AIMS/HYPOTHESIS Type 2 diabetes has been demonstrated to predispose to aortic valve calcification. We investigated whether type 2 diabetes concomitant to aortic stenosis (AS) enhances valvular inflammation and coagulation activation via upregulated expression of NF-κB, with subsequent increased expression of bone morphogenetic protein 2 (BMP-2). METHODS In this case-control study, 50 individuals with severe isolated AS and concomitant type 2 diabetes were compared with a control group of 100 individuals without diabetes. The median (IQR) duration of diabetes since diagnosis was 11 (7-18) years, and 36 (72%) individuals had HbA1c ≥48 mmol/mol (≥6.5%). Stenotic aortic valves obtained during valve replacement surgery served for in loco NF-κB, BMP-2, prothrombin (FII) and active factor X (FXa) immunostaining. In vitro cultures of valve interstitial cells (VICs), isolated from obtained valves were used for mechanistic experiments and PCR investigations. RESULTS Diabetic compared with non-diabetic individuals displayed enhanced valvular expression of NF-κB, BMP-2, FII and FXa (all p ≤ 0.001). Moreover, the expression of NF-κB and BMP-2 positively correlated with amounts of valvular FII and FXa. Only in diabetic participants, valvular NF-κB expression was strongly associated with serum levels of HbA1c, and moderately with fructosamine. Of importance, in diabetic participants, valvular expression of NF-κB correlated with aortic valve area (AVA) and maximal transvalvular pressure gradient. In vitro experiments conducted using VIC cultures revealed that glucose (11 mmol/l) upregulated expression of both NF-κB and BMP-2 (p < 0.001). In VIC cultures treated with glucose in combination with reactive oxygen species (ROS) inhibitor (N-acetyl-L-cysteine), the expression of NF-κB and BMP-2 was significantly suppressed. A comparable effect was observed for VICs cultured with glucose in combination with NF-κB inhibitor (BAY 11-7082), suggesting that high doses of glucose activate oxidative stress leading to proinflammatory actions in VICs. Analysis of mRNA expression in VICs confirmed these findings; glucose caused a 6.9-fold increase in expression of RELA (NF-κB p65 subunit), with the ROS and NF-κB inhibitor reducing the raised expression of RELA by 1.8- and 3.2-fold, respectively. CONCLUSIONS/INTERPRETATION Type 2 diabetes enhances in loco inflammation and coagulation activation within stenotic valve leaflets. Increased valvular expression of NF-κB in diabetic individuals is associated not only with serum HbA1c and fructosamine levels but also with AVA and transvalvular gradient, indicating that strict long-term glycaemic control is needed in AS patients with concomitant type 2 diabetes. This study suggests that maintaining these variables within the normal range may slow the rate of AS progression.

中文翻译：

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伴有主动脉瓣狭窄的糖尿病与 NF-κB 表达增加和更明显的瓣膜钙化有关。

目的/假设 2 型糖尿病已被证明易患主动脉瓣钙化。我们研究了伴随主动脉瓣狭窄 (AS) 的 2 型糖尿病是否通过上调 NF-κB 的表达来增强瓣膜炎症和凝血激活，随后骨形态发生蛋白 2 (BMP-2) 的表达增加。方法 在这项病例对照研究中，将 50 名患有严重孤立性 AS 并伴有 2 型糖尿病的个体与 100 名无糖尿病的对照组进行了比较。自诊断以来糖尿病的中位 (IQR) 持续时间为 11 (7-18) 年，36 (72%) 人的 HbA1c ≥48 mmol/mol (≥6.5%)。在瓣膜置换手术中获得的狭窄主动脉瓣用于 NF-κB、BMP-2、凝血酶原 (FII) 和活性因子 X (FXa) 免疫染色。从获得的瓣膜中分离出的瓣膜间质细胞 (VIC) 的体外培养物用于机械实验和 PCR 研究。结果 糖尿病患者与非糖尿病患者相比，NF-κB、BMP-2、FII 和 FXa 的瓣膜表达增强（所有 p ≤ 0.001）。此外，NF-κB 和 BMP-2 的表达与瓣膜 FII 和 FXa 的量呈正相关。仅在糖尿病参与者中，瓣膜 NF-κB 表达与血清 HbA1c 水平密切相关，与果糖胺中度相关。重要的是，在糖尿病参与者中，NF-κB 的瓣膜表达与主动脉瓣面积 (AVA) 和最大跨瓣压梯度相关。使用 VIC 培养物进行的体外实验表明，葡萄糖 (11 mmol/l) 上调了 NF-κB 和 BMP-2 的表达 (p < 0.001)。在用葡萄糖和活性氧 (ROS) 抑制剂 (N-乙酰-L-半胱氨酸) 联合处理的 VIC 培养物中，NF-κB 和 BMP-2 的表达被显着抑制。对于用葡萄糖与 NF-κB 抑制剂 (BAY 11-7082) 联合培养的 VIC，观察到了类似的效果，这表明高剂量的葡萄糖会激活氧化应激，从而导致 VIC 中的促炎作用。对 VIC 中 mRNA 表达的分析证实了这些发现；葡萄糖导致 RELA（NF-κB p65 亚基）表达增加 6.9 倍，ROS 和 NF-κB 抑制剂分别降低 RELA 表达增加 1.8 倍和 3.2 倍。结论/解释 2 型糖尿病增强了狭窄瓣叶内的局部炎症和凝血激活。糖尿病个体中 NF-κB 瓣膜表达增加不仅与血清 HbA1c 和果糖胺水平有关，还与 AVA 和跨瓣膜梯度有关，这表明合并 2 型糖尿病的 AS 患者需要严格的长期血糖控制。这项研究表明，将这些变量保持在正常范围内可能会减慢 AS 进展的速度。