This document discusses the concept of vulnerable blood and its role in atherosclerosis and atherothrombosis. It notes that vulnerable lesions play a critical role in acute coronary syndrome onset. These lesions are focal episodes compared to the diffuse nature of atherothrombosis. Several risk factors are associated with hyperreactive or vulnerable blood, including diabetes, smoking, and inflammation. Elevated tissue factor activity in the blood has been linked to cardiovascular risk factors and events. Improved glycemic control can reduce blood thrombogenicity in diabetics. The relationship between inflammation, thrombosis, and atherosclerosis is explored.

1. The Cardiovascular Institute
Mount Sinai School of Medicine, New York
Concept ofConcept of
Vulnerable BloodVulnerable Blood
Juan Jose Badimon, Ph.DJuan Jose Badimon, Ph.D
Director,Cardiovascular BiologyDirector,Cardiovascular Biology
Research LaboratoryResearch Laboratory
Professor of MedicineProfessor of Medicine
IXth VP Symposium (AHA 2005)IXth VP Symposium (AHA 2005)
November 12th, 2005November 12th, 2005
Dallas, TXDallas, TX

2. Atherosclerosis vs Atherothrombosis
Atherosclerosis ProgressionAtherosclerosis Progression AtherothrombosisAtherothrombosis

3. ““Vulnerable“Vulnerable“ lesions play a criticallesions play a critical
role in the onset of ACS.role in the onset of ACS.
Atherothrombosis is aAtherothrombosis is a diffusediffuse
disease while “disease while “Vulnerable“Vulnerable“ lesionslesions
areare “focal“focal”” episodes.episodes.
Do disruptedDo disrupted VulnerableVulnerable lesionslesions
Always trigger an ACS?Always trigger an ACS?

4. CULPRIT LESION VS. DIFUSE DISEASECULPRIT LESION VS. DIFUSE DISEASE
One single culprit lesion but multipleOne single culprit lesion but multiple
plaque ruptures in the same patientplaque ruptures in the same patient 11
..
The difuse disease may be responsibleThe difuse disease may be responsible
for the widespread coronaryfor the widespread coronary
inflammation observed in UAinflammation observed in UA22
11
Rioufol G. Circ.2002;106:804-808Rioufol G. Circ.2002;106:804-808 22
Buffon A, NEJMBuffon A, NEJM
2002;347:5-122002;347:5-12
Multiple complex coronaryMultiple complex coronary
plaques in AMI patients.plaques in AMI patients.
Goldstein JA NEJM 2000;343:915Goldstein JA NEJM 2000;343:915

5. ++++++++++++PeripheralsPeripherals
++++++++++CarotidsCarotids
++++++++++++CoronariesCoronaries
BloodBlood
thrombogenicitythrombogenicity
RheologyRheologyPlaquePlaque
DisruptionDisruption
Virchow’s Triad and Arterial BedsVirchow’s Triad and Arterial Beds

6. Vulnerable (High-risk) PlaqueVulnerable (High-risk) Plaque
++
==
High-RiskHigh-Risk (Vulnerable)(Vulnerable) PatientPatient
Plaque - Blood - High Risk PatientPlaque - Blood - High Risk Patient
Vulnerable (High-Risk) BloodVulnerable (High-Risk) Blood

7. ““ Vulnerable /Hyper-reactive” BloodVulnerable /Hyper-reactive” Blood
Several risk factors correlate with hyperreactive blood. These factorsSeveral risk factors correlate with hyperreactive blood. These factors
may contribute to the clinical presentation after plaque disruptionmay contribute to the clinical presentation after plaque disruption
““Classic”Classic”
Diabetes Smoking Hyperlipidemia
Inflammation/ Apoptosis/ Infection? Cathecholamines
Fibrinogen Lp(a) Homocysteinemia
Factor V Leiden Platelet polymorph Shear rate
Genetic Protein deficiencies (AT III, Prot C or S)
Hypercoagulable state (↑FVII, ↑ F1.2, ↑ FPA)
Hypofibrinolytic state (↑PAI-1, ↓t-PA, ↓ u-PA)
““Not so-classic”Not so-classic”
DepressionDepression Circulating TF activityCirculating TF activity StressStress

8. BLOOD BORNE - TISSUE FACTORBLOOD BORNE - TISSUE FACTOR
Giesen P et al.Giesen P et al.
PNAS 1999; 96:2311PNAS 1999; 96:2311
Thrombus formation isThrombus formation is
inhibited by theinhibited by the
systemic administrationsystemic administration
of an anti-TF antibodyof an anti-TF antibody

9. Tissue Factor:Tissue Factor:
a key player for thrombosis and inflammationa key player for thrombosis and inflammation
Juno, the two-faced GodJuno, the two-faced God
Vessel Wall TFVessel Wall TF Circulating TFCirculating TF

10. Diabetes and Blood ThrombogenicityDiabetes and Blood Thrombogenicity
Rauch U et al. Am J Cardiol 2000; 86:246Rauch U et al. Am J Cardiol 2000; 86:246

12. Probability of CV Event in theProbability of CV Event in the nextnext 5 Years5 Years
No DiabetesNo Diabetes
Men Women
4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8
180/105
160/95
140/85
120/75
180/105
160/95
140/85
120/75
180/105
160/95
140/85
120/75
Age
70
Age
60
Age
50
Nonsmoker Smoker Nonsmoker Smoker
Total Chol.: HDL Chol. Total Chol.: HDL Chol.
> 20%> 20%
15% - 20%15% - 20%
10% - 15%10% - 15%
5% - 10%5% - 10%
2.5% - 5%2.5% - 5%
< 2.5%< 2.5%
P. Deedwania at the 2002P. Deedwania at the 2002

13. 180/105
160/95
140/85
120/75
180/105
160/95
140/85
120/75
180/105
160/95
140/85
120/75
DiabetesDiabetes
Men Women
4 5 6 7 8 4 5 6 7 8 4 5 6 7 8 4 5 6 7 8
Age
70
Age
60
Age
50
Nonsmoker Smoker Nonsmoker Smoker
Total Chol.: HDL Chol. Total Chol.: HDL Chol.
> 20%> 20%
15% - 20%15% - 20%
10% - 15%10% - 15%
5% - 10%5% - 10%
2.5% - 5%2.5% - 5%
< 2.5%< 2.5%
Probability of CV Event in the next 5 YearsProbability of CV Event in the next 5 Years
P. Deedwania at the 2002P. Deedwania at the 2002

14. Risk factors and circulating TF activityRisk factors and circulating TF activity
Control Smokers Hyperlipidemic Diabetics
0
100
200
300
400
500
TissueFactoractivity
(pmolFXa/L)
Sambola A. Circulation 2003; 107: 973-979

15. BloodThrombogenicityBloodThrombogenicity
CirculatingTFactivityCirculatingTFactivity
Glycemic ImprovementGlycemic Improvement
No Glycemic ImprovementNo Glycemic Improvement
Glycemic Control & Blood ThrombogenicityGlycemic Control & Blood Thrombogenicity
Sambola Circ. 2003Sambola Circ. 2003

16. monocyte
TF PMN
BLOOD
VESSEL WALL
AT plaque
SMC
lipid core
macrophage
fibroblast
myocyte
HEART
myocardial
ischemia
TF Circulates in Blood: Possible Cellular Sources
EndothelialEndothelial
cellcell

17. Circulating TF activity and Cardiovascular DiseasesCirculating TF activity and Cardiovascular Diseases
Several studies have associated high levels of plasma TF activitySeveral studies have associated high levels of plasma TF activity
with severity of atherosclerosis, certain cardiovascular risk factorswith severity of atherosclerosis, certain cardiovascular risk factors
and events.and events. Tan K Thromb Haemost. 2005Tan K Thromb Haemost. 2005
Tissue Factor ActivityTissue Factor Activity
CellularCellular SystemicSystemic
asTFasTF MicroparticlesMicroparticles
platelets apoptotic cellsplatelets apoptotic cellsWBC’s origin???WBC’s origin???

18. Inflammation Thrombosis
Atherosclerosis
ApoptosisApoptosis Tissue factorTissue factor
micro-particlesmicro-particles
Aggregated Platelets
PDGF
Thrombin
IL-6
TF
MMP
ICAM-1
IL-1
CVRisk
Factors
ACS
The Inflammation-ThrombosisThe Inflammation-Thrombosis LinkLink
Clinical evidence: Septic shockClinical evidence: Septic shock
Inflammation subsequent to bacterial endotoxin induces endothelialInflammation subsequent to bacterial endotoxin induces endothelial
TF and PAI-1 expression leading to thrombotic complications (DIC)TF and PAI-1 expression leading to thrombotic complications (DIC)
CD40L/CRPCD40L/CRP

19. Caspase-3 and TFCaspase-3 and TF
Co-localization inCo-localization in
Lipid-Rich Area ofLipid-Rich Area of
Human AtheromaHuman Atheroma
Hutter R, Badimon J et al, Circulation, 2004;109:2001Hutter R, Badimon J et al, Circulation, 2004;109:2001

20. Inflammatory Cytokines Release Soluble TF from HUVECInflammatory Cytokines Release Soluble TF from HUVEC
CONTROLCONTROL
TNFTNF αα
IL-6IL-6
asTFasTF NucleusNucleus ComboCombo
Incubation time : 6 hoursIncubation time : 6 hours Szotowski B et al. Circ Res 2005; 96: 1233Szotowski B et al. Circ Res 2005; 96: 1233

21. QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.
asTFasTF participatesparticipates
in the growth andin the growth and
maintainance ofmaintainance of
acute thrombosisacute thrombosis
Bogdanov et al. Nature Med 2003Bogdanov et al. Nature Med 2003

22. Independently of its source, the more important issueIndependently of its source, the more important issue
is to define the pathophysiologic role of high levelsis to define the pathophysiologic role of high levels
of circulating TF:of circulating TF:
Do they have aDo they have a “predictive”“predictive” value for CVD events?value for CVD events?
Do they play aDo they play a “causative”“causative” role on the severity ofrole on the severity of
CVD events by modulating the magnitude of theCVD events by modulating the magnitude of the
thrombotic response to plaque disruption??thrombotic response to plaque disruption??
Several methodological factors such as difficulty,Several methodological factors such as difficulty,
time consuming and use of different antibodiestime consuming and use of different antibodies
complicates the responses to the above questions.complicates the responses to the above questions.

23. F XF X
F IxaF Ixa
F VIIIaF VIIIa
ProthrombinProthrombin
F XaF Xa
Tenase complexTenase complex
ThrombinThrombin
Prothrombinase complexProthrombinase complex
F XaF Xa
F VaF Va
F VIIaF VIIa
Tissue factorTissue factor
Potential therapeutic targetsPotential therapeutic targets
TF: FVIIaTF: FVIIa
FXaFXa
ThrombinThrombin

24. Platelet-derived growth factorPlatelet-derived growth factor RANTES (CCL5)RANTES (CCL5)
CD 40LCD 40L ENA-78 (CXCL5)ENA-78 (CXCL5)
ThrombospondinThrombospondin MIP (CCL3)MIP (CCL3)
Platelet activating factor (PAF)Platelet activating factor (PAF) Platelet factor IV (CXCL4)Platelet factor IV (CXCL4)
Platelet Activation - Plaque Stability - InflammationPlatelet Activation - Plaque Stability - Inflammation
Exposure of monocytes to PAF and P-selectin activates NFKBExposure of monocytes to PAF and P-selectin activates NFKB

25. Life-styleLife-style
StatinsStatins
AntiplateletsAntiplatelets
AnticoagulantsAnticoagulants
etcetc
Life-styleLife-style
StatinsStatins
ACE’sACE’s
ARB’sARB’s
Hypoglicemics,Hypoglicemics,
HDL-raisers,HDL-raisers,
etcetc
High-Risk PatientHigh-Risk Patient
Vulnerable PlaqueVulnerable Plaque
Vulnerable BloodVulnerable Blood
++
==
High-Risk PatientHigh-Risk PatientHigh-Risk PatientHigh-Risk Patient

26. QuickTime™ and a
TIFF (LZW) decompressor
are needed to see this picture.

27. Alternatively spliced Tissue FactorAlternatively spliced Tissue Factor
 Spliced TFSpliced TF contains most of the extracellular domain of TFcontains most of the extracellular domain of TF
 Lacks a transmembrane domainLacks a transmembrane domain
 Terminates with an unique peptide sequenceTerminates with an unique peptide sequence
 Soluble and circulates in bloodSoluble and circulates in blood
 Exhibits pro-coagulant activity (exposed to PL)Exhibits pro-coagulant activity (exposed to PL)
 Is incorporated into thrombiIs incorporated into thrombi
Bogdanov et al. Nature Med 2003Bogdanov et al. Nature Med 2003
PlateletsPlatelets asTFasTF