Relationship between ‘on-treatment platelet reactivity’, shear stress, and micro-embolic signals in asymptomatic and symptomatic carotid stenosis
Assessment of ‘high on-treatment platelet reactivity (HTPR)’ could enhance understanding of the pathophysiology of first or recurrent vascular events in carotid stenosis patients on antiplatelet therapy.
This prospective, multi-centre study assessed antiplatelet–HTPR status and its relationship with micro-emboli signals (MES) in asymptomatic vs. symptomatic ≥ 50–99% carotid stenosis. Platelet function/reactivity was assessed under ‘moderately high shear stress’ with the PFA-100® and ‘low shear stress’ with VerifyNow® and Multiplate® analysers. Bilateral 1-h transcranial Doppler ultrasound of the middle cerebral arteries classified patients as MES + ve or MES − ve.
Data from 34 asymptomatic patients were compared with 43 symptomatic patients in the ‘early phase’ (≤ 4 weeks) and 37 patients in the ‘late phase’ (≥ 3 months) after TIA/ischaemic stroke. Median daily aspirin doses were higher in early symptomatic (225 mg; P < 0.001), but not late symptomatic (75 mg; P = 0.62) vs. asymptomatic patients (75 mg). There was a lower prevalence of aspirin–HTPR in early (28.6%; P = 0.028), but not late symptomatic (38.9%; P = 0.22) compared with asymptomatic patients (56.7%) on the PFA-100®, but not on the VerifyNow® or Multiplate® (P ≤ 0.53). Early symptomatic patients had a higher prevalence of aspirin–HTPR on the PFA-100® (28.6%) vs. VerifyNow® (9.5%; P = 0.049), but not Multiplate® assays (11.9%, P = 0.10). There was no difference in aspirin–HTPR prevalence between any symptomatic vs. asymptomatic MES + ve or MES − ve subgroup.
Recently symptomatic moderate–severe carotid stenosis patients had a lower prevalence of aspirin–HTPR than their asymptomatic counterparts on the PFA-100®, likely related to higher aspirin doses. The prevalence of antiplatelet–HTPR was positively influenced by higher shear stress levels, but not MES status.
KeywordsCarotid stenosis Platelet function High on-treatment platelet reactivity Transcranial Doppler ultrasound Micro-embolic signals
All HEIST collaborators qualified for authorship as they contributed to data acquisition or study design, and all critically appraised the manuscript for important intellectual content. Dr Murphy’s research was funded by the Trinity College Dublin Innovation Bursary, the Meath Foundation, Ireland, Joint IICN/Merck Serono Fellowship in Neuroscience, The Vascular Neurology Research Foundation, Ireland, and by an unrestricted educational grant from Bayer HealthCare Ireland, and Verum Diagnostica, GmbH. Dr. Lim’s research was funded by the Meath Foundation, Ireland, The Irish Institute of Clinical Neuroscience (IICN)/Novartis Ireland Fellowship Grant, The Irish Heart Foundation Stroke Prevention Bursary, and by unrestricted educational grant funding from Biogen Idec Ireland. None of the above charities or funding bodies had any influence on design or conduct of this study, or had any influence on the decision to submit the final manuscript for publication. All authors critically reviewed and approved the final submitted manuscript. The manuscript has not been submitted elsewhere and has not been published elsewhere in whole or in part, except as an abstract.
Compliance with ethical standards
Conflicts of interest
This study been approved by the local ethics committee and has, therefore, been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. All persons gave their written informed consent prior to their inclusion in the study. The authors declare that they have no conflicts of interest.
- 1.McCabe DJ, Harrison P, Mackie IJ, Sidhu PS, Purdy G, Lawrie AS, Watt H, Brown MM, Machin SJ (2004) Platelet degranulation and monocyte-platelet complex formation are increased in the acute and convalescent phases after ischaemic stroke or transient ischaemic attack. Br J Haematol 125(6):777–787. https://doi.org/10.1111/j.1365-2141.2004.04983.x CrossRefPubMedGoogle Scholar
- 2.McCabe DJ, Harrison P, Mackie IJ, Sidhu PS, Purdy G, Lawrie AS, Watt H, Machin SJ, Brown MM (2005) Increased platelet count and leucocyte-platelet complex formation in acute symptomatic compared with asymptomatic severe carotid stenosis. J Neurol Neurosurg Psychiatry 76(9):1249–1254. https://doi.org/10.1136/jnnp.2004.051003 CrossRefPubMedPubMedCentralGoogle Scholar
- 3.McCabe DJ, Harrison P, Mackie IJ, Sidhu PS, Lawrie AS, Purdy G, Machin SJ, Brown MM (2005) Assessment of the antiplatelet effects of low to medium dose aspirin in the early and late phases after ischaemic stroke and TIA. Platelets 16(5):269–280. https://doi.org/10.1080/09537100400020567 CrossRefPubMedGoogle Scholar
- 5.Tobin WO, Kinsella JA, Coughlan T, Collins DR, O’Neill D, Murphy RP, Egan B, Tierney S, Feeley TM, McCabe DJ (2013) High on-treatment platelet reactivity on commonly prescribed antiplatelet agents following transient ischaemic attack or ischaemic stroke: results from the Trinity Antiplatelet Responsiveness (TRAP) study. Eur J Neurol 20(2):344–352. https://doi.org/10.1111/j.1468-1331.2012.03861.x CrossRefPubMedGoogle Scholar
- 6.Cha JK, Jeong MH, Jang JY, Bae HR, Lim YJ, Kim JS, Kim SH, Kim JW (2003) Serial measurement of surface expressions of CD63, P-selectin and CD40 ligand on platelets in atherosclerotic ischemic stroke. A possible role of CD40 ligand on platelets in atherosclerotic ischemic stroke. Cerebrovasc Dis 16(4):376–382CrossRefGoogle Scholar
- 7.Kinsella JA, Tobin WO, Tierney S, Feeley TM, Egan B, Collins DR, Coughlan T, O’Neill D, Harbison J, Madhavan P, Moore DJ, O’Neill SM, Colgan MP, Doherty CP, Murphy RP, Saqqur M, Moran N, Hamilton G, McCabe DJ (2013) Increased platelet activation in early symptomatic vs. asymptomatic carotid stenosis and relationship with microembolic status: results from the Platelets and Carotid Stenosis Study. J Thromb Haemost 11(7):1407–1416. https://doi.org/10.1111/jth.12277 CrossRefPubMedGoogle Scholar
- 8.Lukasik M, Rozalski M, Luzak B, Michalak M, Ambrosius W, Watala C, Kozubski W (2013) Enhanced platelet-derived microparticle formation is associated with carotid atherosclerosis in convalescent stroke patients. Platelets 24(1):63–70. https://doi.org/10.3109/09537104.2011.654292 CrossRefPubMedGoogle Scholar
- 10.Murphy SJX, Lim ST, Kinsella JA, Tierney S, Egan B, Feeley TM, Murphy SM, Walsh RA, Collins DR, Coughlan T, O’Neill D, Harbison JA, Madhavan P, O’Neill SM, Colgan MP, Cox D, Moran N, Hamilton G, McCabe DJH (2019) Increased leucocyte-platelet complex formation in recently symptomatic versus asymptomatic carotid stenosis patients and in micro-emboli negative subgroups. Thromb Haemost 119(5):821–833. https://doi.org/10.1055/s-0039-1678666 CrossRefPubMedGoogle Scholar
- 12.Naylor AR, Ricco JB, de Borst GJ, Debus S, de Haro J, Halliday A, Hamilton G, Kakisis J, Kakkos S, Lepidi S, Markus HS, McCabe DJ, Roy J, Sillesen H, van den Berg JC, Vermassen F, Esvs Guidelines C, Kolh P, Chakfe N, Hinchliffe RJ, Koncar I, Lindholt JS, Vega de Ceniga M, Verzini F, Esvs Guideline R, Archie J, Bellmunt S, Chaudhuri A, Koelemay M, Lindahl AK, Padberg F, Venermo M (2018) Editor’s choice—management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 55(1):3–81. https://doi.org/10.1016/j.ejvs.2017.06.021 CrossRefPubMedGoogle Scholar
- 13.Rothwell PM, Algra A, Chen Z, Diener HC, Norrving B, Mehta Z (2016) Effects of aspirin on risk and severity of early recurrent stroke after transient ischaemic attack and ischaemic stroke: time-course analysis of randomised trials. Lancet 388(10042):365–375. https://doi.org/10.1016/s0140-6736(16)30468-8 CrossRefPubMedPubMedCentralGoogle Scholar
- 17.Murphy SJX, Naylor AR, Ricco JB, Sillesen H, Kakkos S, Halliday A, de Borst GJ, Vega de Ceniga M, Hamilton G, McCabe DJH (2019) Optimal antiplatelet therapy in moderate to severe asymptomatic and symptomatic carotid stenosis: a comprehensive review of the literature. Eur J Vasc Endovasc Surg 57(2):199–211. https://doi.org/10.1016/j.ejvs.2018.09.018 CrossRefPubMedGoogle Scholar
- 18.Breet NJ, van Werkum JW, Bouman HJ, Kelder JC, Ruven HJ, Bal ET, Deneer VH, Harmsze AM, van der Heyden JA, Rensing BJ, Suttorp MJ, Hackeng CM, ten Berg JM (2010) Comparison of platelet function tests in predicting clinical outcome in patients undergoing coronary stent implantation. JAMA 303(8):754–762. https://doi.org/10.1001/jama.2010.181 CrossRefPubMedGoogle Scholar
- 19.Bonello L, Tantry US, Marcucci R, Blindt R, Angiolillo DJ, Becker R, Bhatt DL, Cattaneo M, Collet JP, Cuisset T, Gachet C, Montalescot G, Jennings LK, Kereiakes D, Sibbing D, Trenk D, Van Werkum JW, Paganelli F, Price MJ, Waksman R, Gurbel PA, Working Group on High On-Treatment Platelet Reactivity (2010) Consensus and future directions on the definition of high on-treatment platelet reactivity to adenosine diphosphate. J Am Coll Cardiol 56(12):919–933. https://doi.org/10.1016/j.jacc.2010.04.047 CrossRefPubMedGoogle Scholar
- 20.Price MJ, Angiolillo DJ, Teirstein PS, Lillie E, Manoukian SV, Berger PB, Tanguay JF, Cannon CP, Topol EJ (2011) Platelet reactivity and cardiovascular outcomes after percutaneous coronary intervention: a time-dependent analysis of the gauging responsiveness with a VerifyNow P2Y12 assay: impact on thrombosis and safety (GRAVITAS) trial. Circulation 124(10):1132–1137. https://doi.org/10.1161/CIRCULATIONAHA.111.029165 CrossRefPubMedGoogle Scholar
- 21.Mangiacapra F, Patti G, Barbato E, Peace AJ, Ricottini E, Vizzi V, Gatto L, D’Ambrosio A, De Bruyne B, Wijns W, Di Sciascio G (2012) A therapeutic window for platelet reactivity for patients undergoing elective percutaneous coronary intervention: results of the ARMYDA-PROVE (Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty-Platelet Reactivity for Outcome Validation Effort) study. JACC Cardiovasc Interv 5(3):281–289. https://doi.org/10.1016/j.jcin.2012.01.009 CrossRefPubMedGoogle Scholar
- 22.Pettersen AA, Seljeflot I, Abdelnoor M, Arnesen H (2012) High on-aspirin platelet reactivity and clinical outcome in patients with stable coronary artery disease: results from ASCET (Aspirin Nonresponsiveness and Clopidogrel Endpoint Trial). J Am Heart Assoc 1(3):e000703. https://doi.org/10.1161/jaha.112.000703 CrossRefPubMedPubMedCentralGoogle Scholar
- 23.Fiolaki A, Katsanos AH, Kyritsis AP, Papadaki S, Kosmidou M, Moschonas IC, Tselepis AD, Giannopoulos S (2017) High on treatment platelet reactivity to aspirin and clopidogrel in ischemic stroke: a systematic review and meta-analysis. J Neurol Sci 376:112–116. https://doi.org/10.1016/j.jns.2017.03.010 CrossRefPubMedGoogle Scholar
- 24.Alberts MJ, Bergman DL, Molner E, Jovanovic BD, Ushiwata I, Teruya J (2004) Antiplatelet effect of aspirin in patients with cerebrovascular disease. Stroke 35(1):175–178. https://doi.org/10.1161/01.STR.0000106763.46123.F6 CrossRefPubMedGoogle Scholar
- 25.Gengo FM, Rainka M, Robson M, Gengo MF, Forrest A, Hourihane M, Bates V (2008) Prevalence of platelet nonresponsiveness to aspirin in patients treated for secondary stroke prophylaxis and in patients with recurrent ischemic events. J Clin Pharmacol 48(3):335–343. https://doi.org/10.1177/0091270007313324 CrossRefPubMedGoogle Scholar
- 26.Harrison P, Segal H, Blasbery K, Furtado C, Silver L, Rothwell PM (2005) Screening for aspirin responsiveness after transient ischemic attack and stroke: comparison of 2 point-of-care platelet function tests with optical aggregometry. Stroke 36(5):1001–1005. https://doi.org/10.1161/01.STR.0000162719.11058.bd CrossRefPubMedGoogle Scholar
- 27.Assadian A, Lax J, Meixner-Loicht U, Hagmuller GW, Bayer PM, Hubl W (2007) Aspirin resistance among long-term aspirin users after carotid endarterectomy and controls: flow cytometric measurement of aspirin-induced platelet inhibition. J Vasc Surg 45(6):1142–1147. https://doi.org/10.1016/j.jvs.2007.01.064 (discussion 1147) CrossRefPubMedGoogle Scholar
- 32.Szapary L, Bagoly E, Kover F, Feher G, Pozsgai E, Koltai K, Hanto K, Komoly S, Doczi T, Toth K (2009) The effect of carotid stenting on rheological parameters, free radical production and platelet aggregation. Clin Hemorheol Microcirc 43(3):209–217. https://doi.org/10.3233/CH-2009-1210 CrossRefPubMedGoogle Scholar
- 35.Kinsella JA, Tobin WO, Tierney S, Feeley TM, Egan B, Coughlan T, Collins DR, O’Neill D, Harbison JA, Doherty CP, Madhavan P, Moore DJ, O’Neill SM, Colgan MP, Saqqur M, Murphy RP, Moran N, Hamilton G, McCabe DJH (2017) Assessment of ‘on-treatment platelet reactivity’ and relationship with cerebral micro-embolic signals in asymptomatic and symptomatic carotid stenosis. J Neurol Sci 376:133–139. https://doi.org/10.1016/j.jns.2017.03.015 CrossRefPubMedGoogle Scholar
- 36.Grant EG, Benson CB, Moneta GL, Alexandrov AV, Baker JD, Bluth EI, Carroll BA, Eliasziw M, Gocke J, Hertzberg BS, Katarick S, Needleman L, Pellerito J, Polak JF, Rholl KS, Wooster DL, Zierler E, Society of Radiologists in U (2003) Carotid artery stenosis: grayscale and Doppler ultrasound diagnosis–Society of Radiologists in Ultrasound consensus conference. Ultrasound Q 19(4):190–198CrossRefGoogle Scholar
- 38.Murphy SJX, Lim ST, Kinsella JA, Murphy D, Enright HM, McCabe DJH, HEIST Study Group (2018) Increased platelet count and reticulated platelets in recently symptomatic versus asymptomatic carotid artery stenosis and in cerebral microembolic signal-negative patient subgroups: Results from the HaEmostasis In carotid STenosis (HEIST) study. J Neurol 265(5):1037–1049. https://doi.org/10.1007/s00415-018-8797-8 CrossRefPubMedGoogle Scholar
- 41.Grau AJ, Reiners S, Lichy C, Buggle F, Ruf A (2003) Platelet function under aspirin, clopidogrel, and both after ischemic stroke: a case-crossover study. Stroke 34(4):849–854. https://doi.org/10.1161/01.STR.0000064326.65899.AC CrossRefPubMedGoogle Scholar
- 42.Kinsella JA, Tobin WO, Cox D, Coughlan T, Collins R, O’Neill D, Murphy RP, McCabe DJ (2013) Prevalence of ex vivo high on-treatment platelet reactivity on antiplatelet therapy after transient ischemic attack or ischemic stroke on the PFA-100® and VerifyNow®. J Stroke Cerebrovasc Dis 22(7):e84–e92. https://doi.org/10.1016/j.jstrokecerebrovasdis.2012.07.012 CrossRefPubMedGoogle Scholar
- 43.Tobin WO, Kinsella JA, Collins DR, Coughlan T, O’Neill D, Egan B, Tierney S, Feeley TM, Murphy RP, McCabe DJ (2011) Enhanced ex vivo inhibition of platelet function following addition of dipyridamole to aspirin after transient ischaemic attack or ischaemic stroke: first results from the TRinity AntiPlatelet responsiveness (TrAP) study. Br J Haematol 152(5):640–647. https://doi.org/10.1111/j.1365-2141.2010.08539.x CrossRefPubMedGoogle Scholar
- 46.Al-Tamimi M, Tan CW, Qiao J, Pennings GJ, Javadzadegan A, Yong AS, Arthur JF, Davis AK, Jing J, Mu FT, Hamilton JR, Jackson SP, Ludwig A, Berndt MC, Ward CM, Kritharides L, Andrews RK, Gardiner EE (2012) Pathologic shear triggers shedding of vascular receptors: a novel mechanism for down-regulation of platelet glycoprotein VI in stenosed coronary vessels. Blood 119(18):4311–4320. https://doi.org/10.1182/blood-2011-10-386607 CrossRefPubMedGoogle Scholar
- 47.Yip HK, Lu CH, Yang CH, Chang HW, Hung WC, Cheng CI, Chen SM, Wu CJ (2006) Levels and value of platelet activity in patients with severe internal carotid artery stenosis. Neurology 66(6):804–808. https://doi.org/10.1212/01.wnl.0000208220.04165.05 CrossRefPubMedGoogle Scholar
- 48.Taylor DW, Barnett HJ, Haynes RB, Ferguson GG, Sackett DL, Thorpe KE, Simard D, Silver FL, Hachinski V, Clagett GP, Barnes R, Spence JD, ASA and Carotid Endarterectomy (ACE) Trial Collaborators (1999) Low-dose and high-dose acetylsalicylic acid for patients undergoing carotid endarterectomy: a randomised controlled trial. Lancet 353(9171):2179–2184CrossRefGoogle Scholar
- 51.Safouris A, Katsanos AH, Kerasnoudis A, Krogias C, Kinsella JA, Sztajzel R, Lambadiari V, Deftereos S, Kargiotis O, Sharma VK, Demchuk AM, Saqqur M, McCabe DJH, Tsivgoulis G (2018) Statin pretreatment and microembolic signals in large artery atherosclerosis. Stroke 49(8):1992–1995. https://doi.org/10.1161/STROKEAHA.118.021542 CrossRefPubMedGoogle Scholar
- 53.Wang Y, Zhao X, Lin J, Li H, Johnston SC, Lin Y, Pan Y, Liu L, Wang D, Wang C, Meng X, Xu J, Wang Y, Investigators CHANCE (2016) Association between CYP2C19 loss-of-function allele status and efficacy of clopidogrel for risk reduction among patients with minor stroke or transient ischemic attack. JAMA 316(1):70–78. https://doi.org/10.1001/jama.2016.8662 CrossRefPubMedGoogle Scholar
- 54.Kashiwazaki D, Kuwayama N, Akioka N, Hayakawa Y, Kuroda S (2014) The roles and issues of P2Y12 percent inhibition assessed by VerifyNow assay for patients undergoing neurointervention: a prospective study. J Stroke Cerebrovasc Dis 23(7):1830–1836. https://doi.org/10.1016/j.jstrokecerebrovasdis.2014.04.014 CrossRefPubMedGoogle Scholar
- 55.Song TJ, Suh SH, Min PK, Kim DJ, Kim BM, Heo JH, Kim YD, Lee KY (2013) The influence of anti-platelet resistance on the development of cerebral ischemic lesion after carotid artery stenting. Yonsei Med J 54(2):288–294. https://doi.org/10.3349/ymj.2013.54.2.288 CrossRefPubMedPubMedCentralGoogle Scholar