Obesity/insulin resistance is associated with endothelial dysfunction. Implications for the syndrome of insulin resistance

Peroxisome proliferator-activated receptor-γ and the endothelium: implications in cardiovascular disease

Peroxisome proliferator-activated receptors-γ (PPARγs) are ligand-activated transcription factors that play a crucial regulatory role in the transcription of a large number of genes involved in lipid metabolism and inflammation. In addition to physiological ligands, synthetic ligands (the thiazoledinediones) have been developed. In spite of the much publicized adverse cardiovascular effects of one such thiazoledinedione (rosiglitazone), PPARγ activation may have beneficial cardiovascular effects. In this article we review the effects of PPARγ activation on the endothelium with special emphasis on the possible implications in cardiovascular disease. We discuss its possible role in inflammation, vasomotor function, thrombosis, angiogenesis, vascular aging and vascular rhythm. We also briefly review the clinical implications of these lines of research.

The role of IGF-1 resistance in obesity and type 2 diabetes-mellitus-related insulin resistance and vascular disease

IMPORTANCE OF THE FIELD

The insulin-resistant conditions of type 2 diabetes mellitus (T2DM) and obesity are a major cause of cardiovascular disease on a global scale. These disorders are not only a cause of ill health but are a huge financial drain on healthcare systems. T2DM leads to an increased risk of cardiovascular mortality equivalent to over 10 years of ageing while obesity independent of T2DM also leads to a substantially increased risk of acute myocardial infarction. Recent trials of therapeutic agents and approaches to preventing the cardiovascular complications of type 2 diabetes have been disappointing.

AREAS COVERED IN THIS REVIEW

The role of insulin resistance in the endothelium in the regulation of the anti-atherosclerotic signalling molecule NO and a potential important role for IGF-1 in vascular NO production.

WHAT THE READER WILL GAIN

A comprehensive understanding of how insulin and IGF-1 regulate vascular function and the effect of type 2 diabetes on these pathways.

TAKE HOME MESSAGE

The roles of insulin and IGF-1 in vascular function are complex and intimately related. Nevertheless IGF-1 signalling in the arterial wall has the potential to be manipulated to protect the vasculature against the development of atherosclerosis and its devastating complications.

Contribution of insulin resistance to vascular dysfunction

Insulin is a vascular hormone, able to influence vascular cell responses. In this review, we consider the insulin actions on vascular endothelium and on vascular smooth muscle cells (VSMC) both in physiological conditions and in the presence of insulin resistance. In particular, we focus the relationships between activation of insulin signalling pathways of phosphatidylinositol-3 kinase (PI3-K) and mitogen-activated protein kinase (MAPK) and the different vascular actions of insulin, with a particular attention to the insulin ability to activate the pathway nitric oxide (NO)/cyclic GMP/PKG via PI3-K, owing to the peculiar relevance of NO in vascular biology. We also discuss the insulin actions mediated by the MAPK pathway (such as endothelin-1 synthesis and secretion and VSMC proliferation and migration) and by the interactions between the two pathways, both in insulin-sensitive and in insulin-resistant states. Finally, we consider the influence of free fatty acids, cytokines and endothelin on vascular insulin resistance.

Vascular insulin response is preserved in non‐diabetic patients with coronary artery disease, despite endothelial dysfunction

BACKGROUND

Patients with coronary artery disease (CAD) are often insulin resistant, a state that predisposes to increased atherosclerosis. Recently, it was suggested that a "vascular insulin resistance" could explain this association, causing endothelial dysfunction and hence atherosclerosis. We therefore studied the vascular insulin response in patients with CAD.

MATERIALS AND METHODS

Nine non-diabetic patients with documented CAD and 31 lean healthy controls were examined. Forearm blood flow was measured by venous occlusion plethysmography. Dose-response studies of acetylcholine (ACh) and sodium nitroprusside (SNP) elicited endothelium-dependent and -independent vasodilation and were repeated during intra-arterial insulin infusion.

RESULTS

Patients were insulin resistant as determined by HOMA index. Insulin infusion resulted in high physiological levels of insulin in the forearm without systemic effects. Patients had a reduced ACh response but insulin infusion increased the ACh response equally in patients and controls (a mean increase of 74+/-37 vs 57+/-24%, patients vs controls, p=0.12). A minor increase of the SNP response was also noted during insulin infusion.

CONCLUSION

Vascular insulin response is intact in non-diabetic CAD patients in spite of insulin resistance and endothelial dysfunction.

Microcirculation and oxidative stress

The microcirculation is a complex and integrated system, transporting oxygen and nutrients to the cells. The key component of this system is the endothelium, contributing to the local balance between pro and anti-inflammatory mediators, hemostatic balance, as well as vascular permeability and cell proliferation. A constant shear stress maintains vascular endothelium homeostasis while perturbed shear stress leads to changes in secretion of vasodilator and vasoconstrictor agents. Increased oxidative stress is a major pathogenetic mechanism of endothelial dysfunction by decreasing NO bioavailability, promoting inflammation and participating in activation of intracellular signals cascade, so influencing ion channels activation, signal transduction pathways, cytoskeleton remodelling, intercellular communication and ultimately gene expression. Targeting the microvascular inflammation and oxidative stress is a fascinating approach for novel therapies in order to decrease morbidity and mortality of chronic and acute diseases.

Novel therapies targeting vascular endothelium

Endothelial dysfunction has been identified as a major mechanism involved in all the stages of atherogenesis. Evaluation of endothelial function seems to have a predictive role in humans, and therapeutic interventions improving nitric oxide bioavailability in the vasculature may improve the long-term outcome in healthy individuals, high-risk subjects, or patients with advanced atherosclerosis. Several therapeutic strategies are now available, targeting both the synthesis and oxidative inactivation of nitric oxide (NO) in human vasculature. Statins seem to be currently the most powerful category of these agents, improving endothelial function and decreasing cardiovascular risk after long-term administration. Other cardiovascular agents improving endothelial function in humans are angiotensin-converting enzyme inhibitors/angiotensin receptors blockers, which increase NO bioavailability by modifying the rennin-angiotensin-aldosterone system. Newer therapeutic approaches targeting endothelial dysfunction in specific disease states include insulin sensitizers, L-arginine (the substrate for endothelial NO synthase [eNOS]) as well as substances that target eNOS "coupling," such as folates or tetrahydrobiopterin. Although there are a variety of strategies to improve NO bioavailability in human endothelium, it is still unclear whether they have any direct benefit at a clinical level.

Cardiovascular consequences of the obesity pandemic: need for action

Due to changes in nutritional patterns and physical activity as well as economic growth in developing countries, the prevalence of obesity has reached pandemic proportions in the past decades. Consequences of diseases related to obesity, such as coronary heart disease, hypertension, diabetes and renal disease, account for much of the morbidity in these patients and are rarely treated adequately. There is an enormous need to provide information to the general population and particularly parents concerning the risks of childhood obesity and the importance of regular exercise. Physicians and scientists have now realised that obesity is a pathophysiological entity with important clinical complications. Current actions to prevent obesity should not only be directed towards the development of drugs controlling weight gain, but should also include educational programs, which will guarantee adequate awareness and prevention of this disease.