Professional Documents
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From the Department of Internal Medicine/Cardiology, University of Leipzig, Heart Center, Leipzig, Germany.
Correspondence to Volker Adams, PhD, Department of Internal Medicine/Cardiology, University of Leipzig, Heart Center, Strumpellstrae 39, 04289
Leipzig, Germany. E-mail adav@medizin.uni-leipzig.de
(Circulation. 2010;122:1221-1238.)
2010 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.110.939959
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Figure 1. Summary of exercise-mediated effects on different parts of the cardiovascular system. Max. indicates maximum; HFNEF,
heart failure with normal ejection fraction; ANP, atrial natriuretic peptide; and BNP, brain natriuretic peptide.
Gielen et al
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Figure 2. Exercise training has the potential to prevent myocardial damage related to I/R injury. Exercise training induces an upregulation of
key antioxidative enzymes such as MnSOD, glutathione peroxidase (GPX), and catalase. Opening the sarcolemmal (sarco) KATP channel
accelerates cardiomyocyte repolarization by increasing K outflow. As a result of the shorter action potential, Ca2 overloading is prevented
by reducing opening rates of the L-type Ca2 channel. Although not essential for I/R protection, increased levels of HSP72 were observed
after training. HSP72 can prevent apoptotic cell death, likely by interaction with caspase-3. Adapted from Powers et al 37 with kind permission of Springer Science and Business Media. Copyright 2008, Springer Science and Business Media
Gielen et al
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Figure 3. In systolic heart failure, endurance exercise can induce reverse remodeling with improvement of systolic and diastolic LV
function and reduction of LV end-diastolic diameters. It does so by interfering with the vicious cycle of CHF-associated skeletal muscle
hypoperfusion with increased local ROS and cytokine generation resulting in endothelial function and sympathetic activation, which further increases afterload and worsens LV function. The reverse remodeling is a consequence of peripheral training effects (eg, improved
antioxidative protection in the skeletal muscle, increased parasympathetic tone, improved endothelial function as a result of increased
NO production and bioavailability, and direct cardiac effects related to improved Ca handling, increased PI3K [p110] activity, reduction
of fibrosis, and cardiomyocyte apoptosis). NE indicates norepinephrine; AT II, angiotensin II; ecSOD, extracellular SOD; GPX, glutathione peroxidase; and ox. Phos, oxidative phosphorylation.
came from Hambrecht et al,65 who demonstrated that endurance training led to reverse LV remodeling with modest
improvements of ejection fraction from 30% to 35% and
reductions of LV end-diastolic diameter in a mixed population of subjects with ischemic and dilated cardiomyopathy.
These findings were corroborated by the Exercise in Left
Ventricular Dysfunction and Chronic Heart Failure study.66 A
recent study in our institution indicates that the reverse LV
remodeling occurs as early as 4 weeks after the initiation of
endurance training (unpublished data, 2010).
Mechanisms Explaining Reverse Remodeling in CHF
In the absence of myocardial biopsies for molecular analysis
of myocardial changes induced by training, most authors
interpreted this favorable training effect as secondary to
afterload reduction with reduced resting blood pressure due to
improved endothelial function.65 67 However, animal models
reveal that there are clear direct myocardial effects of training
that are related to signaling pathways of myocardial hypertrophy and fibrosis (Figure 3)
Phosphoinositide-3 Kinase (p110). On the molecular basis,
recent animal studies suggest that activation of PI3K (p110)
is involved in exercise-mediated cardioprotection: In mice
with dilated cardiomyopathy, both swim training and consti-
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Cardiac Valves
Aortic Valve Sclerosis/Stenosis
Currently, no effective therapy to prevent calcified aortic
valve disease is established. Calcified aortic valve disease
confers significant morbidity and mortality as the severity of
disease progresses.90
Degenerative calcified aortic valve disease and atherosclerosis share similar mechanisms (ie, clinical risk factors and
histopathological features). Pathological examinations of diseased aortic valves showed areas of subendothelial thickening
with the disruption of the basement membrane, accumulation
of inflammatory infiltrates, and calcium deposits.91,92 It is
well accepted that regular physical exercise prevents the
progression of atherosclerosis by modulating endothelial
function or oxidative stress.93,94 Using low-density lipoprotein receptor knockout mice, we recently demonstrated that
regular exercise training as primary prevention prevents the
development of aortic valve sclerosis.95 It has been proposed
that apoptosis of endothelial cells and myofibroblasts in the
valve,96 elastin degradation and collagen synthesis by MMPs
and/or cathepsin,97 increased oxidative stress,98 and enhanced
osteogenesis99 contribute to aortic valve degeneration. In
consequence, procalcific gene expression such as bone morphogenetic protein 2 (BMP2), CBFA1/Runx2 (runt-related
transcription factor 2), and osteocalcin was amplified.98 The
activation of BMP2 and CBFA1/Runx2, particularly in the
noncalcified valve tissue, reflects an early stage of transdifferentiation of myofibroblast to a more osteoblast-like
phenotype.100
Gielen et al
In the low-density lipoprotein receptor knockout mouse
model, regular exercise attenuated the deleterious elevation of
oxidative stress and reduced expression of BMP2, Runx2,
and osteoblast differentiation marker. Additionally, the disruption of the aortic valve endothelium was prevented.95
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Aorta
Although the aorta is a standard vessel to quantify changes in
endothelial function in animal experiments involving small
rodents, it is rarely a target vessel in human vascular research.
The composition of the extracellular matrix has changed
through the evolution of species and is influenced by pulse
pressure amplitude and wall tension. In fact, there seems to be
a universal elastic modulus that determines the relative
proportion of elastic lamellae, collagen fibers, and smooth
muscle cells in the aortic wall.109 Aging, coronary artery
disease, and myocardial infarction are often accompanied by
increased aortic stiffness and reduced compliance.110,111
Among healthy individuals, high-intensity exercise led to
vascular remodeling with up to 51% enlarged brachial conduit artery area and reduced distal aortic cross-sectional areas
(up to 8%), whereas aortic distensibility remained unchanged.112 However, endurance and strength training have
opposite effects on aortic compliance and vascular stiffness;
in an elegant study, Otsuki et al113 measured plasma
endothelin-1, nitric oxide (NO), and arterial stiffness in
young, healthy endurance-trained versus strength-trained
men. They demonstrated that aortic pulse-wave velocity as an
established index of vascular stiffness was significantly
increased in strength athletes and reduced in endurance
athletes versus healthy controls.113 Strength athletes displayed elevated endothelin-1 levels that correlated with aortic
pulse-wave velocity. Reductions of aortic stiffness after
endurance training were confirmed in patients with hypertension114 and coronary artery disease.115
Large Arterial Conduit Vessels
Conduit vessels 2 to 4 mm in diameter are the preferred target
vessels in clinical research because they may be assessed
readily by either noninvasive of invasive methods. After the
first description of coronary endothelial dysfunction,116 it was
quickly recognized that coronary endothelial function
could serve as a stress index integrating the cardiovascular
effects of risk factors and may provide pivotal diagnostic
and prognostic information in patients with coronary heart
disease.103
Exercise and Conduit Vessel Vasomotor Function in
Coronary Artery Disease
The clinical effects of endurance exercise training on coronary endothelial function were first studied in humans by
Hambrecht et al117: A 4-week endurance training program
was effective in attenuating the paradoxical arterial vasoconstriction in epicardial conduit vessels by 54% and increased
average peak flow velocity by 78% in response to intracoronary acetylcholine infusion. The improvements in coronary endothelial function were partially lost during a consecutive 5-month home-based endurance training program at
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Figure 4. The majority of exercise effects on the vascular endothelium are mediated by intermittent increases of laminar shear stress
associated with increased cardiac output during physical exertion. On the luminal side of the endothelial cells, direct signaling can
occur through deformation of the glycocalyx. This shear stressinduced signal can activate calcium ion channels, phospholipase activity leading to calcium signaling, prostaglandin I2 (PGI2) release, and cAMP-mediated smooth muscle cell relaxation. VEGF receptor 2
(VEGFR2) located at the luminal surface can associate with vascular endothelial cadherin, [beta]-catenin, and PI3K to phosphorylate Akt
and induce AKT-mediated eNOS phosphorylation, which leads to higher NO production. Mechanical forces are also transmitted by the
cytoskeleton to adhesion sites, where transmembrane integrins bound to the extracellular matrix serve as a focus for deformation. This
integrin-mediated pathway leads to the activation of Rasmitogen-activated protein kinase activity. In turn, Ras releases nuclear
factor-B (NFB) from its cytosolic inhibitor and thus enables its translocation to the nucleus, where it binds to the promoters of multiple target genes, including the eNOS gene. Increased NO synthesis in response to shear stress induces extracellular SOD (ecSOD) in a
feed-forward fashion to inhibit the degradation of NO by ROS with consecutive formation of the toxic peroxynitrite. Akt indicates protein kinase B; PECAM-1, platelet endothelial cell adhesion molecule-1; Ras, small GTPase; ONOO, peroxynitrite; and AA, Arachidonic
acid. Reprinted from Davies et al 121 with permission of the publisher. Copyright 2008, Cambridge University Press.
Gielen et al
PI3K, which is essential for AKT-mediated phosphorylation
and activation of endothelial NO synthase (eNOS).123 In
contrast to laminar shear stress, the atherogenic flow patterns
include turbulent or disturbed flow, low flow, gradients, and
flow reversal. These conditions are associated with high rates
of endothelial cell proliferation and apoptosis, increased
production of ROS, and increased expression of inflammatory markers inducing a preatherosclerotic vascular phenotype.122 In the presence of additional atherogenic risk factors,
such as hypertension, dyslipidemia, and diabetes mellitus,
atherogenesis is significantly accelerated.
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Figure 5. A model for mobilization of circulating progenitor cells from the bone marrow by increased shear stress induced by exercise.
Increased laminar shear stress results in an activation of eNOS, resulting in an increase of NO. Subsequently, MMP-9 and MMP-2 are
activated, resulting in the release of sKitL. SKitL confers signals enhancing mobility of circulating progenitor cells. Along with stromalderived factor-1 (SDF-1 gradient, the circulating progenitor cells are mobilized into the peripheral circulation. CPC indicates circulating progenitor cells; VCAM-1, vascular cell adhesion molecule-1; and VLA4, very late antigen-4.
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Figure 6. In the microcirculation, several pathways for metabolic vasodilation have been described. PO2-dependent regulation represents hypoxic coronary flow control; metabolic rate of oxygen (MRO2) dependent regulation represents normoxic coronary flow control. Under hypoxemic conditions, Ca2i is increased in endothelial cells, leading to phospholipase activation with consecutive generation of prostaglandins and cAMP-mediated metabolic vasodilation. Alternatively, ATP release either from erythrocytes or from the
working skeletal muscle activates the adenosine purinergic A2A receptor, resulting in activation of the KATP channel with potassium loss
and hyperpolarization of the vascular smooth muscle cell. As a consequence, voltage-gated Ca2 channels (VGCC) are opened, and
Ca2i is decreased with vascular relexation and vasodilation. Acidosis can directly influence the opening probability of the KATP channel. Exercise increases the adenosine sensitivity, resulting in larger metabolic vasorelaxation. Hb indicates hemoglobin; AC, adenylate
cyclase; and PGI2, prostaglandin I2. Adapted from Deussen et al 162 with kind permission of Springer Science and Business Media.
Copyright 2006, Springer Science and Business Media
Myogenic Control
It is well established in porcine animal models of treadmill
training that myogenic vasoconstriction to increases in perfusion pressure (particularly 40 mm Hg) is augmented after
exercise.170 Evidence is accumulating that L-type voltagegated calcium channels and protein kinase C determine
myogenic tone under physiological conditions.171 Korzick et
al172 demonstrated that increased myogenic tone in trained
pigs involves changes in protein kinase C- expression and
phosphorylation, which augment the depolarization-related
opening of voltage-gated calcium channels in smooth muscle
cells and increase of intracellular calcium.
Angiogenesis and Microcirculation
In the cardiac muscle, White et al173 conclusively showed in
a porcine model of exercise training that training increases
the total vascular bed cross-sectional area by up to 37% after
16 weeks. In humans, changes in cardiac vascularization are
difficult to assess.
More data, however, are available for the skeletal muscle.
In addition to an effect on metabolic alterations and the
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catabolic/anabolic balance within the skeletal muscle, exercise also affects the vascularization of the skeletal muscle. It
has been known for a long time that endurance exercise
training induces a significant increase in muscle capillaries in
either animals or humans.174,175 This process is largely
coordinated by soluble factors emanating from tissues in need
of vascularization. One of the best factors to study in this
scenario is VEGF. It is a powerful activator of endothelial
proliferation and is crucial for nearly all forms of neovascularization.176 With respect to exercise training, several studies
showed that VEGF transcription in skeletal muscle is increased by short-term177 as well as endurance training.142 It is
thought that local skeletal muscle hypoxia stabilizes the
transcription factor hypoxia inducible factor-1, leading to
the induction of VEGF. However, this concept must be
questioned because the deletion of hypoxia inducible
factor-1 in the skeletal muscle increases rather than decreases capillary density.178
In recent years, the transcriptional coactivator peroxisome
proliferator-activated receptor- coactivator (PGC)-1 has
been regarded as an important exercise-mediated regulator of
VEGF transcription. Mice lacking PGC-1 in their skeletal
muscle failed to increase capillary density in response to
exercise training.179 The central role of PGC-1 is furthermore supported by the observation that transgenic expression
of PGC-1 in skeletal muscle dramatically increases capillary
density.180 The mechanism by which PGC-1 induces VEGF
transcription appears to involve the coactivation of the orphan
nuclear receptor ERR.180 Which signals are upstream of
PGC-1 mediating the exercise-induced angiogenesis? One
pathway is the exercise-dependent modulation of high-energy
phosphates and the concomitant activation of AMP-activated
protein kinase.181 However, if this pathway is only responsible for basal VEGF expression and capillarization and not for
exercise-induced angiogenesis is still an ongoing discussion.182 In addition to activation of AMPK, the activation of
the p38MAPK (Mitogen-activated protein kinase) pathway
by exercise training also leads to the activation of PGC-1.183
Last but not least, the increased production of ROS by
exercise training can also contribute to the induction of
PGC-1.184 Therefore, one may summarize that endurance
exercise by activating PGC-1 via AMPK or p38MAPK or
ROS leads to an enhanced transcription of VEGF, finally
resulting in angiogenesis (Figure 7).
Venous Circulation
Compared with the arterial bed, the venous circulation has
received less attention in vascular research, particularly with
regard to training effects. The reasons are diverse, ranging
from methodological problems to underestimation of the
physiological relevance of venous function.185
Key parameters of venous function such as venous capacitance, which reflects the blood volume stored in the venous
system, and venous compliance, which represents the change
in volume in response to a change in pressure, change with
aging, posture, and physical activity. Aging alters the composition of the venous wall, resulting in lower venous
compliance in sedentary senior individuals.186 In both young
and elderly endurance-trained men, however, venous compliance was 70% to 120% higher compared with their sedentary
age-matched counterparts. It is currently unclear whether
these changes are primarily the result of factors such as
increased venous NO availability and decreased venous
smooth muscle tone, sympathetic -adrenergic vasomotor
control, or structural effects on elastin-to-collagen ratio.
Gielen et al
Immobilization, as tested in bed rest studies, demonstrated
a significant decline in venous capacitance after 52 days,
which was not affected by resistive vibration exercise.187
Venous compliance remained unaffected.
In patients with heart failure, exercise forearm venous
capacitance and venous outflow, as measured by strain-gauge
plethysmography, are significantly reduced and seem to be
related to maximal walking distance.188 Although the methodology of strain-gauge plethysmography was used in a
number of studies to examine training effects on vascular
function,189,190 changes of venous capacitance induced by
training have not been reported thus far. From animal
experiments, we know that the capillary domain area values
for venular capillaries were significantly decreased after 4
weeks of training.191
Pulmonary Circulation
Pulmonary hypertension is a frequent accompanying problem
in heart failure or valvular heart disease. Similar to heart
failure, exercise has long been regarded as detrimental and
was discouraged in pulmonary hypertension because of the
fear of fatal cardiovascular compromise.
Human Data
The first reports on training effects on pulmonary pressure
came from aerobic training studies in patients with stable
CHF. Lee et al192 were the first to demonstrate the lack of any
exercise-induced rise in resting pulmonary artery pressure in
patients with CHF, a finding confirmed by Dubach et al193 18
years later. In a large prospective randomized study involving
73 patients with CHF, Hambrecht et al65 were finally able to
demonstrate that pulmonary vascular resistance at rest and at
peak exercise was decreased after 6 months of endurance
training.
Just recently, the first clinical study in patients with stable
precapillary pulmonary hypertension confirmed that 15
weeks of endurance exercise are effective in significantly
improving 6-minute walking distance on top of optimal
medical therapy.194
Animal Experiments
The first rat model of pulmonary hypertension to be used with
exercise training was hypobaric hypoxia. Rats were trained
for 4 and 6 weeks under hypobaric hypoxia (equivalent to
altitudes of 2500 and 5500 m). Kashimura et al196 found that
the increase in resting mean pulmonary arterial pressure with
increasing equivalent altitude was lower in the 2 trained
groups than in the control group and greater after 6 than after
4 weeks of exercise.195 In a follow-up study, they showed that
6 weeks of training can attenuate the hypoxia-induced and
angiotensin IIinduced PH. These findings were extended by
Favret et al,197 who demonstrated that exercise training
improved lung gas exchange and attenuated acute hypoxic
pulmonary hypertension but did not prevent pulmonary hypertension of prolonged hypoxia.
In rabbits, it was soon documented that treadmill exercise
improved acetylcholine-induced endothelium-dependent vasodilatation not only in aortic rings but also in precontracted
pulmonary artery rings,198 a finding that could not be reproduced in Sprague-Dawley rats, however.199 A possible expla-
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Conclusion
To summarize, cardiac effects of exercise include an improved protection against I/R injury primarily as a result of
higher antioxidative protection and improved LV diastolic
and systolic function in chronic heart failure due to favorable
changes in neurohormonal state, activation of PI3K (p110)
attenuating pathological hypertrophy, normalization of cardiomyocyte calcium handling, and inhibition of the catabolic
ubiquitin-proteasome system.
Vascular effects are based on improved endotheliummediated flow-induced vasodilatation in conduit arteries and
larger resistance arteries, higher myogenic control, and increased metabolic vasodilatation in small resistance arteries.
Vascular regeneration by mobilization of endothelial progenitor cells is augmented by exercise. Recently, improved
endothelial vasodilatation has also been confirmed in the
pulmonary artery.
Extending our concept of molecular mechanisms of exercise is essential to further optimize training interventions with
regard to their clinical efficacy and to identify novel targets
for pharmaceutical intervention. However, certain areas (ie,
microcirculation and the venous system) are still incompletely understood and merit further molecular studies. Residual incomplete molecular understanding should not prevent the clinical use of training interventions with established
clinical benefit.
Sources of Funding
Dr Gielen is supported by the Deutsche Forschungsgemeinschaft,
grant GI535/11.
Disclosures
None.
References
1. Booth F, Laye M, Lees S, Rector R, Thyfault J. Reduced physical
activity and risk of chronic disease: the biology behind the consequences. Eur J Appl Physiol. 2008;102:381390.
1234
Circulation
2. Mokdad AH, Giles WH, Bowman BA, Mensah GA, Ford ES, Smith
SM, Marks JS. Changes in health behaviors among older Americans,
1990 to 2000. Public Health Rep. 2004;119:356 361.
3. Perhonen MA, Franco F, Lane LD, Buckey JC, Blomqvist CG, Zerwekh
JE, Peshock RM, Weatherall PT, Levine BD. Cardiac atrophy after bed
rest and spaceflight. J Appl Physiol. 2001;91:645 653.
4. Dorfman TA, Levine BD, Tillery T, Peshock RM, Hastings JL,
Schneider SM, Macias BR, Biolo G, Hargens AR. Cardiac atrophy in
women following bed rest. J Appl Physiol. 2007;103:8 16.
5. Sipola P, Heikkinen J, Laaksonen DE, Kettunen R. Influence of 12
weeks of jogging on magnetic resonance-determined left ventricular
characteristics in previously sedentary subjects free of cardiovascular
disease. Am J Cardiol. 2009;103:567571.
6. Navarro-Arevalo A, Canavate C, Sanchez-del-Pino M. Myocardial and
skeletal muscle aging and changes in oxidative stress in relationship to
rigorous exercise training. Mech Ageing Dev. 1999;108:207217.
7. Rinaldi B, Corbi G, Boccuti S, Filippelli W, Rengo G, Leosco D, Rossi
F, Filippelli A, Ferrara N. Exercise training affects age-induced changes
in SOD and heat shock protein expression in rat heart. Exp Gerontol.
2006;41:764 770.
8. Devi SA, Prathima S, Subramanyam MVV. Dietary vitamin E and
physical exercise, II: antioxidant status and lipofuscin-like substances in
aging rat heart. Exp Gerontol. 2003;38:291297.
9. Martin JL, Mestril R, Hilal-Dandan R, Brunton LL, Dillmann WH.
Small heat shock proteins and protection against ischemic injury in
cardiac myocytes. Circulation. 1997;96:4343 4348.
10. Starnes JW, Choilawala AM, Taylor RP, Nelson MJ, Delp MD. Myocardial heat shock protein 70 expression in young and old rats after
identical exercise programs. J Gerontol A Biol Sci Med Sci. 2005;60:
963969.
11. Olivetti G, Melissari M, Capasso JM, Anversa P. Cardiomyopathy of the
aging human heart: myocyte loss and reactive cellular hypertrophy. Circ
Res. 1991;68:1560 1568.
12. Phaneuf S, Leeuwenburgh C. Cytochrome c release from mitochondria
in the aging heart: a possible mechanism for apoptosis with age. Am J
Physiol. 2002;282:R423R430.
13. Sussman MA, Anversa P. Myocardial aging and senescence: where have
the stem cells gone? Annu Rev Physiol. 2004;66:29 48.
14. Kwak HB, Song W, Lawler JM. Exercise training attenuates ageinduced elevation in Bax/Bcl-2 ratio, apoptosis, and remodeling in the
rat heart. FASEB J. 2006;20:791793.
15. Pugh KG, Wei JY. Clinical implications of physiological changes in the
aging heart. Drugs Aging. 2001;18:263276.
16. Arbab-Zadeh A, Dijk E, Prasad A, Fu Q, Torres P, Zhang R, Thomas JD,
Palmer D, Levine BD. Effect of aging and physical activity on left
ventricular compliance. Circulation. 2004;110:1799 1805.
17. Pluim BM, Zwinderman AH, van der Laarse A, van der Wall EE. The
athletes heart: a meta-analysis of cardiac structure and function.
Circulation. 2000;101:336 344.
18. Pelliccia A, Culasso F, Di Paolo FM, Maron BJ. Physiologic left ventricular cavity dilatation in elite athletes. Ann Intern Med. 1999;130:
2331.
19. Fagard R. Athletes heart. Heart. 2003;89:14551461.
20. Maron BJ. Distinguishing hypertrophic cardiomyopathy from athletes
heart physiological remodelling: clinical significance, diagnostic
strategies and implications for preparticipation screening. Br J Sports
Med. 2009;43:649 656.
21. Neri Serneri GG, Boddi M, Modesti PA, Cecioni I, Coppo M, Padeletti
L, Michelucci A, Colella A, Galanti G. Increased cardiac sympathetic
activity and insulin-like growth factor-I formation are associated with
physiological hypertrophy in athletes. Circ Res. 2001;89:977982.
22. McMullen JR, Amirahmadi F, Woodcock EA, Schinke-Braun M,
Bouwman RD, Hewitt KA, Mollica JP, Zhang L, Zhang Y, Shioi T,
Buerger A, Izumo S, Jay PY, Jennings GL. Protective effects of exercise
and phosphoinositide 3-kinase(p110) signaling in dilated and hypertrophic cardiomyopathy. Proc Natl Acad Sci U S A. 2007;104:612 617.
23. Luo J, McMullen JR, Sobkiw CL, Zhang L, Dorfman AL, Sherwood
MC, Logsdon MN, Horner JW, DePinho RA, Izumo S, Cantley LC.
Class IA phosphoinositide 3-kinase regulates heart size and physiological cardiac hypertrophy. Mol Cell Biol. 2005;25:94919502.
24. Care` A, Catalucci D, Felicetti F, Bonci D, Addario A, Gallo P, Bang
ML, Segnalini P, Gu Y, Dalton ND, Elia L, Latronico MVG, Hoydal M,
Autore C, Russo MA, Dorn GW, Ellingsen O, Ruiz-Lozano P, Peterson
KL, Croce CM, Peschle C, Condorelli G. MicroRNA-133 controls
cardiac hypertrophy. Nat Med. 2007;13:613 618.
Gielen et al
48. Hamilton KL, Quindry JC, French JP, Staib J, Hughes J, Mehta JL,
Powers SK. MnSOD antisense treatment and exercise-induced protection against arrhythmias. Free Radic Biol Med. 2004;37:1360 1368.
49. Powers SK, Criswell D, Lawler J, Martin D, Lieu FK, Ji LL, Herb RA.
Rigorous exercise training increases superoxide dismutase activity in
ventricular myocardium. Am J Physiol. 1993;34:H2094 H2098.
50. Kanter MM, Hamlin RL, Unverferth DV, Davis HW, Merola AJ. Effect
of exercise training on antioxidant enzymes and cardiotoxicity of doxorubicin. J Appl Physiol. 1985;59:1298 1303.
51. Lennon SL, Quindry JC, Hamilton KL, French JP, Hughes J, Mehta JL,
Powers SK. Elevated MnSOD is not required for exercise-induced
cardioprotection against myocardial stunning. Am J Physiol. 2004;287:
H975H980.
52. Marcil M, Bourduas K, Ascah A, Burelle Y. Exercise training induces
respiratory substrate-specific decrease in Ca2-induced permeability
transition pore opening in heart mitochondria. Am J Physiol. 2006;290:
H1549 H1557.
53. Starnes JW, Barnes BD, Olsen ME. Exercise training decreases rat heart
mitochondria free radical generation but does not prevent Ca2-induced
dysfunction. J Appl Physiol. 2007;102:17931798.
54. Kavazis AN. Exercise preconditioning of the myocardium. Sports Med.
2009;39:923935.
55. Pchejetski D, Kunduzova O, Dayon A, Calise D, Seguelas MH, Leducq
N, Seif I, Parini A, Cuvillier O. Oxidative stress dependent sphingosine
kinase-1 inhibition mediates monoamine oxidase Aassociated cardiac
cell apoptosis. Circ Res. 2007;100:41 49.
56. Gross GJ, Peart JN. KATP channels and myocardial preconditioning: an
update. Am J Physiol. 2003;285:H921H930.
57. Goll DE, Thompson VF, Li H, Wei W, Cong J. The calpain system.
Physiol Rev. 2003;83:731 801.
58. French JP, Quindry JC, Falk DJ, Staib JL, Lee Y, Wang KKW, Powers
SK. Ischemia-reperfusion-induced calpain activation and SERCA2a
degradation are attenuated by exercise training and calpain inhibition.
Am J Physiol. 2006;290:H128 H136.
59. Starnes JW, Taylor RP, Ciccolo JT. Habitual low-intensity exercise does
not protect against myocardial dysfunction after ischemia in rats. Eur
J Cardiovasc Prev Rehabil. 2005;12:169 174.
60. Lennon SL, Quindry JC, French JP, Kim S, Mehta JL, Powers SK.
Exercise and myocardial tolerance to ischaemia-reperfusion. Acta
Physiol Scand. 2004;182:161169.
61. Demirel HA, Powers SK, Zergeroglu MA, Shanely RA, Hamilton K,
Coombes J, Naito H. Short-term exercise improves myocardial tolerance
to in vivo ischemia-reperfusion in the rat. J Appl Physiol. 2001;91:
22052212.
62. Lennon SL, Quindry J, Hamilton KL, French J, Staib J, Mehta JL,
Powers SK. Loss of exercise-induced cardioprotection after cessation of
exercise. J Appl Physiol. 2004;96:1299 1305.
63. Volterrani M, Clark AL, Ludman PF, Swan JW, Adamopoulos S,
Piepoli M, Coats AJS. Predictors of exercise capacity in chronic heart
failure. Eur Heart J. 1994;15:801 809.
64. Sullivan MJ, Higginbotham MB, Cobb FR. Exercise training in patients
with severe left ventricular dysfunction: hemodynamic and metabolic
effects. Circulation. 1988;78:506 515.
65. Hambrecht R, Gielen S, Linke A, Fiehn E, Yu J, Walther C, Schoene N,
Schuler G. Effects of exercise training on left ventricular function and
peripheral resistance in patients with chronic heart failure: a randomised
trial. JAMA. 2000;283:30953101.
66. Giannuzzi P, Temporelli PL, Corra U, Tavazzi L. Antiremodeling effect
of long-term exercise training in patients with stable chronic heart
failure: results of the Exercise in Left Ventricular Dysfunction and
Chronic Heart Failure (ELVD-CHF) Trial. Circulation. 2003;108:
554 559.
67. Hambrecht R, Fiehn E, Weigl C, Gielen S, Hamann C, Kaiser R, Yu J,
Adams V, Niebauer J, Schuler G. Regular physical exercise corrects
endothelial dysfunction and improves exercise capacity in patients with
chronic heart failure. Circulation. 1998;98:2709 2715.
68. Adams V, Link A, Gielen S, Erbs S, Hambrecht R, Schuler G. Modulation of Murf-1 and MAFbx expression in the myocardium by physical
exercise training. Eur J Cardiovasc Prev Rehabil. 2008;15:293299.
69. Lenk K, Schur R, Linke A, Erbs S, Matsumoto Y, Adams V, Schuler G.
Impact of exercise training on myostatin expression in the myocardium
and skeletal muscle in a chronic heart failure model. Eur J Heart Fail.
2009;11:342348.
70. Rolim NPL, Medeiros A, Rosa KT, Mattos KC, Irigoyen MC, Krieger
EM, Krieger JE, Negrao CE, Brum PC. Exercise training improves the
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
1235
1236
Circulation
89. Choi SY, Chang HJ, Choi SI, Kim KI, Cho YS, Youn TJ, Chung WY,
Chae IH, Choi DJ, Kim HS, Kim CH, Oh BH, Kim MH. Long-term
exercise training attenuates age-related diastolic dysfunction: association of myocardial collagen cross-linking. J Korean Med Sci. 2009;
24:3239.
90. Goldbarg SH, Elmariah S, Miller MA, Fuster V. Insight into degenerative aortic valve disease. J Am Coll Cardiol. 2007;50:12051213.
91. Agmon Y, Khandheria BK, Meissner I, Sicks JD, OFallon WM,
Wiebers DO, Whisnant JP, Seward JB, Tajik AJ. Aortic valve sclerosis
and aortic atherosclerosis: different manifestations of the same disease?
Insights from a population-based study. J Am Coll Cardiol. 2001;38:
827 834.
92. Aikawa E, Aikawa M, Libby P, Figueiredo JL, Rusanescu G, Iwamoto
Y, Fukuda D, Kohler RH, Shi GP, Jaffer FA, Weissleder R. Arterial and
aortic valve calcification abolished by elastolytic cathepsin S deficiency
in chronic renal disease. Circulation. 2009;119:17851794.
93. Laufs U, Wassmann S, Czech T, Munzel T, Eisenhauer M, Bohm M,
Nickenig G. Physical inactivity increases oxidative stress, endothelial
dysfunction, and atherosclerosis. Arterioscler Thromb Vasc Biol. 2005;
25:809 814.
94. Adams V, Linke A, Krankel N, Erbs S, Gielen S, Mobius-Winkler S,
Gummert JF, Mohr FW, Schuler G, Hambrecht R. Impact of regular
physical activity on the NAD(P)H oxidase and angiotensin receptor
system in patients with coronary artery disease. Circulation. 2005;111:
555562.
95. Matsumoto Y, Adams V, Jacob S, Mangner N, Schuler G, Linke A.
Regular exercise training prevents aortic valve disease in LDLR
deficient mice. Circulation. 2010;121:759 767.
96. Mohler ER III. Mechanisms of aortic valve calcification. Am J Cardiol.
2004;94:1396 1402.
97. Helske S, Syvaranta S, Lindstedt KA, Lappalainen J, Oorni K, Mayranpaa MI, Lommi J, Turto H, Werkkala K, Kupari M, Kovanen PT.
Increased expression of elastolytic cathepsins S, K, and V and their
inhibitor cystatin C in stenotic aortic valves. Arterioscler Thromb Vasc
Biol. 2006;26:17911798.
98. Miller JD, Chu Y, Brooks RM, Richenbacher WE, Peta-Silva R, Heistad
DD. Dysregulation of antioxidant mechanisms contributes to increased
oxidative stress in calcific aortic valvular stenosis in humans. J Am Coll
Cardiol. 2008;52:843 850.
99. Weiss RM, Ohashi M, Miller JD, Young SG, Heistad DD. Calcific aortic
valve stenosis in old hypercholesterolemic mice. Circulation. 2006;114:
20652069.
100. Hruska KA, Mathew S, Saab G. Bone morphogenetic proteins in
vascular calcification. Circ Res. 2005;97:105114.
101. Altschul R. Endothelium, its Development, Morphology, Function, and
Pathology. New York, NY: Macmillan; 1954.
102. Ross J. The pathogenesis of atherosclerosis: a perspective for the 1990s.
Nature. 1993;362:801 809.
103. Schachinger V, Britten MB, Zeiher A. Prognostic impact of coronary
vasodilator dysfunction on adverse long-term outcome of coronary heart
disease. Circulation. 2000;101:1899 906.
104. Perticone F, Ceravolo R, Pujia A, Ventura G, Iacopino S, Scozzafava A,
Ferraro A, Chello M, Mastroroberto P, Verdecchia P, Schillaci G.
Prognostic significance of endothelial dysfunction in hypertensive
patients. Circulation. 2001;104:191196.
105. Landmesser U, Drexler H. The clinical significance of endothelial dysfunction. Curr Opin Cardiol. 2005;20:547551.
106. Ghiadoni L, Versari D, Giannarelli C, Faita F, Taddei S. Non-invasive
diagnostic tools for investigating endothelial dysfunction. Curr Pharm
Des. 2008;14:37153722.
107. Jones CJ, Kuo L, Davis MJ, Chilian WM. Regulation of coronary blood
flow: coordination of heterogeneous control mechanisms in vascular
microdomains. Cardiovasc Res. 1995;29:585596.
108. Kuo L, Davis MJ, Chilian WM. Longitudinal gradients for endothelium-dependent and -independent vascular responses in the coronary
microcirculation. Circulation. 1995;92:518 525.
109. Wagenseil JE, Mecham RP. Vascular extracellular matrix and arterial
mechanics. Physiol Rev. 2009;89:957989.
110. Dart AM, Lacombe F, Yeoh JK, Cameron JD, Jennings GL, Laufer E,
Esmore DS. Aortic distensibility in patients with isolated hypercholesterolaemia, coronary artery disease, or cardiac transplant. Lancet. 1991;
338:270 273.
111. Avolio A, Jones D, Tafazzoli-Shadpour M. Quantification of alterations
in structure and function of elastin in the arterial media. Hypertension.
1998;32:170 175.
112. Petersen SE, Wiesmann F, Hudsmith LE, Robson MD, Francis JM,
Selvanayagam JB, Neubauer S, Channon KM. Functional and structural
vascular remodeling in elite rowers assessed by cardiovascular magnetic
resonance. J Am Coll Cardiol. 2006;48:790 797.
113. Otsuki T, Maeda S, Iemitsu M, Saito Y, Tanimura Y, Ajisaka R,
Miyauchi T. Vascular endothelium-derived factors and arterial stiffness
in strength- and endurance-trained men. Am J Physiol. 2007;292:
H786 H791.
114. Collier SR, Kanaley JA, Carhart R Jr, Frechette V, Tobin MM, Hall AK,
Luckenbaugh AN, Fernhall B. Effect of 4 weeks of aerobic or resistance
exercise training on arterial stiffness, blood flow and blood pressure in
pre- and stage-1 hypertensives. J Hum Hypertens. 2008;22:678 686.
115. Edwards DG, Schofield RS, Magyari PM, Nichols WW, Braith RW.
Effect of exercise training on central aortic pressure wave reflection in
coronary artery disease. Am J Hypertens. 2004;17:540 553.
116. Ludmer PL, Selwyn AP, Shook TL, Wayne RR, Mudge GH, Alexander
RW, Ganz P. Paradoxical vasoconstriction induced by acetylcholine in
atherosclerotic coronary arteries. N Engl J Med. 1986;315:1046 1051.
117. Hambrecht R, Wolff A, Gielen S, Linke A, Hofer J, Erbs S, Schoene N,
Schuler G. Effect of exercise on coronary endothelial function in
patients with coronary artery disease. N Engl J Med. 2000;342:
454 460.
118. Gielen S, Erbs S, Linke A, Mobius-Winkler S, Schuler G, Hambrecht R.
Home-based versus hospital-based exercise programs in patients with
coronary artery disease: effects on coronary vasomotion. Am Heart J.
2003;145:E3.
119. Gokce N, Vita JA, Bader DS, Sherman DL, Hunter LM, Holbrook M,
OMalley JF, Balady GJ. Effect of exercise on upper and lower
extremity endothelial function in patients with coronary artery disease.
Am J Cardiol. 2002;90:124 127.
120. Linke A, Schoene N, Gielen S, Hofer J, Erbs S, Schuler G, Hambrecht
R. Endothelial dysfunction in patients with chronic heart failure:
systemic effects of lower-limb exercise training. J Am Coll Cardiol.
2001;37:392397.
121. Davis PF, Helmke BP. Endothelial mechanotransduction. In: Mofrad
MRK, Kamm RD, eds. Cellular Mechanotransduction: Diverse Perspectives From Molecules to Tissue. New York, NY: Cambridge University Press; 2010:20 60.
122. Li YS, Haga JM, Chien S. Molecular basis of the effects of shear stress
on vascular endothelial cells. J Biomech. 2005;38:1949 1971.
123. Tzima E, Irani-Tehrani M, Kiosses WB, Dejana E, Schultz DA,
Engelhardt B, Cao G, DeLisser H, Schwartz MA. A mechanosensory
complex that mediates the endothelial cell response to fluid shear stress.
Nature. 2005;437:426 431.
124. Boger RH, Bode-Boger SM, Szuba A, Tsao PS, Chan JR, Tangphao O,
Blaschke TF, Cooke JP. Asymmetric dimethylarginine (ADMA): a
novel risk factor for endothelial dysfunction: its role in hypercholesterolemia. Circulation. 1998;98:18421847.
125. Wassmann S, Wassmann K, Nickenig G. Modulation of oxidant and antioxidant enzyme expression and function in vascular cells. Hypertension.
2004;44:381386.
126. Crosby JR, Kaminski WE, Schatteman G, Martin PJ, Raines EW, Seifert
RA, Bowen-Pope DF. Endothelial cells of hematopoietic origin make a
significant contribution to adult blood vessel formation. Circ Res. 2000;
87:728 730.
127. Forstermann U, Munzel T. Endothelial nitric oxide synthase in vascular
disease. Circulation. 2006;113:1708 1714.
128. Widder JD, Chen W, Li L, Dikalov S, Thony B, Hatakeyama K,
Harrison DG. Regulation of tetrahydrobiopterin biosynthesis by shear
stress. Circ Res. 2007;101:830 838.
129. Lam CF, Peterson TE, Richardson DM, Croatt AJ, dUscio LV, Nath
KA, Katusic ZS. Increased blood flow causes coordinated upregulation
of arterial eNOS and biosynthesis of tetrahydrobiopterin. Am J Physiol.
2006;290:H786 H793.
130. Sindler AL, Delp MD, Reyes R, Wu G, Muller-Delp JM. Effects of
ageing and exercise training on eNOS uncoupling in skeletal muscle
resistance arterioles. J Physiol. 2009;587:38853897.
131. Richter B, Niessner A, Penka M, Grdic M, Steiner S, Strasser B, Ziegler
S, Zorn G, Maurer G, Simeon-Rudolf V, Wojta J, Huber K. Endurance
training reduces circulating asymetric dimethylarginine and myeloperoxidase levels in persons at risk of coronary events. Thromb Haemost.
2005;94:1306 1311.
132. Hambrecht R, Adams V, Erbs S, Linke A, Krankel N, Shu Y, Baither
Y, Gielen S, Gummert JF, Mohr FW, Schuler G. Regular physical
activity improves endothelial function in patients with coronary
Gielen et al
133.
134.
135.
136.
137.
138.
139.
140.
141.
142.
143.
144.
145.
146.
147.
148.
149.
150.
1237
1238
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endothelium
exercise
myocardium
Circulation. 2010;122:1221-1238
doi: 10.1161/CIRCULATIONAHA.110.939959
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