永井 良三

OBJECTIVES: We hypothesized that a large number of patients with diabetic retinopathy who could benefit greatly from early coronary artery bypass grafting would not be identified. METHODS: Patients with diabetic retinopathy receiving ophthalmologic care as outpatients in our hospital in whom coronary artery disease was not previously suspected were referred randomly to the diabetic retinocoronary clinic and were asked to participate in diagnostic tests, including an exercise treadmill test and exercise thallium scintigraphy or coronary computed tomography. Patients who had type 1 diabetes mellitus, required hemodialysis, or both were excluded from this study. A definitive diagnosis of coronary artery disease was confirmed by means of coronary angiography. RESULTS: Of 214 patients with diabetic retinopathy, 55 (25.7%) were confirmed as having significant stenotic coronary artery disease. Patients with angiographically confirmed coronary disease were older than those with negative results on diagnostic tests (62.2 + or - 9.8 vs 57.9 + or - 10.3 years, P = .01). Fifteen had 1-vessel disease, 17 had 2-vessel disease, 14 had 3-vessel disease, 1 had left main trunk plus 1-vessel disease, 2 had left main trunk plus 2-vessel disease, and 5 had left main trunk plus 3-vessel disease. Eight patients had left main trunk disease, and 18 patients with non-left main trunk disease had proximal left anterior descending coronary artery (LAD) disease. Forty-two patients showed indications of coronary revascularization (coronary artery bypass grafting in 17 and percutaneous coronary intervention in 25). During the entire follow-up (287.6 + or - 183.2 days) of 39 patients undergoing coronary revascularization, all were alive without myocardial infarction, but 8 experienced vitreous hemorrhage. CONCLUSIONS: Approximately 25% of patients with diabetic retinopathy receiving ophthalmologic care as outpatients have a significant stenotic coronary artery disease. Of the total diabetic population, a large number of patients with diabetic retinopathy who show strong indications for early coronary artery bypass grafting might well go unrecognized.

Aim: Changes in indexes of obesity, such as waist circumference (WC) and body mass index (BMI), may influence some glucose metabolism-related parameters in both obese and non-obese subjects. We have investigated the impact of changes in WC and in BMI on data related to glucose metabolism over a one-year period. Methods: Data from 3213 individuals (2014 men, 1199 women) who underwent a general health screening two years running and were not taking antidiabetic medication were analyzed. Results: In men, percent changes in WC (%dWC) and BMI (%dBMI) were both significantly correlated with percent changes in fasting glucose (%dFG), in hemoglobin A(1c) (%dHbA(1c)), and in HOMA-IR (%dHOMA-IR). In women, these relationships were not significant except for the relationship between %dBMI and %dHOMA-IR. In a multivariate linear regression analysis using age, %dBMI, and %dWC as independent variables, %dBMI, but not %dWC, was found to be an independent predictor of %dHOMA-IR in both genders. Furthermore, in men, %dBMI was also an independent factor predicting %dFG and %dHbA(1c). Conclusion: During the one-year period, a reduction in BMI, and thus weight loss, was found to be associated with the improvement of insulin sensitivity, especially in men. A reduction in WC was also associated with an improvement in insulin sensitivity in men; however, this relationship did not remain significant after controlling for changes in BMI.

Fibroblasts, which are the most numerous cell type in the heart, interact with cardiomyocytes in vitro and affect their function; however, they are considered to play a secondary role in cardiac hypertrophy and failure. Here we have shown that cardiac fibroblasts are essential for the protective and hypertrophic myocardial responses to pressure overload in vivo in mice. Haploinsufficiency of the transcription factor-encoding gene Krüppel-like factor 5 (Klf5) suppressed cardiac fibrosis and hypertrophy elicited by moderate-intensity pressure overload, whereas cardiomyocyte-specific Klf5 deletion did not alter the hypertrophic responses. By contrast, cardiac fibroblast-specific Klf5 deletion ameliorated cardiac hypertrophy and fibrosis, indicating that KLF5 in fibroblasts is important for the response to pressure overload and that cardiac fibroblasts are required for cardiomyocyte hypertrophy. High-intensity pressure overload caused severe heart failure and early death in mice with Klf5-null fibroblasts. KLF5 transactivated Igf1 in cardiac fibroblasts, and IGF-1 subsequently acted in a paracrine fashion to induce hypertrophic responses in cardiomyocytes. Igf1 induction was essential for cardioprotective responses, as administration of a peptide inhibitor of IGF-1 severely exacerbated heart failure induced by high-intensity pressure overload. Thus, cardiac fibroblasts play a pivotal role in the myocardial adaptive response to pressure overload, and this role is partly controlled by KLF5. Modulation of cardiac fibroblast function may provide a novel strategy for treating heart failure, with KLF5 serving as an attractive target.

Background: Beta-blockers are underprescribed for coronary artery disease (CAD) patients in Japan. Considering the vast amount of evidence showing their benefits in this group of patients, the aim of the present study was to investigate the use of β-blockers in a large cohort of CAD patients. Methods and Results: The 13,812 patients with angiographically confirmed CAD were followed up for 2.7 years. From this group, 4,160 (30.1%) patients were prescribed β-blockers at the time of discharge. These patients were significantly more likely to have hypertension, hyperlipidemia, obesity, a family history of ischemic diseases and a higher number of diseased arteries. The rate of continuation for β-blockers was 90.8%. A propen-sity score matching analysis showed no additional benefits of β-blockers in reducing all-cause mortality, cardiac events and cerebrovascular events. Lipophilic β-blockers were significantly more effective than hydrophilic ones in reducing all-cause mortality (hazard ratio 0.467, 95% confidence interval 0.247-0.880, P=0.019). Conclusions: Despite the low prescription rate of β-blockers for CAD patients among Japanese physicians, the continuation rate was relatively high. Lipophilic β-blockers may be a better choice than hydrophilic β-blockers in terms of mortality risk, although a randomized control study would need to be conducted to verify this assertion.

Calcium channel blockers (CCB) and statins are frequently prescribed for patients with coronary artery disease (CAD) complicated by hypertension and/or hypercholesterolemia. CCB have pleiotropic actions beyond their blood pressure-lowering effect, while statins have pleiotropic actions beyond their cholesterol-lowering effect. We assessed the hypothesis that combined treatment with CCB and statins has additional prognostic benefits resulting from potential additive or synergistic pleiotropic actions of both classes of drugs in the Japanese CAD (JCAD) study population. The JCAD study consisted of 13,812 patients with angiographically demonstrable significant coronary narrowing in at least 1 of 3 major coronary arteries who were followed-up for a mean of 2.7 years (follow-up rate, 88.4%). The primary endpoint of the present study was all cardiovascular events. We compared the event rate between patients receiving neither CCB nor statins and those receiving each drug alone or as a combination treatment using propensity score matching analysis. The rate of all events was 62.8 per 1,000 patient-years in the JCAD study. Kaplan-Meier analysis with the logrank test showed no statistically significant difference in the event rate in each comparison. In conclusion, there may be no additional prognostic benefit beyond the blood-pressure-lowering and cholesterol-lowering effects in the combined treatment with CCB and statins for angiographically documented CAD patients.

Abnormal transforming growth factor-beta (TGF-beta) signaling is a critical contributor to the pathogenesis of various human diseases ranging from tissue fibrosis to tumor formation. Excessive TGF-beta signaling stimulates fibrotic responses. Recent research has focused in the main on the antiproliferative effects of TGF-beta in fibroblasts, and it is presently understood that TGF-beta-stimulated cyclooxygenase-2 (COX-2) induction in fibroblasts is essential for antifibroproliferative effects of TGF-beta. Both TGF-beta and COX-2 have been implicated in tumor growth, invasion, and metastasis, and therefore tumor-associated fibroblasts are a recent topic of interest. Here we report the identification of positive and negative regulatory factors of COX-2 expression induced by TGF-beta as determined using proteomic approaches. We show that TGF-beta coordinately up-regulates three factors, heterogeneous nuclear ribonucleoprotein A/B (HNRPAB), nucleotide diphosphate kinase A (NDPK A), and nucleotide diphosphate kinase A (NDPK B). Functional pathway analysis showed that HNRPAB augments mRNA and protein levels of COX-2 and subsequent prostaglandin E(2) (PGE(2)) production by suppressing degradation of COX-2 mRNA. In contrast, NDPK A and NDPK B attenuated mRNA and protein levels of COX-2 by affecting TGF-beta-Smad2/3/4 signaling at the receptor level. Collectively, we report on a new regulatory pathway of TGF-beta in controlling expression of COX-2 in fibroblasts, which advances our understanding of pathophysiological mechanisms of TGF-beta.

The REduction of Atherothrombosis for Continued Health (REACH) Registry is a large, international, prospective cohort of patients with atherothrombosis or multiple (≥ 3) risk factors (MRFs) for atherothrombosis. Japanese patients (n = 5193) were enrolled into the REACH registry between August and December 2004. One-year event rate in patients with cerebrovascular disease (CVD) was compared with that of patients with symptomatic atherothrombosis at other locations. After one year (n = 5021), patients with CVD (n = 1962) experienced a higher rate of non-fatal strokes than patients with coronary artery disease (CAD), peripheral artery disease (PAD) or MRFs alone (2.77% vs. 1.28%, 2.07% and 1.56%, respectively), but a lower rate of non-fatal myocardial infarction (0.45% vs. 1.31%, 0.77% and 0.66%, respectively). Patients with CVD plus disease in ≥ 1 other vascular bed had higher rates of cardiovascular events than patients with CVD alone. Overall, event rates including non-fatal stroke, non-fatal myocardial infarction and cardiovascular death were higher for patients with CVD and PAD than for patients with CVD and CAD. Asymptomatic carotid stenosis ≥ 70% and ankle-brachial index &lt 0.9 were significant predisposing factors for stroke. Patients with CVD and co-existing atherothrombotic diseases had a high risk of recurrent events, including events arising in other vascular beds than originally diagnosed. © 2009 Elsevier B.V.

Recent evidence indicates that renin-angiotensin system (RAS) plays an important role in the pathogenesis of atherosclerosis. It was reported that inhibition of RAS with angiotensin II type I receptor blockers (ARBs) or angiotensin converting enzyme inhibitors (ACEIs) is effective in prevention of atherosclerosis. Here, we investigated the effects of an ARB or/and an ACEI on atherosclerosis development and periadventitial inflammation in apolipoprotein E (ApoE)-deficient mice. RT-PCR revealed that major RAS components were expressed in periaortic tissue. Ang II infusion significantly increased accumulation of bone marrow derived cells into both neointima (p < 0.05) and periaortic tissue (p < 0.01). Male ApoE- deficient mice were treated with either vehicle, TA606A (10 mg/kg/day, ARB), imidapril Q mg/kg/day, ACEI) or TA606A plus imidapril (TA606A 10 mg/kg/day + imidapril 3 mg/kg/day, ARB + ACEI) for 24 weeks starting at 12 weeks of age. ARB, ACEI, and ARB + ACEI significantly reduced atherosclerotic lesion formation in aorta compared with vehicle (p < 0.05), with reduced expression of monocyte chemoattractant protein-1 in periaortic tissues (p < 0.01). Neither blood pressure nor heart rate was changed by the treatments at these lower doses. Imidapril significantly reduced lipid deposition in atheroma and plasminogen activator inhibitor-1 expression in periadventitial tissue (p < 0.05, respectively). Imidapril and combination therapy significantly attenuated macrophage infiltration into the atherosclerotic plaque (p < 0.05, respectively). All treatments reduced macrophage accumulation in the periadventitial tissue 12 weeks after treatment (p < 0.05, respectively). These results suggest that inhibition of renin-angiotensin system attenuates periadventitial inflammation and reduces atherosclerotic lesion formation. (C) 2009 Elsevier Masson SAS. All rights reserved.

症例は72歳女性。61歳時に僧帽弁狭窄症に対し僧帽弁置換術が施行され、高血圧、慢性腎臓病とともに外来フォローされていた。陳旧性心筋梗塞、慢性心房細動もあり、2001年頃より、心不全増悪による入退院をくり返していた。2008年3月初旬、うっ血性心不全による入院後、利尿剤・カテコラミン等による加療中に腎機能悪化を認め、自尿確保も困難となったため、血液透析(HD)導入となった。その後、両側腎動脈の起始部に高度狭窄病変が存在することが判明し、再発性心不全および腎機能急性増悪の主因と考えられた。透析から離脱困難であったこともあり、腎機能および血行動態の改善を目的に経皮的腎動脈形成術(PTRA)を施行する方針となった。5月初旬、両側腎動脈狭窄症(RAS)に対しそれぞれPTRA(ステント留置)を行ったところ、著明な腎機能改善を認め、最終的にはHD離脱可能となった。その後、半年以上の経過観察中で明らかな心不全入院、腎機能再増悪なども認めておらず血圧コントロールも改善された。RASは特異的な臨床症状に乏しく見逃されがちであるが、他の動脈硬化性疾患とともに増加が予想されており、再発性うっ血性心不全や腎不全症例の病因を考える上でも本症例は貴重であると考え報告する。(著者抄録)

Rationale: Obesity is associated with a high incidence of cardiovascular complications. However, the molecular link between obesity and vascular disease is not fully understood. Most previous studies have focused on the association between cardiovascular disease and accumulation of visceral fat. Periadventitial fat is distributed ubiquitously around arteries throughout the body. Objective: Here, we investigated the impact of obesity on inflammation in the periadventitial adipose tissue and on lesion formation after vascular injury. Methods and Results: High-fat, high-sucrose feeding induced inflammatory changes and decreased adiponectin expression in the periadventitial adipose tissue, which was associated with enhanced neointima formation after endovascular injury. Removal of periadventitial fat markedly enhanced neointima formation after injury, which was attenuated by transplantation of subcutaneous adipose tissue from mice fed on regular chow. Adiponectindeficient mice showed markedly enhanced lesion formation, which was reversed by local delivery, but not systemic administration, of recombinant adiponectin to the periadventitial area. The conditioned medium from subcutaneous fat attenuated increased cell number of smooth muscle cells in response to platelet derived growth factor-BB. Conclusions: Our findings suggest that periadventitial fat may protect against neointimal formation after angioplasty under physiological conditions and that inflammatory changes in the periadventitial fat may have a direct role in the pathogenesis of vascular disease accelerated by obesity. © 2009 American Heart Association, Inc.

It has long been a matter of debate whether the hormone-sensitive lipase (HSL)-mediated lipolysis in pancreatic beta-cells can affect insulin secretion through the alteration of lipotoxicity. We generated mice lacking both leptin and HSL Lep(ob/ob)/HSL(-/-) and explored the role of HSL in pancreatic beta-cells in the setting of obesity. Lep(ob/ob)/HSL(-/-) developed elevated blood glucose levels and reduced plasma insulin levels compared with Lep(ob/ob)/HSL(+/+) in a fed state, while the deficiency of HSL did not affect glucose homeostasis in Lep(+/+) background. The deficiency of HSL exacerbated the accumulation of triglycerides in Lep(ob/ob) islets, leading to reduced glucose-stimulated insulin secretion. The deficiency of HSL also diminished the islet mass in Lep(ob/ob) mice due to decreased cell proliferation. In conclusion, HSL affects insulin secretary capacity especially in the setting of obesity.

Cholesterol ester (CE)-laden macrophage foam cells are the hallmark of atherosclerosis, and the hydrolysis of intracellular CE is one of the key steps in foam cell formation. Although hormone-sensitive lipase (LIPE) and cholesterol ester hydrolase (CEH), which is identical to carboxylsterase 1 (CES1, hCE1), were proposed to mediate the neutral CE hydrolase (nCEH) activity in macrophages, recent evidences have suggested the involvement of other enzymes. We have recently reported the identification of a candidate, neutral cholesterol ester hydrolase 1(Nceh1). Here we demonstrate that genetic ablation of Nceh1 promotes foam cell formation and the development of atherosclerosis in mice. We further demonstrate that Nceh1 and Lipe mediate a comparable degree of nCEH activity in macrophages and together account for most of the activity. Mice lacking both Nceh1 and Lipe aggravated atherosclerosis in an additive manner. Thus, Nceh1 is a promising target for the treatment of atherosclerosis.

Use of short interfering RNA (siRNA) is a promising new approach thought to have a strong potential to lead to rapid development of gene-oriented therapies. Here, we describe a newly developed, systemically injectable siRNA vehicle, the "wrapsome" (WS), which contains siRNA and a cationic lipofection complex in a core that is fully enveloped by a neutral lipid bilayer and hydrophilic polymers. WS protected siRNA from enzymatic digestion, providing a long half-life in the systemic circulation. Moreover, siRNA/WS leaked from blood vessels within tumors into the tumor tissue, where it accumulated and was subsequently transfected into the tumor cells. Because the transcription factor KLF5 is known to play a role in tumor angiogenesis, we designed KLF5-siRNA to test the antitumor activity of siRNA/WS. KLF5-siRNA/WS exhibited significant antitumor activity, although neither WS containing control scrambled-siRNA nor saline containing KLF5-siRNA affected tumor growth. KLF5-siRNA/WS inhibited Klf5 expression within tumors at both mRNA and protein levels, significantly reducing angiogenesis, and we detected no significant acute or long-term toxicity. Our findings support the idea that siRNA/WS can be used to knock down specific genes within tumors and thereby exert therapeutic effects against cancers.

Metabolic syndrome is a major risk factor for cardiovascular and metabolic diseases. Playing a central role in the development of metabolic syndrome and in its clinical consequences is visceral obesity. Adipose tissue is now considered to be an active endocrine organ that secretes various humoral factors (adipokines), and its shift to production of proinflammatory cytokines in obesity likely contributes to the low-level systemic inflammation that is seen in metabolic syndrome-associated chronic pathologies such as atherosclerosis. Recent studies have shown that obesity induces chronic local inflammation in adipose tissue, and that cells of the innate immune system, particularly macrophages, are crucially involved in adipose inflammation and systemic metabolic abnormalities. Moreover, we and others recently revealed that T cells are key regulators of adipose inflammation, and that the adaptive immune system is also crucially important. In mouse models modulation of T cell function ameliorated not only adipose inflammation but also systemic insulin resistance induced by obesity. Thus clarification of the inflammatory processes ongoing in obese adipose tissue would seem essential for the understanding of metabolic syndrome and for developing novel therapeutic strategies to treat it.

Inflammation is increasingly regarded as a key process underlying metabolic diseases in obese individuals. In particular, obese adipose tissue shows features characteristic of active local inflammation. At present, however, little is known about the sequence of events that comprises the inflammatory cascade or the mechanism by which inflammation develops. We found that large numbers of CD8(+) effector T cells infiltrated obese epididymal adipose tissue in mice fed a high-fat diet, whereas the numbers of CD4(+) helper and regulatory T cells were diminished. The infiltration by CD8(+) T cells preceded the accumulation of macrophages, and immunological and genetic depletion of CD8(+) T cells lowered macrophage infiltration and adipose tissue inflammation and ameliorated systemic insulin resistance. Conversely, adoptive transfer of CD8(+) T cells to CD8-deficient mice aggravated adipose inflammation. Coculture and other in vitro experiments revealed a vicious cycle of interactions between CD8(+) T cells, macrophages and adipose tissue. Our findings suggest that obese adipose tissue activates CD8(+) T cells, which, in turn, promote the recruitment and activation of macrophages in this tissue. These results support the notion that CD8(+) T cells have an essential role in the initiation and propagation of adipose inflammation.

AIMS: It was reported that administration of angiogenic growth factors can augment collateral growth in ischemic tissues. It is assumed that angiogenic effects of cell transplantation may be mainly mediated by secretion of angiogenic cytokines. We tested feasibility of clinical use of ONO-1301, a synthetic small molecule that stimulates secretion of growth factors from various cell types, to treat patients with chronic myocardial ischemia. MAIN METHODS: Effects of ONO-1301 on fibroblasts and endothelial cells were evaluated in vitro. We examined the efficacy of local delivery of ONO-1301 in models of rat hindlimb ischemia and swine chronic ischemic myocardium. KEY FINDINGS: ONO-1301 stimulated hepatocyte growth factor secretion from human fibroblasts. ONO-1301 promoted vascular-like tube formation by endothelial cells in vitro. Direct injection of a slow-release form of ONO-1301 (SR-ONO) to rat hindlimb ischemic muscle enhanced perfusion recovery. In a swine cardiac ischemia model, direct injection of SR-ONO into the ischemic myocardium significantly augmented collateral formation (SR-ONO vs. control; 1.7+/-0.2 vs. 1.0+/-0.2 Rentrop score), with improved local ventricular wall motion, reduced enlargement of left ventricular diastolic volume (49.5+/-1.9 mL vs. 59.7+/-4.2 mL) and increased cardiac index (4.2+/-0.1 vs. 3.4+/-0.2 L/min/m(2)). Histological analysis revealed that SR-ONO suppressed fibrosis in ischemic tissue (collagen volume fraction; 7.5+/-1.1% vs. 12.8+/-2.2%) and enhanced neovascularization (capillary density, 275.6 vs. 159.3/mm(2); arterioles 36.6 vs. 25.5 /mm(2)). SIGNIFICANCE: Local delivery of SR-ONO might be effective for therapeutic angiogenesis and propose that local administration of slow-release of synthetic small molecules represents new strategy for therapeutic angiogenesis.

症例は22歳、男性。既往歴、突然死の家族歴ともになし、大学講内でアメリカン・フットボール中に意識消失し当院救急搬送となった。初診時、心室細動(VF)による心肺停止状態であり、自動体外除細動器(AED)にて蘇生された。明らかな頭部病変なし。全身集中管理により後遺症なく回復した。心電図・心エコーとも正常。T-wave alterans(TWA)は陰性ながらlate potential(LP、SAECG)は陽性を示した。電気生理学的検査では右室流出路で一部に低電位領域を認めたが、持続性心室性不整脈は誘発されず。原因として心臓震盪(commotio cordis)をはじめ不整脈原性右室心筋症や特発性VFなどが考慮されたが、器質的心疾患を完全には否定しきれない状況および本人・家族の意向も加味して植込み型除細動器(ICD)移植術を行った。外来での経過観察中に数回ICD正常動作あり。本症例はICD適応検討や運動場へのAED設置、競技関係者の心肺蘇生普及にあたり示唆的と考え報告する。(著者抄録)

Obesity increases the risk for chronic kidney disease (CKD). By analyzing data on individuals who underwent general health screening in two consecutive years, we investigated whether changes in body mass index (BMI) or waist circumference (WC) were associated with the appearance or disappearance of the CKD components micro-/macroalbuminuria (≥30 mg urinary albumin per gram creatinine) and a low estimated glomerular filtration rate (eGFR &lt 60 ml/min/1.73 m2). Logistic regression analysis showed that in men with micro-/macroalbuminuria at the first visit, a BMI reduction of ≥0.42 or a WC reduction of ≥3.0 cm over the 1-year period resulted in a significantly reduced incident of micro-/macroalbuminuria at the second visit. On the other hand, a BMI gain of ≥0.33 over 1 year in men without micro-/macroalbuminuria and a low eGFR at the fist visit significantly increased the incident of micro-/macroalbuminuria and a low eGFR, respectively, at the second visit. These findings indicate that lowering the obesity indexes in men with micro-/macroalbuminuria reduced the incidence of this condition at the 1-year follow-up and that, on the contrary, an increase in BMI in men without micro-/macroalbuminuria and a low eGFR at the first examination increased the risk of these conditions during the 1-year follow-up period. © 2009 S. Karger AG, Basel.

Introduction: Whether or not metabolic syndrome is predictive of atherosclerotic disorders may depend on the population studied. We investigated whether metabolic syndrome is associated with carotid atherosclerosis in individuals who were shown not to have diabetes mellitus based on results of the 75-g oral glucose tolerance test (OGTT). Methods and results: Between 1994 and 2003, 3904 individuals underwent general health screening that included the OGTT. Among these 3904 individuals, 3679 had a fasting plasma glucose of <126 mg/dL (subgroup 1), and 3488 had a 2-h post-OGTT glucose value of <200 mg/dL (subgroup 2). In both subgroups, metabolic syndrome was found to be a risk factor for carotid plaque and for carotid intima-media thickening in men, and tended to be a risk factor for carotid plaque in women after adjustment for age. Among 3473 individuals who had both a fasting plasma glucose value of <126 mg/dL and a 2-h post-OGTT glucose of <200 mg/dL, 2440 did not have hypertension, which was defined as systolic and diastolic blood pressure of <140/90 mmHg and absence of use of anti-hypertensive medication. In these non-diabetic non-hypertensive individuals, the association between metabolic syndrome and carotid plaque or carotid intima-media thickening was not statistically significant even with adjustment only for age. Conclusions: In men who did not have impaired fasting glycemia and/or in those without impaired glucose tolerance, metabolic syndrome was a predictor of carotid atherosclerosis after age adjustment, although metabolic syndrome was not found to be a predictor of carotid atherosclerosis when hypertensive individuals were excluded from the study population. (C) 2008 Elsevier Ireland Ltd. All rights reserved.

Background. Prostaglandin E-2 (PGE(2)) is a pathogenesis of inflammatory diseases; PGE(2) plays a key role in association of anti-inflammation and immune suppression. EP4, which is a PGE(2) receptor, is known to suppress the production of inflammatory cytokines and chemokines in vitro. Although it has been reported that EP4 agonists prolonged cardiac allograft survival, little has been elucidated the immunologic mechanism. Methods. We injected a selective EP4 agonist (EP4RAG) into recipient mice with heterotopic cardiac transplantation. Results. EP4RAG significantly prolonged the graft survival compared with the vehicle-treated group. Although the vehicle-treated group showed severe myocardial cell infiltration, the EP4RAG-treated group attenuated the development on day 7. EP4RAG suppressed various proinflammatory factors such as cytokines, chemokines, adhesion molecules, and nuclear factor-kappa B (NF-kappa B) compared with the vehicle-treated group. We also demonstrated that EP4RAG suppressed the activation of macrophages, but it did not affect to T lymphocytes in vitro. EP4RAG inhibited the activation of NF-kappa B compared with the control group. Conclusion. Pharmacological selective EP4 activation suppressed the production of proinflammatory factors by inhibition of NF-kappa B activity in cardiac transplantation.

Sirolimus-eluting stent reduces restenosis after percutaneous coronary intervention. However. accumulating evidence suggests that sirolimus potentially affects re-endothelialization, leading to late thrombosis. Statins have protective effects on endothelium. Recently, statins are reported to increase the number of circulating endothelial progenitor cells (EPCs) and accelerate re-endothelialization after vascular injury. Here, we tested the hypothesis that fluvastatin has beneficial effect oil re-endothelialization after local sirolimus treatment. We performed wire-mediated vascular injury to both sides of femoral arteries of wild-type mice and bone marrow chimeric mice. Either sirolimus (100 mu g) or DMSO was administered locally to the perivascular area of the injured arteries. All mice received either fluvastatin (5 mg/kg/day) or vehicle by gavage starting at one week before the surgery until sacrifice. At 4 weeks after the surgery, re-endothelialization of the sirolimus-treated artery was significantly less than that of DMSO-treated one in the vehicle-treated mice as determined by the percentage of CD31-positive area (P<0.05). Systemic administration of fluvastatin accelerated the re-endothelialization in the sirolimus-treated artery to the similar degree of that in the DMSC-treated artery (P=NS). Contribution of bone marrow-derived cells to re-endothelialization was seldom observed in bone marrow chimeric mice regardless Of fluvastatin administration. Fluvastatin significantly ameliorated proliferation (2.5-folds) and migration activities (2.3-folds) of mature endothelial cells impaired by sirolimus treatment (P<0.05. respectively). Fluvastatin increased endothelial nitric oxide synthase expression and decreased plasminogen activator inhibitor-1 expression in mature endothelial cell in the presence of sirolimus (P<0.05, respectively). Our findings suggest that fluvastatin has protective effects against impaired re-endothelialization after sirolimus treatment. (C) 2009 Elsevier B.V. All rights reserved.

BACKGROUND: D-dimer has been reported to be elevated in acute aortic dissection. Potential use as a "rule-out" marker has been suggested, but concerns remain given that it is elevated in other acute chest diseases, including pulmonary embolism and ischemic heart disease. We evaluated the diagnostic performance of D-dimer testing in a study population of patients with suspected aortic dissection. METHODS AND RESULTS: In this prospective multicenter study, 220 patients with initial suspicion of having acute aortic dissection were enrolled, of whom 87 were diagnosed with acute aortic dissection and 133 with other final diagnoses, including myocardial infarction, angina, pulmonary embolism, and other uncertain diagnoses. D-dimer was markedly elevated in patients with acute aortic dissection. Analysis according to control disease, type of dissection, and time course showed that the widely used cutoff level of 500 ng/mL for ruling out pulmonary embolism also can reliably rule out aortic dissection, with a negative likelihood ratio of 0.07 throughout the first 24 hours. CONCLUSIONS: D-dimer levels may be useful in risk stratifying patients with suspected aortic dissection to rule out aortic dissection if used within the first 24 hours after symptom onset.

BACKGROUND: Inflammation plays an important role in neointimal hyperplasia after vascular injury. COX-2 is a key mediator of inflammation and contributes to several inflammatory diseases. Although selective COX-2 inhibitors affect pathological conditions in inflammatory diseases, little is known about the effects on vascular remodeling after mechanical injury. METHODS: To clarify the role of COX-2 in vascular remodeling after arterial injury, we made a wire-injury model using C57BL/6J mice. These mice were orally administrated a selective COX-2 inhibitor twice a day. COX-2 mRNA expression was analyzed in injured femoral arteries. RESULTS: COX-2 expression was markedly enhanced in the arterial wall on day 7; the expression was gradually decreased from day 14. In histopathological analyses, the COX-2 inhibitor significantly suppressed the progression of neointimal formation in comparison with non-treated mice. In an in vitro study, RNA was collected from macrophages after stimulation. The stimulation resulted in enhanced expression of IL-6 compared with the control, and the COX-2 inhibitor decreased this expression. CONCLUSION: COX-2 is enhanced in the neointima after mechanical injury, and inhibition attenuated this. Therefore, regulation of COX-2 may be useful for preventing neointimal formation after coronary intervention.

Background: Gender differences among patients with coronary artery disease vary from study to study. In one of the largest studies, the Japanese Coronary Artery Disease (JCAD) Study, gender differences in patients were investigated. Methods and Results: Consecutive patients diagnosed with stenosis 75% or more in at least one branch of the coronary arteries were enrolled in the study. The endpoint is a composite of all-cause death and cardiovascular events. Data were collected over the internet. Out of 15,628 patients screened, 13,812 of them met the inclusion criteria and were followed up for a mean period of 2.7 years. The event rate was 62.8 per 1,000 patients-year, all-cause death 17.3 and total cardiac events 47.4. The incident rate of unstable angina was higher in females (27.1) than males (21.8) (P=0.0363). The incidence of all-cause death was lower in females than males (16.9 and 17.8, respectively P=0.0148). Other than gender, hypertension and number of vessel disease contribute to the event of unstable angina, and age, family history, obesity, impaired fasting glycemia, hyperlipidemia, congestive heart failure and number of vessel disease contribute to the all-cause death. Conclusions: Gender is an independent contributing factor of unstable angina and of all-cause death.

Background: The association of elevated serum uric acid (UA) with cardiovascular events in patients with severe coronary artery stenosis was examined. Methods and Results: Patients with stenosis ≥75% (n=8,832) were followed for "all events" (cardiovascular events and all-cause mortality) for 3 years. The group was divided into quartiles based on baseline UA level. The incidence rate of all events was significantly different among quartiles (58.3, 56.5, 61.2, 76.3/1,000 patients-year, P&lt 0.001). Cox's proportional hazard regression analysis showed that the hazard ratio (HR) for all events was 1.25 [95% confidence interval (CI): 1.07-1.45, P&lt 0.01] in the highest quartile (UA ≥6.8 mg/dl). The group in which UA increased ≥1.0 mg/dl after 6 months had significantly higher cardiovascular events rate than the group in which UA did not change (70.6 vs 58.8/1,000 patients-year, P=0.042). Propensity score matching was performed and 4,206 patients were divided into the highest quartile and the rest. High UA remained an independent predictor of all events (HR 1.25, 95%CI 1.06-1.43). However, no significant difference was observed between the group with increased UA ≥1.0 mg/dl and the group with unchanged UA level. Conclusions: Elevated UA is an independent predictor of cardiovascular events and all-cause mortality combined in patients with coronary artery stenosis.

Adiponectin, one of the insulin-sensitizing adipokines, has been shown to activate fatty acid oxidation in liver and skeletal muscle, thus maintaining insulin sensitivity. However, the precise roles of adiponectin in fatty acid synthesis are poorly understood. Here we show that adiponectin administration acutely suppresses expression of sterol regulatory element-binding protein (SREBP) 1c, the master regulator which controls and upregulates the enzymes involved in fatty acid synthesis, in the liver of +Lepr(db)/+Lepr(db) (db/db) mouse as well as in cultured hepatocytes. We also show that adiponectin suppresses SREBP1c by AdipoR1, one of the functional receptors for adiponetin, and furthermore that suppressing either AMP-activated protein kinase (AMPK) via its upstream kinase LKB1 deletion cancels the negative effect of adiponectin on SREBP1c expression. These data show that adiponectin suppresses SREBP1c through the AdipoR1/LKB1/AMPK pathway, and suggest a possible role for adiponectin in the regulation of hepatic fatty acid synthesis.

Krüppel-like factor 5 (KLF5), originally isolated as a regulator of phenotypic modulation of vascular smooth muscle cells, induces pathological cell growth and is expressed in the neointima. Although induction of KLF5 up-regulates growth factors like platelet-derived growth factor-A chain, how KLF5 actually contributes to vascular remodeling, notably its direct effects on cell proliferation, had been poorly clarified. To investigate the effects of KLF5 on neointimal formation, we at first performed adenoviral overexpression of KLF5 to rats subjected to carotid balloon injury. Neointimal formation and proliferating cell nuclear antigen-positive rate were significantly increased at 14 days after injury in the KLF5-treated animals. At the cellular level, overexpression of KLF5 also resulted in markedly increased cell proliferation and cell cycle progression. As a molecular mechanism, we showed that KLF5 directly bound to the promoter and up-regulated gene expression of cyclin D1, as well as showing specific transactivation of cyclins and cyclin-dependent kinase inhibitors in cardiovascular cells. Conversely, knockdown of KLF5 by RNA interference specifically down-regulated cyclin D1 and impaired vascular smooth muscle cell proliferation. Furthermore, KLF5 attenuated cleavage of caspase-3 under conditions of apoptotic stimulation. Moreover, KLF5-administered animals exhibited a significant decrease in terminal deoxynucleotidyltransferase-mediated dUTP nick end-labeling-positive cells in the medial layer, suggesting inhibition of apoptosis in the early phase after denudation. These findings collectively suggest that KLF5 plays a central role in cardiovascular pathologies through direct and specific stimulation of cell growth as well as inhibition of apoptosis.

Metabolic syndrome is a major risk factor of cardiovascular events, and obese visceral adipose tissue remodeling and malfunctioning based on chronic inflammation play a central role. To assess dynamic multi-cellular interplay, a novel ex vivo and in vivo adipose tissue imaging method was developed. We found close spatial and temporal interrelationships between angiogenesis and adipogenesis, and both were augmented in obese adipose. In addition, we found increased leukocyte-platelet-endothelial cell interactions in the microcirculation of obese visceral adipose that were indicative of activation of the leukocyte adhesion cascade, a hallmark of inflammation. Both macrophages and endothelial cells showed increased adhesion molecules, and platelets were also activated locally in obese adipose. Up-regulated expression of adhesion molecules on multiple cell types suggests that their increased interactions contribute to local activation of inflammatory processes within visceral obese adipose tissue. Interestingly, the heightened leukocyte-platelet-endothelial interactions were not observed in obese subcutaneous fat pads. Our results demonstrated the power of our imaging technique to analyze complex cellular interplays in vivo and to evaluate new therapeutic interventions against them. Results also indicate that visceral obese adipose tissue is an inflammatory site itself.

BACKGROUND: Beraprost sodium, an orally active prostacyclin analogue, has proved to be beneficial for the patients with primary pulmonary hypertension and obstructive peripheral arterial disease. METHODS: In this study, we examined the effects of BPS on the expression of the VEGF and PAI-1 genes in vascular smooth muscle cells. RESULTS: The mRNA levels for VEGF were increased by BPS in C2/2 cells and cultured rat aortic smooth muscle cells. In contrast, PAI-1 mRNA levels were significantly decreased by BPS. Luciferase assays and mRNA decay assays showed that BPS increases VEGF promoter activity and has no effects on its mRNA stability. Likewise, BPS decreases PAI-1 promoter activity without affecting its mRNA stability. Experiments using various pharmacological inhibitors for protein kinases showed that activation of cAMP-dependent protein kinase (PKA) was involved in BPS-mediated regulation of VEGF and PAI-1 mRNA expression. Overexpression of CREB (cAMP-responsive element binding protein) induces VEGF promoter and reduces PAI-1 promoter activities. CREMepsilon, a dominant negative form of CREB, inhibits BPS-mediated changes in VEGF and PAI-1 promoter activities. While BPS augmented hypoxia-induced VEGF mRNA expression, it blunted hypoxia-induced PAI-1 mRNA expression. CONCLUSION: These results suggest that BPS increases VEGF and decreases PAI-1 gene expression through PKA/CREB-dependent mechanisms in vascular smooth muscle cells. Because these effects are observed more prominently under the hypoxic condition compared to normoxic condition, BPS may have a potential to relieve hypoxia by inducing neovasculization and by reducing thrombosis.

We experienced a case in which live 3D transoesophageal echocardiography (TEE) was found much more valuable than 2D TEE in assessing mitral lesions in circumferential direction and making surgical plans for mitral valve prolapse.