Articles |
From the Departments of Experimental Pathology (C.J.S., B.S.R., Y.K., K.P.) and Physiology (D.S., C.H., X.Z., G.Z., X.-B.X., T.H.H.), New York Medical College, Valhalla, NY, and the Department of Molecular Cardiobiology (W.C.S.), Boyer Center for Molecular Medicine, Yale University School of Medicine, New Haven, Conn.
Correspondence to Thomas H. Hintze, PhD, Professor, Department of Physiology, New York Medical College, Valhalla, NY 10595.
| Abstract |
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Key Words: GAPDH endothelial cell NO synthase cyclooxygenase-1 von Willebrand factor Northern blots
| Introduction |
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Recent studies in our laboratory indicate that severe (pacing-induced) congestive heart failure in dogs is associated with alterations in endothelium-derived NO and prostaglandin-related regulation in the large coronary artery.4 Coronary microvessels from failing hearts exhibit reduced acetylcholine-dependent production of nitrite (the stable metabolite of NO in aqueous solution).4 In addition, increases in coronary artery diameter that are induced by brief occlusion, acetylcholine, or arachidonic acid are all depressed in heart failure.4 In contrast, the responses of the coronary artery diameter to nitroglycerin and exogenous prostacyclin are unaffected. Thus, heart failure is characterized by an apparent reduction in the release of NO and other vasodilators in the coronary vasculature.
The objective of the present study was to elucidate the molecular basis for the coronary endothelial dysfunction that we have found previously in heart failure. Perhaps endothelial dysfunction involves specific alterations in gene expression for ecNOS.9 10 Alternatively, heart failure may be associated with a nonspecific depression in ecNOS and other enzymes that produce vasodilators (eg, constitutive COX-1) by means of an alteration in endothelial function. To determine whether ecNOS gene expression could be selectively regulated, the changes in endothelial gene expression in dogs with HF were compared with those in normal dogs chronically administered an NO-releasing agent, CAS 936, with the goal of selectively downregulating ecNOS gene expression.
| Materials and Methods |
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At the beginning and end of the present study, cardiovascular responses were obtained in dogs used for pacing-induced heart failure. The following hemodynamic variables were measured when the dogs were lying quietly on a table: LV systolic and end-diastolic pressure, systemic arterial pressure, LV dP/dt, and heart rate, as described previously.4 11 12 The previously implanted catheters were attached to P23ID strain-gauge transducers (Statham Instruments) for the measurement of arterial and atrial pressures. LV pressure was measured with the solid-state pressure gauge. The data were recorded on a 14-channel tape recorder (Bell and Howell 3700B) and played back on a direct-writing oscillograph (Gould 2800s). Mean values were derived for pressures using 2-Hz resistance-capacitance filters. Heart rate was measured with a cardiotachometer (model 9857B, Beckman Instruments) from the LV pressure pulse interval. The first derivative of LV pressure, LV dP/dt, was derived with an operational amplifier (National Semiconductor 324). Triangular wave signals with known slopes were substituted for the pressure signals to calibrate the differentiators directly. The tape recording system and strip-chart recorder were calibrated periodically during the experiment to eliminate electronic drift.
The protocols were approved by the Institutional Animal Care and Use Committee of New York Medical College and conform to the guiding principles for the use and care of laboratory animals of the American Physiological Society and the National Institutes of Health.
ecNOS and COX-1 During Heart Failure
Dogs were paced at 210
bpm for 3 weeks, and the pacing was
increased to 240 bpm for an additional week with an external pacemaker
(model EV4543, Pace Medical), which the dog carried in a vest.
Hemodynamic measurements in all 7 dogs were made before
and at 4 to 5 weeks after chronic LV pacing when the pacer was turned
off and with the heart in spontaneous rhythm. We have used these
techniques previously.4 11 12 The mRNAs
for ecNOS, COX-1,
GAPDH, and vWF were isolated from the aorta of each dog. Protein was
isolated from the abdominal aorta for Western analysis. In
addition, to determine the enzyme activity from the aorta, pieces of
the thoracic aorta were incubated in buffer with increasing doses of
acetylcholine or bradykinin, and nitrite was measured by using the
Greiss reaction. Nitrite is the hydration product of NO. To ensure
that nitrite reflected NO production, the highest dose of each
agonist was repeated after preincubation with
nitro-L-arginine (100 µmol/L), which blocks NO synthase.
We have used these techniques previously.4 13
Administration of an NO-Releasing Agent
In another group of 7
dogs, the orally active NO-releasing
agent, CAS 936, was given twice a day at a dose of 20 mg/kg for 1 week.
Only arterial pressure and heart rate were determined in
those dogs. We have used this compound previously to cause NO-dependent
vasodilation in the normal dog and dogs with pacing-induced heart
failure.12 After 1 week, the dogs were killed, the aortas
were removed, and endothelium was processed for
measurement of mRNA.
ecNOS and COX-1 mRNA During Heart Failure and CAS 936
Total
RNA was isolated from the endothelium of
thoracic aortas as previously described13 from 7 dogs with
chronic LV pacing, 7 dogs after 1 week of CAS 936 administration, and
17 historic control dogs (ie, dogs similarly instrumented). The vessel
was flushed in situ with aerated sterile medium 199 with HBSS, and a
10- to 12-cm segment of the thoracic aorta was dissected free and
opened lengthwise. Endothelium was removed by gently
scraping the lumen with a scalpel blade (No. 10) after prewetting the
surface with guanidine isothiocyanate to harvest total
RNA.13 Total RNA (10 to 2 µg) was denatured by heating
(65°C) in 50% (vol/vol) formamide and 4.4 mol/L formaldehyde,
electrophoresed through a 1% agarose gel containing 2.2 mol/L
formaldehyde, and transferred by capillary blotting to a nylon membrane
(BioRad Zeta-Probe). The RNA was cross-linked to the blot by UV
irradiation (Stratagene).
cDNA probes were labeled with [32P]dCTP (1 to 3x109 cpm/µg) by random priming (Ambion). The cDNA for ovine prostaglandin H synthase-1/COX-1 (catalogue No. R74) was obtained from Oxford Biomedical, and a 1.1-kb fragment of the cDNA for human GAPDH was from Clonetech; a full-length bovine ecNOS cDNA8 9 was used as in a previous study.13 After a 2-hour prehybridization period, nylon blots were hybridized overnight with radiolabeled cDNAs probes under high-stringency conditions as indicated below. Hybridizations with COX-1 and GAPDH were carried out at 42°C in 50% formamide, 5x Denhardt's solution, 28 mmol/L sodium phosphate (pH 7.4), 375 mmol/L NaCl, 1% N-lauroylsarcosine, 0.5 mg/mL heparin, and 0.2 mg/mL salmon sperm DNA. These blots were washed at 55°C for 30 minutes each in 2x SSC/0.5% SDS, 1x SSC/0.5% SDS, and 0.5x SSC/0.25% SDS. Hybridization of blots with ecNOS was carried out at 65°C under high-stringency conditions as described previously9 ; these blots were washed twice in 2x SSC/0.1% SDS for 15 minutes at room temperature, followed by two washes in 0.4x SSC/0.1% SDS for 15 minutes at 65°C. Blots were dried and exposed to Kodak OMAT x-ray film in the presence of intensifying screens at -80°C for 3 (COX-1) to 10 (ecNOS) days.
Approximately 15 µg of endothelial total RNA was typically recovered from a single aorta. Five separate Northern blots were prepared for the heart failure study, and three were prepared for the NO-releaser study. Each blot contained samples from 1 or 2 dogs with heart failure along with 3 to 5 control dogs or from 2 or 3 dogs infused with CAS 936 along with 3 or 4 control dogs. Blots were stripped after probing with one cDNA and then rehybridized with another probe. All of the blots were sequentially probed for COX-1, GAPDH, ecNOS, and vWF13 mRNAs. Previous studies13 and unpublished data from this laboratory validated the use of either vWF (an endothelium-specific gene) or GAPDH as a denominator for RNA loading/transfer of canine aortic endothelial RNA. Optical densities of hybridization signals on several x-ray film exposures were quantified by laser-scanning densitometry (LKB Ultrascan) to determine steady state RNA levels.
ecNOS Protein During Heart Failure
Protein was also isolated
from the abdominal aorta of each of
the dogs used to study heart failure and saved for Western
analysis of ecNOS. Protein was centrifuged for 2
minutes at 4°C at 12 000g, the PBS was decanted, and the pellet was
resuspended in 60 to 100 µL of detergent containing lysis
buffer.14 The composition of the lysis buffer was 10
mmol/L HEPES, pH 7.45, 315 mmol/L sucrose, 10% glycerol, 1% NP-40
detergent, 0.1 mmol/L EDTA, 1 mmol/L dithiothreitol, 2 µg/mL
aprotinin, and 10% glycerol/mL of leupeptin, soybean trypsin
inhibitor, and phenylmethylsulfonyl fluoride. The
endothelial lysate was stored at -80°C until
used for protein quantification and subsequent precipitation by TCA
(5% final TCA) for SDS-PAGE of crude endothelial
lysates. Between 20 and 100 µg of total endothelial
protein scrapings (lysed in detergent buffer) were recovered per
abdominal aorta segment. Protein recovery following detergent
solubilization of the lysate was
50%. In three initial Western
blots (each with 2 or 3 control and 2 or 3 HF samples, total aortic
protein before solubilization), individual dogs were analyzed
(25 to 100 µg TCA-precipitated protein per lane).
Two methods were used to quantify ecNOS protein: (1) Western blotting of isolated protein from individual dogs and (2) affinity purification of pooled NADPH binding proteins from several dogs by use of ADP-Sepharose followed by Western blotting. The first method and three different blots with individual lanes were used for 7 HF and 7 normal dogs, and ecNOS protein (135-kD band) was found to be generally more intense in control samples compared with HF samples. However, in two of the three experiments, ecNOS was barely detectable (even with the sensitive chemiluminescence secondary antibody detection method) and made our conclusions unreliable. Therefore, we used the second method and increased the amount of the ecNOS protein by almost an order of magnitude by combining detergent-solubilized protein from a number of dogs (7 HF and 9 normal dogs) and again performed Western blot analysis.
The second method involved gentle mixing of the lysate for 16
hours at
4°C followed by 10-minute centrifugation to remove
detergent-insoluble protein. Soluble protein was pooled from
several animals and quantified, and comparable total amounts (
300
µg in 0.5 mL; see Fig 4
) from control and HF groups were
further
incubated for 2 hours at 4°C with 30 µL of a 50% suspension
of ADP-Sepharose as described previously.14 ecNOS
quantitatively binds to this resin and allows for concentration
of ecNOS protein and other NADPH binding proteins. Protein samples were
placed in 50 µL Laemmli sample buffer before SDS8% PAGE. Similar
procedures were performed on protein isolated from cultured human
umbilical vein endothelial cells grown in culture and
used as a method for determining the sensitivity of the method.
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Western Blotting
Proteins were transferred to PVDF membranes
(Millipore) in 10
mmol/L CAPS buffer. The PVDF membrane was blocked for 1.5 hours at room
temperature in 5% BSA in 1x TBS with 0.05% Tween 20, followed by an
overnight incubation at 4°C with the primary ecNOS antibody diluted
1:1000 in TBS-T/1% BSA. The membrane was washed four times in
TBS-T/1% BSA, incubated 1.5 hours with the secondary antibody
(1:10 000), and finally washed four times in TBS-T/BSA before signal
detection with the chemiluminescence ECL method (Amersham). The 135-kD
ecNOS band was detected by scanning densitometry of film
autoradiograms as previously described. The
primary antibody was rabbit polyclonal anti-bovine ecNOS peptide
antibody (Affinity Bioreagents); rabbits were immunized with a
C-terminal peptide (amino acids 599 to 613) coupled to keyhole
limpet hemocyanin.
Nitrite Production by Thoracic Aorta After Heart
Failure
The thoracic aorta was cut into 30- to 50-mg pieces, and each
piece was incubated in PBS for 20 minutes (control) or in the presence
of increasing doses of acetylcholine or bradykinin for 20 minutes.
After 20 minutes, the buffer was removed, and the amount of nitrite
produced was quantified by using the Greiss reaction as we have done
previously.4 13 In all of the studies,
nitro-L-arginine (100 µmol/L) was added to the aorta 10
minutes before the addition of the highest dose of either bradykinin or
acetylcholine to ensure that the production of nitrite
reflected NO production.
Statistical Analysis
Results are expressed as the
mean±SEM from n dogs. The data
from Northern blots were analyzed by an unpaired Student's
t test; a paired t test was used in dogs to
compare hemodynamics in the same animal before and
after heart failure or chronic CAS 936 treatment. A value of
P<.05 was considered statistically significant. All figures
were produced by using SLIDEWRITE PLUS
FOR WINDOWS.
| Results |
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ecNOS and COX-1 mRNA During Heart Failure
Total RNA was
isolated from endothelium scraped
from the thoracic aortas of dogs subjected to chronic pacing and
control dogs. Steady state mRNA levels for ecNOS and COX-1 were
evaluated in these samples by Northern blotting (Fig 1
).
Under the hybridization conditions used, each radiolabeled cDNA probe
identified one major mRNA species. The bovine ecNOS cDNA hybridized to
a 4.4-kb ecNOS mRNA and did not detect a
cytokine-inducible-INOS.13 Similarly, the
ovine COX-1 cDNA bound to a 2.8-kb COX-1 mRNA and did not interact with
a larger message (4.2 kb, near 28S ribosomal RNA), which would be
expected for the mitogen-responsive
COX-2.15 16 17
Scanning densitometry of COX-1 or ecNOS mRNA signals was normalized
against that for GAPDH (Fig 2
) and vWF (Fig 3
)
to quantify differences between control and HF
groups. Heart failure was associated with a significant reduction
(P<.05) in both mRNA levels, with a significant
(P<.05) decrease in both the ratio of COX-1 to GAPDH (64%)
and the ratio of ecNOS to GAPDH (56%) (Fig 2
). Because there
was also
a reduction in vWF after pacing-induced heart failure, the ratios
of COX-1 to vWF or ecNOS to vWF were not altered (Fig 3
).
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ecNOS Protein During Heart Failure
In preliminary
experiments, the signal-to-noise ratio for
detection of the 135-kD ecNOS protein was poor when material from
individual dogs was evaluated. We subsequently pooled protein from 7
dogs with HF and 9 normal dogs and used ADP-Sepharose affinity
chromatography to enrich ecNOS. There was a marked
reduction in ecNOS protein after pacing-induced heart failure as
illustrated by Western blotting (Fig 4
). Four of seven
of the animals used in the HF group for data in Fig 4
were also
used
for ecNOS gene expression in Fig 2
. Scanning densitometry
showed an
70% reduction in ecNOS protein in the pooled dogs with HF compared
with control dogs.
Nitrite Production by Thoracic Aorta After Heart
Failure
There was a marked reduction in acetylcholine- or
bradykinin-induced nitrite production in the thoracic aorta
after pacing-induced heart failure as shown in Fig 5
. When
nitro-L-arginine was incubated with
aorta before the addition of the highest dose of either bradykinin or
acetylcholine, the increase in nitrite production was totally
eliminated. This indicates that nitrite production reflects NO
production.
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Administration of an NO-Releasing Agent
There were no
significant changes in mean arterial
blood pressure or heart rate during the chronic infusion of CAS 936,
consistent with the results of our previous
studies.11 In contrast to the concurrent reductions in
ecNOS and COX-1 in our model of heart failure, there were marked
differences in the expression of these genes in dogs with NO infusion.
There was a selective 52% decrease in the ratio of ecNOS to GAPDH
(P<.05 versus the control value) and no change in the ratio
of COX-1 to GAPDH (Fig 6
). Unlike the response during
heart failure, there was also a depression in the ratio of ecNOS to vWF
but not in the ratio of COX-1 to vWF (Fig 7
).
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| Discussion |
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The hemodynamic changes that occurred in dogs with either pacing-induced cardiomyopathy or chronic NO infusion were similar to those found in our previous studies.4 11 12 Most important, pacing-induced heart failure was characterized by increases in LV end-diastolic pressure and reductions in myocardial contractile state, mean arterial pressure, and resting tachycardia. In addition, there was an increase in LV diameter and some diffuse fibrosis in the LV.18 In other studies using this model, the reduction in cardiac output occurred only after a prolonged period of pacing in conscious dogs,19 which is, by definition, the onset of overt heart failure. Thus, we were careful to assess changes in endothelial function in dogs with prolonged LV pacing. In previous studies using this model, we have also shown that the production of nitrite, the hydration product of NO metabolism in vitro, was reduced and that endothelium-dependent dilation in vivo was almost abolished after the development of pacing-induced heart failure.4
In dogs with chronic administration of the NO-releasing agent CAS 936, there was no change in heart rate or mean arterial pressure. These results are consistent with many previous studies indicating that organic nitrates dilate primarily the venous circulation and large arteries.20 21 These results are also consistent with our previous studies indicating that CAS 936 reduces preload in normal dogs and dogs with HF, perhaps by dilating veins, and increases large coronary artery diameter without affecting coronary or peripheral vascular resistance.11 The selective large vesseldilating effects of this NO-releasing agent suggested to us that this agent caused such dilation by an NO-dependent mechanism, making it likely that the aorta would also be a target for this compound.
The reductions in ecNOS and COX-1 gene expression that we measured after pacing-induced heart failure are consistent with our previous studies and may be the mechanism responsible for the reduced NO-dependent dilation that we measured in vivo and the reduced nitrite production that we found in vitro.4 Furthermore, the present investigation supports our conclusions that the heart failureassociated defect in nitrite production in vitro was not due to reduced availability of L-arginine, since the addition of L-arginine in vitro did not enhance nitrite production in coronary microvessels from either normal or dogs with HF. Since ecNOS protein levels and nitrite production were also reduced, these further suggest a reduction in NO synthesis. This may be analogous to the impaired peripheral vasodilator responses in humans with congestive heart failure,5 some of which our data suggest may be attributed to reduced release of NO.
The mechanisms responsible for the downregulation of the constitutive NO synthase gene expression after heart failure are not known. In our previous studies, we have found that 3 weeks of pacing results in an increase in endothelium-dependent dilation of large coronary arteries in vivo, and only after the development of overt heart failure do EDRF-dependent responses disappear.4 22 These data are supported by a recent study by O'Murchu et al,23 although there is some difference in the interpretation of those data. In a recent study from our laboratory, Zhao et al24 also showed that cholinergic reflex coronary NO-dependent vasodilation is reduced after 4 weeks of chronic pacing (ie, after the development of overt congestive heart failure) but not after 3 weeks of pacing in the conscious dog (ie, during compensated cardiac dysfunction but no clinical signs of heart failure). This is consistent with preliminary studies demonstrating no obvious reduction in ecNOS gene expression in extracts prepared from a single dog paced for 3 weeks before the development of overt heart failure. In addition, we have recently found that after 1 week of chronic exercise, there is an increase in EDRF-dependent responses, increased nitrite production in vitro, and upregulation of ecNOS mRNA levels in the aorta.13 This is probably due to a biochemical mechanism that is coupled to the increase in blood flow and vessel shear stress that occurs during exercise. In our pacing model, there is no increase in cardiac output with pacing, since the end-diastolic filling time will be reduced at the high heart rates that we used and since there will be no alteration in the regulation of venous return by the peripheral circulation.19 Thus, there is no obvious change in aortic blood flow or cardiac output. However, there will be a marked alteration in the "pulsatility," since heart rate and stretch of the aorta will be 210 to 240 times per minute as long as the pacemaker is turned on. Pulsatility is believed to be a potent stimulus for EDRF production in blood vessels both in vivo25 and in vitro,26 and cyclic strain on cultured endothelial cells increases ecNOS activity and nitrite release.27 Alternatively, there may be alterations in local or circulating hormones that occur with the development of heart failure, such as angiotensins.28
However, our data indicate that the alteration in NO synthase gene expression is not selective, since cyclooxygenase gene expression is also decreased. This is further supported by the finding that the ratio of either COX-1 or ecNOS to vWF is not altered after heart failure. vWF gene expression is also a marker for endothelial cells. Thus, whatever mechanism is responsible for the reduction in ecNOS in heart failure may also be responsible for the reduction in COX-1, although these two genes could be independently regulated.
Another provocative finding in the present study is that infusion of an NO donor selectively downregulated ecNOS gene expression. To our knowledge, this is the first demonstration that exogenous NO can influence steady state ecNOS mRNA levels and complements the inhibitory action of NO on NO production. Recently Pilz et al29 showed that both cGMP and NO can regulate a number of transcriptional factors, including TPA response elementregulated genes. The molecular mechanism of NO inhibition of ecNOS is unknown and under investigation. A previous study in cultured cells by Buga et al30 suggested that chronic exposure to NO could inhibit NO production, presumably by inhibiting enzyme activity. The present study provides evidence of an additional mechanism for the NO control of NO synthase by the control of gene expression. Furthermore, these data suggest that NO synthase and COX-1 gene expression are separable and that they can be independently regulated.
There is increasing evidence that myocytes can make NO, especially after exposure to cytokines.31 32 There is also some evidence that circulating tumor necrosis factor increases in patients with heart failure and that peripheral venous nitrate, the product of NO metabolism in blood, is increased in heart failure.33 34 Together, these studies suggest that NO production may be enhanced after heart failure. Our previously published in vitro data from dogs4 and from humans35 suggest that this enhanced NO production does not come from blood vessels. We have examined, in a preliminary fashion, blood vessels for the expression of an inducible form of NO synthase. The basal production of NO by these tissues was not as high as would be expected. Thus, we did not systematically evaluate the expression of the inducible genes, although we do not believe that there is enhanced production of NO or prostaglandins in blood vessels from the dogs in the present study.
In summary, we have found that both ecNOS and COX-1 mRNA are reduced in aortic endothelial cells from dogs with HF and that ecNOS protein and nitrite production, reflecting enzyme activity, are also reduced. The reduced gene expression for these enzymes may be responsible for the reduced NO production that we have previously observed during heart failure in dogs and, as we recently reported, in human coronary microvessels.4 35 Furthermore, since two endothelial vasodilator systems are depressed, although they can be independently regulated by chronic exposure to NO in vivo, these alterations are most likely indicative of altered regulation of multiple endothelial cell genes after heart failure.
| Selected Abbreviations and Acronyms |
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| Acknowledgments |
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| Footnotes |
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This manuscript was sent to Leslie A. Leinwand, Consulting Editor, for review by expert referees, editorial decision, and final disposition.
Received December 21, 1994; accepted August 29, 1995.
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C. J. Smith, R. Huang, D. Sun, S. Ricketts, C. Hoegler, J.-Z. Ding, R. A. Moggio, and T. H. Hintze Development of Decompensated Dilated Cardiomyopathy Is Associated With Decreased Gene Expression and Activity of the Milrinone-Sensitive cAMP Phosphodiesterase PDE3A Circulation, November 4, 1997; 96(9): 3116 - 3123. [Abstract] [Full Text] |
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B. D. Prendergast, B M. Sci, V. F. Sagach, and A. M. Shah Basal Release of Nitric Oxide Augments the Frank-Starling Response in the Isolated Heart Circulation, August 19, 1997; 96(4): 1320 - 1329. [Abstract] [Full Text] |
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G. Zhao, X. Zhang, X. Xu, M. Ochoa, and T. H. Hintze Short-term Exercise Training Enhances Reflex Cholinergic Nitric Oxide–Dependent Coronary Vasodilation in Conscious Dogs Circ. Res., June 19, 1997; 80(6): 868 - 876. [Abstract] [Full Text] |
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Y.-W. Xie, W. Shen, G. Zhao, X. Xu, M. S. Wolin, and T. H. Hintze Role of Endothelium-Derived Nitric Oxide in the Modulation of Canine Myocardial Mitochondrial Respiration In Vitro: Implications for the Development of Heart Failure Circ. Res., September 1, 1996; 79(3): 381 - 387. [Abstract] [Full Text] |
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M. R. Kichuk, N. Seyedi, X. Zhang, C. C. Marboe, R. E. Michler, L. J. Addonizio, G. Kaley, A. Nasjletti, and T. H. Hintze Regulation of Nitric Oxide Production in Human Coronary Microvessels and the Contribution of Local Kinin Formation Circulation, July 1, 1996; 94(1): 44 - 51. [Abstract] [Full Text] |
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D. B. Haitsma, D. Merkus, J. Vermeulen, P. D. Verdouw, and D. J. Duncker Nitric oxide production is maintained in exercising swine with chronic left ventricular dysfunction Am J Physiol Heart Circ Physiol, June 1, 2002; 282(6): H2198 - H2209. [Abstract] [Full Text] [PDF] |
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Y. Chu, D. D. Heistad, K. L. Knudtson, K. G. Lamping, and F. M. Faraci Quantification of mRNA for Endothelial NO Synthase in Mouse Blood Vessels by Real-Time Polymerase Chain Reaction Arterioscler Thromb Vasc Biol, April 1, 2002; 22(4): 611 - 616. [Abstract] [Full Text] [PDF] |
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