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Abstract
Antiplatelet therapy is a cornerstone of secondary prevention of cardiovascular diseases (CVDs). However, current guidelines are based on data derived primarily from men, as women are generally underrepresented in trials. Consequently, there are insufficient and inconsistent data on the effect of antiplatelet drugs in women. Sex differences were reported in platelet reactivity, patient management, and clinical outcomes after treatment with aspirin, P2Y12 inhibitor, or dual antiplatelet therapy. To evaluate whether sex-specific antiplatelet therapy is needed, in this review we discuss (i) how sex affects platelet biology and response to antiplatelet agents, (ii) how sex and gender differences translate into clinical challenges and (iii) how the cardiological care in women might be improved. Finally, we highlight the challenges faced in clinical practice regarding the different needs and characteristics of female and male patients with CVD and address issues requiring further investigation.
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Affiliation(s)
- Aleksandra Gasecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Independent Public Central Teaching Hospital, Warsaw, Poland
| | - Jakub M Zimodro
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Independent Public Central Teaching Hospital, Warsaw, Poland
| | - Yolande Appelman
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University, Amsterdam, The Netherlands
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Occhipinti G, Greco A, Angiolillo DJ, Capodanno D. Gender differences in efficacy and safety of antiplatelet strategies for acute coronary syndromes. Expert Opin Drug Saf 2023; 22:669-683. [PMID: 37542468 DOI: 10.1080/14740338.2023.2245331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/15/2023] [Accepted: 08/03/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Dual antiplatelet therapy (DAPT) represents the cornerstone of secondary prevention in patients presenting with acute coronary syndrome (ACS) and undergoing percutaneous coronary intervention. Despite its undisputed efficacy in reducing thrombotic events, DAPT increases the risk of bleeding, which is associated with higher morbidity and mortality. Novel antiplatelet strategies (i.e. in terms of timing, selection of drugs and their combinations, and modulation strategies) have been tested in randomized trials, suggesting the utility of tailored approaches in selected populations (i.e. patients at high bleeding or ischemic risk). It remains uncertain whether the effect of these strategies is influenced by sex. AREAS COVERED This narrative review provides an overview of available evidence surrounding sex differences in the efficacy and safety of antiplatelet strategies for ACS and analyzes the potential reasons behind these findings. Relevant content was searched for in PubMed. EXPERT OPINION Significant differences between women and men exist in terms of clinical presentation, pharmacotherapies, interventional management, and prognosis of ACS. However, these observations do not appear to be attributed to different pharmacodynamic effects of antiplatelet therapies between women and men. Unfortunately, a critical issue depends on women being often underrepresented in clinical trials, leading to a substantial lack of sex-specific evidence.
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Affiliation(s)
- Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania, Italy
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Laborante R, Borovac JA, Galli M, Rodolico D, Ciliberti G, Restivo A, Cappannoli L, Arcudi A, Vergallo R, Zito A, Princi G, Leone AM, Aurigemma C, Romagnoli E, Montone RA, Burzotta F, Trani C, D’Amario D. Gender-differences in antithrombotic therapy across the spectrum of ischemic heart disease: Time to tackle the Yentl syndrome? Front Cardiovasc Med 2022; 9:1009475. [PMID: 36386309 PMCID: PMC9659635 DOI: 10.3389/fcvm.2022.1009475] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/14/2022] [Indexed: 08/11/2023] Open
Abstract
The incidence and clinical presentation of ischemic heart disease (IHD), as well as thrombotic and bleeding risks, appear to differ between genders. Compared with men, women feature an increased thrombotic risk, probably related to an increased platelet reactivity, higher level of coagulation factors, and sex-associated unique cardiovascular risk factors, such as pregnancy-related (i.e., pre-eclampsia and gestational diabetes), gynecological disorders (i.e., polycystic ovary syndrome, early menopause) and autoimmune or systemic inflammatory diseases. At the same time, women are also at increased risk of bleeding, due to inappropriate dosing of antithrombotic agents, smaller blood vessels, lower body weight and comorbidities, such as diabetes and chronic kidney disease. Pharmacological strategies focused on the personalization of antithrombotic treatment may, therefore, be particularly appealing in women in light of their higher bleeding and ischemic risks. Paradoxically, although women represent a large proportion of cardiovascular patients in our practice, adequate high-quality clinical trial data on women remain scarce and inadequate to guide decision-making processes. As a result, IHD in women tends to be understudied, underdiagnosed and undertreated, a phenomenon known as a "Yentl syndrome." It is, therefore, compelling for the scientific community to embark on dedicated clinical trials to address underrepresentation of women and to acquire evidence-based knowledge in the personalization of antithrombotic therapy in women.
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Affiliation(s)
- Renzo Laborante
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Josip Andjelo Borovac
- Department of Pathophysiology, University of Split School of Medicine, Split, Croatia
| | - Mattia Galli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Daniele Rodolico
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Ciliberti
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Attilio Restivo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Luigi Cappannoli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Alessandra Arcudi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Rocco Vergallo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Andrea Zito
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Princi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Antonio Maria Leone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Cristina Aurigemma
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Enrico Romagnoli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Rocco Antonio Montone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Domenico D’Amario
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Chen S, Che Q, Zheng Q, Zhang Y, Jia J, Wu Y, Huo Y, Chen D. Relationship Between Different Risk Factor Patterns and Follow-Up Outcomes in Patients With ST-Segment Elevation Myocardial Infarction. Front Cardiovasc Med 2021; 8:633992. [PMID: 34113659 PMCID: PMC8185218 DOI: 10.3389/fcvm.2021.633992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 03/29/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Few studies have been concerned with the combined influences of the presence of multiple risk factors on follow-up outcomes in AMI patients. Our study aimed to identify risk factor patterns that may be associated with 1-year survival in male patients with ST-segment elevation myocardial infarction (STEMI). Methods: Data were from the China STEMI Care Project Phase 2 (CSCAP-2) collected between 2015 and 2018. A total of 15,675 male STEMI patients were enrolled in this study. Risk factor patterns were characterized using latent class analysis (LCA) according to seven risk factors. Associations between risk factor patterns and follow-up outcomes, including the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause death, were investigated by Cox proportional hazard regression analysis. Results: We obtained four risk factor patterns as "young and middle-aged with low levels of multimorbidity," "middle-aged with overweight," "middle-aged and elderly with normal weight," and "elderly with high multimorbidity." Four patterns had significant differences in event-free survival (P < 0.001). As compared with the patients of "young and middle-aged with low levels of multimorbidity" pattern, the risk of incidence of MACCE and all-cause death were increased in patients of "middle-aged with overweight" pattern (All-cause death: HR = 1.70, 95% CI:1.29~2.23; MACCE: HR = 1.49, 95% CI:1.29~1.72), "middle-aged and elderly with normal weight" pattern (All-cause death: HR = 3.04, 95% CI: 2.33~3.98; MACCE: HR = 1.82, 95% CI: 1.56~2.12), and "elderly with high multimorbidity" pattern (All-cause death: HR = 5.78, 95% CI: 4.49~7.42; MACCE: HR = 2.67, 95% CI: 2.31~3.10). Conclusions: By adopting a Latent Class Analysis Approach, STEMI patients can be characterized into four risk factor patterns with significantly different prognosis. The data is useful for the improvement of community health management in each specific subgroup of patients, which indicates a particular risk factor pattern.
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Affiliation(s)
- Si Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Qianzi Che
- Department of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Qiwen Zheng
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Yan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jia Jia
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yiqun Wu
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Dafang Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
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Schreuder MM, Badal R, Boersma E, Kavousi M, Roos-Hesselink J, Versmissen J, Visser LE, Roeters van Lennep JE. Efficacy and Safety of High Potent P2Y 12 Inhibitors Prasugrel and Ticagrelor in Patients With Coronary Heart Disease Treated With Dual Antiplatelet Therapy: A Sex-Specific Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 9:e014457. [PMID: 32063118 PMCID: PMC7070195 DOI: 10.1161/jaha.119.014457] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Sex differences in efficacy and safety of dual antiplatelet therapy remain uncertain because of the underrepresentation of women in cardiovascular trials. The aim of this study was to perform a sex‐specific analysis of the pooled efficacy and safety data of clinical trials comparing a high potent P2Y12 inhibitor+aspirin with clopidogrel+aspirin in patients with acute coronary syndrome. Methods and Results A systematic literature search was performed. Randomized clinical trials that compared patients following percutaneous coronary intervention/acute coronary syndrome who were taking high potent P2Y12 inhibitors+aspirin versus clopidogrel+aspirin were selected. Random effects estimates were calculated and relative risks with 95% CIs on efficacy and safety end points were determined per sex. We included 6 randomized clinical trials comparing prasugrel/ticagrelor versus clopidogrel in 43 990 patients (13 030 women), with a median follow‐up time of 1.06 years. Women and men had similar relative risk (RR) reduction for major cardiovascular events (women: RR, 0.89 [95% CI, 0.80–1.00; men: RR, 0.84 [95% CI, 0.79–0.91) (P for interaction=0.39). Regarding safety, women and men had similar risk of major bleeding by high‐potency dual antiplatelet therapy (RR, 1.18 [95% CI, 0.98–1.41] versus RR, 1.03 [95% CI, 0.93–1.14]) (P for interaction=0.20). Conclusions The small and statistically insignificant difference in efficacy and safety estimates of high‐potency dual antiplatelet therapy between women and men following percutaneous coronary intervention/acute coronary syndrome do not justify differential dual antiplatelet therapy treatment for both sexes.
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Affiliation(s)
- Michelle M Schreuder
- Department of Internal Medicine Erasmus Medical Centre Rotterdam The Netherlands
| | - Ricardo Badal
- Department of Internal Medicine Erasmus Medical Centre Rotterdam The Netherlands
| | - Eric Boersma
- Department of Epidemiology Erasmus Medical Centre Rotterdam The Netherlands
| | - Maryam Kavousi
- Department of Epidemiology Erasmus Medical Centre Rotterdam The Netherlands
| | | | - Jorie Versmissen
- Department of Internal Medicine Erasmus Medical Centre Rotterdam The Netherlands
| | - Loes E Visser
- Department of Epidemiology Erasmus Medical Centre Rotterdam The Netherlands
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Abstract
BACKGROUND Despite advancements in treatment, acute myocardial infarction (AMI) remains a leading cause of morbidity and mortality in the elderly population. Previous research has highlighted long-standing sex disparities in the care of these patients. However, differences in the patterns of discharge are not well described. One key parameter is the destination of discharge, and in particular - discharge to skilled nursing facilities (SNFs), a factor associated with worse prognosis and greater costs to the healthcare system. Our aim, therefore, was to observe destination differences after AMI on the basis of sex and other baseline characteristics. MATERIALS AND METHODS From a cohort of 143 180 claims, we carried out an observational analysis of 6123 Medicare beneficiaries discharged following AMI during the first quarter of 2016. RESULTS For patients who were referred from SNF, the rates of in-hospital death are higher, even after adjustment for baseline characteristics (odds ratio: 1.78, 95% confidence interval: 1.17-2.70). Of those discharged to SNF or home, 36.33% of the female patients were discharged to an SNF versus 25.12% (P<0.01) of the male patients. After adjusting for baseline characteristics, discharge to SNF remained significantly higher among female patients (odds ratio: 1.57, 95% confidence interval: 1.27-1.94). CONCLUSION Discharge to SNF following AMI is more frequent for female patients, even after adjustment for risk factors. Our findings highlight the need to better characterize this unique patient population and understand the cycle of care that they receive following AMI.
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Long-term outcomes in men and women with ST-segment elevation myocardial infarction and incomplete reperfusion after a primary percutaneous coronary intervention. Coron Artery Dis 2019; 30:171-176. [DOI: 10.1097/mca.0000000000000703] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zandecki Ł, Sadowski M, Janion M, Kurzawski J, Gierlotka M, Poloński L, Gąsior M. Survival benefit from recent changes in management of men and women with ST-segment elevation myocardial infarction treated with percutaneous coronary interventions. Cardiol J 2018; 26:459-468. [PMID: 29924379 DOI: 10.5603/cj.a2018.0057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 10/04/2018] [Accepted: 01/17/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Nowadays, the majority of patients with myocardial infarction with ST-segment elevation (STEMI) are treated with primary percutaneous coronary interventions (PCI). In recent years, there have been ongoing improvements in PCI techniques, devices and concomitant pharmacotherapy. However, reports on further mortality reduction among PCI-treated STEMI patients remain inconclusive. The aim of this study was to compare changes in management and mortality in PCI-treated STEMI patients between 2005 and 2011 in a real-life setting. METHODS Data on 79,522 PCI-treated patients with STEMI from Polish Registry of Acute Coronary Syndromes (PL-ACS) admitted to Polish hospitals between 2005 and 2011 were analyzed. First, temporal trends of in-hospital management in men and women were presented. In the next step, patients from 2005 and 2011 were nearest neighbor matched on their propensity scores to compare in-hospital, 30-day and 1-year mortality rates and in-hospital management strategies and complications. RESULTS Some significant changes were noted in hospital management including shortening of median times from admission to PCI, increased use of drug-eluting stents, potent antiplatelet agents but also less frequent use of statin, beta-blockers and angiotensin converting enzyme inhibitors and angiotensin II receptor blockers. There was a strong tendency toward preforming additional PCI of non-infarct related arteries, especially in women. After propensity score adjustment there were significant changes in inhospital but not in 30-day or 1-year mortality rates between 2005 and 2011. The results were similar in men and women. CONCLUSIONS There were apparent changes in management and significant in-hospital mortality reductions in PCI-treated STEMI patients between 2005 and 2011. However, it did not result in 30-day or 1-year survival benefit at a population level. There may be room for improvement in the use of guideline-recommended pharmacotherapy.
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Affiliation(s)
- Łukasz Zandecki
- 2nd Cardiology Clinic, Swietokrzyskie Cardiology Center, Kielce, Poland. .,The Faculty of Medicine and Health Sciences, The Jan Kochanowski University, Kielce, Poland.
| | - Marcin Sadowski
- Department of Interventional Cardiology, Swietokrzyskie Cardiology Center, Kielce, Poland.,The Faculty of Medicine and Health Sciences, The Jan Kochanowski University, Kielce, Poland
| | - Marianna Janion
- 2nd Cardiology Clinic, Swietokrzyskie Cardiology Center, Kielce, Poland.,The Faculty of Medicine and Health Sciences, The Jan Kochanowski University, Kielce, Poland
| | - Jacek Kurzawski
- 2nd Cardiology Clinic, Swietokrzyskie Cardiology Center, Kielce, Poland
| | - Marek Gierlotka
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland.,Department of Cardiology, University Hospital, Institute of Medicine, University of Opole, Poland
| | - Lech Poloński
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Mariusz Gąsior
- 3rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland
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Lu J, Guo Y, Guo CQ, Shi XM, Du NY, Zhao RL, Du WP, Liang JR, Zhu SP, Chen H. Acupuncture with reinforcing and reducing twirling manipulation inhibits hippocampal neuronal apoptosis in spontaneously hypertensive rats. Neural Regen Res 2017; 12:770-778. [PMID: 28616034 PMCID: PMC5461615 DOI: 10.4103/1673-5374.206648] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
To observe the effects of different acupuncture manipulations on blood pressure and target organ damage in spontaneously hypertensive rats (SHRs), this study used the reinforcing twirling method (1.5–2-mm depth; rotating needle clockwise for 360° and then counter clockwise for 360°, with the thumb moving heavily forward and gently backward, 60 times per minute for 1 minute, and retaining needle for 9 minutes), the reducing twirling method (1.5–2-mm depth; rotating needle counter clockwise for 360° and then clockwise for 360°, with the thumb moving heavily backward and gently forward, 60 times per minute for 1 minute, and retaining needle for 9 minutes), and the needle retaining method (1.5–2-mm depth and retaining the needle for 10 minutes). Bilateral Taichong (LR3) was treated by acupuncture using different manipulations and manual stimulation. Reinforcing twirling, reducing twirling, and needle retaining resulted in a decreased number of apoptotic cells, reduced Bax mRNA and protein expression, and an increased Bcl-2/Bax ratio in the hippocampus compared with the SHR group. Among these groups, the Bcl-2/Bax protein ratio was highest in the reducing twirling group, and the Bcl-2/Bax mRNA ratio was highest in the needle retaining group. These results suggest that reinforcing twirling, reducing twirling, and needle retaining methods all improve blood pressure and prevent target organ damage by increasing the hippocampal Bcl-2/Bax ratio and inhibiting cell apoptosis in the hippocampus in SHR.
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Affiliation(s)
- Juan Lu
- First Hospital Affiliated to Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yan Guo
- Collage of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Chang-Qing Guo
- First Hospital Affiliated to Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xue-Min Shi
- Collage of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, China
| | - Ning-Yu Du
- First Hospital Affiliated to Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Rui-Li Zhao
- First Hospital Affiliated to Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Wen-Ping Du
- Shijiazhuang Hospital of Traditional Chinese Medicine, Shijiazhuang, Hebei Province, China
| | - Jing-Rong Liang
- First Hospital Affiliated to Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Shi-Peng Zhu
- Second School of Clinical Medicine of Nanjing University of Traditional Chinese Medicine, Nanjing, Jiangsu Province, China
| | - Huan Chen
- Department of Acupuncture and Moxibustion, Jiangsu Province Hospital, Nanjing, Jiangsu Province, China
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