Η συγκόλληση των αιμοπεταλίων προάγεται από το ινωδογόνο, μια εξωκυττάρια πρωτεΐνη, η οποία δεσμεύεται εκλεκτικά στον υποδοχέα GP IIb/IIIa. Το τριπεπτίδιο RGD (Arg-Gly-Asp) συνιστά τη μικρότερη αλληλουχία, η οποία είναι απαραίτητη για την αναγνώριση και πρόσδεση του ινωδογόνου στον υποδοχέα και απαντάται και σε άλλες συγκολλητικές πρωτεΐνες, οι οποίες είναι παρούσες στον εξωκυττάριο χώρο και στο αίμα, όπως η ινοσυνδετίνη, το κολλαγόνο, ο παράγοντας Von Willebrand, κτλ. Η αντιπηκτική θεραπεία έχει βασιστεί σε δύο διαφορετικές προσεγγίσεις του προβλήματος. Η μία προσέγγιση αφορά την εμπόδιση της πρωταρχικής διέγερσης των αιμοπεταλίων από διάφορους αγωνιστές, όπως θρομβίνη, επινεφρίνη, κολλαγόνο, κτλ. Η άλλη προσέγγιση περιλαμβάνει την διακοπή του μηχανισμού μεταγωγής σήματος, ο οποίος ακολουθεί την πρόσδεση του αγωνιστή στην επιφάνεια των αιμοπεταλίων. Η ασπιρίνη, παράγωγο του σαλικυλικού οξέος, αναστέλλει το πρώτο βήμα στη βιοσύνθεση της θρομβοξάνης Α2 από αραχιδονικό οξύ μέσω ακετυλίωσης του ενζύμου κυκλοοξυγενάση 1. Στην παρούσα διατριβή πραγματοποιήθηκε ο σχεδιασμός και η σύνθεση γραμμικών και κυκλικών αναλόγων του τριπεπτιδίου RGD με ενσωματωμένο σαλικυλικό οξύ ή παράγωγά του. Τα διάφορα ανάλογα συντέθηκαν με κλασικές μεθόδους πεπτιδικής σύνθεσης σε υγρή και στερεά φάση. Τη σύνθεση των αναλόγων ακολούθησε καθαρισμός τους (HPLC) και προσδιορισμός της δομής τους με (ESI-MS). Στη συνέχεια, προσδιορίστηκε in vitro με φωτομετρική μέθοδο στους 37C και συνεχή καταγραφή της διερχόμενης ακτινοβολίας με ειδικό όργανο (Dual Channel Aggregometer) η ανασταλτική τους δράση στη συγκολλητικότητα των αιμοπεταλίων του ανθρώπου. Προς περαιτέρω επιβεβαίωση των πειραμάτων συσσώρευσης και μελέτη της πρόσδεσης των αναλόγων στις ιντεγκρίνες χρησιμοποιήθηκε η κυτταρομετρία ροής με μονοκλωνικά αντισώματα έναντι των υποδοχέων Gp Ia, Gp IIb/IIIa, Gp IIIa και GMp 140. Αναλύοντας τα αποτελέσματα των βιολογικών μελετών, τόσο της αναστολής της συσσωμάτωσης των αιμοπεταλίων του ανθρώπου in vitro όσο και της κυτταρομετρίας ροής σε ενεργοποιημένα αιμοπετάλια για τα δραστικά πεπτίδια, οδηγούμαστε στα επόμενα συμπεράσματα: 1. Από τη σειρά των RGD γραμμικών αναλόγων που μελετήθηκαν, βρέθηκαν δραστικά μόνο στην περίπτωση που τα πεπτίδια έχουν στο C-τελικό τους άκρο αμίδιο. 2. Η σύζευξη του σαλικυλικού οξέος στο τριπεπτίδιο - αμίδιο RGD ενισχύει την αντισυγκολλητική του δράση έναντι των αιμοπεταλίων in vitro. Από αυτά τα ανάλογα 26 (IC50= 50μΜ), 27 (38μΜ) και 28 (53μΜ) (ενσωματωμένο σαλικυλικό οξύ στο τριπεπτίδιο) έχουν την ισχυρότερη δράση, ενώ μόνο το τριπεπτίδιο 23 έχει IC50= 540μΜ 3. Η προστασία του β-καρβοξυλίου του Asp με βενζυλομάδα αυξάνει τη δράση του πεπτιδίου σε σχέση με την ύπαρξη ελεύθερου β-καρβοξυλίου. Αυτό διαπιστώνεται από το γεγονός ότι όλα τα βιολογικώς δραστικά ανάλογα έχουν το β-καρβοξύλιο προστατευμένο με βενζυλομάδα και αυτό έρχεται σε συμφωνία με βιβλιογραφικά δεδομένα άλλων ερευνητών περί αναγκαιότητας ύπαρξης λιπόφιλης ομάδας στο C-τελικό άκρο του πεπτιδίου. 4. Αντίθετα, η ενσωμάτωση σαλικυλο-παραγώγων (βρώμο-, χλώρο-, νίτρο-, άμινο-, κτλ) στα ανάλογα δίνει πολύ μικρή αντισυγκολλητική δράση στα αιμοπετάλια του ανθρώπου in vitro σε σχέση με το σαλικυλικό οξύ. 5. Από τα συντεθέντα κυκλικά ανάλογα μόνο το ανάλογο 61, που φέρει δισουλφιδικό δεσμό μεταξύ της κυστεΐνης και του θειοσαλικυλικού οξέος, επέδειξε ισχυρή αντισυγκολλητική δράση έναντι των αιμοπεταλίων του ανθρώπου in vitro με τιμή IC50= 8μΜ, που είναι και η καλύτερη τιμή IC50 για όλα τα ανάλογα που συντέθηκαν (γραμμικά και κυκλικά). 6. Και στην περίπτωση των κυκλικών πεπτιδίων, τα ανάλογα με το προστατευμένο β-καρβοξύλιο εμφανίζουν ισχυρότερη ανασταλτική δράση έναντι εκείνων που φέρουν το β-καρβοξύλιο ελεύθερο. 7. Από όλα τα γραμμικά ανάλογα που περιέχουν παράγωγα του σαλικυλικού οξέος το ανάλογο 39 που περιέχει το 5-χλωρο σαλικυλικό οξύ εμφανίζει ισχυρή ανασταλτική δράση έναντι του υποδοχέα Gp Ib. 8. Τέλος, θα πρέπει να αναφερθεί ότι είναι η πρώτη φορά που συνθετικά πεπτιδικά ανάλογα του RGD εμφανίζουν ισχυρή πρόσδεση στον υποδοχέα Gp Ib, o οποίος ευθύνεται για την προσκόλληση των αιμοπεταλίων στο κυτταρικό τοίχωμα. / Integrins constitute a large family of heterodimeric cell-surface, transmembrane receptors, which play a major role in cell/cell and cell/matrix adhesive interactions. The Arg-Gly-Asp (RGD) sequence is known to be the integrin recognition site of many extracellular matrix proteins such as fibronectin, osteopontin, collagen, fibrinogen, von Willebrand factor, laminin, etc. On the other hand, it is well known that low doses of aspirin (acetyl salicylic acid) decrease platelet aggregation by causing an inhibitory effect on thromboxane A2 production by platelets. Several antiplatelet strategies have already been developed and are under preclinical or clinical investigation. In the present thesis, the synthesis of linear and cyclic RGD analogs incorporating salicylic acid derivatives is reported. The syntheses of the new analogs were carried out by using classic methods of peptide synthesis in liquid or solid phase. The synthesized compounds were purified by RP-HPLC and lyophilised to give fluffy solid, identified by ESI-MS spectra. These compounds were tested for inhibitory activity on human platelet aggregation in vitro, by adding common aggregation reagents to citrated platelet rich plasma (PRP). The aggregation was determined using a dual channel electronic aggregometer by recording the increase of light transmission. Their specificity for the Gp receptors was checked by using flow cytometry with monoclonal antibodies against Gp Ib, Gp IIb/IIIa, Gp IIIa and GMP140 receptors. Based on the results of the biological studies we could report the next inferences: 1. From the studied synthetic RGD analogs only peptides – amides are active against human platelet aggregation in vitro. 2. The coupling of salicylic acid with the RGD peptides enforces the antiplatelet activity in vitro of the single tripeptide. From the above peptides, the analog 26 (tripeptide incorporating salicylic acid) shows strong antiplatelet activity (IC50=50 μΜ), whereas the analog 23 (only tripeptide) has IC50= 540μΜ. 3. The protection of the β-carboxy group of Asp as benzylester increases the activity of the peptides in comparison with those having the β-carboxy group unprotected. Thus, our results ensure the theory of necessity of the existence a lipophile center on the C-terminal side of the peptide. 4. The incorporation of salicylic acid derivatives in the RGD peptide does not increase further the antiplatelet activity than the incorporation of salicylic acid does. 5. Among the cyclic RGD peptides only the analog 61, having the disulfide bridge between the cysteine and the thiosalicylic acid, shows strong antiplatelet activity in vitro (IC50= 8μΜ). 6. Most of the analogs show high binding affinity for the Gp Ib receptor. The cyclic analog 61 shows special selectivity for this receptor at concetrations of 110 μΜ. 7. The analog 39, although it shows low antiplatelet activity, has high binding affinity for the Gp Ib receptor. Probably, this activity is due to the atom of Cl at the 5 position of aromatic ring of salicylic acid. 8. According to the literature data, it is the first time that synthetic RGD peptides show strong binding affinity for the Gp Ib receptor, which is responsible for the platelet adhesion to the subenthothelium.

A adesão de plaquetas nas paredes dos vasos sanguíneos e subsequente agregação são eventos cruciais tanto na hemorragia e quanto na trombose. A hiperagregação (agregação excessiva) das plaquetas pode causar a formação de um trombo e a posterior oclusão dos vasos sanguíneos levando a um processo isquêmico. A terapia antiplaquetária com ácido acetilsalicílico reduz em até 25% o risco de infartos do miocárdio não-fatais, acidentes vasculares cerebrais isquêmicos ou mortes de causa vascular em pacientes de alto risco, independentemente do sexo ou idade. Para avaliar laboratorialmente a eficácia dessa terapêutica, o método mais utilizado é o teste de agregação plaquetária, que pode ser feito em duas metodologias, a turbidimétrica e a por impedância elétrica. Com esse cenário, o objetivo do estudo é comparar essas duas metodologias para a monitorização do tratamento. Para isso foram utilizadas amostras de sangue de 30 pacientes adultos (média de 42 anos) de ambos os sexos que fazem uso regular do fármaco e analisadas através das duas metodologias, tendo seus resultados analisados e comparados. Os resultados do estudo mostraram pouca diferença estatística significante (p<0,05) entre os dois métodos nos principais agentes estimulantes, indicando que o método de impedância elétrica pode ser utilizado em rotina laboratorial em substituição, ou em complementação, com a metodologia turbidimétrica para monitorar a terapia antiplaquetária a base de ácido acetilsalicílico / The adhesion of platelets in the blood vessel wall and subsequent aggregation are crucial events in both bleeding and thrombosis. The hyperaggregation (excessive aggregation) of platelets can cause the formation of a thrombus and subsequent occlusion of blood vessels leading to an ischemic process. Antiplatelet therapy with acetylsalicylic acyd reduces by 25% the risk of myocardial infarctions, non-fatal strokes or deaths from vascular causes in patients at high risk, regardless of sex or age. To laboratory evaluation of the effectiveness of this therapy, the method most used is the platelet aggregation test, which can be done in two methods, the turbidimetric and electrical impedance. With this scenario, the objective of the study is to compare these two methodologies for monitoring the treatment. For such purpose, blood samples from 30 adult patients (mean 42 years) of both sexes who make regular use of the drug was analyzed using the two methodologies, and their results was analyzed and compared. The studys results showed little difference statistically significant (p <0.05) between the two methods with the main stimulant agents, indicating that the method of electrical impedance can be used in routine laboratory instead or complementing the methodology of turbidimetric for monitor antiplatelet therapy by acetylsalicylic acyd

Made available in DSpace on 2016-08-17T17:39:01Z (GMT). No. of bitstreams: 1 DISSERTACAO_ELYJANY MORAIS LIMA SENA.pdf: 1561186 bytes, checksum: 888156a1b9f61af2c114710a272cf739 (MD5) Previous issue date: 2014-10-17 / Conselho Nacional de Desenvolvimento Científico e Tecnológico / Protein disulfide isomerase (PDI) plays an important role in platelet aggregation involving thiol containing surface proteins in both dependent pathways and independent of ADP. Recently it has been shown that one dodecapeptide (CXXC) containing the catalytic motif PDI was able to decrease the reductase activity of PDI opening the perspective of using the same as antithrombotic therapeutic agent. This study aimed to investigate the effects of peptides PDI - like on platelet aggregation in vitro and molecular mechanism of action of the same. For in silico analysis using a molecular docking program, it was observed that the CXXC peptide as well as its control peptide, scrambled (SCR) and AXXA were all capable of binding to the substrate site of the lligação PDI. Posteriorly, Western blot, it was demonstrated that the peptide CXXC (25  M) induced a slight but significant reduction of free thiols marking PDI suggesting physical association between the peptide and the protein. The same was not observed in samples incubated with Scr and AXXA peptides at the same concentration. In platelet aggregation assays, the platelet-rich plasma (PRP) was pre-incubated with the CXXC, Scr and AXXA peptides using ADP (5  M) as aggregating agent. CXXC found that the peptide reduced the maximum aggregation by 14%, 27% and 30% at concentrations of 3, 10 and 30μM, respectively. The Scr AXXA peptide and the peptide had no effect on platelet aggregation induced by ADP in the same concentrations. Thus, all the data presented here suggest that the CXXC peptide is associated with PDI surface and partially inhibits platelet aggregation via mechanisms mediated by thiol-disulfide exchange. / A Proteína dissulfeto isomerase (PDI) desempenha um importante papel na agregação de plaquetas, envolvendo proteínas tiólicas de superfície tanto em vias dependentes, quanto independentes de ADP. Recentemente foi demostrado que um dodecapeptídeo (CxxC), contendo o motivo catalítico da PDI, era capaz de diminuir a atividade redutase da PDI, abrindo a perspectiva do uso do mesmo como agente terapêutico antitrombótico. Assim, este trabalho teve como objetivo investigar os efeitos de peptídeos PDI símile sobre a agregação plaquetária in vitro e o mecanismo molecular de ação dos mesmos. Por análises in silico utilizando um programa de ancoragem molecular, observou-se que o peptídeo CxxC, bem como os seus peptídeos controle, scrambled (Scr) e AxxA, foram todos capazes de se ligar ao sítio de lligação do substrato na PDI. Posteriomente, por western blot ,demonstrou-se que o peptídeo CxxC (25 M) promoveu uma discreta, mas importante, redução da marcação de tióis livres da PDI sugerindo associação física entre o peptídeo e a proteína. O mesmo não foi observado nas amostras incubadas com os peptídeos Scr e AxxA, na mesma concentração. Nos ensaios de agregação plaquetária, o plasma rico em plaquetas (PRP) foi pré-incubado com os peptídeos CxxC, Scr e AxxA utilizando ADP (5M) como agente agregante. Encontramos que o peptídeo CxxC reduziu a agregação máxima em 14%, 27% e 30% nas concentrações de 3, 10 e 30μM, respectivamente. O peptídeo Scr e o peptídeo AxxA, não afetaram a agregação plaquetária induzida por ADP nas mesmas concentrações. Sendo assim, o conjunto dos dados aqui apresentados sugerem que o peptídeo CxxC associa-se à PDI de superfície e inibe parcialmente a agregação plaquetária via mecanismos mediados por trocas tiol-dissulfeto.

Orientador: Edson Antunes / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-21T23:29:22Z (GMT). No. of bitstreams: 1 Monteiro_PriscilaFukumura_M.pdf: 903494 bytes, checksum: 9d17a9657d72fedec2f6efc40cc3b082 (MD5) Previous issue date: 2013 / Resumo: As plaquetas desempenham uma função fisiológica importante no sistema hemostático, em resposta a lesão vascular através da prevenção da hemorragia. A adesão ou agregação plaquetária são eficazes na contribuição sinérgica de várias interações de múltiplos receptores, que transmitem sinais de ativação que iniciam uma série de respostas bioquímicas e morfológicas, associadas à remodelação do citoesqueleto, a secreção granular e a geração e liberação de agonistas endógenos solúveis, tais como ADP e tromboxano A2 (TXA2). O NO derivado da célula endotelial exerce um efeito inibitório na função da plaquetaria através da ativação de cGMP / PKG, a qual, por sua vez leva a uma redução na concentração de Ca2 + prevenindo assim a adesão e agregação de plaquetas à parede vascular. No entanto, a disfunção endotelial, presente em certas condições patológicas é caracterizada por uma diminuição da biodisponibilidade de NO que leva a ativação anormal das plaquetas conduzindo a trombose vascular À disfunção plaquetária é considerada uma fase final de complicações cardiovasculares no diabetes mellitus tipo II, obesidade, aterosclerose, levando ao resultado clínico, tais como enfarte do miocárdio, acidente vascular cerebral e doença arterial periférica. A obesidade é um importante problema de saúde pública, atingindo todas as idades e grupos socioeconômicos elevando a incidência de doenças cardiovasculares e endócrino-metabólica. Um estado crônico de stress oxidativo e inflamação são a marcados pela adiposidade que desempenha um papel crucial nos eventos fisiopatológicos desta desordem. Estes efeitos pró-inflamatórios e pró-oxidante estão associados com o aumento de ERO com diminuição da biodisponibilidade, o que aumenta o risco de eventos trombóticos aterosclerose. No entanto, os mecanismos pelos quais a adiposidade induz disfunção plaquetária são pouco esclarecidos. Além disso, a maioria dos eventos cardiovasculares fatais como consequência de complicação trombótica não estão associadas à estenose vascular completa, mas sim com as alterações de biomarcadores pró-inflamatórios e pró-oxidantes, o que pode prever futuros eventos cardiovasculares. Nossa hipótese é que a produção de ERO intraplaquetário causada pela adiposidade contribui para eventos trombóticos e distúrbios endocrinometabólico. Assim, investigou-se a reatividade plaquetária ex-vivo em resposta ao ADP e trombina, em ratos alimentados com dieta hiperlipídica, e o envolvimento de ERO e via do NO-cGMP na modulação da reatividade de plaquetária / Abstract: Platelets play an important physiological function in haemostasis system in response to vascular injury by preventing hemorrhage. Effective platelet adhesion and aggregation require the synergistic contribution of multiple receptor-ligand interactions that transmit activating signals initiating a range of platelet biochemical and morphological responses, linked to cytoskeleton remodeling, granule secretion and the generation and release of endogenous soluble agonists, such as ADP and thromboxane A2 (TXA2). Endothelial cell-derived nitric oxide (NO) exerts an inhibitory effect in the platelet function by activation of cGMP/PKG pathway, which in turn leads to reduction in concentration of Ca2+, thus preventing adhesion and aggregation of platelets to the vascular wall. Nonetheless, endothelium dysfunction, present in certain pathological conditions is characterized by a decreased NO bioavailability which incites abnormal platelet activation leading to vascular thrombosis. Platelet dysfunction is considered an end stage of cardiovascular complications in type II diabetes mellitus, obesity and atherosclerosis that results in clinical outcomes such as myocardial infarction, stroke and peripheral artery disease. Obesity is an important public health problem affecting all ages and socioeconomic groups greatly elevating the incidence of cardiovascular and endocrine-metabolic disorders. A chronic state of oxidative stress and inflammation are the hallmark of adiposity that plays a pivotal role in the physiopathological events in this disorder. These proinflammatory and pro-oxidant effects are associated with increased reactive-oxygen species (ROS) production and decreased NO bioavailability, which increases the risk of athero thrombotic events. Nonetheless, the exact mechanisms by which adiposity induces platelet dysfunction remain poorly investigated. In addition, most of fatal cardiovascular events as consequence of thrombotic complication are not associated with complete vascular stenosis, but rather with alterations of pro-inflammatory and pro-oxidant biomarkers, which can predict future cardiovascular events. We hypothesized that intraplatelet ROS production in adiposity contributes to thrombotic events in endocrinemetabolic disorders. Therefore, we have investigated the ex-vivo platelet reactivity in response to ADP and thrombin in high fat-fed rats, and the involvement of platelet-derived ROS and NO-cGMP pathway in modulating the platelet reactivity / Mestrado / Farmacologia / Mestra em Farmacologia

Certains facteurs de risque, comme l’hyperlipidémie, l’hyper-agrégabilité des plaquettes sanguines et le stress oxydant favorisent la progression des maladies cardiovasculaires. L’objectif de ce travail est de comparer les effets des AGPI-LC issus de sources différentes (microalgue marine, huile d’argan et de poisson) sur l’installation du syndrome métabolique chez des rats soumis à un régime hyperlipidique. Les effets de l’huile d’argan sur la fonction plaquettaire et sur le bilan lipidique ont aussi été testés chez des patients dyslipidémiques. Une étude préliminaire sur des rats a été réalisée afin de rechercher la dose minimale de la microalgue (Odontella aurita) à incorporer dans le régime pour obtenir un effet positif sur les différents paramètres mesurés. Nous avons ensuite étudié l’effet du lyophilisat d’O. aurita sur les facteurs de risque cardiovasculaire induits par un régime hyperlipidique chez le rat. Les résultats ont montré, que l'apport d'O. aurita induit une diminution de la glycémie et des teneurs en lipides plasmatiques ainsi qu’une réduction de l'agrégation plaquettaire. Nous avons ensuite comparé les effets de cette microalgue avec l’huile de poisson. Pour cela une étude nutritionnelle a été réalisée chez des rats soumis à un régime hyperlipidique supplémenté ou non avec du lyophilisat d’O. aurita ou de l’huile de poisson. Il a ainsi été montré que la supplémentation en lyophilisat d’O. aurita et en huile de poisson diminue l’agrégation plaquettaire et le stress oxydatif. Nous avons par la suite comparé les effets de l’huile de poisson riche en oméga-3, et de l’huile d’argan riche en oméga-6 et oméga-9. Nos résultats montrent que les 2 sources diminuent l’agrégation plaquettaire et les facteurs de risque du syndrome métabolique mais leurs mécanismes d’action semblent être différent. En complément Nous avons sur l’huile d’argan, réalisé au Maroc une étude clinique pour rechercher l’effet antiagrégant et hypolipémiant chez des patients dyslipidémiques. Les résultats obtenus montrent une amélioration significative des lipides athérogènes chez les patients consommant de l'huile d’argan. Cette amélioration consiste en une baisse très significative des taux de cholestérol total et de LDL-cholestérol sériques auxquels s'ajoutent une diminution de l’agrégation plaquettaire et du stress oxydatif chez les patients consommant de l'huile d’argan. / Some risk factors, such as hyperlipidemia, hyperaggregability of blood platelets and oxidative stress promotes the progression of cardiovascular disease. The objective of this study was to compare the effects of LC-PUFA from different sources (marine microalgae, argan oil and fish oil) on installing the metabolic syndrome in rats fed high fat diet. The effects of argan oil on platelet function and lipid profiles were also tested in dyslipidemic patients. A preliminary study was conducted to find the minimum dose of microalgae (Odontella aurita) to be incorporated in the diet for a positive effect on the different parameters measured. We then studied the effect of lyophilized O. aurita on cardiovascular risk factors induced by a high fat diet in rats. The results showed that the addition of O. aurita induces a reduction in blood glucose and plasma lipid levels and a reduction in platelet aggregation. We then compare the effects of microalgae with fish oil. For this, a nutritional study was conducted in rats subjected to a high fat diet (HF) supplemented or not with the freeze-dried O. aurita (HFOA) or fish oil (HFFO). Supplementation lyophilized O. aurita and fish oil decreases platelet aggregation and oxidative stress.We subsequently compared the effects of fish oil rich in omega-3, and argan oil which is rich in omega-6 and omega-9. Our results show that 2 sources of LC-PUFA decrease platelet aggregation and the risk factors of metabolic syndrome, but their mechanism of action appears to be different.We have also conducted a clinical study in Morocco to investigate the antiplatelet and lipid lowering effect of argan oil in patients with dyslipidemia. The results show a significant improvement in atherogenic lipids in patients consuming argan oil for 3 weeks. This improvement consists in a very significant reduction in total cholesterol and serum LDL cholesterol, with a decreased platelet aggregation and oxidative stress in patients consuming argan oil.

Purpose. The use of antiplatelet agents in patients hospitalized with ischemic stroke was studied. Methods. Patients with a primary or secondary diagnosis of noncardiogenic, thrombotic ischemic stroke from January 2002 through December 2004 were included in the analysis. Patients were then subdivided into four treatment groups and one no-treatment group based on whether they were charged for any of four antiplatelet regimens (low-dose aspirin [≤325 mg daily], extended-release dipyridamole 200 mg with aspirin 25 mg, clopidogrel 75 mg, and clopidogrel 75 mg [as the bisulfate] plus low-dose aspirin) at any time during hospitalization. Patients who did not receive any of these medications during hospitalization were defined as the no-treatment group. A patient's illness severity was measured and compared with other patients in the data set. Results. A total of 44,108 patients were assigned to the treatment group, and 14,255 patients were assigned to the no-treatment group. In general, longer lengths of stay and higher institutional costs were associated with the no-treatment group. Patients in the no-treatment group consistently displayed more comorbid conditions than did patients in the treatment group. The no-treatment group exhibited higher usage rates of both fibrinolytic agents and vitamin K. More patients in the treatment group were discharged to home or rehabilitation, while more patients in the no-treatment group were either discharged to another nursing facility or died before discharge. Conclusion. A retrospective analysis of a large national hospital database revealed that one quarter of patients who suffered an acute stroke did not receive antiplatelet drugs during their patient stay. Outcomes for such patients were poorer than for patients who had received antiplatelet therapy.

Introdução. A dupla antiagregação plaquetária traz benefícios no tratamento do infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMSST). Há variabilidade intra e interindividual no uso do clopidogrel e isso influencia no benefício do seu uso nesse grupo de pacientes. O objetivo desta pesquisa foi avaliar os efeitos de novo antiagregantes plaquetários (prasugrel e ticagrelor) administrados na sala de emergência (\"upstream\") sobre o resultado angiográfico da angioplastia primária, levando em conta o fluxo coronariano TIMI, o blush miocárdico e a carga de trombo. Métodos. Foi realizado um ensaio clínico, randomizado, cego, com 131 pacientes admitidos com IAMSST. Todos os pacientes receberam ácido acetilsalicílico (AAS). Os pacientes foram randomizados para receber clopidogrel (n=44), prasugrel (n=41) ou ticagrelor (n=46) como dose de ataque ainda na emergência. Todos os pacientes foram submetidos a aspiração manual de trombos. Ao término do procedimento, o resultado angiográfico foi avaliado quanto ao fluxo TIMI, o blush miocárdico e a carga de trombo. Resultados. O fluxo coronariano TIMI >= 1 antes do procedimento foi observado mais frequentemente com o uso de ticagrelor (n = 10, 21,7%) do que com o clopidogrel (n = 1, 2,3%) e prasugrel (n = 5, 12,2%; p = 0,019). O fluxo TIMI coronária no fim do procedimento não diferiu significativamente entre os grupos (p = 0,101). Melhor resultado no que diz respeito ao blush miocárdico foi observada com prasugrel, que produziu um grau de blush III em 85,4% (n = 35) dos pacientes, em comparação com o clopidogrel (54,5%; n = 24) e ticagrelor (67,4%; n = 31; p = 0,025). A carga de trombo pré-procedimento foi maior no grupo de clopidogrel, em que 97,7% (n = 43) dos casos denotaram carga de trombo grau 4/5, enquanto 87,8% (n = 36) do grupo prasugrel tiveram respostas semelhantes, e 80,4% (n = 37) foram observadas no grupo ticagrelor (p = 0,03). Conclusão. Os novos antiagregantes plaquetários ticagrelor e prasugrel parecem exercer efeito sobre o resultado angiográfico dos pacientes submetidos a angioplastia primária. O uso do ticagrelor propiciou menor carga de trombo e um fluxo TIMI melhor no pré-procedimento e o uso do prasugrel ensejou melhor perfusão miocárdica analisada pelo blush miocárdico. Não houve diferença no fluxo angiográfico TIMI pós procedimento / Introduction. Dual antiplatelet therapy has benefits in the treatment of acute myocardial infarction with ST-segment elevation (STEMI). There is variability intra and inter individual in the use of clopidogrel and this influences the benefit of its use in this group of patients. The objective of this research was to evaluate the angiographic results of Upstream Clopidogrel, Prasugrel, or Ticagrelor For Patients Treated With Primary Angioplasty. Methods. A clinical trial was conducted, randomized, double blind, with 131 patients admitted with STEMI. All patients received acetylsalicylic acid (ASA). Patients were randomized to receive clopidogrel (n = 44), prasugrel (n = 41) or ticagrelor (n = 46) as loading dose even in emergency. All patients were submitted to manual thrombus aspiration. At the end of the procedure, the angiographic result was evaluated for TIMI flow, myocardial blush and thrombus burden. Results. A coronary TIMI flow >= 1 before the percutaneous procedure was observed more frequently with the use of ticagrelor (n=10, 21.7%) than with clopidogrel (n=1, 2.3%) and prasugrel (n=5, 12.2%; p=0.019). The coronary TIMI flow at the end of the procedure did not significantly differ between the groups (p=0.101). A better result with respect to myocardial blush was observed with prasugrel, which yielded a blush grade of III in 85.4% (n=35) of patients, compared with clopidogrel (54.5%; n=24) and ticagrelor (67.4%; n=31; p=0.025). The pre-procedural thrombus burden was found to be of a higher grade in the clopidogrel group, in which 97.7% (n=43) of the cases exhibited thrombus burdens grade 4/5, whereas 87.8% (n=36) of the prasugrel group had similar responses, and 80.4% (n=37) were observed in the ticagrelor group (p=0.03). Conclusions. The novel antiplatelet agents represented by ticagrelor and prasugrel appear to have effect on the angiographic outcome of patients undergoing primary angioplasty. The use of ticagrelor led to a smaller thrombus burden and better TIMI flow at the beginning of the procedure and the use of prasugrel produced a better myocardial perfusion analyzed by myocardial blush. There was no difference in post angioplasty TIMI flow

INTRODUÇÃO: Racional: A alta atividade plaquetária residual (AAPR) em uso do AAS é considerada um fator de mau prognóstico em portadores de síndrome isquêmica miocárdica instável (SIMI). Adicionalmente, as taxas de prevalência de AAPR verificadas em diferentes estudos realizados na fase aguda das SIMI são consideradas elevadas em relação às verificadas em portadores de doença arterial coronariana estável. Todavia, não está bem demostrado se essa elevada prevalência de AAPR diagnosticada na fase aguda das SIMI representa um fenômeno transitório, desaparecendo na fase tardia, ou se é um estado permanente, independente da fase aguda. MÉTODOS: O objetivo primário do presente estudo foi o de comparar, em pacientes com SIMI sem supradesnível do segmento ST, a resposta antiplaquetária ao AAS nas fases aguda e tardia na mesma população. Foram incluídos 70 pacientes com SIMI sem supradesnível de ST (77% com angina instável e 22% com IAM sem supra de ST), com idade média de 64,97 anos, sendo 54% do sexo feminino, todos em uso de AAS na dose de 100 a 200mg por pelo menos sete dias anteriores à inclusão. Os pacientes foram submetidos a cinco testes de agregação plaquetária na fase aguda, e os mesmos testes foram repetidos na fase tardia, três meses depois: VerifyNowAspirin®, agregometria de sangue total (AST) com ácido aracdônico (AA) e colágeno, tromboxane B2 sérico, PFA-100. RESULTADOS: De acordo com os testes COX-1 específicos (VFN e AST com AA), a AAPR em uso do AAS foi mais prevalente na fase aguda das SIMI do que na fase tardia (VFN: 32,1% versus 16%, p=0,049; e AST com AA: 31,4% versus 12,8%, p=0,015). Os testes não específicos (AST com colágeno, PFA) e o teste bioquímico não conseguiram demonstrar diferenças entre as fases. A correlação entre os cinco testes realizados foi considerada fraca ou moderada. CONCLUSÃO: A alta prevalência de AAPR, apesar do uso da AAS durante as SIMI, reflete mais provavelmente um estado de hiper-reatividade plaquetária transitória, que se reverte na fase crônica e estável da DAC, de acordo com os testes COX-1 específicos. A correlação entre os testes plaquetários foi apenas moderada nos dois cenários / BACKGROUND: The high residual platelet activity (HRPA) in response to acetylsalicilic acid (ASA) is considered a poor prognostic factor in patients with acute coronary syndromes (ACS). Additionally, the HRPA prevalence rates reported by different studies in ACS patients are considered high compared to those reported in patients with stable coronary artery disease. However, it is not well demonstrated whether this high HRPA prevalence diagnosed during the acute phase represents a transient phenomenon, disappearing in the late phase, or if it is a permanent state, independent of the acute phase. The aim of this study was to compare platelet aggregation in response to ASA during the ACS acute phase with the platelet aggregation in chronic stable phase. METHODS: Inclusion of patients with non ST ACS who were on aspirin at a dose of 100mg to 200mg per day for at least seven days prior to inclusion. We conducted five tests of platelet aggregation in the first 48 hours and repeated them three months later: VerifyNow Aspirin® (VFN), Whole Blood aggregometry (WBA) with arachidonic acid (AA) and collagen, thromboxane B2, PFA-100®. We analyzed 70 patients (77% with unstable angina and 22% with non ST AMI), mean age 64.97 years, 54% female. According to the COX-1 specific tests, the HRPA was more frequent in the acute phase than in the chronic phase (VerifyNowAspirin®: 31.4% versus 12.8%, p=0.015; and WBA with AA: 32.1% versus 16%, p=0.049; respectively). The non specific tests (AST with collagen and PFA) and the biochemical test sTXB2 failed to show differences between the phases. The correlation between the five tests was considered weak or moderate. CONCLUSION: The high prevalence of RPA despite the use of aspirin during the acute phase of the SCA most likely reflects a state of transient platelet hyperreactivity, which is reversed in the chronic phase. The correlation between platelet tests was only moderate in both scenarios

Introdução. A dupla antiagregação plaquetária traz benefícios no tratamento do infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMSST). Há variabilidade intra e interindividual no uso do clopidogrel e isso influencia no benefício do seu uso nesse grupo de pacientes. O objetivo desta pesquisa foi avaliar os efeitos de novo antiagregantes plaquetários (prasugrel e ticagrelor) administrados na sala de emergência (\"upstream\") sobre o resultado angiográfico da angioplastia primária, levando em conta o fluxo coronariano TIMI, o blush miocárdico e a carga de trombo. Métodos. Foi realizado um ensaio clínico, randomizado, cego, com 131 pacientes admitidos com IAMSST. Todos os pacientes receberam ácido acetilsalicílico (AAS). Os pacientes foram randomizados para receber clopidogrel (n=44), prasugrel (n=41) ou ticagrelor (n=46) como dose de ataque ainda na emergência. Todos os pacientes foram submetidos a aspiração manual de trombos. Ao término do procedimento, o resultado angiográfico foi avaliado quanto ao fluxo TIMI, o blush miocárdico e a carga de trombo. Resultados. O fluxo coronariano TIMI >= 1 antes do procedimento foi observado mais frequentemente com o uso de ticagrelor (n = 10, 21,7%) do que com o clopidogrel (n = 1, 2,3%) e prasugrel (n = 5, 12,2%; p = 0,019). O fluxo TIMI coronária no fim do procedimento não diferiu significativamente entre os grupos (p = 0,101). Melhor resultado no que diz respeito ao blush miocárdico foi observada com prasugrel, que produziu um grau de blush III em 85,4% (n = 35) dos pacientes, em comparação com o clopidogrel (54,5%; n = 24) e ticagrelor (67,4%; n = 31; p = 0,025). A carga de trombo pré-procedimento foi maior no grupo de clopidogrel, em que 97,7% (n = 43) dos casos denotaram carga de trombo grau 4/5, enquanto 87,8% (n = 36) do grupo prasugrel tiveram respostas semelhantes, e 80,4% (n = 37) foram observadas no grupo ticagrelor (p = 0,03). Conclusão. Os novos antiagregantes plaquetários ticagrelor e prasugrel parecem exercer efeito sobre o resultado angiográfico dos pacientes submetidos a angioplastia primária. O uso do ticagrelor propiciou menor carga de trombo e um fluxo TIMI melhor no pré-procedimento e o uso do prasugrel ensejou melhor perfusão miocárdica analisada pelo blush miocárdico. Não houve diferença no fluxo angiográfico TIMI pós procedimento / Introduction. Dual antiplatelet therapy has benefits in the treatment of acute myocardial infarction with ST-segment elevation (STEMI). There is variability intra and inter individual in the use of clopidogrel and this influences the benefit of its use in this group of patients. The objective of this research was to evaluate the angiographic results of Upstream Clopidogrel, Prasugrel, or Ticagrelor For Patients Treated With Primary Angioplasty. Methods. A clinical trial was conducted, randomized, double blind, with 131 patients admitted with STEMI. All patients received acetylsalicylic acid (ASA). Patients were randomized to receive clopidogrel (n = 44), prasugrel (n = 41) or ticagrelor (n = 46) as loading dose even in emergency. All patients were submitted to manual thrombus aspiration. At the end of the procedure, the angiographic result was evaluated for TIMI flow, myocardial blush and thrombus burden. Results. A coronary TIMI flow >= 1 before the percutaneous procedure was observed more frequently with the use of ticagrelor (n=10, 21.7%) than with clopidogrel (n=1, 2.3%) and prasugrel (n=5, 12.2%; p=0.019). The coronary TIMI flow at the end of the procedure did not significantly differ between the groups (p=0.101). A better result with respect to myocardial blush was observed with prasugrel, which yielded a blush grade of III in 85.4% (n=35) of patients, compared with clopidogrel (54.5%; n=24) and ticagrelor (67.4%; n=31; p=0.025). The pre-procedural thrombus burden was found to be of a higher grade in the clopidogrel group, in which 97.7% (n=43) of the cases exhibited thrombus burdens grade 4/5, whereas 87.8% (n=36) of the prasugrel group had similar responses, and 80.4% (n=37) were observed in the ticagrelor group (p=0.03). Conclusions. The novel antiplatelet agents represented by ticagrelor and prasugrel appear to have effect on the angiographic outcome of patients undergoing primary angioplasty. The use of ticagrelor led to a smaller thrombus burden and better TIMI flow at the beginning of the procedure and the use of prasugrel produced a better myocardial perfusion analyzed by myocardial blush. There was no difference in post angioplasty TIMI flow

Os envenenamentos causados pelas serpentes do gênero Bothrops são os mais importantes do ponto de vista médico e econômico na América Central. Dentre estas, a serpente Bothrops asper é responsável por 90% dos envenenamentos ofídicos registrados no Panamá anualmente. Apesar da relevância médica e econômica, só a peçonha de populações de B. asper da Costa Rica e Guatemala tem sido estudadas em detalhes. Neste trabalho apresentamos a caracterização da peçonha da B. asper do Panamá e o isolamento, a caracterização funcional e estrutural de quatro fosfolipases A2 básicas denominadas MTX-I, MXT-II, MTX-III e MXT-IV e de uma fosfolipase A2acídica denominada Basp-I-PLA2. As fosfolipases A2 foram isoladas da peçonha em duas etapas usando cromatografia de troca iônica em CM-Sepharose (0,05 M NH4HCO3 pH 8,1), e cromatografia hidrofóbica em Fenil-Sepharose (0,05 M Tris-HCl pH 7,4) seguida de gradiente de concentração de 4 a 0 M NaCl no mesmo tampão a temperatura ambiente (25°C). A isoforma acídica demonstrou maior atividade catalítica que as isoformas básicas, quando atuou sobre fosfatidilcolina e fosfatidilglicerol. A focalização isoelétrica evidencia pIs de 8,1 a 8,3 para as MTXs e 4,6 para isoforma Basp-I-PLA2. A determinação da massa molecular por espectrometria de massa mostrou que MTX-1 14,156.5; MTX-2 14,249.5 e MTX-3 14,253.0 e Basp-I-PLA2 14,246.0 Da. As PLA2s (MTX-I, II, III e IV) induziram atividade miotóxica, reação inflamatória com migração de leucócitos ao músculo e ativação de macrófagos para exercer fagocitose e produção de superóxido. MTX-II exerceu um forte efeito citotóxico contra células tumorais JURKAT, C. albicans e E. coli. A fosfolipase A2 acídica, testada no plasma enriquecido com plaquetas, mostrou potente efeito inibitório na agregação plaquetária induzida pela ADP e colágeno. A análise de seqüência N- terminal demonstrou que as proteínas MTX-I, MTX-III e Basp-I-PLA2 pertencem à subclasse de fosfolipases A2 Asp49 cataliticamente ativas, enquanto que, MTX-II e MTX-IV pertencem à subclasse de fosfolipases A2 Lys49-homólogas cataliticamente inativas. Além disso, a sequência N-terminal das fosfolipases A2 básicas isoladas, demonstrou claramente que as miotoxinas isoladas neste trabalho são similares às miotoxinas previamente isoladas da peçonha da B. asper da Costa Rica. A Basp-I-PLA2 é uma nova fosfolipase A2 acídica isolada da peçonha de B. asper do Panamá e sua seqüência N-terminal revelou uma alta homologia com outras PLA2s acídicas Asp49 isoladas de peçonhas de serpentes. / Envenoming by Bothrops snakes is the most serious kind of envenoming from the medical and economical point of view in Central America. Bothrops asper snake is responsible for 90% of the snakebites registered in Panama every year. Despite its medical and economical relevance, only the venom of Costa Rica and Guatemala populations of this species has been studied to some detail, and there is very little information on intraspecies variability in venom composition and toxicity. In this study the crude venom of B. asper from Panama was characterized and its pharmacological and biochemistry activities were investigated with standard laboratory assays. Furthermore, we describe the isolation, functional and structural characterization of four basic phospholipases A2, named MTX-I, MTX-II, MTX-III, MTX-IV and a new acid phospholipase A2 named Basp-I-PLA2. The proteins were isolated from the crude venom by a combination of two chromatographic steps, using ion-exchange chromatography on CM-Sepharose (0.05 M NH4HCO3 pH 8.1 buffer), and hydrophobic chromatography on Phenyl-Sepharose (0.05 M Tris-HCl pH 7.4), followed by concentration gradient from 4 to 0 M NaCl at 25°C in the same buffer. Analyses of phospholipids hydrolyzed by these enzymes have shown that all phospholipases belong to type A2. The acidic isoform demostraded more catalytic activity than the basic PLA2s. This enzyme was more active on substrates as phosphotidylcholine and phosphatidylglycerol. The isoelectric focusing evidenced pIs beetwen 8.1 to 8.3 for the MTXs and 4.6 for the isoform Basp-I-PLA2. Its mol. Wt was estimated by Mass spectrometry to be MTX-1 14,156.5; MTX-2 14,249.5 and MTX-3 14,253.0 and Basp-I-PLA2 14,246.0 Da. The PLA2s (MTX-I, II, III and IV) induced myotoxic activity, inflammatory reaction mainly leukocyte migration to the muscle and activation of macrophages to exert phagocytic activity and production of superoxide. MTX-II, the most abundant one showed to be cytotoxic against JURKAT tumor cell line, C. albicans and E. coli. The acidic phospholipases A2 when tested in platelet rich plasma, showed a potent inhibitory effect on aggregation induced by ADP and collagen. The analysis of the sequence N-terminal demonstrated that the MTX-I, MTX-III and BASP-I-PLA2 belong to the subclass of Asp49 phospholipases A2 catalytically active, whereas, MTX-II and MTX-IV belong to proteins of the subclass of the enzymatically inactive Lys49 PLA2 s-like. In addition, a sequence of the region N-terminal of the PLA2s basic isolated, demonstrated clearly, that the isolated myotoxins in this work are similar of the previously isolated myotoxins of the snake venom Bothrops asper from Costa Rica. The Basp-I-PLA2 is a new acidic PLA2 and his sequence N-terminal revealed a high homology with other Asp49 acidic PLA2 s from snake venoms.