1. Arterial Calcification and Arterial Stiffness Alberto Avolio Department of Biomedical Sciences Faculty of Medicine and Health Sciences Macquarie University Sydney, Australia Sydney, Australia. alberto.avolio@mq.ed.au

2. Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia Arterial Calcification Can arterial calcification be a treatment target for arterial stiffness ?

3. Arterial Calcification Intimal calcification Medial calcification Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

4. Persy V and D’Hasse P. Trends in Molecular Medicine, 2009; 15(9): 405-416 Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia INTIMAL and MEDIAL Calcification

5. Arterial Calcification Mechanisms for deposition of calcium in arteries are similar to mechanisms for bone formation. Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia The vasculature - second most calcified structure in humans after the skeleton

6. Arterial Calcification 1500 Benivieni &Falopio..“degeneration of arteries into bone” 1863VirchowDescribed vascular changes as “ossification” (rather than ‘calcification’) 1906BuntinDemonstration of bone marrow in sclerotic aorta Santos et al, Clin Med Insights: Endocrinol Diabetes 2012;5:47-54 Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

8. Pathways and mediators involved in vascular calcification and the calcification paradox Persy V and D’Hasse P. Trends in Molecular Medicine, 2009; 15(9): 405-416 Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

9. FINDNGS: Association between increased arterial stiffness (PWV) and arterial calcification (detected by CT) - explained by a common genetic etiology - independent of noncalcified atheromatous plaque - independent of bone mineral density Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

10. Atkinson J et al Am J Physiol 1994;266:H540-547 Carotid Artery Compliance Control VDN Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

11. 130 125 120 115 110 105 100 95 90 85 80 75 70 65 mmHg Pres1 2 6 767.15767.20767.25 767.30767.35767.40767.45767.50767.55 ECG (PE, 50ug/min; SNP, 10ug/min) a b Transducer 2 Transducer 1 Catheter 1 Catheter 2 Drug infusion Aortic Pulse Wave Velocity in Rat Models Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

12. Sodium nitroprusside phynelephrine P1, mmHg P2, mmHg HR, bpm PWV, m/sec Time, sec Aortic Pulse Wave Velocity in Rat Models Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

13. Thoracic Aorta Abdominal Aorta Calcification Aortic Pulse Wave Velocity in Rat Models Aortic calcificaton induced by Nicotine and Vitamin D Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

14. Wall Area Elastic Modulus Wall Stress Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

15. Thoracic Aorta Abdominal Aorta : (a,b) Wall stress (10 6 dyne/cm 2 ), (c,d) elastic modulus (10 6 dyne/cm 2 ) and (e,f) elastic modulus/wall stress of the thoracic (a,c,e) and abdominal (b,d,f) aorta in WKY (white column), VDN (grey column) and SHR (black column). * P<0.05. Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

16. Ng K, Hildreth CM, Phillips JK, Avolio AP Aortic stiffness is associated with vascular calcification and remodeling in a chronic kidney disease rat model. Am J Physiol Renal Physiol 2011; 300: F1431–F1436 Arterial calcification and stiffness Chronic Kidney Disease Rat Model (*) Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia (*) Rat model: Lewis Polycystic Kidney (LPK) ]

17. Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia Ng K et al. Am J Physiol Renal Physiol 2011; 300: F1431–F1436

18. LKP Increased isobaric pulse wave velocity ~ 30% Increased aortic calcification ~ 600% Decreased elastin lamella density Decreased interlamellar elastin Increased smooth muscle cell density Reduced size of smooth muscle cell nucleus Lewis Polycystic Kidney (LPK) Disease Rat Model Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia Ng K et al. Am J Physiol Renal Physiol 2011; 300: F1431–F1436

19. Ng K, Hildreth CM, Avolio AP, Phillips JK. Angiotensin converting enzyme inhibitor limits pulse- wave velocity and aortic calcification in a rat model of cystic renal disease. Am J Physiol Renal Physiol 2011; 301: F959–F966 Arterial calcification and stiffness - Treatment Blunted by ACE inhibition (Perindopril) Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

20. Ng K et al. Am J Physiol Renal Physiol 2011; 301: F959–F966

21. Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia Ng K et al. Am J Physiol Renal Physiol 2011; 301: F959–F966 ControlPerindopril Wall Area Calcification Wall Stiffness Effect of ACE Inhibition Elastin density [ treatment 6-12 weeks ]

22. ACEi and pressure–dependent PWV in LKP rat aorta 30 % ~ 70 mmHg Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia Ng K et al. Am J Physiol Renal Physiol 2011; 301: F959–F966

23. Arterial calcification and stiffness Affected by Renin-Angiotensin System? Vascular calcification inhibited by preventing vascular osteogenesis Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

27. Atkinson J. J Appl Physiol 2008;105:1643-1651 Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

28. Avolio A. Arterial Stiffness. Pulse 2013;1:14-28 Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

29. NO-related Mechanisms of Arterial Stiffness D. Berkowitz, Jonhs Hopkins University Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

30. D. Berkowitz, Jonhs Hopkins University Studies of NOS and TG2 in knockout mice models TG2 activity Pulse Wave Velocity Arterial Compliance Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

32. Studies of NOS and TG2 in aging rat models D. Berkowitz, Jonhs Hopkins University TG2 activity E : endothelium TG2 S-Nitrosylation Reduction of PWV with TG2 Inhibitor Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

33. Increase of TG2 activity with age in human aorta Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

34. 1.Arterial Calcification 2.Nitric Oxide and alteration of extracellular matrix Two mechanisms of cellular and molecular factors of arterial stiffness : Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

35. 1.Arterial Calcification 2.Nitric Oxide and alteration of extracellular matrix Two mechanisms of cellular and molecular factors of arterial stiffness : Question: Any possible connection ? Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

36. 1.Arterial Calcification 2.Nitric Oxide and alteration of extracellular matrix Two mechanisms of cellular and molecular factors of arterial stiffness : Answer: Tissue transglutaminase (TG2) ? Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

37. Johnson KA et al, Circ Res, 2008;102:529-537 Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

38. Johnson KA et al, Circ Res, 2008;102:529-537 Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

39. Van Bavel E, Bakker E, Circ Res, 2008;102:507-509 Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

40. Vascular Effects of Biophosphonates Biophosphonates used in treating osteoporosis; act on body’s source of hydroxyapatite - skeleton Santos LL et al, Vascular effects of bisphosphonates-a systematic review. Clin Med Insights Endocrinol Diabetes. 2012;5:47-54 Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia

41. Conclusion Can arterial calcification be a treatment target for arterial stiffness ? Experimental data aimed at uncovering basic mechanisms of arterial calcification and arterial stiffness indicates potential pathways. Faculty of Medicine and Health Sciences Macquarie University, Sydney, Australia