Long-term Anticoagulant Therapy after Myocardial Infarction in Women

A multicentre trial from five medical departments in Oslo has been carried out to determine the value in women patients of one year''s long-term anticoagulant therapy. Follow-up long-term laboratory control and anticoagulant dosage were performed at one centre (the Rikshospitalet). One hundred and fifty-nine patients were assigned randomly into two similar well-matched groups (control and treatment). Dosage was controlled by Thrombotest, aiming at 10–20% levels, and 50% of the tests were less than 14%. Compared with the control group, the treatment group showed a significant reduction in mortality and in reinfarction rate. No serious bleeding complications occurred. It is concluded that women benefit as much as men from long-term anticoagulant therapy.     

A Comparison of Warfarin Sodium and Bishydroxycoumarin in Long-Term Anticoagulant Therapy

Warfarin sodium was compared with bishydroxycoumarin (Dicumarol) in 16 patients on long-term anticoagulant therapy. When the patients were changed from bishydroxycoumarin to warfarin sodium there was no improvement in control of their prothrombin times. It was found that 5 mg. of warfarin had slightly less effect than 50 mg. of bishydroxycoumarin. It was concluded that the drugs were equally effective in long-term anticoagulant therapy. The metabolism of the ingested drug was more important than absorption in determining the control of the patients'' prothrombin times.     

Anticoagulant Therapy in Coronary Artery Disease: A Therapeutic Enigma

The authors'' experience with anticoagulant therapy in both the acute phase and the long-term management of myocardial infarction has proved disappointing. A review of the literature has failed to establish benefit when all patients with coronary artery disease are treated with anticoagulant drugs. A need for well-controlled studies still exists.     

Implications of Using Different Methods to Characterise Anticoagulant Control in Patients with Second Generation Mechanical Heart Valve Prostheses

Objective

Characterisation of anticoagulant control is fundamental to investigations of its association with clinical outcome. Anticoagulant control depends on several factors. This paper aims to illustrate the implications of different methods for measuring and analysing anticoagulant control in patients with second generation mechanical heart valve prostheses.

Methods

International normalised ratio (INR) data collected during the 10-year follow-up of a randomised controlled trial were analysed. We considered the influence of: 3 different target INR ranges; anticoagulant control expressed as the proportion of INR readings (PoR) vs. anticoagulant control follow-up time (PoT); 3 ways of describing the profile of anticoagulant control over time.

Results

Different target INR ranges dramatically influenced derived measures of anticoagulant control; the PoT within the target range varied from 88% for the widest to 28% for narrowest range. Overall distributions of PoR and PoT observations were similar but differed by up to ±20% for individuals; PoT exceeded PoR when control was good but was less than PoR when control was poor. Classifying PoT outside the target range showed that widely varying combinations of PoT too high and too low are possible across individuals.

Conclusions

Researchers'' choices about methods for measuring and quantifying anticoagulant control markedly influence the values derived from INR readings. The use of different methods across studies makes it difficult or impossible to compare findings and to establish an evidence base for clinical practice. Methods for quantifying anticoagulant control should be standardised.     

Diet as prophylaxis and treatment for venous thromboembolism?

Background

Both prophylaxis and treatment of venous thromboembolism (VTE: deep venous thrombosis (DVT) and pulmonary emboli (PE)) with anticoagulants are associated with significant risks of major and fatal hemorrhage. Anticoagulation treatment of VTE has been the standard of care in the USA since before 1962 when the U.S. Food and Drug Administration began requiring randomized controlled clinical trials (RCTs) showing efficacy, so efficacy trials were never required for FDA approval. In clinical trials of 'high VTE risk' surgical patients before the 1980s, anticoagulant prophylaxis was clearly beneficial (fatal pulmonary emboli (FPE) without anticoagulants = 0.99%, FPE with anticoagulants = 0.31%). However, observational studies and RCTs of 'high VTE risk' surgical patients from the 1980s until 2010 show that FPE deaths without anticoagulants are about one-fourth the rate that occurs during prophylaxis with anticoagulants (FPE without anticoagulants = 0.023%, FPE while receiving anticoagulant prophylaxis = 0.10%). Additionally, an FPE rate of about 0.012% (35/28,400) in patients receiving prophylactic anticoagulants can be attributed to 'rebound hypercoagulation' in the two months after stopping anticoagulants. Alternatives to anticoagulant prophylaxis should be explored.

Methods and Findings

The literature concerning dietary influences on VTE incidence was reviewed. Hypotheses concerning the etiology of VTE were critiqued in relationship to the rationale for dietary versus anticoagulant approaches to prophylaxis and treatment. Epidemiological evidence suggests that a diet with ample fruits and vegetables and little meat may substantially reduce the risk of VTE; vegetarian, vegan, or Mediterranean diets favorably affect serum markers of hemostasis and inflammation. The valve cusp hypoxia hypothesis of DVT/VTE etiology is consistent with the development of VTE being affected directly or indirectly by diet. However, it is less consistent with the rationale of using anticoagulants as VTE prophylaxis. For both prophylaxis and treatment of VTE, we propose RCTs comparing standard anticoagulation with low VTE risk diets, and we discuss the statistical considerations for an example of such a trial.

Conclusions

Because of (a) the risks of biochemical anticoagulation as anti-VTE prophylaxis or treatment, (b) the lack of placebo-controlled efficacy data supporting anticoagulant treatment of VTE, (c) dramatically reduced hospital-acquired FPE incidence in surgical patients without anticoagulant prophylaxis from 1980 - 2010 relative to the 1960s and 1970s, and (d) evidence that VTE incidence and outcomes may be influenced by diet, randomized controlled non-inferiority clinical trials are proposed to compare standard anticoagulant treatment with potentially low VTE risk diets. We call upon the U. S. National Institutes of Health and the U.K. National Institute for Health and Clinical Excellence to design and fund those trials.     

Protective Effects of Non-Anticoagulant Activated Protein C Variant (D36A/L38D/A39V) in a Murine Model of Ischaemic Stroke

Ischaemic stroke is caused by occlusive thrombi in the cerebral vasculature. Although tissue-plasminogen activator (tPA) can be administered as thrombolytic therapy, it has major limitations, which include disruption of the blood-brain barrier and an increased risk of bleeding. Treatments that prevent or limit such deleterious effects could be of major clinical importance. Activated protein C (APC) is a natural anticoagulant that regulates thrombin generation, but also confers endothelial cytoprotective effects and improved endothelial barrier function mediated through its cell signalling properties. In murine models of stroke, although APC can limit the deleterious effects of tPA due to its cell signalling function, its anticoagulant actions can further elevate the risk of bleeding. Thus, APC variants such as APC(5A), APC(Ca-ins) and APC(36-39) with reduced anticoagulant, but normal signalling function may have therapeutic benefit. Human and murine protein C (5A), (Ca-ins) and (36-39) variants were expressed and characterised. All protein C variants were secreted normally, but 5-20% of the protein C (Ca-ins) variants were secreted as disulphide-linked dimers. Thrombin generation assays suggested reductions in anticoagulant function of 50- to 57-fold for APC(36-39), 22- to 27-fold for APC(Ca-ins) and 14- to 17-fold for APC(5A). Interestingly, whereas human wt APC, APC(36-39) and APC(Ca-ins) were inhibited similarly by protein C inhibitor (t_½ - 33 to 39 mins), APC(5A) was inactivated ~9-fold faster (t_½ - 4 mins). Using the murine middle cerebral artery occlusion ischaemia/repurfusion injury model, in combination with tPA, APC(36-39), which cannot be enhanced by its cofactor protein S, significantly improved neurological scores, reduced cerebral infarct area by ~50% and reduced oedema ratio. APC(36-39) also significantly reduced bleeding in the brain induced by administration of tPA, whereas wt APC did not. If our data can be extrapolated to clinical settings, then APC(36-39) could represent a feasible adjunctive therapy for ischaemic stroke.     

肝素硫酸转移酶优化表达及其在动物源肝素硫酸化中的应用

肝素是一种重要的凝血药物,目前主要依赖于动物小肠粘膜的提取。动物源肝素含有的抗凝血活性五糖单位GlcNS6S-GlcA-GlcNS6S3S-Ido2S-GlcNS6S少,抗凝血活性低下。文中提出并验证了一种基于酶法催化动物源肝素,提高其硫酸化程度和抗凝血活性的方法。通过比较3种硫酸转移酶肝素-2-硫酸转移酶(Heparan sulfate-2-O-sulfotransferase,HS2ST)、肝素-6-硫酸转移酶(Heparan sulfate-6-O-sulfotransferase,HS6ST)、肝素-3-硫酸转移酶(Heparan sulfate-3-O-sulfotransferase,HS3ST)在重组大肠杆菌及重组毕赤酵母中表达,确定了毕赤酵母作为3种硫酸转移酶的表达宿主;进一步通过N端融合麦芽糖融合蛋白MBP和硫氧还蛋白Trx A,HS2ST和HS6ST的酶表达水平分别提高至(839?14) U/L和(792?23) U/L。通过3种硫酸转移酶HS2ST、HS6ST和HS3ST共同催化动物源肝素,其抗凝血活性由(76?2) IU/mg提高至(189?17) IU/mg。     

PROTHROMBIN TIME—Determination by a Whole Blood Micro-Method for Control of Anticoagulant Therapy

A micro technique that is here described for “prothrombin time” determinations, employing capillary whole blood, provides a range of values which is closely correlated with the Quick one-stage plasma method, thus providing inter-changeability of results both in normal persons and in patients who have been treated with anticoagulant drugs.Avoidance of the use of a water bath and centrifuge permit this technique to yield immediate results at the bedside, in the office or in the patient''s home.The use of a whole blood instead of a plasma technique lends additional safety to control of anticoagulant medication, since it may reflect depression of clotting factors not apparent by the usual plasma methods.     

Separation,purification, anticoagulant activity and preliminary structural characterization of two sulfated polysaccharides from sea cucumber Acaudina molpadioidea and Holothuria nobilis

In this study, we isolated two fucosylated polysaccharide sulfates (ACP and HOP) from sea cucumber Acaudina molpadioidea and Holothuria nobilis, with an average molecular weight of 90.8 and 135.8 kDa, respectively. We investigated and compared their anticoagulant activities through anticoagulant assay. Our data showed that both polysaccharides possessed good anticoagulant activity, but HOP's activity was higher than that of ACP. Due to the different anticoagulant activities of ACP and HOP, we compared the preliminary structural characterizations of these two sulfated polysaccharides, and found that both ACP and HOP consisted of β-d-glucuronic acid, β-d-N-acetyl-galactosamine, α-l-fucose and sulfate groups. ACP and HOP had almost identical ratios of glucuronic acid, N-acetyl-galactosamine and fucose. However, the sulfate contents and sulfation patterns of fucose residues of ACP and HOP were obviously different. There were 4-O-sulfated fucose, 3,4-O-disulfated fucose and 2,4-O-disulfated fucose in ACP, but only 3-O-sulfated fucose and 2,4-O-disulfated fucose were present in HOP. Therefore, their distinct anticoagulant activities might be due to the different sulfate contents and sulfation patterns of their fucose residues.     

Prophylactic Anticoagulant Therapy against Pulmonary Emboli in Acute Paraplegia

Prophylactic anticoagulant therapy within a few days of admitting a patient with a spinal injury appears to offer advantages in preventing pulmonary emboli. It was not found to hinder the patient''s management.     

Thrombosis in systemic lupus erythematosus: striking association with the presence of circulating lupus anticoagulant.

The lupus anticoagulant was found in the plasma of 31 of 60 patients with systemic lupus erythematosus and other connective tissue disorders (mixed connective tissue disease, systemic vasculitis, polyarteritis nodosa, primary sicca syndrome, discoid lupus, Behcet''s syndrome, and systemic sclerosis). Strong associations were found with biological false positive seroreaction for syphilis and thrombocytopenia. The most striking association, however, was with the high prevalence of thrombosis. This tendency to thrombosis was independent of disease activity of systemic lupus erythematosus. The lupus anticoagulant appears to be a useful marker for a subset of patients with systemic lupus erythematosus at risk for the development of thromboembolic complications.     

Computer control of anticoagulant dose for therapeutic management.

OBJECTIVE--To improve the standard of managing anticoagulant treatment and provide a basis for therapeutic quality control. DESIGN--Implementation of a comprehensive computerised system for decision support. SETTING--Three anticoagulation clinics in South Warwickshire. SUBJECTS--Patients in South Warwickshire receiving anticoagulant treatment from September 1988 to March 1989. MAIN OUTCOME MEASURE--International normalised ratio was measured and recorded at each visit. RESULTS--688 Patients'' visits were analysed statistically, and a 38% improvement was achieved in the results of international normalised ratios falling within the recommended therapeutic ranges of the British Society for Haematology. CONCLUSIONS--The implementation of a computerised anticoagulation support system resulted in better management of patients. The system provides a basis for uniform management of treatment and a common platform for national or international trials.     

Structure and anticoagulant activity of sulfated fucans. Comparison between the regular, repetitive, and linear fucans from echinoderms with the more heterogeneous and branched polymers from brown algae

Sulfated fucans are among the most widely studied of all the sulfated polysaccharides of non-mammalian origin that exhibit biological activities in mammalian systems. Examples of these polysaccharides extracted from echinoderms have simple structures, composed of oligosaccharide repeating units within which the residues differ by specific patterns of sulfation among different species. In contrast the algal fucans may have some regular repeating structure but are clearly more heterogeneous when compared with the echinoderm fucans. The structures of the sulfated fucans from brown algae also vary from species to species. We compared the anticoagulant activity of the regular and repetitive fucans from echinoderms with that of the more heterogeneous fucans from three species of brown algae. Our results indicate that different structural features determine not only the anticoagulant potency of the sulfated fucans but also the mechanism by which they exert this activity. Thus, the branched fucans from brown algae are direct inhibitors of thrombin, whereas the linear fucans from echinoderms require the presence of antithrombin or heparin cofactor II for inhibition of thrombin, as reported for mammalian glycosaminoglycans. The linear sulfated fucans from echinoderms have an anticoagulant action resembling that of mammalian dermatan sulfate and a modest action through antithrombin. A single difference of one sulfate ester per tetrasaccharide repeating unit modifies the anticoagulant activity of the polysaccharide markedly. Possibly the spatial arrangements of sulfate esters in the repeating tetrasaccharide unit of the echinoderm fucan mimics the site in dermatan sulfate with high affinity for heparin cofactor II.     

Anticoagulants and the propagation phase of thrombin generation

The view that clot time-based assays do not provide a sufficient assessment of an individual''s hemostatic competence, especially in the context of anticoagulant therapy, has provoked a search for new metrics, with significant focus directed at techniques that define the propagation phase of thrombin generation. Here we use our deterministic mathematical model of tissue-factor initiated thrombin generation in combination with reconstructions using purified protein components to characterize how the interplay between anticoagulant mechanisms and variable composition of the coagulation proteome result in differential regulation of the propagation phase of thrombin generation. Thrombin parameters were extracted from computationally derived thrombin generation profiles generated using coagulation proteome factor data from warfarin-treated individuals (N = 54) and matching groups of control individuals (N = 37). A computational clot time prolongation value (cINR) was devised that correlated with their actual International Normalized Ratio (INR) values, with differences between individual INR and cINR values shown to derive from the insensitivity of the INR to tissue factor pathway inhibitor (TFPI). The analysis suggests that normal range variation in TFPI levels could be an important contributor to the failure of the INR to adequately reflect the anticoagulated state in some individuals. Warfarin-induced changes in thrombin propagation phase parameters were then compared to those induced by unfractionated heparin, fondaparinux, rivaroxaban, and a reversible thrombin inhibitor. Anticoagulants were assessed at concentrations yielding equivalent cINR values, with each anticoagulant evaluated using 32 unique coagulation proteome compositions. The analyses showed that no anticoagulant recapitulated all features of warfarin propagation phase dynamics; differences in propagation phase effects suggest that anticoagulants that selectively target fXa or thrombin may provoke fewer bleeding episodes. More generally, the study shows that computational modeling of the response of core elements of the coagulation proteome to a physiologically relevant tissue factor stimulus may improve the monitoring of a broad range of anticoagulants.     

Psychophysiological Characteristics of Nuclear Power Station Operator Activity as a Factor in Accident Rate

Methods of psychological, physiological, and psychophysiological testing were used to assess the intensity of the activity of operators of the power unit control panel of the Khmel'nitskaya nuclear power station. The operators during whose duty serious control errors and preaccident situations were noted were examined. The psychological and psychophysiological characteristics of these operators were shown to differ in that their reactive anxiety was increased and their well-being, activity, and mood scores, as well as the functional reserves of the cardiovascular system and mental and physical working capacity, were decreased. These parameters were considered as criteria in the development of operating measures. It was proposed that not only technological factors but also operators' psychophysiological characteristics in the dynamics of their manifestation be taken into account for elaborating measures of optimal staff selection and placement.     

Thrombotic risk stratification using computational modeling in patients with coronary artery aneurysms following Kawasaki disease

Kawasaki disease (KD) is the leading cause of acquired heart disease in children and can result in life-threatening coronary artery aneurysms in up to 25 % of patients. These aneurysms put patients at risk of thrombus formation, myocardial infarction, and sudden death. Clinicians must therefore decide which patients should be treated with anticoagulant medication, and/or surgical or percutaneous intervention. Current recommendations regarding initiation of anticoagulant therapy are based on anatomy alone with historical data suggesting that patients with aneurysms \(\ge \) 8 mm are at greatest risk of thrombosis. Given the multitude of variables that influence thrombus formation, we postulated that hemodynamic data derived from patient-specific simulations would more accurately predict risk of thrombosis than maximum diameter alone. Patient-specific blood flow simulations were performed on five KD patients with aneurysms and one KD patient with normal coronary arteries. Key hemodynamic and geometric parameters, including wall shear stress, particle residence time, and shape indices, were extracted from the models and simulations and compared with clinical outcomes. Preliminary fluid structure interaction simulations with radial expansion were performed, revealing modest differences in wall shear stress compared to the rigid wall case. Simulations provide compelling evidence that hemodynamic parameters may be a more accurate predictor of thrombotic risk than aneurysm diameter alone and motivate the need for follow-up studies with a larger cohort. These results suggest that a clinical index incorporating hemodynamic information be used in the future to select patients for anticoagulant therapy.     

Dissociation of activated protein C functions by elimination of protein S cofactor enhancement

Activated protein C (APC) plays a critical anticoagulant role in vivo by inactivating procoagulant factor Va and factor VIIIa and thus down-regulating thrombin generation. In addition, APC bound to the endothelial cell protein C receptor can initiate protease-activated receptor-1 (PAR-1)-mediated cytoprotective signaling. Protein S constitutes a critical cofactor for the anticoagulant function of APC but is not known to be involved in regulating APC-mediated protective PAR-1 signaling. In this study we utilized a site-directed mutagenesis strategy to characterize a putative protein S binding region within the APC Gla domain. Three single amino acid substitutions within the APC Gla domain (D35T, D36A, and A39V) were found to mildly impair protein S-dependent anticoagulant activity (<2-fold) but retained entirely normal cytoprotective activity. However, a single amino acid substitution (L38D) ablated the ability of protein S to function as a cofactor for this APC variant. Consequently, in assays of protein S-dependent factor Va proteolysis using purified proteins or in the plasma milieu, APC-L38D variant exhibited minimal residual anticoagulant activity compared with wild type APC. Despite the location of Leu-38 in the Gla domain, APC-L38D interacted normally with endothelial cell protein C receptor and retained its ability to trigger PAR-1 mediated cytoprotective signaling in a manner indistinguishable from that of wild type APC. Consequently, elimination of protein S cofactor enhancement of APC anticoagulant function represents a novel and effective strategy by which to separate the anticoagulant and cytoprotective functions of APC for potential therapeutic gain.     

Coumarin Therapy and Platelet Aggregation

Platelet aggregation has been related to blood coagulation studies in patients on nicoumalone, a coumarin anticoagulant. Aggregation studies were performed by means of Chandler''s tube and the adenosine diphosphate (A.D.P.)-induced optical density method. Platelet aggregation in Chandler''s tube has been shown to be quite different from A.D.P. aggregation and to be dependent on the “intrinsic” (blood) clotting system. When the intrinsic system was depressed by coumarin anticoagulant, aggregation was delayed in Chandler''s tube, but patients with a predominantly “extrinsic” (tissue) system defect gave normal results even when their prothrombin time was excessively prolonged. In contrast there was an increased response to A.D.P. in the anticoagulated patients.The study emphasizes the different mechanisms of platelet aggregation, which we have referred to as coagulation-induced and A.D.P.-induced aggregation. It also shows the limitations of routine control of oral anticoagulants by prothrombin time alone, as the coagulation-induced platelet aggregation appears to be quantitatively related to the overall level of clotting factors in the intrinsic system and independent of the extrinsic system.     

Comparative effect of three rodenticides warfarin,bromadiolone and brodifacoum on the Indian field mouse,Mus booduga gray

Three anticoagulant rodenticides, warfarin, bromadiolone and brodifacoum, were evaluated in the laboratory for their activity against the Indian field mouse, Mus booduga. In oral intubation studies M. booduga was found to be more susceptible to bromadiolone and brodifacoum than warfarin. Feeding studies with 0.005% bromadiolone and brodifacoum baits produced 83% mortality after a single day's feeding while a similar mortality was achieved with 0.025% warfarin only after 6 days of consecutive feeding. The anticoagulant baits were less palatable than the plain (unpoisoned) bait. Laboratory feeding tests confirmed that 0.005% of the active ingredient would be an effective bait concentration for field use of both bromadiolone and brodifacoum. The single-feed potency of bromadiolone and brodifacoum indicate that these rodenticides may be more effective and economical than warfarin in the field.     

Thermal depolymerization of alginate in the solid state

A new method of introduction carboxyl groups to chitosan sulfate by the acylation reaction between hydroxyethyl chitosan sulfates and butane dioic anhydride in homogeneous solution was used to obtain carboxybutyrylated hydroxyethyl chitosan sulfates. The structures of the derivatives were characterized by element analysis, FT-IR, ¹³C-NMR, and gel permeation chromatography. The content and position of the carboxyl groups could be controlled favorably. Their anticoagulant activity was determined for human plasma with respect to activated partial thromboplastin time (APTT), thrombin time (TT), and prothombin time (PT). The introducing of carboxyl groups to amino groups greatly prolonged the APTT and TT. The best result occurred when the degree of substitution of the carboxyl groups was about 0.4/unit that prolonged APTT and TT with about 5 and 1.5 times compared to that of the uncarboxylated hydroxyethyl chitosan sulfates; another conclusion is that introducing of carboxyl groups into N,O-position gave better results than that just into N-positions. Low S% chitosan sulfate and 6-O-desulfated chitosan sulfate showed little anticoagulant activity but their N,O-carboxybutyrylated derivatives (0.6/unit ds) showed increased APTT or TT, while their N-carboxybutyrylated derivatives (0.6/unit ds) gave no improvement. Generally, the introducing of carboxyl groups could not increase PT in spite of the position introduced.