Preventive cardiology

Molecular Mechanisms, Physiological Consequences and Pharmacological Implications of Estrogen Receptor Action

The estrogen receptors (ERs), ERalpha and ERbeta, play a central role in mediating the biological effects of estrogen. The transcription rate of estrogen target genes is determined by several parameters including the type of ligand, estrogen receptor subtype and isoform, as well as interactions with receptor-binding cofactor proteins. The ERs regulate gene expression by binding to specific response element sequences in the promoters of estrogen target genes. Alternative pathways have also been described in which the ERs modulate transcription indirectly, via protein : protein interactions. In this regulatory mode, which has been traced to activator protein (AP)-1-, cyclic adenosine monophosphate (cAMP)-, and Sp1-response elements, the ERs appear to be tethered to target gene promoters via heterologous transcription factors. It has been found that ERalpha and ERbeta have opposite effects on transcription mediated via the indirect mode of action. Moreover, recent studies suggest that ERbeta may inhibit the stimulatory effects of ERalpha on cellular proliferation. Estrogen is a key regulatory hormone that affects numerous physiological processes. Estrogen is required for female pubertal development and affects growth, differentiation and function of the female reproductive system. It has recently been suggested that estrogen also has an important role in the male urogenital tract. In addition, estrogens have profound effects in other tissues. For instance, in the skeleton estrogen prevents bone-resorption by inhibition of osteoclast function. Numerous reports have suggested that estrogen has a beneficial effect in the cardiovascular system and in the CNS; however, this has not been confirmed in randomized clinical trials. In fact, a large randomized trial on healthy postmenopausal women receiving oral estrogen plus progestin showed an increased incidence of cardiovascular disease. In addition, this study revealed an increased risk for dementia and impaired cognitive function in the group receiving oral estrogen/progestin. Additional clinical trials are required to determine which hormonal component causes these health risks or whether the effects were due to the combination of estrogen and progestin.

Lipoprotein-associated PLA2 inhibition--a novel, non-lipid lowering strategy for atherosclerosis therapy

Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a serine lipase that is associated with low density lipoprotein (LDL) in human plasma. Substrates include oxidised phosphatidylcholine (PC), which is hydrolysed by Lp-PLA2 to lyso-PC and oxidised fatty acids. Both products are bioactive and proinflammatory, and implicated in monocyte infiltration into the developing plaque, deposition of foam cells, and plaque progression and instability. Lp-PLA2 has recently been shown to be a risk factor for coronary events in previously asymptomatic, hypercholesterolaemic men. A series of azetidinones was designed as potent and selective inhibitors of this enzyme; SB-222657 inhibited release of the chemotactic cleavage products from oxidised LDL, and SB-244323 reduced atherosclerotic plaque development in a 3 month rabbit study. A series of pyrimidones has been designed from a screening hit, and nanomolar inhibitors identified. Oral efficacy in inhibiting plasma Lp-PLA2 in rabbits has been demonstrated with a variety of structural classes.

Selective estrogen receptor modulators and coronary heart disease

The vasculature has been recognized as an important target of estrogen action through rapid non-genomic effects and/or via the classic pathway (genomic effects) involving estrogen receptors (ER-alpha and ER-beta). Multiple mechanisms participate in the regulation of different estrogen-controlled genes, providing a wide spectrum of possibilities for development of drugs, including pure agonists or antagonists or mixed agonists/antagonists, the so-called selective estrogen receptor modulators (SERM). In theory, an ideal SERM should reduce the risks of coronary heart disease (CHD) and preserve bone density, without or with very low incidences of breast and endometrial neoplasms or venous thromboembolism (VTE). The precise mechanism for the protective effects of estrogens and their receptors on cardiovascular diseases is not yet fully established. In this review, we summarize the recent advances in understanding the action of ERs/ligands, the therapeutic implications for CHD, and highlight the recent progress of both clinical and basic studies on the protection issue. Finally, a number of newly developed SERMs and their clinical applications as well as the laboratory investigations are discussed.