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Ragnoli B, Radaeli A, Pochetti P, Kette S, Morjaria J, Malerba M. Fractional nitric oxide measurement in exhaled air (FeNO): perspectives in the management of respiratory diseases. Ther Adv Chronic Dis 2023; 14:20406223231190480. [PMID: 37538344 PMCID: PMC10395178 DOI: 10.1177/20406223231190480] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/03/2023] [Indexed: 08/05/2023] Open
Abstract
Exhaled nitric oxide (NO) production, upregulated by inflammatory cytokines and mediators in central and peripheral airways, can be easily and non-invasively detected in exhaled air in asthma and other respiratory conditions as a promising tool for disease monitoring. The American Thoracic Society and European Respiratory Society released recommendations that standardize the measurement of the fractional exhaled NO (FeNO). In asthma, increased FeNO reflects eosinophilic-mediated inflammatory pathways and, as a biomarker of T2 inflammation can be used to identify asthma T2 phenotype. In this setting its measurement has shown to be an important tool especially in the diagnostic process, in the assessment and evaluation of poor adherence or predicting positive response to inhaled corticosteroids treatment, in phenotyping severe asthma patients and as a biomarker to predict the response to biologic treatments. The discovery of the role of NO in the pathogenesis of different diseases affecting the airways and the possibility to estimate the predominant site of increased NO production has provided new insight on its regulatory role in the airways, making it suitable for a potential extended use in clinical practice for different pulmonary diseases, even though its role remains less clear than in asthma. Monitoring FeNO in pulmonary obstructive lung diseases including chronic bronchitis and emphysema, interstitial lung diseases, obstructive sleep apnea and other pulmonary diseases is still under debate but has opened up a window to the role NO may play in the management of these diseases. The use of FeNO is reliable, cost effective and recommendable in both adults and children, and should be implemented in the management of patients with asthma and other respiratory conditions.
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Affiliation(s)
| | | | | | - Stefano Kette
- Respiratory Unit, S. Andrea Hospital, Vercelli, Italy
| | - Jaymin Morjaria
- Department of Respiratory Medicine, Harefield Hospital, Guy’s & St Thomas’ NHS Foundation Trust, Harefield, UK
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2
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Maiuolo J, Oppedisano F, Carresi C, Gliozzi M, Musolino V, Macrì R, Scarano F, Coppoletta A, Cardamone A, Bosco F, Mollace R, Muscoli C, Palma E, Mollace V. The Generation of Nitric Oxide from Aldehyde Dehydrogenase-2: The Role of Dietary Nitrates and Their Implication in Cardiovascular Disease Management. Int J Mol Sci 2022; 23:ijms232415454. [PMID: 36555095 PMCID: PMC9779284 DOI: 10.3390/ijms232415454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/29/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022] Open
Abstract
Reduced bioavailability of the nitric oxide (NO) signaling molecule has been associated with the onset of cardiovascular disease. One of the better-known and effective therapies for cardiovascular disorders is the use of organic nitrates, such as glyceryl trinitrate (GTN), which increases the concentration of NO. Unfortunately, chronic use of this therapy can induce a phenomenon known as "nitrate tolerance", which is defined as the loss of hemodynamic effects and a reduction in therapeutic effects. As such, a higher dosage of GTN is required in order to achieve the same vasodilatory and antiplatelet effects. Mitochondrial aldehyde dehydrogenase 2 (ALDH2) is a cardioprotective enzyme that catalyzes the bio-activation of GTN to NO. Nitrate tolerance is accompanied by an increase in oxidative stress, endothelial dysfunction, and sympathetic activation, as well as a loss of the catalytic activity of ALDH2 itself. On the basis of current knowledge, nitrate intake in the diet would guarantee a concentration of NO such as to avoid (or at least reduce) treatment with GTN and the consequent onset of nitrate tolerance in the course of cardiovascular diseases, so as not to make necessary the increase in GTN concentrations and the possible inhibition/alteration of ALDH2, which aggravates the problem of a positive feedback mechanism. Therefore, the purpose of this review is to summarize data relating to the introduction into the diet of some natural products that could assist pharmacological therapy in order to provide the NO necessary to reduce the intake of GTN and the phenomenon of nitrate tolerance and to ensure the correct catalytic activity of ALDH2.
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Affiliation(s)
- Jessica Maiuolo
- Pharmaceutical Biology Laboratory, in Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
- Correspondence: (J.M.); (F.O.)
| | - Francesca Oppedisano
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
- Correspondence: (J.M.); (F.O.)
| | - Cristina Carresi
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
| | - Micaela Gliozzi
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
| | - Vincenzo Musolino
- Pharmaceutical Biology Laboratory, in Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
| | - Roberta Macrì
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
| | - Federica Scarano
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
| | - Annarita Coppoletta
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
| | - Antonio Cardamone
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
| | - Francesca Bosco
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
| | - Rocco Mollace
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
| | - Carolina Muscoli
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
| | - Ernesto Palma
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
| | - Vincenzo Mollace
- Institute of Research for Food Safety & Health (IRC-FSH), Department of Health Sciences, University “Magna Graecia” of Catanzaro, 88100 Catanzaro, Italy
- Renato Dulbecco Institute, Lamezia Terme, 88046 Catanzaro, Italy
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3
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Enhancement of Nitric Oxide Bioavailability by Modulation of Cutaneous Nitric Oxide Stores. Biomedicines 2022; 10:biomedicines10092124. [PMID: 36140225 PMCID: PMC9496039 DOI: 10.3390/biomedicines10092124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 11/17/2022] Open
Abstract
The generation of nitric oxide (NO) in the skin plays a critical role in wound healing and the response to several stimuli, such as UV exposure, heat, infection, and inflammation. Furthermore, in the human body, NO is involved in vascular homeostasis and the regulation of blood pressure. Physiologically, a family of enzymes termed nitric oxide synthases (NOS) generates NO. In addition, there are many methods of non-enzymatic/NOS-independent NO generation, e.g., the reduction of NO derivates (NODs) such as nitrite, nitrate, and nitrosylated proteins under certain conditions. The skin is the largest and heaviest human organ and contains a comparatively high concentration of these NODs; therefore, it represents a promising target for many therapeutic strategies for NO-dependent pathological conditions. In this review, we give an overview of how the cutaneous NOD stores can be targeted and modulated, leading to a further accumulation of NO-related compounds and/or the local and systemic release of bioactive NO, and eventually, NO-related physiological effects with a potential therapeutical use for diseases such as hypertension, disturbed microcirculation, impaired wound healing, and skin infections.
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Stamm P, Kalinovic S, Oelze M, Steven S, Czarnowski A, Kvandova M, Bayer F, Reinhardt C, Münzel T, Daiber A. Mechanistic Insights into Inorganic Nitrite-Mediated Vasodilation of Isolated Aortic Rings under Oxidative/Hypertensive Conditions and S-Nitros(yl)ation of Proteins in Germ-Free Mice. Biomedicines 2022; 10:biomedicines10030730. [PMID: 35327532 PMCID: PMC8945819 DOI: 10.3390/biomedicines10030730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/11/2022] [Accepted: 03/16/2022] [Indexed: 02/07/2023] Open
Abstract
The prevalence and clinical importance of arterial hypertension are still growing. Inorganic nitrite (NO2-) represents an attractive dietary antihypertensive agent, but its metabolism and mode of action, which we aimed to investigate with the present study, are not completely understood. Isolated aortic rings from rats were treated ex vivo with oxidants, and rats were infused in vivo with angiotensin-II. Vascular responses to acetylcholine (ACh) and nitrite were assessed by isometric tension recording. The loss of vasodilatory potency in response to oxidants was much more pronounced for ACh as compared to nitrite ex vivo (but not in vivo with angiotensin-II). This effect may be caused by the redox regulation of conversion to xanthine oxidase (XO). Conventionally raised and germ-free mice were treated with nitrite by gavage, which did not improve ACh-mediated vasodilation, but did increase the plasma levels of S-nitros(yl)ated proteins in the conventionally-raised, but not in the germ-free mice. In conclusion, inorganic nitrite represents a dietary drug option to treat arterial hypertension in addition to already established pharmacological treatment. Short-term oxidative stress did not impair the vasodilatory properties of nitrite, which may be beneficial in cardiovascular disease patients. The gastrointestinal microbiome appears to play a key role in nitrite metabolism and bioactivation.
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Affiliation(s)
- Paul Stamm
- Department of Cardiology, Cardiology I, University Medical Center Mainz, 55131 Mainz, Germany; (P.S.); (S.K.); (M.O.); (S.S.); (A.C.); (M.K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, 55131 Mainz, Germany;
| | - Sanela Kalinovic
- Department of Cardiology, Cardiology I, University Medical Center Mainz, 55131 Mainz, Germany; (P.S.); (S.K.); (M.O.); (S.S.); (A.C.); (M.K.)
| | - Matthias Oelze
- Department of Cardiology, Cardiology I, University Medical Center Mainz, 55131 Mainz, Germany; (P.S.); (S.K.); (M.O.); (S.S.); (A.C.); (M.K.)
| | - Sebastian Steven
- Department of Cardiology, Cardiology I, University Medical Center Mainz, 55131 Mainz, Germany; (P.S.); (S.K.); (M.O.); (S.S.); (A.C.); (M.K.)
- Center for Thrombosis and Hemostasis Mainz, University Medical Center Mainz, 55131 Mainz, Germany;
| | - Alexander Czarnowski
- Department of Cardiology, Cardiology I, University Medical Center Mainz, 55131 Mainz, Germany; (P.S.); (S.K.); (M.O.); (S.S.); (A.C.); (M.K.)
| | - Miroslava Kvandova
- Department of Cardiology, Cardiology I, University Medical Center Mainz, 55131 Mainz, Germany; (P.S.); (S.K.); (M.O.); (S.S.); (A.C.); (M.K.)
| | - Franziska Bayer
- Center for Thrombosis and Hemostasis Mainz, University Medical Center Mainz, 55131 Mainz, Germany;
| | - Christoph Reinhardt
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, 55131 Mainz, Germany;
- Center for Thrombosis and Hemostasis Mainz, University Medical Center Mainz, 55131 Mainz, Germany;
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz, 55131 Mainz, Germany; (P.S.); (S.K.); (M.O.); (S.S.); (A.C.); (M.K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, 55131 Mainz, Germany;
- Correspondence: (T.M.); (A.D.); Tel.: +49-6131-17-6280 (A.D.)
| | - Andreas Daiber
- Department of Cardiology, Cardiology I, University Medical Center Mainz, 55131 Mainz, Germany; (P.S.); (S.K.); (M.O.); (S.S.); (A.C.); (M.K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, 55131 Mainz, Germany;
- Correspondence: (T.M.); (A.D.); Tel.: +49-6131-17-6280 (A.D.)
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5
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Poole DC, Ferguson SK, Musch TI, Porcelli S. Role of nitric oxide in convective and diffusive skeletal microvascular oxygen kinetics. Nitric Oxide 2022; 121:34-44. [PMID: 35123062 DOI: 10.1016/j.niox.2022.01.005] [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: 09/13/2021] [Revised: 12/29/2021] [Accepted: 01/27/2022] [Indexed: 10/19/2022]
Abstract
Progress in understanding physiological mechanisms often consists of discrete discoveries made across different models and species. Accordingly, understanding the mechanistic bases for how altering nitric oxide (NO) bioavailability impacts exercise tolerance (or not) depends on integrating information from cellular energetics and contractile regulation through microvascular/vascular control of O2 transport and pulmonary gas exchange. This review adopts state-of-the-art concepts including the intramyocyte power grid, the Wagner conflation of perfusive and diffusive O2 conductances, and the Critical Power/Critical Speed model of exercise tolerance to address how altered NO bioavailability may, or may not, affect physical performance. This question is germane from the elite athlete to the recreational exerciser and particularly the burgeoning heart failure (and other clinical) populations for whom elevating O2 transport and/or exercise capacity translates directly to improved life quality and reduced morbidity and mortality. The dearth of studies in females is also highlighted, and areas of uncertainty and questions for future research are identified.
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Affiliation(s)
- David C Poole
- Departments of Kinesiology and Anatomy and Physiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Scott K Ferguson
- Department of Kinesiology and Exercise Science, University of Hawaii, Hilo, HI, 96720, USA
| | - Timothy I Musch
- Departments of Kinesiology and Anatomy and Physiology, Kansas State University, Manhattan, KS, 66506, USA
| | - Simone Porcelli
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.
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6
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Alsulayyim AS, Alasmari AM, Alghamdi SM, Polkey MI, Hopkinson NS. Impact of dietary nitrate supplementation on exercise capacity and cardiovascular parameters in chronic respiratory disease: a systematic review and meta-analysis. BMJ Open Respir Res 2021; 8:8/1/e000948. [PMID: 34489239 PMCID: PMC8422488 DOI: 10.1136/bmjresp-2021-000948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/20/2021] [Indexed: 12/15/2022] Open
Abstract
Background Dietary nitrate supplementation, usually in the form of beetroot juice, may improve exercise performance and endothelial function. We undertook a systematic review and meta-analysis to establish whether this approach has beneficial effects in people with respiratory disease. Methods A systematic search of records up to March 2021 was performed on PubMed, CINAHL, MEDLINE (Ovid), Cochrane and Embase to retrieve clinical trials that evaluated the efficacy of dietary nitrate supplementation on cardiovascular parameters and exercise capacity in chronic respiratory conditions. Two authors independently screened titles, abstracts and full texts of potential studies and performed the data extraction. Results After full-text review of 67 papers, eleven (two randomised controlled trials and nine crossover trials) involving 282 participants met the inclusion criteria. Three were single dose; seven short term; and one, the largest (n=122), done in the context of pulmonary rehabilitation. Pooled analysis showed that dietary nitrate supplementation reduced systolic blood pressure (BP), diastolic BP and mean arterial pressure (mean difference (95% CI), −3.39 mm Hg (−6.79 to 0.01); p=0.05 and –2.20 mm Hg (−4.36 to −0.03); p=0.05 and −4.40 mm Hg (−7.49 to −1.30); p=0.005, respectively). It was associated with increased walk distance in the context of pulmonary rehabilitation (standardised mean difference (95% CI), 0.47 (0.11 to 0.83), p=0.01), but no effect was identified in short-term studies (0.08 (−0.32 to 0.49). Conclusion Dietary nitrate supplementation may have a beneficial effect on BP and augment the effect of pulmonary rehabilitation on exercise capacity. Short-term studies do not suggest a consistent benefit on exercise capacity. PROSPERO registration number CRD42019130123.
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Affiliation(s)
- Abdullah S Alsulayyim
- National Heart and Lung Institute, Imperial College London, London, UK.,Faculty of Applied Medical Sciences, Respiratory Therapy Department, Jazan University, Jazan, Saudi Arabia
| | - Ali M Alasmari
- National Heart and Lung Institute, Imperial College London, London, UK.,Faculty of Medical Rehabilitation Sciences, Taibah University, Madinah, Saudi Arabia
| | - Saeed M Alghamdi
- National Heart and Lung Institute, Imperial College London, London, UK.,Clinical Technology Department, Umm Al-Qura University, College of Applied Medical Science, Makkah, Saudi Arabia
| | - Michael I Polkey
- National Heart and Lung Institute, Imperial College London, London, UK
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7
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Repeated administration of inorganic nitrate on blood pressure and arterial stiffness: a systematic review and meta-analysis of randomized controlled trials. J Hypertens 2021; 38:2122-2140. [PMID: 32723980 DOI: 10.1097/hjh.0000000000002524] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE We aim to synthesize effects of repeated administration (≥3 days) of inorganic nitrate on blood pressure and arterial stiffness measures. METHODS We conducted a systematic review and meta-analysis of randomized controlled trials with at least 3 days treatment of inorganic nitrate on blood pressure and arterial stiffness in individuals with or without elevated cardiovascular disease risk. MEDLINE, EMBASE and the Cochrane Library were searched through 2 July 2019. Two independent reviewers extracted relevant study data. Data were pooled using the generic inverse variance method with random-effects model, and expressed as mean differences with 95% confidence intervals. Certainty in the evidence was assessed using GRADE. RESULTS Forty-seven trials were included (n = 1101). Administration of inorganic nitrate significantly lowered SBP [mean difference: -2.91 mmHg, 95% confidence interval (95% CI): -3.92 to -1.89, I = 76%], DBP (mean difference: -1.45 mmHg, 95% CI: -2.22 to -0.68, I = 78%], central SBP (mean difference: -1.56 mmHg, 95% CI: -2.62 to -0.50, I = 30%) and central DBP (mean difference: -1.99 mmHg, 95% CI: -2.37 to -1.60, I = 0%). There was no effect on 24-h blood pressure, augmentation index or pulse wave velocity. Certainty in the evidence was graded moderate for central blood pressure, pulse wave velocity and low for peripheral blood pressure, 24-h blood pressure and augmentation index. CONCLUSION Repeated administration (≥3 days) of inorganic nitrate lower peripheral and central blood pressure. Results appear to be driven by beneficial effects in healthy and hypertensive individuals. More studies are required to increase certainty in the evidence.
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Ostojic SM, Milovancev A, Drid P, Nikolaidis A. Oxygen saturation improved with nitrate-based nutritional formula in patients with COVID-19. J Int Med Res 2021; 49:3000605211012380. [PMID: 33906526 PMCID: PMC8107941 DOI: 10.1177/03000605211012380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In this open-label case series trial, we evaluated the effects of a nitrate-based nutritional formula on oxygen saturation (SpO2) and patient-reported outcomes in individuals with coronavirus disease 2019 (COVID-19). Five adult patients (three men and two women, age 39.6 ± 6.9 years) with a positive COVID-19 test result, breathing difficulties, and SpO2 ≤95%, who were free from other pulmonary and cardiovascular conditions, were recruited for this study. Participants were assigned to receive a multi-component nutritional formula (containing 1200 mg of potassium nitrate, 200 mg of magnesium, 50 mg of zinc, and 1000 mg of citric acid) every 4 hours during the 48-hour monitoring period. In all participants, SpO2 improved immediately after administration of the nutritional formula, from 1 to 7 percentage points (mean increase 3.6 ± 2.7 points; 95% confidence interval 0.3 to 7.0). SpO2 remained above baseline values throughout the monitoring interval, with values persisting over threshold values (>92%) for all patients and at each time point during the 48 hours. No patients reported any side effects of the intervention. These promising and rather unexpected results call for immediate, well-sampled, mechanistic randomized controlled trials to validate our findings.
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Affiliation(s)
- Sergej M Ostojic
- FSPE Applied Bioenergetics Lab, University of Novi Sad, Novi Sad, Serbia
| | | | - Patrik Drid
- FSPE Applied Bioenergetics Lab, University of Novi Sad, Novi Sad, Serbia
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9
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Tawa M, Nagata R, Sumi Y, Nakagawa K, Sawano T, Ohkita M, Matsumura Y. Preventive effects of nitrate-rich beetroot juice supplementation on monocrotaline-induced pulmonary hypertension in rats. PLoS One 2021; 16:e0249816. [PMID: 33831045 PMCID: PMC8031446 DOI: 10.1371/journal.pone.0249816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 03/26/2021] [Indexed: 11/18/2022] Open
Abstract
Beetroot (Beta vulgaris L.) has a high level of nitrate; therefore, its dietary intake could increase nitric oxide (NO) level in the body, possibly preventing the development of pulmonary hypertension (PH). In this study, we examined the effects of beetroot juice (BJ) supplementation on PH and the contribution of nitrate to such effects using a rat model of monocrotaline (MCT, 60 mg/kg s.c.)-induced PH. Rats were injected subcutaneously with saline or 60 mg/kg MCT and were sacrificed 28 days after the injection. In some rats injected with MCT, BJ was supplemented from the day of MCT injection to the day of sacrifice. First, MCT-induced right ventricular systolic pressure elevation, pulmonary arterial medial thickening and muscularization, and right ventricular hypertrophy were suppressed by supplementation with low-dose BJ (nitrate: 1.3 mmol/L) but not high-dose BJ (nitrate: 4.3 mmol/L). Of the plasma nitrite, nitrate, and their sum (NOx) levels, only the nitrate levels were found to be increased by the high-dose BJ supplementation. Second, in order to clarify the possible involvement of nitrate in the preventive effects of BJ on PH symptoms, the effects of nitrate-rich BJ (nitrate: 0.9 mmol/L) supplementation were compared with those of the nitrate-depleted BJ. While the former exerted preventive effects on PH symptoms, such effects were not observed in rats supplemented with nitrate-depleted BJ. Neither supplementation with nitrate-rich nor nitrate-depleted BJ affected plasma nitrite, nitrate, and NOx levels. These findings suggest that a suitable amount of BJ ingestion, which does not affect systemic NO levels, can prevent the development of PH in a nitrate-dependent manner. Therefore, BJ could be highly useful as a therapy in patients with PH.
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Affiliation(s)
- Masashi Tawa
- Laboratory of Pathological and Molecular Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Osaka, Japan
- Department of Pharmacology, Kanazawa Medical University, Kahoku, Ishikawa, Japan
- * E-mail: ,
| | - Rikako Nagata
- Laboratory of Pathological and Molecular Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Osaka, Japan
| | - Yuiko Sumi
- Laboratory of Pathological and Molecular Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Osaka, Japan
| | - Keisuke Nakagawa
- Laboratory of Pathological and Molecular Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Osaka, Japan
| | - Tatsuya Sawano
- Laboratory of Pathological and Molecular Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Osaka, Japan
- Division of Molecular Pharmacology, Faculty of Medicine, Tottori University, Yonago, Tottori, Japan
| | - Mamoru Ohkita
- Laboratory of Pathological and Molecular Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Osaka, Japan
| | - Yasuo Matsumura
- Laboratory of Pathological and Molecular Pharmacology, Osaka University of Pharmaceutical Sciences, Takatsuki, Osaka, Japan
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10
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Lázár Z, Mészáros M, Bikov A. The Nitric Oxide Pathway in Pulmonary Arterial Hypertension: Pathomechanism, Biomarkers and Drug Targets. Curr Med Chem 2021; 27:7168-7188. [PMID: 32442078 DOI: 10.2174/0929867327666200522215047] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/03/2020] [Accepted: 02/20/2020] [Indexed: 11/22/2022]
Abstract
The altered Nitric Oxide (NO) pathway in the pulmonary endothelium leads to increased vascular smooth muscle tone and vascular remodelling, and thus contributes to the development and progression of pulmonary arterial hypertension (PAH). The pulmonary NO signalling is abrogated by the decreased expression and dysfunction of the endothelial NO synthase (eNOS) and the accumulation of factors blocking eNOS functionality. The NO deficiency of the pulmonary vasculature can be assessed by detecting nitric oxide in the exhaled breath or measuring the degradation products of NO (nitrite, nitrate, S-nitrosothiol) in blood or urine. These non-invasive biomarkers might show the potential to correlate with changes in pulmonary haemodynamics and predict response to therapies. Current pharmacological therapies aim to stimulate pulmonary NO signalling by suppressing the degradation of NO (phosphodiesterase- 5 inhibitors) or increasing the formation of the endothelial cyclic guanosine monophosphate, which mediates the downstream effects of the pathway (soluble guanylate cyclase sensitizers). Recent data support that nitrite compounds and dietary supplements rich in nitrate might increase pulmonary NO availability and lessen vascular resistance. This review summarizes current knowledge on the involvement of the NO pathway in the pathomechanism of PAH, explores novel and easy-to-detect biomarkers of the pulmonary NO.
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Affiliation(s)
- Zsófia Lázár
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Martina Mészáros
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Andras Bikov
- Department of Pulmonology, Semmelweis University, Budapest, Hungary,Manchester University NHS Foundation Trust, Manchester, United Kingdom
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11
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Zheng W, Wang Z, Jiang X, Zhao Q, Shen J. Targeted Drugs for Treatment of Pulmonary Arterial Hypertension: Past, Present, and Future Perspectives. J Med Chem 2020; 63:15153-15186. [PMID: 33314936 DOI: 10.1021/acs.jmedchem.0c01093] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pulmonary arterial hypertension (PAH) is a devastating disease that can lead to right ventricular failure and premature death. Although approved drugs have been shown to be safe and effective, PAH remains a severe clinical condition, and the long-term survival of patients with PAH is still suboptimal. Thus, potential therapeutic targets and new agents to treat PAH are urgently needed. In recent years, a variety of related pathways and potential therapeutic targets have been found, which brings new hope for PAH therapy. In this perspective, not only are the marketed drugs used to treat PAH summarized but also the recently developed novel pharmaceutical therapies currently in clinical trials are discussed. Furthermore, the advances in natural products as potential treatment for PAH are also updated.
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Affiliation(s)
- Wei Zheng
- CAS Key Laboratory of Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China.,School of Pharmacy, University of the Chinese Academy of Sciences, Beijing 100049, China
| | - Zhen Wang
- CAS Key Laboratory of Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Xiangrui Jiang
- CAS Key Laboratory of Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Qingjie Zhao
- CAS Key Laboratory of Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China
| | - Jingshan Shen
- CAS Key Laboratory of Receptor Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai 201203, China.,School of Pharmacy, University of the Chinese Academy of Sciences, Beijing 100049, China
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12
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Sánchez-Gloria JL, Osorio-Alonso H, Arellano-Buendía AS, Carbó R, Hernández-Díazcouder A, Guzmán-Martín CA, Rubio-Gayosso I, Sánchez-Muñoz F. Nutraceuticals in the Treatment of Pulmonary Arterial Hypertension. Int J Mol Sci 2020; 21:E4827. [PMID: 32650586 PMCID: PMC7402298 DOI: 10.3390/ijms21144827] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 06/13/2020] [Accepted: 07/01/2020] [Indexed: 12/11/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a severe disease characterized by the loss and obstructive remodeling of the pulmonary arterial wall, causing a rise in pulmonary arterial pressure and pulmonary vascular resistance, which is responsible for right heart failure, functional decline, and death. Although many drugs are available for the treatment of this condition, it continues to be life-threatening, and its long-term treatment is expensive. On the other hand, many natural compounds present in food have beneficial effects on several cardiovascular conditions. Several studies have explored many of the potential beneficial effects of natural plant products on PAH. However, the mechanisms by which natural products, such as nutraceuticals, exert protective and therapeutic effects on PAH are not fully understood. In this review, we analyze the current knowledge on nutraceuticals and their potential use in the protection and treatment of PAH, as well as whether nutraceuticals could enhance the effects of drugs used in PAH through similar mechanisms.
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Affiliation(s)
- José L. Sánchez-Gloria
- Sección de Estudios de Posgrado, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City 11340, Mexico; (J.L.S.-G.); (C.A.G.-M.); (I.R.-G.)
- Departamento de Inmunología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico;
| | - Horacio Osorio-Alonso
- Departamento de Fisiopatología Cardio-Renal, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico; (H.O.-A.); (A.S.A.-B.)
| | - Abraham S. Arellano-Buendía
- Departamento de Fisiopatología Cardio-Renal, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico; (H.O.-A.); (A.S.A.-B.)
| | - Roxana Carbó
- Departamento de Biomedicina Cardiovascular, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico;
| | - Adrián Hernández-Díazcouder
- Departamento de Inmunología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico;
- Posgrado en Biología Experimental, Universidad Autónoma Metropolitana-Iztapalapa, Mexico City 09340, Mexico
| | - Carlos A. Guzmán-Martín
- Sección de Estudios de Posgrado, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City 11340, Mexico; (J.L.S.-G.); (C.A.G.-M.); (I.R.-G.)
- Departamento de Inmunología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico;
| | - Ivan Rubio-Gayosso
- Sección de Estudios de Posgrado, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City 11340, Mexico; (J.L.S.-G.); (C.A.G.-M.); (I.R.-G.)
| | - Fausto Sánchez-Muñoz
- Sección de Estudios de Posgrado, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City 11340, Mexico; (J.L.S.-G.); (C.A.G.-M.); (I.R.-G.)
- Departamento de Inmunología, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City 14080, Mexico;
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13
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Kapil V, Khambata RS, Jones DA, Rathod K, Primus C, Massimo G, Fukuto JM, Ahluwalia A. The Noncanonical Pathway for In Vivo Nitric Oxide Generation: The Nitrate-Nitrite-Nitric Oxide Pathway. Pharmacol Rev 2020; 72:692-766. [DOI: 10.1124/pr.120.019240] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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14
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Bernardi M, Peluso I. Interactions between oxidative stress and cardiorespiratory fitness: Old and new biomarkers. CURRENT OPINION IN TOXICOLOGY 2020. [DOI: 10.1016/j.cotox.2020.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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15
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Dasgupta A, Wu D, Tian L, Xiong PY, Dunham-Snary KJ, Chen KH, Alizadeh E, Motamed M, Potus F, Hindmarch CCT, Archer SL. Mitochondria in the Pulmonary Vasculature in Health and Disease: Oxygen-Sensing, Metabolism, and Dynamics. Compr Physiol 2020; 10:713-765. [PMID: 32163206 DOI: 10.1002/cphy.c190027] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In lung vascular cells, mitochondria serve a canonical metabolic role, governing energy homeostasis. In addition, mitochondria exist in dynamic networks, which serve noncanonical functions, including regulation of redox signaling, cell cycle, apoptosis, and mitochondrial quality control. Mitochondria in pulmonary artery smooth muscle cells (PASMC) are oxygen sensors and initiate hypoxic pulmonary vasoconstriction. Acquired dysfunction of mitochondrial metabolism and dynamics contribute to a cancer-like phenotype in pulmonary arterial hypertension (PAH). Acquired mitochondrial abnormalities, such as increased pyruvate dehydrogenase kinase (PDK) and pyruvate kinase muscle isoform 2 (PKM2) expression, which increase uncoupled glycolysis (the Warburg phenomenon), are implicated in PAH. Warburg metabolism sustains energy homeostasis by the inhibition of oxidative metabolism that reduces mitochondrial apoptosis, allowing unchecked cell accumulation. Warburg metabolism is initiated by the induction of a pseudohypoxic state, in which DNA methyltransferase (DNMT)-mediated changes in redox signaling cause normoxic activation of HIF-1α and increase PDK expression. Furthermore, mitochondrial division is coordinated with nuclear division through a process called mitotic fission. Increased mitotic fission in PAH, driven by increased fission and reduced fusion favors rapid cell cycle progression and apoptosis resistance. Downregulation of the mitochondrial calcium uniporter complex (MCUC) occurs in PAH and is one potential unifying mechanism linking Warburg metabolism and mitochondrial fission. Mitochondrial metabolic and dynamic disorders combine to promote the hyperproliferative, apoptosis-resistant, phenotype in PAH PASMC, endothelial cells, and fibroblasts. Understanding the molecular mechanism regulating mitochondrial metabolism and dynamics has permitted identification of new biomarkers, nuclear and CT imaging modalities, and new therapeutic targets for PAH. © 2020 American Physiological Society. Compr Physiol 10:713-765, 2020.
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Affiliation(s)
- Asish Dasgupta
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Danchen Wu
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Lian Tian
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Ping Yu Xiong
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | | | - Kuang-Hueih Chen
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Elahe Alizadeh
- Department of Medicine, Queen's Cardiopulmonary Unit (QCPU), Translational Institute of Medicine (TIME), Queen's University, Kingston, Ontario, Canada
| | - Mehras Motamed
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - François Potus
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Charles C T Hindmarch
- Department of Medicine, Queen's Cardiopulmonary Unit (QCPU), Translational Institute of Medicine (TIME), Queen's University, Kingston, Ontario, Canada
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada.,Kingston Health Sciences Centre, Kingston, Ontario, Canada.,Providence Care Hospital, Kingston, Ontario, Canada
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16
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Malikova E, Carlström M, Kmecova Z, Marusakova M, Zsigmondova B, Krenek P, Klimas J, Henrohn D. Effects of inorganic nitrate in a rat model of monocrotaline-induced pulmonary arterial hypertension. Basic Clin Pharmacol Toxicol 2019; 126:99-109. [PMID: 31429204 DOI: 10.1111/bcpt.13309] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/11/2019] [Indexed: 12/27/2022]
Abstract
The nitrate-nitrite-nitric oxide (NO) pathway represents an alternative source of NO generation, which is independent of NO synthase and potentiated by hypoxia. Augmentation of this pathway by dietary nitrate has proven favourable effects in several cardiovascular disease models. However, less is known regarding its potential value in pulmonary arterial hypertension (PAH). The aim of this study was to assess the effects of oral inorganic nitrate administration in monocrotaline (MCT)-induced PAH. Male 12-week-old Wistar rats were injected subcutaneously with monocrotaline (MCT, 60 mg/kg). Nitrate treatment (0.3 or 1 mmol/kg/d; drinking water) commenced on day 12 following the MCT injection and continued for 16 days. Nitrate administration did not attenuate right ventricular (RV) hypertrophy, increased lung weight and up-regulated mRNA expression of brain natriuretic peptide. Plasma nitrate and nitrite levels were significantly increased as well as lung nitrate level, whereas nitrite lung level was decreased following nitrate treatment (1 mmol/kg/d). MCT-induced PAH resulted in an increased MnSOD protein level, which was not observed following nitrate treatment. MCT-associated up-regulation of nNOS in the lung appeared to be dose-dependently prevented by nitrate treatment. Western blot analysis did not reveal any differences in eNOS, iNOS, XO or gp91phox expression in the lungs among the groups. In conclusion, nitrate treatment did not significantly attenuate pathological RV and lung remodelling in the rat MCT model of PAH. The suppression of MnSOD and nNOS expression by nitrate could be interpreted as reduced demand of endogenous antioxidant defence in this model.
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Affiliation(s)
- Eva Malikova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - Mattias Carlström
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Zuzana Kmecova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - Margareta Marusakova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - Bianka Zsigmondova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - Peter Krenek
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - Jan Klimas
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovak Republic
| | - Dan Henrohn
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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17
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Cortés-Puch I, Sun J, Schechter AN, Solomon SB, Park JW, Feng J, Gilliard C, Natanson C, Piknova B. Inhaled nebulized nitrite and nitrate therapy in a canine model of hypoxia-induced pulmonary hypertension. Nitric Oxide 2019; 91:1-14. [PMID: 31299340 DOI: 10.1016/j.niox.2019.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/17/2019] [Accepted: 07/02/2019] [Indexed: 12/12/2022]
Abstract
Dysfunction in the nitric oxide (NO) signaling pathway can lead to the development of pulmonary hypertension (PH) in mammals. Discovery of an alternative pathway to NO generation involving reduction from nitrate to nitrite and to NO has motivated the evaluation of nitrite as an alternative to inhaled NO for PH. In contrast, inhaled nitrate has not been evaluated to date, and potential benefits include a prolonged half-life and decreased risk of methemoglobinemia. In a canine model of acute hypoxia-induced PH we evaluated the effects of inhaled nitrate to reduce pulmonary arterial pressure (PAP). In a randomized controlled trial, inhaled nitrate was compared to inhaled nitrite and inhaled saline. Exhaled NO, PAP and systemic blood pressures were continuously monitored. Inhaled nitrite significantly decreased PAP and increased exhaled NO. In contrast, inhaled nitrate and inhaled saline did not decrease PAP or increase exhaled NO. Unexpectedly, we found that inhaled nitrite resulted in prolonged (>5 h) exhaled NO release, increase in nitrate venous/arterial levels and a late surge in venous nitrite levels. These findings do not support a therapeutic role for inhaled nitrate in PH but may have therapeutic implications for inhaled nitrite in various disease states.
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Affiliation(s)
- Irene Cortés-Puch
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA; Division of Pulmonary, Critical Care and Sleep Medicine, University of California Davis, Sacramento, CA, USA
| | - Junfeng Sun
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Alan N Schechter
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
| | - Steven B Solomon
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Ji Won Park
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA
| | - Jing Feng
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Cameron Gilliard
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA; Penn State Health Milton S. Hershey Medical Center, Department of Anesthesia and Perioperative Medicine, Hershey, PA, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Barbora Piknova
- National Institute of Diabetes and Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD, USA.
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18
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Consumption of Nitrate-Rich Beetroot Juice with or without Vitamin C Supplementation Increases the Excretion of Urinary Nitrate, Nitrite, and N-nitroso Compounds in Humans. Int J Mol Sci 2019; 20:ijms20092277. [PMID: 31072023 PMCID: PMC6539140 DOI: 10.3390/ijms20092277] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 04/26/2019] [Accepted: 05/07/2019] [Indexed: 01/01/2023] Open
Abstract
Consumption of nitrate-rich beetroot juice (BRJ) by athletes induces a number of beneficial physiological health effects, which are linked to the formation of nitric oxide (NO) from nitrate. However, following a secondary pathway, NO may also lead to the formation of N-nitroso compounds (NOCs), which are known to be carcinogenic in 39 animal species. The extent of the formation of NOCs is modulated by various other dietary factors, such as vitamin C. The present study investigates the endogenous formation of NOCs after BRJ intake and the impact of vitamin C on urinary NOC excretion. In a randomized, controlled trial, 29 healthy recreationally active volunteers ingested BRJ with or without additional vitamin C supplements for one week. A significant increase of urinary apparent total N-nitroso Compounds (ATNC) was found after one dose (5 to 47 nmol/mmol: p < 0.0001) and a further increase was found after seven consecutive doses of BRJ (104 nmol/mmol: p < 0.0001). Vitamin C supplementation inhibited ATNC increase after one dose (16 compared to 72 nmol/mmol, p < 0.01), but not after seven daily doses. This is the first study that shows that BRJ supplementation leads to an increase in formation of potentially carcinogenic NOCs. In order to protect athlete’s health, it is therefore important to be cautious with chronic use of BRJ to enhance sports performances.
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19
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Rich MW. To Invest or Divest - Tough Choices in the Wake of VEST. J Card Fail 2018; 24:625-626. [PMID: 30447850 DOI: 10.1016/j.cardfail.2018.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Michael W Rich
- Washington University School of Medicine, 660 S. Euclid Ave., Campus Box 8086, St. Louis, MO 63110.
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