Early inflammation precedes cardiac fibrosis and heart failure in desmoglein 2 murine model of arrhythmogenic cardiomyopathy.

The study of a desmoglein 2 murine model of arrhythmogenic cardiomyopathy revealed cardiac inflammation as a key early event leading to fibrosis. Arrhythmogenic cardiomyopathy (AC) is an inherited heart muscle disorder leading to ventricular arrhythmias and heart failure due to abnormalities in the cardiac desmosome. We examined how loss of desmoglein 2 (Dsg2) in the young murine heart leads to development of AC. Apoptosis was an early cellular phenotype, and RNA sequencing analysis revealed early activation of inflammatory-associated pathways in Dsg2-null (Dsg2-/-) hearts at postnatal day 14 (2 weeks) that were absent in the fibrotic heart of adult mice (10 weeks). This included upregulation of iRhom2/ADAM17 and its associated pro-inflammatory cytokines and receptors such as TNFα, IL6R and IL-6. Furthermore, genes linked to specific macrophage populations were also upregulated. This suggests cardiomyocyte stress triggers an early immune response to clear apoptotic cells allowing tissue remodelling later on in the fibrotic heart. Our analysis at the early disease stage suggests cardiac inflammation is an important response and may be one of the mechanisms responsible for AC disease progression.

Cardiovascular risk assessment in women - an update.

Cardiovascular disease is the leading cause of morbidity and mortality in postmenopausal women. Although it is a disease of aging, vascular disease initiates much earlier in life. Thus, there is a need to be aware of the potential to prevent the development of the disease from an early age and continue this surveillance throughout life. The menopausal period and early menopause present an ideal opportunity to assess cardiovascular risk and plan accordingly. Generally in this period, women will be seen by primary health-care professionals and non-cardiovascular specialists. This review addresses female-specific risk factors that may contribute to the potential development of cardiovascular disease. It is important for all health-care professionals dealing with women in midlife and beyond to be cognisant of these risk factors and to initiate female-specific preventative measures or to refer to a cardiovascular specialist.

Fluorescence-labeled reporter gene in transgenic mice provides a useful tool for investigating cutaneous innervation.

B6.Cg-Tg(Thy1-YFP)16Jrs/J transgenic mice were created to express the yellow fluorescent protein gene driven by a mouse Thy1 promoter that labeled motor and sensory neurons such that individual nerves could be followed. These mice were used to identify nerves in the skin that innervate the erector pili and panniculus carnosus muscle. Whole mounts demonstrated yellow fluorescent protein expression in nerves of the skin, which was confirmed by labeling the neuromuscular junction with fluorescinated α-bungarotoxin. Frozen and paraffin-embedded skin sections revealed innervation of the panniculus carnosus muscle. Paraffin sections labeled with an anti-green fluorescent protein antibody revealed innervation of the panniculus carnosus as well as the erector pili muscle and around the hair follicle bulge.

Group support to improve psychosocial well-being and primary-care demands among women with cardiac syndrome X.

BACKGROUND: Women with angina pectoris, a positive exercise electrocardiogram (ECG) for myocardial ischemia and angiographically smooth coronary arteries (cardiac syndrome X), are often characterized by unresolved symptomatology and a poor quality of life. Psychological morbidity and quality of life appear to be related to social support and social isolation. An investigation of group support as an aid to treatment for cardiac syndrome X was therefore undertaken. METHODS: Forty-nine women with cardiac syndrome X (mean ± standard deviation 61.8 ± 8 years) were randomized to 12 monthly support group meetings or usual care control. The Health Anxiety Questionnaire (HAQ), Hospital Anxiety and Depression Scale (HADS), SF-36, York Angina Beliefs scale, ENRICHD Social Support Instrument (ESSI) and a demographic information scale, along with hospital admissions, general practitioner (GP) or cardiologist appointments were measured at baseline, 6 months and 12 months. RESULTS: Support group participants maintained higher levels of social support than controls (ESSI score, 17.18 ± 5.35 vs. 14.45 ± 6.98, p = 0.008). Near significant improvements in health beliefs total score (p = 0.068) and threat perception (p = 0.062) were found among the support group compared to the control; 29% of support patients had made one or more GP visits over the duration of the study, compared with 54% of the control group (p = 0.06). CONCLUSION: Support group participation maintains social support and may reduce health-care demands and misconceived health beliefs among patients with cardiac syndrome X.

Eating-related anxiety in individuals with eating disorders.

Although previous research has supported the importance of anxiety as an etiological and maintenance factor for eating disorders, the specific mechanisms are not well understood. The role of anxiety in the context of eating behavior is especially unclear. The purpose of this study was to identify anxiety-eliciting eating situations and anxiety management strategies patients use to mitigate anxiety experienced in the context of eating as determined by diagnostic groups and symptom patterns. Fifty-three eating disorder outpatients were administered the Eating and Anxiety Questionnaire (EAQ) and the Eating Disorder Diagnostic Scale. Ratings indicated significant anxiety in most eating situations, whereas management strategies were more limited yet regularly employed. Factor analysis of the EAQ revealed a 6-factor solution for anxiety management strategies and a 4-factor solution for anxiety-eliciting situations. These results indicate patients with eating disorders report high levels of anxiety associated with eating behaviors but utilize limited yet consistent anxiety management strategies. Effective intervention strategies for managing eating-related anxiety should be incorporated into treatment and may need to be specified for different diagnostic subgroups.

Esterified estrogens combined with methyltestosterone improve emotional well-being in postmenopausal women with chest pain and normal coronary angiograms.

OBJECTIVE: The cardiac syndrome X is described as the triad of angina pectoris, a positive exercise test for myocardial ischemia, and angiographically smooth coronary arteries. Although syndrome X does not result in an increased risk of cardiovascular mortality, the symptoms are often troublesome and unresponsive to conventional antianginal therapy. The majority of patients are postmenopausal, and estrogen therapy can alleviate anginal symptoms. We investigated the effect of esterified estrogens combined with methyltestosterone (Estratest) on quality of life in postmenopausal women with syndrome X. DESIGN: Patients were withdrawn from antianginal therapy. Sublingual nitrates were allowed for treatment of anginal episodes. Patients underwent treadmill testing, and quality of life was assessed by using the Short Form-36 and Cardiac Health Profile questionnaires after the women had received 8 weeks of Estratest or identical placebo in a randomized, double-blind, cross-over study. RESULTS: Nineteen patients were randomized, and 16 patients completed the protocol. Plasma 17beta-estradiol concentrations were significantly increased by Estratest; however, total testosterone levels were not. The "emotional" score of the Cardiac Health Profile questionnaire was significantly improved after Estratest use compared with placebo (p = 0.03); however, there was no significant change in the Short Form-36 questionnaire for any variable. Estratest significantly increased systolic blood pressure and rate pressure product at rest but had no effect on exercise parameters. Time to onset of chest pain during exercise was also unaffected. CONCLUSIONS: We have demonstrated a beneficial effect of Estratest on emotional well-being in postmenopausal women with cardiological syndrome X. There was no significant treatment effect on exercise parameters, including time to onset of chest pain.

Effect of sex hormones on cardiac mass.

Increased left-ventricular mass is an important cardiovascular risk factor for morbidity and mortality. Apart from obvious differences in cardiac size, the changes in left-ventricular mass in response to age and hypertrophic stimuli are very different in men and women. Whereas left-ventricular mass increases with age in apparently healthy women, it remains constant in men. Under increased cardiac loading conditions, such as hypertension or aortic stenosis, this disparity between sexes is even more striking. Findings are especially pronounced in people aged 50 years or older, in whom reproductive hormone concentrations have fallen. Whether the differences in left-ventricular mass changes are related to endogenous sex-hormone concentrations has never been shown. Androgens have anabolic effects on cardiac cells, and oestrogens have antiproliferative properties, we therefore postulate that the normal decline in endogenous sex hormones with age has contrary effects on ventricular mass in men and women in normal and pathological states.

Natural progesterone, but not medroxyprogesterone acetate, enhances the beneficial effect of estrogen on exercise-induced myocardial ischemia in postmenopausal women.

OBJECTIVES: We sought to compare the effects of estrogen/transvaginal progesterone gel with estrogen/medroxyprogesterone acetate (MPA) on exercise-induced myocardial ischemia in postmenopausal women with coronary artery disease or previous myocardial infarction, or both. BACKGROUND: Estrogen therapy beneficially affects exercise-induced myocardial ischemia in postmenopausal women; however, women with an intact uterus also take progestin to protect against uterine malignancies. The effects of combination estrogen/progestin therapy on myocardial ischemia are unknown. METHODS: Eighteen postmenopausal women (mean +/- SD age 59+/-7 years) were given 17-beta-estradiol in single-blinded manner for four weeks (1 mg/day for three weeks then 2 mg/day for one week). Estradiol (2 mg/day) was then continued, and the patients were randomized (double-blind) for 12 days to either transvaginal progesterone gel (90 mg on alternate days) and oral MPA placebo (10 mg/day), or vice versa. After another two weeks on estradiol alone, the patients crossed over to progestin treatment and repeated the protocol on the opposite treatment. Patients underwent treadmill exercise testing after each estradiol phase and at day 10 of each progestin phase. RESULTS: Exercise time to myocardial ischemia increased after the first estrogen phase as compared with baseline (mean difference with 95% confidence interval [CI]: 72 s [34 to 110], p = 0.001), and was increased by combination estradiol/progesterone therapy as compared with estradiol/MPA therapy (92 s [35 to 149], p = 0.001)). Two patients (11%) were withdrawn while taking estradiol/MPA owing to unstable angina. CONCLUSIONS: Combination estrogen/transvaginal progesterone gel increases exercise time to myocardial ischemia, as compared with estrogen/MPA. These results imply that the choice of progestin in women at higher cardiovascular risk requires careful consideration.

17beta-estradiol decreases endothelin-1 levels in the coronary circulation of postmenopausal women with coronary artery disease.

BACKGROUND: Estrogen reverses acetylcholine-induced coronary vasoconstriction via the possible facilitation of endothelium-derived NO. Estrogen also affects endothelium-derived constrictor factors. We therefore investigated the effects of 17beta-estradiol on coronary vasomotor responses to substance P (SP), and coronary sinus endothelin-1 and NO metabolite levels in postmenopausal women with coronary heart disease. METHODS AND RESULTS: We studied 20 women; 14 received estrogen (mean age 65+/-2 years) and 6 served as ethanol control subjects (age 63+/-3 years). Intracoronary infusions of papaverine (8 mg) and SP were administered before and 20 minutes after 50 pg/min 17beta-estradiol or 0.2 microL/min control. Coronary blood flow was calculated from the diameter, as measured with quantitative coronary angiography, and flow velocity, as measured with intracoronary Doppler. Coronary sinus plasma endothelin-1 and nitrite/nitrate (NO(2)/NO(3)) were measured at baseline, at peak velocity response to each infusion, and every 5 minutes during the estradiol infusion. Endothelin-1 levels were decreased after 20 minutes of estradiol (1.12+/-0.18 versus 0.86+/-0.17 pmol/L baseline2 versus estradiol, P:=0.05). Endothelin-1 levels to SP decreased after 17beta-estradiol (1.29+/-0. 18 versus 1.04+/-0.15 and 1.3+/-0.16 versus 0.99+/-0.17 pmol/L for before versus after estradiol, 10 and 25 pmol/min SP; both P:<0.05). NO(2)/NO(3) levels did not change. There was no change in vasomotor responses to estradiol alone or to papaverine or SP before versus after estradiol. CONCLUSIONS: Short-term intracoronary 17beta-estradiol administration decreases coronary endothelin-1 levels. There was no enhancement of vasomotor responses to SP after the administration of estrogen, suggesting that the effects of estrogen on coronary acetylcholine responses may be a specific and not a generalized effect on coronary vasoreactivity.

Tamoxifen acutely relaxes coronary arteries by an endothelium-, nitric oxide-, and estrogen receptor-dependent mechanism.

In epidemiological studies tamoxifen has been associated with a reduction in the incidence of fatal myocardial infarction in women. However, the effects of tamoxifen on coronary artery reactivity are unknown. We hypothesized that tamoxifen would relax precontracted isolated rabbit coronary arteries. Rings of coronary artery from adult male and nonpregnant female New Zealand White rabbits were suspended in organ baths containing Krebs' solution; isometric tension was measured. Tamoxifen (0.1-100 microM) induced significant endothelium-dependent relaxation in precontracted rabbit coronary arteries. This relaxation was inhibited by N(omega)-nitro-L-arginine methyl ester and the estrogen receptor antagonist ICI 182,780. There was no significant effect on calcium concentration-dependent contraction curves. These data suggest that tamoxifen has beneficial effects on coronary reactivity that could, at least in part, account for the reduction in risk of fatal myocardial infarction in women taking tamoxifen.

Testosterone enhances flow-mediated brachial artery reactivity in men with coronary artery disease.

Acute administration of high-dose testosterone in men with coronary artery disease improves endothelial function.

Plant-derived estrogens relax coronary arteries in vitro by a calcium antagonistic mechanism.

OBJECTIVES: To investigate the potential for plant derived estrogens (phytoestrogens) genistein, phloretin, biochanin A and zearalanone to relax rabbit coronary arteries in vitro and to determine the mechanism(s) of such relaxation. BACKGROUND: Epidemiological data suggests a reduction in the incidence of coronary heart disease in humans who have a high intake of phytoestrogens. METHODS: Isolated rabbit coronary artery rings were suspended in individual organ baths, precontracted with potassium chloride (30 mM), and the relaxing effects and mechanisms of relaxation to genistein, phloretin, biochanin A and zearalanone were determined by measurement of isometric tension. RESULTS: Genistein, phloretin and biochanin A induced significant gender-independent relaxation in rings with and without endothelium. Inhibition of nitric oxide and prostaglandin synthesis with L-NAME and indomethacin had no effect on genistein-induced relaxation. Relaxation was unaffected by the specific estrogen receptor antagonist ICI 182,780, the ATP-sensitive potassium channel inhibitor glibenclamide and the potassium channel inhibitor, barium chloride. Calcium concentration-dependent contraction curves in high potassium depolarization medium were significantly shifted to the right and downward after incubation with genistein and zearalanone. An inhibitory effect of genistein (2 microM) on L-type calcium current in guinea-pig ventricular myocytes confirmed a calcium antagonist relaxing mechanism of action. In healthy volunteers, plasma genistein levels of approximately 2 microM are achieved after ingestion of a commercially available soy protein drink (Supro) containing 37 mg genistein. CONCLUSIONS: This study demonstrates that phytoestrogens induce endothelium-independent relaxation of coronary arteries; the mechanism involves calcium antagonism. These mechanisms may contribute to the potential long-term cardiovascular protective effect of these substances.

Effects of testosterone on coronary vasomotor regulation in men with coronary heart disease.

BACKGROUND: The increased incidence of coronary artery disease in men compared with premenopausal women suggests a detrimental role of male hormones on the cardiovascular system. However, testosterone has direct relaxing effects on coronary arteries in animals, as shown both in vitro and in vivo. The effect of testosterone on the human coronary circulation remains unknown. METHODS AND RESULTS: We studied 13 men (aged 61+/-11 years) with coronary artery disease. They underwent measurement of coronary artery diameter and blood flow after a 3-minute intracoronary infusion of vehicle control (ethanol) followed by 2-minute intracoronary infusions of acetylcholine (10(-7) to 10(-5) mol/L) until peak velocity response. A dose-response curve to 3-minute infusions of testosterone (10(-10) to 10(-7) mol/L) was then determined, and the acetylcholine infusions were repeated. Finally, an intracoronary bolus of isosorbide dinitrate (1000 microgram) was given. Coronary blood flow was calculated from measurements of blood flow velocity using intracoronary Doppler and coronary artery diameter using quantitative coronary angiography. Testosterone significantly increased coronary artery diameter compared with baseline (2.78+/-0. 74 mm versus 2.86+/-0.72 mm [P=0.05], 2.87+/-0.71 mm [P=0.038], and 2.90+/-0.75 mm [P=0.005] for baseline versus testosterone 10(-9) to 10(-7) mol/L, respectively). A significant increase in coronary blood flow occurred at all concentrations of testosterone compared with baseline (geometric mean [95% CI]: 32 [25, 42] versus 36.3 [27, 48] (P=0.006), 35.3 [26, 47] (P=0.029), 36.8 [28, 49] (P=0.002), and 37 [28, 48] (P=0.002), mL/min for baseline versus testosterone 10(-10) to 10(-7) mol/L, respectively). No differences existed in coronary diameter or blood flow responses to acetylcholine before versus after testosterone. CONCLUSIONS: Short-term intracoronary administration of testosterone, at physiological concentrations, induces coronary artery dilatation and increases coronary blood flow in men with established coronary artery disease.

Raloxifene acutely relaxes rabbit coronary arteries in vitro by an estrogen receptor-dependent and nitric oxide-dependent mechanism.

BACKGROUND: Selective estrogen receptor modulators (SERMs) have been defined as compounds that display tissue specificity with regard to estrogenic effects. They appear to share the beneficial effects of estrogen on bone and lipids but are not associated with an increased risk of breast or uterine carcinoma. Estrogen relaxes coronary arteries and has long-term protective effects on the vascular system. The effect of SERMs on the coronary vasculature is unknown. We therefore investigated the effects of the SERM raloxifene on isolated rabbit coronary arteries. METHODS AND RESULTS: Rings of coronary artery from adult male and nonpregnant female New Zealand White rabbits were suspended in organ baths containing Krebs solution; isometric tension was then measured. Raloxifene induced coronary arterial relaxation in male and female coronary arteries by an endothelium-dependent and estrogen receptor-dependent mechanism involving nitric oxide. Raloxifene also had a direct calcium antagonistic effect on the coronary myocyte. Estrogen, however, induced only endothelium-independent coronary arterial relaxation. The endothelium-dependent component of relaxation induced by raloxifene 10(-6) mol/L resulted in almost 100% (79+/-7% versus 43+/-3%, P<0.001) more relaxation than that induced by estrogen 10(-6) mol/L. CONCLUSIONS: These data demonstrate that raloxifene has vascular relaxing properties. The surprising finding is that the receptor-dependent effects via the endothelium are observed in coronary arteries from both male and female animals.

Effect of acute testosterone on myocardial ischemia in men with coronary artery disease.

The effect of acute testosterone administration on exercise-induced myocardial ischemia was assessed in 14 men with coronary artery disease and low plasma testosterone concentrations in a study of randomized, double-blind, crossover design. Testosterone increased time to 1-mm ST-segment depression compared with placebo by 66 (15 to 117) seconds (p = 0.016), suggesting a beneficial effect of testosterone on myocardial ischemia in these patients.

The effect of angiotensin converting enzyme inhibition on myocardial function and blood pressure after coronary artery bypass surgery--a randomised study.

OBJECTIVE: To investigate the effect of 6 weeks' pre-operative treatment with the angiotensin converting enzyme inhibitor, quinapril, on left ventricular function when measured 3 months after coronary artery bypass graft surgery and to examine the safety of such treatment. PATIENTS AND METHODS: Patients (96) [86 males, 10 females; mean age 61 years] with chronic stable angina, on the waiting list for coronary artery bypass graft surgery, underwent measurement of left ventricular function by resting radionuclide ventriculography. Patients were then randomised to quinapril 20 mg once daily or placebo in a double-blind fashion, in addition to existing anti-anginal therapy and this regimen was continued for up to 6 weeks prior to operation. Measurement of left ventricular function was repeated 3 months following surgery, after recommencement of pre-surgery anti-anginal therapy for 1 week. Effects on systemic vascular resistance (SVR) during bypass were calculated from perfusion records and vasoconstrictor use during operation was documented. The safety of the addition of quinapril to the anti-anginal regimen was assessed by measurement of systemic blood pressure (BP) after the first dose of study medication, measurement of intra-operative BP, administration of inotropes and any intra-operative complications. RESULTS: There was no difference between treatment groups in the pre-study left ventricular ejection fraction (mean (S.D.); 54.9 (13.8)% versus 55.6 (13.2)%, quinapril versus placebo, respectively), or 3 months after surgery (58.1 (13.6)%, versus 56.9 (12.6)%, quinapril versus placebo, respectively). Left ventricular ejection fraction 3 months after surgery did not change significantly from pre-treatment in either group (2.8 (10.7)% and 1.5 (10.1)%; quinapril and placebo, respectively). There was no first-dose hypotension (systolic BP < 100 mmHg). The intra-operative BP and the SVR during bypass in the two treatment groups were not significantly different. The ischaemic time (mean = 56 min) and the use of inotropes were the same in both groups and there was no mortality. CONCLUSIONS: Angiotensin converting enzyme inhibitor treatment before coronary artery bypass graft surgery does not have a significant beneficial effect on left ventricular function following coronary artery bypass graft surgery. Angiotensin converting enzyme inhibition, administered in addition to anti-anginal therapy, does not cause first-dose hypotension or increase morbidity or mortality and can safely be used in patients with coronary heart disease prior to coronary artery bypass graft surgery.