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Prepublished online as a Blood First Edition Paper on June 21, 2002; DOI 10.1182/blood-2002-05-1470.
HEMOSTASIS, THROMBOSIS, AND VASCULAR BIOLOGY
From the Cardiovascular Research Institute, Department
of Medicine, and Department of Cellular and Molecular Pharmacology,
University of California, San Francisco.
The recent observation that knock-out of protease-activated
receptor-4 (PAR4) ablates thrombin signaling in mouse platelets and
protects against ferric chloride-induced thrombosis of mouse mesenteric arterioles suggests that thrombin's actions on platelets can play an important role in thrombosis. Complete ablation of thrombin
signaling would be difficult to achieve in human beings because human
platelets have 2 thrombin receptors that are each capable of mediating
transmembrane signaling. However, it is possible that complete ablation
of thrombin signaling in platelets is not necessary for an
antithrombotic effect. In mouse platelets, PAR3 functions as a cofactor
that binds thrombin and promotes productive cleavage of PAR4, and
thrombin responses are decreased but not absent in
Par3 Thrombosis of the arteries that supply the heart,
brain, and other vital organs remains a major cause of morbidity and
mortality, and platelet activation plays a central role in this
process. The coagulation protease thrombin is a potent activator of
platelets, but multiple other agonists can serve this function.
Thrombin's actions on platelets are mediated by protease-activated
receptors (PARs), and we recently showed that complete ablation of
thrombin signaling in mouse platelets by knock-out of PAR4 protected
against ferric chloride-induced mesenteric arteriolar
thrombosis.1 Thus, despite the multiplicity of platelet
agonists, thrombin's actions on platelets can be important for thrombosis.
In human platelets, PAR1 and PAR4 both contribute to thrombin
responsiveness.2 Substantial inhibition of thrombin
signaling in human platelets can be achieved by blocking PAR1 function, but in the absence of PAR1 function, PAR4 can mediate platelet activation in response to high concentrations of
thrombin.2 The presence of 2 thrombin receptors implies
that complete inhibition of thrombin responses in human platelets would
be difficult to achieve pharmacologically, but it is possible that the
partial inhibition might be sufficient for an antithrombotic effect. To further explore the role of thrombin signaling in platelets in thrombosis and to determine whether partial inhibition of thrombin signaling in platelets might be sufficient to protect against thrombosis, we utilized Par3 Mouse lines
Ferric chloride-induced mesenteric thrombosis
Thromboplastin-induced pulmonary embolism We utilized a model similar to those recently described.6,7 The thromboplastin (ThromboMax plus Calcium; Sigma, St Louis, MO) used for these studies was from rabbit brain. The International Sensitivity Index (ISI) for the lot used was 1.78 and 1.73 as determined by the manufacturer by mechanical and optical methods, respectively. Each vial of thromboplastin was resuspended in 40 mL saline (instead of the 10 mL water recommended by the manufacturer), and 5 µL/g of this solution was injected per mouse as below. This dose was chosen such that about 25% of wild-type female mice survived the protocol.Female mice were used because preliminary studies revealed a
sex difference in sensitivity to thromboplastin. Female
littermate offspring from Par3+/ Two minutes after onset of respiratory arrest (but while the heart was
still beating) or at the completion of the 30-minute observation
period, mice were perfused via the inferior vena cava with 0.5 mL Evans
blue solution (1% in saline). Lungs were excised en bloc,
photographed, and fixed in 4% paraformaldehyde for later sectioning.
Two independent observers, each blind to genotype and survival outcome,
scored lungs for Evans blue perfusion defects using the scale shown
(Figure 2C). To assess the correlation of gross perfusion defects with
intravascular thrombi, histologic analysis was performed on 3 hematoxylin and eosin-stained sections of lung from each of 5 mice for
each perfusion score. In addition, lungs from 9 wild-type and 9 Par3 Studies of the effect of PAR4 deficiency in this model were performed as above. Bleeding times Tail bleeding times were measured as described.1 Briefly, littermate offspring of Par3+/
crosses, aged 24 to 31 days, were anesthetized with a mixture of
ketamine and xylazine, and tails were transected 5 mm from the tip with
a scalpel blade. The amputated segment was saved for genotyping. The
bleeding end was immersed in saline at 37°C, and time to cessation of
flow (stoppage for more than 30 seconds) was measured. Assays were
terminated at 10 minutes and were done blind to genotype. This method
differs from that used in the original PAR3 bleeding time
study,3 in which tails were transected only 0.5 to 1 mm
from the tip in awake mice.
Statistics The effects of genotype on the fraction of arterioles patent (Figure 1), mice surviving (Figure 2), or tails bleeding (Figure 3) as a function of time and at the end of the study were assessed using the log-rank and 2 tests, respectively.8
We first examined Par3 We next directly compared the effects of PAR3 and PAR4 deficiency in a
second thrombosis model In addition to the hard end point of death, we assessed the degree of
vascular occlusion in the lungs of thromboplastin-challenged mice by
perfusion with Evans blue solution and by histology (Figure 2C-F).
Normal lungs turned completely blue upon perfusion, lungs with complete
occlusion of the pulmonary arteries remained pink, and lungs with
segmental or lobar defects showed a mixed pattern (Figure 2C). As
expected, perfusion defect score (Figure 2C,D) was inversely correlated
with survival (data not shown) and positively correlated with the
number of intravascular thrombi seen in histologic sections (for
example, Figure 2E,F). Par3 The similar levels of protection against thrombosis associated with
PAR3 versus PAR4 deficiency was curious in light of our initial
characterization of hemostasis in these mice.1,3 While
neither PAR3- nor PAR4-deficient mice were anemic or showed signs of
spontaneous bleeding, no prolongation of bleeding times was found in
Par3
The finding that PAR3 deficiency yielded protection in 2 mouse models of thrombosis and prolonged tail bleeding times is, to our knowledge, the first demonstration that PAR3 function is important in vivo. In an in situ hybridization survey, PAR3 expression was detected in megakaryocytes (where it is coexpressed with PAR4) but not in blood vessels themselves.9 This restricted expression pattern suggests that the effect of PAR3 deficiency on thrombosis and hemostasis is likely due to its effects on the thrombin responses in platelets rather than other cell types. The mechanism by which PAR3 promotes platelet activation is unusual among G protein-coupled receptors in that it functions as a cofactor or coreceptor for thrombin rather than as a bona fide transmembrane signaling molecule.1,4 Our results provide the first evidence that PAR3's peculiar cofactor role in thrombin signaling is important for platelet function in vivo. The observation that even the partial attenuation of thrombin signaling
caused by PAR3 deficiency had dramatic effects in 2 thrombosis
models How is it that attenuated thrombin signaling in platelets
protects against thrombosis given the many potentially redundant pathways involved? In general, the decision to form a clot or a
thrombus reflects a change in the kinetic balance of multiple positive
and negative regulatory pathways.10 In the thromboplastin model, it is likely that thrombin is the initiator of platelet activation, and it is possible that thrombin plays an initiating role
in the ferric chloride injury model. In this case, diminished or
delayed direct platelet aggregation by thrombin and/or diminished or
delayed release of adenosine diphosphate (ADP)6,11
and other amplifiers of platelet activation may slow platelet
incorporation into thrombi sufficiently to account for the protection
against thrombosis conferred by PAR3 deficiency. Interruption of a
positive feedback loop between platelet activation and thrombin
generation might also contribute to the relatively profound effect of
PAR3 deficiency in thrombosis models. Activated platelets and
platelet-derived microparticles provide a favorable surface for the
assembly of coagulation factor complexes; this platelet procoagulant
activity contributes to hemostasis by accelerating local thrombin
generation.10,12,13 The weaker, slower signaling seen in
Par3 The observation that PAR3 deficiency in mice protects against thrombosis but has a relatively mild effect on hemostasis raises the question of whether PAR1 inhibition should be considered as a possible antithrombotic strategy in human beings. In both PAR1-inhibited human platelets and PAR3-deficient mouse platelets, residual platelet responses to thrombin appear to be mediated by PAR4 and, perhaps as a consequence, thrombin responses are remarkably similar.2,3 Human and mouse platelets normally aggregate and secrete their granule constituents in response to 1 to 3 nM thrombin; these responses are virtually absent in both PAR1-inhibited human platelets and PAR3-deficient mouse platelets. At 10 to 30 nM thrombin, PAR1-inhibited human platelets and PAR3-deficient mouse platelets do aggregate and secrete, but such responses are delayed and variably diminished. For example, time to half-maximal adenosine triphosphate (ATP) secretion in response to 30 nM thrombin was about 5 seconds in normal human and mouse platelets but was about 20 seconds in both PAR1-inhibited human and PAR3-deficient mouse platelets.2,3 PAR1 inhibition in human platelets and PAR3 deficiency in mouse platelets also had similar effects on thrombin-induced increases in cytoplasmic calcium (E.J.W. and S.R.C., unpublished data, March 2001). Such functional similarities suggest that, to the extent that mouse thrombosis models are relevant to human beings, blockade of PAR1 might be sufficient to achieve an antithrombotic effect despite the fact that human platelets have 2 thrombin receptors. A small nonhuman primate study supports this hypothesis: Administration of a polyclonal PAR1 antiserum reduced or abolished platelet-dependent cyclic flow variations in the carotid artery in 4 African green monkeys.14 While the latter study suggests that thrombin signaling in platelets might play a relatively important role in primate as well as mouse thrombosis models, there are, of course, noteworthy differences between these models and human thrombotic diseases. The ferric chloride-induced thrombosis model followed injury-induced thrombosis in an arteriole, not arterial thrombosis overlying a ruptured atherosclerotic plaque. The primate study cited above14 examined normal, not atherosclerotic, arteries. The mouse pulmonary embolism model used intravenous thromboplastin; how this relates to embolism of deep venous thrombi caused by stasis or trauma in human beings is unknown. We hope that the current genetic study in mice will, in the context of the previous primate study14 and our present knowledge of species differences in platelet thrombin receptors,1-4 stimulate efforts to develop potent small-molecule PAR1 antagonists or avid blocking monoclonal antibodies. Such reagents will be required to permit more robust exploration of the possible utility of PAR1 inhibition for the prevention and treatment of thrombosis in relevant models.
S.R.C. is an inventor on patents that are related to PAR1. These patents are owned by the Regents of the University of California.
Submitted May 20, 2002; accepted June 10, 2002.
Prepublished online as Blood First Edition Paper, June 21, 2002; DOI 10.1182/blood-2002-05-1470.
Supported in part by NIH HL59202, HL65185, and HL44907 (S.R.C.). J.R.H. was supported by a C. J. Martin Fellowship (no. 166904) from the National Health and Medical Research Council of Australia. K.E.L. was supported by a Sarnoff Foundation Fellowship.
E.J.W. and J.R.H. contributed equally to this work.
The publication costs of this article were defrayed in part by page charge payment. Therefore, and solely to indicate this fact, this article is hereby marked "advertisement" in accordance with 18 U.S.C. section 1734.
Reprints: Shaun R. Coughlin, University of California, San Francisco, 513 Parnassus Ave, Room HSE-1300, San Francisco, CA 94143-0130; e-mail: coughlin{at}cvrimail.ucsf.edu.
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