Perfusion-2013-02 by Sibylle Michna

2 2013

Kreislauf- und Stoffwechselerkrankungen in Klinik und Praxis Jahrgang 26, Heft 2 April 2013

VERLAG

PERFUSION Offizielles Organ der Deutschen Gesellschaft für Arterioskleroseforschung Current Contents/ Clinical Medicine

KASUISTIK Optimierung der Blutzuckereinstellung durch Wechsel von prandialem Humaninsulin auf Insulinglulisin FOREN

Forum cardiologicum: Resolute Integrity Stent: Niedrige Stentthromboserate auch bei nur einmonatiger dualer Antikoagulation Forum antithromboticum: • A ntikoagulation zwischen Indikation und Komplikation • A pixaban – eine neue Option zur Schlaganfallprävention bei nicht valvulärem Vorhofflimmern • A lter – Kosten – fehlende Arzt-Patienten-Bindung: Mythen zum Gerinnungs-Selbstmanagement Forum antihypertensivum: Olmesartan senkt das Risiko für kardio- und zerebrovaskuläre Ereignisse ABSTRACTS Abstracts der wissenschaftlichen Beiträge zur 27. Jahrestagung der Deutschen Gesellschaft für Arterioskleroseforschung e. V. vom 18. bis 20. April 2013 im Schloss Rauischholzhausen REDAKTIONELLER TEIL

Mitteilungen

ISSN 0935-0020

NEU

UND

INNOVATION DURCH INSPIRATION.

eiheit mit LA Therapiefr

NTUS

99 %

n ersicherte der GKV-V vertrag mit Rabatt Bayern * – ohne AOK

1fach LANTUS . ®

Konsequent  



von Anfang an.

1x tägliche Gabe1) Effektive NBZ-Senkung bei geringerem Hypoglykämie-Risiko vs. NPH-Insulin 2) Weniger Dosis vs. Insulindetemir bei vergleichbarer HbA1c-Senkung 3)

iPhone und iPod touch sind im Lieferumfang des iBGStar® nicht enthalten. iBGStar® ist direkt kompatibel mit iPhone 4S, 4, 3GS und 3G sowie iPod touch der 2., 3. und 4. Generation. Die iBGStar®-Diabetes-Manager-App ist über den App-Store erhältlich. iPhone und iPod touch sind Warenzeichen der Apple Inc., eingetragen in den USA und in anderen Ländern.

TYP-1 UND TYP-2 DIABETES

1fach Lantus®. Konsequent von Anfang an. 1) Fachinformation Lantus®, Stand: Mai 2012 (Injektion 1 x täglich zu einer beliebigen, jedoch jeden Tag zur gleichen Zeit); 2) Riddle M et al. Diabetes Care 2003; 26: 3080–6 (n = 756, 24 Wochen, Typ-2-Diabetiker mit BOT vs. Kombinationstherapie mit NPH-Insulin, zu Studienende: NBZ 117 vs. 120 mg/dl (6,5 vs. 6,7 mmol/l), HbA1c 6,96 vs. 6,97 %, Zielerreichung HbA1c ≤ 7% ohne nächtliche Hypoglykämien bei 33,2 vs. 26,7 % der Patienten); 3) Dailey G et al. Diabetes Technol Ther 2010; 12: 1019-27. (∆ -12,75; 95 % Kl -25,72, -0,21 E/d). * Für ca. 99 % der GKV-Versicherten (ohne die KV-Region Bayern) bestehen Verträge nach § 130 a Abs. 8 SGB V, in Bayern bestehen Verträge für 57 % der GKV-Versicherten. Stand: Juli 2012. Lantus® 100 Einheiten/ml Injektionslösung in einer Patrone · Lantus® SoloStar® 100 Einheiten/ml Injektionslösung in einem Fertigpen · Lantus® 100 Einheiten/ml Injektionslösung in einer Durchstechflasche. Wirkstoff: Insulin glargin. Verschreibungspflichtig. Zusammensetzung: 1 ml enthält 100 Einheiten Insulin glargin (entsprechend 3,64 mg). Sonstige Bestandteile: Zinkchlorid, m-Cresol, Glycerol, Salzsäure, Natriumhydroxid, Wasser für Injektionszwecke, (Durchstechflasche 10 ml: Polysorbat 20). Anwendungsgebiete: Zur Behandlung von Diabetes mellitus bei Erwachsenen, Jugendlichen und Kindern im Alter von 2 Jahren und älter. Dosierung, Art und Dauer der Anwendung: Lantus® enthält Insulin glargin, ein Insulinanalogon mit einer lang anhaltenden Wirkdauer. Lantus® sollte einmal täglich zu einer beliebigen Zeit, jedoch jeden Tag zur gleichen Zeit, verabreicht werden. Dosierung und Zeitpunkt der Verabreichung von Lantus® sollten individuell festgelegt werden. Bei Patienten mit Typ-2-Diabetes kann Lantus® auch zusammen mit oralen Antidiabetika gegeben werden. Lantus® wird subkutan verabreicht. Gegenanzeigen: Überempfindlichkeit gegenüber dem Wirkstoff oder einem der sonstigen Bestandteile. Warnhinweise/Vorsichtsmaßnahmen: Nicht das Insulin der Wahl bei diabetischer Ketoazidose. Umstellung auf anderen Insulintyp/-marke/-ursprung nur unter strenger ärztlicher Überwachung. Bei Kombination mit Pioglitazon Herzinsuffizienz möglich, besonders bei Patienten mit Risikofaktoren. Bei Verschlechterung der kardialen Symptomatik Pioglitazon absetzen. Nebenwirkungen: Sehr häufig: Hypoglykämie. Häufig: Reaktionen an der Einstichstelle, Lipohypertrophie. Gelegentlich: Lipoatrophie. Selten: Allergische Reaktionen, Ödeme, Sehstörungen, Retinopathie. Sehr selten: Myalgie, Geschmacksstörung. Im Allgemeinen ist das Sicherheitsprofil bei Kindern und Jugendlichen (≤18 Jahre) ähnlich dem bei Erwachsenen. Gekürzte Angaben, vollständige Information siehe Fachinformation, die wir Ihnen auf Wunsch gern zur Verfügung stellen. Pharmazeutischer Unternehmer: Sanofi-Aventis Deutschland GmbH, D-65926 Frankfurt am Main, Postanschrift: Sanofi-Aventis Deutschland GmbH, Potsdamer Straße 8, 10785 Berlin. Stand: Mai 2012 (025794). AVS 210 11 072c- 028009

EDITORIAL

In praise of good manners Medicine has made numerous important advances many of which have resulted in better health care and longer lives for patients. Mostly, they relate to innovations which are high tech, complicated and expensive. As doctors we rightly are proud of such progress and try to make the best use of it. Often, this means that we have become focussed on new technologies and recent developments. There is, of course, nothing wrong with this development; on the contrary, it is a precondition for delivering the best possible care to our patients. Yet, with all the cutting edge science, we might be in danger of forgetting some of the most elementary, simple and inexpensive features of any good health care – I am speaking of good manners. We probably all remember situations in our careers where a small dose of good manners could have made a big difference. My favourite personal anecdote in this context relates to what happened during one of my medical exams. We were a group of four aspiring doctors who happened to do fairly badly in one particular oral test. When finally the ordeal was all over, our professor, instead of the customary farewell, said “make sure you send me a card when

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02/13 37

Prof. Dr. med. E. Ernst, Exeter, U.K.

you open your own practice, so that I can avoid coming near it.” He probably thought he was being very witty, yet, even after all these years, I am somewhat disturbed by his smug rudeness. As doctors, we have a responsibility to be polite. It goes without saying that this rule has to apply to any contact we have with patients. A good therapeutic relationship is obviously more likely to thrive, if we display good manners; trust is unlikely to develop in the presence of rudeness. The effects of good manners can be tangible; patients are, for instance, more likely to comply with the treatments we prescribe, if we are polite, and patients are bound to be more relaxed and remember our advice, if we are well-mannered. The need for good manners towards patients is, I think, entirely self-evident and should not even require more than a brief mention. Far less obvious is politeness in relation to colleagues and other staff. We all have witnessed scenes where doctors behaved badly towards cleaners, administrators, assistants and other nonclinical personnel. In my view, this is not acceptable. It creates a climate which is not conducive to productive co-operation, and

it sheds an unfortunate light on our profession. Of course, everyone can occasionally have a bad day, but the regular display of bad manners with non-clinical staff is quite simply unprofessional. The same principles obviously apply to clinical staff. We all know that it is not always easy to be patient and polite to colleagues. And we are all aware that the pressures of the daily routine can, at times, render us short-tempered and abrupt. Yet we should realise that bad manners will only make things worse. Bad manners in the contact with colleagues have the added effect of spoiling the climate such that patient care may suffer indirectly. I have recently had the misfortune to encounter surgeries where poor manners had become the accepted norm, so much so that patients and their care were evidently affected. The apparently simple things in medicine are often neither simple nor easy to achieve; good manners seem to fall into this category. We need to realise, however, how important they really are and how many aspects of health care they can affect for better or for worse. A bad-tempered clinician should, in my view, be a contradiction in terms. Edzard Ernst, Exeter

Heft 2 April 2013

44 Forum cardiologicum 45, 46, Forum 48 antithromboticum 49 Forum antihypertensivum 18, 70 Mitteilungen

Offizielles Organ der Deutschen Gesellschaft für Arterioskleroseforschung Current Contents/Clinical Medicine

INHALT EDITORIAL 37 Ein Loblied auf die guten Manieren E. Ernst KASUISTIK 40 Optimierung der Blutzuckereinstellung durch Wechsel von prandialem Humaninsulin auf Insulinglulisin C. Bohl, C. Zemmrich LAUDATIO 43 Glückwünsche an Herrn Professor Hermann Eichstädt zum 65. Geburtstag! H. Schmutzler ABSTRACTS 51 Abstracts der wissenschaftlichen Beiträge zur 27. Jahrestagung der Deutschen Gesellschaft für Arterioskleroseforschung e. V. vom 18. bis 20. April 2013 im Schloss Rauischholzhausen

44 Forum cardiologicum 45, 46, Forum 48 antithromboticum 49 Forum antihypertensivum 18, 70 Informations

CONTENTS EDITORIAL 37 In praise of good manners E. Ernst CASE HISTORY 40 Improvement of glycaemic control by switch from regular human insulin to insulin glulisine C. Bohl, C. Zemmrich LAUDATION 43 Congratulations to Professor Hermann Eichstädt on his 65th birthday! H. Schmutzler ABSTRACTS 51 Abstracts of the 27th Annual Meeting of the German Atherosclerosis Society, April 18–20 2013, Schloss Rauischholzhausen

SeQuent® Please

Paclitaxel-freisetzender koronarer Ballonkatheter mit klinischer Evidenz SeQuent® Please – PACCOCATH® Technology Die einzigartige PACCOCATH® Beschichtungstechnologie gewährleistet eine hohe Bioverfügbarkeit des zellwachstumshemmenden Wirkstoffes Paclitaxel. Klinische Studien zeigten die Überlegenheit von SeQuent® Please im Vergleich zu anderen Behandlungsmethoden. umfangreiche Datenlage für verschiedenste Indikationen in den Leitlinien der Europäischen Fachgesellschaft empfohlene Behandlungsmethode im klinischen Alltag bewährt von Europäischen Gesundheitsbehörden als sicher und effektiv eingestuft

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mit Handlungsempfehlungen der Deutschen Konsensus-Gruppe versehen

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15.04.13 09:04

C. Bohl, C. Zemmrich: Optimierung der Blutzuckereinstellung durch Wechsel von prandialem Humaninsulin auf Insulinglulisin

KASUISTIK

Optimierung der Blutzuckereinstellung durch Wechsel von prandialem Humaninsulin auf Insulinglulisin Christian Bohl1, Claudia Zemmrich2 Facharzt für Allgemeinmedizin, Grafenhausen Institut für Pharmakologie und präventive Medizin, Mahlow

PERFUSION 2013; 26: 40–42

Viele Patienten erreichen trotz intensivierter Insulintherapie mit relativ hohen Dosen Insulin den HbA1c-Zielwert nicht. Diese Patienten sind häufig auf prandiales Humaninsulin eingestellt, obwohl Analoginsuline wie Insulinglulisin ein überlegenes pharmakokinetisches Profil aufweisen und dadurch eine bessere postprandiale Glukosekontrolle sowie geringere Hypoglyk ämieraten ermöglichen. Die vorliegende Kasuistik demonstriert eine Verbesserung der Blutzuckerkontrolle im Rahmen einer Umstellung von prandialem Humaninsulin auf Insulinglulisin. Anamnese und Befund Ein 41-jähriger Typ-2-Diabetiker, Schichtarbeiter, mit einer Körpergröße von 168 cm, normgewichtig und normotensiv, erreichte unter einer intensivierten Insulintherapie mit zuletzt 20 Einheiten Basalinsulin Insulin glargin (Lantus®) und 12–10–15 Internationalen Einheiten prandialem Humaninsulin vor dem Frühstück/Mittagessen/Abendbrot einen HbA1c von 7,0 % bei einem Zielwert von <6,5 % und zeigte persistierende postprandiale Blutzuckerspitzen bis >400 mg/ dl (22,2 mmol/l; siehe Abb. 1a). Der HbA1c-Ausgangswert vor Einführung der intensivierten Insulintherapie betrug 8,1 %. Der Diabetes mellitus war bei Beginn der Insulintherapie bereits seit 8 Jahren bekannt. Einen Überblick über die Stoffwechselsituation des Patienten vor und nach der Umstellung auf Insulinglulisin gibt Tabelle 1. Perfusion 02/2013

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Zusammenfassung Der vorliegende Fall demonstriert eine Verbesserung der Blutzuckereinstellung nach einem Wechsel von prandialem Humaninsulin auf Insulinglulisin (Apidra®) bei einem im Schichtbetrieb arbeitenden Patienten mit ungenügender glykämischer Kontrolle unter bestehender Basis-Bolus-Therapie. Die Therapieumstellung ermöglichte neben einer Gesamt-Dosisreduk tion des prandialen Insulins eine größere Flexibilität für den Patienten bezüglich seiner schichtbedingt variablen Mahlzeitengestaltung ohne klinisch relevante Nebenwirkungen oder eine Verschlechterung anderer Stoffwechselparameter. Schlüsselwörter: Apidra®, Insulinglulisin, prandiales Insulin, Humaninsulin, glykämische Kontrolle Summary The present case report demonstrates an improved glycemic control in a shift-working patient after change of basal-bolus regimen using human insulin to insulin glulisine (Apidra®). After change of therapy, daily dose of prandial insulin glulisine decreased compared to human insulin. The patient experienced increased therapeutic flexibility regarding timing of meals during shift-working. No clinically relevant side effects or impaired metabolism were observed. Key words: Apidra®, insulin glulisine, prandial insulin, humane insulin, glycemic control

Nach schrittweiser Titration der Insulin-glargin-Dosis auf 34 Einheiten konnte das gesamte 24-Stunden-Blutzuckerniveau inklusive der zuvor stark erhöhten frühmorgendlichen Werte (Abb. 1) bereits deutlich abgesenkt werden. Die postprandialen Blutzuckerspitzen persistierten jedoch trotz steigender Dosen prandialen Human insulins, sodass die Umstellung von Humaninsulin auf Insulinglulisin vor-

genommen wurde. Die Dosis des prandialen Insulins halbierte sich in der Folge. Die CGMS-Verlaufskontrolle dokumentierte, dass mit der neuen Dosis des prandialen Analoginsulins Insulinglulisin die postprandialen Blutzuckerspitzen gekappt und insgesamt eine verbesserte glykämische Kontrolle erreicht wurde (Abb 1b). Zusätzlich profitierte der Patient von einer höheren Flexibilität in seiner schichtbedingt © Verlag PERFUSION GmbH

C. Bohl, C. Zemmrich: Optimierung der Blutzuckereinstellung durch Wechsel von prandialem Humaninsulin auf Insulinglulisin

Körpergewicht (kg)

Vor Insulinglulisin 68,3*

Mit Insulinglulisin 69**

Blutdruck (mmHg)

140/80

130/80

HbA1c (%)

7,0

6,5

Insulindosis Human insulin (IE) Insulinglulisin (E)

Neutralfette (mg/dl)

195

125

BE-Verteilung

Kreatinin im Serum (mg/dl)

0,76

0,81

GFR nach MDRF (ml/min)

121

112

BE-Faktor vor und mit Insulinglulisin

Cholesterin (mg/dl)

194

179

* 12 Monate vor Umstellung auf Insulinglulisin ** 15 Monate nach Umstellung auf Insulinglulisin Tabelle 1: Laborwerte 2 Monate vor und 6 Monate nach der Umstellung auf Insulinglulisin

Morgens 4–5

Mittags 10

3 4

7–8

41 Abends 15

5 1,5

Insulin glargin vor und mit Insulinglu lisin

Zur Nacht

7–8

5 1,5

1,5 20

nach Umstellung auf InsuTabelle 2: Insulin-Verordnungsplan vor und linglulisin (BE = Broteinheiten, IE = internationale Einheiten, E = Einheiten)

variierenden Mahlzeitengestaltung. Klinisch relevante Hypoglykämien wurden nach der Umstellung nicht berichtet. Die beschriebene Therapieintervention spiegelte sich 6 Monate nach Umstellung auf Insulinglulisin in einer Reduktion des HbA1c von 7,0 auf 6,5 % und der stark reduzierten Glukosekonzen tration im Tagesverlauf wider. Weitere relevante Stoffwechselveränderungen fielen nicht auf. Diskussion

b) Abbildung 1: CGMS Blutzuckerprofile vor (a) und nach (b) Umstellung auf Insulinglulisin Perfusion 02/2013

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Die vorliegende Kasuistik spiegelt die inzwischen umfangreich vorliegende Datenbasis zu den Vorteilen der prandialen Insulintherapie mit einem Insulinanalogon im Vergleich zu Humaninsulin wider [1–6]. Die Vorteile beruhen auf pharmakokinetischen und pharmakodynamischen Unterschieden zu den Humaninsulinen, die zu einer physiologischeren Nachahmung der endogenen Insulinausschüttung im Rahmen einer Mahlzeit führen [7]. Die Verwendung von Insulinanaloga kann das Weglassen eines Spritz-EssAbstandes ermöglichen, die Hypoglykämierate senken und notwendige Zwischenmahlzeiten reduzieren [8]. Die postprandialen Blutzuckerverläufe können optimiert und der mit einer Insulintherapie verbundene Gewichtsanstieg begrenzt werden. Insulinglulisin mit seinem insgesamt guten Sicherheitsprofil ist in seiner Wirksamkeit zu den anderen verfügbaren Insulinanaloga bioäquivalent [9], zeichnet sich jedoch gegenüber © Verlag PERFUSION GmbH

C. Bohl, C. Zemmrich: Optimierung der Blutzuckereinstellung durch Wechsel von prandialem Humaninsulin auf Insulinglulisin

Insulin lispro durch einen schnelleren Wirkungseintritt aus [10, 11]. Dies macht es besonders für Patienten im Schichtbetrieb geeignet, die – wie im vorliegenden Fall – wegen unregelmäßiger Essenszeiten eine besondere Flexibilität der prandialen Insulintherapie benötigen und hier besonders von der optionalen Verabreichung des Insulins erst nach dem Ende der Mahlzeit profitieren. Retrospektive Daten für Insulinglulisin zeigen einen Hinweis auf eine reduzierte Inzidenz makro- und mikrovaskulärer Ereignisse im Vergleich zu Humaninsulin [12]. Eine Bestätigung dieser Ergebnisse in randomisierten kontrollierten Studien steht jedoch noch aus.

Literatur 1 Garg S, Ampudia-Blasco FJ, Pfohl M. Rapid-acting insulin analogues in basal-bolus regimens in type 1 diabetes mellitus. Endocr Pract 2010;16:486-505

2 Garnock-Jones KP, Plosker GL. Insulin glulisine: a review of its use in the man agement of diabetes mellitus. Drugs 2009;69:1035-1057 3 Iltz JL. Insulin glulisine: aspects of basal/ bolus therapy for optimized treatment of diabetes mellitus. Expert Opin Biol Ther 2009;9:369-375 4 Hohberg C, Forst T, Larbig M et al. Effect of insulin glulisine on microvascular blood flow and endothelial function in the postprandial state. Diabetes Care 2008; 31:1021-1025 5 Rave K, Klein O, Frick AD et al. Advant age of premeal-injected insulin glulisine compared with regular human insulin in subjects with type 1 diabetes. Diabetes Care 2006;29:1812-1817 6 Meyer C, Boron A, Plummer E et al. Glulisine versus human regular insulin in combination with glargine in noncritically ill hospitalized patients with type 2 diabetes: a randomized double-blind study. Diabetes Care 2010;33:2496-2501 7 Werner H, Chantelau EA. Differences in bioactivity between human insulin and insulin analogues approved for therapeutic use – compilation of reports from the past 20 years. Diabetol Metab Syndr 2011;3:13 8 Matthaei S, Bierwirth R, Fritsche A et al. Medikamentöse antihyperglykämische Therapie des Diabetes mellitus Typ 2. Dia betologie und Stoffwechsel 2009;4:32-64

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9 Chao M, Wang W, Zhang Y et al. Bioequivalence between two human insulin analogs in Chinese population: Glulisine and Lispro. Endocrine 2010;38:48-52 10 Garg SK, Ellis SL, Ulrich H. Insulin glulisine: a new rapid-acting insulin analogue for the treatment of diabetes. Exp Opin Pharmacother 2005;6:643-651 11 Heise T, Nosek L, Spitzer H et al. Insulin glulisine: a faster onset of action compar ed with insulin lispro. Diabetes Obes Metab 2007;9:746-753 12 Stelzner F, Kostev K, Dippel FW. Inzidenz kardiovaskulärer Ereignisse bei insulinbehandelten Typ-2-Diabetes-Patienten unter realen Versorgungsbedingungen. Monitor Versorgungsforsch 2012;5:29-33

Für die Verfasser: Dr. med. Claudia Zemmrich Institut für Pharmakologie und präventive Medizin Dr. Bramlage & Dr. Hankowitz Menzelstraße 20 15366 Mahlow E-Mail: claudia.zemmrich@ippmed.de

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LAUDATIO

Glückwünsche an Herrn Professor Hermann Eichstädt zum 65. Geburtstag!

Prof. Dr. Hermann Eichstädt

Der Kardiologe Prof. Dr. H. Eichstädt, Charité Berlin, beging am 15. Februar seinen 65. Geburtstag. Aus Wetzlar/Hessen stammend, absolvierte der Sohn einer Arztfamilie in Mainz sein vorklinisches Medizinstudium, anschließend in Düsseldorf Klinik und Staatsexamen. Auf einer DFG-Stelle beschäftigte sich Eichstädt von 1972 bis 1974 im SFB Physiologie/Kardiologie (Lochner/Loogen/Arnold) mit Gas- und Wärmeaustausch, arbeitete und promovierte dann in der Düsseldorfer Herzchirurgie zum prothetischen Klappenersatz (Bircks). Prof. Dr. H. Roskamm übertrug dem Vitienkenner nach seinem Wechsel an das Herzzentrum Bad Krozingen/Freiburg den Aufbau der Vitienstation des Zentrums, wo er eine Reihe wissenschaftlicher Projekte, Dissertationen und Publikationen betreute. Nach Absolvierung des Teilgebietes Kardiologie wechselte Eichstädt zur Fortführung und zum Abschluss der internistischen Weiterbildung an die Medizinische Universitätsklinik Tübingen zu Prof. Dr. K. Kochsiek. Gleichzeitig

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arbeitete er fast drei Jahre im dortigen Institut für Nuklearmedizin (Feine/Anger) und publizierte zur Entwicklung der damals aufkommenden Isotopen diagnostik des Herzens. Zum Ausbau der fachübergreifenden Bildgebung gemeinsam mit dem Radiologen Prof. Dr. R. Felix wechselte Eichstädt aus Tübingen an meine kardiologische Abteilung des Universitätsklinikums Charlottenburg nach Berlin. Hier wurde der Forschungsprojektschwerpunkt Nuklearkardiologie begründet und zu einer Hochburg des damals so noch nicht bekannten „kardialen Imaging“ gemacht, wofür der Name Eichstädt in den frühen 80er Jahren ein Synonym wurde. Nach seiner Habilitation im Jahr 1982 in der Inneren Medizin wurde Eichstädt 1984 mit nur 36 Jahren auf eine kardiologische Professur nach Essen berufen, die er zugunsten einer Lebenszeit-Professur in Berlin ausschlug. Er bearbeitete sodann alle Entwicklungen des kardialen Imaging mittels DSA, CT, MR und Nuklearmedizin. Besonders ist seine erste Gadolinium-Anwendung bei menschlichen Herzinfarkten mit Welterstpublikation des später sogenannten „late enhancement“ 1984 hervorzuheben. Extrem aktive Jahre folgten und steigerten sein Gesamtopus neben acht Büchern auf etwa 1.100 Zeitschriftenartikel, Abstracts und Buchbeiträge, ebenso viele internationale Vorträge, zahlreiche Vorsitze, Preise und Ämter.

Eichstädt wurde vom Vorstand der Deutschen Gesellschaft für Kardiologie zum ersten Vorsitzenden der neuen Arbeitsgruppe Nuklearkardiologie ernannt, wurde Geschäftsführer der Berlin-Brandenburgischen Kardiologengesellschaft, betreute eine große Anzahl Doktoranden, Facharztausbildungen und Habilitationen der Imagingdisziplinen und gelangte mehrmals in die Endauswahl um kardiologische Lehrstühle. Der Klinikumsvorstand der Charité berief ihn zum Ärztlichen Direktor der kardiologisch-kardiochirurgischen Nachsorgeklinik der Charité in Templin. 2001 wurde Professor Eichstädt der im Virchow-Klinikum der Charité bestehenden Abteilung Kardiologie (Prof. Dietz) fachlich beigeordnet. Nach seinem Eintritt in den Ruhestand hat er nun die Leitung des Bereiches Kardiologie am Rehazen trum Potsdam übernommen. Ich habe seine Kompetenz und Loyalität stets sehr geschätzt und wünsche meinem früheren Schüler in freundschaftlicher Verbundenheit noch viele weitere erfüllte Jahre in seiner neuen Leitungsfunktion, persönliche Befriedigung in der ausgeübten Musik, der tiefgehenden Beschäftigung mit Literatur und Kunst sowie fortdauernde Freude an seinen vier, inzwischen erwachsenen Kindern. Prof. Dr. Horst Schmutzler, Berlin

Forum cardiologicum

Der medikamentenfreisetzenden Resolute Integrity Stent von Medtronic hat kürzlich eine erweiterte CEKennzeichnung erhalten, die eine nur einmonatige duale Plättchenaggregationshemmung (DAPT) erlaubt. Dies ist die kürzeste bisher zugelassene DAPT-Dauer für einen medikamentenfreisetzenden Stent. Die aktualisierte Zulassung basiert auf 1-Jahres-Daten aus dem klinischen RESOLUTE-Programm. Diese belegen, dass die Patienten, die die duale Plättchenaggregationshemmung einen Monat nach der Stent-Implantation unterbrochen oder ganz abgesetzt haben, nach einem Jahr keine erhöhten Stentthromboseraten aufweisen und daher das Risiko einer Stentthrombose als unverändert gering angesehen werden kann.

Resolute Integrity Stent: Niedrige Stentthromboserate auch bei nur einmonatiger dualer Antikoagulation

Kein erhöhtes Risiko nach vorzeitigem Abbruch der Antikoagulation Die DAPT – die Kombination von Acetylsalicylsäure (ASS) und einem Thienopyridin wie Clopidogrel – reduziert das Risiko für die Bildung eines Blutgerinnsels im arteriellen Segment des eingesetzten Stents. Die langfristige Verwendung plättchenhemmender Arzneimittel erhöht jedoch das Risiko von Blutungskomplikationen. Die Abwägung dieser beiden Risiken bleibt eine Herausforderung. Im Allgemeinen wird nach Stentimplantation eine duale Antikoagulation für 6–12 Monate empfohlen. Aus unterschiedlichen Gründen unterbrechen einige Patienten jedoch ihre DAPT oder setzen sie frühzeitig ab, was erhöhte Sicherheitsrisiken mit sich bringt. Wie Daten von fast 5000 Patienten aus dem klinischen RESOLUTEProgramm zeigen, besteht das größte Risiko einer Stentthrombose aufgrund einer DAPT-Unterbrechung innerhalb der ersten 30 Tage nach der Implantation. Die Ergebnisse belegen aber auch, dass eine DAPT-Unterbrechung nach 30 Tagen mit einem niedrigen Risiko einer Stentthrombose und keinem erhöhten Risiko für einen plötzlichen Perfusion 02/2013

26. Jahrgang

Abbildung 1: Der Resolute Integrity ist ein Stent der neuesten Generation von Medtronic. Er vereint die Vorteile des medikamentenfreisetzenden Stents Resolute mit der hochmodernen Konstruktion des Bare-Metal-Stents Integrity, die eine gute Platzierbarkeit und Flexibilität ermöglicht. Der Stent ist mit Zotarolimus beschichtet, das nach und nach abgegeben wird und die Bildung von Narbengewebe verhindert. Dadurch lässt sich das Risiko einer In-Stent-Restenose verringern

Herztod oder einen Myokardinfarkt im Zielgefäß verbunden ist. Einzelheiten zu dieser Analyse präsentierte Professor Sigmund Silber, Leiter des Herzzentrums an der Isar in München, auf dem 24. Transcatheter Cardiovascular Therapeutics Symposium 2012 in Miami: Über zwei Drittel der rund 5000 Patienten in der Analyse setzten die DAPT dauerhaft ab, was in dieser Kohorte nicht immer medizinisch begründet war: • 907 Patienten unterbrachen ihre DAPT nach einem Monat oder setzten sie nach diesem Zeitraum ab. Keiner dieser Patienten erlebte eine definitive oder wahrscheinliche Stentthrombose nach der ARC-De-

finition während der einjährigen Nachbeobachtung. • 816 Patienten unterbrachen ihre DAPT nach 3 Monaten oder setzten sie nach diesem Zeitraum ab. Auch in diesem Fall erlebte keiner dieser Patienten eine definitive oder wahrscheinliche Stentthrombose nach der ARC-Definition während der einjährigen Nachbeobachtung. Für die Praxis bedeutet das, wie Silber betonte, „dass Klinikärzte die gesamte verfügbare Evidenz zur DAPT neu berücksichtigen und basierend darauf ihr klinisches Urteil und die am besten geeigneten Entscheidungen für jeden einzelnen Patienten treffen müssen.“ Brigitte Söllner, Erlangen © Verlag PERFUSION GmbH

Forum antithromboticum

Unter den vielen häufig angewandten Medikamenten haben Antikoagulanzien einen ganz besonderen Stellenwert: Sowohl eine verminderte als auch eine verstärkte Wirkung kann zu folgenschweren Ereignissen führen – einerseits Thrombose, andererseits Blutung. Besonders ist daran auch, dass ein unmittelbarer und klarer Zusammenhang zwischen Medikament und klinischem Ereignis (z.B. Blutung) besteht. VKA versus NOACs Der schwierige Umgang mit VitaminK-Antagonisten (VKA) wurde über mehr als ein halbes Jahrhundert erarbeitet. In wenigen Jahren wurden nun die Wirksamkeit und die Sicherheit gänzlich neuer oraler Antikoagulanzien (NOACs, Tab. 1) in großen Studien geprüft. Die Ergebnisse dieser Studien weisen auf ein verbessertes Profil hinsichtlich Wirksamkeit, Sicherheit und Anwendbarkeit hin. NOACs erlauben fixe Dosierungen, ohne dass Gerinnungsmessungen zur Therapieanpassung notwendig sind. Obwohl Unterschiede in der Pharmakogenetik bestehen, sind sie nicht annähernd so stark wie bei VKA. Auch die Arzneimittelinteraktionen beschränken

Handelsname Angriffspunkt (Faktor) Bioverfügbarkeit (%) Tmax (h) T1/2 (h) Renale Elimination (%) Prodrug Mögliche Interaktion

Dabigatran Pradaxa® IIa 6–7 1,5–3 14–17 80 + PG

Antikoagulation zwischen Indikation und Komplikation

sich für die einzelnen Substanzen auf wenige Medikamente. Die Unabhängigkeit der Wirkung der NOACs von der Ernährung, vor allem bestimmten Nahrungsmitteln, ist ein für die Patienten außerordentlich wichtiger Vorteil. Da die NOACs zumindest zum Teil über die Nieren metabolisiert werden, nehmen die Niereninsuffizienz und damit die Kontrolle der Nierenfunktion einen großen Stellenwert ein. Vor der Therapie muss die Nierenfunktion überprüft werden und bei interkurrenten Erkrankungen ist darauf speziell zu achten. Aufgrund der geringeren renalen Elimination bei direkten FaktorXa-Hemmern wie z.B. Edoxaban wirkt sich eine Einschränkung der Nierenfunktion nicht so gravierend aus wie bei einem Thrombinhemmer. Bei Patienten mit schwerer Niereninsuffizienz können NOACs jedoch generell nicht eingesetzt werden, in diesen Fällen bleiben VKA die Therapie der Wahl. Rivaroxaban Apixaban Xarelto® Eliquis® Xa Xa 80 50 2–4 1–3 9–13 8–15 66 (33 aktiv) 25 – – PG und CYP3A4 CYP3A4 90 87 – – Zulassungsstatus

Edoxaban Lixiana® Xa 50 1–3 9–11 35 – PG und CYP3A4 50 –

Eiweißbindung (%) Dialysierbar

35 +

Prophylaxe bei Hüft- und Kniegelenkersatz Vorhofflimmern VTE-Therapie

in Japan

+ –

+ +

+ –

– –

Tabelle 1: Neue orale Antikoagulanzien Perfusion 02/2013

26. Jahrgang

Umfassende Aufklärung des Patienten zur Sicherung der Adhärenz Viel diskutiert wird die Frage, ob Patienten ihre Medikamente auch tatsächlich einnehmen werden, da eine Laborkontrolle zur Überprüfung der Adhärenz nicht vorgesehen ist und derzeit auch nicht sinnvoll erscheint. Auf die Aufklärung des Patienten in einer für ihn verständlichen Weise ist daher besonderes Augenmerk zu richten. Unterstützt werden kann dies – zusätzlich zum regelmäßigen Arzt-PatientenGespräch – durch verständliche Broschüren und/oder elektronische Erinnerungssysteme. Fazit Die NOACs haben für die Praxis gegenüber den parenteralen Antikoagulanzien und den VKA zweifelsfrei große Vorteile und es ist zu erwarten, dass sie bei den zugelassenen Indikationen zum breiten Einsatz kommen werden. Bei richtiger Anwendung (Indikation, Dosierung) und der Beachtung von kritischen Aspekten (z.B. Niereninsuffizienz oder einzelne Arzneimittelinteraktionen) werden die NOACs imstande sein, die Patienten mit einem sehr guten Sicherheitsprofil vor venösen und arteriellen Thrombosen und Embolien zu schützen. Univ.-Prof. Dr. med. Ingrid PabingerFasching, Wien

Quelle: Satellitensymposium von Daiichi Sankyo Deutschland anlässlich der 57. Jahrestagung der Gesellschaft für Thrombose- und Hämostaseforschung, 20.02.2013 in München © Verlag PERFUSION GmbH

Forum antithromboticum

Patienten mit Vorhofflimmern haben ein bis zu fünffach erhöhtes Schlaganfallrisiko, sodass ein dringender Bedarf an verbesserten Behandlungsmethoden besteht, um dieses Risiko zu reduzieren. Eine neue Option ist Apixaban (Eliquis®). Der direkte, orale Faktor-XaInhibitor erhielt am 19. November 2012 von der European Medical Agency (EMA) die Zulassung zur Prophylaxe von Schlaganfällen und systemischen Embolien bei erwachsenen Patienten mit nicht valvulärem Vorhofflimmern (NVAF) und einem oder mehreren Risikofaktoren wie Schlaganfall oder TIA in der Anamnese, Alter ≥ 75 Jahre, Hypertonie, Diabetes mellitus, symptomatische Herzinsuffizienz (NYHA-Klasse ≥ II) [1]. Die Therapie mit Apixaban oder einem anderen neuen oralen Antikoagulans wird in den Leitlinien der European Society of Cardiology zur Prävention von Schlaganfällen bei Patienten mit NVAF empfohlen, sobald eine Antikoagulation indiziert ist [2]. Wegweisende Studienergebnisse Die Zulassung von Apixaban basiert auf den beiden Phase-III-Studien ARISTOTLE und AVERROES, in denen insgesamt etwa 24.000 Patienten mit nicht valvulärem Vorhofflimmern im bislang umfassendsten, abgeschlossenen Studienprogramm zu dieser Patientengruppe untersucht wurden. Das klinische Studienprogramm mit Apixaban ist das einzige Phase-III-Studienprogramm unter den neuen oralen Antikoagulanzien, das die Wirksamkeit und Verträglichkeit von Apixaban gegenüber Acetylsalicylsäure bei Patienten untersucht hat, die für die Therapie mit Vitamin-K-Antagonisten nicht geeignet sind.

Apixaban – eine neue Option zur Schlaganfallprävention bei nicht valvulärem Vorhofflimmern Other Thromboembolic Events in Atrial Fibrillation [3]) wurden 18.201 Patienten mit Vorhofflimmern und mindestens einem Risikofaktor für Schlaganfall randomisiert entweder mit 2 × täglich 5 mg Apixaban (2,5 mg 2 × täglich bei ausgewählten Patienten) oder Warfarin (dosisangepasst an eine Ziel-INR von 2,0–3,0) behandelt. Die mediane Nachbeobachtungszeit betrug 1,8 Jahre. Am Studienende zeigte sich eine statistisch signifikante Überlegenheit von Apixaban gegenüber Warfarin in den folgenden 3 Wirksamkeitsendpunkten (Abb. 1): • Signifikante relative Risikoreduktion für ischämische und hämorrhagische Schlaganfälle oder systemische Embolien unter Apixaban um 21 % pro Jahr (1,27 % vs. 1,60 %; HR=0,79; CI=0,66–0,95; p<0,001 für Nichtunterlegenheit, p=0,01 für Überlegenheit) • Nahezu Halbierung (Reduktion um 49 %) der Rate hämorrhagischer Schlaganfälle pro Jahr unter Apixaban (0,24 % vs. 0,47 %; p<0,001)

• Signifikante Senkung der Gesamtmortalität unter Apixaban um 11 % pro Jahr (3,52 % vs. 3,94 %; p=0,047) Auch beim primären Sicherheitsendpunkt war Apixaban Warfarin überlegen: • Signifikante relative Risikoreduktion für schwere Blutungen unter Apixaban um 31 % pro Jahr (2,13 % vs. 3,09 %; HR=0,69, CI=0,60–0,80; p<0,001) (Abb. 1) • Insbesondere intrakranielle Blutungen traten mit einer geringeren Häufigkeit unter Apixaban auf (0,33 % vs. 0,80 %; HR=0,69, CI=0,06–0,80; p<0,001). In der ARISTOTLE-Studie verhinderte die Behandlung mit Apixaban über 1,8 Jahre pro 1000 Patienten mit Vorhofflimmern im Vergleich zu Warfarin: • 6 Schlaganfälle, • 15 schwere Blutungen und • 8 Todesfälle.

4 Ereignisrate pro Jahr (%)

3 2 1 0

ARISTOTLE zeigt Überlegenheit gegenüber Warfarin In die ARISTOTLE-Studie (Apixaban for the Reduction in Stroke and Perfusion 02/2013

26. Jahrgang

(n/N)** (265/9081)

(212/9120)

Primärer Wirksamkeitsendpunkt

(462/9052)

(327/9088)

Primärer Sicherheitsendpunkt

(669/9081)

(603/9120)

Wichtiger sekundärer Endpunkt

Abbildung 1: Ergebnisse der ARISTOTLE-Studie: Apixaban war Warfarin hinsichtlich der Risikoreduktion bei den 3 wichtigen Endpunkten Schlaganfall oder systemische Embolie, schwere Blutungen sowie Gesamtmortalität signifikant überlegen [3] © Verlag PERFUSION GmbH

Forum antithromboticum

Outcome

Schlaganfall oder systemische Embolie Schlaganfall

• ischämisch • hämorrhagisch • Ursache unbekannt Systemische Embolie

Apixaban (n=2808)

ASS (n=2791)

Apixaban vs. ASS

Ereignisse

Jährliche Rate

Ereignisse

Jährliche Rate

Relatives Risiko

95%-KI

p-Wert

1,6

113

3,7

0,45

0,32–0,62

<0,001

49 35

1,6 1,1

105 93

3,4 3,0

0,46 0,37

0,33–0,65 0,25–0,55

<0,001 <0,001

0,2

0,3

0,67

0,24–1,88

0,45

0,3

0,1

2,24

0,69–7,27

0,18

0,1

0,4

0,15

0,03–0,68

0,01

Tabelle 1: Ergebnisse der AVERROES-Studie für den primären Wirksamkeitsendpunkt [4]

Die Therapie mit Apixaban führte nicht zu einer Zunahme von Myokardinfarkten. Die Wirksamkeitsendpunkte bei präspezifizierten Subgruppen, darunter CHADS2-Score, Alter, Gewicht, Geschlecht, eingeschränkte Nierenfunktion und früherer Schlaganfall oder TIA, waren konsistent mit den primären Wirksamkeitsendpunkten für die Gesamtpopulation dieser Studie. Apixaban hatte ein günstigeres Nebenwirkungsprofil, im Vergleich zu Warfarin kam es zu weniger Behandlungsabbrüchen (25,3 % vs. 27,5 %). AVERROES-Studie zeigt Überlegenheit gegenüber Acetylsalicylsäure Die AVERROES-Studie (Apixaban Versus Acetylsalicylic Acid to Prevent Strokes [4]) untersuchte die Wirksamkeit und Sicherheit von Apixaban gegenüber Acetylsalicylsäure (ASS) bei der Prophylaxe von Schlaganfällen oder systemischen Embolien bei Patienten mit nicht valvulärem Vorhofflimmern, für die eine Therapie mit Vitamin-K-Antagonisten nicht infrage kam. Die 5599 Patienten erhielten randomisiert entweder Apixaban (2 × täglich 5 mg bzw. 2,5 mg) oder 81–324 mg ASS. Nach einer mittleren Beobachtungszeit von 1,1 Jahren wurde die Studie vom unabhängigen Data Monitoring Committee nach eindeuti-

Perfusion 02/2013

26. Jahrgang

ger Evidenz für eine Überlegenheit von Apixaban vorzeitig abgebrochen. Apixaban war ASS in der AVERROES-Studie bezüglich der Reduktion des primären Wirksamkeitsendpunktes – der Verhinderung von Schlaganfällen (hämorrhagisch, ischämisch oder nicht spezifiziert) und systemischen Embolien – signifikant überlegen (1,62 % vs. 3,63 %; HR=0,45; CI=0,32–0,62; p<0,001) (Tab. 1). Die Gesamtmortalität im Vergleich zu ASS wurde nicht signifikant gesenkt (jährliche Sterblichkeitsrate 3,5 % vs. 4,4 %; p=0,07); das Signifikanzniveau wurde aufgrund der vorzeitigen Beendigung der Studie nicht erreicht. Die Inzidenz schwerer Blutungen war unter Apixaban und ASS vergleichbar (1,41 %/Jahr vs. 0,92 %/Jahr), ebenso die Inzidenz tödlicher Blutungen (0,16 %/Jahr vs. 0,16 %/Jahr) sowie intrakranieller Blutungen (0,34 %/Jahr vs. 0,35 %/Jahr). Fazit für die Praxis Der Faktor-Xa-Inhibitor Apixaban hat sich zur Schlaganfallprophylaxe bei Vorhofflimmern als deutlich wirksamer erwiesen als Warfarin. Bei Patienten, die ungeeignet für eine Therapie mit einem Vitamin-K-Antagonisten sind und daher ASS zur Schlaganfallprävention erhalten, senkte Apixaban die

Schlaganfallrate signifikant um 55 % im Vergleich zu ASS, ohne die Rate relevanter Blutungskomplikationen bzw. intrakranieller Blutungen zu erhöhen. ASS wird daher in der Schlaganfallprävention bei Vorhofflimmern zukünftig kaum eine Rolle mehr spielen [5]. Das orale Antikoagulans Apixaban bietet dagegen aufgrund seiner besseren Wirksamkeit und Sicherheit sowie seiner praktikableren Anwendung deutliche Vorteile gegenüber den dosisangepassten Vitamin-K-Antagonisten und wird deshalb bei den meisten Patienten mit Vorhofflimmern bevorzugt zur Anwendung kommen. Brigitte Söllner, Erlangen Literatur 1 Eliquis® Fachinformation, Stand November 2012 2 Camm AJ, Lip GY, De Caterina R et al. 2012 focused update of the ESC Guidelines for the management of atrial fibrillation. Eur Heart J 2012;33:2719-2747 3 Granger CB, Alexander JH, McMurray JJV et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2011;365:981-992 4 Conolly SJ, Eikelboom J, Joyner C et al.; AVERROES Steering Committee and Investigators. Apixaban in patients with atrial fibrillation. N Engl J Med 2011;364: 806-817 5 Diener HC. Vortrag anlässlich des Presse gesprächs „Schlaganfallprophylaxe bei Vorhofflimmern mit Eliquis® – eine neue Option in der oralen Antikoa gulation“, 15.01.2013

Forum antithromboticum

Alter – Kosten – fehlende Arzt-Patienten-Bindung:

Mythen zum GerinnungsSelbstmanagement

Derzeit leben in Deutschland etwa 900.000 Menschen, die zur Prophylaxe thromboembolischer Ereignisse auf eine orale Langzeitantikoagulation mit einem Vitamin-K-Antagonisten (VKA) angewiesen sind. Die häufigsten Indikationen hierfür sind Vorhofflimmern, der Einsatz nach künstlichem Herzklappenersatz und anderen Erkrankungen des Herz-KreislaufSystems. Begleitendes GerinnungsSelbstmanagement (GSM) kann das Blutungs- und Thromboserisiko signifikant senken [1]. Rund 22 % der Patienten nutzen bereits diese Möglichkeit zur regelmäßigen Messung der Thromboplastinzeit (INR-Wert) und der bedarfsgerechten Anpassung ihrer oralen Antikoagulation. Das selbstständige, in der Regel wöchentliche Messen der INR-Werte geht mit einer hohen Compliance der Betroffenen einher. Bei Patienten, die ihre Gerinnungseinstellung selbst managen, liegen deutlich mehr gemessene INR-Werte im therapeutischen Bereich als bei konventioneller Betreuung in der Hausarztpraxis: So zeigen erstere eine erhöhte TTR (time in therapeutic range) von 80 % gegenüber konventionell betreuten Patienten mit einer TTR von 65 % [2]. Zudem können durch begleitendes Selbstmanagement die Rate an schwerwiegenden thromboembolischen Komplikationen sowie die Mortalität signifikant gesenkt werden [3, 4]. Auch können sich Patienten laut Umfragen durch die Selbstkontrolle, z.B. mit dem Messgerät CoaguChek® XS, schneller auf veränderte Lebenssituationen einstellen, sind mobiler und Perfusion 02/2013

26. Jahrgang

erhöhen dadurch ihre Lebensqualität. Trotzdem gibt es Vorbehalte bei Behandlern, diese leitliniengesicherte [3] Kombination von VKA und GSM einzusetzen. Arzt-Patienten-Kontakt bleibt bestehen Durch die Empfehlung des Gerinnungs-Selbstmanagements, intensiver Schulung in einem qualifizierten Zentrum und anschließender selbständiger Verwendung eines Messgerätes befürchten viele Ärzte den Verlust des notwendigen Arzt-Patienten-Kontakts oder das Wechseln des Patienten in eine andere Arztpraxis. Das Therapiekonzept gefährdet jedoch nicht die persönliche Bindung, sondern sieht explizit die Weiterbetreuung durch den verordnenden und behandelnden Hausarzt vor. Durch die erlernte Eigenverantwortung wird das Arzt-Patienten-Verhältnis sogar gestärkt [5]. Quartalsmäßige Kontrollen der Werte durch den behandelnden Arzt stellen den regelmäßigen Austausch sicher. Die vom Patienten erhobenen Werte können besprochen und bewertet werden. Bei Bedarf ist es dennoch möglich, eine Vergleichsmessung durchzuführen. Positive Ergebnisse bestärken den Patienten in seinem GerinnungsSelbstmanagement und festigen das Arzt-Patienten-Verhältnis. Im Vergleich zu einer 4- oder 6-wöchigen Kontrollmessung unter konventioneller Betreuung bleiben Patienten gleichzeitig unabhängiger.

Abbildung 1: Das CoaguChek® XS System ermöglicht eine flexible Selbstkontrolle des INR-Wertes bei der oralen Antikoagulationstherapie mit Vitamin-K-Antagonisten. Die Messung erfolgt innerhalb einer Minute und benötigt nur eine geringe Menge Blut aus der Fingerbeere (8 μl)

Keine Auswirkungen auf das Budget Entgegen bestehender Meinungen ist die Verordnung nicht budgetbelastend, sondern kann sich kosteneinsparend auswirken [6]. Hinsichtlich der Erstattungsfähigkeit durch die Krankenkassen ist eine Verordnung beispielsweise dann begründet, wenn Komplikationen unter konventioneller Betreuung, schwankende INR-Werte, Schwierigkeiten in Bezug auf regelmäßige Arztbesuche oder schlechte Venenverhältnisse vorherrschen [7]. Patientenschulungen, Messgerät und Teststreifen werden in der Regel von den gesetzlichen Krankenkassen übernommen. Stimmt die Krankenkasse der Verordnung des Messgeräts zu, ist © Verlag PERFUSION GmbH

Forum antihypertensivum

auch das Wirtschaftlichkeitsgebot bei der Teststreifenverordnung gegeben: Bei wirtschaftlicher Verordnung der Teststreifen wird der Wirtschaftlichkeitsbonus des Arztes auch nach der EBM-Reform vom 1. April 2013 nicht belastet – der Anteil der Teststreifen kann aus dem Budget herausgerechnet werden. Alter der Patienten ist nicht entscheidend Häufig werden Patienten aber auch als Selbstmanager unterschätzt. So sind das fortgeschrittene Alter der Patienten und das vermeintliche Fehlen des technischen Know-how mitunter Gründe für eine rein konventionelle Therapie. Gemäß der Leitlinien der European Society of Cardiology [2] kann das Gerinnungs-Selbstmanagement immer dann in Betracht gezogen werden, wenn Patienten physisch und kognitiv dazu in der Lage sind. Selbst im Falle einer körperlichen oder geistigen Beeinträchtigung des Patienten besteht die Möglichkeit, Angehörige, Pflegekräfte oder Betreuer im Rahmen der ärztlichen Schulungen einzuweisen und die Selbstkontrolle zu begleiten [8]. Eine Metaanalyse aus dem Jahr 2012 zeigt, dass das Gerinnungs-Selbstmanagement eine sichere Option für alle Altersklassen darstellt [1]. Elisabeth Wilhelmi, München

Literatur 1 Heneghan et al. Lancet 2012;379:322-334 2 Koertke H, Koerfer R. Ann Thorac Surg 2001;72:44-448 3 Camm A et al. Eur Heart J 2010;31:23892429 4 Bloomfield HE et al. Ann Int Med 2011; 154:472-482 5 Bernardo A et al. DMW 2001;126:346351 6 Taborski U et al. Semin Thromb Hemost 1999;25:103-107 7 Hilfsmittelverzeichnis Produktgruppe 21. Bundesanzeiger 147 vom 9.8.2002 8 Braun S et al. DMW 2009;134:695-700 Perfusion 02/2013

26. Jahrgang

Olmesartan senkt das Risiko für kardio- und zerebrovaskuläre Ereignisse

Eine moderne, leitliniengerechte Hypertoniebehandlung beinhaltet mehr als „nur“ die Senkung des Blutdrucks. Auch die Erfassung des kardiovaskulären Gesamtrisikos ist von großer Bedeutung. Studien haben ergeben, dass der AT1-Rezeptorblocker Olmesartan (z.B. Votum®) zusätzlich zur Blutdrucksenkung nicht nur mittelfristig die Progression der Atherosklerose, die für die meisten Organschäden ursächlich ist, verringern, sondern auch langfristig das relative Risiko für ein kardio- und zerebrovaskuläres Ereignis um 54 % senken kann. Dies sind die Ergebnisse der Follow-up-Studie OLIVUS-EX [1], in die 247 Hypertoniker mit stabiler Angina pectoris eingeschlossen waren. Hemmung der Atherosklerose progression führt langfristig zu weniger Ereignissen Im Rahmen der OLIVUS-Studie [2] wurde zunächst die Wirkung von Olmesartan auf die Progression von atherosklerotischen Plaques in Koronargefäßen über einen Zeitraum von 14 Monaten untersucht. Mittels intravaskulärem Ultraschall (IVUS) wurden im Rahmen geplanter perkutaner Katheterinterventionen die Veränderungen der koronaren Atherosklerose ermittelt. Das Ergebnis nach 14 Monaten: Unter Olmesartan kam es zu einer signifikanten Reduktion der atherosklerotischen Plaqueprogression in den Koronargefäßen im Vergleich zum Kontrollarm (0,6 vs. 5,4 %).

Im Rahmen der Follow-up-Studie OLIVUS-Ex [1] wurden anschließend über einen Zeitraum von 4 Jahren die langfristigen Ergebnisse untersucht. Als Endpunkt wurde die zusammengesetzte Ereignisrate von kardio- und zerebrovaskulärem Tod, Herzinfarkt, Schlaganfall und Angina-bedingter Hospitalisierung (MACCE) definiert. In der Olmesartan-Gruppe trat dieser kombinierte Endpunkt signifikant weniger häufig auf als in der Kontrollgruppe (p=0,04). Damit wurde eindrucksvoll nachgewiesen, dass eine antihypertensive Therapie mit Olmesartan zusätzliche Effekte auf die Progressionshemmung einer Athero sklerose ausübt, die auch langfristig das Auftreten kardio- und zerebrovaskulärer Ereignisse signifikant reduzieren kann. Auch andere Studien wie EUTOPIA [3], MORE [4] oder VIOS [5] konn-

Abbildung 1: Olmesartan (Votum®/Votum® plus) übt in allen Stadien der Atherosklerose einen positiven Effekt auf das Blutgefäß aus, wie verschiedene klinische Studien zeigen konnten [1, 3, 4, 5] (© Berlin-Chemie AG) © Verlag PERFUSION GmbH

Forum antihypertensivum

Verbesserte Zielwerteerreichung bei Behandlung mit der Dreifach-Fixkombination Vocado® HCT Anteil (%) der Patienten, die den Blutdruckzielwert < 140/90 mmHg nach 12 Wochen erreichten OLM – Olmesartan AML – Amlodipin HCT – Hydrochlorothiazid 80

* p<0,001 Dreifachkombination vs jede Zweifachkombination

Zielwerterreichung nach 12 Wochen (%)

69,9* (n=614)

60 50 40 30

53,4 (n=627)

52,9 (n=624)

OLM / HCT 40 / 25 mg

OLM / AML 40 / 10 mg

41,1 (n=539)

20 10 0

AML/HCT 10 / 25 mg

Vocado® HCT OLM / AML / HCT 40 / 10 / 25 mg

Abbildung 2: Mit der Dreifachkombination aus Olmesartan, Amlodipin und HCT (40/10/25 mg) erreichte in der Vocado® HCT-Zulassungsstudie ein signifikant höherer Anteil der Patienten mit mittelschwerer bis schwerer Hypertonie den Blutdruckzielwert <140/90 mmHg als mit den jeweiligen Zweifachkombinationen (p<0,001 für alle Behandlungsvergleiche; durchschnittlicher Ausgangswert 169/101 mmHg) [7]

ten die antiatherosklerotischen Effekte von Olmesartan nachweisen (Abb. 1). Neben dem gut belegten Gefäßschutz zeichnet sich Olmesartan durch eine starke Wirksamkeit aus. Die antihypertensive Wirkung setzt rasch ein und hält nach Einmalgabe über 24 Stunden an. Individuell angepasste, flexible Blutdrucktherapie Olmesartan eignet sich gut als Kombinationspartner in Fixkombinationen

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mit Kalziumantagonisten und/oder Diuretika und bildet damit eine gute Basis für eine effektive Hypertonietherapie. Die Kombination aus Olmesartan und Amlodipin (z.B. Vocado®) führt aufgrund additiver Effekte zu einer stärkeren Blutdrucksenkung im Vergleich zu den einzelnen Wirkstoffen und zeigt zudem positive Zusatzeffekte auf metabolische und inflammatorische Parameter bei Patienten mit gestörter Glukosetoleranz [6]. Diese Kombination kann daher für Hypertoniker mit metabolischem Syndrom und Diabetes einen Zusatznutzen bringen.

Die Dreifach-Fixkombination aus Olmesartan, Amlodipin und HCT (Vocado® HCT) senkt den Blutdruck signifikant stärker als die möglichen Zweifachkombinationen. Außerdem erreichen mehr Patienten den Zielwert (Abb. 2, [7]). Von der DreifachFixkombination profitieren daher vor allem Hochrisikopatienten, bei denen der angestrebte Blutdruckzielwert mit 2 Antihypertensiva nicht erreicht wird. Die Olmesartan-Produktpalette von Berlin-Chemie stellt für eine individuelle Hochdrucktherapie verschiedene Fixkombinationen in unterschiedlichen Dosierstärken zur Verfügung: Olmesartan/HCT (Votum® Plus), Olmesartan/Amlodipin (Vocado®) sowie die Dreifachkombination Olmesartan/ Amlodipin/HCT (Vocado® HCT). So muss bei einer Therapieeskalation der bewährte AT1-Rezeptorblocker Olme sartan nicht gewechselt werden. Fabian Sandner, Nürnberg

Literatur 1 Hirohata A et al. Atherosclerosis 2012; 220:134-138 2 Hirohata A et al. JACC 2010;55:976-982 3 Fliser D et al. Circulation 2004;110:11031107 4 Stumpe KO et al. Ther Adv Cardiovasc Dis 2007;1:97-106 5 Smith RD et al. J Am Soc Hypertens 2008;2:165-172 6 Martinez-Martin FJ et al. J Hum Hypertens 2010;25:346-353 7 Oparil S et al. Clin Ther 2010;32:12521269

Abstracts

Abstracts der wissenschaftlichen Beiträge zur 27. Jahrestagung der Deutschen Gesellschaft für Arterioskleroseforschung e.V. 18. bis 20. April 2013 Schloss Rauischholzhausen I. Vorträge Factors inducing cardiovascular events in patients treated with lipoprotein apheresis U. Julius, K. Taseva, S. Fischer, N. Weiss Medical Clinic III, University Hospital Dresden Background: Lipoprotein apheresis is indicated in patients at high risk for cardiovascular disease due to severe hypercholesterolemia and/or elevation of lipoprotein(a) (Lp(a)) which are not adequately controlled by diet and medication. The extracorporeal therapy reduces the event rate, although it does not completely abolish new events. Patients and methods: We compared atherogenic risk factors in 64 patients (40–80 years old) who were treated at the Apheresis Center of the Dresden University Hospital in 2009 and 2010 with lipoprotein apheresis and who suffered from events (n=20) with patients who did not (n=44). Among the 45 cardiovascular events that occurred four were strokes, one was myocardial infarction, and two were bypass operations (one coronary and one peripheral). The majority were percutaneous coronary interventions. Among the non-major cardiovascular events angina pectoris and occlusions of the arteria carotis interna were observed. Results: The following risk factors were found to be associated with events: male gender, coexisting diabetes/glucose intolerance and elevation of Lp(a) concentrations. In addition, the history of previous cardiovascular Perfusion 02/2013

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events, the efficiency of the lipoprotein apheresis therapy as judged by the reduction rates of LDL-C and of Lp(a), and the duration of the extracorporeal treatment (patients with events had started treatment with lipoprotein apheresis more recently) may play a role. Lipid concentrations (LDL-C, HDL-C, triglycerides), body weight, hypertension or smoking habits were not different between the two groups. Conclusion: Patients on apheresis therapy should be regularly monitored with respect to their risk factor and vascular situation.

Low levels of natural IgM antibodies against phosphorylcholine are independently associated with vascular remodelling in coronary artery disease C. A. Gleissner1, C. Erbel1, J. Haeussler1, G. Conradson2, N. Hofmann1, G. Gitsioudis1, H. A. Katus1, G. Korosoglou1 1 Department of Cardiology, University of Heidelberg 2 Athera Biotechnologies, Solna, Sweden Background: Vascular remodelling of coronary atherosclerotic plaques has been associated with plaque instability and adverse outcome. Currently, the gold standard for diagnosis of remodelling is intravascular ultrasound which is invasive and costly. Coronary computed tomography angiography on the other hand (CCTA), provides non-invasive accurate assessment of

atherosclerotic plaque composition and of vascular remodelling (positive remodelling when the diameter at the plaque site is ≥10 % larger than that measured in the reference segment), if required in a quantitative fashion. Anti-phosphorylcholine (anti-PC) IgM antibodies have been shown to be antiinflammatory mediators in atherosclerosis. Thus, low levels of anti-PC IgM have been associated with increased incidence of adverse events in patients with coronary artery disease (CAD). Hypothesis: We hypothesized that low anti-PCI IgM plasma levels are independently associated with remodelling of coronary atherosclerotic plaques. Methods and results: Cardiac computed tomography angiography (CCTA) was performed on 175 patients with suspected coronary artery disease (mean age 64.8±10.7 years, 48.6 % female). In 96 patients CAD was confirmed by CCTA, 41 of which displayed obstructive CAD (at least one stenosis ≥50 %). Mean anti-PC IgM levels, measured with CVDefine, were 70.4±53.1 U/mL and did not differ between patients with and without CAD. When specifically looking at patients with CAD (n=96, mean age 65.7±10.1 years, 35 (36.5 %) female), mean plaque volume was 19.1±23.1 mm3, mean calcium score 203.3±2.138. Calcified plaques were found in 64 patients, soft plaques in 37 patients. Vascular remodelling was present in 31 (32.3 %) patients. Mean antiPC IgM levels were 65.2±53.1 U/mL. Remodelling correlated with plaque volume (r=0.475, p<0.0001), total calcium score (r=0.332, p<0.01), and hypertension (r=0.249, p<0.05). Anti-PC IgM levels were significantly lower in patients with remodelling (46.5±32.6 versus 74.1±58.6 U/mL, p<0.05). Logistic regression analysis taking into account age, established cardiovascular risk factors and high sensitivity C-reactive protein confirmed anti-PC IgM as independent predictor of remodelling (p<0.05, odds ratio 0.44, 95%-confidence interval 0.229–0.844). Conclusions: Low anti-PC IgM levels are independently related to vascular © Verlag PERFUSION GmbH

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remodelling in patients with coronary atherosclerotic plaques. These findings may represent the link between in vitro studies demonstrating anti-inflammatory effects of anti-PC IgM on human macrophages and clinical data demonstrating that low anti-PC IgM levels are associated with adverse outcome in CAD patients. In summary, anti-PC IgM levels may serve as risk predictor or even as a therapeutic target in CAD patients and in future studies.

An alternative pathway for hypo fibrinolysis in type 2 diabetes: the role of complement C3 K. Hess, S. Alzahrani, J. Price, M. Strachan, N. Oxley, F. Phoenix , N. Marx, V. Schroeder, R. King, R. Ajjan Department of Internal Medicine I, University Hospital Aachen Purpose: Plasminogen activator inhibitor 1 (PAI-1) has been regarded as the main antifibrinolytic protein in diabetes but recent work indicates that complement C3, an inflammatory protein, directly modulates fibrinolysis in type 1 diabetes (T1DM). Therefore, we investigated the role of complement C3 in fibrinolysis in a large cohort of T2DM subjects. Methods: Fibrin clot lysis was determined in 875 patients enrolled on the Edinburgh type 2 diabetes study using a turbidimetric assay. Plasma levels of complement C3, C-reactive protein (CRP), PAI-1 and fibrinogen were analysed by ELISA. Results: Clot lysis time showed a highly significant correlation with C3 and PAI-1 plasma levels (r=0.25, p<0.0001 and r=0.15, p<0.0001; respectively). In contrast, a relatively weak correlation was detected with CRP (r=0.08, p=0.02) and fibrinogen (r=0.08, p=0.01). Plasma levels of C3, CRP, fibrinogen or PAI-1 did not differ in the presence of previous history of myocardial infarction or cerebrovascular disease. Plasma levels of all four proteins correlated with body mass index, but only fibrinogen showed an inPerfusion 02/2013

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teraction with age and duration of diabetes. In a regression model involving these proteins, C3 was a predictor of lysis time (predictive value for 0.1 mg/ ml change in plasma levels 14.4; 95% CI 7.9–21.0; p<0.001), as was PAI-1 (predictive value for 0.1 ng/ml change in plasma levels 8.2; 95% CI 4.2–12.1; p<0.001) with a smaller effect shown for 0.1 mg/ml change in fibrinogen levels (5.3; 95% CI 0.01–10.5; p=0.049) and none detected for CRP (–2.5; 95% CI (–9.7–4.8); p=0.50). No correlation was demonstrated between C3 and PAI-1 plasma levels indicating the two proteins affect different pathways in fibrin clot lysis. In multivariable analysis, drug therapies failed to predict C3 plasma levels, although a trend was observed in men towards a positive and negative association with sulphonylurea and antiplatelet therapy, respectively. Conclusions: C3 is at least as strong as PAI-1 at predicting fibrin clot lysis in subjects with T2DM. Therefore, future studies should analyse C3 plasma levels as a surrogate marker of fibrinolysis potential in this population.

Inhibition of microRNA-146a enhances angiogenesis and functional recovery after myocardial infarction and hind-limb ischemia K. Knöpp, R. Teske, W. Bielenberg, J.-M. Daniel, A. Koch, J. Dutzmann, K. Donde, C. Hamm, C. Troidl, J. Bauersachs, D. Sedding Medical Clinic I, Molecular Cardiology, University of Giessen Background: Regeneration and functional recovery following ischemia critically depends on angiogenic processes in the affected tissue. MicroRNAs (miRs), a class of small non-coding RNAs that regulate gene expression by targeting mRNA for cleavage or translational repression, have been shown to influence angiogenesis; however, the key regulators and underlying mechanisms are incompletely defined. Methods and results: In ischemic tis-

sues of C57BL/6J mice following myocardial infarction as well as hind-limb ischemia, expression levels of miR146a were strongly upregulated (myocardial infarction: 3,5-fold after 48 h; hind-limb: 14-fold after 72 h). In vitro, transfection of endothelial cells with pre-miR-146a significantly attenuated cell proliferation and migration, abrogated endothelial capillary network formation on Matrigel and inhibited cell sprouting from endothelial spheroids. In contrast, an efficient knockdown by antagomiR-146a significantly augmented endothelial cell proliferation, migration, network formation, and sprouting. Among other confirmed targets, NADPH oxidase 4 (Nox4), was identified by in silico predictive approaches as direct target of miR146a and validated by luciferase gene reporter assays. Moreover, siRNAmediated knock-down of Nox4 abrogated the pro-angiogenic effect of antagomiR-146a treatment. In C57BL/6J mice, antagomiR-146a significantly enhanced neo-vascularization in a Matrigel-plug assay (3.8-fold relative increase, p<0.05). Following hindlimb ischemia, systemic application of antagomiR-146a led to enhanced blood vessel growth and blood flow, as determined by histological analysis and laser Doppler imaging, (perfusion recovery: 64±21 % vs. 35±11 %; n=3; p<0.05). Moreover, systemic application of antagomiR-146a after permanent ligation of the left anterior descending coronary artery resulted in a significantly improved cardiac function, as assessed by echocardiography (fractional shortening: 22±4 vs. 11±2; n=6; p<0.01), reduced myocardial infarct size, as assessed by picrosiriusred staining, and increased vascularity in the peri-infarct zone. Conclusions: Our data indicate that miR-146a acts as a critical regulator of angiogenesis during ischemic tissue regeneration. Moreover, miR-146a may represent an attractive target for future therapeutic interventions for the treatment of ischemic heart disease or peripheral arterial disease. © Verlag PERFUSION GmbH

abstracts

Athero-metabolic and inflammatory alterations promote in-stent restenosis in apolipoprotein E deficient rats M. Borinski, S. Simsekyilmaz, M. Afify, C. Flege, N. Krott, N. Marx, F. Vogt Department of Internal Medicine I, University Hospital Aachen Purpose: Recently, apoliprotein E deficient (ApoE–/–) rats have been generated by genetic manipulation, while the bench-to-bedside relevance of this novel model for coronary stenosis research has not been elucidated. Here, we seek to characterize vascular inflammation and in-stent cross-sectional stenosis (ICS) development in the abdominal aorta of ApoE–/– rats. Methods: Trans-abdominal aorta baremetal stent (Multi-LinkMini Vision, Abbott Vascular Inc., Santa Clara, CA; 2.5 x 8 mm; 12 atm) implantation was performed in ApoE–/– rats (Sigma Aldrich Genetic Engineering, Saint Louis, MO). At 7 and 28 days, quantification of ICS, neointimal (NI) area, injury score and inflammation score were conducted using image analysis software (DISKUS, Hilgers, Königs winter). Blood serum analysis for interleukin (IL)-6, -8 and -10 and for cholesterol levels was performed. Results: Serum cholesterol levels were elevated in ApoE–/– rats (8.63±1.73 mmol/l vs. 1.98±0.55 mmol/l; p<0.001) as compared to ApoE+/+ rats. IL-6 and (294.7±80.2 pg/ml vs. 187.2±2.8 pg/ ml; p<0.05) and IL-8/CXCL8 (767.5±127.5 pg/ml vs. 342.0±39.7 pg/ ml; p<0.05) were upregulated, while IL-10/cytokine-synthesis inhibitory factor was downregulated (16.8±1.4 pg/ml vs. 90.7±6.5 pg/ml; p<0.001) in ApoE–/– rats. After stent implantation, injury scores were similar in all groups. At 7 days, ICS (11.1±1.9 % vs. 2.1±0.5 %; p<0.01) and NI area (0.59±0.09 mm2 2 vs. 0.075±0.02 mm ; p<0.01) was increased as compared to controls; concomitantly, at 28 days, ICS (26.6±3.9 % vs. 13.1±1.9 %; p<0.001) and NI area (1.47±0.37 mm2 vs. 0.54±0.10mm2; Perfusion 02/2013

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p<0.01) were elevated. Furthermore, infiltration by chronic inflammatory cells was increased in ApoE–/– rats at 28 days (456.2±181.4 vs. 108.0±25.9 per high power field; p<0.05). Conclusions: In ApoE–/– rats, cholesterol levels as well as pro-inflammatory IL-6 and -8 are upregulated, while antiinflammatory IL-10 is downregulated. Concomitantly, ApoE–/– rats develop increased ICS after abdominal stent implantation. This novel small animal model enables the characterization of distinctive molecular and mechanical ICS mechanisms in an atherogenic milieu that, notably, renders disposable any miniaturization of tested stents as opposed to mouse models.

Overexpression of TGF-β1 in T cells fails to influence atherosclerosis in both chow and high cholesterol fed ApoE-deficient mice K. Reifenberg, F. Cheng, L. Twardowski, I. Küpper, E. Wiese, M. Blessing, K. J. Lackner, M. Torzewski Department of Laboratory Medicine, Robert Bosch Hospital, Stuttgart Background: Clinical data have indicated a negative correlation between plasma TGF-β1 concentrations and the extent of atherosclerosis and have thus led to the hypothesis that the pleiotropic cytokine may have anti-atherogenic properties. T-cells are currently discussed to significantly participate in atherogenesis, but the precise role of adaptive immunity in atherogenesis remains to be elucidated. TGF-β1 is known to strongly modulate the function of T-cells, however, inhibition of TGF-β1 signalling in T-cells of athero sclerosis-prone knock-out mice failed to unequivocally clarify the role of the cytokine for the development of athe rosclerosis. Purpose and methods: In the present study, we thus tried to specify the role of TGF-β1 in atherogenesis by using the murine CD2-TGF-β1 transgenic strain which represents a well characterized model of T-cell specific TGF-β1

overexpression. The CD2-TGF-β1 transgenic mice were crossed to ApoE knock-out mice and quantity and quality of atherosclerosis regarding number of macrophages, smooth muscle cells, CD3 positive T-cells and collagen were analyzed in CD2-TGF-β1 ApoE double mutants as well as in non-transgenic ApoE controls on both normal (16, 24, 32 weeks) and atherogenic (8, 16 or 24 weeks) diet, respectively. Results: In all experimental groups investigated, we failed to detect any influence of TGF-β1 overexpression on disease. Even total number of CD3positive T-lymphocytes was not signi ficantly different in atherosclerotic lesions of CD2-TGF-β1 ApoE–/– females and isogenic ApoE–/– controls after 24 weeks on atherogenic diet. Conclusion: Our data suggest that potential effects of TGF-β1 on atherosclerosis are most probably mediated by other cell types than T-cells.

Impact of differentiation-induced polarization of monocytes/ macrophages on their responsive ness to interleukin 10 M. B. Maeß, W. Schmidt-Heck, S. Lorkowski Institute of Nutrition, Friedrich Schiller University Jena Background: Atherosclerosis, a chronic inflammatory vascular disease, is characterized by lipid depositions and local inflammation within the arterial walls. This is predominantly caused by macrophages which have entered the arterial wall, where they engulf modified lipoproteins, transform into foam cells, and release proinflammatory cytokines and matrix metalloproteases. These processes ultimately contribute to the formation of a necrotic lipid core covered by a fibrous cap which is degraded by the secreted matrix metalloproteases. Thus, the integrity of the atherosclerotic plaque is diminished and the risk for rupture and fatal consequences, such as strokes and myocardial infarctions, increases. Giv© Verlag PERFUSION GmbH

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en the profound impact macrophages exert on atherosclerosis directing and controlling their activities in order to reduce or even completely repress their detrimental effects by pharmaceutical or nutritional means is desirable. In fact, macrophages may enter a more favourable anti-inflammatory, wound healing activation state which is characterized by the production and release of proteins of the extracellular matrix which may contribute to preservation and strengthening of the protective fibrous cap. The major physiological mediator of anti-inflammatory activation is interleukin 10 (IL-10), whose attenuating effects on the secretion of pro-inflammatory cytokines and proteases are well described. Surprisingly, only few IL-10-dependently regulated genes have been identified in macrophage cell lines as well as primary macrophages. Methods and results: Using siRNAmediated knock-down of the IL-10RB mRNA we investigated the response of THP-1 macrophages to exposure with IL-10. In the course of our studies we observed that the applied cell culture conditions have significant influence on the responsiveness of the cells to IL-10, i.e. standard differentiation protocols of THP-1 macrophages cause an activation of the cells which interferes with IL-10 signalling. After appropriate optimization of the transfection as well as the differentiation protocol the sensitivity of cells towards an IL-10 stimulus was considerably improved. Transcriptome studies using microarrays yielded about 50 new IL-10 dependent genes, some of which have already been confirmed in primary cells. Conclusions: These results indicate that even with well-established cell models and standard culturing protocols there has to be awareness towards whether the basal state of monocytes and macrophages can be considered appropriate for the intended stimulus.

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EMMPRIN (Cd147): a crucial receptor in cardiovascular diseases P. Seizer1, C. S. Zuern1, R. Schmidt2, A. E. May1 Department of Internal Medicine III, Cardiology and Circulatory Disorders, University Hospital Tübingen 2 German Heart Center Munich

The Extracellular Matrix Metalloproteinase Inducer (EMMPRIN, synonyms: CD147, basigin) represents a receptor that critically regulates inflammatory cardiovascular processes. While it has initially been described on tumour cells as a MMP inducing receptor, it is now known as a critical initiator of various intracellular inflammatory processes. Multiple activation cascades are typically induced upon ligation by e.g. cyclophilins or homotypic EMMPRIN binding. EMMPRIN is constitutively expressed at very low (if any) levels on various cardiovascular cell types including leukocytes, platelets, endothelial and vascular smooth muscle cells as well as on cardiomyocytes and fibroblasts. Upon stimulation in vitro EMMPRIN becomes upregulated on monocytes, platelets and endothelial cells. Recently, we could show that EMMPRIN (CD147) and its extracellular ligand cyclophilin A (CyPA) are crucially involved in i) myocardial injury upon ischemia and reperfusion, and ii) are required for an adequate inflammatory response and virus elimination in Coxsackie virus B3-induced myocarditis in mice. In endomyocardial biopsies of patients with congestive heart failure, CyPA and CD147 can distinguish inflammatory from non-inflammatory cardiomyopathies and serve as a novel diagnostic marker. Enhanced CyPA expression additionally identifies patients at enhanced risk for an adverse clinical outcome. Together, EMMPRIN is a relevant inducer of inflammatory processes in various vascular cell types and crucially influences inflammation-related cardiovascular diseases.

Mechanisms of integrin regulation in endothelial cells and their role in angiogenesis E. Chavakis Institute of Cardiovascular Regeneration, Centre for Molecular Medicine, and III. Department of Internal Medicine, Cardiology, Goethe University Frankfurt Angiogenesis, the formation of new capillaries from pre-existing ones by endothelial cell sprouting, is involved in many physiologic and pathologic conditions, including morphogenesis during embryonic development, wound healing, rheumatoid arthritis, tumour growth, tumour metastasis, athe rosclerosis progression, proliferative retinopathy and recovery after tissue ischemia. Besides angiogenic growth factors, endothelial β1-integrins are crucial for angiogenesis. Integrins are heterodimeric receptors mediating adhesion to extracellular matrix proteins. Integrin-mediated adhesivity to extracellular matrix ligands is strictly regulated in several cell systems by intracellular signalling. Previous studies from our group provided insight in the regulation of integrin affinity in endothelial cells by the small GTPase Rap1 and its role in endothelial cell migration and angiogenesis. These studies provided the evidence that molecular mechanisms activating integrin affinity are essential for vessel formation. Beyond regulation of integrin affinity, recent investigations from our group shed light to a novel mechanism of regulation of integrin function in endothelial cells involving endocytosis of active (matrix bound) integrins thereby contributing to the disassembly of focal adhesions. Specifically, we found that Brag2, a guanine exchange nucleotide factor (activator) of the small GTPases Arf5 and Arf6 is mediating the internalization of α5β1-integrins in endothelial cells, thereby regulating α5β1-integrin abundance on the cell surface and focal adhesions. Our data provide evidence that Brag2 me© Verlag PERFUSION GmbH

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diates disassembly of focal adhesions containing β1-integrins in an Arf5and Arf6- dependent pathway thereby promoting angiogenic sprouting and migration. In accordance with these results, silencing of Brag2 impaired developmental angiogenesis and vascular patterning in zebrafish during development. In addition, in vivo silencing of Brag2 reduced neovascularization in 2 murine disease models of pathological angiogenesis. Taking together, our studies for the first time link the mechanisms of integrin endocytosis to the process of angiogenesis and shed light in the complexity of regulation of integrin function in endothelial cells. Moreover, our data demonstrate that Brag2 is a promising target for the development of new antiangiogenic approaches to treat patients with pathological angiogenesis.

Nucleoside triphosphates inhibit ADP, collagen, and epinephrine-induced platelet aggregation: Role of P2RY1 and P2RY12 M. Aslam1, R. Schulz2, C. Hamm1, D. Sedding3, D. Gündüz1 1 Cardiology and Angiology, Justus Liebig University, Giessen 2 Institute of Physiology, Justus Liebig University, Giessen 3 Cardiology and Angiology, Medical School, University of Hannover Introduction: Platelets express two ADP receptors P2RY1 and P2RY12, which are involved in platelet activation induced by ADP and other agonists such as collagen and epinephrine. P2RY1 activation leads to platelet shape change while that of P2RY12 leads to platelet aggregation. Adenosine-5’-triphosphate (ATP) has been shown to have dose-dependent pro- or anti-aggregatory effects on ADP-induced platelet aggregation, but solely pro-aggregatory effect on epinephrineinduced platelet aggregation. However, the effect of other nucleoside triphosPerfusion 02/2013

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phates on platelet aggregation is not documented so far. The aim of the present study was to characterize the effects of adenosine, uridine, guanosine, and cytosine, nucleoside triphosphates (ATP, UTP, GTP, and CTP, respectively) on agonist-induced platelet aggregation. Methods: The experiments were carried out on platelet rich plasma freshly isolated from blood donated by healthy human volunteers. Results: All the nucleoside triphosphates tested inhibited ADP- and collagen-induced platelet aggregation in a concentration-dependent manner with a rank order of potency, 2MeSATP ≥ ATP ≥ α,β-methylene ATP ≥ UTP ≥ CTP ≥ GTP. The IC50 values against ADP (10 µM) were 0.039±0.013, 18±7, 25±6, 32±9, 360±130 and 400±160 µM, respectively. At lower concentrations, ATP induced platelet shape change, which was most likely due to contaminating ADP. However, at higher concentrations, ATP antagonised ADP and 2MeSADPinduced platelet shape change. The ATP analogue α,β-methylene ATP and CTP but not UTP and GTP also ant agonised ADP-induced platelet shape change, but less potently. ATP at low concentrations but not its stable analogue α,β-methylene ATP potentiated epinephrine-induced platelet aggregation which was abolished by P2RY1 antagonist MRS2500, suggesting that contaminating ADP activates P2RY1 and thus augments platelet aggregation. However, ATP at higher concentrations, α,β-methylene ATP, CTP, and GTP antagonised epinephrine-induced platelet aggregation. Conclusion: Thus, these data demonstrate for the first time that nucleoside triphosphates in general act as PR2Y12 antagonists and thus can antagonise ADP-, collagen-, and epinephrine-induced platelet aggregation.

Regulation of NOX4 expression by histone deacetylases D. Siuda, U. Zechner, D. Prawitt, N. Xia, H. Li Department of Pharmacology, University Medical Center of the Johannes Gutenberg University, Mainz Background: Oxidative stress plays an important role in the pathogenesis of cardiovascular disease and NADPH oxidases (NOX) represent a major source of superoxide in the cardiovascular system. Among the NOX enzymes, NOX4 is the predominant isoform in endothelial cells. In contrast to other NOX isoforms, NOX4 does not require the regulatory subunits and its activity is mainly dependent on the expression level. The present study was aimed to investigate the role of histone deacetylases (HDAC) in controlling Nox4 transcription. Methods and results: In human umbilical vein endothelial cells (HUVEC) and HUVEC-derived EA.hy 926 cells, treatment with HDAC inhibitors (scriptaid, suberoylanilide hydroxamic acid or trichostatin A) led to a marked decrease in Nox4 mRNA expression. Relatively high expression levels of HDAC1, 3 and 7 were found in EA.hy 926 cells. Knockdown of HDAC3 by siRNA resulted in a NOX4 down-regulation similar to that by HDAC inhibition, indicating the role of this HDAC isoform. HDAC inhibition in endothelial cells was associated with enhanced histone acetylation, increased chromatin accessibility in the human NOX4 promoter region, with no significant changes in DNA methylation. Interestingly, knockdown of c-Jun with siRNA led to a down-regulation of NOX4 mRNA expression, indicating that this transcription factor was involved in the regulation of NOX4 expression. Scriptaid treatment reduced the binding of c-Jun to the NOX4 promoter region despite the open chromatin structure. In parallel, the binding of RNA polymerase IIa to the NOX4 promoter was significantly inhibited as well, which © Verlag PERFUSION GmbH

abstracts

was compatible with the reduction in NOX4 transcription. Conclusion: In conclusion, HDAC inhibition decreases NOX4 transcription in human endothelial cells by preventing the binding of transcription factor(s) and polymerase(s) to the NOX4 promoter, most likely because of a hyperacetylation-mediated steric inhibition.

Angiotensin II-induced impairment of endothelial function is mediated by MPO-dependent reduction of NO-bio availability in mouse aortic segments F. G. Deuschl, A. Klinke, K. Schadwald, K. Friedrichs, T. Ravekes, F. Weinberger, D. Lau, S. Blankenberg, S. L. Hazen, S. Baldus Department of Experimental Cardiology, Heart Center, University Hospital Cologne Background: Myeloperoxidase (MPO), a leukocyte derived heme enzyme with pro-oxidant and nitric oxide (NO)-depleting properties, is related to various cardiovascular disorders like atherosclerosis, heart failure and atrial fibrillation. We have shown recently, that MPO-deficiency preserves NO-dependent endothelial function in humans upon leukocyte activation. In this study we investigate the influence of MPO on vasomotor function of conductance vessels upon angiotensin II (ATII) induced leukocyte activation in a mouse model. Methods and results: C57Bl/6JWild-type (WT) and MPO-deficient (MPO–/–) mice were subjected to 1 ng/g/min ATII or vehicle for 6 weeks via subcutaneous osmotic mini pumps. Endothelium-dependent acetylcholine (ACh)-mediated relaxation of explanted aortic segments, but not endothelium-independent nitroglycerine (NTG)induced relaxation was impaired as a function of MPO: Aortic rings from ATII-treated WT mice displayed attenuated relaxation in response to ACh but not to NTG respectively, as compared to MPO–/– mice (ACh-response: –47.79±4.34 % vs. –60.26±4.31 %, Perfusion 02/2013

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p=0.002; NTG-response: –76.92± 2.78 % vs. –74.42±3.19 %, p=0.774). The MPO inhibitor sodium thiocyanate (supplement to drinking water over 6 weeks) prevented impairment of relaxation in ATII-treated WT mice in response to ACh (ACh-response: –72.04±3.70 %, p=0.683 compared to WT sham, p<0,001 compared to Ang II treated group). Immunoblot analysis of aortic tissue revealed reduced phosphorylation of vasodilator-stimulated phosphoprotein (VASP) in WT compared to MPO–/– mice upon ATII treatment, confirming enhanced NObioavailability in MPO–/– mice. Conclusion: The current data reveal that in this mouse model MPO deteri orates endothelium-dependent but not endothelium-independent relaxation of conductance vessels. NO-consumption is the principal mechanism and ATII demonstrates to impair endothelial function by activation of leukocytes.

OSCAR is an endothelial receptor for leukocyte adhesion in atherosclerosis and inflammation N. Al-Fakhri, K. Nemeth, L. Mey, C. Göttsch, S. Helas, L. C. Hofbauer, M. Schoppet Institute of Laboratory Medicine, Philipps University Marburg Objectives: Osteoclast-associated receptor (OSCAR) is regulated by cytokines and growth factors in endothelial cells (EC) and vascular smooth muscle cells (VSMC) and OSCAR expression is induced by oxLDL, as demonstrated in previous studies. This study characterized the functional role of OSCAR on EC for atherosclerosis development and inflammation. Methods: Wildtype, OSCAR-siRNA treated and OSCAR-overexpressing HUVEC were stimulated with VEGF, bFGF and TGF-β and the proinflammatory cytokines TNF-α, INF-α, and INF-γ. EC were analyzed with BrdUassay and wound-scratch-assay for proliferation and migration. OSCAR expression was determined by immu-

nofluorescence/confocal microscopy, Western blot and real-time RT-PCR. In binding assays the adhesion of β2integrin-expressing and wildtype HEK and CHO cells and of soluble OSCAR to LFA-1 and Mac-1 was analyzed with or without CD18 and CD11b antibodies. Murine models of atherosclerosis (ApoE–/–) and inflammation (LPS-induced pneumonia) were analyzed for OSCAR expression. Results: All cytokines and high concentrations of bFGF, but not VEGF or TGF-β increased OSCAR expression on EC. OSCAR expression was demonstrated on the cell surface and in adherence junctions of EC. Enhanced or deleted OSCAR expression reduced the migratory and proliferative capacity of EC, INF-α and INF-γ augmented these effects in OSCAR-overexpressing cells. OSCAR bound specifically to leukocyte integrins in ligand and cell based assays. OSCAR expression was increased in murine models of atherosclerosis and inflammation. Conclusions: OSCAR is a surface and junctional receptor for leukocytes on EC induced by cytokines. Endothelial OSCAR expression could play a role in leukocyte recruitment in atherosclerosis and inflammation.

Metabolic stress and energy metabolism in endothelial cells S. Lindenmüller, K. Spengler, D. Weigel, R. Heller Institute of Molecular Cell Biology and Center for Sepsis Control and Care (CSCC), University Hospital Jena Introduction: Endothelial cells are characterized by glycolytic energy production and by a large capacity to increase this metabolic pathway if needed. Under certain conditions, i.e. ischemia or angiogenesis, however, additional energy-generating pathways may be important. The current project addresses the question whether endothelial cells undergo a metabolic switch in conditions of low glycolysis. Methods: Our study was performed in © Verlag PERFUSION GmbH

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human umbilical vein endothelial cells (HUVEC), to which 2-deoxyglucose (2-DG), a known competitive inhibitor of hexokinase, the key enzyme of glycolysis, was added (20 mM, 5 min – 7 h). Results: 2-DG induced a rapid and long-lasting decrease of intracellular ATP levels with a maximal reduction after one hour (60 %). Thereafter, a slow but incomplete recovery of ATP levels was seen. ATP decrease in response to 2-DG was accompanied by a rapid and sustained activation of the energy-sensing enzyme AMP-activated kinase (AMPK), which was monitored by phosphorylation of threonine 172, an activating phsophorylation site. AMPK stimulation by 2-DG was mediated by two upstream pathways, the AMP-dependent LKB1 and the Ca++dependent CaMKKβ pathway, which was demonstrated by siRNA-mediated downregulation of the respective kinases. 2-DG triggered phosphorylation of ACC, which is a known target of AMPK. ACC inhibition by AMPK is known to stimulate fatty acid oxidation via reduction of malonyl-CoA, which is an inhibitor of carnitine-palmitoyl transferase and mitochondrial fatty acid transport. Indeed, our data show that 2-DG induced enhanced fatty acid oxidation from exogenously added or endogenous fatty acids. This was, however, only to a minor part dependent on the AMPK-ACC axis suggesting that the reduced availability of acetyl-CoA as a consequence of inhibited glycolysis may affect malonyl-CoA levels independent from ACC inhibition. Importantly, 2-DG led to a transient activation of autophagy, which is a self-digestion pathway that supplies nutrients and contributes to stress adaptation and cell survival. Autophagy induction was indicated by AMPKmediated phosphorylation of Ulk-1, which is part of a complex initiating autophagy, and by inhibition of the mTOR pathway, known to repress autophagy. Furthermore, autophagy was monitored by detecting conjugated Perfusion 02/2013

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LCB3, a marker protein of autophagosomes, in Western blots and immunofluorescence analyses. Conclusions: Taken together, our results demonstrate that endothelial cells respond to inhibition of glycolysis with an increased fatty acid oxidation and activation of autophagy. These processes are in part due to stimulation of AMPK but are not able to completely restore the cellular energy status. Our data suggest that the observed adaptive mechanisms support endothelial survival under stress conditions such as ischemia, which may help to ensure initiation of angiogenesis in post-stress conditions.

Platelet C5a receptor inhibits angiogenesis H. Nording1, J. Patzelt1, F. Emschermann1, J. D. Lambris2, H. F. Langer1 1 Cardioimmunology Research Group, Department for Internal Medicine III, Faculty of Medicine, University of Tübingen 2 Department of Pathology & Laboratory Medicine, University of Pennsylvania School of Medicine, Philadelphia Endothelial cells play a key role in angiogenesis. Crosstalk between platelets and endothelium is particularly well understood for inflammatory conditions such as vascular inflammation. However, platelets also play an important role for angiogenesis. We recently demonstrated that the complement receptor C5aR on macrophages modulates angiogenesis. Interestingly, this receptor is also expressed on platelets. Here, we addressed the cell specific role of platelet C5aR for angiogenesis. Using the Matrigel assay as an in vivo model of angiogenesis we could demonstrate that platelets inhibited growth factor induced angiogenesis. In vitro data showed that platelet C5a receptor inhibited the migration of cells of an endothelial cell line as well as of primary murine lung endothelium cells. Similarly, an inhibitory effect on tube formation could be shown using

both types of cells. However, there was no effect on endothelial proliferation. Previous work demonstrated that C5aR-deficient mice show increased levels of angiogenesis. Here, we observed in vivo that the angiogenesis inhibitory phenotype of C5aR was partially reversible in C5aR-deficient mice being retransfused with wildtype platelets. This indicates that the antiangiogenic effect of the complement receptor C5aR in vivo is partially due to platelet C5a receptor. Finally, our data suggests that the observed effect is due to platelets indirectly affecting the endothelium by means of secreted antiangiogenic factors. Platelet C5aR inhibits angiogenesis indirectly by secretion and presents itself as a potential target for modulating angiogenesis.

Cyclophilin A activates human platelets via EMMPRIN and PI3kinase and promotes platelet adhesion to the vascular wall – implications for patients with acute coronary syndrome P. Seizer, S. v. Ungern-Sternberg, M. Kaleqi, K. Schuster, O. Borst, M. Gawaz, T. Geisler, A.E. May Department of Internal Medicine III, University Hospital Tübingen Introduction: Cyclophilin A (CyPA) is secreted under inflammatory conditions by various cell types (including platelets, leukocytes and smooth muscle cells). We have recently identified its receptor EMMPRIN (CD147) on platelets. Here we investigated the effect of extracellular CyPA on platelet activation and adhesion in vitro and in vivo. Methods and results: Freshly isolated human platelets were stimulated with various concentrations of recombinant CyPA and analyzed after various time points by flow cytometry for the expression of p-selectin, GPVI or SDF1. In fact, p-selectin, GPVI and SDF1 were upregulated in a concentra© Verlag PERFUSION GmbH

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tion- and time-dependent manner on platelets, which was abrogated by an EMMPRIN-blocking mAb. Moreover activation of platelets with CyPA lead to an enhanced expression of phospho-Akt (Western blot), indicating an involvement of phophatidylinositol3-kinase (PI3K). Treatment of platelets with the PI3 inhibitors wortmannin or LY294002 abolished CyPA mediated platelet activation nearly completely measured by p-selectin expression (FACS). Perfusion of CyPA-stimulated platelets over cultivated endothelial cells under arterial shear conditions in vitro showed an enhanced rolling which could be blocked by anti-p-selectin or anti-PSGL-1 treatment (p<0.05). Perfusion of CyPA-stimulated platelets over immobilized collagen (ligand for GPVI) showed enhanced adhesion. Perfusion of ex vivo CyPA-pretreated platelets into mouse carotid arteries after arterial injury showed both enhanced rolling and adhesion as assessed by intravital microscopy, which was blocked by anti-CD147. Finally FACS-measurement of patients with acute coronary syndrome revealed an enhanced presence of CyPA on platelets surface. Conclusion: Extracellular CyPA activates human platelets via EMMPRIN and PI3-kinase and thus enhances adhesion of platelets on endothelial cell and collagen in vitro and in vivo.

Platelet chemokines as possible therapeutic targets in athero sclerosis R. R. Koenen CARIM – School for Cardiovascular Sciences, Department of Biochemistry, Maastricht University Platelets do not only play a crucial role in hemostasis, but it has become increasingly clear that they have an important function as immune cells. In cardiovascular diseases, platelets are responsible for the acute clinical precipitation of atherosclerosis, which is mostly manifest as a myocardial infarcPerfusion 02/2013

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tion or an ischemic stroke, through the thrombotic occlusion of an affected artery. But what is much less well known is that platelets are already involved in very early phases of atherosclerosis. Activated platelets can spark vascular inflammation by interacting with the endothelium and by secreting or presenting cytokines to the vessel wall. This initial vascular inflammation may progress to atherosclerotic plaques and platelets might facilitate this progression throughout the various phases of lesion development. Among the inflammatory payload of platelets are chemokines, small chemotactic cytokines, which direct the trafficking of leukocytes during immune surveillance and inflammation. Chemokines exert their activity through activation of G protein-coupled receptors, resulting in chemotaxis, cell arrest under flow and transendothelial migration. Since the discovery of chemokine receptors as HIV-entry coreceptors, the design and production of chemokine receptor antagonists was in strong focus. This resulted in many compounds with therapeutic potential not only for the treatment of HIV, but also for many other (autoimmune) diseases. Unfortunately, of all chemokine receptor antagonists that made their way into clinical trials, only 2 achieved FDA and EMA approval. Thus, other methods of interference in the chemokine system are necessary. In this study, the role of the platelet chemokines RANTES (CCL5) and platelet factor 4 (CXCL4) were investigated in atherosclerosis. These chemokines can be deposited by activated platelets onto endothelial cells, resulting in an increased recruitment of mononuclear cells, which may ultimately lead to accelerated plaque development. In addition, CXCL4 and CCL5 can form heteromers with enhanced potential to attract monocytes. A peptide inhibitor against the CXCL4/CCL5 interaction reduced monocyte recruitment in vitro and in vivo and attenuated the development of atherosclerosis in hyperlipidemic

mice, without adverse immunologic side effects. Thus targeting interactions between chemokines might present an attractive alternative to full chemokine receptor blockade in the treatment and prevention of inflammatory diseases.

Platelet pharmacogenomics T. Geisler Department of Internal Medicine III, University Hospital Tübingen Platelets are a main driver of atherosclerosis and acute ischemic events thus representing an attractive target for drug therapy in cardiovascular dis ease. In the past antiplatelet strategy has led to a marked improvement of cardiovascular outcome. However, efficacy of antiplatelet drugs shows wide interindividual variability influenced by the clinical and genetic phenotype. Now, that diversive antiplatelet compounds with different profiles are or become available, personalized antiplatelet strategies will increasingly be of clinical importance. An overview over recent landmark clinical trials investigating efficacy and safety of novel antiplatelet compounds will be given. Additionally, potential perspectives and strategies focussing on genetic and clinical risk assessment to select patients that benefit from these therapies will be discussed.

Left ventricular dimensions are related to vulnerability of coronary artery lesions as determined by optical coherence tomography and cardiac magnetic resonance imaging in patients with type 2 diabetes M. Burgmaier, M. Frick, A. Liberman, S. Battermann, A. Jaskolka, N. Marx, S. Reith Department of Internal Medicine I, University Hospital Aachen Background: Patients with type 2 diabetes are at a high risk for acute car© Verlag PERFUSION GmbH

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diovascular events following plaque rupture, which ultimately results in abnormal left ventricular (LV) geometry. This study investigated the relationship between LV-geometry and plaque vulnerability using cardiac magnetic resonance imaging (CMR) and optical coherence tomography (OCT) in patients with type 2 diabetes and stable coronary artery disease. Methods: CMR was performed in 49 patients with type 2 diabetes, in which 72 lesions have been investigated using OCT. Results: Regression analysis revealed that an increase of several CMR-derived parameters including LV-end diastolic volume (LVEDV, r=0.506, p<0.001), LV-end diastolic diameter (LVEDD, r=0.488, p<0.002) and LVend systolic volume (LVESV, r=0.445, p<0.005) was associated with a decreased minimal fibrous cap thickness (FCT) of coronary lesions. Similar results were obtained for mean FCT. Receiver operating curve (ROC) analysis demonstrated that among all CMR-derived parameters investigated, LVEDV had the best diagnostic efficiency (area under the curve 0.686) to predict lesions with a minimal FCT ≤80 µm with an optimal cut-off value of 161.5 ml. Although sensitivity was low (52.6 %), specificity was considerate (84.2 %). Furthermore, there were significant differences between patients with dilated (LVEDV ≥161.5 ml) and non-dilated (LVEDV <161.5 ml) LV for several established cardiovascular risk factors and biomarkers including previous MI (65.4 % vs. 26 %, p<0.001) and PCI (46.9 % vs. 21.1 %, p<0.011), HDL-cholesterol (38.50±5.56 vs. 46.91±10.11 mg/dl, p<0.001), male gender (100.0 % vs. 63.6 %, p<0.006) and leptin (15.37±5.82 vs. 34.25±23.86 ng/ ml, p<0.001), suggesting a link. Conclusion: These data suggest that type 2 diabetic patients with dilated LV are at a particular high risk for vulnerable plaques whereas both vulnerable and stable plaques are present in those with non-dilated LV. Perfusion 02/2013

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The role of the sialic acid-dependent membrane receptor “Sialoadhesin-1” in cellular inflammation: the contribution of extracellular-RNA H. A. Cabrera-Fuentes1, S. Meiler2, Y. Baumer2, S. Fischer1, S. Galuska1, K. T. Preissner1, W. A. Boisvert2 1 Institute of Biochemistry, Medical School, Justus Liebig University, Giessen 2 Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, Honolulu, U.S.A. Background: We have previously shown that extracellular RNA (eRNA) can exert prothrombotic and inflammatory properties in the vasculature as a cofactor in protease auto-activation and cytokine mobilization. Sialoadhesin-1 (Sn-1) is a transmembrane receptor expressed on monocytes and macrophages. Sn-1 mediates interactions with other cells or molecules via recognition of sialylated glycoconjugates, and may facilitate the actions of eRNA. The aim of this study was to determine if eRNA contributes to atherogenesis and if Sn-1 plays a role in mediating this process. Method and results: The role of eRNA/RNase system in atherogenesis was studied in LDL-receptor knockout mice as well as in bone-marrowderived macrophages (BMDM) from wild-type (WT) and Sn-1–/– mice. Using an RNA-binding fluorescence dye the presence of eRNA in atherosclerotic lesions from LDL-receptor knockout mice was demonstrated by confocal microscopy. During various stages of atherosclerosis induced by feeding a high fat diet (HFD) for 4 to 36 weeks, eRNA was detected in association with macrophages and damaged cells within the lesions in a time-progressive fashion. Concomitantly, RNase activity in plasma samples from these mice indicated a biphasic characteristic with a temporary increase during the first two weeks, followed by a significant decrease to about 20 % of control after 8 weeks of HFD regimen. This correlated well with the presence of eRNA in the

necrotic core of atherosclerotic lesions. When WT-BMDM were exposed to eRNA for 24 hours, there was a concentration-dependent upregulation of pro-inflammatory mediators such as tumor necrosis factor-alpha (TNF-α), arginase-2 (ARG-2), Interleukin-1 beta (IL-1β), IL-6, Interferon-gamma (IFN-γ) and Sn-1 with only a moderate increase in IL-10. In contrast, quantitative gene expression analysis in eRNA-treated Sn-1–/– BMDM showed a prominent down-regulation of the pro-inflammatory mediators ARG-2, TNF-α, IL-1β, IL-6 and IFN-γ, while the anti-inflammatory IL-10 and IL-4 were significantly raised. Conclusion: Overall, these results show that eRNA can act as pro-inflammatory contributor to atherogenesis, and that the expression of Sn-1 on macrophages might play an important role in mediating this atherogenic process. These findings identify the eRNA/ RNase1/Sn-1 system as a novel player in atherogenesis.

Inhibition of Sonic hedgehog signalling attenuates smooth muscle cell proliferation and prevents neointimal lesion formation J.-M. Daniel, J. Dutzmann, A. Koch, J. Bauersachs, D. Sedding Department of Cardiology and Angiology, Medical School, University of Hannover Background: De-differentiation and proliferation of smooth muscle cells (SMC) and fibroblasts are hallmarks of vascular proliferative diseases. Sonic hedgehog (Shh) is a regulator of vasculogenesis and has recently also been implicated in proliferation of vascular cells and differentiation of perivascular stem cells in the adult. Moreover, Shh acts as a potent chemoattractive factor for the recruitment of inflammatory cells. The aim of the study was to investigate the role of Shh in vascular proliferative diseases. Methods and results: Wire-mediated injury of the femoral artery was per© Verlag PERFUSION GmbH

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formed in C57BL/6 mice to induce neointimal lesion formation. Shh was significantly up-regulated in neointimal SMC and perivascular cells at 4 and 7 days after injury compared to sham-operated arteries, as determined by qPCR and immunohistochemistry (IHC). In vitro, stimulation of human fibroblasts and human coronary artery SMC with platelet-derived growth factor (PDGF)BB and tumor necrosis factor alpha (TNF-α) resulted in a significant upregulation and secretion of Shh to the supernatant. Incubation of fibroblasts and SMC with recombinant Shh dosedependently induced cell proliferation. Interestingly, this effect was strongly enhanced by the combination of Shh with PDGF-BB as compared to each factor alone. The specific Shh inhibitor GDC-0449 (vismodegib) was not only effective in attenuating Shh signalling but also prevented the Shh/PDGF-BB induced proliferation in fibroblasts and SMC in a dose-dependent manner. Following wire-induced injury, local application of GDC-0449 via a self-degrading Pluronic® F-127 Gel significantly reduced neointimal lesion formation (neointima/media ratio: 2.19±0.17 vs. 0.88±0.19, p<0.001). This was associated with a reduced accumulation of leukocytes as well as reduced proliferation of SMC and perivascular cells. The effects of Shh inhibition on the downstream signalling pathways are currently investigated. Conclusion: Shh signalling is critically involved in neointimal lesion formation by augmenting the proliferation of SMC and perivascular cells. Therefore, these data add significantly to our understanding of vascular proliferative diseases.

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Cardiac allograft vasculopathy after heterotopic rat heart transplantation: impact of extracellular matrix remodelling and implications for targeted imaging and therapy strategies M. Franz1, D. Neri2, H. Kosmehl3, I. Hilger4, H. R. Figulla1, A. Renner5, A. Berndt6 1 Department of Internal Medicine I, University Hospital Jena 2 Institute of Pharmaceutical Sciences, Swiss Federal Institute of Technology, Zurich 3 Institute of Pathology, HELIOS Klinikum Erfurt 4 Department of Experimental Radiology, Institute of Diagnostic & Interventional Radiology I, University Hospital Jena 5 Clinic for Thoracic and Cardiovascular Surgery, Heart Center North Rhine-Westphalia, Ruhr-University of Bochum, Bad Oeynhausen 6 Institute of Pathology, University Hospital Jena Background: Chronic rejection following heart transplantation is mainly represented by cardiac allograft vasculopathy (CAV) and cardiac interstitial fibrosis (CIF), both known to cause severe complications and to determine patients’ prognosis. Thus, there is an urgent need for an early diagnosis and sufficient therapeutic strategies. Cardiac tissue remodelling is intimately associated with a reorganization of the extracellular matrix (ECM) including the reoccurrence of fetal variants of cell adhesion modulating proteins like fibronectin (Fn) or tenascin-C (Tn-C). Interestingly, these molecular variants are virtually absent in healthy adult organs. Purpose of the study was to investigate ECM remodelling in chronic rejection with a special focus on the role of ED-A domain containing Fn (ED-A+ Fn), alpha smooth muscle actin (ASMA) as a marker of vascular smooth muscle cells (VSMCs) and myofibroblasts (MyoFb) and B domain containing Tn-C (B+ Tn-C). Furthermore, we aimed to evaluate the potential of the monoclonal antibody F8, specific to ED-A+ Fn and applicable for targeted imaging and drug delivery, to selectively accumulate in vessels exhibiting CAV.

Methods: A syngeneic immunocompetent rat heart transplantation model was used to induce chronic rejection with CAV and CIF. Allografts, recipient and control hearts were subjected to histological assessment of rejection grade, real-time PCR and to immunfluorescence labelling procedures including CD31, ASMA, CD45, ED-A+ Fn, and B+ Tn-C antibodies. Protein expression levels of ED-A+ Fn and ASMA were measured by quantitative confocal Laser Scanning Microscopy. For near infrared in vivo imaging, the F8 antibody was labelled with the dye DY-682. Results: Histological analysis revealed different grades of chronic rejection including relevant levels of CAV and CIF. By gene expression analysis, a remarkable up-regulation of the majority of ECM genes in association to chronic rejection could be detected. There was an extensive re-occurrence of ED-A+ Fn detectable with the F8 antibody, especially in CAV and CIF. The ED-A+ and ASMA protein deposition levels significantly increased with rising rejection grade. In CAV, there were extensive co-depositions of ED-A+ Fn, ASMA and B+ Tn-C. In vivo imaging studies revealed a relevant accumulation of the F8 antibody in cardiac allografts with a specific localization to areas of CAV and CIF. Conclusions: Chronic cardiac allograft rejection is associated with an extensive ECM remodelling. Interactions of VSMCs and MyoFb with ED-A+ Fn and B+ Tn-C might be functionally in the development of CAV and CIF. EDA+ Fn and ASMA might be usable to monitor chronic rejection. The human F8 antibody is usable to image CAV and CIF. Thus, our findings pave the way 1) to the immuno-PET imaging of the clinical condition also in patients and 2) to a potential application of the F8 antibody as a vehicle to selectively deliver bioactive payloads directly to the side of disease.

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Co-stimulatory signalling through lymphocyte CD40 limits adipose tissue inflammation and protects from de novo and pre-established metabolic disease in mice D. Wolf, F. Jehle, E. N. Bukosza, F. Willecke, P. Stachon, N. Varo, C. Bode, P. Libby, K. Peter, A. Zirlik Department of Cardiology and Angiology I, University Heart Center Freiburg Background: Inflammatory cell recruitment drives adipose tissue inflammation during the metabolic syndrome. Co-stimulatory cascades such as the CD40L-CD40 dyad enhance immune cell activation and inflammation during atherogenesis. Here, we tested the hypothesis that CD40 directly modulates diet-induced obesity (DIO) in vivo. Methods and results: To induce the metabolic syndrome, WT or CD40–/– mice consumed a high fat diet for 20 weeks (n≥15 per group). Surprisingly, CD40–/– mice exhibited an aggravated metabolic phenotype with increased weight gain and enhanced fat depositions in MRI. CD40 deficiency increased accumulation of inflammatory cells in adipose tissue. Accordingly, gene expression chip array analysis revealed up-regulation of multiple proinflammatory gene sets. Moreover, CD40-deficient mice developed aggravated systemic and peripheral insulin resistance as shown by insulin clamp analysis. This pro-inflammatory and worsened metabolic phenotype could be transplanted in WT mice by reconstitution with CD40-deficient bone marrow or bone marrow lacking CD40 expression on lymphocytes, indicating that CD40 on T- or B-cells accounts for its phenotype. In a third experimental approach, mice were fed a high fat diet (HFD) for 6 weeks and randomized to treatment with the activating CD40 antibody FGK45 (n=12 per group) or a control for 6 weeks. Activation of CD40 signalling with FGK45 abolished further weight gain during diet consumption, lowered glucose and improved insulin resistance, suggestive of Perfusion 02/2013

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an improved metabolic phenotype. Proinflammatory cell accumulation in adipose tissue was substantially reduced. Mechanistically, expression of the pro-inflammatory TH1-cytokine IFN-γ in T-helper cells decreased after CD40 activation. To further prove a clinical association, 183 patients with a high prevalence of the metabolic syndrome were screened for plasma levels of soluble CD40. Levels of were elevated in obese patients with a high BMI and high waist circumference, indicating clinical relevance of our findings. Conclusion: We present the surprising finding that CD40 deficiency aggravates adipose tissue inflammation while activation of CD40 signalling improves adipose tissue inflammation and its metabolic complications in pre-established disease in mice. Levels of soluble CD40 were associated with obesity in humans. Positive modulation of co-stimulatory pathways might therefore describe a novel therapeutic concept against cardio-metabolic disease.

Glucagon-like peptide-1 (GLP-1) and its split products GLP-1(9-36) and GLP(28-37) stabilize atherosclerotic lesions in ApoE–/– mice M. Burgmaier, A. Liberman, J. Möllmann, F. Kahles, S. Reith, C. Lebherz, N. Marx, M. Lehrke Department of Internal Medicine I, University Hospital Aachen Background: Glucagon-like peptide-1 (GLP-1) based therapies are new treatment options for patients with type 2 diabetes. Recent reports suggest vasoprotective actions of GLP-1. Similar beneficial effects might be reached by GLP-1(9-37) and the c-terminal GLP1 split product (28-37) although both peptides do not activate the GLP-1 receptor. We therefore investigated the actions of GLP-1(7-37), GLP-1(9-37) as well as GLP-1(28-37) on vascular lesion formation in a mouse model of atherosclerosis. Methods and results: GLP-1(7-37), GLP-1(9-37) and GLP-1(28-37) and

LacZ (control) were overexpressed for a period of 12 weeks in ApoE–/– mice on high-fat diet (n=10/group) using an adeno-associated viral vector system. Neither of the constructs changes overall lesion size. However, GLP-1(7-37), GLP-1(9-37) and GLP-1(28-37) significantly reduced plaque macrophage infiltration (GLP-1(7-37): 44.7 %, GLP1(9-37): 38.7 %, GLP-1(28-37): 41.2 % decrease, p<0.05) and plaque MMP-9 expression (GLP-1(7-37): 46.8 %, GLP-1(9-37): 50 , GLP-1(28-37): 39.8 % decrease, p<0.05) compared to LacZ in the aortic arch. Moreover, all GLP-1 constructs increased plaque collagen content (GLP-1(7-37): 136 %, GLP-1(9-37): 112 %, GLP-1(28-37): 78.8 % increase, p<0.05) and increased fibrous cap thickness (GLP-1(7-37): 187.8 %, GLP-1(9-37): 159.4 % GLP1(28-37): 110.4 % increase, p<0.05). These effects of GLP-1(7-37), GLP1(9-37) and GLP-1(28-37) on plaque macrophage infiltration, MMP-9 expression and plaque collagen content were confirmed in the aortic root. Conclusion: GLP-1(7-37), GLP-1(937) and GLP-1(28-37) reduce plaque inflammation and increase phenotypic characteristics of plaque stability in a murine model of atherosclerosis. Future studies are needed to determine whether these effects translate into improved plaque stability and less cardiovascular events in high-risk patients with type 2 diabetes.

Haematopoietic deficiency of the catalytic PI 3-kinase isoform PI3Kδ aggravates the development of atherosclerosis in LDLR–/– mice M. Zierden, C. Millarg, M. Vantler, C. Herbers, H. ten Freyhaus, S. Rosenkranz Clinic III for Internal Medicine, University Hospital Cologne, and Centre for Molecular Medicine Cologne (CMMC) Background: Atherosclerosis is a chronic inflammatory disease of arterial blood vessels underlying myocardial infarction and ischemic stroke. Athero© Verlag PERFUSION GmbH

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genesis is characterized by chronic infiltration of the arterial wall by macrophages, dendritic cells and T lymphocytes. Although different cell types of the innate and adaptive immune system play central pro-inflammatory roles, they exert regulatory functions in different stages of this complex disease as well. Leukocytes express the catalytic phosphoinositide 3-kinase isoform p110δ (PI3Kδ), a key enzyme involved in the regulation of immune responses. Therefore, PI3Kδ represents an interesting target for the modulation of atherogenesis. Methods and results: To investigate the role of PI3Kδ in leukocytes for the orchestration of atherogenesis, lethally irradiated LDLR–/– mice were either transplanted with bone marrow from PI3Kδ–/– or PI3Kδ+/+ mice. After 4 weeks of recovery, recipient mice were challenged for 6 weeks with atherogenic diet and successful reconstitution with donor bone marrow was verified by the representation of donor alleles in peripheral blood cells. PI3Kδ–/– recipient LDLR–/– mice displayed a profound reduction of peripheral B and T cells as well as strongly impaired CD4+ T-cell activation and largely reduced numbers of regulatory T cells in the spleen and paraaortic lymph nodes compared with PI3Kδ+/+ transplanted recipients. Surprisingly, the profound impairment of the immune system by PI3Kδ-deficiency caused a considerable exacerbation of atherosclerosis in LDLR–/– mice. Atherosclerotic lesion area/aortic root area in PI3Kδ–/– recipient LDLR–/– mice was significantly augmented compared with PI3Kδ+/+ transplanted LDLR–/– mice (0,35±0,05 vs. 0,27±0,05; p<0.05), as shown by staining of proximal aortic sections with Oil Red O. Furthermore, lesion area/total aortic area in PI3Kδ–/– recipients was also significantly higher than in PI3Kδ+/+ transplanted LDLR–/– mice (0,037±0,007 vs. 0,021±0,007; p<0.05), as confirmed by en face analysis of Sudan IV-stained whole aortas. Conclusion: In summary, we demonstrate that haematopoietic PI3Kδ plays Perfusion 02/2013

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a crucial role in regulating immune responses within the arterial wall by exerting protective functions during the development and progression of atherosclerosis. Current studies aim to dissect PI3Kδ-dependent mechanisms that modulate inflammatory processes in multiple stages of atherosclerotic lesion formation.

Macrophages as main source of glutathione peroxidase-1 in murine atherosclerotic lesions: implications for atherogenesis F. Cheng, M. Torzewski, A. Degreif, H. Rossmann, A. Canisius, K. J. Lackner Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University Mainz Background: Clinical and experimental evidence suggest a protective role for the antioxidant enzyme glutathione peroxidase-1 (GPx-1) in the atherogenic process. GPx-1 deficiency accelerates atherosclerosis and increases lesion cellularity in ApoE–/– mice. However, the distribution of GPx-1 within the atherosclerotic lesion as well as the mechanisms leading to increased macrophage numbers in lesions is still unknown. Accordingly, the aims of the present study were (1) to analyze which cells express GPx-1 within atherosclerotic lesions and (2) to determine whether a lack of GPx-1 affects foam cell formation and cellular proliferation. Methods and results: Both in situ-hybridization and immunohistochemistry of lesions of the aortic sinus of ApoE–/– mice after 12 weeks on a Western type diet (WTD) revealed that GPx-1 expression was confined to macrophages whereas smooth muscle cells (SMCs) showed no detectable expression. In isolated mouse peritoneal macrophages differentiated for 3 days with macrophage-colony-stimulating factor (MCSF), GPx-1 deficiency increased oxidized low density-lipoprotein (oxLDL) induced foam cell formation

both qualitatively (lipid staining with Oil-red O) and quantitatively (cholesterol/cholesteryl ester quantitation) and led to increased proliferative activity of peritoneal macrophages (BrdU based chemiluminescence assay). The MCSF- and oxLDL-induced proliferation of peritoneal macrophages from GPx-1–/–ApoE–/– mice was mediated by the p44/42 MAPK (extracellularsignal regulated kinase 1/2; ERK1/2) signalling pathway as demonstrated by ERK1/2 signalling pathways inhibitors, Western blots on cell lysates with primary antibodies against total and phosphorylated ERK1/2, MEK1/2 (mitogen-activated protein kinase 1/2), p90RSK (p90 ribosomal s6 kinase), p38 MAPK and SAPK/JNK (stress-activated protein kinase/c-Jun N-terminal kinase), and immunohistochemistry of mice atherosclerotic lesions with antibodies against phosphorylated ERK1/2, MEK1/2 and p90RSK. Conclusion: The present study demonstrates that GPx-1 deficiency has a significant impact on macrophage foam cell formation and proliferation via the p44/42 MAPK (ERK1/2) pathway encouraging further studies on new therapeutic strategies against atherosclerosis.

Effect of intermittent hypoxia (sleeping apnea) on skeletal muscle vascularisation in wildtype and inducible nitric oxide synthase knockout (iNOS–/–) mice L. Dill1, G. A. Bonaterra1, H. Then1, R. Schulz2, S. Kraut3, N. Weissmann3, R. Kinscherf1, W. Hildebrandt1 1 Department of Medical Cell Biology, Institute of Anatomy and Cell Biology, Philipps University Marburg 2 Department of Sleep Medicine, University Clinics of Giessen and Marburg 3 Excellence Cluster Cardio-Pulmonary System (ECCPS), Universities of Giessen and Marburg Lung Center (UGMLC) Introduction: The obstructive sleep apnea syndrome (OSAS) is indepen© Verlag PERFUSION GmbH

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dently associated with progression of arteriosclerosis, myocardial infarction, stroke or related death and prevalent in up to 10 % of male adults. OSAS imposes a repetitive hypoxia-reoxygenation stress during sleep which is held responsible for endothelial dysfunction, arterial hypertension and insulin resistance. The role of skeletal muscle vascularisation within such risk profile is unclear in view of paradox findings like impaired blood flow at increased angiogenesis. Methods: We therefore studied fiber type-specific capillarisation (computer-assisted morphometry of ATPase and lectin staining) as well as pro-inflammatory gene expression (RT-PCR and IHC) in gastrocnemius and soleus muscle of wildtype (WT) mice under normoxia (NOX, n=12) and in response to 6 weeks of chronic intermittent hypoxia (CIH, n=14) as a model of severe OSAS (8 h/d of switching pO2 between 6–7 % and 21 % every 60 s). In addition the role of inducible nitric oxide synthetase (iNOS) was evaluated by studying iNOS–/– under NOX (n=8) and after CIH (n=8). Results: CIH increased capillary density in both, the soleus and gastro cnemius muscle (from 4925±97 to 6263±177 and 1361±70 to 1593±71 capillaries/mm², respectively; p<0.05). However, a significant angiogenesis as reflected by increased capillary contacts was limited to soleus muscle (all fiber types: from 5.2±0.1 to 5.8± 0.1, i.e. 12 %, type I: 11 %, type IIa: 16 %, type IIx: 9 %) and well reflected by a 4-fold upregulation of vascular endothelial growth factor (VEGF) not seen in gastrocnemius muscle. As an indicator for nutritional capillarisation (e.g. relevant to insulin resistance) the fiber area to capillary contact ratio significantly decreased (improved) by 23 % exclusively in soleus muscle, which was also attributable to a significant decrease in diameter of all soleus fiber types (13 %) not observed in gastrocnemius muscle. There appeared to be a pattern of soleus-specific decrease in inflammatory markers (protein and Perfusion 02/2013

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RNA levels CD68 and COX2), while tumor necrosis factor alpha (TNF-α), interleukin (IL)-1β and IL-6 decreased in gastrocnemius muscle as well. In comparison to WT, iNOS–/– mice kept under NOX revealed a significantly increased angiogenesis in terms of capillary density (from 4925±97 to 6284±203 capillaries/mm², p<0.001) or contacts (from 5.2±0.1 to 6.0±0.1, i.e. 15 %, p<0.01) and of VEGF (4fold) in soleus muscle (at no significant changes in fiber diameter or nutritional capillarisation). Strikingly, when exposed to CIH, iNOS–/– showed no (further) increase in angiogenesis and in contrast to WT revealed pro- rather than anti-inflammatory gene expression (CD68, COX2). Conclusions: This study demonstrates that angiogenetic and fiber responses to CIH are clearly differential between “red” and “white” muscle types. However, in either muscle they are unlikely to be key players in OSAS-related risks like insulin resistance or endothelial activation. iNOS deficiency in NOX appears to partly mimic CIH responses in WT mice, however upon CIH it attenuates angiogenesis and may enhance muscular inflammation.

II. Poster The microRNA-494 is downregulated during vascularproliferative diseases and inhibits proliferation of vascular smooth muscle cells A. Koch, K. Donde, W. Bielenberg, K. Knöpp, R. Teske, J. Dutzmann, J.-M. Daniel, J. Bauersachs, D. Sedding Department of Cardiology and Angiology, Section Molecular Cardiology, University of Giessen Background: Proliferation of vascular smooth muscle cells (VSMC) caused by stimulation of cytokines and growth factors plays a crucial role in the development of vascular proliferative diseases such as atherosclerosis and

in-stent-restenosis after angioplasty. MicroRNAs (miR) are small noncoding RNAs that inhibit gene expression in a posttranscriptional manner and possibly contribute to the differential gene regulation that triggers vascular remodelling processes. Methods and results: Neointimal formation was induced by a wire-mediated injury of the femoral artery in C57BL/6 mice. Microarray analysis of the developing neointimal lesion showed a strong reduction of miR-494 (0.411±0.04) at 7 days after injury as compared to uninjured controls, which could be confirmed by qPCR. In order to investigate the expression levels of miRs in vascular cells, human coronary artery smooth muscle cells (SMC), human coronary artery endothelial cells and human monocytes were analyzed via microarray analysis. Interestingly, miR-494 was found to be predominantly expressed in SMC, which could be confirmed by qPCR. The regulation of miR-494 expression was further analyzed after stimulation of SMC with 10 % FCS. Following this mitogenic stimulation, mir-494 expression dropped robustly and significantly in a time-dependent manner at 6, 9, and 24 hours. To investigate the functional impact of miR-494 on SMC proliferation, miR-494 was overexpressed using miR-494-mimics (20 µM). Overexpression of miR-494 significantly reduced the FCS-induced proliferation of SMC as assessed by BrdU-incorporation and total cell counts. In silico analyses of potential target genes for miR-494 identified PLK1 and KIT, both important molecules for cell cycle regulation, as potential targets of miR-494. Indeed, PLK1 and KIT were found down-regulated on the mRNA and protein level after transfection of SMC with miR-494 mimics and both mulecules could be identified as direct targets using luciferase reporter assays. Conclusion: Taken together, our results show that mir-494 is strongly down-regulated in proliferating SMC in vitro as well as during neointimal lesion formation in vivo. Moreover, the © Verlag PERFUSION GmbH

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anti-proliferative effect of miR-494-reconstitution reveals a crucial functional role of miR-494 in the mitogenic response of SMC. Thus, miR-494 might represent a novel and promising SMCspecific target for future therapeutic strategies in the treatment of vascular proliferative diseases.

Interruption of classic CD40L-CD40 signalling but not of the novel CD40L-Mac-1 interaction limits arterial neointima formation in mice S. Tiwari, F. Willecke, B. Rupprecht, D. Wolf, N. Hoppe, B. Dufner, P. Stachon, I. Hilgendorf, K. Peter, P. Libby, C. Bode, A. Zirlik Department of Cardiology and Angiology I, University Heart Center Freiburg Background: The co-stimulatory immune molecule CD40L figures prominently in a variety of inflammatory conditions including arterial disease. Recently, we made the surprising finding that CD40L mediates atherogenesis independently of its classic receptor CD40 via a novel interaction with the leukocyte integrin Mac-1. In the light of these data we hypothesized that selective blockade of the CD40L-Mac-1 interaction using our self-designed small peptide inhibitor cM7 – proven to be effective in limiting murine atherosclerosis – may also retard restenosis as assessed by neointima formation in mice. Methods and results: We induced neointima formation in C57/BL6 mice by ligation of the left carotid artery, an established model of restenosis. Mice were then randomized to daily intraperitoneal injections of either cM7, a small peptide selectively inhibiting the CD40L-Mac-1 interaction, scM7, a scrambled control peptide or saline for 28 days. Interestingly, cM7-treated mice developed neointima of similar size compared with mice receiving the control peptide or saline as assessed by computer-assisted analysis of histological cross sections. These data demonstrate that the CD40L-Mac-1 interaction is not required for the dePerfusion 02/2013

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velopment of restenosis. In contrast, CD40-deficient mice subjected to carotid ligation in parallel, developed significantly reduced neointimal lesions compared with respective wild-type controls (2872 ± 843 µm² vs. 35469 ±11870 µm²), highlighting the importance of CD40 signalling in restenosis. Conclusion: Unlike in the setting of atherosclerosis, CD40L mediates neointima formation via its classic receptor CD40 rather than via its recently described novel interaction with Mac1. Therefore, selective targeting of CD40L-Mac-1 binding does not appear to be a favourable strategy to fight restenosis.

Vascular endothelial growth factor protects the vascular endothelium from apoptosis by inhibiting proapoptotic endonucleases L. Mey, Z. Kharip, K. Nemeth, A. Hildenberg, M. Heidt, N. Al-Fakhri Institute of Laboratory Medicine, Philipps University Marburg Background: Vascular endothelial growth factor (VEGF) is the most potent anti-apoptotic effector for endothelial cells (EC). Apoptosis is executed by endonucleases like caspaseactivated deoxyribonuclease (CAD), but the influence of VEGF on CAD and inhibitor of caspase-activated deoxyribonuclease (ICAD) has not been investigated previously. Therefore, the effects of VEGF on CAD and ICAD were investigated in EC, an organ culture model and human arteriosclerosis. Methods: EC (HUVEC, EC-lines) were incubated with VEGF-A (165) 100 pg/ml to 1 µg/ml for 24 hours to 6 days in the presence or absence of ICAD-siRNA 10 nM. Apoptosis was induced by cRGDfV 5 µg/ml and measured by annexin-V flow cytometry, caspase-3 and endonuclease activity. ICAD was analyzed by Western blot and real-time PCR. VEGF receptors VEGFR-1, -2 and neuropilin-1 were investigated by immunofluorescence

microscopy and incubation with specific inhibitors. Human arteriosclerotic versus normal arteries and a vascular organ culture model were analyzed by immunohistochemistry for expression of ICAD, CAD, VEGF and VEGFreceptors. Results: Incubation of EC with VEGF reduced the sensitivity to apoptosis and increased ICAD expression leading to reduced CAD activity. The VEGF effect was demonstrated to be ICAD specific by mRNA-knockdown experiments. VEGF signalling involved VEGFR-2 and neuropilin-1. The relevance of in-vitro results was demonstrated in an organ culture model and in human arteriosclerosis. Conclusions: VEGF exerts part of its anti-apoptotic effect by regulation of the endonuclease inhibitor ICAD. VEGF influences endothelial survival by interfering with the terminal stage of apoptosis execution through the inhibition of endonuclease activity. This offers a new potent target for the modulation of VEGF-driven vascular processes such as arteriosclerosis.

Concerted telemetric, invasive, and cell culture approaches for integrative investigations of myocardial function in mice B. Ndongson Dongmo, R. Heller, R. Wetzker, R. Bauer Institute of Molecular Cell Biology and Center for Sepsis Control and Care (CSCC), University Hospital Jena Background: The investigation of complex mechanisms leading to heart failure and myocardial depression requires investigations on systemic, organ and cellular levels. The current study introduces our approaches to study the different levels and their application to investigate the role of the signal protein phosphoinositide 3-kinase gamma (PI3Kγ) in septic cardiomyopathy. Methods and results: To investigate myocardial function on a systemic © Verlag PERFUSION GmbH

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level, telemetric assessment of heart rate variability (HRV) as an established measure of the dynamics of sympathetic-vagal balance was performed. For that purpose mice were implanted with telemetry probes under general anesthesia and sterile conditions for continuous ECG measurement. Analyses were started 6 days after surgery and continued for up to 7 days. Myocardial and hemodynamic functions on an organ level were evaluated by pressurevolume conductance measurements. To this end, mice were tracheotomized under inhalation anesthesia, ventilated and instrumented with a left ventricular catheter. Then, cardiac output and contractility indices were calculated and corrected according to in vitro and in vivo volume calibrations, respectively. In order to study cardiomyocytes on a cellular level and to obtain information about molecular mechanisms and signalling pathways, culture of adult mouse cardiomyocytes was established. Cells were prepared from the excised heart, which was perfused via a cannula fixed in the ascendant aorta above the coronary vessel branching. After rinsing with cold saline, the heart was transferred into a temperature-controlled, flow-optimized perfusion system. Cardiac myocytes were gently isolated by collagenase, enriched by gentle centri fugation, plated after calcium reintroduction and cultured for 1–3 days. To investigate the pathogenesis of cardiomyopathy under sepsis-like conditions, a systemic inflammatory response syndrome (SIRS) was induced by injection of 10 µg/g body weight lipopolysaccharide (LPS). Telemetric assessment of sympathetic-vagal balance by heart rate variability (HRV) showed an early increase of sympathetic tone in PI3Kγ–/– mice. Pressure-volume conductance measurements revealed a significant contractility depression in wild type mice after 3 and 24 hours treatment with LPS. In contrast, in mice lacking the enzyme PI3Kγ (PI3Kγ–/–) a significant hypercontractility after 3 hours and a decreased contractility after 24 hours was observed. Mice exPerfusion 02/2013

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pressing a kinase-dead PI3Kγ mutant (PI3Kγ KD) showed a wild-type behaviour suggesting that not the active kinase but the expression of the PI3Kγ protein and thus a scaffold function is involved in the regulation of cardiac contractility. Studies in cultured cardio myocytes revealed the importance of PI3Kγ-mediated regulation of cAMP-signalling processes in mediating these effects, which is now investigated in more detail. Conclusion: Together our data confirm that disclosure of pathogenetic mechanisms requires the usage of molecular organ physiological and systemic methods. Applying these methods we show for the first time a pivotal role of PI3Kγ in SIRS-induced cardiac dysfunction, which warrants further investigation.

Lipid metabolism after a fatty meal at rest and during exercise in marathon runners and not endurance-trained men D. N. Hessling, B. Feldhaus, A. Nieß, H.-C. Heitkamp Department of Sports Medicine, Medical Clinic, University of Tübingen Purpose and methods: The study investigated the difference in the lipid metabolism of marathon runners (MR) and not specifically endurance-trained allround athletes (AA) after endurance stress. Each group consisted of 15 participants and the subjects were aged between 20 and 34. The examinations were conducted in two appointments. At the first appointment, the physical capacity of the participants was assessed by means of spiroergometry and lactate performance diagnostic. The second appointment took place after overnight fasting. A blood sample was taken followed by a running unit of 30 minutes. Subsequently, a second blood sample was taken and the subject was asked to drink 250 ml cream. After a break of one hour, blood was taken again followed by two consecutive running units which were only intermitted by taking of another blood

sample. Additionally, blood was taken 15 minutes after the last running unit. Based on the blood samples the alterations in total cholesterol, lipoproteins (LDL and HDL), apolipoproteins (Apo A-I und Apo B) and triglycerides were investigated. Results: Although the concentrations of total cholesterol, LDL, triglycerides and ApoB were in the MR group lower at all times of measurement, no significant differences were found between the two groups. However, a significant to highly significant development could be observed in the process of the experiment. HDL and ApoA1 showed a significant group difference. In profile, the MR had higher HDL and ApoA1 values compared to the AA. For both measured values a significant development was seen in the process of the experiment. In both groups and for all parameters, the development of the concentrations during the process of the experiment took place characteristically but on different base levels. Thus, during the first running unit an increase in concentration occurred, followed by a decrease during the onehour break, a further increase during the following two running units and a notable decrease of concentrations during the 15-minute period of rest. Conclusion: In summary, it follows that the metabolism of lipids after a fatty meal may not be influenced by endurance sports. The known positive influence on basal lipid parameters is reflected also in the present study.

Effects of methionine-enriched diet on histopathological changes and acetylcholinesterase activity in the rat heart D. Hrnčić, N. Puškaš, A. Rašić-Marković, M. Čolović, D. Krstić, V. Šušić, D. Djuric, O. Stanojlović Institute of Medical Physiology “Richard Burian”, Faculty of Medicine, University of Belgrade, Serbia Background: Methionine is a sulfurcontaining essential amino acid. Its metabolism is closely related to those © Verlag PERFUSION GmbH

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of homocysteine, well-known risk factor. The aim of the current study was to determine the effects of chronic methionine nutritional overload on the rat heart. Methods: Male Wistar albino rats were randomly divided into control and experimental group and have been fed either with standard laboratory chow or methionine-enriched diet (double content of L-methionine) for 30 consecutive days. At the end of this period, the hearts were removed from rats. Sections 5 µm thick were stained with haematoxylin and eosin (H&E) or Masson’s trichrome and observed under light microscopy. Acetylcholinesterase activity was determined in heart tissue by Ellman’s method. Results: None histopathological changes were observed in the hearts of rats on standard diet. One month of methionine-enriched diet in experimental group caused changes mostly in subendocardial region of the heart wall. There are diffusely distributed cardiomyocytes with condensed homogenous cytoplasm and increased acidofila what can be seen on slices stained with H&E or Masson’s trichrome. In some of these cells nuclear pyknosis can be seen. In surrounding cardiomyocytes vacuolisation of cytoplasm can be noticed. The acetylcholinesterase was not impaired significantly by the applied treatment. Conclusion: It could be concluded that incipient changes caused by methionine nutritional overload used in this study in rats predominantly affected cardiomyocytes and did not change the acetylcholinesterase activity.

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The role of carbon monoxide in DL-homocysteine-thiolactoneinduced effects on cardiodynamic variables and oxidative stress in isolated rat heart V. Zivkovic, V. L. Jakovljevic, M. Vuletic, N. Barudzic, D. Djordjevic, D. M. Djuric Institute of Medical Physiology “Richard Burian”, Faculty of Medicine, University of Belgrade, Serbia Background: Recent investigations noted carbon monoxide (CO) as novel gasotransmitter in the control of the vascular tone. Several theories regarding the toxicity of homocysteine have been elaborated, but none does completely explain the toxicity (and especially cardiotoxicity) of this compound. The aim of this study was to estimate the inﬂuence of CO synthesis inhibitor (zinc protoporphyrin IX, PPR IX) on DL-homocysteine-thiolactone hydrochloride (DL-hcy-TLHC)-induced effects on cardiodynamic parameters, coronary flow and oxidative stress in isolated rat heart. Methods: Hearts (total number n=24, 12 for each experimental group) excised from male Wistar albino rats (age 8 weeks, BM=180–200 g) were retrogradely perfused according to the Langendorff technique at constant perfusion pressure (70 cmH2O) and administered with 10 μM DL-Hcy TLHC, or 10 μM DL-Hcy TLHC + 10 μM PPR IX. After the insertion of sensor in the left ventricle, the cardiodynamic variables – maximum rate of left ventricular pressure development (dp/dt max), minimum rate of left ventricular pressure development (dp/dt min), systolic left ventricular pressure (SLVP), diastolic left ventricular pressure (DLVP), mean blood pressure (MBP), heart rate (HR) and coronary flow (CF) – were continuously registered. In collected samples of coronary venous effluent, oxidative stress markers – index of lipid peroxidation measured as TBARS, nitric oxide measured through nitrites (NO2–), superoxide anion radical (O2–) and hydrogen peroxide (H2O2) – were determined spectrophotometrically.

Results: Our recently published results clearly demonstrated that in isolated rat heart administration of DL-homocysteine, DL-homocysteine thiolactone and L-homocysteine thiolactone significantly decreased contractility (dp/dt max, up to 30 %), decreased coronary flow (range 17–30 %) and induced oxidative stress. Administered alone, PPR IX decreased all tested cardiodynamic variables except of HR. DL-Hcy TLHC alone significantly decreased dp/dt max and SLVP, while the combination of DL-Hcy TLHC + PPR IX induced further depression of cardiac function. Comparing with control, in both experimental groups CF was significantly decreased. Both applied drugs did not promote oxidative stress (DL-Hcy TLHC + PPR IX even decrease the level of H2O2). Conclusion: Our results indicate that DL-Hcy TLHC-induced effects in isolated rat heart are not mediated by CO.

Decreased atherosclerosis progression in growth differentiation factor-15 (GDF-15) deficient mice coincides with an altered amount of T-lymphocyte subpopulations in the spleen H. Kubo, G. A. Bonaterra, S. Zügel, J. Strelau, R. Kinscherf Institute of Anatomy and Cell Biology, Medical Faculty of the Philipps University Marburg Background: The increase of plasma lipids and the incidence of ischemic coronary diseases in patients who underwent splenectomy led to the hypothesis that the spleen participates in lipid metabolism and atherosclerosis. We and others have recently shown that GDF-15 a distant member of the TGF-β superfamily is highly expressed in the atherosclerotic vessel wall and GDF-15 deficiency attenuates atherosclerosis progression. Thus, the aim of this work was to investigate putative GDF-15 dependent morphological changes in the spleen correlating with © Verlag PERFUSION GmbH

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the anti-atherogenic effect of GDF-15 loss. Methods: Using hypercholesterolemic (GDF-15+/+/ApoE+/+, GDF-15–/–/ApoE+/+, GDF-15+/+/ApoE–/– and GDF-15–/–/ ApoE–/–) mice that had been fed with a cholesterol-enriched diet (CED) the central arteries were analyzed (by hematoxylin-eosin staining) for possible pathological alterations. Furthermore, lymphocyte-subpopulations and the area density of mast cells of the spleen were examined immunohistochemically or by toluidine blue staining. Results: We have recently shown that GDF-15 deficiency resulted in an increase in body weight and that GDF15–/–/ApoE–/– animals have significantly higher blood lipid levels compared to GDF-15+/+/ApoE–/– animals. Additionally, we found that after application of a CED for 20 weeks, GDF-15–/–/ ApoE–/– mice revealed a significant inhibition of plaque progression in the aortic arch and innominate artery. However, a difference of the ratio of lumen surface area to vessel surface area in the central arteries was not observed among the groups. The spleen of GDF-15–/–/ApoE–/–mice revealed a significant decrease of the mast cell area density in comparison with GDF-15+/+/ ApoE+/+-mice. Moreover, a significant increase of CD4+ areas in the spleen of GDF-15–/–/ApoE+/+animals compared to GDF-15+/+/ApoE+/+ mice was found. Additionally, GDF15 deficiency resulted in a significant reduction in the amount of cytotoxic T-lymphocytes (CD8+) in the spleen of ApoE–/– mice. However, GDF-15 has no effect on germinal centers. Conclusion: We conclude that GDF15 dependent atherosclerotic lesion progression is accompanied by altered amounts of T-cell subpopulations in the spleen. To address the question, whether the observed effect has direct impact on atherogenesis, we suggest further examinations of arteriosclerotic plaques – in relation to the spleen – with special respect to density of mast cells and T-lymphocyte subsets (CD4+, CD8+). Perfusion 02/2013

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Renal morphologic changes induced by GDF-15 in an experimental atherosclerosis mouse model J. Bochem, H. Kubo, G. A. Bonaterra, S. Zügel, J. Strelau, R. Kinscherf Institute of Anatomy and Cell Biology, Medical Faculty of the Philipps University Marburg Introduction: Growth-differentiation factor-15 (GDF-15) is a distant member of the Transforming-Growth-Factorbeta (TGF-β) superfamily. Expression of GDF-15 is induced under conditions of inflammation and increased GDF15 serum levels are suggested as a risk factor for cardiovascular diseases. Furthermore, atherosclerosis is considered as the major cause for cardiovascular mortality among patients suffering from chronic kidney disease. Thus, the close link between kidney dysfunction and atherosclerosis is evident, however factors which enhance kidney disease and mediate plaque formation are still not identified. In this context, only very little knowledge exists about the impact of GDF-15 during the development of kidney pathologies leading to atherosclerotic lesions. Hence the aim of our present study was to investigate the possible role of GDF-15 on the progression of renal dysfunctions and subsequent atherosclerosis using GDF-15 deficient (GDF-15–/–) mice in a mouse model for experimental atherosclerosis (ApoE–/–). Methods: 10 weeks old GDF-15+/+/ ApoE+/+ (WT), GDF-15–/–/ApoE+/+, GDF-15+/+/ApoE–/– and GDF-15–/–/ ApoE–/– mice received a cholesterol-enriched diet (CED) for 12 or 20 weeks. The animals were sacrificed and the kidneys were excised. Computer-assisted, histomorphometrical investigations were performed to measure the number, area and cross-section dimension of renal corpuscles (RC). Additionally, apoptosis (TUNEL), proliferation (Ki67) and autophagy (ATG5L-ATG5) were immunohistomorphometrically determined. Results: In GDF-15–/–/ApoE–/– after 20 weeks CED and in GDF-15–/–/ApoE+/+

after 12 weeks CED, we found a significant (p<0.05) increase of the number of RC compared to wildtype (GDF15+/+/ApoE+/+). Furthermore, after 20 weeks of CED GDF-15–/–/ApoE–/– mice showed a significant increase in the area of RC by 5780 µm2 compared with GDF-15–/–/ApoE+/+ (4560 µm2) or GDF-15+/+/ApoE–/– (4730 µm2). Moreover, after 20 weeks of CED, GDF-15–/–/ApoE–/– mice revealed a significant increase in diameter of crosssectioned RC (89.1 µm) compared with WT (76.4 µm), GDF-15–/–/ApoE+/+ (80.6 µm) and GDF-15+/+/ApoE–/– (82.6 µm). Regarding apoptosis a significant increase (p<0.03) of the percentage of apoptotic glomerular cells was detected in GDF-15–/–/ApoE+/+ and GDF-15–/–/ApoE–/– compared to WT. No significant differences were found among the groups under test concerning proliferation and autophagy. Conclusion: GDF-15 loss leads to morphologic alterations (number, area, diameter of RC and glomerular apo ptosis) in the kidney of hypercholesterolemic ApoE–/– mice, which may have an impact on the development of cardiovascular diseases. To address this issue we suggest further investigations of kidney supplying blood vessels in terms of the development of arteriosclerotic plaques.

GDF-15-dependent changes in liver in an experimental atherosclerosis mouse model. W. Rempel, J. Bochem, G. A. Bonaterra, S. Zügel, J. Strelau, R. Kinscherf Institute of Anatomy and Cell Biology, Medical Faculty of the Philipps University Marburg Introduction: ApoE deficient (ApoE–/–) mice reveal increased serum cholesterol levels and atherosclerotic lesions. Recent data suggest that the liver plays a key role in the inflammatory response evoked by dietary constituents. Furthermore, the expression of GDF-15 (growth differentiation factor-15) is induced under inflammatory conditions © Verlag PERFUSION GmbH

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and increased GDF-15 serum levels are suggested as a risk factor for cardiovascular diseases. Bonaterra et al. have recently shown that GDF-15 deficiency inhibits atherosclerosis progression in hypercholesterolemic ApoE–/– mice. Hence the aim of the present study was to investigate the possible role of GDF15 on the progression of liver dysfunctions and subsequent atherosclerosis using GDF-15 deficient (GDF-15–/–) mice in a mouse model for experimental atherosclerosis (ApoE–/–). Methods: 10 weeks old GDF-15+/+/ ApoE+/+ (WT), GDF-15–/–/ApoE+/+, GDF-15+/+/ApoE–/– and GDF-15–/–/ ApoE–/– mice received a cholesterol-enriched diet (CED) for 12 or 20 weeks. The animals were sacrificed and the liver was removed and shockfrozen. Immunohistochemical examination of CD68 (macrophage marker) was performed. RNA was isolated and the mRNA expression relevant genes for apoptosis (Casp-3, BAX, BCL-2), inflammation (MIF, TNF-α, COX-2) proliferation (PCNA) were analysed by real-time RT-PCR. Results: After 20 weeks CED computer-assisted, histomorphometrical quantification of CD68+ cells around the central vein in liver of GDF-15–/–/ ApoE–/– revealed a significant 20 % increase compared with GDF-15+/+/ ApoE–/– mice. Furthermore, after 20 weeks of CED, we found in the livers of GDF-15–/–/ApoE–/– mice increases in the expressions of caspase-3 (6fold; 6x), BCL-2 (2.9x), BAX (2x), MIF (4.7x), TNF-α (2x) and PCNA (7x) compared with GDF-15+/+/ApoE–/– mice. Conclusion: GDF-15 deficiency inhibits atherosclerosis progression in the arterial wall and induces a local increase of CD68+ macrophages in the liver, in parallel with an increased expression of pro-inflammatory, pro-apoptotic and proliferation markers. GDF-15 deficiency seems to induce an alteration of the steady state of the cellular components in the liver, which may have an impact on development and progression of systemic atherogenesis. Perfusion 02/2013

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Regulation of adipophilin by long-chain metabolites of α-tocopherol in macrophages is mediated via MAPK pathways M. Wallert, L. Schmölz, S. Becher, M. Birringer, S. Lorkowski Institute of Nutrition, Friedrich Schiller University Jena Vitamin E exhibits anti-atherogenic properties such as decreasing lipid accumulation and inflammatory response in macrophages. Our vitamin E isomer of interest is α-tocopherol (α-TOH) and its physiological long-chain metabolites (LCMs), α-13’-OH and α-13’-COOH, in particular. The physiological function of these LCMs which are formed via oxidative modification of the α-TOH side-chain in the liver is not known. Foam cell formation of macrophages is a hallmark of atherosclerosis and therefore we wondered whether the LCMs affect macrophage foam cell formation. Adipophilin (adipose differentiation-related protein, PLIN2) is an important mediator of lipid accumulation in macrophages and we hypothesized that LCMs may affect its expression. Using quantitative real-time RT-qPCR analyses, Western blotting and enzymatic assays we indeed found that α-13’-OH and α-13’-COOH significantly increase PLIN2 mRNA and protein next to triglyceride accumulation in macrophages. We hypothesized that the increase of PLIN2 on protein level is mediated via mitogen-activated protein kinases (MAPK) pathways which are involved in lipid accumulation. To confirm this we used ERK, JNK and p38 inhibitors in combination with α-TOH and its LCMs to investigate the contribution of MAPK signalling to LCM-mediated regulation of PLIN2 expression and lipid accumulation in macrophages. First results provide evidence that the regulation of PLIN2 via LCMs is mediated by MAPK signalling. Hence it is reasonable to investigate physiological metabolites of vitamin E for better

understanding which molecular properties of the compounds are essentially required for their biological function and to fully understand the assumed anti-atherogenic properties of vitamin E. Additionally our findings let us raise the presumption that the actual active compound is not only vitamin E itself but also its physiological metabolites.

Investigations on the relationship of structure to effectiveness of tocopherols and their long-chain metabolites L. Schmölz, M. Wallert, M. Birringer, S. Lorkowski Institute of Nutrition, Friedrich Schiller University Jena Vitamin E is a generic term describing at least eight natural compounds, namely α-, β-, γ-, δ-tocopherol (TOH) and tocotrienol. For several years vitamin E, mostly in form of α TOH, has been widely used as an antioxidant and protective agent to prevent cardiovascular disease. Most studies on tocophe rol focused on α TOH because it is biologically the most active vitamin E isomer. Tocopherols are metabolized via oxidative modification of the sidechain to 13’-hydroxychromanols and 13’ carboxychromanols whose functions remain unclear because these metabolites have not been available as pure compounds. Recent studies suggest that α-TOH may modulate signal transduction and expression of genes involved in inflammation, proliferation and lipid metabolism. We therefore investigated the effects of α- and δ-TOH and their respective LCMs, α- and δ-13’-OH as well as α-and δ 13’ COOH, on macrophage proteins related to atherogenesis, such as ADRP and CD36. Using RT-qPCR, Western blotting and enzymatic assays we found that δ-13’OH and δ-13’-COOH act in similar fashion on ADRP, CD36 and triglyceride synthesis in macrophages compared to the corresponding LCMs of α-TOH. This lead to the hypothesis © Verlag PERFUSION GmbH

abstracts

that the chemical structure of the sidechain is important in this respect. Pristanic acid is a branched-chain fatty acid and has high structural similarity to the side-chain of α- and δ 13’ COOH. Hence pristanic acid is used to characterize the contribution of the LCMs’ side-chain. The effect of the chromanol ring system of TOHs is investigated via the short-chain TOH metabolites αand δ-CEHC. Based on our findings we propose that the side-chain is important for the regulatory effects of the different LCMs on ADRP and CD36. Our investigations show that it is reasonable to investigate the remaining vitamin E isomers such as δ TOH and their putative metabolites for better understanding the molecular properties of the compounds that are essentially required for their biological function. This knowledge may be used to reveal lead structures for new anti-atherogenic drugs.

Transcriptional regulation of adipose tiglyceride lipase (ATGL) expression by estrogen receptors alpha and beta A. Schwanstecher, V. Benz, S. Kirsch, U. Kintscher, A. Foryst-Ludwig CCR, Institute of Pharmacology, Charité Berlin Aims: Estrogen receptors (ERs) are known to play an important role in the metabolic functions of adipose tissue (AT). Gender specific differences concerning lipolysis have been reported. For instance, female mice are known to mobilize energy from fat more efficiently than male littermates under exercise conditions. Also, changes in fat distribution and metabolic activity of adipose tissue during menopause are associated with an increasing risk for metabolic and cardiovascular complications in humans. The characterization of molecular mechanisms of estrogen-action in AT might help understand and treat metabolic disorders associated with adiposity, as T2D and others, in the future. This study investigates the impact of the nuclear ERs Perfusion 02/2013

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(alpha and beta) on the expression of the adipose triglyceride lipase (ATGL), the rate-limiting lipolytic enzyme catalyzing the first step in the process of triglyceride-degradation. Methods and results: The regulatory impact of ERα and ERβ on the expression of ATGL was investigated in 3T3L1-preadipocytes on promoter-, and mRNA level. Cells were trans iently transfected with ERα/ERβ or PSG5 and stimulated with vehicle vs. selective ERα/ERβ agonists PPT/DPN (c=100 nM) for 24 hours. Promoter-activity of the sequence 3000 bp upstream of the first exon of the ATGL-gene was assessed by performing luciferase assay. Transcription increased both ligand-independently under the overexpression of ERα/ERβ (1.6-/2.5-fold, p<0.05 vs. PSG5-control), as well as under receptor-overexpression and stimulation with the respective ER-agonist (2.7-/3.3-fold, p<0.05 vs. vehicle). In accordance, bioinformatical promoter analysis performed on the murine sequence revealed 7 putative ERβ- and only 1 putative ERαbinding site. qRT-PCR-analysis demonstrated a significant increase in the amount of ATGL-mRNA by factor 1.3 under vehicle- and factor 1.5 under PPT-stimulation for cells overexpressing ERα vs. PSG5-control (both p<0.05). Similar experiments for the overexpression of ERβ showed a significant increase in ATGL-mRNA-amount by factor 3.5 in DPNstimulated cells vs. PSG5-control (p<0.05). Additionally, in cells overexpressing ERβ a significant increase by factor 2.3 could be observed between vehicle- and DPN-stimulation (p<0.05). Most likely attributable to endogenous ERβ a significant 2-fold increase of ATGL-mRNA could be observed under DPN-stimulation in PSG5-control-cells (p<0.05). Conclusions: The present study demonstrates that both ERs exert positive regulatory actions on the expression of ATGL. The impact of ERβ on ATGL promoter-activity and mRNA-expres-

sion appears to be stronger when compared to ERα. Further experiments will be required to determine the importance of these finding for an ER isoform-specific regulation of lipolysis.

ATGL-mediated lipolysis – a major determinant of non-adipose tissue physiology under conditions of high-energy demand J. Salatzki, V. Benz, M. Kreissl, A. Schirbel, E. Kershaw, U. Kintscher, A. Foryst-Ludwig Department of Translational Pharmacology, Charité Berlin, Department of Nuclear Medicine, University Hospital Würzburg, Division of Endocrinology, University of Pittsburgh, USA Background: In situations of high energy demand, processes of energy substrate mobilization and utilization are crucial modifiers of physiological responses. During exercise (E), the mobilization of fatty acids (FA) from adipose tissue (AT) through lipolysis determines circulating FA-availability, an important energy source for nonadipose organs such as the heart. Purpose: The aim of the present study was to assess if AT-lipolysis can determine the physiological response of a non-adipose organ in situations of high energy demand. For this, we investigated the cardiac response to E in mice incompetent for regular AT-lipolysis. Methods and results: Female ATspecific ATGL-deficient (KO) and wt littermate mice were challenged with treadmill running for 1.5 h/d (0.25 m/s) over 4 weeks. Metabolic analysis of the mice indicated that E-induced lipo lytic activity, measured in AT, was significantly reduced in KO mice, when compared to wt. In addition, whereas FFA plasma levels measured in wt mice upon training were significantly elevated, plasma FFA levels in KO mice remained unchanged. Accordingly, the RQ measured during E was significantly higher in KO mice, which is indicative of attenuated utilization of FFA by KO mice. In consonance with these findings, we detected a signifi© Verlag PERFUSION GmbH

abstracts

cantly lower myocardial FFA-uptake of trained KO mice when compared to wt, analyzed by using small-animal PET (injected dose/left ventricular mass LVM [%ID/g], KO 6.9±0.7, wt 23.1±4.3; p<0.05). Diminished cardiac FFA uptake was associated with a reduced physiological cardiac hypertrophic response to E, measured by echocardiography (% increase in LVM: KO 14.1%±0.3, wt 27.7%±1.1; p<0.05). Conclusion: Collectively, our data provide first evidence that ATGL-mediated AT-lipolysis is a key determinant of non-AT physiology (e.g. cardiac physiology) under conditions of high energy demand.

Extracellular ATP contributes to atherogenesis via purinergic receptors by inducing leukocyte recruitment in mice P. Stachon, B. Dufner, S. Hergeth, N. A. Michel, L. Nieto, L. Schulte, D. Wolf, C. Bode, M. Idzko, A. Zirlik Department of Cardiology and Angiology I, University Heart Center Freiburg

MITTEILUNGEN Neues Zertifikat „Klinik für Diabetespatienten geeignet (DDG)“ Die Diagnose Diabetes wird bei 6 Millionen Menschen in Deutschland zur „Nebendiagnose“, wenn sie wegen einer anderen Erkrankung ins Krankenhaus kommen. Das sind 20–30 % aller stationären Fälle, also etwa 2,1 Millionen Patienten pro Jahr, die sich in einer Klinik behandeln lassen müssen. Häufig kommt es gerade bei ihnen zu Komplikationen oder verlängerten Krankenhausaufenthalten wegen einer ungenügenden BlutzuckerstoffwechPerfusion 02/2013

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Introduction: Adenosine triphosphate (ATP) is an essential molecule for cell metabolism. But several pathologic conditions like cell death, inflammation, or thrombocyte activation lead to release of ATP to the extracellular space, where it binds to purinergic receptors and activates inflammation. It could be shown that this pathway is involved in chronic inflammatory diseases like COPD, rheumatoid arthritis, and graft-versus-host disease. Hypothesis: ATP acts via puringeric receptors as a danger signal in vascular inflammation and atherosclerosis. Methods: The expression of purinergic receptors was determined with qPCR and histologically in murine atherosclerotic and non-atherosclerotic arteries. LDLR-deficient mice were fed a high cholesterol diet for 16 weeks and injected with ATP, the purinergic receptor blocker PPADS, or PBS three times per week. Atherosclerotic lesions were assessed histologically in aortic root, arche, and abdominal aorta. Leukocyte or monocyte recruitment was investigated by intravital microscopy after injection of ATP or ATP and PPADS.

Results: The purinergic receptors P2Y2, P2Y6, P2X4, and P2X7 are over-expressed in atherosclerotic lesions. Intraperitoneally application of ATP induces atheroclerosis in aortic arche (control: 0.26 mm², ATP: 0.32 mm², n=15; p=0.04) and abdominal aorta despite a lower weight after diet. PPADS reduces atherosclerosis in abdominal aorta, but not in aortic arche (0.29 mm², n=15). IL-6 levels are elevated in ATP-treated mice. To evaluate the role of ATP in leukocyte recruitment, a key step in atherogenesis, mice were treated with ATP intraperitoneally and intravital microscopy was performed 2 hours later. ATP induces leukocyte rolling and adhesion, which can be blocked by PPADS. Repeating this experiment in CXCR1-GFP-mice shows a significant induction of monocyte recruitment by ATP. Conclusions: Extracellular ATP induces atherosclerosis via purinergic receptors and contributes to monocyte recruitment. ATP and puringeric receptors are a novel pathway in atherogenesis and a potential new target for an anti-atherogenic therapy.

seleinstellung. Das neue Zertifikat „Klinik für Diabetespatienten geeignet (DDG)“ soll helfen, die Behandlungsqualität für diese Patientengruppe zu optimieren.

andere Erkrankung Ursache des Krankenhausaufenthalts ist.“ Aus diesem Grund hat die DDG das neue Zertifikat „Klinik für Diabetespatienten geeignet (DDG)“ geschaffen, mit dem messbare Qualitätsstandards verlässlich abgesichert werden sollen, die heutzutage für zuweisende Ärzte und für Patienten bei der Auswahl einer Klinik immer wichtiger werden. Interessant ist das neue Zertifikat letztendlich für jede Klinik und jedes Krankenhaus in Deutschland, das keine von der DDG zertifizierte diabetologische Fachabteilung vorhält. Voraussetzung dafür sind exakt definierte Kriterien, die zu zertifizierende Einrichtungen erfüllen müssen. Dazu gehört beispielsweise ein spezifisches Notfallmanagement bei Über- und Unterzuckerungen,

Qualitätsstandards anhand definierter Kriterien absichern Der Präsident der Deutschen Diabetes Gesellschaft (DDG) Matthaei erläutert: „Jeder Diabetespatient muss sich sicher sein, dass im Krankenhaus sein Blutzuckerspiegel bedarfsgerecht überwacht wird, die Narkose auf seine Diabeteserkrankung abgestellt ist oder Notfallequipment für den Fall einer Blutzuckerentgleisung bereit steht – gerade auch dann, wenn eine

Mitteilungen

um eine Stoffwechseldekompensation („Entgleisung“) zu vermeiden. Mit dem neuen Zertifikat zeigt eine Klinik nicht nur ihre fächerübergreifende Diabeteskompetenz, sondern kann darüber hinaus auch ihre Kostenstrukturen optimieren. Neue Untersuchungen zeigen, dass Patienten mit der Nebendiagnose Diabetes längere Krankenhausaufenthalte, mehr Komplikationen und höhere Kosten verursachen, wenn sie nicht optimal betreut werden. Zudem erfolgt derzeit bei nur 8–10 % aller Fälle eine korrekte Kodierung der Patienten mit Nebendiagnose Diabetes. Mit der Zertifizierung können Kodierung und Erlössituation verbessert werden. Vor allem aber profitieren die Patienten. Professor Matthaei resümiert: „Die Nebendiagnose Diabetes ist nicht zu unterschätzen – weder in ihrer Häufigkeit noch in ihren Auswirkungen auf den Klinikaufenthalt. Mit dem Zertifikat „Klinik für Diabetespatienten geeignet (DDG)“ soll das Ziel einer bestmöglichen Betreuung der Patienten im Krankenhaus erreicht werden.“ Die bereits von der DDG zertifizierten spezialisierten Diabeteseinrichtungen (Basisanerkennung/Diabetologikum) verfügen bereits über eine zertifizierte Expertise, die weit über dieses neue DDG Zertifikat hinausgeht. Da sie bereits eine adäquate Versorgung von Patienten mit Diabetes gewährleisten, brauchen sie selbstverständlich das neue DDG Zertifikat nicht zu erwerben. Antragstellung und Anerkennungsverfahren Die inhaltliche Prüfung des Antrags erfolgt bei der Diabetes Qualitätsmanagement (DQM) GmbH. Die DQM GmbH teilt ihr Ergebnis dem DDG Ausschuss Qualitätssicherung, Schulung und Weiterbildung (QSW) mit, der nach dem Anerkennungsverfahren dann die Urkunde ausstellt. Zum Zertifizierungsverfahren gehört eine Selbstverpflichtung der antragstellenden Klinik, gemäß den mit dem Antrag eingereichten Standards zu arbeiten. Diese Selbstverpflichtung wird Perfusion 02/2013

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im Rahmen stichprobenartiger Audits überprüft. Die zertifizierte Klinik darf den Titel „Klinik für Diabetespatienten geeignet (DDG)“ für 3 Jahre tragen, danach muss sie sich rezertifizieren lassen. Weitere Informationen zum neuen Zertifikat „Klinik für Diabetespatienten geeignet (DDG)“ können bei der DDGGeschäftsstelle per E-Mail unter hecker@ddg.info angefordert werden. DDG

Gegenmittel zur Aufhebung des gerinnungshemmenden Effekts von Dabigatran Eine bekannte mögliche Komplikation aller gerinnungshemmenden Therapien zur Schlaganfallprävention bei Vorhofflimmern ist das Risiko für Blutungen. Derzeit gibt es weder für einen der neuartigen oralen Gerinnungshemmer noch für Phenprocoumon ein spezifisches und schnell wirkendes Gegenmittel zur Aufhebung des gerinnungshemmenden Effektes [1]. Bei Phenprocoumon wird häufig irrtümlich Vitamin K als schnell wirkendes Gegenmittel angesehen. Dabei ist es de facto ein Ersatz für das Vitamin K, das für die körpereigene Produktion von Gerinnungsfaktoren benötigt und dessen Funktion durch Phenprocoumon blockiert wird. Die Aufhebung des gerinnungshemmenden Effekts von Phenprocoumon ist ein recht langsamer und komplexer Prozess, der bis zu 36 Stunden dauern kann [2]. Die Strategien zur Behandlung schwerer Blutungen sind im Klinikalltag für alle gerinnungshemmenden Therapien gleich [3]. Ausschließlich bei dem oralen Antikoagulans Dabigatran besteht die zusätzliche Möglichkeit, den Wirkstoff per Hämodialyse aus dem Blutkreislauf zu entfernen [4]. Um die Behandlung mit Dabigatran (Pradaxa®) zu optimieren, möchte der Hersteller Boehringer Ingelheim sicherstellen, dass Ärzte über alle Mittel verfügen, die sie für das Management kritischer Situationen benötigen, und forciert daher die Entwicklung eines Gegenmit-

tels. Dieses könnte in kritischen Situationen die etablierten Strategien und Maßnahmen ergänzen, die bereits jetzt in der Notfallmedizin zur Behandlung von Blutungen verfügbar sind [5]. Als vielversprechender Kandidat gilt ein vollständig humanisiertes, monoklonales Antikörperfragment (Fab). In der präklinischen Untersuchung zeigte Fab die folgenden Vorteile: • Sehr hohe Bindungsaffinität und Spezifität für Dabigatran-Moleküle • Schnelle, dosisabhängige Reduktion des Blutverlustes, der im Experiment nach Dabigatran-Vorbehandlung herbeigeführt wurde. Die Wirkung hielt nach Injektion in den Blutkreislauf bis zu 6 Stunden an. • Zuverlässige Neutralisierung des gerinnungshemmenden Effekts von Dabigatran (nachgewiesen in Exvivo-Gerinnungstests) Nach dem erfolgreichen Abschluss der präklinischen Untersuchungen wurde nun eine klinische Phase-I-Studie initiiert, in der Nachweis erbracht werden soll, dass das hochspezifische und selektive Gegenmittel, das momentan entwickelt wird, den gerinnungshemmenden Effekt von Pradaxa® sicher, wirksam und schnell aufheben kann. B. S.

Quellen 1 Kaatz S, et al. Guidance on the emergent reversal of oral thrombin and factor Xa inhibitors. Am J Hematol 2012;87(Suppl 1):S141S145 2 Hanley JP. Warfarin reversal. J Clin Pathol 2004;57:1132-1139 3 Holbrook A et al. Evidence-based management of anticoagulant therapy: antithrombotic therapy and prevention of thrombosis, 9th ed. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141 (Suppl):e152S-e184S 4 Pradaxa European Summary of Product Characteristics, 2012 5 Van Ryn J et al. In vitro chacterization, pharmacokinetics and reversal of supratherapeutic doses of dabigatran-induced bleeding in rats by a specific antibody fragment antidote to dabigatran. Oral Presentation 9928. Presented on 5 November 2012 at the American Heart Association Scientific Sessions 2012 © Verlag PERFUSION GmbH

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Medikamentös nicht kontrollierbare Hypertonie:

EnligHTN-Studie untersucht Vorteile der renalen Denervierung Die renale Denervierung mit dem EnligHTN™-System ist ein katheterbasiertes Ablationsverfahren, mit dessen Hilfe sich ein erhöhter Blutdruck anhaltend senken lässt. Dazu wird ein Katheter durch die Arteria femoralis am Oberschenkel eingeführt, um Zugang zu den Nierenarterien zu erhalten. Nach Platzierung des Katheters wird dessen Spitze gegen die Oberfläche der Arterie gehalten, wobei Hochfrequenzstrom an die umliegenden Nerven abgegeben wird. Der Hochfrequenzstrom setzt Läsionen am renalen Sympathikus – einem Nervennetz, das unter anderem für die Blutdruckregulierung zuständig ist. Durch die Unterbrechung der Nervenversorgung sinkt der Blutdruck. Dies wurde durch die erste Studie mit dem EnligHTN™-System von St. Jude Medical nachgewiesen: Bei den eingeschlossenen Hypertonikern, deren Blutdruck trotz medikamentöser Therapie im Durchschnitt bei 176/96 mmHg lag, sank der systolische Blutdruck nach 30 Tagen um durchschnittlich 28 mmHg und blieb auch 6 Monate nach der renalen Denervierung stabil – ein wichtiger Befund, da das Risiko kardiovaskulärer Todesfälle mit jeder Senkung des systolischen Blutdrucks um 20 mmHg halbiert wird. Daher soll in der Folgestudie EnligHTN II untersucht werden, ob dieser minimal-invasive Ansatz zur Behandlung der Hypertonie auch mit einer Reduzierung schwerwiegender kardialer Ereignisse wie Herzinfarkt, Schlaganfall und Tod einhergeht. Dies soll auch für Subgruppen mit unterschiedlichem Grad der Nierenfunktion evaluiert werden. Die EnligHTN II-Studie wird an 40 Orten in Europa und Australien mit rund 500 Patienten mit unkontrolliertem Bluthochdruck durchgeführt, die ersten Patienten wurden im Januar 2013 eingeschlossen. F. S.

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Einstieg in die basal unterstütze orale Therapie:

Das BOT-Schulungs programm Die Schulungslandschaft für Diabetiker ist groß. Dabei oft vermisst: ein Schulungsprogramm für den Einstieg in die basal unterstütze orale Therapie, kurz BOT genannt. Dabei ist ein früher Einstieg in die Insulintherapie ein wichtiger Grundstein zur Erhaltung der Lebensqualität von Menschen mit Typ-2-Diabetes. Um diese Lücke in der Schulungslandschaft zu schließen, hat Sanofi Diabetes ein interdisziplinäres Team von Fachärzten, Diabetesberaterinnen und Psychologen aus ganz Deutschland bei der Entwicklung des neuen Schulungsprogramms bot leben unterstützt. Flexibles Lernen mit vier Modulen Das BOT-Schulungsprogramm beinhaltet vier, in sich geschlossene, 60-minütige Module, die sektorenübergreifend gelehrt werden können. Im Modul 1 „Grundlagen“ beschäftigt sich der Arzt zusammen mit dem Patienten mit dem Einstieg in die Insulintherapie. Die Hemmungen des Patienten, zum Beispiel vor der Selbstbehandlung mit Insulinspritzen und der Blutzuckermessung, sollen abgebaut werden. Ihm werden die notwendigen Kenntnisse zur Blutzuckermessung, Insulingabe und Erkennung sowie Vermeidung einer Unterzuckerung vermittelt. Dieses Grundwissen wird anschließend in den folgenden 3 Modulen verfeinert. Das Modul 2 „Fit für die Insulingabe“ zeigt auf, wie die Insulininjektion korrekt durchgeführt wird. Dabei soll der Patient vor allem Berührungsängste abbauen und Sicherheit gewinnen. Modul 3 „Unterzuckerung erkennen und vermeiden“ lehrt die ambulante Versorgung und den Umgang mit einer Hypoglykämie. Wie erkennt der Patient eine Hypoglykämie und welche präventiven Maßnahmen kann er

Der Schulungskoffer ist ab Mai 2013 erhältlich unter: www.kirchheim-shop.de

treffen? Modul 4 „Im Alltag zurechtkommen“ gibt dem Patienten grundsätzliche Empfehlungen zur richtigen Ernährung, vor allem für den Umgang mit Kohlenhydraten und Zucker, denn eine gesunde Ernährung kann Folgeerkrankungen vorbeugen. Die Vorteile des BOT-Schulungsprogramms bot leben liegen vor allem in seiner Flexibilität. Der Patient kann die Basisschulung (Modul 1) jederzeit beginnen. Nach dieser können die weiteren Einheiten in unterschiedlicher Reihenfolge absolviert werden. Auch örtlich ist bot leben flexibel, der Patient kann sowohl im Krankenhaus, beim Hausarzt als auch in der Schwerpunktpraxis mit der Schulung beginnen und diese weiter fortführen. Mit bot leben können die Patienten erstmals auch über Sektorgrenzen hinweg in der Klinik, der diabetologischen Schwerpunktpraxis und Hausarztpraxis geschult werden. So gelingt ein einfacher und sicherer Einstieg in die Insulintherapie. Ziel der Initiative ist es, den Patienten emotional abzuholen, seine Sorgen aufzufangen, ihn in seinem Selbstbewusstsein zu stärken und schnellstmöglich jene praktischen Grundfertigkeiten zu vermitteln, die notwendig sind, die basal unterstütze orale Therapie selbstständig und sicher umzusetzen und den Diabetes Tag für Tag besser zu managen. E. W.

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Medizin Jobs – die neue StepStone App für das Gesundheitswesen Ab sofort bietet StepStone einen besonderen Service für Ärzte, Pflegekräfte, Klinikpersonal und alle weiteren Arbeitnehmer in der Gesundheitswirtschaft, die auf der Suche nach einem neuen Job sind. Mit der iPhone-App „MedizinJobs“ finden Sie immer und überall aktuelle Stellenangebote aus dem medizinischen Bereich – selbstverständlich kostenlos und werbefrei.

Alle Vorteile im Überblick: • Neue, top-aktuelle Stellen • Jobsuche nach Stichwort oder Kategorie • Kilometergenaue Eingrenzung bei der Regionalsuche • Unternehmensstandort direkt auf der Karte anzeigen lassen • Jobs in der Favoritenliste speichern • Jobs über E-Mail, Facebook und Twitter weiterempfehlen Mehr Infos dazu unter: http://www. aerzte-pflege-jobs.stepstone.de B. S.

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PERFUSION

IMPRESSUM

OFFIZIELLES ORGAN DER DEUTSCHEN GESELLSCHAFT FÜR ARTERIOSKLEROSEFORSCHUNG

Herausgeber: Univ.-Prof. Dr. Dr. Edzard Ernst, Emeritus Professor of Complementary Medicine, University of Exeter, Peninsula Medical School,Salmon Pool Lane, Exeter EX2 4SG, UK Prof. Dr. med. W. Koenig, Abt. Innere Medizin II, Med. Univ.-Klinik, Robert-Koch-Str. 8, 89070 Ulm Wissenschaftlicher Beirat: Prof. Dr. med. T. von Arnim (Kardiologie), München Prof. Dr. med. G. V. R. Born (Arterioskleroseforschung), London Prof. Dr. med. C. Diehm (Angiologie), Karlsbad Priv.-Doz. Dr. med. Dr. phil. C. Drosde (Kardiologie), Freiburg Dr. med. J. Dyerberg MD, Ph. D. (Klin. Chemie), Aalborg Sygehus, Dänemark Prof. Dr. med. H. W. Eichstädt, (Kardiologie), Berlin Doz. Dr. rer. nat. F.-D. Ernst (Hämorheologie), Dresden Dr. med. J. Gehring (Kardiologie, Rehabilitation), München Prof. Dr. med. J. D. Gruß (Gefäßchirurgie), Kassel Prof. Dr. J. Harenberg (Hämostaseologie), Mannheim Prof. Dr. med. L. Heilmann (Gynäkologie), Rüsselsheim Prof. Dr. med. H. M. Hoffmeister (Kardiologie), Solingen Prof. Dr. med. H. U. Janka (Diabetologie), München Dr. med. J. Janzen MPhil (Pathologie), Bern, Schweiz Prof. Dr. med. L. Kollár M. D., PhD (Gefäßchirurgie), Universität Pécs, Ungarn Prof. Dr. med. M. Marshall (Phlebologie), Rottach Egern Prof Dr. med. J. Matsubara (Chirurgie), Ishikawa, Japan Prof. Dr. med. G. Mchedlishvilli (Mikrozirculation), Tbilisi, Georgien Prof. Dr. med. V. Mitrovic (Kardiologie, Klinische Pharmakologie), Bad Nauheim Prof. Dr. med. H. Mörl (Angiologie), Mannheim Prof. Dr. med. F. J. Neumann (Kardiologie), Bad Krozingen Prof. Dr. med. K. L. Resch (Medizin-Statistik), Bad Elster Prof. Dr. med. G. Rettig (Kardiologie), Homburg Prof. Dr. med. G. Schmid-Schönbein (Biomechanik), La Jolla, USA Prof. Dr. med. H. Schmid-Schönbein (Physiologie), Aachen Prof. Dr. med. A. Schrey (Pharmakologie), Düsseldorf Prof. Dr. med. H. Sinzinger (Nuklearmedizin), Wien, Österreich Prof. Dr. med. T. Störk (Kardiologie, Angiologie), Göppingen Prof. Dr. med. I. Szirmai M. D. (Neurologie), Universität Budapest, Ungarn Prof. Dr. med. G. Trübestein (Angiologie), Bonn Prof. Dr. med. B. Tsinamdzvrishvili (Kardiologie, Hypertonie), Tbilisi, Georgien Prof. Dr. med. W. Vanscheidt (Dermatologie), Freiburg Prof. Dr. med. H. Weidemann (Kardiologie, Sozialmedizin), Bad Krozingen

Schriftleitung: Univ.-Prof. Dr. Dr. Edzard Ernst, Emeritus Professor of Complementary Medicine, University of Exeter, Peninsula Medical School, Salmon Pool Lane, Exeter EX2 4SG, UK E-Mail: Edzard.Ernst@pms.ac.uk Tel: +44 (0) 1392 726029 Fax: +44 (0) 1392 421009 Die Zeitschrift erscheint 6-mal im Jahr; Jahresabonnement 27,–; Einzelheft 5,50, inklusive MwSt., zuzüglich Versandspesen. Der Abonnementpreis ist im voraus zahlbar. Stornierungen sind bis 6 Wochen vor Ablauf eines Kalenderjahres möglich. Abonnementbestellungen direkt beim Verlag.

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