10 ORIGINAL ARTICLE Acta Medica Indonesiana - The Indonesian Journal of Internal Medicine Hemostatic Status of Pre and Post Intracoronary Injection of Peripheral Blood Stem Cells in Patients with Recent Myocardial Infarction Cosphiadi Irawan1,Teguh Santoso1,3, Djumhana Atmakusumah1, Idrus Alwi1, Agus Kosasih2, Auda Aziz2, Abdulmuthalib1, Lyana-S2, Sri Inggriani3, Ardian Saputra3, Merry Wintery3, Linda Lison3, Ary H. Reksodiputro1, Aru W. Sudoyo1 1 Department of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia. 2 Dharmais Cancer Hospital, Jakarta, Indonesia. 3 Medistra Hospital, Jakarta, Indonesia Correspondence mail: Division of Hematology and Medical Oncology, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital. Jl. Diponegoro no. 71, Jakarta 10430, Indonesia. email: cosphiadi@yahoo.com ABSTRAK Tujuan: untuk melaporkan perubahan-perubahan parameter hemostasis, misalnya agregasi trombosit, viskositas darah dan plasma, waktu protrombin, APTT, CRP, dan fibrinogen sebelum dan sesudah pemberian terapi sel punca. Metode: terdapat 24 pasien yang ikut serta dalam penelitian ini. PBSCs dipanen dan disuntikkan ke arteri yang berhubungan dengan infark (infarct-related artery) setelah pemberian G-CSF selama 5 hari berturut-turut. Rekombinan eritropoietin manusia/recombinant human erythropoietin diberikan pada saat penyuntikan PBSCs intrakoroner dilakukan. Hasil: kami dapat melakukan evaluasi pada 11 dari 24 pasien tentang status hemostasis pra- dan pasca-suntikan sel punca. Tidak ada perbedaan yang bermakna antara data dasar dan 3 bulan kemudian dalam hal aggregasi spontan (p=0,350), PT (p=0,793), aPTT (p=0,255) dan TT (p=0,254). Juga tidak ada perbedaan bermakna antara data dasar dan 3 bulan kemudian dalam hal viskositas plasma (p=0,442) dan viskositas darah (p=0,843). Meskipun demikian, pasien yang memiliki viskositas darah dan plasma di atas atau di bawah kisaran normal nilai laboratorium belum kembali ke titik normal setelah perlakuan. Baik PT maupun APTT, keduanya menunjukkan nilai normal. Kadar fibrinogen dan CRP menunjukkan penurunan yang bermakna antara data dasar dan 3 bulan setelah pengobatan, masing-masing dengan nilai p=0,009 dan p=0,04. Kesimpulan: kombinasi G-CSF dan EPO based-intracoronary infusion dari PBSCs dapat membuka perspektif baru dalam pengobatan keadaan hiperkoagulabilitas pasca infark miokardium akut/AMI. Kata kunci: koagulasi, agregasi trombosit, infark miokardium, hiperkoagulasi. ABSTRACT Aim: to investigate hemostatic parameter changes, such as platelet aggregation, blood and plasma viscosity, prothrombin time, APTT, CRP and fibrinogen, before and after administration of stem cell therapy. Methods: a total of 24 patients were enrolled. Peripheral blood stem cells (PBSCs) were harvested and injected into the infarct-related artery after 5 consecutive days of G-CSF administration. Recombinant human erythropoietin was administered at the time of intracoronary PBSCs injection. Results: we were able to evaluate Vol 46 • Number 1 • January 2014 Hemostatic status of pre and post intracoronary injection 11 INTRODUCTION Cardiovascular disease has increased in the last half century, becoming one of the major causes of morbidity in all hospital admissions. Hypertension and coronary heart disease (CHD) constitute a major bulk of these CVD cases, where myocardial infarction (MI) constitutes half of all CHD cases.1 In 2008, 1 of 6 deaths in United States was caused by coronary heart disease.2 Current guidelines emphasize acute myocardial infarction (AMI) therapy on early coronary reperfusion that alleviates mortality rates such as primary percutaneous coronary intervention (PCI) or thrombolytic therapy. However, these conventional therapy sometimes cannot reverse the damage to infarcted myocardium.1,3 Virchow in 1856 postulated a triad of predisposition to thrombus formation. These triads are abnormalities of blood flow, blood constituents, and vessel wall. Abnormal elevation, even one of these factors, predispose to a “prothrombotic” or “hypercoagulable” state.4,5 Population of patients with AMI showed these state very clearly. Even those undergoing optimal treatment procedure are still at risk for further ischemic events not only because procedure- related platelet activation occurs, but also due to the persistent platelet hyperreactivity and enhanced thrombin generation associated with ACS.6,7 Hyperreactivity of platelets was shown in TIMI 12 trial up to 28 days and PREPARE trial in up to 6 months.8-10 It is not known how the acute coronary thrombosis alter the kinetics of the systemic coagulation system. There are some theory proposed like increased activity of fIX and decreased fII and fV, elevated fVII antigen and coagulant activity.11 Latest researches has highlighted stem cell therapy for patient population at risk for heart failure. Recent meta-analysis showed adult stem cell have shown significant, safety and favourable impact in treating heart failure and myocardial infarction.3,12-15 G-CSF-based stem cell therapy has been proposed as a practical and non-invasive alternative to stem cell therapy using bone marrow stem cells.16 G-CSF might be considered mostly as a mobilizer to enrich peripheral blood stem cells (PBSCs). Despite the potential adverse effects of increasing vascular events, short term use of G-CSF in patients with AMI seems to be safe. In 2008, we published an article showing 18 patients with anterior ST-segment elevation AMI, which showed improvement in most of the cardiac functions after injection of peripheral blood stem cells (PBSCs) into the infarct-related artery.3 With the same protocol we are able to evaluate 6 more patients further regarding pre- and post- treatment (3 months) hemostatic profile such as platelet aggregation, blood and plasma viscosity, prothrombin time, APTT, CRP and fibrinogen. The purpose of this study is to investigate hemostasic parameter changes before and after administration of stem cell therapy. METHODS We enrolled 24 patients diagnosed with ST-segment elevation anterior wall infarction who had successful PCI with drug-eluting stent implantation and were referred late (more than 2 hours) to our hospital but still within 15 days after onset of symptom. None of the patients received fibrinolytic therapy. PCI was performed regardless of the patients’ hemodynamic condition. Other 11 from 24 of patients regarding hemostatic status pre–post stem cell injection. There were no significant difference between baseline vs 3 months in spontaneous aggregation (p=0.350), PT (p=0.793), aPTT (p=0.255) and TT (p=0.254). There were also no significant difference between baseline vs 3 months in plasma viscosity (p=0.442) and blood viscosity (p=0.843). Nevertheless the patient who had their blood and plasma viscosity above or below normal laboratory range return to normal level after the treatment. Both PT and APTT also show normalization value. Both Fibrinogen and CRP level show significant decrease between baseline and 3 months after treatment (p=0.009) and (p=0.04) respectively. Conclusion: combined G-CSF and EPO based- intracoronary infusion of PBSCs may open new perspective in the treatment of hypercoagulable state post AMI. Key words: coagulation, platelet aggregation, myocardial infarction, hypercoagulation. Cosphiadi Irawan Acta Med Indones-Indones J Intern Med 12 inclusion criteria were as follows: age 20 years or over and subject’s willingness to comply with specific follow-up evaluations. All patients had complete revascularization even in non-infarct related territory. Exclusion criteria were: 1). hemodynamic instability during the procedure or any condition that may put the patient at undue risk such as pulmonary edema and cardiogenic shock, 2). previous or current severe co-existing diseases, such as cancer, hematological disorders (Hb <10 g/dL, WBC <4 or >11x109/L, or platelets <100x109/L), renal failure (creatinine level >2.5 mg/dL, or creatinine clearance <30 cc/min), hepatic dysfunction, serious infection or any co- morbidities that may impact patients’ survival), 3). valvular heart disease and prosthetic valves, 4). hypertrophic or restrictive cardiomyopathy, 5). women of child bearing potential, and 6). lack of informed consent. The study was conducted in accordance with the declaration of Helsinki and was approved by the University of Indonesia Medical School Ethical Committee. All patients gave written informed consent. Study Protocol One-to-three days after PCI, a daily dose of 10 μg/kg/day of G-CSF (Lenograstim [ G r a n o c y t e T M ] , Av e n t i s - S a n o f i ) ) w a s administered subcutaneously for 5 consecutive days. CD34+ and CD 45+ cells were quantified at days 1 (baseline), 3, and 5 after injection and subsequently the peripheral blood stem cells (PBSCs) were harvested. A total of 150 ml of PBSCs was processed from the brachial vein using COBE Spectra and placed into a peripheral blood (PB) unfiltered collection bag (Baxter Health Care Corp, IL), which was discarded after PB infusion. CD34+ and CD 45+ cells enumeration was performed using FACSCalibur (Becton Dickinson). To ensure sterility of the harvesting procedure, the white cell concentrate was cultured for bacteria and fungi. Three milliliters of the cell concentrate was injected into BacT Alert PF Pediatric tube (Biomerieux Inc, Durham, NC, cat No. 259794) and the incubated in the BacT Alert 120 system (Organon Teknika, Durham, NC) for 7 days or until the culture become positive. The cell concentrate was also cultured on Sabouraud agar medium (Oxoid, cat No. CM 0041) for fungi. Patients were heparinized during stem cell injection. Cells were injected with the use of a stop flow technique through an over the wire balloon catheter positioned within the segment containing of the stent. The balloon was inflated with low pressure to completely block the blood flow for 3 min, during which time 5-6 ml PBSC suspension was injected. This was interrupted by 3 min of reflow by deflating the balloon to minimize the likelihood of extensive ischemia. After completion of intracoronary cell transplantation, coronary angiography was repeated to ascertain vessel patency and absence of capillary plugging by measuring the myocardial blush grade. Approximately 15-25 x 106 PBSCs were injected during each procedure. All (except one) patients received subcutaneous 4000 IU of recombinant human erythropoietin (EprexTM) and glycoprotein IIb/IIIa inhibitors (IntergrellinTM) intravenous bolus and infusion at the time of intracoronary PBSCs injection. Patients were discharged the day after. Unless there was contraindication, all patients also received optimal standard therapy including aspirin, clopidogrel, nitrates, b-blockers, ACE- inhibitor/angiotensin-receptor blockers and statins. The additional parameter compared in this study were PT, APTT, TT, platelet aggregation, blood and plasma viscosity, fibrinogen and CRP. All parameters were checked before and 3 months after treatment. RESULTS Almost all patients were male in gender and most of them were at the age of 50-59. The common ACS risk factors existed in the patient were dyslipidemia (52%), smoking (42%), and family history (25%). Table 2 shows platelet aggregation from all patients before and after treatment of cell- therapy. No significant difference between baseline and 3 months after in spontaneous aggregation (3.11%+0.02% vs 5.39%+0.07%; p=0.350). Vol 46 • Number 1 • January 2014 Hemostatic status of pre and post intracoronary injection 13 No significant difference between baseline and after 3 months treatment in plasma viscosity (1.64+0.14% vs 1.63+0.07%; p=0.442) and blood viscosity (8.06 +1.70 vs 7.56+0.83%; p=0.843). On the other hand fibrinogen and CRP level showed significant decrease between baseline and 3 months after treatment (575+165 Table 1. Patient’s characteristics Criteria n (%) Age Group - 40-49 2 (8.0) - 50-59 16 (67.0) - 60-69 6 (25.0) Sex - Male 23 (96.0) - Female 1 (4.0) History - Hypertension 4 (17.0) - Diabetes 3 (13.0) - Dyslipidemia 13 (54.0) - Smoking 10 (42.0) - Obesity 5 (21.0) - Family 6 (25.0) Blood test - Ureum >40 mg/dl (n=19) 5 (26.0) - Creatinin >1.5 mg/dl (n=19) 0 (0) - Total Cholesterol >200 mg/dl (n=18) 7 (39.0) - HDL <50 mg/dl (n=18) 16 (89.0) - LDL >150 mg/dl (n=18) 4 (22.0) - Uric Acid >7 mg/dl (n=15) 5 (33.0) Table 2. Platelet aggregattion at baseline and after 3 months treatment No. Baseline 3 Months After PSCT Spont Aggr Aggre 5 Aggre 10 Spont Aggr Aggre 5 Aggre 10 1 3.20% 2.30% 2.70% 6.40% 12.30% 9.10% 2 1.80% 10.00% 12.70% 3.20% 25.50% 35.90% 3 7.30% 10.00% 10.90% 4.10% 1.40% 4.50% 4 4.50% 4.50% 11.40% 4.10% 14.50% 13.20% 5 3.20% 10.90% 17.70% 3.60% 9.10% 20.50% 6 4.10% 57.30% 62.70% 0.90% 36.80% 47.30% 7 3.20% 21.40% 26.40% 1.40% 34.60% 45.00% 8 1.40% 50.90% 55.90% 3.60% 20.00% 32.30% 9 3.20% 8.60% 13.60% 5.60% 3.20% 12.90% 10 2.70% 19.80% 27.30% 1.10% 9.70% 15.00% 11 2.20% 5.80% 65.80% 3.10% 6.00% 8.00% Mean+SD 3.35+0.02 18.32+0.10 27.92+0.23 3.37+0.02 15.74+0.12 22.15+0.15 p value 0.969 0.570 0.408 vs 354+93; p=0.009) and (p=0.04) respectively. Eventhough Table 2 shows no significant changes in blood and plasma viscosity, Figure 1 show trends of normalization. The patients who had their blood and plasma viscosity above normal range returned to normal point after the treatment. The same thing observed in patient who have their viscosity below normal range, it elevated to normal range. No significant difference in: PT (12.31+0.80 vs 12.44+1.36; p=0.793), APTT (36.59+17.89 vs 30.25+2.52; p=0.255) and TT (15.9+0.33 vs 19.7 +7.52; p=0.254) at baseline and at 3 months after therapy. Both PT and APTT also show normalization value, as seen in Table 4. DISCUSSION Stem cell therapy is an intervention strategy that introduces adult stem cells into damaged tissue in order to treat disease or injury. Whereas stem cells are biological cells found in all multicellular organisms that can divide and differentiate into diverse specialized cell types and can self-renew to produce more stem cells. There are minimally 4 accessible source of adult stem cells in humans, bone marrow, adipose tissue, blood, and wharton jelly (umbilical cord).17-20 In this study we do an ad hoc analysis comparing hemostatic profile before and after injection of PBSC cell therapy. We emphasize the Cosphiadi Irawan Acta Med Indones-Indones J Intern Med 14 Figure 1. Normalization of blood and plasma viscosity at baseline and after 3 months of treatment Table 4. PT-APTT-TT at baseline dan 3 months after treatment PT APTT TT Baseline After 3 Months Baseline After 3 Months No of patients Baseline After 3 months 12.4 11.5 25.4 29.5 1 15.4 16.1 13.4 11.9 89.9 32.1 2 15.9 16.6 10.9 11.3 29.7 28.2 3 16.1 19.3 13.3 12.2 32.1 29.6 4 15.8 16.6 11.9 12.5 29.8 31.6 5 15.9 15.0 13.0 12.1 31.7 28.9 6 16.4 34.8 11.3 12.0 32.2 26.7 Mean+SD 15.9+0.33 19.7+7.52 12.3 11.9 32.8 31.3 12.3 12.9 36.9 31.2 12.3 16.1 30.6 35.8 31.4 27.8 Table 3. Blood and plasma viscosity at baseline and after 3 months of therapy No Blood Viscosity Plasma Viscosity Fibrinogen (mg/dl) CRP Baseline After 3 Months Baseline After 3 Months Baseline After 3 months Baseline After 3 months 1 6.85 6.74 1.47 1.55 377 314 20,1 4 2 7.66 6.10 1.53 1.72 937 352 6,9 17,1 3 8.24 7.26 1.70 1.69 458 454 103,1 0,01 4 9.77 7.49 1.76 1.71 680 282 40,4 20,1 5 11.02 7.52 1.76 1.59 552 321 85,3 0,8 6 5.60 8.24 1.66 1.61 446 352 1,5 0,01 7 7.77 7.32 1.87 1.64 570 504 20 1,86 8 9.54 7.31 1.55 1.59 478 468 53,68 6,05 9 7.50 7.50 1.68 1.69 726 218 8,47 13,92 10 5.64 9.07 1.43 1.53 530 276 191,94 1,63 11 9.05 8.63 1.58 1.59 575.4 354.1 53.139 6.548 mean+SD 8.06+1.70 7.56+0.83 1.64+0.14 1.63+0.07 Vol 46 • Number 1 • January 2014 Hemostatic status of pre and post intracoronary injection 15 use of G-CSF as a mobilizer to enrich PBSCs. From 24 patients, most of them are males. The 3 most common risk factors associated with ACS are dyslipidemia, smoking, and family history which exist in 54%, 42%, and 25% of the patients. All patients in this study receive heparin until 3 days after intervention, and afterwards the treatments are continued with standard optimal therapy as indicated. From 24 patients, we are able to follow 11 patients regarding the hemostatic profile. As shown in table 2-4 there are no significant difference between platelet aggregation, blood and plasma viscosity, PT, APTT, and TT pre- and post- treatment. However, surprising result can be seen in Figure 1. There are 8 patients who have increased blood viscosity and 3 patients with increased plasma viscosity before treatment who return to normal laboratory range after treatment. On the other side, there are 2 patients with decreased blood viscosity and 4 patients who have decreased plasma viscosity before treatment. And after treatment they have their laboratory result elevated to normal range. This event have never been reported before, and we refer this event to “normalization”. Moreover, platelet aggregation, PT, APTT, and TT all also showed this normalization. These result does not attributable to anticoagulant therapy, because all patient receive heparin only until the third day post-PCI. According to some studies, restenosis post PCI in AMI patients occurs in 10-60% cases.21 There are several proposed mechanism as to why these event could happen. First, mechanical disruption of coronary plagues by denudation of the arterial endothelium and subsequent exposure to thrombogenic matrix protein, in addition to underlying atherothrombotic disease, results in platelet activation during or after PCI.6 Second, it was found that ACS was associated with persistent platelet hyperreactivity and enhanced thrombin generation. In the thrombolysis in myocardial infarction (TIMI) 12 trials, activation of platelets continues even until 28 days after clinical stabilization post-ACS.6,10 Another study, the platelet reactivity in patients and recurrent events (PREPARE) POST-STENTING study also demonstrated higher posttreatment ADP- induced aggregation in patients who suffered ischemic events over a 6-month period compared with patients without ischemic events (p=0.02).6 There is also reported that the severity of thrombosis was related with more severe or higher level of prothrombotic state as well as reactivity of the platelets. Other interesting parameter are fibrinogen and CRP, both are acute phase markers, showed significant decrease before and after treatment. A research showed that an increase in 1 g/L of plasma fibrinogen was associated with a 45% increased risk of MI.22 CRP is an indicator of the severity of STEMI and the occurence of complications during hospitalization.23 It is also independently stratify patients for in- hospital mortality risk.24 In 2005, Feinbloom suggested new emerging risk factors for arterial thrombosis, and among them are elevated CRP and fibrinogen.25 The 2008 JUPITER trial demonstrates that there was another potential mechanism that increases arterial trombotic event among healthy individuals with elevated hsCRP. Recently, there is also an ongoing trial called Cardiovascular Inflammation Reduction Trial (CIRT), which main purpose is to confirm the inflammatory hypotesis of atherothrombosis, which include decreasing CRP level.26 All these parameter changes are in contrast with other research which show that there are no changes in hemostatic profile after optimal treatments.6,11 The mechanism of normalization and significant decrease of fibrinogen and CRP is still unknown. But it may be related to how the stem cells works, such as paracrine effect and wound healing. The paracrine effect of stem cells has been reported to influence cardiac repair by protecting cardiac myocites from apoptotic stimuli or activate cardiac-resident stem cell to enhance endogenous repair capacity.17 Another potential mechanism is that transplanted stem cell may secrete a variety of growth factor and cytokines, which in turn alter the systemic hemostatic profile.27 There were 3 limitations that need to be addresed regarding the present study. The first limitation concerns the size of the sample. The second limitation has to do with patient’s baseline hemostasis profile. And lastly, the Cosphiadi Irawan Acta Med Indones-Indones J Intern Med 16 third limitation there were no control group. Therefore further study is needed to ensure the underlying mechanism of this event. If future researches are able to conclude the mechanism underlying normalization of hemostatic profile after cell-therapy injection post-AMI, it will help in developing new strategies in the treatment of cardiovascular diseases. We also propose the use of TEG platelet mapping in patients after PCI treatment, to evaluate the complex interaction between fibrin, thrombin, platelets, and coagulation factors during a state of hypercoagulability, which will allow individualized therapy.28 CONCLUSION Our study showed that 3 months after injection of intracoronary peripheral blood stem cell, all the parameters of the hemostatic become normal. Moreover, 2 parameters, fibrinogen and CRP both showed significant improvement. Future prospective studies are needed to investigate the underlying mechanism of this event. REFERENCES 1. Shim W, Mehta A, Lim SY, et al. G-CSF for stem cell therapy in acute myocardial infarction: Friend or foe?: Cardiovascular research advance access; 2010 [cited 2012 20 November ]; Available from: http:// cardiovascres.oxfordjournals.org/content/89/1/20. full?sid=b00cefbe-1f32-465b-9f40-23dedb94d80e. 2. Roger V, Go AS, LLoyd-Jones DM, et al. Executive summary: heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation. 2012;125:188-97. 3. Santoso T, Irawan C, Alwi I, et al. Safety and feasibility of combined granulocyte colony stimulating factor and erythropoetin based-stem cell therapy using intracoronary infusion of peripheral blood stem cells in patients with recent anterior myocardial infarction: One-year follow-up of a phase 1 study. Acta Med Indones-Indones J Intern Med. 2011;43(2):112-21. 4. Lip G, Blann AD. Thrombogenesis and fibrinolysis in acute coronary syndromes. J Am Coll Cardiol. 2000;36(7):2044-6. 5. Chan M, Andreotti F, Becker RC. Hypercoagulable states in cardiovascular disease. Circ. 2008;118:2286- 97. 6. Braunwald E, Angiolillo D, Bates E, et al. The problem of persistent platelet activation in acute coronary syndromes and following percutaneous coronary intervention. Clin Cardiol. 2008;31:17-20. 7. Shih J, Shih JJ. Evaluation of hypercoagulability during acute coronary syndrome using serial TEG platelet mapping. Clin Mol Med. 2010;2(1):1-3. 8. Ageno W, Becattini C, Brighton T, Selby R, Kamphusien PW. Cardiovascular risk factor and venous thromboembolism: A meta-analysis. Circulation. 2008;117:93-102. 9. Holst A, Jensen G, Prescott E. Risk factors for venous thromboembolism: Results from the Copenhagen city heart study. Circulation. 2010;121:1896-903. 10. Ault K, Cannon CP, Mitchell J, et al. Platelet activation in patients after an acute coronary syndrome: results from the TIMI-12 Trial. J Am Coll Cardiol. 1999;33:634-9. 11. Undas A, Szułdrzyn´ski K, Brummel-Ziedins K, et al. Systemic blood coagulation activation in acute coronary syndromes. Blood. 2009;113:2070-8. 12. Jeevanantham V, Butler M, Saad A, et al. Adult bone marrow cell therapy improves survival and induces long-term improvement in cardiac parameters a systematic review and meta-analysis. Circulation. 2012;126:551-68. 13. Lipinski M, Biondi-Zoccai GGL, Abbate A, et al. Impact of intracoronary cell therapy on left ventricular function in the setting of acute myocardial infarction. J Am Coll Cardiol. 2007;50:1761-7. 14. Strauer B, Yousef M, Schanwell CM. The acute and long- term effects of intracoronary stem cell transplantation in 191 patients with chronic heart failure: the STAR- heart study. Eur Heart J. 2010;12:721-9. 15. Martin-Rendon E, Brunskill S, Dorée C, et al. Stem cell treatment for acute myocardial infarction. Cochrane database of systematic review 2008. 16. Kang H, Lee HY, Na SH, et al. Differential effect of intracoronary infusion of mobilized peripheral blood stem cells by granulocyte colony–stimulating factor on left ventricular function and remodeling in patients with acute myocardial infarction versus old myocardial infarction the MAGIC Cell-3-DES randomized controlled trial. Circulation. 2006;114:145-51. 17. Dimmeler S, Burchfield J, Zeiher AM. Cell-based therapy of myocardial infarction. Arterioscler Thromb Vasc Biol. 2008;28:208-16. 18. Gimble J, Gullak F, Bunnell BA. Clinical and preclinical translation of cell-based therapies using adipose tissue-derived cells. Stem Cell Res Ther. 2010;1(19):1-8. 19. Lodi D, Lannitti T, Palmieri B. Stem cells in clinical practice: applications and warnings. J Exp Clin Can Res. 2011;30(9):1-20. 20. Teo A, Vallier L. Emerging use of stem cells in regenerative medicine. Biochem J. 2010;428:11-23. 21. Hoffman R, Mintz GS. Coronary in-stent restenosis - predictors, treatment and prevention. Eur Heart J. 2000;21:1739-49. Vol 46 • Number 1 • January 2014 Hemostatic status of pre and post intracoronary injection 17 22. Van der bom J, de Maat MPM, Bots ML, et al. Elevated plasma fibrinogen cause or consequence of cardiovascular disease? Arterioscler Thromb Vasc Biol. 1998;18:621-5. 23. Dedobbeleer C, Melot C, Renard M. C-reactive protein increase in acute myocardial infarction. Acta Cardiol. 2004;59(3):291-6. 24. Gheno G, Libardoni M, Zeppellini R, Cucchini F. C-reactive protein on admission as a predictor of in- hospital death in the elderly with acute myocardial infarction. Cardiologia. 1999;44(12):1023-8. 25. Feinbloom D, Bauer KA. Assessment of hemostatic risk factors in predicting arterial thrombotic events. Arterioscler Thromb Vasc Biol. 2005;25:2043-53. 26. Ridker P. Testing the inflammatory hypothesis of atherothrombosis: scientific rationale for the cardiovascular inflammation reduction trial (CIRT). J Throm Haemost. 2009;7(Suppl. 1):332-9. 27. Abdel-Latif A, Bolli R, Tleyjeh IM, et al. Adult bone marrow-derived cells for cardiac repair. Arch Intern Med. 2007;167:989-97. 28. M i n g - s h i h J , M i n g - s h i h J J . E v a l u a t i o n o f hypercoagulability during acute coronary syndrome using serial TEG platelet mapping. Clin Mol Med. 2010;2(1):1-3.