Heparin and Direct Oral Anticoagulants have Different Effects on the Phases of Activation and Spatial Spread of Blood Coagulation

Abstract

Background Various reactions are involved in the phases of activation and further propagation of coagulation in space. The effects of different anticoagulants on these phases are unknown. Our aim was to study how different anticoagulants affect the activation and propagation phases of coagulation.

Materials and Methods Coagulation in the presence of low-molecular-weight heparin (nadroparin), and direct oral thrombin or factor Xa inhibitors (dabigatran and rivaroxaban, respectively) was studied in vitro and ex vivo via a global blood coagulation assay (Thrombodynamics-4D), which allows simultaneous analysis of thrombin activity in space and the clot growth rate. The ex vivo measurements were carried out in dynamics (8–9 days). The presence of asymptomatic thrombosis after 7 to 8 days of treatment was determined for each group of patients via ultrasound of the lower extremities.

Results All the tested anticoagulants inhibited thrombin generation but resulted in different patterns of thrombin spatial distribution and clot growth. The reversible inhibitors—dabigatran and rivaroxaban—inhibited the initiation phase of coagulation, while further clot growth was altered moderately. Irreversible nadroparin weakly affected the initiation phase of thrombin generation, but unlike dabigatran and rivaroxaban, it could completely suppress spatial thrombin propagation. Asymptomatic thrombosis was observed in 0%, 11%, and 29% of the patients in the nadroparin, dabigatran, and rivaroxaban groups, respectively.

Conclusion Antithrombin-dependent and independent inhibitors act differently on different phases of coagulation. High concentrations of dabigatran or rivaroxaban are insufficient to completely prevent fibrin clot growth, but even small amounts of heparin completely suppress this growth, due to factor IXa inhibition.

Keywords

anticoagulants - blood coagulation - spatial clot growth rate - spatial thrombin distribution - Thrombodynamics-4D

Ethical Approval Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethical Committee of the Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences (Permit Number: 1/1-12 from December 1, 2014).

Data Availability Statement

All the data generated or analyzed during this study are included in the published article.

Authors' Contribution

F.I.A., N.M.D., A.N.B., and E.I.S. designed and supervised the research. N.M.D., R.A.O., T.A.V., A.N.B., and A.D.K. performed the experiments and collected data. D-C.B.A. and A.I.B. were responsible for patient recruitment and performed the operations. E.I.S. and N.M.D. wrote and edited the manuscript. All the authors reviewed and approved the final version of the manuscript.

Publikationsverlauf

Eingereicht: 12. November 2024

Angenommen: 12. Januar 2025

Artikel online veröffentlicht:
17. Februar 2025

• References

• 1 Panteleev MA, Dashkevich NM, Ataullakhanov FI. Hemostasis and thrombosis beyond biochemistry: roles of geometry, flow and diffusion. Thromb Res 2015; 136 (04) 699-711
• 2 Monroe DM, Hoffman M, Roberts HR. Transmission of a procoagulant signal from tissue factor-bearing cell to platelets. Blood Coagul Fibrinolysis 1996; 7 (04) 459-464
• 3 Hoffman M, Monroe III DM. A cell-based model of hemostasis. Thromb Haemost 2001; 85 (06) 958-965
• 4 Sinauridze EI, Kireev DA, Popenko NY. et al. Platelet microparticle membranes have 50- to 100-fold higher specific procoagulant activity than activated platelets. Thromb Haemost 2007; 97 (03) 425-434
• 5 Lipets E, Vlasova O, Urnova E. et al. Circulating contact-pathway-activating microparticles together with factors IXa and XIa induce spontaneous clotting in plasma of hematology and cardiologic patients. PLoS One 2014; 9 (01) e87692
• 6 Hathcock JJ, Nemerson Y. Platelet deposition inhibits tissue factor activity: in vitro clots are impermeable to factor Xa. Blood 2004; 104 (01) 123-127
• 7 Wielders SJH, Béguin S, Hemker HC, Lindhout T. Factor XI-dependent reciprocal thrombin generation consolidates blood coagulation when tissue factor is not available. Arterioscler Thromb Vasc Biol 2004; 24 (06) 1138-1142
• 8 Dashkevich NM, Ovanesov MV, Balandina AN. et al. Thrombin activity propagates in space during blood coagulation as an excitation wave. Biophys J 2012; 103 (10) 2233-2240
• 9 Ovanesov MV, Ananyeva NM, Panteleev MA, Ataullakhanov FI, Saenko EL. Initiation and propagation of coagulation from tissue factor-bearing cell monolayers to plasma: initiator cells do not regulate spatial growth rate. J Thromb Haemost 2005; 3 (02) 321-331
• 10 Kim JH, Lim K-M, Gwak HS. New anticoagulants for the prevention and treatment of venous thromboembolism. Biomol Ther (Seoul) 2017; 25 (05) 461-470
• 11 Nutescu EA, Burnett A, Fanikos J, Spinler S, Wittkowsky A. Pharmacology of anticoagulants used in the treatment of venous thromboembolism. J Thromb Thrombolysis 2016; 41 (01) 15-31 Erratum in: J Thromb Thrombolysis 2016; 42: 296–311
• 12 Panteleev MA, Balandina AN, Lipets EN, Ovanesov MV, Ataullakhanov FI. Task-oriented modular decomposition of biological networks: trigger mechanism in blood coagulation. Biophys J 2010; 98 (09) 1751-1761
• 13 Balandina AN, Shibeko AM, Kireev DA. et al. Positive feedback loops for factor V and factor VII activation supply sensitivity to local surface tissue factor density during blood coagulation. Biophys J 2011; 101 (08) 1816-1824
• 14 Panteleev MA, Ovanesov MV, Kireev DA. et al. Spatial propagation and localization of blood coagulation are regulated by intrinsic and protein C pathways, respectively. Biophys J 2006; 90 (05) 1489-1500
• 15 Ovanesov MV, Krasotkina JV, Ul'yanova LI. et al. Hemophilia A and B are associated with abnormal spatial dynamics of clot growth. Biochim Biophys Acta 2002; 1572 (01) 45-57
• 16 Sinauridze EI, Vuimo TA, Tarandovskiy ID. et al. Thrombodynamics, a new global coagulation test: Measurement of heparin efficiency. Talanta 2018; 180: 282-291
• 17 Hemker HC, Béguin S. Thrombin generation in plasma: its assessment via the endogenous thrombin potential. Thromb Haemost 1995; 74 (01) 134-138
• 18 Dargaud Y, Wolberg AS, Luddington R. et al. Evaluation of a standardized protocol for thrombin generation measurement using the calibrated automated thrombogram: an international multicentre study. Thromb Res 2012; 130 (06) 929-934
• 19 Gribkova IV, Lipets EN, Rekhtina IG. et al. The modification of the thrombin generation test for the clinical assessment of dabigatran etexilate efficiency. Sci Rep 2016; 6: 29242
• 20 Mann KG, Brummel K, Butenas S. What is all that thrombin for?. J Thromb Haemost 2003; 1 (07) 1504-1514
• 21 Ataullakhanov FI, Guria GT, Sarbash VI, Volkova RI. Spatiotemporal dynamics of clotting and pattern formation in human blood. Biochim Biophys Acta 1998; 1425 (03) 453-468
• 22 Koltsova EM, Kuprash AD, Dashkevich NM. et al. Determination of fibrin clot growth and spatial thrombin propagation in the presence of different types of phospholipid surfaces. Platelets 2021; 32 (08) 1031-1037
• 23 Ovanesov MV, Lopatina EG, Saenko EL. et al. Effect of factor VIII on tissue factor-initiated spatial clot growth. Thromb Haemost 2003; 89 (02) 235-242
• 24 Krasotkina YV, Sinauridze EI, Ataullakhanov FI. Spatiotemporal dynamics of fibrin formation and spreading of active thrombin entering non-recalcified plasma by diffusion. Biochim Biophys Acta 2000; 1474 (03) 337-345
• 25 Eriksson BI, Borris LC, Friedman RJ. et al; RECORD1 Study Group. Rivaroxaban versus enoxaparin for thromboprophylaxis after hip arthroplasty. N Engl J Med 2008; 358 (26) 2765-2775
• 26 Eriksson BI, Dahl OE, Huo MH. et al; RE-NOVATE II Study Group. Oral dabigatran versus enoxaparin for thromboprophylaxis after primary total hip arthroplasty (RE-NOVATE II*). A randomised, double-blind, non-inferiority trial. Thromb Haemost 2011; 105 (04) 721-729
• 27 Jiang S, Du L, Ni C. Comparing the efficacy, safety and cost of the anticoagulants: rivaroxaban and nadroparin in hip replacement surgery. Int J Pharmacol 2018; 14: 1-8
• 28 Rostin M, Montastruc JL, Houin G, D'Azemar P, Bayrou B, Boneu B. Pharmacodynamics of CY 216 in healthy volunteers: inter-individual variations. Fundam Clin Pharmacol 1990; 4 (01) 17-23
• 29 Stangier J. Clinical pharmacokinetics and pharmacodynamics of the oral direct thrombin inhibitor dabigatran etexilate. Clin Pharmacokinet 2008; 47 (05) 285-295
• 30 Kubitza D, Becka M, Voith B, Zuehlsdorf M, Wensing G. Safety, pharmacodynamics, and pharmacokinetics of single doses of BAY 59-7939, an oral, direct factor Xa inhibitor. Clin Pharmacol Ther 2005; 78 (04) 412-421
• 31 Mueck W, Stampfuss J, Kubitza D, Becka M. Clinical pharmacokinetic and pharmacodynamic profile of rivaroxaban. Clin Pharmacokinet 2014; 53 (01) 1-16
• 32 Davis R, Faulds D. Nadroparin calcium. A review of its pharmacology and clinical use in the prevention and treatment of thromboembolic disorders. Drugs Aging 1997; 10 (04) 299-322
• 33 Hirsh J, Anand SS, Halperin JL, Fuster V. American Heart Association. Guide to anticoagulant therapy: Heparin : a statement for healthcare professionals from the American Heart Association. Circulation 2001; 103 (24) 2994-3018
• 34 Fadeeva OA, Panteleev MA, Karamzin SS, Balandina AN, Smirnov IV, Ataullakhanov FI. Thromboplastin immobilized on polystyrene surface exhibits kinetic characteristics close to those for the native protein and activates in vitro blood coagulation similarly to thromboplastin on fibroblasts. Biochemistry (Mosc) 2010; 75 (06) 734-743
• 35 Dashkevich NM, Vuimo TA, Ovsepyan RA. et al. Effect of pre-analytical conditions on the thrombodynamics assay. Thromb Res 2014; 133 (03) 472-476
• 36 Kondratovich AY, Pokhilko AV, Ataullakhanov FI. Spatiotemporal dynamics of contact activation factors of blood coagulation. Biochim Biophys Acta 2002; 1569 (1-3): 86-104
• 37 Merlini PA, Ardissino D, Bauer KA. et al. Persistent thrombin generation during heparin therapy in patients with acute coronary syndromes. Arterioscler Thromb Vasc Biol 1997; 17 (07) 1325-1330
• 38 Furugohri T, Shiozaki Y, Muramatsu S. et al. Different antithrombotic properties of factor Xa inhibitor and thrombin inhibitor in rat thrombosis models. Eur J Pharmacol 2005; 514 (01) 35-42
• 39 de Groot PG, Brinkman HJ, Gonsalves MD, Van Mourik JA. The role of thrombin in the regulation of the endothelial prostaglandin production. Biochim Biophys Acta 1985; 846 (03) 342-349
• 40 Furugohri T, Sugiyama N, Morishima Y, Shibano T. Antithrombin-independent thrombin inhibitors, but not direct factor Xa inhibitors, enhance thrombin generation in plasma through inhibition of thrombin-thrombomodulin-protein C system. Thromb Haemost 2011; 106 (06) 1076-1083
• 41 Kamisato C, Furugohri T, Morishima Y. A direct thrombin inhibitor suppresses protein C activation and factor Va degradation in human plasma: Possible mechanisms of paradoxical enhancement of thrombin generation. Thromb Res 2016; 141: 77-83
• 42 Perzborn E, Heitmeier S, Buetehorn U, Laux V. Direct thrombin inhibitors, but not the direct factor Xa inhibitor rivaroxaban, increase tissue factor-induced hypercoagulability in vitro and in vivo. J Thromb Haemost 2014; 12 (07) 1054-1065
• 43 Olson ST, Swanson R, Raub-Segall E. et al. Accelerating ability of synthetic oligosaccharides on antithrombin inhibition of proteinases of the clotting and fibrinolytic systems. Comparison with heparin and low-molecular-weight heparin. Thromb Haemost 2004; 92 (05) 929-939
• 44 Ataullakhanov FI, Pohilko AV, Sinauridze EI, Volkova RI. Calcium threshold in human plasma clotting kinetics. Thromb Res 1994; 75 (04) 383-394
• 45 Tersteegen A, Burkhardt N. Rivaroxaban – an oral, direct factor Xa inhibitor – binds rapidly to factor Xa. J Thromb Haemost 2007; 5 (Suppl. 02) P-W-651 . Paper presented at: Abstracts of XXIst Congress of International Society on Thrombosis and Haemostasis, July 6 – 12, 2007 , Geneva, Switzerland, Pages P-W-401-P-W-733)
• 46 Park HD, Lee S-H, Kim TH, Lee SH, Cho KH, Kim A. Antithrombotic effects of LB30870, a potent, orally active, selective and direct thrombin inhibitor, and pharmacokinetics of its prodrug. Bioorg Med Chem Lett 2013; 23 (17) 4779-4784
• 47 Hoffman M, Monroe DM, Oliver JA, Roberts HR. Factors IXa and Xa play distinct roles in tissue factor-dependent initiation of coagulation. Blood 1995; 86 (05) 1794-1801
• 48 Rodgers SE, Wong A, Gopal RD, Dale BJ, Duncan EM, McRae SJ. Evaluation of pre-analytical variables in a commercial thrombin generation assay. Thromb Res 2014; 134 (01) 160-164
• 49 Bloemen S, Hemker HC, Al Dieri R. Large inter-individual variation of the pharmacodynamic effect of anticoagulant drugs on thrombin generation. Haematologica 2013; 98 (04) 549-554