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Maga M, Wachsmann-Maga A, Batko K, Włodarczyk A, Kłapacz P, Krężel J, Szopa N, Sliwka A. Impact of Blood-Flow-Restricted Training on Arterial Functions and Angiogenesis-A Systematic Review with Meta-Analysis. Biomedicines 2023; 11:1601. [PMID: 37371696 DOI: 10.3390/biomedicines11061601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 05/29/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
Despite growing evidence of the significant influence of blood-flow-restricted (BFR) training on different body functions, its impact on the vascular system, especially the arteries, is controversial. Therefore, the objective of our study was to analyze how BFR exercise, compared to other types of exercise without the restriction of blood flow, influences arterial functions and angiogenesis in adults. Studies comparing the effect of BFR versus non-BFR training on arterial parameters were divided into three categories: endothelial function, angiogenesis, and other vasculature functions. The search was based on Cochrane Library, PubMed®, and Embase, and 38 studies were included. The meta-analysis revealed a more significant improvement in flow-mediated dilatation (FMD) (p = 0.002) and the production of the primary angiogenesis biomarker vascular endothelial growth factor (VEGF) (p = 0.009) after BFR compared to non-BFR training (p = 0.002). The analysis of the pulse wave velocity, ankle-brachial index, systolic blood pressure, and heart rate did not show significant differences in changes between BFR and non-BFR training. The other parameters examined did not have sufficient data to be included in the meta-analysis. The results obtained present trends that suggest significant impacts of BFR training on endothelial functions and angiogenesis. There is still a lack of multicenter randomized clinical trials including many participants, and such studies are necessary to confirm the advantage of BFR over non-BFR activity.
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Affiliation(s)
- Mikołaj Maga
- Department of Rehabilitation in Internal Diseases, Faculty of Health Sciences, Jagiellonian University Medical College, 31-008 Krakow, Poland
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
| | - Agnieszka Wachsmann-Maga
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Krzysztof Batko
- Department of Research and Design, Medicine Economy Law Society (MELS) Foundation, 30-040 Krakow, Poland
| | - Aleksandra Włodarczyk
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Paulina Kłapacz
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Jakub Krężel
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
| | - Natalia Szopa
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Agnieszka Sliwka
- Department of Rehabilitation in Internal Diseases, Faculty of Health Sciences, Jagiellonian University Medical College, 31-008 Krakow, Poland
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Maga M, Schönborn M, Wachsmann-Maga A, Śliwka A, Krężel J, Włodarczyk A, Olszewska M, Nowobilski R. Stimulation of the Vascular Endothelium and Angiogenesis by Blood-Flow-Restricted Exercise. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192315859. [PMID: 36497934 PMCID: PMC9739167 DOI: 10.3390/ijerph192315859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/26/2022] [Accepted: 11/27/2022] [Indexed: 05/06/2023]
Abstract
Blood-flow-restricted exercise (BFRE) has been gaining constantly increasing interest in rehabilitation, but its influence on endothelial functions has not been well studied yet. Our aim is to examine the influence of low-resistance BFRE on endothelial functions and angiogenesis. This prospective cross-over study involved 35 young healthy adults. They conducted a 21-min low-resistant exercise with blood flow restricted by pressure cuffs placed on arms and tights. They also did the same training but without blood flow restriction. Endothelial parameters and angiogenesis biomarkers were evaluated before and up to 20 min after exercise. Both types of exercise increased Flow-Mediated Dilatation (FMD) but elevation after BFRE was more significant compared to the controls. The stiffness index decreased only after BFRE, while the reflection index decreased significantly after both types of exercise but was higher after BFRE. Platelet endothelial cell adhesion molecule (PECAM-1) and vascular endothelial growth factor receptor 2 (VEGFR-2) concentrations were increased by both exercise types but elevations were higher after BFRE compared to the controls. Only BFRE elevated the mean serum CD34 protein concentration. Based on these results, we can assume that low-resistance BFR exercise stimulates angiogenesis and improves endothelial functions more significantly compared to the same training performed without blood flow restriction.
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Affiliation(s)
- Mikołaj Maga
- Department of Rehabilitation in Internal Diseases, Faculty of Health Sciences, Jagiellonian University Medical College, 31-066 Krakow, Poland
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
- Correspondence: ; Tel.: +48-692814418
| | - Martyna Schönborn
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Agnieszka Wachsmann-Maga
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Agnieszka Śliwka
- Department of Rehabilitation in Internal Diseases, Faculty of Health Sciences, Jagiellonian University Medical College, 31-066 Krakow, Poland
| | - Jakub Krężel
- Clinical Department of Angiology, University Hospital in Krakow, 30-688 Krakow, Poland
| | - Aleksandra Włodarczyk
- Department of Angiology, Faculty of Medicine, Jagiellonian University Medical College, 30-688 Krakow, Poland
| | - Marta Olszewska
- Department of Pediatrics, Institute of Pediatrics, Faculty of Medicine, Jagiellonian University Medical College, 30-663 Krakow, Poland
| | - Roman Nowobilski
- Department of Rehabilitation in Internal Diseases, Faculty of Health Sciences, Jagiellonian University Medical College, 31-066 Krakow, Poland
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Mućka S, Miodońska M, Jakubiak GK, Starzak M, Cieślar G, Stanek A. Endothelial Function Assessment by Flow-Mediated Dilation Method: A Valuable Tool in the Evaluation of the Cardiovascular System. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph191811242. [PMID: 36141513 PMCID: PMC9517126 DOI: 10.3390/ijerph191811242] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/31/2022] [Accepted: 09/05/2022] [Indexed: 05/10/2023]
Abstract
Cardiovascular diseases (CVDs) in the course of atherosclerosis are one of the most critical public health problems in the world. Endothelial cells synthesize numerous biologically active substances involved in regulating the functions of the cardiovascular system. Endothelial dysfunction is an essential element in the pathogenesis of atherosclerosis. Thus, the assessment of endothelial function in people without overt CVD allows for a more accurate estimate of the risk of developing CVD and cardiovascular events. The assessment of endothelial function is primarily used in scientific research, and to a lesser extent in clinical practice. Among the tools for assessing endothelial function, we can distinguish biochemical and physical methods, while physical methods can be divided into invasive and non-invasive methods. Flow-mediated dilation (FMD) is based on the ultrasound assessment of changes in the diameter of the brachial artery as a result of increased blood flow. FMD is a non-invasive, safe, and repeatable test, but it must be performed by qualified and experienced medical staff. The purpose of this paper is to present the literature review results on the assessment of endothelial function using the FMD method, including its methodology, applications in clinical practice and research, limitations, and future perspectives.
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Affiliation(s)
- Szymon Mućka
- Student Research Group, Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland
| | - Martyna Miodońska
- Student Research Group, Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland
| | - Grzegorz K. Jakubiak
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland
- Correspondence: (G.K.J.); (A.S.)
| | - Monika Starzak
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Specialistic Hospital No. 2 in Bytom, Batorego 15 St., 41-902 Bytom, Poland
| | - Grzegorz Cieślar
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland
| | - Agata Stanek
- Department and Clinic of Internal Medicine, Angiology, and Physical Medicine, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Batorego 15 St., 41-902 Bytom, Poland
- Correspondence: (G.K.J.); (A.S.)
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Abstract
Peripheral artery disease (PAD) is a manifestation of systemic atherosclerosis. Modifiable risk factors including cigarette smoking, dyslipidemia, diabetes, poor diet quality, obesity, and physical inactivity, along with underlying genetic factors contribute to lower extremity atherosclerosis. Patients with PAD often have coexistent coronary or cerebrovascular disease, and increased likelihood of major adverse cardiovascular events, including myocardial infarction, stroke and cardiovascular death. Patients with PAD often have reduced walking capacity and are at risk of acute and chronic critical limb ischemia leading to major adverse limb events, such as peripheral revascularization or amputation. The presence of polyvascular disease identifies the highest risk patient group for major adverse cardiovascular events, and patients with prior critical limb ischemia, prior lower extremity revascularization, or amputation have a heightened risk of major adverse limb events. Medical therapies have demonstrated efficacy in reducing the risk of major adverse cardiovascular events and major adverse limb events, and improving function in patients with PAD by modulating key disease determining pathways including inflammation, vascular dysfunction, and metabolic disturbances. Treatment with guideline-recommended therapies, including smoking cessation, lipid lowering drugs, optimal glucose control, and antithrombotic medications lowers the incidence of major adverse cardiovascular events and major adverse limb events. Exercise training and cilostazol improve walking capacity. The heterogeneity of risk profile in patients with PAD supports a personalized approach, with consideration of treatment intensification in those at high risk of adverse events. This review highlights the medical therapies currently available to improve outcomes in patients with PAD.
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Affiliation(s)
- Marc P Bonaca
- Division of Cardiology, CPC Clinical Research, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO (M.P.B.)
| | - Naomi M Hamburg
- Department of Medicine, Whitaker Cardiovascular Institute, Boston University School of Medicine, Section of Vascular Biology, Boston Medical Center, MA (N.M.H.)
| | - Mark A Creager
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH (M.A.C.)
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Andrade-Lima A, Silva Junior N, Chehuen M, Miyasato R, Souza RWA, Leicht AS, Brum PC, de Oliveira EM, Wolosker N, Forjaz CLM. Walking Training Improves Systemic and Local Pathophysiological Processes in Intermittent Claudication. Eur J Vasc Endovasc Surg 2021; 61:954-963. [PMID: 33875324 DOI: 10.1016/j.ejvs.2021.02.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 01/25/2021] [Accepted: 02/16/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study examined the impact of submaximal walking training (WT) on local and systemic nitric oxide (NO) bioavailability, inflammation, and oxidative stress in patients with intermittent claudication (IC). METHODS The study employed a randomised, controlled, parallel group design and was performed in a single centre. Thirty-two men with IC were randomly allocated to two groups: WT (n = 16, two sessions/week, 15 cycles of two minutes walking at an intensity corresponding to the heart rate obtained at the pain threshold interspersed by two minutes of upright rest) and control (CO, n = 16, two sessions/week, 30 minutes of stretching). NO bioavailability (blood NO and muscle nitric oxide synthase [eNOS]), redox homeostasis (catalase [CAT], superoxide dismutase [SOD], lipid peroxidation [LPO] measured in blood and muscle), and inflammation (interleukin-6 [IL-6], C-reactive protein [CRP], tumour necrosis factor α [TNF-α], intercellular adhesion molecules [ICAM], vascular adhesion molecules [VCAM] measured in blood and muscle) were assessed at baseline and after 12 weeks. RESULTS WT statistically significantly increased blood NO, muscle eNOS, blood SOD and CAT, and muscle SOD and abolished the increase in circulating and muscle LPO observed in the CO group. WT decreased blood CRP, ICAM, and VCAM and muscle IL-6 and CRP and eliminated the increase in blood TNF-α and muscle TNF-α, ICAM and VCAM observed in the CO group. CONCLUSION WT at an intensity of pain threshold improved NO bioavailability and decreased systemic and local oxidative stress and inflammation in patients with IC. The proposed WT protocol provides physiological adaptations that may contribute to cardiovascular health in these patients.
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Affiliation(s)
- Aluisio Andrade-Lima
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil.
| | - Natan Silva Junior
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Marcel Chehuen
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Roberto Miyasato
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Rodrigo W A Souza
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | - Anthony S Leicht
- Sport & Exercise Science, James Cook University, Townsville, Australia
| | - Patricia C Brum
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | | | | | - Claudia L M Forjaz
- School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
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Migliacci R, Guglielmini G, Busti C, Falcinelli E, Minuz P, Gresele P. Walking-induced endothelial dysfunction predicts ischemic cardiovascular events in patients with intermittent claudication. Vasc Med 2021; 26:394-400. [PMID: 33845700 DOI: 10.1177/1358863x211001927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Endothelial dysfunction, evaluated by flow-mediated dilatation (FMD), predicts adverse cardiovascular events in patients with intermittent claudication (IC). IC is an example of repeated ischemia/reperfusion injury that may contribute to the progression of vascular disease by worsening endothelial function, a trigger for acute cardiovascular events. The predictive value of effort-induced endothelial dysfunction for cardiovascular events in patients with IC has not been studied previously. The objective of this study was to assess whether exercise-induced endothelial dysfunction is predictive of adverse cardiovascular outcome in IC. In 44 patients with IC, we measured brachial artery FMD by B-mode ultrasonography at rest and 10 minutes after a maximal treadmill exercise. Treadmill exercise halved the FMD (from 3.5 ± 0.6% to 1.45 ± 0.46%, p < 0.05). After a follow-up period of 85 (72-98) months, a total of 20 major cardiovascular events occurred. In a multivariate analysis, a post-exercise reduction of brachial FMD > 1.3% was predictive for cardiovascular events. Maximal exercise-induced endothelial dysfunction is predictive of cardiovascular events in patients with IC.
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Affiliation(s)
- Rino Migliacci
- Division of Internal Medicine, Ospedale della Valdichiana "S Margherita", Cortona, Italy
| | - Giuseppe Guglielmini
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Chiara Busti
- Emergency Medicine Department, San Giovanni Battista Hospital, Foligno, Italy
| | - Emanuela Falcinelli
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Pietro Minuz
- Department of Medicine, Unit of General Medicine for the Study and Treatment of Hypertensive Disease, University of Verona, Policlinico GB Rossi, Verona, Italy
| | - Paolo Gresele
- Department of Medicine and Surgery, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
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Rodrigues E, Silva I. Supervised exercise therapy in intermittent claudication: a systematic review of clinical impact and limitations. INT ANGIOL 2020; 39:60-75. [DOI: 10.23736/s0392-9590.19.04159-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Jansen SCP, Hoorweg BBN, Hoeks SE, van den Houten MML, Scheltinga MRM, Teijink JAW, Rouwet EV. A systematic review and meta-analysis of the effects of supervised exercise therapy on modifiable cardiovascular risk factors in intermittent claudication. J Vasc Surg 2019; 69:1293-1308.e2. [PMID: 30777692 DOI: 10.1016/j.jvs.2018.10.069] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/17/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Cardiovascular events, such as myocardial infarction and stroke, contribute significantly to the prognosis of patients with peripheral artery disease. Therefore cardiovascular risk reduction is a vital element of treatment in patients with intermittent claudication (IC). The cardiovascular risk is largely determined by modifiable risk factors, which can be treated with medical care and lifestyle adjustments, such as increasing physical activity. The objective of this study was to determine the effects of supervised exercise therapy (SET) on modifiable cardiovascular risk factors in IC patients. METHODS This is a systematic review and meta-analysis of prospective studies on the effects of SET on cardiovascular risk factors in symptomatic IC patients. Studies were eligible if they presented baseline and follow-up values for at least one of the following risk factors: blood pressure (systolic or diastolic), heart rate, lipid profile (total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol), glucose, glycated hemoglobin, body weight, body mass index, or cigarette smoking. Pooled mean differences between follow-up and baseline were analyzed using a random-effects model. Data were classified into short-term results (6 weeks-3 months) and midterm results (6-12 months). Statistical heterogeneity was presented as I2 and Q statistic. RESULTS Twenty-seven studies with a total of 808 patients were included in this review. In the short term, SET resulted in significant improvements of systolic blood pressure (decrease of 4 mm Hg; 10 studies; 95% confidence interval [CI], -6.40 to -1.76; I2, 0%) and diastolic blood pressure (decrease of 2 mm Hg; 8 studies; 95% CI, -3.64 to -0.22; I2, 35%). In the midterm, SET contributed to significant lowering of levels of low-density lipoprotein cholesterol (decrease of 0.2 mmol/L; four studies; 95% CI, -0.30 to -0.12; I2, 29%) and total cholesterol (decrease of 0.2 mmol/L, four studies; 95% CI, -0.38 to -0.10; I2, 36%). No significant effects of SET were identified for heart rate, triglycerides, high-density lipoprotein cholesterol, glucose, glycated hemoglobin, body weight, body mass index, or cigarette smoking. CONCLUSIONS This systematic review and meta-analysis shows favorable effects of SET on modifiable cardiovascular risk factors, specifically blood pressure and cholesterol levels. Despite the moderate quality, small trial sample sizes, and study heterogeneity, these findings support the prescription of SET programs not only to increase walking distances but also for risk factor modification. Future studies should address the potential effectiveness of SET to promote a healthier lifestyle and to improve cardiovascular outcomes in patients with claudication.
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Affiliation(s)
- Sandra C P Jansen
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; CAPHRI Research School, Maastricht University, Maastricht, The Netherlands
| | | | - Sanne E Hoeks
- Department of Anaesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Marijn M L van den Houten
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; CAPHRI Research School, Maastricht University, Maastricht, The Netherlands
| | - Marc R M Scheltinga
- Department of Vascular Surgery, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Joep A W Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands; CAPHRI Research School, Maastricht University, Maastricht, The Netherlands.
| | - Ellen V Rouwet
- Department of Vascular Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Januszek R, Mika P, Nowobilski R, Nowak W, Kusienicka A, Klóska D, Maga P, Niżankowski R. Soluble endoglin as a prognostic factor of the claudication distance improvement in patients with peripheral artery disease undergoing supervised treadmill training program. ACTA ACUST UNITED AC 2017; 11:553-564. [DOI: 10.1016/j.jash.2017.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 06/09/2017] [Accepted: 06/20/2017] [Indexed: 10/19/2022]
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Phillips SA, Andaku DK, Mendes RG, Caruso FR, Cabiddu R, Jaenisch RB, Arena R, Borghi-Silva A. Exploring Vascular Function Biomarkers: Implications for Rehabilitation. Braz J Cardiovasc Surg 2017; 32:125-135. [PMID: 28492794 PMCID: PMC5409260 DOI: 10.21470/1678-9741-2016-0085] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 01/07/2017] [Indexed: 01/15/2023] Open
Abstract
The endothelium plays an important role in maintaining vascular homeostasis and
regulating blood vessel function. Endothelial function is considered an
independent predictor for risk of future cardiovascular events in cardiovascular
and non-cardiovascular patients, as well as a predictor for postoperative
complications in cardiovascular surgery patients. Brachial artery flow-mediated
dilation by high-resolution ultrasound is widely used to evaluate
endothelium-dependent vasodilation, which is mainly mediated by nitric oxide
release. Physical exercise exerts beneficial effects on endothelial function and
can be used in both primary and secondary prevention of cardiac and peripheral
artery diseases, even in the postoperative period of cardiovascular surgery.
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Affiliation(s)
- Shane A Phillips
- Department of Physical Therapy, Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Daniela Kuguimoto Andaku
- Cardiopulmonary Physiotherapy Laboratory, Department of Physiotherapy, Universidade Federal de São Carlos (UFSCAR), São Carlos, SP, Brazil
| | - Renata Gonçalves Mendes
- Cardiopulmonary Physiotherapy Laboratory, Department of Physiotherapy, Universidade Federal de São Carlos (UFSCAR), São Carlos, SP, Brazil
| | - Flávia Rossi Caruso
- Cardiopulmonary Physiotherapy Laboratory, Department of Physiotherapy, Universidade Federal de São Carlos (UFSCAR), São Carlos, SP, Brazil
| | - Ramona Cabiddu
- Cardiopulmonary Physiotherapy Laboratory, Department of Physiotherapy, Universidade Federal de São Carlos (UFSCAR), São Carlos, SP, Brazil
| | - Rodrigo Boemo Jaenisch
- Cardiopulmonary Physiotherapy Laboratory, Department of Physiotherapy, Universidade Federal de São Carlos (UFSCAR), São Carlos, SP, Brazil
| | - Ross Arena
- Department of Physical Therapy, Integrative Physiology Laboratory, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, IL, USA
| | - Audrey Borghi-Silva
- Cardiopulmonary Physiotherapy Laboratory, Department of Physiotherapy, Universidade Federal de São Carlos (UFSCAR), São Carlos, SP, Brazil
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