J Mol Med (2006) 84: 469–477

DOI 10.1007/s00109-006-0051-7

REVIEW

Kai Zacharowski . Paula Zacharowski .

Sonja Reingruber . Peter Petzelbauer

Fibrin(ogen) and its fragments in the pathophysiology

and treatment of myocardial infarction

Received: 6 October 2005 / Accepted: 31 January 2006 / Published online: 6 May 2006
# Springer-Verlag 2006

Abstract The occlusion of a coronary artery leads to

ischemia of the myocardium, while permanent occlusion
results in cell death and myocardial dysfunction. Early
restoration of blood flow is the only means to reduce or
prevent myocardial necrosis, but—paradoxically—reper-
fusion itself contributes to injury of the heart. In animal
models, this phenomenon is well described, and there are
many different unrelated approaches to reduce reperfusion
injury. In humans, however, pharmacological interventions
have so far failed to reduce myocardial reperfusion injury.
We summarize the pathogenesis of reperfusion injury,
detailing the role of fibrin(ogen) and its derivatives.
Moreover, we introduce a new concept for fibrin
derivatives as potential targets for reperfusion therapy. KAI ZACHAROWSKI PETER PETZELBAUER
obtained his M.D. and Ph.D. received his training in endo-
Keywords Bβ15–42 . Fibrin fragments . Endothelial cell . from the Universities of Mainz thelial cell biology at Yale
VE-cadherin . Leukocyte transmigration . Myocardial and London. His present po- University (lab of Jordan S.
infarction and reperfusion injury sition is Associate Professor of Pober). His present position is
Anaesthetics at the University Associate Professor of Der-
Hospital Düsseldorf. He is matology and Dermatopathol-
principle investigator of the ogy at the Medical University
Molecular Cardioprotection of Vienna. He is principle
and Inflammation Group and investigator of the Endothelial
chairman of the scientific Cell Biology lab at the Medi-
advisory board of Fibrex cal University and Chief
Medical. His research interests Scientific Officer of Fibrex
include modulation of inflam- Medical. His research focus is
K. Zacharowski (*) . P. Zacharowski mation during conditions of the analysis of endothelial cell
Molecular Cardioprotection and Inflammation Group, myocardial infarction, sys- functions in inflammation.
Department of Anesthesia, temic inflammatory response
University Hospital of syndrome, and sepsis.
Düsseldorf, Moorenstrasse 5,
40225 Düsseldorf, Germany
e-mail: [email protected]

S. Reingruber The experimental concept of myocardial reperfusion injury

Fibrex Medical Research and Development,
Brunnerstrasse 59, The phenomenon of reperfusion injury was first described
1235 Wien, Austria
e-mail: [email protected] in 1935, when reperfusion-induced arrhythmias in pre-
viously ischemic myocardium were observed [1]. Since
P. Petzelbauer then, the existence of reperfusion injury has been a “hot”
Medical University, topic of debate. The first documented report of reperfusion
Department of General Dermatology,
18-20 Währinger Guertel, injury was made by Jennings and colleagues, who
1090 Wien, Austria described the development of tissue necrosis during
e-mail: [email protected] reperfusion of ischemic myocardium [2]. The occurrence
470

of reperfusion arrhythmias was reported in 1971 by Taylor To date, the phenomenon of reperfusion injury has been
[3]. One year later, Hearse and colleagues demonstrated the substantiated by the following observations:
release of intracellular enzymes and cell damage during
(a) In the 1930s, Tennant and Wiggers recognized that the
reperfusion of ischemic myocardium [4–7]. Hearse and
reinitiation of blood flow causes arrhythmias [1]. In
colleagues were probably the first to name the observed
dogs, shorter periods of ischemia were more associated
tissue damage “reperfusion injury,” and as a result, many
with higher frequencies of arrhythmias than longer
scientists and clinicians were convinced of the detrimental
periods of ischemia [16]. Arrhythmias occur within
effects of reperfusion, causing tissue injury separate from
seconds of the onset of reperfusion (for review, see
the ischemic damage. In the 1980s, experiments carried out
[17–22]).
in a dog model of myocardial infarction demonstrated that
(b) Brief periods of reperfusion cause small amounts of
reperfusion-mediated injury is linked to the generation of
myocardial injury while longer periods cause extended
oxygen free radicals during reflow and is distinct from
damage [23].
ischemia injury [8]. Several techniques have been used to
(c) Reperfusion causes stunning (for review, see [24, 25]).
distinguish between ischemia and reperfusion injury using
Prolonged reversible postischemic contractile dysfunc-
magnetic resonance imaging and spectroscopy [9]. One
tion that follows single or multiple brief periods of
study by Farb and colleagues has identified that a subset of
regional or global ischemia has been termed “stunned
myocytes in the border of the ischemic region is viable at
myocardium”. Stunning persists after reperfusion
the start of reperfusion, but becomes irreversibly damaged
despite the absence of irreversible damage and despite
by reperfusion [10]. Since that study, several acute and
the restoration of normal or near-normal coronary
chronic ischemia–reperfusion injury models have been
blood flow [26]. In accordance with this definition,
developed in vivo (Fig. 1) [11, 12] and ex vivo in a number
stunning is reversible and not caused by a primary
of species [13–15].
deficit of myocardial perfusion and, hence, is a
relatively mild, sublethal injury that is quite distinct
from myocardial infarction.
thymus (d) Reperfusion initiates apoptotic cell death [27]. Apo-
right lung left atrium ptosis is a highly regulated form of cell death involving
an ATP-dependent process characterized by a sequence
left lung
of biochemical and morphological changes affecting
the whole cell [28]. There is evidence that the reper-
fusion of previously ischemic myocardium accelerates
the apoptotic process [29]. Apoptosis has been dem-
onstrated in various models of myocardial ischemia
and reperfusion injury [29–32] and the degree of
apoptosis in these different conditions varies from 0.1
to 40% of the respective tissue.
(e) Reperfusion injury can be modified by changing
physiological conditions such as ventilation [33], by
reperfusion with an anoxic solution, by reducing the
concentration of calcium, by infusion of magnesium
A [34, 35], or by changing vessel/blood pH [36]. In
addition, the gradual reperfusion of an occluded vessel
improves contractile recovery compared with those
providing sudden and full reperfusion [37]. Others
authors showed that gradual reperfusion mediates the
accumulation of metabolites important for improved
suture (without occluder) postischemic functional recovery [38].
(f) Numerous studies have shown an adaptive mechanism
LAD
induced by serial brief episodes of ischemia with
B intervening reperfusion increasing the heart’s resis-
tance to a subsequent longer period of ischemia
Fig. 1 Experimental model of myocardial ischemia–reperfusion followed by reperfusion. This phenomenon, originally
injury. a A model of myocardial ischemia–reperfusion injury. described by Murry and colleagues [39], has been
Depicted is an open-chest preparation of a rat, achieved by termed ischemic preconditioning (IP) and has been
midsternal thoracotomy [85]. The chest is kept open by the shown to exist in all animal species studied to date, as
branches of a retractor. b A magnified area of the heart. The left
anterior descending coronary artery (LAD) is represented by a well as in humans. The mechanism of IP involves both
dotted line (inset). A hairline suture around the proximal LAD triggers and mediators such as adenosine, nitric oxide,
results in experimental coronary occlusion leading to myocardial the epsilon isoform of protein kinase C, the mitochon-
ischemia and infarction. Interventions such as administration of the drial ATP-dependent potassium channels, and oxygen
peptide Bβ15–42 reduce reperfusion injury [13]
 471

free radicals, just to name a few (please refer to the Fibrin-derived fragments during myocardial reperfusion
many reviews covering the field of IP). injury—a novel concept
(g) Postconditioning also reduces myocardial damage.
This was first introduced by Vinten-Johansen and E-fragments; pathophysiological background The interac-
colleagues (for review, see [40]). Postconditioning tion of thrombin with fibrinogen causes the release of
comprises a series of brief mechanical periods of two small peptides known as fibrinopeptides A and B.
reperfusion following a specific algorithm applied at As a result, a series of delicately modulated and inter-
the very onset of reperfusion. Although postcondition- dependent reactions are initiated, the end point is the
ing represents a reocclusion procedure of the coronary transition of fibrinogen into cross-linked insoluble fibrin.
artery, the amount of protection achieved by post- This form of fibrin is found in most thrombi. As fibrin
conditioning is comparable to the protection achieved forms, part of a physiological counter regulation is that it
by the gold standard, IP [41, 42]. orchestrates its own degradation. Soluble fibrin degrada-
tion products occur as a result of plasmin digestion [45].
After an attack of plasmin, main soluble degradation
Multiple systems are activated during reperfusion injury products are fibrin D-fragments consisting of the C-terminal
parts and fibrin E-fragments consisting of the N-terminal
The patho-mechanisms of myocardial reperfusion and sections. D-fragments (D-dimers) are routinely measured as
subsequent injury are still under investigation. It is well markers for hypercoagulability, i.e., the formation and
accepted that several factors contribute to reperfusion lysis of cross-linked fibrin. With regard to the N-terminal
injury. However, the precise order of events and their degradation products, the E1-fragment is the first inter-
severity is currently not known. Concepts for the mecha- mediate product. In this molecule, the N-terminal amino
nisms of reperfusion injury have been thoroughly reviewed acids of the α- and β-chain are the same as those of the
in the past. The “Multiple systems are activated during intact fibrin monomer molecule. These N-terminal
reperfusion injury” section briefly summarizes factors sequences represent, so far, only known active sites of
activated in RI. The “Fibrin-derived fragments during E1-fragments. The N terminus of the α-chain interacts
myocardial reperfusion injury—a novel concept” section with CD18 [46], while the N terminus of the β-chain
will focus on the role of a novel player in reperfusion interacts with vascular endothelial (VE)-cadherin (see
injury, i.e., fibrin degradation products. “Fibrin and its fragments cause inflammation”). E1-
The generation of free radical species is usually cited as fragments are rapidly digested into fragments E2 and E3;
the first event to occur during myocardial reperfusion in these molecules the N-terminal sequences are trun-
injury [8]. Before and after primary angioplasty reperfu- cated and thus inactive [47].
sion, a significant increase in free radical production in
coronary venous blood was observed using electron para- Fibrinogen and its derivatives in coronary heart disease In
magnetic resonance spectroscopy and spin trapping the mid 1980s, early studies suggested that increased
techniques [43]. In addition, the function of the cardiac plasma levels of fibrinogen are a possible risk factor for
Na+–Ca2+ exchanger is disturbed. Normally, this system stroke and myocardial infarction [48]. This was supported
extrudes Ca2+, which enters cardiac myocytes on a beat-to- by the findings of the Framingham study, where 1,315
beat rhythm. In a state of dysfunction, Ca2+ is accumulated participants who were free of cardiovascular disease
in the cell, leading to overload and further muscle damage were followed up for 12 years. As a separate variable,
[44]. Activation of phospholipases, eicosanoids, other lipid fibrinogen values were considered comparable to other
molecules, protein kinases, inducible nitric oxide synthase, major risk factors such as blood pressure, hematocrit,
and the expression of adhesion molecules, like P-selectin, obesity, cigarette smoking, and diabetes for cardiovascular
have also been observed during reperfusion. Moreover, the disease. In addition, fibrinogen values were significantly
activation of complement occurs and results in the related to these risk factors, concluding that fibrinogen
formation of the anaphylatoxins C3a, C4a, and C5a, as should be included on the profile of cardiovascular risk
well as of the membrane attack complex. In particular, C5a factors [49]. As published in the Lancet [50], authors of the
is a potent stimulator of neutrophil adherence and super- “Northwick Park Heart study” revealed that the risk of
oxide production, and inflammatory cytokines are released. ischemic heart disease in patients with high fibrinogen
Platelets are activated resulting in local platelet aggregation levels is greater in younger than in older men.
and microvascular dysfunction. Platelet-derived products In regard to fibrin degradation products, it should be
like thromboxane A2 and serotonin could exacerbate noted that only D-fragments are routinely measured (but
microcirculatory spasms, leading to further microvascular naturally equal amounts of E-fragments occur). The results
congestion, thrombosis, and a sluggish coronary flow. A of a large case study by Koenig and colleagues reported
predominant neutrophilic infiltrate enters the myocardium, that plasma D-dimer levels are independently associated
which potentiates tissue damage. Moreover, the hemor- with the presence of coronary artery disease in patients
rheologic properties of neutrophils contribute to leukocyte with stable angina pectoris. Moreover, plasma concentra-
entrapment in the capillaries, leading to microvascular tions of D-dimers and fibrinogen are independently
plugging. correlated to the severity of atherosclerosis patients with
stable angina after myocardial infarction [51, 52]. Another
472

group determined the role of D-dimers in patients with

unstable angina pectoris on presentation to the emergency
department. D-dimer levels were significantly correlated
to cardiac risk factors and to the length of stay in the
hospital [53]. Finally, levels of soluble fibrin monomers
are considered as predictors of mortality in patients with
myocardial infarction [54]. A recent study evaluated the
contribution of hematological factors and chronic inflam-
mation to the development of myocardial infarction at a
young age (younger than 45 years old). Plasma levels of
soluble fibrin and C-reactive protein were significantly
higher in patients than in controls. On multivariate
regression analysis, soluble fibrin was the strongest Fig. 2 A schematic illustrating leukocyte diapedesis. To leave
predictor of myocardial infarction at a young age [55]. postcapillary venules and reach tissues, circulating leukocytes
Taken together, these data suggest that fibrin formation undergo a tightly coordinated multistep process. At sites of
and degradation are important events in the development, endothelial activation, leukocytes tether, roll, become activated,
progression, and prognosis of cardiovascular disease. and adhere to endothelial surfaces. Up to this point, this process is
fully reversible and leukocytes can “fall back” into the blood stream.
The final step, transmigration through endothelial junctions, is
Fibrin and its fragments cause inflammation Over the last thought to be irreversible. Leukocytes must cross the multilayered
decade, increasing evidence suggests that the plasma molecular zipper of interendothelial junctions. Molecules configur-
protein fibrinogen is involved in the inflammatory ing this zipper include, e.g., junctional adhesion molecules (JAMs),
platelet/endothelial cell adhesion molecule-1 (PECAM-1, CD31),
response. In the 1990s, several studies inferred a role for CD99 and VE-cadherin (CD144). Each of these molecules
fibrinogen in the stimulation of inflammatory mediators participates in zipper formation by homophilic adhesion with
such as IL-1β [56], IL-8 [57], macrophage inflammatory neighboring endothelial cells. JAMs, PECAM-1, and CD99
proteins, and monocyte chemoattractant protein-1 [58]. contribute to leukocyte transmigration by building homophilic
During the inflammatory response, leukocyte–endotheli- and/or heterotypic adhesion to leukocytes. For VE-cadherin, we
recently described a novel indirect mechanism, by which this
um interactions are a key event and, as previously molecule is able to interact with inflammatory cells, namely, the
mentioned, are implicated in the pathophysiology of E1-fragments of fibrin. These fragments build a bridge between
reperfusion injury (Fig. 2). One particular study has VE-cadherin and leukocytes, thereby directing cells into tissues [13]
reported in vivo that, in addition to the regulation of IL-6
and monocyte chemoattractant protein-1, fibrin(ogen) also monocytes neutrophils
stimulates macrophage adhesion [59]. Mice deficient of
fibrinogen displayed suppressed macrophage adhesion.
This finding is also consistent with other studies using CD11c/CD18
fibrinogen knock-out mice. Animals lacking fibrinogen
show an inflammatory cell migration deficit during wound
healing, glomerulonephritis, and in pulmonary fibrosis
[60–62]. Moreover, in a model of tumor metastasis, Aα17-19
lymphogenous and hematogenous tumor spread are E1 fragment
diminished in fibrinogen knock-out animals [63]. This
indicates that fibrinogen and its derivatives are involved in Bβ15-42
mechanisms regulating the transmigration of leukocytes
through endothelial cell surfaces.
Fibrin-derived D-fragments possess binding sites to endothelial cell VE-cadherin
αM/β2, αIIb/β3, α5β1, αvβ3, or intercellular adhesion
molecule-1 (ICAM-1) [64–69]. Fibrin-derived E1-frag- Fig. 3 Binding sites on E1-fragments. E1-fragments are composed
ments carry a binding site for VE-cadherin [70, 71], and of the N-terminal segments of fibrin [86]. These fragments carry a
also CD11c [46]. We have investigated proinflammatory binding site for VE-cadherin localized at the N terminus of the
activities of fibrinogen and fibrin-derived degradation β-chain and a binding site for CD11c localized at the N terminus of
products and found that the fibrin E1-fragment induces the α-chain [46]. By building a bridge between inflammatory cells
and endothelium, E1-fragments induce transmigration [13]
leukocyte transmigration through endothelial cell mono-
layers in vitro. This function of the E1-fragment is based
on its ability to bind to the endothelial cell adhesion A pathogenic role for fibrin derivatives during reperfusion
molecule VE-cadherin (Fig. 3). This interaction is injury A pathogenic role for fibrin-derived products during
mediated by the N-terminal amino acids of the fibrin β- reperfusion injury has been questioned for many years.
chain, covering amino acids Bβ15–42. Using a small This is based largely on data which have been obtained in
peptide with exactly this sequence (peptide Bβ15–42), we animal models, where defibrinogenation was achieved by
were able to block E1-fragment induced transmigration in using the drug ancrod. This fibrinogenolytic agent was
vitro [13]. shown to be ineffective in myocardial ischemia–reperfu-
 473

sion models [72, 73]. Ancrod reduces plasma levels of

fibrinogen, but simultaneously increases fibrin(ogen)-
degradation products [74]. Therefore, it is probably not a
suitable compound to use for the study of the role of fibrin
(ogen) during reperfusion injury. Indirect evidence for
fibrin(ogen) during reperfusion injury comes from in vivo
findings of Erlich and colleagues. The inhibition of tissue
factor (which impedes thrombin- and, subsequently, fibrin-
formation) resulted in a reduction in myocardial inflam-
mation and infarct size [75]. The authors concluded that
tissue factor-generated thrombin plays a significant role in Fig. 4 Myocardial area at risk and infarct size. The area of risk (AR)
myocardial infarction through proinflammatory mecha- represents the nonperfused zone due to left anterior descending
nisms aside from coagulation and thrombus formation. coronary artery occlusion. Persisting occlusion without reperfusion
However, these studies do not define the mechanism of leads to complete necrosis of the region of muscle supplied with
how the inhibition of tissue factor is anti-inflammatory and oxygen and metabolites by the respective coronary artery (blue
area). Reperfusion of viable myocardium can save muscle resulting
cardioprotective. The question needs to be raised whether in less tissue damage (pink area). Therapies directed at reducing
the effects are mediated via prevention of the proin- reperfusion injury, such as peptide Bβ15–42, further decrease the area
flammatory actions of thrombin [76] and/or through the of muscle necrosis (red area)
prevention of fibrin formation. As outlined in the previous
paragraph, fibrin and its plasmin digests possess many
binding sites for leukocytes, and thus could well be However, so far, it is not clear how inflammatory cells
involved in mediating myocardial inflammation and interact with this molecule to cross endothelial junctions.
damage during reperfusion. We have extended these The herein-described “E1-fragment bridge” between en-
studies and found that a specific derivative of fibrin, the dothelium and leukocytes is the first to offer a concept of
E1-fragments, is proinflammatory and induces the trans- how inflammatory cells interact with VE-cadherin-con-
migration of neutrophils, monocytes, and lymphocytes in taining junctions. This concept gains pathophysiologic
cell culture (Fig. 3). E1-fragments bind to endothelial cell importance by the fact that inhibiting the interaction of E1-
junctions and induce migration inflammatory through fragments with VE-cadherin by peptide Bβ15–42 blocks
endothelial monolayers. The N terminus of the β-chain of leukocyte migration in vitro and in vivo. However, it
E1-fragments (Bβ15–42) interacts with VE-cadherin [13] should be noted that inflammation is a multistep process
and the N terminus of the a-chain interacts with CD11c involving numerous molecules that overlap in function
[46]. Thereby E1-fragments build a bridge between and even substitute for each other. It is thus clear that the
endothelial cells and inflammatory cells. Consequently, effects of E1-fragments work in conjunction with
peptides matching the VE-cadherin binding site (Bβ15–42) molecules like selectins, vascular cell adhesion mole-
prevent bridge formation and thus E1-fragment-induced cule-1, or ICAM-1. Moreover, fibrinogen and its deriva-
transmigration [13]. It was thus intriguing to speculate that tives may also contribute to myocardial injury through
peptide Bβ15–42 is anti-inflammatory also in in vivo additional pathways such as the induction of endothelial
settings. Indeed, in a rat myocardial ischemia reperfusion ICAM-1 expression, the release of von Willebrand factor
model, intravenous injection of this peptide significantly from storage sites in Weibel–Palade bodies, and the
reduced myocardial inflammation and infarct size (Fig. 4). induction of platelet migration [58, 70, 77–79].
Moreover, in a chronic rat model of myocardial ischemia– The concept that fibrin fragments are directly involved
reperfusion, the peptide Bβ15–42 reduced scar formation. in inflammation and in the pathophysiology of myocardial
To confirm the role of fibrin and inflammatory cells in ischemia–reperfusion injury has potential implications for
reperfusion-injury, we used isolated hearts (Langendorff the clinic. Based on our animal experiments, it is feasible
preparation of regional ischemia–reperfusion) perfused to add a novel therapy to the current treatment of myocardial
with Krebs–Henseleit buffer or with blood depleted of infarction. At the time of reperfusion by percutaneous
leukocytes. In both settings, peptide Bβ15–42 had no effect coronary intervention or lysis, peptide Bβ15–42 could be
on myocardial infarct size. In contrast, in the presence of administered intravenously, thereby preventing reperfusion
whole blood (where fibrinogen and inflammatory cells injury.
were present), infarcts were larger and peptide Bβ15–42
significantly reduced myocardial infarct size [13]. As a
final proof, fibrinogen knock-out mice were used. These Drug development for myocardial ischemia–reperfusion
animals had smaller infarcts as compared to their wild- injury in humans
type littermates and the peptide was without effect [13].
The proposed mechanism is depicted in Fig. 5. This section summarizes anti-inflammatory drugs currently
Therefore, aside from its recognized physiological role tested in reperfusion injury and briefly discusses risk
in coagulation and thrombus formation, we have identified profiles of anti-inflammatory treatments. The list of anti-
a novel role for fibrin in inflammation. For endothelial cell inflammatory approaches in reperfusion injury is very
barrier formation, VE-cadherin is a critical molecule. short, because several approaches have failed in the past
474
Fig. 5 Schematic diagram of
the postulated mechanism in-
volved in Bβ15–42-induced
cardioprotection. Following
coronary artery occlusion
(ischemia), reinitiation of blood
flow (reperfusion) induces free
radical formation, the release of
cytokines, and the activation of
pro- and anticoagulative path-
ways. For example, fibrin for-
mation occurs through tissue
factor expression and fibrin
fragmentation through conver-
sion of plasminogen to plasmin.
As a result, D- and E-fragments
are formed. As depicted on the
left side, E-fragments bind to
endothelial surfaces via
VE-cadherin and augment the
transmigration of inflammatory
cells (neutrophils, monocytes,
and lymphocytes), resulting in
irreversible damage to the myo-
cardium. As depicted on the
right side, high amounts of ex-
ogenous Bβ15–42 (administered
as a reperfusion therapy), com-
pete with fibrin E1-fragments
for binding to VE-cadherin. As
a result, inflammation, myocar-
dial damage, and scar formation
is reduced [13]

(e.g., anti-ICAM-1 or CD18 antibodies). However, some It is extremely difficult to predict the effects of anti-
new drugs are lining up for the clinic: inflammatory drugs on reperfusion injury in the clinic. This
The peptide corresponding to the amino acids 15 to 42 is due to the difficulties in design and endpoints of such a
from the Bβ-chain of fibrin described herein (called FX06) trial [80] and the multiplicity cellular and/or humoral
is developed by Fibrex Medical. A phase IIa in patients components that are activated simultaneously and/or in
with acute myocardial infarction undergoing primary sequence. Many proinflammatory signals are redundant;
percutaneous coronary interventions will be initiated in inhibition of individual factors such as a single selectin
June 2006. does not change the outcome. Others—when inhibited—
A modified form of heparin called PGX-100 is being cause serious side effects. This is of particular interest,
developed by ParinGenix. It is a nonanticoagulant heparin when such a drug inhibits pathways important for wound
derivative that retains its anti-inflammatory activity. Phase healing and tissue regeneration. This would eliminate the
I clinical trials started in 2005. benefit coming from the inhibition of reperfusion-injury.
CTI-01, an ethyl pyruvate, is being developed by Critical This could be one of the reasons for the disastrous outcome
Therapeutics. It functions as an antioxidant that inhibits of the corticosteroid trial in human patients (although
TNF and high mobility group box-1 release. In February animal data in acute reperfusion injury models were
2005 the company announced phase II trials in patients promising) [81]. Steroids clearly impair wound healing.
undergoing cardiopulmonary bypass. Additional examples are inhibition of TNF or IL-6: Both
Alexion has developed a C5 complement inhibitor cytokines are pathogenic in the initial inflammatory injury
antibody (Pexelizumab). In a phase IIa study, Pexelizumab in myocardial ischemia–reperfusion, but both support
has reduced the mortality of myocardial infarction patients cardiac repair and wound healing [82–84]. Also, for
treated with PTCA or thrombolysis, but did not reduce neutrophils, a biphasic function has been described.
infarct size. The phase III Pexelizumab for Reduction of Neutrophils cause damage in the first few hours of
Infarction and Mortality in Coronary Artery Bypass Graft reperfusion, but later on they promote tissue healing and
Surgery 2 clinical trial showed that the drug reduced the protect jeopardized myocardium [84].
primary endpoint, but did not meet the prespecified This has serious implications for drug testing in models
threshold for statistical significance. A phase III study in of reperfusion injury: For example, in acute myocardial
patients with heart attack who were treated with primary ischemia–reperfusion experiments, a study drug could
percutaneous coronary intervention or angioplasty is still reduce myocardial damage after 2 h. However, this
ongoing. experiment does not provide any information regarding
 475

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mostly completed). With regard to anti-inflammatory ML (1986) Reduction in experimental infarct size by recombi-
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