Objective-Chronic thromboembolic pulmonary hypertension (CTEPH) is a fatal disease that is distinct from pulmonary arterial hypertension (PAH). Although CTEPH is characterized by obstruction of major pulmonary artery because of chronic thrombus, it remains unclear whether CTEPH is associated with prothrombotic condition. Approach and Results-In addition to conventional markers, GTP-bound levels of Rap1, RhoA, RalA, Rac1, and Ras in platelets, which are implicated for platelet activation, were measured in patients without pulmonary hypertension (non-PH, n=15), patients with PAH (n=19), and patients with CTEPH (n=25). Furthermore, the responsiveness to ex vivo thrombin stimulation was also evaluated. The ratios of the P-selectin positive platelets in the non-PH patients, patients with PAH, and patients with CTEPH were 1.40% (median and interquartile range, 0.83-1.82), 2.40% (1.80-3.39), and 2.63% (1. 90-8.22), respectively (non-PH versus CTEPH, P<0.01). The activated GPIIb/IIIa-positive platelets were 6.01% (1.34-7.87), 11.39% (5.69-20.86), and 9.74% (7.83-24.01), respectively (non-PH versus CTEPH, P=0.01). GTP-bound RhoA was 1.79% (0.94-2.83), 4.03% (2.01-5.14), and 2.01% (1.22-2.48), respectively (non-PH versus PAH, P=0.04), and GTP-bound RalA was 1.58% (1.08-2.11), 3.02% (2.03-3.54), and 2.64% (1.42-4.28), respectively (non-PH versus PAH, P=0.023; non-PH versus CTEPH, P=0.048). In contrast, Rac1, Rap1, or Ras was not activated in any groups. The platelets of patients with CTEPH exhibited hyperresponsiveness to ex vivo thrombin stimulation compared with those of non-PH patients when evaluated for the surface markers. Either D-dimer or fibrin degradation product level was not increased in patients with CTEPH. Conclusions-These results provide the first direct evidence that platelets of patients with CTEPH are highly activated and exhibit hyperresponsiveness to thrombin stimulation. there have been few reports linking directly CTEPH to platelets activation, to date.In the present study, we thus investigated whether the coagulation and platelet systems were activated in patients without pulmonary hypertension (non-PH), patients with PAH, and patients with CTEPH. In addition to the conventional markers reflecting the activation states of coagulation and platelets, we analyzed the activation levels of several small GTPases, such as Rap1, RhoA, RalA, Rac1, and Ras in platelets, because they were implicated as the novel factors for platelet activation. Furthermore, we also evaluated the responsiveness of platelets to ex vivo thrombin stimulation.
Materials and MethodsMaterials and Methods are available in the online-only Supplement.
Results
Baseline CharacteristicsWe confirmed the principles outlined in the Declaration of Helsinki. The study protocol was approved by the Ethical Committees of Tohoku University, and all patients provided written informed consent. The baseline characteristics of the enrolled patients are shown in Table 1. This study enrolled the non-PH patients as control patients (n=15: hypertension n=7,...