DISFUNO

ENDOTELIAL
Daniel Candeias Faria
Bruno Grima
Servio Medicina 4
Hospital Professor Doutor Fernando Fonseca

06-06-2016

ndice
Endotlio como rgo funcional
xido Ntrico

Disfuno Endotelial
Reparao Endotelial
Aferio Clnica

Definio?

Endotlio como rgo funcional1,2

1- John E. Deanfield, et al, Endothelial Function and Dysfunction, Testing and Clinical Relevance, Circulation. 2007 Mar
13;115(10):1285-95
2- Mudau M, Genis, A, Lochner A, Strijdom H, Endothelial dysfunction: the early predictor ofAtherosclerosis, Cardiovasc
J Afr.2012 May;23(4):222-31.

Endotlio como rgo funcional

1-6x1013 clulas endoteliais
rgo metabolicamente activo
Papel crucial na homoeostasia vascular, com capacidade

para libertar inmeros factores vasoactivos3

3- Chhabra N. Endothelial dysfunction A predictor of atherosclerosis. Internet J Med Update 2009; 4(1): 3341

Endotlio como rgo funcional

Regulao do tnus vascular
Adeso celular

Proliferao de clulas musculares lisas

Tromborresistncia
Inflamao

Endotlio como orgo funcional

Vasodilatao

xido Ntrico (NO)

Vasoconstrio

Factor Hiperpolarizante Derivado

do Endotlio (EDHF)
Prostaciclinas

Endotelina-1 (ET-1)
Angiotensina II
Tromboxano A2

4- Hsueh WA, Lyon CJ, Quinones MJ. Insulin resistance and the endothelium. Am J Med 2004; 117: 109117.

xido Ntrico

xido Ntrico

Nature, Vol.288, 27 November 1980, pag 373-376

xido Ntrico
Factor Relaxante Derivado do Endotlio1
Propriedades vasodilatadoras, anti-inflamatrias e

cardioprotectoras5
Alta difusibilidade inter e intracelular e capacidade

reactiva com vrias molculas5

1- John E. Deanfield, et al, Endothelial Function and Dysfunction, Testing and Clinical Relevance, Circulation. 2007
Mar 13;115(10):1285-95
5- Strijdom H, Chamane N, Lochner A. Nitric oxide in the cardiovascular system: a simple molecule with complex
actions. Cardiovasc J Afr 2009; 20: 303310

Figura 1 Ciclo da sntese de NO

6- James Leiper & Manasi Nandi, The therapeutic potential of targeting endogenous inhibitors of nitric oxide synthesis, Nature
Reviews Drug Discovery 10, 277-291 (April 2011)

xido Ntrico
Todas as isoformas de xido Ntrico Sintetase (NOS)

requerem co-factores7
Co-factores
Tetrahidrobiopeterina (BH4)
Flavina Adenina Dinucletido (FAD)
Flavina Mononucletido (FMN)
Protoporfirina IX (Heme)

Das 3 isoformas de NOS, a variante endotelial (eNOS)

considerada a mais importante em condies fisiolgicas

7-Alderton WK, Cooper CE, Knowles RG. Nitric oxide synthases: structure, function and inhibition. Biochem J 2001;
357: 593615

xido Ntrico

Figura 2 Mecanismos e efeitos fisiolgicos do NO

1- John E. Deanfield, et al, Endothelial Function and Dysfunction, Testing and Clinical Relevance, Circulation. 2007 Mar
13;115(10):1285-95

xido Ntrico
A fora de cisalhamento um dos principais activadores

da eNOS em condies fisiolgicas e adequa a perfuso

s mudanas de dbito cardaco8
Bradicinina, Adenosina, Serotonina, Factor de

Crescimento Vascular Endotelial (VEGF) em resposta

hipxia1
1- John E. Deanfield, et al, Endothelial Function and Dysfunction, Testing and Clinical Relevance, Circulation. 2007 Mar
13;115(10):1285-95
8- Corson MA, James NL, Latta SE, Nerem RM, Berk BC, Harrison DG. Phosphorylation of endothelial nitric oxide
synthase in response to fluid shear stress. Circ Res. 1996;79:984 991.

Mecanismos independentes
Factor Hiperpolarizante Derivado do Endotlio9
Aumento da conduo de potssio
Propagao da despolarizao
Manuteno do tnus vasodilatador
Compensador na perda de dilatao NO-mediada por diminuio da

sua biodisponibilidade
Microcirculao
Prostaciclina10
Papel limitado

9- Busse R, Edwards G, Feletou M, Fleming I, Vanhoutte PM, Weston AH. EDHF: bringing the concepts together.
Trends Pharmacol Sci. 2002;3: 374380.
10- Moncada S, Higgs EA, Vane JR. Human arterial and venous tissues generate prostacyclin (prostaglandin x), a
potent inhibitor of platelet aggregation. Lancet. 1977;1:18 20

Papel na inflamao
Manuteno da parede vascular num estado de quiescncia11:
Anti-oxidante
Inibio da adeso celular
Tromborresistncia

Nitrosilao de resduos de cistena12:

NF-kB
Ciclo celular
Factor tecidual
Limitao da fosforilao oxidativa na mitocndria

11- Stamler JS, Lamas S, Fang FC. Nitrosylation. The prototypic redox-based signaling mechanism. Cell.
2001;106:675 683
12 - Ghosh S, Karin M. Missing pieces in the NF-B puzzle. Cell. 2002; 109:S81S96

Disfuno Endotelial

Stress Oxidativo
Factores de risco cardiovasculares esto associados com

aumento dos nveis e fontes de radicais livres (ROS)3

Vias Propostas
NADPH Oxidase
Xantina Oxidase
Ciclooxigenase
Mitocndria
eNOS

3- Chhabra N. Endothelial dysfunction A predictor of atherosclerosis. Internet J Med Update 2009; 4(1): 3341

Stress Oxidativo

Figura 3 Stress Nitro-oxidativo

1- John E. Deanfield, et al, Endothelial Function and Dysfunction, Testing and Clinical Relevance, Circulation. 2007 Mar
13;115(10):1285-95

Stress Oxidativo

eNOS uncoupling

Figura 3 Stress Nitro-oxidativo

Stress oxidativo
During conditions of oxidative stress, eNOS deviates from its role of being an
essential regulator of the functioning of the cardiovascular system to being an
O2- releasing enzyme.

A vicious circle therefore develops, whereby uncoupled eNOS synthesises

O2- at the expense of NO, further aggravating oxidative stress

2- Mudau M, Genis, A, Lochner A, Strijdom H, Endothelial dysfunction: the early predictor ofAtherosclerosis,
Cardiovasc J Afr.2012 May;23(4):222-31.

Stress Oxidativo
Superxido14
Produo de peroxinitrito - Citotoxicidade (DNA, lpidos, protenas)
eNOS uncoupling

Peroxinitrito15
Oxidao do co-factor essencial da eNOS (BH4)
Produo de BH3- e eNOS uncoupling
Formao de pontes dissulfito e perda dos stios de ligao da L-arginina

e do BH4

14 -Huang PL. Endothelial nitric oxide synthase and endothelial dysfunction - Curr Hypertens Rep 2003; 5: 473480
15 - Forstermann U, Munzel T. Endothelial nitric oxide synthase in vascular disease: from marvel to menace.
Circulation 2006; 113: 17081714.

Stress Oxidativo
Perxido de Hidrognio
eNOS uncoupling
Vitamina C 16
Recilagem de BH3- a BH4

16- Katusic ZS. Vascular endothelial dysfunction: does tetrahydrobiopterin play a role? Am J Physiol Heart Circ Physiol
2001; 281: 981986

Figura 4 eNOS uncoupling

16- Katusic ZS. Vascular endothelial dysfunction: does tetrahydrobiopterin .play a role? Am J Physiol Heart Circ Physiol 2001;
281: 981986

Inflamao
O stress oxidativo amplifica as vias de sinalizao

endoteliais associadas aos estados inflamatrios17

TNF-a
IL-1

VCAM-1
ICAM-1
IL-6

Activao
endotelial

PRINCIPAL PERCURSOR DA DISFUNO ENDOTELIAL

17 - Madamanchi NR, Vendrov A, Runge MS. Oxidative stress and vascular disease. Arterioscler Thromb Vasc Biol
2005; 25: 2938

Inflamao
TNF-a

18

Sndromes Coronrios Agudos

Insuficincia Cardaca
Aterosclerose
Miocardite
Obesidade
Mecanismos
Formao de ROS via NADPH e Xantina Oxidase 19

Degradao do mRNA da eNOS 20

Leso isqumia-reperfuso
18 - Meldrum DR. Tumor necrosis factor in the heart. Am J Physiol Regulatory Intergrative Comp Physiol 1998; 274: 577595

19 - Zhang H, Park Y, Wu J, et al. Role of TNF- in vascular dysfunction - Clin Sci 2009; 116: 219230
20 - Davignon J, Ganz P. Role of endothelial dysfunction in atherosclerosis - Circulation 2004; 109: 2732

Inflamao

N Engl J Med 2007; 356:911-920 March 1, 2007

Inflamao

Grfico 1 Dilatao fluxo-mediada em 6 meses de follow-up

Reparao endotelial

Figura 5 Disfuno Endotelial Induzida por FRCV

2- Mudau M, Genis, A, Lochner A, Strijdom H, Endothelial dysfunction: the early predictor ofAtherosclerosis, Cardiovasc
J Afr.2012 May;23(4):222-31.

Reparao endotelial
Exposio prolongada/repetida a FRCV

Exausto dos mecanismos protectores e

anti-inflamatrios

Micropartculas
derivadas de processos
apoptticos
Clulas inteiras

Perda de integridade, senescncia e

libertao para a circulao

Reparao endotelial
Replicao local de clulas adjacentes
Progenitores endoteliais em circulao21
Recrutamento da medula ssea
Diferenciao em clulas endotelias maduras nos tecidos
Mecanismo NO-dependente
Inibido nos doentes com FRCV22

21 - Asahara T, Murohara T, Sullivan A, Silver M, Zee R, Li T, Witzenbichler B, Schatteman G, Isner JM. Isolation of
putative progenitor endothelial cells for angiogenesis. Science. 1997;275:964-967
22 - Aicher A, Heeschen C, Mildner-Rihm C, Urbich C, Ihling C, Technauhling K, Zeiher AM, Dimmeler S. Essential role
of endothelial nitric oxide synthase for mobilization of stem and progenitor cells. Nat Med 2003;9:1370 1376.

Reparao endotelial

Circulation. 2004 Jan 20;109(2):220-6. 2003 Dec 22

Reparao endotelial

Circulation. 2001 Jun 19;103(24):2885-90

Reparao endotelial

Grfico 2 Percentagem de clulas progenitoras endoteliais em doentes tratados com

atorvastatina

Reparao endotelial
FRCV:
Interferem com o recrutamento de clulas progenitoras endoteliais
Interferem com a sua diferenciao e funo
Diferenciao em clulas da linhagem mieloide (macrfagos,
clulas dendrticas) quando expostas a citocinas prinflamatrias23

23 -Vallance P, Leiper J. Cardiovascular biology of the asymmetric dimethylarginine:dimethylarginine dimethylaminohydrolase

pathway. Arterioscler Thromb Vasc Biol. 2004;24:10231030.

Reparao endotelial

Grfico 3 Associao entre nmero de clulas progenitoras circulantes e a reactividade

braquial; B- Doentes com elevado nmero de clulas progenitores e relao com FRCV

1- John E. Deanfield, et al, Endothelial Function and Dysfunction, Testing and Clinical Relevance, Circulation. 2007 Mar
13;115(10):1285-95

Aferio Clnica

Mtodos de Avaliao Directos

Dilatao Fluxo-Mediada (FMD)
Pletismografia do antebrao
Pletismografia de puslo digital (EndoPat)
Angiografia coronria quantitativa

ndice ntima-mdia (IMT)

ndice ntima-mdia

Grfico 4 Associao entre IMT, FMD e FRCV na infncia e idade adulta

EndoPat

Figura 6 Funo vasodilatadora normal endotelial

EndoPat

Figura 7 Funo vasodilatadora anormal

Biomarcadores
Dimetilarginina assimtrica (ADMA) 23
Anatagonista endgeno da eNOS
Nveis aumentados em doentes com FRCV
Reduz a biodisponibilidade do NO
Actividade reduzida da enzima dimetilamino-hidrolase (DDAH),
associada a TNF-a, LDL-ox e glicmia
Associada a doena aterosclertica pr-clnca24

23 -Vallance P, Leiper J. Cardiovascular biology of the asymmetric dimethylarginine:dimethylarginine

dimethylaminohydrolase pathway. Arterioscler Thromb Vasc Biol. 2004;24:10231030.
24 - Boger RH, Maas R, Schulze F, Schwedhelm E. Elevated levels of asymmetric dimethylarginine (ADMA) as a
marker of cardiovascular disease and mortality. Clin Chem Lab Med. 2005;43:1124 1129

Figura 1 Ciclo da sntese de NO

6- James Leiper & Manasi Nandi, The therapeutic potential of targeting endogenous inhibitors of nitric oxide synthesis, Nature
Reviews Drug Discovery 10, 277-291 (April 2011)

Biomarcadores
Citocinas inflamatrias e molculas de adeso celular25
E-selectina
VCAM-1
ICAM-1
P-selectina

Marcadores pr-coagulantes26
tPA
PAI-1
Factor de VonWillebrand

25 - Ridker PM, Brown NJ, Vaughan DE, Harrison DG, Mehta JL. Established and emerging plasma biomarkers in the
prediction of first atherothrombotic events. Circulation. 2004;109:IV6 IV19
26 -Vaughan DE. PAI-1 and atherothrombosis. J Thromb Haemost. 2005 3:1879 1883

Clulas endotelias e micropartculas

Clulas endoteliais circulantes2
Leso mecnica
Proteases/citocinas
M adeso matriz extracelular
Apoptose (CD146)
Citometria de fluxo e microscopia de fluorescncia
Micropartculas endoteliais (MPE)
Vesculas libertadas pelas clulas activadas e apoptticas
Funo desconhecida (pr-inflamatrias?)
Doentes hipertensos, com doena coronria, artrite reumatide e
lups eritematoso sistmico tm nveis aumentados de MPE em
circulao
Estatinas reduzem o nmero de MPE
2- Mudau M, Genis, A, Lochner A, Strijdom H, Endothelial dysfunction: the early predictor ofAtherosclerosis, Cardiovasc
J Afr.2012 May;23(4):222-31.

Concluses
A Disfuno Endotelial um marcador de leso

provocada pelos factores de risco tradicionais e

emergentes.
Existe a necessidade de utilizao de testes clnicos para

estratificao individual de risco, identificao de doentes

de risco elevado e monitorizao teraputica.
Os testes de funo endotelial reflectem a biologia

vascular, esto relacionados com a gravidade da doena

e com o prognstico, mas so dispendiosos e de difcil
execuo.

Obrigado

Bibliografia
1- John E. Deanfield, et al, Endothelial Function and Dysfunction, Testing and Clinical Relevance,
Circulation. 2007 Mar 13;115(10):1285-95

2- Mudau M, Genis, A, Lochner A, Strijdom H, Endothelial dysfunction: the early predictor

ofAtherosclerosis, Cardiovasc J Afr.2012 May;23(4):222-31.
3- Chhabra N. Endothelial dysfunction A predictor of atherosclerosis. Internet J Med Update 2009; 4(1): 33
41
4- Hsueh WA, Lyon CJ, Quinones MJ. Insulin resistance and the endothelium. Am J Med 2004; 117: 109117.
5- Strijdom H, Chamane N, Lochner A. Nitric oxide in the cardiovascular system: a simple molecule with
complex actions. Cardiovasc J Afr 2009; 20: 303310
6- James Leiper & Manasi Nandi, The therapeutic potential of targeting endogenous inhibitors of nitric oxide
synthesis, Nature Reviews Drug Discovery 10, 277-291 (April 2011)
7-Alderton WK, Cooper CE, Knowles RG. Nitric oxide synthases: structure, function and inhibition. Biochem J
2001; 357: 593615
8- Corson MA, James NL, Latta SE, Nerem RM, Berk BC, Harrison DG. Phosphorylation of endothelial nitric
oxide synthase in response to fluid shear stress. Circ Res. 1996;79:984 991.

Bibliografia
9- Busse R, Edwards G, Feletou M, Fleming I, Vanhoutte PM, Weston AH. EDHF: bringing the
concepts together. Trends Pharmacol Sci. 2002;3: 374380.
10- Moncada S, Higgs EA, Vane JR. Human arterial and venous tissues generate prostacyclin
(prostaglandin x), a potent inhibitor of platelet aggregation. Lancet. 1977;1:18 20

11- Stamler JS, Lamas S, Fang FC. Nitrosylation. The prototypic redox-based signaling mechanism.
Cell. 2001;106:675 683

12 - Ghosh S, Karin M. Missing pieces in the NF-B puzzle. Cell. 2002; 109:S81S96
13- Tohru Fukai, Possible role of endothelial GTPCH in eNOS uncoupling and atherosclerosis,
Arterioscler Thromb Vasc Biol. 2007;27:1493-1495
14 -Huang PL. Endothelial nitric oxide synthase and endothelial dysfunction - Curr Hypertens Rep
2003; 5: 473480
15 - Forstermann U, Munzel T. Endothelial nitric oxide synthase in vascular disease: from marvel to
menace. Circulation 2006; 113: 17081714.

Bibliografia
16- Katusic ZS. Vascular endothelial dysfunction: does tetrahydrobiopterin play a role? Am J Physiol
Heart Circ Physiol 2001; 281: 981986
17 - Madamanchi NR, Vendrov A, Runge MS. Oxidative stress and vascular disease. Arterioscler
Thromb Vasc Biol 2005; 25: 2938

18 - Meldrum DR. Tumor necrosis factor in the heart. Am J Physiol Regulatory Intergrative Comp
Physiol 1998; 274: 577595

19 - Zhang H, Park Y, Wu J, et al. Role of TNF- in vascular dysfunction - Clin Sci 2009; 116: 219230
20 - Davignon J, Ganz P. Role of endothelial dysfunction in atherosclerosis - Circulation 2004; 109:
2732
21 - Asahara T, Murohara T, Sullivan A, Silver M, Zee R, Li T, Witzenbichler B, Schatteman G, Isner
JM. Isolation of putative progenitor endothelial cells for angiogenesis. Science. 1997;275:964-967
22 - Aicher A, Heeschen C, Mildner-Rihm C, Urbich C, Ihling C, Technauhling K, Zeiher AM, Dimmeler
S. Essential role of endothelial nitric oxide synthase for mobilization of stem and progenitor cells. Nat
Med 2003;9:1370 1376.

Bibliografia
23 -Vallance P, Leiper J. Cardiovascular biology of the asymmetric dimethylarginine:dimethylarginine
dimethylaminohydrolase pathway. Arterioscler Thromb Vasc Biol. 2004;24:10231030.
24 - Boger RH, Maas R, Schulze F, Schwedhelm E. Elevated levels of asymmetric dimethylarginine
(ADMA) as a marker of cardiovascular disease and mortality. Clin Chem Lab Med. 2005;43:1124
1129
25 - Ridker PM, Brown NJ, Vaughan DE, Harrison DG, Mehta JL. Established and emerging plasma
biomarkers in the prediction of first atherothrombotic events. Circulation. 2004;109:IV6 IV19
26 -Vaughan DE. PAI-1 and atherothrombosis. J Thromb Haemost. 2005 3:1879 1883
27 - Munzel T, Sinning C, Post F, et al. Pathophysiology, diagnosis and prognostic implication of
endothelial dysfunction. Ann Med 2008; 40:180196.
28 -Rajagopalan S, Somers EC, Brook RD, Kehrer C, Pfenninger D, Lewis E, Chakrabarti A,
Richardson BC, Shelden E, McCune WJ, Kaplan MJ. Endothelial cell apoptosis in systemic lupus
erythematosus: a common pathway for abnormal vascular function and thrombosis propensity. Blood.
2004;103:36773683