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Lai PMR, Akama-Garren E, Can A, Tirado SR, Castro VM, Dligach D, Finan S, Gainer VS, Shadick NA, Savova G, Murphy SN, Cai T, Weiss ST, Du R. Family history as the strongest predictor of aortic and peripheral aneurysms in patients with intracranial aneurysms. J Clin Neurosci 2024; 126:128-134. [PMID: 38870642 DOI: 10.1016/j.jocn.2024.05.041] [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: 02/07/2024] [Revised: 05/10/2024] [Accepted: 05/30/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVE Intracranial aneurysms (IA) and aortic aneurysms (AA) are both abnormal dilations of arteries with familial predisposition and have been proposed to share co-prevalence and pathophysiology. Associations of IA and non-aortic peripheral aneurysms are less well-studied. The goal of the study was to understand the patterns of aortic and peripheral (extracranial) aneurysms in patients with IA, and risk factors associated with the development of these aneurysms. METHODS 4701 patients were included in our retrospective analysis of all patients with intracranial aneurysms at our institution over the past 26 years. Patient demographics, comorbidities, and aneurysmal locations were analyzed. Univariate and multivariate analyses were performed to study associations with and without extracranial aneurysms. RESULTS A total of 3.4% of patients (161 of 4701) with IA had at least one extracranial aneurysm. 2.8% had thoracic or abdominal aortic aneurysms. Age, male sex, hypertension, coronary artery disease, history of ischemic cerebral infarction, connective tissues disease, and family history of extracranial aneurysms in a 1st degree relative were associated with the presence of extracranial aneurysms and a higher number of extracranial aneurysms. In addition, family history of extracranial aneurysms in a second degree relative is associated with the presence of extracranial aneurysms and atrial fibrillation is associated with a higher number of extracranial aneurysms. CONCLUSION Significant comorbidities are associated with extracranial aneurysms in patients with IA. Family history of extracranial aneurysms has the strongest association and suggests that IA patients with a family history of extracranial aneurysms may benefit from screening.
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Affiliation(s)
- Pui Man Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY, United States
| | - Elliot Akama-Garren
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Anil Can
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Department of Neurosurgery, Erasmus Medical Center, Erasmus MC Stroke Center, Rotterdam, the Netherlands
| | - Selena-Rae Tirado
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Victor M Castro
- Research Information Systems and Computing, Massachusetts General Brigham, Boston, MA, United States
| | - Dmitriy Dligach
- Department of Computer Science, Loyola University, Chicago, IL, United States
| | - Sean Finan
- Boston Children's Hospital Informatics Program, Boston, MA, United States
| | - Vivian S Gainer
- Research Information Systems and Computing, Massachusetts General Brigham, Boston, MA, United States
| | - Nancy A Shadick
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, United States
| | - Guergana Savova
- Boston Children's Hospital Informatics Program, Boston, MA, United States
| | - Shawn N Murphy
- Research Information Systems and Computing, Massachusetts General Brigham, Boston, MA, United States; Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Tianxi Cai
- Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Scott T Weiss
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, United States
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
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Miyata T, Minami M, Kataoka H, Hayashi K, Ikedo T, Yang T, Yamamoto Y, Yokode M, Miyamoto S. Osteoprotegerin Prevents Intracranial Aneurysm Progression by Promoting Collagen Biosynthesis and Vascular Smooth Muscle Cell Proliferation. J Am Heart Assoc 2020; 9:e015731. [PMID: 32856519 PMCID: PMC7660769 DOI: 10.1161/jaha.119.015731] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Decreased extracellular matrix formation and few vascular smooth muscle cells (VSMCs) in cerebral vascular walls are the main characteristics of intracranial aneurysm (IA) pathogenesis. Recently, osteoprotegerin was reported to activate collagen biosynthesis and VSMC proliferation via the TGF-β1 (transforming growth factor-β1) signaling. This study aimed to investigate whether osteoprotegerin can prevent IA progression in rats through enhanced collagen expression and VSMC proliferation. Methods and Results IAs were surgically induced in 7-week-old male Sprague-Dawley rats; at 1-week post-operation, recombinant mouse osteoprotegerin or vehicle control was continuously infused for 4 weeks into the lateral ventricle using an osmotic pump. In the osteoprotegerin-treatment group, the aneurysmal size was significantly smaller (37.5 μm versus 60.0 μm; P<0.01) and the media of IA walls was thicker (57.1% versus 36.0%; P<0.01) than in the vehicle-control group. Type-I and type-III collagen, TGF-β1, phosphorylated Smad2/3, and proliferating cell nuclear antigen were significantly upregulated in the IA walls of the osteoprotegerin group than that in the control group. No significant difference was found in the expression of proinflammatory genes between the groups. In mouse VSMC cultures, osteoprotegerin treatment upregulated the expression of collagen and TGF-β1 genes, and activated VSMC proliferation; the inhibition of TGF-β1 signaling nullified this effect. Conclusions Osteoprotegerin suppressed the IA progression by a unique mechanism whereby collagen biosynthesis and VSMC proliferation were activated via TGF-β1 without altering proinflammatory gene expression. Osteoprotegerin may represent a novel therapeutic target for IAs.
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Affiliation(s)
- Takeshi Miyata
- Department of Neurosurgery Kyoto University Graduate School of Medicine Kyoto Japan.,Department of Clinical Innovative Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Manabu Minami
- Department of Clinical Innovative Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery Kyoto University Graduate School of Medicine Kyoto Japan
| | - Kosuke Hayashi
- Department of Neurosurgery Kyoto University Graduate School of Medicine Kyoto Japan.,Department of Clinical Innovative Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Taichi Ikedo
- Department of Neurosurgery Kyoto University Graduate School of Medicine Kyoto Japan
| | - Tao Yang
- Department of Neurosurgery Kyoto University Graduate School of Medicine Kyoto Japan.,Department of Clinical Innovative Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Yu Yamamoto
- Department of Neurosurgery Kyoto University Graduate School of Medicine Kyoto Japan.,Department of Clinical Innovative Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Masayuki Yokode
- Department of Clinical Innovative Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Susumu Miyamoto
- Department of Neurosurgery Kyoto University Graduate School of Medicine Kyoto Japan
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3
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Fiatal S, Ádány R. Application of Single-Nucleotide Polymorphism-Related Risk Estimates in Identification of Increased Genetic Susceptibility to Cardiovascular Diseases: A Literature Review. Front Public Health 2018; 5:358. [PMID: 29445720 PMCID: PMC5797796 DOI: 10.3389/fpubh.2017.00358] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 12/15/2017] [Indexed: 12/17/2022] Open
Abstract
Background Although largely preventable, cardiovascular diseases (CVDs) are the biggest cause of death worldwide. Common complex cardiovascular disorders (e.g., coronary heart disease, hypertonia, or thrombophilia) result from a combination of genetic alterations and environmental factors. Recent advances in the genomics of CVDs have fostered huge expectations about future use of susceptibility variants for prevention, diagnosis, and treatment. Our aim was to summarize the latest developments in the field from a public health perspective focusing on the applicability of data on single-nucleotide polymorphisms (SNPs), through a systematic review of studies from the last decade on genetic risk estimating for common CVDs. Methods Several keywords were used for searching the PubMed, Embase, CINAHL, and Web of Science databases. Recent advances were summarized and structured according to the main public health domains (prevention, early detection, and treatment) using a framework suggested recently for translational research. This framework includes four recommended phases: “T1. From gene discovery to candidate health applications; T2. From health application to evidence-based practice guidelines; T3. From evidence-based practice guidelines to health practice; and T4. From practice to population health impacts.” Results The majority of translation research belongs to the T1 phase “translation of basic genetic/genomic research into health application”; there are only a few population-based impacts estimated. The studies suggest that an SNP is a poor estimator of individual risk, whereas an individual’s genetic profile combined with non-genetic risk factors may better predict CVD risk among certain patient subgroups. Further research is needed to validate whether these genomic profiles can prospectively identify individuals at risk to develop CVDs. Several research gaps were identified: little information is available on studies suggesting “Health application to evidence-based practice guidelines”; no study is available on “Guidelines to health practice.” It was not possible to identify studies that incorporate environmental or lifestyle factors in the risk estimation. Conclusion Currently, identifying populations having a larger risk of developing common CVDs may result in personalized prevention programs by reducing people’s risk of onset or disease progression. However, limited evidence is available on the application of genomic results in health and public health practice.
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Affiliation(s)
- Szilvia Fiatal
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary.,WHO Collaborating Centre on Vulnerability and Health, Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Róza Ádány
- Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary.,WHO Collaborating Centre on Vulnerability and Health, Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary.,MTA-DE Public Health Research Group of the Hungarian Academy of Sciences, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
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Bo L, Wei B, Wang Z, Li C, Gao Z, Miao Z. Bioinformatic analysis of gene expression profiling of intracranial aneurysm. Mol Med Rep 2017; 17:3473-3480. [PMID: 29328431 PMCID: PMC5802158 DOI: 10.3892/mmr.2017.8367] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 04/04/2017] [Indexed: 01/22/2023] Open
Abstract
Intracranial aneurysm (IA) is a severe clinical condition of primary concern and currently, there is no effective therapeutic reagent. The present study aimed to investigate the molecular mechanism of IA via bioinformatic analysis. Various gene expression profiles (GSE26969) were downloaded from the Gene Expression Omnibus database, including 3 IA and 3 normal superficial temporal artery samples. Firstly, the limma package in R language was used to identify differentially expressed genes (DEGs; P-value <0.01 and |log2 FC|≥1). Secondly, the database for annotation, visualization and integrated discovery software was utilized to perform pathway and functional enrichment analyses (false discovery rate ≤0.05). Finally, protein-protein interaction (PPI) network and sub-network clustering analyses were performed using the biomolecular interaction network database and ClusterONE software, respectively. Following this, a transcription factor regulatory network was identified from the PPI network. A total of 1,124 DEGs were identified, of which 989 were upregulated and 135 downregulated. Pathway and functional enrichment analyses revealed that the DEGs primarily participated in RNA splicing, functioning of the spliceosome, RNA processing and the mRNA metabolic process. Following PPI network analysis, 1 hepatocyte nuclear factor (HNF) 4A (transcription factor)-centered regulatory network and 5 DEG-centered sub-networks were identified. On analysis of the transcription factor regulatory network, 6 transcription factors (HNF6, HNF4A, E2F4, YY1, H4 and H31T) and a regulatory pathway (HNF6-HNF4-E2F4) were identified. The results of the present study suggest that activating transcription factor-5, Jun proto-oncogene, activator protein-1 transcription factor subunit, HNF6, HNF4 and E2F4 may participate in IA progression via vascular smooth muscle cell apoptosis, inflammation, vessel wall remodeling and damage and the tumor necrosis factor-β signaling pathway. However, further experimental studies are required to validate these predictions.
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Affiliation(s)
- Lijuan Bo
- Department of Infection, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Bo Wei
- Department of Neurosurgery, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Zhanfeng Wang
- Department of Neurosurgery, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Chaohui Li
- Department of Neurosurgery, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
| | - Zheng Gao
- Department of Neurosurgery, Dandong First Hospital, Dandong, Liaoning 118000, P.R. China
| | - Zhuang Miao
- Department of Neurosurgery, China‑Japan Union Hospital of Jilin University, Changchun, Jilin 130033, P.R. China
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Hsu W, Gonzalez NR, Chien A, Pablo Villablanca J, Pajukanta P, Viñuela F, Bui AAT. An integrated, ontology-driven approach to constructing observational databases for research. J Biomed Inform 2015; 55:132-42. [PMID: 25817919 DOI: 10.1016/j.jbi.2015.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 02/14/2015] [Accepted: 03/19/2015] [Indexed: 11/28/2022]
Abstract
The electronic health record (EHR) contains a diverse set of clinical observations that are captured as part of routine care, but the incomplete, inconsistent, and sometimes incorrect nature of clinical data poses significant impediments for its secondary use in retrospective studies or comparative effectiveness research. In this work, we describe an ontology-driven approach for extracting and analyzing data from the patient record in a longitudinal and continuous manner. We demonstrate how the ontology helps enforce consistent data representation, integrates phenotypes generated through analyses of available clinical data sources, and facilitates subsequent studies to identify clinical predictors for an outcome of interest. Development and evaluation of our approach are described in the context of studying factors that influence intracranial aneurysm (ICA) growth and rupture. We report our experiences in capturing information on 78 individuals with a total of 120 aneurysms. Two example applications related to assessing the relationship between aneurysm size, growth, gene expression modules, and rupture are described. Our work highlights the challenges with respect to data quality, workflow, and analysis of data and its implications toward a learning health system paradigm.
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Affiliation(s)
- William Hsu
- Department of Radiological Sciences, UCLA David Geffen School of Medicine, Los Angeles, CA, United States.
| | - Nestor R Gonzalez
- Department of Radiological Sciences, UCLA David Geffen School of Medicine, Los Angeles, CA, United States; Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Aichi Chien
- Department of Radiological Sciences, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - J Pablo Villablanca
- Department of Radiological Sciences, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Päivi Pajukanta
- Department of Human Genetics, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Fernando Viñuela
- Department of Radiological Sciences, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Alex A T Bui
- Department of Radiological Sciences, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
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Bakir-Gungor B, Sezerman OU. The identification of pathway markers in intracranial aneurysm using genome-wide association data from two different populations. PLoS One 2013; 8:e57022. [PMID: 23483893 PMCID: PMC3590201 DOI: 10.1371/journal.pone.0057022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 01/20/2013] [Indexed: 02/03/2023] Open
Abstract
The identification of significant individual factors causing complex diseases is challenging in genome-wide association studies (GWAS) since each factor has only a modest effect on the disease development mechanism. In this study, we hypothesize that the biological pathways that are targeted by these individual factors show higher conservation within and across populations. To test this hypothesis, we searched for the disease related pathways on two intracranial aneurysm GWAS in European and Japanese case-control cohorts. Even though there were a few significantly conserved SNPs within and between populations, seven of the top ten affected pathways were found significant in both populations. The probability of random occurrence of such an event is 2.44E-36. We therefore claim that even though each individual has a unique combination of factors involved in the mechanism of disease development, most targeted pathways that need to be altered by these factors are, for the most part, the same. These pathways can serve as disease markers. Individuals, for example, can be scanned for factors affecting the genes in marker pathways. Hence, individual factors of disease development can be determined; and this knowledge can be exploited for drug development and personalized therapeutic applications. Here, we discuss the potential avenues of pathway markers in medicine and their translation to preventive and individualized health care.
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Affiliation(s)
- Burcu Bakir-Gungor
- Department of Genetics and Bioinformatics, Faculty of Arts and Sciences, Bahcesehir University, Istanbul, Turkey.
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7
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Chalouhi N, Ali MS, Starke RM, Jabbour PM, Tjoumakaris SI, Gonzalez LF, Rosenwasser RH, Koch WJ, Dumont AS. Cigarette smoke and inflammation: role in cerebral aneurysm formation and rupture. Mediators Inflamm 2012; 2012:271582. [PMID: 23316103 PMCID: PMC3532877 DOI: 10.1155/2012/271582] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Accepted: 10/27/2012] [Indexed: 12/17/2022] Open
Abstract
Smoking is an established risk factor for subarachnoid hemorrhage yet the underlying mechanisms are largely unknown. Recent data has implicated a role of inflammation in the development of cerebral aneurysms. Inflammation accompanying cigarette smoke exposure may thus be a critical pathway underlying the development, progression, and rupture of cerebral aneurysms. Various constituents of the inflammatory response appear to be involved including adhesion molecules, cytokines, reactive oxygen species, leukocytes, matrix metalloproteinases, and vascular smooth muscle cells. Characterization of the molecular basis of the inflammatory response accompanying cigarette smoke exposure will provide a rational approach for future targeted therapy. In this paper, we review the current body of knowledge implicating cigarette smoke-induced inflammation in cerebral aneurysm formation/rupture and attempt to highlight important avenues for future investigation.
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Affiliation(s)
- Nohra Chalouhi
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Muhammad S. Ali
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Robert M. Starke
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, VA 22903, USA
| | - Pascal M. Jabbour
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Stavropoula I. Tjoumakaris
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - L. Fernando Gonzalez
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Robert H. Rosenwasser
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Walter J. Koch
- Center for Translational Medicine and George Zallie and Family Laboratory for Cardiovascular Gene Therapy, Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Aaron S. Dumont
- Joseph and Marie Field Cerebrovascular Research Laboratory, Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Division of Neurovascular & Endovascular Surgery, Department of Neurological Surgery, Thomas Jefferson University, 901 Walnut Street, 3rd Floor, Philadelphia, PA 19107, USA
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Aoki T, Nishimura M. Targeting chronic inflammation in cerebral aneurysms: focusing on NF-κB as a putative target of medical therapy. Expert Opin Ther Targets 2010; 14:265-73. [DOI: 10.1517/14728221003586836] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Wang SS, Martin LJ, Schadt EE, Meng H, Wang X, Zhao W, Ingram-Drake L, Nebohacova M, Mehrabian M, Drake TA, Lusis AJ. Disruption of the aortic elastic lamina and medial calcification share genetic determinants in mice. CIRCULATION. CARDIOVASCULAR GENETICS 2009; 2:573-82. [PMID: 20031637 PMCID: PMC2836127 DOI: 10.1161/circgenetics.109.860270] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Disruption of the elastic lamina, as an early indicator of aneurysm formation, and vascular calcification frequently occur together in atherosclerotic lesions of humans. METHODS AND RESULTS We now report evidence of shared genetic basis for disruption of the elastic lamina (medial disruption) and medial calcification in an F(2) mouse intercross between C57BL/6J and C3H/HeJ on a hyperlipidemic apolipoprotein E (ApoE(-/-)) null BACKGROUND gene, known to mediate myocardial calcification. Using transgenic complementation, we show that Abcc6 also contributes to aortic medial calcification. CONCLUSIONS Our data indicate that calcification, though possibly contributory, does not always lead to medial disruption and that in addition to aneurysm formation, medial disruption may be the precursor to calcification.
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Affiliation(s)
- Susanna S Wang
- Department of Human Genetics, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
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