Effect of intensive multifactorial treatment on vascular progenitor cells in hypertensive patients
Effect of intensive multifactorial treatment on vascular progenitor cells in hypertensive patients
Charbel Maroun-Eid 0 1
Adriana Ortega-HernaÂ ndez 1
Javier Modrego 1
MarÂõa Abad- Cardiel 0 1
JoseÂ Antonio GarcÂõa-Donaire 0 1
Leonardo Reinares 1
Nieves Martell-Claros 0 1
Dulcenombre GoÂ mez-Garre 1
0 Unit of Hypertension, AÂ rea de PrevencioÂ n Cardiovascular, Hospital ClÂõnico San Carlos, Instituto de InvestigacioÂ n Sanitaria del Hospital ClÂõnico San Carlos (IdISSC) , Madrid , Spain , 2 Vascular Biology Research Laboratory, Hospital ClÂõnico San Carlos-IdISSC , Madrid , Spain , 3 Biomedical Research Networking Center in Cardiovascular Diseases (CIBERCV) , Madrid , Spain , 4 Unit of Lipids, AÂ rea de PrevencioÂ n Cardiovascular, Hospital ClÂõnico San Carlos-IdISSC , Madrid , Spain
1 Editor: Matteo Pirro, Universita degli Studi di Perugia , ITALY
Data Availability Statement: All relevant data are
within the paper.
Funding: This work has been partially supported by
grants from Instituto de Salud Carlos III (FIS PI14/
1856), and the European Regional Development's
funds (FEDER). There was no additional external
funding received for this study.
Competing interests: The authors have declared
that no competing interests exist.
Most hypertensive patients, despite a proper control of their cardiovascular risk factors,
have cardiovascular complications, evidencing the importance of controlling and/or
reversing target-organ damage. In this sense, endothelial dysfunction has been associated with
the presence of cardiovascular risk factors and related cardiovascular outcomes. Since
hypertension often clusters with other risk factors such as dyslipemia, diabetes and obesity,
in this study we have investigated the effect of intensive multifactorial treatment on
circulating vascular progenitor cell levels on high-risk hypertensive patients.
We included108 hypertensive patients receiving intensive multifactorial pharmacologic
treatment and dietary recommendations targeting blood pressure, dyslipemia,
hyperglycemia and weight for 12 months. After the treatment period, blood samples were collected and
circulating levels of endothelial (CD34+/KDR+, CD34+/VE-cadherin+) and smooth muscle
(CD14+/endoglin+) progenitor cells were identified by flow cytometry. Additionally, plasma
concentration of vascular endothelial growth factor (VEGF) was determined by ELISA.
Most hypertensive patients (61±12 years, 47% men) showed cardiovascular parameters
within normal ranges at baseline. Moreover, body mass index and the majority of the
biochemical parameters (systolic and diastolic blood pressure, fasting glucose, total
cholesterol, HDL-c, LDL-c, creatinine and hs-CRP) significantly decreased overtime. After 12
months of intensive treatment, CD34+/KDR+ and CD14+/endoglin+ levels did not change,
but CD34+/VE-cadherin+ cells increased significantly at month 12 [0.9(0.05±0.14)% vs 0.05
(0.02±0.09)% P<0.05]. However, VEGF plasma concentration decreased significantly
overtime [89.1(53.9±218.7) vs [66.2(47.5±104.6) pg/mL, P<0.05].
Long-term intensive treatment in hypertensive patients further improves cardiovascular risk and increases circulating EPCs, suggesting that these cells could be a therapeutic target.
In the past, the goal of treating hypertension was merely blood pressure (BP) reduction, and
antihypertensive therapy demonstrated to diminish cardiovascular events around 25% [
Updated guidelines target reductions in overall cardiovascular risk since hypertension usually
occurs in association with other major risk factors. However, optimally treated hypertensive
patients still have an around 50% increased risk of any cardiovascular event [
The balance between endothelial injury and endothelial recovery is critical to the reduction
of cardiovascular events [
]. The injured vessels release circulating endothelial cells (CECs)
and endothelial microparticles (EMPs), and their determination have demonstrated to closely
reflect the status of activated/damaged endothelium [
].However, endothelial cells have
limited capacity for regeneration, contrasting to the traditional concept that the repair of vascular
endothelium was achieved by neighboring endothelial proliferation [
]. Since the
identification of endothelial progenitor cells (EPCs) by Asahara et al., and their capacity to differentiate
into mature cells and restore endothelial integrity and function has been evidenced, there has
been a growing interest in their involvement in cardiovascular disease [
]. The balance
between endothelial fragmentation into EMPs and endothelial repair by EPCs has been
defined as ªvascular competenceº of each individual . In this sense, in untreated
hypercholesterolemic patients, Pirro et al. have reported an increased ratio of EMPs/EPCs, as well as
a positive correlation with aortic stiffness, a reliable marker of atherosclerosis [
Circulating EPCs are bone marrow derived cells characterized by the expression of both
hematopoietic (CD34, CD133) and endothelial [KDR (a vascular endothelial growth factor
receptor), VE-cadherin, von Willebrand factor or CD31] surface markers [
] that have
demonstrated their capacity to maintain the integrity of the blood vessels by homing into sites of
endothelial injury and differentiating into mature endothelium [
]. Increasing evidence
suggest that cardiovascular risk factors associated with endothelial dysfunction, affect the
amount and properties of the EPCs [
]. For example, chronic smokers have endothelial
dysfunction and it has been reported that smoking cessation led to a rapid restoration of EPCs
]. As well, a low number of EPCs were found in subjects with diabetes mellitus type 2
]. In addition, in chronic exposure to increased plasma cholesterol levels, the availability of
EPCs is reduced [
]. In fact, the number of EPCs is a better indicator of endothelial
dysfunction than the Framingham risk score [
]. The depletion in the number of EPCs has been used
as a biomarker of the occurrence of a first major cardiovascular event in patients at different
risks or even in healthy subjects [
]. Moreover, restoration of EPC number and/or
functionality is possible through current therapies for cardiovascular risk factors and other means
[19±21], suggesting that they could also be a promising tool for measuring therapeutic efficacy.
In the last years, the participation in vascular diseases of another circulating bone
marrowderived progenitor cell population has been reported [
]. In this sense, cells expressing
CD14/endoglin have been identified as circulating smooth muscle progenitor cells (SMPCs)
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and associated with the formation of intimal lesions in experimental models [
with coronary artery disease (CAD) show higher number of SMPCs than patients without
Previously, we have reported that the number of EPCs in treated hypertensive patients was
not normalized despite showing cardiovascular parameters within normal ranges [
the aim of the present study was to evaluate the effect of a long multifactorial intensified
treatment on the number of different phenotypes of circulating vascular progenitor cells on high
cardiovascular risk hypertensive patients in ordering to justify their use as biomarkers of
Material and methods
Consecutive consenting adult hypertensive patients with moderate, high or very high
cardiovascular risk according to 2007 European Society of Hypertension/European Society of
Cardiology (ESH/ESC) Guidelines for the management of arterial hypertension [
] who attended
the Hypertension Unit of Hospital ClÂõnico San Carlos were included in the study (n = 108).
Very high-risk patient were those having an established cardiovascular or renal disease, at high
cardiovascular risk when the patient had 3 or more risk factors, organ damage or diabetes
mellitus, and moderate cardiovascular risk when the patient has one or two risk factors. Patients
with acute myocardial infarction (< 3 months), acute or chronic inflammatory or malignant
disease, as well as any other pathology which might interfere with the study results at the
investigator's discretion were excluded from the study.
Once the patient was included in the study, the treatment of all cardiovascular risk factors
were reviewed and optimized aiming to achieve the highest therapeutic targets suggested by
the guidelines for the management of arterial hypertension: systolic/diastolic BP (SBP/DBP)
140/90 mmHg, total cholesterol <175 mg/dL, LDL-cholesterol <100 mg/dL (80 mg/dL if
possible), triglycerides <150 mg/dL, HbA1c 7%, and smoking cessation. For this purpose,
all patients were prescribed an angiotensin converting enzyme (ACE) inhibitor or, if such a
drug was contraindicated, an angiotensin II receptor antagonist (ARAII) irrespective of the BP
level. If a patient had SBP/DBP >140/90 mmHg, diuretics, calcium channel blockers, and
beta-blockers were added as needed. The combination of an ACE inhibitor and an ARAII
could also be used. Patients were also prescribed a statin irrespective of fasting serum
cholesterol concentration. Fibrates were added to statin treatment if the triglyceride concentration
was also elevated (>350 mg/dL).If patients showed HbA1c >7%, an oral antidiabetic agent
was started, and if high HbA1c value persisted they were added or switched to insulin. When
indicated, platelet antiaggregants or oral anticoagulants were also prescribed. All smoking
patients were invited to participate in smoking-cessation programs. Simultaneously, patients
were recommended non-drug therapy, including weight reduction, moderation in the
consumption of alcohol, physical exercise, reduced salt intake and follow a Mediterranean diet
type or a Dietary Approaches to Stop Hypertension diet (DASH diet). During the study,
patients were asked about their adherence to the recommendations in each visit. Patients were
followed up by means of clinic visits one month after their inclusion in the study and every
third month. After 12 months of follow up, we proceeded to the final visit in which all
determinations of baseline (clinical biochemical variables, and quantification of progenitor cells and
VEGF) were repeated.
The protocol of this study complies with the principles of the Helsinki Declaration and has
been approved by the Ethics and Clinical Investigation Committee of Hospital ClÂõnico San
Carlos. Informed consent was obtained from all subjects.
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Clinical and laboratory measurements
Medical records were carefully reviewed at an interview, and a thorough physical examination
was performed. Gender, age, anthropometric measurements (weight, height), SBP/DBP,
smoking habit and personal history was recorded. Body mass index (BMI) was calculated.
A sample of fasting venous blood was drawn for routine biochemical measurements and
Service of Clinical Biochemistry at the Hospital ClÂõnico San Carlos performed all analysis
unless noted otherwise.
Quantification of circulating vascular progenitor cells
Blood samples were processed within four hours after collection. Peripheral blood cells were
analyzed by direct flow cytometry as previously described [
]. Briefly, 100 μl of blood was
incubated on ice protected from light with specific antibodies: anti-CD34
phycoerythrin-cyanin 7 (PC7)-conjugated (mouse IgG1, Beckman Coulter), anti-CD3 phycoerythrin-Texas
Redx (ECD)-conjugated (mouse IgG1, Beckman Coulter), anti-KDR phycoerythrin
(PE)-conjugated (mouse IgG1, R&D Systems), anti-VE-cadherin(CD144) PE-conjugated (mouse IgG2b,
R&D Systems), anti-CD14 PC7-conjugated (mouse IgG1, Beckman Coulter), and
anti-endoglin(CD105) PE-conjugated (mouse IgG2b R&D Systems). Appropriate isotype controls were
used for each staining procedure. After 30 minutes of incubation, red blood cells were lysed by
a commercial lysis solution (BD FACS Lysis solution, Becton Dickinson) for 10 minutes at
room temperature and washing in PBS. After two washing steps, cells were resuspended in
300 μl of PBS and acquired on a FC500 flow cytometer (Beckman Coulter). Data are expressed
as percentage of positive cells CD34/KDR, CD34/VE-cadherin and CD14/endoglin.
Measurement of vascular endothelial growth factor (VEGF)
VEGF levels were determined using a commercially available kit (Quantikine, R&D Systems,
UK). The concentrations were determined by comparison with a standard curve, following the
Qualitative variables were summarized by their frequency distribution as well as quantitative
variables by their mean and standard deviation (± SD). The continuous non-normally
distributed variables were summarized by the median and interquartile range (IQR: P25-P75). The
Kolmogorov-Smirnov test was used to prove Gaussian distribution. In case of qualitative
variables, comparison was evaluated by the test of χ2. For continuous normally distribute variables
the T-Student test was used to compare two groups. The Mann-Whitney U test was used for
continuous not normally distributed variables. The association between continuous variables
was tested using the non-parametric Spearman's correlations coefficient. As circulating
vascular progenitor cells were not normally distributed, these data were log-transformed to improve
their distribution for statistical testing, with back-transformed results for presentation in
figures and tables. A multivariate linear regression analysis was fitted in order to evaluate the
variables associated with circulating vascular progenitor cells. Adjustment was with those
variables which, in the univariate analyses, showed a level of statistical significance of P<0.05,
and/or were considered clinically relevant. Null hypothesis was rejected by a type I error
minor than 0.05 (P<0.05). Statistical analyses were performed using the SPSS 17.0 statistical
4 / 14
Effect of intensive therapy on circulating vascular progenitor cell levels
The clinical, biochemical characteristics of the participants and their treatments at start and
after treatment intensification during 12 months are presented in Table 1. Within the clinical
history of our hypertensive patients, 67.6% showed also dyslipidemia, 31.5% diabetes mellitus,
30.6% have been suffered or suffer cardiovascular complications (heart disease, advanced
retinopathy, peripheral artery disease, stroke and/or chronic kidney disease), and 14.8% were
current smokers. By exception BMI, patients presented a good control of their cardiovascular risk
factors but the multifactorial intensive treatment for 12 months improved them even more
Regarding the cardiovascular risk stratification, CD34+/KDR+ and CD34+/VE-cadherin
+ cell levels did not differ significantly when cardiovascular risk increases according to the
model of qualitative cardiovascular risk stratification taken from 2007 ESH/ESC Guidelines
(Fig 1A and 1B). However, there was a marked increase in CD14+/endoglin+ cells when the
cardiovascular risk worsens (Fig 1C).
Table 2 describes the association between demographic characteristics, cardiovascular risk
factors, and clinical and biochemical parameters of patients with the levels of progenitor cells
CD34+/KDR+, CD34+/VE-cadherin+ and CD14+/endoglin+. Patients with a higher number
(above 25th percentile) of CD34+/KDR+ and CD34+/VE-cadherin+ and lower of CD14
5 / 14
Fig 1. Circulating vascular progenitor cell levels in hypertensive patients according to cardiovascular
risk stratification prior to intensive treatment. We divided the patients into three groups according to 2007
European Society of Hypertension/European Society of Cardiology (ESH/ESC) Guidelines for the
management of arterial hypertension [
]: very high-risk patient were those having an established
cardiovascular or renal disease, high cardiovascular risk when the patient had 3 or more risk factors, organ
6 / 14
damage or diabetes mellitus, and moderate cardiovascular risk when the patient had one or two risk factors.
Results are expressed as percentage of CD34+/KDR+, CD34+/VE-cadherin+ or CD14+/endoglin+ cells in the
PBMC gated area once excluded CD3+ cells and data visualized as standard box plots. * P<0.05 vs
moderate cardiovascular risk.
+/endoglin+ cells (equal or below 75th percentile) were younger, with less years since diagnosis
of hypertension, and with lower BP. These associations were maintained in a multivariate
analysis. No differences were found regarding other cardiovascular risk factors. Interesting,
patients with previous cardiovascular disease (ischemic stroke, myocardial infarction,
symptomatic peripheral artery disease, some revascularization procedure, chronic kidney disease,
and/or advanced retinopathy) tended to have higher number of CD14+/endoglin+ cells than
those without a cardiovascular event.
The multifactorial intensive treatment for 12 months did not modify CD34+/KDR+ and
CD14+/endoglin+ cells with respect to baseline (Fig 2A and 2C). By contrast,
CD34+/VE-cadherin+ cells changed significantly after the treatment, increasing around 2-fold with respect to
basal levels (Fig 2B).
VEGF levels in hypertensive patients
Since VEGF is one of the best characterized growth factors responsible of the mobilization of
EPCs from the bone marrow [
], we investigated its plasma levels before and after the
intensive treatment. As can be seen in Fig 3, VEGF plasma levels decreased after 12 months of
Data are media ±± SD or median (interquartile range). Previous cardiovascular disease: Ischemic stroke, myocardial infarction, symptomatic peripheral
artery disease and/or any revascularization procedure, chronic kidney disease, advanced retinopathy. Abbreviations: BMI, body mass index; SBP, systolic
blood pressure; DBP, diastolic blood pressure; CRP, C-reactive protein.
* P< 0.05 vs low levels of the same progenitor subtype cells.
7 / 14
Fig 2. Circulating vascular progenitor cell levels in hypertensive patients before (baseline) and after
treatment intensification during 12 months. Results are expressed as percentage of CD34+/KDR+, CD34
+/VE-cadherin+ or CD14+/endoglin+ cells in the PBMC gated area once excluded CD3+ cells and data
visualized as standard box plots, *P<0.05 vs before intensification of treatment.
Our data demonstrate that a long intensive multifactorial treatment aiming to achieve the
highest therapeutic targets for traditional cardiovascular risk factors increases levels of
circulating EPCs of hypertensive patients.
EPCs reduction or dysfunction has been inversely associated with traditional cardiovascular
risk factors and with the development of future cardiovascular events, having been revealed as
a new cardiovascular biomarker [
]. Therefore, we focus this work on the analysis of the
EPCs number since it has been considered a promising therapy in the treatment of
cardiovascular diseases. It is well accepted that CD34+/KDR+ cells are less mature or early circulating
EPCs, whereas more mature circulating EPCs are positive for CD34/VE-cadherin. At present,
CD34+/KDR+ cells are the only EPC subtype that has demonstrated to have a strong
association with cardiovascular risk .
Several studies have investigated the effect of drugs commonly used in the treatment of
cardiovascular diseases on the number of EPCs and their functionality. Most studies have
demonstrated that antihypertensive drugs such as ACE inhibitors, ARAII and calcium channel
antagonists can improve the number and functionality of EPCs and that these effects are
independent of the BP lowering effect [29±31]. Similarly, anti-diabetic drugs and statins, such as
dipeptidyl peptidase 4 (DPP4) inhibitors and rosuvastatin respectively, may directly affects
]. Therefore, it could be speculate that the beneficial effects of these drugs in the
outcome of cardiovascular patients should be due, at least in part, to their actions on EPCs.
Fig 3. Plasma levels of VEGF in hypertensive patients before (baseline) and after treatment
intensification during 12 months. Results are expressed as (pg/mL) of VEGF plasma levels. Data are
visualized as standard box plots. * P<0.05 vs before intensification of treatment.
9 / 14
In this study, we have included hypertensive patients with added cardiovascular risk that
have received an intensive and multifactorial treatment. Hypertensive subjects often have a
cluster of risk factors that greatly augments the cardiovascular hazard of elevated BP [
Therefore, the goal of therapy should be to improve the global risk profile of the patients and
recent guidelines have factored into more aggressive therapeutic decisions [
with optimal BP, high-normal BP is associated with 1.6±2.5 fold increased risk of presenting a
cardiovascular event [
]. Our data demonstrate that intensive treatment aiming to achieve
the highest therapeutic targets increased circulating CD34+/VE-cadherin+ cells. Although we
did not find changes in CD34+/KDR+ and CD14+/endoglin+ cell levels, our data suggest a
beneficial effect of the treatment on EPC mobilization. As we have commented before, many
drugs used for managing of cardiovascular risk factors of our patients have been reported to
increase the number and/or the functionality of EPCs, although most of these trials have
evaluated short period of treatments (< 6 months) [
]. However, Schmidt-Luckeet al. reported
that long-term administration of a statin predicts reduced numbers of EPCs in patients with
]. Furthermore, Deschaseaux et al. demonstrated that long-term statin therapy raises
EPC levels by increasing EPC populations positive to CD34/VE-cadherin without affecting
levels of cells characterized by expressing CD34/KDR [
]. These results suggest that the effects
of statins on EPC mobilization may be transient. In early stages, statins help mobilize EPCs
CD34+/KDR+, which is especially important in conditions of acute ischemia, but in the
longterm, they increase CD34+/VE-cadherin+ cells, considered as the "true" EPCs responsible for
], and providing a mechanism for the beneficial effects of these drugs.
Unfortunately, we did not measured EPCs at short times, although this is a very interesting
aspect that deserves further studies.
The mechanisms by which the intensification of drug treatment of hypertensive patients
may have a beneficial effect on circulating EPCs are not well-known. Cardiovascular risk
factors cause oxidative stress that alters VEGF regulation by preventing the attachment to its
receptor on bone marrow [
]. Our patients showed elevated plasma levels of VEGF associated
to decrease levels of EPCs, meanwhile intensive treatment-induced circulating EPCs
mobilization was associated to a significant reduction of plasma VEGF concentration, suggesting that a
further reduction of oxidative stress could be occurring. In this sense, several drugs, including
ACE inhibitors and statins, have demonstrated antioxidant and anti-inflammatory actions and
a protective effect against endothelial dysfunction through different mechanisms, and their
combination achieves additional beneficial effects than monotherapies [37±39]. However, we
cannot rule out that the combination of drugs and/or increasing doses might have a
stimulatory direct effect on bone marrow.
In this paper we have also shown that hypertensive patients had an increase in the SMPCs
CD14+/endoglin+ that did not change after the intensive treatment. Although several studies
have shown the presence of SMPCs in atherosclerotic lesions [
], their exact role is not
too clear. There is some evidence showing that these cells can contribute to the development
of vascular disease. Patients with previous cardiovascular disease had higher numbers of CD14
+/endoglin+ cells than those without previous cardiovascular disease . However, in several
experimental models, the administration of SMPCs limited the development of atherosclerotic
lesions and induced plaque stabilization [
]. In patients with acute coronary syndrome,
SMPCs deficiency has been associated with plaque vulnerability . A previous study from
our laboratory has shown that in HIV patients, the profile of CD34+/KDR+ and
CD34+/VEcadherin+ diminished and CD14+/endoglin+ increased is associated with higher
cardiovascular risk [
]. However, longer longitudinal studies are required to establish what might be the
role of CD14+/endoglin+ cells in the process of atherosclerosis in patients with hypertension.
10 / 14
Our study has some limitations. We have not evaluated EPC functions in this study since
our aim was to investigate the variation in the number of circulating vascular progenitor cells
after 12 months of intensive therapy in order to justify its use as a biomarker of therapeutic
efficacy, requiring to this purpose simple, rapid and reproducible methods as flow cytometry.
During our study, only one patient suffered a cardiovascular event. These patients are
currently being followed up in our Unit of Hypertension in order to evaluate whether changes in
the number of EPCs showed in this study translate into a reduction of cardiovascular events.
In addition, we know that in multifactorial interventions are not possible to clear out which
part has been most efficient. Although, previous studies have indicated that most of the CVD
benefit came from statin therapies[
In conclusion, we have demonstrated that EPCs can be good therapeutic target in
hypertensive patients, suggesting a new potential pharmacological mobilization therapy. In this sense,
the use of cellular therapeutic strategies has emerged as a powerful tool contributing to
cardiovascular regeneration. Thereby, different routes of EPCs administration such as autologous
EPC injection, pharmacological mobilization and EPCs capture stents have demonstrated to
stimulate the revascularization of ischemic vessels in different animal models of limb ischemia
or myocardial infarction However the clinical transfer of EPC-based therapies has shown
conflicting results, with only some trials reporting an improvement of cardiac function and a
reduction of important clinical end-points [
]. Many reasons could account for these
data, including different patient characteristics and EPCs sources and/or phenotypes. In this
sense, there are not specific cell surface markers that precisely identify the different subtypes of
EPCs, resulting in the use of different EPCs populations to induce regeneration. In addition,
the efficacy of bone marrow-derived EPCs over peripheral blood-derived EPCs (or vice versa)
is still lacking. On the other hand, EPCs from patients with high cardiovascular risk are known
to be numerical and functionally impaired. It is possible that in the future, treatment of these
patients will require therapy aimed to restore directly the progenitor cell reservoir in the bone
marrow, although its regenerative efficacy needs to be elucidated.
This work has been partially supported by grants from Instituto de Salud Carlos III (FIS PI14/
1856), and the European Regional Development's funds (FEDER).There was no additional
external funding received for this study.
Conceptualization: Charbel Maroun-Eid, Nieves Martell-Claros, Dulcenombre
Data curation: Nieves Martell-Claros, Dulcenombre GoÂmez-Garre.
Funding acquisition: Dulcenombre GoÂmez-Garre.
Investigation: Adriana Ortega-HernaÂndez, Javier Modrego.
Methodology: Adriana Ortega-HernaÂndez, MarÂõa Abad-Cardiel, JoseÂ Antonio
Donaire, Leonardo Reinares, Dulcenombre GoÂmez-Garre.
Resources: Charbel Maroun-Eid, MarÂõa Abad-Cardiel, JoseÂ Antonio GarcÂõa-Donaire,
Supervision: Adriana Ortega-HernaÂndez, Dulcenombre GoÂmez-Garre.
Validation: Javier Modrego, Nieves Martell-Claros, Dulcenombre GoÂmez-Garre.
11 / 14
Visualization: Javier Modrego.
Writing ± original draft: Charbel Maroun-Eid, Adriana Ortega-HernaÂndez, Dulcenombre
Writing ± review & editing: Charbel Maroun-Eid, Adriana Ortega-HernaÂndez, Nieves
Martell-Claros, Dulcenombre GoÂmez-Garre.
12 / 14
treatment. Atherosclerosis 2007; 192: 413±20. https://doi.org/10.1016/j.atherosclerosis.2006.05.031
13 / 14
1. Psaty BM , Lumly TM , Furberg CD , Schellenbaum G , Pahor M , Alderman MH , et al. Health outcomes associated with various antihypertensive therapies used as first-line agents: A network meta-analysis . JAMA 2009 ; 289 : 2534 ± 2544 .
2. Kannel WB . Hypertension: reflections on risks and prognostication . Med Clin North Am 2009 ; 93 : 541 ± 558 . https://doi.org/10.1016/j.mcna. 2009 . 02 .006 PMID: 19427490
3. Endemann DH , Schiffrin EL.Endothelial Dysfunction . J Am Soc Nephrol 2004 ; 15 : 1983 ± 1992 . https:// doi.org/10.1097/01.ASN. 0000132474 .50966.DA PMID: 15284284
4. Mannarino E , Pirro M. Endothelial injury and repair: A novel theory for atherosclerosis . Angiology 2008 ; 59 :69S± 72S . https://doi.org/10.1177/0003319708320761 PMID: 18628277
5. Hirase T , Node K. Endothelial dysfunction as a cellular mechanism for vascular failure . Am J Physiol Heart Circ Physiol 2012 ; 302 : H499±H505 . https://doi.org/10.1152/ajpheart.00325. 2011 PMID: 22081698
6. Asahara T , Murohara T , Sullivan A , Silver M , van der Zee R , Li T , et al. Isolation of putative progenitor endothelial cells for angiogenesis . Science 1997 ; 275 : 964 ± 967 . PMID: 9020076
7. Aragona CO , Imbalzano E , Mamone F , Cairo V , Lo Gullo A , D'Ascola A , et al. Endothelial progenitor cells for diagnosis and prognosis in cardiovascular disease . Stem Cells Int 2016 ; 2016 :8043792. https:// doi.org/10.1155/ 2016 /8043792 PMID: 26839569
8. Pirro M , Schillaci G , Paltriccia R , Bagaglia F , Menecali C , Mannarino MR et al. Increased ratio of CD31 +/CD42- microparticles to endotelial progenitors as a novel marker of ahterosclerosis in hypercholesterolemia . Arterioscler Thromb Vasc Biol 2006 ; 26 : 2530 ± 2535 . https://doi.org/10.1161/01.ATV. 0000243941 .72375.15 PMID: 16946129
9. Yoder MC . Endothelial progenitor cell: a blood cell by many other names may serve similar functions . J Mol Med (Berl) 2013 ; 91 : 285 ± 95 .
10. Urbich C , Dimmeler S . Endothelial progenitor cell: characterization and role in vascular biology . Circ Res 2004 ; 95 : 343 ± 353 . https://doi.org/10.1161/01.RES. 0000137877 .89448.78 PMID: 15321944
11. Rafii S , Lyden D . Therapeutic stem and progenitor cell transplantation for organ vascularization and regeneration . Nat Med 2003 ; 9 : 702 ± 712 . https://doi.org/10.1038/nm0603-702 PMID: 12778169
12. Vasa M , Fichtlscherer S , Aicher A , Adler K , Urbich C , Martin H , et al Number and migratory activity of circulating endothelial progenitor cells inversely correlate with risk factors for coronary artery disease . Circ Res 2001 ; 89 : E1 ± 7 . PMID: 11440984
13. Hill JM , Zalos G , Halcox JP , Schenke W , Waclawiw MA , Quyyumi A , et al Circulating endothelial progenitor cells, vascular function and cardiovascular risk . N Engl J Med2003 ; 348 : 593 ± 600 .
14. Kondo T , Hayashi M , Takeshita K , Numaguchi Y , Kobayashi K , Iino S et al. Smoking cessation rapidly increases circulating progenitor cells in peripheral blood in chronic smokers . Arterioscler Thromb Vasc Biol 2004 ; 24 : 1442 ±7. https://doi.org/10.1161/01.ATV. 0000135655 .52088.c5 PMID: 15191940
15. Fadini GP , Sartore S , Agostini C , Avogaro A. Significance of endothelial progenitor cells in subjects with diabetes . Diabetes care 2007 ; 30 : 1305 ± 13 . https://doi.org/10.2337/dc06-2305 PMID: 17277037
16. Pirro M , Baglaglia F , Paoletti L , Razzi R , Mannarino MR . Hypercholesterolemia-associated endothelial progenitor cell dysfunction . Ther Adv Cardiosvasc Dis . 2008 ; 2 : 329 ± 39 .
17. Schmidt-Lucke C , RoÈssig L , Fichtlscherer S , Vasa M , Britten M , KaÈmper U , et al. Reduced Number of Circulating Endothelial Progenitor Cells Predicts Future Cardiovascular EventsÐProof of Concept for the Clinical Importance of Endogenous Vascular Repair . Circulation 2005 ; 111 : 2981 ± 2987 . https://doi. org/10.1161/CIRCULATIONAHA.104.504340 PMID: 15927972
18. Werner N , Kosiol S , Schiegl T , Ahlers P , Walenta K , Link A , et al. Circulating endothelial progenitor cells and cardiovascular outcomes . N Engl J Med 2005 ; 353 : 999 ± 1007 . https://doi.org/10.1056/ NEJMoa043814 PMID: 16148285
19. Hristov M , Fach C , Becker C , Heussen N , Liehn EA , Blindt R , et al. Reduced number of circulating endothelial progenitor cells in patients with coronary artery disease associated with long-term statin
20. Albiero M , Menegazzo L , Avogaro A , Fadini GP . Pharmacologic targeting of endothelialprogenitorcells . Cardiovasc Hematol Disord Drug Targets 2010 ; 10 : 16 ± 32 . PMID: 20100167
21. Vasa M , Fichtlscherer S , Adler K , Aicher A , Martin H , Zeiher AM , et al. Increase in circulating endothelial progenitor cells by statin therapy in patients with stable coronary artery disease . Circulation 2001 ; 103 : 2885 ± 2990 . PMID: 11413075
22. Sugiyama S , Kigiyama K , Nakamura S , Kataoka K , Aikawa M , Shimizu K , et al. Characterization of smooth muscle-like cells in circulating human peripheral blood . Atherosclerosis 2006 ; 187 : 351 ± 362 . https://doi.org/10.1016/j.atherosclerosis. 2005 . 09 .014 PMID: 16253262
23. Sirker AA , Astroulakis ZMJ , Hill JM . Vascular progenitor cells and translational research: the role of endothelial and smooth muscle progenitor cells in endogenous arterial remodeling in the adult . Clin Sci 2009 ; 116 : 283 ± 299 . https://doi.org/10.1042/CS20080001 PMID: 19138170
24. Yu H , Stoneman V , Clarke M , Figg N , Xin HB , Kotlikoff M , Littlewood T , etal. Bone marrow-derived smooth muscle-like cells are infrequent in advance primary atherosclerotic plaques but promote atherosclerosis . Arterioscler Thromb Vasc Biol 2011 ; 31 : 1291 ±9. https://doi.org/10.1161/ATVBAHA.110. 218578 PMID: 21372299
25. Maroun-Eid C , Ortega-HernaÂndez A , Abad M , GarcÂõa-Donaire JA , Barbero A , Reinares L , et al. Niveles de ceÂlulas progenitoras endoteliales circulantes en pacientes hipertensos tratados . Hipertens Riesgo Vasc 2015 ; 32 : 142 ± 150 . https://doi.org/10.1016/j.hipert. 2015 . 07 .002 PMID: 26486462
26. Mancia G , De Backer G , Dominiczak A , Cifkova R , Fagard R , Germano G , et al; ESH-ESC Task Force on the Management of Arterial Hypertension2007 ESH-ESC Practice Guidelines for the Management of Arterial Hypertension: ESH-ESC Task Force on the Management of Arterial Hypertension . J Hypertens 2007 ; 25 : 1751 ± 1762 . https://doi.org/10.1097/HJH.0b013e3282f0580f PMID: 17762635
27. Asahara T , Takahashi T , Masuda H , Kalka C , Chen D , Iwaguro H , et al. VEGF contributes to postnatal revascularization by mobilizing bone marrow-derived endothelial progenitor cells . EMBO J 1999 ; 18 : 3964 ± 3972 . https://doi.org/10.1093/emboj/18.14.3964 PMID: 10406801
28. GoÂmez-Garre D , Estrada V , Ortega-HernaÂndez A , Muñoz-Pacheco P , Serrano-Villar S , Avila M et al. Association of HIV-Infection and antiretroviral therapy with levels of endothelial progenitor cells and subclinical atherosclerosis . J Acquir Immune Defic Syndr . 2012 ; 61 : 545 ± 51 . https://doi.org/10.1097/QAI. 0b013e31826afbfc PMID: 22842847
29. Cacciatore F , Bruzzese G , Vitale DF , Liguori A , de Nigris F , Fiorito C , et al. Effects of ACE inhibition on circulating endothelial progenitor cells, vascular damage, and oxidative stress in hypertensive patients . Eur J Clin Pharmacol 2011 ; 67 : 877 ± 83 . https://doi.org/10.1007/s00228-011 -1029-0 PMID: 21445638
30. Georgescu A , Alexandru N , Nemecz M , Titorencu I , Popov D. Irbesartan administration therapeutically influences circulating endothelial progenitor cell and microparticle movilization by involvement of proinflammatory cytokines . Eur J Pharmacol 2013 ; 711 : 27 ±35 https://doi.org/10.1016/j.ejphar. 2013 . 04 . 004 PMID: 23639758
31. Fukao K , Shimada K , Hiki M , Kiyanagi T , Hirose K , Kume A , et al. Effects of calcium channel blockers on glucose tolerance, inflammatory state, and circulating progenitor cells in non-diabetic patients with essential hypertension: a comparative study between azelnidipine and amlodipine on glucose tolerance and endothelial functionÐa crossover trial (AGENT) . Cardiovasc Diabetol 2011 ; 10 : 79 . https://doi.org/ 10.1186/ 1475 -2840-10-79 PMID: 21906391
32. Huang CY , Shih CM , Tsao NW , Lin YW , Huang PH , Wu SC , et al. Dipeptidyl peptidase 4-inhibitor improves neovascularization by increasing circulating endothelial progenitor cells . Br J Pharmacol 2012 ; 167 : 1506 ± 19 . https://doi.org/10.1111/j.1476- 5381 . 2012 . 02102 . x PMID : 22788747
33. Pirro M , Schillaci G , Romagno PF , Mannarino MR , Bagaglia F , Razzi R et al. Influence of short-term rosuvastatin therapy on endothelial progenitor cells and endothelial function . J Cardiovasc Pharmacol Ther 2009 ; 14 : 14 ± 21 . https://doi.org/10.1177/1074248408331021 PMID: 19158317
34. Schmidt-Lucke C , Fichtlscherer S , RoÈssig L , KaÈmper U , Dimmeler S. Improvement of endothelial damage and regeneration indexes in patients with coronary artery disease after 4 weeks of statins therapy . Atherosclerosis 2010 ; 211 : 249 ± 54 . https://doi.org/10.1016/j.atherosclerosis. 2010 . 02 .007 PMID: 20211468
35. Deschaseaux F , Selmani Z , Falcoz PE , Mersin N , Meneveau N , Penfornis A , et al. Two types of circulating endothelialprogenitorcells in patients receiving long term therapy by HMG-CoA reductaseinhibitors . Eur J Pharmacol 2007 ; 562 : 111 ± 118 . https://doi.org/10.1016/j.ejphar. 2007 . 01 .045 PMID: 17320859
36. Imanishi T , Tsujioka H , Akasaka T Endothelial Progenitor Cells Dysfunction and Senescence: Contribution to Oxidative Stress . Current Cardiology Reviews 2008 ; 4 : 275 ± 286 . https://doi.org/10.2174/ 157340308786349435 PMID: 20066135
37. GoÂmez-Garre D , GonzaÂlez-Rubio ML , Muñoz-Pacheco P , Caro-Vadillo A , Aragoncillo P , FernaÂndezCruz A . Rosuvastatin added to standard heart failure therapy improves cardiac remodelling in heart failure rats with preserved ejection fraction Eur J Heart Fail 2010 ; 12 : 903 ± 912 . https://doi.org/10.1093/ eurjhf/hfq101 PMID: 20601374
38. Bertrand ME , Vlachopoulos C , Mourad JJ . Triple combination therapy for global cardiovascular risk: Atorvastatin, perindopril and amlodipine . Am J Cardiovasc Drugs 2014 ; 16 : 241 ± 53 .
39. Koh KK , Quon MJ , Han SH , Ahn JY , Jin DK , Kim HS , et al. Vascular and metabolic effects of combined therapy with ramipril and simvastatin in patients with type 2 diabetes . Hypertension 2005 ; 45 : 1088 ± 1093 . https://doi.org/10.1161/01.HYP. 0000166722 .91714. ba PMID : 15883229
40. Merkulova-Rainon T , Broquères-You D , Kubis N , Silvestre JS , LeÂvy BI Towards the therapeutic use of vascular smooth muscle progenitor cells . Cardiovasc Res 2012 ; 95 : 205 ± 14 . https://doi.org/10.1093/ cvr/cvs097 PMID: 22354897
41. Zoll J , Fontaine V , Gourdy P , Barateau V , Vilar J , Leroyer A , et al. Role of human smooth muscle cell progenitors in atherosclerotic plaque development and composition . Cardiovasc Res 2008 ; 77 : 471 ± 480 . https://doi.org/10.1093/cvr/cvm034 PMID: 18006460
42. Akhtar S , Gremse F , Kiessling F , Weber C , Schober A. CXCL12 promotes the stabilization of atherosclerosis lesions mediated by smooth muscle progenitor cells in Apoe-deficient mice . Arterioscler Thromb Vasc Biol 2013 ; 33 : 679 ± 86 . https://doi.org/10.1161/ATVBAHA.112.301162 PMID: 23393393
43. GoÂmez-Garre D , Estrada V , Ortega-HernaÂndez A , Muñoz-Pacheco P , Serrano-Villar S , AÂ vila M , et al. Association of HIV-infection and antiretroviral therapy with levels of endothelial progenitor cells and subclinical atherosclerosis . J Acquir Immune Defic Syndr 2012 ; 61 : 545 ± 551 . https://doi.org/10.1097/QAI. 0b013e31826afbfc PMID: 22842847
44. Gaede P , Lund-Andersen H , Parving HH , Pedersen O . Effect of a multifactorial intervention on mortality in type 2 diabetes . N Engl J Med2008 7 ; 358 : 580 .
45. Bianconi V , Fallarino F , Mannarino MR , Bagaglia F , Kararoudi MN , Aragona CO et al. Autologous cell therapy for vascular regeneration: the role of proangiogenic cells . Curr Med Chem 2017 [Epub ahead of print].
46. Bianconi V , Sahebkar A , Kovanen P , Bagaglia F , Ricciuti B , Calabro P et al. Endothelial and cardiac progenitor cells for cardiovascular repair: A controversial paradigm in cell therapy . Pharmacol Ther 2017 . [Epub ahead of print].