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PubMed1998

Gene therapy for vascular disease.

Disorders of the vascular system are the leading cause of death and disability in the Western world. Mechanical interventions, such as angioplasty and bypass grafting, constitute the mainstay of treatment for end-stage occlusive lesions. Although initially successful in the majority of cases, the vascular response to injury and subsequent restenosis limits their long-term efficacy. Current work in the field of gene therapy has focused on the development of strategies to prevent these complications by the use of recombinant DNA technology. This review focuses on the latest advances in gene therapy for vascular disease, including the development of new vectors for vascular gene delivery, novel treatments for angioplasty-induced restenosis and vein graft intimal hyperplasia, and therapeutic angiogenesis.

Adenoviridae↗
PubMed2006

Egr-1 transcription activation exists in placental endothelium when vascular disease is present.

OBJECTIVE: To seek evidence of early vascular injury in the placental villous microcirculation in placental insufficiency identified by a high-resistance umbilical Doppler study by examining for expression of fibroblast growth factor receptor-1 (FGFR-1), its transcription factor, early growth response factor-1 (Egr-1) and plasma fibroblast growth factor-2 (FGF-2). DESIGN: Case-control study. SETTING: University teaching hospital. SAMPLE: Placentas and umbilical vein blood were collected at delivery from 12 women with normal pregnancy delivered at term and 14 with placental vascular disease defined by an abnormal umbilical artery Doppler study. METHODS: Microvascular endothelial cells were isolated from fresh human placentas using collagenase digestion and Dynabeads coated with monoclonal antibody against CD31. RNA was extracted from the isolated endothelial cells. The messenger RNA (mRNA) expression of FGFR-1 and Egr-1 production were assessed by reverse transcription polymerase chain reaction and factored relative to 18S ribosomal RNA. To confirm that FGF-2 was playing a significant role in this microvascular endothelial cell injury in the placenta, we also measured the soluble fraction of FGF-2 in fetal plasma from same groups of pregnancies using an enzyme-linked immunosorbent assay. MAIN OUTCOME MEASURES: Microvascular endothelial cells expression of Egr-1mRNA, FGFR-1 mRNA and presence of soluble FGF-2 in fetal plasma. RESULTS: The soluble level of FGF-2 in the fetal placental circulation from pregnancy with placental vascular disease was increased when compared with normal pregnancy (median 10.15 pg/ml and interquartile range 5.34-21.83 pg/ml versus 4.46 pg/ml and 3.69-5.66 pg/ml; P < 0.05). Microvascular endothelial cells from the placental villi with placental vascular disease showed upregulation of both FGFR-1 mRNA expression (median 0.72 and interquartile range 0.40-1.64 versus 0.34 and 0.19-0.71; P<0.05) and Egr-1 expression (median 0.79 and interquartile range 0.27-1.86 versus 0.23 and 0.17-0.67; P<0.05) in comparison with normal pregnancy. CONCLUSIONS: Endothelial cells from the placental villi are upregulated for expression of Egr-1 transcription factor gene in placental vascular disease. The FGFR-1 activation and increase in FGF-2 in the fetal circulation are known to be very early features of the response of endothelium to injury. Egr-1 is a promoter of many key pathophysiologically relevant target genes, which influence the development of subsequent vascular lesions. This change may occur before the pathological features recognised on microscopy.

Case-Control Studies↗
PubMed2001

The HCMV chemokine receptor US28 is a potential target in vascular disease.

The human cytomegalovirus (HCMV) has been implicated in the acceleration of vascular disease for some time. The development of vascular disease involves a chronic inflammatory process with many contributing factors, and of these, chemokines and their receptors have recently been identified as key mediators. Interestingly, HCMV encodes four potential chemokine receptors (US27, US28, UL33 and UL78). Of these virally-encoded chemokine receptors, US28 has been the most widely characterized. US28 binds many of the CC-chemokines, and this class of chemokines contributes to the development of vascular disease. Importantly, HCMV infection mediates in vitro SMC migration, which is dependent upon expression of US28 and CC-chemokine binding. US28 and the US28 functional homologues that are capable of inducing the migration of SMC represent potential targets in the treatment of CMV-accelerated vascular disease such as atherosclerosis, restenosis, and transplant vascular sclerosis.

Animals↗
PubMed2005

The correlation of paraoxonase (PON1) activity with lipid and lipoprotein levels differs with vascular disease status.

Paraoxonase (PON1) is an HDL-associated enzyme. Low PON1 activity predicts vascular disease status and is a more reliable predictor of vascular disease than are functional PON1 genotypes. There is evidence that the relationship of PON1 to vascular disease is, in part, due to its antioxidant activity. However, the physical relationship of PON1 with HDL and the existence of cholesterol pathway regulatory elements at the PON1 locus suggest a further relationship of PON1 with lipoproteins, which may contribute to its role in vascular disease. We investigated the relationship of PON1 activity and genotype to lipid-related traits in 91 Caucasian men with severe carotid artery disease and 184 without vascular disease who were not on lipid-lowering medications. Prior studies of PON1 relationship to lipids have not stratified by disease status.. We found that PON1 activity was correlated with HDL traits in controls and with LDL- and VLDL-related traits in cases. We hypothesize differences in the joint regulation of PON1 and lipoproteins in cases and controls.

Adult↗
PubMed1981

Haemoglobin, smoking and peripheral vascular disease.

One hundred and four patients with peripheral vascular disease requiring operation were reviewed retrospectively with respect to age, sex, preoperative haemoglobin, smoking habits and diabetic status. The preoperative haemoglobin levels and smoking status in 63 non-diabetic male patients with peripheral vascular disease were compared with a matched group of individuals treated for inguinal hernia. For all patients there was a significant correlation between smoking habits, preoperative haemoglobin level and the presence of peripheral vascular disease. The mechanisms by which smoking may damage the vascular tree are reviewed.

Age Factors↗
PubMed1992

Evaluation of leg perfusion during exercise using technetium 99m sestamibi. A new test for peripheral vascular disease.

Thirty patients with occlusive peripheral vascular disease underwent clinical examination, segmental blood pressure determinations, intra-arterial digital subtraction angiography, and treadmill stress testing with injection of technetium 99m sestamibi at peak exercise. Radionuclide images of the thighs, calves, and feet showed clear delineation of major muscle groups. Diminished radiotracer distribution was closely correlated with the presence of occlusive vascular disease on angiography and with the presence of claudication and reduced segmental blood pressure. A quantitative scheme based on pixel intensity was developed to compare areas of regional perfusion.

Arteriosclerosis↗
PubMed1983

Unsuspected vascular disease: a potential limitation to the use of the intra-aortic balloon.

Since vascular tortuosity of stenosis may preclude placement of the intra-aortic balloon, 63 consecutive patients (37 men) having routine Judkins' cardiac catheterization had an aortogram prior to withdrawal of the last catheter. No patient had a history of claudication, palpable aneurysms, pulse deficit, or bruit. No complications occurred. Significant peripheral vascular disease was found in ten patients: three had aortic, one had iliac, and six had femoral stenosis or tortuosity. All were men. The age of patients with peripheral vascular disease was 61.4 +/- 7.7 years, while those without were 56.9 +/- 9.3 years (P = NS). No difficulty was encountered entering the femoral artery in any patient; there was difficulty advancing the catheter in five of ten (50%) patients with peripheral vascular disease and in three of 54 (6%) patients without (P less than 0.002). Fifteen patients without peripheral vascular disease had normal coronary arteries, while none with peripheral vascular disease was normal. In patients with coronary disease, the number of vessels involved was the same in both groups. Peripheral vascular disease that might preclude placement of the intra-aortic balloon occurs in 14% of patients undergoing cardiac catheterization and 18% of patients with coronary artery disease. Aortography may be safely performed and should be considered during routine cardiac catheterization in patients who may require intra-aortic balloon placement.

Adult↗
PubMed2006

Can the presence of carotid artery calcification on panoramic radiographs predict the risk of vascular diseases among 80-year-olds?

OBJECTIVE: The purpose of this study was to evaluate whether subsequent vascular diseases and related death could be predicted by the presence of carotid artery calcification detected on panoramic radiographs among elderly persons. STUDY DESIGN: We evaluated 659 panoramic radiographs from 262 male and 397 female 80-year-old subjects and their general medical examination data to assess the relationship between the presence of carotid artery calcification and vascular disease risk at baseline examination. Of these subjects, the occurrence of vascular diseases within 5 years after baseline examination was examined in 191 subjects. Further, the causes of death were examined in 108 subjects who died within 5 years after baseline examination. RESULTS: There was a significant difference in the history of past vascular diseases among subjects with and without carotid artery calcifications; however, no significant difference in the occurrence of subsequent vascular diseases was found among them. Further, there was no significant difference in the occurrence of vascular disease-related death within 5 years after baseline examination among subjects with and without carotid artery calcifications (P = 0.719). CONCLUSION: Our results suggest that the presence of carotid artery calcifications on panoramic radiographs may be related to the history of past vascular diseases; however, this is not a useful marker for subsequent vascular diseases and related death among 80-year-olds.

Aged, 80 and over↗
PubMed2000

Hyperhomocysteinemia and risk of vascular disease in women.

Plasma levels of total homocysteine (tHcy), a possible risk factor for vascular disease, are generally lower in women than in men and lower in premenopausal women than in postmenopausal women. This article reviews studies that have investigated associations of hyperhomocysteinemia with risk of vascular disease among women or that compared risk by stratum of gender or menopausal status. Seven out of 12 epidemiological studies that included both men and women found hyperhomocysteinemia to be a stronger risk factor in women than in men. However, the interaction effect was statistically significant for only 1 study. Three studies observed no risk difference between men and women, and 2 observed a weaker association in women. In addition, 3 studies that consisted (almost) entirely of women observed direct associations of hyperhomocysteinemia with vascular disease risk, comparable to associations observed in male populations. Hyperhomocysteinemia was associated with increased risk in populations of both young and elderly women, but only few studies have compared risks among premenopausal and postmenopausal women. However, the limited data indicate that hyperhomocysteinemia is also associated with elevation of vascular disease risk before the menopause. The stronger association among women in some studies may be explained by aspects of the study design, such as age at inclusion (i.e., women usually suffer from vascular diseases later in life than do men), or aspects of the data analysis, such as use of an overall instead of a gender-specific cutoff point. Of course, one cannot exclude the possibility that women are somehow more susceptible to detrimental effects of tHcy than men are, although there is evidence from other studies that estrogens have a "protective" effect on the vascular wall and a favorable effect on hemostasis. In conclusion, we should consider hyperhomocysteinemia as a potential risk factor for vascular disease in both men and women, before and after the menopause.

Adult↗
PubMed1998

[The screening for asymptomatic vascular disease and risk factors in high risk patients: current practice].

OBJECTIVE: To assess current practice in screening for asymptomatic vascular disease and risk factors in patients referred with vascular disease or cardiovascular risk factors. DESIGN: Descriptive, retrospective. SETTING: University Hospital Utrecht, Utrecht, the Netherlands. METHOD: By means of the computerized hospital registration system all patients who were referred to the outpatient clinic with carotid stenosis, peripheral artery disease, abdominal aortic aneurysm, diabetes mellitus, hyperlipidaemia or hypertension during one year were identified. By means of the same hospital registration system the frequency of diagnostic tests performed to detect atherosclerosis or risk factors in these patients within a period of 5 months round the first attendance was determined. RESULTS: 372 Patients with a vascular disease and 317 patients with a risk factor were identified. Tests to detect carotid stenosis, peripheral artery disease or an abdominal aortic aneurysm were each performed in less then 6% of all patients except the test for abdominal aortic aneurysm. Tests to detect coronary artery disease were performed in about 50% of all patients. Tests to detect diabetes mellitus were performed in 35% of the patients with vascular disease and in 81% of the patients presenting with hyperlipidaemia or hypertension. Tests to detect hyperlipidaemia were performed in 18% of the patients with a vascular disease and in 76% of the patients with diabetes or hypertension. CONCLUSION: The results of this study suggest that in current practice patients referred for vascular disease or cardiovascular risk factors are infrequently screened for asymptomatic macrovascular disease and risk factors.

Adult↗
PubMed2001

Hemodynamic unloading leads to regression of pulmonary vascular disease in rats.

OBJECTIVE: Treatment options for patients with advanced pulmonary vascular disease caused by a congenital heart defect are still mainly limited to heart-lung transplantation or lung transplantation with repair of the cardiac lesion. Because we have previously shown that the structural changes associated with pulmonary hypertension can be reversed by stress unloading in an organ culture model, we now investigate whether hemodynamic unloading will lead to regression of pulmonary vascular disease in the intact animal. METHODS: Right middle and lower lobectomy and monocrotaline injection were performed in Lewis rats (n = 22) to cause pulmonary vascular disease from a combined hemodynamic and toxic injury. Twenty-eight days later the left lungs were examined (n = 10) or exposed to normal pulmonary artery pressure for an additional 14 (n = 5) or 28 (n = 7) days by transplantation into healthy recipients. Pulmonary artery pressure, ventricular weight, and pulmonary artery morphology were evaluated in each group. RESULTS: Pulmonary hypertension (50 vs 16 mm Hg; P <.001) and right ventricular hypertrophy (right ventricular/left ventricular weight 0.69 vs 0.32; P <.001) associated with pulmonary artery medial hypertrophy (28.2% vs 7.2% wall thickness; P <.001) and muscularization of small pulmonary arteries (92.3% vs 19.4%; P <.001) developed by day 28 (compared with untreated controls). However, transplantation into healthy recipients effectively unloaded the lungs (mean pulmonary artery pressure 17 and 24 mm Hg at 14 and 28 days after transplantation) and resulted in progressive normalization of medial hypertrophy (15.6% and 12.1% at 14 and 28 days) and muscularization (65.1% and 42.2% at 14 and 28 days) relative to nontransplanted controls (P <.005 in each case). CONCLUSIONS: Hemodynamic unloading of lungs with pulmonary vascular disease results in progressive normalization of pulmonary artery structure. These results are the first to provide a rationale for attempting to induce regression of pulmonary vascular disease by pressure unloading of the pulmonary circulation. Methods to mechanically unload the pulmonary circulation should be critically evaluated as a strategy for staged surgical repair of congenital heart defects despite presumed irreversible pulmonary hypertension.

Animals↗
PubMed1999

Risks of endoscopy in hospitalized pediatric patients with collagen vascular diseases.

BACKGROUND: The gastrointestinal manifestations of the collagen vascular diseases have been well described in the pediatric population. These patients frequently have symptoms that constitute indications for endoscopy. However, the risks and benefits of endoscopy in this population have not been examined. METHODS: A retrospective review of all patients with collagen vascular diseases hospitalized during a 7-year period was undertaken, and those patients who underwent endoscopy were identified. RESULTS: Nine patients (5%) underwent endoscopic procedures (eight upper and three lower endoscopy). Complications and outcomes were analyzed. Indications for endoscopy included abdominal pain, gastrointestinal (GI) bleeding, and/or vomiting and diarrhea. Two patients had complications that required surgery within 1 day of the endoscopic procedure. One of these patients subsequently died with GI bleeding. Five of the nine patients had changes in their management after endoscopy. Helicobacter pylori infection was identified and treated in two patients. Three patients had esophagitis or gastritis and acid suppression treatment was started or optimized. Vasculopathy was present in the patients who had complications. CONCLUSIONS: This series suggests that endoscopy can provide useful information for the management of the pediatric patient with GI symptoms and collagen vascular diseases. However, because serious and potentially life-threatening complications can occur, great care is needed in evaluating the risk/benefit ratio of endoscopy in these patients.

Adolescent↗
PubMed1997

Plasma homocysteine as a risk factor for vascular disease. The European Concerted Action Project.

CONTEXT: Elevated plasma homocysteine is a known risk factor for atherosclerotic vascular disease, but the strength of the relationship and the interaction of plasma homocysteine with other risk factors are unclear. OBJECTIVE: To establish the magnitude of the vascular disease risk associated with an increased plasma homocysteine level and to examine interaction effects between elevated plasma homocysteine level and conventional risk factors. DESIGN: Case-control study. SETTING: Nineteen centers in 9 European countries. PATIENTS: A total of 750 cases of atherosclerotic vascular disease (cardiac, cerebral, and peripheral) and 800 controls of both sexes younger than 60 years. MEASUREMENTS: Plasma total homocysteine was measured while subjects were fasting and after a standardized methionine-loading test, which involves the administration of 100 mg of methionine per kilogram and stresses the metabolic pathway responsible for the irreversible degradation of homocysteine. Plasma cobalamin, pyridoxal 5'-phosphate, red blood cell folate, serum cholesterol, smoking, and blood pressure were also measured. RESULTS: The relative risk for vascular disease in the top fifth compared with the bottom four fifths of the control fasting total homocysteine distribution was 2.2 (95% confidence interval, 1.6-2.9). Methionine loading identified an additional 27% of at-risk cases. A dose-response effect was noted between total homocysteine level and risk. The risk was similar to and independent of that of other risk factors, but interaction effects were noted between homocysteine and these risk factors; for both sexes combined, an increased fasting homocysteine level showed a more than multiplicative effect on risk in smokers and in hypertensive subjects. Red blood cell folate, cobalamin, and pyridoxal phosphate, all of which modulate homocysteine metabolism, were inversely related to total homocysteine levels. Compared with nonusers of vitamin supplements, the small number of subjects taking such vitamins appeared to have a substantially lower risk of vascular disease, a proportion of which was attributable to lower plasma homocysteine levels. CONCLUSIONS: An increased plasma total homocysteine level confers an independent risk of vascular disease similar to that of smoking or hyperlipidemia. It powerfully increases the risk associated with smoking and hypertension. It is time to undertake randomized controlled trials of the effect of vitamins that reduce plasma homocysteine levels on vascular disease risk.

Adult↗
PubMedDate not supplied

Prevalence of symptomatic diastolic heart failure in patients hospitalized with cerebral or peripheral vascular disease.

The authors sought to determine the prevalence of diastolic heart failure (DHF) in patients hospitalized with their first stroke, transient ischemic attack, or new onset of peripheral vascular disease. A total of 216 prospective consecutive stroke, transient ischemic attack, and peripheral vascular disease patients (vascular group) were identified at their first noncardiac presentation to a hospital and compared with 164 age-matched control patients (nonvascular group). DHF was clinically defined as the presence of left ventricular ejection fraction>or=45% on echocardiography. DHF occurred in 40% and 73% of vascular and control patients, respectively, with symptomatic heart failure. Overall, it was found in 12% of vascular (10% of stroke/transient ischemic attack, 16% of peripheral vascular disease) and 11% of control patients. Advancing age and female gender were independently associated with the presence of DHF in vascular patients (p<0.05). DHF is found in a similar percentage of vascular and nonvascular patients. Symptomatic DHF is less common than systolic heart failure among vascular disease patients with heart failure. In contrast, symptomatic DHF is found in three times as many age-matched control heart failure patients without clinical vascular disease.

Aged↗
PubMed2002

Prospective multicentre study of the natural history of atherosclerotic renal artery stenosis in patients with peripheral vascular disease.

BACKGROUND: Many patients with peripheral vascular disease have coincident renal artery stenosis. The present study characterized the natural history of the condition. METHODS: Some 98 patients (71 men) with more than 50 per cent atherosclerotic renal artery stenosis (unilateral 64, bilateral 34) were recruited prospectively. Measurements of serum creatinine, blood pressure and renal size were recorded at baseline and every 6 months, for a minimum of 2 years. RESULTS: Data were available for 85 patients with a minimum follow-up of 2 years. The mean age was 71 (range 51-87) years. All 52 patients with unilateral renal artery stenosis were managed conservatively (group 1); 21 of the 33 patients with bilateral disease had no intervention (group 2) and the remaining 12 had angioplasty or reconstruction (group 3). The overall mortality rate was 32 per cent at 2 years (27 patients) and this was similar in all three groups. In only three patients was death related directly to renovascular disease; coronary disease accounted for the majority of deaths. All three patients who needed dialysis died within 1 year. In survivors from groups 1 and 3 there was a significant increase in serum creatinine concentration at follow-up. Blood pressure did not increase significantly. CONCLUSION: Patients with renal artery stenosis and peripheral vascular disease had a poor prognosis, but this was not directly attributable to renal failure.

Aged↗
PubMed1999

Blood pressure levels and measurement of subclinical vascular disease.

Increased blood pressure, especially systolic blood pressure (SBP), is linearly associated with an increased risk of cardiovascular disease and stroke. The attributable risk of vascular disease due to elevated blood pressure is greater for normal and high normal blood pressures and stage 1 hypertension than for more advanced hypertension (stages 2 and 3). The development of noninvasive methods for measuring the effects of blood pressure on the vascular system help identify early vascular disease, high risk populations at similar levels of blood pressure, and successful methods of therapy. The future goals of the control of elevated blood pressure should be to prevent: (1) the rise in blood pressure associated with increasing age; (2) the development of subclinical vascular disease associated with even slightly elevated blood pressure; and (3) clinical disease. Measurement of subclinical vascular disease should be a component of both observational epidemiological studies and clinical trials. The subclinical measures should include those primarily associated with the progression of atherosclerosis and the pathophysiology of elevated blood pressure.

Blood Pressure↗
PubMed2006

Peripheral arterial disease versus other localizations of vascular disease: the ATTEST study.

OBJECTIVE: Despite the increased cardiovascular morbidity and mortality risk of patients with peripheral arterial disease, previous worldwide studies have documented undertreatment of cardiovascular risk factors in such patients. METHOD: The ATTEST study was an observational cross-sectional epidemiologic study. Patients (n = 8475) were selected by 3020 general practitioners in France who were asked to include the first three patients with at least one site of proven atherothrombotic disease (peripheral arterial disease of the lower limbs for two patients and coronary artery disease or ischemic stroke for the third patient). We designed the ATTEST study to compare medical management of patients with peripheral arterial disease, including pharmacologic treatment, cardiovascular tests, and physician's assessment of future cardiovascular and amputation risks, with patients with coronary artery disease or ischemic stroke. RESULTS: Only 13% of the patients with peripheral arterial disease (n = 3811) received angiotensin converting enzyme inhibitors, statins, and antiplatelet agents vs 30% of the patients with coronary artery disease or ischemic stroke (n = 4664). This undertreatment of the population with peripheral arterial disease was associated with a too-optimistic physician's assessment of future cardiovascular risk: only 27% of the general practitioners predicted a 5-year cardiovascular risk >20%. Conversely, amputation risk prediction was greatly overestimated: only 44% of the practitioners predicted a 5-year amputation risk <5%. CONCLUSIONS: Patients with atherothrombotic disease recruited from primary care practices were not adequately tested and treated, especially the patients with peripheral arterial disease. To improve the medical management of patients with peripheral arterial disease, there is a need for epidemiologic and clinical education of physicians.

Aged↗