Intravascular cells and circulating microparticles induce procoagulant activity via phosphatidylserine exposure in heart failure

  • Yan Kou
  • Lili Zou
  • Ruipeng Liu
  • Xinyi Zhao
  • Ying Wang
  • Cong Zhang
  • Zengxiang Dong
  • Junjie Kou
  • Yayan Bi
  • Lu FuEmail author
  • Jialan ShiEmail author


Relatively little information is known about the definitive role of phosphatidylserine (PS) in the hypercoagulability of heart failure (HF). Our objectives were to assess the levels of PS exposure on microparticles (MPs) and blood cells (BCs) in each group of HF patients and to evaluate their procoagulant activity (PCA). HF patients in each NYHA functional class II–IV (II n = 30, III n = 30, IV n = 30) and healthy controls (n = 25) were enrolled in the present study. PS exposure on MPs, BCs was analyzed with flow cytometry. MPs were classified based on their cellular origin: platelets (CD41a+), neutrophils (CD66b+), endothelial cells (CD31+CD41a), erythrocytes (CD235a+), monocytes (CD14+), T lymphocytes (CD3+), and B lymphocytes (CD19+). PCA was evaluated by clotting time, extrinsic/intrinsic FXa and prothrombinase production assays, as well as fibrin formation assays. Inhibition assays of PCA of PS+ BCs and MPs were performed by lactadherin. There was no significant difference in MP cellular origin between healthy and HF subjects. However, the total number of PS+ MPs was significantly increased in HF patients compared with healthy controls. In addition, circulating PS+ BCs cooperated with PS+ MPs to markedly shorten coagulation time and dramatically increase FXa/thrombin generation and fibrin formation in each HF group. Moreover, blockade of exposed PS on BCs and MPs with lactadherin inhibited PCA by approximately 80%. Our results lead us to believe that exposing PS on the injured BCs and MPs played a pivotal role in the hypercoagulability state in HF patients.


Heart failure Phosphatidylserine Blood cells Microparticles Procoagulant activity 



We are grateful to all the patients for their participation in the investigation, staff for excellent technical assistance and the sample collection. The authors are fully responsible for the study design, data collection, analysis and interpretation of the data, and writing of the manuscript. All authors agreed to submit the manuscript for publication.

Author contributions

YK conceived and designed the study, analyzed the data, made the figures and wrote the manuscript. LZ, RL, XZ, YW, CZ and ZD conducted the assays and contributed to data acquisition. JK and YB designed the study. LF and JS, designed the study, provide the patient samples and revised the manuscript.


This work was supported by grants from the National Natural Science Foundation of China (Grant Nos. 81470301, 81670128, 81873433).

Compliance with ethical standards

Conflict of interest

The authors declare no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

11239_2019_1889_MOESM1_ESM.docx (2.3 mb)
Supplementary material 1 (DOCX 2392 kb)


  1. 1.
    Felker GM, Thompson RE, Hare JM et al (2000) Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med 342:1077–1084CrossRefGoogle Scholar
  2. 2.
    Zannad F, Stough WG, Regnault V et al (2013) Is thrombosis a contributor to heart failure pathophysiology? possible mechanisms, therapeutic opportunities, and clinical investigation challenges. Int J Cardiol 167:1772–1782CrossRefGoogle Scholar
  3. 3.
    Isnard R, Bauer F, Cohen-Solal A et al (2016) Non-vitamin K antagonist oral anticoagulants and heart failure archives of cardiovascular disease. Arch Cardiovasc Dis 109:641–650CrossRefGoogle Scholar
  4. 4.
    Homma S, Thompson JL, Pullicino PM et al (2012) Warfarin and aspirin in patients with heart failure and sinus rhythm. N Engl J Med 366:1859–1869CrossRefGoogle Scholar
  5. 5.
    Bettari L, Fiuzat M, Becker R et al (2011) Thromboembolism and antithrombotic therapy in patients with heart failure in sinus rhythm: current status and future directions. Circ Heart Fail 4:361–368CrossRefGoogle Scholar
  6. 6.
    Lip GY, Gibbs CR (1999) Does heart failure confer a hypercoagulable state? Virchow’s triad revisited. J Am Coll Cardiol 33:1424–1426CrossRefGoogle Scholar
  7. 7.
    Gheorghiade M, Vaduganathan M, Fonarow GC et al (2013) Anticoagulation in heart failure: current status and future direction. Heart Fail Rev 18:797–813CrossRefGoogle Scholar
  8. 8.
    Kay JG, Grinstein S (2013) Phosphatidylserine-mediated cellular signaling. Adv Exp Med Biol 991:177–193CrossRefGoogle Scholar
  9. 9.
    Chung I, Choudhury A, Lip GY (2007) Platelet activation in acute, decompensated congestive heart failure. Thromb Res 120:709–713CrossRefGoogle Scholar
  10. 10.
    Chung I, Choudhury A, Patel J et al (2009) Soluble, platelet-bound, and total P-selectin as indices of platelet activation in congestive heart failure. Ann Med 41:45–51CrossRefGoogle Scholar
  11. 11.
    Wirtz PH, Hong S, Redwine LS et al (2009) Depressive symptoms are associated with soluble P-selectin reactivity to acute exercise in heart failure. Biol Psychiatry 65:801–807CrossRefGoogle Scholar
  12. 12.
    Gibbs CR, Blann AD, Edmunds E et al (2001) Effects of acute exercise on hemorheological, endothelial, and platelet markers in patients with chronic heart failure in sinus rhythm. Clin Cardiol 24:724–729CrossRefGoogle Scholar
  13. 13.
    Malinin AI, O’Connor CM, Dzhanashvili AI et al (2003) Platelet activation in patients with congestive heart failure: do we have enough evidence to consider clopidogrel? Am Heart J 145:397–403CrossRefGoogle Scholar
  14. 14.
    Andreassen AK, Nordøy I, Simonsen S et al (1998) Levels of circulating adhesion molecules in congestive heart failure and after heart transplantation. Am J Cardiol 81:604–608CrossRefGoogle Scholar
  15. 15.
    Shirazi LF, Bissett J, Romeo F et al (2017) Role of inflammation in heart failure. Curr Atheroscler Rep 19:27CrossRefGoogle Scholar
  16. 16.
    Abraityte A, Aukrust P, Kou L et al (2019) T cell and monocyte/macrophage activation markers associate with adverse outcome, but give limited prognostic value in anemic patients with heart failure: results from RED-HF. Clin Res Cardiol 108:133–141CrossRefGoogle Scholar
  17. 17.
    Lippi G, Turcato G, Cervellin G et al (2018) Red blood cell distribution width in heart failure: a narrative review. World J Cardiol 10:6–14CrossRefGoogle Scholar
  18. 18.
    Westenbrink BD, Voors AA, de Boer RA et al (2010) Bone marrow dysfunction in chronic heart failure patients. Eur J Heart Fail 12:676–684CrossRefGoogle Scholar
  19. 19.
    Poglajen G, Sever M, Černelč P et al (2015) Increased red cell distribution width is associated with poor stem cell mobilization in patients with advanced chronic heart failure. Biomarkers 20:365–370CrossRefGoogle Scholar
  20. 20.
    Lippi G, Cervellin G (2014) Risk assessment of post-infarction heart failure. Systematic review on the role of emerging biomarkers. Crit Rev Clin Lab Sci 51:13–29CrossRefGoogle Scholar
  21. 21.
    Imai R, Uemura Y, Okumura T et al (2017) Impact of red blood cell distribution width on non-cardiac mortality in patients with acute decompensated heart failure with preserved ejection fraction. J Cardiol 70:591–597CrossRefGoogle Scholar
  22. 22.
    Burger D, Touyz RM (2012) Cellular biomarkers of endothelial health: microparticles, endothelial progenitor cells, and circulating endothelial cells. J Am Soc Hypertens 6:85–99CrossRefGoogle Scholar
  23. 23.
    Wang L, Bi Y, Cao M et al (2016) Microparticles and blood cells induce procoagulant activity via phosphatidylserine exposure in NSTEMI patients following stent implantation. Int J Cardiol 223:121–128CrossRefGoogle Scholar
  24. 24.
    Yao Z, Wang L, Wu X et al (2017) Enhanced procoagulant activity on blood cells after acute ischemic stroke. Transl Stroke Res 8:83–91CrossRefGoogle Scholar
  25. 25.
    Gao C, Xie R, Yu C et al (2012) Procoagulant activity of erythrocytes and platelets through phosphatidylserine exposure and microparticles release in patients with nephrotic syndrome. Thromb Haemost 107:681–689CrossRefGoogle Scholar
  26. 26.
    Montoro-García S, Shantsila E, Wrigley BJ et al (2015) Small-size microparticles as indicators of acute decompensated state in ischemic heart failure. Rev Esp Cardiol (Engl Ed) 68:951–958CrossRefGoogle Scholar
  27. 27.
    Popovic B, Zannad F, Louis H et al (2019) Endothelial-driven increase in plasma thrombin generation characterising a new hypercoagulable phenotype in acute heart failure. Int J Cardiol 274:195–201CrossRefGoogle Scholar
  28. 28.
    Nozaki T, Sugiyama S, Sugamura K et al (2010) Prognostic value of endothelial microparticles in patients with heart failure. Eur J Heart Fail 12:1223–1228CrossRefGoogle Scholar
  29. 29.
    Shi J, Gilbert GE (2003) Lactadherin inhibits enzyme complexes of blood coagulation by competing for phospholipid binding sites. Blood 101:2628–2636CrossRefGoogle Scholar
  30. 30.
    Hou J, Fu Y, Zhou J et al (2011) Lactadherin functions as a probe for phosphatidylserine exposure and as an anticoagulant in the study of stored platelets. Vox Sang 100:187–195CrossRefGoogle Scholar
  31. 31.
    Chung I, Choudhury A, Lip GY (2007) Platelet activation in acute, decompensated congestive heart failure. Thromb Res 120:709–713CrossRefGoogle Scholar
  32. 32.
    Hildemann SK, Schulz C, Fraccarollo D et al (2014) Fractalkine promotes platelet activation and vascular dysfunction in congestive heart failure. Thromb Haemost 111:725–735CrossRefGoogle Scholar
  33. 33.
    Szyguła-Jurkiewicz B, Siedlecki Ł, Pyka Ł et al (2018) Red blood cell distribution width, relative lymphocyte count, and type 2 diabetes predict all-cause mortality in patients with advanced heart failure. Pol Arch Intern Med 128:115–120Google Scholar
  34. 34.
    Shirazi LF, Bissett J, Romeo F et al (2017) Role of inflammation in heart failure. Curr Atheroscler Rep 19:27CrossRefGoogle Scholar
  35. 35.
    Paulus WJ (2000) Cytokines and heart failure. Heart Fail Monit 1:50–56Google Scholar
  36. 36.
    Berezin AE, Kremzer AA, Cammarota G et al (2016) Circulating endothelial-derived apoptotic microparticles and insulin resistance in non-diabetic patients with chronic heart failure. Clin Chem Lab Med 54:1259–1267CrossRefGoogle Scholar
  37. 37.
    Berezin AE, Kremzer AA, Samura TA et al (2015) Predictive value of apoptotic microparticles to mononuclear progenitor cells ratio in advanced chronic heart failure patients. J Cardiol 65:403–411CrossRefGoogle Scholar
  38. 38.
    Schurgers LJ, Burgmaier M, Ueland T et al (2016) Circulating annexin A5 predicts mortality in patients with heart failure. J Intern Med 279:89–97CrossRefGoogle Scholar
  39. 39.
    Drake TA, Morrissey JH, Edgington TS (1989) Selective cellular expression of tissue factor in human tissues. Implications for disorders of hemostasis and thrombosis. Am J Pathol 134:1087–1097Google Scholar
  40. 40.
    Reichman-Warmusz E, Domal-Kwiatkowska D, Matysiak N et al (2016) Tissue factor is unregulated in microvascular endothelial cells of patients with heart failure. J Clin Pathol 69:221–225CrossRefGoogle Scholar
  41. 41.
    Kay JG, Grinstein S (2013) Phosphatidylserine-mediated cellular signaling. Adv Exp Med Biol 991:177–193CrossRefGoogle Scholar
  42. 42.
    Sinauridze EI, Kireev DA, Popenko NY et al (2007) Platelet microparticle membranes have 50- to 100-fold higher specific procoagulant activity than activated platelets. Thromb Haemost 97:425–434CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Yan Kou
    • 1
  • Lili Zou
    • 2
  • Ruipeng Liu
    • 2
  • Xinyi Zhao
    • 2
  • Ying Wang
    • 2
  • Cong Zhang
    • 3
  • Zengxiang Dong
    • 1
  • Junjie Kou
    • 2
  • Yayan Bi
    • 1
  • Lu Fu
    • 1
    Email author
  • Jialan Shi
    • 4
    • 5
    Email author
  1. 1.Department of Cardiology of the First Hospital, Harbin Medical UniversityHarbinChina
  2. 2.Department of Cardiology of the Second Hospital, Harbin Medical UniversityHarbinChina
  3. 3.Department of Ultrasonography of the First HospitalHarbin Medical UniversityHarbinChina
  4. 4.Department of Hematology of the First HospitalHarbin Medical UniversityHarbinChina
  5. 5.Departments of Research and Surgery, VA Boston Healthcare SystemBrigham and Women’s Hospital, Harvard Medical SchoolBostonUSA

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