results showed no statistically meaningful distinction in the primary efficacy between patients receiving FXIa inhibitors compared to controls (RR = 0.796; 95% CI: 0.606-1.046; I2 = 68%). The outcomes did not indicate a statistical difference in the occurrence of any bleeding between patients receiving FXIa inhibitors compared to controls (RR = 0.717; 95% CI: 0.502-1.023; I2 = 60%). A subgroup analysis found significant differences in severe bleeding and clinically relevant hemorrhaging in subjects receiving FXIa inhibitors compared to Enoxaparin (RR = 0.457; 95% CI: 0.256-0.816; I2 = 0%). CONCLUSIONS Clinical trials to date have indicated that factor XIa is a potential anticoagulation target, and factor XIa inhibitors may play an important role in the development of anticoagulants.
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Affiliation(s)
- Yunqing Xia
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
- Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Liang Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
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7
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Sagris M, Theofilis P, Papanikolaou A, Antonopoulos AS, Tsioufis C, Tousoulis D. Direct Oral Anticoagulants use in Patients with Stable Coronary Artery Disease, Acute Coronary Syndrome or Undergoing Percutaneous Coronary Intervention. Curr Pharm Des 2023; 29:2787-2794. [PMID: 38038010 DOI: 10.2174/0113816128259508231118141831] [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: 05/22/2023] [Revised: 10/27/2023] [Accepted: 11/06/2023] [Indexed: 12/02/2023]
Abstract
The investigation for the optimal anticoagulation strategy for patients with stable coronary artery disease, acute coronary syndromes, and undergoing percutaneous coronary intervention constitutes a great challenge for physicians and is a field of extensive research. Although aspirin is commonly recommended as a protective measure for all patients with coronary artery disease and dual antiplatelet therapy for those undergoing procedures, such as percutaneous coronary intervention or coronary artery bypass graft surgery, the risk of recurrent cardiovascular events remains significant. In this context, the shortcomings associated with the use of vitamin K antagonists have led to the assessment of direct oral anticoagulants as promising alternatives. This review will explore and provide a comprehensive analysis of the existing data regarding the use of direct oral anticoagulants in patients with stable coronary artery disease or acute coronary syndrome, as well as their effectiveness in those undergoing percutaneous coronary intervention or coronary artery bypass graft surgery.
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Affiliation(s)
- Marios Sagris
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Panagiotis Theofilis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Angelos Papanikolaou
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Alexios S Antonopoulos
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Constantinos Tsioufis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, "Hippokration" General Hospital, University of Athens Medical School, Athens, Greece
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8
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Anticoagulation Management during Extracorporeal Membrane Oxygenation-A Mini-Review. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121783. [PMID: 36556985 PMCID: PMC9782867 DOI: 10.3390/medicina58121783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has been established as a life-saving technique for patients with the most severe forms of respiratory or cardiac failure. It can, however, be associated with severe complications. Anticoagulation therapy is required to prevent ECMO circuit thrombosis. It is, however, associated with an increased risk of hemocoagulation disorders. Thus, safe anticoagulation is a cornerstone of ECMO therapy. The most frequently used anticoagulant is unfractionated heparin, which can, however, cause significant adverse effects. Novel drugs (e.g., argatroban and bivalirudin) may be superior to heparin in the better predictability of their effects, functioning independently of antithrombin, inhibiting thrombin bound to fibrin, and eliminating heparin-induced thrombocytopenia. It is also necessary to keep in mind that hemocoagulation tests are not specific, and their results, used for setting up the dosage, can be biased by many factors. The knowledge of the advantages and disadvantages of particular drugs, limitations of particular tests, and individualization are cornerstones of prevention against critical events, such as life-threatening bleeding or acute oxygenator failure followed by life-threatening hypoxemia and hemodynamic deterioration. This paper describes the effects of anticoagulant drugs used in ECMO and their monitoring, highlighting specific conditions and factors that might influence coagulation and anticoagulation measurements.
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9
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Bifunctional fusion protein targeting both FXIIa and FXIa displays potent anticoagulation effects. Life Sci 2022; 309:121021. [DOI: 10.1016/j.lfs.2022.121021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 11/21/2022]
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10
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Anticoagulation for Percutaneous Ventricular Assist Device-Supported Cardiogenic Shock: JACC Review Topic of the Week. J Am Coll Cardiol 2022; 79:1949-1962. [PMID: 35550692 DOI: 10.1016/j.jacc.2022.02.052] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 02/08/2022] [Accepted: 02/22/2022] [Indexed: 12/31/2022]
Abstract
Interest in the use of mechanical circulatory support for patients presenting with cardiogenic shock is growing rapidly. The Impella (Abiomed Inc), a microaxial, continuous-flow, short-term, ventricular assist device (VAD), requires meticulous postimplantation management. Because systemic anticoagulation is needed to prevent pump thrombosis, patients are exposed to increased bleeding risk, further aggravated by sepsis, thrombocytopenia, and high shear stress-induced acquired von Willebrand syndrome. The precarious balance between bleeding and thrombosis in percutaneous VAD-supported cardiogenic shock patients is often the main reason that patient outcomes are jeopardized, and there is a lack of data addressing optimal anticoagulation management strategies during percutaneous VAD support. Here, we present a parallel anti-Factor Xa/activated partial thromboplastin time-guided anticoagulation algorithm and discuss pitfalls of heparin monitoring in critically ill patients. This review will guide physicians toward a more standardized (anti)coagulation approach to tackle device-related morbidity and mortality in this critically ill patient group.
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11
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Nopp S, Kraemmer D, Ay C. Factor XI Inhibitors for Prevention and Treatment of Venous Thromboembolism: A Review on the Rationale and Update on Current Evidence. Front Cardiovasc Med 2022; 9:903029. [PMID: 35647061 PMCID: PMC9133368 DOI: 10.3389/fcvm.2022.903029] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022] Open
Abstract
Although anticoagulation therapy has evolved from non-specific drugs (i.e., heparins and vitamin K antagonists) to agents that directly target specific coagulation factors (i.e., direct oral anticoagulants, argatroban, fondaparinux), thrombosis remains a leading cause of death worldwide. Direct oral anticoagulants (i.e., factor IIa- and factor Xa-inhibitors) now dominate clinical practice because of their favorable pharmacological profile and ease of use, particularly in venous thromboembolism (VTE) treatment and stroke prevention in atrial fibrillation. However, despite having a better safety profile than vitamin K antagonists, their bleeding risk is not insignificant. This is true for all currently available anticoagulants, and a high bleeding risk is considered a contraindication to anticoagulation. As a result, ongoing research focuses on developing future anticoagulants with an improved safety profile. Several promising approaches to reduce the bleeding risk involve targeting the intrinsic (or contact activation) pathway of coagulation, with the ultimate goal of preventing thrombosis without impairing hemostasis. Based on epidemiological data on hereditary factor deficiencies and preclinical studies factor XI (FXI) emerged as the most promising candidate target. In this review, we highlight unmet clinical needs of anticoagulation therapy, outlay the rationale and evidence for inhibiting FXI, discuss FXI inhibitors in current clinical trials, conduct an exploratory meta-analysis on their efficacy and safety, and provide an outlook on the potential clinical application of these novel anticoagulants.
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Affiliation(s)
| | | | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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12
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Choxi R, Kapoor K, Mackman N, Jovin IS. Direct Oral Anticoagulants and Coronary Artery Disease. Arterioscler Thromb Vasc Biol 2022; 42:553-564. [PMID: 35296151 DOI: 10.1161/atvbaha.121.317171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Coronary artery disease is a leading cause of morbidity and mortality worldwide. Acute coronary syndrome as a first presentation is common and patients with established disease have a high rate of recurrent ischemic events, despite antiplatelet therapy. Over the past several years, direct oral anticoagulants have become available and have been studied in patients with coronary artery disease. These medications directly inhibit either thrombin or factor Xa which contribute to atherothrombosis. This review will summarize the clinical data regarding the use of direct oral anticoagulants in different patient populations with coronary disease and the balance between protection against ischemia and bleeding. Additionally, the review will summarize the available data on the use of direct oral anticoagulants periprocedurally in patients undergoing percutaneous coronary intervention. The future direction of coronary artery disease and the role of direct oral anticoagulants will rely on further studies determining the optimal combination of antiplatelet and oral anticoagulant regimens that derive ischemic benefit without increased rates of bleeding. Additional upstream blockade of the coagulation cascade with factor XIIa and factor XIa inhibitors may also improve treatment in the future.
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Affiliation(s)
- Ravi Choxi
- Department of Medicine, Virginia Commonwealth University, Richmond (R.C., K.K., I.S.J.)
| | - Kunal Kapoor
- Department of Medicine, Virginia Commonwealth University, Richmond (R.C., K.K., I.S.J.)
| | - Nigel Mackman
- UNC Blood Research Center, Department of Medicine, University of North Carolina at Chapel Hill (N.M.)
| | - Ion S Jovin
- Department of Medicine, Virginia Commonwealth University, Richmond (R.C., K.K., I.S.J.).,McGuire Veterans Administration Medical Center Richmond, VA (I.S.J.)
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13
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Navarrete S, Solar C, Tapia R, Pereira J, Fuentes E, Palomo I. Pathophysiology of deep vein thrombosis. Clin Exp Med 2022:10.1007/s10238-022-00829-w. [PMID: 35471714 DOI: 10.1007/s10238-022-00829-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 03/31/2022] [Indexed: 12/29/2022]
Abstract
Deep venous thrombosis is a frequent, multifactorial disease and a leading cause of morbidity and mortality. Most of the time deep venous thrombosis is triggered by the interaction between acquired risk factors, such as hip fracture, pregnancy, and immobility, and hereditary risk factors such as thrombophilias. The mechanisms underlying deep venous thrombosis are not fully elucidated; however, in recent years, important advances have shed light on the role of venous flow, endothelium, platelets, leukocytes, and the interaction between inflammation and hemostasis. It has been described that the alteration of venous blood flow produces endothelial activation, favoring the adhesion of platelets and leukocytes, which, through tissue factor expression and neutrophil extracellular traps formation, contribute to the activation of coagulation, trapping more cells, such as red blood cells. Thus, the concerted interaction of these phenomena allows the formation and growth of the thrombus. In this work, the main mechanisms involved in the pathophysiology of deep vein thrombosis will be described.
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Affiliation(s)
- Simón Navarrete
- Thrombosis Research Center, Medical Technology School, Department of Clinical Biochemistry and Immunohaematology, Faculty of Health Sciences, Universidad de Talca, Av. Lircay s/n, 3460000, Talca, Chile
| | - Carla Solar
- Thrombosis Research Center, Medical Technology School, Department of Clinical Biochemistry and Immunohaematology, Faculty of Health Sciences, Universidad de Talca, Av. Lircay s/n, 3460000, Talca, Chile
| | | | - Jaime Pereira
- Department of Hematology-Oncology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Fuentes
- Thrombosis Research Center, Medical Technology School, Department of Clinical Biochemistry and Immunohaematology, Faculty of Health Sciences, Universidad de Talca, Av. Lircay s/n, 3460000, Talca, Chile
| | - Iván Palomo
- Thrombosis Research Center, Medical Technology School, Department of Clinical Biochemistry and Immunohaematology, Faculty of Health Sciences, Universidad de Talca, Av. Lircay s/n, 3460000, Talca, Chile.
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14
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Meng Y, Li Y, Ye YJ, Ma Q, Zhang JB, Qin H, Deng YY, Tian HY. Associations between coagulation factor XII, coagulation factor XI, and stability of venous thromboembolism: A case-control study. World J Clin Cases 2022. [DOI: 10.12998/wjcc.v10.i9.2698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is a fatal clinical syndrome that is generally caused by an embolus from unstable deep venous thrombosis (DVT). However, clinical and biochemical factors that are related to the stability of DVT are not fully understood.
AIM To evaluate the relationships between plasma antigen levels of factor XII (FXII:Ag) and factor XI (FXI:Ag) with the stability of DVT.
METHODS Patients with DVT and no PE, DVT and PE, and controls with no DVT or PE that matched for age, gender, and comorbidities were included in this study. FXII:Ag and FXI:Ag in peripheral venous blood were measured using enzyme-linked immunosorbent assays.
RESULTS Using the 95th percentile of FXI:Ag in patients with DVT and PE as the cut-off, a higher FXI:Ag was associated with a higher risk of unstable DVT (odds ratio: 3.15, 95% confidence interval: 1.18-8.43, P = 0.019). Stratified analyses showed consistent results in patients ≤ 60 years (P = 0.020), but not in those > 60 years (P = 0.346).
CONCLUSION Higher plasma FXI:Ag might be a marker for unstable DVT, which might be associated with PE in these patients.
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Affiliation(s)
- Yan Meng
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
| | - You Li
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
| | - Yan-Jun Ye
- Department of Breast and Thyroid Surgery, Baoji People’s Hospital, Baoji 721000, Shannxi Province, China
| | - Qiang Ma
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
| | - Jun-Bo Zhang
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
| | - Hao Qin
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
| | - Yang-Yang Deng
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
| | - Hong-Yan Tian
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
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15
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Meng Y, Li Y, Ye YJ, Ma Q, Zhang JB, Qin H, Deng YY, Tian HY. Associations between coagulation factor XII, coagulation factor XI, and stability of venous thromboembolism: A case-control study. World J Clin Cases 2022; 10:2700-2709. [PMID: 35434115 PMCID: PMC8968801 DOI: 10.12998/wjcc.v10.i9.2700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/29/2021] [Accepted: 02/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pulmonary embolism (PE) is a fatal clinical syndrome that is generally caused by an embolus from unstable deep venous thrombosis (DVT). However, clinical and biochemical factors that are related to the stability of DVT are not fully understood.
AIM To evaluate the relationships between plasma antigen levels of factor XII (FXII:Ag) and factor XI (FXI:Ag) with the stability of DVT.
METHODS Patients with DVT and no PE, DVT and PE, and controls with no DVT or PE that matched for age, gender, and comorbidities were included in this study. FXII:Ag and FXI:Ag in peripheral venous blood were measured using enzyme-linked immunosorbent assays.
RESULTS Using the 95th percentile of FXI:Ag in patients with DVT and PE as the cut-off, a higher FXI:Ag was associated with a higher risk of unstable DVT (odds ratio: 3.15, 95% confidence interval: 1.18-8.43, P = 0.019). Stratified analyses showed consistent results in patients ≤ 60 years (P = 0.020), but not in those > 60 years (P = 0.346).
CONCLUSION Higher plasma FXI:Ag might be a marker for unstable DVT, which might be associated with PE in these patients.
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Affiliation(s)
- Yan Meng
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
| | - You Li
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
| | - Yan-Jun Ye
- Department of Breast and Thyroid Surgery, Baoji People’s Hospital, Baoji 721000, Shannxi Province, China
| | - Qiang Ma
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
| | - Jun-Bo Zhang
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
| | - Hao Qin
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
| | - Yang-Yang Deng
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
| | - Hong-Yan Tian
- Department of Peripheral Vascular Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shannxi Province, China
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Yao N, Jia Z, Tian Y, Hou S, Yang X, Han J, Duan Y, Liao C, Kong Y, Xie Z. Targeting the S2 Subsite Enables the Structure-Based Discovery of Novel Highly Selective Factor XIa Inhibitors. J Med Chem 2022; 65:4318-4334. [DOI: 10.1021/acs.jmedchem.1c02153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ningning Yao
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Zhiping Jia
- School of Life Science & Technology, China Pharmaceutical University, Nanjing 210009, P.R. China
| | - Yongbin Tian
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Shuzeng Hou
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Xiaoxiao Yang
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Jihong Han
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Yajun Duan
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Chenzhong Liao
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Yi Kong
- School of Life Science & Technology, China Pharmaceutical University, Nanjing 210009, P.R. China
| | - Zhouling Xie
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
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17
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Carle V, Wu Y, Mukherjee R, Kong XD, Rogg C, Laurent Q, Cecere E, Villequey C, Konakalla MS, Maric T, Lamers C, Díaz-Perlas C, Butler K, Goto J, Stegmayr B, Heinis C. Development of Selective FXIa Inhibitors Based on Cyclic Peptides and Their Application for Safe Anticoagulation. J Med Chem 2021; 64:6802-6813. [PMID: 33974422 DOI: 10.1021/acs.jmedchem.1c00056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Coagulation factor XI (FXI) has emerged as a promising target for the development of safer anticoagulation drugs that limit the risk of severe and life-threatening bleeding. Herein, we report the first cyclic peptide-based FXI inhibitor that selectively and potently inhibits activated FXI (FXIa) in human and animal blood. The cyclic peptide inhibitor (Ki = 2.8 ± 0.5 nM) achieved anticoagulation effects that are comparable to that of the gold standard heparin applied at a therapeutic dose (0.3-0.7 IU/mL in plasma) but with a substantially broader estimated therapeutic range. We extended the plasma half-life of the peptide via PEGylation and demonstrated effective FXIa inhibition over extended periods in vivo. We validated the anticoagulant effects of the PEGylated inhibitor in an ex vivo hemodialysis model with human blood. Our work shows that FXI can be selectively targeted with peptides and provides a promising candidate for the development of a safe anticoagulation therapy.
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Affiliation(s)
- Vanessa Carle
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Yuteng Wu
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Rakesh Mukherjee
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Xu-Dong Kong
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Chloé Rogg
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Quentin Laurent
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Enza Cecere
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Camille Villequey
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Madhuree S Konakalla
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Tamara Maric
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Christina Lamers
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Cristina Díaz-Perlas
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Kaycie Butler
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Junko Goto
- Department of Public Health and Clinical Medicine, University of Umeå, SE-901 87 Umeå, Sweden
| | - Bernd Stegmayr
- Department of Public Health and Clinical Medicine, University of Umeå, SE-901 87 Umeå, Sweden
| | - Christian Heinis
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
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18
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Eltringham-Smith LJ, Bhakta V, Sheffield WP. Selection and in vitro and in vivo characterization of a Kunitz protease inhibitor domain of protease nexin 2 variant that inhibits factor XIa without inhibiting plasmin. J Biotechnol 2021; 330:61-69. [PMID: 33689867 DOI: 10.1016/j.jbiotec.2021.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 02/25/2021] [Accepted: 02/27/2021] [Indexed: 02/06/2023]
Abstract
The 57-amino acid Kunitz Protease Inhibitor (KPI) domain of Protease Nexin 2 inhibits Factor XIa (FXIa) and other proteases. We previously fused KPI to human serum albumin (KPIHSA). KPIHSA inhibits coagulation Factor XIa (FXIa) 6-fold more rapidly than plasmin. We screened a bacterial expression library of KPI variants randomized at M17, and selected M17D as having the highest anti-FXIa: antiplasmin activity ratio. Expressed as HSA fusion proteins in Pichia pastoris, KPIHSA and KPI(M17D)HSA inhibited FXIa indistinguishably (Ki 9 nM) but KPI(M17D)HSA lacked detectable antiplasmin activity. Purified variant and wild-type KPIHSA were expressed and injected into mice with ferric chloride-treated carotid arteries, with or without systemic administration of tissue plasminogen activator (Tenecteplase, TNKase). The time to arterial occlusion (TTO) or reperfusion (TTR) was assessed by Doppler ultrasound. TTR did not differ between mice treated with TNKase alone or with TNKase supplemented with 38 mg/kg KPI(M17D)HSA but was significantly prolonged to >60 min in all mice treated with TNKase and 38 mg/kg KPIHSA. TTO was significantly but equally prolonged by either 38 mg/kg KPIHSA or KPI(M17D)HSA versus vehicle controls. The antiplasmin activity of KPI is relevant in vivo but its elimination did not enhance counter-thrombosis by KPI.
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Affiliation(s)
| | - Varsha Bhakta
- Canadian Blood Services, Centre for Innovation, Hamilton, Ontario, Canada
| | - William P Sheffield
- Canadian Blood Services, Centre for Innovation, Hamilton, Ontario, Canada; Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.
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19
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Alqahtany FS, Algahtani FH, Alshebly MM, Albegamy TS, Alghamdi ES, Alnakhli MA, Madkhaly FM, Alharbi AA, Alqahtani NA. Factor XII deficiency in asymptomatic Saudi population: A retrospective cohort study. Saudi J Biol Sci 2021; 28:2004-2006. [PMID: 33732086 PMCID: PMC7938109 DOI: 10.1016/j.sjbs.2021.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/29/2020] [Accepted: 01/03/2021] [Indexed: 11/26/2022] Open
Abstract
Factor XII (FXII) deficiency is a rare genetic blood disorder. It can lead to a higher risk of developing deep vein thrombosis or acquired thrombotic disorders than the general population. This retrospective study evaluated patients who opted for surgery and were found to have abnormal clotting profiles and clotting factors on preoperative routine blood. Patients were included regardless of whether they were symptomatic or asymptomatic. The cohort comprised 115 patients with a mean FXII level of 128.04 ± 36.93%. Two (1.79%) patients, both of whom were women, had FXII levels <60%. The mean FXII level was 58 ± 1.41 (range, 57–59%) in this group. The present study shows the prevalence of FXII in the asymptomatic Saudi population. The results provide the normal range for FXII. The findings of our study provide the basis for diagnosing F XII deficiency in the asymptomatic Saudi population.
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Affiliation(s)
- Fatmah S Alqahtany
- Department of Pathology, Hematopathology Unit, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Farjah H Algahtani
- Department of Medicine, Division of Oncology/Hematology, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Mashael M Alshebly
- Department of Obstetrics and Gynecology, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Thamer S Albegamy
- Department of Pathology, Hematopathology Unit, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Essam S Alghamdi
- Heamatopathology & Blood Transfusion Consultant, Ministry of Health, Riyadh, Saudi Arabia
| | - Mohammed A Alnakhli
- Department of Pathology, Hematopathology Unit, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Fatimah M Madkhaly
- Department of Pathology, Hematopathology Unit, College of Medicine, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah A Alharbi
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Nawaf A Alqahtani
- College of Medicine, King Saud Bin Abdul Aziz University for Health Sciences, Riyadh, Saudi Arabia
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20
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Ozbasli E, Takmaz O, Karabuk E, Gungor M. Comparison of factor XII levels in gestational diabetes, fetal macrosomia, and healthy pregnancies. BMC Pregnancy Childbirth 2020; 20:752. [PMID: 33267793 PMCID: PMC7709445 DOI: 10.1186/s12884-020-03455-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/24/2020] [Indexed: 12/18/2022] Open
Abstract
Background If not detected and treated, gestational diabetes mellitus (GDM) can cause serious pregnancy complications such as macrosomia, preeclampsia, and fetal/neonatal mortality. Many studies have examined underlying contributing factors for GDM, including hypercoagulation. Factor XII (FXII) is a coagulation factor that increases throughout normal pregnancies, and we evaluated the relationship of GDM with FXII, FXIIa (activated FXII), and other coagulation parameter levels. GDM and macrosomia are closely related, but it is not known whether FXII could be an independent causal factor for macrosomia. Methods In this prospective study, blood samples were taken from 69 pregnant women at the time of term delivery to determine levels of FXII, FXIIa, and other coagulation parameters. Based on the results, pregnancies fell into GDM, non-diabetic with macrosomia (M), or healthy (C [control]). Results FXII concentration levels were significantly higher in GDM patients compared with the M and C groups. There were no significant differences when comparing FXIIa, activated partial thromboplastin time, prothrombin time (PT), and international normalized ratio. The GDM group saw a significant negative correlation between FXII concentrations and maternal pregestational body mass index (BMI) and BMI before delivery. In the M group, a positive correlation was observed between FXII concentrations and newborn weight and newborn weight percentile. Conclusions An increase in FXII levels was observed in patients with gestational diabetes. Associations between coagulation parameters and GDM should be further analyzed to define the mechanisms of GDM and possible treatment modalities. Trial registration Our study has been registered at clinicaltrials.gov (NCT03583216). Registered on July 11, 2018,
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Affiliation(s)
- Esra Ozbasli
- Department of Obstetrics and Gynecology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Darüşşafaka, Büyükdere Cad. No: 40, Sarıyer, 34457, Istanbul, Turkey.
| | - Ozguc Takmaz
- Department of Obstetrics and Gynecology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Darüşşafaka, Büyükdere Cad. No: 40, Sarıyer, 34457, Istanbul, Turkey
| | - Emine Karabuk
- Department of Obstetrics and Gynecology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Darüşşafaka, Büyükdere Cad. No: 40, Sarıyer, 34457, Istanbul, Turkey
| | - Mete Gungor
- Department of Obstetrics and Gynecology, Acibadem Mehmet Ali Aydinlar University School of Medicine, Darüşşafaka, Büyükdere Cad. No: 40, Sarıyer, 34457, Istanbul, Turkey
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21
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Sniecinski RM, Levy JH. The Contact Activation System: Problems and Paradoxes for Cardiac Anesthesiologists. Anesth Analg 2020; 131:152-154. [PMID: 32541589 DOI: 10.1213/ane.0000000000004745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Roman M Sniecinski
- From the Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina
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22
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Novel antithrombotic strategies for treatment of venous thromboembolism. Blood 2020; 135:351-359. [PMID: 31917385 DOI: 10.1182/blood.2019000919] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 12/16/2019] [Indexed: 12/25/2022] Open
Abstract
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cause of vascular death after heart attack and stroke. Anticoagulation therapy is the cornerstone of VTE treatment. Despite such therapy, up to 50% of patients with DVT develop postthrombotic syndrome, and up to 4% of patients with PE develop chronic thromboembolic pulmonary hypertension. Therefore, better therapies are needed. Although direct oral anticoagulants are more convenient and safer than warfarin for VTE treatment, bleeding remains the major side effect, particularly in cancer patients. Factor XII and factor XI have emerged as targets for new anticoagulants that may be safer. To reduce the complications of VTE, attenuation of thrombin activatable fibrinolysis inhibitor activity is under investigation in PE patients to enhance endogenous fibrinolysis, whereas blockade of leukocyte interaction with the vessel wall is being studied to reduce the inflammation that contributes to postthrombotic syndrome in DVT patients. Focusing on these novel antithrombotic strategies, this article explains why safer anticoagulants are needed, provides the rationale for factor XII and XI as targets for such agents, reviews the data on the factor XII- and factor XI-directed anticoagulants under development, describes novel therapies to enhance fibrinolysis and decrease inflammation in PE and DVT patients, respectively, and offers insights into the opportunities for these novel VTE therapies.
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23
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Zhao S, Hong X, Cao J, Zhang J, Ma P. Current Evidence for Pharmacologic Reversal Using Direct Oral Anticoagulants: What's New? Am J Cardiovasc Drugs 2020; 20:117-123. [PMID: 31440983 DOI: 10.1007/s40256-019-00366-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Direct oral anticoagulants are increasingly used in clinical practice and have addressed many of the issues related to vitamin K antagonists. However, the lack of reversal in life-threatening situations raises concerns regarding patient safety. Thus, current research is aimed at developing reversal agents that can safely neutralize the effects of anticoagulants. We present the design and mechanisms of action of and the animal models, clinical trials, and current evidence supporting the use of these emerging reversal agents. Idarucizumab is approved in many countries, and andexanet alfa has been approved by the US FDA, whereas others are in clinical trials. In view of the results of clinical studies to date, the problems of safety, price and accessibility remain. Therefore, these antidotes are a significant step towards improving the field of urgent and emergency reversal. From a practical perspective, post-market surveillance will be crucial to monitor the safety and effectiveness of these agents.
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Affiliation(s)
- Shujuan Zhao
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Xuejiao Hong
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Jingjing Cao
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Jing Zhang
- Department of Cardiovascular Medicine, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China
| | - Peizhi Ma
- Department of Pharmacy, People's Hospital of Henan Province, Zhengzhou, 450003, Henan, China.
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24
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Vandenbriele C, Vanassche T, Price S. Why we need safer anticoagulant strategies for patients on short-term percutaneous mechanical circulatory support. Intensive Care Med 2020; 46:771-774. [PMID: 31974917 DOI: 10.1007/s00134-019-05897-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/06/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Christophe Vandenbriele
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Adult Intensive Care, Royal Brompton NHS Foundation Trust, Imperial College London, Sydney Street, London, SW36NP, UK.
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Susanna Price
- Department of Adult Intensive Care, Royal Brompton NHS Foundation Trust, Imperial College London, Sydney Street, London, SW36NP, UK
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25
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From multi-target anticoagulants to DOACs, and intrinsic coagulation factor inhibitors. Blood Rev 2020; 39:100615. [DOI: 10.1016/j.blre.2019.100615] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 08/08/2019] [Accepted: 08/27/2019] [Indexed: 01/10/2023]
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26
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Schaefer M, Buchmueller A, Dittmer F, Straßburger J, Wilmen A. Allosteric Inhibition as a New Mode of Action for BAY 1213790, a Neutralizing Antibody Targeting the Activated Form of Coagulation Factor XI. J Mol Biol 2019; 431:4817-4833. [PMID: 31655039 DOI: 10.1016/j.jmb.2019.09.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/26/2019] [Accepted: 09/10/2019] [Indexed: 12/20/2022]
Abstract
Factor XI (FXI), the zymogen of activated FXI (FXIa), is an attractive target for novel anticoagulants because FXI inhibition offers the potential to reduce thrombosis risk while minimizing the risk of bleeding. BAY 1213790, a novel anti-FXIa antibody, was generated using phage display technology. Crystal structure analysis of the FXIa-BAY 1213790 complex demonstrated that the tyrosine-rich complementarity-determining region 3 loop of the heavy chain of BAY 1213790 penetrated deepest into the FXIa binding epitope, forming a network of favorable interactions including a direct hydrogen bond from Tyr102 to the Gln451 sidechain (2.9 Å). The newly discovered binding epitope caused a structural rearrangement of the FXIa active site, revealing a novel allosteric mechanism of FXIa inhibition by BAY 1213790. BAY 1213790 specifically inhibited FXIa with a binding affinity of 2.4 nM, and in human plasma, prolonged activated partial thromboplastin time and inhibited thrombin generation in a concentration-dependent manner.
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Affiliation(s)
- Martina Schaefer
- Bayer AG, Research and Development, Pharmaceuticals, Structural Biology, 13342 Berlin, Germany.
| | - Anja Buchmueller
- Bayer AG, Research and Development, Pharmaceuticals, Cardiovascular, 42096 Wuppertal, Germany
| | - Frank Dittmer
- Bayer AG, Product Supply, Pharmaceuticals, Quality Control, 51368 Leverkusen, Germany
| | - Julia Straßburger
- Bayer AG, Research and Development, Pharmaceuticals, Cardiovascular, 42096 Wuppertal, Germany
| | - Andreas Wilmen
- Bayer AG, Research and Development, Pharmaceuticals, Protein Engineering and Assays, 50829 Cologne, Germany
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27
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Song DY, Gu JY, Yoo HJ, Kim YI, Nam-Goong IS, Kim ES, Kim HK. Activation of Factor XII and Kallikrein-Kinin System Combined with Neutrophil Extracellular Trap Formation in Diabetic Retinopathy. Exp Clin Endocrinol Diabetes 2019; 129:560-565. [PMID: 31426112 DOI: 10.1055/a-0981-6023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND In diabetic retinopathy (DR), neutrophil extracellular traps (NET) and kallikrein-kinin system are considered as contributing factors. However, the detail activation mechanisms has not been fully understood. Since the NET could provide negative-charged surface for factor XII activation and the activated factor XII (XIIa) can initiate kallikrein-kinin system, this study investigated whether patients with DR show activation of NET, factor XII and kallikrein-kinin system. METHODS The markers related to NET (DNA-histone complex) and kallikrein-kinin system (high-molecular-weight kininogen, prekallikrein, bradykinin) and factor XIIa were measured in 253 patients with diabetes. To access ex vivo effect of glucose, DNA-histone complex and factor XIIa were measured in whole blood stimulated by glucose. RESULTS The circulating level of DNA-histone complex and factor XIIa were significantly higher in patients with DR than those without DR. In logistic regression analysis, DNA-histone complex, factor XIIa, and high-molecular-weight kininogen were the risk factors of DR. In recursive partitioning analysis, among patients with diabetes duration less than 10 years, patients with high level of DNA-histone complex (>426 AU) showed high risk of DR. In ex vivo experiment, glucose significantly elevated both DNA-histone complex and factor XIIa. CONCLUSION Our findings suggest that activation of factor XII and kallikrein-kinin system combined with NET formation actively occur in patients with DR and circulating levels of DNA-histone complex, factor XIIa and HMWK can be potential biomarkers to estimate the risk of DR. Strategies against factor XII activation may be beneficial to inhibit DR.
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Affiliation(s)
- Da Young Song
- Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Ja-Yoon Gu
- Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Ju Yoo
- Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Young Il Kim
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Il Sung Nam-Goong
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Eun Sook Kim
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hyun Kyung Kim
- Department of Laboratory Medicine and Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
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28
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Venous stasis-induced fibrinolysis prevents thrombosis in mice: role of α2-antiplasmin. Blood 2019; 134:970-978. [PMID: 31395599 DOI: 10.1182/blood.2019000049] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 08/01/2019] [Indexed: 02/07/2023] Open
Abstract
Stasis of venous blood triggers deep vein thrombosis by activating coagulation, yet its effects on the fibrinolytic system are not fully understood. We examined the relationship between stasis, fibrinolysis, and the development of experimental venous thrombosis. Effects of stasis-induced deep vein thrombosis and fibrinolysis on thrombosis were examined by inferior vena cava ligation in congenic mice with and without α2-antiplasmin (α2AP), the primary inhibitor of plasmin. Venous thrombus weights were measured and thrombus composition was determined by Martius scarlet blue and immunofluorescence staining. Venous thrombi from α2AP+/+ mice contained plasminogen activators, plasminogen activator inhibitor-1, plasminogen, and α2AP, which changed with thrombus age. Normal, α2AP+/+ mice developed large, occlusive thrombi within 5 hours after ligation; thrombi were even larger in plasminogen-deficient mice (P < .001). No significant thrombus formation was seen in α2AP-/- mice (P < .0001) or in α2AP+/+ mice treated with an α2AP-inactivating antibody (P < .001). Venous stasis activated fibrinolysis, measured by D-dimer levels, in α2AP-/- mice vs α2AP+/+ mice (P < .05). Inhibition of fibrinolysis by the indirect plasmin inhibitor ε-aminocaproic acid or by α2AP restored thrombosis in α2AP-/- mice. In addition to its effects on acute thrombosis, thrombus formation was also markedly suppressed in α2AP-/- mice vs α2AP+/+ mice (P < .0001) 1, 7, and 14 days after ligation. We conclude that experimental venous stasis activates the fibrinolytic system to block the development of venous thrombosis. Suppression of fibrinolysis by α2AP appears essential for stasis-induced thrombus development, which suggests that targeting α2AP may prove useful for preventing venous thrombosis.
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29
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Abstract
PURPOSE OF REVIEW Since the selection of the first thrombin-binding aptamer in 1992, the use of nucleic acid aptamers to target specific coagulation factors has emerged as a valuable approach for generating novel anticoagulant and procoagulant therapeutics. Herein, we highlight the most recent discoveries involving application of aptamers for those purposes. RECENT FINDINGS Learning from the successes and pitfalls of the FIXa-targeting aptamer pegnivacogin in preclinical and clinical studies, the latest efforts to develop antidote-controllable anticoagulation strategies for cardiopulmonary bypass that avoid unfractionated heparin involve potentiation of the exosite-binding factor X (FX)a aptamer 11F7t by combination with either a small molecule FXa catalytic site inhibitor or a thrombin aptamer. Recent work has also focused on identifying aptamer inhibitors of contact pathway factors such as FXIa and kallikrein, which may prove to be well tolerated and effective antithrombotic agents in certain clinical settings. Finally, new approaches to develop procoagulant aptamers to control bleeding associated with hemophilia and other coagulopathies involve targeting activated protein C and tissue plasminogen activator. SUMMARY Overall, these recent findings exemplify the versatility of aptamers to modulate a variety of procoagulant and anticoagulant factors, along with their capacity to be used complementarily with other aptamers or drugs for wide-ranging applications.
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Abstract
Thrombosis remains a major cause of morbidity and mortality. Consequently, advances in antithrombotic therapy are needed to reduce the disease burden. This article focuses on 2 such advances. First, the prevention of atherothrombosis in patients with coronary or peripheral artery disease, which has been enhanced by the finding that the combination of low-dose rivaroxaban plus aspirin is superior to aspirin alone for prevention of recurrent ischemic events. However, this benefit comes at the cost of increased bleeding albeit not fatal bleeding. To overcome this problem, the second advance is the identification of factor XI as a target for new anticoagulants that are potentially safer than those currently available.
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Affiliation(s)
- Jeffrey I. Weitz
- From the Thrombosis and Atherosclerosis Research Institute and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Noel C. Chan
- From the Thrombosis and Atherosclerosis Research Institute and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Xu P, Huang M. Small Peptides as Modulators of Serine Proteases. Curr Med Chem 2018; 27:3686-3705. [PMID: 30332941 DOI: 10.2174/0929867325666181016163630] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/26/2018] [Accepted: 10/09/2018] [Indexed: 02/08/2023]
Abstract
Serine proteases play critical roles in many physiological and pathological processes, and are proven diagnostic and therapeutic targets in a number of clinical indications. Suppression of the aberrant proteolytic activities of these proteases has been clinically used for the treatments of relevant diseases. Polypeptides with 10-20 residues are of great interests as medicinal modulators of serine proteases, because these peptides demonstrate the characteristics of both small molecule drugs and macromolecular drugs. In this review, we summarized the recent development of peptide-based inhibitors against serine proteases with potent inhibitory and high specificity comparable to monoclonal antibodies. In addition, we also discussed the strategies of enhancing plasma half-life and bioavailability of peptides in vivo, which is the main hurdle that limits the clinical translation of peptide-based drugs. This review advocates new avenue for the development of effective serine protease inhibitors and highlights the prospect of the medicinal use of these inhibitors.
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Affiliation(s)
- Peng Xu
- College of Biological Science and Engineering, Fuzhou University, Fuzhou, Fujian 350116, China
| | - Mingdong Huang
- College of Chemistry, Fuzhou University, Fuzhou, Fujian 350116, China
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Artificial Lungs for Lung Failure. J Am Coll Cardiol 2018; 72:1640-1652. [DOI: 10.1016/j.jacc.2018.07.049] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/13/2018] [Accepted: 07/03/2018] [Indexed: 12/20/2022]
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Boon G, Van Dam LF, Klok FA, Huisman MV. Management and treatment of deep vein thrombosis in special populations. Expert Rev Hematol 2018; 11:685-695. [PMID: 30016119 DOI: 10.1080/17474086.2018.1502082] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most frequent cardiovascular disease besides myocardial infarction and stroke. Because DVT may cause life-threatening conditions, treatment should be started as soon as possible. This comprises certain challenges in special populations. Areas covered: In cancer-associated VTE, current treatment is different from non-cancer VTE due to disease-related interventions and higher bleeding risks. In the treatment of patients with extensive DVT, the role of catheter-directed thrombolysis has been investigated in two randomized trials, but results do not yield a recommendation for standard thrombolysis. The diagnosis of suspected recurrent DVT is especially challenging in case of ipsilateral DVT. Treatment strategies in recurrent DVT are dependent on the case and on particular risk factors. Also discussed is the therapy for DVT in pregnant women, which is more complex as a result of anticoagulants crossing the placenta. Expert commentary: DVT treatment in special populations poses special challenges due to high thrombotic and bleeding risk. This will be discussed in more detail in this review.
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Affiliation(s)
- Gudula Boon
- a Department of Thrombosis and Hemostasis , Leiden University Medical Center , Leiden , The Netherlands
| | - L F Van Dam
- a Department of Thrombosis and Hemostasis , Leiden University Medical Center , Leiden , The Netherlands
| | - F A Klok
- a Department of Thrombosis and Hemostasis , Leiden University Medical Center , Leiden , The Netherlands
| | - M V Huisman
- a Department of Thrombosis and Hemostasis , Leiden University Medical Center , Leiden , The Netherlands
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Abstract
Pulmonary embolism (PE) is caused by emboli, which have originated from venous thrombi, travelling to and occluding the arteries of the lung. PE is the most dangerous form of venous thromboembolism, and undiagnosed or untreated PE can be fatal. Acute PE is associated with right ventricular dysfunction, which can lead to arrhythmia, haemodynamic collapse and shock. Furthermore, individuals who survive PE can develop post-PE syndrome, which is characterized by chronic thrombotic remains in the pulmonary arteries, persistent right ventricular dysfunction, decreased quality of life and/or chronic functional limitations. Several important improvements have been made in the diagnostic and therapeutic management of acute PE in recent years, such as the introduction of a simplified diagnostic algorithm for suspected PE as well as phase III trials demonstrating the value of direct oral anticoagulants in acute and extended treatment of venous thromboembolism. Future research should aim to address novel treatment options (for example, fibrinolysis enhancers) and improved methods for predicting long-term complications and defining optimal anticoagulant therapy parameters in individual patients, and to gain a greater understanding of post-PE syndrome.
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Plow EF, Wang Y, Simon DI. The search for new antithrombotic mechanisms and therapies that may spare hemostasis. Blood 2018; 131:1899-1902. [PMID: 29467183 PMCID: PMC5921961 DOI: 10.1182/blood-2017-10-784074] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 02/13/2018] [Indexed: 12/20/2022] Open
Abstract
Current antithrombotic drugs, including widely used antiplatelet agents and anticoagulants, are associated with significant bleeding risk. Emerging experimental evidence suggests that the molecular and cellular mechanisms of hemostasis and thrombosis can be separated, thereby increasing the possibility of new antithrombotic therapeutic targets with reduced bleeding risk. We review new coagulation and platelet targets and highlight the interaction between integrin αMβ2 (Mac-1, CD11b/CD18) on leukocytes and GPIbα on platelets that seems to distinguish thrombosis from hemostasis.
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Affiliation(s)
| | - Yunmei Wang
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Daniel I Simon
- Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Case Cardiovascular Research Institute, Case Western Reserve University School of Medicine, Cleveland, OH
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Sheffield WP, Eltringham-Smith LJ, Bhakta V. A factor XIa-activatable hirudin-albumin fusion protein reduces thrombosis in mice without promoting blood loss. BMC Biotechnol 2018; 18:21. [PMID: 29621998 PMCID: PMC5887181 DOI: 10.1186/s12896-018-0431-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 03/27/2018] [Indexed: 01/13/2023] Open
Abstract
Background Hirudin is a potent thrombin inhibitor but its antithrombotic properties are offset by bleeding side-effects. Because hirudin’s N-terminus must engage thrombin’s active site for effective inhibition, fusing a cleavable peptide at this site may improve hirudin’s risk/benefit ratio as a therapeutic agent. Previously we engineered a plasmin cleavage site (C) between human serum albumin (HSA) and hirudin variant 3 (HV3) in fusion protein HSACHV3. Because coagulation factor XI (FXI) is more involved in thrombosis than hemostasis, we hypothesized that making HV3 activity FXIa-dependent would also improve HV3’s potential therapeutic profile. We combined albumin fusion for half-life extension of hirudin with positioning of an FXIa cleavage site N-terminal to HV3, and assessed in vitro and in vivo properties of this novel protein. Results FXIa cleavage site EPR was employed. Fusion protein EPR-HV3HSA but not HSAEPR-HV3 was activated by FXIa in vitro. FVIIa, FXa, FXIIa, or plasmin failed to activate EPR-HV3HSA. FXIa-cleavable EPR-HV3HSA reduced the time to occlusion of ferric chloride-treated murine arteries and reduced fibrin deposition in murine endotoxemia; noncleavable mycHV3HSA was without effect. EPR-HV3HSA elicited less blood loss than constitutively active HV3HSA in murine liver laceration or tail transection but extended bleeding time to the same extent. EPR-HV3HSA was partially activated in citrated human or murine plasma to a greater extent than HSACHV3. Conclusions Releasing the N-terminal block to HV3 activity using FXIa was an effective way to limit hirudin’s bleeding side-effects, but plasma instability of the exposed EPR blocking peptide rendered it less useful than previously described plasmin-activatable HSACHV3.
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Affiliation(s)
- William P Sheffield
- Department of Pathology and Molecular Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada. .,Centre for Innovation, Canadian Blood Services, Hamilton, ON, Canada.
| | - Louise J Eltringham-Smith
- Department of Pathology and Molecular Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Varsha Bhakta
- Centre for Innovation, Canadian Blood Services, Hamilton, ON, Canada
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Faes C, Sparkenbaugh EM, Pawlinski R. Hypercoagulable state in sickle cell disease. Clin Hemorheol Microcirc 2018; 68:301-318. [DOI: 10.3233/ch-189013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Camille Faes
- Interuniversity Laboratory of Human Movement Biology EA7424, Vascular biology and Red Blood Cell Team, University Claude Bernard Lyon1, Villeurbanne, France; Laboratory of Excellence “GR-Ex, ” Paris, France
| | - Erica M. Sparkenbaugh
- McAllister Heart Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rafal Pawlinski
- Department of Medicine, Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Abstract
Despite advances made in technology and neonatal intensive care, the rate of hemorrhagic and thrombotic complications remains unacceptably high in patients undergoing extracorporeal membrane oxygenation (ECMO) and these complications negatively impact morbidity and mortality. Management of anticoagulation in neonates who have a developing hemostatic system is vastly different from adults and poses unique challenges. Variation in practice among ECMO centers regarding anticoagulation monitoring and titration reflects the lack of high-quality evidence. Novel anticoagulants may offer alternative options, though their impact on outcomes is yet to be demonstrated. In this chapter, we review the hemostatic alterations that occur during ECMO with a focus on current approaches and limitations to anticoagulation titration in neonates on ECMO.
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Affiliation(s)
- Aditi Kamdar
- Division of Hematology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Natalie Rintoul
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Leslie Raffini
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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Weitz JI, Fredenburgh JC. 2017 Scientific Sessions Sol Sherry Distinguished Lecture in Thrombosis. Arterioscler Thromb Vasc Biol 2018; 38:304-310. [DOI: 10.1161/atvbaha.117.309664] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 12/05/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Jeffrey I. Weitz
- From the Department of Medicine (J.I.W., J.C.F.) and Department of Biochemistry and Biomedical Sciences (J.I.W.), McMaster University, Hamilton, Ontario, Canada; and Thrombosis and Atherosclerosis Research Institute (J.I.W., J.C.F.), Hamilton, Ontario, Canada
| | - James C. Fredenburgh
- From the Department of Medicine (J.I.W., J.C.F.) and Department of Biochemistry and Biomedical Sciences (J.I.W.), McMaster University, Hamilton, Ontario, Canada; and Thrombosis and Atherosclerosis Research Institute (J.I.W., J.C.F.), Hamilton, Ontario, Canada
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Sartori M, Cosmi B. Andexanet alfa to reverse the anticoagulant activity of factor Xa inhibitors: a review of design, development and potential place in therapy. J Thromb Thrombolysis 2018; 45:345-352. [DOI: 10.1007/s11239-018-1617-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Dimitropoulos G, Rahim SMZ, Moss AS, Lip GYH. New anticoagulants for venous thromboembolism and atrial fibrillation: what the future holds. Expert Opin Investig Drugs 2017; 27:71-86. [DOI: 10.1080/13543784.2018.1416090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Gerasimos Dimitropoulos
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Cardiology Department, City Hospital, Birmingham, UK
| | - S. M. Zubair Rahim
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Cardiology Department, City Hospital, Birmingham, UK
| | - Alexandra Sophie Moss
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Cardiology Department, City Hospital, Birmingham, UK
| | - Gregory Y. H. Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Raffini L. Anticoagulation with VADs and ECMO: walking the tightrope. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:674-680. [PMID: 29222320 PMCID: PMC6142601 DOI: 10.1182/asheducation-2017.1.674] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
The evolution of devices for mechanical circulatory support (MCS), including ventricular assist devices (VADs) for patients with heart failure and extracorporeal membrane oxygenation (ECMO) for patients with acute cardiac or respiratory failure, has improved survival for subsets of critically ill children and adults. The devices are intricate and complex, allowing blood to bypass the heart or lungs (or both). As blood flows through these artificial devices, normal hemostasis is disrupted, coagulation is promoted, and in the absence of anticoagulation, a thrombus may form in the device, resulting in device failure or embolic stroke. Therefore, anticoagulation is necessary to prevent thrombus formation and maintain device function. However, patients on MCS also have very high bleeding rates. Titrating anticoagulation to prevent hemorrhagic complications and thrombotic events can be a challenge, and hematologists may be consulted in complex cases. Substantial variability remains in the approach to anticoagulant and antiplatelet therapy for patients on MCS, largely because of the lack of high-quality data. Improvements in the design and manufacture of these devices, as well as in the individualized titration of antithrombotic intensity, are expected to enhance outcomes. Several factors pertaining to both the device and the patient (adult and children) should be considered when attempting to optimize this delicate balance.
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Affiliation(s)
- Leslie Raffini
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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43
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Weitz JI, Harenberg J. New developments in anticoagulants: Past, present and future. Thromb Haemost 2017; 117:1283-1288. [DOI: 10.1160/th16-10-0807] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/09/2017] [Indexed: 12/22/2022]
Abstract
SummaryThrombosis is a leading cause of death and disability worldwide, and anticoagulants are the mainstay of its prevention and treatment. Starting with unfractionated heparin (UFH) and vitamin K antagonists (VKAs) such as warfarin, the choices of anticoagulants have exploded in the past 20 years. With over 90% subcutaneous bioavailability, no need for coagulation monitoring and dose adjustment, and a lower risk of heparin-induced thrombocytopenia, low-molecular-weight heparin and fondaparinux have replaced UFH for prevention and initial treatment of venous thromboembolism and for secondary prevention in cancer patients. In patients undergoing percutaneous interventions, bivalirudin is often used instead of UFH. Oral anticoagulation therapy has advanced with the introduction of the non-vitamin K antagonist oral anticoagulants (NOACs), which include dabigatran, rivaroxaban, apixaban and edoxaban. With efficacy at least equal to that of VKAs but with greater safety and convenience, the NOACs are now replacing VKAs for many indications. This paper a) highlights these advances, b) outlines how specific reversal agents for the NOACs will enhance their safety, c) reviews some of the ongoing trials with the NOACs, and d) describes the inhibitors of factor XII and XI that are under investigation as anticoagulants.
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44
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Bouckaert C, Zhu S, Govers-Riemslag JW, Depoorter M, Diamond SL, Pochet L. Discovery and assessment of water soluble coumarins as inhibitors of the coagulation contact pathway. Thromb Res 2017; 157:126-133. [DOI: 10.1016/j.thromres.2017.07.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/26/2017] [Accepted: 07/14/2017] [Indexed: 12/20/2022]
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Schulman S, Ageno W, Konstantinides SV. Venous thromboembolism: Past, present and future. Thromb Haemost 2017; 117:1219-1229. [PMID: 28594049 DOI: 10.1160/th16-10-0823] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 12/02/2016] [Indexed: 12/28/2022]
Abstract
Venous thromboembolism (VTE), the third most frequent acute cardiovascular syndrome, is associated with a considerable disease burden which continues to grow along with the longer life expectancy of the population worldwide. In the past century, parenteral heparin prophylaxis was established for hospitalised patients at elevated risk of VTE. More recently, non-vitamin K antagonist oral anticoagulants (NOACs) with a direct inhibiting effect on factor Xa or thrombin, underwent extensive testing in clinical trials and have been approved for patients undergoing hip or knee replacement. Clinical investigation is ongoing in further areas of thromboprophylaxis, including medical prophylaxis in patients and high-risk situations in the outpatient setting. The diagnostic approach to suspected VTE is now based on advanced imaging techniques and robust diagnostic algorithms which ensure high sensitivity and specificity. Nevertheless, the role of clinical, or pre-test, probability assessment remains crucial to avoid overdiagnosis and treatment errors. Advances in reperfusion strategies, along progressive establishment of the NOACs as the new standard of anticoagulation treatment, have simplified the management of VTE, improving outcomes and particularly safety. While new molecular targets for anticoagulation are being investigated in the quest to further reduce bleeding risk, adjusting the initial regimen to the patient's risk and finding the optimal duration of anticoagulation after an index VTE event will be some of the top priorities in the years to come. Importantly, and in parallel to new drugs and technical advances in imaging, incentives such as hospital accreditation and funding based on evidence-based practice need to be implemented to increase guideline adherence.
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Affiliation(s)
- Sam Schulman
- Sam Schulman, MD, PhD, Thrombosis Service, HHS-General Hospital, 237 Barton St E, Hamilton, ON, L8L 2X2, Canada, Tel. : +1 905 5270271, ext 44479, Fax: +1 905 5211551, E-mail
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Donkor DA, Bhakta V, Eltringham-Smith LJ, Stafford AR, Weitz JI, Sheffield WP. Selection and characterization of a DNA aptamer inhibiting coagulation factor XIa. Sci Rep 2017; 7:2102. [PMID: 28522812 PMCID: PMC5437010 DOI: 10.1038/s41598-017-02055-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 04/05/2017] [Indexed: 12/26/2022] Open
Abstract
Factor XIa (FXIa) is a serine protease that catalyzes the activation of Factor IX (FIX) in the blood coagulation cascade. FXIa and its precursor FXI are emergent therapeutic targets for the development of safer anticoagulant agents. Here, we sought a novel DNA-based agent to inhibit FXIa. Towards this goal, an 80 base, single-stranded DNA aptamer library (containing a 40 base randomized core) was screened for FXIa-binding candidates, using ten rounds of positive and negative selection. After selection, 6 of 89 different sequences inhibited FXIa-mediated chromogenic substrate S2366 cleavage. The most active anti-FXIa aptamer had a hypervariable central sequence 5′-AACCTATCGGACTATTGTTAGTGATTTTTATAGTGT-3′ and was designated Factor ELeven Inhibitory APtamer (FELIAP). FELIAP, but not a scrambled aptamer control (SCRAPT), competitively inhibited FXIa-catalyzed S2366 cleavage, FIX activation, and complex formation with antithrombin. No effect of FELIAP on FXI activation was observed. FELIAP inhibited plasma clotting and thrombin generation assays to a significantly greater extent than SCRAPT. Immobilized FELIAP bound FXIa with strong affinity and an equilibrium binding constant (KD) in the low nanomolar range determined using surface plasmon resonance. FELIAP is the first FXIa-inhibitory aptamer to be described and constitutes a lead compound to develop related aptamers for in vivo use.
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Affiliation(s)
- David A Donkor
- Centre for Innovation, Canadian Blood Services, Hamilton, Ontario, Canada.,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Varsha Bhakta
- Centre for Innovation, Canadian Blood Services, Hamilton, Ontario, Canada
| | | | - Alan R Stafford
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - William P Sheffield
- Centre for Innovation, Canadian Blood Services, Hamilton, Ontario, Canada. .,Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada.
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Kim N, Gu JY, Yoo HJ, Han SE, Kim YI, Nam-Goong IS, Kim ES, Kim HK. Contact system activation and high thrombin generation in hyperthyroidism. Eur J Endocrinol 2017; 176:583-589. [PMID: 28137735 DOI: 10.1530/eje-16-0835] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Revised: 01/17/2017] [Accepted: 01/30/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hyperthyroidism is associated with increased thrombotic risk. As contact system activation through formation of neutrophil extracellular traps (NET) has emerged as an important trigger of thrombosis, we hypothesized that the contact system is activated along with active NET formation in hyperthyroidism and that their markers correlate with disease severity. SUBJECTS AND METHODS In 61 patients with hyperthyroidism and 40 normal controls, the levels of coagulation factors (fibrinogen, and factor VII, VIII, IX, XI and XII), D-dimer, thrombin generation assay (TGA) markers, NET formation markers (histone-DNA complex, double-stranded DNA and neutrophil elastase) and contact system markers (activated factor XII (XIIa), high-molecular-weight kininogen (HMWK), prekallikrein and bradykinin) were measured. RESULTS Patients with hyperthyroidism showed higher levels of fibrinogen (median (interquartile range), 315 (280-344) vs 262 (223-300), P = 0.001), D-dimer (103.8 (64.8-151.5) vs 50.7 (37.4-76.0), P < 0.001), peak thrombin (131.9 (102.2-159.4) vs 31.6 (14.8-83.7), P < 0.001) and endogenous thrombin potential (649 (538-736) vs 367 (197-1147), P = 0.021) in TGA with 1 pM tissue factor, neutrophil elastase (1.10 (0.39-2.18) vs 0.23 (0.20-0.35), P < 0.001), factor XIIa (66.9 (52.8-87.0) vs 73.0 (57.1-86.6), P < 0.001), HMWK (6.11 (4.95-7.98) vs 3.83 (2.60-5.68), P < 0.001), prekallikrein (2.15 (1.00-6.36) vs 1.41 (0.63-2.22), P = 0.026) and bradykinin (152.4 (137.6-180.4) vs 118.3 (97.1-137.9), P < 0.001) than did normal controls. In age- and sex-adjusted logistic regression analysis, fibrinogen, factor VIII, IX and XIIa, D-dimer, peak thrombin, neutrophil elastase, HMWK and bradykinin showed significant odds ratios representing hyperthyroidism's contribution to coagulation and contact system activation. Free T4 was significantly correlated with factors VIII and IX, D-dimer, double-stranded DNA and bradykinin. CONCLUSION This study demonstrated that contact system activation and abundant NET formation occurred in the high thrombin generation state in hyperthyroidism and were correlated with free T4 level.
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Affiliation(s)
- Namhee Kim
- Department of Laboratory Medicine and Cancer Research InstituteSeoul National University College of Medicine, Seoul, Korea
| | - Ja-Yoon Gu
- Department of Laboratory Medicine and Cancer Research InstituteSeoul National University College of Medicine, Seoul, Korea
| | - Hyun Ju Yoo
- Department of Laboratory Medicine and Cancer Research InstituteSeoul National University College of Medicine, Seoul, Korea
| | - Se Eun Han
- Department of Internal MedicineUlsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Young Il Kim
- Department of Internal MedicineUlsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Il Sung Nam-Goong
- Department of Internal MedicineUlsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Eun Sook Kim
- Department of Internal MedicineUlsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hyun Kyung Kim
- Department of Laboratory Medicine and Cancer Research InstituteSeoul National University College of Medicine, Seoul, Korea
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Bain J, Flannery AH, Flynn J, Dager W. Heparin induced thrombocytopenia with mechanical circulatory support devices: review of the literature and management considerations. J Thromb Thrombolysis 2017; 44:76-87. [DOI: 10.1007/s11239-017-1494-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Heestermans M, van Vlijmen BJ. Oligonucleotides targeting coagulation factor mRNAs: use in thrombosis and hemophilia research and therapy. Thromb J 2017; 15:7. [PMID: 28286423 PMCID: PMC5341404 DOI: 10.1186/s12959-017-0130-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 02/27/2017] [Indexed: 02/08/2023] Open
Abstract
Small interfering (si) RNAs and antisense oligonucleotides (ASOs; here for simplicity reasons, both referred to as oligonucleotides) are small synthetic RNA or DNA molecules with a sequence complementary to a (pre)mRNA. Although the basic mechanisms of action between siRNAs and ASO are distinct, a sequence-specific interaction of the both oligonucleotides with the target (pre)mRNA alters the target's fate, which includes highly effective sequence-specific blockade of translation and consequently depletion of the corresponding protein. For a number of years, these oligonucleotides have been used as a tool in biological research to study gene function in vitro. More recently, safe and specific delivery of these oligonucleotides to the liver of mammals has been achieved and optimized. This not only allowed their use for in vivo gene studies in physiology and disease, but also opened the opportunity for the development of a new generation of RNA-specific drugs for therapeutic purposes. In 2013, the first oligonucleotide product targeting RNA from the hepatic cholesterol pathway was approved. For blood coagulation, a large portion of key proteins are produced in the liver, and thereby siRNAs and ASOs can also be used as appropriate tools to target these proteins in vivo. In this review, we describe the first use of oligonucleotides for this purpose from zebrafish to primates. As the use of oligonucleotides allows avoidance of early lethality associated with full deficiency of several coagulation factors, it has proved to be of value for studying these proteins in physiology and disease. Currently, oligonucleotides are tested as therapeutics, with the ultimate goal to beneficially modulate the hemostatic balance in thrombosis and hemophilia patients. We discuss both the preclinical and clinical studies of a number of siRNAs and ASOs with the potential to be introduced as drugs for prophylactic and/or treatment of thrombosis or hemophilia. We conclude that for the coagulation field, oligonucleotides are of value for research purposes, and now the moment has come to fulfill their promise as therapeutics.
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Affiliation(s)
- Marco Heestermans
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart J.M. van Vlijmen
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Weitz JI, Fredenburgh JC. Factors XI and XII as Targets for New Anticoagulants. Front Med (Lausanne) 2017; 4:19. [PMID: 28286749 PMCID: PMC5323386 DOI: 10.3389/fmed.2017.00019] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 02/10/2017] [Indexed: 01/01/2023] Open
Abstract
Compared with vitamin K antagonists, the direct oral anticoagulants (DOACs) are simpler to administer and are associated with less intracranial bleeding. Nonetheless, even with the DOACs, bleeding still occurs and many patients with atrial fibrillation fail to receive anticoagulant thromboprophylaxis because of the fear of bleeding. Therefore, there is an urgent need for safer anticoagulants. Recent investigations into the biochemistry of hemostasis and thrombosis have identified new targets for development of novel anticoagulants. Using data from complementary sources, including epidemiological studies and investigations in various animal models, the contact pathway has emerged as a potential mediator of thrombosis that plays a minor part in hemostasis. Consequently, factor (F) XII of the contact system and FXI in the intrinsic pathway have been identified as potentially safer targets of anticoagulation than thrombin or FXa. However, further studies are needed to identify which is the better target for the appropriate indication. This review highlights the evidence for focusing on FXI and FXII and examines the novel approaches directed at these new targets. These emerging strategies should address current unmet medical needs and provide new avenues by which to improve anticoagulant therapy by reducing the risk of bleeding.
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Affiliation(s)
- Jeffrey I. Weitz
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- The Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- *Correspondence: Jeffrey I. Weitz,
| | - James C. Fredenburgh
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- The Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
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