Venous Thromboembolism: Risk Factors, Biomarkers, and Treatment

Articles in this series: •Zhu T, Martinez I, Emmerich J. Venous thromboembolism: risk factors for recurrence. Arterioscler Thromb Vasc Biol. 2009;29:298–310. •Jang MJ, Choi W, Bang SM, Lee T, Yeo-Kyeoung K, Ageno W, Doyeun Oh. Metabolic syndrome is associated with venous thromboembolism in the Korean population. Arterioscler Thromb Vasc Biol. 2009;29:311–315. •Sousou T, Khorana AA. New insights into cancer-associated thrombosis. Arterioscler Thromb Vasc Biol. 2009;29:316–320. •Farmer-Boatwright MK, Roubey RAS. Venous thrombosis in the antiphospholipid syndrome. Arterioscler Thromb Vasc Biol. 2009;29:321–325. •James AH. Venous thromboembolism in pregnancy. Arterioscler Thromb Vasc Biol. 2009;29:326–331. •Pabinger I, Ay C. Biomarkers and venous thromboembolism. Arterioscler Thromb Vasc Biol. 2009;29:332–336. In 2005, the U.S. Senate declared March as deep vein thrombosis (DVT) awareness month. This is the second year in which we have highlighted this event with a collection of 6 articles in Arteriosclerosis, Thrombosis, and Vascular Biology focused on DVT. It is estimated that 2 million Americans per year develop DVT, which is associated with life-threatening pulmonary embolism (PE). DVT and PE are collectively termed venous thromboembolism (VTE). Despite the large number of cases, a survey conducted by the American Public Health Association in 2002 found that 74% of Americans were unaware of venous thrombosis.1 The risk of VTE increases with thrombophilias, age, pregnancy, and comorbidities, including cancer and antiphospholipid syndrome (APS). It has not yet been determined whether similar mechanisms lead to VTE in each of these disorders. The articles in this issue describe current research into disorders associated with increased VTE risk, including potential pathophysiologic mechanisms, treatment of these clinical situations, and a review on biomarkers for the detection and prevention of VTE.

Thrombin generation, fibrin clot formation and hemostasis

Hemostatic clot formation entails thrombin-mediated cleavage of fibrinogen to fibrin. Previous in vitro studies have shown that the thrombin concentration present during clot formation dictates the ultimate fibrin structure. In most prior studies of fibrin structure, clotting was initiated by adding thrombin to a solution of fibrinogen; however, clot formation in vivo occurs in an environment in which the concentration of free thrombin changes over the reaction course. These changes depend on local cellular properties and available concentrations of pro- and anti-coagulants. Recent studies suggest that abnormal thrombin generation patterns produce abnormally structured clots associated with an increased risk of bleeding or thrombosis. Further studies of fibrin formation during in situ thrombin generation are needed to understand fibrin clot formation in vivo

Book Reviews

Book 1Book Title: Getting into Residency: A Guide for Medical StudentsBook Author: Kenneth V. IsersonPp. xviii + 431. $28,95. Tucson: Galen Press. 1993. ISBN 1-883620-10-4.Book 2Book Title: Molecular Biology of Digestive DiseaseBook Author: Ed. by Philip QuirkePp. vii + 116. £15. London: BMJ. 1994. ISBN 0-7279-0827-8.Book 3Book Title: Parkinson's DiseaseBook Author:  Ed. by Merton Sandler.Pp. ix + 65. £12/US$24. London: John Libbey, 1993. ISBN 0-86196-404-7.Book 4Book Title: Brain Work and Mental Activity: Quantitative Studies With Radioactive TracersBook Author: Ed. by N. A. Lassen, D. A. Ingvar, M. A. Raichle & L. FribergPP. 446. Illustrated. Copenhagen: Munksgaard. 1991. ISBN 87-16-10698-9.Book 5Book Title: Guidelines for Quality Assurance Programmes for Blood Transfusion ServicesBook Author: WHOPp. IV + 50. (Available in English; French and Spanish in preparation). SFr.12/US$10,80 (in developing countries SFr.8,40). Geneva: WHO. 1993. ISBN 92-4-154448-1. Order No. 1150392.Book 6Book Title: ABC of AlcoholBook Author: Ed. by Alex PatonPp. ix + 32. illustrated. £10. London: BMJ. 1994. ISBN 0-7279-D812-X.Book 7Book Title: Atlas of Surgical Exposures ofthe Lower ExtremityBook Author: A. Masquelet, C. McCullough, R Tubiana, I. Fyfe, L. Klenerman, E. LetoumelPp. 414. Illustrated. London: Manin Dunitz. 1993. ISBN 1-85317-D03-8

Air Pollution Upregulates Endothelial Cell Procoagulant Activity via Ultrafine Particle-Induced Oxidant Signaling and Tissue Factor Expression

Air pollution exposure is associated with cardiovascular events triggered by clot formation. Endothelial activation and initiation of coagulation are pathophysiological mechanisms that could link inhaled air pollutants to vascular events. Here we investigated the underlying mechanisms of increased endothelial cell procoagulant activity following exposure to soluble components of ultrafine particles (soluble UF). Human coronary artery endothelial cells (HCAEC) were exposed to soluble UF and assessed for their ability to trigger procoagulant activity in platelet-free plasma. Exposed HCAEC triggered earlier thrombin generation and faster fibrin clot formation, which was abolished by an anti-tissue factor (TF) antibody, indicating TF-dependent effects. Soluble UF exposure increased TF mRNA expression without compensatory increases in key anticoagulant proteins. To identify early events that regulate TF expression, we measured endothelial H2O2 production following soluble UF exposure and identified the enzymatic source. Soluble UF exposure increased endothelial H2O2 production, and antioxidants attenuated UF-induced upregulation of TF, linking the procoagulant responses to reactive oxygen species (ROS) formation. Chemical inhibitors and RNA silencing showed that NOX-4, an important endothelial source of H2O2, was involved in UF-induced upregulation of TF mRNA. These data indicate that soluble UF exposure induces endothelial cell procoagulant activity, which involves de novo TF synthesis, ROS production, and the NOX-4 enzyme. These findings provide mechanistic insight into the adverse cardiovascular effects associated with air pollution exposure

Human Factor IX Binds to Specific Sites on the Collagenous Domain of Collagen IV

The primary region of factor IX that mediates binding to bovine aortic endothelial cells resides in residues 3-11 of the N-terminal region known as the Gla domain. Recently, it was proposed that the observed binding to endothelial cells is actually a measure of the interaction between factor IX and collagen IV (Cheung, W. F., van den Born, J., Kuhn, K., Kjellen, L., Hudson, B. G., and Stafford, D. W. (1996) Proc. Natl. Acad. Sci. U. S. A. 93, 11068-11073). To confirm that factor IX binds to collagen IV and to examine the specificity of this interaction, we used scanning force microscopy to examine factor IX binding to collagen IV. We imaged collagen IV in the presence and the absence of factor IX and observed specific interactions between factor IX and collagen IV. Our results demonstrate that factor IX binds to collagen IV at specific sites in the collagenous domain approximately 98 and approximately 50 nm from the C-terminal pepsin-cleaved end

Differential contributions of monocyte- and platelet-derived microparticles towards thrombin generation and fibrin formation and stability: Differential MP procoagulant activity

Microparticles (MPs) are submicron vesicles shed by activated or apoptotic cells, including platelets and monocytes. Increased circulating MPs are associated with thrombosis; however, their role in thrombogenesis is poorly understood

Abnormal plasma clot structure and stability distinguish bleeding risk in patients with severe factor XI deficiency

Factor XI (FXI) deficiency is a rare autosomal recessive disorder. Many patients with even very low FXI levels (<20 IU/dL) are asymptomatic or exhibit only mild bleeding, whereas others experience severe bleeding usually following trauma. Neither FXI antigen nor activity predicts bleeding risk in FXI-deficient patients

Cellular Procoagulant Activity Dictates Clot Structure and Stability as a Function of Distance From the Cell Surface

Thrombin concentration modulates fibrin structure and fibrin structure modulates clot stability; however, the impact of localized, cell surface-driven in situ thrombin generation on fibrin structure and stability has not previously been evaluated

Venous thromboembolism research priorities: A scientific statement from the American Heart Association and the International Society on Thrombosis and Haemostasis

Venous thromboembolism (VTE) is a major cause of morbidity and mortality. The impact of the Surgeon General’s Call to Action in 2008 has been lower than expected given the public health impact of this disease. This scientific statement highlights future research priorities in VTE, developed by experts and a crowdsourcing survey across 16 scientific organizations. At the fundamental research level (T0), researchers need to identify pathobiologic causative mechanisms for the 50% of patients with unprovoked VTE and better understand mechanisms that differentiate hemostasis from thrombosis. At the human level (T1), new methods for diagnosing, treating, and preventing VTE will allow tailoring of diagnostic and therapeutic approaches to individuals. At the patient level (T2), research efforts are required to understand how foundational evidence impacts care of patients (eg, biomarkers). New treatments, such as catheter‐based therapies, require further testing to identify which patients are most likely to experience benefit. At the practice level (T3), translating evidence into practice remains challenging. Areas of overuse and underuse will require evidence‐based tools to improve care delivery. At the community and population level (T4), public awareness campaigns need thorough impact assessment. Large population‐based cohort studies can elucidate the biologic and environmental underpinings of VTE and its complications. To achieve these goals, funding agencies and training programs must support a new generation of scientists and clinicians who work in multidisciplinary teams to solve the pressing public health problem of VTE.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/156163/2/rth212373_am.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/156163/1/rth212373.pd