Association between admission ECG changes and long-term mortality in patients with an incidental myocardial infarction: Results from the KORA myocardial infarction registry.

BACKGROUND: The aim of this study was to examine the predictive value of specific changes in admission ECG on long-term outcome in acute myocardial infarction (AMI). METHODS: From 2000 until 2017 all AMI cases (n = 9,689) in the study area of Augsburg, Germany, were prospectively recorded. For this study, all patients with a first-time AMI, who survived the first 28 days, were considered. Median observational time was 6.7 years (IQR: 3.6-10.9). Each case was assigned to one of the following groups according to the admission ECG: 'ST-segment elevation', 'ST-segment depression', 'T-wave inversion', 'unspecific changes', 'normal ECG' and 'bundle branch block' (BBB). Multivariable adjusted COX regression models were calculated to compare long-term all-cause mortality. RESULTS: The final regression model revealed a significantly higher mortality among patients with BBB (HR: 1.52 [1.34-1.73], p-value: < 0.001) and 'ST-segment depression' (HR: 1.16 [1.03-1.29], p-value: 0.01252) compared to the STEMI group (reference group). The 'normal ECG' group (HR: 0.76 [0.66-0.87], p-value: < 0.001) on the other hand was associated with significantly lower long-term mortality. The 'T-wave inversion' group (HR: 1.08 [0.96-1.21]) and the 'unspecific changes' group (HR: 1.05 [0.94-1.17]) did not differ significantly from the STEMI group. CONCLUSION: ST-segment depressions and BBB admission ECGs go along with higher long-term mortality in AMI patients compared to STEMI cases. This should be taken into account by physicians when treating patients with NSTEMIs. Only the complete absence of AMI-related ECG changes predicts a more favorable outcome.

Subendothelial matrix components influence endothelial cell apoptosis in vitro.

The programmed form of cell death (apoptosis) is essential for normal development of multicellular organisms. Dysregulation of apoptosis has been linked with embryonal death and is involved in the pathophysiology of various diseases. Specifically, endothelial apoptosis plays pivotal roles in atherosclerosis whereas prevention of endothelial apoptosis is a prerequisite for neovascularization in tumors and metastasis. Endothelial biology is intertwined with the composition of subendothelial basement membrane proteins. Apoptosis was induced by addition of tumor necrosis factor-α to cycloheximide-sensitized endothelial cells. Cells were either grown on polystyrene culture plates or on plates precoated with healthy basement membrane proteins (collagen IV, fibronectin, or laminin) or collagen I. Our results reveal that proteins of healthy basement membrane alleviate cytokine-induced apoptosis whereas precoating with collagen type I had no significant effect on apoptosis by addition of tumor necrosis factor-α to cycloheximide-sensitized endothelial cells compared with cells cultured on uncoated plates. Yet, treatment with transforming growth factor-ß1 significantly reduced the rate of apoptosis endothelial cells grown on collagen I. Detailed analysis reveals differences in intracellular signaling pathways for each of the basement membrane proteins studied. We provide additional insights into the importance of basement membrane proteins and the respective cytokine milieu on endothelial biology. Exploring outside-in signaling by basement membrane proteins may constitute an interesting target to restore vascular function and prevent complications in the atherosclerotic cascade.

CD34+ circulating cells display signs of immune activation in patients with acute coronary syndrome.

Bone marrow-derived endothelial progenitor cells (EPC) are released into the peripheral blood in situations of vascular repair/angiogenesis. Regulation of vascular repair and angiogenesis by EPC depends not only on the number of circulating EPC but also on their functionality. As endothelial cells can act as antigen-presenting cells in coronary artery disease (CAD), we postulated that EPC can be immune activated here as well. CD34+-EPC were isolated from peripheral blood of patients with ST-elevation myocardial infarction (STEMI, n = 12), non-STEMI/unstable angina (UA, n = 15), and stable CAD (SA, n = 18). Expression of HLA-DR, adhesion and costimulatory molecules by isolated CD34+-EPC were compared with levels in healthy controls (n = 18). There were no significant differences in VCAM-1 and CD80 expression by peripheral circulating CD34+-EPC between the four groups, yet expression of CD86 was highest in UA (p < 0.05). ICAM-1 expression was lowest in SA (p < 0.01). CD34+-EPC constitutively expressed HLA-DR across all groups. Of note, patients pretreated with HMG-CoA reductase inhibitors exhibited lower expression of VCAM-1 by CD34+-EPC throughout all patient groups; furthermore, statins significantly limited ex vivo-induced upregulation of ICAM-1 by TNF-alpha. To the best of our knowledge, this is the first study to examine the expression of immune markers in peripheral circulating CD34+-EPC ex vivo. We demonstrate that CD34+-EPC display different patterns of adhesion and costimulatory molecules in various states of CAD. Expression levels were affected by pretreatment with statins. Hence, immune activity of peripheral circulating CD34+ cells might play a pathophysiologic role in evolution of CAD.

Glucocorticoid-remediable aldosteronism in a young adult with a family history of Conn's syndrome.

Glucocorticoid-remediable aldosteronism is a hereditary form of primary hyperaldosteronism and the most common monogenic cause of hypertension. We present the case of a 24-year-old man with a family history of Conn's syndrome. Yet, in the index patient, classical characteristics of mineralocorticoid excess could be reversed by exogenous glucocorticoids.

3D matrix-embedding inhibits cycloheximide-mediated sensitization to TNF-alpha-induced apoptosis of human endothelial cells.

The programmed form of cell death (apoptosis) is essential for normal development of multicellular organisms. Dysregulation of apoptosis has been linked with embryonal death and is involved in the pathophysiology of various diseases. Others and we previously demonstrated endothelial biology being intertwined with biochemical and structural composition of the subendothelial basement membrane. We now demonstrate that a three-dimensional growing environment significantly shields endothelial cells from cytokine-induced apoptosis. Detailed analysis reveals differences in intracellular signaling pathways in naive endothelial cells and cytokine-stimulated endothelial cells when cells are grown within a three-dimensional collagen-based matrix compared to cells grown on two-dimensional tissue culture plates. Main findings are significantly reduced p53 expression and level of p38-phosphorylation in three-dimensional grown endothelial cells. Despite similar concentrations of focal adhesion kinase, three-dimensional matrix-embedded endothelial cells express significantly less tyrosine-phosphorylated focal adhesion kinase. Pretreatment with antibodies against integrin αv ß3 partially reversed the protective effect of three-dimensional matrix-embedding on endothelial apoptosis. Our findings provide detailed insights into the mechanisms of endothelial apoptosis with respect to the spatial matrix environment. These results enhance our understanding of endothelial biology and may otherwise help in the design of tissue-engineered materials. Furthermore, findings on focal adhesion kinase phosphorylation might enhance our understanding of clinical studies with tyrosine kinase inhibitors.

Influence of polyphenol-rich diet on exercise-induced immunomodulation in male endurance athletes.

Stress is associated with increased susceptibility to infection. We investigated if the mechanism involves immunomodulation of dendritic cells and whether this can be inhibited by a polyphenol-rich diet. Blood samples were taken from a total of 100 male endurance athletes at 5 time points around a marathon run: 4 weeks before; 1 week before; and immediately, 24 h, and 72 h after. Participants were randomized into 2 double-blinded groups. One group received a polyphenol-rich beverage during a 3-week training phase before marathon while the other group received a placebo beverage. Flow cytometric analysis of dendritic cell (DC) counts and subpopulation counts (myeloid, plasmocytoid DCs) was performed. Levels of viral antigen presenting toll-like receptor (TLR) 7 messenger RNA was measured by real-time polymerase chain reaction. Marathon running induced a significant increase of circulating myeloid DCs (0.2% vs. 0.33% of whole-blood leukocytes (wbl); p < 0.01) and a significant decrease of plasmozytoid DCs (0.12% vs. 0.03% of wbl; p < 0.01) and TLR7 expression (decline of 60%; p < 0.01). Polyphenol supplementation did not significantly affect mobilization of dendritic cells but showed beneficial effects on regeneration of TLR7 expression in wbl at 3 days postmarathon (decline of 40% vs. increase of 1000%; p < 0.05). In conclusion, physical stress affects circulating DCs, with an increase of myeloid and a decrease of plasmozytoid DCs. This may partially explain the susceptibility to viral infections after strenuous exercise. These detrimental effects are not attenuated by polyphenol supplementation. However, polyphenols support regeneration of viral antigen presenting TLR7 after strenuous exercise.

Cell matrix contact modifies endothelial major histocompatibility complex class II expression in high-glucose environment.

Atherosclerosis is a chronic inflammatory disease. Cardiovascular risk factors such as hyperglycemia, hyperlipidemia, and arterial hypertension induce endothelial dysfunction with alterations in endothelial biosecretion and immune behavior. The aim of this study is to elucidate whether glucose-induced modifications of endothelial biosecretory and immune functions are regulated by interactions of endothelial cells (ECs) with their extracellular matrix [ECs plated on polystyrene-coated tissue culture plates (TC-EC) vs. ECs embedded within three-dimensional (3-D) collagen-based matrixes (3D-EC)]. In the absence of glucose, IFN-γ-induced phosphorylation of JAK and STAT proteins and human leukocyte antigen (HLA)-DR expression were lower in 3D-EC compared with TC-EC. Inversely, the expression of suppressor of cytokine signaling proteins (SOCS)-1 and -3 were significantly higher in naïve 3D-EC compared with naïve TC-EC. IFN-γ-induced upregulation of SOCS proteins was further amplified by the 3-D environment. Glucose significantly augmented IFN-γ-dependent signaling pathways in TC-EC. IFN-γ-induced phosphorylation of JAK and STAT proteins as well as HLA-DR expression by ECs in low- and high-glucose medium was significantly lower in 3-D than in two-dimensional environment. Glucose increased SOCS expression in TC-EC and 3D-EC to the same extent, such that expression levels in 3D-EC exceeded SOCS-1 and -3 expression in TC-EC by 1.6-2.5-fold. In conclusion, low- and high-glucose concentrations amplify IFN-γ-induced signaling pathways in TC-EC. Increased SOCS expression raises the threshold for IFN-γ to induce HLA-DR expression in a 3-D environment. This immunoprotective effect is maintained even in states of experimental hyperglycemia.

The effect of substrate modulus on the growth and function of matrix-embedded endothelial cells.

Endothelial cells (EC) are potent bioregulatory cells, modulating thrombosis, inflammation and control over mural smooth muscle cells and vascular health. The biochemical roles of EC are retained when cells are embedded within three-dimensional (3D) denatured collagen matrices. Though substrate mechanics have long been known to affect cellular morphology and function and 3D-EC systems are increasingly used as therapeutic modalities little is known about the effect of substrate mechanics on EC in these 3D systems. In this work, we examined the effect of isolated changes in modulus on EC growth and morphology, extracellular matrix gene expression, modulation of smooth muscle cell growth, and immunogenicity. EC growth, but not morphology was dependent on scaffold modulus. Increased scaffold modulus reduced secretion of smooth muscle cell growth inhibiting heparan sulfate proteoglycans (HSPGs), but had no effect on secreted growth factors, resulting in a loss of smooth muscle cell growth inhibition by EC on high modulus scaffolds. Expression of ICAM-1, VCAM-1 and induction of CD4(+) T cell proliferation was reduced by increased scaffold modulus, and correlated with changes in integrin α5 expression. Expression of several common ECM proteins by EC on stiffer substrates dropped, including collagen IV(α1), collagen IV(α5), fibronectin, HSPGs (perlecan and biglycan). In contrast, expression of elastin and TIMPs were increased. This work shows even modest changes in substrate modulus can have a significant impact on EC function in three-dimensional systems. The mechanism of these changes is not clear, but the data presented here within suggests a model wherein EC attempt to neutralize changes in environmental force balance by altering ECM and integrin expression, leading to changes in effects on downstream signaling and function.

Relation of matrix metalloproteinase-9/tissue inhibitor of metalloproteinase-1 ratio in peripheral circulating CD14+ monocytes to progression of coronary artery disease.

Atherosclerosis is an inflammatory disease in which systemic inflammation correlates with disease activity. Matrix metalloproteinases (MMPs) contribute to collagen breakdown in atherosclerotic plaques. In the present study, we investigated whether the ratio of MMP-9 and its endogenous inhibitor, tissue inhibitor of metalloproteinase (TIMP)-1, in circulating monocytes correlates with the clinical stages of coronary artery disease. We studied 18 patients with stable angina pectoris (SAP), 14 patients with unstable angina pectoris and non-ST-segment elevation myocardial infarction (UAP/NSTEMI), 14 patients with ST-elevation myocardial infarction (STEMI), and 16 healthy controls. The protein and mRNA levels of MMP-9 and TIMP-1 in CD14+ monocytes were analyzed using real-time polymerase chain reaction and enzyme-linked immunosorbent assay. The activity of serum MMP-9 was assessed using zymography. Compared to the controls (0.07 +/- 0.01 relative units) and patients with SAP (0.25 +/- 0.1 relative units, p = NS), the monocytic MMP-9 mRNA levels were increased in those with UAP/NSTEMI (0.9 +/- 0.3 relative units, p <0.05 vs SAP) or STEMI (1.6 +/- 0.4 relative units, p <0.05 vs UAP/NSTEMI). In contrast, the protein and mRNA expression of monocytic TIMP-1 levels was 4.5- to 4.7-fold lower in patients with STEMI than in the controls or those with SAP or UAP/NSTEMI (p <0.05). Changes in monocytic expression of MMP-9 and TIMP-1 tracked with the serum levels of MMP-9 and TIMP-1. The activity of serum MMP-9 correlated with the individual MMP-9/TIMP-1 ratio in the peripheral circulating monocytes (r(2) = 0.82, p <0.02). In conclusion, the progression of coronary artery disease was mirrored by an increasing MMP-9/TIMP-1 ratio in the peripheral circulating CD14+ monocytes and serum, respectively. Circulating monocytes displayed the same pattern of imbalance in the expression of MMP-9 and TIMP-1 as previously reported for monocyte-derived macrophages within atherosclerotic plaques, supporting the notion of atherosclerosis as a systemic inflammatory disease.

T-helper 2 cells are essential for modulation of vascular repair by allogeneic endothelial cells.

BACKGROUND: Endothelial cells (ECs) embedded within 3-dimensional matrices (MEEC) control lumenal inflammation and intimal hyperplasia when placed in the vascular adventitia. Matrix embedding alters endothelial immunogenicity in vitro. T-helper (Th) cell-driven host immunity is an impediment of allogeneic grafts. We aimed to identify if modulation of Th balance would affect immune compatibility and endothelial regulation of vascular repair in vivo. METHODS: Pigs (n = 4/group) underwent carotid artery balloon injury and were left untreated (Group 1) or received perivascular porcine MEEC implants (Group 2), 12 days of cyclosporine A (CsA; Group 3), or MEEC and CsA (Group 4). Host immune reactivity was analyzed after 28 and 90 days. RESULTS: MEEC treatment induced formation of EC-specific immunoglobulin (Ig) G(1) antibodies (41 +/- 6 mean fluorescence intensity [MFI]) and differentiation of host splenocytes into Th2, but not Th1, cytokine-producing cells (interleukin [IL]-4, 242 +/- 102; IL-10, 273 +/- 114 number of spots). Concomitant CsA therapy reduced IgG(1) antibody frequency (25 +/- 2 MFI; p < 0.02) and Th2-cytokine producing splenocytes upon MEEC treatment (IL-4, 157 +/- 19; IL-10, 124 +/- 26 number of spots; p < 0.05). MEECs inhibited luminal occlusion 28 and 90 days after balloon injury (12 +/- 7%) vs untreated controls (68 +/- 14%; p < 0.001) but to a lesser extent with concomitant CsA treatment (34 +/- 13%; p < 0.02 vs Group 2). CONCLUSIONS: MEECs do not induce a significant Th1-driven immune response but do enhance differentiation of splenocytes into cells producing Th2 cytokine. Reduction in this Th2 response reduces the vasoregulatory effects of allogeneic ECs after injury.

Function and mode of regulation of endothelial major histocompatibility complex class II.

Tissue engineering is a promising approach to implement endothelial cells as a cellular delivery therapy for vascular disease. We and others previously demonstrated that endothelial cells embedded in three-dimensional collagen-based matrices retain their full biosecretory spectrum, enabling them to serve as powerful regulators of vascular diseases. Fascinatingly, matrix embedding of endothelial cells not only allows for their implantation but also seems to provide protection from allo- and xenogeneic-triggered host immune responses. This is not an effect of simple physical shielding but a more fundamental influence of cell-matrix interconnectivity on the cellular immune phenotype. Reduced cytokine-induced levels of costimulatory and adhesion molecules associated with significantly lower expression levels of major histocompatibility class II expression on matrix-embedded human aortic endothelial cells when compared to the same cells cultured on two-dimensional polystyrene coated-tissue culture plates. Strikingly, the entire interferon-gamma-dependent signaling cascade resulting in MHC class II molecule expression is markedly suppressed in endothelial cells grown to confluence within three-dimensional scaffolds. These findings might be of pivotal importance for designing endothelial cell-based therapies in general and might enhance our understanding of the underlying pathophysiology in a broad range of cardiovascular diseases (e.g., atherosclerosis, vasculitis, chronic allograft vasculopathy).

NF-kappaB activity in endothelial cells is modulated by cell substratum interactions and influences chemokine-mediated adhesion of natural killer cells.

Because changes in subendothelial matrix composition are associated with alterations of the endothelial immune phenotype, we sought to understand if cytokine-induced NF-kappaB activity and downstream effects depend on substrate adherence of endothelial cells (EC). We compared the upstream phosphorylation cascade, activation of NF-kappaB, and expression/secretion of downstream effects of EC grown on tissue culture polystyrene plates (TCPS) with EC embedded within collagen-based matrices (MEEC). Adhesion of natural killer (NK) cells was quantified in vitro and in vivo. NF-kappaB subunit p65 nuclear levels were significantly lower and p50 significantly higher in cytokine-stimulated MEEC than in EC-TCPS. Despite similar surface expression of TNF-alpha receptors, MEEC had significantly decreased secretion and expression of IL-6, IL-8, MCP-1, VCAM-1, and ICAM-1. Attenuated fractalkine expression and secretion in MEEC (two to threefold lower than in EC-TCPS; p < 0.0002) correlated with 3.7-fold lower NK cell adhesion to EC (6,335 +/- 420 vs. 1,735 +/- 135 cpm; p < 0.0002). Furthermore, NK cell infiltration into sites of EC implantation in vivo was significantly reduced when EC were embedded within matrix. Matrix embedding enables control of EC substratum interaction. This in turn regulates chemokine and surface molecule expression and secretion, in particular of those compounds within NF-kappaB pathways, chemoattraction of NK cells, local inflammation, and tissue repair.

The effect of three-dimensional matrix-embedding of endothelial cells on the humoral and cellular immune response.

The endothelium is a unique immunologic target. The first host-donor reaction in any cell, tissue or organ transplant occurs at the blood-tissue interface, the endothelium. When endothelial cells are themselves the primary component of the implant a second set of immunologic reactions arises. Injections of free endothelial cell implants elicit a profound major histocompatibility complex (MHC) II dominated immune response with significant sensitivity, cascade enhancement and immune memory. Endothelial cells embedded within three-dimensional matrices retain all the biosecretory capacity of quiescent endothelial cells. Perivascular implants of such cells are the most potent inhibitor of intimal hyperplasia and thrombosis following controlled vascular injury, but without any immune reactivity. Allo- and even xenogeneic endothelial cells evoke no significant humoral or cellular immune response in immunocompetent hosts when embedded within matrices. Moreover, endothelial implants are immunomodulatory, reducing the extent of the memory response to previous free cell implants. Attenuated immunogenicity results in muted activation of adaptive and innate immune cells. These findings point toward a pivotal role of matrix-cell-interconnectivity for the cellular immune phenotype and might therefore assist in the design of extracellular matrix components for successful tissue engineering.

Endothelial immunogenicity--a matter of matrix microarchitecture.

The endothelium is a highly specialized active interface between blood and the underlying tissues, maintaining vascular tone, thrombo-resistance and selective permeability to cells and proteins. It is also an important regulator of inflammatory diseases, and endothelial-leukocyte interactions often herald complex diseases with an inflammatory component. Yet, the exact mechanisms promoting immune activation of endothelial cells (EC) are incompletely understood. Knowledge is accumulating that the immediate environment defines the cellular phenotype, whereby matrix composition and spatial formation (three- versus two-dimensional) seem to act as pivotal mediators. Here we summarize current findings denoting a key role of matrix environment in regulating endothelial immunogenicity. The immune response to three-dimensional matrix-embedded EC stands in stark contrast to the response engendered by injection of these same cells in their free state. Matrix-embedding confers a quiescent endothelial state with reduced expression levels of chemokines, adhesion, costimulatory, and major histocompatibility complex II molecules. Compared to EC grown on two-dimensional tissue culture plates, cytokine-stimulation of matrix-embedded EC results in significantly reduced adhesion of natural killer cells and proliferation of co-cultivated allogeneic T cells. On the contrary, matrix-embedded EC induce an immune-inhibitory phenotype of dendritic cells and T regulatory cells to a greater extent than non-embedded EC. As vascular diseases are associated with profound changes in basement membrane composition and overall tissue architecture, our results indicate that the immediate environment of EC might play a pivotal role in initiating and regulating of different vascular diseases. Cell-matrix interconnections appear to govern endothelial immunogenicity and interactions between EC and immune cells.

Endothelial cell-matrix interactions determine maturation of dendritic cells.

The fate of allo- and xenogeneic endothelial cell (EC) implants is regulated by EC-matrix interactions. While free EC are destroyed by a vigorous immune reaction, EC embedded within 3D collagen cells are well tolerated. Given the critical role DC serve in immune reactivity, we hypothesized that EC-driven DC maturation depends on EC-matrix contact. In marked contrast to DC co-cultured with a cytokine cocktail or with allo- and xenogeneic EC grown to confluence on 2D tissue culture plates, DC exposed to 3D matrix-embedded allo- and xenogeneic EC failed to mature, retaining their endocytic activity and exhibiting significantly reduced expression of maturation markers (costimulatory molecules, HLA-DR, CD83; p <0.01). Matrix-embedded EC also limited cytokine-induced maturation and activity of DC. Incubation with matrix-embedded EC inhibited DC induction of allogeneic lymphocyte proliferation (p <0.002) and EC cross-activation (ICAM-1, VCAM-1, HLA-DR, TLR2 and 4; p <0.01). The endothelium in its quiescent state is confluent and substrate adherent. The former ensures secretion of growth inhibitors rather than promoters, and the latter may ensure immune acceptance. We now demonstrate for the first time that interactions of EC with an underlying 3D matrix affect the ability of EC to drive DC maturation.

Matrix adherence of endothelial cells attenuates immune reactivity: induction of hyporesponsiveness in allo- and xenogeneic models.

Endothelial integrity regulates vascular tone, luminal patency, and the immune reactivity to tissue grafts. Endothelial dysfunction is the first marker and site of disease initiation and severity. It has long been known that endothelial biochemical function is density dependent, and we have recently shown that endothelial immunobiology is anchorage dependent. Matrix-embedded endothelial cells (EC) establish a controlled anchorage state and are not only immune protected but also induce a system immune protective state. We now define this aspect of vascular and immune biology in detail. The in vitro immune response of allogeneic splenocytes (proliferation, lytic activity, and cytokine expression) on exposure to aortic EC was significantly reduced if EC were embedded within three-dimensional collagen matrices (3D-EC; P<0.005) to an even greater extent than EC that had reached confluence as monolayers on tissue culture plates (EC-TCPS). Splenocyte reactivity was enhanced with repeated exposure to EC-TCPS but minimally if preexposed to 3D-EC (P<0.002). 3D-EC induced significantly greater differentiation of splenocytes into CD4+ CD25+ Foxp3+ regulatory T cells than EC-TCPS (P<0.02). The reduced response to 3D-EC and potential protective effect to subsequent exposure were confirmed in vivo. Repeated exposure of immune-competent mice to injections of xenogeneic EC-TCPS induced vigorous host immunity. In contrast, prior implantation of 3D-EC induced hyporesponsiveness toward subsequent injection of EC-TCPS with reduced humoral response, decreased lytic activity, and lower frequency of effector splenocytes (P<0.001). EC interaction with its matrix determines phenotype, viability, and biosecretory potential. We now show that this microenvironmental interaction also influences endothelial-mediated activation of allo- and xenogeneic immune cells. 3D matrix-embedding limits the ability of EC to initiate adaptive immunity, and initial exposure to 3D-EC confers hyporesponsiveness to subsequent exposure to immunogeneic EC. These effects transcended the traditional control that confluence imposes on EC and reflects perhaps even higher order control. Our findings might offer novel insights to endothelial-mediated diseases and potential cell-based therapies.