Comparison of ultrasound assessment of flow-mediated dilatation in the radial and brachial artery with upper and forearm cuff positions

A flexible optoacoustic blood 'stethoscope' for noninvasive multiparametric cardiovascular monitoring

Quantitative and multiparametric blood analysis is of great clinical importance in cardiovascular disease diagnosis. Although there are various methods to extract blood information, they often require invasive procedures, lack continuity, involve bulky instruments, or have complicated testing procedures. Flexible sensors can realize on-skin assessment of several vital signals, but generally exhibit limited function to monitor blood characteristics. Here, we report a flexible optoacoustic blood 'stethoscope' for noninvasive, multiparametric, and continuous cardiovascular monitoring, without requiring complicated procedures. The optoacoustic blood 'stethoscope' features the light delivery elements to illuminate blood and the piezoelectric acoustic elements to capture light-induced acoustic waves. We show that the optoacoustic blood 'stethoscope' can adhere to the skin for continuous and non-invasive in-situ monitoring of multiple cardiovascular biomarkers, including hypoxia, intravascular exogenous agent concentration decay, and hemodynamics, which can be further visualized with a tailored 3D algorithm. Demonstrations on both in-vivo animal trials and human subjects highlight the optoacoustic blood 'stethoscope''s potential for cardiovascular disease diagnosis and prediction.

Effects and Optimal Dose of Exercise on Endothelial Function in Patients with Heart Failure: A Systematic Review and Meta-Analysis

BACKGROUND

Exercise-based cardiac rehabilitation (CR) is considered an effective treatment for enhancing endothelial function in patients with heart failure (HF). However, recent studies have been published and the optimal "dose" of exercise required to increase the benefits of exercise-based CR programmes on endothelial function is still unknown.

OBJECTIVES

(a) To estimate the effect of exercise-based CR on endothelial function, assessed by flow-mediated dilation (FMD), in patients with HF; (b) to determine whether high-intensity interval training (HIIT) is better than moderate-intensity training (MIT) for improving FMD; and (c) to investigate the influence of exercise modality (i.e. resistance exercise vs. aerobic exercise and combined exercise vs. aerobic exercise) on the improvement of endothelial function.

METHODS

Electronic searches were carried out in PubMed, Embase, and Scopus up to February 2022. Random-effects models of between-group mean differences were estimated. Heterogeneity analyses were performed by means of the chi-square test and I² index. Subgroup analyses and meta-regressions were used to test the influence of potential moderator variables on the effect of exercise.

RESULTS

We found a FMD increase of 3.09% (95% confidence interval [CI] = 2.01, 4.17) in favour of aerobic-based CR programmes compared with control groups in patients with HF and reduced ejection fraction (HFrEF). However, the results of included studies were inconsistent (p < .001; I² = 95.2%). Higher FMD improvement was found in studies which were randomised, reported radial FMD, or performed higher number of training sessions a week. Moreover, HIIT enhanced FMD to a greater extent than MIT (2.35% [95% CI = 0.49, 4.22]) in patients with HFrEF. Insufficient data prevented pooled analyses for the effect of exercise in patients with HF and preserved ejection fraction and the influence of exercise modality on the improvement of endothelial function.

CONCLUSION

Aerobic-based CR is a non-pharmacological treatment for enhancing endothelial function in patients with HFrEF. However, higher training frequency and HIIT induce greater adaptation of endothelial function in these patients, which should betaken into consideration when designing exercise-based CR programmes. Trial registration The protocol was prospectively registered on the PROSPERO database (CRD42022304687).

Acute effects of the different relaxation periods during passive intermittent static stretching on arterial stiffness

To clarify whether the relaxation period during stretching affects the degree of elevated shear rate and the degree of reduction of arterial stiffness, we examined relaxation duration to build an adequate stretching protocol. In Experiment 1, the changes in cardiac output, the shear rate in the posterior tibial artery, and blood volume in the calf muscle were measured during recovery (0-60 s) from a single bout of one-legged passive calf stretching in 12 healthy young men. In Experiment 2, the effects of different relaxation periods (5-, 10-, 20-, and 60-s) of passive one-legged intermittent calf stretching (30-s × 6 sets) on the femoral-ankle pulse wave velocity (faPWV) as an index of peripheral arterial stiffness were identified in 17 healthy young men. As a result, the stretched leg's shear rate significantly increased from 0 to 10th s after stretching. The muscle blood volume in the stretched leg significantly reduced during stretching, and then significantly increased during the recovery period after stretching; however, cardiac output remained unchanged during stretching and recovery. Additionally, the reduction in faPWV from the pre-stretching value in the stretched leg was significantly larger in the protocol with 10-s and 20-s relaxation periods than that in the non-stretched leg, but this did not differ in the 5-s and 60-s relaxation periods. These findings suggest that the relaxation periods of intermittent static stretching that cause a high transient increase in shear rate (via reperfusion after microvascular compression by the stretched calf muscles) are effective to reduce arterial stiffness.

The impact of hypoxaemia on vascular function in lowlanders and high altitude indigenous populations

Exposure to hypoxia elicits widespread physiological responses that are critical for successful acclimatization; however, these responses may induce apparent maladaptive consequences. For example, recent studies conducted in both the laboratory and the field (e.g. at high altitude) have demonstrated that endothelial function is reduced in hypoxia. Herein, we review the several proposed mechanism(s) pertaining to the observed reduction in endothelial function in hypoxia including: (i) changes in blood flow patterns (i.e. shear stress), (ii) increased inflammation and production of reactive oxygen species (i.e. oxidative stress), (iii) heightened sympathetic nerve activity, and (iv) increased red blood cell concentration and mass leading to elevated nitric oxide scavenging. Although some of these mechanism(s) have been examined in lowlanders, less in known about endothelial function in indigenous populations that have chronically adapted to environmental hypoxia for millennia (e.g. the Peruvian, Tibetan and Ethiopian highlanders). There is some evidence indicating that healthy Tibetan and Peruvian (i.e. Andean) highlanders have preserved endothelial function at high altitude, but less is known about the Ethiopian highlanders. However, Andean highlanders suffering from chronic mountain sickness, which is characterized by an excessive production of red blood cells, have markedly reduced endothelial function. This review will provide a framework and mechanistic model for vascular endothelial adaptation to hypoxia in lowlanders and highlanders. Elucidating the pathways responsible for vascular adaption/maladaptation to hypoxia has potential clinical implications for disease featuring low oxygen delivery (e.g. heart failure, pulmonary disease). In addition, a greater understanding of vascular function at high altitude will clinically benefit the global estimated 85 million high altitude residents.

Characterization of age-related penile microvascular hemodynamic impairment using laser speckle contrast imaging: possible role of increased fibrogenesis

Current technology for penile hemodynamic evaluations in small animals is invasive and has limitations. We evaluated a novel laser speckle contrast imaging (LSCI) technique to determine age‐related changes in penile microvascular perfusion (PMP) and tested the role of cavernosal muscle (CC) fibrosis mediated by Wnt‐TGF β1 signaling pathways in a mouse model. Ten young (2–3 months) and old (24–28 months) wild‐type C57BL6 male mice were subjected to PMP measured using a LSCI system. Penile blood flow (PBF, peak systolic velocity, PSV) was also measured using a color Doppler ultrasound for comparison. Measurements were made before and after injection of vasoactive drugs: prostaglandin E₁ (PGE₁) and acetylcholine (ACh). CC was processed for immunohistochemical studies for markers of endothelium and fibrosis. Protein levels were quantified by Western blot.PMP and PBF increased significantly from baseline after injection of vasoactive drugs. Peak PMP after PGE₁ and ACh was higher in young mice (225.0 ± 12.0 and 211.3 ± 12.1 AU) compared to old (155.9 ± 7.1 and 162.6 ± 5.1 AU, respectively). PSV after PGE₁ was higher in young than old mice (112.7 ± 8.5 vs. 78.2 ± 4.6 mm/sec). PSV after ACh was also higher in young (112.7 ± 5.6 mm/sec) than older mice (69.2 ± 7.1 mm/sec). PMP positively correlated with PSV (r = 0.867, P = 0.001). Immunostaining and Western blot showed increased protein expression of all fibrosis markers with aging. LSCI is a viable technique for evaluating penile hemodynamics. Increased cavernosal fibrosis may cause impaired penile hemodynamics and increased incidence of erectile dysfunction in older men.

20-MHz Ultrasound for Measurements of Flow-Mediated Dilation and Shear Rate in the Radial Artery

A high-frequency scanning system consisting of a 20-MHz linear array transducer combined with a 20-MHz pulsed Doppler probe was introduced to evaluate the degree of radial artery flow-mediated dilation (FMD [%]) in two groups of patients after 5 min of controlled forearm ischemia followed by reactive hyperemia. In group I, comprising 27 healthy volunteers, FMD (mean ± standard deviation) was 15.26 ± 4.90% (95% confidence interval [CI]: 13.32%-17.20%); in group II, comprising 17 patients with chronic coronary artery disease, FMD was significantly less at 4.53 ± 4.11% (95% CI: 2.42%-6.64%). Specifically, the ratio FMD/SR (mean ± standard deviation), was equal to 5.36 × 10^-4 ± 4.64 × 10^-4 (95% CI: 3.54 × 10^-4 to 7.18 × 10^-4) in group I and 1.38 × 10^-4 ± 0.89 × 10^-4 (95% CI: 0.70 × 10^-4 to 2.06 × 10^-4) in group II. Statistically significant differences between the two groups were confirmed by a Wilcoxon-Mann-Whitney test for both FMD and FMD/SR (p <0.01). Areas under receiver operating characteristic curves for FMD and FMD/SR were greater than 0.9. The results confirm the usefulness of the proposed measurements of radial artery FMD and SR in differentiation of normal patients from those with chronic coronary artery disease.

Exercise-induced heat stress disrupts the shear-dilatory relationship

NEW FINDINGS

What is the central question of this study? Although heat stress is known to increase cardiovascular strain, no study, to date, had explored the potential impact of exercise-induced heat stress on vascular function. What is the main finding and its importance? We found that acute exercise tended to reduce flow-mediated dilatation (FMD), owing in part to reduced reactive hyperaemia/shear stimulus; thus, when FMD is normalized to shear no postexercise deficit exists. Exercise-induced heat stress increased reactive hyperaemia, shear rate, coupled with a sustained FMD postexercise, suggests that exercise-induced heat stress increases the amount of shear stimulus to elicit a similar response, indicating reduced vascular responsiveness, or reserve, which might increase cardiovascular susceptibility. Heat stress increases cardiovascular strain and is of particular concern in occupations, such as firefighting, in which individuals are required to perform strenuous work while wearing personal protective equipment. Sudden cardiac events are associated with strenuous activity and are the leading cause of duty-related death among firefighters, accounting for ∼50% of duty-related fatalities per year. Understanding the acute effects of exercise-induced heat stress (EIHS) on vascular endothelial function may provide insight into the mechanisms precipitating acute coronary events in firefighters. The purpose of this study, therefore, was to determine the effects of EIHS on vascular endothelial function. Using a balanced crossover design, 12 healthy men performed 100 min of moderate-intensity, intermittent exercise with and without EIHS (personal protective equipment or cooling vest, respectively). Measurements of flow-mediated dilatation (FMD), reactive hyperaemia and shear rate area under the curve (SR_AUC ) were performed pre- and postexercise. During EIHS, core temperature was significantly higher (38 ± 0.1 versus 37 ± 0.1°C). Postexercise FMD tended to be suppressed in both conditions, but was not different from pre-exercise. Reactive hyperaemia was reduced after no-EIHS but increased after EIHS. Thus, normalizing FMD to the shear stimulus (FMD/SR_AUC ) revealed a significant reduction in FMD after EIHS only (pre-exercise 0.15 ± 0.04 and 0.13 ± 0.02 s^-1 versus postexercise, 0.13 ± 0.02 and 0.06 ± 0.02 s^-1 , no-EIHS and EIHS, respectively). We conclude that moderate heat stress superimposed on moderate-intensity exercise resulted in reduced vascular endothelial function. This heat stress-induced alteration in the shear-dilatory relationship may relate to the increased risk of acute coronary events associated with activities that combine physical exertion and heat stress (i.e. firefighting).

Radial artery vasomotor function following transradial cardiac catheterisation

Aims

To determine the reproducibility of flow-mediated dilation (FMD) and nitrate-mediated dilation (NMD) in the assessment of radial artery vasomotor function, and to examine the effect of transradial catheterisation on radial artery injury and recovery.

Methods

Radial artery FMD and NMD were examined in 20 volunteers and 20 patients on four occasions (two visits at least 24 hours apart, with two assessments at each visit). In a further 10 patients, radial artery FMD was assessed in the catheterised arm prior to, at 24 hours and 3 months following cardiac catheterisation.

Results

There were no differences in baseline radial artery diameter (2.7±0.4 mm vs 2.7±0.4 mm), FMD (13.4±6.4 vs 12.89±5.5%) or NMD (13.6±3.8% vs 10.1±4.3%) between healthy volunteers and patients (p>0.05 for all comparisons). Mean differences for within and between day FMD were 2.53% (95% CIs −15.5% to 20.5%) and −4.3% (−18.3% to 9.7%) in patients. Compared to baseline, radial artery FMD was impaired at 24 hours (8.7±4.1% vs 3.9±2.9%, p=0.015) but not 3 months (8.7±4.1% vs 6.2±4.4, p=0.34) following transradial catheterisation.

Conclusions

Radial FMD is impaired early after transradial catheterisation but appears to recover by 3 months. While test–retest variability was demonstrated, our findings suggest that transradial access for cardiac catheterisation may afford a potential model of vascular injury and repair in vivo in man.

Ultrasound Assessment of Endothelial Function: A Technical Guideline of the Flow-mediated Dilation Test

Cardiovascular disease is the primary cause of mortality and a major cause of disability worldwide. The dysfunction of the vascular endothelium is a pathological condition characterized mainly by a disruption in the balance between vasodilator and vasoconstrictor substances and is proposed to play an important role in the development of atherosclerotic cardiovascular disease. Therefore, a precise evaluation of endothelial function in humans represents an important tool that could help better understand the etiology of multiple cardio-centric pathologies. Over the past twenty-five years, many methodological approaches have been developed to provide an assessment of endothelial function in humans. Introduced in 1989, the FMD test incorporates a forearm occlusion and subsequent reactive hyperemia that promotes nitric oxide production and vasodilation of the brachial artery. The FMD test is now the most widely utilized, non-invasive, ultrasonic assessment of endothelial function in humans and has been associated with future cardiovascular events. Although the FMD test could have clinical utility, it is a physiological assessment that has inherited several confounding factors that need to be considered. This article describes a standardized protocol for determining FMD including the recommended methodology to help minimize the physiological and technical issues and improve the precision and reproducibility of the assessment.

Investigation of Ultrasound-Measured Flow Rate and Wall Shear Rate in Wrist Arteries Using Flow Phantoms

The aim of this study was to evaluate the errors in measurement of volumetric flow rate and wall shear rate measured in radial and ulnar arteries using a commercial ultrasound scanning system. The Womersley equations were used to estimate the flow rate and wall shear rate waveforms, based on the measured vessel diameter and centerline velocity waveform. In the experiments, each variable (vessel depth, diameter, flow rate, beam-vessel angle and different waveform) in the phantom was investigated in turn, and its value was varied within a normal range while others were fixed at their typical values. The outcomes revealed that flow rate and wall shear rate were overestimated in all cases, from around 13% to nearly 50%. It is concluded that measurements of flow rate and wall shear rate in radial and ulnar arteries with a clinical ultrasound scanner are vulnerable to overestimation.

Usefulness of brachial artery flow-mediated dilation to predict long-term cardiovascular events in subjects without heart disease

Endothelial dysfunction is considered an important prognostic factor in atherosclerosis. To determine the long-term association of brachial artery flow-mediated dilation (FMD) and adverse cardiovascular (CV) events in healthy subjects, we prospectively assessed brachial FMD in 618 consecutive healthy subjects with no apparent heart disease, 387 men (63%), and mean age 54 ± 11 years. After overnight fasting and discontinuation of all medications for ≥12 hours, FMD was assessed using high-resolution linear array ultrasound. Subjects were divided into 2 groups: FMD ≤11.3% (n = 309) and >11.3% (n = 309), where 11.3% is the median FMD, and were comparable regarding CV risk factors, lipoproteins, fasting glucose, C-reactive protein, concomitant medications, and Framingham 10-year risk score. In a mean clinical follow-up of 4.6 ± 1.8 years, the composite CV events (all-cause mortality, nonfatal myocardial infarction, hospitalization for heart failure or angina pectoris, stroke, coronary artery bypass grafting, and percutaneous coronary interventions) were significantly more common in subjects with FMD ≤11.3% rather than >11.3% (15.2% vs 1.2%, p = 0.0001, respectively). Univariate analysis demonstrated that the median FMD significantly predicted CV events (odds ratio 2.78, 95% CI 1.35 to 5.71, p <0.001). Multivariate analysis, controlling for traditional CV risk factors, demonstrated that median FMD was the best independent predictor of long-term CV adverse events (odds ratio 2.93, 95% CI 1.28 to 6.68, p <0.001). In conclusion, brachial artery median FMD independently predicts long-term adverse CV events in healthy subjects with no apparent heart disease in addition to those derived from traditional risk factor assessment.

Effect of orthostasis on endothelial function: a gender comparative study

As the vascular endothelium has multiple functions, including regulation of vascular tone, it may play a role in the pathophysiology of orthostatic intolerance. We investigated the effect of orthostasis on endothelial function using EndoPAT®, a non-invasive and user-independent method, and across gender. As sex steroid hormones are known to affect endothelial function, this study examined the potential effect of these hormones on the endothelial response to orthostasis by including females at different phases of the menstrual cycle (follicular and luteal—where the hormone balance differs), and females taking an oral contraceptive. A total of 31 subjects took part in this study (11 males, 11 females having normal menstrual cycles and 9 females taking oral contraceptive). Each subject made two visits for testing; in the case of females having normal menstrual cycles the first session was conducted either 1–7 (follicular) or 14–21 days (luteal) after the start of menstruation, and the second session two weeks later, i.e., during the other phase, respectively. Endothelial function was assessed at baseline and following a 20-min orthostatic challenge (active standing). The EndoPAT® index increased from 1.71 ± 0.09 (mean ± SEM) at baseline to 2.07 ± 0.09 following orthostasis in females (p<0.001). In males, the index increased from 1.60 ± 0.08 to 1.94 ± 0.13 following orthostasis (p<0.001). There were no significant differences, however, in the endothelial response to orthostasis between females and males, menstrual cycle phases and the usage of oral contraceptive. Our results suggest an increased vasodilatatory endothelial response following orthostasis in both females and males. The effect of gender and sex hormones on the endothelial response to orthostasis appears limited. Further studies are needed to determine the potential role of this post orthostasis endothelial response in the pathophysiology of orthostatic intolerance.

Does brachial artery flow-mediated vasodilation provide a bioassay for NO?

This study sought to better define the role of NO in brachial artery flow-mediated vasodilation (FMD) in young, healthy humans. Brachial artery blood velocity and diameter were determined (ultrasound Doppler) in 8 volunteers (26 ± 1 year) before and after 5-minute forearm circulatory occlusion with and without intra-arterial infusion of the endothelial NO synthase inhibitor N(G)-monomethyl-L-arginine (L-NMMA; 0.48 mg/dL per minute). Control (CON) and L-NMMA trials were performed with the occlusion cuff placed in the traditional distal position, as well as proximal to the measurement site. FMD was significantly reduced, but not abolished, by L-NMMA in the distal cuff trial (8.9 ± 1.3%-6.0 ± 0.7%, CON versus L-NMMA; P=0.02), with no effect of L-NMMA on FMD with proximal cuff placement (10.6 ± 1.2%-12.4 ± 1.7%, CON versus L-NMMA; P=0.39). When the reduction in shear stimulus after L-NMMA was taken into account, no drug difference was observed for either distal (0.26 ± 0.02-0.23 ± 0.03, CON versus L-NMMA; P=0.40) or proximal (0.23 ± 0.08-0.23 ± 0.03, CON versus L-NMMA; P=0.89) FMD trials. These findings challenge the assertion that NO is obligatory for brachial artery FMD and call into question the sensitivity of this procedure for noninvasive determination of NO bioavailability in young, healthy humans.

Characterisation of hypertensive patients with improved endothelial function after dark chocolate consumption

Recent findings indicate an inverse relationship between cardiovascular disease and consumption of flavonoids. We aimed to identify clinical and vascular parameters of treated hypertensive who present beneficial effects of dark chocolate for one-week period on vascular function. Twenty-one hypertensive subjects, aged 40–65 years, were included in a prospective study with measurement of blood pressure (BP), brachial flow-mediated dilatation (FMD), peripheral arterial tonometry, and central hemodynamic parameters. These tests were repeated after seven days of eating dark chocolate 75 g/day. Patients were divided according to the response in FMD: responders (n = 12) and nonresponders (n = 9). The responder group presented lower age (54 ± 7 versus 61 ± 6 years, P = 0.037), Framingham risk score (FRS) (2.5 ± 1.8 versus 8.1 ± 5.1%, P = 0.017), values of peripheral (55 ± 9 versus 63 ± 5 mmHg, P = 0.041), and central pulse pressure (PP) (44 ± 10 versus 54 ± 6 mmHg, P = 0.021). FMD response showed negative correlation with FRS (r = −0.60, P = 0.014), baseline FMD (r = −0.54, P = 0.011), baseline reactive hyperemia index (RHI; r = −0.56, P = 0.008), and central PP (r = −0.43, P = 0.05). However, after linear regression analysis, only FRS and baseline RHI were associated with FMD response. In conclusion, one-week dark chocolate intake significantly improved endothelial function and reduced BP in younger hypertensive with impaired endothelial function in spite of lower cardiovascular risk.

Comparison of passive leg raising and hyperemia on macrovascular and microvascular responses

Passive leg raising is a simple diagnostic maneuver that has been proposed as a measure of arterial vasodilator reserve and possibly endothelial function. While passive leg raising has previously been shown to lower blood pressure, increase flow velocity and cause brachial artery dilation, its effects on microvascular flow has not been well studied. Also, passive leg raising has been directly compared previously to upper arm but never to lower arm occlusion of blood flow induced hyperemia responses. We compared changes in macrovascular indices measured by brachial artery ultrasound and microvascular perfusion measured by Laser Doppler Flowmetry induced by passive leg raising to those provoked by upper arm and lower arm induced hyperemia in healthy subjects. Upper arm induced hyperemia increased mean flow velocity by 398%, induced brachial artery dilatation by 16.3%, and increased microvascular perfusion by 246% (p<.05 for all). Lower arm induced hyperemia increased flow velocity by 227%, induced brachial artery dilatation by 10.8%, and increased microvascular perfusion by 281%. Passive leg raising increased flow velocity by 29% and brachial artery dilatation by 5.6% (p<.05 for all), but did not change microvascular perfusion (-5%, p=ns). In conclusion, passive leg raising increases flow velocity orders of magnitude less than does upper arm or lower arm induced hyperemia. Passive leg raising-induced brachial artery dilatation is less robust than either of these hyperemic techniques. Finally, although upper arm and lower arm hyperemia elicits macrovascular and microvascular responses, passive leg raising elicits only macrovascular responses.

Acute effects of ingestion of a novel whey-derived extract on vascular endothelial function in overweight, middle-aged men and women

Whey protein intake reduces CVD risk, but little is known whether whey-derived bioactive peptides regulate vascular endothelial function (VEF). We determined the impact of a whey-derived extract (NOP-47) on VEF in individuals with an increased cardiovascular risk profile. Men and women with impaired brachial artery flow-mediated dilation (FMD) (n 21, age 55 (sem 1·3) years, BMI 27·8 (sem 0·6) kg/m2, FMD 3·7 (sem 0·4) %) completed a randomised, cross-over study to examine whether ingestion of NOP-47 (5 g) improves postprandial VEF. Brachial artery FMD, plasma amino acids, insulin, and endothelium-derived vasodilators and vasoconstrictors were measured for 2 h after ingestion of NOP-47 or placebo. Acute NOP-47 ingestion increased FMD at 30 min (4·6 (sem 0·5) %) and 120 min (5·1 (sem 0·5) %) post-ingestion (P< 0·05, time × trial interaction), and FMD responses at 120 min were significantly greater in the NOP-47 trial compared with placebo (4·3 (sem 0·5) %). Plasma amino acids increased at 30 min following NOP-47 ingestion (P< 0·05). Serum insulin increased at 15, 30 and 60 min (P< 0·001) following NOP-47 ingestion. No changes were observed between the trials for plasma NO∙ and prostacyclin metabolites or endothelin-1. Ingestion of a rapidly absorbed extract derived from whey protein improved endothelium-dependent dilation in older adults by a mechanism independent of changes in circulating vasoactive compounds. Future investigation is warranted in individuals at an increased CVD risk to further elucidate potential health benefits and the underlying mechanisms of extracts derived from whey.

Evaluation of gender differences in endothelium-independent dilation using peripheral arterial tonometry

BACKGROUND

A change in peripheral arterial tonometry (PAT) in response to reactive hyperaemia is often used to provide a non-invasive measure of endothelium-dependent dilation (EDD). Reactive hyperaemia does not allow one to quantify endothelium-independent dilation (EID), which is part of overall vascular function. Although most research examining vascular function and cardiovascular disease has focused on EDD, there is evidence that cardiovascular risk factors may impair EID.

PURPOSE

To examine the microvascular vasodilation response to nitroglycerin (NTG) in healthy adults using PAT.

METHODS

Microvascular responses to reactive hyperaemia and NTG were evaluated in 86 (41 female and 45 male) healthy subjects (age 37 ± 5 years). Beat-to-beat plethysmographic measurements of finger arterial pulse waves were recorded for 5 min following reactive hyperaemia. After a 10-min rest period, sublingual NTG (0.4 mg) was administered and PAT signal changes were measured for 10 min. Peak reactive hyperaemic index (RHI) and peak NTG-mediated index (NMI) were determined in all subjects.

RESULTS

There were no significant gender differences in peak RHI (females: 2.07 ± 0.56 versus males: 1.91 ± 0.58, P = 0.20). Mean peak NMI for all subjects was 2.78 (± 1.49). Peak NMI was significantly greater in females than in males (3.11 ± 1.59 versus 2.50 ± 1.34, P = 0.05). Time to peak NMI was not significantly different between genders (7 min, 28 s [± 1 min, 47 s], versus 7 min, 14 s [± 1 min, 49 s], P = 0.58).

CONCLUSION

In this population of healthy adults, peak NMI was significantly greater in females than in males. These findings suggest that gender differences exist in the microvascular vasodilation responses to NTG using PAT.

Comparison of Hyperemic Changes in Carotid-Radial Pulse Wave Velocity by Upper and Lower Arm Cuff Occlusion

Carotid-radial pulse wave velocity (PWV) normally decreases following release of upper arm cuff occlusion (hyperemia). Lower arm (LA) elicits less brachial artery dilation than upper arm (UA) occlusion but more closely reflects endothelial function. Using applanation tonometry, we compared changes (Δ) in PWV induced by UA and LA hyperemia in 65 healthy participants. Pulse wave velocity was measured serially. Both techniques decreased PWV maximally at 1 minute with gradual return to baseline by 9 minutes. ΔPWV1min was greater for UA than LA occlusion (-11.5% vs -6.8%, P = .02). Multivariate analysis showed arm location independently related to ΔPWV (P = .036). In participants with variable cardiovascular risk, PWV decline lessened with increasing Framingham risk for both techniques. In conclusion: UA and LA occlusion decrease PWV maximally at 1 minute after release of arterial occlusion. PWV 1 min decline are more marked after UA than LA occlusion and progressively lessens with increasing Framingham risk.

Endothelial function in a cardiovascular risk population with borderline ankle-brachial index

Introduction:

The diagnosis of peripheral arterial disease (PAD) can be made by measuring the ankle–brachial index (ABI). Traditionally ABI values > 1.00–1.40 have been considered normal and ABI ≤ 0.90 defines PAD. Recent studies, however, have shown that individuals with ABI values between 0.90–1.00 are also at risk of cardiovascular events. We studied this cardiovascular risk population subgroup in order to determine their endothelial function using peripheral arterial tonometry (PAT).

Methods:

We selected 66 individuals with cardiovascular risk and borderline ABI. They all had hypertension, newly diagnosed glucose disorder, metabolic syndrome, obesity, or a ten year risk of cardiovascular disease death of 5% or more according to the Systematic Coronary Risk Evaluation System (SCORE). Subjects with previously diagnosed diabetes or cardiovascular disease were excluded. Endothelial function was assessed by measuring the reactive hyperemia index (RHI) from fingertips using an Endo-PAT device.

Results:

The mean ABI was 0.95 and mean RHI 2.11. Endothelial dysfunction, defined as RHI < 1.67, was detected in 15/66 (23%) of the subjects. There were no statistically significant differences in RHI values between subjects with different cardiovascular risk factors. The only exception was that subjects with impaired fasting glucose (IFG) had slightly lower RHI values (mean RHI 1.91) than subjects without IFG (mean RHI 2.24) (P = 0.02).

Conclusions:

In a cardiovascular risk population with borderline ABI nearly every fourth subject had endothelial dysfunction, indicating an elevated risk of cardiovascular events. This might point out a subgroup of individuals in need of more aggressive treatment for their risk factors.

Prolonged ischaemia impairs muscle blood flow and oxygen uptake dynamics during subsequent heavy exercise

Muscle oxygen uptake ( ˙VO₂,mus) dynamics at the onset of exercise can be affected by prior heavy exercise.We tested the hypothesis that elevated forearm blood flow (FBF) following prior circulatory occlusion would also be associated with accelerated ˙VO₂,mus dynamics during subsequent heavy hand-grip exercise. Ten trained young men performed 5 min of heavy hand-grip exercise at 30% MVC as a control (CON), and four additional heavy bouts after brief recovery from: (1) prior heavy exercise (Heavy A), (2) heavy exercise followed by 2 min occlusion (Heavy B), (3) 15 min occlusion (Heavy C), and (4) 5 min occlusion with 1 min of moderate exercise during occlusion (Heavy D). FBF was measured by ultrasound and arterial venous oxygen content difference was calculated from venous blood samples to estimate ˙VO₂,mus. FBF and ˙VO₂,mus dynamics were quantified from the rise time. All priming conditions elevated FBF immediately before the start of subsequent heavy bout (Heavy A: 207.4 ±92.8, B: 207.8±75.8, C: 135.8±59.2, D: 199.5±59.0 vs. CON: 57.4±16.6mlmin−1, P <0.01). Unexpectedly, prior occlusion reduced FBF and O2 extraction at the onset of subsequent heavy exercise and consequently slowed ˙VO₂,mus dynamics (Heavy C: rise time=95.9±28.9 vs. CON: 58.6±14.3 s, P <0.01). FBF and ˙VO₂,mus dynamics were faster in Heavy A, B and D compared to CON (P <0.05). Overall, there was a positive correlation between the rise times for ˙VO₂,mus and FBF (r² =0.75) indicating that ˙VO₂,mus dynamics during heavy forearm exercise are linked to O₂ delivery in trained young men. To investigate a possible mechanism for slower adaptation of ˙VO₂,mus following ischaemia, the prior occlusion condition was repeated after ingesting a high dose of ibuprofen. This resulted in restoration of the FBF and ˙VO₂,mus to control levels suggesting that a prostaglandin-mediated mechanism after occlusion retarded the adaptation of blood flow and oxygen consumption at the onset of subsequent heavy exercise.

Assessment of flow-mediated dilation in humans: a methodological and physiological guideline

Endothelial dysfunction is now considered an important early event in the development of atherosclerosis, which precedes gross morphological signs and clinical symptoms. The assessment of flow-mediated dilation (FMD) was introduced almost 20 years ago as a noninvasive approach to examine vasodilator function in vivo. FMD is widely believed to reflect endothelium-dependent and largely nitric oxide-mediated arterial function and has been used as a surrogate marker of vascular health. This noninvasive technique has been used to compare groups of subjects and to evaluate the impact of interventions within individuals. Despite its widespread adoption, there is considerable variability between studies with respect to the protocols applied, methods of analysis, and interpretation of results. Moreover, differences in methodological approaches have important impacts on the response magnitude, can result in spurious data interpretation, and limit the comparability of outcomes between studies. This review results from a collegial discussion between physiologists with the purpose of developing considered guidelines. The contributors represent several distinct research groups that have independently worked to advance the evidence base for improvement of the technical approaches to FMD measurement and analysis. The outcome is a series of recommendations on the basis of review and critical appraisal of recent physiological studies, pertaining to the most appropriate methods to assess FMD in humans.

Nitric oxide and reactive hyperemia: role of location and duration of ischemia

BACKGROUND

Ischemia-induced reactive hyperemia (RH) is mediated by various factors including release of nitric oxide (NO). The contribution of NO to RH equals the extent of L-NMMA-dependent reduction of forearm blood flow (FBF). Because the optimal duration and location of ischemia that provokes maximum NO activation is unknown, we analyzed which duration and location stimulates most NO release, aiming at developing a noninvasive tool to measure endothelial integrity by NO synthase activity in humans.

METHODS

FBF was measured by strain gauge plethysmography after ischemia applied at the upper arm and wrist during intra-arterial infusion of L-NMMA or saline. To obtain similar FBF before RH, clamping with sodium nitroprissude was performed. Twenty-eight healthy male volunteers were randomly assigned to two groups (N = 15) undergoing ischemia of 1 and 5 min or 2 and 5 min (N = 13) at both locations.

RESULTS

Peak FBF was not affected by L-NMMA infusion. The change of FBF during L-NMMA expressed as area under the curve (AUC) of the first minute was significantly reduced after 1 (-0.70 +/- 1.63 ml, P < 0.001) and 2 min (1.67 +/- 2.65 ml, P < 0.01) of ischemia applied at wrist level compared to 5 min (7.49 +/- 7.92 ml). Ischemia applied to the upper arm showed no significant differences of FBF after L-NMMA or saline infusion, irrespective of the duration of ischemia.

CONCLUSIONS

Our data indicate that only immediately after ischemia the vasodilatatory response is most NO-dependent. RH as a test of NO activity in the forearm microcirculation should be applied at the wrist and last 1 min.

Nitric oxide is not obligatory for radial artery flow-mediated dilation following release of 5 or 10 min distal occlusion

This study investigated the nitric oxide (NO) dependence of radial artery (RA) flow-mediated dilation (FMD) in response to three different reactive hyperemia (RH) shear stimulus profiles. Ten healthy males underwent the following three RH trials: 1) 5 min occlusion (5 trial), 2) 10 min occlusion (10 trial), and 3) 10 min occlusion with cuff reinflation at 30 s (10–30 trial). Trials were performed during saline infusion and repeated during NG-monomethyl-l-arginine (l-NMMA) infusion in the brachial artery. RA blood flow velocity was measured with Doppler ultrasound, and B-mode RA images were analyzed using automated edge detection software. Shear rate estimation of shear stress was calculated as the blood flow velocity/vessel diameter. l-NMMA decreased baseline vascular conductance by 35%. l-NMMA infusion did not affect the peak shear rate stimulus ( P = 0.681) or the area under the curve (AUC) of shear rate to peak FMD ( P = 0.088). The AUC was significantly larger in the 10 trial vs. the 10–30 or 5 trial ( P < 0.001). Although percent FMD (%change in diameter) in the 10 trial was larger than that in the 5 trial ( P = 0.035), there was no significant difference in %FMD between the saline and l-NMMA conditions in any trial: 5 trial, 5.62 ± 1.48 vs. 5.63 ± 1.27%; 10 trial, 9.07 ± 1.16 vs. 11.22 ± 2.21%; 10–30 trial, 6.52 ± 1.43 vs. 7.98 ± 1.51% for saline and l-NMMA, respectively ( P = 0.158). We conclude the following: 1) RH following 10 min of occlusion results in an enhanced stimulus and %FMD compared with 5 min of occlusion. 2) When the occlusion cuff is reinflated 30 s postrelease of a 10 min occlusion, it does not result in an enhanced %FMD compared with that which results from RH following 5 min of occlusion. 3) The lack of effect of l-NMMA on FMD suggests that NO may not be obligatory for radial artery FMD in response to either 5 or 10 min of occlusion in healthy volunteers.

Noninvasive assessment of subclinical atherosclerosis in children and adolescents: recommendations for standard assessment for clinical research: a scientific statement from the American Heart Association

Deterioration in endothelial function and arterial stiffness are early events in the development of cardiovascular diseases. In adults, noninvasive measures of atherosclerosis have become established as valid and reliable tools for refining cardiovascular risk to target individuals who need early intervention. With limited pediatric data, the use of these techniques in children and adolescents largely has been reserved for research purposes. Therefore, this scientific statement was written to (1) review the current literature on the noninvasive assessment of atherosclerosis in children and adolescents, (2) make recommendations for the standardization of these tools for research, and (3) stimulate further research with a goal of developing valid and reliable techniques with normative data for noninvasive clinical evaluation of atherosclerosis in pediatric patients. Precise and reliable noninvasive tests for atherosclerosis in youth will improve our ability to estimate future risk for heart attack and stroke. Currently, large longitudinal studies of cardiovascular risk factors in youth, such as the Bogalusa and Muscatine studies, lack sufficient adult subjects experiencing hard outcomes, such as heart attack and stroke, to produce meaningful risk scores like those developed from Framingham data.

Relationship between upper limb peripheral artery stiffness using the radial artery and atherosclerotic parameters

PURPOSE

A new method has been developed for evaluating arterial stiffness using transcutaneous and high-frequency ultrasound. There may be a difference in the clinical significance of peripheral arteries, such as the radial artery (a muscular property), and other medium/large-sized arteries (an elastic property). The aim of this study was to determine the relationship between upper limb peripheral arterial stiffness (ULPAS) using the new method for the radial artery and atherosclerotic parameters in comparison with carotid intima-media thickness (IMT) and cardio-ankle vascular index (CAVI) in a healthy population and a diseased population with hypertension (HT) and diabetes mellitus (DM).

METHODS

Forty-four apparently healthy individuals (mean age = 26.3 years, men/women = 14/30), 45 patients with drug-treated HT (mean age = 55.3 years, men/women = 17/28), and 37 patients with drug-treated DM (mean age = 55.2 years, men/women = 21/16) were investigated. Body mass index, systolic blood pressure (SBP), diastolic blood pressure (DBP), CAVI, IMT, ultrasonographically measured ULPAS, blood lipid/glucose-related parameters, and C-reactive protein (CRP) were all determined.

RESULTS

Among the healthy subjects, ULPAS showed a significantly positive correlation with SBP and CRP. ULPAS showed a different correlation pattern with atherosclerotic parameters from that of IMT and CAVI. The HT subjects had significantly higher ULPAS levels than those with DM. In this diseased population, ULPAS showed a significant positive correlation with SBP and DBP, as well as a significant negative correlation with glucose.

CONCLUSION

These results suggest that ULPAS may provide new information in association with some atherosclerotic conditions as a unique index different from IMT and CAVI.

Measurement of endothelial function and its clinical utility for cardiovascular risk

Over the past two decades, the central role of the endothelium in the initiation, progression, and clinical sequelae of atherosclerosis has been increasingly recognized. Assessment of the pathobiology of the endothelium and its ability to act as a potential therapeutic target remains an area of active research interest. Whilst endothelial function has been shown to be a marker for risk of cardiovascular events in high-risk groups, there remains considerable debate about the most appropriate way to assess this. We discuss the different clinical methods to assess endothelial function, focusing on flow-mediated dilatation (FMD) of the brachial artery, highlighting the importance of using a standardized methodology, as well as discussing the clinical limitations of using FMD in individuals.

Long-term association of brachial artery flow-mediated vasodilation and cardiovascular events in middle-aged subjects with no apparent heart disease

BACKGROUND

Endothelial dysfunction is considered an important prognostic factor in atherosclerosis. The aim of this study was to detect the long-term association of peripheral vascular endothelial function and clinical outcome in healthy subjects without apparent coronary artery disease (CAD).

METHODS

We prospectively assessed brachial flow-mediated dilation (FMD) in 435 consecutive healthy subjects: 281 (65%) men, mean age 54+/-12 years and body mass index 28+/-4 kg/m(2). After overnight fasting and discontinuation of all medications for > or =12 h, FMD and endothelium-independent nitroglycerin-mediated vasodilation were assessed using high resolution linear array ultrasound.

RESULTS

Subjects were divided into 2 groups: below (n=221) and above (n=214) the median FMD of 10.7%, and were comparable regarding CAD risk factors, lipoproteins, fasting glucose, C-reactive protein, and concomitant medications, with a mean clinical follow-up of 32+/-2 months. Composite cardiovascular endpoints (all-cause mortality, non-fatal myocardial infarction, heart failure or angina pectoris hospitalization, stroke, coronary artery bypass grafting and percutaneous coronary interventions) were significantly more common in subjects with below median FMD of 10.7%, than above (11.8% vs 4.7%, p=0.007, respectively). Univariate analysis demonstrated that median FMD significantly predicted cardiovascular events [odds ratio (OR) of 2.78 and 95% CI 1.35 to 5.71 (p=0.003)]. After multivariate analysis including conventional CAD risk factors, median FMD was the best independent predictor of long-term cardiovascular adverse events [OR of 2.70 and 95% CI 1.16 to 6.32 (p=0.011)].

CONCLUSIONS

Brachial artery median FMD independently predicts long-term adverse cardiovascular events in healthy subjects in addition to traditional risk factor assessment.

Video rate electrical impedance tomography of vascular changes: preclinical development

Peripheral vasculature disease is strongly correlated with cardiovascular-associated mortality. Monitoring circulation health, especially in the peripheral limbs, is vital to detecting clinically significant disease at a stage when it can still be addressed through medical intervention. Electrical impedance tomography (EIT) maps the electrical properties of tissues within the body and has been used to image dynamically varying physiology, including blood flow. Here, we suggest that peripheral vasculature health can be monitored with EIT by imaging the hemodynamics of peripheral vessels and the surrounding tissues during reactive hyperemia testing. An analysis based on distinguishability theory is presented that indicates that an EIT system capable of making measurements with a precision of 50 microV may be able to detect small changes in vessel size associated with variations in blood flow. An EIT system with these precision capabilities is presented that is able to collect data at frame rates exceeding 30 fps over a broad frequency range up to 10 MHz. The system's high speed imaging performance is verified through high contrast phantom experiments and through physiological imaging of induced ischemia with a human forearm. Region of interest analysis of the induced ischemia images shows a marked decrease in conductivity over time, changing at a rate of approximately -3 x 10(-7) S m(-1) s(-1), which is the same order of magnitude as reported in the literature. The distinguishability analysis suggests that a system such as the one developed here may provide a means to characterize the hemodynamics associated with blood flow through the peripheral vasculature.

The relation of arterial stiffness to endothelial function in healthy subjects

Local wall stiffness affects endothelial responsiveness but how global measures affect responsiveness is unanswered. We assessed this by comparing reactive hyperaemic responses of brachial diameter (RHRBD) with central (heart-to-brachial artery pulse wave velocity (PWV); large (C1)) and peripheral (C2) arterial stiffness. Twelve healthy subjects were investigated. RHRBD was induced via an upper- or forearm occluding cuff. Arterial diameter changes were measured using echo ultrasound. Arterial stiffness and RHRBD were compared using a Pearson correlation coefficient (r) and Bland-Altman analysis of Z-scores (indicated as 95% confidence intervals (CI) and expressed in units of standard deviation (SD) from the mean). Weak relations were found between upper-arm RHRBD responses and C2 (r = 0.56, P = 0.06; 95% CI +/- 1.84 SDs) and C1 (r = 0.55, P = 0.06; 95% CI +/- 1.86 SDs). An inverse relation was found between upper-arm RHRBD responses and PWV (r = -0.55, P = 0.06), but Bland-Altman plots revealed no agreement between these parameters (P > 0.05; 95% CI +/- 3.46 SDs). Forearm RHRBD were not related to PWV, C1 or C2 (P > 0.05; 95% CI > 2 SDs). The weak relation between upper-arm endothelial responses and C2 and C1 seems to suggest that C2, and also C1, is not a good and reliable method for assessments of endothelial health. Furthermore, if anything, upper-arm mediated RHRBD responses are more affected by arterial stiffness than forearm responses.

Peak vs. total reactive hyperemia: which determines the magnitude of flow-mediated dilation?

We investigated the independent contributions of the peak and continued reactive hyperemia on flow-mediated dilation (FMD). 1) For the duration manipulation experiment (DME), 10 healthy males experienced reactive hyperemia durations of 10 s, 20 s, 30 s, 40 s, 50 s, or full reactive hyperemia (RH). 2) For the peak manipulation experiment (PME), eight healthy males experienced reactive hyperemia trials with three peak shear rate magnitudes (large, medium, and small). Data are means ± SD. For the DME, peak shear rate was not different between trials ( P = 0.326). Shear rate area under the curve (AUC) was P < 0.001. Peak %FMD was dependent on shear rate AUC: 10 s, 2.7 ± 1.3; 20 s, 6.2 ± 1.9; 30 s, 7.9 ± 2.9; 40 s, 8.3 ± 3.2; 50 s, 7.9 ± 3.2; full RH, 9.3 ± 4.1, with 10 and 20 s less than full RH ( P < 0.001). For the PME, peak shear rate was different between trials (large, 1,049.1 ± 285.8; medium, 726.4 ± 228.8; small, 512.8 ± 161.8; P < 0.001). AUC of the continued shear rate was not ( P = 0.412). Peak %FMD was unaffected by peak shear rate (large, 7.0 ± 2.7%; medium, 7.4 ± 2.6%; small, 6.6 ± 1.8%; P = 0.542). Peak and AUC shear stimulus were not significantly related in full RH ( r2 = 0.35, P = 0.07). We conclude that the shear stimulus AUC, not the peak itself, is the critical determinant of the peak FMD response. This indicates AUC as the best method of quantifying reactive hyperemia shear stimulus for %FMD normalization.

Flow mediated dilation of the brachial artery: an investigation of methods requiring further standardization

Background

In order to establish a consistent method for brachial artery reactivity assessment, we analyzed commonly used approaches to the test and their effects on the magnitude and time-course of flow mediated dilation (FMD), and on test variability and repeatability. As a popular and noninvasive assessment of endothelial function, several different approaches have been employed to measure brachial artery reactivity with B-mode ultrasound. Despite some efforts, there remains a lack of defined normal values and large variability in measurement technique.

Methods

Twenty-six healthy volunteers underwent repeated brachial artery diameter measurements by B-mode ultrasound. Following baseline diameter recordings we assessed endothelium-dependent flow mediated dilation by inflating a blood pressure cuff either on the upper arm (proximal) or on the forearm (distal).

Results

Thirty-seven measures were performed using proximal occlusion and 25 with distal occlusion. Following proximal occlusion relative to distal occlusion, FMD was larger (16.2 ± 1.2% vs. 7.3 ± 0.9%, p < 0.0001) and elongated (107.2 s vs. 67.8 s, p = 0.0001). Measurement of the test repeatability showed that differences between the repeated measures were greater on average when the measurements were done using the proximal method as compared to the distal method (2.4%; 95% CI 0.5–4.3; p = 0.013).

Conclusion

These findings suggest that forearm compression holds statistical advantages over upper arm compression. Added to documented physiological and practical reasons, we propose that future studies should use forearm compression in the assessment of endothelial function.

What is the most appropriate methodology for detection of conduit artery endothelial dysfunction?

BACKGROUND

Use of upper-arm arterial occlusion to induce reactive hyperemia, and endothelium-dependent flow-mediated dilation (FMD) of the brachial artery, induces greater conduit vessel dilatation than lower-arm occlusion. However, brachial artery ischemia after upper arm arterial occlusion may make this approach unreliable. We studied whether upper or lower arm occlusions differ in their ability to detect endothelial dysfunction in cigarette smokers, and its improvement with an antioxidant strategy.

METHODS AND RESULTS

Ten cigarette smokers with a >20 pack year history and 10 age- and gender-matched healthy controls participated in a 2-phase randomized controlled study of xanthine oxidase inhibition, using a 600-mg oral dose of allopurinol administered beforehand. Endothelium-dependent dilatation was assessed using ultrasound-Doppler after lower and upper arm occlusion. After lower arm occlusion, FMD was significantly impaired in smokers compared with controls (3.8+/-1.1% versus 8.7+/-2.2%; P=0.001). However, after upper arm occlusion, brachial artery dilatation in smokers was higher (11.8+/-2.7%; P<0.0001 versus lower arm) and did not differ from controls (9.4+/-2.9%; P=0.3). There was no difference in endothelium-independent dilatation to sublingual nitroglycerin between smokers and controls. Inhibition of xanthine oxidase with allopurinol improved lower arm FMD (3.8+/-1.1 to 10.1+/-1.9%; P<0.0001), but did not improve upper arm FMD (11.8+/-2.7 to 14.1+/-3.7%; P=0.4).

CONCLUSIONS

Although upper arm occlusion induces robust brachial vasodilatation, it cannot detect endothelial dysfunction induced by smoking or its improvement by inhibition of xanthine oxidase. The increase in brachial artery diameter with upper arm occlusion may be confounded by ischemia of the artery. Conduit artery FMD after release of lower arm occlusion appears to be a more valid method for assessment of endothelial function in humans.

Inhalation of ultrafine and fine particulate matter disrupts systemic vascular function

This study investigated the effects of particulate matter (PM) with aerodynamic diameter 0.02-1 microm (noted as PM1) inhalation during exercise on conduit artery and microvascular function. Inhalation of internal combustion-derived PM is associated with cardiovascular mortality and morbidity. Direct action of PM on the vascular endothelium is likely, as a substantial fraction of ultrafine PM translocates from the alveoli to the circulatory system. Sixteen intercollegiate athletes performed 30 min of exercise while inhaling low or high PM1. Flow-mediated brachial artery dilation (FMD) using high-resolution ultrasonography with simultaneous measurements of forearm oxygen kinetics using near infrared spectrophotometry (NIRS) was done before and after exercise. Basal brachial artery vasoconstriction was found after high PM1 exercise (4.0%, 4.66 +/- 0.609 to 4.47 +/- 0.625 mm diameter; p = .0002), but not after low PM1 exercise (-0.3%, 4.66 +/- 0.626 to 4.68 +/- 0.613 mm diameter). FMD was impaired after high PM1 exercise (6.8 +/- 3.58% for preexercise FMD and 0.30 +/- 2.74% for postexercise FMD, p = .0001), but not after low PM1 exercise (6.6 +/- 4.04% for preexercise FMD and 4.89 +/- 4.42% for postexercise FMD). Reduction in forearm muscle reperfusion estimated by reoxygenation slope-to-baseline after 4 min cuff ischemia was observed for high PM1 exercise (55% vs. 3%, p = .0006); no difference was noted for low PM1 exercise. Brachial artery FMD was significantly correlated to muscle reoxygenation slope-to-baseline (r = .50, p = .005). Acute inhalation of high [PM1] typical of urban environments impairs both systemic conduit artery function and microcirculation. The observed decrease reoxygenation slope-to-baseline after cuff release is consistent with reduced blood flow in the muscle microvasculature.

A comparison between active- and reactive-hyperaemia-induced brachial artery vasodilation

The measurement of brachial artery vasodilation in response to a hyperaemic stimulus has been used extensively to assess changes in endothelial function. However, whether or not similar changes occur in response to an active hyperaemic stimulus is unknown. The purpose of the present study was to compare brachial artery vasodilation in response to an active compared with a reactive hyperaemic stimulus following a known perturbation of endothelial function. Eight apparently healthy adults were assigned to four treatment conditions in a counter-balanced design: (i) low-fat meal with active hyperaemic stimulus (LFM-A), (ii) high-fat meal with active hyperaemic stimulus (HFM-A), (iii) low-fat meal with reactive hyperaemic stimulus (LFM-R), and (iv) high-fat meal with reactive hyperaemic stimulus (HFM-R). Meals were ingested at 08:00 hours on each treatment day. Brachial artery vasodilation was assessed via ultrasound 4 h after ingestion of each meal. The active hyperaemic stimulus was induced by 5 min of rhythmic handgrip exercise, whereas reactive hyperaemia was induced by 5 min of forearm occlusion. Brachial artery vasodilation was expressed as the percentage change in diameter from baseline to post-active/reactive hyperaemia. Using a 2x2 repeated measures ANOVA, a significant stimulusxmeal interaction (P=0.025) was found. Simple main effects revealed no difference (P=0.541) in brachial artery vasodilation between LFM-A (5.75+/-1.64%) and HFM-A (6.39+/-1.45%); however, a significant decrease (P=0.014) in brachial artery vasodilation was found in the HFM-R (4.29+/-1.64%) compared with the LFM-R (7.18+/-1.13%) treatment. In conclusion, the measurement of brachial artery vasodilation in response to active hyperaemia did not detect a change in endothelial function following a single perturbation meal, whereas reactive hyperaemia did.

Colombian study to assess the use of noninvasive determination of the endothelium-mediated vasodilation (CANDEV) II: does location of the occlusion device affects the accuracy of the diagnosis?

Endothelial dysfunction (ED), which is often evaluated by flow-mediated vasodilation (FMV) in the brachial artery, has been postulated as a predictor of cardiac events. Although the upper and forearm location of the occlusion device have been used for FMV evaluation, currently there is no consensus whether they provide the same information. The main goal of this study was to evaluate if both techniques have the same accuracy to differentiate subjects with and without cardiovascular risk factors (CRFs). A cross-sectional study in 124 subjects was performed. The volunteers were divided in two groups: 62 subjects (20 women and 42 men) with at least one CRF and 62 (20 women and 42 men) healthy subjects without CRFs. FMV measurements using the cuff in the upper arm and forearm with intervals of 30 min were taken. In all subjects, %FMV with the cuff located in the upper arm was 10.13 +/- 4.5 and 9.8 +/- 4.1 with the cuff located below the elbow. In healthy subjects without CRFs the %FMV in the upper arm was 12.19 +/- 4.0 versus 12.31 +/- 3.4 in the upper forearm, in CRF subjects it was 8.08 +/- 4.0 vs 7.29 +/- 3.2., respectively. FMV was not affected by the location of the cuff in maintaining the test ability and accuracy to differentiate subjects with and without CRFs.

The relationship between shear stress and flow-mediated dilatation: implications for the assessment of endothelial function

Endothelium-dependent flow-mediated dilatation (FMD) describes the vasodilatory response of a vessel to elevations in blood flow-associated shear stress. Nitric oxide (NO), one of many vasoactive substances released by the endothelium in response to shear stress, is of particular interest to researchers as it is an antiatherogenic molecule, and a reduction in its bioavailability may play a role in the pathogenesis of vascular disease. The goal of many human studies is to create a shear stress stimulus that produces an NO-dependent response in order to use the FMD measurements as an assay of NO bioavailability. The most common non-invasive technique is the 'reactive hyperaemia test' which produces a large, transient shear stress profile and a corresponding FMD. Importantly, not all FMD is NO mediated and the stimulus creation technique is a critical determinant of NO dependence. The purpose of this review is to (1) explain that the mechanisms of FMD depend on the nature of the shear stress stimulus (stimulus response specificity), (2) provide an update to the current guidelines for FMD assessment, and (3) summarize the issues that surround the clinical utility of measuring both NO- and non-NO-mediated FMD. Future research should include (1) the identification and partitioning of mechanisms responsible for FMD in response to various shear stress profiles, (2) investigation of stimulus response specificity in coronary arteries, and (3) investigation of non-NO FMD mechanisms and their connection to the development of vascular disease and occurrence of cardiovascular events.

Is endothelial function impaired in erectile dysfunction patients?

Erectile dysfunction (ED) and vascular disease are thought to be linked at the level of the endothelium. Endothelial dysfunction, resulting in the inability of the smooth muscle cells lining the arterioles to relax, prevents vasodilatation. Likewise, penile erection depends on the relaxation of smooth muscle in the corpus cavernosum and the wall of small arteries. The aim was to assess the systemic vascular function in patients with ED. In all, 32 ED patients diagnosed with Doppler Ultrasound and the International Index of Erectile Function-5-item questionnaire and 25 healthy men as a control group enrolled to the study. They all underwent the tests including serum glucose and lipid levels. Echocardiography and exercise stress test was performed routinely. Baseline demographics (body mass index, heart rate and blood pressures), fasting glucose and lipid levels were not significantly different between ED and control groups. Endothelial-dependent brachial artery flow-mediated vasodilatation and brachial artery response to 0.4 mg nitroglycerine (NTG) were measured. Participants were negative on exercise stress test, and echocardiographic parameters including ejection fraction were similar. Endothelial-dependent brachial artery percent diameter change with flow-mediated dilatation (6.01+/-2.9 vs 12.3+/-3.5) and brachial artery response to NTG (12.8+/-4.2 vs 17.8+/-5.2) were significantly different between groups (P<0.001). We found that endothelial function was impaired in ED patients with no apparent cardiovascular disease and diabetes mellitus. This impaired function might be explained by the abnormality in systemic nitric oxide-cyclic guanosine monophosphate vasodilator system and suggest that ED and vascular disease may be linked at the level of the endothelium.

Evaluation of arterial endothelial function using transit times of artificially induced pulses

Impairment of arterial endothelial function is an early event in atherosclerosis and correlates with the major risk factors for cardiovascular disease. The most widely employed non-invasive measure of endothelial function involves brachial artery (BA) diameter measurement using ultrasound imaging before and after several minutes of blood flow occlusion. The change in arterial diameter is a measure of flow-mediated vasorelaxation (FMVR). The high between-laboratory variability of results and cost of instrumentation render this technique unsuitable for routine clinical use. We induce artificial pulses at the superficial radial artery using a linear actuator. An ultrasonic Doppler stethoscope detects these pulses 10-30 cm proximal to the point of pulse induction. The delay between pulse application and detection provides the pulse transit time (PTT). By measuring PTT before and after 5 min of BA occlusion and ensuing reactive hyperemia, FMVR may be measured based on the changes in PTT caused by changes in vessel caliber, smooth muscle tone and wall thickness. We (1) validate the sensitivity of this technique to arterial wall tone using sublingual nitroglycerin and (2) compare measurements of endothelial function to ultrasound BA diameter measurements in 12 human subjects. The PTT-based method is verified to measure arterial wall tone and is shown to provide 37% greater sensitivity (p < 0.05) to FMVR than BA diameter measurements. By measuring the change in pulse transit time before and after endothelial stimulus, a sensitive, reproducible and convenient measure of endothelial function may be obtained at a low cost.

Why is flow-mediated dilation dependent on arterial size? Assessment of the shear stimulus using phase-contrast magnetic resonance imaging

Flow-mediated dilation (FMD) is strongly dependent on arterial size, but the reasons for this phenomenon are poorly understood. We have previously shown that FMD is greater in small brachial arteries because the shear stress stimulus is greater in small brachial arteries. However, it is unclear why the shear stimulus is greater in small arteries. Furthermore, this relationship has not been investigated in other, differently sized arterial beds. Postischemic systolic shear stress and resulting FMD were evaluated in the brachial and femoral arteries of 24 young, healthy adults using phase-contrast magnetic resonance imaging. Arterial shear and radius were calculated from the velocity profile via a best-fit parabola before and after occlusion. Summing the velocity pixels provided hyperemic systolic flow. FMD was proportional to hyperemic shear in the brachial and femoral arteries ( P < 0.0001, r = 0.60). Hyperemic systolic flow was proportional to radius2 ( P < 0.0001, r = 0.93). Applying this relationship to the Poiseuille equation (shear is proportional to flow/radius3) shows that hyperemic shear is proportional to radius2/radius3 and, therefore, explains why hyperemic shear is proportional to 1/radius. We conclude that FMD is proportional to hyperemic systolic shear stress in both the brachial and the femoral arteries. The hyperemic shear stimulus for FMD is greater in small arteries due to the dependence of postischemic systolic flow on radius squared. Therefore, greater FMD in small arteries does not necessarily reflect better conduit artery endothelial function. Evaluating the shear stimulus using phase-contrast magnetic resonance imaging enhances the understanding of mechanisms underlying FMD.

Assessment of flow-mediated vasodilatation (FMD) of the brachial artery: effects of technical aspects of the FMD measurement on the FMD response

AIMS

The ability to assess endothelial function non-invasively with B-mode ultrasound has lead to its widespread application in a variety of studies. However, the absolute values obtained using this approach vary considerably across studies. We studied whether technical aspects of the methodology can explain the wide variety in absolute values across studies.

METHODS AND RESULTS

A literature search was performed to identify published reports on flow-mediated vasodilatation (FMD) of the brachial artery published between 1992 and 2001. Information on type of equipment (wall track/B-mode), location of the measurement (antecubital fossa/upper arm), occlusion site (lower/upper arm), occlusion duration (min), and occlusion pressure was extracted. Patient characteristics were also extracted. For the healthy populations, mean FMD varied from 0.20 to 19.2%; for the coronary heart disease (CHD) patients FMD varied from -1.3 to 14%; for subjects with diabetes mellitus FMD varied from 0.75 to 12%. Compared with occlusion at the upper arm, lower arm occlusion was related to decreased FMD (mean difference in FMD -2.47%; 95% CI 0.55-4.39). An occlusion duration of > or =4.5 min was related to an increased FMD compared with an occlusion time of < or =4 min (mean difference 1.30%; 95% CI 0.35-2.46). These findings were adjusted for other technical aspects of the methodology and for differences in risk factors between populations.

CONCLUSION

Mean FMD differs widely between studies. There is a great overlap between populations (healthy, CHD, diabetics). Our findings suggest that the technical aspects of the measurements, the location, and the duration of the occlusion may explain some of these differences, whereas type of equipment, location of the measurement, and occlusion pressure do not.

Flow-mediated dilation in human brachial artery after different circulatory occlusion conditions

Different magnitudes and durations of postocclusion reactive hyperemia were achieved by occluding different volumes of tissue with and without ischemic exercise to test the hypotheses that flow-mediated dilation (FMD) of the brachial artery would depend on the increase in peak flow rate or shear stress and that the position of the occlusion cuff would affect the response. The brachial artery FMD response was observed by high-frequency ultrasound imaging with curve fitting to minimize the effects of random measurement error in eight healthy, young, nonsmoking men. Reactive hyperemia was graded by 5-min occlusion distal to the measurement site at the wrist and the forearm and proximal to the site in the upper arm. Flow was further increased by exercise during occlusion at the wrist and forearm positions. For the two wrist occlusion conditions, flow increased eightfold and FMD was only 1 to 2% (P > 0.05). After the forearm and upper arm occlusions, blood flow was almost identical but FMD after forearm occlusions was 3.4% (P < 0.05), whereas it was significantly greater (6.6%, P < 0.05) and more prolonged after proximal occlusion. Forearm occlusion plus exercise caused a greater and more prolonged increase in blood flow, yet FMD (7.0%) was qualitatively and quantitatively similar to that after proximal occlusion. Overall, the magnitude of FMD was significantly correlated with peak forearm blood flow (r = 0.59, P < 0.001), peak shear rate (r = 0.49, P < 0.002), and total 5-min reactive hyperemia (r = 0.52, P < 0.001). The prolonged FMD after upper arm occlusion suggests that the mechanism for FMD differs with occlusion cuff position.