1. 1
Supplemental Material to Huskens, Roest, Remijn et
al. “Strenuous exercise induces a hyperreactive
rebalanced haemostatic state that is more
pronounced in men” (Thromb Haemost 2016; 115.6)
Sample size calculation
The purpose of this study is to compare the coagulation status of healthy donors before and after
strenuous exercise (= participation at the Amstel Gold Race). Intitially, we considered the peak height
of the thrombin generation assay in whole blood as the most important parameter in our study. The
mean value of the peak is 128 nM (n=40) with SD of 40 nM. We expect to have at least an effect of
10%, which means that the sample size has to be 90 if tested 2-sided with a desired power of 85% and
a p-value of 0.05 (Calculated with Power and Sample Size Calculations version 3.12). A letter with
information about our study was send to all participants and 103 persons wanted to participate in our
study. On the day of the Amstel Gold Race, 94 participants presented themselves before the start of
the race and finally two were excluded because of age or not cycling the minimal distance (100 km). In
total 92 volunteers were tested.
Blood samples
Blood of the healthy participants was aseptically drawn in Vacutainer tubes (BD Vacutainer System)
just before the race (baseline) and immediately after the race (post-exercise). Serum was stored at -
80°C until further use. PRP was prepared by centrifuging the whole blood at 250 g for 15 min. PPP was
prepared by double centrifugation of the blood at 1,000 g for 10 min. The residual PPP was stored at -
80°C until further use. Cell counts in whole blood and PRP were performed with a Coulter Counter
analyzer (Beckman Coulter, Woerden, the Netherlands).
Reagents
2. 2
PRP reagent (1 pmol/L of Tissue Factor (TF) and a minimal amount of phospholipids), PPP reagent (5
pmol/L of TF and phospholipids), PPP reagent low (1 pmol/L of TF and phospholipids), MP reagent
(phospholipids but no TF) and Thrombin Calibrator, purchased from Thrombinoscope BV (Maastricht,
the Netherlands), were reconstituted in 1 ml of deionized water. The FluCa-kit consisting of Fluo-
Substrate and Fluo-buffer was also purchased from Thrombinoscope BV. For thrombin generation in
whole blood we used rhodamine substrate (P2Rho), a gift from Diagnostica Stago (Asnières sur Seine,
France). Recombinant TF was purchased from Innovin (Dade-Behring, Marburg, Germany). The
calibrator, α2-macroglobulin-thrombin complex, used for whole blood thrombin generation was
prepared in house as described previously (1). BSA5 contains 20 mmol/L Hepes, 140 mmol/L NaCl,
0.02% NaN3 and 5 g/L bovine serum albumine (BSA) at pH 7.35. BSA60 contains 20 mmol/L Hepes,
0.02 % NaN3 and 60 g/L BSA at pH 7.35.
FITC-conjugated anti-fibrinogen and PE-conjugated anti-P-selectin were purchased from DAKO (F0111,
Dako, Glostrup, Denmark) and BD-Biosciences (555524; BD PharmingenTM
, Franklin Lakes, NJ, USA),
respectively. Platelet agonists include the P2Y12 agonist ADP (01897, Sigma-Aldrich, Zwijndrecht, the
Netherlands), the protease activated receptor (PAR)-1 agonist thrombin receptor activator peptide
(SFLLRN, H-2936; Bachem, Weil am Rhein, Germany), the PAR-4 agonist AYPGKF (Netherlands Cancer
Institute, Amsterdam, the Netherlands) and the glycoprotein VI (GPVI) agonist collagen-related
peptide (CRP, a generous gift by Professor Farndale, university of Cambridge, UK).
Measurement of in vitro thrombin generation by means of CAT
The plasma CAT thrombin generation was measured in a mixture of 80 µL PPP or PRP and 20 µL of PPP
reagent, PPP reagent LOW, MP reagent or PRP reagent (1). In the calibration well, 20 µL of Thrombin
Calibrator was added to 80 µL of plasma. Immulon 2HB, 96-well plates were placed on a heating plate
to reach 37°C (10 min). At the start of the experiment, the fluorometer (Ascent reader,
Thermolabsystems OY, Helsinki, Finland) dispensed 20 µL of FluCa into the wells before reading. The
thrombin generation curves and their parameters were derived from the fluorescence curves using
3. 3
the dedicated software provided with the CAT method (Thrombinoscope BV, Maastricht, the
Netherlands) (2).
Platelet activation test in whole blood
Briefly, 5 µL whole blood was added to 50 µL reaction mix, consisting of agonist (500 ng/mL collagen-
related peptide (CRP), 50 µmol/l thrombin receptor activator peptide (SFLLRN), 15 µmol/l ADP, 750
µmol/l AYPGKF (protease activated receptor (PAR)-4 agonist)) and 40 µl/ml FITC-conjugated anti-
fibrinogen, 40 µl/ml PE-conjugated anti-P-selectin in HEPES-buffered saline (HBS: 10 mmol/l HEPES,
150 mmol/l NaCl, 1 mmol/l MgSO4, 5 mmol/l KCL, pH 7.4). Flow cytometry was used to distinguish
between platelets and other cells on forward and sideward scatter pattern. Fluorescent intensity in
the PE gate was selected to determine P-selectin density, and fluorescent intensity in the FITC gate
was used to determine fibrinogen binding, which indicates αIIbβ3 activation. Results are expressed as
arbitrary units (AU).
4. 4
Suppl. Table 1. Platelet reactivity at baseline and post-exercise
Agonist
No
agonist PAR-1 PAR-4 P2Y12 GPVI
P-selectin
expression
(AU)
Baseline median 27 4404 3549 1012 3839
IQR (21-31) (3625-5192) (2600-4332) (706-1418) (3112-4435)
Post-
exercise
median 29**** 5497**** 4901**** 1488**** 5276****
IQR (24-39) (4890-6171) (3815-5466) (1110-1873) (4212-6138)
αIIbβ3
activation
(AU)
Baseline median 42 809 524 663 877
IQR (27-47) (659-944) (331-711) (476-823) (641-1017)
Post-
exercise
median 50**** 1304**** 1060**** 1041**** 1477****
IQR (44-53) (1034-1510) (598-1322) (828-1278) (1091-1799)
Data are given as medians with interquartile ranges (n=53-60) and tested with the Wilcoxon matched-
pairs signed rank test. **** P<0.0001.
6. 6
0 5 1 0 1 5 2 0 2 5
0
1 0 0
2 0 0
3 0 0
4 0 0
5 0 0
T im e (m in )
Thrombin(nmol/L)
P P P
n o a d d F V III 1 U /m l F V III 2 U /m l
F V III 5 U /m l F V III 1 0 U /m l
0 1 0 2 0 3 0 4 0
0
5 0
1 0 0
1 5 0
2 0 0
T im e (m in )
Thrombin(nmol/L)
P R P
0 5 1 0 1 5 2 0 2 5
0
5 0
1 0 0
1 5 0
T im e (m in )
Thrombin(nmol/L)
w h o le b lo o d
Suppl. Figure 1. Effect of the exercise-induced increase of FVIII on thrombin generation. Thrombin
generation measured in PPP (A) and PRP (B) triggered with 1 pM of TF and in whole blood (C) triggered
with 0.5 pM of TF. Plasma and whole blood were spiked with or without different concentrations of
FVIII.
A
B
C
7. 7
IIb3activation(AU)
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
0
5 0 0
1 0 0 0
1 5 0 0
2 0 0 0
2 5 0 0
*** ***
P A R -1
P-selectinexpression(AU)
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
0
2 0 0 0
4 0 0 0
6 0 0 0
8 0 0 0
1 0 0 0 0
***
P A R -1
IIb3activation(AU)
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
0
5 0 0
1 0 0 0
1 5 0 0
2 0 0 0
**
P A R -4
*
P-selectinexpression(AU)
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
0
2 0 0 0
4 0 0 0
6 0 0 0
8 0 0 0
***
P A R -4
IIb3activation(AU)
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
0
5 0 0
1 0 0 0
1 5 0 0
2 0 0 0
***
P 2 Y 12
P-selectinexpression(AU)
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
0
1 0 0 0
2 0 0 0
3 0 0 0
**
P 2 Y 12
IIb3activation(AU)
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
0
5 0 0
1 0 0 0
1 5 0 0
2 0 0 0
2 5 0 0
*** *
G P V I
P-selectinexpression(AU)
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
B
a
s
e
lin
e
P
o
s
t-e
x
e
rc
is
e
0
2 0 0 0
4 0 0 0
6 0 0 0
8 0 0 0
1 0 0 0 0
**
G P V I
m e n w o m e n
8. 8
Suppl. Figure 2. Effect of strenuous exercise on platelet reactivity in men and women after
adjustment for sample size, age and distance cycled. Thrombin receptor activator peptide (SFLLRN),
AYPGKF, ADP and collagen-related peptide (CRP) were used to activate platelets via Proteinase
Activated Receptor-1 (PAR-1) (A and B), PAR-4 (C and D), P2Y12 receptor (E and F) and glycoprotein VI
receptor (GPVI) (G and H), respectively. Scatter plots of αIIbβ3 activation (left) and P-selectin expression
(right) in men and women measured before and after the race are shown. To compare males and
females of the same age and distance cycled, a restricted analysis was performed on men below 40
years who have ridden 150 km or less (12 men with mean age 31 years and mean distance cycled 137
km were compared with 15 women with mean age 28 years and mean distance cycled 123 km). The
black bars represent medians with interquartile ranges and significance was tested with the Wilcoxon
matched-pairs signed rank test. *P<0.05, *** P<0.001, **** P<0.0001.
Suppl. References
1. Hemker HC, Giesen P, Al Dieri R, et al. Calibrated automated thrombin generation
measurement in clotting plasma. Pathophysiol Haemost Thromb. 2003; 33: 4-15.
2. Hemker HC, Kremers R. Data management in thrombin generation. Thromb Res. 2013; 131: 3-
11.
