Relation of soluble and platelet p-selectin to early outcome in patients with acute myocardial infarction after thrombolytic therapy

thrombus formation and the systemic hemostatic profile. J Am Coll Cardiol 1999;33:1294 –1304. 11. Jay RH, Ramply MW, Betteridge DJ. Abnormalities of blood rheology in familial hypercholesterolemia: effects of treatment. Am J Cardiol 1993;72:1031– 1037. 12. Beigel Y, Fuchs J, Snir M, Green P, Lurie Y, Djaldetti M. Lovastatin therapy in hypercholesterolemia: effect on fibrinogen, hemorrheologic parameters, platelet activity, and red blood cell morphology. J Clin Pharmacol 1991;31:512–517. 13. Mayer J, Eller T, Brauer P, Solleder EM, Schafer RM, Keller F, Kochsiek K. Effects of long-term treatment with lovastatin on the clotting system and blood platelets. Ann Hematol 1992;64:196 –201. 14. Le Quan Sang KH, Levenson J, Megnien JL, Simon A, Devynck MA. Platelet cytosolic CA2⫹ and membrane dynamics in patients with primary hypercholesterolemia: effects of pravastatin. Arterioscler Thromb Vasc Biol 1995;15:759 – 764. 15. Lacoste L, Lam JYT. Comparative effect of pravastatin and simvastatin on

platelet-thrombus formation in hypercholesterolemic coronary patients (abstr). J Am Coll Cardiol 1996;27:413A. 16. Treasure CB, Klein JL, Weintraub WS, Talley JD, Stillabower ME, Kosinski AS, Zhang J, Boccuzzi SJ, Cedarholm JC, Alexander RW. Beneficial effects of cholesterol lowering therapy on the coronary endothelium in patients with coronary artery disease. N Engl J Med 1995;332:481– 487. 17. Dupuis J, Tardif J-C, Cernacek P, Theroux P. Cholesterol reduction rapidly improves endothelial function after acute coronary syndromes: The RECIFE (reduction of cholesterol in ischemia and function of the endothelium) trial. Circulation 1999;99:3227–3233. 18. Rosenson RS, Tangney CC. Antiatherothrombotic properties of statins. JAMA 1998;279:1643–1650. 19. Vaughan CJ, Murphy MB, Buckley BM. Statins do more than lower cholesterol. Lancet 1996;348:1079 –1082. 20. Gillum RF, Fortmann SP, Prineas RJ, Kottke TE. WHO criteria for diagnosis of acute myocardial infarction. Am Heart J 1984;108:150 –158.

Relation of Soluble and Platelet P-Selectin to Early Outcome in Patients With Acute Myocardial Infarction After Thrombolytic Therapy Paul A. Gurbel,

MD,

Christopher M. O’Connor, MD, Margaret R. Dalesandro, Victor L. Serebruany, MD, PhD

-selectin, an integral membrane glycoprotein and a member of the selectin superfamily, is rapidly P expressed on the surface of activated platelets and endothelial cells.1 This receptor participates in endothelial leukocyte rolling and platelet-leukocyte interactions. A soluble form of P-selectin (Sp), smaller than the platelet-bound molecule (Pp), results from an alternatively spliced messenger ribonucleic acid from which the exon-containing transmembrane domain has been removed, and also from probable proteolysis of cellular P-selectin.2,3 In animals, administration of monoclonal antibodies against P-selectin resulted in infarct size reduction.4,5 These studies suggest that P-selectin may be an attractive target for adjunctive therapy of acute myocardial infarction (AMI). There are limited data on Pp expression and the respective Sp in AMI patients. Similarly, the effects of thrombolytic therapy on the P-selectin pool are unknown. It is hypothesized that Pp and Sp could be related to outcomes after thrombolysis in humans. We defined the early effects of thrombolytic therapy on the plasma concentrations and platelet expression of P-selectin in patient with AMI and correlated these results with clinical outcomes. •••

Ten nonsmoking, healthy subjects (6 men and 4 women, aged 21 to 43 years) served as controls. Twenty-three patients enrolled in the Global Utilization of Streptokinase and t-PA for Occluded Coronary From the Sinai Hospital, Baltimore, Maryland; Duke University Medical Center, Durham, North Carolina; and SmithKline Beecham, Philadelphia, Pennsylvania. Dr. Gurbel’s address is: Center for Thrombosis Research, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Schapiro Research Building-R 202, Baltimore, Maryland 21215. E-mail: [email protected]. Manuscript received August 7, 2000; revised manuscript received and accepted October 2, 2000.

774

©2001 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 87 March 15, 2001

PhD,

and

Arteries-III trial (reteplase [n ⫽ 13] versus accelerated alteplase [n ⫽ 10]) were studied.6 Blood samples were collected before thrombolytic therapy and then serially at 3, 6, 12, and 24 hours thereafter. A successful course after thrombolytic therapy was defined as the resolution of chest pain, the occurrence of ⬎50% resolution of the sum of ST elevation by 3 hours after onset of treatment, and the absence of recurrent ischemia (angina with electrocardiographic changes [STsegment depression or T-wave inversion]). Enzyme-linked immunosorbent assays for P-selectin (Centocor, Inc., Malvern, Pennsylvania) were performed on the platelet-poor plasma according to standard techniques. Flow cytometry procedures were described in detail previously.7,8 Platelet-bound P-selectin expression was determined with monoclonal murine antihuman antibodies to P-selectin (PharMingen, Inc., San Diego, California). A Wilcoxon rank-sum test was used to analyze nonparametric data. Normally distributed data are expressed as mean ⫾ SEM; and p ⬍0.05 was considered significant. Differences between individual flow cytometric histograms were assessed using the SmirnovKolmogorov test incorporated in the CELLQuest software (San Jose, California). Eighteen patients underwent successful reperfusion and remained free of recurrent myocardial ischemia in the first 24 hours of their hospitalization. Three patients (2 taking reteplase, 1 taking alteplase) had persistent chest pain and ST elevation, and later underwent angiography that revealed absence of reperfusion. Two patients (1 taking reteplase, 1 taking alteplase) developed recurrent ischemia in the first 24 hours and also underwent emergency angiography. Demographics were similar between groups. However, patients with an early adverse clinical course were not alcohol drinkers (vs 7 of 18), or aspirin users 0002-9149/01/$–see front matter PII S0002-9149(00)01502-2

FIGURE 1. Individual dynamic changes in soluble P-selectin during the first 24 hours after thrombolysis. A, patients with successful thrombolysis; B, patients who had unsuccessful reperfusion.

TABLE 1 Soluble and Platelet P-Selectin in Patients with AMI After Thrombolytic Therapy and in Healthy controls Time (hours) Parameter

Baseline

3

6

12

24

Patients With Successful Reperfusion (n ⫽ 18) Soluble P-selectin Platelet P-selectin

25 ⫾ 3‡ 28 ⫾ 2

43 ⫾ 6* 27 ⫾ 1

27 ⫾ 2.0 28 ⫾ 1

27 ⫾ 2 30 ⫾ 1

24 ⫾ 2 31 ⫾ 1‡

Patients With Adverse Outcomes (n ⫽ 5) Soluble P-selectin Platelet P-selectin

29 ⫾ 8‡ 34 ⫾ 1†‡

23 ⫾ 5† 35 ⫾ 2†‡

21 ⫾ 6 34 ⫾ 2†‡

26 ⫾ 7 34 ⫾ 2†‡

26 ⫾ 8 36 ⫾ 2†‡

Controls (n ⫽ 10) Soluble P-selectin Platelet P-selectin

11 ⫾ 1 25 ⫾ 3

*p ⬍0.05 versus corresponding baseline measurement; †p ⬍0.05 versus corresponding measurement between groups; ‡p ⬍0.05 versus controls. Values are expressed as mean ⫾ SEM, as nanograms per milliliter for soluble form, and log fluorescence intensity for platelet expression.

(vs 6 of 18 in the successful reperfusion group). Laboratory data were similar between groups. Sp levels were consistently at least twice higher in patients with AMI than in healthy controls (Table 1). An increase in Sp occurred at 3 hours after successful thrombolysis (p ⫽ 0.002) and rapidly returned toward baseline at 6 hours. Of the 18 patients with successful thrombolysis, 16 experienced an increase in Sp at 3 hours, and in 9 patients Sp levels doubled. In contrast, patients in whom reperfusion was unsuccessful had high but flat patterns of Sp during the first 24 hours after thrombolytic therapy (Figure 1). At baseline, Pp was higher in patients with AMI who experienced unsuccessful thrombolysis than in the successfully reperfused group (p ⫽ 0.027) and in controls (p ⫽ BRIEF REPORTS

775

FIGURE 2. Individual dynamic changes in platelet-bound P-selectin during the first 24 hours after thrombolysis. A, patients with successful thrombolysis; B, patients who had unsuccessful reperfusion.

0.01). Platelet P-selectin was also higher in patients with an adverse clinical course throughout the first 24 hours (p ⬍0.05). Individual data are expressed in Figure 2. •••

The most obvious differences between groups with AMI in the present study occurred early, 3 hours after attempted reperfusion with thrombolytic agents. In the successfully reperfused patients, systemic soluble Pselectin levels markedly increased when compared with their own baseline. Conversely, in patients in whom sustained reperfusion was not achieved, patterns void of this early peak of plasma P-selectin occurred. Taking into account these distinct patterns of soluble P-selectin and the flat patterns of plateletbound P-selectin, it is possible that the origin of such a plasma peak is due to the release of this molecule from the reperfused myocardium. Similar increases in systemic soluble P-selectin early after attacks of vasospastic angina have been observed.9 Thus, it does not appear that the observed peak of soluble P-selectin is caused by the particular thrombolytic agent; rather it may reflect successful reperfusion itself, with release occurring regionally from either the endothelium or platelets, or both. There are several limitations to the study. Success776 THE AMERICAN JOURNAL OF CARDIOLOGY姞

VOL. 87

ful reperfusion was defined by clinical and electrocardiographic characteristics. Angiography was not performed. Platelet-bound P-selectin was measured in washed platelets, which may result in platelet activation. Recent studies suggest that whole blood determinations using pan-platelet antibodies in addition to P-selectin are more accurate. The overall sample size was small. However, the patterns were uniform among the respective groups. Clinical characteristics such as use of antecedent aspirin and time of thrombolytic agent delivery may also influence results. In conclusion, the ability to determine predictors of thrombolysis success in AMI cannot be overstated. If platelet-leukocyte interactions and the up-regulation of adhesion molecules are indeed vital elements of the occlusive process, then the degree of their activation could affect the response to coronary thrombolysis. Increased plateletbound P-selectin and absence of an early increase in soluble P-selectin correlated with unsuccessful coronary thrombolysis in patients presenting with AMI. Further investigation of P-selectin as a possible predictor of outcome after thrombolytic therapy in a large scale angiographic clinical trial is underway. MARCH 15, 2001

1. Carlos TM, Harlan JM. Leukocyte-endothelial cell adhesion molecules. Blood 1994;84:2069 –2101. 2. Johnston GI, Bliss GA, Newman PJ, McEver RP. Structure of the human gene encoding granule membrane protein-140, a member of the selectin family of adhesion receptors for leukocytes. J Biol Chem 1990;265:21381–21385. 3. Michelson A, Bernard M, Hechtman H. In vivo trafficking of platelets: circulating degranulated platelets rapidly loose surface but continue to circulate and function. Proc Natl Acad Sci 1996;93:11877–11882. 4. Weyrich AS, Ma XL, Lefer DJ, Albertine KH, Lefer AM. In vivo neutralization of P-selectin protects feline heart and endothelium in myocardial ischemia and reperfusion injury. J Clin Invest 1993;91:2620 –2629. 5. Ueyama T, Ikeda H, Haramaki N, Kuwano K, Imaizumi T. Effects of monoclonal antibody to P-selectin and analogue of sialyl Lewis X on cyclic flow

variations in stenosed and endothelium-injured canine coronary arteries. Circulation 1997;95:1554 –1559. 6. The GUSTO Investigators. An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993;329: 673– 682. 7. Ault KA. Flow cytometric measurement of platelet function and reticulated platelets. Ann New York Acad Sci 1993;677:293–308. 8. Serebruany VL, Ordonez JV, Herzog WR, Rohde M, Mortensen SA, Folkers K, Gurbel PA. Dietary coenzyme Q10 supplementation alters platelet size and inhibits human vitronectin (CD51/CD61) receptor expression. J Cardiovasc Pharmacol 1997;29:16 –22. 9. Itoh T, Nakai K, Ono M, Hiramori K. Can the risk for acute cardiac events in acute coronary syndrome be indicated by platelet membrane activation marker P-selectin? Coron Artery Dis 1995;6:645– 650.

Usefulness of Oral Dipyridamole Therapy for Angiographic Slow Coronary Artery Flow Nuri Kurtoglu,

MD,

Ahmet Akcay,

low runoff dye in the coronary arteries during selective coronary angiography is known as slow S coronary artery flow (SCAF). It was first described by Tambe et al1 in 1972. However, since that time there has only been a limited number of studies published concerning the etiology and treatment of SCAF.2,3 Histopathologic studies have revealed the existence of fibromuscular hyperplasia and myofibrilar hypertrophy in these patients.4 We suggest that these histopathologic changes lead to abnormally increased microvascular tone. Mangieri et al5 showed that intracoronary dipyridamole injection relieves microvascular tone and accelerates dye runoff in the coronary arteries. We could not find any published data related to long-term oral therapy for patients with SCAF. In this study the effect of oral dipyridamole therapy for SCAF was examined. •••

Twenty-five angiographically diagnosed patients with SCAF were enrolled in the study from 1997 to 1999 (19 men and 6 women, mean age 48 ⫾ 10 years) (Table 1). All patients had atypical anginal pain. Neither hypertension, diabetes, connective tissue disorder, nor any other systemic disease was detected. Echocardiographic study performed before coronary angiography showed no valvular heart disease, hypertrophic or dilated cardiomyopathy, or myocardial hypertrophy. All patients were in sinus rhythm. At the end of a 3-day anti-ischemic drug-free interval, exercise testing was performed by using the standard Bruce protocol as described previously.6 The target heart rate was calculated as 220 ⫺ patient’s age. Termination criteria were excessive fatigue, chest pain, and attainment of maximal age-predicted heart rate. Selective coronary angiography was performed in all From the Kosuyolu Heart and Research Hospital, Cardiology Department, Istanbul, Turkey. Dr. Kurtoglu’s address is: Cardiology Department, Kosuyolu Heart and Research Hospital, 81020 Kosuyolu, Istanbul, Turkey. E-mail: [email protected]. Manuscript received August 7, 2000; revised manuscript received and accepted September 29, 2000. ©2001 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 87 March 15, 2001

MD,

and Ismet Dindar,

MD

TABLE 1 Clinical and Angiographic Properties of Patients With SCAF Patients 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Age (yrs) & Sex 60 28 60 35 37 50 45 58 63 58 56 44 52 50 45 60 46 45 49 36 35 63 60 34 40

M M M M M F M F M F M M M M M M F M M F M M M F M

ECG

Heart Rate* (beats/min)

LVEDP (mm Hg)

N V1-V3 N N DIII, aVF N V5-V6 N N N N N N N N N DIII, aVF N N N N N N N N

88 90 78 77 74 78 84 85 78 82 80 69 73 72 70 82 80 78 76 74 76 78 82 80 69

10 11 10 12 9 10 11 10 10 13 12 11 10 10 10 10 12 11 11 11 10 12 12 10 10

*During coronary angiography. All patients had atypical angina pectoris; all exercise tests revealed negative results; slow coronary artery flow was found in the left anterior descending, left circumflex, and right coronary arteries in all patients. DIII ⫽ DIII derivation; ECG ⫽ electrocardiography; LVEDP ⫽ left ventricular end-diastolic pressure; N ⫽ normal.

patients by using the Judkins technique. Coronary arteries were imaged in multiple views including the left and right anterior oblique views with cranial and caudal angulations. Left ventriculography was performed in left and right anterior oblique views. Left ventricular and aortic pressures were measured and ejection fraction was calculated. A mechanical electrocardiographic-gated power injector (Angiomat 6000, Liebel-Flarsheim Com0002-9149/01/$–see front matter S0002-9149(00)01503-4

777