Synthesis of basement membrane collagen by cultured human endothelial cells.

Studies were performed to determine if cultured human endothelial cells synthesized basement membrane collagen. In culture, endothelial cells were attached to grossly visible membranous structures which on light microscopy were composed of ribbons of dense, amorphous material. On transmission electron microscopy, these membranous structures consisted of amorphous basement membrane, and material morphologically similar to microfibrils and elastic fibers. By immunofluorescence microscopy, these membranous structures stained brightly with antisera to human glomerular basement membrane. Cultured endothelial cells incorporated [3H]proline into protein; 18% of the incorporated [3H]proline was solubilized by purified collagenase. When endothelial cells were cultured with [14C]proline, 7.1% of the incorporated counts were present as [14C]hydroxyproline. Cultured endothelial cells were labeled with [3H]glycine and [3H]proline and digested with pepsin. The resulting fractions on analysis by SDS-polyacrylamide gel electrophoresis contained two radioactive protein peaks of mol wt 94,200 and 120,500. Both these peaks disappeared after digestion with purified collagenase. The peak of mol wt 120,500 corresponds to that of alpha1 (IV) collagen; the peak of the mol wt 94,200 probably corresponds to that of alpha1 (III) collagen. Thus, cultured human endothelial cells synthesize material which is morphologically and immunologically like amorphous basement membrane and biochemically like basement membrane collagen. Cultured endothelial cells probably also synthesize material which is morphologically similar to microfibrils and elastic fibers.

Plasmin inhibition of platelet function and of arachidonic acid metabolism.

To study interactions between platelets and the fibrinolytic system, we examined the effects of human plasmin on human platelets washed by gel filtration. Plasmin concentrations that did not affect platelet shape change, release, or aggregation (less than 1.0 caseinolytic units [CU]/ml) caused a dose- and time-dependent inhibition of platelet aggregation in response to thrombin, ionophore A23187, and collagen. Complete loss of aggregation occurred at 0.1-0.5 CU/ml of plasmin. In a parallel dose-dependent manner, plasmin likewise inhibited thrombin, ionophore, and collagen-stimulated thromboxane B2 production. In contrast, neither aggregation nor thromboxane B2 formation induced by arachidonate was inhibited by plasmin pretreatment of the platelets. Plasmin blocked the thrombin-induced release of [3H]arachidonic acid from platelet membrane phospholipids and the thrombin-induced platelet oxygen burst. However, plasmin did not inhibit the arachidonate-induced oxygen burst. Inhibition of arachidonic acid release by plasmin was not mediated by increase in platelet cyclic AMP. These results suggest that plasmin inhibits platelet function, at least in part, by blocking the mobilization of arachidonic acid from membrane phospholipid pools. The effects of plasmin on platelets may contribute to the hemostatic abnormalities seen in pathologic and pharmacologic fibrinolysis.

Platelet storage results in a redistribution of glycoprotein Ib molecules. Evidence for a large intraplatelet pool of glycoprotein Ib.

Platelet membrane glycoprotein (GP) Ib contains receptor for von Willebrand factor and thrombin. Its proteolytic fragment, glycocalicin, circulates in normal plasma. In this study, storage of platelet concentrates for 5 d resulted in a 221% increase in plasma glycocalicin (1.3 times the total amount of glycocalicin present on the surface of all platelets), an 8% overall increase in platelet surface GPIb, and the appearance of a surface GPIb-negative subpopulation of platelets. Total platelet GPIb content of fresh washed platelets, determined by gel electrophoresis and immunoassay of Triton X-100 lysates, averaged 159,740 molecules per platelet. There were 36,360 surface GPIb molecules per platelet, determined by immunoassay of the supernatant of fresh washed platelets whose surface GPIb had been completely plasmin-cleaved. In summary, these studies provide evidence for (a) a redistribution of GPIb molecules with platelet storage, and (b) a large intraplatelet pool of GPIb (approximately threefold larger than the platelet surface pool of GPIb).

Identification and isolation of a platelet GPIb-like protein in human umbilical vein endothelial cells and bovine aortic smooth muscle cells.

Glycoprotein Ib (GPIb) is an intrinsic platelet membrane protein that plays a major role in platelet adherence and mediates ristocetin-dependent platelet von Willebrand factor binding. Recent reports that the platelet membrane glycoprotein complex IIb/IIIa is expressed in several cell types prompted us to look for GPIb expression in other vascular cells. Immunoperoxidase staining of human stomach and skin histologic sections with polyclonal as well as monoclonal anti-GPIb antibody revealed the presence of GPIb in the endothelial cell and smooth muscle cell layers. Western blotting using monospecific polyclonal anti-GPIb antibodies confirmed the presence of immunoreactive GPIb in human umbilical vein endothelial and bovine aortic smooth muscle cell cultures. Fab fragments of a monoclonal anti-GPIb antibody were used to immunoprecipitate [3H]leucine labeled GPIb from metabolically labeled cells. The GPIb in these cells was functional as measured by ristocetin-dependent cell agglutination and by vWF binding. Endothelial cells as well as smooth muscle cells bound 125I-labeled vWF in a ristocetin-dependent manner, with a Kd of 7.9 nM.

Heparin inhibition of von Willebrand factor-dependent platelet function in vitro and in vivo.

The intravenous administration of heparin to patients before open heart surgery reduced ristocetin cofactor activity by 58% (P less than 0.01, t test), and this impairment of von Willebrand factor-dependent platelet function was closely related to plasma heparin levels (r2 = 0.9), but not to plasma von Willebrand factor (vWF) levels. We hypothesized that heparin may inhibit vWF-dependent platelet hemostatic functions by directly binding vWF in solution and interfering with vWF-GpIb binding. Using the in vitro techniques of ristocetin-induced platelet agglutination, fluorescent flow cytometric measurement of vWF-platelet binding, and conventional radioligand binding assays we observed that heparin inhibited both vWF-dependent platelet function and vWF-platelet binding in a parallel and dose-dependent manner. Heparin also inhibited platelet agglutination induced by bovine vWF and inhibited the binding of human asialo-vWF to platelets in ristocetin-free systems. The inhibitory potency of heparin was not dependent upon its affinity for antithrombin III, but was molecular weight dependent: homogeneous preparations of lower molecular weight were less inhibitory. Heparin impairment of vWF function may explain why some hemorrhagic complications of heparin therapy are not predictable based on techniques for monitoring the conventional anticoagulant effects of heparin.

HL-60-1E3, a novel phorbol diester-resistant HL-60 cell line.

The HL-60 (human promyelocytic leukemia) cell line has proved to be a useful model for the study of the expression of cellular functions and markers associated with hematopoietic differentiation. We report here the development and initial characterization of a novel, differentiation-resistant HL-60 cell line (HL-60-1E3) which was established by cloning the parent HL-60 line in the absence of mutagens or differentiation-inducing agents. HL-60-1E3 exhibits markedly reduced phorbol diester-induced expression of extracellular cytolytic activity, nonspecific esterase, phagocytosis, and surface Mo1 antigen. In addition, dimethyl sulfoxide-induced expression of both Mo1 and Mo2 is markedly reduced. However, if HL-60-1E3 is exposed to dimethyl sulfoxide, it acquires appreciable phorbol diester-triggered cytolytic activity and production of superoxide anion (O2-). Phorbol diester receptor number and dissociation constant (Kd) obtained by Scatchard analysis are not significantly different for the two cell lines. The HL-60-1E3 cell line should provide a useful adjunct to other cell lines used in the study of normal myeloid and leukemic cell differentiation, as well as the study of cytokine maturation factors and oncogene expression.

Effect of transient abrupt vessel closure during otherwise successful angioplasty for unstable angina on clinical outcome at six months. Hirulog Angioplasty Study Investigators.

OBJECTIVES: The objective of this study was to identify predictors of major adverse cardiac events after successful coronary angioplasty. BACKGROUND: The acute complications of angioplasty are related to baseline clinical and angiographic variables, and early complications adversely affect long-term outcome. However, the predictors of enduring success after uncomplicated angioplasty are less well defined. METHODS: Of 4,098 patients undergoing angioplasty in the Hirulog Angioplasty Study, 3,899 (95%) had a successful procedure without in-hospital death, emergent bypass surgery or clinical evidence of myocardial infarction. Baseline and procedural variables for these 3,899 patients were examined. RESULTS: Major adverse cardiac events occurred in 22% of the patients with initially successful procedures at 6 months: death in 1%, myocardial infarction in 2% and repeat revascularization in 21%. Univariable predictors of increased events included successful salvage from abrupt vessel closure (p < 0.001), emergency stenting (p < 0.001), multilesion angioplasty (p < 0.001), diabetes (p=0.02), target lesion in the left anterior descending artery (p=0.02), unstable angina (p=0.03) and smaller final luminal diameter (p=0.04). There was a trend toward increased events among patients with prior angioplasty (p=0.08), but asymptomatic elevation of the creatine kinase was not predictive (p=0.5). In a multivariable model, abrupt vessel closure was the strongest independent predictor of major adverse cardiac events at 6 months (p < 0.001; odds ratio [95% confidence interval]=3.6 [2.5 to 5.1]), while multivessel angioplasty, target lesion in the left anterior descending artery and diabetes also remained independent predictors (all p < or = 0.02). CONCLUSIONS: This analysis suggests that "uncomplicated" abrupt vessel closure is a powerful predictor of adverse clinical outcome following successful angioplasty. Improved techniques to reduce abrupt closure during angioplasty are thus urgently needed, and patients who experience "uncomplicated" closure require closer surveillance during follow-up.

Plasminogen interactions with immobilized fibrinogen.

This report describes the binding of plasminogen to fibrinogen adsorbed onto polystyrene wells. Binding was determined by enzyme linked immunosorbent assay. Both glu- and lys-plasminogen bound to immobilized fibrinogen in a dose-dependent fashion. However, more lys- than glu-plasminogen bound when equal concentrations of either were added to immobilized fibrinogen. Plasminogen binding was inhibited by epsilon aminocaproic acid indicating that binding was mediated via lysine-binding regions of plasminogen. Soluble fibrinogen added in excess of immobilized fibrinogen did not compete for plasminogen binding but fibrinogen fragments produced by plasmin digestion of fibrinogen did. Treatment of immobilized fibrinogen with thrombin caused a small but significant (p less than 0.01) increase in plasminogen binding. These studies demonstrate that immobilized fibrinogen binds both glu- and lys-plasminogen and that binding is mediated via lysine-binding regions. These interactions may facilitate plasminogen binding to fibrinogen adsorbed on to surfaces and to cells such as platelets which bind fibrinogen.

Usefulness and tolerability of hirulog, a direct thrombin-inhibitor, in unstable angina pectoris.

In an open-label pilot study of 20 patients with unstable angina (Braunwald class I-IIIB), hirulog was administered as a continuous intravenous infusion for 5 days in a dose of 0.2 mg/kg/hour to produce an activated partial thromboplastin time of approximately 200% of control. The primary end points of the study were: death, development of a transmural myocardial infarction, and intractable angina needing interventions such as an intraaortic balloon pump insertion, angioplasty and surgery. The secondary end points were the presence of an intracoronary thrombus detected on angiography and hemorrhagic complications during therapy. There was no death or transmural infarction in this study cohort; however, 1 patient developed intractable angina. Intracoronary thrombus was documented in 2 patients. Infusion of hirulog resulted in a steady prolongation of the activated partial thromboplastin time without any hemorrhagic or other adverse effect. Hirulog appears to be an effective antithrombotic agent that is tolerated well and may have advantages over heparin in the management of patients with unstable angina.

Effect of direct thrombin inhibition with Bivalirudin (Hirulog) on restenosis after coronary angioplasty.

The direct antithrombin, bivalirudin, did not reduce angiographic restenosis measured either as the dichotomous restenosis rate of 62% for bivalirudin and 58% for heparin (p = 0.70), or as the late loss in lumen diameter of 0.44 +/- 0.47 mm for bivalirudin and 0.39 +/- 0.53 mm for heparin (p = 0.62). Direct thrombin inhibition with bivalirudin neither reduces angiographic restenosis nor alters the impact of several established risk factors for restenosis.

Anticoagulant effects of hirulog, a novel thrombin inhibitor, in patients with coronary artery disease.

Selective thrombin inhibitors are a new class of antithrombotic drugs that, unlike heparin, can effectively inhibit clot-bound thrombin and escape neutralization by activated platelets. Hirulog is a 20 amino acid hirudin-based synthetic peptide that has shown promise in experimental models of thrombosis. Little information is available about the effects of hirulog in patients with coronary artery disease. Forty-five patients undergoing cardiac catheterization, who were taking aspirin, were randomized to receive either (1) hirulog, 0.05 mg/kg intravenous bolus followed by 0.2 mg/kg/hour intravenous infusion until the end of the catheterization; (2) hirulog, 0.15 mg/kg intravenous bolus followed by 0.6 mg/kg/hour intravenous infusion; or (3) heparin; 5,000 U intravenous bolus. Serial activated partial thromboplastin time (APTT), prothrombin time, activated clotting time and fibrinopeptide A were measured. Hirulog produced a dose-dependent prolongation of all coagulation parameters; the 0.6 mg/kg/hour dose prolonged the APTT to 218 +/- 50% of baseline after 2 minutes and 248 +/- 50% of baseline after 15 minutes. The half-life of the effect on APTT was 40 minutes. The hirulog blood level correlated well with the APTT, prothrombin time and activated clotting time (r = 0.77, 0.73, and 0.82 respectively, all p < 0.001). Both doses of hirulog potently suppressed the generation of fibrinopeptide A (p < 0.05). There were no major hemorrhagic, thrombotic or allergic complications in patients treated with hirulog or heparin. Thus, hirulog, a direct thrombin inhibitor, provides a predictable level of anticoagulation and appears to have a potent yet well-tolerated anticoagulant profile in patients with coronary artery disease.

In vivo imaging and evaluation of platelet accumulation vs. time at arterial injury site.

The feasibility of quantitatively imaging platelet deposition over time following angioplasty of the abdominal aorta in a rabbit model, with and without antiplatelet treatment, was investigated. Ten male 3-4 kg rabbits were balloon de-endothelialized and placed on 2% cholesterol diet for eight weeks. Group A was untreated. In Group B, donors and recipients were treated with aspirin (5 mgm/kg) prior to and after angioplasty. Platelets were labelled with indium-111. Labelled platelets were injected just prior to PTA and images of 100,000 counts were obtained immediately and at 30 minutes, 1 hour, and 24 hours. In Group A, increased activity of angioplasty site vs. nonangioplastied aorta was seen immediately. This focal increase became more marked in hypercholesterolemic animals over the 24-hour period. In Group B, both hypercholesterolemic and normocholesterolemic, no focal uptake could be documented on sequential scans. This method and model are promising for in vivo evaluation of platelet-vessel wall interactions, in the setting of angioplasty and antiplatelet therapy.

Nitric oxide-mediated, endothelium-dependent vasodilation is selectively attenuated in the postischemic extremity.

BACKGROUND: Attenuation of endothelium-dependent relaxing factor (EDRF) release may contribute to adverse sequelae commonly seen after reperfusion of an acutely ischemic extremity. The purpose of this study was to identify the compound responsible for the EDRF activity in the extremity and to evaluate its modulation by ischemia and reperfusion. METHODS: Isolated rat hindlimbs were perfused at constant pressure with an albumin-enriched crystalloid buffer. Increasing log dose infusions of acetylcholine and nitroprusside were used to measure endothelium-dependent (EDRF-mediated) and endothelium-independent vasoreactivity, respectively. RESULTS: Graded reductions in total vascular resistance were seen in response to both agonists in the control group (n = 11). In the postischemic group (n = 7), 60 minutes of normothermic ischemia and 10 minutes of reperfusion reduced endothelium-dependent vasodilation to acetylcholine by approximately 40% (p < 0.01). Endothelium-independent vasodilation to nitroprusside was unaffected. NG-monomethyl-L-arginine (L-NMMA), a competitive inhibitor of nitric oxide release, attenuated vasodilation to acetylcholine (p < 0.01) but not nitroprusside in both control and postischemic groups. CONCLUSIONS: Endothelium-dependent vasodilation in the rat hindlimb, mediated by nitric oxide, was selectively impaired by injury from ischemia and reperfusion. Strategies designed to minimize postischemic attenuation of nitric oxide release may be beneficial in the management of acute limb ischemia.

Characterization of platelet binding of heparins and other glycosaminoglycans.

The binding of glycosaminoglycans to intact washed human platelets was studied. The platelet binding of a 3H-labeled unfractionated heparin was saturable and reached equilibrium in 10-15 minutes. Heparin binding was specific: a 50-fold molar excess of an equivalent unlabeled heparin displaced up to 90% of labeled heparin, while chondroitin sulfate A and hyaluronic acid minimally displaced the binding of labeled heparin. Low molecular weight heparin fragments showed intermediate efficacy in displacing the binding of unfractionated [3H]heparin. Dextran sulfate (Mr 8,000, sulfation 17%) was as potent as unfractionated heparin in displacing binding, while neutral dextrans were ineffective. We observed that platelet activation by the calcium ionophore A23187 increased heparin binding by 2 to 3-fold, principally by enhancement of binding capacity not binding affinity. This process of heparin binding to the platelet surface may mediate some of the reported effects of heparin on platelet behavior.

Hirulog: a direct thrombin inhibitor for management of acute coronary syndromes.

Hirulog therapy has been studied extensively in numerous settings including prevention of DVT, treatment of unstable angina, treatment of acute myocardial infarction during thrombolysis, and prevention of acute complications of PTCA. Being one of the first direct thrombin inhibitors in clinical development, it has had to 'test the waters', so to speak, of the relationship between pathophysiology and clinical trial design: what are the correct indications, patient entry criteria, endopoints, frequency and duration of dosing, and so on? Our findings validate a role for thrombin in treating arterial thromboembolism and demonstrate clinical activity and tolerability of Hirulog.

Percutaneous Transluminal Coronary Angioplasty for Unstable Angina: Predictors of Outcome in a Multicenter Study.

Background: Angiographic and clinical studies have demonstrated that coronary artery plaque rupture with thrombus formation, spasm, or both are frequently responsible for the syndrome of unstable angina. Percutaneous transluminal coronary angioplasty (PTCA) is commonly used in the treatment of patients with coronary artery disease and unstable angina. A number of studies have shown, however, that intracoronary thrombus increases the risk of abrupt vessel closure. The purpose of this study was to define preprocedural variables predictive of the outcome of PTCA performed on patients with unstable angina in a prospective multicenter study using a core angiographic laboratory. Methods and Results: A total of 386 patients with unstable angina underwent coronary angioplasty of 487 lesions treated with balloon PTCA at 9 medical centers. Multivessel or left main coronary artery diseasewas present in 55% and recent myocardial infarction in 22%. Clinical success was achieved in 317 of 386 patients (82.1%), as defined by <50% residual stenosis at every target lesion evaluated in the core angiographic laboratory and no major complication during hospitalization. Major complications (death, Q-wave or non-Q-wave myocardial infarction, or emergency coronary artery bypass surgery) occurred in 36 patients (9.3%), and abrupt vessel closure occurred in 50 (13.0%). Logistic regression analysis identified preprocedural variables that were predictive of outcome of angioplasty. Strong predictors of any complication (major complication or abrupt vessel closure) included age [odds ratio (OR) = 1.04; 95% confidence interval [CII 1.02. 1.071) for each additional year of age; p < 0.001), number of diseased vessels (OR = 1.58; 95% Cl = 1.16, 2.15 per additional vessel; is = 0.012), the number of le~ions treated at angioplasty (OR) = 1.04%; 95% confidence interval [CI] 1.02, 1.07]) for each additional year of age; p < 0.001), number of diseased vessels (OR = 1.58%; 95% CI = 1.16, 2.15 per additional vessel; p = 0.012), the number of lesions treated at angioplasty (OR = 1.72%; 95% CI = 1.11, 2.66;; p = 0.014), and angiographic evidence of filling defect preceding angioplasty (OR = 3.30; 95% CI = 1.11, 9.75; p < 0.001). Conclusions: The outcome of PTCA performed for unstable angina is influenced by a combination of clinical, angiographic, and procedural variables. This study suggests that PTCA performed on lesions associated with filling defects or on more than one lesion at the time of the procedure carries an increased risk of complication. The outcome of PTCA for unstable angina may be improved by identifying new strategies for the treatment of lesions associated with filling defects and by using more accurate methods to identify and treat the culprit lesion responsible for unstable angina.

Heparin-associated thrombocytopenia: a critical review and pooled analysis.

The purpose of this study is to determine the incidence of heparin-associated thrombocytopenia (HAT) for various subgroups of heparin exposed patients and the impact of study quality on the reported incidence. Articles were identified using a Medline search, a manual search of the Index Medicus, and a review of article references. Key data included heparin type, administration route, indication, treatment duration, outcome criteria, incidence, and platelet count reliability. The pooled incidence estimate in studies requiring a repeatedly abnormal platelet count was compared with estimates from studies not requiring a repeated platelet count. The results showed that there were no adequately designed studies to estimate the incidence of HAT-related thrombosis or hemorrhage. The pooled incidence of HAT in studies requiring a reproducibly lowered platelet count (< 100,000/microL) was 3/281 (1.1%) with intravenous porcine heparin and 4/140 (2.9%) with intravenous bovine heparin. This difference was not statistically significant. The incidence of HAT with intravenous bovine heparin was significantly lower in studies that required a repeated platelet count. The incidence of HAT with heparin administered subcutaneously was small (0%) and in those studies requiring a repeatedly abnormal platelet count, there was no difference between porcine and bovine heparin. The authors concluded that the incidence of HAT is < 3% with intravenous heparin and extremely low for subcutaneous heparin. Study quality may influence the reported incidence of HAT.

The use of antithrombotic therapy in the elderly.

The elderly are predisposed to atherosclerosis and venous thrombosis, the conditions for which anticoagulants are used. Anticoagulants can be used safely in the elderly with little or no more risk of bleeding than exists in younger patients. The prescribing physician must know the mechanism of drug action, be attentive to potential side effects, and monitor drug activity adequately. The authors emphasize the oral anticoagulants and heparin because, in general, their use is associated with a greater degree of risk and more clearly defined benefits than would apply for the antiplatelet agents.