Vascular Pharmacology 62 (2014) 162166

Contents lists available at ScienceDirect

Vascular Pharmacology
journal homepage: www.elsevier.com/locate/vph

Review

Mechanism of antiplatelet action of hypolipidemic, antidiabetic

and antihypertensive drugs by PPAR activation
PPAR agonists: New antiplatelet agents
Eduardo Fuentes , Ivn Palomo
Department of Clinical Biochemistry and Immunohaematology, Faculty of Health Sciences, Interdisciplinary Excellence Research Program on Healthy Aging (PIEI-ES), Universidad de Talca, Talca, Chile
Centro de Estudios en Alimentos Procesados (CEAP), CONICYT-Regional, Gore Maule, R09I2001, Chile

a r t i c l e

i n f o

Article history:
Received 20 February 2014
Received in revised form 8 May 2014
Accepted 15 May 2014
Available online 27 May 2014
Keywords:
Antiplatelet
Hypolipidemic
Antidiabetic
Antihypertensive peroxisome
proliferator-activated receptors

a b s t r a c t
Given the prevalence of cardiovascular disease in patients with cardiovascular risk factors (i.e., hypertension, diabetes, smoking and obesity) and that platelet activation plays an important pathogenic role in cardiovascular diseases, it is very important to identify the drugs that have multiple targets. In this sense, the present article describes
the mechanism of antiplatelet action of hypolipidemic (statins and brates), antidiabetic (thiazolidinediones) and
antihypertensive (nifedipine) drugs via peroxisome proliferator-activated receptor (PPAR) activation. The mechanism of antiplatelet action of the drugs is by direct activation of PPARs with the inhibition of cyclooxygenase-1,
protein kinase C-alpha, calcium mobilization, thromboxane A2, sCD40L, platelet microparticles and cAMPphosphodiesterase, and the stimulation of proteins kinase G and A. Thus, these observations highlight PPARs as a
novel therapeutic target for the treatment and prevention of cardiovascular diseases.
2014 Elsevier Inc. All rights reserved.

Contents
1.
2.
3.
4.

Introduction . . . . . . . . . . . . . . . . . .
PPARs and atherothrombosis . . . . . . . . . .
Mechanism of antiplatelet action by PPAR activation
Drugs and platelet inhibition: role of PPAR activation
4.1.
Statins and brates . . . . . . . . . . .
4.2.
Thiazolidinediones . . . . . . . . . . .
4.3.
Nifedipine . . . . . . . . . . . . . . .
5.
Conclusions . . . . . . . . . . . . . . . . . .
Declaration of interest . . . . . . . . . . . . . . . .
Acknowledgments . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . .

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1. Introduction
Cardiovascular diseases (CVD) (i.e., acute myocardial infarction,
cerebrovascular disease and peripheral arterial thrombosis) have
signicantly increased in recent years [1,2]. The most frequent and
independent risk factors for CVD are cigarette smoking, elevated
Corresponding authors at: Immunology and Haematology Laboratory, Faculty of
Health Sciences, Universidad de Talca, Casilla, 747, Talca, Chile. Tel.: + 56 71 200493;
fax: +56 71 20048.
E-mail addresses: edfuentes@utalca.cl (E. Fuentes), ipalomo@utalca.cl (I. Palomo).

http://dx.doi.org/10.1016/j.vph.2014.05.008
1537-1891/ 2014 Elsevier Inc. All rights reserved.

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162
163
163
163
163
164
164
165
165
165
165

blood pressure, elevated serum total cholesterol and diabetes,

among others [3,4].
In most cases, CVD is the consequence of an atherosclerotic plaque
rupture and thrombus formation. Accelerated atherosclerosis and an increased risk of thrombotic vascular events in diabetes may result from
dyslipidemia, endothelial dysfunction and platelet hyperreactivity [5,
6]. Platelets from patients with type 1 and type 2 diabetes exhibit enhanced platelet aggregation activity early in the disease course that
may precede CVD development [7,8]. Thus, platelets adhere; secrete
their granule contents, aggregate and initiate thrombus formation following an atheromatous plaque rupture, [9,10].

E. Fuentes, I. Palomo / Vascular Pharmacology 62 (2014) 162166

Given the central role of platelets in the atherosclerotic-related inammatory response and the subsequent thrombotic event, a variety
of antiplatelet agents have been developed [11,12]. Although antiplatelet drugs have been proven to be benecial in patients with clinical evidence of CVD, outcomes still remain poor [13]. In this way, platelets
from diabetic patients release greater amounts of thromboxane A2
(TXA2) than platelets from non-diabetic patients receiving treatment
with low-dose aspirin [14]. This is because all the current available antiplatelet agents only target one signal pathway and moderately inhibit
platelet activation (e.g. aspirin and clopidogrel) [15]. Therefore, there is
much room for further improvement of antiplatelet treatment and the
need to identify the mechanisms by which hypolipidemic (statins and
brates), antidiabetic (thiazolidinediones) and antihypertensive (nifedipine) drugs inhibit platelet activation. It has also been observed that
these drugs are ligands for peroxisome proliferator-activated receptors
(PPARs) in cells which have a nucleus [1618].
PPARs are involved in many biological processes, including lipid and
energy metabolism inammation responses, and atherosclerotic plaque
formation [1921]. Selective agonists through their action on nuclear
receptors (e.g. PPARs) regulate platelet function despite the absence of
a nucleus in platelets. [22]. In this sense, the present article describes
the antiplatelet action mechanism of hypolipidemic, antidiabetic and
antihypertensive drugs via PPAR activation.

163

the expression of nitric oxide synthase (NOS) and thrombomodulin

[46]. PPAR- activation also inhibits platelet function induced by collagen through the modulation of early glycoprotein (GP) VI signaling, at
the level of Syk and LAT [47]. In addition, platelet incubation with a natural PPAR- agonist (15d-PGJ(2)) or with a potent synthetic PPAR- ligand (rosiglitazone) not only attenuates platelet activation, but also
decreases the release of platelet proinammatory and procoagulant mediators (sCD40L and TXA2) [33,37].
Agonists of PPAR-, including GW0742 and L-165041, inhibit platelet activation after 5 min of incubation. Clearly with such acute exposure
and as platelets have no nucleus, PPAR- is an active antithrombotic
pathway in platelets, whose effects are independent of the nucleus [38].
Moreover, PPAR- activators may exert vasculo-protective action
through suppression of PDGF-BB production in a megakaryocyte/platelet
pathway [48]. Prostacyclin formed by the consecutive actions of
cyclooxygenase-1 (COX-1) and prostacyclin synthase is arguably the
most important endogenous antiplatelet hormone identied to date
[49]. Prostacyclin inhibits platelet function via stimulation of a surface
prostanoid receptor linked to the activation of adenylyl cyclase and increased intracellular levels of cyclic adenosine monophosphate (cAMP)
[50]. Moreover, prostacyclin activates PPAR-/ in human platelets in
the low 109 M range. Therefore, an additional mechanism of antiplatelet action by prostacyclin occurs by activation of PPAR-/ and its effects
on platelet aggregation is synergistic with nitric oxide (NO) [38,51].

2. PPARs and atherothrombosis

PPARs consist of a family of three nuclear receptor isoforms (, /,
and ) [23]. PPARs are the key regulators of metabolism and inammation, and play an important role in chronic inammatory disease processes [24,25]. Accumulating evidence suggests that PPAR activation is
a key mechanism to reduce atherosclerosis and improve cardiovascular
function [2628].
Recent studies suggest that PPAR- activation decreases atherogenesis, not only by correcting metabolic disorders, but also through its direct effects on the vascular wall [29]. In addition, PPAR- and PPAR-/
have also been suggested in the regulation of inammation and slow
atherosclerosis progression [20,30].
Ligands of PPAR- are important regulators of lipid and lipoprotein
metabolism, thereby positively affecting plasma lipid risk factors related
to atherosclerosis [31]. In this context, the lipid-lowering effect of
fenobrate is achieved by activating PPAR- and AMP-activated protein
kinase (AMPK) signaling pathway that results in increasing lipolysis and
fatty acid -oxidation [32].
PPARs appear to play a major role in the regulation of atherogenesis
by countering the inammation-provoking action of platelet adhesion
and activation [33].
3. Mechanism of antiplatelet action by PPAR activation
Nuclear receptors are transcription factors that are activated by ligands and subsequently bind to regulatory regions in target genes;
allowing the organism to integrate signals coming from the environment [34]. While steroid/nuclear receptors are recognized via for their
role in gene regulation, increasing evidence supports nongenomic actions of these receptors [35,36]. Thus, although platelets lack a nucleus,
they express a number of transcription factors including steroid/nuclear
receptors such as PPARs [37,38], glucocorticoid receptor (GR) [39],
retinoic X receptor (RXR) [41], estrogen receptor (ER) [40] and nuclear
factor kappa B (NF-B) [42]. Thus, selective ligands for these receptors
regulate platelet aggregation and activation [22,43].
While many reports focus on PPAR expression in the nucleus [44,45],
in this article we focus on the role of PPAR-cytoplasm in platelet function. Recent studies have provided the rst evidence that human bone
marrow megakaryocytes and human platelets express PPAR- [37].
PPAR- activation decreases platelet aggregation and delays intraarterial thrombus formation in rats, at least partially, by an increase in

4. Drugs and platelet inhibition: role of PPAR activation

Given the prevalence of CVD in patients with cardiovascular risk
factors (i.e., hypertension, diabetes, smoking and obesity) and that
platelet activation plays an important pathogenic role in atherothrombosis [3,52], it is very important to identify the drugs that
have multiple targets. In this sense, the present article describes
the mechanism of antiplatelet action of hypolipidemic (statins and
brates), antidiabetic (thiazolidinediones) and antihypertensive
(nifedipine) drugs by PPAR activation.
4.1. Statins and brates
The 3-hydroxy-3-methylglutaryl-coenzyme (HMG-CoA) reductase
inhibitors, also known as statins, are the most effective class of drugs
for lowering serum low-density lipoprotein cholesterol (LDL-C) concentrations [53]. In this way, another class of drug called brates reduces
triglycerides and increases high-density lipoprotein cholesterol (HDLC) [54]. In this article, we discuss how statins and brates appear to
have more biological effects than those originally targeted. Statins and
brates can exert benecial anti-inammatory and antithrombotic effects in after patients with a high risk of coronary artery disease as
early as 3 days after therapy [55]. Thus, statins (simvastatin, atorvastatin, or cerivastatin) decrease morbidity and mortality in patients with
CVD by their effects on proinammatory cytokines: interleukin 6 (IL6), IL-8, and monocyte chemoattractant protein-1 (MCP-1) [56]. Meanwhile, brates by PPAR-activation may inhibit atherosclerosis development in vivo [57].
Interestingly both statins and brates inhibit platelet function [54].
Inhibition of platelet aggregation by simvastatin involves the activation
of the cAMP-eNOS/NO-cGMP pathway, resulting in the inhibition of the
PLC-2/PKC/p38 MAPK/TXA2 cascade [58,59]. Therefore, the direct inhibitory effects of statins and brates on platelet activation are mediated by PPAR activation and this new nding reveals some of the
pleiotropic effects of these drugs [60]. In platelets, PPAR signaling pathway activation involves binding and repression of PKC, and increasing of
cAMP and cGMP levels [60]. The increase of intraplatelet levels of cAMP
is due to the fact that the repression of PKC allows greater activity of
adenylyl cyclase, which converts ATP to cAMP [61,62]. In addition,
cAMP induced inhibition of platelet P-selectin expression, platelet

164

E. Fuentes, I. Palomo / Vascular Pharmacology 62 (2014) 162166

Fig. 1. Mechanism of antiplatelet action of PPAR ligands. AA = arachidonic acid; AKT = known as protein kinase B; AMP = adenosine monophosphate; cAMP = cyclic adenosine
monophosphate; cGMP = cyclic guanosine monophosphate; COX-1 = cyclooxygenase-1; NO = nitric oxide; NOS = nitric oxide synthase; PDE3 = phosphodiesterase-3; PGH2 = prostaglandin H2; PGG2 = prostaglandin G2; PKA = protein kinase A; PKC = protein kinase C; PKG = protein kinase G; PLA2 = phospholipase A2; PMP = platelet microparticles; PPARs = peroxisome
proliferator-activated receptors; TXA2 = thromboxane A2; VASP = vasodilator-stimulated phosphoprotein; VASP-P = vasodilator-stimulated phosphoprotein phosphorylation.

aggregation and release of sCD40L, for the large part, is mediated

through the activation of protein kinase A (PKA) [6366].
Platelet microparticles (PMP) have an average diameter of 0.1 m
[67], and are the most abundant type of microparticles (MP) in human
blood (representing 7090%) and contribute to many biologically processes [68]. PMP levels are greatly elevated in patients (range from
~ 300011,000/L) with diseases including venous thromboembolism
[69], hypertension [70], diabetes [71], cancer [72], immunologic platelet
disorders and arterial thrombosis [73,74]. In humans, plasma levels of
circulating PMP are known to increase with the presence of cardiovascular risk factors and progression of atherosclerosis [75]. Even after initiation of antithrombotic treatment, PMP are still elevated after six
months [76]. Possibly because a low dose of aspirin might not be strong
enough to suppress the shedding of PMP in the microcirculation [77].
With respect to the role of statins, MP from hypercholesterolemia patients with statin treatment had reduced markers of activated platelets
(GPIIb-IIIa), activated inammatory cells (Mac-1) and tissue factor [78].
Meanwhile atorvastatin reduces thrombin generation and expression of
tissue factor, GPIIIa and P-selectin on PMP in patients with peripheral
vascular disease [79]. In this way statins may inhibit thrombotic event
generation partly through a PMP dependent mechanism.

4.2. Thiazolidinediones
The thiazolidinediones (TZDs) are a class of oral antidiabetic drugs
that exert effects through a mechanism that involves an activation of
PPAR- [80]. TZDs (rosiglitazone, pioglitazone and troglitazone) have
been shown to protect LDL-C from oxidative modication in patients
with type 2 diabetes that were treated for 8 weeks, one of the key initial
events in atherogenesis [81]. In addition, TZD activation of PPAR- reduced the progression of subclinical atherosclerosis by normalizing

proatherogenic metabolic abnormalities of the insulin resistance, and

through an inhibition of vascular cell growth and movement [82].
Recent studies suggest that TZDs may also be clinically benecial to
inammatory mediators [83]. Matrix metalloproteinase-9 (MMP-9) is
critically involved in the development of unstable plaques [84]. Also
MMP-9 levels are increased in type 2 diabetes patients with coronary
artery disease, and the treatment of these patients with the antidiabetic
PPAR-activator rosiglitazone signicantly reduces the serum levels of
MMP-9, tumor necrosis factor alpha (TNF-) and serum amyloid A [85].
Troglitazone has a potent inhibitory effect on platelet aggregation via
the suppression of the thrombin-induced activation of phosphoinositide
signaling in human platelets [86]. Based on the function of other cells
(astrocyte cells), the TZD mode of action is likely related to the elevation
of the intracellular cAMP level by PPAR- activation [87]. This could explain why the treatment with TZDs reduces sCD40L serum levels in patients with type 1 and 2 diabetes and coronary artery disease [88,89].
PPAR- containing PMP are quickly released from -granule into extracellular parts when platelets are activated by collagen [90]. Then,
PMP-PPAR- can be internalized by the monocytic cell line (THP-1). In
this way, THP-1 cell activation can be attenuated in the presence of a
PPAR- agonist (rosiglitazone) [91,92].
In addition, one possible mechanism explaining the antiinammatory activity of TZDs is its ability to activate GR [93]. In
this way, classic anti-inammatory glucocorticoids are due to the
fact that human platelets contain GR [39].
4.3. Nifedipine
Nifedipine, a L-type calcium channel blocker, is widely used in the
treatment of hypertension and coronary heart disease [94,95]. Nifedipine increases the activity and intracellular expression of PPAR-/
from activated platelets. Therefore, the mechanism of antiplatelet action

E. Fuentes, I. Palomo / Vascular Pharmacology 62 (2014) 162166

of nifedipine is PAR-/-dependent with upregulation of the PI3K/Akt/

NO/cGMP/PKG pathway, and the inhibition of PKC activity and intracellular Ca2+ mobilization in platelets [96]. Taking into consideration all
these ndings in vivo evidence of such in vitro-related nifedipineantithrombotic effects is provided. Indeed, using a murine model of
thrombus formation, the administration of nifedipine substantially
inhibited uorescein sodium-induced vessel thrombus formation. In addition, its antithrombotic effect is considerably reduced in the presence
of PPAR-/ antagonists [96].
Finally, the mechanism of antiplatelet action of statins, brates, TZDs
and nifedipine by direct activation of PPARs is mediated by inhibition of
COX-1 [37], PKC [62] and Ca2+ mobilization [47], and indirect inhibition
of TXA2, sCD40L, PMP, P-selectin and cAMP-phosphodiesterase, and
stimulation of PKG (increased levels of cGMP) and PKA (increased levels
of cAMP) [63,97] (Fig. 1).
5. Conclusions
The data presented in this article has demonstrated that the ability of
statins, brates, TZDs and nifedipine to inhibit platelet activation is likely attributable to their inuence on PPAR activation. Thus, these observations highlight PPARs as a novel therapeutic target for the treatment
and prevention of cardiovascular risk factors and CVD.
Declaration of interest
The authors report no declarations of interest.
Acknowledgments
This work was funded by CONICYT REGIONAL/GORE MAULE/CEAP/
R09I2001, Programa de Investigacin de Excelencia Interdisciplinaria
en Envejecimiento Saludable (PIEI-ES), and supported by grant no.
1130216 (I.P., M.G., R.M., M.A., J.C.) from Fondecyt, Chile.
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