Publications by authors named "Argyri Gialeraki"

32 Publications

The Safety and Efficacy of Tranexamic Acid in Oncology Patients Undergoing Endoprosthetic Reconstruction and a ROTEM-Based Evaluation of Their Hemostatic Profile: A Pilot Study.

Cancers (Basel) 2021 Aug 5;13(16). Epub 2021 Aug 5.

Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece.

Background: An endoprosthetic reconstruction in musculoskeletal oncology patients is associated with significant blood loss. The purpose of this study is to evaluate the safety and efficacy of tranexamic acid (TXA) for these patients and to assess any changes in their hemostatic profile using rotational thromboelastometry (ROTEM).

Methods: A retrospective observational study was performed including 61 patients with primary or metastatic bone tumors who underwent surgery. Group A ( = 30) received both intravenous and local TXA whereas Group B ( = 31) was the control group. The primary outcomes were perioperative blood loss and blood unit transfusions and the secondary outcomes included the incidence of thromboembolic complications and a change in blood coagulability as reflected by ROTEM parameters.

Results: The median difference in blood loss between the two groups was 548.5 mL, indicating a 29.2% reduction in the 72 h blood loss following TXA administration ( < 0.001). TXA also led to a reduced transfusion of 1 red blood cell (RBC) unit per patient ( < 0.001). The two groups had similar rates of thromboembolic complications ( = 0.99). The antifibrinolytic properties of TXA were confirmed by the significantly higher INTEM, FIBTEM and EXTEM LI60 ( < 0.001, = 0.005 and < 0.001, respectively) values in the TXA group.

Conclusion: Tranexamic acid was associated with a significant reduction in perioperative blood loss and transfusion requirements without a complete shutdown of the fibrinolysis. Larger studies are warranted to assess the frequency of these outcomes in musculoskeletal oncology patients.
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http://dx.doi.org/10.3390/cancers13163951DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8392365PMC
August 2021

Rotational Thromboelastometry Findings Are Associated with Symptomatic Venous Thromboembolic Complications after Hip Fracture Surgery.

Clin Orthop Relat Res 2021 06 2. Epub 2021 Jun 2.

A. G. Tsantes, A. Gialeraki, A. E. Tsantes, Laboratory of Haematology and Blood Bank Unit, Attiko Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.

Background: Venous thromboembolism is a common complication after hip fractures. However, there are no reliable laboratory assays to identify patients at risk for venous thromboembolic (VTE) events after major orthopaedic surgery.

Question/purposes: (1) Are rotational thromboelastometry (ROTEM) findings associated with the presence or development of symptomatic VTE after hip fracture surgery? (2) Were any other patient factors associated with the presence or development of symptomatic VTE after hip fracture surgery? (3) Which ROTEM parameters were the most accurate in terms of detecting the association of hypercoagulability with symptomatic VTE?

Methods: This retrospective study was conducted over a 13-month period. In all, 354 patients with femoral neck and peritrochanteric fractures who underwent hip hemiarthoplasty or cephallomedullary nailing were assessed for eligibility. Of those, 99% (349 of 354) were considered eligible for the study, 1% (3 of 354) of patients were excluded due to coagulation disorders, and another 1% (2 of 354) were excluded because they died before the postoperative ROTEM analysis. An additional 4% (13 of 354) of patients were lost before the minimum study follow-up of 3 months, leaving 95% (336 of 354) for analysis. A ROTEM analysis was performed in all patients at the time of their hospital admission, within hours of the injury, and on the second postoperative day. The patients were monitored for the development of symptoms indicative of VTE, and the gold standard tests for diagnosing VTE, such as CT pulmonary angiography or vascular ultrasound, were selectively performed only in symptomatic patients and not routinely in all patients. Therefore, this study evaluates the association of ROTEM with only clinically evident VTE events and not with all VTE events. ROTEM results did not affect the clinical surveillance of the study group and the decision for further work up. To determine whether ROTEM findings were associated with the presence or development of symptomatic VTE, ROTEM parameters were compared between patients with and without symptomatic VTE. To establish whether any other patient factors were associated with the presence or development of symptomatic VTE after hip fracture surgery, clinical parameters and conventional laboratory values were also compared between patients with and without symptomatic VTE. Finally, to determine which ROTEM parameters were the most accurate in terms of detecting the association of hypercoagulability with symptomatic VTE, the area under the curve (AUC) for certain cut off values of ROTEM parameters was calculated.

Results: We found several abnormal ROTEM values to be associated with the presence or development of symptomatic VTE. The preoperative maximum clot firmness was higher in patients with clinically evident VTE than in patients without these complications (median [interquartile range] 70 mm [68 to 71] versus 65 mm [61 to 68]; p < 0.001). The preoperative clot formation time was lower in patients with clinically evident VTE than those without clinically evident VTE (median 61 seconds [58 to 65] versus 70 seconds [67 to 74]; p < 0.001), and also the postoperative clot formation time was lower in patients with clinically evident VTE than those without these complications (median 52 seconds [49 to 59] versus 62 seconds [57 to 68]; p < 0.001). Increased BMI was also associated with clinically evident VTE (odds ratio 1.26 [95% confidence interval 1.07 to 1.53]; p < 0.001). We found no differences between patients with and without clinically evident VTE in terms of age, sex, smoking status, comorbidities, and preoperative use of anticoagulants. Lastly, preoperative clot formation time demonstrated the best performance for detecting the association of hypercoagulability with symptomatic VTE (AUC 0.89 [95% CI 0.81 to 0.97]), with 81% (95% CI 48% to 97%) sensitivity and 86% (95% CI 81% to 89%) specificity for clot formation time ≤ 65 seconds.

Conclusion: ROTEM's performance in this preliminary study was promising in terms of its association with symptomatic VTE. This study extended our earlier work by demonstrating that ROTEM has a high accuracy in detecting the level of hypercoagulability that is associated with symptomatic VTE. However, until its performance is validated in a study that applies a diagnostic gold standard (such as venography, duplex/Doppler, or chest CT) in all patients having ROTEM to confirm its performance, ROTEM should not be used as a regular part of clinical practice.

Level Of Evidence: Level IV, diagnostic study.
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http://dx.doi.org/10.1097/CORR.0000000000001832DOI Listing
June 2021

Seeking Strategies to Optimize Blood Utilization: The Preliminary Experience with Implementing a Patient Blood Management Program in a Greek Tertiary Hospital.

J Clin Med 2021 May 15;10(10). Epub 2021 May 15.

Laboratory of Haematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece.

Objectives: Our aim was to assess blood utilization after implementation of a patient blood management (PBM) program in a Greek tertiary hospital.

Methods: An electronic transfusion request form and a prospective audit of transfusion practice were implemented. After the one-year implementation period, a retrospective review was performed to assess transfusion practice in medical patients.

Results: Pre-PBM, a total of 9478 RBC units were transfused (mean: 1.75 units per patient) compared with 9289 transfused units (mean: 1.57 units per patient) post-PBM. Regarding the post-PBM period, the mean hemoglobin (Hb) level of the 3099 medical patients without comorbidities transfused was 7.19 ± 0.79 gr/dL. Among them, 2065 (66.6%) had Hb levels >7.0 gr/dL, while 167 (5.3%) had Hb levels >8.0 gr/dL. In addition, 331 (25.3%) of the transfused patients with comorbidities had Hb >8.0 gr/dL. The Hb transfusion thresholds significantly differed across the clinics ( < 0.001), while 21.8% of all medical non-bleeding patients received more than one RBC unit transfusion.

Conclusion: A poor adherence with the restrictive transfusion threshold of 7.0 gr/dL was observed. The adoption of a less strict threshold might be a temporary step to allow physicians to become familiar with the program and be informed on the safety and advantages of the restrictive transfusion strategy.
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http://dx.doi.org/10.3390/jcm10102141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8157216PMC
May 2021

Haemostatic profile of riboflavin-treated apheresis platelet concentrates.

Blood Transfus 2021 May 21. Epub 2021 May 21.

Laboratory of Haematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.

Background: The haemostatic activity of platelet concentrates (PCs) treated with pathogen reduction technology (PRT) remains a subject of debate. Our aim was to investigate the effect of Mirasol PRT on the haemostatic properties of PCs stored in plasma.

Material And Methods: Untreated and Mirasol-treated platelets stored in plasma and derived from ten split double-dose apheresis PCs were evaluated in vitro on days 1, 3 and 5 post collection for functionality, microparticle procoagulation activity (MPA), endogenous thrombin potential (ETP), and haemostatic profile using rotational thromboelastometry (ROTEM).

Results: P-selectin expression was significantly higher in Mirasol-treated platelets compared with untreated counterparts on days 3 and 5 (p=0.003 and p=0.002, respectively). Clot strength, as shown by EXTEM maximum clot firmness (MCF), was significantly lower in the Mirasol-treated platelets at all time points (days 1, 3, 5) than in untreated platelets (p=0.009, p<0.001, p<0.001, respectively). There was a considerable increase in MPA over time (p<0.001) and this was significantly higher in the Mirasol-treated platelets on day 5 (p=0.015). A notable acceleration of decrease in ETP values was observed for Mirasol-treated PCs over time (p<0.001), with significant differences between PRT-treated and untreated PCs on days 3 and 5 (p=0.038 and p=0.019, respectively). Clot strength attenuation was significantly associated with pH reduction (p<0.001, Spearman's rho: 0.84), increased microparticle procoagulant activity (p<0.001, Spearman's rho: -0.75), and with decreased ETP (p<0.032, Spearman's rho: 0.41).

Discussion: Increased platelet activation induced by PRT treatment leads to a decrease in in vitro haemostatic capacity as seen by reduced clot strength and thrombin generation capacity over time. The clinical relevance of this needs to be investigated.
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http://dx.doi.org/10.2450/2021.0089-21DOI Listing
May 2021

Homozygosity of the TT methylenetetrahydrofolate reductase C677T genotype is an independent long-term predictor of cardiac death in patients with premature myocardial infarction.

Curr Med Res Opin 2021 07 21;37(7):1079-1084. Epub 2021 Apr 21.

Laboratory of Haematology and Blood Transfusion Unit, National & Kapodistrian University of Athens School of Medicine, University General Hospital Attikon, Athens, Greece.

Background: Methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism is the main genetic modulator of homocysteine. Data suggest a potential association of homozygosity for the TT MTHFR genotype with premature myocardial infarction (MI). We explored whether TT homozygosity is associated with long-term prognosis in patients with premature ST-segment elevation MI (STEMI).

Methods: A total of 265 consecutive patients who had survived their first STEMI ≤35 years of age were followed for a median of 8 years (5-12). Primary endpoints were cardiac death and secondary endpoints were hospitalizations for acute coronary syndrome, myocardial revascularization, arrhythmic event or ischemic stroke. Serum lipids, homocysteine, folate levels were measured at baseline and all patients were also tested for the MTHFR C677T polymorphism.

Results: During follow-up 14 patients died (cardiac death) [5.3%] while 84 (31.7%) met the secondary endpoints. In univariate Cox regression analysis TT homozygosity predicted the occurrence of cardiac death (Hazard ratio (HR): 4.071; 95% confidence interval (CI): 1.404-11.809,  = .010) but not the occurrence of secondary endpoints (HR: 0.877; 95% CI: 0.479-1.605,  = .669). TT homozygosity remained an independent predictor of cardiac death after adjustment for conventional risk factors (i.e., sex, diabetes mellitus, hypertension, family history of premature coronary artery disease [CAD]) [HR: 4.350; 95% CI: 1.472-12.856,  = .008]. The association also remained after adjustment for left ventricular ejection fraction or the presence of significant CAD.

Conclusions: Homozygosity for the TT MTHFR is an independent long-term predictor of cardiac death in patients with premature STEMI.
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http://dx.doi.org/10.1080/03007995.2021.1912720DOI Listing
July 2021

The haemostatic profile in critically ill COVID-19 patients receiving therapeutic anticoagulant therapy: An observational study.

Medicine (Baltimore) 2020 Nov;99(47):e23365

Second Department of Critical Care, "Attikon" University Hospital, National and Kapodistrian University of Athens, Medical School.

Hypercoagulability and thrombosis remain a challenge in severe coronavirus disease 2019 (COVID-19) infections. Our aim is to investigate the hemostatic profile of critically ill COVID-19 patients on therapeutic anticoagulant treatment.Forty one patients were enrolled into the study. We recruited 11 consecutive, COVID-19, patients who received therapeutic anticoagulant treatment on intensive care unit (ICU) admission. Disease severity indexes, biochemical, hematological and haemostatic parameters, endogenous thrombin potential (ETP), plasminogen activator inhibitor-1 (PAI-1) activity and extrinsically activated rotational thromboelastometry assay (EXTEM) were recorded on days 1, 3, 7. We also enrolled 9 ICU non-COVID-19, 21 non-ICU COVID-19 patients and 20 healthy blood donors as control populations.Critically ill COVID-19 patients demonstrated a more hypercoagulable and hypofibrinolytic profile related to those with COVID-19 mild illness, based on EXTEM amplitude at 10 min (A10), maximum clot firmness (MCF) and lysis index at 60 min (LI60) variables (p = 0.020, 0.046 and 0.001, respectively). Similarly, a more hypercoagulable state was detected in COVID-19 ICU patients related to non-COVID-19 ICU patients based on A10 and MCF parameters (p = 0.03 and 0.04, respectively). On the contrary, ETP and EXTEM (clotting time) CT values were similar between patients with severe and mild form of the COVID-19 infection, probably due to anticoagulant treatment given.Critically ill COVID-19 patients showed a hypercoagulable profile despite the therapeutic anticoagulant doses given. Due to the small sample size and the study design, the prognostic role of the hypercoagulability in this clinical setting remains unknown and further research is required in order to be assessed.
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http://dx.doi.org/10.1097/MD.0000000000023365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676559PMC
November 2020

The role of ROTEM variables based on clot elasticity and platelet component in predicting bleeding risk in thrombocytopenic critically ill neonates.

Eur J Haematol 2021 Feb 27;106(2):175-183. Epub 2020 Oct 27.

Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.

Background: Our aim was to investigate the role of thromboelastometry (ROTEM) parameters, including maximum clot elasticity (MCE) and platelet component (PLTEM MCE and PLTEM MCF), in early prediction of bleeding events in thrombocytopenic critically ill neonates.

Material And Methods: This single-center, prospective cohort study included 110 consecutive thrombocytopenic neonates with sepsis, suspected sepsis, or hypoxia. On the first day of disease onset, ROTEM EXTEM and FIBTEM assays were performed and the neonatal bleeding assessment tool was used for the evaluation of bleeding events.

Results: Most EXTEM and FIBTEM ROTEM parameters significantly differed between neonates with (n = 77) and without bleeding events (n = 33). Neonates with bleeding events had significantly lower PLTEM MCE and PLTEM MCF values compared to those without bleeding events (P < .001). Platelet count was found to be strongly positively correlated with EXTEM A5 (Spearman's rho = 0.61, P < .001) and A10 (rho = 0.64, P < .001). EXTEM A10 demonstrated the best prognostic performance (AUC = 0.853) with an optimal cutoff value (≤37 mm) (sensitivity = 91%, specificity = 76%) for prediction of bleeding events in thrombocytopenic neonates.

Conclusions: EXTEM A5 and EXTEM A10 were found to be strong predictors of hemorrhage, compared to most ROTEM variables quantifying clot elasticity and platelet component in thrombocytopenic critically ill neonates.
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http://dx.doi.org/10.1111/ejh.13534DOI Listing
February 2021

The prognostic value of multiple electrode aggregometry and light transmittance aggregometry in stable cardiovascular patients with type 2 diabetes mellitus.

Thromb Res 2019 08 4;180:47-54. Epub 2019 Jun 4.

Second Cardiology Department, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.

Aim: Limited data are available regarding the clinical relevance of platelet function measurements in stable patients with coronary artery disease (CAD). Our aim is to evaluate the agreement between multiple electrode aggregometry (MEA) and light transmittance aggregometry (LTA) in detecting clopidogrel low responders and their prognostic value in CAD patients with type 2 diabetes mellitus (T2DM) on dual platelet inhibition.

Methods: LTA and MEA were performed in 122 stable cardiovascular patients with T2DM. The upper quartile of patients according to maximum LTA (LTAmax) and MEA measurements were defined as clopidogrel low responders. Agreement between the two methods was evaluated by kappa statistics. We assessed the potential correlation between antiplatelet response and clinical outcome and the optimal cutoff value according to ROC analysis to predict the occurrence of major adverse cardiovascular events (MACE), during 1-year follow-up period.

Results: Cohen's kappa coefficients (0.214) indicated fair agreement (70.2%) between LTA and MEA. A total of 25 MACE occurred in 108 patients (23.1%). Patients with MACE had higher LTAmax than those without (57.1 ± 16.5 vs 49.3 ± 18.3, respectively, p = 0.023). MEA measurements were similar between patients with and without MACE (30.1 ± 15.4 vs 30.6 ± 20.8, respectively; p = 0.84). Multiple logistic regression showed LTAmax response as an independent predictor of death from cardiovascular causes (Odds Ratio, adjusted:0.2;0.05-0.81). ROC analysis indicated that LTAmax cutoff of 62.5% best predicted death (AUC = 0.67, sensitivity = 78%, specificity = 61.5%).

Conclusions: The assessment of platelet responsiveness remains highly test-specific. Our results support the prognostic role of LTA, but not MEA testing, for death risk evaluation in stable cardiovascular T2DM patients.
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http://dx.doi.org/10.1016/j.thromres.2019.06.001DOI Listing
August 2019

Platelet and coagulation disorders in newly diagnosed patients with pulmonary arterial hypertension.

Platelets 2019 26;30(5):646-651. Epub 2018 Jul 26.

d Laboratory of Hematology & Blood Bank Unit , University Hospital Attikon, School of Medicine, National and Kapodistrian University of Athens , Athens , Greece.

There is a complex and not fully elucidated association between pulmonary arterial hypertension (PAH) and coagulation disorders. The goal of this study was to evaluate platelet function, coagulation and fibrinolysis in PAH patients at diagnosis, before PAH-specific treatment initiation. We enrolled 20 healthy controls and 30 PAH patients (20 with connective tissue disease (CTD-PAH) and 10 idiopathic (iPAH)). None of the participants was on any antiplatelet or anticoagulation therapy. Blood samples from PAH patients were collected during the initial right heart catheterization. All subjects were assessed with platelet function analyzer-100 (PFA-100), epinephrine (Epi) and ADP-induced light transmission aggregometry (LTA), thromboelastometry (ROTEM) and endogenous thrombin potential (ETP). Our results showed that Epi and ADP-LTA values were significantly lower in newly diagnosed PAH patients compared to controls. Disaggregation was present in 73% of patients, a characteristic not seen in healthy individuals. In ROTEM assay, CT and CFT measurements were significantly higher and a angle lower compared to controls. ETP testing revealed significantly reduced outcomes in AUC, Cmax and Tmax. When CTD-PAH and iPAH patient groups were compared, iPAH ADP-LTA values were significantly decreased compared to CTD-PAH. In conclusion, newly diagnosed PAH patients presented with decreased platelet aggregation, clot propagation and thrombin generation, along with delayed initiation of the coagulation process. These hemostatic deficits could indicate an "exhaustion" of the coagulation process that could be caused by endothelial dysfunction and chronic activation of the procoagulant pathways. Further studies are warranted to confirm these laboratory findings and assess their potential clinical significance.
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http://dx.doi.org/10.1080/09537104.2018.1499890DOI Listing
November 2019

Comparison between Nageotte and flow cytometric counting of residual leucocytes in freshly prepared leucocyte-reduced red blood cell components.

Transfus Apher Sci 2018 Aug 7;57(4):544-548. Epub 2018 Jun 7.

Laboratory of Haematology & Blood Bank Unit, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, 1 Rimini Str., 12462, Athens, Greece. Electronic address:

Background: Flow cytometry (FC) and Nageotte hemocytometry represent the most widely accepted methods for counting residual white blood cells (rWBCs) in leucocyte-reduced (LR) blood components. Our aim was to study the agreement between the two methods, under real working blood bank conditions.

Materials And Methods: 94 freshly produced LR red blood cell (RBC) units were tested for rWBC concentrations by FC and Nageotte. To assess the precision of each method, we calculated the intra-assay coefficients of variation (CV), and followed the Bland-Altman methodology to study the agreement between the two methods.

Results: CV was 18.5% and 26.2% for the Nageotte and the FC, respectively. However, the agreement between the duplicate observations, using the binary cut-off threshold of 1 × 10 WBCs per unit to define the results as "pass/fail", was 71.9% for the Nageotte and 93.3% for the FC. Linear regression analysis did not show any correlation (R-squared = 0.01, p = 0.35) between the two methods, while the Bland-Altman analysis for the measuring agreement showed a bias toward a higher Nageotte count of 0.77 × 10 leucocytes per unit (p < 0.001) with the 95% limits of agreement (d ± 2 sd) ranging from -0.40 × 10 to 1.94 × 10 leucocytes per unit.

Conclusion: The absence of agreement between Nageotte and FC method, with the differences within d ± 2 sd being of high clinical importance, suggests that the two methods cannot be used for clinical purposes interchangeably. The Nageotte seems unsuitable for quality control even with a pass-fail criterion, under real working blood bank conditions.
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http://dx.doi.org/10.1016/j.transci.2018.06.002DOI Listing
August 2018

Characteristics and Long-Term Prognosis of Patients ≤35 Years of Age with ST Segment Elevation Myocardial Infarction and "Normal or Near Normal" Coronary Arteries.

Am J Cardiol 2017 Sep 13;120(5):740-746. Epub 2017 Jun 13.

Second Department of Cardiology, University General Hospital Attikon, Athens, Greece.

There are scarce data regarding risk factors and prognosis of patients with premature ST segment elevation myocardial infarction (STEMI) and "normal or near normal" coronary arteries (N/NNCAs). We compared the characteristics and long-term prognosis of patients with premature STEMI and N/NNCAs with their counterparts with significant coronary artery disease (CAD). We recruited 330 patients who had STEMI ≤35 years of age and 167 age- and gender-matched controls. All patients underwent coronary angiography. Coronary arteries with no lesions or lesions causing <30% reduction in lumen diameter were defined as N/NNCAs, whereas narrowings causing ≥50% diameter reduction formed the significant CAD group. Lipid profile, homocysteine levels, and methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism were determined. Sixty patients (18%) had N/NNCAs. Patients with N/NNCAs had lower low-density lipoprotein-cholesterol and higher high-density lipoprotein-cholesterol levels, higher homocysteine levels, and higher prevalence of MTHFR TT genotype (34.6 vs 18%, p = 0.008) compared with patients with significant CAD. After a median follow-up of 8 years, cardiovascular events occurred in 105 (36%) of 291 patients with available follow-up data. Significant CAD was associated with higher risk for recurrent cardiovascular events after adjustment for traditional risk factors (hazard ratio 2.095, 95% confidence interval 1.088 to 3.664, p = 0.022) and additional adjustment for the left ventricular ejection fraction, reperfusion therapy, and persistent smoking (hazard ratio 1.869, 95% confidence interval 1.007 to 3.468, p = 0.041). In conclusion, patients with premature STEMI and N/NNCAs have fewer lipid abnormalities, higher homocysteine levels and prevalence of MTHFR TT genotype, and better long-term prognosis compared with their counterparts with significant CAD.
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http://dx.doi.org/10.1016/j.amjcard.2017.06.002DOI Listing
September 2017

Prothrombotic genetic risk factors in patients with very early ST-segment elevation myocardial infarction.

J Thromb Thrombolysis 2017 Aug;44(2):267-273

Second Department of Cardiology, University General Hospital Attikon, 1 Rimini St., Chaidari, 12462, Athens, Greece.

The contribution of prothrombotic genetic risk factors in the pathogenesis of premature acute myocardial infarction (MI) is controversial. We examined the prevalence of prothrombotic polymorphisms (G1691A of factor V gene [FV Leiden] and G20210A of prothrombin [FII] gene), deficiencies of natural anticoagulants (protein C, protein S and antithrombin III) and antiphospholipid syndrome (APS) in patients with early ST-segment elevation MI (STEMI). We recruited 255 consecutive patients who had survived a STEMI ≤ 35 years of age (224 men). The control group consisted of 400 healthy individuals matched with cases for age and sex. G20210A polymorphism of FII gene was more frequent in young patients than in controls (7.4 vs. 3.5%, p = 0.023). The odds ratio (OR) for STEMI for carriers versus non-carriers was 2.239 (95% CI 1.102-4.250). The adjusted OR for major cardiovascular risk factors was 2.569 (95% CI 1.086-6.074). The risk was increased by 22-fold (95% CI 9.192-66.517) when G20210A polymorphism was present in combination with smoking. There was no difference in the prevalence of FV Leiden between patients and controls (7.8 vs. 6.5%, p = 0.512). There was only one patient (0.4%) with protein C deficiency and one with APS (0.4%). G20210A polymorphism of FII gene may be associated with increased risk of premature STEMI and the risk increases substantially when smoking is present. The contribution of other prothrombotic disorders such as deficiencies of protein C, protein S and antithrombin III and APS was minimal in this cohort.
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http://dx.doi.org/10.1007/s11239-017-1520-2DOI Listing
August 2017

Reference ranges of thromboelastometry in healthy full-term and pre-term neonates.

Clin Chem Lab Med 2017 Aug;55(10):1592-1597

.

Background: Rotational thromboelastometry (ROTEM) is an attractive method for rapid evaluation of hemostasis in neonates. Currently, no reference values exist for ROTEM assays in full-term and pre-term neonates. Our aim was to establish reference ranges for standard extrinsically activated ROTEM assay (EXTEM) in arterial blood samples of healthy full-term and pre-term neonates.

Methods: In the present study, EXTEM assay was performed in 198 full-term (≥37 weeks' gestation) and 84 pre-term infants (<37 weeks' gestation) using peripheral arterial whole blood samples.

Results: Median values and reference ranges (2.5th and 97.5th percentiles) for the following main parameters of EXTEM assay were determined in full-term infants: clotting time (seconds), 41 (range, 25.9-78); clot formation time (seconds), 70 (range, 40-165.2); maximum clot firmness (mm), 66 (range, 41-84.1); lysis index at 60 min (LI60, %), 97 (range, 85-100). The only parameter with a statistically significant difference between full-term and pre-term neonates was LI60 (p=0.006). Furthermore, it was inversely correlated with gestational age (p=0.002) and birth weight (p=0.016) in pre-term neonates.

Conclusions: In conclusion, an enhanced fibrinolytic activity in pre-term neonates was noted. For most EXTEM assay parameters, reference ranges obtained from arterial newborn blood samples were comparable with the respective values from studies using cord blood. Modified reagents, small size samples, timing of sampling, and different kind of samples might account for any discrepancies among similar studies. Reference values hereby provided can be used in future studies.
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http://dx.doi.org/10.1515/cclm-2016-0931DOI Listing
August 2017

Oral Contraceptives and HRT Risk of Thrombosis.

Clin Appl Thromb Hemost 2018 Mar 4;24(2):217-225. Epub 2017 Jan 4.

2 Hematology Laboratory - Blood Bank, ARETAIEION Hospital, National and Kapodistrian University of Athens, Athens, Greece.

Estrogen-containing medication, prescribed either for contraception in women of reproductive age or for prevention of cardiovascular events and osteoporosis as well as for alleviation of symptoms related to menopause, is associated with changes in the hemostatic balance and contributes to increased risk of development of venous thromboembolic complications. This risk is dose and medication dependent, increases with age, congenital and/or acquired predisposition to thrombosis, and mode of administration. This review attempts to summarize the current knowledge regarding the pathophysiology of oral contraceptive (OC) and hormone replacement therapy (HRT) -induced prothrombotic state in women, the risk of thrombosis associated with administration of various commercially available OCs and HRT, the additional risk in women with hereditary or acquired thrombophilia, and the currently available recommendations regarding massive screening of women for thrombophilia prior to initial prescription or continuation of treatment with OCs and HRT preparations.
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http://dx.doi.org/10.1177/1076029616683802DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714678PMC
March 2018

Current trends in platelet transfusions practice: The role of ABO-RhD and human leukocyte antigen incompatibility.

Asian J Transfus Sci 2015 Jul-Dec;9(2):117-23

Department of Blood Transfusion, Aretaieion Hospital, Athens University Medical School, Athens, Greece.

Platelet transfusions have contributed to the revolutionary modern treatment of hypoproliferative thrombocytopenia. Despite the long-term application of platelet transfusion in therapeutics, all aspects of their optimal use (i.e., in cases of ABO and/or Rh (D incompatibility) have not been definitively determined yet. We reviewed the available data on transfusion practices and outcome in ABO and RhD incompatibility and platelet refractoriness due to anti-human leukocyte antigen (HLA) antibodies. Transfusion of platelets with major ABO-incompatibility is related to reduced posttransfusion platelet (PLT) count increments, compared to ABO-identical and minor, but still are equally effective in preventing clinical bleeding. ABO-minor incompatible transfusions pose the risk of an acute hemolytic reaction of the recipient that is not always related to high anti-A, B donor titers. ABO-identical PLT transfusion seems to be the most effective and safest therapeutic strategy. Exclusive ABO-identical platelet transfusion policy could be feasible, but alternative approaches could facilitate platelet inventory management. Transfusion of platelets from RhD positive donors to RhD negative patients is considered to be effective and safe though is associated with low rate of anti-D alloimmunization due to contaminating red blood cells. The prevention of D alloimmunization is recommended only for women of childbearing age. HLA alloimmunization is a major cause of platelet refractoriness. Managing patients with refractoriness with cross-matched or HLA-matched platelets is the current practice although data are still lacking for the efficacy of this practice in terms of clinical outcome. Leukoreduction contributes to the reduction of both HLA and anti-D alloimmunization.
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http://dx.doi.org/10.4103/0973-6247.162684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4562128PMC
September 2015

Circadian pattern of symptoms onset in patients ≤35 years presenting with ST-segment elevation acute myocardial infarction.

Eur J Intern Med 2015 Oct 12;26(8):607-10. Epub 2015 Jun 12.

Second Department of Cardiology, University General Hospital Attikon, Athens, Greece.

Background: There are scarce data regarding the circadian pattern of symptoms onset in young patients presenting with acute myocardial infarction (AMI). We explored whether young patients with ST-segment elevation AMI exhibit a circadian variation in symptoms onset.

Methods: We recruited prospectively 256 consecutive patients who had survived their first ST-segment elevation AMI ≤35 years of age. Patients were categorized into 4 groups by 6-h intervals over 24 h.

Results: In 49 patients (19.1%) the clinical presentation of AMI was atypical. The symptoms onset was as follows: 00:01 to 06:00, 19.1%, 06:01 to 12:00, 32.4%; 12:01 to 18:00, 28.1%; and 18:01 to 24:00, 20.3%. There was a significant association between the time of day and the likelihood of symptoms onset (Rayleigh test, p<0.001). Between 00:01 and 06:00 the incidence of AMI onset was lower than expected and between 06:01 and 12:00 was higher (p=0.034 and p=0.011, respectively), whereas in the other 6-h period groups no difference was found between expected and observed AMI incidence (p=0.280 and p=0.131). No significant differences were found regarding clinical characteristics, i.e. traditional risk factors, reperfusion treatment of AMI, ejection fraction of left ventricle, time interval from pain onset to hospital arrival, dietary habits and physical activity, among the 6-h period groups.

Conclusions: ST-segment elevation AMI in individuals ≤35 years of age follows a circadian pattern with a morning peak. This information might be useful for the prompt diagnosis and treatment of AMI in very young patients which occurs rarely and frequently with atypical clinical presentation.
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http://dx.doi.org/10.1016/j.ejim.2015.05.014DOI Listing
October 2015

Endothelial Protein C Receptor Gene Variants and Risk of Thrombosis.

Clin Appl Thromb Hemost 2016 Mar 13;22(2):199-204. Epub 2014 Aug 13.

Laboratory of Haematology and Blood Transfusion Unit, Attikon Hospital, School of Medicine, University of Athens, Athens, Greece.

Endothelial protein C receptor (EPCR) is a candidate mediator in the pathogenesis of thrombosis, as several data in the literature indicate that polymorphisms such as EPCR 4678G/C and 4600A/G are associated with either protective effect or increased risk of thrombosis, respectively. We investigated the prevalence of these polymorphisms in patients with thrombotic disorders as well as their impact on the risk of thrombosis, the age of first thrombotic episode, and recurrence. The prevalence of the rare EPCR alleles 4600G and 4678C was comparable in patients and controls. However, in a subset analysis, we observed that 4600G allele was more prevalent among patients who developed thrombosis at younger age (<35 years). Moreover, the prevalence of 4678C allele was significantly lower in younger patients compared to older patients. Neither polymorphism seemed to have an impact on recurrence regardless of age. Soluble EPCR levels were elevated in 4600AG patients compared to controls while 4678CC patients presented with lower levels of soluble form of EPCR compared to carriers of at least 1 4678G allele. Our data suggest that either the lack of the protective EPCR 4678C allele or the presence of EPCR 4600G allele may be associated with earlier development of thrombosis.
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http://dx.doi.org/10.1177/1076029614547261DOI Listing
March 2016

Decreased incidence of EPCR 4678G/C SNP in multiple myeloma patients with thrombosis.

Thromb Res 2013 Sep 8;132(3):400-1. Epub 2013 Aug 8.

Medical School, National and Kapodistrian Athens University, Greece.

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http://dx.doi.org/10.1016/j.thromres.2013.07.024DOI Listing
September 2013

eNOS gene variants and the risk of premature myocardial infarction.

Dis Markers 2013 ;34(6):431-6

Laboratory of Haematology and Blood Transfusion Unit, Attikon Hospital, School of Medicine, University of Athens, Athina, Greece.

Background: Endothelial nitric oxide synthase (eNOS) as well as nitric oxide play an important role in the regulation of cardiovascular function. There are limited and controversial data regarding the impact of polymorphisms of eNOS gene that is implicated in the vasoconstrictive properties of the endothelium in the pathogenesis of premature myocardial infarction (MI).

Objective: We examined whether two common polymorphisms of eNOS gene (G894T and T786C) are associated with the development of premature MI.

Methods: We recruited 107 patients with premature MI and compared them to 103 age- and sex- matched controls. All patients underwent coronary angiogram and were classified into the subgroup of patients with 'normal' or 'near normal' coronary arteries and the subgroup of patients with significant coronary artery disease (≥ 50% stenosis in lumen diameter of coronary arteries). The genetic polymorphisms of eNOS gene were assayed with polymerase chain reaction and reverse hybridization.

Results: Nineteen patients (17.8%) had 'normal' or 'near normal' coronary arteries. A significantly higher frequency of homozygosity for the 786C (32%) and the 894T (21%) alleles of the eNOS gene in patients who develop early MI in the setting of angiographically 'normal' or 'near normal' coronary arteries were found.

Conclusions: Our data suggest that the T786C and the G894T genetic polymorphisms are associated with the development of MI in very young individuals, whose coronary arteries are characterized by very small atheromatic burden.
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http://dx.doi.org/10.3233/DMA-130987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3809742PMC
October 2013

Retinal vein occlusion: genetic predisposition and systemic risk factors.

Blood Coagul Fibrinolysis 2013 Apr;24(3):279-83

Haematology Laboratory, ATTIKON University Hospital, School of Medicine, Athens, Greece.

The role of systemic risk factors (age, smoking, diabetes, arterial hypertension) in the development of retinal vein occlusion (RVO) is well established. However, the association of RVO with genetic predisposition to thrombosis remains poorly understood. The aim of the study was to assess any possible additional effect of genetic predisposition to the already well known 'classical' risk factors of RVO in a cohort of elderly Greek patients. Fifty-one elderly patients with RVO and 51 healthy individuals matched for age and sex were evaluated for systemic risk factors (smoking, diabetes, dyslipidemia, arterial hypertension) and coagulation defects (lupus anticoagulant, natural inhibitors of coagulation). Additionally, genotyping was performed for mutations/polymorphisms involved in haemostasis such as: FV G1691A, FV G4070A, FIIG 20210A, MTHFR C677T and A1298C, PAI-1-675 4G/5G, F XIII exon 2G/T, EPCR A4600G and G4678C. We identified systemic risk factors in the majority of the patients Hypertension (P=0.001), dyslipidemia (P=0.029) and diabetes (P=0.01) are associated with RVO in the majority of the patients. The prevalence of prothrombotic risk factors was not significantly different in the patients with RVO compared to controls. Apart from systemic risk factors, genetic predisposition to thrombosis does not seem to have an important association with RVO in this group of elderly patients.
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http://dx.doi.org/10.1097/MBC.0b013e32835bfda1DOI Listing
April 2013

Thrombomodulin as a regulator of the anticoagulant pathway: implication in the development of thrombosis.

Blood Coagul Fibrinolysis 2012 Jan;23(1):1-10

Attikon University Hospital, Athens, Greece.

Thrombomodulin is a cell surface-expressed glycoprotein that serves as a cofactor for thrombin-mediated activation of protein C (PC), an event further amplified by the endothelial cell PC receptor. The PC pathway is a major anticoagulant mechanism that downregulates thrombin formation and hedges thrombus formation. The objectives of this review were to review recent findings regarding thrombomodulin structure, its involvement in the regulation of hemostasis and further discuss the implication, if any, of the genetic polymorphisms in the thrombomodulin gene in the risk of development of thrombosis. We performed a literature search by using electronic bibliographic databases. Although the direct evaluation of risk situations associated with thrombomodulin mutations/polymorphisms could be of clinical significance, it appears that mutations that affect the function of thrombomodulin are rarely associated with venous thromboembolism. However, several polymorphisms are reported to be associated with increased risk for arterial thrombosis. Additionally studies on knock out mice as well studies on humans bearing rare mutations suggest that thrombomodulin dysfunction may be implicated in the pathogenesis of myocardial infraction.
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http://dx.doi.org/10.1097/MBC.0b013e32834cb271DOI Listing
January 2012

Do different substitution patterns or plant origin in hydroxyethyl starches affect blood coagulation in vitro?

Blood Coagul Fibrinolysis 2010 Jul;21(5):448-51

Department of Anesthesiology, University of Athens, 'Attikon' Hospital, Greece.

The effect of hydroxyethyl starches (HES) on blood coagulation is affected by their molecular weight, their molar substitution and the C2/C6 ratio. The solutions of 6% HES 130/0.4 and 6% HES 130/0.42 have similar molecular weight and molar substitution but different C2/C6 ratio and plant origin. In the present study, the comparative effect of 6% HES 130/0.4 versus 6% HES 130/0.42 on blood coagulation was investigated in vitro. Thirty milliliter of blood was obtained from 10 healthy volunteers and was diluted by 10, 30 and 50% using either 6% HES 130/0.4 or HES 130/0.42, respectively. Blood coagulation was assessed using thrombelastography measurements (clotting time, clot formation time, maximal clot firmness and alpha-angle). The assessment of platelet function was performed with whole blood aggregometry after adding thrombin-receptor-activating protein. No differences were noted between respective dilutions of the two HES. Both colloids produced significant reductions below the reference values range in clotting time at 10, 30 and 50% dilutions. The 50% dilution of both colloids resulted in significant reduction of maximal clot firmness, alpha-angle and platelet aggregation. The present study showed that the corn-derived 6% HES 130/0.4 and the potato-derived 6% HES 130/0.42 have the same effect on blood coagulation in vitro.
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http://dx.doi.org/10.1097/MBC.0b013e328338db67DOI Listing
July 2010

Reduced carriership of 4G allele of plasminogen activator inhibitor-1 4G/5G polymorphism in very young survivors of myocardial infarction.

J Thromb Thrombolysis 2010 May;29(4):497-502

Second Department of Cardiology, Attikon Hospital, School of Medicine, University of Athens, Athens, Greece.

There are limited and controversial data regarding the impact of 4G/5G polymorphism of the plasminogen activator inhibitor-1 (PAI-1) gene in the pathogenesis of premature myocardial infarction (MI). We explored whether 4G/5G polymorphism of the PAI-1 gene is associated with the development of MI
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http://dx.doi.org/10.1007/s11239-009-0398-zDOI Listing
May 2010

Portal, splenic and mesenteric vein thrombosis in a patient double heterozygous for factor V Leiden and prothrombin G20210A mutation.

Blood Coagul Fibrinolysis 2009 Dec;20(8):722-5

Laboratory of Hematology and Blood Bank Unit, Attikon Hospital, University of Athens, Greece.

We herein report a 56-year-old man who presented with abdominal pain, diarrhea and a 22-kg-weight loss over 4 months. He was on acenocoumarol treatment because of portal, splenic and mesenteric vein thrombosis (PSMVT) 3 months before, with admission international normalized ratio (INR):1.6. Doppler ultrasonography and helical computerized tomographic scan of the abdomen showed complete thrombosis of the extrahepatic portal vein extending into the superior mesenteric vein and splenic vein. The manifestation of thrombosis was in the absence of provocative stimuli or local cause. The patient had a negative history of venous thromboembolism. Thrombophilia workup revealed double heterozygosity for factor V Leiden and prothrombin G20210A mutation. He was immediately started with intravenous unfractionated heparin, followed by oral anticoagulation with target INR 2-3. Five days after a Doppler examination showed significant improvement in the flow within the portal vein, and a computerized tomographic scan of the abdomen 1 month later showed extensive recanalization of the portal venous system. The patient is now 36 months out from the second PSMVT episode and is doing well although maintaining oral lifelong anticoagulation. The case is of particular interest in that PSMVT was the first manifestation of this combined disorder. We conclude that all patients presenting with unexplained PSMVT should be investigated for the presence of a hypercoagulable state. Anticoagulation should be considered in all patients with this diagnosis and should be a lifelong therapy in those with an underlying thrombophilia.
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http://dx.doi.org/10.1097/MBC.0b013e3283306e3cDOI Listing
December 2009

Evaluation of a reverse-hybridization StripAssay for the detection of genetic polymorphisms leading to acenocoumarol sensitivity.

Mol Biol Rep 2010 Apr 28;37(4):1693-7. Epub 2009 Jun 28.

Haematology Laboratory, ATTIKON Hospital, School of Medicine, University of Athens, 8 Athanasiou Diakou Street, 14671, Kastri, Athens, Greece.

Acenocoumarol is mainly catabolized by CYP2C9 isoform of cytochrome P450 (CYP) liver complex and exerts its anticoagulant effect through the inhibition of Vitamin K Epoxide Reductase (VKOR). The most important genetic polymorphisms which lead to an impaired enzymatic activity and therefore predispose to acenocoumarol sensitivity, are considered to be CYP2C9*2 (Arg144Cys), CYP2C9*3 (Ile359Leu) and VKORC1-1639G>A, respectively. In this study we compared the results of the PGXThrombo StripAssay kit (ViennaLab Diagnostics,Vienna, Austria) with direct DNA sequencing and in house Restriction Fragment Length Polymorphisms (RFLP) for the detection of the aforementioned Single Nucleotide Polymorphisms (SNPs). The reverse hybridization StripAssay was found to be equally effective with RFLP and direct DNA sequencing for the detection of CYP2C9*2 and CYP2C9*3 polymorphisms, respectively. The comparison of the RFLP reference method with the reverse hybridization StripAssay for the detection of VKORC1-1639 G>A polymorphism showed that the reverse hybridization StripAsssay might misclassify some A/A homozygotes as heterozygotes. Optimization of the hybridization procedures may eliminate the extra low signal band observed in some samples at the reverse hybridization StripAssay and improve its diagnostic value.
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http://dx.doi.org/10.1007/s11033-009-9587-2DOI Listing
April 2010

Lack of association of angiotensin-converting enzyme insertion/deletion polymorphism and myocardial infarction at very young ages.

Biomarkers 2009 Sep;14(6):401-5

Second Department of Cardiology, Attikon Hospital, School of Medicine, University of Athens, Greece.

We examined whether angiotensin-converting enzyme (ACE) insertion (I)/deletion (D) polymorphism is associated with the development of myocardial infarction (MI) at < or = 35 years of age. The study sample consisted of 201 patients with premature MI and 140 age- and sex-matched healthy individuals. No difference was found in the distribution of ACE genotypes between the patients and controls. A higher prevalence of the DD genotype among hypertensives was found compared with the non-hypertensive patients (62.5% vs 35.6%, p = 0.01). ACE polymorphism is not associated with the development of premature MI and this might be due to the low prevalence of hypertension in young coronary patients.
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http://dx.doi.org/10.1080/13547500903039966DOI Listing
September 2009

G-455A polymorphism of beta-fibrinogen gene and the risk of premature myocardial infarction in Greece.

Thromb Res 2010 Jan 1;125(1):34-7. Epub 2009 May 1.

Second Department of Cardiology, Attikon Hospital, School of Medicine, University of Athens, Greece.

Introduction: There are limited and controversial data regarding the impact of G-455A polymorphism of beta-fibrinogen gene in the pathogenesis of premature myocardial infarction (MI). We examined whether the G-455A polymorphism of beta-fibrinogen gene is associated with the development of MI< or =35 years of age.

Methods: We recruited 181 consecutive patients who had survived their first acute MI< or =35 years of age (mean age=32.2+/-3.4 years). The control group consisted of 129 healthy individuals matched with cases for age and sex, without a family history of premature coronary heart disease. G-455A polymorphism of beta-fibrinogen was tested with polymerase chain reaction and reverse hybridization.

Results: There was a higher prevalence of carriers of the A allele (GA+AA genotype) in controls than in patients (odds ratio [OR] 0.57, 95% confidence interval [CI] 0.36 to 0.91, p=0.02). G-455A polymorphism of beta-fibrinogen gene was associated with lower risk for acute MI (OR 0.46, 95% CI 0.25 to 0.83, p=0.01) after adjusting for major cardiovascular risk factors. Fibrinogen levels were higher in patients compared to controls [332 (292-385) vs. 311 (262-373) mg/dL, p=0.01], but the adjusted for classical risk factors fibrinogen levels did not differ (OR 1.003, 95% CI 0.99 to 1.01, p=0.37). Patients possessing the A allele did not differ in their fibrinogen and lipid levels compared to patients with the -455GG genotype.

Conclusions: Our data indicate that the presence of the G-455A polymorphism of beta-fibrinogen gene has a "protective effect" against the development of non-fatal acute MI< or =35 years of age in Greece.
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http://dx.doi.org/10.1016/j.thromres.2009.02.017DOI Listing
January 2010

Central retinal vein occlusion secondary to clomiphene treatment in a male carrier of factor V Leiden.

Genet Test Mol Biomarkers 2009 Apr;13(2):155-7

We report a case of a 35-year-old previously healthy man treated with clomiphene for infertility, who presented with blurred vision in his left eye due to ocular vein occlusion as documented by fluorescein angiography. The patient was heterozygous for the factor V Leiden (FV Leiden) mutation and for the 1298 A-C polymorphism of the methylene-tetrahydrofolate reductase (MTHFR) gene. He was treated with clopidogrel and is now free of symptoms. Because congenital thrombophilia is a moderate risk factor for central retinal vein occlusion and the administration of clomiphene may trigger this process, we recommend screening of young patients for FV Leiden before clomiphene treatment.
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http://dx.doi.org/10.1089/gtmb.2008.0104DOI Listing
April 2009
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