BACKGROUND:
ADP-induced platelet activation leads to cell surface expression of several proteins, including TF (tissue factor). The role of ADP receptors in platelet TF modulation is still unknown. We aimed to assess the (1) involvement of P2Y
1
and P2Y
12
receptors in ADP-induced TF exposure; (2) modulation of TF
pos
-platelets in anti-P2Y
12
–treated patients with coronary artery disease. Based on the obtained results, we revisited the intracellular localization of TF in platelets.
METHODS:
The effects of P2Y
1
or P2Y
12
antagonists on ADP-induced TF expression and activity were analyzed in vitro by flow cytometry and thrombin generation assay in blood from healthy subjects, P2Y
12
−/−
, and patients with gray platelet syndrome.
Ex vivo, P2Y
12
inhibition of TF expression by clopidogrel/prasugrel/ticagrelor, assessed by VASP (vasodilator-stimulated phosphoprotein) platelet reactivity index, was investigated in coronary artery disease (n=238). Inhibition of open canalicular system externalization and electron microscopy (TEM) were used for TF localization.
RESULTS:
In blood from healthy subjects, stimulated in vitro by ADP, the percentage of TF
pos
-platelets (17.3±5.5%) was significantly reduced in a concentration-dependent manner by P2Y
12
inhibition only (−81.7±9.5% with 100 nM AR-C69931MX). In coronary artery disease, inhibition of P2Y
12
is paralleled by reduction of ADP-induced platelet TF expression (VASP platelet reactivity index: 17.9±11%, 20.9±11.3%, 40.3±13%; TF
pos
-platelets: 10.5±4.8%, 9.8±5.9%, 13.6±6.3%, in prasugrel/ticagrelor/clopidogrel-treated patients, respectively). Despite this, 15% of clopidogrel good responders had a level of TF
pos
-platelets similar to the poor-responder group. Indeed, a stronger P2Y
12
inhibition (130-fold) is required to inhibit TF than VASP. Thus, a VASP platelet reactivity index <20% (as in prasugrel/ticagrelor-treated patients) identifies patients with TF
pos
-platelets <20% (92% sensitivity). Finally, colchicine impaired in vitro ADP-induced TF expression but not α-granule release, suggesting that TF is open canalicular system stored as confirmed by TEM and platelet analysis of patients with gray platelet syndrome.
CONCLUSIONS:
Data show that TF expression is regulated by P2Y
12
and not P2Y
1
; P2Y
12
antagonists downregulate the percentage of TF
pos
-platelets. In clopidogrel good-responder patients, assessment of TF
pos
-platelets highlights those with residual platelet reactivity. TF is stored in open canalicular system, and its membrane exposure upon activation is prevented by colchicine.