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Endothelial Dysfunction (Vascular Dysfunction) and Various Diseases This slide shows the extent of involvement of endothelial dysfunction in various diseases, much like a high blood pressure measurement or fever that is indicative of different problems. This is why we believe endothelial function monitoring will be adopted as part of routine vital sign monitoring, not as an indicator of an acute condition but rather for chronic health and preventive maintenance.

(S) The vascular endothelium serves multiple functions: Endothelial cells serve multiple functions. (S) The vascular endothelium serves multiple functions: it regulates fluid and molecule traffic between blood and tissues it is an anti-coagulant surface it contributes to vascular homeostasis and repair it plays a vital role in vascular tone and blood flow regulation *** Assessing this function is the most practical way of measuring endothelial function.

Endothelial and Vascular Dysfunction: A “Barometer of Cardiovascular Risk” Marker of the inherent atherosclerotic risk An integrated index of both the overall CV risk factor burden and the sum of all vasculoprotective factors in an individual. Aging Diet Smoking Inactivity Diabetes ↑ Cholesterol ↑ Blood Pressure Oxidative Stress Genetics Medications

Brachial Artery Ultrasound with FMD BASELINE POST OCCLUSION CP914474 Lerman, A pjs 03-03-2000

Reactive Hyperemia Reactive hyperemia is the transient increase in organ blood flow that occurs following a brief period of ischemia (e.g., arterial occlusion). The left panel shows the effects of a 2 min arterial occlusion on blood flow. In this example, blood flow goes to zero during arterial occlusion. When the occlusion is released, blood flow rapidly increases (i.e., hyperemia occurs) that lasts for several minutes. The hyperemia occurs because during the period of occlusion, tissue hypoxia and a build up of vasodilator metabolites (e.g., adenosine) dilate arterioles and decrease vascular resistance. Then when perfusion pressure is restored (i.e., occlusion released), flow becomes elevated because of the reduced vascular resistance. During the hyperemia, the tissue becomes reoxygenated and vasodilator metabolites are washed out of the tissue. This causes the resistance vessels to regain their normal vascular tone, thereby returning flow to control. http://www.cvphysiology.com/Blood%20Flow/BF006.htm

Endothelial Function Basic Science to Clinical Practice Comparison peripheral and coronary endothelial function Discovery of NO and the role of the endothelium Endothelial function with exercise and mental stress Endothelial function and myocardial ischemia FDA approved device to assess endothelial function 1980 1989 1995 1995- 1997 2005 Comparison between the PAT and coronary endothelial function 2006 Coronary endothelial function in clinical practice Association between endothelial function and CV events First endothelial function in humans Noninvasive endothelial function 1986 1992 1996 2000- 2004 2005 Clinical practice Basic science CP914474 Lerman, A pjs 03-03-2000

Brachial Artery Ultrasound FMD VENDYS® - Endothelix, Inc. Moving Endothelial Function Testing out of the Research Lab and into Doctors Offices Brachial Artery Ultrasound FMD VENDYS® - Endothelix, Inc. Ultrasound measurement of brachial artery dilation 15-minute test Not automated Requires skilled operator Fingertip temperature changes 15-minute test Fully automated Operator independent

What is VENDYS® technology?

How does VENDYS® measure vascular function?

VENDYS® Vascular Function Monitoring Blood Pressure “Occluding” Cuff on Right Upper Arm Fingertip Temperature Sensors on Both Index Fingers

VENDYS® Vascular Function Monitoring

Infrared Imaging Cuff inflated Post cuff deflation

To schedule a free demo or learn more, send an email to info@endothelix.com.

VENDYS® Portable A complete system to perform automated, vascular function studies Cuff management module (CMM) Digital thermal monitoring (DTM) module VENDYS® fingertip probes Laptop computer with pre-installed software Data acquisition Report generation and data tabulation

Software Screenshots The VENDYS Report

Software Screenshots Report Viewer

The VENDYS® Report Temperature Curves Vascular Reactivity Gauge Red = right finger Blue = left finger Vascular Reactivity Gauge Green = Good Yellow = Intermediate Red = Poor Flags help to notify user of conditions that may affect the technical quality of the study. A summary of VENDYS indices is shown here. aTR is the primary vascular reactivity index. Ambient room temperature is recorded throughout the study.

Sample Report Screen: “Good” Vascular Reactivity

Sample Report Screen: “Intermediate” Vascular Reactivity

Sample Report Screen: “Poor” Vascular Reactivity

Digital Thermal Monitoring of Vascular Function is Reproducible Reproducibility and Variability of Vascular Reactivity Measurement using Digital Thermal Monitoring Background: Previous studies demonstrated that Digital Thermal Monitoring (DTM) of vascular reactivity, a new test for vascular function assessment, is well-correlated with Framingham Risk Score, coronary calcium score and CT angiography. This study evaluates the variability and reproducibility of DTM measurements. We hypothesized that DTM is reproducible and its variability falls within the accepted range of clinical diagnostic tests. A fully automated DTM device (VENDYS, Endothelix Inc., Houston) was used for repeated measurement of vascular reactivity and endothelial function in 18 healthy volunteers (age 35�4 years, 74% male) after 24hours. All subjects underwent overnight fasting, and the test was preceded by 30 minute rest in a supine position inside a dimmed-room with temperature 22�C to 24 �C. The measurements were obtained during and after a 2 minute supra systolic arm-cuff occlusion induced reactive hyperemia procedure. Post cuff-deflation adjusted temperature rebound (TR) and AUC (area under the temperature curve), DTM indices of vascular function, were studied. Day to day coefficient of repeatability was 7.1 % for baseline temperature, 7.5% for mean blood pressure and 10.6% for heart rate. The coefficient of repeatability (CR) of TR and AUC were 2.4% and 2.8%, respectively. In a controlled-environment, the repeatability of DTM is excellent. DTM can be used as a reproducible and operator-independent test for measurement of vascular function in clinical trials and cardiovascular risk assessment clinics. Variable D SDD CV (%) CR (%) ICC P value Heart Rate 0.47 0.054 11.4 10.6 0.7 0.01 Mean Arterial Pressure 0.44 0.038 8.7 7.5 0.79 0.0005 Start Temperature 0.51 0.036 7.1 0.81 0.0001 DTM (VENDYS®) Indices of Vascular Function TR (°C) 0.209 0.012 5.7 2.4 0.82 AUC 0.292 0.014 4.8 2.8 0.83 D: mean absolute difference; SDD: SD of mean differences; CV: coefficient of variability [(SDD /D)*100]; CR: coefficient of repeatability [(SDD *1.96)*100)]; ICC: Intra-class Correlation Coefficient.

12-month Treatment with Aged Garlic Extract was Associated with Lower Coronary Calcium Progression and Higher Fingertip Temperature Rebound Aged garlic extract supplemented with B vitamins, folic acid and L-arginine retards the progression of subclinical atherosclerosis: A randomized clinical trial   Objectives. Previous studies demonstrated that aged garlic extract reduces multiple cardiovascular risk factors. This study was designed to assess whether aged garlic extract therapy with supplements (AGE+S) favorably affects inflammatory and oxidation biomarkers, vascular function and progression of atherosclerosis as compared to placebo. Methods. In this placebo-controlled, double-blind, randomized trial (conducted 2005�2007), 65 intermediate risk patients (age 60�9 years, 79% male) were treated with a placebo capsule or a capsule containing aged garlic extract (250 mg) plus Vitamin B12 (100 μg), folic acid (300 μg), Vitamin B6 (12.5 mg) and L-arginine (100 mg) given daily for a 1 year. All patients underwent coronary artery calcium scanning (CAC), temperature rebound (TR) as an index of vascular reactivity using Digital Thermal Monitoring (DTM), and measurement of lipid profile, autoantibodies to malondialdehyde (MDA)-LDL, apoB-immune complexes, oxidized phospholipids (OxPL) on apolipoprotein B-100 (OxPL/apoB), lipoprotein (a) [Lp (a)], C-reactive protein (CRP), homocysteine were measured at baseline and 12 months. CAC progression was defined as an increase in CACN15% per year and an increase in TR above baseline was considered a favorable response. Results. At 1 year, CAC progression was significantly lower and TR significantly higher in the AGE+S compared to the placebo group after adjustment of cardiovascular risk factors (pb0.05). Total cholesterol, LDL-C, homocysteine, IgG and IgM autoantibodies to MDA-LDL and apoB-immune complexes were decreased, whereas HDL, OxPL/apoB, and Lp (a) were significantly increased in AGE+S to placebo. Conclusion. AGE+S is associated with a favorable improvement in oxidative biomarkers, vascular function, and reduced progression of atherosclerosis.

Comparison with Competitor VENDYS® - Endothelix, Inc. EndoPAT® - Itamar Medical Inc. Fingertip temperature changes 15-minute test Fully automated Fingertip pressure changes 15-minute test Not automated

VENDYS Publications DTM Clinical Papers:   DTM Clinical Papers: Association of coronary artery calcium score and vascular dysfunction in long-term hemodialysis patients. Hemodialysis International, International Society for Hemodialysis (2013). PDF Beneficial effects of aged garlic extract and coenzyme Q10 on vascular elasticity and endothelial function: The FAITH randomized clinical trial Nutrition / Elsevier (2013). PDF   Evaluation of Digital Thermal Monitoring as a Tool to Assess Perioperative Vascular Reactivity J Atheroscler Thromb (2013). PDF   A Novel Technique for the Assessment of Preoperative Cardiovascular Risk: Reactive Hyperemic Response to Short-Term Exercise BioMed Research International (2013). PDF   Fingertip Digital Thermal Monitoring: A Fingerprint for Cardiovascular Disease? Int J Cardiovasc Imaging (2010). PDF   Aged garlic extract supplemented with B vitamins, folic acid and L-arginine retards the progression of subclinical atherosclerosis: A randomized clinical trial. Preventive Medicine (2009). PDF   Low fingertip temperature rebound measured by digital thermal monitoring strongly correlates with the presence and extent of coronary artery disease diagnosed by 64-slice multi-detector computed tomography. Int. J Cardiovasc Imaging (2009). PDF  Accompanying Editorial: Digital thermal monitoring of vascular function: a novel tool to improve cardiovascular risk assessment. Vascular Medicine (2009). PDF Concomitant insulin resistance and impaired vascular function is associated with increased coronary artery calcification. Int. Journal of Cardiology (2009). PDF   Vascular dysfunction measured by fingertip thermal monitoring is associated with the extent of myocardial perfusion defect. JNC (2009). PDF   Vascular function measured by fingertip thermal reactivity is impaired in patients with metabolic syndrome and diabetes. J Clin Hypertens (2009). PDF   Relations between digital thermal monitoring of vascular function, the Framingham risk score, and coronary artery calcium score. JCCT (2008). PDF  Accompanying Editorial: Anatomy, physiology, or epidemiology: Which is the best target for assessing vascular health? JCCT (2008). Abstract   Flow mediated change of finger tip temperature in patients with high cardiovascular risk. Cardiologia Hungarica (2005). PDF English summary PDF Graphical Data   Post-Exercise Reactive Hyperemia: A Novel Preoperative Risk Assessment Tool Poster Abstract   Digital Thermal Monitoring: Non-Invasive Assessment of Perioperative Microvascular Function Poster Abstract

Review Articles about Vascular/Endothelial Dysfunction Measurement: DTM Technical Papers: Reproducibility and variability of digital thermal monitoring of vascular reactivity. Clin Physiol Funct Imaging (2011). PDF   Use of temperature alterations to characterize vascular reactivity. Clin Physiol Funct Imaging (2011). PDF   Sensitivity of Digital Thermal Monitoring Parameters to Reactive Hyperemia. Journal of Biomechanical Engineering, ASME (2010). PDF    Digital Thermal Monitoring (DTM) of Vascular Reactivity Closely Correlates with Doppler Flow Velocity. Conf Proc IEEE Eng Med Biol Soc (2009). PDF   Lumped parameter thermal model for the study of vascular reactivity in the fingertip. J Biomech Eng (2008). Abstract   Interrelationships among noninvasive measures of postischemic macro- and microvascular reactivity J Appl Physiol (2008). PDF Review Articles about Vascular/Endothelial Dysfunction Measurement: Endothelial dysfunction over the course of coronary artery disease. Eur Heart J (2013). PDF   The Assessment of Endothelial Function: From Research Into Clinical Practice. Circulation (2012). PDF   The Endothelial Cell in Health and Disease: Its Function, Dysfunction, Measurement and Therapy. Int J Impot Res (2010). PDF   Endothelial function as a functional expression of cardiovascular risk factors. Biomark Med (2010). PDF  

Additional Publications 1. Schier R, Hinkelbein J, Marcus H, Smallwood A, Correa AM, Mehran R, El-Zein R, Riedel B. A novel technique for the assessment of preoperative cardiovascular risk: reactive hyperemic response to short-term exercise. Biomed Res Int. 2013;2013:837130. PMID: 23691513 2. Schier R, Marcus HE, Mansur E, Lei X, El-Zein R, Mehran R, Purugganan R, Heir JS, Riedel B, Gottumukkala V. Evaluation of digital thermal monitoring as a tool to assess perioperative vascular reactivity J Atheroscler Thromb. 2013;20(3):277-86. PMID: 23197179 3. Ahmadi N, McQuilkin GL, Akhtar MW, Hajsadeghi F, Kleis SJ, Hecht H, Naghavi M, Budoff M. Reproducibility and variability of digital thermal monitoring of vascular reactivity. Clin Physiol Funct Imaging. 2011 Nov;31(6):422-8. PMID: 21981452 4. Akhtar MW, Kleis SJ, Metcalfe RW, Naghavi M. Sensitivity of digital thermal monitoring parameters to reactive hyperemia. J Biomech Eng. 2010 May;132(5):051005. PMID: 20459206 5. Schwartz BG, Economides C, Mayeda GS, Burstein S, Kloner RA. The endothelial cell in health and disease: its function, dysfunction, measurement and therapy. Int J Impot Res. 2010 Mar-Apr;22(2):77-90. Review. PMID: 20032988 6. van der Wall EE, Schuijf JD, Bax JJ, Jukema JW, Schalij MJ. Fingertip digital thermal monitoring: a fingerprint for cardiovascular disease? Int J Cardiovasc Imaging. 2010 Feb;26(2):249-52. PMID: 20012695