Direct Oral Anticoagulants and Coronary Artery Disease

Leech bionic Hirudin fusion protein prodrug loaded microneedles for long-term inhibition of thrombosis

The clinical use of anticoagulant drugs for thrombosis is limited by short half-life and bleeding risk, requiring frequent administration and close monitoring. Here, inspired by leech mouthparts, we present a hirudin-based fusion protein prodrug incorporated with microneedles (MNs) for long-term antithrombotic therapy to achieve a simplified dosing regimen, continuous protection, and on-demand antithrombotic bioactivity recovery. Genetic-engineered anticoagulant prodrugs are precisely customized by fusing hirudin to elastin-like polypeptides with adjustable assembly characteristics. The introduction of elastin-like polypeptides can shield the biological activity of hirudin, drive the self-assembly of fusion proteins, and prolong their half-life in vivo. The fusion protein prodrugs circulate in the blood as sentinels and accumulate in the thrombus site with the assistance of the clot-targeted motif. Under the catalysis of FXa during thrombosis, the fusion protein prodrugs adaptively restore anticoagulant activity to inhibit thrombus formation. Notably, the assembled prodrugs were integrated into an MN matrix made of silk fibroin and chitosan through photopolymerization for long-term controlled release and facile self-administration. It was proved that the bionic MNs conveniently provide long protection against thrombosis without increasing bleeding events. These excellent performances indicate that the bionic MN patch has broad application prospects in thrombosis and related diseases.

Mortality patterns of coronary artery diseases and atrial fibrillation in adults in the United States from 1999 to 2022: An analysis using CDC WONDER

BACKGROUND

Coronary artery disease (CAD) and atrial fibrillation (AF) contribute significantly to global mortality and frequently co-exist due to shared risk factors like hypertension and diabetes. This study seeks to explore the relatively overlooked area of mortality patterns among adults who have both coronary artery disease and atrial fibrillation.

METHODS

Mortality data for individuals aged ≥25 were obtained from CDC WONDER using ICD-10 codes I20-25 (CAD) and I48 (AF). Age-adjusted mortality rates (AAMR) and crude mortality rates per 100,000 were calculated. Trends were analyzed by gender, year, race, urbanization, and state. JoinPoint regression estimated annual percent change (APC) and average annual percent change (AAPC) with 95 % confidence intervals (CI).

RESULTS

From 1999 to 2022, there were 942,461 recorded deaths among individuals with CAD and AF in the United States. The AAMR rose from 14.35 in 1999 to 24.53 in 2022, resulting in an AAPC of 2.56* (95 % CI, 2.24 - 2.85). The AAMR showed a consistent increase throughout the study period, with a significant spike from 2018 to 2022 (APC: 6.87*; 95 % CI, 4.82 - 10.66). Men consistently had higher AAMRs than women. Non-Hispanic (NH) White individuals reported the highest AAMR, followed by NH Black, Hispanic, and NH other populations. Nonmetropolitan areas exhibited higher AAMR than metropolitan regions.

CONCLUSIONS

AAMR showed a moderate rise from 1999-2018, followed by a sharp increase from 2018-2022, possibly linked to COVID-19. Further research is needed to understand contributing factors.

Anticoagulation vs Antiplatelets Across Subgroups of Embolic Stroke of Undetermined Source: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVES

The term "embolic stroke of undetermined source" (ESUS) encompasses a substantial but heterogeneous population of patients with ischemic stroke, underscoring the importance of identifying personalized treatment strategies. In subgroups of patients randomized in ESUS trials, we evaluated the effectiveness of anticoagulation compared with antiplatelet therapy in secondary ischemic stroke prevention.

METHODS

A study-level meta-analysis was conducted on randomized controlled trials of patients with ESUS, comparing anticoagulation with antiplatelet therapy. The primary efficacy outcome was recurrent ischemic stroke, and safety outcomes were major bleeding and death. Subgroups assessed were age, sex, presence of patent foramen ovale (PFO), left atrial enlargement (LAE), and atrial cardiopathy. Pooled risk ratios (RRs) were meta-analyzed. Cochrane Risk of Bias Tool 2.0 was used for risk-of-bias assessment.

RESULTS

A total of 7 randomized controlled trials involving 14,804 patients were analyzed, with 7,406 patients treated with anticoagulation and 7,398 treated with antiplatelet therapy. Compared with antiplatelet therapy, anticoagulation was associated with a similar rate of recurrent ischemic stroke (RR 0.91, 95% CI 0.80-1.05; I2 = 0%). In ESUS with PFO, anticoagulation was associated with significantly lower risk of ischemic stroke (RR 0.59, 95% CI 0.35-0.98; I2 = 0%). Heterogeneity was present in those with LAE: antiplatelet therapy was superior in trials allowing cardiac monitoring after randomization (RR 6.65, 95% CI 1.26-35.08; I2 = 0%), but anticoagulation was superior in trials prohibiting cardiac monitoring after randomization (RR 0.25 95% CI 0.07-0.89). Subgroups based on age, sex, or presence of atrial cardiopathy did not benefit from anticoagulation over antiplatelet therapy.

DISCUSSION

In this meta-analysis, an empiric anticoagulation approach is not beneficial for patients with ESUS. This finding highlights the importance of an individualized treatment strategy. Such a strategy should include prolonged cardiac monitoring for atrial fibrillation, particularly in patients with moderate-to-severe LAE. Anticoagulation treatment showed promise in patients with medically treated PFO. Other subgroups did not benefit from anticoagulation therapy. Large prospective studies within ESUS subgroups are needed to validate our findings.

A metabolomics discrimination-based strategy for screening the antithrombin active markers of perilla seeds: A natural oil crop

Natural crops oil with high nutritional value has gradually attracted attention. Perilla seeds are regarded as a source of functional edible oil in America, Asia and European countries due to its abundant nutrients. In this research, samples were extracted by different polarity solvents and evaluated their thrombin inhibition activities in vitro. Metabolomics combined with chemometrics revealed the antithrombin active markers of perilla seeds. The enzyme kinetics and molecular docking results were useful in clarifying their inhibition of thrombin. The orthogonal experimental design was applied to optimize the extraction process of six antithrombin active markers from perilla seeds. The results showed that rosmarinic acid, luteolin, luteolin-7-O-glucoside, α-linolenic acid, linoleic acid, and oleic acid were screened out as functional and active markers. Besides, perilla seeds as a natural oil crop had the potential of antithrombin. It can also be applied in the food field because of its nutraceutical functions. Metabolomics combined with chemometrics will facilitate the discovery of functional, active markers in perilla seeds, which is conducive to accurate quality control.

Direct Oral Anticoagulants use in Patients with Stable Coronary Artery Disease, Acute Coronary Syndrome or Undergoing Percutaneous Coronary Intervention

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.

Assessing the Role of a Malonamide Linker in the Design of Potent Dual Inhibitors of Factor Xa and Cholinesterases

The rational discovery of new peptidomimetic inhibitors of the coagulation factor Xa (fXa) could help set more effective therapeutic options (to prevent atrial fibrillation). In this respect, we explored the conformational impact on the enzyme inhibition potency of the malonamide bridge, compared to the glycinamide one, as a linker connecting the P1 benzamidine anchoring moiety to the P4 aryl group of novel selective fXa inhibitors. We carried out structure–activity relationship (SAR) studies aimed at investigating para- or meta-benzamidine as the P1 basic group as well as diversely decorated aryl moieties as P4 fragments. To this end, twenty-three malonamide derivatives were synthesized and tested as inhibitors of fXa and thrombin (thr); the molecular determinants behind potency and selectivity were also studied by employing molecular docking. The malonamide linker, compared to the glycinamide one, does significantly increase anti-fXa potency and selectivity. The meta-benzamidine (P1) derivatives bearing 2′,4′-difluoro-biphenyl as the P4 moiety proved to be highly potent reversible fXa-selective inhibitors, achieving inhibition constants (K_i) in the low nanomolar range. The most active compounds were also tested against cholinesterase (ChE) isoforms (acetyl- or butyrylcholinesterase, AChE, and BChE), and some of them returned single-digit micromolar inhibition potency against AChE and/or BChE, both being drug targets for symptomatic treatment of mild-to-moderate Alzheimer’s disease. Compounds 19h and 22b were selected as selective fXa inhibitors with potential as multimodal neuroprotective agents.