Elevation of plasma fibrinogen in silent myocardial ischaemia.

High plasma levels of fibrinogen and plasminogen activator inhibitor (PAI-1) are reported to be correlated with coronary heart disease. Therefore the level of fibrinogen concentration in plasma was examined and verified for the possible correlation with the previously explored PAI-1 antigen and PAI-1 activity in the pathogenesis of premature atherosclerosis (Grzywacz et al., 1998, Blood Coagul Fibrinol. 9, 245-249). Examination included only men, aged 33-46 years, who were in a stable condition for at least six months after the acute event. They were divided into two subgroups: group A (n = 14) with and group B (n = 15) without ischaemic changes in 24 h Holter electrocardiogram. The number of involved vessels visible on the coronarography picture was similar in both groups. In the patients of group A the mean level of fibrinogen (3.92 vs 3.23 g/l, P < 0.05) was higher than in the controls (n = 15). No statistically differences were found between group B and control healthy subjects in any of the parameters measured. There were no correlation between fibrinogen concentration and PAI-1 antigen and activity levels, which were elevated in both groups of patients according to our previous study. Our results indicate that elevated levels of plasma fibrinogen and PAI-1 appeared in the group of patients with more severe disease, as revealed by silent myocardial ischaemia.

Impairment of plasma fibrinolysis in young survivors of myocardial infarction with silent ischaemia.

The aim of this study was to compare fibrinolytic parameters in two subgroups of young survivors of myocardial infarction: group A (n = 14) with silent myocardial ischaemia and group B (n = 15) without silent myocardial ischaemia, as assessed by 24 h Holter electrocardiogram monitoring. Only men aged 33-46 years who were in a stable condition at least 6 months after the acute event were included in the survey. All patients were normolipaemic or had only mild hyperlipidaemia, non-diabetic, normotensive, non-current smokers and with a normal body mass index. The control group consisted of 15 age-matched healthy men. Blood samples were taken at 7.30 a.m. In the group A patients, we found higher mean levels of tissue plasminogen activator (t-PA) total antigen (11.1 versus 6.9 ng/ml, P < 0.01), its inhibitor plasminogen activator inhibitor-1 (PAI-1) antigen (58.1 versus 34.8 ng/ml, P < 0.01), PAI-1 activity (4.9 versus 3.4 U/ml, P < 0.05) and tPA-PAI-1 complexes (5.1 versus 3.5 ng/ml, P < 0.05) as well as a lower level of t-PA activity (0.5 versus 0.8 IU/ml, P < 0.01) and free t-PA antigen (0.8 versus 1.3 ng/ml, P < 0.01) compared with the controls. However, group A patients exhibited higher PAI-1 antigen levels (58.1 versus 41.6 ng/ml, P < 0.05) than those without silent ischaemia. There were no differences between group B and controls in any of the parameters measured. Our results indicate that patients with more severe disease, as revealed by silent myocardial ischaemia, had lower levels of free t-PA as a result of the excess of PAI-1.

[Low molecular weight heparin (Fraxiparine) as adjunctive therapy with thrombolysis for acute myocardial infarction: a pilot study with a one year follow up]. / Drobnoczasteczkowa heparyna (Fraksyparyna) jako uzupe-nienie leczenia trombolitycznego swiezego zawalu serca; próba "pilotowa" z roczna obserwacja chorych.

In 53 patients with recent (< 6 hrs) acute myocardial infarction a study was undertaken to evaluate the safety of conjunctive therapy with streptokinase (1.5 mln U), aspirin (150 mg) and low molecular weight heparin (Fraxiparine). Patients were treated with Fraxiparine 250 U anti-Xa IC/kg/24 hrs iv for 2 days (with bolus 12.5 U anti-Xa IC/kg), and 125 U anti-Xa IC/kg twice a day sc for 5 subsequent days. Clinical course in one-year observation was compared regarding the time the therapy was initiated. In the group undergoing therapy 3-6 hrs after the infarct had occurred 4 (7.5%) patients died (2 during hospitalization, 2 after discharge). In 31 patients treated within 3 hrs of the myocardial infarction there were fewer cases of recurrent myocardial infarction, unstable angina or congestive heart failure necessitating rehospitalization their (9.1%) than in 22 patients included in the treatment regimen between 3 rd and 6th h of the infarction (27.3%). Earlier thrombolysis was also connected with higher left ventricular ejection fraction (55 +/- 8% vs 49 +/- 10%) and more frequent peak CK-MB values 12 hrs after thrombolysis (81% and 68% of patients respectively). Neither symptomatic deep vein thrombosis nor pulmonary embolism was detected. The left ventricular thrombosis was diagnosed by echocardiography in 4 of 20 patients (20%) with the first anterior myocardial infarction. There was neither bleeding requiring blood transfusion nor cerebrovascular stroke. The treatment with Fraxiparine did not induce the prolongation of APTT values. Conjunctive thrombolytic therapy with low molecular weight heparin was safe and followed by a favorable outcome of the acute myocardial infarction, especially if instituted within the first 3 hrs after the onset of infarction.

[Haemostatic defects in venous thromboembolic disease]. / Zaburzenia hemostazy w zylnej chorobie zakrzepowo-zatorowej.

The aim of this study was to assess the frequency of haemostatic defects in 78 patients with the history of venous thromboembolic disease. In all patients antithrombin III activity and in 50 of them protein C, in 53-protein S, in 49 activated protein C (APC) resistance, plasminogen, alfa-2-antiplasmin were measured. We found 35 patients with haemostatic defect: 3 patients with decreased protein C activity and one case with decrease of protein C both activity and antigen level; 15 patients with decreaced antithrombin III activity; 7 patients with decreased free protein S antigen level; 5 patients with APC resistance. In 4 patients we found more than one defect; 2 patients had decreased concentration of free protein S and APC resistance, one patient had decreased activity of both antithrombin III and protein C, one patient had decreased antithrombin III activity and free protein S antigen level. Plasminogen and alfa-2-antiplasmin levels were within the normal range. Family studies indicated hereditary thrombophilia in 6 families. Screening for thrombophilia is very important for the optimal prophylaxis and treatment of venous thromboembolic disease.

[Function of platelets in patients with occlusive atherosclerotic arterial disease of the lower extremities]. / Czynnosc krwinek plytkowych u chorych na miazdzycowe niedokrwienie konczyn dolnych.

The platelet function as well as parameters of lipid metabolism and glucose tolerance were investigated in 30 men with occlusive atherosclerotic arterial disease of the low extremities (IIIB or IV Fontaine's stage). The platelet aggregation, platelet survival, activity of intraplatelet metabolism of arachidonic acid, radiofibrinogen binding to platelet, circulating platelet aggregates and both the activity of factor VIII and the concentration of von Willebrand factor antigen in the plasma were measured. In the majority of patients the impairment of platelet aggregation with ADP, enhancement of radiofibrinogen binding to platelets and an increase of factor VIII level in the plasma were established. There was an interrelationship between platelet dysfunction and disturbances of lipid metabolism. Platelet survival was shortened in patients with moderate hyperlipidemia and correlated with a concentration of HDL-cholesterol in the serum. The radiofibrinogen binding to platelets was the most pronounced in patients with severe hyperlipidemia and correlated with a concentration of total cholesterol in the serum. The results may suggest the potential usefulness of antiplatelet drugs in patients with occlusive atherosclerotic arterial disease.

[Activation of the fibrinolytic system following subcutaneous administration and inhalation of heparin]. / Aktywacja ukladu fibrynolitycznego po podskórnym i wziewnym podaniu heparyny.

Heparin was administered to 113 patients at risk of thrombosis classified to abdominal surgery either alone (subcutaneously or in inhalation) or in combination with anabolic steroid (nandrolone). No pharmaco-prophylaxis was used in 10 patients. On the day of surgery, heparin activated plasma fibrinolytic activity, prior to an introduction to anesthesia. Measurements of euglobulins clot lysis have shown an increase in endogenous fibrinolytic activity dependent and independent on Hageman's factor and an increase in exogenous fibrinolysis, tested after venous stasis was produced. Heparin had profibrinolytic activity, stimulating plasminogen activators in the blood plasma without the signs of hyperplasminemia. Fibrinolytic system response was the same following subcutaneous injection and heparin inhalations. Administration of heparin combined with anabolic steroid has no additional effect on plasma fibrinolytic activity.

[Evaluation of thrombotic risk in young men after myocardial infarction during a period of clinical stability]. / Ocena zagrozenia zakrzepowego u mlodych mezczyzn po zawale serca w okresie klinicznej stabilnosci.

The study was aimed at an evaluation of individualized indications for antithrombotic therapy for secondary prevention in a group of 40 young survivors (aged 30-40 years) of myocardial infarction, presenting a stable phase of coronary disease. The control group consisted of 19 healthy men, of approximately similar age distribution. The determinations concerned the following: in vitro ADP and collagen induced platelet aggregation, plasma fibrinogen concentration, factor VII, VIII and antithrombin III activity, protein C concentration, spontaneous fibrinolytic activity and fibrinolytic activity after venostasis, plasminogen and alpha-2 antiplasmin activity. Moreover, to determine correlations with hemostatic parameters lipids, apolipoproteins, glucose, uric acid plasma concentration as well as percentages of lipoproteins and glycolyzed hemoglobin were also studied. In the study group various hemostasis disturbances were found: an increased platelet aggregation induced by low concentrations of ADP, increased plasma fibrinogen concentration and factor VII activity, decreased protein C concentration and impaired plasma fibrinolytic activity after venostasis. Some correlations between hemostatic and lipids parameters were also observed. Results of the study have suggested necessity for the individualized antithrombotic prevention in young survivors of myocardial infarction with antiplatelet and/or anticoagulant drugs.

[Platelet activation in young men after myocardial infarction: its relation to metabolic coronary risk factors]. / Aktywacja plytek krwi u mlodych mezczyzn po przebytym zawale serca. Zaleznosc od metabolicznych czynników zagrozenia wiencowego.

Selected parameters of platelet function as well as their relationship with metabolic coronary risk factors are studied in a group of 40 young survivors (aged 30-40 years) of myocardial infarction, now presenting stable coronary disease. Nineteen healthy men, of approximately similar age-span, constituted the control group. The following parameters were determined: platelet survival half-time (via non-isotope method), intraplatelet activity of cyclooxygenase and lipoxygenase pathway of arachidonic acid (by measurements of malondialdehyde concentration before and after incubation with acetylsalicylic acid acid) and 125-I-fibrinogen binding to platelets. Moreover, the plasmatic concentration of total cholesterol, HDL-cholesterol, triglycerides, phospholipids, Apo A and B, total beta lipoproteins, glucose, uric acid as well as percentages of beta, prebeta, alpha lipoproteins and glycosylated hemoglobin were also studied. Platelet survival half-time in patients was significantly shortened (3.64 +/- 1.37 days) when compared with the control group (4.97 +/- 1.7 days). A higher intraplatelet activity of lipoxygenase pathway (2.02 +/- 0.62 and 1.49 +/- 0.54 nmol MDA/10(9) platelets, respectively) was also found. However, activity of cyclooxygenase pathway of arachidonic acid and 125-I-fibrinogen binding to platelets remained unchanged. Shortened platelet survival half-time and the hyperactivity of intraplatelet lipoxygenase pathway correlated with a reduced plasmatic concentration of HDL-cholesterol (r = 0.323, p less than 0.05 and r = -0.451, p less than 0.05, respectively). The remaining parameters of platelet function were not statistically related to metabolic risk factors. The values of platelet function indicators in subgroups of patients divided according to family history of coronary heart disease, oral glucose load test result, and submaximal exercise test result did not differ significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparative evaluation of treatment results in advanced multiple myeloma with the help of polychemotherapy with vincristine, doxorubicin, dexamethasone (VAD) or only with dexamethasone]. / Ocena porównawcza wyników leczenia zaawansowanych postaci szpiczaka mnogiego za pomoca polichemioterapii winkrystyna, doksorubicyna i deksametazonem (VAD) oraz wylacznie deksametazonem.

A prospective clinical trial was undertaken to determine the therapeutical effectiveness of multidrug chemotherapy consisting of vincristine, doxorubicin and dexamethasone (VAD) or only high dose of dexamethasone (D) in 56 patients with multiple myeloma (MM). The group of patients included 41 with intermediate (II) and 15 with high (III) tumor mass. The final evaluation was performed in 19 patients treated with D and in 19 receiving VAD regimen. Improvement was defined by at least 50% reduction of serum myeloma protein concentration or disappearance of light chain proteinuria. The VAD regimen was more effective giving improvement in 90% of patients with no prior therapy and in 44% of patients with reflectory myeloma. In this respect, cytoreduction of the same magnitude was noted both in stages II and III. Higher therapeutical effect of VAD regimen was observed independently of the immunological type of MM. The treatment with D has given the improvement in 56% of patients with no previous therapy. Our results support the usefulness of VAD regimen in MM-patients with no prior therapy and with refractory myeloma. High frequency of therapy-related complications, however, indicates that VAD treatment should rather be reserved for the patients with resistant MM.

[Continuous intravenous infusion versus intermittent administration of streptokinase in patients with deep venous thrombosis of the lower extremity]. / Ciagly wlew dozylny i przerywane stosowanie streptokinazy u chorych na zakrzepice zyl glebokich konczyn dolnych.

In a multicenter randomized trial, the efficacy and safety of two streptokinase (SK) dosage regimens have been evaluated in patients with proximal deep vein thrombosis of inferior limbs. Twenty-nine patients received SK by a continuous intravenous infusion (250,000 IU as initial dose, 100,000 IU/h as maintenance dose), and 26 patients were treated with intermittent SK administration (500,000 IU as initial dose, followed by 250,000 IU every 12 h). Thrombolytic therapy was continued for 4 days, then the patients received heparin for 5 days and oral anticoagulant for 3 months. The results of treatment as judged by phlebographic examinations were similar in the two groups. Complete, substantial or partial thrombolysis was achieved in 52% of patients in the continuous infusion group and in 58% of patients in the intermittent treatment group. During SK administration, major bleeding complications occurred in 6 patients treated by continuous infusion and in 2 of the second group. The results showed that the intermittent SK administration is as effective and safe as the method of continuous SK infusion in the treatment of deep vein thrombosis.

[Assessment of hemostasis in patients with myocardial infarction complicated by deep venous thrombosis]. / Ocena ukladu hemostazy u chorych na zawal serca powiklany zakrzepica zyl glebokich konczyn dolnych.

The study was carried out of 53 patients with acute myocardial infarction receiving no anticoagulant treatment. Changes were traced in certain indices of the blood clotting system and fibrinolysis in plasma in the first 14 days of the disease, with particular attention given to patients in whom during the hospitalization signs of deep vein thrombosis in the lower extremities appeared or a positive result was obtained of the test with 125I-fibrinogen. In a group of 9 patients with deep vein thrombosis developing during the observation, on the first day of myocardial infarction shortening of the kaolin-cephalin clotting time and considerable rise of the level of fibrinogen-fibrin (FDP) degradation products were noted in serum, and on the 14th day raised fibrinogen level and reduced exogenous fibrinolytic activity of the plasma were noted. Increased level of fibrinogen and FDP and exogenous and endogenous plasma fibrinolytic activity observed on the 7th day of the disease were not related to the development of thrombotic complications. The thrombin clotting time, platelet count, factor X level, protein C concentration and antithrombin III activity in the plasma were not significantly changed during myocardial infarction. The obtained results suggest a limited usefulness of the basic tests of the clotting and fibrinolytic systems for early diagnosis of deep vein thrombosis in acute myocardial infarction.

Fluctuation of thrombin-antithrombin III complex in patients with acute myocardial infarction: influence of low-dose heparin administration.

The haemostatic parameters were studied within 14 days of acute myocardial infarction (AMI) in 103 patients randomly allocated into a group receiving low-dose heparin or into a group treated without anticoagulants. Patients with isotopic evidence of deep vein thrombosis were excluded from the analysis. An important formation of thrombin-antithrombin III complex (TAT) in the plasma was detected in the early stage of the disease. It was accompanied by an activation of plasma intrinsic fibrinolysis (IF), an elevation of fibrinogen and its degradation products (FDP) and a reduction of extrinsic plasma fibrinolytic activity (EF) together with normal levels of factor X, antithrombin III (AT III), protein C and alpha-2-antiplasmin. Sequentially studies periods of the disease revealed a diminution of TAT complex concentration in the plasma on the seventh day of AMI together with a rise of the both plasma fibrinolytic activities (IF, EF) as well as an elevation of fibrinogen and its degradation products, returning to the initial values on the 14 day of AMI. In the patients treated with heparin the augmentation of TAT complex in the plasma was prolonged until the fifth day of AMI. Moreover, heparin administration was connected with significantly higher levels of AT III and protein C along with a lower concentration of factor X and FDP on the seventh day of the disease. The fluctuation of fibrinolytic activities (IF, EF) in the plasma was heparin-independent. The present results indicate that low-dose heparin treatment modulates the plasmatic fluctuation of TAT complex as well as factor X, AT III and protein C levels in patients with acute myocardial infarction.

Nebulized heparin and anabolic steroid in the prevention of postoperative deep vein thrombosis following elective abdominal surgery.

One hundred eighty three patients, all over 40 years old, who underwent major abdominal surgery, were randomized into 3 groups: Group I received a single dose of nebulized heparin (800 IU per kg b.w.) administered by inhalation one day prior to surgery. Group II besides the above, also received a single injection of 50 mg of long acting anabolic steroid (nandrolone phenylpropionate) intramuscularly. Group III received 5000 IU heparin subcutaneously on hr prior to surgery as well as every 12 h for the next 5 postoperative days. Postoperatively the patients were evaluated for deep vein thrombosis (DVT) using the 125-I-fibrinogen test. The occurrence of DVT was determined as: in Group I--16%, in Group II--7.9%, in Group III--7.8%. Haemorrhagic complications (clinically important) were observed in 7.8% of patients from Group III, but only in 1.7% of patients in Group I and 1.6% in Group II. For DVT prophylaxis following abdominal surgery a single application of nebulized heparin and long acting anabolic steroid is as effective as conventional low-dose subcutaneous heparin administration, but gives less haemorrhagic complications. This method is also more advantagenous in term of acceptance by the patients and represents considerable saving of nursing time.

Low-dose heparin in the prevention of thrombotic complications following acute myocardial infarction.

103 patients with acute myocardial infarction (AMI), disqualified for thrombolytic treatment, were randomized into two groups. Group I received 5000 IU of heparin (subcutaneously, twice daily) for 14 to 21 days. Group II was without anticoagulant prophylaxis. Patients were evaluated for deep vein thrombosis (DVT) using radiofibrinogen uptake test and for the presence of intracardiac mural thrombus (ICT) by two-dimensional echocardiography (50 patients). The incidence of DVT was 4% in group I and 19% in group II. ICT was diagnosed in three patients (13%) of group I and in 10 patients (45%) of group II. Five patients under heparin prophylaxis and 6 non-anticoagulant patients died in the hospital of cardiac causes. There were no bleeding complications. Low-dose heparin seems to be an effective prophylaxis of thrombotic complications in patients with AMI.

Kinetics of radiolabelled (99mTc) heparin and low molecular weight heparin fractions CY 216, CY 222 in patients with uncomplicated myocardial infarction.

Kinetics of plasmatic disappearance of radiolabelled (99mTc) heparin (Choay, Mr mean 15,000) and low molecular weight heparin (LMWH) fraction CY 216 (Choay, Mr mean 5,000) and CY 222 (Choay, Mr mean 4,000) was compared in 2 women and 8 men (aged 50-71, mean 65 years) with uncomplicated myocardial infarction. The three technetiated heparins were consecutively injected intravenously (67 nanomoles) to each of 10 patients, at intervals of 3-5 days, 14-28 days after acute cardiac onset. The plasma radioactivity was counted in blood samples collected within a period of 5 h. Radiolabelled heparin and LMWH fractions CY 216, CY 222 disappeared from plasma following a biexponential clearance curve with a fast and slow component reflecting the biodistribution (alpha) and elimination (beta) phase. The bioavailability values (AUC, t0.5 alpha, t0.5 beta) as well as distribution and elimination rates were similar for all three technetiated heparins. The bulk of injected 99mTc-heparin or LMWH fraction was rapidly distributed to the tissular compartment (t0.5 alpha = 13 min), whereas the radiocomplex remaining in the circulation was slowly eliminated with a half-time (t0.5 beta) of an average 320 min. Radioactivity eliminated from plasma was only partially (30-50%) excreted in the urine. The results indicate that after a low-dose intravenous administration LMWH fractions CY 216 and CY 222 maintain the pharmacokinetics properties of standard heparin, especially the rapid distribution to the tissular compartment.

Binding of heparin to human endothelial cell monolayer and extracellular matrix in culture.

Endothelial binding of heparin contributes to its local antithrombotic action and catabolism. However, it is uncertain whether heparin may be bound to a damaged or even de-endothelialized vessel surface. Therefore, the binding of 3H-heparin to cultured endothelial cell monolayer and extracellular matrix was studied. The binding reached equilibrium after 4 h. 3H-heparin bound to endothelium could be displaced by unlabelled heparin which competed for about 80% of binding. The binding became saturable when the concentration of heparin exceeded 30-times the therapeutical value. Approximately 6 X 10(11) binding sites for heparin per cm2 of endothelium were calculated. Heparin was bound not only to endothelial cells but also to extracellular matrix, even when it was exposed in the absence of cells. About 40% of binding sites were localized in the extracellular matrix fraction. A similar affinity of binding of 3H-heparin to complete endothelium, endothelial cells and extracellular matrix was estimated /Kd of almost 1 microM/. The binding of heparin to extracellular matrix should be considered in the interpretation of heparin interaction with endothelium.