Search

OBJETIVO: Avaliar o prognóstico do tromboembolismo pulmonar usando o ecocardiograma com Doppler tecidual e o peptídeo atrial natriurético. MÉTODOS: Pacientes com idade acima de 18 anos foram avaliados pelo ecocardiograma bidimensional e Doppler tecidual para medidas das velocidades miocárdicas (s'), strain e índice de performance miocárdica do ventrículo direito até 24 horas da confirmação diagnóstica do tromboembolismo pulmonar (tomografia/ cintilografia), sendo também o peptídeo atrial natriurético obtido até 24 horas. A influência das variáveis na mortalidade até 1 ano foi testada pela regressão de Cox. RESULTADOS: Dos 118 pacientes estudados, 100 foram incluídos, sendo 60 homens, com idade de 55±17 anos. Pelo ecocardiograma bidimensional, 28% dos pacientes apresentavam disfunção do ventrículo direito. As medidas da onda s', strain e deslocamento estiveram diminuídas para tais pacientes, que apresentavam, ainda, índice de performance miocárdica e pressão sistólica pulmonar aumentados. O peptídeo atrial natriurético médio foi de 66±111pg/mL, sendo 136±146pg/mL para pacientes com disfunção do ventrículo direito. A mortalidade foi 11% e pela análise univariada, relacionada à idade, neoplasia e peptídeo atrial natriurético. Entre as variáveis ecocardiográficas, somente a onda s' do Doppler tecidual e a pressão pulmonar associaram-se à maior mortalidade. Pela análise multivariada, entretanto, a presença de neoplasia foi o único preditor de óbito. CONCLUSÃO: Velocidades miocárdicas diminuídas e peptídeo atrial natriurético elevado estão associados a pior prognóstico em pacientes com tromboembolismo pulmonar, mas, nessa população, somente a presença de neoplasia foi capaz de predizer a mortalidade de maneira independente. OBJECTIVE: To assess prognosis of pulmonary thromboembolism using tissue Doppler echocardiography and brain natriuretic peptide. METHODS: Patients aged over 18 years were evaluated within 24 hours of confirmed diagnosis (chest tomography/pulmonary scintigraphy) of pulmonary embolism using two-dimensional echocardiography and tissue Doppler for right ventricular systolic (s') velocities, strain, tissue tracking and myocardial performance index. Plasma brain natriuretic peptide was also obtained within 24 hour. The influence of echocardiographic and clinical variables on mortality was examined (up to 12 months) using Cox regression analysis. RESULTS: Out of 118 patients, 100 patients were included in the study (60 males, aged 55±17 years). Right ventricular dysfunction was observed in 28% using two-dimensional echocardiography. Tissue Doppler right ventricular variables (s' velocities, tissue tracking and strain) were decreased only for patients with right ventricular dysfunction, whereas myocardial performance index and systolic pulmonary artery pressure were increased. Mean brain natriuretic peptide value was 66±111pg/mL, also increased in patients with right ventricular dysfunction (136±146pg/mL). Mortality was 11% and related to age, malignancy and brain natriuretic peptide levels. The only echocardiographic variables capable of predicting events by univariate analysis were pulmonary pressure and right ventricular s' velocity. However, multivariate analysis showed only malignancy to predict mortality in this group. CONCLUSION: Lower tissue Doppler systolic velocities and elevated brain natriuretic peptide levels are associated with poorer prognosis in patients with pulmonary thromboembolism; but only malignancy emerged as an independent predictor of mortality.

BACKGROUND: Left ventricular remodeling (LVR) after AMI characterizes a factor of poor prognosis. There is little information in the literature on the LVR analyzed with three-dimensional echocardiography (3D ECHO). OBJECTIVE: To analyze, with 3D ECHO, the geometric and volumetric modifications of the left ventricle (VE) six months after AMI in patients subjected to percutaneous primary treatment. METHODS: Prospective study with 3D ECHO of 21 subjects (16 men, 56 ± 12 years-old), affected by AMI with ST segment elevation. The morphological and functional analysis (LV) with 3D ECHO (volumes, LVEF, 3D sphericity index) was carried out up to seven days and six months after the AMI. The LVR was considered for increase > 15% of the end diastolic volume of the LV (LVEDV) six months after the AMI, compared to the LVEDV up to seven days from the event. RESULTS: Eight (38%) patients have presented LVR. Echocardiographic measurements (n = 21 patients): I- up to seven days after the AMI: 1- LVEDV: 92.3 ± 22.3 mL; 2- LVEF: 0.51 ± 0.01; 3- sphericity index: 0.38 ± 0.05; II- after six months: 1- LVEDV: 107.3 ± 26.8 mL; 2- LVEF: 0.59 ± 0.01; 3- sphericity index: 0.31 ± 0.05. Correlation coefficient (r) between the sphericity index up to seven days after the AMI and the LVEDV at six months (n = 8) after the AMI: r: 0.74, p = 0.0007; (r) between the sphericity index six months after the AMI and the LVEDV at six months after the AMI: r: 0.85, p < 0.0001. CONCLUSION: In this series, LVR has been observed in 38% of the patients six months after the AMI. The three-dimensional sphericity index has been associated to the occurrence of LVR.

Smooth muscle cells (SMC) contribute to the development and stability of atherosclerotic lesions. The molecular mechanisms that mediate their properties are incompletely defined. We employed proteomics and in vitro functional assays to identify the unique characteristics of intimal SMC isolated from human carotid endarterectomy specimens and medial SMC from thoracic aortas and carotids. We verified our findings in the Tampere Vascular Study. Human atheroma-derived SMC exhibit decreased expression of mitochondrial proteins ATP Synthase subunit-beta and Aldehyde dehydrogenase 2, and decreased mitochondrial activity when compared to control SMC. Moreover, a comparison between plaque-derived SMC isolated from patients with or without recent acute cerebrovascular symptoms uncovered an increase in Annexin A1, an endogenous anti-inflammatory protein, in the asymptomatic group. The deletion of Annexin A1 or the blockade of its signaling in SMC resulted in increased cytokine production at baseline and after stimulation with the pro-inflammatory cytokine Tumor Necrosis Factor α. In summary, our proteomics and biochemical analysis revealed mitochondrial damage in human plaque-derived SMC as well as a role of Annexin A1 in reducing the production of pro-inflammatory mediators in SMC.

Tumor necrosis factor (TNF) is one of the most important cytokines produced by macrophages. TNF is a very important component of host defense, released very rapidly after all types of injuries and stimuli. The kinetics of TNF release are short, and so it is perhaps not surprising that prolonged TNF production is associated with pathology. This was first elucidated in rheumatoid arthritis but extends to other chronic inflammatory diseases such as Crohn’s disease and psoriasis. In this chapter, the discovery of anti-TNF therapy is reviewed, with its benefit but also its limitations. The potential of anti-TNF therapy in other diseases, e.g., cardiovascular and fibrosis, is discussed, as is the opportunity to define ways of blocking TNF synthesis.

Although dendritic cells (DCs) are the most potent antigen-presenting cells involved in numerous physiologic and pathologic processes, little is known about the signaling pathways that regulate DC activation and antigen-presenting function. Recently, we demonstrated that nuclear factor (NF)-κB activation is central to that process, as overexpression of IκBα blocks the allogeneic mixed lymphocyte reaction (MLR), an in vitro model of T-cell activation. In this study, we investigated the role of 2 putative NF-κB–inducing components, NF-κB–inducing kinase (NIK), and IκB kinase 2 (IKK2). Using an adenoviral gene transfer method to efficiently express dominant-negative (dn) forms of these molecules in monocyte-derived DCs, we found that IKK2dn but not NIKdn inhibited the allogeneic MLR. When DCs were fixed, this inhibitory effect of IKK2dn was lost, suggesting that IKK2 is involved in T-cell–derived signals that enhance DC antigen presentation during the allogeneic MLR period and does not have an effect on viability or differentiation state of DCs prior to coculture with T cells. One such signal is likely to be CD40 ligand (CD40L), as IKK2dn blocked CD40L but not lipopolysaccharide (LPS)–induced NF-κB activation, cytokine production, and up-regulation of costimulatory molecules and HLA-DR in DCs. In summary, our results demonstrate that IKK2 is essential for DC activation induced by CD40L or contact with allogeneic T cells, but not by LPS, whereas NIK is not required for any of these signals. In addition, our results support IKK2 as a potential therapeutic target for the down-regulation of unwanted immune responses that may occur during transplantation or autoimmunity.

OBJECTIVE: Cognitive decline accompanies acute illness and surgery, especially in the elderly. Surgery engages the innate immune system that launches a systemic inflammatory response that, if unchecked, can cause multiple organ dysfunction. We sought to understand the mechanisms whereby the brain is targeted by the inflammatory response and how this can be resolved. METHODS: C57BL/6J, Ccr2(RFP/+)Cx3cr1(GFP/+), Ikk(F/F) mice and LysM-Cre/Ikk(F/F) mice underwent stabilized tibial fracture operation under analgesia and general anesthesia. Separate cohorts of mice were tested for systemic and hippocampal inflammation, integrity of the blood-brain barrier (BBB), and cognition. The putative resolving effects of the cholinergic pathway on these postoperative responses were also studied. RESULTS: Peripheral surgery disrupts the BBB via release of tumor necrosis factor-alpha (TNFα), which facilitates the migration of macrophages into the hippocampus. Macrophage-specific deletion of Ikappa B kinase (IKK)β, a central coordinator of TNFα signaling through activation of nuclear factor (NF) κB, prevents BBB disruption and macrophage infiltration in the hippocampus following surgery. Activation of the α7 subtype of nicotinic acetylcholine receptors, an endogenous inflammation-resolving pathway, prevents TNFα-induced NF-κB activation, macrophage migration into the hippocampus, and cognitive decline following surgery. INTERPRETATION: These data reveal the mechanisms for bidirectional communication between the brain and immune system following aseptic trauma. Pivotal molecular mechanisms can be targeted to prevent and/or resolve postoperative neuroinflammation and cognitive decline.

Surgery and critical illness often associate with cognitive decline. Surgical trauma or infection can independently lead to learning and memory impairments via similar, but not identical, cellular signaling of the innate immune system that promotes neuroinflammation. In this study we explored the putative synergism between aseptic orthopedic surgery and infection, the latter reproduced by postoperative lipopolysaccharide (LPS) administration. We observed that surgery and LPS augmented systemic inflammation up to postoperative day 3 and this was associated with further neuroinflammation (CD11b and CD68 immunoreactivity) in the hippocampus in mice compared to those received surgery or LPS alone. Administration of a selective alpha 7 subtype nicotinic acetylcholine receptor (α7 nAChR) agonist 2 hours after the LPS significantly improved neuroinflammation and hippocampal-dependent memory dysfunction. Modulation of nuclear factor-kappa B (NFκB) activation in monocytes and regulation of the oxidative stress response through nicotinamide adenine dinucleotide phosphate (NADPH) signaling appear to be key targets in modulating this response. Overall, these results suggest that it may be conceivable to limit and possibly prevent postoperative complications, including cognitive decline and/or infections, through stimulation of the cholinergic anti-inflammatory pathway.

Background: In atherosclerosis, proteoglycan accumulation results in increased lipoprotein retention. Results: ADAMTS-5 is reduced in aortas of apolipoprotein E-null mice. ADAMTS-5 deficiency impairs processing of vascular proteoglycans, and ADAMTS-5 activity affects proteoglycan-mediated lipoprotein retention. Conclusion: ADAMTS-5 regulates vascular proteoglycan catabolism and alters lipoprotein retention. Significance: This is the first study implicating ADAMTS-5 proteolytic activity in atherosclerosis., Atherosclerosis is initiated by the retention of lipoproteins on proteoglycans in the arterial intima. However, the mechanisms leading to proteoglycan accumulation and lipoprotein retention are poorly understood. In this study, we set out to investigate the role of ADAMTS-5 (a disintegrin and metalloprotease with thrombospondin motifs-5) in the vasculature. ADAMTS-5 was markedly reduced in atherosclerotic aortas of apolipoprotein E-null (apoE−/−) mice. The reduction of ADAMTS-5 was accompanied by accumulation of biglycan and versican, the major lipoprotein-binding proteoglycans, in atherosclerosis. ADAMTS-5 activity induced the release of ADAMTS-specific versican (DPEAAE441) and aggrecan (374ALGS) fragments as well as biglycan and link protein from the aortic wall. Fibroblast growth factor 2 (FGF-2) inhibited ADAMTS-5 expression in isolated aortic smooth muscle cells and blocked the spontaneous release of ADAMTS-generated versican and aggrecan fragments from aortic explants. In aortas of ADAMTS-5-deficient mice, DPEAAE441 versican neoepitopes were not detectable. Instead, biglycan levels were increased, highlighting the role of ADAMTS-5 in the catabolism of vascular proteoglycans. Importantly, ADAMTS-5 proteolytic activity reduced the LDL binding ability of biglycan and released LDL from human aortic lesions. This study provides the first evidence implicating ADAMTS-5 in the regulation of proteoglycan turnover and lipoprotein retention in atherosclerosis.

Purpose: Atherosclerosis occurs in vascular sites subjected to complex flow, causing oscillatory shear stress (OSS) or low shear stress (LSS). Macrophages can be skewed towards a pro-inflammatory phenotype (called M1) or a regulatory one (broadly named M2) and may determine atherosclerotic plaque outcome. The aim of this study is to establish the polarisation of macrophages in different plaque phenotypes and shear stress conditions. Methods: A perivascular shear stress modifying cast was tied around a carotid artery for 6 or 9 weeks, mimicking LSS and OSS in ApoE-/- mice fed a high fat diet (HFD) from 17 weeks of age. We examined the expression of the pan-macrophage marker CD68 and polarisation markers iNOS (M1), CD206 (M2) and HO-1 (Mox subset) in the aortic root at 12, 20, 28, 35 and 53 weeks of age, and cast-treated carotid artery by Immunohistochemistry and Confocal Immunolocalisation Results: In the aortic root, most CD68+ cells stained positively for HO-1, particularly at 28 weeks (36.3±1.2% of lesion area; p

Background Toll-like receptors (TLRs) have long been considered to be major culprits in the development of atherosclerosis, contributing both to its progression and clinical complications. However, evidence for most TLRs beyond TLR2 and TLR4 is lacking. Methods and Results We used experimental mouse models, human atheroma cultures, and well-established human biobanks to investigate the role of TLR7 in atherosclerosis. We report the unexpected finding that TLR7, a receptor recognizing self–nucleic acid complexes, is protective in atherosclerosis. In Apoe −/− mice, functional inactivation of TLR7 resulted in accelerated lesion development, increased stenosis, and enhanced plaque vulnerability as revealed by Doppler ultrasound and/or histopathology. Mechanistically, TLR7 interfered with macrophage proinflammatory responses to TLR2 and TLR4 ligands, reduced monocyte chemoattractant protein-1 production, and prevented expansion of Ly6C hi inflammatory monocytes and accumulation of inflammatory M1 macrophages into developing atherosclerotic lesions. In human carotid endarterectomy specimens TLR7 levels were consistently associated with an M2 anti-inflammatory macrophage signature (interleukin [IL]-10, IL-1RA, CD163, scavenger and C-type lectin receptors) and collagen genes, whereas they were inversely related or unrelated to proinflammatory mediators (IL-12/IL-23, interferon beta, interferon gamma, CD40L) and platelet markers. Moreover, in human atheroma cultures, TLR7 activation selectively suppressed the production of key proatherogenic factors such as monocyte chemoattractant protein-1 and tumor necrosis factor without affecting IL-10. Conclusions These findings provide evidence for a beneficial role of TLR7 in atherosclerosis by constraining inflammatory macrophage activation and cytokine production. This challenges the prevailing concept that all TLRs are pathogenic and supports the exploitation of the TLR7 pathway for therapy.

Seminal research over the past 20 years has revealed atherosclerosis to be a chronic inflammatory process that shares features with traditional inflammatory diseases including rheumatoid arthritis. More recently, emphasis has been placed on the role of innate immunity in the development and progression of atherosclerosis. In particular, pattern recognition receptors, including Toll-like receptors (TLRs), have been the focus of much attention as modulators of atherogenesis. This review provides an update on the developments in this area of research in the past 2 years, with a specific focus on the current controversies and how these may affect the design of therapeutics. Specifically, we will address the recent evidence that TLRs elicit both protective and detrimental effects in atherosclerosis and the emerging observation that the outcome of TLR signaling is dependent on the agonist and responding cell type.

OBJECTIVES: Identification of those patients with high-risk asymptomatic carotid plaques remains an elusive but essential step in stroke prevention. Inflammation is a key process in plaque destabilization and the propensity of atherosclerotic lesions to cause clinical sequelae. There is currently no clinical imaging technique available to assess the degree of inflammation associated with plaques. This study aims at visualizing and characterizing atherosclerosis using antibody-conjugated superparamagnetic iron oxide (SPIO) particles as an MRI probe to assess inflammation in human atherosclerotic plaques. METHODS: Atherosclerotic plaques were collected from 20 consecutive patients (n=10 from symptomatic patients, n=10 from asymptomatic patients) undergoing carotid endarterectomy (CEA) for extracranial high-grade internal carotid artery (ICA) stenosis (>70% luminal narrowing). Inflammatory markers on human atherosclerotic plaques were detected and characterized by ex vivo magnetic resonance imaging (MRI) using anti-VCAM-1 antibody and anti-E-selectin antibody-conjugated SPIO with confirmatory immunohistochemistry. RESULTS: Inflammation associated with human ex vivo atherosclerotic plaques could be imaged using dual antibody-conjugated SPIO by MRI. Symptomatic plaques could be distinguished from asymptomatic ones by the degree of inflammation, and the MR contrast effect was significantly correlated with the degree of plaque inflammation (r=.64, p

Atherosclerosis is a multi-factorial inflammatory disease and is the primary initiator of cerebrovascular disease. At first many saw atherosclerosis as a lipid-driven disease. Recently inflammation has appeared as a significant factor in the disease. Innate immune cells, for example monocytes and macrophages, are important in atherosclerosis. Toll-like receptors (TLRs) are the most characterised innate immune receptors. TLR engagement with their ligands stimulate transcription of pro-inflammatory cytokines, foam cell formation and can activate adaptive immunity. Recently certain TLRs have shown a protective role in atherosclerosis. In this review, we analyse the role of innate immunity, specifically macrophages and TLR signalling, in atherosclerosis and acute cerebrovascular complications, and thereby discuss the potential of TLRs to act as therapeutic targets.

Background and Purpose— Development of translational functional imaging modalities for atherosclerosis risk stratification is sought for stroke prediction. Our group has developed late-phase contrast-enhanced ultrasound (LP-CEUS) to quantify microbubble contrast retention within carotid atherosclerosis and shown it to separate asymptomatic plaques from those responsible for recent cerebrovascular events. We hypothesized that microbubbles are retained in areas of plaque inflammation, aiming to examine whether LP-CEUS signal reflects plaque biology. Methods— Subjects awaiting carotid endarterectomy (n=31) underwent axial LP-CEUS and diseased intimal segments were symmetrically divided in the long axis. Half-specimens underwent quantitative immunohistochemical analysis for CD68 (macrophages) and CD31 (angiogenesis). Half-specimens were processed for atheroma cell culture and supernatant collected at 24 hours for multianalyte profiling for 34 analytes. Results— Percentage area immunopositivity was significantly higher in subjects in which normalized plaque late-phase intensity was ≥0 versus P =0.004; CD31 mean 9.45 versus 4.82, P =0.025). Interleukin-6, matrix metalloproteinase-1, and matrix metalloproteinase-3 were significantly higher by multianalyte profiling when LP-CEUS was ≥0. Conclusions— LP-CEUS reflects biological features of inflammation and angiogenesis, key features predisposing to plaque rupture. Further investigation of LP-CEUS as a tissue-specific marker of inflammation for risk stratification of carotid atherosclerosis is warranted.

Atherosclerosis is a multi-factorial inflammatory disease and is the primary initiator of coronary artery and cerebrovascular disease. Initially believed to be exclusively lipid-driven, recent evidence demonstrates that inflammation is a significant driving force of the disease. Cellular components of innate immunity, for example monocytes and macrophages, play a predominant role in atherosclerosis. Toll-like receptors (TLRs) are the most characterised innate immune receptors and recent evidence demonstrates an important role in atherogenesis. Engagement of TLRs results in the transcription of pro-inflammatory cytokines, foam cell formation and activation of adaptive immunity. Recently they have also been implicated in protection from vascular disease. In this review, we detail the role of the innate immune system, specifically macrophages and TLR signalling, in atherosclerosis and acute cardiovascular complications, and thereby identify the potential of TLRs to act as therapeutic targets.

SummaryMolecular characterisation of vulnerable atherosclerosis is necessary for targeting functional imaging and plaque-stabilising therapeutics. Inflammation has been linked to atherogenesis and the development of high-risk plaques. We set to quantify cytokine, chemokine and matrix metalloproteinase (MMP) protein production in cells derived from carotid plaques to map the inflammatory milieu responsible for instability. Carotid endarterectomies from carefully characterised symptomatic (n=35) and asymptomatic (n=32) patients were enzymatically dissociated producing mixed cell type atheroma cell suspensions which were cultured for 24 hours. Supernatants were interrogated for 45 analytes using the Luminex 100 platform. Twenty-nine of the 45 analytes were reproducibly detectable in the majority of donors. The in vitro production of a specific network of mediators was found to be significantly higher in symptomatic than asymptomatic plaques, including: tumour necrosis factor α, interleukin (IL) 1β, IL-6, granulocytemacrophage colony-stimulating factor (GM-CSF), macrophage colonystimulating factor (M-CSF), CCL5, CCL20, CXCL9, matrix metalloproteinase (MMP)-3 and MMP-9. Ingenuity pathway analysis of differentially expressed analytes between symptomatic and asymptomatic patients identified a number of key biological pathways (p > 10–25). In conclusion, the carotid artery plaque culprit of ischaemic neurological symptoms is characterised by an inflammatory milieu favouring inflammatory cell recruitment and pro-inflammatory macrophage polarisation.Supplementary Material to this article is available online at www.thrombosis-online.com.

Rupture of tricuspid valve is unusual, occurring mainly in the setting of blunt trauma or endomyocardial biopsy. Spontaneous tricuspid valve chordal rupture is particularly rare. We report herein a case of a patient with severe pulmonary hypertension, on the lung transplantation waiting list, who presented with spontaneous chordal rupture, exacerbation of tricuspid insufficiency and worsening of clinical status. Diagnosis and treatment, along with possible mechanisms for this complication, are discussed.

Cognitive decline following surgery in older individuals is a major clinical problem of uncertain mechanism; a similar cognitive decline also follows severe infection, chemotherapy, or trauma and is currently without effective therapy. A variety of mechanisms have been proposed, and exploring the role of inflammation, we recently reported the role of IL-1β in the hippocampus after surgery in mice with postoperative cognitive dysfunction. Here, we show that TNF-α is upstream of IL-1 and provokes its production in the brain. Peripheral blockade of TNF-α is able to limit the release of IL-1 and prevent neuroinflammation and cognitive decline in a mouse model of surgery-induced cognitive decline. TNF-α appears to synergize with MyD88 , the IL-1/TLR superfamily common signaling pathway, to sustain postoperative cognitive decline. Taken together, our results suggest a unique therapeutic potential for preemptive treatment with anti-TNF antibody to prevent surgery-induced cognitive decline.

Rheumatoid arthritis (RA) is an autoimmune disease affecting approximately 1% of the population. Patients have reduced life expectancy and the leading cause of death is cardiovascular disease (CVD), with patients experiencing at least a 2-fold increased risk of myocardial infarction. RA is recognized as an independent risk factor for CVD. Inflammation is a key contributor to the pathogenesis of atherosclerosis and cardiovascular events. As a common catalyst of both diseases, inflammation is the likely cause of increased prevalence of CVD in the RA population. Abating disease-related inflammation in RA may be an effective strategy in reducing CVD risk. Several other therapies used to modify cardiovascular risk factors in the general population such as statins and angiotensin-converting enzyme inhibitors are under investigation in patients with RA. This review discusses the parallels in the pathology of RA and atherosclerosis and discusses current therapies for RA and how they affect cardiovascular risk.

Thus far, little has been written concerning echocardiographic identification of the oblique vein of the left atrium, or Marshall's vein. There is much discussion, nonetheless, on the potential significance of the vein, or its ligamentous remnant, as an arrhythmic substrate. We describe here four patients in whom transthoracic echocardiography revealed a venous structure protruding within the cavity of the left atrium. We discuss the possibility that these structures represent Marshall's vein, albeit probably as part of a persistent left superior caval vein.

Atherosclerosis is an inflammatory disease with a strong involvement of innate immunity. Toll-like receptors (TLRs) are the best-characterized pattern recognition receptors of the innate immune system. Almost all cell types in lesions, inflammatory leukocytes and resident vascular cells alike express TLRs. TLRs are able to sense modified lipids, enhance foam cell formation, induce leukocyte recruitment, and increase cytokine and matrix metalloproteinase production within atherosclerotic lesions. As such, TLRs represent an important link between atheroma and inflammation, making them attractive targets for the treatment of cardiovascular disease. Novel TLR-specific biologics are being developed and tested in other inflammatory diseases. This article will describe the exciting potential of TLRs as therapeutic targets for the treatment of atherosclerosis and will also highlight the potential challenges in the clinical application of TLR-based therapeutics in cardiovascular disease.

Traditionally, stroke risk stratification has centred on the degree of internal carotid artery stenosis, and the presence of focal neurological symptoms. However, degree of stenosis alone is a relatively poor predictor of future stroke in asymptomatic patients; the Asymptomatic Carotid Surgery Trial highlighting the need to identify a subgroup of asymptomatics that may benefit from intervention. Attempting to define this subgroup has inspired imaging research to identify, in vivo, high-risk plaques. In addition to pre-operative risk stratification of carotid stenosis, contrast enhanced ultrasound (CEUS) may be employed in monitoring response to plaque-stabilising therapies.Unlike most contrast agents used for computed tomography and magnetic resonance imaging, microbubbles used in CEUS remain within the vascular space and can hence be used to study the vasculature. In addition to improving current carotid structural scans, CEUS has potential to add extra information on plaque characteristics. Furthermore, by targeting microbubbles to specific ligands expressed on vascular endothelium, CEUS may have the ability to probe plaque biology.This review describes the current carotid ultrasound examination and the need to improve it, rationale for imaging neovascularisation, use of CEUS to image neovascularisation, microbubbles in improving the structural imaging of plaque, potential problems with CEUS, and future directions.

Inflammation drives atherosclerosis. Both immune and resident vascular cell types are involved in the development of atherosclerotic lesions. The phenotype and function of these cells are key in determining the development of lesions. Toll-like receptors are the most characterised innate immune receptors and are responsible for the recognition of exogenous conserved motifs on pathogens, and, potentially, some endogenous molecules. Both endogenous and exogenous TLR agonists may be present in atherosclerotic plaques. Engagement of toll-like receptors on immune and resident vascular cells can affect atherogenesis as signalling downstream of these receptors can elicit proinflammatory cytokine release, lipid uptake, and foam cell formation and activate cells of the adaptive immune system. In this paper, we will describe the expression of TLRs on immune and resident vascular cells, highlight the TLR ligands that may act through TLRs on these cells, and discuss the consequences of TLR activation in atherosclerosis.

FUNDAMENTO: A ecocardiografia transesofágica (ETE) é um exame semi-invasivo amplamente utilizado e seu uso associado a sedativos poderá influenciar a segurança do procedimento. OBJETIVO: analisar aspectos da segurança da ETE associada ao uso de midazolam (MZ) e flumazenil (FL) e a influência de variáveis clínicas na taxa de eventos. MÉTODO: estudo prospectivo com 137 pacientes que realizaram ETE com MZ associado à sedação moderada. Analisamos as seguintes ocorrências: complicações com anestesia tópica, ao uso do MZ e complicações relacionadas ao procedimento. Análises uni e multivariada foram usadas para testar a influência das variáveis clínicas: idade, sexo, acidente vascular cerebral (AVC), miocardiopatia (MP), duração do exame, insuficiência mitral (IM) e dose de MZ. RESULTADOS: todos pacientes (65±16 anos; 58% masculino) completaram o exame. As doses médias de MZ e FL foram de 4,3±1,9 mg e 0,28±0,2 mg, respectivamente. A duração do exame e a fração de ejeção (FE) média foram de 16.4±6.1 minutos e 60±9%, respectivamente. O evento mais comum foi a hipóxia leve (SO25mg) tiveram associação com tais eventos (p5mg) were associated with events (p5mg) se asociaron a tales complicaciones (p

Background: There is a paucity of information concerning left ventricular (LV) dyssynchrony assessment by real time three-dimensional (3D) echocardiography (RT3DE) versus tissue Doppler imaging (TDI). Aims: To compare RT3DE and TDI LV dyssynchrony assessment. Methods: A prospective study of 92 individuals (56 men, age 47 ± 10 years), 32 with dilated cardiomyopathy (CMP), and 60 healthy individuals. By RT3DE, we measured the LV% dyssynchrony index (DI) of 6, 12, and 16 segments (SDI). By pulsed-wave TDI, we measured the QS electromechanical interval in the basal segments of the mitral valve annulus of the septum, the lateral, anterior and inferior walls, and the TDI% DI. Results: In the normal group, the 3D DI was 1.1 ± 0.8%, 1.4 ± 1.3%, 1.8 ± 1.7%, for 6 segments, 12 segments, and SDI, respectively. The correlation coefficient (Pearson's r) for the TDI DI and SDI was r = 0.2381 (P = 0.0470). In CMP group, the 3D DI was 4.6 ± 5.4%, 7.9 ± 7.1%, 11.1 ± 7.1%, for 6 segments, 12 segments, and SDI, respectively. The correlation coefficient for TDI DI and SDI was r = 0.7838 (P < 0.0001). Conclusions: We observed a good correlation between RT3DE and tissue Doppler LV dyssynchrony assessment in patients with advanced heart failure. (ECHOCARDIOGRAPHY, Volume 26, July 2009)

Several studies support C-reactive protein (CRP) as a systemic cardiovascular risk factor. The recent detection of CRP in arterial intima suggests a dual activity in atherosclerosis as a circulating and tissue mediator on vascular and immune cells. In the present paper, we focused on the inflammatory effects of CRP on human monocytes, which were isolated by Ficoll-Percoll gradients and cultured in adherence to polystyrene, endothelial cell monolayer, or in suspension. Chemokine levels, adhesion molecule, and chemokine receptor expression were detected by ELISA, flow cytometry, and real-time RT-PCR. Migration assays were performed in a Boyden chamber. Stimulation with CRP induced release of CCL2, CCL3, and CCL4 in adherent monocytes through the binding to CD32a, CD32b, and CD64, whereas no effect was observed in suspension culture. This was associated with CRP-induced up-regulation of adhesion molecules membrane-activated complex 1 (Mac-1) and ICAM-1 on adherent monocytes. Blockade of Mac-1/ICAM-1 interaction inhibited the CRP-induced chemokine secretion. In addition, CRP reduced mRNA and surface expression of corresponding chemokine receptors CCR1, CCR2, and CCR5 in adherent monocytes. This effect was a result of chemokine secretion, as coincubation with neutralizing anti-CCL2, anti-CCL3, and anti-CCL4 antibodies reversed the effect of CRP. Accordingly, a reduced migration of CRP-treated monocytes to CCL2 and CCL3 was observed. In conclusion, our data suggest an in vitro model to study CRP activities in adherent and suspension human monocytes. CRP-mediated induction of adhesion molecules and a decrease of chemokine receptors on adherent monocytes might contribute to the retention of monocytes within atherosclerotic lesions and recruitment of other circulating cells.

1-4 . This fact becomes especially relevant when anatomical observation translates into prognostic clinical implications, such as in the identification of images of thrombi in the left atrium or left atrial appendage. In most clinical situations, the investigation of intra-atrial images of thrombi with the use of two-dimensional transthoracic echocardiography does not allow anatomical information reliable enough for a diagnostic definition. Use of multiplane bidimensional transesophagic echocardiography enabled additional diagnostic information for discrimination of intra-atrial masses caused by the use of transducers with a greater ultrasound emission frequency, at a greater proximity to the structure of interest, providing images with a better quality of structural definition. Nevertheless, this semi-invasive echocardiographic modality does not yet allow structural from all anatomic planes of observation (a primary limitation for structural identification based on frontal and transversal cardiac planes, with observation point in atrioventricular, pulmonary, and aortic valve rings). Real-time three-dimensional transthoracic echocardiography is an advancement in anatomical analysis because it allows a rotation of heart structures based on three primary planes of structural definition (infero-superior plane, mid-lateral plane, and depth or elevation plane), as well as a structural composition based on the analysis of composite planes or diagonal planes. Image acquisition is made in real-time, and the final image may be obtained by the projection of interest to the clinician or surgeon. In the case shown, we observe the two-dimensional transthoracic echocardiographic analysis of the left atrial appendage (Figure 1), and the real-time three-dimensional transthoracic image of the left atrial appendage from different observation planes (Figures 2A, 2B and 2C), as from the frontal plane (en face). Currently, transesophagic echocardiography is still the most appropriate echocardiographic technique for visualization of the left atrial appendage and investigation of intracavitary thrombi, as it shows evidence based on analyses with a large number of patients. Further studies are needed for a definition of the diagnostic and prognostic impact of the anatomical findings obtained by the use of real-time threedimensional transthoracic echocardiography.

Identification of subjects at increased risk for cardiovascular events plays a central role in the worldwide efforts to improve prevention, prediction, diagnosis, and prognosis of cardiovascular disease and to decrease the related costs. Despite their high predictive value on population level, traditional risk factors fail to fully predict individual risk. This position paper provides a summary of current vascular biomarkers other than the traditional risk factors with a special focus on the emerging -omics technologies. The definition of biomarkers and the identification and use of classical biomarkers are introduced, and we discuss the limitations of current biomarkers such as high sensitivity C-reactive protein (hsCRP) or N-terminal pro-brain natriuretic peptide (NT-proBNP). This is complemented by circulating plasma biomarkers, including high-density lipoprotein (HDL), and the conceptual shift from HDL cholesterol levels to HDL composition/function for cardiovascular risk assessment. Novel sources for plasma-derived markers include microparticles, microvesicles, and exosomes and their use for current omics-based analytics. Measurement of circulating micro-RNAs, short RNA sequences regulating gene expression, has attracted major interest in the search for novel biomarkers. Also, mass spectrometry and nuclear magnetic resonance spectroscopy have become key complementary technologies in the search for new biomarkers, such as proteomic searches or identification and quantification of small metabolites including lipids (metabolomics and lipidomics). In particular, pro-inflammatory lipid metabolites have gained much interest in the cardiovascular field. Our consensus statement concludes on leads and needs in biomarker research for the near future to improve individual cardiovascular risk prediction.

SummaryAuto-antibodies to apolipoprotein A-1 (anti-apoA-1 IgG) were shown to promote inflammation and atherogenesis, possibly through innate immune receptors signalling. Here, we aimed at investigating the role of Toll-like receptors (TLR) 2 and 4 on anti-apoA-1 IgG-induced athero-sclerotic plaque vulnerability, myocardial necrosis and mortality in mice. Adult male apolipoprotein E knockout (ApoE)-/- (n=72), TLR2-/-ApoE-/- (n=36) and TLR4-/-Apo-/- (n=28) mice were intravenously injected with 50 µg/mouse of endotoxin-free polyclonal anti-apoA-1 IgG or control isotype IgG (CTL IgG) every two weeks for 16 weeks. Atherosclerotic plaque size and vulnerability were assessed by histology. Myocardial ischaemia and necrosis, respectively, were determined by electrocardiographic (ECG) changes assessed by telemetry and serum troponin I (cTnI) measurements. Impact on survival was assessed by Kaplan-Meier analyses. In ApoE-/- mice, anti-apoA-1 IgG passive immunisation enhanced histological features of athero-sclerotic plaque vulnerability (increase in neutrophil and MMP-9 and reduction in collagen content), induced a substantial cTnI elevation (p=0.001), and increased mortality rate by 23 % (LogRank, p=0.04) when compared to CTL IgG. On a subgroup of ApoE-/- mice equipped with telemetry (n=4), a significant ST-segment depression was noted in anti-apoA-1 IgG-treated mice when compared to CTL IgG recipients (p< 0.001), and an acute ST-segment elevation myocardial infarction preceding mouse death was observed in one case. The deleterious effects of anti-apoA-1 IgG on atherosclerotic plaque vulnerability, myocardial necrosis and death were partially reversed in TLR2-/-ApoE-/- and TLR4-/-ApoE-/- backgrounds. In conclusion, anti-apoA-1 auto-antibodies seem to be active mediators of atherosclerotic plaque vulnerability, myocardial necrosis, and mortality in mice through TLR2- and TLR4-mediated pathways.

Nuclear factor kappa B (NF-kappa B) activation has been observed in human atherosclerotic plaques and is enhanced in unstable coronary plaques, but whether such activation has a protective or pathophysiological role remains to be determined. We addressed this question by developing a short-term culture system of cells isolated from human atherosclerotic tissue, allowing efficient gene transfer to directly investigate signaling pathways in human atherosclerosis. We found that NF-kappa B is activated in these cells and that this activity involves p65, p50, and c-Rel but not p52 or RelB. This NF-kappa B activation can be blocked by overexpression of I kappa B alpha or dominant-negative I kappa B kinase (IKK)-2 but not dominant-negative IKK-1 or NF-kappa B-inducing kinase, resulting in selective inhibition of inflammatory cytokines (tumor necrosis factor alpha, IL-6, and IL-8), tissue factor, and matrix metalloproteinases without affecting the antiinflammatory cytokine IL-10 or tissue inhibitor of matrix metalloproteinases. Our results demonstrate that the canonical pathway of NF-kappa B activation that involves p65, p50, c-Rel, and IKK-2 is activated in human atherosclerosis and results in selective up-regulation of major proinflammatory and prothrombotic mediators of the disease.

Cardiovascular diseases are the leading cause of morbidity and mortality in Western countries. Atherosclerosis, the background for many cardiovascular diseases, is characterized by the accumulation of lipid and fibrotic entities in large arteries and bears many similarities with chronic inflammatory diseases such as rheumatoid arthritis. Common features include extravasation of blood-derived leukocytes, as well as production of cytokines, chemokines and matrix-degrading enzymes. There are also many shared signaling pathways, including activation of the nuclear factor kappaB (NFkappaB) cascade. In the context of atherosclerosis, there are a range of candidate stimuli which can activate NFkappaB, including traditional risk factors, infectious agents, cytokines and cell-cell contact. Many inflammatory genes relevant to the pathogenesis of atherosclerosis are regulated by NFkappaB, the activated form of which is present in atherosclerotic plaques. Thus, it is essential to understand the role of this important signaling cascade in atherosclerosis, in a quest for more specific therapeutic targets.

Vascular endothelial growth factor (VEGF) is the most endothelial cell-specific angiogenic factor characterised to date, and it is produced by a variety of cell types. In macrophages, VEGF has been shown to be upregulated by the inflammatory mediator lipopolysaccharide (LPS) and by engagement of CD40 by CD40 ligand (CD40L). Because LPS and CD40L activate nuclear factor-kappaB (NF-kappaB) in monocytes, we investigated in this study whether VEGF production in macrophages, when stimulated with either LPS or CD40L, is NF-kappaB-dependent. We used adenoviral constructs over-expressing either IkappaBalpha (AdvIkappaBalpha), the endogenous inhibitor of NF-kappaB, or a kinase-defective mutant of IKK-2 (AdvIKK-2dn), an upstream activator of IkappaBalpha, to infect normal human monocyte-derived macrophages. We observed that LPS-induced production of VEGF in human macrophages was almost completely inhibited (>90%) following adenoviral transfer of IkappaBalpha. In addition, we observed significant inhibition of the CD40L-induced VEGF production in macrophages following infection with AdvIkappaBalpha. Expression of IKK-2dn in macrophages decreased VEGF production in response to LPS or CD40L by approximately 50%, suggesting that in addition to IKK-2, other kinases might be involved in NF-kappaB activation. These results show for the first time that VEGF production in human macrophages is NF-kappaB dependent. NF-kappaB regulates many of the genes involved in immune and inflammatory responses, and our study adds the angiogenic cytokine VEGF to the list of NF-kappaB-dependent cytokines.

Background— Patients undergoing revascularization procedures for peripheral vascular disease (PVD) have a greatly increased risk for coronary artery disease (CAD) that is predicted only partly by clinical data and cardiovascular risk factors. We investigated whether the prognostic assessment in PVD patients could be improved by preoperative measurements of C-reactive protein (CRP). Methods and Results— We assessed clinical and risk factors profiles, Eagle clinical scores, and preoperative CRP serum levels in 51 patients with PVD at Fontaine-Leriche stages II to IV without severe rest ventricular dysfunction or ischemia. During 24 months of follow-up, 17 patients (34%) had fatal (11) or nonfatal (6) myocardial infarction (MI). With univariate logistic regression analysis, only previous history of CAD, Eagle score, and CRP were independently related to MI. At multivariate logistic regression analysis, only CRP values in the upper tertile (P Conclusions— The high incidence of MI in patients with PVD severe enough to require revascularization is strongly predicted by preprocedural measurements of serum CRP, independent of previous CAD, Eagle score index, and traditional cardiovascular risk factors. These patients may benefit from therapy modulating the inflammatory response.

Different vascular abnormalities have been reported under the denomination of "persistence of the fifth aortic arch." Detailed studies on experimental embryology raised the discussion about the existence of the fifth aortic arch as an embryological structure, both in humans and mammals. In 1969 the Van Praaghs described the occurrence of double left aortic arch, denominating such anomaly as persistence of the fifth arch. We describe here a female patient showing the presence of an anomalous vessel in parallel with the aortic arch. The finding was occasional, during a preoperative evaluation for cholecystectomy.

In myeloid cells, the mRNA-destabilizing protein tristetraprolin (TTP) is induced and extensively phosphorylated in response to LPS. To investigate the role of two specific phosphorylations, at serines 52 and 178, we created a mouse strain in which those residues were replaced by nonphosphorylatable alanine residues. The mutant form of TTP was constitutively degraded by the proteasome and therefore expressed at low levels, yet it functioned as a potent mRNA destabilizing factor and inhibitor of the expression of many inflammatory mediators. Mice expressing only the mutant form of TTP were healthy and fertile, and their systemic inflammatory responses to LPS were strongly attenuated. Adaptive immune responses and protection against infection by Salmonella typhimurium were spared. A single allele encoding the mutant form of TTP was sufficient for enhanced mRNA degradation and underexpression of inflammatory mediators. Therefore, the equilibrium between unphosphorylated and phosphorylated TTP is a critical determinant of the inflammatory response, and manipulation of this equilibrium may be a means of treating inflammatory pathologies.

While for a century therapeutics has been dominated by small molecules, i.e. organic chemicals of ~400Da absorbable via the gut, this is no longer the case. There are now a plethora of important medicines which are proteins and injectable, which have dramatically improved the therapy of many inflammatory diseases and of cancer. Most of these are monoclonal antibodies, some are receptor Ig Fc fusion proteins, others are cytokines or enzymes. The key to this new aspect of therapeutics has been the filling of unmet needs, and the consequent commercial success, which promoted further research and development. The first ‘biologic’ for a common disease, rheumatoid arthritis (RA), was a monoclonal antibody, infliximab, to human tumour necrosis factor (TNF). This was based on our work, which is described in this review, summarizing how TNF was defined as a good target in RA, how it was developed is described here, as well as future indications for anti-TNF and related agents. Biologics are now the fastest growing sector of therapeutics.

The impact of pulmonary embolism on right ventricular (RV) performance can be evaluated by echocardiography, however, the relationship between pulmonary vascular involvement and RV burden is controversial. To assess the effect of clot burden on RV performance we studied 85 patients (aged 53 ± 17 years, 39 female) with confirmed PE by multislice computed tomography (CT) and echocardiography within 24 h of diagnosis. A CT score ranging from 1 to 20 points according to the pulmonary arteries involved was used. RV function was evaluated with fractional area change (FAC), with dysfunction present when FAC < 40%. Tissue Doppler RV systolic (s') velocities and myocardial performance index (MPI) were obtained, as well as pulmonary artery pressure (PAP). Mean CT score was 9.4 ± 6.7. Only 31 out of 85 patients (37%) presented with RV dysfunction, with FAC measuring 27.8 ± 7.2% in patients with dysfunction compared to 47.8 ± 4.4 for those with preserved RV function (p < 0.05). RV dysfunction was associated to older age, higher CT scores, increased pulmonary pressures and MPI and decreased s' (p < 0.001). An inverse correlation with CT clot burden was found for FAC (r = -0.57), whereas a direct correlation was seen for PAP (r = 0.51) and MPI (0.32). No correlation was observed for tissue Doppler velocities. In patients with acute PE, the effect of clot burden on RV performance is better expressed FAC than tissue Doppler indexes; the increase in pulmonary pressure is proportional to the magnitude of obstruction.

Results: The individuals of both groups had similar anthropometric variables. The following was observed in the cyclist group as for the controls: lower A’ wave velocity (5.9 cm/s ± 2.2 versus 7.6 ± 2.3 cm/s, with P = 0.03), smaller atrial contraction force (4.7 ± 1,4Kdyn vs. 6.2 ± 2.1Kdyn, P = 0.02) and greater passive emptying fraction (43.8% ± 12.8 versus 34.8 ± 10.4% with P = 0.03). A linear correlation was found between A’ wave velocity and atrial contraction force in the cyclists group (r = 0.65, P

The growing size of trials on primary and secondary prevention of acute coronary syndromes characterised by very broad inclusion criteria may seem logical to `trialists', who reason that the broader the inclusion criteria, the easier it is to recruit large numbers of patients in a short period of time and the more widely applicable are the results of the study. However, large trials with very broad inclusion criteria raise two grounds for concern for physicians. The first is that the broader the inclusion criteria for enrolment in a trial in order to prove a statistically significant benefit, the greater the heterogeneity of the study population which is likely to include both susceptible and non-susceptible patients to the tested treatment. The second is that this method of assessment rapidly increases the number of treatments that produce a statistically-significant improvement in prognosis within the same broad group of patients. On the contrary, the identification of potential responders to a specific treatment can provide a personalised form of medical care suited to the needs of each individual patient with an optimal cost–benefit ratio. This approach, however, represents a major challenge as it can only be based on the identification of homogeneous subgroups of patients with common risk factors for the development of acute coronary syndromes or of their recurrence. This challenge can only be overcome by a strong commitment in funding studies on the multiple causes of acute coronary syndromes.

Intimal hyperplasia (IH) is a leading cause of obstruction of vascular interventions, including arterial stents, bypass grafts and arteriovenous grafts and fistulae. Proposals to account for arterial stent-associated IH include wall damage, low wall shear stress (WSS), disturbed flow and, although not widely recognized, wall hypoxia. The common non-planarity of arterial geometry and flow, led us to develop a bare-metal, nitinol, self-expanding stent with three-dimensional helical-centreline geometry. This was deployed in one common carotid artery of healthy pigs, with a straight-centreline, but otherwise identical (conventional) stent deployed contralaterally. Both stent types deformed the arteries, but the helical-centreline device additionally deformed them helically and caused swirling of intraluminal flow. At sacrifice, one month post stent deployment, histology revealed significantly less IH in the helical-centreline than straight-centreline stented vessels. Medial cross-sectional area was not significantly different in helical-centreline than straight-centreline stented vessels. By contrast, luminal cross-sectional area was significantly larger in helical-centreline than straight-centreline stented vessels. Mechanisms considered to account for those results include enhanced intraluminal WSS and enhanced intraluminal blood–vessel wall mass transport, including of oxygen, in the helical-centreline stented vessels. Consistent with the latter proposal, adventitial microvessel density was lower in the helical-centreline stented than straight-centreline stented vessels.

BACKGROUND AND AIM: Patients with systemic lupus erythematosus (SLE) have a higher prevalence of subclinical atherosclerosis and higher risk of cardiovascular (CV) events compared to the general population. The relative contribution of CV-, immune- and disease-related risk factors to accelerated atherogenesis in SLE is unclear. METHODS AND RESULTS: Fifty SLE patients with long-lasting disease (mean age 44 ± 10 years, 86% female) and 50 sex- and age-matched control subjects were studied. Common carotid artery intima-media thickness (CCA-IMT) was used as a surrogate marker of atherosclerosis. We evaluated traditional and immune- and disease-related factors, assessed multiple T-cell subsets by 10-parameter-eight-colour polychromatic flow cytometry and addressed the effect of pharmacological therapies on CCA-IMT. In SLE patients, among several cardiometabolic risk factors, only high-density lipoprotein levels (HDL) and their adenosine triphosphate-binding cassette transporter 1 (ABCA-1)-dependent cholesterol efflux capacity were markedly reduced (p