Vascular Calcification

Kristina Bostrm, MD, PhD Cardiology, UCLA

Case Presentation
74 y o Caucasian female, with hypertension and critical aortic stenosis. One year prior to presentation, aortic valve replacement had been attempted but was aborted due to severe aortic calcification, so called porcelain aorta. Now increasing symptoms of shortness of breath with exertion and chest pain, with recurrent hospital admissions for congestive heart failure.

Echocardiogram: LVEF >60% with concentric left ventricular hypertrophy and diastolic dysfunction. Mild mitral regurgitation. Moderate tricuspid regurgitation. Cardiac Catheterization: Normal systolic function. Non-obstructive coronary disease. CT Chest: Uniform, smooth calcification of the ascending aorta extending from the root to the origin of great vessels, with trivial atherosclerotic calcifications of the descending aorta. The appearance of the ascending aorta is reminiscent of aortic graft. Extensive aortic valve calcification and moderate mitral valve calcification.

Circumferential Calcification in the Ascending Aorta

Left Ventricular Apical Conduit to Descending Thoracic Aorta

This Case Illustrates .

Calcification can be characterized by the anatomical location. There are more than one type of vascular calcification. We are unable to efficiently treat vascular calcification. Vascular calcification may cause clinical complications.

Vascular Calcification Differs in:

Anatomical location Aortic Coronary Peripheral arteries Heart valve Intima Media Adventitia Heart valve Atherosclerosis Mnckebergs (Media Sclerosis) Diabetes Renal Failure

Vascular layer

Association with disease

Vascular Calcification Is Associated with Vascular Disease:

Intima

Atherosclerosis Renal Failure Diabetes Mnckebergs (Media sclerosis) Renal Failure Diabetes Diabetes

Media

Adventitia

Heart valves

Atherosclerosis

Intimal Calcification - Atherosclerosis

Sangiorgi et al. JACC 1998

CLINICAL IMPLICATIONS OF INTIMAL CALCIFICATION

Coronary Arteries Correlated with Coronary Artery Disease and atherosclerotic plaque burden. Associated with Sudden Cardiac Death Promotes dissection following angioplasty
Media

Calcified, Atherosclerotic Coronary Artery

Intima

Calcification

Webpath

Rupture at Edge of Calcified Lesion

In Vitro

In Vivo - after angioplasty

Mechanical stress analysis of a rigid inclusion in distensible material: a model of atherosclerotic calcification and plaque vulnerability. Hoshino et al. Am J Physiol 2009

Coronary Calcification
Detected by Electron Beam CT (EBCT) - Heart Scans

Coronary Calcification - EBCT

A negative EBCT test is associated with a low risk of a cardiovascular event in the next 2 to 5 years. A positive EBCT confirms the presence of a coronary atherosclerotic plaque. The greater the amount of calcium, the greater the likelihood of occlusive CAD, but there is not a 1-to1 relationship, and findings may not be site specific. The total amount of calcium correlates best with the total amount of atherosclerotic plaque, although the true "plaque burden" is underestimated

Atherosclerotic Plaques

Medial Calcification

VASCULAR MEDIAL CALCIFICATION

(Mnckebergs media sclerosis, elastocalcinosis) Arteriosclerosis associated with aging, diabetes, and end stage renal disease

Webpath Price et al. ATVB 2000

CLINICAL IMPLICATIONS OF VASCULAR MEDIAL CALCIFICATION Aorta Correlates with increased ischemic episodes in peripheral vascular disease (PVD) Peripheral Arteries Strong marker for future cardiac events, PVD, and lower extremity amputations in diabetics Prognostic marker for all-cause and cardiovascular mortality in dialysis patients

Causes increased aortic stiffness, pulse pressure, left ventricular hypertrophy and cardiovascular mortality

Medial Calcification in Arteries of Dialysis Patients 30-700 fold increase in cardiovascular mortality risk in dialysis patients compared to the general population. Decreased survival in end stage renal disease patient with intimal and medial vascular calcification

Moe et al. Kidney Int. 2002

Heart Valve Calcification

Normal Aortic Valve

Senile Aortic Stenosis

Calcified Bioprosthetic Valve

CLINICAL IMPLICATIONS OF VALVE CALCIFICATION

Major cause of failure in native valves Major cause of failure in bioprosthetic valves Highly prevalent in patients with end stage renal failure

Mechanisms of Vascular Calcification

Normal Vessels Dont Mineralize

Active Inducers

Active Inhibitors

Both Inhibitors and Promotors of Calcification in Atherosclerotic Plaques

Inhibitors

Promotors

Dhore et al. ATVB 2001

Major Theories of Vascular Calcification

DISTURBED Ca/Pi BALANCE Hyperphosphatemia Hypercalcemia LOSS OF INHIBITION Pyrophosphate MGP OPN Fetuin/alpha2-HS glycoprotein Others

Ca x Pi

INDUCING FACTORS Pi Lipids Inflammatory cytokines Others

VASCULAR CALCIFICATION

INDUCTION OF BONE FORMATION Vascular bone and cartilage-like cells

CIRCULATING NUCLEATIONAL COMPLEXES Apoptotic bodies Bisphosphonates OPG Bone Remodeling CELL DEATH

Matrix Vesicles

Adapted from Speer & Giachelli, Cardiovasc Path 2004

Major Theories of Vascular Calcification

DISTURBED Ca/Pi BALANCE Hyperphosphatemia Hypercalcemia LOSS OF INHIBITION Pyrophosphate MGP OPN Fetuin/alpha2-HS glycoprotein Others

Ca x Pi

INDUCING FACTORS Pi Lipids Inflammatory cytokines Others

VASCULAR CALCIFICATION

INDUCTION OF BONE FORMATION Vascular bone and cartilage-like cells

CIRCULATING NUCLEATIONAL COMPLEXES Apoptotic bodies Bisphosphonates OPG Bone Remodeling CELL DEATH

Matrix Vesicles

Adapted from Speer & Giachelli, Cardiovasc Path 2004

GENERALIZED INFANTILE ARTERIAL CALCIFICATION

Rare human genetic disorder; early lethal Vascular medial calcification leading to a stenosing, fibroproliferative arterial process Characterized by deficiency in extracellular pyrophosphate (PPi), due to a deficiency in PPi-generating nucleoside triphosphate pyrophosphohydrolase plasma membrane 1 enzyme (PC-1, ENPP1).

Long-axis image of aorta and aortic arch

Levine et al. Circulation 2001

Matrix Gla Protein (MGP)

Inhibitor of Bone Morphogenetic Proteins (BMP)
(Zebboudj 2002, Yao 2006)

Dependent on Vitamin K for correct gamma-carboxylation of glutamates (Gla-modifications) and anti-calcific activity
(Murshed 2004)

Dependent on specific proline and Gla-residues for BMP binding (Yao 2008) MGP loss of function mutations in humans cause Keutel syndrome (Keutel 1971, Munroe 1999)

Vascular Calcification in MGP Null Mice

MGP null

Aortic media

Wild type
Aortic media

Luo et al. Science 1997

BONE MORPHOGENETIC PROTEINS (BMP)

Potent inducers of bone formation Inflammatory mediators induced in vascular endothelium by abnormal oscillatory flow (Sorescu et al. 2004) Promotes hypertension and atherogenesis in mice
(Miriyala et al. 2006, Jo et al. - in prep.)

MGP reduces formation of atherosclerotic plaques and lesions calcification

(Yao et al. - in revision)

Warfarin / Coumadin Use:

Inhibits MGP gamma-carboxylation, induces vascular calcification in growing rats
(Price 1998, Essalihi 2003, Schurgers 2007)

Correlated with increased coronary and valve calcification

(Schurgers 2004, Koos 2005)

Associated with calcific uremic arteriolopathy in dialysis patients

(Coates 1998, Piccoli 2002)

Fetuin, 2 Hermann-Schmid Glycoprotein (AHSG)

Made in the liver Inhibitor of spontaneous hydroxyapatite (HA) formation from supersaturated calcium- and phosphate containing solutions Fetuin null mice have decreased serum HA inhibitory activity and increased soft tissue calcification
(Jahnen-Dechent 1997, Schafer 2003)

Normal mouse after phosphate challenge

Fetuin-deficient mouse after phosphate challenge Westenfeld et al. Trends Cardiovasc Med 2007

OSTEOPONTIN
Acidic phosphoprotein found in bone and teeth Inhibitor of apatite crystal growth Promotes osteoclast function

Osteopontin Deficiency Worsens Calcification in MGP Null Mice

Speer MY et al. 2002

Major Theories of Vascular Calcification

DISTURBED Ca/Pi BALANCE Hyperphosphatemia Hypercalcemia LOSS OF INHIBITION MGP OPN Fetuin/alpha2-HS glycoprotein Pyrophosphate Others

Ca x Pi

INDUCING FACTORS Pi Lipids Inflammatory cytokines Others

VASCULAR CALCIFICATION

INDUCTION OF BONE FORMATION Vascular bone and cartilage-like cells

CIRCULATING NUCLEATIONAL COMPLEXES Apoptotic bodies Bisphosphonates OPG Bone Remodeling CELL DEATH

Matrix Vesicles

Adapted from Speer & Giachelli, Cardiovasc Path 2004

Ectopic Calcification in Atherosclerotic Plaqes

Chondrocytes in Mouse Atherosclerotic Lesions

Rattazzi et al. ATVB 2005

Mineral Precipitation
Ca2+ PO42-

Cell Differentiation
osteoblast-like cell matrix vesicles

CaPO4 mineral precipitation Active inhibitor Ca2+ PO42-

osteoid (matrix)

CaPO4 mineral precipitation

hydroxyapatite

Potential Origins of Osteoblast-like Cells in the Artery Wall Pericytes Mesenchymal stem cells Multipotent cells from the adventitia Resident cells in the media or intima Trans-differentiated SMC (Synthetic vs contractile phenotype)

Calcifying Vascular Cells (CVC)

UNDIFFERENTIATED

CONDENSATION

CALCIFIED NODULES

Bone Related Factors in Calcified Artery Wall

BMP-2 and -4 Cbfa1 Osterix Collagen I Alkaline Phosphatase Osteocalcin Hydroxyapatite Osteopontin Matrix GLA protein (MGP) Osteoprotegerin and others ..

Both Inhibitors and Promotors of Calcification in Plaques

Dhore et al. ATVB 2001

Major Theories of Vascular Calcification

DISTURBED Ca/Pi BALANCE Hyperphosphatemia Hypercalcemia LOSS OF INHIBITION MGP OPN Fetuin/alpha2-HS glycoprotein Pyrophosphate Others

Ca x Pi

INDUCING FACTORS Pi Lipids Inflammatory cytokines Others

VASCULAR CALCIFICATION

INDUCTION OF BONE FORMATION Vascular bone and cartilage-like cells

CIRCULATING NUCLEATIONAL COMPLEXES Apoptotic bodies Bisphosphonates OPG Bone Remodeling CELL DEATH

Matrix Vesicles

Adapted from Speer & Giachelli, Cardiovasc Path 2004

Normal Vessels Dont Mineralize

(Despite serum Ca x P at or near solubility product) Active Inducers

Active Inhibitors

Intima

Atherosclerosis Renal Failure Diabetes Mnckebergs (Media sclerosis) Renal Failure Diabetes Diabetes

Media

Adventitia

Heart valves

Atherosclerosis

Calcium x Phosphate Product

Already above precipitation point at certain places Renal failure may increase Ca x P product further

Hyperphosphatemia:
Major independent risk factor for vascular calcification and cardiovascular mortality in dialysis patients
(Block 1998, 2004, Goodman 2000, Shigematsu 2003, Young 2005)

Phosphate-Induced Changes in SMC Differentiation

Pi/Ca

Contractile SMC SM-MHC SM22alpha SM-alpha actin Desmin

Osteochondrogenic cell Cbfa1 OPN Osteocalcin Alk Phos

Type III sodium-dependent phosphate co-transporters (Pit-1, Pit-2) Blockage of these transporters leads to phosphate induced SMC mineralization Pit-1 can be induced by BMP-2

Calcified Vascular Smooth Muscle Cells

Wada et al. Circ Res 1999

Major Theories of Vascular Calcification

DISTURBED Ca/Pi BALANCE Hyperphosphatemia Hypercalcemia LOSS OF INHIBITION MGP OPN Fetuin/alpha2-HS glycoprotein Pyrophosphate Others

Ca x Pi

INDUCING FACTORS Pi Lipids Inflammatory cytokines Others

VASCULAR CALCIFICATION

INDUCTION OF BONE FORMATION Vascular bone and cartilage-like cells

CIRCULATING NUCLEATIONAL COMPLEXES Apoptotic bodies Bisphosphonates OPG Bone Remodeling CELL DEATH

Matrix Vesicles

Degenerative Joint Diseases are Connection between Crystal diseases Vascular Calcification and Bone where synovial fibroblasts have an inflammatory response to the crystals.

Aortic Calcification and Osteoporosis Frequently Coexist

Similarities to Bone: Bone Proteins Osteoblast-like Cells Osteoclast-like Cells

The paradox of arterial calcification in osteoporotic patients

Parhami et al. ATVB 1997

Oxidized lipids or other agents may be mediating the effect.

Mody et al. J Nucl Card 2003

Resorptive osteoclast-like cells are found in calcified atherosclerotic lesions. (Tintut et al. 2002) Maybe derived from blood monocytes

Osteoclast-like cell with multiple nuclei

Osteoprotegerin (OPG)
OPG is a secreted protein that inhibits osteoclast formation OPG deficient mice have osteoporosis and arterial (medial) calcification

OPG Null Mouse

Bucay et al. Genes & Development 1998

Bone Resorption in the Skeleton Often Coexists with Bone Formation in the Vasculature

Panizo et al., Circ Res 2009 Alexander, Circ Res 2009

VASCULAR CALCIFICATION AND INFLAMMATION

The Size of Vascular Calcification May Matter!

Large Chunks

Small BCP Crystals

Dhore et al. ATVB 2001

Engelse et al.2001

BCP = Basic calcium phosphate

Degenerative Joint Diseases are Crystal diseases where synovial fibroblasts have an inflammatory response to the crystals.

Nadra et al. Circ Res 2005

The ingestion of BCP crystals by human monocyte-derived macrophages generates a pro-inflammatory response.

BCP Crystals Induces Pro-Inflammatory Factors in Macrophages

TNF-alpha

TNF-alpha Increases Calcification in Calcifying Vascular Cells (CVC)

Nadra et al. Circ Res 2005 Tintut et al. Circ 2000

Large calcified areas may be less pro-inflammatory. How dangerous is the calcification we find on EBCT?

Mouse models for vascular calcification

Genes Associated with Ectopic Calcification in Mice

MUTATION Matrix Gla Protein Fetuin Osteopontin Fibrillin Osteoprotegerin FGF23 PC-1/Enpp1/NPP1 (nucleotide pyrophosphatase) Ank (pyrophosphate transporter) -glucosidase (klotho) Carbonic Anhydrase II Smad6 Desmin PHENOTYPE Arterial, valve and cartilage calcification Decreased serum HA inhibitory activity Increased calcification of implanted bioprosthetic valves Vascular calcification, aortic stenosis Osteoporosis, vascular calcification Hyperphosphatemia, vascular calcification Vascular and articular cartilage calcification Articular cartilage calcification, soft tissue calcification Vascular calcification, rapid aging Calcification of small arteries Valve calcification Neonatal cardiomyopahty with calcificationAriall

Mouse Models Illustrate the Diversity of Vascular Calcification

MGP knockout Fat-fed ApoE (or LDLR) knockout mice Fibrillin-1 deficient

Carbonic anhydrase II deficient OPG knockout

Warfarin treated rat VitD/Ca Smad6 knockout

Vascular calcification is heterogeneous and is triggered through multiple mechanisms