Tissue Factor Pathway InhibitorA New Link Among Arterial Stiffness, Pulse Pressure, and Coagulation in
Postmenopausal Women
Veronique Regnault, Christine Perret-Guillaume, Anna Kearney-Schwartz, Jean-Pierre Max,Carlos Labat, Huguette Louis, Denis Wahl, Bruno Pannier, Thomas Lecompte, Georges Weryha,
Pascal Challande, Michel E. Safar, Athanase Benetos, Patrick Lacolley
Objective—To investigate in women older than 60 whether aortic stiffness or pulse pressure (PP) is associated with selectedprocoagulant or anticoagulant factors and to examine whether pulsatile stretch influences these factors in humanvascular smooth muscle cells (VSMCs) in vitro.
Methods and Results—Aortic pulse wave velocity (PWV) and carotid PP were studied in 123 apparently healthypostmenopausal women. PWV, PP, von Willebrand factor, and free tissue factor pathway inhibitor (TFPI), but not meanarterial pressure, increased with age. Free TFPI and PWV were positively correlated, even after adjustment for age andPP and other confounding parameters. In vitro, 5% or 10% pulsatile stretch (at 1 Hz) enhanced TFPI synthesis andsecretion by VSMCs in a time-independent manner (1 to 48 hours) without changes in protein level of smooth musclemyosin heavy chain. Application of 5% static stretch had no effect.
Conclusion—In postmenopausal women, free TFPI increases as vascular wall function deteriorates and PP increases.These findings are supported by the increase in TFPI synthesized by VSMCs in response to cyclic stress in vitro. Theysuggest that VSMCs require pulsatility to interfere with the coagulation process and highlight the relevance of plasmafree TFPI levels to cardiovascular diseases. (Arterioscler Thromb Vasc Biol. 2011;31:1226-1232.)
Arterial stiffness, pulse pressure (PP), and a prothrom-botic state are different vascular parameters that all
increase consistently with age and are observed mainly in oldpeople. Pulse wave velocity (PWV) and PP, 2 classicalmarkers of arterial stiffness, and fibrinogen, 1 of the majorcoagulation proteins, are powerful and independent predictorsof cardiovascular (CV) risk.1–5 Such findings suggest that, inthe elderly, consistent pathophysiological links are presentamong arterial stiffness, PP and coagulation. A causal rela-tionship of these parameters might be even suspected insituations where a prothrombotic state and CV disease (suchas in coronary heart disease or arterial thrombosis) areassociated with increased stiffness and respond positively toanticoagulation treatment.6–8 Nevertheless, such observationsremain scarce in the literature, and the relationship of age,arterial stiffness, and coagulation factors has not been inves-tigated within a single population.
The geometric and hemodynamic features of a cylindricalarterial vessel are relatively easy to determine using noninvasive
measurements. The vascular wall acts as an anticoagulant bloodcontainer and requires the separate study of various compounds,which are classified either as procoagulant (such as von Wille-brand factor [vWF]) or anticoagulant (such as free tissue factorpathway inhibitor [TFPI]).9 It is well recognized that endotheli-um-mediated functions are modulated by hemodynamic forces,including shear stress and pulsatile pressure, which causechanges in intracellular mechanics and mechanotransduction(reviewed by Chien10). Although the role of shear stress onchanges in antithrombotic and prothrombotic activities of endo-thelium has been extensively studied, scarce and controversialfindings have been reported on the effects of pulsatile pressureon these functions.11,12
It has previously been established that increased circulatingvWF is consistently associated with endothelial dysfunction.13
Although high TFPI might also indicate endothelial dysfunc-tion,14 recent work has suggested that TFPI levels in medialvascular smooth muscle cells (VSMCs) may serve primarily to
Received on: March 19, 2010; final version accepted on: January 24, 2011.From Institut National de la Sante et de la Recherche Medicale, U961, Vandoeuvre-les-Nancy, France (V.R., J.-P.M., C.L., H.L., D.W., T.L., A.B.,
P.L.); Nancy Universite, Nancy, France (V.R., J.-P.M., C.L., H.L., D.W., T.L., G.W., A.B., P.L.); Geriatric Department (C.P.-G., A.K.-S., A.B.) andEndocrinology Department (G.W.), Nancy Hospital, Nancy, France; Manhes Hospital, Fleury-Merogis, France (B.P.); University Pierre and Marie Curie,University of Paris 06, Centre National de la Recherche Scientifique Unité Mixte de Recherche 7190, Paris, France (P.C.); Centre de Diagnostic,Hotel-Dieu, Paris, France (M.E.S.).
Correspondence to Veronique Regnault, INSERM U961, Faculte de Medecine, 9 ave de la foret de Haye, 54500 Vandoeuvre-les-Nancy, France. [email protected]
prevent arterial thrombosis and even intimal hyperplasia.15
Whether pulsatile hemodynamic stress and PWV may influencecirculating levels of these factors with advancing age remains tobe investigated. This can be attempted by using an in vitrocellular test designed to explore intravascular TFPI and vWFsynthesis and release under pulsatile conditions as close aspossible to those in vivo.
A cohort of postmenopausal women represents a homoge-neous human model in which an increase in arterial stiffnessis associated with both changes in vascular wall status and thepresence of a hypercoagulable state.16 In postmenopausalwomen, PWV is increased to the same level as that of men ofthe same age and blood pressure, whereas carotid wavereflections are consistently higher than in men. A prothrom-botic state is frequently observed in older women, in associ-ation with fluctuations in estrogenic hormone levels re-lated to menopause and hormone replacement therapy(HRT). Therefore, the primary objective of this study wasto investigate clinically, in postmenopausal women aged�60 years and not having experienced any CV event, therelationship of arterial stiffness and PP with selectedprocoagulant and anticoagulant factors, such as vWFantigen, factor VIII, fibrinogen, TFPI, soluble endothelialprotein C receptor, soluble thrombomodulin, and totalprotein S. To explain the link of arterial stiffness, pulsatilehemodynamics, and coagulation, the second objective ofour study was to examine the in vitro response of humanvascular cells to mechanical stretch with respect to vWFand TFPI expression and release.
MethodsStudy PopulationThe ARTEOS study is a cross-sectional study of 123 postmeno-pausal women volunteers recruited between March 2006 and January2007 by means of information posters displayed in outpatient waitingrooms of the Department of Endocrinology, Nancy Hospital, and theDepartment of Health and Prevention, Luxembourg. Inclusion crite-ria were age greater than 60 years and the absence of target organdamage, including any clinically significant CV disease and atrialfibrillation. Women were excluded for the following reasons: con-traindications to performing blood sampling or measurements ofarterial wall structure and function. The regional ethics boardapproved the study protocol; all eligible women gave signed in-formed consent. All CV and coagulation parameters, as well as thebiological active estradiol plasma level, were recorded in the NancyHospital and Institut National de la Sante et de la RechercheMedicale U961.
CV MeasurementsBrachial blood pressure and heart rate were measured with a validatedautomatic device (DINAMAP 400Pro) after at least 10 minutes of restin a quiet room and constant temperature. PP was calculated bysubtracting diastolic blood pressure (DBP) from systolic blood pressure(SBP), and mean arterial pressure (MAP) was calculated by addingone-third PP to DBP. Assessment of arterial stiffness by PWV andcentral (carotid) blood pressure was obtained by applanation tonometryof the common carotid and femoral arteries using the PulsePen device aspreviously described and validated.17 The variation coefficients of theinterobserver and intraobserver reproducibility for the PulsePen were7.9% and 7.2%, respectively. PP amplification was obtained from theratio between brachial PP and carotid PP. High resolution B-modeultrasound was used to measure intima-media thickness across 1-cm
segments of the near and far walls of the common carotid artery 2 to 3cm proximal to the bifurcation on both right and left sides. Carotidarterial radius was measured at the same time. The circumferential wallstress (�) was calculated according to the Laplace’s law with thefollowing equation: ��(2LCSA�P)/MCSA, where LCSA is the lumencross-sectional area, P is the pressure, and MCSA is the medialcross-sectional area.
Hemostatic Variables and Endothelial MarkersAll measurements were performed with platelet-poor plasma ob-tained from venous blood drawn into 0.106 mol/L sodium citrate (9:1vol/vol) by double centrifugation at 1750g for 10 minutes. Solublethrombomodulin, soluble endothelial protein C receptor, total andfree TFPI, vWF antigen, and D-dimers were measured by ELISA kits(Asserachrom, Diagnostica Stago, Asnieres, France). Thrombin-antithrombin complexes were measured by ELISA (Dade Behring,Marburg, Germany). Fibrinogen was measured by a Clauss assaywith bovine thrombin from Biomerieux (Durham, NC). Coagula-tion factor VIII was measured by a 1-stage method using factorVIII– deficient plasma (Dade Behring) and an activated partialthromboplastin time reagent with kaolin as contact phase activa-tor (CK Prest, Diagnostica Stago). The activated proteinC-dependent anticoagulant function of protein S was determinedusing the STA-Staclot Protein S kit (Diagnostica Stago). SolubleCD146 was also assayed using a kit (Cy-Quant ELISA) fromBiocytex (Marseille, France).
Cell Culture and StretchClonetics human VSMCs and aortic endothelial cells (ECs) fromLonza (Basel, Switzerland) were used at passages 4 to 8. Studieswere conducted on VSMCs grown to subconfluence in CloneticsSmooth Muscle Growth Medium-2 and EC in Clonetics EndothelialCell Growth Medium-2, followed by serum withdrawal (with theFBS decreased to 0.5%) for 1 day to achieve quiescence. For stretchexperiments, cells were seeded at 6�105 cells/well on 6-wellcollagen-coated silicone elastomer-bottomed plates. Cells were sub-jected to either cyclic stretch (equiaxial stretch of 5% or 10% at afrequency of 1 Hz) or 5% static stretch in a FX-4000T FlexercellStrain Unit (Flexcell). Cells cultured without stretch were used as acontrol. At various times (1, 6, 24, and 48 hours), conditionedmedium was collected for measurement of total and free TFPIsecreted. Cell extracts were obtained by lysing VSMCs or ECs incomplete Lysis-M buffer (Roche Diagnostics Corporation, Basel,Switzerland). Total and free TFPI and vWF synthesis and release bythese cells were measured by ELISA and expressed per mL ofconditioned medium or per mg of cell proteins. Total RNA wasisolated from the VSMCs or ECs with the RNeasy Mini kit (Qiagen).The first-strand cDNA and polymerase chain reaction analysis werethen performed as previously described.18 Primer sequences arelisted in the Supplemental Data, available online athttp://atvb.ahajournals.org.
Statistical AnalysisClinical data are presented as means�SD and in vitro data asmeans�SEM. HRT effects were analyzed by the Student t test.Relationships between continuous variables were determined usingPearson correlation coefficients. The association between age tertilesand CV or hemostatic parameters was tested using a trend test analysisof variance. Multiple linear regression analysis was used to identify thebest independent predictors of free TFPI and vWF. We repeated ouranalyses with adjustments for potential confounders (carotid PP,fibrinogen, risk factors, or treatments). TFPI and vWF expres-sions in cell biology experiments were analyzed by the Student ttest. Statistical analysis was performed using NCSS 2004 soft-ware package. Probability values �0.05 were consideredsignificant.
Regnault et al Arterial Stiffness, PP, and Coagulation 1227
ResultsPatient CharacteristicsSubjects were divided into 3 tertiles according to age. Table 1indicates a slight, nonsignificant increase in brachial andcarotid SBP and a similar decrease in DBP with age. Brachialand carotid PP were highly significantly different among the3 tertiles. Significant increases with age were observed forcarotid wall thickness, internal diameter, and especiallyPWV. MAP did not differ among tertiles. Blood pressure wasnormal in 100 subjects (SBP �140 mm Hg and DBP�90 mm Hg), and elevated (140 � SBP �190 mm Hgwhatever DBP may be) in 23 subjects. There was nodifference in heart rate and circumferential wall stress amongthe 3 tertiles, but there was a trend toward an attenuation ofPP amplification with age. The distribution of CV risk factorsand drug treatments differed significantly among the 3 tertilesexcept for body mass index and treatments for hypertension.Forty-four subjects were on antihypertensive therapy, includ-ing diuretics, �-blockers, calcium channel blockers, or block-ers of the renin-angiotensin system. Fifty-four subjects were
past and 22 were current HRT users (4 oral and 18 transder-mal HRT). Biologically active estradiol plasma levels rangedfrom 4 to 370 pg/mL in current users and from 2 to 64 pg/mLin women receiving no therapy.
As classically observed, several coagulation and endothelialvariables were positively associated with age: factor VIII, vWF,free TFPI, soluble thrombomodulin, and D-dimers (Table 2), butfibrinogen, soluble endothelial protein C receptor, and protein Sactivity did not differ among the 3 tertiles. The elevation inD-dimer levels was not accompanied by an increase in plasmalevels of thrombin-antithrombin complexes.
Estradiol levels were not correlated with hemodynamics orhemostatic parameters in the total population or in the HRTuser subgroup. However, current HRT was associated with adecrease in free TFPI levels (9.6�2.4 versus 11.8�3.2ng/mL, P�0.003), and this difference remained significantafter adjustment for age (P�0.03).
Correlation Between Coagulation Factors andArterial StiffnessFigure 1 represents the univariate correlations between free TFPIor vWF (y-axis) and PWV (x-axis). The most significant
Table 1. Characteristics of the 123 Subjects
Cardiovascular CharacteristicsAll Subjects
(n�123)First Age
TertileSecond Age
TertileThird Age
TertileLinear Trend
ANOVA P Values
Age, years (age range) 67.2�5.6 61.7�1.2 (60 to 64) 66.1�1.3 (64 to 69) 73.8�3.9 (69 to 84)
correlation was between free TFPI and PWV (r�0.366;P�0.0001), but a positive correlation was also observed be-tween vWF and PWV (r�0.287; P�0.001). Such correlationsremained significant after adjustment for age. When womencurrently on HRT were excluded, the correlation between freeTFPI or vWF and PWV remained significant (r�0.332,P�0.0007, and r�0.302, P�0.002, respectively). It is notewor-thy that PP (carotid or brachial) but not MAP was positivelycorrelated with free TFPI and vWF (data not shown).
Using multiple regression analysis in the entire population,we further tested the relationship between PWV and bothTFPI and vWF by also including age and HRT in themultivariate model (Table 3). This analysis showed that PWVwas independently associated with free TFPI and vWF andaccounted for 5.4% and 3.1% of the variations in free TFPIand vWF, respectively. The total model explained 23.0% ofthe free TFPI variation and 19.4% of the variation in vWF.
When including fibrinogen, carotid PP, risk factors, ortreatments in this model, the same parameters remainedindependently associated between PWV and free TFPI. Onthe contrary, when the same parameters were included in
analysis of the association between PWV and vWF levels, thesignificance of the correlation disappeared. Nevertheless, asignificant, positive correlation between carotid PP and vWFremained (P�0.01).
In Vitro ExperimentsFigure 2 shows the effects of mechanical stretch on TFPIsynthesis and release by cultured human VSMCs. WhenVSMCs were subjected to 5% cyclic stretch at a frequency of 1Hz, there was no significant increase in TFPI gene expression(Figure 2A). At the protein level, there was a significant increasein TFPI protein content, including cell-associated TFPI and totaland free TFPI released into the cell supernatant. We furtherexamined the effects of 10% of cyclic stretch (Figure 2B). TFPImRNA levels were increased as early as 1 hour and remainedelevated until 48 hours. The changes in TFPI mRNA levelsincluded similar changes in all 3 forms of TFPI, which werehigher than in VSMCs exposed to 5% cyclic stretch.
To determine whether pulsatility plays a role in mechanicalstimulation of VSMCs, cells were exposed to 5% static stretch,the mean amplitude of the 10% cyclic stretch. As shown inFigure 2C, no significant difference was observed in TFPIproduction at any time point studied in response to static stretch.
Because the expression and release of TFPI is upregulated indedifferentiated rat smooth muscle cells in culture, we examinedwhether the mRNA and protein levels of specific VSMCmarkers, ie, smooth muscle myosin heavy chain and smoothelin,were altered by cyclic mechanical stretch (Supplemental FigureI). When cells were exposed to 10% cyclic stretch, there was atime-dependent increase in the expression of smooth musclemyosin heavy chain and smoothelin genes. No modifications ofthese markers were detected at the protein level.
To investigate a distinctive impact of cyclic mechanicalstretch on VSMCs and ECs, human cultured ECs wereexposed to 5% or 10% cyclic stretch (Supplemental Figure
Figure 1. Relationship between arterial stiffness and hemostaticparameters. Statistically significant correlations between freeTFPI and PWV (r�0.366; P�0.0001) and between vWF andPWV (r�0.287; P�0.001) were observed.
II). Cell-associated TFPI and secreted TFPI were increased ina time-dependent and amplitude-dependent manner. At 10%cyclic stretch, the increase in all forms of TFPI was accom-panied by an increase of TFPI mRNA. In contrast to VSMCs,the effect was significant only at 48 hours, and the overallresponse was markedly lower. There was also an amplitude-dependent increase in vWF antigen levels at 24 and 48 hoursin response to cyclic stretch.
DiscussionOur data demonstrate a coupling between vascular stiffeningand several procoagulant and anticoagulant factors in post-menopausal women. The most important result, which is notexplained by age per se, is the positive relationship betweencirculating free TFPI and arterial stiffness or PP (brachial orcarotid). Circulating vWF was also associated with PWV, aspreviously reported,19 but the correlation disappeared afteradjustment to PP. In vitro experiments demonstrated for thefirst time the crucial role of pulsatile hemodynamics on theproduction and secretion of TFPI by VSMCs.
Our population was principally characterized by an increasein PP (carotid and brachial) and PWV with age, accompanied bya trend toward an attenuation of PP amplification, whereas MAPand circumferential wall stress did not change. According to therecently proposed reference values of aortic PWV in the elderlyusing the same measurement device,20 27% of subjects had highnormal values, and 9% had elevated PWV. Thus, these data areconsistent with a significant impairment of pulsatile hemody-namics with advancing age.
To understand our findings, it is important to recall that thevascular wall is one of the major contributors to the throm-botic response, in part via the production of vWF and TFPI.21
Aging causes well-described structural and molecular rear-rangements of the vascular wall leading to arterial stiffening.This parameter depends mainly on the structure of the mediaand less on the endothelium.22–26 The correlation betweenfree TFPI levels and PWV was likely related to the globalalterations of the vascular wall, a finding previously sug-gested for coronary artery disease by Morange et al andindicated by the presence of a positive correlation betweenTFPI and wall stress.27 In the present study, free TFPI andvWF plasma concentrations were significantly associatedwith PWV when controlling solely for age and HRT. Theassociation between free TFPI and PWV was still significantafter adjustment for potential confounders, such as fibrino-gen, CV risk factors or drug treatments, and above all for PP.In contrast, carotid PP but not PWV was independently
associated with vWF when all these factors were considered.These results suggest the involvement of pulsatile compo-nents of blood pressure and vascular wall stiffness in deter-mining plasma levels of free TFPI and confirm that circulat-ing vWF levels are somewhat dependent on pulsatilepressure28 in addition to the predominant role of flow.29
The first part of this work was a cross-sectional in vivo studyin a human population and could not establish a causal linkbetween TFPI and arterial stiffness. Although vWF is producedalmost exclusively by ECs, other vascular wall cells constitu-tively synthesize TFPI, particularly smooth muscle cells, at alevel equivalent to that of ECs.30,31 Plasma TFPI exists in severalforms, both full-length and truncated forms,32 but the inability toassay cellular TFPI in patients explains why we cannot deter-mine whether these different forms originate from differentvascular cell types. Therefore, we designed the second part ofthe study to explore in vitro the direct effects of pulsatilehemodynamics on TFPI expression in VSMCs and ECs.
The present study describes a previously unrecognized in-crease in TFPI synthesis and secretion induced by mechanicalpulsatile forces. Upregulation of TFPI expression in VSMCs bygrowth factors, as well as by changes of cell phenotype towarda synthetic state, has been reported in a few experimentalstudies.31,33,34 The effects of inflammatory processes are morecomplex, because it has been reported that they induced eitherno modification34 or a decreased expression of TFPI.35 Ourresults provide evidence that cyclic stretch induced an increasein TFPI synthesis and secretion by VSMCs, whereas no changeswere observed in cells exposed to static stretch. The responseoccurred early and was unaltered over time but was dependenton the amplitude of cyclic stretch. It is likely that the mechanicalpulsatile stretch applied with the Flexercell system producedeffects similar to the pulsatile stresses exerted on VSMCs in situ.Parallel increases in TFPI mRNA and protein levels in culturedVSMCs also suggest that control of TFPI expression by me-chanical stress occurs both via transcriptional and translationalregulations. We also demonstrate that the increase in TFPI undercyclic stretch was not due to modifications of the cellularphenotype toward a dedifferentiated state. Although ECs havebeen thought to be the primary source of TFPI within thevasculature, our findings indicate that cultured ECs were lesssensitive to cyclic stretch-mediated increases in TFPI productionthan VSMCs exposed to an equivalent level of stretch. Finally,our data provide experimental evidence that pulsatility is neces-sary and sufficient to modulate VSMC TFPI expression, sug-gesting that changes in free TFPI plasma levels in our populationmainly originated from the smooth muscle cells of the vascular
Table 3. Multiple Regression Analysis on the Influence of Age, Current HRT, and PWV onTFPI and vWF
Free TFPI vWF
R2 (%)Regression
Coefficient�SEM P Value R2 (%)Regression
Coefficient�SEM P Value
Age (10 years) 5.67 1.468�0.496 0.0037 11.06 23.437�5.799 0.0001
wall. The higher amount of TFPI, both total and free forms,within the arterial media induces changes in the biology of theVSMC membrane that could play a role in the regulation ofthrombosis triggered by endothelial denudation. This suggests adirect relationship of TFPI with aortic stiffness, which is inagreement with the independent association of plasma levels offree TFPI with PWV in our population. In the same way,
modulation of vWF in stretched ECs provides an explanation forthe clinical association between PP and vWF. Increases in TFPIand vWF occurred in parallel and thus may compensate for eachother because these 2 molecules have opposite effects on thecoagulation process (anti- and procoagulant effects, respec-tively). Using DNA microarray techniques, it has been demon-strated that cyclic strain in human cultured VSMCs changes theexpression of several genes, including those encoding anticoag-ulant factors.36 This highlights that the interaction betweenpulsatile signals and selected procoagulant and anticoagulantfactors originating from the vascular wall should be investigatedfurther both in vivo and in vitro. Clinical studies have shown thatcoronary mortality can be predicted not only by brachial andcarotid PP but also by carotid distension.37
One potential limitation of our study is that we analyzed apopulation selected with regard to gender and the absence ofovert CV disease, and so our findings cannot be extrapolated tomale subjects or patients identified as being at higher CV risk.However, it has previously been shown that the increase withage of the components of the tissue factor coagulation pathwayis mainly due to the contribution of the female part of the normalpopulation.38 In line with our results, it has been reported thatfree TFPI decreased with HRT use, and this was consistentlytrue for oral regimens,39–41 whereas it was more debated fortransdermal therapy.42,43 Several groups of investigators werecautious in suggesting favorable effects of administered estrogenon PWV.44 Here we show that the correlation between free TFPIand PWV remains significant even when excluding womencurrently on HRT, in particular those on oral HRT, indicatingthat this correlation is not dependent on HRT effects.
In conclusion, in postmenopausal women older than 60 andfree of any target organ damage, we report a correlation betweenincreased PWV or PP and circulating free TFPI, indicating thatfree TFPI increases as vascular wall function deteriorates. Therelationship between TFPI and pulsatile stretch in culturedVSMCs supports this clinical finding and provides a possiblemechanistic link between arterial stiffness and coagulation pro-teins in our population. The pathophysiological relevance ofincreased plasma levels of free TFPI for CV death in patientswith coronary artery disease has previously been underlined.27 Inview of these findings, it would be of great interest to set up alongitudinal study to establish the predictive value of free TFPIwith respect to the occurrence of CV events in patients withincreased arterial stiffness.
AcknowledgmentsWe thank Coenraad H. Hemker and Mary Osborne-Pellegrin forhelpful discussion and comments on the manuscript. We also thankCecile Lakomy for her contribution to the in vitro study.
Sources of FundingThis study was supported by the Nancy University Hospital, theRegion Lorraine, and the Communaute Urbaine du Grand Nancy.
DisclosuresNone.
Figure 2. TFPI synthesis and secretion by cultured human aorticVSMCs exposed to mechanical stretch. VSMCs grown oncollagen-coated silicone elastomer-bottomed plates were sub-jected to 5% (A) or 10% (B) cyclic or to 5% static (C) mechani-cal stretch. Results (means�SEM of 3 experiments performed induplicate) are expressed as ratios of values obtained instretched cells (S) to those obtained with control (unstretched)cells (NS) at each time point studied. Cell TFPI indicates TFPI incell lysates; TFPI and f-TFPI, total TFPI and free TFPI in condi-tioned medium, respectively. *P�0.05 vs a ratio value of 1;†P�0.05 vs 5% cyclic stretch.
Regnault et al Arterial Stiffness, PP, and Coagulation 1231
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Weryha, Pascal Challande, Michel E. Safar, Athanase Benetos and Patrick LacolleyCarlos Labat, Huguette Louis, Denis Wahl, Bruno Pannier, Thomas Lecompte, Georges
Veronique Regnault, Christine Perret-Guillaume, Anna Kearney-Schwartz, Jean-Pierre Max,and Coagulation in Postmenopausal Women
Tissue Factor Pathway Inhibitor: A New Link Among Arterial Stiffness, Pulse Pressure,
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