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Carazo A, Hrubša M, Konečný L, Gunaseelan C, Fadraersada J, Skořepa P, Paclíková M, Musil F, Karlíčková J, Javorská L, Matoušová K, Kujovská Krčmová L, Šmahelová A, Blaha V, Mladenka P. Correlations among different platelet aggregation pathways in a group of healthy volunteers. Platelets 2024; 35:2336093. [PMID: 38602464 DOI: 10.1080/09537104.2024.2336093] [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: 05/12/2023] [Accepted: 03/21/2024] [Indexed: 04/12/2024]
Abstract
Platelet aggregation is a complicated process mediated by different signaling pathways. As the process is highly complex and apparently redundant, the relationships between these pathways are not yet fully known. The aim of this project was to study the interconnections among seven different aggregation pathways in a group of 53 generally healthy volunteers aged 20 to 66 years. Platelet aggregation was induced with thrombin receptor activating peptide 6 (TRAP), arachidonic acid (AA), platelet activating factor 16 (PAF), ADP, collagen, thromboxane A2 analogue U46619 or ristocetin (platelet agglutination) ex vivo in fasting blood samples according to standardized timetable protocol. Additionally, some samples were pre-treated with known clinically used antiplatelet drugs (vorapaxar, ticagrelor or acetylsalicylic acid (ASA)). Significant correlations among all used inducers were detected (Pearson correlation coefficients (rP): 0.3 to 0.85). Of all the triggers, AA showed to be the best predictor of the response to other inducers with rP ranging from 0.66 to 0.85. Interestingly, the antiplatelet response to ticagrelor strongly predicted the response to unrelated drug vorapaxar (rP = 0.71). Our results indicate that a response to one inducer can predict the response for other triggers or even to an antiplatelet drug. These data are useful for future testing but should be also confirmed in patients.
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Affiliation(s)
- Alejandro Carazo
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Marcel Hrubša
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Lukáš Konečný
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Catherine Gunaseelan
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Jaka Fadraersada
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Pavel Skořepa
- 3rd Department of Internal Medicine-Metabolic Care and Gerontology, University Hospital and Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic
- Department of Military Internal Medicine and Military Hygiene, Faculty of Military Health Sciences, University of Defence, Hradec Králové, Czech Republic
| | - Markéta Paclíková
- 3rd Department of Internal Medicine-Metabolic Care and Gerontology, University Hospital and Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - František Musil
- Department of Occupational Medicine, University Hospital and Faculty of Medicine in Hradec Kralove, Charles University, Hradec Králové, Czech Republic
| | - Jana Karlíčková
- Department of Pharmacognosy and Pharmaceutical Botany, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Lenka Javorská
- Department of Clinical Biochemistry and Diagnostics, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Kateřina Matoušová
- Department of Clinical Biochemistry and Diagnostics, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Lenka Kujovská Krčmová
- Department of Clinical Biochemistry and Diagnostics, University Hospital Hradec Králové, Hradec Králové, Czech Republic
- Department of Analytical Chemistry, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Alena Šmahelová
- 3rd Department of Internal Medicine-Metabolic Care and Gerontology, University Hospital and Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Vladimír Blaha
- 3rd Department of Internal Medicine-Metabolic Care and Gerontology, University Hospital and Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Přemysl Mladenka
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
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Gupta R, Lin M, Mehta A, Aedma SK, Shah R, Ranchal P, Vyas AV, Singh S, Kluck B, Combs WG, Patel NC. Protease-Activated Receptor Antagonist for Reducing Cardiovascular Events - A Review on Vorapaxar. Curr Probl Cardiol 2023; 48:101035. [PMID: 34718032 DOI: 10.1016/j.cpcardiol.2021.101035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 10/16/2021] [Indexed: 02/01/2023]
Abstract
Acute Coronary Syndrome (ACS) is a term that describes pathologies related to myocardial ischemia, and is comprised of unstable angina, non-ST elevation myocardial infarction, and ST elevation myocardial infarction. Urgent management of ACS is typically necessary to prevent future morbidity and mortality. Current medical recommendations of ACS management involve use of dual antiplatelet therapy, typically with aspirin and clopidogrel. However, newer therapies are being designed and researched to improve outcomes for patients with ACS. Vorapaxar is a novel antiplatelet therapy that inhibits thrombin-mediated platelet aggregation to prevent recurrence of ischemic events. It has been Food and Drug Administration approved for reduction of thrombotic cardiovascular events in patients with a history of MI or peripheral arterial disease with concomitant use of clopidogrel and/or aspirin, based upon the findings of the TRA 2°P-TIMI 50 trial. However, Vorapaxar was also found to have a significantly increased risk of bleeding, which must be considered when administering this drug. Based upon further subgroup analysis of both the TRA 2°P-TIMI 50 trial and TRACER trial, Vorapaxar was found to be potentially beneficial in patients with peripheral artery disease, coronary artery bypass grafting, and ischemic stroke. There are current trials in progress that are further evaluating the use of Vorapaxar in those conditions, and future research and trials are necessary to fully determine the utility of this drug.
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Affiliation(s)
- Rahul Gupta
- Department of Cardiology, Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, Allentown, PA.
| | - Muling Lin
- Department of Medicine, University of South Florida, Morsani College of Medicine, Tampa, FL
| | - Anila Mehta
- Department of Internal Medicine, Carle Foundation Hospital, Urbana, IL
| | - Surya K Aedma
- Department of Internal Medicine, Carle Foundation Hospital, Urbana, IL
| | - Rajendra Shah
- Vassar Brothers Medical Center, Nuvance Health, Poughkeepsie, NY
| | - Purva Ranchal
- Department of Internal Medicine, Boston University, Boston, MA
| | - Apurva V Vyas
- Department of Cardiology, Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, Allentown, PA
| | - Shailendra Singh
- Department of Cardiology, Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, Allentown, PA
| | - Bryan Kluck
- Department of Cardiology, Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, Allentown, PA
| | - William G Combs
- Department of Cardiology, Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, Allentown, PA
| | - Nainesh C Patel
- Department of Cardiology, Lehigh Valley Heart and Vascular Institute, Lehigh Valley Health Network, Allentown, PA
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Abstract
INTRODUCTION Platelets play a key role in arterial thrombosis and antiplatelet therapy is pivotal in the treatment of cardiovascular disease. Current antiplatelet drugs target different pathways of platelet activation and show specific pharmacodynamic and pharmacokinetic characteristics, implicating clinically relevant drug-drug interactions. AREAS COVERED This article reviews the role of platelets in hemostasis and cardiovascular thrombosis, and discusses the key pharmacodynamics, drug-drug interactions and reversal strategies of clinically used antiplatelet drugs. EXPERT OPINION Antiplatelet therapies target distinct pathways of platelet activation: thromboxane A2 synthesis, adenosine diphosphate-mediated signaling, integrin αIIbβ3 (GPIIb/IIIa), thrombin-mediated platelet activation via the PAR1 receptor and phosphodiesterases. Key clinical drug-drug interactions of antiplatelet agents involve acetylsalicylic acid - ibuprofen, clopidogrel - omeprazole, and morphine - oral P2Y12 inhibitors, all of which lead to an attenuated antiplatelet effect. Platelet function and genetic testing and the use of scores (ARC-HBR, PRECISE-DAPT, ESC ischemic risk definition) may contribute to a more tailored antiplatelet therapy. High on-treatment platelet reactivity presents a key problem in the acute management of ST-elevation myocardial infarction (STEMI). A treatment strategy involving early initiation of an intravenous antiplatelet agent may be able to bridge the gap of insufficient platelet inhibition in high ischemic risk patients with STEMI.
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Affiliation(s)
- Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Mosconi MG, Paciaroni M, Ageno W. Investigational drugs for ischemic stroke: what's in the clinical development pipeline for acute phase and prevention? Expert Opin Investig Drugs 2022; 31:645-667. [PMID: 35486110 DOI: 10.1080/13543784.2022.2072725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Stroke is a leading cause of disability and mortality and its burden expected to increase. The only approved drug for acute ischemic stroke is the intravenous thrombolytic alteplase. The risk of bleeding complications is one of the reasons for the undertreatment of eligible patients. Numerous drugs are currently being developed to improve safety-efficacy. AREAS COVERED We reviewed literature from January 1st, 2000, to 15th January 2022 for the development and testing of novel drugs with the aim of targeting treatment at prevention of ischemic stroke: PubMed, MEDLINE, Google Scholar, and ClinicalTrial.gov. EXPERT OPINION The pathophysiology of ischemic stroke involves multiple pathways causing cerebral artery obstruction and brain tissue ischemia. Data suggest that tenecteplase is a more promising fibrinolytic agent with a superior efficacy-safety profile, compared to the currently approved alteplase. Current guidelines consider a short-term cycle of mannitol or hypertonic saline to be advisable in patients with space-occupying hemispheric infarction. Regarding primary and secondary prevention, research is primarily focused on identifying mechanisms to improve the safety-efficacy profile using a "hemostasis-sparing" approach. Further evaluation on those agents that have already shown promise for their risk/benefit profiles, would benefit greatly a neurologist's capacity to successfully prevent and treat ischemic stroke patients.
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Affiliation(s)
- Maria Giulia Mosconi
- Emergency and vascular medicine Stroke Unit University of Perugia, Perugia, Italy
| | - Maurizio Paciaroni
- Emergency and vascular medicine Stroke Unit University of Perugia, Perugia, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Motta JP, Deraison C, Le Grand S, Le Grand B, Vergnolle N. PAR-1 Antagonism to Promote Gut Mucosa Healing in Crohn's Disease Patients: A New Avenue for CVT120165. Inflamm Bowel Dis 2021; 27:S33-S37. [PMID: 34791291 DOI: 10.1093/ibd/izab244] [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] [Received: 02/28/2021] [Indexed: 12/17/2022]
Abstract
A new paradigm has been added for the treatment of inflammatory bowel diseases such as Crohn's disease and ulcerative colitis. In addition to resolving symptoms and inflammatory cell activation, the objective of tissue repair and mucosal healing is also now considered a primary goal. In the search of mediators that would be responsible for delayed mucosal healing, protease-activated receptor-1 (PAR-1) has emerged as a most interesting target. Indeed, in Crohn's disease, the endogenous PAR-1 agonist thrombin is drastically activated. Activation of PAR-1 is known to be associated with epithelial dysfunctions that hamper mucosal homeostasis. This review gathers the scientific evidences of a potential role for PAR-1 in mucosal damage and mucosal dysfunctions associated with chronic intestinal inflammation. The potential clinical benefits of PAR-1 antagonism to promote mucosal repair in CD patients are discussed. Targeted local delivery of a PAR-1 antagonist molecule such as CVT120165, a formulated version of the FDA-approved PAR-1 antagonist vorapaxar, at the mucosa of Crohn's disease patients could be proposed as a new indication for IBD that could be rapidly tested in clinical trials.
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Affiliation(s)
- Jean-Paul Motta
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, INRA, ENVT, UPS, U1220, CHU Purpan, CS60039, Toulouse, France.,CVasThera, Arobase Castres-Mazamet, Castres, France
| | - Celine Deraison
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, INRA, ENVT, UPS, U1220, CHU Purpan, CS60039, Toulouse, France
| | | | | | - Nathalie Vergnolle
- Institut de Recherche en Santé Digestive, Université de Toulouse, INSERM, INRA, ENVT, UPS, U1220, CHU Purpan, CS60039, Toulouse, France.,Departments of Physiology & Pharmacology, and Medicine, University of Calgary Cumming School of Medicine, 3330 Hospital Drive NW, Calgary, Alberta, Canada
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6
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Fan M, Han M, Xia Y, Zhang Y, Chu Y, Bai G, Li W, Li J, Zhao L, He Y, Ma X, Duan Z. Design and synthesis of potent PAR-1 antagonists based on vorapaxar. Bioorg Med Chem Lett 2020; 30:127046. [PMID: 32122739 DOI: 10.1016/j.bmcl.2020.127046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/11/2020] [Accepted: 02/15/2020] [Indexed: 01/23/2023]
Abstract
A series of novel vorapaxar analogues with different amino substitutes at the C-7, C-9a and aromatic substitutes at the C-4 position were designed, synthesized, and evaluated for their inhibitory activity to PAR-1. Several compounds showed good potency in antagonist activity based on the intracellular calcium mobilization assay and excellent pharmacokinetics profile in rats. Among these analogues, 3d exhibited excellent PAR-1 inhibitory activity (IC50 = 0.18 μM) and the lower ability to cross the blood-brain barrier compared with vorapaxar (IC50 = 0.25 μM). Compound 3d has the potential to be developed as a new generation of PAR-1 antagonists with a better therapeutic window.
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Affiliation(s)
- Mengna Fan
- Hebei University of Technology, Tianjin 300100, China; Tianjin Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China; State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Holding Group Co., Ltd., Tianjin 300410, China
| | - Min Han
- Tianjin Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China; State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Holding Group Co., Ltd., Tianjin 300410, China
| | - Yan Xia
- Tianjin Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China; State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Holding Group Co., Ltd., Tianjin 300410, China
| | - Yingbin Zhang
- Hebei University of Technology, Tianjin 300100, China; Tianjin Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China; State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Holding Group Co., Ltd., Tianjin 300410, China
| | - Yang Chu
- Tianjin Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China; State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Holding Group Co., Ltd., Tianjin 300410, China
| | - Guirong Bai
- Tianjin Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China; State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Holding Group Co., Ltd., Tianjin 300410, China
| | - Wei Li
- Tianjin Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China; State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Holding Group Co., Ltd., Tianjin 300410, China
| | - Ju Li
- Tianjin Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China; State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Holding Group Co., Ltd., Tianjin 300410, China
| | - Lihui Zhao
- Tianjin Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China; State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Holding Group Co., Ltd., Tianjin 300410, China
| | - Yi He
- Tianjin Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China; State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Holding Group Co., Ltd., Tianjin 300410, China
| | - Xiaohui Ma
- Tianjin Tasly Academy, Tasly Holding Group Co., Ltd., Tianjin 300410, China; State Key Laboratory of Core Technology in Innovative Chinese Medicine, Tasly Holding Group Co., Ltd., Tianjin 300410, China
| | - Zhongyu Duan
- Hebei University of Technology, Tianjin 300100, China.
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7
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Wadowski PP, Pultar J, Weikert C, Eichelberger B, Panzer B, Huber K, Lang IM, Koppensteiner R, Panzer S, Gremmel T. Protease-activated receptor-mediated platelet aggregation in acute coronary syndrome patients on potent P2Y 12 inhibitors. Res Pract Thromb Haemost 2019; 3:383-390. [PMID: 31294325 PMCID: PMC6611376 DOI: 10.1002/rth2.12213] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 04/05/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Despite the increasing use of potent P2Y12 inhibitors, further atherothrombotic events still impair the prognosis of many acute coronary syndrome (ACS) patients. This may in part be attributable to intact platelet aggregation via the human thrombin receptors protease-activated receptor (PAR)-1 and PAR-4. OBJECTIVE We studied PAR mediated platelet aggregation in ACS patients following percutaneous coronary intervention (PCI) with stent implantation in a cross-sectional study. METHODS Platelet aggregation to ADP as well as to the PAR-1 agonist SFLLRN and the PAR-4 agonist AYPGKF was assessed by multiple electrode aggregometry in 194 ACS patients on dual antiplatelet therapy with aspirin and either prasugrel (n = 114) or ticagrelor (n = 80) 3 days after PCI. RESULTS Based on the consensus cutoff value, high on-treatment residual platelet reactivity to ADP (HRPR ADP) was observed in only 2 prasugrel-treated patients. Both patients with HRPR ADP had also a normal response to SFLLRN and AYPGKF. Among the 112 prasugrel-treated patients with adequate P2Y12 inhibition, 50 patients (45%) still had a normal response to SFLLRN, and 70 patients (63%) still had a normal response to AYPGKF. Among the 80 ticagrelor-treated patients with adequate P2Y12 inhibition, 25 patients (31%) still had a normal response to SFLLRN, and 50 (63%) still had a normal response to AYPGKF. CONCLUSION Normal platelet aggregation via PAR-1 and PAR-4 is preserved in many patients with adequate P2Y12 inhibition by prasugrel and ticagrelor. The present findings may at least in part explain adverse ischemic events despite potent P2Y12 inhibition.
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Affiliation(s)
| | - Joseph Pultar
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Constantin Weikert
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | - Beate Eichelberger
- Department of Blood Group Serology and Transfusion MedicineMedical University of ViennaViennaAustria
| | - Benjamin Panzer
- Department of Blood Group Serology and Transfusion MedicineMedical University of ViennaViennaAustria
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care MedicineChest Pain UnitWilhelminenhospitalViennaAustria
| | - Irene M. Lang
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
| | | | - Simon Panzer
- Department of Blood Group Serology and Transfusion MedicineMedical University of ViennaViennaAustria
| | - Thomas Gremmel
- Department of Internal Medicine IIMedical University of ViennaViennaAustria
- Department of Internal Medicine, Cardiology and NephrologyLandesklinikum Wiener NeustadtWiener NeustadtAustria
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Pultar J, Wadowski PP, Panzer S, Gremmel T. Oral antiplatelet agents in cardiovascular disease. VASA 2018; 48:291-302. [PMID: 30324870 DOI: 10.1024/0301-1526/a000753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Antiplatelet agents significantly reduce mortality and morbidity in ischemic heart disease, cerebrovascular disease and peripheral artery disease (PAD), and are therefore part of guideline-driven daily medical treatment in these patients. Due to its beneficial effects in the secondary prevention of atherothrombotic events, aspirin remains the most frequently prescribed antiplatelet agent in cardiovascular disease. In patients with acute coronary syndromes (ACS) and in those undergoing angioplasty with stent implantation dual antiplatelet therapy with aspirin and an adenosine diphosphate (ADP) receptor antagonist is indicated. The development of the newer ADP P2Y12 inhibitors prasugrel and ticagrelor has further improved prognosis in ACS patients compared to clopidogrel. Moreover, vorapaxar allows the inhibition of platelet activation by thrombin via protease-activated receptor-1 and has been approved for the use in patients with PAD and in those with a history of myocardial infarction. This review article summarizes the current evidence on oral antiplatelet agents in cardiovascular disease. Keywords: Aspirin, clopidogrel, prasugrel, ticagrelor, vorapaxar, cardiovascular disease.
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Affiliation(s)
- Joseph Pultar
- 1 Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,a Joseph Pultar and Patricia P. Wadowski share first authorship
| | - Patricia P Wadowski
- 1 Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,a Joseph Pultar and Patricia P. Wadowski share first authorship
| | - Simon Panzer
- 2 Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Gremmel
- 1 Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.,3 Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
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Lettino M, Leonardi S, De Maria E, Halvorsen S. Antiplatelet and antithrombotic treatment for secondary prevention in ischaemic heart disease. Eur J Prev Cardiol 2018; 24:61-70. [PMID: 28618904 DOI: 10.1177/2047487317707854] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Platelets play a key role in the pathogenesis of acute coronary syndromes and this is why antiplatelet drugs are essential, both in the acute phase and in the long-term follow-up in preventing recurrent myocardial infarction, stroke and cardiovascular death. Aspirin is the most used agent and still remains the first choice drug for lifelong administration in secondary prevention after myocardial infarction. Dual antiplatelet therapy, targeting more than one pathway of platelet activation, has significantly improved the outcome of patients with acute coronary syndromes despite an increased risk of bleeding complications. The aim of this article is to provide an overview of the evidence from randomized clinical trials with a focus on the best association between aspirin and a P2Y12 inhibitor such as clopidogrel, prasugrel or ticagrelor, on the selection of the appropriate agent based on the revascularization strategy and on the optimal duration of such an intensive treatment. We will also provide the latest evidence regarding new antithrombotic agents, such as vorapaxar or low dose rivaroxaban, that could be associated with dual antiplatelet therapy in high risk patients with the aim of further reducing the rate of major ischaemic complications. Finally we will address the issue of patients presenting with atrial fibrillation and a concomitant acute coronary syndrome who frequently need a percutaneous coronary intervention, with a specific focus on the combination therapy of antiplatelet and anticoagulant agents and on the current recommendations of the guidelines.
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Affiliation(s)
- Maddalena Lettino
- 1 Cardiovascular Department, Humanitas Research Hospital, Rozzano, Italy
| | | | | | - Sigrun Halvorsen
- 4 Department of Cardiology, Ulleval and University of Oslo, Norway
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10
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de Vries MR, Simons KH, Jukema JW, Braun J, Quax PHA. Vein graft failure: from pathophysiology to clinical outcomes. Nat Rev Cardiol 2016; 13:451-70. [PMID: 27194091 DOI: 10.1038/nrcardio.2016.76] [Citation(s) in RCA: 187] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Occlusive arterial disease is a leading cause of morbidity and mortality worldwide. Aside from balloon angioplasty, bypass graft surgery is the most commonly performed revascularization technique for occlusive arterial disease. Coronary artery bypass graft surgery is performed in patients with left main coronary artery disease and three-vessel coronary disease, whereas peripheral artery bypass graft surgery is used to treat patients with late-stage peripheral artery occlusive disease. The great saphenous veins are commonly used conduits for surgical revascularization; however, they are associated with a high failure rate. Therefore, preservation of vein graft patency is essential for long-term surgical success. With the exception of 'no-touch' techniques and lipid-lowering and antiplatelet (aspirin) therapy, no intervention has hitherto unequivocally proven to be clinically effective in preventing vein graft failure. In this Review, we describe both preclinical and clinical studies evaluating the pathophysiology underlying vein graft failure, and the latest therapeutic options to improve patency for both coronary and peripheral grafts.
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Affiliation(s)
- Margreet R de Vries
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.,Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Karin H Simons
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.,Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - J Wouter Jukema
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.,Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Jerry Braun
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Paul H A Quax
- Department of Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands.,Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
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11
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Vorapaxar: a review of its use in the long-term secondary prevention of atherothrombotic events. Drugs 2016; 75:797-808. [PMID: 25895464 DOI: 10.1007/s40265-015-0387-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Vorapaxar (Zontivity®) is a first-in-class, potent and orally-active protease-activated receptor 1 (PAR-1) antagonist that blocks thrombin-mediated platelet activation without interfering with thrombin-mediated fibrin deposition. The long-term efficacy of once-daily vorapaxar added to standard antiplatelet therapy (aspirin with or without clopidogrel) in the secondary prevention of atherothrombotic events in patients with a history of myocardial infarction (MI), ischaemic stroke or peripheral arterial disease was investigated in the large, multinational TRA 2°P-TIMI 50 trial. Compared with placebo, vorapaxar significantly reduced the risk of the composite endpoints of cardiovascular (CV) death, MI or stroke, and CV death, MI, stroke or urgent coronary revascularization in the overall trial population. Vorapaxar also significantly reduced the risk of these composite endpoints in the subgroup of patients with prior MI (the largest qualifying disease cohort) and the subset of post-MI patients with no history of stroke or transient ischaemic attack (TIA). Vorapaxar significantly increased the risk of GUSTO moderate and/or severe bleeding in the overall trial population and all key subgroups (including post-MI patients with no history of stroke or TIA). Vorapaxar also significantly increased the risk of intracranial haemorrhage (ICH) in the overall trial population and the subgroup of patients with prior stroke, but not the subgroup of post-MI patients or the subset of post-MI patients with no history of stroke or TIA. Based on these results, vorapaxar has been approved in the EU as an adjunctive treatment for the secondary prevention of atherothrombotic events in patients with prior MI who do not have a history of stroke, TIA or ICH.
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Franchi F, Rollini F, Park Y, Angiolillo DJ. Platelet thrombin receptor antagonism with vorapaxar: pharmacology and clinical trial development. Future Cardiol 2015; 11:547-64. [PMID: 26406386 DOI: 10.2217/fca.15.50] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Oral antiplatelet therapies for secondary prevention of ischemic recurrences in patients with atherosclerotic disease manifestations include aspirin and P2Y12 receptor antagonists. Despite the use of these therapies, patients remain at risk for recurrent ischemic events, which may be attributed to other platelet signaling pathways which continue to be activated. More intense antithrombotic strategies have been investigated, including identifying additional targets to modulate platelet activation. Among these, thrombin-mediated platelet activation through PAR-1 has been subject to broad clinical investigation. Vorapaxar is the only PAR-1 receptor antagonists that completed large-scale clinical investigations and is approved for clinical use. This manuscript provides an overview of the pharmacology and clinical trial development of vorapaxar as well as its role in clinical practice.
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Affiliation(s)
- Francesco Franchi
- University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Fabiana Rollini
- University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Yongwhi Park
- University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
| | - Dominick J Angiolillo
- University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA
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Abstract
Vorapaxar [Zontivity(®) (US)], an orally active protease-activated receptor-1 (PAR-1) receptor antagonist, has been developed by Merck & Co for the reduction of thrombotic cardiovascular events in patients with a history of myocardial infarction (MI) or peripheral arterial disease (PAD). Vorapaxar has received its first global approval for this indication in the US. This article summarizes the milestones in the development of vorapaxar leading to this first approval for the reduction of thrombotic cardiovascular events in patients with a prior MI or PAD.
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Efficacy and Safety of Thrombin-Receptor Antagonist (Atopaxar and Vorapaxar) in Patients with Acute Coronary Syndrome or Coronary Artery Disease—A Meta-Analysis of Randomized Controlled Trials. Value Health Reg Issues 2015; 6:22-32. [DOI: 10.1016/j.vhri.2015.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Hosokawa K, Ohnishi T, Miura N, Sameshima H, Koide T, Tanaka KA, Maruyama I. Antithrombotic effects of PAR1 and PAR4 antagonists evaluated under flow and static conditions. Thromb Res 2014; 133:66-72. [DOI: 10.1016/j.thromres.2013.10.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 10/09/2013] [Accepted: 10/28/2013] [Indexed: 01/22/2023]
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Abstract
Currently available antiplatelet agents have shown improved short- and long-term clinical outcomes but are associated with increased bleeding risk, and the rates of recurrent ischemic events still remain high. Selective inhibition of protease-activated receptor-1 for thrombin represents a potential novel strategy to reduce ischemic events without increasing the risk of bleeding. Two protease-activated receptor-1 antagonists are currently being evaluated in clinical trials: SCH 530348 and E5555. Results of phase II trials have shown that SCH 530348, when added to standard antiplatelet therapy, was well tolerated and not associated with increased bleeding risk. Two large-scale phase III trials assessing the efficacy of SCH 530348 in addition to the standard of care are currently ongoing. This review provides an outline of the current status of understanding on platelet thrombin-receptor antagonist SCH 530348, focusing on its pharmacologic properties and clinical development.
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Kim FY, Marhefka G, Ruggiero NJ, Adams S, Whellan DJ. Saphenous vein graft disease: review of pathophysiology, prevention, and treatment. Cardiol Rev 2013; 21:101-9. [PMID: 22968180 DOI: 10.1097/crd.0b013e3182736190] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Saphenous vein graft (SVG) disease after coronary artery bypass grafting (CABG) occurs in three phases: thrombosis, intimal hyperplasia, and atherosclerosis. Within the first month, thrombosis plays a major role. From month 1 to month 12, intimal hyperplasia occurs. Beyond 12 months, atherosclerosis becomes the primary cause for late graft failure. Endothelial damage has been shown to be the major underlying pathophysiology of SVG disease. Many factors contribute to endothelial damage from the moment the vein is harvested to when the vein is grafted into an arterial environment. To address this disease process, various therapeutic modalities, from surgical methods to medical treatment, have been evaluated. Surgically, the technical method of harvesting the vein has been shown to affect SVG patency. From a pharmacologic perspective, only two guideline class I recommended medications, aspirin and statins, have been shown to improve short- and long-term SVG patency after CABG. Despite these surgical and medical advances, SVG disease remains a significant problem with 1-year patency rates of 89% dropping to 61% after 10 years. This review discusses the pathogenesis of SVG disease, predictors of SVG failure, and current surgical and pharmacologic therapies to address SVG disease, including possible future treatment.
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Affiliation(s)
- Francis Y Kim
- Jefferson Coordinating Center for Clinical Research, Thomas Jefferson University, Philadelphia, PA 19107, USA
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Novel Anti-platelet Agents: Focus on Thrombin Receptor Antagonists. J Cardiovasc Transl Res 2013; 6:415-24. [DOI: 10.1007/s12265-013-9454-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 02/05/2013] [Indexed: 11/25/2022]
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Wurster T, May AE. Atopaxar. A novel player in antiplatelet therapy? Hamostaseologie 2012; 32:228-233. [PMID: 22859265 DOI: 10.5482/hamo-12-05-0009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 06/19/2012] [Indexed: 12/13/2022] Open
Abstract
Atopaxar, also known as E 5555 is a novel reversible protease-activated receptor-1 (PAR-1) thrombin receptor antagonist. To date, Atopaxar has been investigated in phase II trials with focus on safety and tolerability in patients with acute coronary syndromes or stable coronary artery disease on top of standard antiplatelet therapy. Atopaxar was generally well tolerated, however a rise in liver enzymes and prolongation of the QTcF interval were observed. The data suggest, that atopaxar administration may promote some minor bleeding complications, but does not seem to significantly increase the risk of major bleeding. Although not powered for efficacy, the currently available data suggest potential benefits in patients at high risk for recurrent ischemic events on top of standard antiplatelet therapy. In conclusion, more studies (e.g. phase III) are needed to evaluate efficacy and safety of atopaxar.
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Affiliation(s)
- T Wurster
- Medizinische Klinik III, Eberhard-Karls-Universität Tübingen, Germany
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Chinitz JS, Castellano JM, Kovacic JC, Fuster V. Atrial fibrillation, stroke, and quality of life. Ann N Y Acad Sci 2012; 1254:140-150. [PMID: 22548580 DOI: 10.1111/j.1749-6632.2012.06494.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Contemporary management of atrial fibrillation imposes many challenges, particularly in the setting of our aging population. In addition to well-recognized consequences, such as stroke and mortality, emerging evidence relates atrial fibrillation to elevated risk of dementia, posing further therapeutic challenges. As the incidence of atrial fibrillation rises with age, the balance of controlling stroke risk and limiting major hemorrhage on anticoagulation has become increasingly critical in elderly patients. Appreciation of more extensive risk factors has made it possible to identify patients at very low risk of thromboembolism and higher risk of bleeding. However, practice guidelines in the United States and abroad have occasionally divergent viewpoints regarding how to best manage patients in various risk strata. Options for stroke prevention have expanded with novel antithrombotics and promising mechanical alternatives to anticoagulation, which may be at least as effective in preventing stroke without increasing bleeding risk. Catheter ablation has demonstrated impressive success at preventing atrial fibrillation recurrence in selected patients, and has the potential to further improve outcomes. In addition, the role of antiplatelet medications in patients deemed unsuitable for anticoagulation has been better clarified, although novel agents require further study to assess their impact on thromboembolism. High-bleeding risks associated with the concomitant use of multiple antithrombotics remains a major obstacle in patients with indications for both antiplatelet and anticoagulant therapy.
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Affiliation(s)
- Jason S Chinitz
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai School of Medicine, New York, New York 10029-6574, USA
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Packard KA, Campbell JA, Knezevich JT, Davis EM. Emerging Antiplatelet Therapy for Coronary Artery Disease and Acute Coronary Syndrome. Pharmacotherapy 2012; 32:244-73. [DOI: 10.1002/j.1875-9114.2012.01021.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
| | | | - Jon T. Knezevich
- Department of Pharmacy Practice; School of Pharmacy and Health Professions
| | - Estella M. Davis
- Department of Pharmacy Practice; School of Pharmacy and Health Professions
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Thrombin induced connective tissue growth factor expression in rat vascular smooth muscle cells via the PAR-1/JNK/AP-1 pathway. Acta Pharmacol Sin 2012; 33:49-56. [PMID: 22212430 DOI: 10.1038/aps.2011.178] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
AIM To investigate the signaling pathways involved in thrombin-induced connective tissue growth factor (CTGF) expression in rat vascular smooth muscle cells (VSMCs). METHODS Experiments were preformed on primary rat aortic smooth muscle cells (RASMCs) and a rat VSMC line (A10). CTGF protein levels were measured using Western blotting. Luciferase reporter genes and dominant negative mutants (DNs) were used to investigate the signaling pathways mediating the induction of CTGF expression by thrombin. RESULTS Thrombin (0.3-3.0 U/mL) caused a concentration- and time-dependent increase in CTGF expression in both RASMCs and A10 cells. Pretreating A10 cells with the protease-activated receptor 1 (PAR-1) antagonist SCH79797 (0.1 μmol/L) significantly blocked thrombin-induced CTGF expression, while the PAR-4 antagonist tcY-NH(2) (30 μmol/L) had no effect. The PAR-1 agonist SFLLRN-NH(2) (300 μmol/L) induced CTGF expression, while the PAR-4 agonist GYPGQV-NH(2) (300 μmol/L) had no effect. Thrombin (1 U/mL) caused time-dependent phosphorylation of c-Jun N-terminal kinase (JNK). Pretreating with the JNK inhibitor SP600125 (3-30 μmol/L) or transfection with DNs of JNK1/2 significantly attenuated thrombin-induced CTGF expression. Thrombin (0.3-3.0 U/mL) increased activator protein-1 (AP-1)-luciferase activity, which was inhibited by the JNK inhibitor SP600125. The AP-1 inhibitor curcumin (1-10 μmol/L) concentration-dependently attenuated thrombin-induced CTGF expression. CONCLUSION Thrombin acts on PAR-1 to activate the JNK signaling pathway, which in turn initiates AP-1 activation and ultimately induces CTGF expression in VSMCs.
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Kogushi M, Matsuoka T, Kuramochi H, Murakami K, Kawata T, Kimura A, Chiba K, Musha T, Suzuki S, Kawahara T, Kajiwara A, Hishinuma I. Oral administration of the thrombin receptor antagonist E5555 (atopaxar) attenuates intimal thickening following balloon injury in rats. Eur J Pharmacol 2011; 666:158-64. [PMID: 21635884 DOI: 10.1016/j.ejphar.2011.05.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 04/27/2011] [Accepted: 05/11/2011] [Indexed: 11/15/2022]
Abstract
Thrombin is a powerful agonist for a variety of cellular responses including platelet aggregation and vascular smooth muscle cell (SMC) proliferation. These actions are mediated by a thrombin receptor known as protease-activated receptor-1 (PAR-1). Recently we discovered that 1-(3-tert-butyl-4-methoxy-5-morpholinophenyl)-2-(5,6-diethoxy-7-fluoro-1-imino-1,3-dihydro-2H-isoindol-2-yl)ethanone hydrobromide (E5555, atopaxar) is a potent and selective thrombin receptor antagonist. This study characterized the pharmacological effects of E5555 on SMC proliferation in vitro and in a rat model of intimal thickening after balloon injury in vivo. E5555 selectively inhibited rat aortic SMC proliferation induced by thrombin and thrombin receptor-activating peptide (TRAP) with half maximal inhibitory concentration (IC(50)) values of 0.16 and 0.038 μM, respectively. E5555 did not inhibit rat SMC proliferation induced by basic fibroblast growth factor (bFGF) and platelet-derived growth factor (PDGF) at concentrations up to 1μM. In addition, E5555 inhibited human aortic SMC proliferation induced by thrombin at concentrations of 0.3 and 3units/ml with IC(50) values of 0.028 and 0.079 μM, respectively, whereas it did not affect bFGF-induced proliferation at concentrations up to 1μM. Repeated oral administration of 30 mg/kg E5555 (once daily for 16 days) significantly reduced neointimal formation in the balloon-injured rat arterial model. These results suggested that a PAR-1 antagonist could be effective for treating restenosis following vascular intervention in addition to preventing thrombus formation. E5555 could thus have therapeutic potential for restenosis and chronic atherothrombotic disease.
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Affiliation(s)
- Motoji Kogushi
- Eisai Tsukuba Research Laboratories, Eisai Co., Ltd., 5-1-3 Tokodai, Tsukuba, Ibaraki 300-2635, Japan.
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