Oral Presentation No. 41 High plasma von Willebrand factor concentration is associated with the development of bleeding complications in patients with polyvascular disease receiving multicomponent antithrombotic therapy

Background

von Willebrand factor (VWF) is well known biochemical marker of endothelial dysfunction that increased may be associated with the development of thrombotic complications in patients with polyvascular disease (PD). We aimed to asses the relation of VWF to the development of bleeding outcomes in patients with PD receiving multicomponent antithrombotic therapy (MAT).

Material and methods

The data were obtained during the prospective register REGATA-1, NCT04347200. 95 patients (70 males), median age 67 [IQR 61; 72] with PD (coronary artery disease and peripheral atherosclerosis of at least one vascular territory ≥ 50%) were enrolled. 61% of patients received acetylsalicylic acid in combination with rivaroxaban 2.5 mg bid, other (39%)with clopidogrel. Median follow-up was 10 months [IQR 8.0; 12.0]. The safety end point was major and clinically relevant bleedings (type 2–5) according to the BARC classification. Plasma samples for VWF were taken at the inclusion and analyzed using ELISA.

Results

Frequency of BARC 2–5 bleedings was 20%. The most frequent (79%) was gastrointestinal bleedings. Median VWF plasma concentration was 154% [116; 196]. According to the quartile analysis, VWF values in the top three quartiles distribution (cut-off value > 122%) were associated with a higher frequency of bleeding events: 3.7% versus 36.7%, OR 8.8; CI 1,11-69,9, ? = 0.0392. Bleeding-free survival in groups formed depending on the VFW plasma concentration (122 > and ≤ 122%) was 96.2% vs. 73.9%, respectively, Log-Rank P = 0.0488.

Conclusions

Increase of VWF plasma concentration (> 122%) is associated with the development of major and clinically relevant bleedings in patients with PD receiving MAT.

Oral Presentation No. 03 Growth differentiation factor-15 and bleeding complication risk in patients with coronary artery disease, receiving combined antithrombotic therapy

Introduction

Recent studies are aimed to find laboratory predictors of bleeding complications in patients receiving various regimens of antithrombotic therapy. One of these biomarkers is GDF-15.

Purpose

To study the significance of GDF-15 in relation to the development of bleeding outcomes in CAD patients with multifocal atherosclerosis, receiving combined antithrombotic therapy.

Methods

The data was obtained from the prospective registry REGATA-1 (NCT04347200). 122 patients (90 males), median age 69 [IQR 64; 76] yrs) with CAD and peripheral atherosclerosis of at least one vascular territory (≥ 50%), were enrolled. Half of the patients (47.5%) with sinus rhythm received acetylsalicylic acid in combination with rivaroxaban 2.5 mg bid. Other patients (52.5%) with concomitant atrial fibrillation received direct oral anticoagulants in combination with antiplatelet therapy after elective PCI. Median follow-up was 10 months [IQR 7.0;12.0]. The safety end point was BARC 2–5 bleedings. Plasma samples for GDF-15 identification were taken at the inclusion and analyzed using ELISA.

Results

Frequency of BARC 2–5 bleedings was 14%. Median GDF-15 level was 1248.5 pg/ml [947.8; 1791.0]. According to the quartile analysis, GDF-15 values in the top three quartiles of the distribution (cut-off value > 948 pg/ml) were associated with higher frequency of bleeding events: 3.1% versus 17.8%, P = 0.0411. Bleeding-free survival in groups, formed depending on the level of GDF-15 (948 > and ≤ 948 pg/ml), was 96.7% vs. 82.2%, respectively, Log-Rank P = 0.0408.

Conclusions

Increase in GDF-15 level (> 948 pg/ml) is associated with the development of BARC 2-5 bleedings in CAD patients with multifocal atherosclerosis, receiving combined antithrombotic therapy.

Growth differentiation factor-15 and plasminogen activator inhibitor-1 are possible predictors of cardiovascular events in atrial fibrillation patients after elective PCI

Introduction

Patients (pts) with AF (atrial fibrillation), undergoing elective PCI (percutaneous coronary intervention), receiving combined antithrombotic therapy (AT) have high risk of stroke/systemic embolism, coronary events and bleedings. Minimizing the duration of combined AT is the main way to improve the safety of treatment. However, due to the high risk of thrombotic events, patient stratification is necessary. Biomarkers of high risk cardiovascular events (CVE) could be the rational reason to prolong combined AT for some pts. The search for them is relevant. There is data on relationship between growth differentiation factor-15 (GDF-15) level, plasminogen activator inhibitor-1 (PAI-1) level and adverse CVE.

Purpose

To investigate the prognostic value of GDF-15 and PAI-1 levels in AF pts after elective PCI during 1 year follow up.

Methods

150 pts (104 males), aged 70.8±8.5 years, with AF after elective PCI were enrolled in the prospective study. All pts received direct oral anticoagulants and double (89.3%) or single (10.7%) antiplatelet therapy. Median duration of follow up period was 11.5 months [IQR 8.0; 12.0]. Efficacy endpoint of the study was the sum of CVE: ACS (acute coronary syndrome), ischemic stroke (IS), VTE (venous thrombotic events), cardiovascular death and need for unplanned PCI. Plasma samples for GDF-15 and PAI-1 were taken before PCI and analyzed using ELISA.

Results

AF pts receiving combined AT demonstrated high thrombotic risk (CHA2DS2-VASc, Med 5 [IQR 4; 6]), high rate of comorbidity (index Charlson, Med 7 [IQR 5; 9]). Frequency of CVE during follow up period was 16% (ACS 2; fatal IS 2; VTE 2, include 1 fatal pulmonary embolism; cardiovascular death 2; pts needed an unplanned PCI 16). Median GDF-15 level was 1270 pg/ml [IQR 953; 1778]. Median PAI-1 level was 10.15 U/ml [6,3; 17,0].

By linear correlation analysis (r=0.24; p=0.0037) and by regression model (F-ratio 157.4, p<0.0001) GFD-15 and PAI-1 are exhibited a relation.

According to ROC analysis GDF-15 level >1191 pg/ml (sensitivity 83.0, specifity 50.0) and PAI-1 level >13.2 U/ml (sensitivity 58.3, specifity 68.6) increases the probability of the development of CVE (AUC=0.647, p=0.0076, CI 0.565–0.723; AUC=0.652, p=0.0135, CI 0.569–0.728 respectively). Kaplan-Meier curves demonstrated significant difference in CVE free survival between the patients with GDF-15 level > and ≤1191 pg/ml (75.9% and 94.0% respectively, p=0.0032 [HR 4.36, CI 1.50–7.48]); and with PAI-1 level > and ≤13.2 U/ml (74% and 89% respectively, p=0.0112 [HR 2.73, CI 1.28–6.98]). The multivariable Cox regression model demonstrated that GDF-15 (p=0.0363) and PAI-1 (p=0.0074), were independently associated with an increased risk of CVE (op=0.0022).

Conclusions

GDF-15 and PAI-1 are correlated, and they are new markers of CVE in AF pts after elective PCI.

Funding Acknowledgement

Type of funding sources: None.

Plasma urokinase antigen and C-reactive protein predict angina recurrence after coronary angioplasty

This study evaluates the predictive value of several biochemical indices of the coagulation-fibrinolysis system, platelet function, and inflammatory state for angina recurrence after successful percutaneous transluminal coronary angioplasty (PTCA). We measured preprocedural and follow-up plasma levels of C-reactive protein (CRP), fibrinogen, and urokinase plasminogen activator antigen (uPA), plasminogen activator inhibitor-1 (PAI-1) activity, tissue plasminogen activator activity, and adenosine diphosphate-induced platelet aggregation in 53 patients with chronic stable angina who underwent successful elective PTCA of single hemodynamically significant lesions in coronary arteries. All patients were followed up for 12 months after PTCA. The Cox proportional hazards model was used to assess the association of variables with angina recurrence rate. At the end of the follow-up, 16 patients had angina recurrence. Among 36 clinical, biochemical, and angiographic variables, the duration of stable angina more than 12 months before PTCA (χ (2) = 5.73; P = 0.02, hazard ratio (HR) 3.7, 95 % confidence interval (CI) 1.26-10.6), high baseline levels of CRP (>7 mg/l) (χ (2) = 8.34; P = 0.004, HR 2.9, 95 % CI 1.4-5.9), uPA antigen baseline (>1 ng/ml) (χ (2) = 17.11; P = 0.0001, HR 11.5, 95 % CI 3.6-36.7) and 48 h after PTCA (χ (2) = 15.73; P = 0.0001, HR 8.8, 95 % CI 3.01-25.96), baseline PAI-1 activity (>18 IU/ml) (χ (2) = 9.37; P = 0.002, HR 7.6, 95 % CI 2.07-27.84) were significant predictors of recurrent angina by univariate analyses. According to stepwise multivariate analyses, only the levels of plasma uPA antigen and serum CRP were shown to be significant independent predictors of angina recurrence (multivariate uPA χ (2) = 8.22, P = 0.004, HR 6.2, 95 % CI 1.78-21.67; CRP χ (2) = 4.09, P = 0.04, HR 1.9, 95 % CI 1.02-3.68). High preprocedural plasma uPA and serum CRP levels are indicative of angina recurrence after successful PTCA, and are valuable for the prognosis of restenosis.

D-dimer and platelet aggregability are related to thrombotic events in patients with peripheral arterial occlusive disease

AIMS

To evaluate the frequency of arterial thrombotic events in patients with peripheral arterial occlusive disease during 3-5 years of follow-up and to determine whether baseline levels of haemostatic factors were related to the risk of future thrombotic events.

METHODS AND RESULTS

One hundred and twenty-three patients, mean age 56 years, with peripheral arterial occlusive disease and intermittent claudication were followed prospectively for an average of 4.2 years. Fibrinogen, prothrombin fragment 1+2, D-dimer, tissue plasminogen activator, plasminogen activator inhibitor type I antigen and activity, plasmin-alpha(2)-antiplasmin complex, beta thromboglobulin and ADP-induced platelet aggregation were measured at the recruitment. Thirty-eight new vascular events (15 fatal) were identified. Age- (and other clinical and laboratory variables) -adjusted relative risks (RR) of thrombotic events were significantly elevated (P<0.05) per higher value of D-dimer (RR: 14.1, 95% CI 1.7;115.8) and platelet aggregation was low (RR: 4.6, 95% CI 1.3;16.3). Diabetes mellitus, cerebrovascular disease, and continuing deterioration of intermittent claudication at the recruitment were also independently associated with risk of thrombotic events in the multiple regression model (RR: 5.2, 95% CI 1.5;17.5; RR: 8.6, 95% CI 2.7;27.4; RR: 2.6, 95% CI 1.2;5.7 respectively).

CONCLUSION

Elevated level of D-dimer and low platelet aggregation are independent haemostatic predictors of thrombotic events in patients with peripheral arterial occlusive disease.

Effects of indobufen and pentoxifylline on walking capacity and hemostasis in patients with intermittent claudication: results of six months of treatment

Seventy-one patients with peripheral arterial occlusive disease (PAOD) were randomized into two groups of different treatment modalities. The diagnosis of PAOD was established by history of intermittent claudication, clinical examination, and by Doppler pressure assessment or lower extremity arteriography. After a three-month washout period, 35 patients (Group 1) started treatment with indobufen (400 mg per day) and 36 patients (Group 2) with pentoxifylline (600 mg per day). Twenty-nine patients from each group completed six months of treatment. Both of the drugs significantly improved maximal and pain-free walking distances, but the effect of indobufen was more pronounced than that of pentoxifylline. Patients with PAOD exhibited signs of hypercoagulation. Fibrinogen, D-dimer, and b-thromboglobulin concentrations did not change significantly following treatment in both of the groups. The authors observed a decrease of platelet aggregation after treatment with indobufen and a decrease of F1 + 2 fragment and PAI-1 antigen after treatment with pentoxifylline.

D-dimer and fibrinolysis in patients with various degrees of atherosclerosis

D-dimer, plasminogen activator inhibitor (PAI-1) activity at rest and after exercise, and tissue plasminogen activator (t-PA) activity after exercise were measured in venous blood in 88 patients with atherosclerotic lesions of various degrees. According to clinical symptoms, coronary angiography (CAG), ultrasound Doppler signal and duplex and colour Doppler scanning of carotid arteries and their branches, subclavian, vertebral and peripheral arteries of the lower limbs, patients were divided into four groups. Group 1, 16 men without CAG and ultrasound signs of atherosclerotic lesions; group 2, 27 patients with CAG-confirmed coronary artery disease; group 3, 18 patients with peripheral artery occlusive disease; group 4, 27 patients with coexistence of two or more regions of atherosclerotic lesions. D-dimer was the highest in patients with the most extensive atherosclerosis: 432 +/- 164 ng.ml-1 in group 3, 429 +/- 98 ng.ml-1 in group 4 vs 163 +/- 25 ng.ml-1 in group 1, P < 0.05. There were correlations (P < 0.05) between: age and D-dimer (r = 0.29); D-dimer and t-PA (r = 0.34); D-dimer and PAI-1, r = -0.29. Patients were also analysed according to D-dimer level. In patients with the highest level of D-dimer, the lowest level of PAI-1 activity and the highest level of t-PA activity after exercise were observed. The low PAI-1 activity is probably the result of an increased release of t-PA in these patients.

The effect of exogenous phosphocreatine on maximal walking distance, blood rheology, platelet aggregation, and fibrinolysis in patients with intermittent claudication

Thirty-seven men with angiography or ultrasound confirmed peripheral arterial occlusive disease were divided into two groups. Group 1 included 24 patients treated with one daily infusion of 10 g of phosphocreatine in 200 ml of solvent for 10 days. Group 2 included 13 patients who were given 0.9% NaCl in the same scheme. Groups were comparable in: duration of intermittent claudication, maximal walking distance, Ketle index, cholesterol, triglycerides, frequency of ischemic heart disease, hypertension, diabetes, smoking. Patients were examined 4 times: before starting, on second day, after treatment period, and 1 month after. Treadmill-test; ADP-, PAF-, 5-HT-induced platelet aggregation; D-dimer; PAI-1 activity; blood viscosity at high and low shear rate; hematocrit were performed. After treatment maximal walking distance significantly increased in patients of Group 1. Mechanisms of this effects include positive influence of phosphocreatine on platelet aggregation, blood rheology, coagulation and fibrinolytic systems.