Thrombocytopenia associated with c7E3 Fab (abciximab)

Abciximab (c7E3 Fab) inhibits platelet aggregation and is used to prevent complications of percutaneous coronary intervention. Thrombocytopenia is an often-cited complication of abciximab. Pseudothrombocytopenia is due to ethylenediaminetetraacetate (EDTA)-activated platelet agglutination, resulting in a spuriously low platelet count. We have looked at both "true" and pseudothrombocytopenia after infusion of abciximab. Sixty-six patients receiving their first exposure to abciximab after an unstable coronary event/revascularization were eligible. All the patients received a bolus of c7E3 Fab followed by a continuous infusion. Platelets were monitored in all patients at 2, 4, 12, 24, and 48 h, and more frequently if required. The incidence of thrombocytopenia and acute severe thrombocytopenia (platelet count < or =20,000/microl) was evaluated. A peripheral blood smear was performed on all patients showing thrombocytopenia to evaluate for pseudothrombocytopenia. Seventeen (25.6%) developed thrombocytopenia and nine (13.6%) developed acute severe thrombocytopenia. However, 18 of these patients had pseudothrombocytopenia. The onset of true thrombocytopenia was at 4 h after the infusion, while pseudothrombocytopenia occurred at anytime during the first 24 h. Only two (3.03%) patients required platelet transfusions. No life-threatening hemorrhagic complications were recognized. Five of six subjects with true thrombocytopenia had positive laboratory findings of disseminated intravascular coagulation; however, none had an adverse outcome. Acute severe thrombocytopenia was noted to be a relatively benign adverse effect of abciximab. There is an increasing incidence of pseudothrombocytopenia in this subgroup of patients. It would be worthwhile examining a peripheral blood smear or collecting blood for platelet counts in a heparin-coated tube in order to exclude this phenomenon and thereby prevent inappropriate discontinuation of this drug.     

Inhibition of angiogenesis and tumor growth by murine 7E3, the parent antibodyof c7E3 Fab (abciximab; ReoProTM)

Angiogenesis plays an essential role in the growth and dissemination of solid tumor cancers. The expression of endothelial cell integrin αvβ3 has been shown to increase during vascular proliferation associated with human tumors. Selective antagonists of αvβ3 can block angiogenesis and tumor growth by inducing programmed cell death in proliferating endothelial cells. Monoclonal antibody 7E3, an antagonist of the human, but not murine, integrins αvβ3 and αIIbβ3 (GPIIb/IIIa), inhibits platelet aggregation. It is the parent antibody of a mouse/human chimeric antibody fragment approved for adjunctive therapy of patients undergoing percutaneous coronary interventions to prevent ischemic complications (c7E3Fab; abciximab; ReoPro). To evaluate the potential of 7E3 to inhibit human angiogenesis and tumor growth independent of its antiplatelet effects, we established integrin αvβ3-negative human melanoma tumors in full-thickness human skin grafted onto SCID mice. The resulting tumors induce a human angiogenic response as assessed by the immunoreactivity of vascular cells with monoclonal antibodies specific for human CD31. Administration of 7E3 prevented or significantly inhibited the growth of tumors, and this effect correlated with a significant reduction in the number of blood vessels supplying the tumors. These results support the previous findings that blockade of integrin αvβ3 inhibits angiogenesis and tumor growth and indicates that dual inhibitors of αvβ3 and αIIbβ3 are effective in blocking tumor growth and angiogenesis. This revised version was published online in June 2006 with corrections to the Cover Date.     

Use of abciximab (c7E3 Fab, ReoPro) as an adjunct to balloon angioplasty

OBJECTIVE: To estimate the magnitude of the clinical benefits that may result from use of abciximab at the time of angioplasty and the cost of achieving them. DATA SOURCES: Four published randomized control trials. DATA SYNTHESIS: Meta-analysis of outcomes at six months. RESULTS: Use of abciximab in comparable high risk populations, in the manner described in these trials, is estimated to have the following effects: It does nto influence mortality within the first six months. It reduces the rate of myocardial infarction (MI) by 3.3/100 treatments with a 95% CI of 1.6 to 5.2. It may reduce the need for revascularization (angioplasty or coronary artery bypass graft) by 2.1/100 treatments (95% CI -1.0 to 5.0). It does not cause any significant increase in major hemorrhagic events. There is no evidence that it influences restenosis rates. The net cost per MI prevented would be approximately $44,000, ranging from approximately $29,000 to $71,000 on sensitivity analysis. The net cost per adverse event prevented (MI plus revascularization procedure) would be approximately $27,000 (sensitivity analysis $16,000 to $57,000). Use of abciximab for all of the approximately 17,487 angioplasties carried out in Canada each year may prevent 395 myocardial infarcts and 186 revascularization procedures, at an overall cost of approximately $29 million and a cost effectiveness of approximately $50,000 per adverse event prevented. (This assumes the same proportional reduction in events as in these four studies, and that 35% of procedures are high risk). SIGNIFICANCE: Possible eventual prolongation of life due to fewer periprocedural MIs with abciximab use cannot be quantified. Thus, these estimates of cost effectiveness cannot be used to compare this intervention directly with others in terms of dollars per life year saved. The field is evolving rapidly and these conclusions may soon have to be modified. Increasing use of stents will probably slightly reduce, but not abolish, the health benefits of abciximab use. These estimates are based on only four trials. However, until more trials are completed they provide the best available evidence on which to base policy decisions.     

Inhibition of cultured vascular smooth muscle cell migration by simvastatin (MK-733).

The effect of simvastatin (MK-733), a potent 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, on the migration of cultured porcine smooth muscle cells (SMCs) was investigated in modified Boyden chambers. Platelet-derived growth factor (PDGF) stimulated the SMC migration dose dependently. MK-733 inhibited the migration response induced by PDGF with an IC50 value of 2 microM. Supplementation with mevalonate restored the migration response inhibited by MK-733 but the addition of low-density-lipoprotein (LDL) did not change the response. Another HMG-CoA reductase inhibitor, pravastatin (CS-514), also reduced the migration response. However its potency was far less than that of MK-733. MK-733 also inhibited the SMC migration stimulated by fibrinogen. These results suggest that non-sterol metabolite(s) of mevalonate, possibly prenylated proteins, are involved in a migration signaling pathway and that HMG-CoA reductase inhibitors are effective in the prevention of the formation of intimal hyperplasia in atherosclerosis.     

Inhibition of vascular smooth muscle cell migration by cytochrome p450 epoxygenase-derived eicosanoids

Vascular smooth muscle cell (SMC) migration and proliferation contribute to neointimal hyperplasia and restenosis after vascular injury. The epoxyeicosatrienoic acids (EETs), which are products of cytochrome P450 (CYP) epoxygenases, possess vasodilatory, antiinflammatory, and fibrinolytic properties. To determine whether these compounds also possess antimigratory and antiproliferative properties, we stimulated rat aortic SMCs with either 20% serum or platelet-derived growth factor (PDGF-BB, 20 ng/mL). In a concentration-dependent manner, treatment with EETs, particularly 11,12-EET, inhibited SMC migration through a modified transwell filter by 53% to 60%. EETs, however, have no inhibitory effects on PDGF-stimulated SMC proliferation. Adenoviral-mediated overexpression of the CYP isoform, CYP2J2, in SMCs also inhibited serum- and PDGF-induced SMC migration by 32% and 26%, respectively; both effects of which were reversed by the CYP inhibitors SKF525A or clotrimazole, but not by the K(Ca) channel blocker, charybdotoxin, or the cyclooxygenase inhibitor, diclofenac. The effect of EETs correlated with increases in intracellular cAMP levels. Indeed, forskolin and 8-bromo-cAMP exert similar inhibitory effects on SMC migration as 11,12-EET and the effects of 11,12-EET were blocked by cAMP and protein kinase A (PKA) inhibitors. These findings indicate that EETs possess antimigratory effects on SMCs through the cAMP-PKA pathway and suggest that CYP epoxygenase-derived eicosanoids may play important roles in vascular disease and remodeling.     

Inhibition of vascular smooth muscle cell migration by elevation of extracellular potassium concentration

The effect of potassium on the migration of vascular smooth muscle cells was analyzed in media made with extracellular potassium concentrations of 3, 4, 5, and 6 mmol/L. The migration of cultured porcine coronary artery cells was stimulated with platelet-derived growth factor (PDGF)-BB. In the first study, cells were exposed to PDGF-BB at concentrations of 0, 10, or 20 ng/mL for 5 hours with the use of a Boyden chamber. Cells were quiescent overnight in 0.5% fetal bovine serum in Dulbecco's modified Eagle's medium with an extracellular potassium concentration of 4 mmol/L. With increasing potassium concentration, migration was significantly inhibited (P<0. 02, 2-way ANOVA). In the cells exposed to 10 ng/mL PDGF-BB, migration ranged from 500+/-86% to 294+/-44% (value in wells with 0 ng/mL PDGF-BB and 4 mmol/L potassium concentration=100%) in medium containing 3 to 6 mmol/L extracellular potassium concentration (P<0. 03). Long-term potassium exposure was investigated in cells grown in 5% serum in Dulbecco's modified Eagle's medium with an extracellular potassium concentration of 3, 4, 5, or 6 mmol/L for 3 to 4 weeks. Migration was assessed with 0 or 20 ng/mL PDGF-BB. Migration was significantly inhibited by the elevation of extracellular potassium concentration (P<0.01, 2-way ANOVA). With 20 ng/mL PDGF-BB, the migration rates ranged from 152+/-11% in medium with 3 mmol/L potassium to 69+/-5% in 6 mmol/L potassium (P<0.01). Increases in extracellular potassium concentration within the physiological range significantly and directly inhibit vascular smooth muscle cell migration.     

siRNA silencing reveals role of vascular cell adhesion molecule-1 in vascular smooth muscle cell migration

Vascular cell adhesion molecule-1 (VCAM-1) is an adhesion molecule expressed by endothelial cells for recruitment of leukocytes during inflammation. It is also abundantly expressed by smooth muscle cells in atherosclerotic lesions and in injured arteries. In this study, we examined the role of VCAM-1 in smooth muscle cell migration. Smooth muscle cells were isolated from the aorta of C57BL/6 mice and transfected with short interfering RNAs (siRNAs) targeting VCAM-1. Inhibition on VCAM-1 expression by siRNAs was assessed by Western blot analysis, RT-PCR and by measuring soluble VCAM-1 concentrations in the incubation medium. One siRNA that showed greater suppression on VCAM-1 expression was used for migration assay. A single scratch wound was made on 70% confluent cells and cells migrated from wounded monolayer were counted 24 and 48h after injury. Treatment with VCAM-1 siRNA resulted in a significant reduction in the number of migrated cells. This siRNA also exhibited a minor effect on smooth muscle cell proliferation. Thus, our findings indicate that VCAM-1 is necessary for the migration of smooth muscle cells and interfering VCAM-1 expression could be an effective approach to prevention and treatment of atherosclerosis and restenosis.     

Decrease of vascular smooth muscle cell locomotion by abciximab,but not tirofiban: a possible role of different affinity to alpha v beta 3 integrins

AIM: The EPISTENT and EPIC studies demonstrated a reduction of clinically driven re-interventions after percutaneous transluminal coronary angioplasty (PTCA) and stent implantation in patients treated with abciximab, while for tirofiban no similar effects could be demonstrated. This may be explained by the different effects on the migratory and invasive potential of vascular smooth muscle cells (VSMCs) by integrin alpha v beta 3 blockade. Therefore, the objective of this study was to compare the effectiveness of abciximab and tirofiban to affect VSMC migration and invasion. METHODS: Vascular smooth muscle cells were treated with abciximab (0.1-1 microg/ml), tirofiban (0.1-1 microg/ml), and the alpha v beta 3 specific antibody LM609 (1-5 microg/ml), that was used as a positive control during the assay (treatment) over 24 h before the assay (pre-treatment), or before and during the assay (combined treatment). Sodium 3'-[1-(phenylaminocarbonyl)-3,4-tetrazolium]-bis (4-methoxyy-6-nitro) benzene sulfonic acid (XTT)-assay and cell counting measured the influence of the substances on VSMC proliferation. Using a Boyden Chamber model, the capability of VSMCs for migration and invasion was tested with different chemo-attractants and barriers. RESULTS: Any influence of the platelet glycoprotein (GP) IIb/IIIa receptor (integrin alpha IIb beta 3) antagonists on VSMC proliferation could be excluded. After combined treatment, abciximab demonstrated a dose-dependent inhibition of migration (IC50 = 33 microg/ml) and invasion (IC50 = 0.5 microg/ml) of VSMCs. Administration during the assay without pre-treatment inhibited migration similarly (IC50 = 32 microg/ml) but invasion to a significant lower extent (IC50 = 44 microg/ml). Administration of tirofiban during the assay with or without pre-treatment had no inhibitory effect on VSMC migration and invasion. Pre-treatment alone with one of the substances also did not alter VSMC migration or invasion. CONCLUSION: Abciximab administration in physiological concentrations was capable of significantly inhibiting the migratory and invasive potential of VSMCs, while for tirofiban no similar effect could be demonstrated.     

Labeling of the internal pool of GP IIb-IIIa in platelets by c7E3 Fab fragments (abciximab): flow and endocytic mechanisms contribute to the transport

Abciximab is a new antiplatelet therapeutic in ischemic cardiovascular disease. The drug, chimeric Fab fragments of a murine monoclonal antibody (MoAb) (c7E3), blocks GP IIb-IIIa function. However, its capacity to reach all receptor pools in platelets is unknown. Electron microscopy and immunogold labeling were used to localize abciximab in platelets of patients receiving the drug for up to 24 hours. Studies on frozen-thin sections showed that c7E3 Fab, in addition to the surface pool, also labeled the surface-connected canalicular system (SCCS) and alpha-granules. Analysis of gold particle distribution showed that intraplatelet labeling was not accumulative and in equilibrium with the surface pool. After short-term incubations of platelets with c7E3 Fab in vitro, gold particles were often seen in lines within thin elements of the SCCS, some of which appeared in contact with alpha-granules. Little labeling was associated with Glanzmann's thrombasthenia platelets, confirming that the channels contained bound and not free c7E3 Fab. Endocytosis of abciximab in clathrin-containing vesicles was visualized by double staining and constitutes an alternative mechanism of transport. The remaining free pool of GP IIb-IIIa was evaluated with the MoAb AP-2; flow cytometry showed it to be about 9% on the surface of nonstimulated platelets but 33% on thrombin-activated platelets. The ability of drugs to block all pools of GP IIb-IIIa and then to be associated with secretion-dependent residual aggregation must be considered when evaluating their efficiency in a clinical context.     

Impaired ceramide signalling in spontaneously hypertensive rat vascular smooth muscle: a possible mechanism for augmented cell proliferation

OBJECTIVES: In hypertension, the vascular wall undergoes morphological changes that alter mechanical responses to vasoactive substances. Ceramide is a recently identified second messenger synthesized in response to cytokines such as tumour necrosis factor alpha (TNF-alpha). It has been previously demonstrated that vascular smooth muscle cells (VSMC) from genetically hypertensive rats proliferate at a higher rate than those of normotensive origin. We tested the hypothesis that the ceramide pathway is impaired in VSMC from spontaneously hypertensive rats (SHR). DESIGN: VSMC were isolated from aortae of SHR and from Wistar-Kyoto (WKY) rats. Ceramide levels were measured under baseline and agonist-stimulated conditions and cell proliferation was monitored. METHODS: Cell proliferation was determined by cell counting. Ceramide levels were determined via radioactive labelling, high-performance thin-layer chromatography and phosphorimaging. Relative mRNA levels of neutral sphingomyelinase were determined using semi-quantitative polymerase chain reaction (PCR). RESULTS: Basal ceramide levels in untreated cells were lower in cells from SHR compared to WKY rats. During chronic treatment with TNF-alpha, ceramide levels increased in WKY rat cells but remained unchanged in cells from SHR. TNF-alpha treatment had an inhibitory effect on WKY rat VSMC proliferation, but stimulated proliferation in cells from SHR. Short-term incubation with TNF-alpha resulted in a greater increase in ceramide in cells from WKY rats than those from SHR. Semiquantitative PCR analysis indicated that neutral sphingomyelinase mRNA may be reduced in SHR VSMC. CONCLUSIONS: We conclude that ceramide synthesis is impaired in vascular smooth muscle from SHR and may contribute to increased VSMC proliferation in hypertension.     

放射治疗支架内再狭窄诱导平滑肌细胞凋亡的分子机制

目的 研究支架内再狭窄部位平滑肌细胞（rVSMC）凋亡水平改变的机制,并探讨放疗诱导细胞凋亡的调控途径.方法 50例支架术后再狭窄患者,取其斑块标本,检测p53、p21和Cyclin D1的表达水平,并与正常冠脉血管平滑肌细胞（nVSMC）进行比较.结果 rVSMC中,p53和p21的表达略低于正常细胞,分别为80%和75%左右（P＜0.05）;Cyclin D1则达到了正常细胞的2倍以上（P＜0.01）.照射后,rVSMC和nVSMC的细胞凋亡均有上升（P＜0.01）,且rVSMC的上升幅度大于nVSMC（P＜0.05）;而两组细胞中p53、p21和Cyclin D1的表达水平基本相同.结论 rVSMC中p53、p21和Cyclin D1的表达水平发生改变,导致细胞凋亡减少,是发生支架内再狭窄的重要原因.放疗可改变rVSMC中各凋亡相关分子的表达,诱导细胞凋亡.     

Inhibition of vascular smooth muscle cell proliferation by endothelium-dependent vasodilators.

This review considers the hypothesis that the endothelium-derived vasodilator agents, prostacyclin and nitric oxide, also function physiologically to inhibit vascular smooth muscle cell (VSMC) proliferation. The underlying biochemical mechanisms are also discussed. Prostacyclin and other agents that increase intracellular cAMP concentration are potent and effective inhibitors of the proliferation of isolated VSMC in culture. Such agents inhibit the initiation of proliferation in quiescent cells and the proliferation of logarithmically growing cells from a variety of sources, including man. The data implicate prostacyclin as an important regulator of VSMC proliferation, although there is little direct in vivo evidence. Nitric oxide-releasing drugs (and atriopeptins which increase intracellular cGMP concentration by a different mechanism) also inhibit proliferation of cultured VSMC. The effects are, however, partial and obtained at higher concentrations than those required for vasodilatation. Even allowing for the instability of the agents under tissue culture conditions, cGMP-elevating agents appear to be poorer at inhibiting proliferation than cAMP-elevating agents, despite similar or greater vasodilator potency. These data imply that nitric oxide is less likely than prostacyclin to be a physiological regulator of VSMC proliferation, although definitive experiments in vivo are again lacking. It also follows that nitrovasodilators are less attractive as therapy for VSMC proliferation than prostacyclin analogues or other cAMP-elevating agents, such as phosphodiesterase inhibitors. By analogy with the mechanisms of vasodilatation, inhibition of calcium mobilization and the subsequent activation of protein kinase C are considered as possible mechanisms underlying inhibition of proliferation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Inhibition of vascular smooth muscle cell proliferation,migration, and survival by the tumor suppressor protein PTEN

Phosphatidylinositol (PI) 3-kinase signaling regulates numerous cellular processes, including proliferation, migration, and survival, which are required for neointimal hyperplasia and restenosis. The effectors of PI 3-kinase are activated by the phospholipid products of PI 3-kinase. In this report, we investigated the hypothesis that overexpression of the tumor suppressor protein PTEN, an inositol phosphatase specific for the products of PI 3-kinase, would inhibit the vascular smooth muscle cell (VSMC) responses necessary for neointimal hyperplasia and restenosis. Effects of PTEN were assessed in primary rabbit VSMCs after overexpression with a recombinant adenovirus and compared with uninfected or control virus-infected cells. PTEN was expressed endogenously in VSMCs, and PTEN overexpression inhibited PDGF-induced phosphorylation of p70(s6k), Akt, and glycogen synthase kinase-3-alpha and -beta but not ERK1 or -2. Overexpression of PTEN significantly inhibited both basal and PDGF-mediated VSMC proliferation and migration, the latter possibly due in part to downregulation of focal adhesion kinase. Moreover, PTEN overexpression induced cleavage of caspase-3 and significantly increased apoptosis compared with control cells. Taken together, these results demonstrate that PTEN overexpression potently inhibits the VSMC responses required for neointimal hyperplasia and restenosis. Adenovirus-expressed PTEN may therefore provide a useful tool for the local treatment of these and other vascular proliferative disorders.     

The beta3 integrin antagonist m7E3 reduces matrix metalloproteinase activity and smooth muscle cell migration.

Treatment with c7E3 (abciximab, ReoPro) has been associated with a reduction in coronary events and the need for revascularization. Some of these beneficial effects may be due to blockade of the alphavbeta3 integrin receptor on smooth muscle cells (SMCs), however very little is known about the mechanisms involved. The current studies were designed to test the hypothesis that beta3 integrin antagonists inhibit the arterial response to injury by reducing matrix metalloproteinase (MMP) activity in the vessel wall. Male Sprague-Dawley rats were treated with daily intraperitoneal injections of the monoclonal antibody m7E3 at a dose of 6 mg/kg/day. MMP-9 activity was reduced by 73%, and MMP-2 activity by 75%, in the injured carotids of the m7E3-treated rats compared to saline-treated controls. By contrast, tissue inhibitor metalloproteinase (TIMP) activity was not changed. SMC migration assayed at 4 days after injury was reduced from 56.7 +/- 14 cells/mm(2) intimal surface area in controls to 17.5 +/- 5 cells/mm(2) in m7E3-treated rats (p = 0.02). Medial cell replication measured at 4 days and intimal cell replication measured at 7 days were not affected. Intimal cross-sectional area, measured 14 days after injury was reduced by 28% after m7E3 treatment (p = 0.05). Intimal smooth muscle cell number and the ratio of intima/media cross-section area were also reduced. By contrast, intimal SMC density was not affected by m7E3 treatment, indicating no effect on matrix accumulation. We conclude that treatment with m7E3 reduced SMC migration following vascular injury, possibly via an inhibitory effect on MMP activity, and this resulted in a decrease in intimal size at 14 days after injury.     

黏着斑激酶对血小板源性生长因子刺激的血管平滑肌细胞迁移和黏附的调控

目的探讨黏着斑激酶(FAK)信号分子在雷帕霉素抑制血小板源性生长因子(PDGF)诱导血管平滑肌细胞(VSMC)迁移、黏附中的调控作用。方法将培养的大鼠VSMC分为对照组、PDGF组、雷帕霉素+PDGF组(雷帕霉素组)和FAK反义寡核苷酸+PDGF组(FAK组)。用PDGF诱导VSMC的迁移和黏附,计数贴壁细胞;采用Boyden检测细胞迁移;采用RT-PCR、Western blot、免疫沉淀方法分别检测FAK基因、蛋白及蛋白磷酸化表达量。将FAK反义寡核苷酸经脂质体转染VSMC,观察FAK mRNA及蛋白磷酸化、细胞迁移和黏附的变化。结果与对照组比较,PDGF组明显诱导细胞迁移和黏附,上调FAK mRNA的表达,提高FAK蛋白和磷酸化FAK表达,差异有统计学意义(P0.05),与PDGF组比较,FAK组和雷帕霉素组细胞迁移、黏附能力减弱,FAK mRNA、FAK蛋白和磷酸化FAK表达水平明显降低,差异有统计学意义(P0.05)。结论 PDGF诱导细胞迁移和黏附可能是FAK介导的,雷帕霉素可能是通过抑制FAK蛋白和磷酸化FAK来抑制VSMC的迁移和黏附。