warfarin and Calcinosis

Calcinosis cutis constitutes a heterogeneous group of chronic disorder. It can be associated with disturbance of calcium and/or phosphate metabolism (metastatic, tumor calcinosis, calciphylaxis) but may also develop without any metabolic disorder, in particular during the course of connective tissue diseases. Among these, the most common are dermatomyositis and the limited form of systemic sclerosis. The physiopathology of calcinosis cutis is poorly known. It can cause pain, chronic ulcerations, infections, which are sources of sometimes major disability. Treatment of calcinosis is challenging because no drug has been shown to be reliably effective in stopping the progression or decreasing dystrophic calcifications in controlled trials. Calcium blocker and colchicine are generally prescribed as the first line systemic therapy. In the localized forms of small lesions, surgical excision is often effective and sometimes preceded by local treatments (laser therapy, extracorporeal shock wave lithotripsy, topical sodium thiosulfate, etc.) or systemic treatment (minocycline, warfarine). When calcinosis is disseminated, it may require additional treatments (aluminium hydroxyde, bisphosphonates) possibly associated with surgery in case of large lesions. Time to response may be prolonged from weeks to months. The calcinosis cutis can lead to secondary infection, pain and functional disability that have to be prevented.

Topics: Calcinosis; Calcium Channel Blockers; Colchicine; Dermatomyositis; Humans; Minocycline; Scleroderma, Systemic; Warfarin

Vitamin K is required for the activity of various biologically active proteins in our body. Apart from clotting factors, vitamin K-dependent proteins include regulatory proteins like protein C, protein S, protein Z, osteocalcin, growth arrest-specific gene 6 protein, and matrix Gla protein. Glutamic acid residues in matrix Gla protein are γ-carboxylated by vitamin K-dependent γ-carboxylase, which enables it to inhibit calcification. Warfarin, being a vitamin K antagonist, inhibits this process, and has been associated with calcification in various animal and human studies. Though no specific guidelines are currently available to prevent or treat this less-recognized side effect, discontinuing warfarin and using an alternative anticoagulant seems to be a reasonable option. Newer anticoagulants such as dabigatran and rivaroxaban offer promise as future therapeutic options in such cases. Drugs including statins, alendronate, osteoprotegerin, and vitamin K are currently under study as therapies to prevent or treat warfarin-associated calcification. Copyright © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Topics: Anticoagulants; Calcinosis; Diphosphonates; Heart Valve Diseases; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Hyperbaric Oxygenation; Muscle, Smooth, Vascular; Osteoprotegerin; Vitamin K; Warfarin

Because calcinosis cutis is a rare syndrome, there is a notable lack of controlled clinical trials on its treatment. The efficacy of calcinosis treatment has only been reported in single cases or small case series. No treatment has been generally accepted as standard therapy, although various treatments have been reported to be beneficial, including warfarin, bisphosphonates, minocycline, ceftriaxone, diltiazem, aluminium hydroxide, probenecid, intralesional corticosteroids, intravenous immunoglobulin, curettage, surgical excision, carbon dioxide laser, and extracorporeal shock wave lithotripsy.

Topics: Biopsy, Needle; Calcinosis; Ceftriaxone; Combined Modality Therapy; Drug Therapy, Combination; Education, Medical, Continuing; Evidence-Based Medicine; Female; Humans; Immunoglobulins, Intravenous; Immunohistochemistry; Laser Therapy; Lasers, Gas; Male; Minocycline; Prognosis; Recurrence; Risk Assessment; Severity of Illness Index; Skin Diseases; Treatment Outcome; Warfarin

Warfarin-induced skin necrosis (WISN) and calciphylaxis share similar early clinical findings and can both lead to significant morbidity and mortality. The authors reviewed the literature on both conditions and describe a case of extensive skin necrosis in a patient with end-stage renal disease who was initially suspected to have calciphylaxis. Further investigation supported a diagnosis of WISN. The pathogenesis, clinical manifestations and treatment of WISN and calciphylaxis are discussed, with emphasis on a diagnostic approach for early recognition.

Topics: Adult; Anticoagulants; Calcinosis; Female; Humans; Necrosis; Skin; Warfarin

Vitamin K-dependent proteins (VKDPs) require carboxylation to become biologically active. Although the coagulant factors are the most well-known VKDPs, there are many others with important physiologic roles. Matrix Gla Protein (MGP) and Growth Arrest Specific Gene 6 (Gas-6) are two particularly important VKDPs, and their roles in vascular biology are just beginning to be understood. Both function to protect the vasculature; MGP prevents vascular calcification and Gas-6 affects vascular smooth muscle cell apoptosis and movement. Unlike the coagulant factors, which undergo hepatic carboxylation, MGP and Gas-6 are carboxylated within the vasculature. This peripheral carboxylation process is distinct from hepatic carboxylation, yet both are inhibited by warfarin administration. Warfarin prevents the activation of MGP and Gas-6, and in animals, induces vascular calcification. The relationship of warfarin to vascular calcification in humans is not fully known, yet observational data suggest an association. Given the high risk of vascular calcification in those patients with chronic kidney disease, the importance of understanding warfarin's effect on VKDPs is paramount. Furthermore, recognizing the importance of VKDPs in vascular biology will stimulate new areas of research and offer potential therapeutic interventions.

Topics: Animals; Anticoagulants; Blood Vessels; Calcinosis; Calcium-Binding Proteins; Extracellular Matrix Proteins; Humans; Intercellular Signaling Peptides and Proteins; Kidney Failure, Chronic; Matrix Gla Protein; Protein Processing, Post-Translational; Risk Assessment; Risk Factors; Vascular Diseases; Vitamin K; Warfarin

Topics: Animals; Anticoagulants; Calcinosis; Chronic Disease; Humans; Renal Dialysis; Renal Insufficiency; Vascular Diseases; Vitamin K; Vitamin K Deficiency; Warfarin

Topics: Animals; Antibiotic Prophylaxis; Anticoagulants; Aortic Valve Insufficiency; Aortic Valve Stenosis; Bioprosthesis; Calcinosis; Defibrillators, Implantable; Echocardiography, Doppler; Endarterectomy; Endocarditis, Bacterial; Female; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valves; Hemodynamics; Humans; Immunohistochemistry; Magnetic Resonance Imaging; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Platelet Aggregation Inhibitors; Pregnancy; Pregnancy Complications, Cardiovascular; Pulmonary Artery; Tricuspid Valve Insufficiency; Ventricular Function, Left; Warfarin

Arteriosclerosis, characterized by remodeling and stiffening of large elastic arteries is the most significant manifestation of vascular aging. The increased stiffening is believed to originate from a gradual mechanical senescence of the elastic network, alterations in cross-linking of extracellular matrix components, fibrosis and calcification of elastic fibers (medial elastocalcinosis). The stiffening of large arteries reduces their capacitance and accelerates pulse wave velocity, thus contributing to a widening of pulse pressure and to the increased prevalence of isolated systolic hypertension with age. Current antihypertensive drugs were mainly designed to reduce peripheral resistance and are not adequate to alter the pathological process of vascular stiffening or even to selectively reduce systolic blood pressure in isolated systolic hypertension. This review puts forward the concept that elastocalcinosis is a valuable therapeutic target and presents evidence that this process can be prevented and reversed pharmacologically.

Topics: Aged; Aging; Antihypertensive Agents; Arteries; Arteriosclerosis; Calcinosis; Humans; Hypertension; Muscle, Smooth, Vascular; Osteoporosis; Systole; Vitamin K; Warfarin

To evaluate the effect of low doses of warfarin in patients with systemic sclerosis with disseminated subcutaneous calcinosis.. Three patients with disseminated subcutaneous calcinosis were treated with low doses of warfarin for 1 year. Subcutaneous calcinotic lesions, coagulation blood parameters, and the tendency for bleeding were followed up during the year.. Two of the patients, who had newly diagnosed, diffuse, and relatively small calcinotic lesions, responded to warfarin treatment, with complete resolution of the calcinosis. The other patient, with larger and longer standing calcinotic lesions, did not respond to warfarin treatment. None of the three patients showed a prolongation of prothrombin time or partial thromboplastin time, nor did any have an increased tendency for bleeding.. Low dose warfarin may serve as an effective treatment for calcinosis in a selected group of patients who have small and relatively new onset calcinosis. This treatment does not prolong the coagulation of blood and there is no increased tendency for bleeding.

Topics: Adult; Aged; Calcinosis; Dermatologic Agents; Drug Administration Schedule; Female; Humans; Scleroderma, Systemic; Skin Diseases; Warfarin

Topics: Abnormalities, Drug-Induced; Abnormalities, Multiple; Calcinosis; Diagnosis, Differential; Epiphyses; Female; Fetal Diseases; Humans; Infant, Newborn; Nose; Pregnancy; Prenatal Exposure Delayed Effects; Prognosis; Syndrome; Vitamin K Deficiency; Warfarin

Topics: Calcinosis; Endocarditis; Fibrinolytic Agents; Heart Septal Defects, Atrial; Heart Valve Diseases; Humans; Mitral Valve Prolapse; Rheumatic Heart Disease; Thromboembolism; Warfarin

The sudden development of cyanotic lesions on the feet may be a result of atheroembolic disease or a number of medical conditions. A careful history and physical examination, basic laboratory tests, and noninvasive vascular assessment usually distinguish between medical and surgical causes and direct the choice of further investigations. Specific therapy is often available for medical conditions causing this syndrome. The management of atheroembolic disease is more controversial. In particular, further research is necessary to determine which patients need surgical intervention and which patients can be managed safely by medical therapy.

Topics: Adrenal Cortex Hormones; Blood Coagulation Disorders; Calcinosis; Cyanosis; Embolism; Humans; Ischemia; Postoperative Complications; Skin Diseases; Syndrome; Toes; Vasculitis; Warfarin

Premature cartilaginous calcification and nasal hypoplasia following first trimester exposure to warfarin are known as the Foetal Warfarin Syndrome (FWS). There are over 40 cases reported in the literature, many of which describe breathing and feeding difficulties in the first few months of life. We report a case where a child had had difficulties breathing and feeding in the first months of life. These had been attributed to nasal hypoplasia. After proper ENT assessment the child benefitted from adenoidectomy. ENT surgeons should be aware of the syndrome as more women of child bearing age are taking warfarin following cardiac surgery and treatment of thromboembolic disease. ENT surgeons may be asked to review these children who often present with airway and feeding problems which have been attributed to nasal hypoplasia.

Topics: Calcinosis; Cartilage Diseases; Female; Humans; Infant; Male; Nasal Obstruction; Nose; Pregnancy; Prenatal Exposure Delayed Effects; Warfarin

Treatment of calcified (in contrast to simple) lesions with PTCA has been associated with a lower success rate and more procedural complications. Rotablation can improve acute results, but the high restenosis rate remains a problem. The purpose of this study was to evaluate the clinical and angiographic outcome of patients with complex and calcified lesions treated with a combination of rotablation and stenting.. Seventy-five consecutive patients with 106 lesions had rotablation prior to coronary stenting. Intravascular ultrasound-guided stenting was used without subsequent anticoagulation in 93% of patients. Procedural success was achieved in 93.4% of lesions. Acute stent thrombosis occurred in two lesions (1.9%), and subacute stent thrombosis in one lesion (0.9%). Angiographic follow-up was performed in 82.5% of lesions at 4.6 +/- 1.9 months with an angiographic restenosis rate of 22.5%. Clinical follow-up was performed in all patients at 6.4 +/- 3 months; target lesion revascularization was needed in 18% of lesions; Q-wave myocardial infarction occurred in 1.3%, coronary bypass surgery in 4.0%, and death in 1.3%.. Optimal coronary stenting after rotablation in calcified and complex lesions can be performed with a high success rate, an acceptable rate of procedural complications, and a low rate of stent thrombosis. This approach was associated with a low incidence of angiographic restenosis compared with results usually obtained with other interventional strategies in calcified and complex lesion subsets.

Topics: Aged; Aspirin; Atherectomy, Coronary; Calcinosis; Coronary Angiography; Coronary Disease; Coronary Thrombosis; Female; Fibrinolytic Agents; Follow-Up Studies; Heparin; Humans; Male; Middle Aged; Recurrence; Retrospective Studies; Stents; Ticlopidine; Ultrasonography; Warfarin

Patients with calcinosis universalis secondary to dermatomyositis or systemic sclerosis have increased levels of the calcium-binding amino acid, gamma-carboxyglutamic acid. The enzyme that effects gamma carboxylation of glutamic acid is warfarin-sensitive. Four patients with calcinosis universalis were treated with 1 mg per day of warfarin for 18 months in a non-blind initial study. Two patients had both decreased gamma-carboxyglutamic acid urinary concentration and decreased extra-skeletal uptake on technetium 99m-diphosphonate whole-body nuclear scanning. In a subsequent double-blind placebo study, two thirds of the patients receiving 1 mg per day of warfarin had decreases in extra-skeletal nuclear tracer uptake after 18 months, compared with none of the four patients receiving placebo. No patient had a change in clinical assessment, bleeding complication, or baseline normal prothrombin time. This low-dose warfarin regimen appears to have no demonstrable adverse effects, and these results suggest a beneficial effect on the progression of calcinosis in these rheumatic diseases.

Topics: Bone and Bones; Calcinosis; Dermatomyositis; Double-Blind Method; Drug Evaluation; Humans; Radiography; Radionuclide Imaging; Random Allocation; Scleroderma, Systemic; Skin Diseases; Time Factors; Warfarin

Arterial media calcification refers to the pathological deposition of calcium phosphate crystals in the arterial wall. This pathology is a common and life-threatening complication in chronic kidney disease, diabetes and osteoporosis patients. Recently, we reported that the use of a TNAP inhibitor, SBI-425, attenuated arterial media calcification in a warfarin rat model. Employing a high-dimensionality unbiased proteomic approach, we also investigated the molecular signaling events associated with blocking arterial calcification through SBI-425 dosing. The remedial actions of SBI-425 were strongly associated with (i) a significant downregulation of inflammatory (acute phase response signaling) and steroid/glucose nuclear receptor signaling (LXR/RXR signaling) pathways and (ii) an upregulation of mitochondrial metabolic pathways (TCA cycle II and Fatty Acid β-oxidation I). Interestingly, we previously demonstrated that uremic toxin-induced arterial calcification contributes to the activation of the acute phase response signaling pathway. Therefore, both studies suggest a strong link between acute phase response signaling and arterial calcification across different conditions. The identification of therapeutic targets in these molecular signaling pathways may pave the way to novel therapies against the development of arterial media calcification.

Topics: Acute-Phase Reaction; Alkaline Phosphatase; Animals; Calcinosis; Proteomics; Rats; Vascular Calcification; Warfarin

Topics: Anticoagulants; Calcinosis; Humans; Vascular Calcification; Warfarin

Arterial media calcification is an active cell process. This encompasses osteochondrogenic transdifferentiation of vascular smooth muscle cells followed by the deposition of calcium-phosphate crystals. Increasing evidence suggests a significant role for endothelial cells (ECs) in the development of arterial media calcification. This manuscript explores a role for endothelial dysfunction in the disease progression of arterial media calcification. Male rats were randomly assigned to four different groups. The first group received standard chow. The second group was given L-NAME (≈50 mg kg

Topics: Animals; Calcinosis; Calcium; Disease Progression; Endothelial Cells; Male; NG-Nitroarginine Methyl Ester; Rats; Tunica Media; Vascular Calcification; Vascular Diseases; Warfarin

Topics: Anticoagulants; Calcinosis; Humans; Warfarin

Rivaroxaban is a direct inhibitor of activated Factor X (FXa), an anti-inflammatory protein exerting a protective effect on the cardiac valve and vascular endothelium. We compare the effect of Warfarin and Rivaroxaban on inflammation biomarkers and their contribution to heart valve calcification progression and renal preservation in a population of atrial fibrillation (AF) patients with chronic kidney disease (CKD) stage 3b - 4.. This was an observational, multicenter, prospective study enrolling 347 consecutive CKD stage 3b - 4 patients newly diagnosed with AF: 247 were treated with Rivaroxaban and 100 with Warfarin. Every 12 months, we measured creatinine levels and cardiac valve calcification via standard trans-thoracic echocardiogram, while plasma levels of inflammatory mediators were quantified by ELISA at baseline and after 24 months.. Over a follow-up of 24 months, long-term treatment with Rivaroxaban was associated with a significative reduction of cytokines. Patients treated with Rivaroxaban experienced a more frequent stabilization/regression of valve calcifications comparing with patients treated with Warfarin. Rivaroxaban use was related with an improvement in kidney function in 87.4% of patients, while in those treated with Warfarin was reported a worsening of renal clearance in 98% of cases. Patients taking Rivaroxaban experienced lower adverse events (3.2% vs 49%, p-value <0.001).. Our findings suggest that Rivaroxaban compared to Warfarin is associated with lower levels of serum markers of inflammation. The inhibition of FXa may exert an anti-inflammatory effect contributing to reduce the risk of cardiac valve calcification progression and worsening of renal function.

Topics: Anticoagulants; Atrial Fibrillation; Calcinosis; Factor Xa Inhibitors; Heart Valves; Humans; Inflammation; Kidney; Prospective Studies; Rivaroxaban; Stroke; Treatment Outcome; Warfarin

Calcific aortic valve disease is a common heart disease that contributes to increased cardiovascular morbidity and mortality. There is a lack of effective pharmaceutical therapy because its mechanisms are not yet fully known. Ginkgo biloba extract (EGB761) is reported to alleviate vascular calcification. However, whether EGB761 protects against aortic valve calcification, a disease whose pathogenesis shares many similarities with vascular calcification, and potential molecular mechanisms remain unknown. In this study, porcine aortic valve interstitial cell (pAVIC) calcification was induced by warfarin with or without the presence of EGB761. Immunostaining was performed to establish and characterize the pAVIC phenotype. Calcium deposition and calcium content were examined by Alizarin Red S staining and an intracellular calcium content assay. Alkaline phosphatase activity was detected by the p-nitrophenyl phosphate method. The expression levels of bone morphogenetic protein-2 (BMP2), Runt-related transcription factor 2 (Runx2), homeobox protein MSX-2, and phosphorylated (p)-Smad1/5 were detected by reverse transcription-quantitative polymerase chain reaction (PCR) and Western blot analysis. Consistent with these in vitro data, we also confirmed the suppression of in vivo calcification by EGB761 in the warfarin-induced C57/Bl6 mice. The results indicated that both pAVICs and aortic valves tissue of mice stimulated with warfarin showed increased calcium deposition and expression of osteogenic markers (alkaline phosphatase, BMP2, homeobox protein MSX-2, and Runx2) and promoted p-Smad1/5 translocation from the cytoplasm to the nucleus. The addition of EGB761 significantly inhibited p-Smad1/5 translocation from the cytoplasm to the nucleus, thus suppressing calcification. In conclusion, EGB761 could ameliorate warfarin-induced aortic valve calcification through the inhibition of the BMP2-medicated Smad1/5/Runx2 signaling pathway.

Topics: Active Transport, Cell Nucleus; Animals; Aortic Valve; Bone Morphogenetic Protein 2; Calcinosis; Calcium; Cells, Cultured; Core Binding Factor Alpha 1 Subunit; Disease Models, Animal; Ginkgo biloba; Heart Valve Diseases; Homeodomain Proteins; Male; Mice, Inbred C57BL; Osteogenesis; Phosphorylation; Plant Extracts; Signal Transduction; Smad1 Protein; Smad5 Protein; Sus scrofa; Warfarin

When patients with extensive mitral annular calcification undergo mitral valve replacement, excessive debridement of calcification may result in fatal complications and may protract operation time. We report a case of supra-annular MVR using "the chimney technique" on a high-risk patient for severe mitral stenosis with extensive mitral annular calcification. This technique is usually used in small infants whose mitral annulus is smaller than the smallest available prosthetic valve. We apply this technique to minimize the debridement of calcification and shorten the operation time. The operation was successfully completed, and the postoperative course has been uneventful. This technique was safely and easily performed, and eliminated the need for aggressive debridement of the calcification. We believe this technique may be a good choice for high-risk patients with mitral annular calcification.

Topics: Aged; Anticoagulants; Blood Pressure; Calcinosis; Cardiopulmonary Bypass; Echocardiography; Female; Heart Defects, Congenital; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Humans; Mitral Valve; Mitral Valve Insufficiency; Mitral Valve Stenosis; Tomography, X-Ray Computed; Warfarin

Topics: Anticoagulants; Calcinosis; Humans; Vitamin K; Warfarin

We aimed to investigate the role of the miR-29b and its effect on TGF-β3 pathway in vascular and valvular calcification in a rat model of calcific aortic valve diseases (CAVD). A rat model of CAVD was established by administration of warfarin plus vitamin K. The expression levels of miR-29b, osteogenic markers and other genes were determined by qRT-PCR, Western blot and/or immunofluorescence and immunohistochemistry. The calcium content and alkaline phosphatase (ALP) activity were measured. The calcium content, ALP activity and osteogenic markers levels in calcified aorta and aortic valve were augmented compared to controls. The expression of miR-29b, p-Smad3, and Wnt3 and β-catenin was significantly up-regulated, whereas TGF-β3 was markedly down-regulated. However, compared with the CAVD model group, the calcium content and ALP activity in rats treated with antagomiR-29b were significantly decreased, and antagomiR-29b administration reversed the effects of CAVD model on the expression of miR-29b and osteogenic markers. Inhibition of miR-29b in CAVD rats prevented from vascular and valvular calcification and induced TGF-β3 expression, suggesting that the miR-29b/TGF-β3 axis may play a regulatory role in the pathogenesis of vascular and valvular calcification and could play a significant role in the treatment of CAVD and other cardiovascular diseases.

Topics: Animals; Antagomirs; Aortic Valve; Aortic Valve Stenosis; Calcification, Physiologic; Calcinosis; Disease Models, Animal; Heart; Male; MicroRNAs; Osteogenesis; Osteopontin; Rats, Sprague-Dawley; Smad3 Protein; Transforming Growth Factor beta3; Up-Regulation; Vascular Calcification; Warfarin; Wnt Signaling Pathway

Warfarin, a vitamin K antagonist, is the most common anticoagulant used to prevent thromboembolisms associated with atrial fibrillation or following valvular surgery. Although several studies have revealed that long-term warfarin use accelerates aortic valve calcification and the development of aortic stenosis (AS), the detailed mechanism for this phenomenon remains unclear. Therefore, our aim was twofold: to establish the conditions for warfarin-induced calcification of human aortic valve interstitial cells (HAVICs) using high-inorganic phosphate (Pi) conditions and to investigate the underlying mechanism. We prepared and cultured HAVICs from aortic valves affected by calcific aortic valve stenosis (AS group) and aortic valves affected by aortic regurgitation but without any signs of calcification (non-AS group). Under Pi concentrations of 3.2 mM, warfarin significantly increased the calcification and alkaline phosphatase (ALP) activity of AS but not non-AS group HAVICs. Furthermore, gene expression of bone morphogenetic protein 2 (BMP2), a calcigenic marker, was significantly increased following 7 days of warfarin treatment. Warfarin-induced calcification of AS group HAVICs at 3.2 mM Pi was significantly inhibited by dorsomorphin, a Smad inhibitor, and the pregnane X receptor (PXR) inhibitors, ketoconazole and coumestrol, but was unaffected by SN-50, an NF-κB inhibitor. Warfarin was also able to increase BMP2 gene expression at a physiological Pi concentration (1.0 mM). Furthermore, excess BMP2 (30 ng/mL) facilitated warfarin-induced ALP upregulation and HAVIC calcification, an effect which was significantly reduced in the presence of coumestrol. Together, our results suggest that warfarin accelerates calcification of HAVICs from AS patients via the PXR-BMP2-ALP pathway.

Topics: Aortic Valve; Aortic Valve Stenosis; Bone Morphogenetic Protein 2; Calcinosis; Cells, Cultured; Female; Gene Expression Regulation; Humans; Male; Middle Aged; Models, Biological; Phosphates; Pregnane X Receptor; Warfarin

Topics: Aged; Anticoagulants; Aortic Valve; Aortic Valve Stenosis; Calcinosis; Disease Progression; Echocardiography; Factor Xa Inhibitors; Female; Follow-Up Studies; Humans; Male; Middle Aged; Pharmacovigilance; Warfarin

The most frequently used oral anti-coagulant warfarin has been implicated in inducing calcification of aortic valve interstitial cells (AVICs), whereas the mechanism is not fully understood. The low-level activation of p53 is found to be involved in osteogenic transdifferentiation and calcification of AVICs. Whether p53 participates in warfarin-induced AVIC calcification remains unknown. In this study, we investigated the role of low-level p53 overexpression in warfarin-induced porcine AVIC (pAVIC) calcification. Immunostaining, quantitative PCR, and Western blotting revealed that p53 was expressed in human and pAVICs and that p53 expression was slightly increased in calcific human aortic valves compared with non-calcific valves. Terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling staining indicated that apoptosis slightly increased in calcific aortic valves than in non-calcific valves. Warfarin treatment led to a low-level increase of p53 mRNA and protein in both pAVICs and mouse aortic valves. Low-level overexpression of p53 in pAVICs via an adenovirus vector did not affect pAVIC apoptosis but promoted warfarin-induced calcium deposition and expression of osteogenic markers. shRNA-mediated p53 knockdown attenuated the pAVIC calcium deposition and osteogenic marker expression. Moreover, ChIP and luciferase assays showed that p53 was recruited to the

Topics: Animals; Anticoagulants; Antifibrinolytic Agents; Aortic Valve; Atrial Fibrillation; Calcinosis; Cells, Cultured; Disease Models, Animal; Epigenesis, Genetic; Gene Expression Regulation; Genes, Reporter; Heart Valve Diseases; Humans; Male; Mice, Inbred C57BL; Promoter Regions, Genetic; Recombinant Proteins; Rheumatic Heart Disease; RNA Interference; Snail Family Transcription Factors; Sus scrofa; Tumor Suppressor Protein p53; Vitamin K 1; Warfarin

Lutembacher syndrome is characterized by a congenital ostium secundum atrial septal defect and an acquired mitral valve stenosis. We present a similar case in a 31-year old male who came in with orthopnoea, central cyanosis and pedal oedema. Examination revealed cardiac murmurs in tricuspid and apical regions. Chest x-ray showed signs of pulmonary congestion and ventricular enlargement. Electrocardiogaphy (ECG) revealed right axis deviation and right bundle branch block along with atrial fibrillation and Transthoracic Echocardiography (TTE) showed abnormal valves (mitral stenosis with calcification and tricuspid regurgitation) and dilated cardiac chambers. The patient was consequently treated with beta-blockers and diuretics and scheduled for valvular and septal repair via open heart surgery. The purpose of this case report is to assist cardiologists in diagnosing this syndrome accurately on the basis of symptoms and investigations.

Topics: Adrenergic beta-Antagonists; Adult; Amiloride; Anticoagulants; Atrial Fibrillation; Bundle-Branch Block; Calcinosis; Cardiac Surgical Procedures; Cardiomegaly; Cyanosis; Diuretics; Echocardiography; Edema; Electrocardiography; Foot; Furosemide; Heart Septal Defects, Atrial; Humans; Lutembacher Syndrome; Male; Mitral Valve Annuloplasty; Mitral Valve Stenosis; Tricuspid Valve Insufficiency; Warfarin

Vitamin K antagonists, such as warfarin, are known to promote arterial calcification through blockade of gamma-carboxylation of Matrix-Gla-Protein. It is currently unknown whether other oral anticoagulants such as direct inhibitors of Factor Xa can have protective effects on the progression of aortic valve calcification.. To compare the effect of warfarin and rivaroxaban on the progression of aortic valve calcification in atherosclerotic mice.. 42 ApoE-/- mice fed with Western-type Diet (WTD) were randomized to treatment with warfarin (n = 14), rivaroxaban (n = 14) or control (n = 14) for 8 weeks. Histological analyses were performed to quantify the calcification of aortic valve leaflets and the development of atherosclerosis. The analyses showed a significant increase in valve calcification in mice treated with warfarin as compared to WTD alone (P = .025) or rivaroxaban (P = .005), whereas no significant differences were found between rivaroxaban and WTD (P = .35). Quantification of atherosclerosis and intimal calcification was performed on the innominate artery of the mice and no differences were found between the 3 treatments as far as atherogenesis and calcium deposition is concerned. In vitro experiments performed using bovine interstitial valve cells (VIC) showed that treatment with rivaroxaban did not prevent the osteogenic conversion of the cells but reduce the over-expression of COX-2 induced by inflammatory mediators.. We showed that warfarin, but not rivaroxaban, could induce calcific valve degeneration in a mouse model of atherosclerosis. Both the treatments did not significantly affect the progression of atherosclerosis. Overall, these data suggest a safer profile of rivaroxaban on the risk of cardiovascular disease progression.

Topics: Animals; Anticoagulants; Aortic Valve; Aortic Valve Stenosis; Atherosclerosis; Calcinosis; Cattle; Cells, Cultured; Cyclooxygenase 2; Disease Models, Animal; Disease Progression; Factor Xa Inhibitors; Female; Male; Mice, Knockout, ApoE; Risk Assessment; Rivaroxaban; Time Factors; Vascular Calcification; Warfarin

Essentials Vitamin K plays a role in coagulation, and deficiency may promote coronary artery calcification. The role of vitamin K1 in heart disease was assessed using Mendelian randomization in Caucasians. Genetically higher vitamin K1 was associated with a higher risk of ischemic heart disease. Further research elucidating the role of vitamin K1 in ischemic heart disease could be useful.. Background Vitamin K1 is a nutrient in green leafy vegetables; deficiency may promote coronary artery calcification. Warfarin, an anticoagulant used in secondary prevention of thrombotic events, is a vitamin K antagonist. Thrombotic and coronary events may share risk factors. Objectives To clarify the role of vitamin K1 in ischemic heart disease, the risk of coronary artery disease/myocardial infarction (CAD/MI) was assessed according to genetically determined vitamin K1 levels. Given vitamin K1 is fat soluble, associations with lipids were similarly assessed to assess pleotropic effects via lipids. Methods Separate sample instrumental variable analysis with genetic instruments (Mendelian randomization) was used to obtain an unconfounded estimate of the association of vitamin K1 (based on rs2108622 [CYP4F2], rs4645543 [KCNK9] and rs2192574 [CTNNA2] from a genome-wide association study) with CAD/MI using CARDIoGRAMplusC4D (cases = 64 374; controls = 130 681) and with lipids using Global Lipids Genetics Consortium Results (n = 196 475). Results Vitamin K1 single nucleotide polymorphisms were positively associated with CAD/MI (odds ratio [OR], 1.17 per unit [nmol L(-1) ] of natural log-transformed genetically predicted vitamin K1 ; 95% confidence interval [CI], 1.08-1.26), but not with inverse normal transformed low-density lipoprotein cholesterol (-0.0003; 95% CI, -0.03 to 0.03), high-density lipoprotein cholesterol (0.02; 95% CI, -0.01 to 0.05) or triglycerides (-0.01; 95% CI, -0.04 to 0.02). Considering only rs2108622, which is functionally relevant to vitamin K1 , the association for CAD/MI was stronger (OR, 1.21; 95% CI, 1.08-1.36). Conclusions Vitamin K may cause CAD/MI; whether vitamin K or other determinants of coagulation could be relevant to primary prevention might be worth considering.

Topics: Calcinosis; Case-Control Studies; Cholesterol, LDL; Coronary Artery Disease; Coronary Vessels; Diet; Female; Genome-Wide Association Study; Humans; Linkage Disequilibrium; Male; Mendelian Randomization Analysis; Middle Aged; Myocardial Infarction; Myocardial Ischemia; Polymorphism, Single Nucleotide; Risk Factors; Triglycerides; Vitamin K; Warfarin; White People

The aim of this study was to investigate the effect of vitamin K2 on aortic calcification induced by warfarin via Gas6/Axl survival pathway in rats. A calcification model was established by administering 3mg/g warfarin to rats. Rats were divided into 9 groups: control group (0W, 4W, 6W and 12W groups), 4W calcification group, 6W calcification group, 12W calcification group, 6W calcification+6W normal group and 6W calcification+6W vitamin K2 group. Alizarin red S staining measured aortic calcium depositions; alkaline phosphatase activity in serum was measured by a kit; apoptosis was evaluated by TUNEL assay; protein expression levels of Gas6, Axl, phosphorylated Akt (p-Akt), and Bcl-2 were determined by western blotting. The calcium content, calcium depositions, ALP activity and apoptosis were significantly higher in the calcification groups than control group. Gas6, Axl, p-Akt and Bcl-2 expression was lower in the calcification group than control group. 100μg/g vitamin K2 treatment decreased calcium depositions, ALP activity and apoptosis significantly, but increased Gas6, Axl, p-Akt and Bcl-2 expression. 100μg/g vitamin K2 reversed 44% calcification. Pearson correlation analysis showed a positive correlation between formation calcification and apoptosis (R(2)=0.8853, P<0.0001). In conclusion, we established a warfarin-induced calcification model and showed vitamin K2 can inhibit warfarin-induced aortic calcification and apoptosis. The regression of aortic calcification by vitamin K2 involved the Gas6/Axl axis. This data may provide a theoretical basis for future clinical treatments for aortic calcification.

Topics: Alkaline Phosphatase; Animals; Aorta; Apoptosis; Axl Receptor Tyrosine Kinase; Calcinosis; Intercellular Signaling Peptides and Proteins; Male; Phosphoproteins; Proto-Oncogene Proteins; Proto-Oncogene Proteins c-akt; Proto-Oncogene Proteins c-bcl-2; Rats; Rats, Sprague-Dawley; Receptor Protein-Tyrosine Kinases; Up-Regulation; Vitamin K 2; Warfarin

Cardiovascular calcifications can be prevented by vitamin K and are accelerated by vitamin K antagonists. These effects are believed to be mainly mediated by the vitamin K-dependent matrix Gla protein. Another vitamin K-dependent protein, Gas6, is also expressed in vascular smooth muscle cells (VSMC). In vitro Gas6 expression was shown to be regulated in VSMC calcification and apoptotic processes.. We investigated the role of Gas6 in vitro using VSMC cultures and in vivo in young and old Gas6-deficient (Gas6(-/-)) and wildtype (WT) mice. In addition, Gas6(-/-) and WT mice were challenged by (a) warfarin administration, (b) uninephrectomy (UniNX) plus high phosphate diet, or (c) UniNX plus high phosphate plus electrocautery of the residual kidney.. In vitro VSMC from WT and Gas6(-/-) mice exposed to warfarin showed increased apoptosis and calcified similarly. In vivo, aortic, cardiac and renal calcium content in all groups was similar, except for a lower cardiac calcium content in Gas6(-/-) mice (group a). Von Kossa staining revealed small vascular calcifications in both WT and Gas6(-/-) mice (groups a-c). In aging, non-manipulated mice, no significant differences in vascular calcification were identified between Gas6(-/-) and WT mice. Gas6(-/-) mice exhibited no upregulation of matrix Gla protein in any group. Cardiac output was similar in all treatment groups.. Taken together, in our study Gas6 fails to aggravate calcification against the previous assumption.

Topics: Aging; Animals; Anticoagulants; Aorta; Apoptosis; Calcinosis; Calcium; Calcium-Binding Proteins; Cardiac Output; Cells, Cultured; Diet; Echocardiography; Extracellular Matrix Proteins; Female; Heart; Intercellular Signaling Peptides and Proteins; Kidney; Matrix Gla Protein; Mice; Mice, Inbred C57BL; Muscle, Smooth, Vascular; Myocardium; Nephrectomy; Phosphates; Warfarin

The mineralisation disorder pseudoxanthoma elasticum (PXE) is associated with mutations in the transporter protein ABCC6. Patients with PXE suffer from calcified lesions in the skin, eyes and vasculature, and PXE is related to a more severe vascular calcification syndrome called generalised arterial calcification of infancy (GACI). Mutations in ABCC6 are linked to reduced levels of circulating vitamin K. Here, we describe a mutation in the zebrafish (Danio rerio) orthologue abcc6a, which results in extensive hypermineralisation of the axial skeleton. Administration of vitamin K to embryos was sufficient to restore normal levels of mineralisation. Vitamin K also reduced ectopic mineralisation in a zebrafish model of GACI, and warfarin exacerbated the mineralisation phenotype in both mutant lines. These data suggest that vitamin K could be a beneficial treatment for human patients with PXE or GACI. Additionally, we found that abcc6a is strongly expressed at the site of mineralisation rather than the liver, as it is in mammals, which has significant implications for our understanding of the function of ABCC6.

Topics: Animals; Anthraquinones; ATP-Binding Cassette Transporters; Calcinosis; Chromosomes, Artificial, Bacterial; DNA Primers; In Situ Hybridization; Mutation; Pseudoxanthoma Elasticum; Transgenes; Vascular Calcification; Vitamin K; Warfarin; Zebrafish; Zebrafish Proteins

Warfarin, a widely used anticoagulant, is a vitamin K antagonist impairing the activity of vitamin K-dependent Bone Gla Protein (BGP or Osteocalcin) and Matrix Gla Protein (MGP). Because dabigatran, a new anticoagulant, has no effect on vitamin K metabolism, the aim of this study was to compare the impact of warfarin and dabigatran administration on bone structure and vascular calcification.. Rats with normal renal function received for 6 weeks warfarin, dabigatran or placebo. Bone was evaluated immuno-histochemically and hystomorphometrically after double labelling with declomycin and calcein. Aorta and iliac arteries were examined histologically.. Histomorphometric analysis of femur and vertebrae showed significantly decreased bone volume and increased trabecular separation in rats treated with warfarin. Vertebra analysis showed that the trabecular number was higher in dabigatran treated rats. Osteoblast activity and resorption parameters were similar among groups, except for maximum erosion depth, which was higher in warfarin treated rats, suggesting a higher osteoclastic activity. Therefore, warfarin treatment was also associated with higher bone formation rate/bone surface and activation frequency. Warfarin treatment may cause an increased bone turnover characterized by increased remodelling cycles, with stronger osteoclast activity compared to the other groups. There were no differences among experimental groups in calcium deposition either in aortic or iliac arteries.. These findings suggest for the first time that dabigatran has a better bone safety profile than warfarin, as warfarin treatment affects bone by reducing trabecular size and structure, increasing turnover and reducing mineralization. These differences could potentially result in a lower incidence of fractures in dabigatran treated patients.

Topics: Animals; Anticoagulants; Antithrombins; Aorta; Bone and Bones; Bone Diseases, Metabolic; Bone Remodeling; Calcinosis; Dabigatran; Female; Fractures, Spontaneous; Iliac Artery; Kidney; Minerals; Osteoblasts; Osteoclasts; Random Allocation; Rats; Rats, Sprague-Dawley; Vascular Diseases; Vitamin K; Warfarin

This study identified tracheobronchial cartilage calcification in children with congenital heart disease. Calcification of the tracheobronchial airways has been found previously in adults receiving warfarin and in children receiving warfarin after mitral valve replacement. A 9-year-old girl who had received a Fontan repair 6 years previously underwent a cardiac computed tomography (CT) scan to evaluate pulmonary artery size. The result was an incidental finding of extensive tracheobronchial cartilage calcification. A retrospective review of all pediatric Fontan patients who had undergone cardiac CT was conducted to search for calcification of the tracheobronchial cartilage. The study investigated ten pediatric Fontan patients who had undergone cardiac CT scanning. Two patients with extensive calcification of the tracheobronchial airways were identified. The index case had hypoplastic left heart syndrome, and the patient had undergone a staged repair with the Fontan at the age of 3 years. A 16-year-old boy with tricuspid atresia had undergone staged repair and Fontan at the age of 3.5 years. These two patients had received continuous warfarin therapy for 6 and 13 years, respectively. Other common causes of airway calcification were excluded from the study. This report describes warfarin-induced tracheobronchial calcification in patients after the Fontan procedure. This finding has possible implications for airway growth and vascular calcification.

Topics: Adolescent; Anticoagulants; Bronchi; Calcinosis; Child; Child, Preschool; Female; Fontan Procedure; Heart Defects, Congenital; Humans; Male; Postoperative Period; Time; Tomography, X-Ray Computed; Trachea; Warfarin

Topics: Anticoagulants; Bronchial Diseases; Calcinosis; Female; Humans; Middle Aged; Tomography, X-Ray Computed; Tracheal Diseases; Warfarin

Tracheobronchial calcifications are considered a rare radiologic finding in children. Our clinical experience indicates that this finding is not infrequently seen among children with prosthetic heart valves who have been treated with warfarin sodium.. We hypothesized that calcifications of the tracheobronchial tree are more common than previously reported in this patient population.. We reviewed the medical records and imaging studies of children who underwent cardiac valve replacement at our institution to estimate the prevalence.. Tracheobronchial calcifications were identified on chest radiographs in 6 out of 17 children (35%), indicating that this imaging finding might be frequently overlooked.. All children positive for tracheobronchial calcifications had been anticoagulated with warfarin sodium between the time of surgery and development of positive imaging findings. Our findings suggest that tracheobronchial calcifications are not uncommon in children treated with warfarin. Further investigation is necessary to determine wether there is a cause-effect relationship in these children.

Topics: Bronchial Diseases; Calcinosis; Child; Child, Preschool; Diagnosis, Differential; Female; Heart Valve Prosthesis; Humans; Infant; Male; Radiography; Tracheal Diseases; Warfarin

Topics: Aged, 80 and over; Anticoagulants; Calcinosis; Female; Hip; Humans; Hyperparathyroidism, Secondary; Kidney Failure, Chronic; Radiography; Renal Dialysis; Vascular Diseases; Warfarin

Coronary artery calcification is a recognised risk factor for ischaemic heart disease and mortality. Evidence is now strong that Mönckeberg's arteriosclerosis, a form of vascular calcification, can be attributable to vitamin K deficiency, but that vitamin K-2, especially the MK-4 form from foods like cheese can be protective. Warfarin blocks the recycling of hepatic and peripheral vitamin K leading to secondary vitamin K deficiency with adverse effects on vasculature, bone, kidneys, brain and other tissues and systems (inflammatory, immune function and neoplasia at least). There is individual susceptibility to vitamin K deficiency and warfarin sensitivity, partly explicable in terms of genetic polymorphisms, epigenetics, diet and pharmacotherapy. The emergence of extensive coronary calcification in a man with atrial fibrillation treated for a decade with warfarin is described by way of illustration and to raise the present clinical management conundrums. Finally, a putative set of recommendations is provided.

Topics: Calcinosis; Coronary Artery Disease; Diet; Factor Xa Inhibitors; Humans; Male; Middle Aged; Monckeberg Medial Calcific Sclerosis; Vitamin K 1; Vitamin K 2; Vitamin K Deficiency; Warfarin

Aortic medial calcification is a cellular-regulated process leading to arterial stiffness. Although epidemiological studies have suggested an association between the saturation of fatty acids (FA) and arterial stiffness, there is no evidence that saturated FA can induce arterial calcification. This study investigated the capacity of palmitic acid (PA) to induce medial calcification and the signaling pathway(s) implicated in this process.. Rat aortic segments and vascular smooth muscle cells (VSMC) were exposed to calcification medium supplemented with PA. In vivo, rats were treated with warfarin to induce calcification and fed a PA-enriched diet.. In vitro and ex vivo, palmitate increases calcification and ROS production. Palmitate increases extracellular-signal-regulated kinase (ERK1/2) phosphorylation and osteogenic gene expression. Inhibition of NADPH oxidase with apocynin or an siRNA prevents these effects. ERK1/2 inhibition attenuates the amplification of osteogenic gene expression and calcification induced by palmitate. In vivo, a PA-enriched diet amplified medial calcification and pulse wave velocity (PWV). These effects are mediated by ROS production as indicated by the inhibition of calcification and PWV normalization in rats concomitantly treated with apocynin.. ROS induction by palmitate leads to ERK1/2 phosphorylation and subsequently induces the osteogenic differentiation of VSMC. © 2013 S. Karger AG, Basel.

Topics: Acetophenones; Animals; Aorta; Calcinosis; Cell Transdifferentiation; Extracellular Signal-Regulated MAP Kinases; Male; Muscle, Smooth, Vascular; Myocytes, Smooth Muscle; NADPH Oxidases; Oxidative Stress; Palmitic Acid; Phosphorylation; Rats; Rats, Wistar; Reactive Oxygen Species; Vascular Calcification; Warfarin

Calcific aortic valve disease is the most common heart valve disorder. So far, there is no medical treatment for calcific aortic valve disease. The expression of ectonucleotidases, which metabolize nucleotides into phosphate products, may influence the calcification of the aortic valve. In this study, we investigated if the administration of an ectonucleotidase inhibitor, ARL67156 (6-N,N-Diethyl-D-β,γ-dibromomethyleneATP trisodium salt), may prevent the calcification of the aortic valve in the warfarin-induced mineralization rat model. Male Wistar rats were treated with warfarin or warfarin+ARL67156 for 28 days. All rats had comprehensive Doppler-echocardiographic studies at 28 day. A gene profiling of ectonucleotidases expressed in aortas of rats was documented by quantitative real-time PCR. The amount of calcium was determined by quantitative method and von Kossa staining. Ex vivo cultures of rat aortas were also used to further assess the effect of ARL67156 on the calcifying process and Akt signaling. Mineralization of the aorta/aortic valve was documented in warfarin-treated rats and was accompanied by the development of aortic stenosis. These changes were paralleled by an increased of ectonucleotide pyrophosphatase/phosphodiesterase-1 (ENPP1). Administration of the ectonucleotidase inhibitor, ARL67156 prevented the development of aortic stenosis by lowering the level of apoptosis and mineralization of the aortic valve/aorta. In addition, ARL67156 normalized the level of pAkt, an important kinase involved in the survival pathway. Inhibition of ectonucleotidase activity prevented the development of calcific aortic valve disease in a rat model. On that account, ectonucleotidase may represent a novel target in the treatment of calcific aortic valve disease.

Topics: Adenosine Triphosphatases; Adenosine Triphosphate; Animals; Aortic Valve Stenosis; Calcinosis; Male; Phosphoric Diester Hydrolases; Pyrophosphatases; Rats; Rats, Wistar; Treatment Outcome; Warfarin

Vitamin K-antagonists (VKA) are treatment of choice and standard care for patients with venous thrombosis and thromboembolic risk. In experimental animal models as well as humans, VKA have been shown to promote medial elastocalcinosis. As vascular calcification is considered an independent risk factor for plaque instability, we here investigated the effect of VKA on coronary calcification in patients and on calcification of atherosclerotic plaques in the ApoE(-/-) model of atherosclerosis.. A total of 266 patients (133 VKA users and 133 gender and Framingham Risk Score matched non-VKA users) underwent 64-slice MDCT to assess the degree of coronary artery disease (CAD). VKA-users developed significantly more calcified coronary plaques as compared to non-VKA users. ApoE(-/-) mice (10 weeks) received a Western type diet (WTD) for 12 weeks, after which mice were fed a WTD supplemented with vitamin K(1) (VK(1), 1.5 mg/g) or vitamin K(1) and warfarin (VK(1)&W; 1.5 mg/g & 3.0 mg/g) for 1 or 4 weeks, after which mice were sacrificed. Warfarin significantly increased frequency and extent of vascular calcification. Also, plaque calcification comprised microcalcification of the intimal layer. Furthermore, warfarin treatment decreased plaque expression of calcification regulatory protein carboxylated matrix Gla-protein, increased apoptosis and, surprisingly outward plaque remodeling, without affecting overall plaque burden.. VKA use is associated with coronary artery plaque calcification in patients with suspected CAD and causes changes in plaque morphology with features of plaque vulnerability in ApoE(-/-) mice. Our findings underscore the need for alternative anticoagulants that do not interfere with the vitamin K cycle.

Topics: Aged; Animals; Apolipoproteins E; Atherosclerosis; Calcinosis; Coronary Artery Disease; Female; Humans; Male; Mice; Mice, Transgenic; Middle Aged; Phenotype; Plaque, Atherosclerotic; Risk; Thromboembolism; Vitamin K; Warfarin

The case of a 49-year-old male patient who presented with recurrent pulmonary emboli secondary to a calcified lesion within his inferior vena cava is presented. The diagnosis and relevant literature is reviewed. This is the first time that calcification within the inferior vena cava has presented this way in adults, and it is important to consider this diagnosis in patients presenting with recurrent pulmonary emboli.

Topics: Anticoagulants; Calcinosis; Humans; Male; Middle Aged; Pulmonary Embolism; Recurrence; Tomography, X-Ray Computed; Vena Cava, Inferior; Warfarin

Eicosapentaenoic acid (EPA), a major n-3 polyunsaturated fatty acid, is reported to have various protective effects for cardiovascular disease. However, few studies have focused on the influence of EPA on vascular calcification.. Arterial medial calcification (AMC) was induced by administering warfarin (3 mg/g food) and vitamin K1 (1.5 mg/g food) for 2 weeks in Sprague-Dawley rats (control group), and EPA (1 g/kg/day) was administered for 2 weeks simultaneously with warfarin and vitamin K1 (EPA group) or after initiation of AMC (late EPA group). EPA showed a marked reduction of medial calcification in the EPA group, and showed a similar effect in the late EPA group. Immunohistochemical and RT-PCR analyses showed that EPA lowered the expression of osteogenetic markers, such as osteopontin, alkaline phosphatase and core binding factor-α1 in the aorta. Significant migration of macrophages with expression of matrix-metalloproteinase (MMP)-2 or MMP-9 was observed in the aortic adventitia around calcification. EPA also reduced macrophage infiltration, MMP-9 expression as well as gene expression of monocyte chemotactic protein (MCP)-1.. These observations indicate that EPA attenuates arterial medial calcification through an effect associated with the suppression of MMP-9 activity and inhibition of macrophage infiltration as well as osteogenic protein expression in warfarin-induced rat models.

Topics: Animals; Aorta; Calcinosis; Chemokine CCL2; Eicosapentaenoic Acid; Iliac Artery; Male; Matrix Metalloproteinase 2; Matrix Metalloproteinase 9; Rats; Rats, Sprague-Dawley; Vitamin K 1; Warfarin

Matrix Gla protein (MGP) is an inhibitor of vascular calcification but its mechanism of action and pathogenic role are unclear. This was examined in cultured rat aortas and in a model of vascular calcification in rats with renal failure. Both carboxylated (GlaMGP) and uncarboxylated (GluMGP) forms were present in aorta and disappeared during culture with warfarin. MGP was also released into the medium and removed by ultracentrifugation, and similarly affected by warfarin. In a high-phosphate medium, warfarin increased aortic calcification but only in the absence of pyrophosphate, another endogenous inhibitor of vascular calcification. Although GlaMGP binds and inactivates bone morphogenic protein (BMP)-2, a proposed mediator of vascular calcification through up-regulation of the osteogenic transcription factor runx2, neither warfarin, BMP-2, nor the BMP-2 antagonist noggin altered runx2 mRNA content in aortas, and noggin did not prevent warfarin-induced calcification. Aortic content of MGP mRNA was increased 5-fold in renal failure but did not differ between calcified and noncalcified aortas. Immunoblots showed increased GlaMGP in noncalcified (5-fold) and calcified (20-fold) aortas from rats with renal failure, with similar increases in GluMGP. We conclude that rat aortic smooth muscle produces both GlaMGP and GluMGP in tissue-bound and soluble, presumably vesicular, forms. MGP inhibits calcification independent of BMP-2-driven osteogenesis and only in the absence of pyrophosphate, consistent with direct inhibition of hydroxyapatite formation. Synthesis of MGP is increased in renal failure and deficiency of GlaMGP is not a primary cause of medial calcification in this condition.

Topics: Animals; Anticoagulants; Aorta; Bone Morphogenetic Protein 2; Calcinosis; Calcium-Binding Proteins; Core Binding Factor Alpha 1 Subunit; Durapatite; Extracellular Matrix Proteins; Male; Matrix Gla Protein; Models, Biological; Muscle, Smooth, Vascular; Organ Culture Techniques; Osteogenesis; Protein Binding; Rats; Rats, Sprague-Dawley; Renal Insufficiency; RNA, Messenger; Up-Regulation; Uremia; Warfarin

We report an uncommon case of thrombogenesis in the distal aortic arch after apicoaortic conduit (AAC) for severe aortic stenosis (AS). A 71-year-old woman underwent AAC with a bioprosthetic valve for severe AS because of heavy calcification of the ascending aorta. Although anticoagulant therapy with warfarin was performed, a postoperative computed tomographic (CT) scan revealed a thrombus in the distal aortic arch. Cine magnetic resonance imaging (MRI) revealed stagnation of the blood flow at that site. Administration of warfarin was continued. A follow-up CT-scan showed a marked reduction of the thrombus at six months after the surgery. A follow-up MRI revealed that the antegrade flow through the native aortic valve was decreased at one year after the surgery. We suggest that thrombogenesis may occur after AAC because of stagnation of the blood flow and that the distribution of the blood flow may change during the follow-up period. Therefore, we recommend that postoperative anticoagulant therapy should be initiated immediately, even when a bioprosthetic valve is used.

Topics: Aged; Anticoagulants; Aortic Diseases; Aortic Valve Stenosis; Aortography; Bioprosthesis; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Calcinosis; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Magnetic Resonance Imaging, Cine; Severity of Illness Index; Thrombosis; Tomography, X-Ray Computed; Warfarin

Calcific aortic valve disease (CAVD) is the most common etiology of acquired valvular heart disease, and hypertension is a principal underlying disease. The Japanese Aortic Stenosis Study (JASS) Retrospective Analysis is a retrospective observational study to clarify the prognostic factors for progression of CAVD in Japanese. Data from 556 subjects who met the following criteria were analyzed: (1) >or=50 years old; (2) calcification in any aortic valve leaflet or peak aortic jet velocity >or=2 m s(-1) on an echocardiographic study performed between July 2004 and June 2007; and (3) availability of earlier echocardiographic data from within the previous 2-5 years to assess the progression of CAVD. The subjects were divided into two groups according to CAVD severity on the preceding echocardiographic examination. In early-stage subjects with calcification in one or zero leaflets who were without aortic stenosis on the preceding echocardiographic study (n=157), the prognostic factors for progression were the following: (1) no use of angiotensin receptor blockers (ARB) and (2) use of warfarin. In late-stage subjects with calcification in two or three leaflets and/or aortic stenosis on the preceding echocardiographic study (n=399), progression was observed in females and in subjects with low hemoglobin and a concentric left ventricle. There was no relation between medications and changes in CAVD. Prognostic factors for the progression of CAVD were different between the early and late stages. Initiation of ARB treatment during the early stage may be effective, and we should be vigilant about progression of CAVD in patients treated with warfarin.

Topics: Aged; Aged, 80 and over; Angiotensin II Type 1 Receptor Blockers; Anticoagulants; Aortic Valve Stenosis; Calcinosis; Disease Progression; Echocardiography; Female; Humans; Japan; Male; Middle Aged; Prognosis; Retrospective Studies; Severity of Illness Index; Warfarin

To examine the in vivo effects of atorvastatin (AT) on arterial calcification in rats, arterial calcification was established by subcutaneous injection of vitamin D3 and Warfarin. Intragastric administration of AT began 4 days before establishment of arterial calcification in the AT group (n=6). Blood samples were taken and abdominal aortas were collected and stained. After induction of calcification, plasma Ca(2+) levels in the CA and AT groups were significantly higher than those before treatment and in the untreated controls. Plasma Ca(2+) levels in the AT group were significantly lower than in the CA group. The relative calcification area in aortic specimens from the AT group was significantly smaller than in the CA group. Rat aortic vascular smooth muscle cells (VMSC) were isolated from abdominal aortic segments and pre-treated with AT (1, 5, or 10 μM) for 24 hr. Cells in the calcification (CA) group and the AT group were cultured with β-glycerophosphate, insulin and vitamin C for 14 days to induce cell calcification. Calcium deposition and alkaline phosphatase activity were significantly increased in the CA group compared to untreated controls (p<0.01). This effect was ameliorated by AT (all p<0.01). In vivo administration of AT reduced arterial calcification and plasma Ca(2+) concentration. In vitro, AT reduced calcification markers in rat aortic vascular smooth muscle cells.

Topics: Animals; Aorta, Abdominal; Atorvastatin; Calcinosis; Calcium; Cells, Cultured; Drug Combinations; Heptanoic Acids; Hydroxymethylglutaryl-CoA Reductase Inhibitors; In Vitro Techniques; Injections, Subcutaneous; Male; Muscle, Smooth, Vascular; Myocytes, Smooth Muscle; Pyrroles; Rats; Rats, Sprague-Dawley; Thoracic Arteries; Vitamin D; Warfarin

Topics: Calcinosis; Cardiomyopathies; Fatal Outcome; Female; Humans; Middle Aged; Pericarditis; Warfarin

Matrix Gla protein (MGP) is a calcification inhibitor and alterations in circulating MGP have been observed in different populations characterized by vascular calcification. We hypothesized that patients with calcific valvular aortic stenosis (AS) would have dysregulated circulating MGP levels.. We examined plasma levels of nonphosphorylated carboxylated and undercarboxylated MGP (dp-cMGP and dp-ucMGP, respectively) in 147 patients with symptomatic severe AS and in matched healthy controls.. We further investigated the relationship between MGP levels and aortic pressure gradients and valve area by echocardiography and measures of heart failure. Finally, we assessed the prognostic value of elevated plasma dp-ucMGP level in relation to all-cause mortality in patients with AS.. We found markedly enhanced plasma levels of dp-cMGP and in particular of dp-ucMGP in patients with symptomatic AS. Although only weak correlations were found with the degree of AS, circulating dp-ucMGP was associated with cardiac function and long-term mortality in multivariate analysis.. A dysregulated MGP system may have a role in the development of left ventricular dysfunction in patients with symptomatic AS.

Topics: Aged; Aged, 80 and over; Anticoagulants; Aorta; Aortic Valve; Aortic Valve Stenosis; Biomarkers; Blood Pressure; Calcinosis; Calcium-Binding Proteins; Cause of Death; Echocardiography; Extracellular Matrix Proteins; Female; Heart Failure; Humans; Male; Matrix Gla Protein; Middle Aged; Prognosis; Warfarin

We describe a case of rapid onset of vascular calcification coincident with the initiation of warfarin therapy in a kidney transplant recipient. Calcification developed within the media of the blood vessel wall, with relative intimal sparing. Medium and small arteries were affected; however, the aorta was mostly free of calcifications, suggesting a differential response to warfarin between the intima and media and between different vascular beds. In addition, unlike the highly calcified native kidney's vessels, the kidney allograft was not calcified, suggesting local genetically determined mechanisms in preventing vascular calcification. Distal subcutaneous necrosis ultimately led to the patient's death.

Topics: Anticoagulants; Atrial Fibrillation; Calcinosis; Fatal Outcome; Humans; Kidney Transplantation; Male; Middle Aged; Tomography, X-Ray Computed; Tunica Intima; Tunica Media; Vascular Diseases; Warfarin

Matrix-Gla Protein (MGP) is a vitamin K-dependent protein acting as a local inhibitor of vascular calcification. Vitamin K-antagonists (oral anticoagulant; OAC) inhibit the activation of MGP by blocking vitamin K-metabolism. The aim of this study was to investigate the effect of long-term OAC treatment on circulating MGP levels in humans and on MGP expression in mice. Additionally, we tested the association between circulating inactive MGP (ucMGP) levels and the presence and severity of AVC in patients with aortic valve disease (AVD). We analysed circulating ucMGP levels in 191 consecutive patients with echocardiographically proven calcific AVD and 35 control subjects. The extent of AVC in the patients was assessed by multislice spiral computed tomography. Circulating ucMGP levels were significantly lower in patients with AVD (348.6 +/- 123.1 nM) compared to the control group (571.6 +/- 153.9 nM, p < 0.001). Testing the effect of coumarin in mice revealed that also the mRNA expression of MGP in the aorta was downregulated. Multifactorial analysis revealed a significant effect of glomerular filtration rate and long-term OAC therapy on circulating ucMGP levels in the patient group. Subsequently, patients on long-term OAC had significantly increased AVC scores. In conclusion, patients with calcific AVD had significantly lower levels of circulating ucMGP as compared to a reference population, free of coronary and valvular calcifications. In addition, our data suggest that OAC treatment may decrease local expression of MGP, resulting in decreased circulating MGP levels and subsequently increased aortic valve calcifications as an adverse side effect.

Topics: Administration, Oral; Adult; Aged; Aged, 80 and over; Animals; Anticoagulants; Aorta; Aortic Valve; Biomarkers; Calcinosis; Calcium-Binding Proteins; Case-Control Studies; Cross-Sectional Studies; Disease Models, Animal; Down-Regulation; Echocardiography; Extracellular Matrix Proteins; Female; Glomerular Filtration Rate; Heart Valve Diseases; Humans; Male; Matrix Gla Protein; Mice; Mice, Inbred DBA; Middle Aged; Osteopontin; Prognosis; Risk Assessment; Risk Factors; RNA, Messenger; Severity of Illness Index; Time Factors; Tomography, Spiral Computed; Vitamin K; Warfarin

Warfarin affects the synthesis and function of the matrix Gla-protein, a vitamin K-dependent protein, which is a potent inhibitor of tissue calcification.. To investigate the incidence of mitral valve calcium (MVC), mitral annular calcium (MAC) and aortic valve calcium (AVC) in patients with non-valvular atrial fibrillation (AF) treated with warfarin vs. no warfarin.. Of 1155 patients, mean age 74 years, with AF, 725 (63%) were treated with warfarin and 430 (37%) without warfarin. The incidence of MVC, MAC and AVC was investigated in these 1155 patients with two-dimensional echocardiograms. Unadjusted logistic regression analysis was conducted to examine the association between the use of warfarin and the incidence of MVC, MAC or AVC. Logistic regression analyses were also conducted to investigate whether the relationship stands after adjustment for confounding risk factors such as age, sex, race, ejection fraction, smoking, hypertension, diabetes, dyslipidemia, coronary artery disease (CAD), glomerular filtration rate, calcium, phosphorus, calcium-phosphorus product, alkaline phosphatase, use of aspirin, beta blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and statins.. There was a significant association between the use of warfarin and the risk of calcification [unadjusted odds ratio = 1.71, 95% CI = (1.34-2.18)]. The association still stands after adjustment for confounding risk factors. MVC, MAC or AVC was present in 473 of 725 patients (65%) on warfarin vs. 225 of 430 patients (52%) not on warfarin (P < 0.0001). Whether this is a causal relationship remains unknown.. Use of warfarin in patients with AF is associated with an increased prevalence of MVC, MAC or AVC.

Topics: Aged; Aged, 80 and over; Aortic Valve; Atrial Fibrillation; Calcinosis; Calcium-Binding Proteins; Extracellular Matrix Proteins; Female; Humans; Male; Matrix Gla Protein; Middle Aged; Mitral Valve; Regression Analysis; Retrospective Studies; Risk; Risk Factors; Warfarin

Warfarin has been shown to accelerate vascular calcification in experimental animals, and possibly humans, through inhibition of the vitamin K-dependent protein matrix gla protein, a potent inhibitor of tissue calcification. We performed a cross-sectional analysis of the extent of coronary artery calcification (CAC) in patients without coronary heart disease, currently taking or referred for warfarin therapy. The primary end point was severity of CAC measured by electron beam computed tomography attributed to duration of warfarin use, after adjustment for cardiovascular risk factors. Seventy patients (46 men, mean age 68 +/- 13 years) were enrolled from three groups of warfarin use duration: (1) <6 months (n = 31, mean duration 1 +/- 1 months), (2) 6-24 months (n = 11), and (3) >24 months (n = 28, mean 67 +/- 40 months). Overall, the mean total CAC score (Agatston) was 293 +/- 560: group 1 (175 +/- 285), group 2 (289 +/- 382), and group 3 (426 +/- 789). In univariate analysis, there was a nonsignificant trend to increased CAC with increasing warfarin exposure (P = 0.18). Bivariate analysis revealed no correlation between warfarin duration and CAC score (r = 0.075, P = 0.537). Linear regression for the independent variable coronary calcium score controlling for warfarin treatment duration and intensity (duration of warfarin use months x mean INR), Framingham risk score, and creatinine clearance showed that only the Framingham risk score was associated with CAC (P = 0.001). Among patients without known coronary heart disease, duration of warfarin exposure was not associated with extent of coronary calcification.

Topics: Aged; Aged, 80 and over; Anticoagulants; Calcinosis; Cardiomyopathies; Coronary Angiography; Coronary Artery Disease; Cross-Sectional Studies; Female; Humans; Linear Models; Male; Middle Aged; Risk Factors; Warfarin

We present a 36-year-old male patient with a previous diagnosis (22 years) of Eisenmenger's syndrome, who had a giant proximal pulmonary artery aneurysm complicated by massive thrombus formation. The patient experienced paroxysmal atrial fibrillation attacks for the past month. His functional capacity was New York Heart Association class III. Chest radiography showed aneurysmal dilatation in the left pulmonary artery. The patient was assessed by transthoracic echocardiography and multislice computed tomography. There was mild narrowing in the thick and calcified pulmonary valve (peak systolic gradient 35 mmHg) and moderate regurgitation. The mean pulmonary artery pressure was estimated as 50 mmHg. The diameters of the main, left, and right pulmonary arteries were 6.5 cm, 10 cm, and 3.7 cm, respectively. There was a massive thrombus in the aneurysmatic left pulmonary artery. The patient was referred to the cardiovascular surgery department for pulmonary artery reconstruction and cardiopulmonary transplantation. In addition, medical treatment was instituted with warfarin for thrombus and paroxysmal atrial fibrillation, metoprolol for atrial fibrillation, and bosentan for pulmonary hypertension. The patient's functional capacity showed improvement after the first month of medical treatment and no complications were seen within a year follow-up.

Topics: Anti-Arrhythmia Agents; Anticoagulants; Atrial Fibrillation; Calcinosis; Child; Coronary Vessel Anomalies; Eisenmenger Complex; Humans; Male; Metoprolol; Pulmonary Embolism; Radiography, Thoracic; Tomography, X-Ray Computed; Treatment Outcome; Warfarin

Topics: Aged, 80 and over; Anticoagulants; Calcinosis; Diagnosis, Differential; Female; Humans; Radiography, Thoracic; Tracheal Diseases; Warfarin

The effect of atorvastatin on warfarin-induced aortic medial calcification and systolic blood pressure (SBP) of rats induced by warfarin was studied. Thirty healthy and adult rats were randomly divided into Warfarin group (n=10), Atorvastatin group (n=10) and normal control group (n=10). Caudal arterial pressure of rats was measured once a week, and 4 weeks later, aorta was obtained. Elastic fiber, collagen fiber and calcium accumulation in tunica media of cells were measured by Von Kossa staining. The results showed that warfarin treatment led to elevation of systolic blood pressure and aortic medial calcification. The chronic treatment also increased collagen, but decreased elastin in the aorta. However, the atorvastatin treatment had adverse effects. It was concluded that treatment with atorvastatin presented evidence of blood pressure lowing and calcification reducing. These data demonstrate that atorvastatin protected aortic media from warfarin-induced calcification and elevation of systolic blood pressure.

Topics: Animals; Aortic Diseases; Atorvastatin; Blood Pressure; Calcinosis; Heptanoic Acids; Hypertension; Male; Pyrroles; Random Allocation; Rats; Rats, Wistar; Warfarin

Isolated systolic hypertension is associated with increased elastase activity, vascular calcification, and vascular stiffness. We sought to determine the importance of elastase activity and matrix degradation in the development of elastocalcinosis.. Elastocalcinosis was induced in vivo and ex vivo using warfarin. Hemodynamic parameters, calcium deposition, elastin degradation, transforming growth factor (TGF)-beta signaling, and elastase activity were evaluated at different time points in the in vivo model. Metalloproteinases, serine proteases, and cysteine proteases were blocked to measure their relative implication in elastin degradation. Gradual elastocalcinosis was obtained, and paralleled the elastin degradation pattern. Matrix metalloproteinase (MMP)-9 activity was increased at 5 days of warfarin treatment, whereas TGF-beta signaling was increased at 7 days. Calcification was significantly elevated after 21 days. Blocking metalloproteinases activation with doxycycline and TGF-beta signaling with SB-431542 were able to prevent calcification.. Early MMP-9 activation precedes the increase of TGF-beta signaling, and overt vascular elastocalcinosis and stiffness. Modulation of matrix degradation could represent a novel therapeutic avenue to prevent the gradual age-related stiffening of large arteries, leading to isolated systolic hypertension.

Topics: Animals; Aorta, Abdominal; Calcinosis; Collagen; Disease Models, Animal; Durapatite; Elastin; Femoral Artery; Male; Matrix Metalloproteinase 9; Osteopontin; Rats; Rats, Wistar; Signal Transduction; Transforming Growth Factor beta; Vascular Diseases; Warfarin

Arterial calcification is ubiquitous in vascular disease and is, in part, prevented by matrix Gla protein (MGP). MGP binds calcium ions through gamma-carboxylated glutamates (Gla residues) and inhibits bone morphogenetic protein (BMP)-2/-4. We hypothesized that a conserved proline (Pro)64 is essential for BMP inhibition. We further hypothesized that calcium binding by the Gla residues is a prerequisite for BMP inhibition. Site-directed mutagenesis was used to modify Pro64 and the Gla residues, and the effect on BMP-4 activity, and binding of BMP-4 and calcium was tested using luciferase reporter gene assays, coimmunoprecipitation, crosslinking, and calcium quantification. The results showed that Pro64 was critical for binding and inhibition of BMP-4 but not for calcium binding. The Gla residues were also required for BMP-4 binding but flexibility existed. As long as 1 Gla residue remained on each side of Pro64, the ability to bind and inhibit BMP-4 was preserved. Chelation of calcium ions by EDTA or warfarin treatment of cells led to loss of ability of MGP to bind BMP-4. Our results also showed that phenylalanine could replace Pro64 without loss of function and that zebrafish MGP, which lacks upstream Gla residues, did not function as a BMP inhibitor. The effect of MGP mutagenesis on vascular calcification was determined in calcifying vascular cells. Only MGP proteins with preserved ability to bind and inhibit BMP-4 prevented osteogenic differentiation and calcification. Together, our results suggest that BMP and calcium binding in MGP are independent but functionally intertwined processes and that the BMP binding is essential for prevention of vascular calcification.

Topics: 1-Carboxyglutamic Acid; Animals; Binding Sites; Bone Morphogenetic Protein 4; Bone Morphogenetic Proteins; Calcinosis; Calcium; Calcium-Binding Proteins; Cattle; Cell Line; Cells, Cultured; Chelating Agents; Edetic Acid; Endothelial Cells; Extracellular Matrix Proteins; Genes, Reporter; Humans; Matrix Gla Protein; Mice; Mutagenesis, Site-Directed; Osteogenesis; Pluripotent Stem Cells; Proline; Protein Binding; Recombinant Proteins; Transfection; Warfarin; Zebrafish Proteins

Isolated systolic hypertension results from a gradual stiffening of large arteries, to which medial elastocalcinosis (calcification of elastic lamellae) contributes. There is compelling evidence that reactive oxygen species (ROS) are associated with several disease processes affecting the cardiovascular system, including hypertension. The present study was designed to investigate whether the inhibition of ROS production by alpha-lipoic acid can prevent vascular calcification. Sprague-Dawley rats were treated with warfarin (20 mg/kg/day) and vitamin K (15 mg/kg/day) (WVK) for 4 weeks to induce large artery calcification. Subgroups received either a normal diet or a diet supplemented with lipoic acid (1000 mg/kg/day). The WVK treatment produced a small elevation of aortic superoxide levels that did not reach statistical significance. Alpha-lipoic acid reduced the elevation below baseline levels. In rats treated with alpha-lipoic acid, the WVK-induced elevation of pulse wave velocity (an index of arterial stiffness), left ventricular hypertrophy, and aortic, femoral and carotid elastocalcinosis were not prevented. Although a contribution of oxidative stress has been suggested in the aging cardiovascular system, this alteration does not appear to contribute to the calcification process and the subsequent stiffening of large arteries in the animal model tested.

Topics: Animals; Arteries; Calcinosis; Dietary Fats; Hypertrophy, Left Ventricular; Male; Oxidative Stress; Rats; Rats, Sprague-Dawley; Reactive Oxygen Species; Superoxides; Thioctic Acid; Vascular Diseases; Vitamin K; Warfarin

Topics: 1-Carboxyglutamic Acid; Anticoagulants; Atherosclerosis; Calcinosis; Humans; Immunohistochemistry; Vascular Diseases; Warfarin

Arterial calcification (AC) is generally regarded as an independent risk factor for cardiovascular morbidity and mortality. Matrix Gla protein (MGP) is a potent inhibitor of AC, and its activity depends on vitamin K (VK). In rats, inactivation of MGP by treatment with the vitamin K antagonist warfarin leads to rapid calcification of the arteries. Here, we investigated whether preformed AC can be regressed by a VK-rich diet. Rats received a calcification-inducing diet containing both VK and warfarin (W&K). During a second 6-week period, animals were randomly assigned to receive either W&K (3.0 mg/g and 1.5 mg/g, subsequently), a diet containing a normal (5 microg/g) or high (100 microg/g) amount of VK (either K1 or K2). Increased aortic calcium concentration was observed in the group that continued to receive W&K and also in the group changed to the normal dose of VK and AC progressed. Both the VK-rich diets decreased the arterial calcium content by some 50%. In addition, arterial distensibility was restored by the VK-rich diet. Using MGP antibodies, local VK deficiency was demonstrated at sites of calcification. This is the first study in rats demonstrating that AC and the resulting decreased arterial distensibility are reversible by high-VK intake.

Topics: Animals; Aorta, Thoracic; Arteries; Biomechanical Phenomena; Calcinosis; Calcium; Calcium-Binding Proteins; Carotid Arteries; Extracellular Matrix Proteins; Male; Matrix Gla Protein; Rats; Rats, Inbred WKY; Vitamin K; Warfarin

Age-related medial calcification (elastocalcinosis) of large arteries is accelerated in diabetes and appears mainly in distal arteries. The aim was to devise a rat model of elastocalcinosis in association with diabetes to examine the hypothesis that diabetes accelerates vascular calcification experimentally.. Male Wistar rats received a high fat diet during 2 months followed by a low dose of streptozotocin to induce diabetes (D). Elastocalcinosis was facilitated by 3 weeks of treatment with warfarin and vitamin K (WVK). We started WVK treatment 1 week (D4WVK) and 4 weeks (D7WVK) after the injection of streptozotocin and in age-matched healthy rats. Measurements of hemodynamic and metabolic parameters, aortic and femoral calcium content, and immunohistochemistry for alkaline phosphatase, osteopontin, tumor necrosis factor (TNF)-alpha, and transforming growth factor (TGF)-TGF-beta were performed.. Three weeks of WVK treatment alone did not increase the calcium content in the aorta and femoral arteries. However, in the D7WVK group, femoral calcification, but not aortic calcium content, increased significantly as compared to the WVK group. This response was not observed in the D4WVK group. In femoral arteries, strong immunostaining for alkaline phosphatase and osteopontin was observed in the D7WVK group. TNF-alpha and TGF-beta expressions were mainly localized in the adventitia of arteries from diabetic rats.. We have established a model of accelerated elastocalcinosis in diabetes related to its duration and localized in distal arteries. The modification of local protein expression is also in accordance with clinical data, suggesting that this model could be useful to investigate mechanisms related to this important clinical macrovascular complication of diabetes.

Topics: Alkaline Phosphatase; Animals; Aorta; Arteriosclerosis; Calcinosis; Calcium; Diabetes Mellitus, Experimental; Diabetic Angiopathies; Femoral Artery; Immunohistochemistry; Male; Models, Animal; Osteopontin; Rats; Rats, Wistar; Transforming Growth Factor beta; Tumor Necrosis Factor-alpha; Vitamin K; Warfarin

This study was designed to identify the global pattern of differentially expressed genes in human varicose veins. Using suppressive subtractive hybridization, we identified overexpression of genes known to be associated with extracellular matrix remodeling, including collagen III, tissue inhibitor of metalloproteinases I, dermatopontin, matrix Gla protein (MGP) and tenascin C. Real-time polymerase chain reaction analysis confirmed the differential expression of these genes. The overexpression of MGP transcript was associated with increased MGP level in varicose veins, in particular the undercarboxylated form of the protein. Smooth muscle cells from varicose veins showed increased proliferation rate and enhanced matrix mineralization. This observation correlated with the presence of ectopic mineralization areas in the varicose vein walls. The use of warfarin, to inhibit MGP activity, or siRNA targeting MGP transcript induced a reduction in the exacerbated proliferation of varicose vein smooth muscle cells. Our results suggest that high expression of MGP in varicose veins may contribute to venous wall remodeling by affecting proliferation and mineralization processes probably through impaired carboxylation of MGP. In addition, suppressive subtractive hybridization results also produce a profile of differentially expressed genes in varicose veins, in particular extracellular matrix components. Further study of these genes will provide insights into their specific roles in the etiology of venous disease.

Topics: Adult; Aged; Aged, 80 and over; Calcinosis; Calcium-Binding Proteins; Case-Control Studies; Cell Proliferation; Cells, Cultured; Dose-Response Relationship, Drug; Extracellular Matrix; Extracellular Matrix Proteins; Gene Expression Profiling; Gene Expression Regulation; Glycerophosphates; Humans; Male; Matrix Gla Protein; Middle Aged; Muscle, Smooth, Vascular; Oligonucleotide Array Sequence Analysis; Protein Processing, Post-Translational; Reproducibility of Results; Reverse Transcriptase Polymerase Chain Reaction; RNA Interference; RNA, Messenger; RNA, Small Interfering; Saphenous Vein; Up-Regulation; Varicose Veins; Warfarin

Matrix Gla protein (MGP) is a small vitamin K-dependent protein containing five gamma-carboxyglutamic acid (Gla) residues that are believed to be important in binding Ca(2+), calcium crystals and bone morphogenetic protein. In addition, MGP contains phosphorylated serine residues that may further regulate its activity. In vivo, MGP has been shown to be a potent inhibitor of vascular calcification; however, the precise molecular mechanism underlying the function of MGP is not yet fully understood.. We investigated the effects of MGP in human vascular smooth muscle cell (VSMC) monolayers that undergo calcification after exposure to an increase in Ca(2+) concentration. Increased calcium salt deposition was found in cells treated with the vitamin K antagonist warfarin as compared to controls, whereas cells treated with vitamin K(1) showed decreased calcification as compared to controls. With conformation-specific antibodies, it was confirmed that warfarin treatment of VSMCs resulted in uncarboxylated (Gla-deficient) MGP. To specifically test the effects of MGP on VSMC calcification, we used full-length synthetic MGP and MGP-derived peptides representing various domains in MGP. Full length MGP, the gamma-carboxylated motif (Gla) (amino acids 35-54) and the phosphorylated serine motif (amino acids 3-15) inhibited calcification. Furthermore, we showed that the peptides were not taken up by VSMCs but bound to the cell surface and to vesicle-like structures.. These data demonstrate that both gamma-glutamyl carboxylation and serine phosphorylation of MGP contribute to its function as a calcification inhibitor and that MGP may inhibit calcification via binding to VSMC-derived vesicles.

Topics: 1-Carboxyglutamic Acid; Adolescent; Adult; Amino Acid Sequence; Calcinosis; Calcium; Calcium-Binding Proteins; Cell Membrane; Cells, Cultured; Extracellular Matrix Proteins; Female; Humans; Male; Matrix Gla Protein; Middle Aged; Molecular Sequence Data; Muscle, Smooth, Vascular; Myocytes, Smooth Muscle; Peptide Fragments; Phosphorylation; Protein Processing, Post-Translational; Protein Structure, Tertiary; Serine; Transport Vesicles; Vitamin K; Vitamin K 1; Warfarin

To determine whether serum contains an activity that induces artery calcification.. The elastic lamellae of devitalized rat aortas calcify rapidly in rat or bovine serum, or in human serum provided [Pi] > or =2 mmol/L. This calcification is attributable to a potent serum calcification factor (SCF), one that causes devitalized aortas to calcify when incubated in DMEM containing as little as 1.5% serum but not in DMEM alone. The SCF that initiates medial elastin calcification has the same 50- to 150-kDa size and protease sensitivity as the SCF shown previously to initiate calcification of type I collagen. Our working hypothesis is that the same SCF initiates calcification of collagen and elastin, and that this SCF arises from sites of normal bone mineralization and, like alkaline phosphatase, is released into general circulation. The SCF does not initiate medial elastin calcification in living arteries, which suggests that vascular cells may prevent this calcification. This hypothesis is supported by the observations that living arteries secrete the calcification inhibitor matrix Gla protein (MGP); that inactivation of MGP with warfarin causes living arteries to calcify; and that addition of MGP to medium containing warfarin prevents this calcification.. The elastic lamellae of devitalized aortas calcify rapidly in serum.

Topics: Animals; Arteries; Calcification, Physiologic; Calcinosis; Calcium-Binding Proteins; Cattle; Extracellular Matrix Proteins; Humans; Kidney Diseases; Matrix Gla Protein; Rats; Serum; Warfarin

Topics: Abciximab; Antibodies, Monoclonal; Aorta, Abdominal; Aortic Diseases; Calcinosis; Combined Modality Therapy; Drug Therapy, Combination; Femoral Artery; Heparin; Humans; Immunoglobulin Fab Fragments; Ischemia; Magnetic Resonance Imaging; Male; Middle Aged; Platelet Aggregation Inhibitors; Sensation Disorders; Spinal Cord; Thrombosis; Urinary Incontinence; Warfarin

We sought to determine whether carbonic anhydrase (CA), which plays an important role in bone resorption, contributes to vascular mineral loss induced by an endothelin receptor antagonist.. Wistar rats were compared with rats receiving warfarin and vitamin K1 (WVK) for 8 weeks alone or in association with the endothelin receptor antagonist darusentan (30 mg/kg per day), the CA inhibitor acetazolamide (100 mg/kg per day), or both for the last 4 weeks. Rats were also treated with WVK for 5 or 6 weeks, and darusentan was added for the last week or last 2 weeks of treatment, respectively. Treatment with WVK produced medial elastocalcinosis in the aorta and carotid arteries. Immunohistochemistry revealed that CA II was already abundant in the adventitia and in calcified areas of aortic sections from WVK-treated rats. Darusentan did not significantly modify its abundance or distribution. In contrast, CA IV immunostaining, which was weak in WVK-treated rats, became apparent after 1 week of darusentan treatment and declined toward basal levels thereafter. These findings were confirmed by a parallel increase in CA IV protein abundance and activity in the aorta. The mineral loss induced by darusentan was blunted by acetazolamide treatment, confirming the functional relevance of the biochemical findings. Moreover, CA IV immunostaining was enhanced much later in the carotids, where darusentan did not cause regression of elastocalcinosis.. Vascular mineral loss induced by the blockade of endothelin receptors seems dependent on the activation of membrane-bound CA IV, suggesting that mineral loss may proceed via local changes in pH similar to that seen in bone resorption.

Topics: Animals; Aorta; Aortic Diseases; Calcinosis; Calcium; Carbonic Anhydrase II; Carbonic Anhydrase IV; Carotid Arteries; Endothelin Receptor Antagonists; Enzyme Activation; Hemodynamics; Male; Phenylpropionates; Pyrimidines; Rats; Rats, Wistar; Remission Induction; Vitamin K 1; Warfarin

Vitamin K antagonists, known as oral anticoagulants, affect the synthesis and function of the matrix Gla protein, which is a potent inhibitor of tissue calcification. We performed multislice spiral computed tomography in 86 patients (53 men, mean age 71 +/- 8 years) with calcific aortic valve disease to quantitate the amount of calcification in the aortic valve and coronary arteries. Patients with long-term oral anticoagulation therapy (mean duration 88 +/- 113 months; n = 23) were compared with those without anticoagulation (n = 63). No differences were found in the demographic, clinical, or echocardiographic characteristics between the 2 study groups. Patients on oral anticoagulant therapy had increased coronary calcium (coronary Agatston score 1,561 +/- 1,141 vs 738 +/- 978, respectively; p = 0.024) and valvular calcium (valvular Agatston score 2,410 +/- 1,759 vs 1,070 +/- 1,085, respectively; p = 0.002) compared with patients without anticoagulation treatment. The results of our study have demonstrated that oral anticoagulation may be associated with increased valvular and coronary calcium in patients with aortic valve disease, presumably due to decreased activation of the matrix Gla protein.

Topics: Administration, Oral; Aged; Anticoagulants; Aortic Valve; Calcinosis; Coronary Artery Disease; Female; Heart Valve Diseases; Humans; Male; Tomography, Spiral Computed; Treatment Outcome; Warfarin

To report a case of arterial calcification in a person who has had long-term treatment with warfarin. Although the anticoagulant has been shown to induce arterial calcification in laboratory animals, there have been no previous reports implicating warfarin as a clinical factor.. On routine annual examination, the coronary arteries of a healthy man with no symptoms who has had long-term warfarin treatment were found to be highly calcified.. It would be prudent to further evaluate experimentally the relationship of warfarin and arterial calcification. We suggest that physicians prescribing long-term warfarin treatment consider arterial calcification as one of its potential consequences.

Topics: Anticoagulants; Arteries; Calcinosis; Humans; Male; Middle Aged; Warfarin

Topics: Abdominal Abscess; Anticoagulants; Aortic Diseases; Arterial Occlusive Diseases; Arteriosclerosis; Calcinosis; Conversion Disorder; Diagnostic Errors; Female; Humans; Hypesthesia; Ischemia; Leg; Middle Aged; Muscle Denervation; Paraplegia; Peripheral Nerves; Thrombosis; Tibial Arteries; Tomography, X-Ray Computed; Warfarin

We have previously shown that an endothelin receptor antagonist can regress medial arterial calcification in a rat model. The aim of this study was to characterize the phenotypic changes of vascular smooth muscle cells during calcification and mineral loss, in order to understand better the underlying mechanisms. Control Wistar rats were compared with rats treated only with warfarin/ vitamin K1 (15 mg/kg per day) for 8 weeks, or in combination with darusentan (30 mg/kg per day) for the final 4 weeks. Vascular smooth muscle cell, bone cell and macrophage phenotypes were evaluated by the local expression of alpha-actin, tartrate-resistant acid phosphatase and ED-1, respectively. Proteins involved in the modulation of bone resorption like osteopontin and osteoprotegerin were also evaluated by immunohistochemistry. The warfarin/vitamin K1 treatment increased medial arterial calcification ninefold (P < 0.05). At sites of calcification, there was a decrease in alpha-actin localization, and an appearance of osteopontin immunostaining. Histochemical and immunostaining for osteoclast and macrophage markers, as well as for osteoprotegerin, were negative. Although the extent of calcification foci was reduced by darusentan, protein localization in the calcified areas was not modified. Thus, the development of medial arterial calcification produces a phenotypic change in vascular smooth muscle cells that does not appear to be normalized in regions remaining calcified during mineral loss.

Topics: Animals; Aorta, Thoracic; Aortic Diseases; Calcinosis; Disease Models, Animal; Endothelin Receptor Antagonists; Endothelin-1; Macrophages; Male; Muscle, Smooth, Vascular; Myocytes, Smooth Muscle; Osteoclasts; Osteopontin; Osteoprotegerin; Phenotype; Phenylpropionates; Pyrimidines; Rats; Rats, Wistar; Receptors, Endothelin; Vitamin K 1; Warfarin

Isolated systolic hypertension is the predominant form of hypertension in the elderly population. Reduction of arterial compliance appears to contribute to the elevation of pulse pressure (PP) and among potential mechanisms, gradual vascular calcification, fragmentation of elastic lamellae, and augmentation of rigid component like collagen could contribute to increase aortic stiffening. Few experimental models of the disease are currently available.. To induce large artery calcification, rats were treated with warfarin and vitamin K(1) (WK) for 4 and 8 weeks, to inhibit the maturation of matrix Gla protein. The impact of chronic PP elevation was determined on large artery and cardiac remodeling and on aortic endothelial function.. The WK treatment led to aortic medial calcification and a proportional elevation of PP, attributable mainly to a selective elevation of systolic blood pressure. The chronic treatment also increased collagen, whereas elastin decreased in the aorta. Pulse wave velocity, an index of aortic stiffening, increased in rats treated with WK. However, indices of left ventricular and aortic hypertrophy and remodeling remained normal. In addition, the WK treatment did not modify the vasoconstriction to norepinephrine and endothelin-1, and the vasodilatory response to acetylcholine and sodium nitroprusside.. Chronic treatment with WK represents a new model of isolated systolic hypertension with several characteristics of the human disease. The relative ease to induce calcification in this model may help to foster more fundamental research, which is lacking in this type of hypertension.

Topics: Animals; Anticoagulants; Antifibrinolytic Agents; Aorta; Calcinosis; Calcium; Collagen; Disease Models, Animal; Drug Administration Schedule; Elastin; Hemodynamics; Hypertension; Male; Rats; Rats, Wistar; Renin; Systole; Vascular Diseases; Vasomotor System; Vitamin K 1; Warfarin

Calcification of the trachea and proximal bronchi is a common, normal finding on chest radiographs in the elderly population, especially in women. More extensive airway calcification is also a rare manifestation of many pathologic conditions. The authors report a case of pathologic tracheobronchial calcification associated with long-term warfarin therapy. Chest radiographs showed prominent, diffuse calcification of the tracheobronchial tree. Computed tomography showed extensive calcification of the airway walls, extending from the trachea to the lung periphery.

Topics: Aged; Anticoagulants; Aortic Valve; Bronchial Diseases; Calcinosis; Heart Valve Prosthesis; Humans; Male; Mitral Valve; Tomography, X-Ray Computed; Tracheal Diseases; Warfarin

The present experiments were carried out to test the hypothesis that artery calcification is linked to bone resorption by determining whether the selective inhibition of bone resorption with the bisphosphonates alendronate and ibandronate will inhibit artery calcification. Artery calcification was first induced by treatment of 42-day-old male rats with warfarin, a procedure that inhibits the gamma-carboxylation of matrix Gla protein and has been shown to cause extensive calcification of the artery media within 2 weeks. These experiments revealed that ibandronate (0.05 mg. kg(-1). d(-1)) and alendronate (0.1 mg x kg(-1) x d(-1)) completely inhibited calcification of all arteries and heart valves examined after 2 and 4 weeks of warfarin treatment. A 10-fold lower dose of alendronate reduced artery calcification by 50% (P<0.005). These bisphosphonate doses are comparable to those that inhibit bone resorption in rats of this age. More rapid artery calcification was induced by treatment with warfarin together with high doses of vitamin D, a procedure that causes extensive artery calcification by 84 hours. Alendronate and ibandronate again completely inhibited calcification of all arteries and heart valves examined. The subcutaneous doses of alendronate and ibandronate necessary to inhibit artery calcification are comparable to the daily subcutaneous doses of these drugs that have previously been shown to inhibit bone resorption in rats of the same age, with 50% inhibition of artery calcification at 20 microg alendronate x kg(-1) x d(-1) and at 1 microg ibandronate x kg(-1) x d(-1) x Bisphosphonate treatment did not affect serum calcium and phosphate, and so the inhibition of artery calcification cannot be due to a simple lowering of the serum calcium phosphate ion product. We conclude that bisphosphonates inhibit the calcification of arteries and heart valves at doses comparable to the doses that inhibit bone resorption. These results support the hypothesis that artery calcification is linked to bone resorption. The mechanism of this linkage remains to be established, however, and an alternative explanation for the present results is also considered.

Topics: Alendronate; Animals; Aortic Diseases; Bone Resorption; Calcification, Physiologic; Calcinosis; Diphosphonates; Drug Administration Schedule; Etidronic Acid; Female; Humans; Ibandronic Acid; Male; Muscle, Smooth, Vascular; Osteoporosis; Rats; Rats, Sprague-Dawley; Vitamin D; Warfarin

The present experiments were carried out to test the hypothesis that arterial calcification is linked to bone resorption by determining whether the selective inhibition of bone resorption with osteoprotegerin will inhibit arterial calcification. In the first test, arterial calcification was induced by treating 22-day-old male rats with warfarin, a procedure that inhibits the gamma-carboxylation of matrix Gla protein and causes extensive calcification of the arterial media. Compared with rats treated for 1 week with warfarin alone, rats treated with warfarin plus osteoprotegerin at a dose of 1 mg/kg per day had dramatically reduced alizarin red staining for calcification in the aorta and in the carotid, hepatic, mesenteric, renal, and femoral arteries, and they had 90% lower levels of calcium and phosphate in the abdominal aorta (P<0.001) and in tracheal ring cartilage (P<0.01). More rapid arterial calcification was induced by treating 49-day-old male rats with toxic doses of vitamin D. Treatment for 96 hours with vitamin D caused widespread alizarin red staining for calcification in the aorta and the femoral, mesenteric, hepatic, renal, and carotid arteries, and osteoprotegerin completely prevented calcification in each of these arteries and reduced the levels of calcium and phosphate in the abdominal aorta to control levels (P<0.001). Treatment with vitamin D also caused extensive calcification in the lungs, trachea, kidneys, stomach, and small intestine, and treatment with osteoprotegerin reduced or prevented calcification in each of these sites. Measurement of serum levels of cross-linked N-teleopeptides showed that osteoprotegerin dramatically reduced bone resorption activity in each of these experiments (P<0.001). Therefore, we conclude that doses of osteoprotegerin that inhibit bone resorption are able to potently inhibit the calcification of arteries that is induced by warfarin treatment and by vitamin D treatment. These results support the hypothesis that arterial calcification is linked to bone resorption.

Topics: Animals; Arteries; Bone Resorption; Calcinosis; Collagen; Collagen Type I; Drug Antagonism; Glycoproteins; Lung; Male; Osteoprotegerin; Peptides; Rats; Receptors, Cytoplasmic and Nuclear; Receptors, Tumor Necrosis Factor; Trachea; Vascular Diseases; Vitamin D; Warfarin

The present studies demonstrate that growth and vitamin D treatment enhance the extent of artery calcification in rats given sufficient doses of Warfarin to inhibit gamma-carboxylation of matrix Gla protein, a calcification inhibitor known to be expressed by smooth muscle cells and macrophages in the artery wall. The first series of experiments examined the influence of age and growth status on artery calcification in Warfarin-treated rats. Treatment for 2 weeks with Warfarin caused massive focal calcification of the artery media in 20-day-old rats and less extensive focal calcification in 42-day-old rats. In contrast, no artery calcification could be detected in 10-month-old adult rats even after 4 weeks of Warfarin treatment. To directly examine the importance of growth to Warfarin-induced artery calcification in animals of the same age, 20-day-old rats were fed for 2 weeks either an ad libitum diet or a 6-g/d restricted diet that maintains weight but prevents growth. Concurrent treatment of both dietary groups with Warfarin produced massive focal calcification of the artery media in the ad libitum-fed rats but no detectable artery calcification in the restricted-diet, growth-inhibited group. Although the explanation for the association between artery calcification and growth status cannot be determined from the present study, there was a relationship between higher serum phosphate and susceptibility to artery calcification, with 30% higher levels of serum phosphate in young, ad libitum-fed rats compared with either of the groups that was resistant to Warfarin-induced artery calcification, ie, the 10-month-old rats and the restricted-diet, growth-inhibited young rats. This observation suggests that increased susceptibility to Warfarin-induced artery calcification could be related to higher serum phosphate levels. The second set of experiments examined the possible synergy between vitamin D and Warfarin in artery calcification. High doses of vitamin D are known to cause calcification of the artery media in as little as 3 to 4 days. High doses of the vitamin K antagonist Warfarin are also known to cause calcification of the artery media, but at treatment times of 2 weeks or longer yet not at 1 week. In the current study, we investigated the synergy between these 2 treatments and found that concurrent Warfarin administration dramatically increased the extent of calcification in the media of vitamin D-treated rats at 3 and 4 days. There was a close parallel

Topics: Aging; Animals; Anticoagulants; Aorta; Aortic Diseases; Arteries; Calcinosis; Drug Combinations; Drug Synergism; Male; Rats; Rats, Sprague-Dawley; Time Factors; Vascular Diseases; Vitamin D; Warfarin

There is evidence from knock-out mice that the extrahepatic vitamin K-dependent protein, matrix gla protein, is necessary to prevent arterial calcification. The aim of this study was to determine if a warfarin treatment regimen in rats, designed to cause extra-hepatic vitamin K deficiency, would also cause arterial calcification. Sprague-Dawley rats were treated from birth for 5-12 weeks with daily doses of warfarin and concurrent vitamin K1. This treatment causes an extrahepatic vitamin K deficiency without affecting the vitamin K-dependent blood clotting factors. At the end of treatment the rats were killed and the vascular system was examined for evidence of calcification. All treated animals showed extensive arterial calcification. The cerebral arteries and the veins and capillaries did not appear to be affected. It is likely that humans on long-term warfarin treatment have extrahepatic vitamin K deficiency and hence they are potentially at increased risk of developing arterial calcification.

Topics: Animals; Arterial Occlusive Diseases; Calcinosis; Rats; Rats, Sprague-Dawley; Vitamin K Deficiency; Warfarin

Topics: Anticoagulants; Bronchial Diseases; Calcinosis; Female; Humans; Middle Aged; Tomography, X-Ray Computed; Tracheal Diseases; Warfarin

Topics: Anticoagulants; Aorta, Thoracic; Blood Vessels; Calcinosis; Coronary Disease; Humans; Osteocalcin; Warfarin

High doses of warfarin cause focal calcification of the elastic lamellae in the media of major arteries and in aortic heart valves in the rat. Aortic calcification was first seen after 2 weeks of warfarin treatment and progressively increased in density at 3, 4, and 5 weeks of treatment. By 5 weeks, the highly focal calcification of major arteries could be seen on radiographs and by visual inspection of the artery. The calcification of arteries induced by warfarin is similar to that seen in the matrix Gla protein (MGP)-deficient mouse, which suggests that warfarin induces artery calcification by inhibiting gamma-carboxylation of MGP and thereby inactivating the putative calcification-inhibitory activity of the protein. Warfarin treatment markedly increased the levels of MGP mRNA and protein in calcifying arteries and decreased the level of MGP in serum. Warfarin treatment did not affect bone growth, overall weight gain, or serum calcium and phosphorus levels, and, because of the concurrent administration of vitamin K, prothrombin times and hematocrits were normal. The results indicate that the improved warfarin plus vitamin K treatment protocol developed in this study should provide a useful model to investigate the role of MGP in preventing calcification of arteries and heart valves.

Topics: Animals; Arteries; Calcinosis; Calcium-Binding Proteins; Extracellular Matrix Proteins; Heart Valve Diseases; Male; Matrix Gla Protein; Rats; Rats, Sprague-Dawley; Vascular Diseases; Vitamin K; Warfarin

A 27-year-old male patient with calcinosis universalis resulting from dermatomyositis was successfully treated with low-dose warfarin. On his trunk and extremities, there were many subcutaneous calcified nodules, and knee flexion was difficult. After oral warfarin therapy for three years, the calcified nodules became smaller, and the knee mobility improved. His serum vitamin K level was abnormally high, decreased just after starting warfarin therapy, and then remained within the normal range. Since vitamin K has been known to play an important role in the Ca2+ binding process in bones or tissues, we suggest that this therapy is effective in reducing subcutaneous calcification through the vitamin K cycle.

Topics: Administration, Oral; Adult; Calcinosis; Dermatomyositis; Dose-Response Relationship, Drug; Follow-Up Studies; Humans; Male; Radiography; Treatment Outcome; Warfarin

We present an infant who was exposed to warfarin throughout pregnancy and has warfarin embryopathy. When the child was examined radiologically at 20 months areas of calcification were visible in the septal and alar cartilages of the small external part of the nose. The location of this ectopic calcification is consistent with that seen in an animal model of the warfarin embryopathy. It supports the hypothesis that warfarin interferes with the prenatal growth of the cartilaginous nasal septum by inhibiting the normal formation of a vitamin K-dependent protein that prevents calcification of cartilage. The child also had severe abnormalities of the cervical vertebrae and secondary damage to the spinal cord. Cervical vertebral anomalies are a relatively common finding in the warfarin embryopathy and in the related Binder syndrome.

Topics: Adolescent; Antithrombin III Deficiency; Calcinosis; Cervical Vertebrae; Female; Humans; Infant; Male; Middle Aged; Nasal Septum; Pregnancy; Prenatal Exposure Delayed Effects; Radiography; Spinal Cord Diseases; Warfarin

Several studies have demonstrated an association between mitral annular calcification and stroke; however, the pathophysiological explanation remains speculative.. We describe two patients with cerebral embolism in whom mitral valve calcification was demonstrated by transthoracic echocardiography. In both patients, transesophageal echocardiography identified a mass that appeared to be thrombus on the calcified portion of the mitral apparatus. There was no evidence of a hypercoagulable state or endocarditis in either case. Repeated transesophageal echocardiography after anticoagulation demonstrated resolution of the masses in both patients.. These cases support the hypothesis that thrombus formation may be a pathophysiological link between ischemic cerebral events and mitral annular calcification in some patients.

Topics: Aged; Brain Ischemia; Calcinosis; Cerebral Infarction; Cerebrovascular Disorders; Echocardiography; Echocardiography, Transesophageal; Female; Heart Valve Diseases; Humans; Intracranial Embolism and Thrombosis; Middle Aged; Mitral Valve; Thrombosis; Warfarin

We describe the use of low doses of warfarin to treat calcinosis in a patient with systemic sclerosis or CREST syndrome. Our patient had Raynaud's phenomenon, skin sclerosis of the neck and the distal surface of the elbows, and pitting ulcers and scarification of the fingers as well as cutaneous calcinosis. After beginning warfarin, no calcium containing substance was discharged from the fingertip ulcers. There was no tendency to bleed and activated partial thromboplastin time and prothrombin time were normal. Sequential radiographs of the hands showed that calcinosis had improved. Since there seem to be few adverse effects, the use of warfarin in patients with calcinosis warrants further study.

Topics: Calcinosis; Dose-Response Relationship, Drug; Female; Hand; Humans; Middle Aged; Partial Thromboplastin Time; Prothrombin Time; Radiography; Scleroderma, Systemic; Skin Diseases; Warfarin

Sprague-Dawley rats were given daily subcutaneous doses of sodium warfarin (100 mg/kg) and vitamin K1 (10 mg/kg) for up to 12 weeks, starting on the day after birth. This dosing regimen creates an extrahepatic vitamin K deficiency while preserving the vitamin K-dependent processes of the liver. Control rats received either vitamin K1 only or were untreated. All rats survived without any signs of hemorrhage. The warfarin-treated rats developed a marked maxillonasal hypoplasia associated with a 11-13% reduction in the length of the nasal bones compared with controls. The length of the posterior part of the skull was not significantly different from controls. In the warfarin-treated rats, the septal cartilage of the nasal septum showed large areas of calcification, not present in controls, and abnormal calcium bridges in the epiphyseal cartilages of the vertebrae and long bones. The ectopic calcification in the septal cartilage may have been the cause of the reduced longitudinal growth of the nasal septum and the associated maxillonasal hypoplasia. It is proposed that (1) the facial features of the human warfarin embryopathy are caused by reduced growth of the embryonic nasal septum, and (2) the septal growth retardation occurs because the warfarin-induced extrahepatic vitamin K deficiency prevents the normal formation of the vitamin K-dependent matrix gla protein in the embryo.

Topics: Animals; Animals, Newborn; Calcinosis; Cartilage Diseases; Female; Growth Plate; Male; Maxilla; Models, Biological; Nasal Bone; Nasal Septum; Rats; Rats, Sprague-Dawley; Skull; Species Specificity; Vitamin K 1; Vitamin K Deficiency; Warfarin

Topics: Aged; Angiodysplasia; Aortic Valve Stenosis; Calcinosis; Gastrointestinal Hemorrhage; Heart Valve Prosthesis; Humans; Male; Recurrence; Syndrome; Warfarin

Progressive calcification of the cartilaginous rings (CCR) of the trachea and bronchi has been observed in patients undergoing prolonged prophylactic anticoagulant therapy with warfarin sodium. The purpose of this study was to validate the relationship of warfarin sodium and CCR, as well as to present the appearance and sex and age distribution of the normal degenerative CCR seen in the elderly. Chest radiographs were scrutinized for evidence of CCR in 92 patients who underwent warfarin sodium therapy and in 105 patients used as a control group. CCR was classified as not present (scored as 0), subtle (scored as 1), and extensive (scored as 2). In the warfarin sodium study group, 47% of patients (43 of 92) exhibited level 1 or level 2 CCR. This proportion was 19% (20 of 105) in the control group. The difference was statistically significant (P less than .001). A significant positive correlation (P less than .001) was also present between the duration of warfarin sodium therapy and increased levels of CCR.

Topics: Aged; Bronchi; Calcinosis; Cartilage Diseases; Female; Humans; Male; Middle Aged; Retrospective Studies; Trachea; Warfarin

Topics: Calcinosis; Dermatomyositis; Humans; Warfarin

Tracheal calcification in children may be congenital or acquired. The authors describe three children in whom tracheal or tracheobronchial calcification was noted on radiographs after prosthetic mitral valve replacement and after long periods of warfarin sodium therapy. Laryngeal and tracheal calcification has been known to occur in warfarin embryopathy. This suggests that possibility of warfarin sodium as an etiologic factor in the development of the tracheal or tracheobronchial calcification in these children. However, further investigation is necessary.

Topics: Bronchial Diseases; Calcinosis; Child; Female; Heart Valve Prosthesis; Humans; Mitral Valve; Radiography; Time Factors; Tracheal Diseases; Warfarin

Topics: Adolescent; Adult; Calcinosis; Child; Dermatomyositis; Female; Humans; Male; Scleroderma, Systemic; Tomography, X-Ray Computed; Warfarin

Topics: Adolescent; Anticoagulants; Calcinosis; Child; Female; Humans; Myositis; Warfarin

Topics: Calcinosis; Humans; Warfarin

Synthesis of a calcium-binding amino acid, gamma-carboxyglutamic acid, is a vitamin K-dependent enzymatic process. Warfarin inhibits gamma-carboxyglutamic acid synthesis and, therefore, might diminish the calcification of porcine bioprosthetic valves. To evaluate this, we studied 40 porcine bioprosthetic valves removed because of spontaneous degeneration; 17 patients were treated with warfarin (prothrombin time greater than or equal to 1.5 control) and 23 were untreated. Gross visualization of calcification corresponded closely to x-ray visualization of calcification in explanted valves. No grossly visible calcification or only a single localized nodule was shown in 11 of 17 valves (65%) in treated patients and in only five of 23 valves (22%) in untreated patients (p less than 0.02). Histologic examination showed no calcium or only fine specks of calcium in nine of 13 valves (69%) among warfarin-treated patients and three of 19 valves (16%) from untreated patients. Warfarin, therefore, administered in usual clinical doses, appeared to diminish calcification in spontaneously degenerated porcine bioprosthetic valves.

Topics: 1-Carboxyglutamic Acid; Adult; Aged; Aortic Valve; Bioprosthesis; Calcinosis; Carbon-Carbon Ligases; Female; Glutamates; Glutamic Acid; Heart Valve Prosthesis; Humans; Ligases; Male; Middle Aged; Mitral Valve; Warfarin

Calcification of glutaraldehyde-preserved bioprosthetic cardiac valves represents a serious clinical problem. Previous work from this laboratory has established the presence in clinical bioprosthetic valve calcifications of vitamin K-dependent calcium-binding proteins, which contain the calcium-binding amino acid gamma-carboxyglutamic acid; no proteins containing gamma-carboxyglutamic acid are present in nonmineralized valves. The purpose of the present study was to examine a series of bovine circulatory bioprosthetic valve explants for calcification and proteins containing gamma-carboxyglutamic acid. Biochemical analyses of explanted bioprosthetic valves from calves demonstrated proteins with gamma-carboxyglutamic acid accumulating in calcified valves during both the onset and progression of valve calcification; calcium levels in the explanted calf bioprostheses were in the same range as those noted in clinical material. Accumulation of calcium and protein with gamma-carboxyglutamic acid occurred simultaneously and progressively, beginning 2 months after implantation. Small amounts of osteocalcin, the bone-derived protein containing gamma-carboxyglutamic acid, were present in both human and bovine bioprosthetic valve calcifications at comparable levels. No osteocalcin was detectable in non-mineralized valve tissue. Warfarin anticoagulant therapy did not prevent calcification or accumulation of protein with gamma-carboxyglutamic acid. It is concluded that proteins containing gamma-carboxyglutamic acid are involved in both the onset and progression of bioprosthetic valve calcification, and that conventional means of vitamin K antagonism do not alter this association or the course of bioprosthetic valve mineralization.

Topics: 1-Carboxyglutamic Acid; Adolescent; Animals; Aortic Valve; Bioprosthesis; Calcinosis; Calcium; Calcium-Binding Proteins; Cattle; Child; Child, Preschool; Heart Valve Prosthesis; Humans; Male; Osteocalcin; Prothrombin Time; Warfarin

Bioprosthetic cardiac valve calcification is a frequent complication after long-term valve replacement. In this study the authors sought to examine the biologic determinants of this type of dystrophic calcification using subcutaneous implants of glutaraldehyde-preserved porcine aortic valve leaflets (GPVs) in rats. GPVs and clinical valvular bioprostheses were prepared identically. Retrieved implants were examined for calcification and the deposition of osteocalcin (OC), a vitamin K-dependent, bone-derived protein, that is found in other dystrophic and ectopic calcifications. GPVs implanted in 3-week-old rats calcified progressively (GPV Ca2+, 122.9 +/- 6.0 micrograms/mg) after 21 days, with mineral deposition occurring in a morphologic pattern comparable to that noted in clinical retrievals. Calcified GPVs accumulated osteocalcin (OC, 183.4 +/- 19.4 ng/mg); Nonpreserved porcine aortic leaflet implants did not calcify (Ca2+ + 5.6 +/- 1.0 micrograms/mg). Millipore diffusion chamber (0.45-mu pore size enclosed GPV implants accumulated calcium and adsorbed osteocalcin despite the absence of attached host cells. GPVs implanted for 21 days in 8-month-old rats calcified less (GPV Ca2+, 22.4 +/- 5.0 micrograms/mg) than did GPVs implanted in 3-week-old rats (see above). High-dose warfarin therapy (80 mg/kg) did not alter GPV calcification (GPV Ca2+, 39.6 +/- 2.9 micrograms/mg) in 72-hour subcutaneous implants in 3-week-old male rats, compared with control rats (GPV Ca2+, 40.8 +/- 4.8 micrograms/mg).

Topics: Age Factors; Animals; Bioprosthesis; Calcinosis; Calcium-Binding Proteins; Heart Valve Prosthesis; Kinetics; Male; Osteocalcin; Rats; Rats, Inbred Strains; Stress, Mechanical; Tissue Preservation; Warfarin

Rats maintained for 8 months on a level of warfarin sufficient to decrease the vitamin K-dependent protein of bone (bone Gla protein) to 2% of normal have an excessive mineralization disorder characterized by complete fusion of the proximal tibial growth plate and cessation of longitudinal growth. The general features of this abnormality resemble the fetal warfarin syndrome in humans, a disorder also characterized by excessive mineralization of the growth plate. These excessive mineralization disorders may be caused by the decreased levels of bone Gla protein, a protein that potently inhibits mineralization in vitro.

Topics: Animals; Bone Development; Calcinosis; Calcium-Binding Proteins; Osteocalcin; Radiography; Rats; Time Factors; Warfarin

Intracavitary calcium phosphate deposits were observed in smooth, elastomeric blood pump sacs implanted in male calves for periods of 115 to 166 days. These deposits occurred predominantly on the flexing surface of the sacs. In contrast, similar pump sacs remained generally free of mineral deposits for up to 150 days in calves treated with the anticoagulant warfarin-sodium. These results implicate a vitamin K-dependent process in calcium phosphate deposition on elastomeric sacs.

Topics: Animals; Calcinosis; Calcium Phosphates; Cattle; Heart, Artificial; Polyurethanes; Warfarin

Topics: Anti-Bacterial Agents; Aortic Valve; Aspergillosis; Bacterial Infections; Calcinosis; Diagnosis, Differential; Embolism; Endocarditis; Furosemide; Heart Auscultation; Heart Valve Prosthesis; Heparin; Humans; Kidney; Lanatosides; Leg; Male; Middle Aged; Morphine; Myocardial Infarction; Myocardium; Oxygen; Postoperative Complications; Renal Artery; Thrombosis; Tooth Extraction; Warfarin