Blood coagulation and the risk of atherothrombosis: a complex relationship

Abstract

The principles of Virchov's triad appear to be operational in atherothrombosis or arterial thrombosis: local flow changes and particularly vacular wall damage are the main pathophysiological elements. Furthermore, alterations in arterial blood composition are also involved although the specific role and importance of blood coagulation is an ongoing matter of debate. In this review we provide support for the hypothesis that activated blood coagulation is an essential determinant of the risk of atherothrombotic complications. We distinguish two phases in atherosclerosis: In the first phase, atherosclerosis develops under influence of "classical" risk factors, i.e. both genetic and acquired forces. While fibrinogen/fibrin molecules participate in early plaque lesions, increased activity of systemic coagulation is of no major influence on the risk of arterial thrombosis, except in rare cases where a number of specific procoagulant forces collide. Despite the presence of tissue factor - factor VII complex it is unlikely that all fibrin in the atherosclerotic plaque is the direct result from local clotting activity. The dominant effect of coagulation in this phase is anticoagulant, i.e. thrombin enhances protein C activation through its binding to endothelial thrombomodulin.The second phase is characterized by advancing atherosclerosis, with greater impact of inflammation as indicated by an elevated level of plasma C-reactive protein, the result of increased production influenced by interleukin-6. Inflammation overwhelms protective anticoagulant forces, which in itself may have become less efficient due to down regulation of thrombomodulin and endothelial cell protein C receptor (EPCR) expression. In this phase, the inflammatory drive leads to recurrent induction of tissue factor and assembly of catalytic complexes on aggregated cells and on microparticles, maintaining a certain level of thrombin production and fibrin formation. In advanced atherosclerosis systemic and vascular wall driven coagulation becomes more important and elevated levels of D-dimer fragments should be interpreted as markers of this hypercoagulability.

Figure 1

The initiation of an atherosclerotic lesion is characterized by retention of LDL and subsequent oxidative modification (oxLDL) within the matrix of the vascular intima. Stimulation of the overlying endothelial cells by oxLDL recruits monocytes from the circulation to the vessel wall. Differentiation of monocytes into macrophages and scavenger receptor mediated uptake of oxLDL aggregates results in the formation of foam-cells. Upon stimulation vascular smooth muscle cells (VSMC) migrate and proliferate. Tissue factor is expressed on macrophages and VSMCs within the advanced lesion and is likely to be involved in the conversion of accumulated fibrinogen into fibrin, although fibrin polymerization can be facilitated by other enzymes than thrombin. Furthermore, VSMCs and macrophage derived apoptotic bodies exposing TF probably contribute in thrombin formation. Considering atherosclerosis as a chronic inflammation, the inflammatory drive leads to IL-6 induced TF expression of circulating monocytes and the formation of microparticle exposing TF in the circulation, maintaining a certain level of thrombin production and fibrin formation. Increased circulating D-dimer levels are thus the result of fibrin proteolysis in both circulation and the advanced atherosclerotic lesion.