Circulating endothelial cells are elevated in patients with type 2 diabetes mellitus independently of HbA(1)c

The research progress of crosstalk mechanism of autophagy and apoptosis in diabetic vascular endothelial injury

In recent years, the widespread prevalence of diabetes has become a major killer that threatens the health of people worldwide. Of particular concern is hyperglycemia-induced vascular endothelial injury, which is one of the factors that aggravate diabetic vascular disease. During the process of diabetic vascular endothelial injury, apoptosis is an important pathological manifestation and autophagy is a key regulatory mechanism. Autophagy and apoptosis interact with each other. Hence, the crosstalk mechanism between the two processes is an important means of regulating diabetic vascular endothelial injury. This article reviews the research progress in apoptosis in the context of diabetic vascular endothelial injury and discusses the crosstalk mechanism of autophagy and apoptosis and its role in this injury. The purpose is to guide the prevention and treatment of diabetic vascular endothelial injury in the future.

Different exercise training intensities prevent type 2 diabetes mellitus-induced myocardial injury in male mice

Type 2 diabetes mellitus (T2DM) usually develop myocardial injury and that exercise may have a positive effect on cardiac function. However, the effect of exercise intensity on cardiac function has not yet been fully examined. This study aimed to explore different exercise intensities on T2DM-induced myocardial injury. 18-week-old male mice were randomly divided into four groups: a control group, the T2DM, T2DM + medium-intensity continuous training (T2DM + MICT), and T2DM + high-intensity interval training (T2DM + HIIT) groups. In the experimental group, mice were given high-fat foods and streptozotocin for six weeks and then divided into two exercise training groups, in which mice were subjected to exercise five days per week for 24 consecutive weeks. Finally, metabolic characteristics, cardiac function, myocardial remodeling, myocardial fibrosis, oxidative stress, and apoptosis were analyzed. HIIT treatment improved cardiac function and improved myocardial injury. In conclusion, HIIT may be an effective means to guard against T2DM-induced myocardial injury.

Physiological and pathological characteristics of vascular endothelial injury in diabetes and the regulatory mechanism of autophagy

Vascular endothelial injury in diabetes mellitus (DM) is the major cause of vascular disease, which is closely related to the occurrence and development of a series of vascular complications and has a serious negative impact on a patient's health and quality of life. The primary function of normal vascular endothelium is to function as a barrier function. However, in the presence of DM, glucose and lipid metabolism disorders, insulin resistance, inflammatory reactions, oxidative stress, and other factors cause vascular endothelial injury, leading to vascular endothelial lesions from morphology to function. Recently, numerous studies have found that autophagy plays a vital role in regulating the progression of vascular endothelial injury. Therefore, this article compares the morphology and function of normal and diabetic vascular endothelium and focuses on the current regulatory mechanisms and the important role of autophagy in diabetic vascular endothelial injury caused by different signal pathways. We aim to provide some references for future research on the mechanism of vascular endothelial injury in DM, investigate autophagy's protective or injurious effect, and study potential drugs using autophagy as a target.

Exploring Endothelial Colony-Forming Cells to Better Understand the Pathophysiology of Disease: An Updated Review

Endothelial cell (EC) dysfunction has been implicated in a variety of pathological conditions. The collection of ECs from patients is typically conducted postmortem or through invasive procedures, such as surgery and interventional procedures, hampering efforts to clarify the role of ECs in disease onset and progression. In contrast, endothelial colony-forming cells (ECFCs), also termed late endothelial progenitor cells, late outgrowth endothelial cells, blood outgrowth endothelial cells, or endothelial outgrowth cells, are obtained in a minimally invasive manner, namely, by the culture of human peripheral blood mononuclear cells in endothelial growth medium. ECFCs resemble mature ECs phenotypically, genetically, and functionally, making them excellent surrogates for ECs. Numerous studies have been performed that examined ECFC function in conditions such as coronary artery disease, diabetes mellitus, hereditary hemorrhagic telangiectasia, congenital bicuspid aortic valve disease, pulmonary arterial hypertension, venous thromboembolic disease, and von Willebrand disease. Here, we provide an updated review of studies using ECFCs that were performed to better understand the pathophysiology of disease. We also discuss the potential of ECFCs as disease biomarkers and the standardized methods to culture, quantify, and evaluate ECFCs and suggest the future direction of research in this field.

Urine-Derived Stem Cells Versus Their Lysate in Ameliorating Erectile Dysfunction in a Rat Model of Type 2 Diabetes

Background: Diabetic erectile dysfunction (DED) is a significant consequence of diabetes mellitus, and it is a multifactorial phenomenon that has no definitive treatment until now. Many therapeutic options provide symptomatic improvement rather than addressing the underlying etiology or restoring normal function. Stem cell (SC) therapy represents a potential hope in DED management. It is well established that the regenerative effect of stem cells can be attained by their paracrine action and their ability to differentiate into many cell lineages, including endothelial and smooth muscle cells. Hence, we tried to compare the effects of transplantation of urine-derived stem cells (USCs) or their lysate (USC-L) into the corpora cavernosa (CCs) of rats with DED.

Materials and Methods: A total of 55 adult male Wistar rats were included in this study. USCs were obtained from ten healthy rats. Another ten rats did not subject to any intervention and served as a control (group I). Type 2 DM and DED were induced in the remaining 35 rats, but DED was tested and proved in only 24 rats, which were randomly divided into three groups (n = 8 in each). The DED group (group II) and either USCs (2 × 10⁶ cells) or their lysate (200 μl) were transplanted into the CCs of each rat in the other two groups (groups III and IV), respectively.

Results: Although the DED rats exhibited deterioration in all copulatory functions as compared to the control group, our histopathological, immunohistochemical, and morphometric results revealed that both USCs and USC-L have significantly restored the cavernous spaces, the ultrastructures of the endothelium that line the cavernous spaces, collagen/smooth muscle ratio, and the mean area percentage of α-SMA in the CCs as compared to DED rats. A respectable number of USCs was detected in the CCs of group III at the 4th week after transplantation, but this number significantly declined by the 8th week.

Conclusion: Both USCs and USC-L can repair the structure and ultrastructure of CCs and improve the copulatory functions in the DED rat model. However, USC-L could be better used in DED to guard against the strange behavior of USCs after transplantation and their decreased survivability with time.

Circulating endothelial cells and endothelial progenitor cells as potential predictors of acute GVHD after allogeneic hematopoietic stem cell transplantation

OBJECTIVE

Acute graft-versus-host disease (aGVHD) is a major cause of treatment-related mortality after allogeneic hematopoietic stem cell transplantation. Endothelial cell damage may trigger the initiation of aGVHD.

METHODS

Endothelial damage and repair were evaluated by counting circulating endothelial cells (CECs) and endothelial progenitor cells (EPCs) in 17 allogeneic hematopoietic stem cell transplantation patients at pre-conditioning, day 0, day 7, day 14, day 30, and day 60 by multicolor flow cytometry. Von Willebrand factor activity was simultaneously measured.

RESULTS

Eight patients developed aGVHD and were compared to non-aGVHD patients. Patients' characteristics were not different, except for previous treatment courses. There was no difference in von Willebrand factor activity between the two groups. Both CEC and EPC counts were decreased on day 7 and day 14 and then increased thereafter. The CEC count on day 7 was significantly lower in the aGVHD group than in the non-aGVHD group (p = .0401). Restoration of the EPC count on day 60 was significantly suppressed in the aGVHD group (p = .0464). The CEC count on day 7 could predict aGVHD development (AUC 0.8214, p = .0372).

CONCLUSION

The present results showed that CEC count on day 7 could be a predictor of aGVHD.

A comprehensive review on LED-induced fluorescence in diagnostic pathology

Sensitivity, specificity, mobility, and affordability are important criteria to consider for developing diagnostic instruments in common use. Fluorescence spectroscopy has been demonstrating substantial potential in the clinical diagnosis of diseases and evaluating the underlying causes of pathogenesis. A higher degree of device integration with appropriate sensitivity and reasonable cost would further boost the value of the fluorescence techniques in clinical diagnosis and aid in the reduction of healthcare expenses, which is a key economic concern in emerging markets. Light-emitting diodes (LEDs), which are inexpensive and smaller are attractive alternatives to conventional excitation sources in fluorescence spectroscopy, are gaining a lot of momentum in the development of affordable, compact analytical instruments of clinical relevance. The commercial availability of a broad range of LED wavelengths (255-4600 nm) has opened up new avenues for targeting a wide range of clinically significant molecules (both endogenous and exogenous), thereby diagnosing a range of clinical illnesses. As a result, we have specifically examined the uses of LED-induced fluorescence (LED-IF) in preclinical and clinical evaluations of pathological conditions, considering the present advancements in the field.

Predictive Value of CHA2DS2 -VASc-HSF Score for Severity of Acute Coronary Syndrome

CHADS₂ and CHA₂DS₂-VASc scores have been used to assess the prognostic risk of thromboembolism in non-valvular atrial fibrillation patients. Recent studies have shown the utility of CHADS₂ and CHA₂DS₂-VASc scores for evaluating the severity of coronary artery disease (CAD). The newly defined CHA₂DS₂-VASc-HSF score evaluates atherosclerosis and is associated with CAD severity. This study investigated the association between the CHA₂DS₂-VASc-HSF score and acute coronary syndrome (ACS) severity as assessed by the Gensini score and the number of vessels. Furthermore, this study also compared the diagnostic value of the CHADS₂, CHA2 DS2-VASc, and CHA₂DS₂-VASc-HSF score for ACS. A total of 2367 eligible inpatients (ACS group [n = 2030]; non-CAD group [n = 337]) were consecutively enrolled in this study. Receiver operating characteristic curve diagnostic tests and logistic regression models were used to analyze the risk factors for ACS. The CHADS₂, CHA₂DS₂-VASc, and CHA₂DS₂-VASc-HSF scores were significantly higher in the ACS group than those in the control group. After adjusting for numerous traditional CAD risk factors, an increased CHA₂DS₂-VASc-HSF score was found to be an independent risk factor for patients with ACS (odds ratio 1.401, 95% confidence interval 1.044, −1.879; P < 0.05). A newly diagnosed CHA₂DS₂-VASc-HSF score predicts the severity of ACS.

Biomedical applications of electrospun nanofibers in the management of diabetic wounds

Diabetes mellitus (DM) is a complex disease that affects almost all the body's vital organs. Around 415 million people have been diagnosed with DM worldwide, and most of them are due to type 2 DM. The incidence of DM is estimated to increase by 642 million individuals by 2040. DM is considered to have many complications among which diabetic wound (DW) is one of the most distressing complication. DW affects 15% of people with diabetes and is triggered by the loss of glycaemic control, peripheral neuropathy, vascular diseases, and immunosuppression. For timely treatment, early detection, debridement, offloading, and controlling infection are crucial. Even though several treatments are available, the understanding of overlying diabetes-related wound healing mechanisms as therapeutic options has increased dramatically over the past decades. Conventional dressings are cost-effective; however, they are not productive enough to promote the overall process of DW healing. Thanks to tissue engineering developments, one of the promising current trends in innovative wound dressings such as hydrocolloids, hydrogels, scaffolds, films, and nanofibers which merges traditional healing agents and modern products/practices. Nanofibers prepared by electrospinning with enormous porosity, excellent absorption of moisture, the better exchange rate of oxygen, and antibacterial activities have increased interest. The application of these nanofibers can be extended by starting with a careful selection of polymers, loading with active therapeutic moieties such as peptides, proteins, active pharmaceutical ingredients (API), and stem cells, etc. to make them as potential dosage forms in the management of DWs. This review explains the potential applications of electrospun nanofibers in DW healing. A schematic view of role of nanofibers in diabetic wounds.

The Association of Nephroblastoma Overexpressed (NOV) and Endothelial Progenitor Cells with Oxidative Stress in Obstructive Sleep Apnea

Objective

Obstructive sleep apnea (OSA) is a sleep disorder characterized by intermittent hypoxia, chronic inflammation, and oxidative stress and is associated with cardiometabolic disease. Several biological substrates have been associated with OSA such as nephroblastoma overexpressed (NOV), endothelial progenitor cells (EPC), and circulating endothelial cells (CEC). Few studies have looked at the association of NOV with OSA while the EPC/CEC relationships with OSA are unclear. In this study, we hypothesize that (1) NOV is associated with the severity of OSA independent of BMI, identifying a protein that may play a role in the biogenesis of OSA complications, and (2) EPCs and CECs are also associated with the severity of OSA and are biomarkers of endothelial dysfunction in OSA.

Methods

61 subjects underwent overnight polysomnography (PSG), clinical evaluation, and blood analysis for NOV, EPC, CEC, interleukin 6 (IL-6), and other potential biomarkers.

Results

NOV and EPCs were independently associated with the oxygen desaturation index (ODI) after adjusting for potential confounders including body mass index (BMI), age, and sex (NOV p = 0.032; EPC p = 0.001). EPC was also independently associated with AHI after adjusting for BMI, age, and sex (p = 0.017). IL-6 was independently associated with AHI, but not with ODI.

Conclusion

NOV and EPC levels correlate with the degree of OSA independent of BMI, indicating that these biomarkers could potentially further elucidate the relationship between OSA patients and their risk of the subsequent development of cardiovascular disease.

Systemic cytology. A novel diagnostic approach for assessment of early systemic disease

Recognition of low grade or asymptomatic systemic diseases suggests prevention of the worst, yet has been proven challenging ever since. Biomarker-based liquid biopsy has emerged in recent years as a practical platform for the assessment of systemic diseases yet, technical realizations were mainly focused on cancer, faced challenges in accuracy at early stage and are lacking provision of sufficient evidence of disease. In particular in cell-based cancer liquid biopsy, obstacles are rarity and heterogeneity of circulating tumor and tumor-associated rare cells. Evidence is mounting about an entire spectrum of distinct circulating rare cell types that denotes the systemic component of a certain physiological state. Therefore, circulating rare cells in combination may arise from yet, also account for systemic diseases, which we denote as multi-rare cell association and involves foremost bone marrow-derived progenitor and stem cells yet, also matured somatic cell types. One would expect immense diagnostic value in the read-out of the so called rare cell population which represents cytological evidence of abnormality. We hypothesize that comprehensive rare cell population profiling as contrasted to the biomarker screening approach may realize the premise of a biopsy as to confirm, characterize, grade, stage or predict a systemic disease. This novel approach represents the "missing link" in diagnostic care of in particular early or residual systemic disease and presumes a steady gain in knowledge about the clinical interpretation of rare cell population profiles thus, expecting the knowledge-driven transformation of cell-based liquid biopsy from suggestion to confirmation. We support our hypothesis by past findings made by others and us and provide insights how to interpret a certain rare cell population profile.

Advances of Endothelial Progenitor Cells in the Development of Depression

Depression is a major psychological disease of human beings. With the severity of depression, it elevates the risk of cardiovascular disease (CVD), especially acute coronary syndrome (ACS), resulting in serious harm to human health. The number of endothelial progenitor cells (EPCs) is closely related to the development of depression. It has been reported that the number of peripheral blood EPCs in patients with depression was reduced. However, effects on the function of EPCs in depression are still unclear. This paper aims to analyze and summarize the research of EPCs in depression, and we envision that EPCs might act as a new target for evaluating the severity of depression and its complications.

Carotid artery molecular calcification assessed by [18F]fluoride PET/CT: correlation with cardiovascular and thromboembolic risk factors

OBJECTIVES

There is growing evidence that sodium fluoride ([¹⁸F]fluoride) PET/CT can detect active arterial calcifications at the molecular stage. We investigated the relationship between arterial mineralization in the left common carotid artery (LCC) assessed by [¹⁸F]fluoride PET/CT and cardiovascular/thromboembolic risk.

METHODS

In total, 128 subjects (mean age 48 ± 14 years, 51% males) were included. [¹⁸F]fluoride uptake in the LCC was quantitatively assessed by measuring the blood-pool-corrected maximum standardized uptake value (SUVmax) on each axial slice. Average SUVmax (aSUVmax) was calculated over all slices and correlated with 10-year risk of cardiovascular events estimated by the Framingham model, CHA2DS2-VASc score, and level of physical activity (LPA).

RESULTS

The aSUVmax was significantly higher in patients with increased risk of cardiovascular (one-way ANOVA, p < 0.01) and thromboembolic (one-way ANOVA, p < 0.01) events, and it was significantly lower in patients with greater LPA (one-way ANOVA, p = 0.02). On multivariable linear regression analysis, age ( = 0.07, 95% CI 0.05 - 0.10, p < 0.01), body mass index ( = 0.02, 95% CI 0.01 - 0.03, p < 0.01), arterial hypertension ( = 0.15, 95% CI 0.08 - 0.23, p < 0.01), and LPA ( = -0.10, 95% CI -0.19 to -0.02, p=0.02) were independent associations of aSUVmax.

CONCLUSIONS

Carotid [¹⁸F]fluoride uptake is significantly increased in patients with unfavorable cardiovascular and thromboembolic risk profiles. [¹⁸F]fluoride PET/CT could become a valuable tool to estimate subjects' risk of future cardiovascular events although still major trials are needed to further evaluate the associations found in this study and their potential clinical usefulness.

KEY POINTS

• Sodium fluoride ([¹⁸F]fluoride) PET/CT imaging identifies patients with early-stage atherosclerosis. • Carotid [¹⁸F]fluoride uptake is significantly higher in patients with increased risk of cardiovascular and thromboembolic events and inversely correlated with the level of physical activity. • Early detection of arterial mineralization at a molecular level could help guide clinical decisions in the context of cardiovascular risk assessment.

The Role of miR-342 in Vascular Health. Study in Subclinical Cardiovascular Disease in Mononuclear Cells, Plasma, Inflammatory Cytokines and PANX2

Cardiovascular disease (CVD) correlates with inflammation and a reduction in circulating endothelial progenitor cells (cEPCs). Recently, CVD was shown to be the main cause of mortality in individuals with type 1 diabetes (T1DM). In animals, miR-342 was shown to exert an anti-inflammatory effect in CVD. Hypothesis: miR-342-3p/-5p are downregulated in subclinical CVD (T1DM), whereas inflammatory cytokines are upregulated. We studied miR -342 -3p/5p in plasma/peripheral blood mononuclear cells (PBMCs) in 29 T1DM and 20 controls (HC). Vascular health was measured by fibronectin adhesion assay (FAA), cEPCs (CD45^dimCD34⁺133⁺ cells) and by assessing inflammation and tissue inhibition of metalloproteases (TIMP-1). In T1DM IL-7, IL-8, TNFα and VEGF-C were increased in plasma. MiR-342-3p/-5p were downregulated in PBMCs in T1DM, but not in plasma. PANX2, chemokine receptors CXCR1/2 mRNAs, were increased in PBMCs in T1DM. MiR-342-3p was negatively correlated with TIMP-1, IL-6, IL-8, TNF-α, HbA_1c and CXCR2, whilst miR-342-5p was negatively correlated with TIMP-1, IL-6, IL-8 and HbA_1c. There was a positive correlation among miR-342-3p, FAA and cEPCs, and between miR-342-5p and cEPCs. ROC curve analyses showed significant downregulation of miR-342-3p/-5p at HbA_1c > 46.45 mmol/mol, indicating their potential as biomarkers for subclinical CVD. Our findings validated animal studies and confirmed the proangiogenic properties of miR-342-3p/-5p. MiR-342-3p/-5p-based intervention or monitoring may prove to be beneficial in managing CVD.

Prognostic value of CHADS2 and CHA2DS2-VASc scores for post-discharge outcomes in patients with acute coronary syndrome undergoing percutaneous coronary intervention

The CHADS2 and CHA2DS2-VASc scores were initially developed to assess the risk of stroke or systemic embolism in patients with atrial fibrillation (AF). Recently, these two scoring systems have been demonstrated to predict long- and short-term cardiovascular (CV) outcomes in many patient cohorts. However, to the best of our knowledge, their prognostic value has not been fully elucidated in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). This study aimed to investigate the association of CHADS2 and CHA2DS2-VASc scores with CV outcomes in such patients.We included a total of 915 ACS patients undergoing PCI in this study. CHADS2 and CHA2DS2-VASc scores were calculated from data collected before discharge. The primary endpoint was defined as a composite of major adverse CV events (MACE) including overall death, nonfatal stroke, nonfatal myocardial infarction (MI) and unplanned repeat revascularization. We assessed MACE's relationship to CHADS2 and CHA2DS2-VASc scores using Cox proportional-hazard regression analyses.Mean follow-up duration was 918 days. MACE occurred in 167 (18.3%) patients. A higher CHADS2 score was associated with reduced event-free survival (EFS) from MACE (logrank test, P = .007) with differences potentiated if stratified by CHA2DS2-VASc score (logrank test, P < .001). Univariate analysis showed that both CHADS2 and CHA2DS2-VASc scores were good predictors of MACE. In the multivariate Cox proportional-hazard regression analysis, CHA2DS2-VASc score (hazard ratio [HR], 1.15; 95% confidence interval [CI] 1.04-1.27; P = .007) remained a useful predictor of MACE; however, CHADS2 score was no longer associated with increased risk of MACE. C-statistics for CHA2DS2-VASc score, GRACE (Global Registry of Acute Coronary Events) hospital discharge risk score (GRACE Score) and SYNTAX (Synergy between PCI with TAXUS and Cardiac Surgery) Score II (SS II) in predicting MACE were 0.614, 0.598, and 0.609, respectively.CHA2DS2-VASc score was an independent and significant predictor of MACE in ACS patients undergoing PCI, and its discriminatory performance was not inferior to those of GRACE Score and SS II.

The Effects of Type 2 Diabetes Mellitus on Organ Metabolism and the Immune System

Metabolic abnormalities such as dyslipidemia, hyperinsulinemia, or insulin resistance and obesity play key roles in the induction and progression of type 2 diabetes mellitus (T2DM). The field of immunometabolism implies a bidirectional link between the immune system and metabolism, in which inflammation plays an essential role in the promotion of metabolic abnormalities (e.g., obesity and T2DM), and metabolic factors, in turn, regulate immune cell functions. Obesity as the main inducer of a systemic low-level inflammation is a main susceptibility factor for T2DM. Obesity-related immune cell infiltration, inflammation, and increased oxidative stress promote metabolic impairments in the insulin-sensitive tissues and finally, insulin resistance, organ failure, and premature aging occur. Hyperglycemia and the subsequent inflammation are the main causes of micro- and macroangiopathies in the circulatory system. They also promote the gut microbiota dysbiosis, increased intestinal permeability, and fatty liver disease. The impaired immune system together with metabolic imbalance also increases the susceptibility of patients to several pathogenic agents such as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Thus, the need for a proper immunization protocol among such patients is granted. The focus of the current review is to explore metabolic and immunological abnormalities affecting several organs of T2DM patients and explain the mechanisms, whereby diabetic patients become more susceptible to infectious diseases.

Circulating Endothelial Cells, Circulating Endothelial Progenitor Cells, and Circulating Microparticles in Type 1 Diabetes Mellitus

Background and Aim:

Hyperglycemia in type 1 diabetes (T1D) is accompanied by endothelial cell dysfunction which is known to contribute to the pathogenesis of cardiovascular disorders. The aim of the current study was to explore the profile of circulating endothelial progenitor cells (EPCs), circulating endothelial cells (CECs), endothelial and platelet derived micropaticles (EMPs, PMPs) and total microparticles (TMPs), in T1D children in relation to each other and to the metabolic disorders accompanying T1D.

Patients and Methods:

Thirty T1D patients and 20 age and sex matched healthy volunteers were assessed for HbA1c level and lipid profile. Quantification of CECs, EPCs, TMPs, EMPs and PMPs was done by flow cytometry.

Results:

The mean levels of EMPs, PMPs, TMPs and CECs were significantly higher in diabetic children compared to controls. Meanwhile, the levels of EPCs were significantly lower in diabetic children compared to controls. Both PMPs and CECs showed the highest significant differences between patients and controls and their levels were directly related to HbA1c, total cholesterol, LDL and triglycerides. A moderate correlation was observed between the frequency of PMPs and CECs. EPCs revealed negative correlations with both LDL and triglycerides. TMPs were only related to LDL, while EMPs were only related to HbA1c.

Conclusion:

Although there is disturbance in the levels of EMPs, PMPs, TMPs, CECs and EPCs in type 1 diabetic children compared to the controls, only the levels of PMPs and CECs were closely affected by the poor glycemic control and dyslipidemia occurring in T1D; thus may contribute to a higher risk of cardiovascular diseases.

Clinical significance of atrial high-rate episodes for thromboembolic events in Japanese population

OBJECTIVE

The clinical significance of atrial high-rate episodes (AHREs) detected by cardiac devices among patients with implantable pacemakers has recently emerged. However, the relationship between AHREs and ischaemic stroke and systemic embolism (SE) is not well understood in the Japanese population.

METHODS

This study included 343 patients with pacemakers capable of continuous atrial rhythm monitoring (167 males; mean age, 80±7 years). Atrial tachyarrhythmia detection was programmed to the nominal setting of each device, and AHRE was defined as any episode of sustained atrial tachyarrhythmia lasting for more than 6 min. Thromboembolic risk was defined based on the CHADS2 score.

RESULTS

During the follow-up period (52±30 months), 165 (48%) patients had at least one episode of AHREs, and 19 (6%) patients experienced stroke/SE. Among patients who experienced stroke/SE, 14 had AHREs before the stroke/SE. AHREs were significantly associated with stroke/SE (HR 2.87; 95% CI 1.10 to 8.90; p=0.03). Subgroup analysis conducted to investigate the impact of the CHADS2 score severity on stroke/SE revealed that AHREs were not associated with stroke/SE in patients with low or intermediate thromboembolic risk (CHADS2 score 0-2; n=217). In contrast, among patients with high thromboembolic risk (CHADS2 score>2; n=126), there was a significant association between AHREs and the incidence of stroke/SE (HR 3.73; 95% CI 1.06 to 13.1; p=0.04).

CONCLUSION

AHREs detected by pacemaker were associated with ischaemic stroke/SE in the Japanese population. However, this association was observed only in the high thromboembolic risk group.

Prognostic Value of the CHADS2 Score for Adverse Cardiovascular Events in Coronary Artery Disease Patients Without Atrial Fibrillation-A Multi-Center Observational Cohort Study

Background

The CHADS₂ score has mainly been used to predict the likelihood of cerebrovascular accidents in patients with atrial fibrillation. However, increasing attention is being paid to this scoring system for risk stratification of patients with coronary artery disease. We investigated the value of the CHADS₂ score in predicting cardiovascular/cerebrovascular events in coronary artery disease patients without atrial fibrillation.

Methods and Results

This was a multicenter, observational cohort study. The subjects had been admitted to one of the participating institutions with coronary artery disease requiring percutaneous coronary intervention. We calculated the CHADS₂ scores for 7082 patients (mean age, 69.7 years; males, 71.9%) without clinical evidence of atrial fibrillation. Subjects were subdivided into low‐ (0–1), intermediate‐ (2–3), and high‐score (4–6) groups and followed for 1 year. The end point was a composite of cardiovascular/cerebrovascular death, nonfatal myocardial infarction, and ischemic stroke at 1‐year follow‐up. Rates of triple‐vessel/left main trunk disease correlated positively with CHADS₂ score categories. CHADS₂ scores among single, double, and triple‐vessel/left main trunk groups were 2 (1–2), 2 (1–3), and 2 (2–3), respectively (P<0.001). A total of 194 patients (2.8%) had a cardiovascular/cerebrovascular event, and Kaplan–Meier analysis demonstrated a significantly higher probability of cardiovascular/cerebrovascular events in proportion to a higher CHADS₂ score (log‐rank test, P<0.001). Multivariate Cox hazard analysis identified CHADS₂ score (per 1 point) as an independent predictor of cardiovascular/cerebrovascular events (hazard ratio, 1.31; 95% CI, 1.17–1.47; P<0.001).

Conclusions

This large cohort study indicated that the CHADS₂ score is useful for the prediction of cardiovascular/cerebrovascular events in coronary artery disease patients without atrial fibrillation.

Enumeration of circulating endothelial cell frequency as a diagnostic marker in aortic valve surgery - a flow cytometric approach

Background

The frequency of circulating endothelial cells (CEC) in patients’ peripheral blood can be assessed as a direct marker of endothelial damage. However, conventional enumeration methods are extremely challenging. We developed a novel, automated approach to determine CEC frequencies and tested this method on two groups of patients undergoing conventional (CAVR) versus trans-catheter aortic valve implantation (TAVI).

Methods

CEC frequencies were assessed by a flow cytometric approach, including automated pre-enrichment of CD34 positive blood cell subpopulation and isotype controls. The efficacy and reproducibility of the CEC enumeration method was validated by spiking blood samples of healthy control donors with defined numbers of endothelial cells.

Results

CEC frequencies were significantly higher in the TAVI group before (9.8 ± 4.1 vs. 5.5 ± 2.2, p = 0.019) and 1 h after surgery (13.4 ± 5.1 vs. 8.2 ± 4.1, p = 0.030) corresponding to higher Euroscore, STS score in higher risk patients from the TAVI group. Five days after surgery, CEC frequencies became significantly higher in the more invasive CAVR group (39.0 ± 13.0 vs. 14.3 ± 4.4, p < 0.001) compared to minimally invasive TAVI approach.

Conclusions

The new flow cytometric approach might be a robust and reliable method for CEC enumeration. Initial results show that CEC frequency is a valid clinical marker for the assessment of pre-operative risk, invasiveness of surgical procedure and clinical outcome. Further studies are necessary to validate the practical clinical usefulness and the potential superiority compared to conventional markers.

iNOS-derived peroxynitrite mediates high glucose-induced inflammatory gene expression in vascular smooth muscle cells through promoting KLF5 expression and nitration

Inducible NO synthase (iNOS) expression and peroxynitrite formation are significantly increased in diabetic vascular tissues. Transcription factor KLF5 activates iNOS gene transcription and is involved in vascular inflammatory injury and remodeling. However, mutual regulation between KLF5, iNOS and peroxynitrite in diabetic vascular inflammation, as well as the underlying mechanisms, remain largely unknown. In this study, we found a marked increase in KLF5 and iNOS expression in vascular smooth muscle cells (VSMC) of diabetic patients. High glucose-induced expression of KLF5 and iNOS was also observed in cultured mouse VSMCs. Further investigation showed that high glucose induced KLF5 nitration by iNOS-mediated peroxynitrite generation, and nitrated KLF5 increased its interaction with NF-κB p50 and thus cooperatively activated the expression of inflammatory cytokines TNF-α and IL-1β. Furthermore, we showed that the VSMC-specific knockout of KLF5 dramatically reduced inflammatory cytokine expression in the vascular tissues of diabetic mice. Moreover, 17β-estradiol (E2) inhibited high glucose-mediated effects in VSMCs, and in the response to E2, estrogen receptor (ER) α competed with KLF5 for binding to NF-κB p50, which in turn leads to the suppression of inflammatory gene expression in VSMCs. Together, the present findings were the first to show that KLF5 expression and nitration by iNOS-mediated peroxynitrite are necessary for the induction of TNF-α and IL-1β expression in VSMCs of diabetic vascular tissues.

Diabetes and Wound Angiogenesis

Diabetes Mellitus Type II (DM2) is a growing international health concern with no end in sight. Complications of DM2 involve a myriad of comorbidities including the serious complications of poor wound healing, chronic ulceration, and resultant limb amputation. In skin wound healing, which has definite, orderly phases, diabetes leads to improper function at all stages. While the etiology of chronic, non-healing diabetic wounds is multi-faceted, the progression to a non-healing phenotype is closely linked to poor vascular networks. This review focuses on diabetic wound healing, paying special attention to the aberrations that have been described in the proliferative, remodeling, and maturation phases of wound angiogenesis. Additionally, this review considers therapeutics that may offer promise to better wound healing outcomes.

Metformin improves circulating endothelial cells and endothelial progenitor cells in type 1 diabetes: MERIT study

Background

Type 1 diabetes is associated with increased cardiovascular disease (CVD). Decreased endothelial progenitor cells (EPCs) number plays a pivotal role in reduced endothelial repair and development of CVD. We aimed to determine if cardioprotective effect of metformin is mediated by increasing circulating endothelial progenitor cells (cEPCs), pro-angiogenic cells (PACs) and decreasing circulating endothelial cells (cECs) count whilst maintaining unchanged glycemic control.

Methods

This study was an open label and parallel standard treatment study. Twenty-three type 1 diabetes patients without overt CVD were treated with metformin for 8 weeks (treatment group-TG). They were matched with nine type 1 diabetes patients on standard treatment (SG) and 23 age- and sex-matched healthy volunteers (HC). Insulin dose was adjusted to keep unchanged glycaemic control. cEPCs and cECs counts were determined by flow cytometry using surface markers CD45^dimCD34⁺VEGFR-2⁺ and CD45^dimCD133⁻CD34⁺CD144⁺ respectively. Peripheral blood mononuclear cells were cultured to assess changes in PACs number, function and colony forming units (CFU-Hill’s colonies).

Results

At baseline TG had lower cEPCs, PACs, CFU-Hills’ colonies and PACs adhesion versus HC (p < 0.001-all variables) and higher cECs versus HC (p = 0.03). Metformin improved cEPCs, PACs, CFU-Hill’s colonies number, cECs and PACs adhesion (p < 0.05-all variables) to levels seen in HC whilst HbA1c (one-way ANOVA p = 0.78) and glucose variability (average glucose, blood glucose standard deviation, mean amplitude of glycaemic excursion, continuous overall net glycaemic action and area under curve) remained unchanged. No changes were seen in any variables in SG. There was an inverse correlation between CFU-Hill’s colonies with cECs.

Conclusions

Metformin has potential cardio-protective effect through improving cEPCs, CFU-Hill’s colonies, cECs, PACs count and function independently of hypoglycaemic effect. This finding needs to be confirmed by long term cardiovascular outcome studies in type 1 diabetes.

Trial registration ISRCTN26092132

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-016-0413-6) contains supplementary material, which is available to authorized users.

The CHADS2 score predicts ischemic stroke in chronic heart failure patients without atrial fibrillation: comparison to other stroke risk scores

The CHADS₂ score is useful in stratifying the risk of ischemic stroke or transient ischemic attack (TIA) in patients with non-valvular atrial fibrillation (AF). However, it remains unclear whether the CHADS₂ score could predict stroke or TIA in chronic heart failure (CHF) patients without AF. Recently, the new stroke risk score was proposed from 2 contemporary heart failure trials. We evaluated the prognostic power of the CHADS₂ score for stroke or TIA in CHF patients without AF in comparison to the "stroke risk score". We retrospectively studied 127 CHF patients [left ventricular ejection fraction (LVEF) <40 %] without AF, who had been enrolled in our previous prospective cohort study. The primary endpoint was the incidence of stroke or TIA. The mean baseline CHADS₂ score was 2.1 ± 1.0. During the follow-up period of 8.4 ± 5.1 years, stroke or TIA occurred in 21 of 127 patients. At multivariate Cox analysis, CHADS₂ score (C-index 0.794), but not "stroke risk score" (C-index 0.625), was significantly and independently associated with stroke or TIA. The incidence of stroke or TIA appeared to increase in relation to the CHADS₂ score [low (=1), 0 per 100 person-years; intermediate (=2), 1.6 per 100 person-years; high (≥3), 4.7 per 100 person-years; p = 0.04]. CHADS₂ score could stratify the risk of ischemic stroke in CHF patients with the absence of AF, with greater prognostic power than the "stroke risk score".

Plerixafor improves the endothelial health balance. The effect of diabetes analysed by polychromatic flow cytometry

BACKGROUND AND AIMS

Diabetes damages the endothelium and reduces the availability of bone marrow (BM)-derived endothelial progenitor cells (EPCs). The mobilization of hematopoietic stem cells (HSCs) and EPCs in response to G-CSF is impaired by diabetes, owing to CXCL12 dysregulation. We have previously shown that the CXCR4/CXCL12 disruptor plerixafor rescues HSC and EPC mobilization in diabetes. We herein explored the effects of plerixafor on HSCs, EPCs, and circulating endothelial cells (CECs) in patients with and without diabetes.

METHODS

We re-analysed data gathered in the NCT02056210 trial, wherein patients with (n = 10) and without diabetes (n = 10) received plerixafor to test stem/progenitor cell mobilization. We applied a novel and very specific polychromatic flow cytometry (PFC) approach to identify and quantify HSCs, EPCs, and CECs.

RESULTS

We found that 7-AAD(-)Syto16(+)CD34(+)CD45(dim) HSC levels determined by PFC strongly correlated to the traditional enumeration of CD34(+) cells, whereas 7-AAD(-)Syto16(+)CD34(+)CD45(neg)KDR(+) EPCs were unrelated to the traditional enumeration of CD34(+)KDR(+) cells. Using PFC, we confirmed that plerixafor induces rapid mobilization of HSCs and EPCs in both groups, with a marginally significant defect in patients with diabetes. Plerixafor reduced live (7-AAD(-)) and dead (7-AAD(+)) Syto16(+)CD34(bright)CD45(neg)CD146(+) CECs more in patients without than in those with diabetes. The EPC/CEC ratio, a measure of the vascular health balance, was increased by plerixafor, but less prominently in patients with that in those without diabetes.

CONCLUSIONS

In addition to rescuing defective mobilization associated with diabetes, plerixafor improves the balance between EPCs and CECs, but the latter effect is blunted in patients with diabetes.

Relationship between insulin resistance and circulating endothelial cells in pre-eclampsia

Endothelial dysfunction and insulin resistance (IR) are established features of pre-eclampsia, however the cause and effect relationship between them remain unexplained. Circulating endothelial cells (CEC) are increased in pre-eclampsia and appear to correlate with the degree of endothelial dysfunction. We hypothesised that CEC count in pre-eclampsia would correlate with IR and might provide a simple measure of IR in pregnancies complicated by the disease. CEC count and IR were measured in 10 women with pre-eclampsia and 10 normal pregnant controls matched for maternal age, body mass index and gestational age during the third trimester. CEC count was determined using an established immunomagnetic bead separation method and IR was measured by the homeostasis model test. CEC count and IR were significantly increased in pre-eclampsia compared to normal pregnancy. However, there was no correlation between the CEC count and IR in pre-eclampsia. The data suggest that CEC count in pre-eclampsia is not a useful measure on its own of IR in pregnancies complicated by the disease.

Endothelial Progenitor Cells Predict Cardiovascular Events after Atherothrombotic Stroke and Acute Myocardial Infarction. A PROCELL Substudy

Introduction

The aim of this study was to determine prognostic factors for the risk of new vascular events during the first 6 months after acute myocardial infarction (AMI) or atherothrombotic stroke (AS). We were interested in the prognostic role of endothelial progenitor cells (EPC) and circulating endothelial cells (CEC)

Methods

Between February 2009 and July 2012, 100 AMI and 50 AS patients were consecutively studied in three Spanish centres. Patients with previously documented coronary artery disease or ischemic strokes were excluded. Samples were collected within 24h of onset of symptoms. EPC and CEC were studied using flow cytometry and categorized by quartiles. Patients were followed for up to 6 months. NVE was defined as new acute coronary syndrome, transient ischemic attack (TIA), stroke, or any hospitalization or death from cardiovascular causes. The variables included in the analysis included: vascular risk factors, carotid intima-media thickness (IMT), atherosclerotic burden and basal EPC and CEC count. Multivariate survival analysis was performed using Cox regression analysis.

Results

During follow-up, 19 patients (12.66%) had a new vascular event (5 strokes; 3 TIAs; 4 AMI; 6 hospitalizations; 1 death). Vascular events were associated with age (P = 0.039), carotid IMT≥0.9 (P = 0.044), and EPC count (P = 0.041) in the univariate analysis. Multivariate Cox regression analysis showed an independent association with EPC in the lowest quartile (HR: 10.33, 95%CI (1.22–87.34), P = 0.032] and IMT≥0.9 [HR: 4.12, 95%CI (1.21–13.95), P = 0.023].

Conclusions

Basal EPC and IMT≥0.9 can predict future vascular events in patients with AMI and AS, but CEC count does not affect cardiovascular risk.

Circulating endothelial cells in children: role of fitness, activity, and adiposity

PURPOSE

Circulating endothelial cells (CEC) are thought to be useful biomarkers of endothelial dysfunction and overall cardiovascular health. The extent to which CEC are influenced by fitness, physical activity, and adiposity in youth remains unknown, as they have seldom been examined in the pediatric population. This study assessed resting levels of CEC in boys and girls of different chronological and biological age and explored the relationship between these cells and aerobic fitness, physical activity, and adiposity.

METHODS

Seventy-five children (39 males; median [interquartile range], age = 14.4 [5.8]) completed two study visits. During the first visit, basic anthropometric data were collected and biological age was calculated. Peak mechanical power (Wpeak) was determined using the McMaster All-Out Continuous cycling test. Participants then wore an accelerometer over a 7-d period to assess habitual levels of moderate-to-vigorous physical activity. During visit 2, percent body fat (%BF) was assessed by dual-energy x-ray absorptiometry. A fasted blood sample was also collected from which concentrations of CEC, identified as CD31CD34CD45CD133, were quantified by flow cytometry.

RESULTS

No differences were seen in CEC by sex, chronological age, or biological age. The median (interquartile range) CEC concentration was 32.3 × 10 (63.0 × 10), representing 1.3% (2.7%) of collected peripheral blood mononuclear cells. CEC concentration was associated with Wpeak normalized to lean body mass (r = 0.36, P < 0.01) and time spent in moderate-to-vigorous physical activity (r = -0.27, P = 0.02). No relationship was observed between CEC and %BF.

CONCLUSION

Healthy children demonstrate relatively low concentrations of CECs. Because CEC represent a population of mature endothelial cells shed from the intima after irreversible damage, they may be more reflective of recent physical activity levels rather than fitness or level of adiposity.

The real face of endothelial progenitor cells - Circulating angiogenic cells as endothelial prognostic marker?

Endothelial progenitor cells (EPCs) have been extensively studied for almost 19 years now and were considered as a potential marker for endothelial regeneration ability. On the other hand, circulating endothelial cells (CEC) were studied as biomarker for endothelial injury. Yet, in the literature, there is also huge incoherency in regards to terminology and protocols used. This results in misleading conclusions on the role of so called "EPCs", especially in the clinical field. The discrepancies are mainly due to strong phenotypic overlap between EPCs and circulating angiogenic cells (CAC), therefore changes in "EPC" terminology have been suggested. Other factors leading to inconsistent results are varied definitions of the studied populations and the lack of universal data reporting, which could strongly affect data interpretation. The current review is focused on controversies concerning the use of "EPCs"/CAC and CEC as putative endothelial diagnostic markers.

Insulin-resistant subjects have normal angiogenic response to aerobic exercise training in skeletal muscle, but not in adipose tissue

Reduced vessel density in adipose tissue and skeletal muscle is associated with obesity and may result in decreased perfusion, decreased oxygen consumption, and insulin resistance. In the presence of VEGFA, Angiopoietin-2 (Angpt2) and Angiopoietin-1 (Angpt1) are central determinants of angiogenesis, with greater Angpt2:Angpt1 ratios promoting angiogenesis. In skeletal muscle, exercise training stimulates angiogenesis and modulates transcription of VEGFA, Angpt1, and Angpt2. However, it remains unknown whether exercise training stimulates vessel growth in human adipose tissue, and it remains unknown whether adipose angiogenesis is mediated by angiopoietin signaling. We sought to determine whether insulin-resistant subjects would display an impaired angiogenic response to aerobic exercise training. Insulin-sensitive (IS, N = 12) and insulin-resistant (IR, N = 14) subjects had subcutaneous adipose and muscle (vastus lateralis) biopsies before and after 12 weeks of cycle ergometer training. In both tissues, we measured vessels and expression of pro-angiogenic genes. Exercise training did not increase insulin sensitivity in IR Subjects. In skeletal muscle, training resulted in increased vessels/muscle fiber and increased Angpt2:Angpt1 ratio in both IR and IS subjects. However, in adipose, exercise training only induced angiogenesis in IS subjects, likely due to chronic suppression of VEGFA expression in IR subjects. These results indicate that skeletal muscle of IR subjects exhibits a normal angiogenic response to exercise training. However, the same training regimen is insufficient to induce angiogenesis in adipose tissue of IR subjects, which may help to explain why we did not observe improved insulin sensitivity following aerobic training.

Endothelial Injury Associated with Cold or Warm Blood Cardioplegia during Coronary Artery Bypass Graft Surgery

The aim of this investigation was to analyze the impact of intermittent cold blood cardioplegia (ICC) and intermittent warm blood cardioplegia (IWC) on endothelial injury in patients referred to elective on-pump coronary artery bypass graft (CABG) surgery. Patients undergoing CABG procedures were randomized to either ICC or IWC. Myocardial injury was assessed by CK-MB and cardiac troponin T (cTnT). Endothelial injury was quantified by circulating endothelial cells (CECs), von Willebrand factor (vWF), and soluble thrombomodulin (sTM). Perioperative myocardial injury (PMI) and major adverse cardiac events (MACE) were recorded. Demographic data and preoperative risk profile of included patients (ICC: n = 32, IWC: n = 36) were comparable. No deaths, PMI, or MACE were observed. Levels of CK-MB and cTnT did not show intergroup differences. Concentrations of CECs peaked at 6 h postoperatively with significantly higher values for IWC-patients at 1 h (ICC: 10.1 ± 3.9/mL; IWC: 18.4 ± 4.1/mL; P = 0.012) and 6 h (ICC: 19.3 ± 6.2/mL; IWC: 29.2 ± 6.7/mL; P < 0.001). Concentrations of vWF (ICC: 178.4 ± 73.2 U/dL; IWC: 258.2 ± 89.7 U/dL; P < 0.001) and sTM (ICC: 3.2 ± 2.1 ng/mL; IWC: 5.2 ± 2.4 ng/mL; P = 0.011) were significantly elevated in IWC-group at 1 h postoperatively. This study shows that the use of IWC is associated with a higher extent of endothelial injury compared to ICC without differences in clinical endpoints.

Brain-derived circulating endothelial cells in peripheral blood of newborn infants with seizures: a potential biomarker for cerebrovascular injury

Neonatal seizures have been associated with cerebrovascular endothelial injury and neurological disabilities. In a piglet model, the long-term loss of endothelial regulation of cerebral blood flow coincides with the surge of brain-derived circulating endothelial cells (BCECs) in blood. We hypothesized that BCECs could serve as a noninvasive biomarker of cerebrovascular injury in neonates with seizures. In a prospective pilot feasibility study, we enrolled newborn infants with confirmed diagnoses of perinatal asphyxia and intraventricular hemorrhage (IVH); both are commonly associated with seizures. Infants without clinical evidence of cerebrovascular injuries were representative of the control group. BCECs were detected in the CD45-negative fraction of peripheral blood mononuclear cells by coexpression of CD31 (common endothelial antigen) and GLUT1 (blood-brain barrier antigen) via automated flow cytometry method. In Infants with asphyxia (n = 12) and those with IVH grade III/IV (n = 5), the BCEC levels were 9.9 ± 0.9% and 19.0 ± 2.0%, respectively. These levels were significantly higher than the control group (n = 27), 0.9 ± 0.2%, P < 0.001. BCECs in infants with cerebrovascular insults with documented clinical seizures (n = 10; 16.8 ± 1.3%) were significantly higher than infants with cerebrovascular insults with subclinical or no seizures (n = 7; 9.5 ± 1.2%); P < 0.001. BCEC levels decreased with seizure control. BCECs levels were elevated in infants with seizures caused by severe IVH and perinatal asphyxia. We suggest that monitoring BCEC levels in peripheral blood can potentially offer a biological marker that reflects cerebrovascular insult and recovery. Further studies with a larger number of patients are required to support these findings.

Scientific and Regulatory Policy Committee Points-to-consider Paper*

Drug-induced vascular injury (DIVI) is a recurrent challenge in the development of novel pharmaceutical agents. Although DIVI in laboratory animal species has been well characterized for vasoactive small molecules, there is little available information regarding DIVI associated with biotherapeutics such as peptides/proteins or antibodies. Because of the uncertainty about whether DIVI in preclinical studies is predictive of effects in humans and the lack of robust biomarkers of DIVI, preclinical DIVI findings can cause considerable delays in or even halt development of promising new drugs. This review discusses standard terminology, characteristics, and mechanisms of DIVI associated with biotherapeutics. Guidance and points to consider for the toxicologist and pathologist facing preclinical cases of biotherapeutic-related DIVI are outlined, and examples of regulatory feedback for each of the mechanistic types of DIVI are included to provide insight into risk assessment.

Diabetes and hyperlipidemia induce dysfunction of VSMCs: contribution of the metabolic inflammation/miRNA pathway

Vascular endothelial cell injury is considered to be the major factor inducing vascular complications in metabolic diseases and plays an important role in other organ damage. With diabetic and hyperlipidemic rats and cultured VSMCs, the present study was aimed at investigating whether the early damage of VSMCs during metabolic diseases plays a critical role in vascular dysfunction and the underlying mechanisms and would be a promising treatment target. With diabetic and hyperlipidemic rats and cultured VSMCs, the changes and relationships of vascular relaxation and contractile function to the vital organ damage and the underlying mechanisms were investigated; meanwhile, the protective and preventive effects of lowering blood lipid and glucose and inhibition of diabetes and hyperlipidemia-induced vascular hyperreactivity were observed. Diabetic and hyperlipidemic rats presented hyperreactivity in vascular contractile response in the early stages. Hyperglycemia and hyperlipidemia directly affected the contractile function of VSMCs. Early application of fasudil, a specific antagonist of Rho kinase, significantly alleviated diabetes and hyperlipidemia-induced organ damage by inhibiting vascular hyperreactivity. Diabetes and hyperlipidemia-induced inflammatory response could upregulate the expression of connexins and Rho kinase by selective downregulation of the expression of miR-10a, miR-139b, miR-206, and miR-222. These findings suggest that hyperglucose and lipid may directly impair VSMCs and induce vascular hyperreactivity in the early stages. Metabolic inflammation-induced changes in the miRNA-connexin/Rho kinase regulatory pathway are the main mechanism for vascular hyperreactivity and organ damage. Measures inhibiting vascular hyperreactivity are promising for the prevention of organ damage induced by metabolic diseases.

Diabetes to cardiovascular disease: is depression the potential missing link?

The etiopathological consequences of diabetes and its imperative sequels have been explored extensively in the scientific arena of cardiovascular diabetology. Innumerable risk covariates and confounders have been delineated for the primary and secondary prevention of diabetes and cardiovascular diseases (CVD). However, an intricate interaction of depression on them has been largely overlooked. Depression influences and participates in each and every step that worsens the diabetic state for developing cardiovascular complications. The dilemma is that it coexists, remains silent and generally not considered as relevant clinical parameter amenable to intervention. In this review, it is highlighted that depression has strong association and linkages with both diabetes and CVD and it should be considered and diagnosed at every stage of the diabetes to CVD continuum. Careful attention to the diagnosis and management of these disease states would contribute in lessening the CVD burden of the society.

Diabetes, Endothelial Dysfunction, and Vascular Repair: What Should a Diabetologist Keep His Eye on?

Cardiovascular complications are the most common complications of diabetes mellitus. A prominent attribute of diabetic cardiovascular complications is accelerated atherosclerosis, considered as a still incurable disease, at least at more advanced stages. The discovery of endothelial progenitor cells (EPCs), able to replace old and injured mature endothelial cells and capable of differentiating into healthy and functional endothelial cells, has offered the prospect of merging the traditional theories on the pathogenesis of atherosclerosis with evolving concepts of vascular biology. The literature supports the notion that EPC alterations are involved in the pathogenesis of vascular diseases in diabetics, but at present many questions remain unanswered. In this review the aspects linking endothelial progenitor cells to the altered vascular biology in diabetes mellitus are discussed.

The CHADS2 Score to Predict Stroke Risk in the Absence of Atrial Fibrillation in Hypertensive Patients Aged 65 Years or Older

INTRODUCTION AND OBJECTIVES

The CHADS2 score is a proven, essential tool for estimating cardioembolic risk (mainly stroke) in patients with nonvalvular atrial fibrillation, with the purpose of determining the indication for anticoagulant therapy. In this study we analyzed the use of CHADS2 in hypertensive patients without known atrial fibrillation in a Mediterranean population.

METHODS

The study included 887 hypertensive patients aged 65 years or older without atrial fibrillation or anticoagulant therapy, who attended a medical consultation. Data on the patients' main risk factors, cardiovascular history, and medication were collected, basic laboratory analyses and electrocardiography were performed, and the CHADS2 score (heart failure, hypertension, age ≥ 75 years, diabetes mellitus, and previous stroke or transient ischemic attack) was calculated. A clinical follow-up was carried out, recording hospital admissions for a stroke or transient ischemic attack. The median duration of follow-up was 804 days.

RESULTS

Mean age was 72.5 (SD,5.7) years, 46.6% were men, 27.8% had diabetes, and 8.6% were smokers. During follow-up, 40 patients were hospitalized for a stroke or transient ischemic attack (4.5%). The event-free survival analysis showed significant differences according to the CHADS2 score (log rank test, P < .001). On multivariate analysis, smoking and CHADS2 ≥3 were independent predictors of stroke or transient ischemic attack.

CONCLUSIONS

The CHADS2 may be useful for estimating the risk of stroke or transient ischemic attack in hypertensive patients without known atrial fibrillation.

Subclinical vascular endothelial dysfunctions and myocardial changes with type 1 diabetes mellitus in children and adolescents

Vascular endothelial dysfunction, accelerated thickening of arterial intima, and changes in ventricular functions contribute to increased cardiovascular morbidity in type 1 diabetes mellitus (T1DM). This study aimed to investigate the functional-structural changes in the arteries and myocardium together with affection of highly sensitive C-reactive protein (hsCRP), circulating endothelial cells (CECs), and vitamin C levels in children with T1DM. Also, to test the association with early atherosclerotic changes. The study included 30 children with a diagnosis of T1DM and 30 healthy subjects matched by sex, age, and body mass index. Serum lipids, HbA1c, hsCRP, vitamin C, and CECs were detected. Corrected QT interval (QTc), cardiac dimensions, and left ventricular (LV) functions were assessed using conventional echocardiography. Noninvasive ultrasound was used to measure brachial artery flow-mediated dilation (FMD) responses and carotid intima-media thickness (IMT). The QTc interval was significantly higher in the diabetic patients than in the control subjects (P < 0.001). The findings showed LV diastolic dysfunction as reflected by significantly lower early peak flow velocity, decreased E/A ratio, increased early filling deceleration time (DcT), and prolonged isovolumic relaxation time (IVRT) (P < 0.001 for each). The children with diabetes had a significantly lower FMD response, increased IMT, lower vitamin C level, higher hsCRP, and higher CEC compared with the control subjects (P < 0.001 for each). A positive correlation between CEC and HbA1c was found (P = 0.004). An alteration in myocardial function and endothelial dysfunction may begin early with the association of early atherosclerotic changes. These changes are accelerated when glycemic control is poor. The authors recommend early and close observation of children with diabetes for any alterations in cardiac and vascular endothelial function. Vitamin C supplementation may reduce the risk of complications.

The relationship between early atherosclerosis and endothelial dysfunction in type 1 diabetic patients as evidenced by measurement of carotid intima-media thickness and soluble CD146 levels: a cross sectional study

Background

Detection of early vascular changes prior to clinical manifestations of atherosclerosis, such as increased arterial carotid intima-media thickness (CIMT) and impaired endothelial function is of paramount importance for early identification of subjects at increased risk of accelerated atherosclerosis. The present study was designed to evaluate the relationship between early atherosclerosis and endothelial dysfunction in type 1 diabetic patients based on measurements of CIMT and soluble CD146 (sCD146) levels.

Methods

Thirty-seven patients with type 1 diabetes, 14 males (37.8%) and 23 females (62.2%), of mean (SD) age 26.2 (4.1) years admitted to the outpatient diabetes clinic at Okmeydani Training and Research Hospital, Istanbul, between January 2008 and December 2012, and 37 healthy controls, 16 males (43.2%) and 21 females (56.8%), of mean (SD) age 25.8 (3.1) years, selected from relatives of patients, were included. Anthropometric measures; fasting plasma glucose; and serum HbA1c, total cholesterol, HDL-cholesterol, LDL-cholesterol, triglyceride and creatinine concentrations were compared, as were CIMT and serum sCD146.

Results

Mean (SD) sCD146 levels were significantly higher in patients than in controls (314.6 (141.9) ng/ml vs. 207.8 (34.5) ng/ml, p = 0.001), but mean (SD) CIMT did not differ (0.5 (0.1) mm vs. 0.4 (0.1) mm). ROC curves for sCD146 significantly differed in differentiating type 1 diabetics from healthy controls (p = 0.0047) with a significantly higher percentage of patients than controls having sCD146 levels >260 ng/ml (21/37 (56.8%) vs. 2/37 (5.4%), p = 0.00011).

Conclusion

Our findings emphasize that sCD146 levels may be a more sensitive marker than CIMT for earlier identification of type 1 diabetic patients at high risk for atherosclerosis.

Circulating endothelial cell levels in psoriatic patients and their modification after an anti-TNF-alpha (Etanercept) treatment

BACKGROUND

Endothelial function in psoriatic patients has been mainly evaluated through a high-resolution ultrasound measurement of flow-mediated vasodilation in the brachial artery, which is an operator-dependent and technically demanding technique: this characteristic, together with different patient selection criteria, could account for the conflicting results emerging from different studies. Recently, Circulating Endothelial Cells (CECs) level has been suggested as a novel biomarker of vascular injury.

METHODS

The number of CECs was determined by a semi-automated immunomagnetic system (CellSearch system) in peripheral blood of psoriatic patients (n = 48) and healthy subjects (n = 50). In 15 patients, CEC level was also evaluated after 6 months of treatment with an anti-TNF-alpha agent, Etanercept. The plasma levels of high-sensitivity C-reactive Protein (CRP), E-selectin, VEGF and PAI-1 were measured by ELISA. The psoriasis severity was assessed by PASI score.

RESULTS

A statistically significant difference (P = 0.001) was found between CEC level in psoriatic patients (10.6 ± 9.4 cells/mL) vs. the control group (3.9 ± 0.9 cells/mL). This count inversely correlated with sE-selectin levels (r(2) = 0.16; P = 0.03). After 6 months of therapy, patients experienced a significant (P < 0.05) decrease in CEC levels (3.4 ± 1.3 cells/mL) and in PASI score (from 11.7 ± 8.1 to 2.1 ± 4.0).

CONCLUSIONS

The elevated CECs level that we found in a sample of high selected psoriatic patients could be expression of endothelial damage. Lowering of CECs count after treatment with Etanercept support the hypothesis that an effective systemic therapy of psoriasis may also improve the endothelial function.

Aspirin treatment hampers the use of plasma microRNA-126 as a biomarker for the progression of vascular disease

AIMS

MicroRNA-126 (miR-126) facilitates angiogenesis and regulates endothelial cell function. Recent data suggest that miR-126 can serve as a biomarker for vascular disease. Although endothelial cells are enriched for miR-126, platelets also contain miR-126. In this paper, we investigated the contribution of platelets to the pool of miR-126 in plasma of patients with type 2 diabetes (DM2) and how this is affected by aspirin.

METHODS AND RESULTS

In vitro platelet activation resulted in the transfer of miR-126 from the platelet to the plasma compartment, which was prevented by aspirin. In vivo platelet activation, monitored in patients with DM2 by measuring soluble P-selectin, correlated directly with circulating levels of miR-126. The administration of aspirin resulted both in platelet inhibition and concomitantly reduced circulating levels of platelet-derived microRNAs including miR-126.

CONCLUSION

Platelets are a major source of circulating miR-126. Consequently, in patho-physiological conditions associated with platelet activation, such as diabetes type 2, the administration of aspirin may lead to reduced levels of circulating miR-126. Thus, the use of platelet inhibitors should be taken into account when using plasma levels of miR-126 as a biomarker.

An observational study of endothelial function in early arthritis

BACKGROUND

Endothelial dysfunction is present in established rheumatoid arthritis, but it is not clear at what stage of the disease this abnormality develops. We set out to determine whether endothelial damage/dysfunction is present in a group of patients with early arthritis (EA) (new onset inflammatory arthritis, EA).

MATERIALS AND METHODS

Eighteen patients with EA, 48 healthy controls and 25 disease controls were recruited. Plasma was obtained for endothelial [von Willebrand factor (vWF) and soluble E-selectin] and angiogenesis markers (vascular endothelial growth factor and its receptor sFlt-1), adhesion molecules (intercellular adhesion molecule 1 and vascular cell adhesion molecule 1) and circulating endothelial cells (CECs, as a marker of endothelial damage). Microvascular endothelial function was assessed using laser Doppler perfusion imaging and macrovascular function using flow-mediated dilatation of the brachial artery.

RESULTS

von Willebrand factor and CECs (both P < 0.05) were significantly elevated in EA suggesting endothelial dysfunction and damage but were unrelated to classical laboratory markers of inflammation C-reactive protein, erythrocyte sedimentation rate or IL6. No other biomarkers was elevated in EA. Microvascular and macrovascular abnormalities were confined to endothelium-independent (smooth muscle cell) responses.

CONCLUSIONS

Endothelial damage/dysfunction is present early in the course of inflammatory arthritis but is not directly related to inflammation markers.

Amelioration of glucose control mobilizes circulating pericyte progenitor cells in type 2 diabetic patients with microangiopathy

Chronic diabetic complications result from an imbalance between vascular damage and regeneration. Several circulating lineage-committed progenitor cells have been implicated, but no data are available on pericyte progenitor cells (PPCs). Based on the evidence that PPCs increase in cancer patients after chemotherapy, we explored whether circulating PPC levels are affected by glucose control in type 2 diabetic patients, in relation to the presence of chronic complications. We enumerated peripheral blood PPCs as Syto16+CD45−CD31−CD140b+ events by flow cytometry at baseline and after 3 and 6 months of glucose control by means of add-on basal insulin therapy on top of oral agents in 38 poorly controlled type 2 diabetic patients. We found that, in patients with microangiopathy (n = 23), the level of circulating PPCs increased about 2 fold after 3 months and then returned to baseline at 6 months. In patients without microangiopathy (control group, n = 15), PPCs remained fairly stable during the whole study period. No relationship was found between change in PPCs and macroangiopathy (either peripheral, coronary, or cerebrovascular). We conclude that glucose control transiently mobilizes PPCs diabetic patients with microangiopathy. Increase in PPCs may represent a vasoregenerative event or may be a consequence of ameliorated glucose control on microvascular lesions.

Cellular biomarkers of endothelial health: microparticles, endothelial progenitor cells, and circulating endothelial cells

Endothelial dysfunction, the shift from a healthy endothelium to a damaged pro-coagulative, pro-inflammatory, and pro-vasoconstrictive phenotype, is an early event in many chronic diseases that frequently precedes cardiovascular complications. Functional assessment of the endothelium can identify endothelial damage and predict cardiovascular risk; however, this assessment provides little information as to the mechanisms underlying development of endothelial dysfunction. Changes in plasma asymmetric dimethyl arginine levels, markers of lipid peroxidation, circulating levels of inflammatory mediators, indices of coagulation and cellular surrogates such as microparticles, circulating endothelial cells, and endothelial progenitor cells may reflect alterations in endothelial status and as such have been defined as "biomarkers" of endothelial function. Biomarkers may be chemical or cellular. This review examines some markers of endothelial dysfunction, with a particular focus on cellular biomarkers of endothelial dysfunction and their diagnostic potential.

Off-pump or minimized on-pump coronary surgery--initial experience with Circulating Endothelial Cells (CEC) as a supersensitive marker of tissue damage

BACKGROUND

Off-pump-coronary-artery-bypass-grafting (OPCAB) and minimized-extracorporeal-circulation (Mini-HLM) have been proposed to avoid harmful effects of cardiopulmonary-bypass (CPB). Controversies exist whether OPCAB is still superior in perioperative outcome. Circulating endothelial cells (CEC) are sensitive markers of endothelial damage and are significantly elevated in conventional-CPB-procedures as compared to Mini-HLM-revascularisation. Therefore, CEC might be of specific value in evaluating effectiveness of Mini-HLM and OPCAB as currently applied less-invasive coronary procedures.

METHODS

76 coronary patients were randomly assigned either to OPCAB (n = 34) or to Mini-HLM (ROCsafe™, Terumo Inc., n = 42) procedures. Perioperative data, clinical and serological outcome and measurements of CEC-release and parameters of endothelial function (v.Willebrand-Factor, soluble-thrombomodulin) perioperatively (pre-operative-baseline, post-Mini-HLM/release of OPCAB-stabilizer, 6 h, 12 h, 24 h and 5 days postoperatively) were obtained and compared by ANOVA models including repeated-measures-analysis.

RESULTS

Mean graft-number was 3.06 ± 0.72 in Mini-HLM-patients and 1.89 ± 0.74 in OPCAB-patients (p < 0.001). However, ventilation-, ICU- and total-hospital duration were comparable between groups as well as chest-tube-drainage, transfusion requirements, hemodynamics and catecholaminergic support (p > 0.05). CEC-release did not differ between groups (p = 0.274) and was generally within normal limits, Troponin-T levels where not significanty different (p = 0.108). No myocardial infarctions, strokes or deaths occurred, neuron specific enolase (NSE) did not show any differences between groups (p = 0.194).

CONCLUSION

Conceptional advantages of minimized CPB systems (ROCsafe™) result in morbidity and mortality comparable with OPCAB procedures. Mini-HLM therefore minimizes CPB-related systemic and organ injury as demonstrated by low CEC-values which indicates intact endothelial integrity. Furthermore, Mini-HLM combines OPCAB-benefits with low morbidity in high-risk patients while facilitating more complete revascularization in complex patients.

C-reactive protein induces release of both endothelial microparticles and circulating endothelial cells in vitro and in vivo: further evidence of endothelial dysfunction

BACKGROUND

Inflammation is pivotal in atherosclerosis. A key early event in atherosclerosis is endothelial dysfunction. C-reactive protein (CRP), the prototypic marker of inflammation in humans, is a risk marker for cardiovascular disease, and there is mounting evidence to support its role in atherothrombosis. CRP has been shown to promote endothelial dysfunction both in vitro and in vivo. Emerging biomarkers of endothelial dysfunction include circulating endothelial cells (CECs) and endothelial microparticles (EMPs). However, there is a paucity of data examining the effect of CRP on CEC and EMP production in vitro and in vivo.

METHODS

In this report, we treated human aortic endothelial cells (HAECs) with increasing concentrations of CRP (0-50 μg/mL) or boiled CRP. We counted CECs and EMPs by flow cytometry.

RESULTS

Although CRP treatment resulted in a significant increase in release of both CECs and EMPs, boiled CRP failed to have an effect. Pretreatment of HAECs with sepiapterin or diethylenetriamine NONOate, both of which preserve nitric oxide (NO), resulted in attenuation of CRP's effects on CECs and EMPs. CD32 and CD64 blocking antibodies but not CD16 antibody or lectin-like oxidized LDL receptor 1 small interfering RNA (LOX-1 siRNA) prevented CRP-induced production of CECs and EMPs. Furthermore, delivery of human CRP to Wistar rats compared with human serum albumin resulted in significantly increased CECs and EMPs, corroborating the in vitro findings.

CONCLUSIONS

We provide novel data that CRP, via NO deficiency, promotes endothelial dysfunction by inducing release of CECs and EMPs, which are biomarkers of endothelial dysfunction.