ΕΝΔΟΘΗΛΙΑΚΟΣ ΓΛΥΚΟΚΑΛΥΚΑΣ. ΕΝΑΣ ΕΚΚΟΛΑΠΤΟΜΕΝΟΣ ΣΤΟΧΟΣ ΤΗΣ ΠΡΟΛΗΠΤΙΚΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ?

Transcription

1 ΕΝΔΟΘΗΛΙΑΚΟΣ ΓΛΥΚΟΚΑΛΥΚΑΣ. ΕΝΑΣ ΕΚΚΟΛΑΠΤΟΜΕΝΟΣ ΣΤΟΧΟΣ ΤΗΣ ΠΡΟΛΗΠΤΙΚΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ? ΙΩΑΝΝΗΣ ΛΕΚΑΚΗΣ ΚΑΘΗΓΗΤΗΣ ΚΑΡΔΙΟΛΟΓΙΑΣ Β ΠΑΝΕΠΙΣΤΗΜΙΑΚΗ ΚΑΡΔΙΟΛΟΓΙΚΗ ΚΛΙΝΙΚΗ, ΕΚΠΑ ΝΟΣΟΚΟΜΕΙΟ ΑΤΤΙΚΟΝ

2 Endothelial Glycocalyx. S Reitsma, DW Slaaf, H Vink et al. The endothelial glycocalyx: composition, functions, and visualization. Pflugers Arch. 2007

3 Endothelial Glycocalyx of at least 200 nm on the luminal side of healthy vasculature plays a vital role in vascular permeability

4 Endothelial glycocalyx: a vital role in vascular permeability and inflammation

5 Endothelial Glycocalyx Damage to the endothelial glycocalyx is associated with influx of lipoproteins, leakage of macromolecules adhesion of circulating cells to the endothelium. to an imbalance in enzymatic systems such as coagulation and antioxidant defence as well as an impaired NO release. Lekakis J, Ikonomidis I,Vlachopoulos C Eur J Cardiovasc Prev Rehabil Dec;18(6):775-89

6 Vink H Pflugers Arch. 2007

7 METHODS TO ASSESS GLYCOCALYX Electron microscopy (Luft JH 1966) Intravital miscroscopy Two-photon laser scanning microscopy (antibodies against glycocalyx proteins with fluoresence properties)

8 METHODS TO ASSESS GLYCOCALYX in vivo Systemic glycocalyx volume is measured using a glycocalyx permeable tracer (Dextran 40) v.s a glycocalyx impermeable tracer, (fluorescein-labelled erythrocytes). differences in intravascular volumes that these tracers occupy renders a reasonable estimation of whole-body glycocalyx volume. the invasive nature and the time consuming preparations

9 METHODS TO ASSESS GLYCOCALYX in vivo Noninvasive: a semiautomated imaging method to estimate glycocalyx thickness by OPS (Orthogonal Polarization Spectral imaging) SDF (Sideview Darkfield imaging) at the superficial microvasculature this imaging method uses the erythrocyte endothelium gap of the capillaries in the image to quantify glycocalyx thickness.

10 Increased PBR: an accurate index of reduced endothelial glycocalyx thickness

11 GLYCOCHECK CAMERA 1. Collected movie frame (Ν=40) 2. Vascular segments defined (Ν=75) Small vascular segments every 10 μm along the length of the detected vasculature: 840 radial intensity profiles are obtained for RBC-perfused lumen

12 GLYCOCHECK CAMERA 3. For each vascular segment: calculation of RBC column width for series of consecutive frames 4. For each vascular segment: calculation of PBR Dperf (RBC-perfused lumen) RBC column width (µm) Frames P50 (RBCW) Glycocalyx (RBC permeable) Outer edge of RBC-perfused core 40 frames x 75 segments=3000 DURATION :3min PBR (Perfused Boundary Region) PBR=(Dperf RBCW) / 2

13 MICROSCAN CAMERA

14 GLYCOCALYX EXAMINATION

15 GLYCOCALYX RESULTS (Microns) (Microns)

16 NORMAL VALUES REPRODUCIBILITY

17 Endothelial glycocalyx damage Hypercholesterolemia (partial reversal by statins Acute Hyperglycemia Association with carotid IMT in type 1 diabetes Renal disease Inflammation-sepsis Lekakis J, Ikonomidis I,Vlachopoulos C Eur J Cardiovasc Prev Rehabil Dec;18(6):775-89

18 Glycocalyx measurement Pilot data of PBR values obtained with GlycoCheck TM Glycocalyx Measurement Software in healthy young volunteers on two consecutive visits, in healthy old subjects (age: years), in type 2 diabetics, and in critical ill patients during septic shock. Groups consist of n=11-16 patients.

19 Vink H et al. Circulation. 2000;101: Examples of light microscopic images of RBCs flowing through a hamster cremaster muscle capillary during an Ox-LDL experiment, showing gap between flowing RBCs and luminal EC membrane. Reduction 24, and 70 min after bolus injection of Ox-LDL

20 Damage of the Endothelial Glycocalyx in Dialysis Patients

21 Damage of the Endothelial Glycocalyx in Dialysis Patients with high CRP

22 Damage of the Endothelial Glycocalyx in Dialysis Patients with CVD

23 Effect of age and sepsis Young1 Young2 Age Diabetes 60-83y Sepsis survivors Sepsis Non-survivors Virulence 5:1, 73 79; January 1, 2014

24 Endothelial Glycocalyx in Sepsis Sublingual microcirculation in sepsis. Relationship between sublingual microcirculation and ICU mortality in patients with severe sepsis. D De Backer et al:pathophysiology of microcirculatory dysfunction and the pathogenesis of septic shock. Virulence 5:1, 73 79; January 1, 2014

25 Endothelial glycocalyx thickness in various cohorts Results of Perfused Boundary Region (PBR) in healthy controls (n=20), hypertensives (n=101), smokers (n=130), patients with psoriasis (n=72) and diabetics (n=36).*p<0.05 patients vs controls. Laboratory of Preventive Cardiology, Attikon Hospital AHA 2013

26 EFFECT OF SMOKING REDUCTION ON ENDOTHELIAL GLYCOCALYX AND ARTERIAL WAVE REFLECTION DURING MEDICALLY-AIDED SMOKING CESSATION PROGRAM I.IKONOMIDIS, K. KOUREA, G. PAVLIDIS, I. TSOUGOS, M. MARINOU, I. PAPADAKIS, H. TRIANTAFYLLIDI, M. ANASTASIOU-NANA, J. LEKAKIS UNIVERSITY OF ATHENS MEDICAL SCHOOL, ATTIKON HOSPITAL, 2 ND DEPARTMENT OF CARDIOLOGY, ATHENS, GREECE AHA 2013 Circulation. 2013;128:A12610

27 RESULTS SMOKERS (N=180) p* NON-SMOKERS (n=40) p # BASELINE 12 WEEKS Cigarettes, n 31±8 6±9 < <0.05 CO, ppm 32±18 10±13 < ±1.1 <0.05 PBR, microns 2.03± ±0.24 < ±0.14 <0.05 PWVc, m/sec 10±2 10±2 NS 8.5±2 <0.05 AI, % 33±18 15±10 < ±10 <0.05 * Baseline vs. 12 weeks in smokers # Smokers vs. non-smokers at baseline

28 GLYCOCALYX RESULTS

29 Effects of smoking cessation on glycocalyx Greater CO reduction by var vs NRT

30 RESULTS- 3 months post smoking cessation PBR was related with CO (r=0.88, p<0.05) PBR was related with AI (r=0.47, p<0.05)

31 Effects of smoking relapse vs. smoking abstinence 12months after a medically assisted smoking cessation program

32 CONCLUSION Endothelial glycocalyx thickness is reduced in smokers compared to non smokers. Medically-aided smoking reduction contributes to restoration of endothelial glycocalyx thickness and reduction of abnormal wave reflections. Improvement of endothelial glycocalyx is linked with improved arterial elasticity during smoking cessation.

33 Impaired endothelial glucocalyx is related with abnormal aortic and coronary function in newly diagnosed untreated hypertensives I.Ikonomidis, A. Voumvourakis, M. Varoudi, I. Papadakis, G. Pavlidis, H. Triantafyllidi, M. Anastasiou-Nana, J. Lekakis Second Department of Cardiology, University of Athens Medical School, Attikon University Hospital, Athens, Greece. ΑΗΑ 2013, Circulation. 2013;128:A11263

34 RESULTS Compared to controls, hypertensives HYPERTENSIVES (Ν=101) CONTROLS (Ν=50) PBR 2,02±0,17 1,89±0,14 PWVc 10±2 8,5±2 csbp 140±21 95±20 cpp 46±17 30±5 AI 28±16 15±10 CFR 2,5±0,7 3,5±1 GLS -17±4-22±2,5

35 Glycocalyx and central SBP R=0.50 p<0.01

36 Glycocalyx and PWV R=0.47 p<0.01

37 Glycocalyx thickness and CFR in hypertensives R=0.40 p<0.05

38 Conclusion Endothelial glucocalyx -is impaired in newly diagnosed untreated hypertensives and -is related with abnormal aortic elastic properties and coronary microcirculatory function leading to impaired LV longitudinal deformation

39 Intact glycocalyx in associated with fetuin: a biofactor preventing vascular calcification in psoriasis r=-0.48, P<0.05

40 Glycocalyx in psoriasis Reduced endothelial glucocalyx thickness as assessed by increased PBR was related with increased: P<0.05 for all associations. PBR among 5-9 micron showed higher correlation coefficients with the above markers.

41 Glycocalyx and hyperglycemia Acute and long-term hyperglycemia, high vascular shear stress, oxidative stress and inflammation are associated with the profound thinning of the glycocalyx. Impaired glycocalyx facilitates attachment and rolling of circulating inflammatory cells in the subendothelial space and increases endothelial permeability to oxidiced lipids and proteins. Thus, reduced glycocalyx thickness may promote inflammation, oxidative stress and apoptosis within the myocardial layers. Reduced glycocalyx thickness and impaired LV longitudinal strain and twisting-untwisting play an important role in the pathogenesis of diabetic heart.

42 Changes in glycocalyx thickness and LV myocardial deformation during oral glucose tolerance test (OGTT) NORMOGLYCAEMIC SUBJECTS (n=20) FIRST DEGREE RELATIVES (n=40) DYSGLYCAEMIC SUBJECTS (n=40) Time, min GLS, % -19.2± ± ± ±2.3* -16.8±2-16.2±1.4 ptw, deg 16.9± ±4.7* 14.4± ±5.8* 15.6± ±6.0* putwvel, deg/sec ± ± ± ±34.9* -103± ±37* PBR, µm 2.4± ± ± ±0.4* 2.5± ±0.4* *p<0.05, p<0.01 vs. baseline. p<0.05 for normoglycaemic vs. first degree relatives and dysglycaemic subjects at baseline.

43 Association of insulin resistance with endothelial glycocalyx thickness Association of tertiles (T1-T2-T3) of Matsuda index with perfused boundary region (PBR) measured in the microvessels ranged from 20-25µm indicating a damaged glycocalyx at baseline in all subjects (F=4.8, p=0.03). *p=0.04 by post hoc analysis for comparison of T1 vs. T2 and T3. I. Ikonomidis et al. ESC Congress 2016

44 Glycocalyx and LV myocardial strain Association of tertiles (T1-T2-T3) of perfused boundary region (PBR) measured in the microvessels ranged from 20-25µm with global longitudinal strain at baseline (F=4.4, p<0.005) and 120 min of OGTT (F=5.4, p<0.001), in first degree relatives. *p<0.05 by post hoc analysis for comparison of T1 vs. T2 and T3. I. Ikonomidis et al. ESC Congress 2016

45 Effects of glycemic control on arterial properties in diabetics (n=75) Time, months baseline 6m -Post treatment HbA1c, % 8.7±3 6.2±0.9 <0.05 Fasting Glucose, mg/dl 172±44 108±19 <0.05 PWVc, m/sec 12.3± ±3.2 <0.05 p PBR, µm 2.17± ±0.2 <0.05 puntwvel, deg/ sec -88±31-98±33 <0.05 %dptw-utw MVO 25±9 31±2 <0.05 %dptw-utw PEF 46±17 56±19 <0.05 FMD% 8.6±5 12.2±6 <0.01

46 CONCLUSION Glycaemic control after optimizing medical treatment imrpoves arterial stifness, LV myocardial strain, twistinguntwisting velocity and glycocalyx thickness in diabetics.

47 Remote ischemic conditioning results in oxidative stress reduction and nitrate- nitrite- nitric oxide pathway activation in acute myocardial infarction patients I. Ikonomidis¹, D. Vlastos², I. Andreadou², P. Efentakis², M. Varoudi², G. Pavlidis², G. Makavos², S. Vlachos², D. Mpenas², H. Triantafyllidi², E. Seitanidi², EK. Iliodromitis², J. Lekakis² - (1) University of Athens, Athens, Greece; (2) University of Athens Medical School, Attikon Hospital, 2nd Department of Cardiology, Athens, Greece

48 METHODS

49 RESULTS 2,5 PBR single cuff 2,4 PBR double cuff 2,325 2,25 2,15 2,1 1,975 1,95 1,8 T0 T1 T2 T3 1,8 T0 T1 T2 T3

50 RESULTS 2,8 MDA 13 NOx 2,6 11,25 2,4 9,5 2,1 7,75 1,9 Τ0 p>0.05 single cuff double cuff T3 6 Τ0 p<0.05 single cuff double cuff T3

51 CONCLUSION Remote ischemic conditioning by a single 5-min cuff inflation confers acute short-term improvement of vascular function, likely through oxidative stress reduction and nitratenitrite-no pathway activation.

52 Vascular properties in cryptogenic stroke cryptogenic stroke controls p value PWVao (m/s) 11.8 ± ± SBPao (mmhg) 137 ± ± PPao (mmhg) 51.2 ± ± Aixao (%) 32 ± ± PBR 5-25 (µm) 2.06 ± ± 0.2 <0.04 PBR 5-9 (µm) 1.29 ± ± 0.02 <0.001 There was a significant positive correlation of PBR 5-25 with PWVao (p= 0.036).

53 CONCLUSIONS Increased arterial stiffness and impairment of endothelial glycocalyx coexist in patients with cryptogenic stroke and could serve as pathophysiologic substrates of these ischemic episodes.

54 ΣΥΜΠΕΡΑΣΜΑ Η µελέτη του ενδοθηλιακού γλυκοκαλυκα είναι εφικτή µε νέες µη επεµβατικές τεχνικές Αποτελεί µια νέα ερευνητική πρόκληση για την πρώιµη διάγνωση αγγειακής βλάβης και την παρακολούθηση θεραπευτικών παρεµβάσεων

55 ΕΥΧΑΡΙΣΤΩ ΓΙΑ ΤΗΝ ΠΡΟΣΟΧΗ ΣΑΣ

56 Overview of alternated glycocalyx functions as a result of its shedding which could lead to pathological states connectedwith various diseases. Matrix metalloproteinases (MMPs), reactive oxygen and nitrogen species (ROSs/RNSs), and tumor necrosis factor α (TNF-α). Kolářová H et al. Mediators Inflamm. 2014;2014:

57 Glycocalyx characteristics in normal endothelium (left) and during endothelial dysfunction (right). ETC, endothelial cleft. Chelazzi et al. Critical Care (2015) 19:26

58 Damage of the Endothelial Glycocalyx in Dialysis Patients CA Vlahu, BA Lemkes, DG Struijk et al. J Am Soc Nephrol 23: , 2012.

59 baseline GLYCOCALY (Microns) 3 months post cessation X RESULTS (Microns)

60 RESULTS Baseline 3 months post cessation

61 Relationship arterial stiffness, coronary flow reserve with myocardial strain Increased PWV and csbp were related with: reduced GLS (r=0,35, r=0,40) reduced CFR (r=-0,40, r=-0,35) (p<0,05 for all associations) reduced CFR was also associated with impaired GLS (r=0,36) (p<0,05)

62 Glycocalyx and LV myocardial strain Association of tertiles (T1-T2-T3) of perfused boundary region (PBR) measured in the microvessels ranged from 20-25µm with subendocardial longitudinal strain at baseline (F=4.3, p=0.006) and 120 min after OGTT (F=4.8, p=0.02), in first degree relatives. *p<0.05 by post hoc analysis for comparison of T1 vs. T2 and T3. I. Ikonomidis et al. ESC Congress 2016

63 Glycocalyx and LV myocardial deformation Association of tertiles (T1-T2-T3) of perfused boundary region (PBR) measured in the microvessels ranged from 20-25µm with peak twisting at baseline (F=5.4, p<0.001) and 120 min after OGTT (F=8.9, p<0.001), in first degree relatives. *p<0.05 by post hoc analysis for comparison of T1 vs. T2 and T3. I. Ikonomidis et al. ESC Congress 2016

64 Glycocalyx thickness increases post antinflammatory treatment in parallel with fetuin increase and reduction of oxidative stress P<0.05 P<0.05 P<0.05

65 Glycocalyx in psoriasis Reduced endothelial glucocalyx thickness as assessed by increased PBR was related with increased: p<0.05 for all associations. PBR among 5-9 micron showed higher correlation coefficients with the above markers.