Endothelial progenitor cells in cardiovascular disease and hypoxia--potential implications to obstructive sleep apnea

Endothelial progenitor cell-derived extracellular vesicles: the world of potential prospects for the treatment of cardiovascular diseases

Cardiovascular diseases (CVDs) have emerged as a predominant threat to human health, surpassing the incidence and mortality rates of neoplastic diseases. Extracellular vesicles (EVs) serve as vital mediators in intercellular communication and material exchange. Endothelial progenitor cells (EPCs), recognized as precursors of vascular endothelial cells (ECs), have garnered considerable attention in recent years due to the potential therapeutic value of their derived extracellular vesicles (EPC-EVs) in the context of CVDs. This comprehensive review systematically explores the origins, characteristics, and functions of EPCs, alongside the classification, properties, biogenesis, and extraction techniques of EVs, with particular emphasis on their protective roles in CVDs. Additionally, we delve into the essential bioactive components of EPC-EVs, including microRNAs, long non-coding RNAs, and proteins, analyzing their beneficial effects in promoting angiogenesis, anti-inflammatory and anti-oxidant activities, anti-fibrosis, anti-apoptosis, and myocardial regeneration. Furthermore, this review comprehensively investigates the therapeutic potential of EPC-EVs across various CVDs, encompassing acute myocardial infarction, myocardial ischemia-reperfusion injury, atherosclerosis, non-ischemic cardiomyopathies, and diabetic cardiovascular disease. Lastly, we summarize the potential challenges associated with the clinical application of EPC-EVs and outline future directions, aiming to offer a valuable resource for both theoretical insights and practical applications of EPC-EVs in managing CVDs.

Assessment of bone mineral density and bone metabolism in young men with obstructive sleep apnea: a cross-sectional study

BACKGROUND

Hypoxia in obstructive sleep apnea (OSA) patients during sleep may have an effect on bone metabolism. Few data regarding evaluation of bone metabolism in young individuals diagnosed with OSA. In this study, we aim to identify the association between bone mineral density and OSA in young men (≤ 40 years old of age).

METHODS

Consecutive male subjects who underwent polysomnography were enrolled. Serum calcium, 25-hydroxyvitamin-D3, β-isomerized form C-terminal telopeptide of type I collagen, osteocalcin and procollagen type 1 N-propeptide were measured in all participants, and bone mineral density (BMD) at lumbar spine (L1-L4), femoral neck and hip total were determined by dual energy X-ray absorption (DXA).

RESULTS

The population consisted of 85 subjects (mean age 35.53 years). The BMD at lumbar spine (L1-L4) in moderate OSA patients was higher than control and severe OSA group significantly (p = 0.036). After adjustment for confounding factors, stepwise multiple linear regression analyses showed LaSO₂ (β = 0.340, p = 0.008) as an independent explanatory variable for Lumbar L1-L4 BMD, LaSO₂ (β = 0.304, p = 0.037), BMI (β = 0.393, p = 0.008) for femur neck BMD and BMI (β = 0.720, p = 0.002) for hip total BMD.

CONCLUSIONS

Our finding indicated that there was a relationship between OSA and bone metabolism in younger men, and moderate OSA-related hypoxia positively related with BMD. This study also showed that different degrees of recurrent hypoxia had different effects on bone metabolism, a finding that required further investigation.

Intermittent hypoxia changes the interaction of the kinin-VEGF system and impairs myocardial angiogenesis in the hypertrophic heart

Intermittent hypoxia (IH) is a feature of obstructive sleep apnea (OSA), a condition highly associated with hypertension-related cardiovascular diseases. Repeated episodes of IH contribute to imbalance of angiogenic growth factors in the hypertrophic heart, which is key in the progression of cardiovascular complications. In particular, the interaction between vascular endothelial growth factor (VEGF) and the kallikrein-kinin system (KKS) is essential for promoting angiogenesis. However, researchers have yet to investigate experimental models of IH that reproduce OSA, myocardial angiogenesis, and expression of KKS components. We examined temporal changes in cardiac angiogenesis in a mouse IH model. Adult male C57BI/6 J mice were implanted with Matrigel plugs and subjected to IH for 1-5 weeks with subsequent weekly histological evaluation of vascularization. Expression of VEGF and KKS components was also evaluated. After 3 weeks, in vivo myocardial angiogenesis and capillary density were decreased, accompanied by a late increase of VEGF and its type 2 receptor. Furthermore, IH increased left ventricular myocardium expression of the B2 bradykinin receptor, while reducing mRNA levels of B1 receptor. These results suggest that in IH, an unexpected response of the VEGF and KKS systems could explain the reduced capillary density and impaired angiogenesis in the hypoxic heart, with potential implications in hypertrophic heart malfunction.

Sleep Apnea and Cardiovascular Disease: An Enigmatic Risk Factor

Synchronization of molecular, metabolic, and cardiovascular circadian oscillations is fundamental to human health. Sleep-disordered breathing, which disrupts such temporal congruence, elicits hemodynamic, autonomic, chemical, and inflammatory disturbances with acute and long-term consequences for heart, brain, and circulatory and metabolic function. Sleep apnea afflicts a substantial proportion of adult men and women but is more prevalent in those with established cardiovascular diseases and especially fluid-retaining states. Despite the experimental, epidemiological, observational, and interventional evidence assembled in support of these concepts, this substantial body of work has had relatively modest pragmatic impact, thus far, on the discipline of cardiology. Contemporary estimates of cardiovascular risk still are derived typically from data acquired during wakefulness. The impact of sleep-related breathing disorders rarely is entered into such calculations or integrated into diagnostic disease-specific algorithms or therapeutic recommendations. Reasons for this include absence of apnea-related symptoms in most with cardiovascular disease, impediments to efficient diagnosis at the population level, debate as to target, suboptimal therapies, difficulties mounting large randomized trials of sleep-specific interventions, and the challenging results of those few prospective cardiovascular outcome trials that have been completed and reported. The objectives of this review are to delineate the bidirectional interrelationship between sleep-disordered breathing and cardiovascular disease, consider the findings and implications of observational and randomized trials of treatment, frame the current state of clinical equipoise, identify principal current controversies and potential paths to their resolution, and anticipate future directions.

MicroRNA-129-1-3p regulates cyclic stretch-induced endothelial progenitor cell differentiation by targeting Runx2

Endothelial progenitor cells (EPCs) are vital to the recovery of endothelial function and maintenance of vascular homeostasis. EPCs mobilize to sites of vessel injury and differentiate into mature endothelial cells (ECs). Locally mobilized EPCs are exposed to cyclic stretch caused by blood flow, which is important for EPC differentiation. MicroRNAs (miRNAs) have emerged as key regulators of several cellular processes. However, the role of miRNAs in cyclic stretch-induced EPC differentiation remains unclear. Here, we investigate the effects of microRNA-129-1-3p (miR-129-1-3p) and its novel target Runt-related transcription factor 2 (Runx2) on EPC differentiation induced by cyclic stretch. Bone marrow-derived EPCs were exposed to cyclic stretch with a magnitude of 5% (which mimics physiological mechanical stress) at a constant frequency of 1.25 Hz for 24 hours. The results from a miRNA array revealed that cyclic stretch significantly decreased miR-129-1-3p expression. Furthermore, we found that downregulation of miR-129-1-3p during cyclic stretch-induced EPC differentiation toward ECs. Meanwhile, expression of Runx2, a putative target gene of miR-129-1-3p, was increased as a result of cyclic stretch. A 3'UTR reporter assay validated Runx2 as a direct target of miR-129-1-3p. Furthermore, small interfering RNA (siRNA)-mediated knockdown of Runx2 inhibited EPC differentiation into ECs and attenuated EPC tube formation via modulation of vascular endothelial growth factor (VEGF) secretion from EPCs in vitro. Our findings demonstrated that cyclic stretch suppresses miR-129-1-3p expression, which in turn activates Runx2 and VEGF to promote endothelial differentiation of EPCs and angiogenesis. Therefore, targeting miR-129-1-3p and Runx2 may be a potential therapeutic strategy for treating vessel injury.

[Sleep disorders and circadian rhythms in diseases of the cardiovascular system]

OBJECTIVE

To study disturbances of sleep and circadian rhythms in patients with cardiovascular diseases taking into account the level of melatonin secretion and to optimize a complex approach to their treatment.

MATERIALS AND METHODS

The study included patients with cardiovascular diseases with- (n=121) and without (n=105) cerebrovascular diseases (CVD). All patients received melaxen in dose 3 mg daily 30-40 min before sleep. Examination of patients included assessment of neurological status, psychometric scales, the definition of circadian rhythm of the heart and blood pressure, determination of 6-SOMT in daily urine.

RESULTS

Pathological changes in circadian rhythms affected sleep disturbances, emotional and cognitive disorders and were associated with a reduction in the level of 6-SOMT in the urine. These changes were most pronounced in patients with CVD and stroke. The inclusion of melaxen in the comprehensive regimen of treatment improved sleep, reduced mood disorders and normalized the circadian heart rate profile and blood pressure.

CONCLUSION

The data obtained allowed to consider melaxen as an effective tool in the complex therapy of patients with CVD.

Nocturnal stem cell mobilization in patients with obstructive sleep apnoea: a pilot study

BACKGROUND

Patients with obstructive sleep apnoea (OSA) experience repetitive cessation of breathing during sleep, leading to intermittent hypoxaemia, excessive oxidative stress and systemic inflammation. These insults may damage the vasculature and provoke the corresponding repair response, such as stem cell mobilization to peripheral blood. This study aimed to investigate nocturnal mobilization of stem cells in OSA.

METHODS

Thirty-five patients with OSA and thirteen healthy controls were enrolled. Polysomnography was performed, and severity of OSA was defined by apnoea-hypopnoea index (AHI). Peripheral venous blood was drawn after and before sleep for measurement of CD34+ cell and SDF-1α level. Stem cell mobilization was gauged by ratios of the CD34+ level in the morning to that at night or by their difference. Correlation analysis was performed to identify factors related to stem cell mobilization.

RESULTS

Compared to controls, the nocturnal ratios and difference of CD34+ cell levels were larger in patients with OSA (ratios: 1·141 vs. 0·896, P = 0·036; difference: 340 vs. -166/cc blood, P = 0·036), suggestive of stem cell mobilization. The mobilization ratios were related to AHI, body mass index (BMI), SpO2 nadir, oxygen desaturation index and time sustaining hypoxaemia. After adjusting age, gender and BMI, AHI (r = 0·357, P = 0·016) and hypoxaemia-related parameter remained significant. Paired nocturnal differences in CD34+ cell count (P = 0·009) and SDF-1α (P = 0·001) were also significant in patients with OSA, but not in controls. After CPAP therapy for 6 months, the elevated mobilization ratios in patients with OSA tended to decline (P = 0·059).

CONCLUSION

CD34+ stem cell mobilization during sleep was observed in OSA.

Unexpected benefits of intermittent hypoxia: enhanced respiratory and nonrespiratory motor function

Intermittent hypoxia (IH) is most often thought of for its role in morbidity associated with sleep-disordered breathing, including central nervous system pathology. However, recent evidence suggests that the nervous system fights back in an attempt to minimize pathology by increasing the expression of growth/trophic factors that confer neuroprotection and neuroplasticity. For example, even modest ("low dose") IH elicits respiratory motor plasticity, increasing the strength of respiratory contractions and breathing. These low IH doses upregulate hypoxia-sensitive growth/trophic factors within respiratory motoneurons but do not elicit detectable pathologies such as hippocampal cell death, neuroinflammation, or systemic hypertension. Recent advances have been made toward understanding cellular mechanisms giving rise to IH-induced respiratory plasticity, and attempts have been made to harness the benefits of low-dose IH to treat respiratory insufficiency after cervical spinal injury. Our recent realization that IH also upregulates growth/trophic factors in nonrespiratory motoneurons and improves limb (or leg) function after incomplete chronic spinal injuries suggests that IH-induced plasticity is a general feature of motor systems. Collectively, available evidence suggests that low-dose IH may represent a safe and effective treatment to restore lost motor function in diverse clinical disorders that impair motor function.

Circulating microparticles from obstructive sleep apnea syndrome patients induce endothelin-mediated angiogenesis

Microparticles are deemed true biomarkers and vectors of biological information between cells. Depending on their origin, the composition of microparticles varies and the subsequent message transported by them, such as proteins, mRNA, or miRNA, can differ. In obstructive sleep apnea syndrome (OSAS), circulating microparticles are associated with endothelial dysfunction by reducing endothelial-derived nitric oxide production. Here, we have analyzed the potential role of circulating microparticles from OSAS patients on the regulation of angiogenesis and the involved pathway. VEGF content carried by circulating microparticles from OSAS patients was increased when compared with microparticles from non-OSAS patients. Circulating microparticles from OSAS patients induced an increase of angiogenesis that was abolished in the presence of the antagonist of endothelin-1 receptor type B. In addition, endothelin-1 secretion was increased in human endothelial cells treated by OSAS microparticles. We highlight that circulating microparticles from OSAS patients can modify the secretome of endothelial cells leading to angiogenesis.

Obstructive sleep apnea is associated with preserved bone mineral density in healthy elderly subjects

STUDY OBJECTIVES

Chronic intermittent hypoxia (IH) acts as a stimulator of mesenchymal stem cell (MSC) mobilization, intensifying osteoblast formation in animal models. The recurrence of apnea and oxygen desaturation in obstructive sleep apnea (OSA) may mimic experimental models of IH. We hypothesized that in elderly with OSA, apnea-related IH may mobilize MSCs and thereby prevent the age-related decline in osteogenesis. This study explored the relationship between OSA and bone mineral density (BMD), and the effect of IH on BMD, in a large sample of elderly subjects.

PARTICIPANTS

There were 833 volunteers age 68.6 ± 0.8 y (59% women).

INTERVENTION

Each participant underwent evaluation of BMD at lumbar spine and femoral sites by dual-energy x-ray absorptiometry (DEXA) as well as clinical and polygraphic examinations. OSA was diagnosed on the basis of an apnea-hypopnea index (AHI) ≥ 15.

MEASUREMENTS AND RESULTS

There were 55% of the participants who presented with OSA, and these subjects were predominantly male and overweight. Compared with subjects without OSA, those with OSA had a higher femoral and spinal BMD (P < 0.001). Body mass index (BMI), AHI, and oxygen desaturation index (ODI) (P < 0.01) were significantly related to BMD. After adjustment for sex, BMI, metabolic values, and hypertension, multiple regression analysis showed a significant association between femoral and lumbar T scores and both daily energy expenditure (P < 0.001) and ODI (P = 0.007).

CONCLUSIONS

In elderly subjects, the presence of obstructive sleep apnea is associated with higher bone mineral density, with oxygen desaturation index being a significant determinant of bone metabolism. These results suggest that apnea-related intermittent hypoxia may stimulate the bone remodeling process in older population.

CLINICAL TRIAL REGISTRATION

NCT 00759304 and NCT 00766584.

Pathophysiologic mechanisms of cardiovascular disease in obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) is a highly prevalent sleep disorder, characterized by repeated disruptions of breathing during sleep. This disease has many potential consequences including excessive daytime sleepiness, neurocognitive deterioration, endocrinologic and metabolic effects, and decreased quality of life. Patients with OSAS experience repetitive episodes of hypoxia and reoxygenation during transient cessation of breathing that provoke systemic effects. Furthermore, there may be increased levels of biomarkers linked to endocrine-metabolic and cardiovascular alterations. Epidemiological studies have identified OSAS as an independent comorbid factor in cardiovascular and cerebrovascular diseases, and physiopathological links may exist with onset and progression of heart failure. In addition, OSAS is associated with other disorders and comorbidities which worsen cardiovascular consequences, such as obesity, diabetes, and metabolic syndrome. Metabolic syndrome is an emerging public health problem that represents a constellation of cardiovascular risk factors. Both OSAS and metabolic syndrome may exert negative synergistic effects on the cardiovascular system through multiple mechanisms (e.g., hypoxemia, sleep disruption, activation of the sympathetic nervous system, and inflammatory activation). It has been found that CPAP therapy for OSAS provides an objective improvement in symptoms and cardiac function, decreases cardiovascular risk, improves insulin sensitivity, and normalises biomarkers. OSAS contributes to the pathogenesis of cardiovascular disease independently and by interaction with comorbidities. The present review focuses on indirect and direct evidence regarding mechanisms implicated in cardiovascular disease among OSAS patients.

Cyclic alternating pattern is associated with cerebral hemodynamic variation: a near-infrared spectroscopy study of sleep in healthy humans

The cyclic alternating pattern (CAP), that is, cyclic variation of brain activity within non-REM sleep stages, is related to sleep instability and preservation, as well as consolidation of learning. Unlike the well-known electrical activity of CAP, its cerebral hemodynamic counterpart has not been assessed in healthy subjects so far. We recorded scalp and cortical hemodynamics with near-infrared spectroscopy on the forehead and systemic hemodynamics (heart rate and amplitude of the photoplethysmograph) with a finger pulse oximeter during 23 nights in 11 subjects. Electrical CAP activity was recorded with a polysomnogram. CAP was related to changes in scalp, cortical, and systemic hemodynamic signals that resembled the ones seen in arousal. Due to their repetitive nature, CAP sequences manifested as low- and very-low-frequency oscillations in the hemodynamic signals. The subtype A3+B showed the strongest hemodynamic changes. A transient hypoxia occurred during CAP cycles, suggesting that an increased CAP rate, especially with the subtype A3+B, which may result from diseases or fragmented sleep, might have an adverse effect on the cerebral vasculature.

Potential role of adult stem cells in obstructive sleep apnea

Adult stem cells are undifferentiated cells that can be mobilized from the bone marrow or other organs, home into injured tissues, and differentiate into different cell phenotypes to serve in a repairing capacity. Furthermore, these cells can respond to inflammation and oxidative stress by exhibiting immunomodulatory properties. The protective and reparative roles of mesenchymal stem cells (MSCs), very small embryonic-like stem cells (VSELs), and endothelial progenitor cells (EPCs) have primarily been examined and characterized in auto-immune and cardiovascular diseases. Obstructive sleep apnea (OSA) is a very prevalent disease (4-5% of adult population and 2-3% of children) characterized by an abnormal increase in upper airway collapsibility. Recurrent airway obstructions elicit arterial oxygen desaturations, increased inspiratory efforts, and sleep fragmentation, which have been associated with important long-term neurocognitive, metabolic, and cardiovascular consequences. Since inflammation, oxidative stress and endothelial dysfunction are key factors in the development of the morbid consequences of OSA, bone marrow-derived stem cells could be important modulators of the morbid phenotype by affording a protective role. This mini-review is focused on the recent data available on EPCs, VSELs, and MSCs in both animal models and patients with OSA.