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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
Servier.
Correspondence to Mark A. Creager, MD, Brigham and Womens Hospital, Cardiovascular Division, 75 Francis St, Boston, MA 02115. E-mail
mcreager@partners.org
(Circulation 2003;108:1527-1532.)
2003 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org

DOI: 10.1161/01.CIR.0000091257.27563.32

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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
dysfunction.49

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

1529

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
thrombosis.73,74
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
mediators.95
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.

Conclusions
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.

Acknowledgments
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
Hospital.

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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.
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