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Review: Clinical Cardiology: New Frontiers

Diabetes and Vascular Disease

Pathophysiology, Clinical Consequences, and Medical Therapy: Part I
Mark A. Creager, MD; Thomas F. Lscher, MD, FRCP; and prepared with the assistance of
Francesco Cosentino, MD, PhD; Joshua A. Beckman, MD

iabetes mellitus affects approximately 100 million persons worldwide.1 Five to ten percent have type 1
(formerly known as insulin-dependent) and 90% to 95% have
type 2 (noninsulin-dependent) diabetes mellitus. It is likely
that the incidence of type 2 diabetes will rise as a consequence of lifestyle patterns contributing to obesity.2 Cardiovascular physicians are encountering many of these patients
because vascular diseases are the principal causes of death
and disability in people with diabetes. The macrovascular
manifestations include atherosclerosis and medial calcification. The microvascular consequences, retinopathy and nephropathy, are major causes of blindness and end-stage renal
failure. Physicians must be cognizant of the salient features of
diabetic vascular disease in order to treat these patients most
effectively. The present review will focus on the relationship
of diabetes mellitus and atherosclerotic vascular disease,
highlighting pathophysiology and molecular mechanisms
(Part I) and clinical manifestations and management strategies (Part II).

Pathophysiology of Diabetic Vascular Disease

Abnormalities in endothelial and vascular smooth muscle cell
function, as well as a propensity to thrombosis, contribute to
atherosclerosis and its complications. Endothelial cells, because of their strategic anatomic position between the circulating blood and the vessel wall, regulate vascular function
and structure. In normal endothelial cells, biologically active
substances are synthesized and released to maintain vascular
homeostasis, ensuring adequate blood flow and nutrient
delivery while preventing thrombosis and leukocyte diapedesis.3 Among the important molecules synthesized by the
endothelial cell is nitric oxide (NO), which is constitutively
produced by endothelial NO synthase (eNOS) through a
5-electron oxidation of the guanidine-nitrogen terminal of
L-arginine.4 The bioavailability of NO represents a key
marker in vascular health. NO causes vasodilation by activating guanylyl cyclase on subjacent vascular smooth muscle

cells.4 In addition, NO protects the blood vessel from endogenous injuryie, atherosclerosis by mediating molecular
signals that prevent platelet and leukocyte interaction with the
vascular wall and inhibit vascular smooth muscle cell proliferation and migration.57 Conversely, the loss of endothelium-derived NO permits increased activity of the proinflammatory transcription factor nuclear factor kappa B (NF-),
resulting in expression of leukocyte adhesion molecules and
production of chemokines and cytokines.8 These actions
promote monocyte and vascular smooth muscle cell migration into the intima and formation of macrophage foam cells,
characterizing the initial morphological changes of atherosclerosis.8 12 Endothelial dysfunction, as represented by impaired endothelium-dependent, NO-mediated relaxation, occurs in cellular and experimental models of diabetes.1316
Similarly, many, but not all, clinical studies have found that
endothelium-dependent vasodilation is abnormal in patients
with type 1 or type 2 diabetes.1720 Thus, decreased levels of
NO in diabetes may underlie its atherogenic predisposition.
The bioavailability of NO reflects a balance between its
production via NOS and its degradation, particularly by
oxygen-derived free radicals.20 22 Many of the metabolic
derangements known to occur in diabetes, including hyperglycemia, excess free fatty acid liberation, and insulin resistance, mediate abnormalities in endothelial cell function by
affecting the synthesis or degradation of NO (Figure 2).23

Hyperglycemia and NO
The intracellular glucose concentration of endothelial cells
mirrors the extracellular environment.24 Experimental evidence supports the notion that hyperglycemia decreases
endothelium-derived NO (Figure 1). When normal aortic
rings are incubated in a hyperglycemic milieu, endotheliumdependent relaxation is impaired.25 Similarly, endotheliumdependent vasodilation is reduced in healthy subjects during
hyperglycemic clamping.26 Hyperglycemia induces a series
of cellular events that increase the production of reactive

From the Cardiovascular Division, Brigham and Womens Hospital, Harvard Medical School, Boston, Mass (M.A.C., J.A.B.); Cardiology,
CardioVascular Center, University Hospital and Cardiovascular Research, Institute of Physiology, University Zrich, Switzerland (T.F.L., F.C.); and
Cardiology, II Faculty of Medicine, University La Sapienza, Rome & IRCCS Neuromed, Pozzilli, Italy (F.C.).
This article is part I of a 2-part article. Part II will appear in the September 30, 2003 issue of Circulation.
Dr Creager has served on the scientific advisory boards of Bristol Myers Squibb, KOS, Pfizer, and Sanofi-Synthelabo; and the speakers bureau of
Merck, Inc; he has received research grants from Bristol Myers Squibb, Eli Lilly, and Pfizer. Dr Lscher has served as a consultant on clopidogrel for
Correspondence to Mark A. Creager, MD, Brigham and Womens Hospital, Cardiovascular Division, 75 Francis St, Boston, MA 02115. E-mail
(Circulation 2003;108:1527-1532.)
2003 American Heart Association, Inc.
Circulation is available at

DOI: 10.1161/01.CIR.0000091257.27563.32

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September 23, 2003

Figure 1. Hyperglycemia and endotheliumderived vasoactive substances. Hyperglycemia decreased the bioavailability of nitric
oxide (NO) and prostacyclin (PGI2), and
increased the synthesis of vasoconstrictor
prostanoids and endothelin (ET-1) via multiple mechanisms, as discussed in the text.
PLC indicates phospholipase C; DAG,
diacylglycerol; PKC, protein kinase C;
eNOS, endothelial nitric oxide synthase;
Thr, thrombin; NAD(P)H Ox, nicotinamide
adenine dinucleotide phosphate oxidase;
O2, superoxide anion; ONOO, peroxynitrite; MCP-1, monocyte chemoattractant
protein-1; NF, nuclear factor kappa ;
TNF, tumor necrosis factor; ILs, interleukins; and COX-2, cyclooxygenase-2.

oxygen species (such as superoxide anion) that inactivate NO

to form peroxynitrite.27,28 Hyperglycemia may initiate this
process by increasing superoxide anion production via the
mitochondrial electron transport chain.28 Superoxide anion
then promotes a cascade of endothelial processes that engage
increasing numbers of cellular elements to produce oxygenderived free radicals. For example, superoxide anion activates
protein kinase C (PKC),28 or visa versa, activation of PKC
may contribute to superoxide generation.29,30 Activation of
PKC by glucose has been implicated in the regulation and
activation of membrane-associated NAD(P)H-dependent oxidases and subsequent production of superoxide anion.29
Indeed, the activity of NAD(P)H oxidase and levels of its
protein subunits are increased in internal mammary arteries
and saphenous veins of patients with diabetes.31 Peroxynitrite, resulting from the interaction of NO and superoxide
anion, oxidizes the NOS co-factor tetrahydrobiopterin.32,33
This uncouples the enzyme, which then preferentially increases superoxide anion production over NO production.34,35

Hence, a cascade effect occurs that results in ever-increasing

production of superoxide anion and inactivation of NO.
Mitochondrial production of superoxide anion also increases intracellular production of advanced glycation end
products (AGEs).28 These glycated proteins adversely affect
cellular function both by affecting protein function and by
activation of the receptor for AGEs (RAGE).36,37 AGEs, per
se, increase production of oxygen-derived free radicals, and
RAGE activation increases intracellular enzymatic superoxide oxide production.38 40 In addition, increased superoxide
anion production activates the hexosamine pathway, which
diminishes NOS activation by protein kinase Akt.41 These
processes likely recruit extracellular xanthine oxidase, which
further augments the oxidative stress.42 Hyperglycemiainduced oxidative stress also may increase levels of asymmetric dimethylarginine, a competitive antagonist of NOS, by
impairing the ability of dimethylarginine dimethylaminohydrolase to metabolize asymmetric dimethylarginine.43 The
concept that hyperglycemia-induced oxidative stress medi-

Figure 2. The metabolic abnormalities

that characterize diabetes, particularly
hyperglycemia, free fatty acids, and insulin resistance, provoke molecular mechanisms that alter the function and structure of blood vessels. These include
increased oxidative stress, disturbances
of intracellular signal transduction (such
as activation of PKC), and activation of
RAGE. Consequently, there is decreased
availability of NO, increased production
of endothelin (ET-1), activation of transcription factors such as NF-B and
AP-1, and increased production of prothrombotic factors such as tissue factor
(TF) and plasminogen activator inhibitor-1 (PAI-1)

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Creager and Lscher

ates endothelial dysfunction in patients with diabetes is
supported by the observations that intra-arterial infusion of
ascorbic acid, a water-soluble antioxidant capable of scavenging superoxide anion,44 restores endothelium-dependent
vasodilation in healthy subjects exposed to a hyperglycemic
clamp and in patients with type 1 or type 2 diabetes.27,45,46
Hyperglycemia also increases the production of the lipid
second messenger diacylglycerol, which causes the membrane translocation and activation of PKC.47,48 Activation of
PKC inhibits the activity of the phosphatidylinositol 3 kinase
pathway, thereby limiting activation of Akt kinase and
subsequent phosphorylation of NOS, which results in less NO
production. Diminished endothelium-dependent relaxation of
rabbit aorta exposed to elevated glucose levels is restored by
PKC inhibition.25 Administration of a PKC isoform inhibitor
to healthy subjects prevents abnormal endotheliumdependent vasodilation caused by hyperglycemia, which
confirms the contribution of PKC to endothelial

Free Fatty Acid Liberation and

Endothelial Function
Circulating levels of free fatty acids are elevated in diabetes
because of their excess liberation from adipose tissue and
diminished uptake by skeletal muscle.50 52 Free fatty acids
may impair endothelial function through several mechanisms,
including increased production of oxygen-derived free radicals, activation of PKC, and exacerbation of dyslipidemia.5355 Infusion of free fatty acids reduces endotheliumdependent vasodilation in animal models and in humans in
vivo.56 Co-infusion of the antioxidant ascorbic acid improves
endothelium-dependent vasodilation in humans treated with
free fatty acids, which indicates that oxidative stress mediates
the abnormality.57 Elevation of free fatty acid concentrations
activate PKC and decrease insulin receptor substrate-1
associated phosphatidylinosital-3 kinase activity.53,58 These
effects on signal transduction may decrease NOS activity as
discussed above.
The liver responds to free fatty acid flux by increasing
very-low-density lipoprotein production and cholesteryl ester
synthesis.59 This increased production of triglyceride-rich
proteins and the diminished clearance by lipoprotein lipase
results in hypertriglyceridemia, which is typically observed in
diabetes.60 Elevated triglyceride concentrations lower HDL
by promoting cholesterol transport from HDL to very-lowdensity lipoprotein.59 These abnormalities change LDL morphology, increasing the amount of the more atherogenic,
small, dense LDL.61,62 Both hypertriglyceridemia and low
HDL have been associated with endothelial dysfunction.63,64

Insulin Resistance and NO

Type 2 diabetes mellitus is characterized by insulin resistance. Insulin stimulates NO production from endothelial
cells by increasing the activity of NOS via activation of
phosphatidylinositol-3 kinase and Akt kinase.65 67 Thus, in
healthy subjects, insulin increases endothelium-dependent
(NO-mediated) vasodilation. In insulin-resistant subjects, endothelium-dependent vasodilation is reduced.68 Furthermore,
insulin-mediated glucose disposal correlates inversely with

Diabetes and Vascular Disease Pathophysiology


the severity of the impairment in endothelium-dependent

vasodilation.69 Drug therapies that increase insulin sensitivity, such as metformin and the thiazolidinediones, improve
endothelium-dependent vasodilation.70,71 Abnormal endothelium-dependent vasodilation in insulin-resistant states may be
explained by alterations in intracellular signaling that reduce
the production of NO. Specifically, insulin signal transduction via the phosphatidylinositol-3 kinase pathway is impaired, and insulin is less able to activate NOS and produce
NO.53,55,72 Insulin signaling via the mitogen-activated protein
kinase pathway remains intact.55,72 Mitogen-activated protein
kinase activation is associated with increased endothelin
production and a greater level of inflammation and
Also, insulin resistance is associated with elevations in free
fatty acid levels. Abdominal adipose tissue, the type found
prominently in type 2 diabetes, is more insulin resistant and
releases more free fatty acids compared with the type of
adipose in other locations. Activating lipoprotein lipase to
metabolize these free fatty acids increases insulin sensitivity.75,76 Thus, free fatty acidinduced alterations in intracellular signaling, as discussed previously, may also contribute to
decreased NOS activity and reduced production of NO in
insulin-resistant states such as type 2 diabetes.

Endothelial Production of Vasoconstrictors

In diabetes, endothelial cell dysfunction is characterized not
only by decreased NO but also by increased synthesis of
vasoconstrictor prostanoids and endothelin.77 80 Hyperglycemia increases the expression of cyclooxygenase-2 mRNA and
protein levels but not the expression of cyclooxygenase-1
mRNA in cultured human aortic endothelial cells.30 In rabbit
arteries exposed to a hyperglycemic milieu in vitro, the
production of vasoconstrictor prostanoids is increased, and
both cyclooxygenase inhibitors and prostaglandin
H2/thromboxane A2 receptor antagonists restore endotheliumdependent relaxation.13
Endothelin may be particularly relevant to the pathophysiology of vascular disease in diabetes because endothelin
promotes inflammation and causes vascular smooth muscle
cell contraction and growth.81 Insulin increases endothelin-1
immunoreactivity in endothelial cells. Also, plasma
endothelin-1 concentration increases after administration of
insulin to healthy subjects and patients with type 2 diabetes
mellitus.73,74,82,83 In healthy subjects, blockade of endothelin
A and B receptors increases forearm blood flow after intraarterial administration of insulin, which indicates that insulin
may affect vascular tone via stimulation of endothelin.84
Blockade of endothelin A receptors also increases forearm
blood flow in patients with type 2 diabetes mellitus, implicating enhanced activity of endogenous endothelin-1 in resistance vessels of these patients.85

Diabetes and Vascular Smooth Muscle Function

The impact of diabetes mellitus on vascular function is not
limited to the endothelium. In patients with type 2 diabetes
mellitus, the vasodilator response to exogenous NO donors is
diminished.18 Moreover, vasoconstrictor responsiveness to
exogenous vasoconstrictors, such as endothelin-1, is re-

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September 23, 2003

Figure 3. Platelet function and plasma

coagulation factors are altered in diabetes, favoring platelet aggregation and a
propensity for thrombosis. There is
increased expression of glycoprotein Ib
and IIb/IIIa, augmenting both platelet
von Willebrand (vWF) factor and platelet
fibrin interaction. The bioavailability of
NO is decreased. Coagulation factors,
such as tissue factor, factor VII, and
thrombin, are increased; plasminogen
activator inhibitor (PAI-1) is increased;
and endogenous anticoagulants such as
thrombomodulin are decreased.

duced.86 Dysregulation of vascular smooth muscle function is

exacerbated by impairments in sympathetic nervous system
function.87 Diabetes increases PKC activity, NF- production, and generation of oxygen-derived free radicals in
vascular smooth muscle, akin to these effects in endothelial
cells.55,88 Moreover, diabetes heightens migration of vascular
smooth muscle cells into nascent atherosclerotic lesions,
where they replicate and produce extracellular matrix
important steps in mature lesion formation.89 Vascular
smooth muscle cell apoptosis in atherosclerotic lesions is also
increased, such that patients with diabetes tend to have fewer
smooth muscle cells in the lesions, which increases the
propensity for plaque rupture.90 In persons with diabetes,
elaboration of cytokines diminishes vascular smooth muscle
synthesis of collagen and increases production of matrix
metalloproteinases, yielding an increased tendency for plaque
destabilization and rupture.91,92

Diabetes, Thrombosis, and Coagulation

Platelet function is abnormal in diabetes as well. Expression
of both glycoprotein Ib and IIb/IIIa is increased, augmenting
both plateletvon Willebrand factor and plateletfibrin interaction (Figure 3).93 The intracellular platelet glucose concentration mirrors the extracellular environment and is associated
with increased superoxide anion formation and PKC activity
and decreased platelet-derived NO.93,94 Hyperglycemia further changes platelet function by impairing calcium homeostasis and thereby alters aspects of platelet activation and
aggregation, including platelet conformation and release of
In diabetes, plasma coagulation factors (eg, factor VII and
thrombin) and lesion-based coagulants (eg, tissue factor) are
increased, and endogenous anticoagulants (eg, thrombomodulin and protein C) are decreased.96 98 Also, the production of plasminogen activator inhibitor-1, a fibrinolysis inhibitor, is increased.8790,93,96,99 101 Thus, a propensity for platelet
activation and aggregation, coupled with a tendency for
coagulation, is relevant to a risk of thrombosis complicating
plaque rupture.

Vascular diseases, particularly atherosclerosis, are major
causes of disability and death in patients with diabetes

mellitus. Diabetes mellitus substantially increases the risk of

developing coronary, cerebrovascular, and peripheral arterial
disease. The pathophysiology of vascular disease in diabetes
involves abnormalities in endothelial, vascular smooth muscle cell, and platelet function. The metabolic abnormalities
that characterize diabetes, such as hyperglycemia, increased
free fatty acids, and insulin resistance, each provoke molecular mechanisms that contribute to vascular dysfunction.
These include decreased bioavailability of NO, increased
oxidative stress, disturbances of intracellular signal transduction, and activation of receptors for AGEs. In addition,
platelet function is abnormal, and there is increased production of several prothrombotic factors. These abnormalities
contribute to the cellular events that cause atherosclerosis and
subsequently increase the risk of the adverse cardiovascular
events that occur in patients with diabetes and atherosclerosis.
A better understanding of the mechanisms leading to vascular
dysfunction may unmask new strategies to reduce cardiovascular morbidity and mortality in patients with diabetes.

This work is supported by grants from the National Institutes of
Health (HL-56607 and HL-04169), the Swiss National Research
Foundation (31-68 118.02; 32-67202.01), the Italian Ministry of
Health (ICS 030.6/RF00-49), the Swiss Heart Foundation, and the
Roche Research Foundation. Dr Creager is the Simon C. Fireman
Scholar in Cardiovascular Medicine at Brigham and Womens

1. Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes
and its complications: estimates and projections to the year 2010. Diabet
Med. 1997;14(suppl 5):S1S85.
2. Mokdad AH, Bowman BA, Ford ES, et al. The continuing epidemics of
obesity and diabetes in the United States. JAMA. 2001;286:11951200.
3. Kinlay S, Libby P, Ganz P. Endothelial function and coronary artery
disease. Curr Opin Lipidol. 2001;12:383389.
4. Moncada S, Higgs A. The L-argininenitric oxide pathway. N Engl
J Med. 1993;329:20022012.
5. Radomski MW, Palmer RM, Moncada S. The role of nitric oxide and
cGMP in platelet adhesion to vascular endothelium. Biochem Biophys
Res Commun. 1987;148:14821489.
6. Sarkar R, Meinberg EG, Stanley JC, et al. Nitric oxide reversibly
inhibits the migration of cultured vascular smooth muscle cells. Circ
Res. 1996;78:225230.

Downloaded from by guest on March 12, 2015

Creager and Lscher

7. Kubes P, Suzuki M, Granger DN. Nitric oxide: an endogenous modulator of leukocyte adhesion. Proc Natl Acad Sci U S A. 1991;88:
4651 4655.
8. Zeiher AM, Fisslthaler B, Schray-Utz B, et al. Nitric oxide modulates
the expression of monocyte chemoattractant protein 1 in cultured human
endothelial cells. Circ Res. 1995;76:980 986.
9. Libby P. Changing concepts of atherogenesis. J Intern Med. 2000;247:
349 358.
10. Nomura S, Shouzu A, Omoto S, et al. Significance of chemokines and
activated platelets in patients with diabetes. Clin Exp Immunol. 2000;
121:437 443.
11. Mohamed AK, Bierhaus A, Schiekofer S, et al. The role of oxidative
stress and NF-kappaB activation in late diabetic complications. Biofactors. 1999;10:157167.
12. Collins T, Cybulsky MI. NF-kappaB: pivotal mediator or innocent
bystander in atherogenesis? J Clin Invest. 2001;107:255264.
13. Tesfamariam B, Brown ML, Deykin D, et al. Elevated glucose promotes
generation of endothelium-derived vasoconstrictor prostanoids in rabbit
aorta. J Clin Invest. 1990;85:929 932.
14. Bohlen HG, Lash JM. Topical hyperglycemia rapidly suppresses EDRFmediated vasodilation of normal rat arterioles. Am J Physiol. 1993;265:
H219 H225.
15. Meraji S, Jayakody L, Senaratne MP, et al. Endothelium-dependent
relaxation in aorta of BB rat. Diabetes. 1987;36:978 981.
16. Pieper GM, Meier DA, Hager SR. Endothelial dysfunction in a model of
hyperglycemia and hyperinsulinemia. Am J Physiol. 1995;269:
17. Johnstone MT, Creager SJ, Scales KM, et al. Impaired endotheliumdependent vasodilation in patients with insulin-dependent diabetes
mellitus. Circulation. 1993;88:2510 2516.
18. Williams SB, Cusco JA, Roddy MA, et al. Impaired nitric oxidemediated vasodilation in patients with noninsulin-dependent diabetes
mellitus. J Am Coll Cardiol. 1996;27:567574.
19. Clarkson P, Celermajer DS, Donald AE, et al. Impaired vascular reactivity in insulin-dependent diabetes mellitus is related to disease duration
and low density lipoprotein cholesterol levels. J Am Coll Cardiol.
20. McVeigh GE, Brennan GM, Johnston GD, et al. Impaired endotheliumdependent and independent vasodilation in patients with type 2
(noninsulin-dependent) diabetes mellitus. Diabetologia. 1992;35:
21. Arnal JF, Dinh-Xuan AT, Pueyo M, et al. Endothelium-derived nitric
oxide and vascular physiology and pathology. Cell Mol Life Sci. 1999;
55:1078 1087.
22. Cosentino F, Hishikawa K, Katusic ZS, et al. High glucose increases
nitric oxide synthase expression and superoxide anion generation in
human aortic endothelial cells. Circulation. 1997;96:2528.
23. King GL. The role of hyperglycaemia and hyperinsulinaemia in causing
vascular dysfunction in diabetes. Ann Med. 1996;28:427 432.
24. Kaiser N, Sasson S, Feener EP, et al. Differential regulation of glucose
transport and transporters by glucose in vascular endothelial and smooth
muscle cells. Diabetes. 1993;42:80 89.
25. Tesfamariam B, Brown ML, Cohen RA. Elevated glucose impairs endothelium-dependent relaxation by activating protein kinase C. J Clin
Invest. 1991;87:16431648.
26. Williams SB, Goldfine AB, Timimi FK, et al. Acute hyperglycemia
attenuates endothelium-dependent vasodilation in humans in vivo. Circulation. 1998;97:16951701.
27. Beckman JA, Goldfine AB, Gordon MB, et al. Ascorbate restores
endothelium-dependent vasodilation impaired by acute hyperglycemia
in humans. Circulation. 2001;103:1618 1623.
28. Nishikawa T, Edelstein D, Du XL, et al. Normalizing mitochondrial
superoxide production blocks three pathways of hyperglycaemic
damage. Nature. 2000;404:787790.
29. Hink U, Li H, Mollnau H, et al. Mechanisms underlying endothelial
dysfunction in diabetes mellitus. Circ Res. 2001;88:E14 E22.
30. Cosentino F, Eto M, De Paolis P, et al. High glucose causes upregulation
of cyclooxygenase-2 and alters prostanoid profile in human endothelial
cells: role of protein kinase C and reactive oxygen species. Circulation.
31. Guzik TJ, Mussa S, Gastaldi D, et al. Mechanisms of increased vascular
superoxide production in human diabetes mellitus: role of NAD(P)H
oxidase and endothelial nitric oxide synthase. Circulation. 2002;105:
1656 1662.

Diabetes and Vascular Disease Pathophysiology


32. Koppenol WH, Moreno JJ, Pryor WA, et al. Peroxynitrite, a cloaked
oxidant formed by nitric oxide and superoxide. Chem Res Toxicol.
1992;5:834 842.
33. Laursen JB, Somers M, Kurz S, et al. Endothelial regulation of vasomotion
in apoE-deficient mice: implications for interactions between peroxynitrite
and tetrahydrobiopterin. Circulation. 2001;103:12821288.
34. Milstien S, Katusic Z. Oxidation of tetrahydrobiopterin by peroxynitrite:
implications for vascular endothelial function. Biochem Biophys Res
Comm. 1999;263:681 684.
35. Wever RM, Luscher TF, Cosentino F, et al. Atherosclerosis and the two
faces of endothelial nitric oxide synthase. Circulation. 1998;97:
108 112.
36. Schmidt AM, Yan SD, Wautier JL, et al. Activation of receptor for
advanced glycation end products: a mechanism for chronic vascular
dysfunction in diabetic vasculopathy and atherosclerosis. Circ Res.
1999;84:489 497.
37. Schmidt AM, Hori O, Brett J, et al. Cellular receptors for advanced
glycation end products: implications for induction of oxidant stress and
cellular dysfunction in the pathogenesis of vascular lesions. Arterioscler
Thromb. 1994;14:15211528.
38. Schmidt AM, Stern D. Atherosclerosis and diabetes: the RAGE connection. Curr Atheroscler Rep. 2000;2:430 436.
39. Tan KC, Chow WS, Ai VH, et al. Advanced glycation end products and
endothelial dysfunction in type 2 diabetes. Diabetes Care. 2002;25:
40. Wautier MP, Chappey O, Corda S, et al. Activation of NADPH oxidase
by AGE links oxidant stress to altered gene expression via RAGE. Am J
Physiol Endocrinol Metab. 2001;280:E685E694.
41. Du XL, Edelstein D, Dimmeler S, et al. Hyperglycemia inhibits endothelial nitric oxide synthase activity by posttranslational modification at
the Akt site. J Clin Invest. 2001;108:13411348.
42. Desco MC, Asensi M, Marquez R, et al. Xanthine oxidase is involved in
free radical production in type 1 diabetes: protection by allopurinol.
Diabetes. 2002;51:1118 11124.
43. Lin KY, Ito A, Asagami T, et al. Impaired nitric oxide synthase pathway
in diabetes mellitus: role of asymmetric dimethylarginine and dimethylarginine dimethylaminohydrolase. Circulation. 2002;106:987992.
44. Jackson TS, Xu A, Vita JA, et al. Ascorbate prevents the interaction of
superoxide and nitric oxide only at very high physiological concentrations. Circ Res. 1998;83:916 922.
45. Timimi FK, Ting HH, Haley EA, et al. Vitamin C improves endothelium-dependent vasodilation in patients with insulin-dependent diabetes
mellitus. J Am Coll Cardiol. 1998;31:552557.
46. Ting HH, Timimi FK, Boles KS, et al. Vitamin C improves endothelium-dependent vasodilation in patients with noninsulin-dependent
diabetes mellitus. J Clin Invest. 1996;97:2228.
47. Xia P, Inoguchi T, Kern TS, et al. Characterization of the mechanism for
the chronic activation of diacylglycerolprotein kinase C pathway in
diabetes and hypergalactosemia. Diabetes. 1994;43:11221129.
48. Inoguchi T, Xia P, Kunisaki M, et al. Insulins effect on protein kinase
C and diacylglycerol induced by diabetes and glucose in vascular
tissues. Am J Physiol. 1994;267:E369 E379.
49. Beckman JA, Goldfine AB, Gordon MB, et al. Inhibition of protein
kinase C beta prevents impaired endothelium-dependent vasodilation
caused by hyperglycemia in humans. Circ Res. 2002;90:107111.
50. Boden G. Free fatty acids, insulin resistance, and type 2 diabetes
mellitus. Proc Assoc Am Physicians. 1999;111:241248.
51. Fujimoto WY. The importance of insulin resistance in the pathogenesis
of type 2 diabetes mellitus. Am J Med. 2000;108(suppl 6a):9S14S.
52. Kelley DE, Simoneau JA. Impaired free fatty acid utilization by skeletal
muscle in noninsulin-dependent diabetes mellitus. J Clin Invest. 1994;
94:2349 2356.
53. Dresner A, Laurent D, Marcucci M, et al. Effects of free fatty acids on
glucose transport and IRS-1associated phosphatidylinositol 3-kinase
activity. J Clin Invest. 1999;103:253259.
54. Dichtl W, Nilsson L, Goncalves I, et al. Very low-density lipoprotein
activates nuclear factor-kappaB in endothelial cells. Circ Res. 1999;84:
55. Inoguchi T, Li P, Umeda F, et al. High glucose level and free fatty acid
stimulate reactive oxygen species production through protein kinase
C dependent activation of NAD(P)H oxidase in cultured vascular cells.
Diabetes. 2000;49:1939 1945.
56. Steinberg HO, Tarshoby M, Monestel R, et al. Elevated circulating free
fatty acid levels impair endothelium-dependent vasodilation. J Clin
Invest. 1997;100:1230 1239.

Downloaded from by guest on March 12, 2015



September 23, 2003

57. Pleiner J, Schaller G, Mittermayer F, et al. FFA-induced endothelial

dysfunction can be corrected by vitamin C. J Clin Endocrinol Metab.
58. Griffin ME, Marcucci MJ, Cline GW, et al. Free fatty acidinduced
insulin resistance is associated with activation of protein kinase C theta
and alterations in the insulin signaling cascade. Diabetes. 1999;48:
1270 1274.
59. Sniderman AD, Scantlebury T, Cianflone K. Hypertriglyceridemic
hyperapob: the unappreciated atherogenic dyslipoproteinemia in type 2
diabetes mellitus. Ann Intern Med. 2001;135:447 459.
60. Cummings MH, Watts GF, Umpleby AM, et al. Increased hepatic
secretion of very-low-density lipoprotein apolipoprotein B-100 in
NIDDM. Diabetologia. 1995;38:959 967.
61. Sniderman A, Thomas D, Marpole D, et al. Low density lipoprotein: a
metabolic pathway for return of cholesterol to the splanchnic bed. J Clin
Invest. 1978;61:867 873.
62. Dimitriadis E, Griffin M, Owens D, et al. Oxidation of low-density
lipoprotein in NIDDM: its relationship to fatty acid composition. Diabetologia. 1995;38:1300 1306.
63. de Man FH, Weverling-Rijnsburger AW, van der Laarse A, et al. Not
acute but chronic hypertriglyceridemia is associated with impaired endothelium-dependent vasodilation: reversal after lipid-lowering therapy
by atorvastatin. Arterioscler Thromb Vasc Biol. 2000;20:744 750.
64. Kuhn FE, Mohler ER, Satler LF, et al. Effects of high-density
lipoprotein on acetylcholine-induced coronary vasoreactivity. Am J
Cardiol. 1991;68:14251430.
65. Zeng G, Quon MJ. Insulin-stimulated production of nitric oxide is
inhibited by wortmannin: direct measurement in vascular endothelial
cells. J Clin Invest. 1996;98:894 898.
66. Kuboki K, Jiang ZY, Takahara N, et al. Regulation of endothelial
constitutive nitric oxide synthase gene expression in endothelial cells
and in vivo: a specific vascular action of insulin. Circulation. 2000;101:
676 681.
67. Zeng G, Nystrom FH, Ravichandran LV, et al. Roles for insulin
receptor, PI3-kinase, and Akt in insulin-signaling pathways related to
production of nitric oxide in human vascular endothelial cells. Circulation. 2000;101:1539 1545.
68. Laakso M, Edelman SV, Brechtel G, et al. Decreased effect of insulin to
stimulate skeletal muscle blood flow in obese man: a novel mechanism
for insulin resistance. J Clin Invest. 1990;85:1844 1852.
69. Mather K, Laakso M, Edelman S, et al. Evidence for physiological
coupling of insulin-mediated glucose metabolism and limb blood flow.
Am J Physiol Endocrinol Metab. 2000;279:E1264 E1270.
70. Mather KJ, Verma S, Anderson TJ. Improved endothelial function with
metformin in type 2 diabetes mellitus. J Am Coll Cardiol. 2001;37:
1344 1350.
71. Watanabe Y, Sunayama S, Shimada K, et al. Troglitazone improves
endothelial dysfunction in patients with insulin resistance. J Atheroscler
Thromb. 2000;7:159 163.
72. Montagnani M, Golovchenko I, Kim I, et al. Inhibition of phosphatidylinositol 3-kinase enhances mitogenic actions of insulin in endothelial
cells. J Biol Chem. 2002;277:1794 1799.
73. Oliver FJ, de la Rubia G, Feener EP, et al. Stimulation of endothelin-1
gene expression by insulin in endothelial cells. J Biol Chem. 1991;266:
74. Ferri C, Pittoni V, Piccoli A, et al. Insulin stimulates endothelin-1
secretion from human endothelial cells and modulates its circulating
levels in vivo. J Clin Endocrinol Metab. 1995;80:829 835.
75. de Souza CJ, Eckhardt M, Gagen K, et al. Effects of pioglitazone on
adipose tissue remodeling within the setting of obesity and insulin
resistance. Diabetes. 2001;50:18631871.
76. Kusunoki M, Hara T, Tsutsumi K, et al. The lipoprotein lipase activator,
NO-1886, suppresses fat accumulation and insulin resistance in rats fed
a high-fat diet. Diabetologia. 2000;43:875 880.
77. De Vriese AS, Verbeuren TJ, Van de Voorde J, et al. Endothelial
dysfunction in diabetes. Br J Pharmacol. 2000;130:963974.
78. Luft FC. Proinflammatory effects of angiotensin II and endothelin:
targets for progression of cardiovascular and renal diseases. Curr Opin
Nephrol Hypertens. 2002;11:59 66.
79. Golovchenko I, Goalstone ML, Watson P, et al. Hyperinsulinemia
enhances transcriptional activity of nuclear factor-kappaB induced by



















angiotensin II, hyperglycemia, and advanced glycosylation end products

in vascular smooth muscle cells. Circ Res. 2000;87:746 752.
ODriscoll G, Green D, Rankin J, et al. Improvement in endothelial
function by angiotensin converting enzyme inhibition in insulindependent diabetes mellitus. J Clin Invest. 1997;100:678 684.
Hopfner RL, Gopalakrishnan V. Endothelin: emerging role in diabetic
vascular complications. Diabetologia. 1999;42:13831394.
Piatti PM, Monti LD, Conti M, et al. Hypertriglyceridemia and hyperinsulinemia are potent inducers of endothelin-1 release in humans.
Diabetes. 1996;45:316 321.
Wolpert HA, Steen SN, Istfan NW, et al. Insulin modulates circulating
endothelin-1 levels in humans. Metabolism. 1993;42:10271030.
Cardillo C, Nambi SS, Kilcoyne CM, et al. Insulin stimulates both
endothelin and nitric oxide activity in the human forearm. Circulation.
1999;100:820 825.
Cardillo C, Campia U, Bryant MB, et al. Increased activity of endogenous endothelin in patients with type II diabetes mellitus. Circulation.
Nugent AG, McGurk C, Hayes JR, et al. Impaired vasoconstriction to
endothelin 1 in patients with NIDDM. Diabetes. 1996;45:105107.
McDaid EA, Monaghan B, Parker AI, et al. Peripheral autonomic
impairment in patients newly diagnosed with type II diabetes. Diabetes
Care. 1994;17:14221427.
Hattori Y, Hattori S, Sato N, et al. High-glucose-induced nuclear factor
kappaB activation in vascular smooth muscle cells. Cardiovasc Res.
2000;46:188 197.
Suzuki LA, Poot M, Gerrity RG, et al. Diabetes accelerates smooth
muscle accumulation in lesions of atherosclerosis: lack of direct growthpromoting effects of high glucose levels. Diabetes. 2001;50:851 860.
Fukumoto H, Naito Z, Asano G, et al. Immunohistochemical and morphometric evaluations of coronary atherosclerotic plaques associated
with myocardial infarction and diabetes mellitus. J Atheroscler Thromb.
1998;5:29 35.
Hussain MJ, Peakman M, Gallati H, et al. Elevated serum levels of
macrophage-derived cytokines precede and accompany the onset of
IDDM. Diabetologia. 1996;39:60 69.
Uemura S, Matsushita H, Li W, et al. Diabetes mellitus enhances
vascular matrix metalloproteinase activity: role of oxidative stress. Circ
Res. 2001;88:12911298.
Vinik AI, Erbas T, Park TS, et al. Platelet dysfunction in type 2 diabetes.
Diabetes Care. 2001;24:1476 1485.
Assert R, Scherk G, Bumbure A, et al. Regulation of protein kinase C by
short term hyperglycaemia in human platelets in vivo and in vitro.
Diabetologia. 2001;44:188 195.
Li Y, Woo V, Bose R. Platelet hyperactivity and abnormal Ca(2)
homeostasis in diabetes mellitus. Am J Physiol Heart Circ Physiol.
2001;280:H1480 H1489.
Hafer-Macko CE, Ivey FM, Gyure KA, et al. Thrombomodulin deficiency in human diabetic nerve microvasculature. Diabetes. 2002;51:
Ceriello A, Giacomello R, Stel G, et al. Hyperglycemia-induced
thrombin formation in diabetes: the possible role of oxidative stress.
Diabetes. 1995;44:924 928.
Ceriello A, Giugliano D, Quatraro A, et al. Evidence for a
hyperglycaemia-dependent decrease of antithrombin IIIthrombin
complex formation in humans. Diabetologia. 1990;33:163167.
Ren S, Lee H, Hu L, et al. Impact of diabetes-associated lipoproteins on
generation of fibrinolytic regulators from vascular endothelial cells.
J Clin Endocrinol Metab. 2002;87:286 291.
Kario K, Matsuo T, Kobayashi H, et al. Activation of tissue factorinduced coagulation and endothelial cell dysfunction in noninsulindependent diabetic patients with microalbuminuria. Arterioscler Thromb
Vasc Biol. 1995;15:1114 1120.
Pandolfi A, Cetrullo D, Polishuck R, et al. Plasminogen activator inhibitor type 1 is increased in the arterial wall of type II diabetic subjects.
Arterioscler Thromb Vasc Biol. 2001;21:1378 1382.

KEY WORDS: diabetes mellitus

atherosclerosis insulin

cardiovascular diseases

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nitric oxide

Diabetes and Vascular Disease: Pathophysiology, Clinical Consequences, and Medical

Therapy: Part I
Mark A. Creager, Thomas F. Lscher, prepared with the assistance of, Francesco Cosentino and
Joshua A. Beckman
Circulation. 2003;108:1527-1532
doi: 10.1161/01.CIR.0000091257.27563.32
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2003 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539

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