1
|
Corbi G, Comegna M, Vinciguerra C, Capasso A, Onorato L, Salucci AM, Rapacciuolo A, Cannavo A. Age and sex mediated effects of estrogen and Β3-adrenergic receptor on cardiovascular pathophysiology. Exp Gerontol 2024; 190:112420. [PMID: 38588751 DOI: 10.1016/j.exger.2024.112420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/29/2024] [Accepted: 04/05/2024] [Indexed: 04/10/2024]
Abstract
Sex differences are consistently identified in determining the prevalence, manifestation, and response to therapies in several systemic disorders, including those affecting the cardiovascular (CV), skeletal muscle, and nervous system. Interestingly, such differences are often more noticeable as we age. For example, premenopausal women experience a lower risk of CV disease than men of the same age. While at an advanced age, with menopause, the risk of cardiovascular diseases and adverse outcomes increases exponentially in women, exceeding that of men. However, this effect appears to be reversed in diseases such as pulmonary hypertension, where women are up to seven times more likely than men to develop an idiopathic form of the disease with symptoms developing ten years earlier than their male counterparts. Explaining this is a complex question. However, several factors and mechanisms have been identified in recent decades, including a role for sex hormones, particularly estrogens and their related receptors. Furthermore, an emerging role in these sex differences has also been suggested for β-adrenergic receptors (βARs), which are essential regulators of mammalian physiology. It has in fact been shown that βARs interact with estrogen receptors (ER), providing further demonstration of their involvement in determining sexual differences. Based on these premises, this review article focused on the β3AR subtype, which shows important activities in adipose tissue but with new and interesting roles in regulating the function of cardiomyocytes and vascular cells. In detail, we examined how β3AR and ER signaling are intertwined and whether there would be sex- and age-dependent specific effects of these receptor systems.
Collapse
Affiliation(s)
- Graziamaria Corbi
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Marika Comegna
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy; CEINGE-Advanced Biotechnologies - Franco Salvatore, Naples, Italy
| | - Caterina Vinciguerra
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Alessio Capasso
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Luigi Onorato
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | | | - Antonio Rapacciuolo
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Alessandro Cannavo
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy.
| |
Collapse
|
2
|
Visniauskas B, Kilanowski-Doroh I, Ogola BO, Mcnally AB, Horton AC, Imulinde Sugi A, Lindsey SH. Estrogen-mediated mechanisms in hypertension and other cardiovascular diseases. J Hum Hypertens 2023; 37:609-618. [PMID: 36319856 PMCID: PMC10919324 DOI: 10.1038/s41371-022-00771-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/06/2022] [Accepted: 10/18/2022] [Indexed: 06/08/2023]
Abstract
Cardiovascular disease (CVD) is the leading cause of death globally for men and women. Premenopausal women have a lower incidence of hypertension and other cardiovascular events than men of the same age, but diminished sex differences after menopause implicates 17-beta-estradiol (E2) as a protective agent. The cardioprotective effects of E2 are mediated by nuclear estrogen receptors (ERα and ERβ) and a G protein-coupled estrogen receptor (GPER). This review summarizes both established as well as emerging estrogen-mediated mechanisms that underlie sex differences in the vasculature during hypertension and CVD. In addition, remaining knowledge gaps inherent in the association of sex differences and E2 are identified, which may guide future clinical trials and experimental studies in this field.
Collapse
Affiliation(s)
- Bruna Visniauskas
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Benard O Ogola
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Alexandra B Mcnally
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Alec C Horton
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Ariane Imulinde Sugi
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Sarah H Lindsey
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, LA, USA.
- Tulane Center of Excellence in Sex-Based Biology and Medicine, New Orleans, LA, USA.
- Tulane Brain Institute, New Orleans, LA, USA.
| |
Collapse
|
3
|
Nwia SM, Leite APO, Li XC, Zhuo JL. Sex differences in the renin-angiotensin-aldosterone system and its roles in hypertension, cardiovascular, and kidney diseases. Front Cardiovasc Med 2023; 10:1198090. [PMID: 37404743 PMCID: PMC10315499 DOI: 10.3389/fcvm.2023.1198090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/06/2023] [Indexed: 07/06/2023] Open
Abstract
Cardiovascular disease is a pathology that exhibits well-researched biological sex differences, making it possible for physicians to tailor preventative and therapeutic approaches for various diseases. Hypertension, which is defined as blood pressure greater than 130/80 mmHg, is the primary risk factor for developing coronary artery disease, stroke, and renal failure. Approximately 48% of American men and 43% of American women suffer from hypertension. Epidemiological data suggests that during reproductive years, women have much lower rates of hypertension than men. However, this protective effect disappears after the onset of menopause. Treatment-resistant hypertension affects approximately 10.3 million US adults and is unable to be controlled even after implementing ≥3 antihypertensives with complementary mechanisms. This indicates that other mechanisms responsible for modulating blood pressure are still unclear. Understanding the differences in genetic and hormonal mechanisms that lead to hypertension would allow for sex-specific treatment and an opportunity to improve patient outcomes. Therefore, this invited review will review and discuss recent advances in studying the sex-specific physiological mechanisms that affect the renin-angiotensin system and contribute to blood pressure control. It will also discuss research on sex differences in hypertension management, treatment, and outcomes.
Collapse
Affiliation(s)
- Sarah M. Nwia
- Tulane Hypertension and Renal Center of Excellence, Tulane University School of Medicine, New Orleans, LA, United States
- Department of Physiology, Tulane University School of Medicine, New Orleans, LA, United States
| | - Ana Paula O. Leite
- Department of Pharmacology, Tulane University School of Medicine, New Orleans, LA, United States
| | - Xiao Chun Li
- Tulane Hypertension and Renal Center of Excellence, Tulane University School of Medicine, New Orleans, LA, United States
- Department of Physiology, Tulane University School of Medicine, New Orleans, LA, United States
| | - Jia Long Zhuo
- Tulane Hypertension and Renal Center of Excellence, Tulane University School of Medicine, New Orleans, LA, United States
- Department of Physiology, Tulane University School of Medicine, New Orleans, LA, United States
| |
Collapse
|
4
|
Asai K, Murai K, Shirakabe A, Kamiya M, Noma S, Sato N, Mizuno K, Shimizu W. Effect of Gonadectomy and Angiotensin II Receptor Blockade in a Mouse Model of Isoproterenol-induced Cardiac Diastolic Dysfunction. J NIPPON MED SCH 2021; 88:113-120. [PMID: 32475904 DOI: 10.1272/jnms.jnms.2021_88-303] [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: 11/19/2022]
Abstract
BACKGROUND Although heart failure (HF) with preserved ejection fraction (HFpEF) is more common in postmenopausal women than in men, the effect of sex hormones on cardiac diastolic function remains unclear. We examined the effect of gonadectomy with or without the angiotensin receptor blocker olmesartan (Olm) in an isoproterenol (ISO) -induced mouse model of left ventricular hypertrophy (LVH) and cardiac diastolic dysfunction. METHODS ISO or ISO with Olm were administered for 28 days in sham-operated male and female, castrated (CAS), and ovariectomized (OVX) mice. LV ejection fraction (EF) and E/A ratio were analyzed by echocardiography, and the LV and lung weight corrected by tibial length were used as indices of LVH and lung congestion, respectively. RESULTS On echocardiography, systolic function did not differ between the four groups. LV/tibial length (TL) and Lung/TL significantly increased in all groups. The LV/TL ratio was lower in castrated-ISO vs. Male-Sham-ISO but did not differ between Female-Sham-ISO and OVX-ISO. However, the Lung/TL ratio of OVX-ISO was greater than that of Female-Sham-ISO. Olm prevented LV hypertrophy in all groups. The decrease in E/A and increase in lung weight were improved by Olm in Male-Sham and OVX-ISO but not in the other groups. CONCLUSION These sex differences suggest that sex hormones play a pivotal role in modulating cardiac hypertrophy and diastolic dysfunction induced by chronic β-adrenoceptor stimulation, and thus affect the therapeutic potential of angiotensin receptor blockade.
Collapse
Affiliation(s)
- Kuniya Asai
- Intensive Care Unit, Nippon Medical School Chiba Hokusoh Hospital
| | - Koji Murai
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | - Masataka Kamiya
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Satsuki Noma
- Department of Cardiovascular Medicine, Nippon Medical School
| | - Naoki Sato
- Department of Cardiovascular Medicine, Nippon Medical School
| | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School
| |
Collapse
|
5
|
Gao X, Yamazaki Y, Tezuka Y, Omata K, Ono Y, Morimoto R, Nakamura Y, Satoh F, Sasano H. Gender differences in human adrenal cortex and its disorders. Mol Cell Endocrinol 2021; 526:111177. [PMID: 33582213 DOI: 10.1016/j.mce.2021.111177] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 01/14/2021] [Accepted: 01/19/2021] [Indexed: 12/11/2022]
Abstract
The adrenal cortex plays pivotal roles in the maintenance of blood volume, responsiveness to stress and the development of gender characteristics. Gender differences of human adrenal cortex have been recently reported and attracted increasing interests. Gender differences occur from the developing stage of the adrenal, in which female subjects had more activated stem cells with higher renewal capacity resulting in gender-associated divergent structures and functions of cortical zonations of human adrenal. Female subjects generally have the lower blood pressure with the lower renin levels and ACE activities than male subjects. In addition, HPA axis was more activated in female than male, which could possibly contribute to gender differences in coping with various stressful events in our life. Of particular interest, estrogens were reported to suppress RAAS but activate HPA axis, whereas androgens had opposite effects. In addition, adrenocortical disorders in general occur more frequently in female with more pronounced adrenocortical hormonal abnormalities possibly due to their more activated WNT and PRK signaling pathways with more abundant activated adrenocortical stem cells present in female adrenal glands. Therefore, it has become pivotal to clarify the gender influence on both clinical and biological features of adrenocortical disorders. We herein reviewed recent advances in these fields.
Collapse
Affiliation(s)
- Xin Gao
- Department of Pathology, Tohoku University Graduate School of Medicine, Japan
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Japan
| | - Yuta Tezuka
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Japan; Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Japan
| | - Kei Omata
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Japan; Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Japan
| | - Yoshikiyo Ono
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Japan
| | - Ryo Morimoto
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Japan
| | - Fumitoshi Satoh
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Japan; Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Japan
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Japan.
| |
Collapse
|
6
|
Nicolaou PA. Sex differences in heart failure medications targeting the renin-angiotensin-aldosterone system. Eur J Pharmacol 2021; 897:173961. [PMID: 33617824 DOI: 10.1016/j.ejphar.2021.173961] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 02/05/2021] [Accepted: 02/15/2021] [Indexed: 12/28/2022]
Abstract
Heart failure (HF) is a major healthcare problem. Sex-related differences in clinical manifestations, outcomes, risk factors and symptoms in HF have been described in the literature. Sex-related differences have also been described in the regulation of the renin-angiotensin-aldosterone system (RAAS), which is at the core of the pathophysiology of HF. Considering that drugs targeting RAAS are cornerstones in the treatment of HF, it is important to determine whether sex-related differences exist in the use of angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), mineralocorticoid receptor antagonists (MRAs) and ARB/neprilysin inhibitors (ARNIs). In regards to the relative efficacy of RAAS drugs in men vs. women in HF, there are conflicting results, which may stem from the fact that a lot of clinical trials were not specifically designed to investigate sex differences, with many of them having an underrepresentation of women. With respect to optimal dosage of RAAS drugs, even though, current HF guidelines, recommend up-titration to the same target dose in both men and women, evidence suggests that lower doses could be used in women. Furthermore, several studies have reported underutilization of guideline-directed medical therapy in women, including ACEIs, ARBs and MRAs, which may be at least partially attributed to increased prevalence of HF with a preserved ejection fraction and increased propensity for adverse effects in women. Overall, these investigations have shed some light on sex-related differences but there is scope for conducting further studies to determine the optimal use of RAAS drugs in men and women with failing hearts.
Collapse
Affiliation(s)
- Persoulla A Nicolaou
- Department of Basic and Clinical Sciences, Medical School, University of Nicosia, Cyprus; Honorary Senior Lecturer, St. George's, University of London, UK.
| |
Collapse
|
7
|
Sabbatini AR, Kararigas G. Estrogen-related mechanisms in sex differences of hypertension and target organ damage. Biol Sex Differ 2020; 11:31. [PMID: 32487164 PMCID: PMC7268741 DOI: 10.1186/s13293-020-00306-7] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/04/2020] [Indexed: 12/13/2022] Open
Abstract
Hypertension (HTN) is a primary risk factor for cardiovascular (CV) events, target organ damage (TOD), premature death and disability worldwide. The pathophysiology of HTN is complex and influenced by many factors including biological sex. Studies show that the prevalence of HTN is higher among adults aged 60 and over, highlighting the increase of HTN after menopause in women. Estrogen (E2) plays an important role in the development of systemic HTN and TOD, exerting several modulatory effects. The influence of E2 leads to alterations in mechanisms regulating the sympathetic nervous system, renin-angiotensin-aldosterone system, body mass, oxidative stress, endothelial function and salt sensitivity; all associated with a crucial inflammatory state and influenced by genetic factors, ultimately resulting in cardiac, vascular and renal damage in HTN. In the present article, we discuss the role of E2 in mechanisms accounting for the development of HTN and TOD in a sex-specific manner. The identification of targets with therapeutic potential would contribute to the development of more efficient treatments according to individual needs.
Collapse
Affiliation(s)
| | - Georgios Kararigas
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany.
| |
Collapse
|
8
|
White MC, Fleeman R, Arnold AC. Sex differences in the metabolic effects of the renin-angiotensin system. Biol Sex Differ 2019; 10:31. [PMID: 31262355 PMCID: PMC6604144 DOI: 10.1186/s13293-019-0247-5] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 06/18/2019] [Indexed: 02/07/2023] Open
Abstract
Obesity is a global epidemic that greatly increases risk for developing cardiovascular disease and type II diabetes. Sex differences in the obese phenotype are well established in experimental animal models and clinical populations. While having higher adiposity and obesity prevalence, females are generally protected from obesity-related metabolic and cardiovascular complications. This protection is, at least in part, attributed to sex differences in metabolic effects of hormonal mediators such as the renin-angiotensin system (RAS). Previous literature has predominantly focused on the vasoconstrictor arm of the RAS and shown that, in contrast to male rodent models of obesity and diabetes, females are protected from metabolic and cardiovascular derangements produced by angiotensinogen, renin, and angiotensin II. A vasodilator arm of the RAS has more recently emerged which includes angiotensin-(1-7), angiotensin-converting enzyme 2 (ACE2), mas receptors, and alamandine. While accumulating evidence suggests that activation of components of this counter-regulatory axis produces positive effects on glucose homeostasis, lipid metabolism, and energy balance in male animal models, female comparison studies and clinical data related to metabolic outcomes are lacking. This review will summarize current knowledge of sex differences in metabolic effects of the RAS, focusing on interactions with gonadal hormones and potential clinical implications.
Collapse
Affiliation(s)
- Melissa C White
- Department of Comparative Medicine, Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA, USA
| | - Rebecca Fleeman
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, 500 University Drive, Mail Code H109, Hershey, PA, 17033, USA
| | - Amy C Arnold
- Department of Neural and Behavioral Sciences, Pennsylvania State University College of Medicine, 500 University Drive, Mail Code H109, Hershey, PA, 17033, USA.
| |
Collapse
|
9
|
The Association between Female Reproductive Factors and Open-Angle Glaucoma in Korean Women: The Korean National Health and Nutrition Examination Survey V. J Ophthalmol 2018; 2018:2750786. [PMID: 30026984 PMCID: PMC6031087 DOI: 10.1155/2018/2750786] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 05/09/2018] [Indexed: 11/24/2022] Open
Abstract
Purpose We investigated associations between female reproductive factors and open-angle glaucoma (OAG) in Korean females using the Korea National Health and Nutrition Examination Survey (KNHANES). Methods A nationwide, population-based, cross-sectional study was conducted. We enrolled 23,376 participants from the KNHANES who had undergone ophthalmologic exams from 2010 through 2012. Associations between undiagnosed OAG and female reproductive factors such as age at menarche and menopause, parity, history of lactation, and administration of oral contraceptives (OC) or hormone replacement therapy (HRT) were determined using stepwise logistic regression analyses. Results Of the enrolled participants, 6,860 participants (397 with OAG and 6,463 without OAG) met our study criteria and were included in the analyses. In the multivariate logistic regression analysis after adjusting for all potential confounding factors, only early menopause (younger than 45 years) was significantly associated with OAG in participants with natural menopause (OR 2.28, 95% CI 1.17–4.46). Age at menarche, parity, history of lactation, and administration of OC or HRT were not significantly associated with OAG. Conclusions Only early menopause was associated with an increased risk of OAG in our study, in contrast to previous Western studies reporting both early menopause and late menarche as associated factors.
Collapse
|
10
|
The Complex Interaction Between Polycystic Ovary Syndrome and Hereditary Angioedema: Case Reports and Review of the Literature. Obstet Gynecol Surv 2018; 72:417-424. [PMID: 28715060 DOI: 10.1097/ogx.0000000000000457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Importance Hereditary angioedema (HAE) is a rare but severe disease, with high risk of death, and attacks have been associated to high estrogen levels. Polycystic ovary syndrome (PCOS) is a common hyperandrogenic condition, which is frequently treated with combined oral contraceptives. Objective The aim of this study was to describe 2 clinical cases of young women diagnosed as having PCOS who developed HAE attacks after the introduction of combined estrogen-progestin pills to treat PCOS symptoms. Evidence Acquisition Literature review of sex hormones' role in genesis of HAE attacks and possible mechanisms involved. Results In the cases reported, after initiation of combined contraceptives, patients presented with facial swelling with airway involvement (laryngeal edema) and abdominal pain. They had a familial history of angioedema and normal C1 inhibitor (C1-INH) levels, leading to the diagnosis of HAE with normal C1-INH (HAEnC1-INH) or HAE type III. After suspension of exogenous estrogen, patients remained asymptomatic from HAE. Conclusions and Relevance HAEnC1-INH is an estrogen-dependent form of HAE. It is well established that exogenous estrogen triggers attacks of all types of HAE. However, this is the first description of the association between PCOS and HAE, in which PCOS could be masking HAE symptoms. We propose that PCOS might have a protective role regarding HAE attacks, because of its particular hormonal features, that is, hyperandrogenism and relative stable levels of estradiol. The use of combined estrogen-progestin compounds in women with PCOS and HAE must be avoided, and treatment must be individualized.
Collapse
|
11
|
Sex Differences in Vascular Reactivity to Angiotensin II During the Evolution of Myocardial Infarction. J Cardiovasc Pharmacol 2018; 71:19-25. [DOI: 10.1097/fjc.0000000000000542] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
12
|
Bukowska A, Spiller L, Wolke C, Lendeckel U, Weinert S, Hoffmann J, Bornfleth P, Kutschka I, Gardemann A, Isermann B, Goette A. Protective regulation of the ACE2/ACE gene expression by estrogen in human atrial tissue from elderly men. Exp Biol Med (Maywood) 2017; 242:1412-1423. [PMID: 28661206 DOI: 10.1177/1535370217718808] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Data from animal experiments and clinical investigations suggest that components of the renin-angiotensin system are markedly affected by sex hormones. However, whether estrogen affects human atrial myocardium has not been investigated yet. In this study, we determined the effects of estrogen on key components of atrial renin-angiotensin system: angiotensin-converting enzyme, responsible for generation of angiotensin II and angiotensin-converting enzyme 2, counteracting majority of AngII effects, and different renin-angiotensin system receptors, AT1R, AT2R, and MAS. First, the expression levels of estrogen receptors mRNA were determined in right atrial appendages obtained from patients undergoing heart surgery. The amounts of estrogen receptor α and estrogen receptor β mRNA were similar between women ( n = 14) and men ( n = 10). Atrial tissue slices (350 µm) were prepared from male donors which were exposed to estrogen (1-100 nM; n = 21) or stimulated at 4 Hz for 24 h in the presence or absence of 100 nM estrogen ( n = 16), respectively. The administration of estrogen did not change mRNA levels of estrogen receptors, but activated MAP kinases, Erk1/2. Furthermore, estrogen increased the amounts of angiotensin-converting enzyme 2-mRNA (1.89 ± 0.23; P < 0.05) but reduced that of angiotensin-converting enzyme-mRNA (0.78 ± 0.07, P < 0.05). In addition, the transcript levels of AT2R and MAS were upregulated by estrogen. Pacing of tissue slices significantly increased the angiotensin-converting enzyme/angiotensin-converting enzyme 2 ratio at both the mRNA and protein level. During pacing, administration of estrogen substantially lowered the angiotensin-converting enzyme/angiotensin-converting enzyme 2 ratio at the transcript (0.92 ± 0.21 vs. 2.12 ± 0.27 at 4 Hz) and protein level (0.94 ± 0.20 vs. 2.14 ± 0.3 at 4 Hz). Moreover, estrogen elicited anti-inflammatory and anti-oxidative effects on renin-angiotensin system-associated downstream effectors such as pro-oxidative LOX-1 and pro-inflammatory ICAM-1. An antagonist of estrogen receptor α reversed these anti-inflammatory and anti-oxidative effects of estrogen significantly. Overall, our results demonstrated that estrogen modifies the local renin-angiotensin system homeostasis and achieves protective effects in atrial myocardium from elderly men. Impact statement The present study demonstrates that estrogen affects the human atrial myocardium and mediates protective actions through estrogen receptors-(ER) dependent signaling. Estrogen substantially modulates the local RAS via downregulation of ACE and simultaneous upregulation of ACE2, AT2R and MAS expression levels. This is indicative of a shift of the classical RAS/ACE axis to the alternative, protective RAS/ACE2 axis. In support of this view, estrogen attenuated the expression of RAS-associated downstream effectors, LOX-1, and ICAM-1. A specific antagonist of ERα reversed the anti-inflammatory and anti-oxidative effects of estrogen in paced and non-paced atrial tissue slices. In summary, our data demonstrate the existence of protective effects of estrogen in atrial tissue from elderly men which are at least in part, mediated by the regulation of local RAS homeostasis.
Collapse
Affiliation(s)
- A Bukowska
- 1 Institute of Clinical Chemistry and Pathobiochemistry, Department of Pathobiochemistry, Otto-von-Guericke University Magdeburg, Magdeburg 39120, Germany
| | - L Spiller
- 2 Medical Department I, Division of Rheumatology, Charitá University Medicine Berlin, Berlin 12203, Germany
| | - C Wolke
- 3 Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, Greifswald 17479, Germany
| | - U Lendeckel
- 3 Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, Greifswald 17479, Germany
| | - S Weinert
- 4 Department of Cardiology, Otto-von-Guericke University Magdeburg, Magdeburg 39120, Germany
| | - J Hoffmann
- 5 Department of Clinical Chemistry, Institute of Clinical Chemistry and Pathobiochemistry, Otto-von-Guericke University Magdeburg, Magdeburg 39120, Germany
| | - P Bornfleth
- 1 Institute of Clinical Chemistry and Pathobiochemistry, Department of Pathobiochemistry, Otto-von-Guericke University Magdeburg, Magdeburg 39120, Germany
| | - I Kutschka
- 6 Department of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg 39120, Germany
| | - A Gardemann
- 1 Institute of Clinical Chemistry and Pathobiochemistry, Department of Pathobiochemistry, Otto-von-Guericke University Magdeburg, Magdeburg 39120, Germany
| | - B Isermann
- 5 Department of Clinical Chemistry, Institute of Clinical Chemistry and Pathobiochemistry, Otto-von-Guericke University Magdeburg, Magdeburg 39120, Germany
| | - A Goette
- 1 Institute of Clinical Chemistry and Pathobiochemistry, Department of Pathobiochemistry, Otto-von-Guericke University Magdeburg, Magdeburg 39120, Germany.,7 St. Vincenz-Hospital, Paderborn 33098, Germany
| |
Collapse
|
13
|
Epochs in the depressor/pressor balance of the renin-angiotensin system. Clin Sci (Lond) 2017; 130:761-71. [PMID: 27128801 DOI: 10.1042/cs20150939] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 02/01/2016] [Indexed: 12/17/2022]
Abstract
The renin-angiotensin system (RAS) plays a commanding role in the regulation of extracellular fluid homoeostasis. Tigerstadt and Bergman first identified the RAS more than two centuries ago. By the 1980s a voyage of research and discovery into the mechanisms and actions of this system led to the development of drugs that block the RAS, which have become the mainstay for the treatment of cardiovascular and renal disease. In the last 25 years new components of the RAS have come to light, including the angiotensin type 2 receptor (AT2R) and the angiotensin-converting enzyme 2 (ACE2)/angiotensin-(1-7) [Ang(1-7)]/Mas receptor (MasR) axis. These have been shown to counter the classical actions of angiotensin II (AngII) at the predominant angiotensin type 1 receptor (AT1R). Our studies, and those of others, have demonstrated that targeting these depressor RAS pathways may be therapeutically beneficial. It is apparent that the evolution of both the pressor and depressor RAS pathways is distinct throughout life and that the depressor/pressor balance of the RAS vary between the sexes. These temporal patterns of expression suggest that therapies targeting the RAS could be optimized for discrete epochs in life.
Collapse
|
14
|
Taguchi A, Suei Y, Sanada M, Higashi Y, Ohtsuka M, Nakamoto T, Tsuda M, Ohama K, Tanimoto K. Detection of Vascular Disease Risk in Women by Panoramic Radiography. J Dent Res 2016; 82:838-43. [PMID: 14514767 DOI: 10.1177/154405910308201015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Low bone mineral density and rapid bone loss of the skeleton are associated with mortality risk from vascular diseases in post-menopausal women. Panoramic radiographic measurements are considered as indicators of skeletal bone mineral density or bone turnover. We hypothesize that such measurements may be associated with vascular disease risk in post-menopausal women. Associations of mandibular cortical shape and width on panoramic radiographs with skeletal bone mineral density and risk factors related to vascular diseases were investigated in 87 post-menopausal women. Cortical shape was associated with skeletal bone mineral density, low-density lipoprotein cholesterol, apolipoprotein B, resting heart rate, and endothelial dysfunction. Cortical width was associated with skeletal bone mineral density, low-density lipoprotein cholesterol, and apolipoprotein A1. Dentists may be able to refer women with increased risk of vascular diseases, as well as low bone mineral density, to medical professionals for further examination by panoramic findings.
Collapse
Affiliation(s)
- A Taguchi
- Department of Oral and Maxillofacial Radiology, Hiroshima University Dental Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8553, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Takeoka A, Tayama J, Yamasaki H, Kobayashi M, Ogawa S, Saigo T, Kawano H, Abiru N, Hayashida M, Maeda T, Shirabe S. Intra-abdominal fat accumulation is a hypertension risk factor in young adulthood: A cross-sectional study. Medicine (Baltimore) 2016; 95:e5361. [PMID: 27828861 PMCID: PMC5106067 DOI: 10.1097/md.0000000000005361] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Accumulation of intra-abdominal fat is related to hypertension. Despite this, a relationship between hypertension and intra-abdominal fat in young adulthood is not clear. In this study, we verify whether intra-abdominal fat accumulation increases a hypertension risk in young adult subjects.In a cross-sectional study, intra-abdominal fat area was measured using a dual bioelectrical impedance analysis instrument in 697 university students (20.3 ± 0.7 years, 425 men). Blood pressure and anthropometric factors were measured. Lifestyle variables including smoking, drinking, physical activity, and eating behavior were assessed with questionnaire. High blood pressure risk (systolic blood pressure ≥130 mm Hg and/or diastolic blood pressure ≥85 mm Hg) with increasing intra-abdominal fat area was evaluated.Participants were divided into 5 groups according to their intra-abdominal fat area (≤24.9, 25-49.9, 50-74.9, 75-99.9, and ≥100 cm). As compared with the values of the smallest intra-abdominal fat area group, the crude and lifestyle-adjusted odds ratios (ORs) were elevated in larger intra-abdominal fat area groups [OR 1.31, 95% confidence interval (CI) 0.66-2.80; OR 3.38, 95% CI 1.60-7.57; OR 7.71, 95% CI 2.75-22.22; OR 18.74, 95% CI 3.93-105.64, respectively). The risk increase was observed only in men.Intra-abdominal fat accumulation is related to high blood pressure in men around 20 years of age. These results indicate the importance of evaluation and reduction of intra-abdominal fat to prevent hypertension.
Collapse
Affiliation(s)
- Atsushi Takeoka
- Unit of Preventive Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Jun Tayama
- Graduate School of Education, Nagasaki University, Nagasaki, Japan
| | - Hironori Yamasaki
- Department of Endocrinology and Metabolism, Sasebo City General Hospital, Sasebo, Japan
- Correspondence: Hironori Yamasaki, Department of Endocrinology, Diabetes and Metabolism, Sasebo City General Hospital, 9-3 Hirase, Sasebo 857-8511, Japan (e-mail: )
| | - Masakazu Kobayashi
- Center for Health and Community Medicine, Nagasaki University, Nagasaki, Japan
| | - Sayaka Ogawa
- Unit of Preventive Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tatsuo Saigo
- Unit of Preventive Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Norio Abiru
- Department of Endocrinology and Metabolism, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaki Hayashida
- Unit of Preventive Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takahiro Maeda
- Unit of Community Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
| | - Susumu Shirabe
- Center for Health and Community Medicine, Nagasaki University, Nagasaki, Japan
| |
Collapse
|
16
|
Sanders J, Harris J, Cooper J, Gohlke P, Humphries SE, Montgomery H, Woods DR. Lack of change in serum angiotensin-converting enzyme activity during the menstrual cycle. J Renin Angiotensin Aldosterone Syst 2016; 7:231-5. [PMID: 17318793 DOI: 10.3317/jraas.2006.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Introduction. The Deletion (D) rather than Insertion (I) variant of the angiotensin-converting enzyme (ACE) gene is associated with higher circulating ACE activity. Meanwhile, coronary risk rises with the menstrual nadir in oestrogen levels, exogenous oestrogen reduces serum ACE activity (with a greater reduction the higher the baseline ACE activity), and pharmacological reduction in ACE activity is cardioprotective. Alterations in coronary risk associated with the menstrual cycle may thus be mediated through (genotype-dependent) changes in ACE activity. We have examined this hypothesis. Materials and methods. Twenty-three healthy female subjects (12 II, 11 DD genotype) were studied. None were taking oral contraceptive agents. Blood was assayed for oestrogen, follicle stimulating hormone (FSH), luteinising hormone (LH), progesterone and ACE activity every three days throughout their menstrual cycle. Results ACE activity was unrelated to oestrogen, FSH or LH during the menstrual cycle, irrespective of ACE genotype. Conclusions. The increase in myocardial ischaemia during low oestrogen phases of the menstrual cycle does not appear mediated through a fall in serum ACE activity.
Collapse
Affiliation(s)
- Julie Sanders
- Rayne Institute, UCL Centre for Cardiovascular Genetics, 5 University Street, London, UK
| | | | | | | | | | | | | |
Collapse
|
17
|
Role of Mas Receptor Antagonist A799 in Renal Blood Flow Response to Ang 1-7 after Bradykinin Administration in Ovariectomized Estradiol-Treated Rats. Adv Pharmacol Sci 2015; 2015:801053. [PMID: 26421009 PMCID: PMC4573425 DOI: 10.1155/2015/801053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2015] [Revised: 08/11/2015] [Accepted: 08/12/2015] [Indexed: 01/09/2023] Open
Abstract
Background. The accompanied role of Mas receptor (MasR), bradykinin (BK), and female sex hormone on renal blood flow (RBF) response to angiotensin 1-7 is not well defined. We investigated the role of MasR antagonist (A779) and BK on RBF response to Ang 1-7 infusion in ovariectomized estradiol-treated rats. Methods. Ovariectomized Wistar rats received estradiol (OVE) or vehicle (OV) for two weeks. Catheterized animals were subjected to BK and A799 infusion and mean arterial pressure (MAP), RBF, and renal vascular resistance (RVR) responses to Ang 1-7 (0, 100, and 300 ng kg−1 min−1) were determined. Results. Percentage change of RBF (%RBF) in response to Ang1-7 infusion increased in a dose-dependent manner. In the presence of BK, when MasR was not blocked, %RBF response to Ang 1-7 in OVE group was greater than OV group significantly (P < 0.05). Infusion of 300 ng kg−1 min−1 Ang 1-7 increased RBF by 6.9 ± 1.9% in OVE group versus 0.9 ± 1.8% in OV group. However when MasR was blocked, %RBF response to Ang 1-7 in OV group was greater than OVE group insignificantly. Conclusion. Coadministration of BK and A779 compared to BK alone increased RBF response to Ang 1-7 in vehicle treated rats. Such observation was not seen in estradiol treated rats.
Collapse
|
18
|
|
19
|
Odutayo A, Cherney D, Miller J, Ahmed SB, Lai V, Dunn S, Pun N, Moineddin R, Hladunewich MA. Transdermal contraception and the renin-angiotensin-aldosterone system in premenopausal women. Am J Physiol Renal Physiol 2015; 308:F535-40. [DOI: 10.1152/ajprenal.00602.2014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The oral contraceptive pill (OCP) activates the renin-angiotensin-aldosterone system (RAAS) through first-pass hepatic metabolism. Although usually benign, RAAS activation may have detrimental effects on renal and hemodynamic function in some women. Since combined hormonal contraception with the transdermal patch (EVRA) does not undergo first-pass hepatic metabolism, we hypothesized that the RAAS response would be different from that of OCP subjects. Thirty-five nonsmoking, premenopausal women (15 control subjects, 10 OCP subjects, and 10 contraceptive patch subjects) without evidence of cardiovascular disease, renal disease, or diabetes were studied. Baseline angiotensinogen, renin, angiotensin II, aldosterone, and plasma renin activity were assessed along with hormonal and hemodynamic responses to simulated orthostatic stress using incremental lower body negative pressure (LBNP; −15, −25, and −40 mmHg). Baseline levels of angiotensinogen, angiotensin II, and plasma renin activity were significantly higher in OCP subjects compared with normotensive control and contraceptive patch subjects ( P < 0.05), whereas aldosterone was significantly higher in OCP versus control subjects only ( P < 0.05). Plasma renin levels were significantly lower at baseline in contraceptive patch subjects compared with normotensive control and OCP subjects ( P < 0.05). In response to LBNP, increases in renin, angiotensin II, and aldosterone were attenuated in contraceptive patch subjects in conjunction with an exaggerated decline in mean arterial pressure ( P < 0.05 vs. control and OCP subjects). The contraceptive patch in healthy premenopausal women is associated with an impaired ability to maintain blood pressure in response to LBNP, possibly due to insensitivity of the endogenous RAAS. Further evaluation may be beneficial in women with kidney disease.
Collapse
Affiliation(s)
- Ayodele Odutayo
- Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - David Cherney
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Judith Miller
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Vesta Lai
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sheila Dunn
- Department of Family and Community Medicine, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada; and
| | - Nicole Pun
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- The Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Michelle A. Hladunewich
- Division of Nephrology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
20
|
Kim JH, Kim JS. Effects of Lycii Fructus and Lycii Folium Extracts on Osteoporosis in Ovariectomized Rats. ACTA ACUST UNITED AC 2014. [DOI: 10.3746/jkfn.2014.43.1.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
21
|
Zhao Z, Wang H, Jessup JA, Lindsey SH, Chappell MC, Groban L. Role of estrogen in diastolic dysfunction. Am J Physiol Heart Circ Physiol 2014; 306:H628-40. [PMID: 24414072 DOI: 10.1152/ajpheart.00859.2013] [Citation(s) in RCA: 136] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The prevalence of left ventricular diastolic dysfunction (LVDD) sharply increases in women after menopause and may lead to heart failure. While evidence suggests that estrogens protect the premenopausal heart from hypertension and ventricular remodeling, the specific mechanisms involved remain elusive. Moreover, whether there is a protective role of estrogens against cardiovascular disease, and specifically LVDD, continues to be controversial. Clinical and basic science have implicated activation of the renin-angiotensin-aldosterone system (RAAS), linked to the loss of ovarian estrogens, in the pathogenesis of postmenopausal diastolic dysfunction. As a consequence of increased tissue ANG II and low estrogen, a maladaptive nitric oxide synthase (NOS) system produces ROS that contribute to female sex-specific hypertensive heart disease. Recent insights from rodent models that mimic the cardiac phenotype of an estrogen-insufficient or -deficient woman (e.g., premature ovarian failure or postmenopausal), including the ovariectomized congenic mRen2.Lewis female rat, provide evidence showing that estrogen modulates the tissue RAAS and NOS system and related intracellular signaling pathways, in part via the membrane G protein-coupled receptor 30 (GPR30; also called G protein-coupled estrogen receptor 1). Complementing the cardiovascular research in this field, the echocardiographic correlates of LVDD as well as inherent limitations to its use in preclinical rodent studies will be briefly presented. Understanding the roles of estrogen and GPR30, their interactions with the local RAAS and NOS system, and the relationship of each of these to LVDD is necessary to identify new therapeutic targets and alternative treatments for diastolic heart failure that achieve the cardiovascular benefits of estrogen replacement without its side effects and contraindications.
Collapse
Affiliation(s)
- Zhuo Zhao
- Department of Cardiology, Jinan Central Hospital, Affiliated with Shandong University, Jinan, China
| | | | | | | | | | | |
Collapse
|
22
|
Zhu X, Lin J, Song Y, Liu H, Zhang R, Fan M, Li Y, Tian R, Fang D. A high-carbohydrate diet lowered blood pressure in healthy Chinese male adolescents. Biosci Trends 2014; 8:132-7. [DOI: 10.5582/bst.8.132] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
23
|
Luptáková L, Benčová D, Siváková D, Cvíčelová M. Association of CILP2 and ACE gene polymorphisms with cardiovascular risk factors in Slovak midlife women. BIOMED RESEARCH INTERNATIONAL 2013; 2013:634207. [PMID: 24350279 PMCID: PMC3854549 DOI: 10.1155/2013/634207] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 09/14/2013] [Accepted: 09/24/2013] [Indexed: 01/11/2023]
Abstract
The aim of this study is to assess the association of two polymorphisms, the cartilage intermediate layer protein 2 (CILP2) G/T and angiotensin converting enzyme (ACE) I/D, with blood pressure and anthropometrical and biochemical parameters related to the development of cardiovascular disease. The entire study sample comprised 341 women ranging in age from 39 to 65 years. The CILP2 genotypes were determined by PCR-RFLP and the ACE genotypes by PCR. The Bonferroni pairwise comparisons showed the effect of the CILP2 genotype on high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), apolipoprotein B (apoB), apoB-to-apoA1 ratio, the total cholesterol (TC)-to-HDL-C ratio, non-HDL-C, and the LDL-C-to-HDL-C ratio (P < 0.05). Here, higher mean levels of HDL-C and lower mean levels of the remaining above mentioned lipid parameters were registered in the GT/TT genotype carriers than in GG carriers. Statistically significant association was identified between the ACE genotype and the following parameters: TC, LDL-C, and non-HDL-C (P < 0.05). The II genotype can lower serum level of TC (B = 0.40), LDL-C (B = 0.37), and non-HDL-C levels. The results of this study suggest that the minor T allele of CILP2 gene and I allele of ACE gene have a protective effect against elevated serum lipid and lipoprotein levels.
Collapse
Affiliation(s)
- Lenka Luptáková
- Department of Anthropology, Faculty of Natural Sciences, Comenius University, Mlynska Dolina, 842 15 Bratislava, Slovakia
| | - Dominika Benčová
- Department of Anthropology, Faculty of Natural Sciences, Comenius University, Mlynska Dolina, 842 15 Bratislava, Slovakia
| | - Daniela Siváková
- Department of Anthropology, Faculty of Natural Sciences, Comenius University, Mlynska Dolina, 842 15 Bratislava, Slovakia
| | - Marta Cvíčelová
- Department of Anthropology, Faculty of Natural Sciences, Comenius University, Mlynska Dolina, 842 15 Bratislava, Slovakia
| |
Collapse
|
24
|
Wang H, Jessup JA, Zhao Z, Da Silva J, Lin M, MacNamara LM, Ahmad S, Chappell MC, Ferrario CM, Groban L. Characterization of the cardiac renin angiotensin system in oophorectomized and estrogen-replete mRen2.Lewis rats. PLoS One 2013; 8:e76992. [PMID: 24204720 PMCID: PMC3808369 DOI: 10.1371/journal.pone.0076992] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 08/28/2013] [Indexed: 01/19/2023] Open
Abstract
The cardioprotective effects of estrogen are well recognized, but the mechanisms remain poorly understood. Accumulating evidence suggests that the local cardiac renin-angiotensin system (RAS) is involved in the development and progression of cardiac hypertrophy, remodeling, and heart failure. Estrogen attenuates the effects of an activated circulating RAS; however, its role in regulating the cardiac RAS is unclear. Bilateral oophorectomy (OVX; n = 17) or sham-operation (Sham; n = 13) was performed in 4-week-old, female mRen2.Lewis rats. At 11 weeks of age, the rats were randomized and received either 17 β-estradiol (E2, 36 µg/pellet, 60-day release, n = 8) or vehicle (OVX-V, n = 9) for 4 weeks. The rats were sacrificed, and blood and hearts were used to determine protein and/or gene expression of circulating and tissue RAS components. E2 treatment minimized the rise in circulating angiotensin (Ang) II and aldosterone produced by loss of ovarian estrogens. Chronic E2 also attenuated OVX-associated increases in cardiac Ang II, Ang-(1–7) content, chymase gene expression, and mast cell number. Neither OVX nor OVX+E2 altered cardiac expression or activity of renin, angiotensinogen, angiotensin-converting enzyme (ACE), and Ang II type 1 receptor (AT1R). E2 treatment in OVX rats significantly decreased gene expression of MMP-9, ACE2, and Ang-(1–7) mas receptor, in comparison to sham-operated and OVX littermates. E2 treatment appears to inhibit upsurges in cardiac Ang II expression in the OVX-mRen2 rat, possibly by reducing chymase-dependent Ang II formation. Further studies are warranted to determine whether an E2-mediated reduction in cardiac chymase directly contributes to this response in OVX rats.
Collapse
Affiliation(s)
- Hao Wang
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Jewell A. Jessup
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Zhuo Zhao
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Jaqueline Da Silva
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Marina Lin
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Lindsay M. MacNamara
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Sarfaraz Ahmad
- Department of Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Mark C. Chappell
- Department of Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Carlos M. Ferrario
- Department of Internal Medicine/Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Leanne Groban
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
- Department of Hypertension and Vascular Research Center, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
- * E-mail:
| |
Collapse
|
25
|
Abstract
Numerous alterations in hormonal secretion occur with aging. In general, these tend towards a disintegration of the normal cyclic secretory patterns resulting in lower total circulating levels. In addition, declines in receptors and postreceptor function further decreases the ability of the hormonal orchestra to maintain coordinated function throughout the organism. Clues to some of these age-related changes in humans may come from the study of simpler organisms where regulatory systems are known to modulate the aging process. In particular, the interactions among the environment, hormones, and insulin receptor genes have led to new insights into the genetic control of longevity and the development of syndrome X.
Collapse
Affiliation(s)
- W A Banks
- Division of Geriatric Medicine, Saint Louis University Medical School, 915 N. Grand Blvd., St. Louis, MO 63106 ; Geriatric Research, Education and Clinical Center, St. Louis VAMC, St. Louis, MO 63125
| | | |
Collapse
|
26
|
Ribeiro RF, Potratz FF, Pavan BMM, Forechi L, Lima FLM, Fiorim J, Fernandes AA, Vassallo DV, Stefanon I. Carvedilol prevents ovariectomy-induced myocardial contractile dysfunction in female rat. PLoS One 2013; 8:e53226. [PMID: 23308166 PMCID: PMC3538779 DOI: 10.1371/journal.pone.0053226] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 11/26/2012] [Indexed: 11/18/2022] Open
Abstract
Carvedilol has beneficial effects on cardiac function in patients with heart failure but its effect on ovariectomy-induced myocardial contractile dysfunction remains unclear. Estrogen deficiency induces myocardial contractile dysfunction and increases cardiovascular disease risk in postmenopausal women. Our aim was to investigate whether carvedilol, a beta receptor blocker, would prevent ovariectomy-induced myocardial contractile dysfunction. Female rats (8 weeks old) that underwent bilateral ovariectomy were randomly assigned to receive daily treatment with carvedilol (OVX+CAR, 20 mg/kg), placebo (OVX) and SHAM for 58 days. Left ventricle papillary muscle was mounted for isometric tension recordings. The inotropic response to Ca2+ (0.62 to 3.75 mM) and isoproterenol (Iso 10−8 to 10−2 M) were assessed. Expression of calcium handling proteins was measured by western blot analysis. Carvedilol treatment in the OVX animals: prevented weight gain and slight hypertrophy, restored the reduced positive inotropic responses to Ca2+ and isoproterenol, prevented the reduction in SERCA2a expression, abolished the increase in superoxide anion production, normalized the increase in p22phox expression, and decreased serum angiotensin converting enzyme (ACE) activity. This study demonstrated that myocardial contractile dysfunction and SERCA2a down regulation were prevented by carvedilol treatment. Superoxide anion production and NADPH oxidase seem to be involved in this response.
Collapse
|
27
|
Circulating ACE is a predictor of weight loss maintenance not only in overweight and obese women, but also in men. Int J Obes (Lond) 2012; 36:1545-51. [PMID: 22270380 DOI: 10.1038/ijo.2011.278] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Circulating angiotensin-converting enzyme (ACE) was identified as a predictor of weight loss maintenance in overweight/obese women of the Diogenes project. OBJECTIVE To investigate whether ACE acted also as a predictor in men of the Diogenes study and to compare it with that in women. DESIGN Subjects, who lost ≥ 8% of body weight induced by low-caloric diet in an 8-week weight loss period, were assigned to weight loss maintenance with dietary intervention for 6 months. SUBJECTS 125 overweight/obese healthy men from eight European countries who completed whole intervention. MEASUREMENTS Concentrations and activity of serum ACE at baseline and after the 8-week weight loss, in addition to anthropometric and physiological parameters. RESULTS Serum ACE concentration decreased by 11.3 ± 10.6% during the weight loss period in men. A greater reduction is associated with less body weight regain during the maintenance period (r=0.227, P=0.012). ACE change was able to predict a weight regain ≤ 20% after 6 months, with an odds ratio of 1.59 (95% confidence interval (CI): 1.09-2.33, P=0.016) for every 10% reduction, which was independent of body mass index and weight loss. The prediction power was weaker in men than in women, but without a significant sex difference (P=0.137). In pooled subjects (N=218), the odds ratio was 1.96 (95% CI: 1.46-2.64, P<0.001). CONCLUSIONS A greater reduction of ACE during weight loss is favorable for weight maintenance in both men and women. This can offer useful information for personalized advice to improve weight loss maintenance. It also confirms the role of ACE in the metabolic pathways of weight regulation.
Collapse
|
28
|
Komukai K, Mochizuki S, Yoshimura M. Gender and the renin-angiotensin-aldosterone system. Fundam Clin Pharmacol 2011; 24:687-98. [PMID: 20608988 DOI: 10.1111/j.1472-8206.2010.00854.x] [Citation(s) in RCA: 185] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Premenopausal women are protected to some extent from cardiovascular and kidney diseases. Because this protection weakens after menopause, sex hormones are believed to play an important role in the pathogenesis of cardiovascular and kidney diseases. The cardiovascular system and the kidneys are regulated by the renin-angiotensin-aldosterone system (RAAS), which in turn, appears to be regulated by sex hormones. In general, oestrogen increases angiotensinogen levels and decreases renin levels, angiotensin-converting enzyme (ACE) activity, AT(1) receptor density, and aldosterone production. Oestrogen also activates counterparts of the RAAS such as natriuretic peptides, AT(2) receptor density, and angiotensinogen (1-7). Progesterone competes with aldosterone for mineralocorticoid receptor. Less is known about androgens, but testosterone seems to increase renin levels and ACE activity. These effects of sex hormones on the RAAS can explain at least some of the gender differences in cardiovascular and kidney diseases.
Collapse
Affiliation(s)
- Kimiaki Komukai
- Division of Cardiology, The Jikei University School of Medicine, 3-25-8 Nishi-shimbashi, Minato-ku, Tokyo 105-8461, Japan
| | | | | |
Collapse
|
29
|
Manhem K, Ghanoum B, Johansson M, Milsom I, Gustafsson H. Influence of chronic hormone replacement therapy on left ventricular mass and serum-ACE activity. Blood Press 2010; 19:295-300. [DOI: 10.3109/08037051.2010.488050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
30
|
Sumino H, Ichikawa S, Kasama S, Takahashi T, Kumakura H, Takayama Y, Kanda T, Murakami M, Kurabayashi M. Effects of raloxifene on the renin-angiotensin-aldosterone system and blood pressure in hypertensive and normotensive osteoporotic postmenopausal women. Geriatr Gerontol Int 2010; 10:70-7. [PMID: 20102385 DOI: 10.1111/j.1447-0594.2009.00562.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM An increase in blood pressure after menopause has been documented. The renin-angiotensin-aldosterone system (RAAS) plays a central role in the regulation of blood pressure and in the pathophysiology of hypertension. This study investigated the effects of raloxifene, a selective estrogen receptor modulator, on components of the RAAS and blood pressure in hypertensive and normotensive osteoporotic postmenopausal women. METHODS A total of 41 hypertensive or normotensive postmenopausal women with osteoporosis or osteopenia were divided into four groups. Eleven hypertensive and eight normotensive women received raloxifene hydrochloride (60 mg/day) p.o. for 6 months, and 12 hypertensive and 10 normotensive women did not receive raloxifene hydrochloride for 6 months. In all of the hypertensive women, blood pressure had been controlled prior to the start of the study using a variety of antihypertensive drugs other than angiotensin-converting enzyme (ACE) inhibitors, angiotensin (Ang)II type 1 receptor antagonists or diuretics. Plasma renin activity (PRA), serum ACE activity, plasma AngI, AngII and aldosterone concentrations, and blood pressure were measured before and 6 months after the start of the study. RESULTS No significant changes in PRA, ACE activity, or the AngI, AngII or aldosterone levels were observed in any of the groups. In all the groups, blood pressure remained unchanged. CONCLUSION Raloxifene may have no significant effect on the RAAS or blood pressure in hypertensive and normotensive osteoporotic postmenopausal women.
Collapse
Affiliation(s)
- Hiroyuki Sumino
- Department of Nursing, Faculty of Nursing, Takasaki University of Health and Welfare, Takasaki, Gunma, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Hormone replacement therapy – practical recommendations. Climacteric 2009. [DOI: 10.1080/13697130410001726090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
32
|
|
33
|
La Corte ALC, Carter AM, Turner AJ, Grant PJ, Hooper NM. The bradykinin-degrading aminopeptidase P is increased in women taking the oral contraceptive pill. J Renin Angiotensin Aldosterone Syst 2008; 9:221-5. [DOI: 10.1177/1470320308096405] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction. The renin-angiotensin and kininogen-kinin hormonal systems are critically involved in regulating blood pressure and are candidates in contributing to oral contraceptive pill (OCP)-induced hypertension.Angiotensin-converting enzyme (ACE) and aminopeptidase P (AP-P) are key enzymes in these systems and are both involved in the degradation of the vasodilator bradykinin. Methods. Circulating ACE and AP-P levels were measured by activity assay using selective fluorogenic peptide substrates in plasma samples from the Leeds Family Study. In addition, the effect of progesterone on the expression of AP-P and ACE was examined in cells. Results. Women on the OCP had higher age-adjusted plasma AP-P (mean [95% confidence interval]) (0.27 [0.23-0.32] nmol/min/ml (n = 53)) compared with women not on the OCP (0.17 [0.16-0.19] nmol/min/ml (n = 133), p < 0.001) or males (0.19 [0.17-0.20] nmol/min/ml (n = 209), p<0.001).There were no differences in the age-adjusted plasma ACE levels among the three groups. In HepG2 cells, progesterone treatment increased the AP-P protein and mRNA expression, whereas no effect of progesterone treatment was observed for ACE. Conclusion. Increased AP-P may result in increased breakdown of bradykinin.These data suggest that progesterone-induced increases in AP-P may contribute to the development of OCP-induced hypertension in susceptible Women.
Collapse
Affiliation(s)
- Amy L Cilia La Corte
- Proteolysis Research Group, Institute of Molecular and Cellular Biology, Faculty of Biological Sciences, and Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds LS2 9JT, UK, , Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds LS2 9JT, UK
| | - Angela M Carter
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds LS2 9JT, UK
| | - Anthony J Turner
- Proteolysis Research Group, Institute of Molecular and Cellular Biology, Faculty of Biological Sciences, and Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds LS2 9JT, UK
| | - Peter J Grant
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds LS2 9JT, UK
| | - Nigel M Hooper
- Proteolysis Research Group, Institute of Molecular and Cellular Biology, Faculty of Biological Sciences, and Leeds Institute of Genetics, Health and Therapeutics, University of Leeds, Leeds LS2 9JT, UK
| |
Collapse
|
34
|
Serrano C, Guilarte M, Tella R, Dalmau G, Bartra J, Gaig P, Cerdà M, Cardona V, Valero A. Oestrogen-dependent hereditary angio-oedema with normal C1 inhibitor: description of six new cases and review of pathogenic mechanisms and treatment. Allergy 2008; 63:735-41. [PMID: 18070231 DOI: 10.1111/j.1398-9995.2007.01579.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hereditary angio-oedema (HAE) is a rare condition in which there is a deficiency in the quantity or activity of C1 inhibitor (C1INH). Recently, an additional type of HAE with no alterations in the levels or the function of C1INH has been reported. It is defined as HAE with normal C1INH, and named type III HAE or oestrogen-dependent HAE. The aim of this study is to describe the clinical and laboratory findings of six new cases of type III HAE and to review the literature about this disease. METHODS A short description of six women with recurrent angio-oedema is provided. The characteristics of the patients are compared with the previously reported case series in a literature-based review. RESULTS The mean age of the patients at onset was 22 years (range 16-30). All of them had angio-oedema attacks during oestrogen-based contraceptive treatment and four reported episodes during pregnancy. Four patients reported a positive past family history. Two of them had experienced episodes of laryngeal oedema. None of the patients responded to corticoids or antihistamines during the attacks. Levels and functional activity of C1INH were within the normal range in all cases. CONCLUSIONS Clinical and laboratory findings mirror the observations of previous reports of oestrogen-dependent angio-oedema with normal C1INH. This is the first published series of type III HAE in Spain.
Collapse
Affiliation(s)
- C Serrano
- Unidad de Alergia, Hospital Clínic, Barcelona, Spain
| | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Effects of estradiol and the angiotensin II receptor blocker irbesartan on vascular function in postmenopausal women. Menopause 2008; 15:44-50. [PMID: 18182939 DOI: 10.1097/gme.0b013e318150d13e] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Estradiol and angiotensin receptor blockers have prominent effects on the renin-angiotensin-aldosterone system. The purpose of this study was to determine whether irbesartan, an angiotensin receptor blocker, has a greater effect on vascular function when combined with estradiol, compared with irbesartan alone, in hypertensive postmenopausal women. DESIGN Fifty-one women were studied while off any antihypertensive medications or hormone therapy at baseline and after randomization to one of four treatment arms for 12 weeks: (1) irbesartan and estradiol, (2) irbesartan and placebo, (3) estradiol and placebo, and (4) placebo/placebo. Estradiol and placebo arms served as control groups. Blood pressure, brachial reactivity, aldosterone, insulin, glucose, 24-hour urinary catecholamines, urinary sodium, and creatinine were measured. Fisher's exact test was used for comparison of differences in blood pressure in the treatment arms. Paired t test and analysis of variance were also performed for within- and between-group analysis. RESULTS A significantly larger number of women in the irbesartan and estradiol group had a decrease of 5 mm Hg or more in both systolic and diastolic blood pressures (P < 0.05) compared with irbesartan alone group. Forearm vascular reactivity was increased significantly compared with baseline (P < 0.05), and there was a significant decrease in the serum aldosterone level after treatment compared with baseline (P < 0.05) in the irbesartan and estradiol combination group. Fasting glucose and insulin, urinary sodium/creatinine ratio, and catecholamines were similar at each time point. CONCLUSIONS The results suggest that irbesartan and estradiol, when used in combination, may cause a greater lowering of blood pressure in postmenopausal hypertensive women. This effect may be mediated via increased vasodilation and lower aldosterone levels. These results warrant further testing in larger clinical trials.
Collapse
|
36
|
Affiliation(s)
- Megan Coylewright
- From the Department of Medicine (M.C., P.O.), Johns Hopkins University School of Medicine, Baltimore, Md; and Physiology and Biophysics (J.F.R.), University of Mississippi Medical Center, Jackson
| | - Jane F. Reckelhoff
- From the Department of Medicine (M.C., P.O.), Johns Hopkins University School of Medicine, Baltimore, Md; and Physiology and Biophysics (J.F.R.), University of Mississippi Medical Center, Jackson
| | - Pamela Ouyang
- From the Department of Medicine (M.C., P.O.), Johns Hopkins University School of Medicine, Baltimore, Md; and Physiology and Biophysics (J.F.R.), University of Mississippi Medical Center, Jackson
| |
Collapse
|
37
|
Menon U, Burnell M, Sharma A, Gentry-Maharaj A, Fraser L, Ryan A, Parmar M, Hunter M, Jacobs I. Decline in use of hormone therapy among postmenopausal women in the United Kingdom. Menopause 2007; 14:462-7. [PMID: 17237735 DOI: 10.1097/01.gme.0000243569.70946.9d] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There has been controversy about the results of the Women's Health Initiative and the Million Women Study and uncertainty about their impact on hormone therapy (HT) use. This study documents recent trends in HT use in postmenopausal women in the United Kingdom. DESIGN Between April 2001 and September 2005, 202,638 postmenopausal women aged 50 to 74 and with no history of bilateral oophorectomy were recruited to the United Kingdom Collaborative Trial of Ovarian Cancer Screening. The proportion of women randomized each month who were using HT was calculated. The trend in HT use was assessed with reference to the publication of the Women's Health Initiative interim results (July 2002), the Million Women Study (August 2003), and advice from the UK Committee on Safety of Medicines (December 2003). RESULTS The median number of women recruited and randomized per month was 3,955 (mean 3,744). The proportion of randomized women using HT between April 2001 and June 2002 was 29%. This was followed by a steady monthly decline, and by February to September 2005, only 10% to 11% of newly recruited women were using HT. This trend was present in all age groups. However, in current users, the average duration of HT use remained steady at 10 to 11 years. CONCLUSIONS There was a steady decline in HT use among postmenopausal women at recruitment into the United Kingdom Collaborative Trial of Ovarian Cancer Screening between April 2001 and September 2005. This is likely to reflect general trends in the UK population and is probably related to the premature closure of the large HT trials and the ensuing publicity.
Collapse
Affiliation(s)
- Usha Menon
- Department of Gynaecological Oncology, UCL Institute for Women's Health, London, UK.
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Affiliation(s)
- Nicholas R Ferreri
- Department of Pharmacology, New York Medical College, Valhalla, NY 10595, USA.
| |
Collapse
|
39
|
Méthot J, Hamelin BA, Arsenault M, Bogaty P, Plante S, Poirier P. The ACE-DD genotype is associated with endothelial dysfunction in postmenopausal women. Menopause 2007; 13:959-66. [PMID: 17003740 DOI: 10.1097/01.gme.0000243576.09065.93] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the effects of the angiotensin-converting enzyme (ACE) insertion/deletion (I/D), the angiotensinogen M235T and the angiotensin II type 1 receptor A1166C polymorphisms, and hormone therapy used on endothelial function in postmenopausal women without manifestation of coronary artery disease. DESIGN Sixty-four postmenopausal women (42 hormone therapy users and 22 hormone therapy nonusers) without clinical manifestation of coronary artery disease were evaluated using external vascular ultrasonography to measure endothelium-dependent (hyperemic response, flow-mediated dilatation) and -independent (nitroglycerin) dilatation. Genotypes were determined by polymerase chain reaction amplification. RESULTS Women with the ACE-DD genotype displayed a lower flow-mediated dilatation compared to those with the ACE-II genotype (8.4% +/- 3.9% vs 12.6% +/- 5.4%, P = 0.04). Endothelial function was not associated with the angiotensinogen M235T and anglotensin II type 1 receptor A1166C polymorphisms. ACE polymorphism seems to modulate endothelial function among postmenopausal women without hormone therapy (8.2% +/- 5.1% vs 18.4% +/- 5.9% for the DD and the II genotype, respectively, P = 0.02). However, in hormone therapy users, flow-mediated dilatation was similar according to the ACE genotypes. CONCLUSIONS Our findings suggest that ACE-I/D polymorphism is related to endothelial dysfunction in postmenopausal women. Furthermore, a potential interaction between estrogen users and ACE polymorphism on endothelial function may be present.
Collapse
Affiliation(s)
- Julie Méthot
- Quebec Heart Institute/Laval Hospital, Laval University, Ste-Foy, Quebec, Canada
| | | | | | | | | | | |
Collapse
|
40
|
Figtree GA, Kindmark A, Lind L, Grundberg E, Speller B, Robinson BG, Channon KM, Watkins H. Novel estrogen receptor alpha promoter polymorphism increases ventricular hypertrophic response to hypertension. J Steroid Biochem Mol Biol 2007; 103:110-8. [PMID: 17095210 DOI: 10.1016/j.jsbmb.2006.09.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2006] [Accepted: 09/05/2006] [Indexed: 11/16/2022]
Abstract
Given the strong genetic contribution to blood pressure and left ventricular hypertrophy (LVH), and the influence of estrogen on these parameters, we hypothesized that polymorphisms in the estrogen receptor alpha (ERalpha) promoter may influence LVH. Three novel polymorphisms were identified upstream of the ERalpha alternatively spliced exon 1E, within sequence which demonstrated significant promoter activity in vitro. Demonstration of ERalpha E isoform expression in human ventricle by RT-PCR supported a possible functional role for the 1E novel polymorphisms in estrogen signaling in the heart. Indeed, G>A (-721 E) was significantly associated with LVH after controlling for systolic blood pressure and sex in a healthy population (n=74), contributing to 23% of interventricular septum (IVS) width variance (p<0.001) and 9.4% of left ventricular mass index (LVMI) variance (p=0.035). In a separate hypertensive cohort, male carriers of the A allele (n=8) had a 17% increase in IVS (95% CI: 6-28%) and a 19% increase in LVMI (3-34%) compared to GG homozygotes (n=84). We conclude that a novel polymorphism in the promoter of a cardiac mRNA splice isoform of ERalpha is associated with LVH.
Collapse
Affiliation(s)
- G A Figtree
- Department of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK.
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Stephens JW, Dhamrait SS, Acharya J, Humphries SE, Hurel SJ. A common variant in the ACE gene is associated with peripheral neuropathy in women with type 2 diabetes mellitus. J Diabetes Complications 2006; 20:317-21. [PMID: 16949519 DOI: 10.1016/j.jdiacomp.2005.07.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2004] [Revised: 02/18/2005] [Accepted: 07/22/2005] [Indexed: 01/24/2023]
Abstract
AIMS The D allele of the ACE I/D gene variant is associated with higher tissue and serum ACE activity. Previously, studies have suggested an association between the D allele with the microvascular complications of diabetes. The aim of this study was to explore the impact of this genotype in relation to clinically manifest peripheral neuropathy (PN) in a cohort of subjects with type 2 diabetes mellitus (type 2 DM). METHODS Five hundred and seventy-two Caucasian subjects (230 females, 342 males) with type 2 DM were recruited from the diabetes clinic at University College London Hospitals NHS Trust. Clinically manifest PN was determined from a standardized clinical examination. RESULTS The ACE I/D genotype distribution was in Hardy-Weinberg equilibrium. In the whole group, no significant association was seen between genotype and PN; however, when stratified by sex, the D allele was associated with PN in females but not in males. The odds ratio (OR) for PN in the D allele carriers compared to those homozygous for the I allele was significantly higher in females [OR 2.93 (1.09-7.63), P=.027] but not in males [OR 1.2 (0.61-2.36), P=.60]. CONCLUSIONS The presence of the D allele is associated with increased risk of peripheral neuropathy in females but not in male subjects with type 2 DM, suggesting a role for the renin-angiotensin system in the development of PN.
Collapse
Affiliation(s)
- Jeffrey W Stephens
- Centre for Cardiovascular Genetics, British Heart Foundation Laboratories, Royal Free and University College London Medical School, London WC1E 6JF, UK.
| | | | | | | | | |
Collapse
|
42
|
Arenas IA, Armstrong SJ, Xu Y, Davidge ST. Tumor Necrosis Factor-α and Vascular Angiotensin II in Estrogen-Deficient Rats. Hypertension 2006; 48:497-503. [PMID: 16864744 DOI: 10.1161/01.hyp.0000235865.03528.f1] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Alterations in the vascular angiotensin II system may play a role in the pathophysiology of vascular disease after menopause. In previous studies we have shown that an increase in tumor necrosis factor (TNF)-α levels in aging rats because of estrogen deficiency may result in vascular dysfunction. In this study we investigated the effect of TNF-α inhibition in angiotensin II modulation of vascular function in aging female animals. Female rats approaching reproductive senescence (12 to 15 months old) were ovariectomized and treated with placebo, estrogen, or a selective TNF-α inhibitor (etanercept) for 4 weeks. Expression of angiotensin II in mesenteric arteries was evaluated by immunofluorescence, and the expression of angiotensin-converting enzyme and angiotensin type I receptor (AT
1
R) was investigated by Western immunoblot. Vascular function was assessed in mesenteric arteries using the myograph system, and the role of endogenous angiotensin II on adrenergic vasoconstriction was evaluated in vitro by selective AT
1
R blockade (Candesartan; 10 μmol/L). Our data demonstrate that estrogen-depleted rats have higher serum levels of TNF-α and greater sensitivity to phenylephrine vasoconstriction compared with estrogen-replaced animals, which was attenuated by AT
1
R blockade. In vivo TNF-α inhibition or estrogen replacement reduced phenylephrine constriction of mesenteric arteries and decreased the modulation of this vasoconstriction by candesartan. These functional changes were accompanied by a reduction in the vascular expression of angiotensin II, angiotensin-converting enzyme, and AT
1
R. These observations indicate that upregulation of TNF-α during estrogen deficiency may contribute to enhance vascular constriction by altering the vascular angiotensin II system.
Collapse
Affiliation(s)
- Ivan A Arenas
- Perinatal Research Centre, Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | | | | | | |
Collapse
|
43
|
Abstract
Since the first identification of renin by Tigerstedt and Bergmann in 1898, the renin-angiotensin system (RAS) has been extensively studied. The current view of the system is characterized by an increased complexity, as evidenced by the discovery of new functional components and pathways of the RAS. In recent years, the pathophysiological implications of the system have been the main focus of attention, and inhibitors of the RAS such as angiotensin-converting enzyme (ACE) inhibitors and angiotensin (ANG) II receptor blockers have become important clinical tools in the treatment of cardiovascular and renal diseases such as hypertension, heart failure, and diabetic nephropathy. Nevertheless, the tissue RAS also plays an important role in mediating diverse physiological functions. These focus not only on the classical actions of ANG on the cardiovascular system, namely, the maintenance of cardiovascular homeostasis, but also on other functions. Recently, the research efforts studying these noncardiovascular effects of the RAS have intensified, and a large body of data are now available to support the existence of numerous organ-based RAS exerting diverse physiological effects. ANG II has direct effects at the cellular level and can influence, for example, cell growth and differentiation, but also may play a role as a mediator of apoptosis. These universal paracrine and autocrine actions may be important in many organ systems and can mediate important physiological stimuli. Transgenic overexpression and knock-out strategies of RAS genes in animals have also shown a central functional role of the RAS in prenatal development. Taken together, these findings may become increasingly important in the study of organ physiology but also for a fresh look at the implications of these findings for organ pathophysiology.
Collapse
Affiliation(s)
- Martin Paul
- Institute of Clinical Pharmacology and Toxicology, Campus Benjamin Franklin, Charité-University Medicine Berlin, Berlin, Germany
| | | | | |
Collapse
|
44
|
Moran CN, Vassilopoulos C, Tsiokanos A, Jamurtas AZ, Bailey MES, Montgomery HE, Wilson RH, Pitsiladis YP. The associations of ACE polymorphisms with physical, physiological and skill parameters in adolescents. Eur J Hum Genet 2006; 14:332-9. [PMID: 16391565 DOI: 10.1038/sj.ejhg.5201550] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Genetic variation in the human Angiotensin I-Converting Enzyme (ACE) gene has been associated with many heritable traits, including physical performance. Herein we report the results of a study of several physical, physiological and skill parameters and lifestyle in 1,027 teenage Greeks. We show that there is a strong association (P < 0.001) between the ACE I/D (insertion/deletion) polymorphism and both handgrip strength and vertical jump in females, homozygotes for the I-allele exhibiting higher performance-related phenotype scores, accounting for up to 4.5% of the phenotypic variance. The association is best explained by a model in which the D-allele is dominant, with the mean phenotypic value in the I/D heterozygotes being close to that of the mean of the DD homozygotes. The association acts across the phenotype distribution in a classical polygenic manner. Other polymorphisms that define major ACE haplotypes in European populations (rs4424958, rs4311) show weaker associations with these performance-related phenotypes than does I/D. Similarly, diplotypes defined by these polymorphisms do not explain significantly larger amounts of the variance than I/D alone. As ACE I/D is the polymorphism most strongly associated with circulating ACE activity in European populations, we propose that the functional allelic differences that influence ACE activity also mediate the associations with the performance-related phenotypes studied here.
Collapse
Affiliation(s)
- Colin N Moran
- Institute of Diet, Exercise and Lifestyle, IDEAL, Institute of Biomedical and Life Sciences, University of Glasgow, Glasgow, UK
| | | | | | | | | | | | | | | |
Collapse
|
45
|
|
46
|
García MP, Giménez J, Serna M, Salom MG, Bonacasa B, Carbonell LF, Quesada T, Hernández I. Effect of estrogen and angiotensin-converting enzyme inhibitor on vascular remodeling in ovariectomized spontaneously hypertensive rats. Menopause 2006; 13:397-403. [PMID: 16735936 DOI: 10.1097/01.gme.0000222472.08593.e4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The present study evaluated whether estrogen influences the effect of angiotensin-converting enzyme inhibition in preventing the vascular remodeling induced by hypertension and also investigated the signal mechanism involved in that effect. DESIGN Ten-week-old female spontaneously hypertensive rats were ovariectomized (OVX) and randomly assigned to the groups: untreated OVX and treated with 17beta-estradiol (estradiol, 1.5 mg) and/or captopril (5 mg/kg/day). Evolution of systolic blood pressure was determined until 18 weeks. At that time, the heart and mesentery were excised. Structural changes in coronary vessels were quantified by an image analyzer. Inmunoblotting was performed on mesenteric arteries for determination of phosphorylated (ERK1/2). RESULTS Estradiol treatment enhanced the antihypertensive effect of captopril in OVX rats. Treatment with captopril slightly modified the media cross-sectional area and wall-to-lumen of myocardial arterioles from OVX spontaneously hypertensive rats, whereas coadministration of captopril and estradiol significantly reduced the media cross-sectional area, wall-to-lumen ratio, and perivascular fibrosis in OVX spontaneously hypertensive rats. Captopril alone did not significantly inhibit extracellular signal-regulated kinase 1/2 phosphorylation, whereas coadministration of captopril and estradiol significantly attenuated this parameter. CONCLUSIONS These results indicate that estrogen may enhance the angiotensin-converting enzyme inhibition-mediated improvement of vascular remodeling in hypertension, which may be partly mediated via inhibition of extracellular signal-regulated kinase 1/2.
Collapse
Affiliation(s)
- Maria P García
- Department of Physiology, Facultad de Medicina, Universidad de Murcia, Murcia, Spain
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Iwakura A, Shastry S, Luedemann C, Hamada H, Kawamoto A, Kishore R, Zhu Y, Qin G, Silver M, Thorne T, Eaton L, Masuda H, Asahara T, Losordo DW. Estradiol enhances recovery after myocardial infarction by augmenting incorporation of bone marrow-derived endothelial progenitor cells into sites of ischemia-induced neovascularization via endothelial nitric oxide synthase-mediated activation of matrix metalloproteinase-9. Circulation 2006; 113:1605-14. [PMID: 16534014 DOI: 10.1161/circulationaha.105.553925] [Citation(s) in RCA: 163] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Recent data have indicated that estradiol can modulate the kinetics of endothelial progenitor cells (EPCs) via endothelial nitric oxide synthase (eNOS)-dependent mechanisms. We hypothesized that estradiol could augment the incorporation of bone marrow (BM)-derived EPCs into sites of ischemia-induced neovascularization, resulting in protection from ischemic injury. METHODS AND RESULTS Myocardial infarction (MI) was induced by ligation of the left coronary artery in ovariectomized mice receiving either 17beta-estradiol or placebo. Estradiol induced significant increases in circulating EPCs 2 and 3 weeks after MI in estradiol-treated animals, and capillary density was significantly greater in estradiol-treated animals. Greater numbers of BM-derived EPCs were observed at ischemic sites in estradiol-treated animals than in placebo-treated animals 1 and 4 weeks after MI. In eNOS-null mice, the effect of estradiol on mobilization of EPCs was lost, as was the functional improvement in recovery from acute myocardial ischemia. A decrease was found in matrix metalloproteinase-9 (MMP-9) expression in eNOS-null mice under basal and estradiol-stimulated conditions after MI, the mobilization of EPCs by estradiol was lost in MMP-9-null mice, and the functional benefit conferred by estradiol treatment after MI in wild-type mice was significantly attenuated. CONCLUSIONS Estradiol preserves the integrity of ischemic tissue by augmenting the mobilization and incorporation of BM-derived EPCs into sites of neovascularization by eNOS-mediated augmentation of MMP-9 expression in the BM. Moreover, these data have broader implications with regard to our understanding of the role of EPCs in post-MI recovery and on the sex discrepancy in cardiac events.
Collapse
Affiliation(s)
- Atsushi Iwakura
- Division of Cardiovascular Research, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
48
|
Valencia JC, Pacheco-Rodriguez G, Carmona AK, Xavier J, Bruneval P, Riemenschneider WK, Ikeda Y, Yu ZX, Ferrans VJ, Moss J. Tissue-specific renin-angiotensin system in pulmonary lymphangioleiomyomatosis. Am J Respir Cell Mol Biol 2006; 35:40-7. [PMID: 16474096 PMCID: PMC2658696 DOI: 10.1165/rcmb.2005-0387oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Lymphangioleiomyomatosis (LAM), a multisystem disease found in middle-aged women, is characterized by cystic lung destruction and abdominal tumors (e.g., angiomyolipomas, lymphangioleimyomas), resulting from proliferation of abnormal-appearing, smooth muscle-like cells (LAM cells). The LAM cells, in combination with other cells, form nodular structures within the lung interstitium and in the walls of the cysts. LAM cells contain mutations in the tuberous sclerosis complex TSC1 and/or TSC2 genes, which lead to dysregulation of the mammalian target of rapamycin, affecting cell growth and proliferation. Proliferation and migration of vascular smooth muscle cells and production of angiogenic factors are regulated, in part, by angiotensin II. To determine whether a LAM-specific renin-angiotensin system might play a role in the pathogenesis of LAM, we investigated the expression of genes and gene products of this system in LAM nodules. mRNA for angiotensinogen was present in RNA isolated by laser-captured microdissection from LAM nodules. Angiotensin I-converting enzyme and chymase-producing mast cells were present within the LAM nodules. We detected renin in LAM cells, as determined by the presence of mRNA and immunohistochemistry. Angiotensin II type 1 and type II receptors were identified in LAM cells by immunohistochemistry and immunoblotting of microdissected LAM nodules. Angiotensin II is localized in cells containing alpha-smooth muscle actin (LAM cells). A LAM-specific renin-angiotensin system appears to function within the LAM nodule as an autocrine system that could promote LAM cell proliferation and migration, and could represent a pharmacologic target.
Collapse
Affiliation(s)
- Julio C Valencia
- Pulmonary-Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Méthot J, Hamelin BA, Bogaty P, Arsenault M, Plante S, Poirier P. ACE-DD genotype is associated with the occurrence of acute coronary syndrome in postmenopausal women. Int J Cardiol 2005; 105:308-14. [PMID: 16274774 DOI: 10.1016/j.ijcard.2005.02.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2004] [Revised: 02/15/2005] [Accepted: 02/18/2005] [Indexed: 11/29/2022]
Abstract
The insertion/deletion (I/D) polymorphism of the angiotensin converting enzyme (ACE), the A1166C polymorphism in the angiotensin type 1 receptor (AT1R), and the M235T polymorphism of the angiotensinogen gene are associated with cardiovascular disease mostly in men. Few data are available on the effects of these genetic variations in postmenopausal women according to hormone replacement therapy (HRT) use. In this case-control study, we determine the frequency of mutant alleles in the ACE I/D, M235T and A1166C polymorphisms in postmenopausal Caucasian women with and without a diagnosis of acute coronary syndrome (ACS). Data from 198 women with ACS (63+/-10 years) and 149 controls (62+/-7 years) showed that ACE-DD genotype was more prevalent in women with ACS compared to controls (30% vs. 19%, P<0.05). There was no difference in genotype distributions for either the M235T or the A1166C polymorphisms between groups. The difference in ACE genotype distribution between ACS women and controls was driven by current HRT users with 30% of ACS and 15% of controls carrying the ACE-DD genotype (P<0.05). The oligenic combination of ACE-DD and M235T-TT genotypes was higher in ACS compared to controls. Among carriers of M235T-TT, 7% of ACS and 1% of controls also had the ACE-DD genotype, P<0.05. Thus, the ACE-DD genotype may be associated with ACS in postmenopausal women, particularly in HRT users.
Collapse
Affiliation(s)
- Julie Méthot
- Quebec Heart Institute, Laval Hospital, 2725 Chemin Ste-Foy, Ste-Foy, Quebec, Canada, G1V 4G5
| | | | | | | | | | | |
Collapse
|
50
|
Pretorius M, Luther JM, Murphey LJ, Vaughan DE, Brown NJ. Angiotensin-converting enzyme inhibition increases basal vascular tissue plasminogen activator release in women but not in men. Arterioscler Thromb Vasc Biol 2005; 25:2435-40. [PMID: 16166566 DOI: 10.1161/01.atv.0000186185.13977.94] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Angiotensin-converting enzyme inhibition (ACEI) increases vascular tissue plasminogen activator (t-PA) release through endogenous bradykinin (BK). We tested the hypothesis that gender influences the effect of ACEI on t-PA release. METHODS AND RESULTS We measured the effect of intra-arterial enalaprilat (0.33 microg/min per 100 mL forearm volume) on forearm blood flow (FBF) and net t-PA release before and during BK (25 to 400 ng/min) and methacholine (3.2 to 12.8 microg/min) in premenopausal women, postmenopausal women not using hormone replacement, young men, and older men. Baseline net t-PA release was similar among groups. Enalaprilat increased basal t-PA release in premenopausal (from 0.9+/-1.0 to 5.1+/-1.7 ng/min per 100 mL, P=0.023) and postmenopausal women (from -3.9+/-2.2 to 3.9+/-1.1 ng/min per 100 mL, P=0.010) but not in young or older men (P=0.028 men versus women). Enalaprilat potentiated the effect of exogenous BK on FBF similarly in all groups. However, during enalaprilat, BK-stimulated t-PA release was greatest in premenopausal women (339.9+/-86.4 ng/min per 100 mL at the 100 ng/min dose, P<0.05 versus any other group), intermediate in postmenopausal women (243.8+/-51.1 ng/min per 100 mL, P<0.05 versus either male group), and least in young (111.9+/-19.2 ng/min/100 mL) and older men (103.4+/-27.6 ng/min/100 mL). CONCLUSIONS ACEI enhances basal t-PA release in women, independent of menopausal status, but not in men. During ACEI, both gender and menopausal status affect BK stimulated t-PA release.
Collapse
Affiliation(s)
- Mias Pretorius
- Veterans Affairs Medical Center, Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | | | | | | | | |
Collapse
|