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Brown AP, Friedrichs GS, Tang HM, Traebert M, Weber V, Yao N, Yan GX. Electrophysiological Changes in the Rabbit Ventricular Wedge and Human-Induced Pluripotent Stem-Cell Derived (IPSC) Cardiomyocytes Translate to Severe Arrhythmia Observed in a Canine Toxicology Study, Not Predicted by Standard In Vitro Ion Channel Assays. Int J Toxicol 2024; 43:231-242. [PMID: 38327194 DOI: 10.1177/10915818241230900] [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] [Indexed: 02/09/2024]
Abstract
During drug discovery, small molecules are typically assayed in vitro for secondary pharmacology effects, which include ion channels relevant to cardiac electrophysiology. Compound A was an irreversible inhibitor of myeloperoxidase investigated for the treatment of peripheral artery disease. Oral doses in dogs at ≥5 mg/kg resulted in cardiac arrhythmias in a dose-dependent manner (at Cmax, free ≥1.53 μM) that progressed in severity with time. Nevertheless, a panel of 13 different cardiac ion channel (K, Na, and Ca) assays, including hERG, failed to identify pharmacologic risks of the molecule. Compound A and a related Compound B were evaluated for electrophysiological effects in the isolated rabbit ventricular wedge assay. Compounds A and B prolonged QT and Tp-e intervals at ≥1 and ≥.3 μM, respectively, and both prolonged QRS at ≥5 μM. Compound A produced early after depolarizations and premature ventricular complexes at ≥5 μM. These data indicate both compounds may be modulating hERG (Ikr) and Nav1.5 ion channels. In human IPSC cardiomyocytes, Compounds A and B prolonged field potential duration at ≥3 μM and induced cellular dysrhythmia at ≥10 and ≥3 μM, respectively. In a rat toxicology study, heart tissue: plasma concentration ratios for Compound A were ≥19X at 24 hours post-dose, indicating significant tissue distribution. In conclusion, in vitro ion channel assays may not always identify cardiovascular electrophysiological risks observed in vivo, which can be affected by tissue drug distribution. Risk for arrhythmia may increase with a "trappable" ion channel inhibitor, particularly if cardiac tissue drug levels achieve a critical threshold for pharmacologic effects.
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Affiliation(s)
- Alan P Brown
- Novartis Biomedical Research, Cambridge, MA, USA
| | | | | | | | | | - Nancy Yao
- Novartis Biomedical Research, East Hanover, NJ, USA
| | - Gan-Xin Yan
- Lankenau Institute for Medical Research, Wynnewood, PA, USA
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2
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Zagrapan B, Klopf J, Celem ND, Brandau A, Rossi P, Gordeeva Y, Szewczyk AR, Liu L, Ahmadi-Fazel D, Najarnia S, Fuchs L, Hayden H, Loewe C, Eilenberg W, Neumayer C, Brostjan C. Diagnostic Utility of a Combined MPO/D-Dimer Score to Distinguish Abdominal Aortic Aneurysm from Peripheral Artery Disease. J Clin Med 2023; 12:7558. [PMID: 38137627 PMCID: PMC10743483 DOI: 10.3390/jcm12247558] [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: 10/25/2023] [Revised: 11/24/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
Abdominal aortic aneurysm (AAA) and peripheral artery disease (PAD) share pathophysiological mechanisms including the activation of the fibrinolytic and innate immune system, which explains the analysis of D-dimer and myeloperoxidase (MPO) in both conditions. This study evaluates the diagnostic marker potential of both variables separately and as a combined MPO/D-dimer score for identifying patients with AAA versus healthy individuals or patients with PAD. Plasma levels of MPO and D-dimer were increased in PAD and AAA compared to healthy controls (median for MPO: 13.63 ng/mL [AAA] vs. 11.74 ng/mL [PAD] vs. 9.16 ng/mL [healthy], D-dimer: 1.27 μg/mL [AAA] vs. 0.58 μg/mL [PAD] vs. 0.38 μg/mL [healthy]). The combined MPO/D-dimer score (median 1.26 [AAA] vs. -0.19 [PAD] vs. -0.93 [healthy]) showed an improved performance in distinguishing AAA from PAD when analysed using the receiver operating characteristic curve (area under the curve) for AAA against the pooled data of healthy controls + PAD: 0.728 [MPO], 0.749 [D-dimer], 0.801 [score]. Diagnostic sensitivity and specificity ranged at 82.9% and 70.2% (for score cut-off = 0). These findings were confirmed for a separate collective of AAA patients with 35% simultaneous PAD. Thus, evaluating MPO together with D-dimer in a simple score may be useful for diagnostic detection and the distinction of AAA from athero-occlusive diseases like PAD.
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Affiliation(s)
- Branislav Zagrapan
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Johannes Klopf
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Nihan Dide Celem
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Annika Brandau
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Patrick Rossi
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Yulia Gordeeva
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Alexandra Regina Szewczyk
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Linda Liu
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Diana Ahmadi-Fazel
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Sina Najarnia
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Lukas Fuchs
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Hubert Hayden
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Christian Loewe
- Department for Bioimaging and Image-Guided Therapy, Division of Cardiovascular and Interventional Radiology, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria;
| | - Wolf Eilenberg
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Christoph Neumayer
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
| | - Christine Brostjan
- Department of General Surgery, Division of Vascular Surgery, University Hospital Vienna, Medical University of Vienna, 1090 Vienna, Austria; (B.Z.); (J.K.); (N.D.C.); (A.B.); (P.R.); (Y.G.); (A.R.S.); (L.L.); (D.A.-F.); (S.N.); (L.F.); (H.H.); (W.E.); (C.N.)
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3
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Regard JB, Harrison TJ, Axford J, Axford L, Lee L, Ren X, Deng L, Reynolds A, Mao J, Liu Q, Patnaik A, Cohick E, Hollis-Symynkywicz M, Loi S, Riek S, McKeever U, Dunstan D, Sung M, Ware NF, Brown AP, Hamann LG, Marcinkeviciene J, Patterson AW, Marro ML. Discovery of a novel, highly potent and orally bioavailable pyrrolidinone indole series of irreversible Myeloperoxidase (MPO) inhibitors. Biochem Pharmacol 2023; 209:115418. [PMID: 36693437 DOI: 10.1016/j.bcp.2023.115418] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Abstract
Myeloperoxidase (MPO) is a heme-containing peroxidase from phagocytic cells, which plays an important role in the innate immune response. The primary anti-microbial function of MPO is achieved by catalyzing the oxidation of halides by hydrogen peroxide (H2O2). Upon activation of phagocytes, MPO activity is detectable in both phagosomes and extracellularly, where it can remain or transcytose into interstitial compartments. Activated MPO leads to oxidative stress and tissue damage in many inflammatory states, including cardiovascular disease. Starting from a low molecular weight (LMW) high throughput screening (HTS) hit, here we report the discovery of a novel pyrrolidinone indole (IN-4) as a highly potent MPO inhibitor. This compound displays similar in vitro potency across peroxidation, plasma and NETosis assays. In a dilution/dialysis study, <5% of the original MPO activity was detected post-incubation of MPO with IN-4, suggesting irreversible enzyme inhibition. A fast MPO inactivation rate (kinact/Ki) and low partition ratio (k3/k4) make IN-4 kinetic properties attractive for an MPO inhibitor. This compound also displays significant selectivity over the closely related thyroid peroxidase (TPO), and is selective for extracellular MPO over intracellular (neutrophil) MPO. Moreover, IN-4 shows good exposure, low clearance and high oral bioavailability in mice, rats and dogs. The high in vitro MPO activity and high oral exposure observed with IN-4 result in a dose-dependent inhibition of MPO activity in three mouse models of inflammation. In conclusion, IN-4 is a novel, potent, mechanism-based and selective MPO inhibitor, which may be used as superior therapeutic agent to treat multiple inflammatory conditions, including cardiovascular disease.
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Affiliation(s)
- Jean B Regard
- Cardiovascular and Metabolic Diseases, Cambridge, MA, USA
| | | | - Jake Axford
- Global Discovery Chemistry, Cambridge, MA, USA
| | - Laura Axford
- Cardiovascular and Metabolic Diseases, Cambridge, MA, USA.
| | - Lac Lee
- Cardiovascular and Metabolic Diseases, Cambridge, MA, USA
| | - Xianglin Ren
- Cardiovascular and Metabolic Diseases, Cambridge, MA, USA
| | | | | | - Justin Mao
- Global Discovery Chemistry, Cambridge, MA, USA
| | - Qian Liu
- Global Discovery Chemistry, Cambridge, MA, USA
| | | | - Evan Cohick
- Cardiovascular and Metabolic Diseases, Cambridge, MA, USA
| | | | - Sally Loi
- Cardiovascular and Metabolic Diseases, Cambridge, MA, USA
| | - Simone Riek
- Novartis Institutes for BioMedical Research, Autoimmunity, Transplantation and Inflammation, Switzlerland
| | - Una McKeever
- Novartis Institutes for BioMedical Research, Autoimmunity, Transplantation and Inflammation, Switzlerland
| | | | - MooJe Sung
- Global Discovery Chemistry, Cambridge, MA, USA
| | | | - Alan P Brown
- Preclinical Safety, Novartis Institutes for BioMedical Research, Fabrikstrasse 2 Novartis Campus, Basel CH-4056, Switzerland
| | | | | | | | - Martin L Marro
- Cardiovascular and Metabolic Diseases, Cambridge, MA, USA
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4
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The Role of Neutrophils in Lower Limb Peripheral Artery Disease: State of the Art and Future Perspectives. Int J Mol Sci 2023; 24:ijms24021169. [PMID: 36674682 PMCID: PMC9866688 DOI: 10.3390/ijms24021169] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 12/19/2022] [Accepted: 12/30/2022] [Indexed: 01/11/2023] Open
Abstract
In recent years, increasing attention has been paid to the role of neutrophils in cardiovascular (CV) disease (CVD) with evidence supporting their role in the initiation, progression, and rupture of atherosclerotic plaque. Although these cells have long been considered as terminally differentiated cells with a relatively limited spectrum of action, recent research has revealed intriguing novel cellular functions, including neutrophil extracellular trap (NET) generation and inflammasome activation, which have been linked to several human diseases, including CVD. While most research to date has focused on the role of neutrophils in coronary artery and cerebrovascular diseases, much less information is available on lower limb peripheral artery disease (PAD). PAD is a widespread condition associated with great morbidity and mortality, though physician and patient awareness of the disease remains low. To date, several studies have produced some evidence on the role of certain biomarkers of neutrophil activation in this clinical setting. However, the etiopathogenetic role of neutrophils, and in particular of some of the newly discovered mechanisms, has yet to be fully elucidated. In the future, complementary assessment of neutrophil activity should improve CV risk stratification and provide personalized treatments to patients with PAD. This review aims to summarize the basic principles and recent advances in the understanding of neutrophil biology, current knowledge about the role of neutrophils in atherosclerosis, as well as available evidence on their role of PAD.
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5
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Myeloperoxidase: A versatile mediator of endothelial dysfunction and therapeutic target during cardiovascular disease. Pharmacol Ther 2020; 221:107711. [PMID: 33137376 DOI: 10.1016/j.pharmthera.2020.107711] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/01/2020] [Indexed: 02/06/2023]
Abstract
Myeloperoxidase (MPO) is a prominent mammalian heme peroxidase and a fundamental component of the innate immune response against microbial pathogens. In recent times, MPO has received considerable attention as a key oxidative enzyme capable of impairing the bioactivity of nitric oxide (NO) and promoting endothelial dysfunction; a clinically relevant event that manifests throughout the development of inflammatory cardiovascular disease. Increasing evidence indicates that during cardiovascular disease, MPO is released intravascularly by activated leukocytes resulting in its transport and sequestration within the vascular endothelium. At this site, MPO catalyzes various oxidative reactions that are capable of promoting vascular inflammation and impairing NO bioactivity and endothelial function. In particular, MPO catalyzes the production of the potent oxidant hypochlorous acid (HOCl) and the catalytic consumption of NO via the enzyme's NO oxidase activity. An emerging paradigm is the ability of MPO to also influence endothelial function via non-catalytic, cytokine-like activities. In this review article we discuss the implications of our increasing knowledge of the versatility of MPO's actions as a mediator of cardiovascular disease and endothelial dysfunction for the development of new pharmacological agents capable of effectively combating MPO's pathogenic activities. More specifically, we will (i) discuss the various transport mechanisms by which MPO accumulates into the endothelium of inflamed or diseased arteries, (ii) detail the clinical and basic scientific evidence identifying MPO as a significant cause of endothelial dysfunction and cardiovascular disease, (iii) provide an up-to-date coverage on the different oxidative mechanisms by which MPO can impair endothelial function during cardiovascular disease including an evaluation of the contributions of MPO-catalyzed HOCl production and NO oxidation, and (iv) outline the novel non-enzymatic mechanisms of MPO and their potential contribution to endothelial dysfunction. Finally, we deliver a detailed appraisal of the different pharmacological strategies available for targeting the catalytic and non-catalytic modes-of-action of MPO in order to protect against endothelial dysfunction in cardiovascular disease.
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6
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Schahab N, Mansuroglu S, Schaefer C, Fimmers R, Nickenig G, Tiyerili V. Prognostic value of myeloperoxidase in patients with peripheral artery disease. Vascular 2020; 29:363-371. [PMID: 32928076 DOI: 10.1177/1708538120957491] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The involvement of myeloperoxidase in the production of dysfunctional high-density lipoproteins and oxidised biomolecules leads to oxidative stress in the blood vessel endothelium. This prospective cohort study aimed to examine the prognostic value of myeloperoxidase in patients with peripheral artery disease in relation to major adverse cardiac events (MACEs), target lesion revascularisation, and major adverse limb events (MALEs) and its association with multi-bed vascular disease, which is defined as any combination of the following: peripheral artery disease and coronary artery disease. METHODS Myeloperoxidase levels were measured in patients with peripheral artery disease and coronary artery disease during angiography. A total of 94 patients were analysed and followed up regarding their MACEs, target lesion revascularisation, and MALEs from August 2016 until February 2019. RESULTS Among patients with peripheral artery disease, the rates of MACE and mortality were higher in patients with high myeloperoxidase levels than in those with low myeloperoxidase levels; the myeloperoxidase levels were 3.68 times higher in these patients (p < 0.0001). Patients with peripheral artery disease and coronary artery disease (multi-bed vascular disease) had higher myeloperoxidase levels than those with only peripheral artery disease and only coronary artery disease (one-bed vascular disease). Peripheral artery disease patients with higher myeloperoxidase levels had significantly higher rates of limb ischaemia, requiring further revascularisation than those with low myeloperoxidase levels. CONCLUSIONS High myeloperoxidase levels suggest poor outcomes and are associated with MACE and limb ischaemia. Our findings indicated that myeloperoxidase levels could become a prognostic marker and may be used in conjunction with other methods for risk stratification in patients with peripheral artery disease and multi-bed vascular disease.
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Affiliation(s)
- Nadjib Schahab
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Seyid Mansuroglu
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Schaefer
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Rolf Fimmers
- Institute of Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
| | - Vedat Tiyerili
- Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Bonn, Germany
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7
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Kremers B, Wübbeke L, Mees B, Ten Cate H, Spronk H, Ten Cate-Hoek A. Plasma Biomarkers to Predict Cardiovascular Outcome in Patients With Peripheral Artery Disease: A Systematic Review and Meta-Analysis. Arterioscler Thromb Vasc Biol 2020; 40:2018-2032. [PMID: 32640905 PMCID: PMC7447177 DOI: 10.1161/atvbaha.120.314774] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Supplemental Digital Content is available in the text. Patients with lower extremity peripheral artery disease (PAD) are at increased risk of major adverse cardiovascular events. Numerous plasma biomarkers have been investigated in lower extremity PAD, but none are used for clinical risk assessment. We aimed to provide a comprehensive overview of biomarker testing in PAD as a first step to improve risk stratification.
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Affiliation(s)
- Bram Kremers
- From the Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry, Maastricht University, the Netherlands (B.K., H.t.C., H.S., A.t.C.-H.)
| | - Lina Wübbeke
- Department of Vascular Surgery (L.W., B.M.), Maastricht University Medical Center, the Netherlands
| | - Barend Mees
- Department of Vascular Surgery (L.W., B.M.), Maastricht University Medical Center, the Netherlands
| | - Hugo Ten Cate
- From the Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry, Maastricht University, the Netherlands (B.K., H.t.C., H.S., A.t.C.-H.).,Department of Internal Medicine (H.t.C.), Maastricht University Medical Center, the Netherlands.,Thrombosis Expertise Center, Maastricht University Medical Center, the Netherlands (H.t.C., A.t.C.-H.)
| | - Henri Spronk
- From the Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry, Maastricht University, the Netherlands (B.K., H.t.C., H.S., A.t.C.-H.)
| | - Arina Ten Cate-Hoek
- From the Laboratory for Clinical Thrombosis and Hemostasis, Department of Biochemistry, Maastricht University, the Netherlands (B.K., H.t.C., H.S., A.t.C.-H.).,Thrombosis Expertise Center, Maastricht University Medical Center, the Netherlands (H.t.C., A.t.C.-H.)
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8
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Misztal T, Golaszewska A, Tomasiak-Lozowska MM, Iwanicka M, Marcinczyk N, Leszczynska A, Chabielska E, Rusak T. The myeloperoxidase product, hypochlorous acid, reduces thrombus formation under flow and attenuates clot retraction and fibrinolysis in human blood. Free Radic Biol Med 2019; 141:426-437. [PMID: 31279970 DOI: 10.1016/j.freeradbiomed.2019.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/24/2019] [Accepted: 07/03/2019] [Indexed: 10/26/2022]
Abstract
Hypochlorite (HOCl), a strong oxidant and antimicrobial agent, has been proposed to be associated with hemostatic abnormalities during inflammatory response. However, its complex impact on hemostasis is not completely understood. In this report we studied the effect of clinically relevant (micromolar) HOCl concentrations on thrombus formation under flow, kinetics of platelet-fibrin clot formation, its architecture, retraction, and lysis. We found that HOCl (up to 500 µM) did not affect kinetics of coagulation measured in whole blood. HOCl (500-1000 µM) markedly diminished thrombus formation under flow. Clot retraction rate was reduced by HOCl dose-dependently (50-500 µM). HOCl (125-500 µM) inhibited fibrinolysis in whole blood and in platelet-depleted plasma, dose-dependently. Activity of plasmin was reduced by HOCl at concentrations started from 500 µM. HOCl (up to 500 µM) did not reduce plasminogen binding to fibrin under flow. HOCl (125-500 µM) modulated architecture of fibrin- and platelet-fibrin clots towards structures made of thin and densely packed fibers. Exposure of pure fibrinogen to HOCl (10-1000 µM) resulted in formation of dityrosine and was associated with altered fibrin structure derived from such modified fibrinogen. HOCl-altered fibrin net structure was not related with modulation of platelet procoagulant response, thrombin generation, and factor XIII activity. We conclude that, in human blood, clinically relevant HOCl concentrations may inhibit thrombus formation under flow, clot retraction and fibrinolysis. Fibrinolysis and clot retraction seem to be the most sensitive to HOCl-evoked inhibition. HOCl-modified fibrinogen and altered clot structure associated with it are likely to be primary sources of attenuated fibrinolysis.
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Affiliation(s)
- Tomasz Misztal
- Department of Physical Chemistry, Medical University of Bialystok, Kilinskiego 1, 15-089, Bialystok, Poland.
| | - Agata Golaszewska
- Department of Physical Chemistry, Medical University of Bialystok, Kilinskiego 1, 15-089, Bialystok, Poland.
| | | | - Marta Iwanicka
- Department of Physical Chemistry, Medical University of Bialystok, Kilinskiego 1, 15-089, Bialystok, Poland.
| | - Natalia Marcinczyk
- Department of Biopharmacy, Medical University of Bialystok, Kilinskiego 1, 15-089, Bialystok, Poland.
| | - Agnieszka Leszczynska
- Department of Biopharmacy, Medical University of Bialystok, Kilinskiego 1, 15-089, Bialystok, Poland.
| | - Ewa Chabielska
- Department of Biopharmacy, Medical University of Bialystok, Kilinskiego 1, 15-089, Bialystok, Poland.
| | - Tomasz Rusak
- Department of Physical Chemistry, Medical University of Bialystok, Kilinskiego 1, 15-089, Bialystok, Poland.
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9
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Searching for the Genetic Determinants of Peripheral Arterial Disease: A Review of the Literature and Future Directions. Cardiol Rev 2019; 27:145-152. [PMID: 30946061 DOI: 10.1097/crd.0000000000000231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Peripheral arterial disease (PAD) is a significant but under-recognized disease that is poorly understood despite population-scale genetic studies. To address this morbid disease, clinicians need additional tools to identify, prevent, and treat patients at risk for PAD. Genetic studies of coronary artery disease have yielded promising results for clinical application, which have thus far been lacking in PAD. In this article, we review recent findings, discuss limitations, and propose future directions of genomic study and clinical application. However, despite many studies, we still lack definitive genetic markers for PAD. This can be attributed to the heterogeneity of PAD's pathogenesis and clinical manifestations, as well as inconsistencies in study methodologies, limitations of current genetic assessment techniques, incompletely comprehended molecular pathophysiology, and confounding generalized atherosclerotic risk factors. The goals of this review are to evaluate the limitations of our current genetic knowledge of PAD and to propose approaches to expedite the identification of valuable markers of PAD.
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10
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Ndrepepa G. Myeloperoxidase - A bridge linking inflammation and oxidative stress with cardiovascular disease. Clin Chim Acta 2019; 493:36-51. [PMID: 30797769 DOI: 10.1016/j.cca.2019.02.022] [Citation(s) in RCA: 231] [Impact Index Per Article: 46.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/20/2019] [Accepted: 02/20/2019] [Indexed: 12/17/2022]
Abstract
Myeloperoxidase (MPO) is a member of the superfamily of heme peroxidases that is mainly expressed in neutrophils and monocytes. MPO-derived reactive species play a key role in neutrophil antimicrobial activity and human defense against various pathogens primarily by participating in phagocytosis. Elevated MPO levels in circulation are associated with inflammation and increased oxidative stress. Multiple lines of evidence suggest an association between MPO and cardiovascular disease (CVD) including coronary artery disease, congestive heart failure, arterial hypertension, pulmonary arterial hypertension, peripheral arterial disease, myocardial ischemia/reperfusion-related injury, stroke, cardiac arrhythmia and venous thrombosis. Elevated MPO levels are associated with a poor prognosis including increased risk for overall and CVD-related mortality. Elevated MPO may signify an increased risk for CVD for at least 2 reasons. First, low-grade inflammation and increased oxidative stress coexist with many metabolic abnormalities and comorbidities and consequently an elevated MPO level may represent an increased cardiometabolic risk in general. Second, MPO produces a large number of highly reactive species which can attack, destroy or modify the function of every known cellular component. The most common MPO actions relevant to CVD are generation of dysfunctional lipoproteins with an increased atherogenicity potential, reduced NO availability, endothelial dysfunction, impaired vasoreactivity and atherosclerotic plaque instability. These actions strongly suggest that MPO is directly involved in the pathophysiology of CVD. In this regard MPO may be seen as a mediator or an instrument through which inflammation promotes CVD at molecular and cellular level. Clinical value of MPO therapeutic inhibition remains to be tested.
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Affiliation(s)
- Gjin Ndrepepa
- Department of Adult Cardiology, Deutsches Herzzentrum München, Technische Universität, Lazarettstrasse 36, 80636 Munich, Germany.
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Marro ML, Patterson AW, Lee L, Deng L, Reynolds A, Ren X, Axford L, Patnaik A, Hollis-Symynkywicz M, Casson N, Custeau D, Ames L, Loi S, Zhang L, Honda T, Blank J, Harrison TJ, Papillon JPN, Hamann LG, Marcinkeviciene J, Regard JB. Discovery of 1-((6-Aminopyridin-3-yl)Methyl)-3-(4-Bromophenyl)Urea as a Potent, Irreversible Myeloperoxidase Inhibitor. J Pharmacol Exp Ther 2018; 367:147-154. [DOI: 10.1124/jpet.118.248435] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 08/01/2018] [Indexed: 11/22/2022] Open
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Meng Q, Wu S, Wang Y, Xu J, Sun H, Lu R, Gao N, Yang H, Li X, Tang B, Aschner M, Chen R. MPO Promoter Polymorphism rs2333227 Enhances Malignant Phenotypes of Colorectal Cancer by Altering the Binding Affinity of AP-2α. Cancer Res 2018. [PMID: 29540402 DOI: 10.1158/0008-5472.can-17-2538] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Myeloperoxidase (MPO) promoter SNPs rs2243828 (-764T>C) and rs2333227 (G-463A) program malignant phenotypes by regulating MPO transcriptional activity. In this study, we enrolled a total of 1,175 controls and 1,078 patients with colorectal cancer with comprehensive clinical and survival information to assess whether these SNPs could affect the susceptibility and development of colorectal cancer. The MPO rs2333227 TT genotype significantly increased the risk of colorectal cancer and decreased the overall survival time of patients. Colorectal cancer cells with the rs2333227 TT genotype exhibited enhanced proliferation, migration, and invasion capacity in vitro and in vivo Mechanistically, we found that MPO SNP rs2333227 C to T mutation altered the binding affinity of the transcription factors AP-2α to the rs2333227 mutation region, sequentially enhancing expression levels of MPO and activating further IL23A-MMP9 axis-mediated oncogenic signaling. Taken together, our findings indicate that MPO SNP rs2333227 serves as a marker of enhanced risk for development of colorectal cancer.Significance: MPO polymorphisms are a guide for high risk and poor prognosis in patients colorectal cancer. Cancer Res; 78(10); 2760-9. ©2018 AACR.
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Affiliation(s)
- Qingtao Meng
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing, China
| | - Shenshen Wu
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing, China
| | - Yajie Wang
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing, China
| | - Jin Xu
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, China
| | - Hao Sun
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing, China
| | - Runze Lu
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing, China
| | - Na Gao
- Institute of Bioinformatics, Heinrich Heine University, Düsseldorf, Germany
| | - Hongbao Yang
- Center for New Drug Safety Evaluation and Research, China Pharmaceutical University, Nanjing, China
| | - Xiaobo Li
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing, China
| | - Boping Tang
- Jiangsu Key Laboratory for Bioresources of Saline Soils, Jiangsu Synthetic Innovation Center for Coastal Bioagriculture, Yancheng Teachers University, Yancheng, China
| | - Michael Aschner
- Department of Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, New York
| | - Rui Chen
- Key Laboratory of Environmental Medicine Engineering, Ministry of Education, School of Public Health, Southeast University, Nanjing, China. .,Institute for Chemical Carcinogenesis, Guangzhou Medical University, Guangzhou, China
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Ganz P, Amarenco P, Goldstein LB, Sillesen H, Bao W, Preston GM, Welch KMA. Association of Osteopontin, Neopterin, and Myeloperoxidase With Stroke Risk in Patients With Prior Stroke or Transient Ischemic Attacks: Results of an Analysis of 13 Biomarkers From the Stroke Prevention by Aggressive Reduction in Cholesterol Levels Trial. Stroke 2017; 48:3223-3231. [PMID: 29114094 DOI: 10.1161/strokeaha.117.017965] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 09/07/2017] [Accepted: 10/02/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Established risk factors do not fully identify patients at risk for recurrent stroke. The SPARCL trial (Stroke Prevention by Aggressive Reduction in Cholesterol Levels) evaluated the effect of atorvastatin on stroke risk in patients with a recent stroke or transient ischemic attack and no known coronary heart disease. This analysis explored the relationships between 13 plasma biomarkers assessed at trial enrollment and the occurrence of outcome strokes. METHODS We conducted a case-cohort study of 2176 participants; 562 had outcome strokes and 1614 were selected randomly from those without outcome strokes. Time to stroke was evaluated by Cox proportional hazards models. RESULTS There was no association between time to stroke and lipoprotein-associated phospholipase A2, monocyte chemoattractant protein-1, resistin, matrix metalloproteinase-9, N-terminal fragment of pro-B-type natriuretic peptide, soluble vascular cell adhesion molecule-1, soluble intercellular adhesion molecule-1, or soluble CD40 ligand. In adjusted analyses, osteopontin (hazard ratio per SD change, 1.362; P<0.0001), neopterin (hazard ratio, 1.137; P=0.0107), myeloperoxidase (hazard ratio, 1.177; P=0.0022), and adiponectin (hazard ratio, 1.207; P=0.0013) were independently associated with outcome strokes. After adjustment for the Stroke Prognostic Instrument-II and treatment, osteopontin, neopterin, and myeloperoxidase remained independently associated with outcome strokes. The addition of these 3 biomarkers to Stroke Prognostic Instrument-II increased the area under the receiver operating characteristic curve by 0.023 (P=0.015) and yielded a continuous net reclassification improvement (29.1%; P<0.0001) and an integrated discrimination improvement (42.3%; P<0.0001). CONCLUSIONS Osteopontin, neopterin, and myeloperoxidase were independently associated with the risk of recurrent stroke and improved risk classification when added to a clinical risk algorithm. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique Identifier: NCT00147602.
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Affiliation(s)
- Peter Ganz
- From Division of Cardiology, San Francisco General Hospital and University of California (P.G.); Paris-Diderot, Sorbonne University, France (P.A.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); Department of Neurology, University of Kentucky, Lexington (L.B.G.); Department of Vascular Surgery, University of Copenhagen, Denmark (H.S.); Pfizer Inc, New York, NY (W.B., G.M.P.); and Rosalind Franklin University of Medicine and Science, North Chicago, IL (K.M.A.W.).
| | - Pierre Amarenco
- From Division of Cardiology, San Francisco General Hospital and University of California (P.G.); Paris-Diderot, Sorbonne University, France (P.A.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); Department of Neurology, University of Kentucky, Lexington (L.B.G.); Department of Vascular Surgery, University of Copenhagen, Denmark (H.S.); Pfizer Inc, New York, NY (W.B., G.M.P.); and Rosalind Franklin University of Medicine and Science, North Chicago, IL (K.M.A.W.)
| | - Larry B Goldstein
- From Division of Cardiology, San Francisco General Hospital and University of California (P.G.); Paris-Diderot, Sorbonne University, France (P.A.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); Department of Neurology, University of Kentucky, Lexington (L.B.G.); Department of Vascular Surgery, University of Copenhagen, Denmark (H.S.); Pfizer Inc, New York, NY (W.B., G.M.P.); and Rosalind Franklin University of Medicine and Science, North Chicago, IL (K.M.A.W.)
| | - Henrik Sillesen
- From Division of Cardiology, San Francisco General Hospital and University of California (P.G.); Paris-Diderot, Sorbonne University, France (P.A.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); Department of Neurology, University of Kentucky, Lexington (L.B.G.); Department of Vascular Surgery, University of Copenhagen, Denmark (H.S.); Pfizer Inc, New York, NY (W.B., G.M.P.); and Rosalind Franklin University of Medicine and Science, North Chicago, IL (K.M.A.W.)
| | - Weihang Bao
- From Division of Cardiology, San Francisco General Hospital and University of California (P.G.); Paris-Diderot, Sorbonne University, France (P.A.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); Department of Neurology, University of Kentucky, Lexington (L.B.G.); Department of Vascular Surgery, University of Copenhagen, Denmark (H.S.); Pfizer Inc, New York, NY (W.B., G.M.P.); and Rosalind Franklin University of Medicine and Science, North Chicago, IL (K.M.A.W.)
| | - Gregory M Preston
- From Division of Cardiology, San Francisco General Hospital and University of California (P.G.); Paris-Diderot, Sorbonne University, France (P.A.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); Department of Neurology, University of Kentucky, Lexington (L.B.G.); Department of Vascular Surgery, University of Copenhagen, Denmark (H.S.); Pfizer Inc, New York, NY (W.B., G.M.P.); and Rosalind Franklin University of Medicine and Science, North Chicago, IL (K.M.A.W.)
| | - K Michael A Welch
- From Division of Cardiology, San Francisco General Hospital and University of California (P.G.); Paris-Diderot, Sorbonne University, France (P.A.); Department of Neurology and Stroke Center, Bichat University Hospital, Paris, France (P.A.); Department of Neurology, University of Kentucky, Lexington (L.B.G.); Department of Vascular Surgery, University of Copenhagen, Denmark (H.S.); Pfizer Inc, New York, NY (W.B., G.M.P.); and Rosalind Franklin University of Medicine and Science, North Chicago, IL (K.M.A.W.)
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A review of the pathophysiology and potential biomarkers for peripheral artery disease. Int J Mol Sci 2015; 16:11294-322. [PMID: 25993296 PMCID: PMC4463701 DOI: 10.3390/ijms160511294] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 03/29/2015] [Accepted: 04/08/2015] [Indexed: 12/12/2022] Open
Abstract
Peripheral artery disease (PAD) is due to the blockage of the arteries supplying blood to the lower limbs usually secondary to atherosclerosis. The most severe clinical manifestation of PAD is critical limb ischemia (CLI), which is associated with a risk of limb loss and mortality due to cardiovascular events. Currently CLI is mainly treated by surgical or endovascular revascularization, with few other treatments in routine clinical practice. There are a number of problems with current PAD management strategies, such as the difficulty in selecting the appropriate treatments for individual patients. Many patients undergo repeated attempts at revascularization surgery, but ultimately require an amputation. There is great interest in developing new methods to identify patients who are unlikely to benefit from revascularization and to improve management of patients unsuitable for surgery. Circulating biomarkers that predict the progression of PAD and the response to therapies could assist in the management of patients. This review provides an overview of the pathophysiology of PAD and examines the association between circulating biomarkers and PAD presence, severity and prognosis. While some currently identified circulating markers show promise, further larger studies focused on the clinical value of the biomarkers over existing risk predictors are needed.
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Dullaart RP, Al-Daghri NM, Ashina M, Bouzas-Mosquera A, Brunetti ND, Buechler C, Chen HS, Corrales JJ, D'Archivio M, Dei Cas A, Pino GG, Gómez-Abril SA, Győri D, Haslacher H, Herder C, Kerstens MN, Koutsilieris M, Lombardi C, Lupattelli G, Mócsai A, Msaouel P, Orfao A, Ormazabal P, Pacher R, Perkmann T, Peteiro J, Plischke M, Reynaert NL, Ricci MA, Robles NR, Rocha M, Rutten EP, Sabico S, Santamaria F, Santoro F, Schmid A, Schmidt M, Schytz HW, Shyu KG, Tada H, Thorand B, Valerio G, Vesely DL, Wu TE, Yamagishi M, Yeh YT. Research update for articles published in EJCI in 2012. Eur J Clin Invest 2014. [DOI: 10.1111/eci.12319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Pilger A, Haslacher H, Ponocny-Seliger E, Perkmann T, Böhm K, Budinsky A, Girard A, Klien K, Jordakieva G, Pezawas L, Wagner O, Godnic-Cvar J, Winker R. Affective and inflammatory responses among orchestra musicians in performance situation. Brain Behav Immun 2014; 37:23-9. [PMID: 24513877 DOI: 10.1016/j.bbi.2013.10.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 10/08/2013] [Accepted: 10/18/2013] [Indexed: 02/07/2023] Open
Abstract
A number of studies have shown that mental challenge under controlled experimental conditions is associated with elevations in inflammatory markers such as interleukin-6 (IL-6) and C-reactive protein (CRP). However, relatively little work has been done on the effects of 'naturalistic' stressors on acute changes in inflammatory markers. The present study examined whether perceived arousal, valence and dominance in musicians are associated with pro-inflammatory and oxidative responses to a concert situation. Blood and salivary samples obtained from 48 members of a symphony orchestra on the day of rehearsal (i.e., control situation) and on the following day of premiere concert (i.e., test situation) were used to determine changes in salivary cortisol, pro-inflammatory markers (plasma myeloperoxidase, serum CRP, plasma IL-6), oxidative stress markers (paraoxonase1 activity and malondialdehyde), and homocysteine, a risk factor for vascular disease. Results of regression analyses showed a significant trend to increased myeloperoxidase (MPO) response in individuals with low valence score. Both affective states, valence and arousal, were identified as significant predictors of cortisol response during concert. In addition, control levels of plasma malondialdehyde were positively correlated with differences in IL-6 levels between premiere and rehearsal (r=.38, p=.012), pointing to higher oxidative stress in individuals with pronounced IL-6 response. Our results indicate that stress of public performance leads to increased concentrations of plasma MPO (20%), IL-6 (27%) and salivary cortisol (44%) in musicians. The decreasing effect of pleasantness on the MPO response was highly pronounced in non-smokers (r=-.60, p<.001), suggesting a significant role of emotional valence in stress-induced secretion of MPO. Additional studies are needed to assess the generalizability of these findings to other 'naturalistic' stress situations.
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Affiliation(s)
- Alexander Pilger
- Institute of Occupational Medicine, Medical University of Vienna, Vienna, Austria.
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Thomas Perkmann
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Karl Böhm
- Austrian Broadcasting Corporation, Occupational Service, Vienna, Austria
| | - Alexandra Budinsky
- Institute of Occupational Medicine, Medical University of Vienna, Vienna, Austria
| | - Angelika Girard
- Institute of Occupational Medicine, Medical University of Vienna, Vienna, Austria
| | - Katharina Klien
- Institute of Occupational Medicine, Medical University of Vienna, Vienna, Austria
| | - Galateja Jordakieva
- Institute of Occupational Medicine, Medical University of Vienna, Vienna, Austria
| | - Lukas Pezawas
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Oswald Wagner
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Jasminka Godnic-Cvar
- Institute of Occupational Medicine, Medical University of Vienna, Vienna, Austria
| | - Robert Winker
- Health and Prevention Center, Sanatorium Hera, Vienna, Austria
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