Amyloid is a form of abnormal protein aggregation within the living body. Massive deposits can lead to organ failure. There is also increasing evidence that smaller pre-amyloid aggregates exert direct toxic effects to cells. To date 25 different proteins are known to occur as amyloid deposition in human tissues, although not all of these conditions are known to be associated with clinical diseases. This thesis deals with the very common form of amyloid localized to the arterial media. The fibril protein called ‘medin’ was identified in 1999. Medin is a 50 amino acid residue internal fragment of the precursor protein lactadherin. Lactadherin, first found in human milk, is expressed in various tissues such as breast epithelium (including carcinomas), macrophages and aorta. The function of the protein is not known but it has several functional domains. There is an EFG like domain, including an RGD-sequence, in the N-terminal part of the molecule. The C-terminal part consists of C1 and C2 coagulation factor V and VIII like domains. Medin is from within the C2 domain. This region is suggested to be involved in phosphatidyl serine binding, important in phagocytosis of apoptotic cells. Medin amyloid was originally described from studies of the aorta. It is shown here that deposits are more widely spread and can be found in many large arteries, particularly within the upper part of the body. The prevalence of medin amyloid increases with age and deposits are found, to a certain degree, in virtually everyone above the age of 60 years. The amyloid is not only found extracellularly but intracellular deposits may also occur. Amyloid is usually associated with elastic lamina or lamellae which often show signs of fragmentation. Given the localization of amyloid to elastic structures of the arterial media, three different vascular diseases were studied: temporal (giant cell) arteritis, thoracic aortic aneurysm and thoracic aortic dissection. Medin amyloid was found in temporal arteries with and without inflammation. In inflamed arteries, amyloid was mainly located along the broken internal elastic lamina. Medin was also demonstrated within giant cells. It is suggested that medin may be an antigen triggering autoimmune giant cell arteritis. In the study of thoracic aortic aneurysms and dissections, we found significant less medin amyloid in diseased aortic tissues compared with a control material. On the other hand, immunoreactive medin, probably in the state of oligomeric aggregates, was regularly found in association with aneurysms and dissections but not in the control material. It is suggested that medin oligomers exert toxic effects on smooth muscle cells which may lead to weakening of the arterial wall with aneurysm or dissection as a consequence.

The present study evaluated genetic and metabolic factors influencing the risk of acute cerebrovascular disease (CVD) and internal carotid artery stenosis (ICA stenosis) in a Swedish community. The threonine (T) containing protein of the FABP2 A54T gene polymorphism has a greater affinity for long chain fatty acids (FFAs) than the alanine (A) containing protein. This altered affinity for FFAs has been shown to affect the intestinal absorption of fatty acids and consequently the fatty acid composition of serum lipids, in particularly postprandially. Endothelium derived NO is a potent vasodilator and antiatherogenic agent. Asymmetric dimethyl arginine (ADMA) is an endogenous competitive inhibitor of endothelial nitric oxide synthase (eNOS). ADMA has been shown to be involved in the pathogenesis of atherosclerotic disease, and ADMA inhibits eNOS by displacement of L-arginine from the enzyme, which in turn is believed to affect the amount of NO available within the endothelium. The FABP2 A54T gene polymorphism was analyzed in 407 patients with acute CVD and also in a subset of these patients whose carotids had been evaluated with ultrasound. Both the FABP2 polymorphism and a common polymorphism of the eNOS gene, Glu298Asp, were analyzed in a different population consisting of 54 matched pairs of patients with ICA stenosis and controls. ADMA levels were measured in both study populations. We found that the T54 allele was more frequent in patients with transient ischaemic attacks (TIA), and that the TT genotype was more prevalent in young, non-smoking patients with CVD than in controls. Increased concentrations of ADMA were observed in cardio-embolic infarction and TIA, but not significantly in non-cardio-embolic infarction nor in haemorrhagic stroke. In multivariate logistic regression models, CVD increased across quartiles of ADMA in all subgroups, but this association was only significant in the TIA group. A decreased arginine/ADMA ratio, a measure of NO availability was associated with CVD in the entire study population. Patients with severe carotid stenosis had significantly higher ADMA levels than the controls. Allele and genotype frequencies of the FABP2 and eNOS polymorphisms did not differ between patients with ICA stenosis and controls. Our results indicate that ADMA is a strong marker for TIA and severe ICA stenosis, and that relative defiency of arginine, measured as L-arginine/ADMA, is present in acute CVD. We also conclude that a common polymorphism of the FABP2 gene increases susceptibility to ischaemic stroke and TIA. / Figure 4 on page 17 is publshed with kind permisson from The Journal of Physiology (http://jp.physoc.org/).

Background: Despite the recent improvements in surgical techniques and postoperative patient care, atrial fibrillation (AF) remains the most frequent complication after cardiac surgery. Although postoperative AF is often regarded as a benign clinical condition, this arrhythmia has significant adverse effects on patient recovery and postoperative survival. Its exact pathophysiology has not yet been elucidated. The present thesis aims to analyze AF risk factors and their interaction, pre-existing histological explanatory alterations of the atrium, the AF impact on postoperative survival and the compliance of a prophylactic drug regimen. Methods: During a 10-year period, consecutive cardiac surgery cases with complete data on AF occurrence and postoperative survival were extracted. All patients were operated on for coronary or valvular surgery, with cardiopulmonary bypass (CPB). Hospital and long-term survival data were obtained from Swedish population registry. Study I) Isolated coronary artery bypass grafting (CABG, n=7056), aortic valve replacement (n=690) and their combination (n=688) were considered. Independent AF risk factors and AF effects on early and 1 year mortality were investigated. Study II) Patients affected by postoperative AF among isolated CABG patients (n=7621), valvular surgeries (n=995) and their combination (n=879) were studied. Long-term survival was obtained and prognostic factors identified. Study III) Seventy patients were randomized to on-pump (n=35) or off-pump (n=35) CABG. Samples from the right atrial appendage were collected and histology was evaluated by means of light and electronic microscopy with reference to preexistent alterations related to postoperative AF. Study IV) Cardiac surgery patients with complete data on smoking status (n=3245) were reviewed. Effects of smoking on AF development and interaction among variables were explored. Study V) CABG patients without clinical contraindications to receive oral sotalol (80 mg twice daily) and magnesium were prospectively enrolled (n = 49) and compared with a matched contemporary control CABG group (n = 844). The clinical compliance to the AF prophylactic drug regimen was tested. Results: The overall AF incidence was around 26%, subdivided into 23%, 40% and 45% for isolated CABG, valve procedures and their combined surgeries, respectively. Age was the strongest predictor of postoperative AF. Coronary disease superimposed risk factors with reference to myocardial conditions at CPB weaning. Considering the preoperative smoking condition, smokers demonstrated a reduced AF incidence compared to non-smokers (20% versus 27%, p<0.001). An interaction between smoking status and inotropic support was observed: without this interaction smoking conferred a 46% risk reduction of AF (p=0.011). At the histological level, myocyte vacuolization and nuclear derangement represented anatomical independent AF predictors (p=0.002 and p=0.016, respectively). CPB exposure was not associated to postoperative AF nor histological changes. Although, postoperative AF increases the length of hospitalization in all patient groups, it did not affect the hospital survival. However, AF independently impaired the late survival, a phenomenon seen in the CABG group only. With reference to the tested sotalolmagnesium drug regimen, only 55% of CABG patients were compliant to the treatment, with marginal effects on AF occurrence. Conclusions: In addition to age, details at the CPB weaning period, pre-existing histopathological changes, the hyperadrenergic state and catecholamines are key mechanisms in the pathophysiology of postoperative AF. In particular, the CPB period hides valuable information for timely AF prophylactic stratifications. Further, compliance effects due to patient selection should also be considered in a prophylactic therapy model. Postoperative AF increases late mortality after isolated CABG surgery, but not after valvular procedures. Although the mechanisms are unclear, our results draw the attention to possible AF recurrence after hospital discharge, indicating a strict postoperative surveillance.

Despite the currently recommended dual antiplatelet treatment (DAT) with aspirin and P2Y12 inhibition in patients with coronary artery disease (CAD) there is a risk of adverse clinical outcome. Pharmacodynamic (PD) poor response to clopidogrel occurs in ~ 30% of clopidogrel-treated patients and is associated with an increased risk of recurrent thrombotic events. The aims of this thesis were to compare the PD and pharmacokinetic effects of clopidogrel 600 mg loading dose (LD)/ 75 mg standard maintenance dose (MD) with the novel P2Y12 inhibitor prasugrel 60 mg LD/10 mg MD, in 110 patients with CAD. The mechanisms behind clopidogrel poor response were investigated by assessing the pharmacodynamics after adding clopidogrel active metabolite (AM) and genotyping for variation in CYP-genes involved in thienopyridine metabolism. In another study, we compared the on-clopidogrel platelet reactivity of patients with stent thrombosis (ST) (n=48) or myocardial infarction (MI) (n=30) while on DAT and their matched controls (n=50 + 28). Prasugrel achieved a faster and greater P2Y12-mediated platelet inhibition than clopidogrel measured with light transmission aggregometry, VASP and VerifyNow® P2Y12. Prasugrel’s greater platelet inhibition was associated with higher exposure of AM. The addition of clopidogrel AM led to maximal platelet inhibition in all subjects, suggesting that prasugrel’s greater antiplatelet effect was related to more efficient AM generation compared to that of clopidogrel. Lower levels of AM as well as less platelet inhibition were seen in clopidogrel-treated patients with reduced-metabolizer genotype CYP2C19 compared to those with normal genotype. Patients with ST while on DAT showed higher on-clopidogrel platelet reactivity compared to matched stented controls. Patients with spontaneous MI after stenting did not. In conclusion, these results showed a high rate PD poor response to a high bolus dose of clopidogrel because of a partly genetically caused lower generation of AM which could be overcome by prasugrel treatment. In patients after coronary stenting, clopidogrel poor response was related to ST but not to spontaneous MI, illustrating difficulties in optimizing treatment with clopidogrel based on platelet function or genetic testing in individual patients.

Non invasive in vivo imaging will lead to better understanding of Angiotensin II Type 1 Receptor’s (AT1R) role in disease progression and may guide therapy in cardiovascular patients. Two models were used in this project: 5/6 nephrectomy and transient left anterior descending (LAD) ligation. Rats were scanned with [13N]ammonia and [11C]methyl-candesartan, both of which are Positron Emission Tomography (PET) tracers, at 8 weeks (nephrectomy) and 2 weeks (LAD ligation) after surgery. Western blot analysis was used to corroborate PET data. Nephrectomy: Renal AT1R image analysis displayed a 40% decrease in kidney AT1R in nephrectomized animals compared to sham (p<0.05) which was confirmed with Western blot and biodistribution. LAD ligation: Left Ventricle AT1R Western blot analysis exhibited a 60% increase in 20min ligation (p<0.05) with maintained myocardial blood flow. In conclusion, changes in renal AT1R were successfully imaged using [11C]methyl-candesartan in nephrectomized animals, and 20min LAD ligation/reperfusion is an appropriate model to image an increase in cardiac AT1R following ischemic injury.

Non invasive in vivo imaging will lead to better understanding of Angiotensin II Type 1 Receptor’s (AT1R) role in disease progression and may guide therapy in cardiovascular patients. Two models were used in this project: 5/6 nephrectomy and transient left anterior descending (LAD) ligation. Rats were scanned with [13N]ammonia and [11C]methyl-candesartan, both of which are Positron Emission Tomography (PET) tracers, at 8 weeks (nephrectomy) and 2 weeks (LAD ligation) after surgery. Western blot analysis was used to corroborate PET data. Nephrectomy: Renal AT1R image analysis displayed a 40% decrease in kidney AT1R in nephrectomized animals compared to sham (p<0.05) which was confirmed with Western blot and biodistribution. LAD ligation: Left Ventricle AT1R Western blot analysis exhibited a 60% increase in 20min ligation (p<0.05) with maintained myocardial blood flow. In conclusion, changes in renal AT1R were successfully imaged using [11C]methyl-candesartan in nephrectomized animals, and 20min LAD ligation/reperfusion is an appropriate model to image an increase in cardiac AT1R following ischemic injury.

Pre-eclampsia is associated with increased risk of cardiovascular disease (CVD) later in life. The ‘gold standard’ for estimating cardiovascular risk - ultrasound assessment of the common carotid artery intima-media thickness (CCA-IMT) - does not convincingly demonstrate this increased risk. The aim of this thesis was to examine whether high-frequency (22 MHz) ultrasound assessment of the individual CCA intima and media layers and calculation of the intima/media (I/M) ratio - can indicate the increased cardiovascular risk after pre-eclampsia. After validation of the method in premenopausal women with systemic lupus erythematosus (SLE) who have a recognized increased risk of CVD, women during and after normal and preeclamptic pregnancies were investigated. Assessment of the individual artery wall layers reliably demonstrated the increased cardiovascular risk in premenopausal women with SLE, while CCA-IMT did not. The artery wall layer dimensions in women with SLE were comparable to those of postmenopausal women without SLE and were 30 years older. Among the women with normal pregnancies negative changes to the artery wall later on in the pregnancy were seen in those with lower serum estradiol, older age, higher body mass index or higher blood pressure early in the pregnancy. About one year postpartum, both the mean intima thickness and the I/M ratio had improved, compared to values during pregnancy. These findings support the theory that normal pregnancy is a stress on the vascular system. Women who developed pre-eclampsia (mean age 31 years) had thicker intima layers, thinner media layers and higher I/M ratios, both at diagnosis and one year postpartum, than women with normal pregnancies, indicating increased cardiovascular risk. Women with a history of severe pre-eclampsia (mean age 44 years; mean 11 years since the last delivery) had thicker intima layers and higher I/M ratios than women with a history of normal pregnancies, indicating long-standing negative vascular effects. Assessment of individual CCA wall layers, but not of CCA-IMT, provided clear evidence of the well-known increased cardiovascular risk in women with SLE or pre-eclampsia. The method has the potential to become an important tool in reducing cardiovascular morbidity and mortality in these women through early diagnosis and intervention.

Objetivos: Evaluar mediante la técnica ultrasonográfica duplex-Doppler (UTD) el flujo sanguíneo de la arteria digital palmar en caballos sanos, con enfermedades que predisponen a laminitis y conlaminitis clínica.Animales: Cuarenta y dos caballos distribuidos en tres grupos: Nuevecaballos sanos (Grupo I), diecinueve caballos con enfermedades quepredisponen a laminitis (Grupo II) y catorce caballos con laminitis clínica(Grupo III). El grupo de caballos enfermos y el grupo de caballos conlaminitis fueron subdivididos en subgrupos (A y B) en función de laexistencia o no de pulso digital (Grupo II) y de cambios radiológicos en latercera falange (Grupo III).Conclusiones y Relevancia clínica: La morfología del espectro Dopplerde la arteria digital palmar junto con el diámetro del vaso, el VF, la ITV y elTAC son los parámetros que más se modifican en caballos con pulsodigital con enfermedades que predisponen a laminitis y laminitis clínica. / To evaluate palmar digital artery blood flow by transcutaneous duplex Doppler ultrasonography (TDU) in healthy horses, horses with diseases those predispose to laminitis and horses with overt laminitis. Animals: Forty-two horses classified in three groups: Nine healthy horses (Group I), nineteen horses with diseases those predispose to laminitis (Group II) and fourteen horses with overt laminitis (Group III). The group of ill horses and the group of horses with overt laminitis were subdivided in subgroups (A and B) depending on the presence of digital pulse (Group II) and the existence of radiological changes in the third phalanx (Group III). Conclusions and Clinical Relevance: Doppler spectrum blood flow patters of the palmar digital artery together with diameter, VF, ITV and TAC are the more significant parameters in horses with digital pulse and diseases that predispose to laminitis and in horses with overt

Atherosclerosis is a systemic disease of the vessel wall that occurs in the aorta, carotid, coronary and peripheral arteries. Atherosclerotic plaques in coronary arteries may cause the narrowing (stenosis) or complete occlusion of the arteries and lead to serious results such as heart attacks and strokes. Medical imaging techniques such as X-ray angiography and computed tomography angiography (CTA) have greatly assisted the diagnosis of atherosclerosis in living patients. Analyzing and quantifying vessels in these images, however, is an extremely laborious and time consuming task if done manually. A novel image segmentation approach and a quantitative shape analysis approach are proposed to automatically isolate the coronary arteries and measure important parameters along the vessels. The segmentation method is based on the active contour model using the level set formulation. Regional statistical information is incorporated in the framework through Bayesian pixel classification. A new conformal factor and an adaptive speed term are proposed to counter the problems of contour leakage and narrowed vessels resulting from the conventional geometric active contours. The proposed segmentation framework is tested and evaluated on a large amount of 2D and 3D, including synthetic and real 2D vessels, 2D non-vessel objects, and eighteen 3D clinical CTA datasets of coronary arteries. The centerlines of the vessels are proposed to be extracted using harmonic skeletonization technique based on the level contour sets of the harmonic function, which is the solution of the Laplace equation on the triangulated surface of the segmented vessels. The cross-sectional areas along the vessels can be measured while the centerline is being extracted. Local cross-sectional areas can be used as a direct indicator of stenosis for diagnosis. A comprehensive validation is performed by using digital phantoms and real CTA datasets. This study provides the possibility of fully automatic analysis of coronary atherosclerosis from CTA images, and has the potential to be used in a real clinical setting along with a friendly user interface. Comparing to the manual segmentation which takes approximately an hour for a single dataset, the automatic approach on average takes less than five minutes to complete, and gives more consistent results across datasets.

Arterien und Venen sind aufgrund ihrer Funktion im Körper morphologisch, funktionell und genetisch unterschiedlich. Schon die großen Blutgefässe auskleidende Endothelzellen zeigen eine arteriovenöse Determinierung. Ausgehend von einer Mikroarray-Analyse der mRNA-Expression arterieller und venöser Endothelzellen der Nabelschnur wurde im Rahmen dieser Arbeit auf Moleküle des Notch-Signalwegs, Dll-4, Notch-4, Hey-1 und Hey-2 fokussiert, die präferenziell bis exklusiv arteriell exprimiert werden. Weitere Gene mit einem arteriellen Expressionsmuster, die im Rahmen der vorliegenden Arbeit analysiert wurden, sind Angiopoietin-2 und CD44s. Trotz der genetisch definierten Unterschiede ließ der Vergleich physiologisch relevanter Funktionen, wie Proliferation oder die Interaktion mit monozytären Zellen keinen vom endothelialen Zelltyp abhängigen Unterschied erkennen. Die im Matrigel ausgebildeten kapillar-ähnlichen Strukturen sind durch homogene, eng beieinander liegende Netzwerke charakterisiert. Studien über den Einfluss von Wachstumsfaktoren und Schubspannung auf die arteriovenöse Expression von Angiopoietin-2 deuten auf eine schubspannungsvermittelte Regulation der Gefäßstabilität und Differenzierung hin. Die in der Zellkultur durchgeführten Manipulationen, wie der Einfluss verschiedener Wachstumsfaktoren oder die Applikation unterschiedlicher Schubspannungen, erreichten in Bezug auf die Expression der untersuchten Markergene keine tiefer greifende Redifferenzierung des jeweiligen endothelialen Phänotyps. Der evolutionär hoch konservierte Notch-Signalweg ist präferenziell arteriell exprimiert, wobei Hey-2 ausschließlich arteriell exprimiert wird. In adulten Endothelzellen erfolgt die Hey-2-Regulation jedoch Notch-unabhängig. Die arteriovenöse Genexpression von Molekülen des Notch-Signalwegs ist unabhängig von der Schubspannung. Unter hypoxischen Bedingungen verringerte sich die Expression von Dll-4, Hey-1 / 2 dramatisch, ohne das jedoch physiologische Beeinträchtigungen zu beobachten waren. Die Expression des venösen COUP-TF II wird in arteriellen Endothelzellen nicht durch den Notch-Signalweg reguliert. Die Auswertung der Daten in der vorgelegten Arbeit lässt vermuten, dass die einmal festgelegte genetische Determinierung adulter Endothelzellen fixiert und äußeren Einflüssen gegenüber stabil und unumkehrbar ist. Dennoch ist eine gewisse Anpassungsfähigkeit der Endothelzellen an bestimmte Situationen möglich, die zwar die Ausprägung von Merkmalen des jeweilig anderen Phänotyps beinhaltet, jedoch nicht eine vollständige Redifferenzierung.