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Endothelial Dysfunction (Vascular Dysfunction) and Various Diseases This slide shows the extent of involvement Endothelial Dysfunction (Vascular Dysfunction) and Various Diseases This slide shows the extent of involvement of endothelial dysfunction in various diseases, much like a high blood pressure measurement or fever that is indicative of different problems. This is why we believe endothelial function monitoring will be adopted as part of routine vital sign monitoring, not as an indicator of an acute condition but rather for chronic health and preventive maintenance.

Endothelial cells serve multiple functions. (S) The vascular endothelium serves multiple functions: 1) 2) Endothelial cells serve multiple functions. (S) The vascular endothelium serves multiple functions: 1) 2) 3) 4) it regulates fluid and molecule traffic between blood and tissues it is an anti-coagulant surface it contributes to vascular homeostasis and repair it plays a vital role in vascular tone and blood flow regulation *** Assessing this function is the most practical way of measuring endothelial function.

Endothelial and Vascular Dysfunction: A “Barometer of Cardiovascular Risk” • Marker of the inherent Endothelial and Vascular Dysfunction: A “Barometer of Cardiovascular Risk” • Marker of the inherent atherosclerotic risk • An integrated index of both the overall CV risk factor burden and the sum of all vasculoprotective factors in an individual. Aging Smoking Diabetes ↑ Blood Pressure Genetics Diet Inactivity ↑ Cholesterol Oxidative Stress Medications

Brachial Artery Ultrasound with FMD BASELINE POST OCCLUSION Brachial Artery Ultrasound with FMD BASELINE POST OCCLUSION

Reactive Hyperemia Reactive hyperemia is the transient increase in organ blood flow that occurs Reactive Hyperemia Reactive hyperemia is the transient increase in organ blood flow that occurs following a brief period of ischemia (e. g. , arterial occlusion). The left panel shows the effects of a 2 min arterial occlusion on blood flow. In this example, blood flow goes to zero during arterial occlusion. When the occlusion is released, blood flow rapidly increases (i. e. , hyperemia occurs) that lasts for several minutes. The hyperemia occurs because during the period of occlusion, tissue hypoxia and a build up of vasodilator metabolites (e. g. , adenosine) dilate arterioles and decrease vascular resistance. Then when perfusion pressure is restored (i. e. , occlusion released), flow becomes elevated because of the reduced vascular resistance. During the hyperemia, the tissue becomes reoxygenated and vasodilator metabolites are washed out of the tissue. This causes the resistance vessels to regain their normal vascular tone, thereby returning flow to control. http: //www. cvphysiology. com/Blood%20 Flow/BF 006. htm

Endothelial Function Basic Science to Clinical Practice Clinical practice Discovery of NO and the Endothelial Function Basic Science to Clinical Practice Clinical practice Discovery of NO and the role of the endothelium Endothelial function with exercise and mental stress First endothelial function in humans 1980 Noninvasive endothelial function 1989 1986 Basic science Comparison peripheral and coronary endothelial function Endothelial function and myocardial ischemia Coronary endothelial function in clinical practice Association between endothelial function and CV events 19951997 1995 1992 FDA approved device to assess endothelial function 1996 Comparison between the PAT and coronary endothelial function 2005 20002004 2006 2005 Clinical practice

Moving Endothelial Function Testing out of the Research Lab and into Doctors Offices Brachial Moving Endothelial Function Testing out of the Research Lab and into Doctors Offices Brachial Artery Ultrasound FMD • Ultrasound measurement of brachial artery dilation • 15 -minute test • Not automated • Requires skilled operator VENDYS® - Endothelix, Inc. • Fingertip temperature changes • 15 -minute test • Fully automated • Operator independent

What is VENDYS technology? ® What is VENDYS technology? ®

How does VENDYS measure vascular function? ® How does VENDYS measure vascular function? ®

VENDYS® Vascular Function Monitoring Blood Pressure “Occluding” Cuff on Right Upper Arm Fingertip Temperature VENDYS® Vascular Function Monitoring Blood Pressure “Occluding” Cuff on Right Upper Arm Fingertip Temperature Sensors on Both Index Fingers

VENDYS® Vascular Function Monitoring VENDYS® Vascular Function Monitoring

Infrared Imaging Cuff inflated Post cuff deflation Infrared Imaging Cuff inflated Post cuff deflation

To schedule a free demo or learn more, send an email to info@endothelix. com. To schedule a free demo or learn more, send an email to [email protected] com.

VENDYS® Portable A complete system to perform automated, vascular function studies • Cuff management VENDYS® Portable A complete system to perform automated, vascular function studies • Cuff management module (CMM) • Digital thermal monitoring (DTM) module • VENDYS® fingertip probes • Laptop computer with pre-installed software – Data acquisition – Report generation and data tabulation

Software Screenshots The VENDYS Report Software Screenshots The VENDYS Report

Software Screenshots Report Viewer Software Screenshots Report Viewer

Temperature Curves The VENDYS® Report Red = right finger Blue = left finger Flags Temperature Curves The VENDYS® Report Red = right finger Blue = left finger Flags help to notify user of conditions that may affect the technical quality of the study. A summary of VENDYS indices is shown here. a. TR is the primary vascular reactivity index. Vascular Reactivity Gauge Green = Good Yellow = Intermediate Red = Poor Ambient room temperature is recorded throughout the study.

Sample Report Screen: “Good” Vascular Reactivity Sample Report Screen: “Good” Vascular Reactivity

Sample Report Screen: “Intermediate” Vascular Reactivity Sample Report Screen: “Intermediate” Vascular Reactivity

Sample Report Screen: “Poor” Vascular Reactivity Sample Report Screen: “Poor” Vascular Reactivity

Digital Thermal Monitoring of Vascular Function is Reproducible Variable D SDD CV (%) CR Digital Thermal Monitoring of Vascular Function is Reproducible Variable D SDD CV (%) CR (%) ICC P value Heart Rate 0. 47 0. 054 11. 4 10. 6 0. 7 0. 01 Mean Arterial Pressure 0. 44 0. 038 8. 7 7. 5 0. 79 0. 0005 Start Temperature 0. 51 0. 036 7. 1 0. 81 0. 0001 DTM (VENDYS®) Indices of Vascular Function TR (°C) 0. 209 0. 012 5. 7 2. 4 0. 82 0. 0001 AUC 0. 292 0. 014 4. 8 2. 8 0. 83 0. 0001 D: mean absolute difference; SDD: SD of mean differences; CV: coefficient of variability [(SDD /D)*100]; CR: coefficient of repeatability [(SDD *1. 96)*100)]; ICC: Intra-class Correlation Coefficient.

12 -month Treatment with Aged Garlic Extract was Associated with Lower Coronary Calcium Progression 12 -month Treatment with Aged Garlic Extract was Associated with Lower Coronary Calcium Progression and Higher Fingertip Temperature Rebound

Comparison with Competitor VENDYS® - Endothelix, Inc. • Fingertip temperature changes • 15 -minute Comparison with Competitor VENDYS® - Endothelix, Inc. • Fingertip temperature changes • 15 -minute test • Fully automated Endo. PAT® - Itamar Medical Inc. • Fingertip pressure changes • 15 -minute test • Not automated

VENDYS Publications DTM Clinical Papers: • Association of coronary artery calcium score and vascular VENDYS Publications DTM Clinical Papers: • Association of coronary artery calcium score and vascular dysfunction in long-term hemodialysis patients. Hemodialysis International, International Society for Hemodialysis (2013). PDF • Beneficial effects of aged garlic extract and coenzyme Q 10 on vascular elasticity and endothelial function: The FAITH randomized clinical trial Nutrition / Elsevier (2013). PDF • Evaluation of Digital Thermal Monitoring as a Tool to Assess Perioperative Vascular Reactivity J Atheroscler Thromb (2013). PDF • A Novel Technique for the Assessment of Preoperative Cardiovascular Risk: Reactive Hyperemic Response to Short-Term Exercise Bio. Med Research International (2013). PDF • Fingertip Digital Thermal Monitoring: A Fingerprint for Cardiovascular Disease? Int J Cardiovasc Imaging (2010). PDF • Aged garlic extract supplemented with B vitamins, folic acid and L-arginine retards the progression of subclinical atherosclerosis: A randomized clinical trial. Preventive Medicine (2009). PDF • Low fingertip temperature rebound measured by digital thermal monitoring strongly correlates with the presence and extent of coronary artery disease diagnosed by 64 -slice multi-detector computed tomography. Int. J Cardiovasc Imaging (2009). PDF Accompanying Editorial: Digital thermal monitoring of vascular function: a novel tool to improve cardiovascular risk assessment. Vascular Medicine (2009). PDF • Concomitant insulin resistance and impaired vascular function is associated with increased coronary artery calcification. Int. Journal of Cardiology (2009). PDF • Vascular dysfunction measured by fingertip thermal monitoring is associated with the extent of myocardial perfusion defect. JNC (2009). PDF • Vascular function measured by fingertip thermal reactivity is impaired in patients with metabolic syndrome and diabetes. J Clin Hypertens (2009). PDF • Relations between digital thermal monitoring of vascular function, the Framingham risk score, and coronary artery calcium score. JCCT (2008). PDF Accompanying Editorial: Anatomy, physiology, or epidemiology: Which is the best target for assessing vascular health? JCCT (2008). Abstract • Flow mediated change of finger tip temperature in patients with high cardiovascular risk. Cardiologia Hungarica (2005). PDF English summary PDF Graphical Data • Post-Exercise Reactive Hyperemia: A Novel Preoperative Risk Assessment Tool Poster Abstract • Digital Thermal Monitoring: Non-Invasive Assessment of Perioperative Microvascular Function Poster Abstract

DTM Technical Papers: Reproducibility and variability of digital thermal monitoring of vascular reactivity. Clin DTM Technical Papers: Reproducibility and variability of digital thermal monitoring of vascular reactivity. Clin Physiol Funct Imaging (2011). PDF Use of temperature alterations to characterize vascular reactivity. Clin Physiol Funct Imaging (2011). PDF Sensitivity of Digital Thermal Monitoring Parameters to Reactive Hyperemia. Journal of Biomechanical Engineering, ASME (2010). PDF Digital Thermal Monitoring (DTM) of Vascular Reactivity Closely Correlates with Doppler Flow Velocity. Conf Proc IEEE Eng Med Biol Soc (2009). PDF Lumped parameter thermal model for the study of vascular reactivity in the fingertip. J Biomech Eng (2008). Abstract Interrelationships among noninvasive measures of postischemic macro- and microvascular reactivity J Appl Physiol (2008). PDF Review Articles about Vascular/Endothelial Dysfunction Measurement: Endothelial dysfunction over the course of coronary artery disease. Eur Heart J (2013). PDF The Assessment of Endothelial Function: From Research Into Clinical Practice. Circulation (2012). PDF The Endothelial Cell in Health and Disease: Its Function, Dysfunction, Measurement and Therapy. Int J Impot Res (2010). PDF Endothelial function as a functional expression of cardiovascular risk factors. Biomark Med (2010). PDF

Additional Publications 1. Schier R, Hinkelbein J, Marcus H, Smallwood A, Correa AM, Mehran Additional Publications 1. Schier R, Hinkelbein J, Marcus H, Smallwood A, Correa AM, Mehran R, El-Zein R, Riedel B. A novel technique for the assessment of preoperative cardiovascular risk: reactive hyperemic response to short-term exercise. Biomed Res Int. 2013; 2013: 837130. PMID: 23691513 2. Schier R, Marcus HE, Mansur E, Lei X, El-Zein R, Mehran R, Purugganan R, Heir JS, Riedel B, Gottumukkala V. Evaluation of digital thermal monitoring as a tool to assess perioperative vascular reactivity J Atheroscler Thromb. 2013; 20(3): 277 -86. PMID: 23197179 3. Ahmadi N, Mc. Quilkin GL, Akhtar MW, Hajsadeghi F, Kleis SJ, Hecht H, Naghavi M, Budoff M. Reproducibility and variability of digital thermal monitoring of vascular reactivity. Clin Physiol Funct Imaging. 2011 Nov; 31(6): 422 -8. PMID: 21981452 4. Akhtar MW, Kleis SJ, Metcalfe RW, Naghavi M. Sensitivity of digital thermal monitoring parameters to reactive hyperemia. J Biomech Eng. 2010 May; 132(5): 051005. PMID: 20459206 5. Schwartz BG, Economides C, Mayeda GS, Burstein S, Kloner RA. The endothelial cell in health and disease: its function, dysfunction, measurement and therapy. Int J Impot Res. 2010 Mar. Apr; 22(2): 77 -90. Review. PMID: 20032988 6. van der Wall EE, Schuijf JD, Bax JJ, Jukema JW, Schalij MJ. Fingertip digital thermal monitoring: a fingerprint for cardiovascular disease? Int J Cardiovasc Imaging. 2010 Feb; 26(2): 249 -52. PMID: 20012695