Hemostatic Biomarkers Research Articles

Abstract P130: Ideal Cardiovascular Health and Incident Cardiovascular Disease: Heterogeneity Across Event Phenotype and Contribution of Multiple Biomarkers. The Prime Study

Background: To which extent the association between ideal cardiovascular health (CVH) and incident vascular events differ by main coronary heart disease (CHD) and main stroke phenotype is currently unknown. Furthermore, data on potential mediating factors underlying the association of ideal CVH with outcomes are lacking. Aims: We aimed to 1) quantify the association between ideal CVH and incident CHD and stroke, 2) to assess for potential heterogeneity across main CHD and main stroke phenotypes and between CHD and stroke; and 3) to assess the mediating effect of a selected panel of key circulatory biomarkers from different relevant disease pathways. Methods and Results: A total of 9312 men middle-aged men (50-59 years) free of CHD and stroke were recruited in the framework of WHO MONICA centres in Lille, Strasbourg, Toulouse (France) and Belfast (Northern Ireland) between 1991 and 1993 and enrolled in the PRIME study. According to the American Heart Association, men with 0-2, 3-4 and 5-7 metrics at the ideal level were categorized as having poor, intermediate and ideal CVH respectively. Hazards ratios (HRs) were estimated using Cox proportional hazards regression and were adjusted for age, centre, education, living alone, marital status, family history of CHD and blood fibrinogen. The contribution of baseline circulating, endothelial inflammatory and haemostatic biomarkers was explored in a case control study nested within the PRIME cohort and settled after 10 years of follow-up. An ideal CVH was observed in 7% of the participants. After a median follow-up of 10 years, 614 first CHD events (myocardial infarction, angina, coronary death) and 117 first stroke events (ischaemic and non ischaemic) were adjudicated. Compared to those with poor CVH, those with an ideal CVH at baseline had a 72% lower risk of CHD (HR=0.28; 95% CI: 0.17; 0.46) and a 76% lower risk of stroke (HR=0.24; 95% CI: 0.06; 0.98) in multivariate analysis. No heterogeneity was detected across main CHD and main stroke phenotypes. While significantly lower mean concentrations of hs-CRP, IL-6, ICAM-1, fibrinogen and von Willbrandt factor were noted in subjects with ideal or intermediate as compared to poor CVH status in the controls, none of these biomarkers contribute to the association of CVH with future CHD. Conclusion: In this study ideal CVH was associated with a substantially lower risk of CHD and stroke, without any difference across phenotypes. Neither inflammatory, endothelial nor haemostatic biomarkers explained the lower risk of CHD in men with ideal CVH.

Physical Activity, Sedentary Behavior, and Inflammatory and Hemostatic Markers in Men.

This study aimed to determine whether higher levels of physical activity (PA) and less sedentary behavior (SB) are associated with less inflammation, indicated by inflammatory and hemostatic biomarkers, in older men. A cross-sectional study of 1139 men, from the British Regional Heart Study (mean ± SD age = 78 ± 5 yr), and longitudinal analyses of 490 men with two PA measures 1 yr apart were used in this study. Single fasting venous blood samples were analyzed for several biomarkers. PA and SB were measured using ActiGraph GT3X accelerometers. Total time and time spent in bouts of moderate to vigorous PA (MVPA), light PA, and SB were derived. Linear regression analyses were used to investigate associations. Cross-sectionally, higher total PA, daily steps, and MVPA were all associated with lower levels of interleukin 6 (IL-6), C-reactive protein (CRP), tissue plasminogen activator (tPA), von Willebrand factor (vWF), and D-dimer, whereas higher levels of SB were associated with higher levels of IL-6, CRP, and tPA. Each additional 10 min of MVPA was associated with a 3.2% lower IL-6 (95% confidence interval [CI] = -4.5% to -1.8%), 5.6% lower CRP (95% CI = -7.8 to -3.3), 2.2% lower tPA (95% CI = -3.0 to -1.4), 1.2% lower vWF (95% CI = -2.1 to -0.3), and 1.8% lower D-dimer (95% CI = -2.9 to -0.7), and for CRP, vWF, and D-dimer independently of SB. Associations between SB and IL-6 or tPA were independent of MVPA. Longer bouts of PA or SB were not more strongly associated with outcomes than shorter bouts. Longitudinal analyses were inconsistent with these findings, possibly because of power limitations. Although PA (particularly MVPA) was generally associated with inflammatory and hemostatic biomarkers, we found no evidence that longer bouts were more important than shorter bouts.

OC-1a: A prospective study of hemostatic biomarkers to predict early recurrence in high-risk breast cancer women undergoing post-surgical adjuvant systemic therapy

OC-1a: A prospective study of hemostatic biomarkers to predict early recurrence in high-risk breast cancer women undergoing post-surgical adjuvant systemic therapy

Diagnosis and Treatment of Hyperfibrinolysis in Trauma (A European Perspective).

Fibrinolysis activation occurs almost universally after severe trauma. Systemic hyperfibrinolysis is a key component of acute traumatic coagulopathy and associated with poor clinical outcomes, although controversy exists over optimal treatment strategies. The mechanistic drivers and dynamics of fibrinolytic activation in response to injury and trauma resuscitation are currently unclear. Furthermore, therapeutic triggers are compounded by the lack of a sensitive and rapid diagnostic tool, with discrepancy between hyperfibrinolysis diagnosed by viscoelastic hemostatic assays versus biomarkers for fibrinolysis. Rotational thromboelastometry and thromboelastography appear capable of detecting the severest forms of hyperfibrinolysis but are relatively insensitive to moderate, yet clinically significant fibrinolytic activation. Rapid evaluation of the current status of the fibrinolytic system remains a challenge and therefore the decision whether to administer an antifibrinolytic agent should be based on available evidence from clinical trials. In line with current European guidelines, we recommend that all bleeding trauma patients, and in particular, severely injured patients with evidence of hemorrhagic shock, should receive early empiric tranexamic acid. This review explains our current knowledge of the pathophysiological pathways which induce hyperfibrinolysis in trauma hemorrhage, evaluates the available diagnostic modalities, and describes current treatment strategies.

Identification & Characterization of Novel Hemostatic Biomarkers of Adverse Clinical Events in Patients with Continuous Flow Left Ventricular Assist Device Implants

Introduction: Heart failure affects over 5 million people in the US. Its rising prevalence coupled with a lack of donor hearts has led to an increase in the use of continuous flow left ventricular assist devices (CF-VAD). However, patients with CF-VAD implants are at risk for complications such as non-surgical bleeding and thrombosis, which significantly increase the risk of patient morbidity and mortality. Identification of novel biomarkers for these events could improve current risk assessment models, treatment, and thus, quality of life for VAD implanted patients.Materials and Methods: 71 blood samples were collected peri-operatively and at varying time points post-operatively from 16 patients implanted with a Thoratec HeartMate II CF-VAD. Plasma was prepared and stored at -70°C until analysis. Plasma samples collected from normal individuals were used as controls. Samples were analyzed for annexin V-positive microparticles and microparticles exposing tissue factor, as well as plasma levels of annexin V and C-reactive protein (CRP) by ELISA. Additionally, surface-enhanced laser desorption ionization - mass spectrometry (SELDI-MS) analysis was used to identify changes in biomarker expression. The occurrence of adverse clinical events was determined using an internal RedCap database. CF-VAD thrombosis was characterized as: cerebrovascular accident/transient ischemic attack diagnosed by a neurologist, rise in LDH or plasma free hemoglobin, hemolysis, evidence of pump dysfunction consistent with thrombus identified by pump parameters, echocardiographic or computed tomographic evidence of clot, or surgical pump exchange for thrombus. CF-VAD bleeding events were characterized as: anemia and bleeding determined by a cardiologist.Results: Annexin V plasma levels were increased approximately 3-fold compared to normal plasma (9.23 ±0.85 vs. 2.76 ±0.2 nM). CRP plasma levels were significantly elevated in CF-VAD patients compared to normals (14.5 ±2.7 vs. 2.2 ± 0.6 µg/ml; p=0.034). Although the level of annexin V-positive microparticles were the same in CF-VAD patients and normals, the amount of microparticles exposing tissue factor was significantly higher in CF-VAD patients (3.7 ± 1.1 vs. 0.5 ± 0.1 pg/ml; p=0.038). SELDI-MS analysis indicated three distinct peaks that were present in CF-VAD patients, but absent from normals (8.1, 11.7 and 15.2/16.2 kDa). During the follow-up period, patients experienced 12 CF-VAD-related thrombotic events, 8 hemorrhagic events and 2 septic events. The 8.1 kDa biomarker was present in 10/12 patients with a thrombotic event, 2/6 patients with a hemorrhagic event, 0/2 patients experiencing sepsis and 0/2 patients without an adverse event. Positive correlations with the SELDI-MS peaks and measured parameters were identified: the 8.1 kDa peak was associated with elevated plasma levels of annexin V (p=0.01) and the presence of annexin V-positive microparticles (p=0.005); the 11.7 kDa peak was associated with elevated plasma levels of CRP (p=0.01); the 15.2/16.2 kDa peaks were associated with the presence of microparticle exposing tissue factor (p=0.002), annexin V-positive microparticles (p<0.001) and elevated plasma levels of annexin V (p=0.03).Conclusions: Despite treatment with low-dose aspirin and warfarin, CF-VAD patients exhibit signs of hemostatic activation. SELDI-MS may be useful in the identification of novel biomarkers of CF-VAD-associated adverse events. This data justifies further evaluation of the utility of the SELDI-MS to readily identify biomarkers related to adverse clinical events in a larger CF-VAD population. DisclosuresNo relevant conflicts of interest to declare.

Markers of Coagulation and Angiogenesis Can Serve As Surrogate Biomarkers for Disease Activity and Survival in Cancer Patients

Based on observations of the link between hemostatic system and malignancy it is plausible to consider that plasma coagulation factors could serve as easily accessible markers for detection of malignant state and monitoring of cancer patients. Therefore, we hypothesized that tissue factor (TF), angiopoietin-2 (Ang-2) and soluble urokinase plasminogen activator receptor (suPAR) might perform as diagnostic and predictive biomarkers for the presence of malignancy as well as for the development of cancer-related events: metastatic progression and death.To analyze their performance TF-associated microparticle activity (MPTF), tissue factor antigen (TFAg), Ang-2 and suPAR were determined in 128 cancer patients with various cancer types receiving chemotherapy by sequential measurements (up to four times) at prespecified time points incorporated into interim and end-of-treatment analysis. MPTF activity was measured with Zymuphen MPTF kit, TFAg, suPAR and ANG-2 were quantitated by ELISA. Patients were followed up for progression free survival (PFS) from therapy initiation until occurrence of a combined event defined as either metastatic progression or death. In order to determine the predictive ability of hemostatic biomarkers for a PFS event Log-rank (Mantel-Cox) test was applied. ROC analysis was used to determine the cut off values for detection of an event, cut off values were transformed into binary variables and Kaplan-Meier curves were constructed. Cox regression analysis was applied to explore quantitatively the effect on the risk of progression.Results: Cut off values for the occurrence of an event were MPTF < 0.5 pg/ml (AUC 0.591), TFAg (√ pg/ml) > 8.28 (AUC 0.603), Ang-2 > 302.3 pg/ml (AUC 0.615) and suPAR (√ pg/ml) > 2.83. Shortened PFS was associated with decreased MPTF procoagulant activity and elevated plasma levels of TFAg, Ang-2, suPAR. As significant predictors for PFS were determined only TFAg (RR 4.57, p=0.038), Ang-2 (RR 2.138, p=0.031) and suPAR (RR 2.238, p=0.049).Conclusion: TFAg, Ang-2 and suPAR might be identified as significant adverse predictors of metastatic progression or death in cancer patients and risk is increased with elevated plasma levels. DisclosuresNo relevant conflicts of interest to declare.

Plasma markers of inflammation and hemostatic and endothelial activity in naturally overweight and obese dogs.

BackgroundObesity is one of the most prevalent health problems in the canine population. While haemostatic parameters and markers of endothelial function have been evaluated in various disease conditions in dogs, there are no studies of these markers in canine obesity. This study was designed to evaluate the effect of naturally gained weight excess and obesity on inflammatory, hemostatic and endothelial biomarkers in dogs. A total of 37 overweight and obese dogs were compared with 28 normal weight dogs.ResultsOverweight and obese dogs had significantly elevated concentrations of serum interleukin-6 (IL-6) and C-reactive protein (hsCRP). Number of platelets, activity of factor X and factor VII were significantly higher, while activated partial thromboplastine time (aPTT) and soluble plasminogen activator receptor (suPAR) were significantly decreased. Statistical analysis of high mobility group box – 1 protein (HMGB-1), soluble intercellular adhesive molecule -1 (sICAM-1) and plasminogen activator inhibitor type 1 (PAI-1) concentrations did not show significant differences between the total overweight and obese group and the normal weight group of dogs.ConclusionsAnalytical changes in the dogs in our study reflects that weight excess in dogs can be associated with a chronic low degree of inflammation and a hypercoagulable state, where primary and secondary hemostasis are both affected. However obesity is not associated with impairment of endothelial function in dogs.

Estimating the associations of apparent temperature and inflammatory, hemostatic, and lipid markers in a cohort of midlife women

Associations between temperature and cardiovascular (CVD) mortality have been reported, but the underlying biological mechanisms remain uncertain. We explored the association between apparent temperature and serum biomarkers for CVD. Using linear mixed effects models, we examined the relationships between residence-proximate apparent temperature (same day and 1, 7, and 30 days prior) and several inflammatory, hemostatic, and lipid biomarkers for midlife women from 1999 through 2004. Our study population consisted of 2,306 women with mean age of 51 years (± 3 years) enrolled in Study of Women's Health Across the Nation (SWAN) in Chicago, Illinois; Detroit, Michigan; Los Angeles and Oakland, California; Newark, New Jersey; and Pittsburgh, Pennsylvania. Mean daily apparent temperature was calculated using temperature and relative humidity data provided by the National Climatic Data Center and the US Environmental Protection Agency, while daily data for fine particles, ozone, carbon monoxide, and nitrogen dioxide from the US Environmental Protection Agency Air Quality Data Mart were considered as confounders. All analyses were stratified by warm and cold seasons.More significant (p < 0.10) negative associations were found during the warm season for various lag times, including hs-CRP, fibrinogen, tissue plasminogen activator antigen (tPA-ag), tissue plasminogen activator antigen (PAI-1), Factor VIIc, high-density lipoprotein (HDL), and total cholesterol. During the cold season, significant negative associations for fibrinogen and HDL, but significant positive associations for tPA-ag, PAI-1, and triglycerides were observed for various lag times. With the exception of ozone, pollutants did not confound these associations. Apparent temperature was associated with several serum biomarkers of CVD risk in midlife women, shedding light on potential mechanisms.

Inflammatory/hemostatic biomarkers and coronary artery calcification in midlife women of African-American and White race/ethnicity: the Study of Women's Health Across the Nation (SWAN) heart study.

Inflammatory/hemostatic biomarkers are associated with coronary heart disease events, but relationships in asymptomatic midlife women are uncertain. We evaluated separately whether high-sensitivity C-reactive protein (hsCRP), fibrinogen, plasminogen-activator inhibitor 1, tissue plasminogen activator antigen, and circulating factor VII (factor VIIc) were associated with coronary artery calcification (CAC) in healthy midlife women. A cross-sectional study was performed of participants from the Study of Women's Health Across the Nation. Logistic and Tobit regression was used to assess associations between log-transformed biomarkers, and CAC presence (CAC > 0) and extent. Effect modification by race/ethnicity was evaluated. The study included 372 women (mean age 51.3 y; 35.2% African-American). All biomarkers were positively associated with CAC presence and extent (P < 0.001 for all), adjusting for Framingham risk score, site, race/ethnicity, menopause status, income, and education. Additional adjustment for body mass index explained all associations except for factor VIIc, which remained associated with CAC extent only (P = 0.02). Final adjustment for insulin resistance, family history of cardiovascular disease, and cardiovascular medication use produced similar results. Associations between hsCRP, and CAC presence and extent were modified by race/ethnicity (P < 0.05). Log(hsCRP) was positively associated with CAC presence (odds ratio 3.25; 95% CI, 1.53-6.90; P = 0.002; per 1 log unit increase) and CAC extent (β = 19.66; SE = 7.67; P = 0.01; per 1 log unit increase) in African-Americans only. Inflammatory/hemostatic biomarkers were associated with CAC through obesity, except for factor VIIc. Among African-American women only, hsCRP was independently associated with CAC, suggesting that hsCRP may have a role in coronary heart disease prevention in African-American midlife women.

Role of Hemostatic and Inflammatory Biomarkers in Alzheimer’s and Vascular Dementia (P5.175)

Role of Hemostatic and Inflammatory Biomarkers in Alzheimer’s and Vascular Dementia (P5.175)

Associations of Serum 25-Hydroxyvitamin D With Hemostatic and Inflammatory Biomarkers in the Multi-Ethnic Study of Atherosclerosis.

Mechanisms explaining documented associations of 25-hydroxyvitamin D [25(OH)D] deficiency with increased risks of cardiovascular disease (CVD) and venous thromboembolism may relate to adverse hemostatic and inflammatory responses. To evaluate whether 25(OH)D deficiency is associated with a prothrombotic and proinflammatory biological profile. Cross-sectional analyses. The Multi-Ethnic Study of Atherosclerosis, a multicenter prospective cohort of American adults. Up to 6554 adults free of CVD. Ten hemostatic biomarkers (D-dimer, fibrinogen, factor VIII, plasmin-antiplasmin, and homocysteine [n = 6443]; von Willebrand factor, soluble tissue factor, plasminogen activator inhibitor-1 (PAI-1), total tissue factor pathway inhibitor (TFPI), and soluble thrombomodulin [n = 814]), and three inflammatory biomarkers (IL-6, C-reactive protein [n = 6443], and TNF-α soluble receptor [n = 3802]). Among 6443 subjects (46.6% men; mean age, 62.1 years; mean body mass index, 28.3 kg/m(2)) of White (37.8%), Black (27.2%), Chinese (12.2%), and Hispanic (21.8%) race/ethnicity, mean 25(OH)D was 25.3 ng/mL. After multiple adjustment, 25(OH)D concentrations were associated with concentrations of IL-6 and homocysteine and also with concentrations of PAI-1 and TFPI: per 10 ng/mL decrement in 25(OH)D, 5.1% higher IL-6 (95% confidence interval [CI], 3.4-6.9; P < .001); 3.7% higher homocysteine (95% CI, 3.0-4.3; P < .001); 7.0% higher PAI-1 (95% CI, 0.9-13.6; P = .025); and 2.1% higher TFPI (95% CI, 0.0-4.2; P = .047), without racial/ethnic heterogeneity. No significant associations were observed for other hemostatic and inflammatory biomarkers. Increased inflammation as reflected by higher circulating IL-6 and increased homocysteine concentrations may represent mechanisms linking 25(OH)D deficiency to greater risks of CVD and perhaps venous thromboembolism. Low concentrations of 25(OH)D were also associated with PAI-1 and TFPI concentrations, but not with other hemostatic biomarkers.

Abstract TP454: Hemostatic Biomarkers Succeed While Inflammatory Biomarkers Fail To Differentiate Vascular Dementia From Alzheimer’S Disease

Introduction: A reliable plasma biomarker in differentiating between Alzheimer’s disease (AD) and Vascular dementia (VaD) is the need of the hour, in most memory clinics. Hypothesis: We assessed the hypothesis that plasma inflammatory [Interleukin 6 (IL 6) and C-Reactive Protein (CRP)] and hemostatic (Fibrinogen and D dimer) biomarkers can aid in differentiating between AD and VaD. Methods: Neuropsychological assessment, MRI brain, FDG-PET brain and CSF biomarkers of AD (Aβ42 and total tau) were used for establishing the diagnosis of Mild Cognitive Impairment (MCI), AD or VaD. ELISA analyses for IL6, Fibrinogen, D dimer and CRP were performed according to the manufacturers’ protocols. Results: During the study period (January 2013-April 2014), 68 diagnosed patients of AD/MCI/VaD were included. FDG PET brain, plasma fibrinogen, D dimer, IL6 and CRP were done in all 68 patients while 48 patients underwent CSF biomarker analysis. Sixteen patients had MCI, of which 11 were MCI-AD and 5 were MCI-VaSC. There were 41 patients with AD (Mild AD- 9, Mod AD -23, Severe AD- 9) and 11 patients with VaD. The Alzheimer group (MCI-AD and AD) and Vascular group (MCI VaSC &amp; VaD) consisted of 52 and 16 patients respectively. Table 1 depicts biomarker levels. Alzheimer and Vascular groups did not exhibit significant difference in IL6 and CRP levels. Plasma fibrinogen levels were significantly higher in VaD and vascular group as compared to Alzheimer group. But MCI-VaSC was not significantly different from MCI-AD. Plasma D dimer levels were significantly higher in all vascular subgroups compared to Alzheimer subgroups except between MCI-VaSC and MCI-AD. Conclusion: In conclusion, hemostatic biomarkers (Plasma Fibrinogen and D dimer) succeed, whereas inflammatory biomarkers (IL6 and CRP) fail in differentiating VaD from AD.

Longitudinal changes in hemostatic parameters and reduced pulsatility contribute to non-surgical bleeding in patients with centrifugal continuous-flow left ventricular assist devices

Bleeding and thromboembolic events are identified complications in patients supported with newer centrifugal continuous-flow left ventricular assist devices (cfLVADs). Bleeding events have been associated with acquired von Willebrand syndrome (vWS) in these patients, though longitudinal changes and the effect of pulsatility remain unquantified. We evaluated longitudinal effects of third-generation cfLVADs on hemostatic biomarkers, non-surgical bleeding, and thromboembolic events. We investigated the association between pulsatility (as defined by aortic valve opening) on von Willebrand Factor (VWF) profile and bleeding. We prospectively studied 28 patients implanted with the HeartWare (HeartWare International, Framingham, MA) cfLVAD for up to 360 days. We performed bleeding and coagulation assays 8 times from pre-implant to Day 360 (D360) post-implant, including platelet aggregometry, VWF collagen binding activity-to-antigen (CBA/Ag) ratio, thromboelastography, soluble P-selectin, platelet-specific marker soluble glycoprotein VI (sGPVI), and platelet microparticles. Aortic valve opening was assessed by echocardiography at each assessment. Bleeding and thromboembolic events were documented. Bleeding events occurred in 14 patients (50%). Maximal platelet inhibition occurred by D30. VWF profile impairment (VWF CBA/Ag < 0.8) was demonstrated in 89% of patients at D30, with subsequent recovery but further deterioration after D180. Bleeding was associated with elevated pre-implant sGPVI (p = 0.008). Pulsatility was associated with higher VWF CBA/Ag (p = 0.02) and a trend to less bleeding. Third-generation cfLVADs were associated with longitudinal changes in hemostatic markers, and bleeding was associated with elevated pre-implant plasma sGPVI. Further, pulsatility may contribute to recovery of the VWF profile and potentially lower bleeding risk.

Haemostatic biomarkers are associated with long-term recurrent vascular events after ischaemic stroke.

Ischaemic stroke patients continue to be at risk for recurrent vascular events for many years. Predictors of long-term prognosis are needed. It was the objective of this study to investigate levels of four haemostatic proteins as long-term predictors of recurrent vascular events after ischaemic stroke. We prospectively followed 548 ischaemic stroke patients, 18-69 years, and registered recurrent vascular events. Plasma levels of tissue-type plasminogen activator (t-PA), von Willebrand factor (VWF), fibrinogen and thrombin activatable fibrinolysis inhibitor activation peptide (TAFI-AP) were measured three months after index stroke. Cox regression models were used to assess associations to outcomes for single biomarkers and for a combined biomarker measure. For single biomarkers significantly associated with any of the outcomes, we performed subanalyses stratified for age, sex, diabetes and atherosclerosis. During 5,637 person-years of follow-up, we registered 74 vascular deaths, 90 recurrent strokes and 62 coronary events. Levels of t-PA, VWF and fibrinogen were significantly associated with vascular death and coronary events. After adjustment, the association between t-PA and vascular death remained (HR per 1 SD increase in plasma level 1.27, 95 % CI 1.00-1.61, p=0.047). The combined effect of t-PA, VWF and fibrinogen was associated with coronary events (adjusted HR 1.35, 1.02-1.80, p=0.04). In non-diabetic patients, an association with coronary events was seen for VWF levels (adjusted HR 2.23, 1.45-3.43, p<0.01). In conclusion, plasma levels of haemostatic factors were associated with vascular death and coronary events, but not with recurrent stroke. Our results suggest that the predictive value of biomarkers differ by specific outcome measure and subgroup of patients.

Shared genetic susceptibility of vascular-related biomarkers with ischemic and recurrent stroke.

To investigate the genetic contributors to cerebrovascular disease and variation in biomarkers of ischemic stroke. The Vitamin Intervention for Stroke Prevention Trial (VISP) was a randomized, controlled clinical trial of B vitamin supplementation to prevent recurrent stroke, myocardial infarction, or death. VISP collected baseline measures of C-reactive protein (CRP), fibrinogen, creatinine, prothrombin fragments F1+2, thrombin-antithrombin complex, and thrombomodulin prior to treatment initiation. Genome-wide association scans were conducted for these traits and follow-up replication analyses were performed. We detected an association between CRP single nucleotide polymorphisms (SNPs) and circulating CRP levels (most associated SNP, rs2592902, p = 1.14 × 10(-9)) in 2,100 VISP participants. We discovered a novel association for CRP level in the AKR1D1 locus (rs2589998, p = 7.3 × 10(-8), approaching genome-wide significance) that also is an expression quantitative trait locus for CRP gene expression. We replicated previously identified associations of fibrinogen with SNPs in the FGB and LEPR loci. CRP-associated SNPs and CRP levels were significantly associated with risk of ischemic stroke and recurrent stroke in VISP as well as specific stroke subtypes in METASTROKE. Fibrinogen levels but not fibrinogen-associated SNPs were also found to be associated with recurrent stroke in VISP. Our data identify a genetic contribution to inflammatory and hemostatic biomarkers in a stroke population. Additionally, our results suggest shared genetic contributions to circulating CRP levels measured poststroke and risk for incident and recurrent ischemic stroke. These data broaden our understanding of genetic contributors to biomarker variation and ischemic stroke risk, which should be useful in clinical risk evaluation.

Association of Haemostatic and Inflammatory Biomarkers with Nephropathy in Type 1 Diabetes Mellitus.

This study aimed at investigating the association between haemostatic biomarkers, proinflammatory, and anti-inflammatory cytokines with chronic kidney disease in type 1 diabetic patients. Patients were divided into two groups: with nephropathy (albuminuria ≥ 30 mg/g and/or GFR < 60 mL/min/1.73 m2), n = 65; and without nephropathy (albuminuria < 30 mg/g and GFR ≥ 60 mL/min/1.73 m2), n = 60. INF-γ, IL-6, IL-10, and TNF-α plasma levels were determined by flow cytometry. VWF, ADAMTS13 antigen, and D-Dimer plasma levels were determined by enzyme-linked immunosorbent assay and ADAMTS13 activity was assessed by fluorescence resonance energy transfer assay. Elevated levels of INF-γ, VWF, ADAMTS13 antigen, D-Dimer, and reduced ADAMTS13 activity/antigen ratio were observed in patients with nephropathy as compared to those without nephropathy (P = 0.001, P < 0.001, P < 0.001, P < 0.001, and P < 0.001, resp.). Cytokines and haemostatic biomarkers remained associated with nephropathy after adjustments (use of statin, acetylsalicylic acid, angiotensin converting enzyme inhibitor, and angiotensin antagonist). INF-γ, TNF-α, and IL-10 significantly correlated with haemostatic biomarkers. Inflammatory and hypercoagulability status are associated with nephropathy in type 1 diabetes mellitus and an interrelationship between them may play an important role in pathogenesis of diabetic nephropathy.

Hypercoagulability and Platelet Abnormalities in Inflammatory Bowel Disease.

Patients with inflammatory bowel disease (IBD) exhibit a threefold higher risk for development of systemic thrombosis than the general population. Although the underlying causes of the increased risk for thrombus development remain poorly understood, there is a large body of evidence suggesting that abnormalities in coagulation, fibrinolysis, and platelet function may contribute to this response. Changes in hemostatic biomarkers are consistent with subclinical activation of coagulation system, including tissue factor activation, impaired protein C pathway, enhanced thrombin generation, and diminished fibrinolytic capacity. There is also evidence for an increased production and reactivity of platelets, with an enhanced formation of platelet-platelet and platelet-leukocyte aggregates. The altered coagulation and platelet function, and the predisposition to thrombus formation have also been demonstrated in animal models of IBD. The animal studies have revealed a major role for inflammatory cytokines, including tumor necrosis factor-α, interleukin (IL)-1β, and IL-6, as mediators of the platelet abnormalities and enhanced thrombus development in experimental IBD. These findings in animal models raise hope for the development of novel therapeutic strategies to reduce thrombosis-related mortality in IBD patients.

Unique effects on hepatic function, lipid metabolism, bone and growth endocrine parameters of estetrol in combined oral contraceptives

Objectives Estetrol (E4) is a natural estrogen produced by the human fetal liver. In combination with drospirenone (DRSP) or levonorgestrel (LNG), E4 blocks ovulation and has less effect on haemostatic biomarkers in comparison with ethinylestradiol (EE) combined with DRSP. This study evaluates the impact of several doses of E4/DRSP and E4/LNG on safety parameters such as liver function, lipid metabolism, bone markers and growth endocrine parameters.Methods This was a dose-finding, single-centre, controlled study performed in healthy women aged 18 to 35 years with a documented pretreatment ovulatory cycle. Participants received 5 mg or 10 mg E4/3 mg DRSP; 5 mg, 10 mg or 20 mg E4/150 μg LNG; or 20 μg EE/3 mg DRSP as a comparator for three consecutive cycles in a 24/4-day regimen. Changes from baseline to end of treatment in liver parameters, lipid metabolism, bone markers and growth endocrinology were evaluated.Results A total of 109 women were included in the study. Carrier proteins were minimally affected in the E4/DRSP and E4/LNG groups, in comparison with the EE/DRSP group, where a significant increase in sex hormone-binding globulin was observed. Similarly, minor effects on lipoproteins were observed in the E4 groups, and the effects on triglycerides elicited by the E4 groups were significantly lower than those in the EE/DRSP group. No imbalances in bone markers were observed in any groups. No alterations in insulin-like growth factor were observed in the E4 groups.Conclusions E4-containing combinations have a limited effect on liver function, lipid metabolism, and bone and growth endocrine parameters.Chinese 摘要目的 雌四醇（E4）是来源于人胎儿肝脏的天然雌激素。雌四醇与屈螺酮（DRSP)或左炔诺孕酮(LNG)配伍的复方口服避孕药制剂，能够抑制排卵，同时相较于炔雌醇(EE)与屈螺酮配伍制剂，它对凝血功能的各项指标影响较小。本研究的目的是为了评估不同剂量的雌四醇与屈螺酮以及左炔诺孕酮的配伍制剂对肝功能、脂代谢、骨骼转换标志物、以及生长激素分泌等安全性指标的影响。方法 本研究为开放的、单中心、剂量定义的对照研究，研究对象为18-35岁、具有良好的排卵周期的健康妇女，受试者分别接受5mg或10mg雌四醇/屈螺酮3mg(E4/DRSP)制剂，5mg、10mg、20mg雌四醇/左炔诺孕酮150ug(E4/LNG)制剂，以及20ug炔雌醇/屈螺酮(EE/DRSP)3mg制剂作为对照，连续三个24/4天周期。自基线到研究结束，测定肝功能、脂代谢、骨转换以及生长激素分泌的各项指标，对其改变进行评估。结果 109名妇女入选该研究。与EE/DRSP组比较，E4/DRSP以及E4/LNG组肝脏产生的运载蛋白受影响很小，但是EE/DRSP组性激素结合蛋白的含量明显增加。同样，E4组的脂蛋白受影响很小，而且对甘油三酯的影响显著低于EE/DRSP组。在所有研究组中，都没有观察到骨转换的失衡。在E4组，没有观察到胰岛素样生长因子的改变。结论 含有E4的复方制剂对肝功能、脂代谢、骨骼转换以及生长内分泌的影响有限。关键词 骨标记物、屈螺酮、内分泌、雌四醇、左炔诺孕酮、脂代谢、肝功能

A Pilot Study to Evaluate Haemostatic Function, following Shock Wave Lithotripsy (SWL) for the Treatment of Solitary Kidney Stones.

PurposeThe number of patients undergoing shock wave lithotripsy (SWL) in the UK for solitary unilateral kidney stones is increasing annually. The development of postoperative complications such as haematuria and sepsis following SWL is likely to increase. Comparing a range of biological markers with the aim of monitoring or predicting postoperative complications following SWL has not been extensively researched. The main purpose of this pilot-study was to test the hypothesis that SWL results in changes to haemostatic function. Subsequently, this pilot-study would form a sound basis to undertake future investigations involving larger cohorts.MethodsTwelve patients undergoing SWL for solitary unilateral kidney stones were recruited. From patients (8 male and 4 females) aged between 31–72 years (median—43 years), venous blood samples were collected pre-operatively (baseline), at 30, 120 and 240 minutes postoperatively. Specific haemostatic biomarkers [platelet counts, prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, D-dimer, von Willebrand Factor (vWF), sE-selectin and plasma viscosity (PV)] were measured.ResultsPlatelet counts and fibrinogen concentration were significantly decreased following SWL (p = 0.027 and p = 0.014 respectively), while D-dimer and vWF levels significantly increased following SWL (p = 0.019 and p = 0.001 respectively). PT, APTT, sE-selectin and PV parameters were not significantly changed following SWL (p>0.05).ConclusionsChanges to specific biomarkers such as plasma fibrinogen and vWF suggest that these represent a more clinically relevant assessment of the extent of haemostatic involvement following SWL. Analysis of such markers, in the future, may potentially provide valuable data on “normal” response after lithotripsy, and could be expanded to identify or predict those patients at risk of coagulopathy following SWL. The validation and reliability will be assessed through the assessment of larger cohorts.

Haemostatic function and biomarkers of endothelial damage before and after RBC transfusion in patients with haematologic disease.

Transfusion of red blood cells (RBC) is beneficial for the patient but can also be harmful, as randomized trials have demonstrated increased infection rates, bleeding and mortality. The study aim was to investigate the response of the vascular system (the haemostatic function and the endothelium) to RBC transfusion. Blood was sampled from patients with various transfusion-dependent haematologic diseases before 1 and 24 h after RBC transfusion. Primary and secondary haemostasis was evaluated by whole-blood impedance aggregometry (Multiplate) and by thromboelastography (TEG). Samples were analysed by ELISA for biomarkers reflecting endothelial activation and damage (sICAM-1, syndecan-1, sThrombomodulin (sTM), sVE-Cadherin), platelet activation (sCD40L) and inflammation (hsCRP). A total of 58 patients were enrolled in the study. Median age was 71 years. Compared to before transfusion, patients had slightly reduced coagulability 1 h after RBC transfusion, assessed by TEG. However, transfusion of older RBC products (>14 days) was associated with increased coagulability (all P < 0·05). The level of syndecan-1 increased slightly 24 h after transfusion (median 12·4 (IQR 9-23) vs. 13·2 (9-25) ng/ml, P < 0·01), indicating increased glycocalyx degradation. Overall, RBC transfusion was associated with reduced coagulability and endothelial glycocalyx degradation. Transfusion of older RBCs was however associated with increased coagulability. The changes observed were small to moderate and the clinical relevance of these findings should be investigated in larger studies.