Role Of Platelets In Hemostasis Research Articles

Advances in Platelet-Dysfunction Diagnostic Technologies.

The crucial role of platelets in hemostasis and their broad implications under various physiological conditions underscore the importance of accurate platelet-function testing. Platelets are key to clotting blood and healing wounds. Therefore, accurate diagnosis and management of platelet disorders are vital for patient care. This review outlines the significant advancements in platelet-function testing technologies, focusing on their working principles and the shift from traditional diagnostic methods to more innovative approaches. These improvements have deepened our understanding of platelet-related disorders and ushered in personalized treatment options. Despite challenges such as interpretation of complex data and the costs of new technologies, the potential for artificial-intelligence integration and the creation of wearable monitoring devices offers exciting future possibilities. This review underscores how these technological advances have enhanced the landscape of precision medicine and provided better diagnostic and treatment options for platelet-function disorders.

Platelets, inflammation, and purinergic receptors in chronic kidney disease

Platelets are anucleated cells that circulate in the bloodstream. Historically, platelets were thought to perform a singular function—stop bleeding via clotting. While platelets do play a key role in hemostasis and thrombosis, recent studies indicate that platelets also modulate inflammation, and this platelet-induced inflammation contributes to the pathophysiology of various diseases such as atherosclerosis and diabetes mellitus. Thus, in recent years, our understanding of platelet function has broadened. In this review, we revisit the classic role of platelets in hemostasis and thrombosis and describe the newly recognized function of platelets in modulating inflammation. We cover the potential use of purinergic receptor antagonists to prevent platelet-modulated inflammation, particularly in patients with chronic kidney disease, and finally, we define key questions that must be addressed to understand how platelet-modulated inflammation contributes to the pathophysiology of chronic kidney disease.

Epic Fail? Try Again

We read with interest the manuscript titled “Failure of Crotalidae Immune F(ab’)2 Equine Antivenom to Achieve Control in a Southern Pacific Rattlesnake Envenomation” by Levine et al. The authors indicate that their patient “failed to respond adequately to F(ab’)2AV” because his initially unmeasurable platelet count reached a maximum of 102,000/μL at 56 hours after envenomation. We have several concerns with this conclusion. Adequate platelet response in the setting of venom-induced hemotoxicity is not universally defined. Although some patients may have complete reversal of thrombocytopenia after a single antivenom dose, others may have increasing platelet numbers but never achieve a platelet count of >150,000/μL. A 2011 study by Yin et al1Yin S. Kokko J. Lavonas E. et al.Factors associated with difficulty achieving initial control with crotalidae polyvalent immune fab antivenom in snakebite patients.Acad Emerg Med. 2011; 18: 46-52Crossref PubMed Scopus (21) Google Scholar suggested that it “may not be reasonable to attempt to completely control” thrombocytopenia. Antivenom may have been underdosed initially. F(ab’)2AV is dosed at 10 vials over 1 hour and repeated hourly until initial control is obtained, as evidenced by the halt of proximal swelling and improvement in laboratory markers. However, as above, there is no consensus on specific numeric goals.2Anavip [Package Insert]. Franklin, TN: Rare Disease Therapeutics, Inc.Google Scholar Although the patient received 10 vials initially, his next dose approximately 1 to 2 hours later was only 4 vials. He received the remaining 6 vials after approximately 9 hours. His platelet count continued to increase. The trend suggests that earlier administration may have prevented persistent thrombocytopenia. After viper envenomation, platelets may be sequestered, pro- and anti-aggregated, and destroyed through multiple mechanisms, leading to recurrent or refractory thrombocytopenia, which is difficult to predict in the absence of routine venomic studies on individual patients. This inability to reliably predict the mechanism of thrombocytopenia results in the inability to predict platelet response to antivenom.3Shen C. Liu M. Mackeigan D.T. et al.Viper venoms drive the macrophages and hepatocytes to sequester and clear platelets: novel mechanism and therapeutic strategy for venom-induced thrombocytopenia.Arch Toxicol. 2021; 95: 3589-3599Crossref PubMed Scopus (4) Google Scholar,4De Queiroz M.R. de Sousa B.B. da Cunha Pereira D.F. et al.The role of platelets in hemostasis and the effects of snake venom toxins on platelet function.Toxicon. 2017; 133: 33-47Crossref PubMed Scopus (45) Google Scholar Owing to platelet sequestration and aggregation, antivenom should quickly reverse thrombocytopenia. However, with platelet destruction or consumption, levels would not increase until the patient could synthesize more platelets de novo. This patient may have had ongoing platelet consumption to repair venom-induced tissue damage, yet the authors did not describe the progression of cytotoxicity. The lack of fibrinogen trend also makes the inference of ongoing venom effect problematic. Rattlesnake antivenom is best suited not to resolve thrombocytopenia but to reverse defibrination, so the significance of persistent thrombocytopenia in the absence of fibrinogen levels is unclear.5Dudley S. Smelski G. Massey D.J. et al.Fashionably late: A characterization of late coagulopathies in rattlesnake envenomations between Fab and F (ab’) 2 antivenoms.Toxicon. 2022; 212: 49-54Crossref Scopus (0) Google Scholar Twenty-three years of unpublished data from the Arizona Poison and Drug Information Center shows that persistent thrombocytopenia after antivenom is common regardless of which of the two commercially available antivenoms is used (FabAV or F[ab’]2AV). Considering cases with thrombocytopenia during initial hospital stay, 197 of 556 (35.43%) FabAV patients and 39 of 107 (36.45%) F(ab’)2AV patients were discharged with a platelet count of < 150,000/μL. Some patients did not develop thrombocytopenia until after discharge. Among FabAV patients, 106 of 472 (22.46%) developed delayed thrombocytopenia compared with only 7 of 130 (5.38%) F(ab’)2AV patients. Similar rates of persistent thrombocytopenia in the inpatient setting suggest that destruction of platelets occurs in some patients regardless of antivenom manufacturer. The difference in delayed thrombocytopenia suggests that the longer half-life of F(ab’)2AV continues to protect against thrombocytopenia compared with FabAV. Finally, the authors did not provide an illustration of the patient’s overall clinical picture throughout his hospital stay, including progression of edema, pain, and coagulation factors. Isolated thrombocytopenia is not an indication to provide more antivenom as bleeding due to thrombocytopenia is unlikely if there is no defibrination. A patient with stabilization of other indicators, despite persistent thrombocytopenia, has had an adequate response to antivenom. As always in medicine, treat the patient, not the number.

Platelet in thrombo-inflammation: Unraveling new therapeutic targets.

In the broad range of human diseases, thrombo-inflammation appears as a clinical manifestation. Clinically, it is well characterized in context of superficial thrombophlebitis that is recognized as thrombosis and inflammation of superficial veins. However, it is more hazardous when developed in the microvasculature of injured/inflamed/infected tissues and organs. Several diseases like sepsis and ischemia-reperfusion can cause formation of microvascular thrombosis subsequently leading to thrombo-inflammation. Thrombo-inflammation can also occur in cases of antiphospholipid syndrome, preeclampsia, sickle cell disease, bacterial and viral infection. One of the major contributors to thrombo-inflammation is the loss of normal anti-thrombotic and anti-inflammatory potential of the endothelial cells of vasculature. This manifest itself in the form of dysregulation of the coagulation pathway and complement system, pathologic platelet activation, and increased recruitment of leukocyte within the microvasculature. The role of platelets in hemostasis and formation of thrombi under pathologic and non-pathologic conditions is well established. Platelets are anucleate cells known for their essential role in primary hemostasis and the coagulation pathway. In recent years, studies provide strong evidence for the critical involvement of platelets in inflammatory processes like acute ischemic stroke, and viral infections like Coronavirus disease 2019 (COVID-19). This has encouraged the researchers to investigate the contribution of platelets in the pathology of various thrombo-inflammatory diseases. The inhibition of platelet surface receptors or their intracellular signaling which mediate initial platelet activation and adhesion might prove to be suitable targets in thrombo-inflammatory disorders. Thus, the present review summarizes the concept and mechanism of platelet signaling and briefly discuss their role in sterile and non-sterile thrombo-inflammation, with the emphasis on role of platelets in COVID-19 induced thrombo-inflammation. The aim of this review is to summarize the recent developments in deciphering the role of the platelets in thrombo-inflammation and discuss their potential as pharmaceutical targets.

Stress Enhances Proinflammatory Platelet Activity: the Impact of Acute and Chronic Mental Stress

The role of platelets in hemostasis and thrombosis has long been recognized, recently their contribution to immunological and inflammatory processes is emerging. Platelets could be the missing link between cardiovascular disease, chronic stress and depressive symptoms. Both physical and mental stressors cause platelet activation reflected by changes in platelet bioactivity and aggregation. Here we evaluate the proinflammatory platelet response to acute and chronic mental stress. In a prospective study design an acute mental stress test was administered to 55 healthy male participants once without and once in the presence of chronic mental stress. Blood was collected prior to and at three time points following an acute mental stress test (0, 30, 60 min). Platelet proinflammatory activation markers, were assessed using FACS analysis and aggregability was measured in response to ADP or epinephrine using PFA-100. A linear mixed model was used for analysis. Chronic mental stress lead to a significant increase in state anxiety (p < 0.001), depressive symptoms (p = 0.045) and perceived stress (p = 0.001). The factor “chronic mental stress” was significantly associated with increased numbers of CD63+ platelets (p = 0.009). The factor “acute mental stress” was associated with alterations in CD62P+ platelets (p < 0.001), CD63+ platelets (p = 0.011), PAC-1+ platelets (p < 0.001) as well as platelet leucocyte aggregates (p = 0.019). The recovery of CD62P function following the acute mental stress exposure was significantly impaired by chronic stress (p = 0.023). Aggregation was affected by chronic and acute mental stress. In conclusion, mental stress is linked to an increased and prolonged proinflammatory platelet bioactivity. This proinflammatory and immunomodulatory stimuli could help to explain the link between mental and somatic disorders.Graphical

Mean platelet volume in arterial and venous thrombotic disorders

Abstract The mean platelet volume (MPV) is an easy, rapid and inexpensive laboratory parameter which basically mirrors platelet size. Due to the essential role of platelets in hemostasis, many studies have assessed the MPV value in patients with arterial and venous thrombotic disorders. These have then been summarized in some interesting meta-analyses and recent studies that will be discussed in this narrative review. Taken together, the currently available evidence suggests that the MPV may be substantially increased in concomitance with acute episodes of coronary artery disease, venous thromboembolism, portal vein thrombosis, stroke, erectile dysfunction and preeclampsia. In many of these conditions, an increased MPV value may also be associated with unfavorable outcomes. Despite these convincing findings, some important technical issues should be considered for improving the clinical usefulness of this measure. These essentially include anticoagulant, timing of sample collection, the sample storage conditions, the influence of the analytical techniques, the approaches used for its calculation, the accurate definition of reference ranges and diagnostic cut-offs, as well as the current lack of standardization, which makes data obtained with different techniques/analyzers poorly comparable. Provided that the impact of these variables can be abated or minimized, the MPV can gain a valuable role in the laboratory workout of many arterial and venous thrombotic disorders.

The Mir-99b/Let-7e/Mir-125a cluster Is Associated with Platelet Count and Mean Platelet Volume and Regulates Megakaryocyte Proplatelet Formation

Platelet count (PC) and mean platelet volume (MPV) are critical measurements when considering the role of platelets in hemostasis and thrombosis, abnormalities in PC and MPV have been shown to be predictors of ischemic cardiovascular disease. Ischemic vascular disease has a known genetic component, and we and others have shown high heritability for both PC and MPV. Many inherited, and most immune, thrombocytopenias show an inverse relationship between PC and MPV, and such a relationship has also been reported in healthy subjects. Although genome-wide association studies have identified numerous single nucleotide variants in protein-coding genes associated with PC and MPV (Geiger Nat Genet 2011), non-coding genes have had rather little consideration. The goal of our studies was to identify microRNAs (miRs) regulating PC and MPV and to begin to understand the molecular mechanisms of this inverse platelet number-volume relationship. Initially, we queried our Platelet RNA and Expression-1 data set and observed that PC and MPV are inversely correlated in these 154 healthy subjects (r=-0.45, p=3.98E-09). We next determined which of the 734 platelet-expressed miRs were significantly (p&lt;0.05) correlated with both PC and MPV. Of these miRs, only miR-125a-5p, miR-99b-5p, let-7e-5p and miR-150-5p had an inverse relationship with PC and MPV. The Table shows the correlations between these miRs and complete blood count data. Subsequent studies focused on miR-125a-5p, miR-99b-5p, let-7e-5p because they (1) were associated with only platelet parameters and not WBC or Hb, (2) were more highly expressed than miR-150-5p and (3) showed the same directionality (e.g., positive r value for PC). We were also intrigued by the fact that these 3 miRs exist as a genomic cluster within 727 bp on chr19q13.41. The expression of each of the 3 miRs in this cluster was strongly correlated with each other in platelets (r=0.93, p=1.02E-68 for miR-125a and let-7e; r=0.91, p=8.53E-61 for miR-99b and let-7e; r=0.89, p=1.19E-52 for miR-125a and miR-99b), consistent with a single, polycistronic transcript containing all genes. To begin to address the potential functionality of this miR cluster, we overexpressed and knocked down their expression in megakaryocytes (MKs), since MK proplatelet formation (PPF) is a necessary step in the generation of peripheral blood platelets. We utilized human umbilical cord blood derived CD34-positive hematopoietic stem and progenitor cells differentiated along the MK lineage with thrombopoietin. Quantification of miR levels with qPCR demonstrated all 3 miRs in the cluster progressively increased from culture day 6 to day 9 to day 13 (the time during which MKs mature in culture). Compared to a scrambled control, when miR activity was knocked down with locked nucleic acids (LNAs), we observed a 61% reduction in PPF for miR-125a-5p (p&lt;0.05), a 54% reduction for let-7e-5p (p&lt;0.05) and a ~28% reduction for miR-99b-5p (p=0.33). PPF was quantified blinded as to treatment group. When all 3 miRs in the cluster were inhibited simultaneously by LNAs, we observed a 74% reduction in PPF (p&lt;0.05) (Figure 1). LNA inhibition of two miRs not associated with PC or MPV did not alter MK PFF. To date, we have only tested the effect of overexpression of one miR, but observed that lentiviral overexpression of miR-125a-5p induced an increase in MK PPF (p&lt;0.05). In summary, we have identified a genomic cluster of miRs (miR-99b/let-7e/miR-125a) that regulates PPF in cultured human MKs and whose expression is positively correlated with human PC and negatively correlated with MPV. We speculate that platelet mass homeostasis, which is determined by PC and MPV, may be controlled in part by this novel genomic locus. Disclosures No relevant conflicts of interest to declare.

In vitro evidence supporting applications of platelet derivatives in regenerative medicine.

The role of platelets in haemostasis has long been known, but understanding of these cells' involvement in wound healing/tissue repair is more recent and has given rise to a multitude of translational studies. Tissue repair processes consist of complex, regulated interactions between cells modulated by biologically active molecules, most of which are growth factors released by activated platelets: this aspect represents the rationale on which the use of platelet derivatives for clinical purposes is based. In the last years, many in vitro studies have focused on the mechanisms of action by which these growth factors affect the biological activities of cells, thus supporting tissue healing. Although limited by some drawbacks (two-dimensional in vitro monocultures cannot replicate the tissue architecture and organisation of organs or the continuous interplay between different cell types), in vitro studies do have the advantages of giving rapid results and allowing precise control of platelet concentrations and other parameters.This review offers an updated overview of the data obtained from the most recent bench-top studies focused on the effects of platelet derivatives on a wide variety of human cells, highlighting their possible impact for in vivo applications. The heterogeneity of the data obtained so far is very evident. This can be explained by the different experimental settings used in each study, which may be the cause of the variability in clinical outcomes. In fact, in vitro studies suggest that the composition of platelet derivatives and the method used for their production and activation (or not) and the platelet concentration used can have profound effects on the final results.

Platelets, NETs and cancer

In addition to the central role of platelets in hemostasis, they contribute to pathological conditions such as inflammation and tumor progression. Aberrant expression and/or exposure of pro-coagulant factors in the tumor microenvironment induce platelet activation and subsequent release of growth factors from platelet granules. Cancer patients are commonly affected by thrombotic events, as a result of tumor-induced platelet activation. A novel player potentially contributing to cancer-associated thrombosis is the formation of neutrophil extracellular traps (NETs). NETs are composed of externalized DNA of nuclear or mitochondrial origin, bound to histones and granular proteases such as neutrophil elastase (NE) and myeloperoxidase (MPO). These extracellular traps help neutrophils to catch and kill pathogens such as bacteria, virus and fungi. It is now clear that NETs form also under conditions of sterile inflammation such as cancer and autoimmunity and can promote thrombosis. Recent data show that platelets play a key role in determining when and where NETs should form. This review will highlight our current insight in the role of platelets as regulators of NET formation, both during infection and sterile inflammation.

Thrombocytosis and thrombocytopenia - background and clinical relevance

Due to the central role of platelets in hemostasis, the clinical relevance of quantitative changes in platelet counts (< 150 G/l or > 450 G/l) may be significant. Thrombopoesis (= production of platelets) occurs in the bone marrow, andthe hormone thrombopoetin takes control on its regulation.In thrombocytosis, primary causes have to be distinguished from the far more common reactive (= secondary) reasons. The most important form of primary thrombocytosis occurs in myeloproliferative neoplasms especially in essential thrombocythemia (ET). Clinically, increased thrombophilia, microcirculatory disturbances as well as an increased hemorrhagic diathesis occur in patients with myeloproliferative neoplasms. According to the WHO diagnosis criteria 2016 standard diagnostic procedure in myeloproliferative neoplasms includes bone marrow biopsy and the detection of one of the acquired and typical MPN mutations in the JAK2, MPL or CALR gene.In contrast, patients with thrombocytopenia more often suffer from bleeding complications, however, in antiphospholipid syndrome or thrombotic microangiopathy (TMA) thrombotic events occur in spite of a low platelet count. Generally it makes sense to differentiate between pathological changes in thrombopoesis and the various causes of increased peripheral platelet turnover. Concerning differential diagnosis a careful anamnesis is very important in order to get hints like drugs associated with thrombocytopenia, signs of infection or autoimmune disorders. As an initial diagnostic approach we recommend examination of the blood smear in order to exclude pseudothrombocytopenia or disorderes like thrombotic microangiopathy, myelodysplasia or other hematological diseases.

Viscoelastic measurements of platelet function, not fibrinogen function, predicts sensitivity to tissue‐type plasminogen activator in trauma patients

Systemic hyperfibrinolysis is a lethal phenotype of trauma-induced coagulopathy. Its pathogenesis is poorly understood. Recent studies have support a central role of platelets in hemostasis and in fibrinolysis regulation, implying that platelet impairment is integral to the development of postinjury systemic hyperfibrinolysis. The objective of this study was to identify if platelet function is associated with blood clot sensitivity to fibrinolysis. We hypothesize that platelet impairment of the ADP pathway correlates with fibrinolysis sensitivity in trauma patients. A prospective observational study of patients meeting the criteria for the highest level of activation at an urban trauma center was performed. Viscoelastic parameters associated with platelet function (maximum amplitude [MA]) were measured with native thrombelastography (TEG), and TEG platelet mapping of the ADP pathway (ADP-MA). The contribution of fibrinogen to clotting was measured with TEG (angle) and the TEG functional fibrinogen (FF) assay (FF-MA). Another TEG assay containing tissue-type plasminogen activator (t-PA) (75 ng mL(-1) ) was used to assess clot sensitivity to an exogenous fibrinolytic stimulus by use of the TEG lysis at 30 min (LY30) variable. Multivariate linear regression was used to identify which TEG variable correlated with t-PA-LY30 (quantification of fibrinolysis sensitivity). Fifty-eight trauma patients were included in the analysis, with a median injury severity score of 17 and a base deficit of 6 mEq L(-1) . TEG parameters that significantly predicted t-PA-LY30 were related to platelet function (ADP-MA, P = 0.001; MA, P < 0.001) but not to fibrinogen (FF-MA, P = 0.773; angle, P = 0.083). Clinical predictors of platelet ADP impairment included calcium level (P = 0.001), base deficit (P = 0.001), and injury severity (P = 0.001). Platelet impairment of the ADP pathway is associated with increased sensitivity to t-PA. ADP pathway inhibition in platelets may be an early step in the pathogenesis of systemic hyperfibrinolysis.

The Platelet and the Biophysical Microenvironment: Lessons from Cellular Mechanics

While the role of platelets in hemostasis is well characterized from a biological perspective, the biophysical interactions between platelets and their mechanical microenvironment are relatively unstudied. The field of cellular mechanics has developed a number of approaches to study the effects of extracellular matrix (ECM)-derived mechanical forces on various cells, and has elucidated that integrin-cytoskeleton-mediated force transduction governs many cellular processes. As platelets adhere and spread via molecular machinery that is similar to that which enables other cells to mechanosense and mechanotransduce forces from their biophysical microenvironment, platelets too are likely governed by the same overarching mechanisms. Indeed, recent platelet mechanobiology studies have revealed that key aspects of platelet physiology and activation are regulated by the mechanical and spatial properties of the ECM microenvironment. At the same time, there are also key differences that make platelets unique in the world of cells-- their size, origin as megakaryocyte fragments, and unique αIIbβ3 integrin-- render their mechanosensing activities particularly interesting. The structurally "simple," anucleate nature of platelets coupled with their high actin concentration (20% of total protein) and integrin density [1] seem to make them ideal for mechanical force generation and transmission. Further studies will enhance our understanding of the role of platelet mechanobiology in hemostasis and thrombosis, potentially leading to new categories of diagnostics that investigate the mechanical properties of clots to determine bleeding risk, as well as therapies that target the mechanotransduction signaling pathway to alter the stability of clots.

Modeling the Thrombopoietic Effects of Burn

Our group is currently developing physiologically based models to understand the impact of radiation combined injury and aid in casualty predictions for catastrophic scenarios. We have developed a model that describes the impact of burn on thrombopoiesis with the aim of integrating it into an existing radiation-effects model. Thrombocytopenia can be a life-threatening condition due to the role of platelets in hemostasis and the immune response. Thermal injury is known to cause thrombocytopenia as well as a subsequent thrombocytosis. Key biological effects of burn were identified, mathematically interpreted, and implemented. These effects include a decreased platelet lifespan and an increased repopulation rate due to increased levels of thrombopoietin within the system. The model predicts platelet and precursor cell concentrations over time, providing details on time, magnitude, and duration of thrombocytopenias. Parameter values were obtained through both the analysis of experimental data and the optimization of the model to observational data on platelet counts following burn. The model was subsequently validated against other datasets and simulations were performed to better understand the characteristics of the model. The model describes the effects of thermal injury on thrombopoiesis, providing realistic predictions that reflect the trends observed in platelet concentrations.

Platelet function testing and prediction of procedural bleeding risk

The essential role of platelets in haemostasis underlies the relationship between platelet function and spontaneous or procedure-related bleeding, which has important prognostic implications. Although not routinely undertaken, platelet function testing offers the potential to tailor antiplatelet therapy for individual patients. However, uncertainties remain about how well platelet function testing may predict haemostasis and guide management of bleeding risk. Studies of aspirin, P2Y12 inhibitors and other antiplatelet drugs clearly demonstrate how inhibition of platelet function increases bleeding risk. More potent antiplatelet drugs are associated with higher bleeding rates, consistent with the levels of platelet inhibition achieved by these drugs. Studies of patients treated with clopidogrel, which is associated with wide inter-individual variation in antiplatelet effect, suggest that platelet function testing may predict bleeding risk related to coronary artery bypass grafting (CABG) surgery and potentially guide the timing of surgery following discontinuation of clopidogrel. Similarly, some studies have demonstrated a relationship between clopidogrel response and bleeding in patients undergoing percutaneous coronary intervention (PCI), although other studies have not supported this. Carriage of the *17 allele of cytochrome P450 2C19, which is associated with gain of function and enhanced response to clopidogrel, seems to be associated with increased bleeding risk, although studies showing lack of apparent effect of loss-of-function alleles provide contradictory evidence. Further large studies are needed to guide best practice in the application of platelet function testing in the clinical management of patients treated with antiplatelet drugs in order to optimise individual care.

The Role of Platelets in Athero-Thrombotic Events

The crucial role of platelets in primary hemostasis and repair of injured endothelium is well established, as is their role in atherothrombosis. No other single cell type is responsible for as much morbidity and mortality, since death from ischemic heart disease or stroke is by far the leading cause of death worldwide. There is no doubt that our understanding of atherothrombosis has guided current antithrombotic strategies that have dramatically reduced ischemic complications and cardiovascular mortality within the last decades. Yet the rate of ischemic complications after optimal revascularization therapy remains disappointingly high. There is still a strong need for new and smart antiplatelet drugs. The ideal antithrombotic drug would spare physiological platelet function, hemostasis and vascular repair in order to avoid bleeding complications, but would exclusively target the pathological atherothrombotic process. As platelet activity might be determined early in the bone marrow, this review starts with insights into the birth of platelets, describes the essential and primary role of platelets in hemostasis with new evidence in signaling cascades, and closes with the deleterious role of platelets in atherosclerosis and atherothrombosis, with a focus on acute coronary syndromes.

Platelets and platelet-like particles mediate intercellular RNA transfer

The role of platelets in hemostasis and thrombosis is clearly established; however, the mechanisms by which platelets mediate inflammatory and immune pathways are less well understood. Platelets interact and modulate the function of blood and vascular cells by releasing bioactive molecules. Although the platelet is anucleate, it contains transcripts that may mirror disease. Platelet mRNA is only associated with low-level protein translation; however, platelets have a unique membrane structure allowing for the passage of small molecules, leading to the possibility that its cytoplasmic RNA may be passed to nucleated cells. To examine this question, platelet-like particles with labeled RNA were cocultured with vascular cells. Coculture of platelet-like particles with activated THP-1, monocytic, and endothelial cells led to visual and functional RNA transfer. Posttransfer microarray gene expression analysis of THP-1 cells showed an increase in HBG1/HBG2 and HBA1/HBA2 expression that was directly related to the transfer. Infusion of wild-type platelets into a TLR2-deficient mouse model established in vivo confirmation of select platelet RNA transfer to leukocytes. By specifically transferring green fluorescent protein, we also observed external RNA was functional in the recipient cells. The observation that platelets possess the capacity to transfer cytosolic RNA suggests a new function for platelets in the regulation of vascular homeostasis.

The Role of Platelets in Atherothrombosis

Platelets have evolved highly specialized adhesion mechanisms that enable cell-matrix and cell-cell interactions throughout the entire vasculature irrespective of the prevailing hemodynamic conditions. This unique property of platelets is critical for their ability to arrest bleeding and promote vessel repair. Platelet adhesion under conditions of high shear stress, as occurs in stenotic atherosclerotic arteries, is central to the development of arterial thrombosis; therefore, precise control of platelet adhesion must occur to maintain blood fluidity and to prevent thrombotic or hemorrhagic complications. Whereas the central role of platelets in hemostasis and thrombosis has long been recognized and well defined, there is now a major body of evidence supporting an important proinflammatory function for platelets that is linked to host defense and a variety of autoimmune and inflammatory diseases. In the context of the vasculature, experimental evidence indicates that the proinflammatory function of platelets can regulate various aspects of the atherosclerotic process, including its initiation and propagation. The mechanisms underlying the proatherogenic function of platelets are increasingly well defined and involve specific adhesive interactions between platelets and endothelial cells at atherosclerotic-prone sites, leading to the enhanced recruitment and activation of leukocytes. Through the release of chemokines, proinflammatory molecules, and other biological response modulators, the interaction among platelets, endothelial cells, and leukocytes establishes a localized inflammatory response that accelerates atherosclerosis. These inflammatory processes typically occur in regions of the vasculature experiencing low shear and perturbed blood flow, a permissive environment for leukocyte-platelet and leukocyte-endothelial interactions. Therefore, the concept has emerged that platelets are a central element of the atherothrombotic process and that future therapeutic strategies to combat this disease need to take into consideration both the prothrombotic and proinflammatory function of platelets.

Involvement of circulating platelets on the hyperalgesic response evoked by carrageenan and Bothrops jararaca snake venom.

The role of platelets in hemostasis is well known, but few papers have reported their role in pain and edema induced by inflammatory agents. To evaluate the role of circulating platelets in the local injury induced by two diverse inflammatory agents, Bothrops jararaca venom (Bjv) and carrageenan. Rats were (i) rendered thrombocytopenic by administration of polyclonal anti-rat platelet IgG (ARPI) or busulfan, or (ii) treated with platelet inhibitors (aspirin or clopidogrel). Edema formation, local hemorrhage and the pain threshold were assessed after intraplantar injection of Bjv or carrageenan in rat hind paws. Additionally, whole platelets or platelet releasate were tested whether they directly induced hyperalgesia. Platelet counts were markedly diminished in rats administered with either ARPI (± 88%) or busulfan (± 96%). Previous treatment with ARPI or busulfan slightly reduced edema induced by Bjv or carrageenan. Injection of Bjv, but not of carrageenan, induced a statistically significance increase in hemorrhage in the hind paws of thrombocytopenic rats. Remarkably, hyperalgesia evoked by Bjv or carrageenan was completely blocked in animals treated with ARPI or busulfan, or pre-treated with aspirin or clopidogrel. On the other hand, intraplantar administration of whole platelets or platelet releasate evoked hyperalgesia, which was inhibited by pre-incubation with alkaline phosphatase. Thrombocytopenia or inhibition of platelet function drastically reduced hyperalgesia induced by injection of carrageenan or Bjv; moreover, platelets per se secrete phosphorylated compounds involved in pain mediation. Thus, blood platelets are crucial cells involved in the pain genesis, and their role therein has been underestimated.

Platelets, Inflammation and Cardiovascular Diseases. New Concepts and Therapeutic Implications

Platelets play a critical role in hemostasis and thrombosis. The role of platelets in hemostasis, clinically relevant bleeding resulting from defects and/or deficiencies in platelets and/or platelet components, and the diagnosis of such defects was the subject of a previous recent issue of Seminars in Thrombosis and Hemostasis.[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] That platelets are of considerable interest to readers of this journal can also be highlighted by the popularity of a previous review published here, “Platelets: Physiology and Biochemistry.[14] Published in 2005, this article was included in the top-20 most popular article listings from this journal in three separate years, 2005, 2006, and 2007,[15] and was also subsequently awarded one of the inaugural (2009) Eberhard F. Mammen awards for most popular articles.[16]

Antiplatelet therapies for the treatment of cardiovascular disease

Antiplatelet therapy has been successful in reducing mortality and morbidity in acute myocardial infarction. Recent advances in understanding the molecular basis of the role of platelets in cardiovascular thrombosis have enabled the development of new agents with the potential to further reduce mortality and morbidity. This article reviews the role of platelets in haemostasis and cardiovascular thrombosis, and discusses the benefits and limitations of current and investigational antiplatelet agents in the treatment of cardiovascular disease.