Association between neutrophil extracellular traps, the Von Willebrand factor axis, and clinical outcome in stable coronary artery disease

Introduction Coronary artery disease (CAD) is the clinical manifestation of atherosclerosis, an inflammatory disorder of the coronary arteries, characterized by endothelial dysfunction, lipid accumulation, immune activation, and formation of atherosclerotic plaques. Despite management of conventional risk factors, CAD is a progressive disease, and may develop vulnerable lesions prone to rupture, causing atherothrombosis and acute coronary syndrome (ACS). Neutrophil extracellular traps (NETs), composed of chromatin and proteases, have been implicated in vascular inflammation and thrombosis, while the von Willebrand Factor (VWF)-ADAMTS13 (a disintegrin and metalloproteinase with thrombospondin type 1 motifs, member 13) axis plays a central role in platelet-mediated thrombus formation. Evidence suggest that NETs may interact with VWF to amplify thromboinflammation. The clinical relevance of this interplay and the prognostic utility of the NETs marker citrullinated histone H 3 (CitH 3 ) in CAD remains unclear. Aims In stable CAD patients we aimed to 1) examine associations between CitH 3, cardiovascular risk factors, and clinical outcome, 2) explore potential interactions between NETs and the VWF-ADAMTS13 axis, and 3) evaluate the predictive value of combined biomarker profiles. Methods Between 2003 and 2010, patients with angiographically verified symptomatic CAD ( n = 1,000) were enrolled in the Aspirin Nonresponsiveness and Clopidogrel Endpoint Trial (ASCET) (NCT00222261). The primary composite endpoint ( n = 73) at two-year follow-up comprised non-hemorrhagic stroke ( n = 28), myocardial infarction ( n = 36) and death ( n = 9). Analyses were performed on baseline blood samples. Results CitH 3 levels were similar between patients with and without endpoints. CitH 3 correlated with neutrophil count ( r = 0.221, p 0.001) and was higher in younger patients (62 years) and in those with BMI above mean (27.4 kg/m 2 ). CitH 3 alone did not predict clinical outcome. However, patients with high VWF, low ADAMTS13, and elevated NETs biomarkers had increased odds of reaching the composite endpoint (adjusted odds ratio 3.14 and 3.68). This subgroup also exhibited higher leukocyte counts and high-sensitivity C-reactive protein. Conclusion CitH 3 alone was not predictive of adverse events in stable CAD. However, combined extreme levels of thromboinflammatory biomarkers VWF, ADAMTS13 and NETs, identified patients at higher risk of adverse events. These findings suggest that integrated thromboinflammatory biomarker profiles may improve risk stratification in stable CAD and warrant validation in independent cohorts.