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Figure 5 summarizes the three different phases in the pathophysiology of disseminated intravascular coagulation exemplified by the effect of endotoxin. During the first phase, the coagulation system is activated to generate soluble fibrin. Fibrin kept in solution by fibrinogen or fibrinolytic degradation products can be cleared from the circulating blood. If the amount of soluble fibrin exceeds a certain threshold, soluble fibrin may precipitate or polymerize to fibrin clots. At this state, active fibrinolysis breaks down the precipitated fibrin to fibrinolytic degradation products preventing the preservation of fibrin. If the capacity of the fibrinolytic system is exhausted, or if fibrinolysis is inhibited, fibrin clots may be preserved, causing cell damage, as for instance bilateral renal cortical necrosis.

The fibrinolytic system is comprised of a series of serine proteases and serine protease inhibitors which are involved in the dissolution of fibrin in the vascular lumen, but also in the migration of cells and in the remodeling of the extracellular matrix of the vascular wall. The transcription, expression and degradation of the various fibrinolytic enzymes by cells in the vascular wall is influenced by lipoproteins and this interrelationship may play a significant role in the development of the atherosclerotic plaque: the transcription of plasminogen activator inhibitor-1 is influenced by very low-density lipoproteins, the expression of both tissue plasminogen activator and plasminogen activator inhibitor-1 is influenced by low-density lipoproteins and lipoprotein(a) (Lp(a)) and the internalization of the urokinase: plasminogen activator inhibitor-1 complex occurs via the low-density lipoprotein related protein. Several clinical studies have shown correlations between fibrinolytic parameters and lipoproteins in healthy populations and in patients with dyslipidemia, but the correlation between single plasma fibrinolytic enzymes and the severity of coronary atherosclerosis is less well documented. The reduction of plasma lipids with lipid-lowering drugs also affects the concentration of fibrinolytic enzymes, although this may also be due to direct effects of the drugs on the expression of the various fibrinolytic enzymes. The reduction of fibrinolytic and proteolytic activity in the atherosclerotic plaque by their lipid-lowering effect and by their direct action on the fibrinolytic system may be one of the mechanisms by which some lipid-lowering drugs achieve plaque stabilization.

Background: Pre-operative autologous blood donation is used to reduce the need of allogeneic blood in patients undergoing coronary bypass surgery operations, but it is not clear what impact the blood donation has on the post-operative course of these patients. Methods: We studied the post-operative course of 210 patients who pre-donated autologous blood before their coronary bypass operation (donors) and of 67 patients who were eligible to pre-donate but did not (controls). Results: The clinical variables and the technical operative parameters of the patients in the two groups were similar. There was no significant difference between the duration of assisted ventilation post-operatively (756±197 vs. 802±395 min; P =0.54) or length of stay in the intensive care unit (1.8±1.1 vs. 1.7±0.9 days; P =0.52) of the two groups. The number of autologous units of packed red cells and of fresh frozen plasma (FFP) received by the donors was significantly higher than the number of units of allogeneic packed red cells (1.5±0.9 vs. 0.3±0.9; P =0.001) and the units of homologous FFP received by the controls (2.3±0.8 vs. 0.6±1; P =0.001). Conclusions: We found no evidence that autologous blood donation exerted a negative influence on the post-operative course of patients undergoing coronary bypass surgery. Patients who pre-donated blood received no allogeneic blood products, but the number of autologous blood products received by donors was higher than the number of blood products received by patients who did not pre-donate.

Blood coagulation parameters (thromboplastin time. PT; activated partial thromboplastin time, aPTT; fibrinogen; antithrombin III, ATIII; von Willebrand factor-concentration, vWF; factor VIII-activity, FVIII) and fibrinolytic parameters (plasminogen; (alpha-antiplasmin; euglobulin-lysis-time, Elt; tissue plasminogenactivator-antigen, tPA-antigen; plasminogenactivator-1-antigen, PAI-1-antigen) were evaluated in 34 women on low-dose oral contraceptives (OC) twice at intervals of 12 weeks each time before and after maximal exercise. During the 12 weeks, 24 women took part in an aerobic conditioning program and 10 women were requested to avoid any kind of sports activity for this period. Blood samples were taken before training and before and after maximal treadmill exercise. This procedure was repeated after the training program. After maximal exercise we found a significant reduction of aPTT and PT (increase in %), a decrease in ATIII, vWF, fibrinogen, plasminogen and alpha2-antiplasmin but an increase in fibrinolytic activity (all p

Currently, in Germany, there is a successful program where patients monitor their own coagulation status through self-testing. The advent of a new generation of coagulometers has allowed more and more patients to use self-testing to monitor their coagulation status. The development of a structured training program by the Association of Self-Management of Anticoagulation (ASA), and the effective cost reimbursement system by health insurance companies has furthered the success of this program. The reliability of the coagulometers is quite important to the success of this program, and has been extensively evaluated. These systems are characterized by high accuracy and precision, and low intra-/interassay variation. They also exhibit excellent recovery of the therapeutic range. Several clinical studies have shown that patients performing self-management remain in the therapeutic range a greater percentage of the time when compared to conventional testing, and tended to have less incidences of bleeding or thromboembolic complications. It is estimated that about 50 to 60% of all patients on anticoagulant therapy in Germany are suitable candidates for self-management.

IntroductionAlthough disseminated intravascular coagulation (DIC) is an “intermediary mechanism of disease”1 that has been intensively studied during the last three decades,2-4 several aspects relating to the clinical problem of DIC are still under debate. For example, a standardized definition of disseminated intravascular coagulation has not yet been agreed upon. A diagnosis can be accurately made using the facilities of a specialized laboratory, but time constraints make the diagnosis of DIC by the general laboratory difficult. Since DIC can be prevented if the right therapy is initiated early, the ability to quickly and accurately diagnose DIC and to monitor the involved dynamic processes are essential prerequisites for the effective management patients with DIC.Due to the problems associated with defining DIC, making an early diagnosis, and effectively treating the condition following diagnosis, the clinical management of DIC can be difficult. The transition from an activated hemostatic system to a well-defined state of DIC is indistinct, and the borderlines cannot easily be distinguished. In addition, different underlying diseases mediating DIC induce different clinical symptoms associated with DIC and demand different therapeutic approaches.

SummaryIn 1994, shortly after a heat-treated prothrombin complex concentrate (PCC) had been withdrawn from the German market due to transmission of hepatitis B, the license of another brand was withdrawn, due to 3 acute fatalities associated with the use of this product. We report on the clinical data of altogether 5 patients, who died during a 3 month period in Germany after having received this brand of PCC. All patients had surgery, acquired deficiencies of coagulation factors, and underlying diseases predisposing for thrombosis or disseminated intravascular coagulation. PCC was administered for the prevention of bleeding. In three patients, a drug interaction of PCC with aprotinin may also have played a role. Several points, however, are suspicious of a major causative effect of the respective product, (a) the close temporal correlation between administration of the drug and the subsequent clinical as well as laboratory deterioration, (b) the accumulation of these adverse events in a short period of time, when the use and market share of this brand increased due to the shortage of other products, and (c) laboratory abnormalities of this brand which have been consistently observed in several in vitro studies.

SummaryThe use of recombinant ® hirudin as an anticoagulant in performing extracorporeal circulation systems including cardiopulmonary bypass (CPB) devices requires a specific and easy to handle monitoring system. The usefulness of the celite-induced activated clotting time (ACT) and the activated partial thromboplastin time (APTT) for r-hirudin monitoring has been tested on ex vivo blood samples obtained from eight patients treated with r-hirudin during open heart surgery. The very poor relationship between the prolongation of the ACT and APTT values and the concentration of r-hirudin as measured using a chromogenic factor Ila assay indicates that both assays are not suitable to monitor r-hirudin anticoagulation. As an alternative approach a whole blood clotting assay based on the prothrombin-activating snake venom ecarin has been tested. In vitro experiments using r-hirudin- spiked whole blood samples showed a linear relationship between the concentration of hirudin added and the prolongation of the clotting times up to a concentration of r-hirudin of 4.0 µg/ml. Interassay coefficients (CV) of variation between 2.1% and 5.4% demonstrate the accuracy of the ecarin clotting time (ECT) assay. Differences in the interindividual responsiveness to r-hirudin were analyzed on r-hirudin- spiked blood samples obtained from 50 healthy blood donors. CV- values between 1.8% and 6% measured at r-hirudin concentrations between 0.5 and 4 µg/ml indicate remarkably slight differences in r-hirudin responsiveness. ECT assay results of the ex vivo blood samples linearily correlate (r = 0.79) to the concentration of r-hirudin. Moreover, assay results were not influenced by treatment with aprotinin or heparin. These findings together with the short measuring time with less than 120 seconds warrant the whole blood ECT to be a suitable assay for monitoring of r-hirudin anticoagulation in cardiac surgery.

SummaryIn the absence of its cofactor thrombomodulin (TM) thrombin is only a poor activator of the anticoagulant serine protease protein C (PC). The TM-dependence of PC-activation has been restricted to a series of molecular structures of the PC molecule including high-affinity calcium binding sites and single amino acid residues. However, thrombin induced activation of a PC derivative altered in all these critical positions is markedly enhanced by TM indicating that additional structures of the PC molecule are involved in determining the TM specificity. Based on the hypothesis that such an additional regulatory element should be located near the thrombin cleavage site and should include negatively charged amino acids to ascertain calcium binding, we studied whether Glu and Asp in positions P7 and P6 relative to the thrombin cleavage site together with Asp in P3 are involved in formation of such a regulatory element. Three PC derivatives containing the neutral counterpart of the negatively charged amino acids in positions P3; P3 and P6; and P3, P6, and P7, respectively, were generated using site-directed mutagenesis. Compared to rPC-wt the initial rates of PC activation of all three mutants were increased 4.0-fold for thrombin/TM and 4.0-, 5.3-fold for activation by thrombin alone. However, compared to the PC derivative neutralized exclusively in P3, additional changes in P6 and P7 showed no increase in the thrombin activation kinetics and calcium binding properties were identical in all of the three mutants. We conclude that .1) among the three negatively charged amino acids at the COOH-terminal end of the activation peptide of PC, only Asp in P3 is involved in calcium-dependent inhibition of PC activation by thrombin; 2) the residues in P7 and P6 do not contribute to the calcium binding properties of PC; 3) P7 and P6 sites are not required for calcium-dependent activation of PC by the thrombin/TM complex.

SummaryThe interaction of radiolabeled factor VII (FVII) and factor VIIa (FVIIa) with endotoxin-stimulated endothelial cells (EC), known to express tissue factor (TF), and unstimulated EC was studied. FVII/FVIIa binding to EC-monolayers was saturable within 4.5-6 h, reversible, temperature and calcium dependent on both, endotoxin-stimulated and on unstimulated EC. Upon 2 h of incubation on EC, FVII was partially converted to FVIIa in the absence of protease inhibitors. The affinity of this binding was K d = 45.4 ± 18.7 nM with a calculated number of binding sites B max = 3.75 ± 0.31 × 106 molecules/cell. In addition to unlabeled FVII and FVIIa, other vitamin K-dependent proteins reduced binding of [125I]-FVII/FVIIa to about 60-70%, and this type of common binding site for vitamin K-dependent proteins revealed a K d = 32.2 ± 5.6 nM and a B max = 3.03 ± 0.14 × 106 molecules/cell. Moreover, in the presence of 1 μM prothrombin to suppress common binding sites, only on endotoxin-stimulated EC additional inhibition of FVII/FVIIa binding was achieved by anti-TF antibodies. The characteristics of the FVII/FVIIa-TF interaction with a K d = 17.2 ± 5.2 nM and a B max = 342,000 ± 1,100 binding sites/cell revealed a similar saturation kinetics in radioligand binding and in functional factor X activation within 90-120 min. These data indicate the presence of at least two independent binding sites for FVII/FVIIa on stimulated EC of which about 10% are TF specific. The existence of binding sites common for vitamin K-dependent proteins on both types of EC may improve the availability of FVII/FVIIa once EC become stimulated and express TF on their surface.

There are currently three established low-density lipoprotein (LDL) apheresis systems: immunoadsorption, heparin-induced extracorporeal LDL precipitation (HELP), and dextran sulfate. We treated the same patient with all three systems and compared the lipid reductions achieved. A total of 135 consecutive treatments were studied, 57 with immunoadsorption, followed by 30 with HELP and 48 with dextran sulfate adsorption. The mean plasma volume (mean +/- SD) treated was 4.9 +/- 0.05, 3.08 +/- 0.091, and 3.39 +/- 0.71 L, respectively. The LDL-cholesterol (LDL-C) reduction was 75.5% +/- 7.4%, 61.6% +/- 5.1%, and 57.1% +/- 12.4%, respectively (P.001 for immunoadsorption vHELP and dextran sulfate). The mean removal efficiency (mass removed/plasma volume treated) for LDL-C was 1.0 +/- 0.12, 1.42 +/- 0.25, and 1.15 +/- 0.21 g/L, respectively (P.001 for HELP v immunoadsorption and dextran sulfate). The mean LDL-C plasma concentration before apheresis was 199 +/- 23.9, 201 +/- 25.7, and 186 +/- 28 mg/dL, respectively (P.001 for dextran sulfate adsorption v immunoadsorption and HELP). Among the three LDL apheresis systems, immunoadsorption caused the greatest percent reduction in LDL-C, while HELP eliminated LDL-C from the plasma most efficiently. Dextran sulfate was similar to HELP in terms of LDL-C reduction, and its removal efficiency was similar to immunoadsorption. Dextran sulfate was also associated with the lowest pretreatment plasma LDL-C concentration.

Immunoadsorption low density lipoprotein (LDL) apheresis is performed with reusable columns containing anti-apolipoprotein B(ApoB) antibodies. We analyzed their long-term efficacy and selectivity. Performance over 60 treatment sessions of six pairs of immunoadsorption LDL apheresis columns was evaluated by analysis of variance using the removal of total cholesterol and ApoB to assess efficacy and the ratio of total cholesterol/high density cholesterol removed to assess selectivity. The removal of cholesterol did not vary significantly with treatment number. The mass of ApoB removed increased significantly (p = 0.002), and the mass of ApoB removed per volume unit of processed plasma showed a trend (p = 0.065) toward an increase with treatment number. Both parameters correlated with the serum ApoB concentration before treatment, which also increased significantly (p = 0.0007) with treatment number. No significant variation of selectivity was found. The efficacy of the LDL apheresis immunoadsorption columns did not decrease after 60 treatment sessions. The columns' selectivity also remained unchanged.

Summary Two glycoforms of a soluble mutant of recombinant human thrombomodulin (rec.TM) were used to identify critical N- and O-linked glycans of the endothelial cell thrombin receptor. While N-linked glycans were not found to be involved in any function of rec.TM, an acidic chondroitin sulphate-like glycosaminoglycan (CSGAG) was found to be critical for all the direct anticoagulant functions of rec.TM, including inhibition of thrombin-mediated platelet aggregation. A glycoform of rec.TM lacking CSGAG had very poor anticoagulant activity. Furthermore, the glycoform of rec.TM possessing CSGAG showed strong inhibition by and had high affinity for poly-cationic basic proteins, whereas the CSGAG-deficient rec.TM did not. Monoclonal antibody binding as well as lectin mapping of rec.TM with agglutinins identified sialic acid containing O-linked glycans in both glycoforms additional to the CSGAG in high molecular weight rec.TM. These findings define important molecular interactions modulating the anticoagulant function of TM, which appear to be critically regulated by CSGAG, and also showed that the overall post-translational glycosylation pattern of the two glycoforms was very similar except for the presence of CSGAG. The possibility exists that differently expressed glycoforms of TM may be crucial for the expression of endothelial cell-related anticoagulant potential in different vascular beds.

SummaryThe regulation of tissue-plasminogen activator (tPA) and plasminogen activator inhibitor 1 (PAI-l) synthesis was studied in cultured human mesothelial cells derived from omentum (HOMC). Heparin (100 U/ml) as well as pentosan polysulfate (300 pg/mt) stimulated tPA synthesis by HOMC 2.9-4.5-fold. Heparin-induced tPA production was dose- and time-dependent and was inhibited by cycloheximide. tPA production by HOMC was also stimulated by phorbol 12-myristrate l3-acetat (2.6-fold), fibrin clots (1.9-fold), or batroxobin (1.9-fold).Heparin and pentosan polysulfate did not stimulate PAI-1 production by HOMC, while phorbol l2-myristrate 13-acetat (100 nM) increased the concentration of PAI-1 in the conditioned medium by 2.6-fold over 24 h. The interaction of heparin with HOMC was studied by direct binding experiments. Dose-dependent specific binding of biotinylated heparin to HOMC was saturable at about 10 pg/ml, the Kp was estimated to about 0.15 pM. Biotinylated heparin bound rapidly to HOMC and reached a plateau within 60 min. Unlabeled heparin as well as pentosan polysulfate inhibited binding of biotinylated heparin in a dose-dependent fashion. These data demonstrate that heparin interacts with HOMC, and increases the fibrinolytic capacity in these cells by selectively increasing the production of tPA.

Patients with hypercholesterolemia and with coronary atherosclerosis have increased plasma levels of plasminogen activator inhibitor (PAI)-1. PAI-1 and low-density lipoproteins (LDL) are also present in the walls of atherosclerotic vessels, where they participate in the development and remodeling of the atherosclerotic plaques. We investigated the influence of LDL on the apical (luminal) and basolateral (subendothelial) secretion of PAI-1 by human umbilical vein endothelial cells in a two-compartment cell-culture model. Confluent cells were incubated with LDL either in the apical compartment or in the basal compartment. Cells incubated with culture medium served as controls. A significantly higher concentration of PAI-1 was found in both the apical (P = 0.025) and the basal compartment (P = 0.025) if cells were incubated with LDL on the basolateral side. In contrast, incubation of the cells with LDL apically resulted in an increased PAI-1 concentration only in the apical compartment (P = 0.028) and not in the basal compartment. Our findings indicate that the LDL particles that reach the subendothelial space can induce an increased release of PAI-1 by endothelial cells into the vessel lumen and also contribute to the release of PAI-1 into the subendothelial space and thus to the process of atherosclerotic plaque remodeling.

SummaryTissue factor pathway inhibitor (TFPI) is an important regulator in the extrinsic blood coagulation pathway. Although the regulatory biochemical role of TFPI is evident, the clinical significance of this proteinase inhibitor remains to be elucidated. The definition of a clinical TFPI deficiency seems to be more complex than that of other coagulation inhibitors because the activity and concentration of circulating TFPI can not be considered a true measure of in vivo levels. Its determination in plasma samples by immunological methods or functional assays has been shown to be inadequate in the detection of a clinical deficiency.Therefore, we screened genomic DNA samples of blood donors and thrombotic patients for alterations in the TFPI gene to assess the influence of a modified TFPI in venous thromboembolic diseases. We detected a single nucleotide substitution in exon 7 (536C→T) leading to a proline to leucine exchange at amino acid position 151 of the protein ([P151L]TFPI) and found the prevalence of heterozygous carriers in German unrelated blood donors to be 0.2% (n = 5120).Four unrelated persons out of 14 probands carrying the genetic variation could be linked to venous thrombosis. For calculation of a potential risk for venous thrombosis for carriers of the mutation we investigated healthy blood donors about thrombotic events. 7 out of 308 blood donors were found to have a history of venous thrombosis, one of them carried the TFPI mutation. Statistical calculation showed a significant relative risk for venous thrombosis for individuals with the trait (odds ratio, 9.3; confidence interval, 1.8-48.6; p

SummaryCD40 is a type I member of the tumour necrosis factor (TNF) receptor superfamily of proteins, and is present on a wide variety of cells including vascular endothelial cells. Ligation of this receptor on endothelial cells is known to increase expression of inflammatory adhesion molecules. We have recently demonstrated that platelets express the ligand of CD40 (CD154) within seconds of exposure to agonist, and interact with endothelial cells to participate directly in the induction of an inflammatory response. Here we show that activated platelets induce tissue factor (TF) expression on endothelial cells in a CD40/CD154-dependent manner, and that the magnitude of this response can equal that induced by TNFα. Moreover, CD40 ligation on endothelial cells downregulates the expression of thrombomodulin. We also show that CD40-mediated TF expression is less sensitive to inhibition with the oxidative radical scavenger pyrrolidine dithiocarbamate than is that mediated by TNFα, indicating that CD40 has a distinct signalling pathway. Tissue factor is a cell membrane protein which functions as the main trigger of the extrinsic pathway of blood coagulation, and its expression on endothelial cells is implicated in wound healing and angiogenesis. Since platelets are among the first cells involved in haemostasis following tissue injury, our data showing that ligation of CD40 by CD154 induces a procoagulant phenotype on vascular endothelial cells suggests that platelets may play an important role in the induction of wound healing.

CD40 ligand (CD40L, CD154), a transmembrane protein structurally related to the cytokine TNF-alpha, was originally identified on stimulated CD4+ T cells, and later on stimulated mast cells and basophils. Interaction of CD40L on T cells with CD40 on B cells is of paramount importance for the development and function of the humoral immune system. CD40 is not only constitutively present on B cells, but it is also found on monocytes, macrophages and endothelial cells, suggesting that CD40L has a broader function in vivo. We now report that platelets express CD40L within seconds of activation in vitro and in the process of thrombus formation in vivo. Like TNF-alpha and interleukin-1, CD40L on platelets induces endothelial cells to secrete chemokines and to express adhesion molecules, thereby generating signals for the recruitment and extravasation of leukocytes at the site of injury. Our results indicate that platelets are not only involved in haemostasis but that they also directly initiate an inflammatory response of the vessel wall.

Assay conditions of a plasma-based ecarin clotting time (ECT) were evaluated and the precision of the ECT in monitoring plasma levels of r-hirudin assessed. The snake venom enzyme ecarin converts prothrombin to meizothrombin possessing only weak coagulant but strong esterase activity. In r-hirudin containing plasma samples, meizo thrombin is rapidly neutralized by r-hirudin resulting in a dose-dependent prolongation of the clotting times. Among the different assay conditions tested, addition of 50 microliters of ecarin (4 U/ml) to 100 microliters of undiluted citrate-anticoagulated plasma gave optimal results with respect to precision and reproducibility. The measuring range of the ECT performed in this way is about 0.02-5.0 micrograms/ml r-hirudin. In vitro studies performed on r-hirudin-spiked plasma samples of 50 healthy individuals demonstrate remarkably low interindividual differences in r-hirudin responsiveness as indicated by CV-values below 5% and 7% at r-hirudin concentrations between 0-3 micrograms/ml and 4-5 micrograms/ml, respectively. The specificity for r-hirudin of the ECT is further demonstrated by the strong correlation (r = 0.94) between the results of a chromogenic assay and the ECT-measured r-hirudin concentrations obtained on 67 ex vivo blood samples. Depending on the concentration of r-hirudin the ECT is sensitive to plasma levels of prothrombin. In the absence of r-hirudin the critical prothrombin concentration was found to be 20% but increasing to 60% in the presence of 2.0 micrograms/ml r-hirudin. A fibrinogen concentration of 50 mg/dl was found to be the minimal concentration independent of the r-hirudin concentration. The precision of the ECT in measuring plasma levels of r-hirudin is not influenced by treatment with heparin, aprotinin or oral anticoagulants. The data demonstrate that the ECT is a rapid and easily perfor mable clotting assay which allows accurate measurement of r-hirudin plasma levels. ECT-monitored hirudin treatment will help to establish optimal dose regimens that are more efficacious but still as safe as heparin.

Background Acute graft thrombosis is a severe complication in vascular surgery that may require limb amputation or even cause death. Because nearly all patients undergoing vascular surgery have had previous exposure to heparin, the presence of heparin-related anti-platelet antibodies typical for heparin-associated thrombocytopenia (HAT) is one underlying possible mechanism of acute graft thrombosis. Although thrombocytopenia is a typical finding of HAT, it is not clear whether the occurrence of clinically important HAT is necessarily associated with thrombocytopenia. Patients and methods Ten out of 246 patients undergoing vascular surgery were diagnosed with HAT because of otherwise unexplained acute graft thrombosis that required recurrent surgical interventions. Results In all of the 10 patients, heparin-related anti-platelet antibodies were detected although the platelet counts were within the normal range. When HAT was diagnosed, heparin administration was stopped and, after autoantibody cross-reactivity with the heparinoid Danaparoid had been excluded, anticoagulation was continued using this anticoagulant. After heparin therapy was discontinued none of the 10 patients developed further thrombotic complications. Conclusion The data presented demonstrate clearly that a normal platelet count does not exclude the possibility of HAT. As a consequence of this, HAT should be suspected in patients who develop thrombotic complications during heparin treatment, regardless of the actual platelet counts.

The fibrinolytic capacity of blood depends mainly on the amount of tissue-type plasminogen activator (t-PA) activity and plasminogen activator inhibitor type-1 (PAI-1) activity. Previous studies linked high PAI activity or low t-PA activity with the development of atherosclerosis and thromboembolic diseases. Yet, there are conflicting reports in the literature as to whether there is higher PAI activity in patients with myocardial infarction (MI) than in patients with coronary artery disease (CAD) without previous MI. In this retrospective study, t-PA activity, t-PA antigen, and PAI activity before and after a venous occlusion test (VOT) of 10 min were assessed in 109 patients with angiographically documented CAD, in two subgroups of CAD patients with (n = 66) or without (n = 43) previous MI, and in subgroups of CAD patients according to their triglyceride levels and other risk factors. The mean values of t-PA activity in the whole patient group showed a 100-fold increase and a 3.1-fold increase in t-PA antigen after VOT (0.03 +/- 0.03 to 3.0 +/- 6.8 U/ml and 16.5 +/- 6.9 to 51.0 +/- 25.4 ng/ml, p0.05). PAI activity was 24.4 +/- 11.0 before and 19.6 +/- 13.2 U/ml after VOT. Within the CAD group, no difference was found between patients without MI and survivors of previous MI in PAI activity before VOT (24.6 +/- 10.7 vs. 24.3 +/- 11.3 U/ml) and after VOT (19.0 +/- 12.1 vs 20.0 +/- 14.0 U/ml), or t-PA activity before (0.03 +/- 0.01 vs. 0.04 +/- 0.04 U/ml) and after VOT (2.8 +/- 7.0 vs. 3.2 +/- 6.7 U/ml). In 39.4% of CAD patients elevated plasma PAI activity before VOT (25 U/ml) was found. This subgroup of patients represented the highest PAI activity after VOT (p0.05), the lowest t-PA activity after VOT (p0.001), and the highest triglyceride levels (p0.05). In 11% of the patients, a small increase in t-PA activity (less than 0.5 U/ml) after VOT was seen. This group showed the lowest t-PA antigen after VOT (p0.001) and the highest fibrinogen level (p0.05). Both subgroups showed the same distribution among patients with and without MI. CAD patients with triglyceride levels over 200 mg/dl had the highest PAI activity values before VOT (28.3 +/- 11.8 U/ml; p0.01) and after VOT (24.9 +/- 13.2 U/ml; p0.01), resulting in low t-PA activity after VOT (p0.01).(ABSTRACT TRUNCATED AT 400 WORDS)

The relationship between thrombomodulin-associated O-linked glycosaminoglycans (GAGs) and the exogenous GAGs heparin or dermatan sulfate was studied in the inhibition of thrombin by antithrombin III (AT III) or heparin cofactor II (HC II). Both rabbit thrombomodulin (TM) and two glycoforms (a high-Mr form containing GAGs and a low-Mr form lacking the majority of O-linked GAGs) of a recombinant human TM deletion mutant (rec-TM) were used. The rapid inactivation of thrombin by HC II in the presence of dermatan sulfate was prevented by both the high-Mr rec-TM and the rabbit TM. In contrast, both rabbit TM treated with chondroitin ABC lyase to remove O-linked GAGs and the low-Mr form of rec-TM had only weak protecting effects. In the absence of exogeneous dermatan sulfate, thrombin inhibition by a high concentration of HC II was slightly accelerated by the high-Mr form of rec-TM but protected by rabbit TM. When thrombin inhibition by AT III in the presence of heparin was studied, both high-Mr rec-TM and rabbit TM again invoked a similar reduction of inactivation rates, whereas in the absence of exogenous heparin, both high-Mr forms accelerated thrombin inhibition by AT III. The diverse reactivities of various forms of TM towards HC II and AT III were also observed during protein C activation by the thrombin-TM complex. These results suggest that thrombin activity at the vessel wall or in fluid phase may undergo major kinetic modulations depending on the type of protease inhibitor, the presence or absence of exogenous GAGs and the glycosylation phenotype of TM. The dependence of TM anticoagulant function on the presence of an intrinsic GAG moiety suggests that variant glycoforms of this endothelial cell cofactor may be expressed differently in a species-, organ-, or tissue-specific manner as a means to regulate TM function in diverse vasculatures.

The comparison of the complement inhibitor S-protein, isolated from human plasma, with vitronectin, a serum spreading factor, revealed a high degree of similarity of both proteins with respect to molecular weight, band pattern in polyacrylamide gels in the presence of sodium dodecyl sulfate and amino acid composition. While radiolabeled S-protein was preciptitated by antiserum against vitronectin, both proteins exhibited precipitin lines of complete identity in double immunodiffusion analysis when tested mutually against antisera of the appropriate components. The functional property of vitronectin to promote cell spreading of fibroblasts was also documented for purified S-protein. These findings indicate a high degree of similarity with respect to structural and functional properties of S-protein and vitronectin and hence may implicate that both proteins are identical.

A quantitative determination of soluble fibrin in plasma was carried out by affinity chromatography. For this purpose, desAA-fibrin and fibrinogen immobilized on Sepharose 4B were used at the stationary side whereas batroxobin-induced 125I-desAA-fibrin or thrombin-induced 125I-desAABB-fibrin mixed with plasma containing 131I-fibrinogen represented the fluid phase. The binding characteristics of these mixtures to the immobilized proteins were compared at 20 degrees C and 37 degrees C. Complete binding of both types of fibrin to the immobilized desAA-fibrin was always seen at 20 degrees C as well as at 37 degrees C. However, binding of soluble fibrin was accompanied by substantial binding of fibrinogen that was more pronounced at 20 degrees C. Striking differences depending on the temperature at which the affinity chromatography was carried out, were documented for the fibrinogen-fibrin interaction. At 20 degrees C more than 90% of the applied desAA-fibrin was bound to the immobilized fibrinogen whereas at 37 degrees C only a mean of 17% were retained at the fibrinogen-Sepharose column. An opposite finding with regard to the tested temperature was made with the desAABB-fibrin. Nearly complete binding to insolubilized fibrinogen was found at 37 degrees C (95%) but only 58% of the desAABB-fibrin were bound at 20 degrees C. The binding patterns did not change when the experiments were performed in the presence of calcium ions. The opposite behaviour of the two types of soluble fibrin to immobilized fibrinogen at the different temperatures, together with the substantial binding of fibrinogen in the presence of soluble fibrin to insolubilized fibrin in every setting tested, devaluates affinity chromatography as a tool in the quantitative assessment of soluble fibrin in patient's plasma.

This study examines the role of neutrophils (PMN) in the pathogenesis of endotoxin-induced microclot formation. It is intended to clarify whether granulocytes are involved in endotoxin-induced activation of intravascular coagulation (generation of soluble fibrin) and/or in endotoxin-induced precipitation of soluble fibrin. Precipitation of soluble fibrin was achieved by injection of endotoxin into ancrod- infused rabbits with circulating soluble fibrin (first model). Activation of intravascular coagulation was elicited by two intravenous injections of endotoxin into rabbits (second model). Seventy-two and ninety-six hours after injection of nitrogen mustard, leukopenic rabbits had PMN counts between 0 and 50 cells per mul. Neutropenia did not prevent the occurrence of glomerular microclots after infusion of ancrod and injection of endotoxin (first model). Neutropenia influenced neither the decrease in mean fibrinogen concentrations nor the drop in mean platelet counts after ancrod and endotoxin administration. In contrast to the first model, neutropenia prevented the occurrence of glomerular microclots and of circulating soluble fibrin after two injections of endotoxin (second model). It did not, however, protect rabbits from the decrease in mean platelet counts after endotoxin administration. These data indicate that granulocytes are involved in endotoxin-induced activation of intravascular coagulation and the production of soluble fibrin but are not essential to endotoxin-induced precipitation of soluble fibrin.

The effect of purified fibrin(ogen) degradation product fragment D on cultured bovine aortic endothelial cells has been investigated. Binding to the cells was studied using purified radiolabelled fragment D and assessment of its recently postulated deleterious action was made by three different approaches: release of 51Cr from prelabelled cell layers, uptake of 3H-adenine by the cultivated cells as well as determination of residual cell number after exposure to various concentrations of fragment D were carried out. None of these methods applied was able to detect any harmful effect of the fragment on endothelial cell integrity and function in vitro. Neither could a specific interaction of the protein with the cultured cells be established. Even huge amounts of fragment D (1 mg/ml) exposed to the cells over 20 h did not reveal any alterations in the typical monolayer morphology. Thus, fragment D, which is generated in large amounts during systemic fibrinolytic treatment, does not exert any perturbation on cultured vascular endothelial cells as had previously been proposed.

Summary. The effect of intravenous infusion of endotoxin on the activation of intravascular coagulation and on the generation of glomerular microclots was studied in rabbits congenitally deficient in the sixth component of complement (C6). Endotoxin infusion induced the formation of circulating soluble fibrin and caused a drop in leucocyte and platelet counts, a decrease in factor-V and factor-VII activities and a prolongation of the thromboplastin time as well as the partial thromboplastin time. These haematological changes are indicative of consumption coagulopathy and were similarly distinctive in C6-deficient as in normal rabbits infused with endotoxin. Furthermore, renal glomerular microclots formed in 90% of the C6-deficient and in 80% of the normal rabbits after endotoxin administration. The haematological as well as the histological results of these experiments demonstrate that the sixth component of complement and the later complement components C7–9 are not essential to the initiation of intravascular coagulation by endotoxin and the manifestation of the generalized Shwartzman reaction. The data make it likely that the release of platelet factor 3 does not represent the trigger mechanism of intravascular coagulation since disseminated intravascular coagulation could be induced in C6-deficient rabbits although the platelets of these animals are incapable of releasing platelet factor 3 activity after platelet-endotoxin interaction.

The fibrinolytic system was investigated in 30 patients under oral anticoagulant therapy, and in 23 control patients not receiving oral anticoagulants. Patients under oral anticoagulant therapy had significantly higher tissue-plasminogen activator (t-PA) antigen levels than patients in the control group. Mean t-PA levels before venous occlusion were 18.4 ng/ml in the anticoagulated patients vs. 7.9 ng/ml in the control patients (p less than 0.001). After venous occlusion for 10 minutes, t-PA levels were 45.0 ng/ml in the anticoagulated patients and 24.2 ng/ml in the control patients (p less than 0.01). Plasminogen activator inhibitor (PAI) capacity was not significantly different in the two groups before venous occlusion (VO) but differed slightly (p less than 0.05) after VO. The net decrease in euglobulin lysis time (ELT) after venous occlusion (= ELT before VO - ELT after VO), indicating the relative potency of the fibrinolytic activity in blood, was also significantly higher in the anticoagulated patients (median 240 min vs. 125 min, p less than 0.001). These data indicate that oral anticoagulant therapy increases the fibrinolytic activity in blood, and thus may have an additional therapeutic effect in addition to anticoagulation.

Small amounts of thrombin were added to human plasma containing 125 I-fibrinogen to generate fibrin. Thereafter, thrombin was quenched with hirudin and 131 I-fibrinogen added for internal calibration. Gel filtration of this mixture on sepharose CL-6B columns equilibrated with plasma revealed two peaks, one (peak A) eluting with the void volume, the other (peak B) with the volume corresponding to the fibrinogen peak. At 20°C, a small amount of 131 I-fibrinogen (4.5%) was eluted together with the thrombin-treated 125 I-fibrinogen in peak A, whereas at 37°C, no 131 I-fibrinogen was recovered in peak A. If isolated fractions of peak A eluted at 20°C were rechromatographed at 20°C, they were eluted again in the void volume. At 37°C, however, this material was mainly eluted in peak B corresponding to the fibrinogen peak. If isolated fractions of peak B at 37°C were rechromatographed at 37°C, they were eluted with the same volume as in the original chromatography. At 20°C, however, the material was eluted in peak A as well as in peak B. These data show that at 20°C fibrin aggregates generated in a plasma medium from monomeric fibrin without incorporating fibrinogen. From these experiments, we conclude that so-called fibrin-fibrinogen complexes not stabilized by factor XIIIa generate only in vitro at 20°C, but do not exist at 37°C.

SummaryRabbits were injected with a platelet antiserum to examine the role of thrombocytopenia on the precipitation of soluble fibrin by endotoxin. Platelet antiserum removed more than 98% of the circulating platelets, and the resulting thrombocytopenia with platelet counts below 10,000 per μl persisted during the entire 10 hr-period of the experiment. Leukocyte counts were not significantly influenced by the platelet antiserum. Since the rabbits were treated with high doses of heparin, activation of intravascular coagulation by the antiserum did not occur.Precipitation of soluble fibrin was achieved by injection of endotoxin into rabbits with ancrod-induced circulating soluble fibrin. Thrombocytopenia did not prevent the occurrence of glomerular microdots after ancrod and endotoxin administration. On the contrary, if endotoxin was injected into antiserum- and heparin-treated rabbits with circulating soluble fibrin, glomerular microdot formation occurred even in a higher percentage than in control rabbits treated with absorbed platelet antiserum. This investigation indicates that platelet antiserum-induced thrombocytopenia does not protect against precipitation of soluble fibrin by endotoxin.

Large vessel and microvascular endothelial cells were compared in their capacity to synthesize and secrete coagulant and fibrinolytic factors. Human omental tissue microvascular endothelial cells (HOTMEC) and human umbilical vein endothelial cells (HUVEC) were isolated, grown to confluency under identical conditions, and studied in primary cultures. After an incubation period of 12 hours in serum-free medium, the conditioned medium of confluent HOTMEC contained 100-fold higher levels of tissue plasminogen activator (tPA) antigen than that of HUVEC. The conditioned media as well as the lysates of both cell types did not contain any free tPA activity, but the free plasminogen activator inhibitor capacity was found intracellularly as well as extracellularly. Although von Willebrand factor was detected in both cell types by immunofluorescence, measurable amounts were only found in HUVEC using an enzyme-linked immunosorbent assay. The kinetics of protein C activation by thrombin on the surface of once-passaged cells were identical for HOTMEC and HUVEC. The present study indicates that cultivated HOTMEC produce larger quantities of tPA than HUVEC do, possess smaller amounts of von Willebrand factor than HUVEC do, and express thrombomodulin for protein C activation as effectively as HUVEC.

A titration assay for the determination of the fast acting plasminogen activator inhibitor capacity (PAI-cap) was developed. Most of the hitherto published assays for fast acting PAI are reported to have the disadvantage of non-parallel titration curves of tissue plasminogen activator (t-PA) in buffer and plasma. In the assay reported here, this problem has been overcome by adequate predilution of the samples, thus achieving parallel titration curves regardless of the individual PAI-cap of a sample. Provided that values are calculated from parallel titration curves, reproducible PAI-cap values at different dilutions of a sample are obtained. This assay can be applied for the determination of PAI-cap in plasma, serum and other biological fluids as platelet releasates and endothelial cell conditioned medium. PAI-cap of plasma of 10 healthy male volunteers ranged from 15.3 to 32.3 arbitrary inhibitor units AU/ml (24.5 ± 5.2, mean ± SD). The alternative use of three different anticoagulants (citrate, EDTA, heparin) had no influence on PAI-cap determinations. Serum generated from blood contained a mean of PAI-cap of 129% in comparison to the plasma of the same donor indicating the release of PAI from cells during clotting. Plasma PAI-cap changed during the day with a constant decrease from the highest levels in the morning (100%) to low levels in the evening (62.9%). Platelets aggregated by thrombin released plasminogen activator inhibitor amounting to a mean PAI-cap of 4.33 ± 2.98 AU per 2.5 × 10 8 cells.

SummaryThe lysis of fibrin clots on the surface of cultured human omental tissue microvascular endothelial cells (HOTMEC) and cultured human umbilical vein endothelial cells (HUVEC) was studied. Fibrin clots were made by mixing fibrinogen, plasminogen and thrombin on the surface of both cell types. Clot lysis was seen only on the surface of HOTMEC, which were found to synthesize about 100-fold more tissue plasminogen activator (tPA) antigen than HUVEC. Clot lysis of HOTMEC could be blocked by anti-tPA IgG but was not affected by the incorporation of exogenous plasminogen activator (PAI) into the clot in concentrations (75 arbitrary units) exceeding the tPA activity (21 ± 2.5 IU) of the cells. Thus, it is likely that tPA secreted by HOTMEC is protected from inhibition by PAI in the presence of fibrin and endothelial cells. The stimulation of EC to release an excess of tPA over PAI, in contrast to the secretion of an excess of PAI over tPA found in unstimulated cells in the absence of fibrin, is obviously no prerequisite for the initiation of fibrinolysis on the surface of HOTMEC. As thrombin was used for clot formation, its influence on tPA and PAI synthesis of both cell types was investigated. In contrast to HOTMEC, which were not affected by Α-thrombin, HUVEC revealed a dose-dependent increase in tPA and PAI synthesis upon incubation with the enzyme. This increase in tPA production by HUVEC was not sufficient to lyse the clots within 48 hours. Furthermore, HUVEC. behaved differently towards thrombin as these cells in contrast to HOTMEC revealed the typical shape change reaction upon incubation with the enzyme

131 I-fibrin solubilized in urea and 125 I-fibrinogen were prepared from purified rabbit fibrinogen and separately injected into 12 rabbits (controls). 131 I-fibrin- 125 I-fibrinogen complexes were made from 131 I-fibrin in urea and 125 I-fibrinogen, and subsequent removal of the urea by dialysis. These complexes were injected into 12 rabbits and the elimination characteristics of both proteins traced for 6 days. The fibrin portion of the complexes behaved like 131 I-fibrin solubilized in urea and the fibrinogen portion of the complexes like 125 I-fibrinogen injected as an isolated protein. Thus, fibrin-fibrinogen complexes prepared in vitro dissociate in vivo and demonstrate their own typical elimination characteristics.