Anneke Pietersma

Late Lumen Loss After Coronary Angioplasty Is Associated With the Activation Status of Circulating Phagocytes Before Treatment

BACKGROUND The purpose of this pilot study was to identify biological risk factors for restenosis after percutaneous transluminal coronary angioplasty (PTCA) to predict the long-term outcome of PTCA before treatment. METHODS AND RESULTS To investigate whether blood granulocytes and monocytes could determine luminal renarrowing after PTCA, several characteristics of these phagocytes were assessed before angioplasty in 32 patients who underwent PTCA of one coronary artery and who had repeat angiograms at 6-month follow-up. The plasma levels of interleukin (IL)-1 beta, tumor necrosis factor-alpha, IL-6, fibrinogen, C-reactive protein, and lipoprotein(a) before angioplasty were assessed as well. We found that the expression of the membrane antigens CD64, CD66, and CD67 by granulocytes was inversely associated with the luminal renarrowing normalized for vessel size (relative loss) at 6 months after PTCA, while the production of IL-1 beta by stimulated monocytes was positively associated with the relative loss. Next, these univariate predictors were corrected for the established clinical risk factors of dilation of the left anterior descending coronary artery and current smoking, which were statistically significant classic predictors in our patient group. Only the expression of CD67 did not predict late lumen loss independent of these established clinical risk factors. Multiple linear regression analysis showed that luminal renarrowing could be predicted reliably (R2 = .65; P < .0001) in this patient group on the basis of the vessel dilated and only two biological risk factors that reflect the activation status of blood phagocytes, ie, the expression of CD66 by granulocytes and the production of IL-1 beta by stimulated monocytes. CONCLUSIONS The results of the present study indicate that activated blood granulocytes prevent luminal renarrowing after PTCA, while activated blood monocytes promote late lumen loss. To validate this new finding, further study in an independent patient group is required.

Leukocyte adhesion molecules on the vascular endothelium: their role in the pathogenesis of cardiovascular disease and the mechanisms underlying their expression.

It is well known that granulocytes increase infarct size after reperfusion of the ischemic myocardium, and that monocytes promote atherogenesis. Those cells are also believed to play a contributory role in pathogenesis of coronary restenosis as response to arterial injury during balloon angioplasty. The adhesion of those leukocytes to the vascular endothelium is a prerequisite for their recruitment and accumulation in the lesion. Inflammatory mediators likely to occur under those conditions, e.g., histamine, thrombin, oxygen-derived free radicals (ODFR), interleukin (IL)-1, tumor necrosis factor (TNF)-alpha, and activated complement factors, induce in a distinct time course the (transient) expression of the leukocyte adhesion molecules P-selectin, E-selectin, intercellular adhesion molecule (ICAM)-1, and vascular cell adhesion molecule (VCAM)-1 on the endothelium. Only VCAM-1 is specific for monocytes; the others mediate the binding and subsequent extravasation of both monocytes and granulocytes. The response to the relevant inflammatory mediators, except for extracellularly produced ODFR, is coupled via specific receptors on the surface of the endothelium to specific signal transduction pathways and, except for P-selectin (early response), is directly dependent on protein synthesis (intermediate and late response). Protein kinase-C-induced phosphorylation of transcription factors is often shown to be involved. Protein synthesis is preceded by increased transcription of mRNA that is regulated in part by the transcription factor NF-kappa B. Indications have been obtained that intracellularly produced ODFR may be involved in the translocation of this transcription factor.(ABSTRACT TRUNCATED AT 250 WORDS)

Association of plasma fibrinogen levels with coronary artery disease, smoking and inflammatory markers

The plasma level of fibrinogen is associated with the risk of ischaemic heart disease (IHD) and the severity of atherosclerosis. It has been suggested that an increased plasma level of fibrinogen is a coronary risk indicator because it reflects the inflammatory condition of the vascular wall. An inflamed vascular wall may increase the production of the cytokines interleukin 6 (IL6), interleukin 1-beta (IL1-beta), and tumour necrosis factor alpha(TNF-alpha), which have a major role in the regulation of synthesis in the liver of acute phase proteins, including fibrinogen. Smoking has also been reported to increase the levels of fibrinogen and C-reactive protein (CRP). This may indicate that smoking induces an inflammatory reaction, probably of the pulmonary bronchi and alveolae. Therefore, we anticipated that with both types of inflammation the levels of acute phase proteins and cytokines would be related. We have investigated the contribution of inflammation to the plasma levels of fibrinogen in 34 patients with severe coronary artery disease (CAD) and 30 healthy controls comparable for age and smoking habits. We did not find a parallel in the effects of smoking and ischaemic heart disease on the plasma levels of fibrinogen, CRP, IL6, IL1-beta and TNF-alpha. Cardiovascular disease had its most important effect on the plasma fibrinogen level, while smoking appeared to increase the CRP levels, while both CAD and smoking seemed to affect the IL6 levels. Our results indicate that both smoking and CAD induce an inflammatory condition but that the increase of plasma levels of different inflammatory markers is complex. Although the acute phase reaction is the main regulatory mechanism of fibrinogen, the increase of fibrinogen in our group of CAD patients could not be fully explained by increased inflammation.

Evidence against the involvement of multiple radical generating sites in the expression of the vascular cell adhesion molecule-1.

The present study was undertaken to investigate the hypothesis that multiple oxygen radical generating systems contribute to the tumor necrosis factor (TNF) alpha-stimulated transcriptional activation of the vascular cell adhesion molecule (VCAM)-1 in endothelial cells. Experimental evidence has implicated the cytochrome P450 monooxygenase and a phagocyte type NADPH-oxidase as a source of oxygen radicals in these cells. We show here that endothelial cells exhibit cytochrome P450 activity by measuring the O-dealkylation of the exogenous substrate 7-ethoxyresorufin, but components of the phagocyte-type NADPH oxidase could not be demonstrated in endothelial cells. In that latter respect it was surprising that the NADPH oxidase inhibitor apocynin completely prevented the accumulation of VCAM-1 mRNA. However, we found that apocynin also acts as an inhibitor of cytochrome P450 activity in endothelial cells. Therefore the inhibitory effect of apocynin on the induction of VCAM-1 may no longer be used to demonstrate a role for the NADPH oxidase in this process. Furthermore, different cytochrome P450 inhibitors Co2+, metyrapone, SKF525a decreased the endothelial VCAM-1 expression stimulated by TNFalpha. Also under hypoxic conditions the expression of VCAM-1 was reduced. On this basis we assume that the oxygen dependent step in the intracellular signalling cascade underlying the TNFalpha stimulated transcriptional activation of VCAM-1 resides in the activity of a cytochrome P450 dependent monooxygenase. The finding that the phospholipase A2 inhibitor bromophenacylbromide inhibited the expression of VCAM-1 may indicate that arachidonic acid serves as a substrate for the cytochrome P450 monooxygenase reaction, but further research is needed to elucidate the particular cytochrome P450 family member mediating the expression of VCAM-1.

Studies on the interaction of leucocytes and the myocardial vasculature. I. Effect of hypoxia on the adherence of blood granulocytes

Granulytes play an important role in increasing the infarct size after ischemia and reperfusion by the release of oxygen-derived free radicals (ODFR) and lysosomal enzymes. It has been shown that the number of granulocytes adhering to the vascular endothelium increases after occlusion of the coronary artery, and that the area of myocardial damage can be reduced by preventing granulocyte adherence with monoclonal antibodies directed against adhesion receptors. The underlying mechanism of granulocyte activation under these conditions is not yet known. We have investigated whether granulocytes can be activated directly by reduced oxygen tensions. Granulocytes were suspended in a hypoxic buffer and incubated on fibronectin and gelatin coated microtitre plates at 1–3% ambient oxygen to study their ability to adhere to these matrices. The results showed that the adherence of granulocytes to fibronectin was dependent on the duration of hypoxia. After 30 min of incubation under hypoxia granulocyte adherence increased 1.3 to 1.8 fold compared to the normoxic control. The adherence to fibronectin could be inhibited partially by anti-CD18 antibody, a monoclonal antibody to the common beta chain of a class of extracellular matrix receptors. This direct activation of granulocytes due to hypoxic conditions may have implications for the interaction of these cells with the vascular endotheliumin vivo, (Mol Cell Biochem116: 197–202, 1992)

Extreme hypoxia decreases the adherence of granulocytes to endothelial cells in vitro

Exposure of HUVEC to extreme hypoxia for a short period of 30 min had no significant effect on the adherence properties of these cells (FIG. 1). When the duration of hypoxia was increased to 2 h the adherence of PMN significantly ( p < 0.02) decreased to about 50% of the normoxic control (FIG. 1). The decreased adherence was not due to a functional impairment of the PMN.3 This suggested that hypoxia directly affects the endothelial cells. Since the viability of these cells did not decrease, the present finding could possibly be due to an increased generation of anti-adhesive factors or a decreased basal expression of leukocyte endothelial cell adhesion molecules. Neither of these possibilities was found to be true.4 The present results seem paradoxical to the in ptvo situation where marginating granulocytes are suspect of mediating some of the early consequences (e.g. , edema) of ischemia. However, when we stimulated HUVEC with lipopolysaccharide (LPS, 0.1 pg/ml) during the 2 h period of hypoxia, PMN adherence increased fivefold. Stimulation of HUVEC with LPS under normoxic conditions increased the adherence of PMN only twoto threefold, but because of a higher basal adherence the number

Studies on the interaction of leucocytes and the myocardial vasculature

Granulytes play an important role in increasing the infarct size after ischemia and reperfusion by the release of oxygen-derived free radicals (ODFR) and lysosomal enzymes. It has been shown that the number of granulocytes adhering to the vascular endothelium increases after occlusion of the coronary artery, and that the area of myocardial damage can be reduced by preventing granulocyte adherence with monoclonal antibodies directed against adhesion receptors. The underlying mechanism of granulocyte activation under these conditions is not yet known. We have investigated whether granulocytes can be activated directly by reduced oxygen tensions. Granulocytes were suspend- ed in a hypoxic buffer and incubated on fibronectin and gelatin coated microtitre plates at 1–3% ambient oxygen to study their ability to adhere to these matrices. The results showed that the adherence of granulocytes to fibronectin was dependent on the duration of hypoxia. After 30 min of incubation under hypoxia granulocyte adherence increased 1.3 to 1.8 fold compared to the normoxic control. The adherence to fibronectin could be inhibited partially by anti-CD18 antibody, a monoclonal antibody to the common beta chain of a class of extracellular matrix receptors. This direct activation of granulocytes due to hypoxic conditions may have implications for the interaction of these cells with the vascular endothelium in vivo, (Mol Cell Biochem 116: 197–202, 1992)

Are Free Radicals Involved in the Expression of Adhesion Molecules

It is beyond doubt that the adhesion of leukocytes to the endothelial lining of the vascular wall plays a key role in various biological processes, including inflammation and thrombosis. This phenomenon is the result of a complex interplay among blood flow, cell adhesion and molecular vascular biology factors. Normally, the circulating granulocytes and monocytes in peripheral blood are distributed over a circulating pool and a marginating pool. The marginating pool comprises about 60% of the total number of cells (Athens, Raab, Haab, Aschenbrucker, and Cartwright, 1961; Van Furth and Sluiter, 1986). The leukocytes of the marginating pool roll along the endothelial line of the vessel. This rolling is governed by the shear force of the flowing blood and the strength of the ionic bonds with the vascular endothelium (Tangelden and Afors, 1991). Under inflammatory conditions the number of rolling leukocytes in the postcapillary vesicles increases drastically. Those leukocytes adhere selectively to the endothelium. Next, these cells traverse the vessel wall between adjacent endothelial cells keeping the monolayer intact, pass the subendothelial layer and accumulate at the site of the inflammation. Strinkingly, granulocytes are commonly the first cells here, followed by the monocytes. It is obvious that knowledge of the mechanism(s) by which granulocytes and monocytes adhere to the vessel wall will enlarge therapeutic modalities (Sluiter, Pietersma, Lamers, and Koster, 1993).

Hypoxia and Endothelial Cell Adhesiveness

Ischemia is a common clinical event leading to local and remote tissue injury. Reperfusion of the ischemic tissues is associated with a local activation and infiltration of granulocytes (Lucchesi et al., Werns et al). These cells form a potential threat to the function and integrity of the endothelial barrier (Wedmore et al), since they can mediate tissue damage by the release of cytotoxic agents, e.g., oxygen derived free radicals and lysosomal enzymes.