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• W3190376089 abstract "Predicting the risk of all-cause mortality, but in particular a cardiovascular (CV) cause, has been extensively researched within different patient populations suffering from endothelial dysfunction due to cardiovascular disease (CVD). Constantly, new blood biomarkers with clinical and prognostic relevance are emerging. For instance, within the last 20 years circulating progenitor cells (CPCs) have come into focus as an independent predictor of all-cause or CV mortality [[1]Fadini G.P. Mehta A. Dhindsa D.S. et al.Circulating stem cells and cardiovascular outcomes: from basic science to the clinic.Eur. Heart J. 2020; 41: 4271-4282Crossref PubMed Scopus (30) Google Scholar]. In a healthy state, progenitor cells are being mobilized from bone marrow to the peripheral blood when needed and circulate in very low quantity. Only ~3 cells/μl of blood are usually CPCs expressing the typical hematopoietic surface marker CD34, while those additionally expressing CD133 or also endothelial markers such as KDR are even rarer (~1 cell/μl or 0.03 cell/μl, respectively) [[2]Cimato T.R. Conway A. Nichols J. et al.CD133 expression in circulating hematopoietic progenitor cells.Cytometry B Clin Cytom. 2019; 96: 39-45Crossref PubMed Scopus (4) Google Scholar,[3]Fadini G.P. Baesso I. Albiero M. et al.Technical notes on endothelial progenitor cells: ways to escape from the knowledge plateau.Atherosclerosis. 2008; 197: 496-503Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar]. In patients with elevated risk experiencing CV events, CPCs are even less numerous [[4]Fadini G.P. Rigato M. Cappellari R. et al.Long-term prediction of cardiovascular outcomes by circulating CD34+ and CD34+CD133+ stem cells in patients with type 2 diabetes.Diabetes Care. 2017; 40: 125-131Crossref PubMed Scopus (49) Google Scholar], possibly explained by an exhaustion of the progenitor cell reserve in bone marrow [[5]Gremmels H. van Rhijn-Brouwer F.C.C. Papazova D.A. et al.Exhaustion of the bone marrow progenitor cell reserve is associated with major events in severe limb ischemia.Angiogenesis. 2019; 22: 411-420Crossref PubMed Scopus (1) Google Scholar]. Despite their scarcity, these cells have the ability to renew the CV system proven by higher numbers of CPC colony-forming units being associated with enhanced endothelial function [[6]Hill J.M. Zalos G. Halcox J.P. et al.Circulating endothelial progenitor cells, vascular function, and cardiovascular risk.N. Engl. J. Med. 2003; 348: 593-600Crossref PubMed Scopus (3043) Google Scholar]. As a logical consequence with less CPCs present for regeneration, a long-term deterioration of health or even death could be probable. However, when interpreting risk or hazard ratios of mortality based on CPC levels, conclusions should be drawn with caution because methodological standards such as cell isolation, acquisition of rare events by flow cytometry, and reporting of outcomes differ between studies [[1]Fadini G.P. Mehta A. Dhindsa D.S. et al.Circulating stem cells and cardiovascular outcomes: from basic science to the clinic.Eur. Heart J. 2020; 41: 4271-4282Crossref PubMed Scopus (30) Google Scholar] and could introduce data variability [[7]Kropfl J.M. Schmid M. Di Marzio Y. et al.Circulating adult stem and progenitor cell numbers-can results be trusted?.Stem Cell Res. Ther. 2019; 10: 305Crossref PubMed Scopus (8) Google Scholar]. Both studies reporting continuous CD34+ proportions and concentrations found negative associations with all-cause and CV mortality [[8]Patel R.S. Li Q. Ghasemzadeh N. et al.Circulating CD34+ progenitor cells and risk of mortality in a population with coronary artery disease.Circ. Res. 2015; 116: 289-297Crossref PubMed Scopus (78) Google Scholar,[9]Fadini G.P. de Kreutzenberg S. Agostini C. et al.Low CD34+ cell count and metabolic syndrome synergistically increase the risk of adverse outcomes.Atherosclerosis. 2009; 207: 213-219Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar]. However, the interpretation of a diminished likelihood of CV death per unit increase in log-transformed CD34+ data very much depends on the unit description of CPCs. A one-unit increase in CD34+ as proportion of nucleated cells in terms of risk reduction is an ambitious goal, if you consider that CD34+ cells fall within a healthy range of only ~0.05% and are even further reduced in CVD. Therefore, reporting CPC concentrations using a single-platform flow cytometry approach instead would seem appropriate to make studies predicting all-cause or CV mortality by CPCs more comparable and results more applicable. Nonetheless, it has to be noted that using a volume-based flow cytometric method, instead of expressing cells as part of total acquired events, bias could be introduced by disease-specific hemodilution or unidentified leucocytosis [[3]Fadini G.P. Baesso I. Albiero M. et al.Technical notes on endothelial progenitor cells: ways to escape from the knowledge plateau.Atherosclerosis. 2008; 197: 496-503Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar]. Only intervention studies assessing CPC changes could apply necessary corrections using differential blood cell counts [[10]Matomaki P. Kainulainen H. Kyrolainen H. Corrected whole blood biomarkers - the equation of Dill and Costill revisited.Phys. Rep. 2018; 6e13749Crossref Scopus (15) Google Scholar]. Furthermore, cell subsets under investigation should be clearly defined and detrimental aspects of each cell type should be considered. Against the common notion of the usually detected negative association between CPCs and mortality in CVD, a recent study found that low levels of a subgroup of CD34+/KDR+ cells were associated with longer incident-free survival in coronary artery disease (CAD) patients. These results were explained by a mechanism of defense in an attempt to compensate for more aggressive pathogenetic factors of atherosclerosis [[11]Pelliccia F. Pasceri V. Moretti A. et al.Endothelial progenitor cells predict long-term outcome in patients with coronary artery disease: ten-year follow-up of the PROCREATION extended study.Int. J. Cardiol. 2020; 318: 123-125Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar], but could also indicate intra-plaque angiogenesis driven by their elevated cell level [[12]Hristov M. Weber C. Ambivalence of progenitor cells in vascular repair and plaque stability.Curr. Opin. Lipidol. 2008; 19: 491-497Crossref PubMed Scopus (27) Google Scholar]. In this issue of Atherosclerosis, Muggeridge and colleagues [[13]Muggeridge D. Dodd J. Ross M.D. CD34+ Progenitors Are Predictive of Mortality and Are Associated with Physical Activity in Cardiovascular Disease Patients. Atherosclerosis, 2021Google Scholar] address the prognostic value of different CPC subpopulations for all-cause and CV associated mortality retrospectively in 1751 individuals from the Framingham Offspring Cohort [[14]Kannel W.B. Feinleib M. McNamara P.M. et al.An investigation of coronary heart disease in families. The Framingham offspring study.Am. J. Epidemiol. 1979; 110: 281-290Crossref PubMed Scopus (1288) Google Scholar]. This cohort comprises healthy subjects that were screened at a follow-up for CVD. The authors found that within the total population - after adjusting for confounders - having one unit more CD34+ CPCs or CD34+/CD133+ CPCs would reduce all-cause mortality by 21% and CV mortality by 37%, respectively. Once the population was divided by CV diagnosis at follow-up, associations of CD34+ and CD34+/CD133+ cells with mortality got stronger in patients with pre-existing CVD - up to 58% risk reduction - and vanished within the healthy cohort. The authors could not detect any significant associations of CD34+/CD133+/KDR+ levels with either all-cause nor CV mortality. Interestingly, self-reported time spent at moderate and heavy physical activity (PA), but not light PA, was positively associated with CD34+ CPCs only in patients with CVD. This work is a stimulating and valuable addition to the literature. It shows not only the importance of distinct CPC subgroups as predictive biomarker in a large, heterogeneous population, but also an increase in CPC predictive strength only in patients with CVD. As with most blood biomarkers, the predictive ability of CPCs is stronger within high-risk patients than healthy populations, for instance, when comparing the risk of CV death between patients with low versus high CPC numbers using cut-off values. In a recent meta-analysis, reduced CPC levels were associated with a ~2-fold increased probability of future CV mortality in patients with high baseline CV risk [[15]Rigato M. Avogaro A. Fadini G.P. Levels of circulating progenitor cells, cardiovascular outcomes and death: a meta-analysis of prospective observational studies.Circ. Res. 2016; 118: 1930-1939Crossref PubMed Scopus (66) Google Scholar]. The most predictive phenotypes were CD34+ and CD34+/CD133+, while the prognostic importance of CD34+/CD133+/KDR+ cells was less clear – possibly due to their lower technical reliability during the enumeration process [[3]Fadini G.P. Baesso I. Albiero M. et al.Technical notes on endothelial progenitor cells: ways to escape from the knowledge plateau.Atherosclerosis. 2008; 197: 496-503Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar]. In the light of CVD prevention, however, studies including both healthy and at risk subjects are still rare. Therefore, the study by Muggeridge and colleagues [[13]Muggeridge D. Dodd J. Ross M.D. CD34+ Progenitors Are Predictive of Mortality and Are Associated with Physical Activity in Cardiovascular Disease Patients. Atherosclerosis, 2021Google Scholar] adds valuable prognostic information to the literature about the general population. Furthermore, it highlights the necessity of PA for regeneration in a diseased state and could add knowledge regarding long-term implications for CVD management. Numerous studies already showed that acute and chronic PA can influence CPC levels in health and CVD [16Landers-Ramos R.Q. Sapp R.M. Shill D.D. et al.Exercise and cardiovascular progenitor cells.Comp. Physiol. 2019; 9: 767-797Crossref PubMed Scopus (7) Google Scholar, 17Recchioni R. Marcheselli F. Antonicelli R. et al.Physical activity and progenitor cell-mediated endothelial repair in chronic heart failure: is there a role for epigenetics?.Mech. Ageing Dev. 2016; 159: 71-80Crossref PubMed Scopus (21) Google Scholar, 18Niemiro G.M. Allen J.M. Mailing L.J. et al.Effects of endurance exercise training on inflammatory circulating progenitor cell content in lean and obese adults.J. Physiol. 2018; 596: 2811-2822Crossref PubMed Scopus (14) Google Scholar]. However, the study by Muggeridge and colleagues [[13]Muggeridge D. Dodd J. Ross M.D. CD34+ Progenitors Are Predictive of Mortality and Are Associated with Physical Activity in Cardiovascular Disease Patients. Atherosclerosis, 2021Google Scholar] sheds more light on the dose-response relationship between the level of CPCs to the intensity and duration of the performed PA. These results combined with already existing literature could be the basis to recommend certain adaptations – such as more frequent high-intensity exercise training sessions - in cardiac rehabilitation programs. It may also help unravel the role of moderate and heavy PA in reducing future event risks in CVD. Furthermore, exercise training adaptations in patients with CVD might be trackable by their CPC levels. Acute PA usually induces a CPC rise in healthy subjects post-exercise [[19]Schmid M. Kropfl J.M. Spengler C.M. Changes in circulating stem and progenitor cell numbers following acute exercise in healthy human subjects: a systematic review and meta-analysis.Stem Cell Rev Rep. 2021; 17: 1091-1120https://doi.org/10.1007/s12015-020-10105-7Crossref PubMed Scopus (6) Google Scholar]. Interestingly, during acute stress testing, CAD patients with stress-induced ischemia experienced a CPC decrease, which was significantly associated with adverse events - per 50% CD34+ decline the risk of CV death or myocardial infarction was increased ~2-fold [[20]Moazzami K. Lima B.B. Hammadah M. et al.Association between change in circulating progenitor cells during exercise stress and risk of adverse cardiovascular events in patients with coronary artery disease.JAMA Cardiol. 2020; 5: 147-155https://doi.org/10.1001/jamacardio.2019.4528Crossref PubMed Scopus (7) Google Scholar]. Chronic PA has therapeutic benefits in CVD by counteracting endothelial dysfunction with increased CPC levels and improved angiogenic properties [[17]Recchioni R. Marcheselli F. Antonicelli R. et al.Physical activity and progenitor cell-mediated endothelial repair in chronic heart failure: is there a role for epigenetics?.Mech. Ageing Dev. 2016; 159: 71-80Crossref PubMed Scopus (21) Google Scholar]. The study by Muggeridge and colleagues [[13]Muggeridge D. Dodd J. Ross M.D. CD34+ Progenitors Are Predictive of Mortality and Are Associated with Physical Activity in Cardiovascular Disease Patients. Atherosclerosis, 2021Google Scholar] adds to this knowledge by suggesting that the observed protection of increased CD34+ CPCs on mortality in CVD is partly driven by the PA levels of individuals. It remains to be shown if chronic PA could counteract any acute stress-induced CPC decline. If so, not only could baseline CPC levels be used as prognostic biomarker in the clinic, but acute stress-induced CPC changes could be established as predictors of adverse events and be an indicator of patient improvement after chronic PA/exercise training (Fig. 1). Although advances have been made towards establishing CPCs as a predictive biomarker for mortality within the last two decades, there are still a lot of questions that need to be answered before CPCs can be routinely applied to any risk stratification in the general or CVD population. Further studies exploring the most adequate methodological standard for CPC identification, investigating the most powerful CPC phenotype as a risk marker, verifying CPCs as clinical-grade biomarker for risk stratification, or elucidating the predictive capacity in short vs. long term, or in no vs. low vs. high risk populations are warranted [[1]Fadini G.P. Mehta A. Dhindsa D.S. et al.Circulating stem cells and cardiovascular outcomes: from basic science to the clinic.Eur. Heart J. 2020; 41: 4271-4282Crossref PubMed Scopus (30) Google Scholar]. Additionally, studies exploring different possibilities to counteract detrimental outcomes – such as by optimized PA/exercise training regimens possibly monitored by CPC responses to single exercise training sessions – should be considered in the future. The author declares that she has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Many thanks to Kyle G. Boyle for language editing." @default.
• W3190376089 created "2021-08-16" @default.
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• W3190376089 date "2021-09-01" @default.
• W3190376089 modified "2023-09-27" @default.
• W3190376089 title "Circulating progenitor cells as predictor of mortality in cardiovascular disease: Could physical activity change the global outcome?" @default.
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