Antiplatelet therapies: from aspirin to GPIIb/IIIa-receptor antagonists and beyond

Regulation of mitochondrial function by hydroquinone derivatives as prevention of platelet activation

Platelet activation plays an essential role in the pathogenesis of thrombotic events in different diseases (e.g., cancer, type 2 diabetes, Alzheimer's, and cardiovascular diseases, and even in patients diagnosed with coronavirus disease 2019). Therefore, antiplatelet therapy is essential to reduce thrombus formation. However, the utility of current antiplatelet drugs is limited. Therefore, identifying novel antiplatelet compounds is very important in developing new drugs. In this context, the involvement of mitochondrial function as an efficient energy source required for platelet activation is currently accepted; however, its contribution as an antiplatelet target still has little been exploited. Regarding this, the intramolecular hydrogen bonding of hydroquinone derivatives has been described as a structural motif that allows the reach of small molecules at mitochondria, which can exert antiplatelet activity, among others. In this review, we describe the role of mitochondrial function in platelet activation and how hydroquinone derivatives exert antiplatelet activity through mitochondrial regulation.

The choice of targets and ligands for site-specific delivery of nanomedicine to atherosclerosis

As nanotechnologies advance into clinical medicine, novel methods for applying nanomedicine to cardiovascular diseases are emerging. Extensive research has been undertaken to unlock the complex pathogenesis of atherosclerosis. However, this complexity presents challenges to develop effective imaging and therapeutic modalities for early diagnosis and acute intervention. The choice of ligand-receptor system vastly influences the effectiveness of nanomedicine. This review collates current ligand-receptor systems used in targeting functionalized nanoparticles for diagnosis and treatment of atherosclerosis. Our focus is on the binding affinity and selectivity of ligand-receptor systems, as well as the relative abundance of targets throughout the development and progression of atherosclerosis. Antibody-based targeting systems are currently the most commonly researched due to their high binding affinities when compared with other ligands, such as antibody fragments, peptides, and other small molecules. However, antibodies tend to be immunogenic due to their size. Engineering antibody fragments can address this issue but will compromise their binding affinity. Peptides are promising ligands due to their synthetic flexibility and low production costs. Alongside the aforementioned binding affinity of ligands, the choice of target and its abundance throughout distinct stages of atherosclerosis and thrombosis is relevant to the intended purpose of the nanomedicine. Further studies to investigate the components of atherosclerotic plaques are required as their cellular and molecular profile shifts over time.

Synthesis and Biological Evaluation of Thio-Derivatives of 2-Hydroxy-1,4-Naphthoquinone (Lawsone) as Novel Antiplatelet Agents

We designed and synthesized in water, using conventional heating and microwave irradiation, new thio-derivatives of 2-hydroxy-1,4-naphthoquinone, a naturally occurring pigment known as lawsone or hennotannic acid, thus improving their antiplatelet activity with relevance to their potential future use in thrombus formation treatment. The structure-activity relationship showed that the thiophenyl moiety enhances the antiplatelet activity. Moreover, the position and nature of the substituent at the phenyl ring have a key effect on the observed biological activity. Compound 4 (2-((4-bromophenyl)thio)-3-hydroxynaphthalene-1,4-dione) was the most active derivative, presenting IC₅₀ values for platelet aggregation inhibition of 15.03 ± 1.52 μM for TRAP-6, and 5.58 ± 1.01 μM for collagen. Importantly, no cytotoxicity was observed. Finally, we discussed the structure-activity relationships of these new lawsone thio-derivatives on inhibition of TRAP-6- and collagen-induced platelet aggregation.

Effects of the RGD loop and C-terminus of rhodostomin on regulating integrin αIIbβ3 recognition

Rhodostomin (Rho) is a medium disintegrin containing a ⁴⁸PRGDMP motif. We here showed that Rho proteins with P48A, M52W, and P53N mutations can selectively inhibit integrin αIIbβ3. To study the roles of the RGD loop and C-terminal region in disintegrins, we expressed Rho ⁴⁸PRGDMP and ⁴⁸ARGDWN mutants in Pichia pastoris containing ⁶⁵P, ⁶⁵PR, ⁶⁵PRYH, ⁶⁵PRNGLYG, and ⁶⁵PRNPWNG C-terminal sequences. The effect of C-terminal region on their integrin binding affinities was αIIbβ3 > αvβ3 ≥ α5β1, and the ⁴⁸ARGDWN-⁶⁵PRNPWNG protein was the most selective integrin αIIbβ3 mutant. The ⁴⁸ARGDWN-⁶⁵PRYH, ⁴⁸ARGDWN-⁶⁵PRNGLYG, and ⁴⁸ARGDWN-⁶⁵PRNPWNG mutants had similar activities in inhibiting platelet aggregation and the binding of fibrinogen to platelet. In contrast, ⁴⁸ARGDWN-⁶⁵PRYH and ⁴⁸ARGDWN-⁶⁵PRNGLYG exhibited 2.9- and 3.0-fold decreases in inhibiting cell adhesion in comparison with that of ⁴⁸ARGDWN-⁶⁵PRNPWNG. Based on the results of cell adhesion, platelet aggregation and the binding of fibrinogen to platelet inhibited by ARGDWN mutants, integrin αIIbβ3 bound differently to immobilized and soluble fibrinogen. NMR structural analyses of ⁴⁸ARGDWN-⁶⁵PRYH, ⁴⁸ARGDWN-⁶⁵PRNGLYG, and ⁴⁸ARGDWN-⁶⁵PRNPWNG mutants demonstrated that their C-terminal regions interacted with the RGD loop. In particular, the W52 sidechain of ⁴⁸ARGDWN interacted with H68 of ⁶⁵PRYH, L69 of ⁶⁵PRNGLYG, and N70 of ⁶⁵PRNPWNG, respectively. The docking of the ⁴⁸ARGDWN-⁶⁵PRNPWNG mutant into integrin αIIbβ3 showed that the N70 residue formed hydrogen bonds with the αIIb D159 residue, and the W69 residue formed cation-π interaction with the β3 K125 residue. These results provide the first structural evidence that the interactions between the RGD loop and C-terminus of medium disintegrins depend on their amino acid sequences, resulting in their functional differences in the binding and selectivity of integrins.

Progress in the research of GPIIb/IIIa antagonists

This review covers the recent advances in the development of small RGD (Arg-Gly-Asp sequence) containing peptides and their mimetics as potential antithrombotic agents. Glycoprotein IIb/IIIa (GPIIb/IIIa) antagonists include monoclonal antibodies, RGD peptides, peptide hybrids and nonpeptide mimetics. The current trend in the development of nonpeptide mimetics is clearly directed toward orally active and safe antithrombotic drug candidates. But several nonpeptide mimetics, being evaluated for their oral activity in human clinical trials, are currently not approved for clinical use due to poor safety profile. It is expected that newer and more effective nonpeptide mimetics will be developed in the near future.

Review: Preeclampsia, acute atherosis of the spiral arteries and future cardiovascular disease: two new hypotheses

Preeclampsia is a serious complication of pregnancy, potentially lethal for women and offspring. Affected women have an augmented risk of later cardiovascular disease and premature death and may have risk factors in common with older persons developing cardiovascular disease. In some cases of preeclampsia, lipid-filled foam cells accumulate in the walls of the spiral arteries of the uteroplacental circulation (acute atherosis). These lesions resemble the early stages of atherosclerosis and are thought to regress after delivery. The mechanisms that contribute to acute atherosis are largely unknown, but are related to defective vascular remodeling of the spiral arteries in the first half of pregnancy. Spiral artery lipid deposition may also occur in normal pregnancies, which suggests that it may not be confined exclusively to maladapted spiral arteries or caused by hypertension. Our first hypothesis is that there are several pathways to the development of acute atherosis, which converge at the point of excessive decidual inflammation in the final common pathway. Our second hypothesis is that acute atherosis, evolving during the short time of pregnancy, identifies a subset of women at augmented risk for atherosclerosis and later chronic arterial disease better than the diagnosis of preeclampsia itself. If confirmed, this may enable better preventive management for the affected women.

Antiplatelet therapies: drug interactions in the management of vascular disorders

Antiplatelet drugs represent a key class of drugs that are of proven value in arterial thromboembolic disorders. There is a need for effective, safe antiplatelet agents or their combinations to provide predictable therapeutic benefit, dosage flexibility, and unique pharmacologic profiles, such as rapid onset in acute thrombotic states, as well as sustained antiplatelet effects in chronic platelet-activating states (e.g., post-stent placement). Aspirin, clopidogrel, or their combination have shown improved clinical outcomes in certain unique settings, and the search for additional antiplatelet agents is ongoing. Current studies suggest that combination antiplatelet therapy with existing agents is best considered a use-adapted strategy, with the greatest clinical benefit of combination therapy realized in acute, platelet-activating, and prothrombotic states.

Construction of drug screening cell model and application to new compounds inhibiting FITC-fibrinogen binding to CHO cells expressing human alphaIIbbeta3

To identify potential candidates for antiplatelet drugs, human alphaIIbbeta3 (GPIIb/IIIa) was expressed in Chinese hamster ovary (CHO) cells, which was validated by tetrapeptide RGDS (Arg-Gly-Asp-Ser) with IC(50) of 0.057 mM, supported by Basani's results [Basani, R. B., French, D. L., Vilaire, G., Brown, D. L., Chen, F., Coller, B. S., Derrick, J. M., Gartner, T. K., Bennett, J. S., Poncz, M., 2000. A naturally occurring mutation near the amino terminus of alpha IIb defines a new region involved in ligand binding to alpha IIbbeta 3. Blood 95, 180-188]. The ability of 2-(4-substituted-piperazin-1-ylacetyl)-1,2,3,4-tetrahydroisoquinoline derivatives to inhibit fibrinogen binding to alphaIIbbeta3 based on the CHO cell model was measured by flow cytometry using GPIIb/IIIa assay, and the IC(50) values of compounds 1-6 were 0.166, 0.037, 0.311, 0.025, 0.034, and 0.184 mM, respectively. Our research results indicated that the compounds with phenylsulfonyl (compounds 1 and 2) and benzoyl groups (compounds 4 and 5) at position 4 of piperazine showed higher IC(50) values of inhibiting ADP-induced human platelet aggregation. Particularly compound 4 possessed IC(50) value of approximately 6.84 nM. Additionally, a complex model of alphaIIbbeta3 with compound 4 revealed that the pharmacophore of compound 4, including m-nitro group of 4-benzene-piperazine, the nitrogen atom in the piperazine group, and 2-nitrogen of 1,2,3,4-tetrahydroisoquinoline nucleus, interacted with the hydroxyl groups of Thr125 of beta3 and Tyr166 of alpha2b by hydrogen bonds and the carboxyl group at side chain of Asp179 of alpha2b in the fashion of electrostatic interaction. MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) assays showed that compounds 4 and 5 possess potential anti-cancer activities, suggesting a potential role of integrin-guided signal pathway in cancer therapy. Further evaluation is under investigation.

The effects of tirofiban on peripheral markers of oxidative stress and endothelial dysfunction in patients with acute coronary syndromes

BACKGROUND

Endothelial dysfunction and oxidative stress are believed to be central mechanisms in atherogenesis. We aimed to determine the effects of tirofiban on oxidative stress and neutrophil-endothelium interaction markers in patients with acute coronary syndromes (ACS).

MATERIALS AND METHODS

We measured malondialdehyde (MDA), interleukin-6 (IL-6) and soluble endothelial intercellular and vascular adhesion molecules (sICAM-1 and sVCAM-1) on admission, at 48 and 72 h and on 5th day of hospitalization in 34 patients (age 66.5+/-1.8 years) with ACS. Patients with recurrent angina, changes on the electrocardiogram and/or elevated troponin I received intravenously tirofiban for 48 h and the others received normal saline.

RESULTS

Baseline concentrations of all markers did not differ significantly and compared with placebo, tirofiban infusion markedly reduced MDA, IL-6, sICAM-1 and sVCAM-1 at 48 h (-31+/-6% vs. 84+/-49%, p=0.007, -12+/-14% vs. 23+/-10%, p=0.05, -20+/-6% vs. 36+/-25%, p=0.04 and -10+/-5% vs. 6+/-5%, p=0.02, respectively). Relative to baseline, significant reductions were observed for all 4 markers at 72 h and day 5 (p<0.05).

CONCLUSION

Tirofiban potentiates the decline in oxidative stress and may reverse abnormal endothelial activation in patients with ACS. This benefit seems to remain over the following 5 days.

Design, synthesis, and structure–activity relationships of potent GPIIb/IIIa antagonists: discovery of FK419

The discovery of the non-peptide antiplatelet injectable agent FK419 is reported. Based on the beta-turn structure of RGD peptide sequences in the alpha chain of fibrinogen, which binds the glycoprotein IIb/IIIa (GPIIb/IIIa) on the surface of platelets to induce platelet aggregation, the prototype 2 was designed. After further substituent effects were investigated at the alpha-position of the carboxylic acid in 2, we enhanced platelet aggregation inhibition, and discovered the useful feature of reduced prolongation of bleeding time. Finally, the potent platelet aggregation inhibitor FK419 (3) could be discovered. FK419 shows a safe feature of reduced prolongation of bleeding time, as well as potent inhibition of platelet aggregation.

Design and synthesis of novel platelet fibrinogen receptor antagonists with 2H-1,4-benzoxazine-3(4H)-one scaffold. A systematic study

New platelet glycoprotein IIb/IIIa (GP IIb/IIIa, integrin alpha(IIb)beta3) antagonists were prepared on a 2H-1,4-benzoxazine-3(4H)-one scaffold. Their anti-aggregatory activities in human platelet rich plasma and their affinity towards alpha(IIb)beta3 and alpha(V)beta3 integrins were assessed. Various substitution positions and side chain variations were studied. In contrast to the generally accepted model, compounds containing ethyl esters as aspartate mimetics were in general more active than the corresponding free acids. We suggest an explanation for the observed behaviour of these new compounds.

2-Phenyl-3-(quinolizidin-1-yl)-5-substituted indoles as platelet antiaggregating agents

A set of ten 2-phenyl-3-(quinolizidin-1-yl)-5-substituted indoles was prepared through the Fischer cyclization of lupinyl- and epi-lupinylphenylketone 4-substituted phenylhydrazones. Compounds were tested for antiaggregating activity on human platelets activated by adenosine diphosphate (ADP), collagen and adrenaline. At 2.5 x 10(-4) M concentration most compounds strongly inhibited the aggregation induced by all the agonists considered and many of them still displayed good activity at 0.625 x 10(-4) M concentration. The least active (1c) and one of the most active (1d) compounds were also tested for antiaggregating activity on rabbit platelets activated by ADP, PAF and sodium arachidonate. Both the compounds were active against ADP and PAF, but only 1d inhibited the arachidonate-induced aggregation (100% at 8 x 10(-6) M concentration) and increased the bleeding time in mice. The same compounds were subjected to a general pharmacological screening and found to display several activities; of particular interest was the dose dependent reduction of serum cholesterol and heparin precipitating betalipoproteins in hypercholesterolemic mice exerted by 1c, which was still significant at the oral dose of 10 mg/kg.

Inhibition of ADP-evoked platelet aggregation by selected poly(ADP-ribose) polymerase inhibitors

Pathologic platelet activation has been implicated in the pathogenesis of ischemic heart disease. Since cardiomyocytes can be protected from ischemia-reoxygenation injury by poly(ADP-ribose) polymerase (PARP) inhibitors mimicking the adenine/ADP part of NAD, their structural resemblance to ADP may also enable the blockade of platelet aggregation via binding to ADP receptors. Blood samples drawn from healthy volunteers were pre-incubated with different concentrations of PARP inhibitors: 4-hydroxyquinazoline, 2-mercapto-4(3 H)-quinazolinone, or HO-3089. ADP-, collagen- and epinephrine-induced platelet aggregation was evaluated according to the method described by Born. The effect of PARP inhibitors on thrombocyte aggregation was also examined when platelets were sensitized by heparin and in the presence of incremental concentrations of ADP. All examined PARP inhibitors reduced the ADP-induced platelet aggregation in a dose-dependent manner (significant inhibition at 20 microM for HO-3089 and at 500 microM for the other agents; P < 0.05), even if platelets were sensitized with heparin. However, their hindrance on platelet aggregation waned as the concentration of ADP rose (no effect at 40 microM ADP). PARP inhibitors had minimal effect on both collagen- and epinephrine-induced platelet aggregation. Our study first demonstrates the feasibility of a design for PARP inhibitors that does not only protect against ischemia-reperfusion-induced cardiac damage but may also prevent thrombotic events.

The low molecular weight heparin, tinzaparin, in thrombosis and beyond

Standard unfractionated heparin (UFH) has been in clinical use for over 50 years. The commercial use of low molecular weight heparins (LMWHs) began in the mid 1980s for hemodialysis and the prophylaxis of deep vein thrombosis (DVT). Initially, the clinical development of LMWHs was concentrated on the European continent. Subsequently, LMWHs were introduced in North America as well. In the initial stages of development of these drugs only nadroparin, dalteparin and enoxaparin were used. Subsequently, several other LMWHs such as ardeparin, tinzaparin, reviparin and parnaparin were introduced. LMWHs constitute a group of important medications with total sales reaching nearly 2.5 billion dollars with expanded indications reaching far beyond the initial indications for the prophylaxis of post-surgical DVT. This review highlights the pharmacology of tinzaparin. Unlike other LMWHs, tinzaparin is prepared by enzymatic hydrolysis with heparinase, while various chemical depolymerization methods are used for the synthesis of other LMWHs. As compared with the standard heparin, LMWHs have different pharmacodynamic, and pharmacokinetic properties; they also differ in clinical benefits.

Anti-integrin as novel drug-discovery targets: potential therapeutic and diagnostic implications

The role of integrin and extracellular matrix proteins in various pathological processes (including angiogenesis, thrombosis, apoptosis and cell migration and proliferation), leading to both acute and chronic disease states (e.g. ocular diseases, metastasis, unstable angina, myocardial infarction, stroke, osteoporosis, a wide range of inflammatory diseases, vascular remodeling and neurodegenerative disorders) has been recently documented. A key success in this field is evident from the potential role of the platelet GPIIb/IIIa (alphaIIbbeta3) integrin in the prevention, treatment and perhaps diagnosis of various thromboembolic disorders. Additionally, progress has been shown in the development of leukocyte alpha4beta1 antagonists for various inflammatory indications and alphav integrin antagonists for angiogenesis and vascular-related disorders. However, the exact modes of action of certain integrin antagonists are still not fully clear. Integrin antagonists in clinical or pre-clinical development are expected to be used as a stand-alone therapy or, better, as an adjunct to other pharmacotherapy, radiotherapy or interventional procedures.

Increased platelet binding to circulating monocytes in acute coronary syndromes

BACKGROUND

Present therapies for acute coronary syndromes aim toward limiting platelet-platelet adhesion and aggregation processes. However, platelet-leukocyte interactions may contribute importantly to disease progression in the arterial wall. Recent studies suggest that prevention of platelet-leukocyte binding via P-selectin glycoprotein ligand-1 (PSGL-1) may be beneficial in animal models of vascular injury.

METHODS AND RESULTS

P-selectin-PSGL-1 interactions were found to account for most platelet-monocyte binding observed in peripheral blood samples from healthy donors. However, a significant component of observed adhesion was calcium independent, involving neither PSGL-1 nor P-selectin. Platelet-monocyte interactions were examined in 52 patients admitted within 14 hours of symptom onset, with acute coronary syndromes defined as unstable angina (n=12) and acute myocardial infarction (n=13) or noncardiac chest pain (n=27). When compared with patients with noncardiac chest pain, significantly elevated levels of platelet-monocyte binding were found in patients with acute myocardial infarction (70.1+/-15.4% versus 45.4+/-23.3%; P<0.01) and unstable angina (67.4+/-12.9% versus 45.4+/-23.3%; P>0.01). Calcium-independent platelet-monocyte binding was significantly elevated in myocardial infarction patients alone (14.7+/-7.7% versus 6.1+/-5.96%; P<0.001).

CONCLUSIONS

There is evidence for a significant P-selectin-independent molecular component to the platelet-monocyte conjugation observed in peripheral blood. Patients with myocardial infarction and unstable angina demonstrate increased total binding of platelets to monocytes. Additionally, calcium-independent adhesion was significantly elevated in patients with evidence of myocardial infarction. These findings demonstrate that novel cation-independent adhesion mechanisms may mediate platelet-monocyte binding, representing a new therapeutic target after vascular injury associated with myocardial infarction.