La medicina de las 4 Ps •PREDICTIVA •PREVENTIVA •PERSONALIZADA •PARTICIPATORIA

1. Telomerós, Envejecimiento y
Prevención
Dr. Arturo Fernández- Cruz

2. Health demographic change and wellbeing

3. The economic crisis

6. Incidencia de IAM en población
de 25 a 74 años por sexos

7. 1200 millones OMS

10. PREVEND
8074
JIM
Nov 2013

11. La medicina de las 4 Ps
•PREDICTIVA
•PREVENTIVA
•PERSONALIZADA
•PARTICIPATORIA
La detección temprana 90%
de supervivencia
La detección tardía 10%
de supervivencia
NEJM Modelo matemático 1980-2000
Reducción de los FRs
Nuevos tratamientos
Solo el 7% debido CABG o STENTs
NEJM enero 2013

12. Progress in science
depends on new techniques,
new discoveries, and new
ideas probably in that order
Sydney Brenner

13. Tecnologías que crecen exponencialmente
Test genéticos a bajo coste
Test de medición de Telomeros
Computadores-Bio-informática, Historia y
archivos electrónicos
Técnicas de imagen TAC, RM (Colonoscopia
virtual), “IPad”
Conexión por Internet, medicina on-line (visitas
virtuales)
Redes Sociales
Mi tecnología favorita es el iPhone “digital medicine”
NUEVAS TECNOLOGÍAS

14. “senescent” cells
healthy
cell
50-70 divisions
healthy cells
are MORTAL
cancer
cell
cancer cells are
IMMORTAL
unlimited divisions
Henrietta
Lacks

15. telomeretelomere
Chromosome
(parent cell)
Telomeres are lost everytime that a cell divides
“the end-replication problem”
DNA is lost from the ends
Chromosome
(daughter cell #1)
Chromosome
(daughter cell #2)

16. An embryonary gene known as telomerase is able to elongate
telomeres to compensate excessive telomere loss during embryo
development.
This gene, telomerase, is silenced after birth … however …
Cancer cells manage to reactivate telomerase, thus escaping the mortal
fate of adult cells and becoming immortal.
TTAGGG TTAGGG
AATCCC AATCCC
genes telomeres
TTAGGG TTAGGG
AATCCC AATCCC
TTAGGG TTAGGG
AATCCC AATCCC
cell death
cell senescence
aging
TTAGGG TTAGGG
AATCCC AATCCC
genes telomeres
cancer
TTAGGG TTAGGG
AATCCC AATCCC
TTAGGG TTAGGG
AATCCC AATCCC
TTAGGG TTAGGG
AATCCC AATCCC
TTAGGG TTAGGG
AATCCC AATCCC
TTAGGG TTAGGG
AATCCC AATCCC

17. Telomere length as a biomarker of biological age & health status
Canela et al., PNAS (2007)
Telomere length predicts age & cognitive impairmentTelomere length decreases with age
HTQFISH

18. cancer
(> 95% of cancers
activate telomerase)
high
Telomerelength
disease
health
age
Telomeres, telomerase and aging
Human pathologies due to telomerase defects
dysqueratosis congenita (DKC1, Terc)
aplastic anemia (Terc, Tert)
idiophatic pulmonary fibrosis (Terc, Tert)
loss of the regenerative capacity of the skin
lungs, bone marrow…
Telomere length=Biomarker of aging?
Lower percentiles of telomere length=
higher risk of diseases (cardiovascular,
neurodegenerative, death by infections)

19. Telomere length measurements for individuals
Life Length´s partnership with:

20. Page 20© 2014 Life Length. All rights reserved. Reproduction of this document or any portion thereof without prior written consent is prohibited.
Telomere Measurements for individuals
Your median telomere length is
estimated to be normal
compared to Life Length´s
database population.
1. Your telomere length
Median Telomere Length: 9.2 Kb
< 7.8 78 – 8.5 8.2 – 13.7 13.7 – 15.3 > 15.3
VERY SHORT SHORT NORMAL LONG VERY LONG
Median Telomere Length (MTL) = 9.2 ± 0.3 Kb
You: 9.2 Kb
The adjacent graph shows a comparative analysis of the
median telomere length in your sample compared with
the control database.
Each line represents a specific percentage of our
database.
For example, falling in the 75th percentile means that
25% of people of your age have a longer median
telomere length than you.
It is therefore best if your sample falls into one of the
higher bands.
2. Median telomere length – Comparison by age band and percentiles
20 30 40 50 60 70 80 90
Chronological age (years)
Mediantelomere
length(Kb)
16
15
14
13
12
11
9
8
95
90
75
50
25
10
05
%
3. Your estimated biological age
Estimated Biological Age: 55 years old
Chronological Age: 50 years old
Value ± SD
Biological age based on
chronological age and
telomere length
Comparison of
MTL per age
group
Comparison of MTL
against entire
database
(to find severe
outliers)
Extract from actual evaluation

21. 0
50
100
150
200
250
300
350
400
450
500
0 5 10 15 20 25 30 35 40
0
50
100
150
200
250
300
350
400
450
500
0 5 10 15 20 25 30 35 40
0
50
100
150
200
250
300
350
400
450
500
0 5 10 15 20 25 30 35 40
0
100
200
300
400
500
600
700
800
0 5 10 15 20 25 30 35 40
0
50
100
150
200
250
300
0 5 10 15 20 25 30 35 40
telomerelength,kb
telomere length, kb
samples
Subject 49- Male 02/02/78 healthy
Subject 50- Male 22/09/77 medular aplasia, TERC mut
Subject 51- Male 17/05/78 healthy
Subject 52- Male 06/06/78 healthy
frequency
telomere length, kb
telomere length, kb
telomere length, kb
telomere length, kb
frequencyfrequencyfrequencyfrequency
Subject 49
9.49 ± 2.81 kb
n=1951
Subject 50
5.7 ± 2.01 kb
n=1685
Subject 51
10.46 ± 3.28 kb
n=2796
Subject 52
10.06 ± 3.34 kb
n=4811
L5178Y-S
10.06 ± 3.34 kb
n=1408
0
5
10
15
20
subject 49 subject 50 subject 51 subject 52 L5178Y-S
%telomeres<8kb
samples
n=1951
n=1685
n=2796 n=4811
n=1408
***
0
10
20
30
40
50
60
70
80
90
100
subject 49 subject 50 subject 51 subject 52 L5178Y-S
***
Telomere length as a diagnosis tool
Hospital
Vall d´Hebrón
Canela et al., unpublished

22. 0 10 20 30 40 50 60 70
0
5
10
15
20
Meantelomerelength(Kb)
Age (years)
0 10 20 30 40 50 60 70
0
10
20
30
40
50
60
%shorttelomeres(<3kb)
Age (years)
Telomere length measurements for individuals
% short telomeres detect more differences between individuals than average length
% short telomeres show higher dispersion as we age
% short telomeres are likely to reflect “way of living” (environment) or biological age

23. Bioactive food components can influence genetic and epigenetic events
associated with a host of disease processes
Trujillo E et al. J Am Diet Assoc 2006;106:403-413

24. Trujillo E et al. J Am Diet Assoc 2006;106:403-413
Dietary factors and the regulation of DNA methylation “CpG sites” 28 millones
S Horvad clock-watcher Nature April
2014 Nature 508,22:2014
Methylation
status
353 CpG sites
algorithm

25. Genetic tests: genes as risk factors for disease
INHERITED
Telomere tests: indication of the degree of aging
INHERITED ENVIRONMENT
MORE POWERFUL PREDICTIONS
OF RISKS AND TIME OF ONSET
# aging is the highest risk factor for all diseases
# telomere length integrates both inheritance & environmental factors EPIGENETICS
DEVELOPMENT OF
NEW TREATMENTS TO
PREVENT DISEASE
A NEW ERA in medicine?: Personalized & preventive medicine

26. Virus
Inflamación crónica
Factores genéticos
Envejecimiento celular – Estrés oxidativo: Integridad del
telómero
Patogenia del cáncer
Inmortalización
celular
Fallo en los
mecanismos de
control

27. Telomere length and Cancer
The Association of Telomeres length and Cancer: a Meta-analysis
S A Savage et al Cancer Epidemiology Biomarkers Prev 20:1238,2011
Short Telomeres are associated with excess Cancer Incidence and mortality
A L Kamaroff JAMA 2010 july 7 P Willet JAMA 304:69, 2010
Fifteen year follow up of association between Telomere length and
incidence Cancer and Cancer mortality
JAMA 306:42,2011

28. Breast cancer: Familial breast cancer
BRCA1/BRCA2
BRCA1
Age (years)
RelativeTelomerelength
BRCA2
Age (years)
RelativeTelomerelength
-0.5
0
0.5
1
1.5
2
2.5
3
3.5
10 20 30 40 50 60 70 80
BRCAX
Age (years)
RelativeTelomerelength
-0.5
0
0.5
1
1.5
2
2.5
3
3.5
10 20 30 40 50 60 70 80
SporadicBC
Age (years)
RelativeTelomerelength
-0.5
0
0.5
1
1.5
2
2.5
3
3.5
10 20 30 40 50 60 70 80
-0.5
0
0.5
1
1.5
2
2.5
3
3.5
10 20 30 40 50 60 70 80
A C
B D
More powerfull tools to predict risk factors and develop new treatments
Javier Benitez (CNIO)

29. MEDICINA PREDICTIVA
• BCR Gail mama BCRAs
• BRACAPRO mama ovario
• BOADICEA mama, ovario,
prostata, melanoma
• PREMM colon
• PULMON
Cancer genograma
Diabetes FINDRISK SCORE
Cribados
Telomeros
Genes

30. Can telomerase delay
aging pathologies?

31. Telomerase as an anti-cancer target (Imetelstat)
Phase II
Clinical trials
(breast, lung, prostate etc)

32. ratones
K5-mTert
No telomerase
Less
aging
Less
cancer
More cancer
Premature aging
La telomerasa se expresa específicamente en células madre
telomerase
Telomere length
Tg telomerase
(epithelia)
Gonzalez-Suarez et al., Oncogene (2004)
Super p53
Super p16
Super p19ARF
Cancer
suppressors
+
SUPER-M

33. Linear regression:
WT: Slope=-7.03 ± 1.24 kb/year
R2=0.31 (Quadratic: R2=0.34)
p<0.0001
TgTERT: Slope=-7.05 ± 1.60 kb/year
R2=0.22 (Quadratic: R2=0.30)
p<0.0001
0.0 0.5 1.0 1.5 2.0 2.5
0
10
20
30
40
50
60
70
80
Age (years)
Meantelomerelength(kb)
Vera et al., Cell Reports, 2012
Mouse telomeres shorten 100-times faster than human telomeres
Humans: 70 bps/year
Mice: 7 Kb/year
Increaseinthe%of
shorttelomeres(permonth)
The increase in the % of short telomeres predicts individual mouse longevity
0 50 100 150 200
-0.5
0.0
0.5
1.0
1.5
Lifespan (weeks)
WT: Slope=-0.005022 ± 0.002550
R2=0.2
p=0.06
TgTERT: Slope=-0.01267 ± 0.005604
R2=0.3
p=0.04
WT
TgTERT
WT
TgTERT

34. telomerase-deficient
wild-type
Blasco et al., Science (1995)
Blasco et al., Cell (1997)
Lee, Blasco, et al., Nature (1998)
González-Suarez et al., Nat Genet (2000)
González-Suarez et al., EMBO J. (2001)
Flores et al., Science (2005)
Telomerase-deficient mice (Terc-/-):
decreased regenerative capacity
due to stem cell dysfunction
less cancer
Super-telomerase mice (K5-Tert):
better tissue fitness
slightly more cancer
The role of telomerase in chromosome stability, cancer & aging

35. Tomás-Loba et al, Cell (2008)
SUPERWild-type
Defeating aging with increased telomerase + tumor suppression

36. Increased “health span” & longevity in SUPER mice
Cancer-free survivalOverall survival
0
20
40
60
80
100
0 60 80 100 120 140 160 180
Sp53 (n=25)
SUPER (p=0.003; n=6)
survival(%)
age (weeks)
+50%
normales (n=25)
0
20
40
60
80
100
0 60 80 100 120 140 160 180
Sp53 (n=49)
SUPER (p<0.001; n=12)
survival(%)
age (weeks)
+40%
normal (n=49)
0
20
40
60
n=25
n=6
p=0.003
0
20
40
60
n=49
n=12
p<0.001
normal SUPER
Survivalat3years(%)
normal SUPER
Survivalat3years(%)
Tomás-Loba et al., Cell (2008)
Healthspan

37. Improved neuromuscular fitness
25000
30000
35000
40000
45000
glucosetolerance(AUC)
**
30-76 weeks
Glucosetolerance(AUC)
n=5
n=3
wildtype SUPER
p=0.02
Improved glucose tolerance
0
25
50
75
100
125
Successrate(%)
n=11
n=9
wildtype
p=0.02
n=8 n=10
SUPER
p=1
young (5-20 weeks) old (116-160 weeks)
Improved health late in life in SUPER mice
Tomás-Loba et al., Cell (2008)

38. SUPER-Mwildtype
young (5-12 weeks)
old (123-165 weeks)
wildtype
Subcutaneousfatlayer(m)
0
20
40
60
80
100
120
n=19
n=24
SUPER-M
n=11
n=61
Less skin aging in SUPER-M mice
Subcutaneous fat
old (123-165 weeks)
Tomás et al., Cell (2008)

39. Telomere length and ATHEROSCLEROSIS
Critical values of replicative senescence the “hayflic limit” vascular age
Circ Res 2006
Family History of CHD Heart 2008
European Atherosclerosis Reseach Study II J Mol Med July 2008
White cell telomere lenght and risk of premature AMI Atherosclerosis
Thromb Vasc Biol 2003 Lancet 2001 the WOSCOP study Lancet 2007
Tromboembolism
RY Zee… P Ridker Int J of Clinical Chemistry 2009; 406:148

40. Telomere length and preclinical ATHEROSCLEROSIS
Framingham Heart Study Arterioesclerosis Thromb Vac Biol May 2011
ASKLEPIOS STUDY European Heart Journal 2009 Obese man
Heart 2008 Carotid Atherosclerosis Hypertension 2004:43;182
Coronary Artery Disease Arterioesclerosis Thromb Vasc Biol 2004:24, 546
Calcium Score Atherosclerosis 2009
Vascular thrombosis RY Zee ..P Ridker 2013

41. Leukocyte and plaque telomere length in cases and controls.
Huzen J et al. Arterioscler Thromb Vasc Biol.
2011;31:1219-1225
Copyright © American Heart Association, Inc. All rights reserved.

42. X
LAD
ligation
Aging is not a disease…but there are many aging-associated diseases
preclinical model for cardiovascular disease
Normal heart
Failing heart
Failing heartNormal heart
PET – FDG uptake
Histopathology
AAV9-TERT
AAV9-empty

43. AAV9-TERT treatment protects 20% of the mice from death by infact
Bruno Bernardes de Jesus
Christian Bär
0 10 20 30 40
40
60
80
100
AAV9-empty
AAV9-mTERT:
2x1012vg/m
No virus
Percentsurvival
Heartinfarct
Days after myocardial infarction
n=35
n=37
n=21
p=0,07
74%
57%
FVB/N
0.0
0.5
1.0
1.5
0.0
0.5
1.0
1.5
Longitudinalthickness
(mm)
Transversalthickness
(mm)
1 week
p=0.02 p=0.01
p=0.5
n=4
n=13
n=5 n=4
n=13
n=5
p=0.03 p=0.01
p=0.7
1 week
AAV9-empty
AAV9-mTERT:
2x1012vg/m
Sham (no myocardial infarction)
Echocardiography

44. Myocardial Infaction
AAV9-empty
SHAM
AAV9-mTERT: 2x1012vg/m
An AAV9-TERT treatment reduces scar formation upon infaction
Bruno Bernardes de Jesus
Christian Bär
Masson trichrome
Scar size/LV size, %
Numberofmice
0
5
10
15
20
Mild
Severe
Extremely severe
AAV9-
eGFP
AAV9-
mTERT
0
10
20
30
40
%ofarea
AAV9-
eGFP
AAV9-
mTERT
n=10
n=7
p=0.14
MI
AAV9-empty
AAV9-mTERT:
2x1012vg/m

45. 0
50
100
150
200
meanspotintensity/
nucleus(a.u.)
mean 52.33 a.u.
(1850 nuclei)
mean 64.98 a.u.
(1968 nuclei)
124% of AAV9 empty
p<0.0001
0
50
100
150
meanspotintensity/
nucleus(a.u.)
mean 40.08 a.u.
(2455 nuclei)
mean 44.85 a.u.
(3096 nuclei)
112% of AAV9 empty
p<0.0001
AAV9-empty (n=4)
AAV9-mTERT (n=4)
(2x1012vg/m)
cardiomyocytes fibroblasts (infarct area)
AAV9-TERT treated mice show longer telomeres in heart after infaction
Bruno Bernardes de Jesus
Christian Bär

46. Telomere length and Diabetes
Association of Telomere shortening with IGT and DM2 macroangiopathy
Atherosclerosis Nov 2007
Accelerated senescence in the kidneys of patients with DM2 nephropathy
American J of Physiology 2008 DM2
Microalbuminuria Diabetes Care 2007;30:2909 Diabetologia 2006
Leukocyte Telomere shortening in elderly type 2 DM with previous AMI
Atherosclñerosis 2009
Association of Telomere length with type 2 DM oxidative stress and
UCP2 gene variation Atherosclerosis 2010
DNA damage. Diabetes Care 2006

47. Challenge: Individualized Risk Assessment
in Low- and Intermediate Risk Individuals
Algorithms
Neural
Network
MSCT, MRT, PET
Telomeres
And
Genes of
clinical
relevance
Lp(a) PLA2
CRP, BNP
Apo A-, HDL 2b
ApoB
Phytosterols
Metabolic syndrome
Other

48. CONFIDENTIAL
Rupture-Prone Plaques may not be Severely Stenosed
but are Inflamed with Thin Fibrous Caps
Early Plaque
with Lipid Pool
Thick Cap with Small
Necrotic Lipid Core
“Stable Plaque”
Thin Cap
“Rupture-Prone”
Plaque
Ruptured Plaque
with Thrombus
in Lumen
Adapted from Kolodgie F, et al. Arterioscler Thromb Vasc Biol 2006.

49. CARE PATHWAY FOR CARDIOVASCULAR RISK CLINIC
CardiologyREFERRAL
General Practice
0
5
10
15
20
25
30
Ave Patient
10yrCVDrisk
Genetic CRF
CLINIC VISIT
Retest
Genetics
Telomeros
Results
RISK SCORE
Clinical Chem
T-Chol/HDL/TG
Lp(a)? etc?
Results
RISK SCORE + BMI/BP/Smoke
Carotid Coronaries
ACTION PLAN
Blood Pressure
Lowering
Lipid
Lowering
Smoking
Cessation
Weight
Loss
GPs -Specialist
Referral
Cardiology
Referral
Patient Appointment
Saliva sample request + Informed consent

50. Monitoring other effects than LDL:
where do we stand ?

51. Statin may reduce the rate at which Telomeres shorten
Lancet 2001 2007 Jan 13
Omega-3 fatty acid supplementation reduces Telomere shortening in the cognitively
impaired J of Nutrition October 22 2013
Omega-3 fatty acids, oxidative stress and leukocyte Telomere length- A randomized
controlled trial E, Balackburn et al Brain Behavior Immunity Sept 2012
Longitudinal association of Telomere length and Obesity indices in an Intervention Study
with Mediterranean Diet the PREDIMED-NAVARRA trial S Garcia-Calzon International
Journal of Obesity 2014, 38:177
Paula Martínez, Gonzalo Gómez-López, Fernando García, Evi Mercken, Sarah Mitchell,
Juana M. Flores, Rafael de Cabo, Maria A. Blasco. RAP1 Protects from Obesity through
Its Extratelomeric Role Regulating Gene Expression. Cell Reports, 2013; DOI: 1-
Metabolic Syndrome PREVEND study JIM Nov 2013

52. The association between Physical Activity in Leisure time and leukocite Telomere
lenght
LF Cherkas Arch Intern Med 2008;168:154. Lancet oncology Sep 2013
Stress can shorten Telomere in chilhood Nature 17 may2011
Telomere length and Aging related to Depression?
Molecular Psychiatry Nov 12 2013 Biol Psychiatry 2012 ;15:294

53. CORRELATION BETWEEN IMT AND EPC LEVELS IN PATIENTS
WITH METABOLIC SYNDROME
0
1
2
3
4
5
6
7
8
9
0,2 0,4 0,6 0,8 1 1,2
GIM
EPCsTardías(%)CD34+/VE-cadherina+(%)
r = - 0,169
P = 0,017
IMT (mm)

54. Telomerase activation
(with smal molecules)

55. Telomerase activation with a nutritional supplement

56. Infancy/youth/adulthood aging
cancer
cardiovascular
diabetes
renal disease
immunosenescence
neurodegeneration
etc…
telomere loss
consequences
Interventions
(ie, TERT)
aging
cancer
cardiovascular
diabetes
renal disease
immunosenescence
neurodegeneration
etc…
Infancy/youth/adulthood
Understanding the molecular basis of aging to prevent disease
genetic &
environmental

57. Everything will be alright in
the end
and if it’s not alright
it’s not the END

58. Muchas Gracias
Gastamos mas en armamentos que en la Prevención