Impaired platelet production of nitric oxide predicts presence of acute coronary syndromes

Background - Thrombus formation within a coronary vessel is the acute precipitating event in most acute coronary syndromes. Recently, constitutive nitric oxide synthase (cNOS) has been identified in human platelets, and platelet-derived nitric oxide has been shown to inhibit platelet recruitment after aggregation. However, its role in regulating platelet responses under normal or pathologic conditions has not yet been elucidated. Methods and Results - We examined nitric oxide (NO) production by platelets isolated from 87 patients undergoing coronary angiography, 37 with stable angina and 50 with unstable angina or a myocardial infarction within 2 weeks. After stimulation with 5 mu mol/L ADP, platelet aggregation and NO production were simultaneously measured with an NO-selective microelectrode adapted for use in a standard platelet aggregometer. Mean (+/- SEM) platelet-derived NO production was 1.78 +/- 0.36 pmol/10(8) and 0.26 +/- 0.05 pmol/10(8) platelets in coronary patients with stable angina and acute coronary syndromes, respectively (P = 0.0001). By logistic regression analysis, heparin treatment (odds ratio 6.6, CI 1.9 to 22.8, P = 0.003), lower platelet-NO production (odds ratio 4.0, CI 1.3 to 11.5, P = 0.01), and extent of atherosclerosis (odds ratio 1.5, CI 1.1 to 2.0, P = 0.02) were independent predictors of an acute coronary syndrome. In the subset of patients with angiographic evidence of atherosclerosis (n = 83), logistic regression demonstrated that platelet NO production (odds ratio 3.9, CI 1.3 to 11.1, P = 0.01) and heparin treatment (odds ratio 6.3, CI 1.9 to 22.0, P = 0.004) were independent predictors of an acute coronary syndrome, whereas extent of atherosclerosis was not. Conclusions - In summary, aggregating platelets from patients with acute coronary syndromes produce less NO. Since platelet aggregation and thrombus formation are implicated in unstable angina and myocardial infarction, impaired platelet-derived NO production may contribute to the development of acute coronary syndromes.