CV Biomarkers Today Inflammation and Proliferation CRP Lp-PLA2 MCSF PDGF FDF FGF Interleukins (1,6,8,10,12,15) MMPs (1,2,3,9) MIP1 (alpha and beta) TNF alpha Proliferating cell nuclear antigen Hyaluronan receptors SR-A, SR-B1 TGF SM myacin heavy chains CD 11, 18, 36, 40, 68 MCP-1 CCR2 Pentraxin-3 C4b binding protein I kappa B-alpha Total sialic acid Osteopontin Adhesion molecules s-ICAM s-VCAM P-selectin E-selectin Serum glycoproteins Alpha 1-antitrypsin Alpha 1 acid glycoprotein Alpha 2-macroglobulin Ceruloplasmin haptoglobin Coagulation VWF tPA PAI-1 PF4 D-dimer Tissue factor Fibrinogen Beta thromboglobulin Erythrocyte sed. Rate RBC adhesiveness/aggreg Genetics ACE polymorphism methylenetetrahydrofolate reductase [MTHFR] apolipoprotein E [apo E] paraoxonase [PON] Immunology Anti-oxLDL IgG Imaging Angiography IVUS 3D reconstruction IVUS Ultrafast CT (coronary) Carotid ultrasound – IMT MRI (carotid, PAD, aortic) PET Aortic CT Scintigraphy (thallium, sestimibe) Intracoronary endo fct (Ach) Brachial ultrasound Plethysmography TEE (aortic) Skin cholesterol Monoclonal antibody imaging Pulsatile flow visualization (aorta) Regional aortic distensibility Aortic stiffness (Doppler) Coronary thermography Coronary elastography Coronary NIR spectroscopy Lipids lipoproteins lipoprotein subfractions (L1-3, V1-6, H1-5) Apolipoproteins (CIII, AII:E, LpB…) Lp(a) Lipid ratios

Endothelial Dysfunction and CAD Adapted from Dzau and Braunwald, Am Heart J, Risk factors   Chol,  BP, DM, insulin resistance), platelets, fibrinogen, etc End-stage heart disease Endothelial dysfunction Coronarythrombosis MI Arrhythmia and loss of muscle Sudden death Myocardialischemia Remodelling CAD Ventriculardilation Atherosclerosis CHF

Smooth muscle - PGI - NO - EDHF Relaxation Inhibition of Proliferation Tone Structure - - Endothelium-derived Relaxing Factors 2 Proliferation Contraction Endothelium-derived Contracting Factors TXA 2 - Free radical - Ang II - Endothelin

BASELINE (3.65 mm) REACTIVE HYPEREMIA (4.02 mm) Flow-Mediated Vasodilation FMD = 10 %

Microvasculature Philpott et al. ATVB 2007;27:2065

Shear stress, hyperemic velocity and Risk Factors FATE – n=1477, Overall R 2 for hyperemic velocity = *Unadjusted (univariate) Coefficient p value**Adjusted Coefficient Age-1.633< Systolic BP-0.894< Fasting Glucose < LDL-8.211< HDL21.187< Current Smoking CRP-1.712< BMI-3.898<

Methods QCA distal to Doppler site for Flow calculation QCA in distal site for vasomotion

LAD-D 5 W LAD- Ach Mild Coronary Dilation Endothelial Function and Atherosclerosis

Methods Coronary flow response to Atrial Pacing Increase in Coronary velocity in normal subject

FATE Prognostic Significance of Markers of Vascular Health: Long-term Results from the Firefighters and their Endothelium (FATE) Study Todd J Anderson, Francois Charbonneau, Lawrence Title, Jean Buithieu, M. Sarah Rose, Heather Conradson, Kathy Hildebrand, Marinda Fung, Subodh Verma, Eva M. Lonn University of Calgary and Libin Cardiovascular Institute McMaster University McGill University University of Toronto Dalhousie University

Methods – Vascular End-points FMD Hyperemic VTI Intima Media Adventitia Lumen CIMT

Results – Cox proportional hazards nHR95% CIWald p FRS/unit SD – 2.87<0.001 FRS/unit SD – 2.54<0.001 VTI/unit SD – FRS/ unit SD – 2.54<0.001 Log IMT/unit SD – FRS/unit SD – 2.78<0.001 Log CRP/unit SD – FRS/unit SD – VTI/unit SD – Log IMT/unit SD – Log CRP/unit SD –

Results – Net Clinical Reclassification Index Clinical Reclassification Improvement I1I1 I2I2 NCRI Zp VTI/unit SD <0.001 (N = 1500) Log IMT/unit SD (N = 1512) Log CRP/unit SD4.172, (N = 1528) VTI/unit SD Log IMT/unit SD (N = 1480)

Endothelial dysfunction thought to play an important role in systolic CHF Role in diastolic CHF has not been as well defined Ventricular-vascular coupling likely important AB-HEART – Vascular physiology studies

Compare peripheral endothelial function in subjects with systolic, diastolic HF with healthy controls –Flow-mediated dilation- conduit vessel function –Hyperemic VTI and PAT – microvascular function –Pulse wave velocity with applanation tonometry Assess the prognostic implication of these measurements in patients with HF AB-HEART – Peripheral arterial studies

Compare coronary endothelial function in subjects with systolic, diastolic HF with healthy controls –Intracoronary Ach, and adenosine –Measures of Pressure and Flow to calculate microvascular resistance –25 patients per group Have not begun these studies as yet AB-HEART – Coronary studies