Felix Böhm

Effect of postconditioning on infarct size in patients with ST elevation myocardial infarction

Background Small studies suggest that postconditioning reperfusion interrupted by brief repetitive cycles of reocclusions, may protect the myocardium in the clinical setting. Objective To test the hypothesis that postconditioning limits infarct size in relation to the area at risk in patients with ST elevation myocardial infarction (STEMI). Methods 76 patients (aged 37–87 years) eligible for primary percutaneous coronary intervention due to STEMI were randomised to standard percutaneous coronary intervention (n=38) or postconditioning, consisting of four cycles of 60 s reperfusion and 60 s of reocclusion before permanent reperfusion (n=38). Results The area at risk was determined from angiographic abnormally contracting segments. Infarct size was quantified from delayed enhancement MRI on days 6–9. Infarct size, expressed in relation to the area at risk, did not differ between the control group (44%; 30, 56) (median and quartiles) and the post-conditioned group (47%; 23, 63). The slope of the regression lines relating infarct size to the area at risk differed between the two groups. Infarct size was significantly (p=0.001) reduced by postconditioning in patients with large areas at risk. The area under the curve and peak troponin T release and CKMB during 48 h did not differ between patients in the control and postconditioning groups. Conclusions This prospective, randomised trial suggests that postconditioning does not reduce infarct size in patients with STEMI in the overall study group. The data indicate that postconditioning may be of value in patients with large areas at risk. Clinical trial registration information Karolinska Clinical Trial Registration (http://www.kctr.se). Unique identifier: CT20080014.

Urotensin II evokes potent vasoconstriction in humans in vivo

The peptide urotensin II (U II) evokes potent vasoconstriction in non‐human primates. In human blood vessels studied in vitro variable effects of U II are reported; vasoconstriction, vasodilatation or no response. It is therefore of importance to determine the vascular effect of U II in humans in vivo. U II (0.1 – 300 pmol min−1) was infused into the brachial artery of nine healthy volunteers. Changes in forearm blood flow (FBF) were determined by venous occlusion plethysmography. U II induced dose‐dependent reduction in FBF. A threshold response was obtained by 1 pmol min−1, and the highest dose of U II (300 pmol min−1) reduced FBF by 31±4% (P<0.01). FBF returned to baseline values within 30 min. This study demonstrates that U II produces potent vasoconstriction in humans in vivo.

Arginase Inhibition Improves Endothelial Function in Patients With Coronary Artery Disease and Type 2 Diabetes Mellitus

Background— Endothelial dysfunction plays an important role in the early development of atherosclerosis and vascular complications in type 2 diabetes mellitus. Increased expression and activity of arginase, metabolizing the nitric oxide substrate L-arginine, may result in reduced production of nitric oxide and thereby endothelial dysfunction. We hypothesized that inhibition of arginase activity improves endothelial function in patients with coronary artery disease (CAD) and type 2 diabetes mellitus. Methods and Results— Three groups of subjects were included: 16 patients with CAD, 16 patients with CAD and type 2 diabetes mellitus (CAD+Diabetes), and 16 age-matched healthy control subjects. Forearm endothelium-dependent and endothelium-independent vasodilatation were assessed with venous occlusion plethysmography before and during intra-arterial infusion of the arginase inhibitor N&ohgr;-hydroxy-nor-L-arginine (nor-NOHA; 0.1 mg/min). Nor-NOHA was also coinfused with the nitric oxide synthase inhibitor (NG-monomethyl L-arginine). The expression of arginase was determined in the internal mammary artery of patients undergoing bypass surgery. Nor-NOHA markedly increased endothelium-dependent vasodilatation (up to 2-fold) in patients with CAD+Diabetes and CAD (P<0.001) but not in the control group. NG-monomethyl L-arginine completely inhibited the increase in endothelium-dependent vasodilatation induced by nor-NOHA. Endothelium-independent vasodilatation was slightly improved by nor-NOHA in the CAD+Diabetes group. Arginase I was expressed in vascular smooth muscle cells and endothelial cells, and arginase II was expressed in endothelial cells of patients with and without diabetes mellitus. Conclusions— Arginase inhibition markedly improves endothelial function in patients with CAD and type 2 diabetes mellitus suggesting that increased arginase activity is a key factor in the development of endothelial dysfunction.

Cholesterol lowering is more important than pleiotropic effects of statins for endothelial function in patients with dysglycaemia and coronary artery disease.

AIMS The importance of pleiotropic effects of statins on endothelial function and inflammatory markers was investigated in patients with dysglycaemia and coronary artery disease (CAD). METHODS AND RESULTS Thirty-nine patients were randomized to simvastatin 80 mg daily (S80; n = 20) or ezetimibe 10 mg and simvastatin 10 mg daily (E10/S10; n = 19) for 6 weeks, aiming at similar cholesterol reduction. Endothelial function, evaluated by brachial artery flow-mediated vasodilatation (FMD) and the effect of endothelin receptor blockade, serum lipids, and inflammatory markers were evaluated at baseline and follow-up. At follow-up, low-density lipoprotein cholesterol decreased from 3.1 (2.8-3.4) (median and quartiles) to 1.5 mmol/L (1.4-1.7) and from 3.0 (2.5-3.4) to 1.3 mmol/L (1.1-1.8), in the S80 and E10/S10 groups, respectively. In the entire study group, FMD increased from 4.3% (3.4-6.1) at baseline to 5.5% (3.4-6.6) at follow-up, while C-reactive protein decreased from 3.1 (1.7-7.6) to 2.3 mg/L (0.9-6.5). The changes in FMD and C-reactive protein from baseline to follow-up were not significantly different between patients on S80 and E10/S10 groups. Endothelin blockade enhanced endothelium-dependent vasodilatation both at baseline and follow-up. CONCLUSION Lipid lowering is more important than pleiotropic effects of statins for improvement in endothelial function and inflammatory markers in patients with dysglycaemia and CAD.

New perspectives on endothelin-1 in atherosclerosis and diabetes mellitus

Endothelin-1 (ET-1) is a vasoconstrictor, proinflammatory and proliferative endothelial cell-derived peptide that is of significant importance in the regulation of vascular function. It is involved in the development of endothelial dysfunction including important interactions with nitric oxide. The expression and functional effects of ET-1 and its receptors are markedly altered during development of cardiovascular disease. Increased production of ET-1 and its receptors mediate many pathophysiological events contributing to the development of atherosclerosis and vascular complications in diabetes mellitus. The present review focuses on the pathophysiological role of ET-1 and the potential importance of ET receptors as a therapeutic target for treatment of these conditions.

Endothelin-1 inhibits endothelium-dependent vasodilatation in the human forearm : reversal by ETA receptor blockade in patients with atherosclerosis

Several cardiovascular disorders, including atherosclerosis, are associated with endothelial dysfunction and enhanced expression of endothelin-1 (ET-1). The role of ET-1 in the development of endothelial dysfunction in vivo remains unclear. The objective of the present study was to investigate the effect of elevated circulating levels of ET-1 on endothelium-dependent vasodilatation (EDV), and to test the hypothesis that ET(A) receptor antagonism improves EDV in patients with atherosclerosis. EDV and endothelium-independent vasodilatation were determined by brachial artery infusion of acetylcholine and sodium nitroprusside respectively during measurement of forearm blood flow (FBF) with venous occlusion plethysmography. A 60 min intra-arterial infusion of ET-1 (n=10) significantly blunted EDV in young healthy males (33 +/- 13% compared with 271 +/- 74% increase in FBF induced by 10 mug/min acetylcholine; P<0.01). Noradrenaline, which evoked a similar degree of vasoconstriction, did not attenuate EDV. In a separate set of experiments, a 60 min intra-arterial infusion of the selective ET(A) receptor antagonist BQ123 evoked a significant increase in EDV in patients with atherosclerosis (n=10; 109 +/- 45% compared with 255 +/- 101% increase in FBF induced by 10 microg/min acetylcholine; P<0.01), whereas no significant change was observed in healthy age-matched controls (n=9). Endothelium-independent vasodilatation was not affected by ET-1 or BQ123. These observations demonstrate that elevated levels of ET-1 impair EDV in healthy control subjects. Furthermore, ET(A) receptor blockade improves EDV in patients with atherosclerosis, indicating that ET-1 attenuates EDV via an ET(A)-receptor-mediated mechanism.

Combined Endothelin Receptor Blockade Evokes Enhanced Vasodilatation in Patients With Atherosclerosis

Endothelin (ET)-1 causes vasoconstriction via ETA and ETB receptors located on vascular smooth muscle cells and vasodilatation via ETB receptors on endothelial cells. Studies in vitro indicate an upregulation of ETB receptors in atherosclerosis. The present study investigated the vascular effects evoked by endogenous ET-1 in atherosclerotic patients. Forearm blood flow (FBF) was measured with venous occlusion plethysmography in 10 patients with atherosclerosis and in 10 healthy control subjects during intra-arterial infusion of selective ET receptor antagonists. The ETB receptor antagonist BQ788 evoked a significant increase in FBF (31±13%) in the patients, whereas a 20±9% reduction was observed in the control subjects. The ETA receptor antagonist BQ123 combined with BQ788 evoked a marked increase in FBF (102±25%) in the patients compared with no effect in the control subjects (−3±9%, P <0.001 versus patients). The ETA receptor antagonist BQ123 increased FBF to a similar degree in patients (39±11%) as in control subjects (41±11%). The increase in FBF evoked by selective ETA receptor blockade was significantly (P <0.05) less than that evoked by combined ETA/ETB receptor blockade in the atherosclerotic patients. These observations suggest an enhanced ET-1–mediated vascular tone in atherosclerotic patients, which is at least partly due to increased ETB-mediated vasoconstriction.

ETA receptors mediate vasoconstriction, whereas ETB receptors clear endothelin-1 in the splanchnic and renal circulation of healthy men

The contribution of the endothelin (ET) receptors ET(A) and ET(B) to basal vascular tone and ET-1-induced vasoconstriction in the renal and splanchnic vasculature was investigated in six healthy humans. ET-1 was infused alone and in combination with the selective ET(A) receptor antagonist BQ123 or the selective ET(B) receptor antagonist BQ788 on three different occasions. BQ123 did not affect basal arterial blood pressure, splanchnic vascular resistance (SplVR) or renal vascular resistance (RVR), but inhibited the increase in vascular resistance induced by ET-1 [64+/-18 versus -1+/-7% in SplVR ( P <0.05); 36+/-6 versus 12+/-3% in RVR ( P <0.0001)]. BQ788 increased basal SplVR and RVR [38+/-16% ( P =0.01) and 21+/-5% ( P <0.0001) respectively], and potentiated the ET-1-induced vasoconstriction. Plasma ET-1 increased more after ET(B) blockade than under control conditions or after ET(A) blockade. These findings suggest that the ET(A) receptor mediates the splanchnic and renal vasoconstriction induced by ET-1 in healthy humans. The ET(B) receptor seems to function as a clearance receptor and may modulate vascular tone by altering the plasma concentration of ET-1.

Different subpopulations of endothelial progenitor cells and circulating apoptotic progenitor cells in patients with vascular disease and diabetes

AIMS Endothelial progenitor cells (EPCs) represent a repair mechanism involving reendothelialization and neoangiogenesis. Patients with both diabetes and known vascular disease have low numbers of circulating EPCs. To assess the role of diabetes in vascular disease we investigated the number and viability of circulating EPCs and related this to endothelial function. METHODS Different EPC subpopulations were enumerated by flow cytometry using triple staining (CD34, CD133, KDR). Viability was assessed by 7AAD and Annexin-V-staining. Endothelial function was evaluated by Endo-PAT2000 in 19 patients with known vascular disease without diabetes and 20 patients with vascular disease and diabetes mellitus. RESULTS CD34+, CD133+, CD34+/CD133+, CD34+/KDR+, CD34+/CD133+/KDR+ cell counts did not differ between patients with and without diabetes. CD34-/CD133+/KDR+ cells were lower, whereas staining for apoptosis in progenitor cells was higher in patients with diabetes. Progenitor cell counts did not correlate to peripheral arterial function test. DISCUSSION Patients having diabetes and vascular disease have lower CD34-/CD133+/KDR+ EPC counts, a recently discovered subpopulation of EPCs, and larger proportion of apoptotic EPCs. Higher apoptotic rates of progenitor cells in diabetes could represent an important mechanism explaining lower functional capability of these cells. These observations may be of importance for the complications associated with diabetes mellitus.

Enhanced vasoconstrictor response to endothelin-B-receptor stimulation in patients with atherosclerosis

The vascular responses to endothelin-1 [ET-1; nonselective endothelin-A and -B (ET(A) and ET(B) agonist)] and sarafotoxin 6c (S6c; ET(B) agonist) were investigated in patients with atherosclerosis. ET-1 and S6c (3, 10 and 30 pmol/min) were infused into the brachial artery while forearm blood flow (FBF) was measured by venous occlusion plethysmography in seven male patients with atherosclerosis and six age-matched healthy male controls. S6c evoked an initial increase followed by a dose-dependent reduction in FBF. The initial dilator component did not differ between the two groups. The vasoconstrictor component of the two lower doses of S6c was significantly larger in the atherosclerotic patients than in controls. The reduction in FBF induced by 3 and 10 pmol/min S6c was 18 +/- 2% and 27 +/- 6% in the control group compared to 29 +/- 3% (p < 0.02) and 42 +/- 2% (p < 0.05) in patients with atherosclerosis. The vasoconstrictor response to S6c correlated with low-density lipoprotein (LDL) cholesterol levels (r = 0.47, p < 0.05). The vasoconstrictor response to ET-1 was similar in the two groups. It is concluded that the forearm vasoconstrictor response to S6c but not that to ET-1 is enhanced in patients with atherosclerosis as compared with healthy controls. This finding suggests an upregulation of vascular smooth muscle ET(B)-receptors in atherosclerosis.