Ι. ΟΙΚΟΝΟΜΙΔΗΣ 1, Γ. ΠΑΥΛΙΔΗΣ 1, Β. ΛΑΜΠΑΔΙΑΡΗ 2, Φ. ΚΟΥΣΑΘΑΝΑ 2, Ε. ΤΡΙΑΝΤΑΦΥΛΛΙΔΗ 1, Μ. ΒΑΡΟΥΔΗ 1, Γ. ΔΗΜΗΤΡΙΑΔΗΣ 2, Ι.

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1 ΜΕΛΕΤΗ ΤΟΥ ΕΝΔΟΘΗΛΙΑΚΟΥ ΓΛΥΚΟΚΑΛΥΚΑ, ΤΩΝ ΕΛΑΣΤΙΚΩΝ ΙΔΙΟΤΗΤΩΝ ΤΩΝ ΑΡΤΗΡΙΩΝ ΚΑΙ ΤΗΣ ΜΥΟΚΑΡΔΙΑΚΗΣ ΠΑΡΑΜΟΡΦΩΣΗΣ ΣΕ ΔΙΑΒΗΤΙΚΟΥΣ ΑΣΘΕΝΕΙΣ ΚΑΙ ΣΕ ΣΥΓΓΕΝΕΙΣ ΠΡΩΤΟΥ ΒΑΘΜΟΥ Ι. ΟΙΚΟΝΟΜΙΔΗΣ 1, Γ. ΠΑΥΛΙΔΗΣ 1, Β. ΛΑΜΠΑΔΙΑΡΗ 2, Φ. ΚΟΥΣΑΘΑΝΑ 2, Ε. ΤΡΙΑΝΤΑΦΥΛΛΙΔΗ 1, Μ. ΒΑΡΟΥΔΗ 1, Γ. ΔΗΜΗΤΡΙΑΔΗΣ 2, Ι. ΛΕΚΑΚΗΣ 1 1 ΙΑΤΡΙΚΗ ΣΧΟΛΗ ΕΚΠΑ, Β ΚΑΡΔΙΟΛΟΓΙΚΗ ΚΛΙΝΙΚΗ, Π.Γ.Ν. «ΑΤΤΙΚΟΝ» 2 ΙΑΤΡΙΚΗ ΣΧΟΛΗ ΕΚΠΑ, Β ΠΡΟΠΑΙΔΕΥΤΙΚΗ ΠΑΘΟΛΟΓΙΚΗ ΚΛΙΝΙΚΗ, Π.Γ.Ν. «ΑΤΤΙΚΟΝ»

ΚΟΥΣΑΘΑΝΑ 2, Ε. ΤΡΙΑΝΤΑΦΥΛΛΙΔΗ 1, Μ. ΒΑΡΟΥΔΗ 1, Γ. ΔΗΜΗΤΡΙΑΔΗΣ 2, Ι.

2 INTRODUCTION The integrity of endothelial glycocalyx plays a vital role in vascular permeability, inflammation and elasticity. The association between damage of endothelial glycocalyx, impaired arterial elastic properties, and LV function in diabetics and first degree relatives has not been explored.

The association between damage of endothelial glycocalyx, impaired arterial

3 ENDOTHELIAL GLYCOCALYX

4 METHODS We examined: 40 untreated patients with newly diagnosed type II diabetes 20 first degree relatives with normal oral glucose tolerance test (OGTT) and 25 controls of similar age and sex and no atherosclerotic risk factors.

normal oral glucose tolerance test (OGTT) and 25 controls

5 STUDY POPULATION DIABETICS RELATIVES CONTROLS p n Age, y 48±12 43±9 39±9 NS Male sex, n (%) 26 (65) 12 (60) 15 (60) NS Smoking, n (%) 14 (35) 8 (40)* 0 (0) <0.05 Hypertension, n (%) 8 (20) 3 (15)* 0 (0) <0.05 Dyslipidemia, n (%) 14 (35) 8 (40)* 0 (0) <0.05 Family history, n (%) 10 (25) 5 (25)* 0 (0) <0.05 BMI, kg/m ± ±5.0* 26.7±4.1 <0.05 Waist, cm 102.7± ±14.3* 91.4±13.3 <0.05 Hips, cm 106.9± ± ±10.8 NS * p>0.05 diabetics vs. relatives

05 Dyslipidemia, n (%) 14 (35) 8 (40)* 0 (0) <0.05 Family history, n (%) 10 (25) 5 (25)* 0 (0) <0.05 BMI, kg/m 2 30.1±3.

6 Glucose (mg/dl) Insulin (μu/ml) ORAL GLUCOSE TOLERANCE TEST (OGTT) CONTROLS 100 CONTROLS DIABETICS 80 DIABETICS 100 RELATIVES 60 RELATIVES Time (min) Time (min)

7 DIABETICS RELATIVES CONTROLS p # n Fasting glucose, mg/dl 115.1± ± ±11.0 <0.001 Peak glucose, mg/dl 225.3± ± ±23.6 < h OGTT glucose, mg/dl 200.7± ± ±15.5 <0.001 Fasting insulin, μu/ml 16.4± ± ± Peak insulin, μu/ml 106.4± ± ± h OGTT insulin, μu/ml 80.9± ± ± HOMA 4.7± ± ± HIS 0.31± ± ±0.20 <0.001 ISI 39.0± ± ±17.1 <0.001 Matsuda index 2.9± ± ±1.5 <0.001 # One-way ANOVA between groups. Data are presented as mean ± SD values.

1 119.2±72.2 58.1±30.3 0.011 2h OGTT insulin, μu/ml 80.9±69.8 58.0±33.0 29.5±13.8 0.001 HOMA 4.7±3.8 3.9±1.9 2.3±1.0 0.009 HIS 0.31±0.18 0.31±0.13 0.50±0.

8 METHODS We measured: a) Carotid-femoral pulse wave velocity (PWVc m/sec, Complior SP ALAM), central systolic blood pressure (csbp-mmhg), augmentation index (AI-%), reflection time (RT-ms) and diastolic reflection area (DRA) of the aortic pulse wave, an index of coronary perfusion (Arteriograph TensioMed)

index (AI-%), reflection time (RT-ms) and diastolic reflection area (DRA) of

9 METHODS b) S, E (m/sec) and E /A of mitral annulus by Tissue Doppler c) LV longitudinal strain (GLS-%), systolic (LongSr- 1/sec) and diastolic (LongSrE-1/sec) strain rate, using speckle tracking echocardiography d) Perfused boundary region (PBR-micrometers) of the sublingual arterial microvessels (ranged from 5-25 micrometers) using Sideview Darkfield imaging (Microscan, Glycocalyx).

tracking echocardiography d) Perfused boundary region (PBR-micrometers) of the sublingual

10 METHODS The PBR in microvessels is the cell-poor layer which results from the phase separation between the flowing red blood cells (RBC) and plasma. The PBR includes the most luminal part of glycocalyx that does allow cell penetration. Increased PBR is considered an accurate index of reduced endothelial glycocalyx thickness because of a deeper penetration of the RBC in the glycocalyx.

The PBR includes the most luminal part of glycocalyx that does allow cell penetration.

11 Increased PBR: an accurate index of reduced endothelial glycocalyx thickness

12 GLYCOCHECK CAMERA 1. Collected movie frame 2. Vascular segments defined

13 RBC column width (μm) GLYCOCHECK CAMERA 3. For each vascular segment: calculation of RBC column width for serie of consecutive frames 4. For each vascular segment: calculation of PBR Dperf (RBC-perfused lumen) Glycocalyx (RBC permeable) Frames P50 (RBCW) Outer edge of RBCperfused core PBR (Perfused Boundary Region) PBR=(Dperf RBCW) / 2

14 MICROSCAN CAMERA

15 GLYCOCALYX EXAMINATION

16 RESULTS DIABETICS RELATIVES CONTROLS p n PBR, microns 2.1± ± ±0.1 <0.05 AI, % 27±16 24±15 17±14 <0.05 DRA 44±12 49±13 68±27 <0.05

RESULTS DIABETICS RELATIVES CONTROLS p n 40 20 25 PWV, m/sec 10.9±2 9.3±2 8.9±2 <0.05 csbp, mmhg 137±19 122±13 116±17 <0.

17 RESULTS DIABETICS RELATIVES CONTROLS p n PWV, m/sec 10.9±2 9.3±2 8.9±2 <0.05 csbp, mmhg 137±19 122±13 116±17 <0.05 RT, ms 118±26 146±25 151±14 <0.05 GLS, % -16±4-19±3-20±3 <0.05 LongSr, 1/sec -0.8± ± ±0.3 <0.05 LongSrE, 1/sec 0.8± ± ±0.5 <0.05

18 LV LONGITUDINAL STRAIN Diabetic Relative

19 MVO EEF 33% 75 % 70 msec Diabetic Normal MVO EEF 26 % 64 % 85 msec

20 RESULTS Reduced endothelial glycocalyx thickness as assessed by increased PBR was related with increased PWV (r=0.35), reduced RT (r=-0.42) and DRA (r=-0.36) in diabetics (p<0.05 for all comparisons). These associations were more prominent for PBR measured in the microvessels ranged from micrometers.

42) and DRA (r=-0.36) in diabetics (p<0.05 for all comparisons).

21 RESULTS Increased PWV were related with reduced: S (r=-0.48) E (r=-0.63) E /A (r=-0.63) GLS (r=0.48) LongSr (r=0.35) LongSrE (r=-0.51) p<0.05 for all associations

22 RESULTS r=0.35, p<0.05 r=-0.51, p<0.05

23 CONCLUSION Endothelial glycocalyx is impaired in newly diagnosed diabetics and first degree relatives and is related with abnormal aortic elastic properties on the grounds of increased insulin resistance leading to impaired LV longitudinal deformation.

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