血小板与血栓性疾病精品课件

Platelets and Thrombosis 阮 长 耿 Jiangsu Institute of Haemotology Suzhou University Medical College Suzhou 215007, P.R. China 血栓形成机制血栓形成机制 “血栓、栓塞、纤血栓、栓塞、纤 维蛋白原维蛋白原”的命名的命名 人德国的人德国的RudolfRudolf VirchowVirchow教授于教授于 18561856年提出血栓形年提出血栓形 成三大要素：血管成三大要素：血管 壁损伤、血流异常壁损伤、血流异常 、血液成分异常。、血液成分异常。 该理论至今仍被该理论至今仍被认认 可。可。 血流因素：血流是否淤滞血流因素：血流是否淤滞 血管因素：血管壁受损血管因素：血管壁受损 血小板因素：形成血小板血栓血小板因素：形成血小板血栓 凝血系统：纤维蛋白形成凝血系统：纤维蛋白形成 纤溶系统：纤维蛋白溶解，血管纤溶系统：纤维蛋白溶解，血管 修复修复 凝血因子 血小板 血管内皮促凝功 能 血流 抗凝蛋白 纤溶蛋白 血管内皮抗凝功能 正 常 止 血 状 态 促凝血活性 抗凝血活性 促凝血活性 凝血因子 血小板 血管内皮促凝功 能 抗凝血活性 血流 抗凝蛋白 纤溶蛋白 血管内皮抗凝功能 栓 倾 向 血 或 血 栓 形 成 血流改变血流改变 血流淤滞与涡流血流淤滞与涡流 血管损伤血管损伤 血小板因素：血小板因素：血小板增多、血小板活化血小板增多、血小板活化 凝血因素：凝血因素： 纤溶因素：纤溶因素： 纤溶活性降低纤溶活性降低 胶原、微纤维暴露胶原、微纤维暴露 血小板活化血小板活化 凝血因子释放凝血因子释放 血血 栓栓 形形 成成 血栓形成机制血栓形成机制 血栓形成是机体促凝血活性与抗凝血活性失衡的结果血栓形成是机体促凝血活性与抗凝血活性失衡的结果 抗凝功能减弱抗凝功能减弱 促凝功能增强促凝功能增强 凝血因子活性增高凝血因子活性增高 抗凝蛋白缺陷抗凝蛋白缺陷 血液成分改变血液成分改变 动脉血栓: 病理过程 阻塞阻塞 急性事件急性事件 栓塞栓塞 慢性缺血慢性缺血 动脉粥样动脉粥样 硬化斑块硬化斑块 斑块产斑块产 生裂隙生裂隙 或完全或完全 破裂破裂 血栓与粥血栓与粥 样斑块融合样斑块融合 血栓形成血栓形成 稳定性斑块稳定性斑块 动脉血栓 定义 (病理生理学): 在动脉粥样硬化血管内形成一个富含血 小板的血栓 临床后果: 累及多处动脉血管床 (如, PAD患者发 生心梗和中风的危险性增高) 导致心肌梗死、缺血性中风、血管性死 亡的主要原因 动脉血栓的流行病学: 心肌梗死和缺血性中风 临床表现临床表现 缺血性中风缺血性中风 心肌梗死心肌梗死 年发病率年发病率, , 美国美国+ +欧盟欧盟* * 1,750,0001,750,000 2,100,0002,100,000 缺血性心脏病缺血性心脏病 ( (包括心梗包括心梗) ) 和和 脑血管疾病脑血管疾病 ( (包括包括 出血性中风出血性中风) ) 在欧洲和北美每年的致死人数占全在欧洲和北美每年的致死人数占全 部死亡人数的部死亡人数的27-30%27-30%。 死亡率死亡率 *17 Western European countries. *17 Western European countries. American Heart Association. Heart and Stroke Facts: 1997 Statistical Supplement; WHO American Heart Association. Heart and Stroke Facts: 1997 Statistical Supplement; WHO Yearbooks, Annual Statistics (last available years 1992-1994 ). Yearbooks, Annual Statistics (last available years 1992-1994 ). 新华社2002年10月8日电讯： “全国高血压日”，有关资料显示： 现有 每年新增 有高血压病史 高血压患者 1亿 300万 脑卒中患者 500多万 150万 76% 冠心病患者 1000万 65% 初期止血机制 TXA2 ADP 纤维蛋白原 凝血酶 PF4 -TG PDGF 纤维蛋白 PGI2 聚集 白色血栓 释放 粘附 v WF EC SE 血栓栓子血栓栓子 血管壁损伤血管壁损伤 血小板附着血小板附着 血小板激活血小板激活 血小板聚集血小板聚集 血栓栓子的形成 GPIa-IIa (2 1); GPIIb-IIIa (II3); GPIc-IIa (51) 血小板膜糖蛋白与血小板的止血功能 活化 聚集 粘附 （Fn：纤维结合蛋白，Coll：胶原，Ec：内皮细胞） Adhension The platelet vWF-subendothelial Axis Immunoinhibitory probes using GPIb MoAb AN 51 suggest that GPIb on the platelet membrance is the vWF receptor. (Ruan et al: Brit.J.Haematal,1981) SZ 1 GPIX 中国科学1986, Blood 1987 SZ 2 GPIb 中国科学1986, Blood 1987 SZ 21 GPIIIa Thromb. Hemostas. 1987 中华内科杂志 1987 SZ 22 GPIIb Thromb. Hemostas. 1987 中华血液杂志 1987 SZ 51 GMP140 ( P-Selectin ) Nouv. Rev. Fr. Hematol.1990 血小板活化的指标 1） TXB2, TG, PF4 2) P-Selectin “gold standard” 3) Platelet microparticles (PMP) 4) Circulating monocyte-platelet aggregates (MPA) 5) (Circulation 2001;104:1533) 6) 5） Others: GPV GMP-140 and TXB2 in patients with Acute myocardial infarction (AMI) n GMP-140 GMP-140 TXB2 (molecules/pit) (ng/ml) (pg/ml) 1 day after AMI 24 2594208* 19.14.7 * 22637* 2 days after AMI 16 3353593* 25.76.7* 27845* 3 days after AMI 18 1485221* 29.68.1* 22448* 7 days after AMI 16 718475 16.09.1* 18329* 10 days after AMI 16 13.2 8.0 normal controls 20 780 196 10.0 4.5 159 32 Data are means SD. * P1001.5 Infusion20-72 h36-96 h12-24 h IMPACT,RESTORE,Official PURSUITPRISMPLUS prescring information GPIIb/IIIa InhibitorsGPIIb/IIIa Inhibitors Pharmacokinetics Pharmacokinetics Eptifibatide Tirofiban Abciximab BindingCompetitiveCompetitive High affinity Half life Plasma1.5 h1.5 h1.0 min Biologic1.5 h1.5 hDays ClearanceRenalRenalRenal/Spleen GPIIb/IIIa InhibitorsGPIIb/IIIa Inhibitors GPIIb/IIIa InhibitorsGPIIb/IIIa Inhibitors Clinical Considerations: ReversibilityClinical Considerations: Reversibility Adapted from Mousa, 1996. Normal return of platelet function Platelet Aggregation Tirofiban Eptifibatide Abciximab Hours 100 80 60 40 20 0 061218243036 Abciximab and AMI: EPIC Abciximab Placebo % patients 30 days P=0.06 -83% 26.1 4.5 4.5 4.5 6 months 47.8 % patients - 91% p=0.002 EP: Death +MI+urgent revascularization The EPIC Investigators am J Cardiol 1996;77:1045-51 EPIC Abciximab B Abciximab B+1 Treatment Group EPILOG Abciximab LDH Abciximab SDH EPISTENT Abciximab + Stent Abciximab + PTCA* IMPACT II Eptifibatide 135/5 Eptifibatide 135/75 RESTORE Tirobifan CAPTURE Abciximab RAPPORT Abciximab Death, MI, or Urgent Revascularization at 30 Days Odds Ratio and 95% Confidence Intervals 0.2514GP IIb/IIIa BetterPlacebo Better Composite 30-day end point (death, myocardial infarction or urgent repeat revascularization) event rates for the 7 GPIIb/IIIa interventional trials. EPIC Abciximab B Abciximab B+1 Treatment Group EPILOG Abciximab LDH Abciximab SDH EPISTENT Abciximab + Stent Abciximab + PTCA* IMPACT II Eptifibatide 135/5 Eptifibatide 135/75 RESTORE Tirobifan CAPTURE Abciximab RAPPORT Abciximab Deather MI at 6 Months Odds Ratio and 95% Confidence Intervals 0.2514GP IIb/IIIa BetterPlacebo Better Composite 6-month end point of death or myocardial (re-) infarction event rates for the GPIIb-IIIa interventional trials. Possible future indications for GP IIb-IIIa antagonists -acute coronary syndromes: combination therapy with a) reduced dose thrombolytic agents, b) LMWH. -AIS -Anti-angiogenesis for cancer therapy 新型抗血小板药物的研究 1） 作用于血栓形成的起始点：血小板粘附 相关的膜（胶原）受体和粘附蛋白（vWF)。 2） 减少出血倾向。 MoAb Ristocetin ADP (adhesion) （aggregation） SZ-2 IgG + SZ-2 ScFv + SZ-21 IgG + SZ-21 ScFv + Bis -ScFv + + Effects of SZ-2 and SZ-21, and its fragments +: very strong ; +: strong; +: moderate; : None Flow Chamber: vWF包被，观定单 抗对血小板粘附、聚集、血栓形成 的影响。 Platelet Adhesion to vWF , Shear Stress=0.2 N/m2 control group (tyrodes) Platelet Adhesion to vWF Inhibitor group 1 (SZ-2 ScFv 20ug/ml) Platelet Adhesion to vWF Inhibitor group 2 (SZ-21 ScFv 20ug/ml) Platelet Adhesion to vWF Inhibitor group 3 (SZ-2/SZ-21 bis-ScFv 20ug/ml) Adhesion probability Shear strees = 0.2 n/m2 t = 30 min Platelet Adhesion to purified vWF T (min) Adhesion probability Platelet Adhesion to purified vWF Shear strees = 0.2 n/m2 Prevention of Arterial Thrombosis in Baboons Combining a GPIb blocker with a GPb/a blocker can achieve a strong antithrombotic effect without increasing the bleeding time. Wu,Deckmyn, ATVB 2002,22:323 胶原受体 GPVI GP VI 为 I 型单链跨膜糖蛋白，属Ig超家族成员。 由339个氨基酸残基组成，分子量62KDa。 平均每个血小板表面含2000个GP VI分子。 GP VI基因定位于19q13.2219q13.33。 人GP VI cDNA已 被克隆，全长1017个碱基。鼠GP VI cDNA也已克隆， 与人GP VI 同源性为67.3%；该序列编码313个氨基酸残基. GP VI在介导胶原诱导的血小板粘附、信号转导、聚集、 促凝活性表达过程中起到重要的作用。 基因敲除试验结果表明GPVI与病理性血栓形成密切相关 ，而似乎在生理性止血过程不起什么作用。(Blood, 2003) 胶原GP VI轴的抑制在血栓性疾病的防治中有重要的价 值，GP VI为抗栓治疗新的靶点。 抗血小板药物 药物 作用环节 第一代 阿司匹林 环氧酶抑制剂 临床应用 Ticlopidine ADP活化抑制剂 临床应用 第二代 Reopro GPIIb-IIIa受体抑制剂 临床应用 第三代 JAQ1 GPVI（胶原）受体抑制剂 动物实验 AjvW2, 6B4 “vWF-GPIb”抑制剂 动物实验 82D6A3 “vWF-胶原” 抑制剂 动物实验 M(gAU4oI$cxR1lFZ9tN)iCW6qK&eyS3nH!bvP+jDY8sM(gAU4oJ%dxR1lFZ9uO-iCW6qK&fzT3nH!bvP0kEY8sM(gAVY9tN)hBV5pJ&eyS2mG#auP+jDX7rL*fAU4oI$cwQ0lFZ9tN)hBV6qK&eyS2mG!bvP+jDX7rM(gAU4oI$cxR1lFZ9tN)iCW6qK&eyS3nH!bvP+jDY8sM(gAU4oJ%dxR1lFZ9uO-iCW6qK&fzT3nH!bvP0kEY8sM(gAV5pJ%dxR1lG#auO-iCW6rL*fzT3nH!cwQ0kEY8sM)hBV5pJ%dQ0kEY8sM(hBV5pJ%dxR2mG#auO- iCX7rL*fzT3nI$cwQ0kEY8tN)hBV5pJ%eyS2mG#auO+jDX7rL*fzU4oI$cwQ0kFZ9tN)hBV5qK&eyS2mG#bvP+jDX7rL(gAU4oI$cwR1lFZ9tN)hCW6qK&eyS2nH!bvP+jDX8sM(gAU4oI%dxR1lFZ9tO-iCW6qK&ezT3nH!bvP+kEY8sM(0kEY9tN)hBV5pJ&eyS2mG#auP+jDX7rL*fAU4oI$wR1lFZ9tN)hCW6qK&eyS2nH!bvP+jDX8sM(gAU4oI%dxR1lFZ9tO-iCW6qK&ezT3nH!bvP+kEY8sM(gAU5pJ%dxR1lF#auO- iCW6qL*fzT3nH!bwQ0kEY8sM(hBV5pJ%dxR2mG#auOS2mG#bvP+jDX7rL(gAU4oI$cwR1lFZ9tN)hCW6qK&eyS2nH!bvP+jDX8sM(gAU4oI%dxR1lFZ9tO-iCW6qK&ezT3nH!bvP+kEY8sM(gAU5pJ%dxR1lF#auO-iCW6qL*fzT3nH!bwQ0kEY8sM(hBV5pJ%dxR2mG#auO-iCX7rL*fzT3nrL(gAU4oI$cwR1lFZ9tN)hCW6qK&eyS2nH!bvP+jDX8sM(gAU4oI%dxR1lFZ9tO-iCW6qK&ezT3nH!bvP+kEY8sM(gAU5pJ%dxR1lF#auO-iCW6qL*fzT3nH!bwQ0kEY8sM(hBV5pJ%dxR2mG#auO-iCX7rL*fzT3nIauO- iCX7rL*fzT3nH$cwQ0kEY8sN)hBV5pJ%dyS2mG#auO-jDX7rL*fzT4oI$cwQ0kEZ9tN)hBV5pK&eyS2mG#avP+jDX7rL*gAU4oI$cwQ1lFZ9tN)hBW6qK&eyS2mH!bvP+jDX7sM(gAU4oI$dxR1lFZ%dxR2mG#auO-iCX7rL*fzT3nI$cwQ0kEY8tN)hBV5pJ%eyS2mG#auO+jDX7rL*fzU4oI$cwQ0kFZ9tN)hBV5qK&eyS2mG#bvP+jDX7rL(gAU4oI$cwR1lFZ9tN)hCW6qK&eyS2nH!bvP+jDX8sM(gAU4H!bvP+jDX7sM(gAU4oI$dxR1lFZ9tN-iCW6qK&eyT3nH!bvP+jEY8sM(gAU4pJ%dxR1lFZauO-iCW6qK*fzT3nH!bvQ0kEY8sM(gBV5pJ%dxR1mG#auO- iCW7rL*fzT39tN-iCW6qK&eyT3nH!bvP+jEY8sM(gAU4pJ%dxR1lFZauO-iCW6qK*fzT3nH!bvQ0kEY8sM(gBV5pJ%dxR1mG#&eyS2mG#bvP+jDX7rL(gAU4oI$cwQ1lFZ9tN)hBW6qK&eyS2mH!bvP+jDX7sM(gAU4oI$dxR1lFZ9tN-iCW6qK&eyT3nH!bvP+jEY8sM(gAU4pJ%dxR1lFZauO-iCW6qK*fzT3nH!bvQ0kEY8sMfzT3nH!bvQ0kEY8sM(gBV5pJ%dxR1mG#auO-iCW7rL*fzT3nH$cwQ0kEY8sN)hBV5pJ%dyS2mG#auO-jDX7rL*fzT4oI$cwQ0kEZ9tN)hBV5pK&eyS2mG#avP+jDX7rL*gAU4oI$cwQ1lFZ9tN)hBFZauO- iCW6qK*fzT3nH!bvQ0kEY8sM(gBV5pJ%dxR1mG#auO-iCW7rL*fzT3nH$cwQ0kEY8sN)hBV5pJ%dyS2mG#auO-jDX7rL*fzT4oI$cwQ0kEZ9tN)hBV5pK&eyS2mG#avP+jDX7rLeyS2mG#auP+jDX7rL*fAU4oI$cwQ0lFZ9vP+jDY8sM(gAU4oJ%dxR1lFZ9uxS2mG#auO-iDX7rL*fzT3oI$cwQ0kEY9tN)hBV5pJ&eyS2mG#auP+jDX7rL*fAU4oI$cwQ0lFZ9tN)hBV6qK&eyS2mG!bvP+jDX7rM(gAU4oI$cxR1lFZ9tN)iCW6qK&eyS3nH!bvP+jDY8sM(gAU4oJ%dxR1lFZ9uO-imG#auO- jDX7rL*fzT4oI$cwQ0kEZ9tN)hBV5pK&eyS2mG#avP+jDX7rL*gAU4oI$cwQ1lFZ9tN)hBW6qK&eyS2mH!bvP+jDX7sM(gAU4oI$dxR1lFZ9tN-iCW6qK&eyT3nH!bvP+jEY8sM(gAU4pJ%dP+jDY8sM(gAU4oJ%dxR1lFZ9uO-iCW6qK&fzT3nH!bvP0kEY8sM(gAV5pJ%dxR1lG#auO-iCW6rL*fzT3nH!cwQ0kEY8sM)hBH!bvP+jDY8sM(gAU4oJ%dxR1lFZ9uO-iCW6qK&fzT3nH!bvP0kEY8sM(gAV5pJ%dxR1lG#auO-iCW6r%dxR1lF#auO-iCW6qL*fzT3nH!bwQ0kEY8sM(hBV5pJ%dxR2mG#auO- iCX7rL*fzT3nI$cwQ0kEY8tN)hBV5pJ%eyS2mG#auO+jDX7rL*fzU4oI$cwQ0kFZ9tN)hBV5qK&-iCW6qK&fzT3nH!bvP0kEY8sM(gAV5pJ%dxR1lG#auO-iCW6rL*fzT3nH!cwQ0kEY8sM)hBV5pJ%dxS2mG#auO-iDX7rL*fzT3oI$cwQ0kEY9tN)hBV5pJ&eyS2mG#auP+jDX7rL*fAU4oIM(gAU4oJ%dxR1lFZ9uO-iCY8sM)hBV5pJbwQ0kEY8sM(hBV5pJ%dxR2mG#auO-iCX7rL*fzT3nI$cwQ0kEY8tN)hBV5pJ%eyS2mG#auO+jDX7rL*fzU4oI$cwQ0kFZ9tN)hBV5qK&eyS2mG#bvP+jDX7rL(gAU4oI$cwR15pJ%dxR1lF#auO- iCW6qL*fzT3nH!bwQ0kEY8sM(hBV5pJ%dxR2mG#auO-iCX7rL*fzT3nI$cwQ0kEY8tN)hBV5pJ%eyS2mG#auO+jDX7rL*fzU4oI$cwQ0kFZ9tN)hBV5qK&eyS2mG#tN)hBV5pK&eyS2mG#avP+jDX7rL*gAU4oI$cwQ1lFZ9tN)hBpJ%eyS2mG#auOhBV5pJ%eyS2mG#auO+jDX7rL*fzU4oI$cwQ0kFZ9tN)hBV5qK&eyS2mG#bvP+jDX7rL(gAU4oI$cwR1lFZ9tN)hCW6qK&eyS2nH!bvP+jDX8sM(gAU4oI%dxR1lFZ9tO- iCW6qK&ezT37rL*fzT3nI$cwQ0kEY8tN)hBV5pJ%eyS2mG#auO+jDX7rL*fzU4oI$cwQ0kFZ9tN)hBV5qK&eyS2mG#bvP+jDX7rL(gAU4oI$cwR1lFZ9tN)hCW6qK&eyS2nH!bvP+jDX8sM(gA2mH!bvP+jDX7sfzU4oI$cwQ0kFZ9tN)hBV5qK&eyS2mG#bvP+BV5pK&eyS2mG#avP+jDX7rL*gAU4oI$cwQ1lFZ9tN)hBW6qK&eyS2mH!bvP+jDX7sM(gAU4oI$dxR1lFZ9tN- iCW6qK&eyT3nH!bvP+jEY8sM(gAU4pJ%dxR1lFJ%eyS2mG#auO+jDX7rL*fzU4oI$cwQ0kFZ9tN)hBV5qK&eyS2mG#bvP+jDX7rL(gAU4oI$cwR1lFZ9tN)hCW6qK&eyS2nH!bvP+jDX8sM(gAU4oI%dxR1lFZuO-iCW6qK&fzT3nH!bvP0kEY8sM(gAV5pJ%dxR1lG#auO-iCW6rL*fzT3nH!cwQ0kEY8sM)hBV5ptN)hBW6qK&eyS2mH!bvP+jDX7sM(gAU4oI$