Hypertensive Emergencies Are Associated with Elevated Markers of Inﬂammation, Coagulation, Platelet Activation and ﬁbrinolysis

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ORIGINAL ARTICLE Hypertensive emergencies are associated with elevated markers of inﬂammation, coagulation, platelet activation and ﬁbrinolysis

U Derhaschnig1,2, C Testori2, E Riedmueller2, S Aschauer1, M Wolzt1 and B Jilma1

Data from in vitro and animal experiments suggest that progressive endothelial damage with subsequent activation of coagulation and inflammation have a key role in hypertensive crisis. However, clinical investigations are scarce. We hypothesized that hypertensive emergencies are associated with enhanced inflammation, endothelial- and coagulation activation. Thus, we enrolled 60 patients admitted to an emergency department in a prospective, cross-sectional study. We compared markers of coagulation, fibrinolysis

(prothrombin fragment F1 þ 2, plasmin–antiplasmin complexes, plasmin-activator inhibitor, tissue plasminogen activator), platelet- and endothelial activation and inflammation (P-selectin, C-reactive protein, leukocyte counts, fibrinogen, soluble vascular adhesion molecule-1, intercellular adhesion molecule-1, myeloperoxidase and asymmetric dimethylarginine) between hypertensive emergencies, urgencies and normotensive patients. In hypertensive emergencies, markers of inflammation and endothelial activation were significantly higher as compared with urgencies and controls (Po0.05). Likewise, plasmin–antiplasmin complexes were 75% higher in emergencies as compared with urgencies (Po0.001), as were tissue plasminogen-activator levels (B30%; Po0.05) and sP-selectin (B40%; Po0.05). In contrast, similar levels of all parameters were found between urgencies and controls. We consistently observed elevated markers of thrombogenesis, fibrinolysis and inflammation in hypertensive emergencies as compared with urgencies. Further studies will be needed to clarify if these alterations are cause or consequence of target organ damage.

Journal of Human Hypertension (2013) 27, 368–373; doi:10.1038/jhh.2012.53; published online 20 December 2012 Keywords: coagulation; ﬁbrinolysis; urgency; hypertensive emergency; inﬂammation

INTRODUCTION lesser extent in hypertensive urgencies without target organ Hypertensive crises are frequently observed medical events.1,2 deterioration. They comprise critical elevation of blood pressure (BP) compli- We therefore prospectively compared markers of inflammatory cated by target organ dysfunction, defined as hypertensive activity, coagulation, platelet and endothelial activation and emergency (HE) or without target organ deterioration, that is, fibrinolysis between patients with hypertensive emergencies and hypertensive urgency (HU).3 urgencies treated at a non-surgical emergency department (ED). The endothelium has a central role in BP homeostasis and Normotensive patients, attending the ED for other reasons, served therefore in the pathogenesis of hypertensive crisis.4 The initial as an additional control group. triggering mechanisms are incompletely understood. It is assumed that hypertensive crisis has multifactorial causes so that mechanical injury, activation of the renin–angiotensin system, MATERIALS AND METHODS oxidative stress and production of inflammatory cytokines together Study population lead to endothelial damage.4 Subsequently, endothelial cells The study was approved by the local Ethics Committee and was carried out release vasodilator molecules, such as nitric oxide.4,5 However, at the non-surgical ED of the Medical University of Vienna, a tertiary care when compensatory mechanisms are overwhelmed, a vicious cycle center, from 2008 to 2009, according to the Declaration of Helsinki. begins and progressive endothelial damage causes further rise in After written informed consent, 60 patients were enrolled in this cross-sectional study—20 consecutive patients with hypertensive emer- BP, increased endothelial permeability, activation of the gencies and 20 with hypertensive urgency. Twenty age-matched coagulation system, inhibition of local fibrinolysis and production normotensive patients, who attended the ED for other reasons (gastritis 4,5 of inflammatory cytokines. These mechanisms can culminate in (n ¼ 2), back pain (n ¼ 8), needlestick injury (n ¼ 1), follow-up after end organ hypoperfusion, ischemia and dysfunction.4,5 needlestick injury (n ¼ 8), electric shock (n ¼ 1)), served as an additional Most of the data supporting the pathophysiological concept control group. are gained from in vitro and animal experiments,4 and clinical HE and HU were defined according to the guidelines3 as follows: investigations are scarce. Only data from patients with malignant elevation of BP X180 mm Hg systolic and/or X110 mm Hg diastolic hypertension, which is a special form of hypertensive crisis without evidence of target organ deterioration (that is, HU). HE was defined as severe BP elevation (s. above) with target organ dysfunction characterized by thrombotic microangiopathy and ischemic 6,7 (acute pulmonary edema, coronary ischemia, hypertensive encephalo- retinal changes, were recently presented. pathy, cerebral infarction, intracerebral hemorrhage, aortic dissection or Thus, we set out to investigate if hypertensive emergencies are acute renal failure defined, according to the RIFLE criteria.8 as well associated with endothelial or coagulation activation and Exclusion criteria were the inability or refusal to give informed consent, inflammation. We further wanted to investigate if this occurs to a pre-eclamsia, eclampsia,3 clinical pattern and additional laboratory signs of

1Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria and 2Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria. Correspondence: Dr B Jilma, Department of Clinical Pharmacology, Medical University of Vienna, Wa¨hringer, Gu¨rtel 18-20, A-1090 Vienna, Austria. E-mail: [email protected] Received 12 June 2012; revised 14 September 2012; accepted 24 October 2012; published online 20 December 2012 Inflammation, coagulation and fibrinolysis in hypertensive crisis U Derhaschnig et al 369 acute infection (that is, initial elevation of C-reactive protein 410 mg dl À 1 patients with diabetes in the emergency group as compared with 1 or fibrinogen 4450 mg dl À ), acute thromboembolic disorders (pulmo- patients with urgencies (Po0.05). nary embolism, deep vein thrombosis), cancer, pre-existent therapy with As expected, initial BP was significantly higher in HE as oral anticoagulants and known chronic kidney disease stage 3 or higher. compared with HU (Po0.05) and pulmonary edema was the Normotensive controls had no history of hypertension, no intake of most frequent kind of end organ damage observed in HE (58%), antihypertensive drugs and a BP o130/85 (measured twice after 5 min of sitting in resting position), no history of diabetes mellitus, pre-existent followed by hemorrhagic stroke (26%). HU patients presented cardiovascular disease or relevant medical illness. with malaise (n ¼ 2), vertigo (n ¼ 5), palpitations (n ¼ 1), headache BP was measured repeatedly within the scope of an ambulant or (n ¼ 5), dizziness (n ¼ 4) and discomfort in the chest (n ¼ 3). intermediate care ED setting with an automated device (Hewlett-Packard, Palo Alto, CA, USA) or within the intensive care setting via direct intra- Markers of inflammation and endothelial activation arterial measurement. B Blood was sampled before any relevant intervention; all diagnostic– In patients with hypertensive emergencies, CRP was twofold therapeutic interventions were performed thereafter under the discretion of higher as compared with urgencies (P ¼ 0.01) and 64% higher the attending physician. A second independent physician, blinded to the than in normotensive controls (P ¼ 0.01, Figure 1, Table 2). primary clinical diagnosis, confirmed the final diagnosis (HE, HU) by chart Leukocyte counts were significantly increased in HE compared review. with HU and controls (Po0.001 for HE vs HU and normotensives) Blood was sampled into evacuated sterile tubes (Vacutainer, BD, NJ, as were fibrinogen levels (P ¼ 0.03 HE vs HU and P ¼ 0.01 HE vs USA). For the analysis of coagulation and inflammatory parameters, blood normotensives, respectively). Concentrations of both biomarkers was immediately centrifuged at 3000 Â g for 15 min and stored as 0.5 ml were not significantly different between HU and normotensive aliqots at À 80 1C until batch analysis. Blood cell counts (Coulter Counter, Beckman Coulter, Brea, CA, USA) and analysis of C-reactive protein (CRP; patients (P ¼ n.s., Figure 1). and fibrinogen (STA, Roche Diagnostics, Vienna, Austria) were done in the VCAM-1 levels were significantly higher in HE patients as central laboratory within the scope of routine laboratory assessment. compared with HU (P ¼ 0.01) and normotensives (P ¼ 0.01), whereas VCAM-1 was not significantly different between HU and Inflammatory parameters and markers of endothelial dysfunction normotensives (P ¼ 0.50, Table 2). No significant difference was observed for ICAM-1 levels for all groups (P ¼ 0.92 HE vs HU; Soluble vascular adhesion molecule (sVCAM)-1, soluble intercellular adhesion molecule (sICAM)-1 and myeloperoxidase (MPO) were measured P ¼ 0.08 HE and P ¼ 0.77 HU vs normotensives, respectively). by ELISA (R&D Systems, Abingdon, UK).9 Asymmetric dimethylarginine Patients with HE exhibited 26% higher MPO levels as compared (ADMA) was measured by high-performance liquid chromatography, as with HU (P ¼ 0.05), whereas MPO levels were not significantly previously described.10 different between HE and normotensive patients (P ¼ 0.08 HE vs controls and P ¼ 0.54 HU vs controls, Table 2). Coagulation parameters ADMA levels were significantly higher in HE as compared with The following parameters were measured by ELISA: Plasmin–antiplasmin HU (P ¼ 0.03), whereas there was no significant difference complex (PAP; Enzygnost PAP micro, Behring, FRA),11 prothrombin between crisis patients and normotensives (P ¼ 0.72 HE and 0.07 12 HU vs normotensives, respectively; Table 2). fragment1 þ 2 (F1 þ 2, Behring, FRA), active plasminogen-activator inhibitor (Technozym PAI-1 Actibind,Technoclone, Vienna, Austria), tissue plasminogen-activator antigen (t-PA Ag), which detects the total amount Markers of coagulation, fibrinolysis and platelet activation of t-PA, and active t-PA, which is not complexed to PAI-1 (t-PA Combi Actibind, Technoclone), soluble (s) P-selectin (R&D Systems).13 F1 þ 2 levels were only 23% higher in hypertensive emergencies as compared with urgencies, (P ¼ 0.69). However, F1 þ 2 levels were 40% higher in HE patients as compared with normotensive Statistical analysis controls (Po0.05), whereas no significant difference was observed Because of the lack of data in patients with hypertensive crisis, a sample between HU and normotensives (Figure 2). size calculation was difficult to perform. In a study comparing CRP levels between normotensives and patients with non dipping essential PAP levels were 75 and 47% higher in HE patients as compared hypertension, 10 patients in each group would have sufficed to provide with urgencies or normotensives, respectively (Po0.001 for both 80% power.14 The primary comparison in our study was between HE and comparisons, Figure 2). Again, there was no significant difference HU. However, no data about HE and HU were available. Hence, we in PAP between HU and normotensive patients (Figure 2). assumed that 20 persons in each group are adequate to have 80% power PAI-1 levels were 66% higher in hypertensive emergencies (a-error of 5%) to detect differences in the primary outcome variable (CRP). and 25% higher in urgencies as compared with normotensives, Continuous data are given as median and range, if not otherwise which, however, was not statistically significant (Figure 2). specified, categorical data as frequencies and percentages. Categorical Patients with HE exhibited 29% higher t-PA Ag levels than data were compared with the Fisher’s exact test. For continuous data patients with urgencies and 43% higher t-PA Ag levels than non parametric tests were applied. The Kruska Wallis ANOVA and the Mann–Whitney U-test were used for comparison between groups. The controls (Po0.05 for both comparisons, Figure 2). Active t-PA Spearman’s correlation was used to measure correlation between levels were about twofold higher in HE as compared with HU or parameters (SPSS 10.0, SPSS Inc., USA). Markers of coagulation, fibrinolysis, normotensives (Po0.05 HE vs HU and normotensives, Table 2). platelet activation and inflammation are interdependent. Yet, we applied As seen with the other markers, there was no significant difference the Bonferroni–Holm procedure to account for multiple comparisons.15 between HU and controls in either t-PA Ag or active t-PA (Figure 2, Table 2). P-selectin was 42% higher in patients with HE as compared RESULTS with urgencies (Po0.05) and 61% higher than in normo- Demographic and clinical data are depicted in Table 1. Twenty tensives (Po0.05, Table 2). No significant difference in P-selectin patients with hypertensive urgencies, 19 with emergencies and 20 was observed between HU and normotensive controls normotensive control patients were finally analyzed. One patient (Table 2). with HE had to be excluded because of incorrectly processed Four HE patients had diabetes mellitus as compared with blood samples. none in the HU group (Po0.05). After exclusion of diabetes There were no significant differences in age, body mass index, patients, CRP, leukocyte counts, MPO, PAP and fibrinogen smoking habits or sex distribution between groups (Table 1). Use levels remained significantly different, whereas P-selectin and of angiotensin-converting enzyme inhibitors, angiotensin receptor ADMA reached only borderline significance (P ¼ 0.06 for P-selectin blockers, statins, as well as aspirin and clopidogrel, was similar in and ADMA) and t-PA and VCAM-1 showed no significant both patient groups (Table 1). There were significantly more difference (P ¼ 0.13).

& 2013 Macmillan Publishers Limited Journal of Human Hypertension (2013) 368 – 373 Inflammation, coagulation and fibrinolysis in hypertensive crisis U Derhaschnig et al 370 nical stretching and angiotensin II.4 It was recently shown that Table 1. Demographics and clinical characteristics hsCRP levels were elevated in hypertensive crisis and declined 18 Normotensives Hypertensive Hypertensive after the acute event. This finding was confirmed by our trial and (n ¼ 20) urgencies emergencies we could additionally show increased fibrinogen and leukocyte (n ¼ 20) (n ¼ 19) counts in patients with HE, reflecting heightened inflammatory activity. Patients with increased CRP levels have impaired Age (years) 52±11 56±12 64±14 vasoreactivity, which might contribute to HE.19,20 Moreover, CRP Sex (f/m) 11/8 10/10 7/12 itself decreases eNOS expression and induces adhesion molecule SBP (mm Hg) 120±10 191±6** 211±28** expression.20 Soluble VCAM-1 levels were higher in our patients ± ± ± DBP (mm Hg) 67 11 95 21** 113 20** with HE, whereas sICAM-levels were similar to controls. Although alterations of both adhesion molecules are reported in essential Medical history 21,22 Current smoker (n, %) 12 (60) 7 (35) 6 (32) hypertension, our results are in accordance with the data Former smoker (n, %) 6 (30) 2 (10) 9 (47) from malignant hypertension, where no difference was found in 23 Cardiovascular 0 4 (20) 5 (26) sICAM-1 levels compared with controls. Shear stress induces disease (n,%) the expression of adhesion molecules in vitro,24 and increased Diabetes mellitus 0 0 4 (21)* expression of adhesion molecules, as observed in HE, can (n,%) À 2 contribute to consecutive loss of endothelial function by BMI (kg m )25±627±529±4 promoting local inflammation.4 1 1 Duration of 0 36 (0–290) 30 (0–420) MPO is a biomarker of inflammation and oxidative stress hypertension 25 (months) produced by neutrophils, monocytes and endothelial cells. It contributes to vascular inflammation by depletion of vascular NO 25 Medication on admission with ensuing endothelial dysfunction. MPO is elevated in 26 ACE inhibitor (n, %) 0 6 (30) 6 (32) preeclampsia, strongly related to endothelial dysfunction and Angiotensin receptor 0 3 (15) 3 (16) associated with risk of cardiovascular disease.21 ADMA is an blocker (n,%) endogenous modulator for endothelial dysfunction and oxidative Diuretics (n, %) 0 3 (15) 4 (21) stress, and increased shear stress triggers ADMA synthesis.27 We b-blocker (n,%) 0 7 (35) 4 (21) found significantly higher MPO and ADMA levels in HE as compared a-blocker (n, %) 0 2 (10) 4 (21) with HU but no significant difference as compared with controls. This Calcium channel 0 1 (5) 0 is in contrast to data from the literature showing that ADMA levels antagonists (n,%) 28,29 Aspirin (n, %) 0 5 (25) 6 (32) are elevated in patients with essential hypertension. However, Clopidogrel (n, %) 0 0 1 (5) the limited sample sizes in our study likely compromises the power Statins (n, %) 0 3 (15) 4 (21) to detect small differences between groups. Data from in vitro and animal experiments revealed that BP End-organ damage on admission elevation and shear stress induces coagulation activation,30,31 and Pulmonary edema (n)11that the extent of coagulation activation is associated with the Angina (n)1degree of target organ damage in patients with essential Stroke (hemorrhagic) 5 hypertension.7,32–34 Also, malignant hypertension, a special form (n) Transistent ischemic 1 of hypertensive crisis characterized by thrombotic microangiopathy, is associated with enhanced thrombogenesis and attack (n) 6 Subarachnoidal 1 fibrinolysis. This is in line with our finding that PAP, a marker of hemorrhage (n) activated fibrinolysis, and t-PA were elevated in patients with hypertensive emergencies. In contrast, there was only a trend Abbreviations: ACE, angiotensin-converting enzyme; BMI, body-mass- toward higher PAI-1 levels in HE, which is consistent with index; DBP, diastolic BP; SBP, systolic BP. Data are given as mean s.d. or þ observations made in malignant hypertension.6 1 median and range; *P ¼ 0.03, **Po0.05 between all groups. Different from the acute BP rise in hypertensive emergencies, patients with chronic essential hypertension appear to have impaired release of t-PA35 and lowering of BP restores impaired Correlation analysis was performed with systolic BP (SBP) and t-PA synthesis and release.36 The higher levels of t-PA Ag biochemical markers. It revealed a weak correlation between SBP and active t-PA in HE could thus potentially reflect a different and leukocyte counts (r ¼ 0.28), fibrinogen (r ¼ 0.32), PAP (r ¼ 0.43), underlying mechanism as compared with chronic essential P-selectin (r ¼ 0.31), sICAM-1 (r ¼ 0.27) and sVCAM-1 (r ¼ 0.36) hypertension. (Table 3). Subgroup analysis showed weak correlation of SBP and Increase in shear stress, angiotensin and stress hormones active t-PA (r ¼ 0.60) and P-selectin (r ¼ 0.55) in normotensives, SBP induces TF-mRNA in vitro.37–39 These factors could contribute to and fibrinogen (r ¼ 0.50) in the HU group (Table 3). No significant the elevated levels of prothrombin fragment F1 þ 2 in HE as correlations were found in the HE group (Table 3). compared with controls. Platelet activation, as measured by P-selectin,40 was also heightened in HE, which is in line with increased P-selectin DISCUSSION levels in malignant hypertension.6 There are several explanations The main findings of our study are that hypertensive emergencies, for this finding. Platelets express angiotensin receptors on their that is BP elevation with target organ damage, are associated surface41 and infusion of angiotensin II leads to platelet with inflammation, coagulation and platelet activation and activation.42 Moreover, sympathetic activation, which is present enhanced fibrinolytic activity. In contrast, patients with hyperten- in hypertensive emergencies, especially in pulmonary edema, and sive urgencies show levels of biomarkers similar to normotensive shear stress lead to platelet activation.43 controls. Interestingly, we found no significant difference in these Endothelial cells exist in a dynamic state and respond to parameters between patients with HU and normotensive controls. alterations in the level of shear stress and various stimuli by This is in contrast to numerous studies showing coagulation and induction of different genes and release of various factors.16,17 platelet activation in essential hypertension.44 However, our They release pro-inflammatory cytokines in response to mecha- results are consistent with the results of van den Born et al.,6

Journal of Human Hypertension (2013) 368 – 373 & 2013 Macmillan Publishers Limited Inflammation, coagulation and fibrinolysis in hypertensive crisis U Derhaschnig et al 371 where a subgroup comparable to HU showed as well no signi- Correlation analysis showed only weak correlation between SBP ficant elevation in F1 þ 2 levels as compared with normotensive and markers of inflammation and coagulation in hypertensive controls. Again the limited sample size precludes detection of urgencies and emergencies, which is rather related to differences small differences. between patient groups. It seems that coagulation and endo-

Figure 1. Patients with hypertensive emergencies have higher Figure 2. Coagulation markers and markers of ﬁbrinolysis. Data are inﬂammatory markers as compared with urgencies or normoten- given as mean±s.e.m.; tPA, tissue plasminogen-activator inhibitor; sives. Data are given as mean±s.e.m.; WBC, white blood cell count; PAI-1, plasminogen-activator inhibitor; F1 þ 2, prothrombinfragment1 þ 2; CRP, C-reactive protein; HU, hypertensive urgencies; HE, hyperten- PAP, plasmin-antiplasmin complex; HU, hypertensive urgencies; HE, sive emergencies; *Po0.05 HE vs HU; **Po0.001 HE vs HU; hypertensive emergencies; *Po0.05 HE vs HU; **Po0.001 HE vs HU; #Po0.05 HE vs normotensives; ##Po0.001 HE vs normotensives. #Po0.05 HE vs normotensives; ##Po0.001 HE vs normotensives.

Table 2. Markers of endothelial and platelet activation

Normotensives Hypertensive Hypertensive (n ¼ 20) urgencies emergencies (n ¼ 20) (n ¼ 19)

Leukocyte count (g l À l) 7.6 (5.5–8.9) 7.1 (6.64–7.7) 11.8 (9.2–14.3)*,## CRP (mg dl À 1) 0.16 (0.08–0.5) 0.18 (0.07–0.38) 0.41 (0.25–0.65)*,# Fibrinogen (mg dl À 1) 321 (313–387) 359 (288–406) 427 (378–491)*,# sICAM-1 (ng ml À 1) 210 (168–236) 206 (164–241) 253 (174–320) sVCAM-1 (ng ml À 1) 559 (439–668) 582 (515–670) 805 (609–983)*,# MPO (ng ml À 1) 74 (54–119) 75 (60–83) 102 (74–272)* ADMA (mmol l À 1) 0.54 (0.46–0.61) 0.49 (0.44–0.54) 0.56 (0.49–0.64)* À 1 # F1 þ 2 (pmol ml ) 216 (169–270) 238 (162–302) 359 (216–418) PAP (mgmlÀ 1) 678 (630–856) 803 (639–1049) 1184 (924–1927)*,## PAI-1 (U ml À 1) 3.3 (1.2–10.8) 4.4 (2.7–9.6) 5.5 (4.1–10.3) t-PA Ag (ng ml À 1) 2.9 (2.5–3.5) 3.1(2.5–9.6) 4.0 (2.9–9.7)*,# t-PA active (U ml À 1) 0.08 (0.06–0.15) 0.08 (0.06–0.14) 0.17 (0.13–0.27)*,# sP-selectin (ng ml À 1) 23 (18–33) 26 (17–31) 37 (25–48)*,##

Abbreviations: ADMA, asymmetric dimethylarginine; CRP, C-reactive protein; F1 þ 2, prothrombinfragment1 þ 2; MPO, myeloperoxidase; PAI-1, plasminogen- activator inhibitor; PAP, plasmin-antiplasmin complex; sICAM-1, soluble intercellular adhesion molecule 1; sP-selectin, soluble P-selectin; sVCAM-1, soluble vascular adhesion molecule 1; t-PA Ag, tissue plasminogen-activator antigen. Data are given as median and range. *Po0.05 HE vs HU. #Po0.05 HE vs normotensives. #Po0.001 HE vs normotensives.

& 2013 Macmillan Publishers Limited Journal of Human Hypertension (2013) 368 – 373 Inflammation, coagulation and fibrinolysis in hypertensive crisis U Derhaschnig et al 372 REFERENCES Table 3. Correlation between systolic BP and markers of inflammation and coagulation 1 Zampaglione B, Pascale C, Marchisio M, Cavallo-Perin P. Hypertensive urgencies and emergencies. Prevalence and clinical presentation. Hypertension 1996; 27: 144–147. Spearman’s correlation coefficient (r) 2 Vilela-Martin JF, Vaz-de-Melo RO, Kuniyoshi CH, Abdo AN, Yugar-Toledo JC. Hypertensive crisis: clinical-epidemiological profile. Hypertens Res 2011; 34: SBP & All Normotensives Hypertensive Hypertensive 367–371. urgencies emergencies 3 The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC V). Arch Intern Med 1993; 153: CRP 0.25 0.23 0.16 À 0.15 154–183. leukocyte 0.28* 0.56 0.22 À 0.34 4 Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet 2000; 356: 411–417. counts 5 Marik PE, Varon J. Hypertensive crises: challenges and management. Chest 2007; Fibrinogen 0.31* À 0.09 0.50* À 0.40 131: 1949–1962. F1 þ 2 0.22 0.15 À 0.26 0.17 6 van den Born BJ, Lowenberg EC, van der Hoeven NV, de Laat B, Meijers JC, Levi M # PAP 0.43 0.2 0.03 À 0.04 et al. Endothelial dysfunction, platelet activation, thrombogenesis and fibrinolysis t-PA Ag 0.17 À 0.37 0.17 À 0.16 in patients with hypertensive crisis. J Hypertens 2011; 29: 922–927. Active t-PA 0.25 0.58* À 0.30 0.14 7 Lip GY, Edmunds E, Hee FL, Blann AD, Beevers DG. A cross-sectional, diurnal, and PAI-1 0.08 À 0.05 0.19 À 0.24 follow-up study of platelet activation and endothelial dysfunction in malignant sP-selectin 0.31* 0.55* 0.13 À 0.42 phase hypertension. Am J Hypertens 2001; 14: 823–828. sICAM-1 0.27* 0.12 0.27 0.22 8 Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute renal failure - sVCAM-1 0.36* À 0.02 0.07 0.33 definition, outcome measures, animal models, fluid therapy and information ADMA 0.04 0.33 0.34 0.09 technology needs: the Second International Consensus Conference of the Acute MPO 0.09 0.03 À 0.03 0.03 Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8: R204–R212. 9 Jilma B, Eichler HG, Breiteneder H, Wolzt M, Aringer M, Graninger W et al. Effects Abbreviations: ADMA, asymmetric dimethylarginine; CRP, C-reactive of 17 beta-estradiol on circulating adhesion molecules. J Clin Endocrinol Metab protein; F , prothrombinfragment ; MPO, myeloperoxidase; PAI-1, 1 þ 2 1 þ 2 1994; 79: 1619–1624. plasminogen-activator inhibitor; PAP, plasmin-antiplasmin complex; 10 Mittermayer F, Namiranian K, Pleiner J, Schaller G, Wolzt M. Acute Escherichia coli sICAM-1, soluble intercellular adhesion molecule 1; sP-selectin, soluble endotoxaemia decreases the plasma l-arginine/asymmetrical dimethylarginine P-selectin; sVCAM-1, soluble vascular adhesion molecule 1; t-PA Ag, tissue ratio in humans. Clin Sci (Lond) 2004; 106: 577–581. plasminogen-activator antigen. *Po0.05; #Po0.001. 11 Derhaschnig U, Bergmair D, Marsik C, Schlifke I, Wijdenes J, Jilma B. Effect of interleukin-6 blockade on tissue factor-induced coagulation in human endotox- thelial activation is not solely dependent on BP levels in emia. Crit Care Med 2004; 32: 1136–1140. 12 Pernerstorfer T, Stohlawetz P, Hollenstein U, Dzirlo L, Eichler HG, Kapiotis S et al. hypertensive emergencies. Thus, it would be interesting to Endotoxin-induced activation of the coagulation cascade in humans: effect of examine if patients will benefit from therapy with antihyperten- acetylsalicylic acid and acetaminophen. Arterioscler Thromb Vasc Biol 1999; 19: sive agents, like angiotensin-converting enzyme-I and ARB that 2517–2523. additionally exert effects on coagulation and endothelial dysfunc- 13 Derhaschnig U, Schweeger-Exeli I, Marsik C, Cardona F, Minuz P, Jilma B. Effects of tion. Further studies will be needed to clarify these questions. aspirin and NO-aspirin (NCX 4016) on platelet function and coagulation in human endotoxemia. Platelets 2010; 21: 320–328. LIMITATIONS 14 Kaya MG, Yarlioglues M, Gunebakmaz O, Gunturk E, Inanc T, Dogan A. Platelet activation and inflammatory response in patients with non-dipper hypertension. Because of our cross-sectional design, we cannot draw conclu- Atherosclerosis 2010; 209: 278–282. sions about cause–effect relationship and can only speculate 15 Holm S. A simple sequentially rejective multiple test procedure. Scand J Stat 1979; about endothelial dysfunction as a pathogenetic factor for some 6: 65–70. of the alterations in biomarkers. Likewise, enhanced inflammation, 16 Lip GY, Blann AD. Endothelium and fibrinolysis in hypertension: important facets platelet activation and coagulation activation could potentially of a prothrombotic state? Hypertension 2008; 52: 218–219. contribute to target organ damage. 17 Thuillez C, Richard V. Targeting endothelial dysfunction in hypertensive subjects. In conclusion, this prospective study revealed altered endothe- J Hum Hypertens 2005; 19: S21–S25. 18 Thiele S, Britz S, Landsiedel L, Wallaschofski H, Lohmann T. Short-term changes in lial function, coagulation and platelet activation and fibrinolysis in hsCRP and NT-proBNP levels in hypertensive emergencies. Horm Metab Res 2008; hypertensive emergencies as compared with urgencies. 40: 561–565. 19 Boos CJ, Lip GY. Elevated high-sensitive C-reactive protein, large arterial stiffness and atherosclerosis: a relationship between inflammation and hypertension? What is known about the topic J Hum Hypertens 2005; 19: 511–513. Hypertensive emergencies are possibly associated with activation of 20 Venugopal SK, Devaraj S, Yuhanna I, Shaul P, Jialal I. Demonstration that coagulation and inflammation. C-reactive protein decreases eNOS expression and bioactivity in human aortic Clinical investigations are scarce. endothelial cells. Circulation 2002; 106: 1439–1441. 21 DeSouza CA, Dengel DR, Macko RF, Cox K, Seals DR. Elevated levels of circulating What this study adds cell adhesion molecules in uncomplicated essential hypertension. Am J Hypertens Patients with hypertensive emergencies have elevated markers of 1997; 10: 1335–1341. thrombogenesis and fibrinolysis as compared with patients with 22 Coppolino G, Bolignano D, Campo S, Loddo S, Teti D, Buemi M. Circulating urgencies. progenitor cells after cold pressor test in hypertensive and uremic patients. Patients with hypertensive emergencies have elevated inflammatory Hypertens Res 2008; 31: 717–724. parameters as compared with urgency patients. 23 Verhaar MC, Beutler JJ, Gaillard CA, Koomans HA, Fijnheer R, Rabelink TJ. Progressive vascular damage in hypertension is associated with increased levels of circulating P-selectin. J Hypertens 1998; 16: 45–50. 24 Walpola PL, Gotlieb AI, Cybulsky MI, Langille BL. Expression of ICAM-1 and VCAM- CONFLICT OF INTEREST 1 and monocyte adherence in arteries exposed to altered shear stress. Arterioscler Thromb Vasc Biol 1995; 15: 2–10. The authors declare no conflicts of interest. 25 Schindhelm RK, van der Zwan LP, Teerlink T, Scheffer PG. Myeloperoxidase: a useful biomarker for cardiovascular disease risk stratification? Clin Chem 2009; 55: ACKNOWLEDGEMENTS 1462–1470. We thank Mrs Karin Petroczi and Astrid Fabry for their valuable laboratory work. This 26 Vita JA, Brennan ML, Gokce N, Mann SA, Goormastic M, Shishehbor MH et al. project was partly supported by a research grant (Number 701) of the Austrian Heart Serum myeloperoxidase levels independently predict endothelial dysfunction in Funds dedicated to UD. humans. Circulation 2004; 110: 1134–1139.

Journal of Human Hypertension (2013) 368 – 373 & 2013 Macmillan Publishers Limited Inflammation, coagulation and fibrinolysis in hypertensive crisis U Derhaschnig et al 373 27 Osanai T, Saitoh M, Sasaki S, Tomita H, Matsunaga T, Okumura K. Effect of shear 36 Ridderstrale W, Ulfhammer E, Jern S, Hrafnkelsdottir T. Impaired capacity for sti- stress on asymmetric dimethylarginine release from vascular endothelial cells. mulated fibrinolysis in primary hypertension is restored by antihypertensive Hypertension 2003; 42: 985–990. therapy. Hypertension 2006; 47: 686–691. 28 Pasini AF, Garbin U, Stranieri C, Boccioletti V, Mozzini C, Manfro S et al. Nebivolol 37 Camera M, Frigerio M, Toschi V, Brambilla M, Rossi F, Cottell DC et al. Platelet treatment reduces serum levels of asymmetric dimethylarginine and improves activation induces cell-surface immunoreactive tissue factor expression, which is endothelial dysfunction in essential hypertensive patients. Am J Hypertens 2008; modulated differently by antiplatelet drugs. Arterioscler Thromb Vasc Biol 2003; 23: 21: 1251–1257. 1690–1696. 29 Sonmez A, Celebi G, Erdem G, Tapan S, Genc H, Tasci I et al. Plasma apelin and 38 Mazzolai L, Silacci P, Bouzourene K, Daniel F, Brunner H, Hayoz D. Tissue factor ADMA levels in patients with essential hypertension. Clin Exp Hypertens 2010; 32: activity is upregulated in human endothelial cells exposed to oscillatory shear 179–183. stress. Thromb Haemost 2002; 87: 1062–1068. 30 Lin MC, Almus-Jacobs F, Chen HH, Parry GC, Mackman N, Shyy JY et al. 39 Nishimura H, Tsuji H, Masuda H, Nakagawa K, Nakahara Y, Kitamura H et al. Shear stress induction of the tissue factor gene. J Clin Invest 1997; 99: Angiotensin II increases plasminogen activator inhibitor-1 and tissue factor mRNA 737–744. expression without changing that of tissue type plasminogen activator or tissue 31 Silverman MD, Waters CR, Hayman GT, Wigboldus J, Samet MM, Lelkes PI. Tissue factor pathway inhibitor in cultured rat aortic endothelial cells. Thromb Haemost factor activity is increased in human endothelial cells cultured under elevated 1997; 77: 1189–1195. static pressure. Am J Physiol 1999; 277: C233–C242. 40 Stohlawetz P, Horvath M, Pernerstorfer T, Nguyen H, Vondrovec B, Robisch A et al. 32 Nadar S, Blann AD, Lip GY. Platelet morphology and plasma indices of platelet Effects of nitric oxide on platelet activation during plateletpheresis and in vivo activation in essential hypertension: effects of amlodipine-based antihypertensive tracking of biotinylated platelets in humans. Transfusion 1999; 39: 506–514. therapy. Ann Med 2004; 36: 552–557. 41 Crabos M, Bertschin S, Buhler FR, Rogg H, Evequoz D, Eberhard M et al. Identifi- 33 Sechi LA, Novello M, Colussi G, Di FA, Chiuch A, Nadalini E et al. Relationship of cation of AT1 receptors on human platelets and decreased angiotensin II binding plasma renin with a prothrombotic state in hypertension: relevance for organ in hypertension. J Hypertens Suppl 1993; 11: S230–S231. damage. Am J Hypertens 2003; 21: 1347–1353. 42 Larsson PT, Schwieler JH, Wallen NH. Platelet activation during angiotensin II 34 Spencer CG, Gurney D, Blann AD, Beevers DG, Lip GY. Von Willebrand factor, infusion in healthy volunteers. Blood Coagul Fibrinolysis 2000; 11: 61–69. soluble P-selectin, and target organ damage in hypertension: a substudy 43 Gkaliagkousi E, Passacquale G, Douma S, Zamboulis C, Ferro A. Platelet activation of the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT). Hypertension 2002; 40: in essential hypertension: implications for antiplatelet treatment. Am J Hypertens 61–66. 2010; 23: 229–236. 35 Hrafnkelsdottir T, Wall U, Jern C, Jern S. Impaired capacity for endogenous fibri- 44 Lip GY, Li-Saw-Hee FL. Does hypertension confer a hypercoagulable state? nolysis in essential hypertension. Lancet 1998; 352: 1597–1598. J Hypertens 1998; 16: 913–916.

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