Six-year effect of combined vitamin C and E supplementation on atherosclerotic progression: the Antioxidant Supplementation in Atherosclerosis Prevention (ASAP) Study

Dietary antioxidants and paraoxonases against LDL oxidation and atherosclerosis development

Oxidative modification of low-density lipoprotein (LDL) in the arterial wall plays a key role in the pathogenesis of atherosclerosis. Under oxidative stress LDL is exposed to oxidative modifications by arterial wall cells including macrophages. Oxidative stress also induces cellular-lipid peroxidation, resulting in the formation of 'oxidized macrophages', which demonstrate increased capacity to oxidize LDL and increased uptake of oxidized LDL. Macrophage-mediated oxidation of LDL depends on the balance between pro-oxidants and antioxidants in the lipoprotein and in the cells. LDL is protected from oxidation by antioxidants, as well as by a second line of defense--paraoxonase 1 (PON1), which is a high-density lipoprotein-associated esterase that can hydrolyze and reduce lipid peroxides in lipoproteins and in arterial cells. Cellular paraoxonases (PON2 and PON3) may also play an important protective role against oxidative stress at the cellular level. Many epidemiological studies have indicated a protective role for a diet rich in fruits and vegetables against the development and progression of cardiovascular disease. A large number of studies provide data suggesting that consumption of dietary antioxidants is associated with reduced risk for cardiovascular diseases. Basic research provides plausible mechanisms by which dietary antioxidants might reduce the development of atherosclerosis. These mechanisms include inhibition of LDL oxidation, inhibition of cellular lipid peroxidation and consequently attenuation of cell-mediated oxidation of LDL. An additional possible mechanism is preservation/increment of paraoxonases activity by dietary antioxidants. This review chapter presents recent data on the anti-atherosclerotic effects and mechanism of action of three major groups of dietary antioxidants-vitamin E, carotenoids and polyphenolic flavonoids.

Vitamin E in Preeclampsia

Preeclampsia is the disorder of pregnancy with the highest rate of both maternal and neonatal morbidity and mortality. The maternal syndrome is characterized by oxidative stress and activation of the vascular endothelium that may originate from placental release of lipid peroxidation products, cytokines, and microparticles leading to an acute inflammatory response. The current understanding of the etiology has allowed the improvement of predictive tests, tests that could make intervention possible from early pregnancy onwards. Although the large secondary intervention antioxidant trials in cardiovascular diseases did not show any beneficial effect of vitamin E and vitamin C, either alone or in combination, knowledge of the nature of the pathogenesis of preeclampsia offers hope for the beneficial use of antioxidants in the prevention of the disorder. Not only has our previous small trial shown that antioxidant prophylactics in high-risk women lowered the prevalence of preeclampsia, but also new evidence has demonstrated multiple other actions of alpha-tocopherol (such as anti-inflammation and inhibition of NAD(P)H oxidase activation) besides its antioxidant properties that could be advantageous in the prevention of the disorder. Several larger trials are under way to investigate the precise role that vitamins C and E can play in the prevention of preeclampsia.

Soy isoflavones improve bone metabolism in postmenopausal Japanese women

1. This study examines whether the supplementation of isoflavones (ISO) exerts beneficial effects on serum and urinary biomarkers of bone metabolism. 2. A total of 102 women were randomly assigned to three groups taking either ISO (40 mg) tablets, tablets containing vitamins C (25 mg) and E (5 mg) (V) or placebo tablets (vehicle only) (P) daily for 4 weeks, in a double-blind parallel placebo controlled design. 3. Among the 67 women who completed the study (24 on ISO, 24 on V, 19 on P), only ISO tablets were proven to decrease significantly urinary deoxypyridinoline (Dpd) excretion (P < 0.05 vs before), a specific biomarker of bone resorption, but there was no significant difference in serum bone gamma-carboxyglutamic acid-containing protein (BGP), a specific serum biomarker of bone formation. 4. Among the 67, 25 women were postmenopausal (8 on ISO, 12 on V, 8 on P) and only ISO tablets decreased significantly urinary Dpd excretion (P < 0.05 vs before) in them. The reduction rate of Dpd in ISO group was also significantly greater than that in P group (P < 0.01). 5. Dietary supplementation of vitamins C 25 mg and E 5 mg did not affect urinary Dpd.

Vitamin E for the Treatment of Cardiovascular Disease: Is There a Future?

Oxidative stress seems to play a key role in the pathogenesis of atherosclerosis. Agents that protect low-density lipoprotein from oxidation have been shown in a range of in vitro and animal models to reduce the development and progression of atherosclerosis. These agents include antioxidant micronutrients such as vitamin E. They have gained wide interest because of the potential for prevention of atherosclerotic vascular disease in humans. In the last decade, many trials with antioxidants have been carried out in patients with cardiovascular disease, but the results are equivocal. The reason for the disappointing findings is unclear, but one possible explanation is the lack of identification criteria of patients who are potential candidates for antioxidant treatment. This review analyses the data reported so far to determine whether they clearly support the premise that patients at risk of cardiovascular disease may be candidates for antioxidant treatment.

Oxidative stress and vascular disease

Growing evidence indicates that chronic and acute overproduction of reactive oxygen species (ROS) under pathophysiologic conditions is integral in the development of cardiovascular diseases (CVD). These ROS can be released from nicotinamide adenine dinucleotide (phosphate) oxidase, xanthine oxidase, lipoxygenase, mitochondria, or the uncoupling of nitric oxide synthase in vascular cells. ROS mediate various signaling pathways that underlie vascular inflammation in atherogenesis: from the initiation of fatty streak development through lesion progress to ultimate plaque rupture. Various animal models of oxidative stress support the notion that ROS have a causal role in atherosclerosis and other cardiovascular diseases. Human investigations also support the oxidative stress hypothesis of atherosclerosis. Oxidative stress is the unifying mechanism for many CVD risk factors, which additionally supports its central role in CVD. Despite the demonstrated role of antioxidants in cellular and animal studies, the ineffectiveness of antioxidants in reducing cardiovascular death and morbidity in clinical trials has led many investigators to question the importance of oxidative stress in human atherosclerosis. Others have argued that the prime factor for the mixed outcomes from using antioxidants to prevent CVD may be the lack of specific and sensitive biomarkers by which to assess the oxidative stress phenotypes underlying CVD. A better understanding of the complexity of cellular redox reactions, development of a new class of antioxidants targeted to specific subcellular locales, and the phenotype-genotype linkage analysis for oxidative stress will likely be avenues for future research in this area as we move toward the broader use of pharmacological and regenerative therapies in the treatment and prevention of CVD.

Pomegranate juice consumption for 3 years by patients with carotid artery stenosis reduces common carotid intima-media thickness, blood pressure and LDL oxidation

Dietary supplementation with polyphenolic antioxidants to animals was shown to be associated with inhibition of LDL oxidation and macrophage foam cell formation, and attenuation of atherosclerosis development. We investigated the effects of pomegranate juice (PJ, which contains potent tannins and anthocyanins) consumption by atherosclerotic patients with carotid artery stenosis (CAS) on the progression of carotid lesions and changes in oxidative stress and blood pressure. Ten patients were supplemented with PJ for 1 year and five of them continued for up to 3 years. Blood samples were collected before treatment and during PJ consumption. In the control group that did not consume PJ, common carotid intima-media thickness (IMT) increased by 9% during 1 year, whereas, PJ consumption resulted in a significant IMT reduction, by up to 30%, after 1 year. The patients' serum paraoxonase 1 (PON 1) activity was increased by 83%, whereas serum LDL basal oxidative state and LDL susceptibility to copper ion-induced oxidation were both significantly reduced, by 90% and 59%, respectively, after 12 months of PJ consumption, compared to values obtained before PJ consumption. Furthermore, serum levels of antibodies against oxidized LDL were decreased by 19%, and in parallel serum total antioxidant status (TAS) was increased by 130% after 1 year of PJ consumption. Systolic blood pressure was reduced after 1 year of PJ consumption by 12% [corrected] and was not further reduced along 3 years of PJ consumption. For all studied parameters, the maximal effects were observed after 1 year of PJ consumption. Further consumption of PJ, for up to 3 years, had no additional beneficial effects on IMT and serum PON1 activity, whereas serum lipid peroxidation was further reduced by up to 16% after 3 years of PJ consumption. The results of the present study thus suggest that PJ consumption by patients with CAS decreases carotid IMT and systolic blood pressure and these effects could be related to the potent antioxidant characteristics of PJ polyphenols.

Serum cholesterols have a more important role than triglycerides in determining intima-media thickness of the common carotid artery in subjects younger than 55 years of age

OBJECTIVE

The role of serum cholesterol and triglycerides in carotid artery atherosclerosis is controversial. We measured carotid artery intima-media thickness (IMT), a marker of atherosclerosis in subjects younger than 55 years of age with a 6-fold range of serum cholesterol levels (3.93-25.03 mmol/L) and a 200-fold range of triglyceride levels (0.36-75.97 mmol/L).

METHODS

Eighty-six patients with increased serum lipid values and 30 subjects with normal lipid values were included. Serum lipids were measured after an overnight fast. High-resolution sonographic investigations of the carotid arteries of all patients were videotaped. Intima-media thickness was measured offline at 1-mm increments in the distal 10-mm segments of both common carotid arteries by a reader blinded to patient characteristics. First, IMT was compared among groups defined by their cholesterol and triglyceride levels with the use of traditional cutoff values. Next, all subjects were pooled, and general regression analysis was performed to identify significant predictors of IMT with age, body mass index, lipid values, sex, diabetes, hypertension, and smoking status as independent variables.

RESULTS

Intima-media thickness was larger in patient groups with high cholesterol levels (ie, the hypercholesterolemic and combined hyperlipidemic groups) than in the control, borderline, and isolated hypertriglyceridemic groups (P < .01). In the general multiple regression model, IMT correlated positively with total cholesterol level (beta = 0.343; P = .002) and age (beta = 0.3; P = .006) but not with triglyceride level.

CONCLUSIONS

Both the group comparisons and the general regression analysis of the pooled data suggest that hypercholesterolemia has an important role in early onset IMT changes in the common carotid artery, whereas hypertriglyceridemia does not have an appreciable role.

Oxidative stress and preeclampsia: rationale for antioxidant clinical trials

Preeclampsia remains a frequent and potentially dangerous complication of pregnancy. The cause remains largely unknown, but oxidative stress and a generalized inflammatory state are features of the maternal syndrome. The placenta appears to be the principal source of free radical synthesis but maternal leukocytes and the maternal endothelium are also likely contributors. Recent reports have suggested an important role for placental trophoblast NAD(P)H oxidase in free radical generation in preeclampsia. The antioxidant vitamin E is now known to have multiple actions in addition to prevention of lipid peroxidation (ie, inhibition of NAD(P)H oxidase activation and the inflammatory response). In view of the abnormally low plasma vitamin C concentrations in preeclampsia, a combination of vitamins C and E is a promising prophylactic strategy for prevention of preeclampsia. Several multicenter randomized clinical trials are now underway. The potential use of antioxidants and the recognized, albeit modest, benefit of low-dose aspirin prophylaxis have heightened the need for a reliable predictive test for preeclampsia. A combination test involving several relevant biomarkers is likely to provide the best predictive potential.

Fresh israeli jaffa sweetie juice consumption improves lipid metabolism and increases antioxidant capacity in hypercholesterolemic patients suffering from coronary artery disease: studies in vitro and in humans and positive changes in albumin and fibrinogen fractions

The contents of the bioactive compounds in the pummelo-grapefruit hybrid juice named Israeli Jaffa Sweetie and their influence on humans suffering from hypercholesterolemia were studied. It was found that Sweetie juice has a high content of bioactive compounds and a high antioxidant potential. Then 72 hypercholesterolemic patients, ages 43-71 years, after coronary bypass surgery recruited from the Institute pool of volunteers, were randomly divided into two experimental (EG1 and EG2) groups and one control (CG) group, each comprising 24 patients. The diets of EG1 and EG2 patients were daily supplemented with 100 or 200 mL of fresh Sweetie juice, respectively. Before and after diet consumption serum lipid levels, albumin and fibrinogen fractions, and their antioxidant capacities were determined. After 30 consecutive days of Sweetie juice supplemented diets, improvements in serum lipids levels were found in EG1 and EG2 versus CG: (a) total cholesterol, 7.34 versus 8.02 mmol/L, -9.5%, and 6.73 versus 8.02 mmol/L, -16.1%, respectively; (b) low-density lipoprotein cholesterol, 5.63 versus 6.37 mmol/L, -11.6%, and 5.03 versus 6.37 mmol/L, -21.0%, respectively; (c) total glycerides, 2.01 versus 2.27 mmol/L, -11.5%, and 1.71 versus 2.27 mmol/L, -24.7%, respectively. Serum albumin concentration was increased but not significantly in EG1 and EG2 versus CG: 47.5 versus 44.5 g/L, +6.7%, and 47.9 versus 44.5 g/L, +7.6%, respectively. A significant increase in the serum, albumin, and fibrinogen antioxidant capacities in EG2 and to a lesser degree in EG1 was observed. No changes in the CG were found. In conclusion, fresh Sweetie juice contains high quantities of bioactive compounds and has a high antioxidant potential. Diet supplemented with this juice positively influences serum lipid, albumin, and fibrinogen levels and their antioxidant capacities. Addition of fresh Sweetie juice to generally accepted diets may be beneficial for hypercholesterolemic patients.

Oxidant stress and platelet activation in hypercholesterolemia

Hypercholesterolemia is the dominant risk factor associated with atherothrombotic disorders in the western world. Consequently, much attention has been devoted to defining its role in the pathogenesis of atherosclerosis. It is currently recognized that hypercholesterolemia induces phenotypic changes in the microcirculation that are consistent with oxidative and nitrosative stresses. Superoxide is generated via several cellular systems and, once formed, participates in a number of reactions, yielding various free radicals, such as hydrogen peroxide, peroxynitrite, or oxidized low-density lipoproteins. Once oxidant stress is invoked, characteristic pathophysiologic features ensue, such as platelet activation and lipid peroxidation, which are both involved in the initiation and progression of the atherosclerotic lesions. Thus, therapeutic strategies that act to maintain the normal balance in the oxidant status of the vascular bed may prove effective in reducing the deleterious consequences of hypercholesterolemia.

Effects of Long-Term Daily Low-Dose Supplementation With Antioxidant Vitamins and Minerals on Structure and Function of Large Arteries

Objective— Limited data exist from randomized trials evaluating, noninvasively, the impact of antioxidant supplementation on vascular structure and function.

Methods and Results— This is a substudy of the SU.VI.MAX Study, which is a randomized, double-blind, placebo-controlled, cardiovascular and cancer primary prevention trial. Eligible participants (free of symptomatic chronic diseases and apparently healthy) were randomly allocated to daily receive either a combination of antioxidants (120 mg vitamin C, 30 mg vitamin E, 6 mg beta carotene, 100 μg selenium, and 20 mg zinc) or placebo and followed-up over an average of 7.2±0.3 years. At the end-trial examination, the carotid ultrasound examination and carotid–femoral pulse-wave velocity (PWV) measurement were performed blindly in 1162 subjects aged older than 50 years and living in the Paris area. The percentage of subjects with carotid plaques was higher in the intervention group compared with the placebo group (35.2% versus 29.5%, P =0.04). Common carotid intima-media thickness (mean±SD) was not different between the 2 groups (0.70±0.08 versus 0.70±0.08 mm, P =0.38). Mean PWV tended to be lower (indicating less stiff aortic arteries) in the intervention group but the difference did not reach statistical significance ( P =0.13).

Conclusion— These results suggest no beneficial effects of long-term daily low-dose supplementation of antioxidant vitamins and minerals on carotid atherosclerosis and arterial stiffness.

Chlamydial infection and progression of carotid atherosclerosis in patients on regular haemodialysis

BACKGROUND

Recent findings have suggested a possible contribution of chlamydial infection to the pathogenesis of atherosclerosis in the general population. However, the role that chlamydial antibody status plays in atherosclerosis generation in haemodialysis (HD) patients remains uncertain.

METHODS

We measured carotid artery intima medial thickness (IMT) over 4 years in 100 HD subjects (age: 58+/-10 years; time on HD: 13+/-7 years; male/female: 67/33) and examined potential associations between Chlamydia pneumoniae (Cp) antibody seropositivity and changes in carotid artery IMT.

RESULTS

During 4 years, carotid artery IMT increased significantly from 0.62+/-0.13 to 0.73+/-0.12 mm (P< 0.01). IMT progression was significantly and positively correlated with age (r = 0.37, P<0.01), log-transformed C-reactive protein (CRP; r = 0.33, P<0.01) and log-transformed interleukin-6 (IL-6; r = 0.22, P<0.04), but inversely correlated with blood creatinine (r = -0.36, P<0.01) and albumin (r = -0.24, P<0.02). IMT increases were more prominent in patients positive for IgA antibodies (0.039+/- 0.022 mm/year, n = 52) compared with those without IgA antibodies (0.025+/-0.032 mm/year, n = 48) (P<0.01). IgA seropositivity did not accelerate IMT progression in patients with increased CRP (>0.11 mg/dl, n = 53), but significantly increased IMT to a greater extent in IgA-positive subjects than in IgA-negative subjects having lower CRP (</=0.11 mg/dl, n = 47) (0.017+/-0.024 vs 0.034+/- 0.021 mm/year; P = 0.01). Multivariate regression analysis revealed that serum creatinine, log-transformed CRP and IgA Cp seropositivity were independent risk factors for IMT progression (P<0.01). In contrast, IgG Cp antibody did not affect IMT progression or carotid plaque formation.

CONCLUSIONS

IMT progression is associated with inflammation and malnutrition. In addition, persistent chlamydial infection may be associated with IMT progression, but only in HD patients having low blood CRP.

Application of gas chromatography-mass spectrometry for analysis of isoprostanes: their role in cardiovascular disease

Cardiovascular disease (CVD) is the major cause of death in the Western hemisphere. Oxidative stress is involved in the pathophysiology of cancer, neurodegenerative conditions and CVD. Lipid peroxidation is one of the oxidative modifications possible in biological systems. The isoprostanes are derivatives of one specific lipid, i.e., arachidonic acid, after lipid peroxidation. Several isoprostanes have been identified in biological tissues and fluids, among them 8-iso prostaglandin F2alpha (8-iso-PGF2alpha, 8-epi-PGF2alpha, iPF2alpha-III, 15-F2t-IsoP) and its metabolite, 2,3-dinor-4,5-dihydro-8-iso-PGF2alpha. The isoprostanes are reliable in vivo markers of lipid peroxidation in humans: they are endogenously formed, characteristic in structure, ubiquitous in nature, stable in- and ex vivo and reliably quantitatable. In this Review, different analytical approaches will be discussed including immunologic, chromatographic and spectrometric techniques with the main emphasis on mass spectrometry. Analysis of isoprostanes applying radio immunoassay (RIA), enzyme immunoassay (EIA), high performance-liquid chromatography (HPLC), liquid chromatography-tandem mass spectrometry (LC-tandem MS), gas chromatography-mass spectrometry (GC-MS) and GC-tandem MS will be exemplified in the field of cardiovascular research. Results from several clinical studies are included indicating the validity of isoprostanes as surrogate parameters of oxidative stress in cardiovascular disease.

The role of alpha-tocopherol in preventing disease: from epidemiology to molecular events

The function of vitamin E has been attributed to its capacity to protect the organism against the attack of free radicals by acting as a lipid based radical chain breaking molecule. More recently, alternative non-antioxidant functions of vitamin E have been proposed and in particular that of a "gene regulator". Effects of vitamin E have been observed at the level of mRNA or protein and could be consequent to regulation of gene transcription, mRNA stability, protein translation, protein stability and post-translational events. Given the high priority functions assigned to vitamin E, it can be speculated that it would be inefficient to consume it as a radical scavenger. Rather, it would be important to protect vitamin E through a network of cellular antioxidant defences, similarly to what occurs with proteins, nucleic acids and lipids.

Preventive effects of diets supplemented with sweetie fruits in hypercholesterolemic patients suffering from coronary artery disease

BACKGROUND

Diets rich in vegetables and fruits prevent development of atherosclerosis.

OBJECTIVE

To investigate the preventive effects of diets supplemented with a new kind of citrus fruit-pummelo-grapefruit hybrid in hypercholesterolemic patients suffering from coronary artery disease (CAD).

SUBJECTS AND METHODS

Sixty-six hypercholesterolemic volunteers after coronary bypass surgery ages 47-68 years were randomly divided into two experimental (EG1 and EG2) groups and one control (CG) group, 22 each. The diets of the patients of the experimental groups (EG1 and EG2) were supplemented with one or two peeled sweeties, respectively. A comprehensive clinical investigation of all 66 patients was done. Blood samples were collected before and after the investigation for a wide range of laboratory tests.

RESULTS

A high content of dietary fibers and antioxidant compounds in peeled sweeties was found. After 30 days of the investigation, peeled sweeties-supplemented diets have decreased plasma lipids levels in EG1 and EG2 vs. CG group: (a) total cholesterol (TC)-7.38 vs. 8.08 mmol/L, - 8.7%, and 6.78 vs. 8.08. mmol/L, -16.1%, respectively; (b) low-density lipoprotein cholesterol (LDL-C)-5.65 vs. 6.39 mmol/L, - 1.6%, and 5.04 vs. 6.39 mmol/L, -21.2%, respectively; (c) triglycerides (TG)-2.01 vs. 2.27 mmol/L, -11.5%, and 1.71 vs. 2.27 mmol/L, -24.7%, respectively. In addition, a significant increase in the plasma antioxidant capacity in EG2, and to a lesser degree in EG1 groups, was observed. No changes in the studied indices in the patients of the CG were detected.

CONCLUSION

Peeled sweeties have high contents of dietary fibers and antioxidant compounds. Diets supplemented with peeled sweeties positively influence plasma lipid metabolism and plasma antioxidant capacity in patients suffering from hypercholesterolemia. Therefore, the addition of peeled sweeties to a generally accepted antiatherosclerotic diet may be beneficial in prevention of atherosclerosis, mainly in hypercholesterolemic patients.

Oligonucleotides in human urine do not contain 8-oxo-7,8-dihydrodeoxyguanosine

The promutagenic DNA modification 8-oxo-7,8-dihydrodeoxyguanosine is the most frequently used marker for oxidative stress to DNA. The unmodified base and nucleoside and the 8-hydroxylated guanine base and nucleoside are found in urine, the latter used as a global measure of oxidative stress to DNA. Nucleotide excision repair (NER) excises a 27- to 29-mer oligonucleotide with oxidative lesions, and if found in urine, it could be used as a measure of DNA repair in vivo. Enzymatic hydrolysis of human urines followed by HPLC-tandem mass spectrometry was not able to reveal oligonucleotides and/or mononucleotides with the 8-oxo-7,8-dihydrodeoxyguanosine modification. The recovery of a synthetic oligonucleotide with the modification was complete (95% confidence limits: 98-124%). These experiments show that oligonucleotides are excreted into urine, but that 8-oxo-7,8-dihydrodeoxyguanosine is found only as the mononucleoside and is not present in any significant amounts in oligonucleotides. We conclude that oligonucleotides are excreted into urine, and they do not contain oxidized lesions. Either NER products are degraded after excision or NER functions differently in vivo in humans compared with cellular systems.

Should antioxidant status be considered in interventional trials with antioxidants?

The last decade has seen many trials with antioxidants in patients with cardiovascular disease, with equivocal results. One possible explanation for the disappointing findings is the lack of identification criteria of patients who are potential candidates for antioxidant treatment. Several studies have been carried out in patients at risk of cardiovascular disease, indicating that enhanced oxidative stress is associated with the presence of diabetes, hypercholesterolaemia, hypertension, and smoking. This review analyses the data reported so far to determine whether they clearly support the premise that patients at risk of cardiovascular events may be candidates for antioxidant treatment.

Executive Summary: Conference on Dietary Supplement Use in the Elderly - Proceedings of the Conference Held January 14-15, 2003, Natcher Auditorium, National Institutes of Health, Bethesda, MD

Several issues prompted the need for this conference. Among these were the reported high prevalence (> 50%) of use of supplements among individuals over 50 years of age, inadequate scientific evidence supporting the safety and benefits of use among these individuals, and a report issued by the General Accounting Office (GAO) in 2001. This GAO report entitled "Health Products for Seniors: 'Anti-Aging' Products Pose Potential for Physical and Economic Harm," arose from concerns among legislators that seniors were spending money from their limited incomes on products that were not only ineffective but also potentially harmful. The conference was organized around three sessions to address the issues highlighted above, which were usage of dietary supplements among the elderly, age-related changes and issues that affect the use of supplements, and the evidence base supporting the use of supplements in disease prevention and health maintenance. Each session was followed by a panel discussion. This Executive Summary is organized around the three major discussion topics. The summary does not explicitly follow the order of the conference presentations; rather it is intended to capture and examine the current research gaps in knowledge and identify future research opportunities. These research opportunities, as expressed by the conference speakers, panelists, and attendees are summarized at the end of this paper under five thematic areas: usage behaviors, methodology, pre-clinical studies and clinical studies, informational databases, and education and dissemination.

Effects of vitamin E on cardiovascular outcomes in people with mild-to-moderate renal insufficiency: Results of the HOPE Study

BACKGROUND

A controlled trial reported cardiovascular benefits of vitamin E in terminal renal insufficiency. There are no data for renal insufficiency before the stage of terminal renal failure. We evaluated effects of vitamin E supplementation on cardiovascular and renal outcomes in 993 people with a serum creatinine > or =1.4 to 2.3 mg/dL.

METHODS

Post-hoc analysis of a randomized trial that compared treatment with natural source vitamin E (400 IU/day) to placebo in 9541 people, 993 of which had renal insufficiency. Participants had either known cardiovascular disease or diabetes and at least one additional coronary risk factor. Exclusion criteria included a serum creatinine > 2.3 mg/dL and dipstick-positive proteinuria. The primary study outcome after an average of 4.5 years was the composite of myocardial infarction, stroke, or cardiovascular death. Secondary outcomes included revascularizations, total mortality, and clinical proteinuria.

RESULTS

In renal insufficiency, vitamin E supplementation had a neutral effect on the primary study outcome, on each component of the composite primary outcome, and on all secondary outcomes. Two hundred twenty-four primary outcomes, 23% of the vitamin E group and 22.1% of the placebo group, relative risk 1.03 (95% CI, 0.79-1.34; P= 0.82), were observed, and 585 secondary outcomes, including death in 17% and 18.8% of the vitamin E and placebo groups, respectively (RR 0.88, 95% CI, 0.66-1.18; P= 0.40). There was no effect of vitamin E on progression of proteinuria.

CONCLUSION

In people with mild-to-moderate renal insufficiency at high cardiovascular risk, vitamin E at a dose of 400 IU/day had no apparent effect on cardiovascular outcomes.

Vitamins in human arteriosclerosis with emphasis on vitamin C and vitamin E

INTRODUCTION

This review focuses on the process of arteriosclerosis arising from oxidative stress on lipoproteins and the general failure of randomized human trials using vitamins to retard this process.

REVIEW

As well as clinical trials, the paper reviews the mechanisms by which a variety of oxidants act. Antioxidants are discussed, emphasizing interactions of vitamins C and E with transition metals that can lead to prooxidation. There is a focus on interactions between supplemental or co-antioxidants that counterbalance prooxidant effects of one another.

CONCLUSIONS

It is concluded that normal cellular supplementation mechanisms are poorly accessible in the arteriosclerotic plaque leading to a prooxidant environment in which the haphazard introduction of vitamins could potentially be hazardous. Continued investigations into basic and clinical redox interactions of the kind discussed in this review using new measuring techniques may lead to approaches whereby antioxidants can be introduced into tissue in controlled ways for reducing arteriosclerosis.

Antioxidant intervention attenuates myocardial neovascularization in hypercholesterolemia

BACKGROUND

Hypercholesterolemia (HC) and atherosclerosis can elicit oxidative stress, coronary endothelial dysfunction, and myocardial ischemia, which may induce growth-factor expression and lead to myocardial neovascularization. We tested the hypothesis that chronic antioxidant intervention in HC would attenuate neovascularization and preserve the expression of hypoxia-inducible factor (HIF)-1alpha and vascular endothelial growth factor (VEGF).

METHODS AND RESULTS

Three groups of pigs (n=6 each) were studied after 12 weeks of normal or 2% HC diet or HC+antioxidant supplementation (100 IU/kg vitamin E and 1 g vitamin C daily). Myocardial samples were scanned ex vivo with a novel 3D micro-CT scanner, and the spatial density and tortuosity of myocardial microvessels were determined in situ. VEGF mRNA, protein levels of VEGF and VEGF receptor-1, HIF-1alpha, nitrotyrosine, and superoxide dismutase (SOD) were determined in myocardial tissue. The HC and HC+antioxidant groups had similar increases in serum cholesterol levels. HC animals showed an increase in subendocardial spatial density of microvessels compared with normal (160.5+/-11.8 versus 95.3+/-8.2 vessels/cm2, P<0.05), which was normalized in HC+antioxidant (92.5+/-20.5 vessels/cm2, P<0.05 versus HC), as was arteriolar tortuosity. In addition, HC induced upregulation of VEGF, HIF-1alpha, and nitrotyrosine expression and decreased SOD expression and activity, all of which were preserved by antioxidant intervention.

CONCLUSIONS

Changes in myocardial microvascular architecture invoked by HC are accompanied by increases in HIF-1alpha and VEGF expression and attenuated by antioxidant intervention. This underscores a role of increased oxidative stress in modulating myocardial microvascular architecture in early atherogenesis.

Determinants of F2-isoprostane biosynthesis and inhibition in man

Several cardiovascular risk factors are characterized by the coexistence of low-grade inflammation, enhanced oxidative stress and lipid peroxidation. It has been hypothesized that F2-isoprostanes, a product of in vivo lipid peroxidation, may transduce the effects of metabolic and hemodynamic abnormalities into increased cardiovascular risk. Thus, the formation of these compounds, including urinary 8-iso-Prostaglandin (PG) F2alpha, has been investigated in clinical settings putatively associated with oxidant stress. Enhanced lipid peroxidation together with increased in vivo platelet activation have been found in association with the major cardiovascular risk factors. Thus, F2-isoprostanes may transduce the effects of oxidant stress associated with complex metabolic disorders into specialized forms of cellular activation. In particular, the low-grade inflammatory state characterizing metabolic disorders such as obesity, hypercholesterolemia, type 2 diabetes mellitus, and homozygous homocystinuria may be the primary trigger of thromboxane-dependent platelet activation mediated, at least in part, through enhanced lipid peroxidation. Moreover, oxidative stress may promote endothelial dysfunction through increased production of reactive oxygen species that inactivate nitric oxide. Accumulation and activation of leukocytes plays a key role in atherosclerosis and its complications. Interestingly, neutrophil adhesion induced by minimally modified low-density lipoproteins is mainly mediated by F2-isoprostanes. Although epidemiological studies suggest an inverse relationship between antioxidant vitamin intake and cardiovascular disease, several clinical trials have obtained conflicting results on the effects of vitamin E supplementation on the risk of cardiovascular events. On the other hand, the use of F2-isoprostane formation as a biochemical end-point for dose-finding studies of vitamin E supplementation has helped clarifying the unique features of its pharmacodynamic effects on lipid peroxidation. This information could be extremely valuable in the selection of the appropriate patient subgroups that may benefit from antioxidant interventions.

Long-term antioxidant intervention improves myocardial microvascular function in experimental hypertension

Hypertension increases oxidative stress, which can impair myocardial microvascular function and integrity. However, it is yet unclear whether long-term antioxidant intervention in early hypertension would preserve myocardial perfusion and vascular permeability responses to challenge. Pigs were studied after 12 weeks of renovascular hypertension without (n=8) or with daily supplementation of antioxidants (100 IU/kg vitamin E and 1 g vitamin C, n=6), and compared with normal controls (n=7). Myocardial perfusion and microvascular permeability were measured in vivo by electron beam computed tomography before and after 2 cardiac challenges (intravenous adenosine and dobutamine). Basal left ventricular muscle mass was also obtained. Mean arterial pressure was significantly increased in both groups of hypertensive animals (without and with antioxidants, 123+/-9 and 126+/-4 mm Hg, respectively, versus normal, 101+/-4 mm Hg; both P<0.05), but muscle mass was not different among the groups. The impaired myocardial perfusion response to adenosine observed in hypertensives (normal, +51+/-14%; P<0.05 versus baseline; hypertension, +14+/-15%; P=0.3 versus baseline) was preserved in hypertensive pigs that received antioxidants (+44+/-15%; P=0.01 compared with baseline). Long-term antioxidant intervention also preserved subendocardial microvascular permeability responses in hypertension. On the other hand, antioxidant intervention had little effect on the hypertension-induced myocardial vascular dysfunction observed in response to dobutamine. This study demonstrates that the impaired myocardial perfusion and permeability responses to increased cardiac demand in early hypertension are significantly improved by long-term antioxidant intervention. These results support the involvement of oxidative stress in myocardial vascular dysfunction in hypertension and suggest a role for antioxidant strategies to preserve the myocardial microvasculature.

Vitamin E Supplementation in Patients With Carotid Atherosclerosis

OBJECTIVE

Oxidative stress is believed to play a pivotal role in the initiation and progression of atherosclerosis. We analyzed whether vitamin E supplementation influences oxidative stress in plasma and atherosclerotic plaques of patients with severe atherosclerosis.

METHODS AND RESULTS

In 16 patients who were candidates for carotid endarterectomy and in 32 age- and sex-matched controls, plasma levels of 7beta-hydroxycholesterol, 7-ketocholesterol, cholesterol, and vitamin E were measured. Patients were randomly allocated to standard treatment with or without 900 mg/d vitamin E. After 6 weeks of treatment, the reported variables were measured in plasma and plaques. The plasma vitamin E/cholesterol ratio was significantly lower in patients than in controls (3.05+/-0.6 versus 6.3+/-1.7 micromol/mmol cholesterol, P<0.001). Plasma 7beta-hydroxycholesterol was significantly higher in patients than in controls (5.0+/-1.04 versus 4.4+/-0.6 ng/mL, P<0.05). Patients who were given vitamin E supplementation showed a significant increase of plasma vitamin E with concomitant decrease of 7beta-hydroxycholesterol. Conversely, no treatment dependence was observed in oxysterol or vitamin E content of plaques.

CONCLUSIONS

An imbalance between oxidative stress and antioxidant status is present in patients with advanced atherosclerosis. Vitamin E supplementation improves this imbalance in plasma but not in plaques.

Pioglitazone inhibits LOX-1 expression in human coronary artery endothelial cells by reducing intracellular superoxide radical generation

OBJECTIVE

LOX-1, a novel lectin-like receptor for oxidized LDL (ox-LDL), is expressed in response to ox-LDL, angiotensin II (Ang II), tumor necrosis factor (TNF)-alpha, and other stress stimuli. It is highly expressed in atherosclerotic tissues. Peroxisome proliferator-activated receptor (PPAR)-gamma ligands, such as pioglitazone, exert antiatherosclerotic effects. This study examined the regulation of LOX-1 expression in human coronary artery endothelial cells (HCAECs) by pioglitazone.

METHODS AND RESULTS

Fourth generation HCAECs were treated with ox-LDL, Ang II, or TNF-alpha with or without pioglitazone pretreatment. All 3 stimuli upregulated LOX-1 expression (mRNA and protein). Pioglitazone, in a concentration-dependent manner, reduced LOX-1 expression (P<0.01 versus ox-LDL, Ang II, or TNF-alpha alone). Ox-LDL, Ang II, and TNF-alpha each enhanced intracellular superoxide radical generation, and pioglitazone pretreatment reduced superoxide generation (P<0.01 versus ox-LDL, Ang II, or TNF-alpha). Furthermore, all 3 stimuli upregulated the expression of the transcription factors nuclear factor-kappaB and activator protein-1 (determined by electrophoretic mobility shift assay), and pioglitazone pretreatment reduced this expression (P<0.01 versus ox-LDL, Ang II, or TNF-alpha). To determine the biological significance of pioglitazone-mediated downregulation of LOX-1, we studied monocyte adhesion to ox-LDL-treated HCAECs. Pioglitazone reduced the adhesion of monocytes to activated HCAECs in a fashion similar to that produced by antisense to LOX-1 mRNA.

CONCLUSIONS

These observations suggest that the PPAR-gamma ligand pioglitazone reduces intracellular superoxide radical generation and subsequently reduces the expression of transcription factors, expression of the LOX-1 gene, and monocyte adhesion to activated endothelium. The salutary effect of PPAR-gamma ligands in atherogenesis may involve the inhibition of LOX-1 and the adhesion of monocytes to endothelium.

Complex Multivitamin Supplementation Improves Homocysteine and Resistance to LDL-C Oxidation

OBJECTIVE

We previously reported in an open-label pilot trial that a 24-ingredient multivitamin formula favorably influenced homocysteine concentration and LDL-C oxidation indices following 24 weeks of supplementation. Our current aim was to more thoroughly examine this same formula in a randomized, placebo-controlled, clinical study.

METHODS

We examined 182 participants for selected plasma vitamin concentrations and clinically relevant variables including homocysteine, lipids and LDL-C oxidation indices at baseline and six months.

RESULTS

We found no significant differences between groups for any parameter at baseline. Following six months of vitamin supplementation, we observed elevations in plasma concentrations of vitamin B6 (as pyridoxal 5'-phosphate; PLP), vitamin B12, folate, vitamin C, vitamin E and beta-carotene (p < 0.0001), all of which were significantly greater than respective placebo group changes (p < 0.0001). Homocysteine decreased in the treatment (8.38 +/- 2.9 vs. 6.93 +/- 2.5 micro mol/L; p < 0.0001) and placebo group (8.17 +/- 3.0 vs. 7.42 +/- 2.2 micro mol/L; p < 0.0001) from baseline to six months, respectively, with reductions in the treatment group being greater than placebo (p < 0.008). LDL-C oxidation indices were also improved as LDL-C oxidation rate was decreased (-0.39 micro mol/min/g protein; p < 0.0003) and LDL-C lag time increased (11.3 min; p < 0.003) in supplemented participants. Further analysis also showed that LDL-C oxidation rate was lower (p < 0.0007) and LDL-C lag time longer (p < 0.0001) for the vitamin group than placebo treatment after six months.

CONCLUSION

We conclude that a multi-ingredient vitamin formula with antioxidant properties has measurable effects on homocysteine and LDL-C oxidation indices.

Beneficial effects of antioxidant vitamins on the stenotic kidney

Renal artery stenosis (RAS) may lead to renal injury, partly mediated through increased oxidative stress. However, the potential effects of chronic oral antioxidant intervention on the stenotic kidney remain unknown. This study was designed to test the hypothesis that chronic antioxidant vitamin supplementation in RAS would preserve renal function and structure. Single-kidney hemodynamics and function were quantified in vivo in pigs using electron-beam CT after 12 weeks of unilateral RAS (n=7), a similar degree of RAS orally supplemented with vitamins C (1 g) and E (100 IU/kg) (RAS+Vitamins, n=7), or controls (normal, n=7). Renal tissue was studied ex vivo using Western blotting and immunohistochemistry. Mean arterial pressure was similarly elevated in both RAS groups, while ischemic renal volume and glomerular filtration rate were similarly reduced. Renal blood flow was decreased in RAS compared with normal (326.5+/-99.9 versus 553.4+/-48.7 mL/min, respectively, P=0.01), but preserved in RAS+Vitamins (485.2+/-104.1 mL/min, P=0.3 versus normal). The marked increase in the expression of the NADPH-oxidase subunits p47phox and p67phox, nitrotyrosine, endothelial and inducible nitric oxide synthase, and nuclear factor-kappaB observed in RAS (P<0.05 versus normal) was normalized in RAS+Vitamins (P>0.1). Furthermore, trichrome staining and the expression of transforming growth factor-beta and tissue inhibitor of matrix-metalloproteinase-1 were also decreased in RAS+Vitamins. In conclusion, chronic blockade of the oxidative stress pathway in RAS using antioxidant vitamins improved renal hemodynamics and decreased oxidative stress, inflammation, and fibrosis in the ischemic kidney. These observations underscore the involvement of oxidative stress in renal injury in RAS and support a role for antioxidant vitamins in preserving the ischemic kidney.

Clinical pharmacokinetics of antioxidants and their impact on systemic oxidative stress

Dietary antioxidants play a major role in maintaining the homeostasis of the oxidative balance. They are believed to protect humans from disease and aging. Vitamin C (ascorbic acid), vitamin E (tocopherol), beta-carotene and other micronutrients such as carotenoids, polyphenols and selenium have been evaluated as antioxidant constituents in the human diet. This article addresses data provided from clinical trials, highlighting the clinical pharmacokinetics of vitamin C, vitamin E, beta-carotene, lycopene, lutein, quercetin, rutin, catechins and selenium. The bioavailability of vitamin C is dose-dependent. Saturation of transport occurs with dosages of 200-400 mg/day. Vitamin C is not protein-bound and is eliminated with an elimination half-life (t((1/2))) of 10 hours. In Western populations plasma vitamin C concentrations range from 54-91 micro mol/L. Serum alpha- and gamma-tocopherol range from 21 micro mol/L (North America) to 27 micro mol/L (Europe) and from 3.1 micro mol/L to 1.5 micro mol/L, respectively. alpha-Tocopherol is the most abundant tocopherol in human tissue. The bioavailability of all-rac-alpha-tocopherol is estimated to be 50% of R,R,R-alpha-tocopherol. The hepatic alpha-tocopherol transfer protein (alpha-TTP) together with the tocopherol-associated proteins (TAP) are responsbile for the endogenous accumulation of natural alpha-tocopherol. Elimination of alpha-tocopherol takes several days with a t((1/2)) of 81 and 73 hours for R,R,R-alpha-tocopherol and all-rac-alpha-tocopherol, respectively. The t((1/2)) of tocotrienols is short, ranging from 3.8-4.4 hours for gamma- and alpha-tocotrienol, respectively. gamma-Tocopherol is degraded to 2, 7, 8-trimethyl-2-(beta-carboxyl)-6-hyrdoxychroman by the liver prior to renal elimination. Blood serum carotenoids in Western populations range from 0.28-0.52 micro mol/L for beta-carotene, from 0.2-0.28 for lutein, and from 0.29-0.60 for lycopene. All-trans-carotenoids have a better bioavailability than the 9-cis-forms. Elimination of carotenoids takes several days with a t((1/2)) of 5-7 and 2-3 days for beta-carotene and lycopene, respectively. The bioconversion of beta-carotene to retinal is dose-dependent, and ranges between 27% and 2% for a 6 and 126mg dose, respectively. Several oxidised metabolites of carotenoids are known. Flavonols such as quercetin glycosides and rutin are predominantly absorbed as aglycones, bound to plasma proteins and subsequently conjugated to glucuronide, sulfate, and methyl moieties. The t((1/2)) ranges from 12-19 hours. The bioavailabillity of catechins is low and they are eliminated with a t((1/2)) of 2-4 hours. Catechins are degraded to several gamma-valerolactone derivatives and phase II conjugates have also been identified. Only limited clinical pharmacokinetic data for other polyphenols such as resveratrol have been reported to date.

Antioxidants attenuate myocyte apoptosis and improve cardiac function in CHF: association with changes in MAPK pathways

Antioxidant vitamins reduce cardiac oxidative stress and cardiomyocyte apoptosis produced by exogenous norepinephrine (NE) and attenuate cardiac dysfunction in animals with pacing-induced congestive heart failure (CHF). This study was carried out to determine whether the mitogen-activated protein kinase (MAPK) signal transduction pathways are involved in oxidative stress-induced myocyte apoptosis. Rabbits with rapid pacing-induced CHF and sham operation were randomized to receive either a combination of antioxidant vitamins (beta-carotene, ascorbic acid, and alpha-tocopherol), alpha-tocopherol alone, or placebo for 8 wk. Compared with sham-operated animals, CHF animals exhibited increased oxidative stress as evidenced by decreased myocardial reduced-to-oxidized glutathione (GSH/GSSG) ratio (27 +/- 7 vs. 143 +/- 24, P < 0.05), myocyte apoptosis (77 +/- 18 vs. 17 +/- 4 apoptotic nuclei/10,000 cardiomyocytes, P < 0.05), increased total and phosphorylated c-Jun NH2-terminal protein kinase (p-JNK; 1.95 +/- 0.14 vs. 1.04 +/- 0.04 arbitrary units, P < 0.05) and phosphorylated p38 kinase (p-p38), and decreased phosphorylated extracellular signal-regulated kinase (p-ERK). Administration of antioxidant vitamins and alpha-tocopherol attenuated oxidative stress, myocyte apoptosis, and cardiac dysfunction, with reversal of the changes of total JNK, p-JNK, and p-ERK in CHF. Furthermore, because NE infusion produced changes of JNK, p-p38, and p-ERK similar to those in CHF, we conclude that NE may play an important role in the production of oxidative stress, MAPK activation, and myocyte apoptosis in CHF.

Interactions of angiotensin II with NAD(P)H oxidase, oxidant stress and cardiovascular disease

An elevation in angiotensin II (Ang II) levels is a common occurrence in a diverse number of cardiovascular diseases including hypertension, hypercholesterolaemia, atherosclerotic coronary artery disease, left ventricular hypertrophy (LVH), heart failure and diabetes. An important effect of Ang II is activation of the NAD(P)H oxidase, a major source of reactive oxygen species (ROS) production by vascular cells. This increase in cellular ROS contributes to the pathogenesis of vascular disease by altering endothelial cell function, enhancing smooth muscle cell growth and proliferation, stimulating inflammatory proteins, including macrophage chemoattractant agents, growth factors and cytokines, and modulating matrix remodelling. Studies of genetically-altered mice have unequivocally shown that activation of the NAD(P)H oxidase by Ang II contributes to hypertension, LVH and atherosclerosis. Furthermore, increasing evidence suggest that the NAD(P)H oxidase contributes to human disease, suggesting that it is a potential target for future therapeutic intervention.