Different DOACs Control Inflammation in Cardiac Ischemia-Reperfusion Differently.
Different DOACs Control Inflammation in Cardiac Ischemia-Reperfusion Differently.
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DOI：
10.1161/circresaha.120.317219
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发表时间：
2021-02-19
影响因子：
20.1
通讯作者：
Shahzad K
中科院分区：
文献类型：
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作者：
Gadi I;Fatima S;Elwakiel A;Nazir S;Mohanad Al-Dabet M;Rana R;Bock F;Manoharan J;Gupta D;Biemann R;Nieswandt B;Braun-Dullaeus R;Besler C;Scholz M;Geffers R;Griffin JH;Esmon CT;Kohli S;Isermann B;Shahzad K
虽然凝血酶是血栓形成中的关键蛋白酶，但其他凝血蛋白酶，如fXa或活化蛋白C（aPC），通过部分不同的受体独立地调节细胞内信号传导。研究fXa或fIIa抑制对心肌缺血再灌注损伤（IRI）基因表达和炎症反应的影响。用直接fIIa抑制剂（fIIai）或直接fXa抑制剂（fXai）处理小鼠，其剂量诱导离体和体内相当的抗凝作用（尾部出血试验和FeCl 3诱导的血栓形成）。通过结扎LAD诱导心肌IRI。我们确定了梗死面积和体内aPC生成，通过RNAseq分析了基因表达，并进行了免疫印迹和ELISA。使用仅信号传导的3 K3 A-aPC变体和阻断aPC的全部或仅抗凝功能的抑制性抗体来确定aPC的作用。fIIai和fXai的剂量诱导相当的抗凝作用，导致梗死面积的减少相当。然而，无偏的基因表达分析揭示了显着的差异，包括与无菌炎症和炎性小体调节相关的途径。fXai而非fIIai通过降低促炎细胞因子（IL-1β、IL-6和TNFα）的表达以及NF-κB和炎性体活化来抑制无菌性炎症。这种抗炎作用与心肌IRI后28天心肌纤维化减少有关。从机制上讲，fXai的体内aPC生成高于fIIai。抑制aPC的抗凝和信号传导特性消除了与fXai相关的抗炎作用，而仅抑制aPC的抗凝功能没有效果。将3 K3 A-aPC与fII ai组合减少了炎症反应，模拟了fXai相关的作用。我们发现，通过DOAC特异性抑制凝血对基因表达和炎症有不同的影响，尽管抗凝作用和梗死面积相当。靶向单个凝血蛋白酶诱导与其抗凝作用无关的特异性细胞应答。心肌梗死和相关血栓形成是世界范围内发病率和死亡率的主要原因。直接口服抗凝剂（DOAC）改变了我们治疗和预防血栓形成和血栓栓塞的方式，但依赖于一种新的机制-特异性抑制单一凝血蛋白酶。我们表明，直接抑制凝血因子fIIa和fXa提供不同的抗炎作用，尽管相同的抗凝效果。这些作用至少部分取决于蛋白C的差异活化，蛋白C是一种信号活性和细胞保护性蛋白酶。这些结果表明，DOAC的疗效不仅取决于其抗血栓形成作用，还取决于细胞效应，如基因表达调节、无菌性炎症和纤维化。这些研究表明，并非所有DOAC都是相同的，即使它们具有相当的抗血栓形成作用，因为它们对细胞反应的影响不同。未来的临床前和临床研究在评估抗凝剂的安全性和有效性时必须考虑其他终点，如炎症和纤维化。
While thrombin is the key protease in thrombus formation, other coagulation proteases, such as fXa or activated protein C (aPC), independently modulate intracellular signaling via partially distinct receptors. To study the differential effects of fXa or fIIa inhibition on gene expression and inflammation in myocardial ischemia-reperfusion injury (IRI). Mice were treated with a direct fIIa inhibitor (fIIai) or direct fXa inhibitor (fXai) at doses that induced comparable anticoagulant effects ex vivo and in vivo (tail bleeding assay and FeCl3-induced thrombosis). Myocardial IRI was induced via LAD ligation. We determined infarct size and in vivo aPC generation, analyzed gene expression by RNAseq, and performed immunoblotting and ELISA. The signaling-only 3K3A-aPC variant and inhibitory antibodies that blocked all or only the anticoagulant function of aPC were used to determine the role of aPC. Doses of fIIai and fXai that induced comparable anticoagulant effects resulted in a comparable reduction in infarct size. However, unbiased gene expression analyses revealed marked differences, including pathways related to sterile inflammation and inflammasome regulation. fXai but not fIIai inhibited sterile inflammation by reducing the expression of proinflammatory cytokines (IL-1β, IL-6, and TNFα) as well as NF-κB and inflammasome activation. This anti-inflammatory effect was associated with reduced myocardial fibrosis 28 days post myocardial IRI. Mechanistically, in vivo aPC generation was higher with fXai than with fIIai. Inhibition of the anticoagulant and signaling properties of aPC abolished the anti-inflammatory effect associated with fXai, while inhibiting only the anticoagulant function of aPC had no effect. Combining 3K3A-aPC with fIIai reduced the inflammatory response, mimicking the fXai-associated effect. We showed that specific inhibition of coagulation via DOACs had differential effects on gene expression and inflammation, despite comparable anticoagulant effects and infarct sizes. Targeting individual coagulation proteases induces specific cellular responses unrelated to their anticoagulant effect. Myocardial infarction and related thrombosis are a major cause of morbidity and mortality worldwide. Direct Oral Anti-Coagulants (DOACs) have changed the way we treat and prevent thrombosis and thromboembolism, but rely on a new mechanism - the specific inhibition of a single clotting protease. We show that the direct inhibition of the coagulation factors fIIa and fXa gives different anti-inflammatory effects despite the same anticoagulant effectiveness. These effects depend at least in part on the differential activation of protein C, a signal-competent and cytoprotective protease. These results show that the efficacy of DOACs depends not only on their antithrombotic effects, but also on cellular effects such as regulation of gene expression, sterile inflammation and fibrosis. These studies show that not all DOACs are equal, even if they convey comparable antithrombotic effects, as they affect cellular responses differently. Future preclinical and clinical studies must consider additional endpoints such as inflammation and fibrosis when evaluating the safety and effectiveness of anticoagulants.