Modelling the effects of 4-factor prothrombin complex concentrate for the management of factor Xa-associated bleeding.

The management of factor Xa (FXa) inhibitor-associated bleeding remains a clinical challenge. Massive bleeding is often associated with complex coagulopathy and, thus, the sole reversal of FXa inhibitors might not be sufficient to restore hemostasis, requiring instead a multimodal approach. Four-factor prothrombin complex concentrate (4F-PCC) is widely recognized as a viable treatment option for FXa inhibitor-associated bleeding. Here, we applied computational models to explore the effect 4F-PCC has on the coagulation cascade and restoration of thrombin generation in a system that simulates a patient that has received a FXa inhibitor. The coagulation model is largely based on a previously developed model with modifications incorporated from various other published sources. The model was calibrated and validated using data from a phase 3 clinical trial of vitamin K antagonist reversal with 4F-PCC. Using the parameters and initial conditions determined during the calibration and validation process, the prothrombin time (PT) test simulations predicted a PT of 11.4 seconds. The model successfully simulated the effects of rivaroxaban and apixaban on total thrombin concentration and showed that 4F-PCC increased thrombin generation in the presence of rivaroxaban or apixaban.

Characterization of recombinant factor IX fusion proteins enabling subcutaneous administration.

BACKGROUND: The X-linked bleeding disorder hemophilia B, caused by mutation(s) in the coagulation factor (F)IX gene, leads to partial or total loss of its function, requiring lifelong FIX replacement therapy. Although new recombinant FIX (rIX) therapeutics like albumin fusion proteins (rIX-FP) enable longer plasma half-life and thus less frequent administration, the complexity of intravenous (i.v.) injection remains. OBJECTIVES: The study aimed to characterize rIX-FP variants with anticipated enhanced specific activity, which would leverage rIX-FP's superior pharmacokinetic profile with beneficial characteristics for subcutaneous (s.c.) administration. METHODS: Two rIX-FP variants, R338L ("Padua variant") and R338L/E410K, were characterized in vitro. Pharmacokinetic profiles of FIX antigen and activity levels were evaluated in FIX-deficient mice after i.v. and s.c. administration of these variants (dosing based on antigen levels). The efficacy of the most promising variant was tested after i.v. and s.c. administration (dosing based on activity) in a tail clip bleeding model. A marketed wild-type (WT) rIX-FP product served as the comparator. RESULTS: Both rIX-FP variants showed a 4- to 5-fold increase in specific activity in vitro compared with rIX(WT)-FP, while FXIa-mediated activation was the fastest for rIX(WT)-FP and rIX(R338L)-FP. Compared with rIX(WT)-FP and rIX(R338L/E410K)-FP, rIX(R338L)-FP exhibited higher FIX activity exposure after i.v. and s.c. administration and demonstrated comparable efficacy with rIX(WT)-FP in reducing bleeding time and blood loss in FIX-deficient mice requiring ∼4 times lower protein amount. CONCLUSION: rIX(R338L)-FP was shown to be a promising candidate for s.c. administration, exhibiting increased specific activity combined with higher activity-based exposure and indicating efficacy at a lower protein dose.

Progressive changes of elastic moduli of arterial wall and atherosclerotic plaque components during plaque development in human coronary arteries.

Stiffness of the arterial wall and atherosclerotic plaque components is a determinant of the stress field within plaques, which has been suggested to be an indicator of plaque vulnerability. The diversity and inhomogeneous structure of atherosclerotic lesions complicate the characterization of plaque components. In the present study, stiffness of the arterial wall and atherosclerotic plaque components in human coronary arteries was examined in early and developed atherosclerotic lesions. The force-spectroscopy mode of the atomic force microscope and histological examination were used for determination of elastic moduli at specified locations within samples. Fibrous cap (E = 14.1 ± 3.8 kPa) showed lower stiffness than the fibrous tissue beneath the lipid pool (E = 17.6 ± 3.2 kPa). Calcification zones (E = 96.1 ± 18.8 kPa) and lipid pools (E = 2.7 ± 1.8 kPa) were the stiffest and softest components of atherosclerotic lesions, respectively. The increase of media stiffness (%44.8) and reduction of the elastic modulus of the internal elastic lamina (%28.9) was observed in coronary arteries. Moreover, significant differences were observed between the stiffness of medial layer in diseased parts and free-plaque segments in incomplete plaques of coronary arteries. Our results can be used for better understanding of remodeling mechanisms of the arterial wall with plaque development. Graphical abstract Stiffness alteration of the arterial wall and atherosclerotic plaque components with plaque development in coronary arteries.

Mechanical Characterization of the Lamellar Structure of Human Abdominal Aorta in the Development of Atherosclerosis: An Atomic Force Microscopy Study.

Atherosclerosis is a major risk factor for cardiovascular disease. However, mechanisms of interaction of atherosclerotic plaque development and local stiffness of the lamellar structure of the arterial wall are not well established. In the current study, the local Young's modulus of the wall and plaque components were determined for three different groups of healthy, mildly diseased and advanced atherosclerotic human abdominal aortas. Histological staining was performed to highlight the atherosclerotic plaque components and lamellar structure of the aortic media, consisting of concentric layers of elastin and interlamellar zones. The force spectroscopy mode of the atomic force microscopy was utilized to determine Young's moduli of aortic wall lamellae and plaque components at the micron level. The high variability of Young's moduli (E) at different locations of the atherosclerotic plaque such as the fibrous cap (E = 15.5± 2.6 kPa), calcification zone (E = 103.7±19.5 kPa), and lipid pool (E = 3.5±1.2 kPa) were observed. Reduction of elastin lamellae stiffness (18.6%), as well as stiffening of interlamellar zones (50%), were detected in the diseased portion of the medial layer of abdominal aortic wall compared to the healthy artery. Additionally, significant differences in the stiffness of both elastin lamellae and interlamellar zones were observed between the diseased wall and disease-free wall in incomplete plaques. Our results elucidate the alternation of the stiffness of different lamellae in the human abdominal aortic wall with atherosclerotic plaque development and may provide new insight on the remodeling of the aortic wall during the progression of atherosclerosis.

Stress analysis of fracture of atherosclerotic plaques: crack propagation modeling.

Traditionally, the degree of luminal obstruction has been used to assess the vulnerability of atherosclerotic plaques. However, recent studies have revealed that other factors such as plaque morphology, material properties of lesion components and blood pressure may contribute to the fracture of atherosclerotic plaques. The aim of this study was to investigate the mechanism of fracture of atherosclerotic plaques based on the mechanical stress distribution and fatigue analysis by means of numerical simulation. Realistic models of type V plaques were reconstructed based on histological images. Finite element method was used to determine mechanical stress distribution within the plaque. Assuming that crack propagation initiated at the sites of stress concentration, crack propagation due to pulsatile blood pressure was modeled. Results showed that crack propagation considerably changed the stress field within the plaque and in some cases led to initiation of secondary cracks. The lipid pool stiffness affected the location of crack formation and the rate and direction of crack propagation. Moreover, increasing the mean or pulse pressure decreased the number of cycles to rupture. It is suggested that crack propagation analysis can lead to a better recognition of factors involved in plaque rupture and more accurate determination of vulnerable plaques.