Ascorbate restores endothelium-dependent vasodilation impaired by acute hyperglycemia in humans

Cardiovascular oxidative stress is reduced by an ACE inhibitor in a rat model of streptozotocin-induced diabetes

Blockade of the renin-angiotensin system (RAS) reduces cardiovascular morbidity and mortality in diabetic patients. Ang II-mediated generation of reactive oxygen species (ROS) has been suggested to be involved in several diabetic complications. We investigated whether the inhibition of Ang II production with an ACE inhibitor (ACEi) reduces oxidative stress and limits structural cardiovascular remodeling in a rat model of streptozotocin (STZ)-induced diabetes. Diabetic rats were treated for 7 weeks with an ACEi (lisinopril, 5 mg/kg/d), an antioxidant (N-acetyl-l-cysteine (NAC), 0.5 g/kg/d) and their combination. At sacrifice, ROS in the myocardium and thoracic aorta, LV myocyte number and size and aorta morphology were determined by quantitative histological methods. Superoxide and hydroxyl radical content, detected by dihydroethidium (DHE) and 8-hydroxydeoxyguanosine (8-OHdG), were 6.7 and 4.5-fold, respectively, higher in diabetic myocardium than in non-diabetic controls (p<0.001). The amount of superoxide was 5-fold higher in the thoracic aorta of diabetic rats compared to controls (p<0.001). Diabetes caused a modest increase in myocyte volume (+13%, p<0.01), a reduction of LV myocyte number (-43%, p<0.001), an accumulation of collagen around coronary arterioles (1.9-fold increase, p<0.01) and a decrease in arterial elastin/collagen ratio (-63%, p<0.001) compared to controls. Treatment with the ACEi attenuated ROS formation and prevented phenotypic changes in the heart (cardiomyocyte hypertrophy, perivascular fibrosis) and in the aorta of diabetic rats to the same extent as NAC. The absence of an additive effect, suggests a common mechanism of action, through the reduction of oxidative stress.

Insulin prevents oxidant-induced endothelial cell barrier dysfunction via nitric oxide-dependent pathway

BACKGROUND

The rigorous maintenance of normoglycemia by the administration of insulin is beneficial to critically ill patients. Because insulin induces endothelial nitric oxide (NO) release, and the constitutive release of NO maintains normal microvascular permeability, the authors postulated that insulin would prevent peroxide (H(2)O(2))-induced endothelial barrier dysfunction, an effect dependent on endothelial NO synthase (eNOS) activity.

METHODS

Murine lung microvascular endothelial cells (LMEC) grown to confluence on 8 micro pore polyethylene filters were exposed to media (control), H(2)O(2) (20 to 500 micromol/L), insulin (1 to 1,000 nmol/L) or insulin (100 nmol/L) + H(2)O(2) (10(-4)mol/L). Endothelial monolayer permeability was quantitated by measuring the transendothelial electrical resistance at 15-minute intervals for 120 minutes. Other cells were exposed to H(2)O(2) and insulin after pretreatment with a NO scavenger (PTIO), an eNOS inhibitor (L-NIO), or a phosphoinositol-3-kinase inhibitor (LY-294002).

RESULTS

H(2)O(2) caused a concentration- and time-dependent reduction in electrical resistance consistent with an increase in monolayer permeability. This effect was prevented by insulin. Inhibiting NO release (L-NIO, LY-294002) or scavenging NO (PTIO) abolished this protective effect.

CONCLUSIONS

These data suggest that insulin may modulate endothelial barrier function during oxidant stress by inducing the release of NO.

High-dose oral vitamin C partially replenishes vitamin C levels in patients with Type 2 diabetes and low vitamin C levels but does not improve endothelial dysfunction or insulin resistance

Endothelial dysfunction is a hallmark of Type 2 diabetes related to hyperglycemia and oxidative stress. Nitric oxide-dependent vasodilator actions of insulin may augment glucose disposal. Thus endothelial dysfunction may worsen insulin resistance. Intra-arterial administration of vitamin C improves endothelial dysfunction in diabetes. In the present study, we investigated effects of high-dose oral vitamin C to alter endothelial dysfunction and insulin resistance in Type 2 diabetes. Plasma vitamin C levels in 109 diabetic subjects were lower than healthy (36 ± 2 μM) levels. Thirty-two diabetic subjects with low plasma vitamin C (<40 μM) were subsequently enrolled in a randomized, double-blind, placebo-controlled study of vitamin C (800 mg/day for 4 wk). Insulin sensitivity (determined by glucose clamp) and forearm blood flow in response to ACh, sodium nitroprusside (SNP), or insulin (determined by plethysmography) were assessed before and after 4 wk of treatment. In the placebo group ( n = 17 subjects), plasma vitamin C (22 ± 3 μM), fasting glucose (159 ± 12 mg/dl), insulin (19 ± 7 μU/ml), and SIClamp [2.06 ± 0.29 × 10−4 dl·kg−1·min−1/(μU/ml)] did not change significantly after placebo treatment. In the vitamin C group ( n = 15 subjects), basal plasma vitamin C (23 ± 2 μM) increased to 48 ± 6 μM ( P < 0.01) after treatment, but this was significantly less than that expected for healthy subjects (>80 μM). No significant changes in fasting glucose (156 ± 11 mg/dl), insulin (14 ± 2 μU/ml), SIClamp [2.71 ± 0.46 × 10−4 dl·kg−1·min−1/(μU/ml)], or forearm blood flow in response to ACh, SNP, or insulin were observed after vitamin C treatment. We conclude that high-dose oral vitamin C therapy, resulting in incomplete replenishment of vitamin C levels, is ineffective at improving endothelial dysfunction and insulin resistance in Type 2 diabetes.

Inhibition of acetylcholine-induced EDHF response by elevated glucose in rat mesenteric artery

The effects of high glucose on endothelium-derived hyperpolarizing factor (EDHF)-mediated relaxations of isolated rat mesenteric artery and the possible involvement of reactive oxygen species in these responses were investigated. After precontraction with phenylephrine (3 x 10(-8)-10(-7) M), acetylcholine (10(-8)-3 x 10(-6) M) and A 23187 (10(-8)-3 x 10(-6) M), a calcium ionophore, induced concentration-dependent relaxations in the presence of N(W)-nitro-l-arginine methyl ester (L-NAME) (10(-4) M) and indomethacin (10(-5) M). These relaxations were abolished in the presence of charybdotoxin (2 x 10(-7) M) plus apamin (10(-7) M) and were assumed to be mediated by EDHF. Effects of elevated glucose were examined by incubating the arterial rings for 6 h in Krebs-Henseleit solution containing 22.2 mM glucose. Under these conditions relaxation to acetylcholine was significantly attenuated but was unchanged when the tissues were incubated for 6 h in solution containing 11.1 mM mannitol used as hyperosmotic control. Addition of superoxide dismutase (SOD) (75 U/ml) and combination of SOD with catalase (200 U/ml) during incubation with high glucose significantly preserved the impairment of EDHF-mediated relaxations to acetylcholine. A 23187-induced endothelium-dependent relaxation was not affected by high glucose. Similarly, relaxations to pinacidil (10(-10)-10(-5) M) and to sodium nitroprusside (SNP) (10(-10)-3 x 10(-7) M) were also unchanged in the rings exposed to high glucose. These results suggest that in rat mesenteric arteries exposed to elevated glucose receptor-dependent EDHF-mediated relaxations (acetylcholine-induced) are impaired whereas receptor-independent ones (A 23187-induced) and responses to smooth muscle relaxants that exert their effects through mechanisms independent of endothelium are unaffected. Our findings lead us to propose that reactive oxygen species like superoxide ((.)O(2)(-)) and hydrogen peroxide (H(2)O(2)) do seem to play a role in the impairment of EDHF-mediated relaxations in the presence of elevated glucose.

DAF-FM (4-amino-5-methylamino-2',7'-difluorofluorescein) diacetate detects impairment of agonist-stimulated nitric oxide synthesis by elevated glucose in human vascular endothelial cells: reversal by vitamin C and L-sepiapterin

Elevated plasma glucose, as commonly seen in types I and II diabetes mellitus, is known to result in endothelial dysfunction, a condition characterized by a loss of nitric oxide (NO)-dependent regulation of vascular tone. In the present study, we have utilized a recently developed NO-sensitive fluorescent dye, DAF-FM (4-amino-5-methylamino-2',7'-difluorofluorescein) diacetate to directly examine the consequences of elevated glucose on agonist-evoked NO synthesis in cultured human vascular endothelial cells. Exposure of cells for 5 to 7 days to high (20 mM) external glucose markedly reduced NO production in response to ATP, histamine, or the calcium ionophore calcimycin A23187 compared with 5 and 10 mM glucose concentrations. However, high glucose did not affect agonist-evoked elevations in cytosolic-free calcium, as monitored by Fluo-3. The addition of vitamin C (150 microM) and L-sepiapterin (20 microM) for approximately 24 h to 20 mM glucose-treated cells improved stimulus-evoked NO synthesis but had no effect on cells exposed to either 5 or 10 mM glucose. Likewise, impaired NO production in high glucose-treated cells was largely reversed by exposure ( approximately 3 h) to superoxide dismutase. Cellular levels of endothelial nitric-oxide synthase protein were unaltered by elevated glucose treatment, and no further change was observed after the addition of vitamin C and l-sepiapterin. Taken together, the results of our study serve to directly explain at the cellular level how glucose-impaired NO production in human endothelial cells may be reversed by agents that are reported clinically to improve endothelium-dependent vasorelaxation in patients.

Effect of ascorbic acid treatment on endothelium-dependent and neurogenic relaxation of corpus cavernosum from middle-aged non-insulin dependent diabetic rats

AIMS

The purpose of the present study was to investigate functional responses and nitric oxide synthase activity in the corpus cavernosum of young control, middle-aged control and middle-aged non-insulin dependent diabetic rats.

METHODS

The animal groups were treated with ascorbic acid.

RESULTS

Acetylcholine-mediated endothelium-dependent relaxation of cavernosal tissue was significantly attenuated from a maximum of 58.0 +/- 4.1% (1 mmol, n = 10) in young rats to 44.3 +/- 1.6% in aged-matched controls (P < 0.05) and to 23.3 +/- 2.8% in non-insulin-dependent diabetes mellitus rats (P < 0.01). These deficits in acetylcholine responsiveness were completely prevented by ascorbic acid treatment. Non-adrenergic non-cholinergic relaxations evoked by electrical field stimulation (0.5-64.0 Hz) in the corpus cavernosum of middle-aged control and non-insulin dependent (NID) diabetic rats are blunted and were not restored by ascorbic acid. The histochemical findings demonstrated a decrease of nicotinamide adenine dinucleotide phosphate-diaphorase staining in the cavernosal tissue obtained from middle-aged control rats and middle-aged diabetic rats.

CONCLUSION

Partial correction by ascorbic acid may suggest the importance of reactive oxygen species and a therapeutic approach in impotent NID diabetic men.

The importance of tight glycemic control

Macrovascular complications of diabetes are the leading cause of morbidity and mortality in patients with diabetes and may begin well before diabetes is diagnosed. The precise mechanism of how postprandial hyperglycemia contributes to the pathogenesis of cardiovascular disease is not fully known but may be a result of direct effects on the vasculature. Several epidemiologic studies have suggested that increased glycemic exposure, especially postchallenge or postprandial hyperglycemia, is an independent risk factor for macrovascular disease with no apparent upper or lower threshold. Evidence is emerging that this association is also present in the prediabetic and nondiabetic states. In fact, therapies targeting postprandial hyperglycemia have shown reductions in cardiovascular events in patients with impaired glucose tolerance. Meal-related self-monitoring of blood glucose can inform patients and their healthcare providers about postprandial glycemic excursions so that diet, exercise, or medications can be adjusted.

Effect of ascorbic acid on microcirculation in patients with Type II diabetes: a randomized placebo-controlled cross-over study

Manifestations of vascular disease, including microvascular changes, constitute the major part of the morbidity and mortality in diabetic patients. Oxidative stress has been suggested to play an important role in the vascular dysfunction of diabetic patients. Furthermore, epidemiological observations indicate a beneficial effect of an increased dietary intake of antioxidants. The present study tested the hypothesis that the antioxidant ascorbic acid influences microcirculatory function in patients with Type II diabetes. Patients with Type II diabetes were treated with 1 g of ascorbic acid three times a day for 2 weeks in a randomized placebo-controlled double-blind cross-over design. Microvascular reactivity was assessed by vital capillaroscopy and PRH (post-occlusive reactive hyperaemia). hs-CRP (high-sensitivity C-reactive protein), IL-6 (interleukin-6), IL-1ra (interleukin-1 receptor antagonist) and ox-LDL (oxidized low-density lipoprotein) were analysed. The results showed no significant change in microvascular reactivity assessed after 2 weeks of ascorbic acid treatment. TtP (time to peak) was 12.0+/-3.3 s before and 11.2+/-3.5 s after ascorbic acid (n=17). In comparison, TtP was 11.5+/-2.9 s before and 10.6+/-2.8 s after placebo (not significant). IL-1ra, IL-6, hs-CRP and ox-LDL did not change significantly after ascorbic acid, neither as absolute or relative values. In conclusion, in contrast with some studies reported previously, we could not demonstrate an effect of continuous oral treatment with ascorbic acid on microvascular reactivity assessed at the level of individual capillaries. Furthermore, we found no indication of an effect on inflammatory cytokines or ox-LDL.

Flow-mediated vasodilation: a diagnostic instrument, or an experimental tool?

Brachial arterial flow-mediated dilation (FMD), assessed by high-resolution ultrasonography, reflects endothelium-dependent vasodilator function. FMD is diminished in patients with atherosclerosis and with coronary risk factors, and improves with risk-reduction therapy. Therefore, the measurement of FMD can be a good prognostic instrument in preventive cardiology, is useful to predict short-term postoperative cardiovascular events in a high-risk population and to assess long-term cardiovascular risk in a lower risk population, and is an excellent experimental tool to detect changes in endothelial function after new therapeutic interventions. In this review article, the pathophysiology of FMD, based on reactive hyperemia, is extensively discussed. Furthermore, an overview is given of the actual clinical indications of FMD measurement.

Mechanisms underlying endothelial dysfunction in diabetes mellitus: therapeutic implications

Hyperglycemia is the major causal factor in the development of endothelial dysfunction in patients with diabetes mellitus. Although the mechanisms underlying this phenomenon are likely to be multifactorial, recent in vivo and in vitro studies have indicated a crucial role of the diacylglycerol (DAG)-protein kinase C (PKC) pathway in mediating this phenomenon. PKC may have multiple adverse effects on vascular function, including the activation of superoxide-producing enzymes such as the nicotinamide adenine dinicleotide phosphate (NADPH) oxidase as well as increased expression of a dysfunctional, superoxide-producing, uncoupled endothelial nitric oxide synthase (NOS III). PKC-mediated superoxide production may inactivate nitric oxide (NO) derived from endothelial NOS III, but also may inhibit the activity and/or expression of the NO downstream target, the soluble guanylyl cyclase. Among the different isoforms of PKC, mainly the beta-isoforms have been shown to be activated. Recent studies with selective (isoform-specific) and non-selective PKC inhibitors show that they are able to beneficially influence glucose-induced endothelial dysfunction in experimental animal models as well as in patients, pointing to the therapeutic potential of these compounds in the prevention and treatment of vascular complications of diabetes.

Acute hyperglycemia does not affect the reactivity of coronary microcirculation in humans

OBJECTIVE

There is some evidence that acute hyperglycemia (H) may cause vascular dysfunction in normal subjects. This study investigates whether acute, short-term H affects coronary vasodilatory function in healthy subjects.

DESIGN

Diastolic peak flow velocity in the left anterior descending coronary artery was measured at rest and after dipyridamole (0.56 mg/kg over 4 min) using transthoracic color Doppler echocardiography in 13 healthy men. Coronary flow reserve (CFR) was defined as the ratio of dipyridamole-induced coronary peak diastolic to resting peak diastolic flow velocity. CFR was measured both in euglycemia (E) and after 3 h H ( approximately 14 mmol/liter) by a variable infusion of glucose and octreotide (0.4 mg/h) to prevent increase in insulin concentration.

RESULTS

Fasting plasma glucose increased to 14.3 +/- 0.33 mmol/liter during the study and maintained variability within less than 10%. Plasma insulin remained nearly stable during H. Resting diastolic flow velocity was 18.5 +/- 0.6 cm/sec in E and increased to 20.0 +/- 0.7 cm/sec during H (P < 0.005). Dipyridamole infusion produced a marked increase in coronary flow velocity, which reached values of 50.8 +/- 2.9 cm/sec in E and 51.8 +/- 2.1 cm/sec in H (P = not significant). CFR was 2.78 +/- 0.16 in E and 2.59 +/- 0.12 in H (P = not significant).

CONCLUSION

Our study indicates that short-term hyperglycemia does not affect the vasodilatory response of coronary microcirculation in healthy subjects.

Role of the sympathetic and renin angiotensin systems in the glucose-induced increase of blood pressure in rats

The pressor effect induced by acute hyperglycemia is not well understood, therefore, it was of interest to study the effect of intravenous glucose infusion on the mean arterial pressure of anesthetized Wistar rats. Animals received glucose (100 mg/kg/min, i.v.), mannitol or saline during 30 min, but only glucose increased the mean arterial pressure (about 40 mm Hg), plasma glucose, insulin and nitric oxide (NO). Pretreatment with reserpine or indorenate (a central antihypertensive) inhibited completely the pressor effect of glucose. Reserpine also decreased the plasma NO levels. Pretreatment with ramipril or with streptozotocin decreased the late phase of the glucose-induced pressor response and the NO levels, the latter treatment also abolishes insulin plasma concentrations. The present results suggest that the pressor effect induced by glucose has an early phase due to an increase of efferent sympathetic discharges and a delayed phase produced by the activation of the renin angiotensin system.

PRETREATMENT WITH INTRAVENOUS ASCORBIC ACID PRESERVES ENDOTHELIAL FUNCTION DURING ACUTE HYPERGLYCAEMIA (R1)

1. Acute hyperglycaemia may impair endothelial function. Ascorbic acid (AA), administered intra-arterially, has been reported to improve endothelium-dependent vasodilatation during a forearm hyperglycaemic clamp. Using a randomized, double-blind, placebo-controlled, cross-over study, we investigated the potential for intravenous ascorbic acid to modify the endothelial response to acute systemic hyperglycaemia in humans. 2. Nine healthy male volunteers were recruited from the hospital staff. Endothelial function was determined by measuring the forearm blood flow responses to intrabrachial infusions of endothelium-dependent (ED) and endothelium-independent (EID) vasodilators. The endothelial function index (EFI) was derived from the ratio of ED and EID vasodilatation. Haemodynamic and endothelial function measurements were performed at baseline and then repeated 2 h after a systemic hyperglycaemic clamp (14 mmol/L). The subjects, studied on two separate occasions, were randomized to placebo or 2 g intravenous ascorbic acid prior to the initiation of hyperglycaemia. 3. After systemic hyperglycaemia with placebo pretreatment, the EFI fell from 1.08 +/- 0.21 to 0.74 +/- 0.13 (difference (95% confidence interval): 0.34 (0.20, 0.47); P < 0.001). When subjects were pretreated with ascorbic acid, the EFI was not affected by hyperglycaemia (1.11 +/- 0.21 to 1.12 +/- 0.17; P = 0.938). This difference between placebo and ascorbic acid was significant (P < 0.001). Plasma ascorbate concentrations decreased during hyperglycaemia and correlated directly with the reduction in the EFI (r = 0.798; P < 0.001). 4. Pretreatment with an intravenous bolus of ascorbic acid can prevent endothelial dysfunction during acute systemic hyperglycaemia. Therefore, ascorbic acid may have potential therapeutic use in clinical situations where acute hyperglycaemia may be a complication.

The effect of glucose and mental stress on cutaneous microvascular endothelial function

Glucose and mental stress, independently, have been found to impair arterial endothelial function (an indicator of vascular health). The present study sought to determine whether the combination of glucose and stress would have a greater effect on microvascular endothelial function than each on its own. To assess endothelial function, surges in skin blood flow (reactive hyperemia), following the release of cuff pressure to the upper arm at 200 mmHg for 5 min, were measured with laser Doppler flowmetry in 40 young, healthy females. Endothelial function did not change significantly following a 5-min mathematics stressor or the consumption of 75 g of glucose. However, the combination of glucose and stress impaired endothelium-dependent dilatation 30 min after glucose consumption. These findings suggest that combinations of vascular risk factors may be more threatening to cardiovascular health than singularly occurring factors.

Non-esterified fatty acids impair endothelium-dependent vasodilation in rat mesenteric resistance vessels

Elevated circulating levels of NEFAs (non-esterified fatty acids) are associated with states of insulin resistance and increased risk of vascular disease. Previous animal and human studies have demonstrated NEFA-induced endothelial dysfunction of large conduit arteries, reversible by the antioxidant ascorbic acid. We therefore investigated the effect of NEFAs on carbachol-induced endothelium-dependent vasodilation of rat resistance arteries in vitro using the technique of wire myography. In addition, we investigated the effect of co-incubation of NEFAs and ascorbic acid. Cumulative concentration-response curves to carbachol (endothelium-dependent vasodilation) and SNAP (S-nitroso-N-acetyl-DL-penicillamine; endothelium-independent vasodilation) were constructed. Those to carbachol were repeated following a 30 min incubation with either oleic acid (10(-4) M) or palmitic acid (10(-4) M), demonstrating significant impairment of endothelium-dependent vasodilation with both [P<0.05, comparison of pD2 values (the negative log concentration of agonist required to effect a 50% response)]. A cumulative concentration-response curve to carbachol was repeated following co-incubation with palmitic acid (10(-4) M) and the antioxidant ascorbic acid (10(-5) M), demonstrating an abolition of the previously observed endothelial dysfunction induced by palmitic acid. There was no impairment of vasodilation to SNAP following NEFA incubation. We conclude that NEFAs directly impair endothelial function in rat resistance arteries via an increase in oxidative stress at the vascular endothelium.

Vitamin C-induced loss of redox-dependent viability in lung microvascular endothelial cells

Recent clinical trials have shown that vitamin C, at pharmacological concentrations (milligram to approximately gram), upon infusion into circulation, modulates vasodilation and vascular tone in humans. This also results in the elevated concentrations of vitamin C in circulation in the millimolar range. Here, it was hypothesized that vitamin C at pharmacological concentrations (millimolar) would induce oxidative stress and cause loss of redox-dependent cell viability in vascular endothelial cells (ECs). To test the hypothesis, bovine lung microvascular ECs (BLMVECs) in monolayer cultures were exposed to vitamin C (0-10 mM) for different time periods (0-2 h). Electron paramagnetic resonance spectroscopy revealed the intracellular formation of ascorbate free radical in a dose- and time-dependent fashion. Vitamin C also induced formation of intracellular reactive oxygen species in a dose-dependent fashion. It was observed that vitamin C induced morphological alterations and loss of cell viability in a dose- and time-dependent fashion, as measured by light microscopy and Alamar Blue redox cell viability assay, respectively. Vitamin C analogues failed to induce such changes. Vitamin C depleted cellular GSH levels in a dose-dependent fashion, suggesting that vitamin C altered thiol-redox status in BLMVECs. Antioxidants, intracellular iron chelator, and catalase protected cells against vitamin C-induced loss of redox-dependent cell viability, confirming the role of hydrogen peroxide and iron during redox cycling of vitamin C. These results, for the first time in detail, established that vitamin C at pharmacological doses induced oxidative stress and loss of redox-dependent cell viability in microvascular ECs.

Postprandial hyperglycemia and diabetes complications: is it time to treat?

Increasing evidence suggests that the postprandial state is a contributing factor to the development of atherosclerosis. In diabetes, the postprandial phase is characterized by a rapid and large increase in blood glucose levels, and the possibility that the postprandial "hyperglycemic spikes" may be relevant to the onset of cardiovascular complications has recently received much attention. Epidemiological studies and preliminary intervention studies have shown that postprandial hyperglycemia is a direct and independent risk factor for cardiovascular disease (CVD). Most of the cardiovascular risk factors are modified in the postprandial phase in diabetic subjects and directly affected by an acute increase of glycemia. The mechanisms through which acute hyperglycemia exerts its effects may be identified in the production of free radicals. This alarmingly suggestive body of evidence for a harmful effect of postprandial hyperglycemia on diabetes complications has been sufficient to influence guidelines from key professional scientific societies. Correcting the postprandial hyperglycemia may form part of the strategy for the prevention and management of CVDs in diabetes.

Oxidative Stress and Antioxidant Treatment in Diabetes

The many studies on oxidative stress, antioxidant treatment, and diabetic complications have shown that oxidative stress is increased and may accelerate the development of complications through the metabolism of excessive glucose and free fatty acids in diabetic and insulin-resistant states. However, the contribution of oxidative stress to diabetic complications may be tissue-specific, especially for microvascular disease that occurs only in diabetic patients but not in individuals with insulin resistance without diabetes, even though both groups suffer from oxidative stress. Although antioxidant treatments can show benefits in animal models of diabetes, negative evidence from large clinical trials suggests that new and more powerful antioxidants need to be studied to demonstrate whether antioxidants can be effective in treating complications. Furthermore, it appears that oxidative stress is only one factor contributing to diabetic complications; thus, antioxidant treatment would most likely be more effective if it were coupled with other treatments for diabetic complications.

Acute effects of glucose and insulin on vascular endothelium

AIMS/HYPOTHESIS

Chronic exposure to high concentrations of glucose has consistently been demonstrated to impair endothelium-dependent, nitric oxide (NO)-mediated vasodilation. In contrast, several clinical investigations have reported that acute exposure to high glucose, alone or in combination with insulin, triggers vasodilation. The aim of this study was to examine whether elevated glucose itself stimulates endothelial NO formation or enhances insulin-mediated endothelial NO release.

METHODS

We measured NO release and vessel tone ex vivo in porcine coronary conduit arteries (PCAs). Intracellular Ca(2+) was monitored in porcine aortic endothelial cells (PAECs) by fura-2 fluorescence. Expression of the Na(+)/glucose cotransporter-1 (SGLT-1) was assayed in PAECs and PCA endothelium by RT-PCR.

RESULTS

Stimulation of PCAs with D: -glucose, but not the osmotic control L: -glucose, induced a transient increase in NO release (EC(50) approximately 10 mmol/l), mediated by a rise in intracellular Ca(2+) levels due to an influx from the extracellular space. This effect was abolished by inhibitors of the plasmalemmal Na(+)/Ca(2+) exchanger (dichlorobenzamil) and the SGLT-1 (phlorizin), which was found to be expressed in aortic and coronary endothelium. Alone, D: -glucose did not relax PCA, but did augment the effect of insulin on NO release and vasodilation.

CONCLUSIONS/INTERPRETATION

An increased supply of extracellular D: -glucose appears to enhance the activity of the endothelial isoform of nitric oxide synthase by increasing intracellular Na(+) concentrations via SGLT-1, which in turn stimulates an extracellular Ca(2+) influx through the Na(+)/Ca(2+) exchanger. This mechanism may be responsible for glucose-enhanced, insulin-dependent increases in tissue perfusion (including coronary blood-flow), thus accelerating glucose extraction from the blood circulation to limit the adverse vascular effects of prolonged hyperglycaemia.

Acute hyperglycaemia: a 'new' risk factor during myocardial infarction

High admission blood glucose levels after acute myocardial infarction are common and are associated with an increased risk of death in subjects with and without diabetes. In this review, the possible toxic action of acute hyperglycaemia is discussed in order to explain the worse prognosis in subjects with myocardial infarction and concomitant hyperglycaemia. The possible usefulness of intensive insulin treatment is also discussed.

Vitamin C treatment reduces transcapillary escape rate of albumin in type 1 diabetes

BACKGROUND: Latent tissue scurvy in clinical and experimental ascorbic acid (AA) deficiency resembles diabetic microangiopathy as reflected in capillary hyperperfusion and increased transcapillary escape rate (TER), von Willebrand factor (vWf), and capillary fragility (CF). We aimed to investigate the possible clinical impact of the low plasma AA level observed in type 1 diabetes mellitus. METHODS: Twenty normoalbuminuric patients with retinopathy were included in a randomized, double-blinded, placebo-controlled 6-month study with AA (6 g/day; n=10, mean age+/-S.D. 35.3+/-8.5 years, diabetes duration 17.2+/-3.3 years) or placebo (n=10; mean age 37.8+/-6.6 years, diabetes duration 18.4+/-1.7 years). RESULTS: An inverse correlation between log plasma AA (HPLC method) and TER of (125)I-labelled albumin was found (r=-0.66, p=0.002). TER decreased in the AA-treated group from 6.8+/-1.0 to 5.4+/-1.5%/h compared to the unchanged placebo group (from 5.6+/-1.5 to 5.9+/-1.1%/h; p=0.031). The CF (capillary resistance test) decreased in the AA group compared to the placebo group (p=0.028), while vWf, fibrinogen and fibronectin levels, and glomerular filtration rate (clearance of (125)I-iothalamate) remained unchanged. CONCLUSIONS: The results suggest that a low plasma AA level might be associated (pathogenetic?) with development of microangiopathy in type 1 diabetes mellitus and points to a possible treatment modality.

Low micromolar concentrations of copper augment the impairment of endothelium-dependent relaxation of aortae from diabetic rabbits

Both diabetes mellitus (DM) and elevated plasma copper concentrations are risk factors for cardiovascular disease (CVD). DM is associated with impaired endothelial nitric oxide (NO) and with excess superoxide (O2*-) formation. Copper is also elevated in DM and is also associated with the generation of O2*-. To explore possible interactions between DM and copper, the effect of exogenous copper (CuCl2) on endothelium-dependent relaxation and cyclic guanosine monophosphate (GMP) formation was investigated in aortae from diabetic rabbits. Rabbits were rendered diabetic by intravenous injection of alloxan. Six months after induction of DM, the aortae were excised, cut into rings, and mounted in an organ bath for isometric measurement of acetylcholine (Ach)-evoked relaxation in rings precontracted with phenylephrine (PE). In parallel studies, cyclic (c)GMP formation by aortic rings following stimulation with Ach, calcium ionophore A23187 (A23187) and sodium nitroprusside (SNP) was assessed using radioimmunoassay. The effect of copper on these parameters was then studied using the same methods. Ach-evoked relaxation and Ach- and A23187-evoked cGMP formation were significantly impaired in aortae from diabetic rabbits compared to controls, effects that were reversed with superoxide dismutase (SOD) and catalase (CAT). In contrast, there were no significant differences in SNP-stimulated relaxation or cGMP formation in aortae from diabetic rabbits compared to controls. Copper (1 to 10 micromol/L) promoted a further significant inhibition of Ach-stimulated relaxation in aortae from diabetic but not control rabbits. This reduction by copper was again reversed by SOD and CAT. We conclude that copper augments the reduction of NO bioavailability, which is already impaired in aortae from diabetic rabbits due to excess production of O2*- and H2O2. These results indicate that patients with DM may be susceptible to copper-mediated vasculopathy at much lower concentrations than those that promote vasculopathy in nondiabetic patients.

Acetylcholine-Induced Relaxation of Rabbit Basilar Artery In Vitro Is Rapidly Reduced by Reactive Oxygen Species in Acute Hyperglycemia

We examined the effects of acute hyperglycemia on the function of rabbit cerebral arteries in vitro. It was hypothesized that increased formation of reactive oxygen species (ROS) could occur, which could explain how hyperglycemia aggravates certain pathologic situations such as cerebral ischemia. Three-millimeter basilar artery segments were incubated in either normoglycemic (NG, 5.5 mM D-glucose) or hyperglycemic (HG, 25 mM D-glucose) solution containing 3.10(-6) M indomethacin. After 90 minutes equilibration, a test (=T1) of relaxation to acetylcholine (Ach) at three concentrations was performed on histamine-precontracted segments. Three further identical tests were performed (T2-T4), after 30-minute rest periods. Ach responses in NG solution were stable, whereas those in HG solution, although greater at T1, fell progressively from one test to the next (P < 0.0001 versus NG), whereas nitroprusside responses did not change. In separate experiments, this time-dependent fall in Ach responses was significantly prevented by superoxide dismutase (SOD) plus catalase (P = 0.0003), but not by SOD alone. It was also significantly prevented by the NAD(P)H oxidase inhibitors diphenyleneiodonium (P = 0.020) and apocynin (P = 0.0179), but not by allopurinol (xanthine oxidase inhibitor). Control experiments with l-glucose ruled out a hyperosmotic or non-specific glucose effect. We conclude that, in HG solution in vitro, rapidly increasing ROS production largely derived from NAD(P)H oxidase reduced relaxation to acetylcholine. The rapidity of this effect suggests that the function of these arteries may be affected during brief periods of hyperglycemia in vivo.

Protective effects of ascorbic acid on arterial hemodynamics during acute hyperglycemia

Mortality increases when acute coronary syndromes are complicated by stress-induced hyperglycemia. Early pulse wave reflection can augment central aortic systolic blood pressure and increase left ventricular strain. Altered pulse wave reflection may contribute to the increase in cardiac risk during acute hyperglycemia. Chronic ascorbic acid (AA) supplementation has recently been shown to reduce pulse wave reflection in diabetes. We investigated the in vivo effects of acute hyperglycemia, with and without AA pretreatment, on pulse wave reflection and arterial hemodynamics. Healthy male volunteers were studied. Peripheral blood pressure (BP) was measured at the brachial artery, and the SphygmoCor pulse wave analysis system was used to derive central BP, the aortic augmentation index (AIx; measure of systemic arterial stiffness), and the time to pulse wave refection ( Tr; measure of aortic distensibility) from noninvasively obtained radial artery pulse pressure (PP) waveforms. Hemodynamics were recorded at baseline and then every 30 min during a 120-min systemic hyperglycemic clamp (14 mmol/l). The subjects, studied on two separate occasions, were randomized in a double-blind, crossover manner to placebo or 2 g intravenous AA before the initiation of hyperglycemia. During hyperglycemia, AIx increased and Tr decreased. Hyperglycemia did not change peripheral PP but did magnify central aortic PP and diminished the normal physiological amplification of PP from the aorta to the periphery. Pulse wave reflection, as assessed from peripheral pulse wave analysis, is enhanced during acute hyperglycemia. Pretreatment with AA prevented the hyperglycemia-induced hemodynamic changes. By protecting hemodynamics during acute hyperglycemia, AA may have therapeutic use.

Free fatty acids exert a greater effect on ocular and skin blood flow than triglycerides in healthy subjects

BACKGROUND

Free fatty acids (FFAs) and triglycerides (TGs) can cause vascular dysfunction and arteriosclerosis. Acute elevation of plasma FFA and TG concentration strongly increase ocular and skin blood flow. This study was designed to discriminate whether FFA or TG independently induce hyperperfusion by measuring regional and systemic haemodynamics.

METHODS

In a balanced, randomized, placebo-controlled, double-blind, three-way, crossover study nine healthy subjects received either Intralipid (Pharmacia and Upjohn, Vienna, Austria) with heparin, Intralipid alone or placebo control. Pulsatile choroidal blood flow was measured with laser interferometry, retinal blood flow and retinal red blood cell velocity with laser Doppler velocimetry, and skin blood flow with laser Doppler flowmetry during an euglycaemic insulin clamp.

RESULTS

A sevenfold increase of FFA during Intralipid/heparin infusion was paralleled by enhanced choriodal, retinal, and skin blood flow by 17 +/- 4%, 26 +/- 5% (P < 0.001), and 47 +/- 19% (P = 0.03) from baseline, respectively. In contrast, a mere threefold increase of FFA by infusion of Intralipid alone did not affect outcome parameters, despite the presence of plasma TG levels of 250-700 mg dL(-1); similar to those obtained during combined Intralipid/heparin infusion. Systemic haemodynamics were not affected by drug infusion.

CONCLUSIONS

Present findings demonstrate a concentration-dependent increase in ocular and skin blood flow by FFA independently of elevated TG plasma concentrations. As vasodilation of resistance vessels occur rapidly, FFA may play a role in the development of continued regional hyperperfusion and deteriorate microvascular function.

Microvascular dysfunction after transient high glucose is caused by superoxide-dependent reduction in the bioavailability of NO and BH(4)

We hypothesized that transient high-glucose concentration interferes with mediation by nitric oxide (NO) of flow-induced dilation (FID) of arterioles due to enhanced production of superoxide. In isolated, pressurized (80 mmHg) rat gracilis muscle arterioles ( approximately 130 microm) after transient high-glucose treatment (tHG; incubation with 30 mM glucose for 1 h), FID was reduced (maximum: control, 38 +/- 4%; after tHG, 17 +/- 3%), which was not further diminished by the NO synthase (NOS) inhibitor N(omega)-nitro-l-arginine methyl ester (l-NAME; 18 +/- 2%). Correspondingly, an enhanced polyethylene-glycol-SOD (PEG-SOD)-sensitive superoxide production was detected after tHG in carotid arteries by dihydroethydine (DHE) staining. Presence of PEG-SOD during tHG prevented the reduction of FID (41 +/- 3%), which could be inhibited by l-NAME (20 +/- 4%). Administration of PEG-SOD after tHG did not prevent the reduction of FID (22 +/- 3%). Sepiapterin, a precursor of the NO synthase cofactor tetrahydrobiopterin (BH(4)), administered during tHG did not prevent the reduction of FID (maximum, 15 +/- 5%); however, it restored FID when administered after tHG (32 +/- 4%). Furthermore, inhibition of either glycolysis by 2-deoxyglucose or mitochondrial complex II by 2-thenoyltrifluoroacetone reduced the tHG-induced DHE-detectable enhanced superoxide production in carotid arteries and prevented FID reduction in arterioles (39 +/- 5 and 35 +/- 2%). Collectively, these findings suggest that in skeletal muscle arterioles, a transient elevation of glucose via its increased metabolism, elicits enhanced production of superoxide, which decreases the bioavailability of NO and the level of the NOS cofactor BH(4), resulting in a reduction of FID mediated by NO.

Oxidative stress and diabetic vascular complications

Vascular complications of diabetes represent the leading cause of morbidity and mortality in affected patients. Production of reactive oxygen species is increased in diabetic patients, especially in those with poor glycemic control. Reactive oxygen species affect vascular smooth muscle cell growth and migration, endothelial function, including abnormal endothelium-dependent relaxation and expression of a proinflammatory phenotype, and modification of the extracellular matrix. All of these events contribute to the development of diabetic microvascular and macrovascular complications, suggesting that the sources of reactive oxygen species and the signaling pathways that they modify may represent important therapeutic targets.

Hyperglycemia-induced oxidative stress in diabetic complications

Reactive oxygen species are increased by hyperglycemia. Hyperglycemia, which occurs during diabetes (both type 1 and type 2) and, to a lesser extent, during insulin resistance, causes oxidative stress. Free fatty acids, which may be elevated during inadequate glycemic control, may also be contributory. In this review, we will discuss the role of oxidative stress in diabetic complications. Oxidative stress may be important in diabetes, not just because of its role in the development of complications, but because persistent hyperglycemia, secondary to insulin resistance, may induce oxidative stress and contribute to beta cell destruction in type 2 diabetes. The focus of this review will be on the role of oxidative stress in the etiology of diabetic complications.

4-Hydroxy tempol-induced impairment of mitochondrial function and augmentation of glucose transport in vascular endothelial and smooth muscle cells

The water-soluble and cell permeable nitroxide derivative 4-hydroxy tempol (TPL) has been shown to reduce or ameliorate oxidative stress-induced dysfunction and damage in vascular endothelial cells. We studied the effects of TPL on glucose transport and metabolism in bovine aortic endothelial (VEC) and smooth muscle cells (VSMC) under normal and high glucose conditions. Normally, these cells operate an autoregulatory protective mechanism that limits the rate of glucose transport under hyperglycemic conditions by decreasing the cell content of their typical glucose transporter GLUT-1 mRNA and protein as well as its plasma membrane abundance. TPL augmented the rate of glucose transport both under normo- and hyperglycemic conditions by increasing GLUT-1 mRNA and protein content and its plasma membrane abundance in both types of cells, leading to an increased flux of glucose into the cells. These effects were found related to ROS-generating and oxidant activities of TPL and to a decreased rate of mitochondrial ATP production under both normo- and hyperglycemic conditions. Since impaired mitochondrial functions, and in particular decreased rate of ATP production, augment the expression of GLUT-1 protein and glucose transport and metabolism, we suggest that the stimulatory effects of TPL in vascular cells results from its unfavorable interactions in the mitochondrion. It is therefore suggested that effects of TPL in cells of cardiovascular system be evaluated in parallel to its adverse effects on glucose and energy metabolism.

Vascular endothelium and inflammatory process, in patients with combined Type 2 diabetes mellitus and coronary atherosclerosis: the effects of vitamin C

AIMS

Type 2 diabetes mellitus (DM) and coronary artery disease (CAD) are both associated with endothelial dysfunction and elevated oxidative and inflammatory state. We examined the effect of vitamin C on endothelial function and levels of soluble vascular cell adhesion molecule (sVCAM-1), interleukin-6 (IL-6) and tumour necrosis factor (TNF-alpha), in DM patients with or without CAD and in non-diabetic subjects.

METHODS

Thirty-seven patients with DM + CAD, 17 patients with DM without CAD and 21 non-diabetic subjects were divided into groups receiving vitamin C 2 g/day or no anti-oxidant for 4 weeks. Forearm blood flow was determined using venous occlusion gauge-strain plethysmography. Forearm vasodilatory response to reactive hyperemia was considered as index of endothelium-dependent dilation.

RESULTS

Baseline levels of IL-6 and TNF-alpha were significantly higher in patients with DM + CAD compared with patients with DM (P < 0.01) or non-diabetic subjects (P < 0.01). IL-6 and TNF-alpha levels were also higher in DM compared with non-diabetic subjects (P < 0.05). sVCAM-1 levels were lower in non-diabetic controls compared with DM + CAD (P < 0.05) or DM (P < 0.05). Reactive hyperaemia was higher in non-diabetic controls compared with DM + CAD (P < 0.001) or DM (P < 0.001). Vitamin C significantly increased reactive hyperaemia only in the DM + CAD group, while it had no effect on serum levels of sVCAM-1, TNF-alpha and IL-6 in any of the groups.

CONCLUSIONS

Type 2 diabetes mellitus is associated with impaired endothelial function and increased levels of TNF-alpha, IL-6 and sVCAM-1, especially in patients with DM and CAD. Vitamin C significantly increased forearm vasodilatory response to reactive hyperaemia only in patients with combined DM and CAD.

Endothelial function and postprandial lipemia

It is widely recognised that post-prandial lipoproteins play a role in the development of atherosclerosis, but the mechanisms underlying this role are unclear. An attractive working hypothesis is that the pathogenetic link is endothelial dysfunction. The available data seem to corroborate this theory and recognise triggering by oxidative stress, but some of the evidence is still contradictory.

Oral L-arginine and vitamins E and C improve endothelial function in women with type 2 diabetes

Endothelial dilator function is impaired in people with type 2 diabetes mellitus (T2DM). Prior research indicates that this can be improved with intravenous administration of ascorbate or L-arginine, but whether these agents have this effect when administered by the clinically practical oral route is unknown. To investigate this question, 10 premenopausal women with T2DM and 10 healthy, premenopausal, non-diabetic women received, in random sequence, a 1-week administration of oral L-arginine (9 g daily) or vitamins E (1800 mg) and C (1000 mg) with an intervening 1-week washout period. Flow-mediated brachial artery dilation (FMD) was measured by ultrasonography and forearm blood flow was measured by plethysmography before and following blood pressure cuff-induced forearm ischemia before and after each week of treatment. At baseline, the women with T2DM had lesser FMD responses (0.028 +/- 0.006 cm vs 0.056 +/- 0.008 cm, p < 0.05). Post-ischemic forearm hyperemia was reduced at baseline in T2DM compared with controls (16.4 +/- 1.8 vs 26.0 +/- 1.4 ml 100 ml(-1) min(-1), p < 0.05). Administration of L-arginine caused a 50 +/- 12% increase in FMD in T2DM (p < 0.05) and raised post-ischemic forearm blood flow by 29 +/- 8% (p < 0.05). No significant changes were seen in controls. Administration of vitamins E and C in women with T2DM produced an increase in the brachial artery diameter response of 79 +/- 15% (p < 0.05), but did not significantly increase the hyperemic blood flow response (p = NS). No significant changes in the responses of controls from pre to post vitamin administration were observed. We concluded that administration of two types of oral agents improved measures of endothelial function in people with T2DM.

Measuring reactive species and oxidative damage in vivo and in cell culture: how should you do it and what do the results mean?

Free radicals and other reactive species (RS) are thought to play an important role in many human diseases. Establishing their precise role requires the ability to measure them and the oxidative damage that they cause. This article first reviews what is meant by the terms free radical, RS, antioxidant, oxidative damage and oxidative stress. It then critically examines methods used to trap RS, including spin trapping and aromatic hydroxylation, with a particular emphasis on those methods applicable to human studies. Methods used to measure oxidative damage to DNA, lipids and proteins and methods used to detect RS in cell culture, especially the various fluorescent "probes" of RS, are also critically reviewed. The emphasis throughout is on the caution that is needed in applying these methods in view of possible errors and artifacts in interpreting the results.

The two faces of endothelial nitric oxide synthase in the pathophysiology of atherosclerosis

In the endothelium, nitric oxide (NO) is constitutively generated from the conversion of L-arginine to L-citrullin by the enzymatic action of endothelial NO synthase (eNOS). An impairment of endothelium-dependent relaxation (EDR) is present in atherosclerotic vessels even before vascular structural changes occur, and represents the reduced eNOS-derived NO activity. Because of its multiple biological actions, NO from eNOS is believed to act as an anti-atherogenic molecule. On the other hand, there is increased production of superoxide in atherosclerotic vessels, which promotes atherogenesis. Recently it is revealed that eNOS becomes dysfunctional and produces superoxide rather than NO under various pathological conditions in which tissue levels of BH4 are reduced. The pathological role of dysfunctional eNOS has attracted attentions in vascular disorders including atherosclerosis, in which abnormal pteridine metabolisms in vascular tissue including decreased BH4 levels and increased BH2 levels have been demonstrated. The presence of dysfunctional eNOS may not only impair EDR but also accelerate lesion formation in atherosclerotic vessels. This review focuses on two faces of eNOS as both an NO- as well as superoxide-producing enzyme depending on tissue pteridine metabolisms in the pathophysiology of atherosclerosis.

Forearm vascular control during acute hyperglycemia in healthy humans

The vascular endothelium is a site of pathological changes in patients with diabetes mellitus that may be related to severe chronic hyperglycemia. However, it is unclear whether transient hyperglycemia alters vascular function in an otherwise healthy human forearm. To test the hypothesis that acute, moderate hyperglycemia impairs endothelium-dependent forearm vasodilation, we measured vasodilator responses in 25 healthy volunteers (11 F, 14 M) assigned to one of three protocols. In protocol 1, glucose was varied to mimic a postprandial pattern (i.e., peak glucose approximately 11.1 mmol/l) commonly observed in individuals with impaired glucose tolerance. Protocol 2 involved 6 h of mild hyperglycemia (approximately 7 mmol/l). Protocol 3 involved 6 h of euglycemia. Glucose concentration was maintained with a variable systemic glucose infusion. Insulin concentrations were maintained at approximately 65 pmol/l by means of a somatostatin and "basal" insulin infusion. Glucagon and growth hormone were replaced at basal concentrations. Forearm blood flow (FBF) was calculated from Doppler ultrasound measurements at the brachial artery. In each protocol, FBF dose responses to intrabrachial acetylcholine (ACh) and sodium nitroprusside (NTP) were assessed at baseline and at 60, 180, and 360 min of glucose infusion. Peak endothelium-dependent vasodilator responses to ACh were not diminished by hyperglycemia in any trial. For example, peak responses to ACh during protocol 2 were 307 +/- 47 ml/min at euglycemic baseline and 325 +/- 52, 353 +/- 65, and 370 +/- 70 ml/min during three subsequent hyperglycemic trials (P = 0.46). Peak endothelium-independent responses to NTP infusion were also unaffected. We conclude that acute, moderate hyperglycemia does not cause short-term impairment of endothelial function in the healthy human forearm.

The post-prandial state in Type 2 diabetes and endothelial dysfunction: effects of insulin aspart

OBJECTIVE

Recently, much attention has been focused on the possibility that the post-prandial state may be a cardiovascular risk factor in diabetes. The aim of the present study was to evaluate whether the post-prandial state is associated with endothelial dysfunction in patients with diabetes and to explore the effect on this aspect of managing post-prandial hyperglycaemia by insulin aspart.

RESEARCH DESIGN AND METHODS

Twenty-three patients with Type 2 diabetes and 10 normal controls were recruited. In the diabetic patients two different tests were performed in each subject: a standard meal preceded by subcutaneous injection of soluble insulin (0.15 U/kg body weight) or of short-acting insulin aspart (0.15 U/kg body weight). These tests were designed to achieve different levels of post-prandial hyperglycaemia. Controls received a single standard meal test. Immediately before, and 1, 2, 4 and 6 h after each meal, blood glucose, triglycerides, free fatty acids and flow-mediated vasodilation were measured.

RESULTS

Compared with regular insulin, insulin aspart significantly reduced the area under the curve for post-prandial hyperglycaemia (58.3 +/- 17.6 vs. 68.1 +/- 17.7; P<0.04), and preserved flow-mediated vasodilation, which was decreased in the post-prandial state (39.4 +/- 2.9 vs. 34.1 +/- 2.2; P<0.01). Triglyceride and free fatty acid levels were not differentially affected by the treatment. In normal controls the meal did not affect flow-mediated vasodilation.

CONCLUSION

This study shows that the post-prandial state is accompanied by endothelial dysfunction in Type 2 diabetic patients and that insulin aspart improved endothelial function.

Nontraditional risk factors for cardiovascular disease in diabetes

People with type 2 diabetes are disproportionately affected by cardiovascular disease (CVD), compared with those without diabetes. Traditional risk factors do not fully explain this excess risk, and other "nontraditional" risk factors may be important. This review will highlight the importance of nontraditional risk factors for CVD in the setting of type 2 diabetes and discuss their role in the pathogenesis of the excess CVD morbidity and mortality in these patients. We will also discuss the impact of various therapies used in patients with diabetes on nontraditional risk factors.

Coping with endothelial superoxide: potential complementarity of arginine and high-dose folate

Superoxide overproduction is a prominent mediator of the endothelial dysfunction associated with a range of vascular disorders, acting in a number of complementary ways to inhibit effective endothelial nitric oxide (NO) activity. The ability of superoxide to quench NO is well known, but oxidants derived from superoxide also appear to inhibit dimethylarginine dimethylaminohydrolase (DDAH) and to oxidize tetrahydrobiopterin (THBP). The former effect boosts the level of methylated arginines that act as potent competitive inhibitors of NO synthase, whereas the latter effect decreases the ability of this enzyme to generate NO, while converting it to a form that readily generates superoxide. The adverse impact of DDAH deficiency on NO production can be offset with supplemental arginine. Although supplementation with THBP has the potential to compensate for the rapid oxidative destruction of this compound, and maintaining optimal vitamin C nutrition may protect or restore the endothelial THBP pool to a limited extent, the most practical way to optimize NO synthase activity in the context of THBP deficit may be administration of high-dose folic acid. The primary circulating metabolite of folate, 5-methyltetrahydrofolate (5MTHF), is structurally analogous to THBP, and appears to normalize the activity of NO synthase in THBP-depleted endothelial cells, either because it "pinch hits" for the absent THBP, or interacts allosterically with NO synthase in some other way to promote the proper function of this enzyme. This observation may rationalize recent clinical studies showing a favorable effect of oral folic acid (5-10 mg daily) on dysfunctional endothelium, independent of any concurrent modulation of homocysteine levels. A recent study reports that, whereas either arginine or THBP alone have only a modest impact on dysfunctional aortic endothelium derived from hypercholesterolemic mice, the combination of the two produces a complete normalization of endothelial function. In aggregate, these considerations suggest that joint administration of arginine and high-dose folate may represent a fruitful approach to preventing and treating vascular disorders - albeit the underlying overproduction of superoxide should also be addressed by ameliorating relevant vascular risk factors.

Coronary vasospasm and the regulation of coronary blood flow

Under physiologic conditions, epicardial arteries contribute minimally to coronary vascular resistance. However, in the presence of endothelial dysfunction, stimuli that normally produce vasodilation may instead cause constriction. Examples include neural release of acetylcholine or norepinephrine, platelet activation and production of serotonin and thrombin, and release of local factors such as bradykinin. This shift from a primary endothelial-mediated vasodilator influence to one of endothelial dysfunction and unchecked vasoconstriction is precisely the milieu in which coronary vasospasm is observed. This condition, which typically occurs during periods of relatively sedentary activity, is associated with focal and transient obstruction of an epicardial arterial segment resulting in characteristic echocardiographic changes and symptoms of myocardial ischemia. This review highlights the current understanding of mechanisms regulating the coronary circulation during health and examines the pathophysiologic changes that occur with coronary spasm. Genetic and other predisposing conditions are addressed, as well as novel therapies based on recent mechanistic insights of the coronary contractile dysfunction associated with coronary spasm.

Low Serum .ALPHA.-Tocopherol Concentrations in Subjects With Various Coronary Risk Factors

BACKGROUND

Oxidative stress may play an important role in the genesis and development of atherosclerosis.

METHODS AND RESULTS

To examine whether oxidative stress is increased in the presence of various coronary risk factors, serum alpha-tocopherol concentrations were determined in 168 apparently healthy subjects recruited from Daioh town (73 men and 95 women, mean age: 42+/-11 years). The alpha-tocopherol concentration (mg/g lipids) was significantly lower in men, older subjects (>or=50 years of age), smokers, those with hyper-low density lipoprotein (LDL)-cholesterolemia (C) (>or=160 mg/dl), hypertriglyceridemia (TG) (>or=150 mg/dl), hypo-high density lipoprotein (HDL)-C (<40 mg/dl), fasting hyperglycemia (>110 mg/dl) and obesity (body mass index >or=25 kg/m (2)) than in women, younger subjects, nonsmokers, those with normoLDL-C, normoTG, normoHDL-C, fasting normoglycemia and the non-obese. The concentration was not significantly different between hypertensives and nonhypertensives. Multivariate logistic regression analysis showed that the adjusted odds ratios (95% confidence interval) for hyperTG and hypoHDL-C as a factor for the lowest tertile of alpha-tocopherol concentration were 6.2 (1.6-24.4, p<0.01) and 6.0 (1.5-22.6, p<0.01), and those of the other risk factors were not significant. The alpha-tocopherol concentrations were significantly positively correlated with HDL-C concentrations (R=0.53) and negatively with TG concentrations (R=-0.53), BMI (R=-0.35), LDL-C concentrations (R=-0.25) and age (R=-0.22).

CONCLUSION

Increased oxidative stress, as shown by decreased alpha-tocopherol concentrations, was linked to the presence of various coronary risk factors, among which hyperTG and hypoHDL-C appeared to be most heavily associated with oxidative stress.

Tetrahydrobiopterin and nitric oxide: mechanistic and pharmacological aspects

In previous minireviews in this journal, we discussed work on induction of tetrahydrobiopterin biosynthesis by cytokines and its significance for nitric oxide (NO) production of intact cells as well as functions of H4-biopterin identified at this time for NO synthases (Proc Soc Exp Biol Med 203: 1-12, 1993; Proc Soc Exp Biol Med 219: 171-182, 1998). Meanwhile, the recognition of the importance of tetrahydrobiopterin for NO formation has led to new insights into complex biological processes and revealed possible novel pharmacological strategies to intervene in certain pathological conditions. Recent work could also establish that tetrahydrobiopterin, in addition to its allosteric effects, is redox-active in the NO synthase reaction. In this review, we summarize the current view of how tetrahydrobiopterin functions in the generation of NO and focus on pharmacological aspects of tetrahydrobiopterin availability with emphasis on endothelial function.

Vitamin C affects thrombosis/ fibrinolysis system and reactive hyperemia in patients with type 2 diabetes and coronary artery disease

OBJECTIVE

To examine the effect of vitamin C on forearm vasodilatory response to reactive hyperemia and on plasma level of plasminogen activator inhibitor 1 (PAI-1), von Willebrand factor (vWF), tissue plasminogen activator (tPA), antithrombin III (ATIII), proteins C and S, and factors V (fV) and VII (fVII) in patients with both type 2 diabetes and CAD.

RESEARCH DESIGN AND METHODS

A total of 39 patients with type 2 diabetes and CAD were divided into two groups and received vitamin C (2 g/day) or no antioxidant for 4 weeks. Forearm blood flow was determined using venous occlusion gauge-strain plethysmography at baseline and after treatment. Forearm vasodilatory response to reactive hyperemia (RH%) or nitrate (NTG%) was defined as the percent change of flow from baseline to the maximum flow during reactive hyperemia or after administration of nitrate, respectively. Biochemical markers were determined by enzyme-linked immunosorbent assay (ELISA) or other standard methods.

RESULTS

RH% was significantly increased after treatment with vitamin C (from 62.4 +/- 7.2 to 83.1 +/- 9.3%, P = 0.024) but remained unaffected in the control group. Vitamin C decreased plasma levels of fV (from 143 +/- 5.4 to 123 +/- 6.03%, P = 0.038), vWF (from 133.5 +/- 14.5 to 109.5 +/- 11.4%, P = 0.016), and tPA (from 12.3 +/- 0.99 to 8.40 +/- 0.60 ng/ml, P = 0.001), whereas these levels remained unaffected in the control group. The changes in RH%, vWF, and tPA were significantly greater (P = 0.028, 0.036, and 0.007, respectively) in the vitamin C-treated group than in the control group. Levels of ATIII, proteins S and C, fVII, and PAI-1 remained unchanged in all groups.

CONCLUSIONS

Short-term treatment with high doses of vitamin C improved RH% and decreased plasma levels of tPA and vWF in patients with type 2 diabetes and CAD.

Role of endothelial dysfunction in insulin resistance

The endothelium regulates vascular tone through the release of vasodilating and vasoconstricting substances. The most important of these vasodilating substances is nitric oxide (NO), which is also vascular protective and inhibits inflammation, oxidation, vascular smooth muscle cell proliferation, and migration. Damage to the endothelium causes endothelial dysfunction with impaired release of NO and loss of its antiatherogenic protection. Traditional risk factors for coronary artery disease, including diabetes, hypercholesterolemia, hypertension, and low levels of high-density lipoprotein cholesterol, are associated with endothelial dysfunction and thus promote the atherogenic process. More recently, insulin resistance in the absence of overt diabetes or the metabolic syndrome has been associated with endothelial dysfunction. This association provides evidence that the atherosclerotic process may actually begin earlier in the spectrum of insulin resistance, ultimately resulting in a progression of the metabolic syndrome to prediabetes and then to type 2 diabetes. Aggressive treatment of dyslipidemia and hypertension, even before the onset of type 2 diabetes, would appear prudent in decreasing the progression of the atherosclerotic process. The thiazolidinediones are peroxisome proliferator-activated receptor-gamma agonists that improve glucose and lipid metabolism. These agents have recently been shown to improve endothelial function in the early stages of insulin resistance. Results from ongoing trials with thiazolidinediones will reveal whether they will also reduce cardiovascular end points.

Influence of acute hyperglycemia in human sepsis on inflammatory cytokine and counterregulatory hormone concentrations

AIM: In human sepsis, a prominent component of the hypermetabolite is impaired glucose tolerance (IGT) and hyperglycemia. Elevations in plasma glucose concentration impair immune function by altering cytokine production from macrophages. We assessed the role of glucose in the regulation of circulating levels of insulin, glucagon, cortisol, IL-6 and TNF-α in human sepsis with normal or impaired glucose tolerance.

METHODS: According to the results of intravenous glucose tolerance test, forty patients were classified into two groups: control group (n = 20) and IGT group (n = 20). Plasma glucose levels were acutely raised in two groups and maintained at 15 mmol/L for 3 hours. Plasma insulin, glucagon and cortisol levels were measured by radioimmunoassay, the levels of TNF-α and IL-6 were detected by ELISA.

RESULTS: In IGT group, the fasting concentrations of plasma glucose, insulin, glucagon, cortisol, IL-6 and TNF-α levels were significantly higher than those in control group (P < 0.05). During clamp, the control group had a higher average amount of dextrose infusion than the IGT group (P < 0.01). In control group, plasma insulin levels rose from a basal value to a peak at an hour (P < 0.05) and maintained at high levels. Plasma glucagon levels descended from a basal value to the lowest level within an hour (P < 0.01) and low levels were maintained throughout the clamp. In IGT group, plasma insulin was more significantly elevated (P < 0.01), and plasma glucagon levels were not significantly declined. Plasma cortisol levels were not significantly changed in two groups. In control group, plasma IL-6 and TNF-α levels rose (P < 0.01) within 2 hours of the clamp and returned to basal values at 3 hours. In IGT group, increased levels of plasma cytokine lasted longer than in control group (3 hours vs. 2 hours, P < 0.05), and the cytokine peaks of IGT group were higher (P < 0.05) than those of control group.

CONCLUSION: Acute hyperglycemia pricks up hyperinsulinemia and increases circulating cytokine concentrations and these effects are more pronounced in sepsis with IGT. This suggests a potential modulation of immunoinflammatory responses in human sepsis by hyperglycemia.

Endothelial control of vasomotion and nitric oxide production

This article has focused on the influence of NO. on vascular homeostasis. Vascular tone, however, is also influenced by other vasoactive factors released by the endothelium, including the endothelial-derived hyperpolarizing factors, prostacyclin, and vasoconstrictor factors. There is also abundant evidence that these factors are altered by pathophysiologic states, although the mechanisms responsible are not as well understood as they seem to be for the NO. system. There is now evidence that several endothelial-derived hyperpolarizing factors may exist. One is almost certainly the cytochrome p450 metabolite of arachidonic acid, epoxyeicosatrienoic acid (EET) [92], whereas another is likely H2O2, which stimulates potassium channel opening in a fashion similar to the EET [93]. EET has anti-inflammatory properties, whereas H2O2 may potentially enhance inflammation and promote vascular hypertrophy. Thus, two factors released by the endothelium with similar acute effects on the vascular smooth muscle may have very different long-term consequences in terms of protecting against or promoting vascular disease. During the past two decades, physicians have gained a substantial understanding of the L-arginine/eNOS/NO. pathway and how this modulates vascular reactivity. Further, physicians now are aware that this process is altered by many risk factors for atherosclerosis and have begun to understand how these disorders alter NO. production and bioavailability. These abnormalities are likely multifactorial and physicians are beginning to understand how they can be corrected. An exciting aspect of endothelial function is that it has prognostic significance above and beyond the traditional risk factors for atherosclerosis. Several studies now have shown that individuals with intact endothelial function in either the forearm or the coronary circulation have a low incidence of events during follow-up periods, whereas those individuals with abnormal endothelial function have a high incidence of major cardiovascular events [94-96]. Because of the complexity of abnormalities that underlie endothelial dysfunction, there are various therapeutic targets that may have to be addressed to improve endothelial function and ultimately improve prognosis in these individuals.

Tetrahydrobiopterin restores endothelial dysfunction induced by an oral glucose challenge in healthy subjects

An oral glucose challenge causes transient impairment of endothelial function, probably because of increased oxidative stress. During oxidative stress, endothelial nitric oxide (NO) synthase (eNOS) becomes uncoupled because of decreased bioavailability of tetrahydrobiopterin (BH4), an essential cofactor of eNOS. Therefore, we examined whether an acute supplement of BH4 could restore endothelial dysfunction induced by an oral glucose challenge. Healthy subjects were examined in 53 experiments. Forearm blood flow was measured by venous occlusion plethysmography. Dose-response studies were obtained during intra-arterial infusion of serotonin to elicit endothelium-dependent, NO-specific vasodilation and during sodium nitroprusside (SNP) infusion to elicit endothelium-independent vasodilation. Subjects were examined before (fasting) and 1 and 2 h after an oral glucose challenge (75 g) with serotonin (n = 10) and SNP (n = 8). On different days (6R)-5,6,7,8-tetrahydro-l-biopterin dihydrochloride (6R-BH4; n = 10), the active cofactor of eNOS or its stereoisomer (6S)-5,6,7,8-tetrahydro-l-biopterin sulfate (6S-BH4; n = 10), which is inactive as a cofactor, was added 10 min (500 microg/min) before and during the 1-h postchallenge serotonin dose-response study. In vitro studies showed that 6R-BH4 and 6S-BH4 were equipotent antioxidants. Serotonin response was reduced by 24 +/- 7% (at the highest dose) at 1 h postchallenge compared with fasting (P = 0.001) and was restored 2 h postchallenge. The reduction was reversed by the administration of 6R-BH4 but not by 6S-BH4. SNP responses were slightly increased 1 and 2 h postchallenge (increased by 15 +/- 13% at third dose 2 h postchallenge, P = 0.0001). An oral glucose challenge causes transient, NO-specific, endothelial dysfunction, which may be reversed by BH4. Transient postprandial endothelial dysfunction may be partly explained by reduced bioavailability of BH4 and NO.

Effect of glycaemic control on the vascular nitric oxide system in patients with type 1 diabetes

OBJECTIVE

The mechanisms underlying the relationship between the vascular complications of diabetes and the glycaemic control are not well understood. We tested whether glycaemic control influences the functioning of the nitric oxide system in type 1 diabetic patients and the role for oxidative stress.

METHODS

The changes in the forearm blood flow after the infusion in the brachial artery of NG-monomethyl-l-arginine, methacholine, methacholine plus superoxide dismutase, and nitroprusside were evaluated using strain gauge plethysmography in 14 healthy subjects and 24 patients with type 1 diabetes (12 with HbA(1c) < 7.5%; 12 with HbA(1c) > or = 7.5%). After adjusting insulin treatment, the vascular studies were repeated in the initially poorly controlled patients (HbA(1c) > or = 7.5%).

RESULTS

Compared with healthy people, impaired vascular responses to NG-monomethyl-l-arginine (P = 0.0001), methacholine (P = 0.007) and nitroprusside (P = 0.0015) were found in the patients with type 1 diabetes and a poor glycaemic control (HbA(1c) >/= 7.5%), but not in subjects with good control (HbA(1c) < 7.5%). Superoxide dismutase improved the responses to methacholine only in those patients with poor control (P = 0.0037). After the adjustment of the insulin treatment in poorly-controlled patients, the responses improved and the effect of superoxide dismutase disappeared only in the patients that achieved good control (n = 9), but not in those who remained poorly-controlled (n = 3).

CONCLUSIONS

In patients with diabetes type 1, glycaemic control determines the functioning of the NO system by a reversible mechanism involving superoxide anions. This finding provides an explanation of the relationship between glycaemic control and vascular complications in diabetes.