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Li Y, Xu YF, Chi HL, Yu JY, Gao YN, Li HB, Kang YM, Yu XJ. Testis-Specific Protein, Y-Encoded-Like 2 Activates JAK2/STAT3 Pathway in Hypothalamic Paraventricular Nucleus to Sustain Hypertension. Am J Hypertens 2024; 37:682-691. [PMID: 38782571 DOI: 10.1093/ajh/hpae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 03/31/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND In the hypothalamic paraventricular nucleus (PVN) of spontaneously hypertensive rats (SHRs), the expression of the testis-specific protein, Y-encoded-like 2 (TSPYL2) and the phosphorylation level of Janus kinase 2 (JAK2)/signal transducer and activator of transcription 3 (STAT3) are higher comparing with the normotensive Wistar Kyoto rats (WKY). But how they are involved in hypertension remains unclear. TSPYL2 may interact with JAK2/STAT3 in PVN to sustain high blood pressure during hypertension. METHODS Knockdown of TSPYL2 via adeno-associated virus (AAV) carrying shRNA was conducted through bilateral microinjection into the PVN of SHR and WKY rats. JAK2/STAT3 inhibition was achieved by intraperitoneally or PVN injection of AG490 into the SHRs. Blood pressure (BP), plasma norepinephrine (NE), PVN inflammatory response, and PVN oxidative stress were measured. RESULTS TSPYL2 knock-down in the PVN of SHRs but not WKYs led to reduced BP and plasma NE, deactivation of JAK2/STAT3, decreased expression of pro-inflammatory cytokine IL-1β, and increased expression of anti-inflammatory cytokine IL-10 in the PVN. Meanwhile, AG490 administrated in both ways reduced the BP in the SHRs and deactivated JAK2/STAT3 but failed to change the expression of TSPYL2 in PVN. AG490 also downregulated expression of IL-1β and upregulated expression of IL-10. Both knockdown of TSPYL2 and inhibition of JAK2/STAT3 can reduce the oxidative stress in the PVN of SHRs. CONCLUSION JAK2/STAT3 is regulated by TSPYL2 in the PVN of SHRs, and PVN TSPYL2/JAK2/STAT3 is essential for maintaining high BP in hypertensive rats, making it a potential therapeutic target for hypertension.
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Affiliation(s)
- Ying Li
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, P.R. China
- Cardiometabolic Innovation Center, Ministry of Education, Xi'an, Shaanxi, P.R. China
| | - Yang-Fei Xu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, P.R. China
- Cardiometabolic Innovation Center, Ministry of Education, Xi'an, Shaanxi, P.R. China
| | - Hong-Li Chi
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, P.R. China
- Cardiometabolic Innovation Center, Ministry of Education, Xi'an, Shaanxi, P.R. China
- School of Life Sciences, Tianjin University, Tianjin, Hebei, P.R. China
| | - Jia-Yue Yu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, P.R. China
- Cardiometabolic Innovation Center, Ministry of Education, Xi'an, Shaanxi, P.R. China
- College of Basic Medicine, Xi'an Medical University, Xi'an, Shaanxi, P.R. China
| | - Ya-Nan Gao
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
| | - Hong-Bao Li
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, P.R. China
- Cardiometabolic Innovation Center, Ministry of Education, Xi'an, Shaanxi, P.R. China
| | - Yu-Ming Kang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, P.R. China
- Cardiometabolic Innovation Center, Ministry of Education, Xi'an, Shaanxi, P.R. China
| | - Xiao-Jing Yu
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Institute of Cardiovascular Sciences, Translational Medicine Institute, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, P.R. China
- Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, P.R. China
- Cardiometabolic Innovation Center, Ministry of Education, Xi'an, Shaanxi, P.R. China
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Chen J, Luo C, Tan D, Li Y. J-shaped associations of pan-immune-inflammation value and systemic inflammation response index with stroke among American adults with hypertension: evidence from NHANES 1999-2020. Front Neurol 2024; 15:1417863. [PMID: 39144717 PMCID: PMC11322096 DOI: 10.3389/fneur.2024.1417863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 07/23/2024] [Indexed: 08/16/2024] Open
Abstract
Introduction Stroke, a leading cause of death and disability worldwide, is primarily ischemic and linked to hypertension. Hypertension, characterized by systemic chronic inflammation, significantly increases stroke risk. This study explores the association of novel systemic inflammatory markers (SII, PIV, SIRI) with stroke prevalence in hypertensive U.S. adults using NHANES data. Methods We analyzed data from hypertensive participants in the NHANES 1999-2020 survey, excluding those under 20, pregnant, or with missing data, resulting in 18,360 subjects. Systemic inflammatory markers (SII, PIV, SIRI) were calculated from blood counts. Hypertension and stroke status were determined by self-report and clinical measurements. Covariates included sociodemographic, lifestyle, and medical history factors. Weighted statistical analyses and multivariate logistic regression models were used to explore associations, with adjustments for various covariates. Ethical approval was obtained from the NCHS Ethics Review Board. Results In a cohort of 18,360 hypertensive individuals (mean age 56.652 years), 7.25% had a stroke. Stroke patients were older, had lower PIR, and were more likely to be female, single, less educated, smokers, non-drinkers, physically inactive, and have diabetes and CHD. Multivariate logistic regression showed that SII was not significantly associated with stroke. However, PIV and SIRI were positively associated with stroke prevalence. Each unit increase in lnPIV increased stroke odds by 14% (OR = 1.140, p = 0.0022), and lnSIRI by 20.6% (OR = 1.206, p = 0.0144). RCS analyses confirmed J-shaped associations for lnPIV and lnSIRI with stroke. Stratified analyses identified gender and smoking as significant effect modifiers. Smoking was significantly associated with elevated PIV, SIRI, and SII levels, especially in current smokers. Conclusion Elevated PIV and SIRI levels significantly increase stroke prevalence in hypertensive individuals, notably among males and smokers. A predictive model with PIV, SIRI, and sociodemographic factors offers strong clinical utility.
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Affiliation(s)
| | | | - Dianhui Tan
- Department of Neurosurgery, the First Affiliated Hospital of Shantou University Medical College, Shantou, China
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Zhang R, Pan Y, Ren YK, Sun QB, Fu TT, Zhao X, Liu Y, Jiang YN. Mediating Effect of the NLR on the Relationship Between HbA1c and Left Atrial Stiffness in Overweight Patients With Hypertension. Am J Hypertens 2024; 37:597-603. [PMID: 38606768 PMCID: PMC11247131 DOI: 10.1093/ajh/hpae043] [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: 09/09/2023] [Revised: 04/02/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND We aimed to investigate the association between hemoglobin A1c (HbA1c) and left atrial (LA) stiffness in patients with hypertension and to explore the mediating effect of the neutrophil/lymphocyte ratio (NLR) on this association. METHODS Essential hypertensive patients (n = 292) aged 18-83 years were enrolled and divided into two groups based on the LA stiffness index (LASI): Group I (LASI ≤ 0.32, n = 146) and Group II (LASI > 0.32, n = 146). The LASI was defined as the ratio of early diastolic transmitral flow velocity/lateral mitral annulus myocardial velocity (E/e') to LA reservoir strain. Multivariate linear regression analysis was performed to determine the independent predictors of the LASI. RESULTS Age, BMI, SBP, HbA1c, CRP, and NLR were significantly greater in Group II than in Group I (P < 0.05). Additionally, Group II had a greater LA volume index (LAVI), left ventricular mass index (LVMI), and early diastolic transmitral flow velocity/lateral mitral annulus myocardial velocity (E/e') and lower LA reservoir, conduit, and booster pump strains than Group I (P < 0.001). Univariate and multivariate linear regression models revealed that age, SBP, HbA1c, and the NLR were independently associated with the LASI. Further mediation analysis was performed to determine the mediating effect of the NLR on the association between HbA1c and the LASI and revealed that the NLR had a mediating role only in overweight hypertensive patients, and the proportion of the mediating effect was 21.9%. CONCLUSIONS The NLR was independently correlated with the LASI and played a mediating role in the relationship between HbA1c and the LASI in overweight hypertensive patients.
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Affiliation(s)
- Ri Zhang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
| | - Yu Pan
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
| | - Yong K Ren
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
| | - Qiao B Sun
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
| | - Ting T Fu
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
| | - Xu Zhao
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
| | - Yan Liu
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
| | - Yi Nong Jiang
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning 116011, China
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Ding P, Song Y, Yang Y, Zeng C. NLRP3 inflammasome and pyroptosis in cardiovascular diseases and exercise intervention. Front Pharmacol 2024; 15:1368835. [PMID: 38681198 PMCID: PMC11045953 DOI: 10.3389/fphar.2024.1368835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/02/2024] [Indexed: 05/01/2024] Open
Abstract
NOD-like receptor protein 3 (NLRP3) inflammasome is an intracellular sensing protein complex that possesses NACHT, leucine-rich repeat, and pyrin domain, playing a crucial role in innate immunity. Activation of the NLRP3 inflammasome leads to the production of pro-inflammatory cellular contents, such as interleukin (IL)-1β and IL-18, and induction of inflammatory cell death known as pyroptosis, thereby amplifying or sustaining inflammation. While a balanced inflammatory response is beneficial for resolving damage and promoting tissue healing, excessive activation of the NLRP3 inflammasome and pyroptosis can have harmful effects. The involvement of the NLRP3 inflammasome has been observed in various cardiovascular diseases (CVD). Indeed, the NLRP3 inflammasome and its associated pyroptosis are closely linked to key cardiovascular risk factors including hyperlipidemia, diabetes, hypertension, obesity, and hyperhomocysteinemia. Exercise compared with medicine is a highly effective measure for both preventing and treating CVD. Interestingly, emerging evidence suggests that exercise improves CVD and inhibits the activity of NLRP3 inflammasome and pyroptosis. In this review, the activation mechanisms of the NLRP3 inflammasome and its pathogenic role in CVD are critically discussed. Importantly, the purpose is to emphasize the crucial role of exercise in managing CVD by suppressing NLRP3 inflammasome activity and proposes it as the foundation for developing novel treatment strategies.
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Affiliation(s)
- Ping Ding
- Center for Drug Research and Development, Guangdong Pharmaceutical University, Guangzhou, China
| | - Yuanming Song
- Center for Drug Research and Development, Guangdong Pharmaceutical University, Guangzhou, China
| | - Yang Yang
- Zhuhai People’s Hospital, Zhuhai Clinical Medical College of Jinan University, Zhuhai, China
| | - Cheng Zeng
- Center for Drug Research and Development, Guangdong Pharmaceutical University, Guangzhou, China
- Key Specialty of Clinical Pharmacy, The First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
- Guangdong Key Laboratory of Pharmaceutical Bioactive Substances, Guangdong Pharmaceutical University, Guangzhou, China
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Wang J, Wang J, Wang S, Ma J, Yin L, Guo Y, Li X. Association Between Dietary Antioxidant Quality Score (DAQS) and All-Cause Mortality in Hypertensive Adults: A Retrospective Cohort Study from the NHANES Database. Biol Trace Elem Res 2024:10.1007/s12011-024-04087-7. [PMID: 38413467 DOI: 10.1007/s12011-024-04087-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/28/2024] [Indexed: 02/29/2024]
Abstract
This study aimed to explore the association between the dietary antioxidant quality scores (DAQS) and all-cause mortality in hypertensive adults. In this retrospective cohort study, participants aged ≥ 18 years with hypertension were extracted from the National Health and Nutrition Examination Survey (NAHNES) 2007-2018. Outcome was all-cause mortality of hypertensive participants. DAQS was the exposure variable calculated based on the intake of vitamin A, C, E, zinc, selenium, and magnesium. The weighted univariable and multivariable COX proportional hazards regression models were utilized to explore the association between the DAQS and the all-cause mortality in hypertensive patients and were described as hazard ratios (HRs) and 95% confidence intervals (CIs). Subgroup analyses based on different age, gender, diabetes, and cardiovascular disease (CVD) history were further assessed this association. A total of 16,240 participants were finally included in this study. Until 12 December 2019, 2710 (16.69%) all-cause deaths were documented. After adjustment for confounding variables, high DAQS was associated with the lower all-cause mortality (HR = 0.83, 95%CI: 0.72-0.96) in hypertensive patients. Subgroup analyses suggested that the association between DAQS and the all-cause mortality in hypertensive patients remain robust, especially in patients with female (HR = 0.77, 95%CI: 0.63-0.95), aged ≥ 60 years (HR = 0.81, 95%CI: 0.69-0.96). High DAQS was associated with the lower odds of all-cause mortality in adults with hypertension and are a promising intervention to be further explored in hypertensive patients.
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Affiliation(s)
- Jiahong Wang
- The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Institute of Health Management, Beijing, 100853, China
| | - Jinwen Wang
- The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Institute of Health Management, Beijing, 100853, China
| | - Shuhong Wang
- The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Institute of Health Management, Beijing, 100853, China
| | - Jing Ma
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Affiliated of Capital Medical University, Beijing, 100029, China
| | - Liang Yin
- Beijing Municipal Bureau of Retired Cadre Service, Beijing, 100038, China
| | - Yijie Guo
- The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Institute of Health Management, Beijing, 100853, China
| | - Xiangchen Li
- Smart Sports Innovation Center, China Institute of Sport Science, No. 11, Tiyuguan Road, Dongcheng District, Beijing, 100061, China.
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Takeda Y, Kimura F, Takasawa S. Possible Molecular Mechanisms of Hypertension Induced by Sleep Apnea Syndrome/Intermittent Hypoxia. Life (Basel) 2024; 14:157. [PMID: 38276286 PMCID: PMC10821044 DOI: 10.3390/life14010157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/13/2024] [Accepted: 01/15/2024] [Indexed: 01/27/2024] Open
Abstract
Intermittent hypoxia (IH) is a central characteristic of sleep apnea syndrome (SAS), and it subjects cells in the body to repetitive apnea, chronic hypoxia, oxygen desaturation, and hypercapnia. Since SAS is linked to various serious cardiovascular complications, especially hypertension, many studies have been conducted to elucidate the mechanism of hypertension induced by SAS/IH. Hypertension in SAS is associated with numerous cardiovascular disorders. As hypertension is the most common complication of SAS, cell and animal models to study SAS/IH have developed and provided lots of hints for elucidating the molecular mechanisms of hypertension induced by IH. However, the detailed mechanisms are obscure and under investigation. This review outlines the molecular mechanisms of hypertension in IH, which include the regulation systems of reactive oxygen species (ROS) that activate the renin-angiotensin system (RAS) and catecholamine biosynthesis in the sympathetic nervous system, resulting in hypertension. And hypoxia-inducible factors (HIFs), Endotheline 1 (ET-1), and inflammatory factors are also mentioned. In addition, we will discuss the influences of SAS/IH in cardiovascular dysfunction and the relationship of microRNA (miRNA)s to regulate the key molecules in each mechanism, which has become more apparent in recent years. These findings provide insight into the pathogenesis of SAS and help in the development of future treatments.
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Affiliation(s)
- Yoshinori Takeda
- Department of Biochemistry, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan;
- Department of Obstetrics and Gynecology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Japan;
| | - Fuminori Kimura
- Department of Obstetrics and Gynecology, Nara Medical University, 840 Shijo-cho, Kashihara 634-8522, Japan;
| | - Shin Takasawa
- Department of Biochemistry, Nara Medical University, 840 Shijo-cho, Kashihara 634-8521, Japan;
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Abubakar M, Rasool HF, Javed I, Raza S, Abang L, Hashim MMA, Saleem Z, Abdullah RM, Faraz MA, Hassan KM, Bhat RR. Comparative Roles of IL-1, IL-6, IL-10, IL-17, IL-18, 1L-22, IL-33, and IL-37 in Various Cardiovascular Diseases With Potential Insights for Targeted Immunotherapy. Cureus 2023; 15:e42494. [PMID: 37637634 PMCID: PMC10455045 DOI: 10.7759/cureus.42494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2023] [Indexed: 08/29/2023] Open
Abstract
In recent years, the study of interleukins (ILs), crucial cytokines involved in immune response and inflammation, has garnered significant attention within the sphere of cardiovascular diseases (CVDs). The research has provided insights into the involvement of ILs in diverse CVDs, including arrhythmias, myocardial infarction, atherosclerosis, and heart failure (HF). ILs have emerged as promising therapeutic targets for drug interventions through their involvement in disease development and progression. This comprehensive review provides a detailed overview of ILs, elucidating their functions within the immune system and offering insights into their specific contributions to various CVDs. Moreover, the article delves into the examination of current and potential drug therapies that selectively target ILs in the management of CVDs, presenting a comprehensive analysis of the advantages and disadvantages associated with these therapeutic approaches. A comprehensive literature review was conducted to investigate the involvement of ILs in CVDs. The relevant articles were searched on PubMed, PubMed Central, Medline, Cochrane, Google Scholar, and ScienceDirect databases. The search encompassed articles published from these databases' inception until July 12, 2023. We first examine generalized aspects of ILs, particularly CVDs. Then, we shift focus towards examining the direct impact of ILs on cardiac cells and tissue; on the immune system and inflammation; endothelial cells and vascular function; and finally, their interactions with other signaling pathways and molecules. Then, we discuss the molecular mechanisms of various ILs. Sequentially, we delve into a comprehensive analysis of the individualized role of each distinct IL in diverse CVDs, examining their specific contributions. Finally, we explore the potential for targeted drug therapy to modulate IL activity, aiming to enhance outcomes for patients burdened with CVD. The objective is the identification of gaps in current knowledge and highlight areas that require further investigation within the context of cardiovascular medicine. Through deepening our comprehension of the intricate involvement of ILs in CVDs and harnessing their potential for targeted drug therapy, novel treatment strategies can be devised, leading to improved patient outcomes in cardiovascular medicine.
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Affiliation(s)
- Muhammad Abubakar
- Department of Internal Medicine, Ameer-Ud-Din Medical College, Lahore General Hospital, Lahore, PAK
- Department of Internal Medicine, Siddique Sadiq Memorial Trust Hospital, Gujranwala, PAK
| | - Hafiz Fahad Rasool
- Department of Public Health, Nanjing Medical University School of Public Health, Nanjing, CHN
| | - Izzah Javed
- Department of Internal Medicine, Ameer-Ud-Din Medical College, Lahore General Hospital, Lahore, PAK
| | - Saud Raza
- Department of Internal Medicine, Ameer-Ud-Din Medical College, Lahore General Hospital, Lahore, PAK
| | - Lucy Abang
- Department of Biochemistry, All Saints University School of Medicine, Roseau, DMA
| | | | - Zartasha Saleem
- Department of Emergency Medicine, The University of Lahore Teaching Hospital, Lahore, PAK
| | | | - Muhammad Ahmad Faraz
- Department of Forensic Medicine, Post Graduate Medical Institute, Lahore General Hospital, Lahore, PAK
| | - Khawaja Mushammar Hassan
- Department of Internal Medicine, Ameer-Ud-Din Medical College, Lahore General Hospital, Lahore, PAK
| | - Rakshita Ramesh Bhat
- Department of Medical Oncology, Mangalore Institute of Oncology, Mangalore, IND
- Department of Internal Medicine, Bangalore Medical College and Research Institute, Bangalore, IND
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