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Basile C, Fucile I, Lembo M, Manzi MV, Ilardi F, Franzone A, Mancusi C. Arterial Hypertension in Aortic Valve Stenosis: A Critical Update. J Clin Med 2021; 10:5553. [PMID: 34884254 PMCID: PMC8658702 DOI: 10.3390/jcm10235553] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 02/04/2023] Open
Abstract
Aortic stenosis (AS) is a very common valve disease and is associated with high mortality once it becomes symptomatic. Arterial hypertension (HT) has a high prevalence among patients with AS leading to worse left ventricle remodeling and faster degeneration of the valve. HT also interferes with the assessment of the severity of AS, leading to an underestimation of the real degree of stenosis. Treatment of HT in AS has not historically been pursued due to the fear of excess reduction in afterload without a possibility of increasing stroke volume due to the fixed aortic valve, but most recent evidence shows that several drugs are safe and effective in reducing BP in patients with HT and AS. RAAS inhibitors and beta-blockers provide benefit in selected populations based on their profile of pharmacokinetics and pharmacodynamics. Different drugs, on the other hand, have proved to be unsafe, such as calcium channel blockers, or simply not easy enough to handle to be recommended in clinical practice, such as PDE5i, MRA or sodium nitroprusside. The present review highlights all available studies on HT and AS to guide antihypertensive treatment.
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Affiliation(s)
| | | | | | | | | | | | - Costantino Mancusi
- Department of Advanced Biomedical Science, Federico II University of Naples, 80131 Naples, Italy; (C.B.); (I.F.); (M.L.); (M.V.M.); (F.I.); (A.F.)
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Vieceli Dalla Sega F, Fortini F, Cimaglia P, Marracino L, Tonet E, Antonucci A, Moscarelli M, Campo G, Rizzo P, Ferrari R. COX-2 Is Downregulated in Human Stenotic Aortic Valves and Its Inhibition Promotes Dystrophic Calcification. Int J Mol Sci 2020; 21:ijms21238917. [PMID: 33255450 PMCID: PMC7727817 DOI: 10.3390/ijms21238917] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/12/2020] [Accepted: 11/20/2020] [Indexed: 12/17/2022] Open
Abstract
Calcific aortic valve disease (CAVD) is the result of maladaptive fibrocalcific processes leading to a progressive thickening and stiffening of aortic valve (AV) leaflets. CAVD is the most common cause of aortic stenosis (AS). At present, there is no effective pharmacotherapy in reducing CAVD progression; when CAVD becomes symptomatic it can only be treated with valve replacement. Inflammation has a key role in AV pathological remodeling; hence, anti-inflammatory therapy has been proposed as a strategy to prevent CAVD. Cyclooxygenase 2 (COX-2) is a key mediator of the inflammation and it is the target of widely used anti-inflammatory drugs. COX-2-inhibitor celecoxib was initially shown to reduce AV calcification in a murine model. However, in contrast to these findings, a recent retrospective clinical analysis found an association between AS and celecoxib use. In the present study, we investigated whether variations in COX-2 expression levels in human AVs may be linked to CAVD. We extracted total RNA from surgically explanted AVs from patients without CAVD or with CAVD. We found that COX-2 mRNA was higher in non-calcific AVs compared to calcific AVs (0.013 ± 0.002 vs. 0.006 ± 0.0004; p < 0.0001). Moreover, we isolated human aortic valve interstitial cells (AVICs) from AVs and found that COX-2 expression is decreased in AVICs from calcific valves compared to AVICs from non-calcific AVs. Furthermore, we observed that COX-2 inhibition with celecoxib induces AVICs trans-differentiation towards a myofibroblast phenotype, and increases the levels of TGF-β-induced apoptosis, both processes able to promote the formation of calcific nodules. We conclude that reduced COX-2 expression is a characteristic of human AVICs prone to calcification and that COX-2 inhibition may promote aortic valve calcification. Our findings support the notion that celecoxib may facilitate CAVD progression.
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Affiliation(s)
| | - Francesca Fortini
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy; (F.V.D.S.); (F.F.); (P.C.); (M.M.); (R.F.)
| | - Paolo Cimaglia
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy; (F.V.D.S.); (F.F.); (P.C.); (M.M.); (R.F.)
| | - Luisa Marracino
- Laboratory for Technologies of Advanced Therapies (LTTA), Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44121 Ferrara, Italy;
| | - Elisabetta Tonet
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, 44124 Cona, Italy; (E.T.); (A.A.); (G.C.)
| | - Antonio Antonucci
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, 44124 Cona, Italy; (E.T.); (A.A.); (G.C.)
| | - Marco Moscarelli
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy; (F.V.D.S.); (F.F.); (P.C.); (M.M.); (R.F.)
| | - Gianluca Campo
- Cardiovascular Institute, Azienda Ospedaliero-Universitaria di Ferrara, 44124 Cona, Italy; (E.T.); (A.A.); (G.C.)
| | - Paola Rizzo
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy; (F.V.D.S.); (F.F.); (P.C.); (M.M.); (R.F.)
- Laboratory for Technologies of Advanced Therapies (LTTA), Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44121 Ferrara, Italy;
- Correspondence: ; Tel.: +39-0532-455-508
| | - Roberto Ferrari
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, Italy; (F.V.D.S.); (F.F.); (P.C.); (M.M.); (R.F.)
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Chronic Kidney Disease and the Pathophysiology of Valvular Heart Disease. Can J Cardiol 2019; 35:1195-1207. [DOI: 10.1016/j.cjca.2019.05.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 05/03/2019] [Accepted: 05/21/2019] [Indexed: 01/01/2023] Open
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Valerio V, Myasoedova VA, Moschetta D, Porro B, Perrucci GL, Cavalca V, Cavallotti L, Songia P, Poggio P. Impact of Oxidative Stress and Protein S-Glutathionylation in Aortic Valve Sclerosis Patients with Overt Atherosclerosis. J Clin Med 2019; 8:jcm8040552. [PMID: 31022838 PMCID: PMC6517913 DOI: 10.3390/jcm8040552] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 04/16/2019] [Accepted: 04/18/2019] [Indexed: 12/15/2022] Open
Abstract
Aortic valve sclerosis (AVSc) is characterized by non-uniform thickening of the leaflets without hemodynamic changes. Endothelial dysfunction, also caused by dysregulation of glutathione homeostasis expressed as ratio between its reduced (GSH) and its oxidised form (GSSG), could represent one of the pathogenic triggers of AVSc. We prospectively enrolled 58 patients with overt atherosclerosis and requiring coronary artery bypass grafting (CABG). The incidence of AVSc in the studied population was 50%. The two groups (No-AVSc and AVSc) had similar clinical characteristics. Pre-operatively, AVSc group showed significantly lower GSH/GSSG ratio than No-AVSc group (p = 0.02). Asymmetric dimethylarginine (ADMA) concentration was significantly higher in AVSc patients compared to No-AVSc patients (p < 0.0001). Explanted sclerotic aortic valves presented a significantly increased protein glutathionylation (Pr-SSG) than No-AVSc ones (p = 0.01). In vitro, inhibition of glutathione reductase caused β-actin glutathionylation, activation of histone 2AX, upregulation of α2 smooth muscle actin (ACTA2), downregulation of platelet and endothelial cell adhesion molecule 1 (PECAM1) and cadherin 5 (CDH5). In this study, we showed for the first time that the dysregulation of glutathione homeostasis is associated with AVSc. We found that Pr-SSG is increased in AVSc leaflets and it could lead to EndMT via DNA damage. Further studies are warranted to elucidate the causal role of Pr-SSG in aortic valve degeneration.
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Affiliation(s)
- Vincenza Valerio
- Centro Cardiologico Monzino IRCCS, Unit for the Study of Aortic, Valvular and Coronary Pathologies, 20138 Milan, Italy.
- Università degli Studi di Napoli Federico II, Dipartimento di Medicina Clinica e Chirurgia, 80131 Napoli, Italy.
| | - Veronika A Myasoedova
- Centro Cardiologico Monzino IRCCS, Unit for the Study of Aortic, Valvular and Coronary Pathologies, 20138 Milan, Italy.
| | - Donato Moschetta
- Centro Cardiologico Monzino IRCCS, Unit for the Study of Aortic, Valvular and Coronary Pathologies, 20138 Milan, Italy.
| | - Benedetta Porro
- Centro Cardiologico Monzino IRCCS, Unit of Metabolomics and Cellular Biochemistry of Atherothrombosis, 20138 Milan, Italy.
| | - Gianluca L Perrucci
- Centro Cardiologico Monzino IRCCS, Unit of Vascular Biology and Regenerative Medicine, 20138 Milan, Italy.
| | - Viviana Cavalca
- Centro Cardiologico Monzino IRCCS, Unit of Metabolomics and Cellular Biochemistry of Atherothrombosis, 20138 Milan, Italy.
| | - Laura Cavallotti
- Centro Cardiologico Monzino IRCCS, Cardiac Surgery Unit, 20138 Milan, Italy.
| | - Paola Songia
- Centro Cardiologico Monzino IRCCS, Unit for the Study of Aortic, Valvular and Coronary Pathologies, 20138 Milan, Italy.
| | - Paolo Poggio
- Centro Cardiologico Monzino IRCCS, Unit for the Study of Aortic, Valvular and Coronary Pathologies, 20138 Milan, Italy.
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Yalta K, Palabiyik O, Gurdogan M, Gurlertop Y. Serum copeptin might improve risk stratification and management of aortic valve stenosis: a review of pathophysiological insights and practical implications. Ther Adv Cardiovasc Dis 2019; 13:1753944719826420. [PMID: 30803406 PMCID: PMC6376527 DOI: 10.1177/1753944719826420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Over recent decades, the prevalence of aortic valve stenosis (AVS) has been constantly increasing possibly owing to the aging of general population. Severe AVS as determined by an aortic valve area (AVA) of <1 cm2 has been regarded as a serious clinical condition potentially associated with a variety of adverse outcomes, including sudden cardiac death (SCD). However, patients with severe AVS (in the absence of overt high-risk features) are usually evaluated and managed exclusively based on symptomatology or imperfect prognostic tools including exercise testing and biomarkers, with a potential risk of mismanagement, suggesting the need for further objective risk stratifiers in this setting. Within this context, copeptin (C-terminal pro-vasopressin), a novel neurohormone widely considered as the surrogate marker of the arginine–vasopressin (AVP) system, may potentially serve as a reliable prognostic and therapeutic guide (e.g. timing of aortic valvular intervention) in patients with severe AVS largely based on its hemodynamic, fibrogenic as well as autonomic implications in these patients. Accordingly, the present paper aims to discuss clinical and pathophysiological implications of copeptin in the setting of AVS along with a summary of biomarkers and other prognostic tools used in this setting.
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Affiliation(s)
- Kenan Yalta
- Trakya University, School of Medicine, Cardiology Department, 22030 Edirne, Turkey
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Elevated Levels of Asymmetric Dimethylarginine (ADMA) in the Pericardial Fluid of Cardiac Patients Correlate with Cardiac Hypertrophy. PLoS One 2015; 10:e0135498. [PMID: 26313940 PMCID: PMC4551682 DOI: 10.1371/journal.pone.0135498] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 07/22/2015] [Indexed: 12/19/2022] Open
Abstract
Background Pericardial fluid (PF) contains several biologically active substances, which may provide information regarding the cardiac conditions. Nitric oxide (NO) has been implicated in cardiac remodeling. We hypothesized that L-arginine (L-Arg) precursor of NO-synthase (NOS) and asymmetric dimethylarginine (ADMA), an inhibitor of NOS, are present in PF of cardiac patients and their altered levels may contribute to altered cardiac morphology. Methods L-Arg and ADMA concentrations in plasma and PF, and echocardiographic parameters of patients undergoing coronary artery bypass graft (CABG, n = 28) or valve replacement (VR, n = 25) were determined. Results We have found LV hypertrophy in 35.7% of CABG, and 80% of VR patients. In all groups, plasma and PF L-Arg levels were higher than that of ADMA. Plasma L-Arg level was higher in CABG than VR (75.7±4.6 μmol/L vs. 58.1±4.9 μmol/L, p = 0.011), whereas PF ADMA level was higher in VR than CABG (0.9±0.0 μmol/L vs. 0.7±0.0 μmol/L, p = 0.009). L-Arg/ADMA ratio was lower in the VR than CABG (VRplasma: 76.1±6.6 vs. CABGplasma: 125.4±10.7, p = 0.004; VRPF: 81.7±4.8 vs. CABGPF: 110.4±7.2, p = 0.009). There was a positive correlation between plasma L-Arg and ADMA in CABG (r = 0.539, p = 0.015); and plasma and PF L-Arg in CABG (r = 0.357, p = 0.031); and plasma and PF ADMA in VR (r = 0.529, p = 0.003); and PF L-Arg and ADMA in both CABG and VR (CABG: r = 0.468, p = 0.006; VR: r = 0.371, p = 0.034). The following echocardiographic parameters were higher in VR compared to CABG: interventricular septum (14.7±0.5 mm vs. 11.9±0.4 mm, p = 0.000); posterior wall thickness (12.6±0.3 mm vs. 11.5±0.2 mm, p = 0.000); left ventricular (LV) mass (318.6±23.5 g vs. 234.6±12.3 g, p = 0.007); right ventricular (RV) (33.9±0.9 cm2 vs. 29.7±0.7 cm2, p = 0.004); right atrial (18.6±1.0 cm2 vs. 15.4±0.6 cm2, p = 0.020); left atrial (19.8±1.0 cm2 vs. 16.9±0.6 cm2, p = 0.033) areas. There was a positive correlation between plasma ADMA and RV area (r = 0.453, p = 0.011); PF ADMA and end-diastolic (r = 0.434, p = 0.015) and systolic diameter of LV (r = 0.487, p = 0.007); and negative correlation between PF ADMA and LV ejection fraction (r = -0.445, p = 0.013) in VR. Conclusion We suggest that elevated levels of ADMA in the PF of patients indicate upregulated RAS and reduced bioavailability of NO, which can contribute to the development of cardiac hypertrophy and remodeling.
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Lerman DA, Prasad S, Alotti N. Calcific Aortic Valve Disease: Molecular Mechanisms and Therapeutic Approaches. Eur Cardiol 2015; 10:108-112. [PMID: 27274771 PMCID: PMC4888946 DOI: 10.15420/ecr.2015.10.2.108] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 10/28/2015] [Indexed: 01/28/2023] Open
Abstract
Calcification occurs in atherosclerotic vascular lesions and In the aortic valve. Calcific aortic valve disease (CAVD) is a slow, progressive disorder that ranges from mild valve thickening without obstruction of blood flow, termed aortic sclerosis, to severe calcification with impaired leaflet motion, termed aortic stenosis. In the past, this process was thought to be 'degenerative' because of time-dependent wear and tear of the leaflets, with passive calcium deposition. The presence of osteoblasts in atherosclerotic vascular lesions and in CAVD implies that calcification is an active, regulated process akin to atherosclerosis, with lipoprotein deposition and chronic inflammation. If calcification is active, via pro-osteogenic pathways, one might expect that development and progression of calcification could be inhibited. The overlap in the clinical factors associated with calcific valve disease and atherosclerosis provides further support for a shared disease mechanism. In our recent research we used an in vitro porcine valve interstitial cell model to study spontaneous calcification and potential promoters and inhibitors. Using this model, we found that denosumab, a human monoclonal antibody targeting the receptor activator of nuclear factor-κB ligand may, at a working concentration of 50 μg/mL, inhibit induced calcium deposition to basal levels.
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Affiliation(s)
- Daniel Alejandro Lerman
- Royal Infirmary Hospital of Edinburgh (NHS Lothian), The University of Edinburgh, United Kingdom
| | - Sai Prasad
- Royal Infirmary Hospital of Edinburgh (NHS Lothian), The University of Edinburgh, United Kingdom
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Lazaros G, Toutouzas K, Drakopoulou M, Boudoulas H, Stefanadis C, Rajamannan N. Aortic sclerosis and mitral annulus calcification: a window to vascular atherosclerosis? Expert Rev Cardiovasc Ther 2014; 11:863-77. [DOI: 10.1586/14779072.2013.811978] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Rattazzi M, Bertacco E, Del Vecchio A, Puato M, Faggin E, Pauletto P. Aortic valve calcification in chronic kidney disease. Nephrol Dial Transplant 2013; 28:2968-76. [PMID: 24097800 DOI: 10.1093/ndt/gft310] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Several clinical studies reported an increased prevalence and accelerated progression of aortic valve calcification among patients with end-stage renal disease when compared with subjects with normal kidney function. Recently, mechanisms of calcific valve degeneration have been further elucidated and many of the pathways involved could be amplified in patients with decreased renal function. In particular, calcium-phosphate balance, MGP metabolism, OPG/RANK/RANKL triad, fetuin-A mineral complexes and FGF-23/Klotho axis have been shown to be impaired among patients with advanced chronic kidney disease and could play a role during vascular/valve calcification. The scope of the present review is to summarize the clinical data and the pathophysiological mechanisms potentially involved in the link between renal function decline and the progression of aortic valve disease.
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Katsi V, Marketou M, Kallistratos MS, Makris T, Manolis AJ, Tousoulis D, Stefanadis C, Vardas P, Kallikazaros I. Aortic valve stenosis and arterial hypertension: a synopsis in 2013. Curr Hypertens Rep 2013; 15:298-303. [PMID: 23843194 DOI: 10.1007/s11906-013-0357-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Systemic hypertension and aortic valve stenosis (AVS) are both age-related diseases. The pathophysiology of AVS shares some similarities with essential hypertension, which might be the link between the two diseases. Although AS is usually related with low blood pressure levels, approximately one third of patients with severe AS suffer from arterial hypertension, a percentage that can increase up to 50 % according some studies. This review will summarize various aspects regarding the prevalence the pathophysiology and the natural history of those two diseases that seems to be linked, as well as the effect of blood pressure and antihypertensive treatment on various echocardiographic parameters in patients with AVS.
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Affiliation(s)
- Vasiliki Katsi
- Cardiology Department, Hippokration Hospital, Athens, Greece
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Khandelwal AR, Hebert VY, Kleinedler JJ, Rogers LK, Ullevig SL, Asmis R, Shi R, Dugas TR. Resveratrol and quercetin interact to inhibit neointimal hyperplasia in mice with a carotid injury. J Nutr 2012; 142:1487-94. [PMID: 22718033 DOI: 10.3945/jn.112.162628] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Restenosis is a critical complication of angioplasty and stenting. Restenosis is multifactorial, involving endothelial injury, inflammation, platelet activation, and vascular smooth muscle cell (VSMC) proliferation. Thus, dietary strategies to prevent restenosis likely require the use of more than one agent. Resveratrol (R) and quercetin (Q) are polyphenols that are known to exhibit vascular protective effects. We tested whether R and Q administered in the diet interact to inhibit vessel stenosis in mice with a carotid injury. B6.129 mice were administered a high-fat diet containing 21% fat and 0.2% cholesterol along with R (25 mg/kg), Q (10 mg/kg), or R + Q for 2 wk. A carotid injury was induced and the mice were again administered the enriched diet for 2 wk. Compared with the controls, R significantly decreased stenosis, assessed as an intima:media ratio, by 76%. Although Q treatment alone exhibited no effect, it potentiated the effect of R in that treatment with R + Q significantly decreased the intima:media ratio by 94%. Moreover, this effect was greater than that of R treatment alone (P < 0.05). Although treatments with R, Q, and R + Q significantly affected platelet activation and endothelial function, the responses observed for R + Q were less than additive. Specifically, the effects of R + Q were less than the sum of effects for treatments with R and Q alone. In contrast, treatment with R + Q exhibited more-than-additive effects on inflammatory markers and significant interactions between R and Q were observed. The presence of synergy between R and Q was thus tested in cultures of VSMC and macrophages. Isobolographic analysis revealed that 2:1 molar ratios of R:Q exhibited synergistic inhibition of VSMC proliferation and macrophage chemotaxis. In conclusion, in combination, R and Q can interact to reduce the extent of restenosis, perhaps due to their synergistic inhibition of VSMC proliferation and inflammation.
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Affiliation(s)
- Alok R Khandelwal
- Department of Pharmacology, Toxicology and Neuroscience, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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Sverdlov AL, Ngo DT, Chan WP, Chirkov YY, Gersh BJ, McNeil JJ, Horowitz JD. Determinants of aortic sclerosis progression: implications regarding impairment of nitric oxide signalling and potential therapeutics. Eur Heart J 2012; 33:2419-25. [DOI: 10.1093/eurheartj/ehs171] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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Prevention of aortic valve stenosis: A realistic therapeutic target? Pharmacol Ther 2012; 135:78-93. [DOI: 10.1016/j.pharmthera.2012.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 03/16/2012] [Indexed: 11/21/2022]
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Sainger R, Grau JB, Poggio P, Branchetti E, Bavaria JE, Gorman JH, Gorman RC, Ferrari G. Dephosphorylation of circulating human osteopontin correlates with severe valvular calcification in patients with calcific aortic valve disease. Biomarkers 2011; 17:111-8. [PMID: 22191734 DOI: 10.3109/1354750x.2011.642407] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONTEXT Calcific Aortic Valve Disease (CAVD) is an active pathological process leading to biomineralization of the aortic cusps. We characterized circulating and tissue Osteopontin (OPN) as a biomarker for CAVD. OBJECTIVES Here we investigate the post-translational modifications of circulating OPN and correlate the phosphorylation status with the ability to prevent calcification. METHODS Circulating OPN levels were estimated in CAVD patients (n = 51) and controls (n = 56). In a subgroup of 27 subjects, OPN was purified and the phosphorylation status analyzed. RESULTS Plasma OPN levels were significantly elevated in CAVD patients as compared to the controls and correlates with the aortic valve calcium score. Our study demonstrates that phospho-threonine levels of OPN purified from controls were higher when compared to CAVD subjects, whereas phospho-serine and phospho-tyrosine levels were comparable between the two groups. CONCLUSION The dephosphorylation of circulating OPN correlates with severe valvular calcification in patients with CAVD.
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Affiliation(s)
- Rachana Sainger
- Perelman School of Medicine at the University of Pennsylvania, Department of Surgery, Division of Cardiovascular Surgery, Philadelphia, PA, USA
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Abstract
Calcific aortic valve stenosis (CAVS) is a major health problem facing aging societies. The identification of osteoblast-like and osteoclast-like cells in human tissue has led to a major paradigm shift in the field. CAVS was thought to be a passive, degenerative process, whereas now the progression of calcification in CAVS is considered to be actively regulated. Mechanistic studies examining the contributions of true ectopic osteogenesis, nonosseous calcification, and ectopic osteoblast-like cells (that appear to function differently from skeletal osteoblasts) to valvular dysfunction have been facilitated by the development of mouse models of CAVS. Recent studies also suggest that valvular fibrosis, as well as calcification, may play an important role in restricting cusp movement, and CAVS may be more appropriately viewed as a fibrocalcific disease. High-resolution echocardiography and magnetic resonance imaging have emerged as useful tools for testing the efficacy of pharmacological and genetic interventions in vivo. Key studies in humans and animals are reviewed that have shaped current paradigms in the field of CAVS, and suggest promising future areas for research.
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Affiliation(s)
- Jordan D Miller
- Department of Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Ngo DT, Stafford I, Sverdlov AL, Qi W, Wuttke RD, Zhang Y, Kelly DJ, Weedon H, Smith MD, Kennedy JA, Horowitz JD. Ramipril retards development of aortic valve stenosis in a rabbit model: mechanistic considerations. Br J Pharmacol 2011; 162:722-32. [PMID: 20958293 DOI: 10.1111/j.1476-5381.2010.01084.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE Aortic valve stenosis (AVS) is associated with significant cardiovascular morbidity and mortality. To date, no therapeutic modality has been shown to be effective in retarding AVS progression. We evaluated the effect of angiotensin-converting enzyme inhibition with ramipril on disease progression in a recently developed rabbit model of AVS. EXPERIMENTAL APPROACH The effects of 8 weeks of treatment with either vitamin D₂ at 25,000 IU for 4 days a week alone or in combination with ramipril (0.5 mg·kg⁻¹) on aortic valve structure and function were examined in New Zealand white rabbits. Echocardiographic aortic valve backscatter (AV(BS)) and aortic valve:outflow tract flow velocity ratio were utilized to quantify changes in valve structure and function. KEY RESULTS Treatment with ramipril significantly reduced AV(BS) and improved aortic valve :outflow tract flow velocity ratio. The intravalvular content of the pro-oxidant thioredoxin-interacting protein was decreased significantly with ramipril treatment. Endothelial function, as measured by asymmetric dimethylarginine concentrations and vascular responses to ACh, was improved significantly with ramipril treatment. CONCLUSIONS AND IMPLICATIONS Ramipril retards the development of AVS, reduces valvular thioredoxin-interacting protein accumulation and limits endothelial dysfunction in this animal model. These findings provide important insights into the mechanisms of AVS development and an impetus for future human studies of AVS retardation using an angiotensin-converting enzyme inhibitor.
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Affiliation(s)
- Doan Tm Ngo
- Department of Medicine, Vascular Disease and Therapeutics Research Group, Basil Hetzel Institute, The Queen Elizabeth Hospital, The University of Adelaide, South Australia, Australia
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Schumm J, Luetzkendorf S, Rademacher W, Franz M, Schmidt-Winter C, Kiehntopf M, Figulla HR, Brehm BR. In patients with aortic stenosis increased flow-mediated dilation is independently associated with higher peak jet velocity and lower asymmetric dimethylarginine levels. Am Heart J 2011; 161:893-9. [PMID: 21570519 DOI: 10.1016/j.ahj.2011.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 02/12/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recently, it has been shown that endothelial dysfunction and aortic stenosis (AS) share several risk factors. Endothelial function represents a crucial factor for the regulation of vascular tonus and its malfunction influences the formation of thrombosis and inflammation. However, the role of endothelial dysfunction in AS remains unclear. METHODS Echocardiographic, clinical, and laboratory data of 34 patients (age 74.5 ± 7.9 years, 20 men) with at least moderate AS (peak jet velocity 3.8 ± 0.8 m/s) were collected. In all patients, endothelial function was determined by brachial artery flow-mediated dilation (FMD). Patients with rheumatic or endocarditic valve disease, bicuspid valves, a left ventricular ejection fraction of ≤40%, and coronary artery disease were excluded. Sixteen volunteers (age 69.3 ± 9.4 years, 10 men) without valve disease served as controls. RESULTS Patients with AS had a trend toward a lower FMD than controls with a comparable risk profile (5.4% ± 3.6% vs 7.4% ± 4.1%, P = .1). Univariate correlates of FMD in patients with AS were peak jet velocity, medication with angiotensin-converting enzyme inhibitor, diabetes, diastolic blood pressure, and asymmetric dimethylarginine. Backward elimination identified peak jet velocity (β = 0.51, P = .001), and asymmetric dimethylarginine (β = -0.45, P = .003) as independent predictors of FMD in multivariate analysis. CONCLUSIONS In patients with AS, we found a strong positive relation between the peak jet velocity and a higher FMD. This effect might be mediated by nitric oxide release due to turbulent poststenotic blood flow or the rising transvalvular gradient, and the increasing pulse pressure may be counteracted by a parallel increase in FMD.
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Butcher JT, Mahler GJ, Hockaday LA. Aortic valve disease and treatment: the need for naturally engineered solutions. Adv Drug Deliv Rev 2011; 63:242-68. [PMID: 21281685 DOI: 10.1016/j.addr.2011.01.008] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 01/05/2011] [Accepted: 01/14/2011] [Indexed: 01/21/2023]
Abstract
The aortic valve regulates unidirectional flow of oxygenated blood to the myocardium and arterial system. The natural anatomical geometry and microstructural complexity ensures biomechanically and hemodynamically efficient function. The compliant cusps are populated with unique cell phenotypes that continually remodel tissue for long-term durability within an extremely demanding mechanical environment. Alteration from normal valve homeostasis arises from genetic and microenvironmental (mechanical) sources, which lead to congenital and/or premature structural degeneration. Aortic valve stenosis pathobiology shares some features of atherosclerosis, but its final calcification endpoint is distinct. Despite its broad and significant clinical significance, very little is known about the mechanisms of normal valve mechanobiology and mechanisms of disease. This is reflected in the paucity of predictive diagnostic tools, early stage interventional strategies, and stagnation in regenerative medicine innovation. Tissue engineering has unique potential for aortic valve disease therapy, but overcoming current design pitfalls will require even more multidisciplinary effort. This review summarizes the latest advancements in aortic valve research and highlights important future directions.
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Zinellu A, Sotgia S, Porcu P, Casu MA, Bivona G, Chessa R, Deiana L, Carru C. Carotid restenosis is associated with plasma ADMA concentrations in carotid endarterectomy patients. Clin Chem Lab Med 2011; 49:897-901. [PMID: 21288172 DOI: 10.1515/cclm.2011.121] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aim of this work has been to study the association between plasma asymmetric dimethylarginine (ADMA) concentrations and carotid stenosis in a group of 64 patients undergoing carotid endarterectomy (CEA). METHODS Arginine, ADMA and symmetric dimethylarginine (SDMA) were measured using capillary electrophoresis with UV detection. An evaluation of plasma concentrations of total cysteine (tCys) and total homocysteine (tHcy) was also performed. RESULTS Pearson's analysis show a positive correlation between ADMA and carotid stenosis (r=0.37, p=0.003), which is also confirmed after stepwise multiple linear regression analysis. ADMA plasma concentrations were significantly associated with tHcy (r=0.40, p=0.001) and to a lesser extent, even if not significantly, with tCys (r=0.23, p=0.07). CONCLUSIONS Our data suggest that plasma ADMA is involved in carotid narrowing after CEA intervention. This suggests that this molecule may have an important role in the events that lead to stenosis.
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Affiliation(s)
- Angelo Zinellu
- Department of Biomedical Sciences and Centre of Excellence for Biotechnology Development and Biodiversity Research, University of Sassari, Sassari, Italy.
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Cagirci G, Cay S, Canga A, Karakurt O, Yazihan N, Kilic H, Topaloğlu S, Aras D, Demir AD, Akdemir R. Association between plasma asymmetrical dimethylarginine activity and severity of aortic valve stenosis. J Cardiovasc Med (Hagerstown) 2011; 12:96-101. [DOI: 10.2459/jcm.0b013e32833cdcea] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Mookadam F, Jalal U, Wilansky S. Aortic valve disease: preventable or inevitable? Future Cardiol 2010; 6:777-83. [PMID: 21142634 DOI: 10.2217/fca.10.94] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Calcific aortic valve stenosis is the most frequent valve disease and the most common cause of aortic valve replacement in the western world, concomitant with aging of the general population and habitual consumption of a high-calorie diet. For years it was considered to be a passive wear and tear process but now it is recognized as an active process similar to atherosclerosis with involvement of several mediators, such as adhesion molecules, TGFs, cathepsin enzymes and bone regulatory proteins. As conviction grew that aortic stenosis has a genesis similar to atherosclerosis, the hypothesis that statins might be able to alter the progression of the disease also grew. Various retrospective studies confirmed the benefits of statin use at an earlier stage of the disease, but some disappointing results were demonstrated by randomized clinical trials.
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Affiliation(s)
- Farouk Mookadam
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, 13400 E Shea Blvd, Scottsdale, AZ 85259, USA.
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Bertacco E, Millioni R, Arrigoni G, Faggin E, Iop L, Puato M, Pinna LA, Tessari P, Pauletto P, Rattazzi M. Proteomic Analysis of Clonal Interstitial Aortic Valve Cells Acquiring a Pro-calcific Profile. J Proteome Res 2010; 9:5913-21. [DOI: 10.1021/pr100682g] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Elisa Bertacco
- Dipartimento di Medicina Clinica e Sperimentale, Dipartimento di Chimica Biologica and VIMM, Venetian Institute of Molecular Medicine, and Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Università degli Studi di Padova, Italy
| | - Renato Millioni
- Dipartimento di Medicina Clinica e Sperimentale, Dipartimento di Chimica Biologica and VIMM, Venetian Institute of Molecular Medicine, and Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Università degli Studi di Padova, Italy
| | - Giorgio Arrigoni
- Dipartimento di Medicina Clinica e Sperimentale, Dipartimento di Chimica Biologica and VIMM, Venetian Institute of Molecular Medicine, and Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Università degli Studi di Padova, Italy
| | - Elisabetta Faggin
- Dipartimento di Medicina Clinica e Sperimentale, Dipartimento di Chimica Biologica and VIMM, Venetian Institute of Molecular Medicine, and Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Università degli Studi di Padova, Italy
| | - Laura Iop
- Dipartimento di Medicina Clinica e Sperimentale, Dipartimento di Chimica Biologica and VIMM, Venetian Institute of Molecular Medicine, and Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Università degli Studi di Padova, Italy
| | - Massimo Puato
- Dipartimento di Medicina Clinica e Sperimentale, Dipartimento di Chimica Biologica and VIMM, Venetian Institute of Molecular Medicine, and Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Università degli Studi di Padova, Italy
| | - Lorenzo A. Pinna
- Dipartimento di Medicina Clinica e Sperimentale, Dipartimento di Chimica Biologica and VIMM, Venetian Institute of Molecular Medicine, and Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Università degli Studi di Padova, Italy
| | - Paolo Tessari
- Dipartimento di Medicina Clinica e Sperimentale, Dipartimento di Chimica Biologica and VIMM, Venetian Institute of Molecular Medicine, and Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Università degli Studi di Padova, Italy
| | - Paolo Pauletto
- Dipartimento di Medicina Clinica e Sperimentale, Dipartimento di Chimica Biologica and VIMM, Venetian Institute of Molecular Medicine, and Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Università degli Studi di Padova, Italy
| | - Marcello Rattazzi
- Dipartimento di Medicina Clinica e Sperimentale, Dipartimento di Chimica Biologica and VIMM, Venetian Institute of Molecular Medicine, and Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, Università degli Studi di Padova, Italy
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Lack of association between aortic sclerosis and left ventricular hypertrophy in elderly subjects. Int J Cardiol 2010; 150:33-8. [PMID: 20236713 DOI: 10.1016/j.ijcard.2010.02.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Revised: 11/28/2009] [Accepted: 02/14/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND The presence of aortic sclerosis has been associated with increased LV mass, particularly in hypertensive subjects. However, aortic sclerosis has also been associated with endothelial dysfunction, which may provide stimuli for development of left ventricular hypertrophy independent of afterload. Thus, we have sought to determine whether aortic sclerosis is a determinant of increased left ventricular mass in a non-hypertensive cohort of aging subjects. METHODS 79 subjects, mean age 68 ± 6 years, without existing cardiovascular disease or previous antihypertensive therapy were studied. LV volumes were calculated from the short axis stack of cardiac MRI and LV mass was indexed to height(2.7). The presence of aortic sclerosis was assessed with echocardiography using backscatter from the aortic valve (AV(BS)) and visual scoring. Plasma asymmetric dimethylarginine levels and vascular responses to salbutamol were used to assess endothelial function. ANCOVA was used to test the relationship between LV mass index and afterload. Univariate and multivariate analyses were performed to find determinants of increased LV mass. RESULTS 15 (19%) of subjects had aortic sclerosis on the basis of AV(BS); none had aortic valve areas <1.5 cm(2). There was no significant difference in LV mass between subjects with and without aortic sclerosis. While LV mass was directly related to systolic blood pressure, this relationship was independent of the presence/absence of aortic sclerosis. On multivariate analysis, significant correlates of increased LV mass were male gender, systolic blood pressure and increased BMI, but not presence of aortic sclerosis. CONCLUSIONS In this aging normotensive population free of established cardiovascular disease, aortic sclerosis is not associated with left ventricular hypertrophy.
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Ngo DT, Sverdlov AL, Willoughby SR, Nightingale AK, Chirkov YY, McNeil JJ, Horowitz JD. Determinants of Occurrence of Aortic Sclerosis in an Aging Population. JACC Cardiovasc Imaging 2009; 2:919-27. [DOI: 10.1016/j.jcmg.2009.03.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Revised: 03/09/2009] [Accepted: 03/25/2009] [Indexed: 10/20/2022]
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Liu H, Qu X, Liang Z, Chen W, Xia W, Song Y. Variance of DDAH/PRMT/ADMA pathway in atrial fibrillation dogs. Biochem Biophys Res Commun 2008; 377:884-8. [DOI: 10.1016/j.bbrc.2008.10.080] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Accepted: 10/16/2008] [Indexed: 10/21/2022]
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Rajamannan NM. Calcific aortic stenosis: lessons learned from experimental and clinical studies. Arterioscler Thromb Vasc Biol 2008; 29:162-8. [PMID: 19023094 DOI: 10.1161/atvbaha.107.156752] [Citation(s) in RCA: 122] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Calcific aortic stenosis is the most common indication for surgical valve replacement in the United States. For years this disease has been described as a passive degenerative process during which serum calcium attaches to the valve surface and binds to the leaflet to form nodules. Therefore, surgical treatment of this disease has been the approach toward relieving outflow obstruction in these patients. Recent studies demonstrate an association between atherosclerosis and its risk factors for aortic valve disease. In 2008, there are increasing number of epidemiology and experimental studies to provide evidence that this disease process is not a passive phenomena. There is an active cellular process that develops within the valve leaflet and causes a regulated bone formation to develop. If the atherosclerotic hypothesis is important in the initiation of aortic stenosis, then treatments used in slowing the progression of atherosclerosis may be effective in patients with aortic valve disease. This review will discuss the pathogenesis and the potential for medical therapy in the management of patients with calcific aortic stenosis by examining the lessons provided from the experimental research.
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Affiliation(s)
- Nalini M Rajamannan
- Division of Cardiology and Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Bukowska A, Lendeckel U, Krohn A, Keilhoff G, Have ST, Neumann KH, Goette A. Atrial fibrillation down-regulates renal neutral endopeptidase expression and induces profibrotic pathways in the kidney. Europace 2008; 10:1212-7. [DOI: 10.1093/europace/eun206] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Ngo DTM, Stafford I, Kelly DJ, Sverdlov AL, Wuttke RD, Weedon H, Nightingale AK, Rosenkranz AC, Smith MD, Chirkov YY, Kennedy JA, Horowitz JD. Vitamin D(2) supplementation induces the development of aortic stenosis in rabbits: interactions with endothelial function and thioredoxin-interacting protein. Eur J Pharmacol 2008; 590:290-6. [PMID: 18585377 DOI: 10.1016/j.ejphar.2008.05.051] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Revised: 04/10/2008] [Accepted: 05/20/2008] [Indexed: 10/22/2022]
Abstract
Understanding of the pathophysiology of aortic valve stenosis (AVS) and finding potentially effective treatments are impeded by the lack of suitable AVS animal models. A previous study demonstrated the development of AVS in rabbits with vitamin D(2) and cholesterol supplementation without any hemodynamic changes in the cholesterol supplemented group alone. The current study aimed to determine whether AVS develops in an animal model with vitamin D(2) supplementation alone, and to explore pathophysiological mechanisms underlying this process. The effects of 8 weeks' treatment with vitamin D(2) alone (n=8) at 25,000 IU/4 days weekly on aortic valve structure and function were examined in male New Zealand white rabbits. Echocardiographic aortic valve backscatter (AV(BS)), transvalvular velocity, and transvalvular pressure gradient were utilized to quantitate changes in valve structure and function. Valvular histology/immunochemistry and function were examined after 8 weeks. Changes in valves were compared with those in endothelial function and in valvular measurement of thioredoxin-interacting protein (TXNIP), a marker/mediator of reactive oxygen species-induced oxidative stress. Vitamin D(2) treated rabbits developed AVS with increased AV(BS) (17.6+/-1.4 dB vs 6.7+/-0.8 dB, P<0.0001), increased transvalvular velocity and transvalvular pressure gradient (both P<0.01 via 2-way ANOVA) compared to the control group. There was associated valve calcification, lipid deposition and macrophage infiltration. Endothelial function was markedly impaired, and intravalvular TXNIP concentration increased. In this model, vitamin D(2) induces the development of AVS with histological features similar to those of early AVS in humans and associated endothelial dysfunction/redox stress. AVS development may result from the loss of nitric oxide suppression of TXNIP expression.
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Affiliation(s)
- Doan T M Ngo
- Cardiology Unit, The Queen Elizabeth Hospital, Department of Medicine, The University of Adelaide, Australia
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Bozbas H, Pirat B, Yildirir A, Simşek V, Sade E, Eroglu S, Atar I, Altin C, Demirtas S, Ozin B, Muderrisoglu H. Coronary flow reserve is impaired in patients with aortic valve calcification. Atherosclerosis 2008; 197:846-52. [PMID: 17825830 DOI: 10.1016/j.atherosclerosis.2007.07.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 07/26/2007] [Accepted: 07/31/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Calcific aortic valve disease is an active and progressive condition. Data indicate that aortic valve calcification (AVC) is associated with endothelial dysfunction and accepted as a manifestation of atherosclerosis. Coronary flow reserve (CFR) determined by transthoracic echocardiography has been introduced as a reliable indicator for coronary microvascular function. In this study we aimed to evaluate CFR in patients with AVC. METHODS Eighty patients, aged more than 60 years, without coronary heart disease or diabetes mellitus were included: 40 had AVC without significant stenosis (peak gradient across the valve <25 mm Hg) and 40 had normal aortic valves (controls). Using transthoracic Doppler echocardiography, we measured coronary diastolic peak flow velocities (PFV) at baseline and after dipyridamole infusion. CFR was calculated as the ratio of hyperemic to baseline diastolic PFV and was compared between groups. RESULTS Mean ages for patients with AVC and controls were 68.9+/-6.2 and 67.6+/-5.9 years (P=.3). There were no significant differences regarding clinical characteristics, laboratory findings, ejection fraction, or peak aortic valve gradients. Mean diastolic PFV at baseline and during hyperemia were 28.4+/-4.2 and 59.2+/-7.8 cm/s for AVC and 27.7+/-3.9 and 68.5+/-10.5 cm/s for controls. Compared with controls, patients with AVC had significantly lower CFR values (2.12+/-0.41 versus 2.51+/-0.51; P<.0001). CONCLUSION CFR is impaired in patients with AVC before valve stenosis develops, suggesting that microvascular-endothelial dysfunction is present during the early stages of the calcific aortic valve disease.
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Affiliation(s)
- Huseyin Bozbas
- Department of Cardiology, Faculty of Medicine, Baskent University, Ankara, Turkey.
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Abstract
BACKGROUND Endothelial dysfunction and subsequently impaired microvascular circulation are the leading mechanisms in the development of cardiac syndrome X (CSX). The study evaluated the plasma asymmetric dimethylarginine (ADMA) and L-arginine levels of the patients with CSX and the control group and aimed to determine any relationship between these parameters and epicardial coronary blood flow and myocardial tissue perfusion. METHODS The study group consisted of 32 patients (mean age: 52.6+/-9.4 years, 14 men) with typical exertional angina, positive exercise test, and normal coronary arteries diagnosed as CSX. Plasma ADMA, L-arginine levels, and L-arginine/ADMA ratio were compared with the values of the control group, which consisted of 17 age-matched and sex-matched individuals. Concentrations of L-arginine and ADMA were measured by high-performance liquid chromatography. In all the coronary territories, epicardial coronary flow was assessed by thrombolysis in myocardial infarction (TIMI) frame count (TFC) method, and tissue level perfusion, by myocardial blush grade (MBG) method. A MBG score less than 3 was considered an impaired myocardial perfusion, and a MBG score of '3' in all the coronary territories, a normal myocardial perfusion. RESULTS The plasma ADMA levels of the study group were higher than those of the control group (0.83+/-0.38 vs. 0.55+/-0.44 micromol/l, P=0.03), whereas plasma L-arginine levels were similar in both groups (70.25+/-21.89 vs. 76.09+/-18.22 micromol/l, P=0.36), resulting in a diminished L-arginine/ADMA ratio in the patients with CSX [82.3 (60.2-128.8) vs. 242.2 (76.7-386.4), P=0.003]. In CSX group, the patients with abnormal myocardial tissue perfusion had increased plasma ADMA levels compared with those with normal tissue perfusion (0.99+/-0.37 vs. 0.69+/-0.34 micromol/l, P=0.02), whereas plasma L-arginine levels were similar in both groups. No correlations were observed between TFC values and plasma ADMA, L-arginine levels, and L-arginine/ADMA ratio. Plasma ADMA levels, however, were negatively correlated with MBG scores (r=-0.349, P=0.014). CONCLUSION We have shown for the first time that in the patients with CSX, increased plasma ADMA levels might be associated with impaired myocardial tissue perfusion when assessed by MBG.
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