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Protease-activated receptor 4 (PAR4) is a potent thrombin receptor. Epigenetic control of the F2RL3 locus (which encodes for PAR4) via DNA methylation is associated with both smoking and cardiovascular disease. We examined the association between DNA hypomethylation at F2RL3 and risk of cardiovascular disease, focusing on acute myocardial infarction (AMI) (n=853/2,352 cases/controls). We used in vitro cell models to dissect the role of DNA methylation in regulating expression of F2RL3. We investigated the interplay between F2RL3 DNA methylation and platelet function in human (n=41). Lastly, we used Mendelian randomization to unify observational and functional work by assessing evidence for causal relationships using data from UK Biobank (n=407,141) and CARDIoGRAMplusC4D (n=184,305). Observationally, one standard deviation (SD) decrease in DNA methylation at F2RL3 was associated with a 25% increase in the odds of AMI. In vitro, short-term exposure of cells to cigarette smoke reduced F2RL3 DNA methylation and increased gene expression. Transcriptional assays flagged a role for a CEBP recognition sequence in modulating the enhancer activity of F2RL3 exon 2. Lower DNA methylation at F2RL3 was associated with increased platelet reactivity in human. The estimated casual odds ratio of ischaemic heart disease was 1.03 (95% CI: 1.00, 1.07) per 1 SD decrease in F2RL3 DNA. In conclusion, we show that DNA methylation-dependent platelet activation is part of a complex system of features contributing to cardiovascular health. Tailoring therapeutic intervention to new knowledge of F2RL3/PAR4 function should be explored to ameliorate the detrimental effects of this risk factor on cardiovascular health.

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