Iron-Deficiency and Estrogen Are Associated With Ischemic Stroke by Up-Regulating Transferrin to Induce Hypercoagulability

Circ Res. 2020 Aug 14;127(5):651-663. doi: 10.1161/CIRCRESAHA.119.316453. Epub 2020 May 26.


Rationale: Epidemiological studies have identified an associate between iron deficiency (ID) and the use of oral contraceptives (CC) and ischemic stroke (IS). To date, however, the underlying mechanism remains poorly understood. Both ID and CC have been demonstrated to upregulate the level and iron-binding ability of Tf (transferrin), with our recent study showing that this upregulation can induce hypercoagulability by potentiating FXIIa/thrombin and blocking antithrombin-coagulation proteases interactions.

Objective: To investigate whether Tf mediates IS associated with ID or CC and the underlying mechanisms.

Methods and results: Tf levels were assayed in the plasma of IS patients with a history of ID anemia, ID anemia patients, venous thromboembolism patients using CC, and ID mice, and in the cerebrospinal fluid of some IS patients. Effects of ID and estrogen administration on Tf expression and coagulability and the underlying mechanisms were studied in vivo and in vitro. High levels of Tf and Tf-thrombin/FXIIa complexes were found in patients and ID mice. Both ID and estrogen upregulated Tf through hypoxia and estrogen response elements located in the Tf gene enhancer and promoter regions, respectively. In addition, ID, administration of exogenous Tf or estrogen, and Tf overexpression promoted platelet-based thrombin generation and hypercoagulability and thus aggravated IS. In contrast, anti-Tf antibodies, Tf knockdown, and peptide inhibitors of Tf-thrombin/FXIIa interaction exerted anti-IS effects in vivo.

Conclusions: Our findings revealed that certain factors (ie, ID and CC) upregulating Tf are risk factors of thromboembolic diseases decipher a previously unrecognized mechanistic association among ID, CC, and IS and provide a novel strategy for the development of anti-IS medicine by interfering with Tf-thrombin/FXIIa interactions.

Keywords: blood; contraceptives; estrogens; thrombosis; transferrin.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Anemia, Iron-Deficiency / blood
  • Anemia, Iron-Deficiency / complications*
  • Anemia, Iron-Deficiency / diagnosis
  • Animals
  • Biomarkers / blood
  • Blood Coagulation*
  • Case-Control Studies
  • Cell Line
  • Contraceptives, Oral, Hormonal / adverse effects*
  • Disease Models, Animal
  • Estrogens / toxicity*
  • Factor XIIa / metabolism
  • Female
  • Humans
  • Ischemic Stroke / blood
  • Ischemic Stroke / diagnosis
  • Ischemic Stroke / etiology*
  • Liver / drug effects
  • Liver / metabolism
  • Male
  • Mice, Inbred C57BL
  • Middle Aged
  • Prospective Studies
  • Risk Assessment
  • Risk Factors
  • Thrombin / metabolism
  • Thrombophilia / blood
  • Thrombophilia / diagnosis
  • Thrombophilia / etiology*
  • Transferrin / metabolism*
  • Up-Regulation
  • Young Adult


  • Biomarkers
  • Contraceptives, Oral, Hormonal
  • Estrogens
  • Transferrin
  • Factor XIIa
  • Thrombin