(Circulation. 2001;103:549.)
© 2001 American Heart Association, Inc.
Basic Science Reports |
From the Department of Internal Medicine, University of Turin (M.F.B., L.F., P.D., A.R., M.P., G.G., G.C., L.P.), and the Division of Vascular Surgery, Ospedale Molinette (M.P.), Turin, Italy.
Correspondence to Luigi Pegoraro, Department of Internal Medicine, University of Turin, Corso Dogliotti 14, 10126 Turin, Italy.
| Abstract |
|---|
|
|
|---|
Methods and
ResultsTwenty atherosclerotic carotid
arterial specimens and 5 early atherosclerotic lesions from the
internal carotid were manually minced to fragments, and T lymphocytes
infiltrating the atherosclerotic plaque were isolated on solid-phase
anti-CD3 polystyrene plates. Southern blot analysis demonstrated that
in all samples, lymphocytes expressed IL-3 and IL-2 receptor
-chain
transcripts, indicating that in this context, the activated T
lymphocytes may release IL-3. We further analyzed the expression of the
IL-3 receptor and the biological effects exerted by the ligand on
vascular SMCs. ß-IL-3transducing subunit was detected both on
cultured SMCs and on endothelial cells and SMCs within atheroma. The
analysis of the IL-3induced biological effects demonstrated that it
was able to trigger both mitogenic and motogenic signals. Moreover, we
demonstrated that the addition of PD98059, a known inhibitor of the
MAPextracellular signaling-regulated/MAP kinase pathway, completely
inhibited IL-3mediated MAP kinase activation and IL-3induced
migration and proliferation. Finally, IL-3 was found to stimulate
vascular endothelial growth factor (VEGF) gene
transcription.
ConclusionsIL-3, expressed by activated T lymphocytes infiltrating early and advanced atherosclerotic plaques, may sustain the atherosclerotic process either directly, by activating SMC migration and proliferation, or indirectly, via VEGF production.
Key Words: atherosclerosis smooth muscle cells cytokines signal transduction
| Introduction |
|---|
|
|
|---|
We recently demonstrated that the hemopoietic growth factor interleukin-3 (IL-3), which is produced predominantly by the CD4 subset of activated T lymphocytes infiltrating the inflammatory tissue,5 is able to induce endothelial cell proliferation and in vivo new vessel formation.6 7 CD4- and CD8-positive lymphocytes are present in the atherosclerotic lesions at all stages of the process.1 Therefore, the aim of the present study was to analyze the role of IL-3 in the atherosclerotic process by evaluating the expression of IL-3 in plaque-infiltrating lymphocytes (PILs) and the ability of this cytokine to exert biological effects on SMCs.
| Methods |
|---|
|
|
|---|
Plaque-Infiltrating Lymphocytes
Twenty-five atherosclerotic plaques were obtained
from human carotid arteries at endarterectomy. Early lesions from
internal carotids were obtained from subjects who died of
noncardiovascular causes. PILs were isolated as
described.9 Peripheral T
lymphocytes were obtained as previously
described.6
Reverse Transcription, Polymerase Chain
Reaction, and Southern and Northern Blot Analysis
Cytoplasmic RNAs were
isolated10 from T
lymphocytes and from cells recovered from a nonatherosclerotic
specimen. After DNAse digestion, RNA was subjected to reverse
transcriptionpolymerase chain reaction (RT-PCR) with specific
primers: IL-3 (5'-GCCCGTCCTGCTCCTGCTCCA-3',
5'-CCGGAATTCA-TTC-CAGTCAC-3'), CD3
-chain
(5'-CATCCTGGCTATCA-TTCTTCTT-3',
5'-GCAGTTCTGACACATTCTGTAA-3'), and IL-2R
-chain
(5'-TTATCATTTCGTGGTGGGGCAGATG-GTTTA-3',
5'-AGATGAGAAGGAGACAGAGGCGACGGTC-CA-3') and subjected to
Southern blot analysis. A 204-bp VEGF cDNA fragment was generated from
human SMCs as described by Williams et
al,11 and Northern blot
analysis was performed by standard
methods.12
Human Vascular SMC Culture and
Migration
Human SMCs were isolated from umbilical
cord13 and identified as
described.13 Migration of
SMCs was performed in Boydens chambers as
described.14
Immunoprecipitation, Immunoblotting, and
Proliferation Assay
Serum-starved SMCs stimulated with IL-3 or PDGF-BB or
unstimulated were subjected to immunoprecipitation and processed for
immunoblotting as previously
described.8 The proliferative
activity of SMCs was assayed as previously described by determination
of the fraction of cells in the S
phase.6
Immunofluorescence Microscopy
Specimens fixed and embedded in paraffin were
deparaffinized and stained with the polyclonal rabbit antiIL-3R
ß-subunit antiserum preadsorbed or not with the immunized synthetic
peptide.8 15
| Results |
|---|
|
|
|---|
-chain
(Figure 1B
-chain
(Figure 1C
-chain and CD40L (data not
shown), peripheral T lymphocytes did not express IL-3. Moreover, the
data reported in lane 2 of
Figure 1A
-chain mRNA, respectively, in cells recovered from a normal arterial
specimen, indicating the absence of inflammatory cells infiltrating the
nonatherosclerotic specimen.
|
SMCs Express the ß-Subunit of the
IL-3R
Cell lysates immunoprecipitated with the
antiß-subunit antiserum or with a preimmune
serum15 were subjected to
SDS-PAGE, and the filter was immunoblotted with the same antiserum. As
shown in
Figure 2
, the antiß-subunit antiserum was able to
recognize the IL-3R ß-subunit both in endothelial cells (used as
positive control) and in SMCs immunoprecipitated with the same
antiserum. Moreover, in experiments that are not presented, we found
that 24 hours of treatment with IL-3 (20 ng/mL) was able to upregulate
60% of the level of the receptor transcript in SMCs.
|
To extend the analysis of the IL-3R expression, in the
context of the atheromatous tissue, sections of advanced
atherosclerotic arterial specimens were subjected to immunofluorescence
analysis using an antiIL-3R ß-subunit antiserum. The results shown
in
Figure 3
demonstrate that both endothelial cells (A) and
SMCs from tunica media (B) and from neointima (C) express the IL-3R
ß-subunit.
|
IL-3 Triggers Erk1/Erk2 MAP Kinase Activation
and Induces SMC Migration via This Signaling Pathway
Erk1/Erk2 MAP kinase activation was investigated to
assess the specificity of IL-3 receptor engagement by the ligand. Cell
extracts from unstimulated or IL-3stimulated SMCs were subjected to
SDS-PAGE, and the filter was immunoblotted with the
antiphospho-Erk1/Erk2 MAP kinase antibody. The results presented in
Figure 4
demonstrate that IL-3 retained the ability to
induce Erk1/Erk2 MAP kinase activation, which peaked after 10
minutes of IL-3 stimulation.
|
To extend the analysis of the role played by IL-3 in SMCs,
we investigated its chemotactic properties. As shown in
Figure 5A
, IL-3 induced chemotaxis of primary SMCs, and
preincubation with an antiIL-3 antiserum almost completely abolished
this effect. Similarly, heat-inactivated IL-3 did not stimulate SMC
migration. The extent of the migratory response observed at a
concentration of 20 ng/mL IL-3 (a dose that was found to induce maximal
migratory effect, data not shown) was much more effective than 10 ng/mL
of VEGF16 but less effective
than the PDGF-BB (20 ng/mL) used as a positive control.
|
The involvement of MAP kinase in SMC migration has been
reported.17 We therefore
evaluated the role of this signaling pathway in mediating IL-3induced
SMC migration. As shown in
Figure 5A
, the Erk1/Erk2 MAP kinase inhibitor
PD9805912 drastically
reduced both IL-3 and VEGF-induced SMC migration. Similar results
were obtained for the biochemical effect exerted by IL-3 on MAP kinase
activation
(Figure 5B
).
IL-3 Triggers SMC DNA Synthesis and VEGF Gene
Transcription
The effect of IL-3 on SMC DNA synthesis was studied. In
our system (data not shown), 20 ng/mL of IL-3 yielded maximal response.
As reported in the
Table
and shown in
Figure 6
, 48 hours of IL-3 treatment led to an increase of
cells in S phase of
5-fold above control. Similar results were
obtained when SMCs were stimulated with bFGF (positive control),
whereas a 3-fold increase was observed on PDGF-BB stimulation.
Moreover, PD98059 completely abrogated the IL-3 and bFGF-mediated DNA
synthesis, indicating that the activation of the Erk1/Erk2 MAP kinase
pathway is a downstream event in IL-3 and bFGF-induced DNA synthesis
(Table
).
|
|
At the site of injury, SMCs are the major cellular source of
VEGF.16 We therefore
evaluated the ability of IL-3 to trigger VEGF gene transcription.
Indeed, IL-3, like PDGF-BB, was able to induce VEGF gene transcription
in SMCs
(Figure 7
). A role of newly produced VEGF in mediating
IL-3induced SMC migration can be postulated; however, the finding
that the anti-VEGF antiserum only partially reduced (
29%) the
chemotactic effect of IL-3 points to a direct effect of
IL-3.
|
| Discussion |
|---|
|
|
|---|
T lymphocytes infiltrating the advanced human atherosclerotic plaques are in a state of immunological activation.20 21 Our finding that IL-3 is also expressed in early lesions indicates that, not only in advanced human atheroma but also at the beginning of the atherosclerotic process, T cells are in an activated state and may contribute, by elaborating soluble mediators, to lesion evolution.
It has been shown that microenvironment may play a role in modulating T-cell cytokine profile.22 Our observation that PILs, but not activated peripheral blood T lymphocytes, did express the IL-3 transcript is consistent with this concept. According to the profile of cytokine produced, T cells may thus regulate important processes associated with plaque formation, such as macrophage activation, SMC growth, synthesis of extracellular matrix component, and synthesis of matrix metalloproteinases.23
SMC migration and proliferation into the intima after vascular injury are triggered and regulated by multiple factors.1 The mechanisms involved in this regulation depend on phosphorylation of cellular proteins, such as kinases. Among these kinases, MAP kinases appear to be nearly universal. In the present study, we demonstrate that in SMCs, IL-3 is able to trigger the activation of the Erk1/Erk2 MAP kinase pathway, which is known to integrate signals involved in cell growth.24 Indeed, we demonstrated that the MAP kinase inhibitor PD98059 completely abrogated the entry into S phase of both IL-3 and bFGF-stimulated SMCs, indicating that IL-3 and bFGF-induced DNA synthesis is strictly dependent on the Erk1/Erk2 MAP kinase pathway. This observation is also supported by our unpublished data demonstrating that PD98059 was also able to block the expression of the cell cyclespecific cyclin D1 in SMCs stimulated with IL-3.
Migration of SMCs from tunica media to intima is mediated by growth factors, such as PDGF-BB and bFGF,25 26 synthesized and released by cells of the vessel wall. Our results demonstrate that IL-3 not only stimulates SMC proliferation but also can act as a SMC chemoattractant. These findings are strengthened by the detection of the IL-3R ß-subunit in primary SMCs from media and thickened intima. Moreover, the finding that PD98059 also abrogates IL-3mediated SMC migration indicates that not only cell growth but also cell migration is strictly dependent on Erk1/Erk2 MAP kinase pathway activation. Cell migration depends on the remodeling of cytoskeletal proteins such as actin and myosin. In this context, it has been reported that activation of MAP kinases can increase cell migration via the phosphorylation of myosin27 and F-actin.28 Therefore, the finding that both DNA synthesis and cell migration triggered by IL-3 depend on the MAP kinase pathway sustains the possibility that the Erk1/Erk2 MAP kinases are involved in the activation of discrete substrates, leading to either cell migration or cell proliferation.
In conditions such as atherosclerosis or thrombosis, intimal angiogenesis occurs as part of an adaptive change recently addressed as vasculature remodeling.29 One current hypothesis of neovascularization in atherosclerosis is that the new, small vessels arise from adventitial vasa vasorum.30 Several factors that stimulate neoangiogenesis both in vitro and in vivo, including VEGF, have been detected in atherosclerotic lesions.4 9 Moreover, recent data demonstrate that VEGF receptors are expressed on SMCs, which, in response to the ligand, acquire the ability to migrate.16 31 Because both endothelial cells and SMCs are capable of synthesizing VEGF at sites of angiogenesis, it can be speculated that autocrine and paracrine actions contribute to SMC activation during neoangiogenesis.31 Our finding that IL-3 was able to induce the expression of VEGF by SMCs and that the anti-VEGF antibody only partially reduced the IL-3mediated motogenesis sustains the possibility that the produced VEGF may be primarily involved in driving neoangiogenesis.
Earlier work32 indicates that vessels, during their development, are dependent on exogenous survival factors. Recent data33 suggest that the association of forming vessels with SMCs/mural cells marks the end of this period of growth factor dependence and mediates vessel stabilization and maturation. Data presented here demonstrating the ability of IL-3 to induce both VEGF expression and SMC migration and proliferation provide new insights to understand the cellular and the molecular bases of new vessel formation and maturation. Moreover, our study provides evidence for a potential role of IL-3 in the atherosclerotic process.
| Acknowledgments |
|---|
Received July 20, 2000; revision received August 2, 2000; accepted August 8, 2000.
| References |
|---|
|
|
|---|
2.
Newby AC, Zaltsman
AB. Fibrous cap formation or destruction: the critical importance of
vascular smooth muscle cell proliferation, migration and matrix
formation. Cardiovasc Res. 1999;41:345360.
3. Ferrara N. Molecular and biological properties of vascular endothelial growth factor. J Mol Med. 1999;77:527543.[Medline] [Order article via Infotrieve]
4.
Inoue M, Itoh H,
Ueda M, et al. Vascular endothelial growth factor (VEGF)
expression in human coronary atherosclerotic lesions: possible
pathophysiological significance of VEGF in progression of
atherosclerosis. Circulation. 1998;98:21082116.
5.
Wimperis JZ,
Niemeyer CM, Sieff CA, et al. Granulocyte-macrophage colony-stimulating
factors and interleukin-3 mRNA are produced by a small fraction of
blood mononuclear cell. Blood. 1989;74:15251530.
6. Brizzi MF, Garbarino G, Rossi PR, et al. Interleukin 3 stimulates proliferation and triggers endothelial-leukocyte adhesion molecule 1 gene activation of human endothelial cells. J Clin Invest. 1993;91:28872892.
7.
Dentelli P, Del
Sorbo L, Rosso A, et al. Human IL-3 stimulates endothelial cell
motility and promotes in vivo new vessel formation.
J Immunol. 1999;163:21512159.
8.
Brizzi MF, Aronica
MG, Rosso A, et al. Granulocyte-macrophage colony stimulating factor
stimulates JAK2 signaling pathway and rapidly activates p93fes, STAT1
p91 and STAT3 p92 in polymorphonuclear leukocytes.
J Biol Chem. 1996;271:35623567.
9.
Peoples GE,
Blotnick S, Takahashi K, et al. T lymphocytes that infiltrate tumors
and atherosclerotic plaques produce heparin-binding epidermal growth
factor-like growth factor and basic fibroblast growth factor: a
potential pathologic role. Proc Natl Acad
Sci
U S A. 1995;92:65476551.
10. Chomczynski P, Sacchi N. Single step method of RNA isolation by acid guanidinium thiocyanate-phenol-chloroform extraction. Anal Biochem. 1987;162:156161.[Medline] [Order article via Infotrieve]
11. Williams B, Gallacher B, Hashmukh P, et al. Glucose-induced protein kinase C activation regulates vascular permeability factor mRNA expression and peptide production by human vascular smooth muscle cells in vitro. Diabetes. 1997;46:14971503.[Abstract]
12.
Brizzi MF,
Defilippi P, Rosso A, et al. Integrin-mediated adhesion of endothelial
cells induces JAK2 and STAT5A activation: role in the control of c-fos
gene expression. Mol Biol Cell. 1999;10:34633471.
13.
Fridell Y-WC,
Villa J, Attar EC, et al. GAS6 induces Axl-mediated chemotaxis of
vascular smooth muscle cells. J Biol
Chem. 1998;273:71237126.
14.
Pauly RR,
Passaniti A, Bilato C, et al. Migration of cultured vascular smooth
muscle cells through a basement membrane barrier requires type IV
collagenase activity and is inhibited by cellular differentiation.
Circ Res. 1994;75:4154.
15.
Brizzi MF,
Battaglia E, Montrucchio G, et al. Thrombopoietin stimulates
endothelial cell motility and neoangiogenesis by platelet-activating
factor-dependent mechanism. Circ
Res. 1999;84:785796.
16. Grosskreutz CL, Anand-Apte B, Duplaa C, et al. Vascular endothelial growth factor-induced migration of vascular smooth muscle cells in vitro. Microvasc Res. 1999;58:128136.[Medline] [Order article via Infotrieve]
17.
Cospedal R, Abedi
H, Zachary I. Platelet-derived growth factor-BB (PDGF-BB) regulation of
migration and focal adhesion kinase phosphorylation in rabbit aortic
vascular smooth muscle cells: roles of phosphatidylinositol 3-kinase
and mitogen-activated protein kinases.
Cardiovasc Res. 1999;41:708721.
18.
Clark SC, Kamen
R. The human hemopoietic growth factors.
Science. 1987;236:12291237.
19.
Khew-Goodall Y,
Butcher M, Litwin MS, et al. Chronic expression of P-selectin on
endothelial cells stimulated by the T-cell cytokine, interleukin-3.
Blood. 1996;87:14321438.
20.
Hansson GK,
Jonasson L, Seifert PS, et al. Immune mechanism in atherosclerosis.
Arteriosclerosis. 1989;9:567578.
21.
Jonasson L, Holm
J, Skalli O, et al. Regional accumulations of T cells, macrophages, and
smooth muscle cells in the human atherosclerotic plaque.
Arteriosclerosis. 1986;6:131138.
22. Frostegard J, Ulfgren AK, Nyberg P, et al. Cytokine expression in advanced human atherosclerotic plaques: dominance of pro-inflammatory (Th1) and macrophage-stimulating cytokines. Atherosclerosis. 1999;145:3334.[Medline] [Order article via Infotrieve]
23. Galis ZS, Muszynski M, Sukhova GK, et al. Enhanced expression of vascular matrix metalloproteinases induced in vitro by cytokines and in regions of human atherosclerotic lesions. Ann N Y Acad Sci. 1995;748:501507.
24. Serger R, Krebs EG. The MAPK signaling cascade. FASEB J. 1995;9:726735.[Abstract]
25. Kennedy SH, Qin H, Lin L, et al. Basic fibroblast growth factor regulates type I collagen and collagenase gene expression in human smooth muscle cells. Am J Pathol. 1995;146:764771.[Abstract]
26. Libby P, Warner SJC, Salomon RN, et al. Production of platelet-derived growth factor-like mitogen by smooth-muscle cells from human atheroma. N Engl J Med. 1988;318:14931498.[Abstract]
27. Ni H, Wang XS, Diener K, et al. MAPKAPK5, a novel mitogen-activated protein kinase (MAPK)-activated protein kinase, is a substrate of the extracellular regulated kinase (ERK) and p38 kinase. Biochem Biophys Res Commun. 1998;243:492496.[Medline] [Order article via Infotrieve]
28.
Hedges JC,
Dechert MA, Yamboliev LA, et al. A role for p38 MAPK/HSP27 pathway in
smooth muscle cell migration. J Biol
Chem. 1999;274:2421124219.
29.
Isner JM.
Vascular remodeling.
Circulation. 1994;89:29372941.
30. Barger AC, Beeuwkes RI, Lainey LL, et al. Hypothesis: vasa vasorum and neovascularization of human coronary arteries: a possible role in the pathophysiology of atherosclerosis. N Engl J Med. 1984;310:175177.[Medline] [Order article via Infotrieve]
31.
Wang H, Keiser
JA. Vascular endothelial growth factor upregulates the expression of
matrix metalloproteinase in vascular smooth muscle cells.
Circ Res. 1998;83:832840.
32. Alon T, Hemo I, Itin A, et al. Vascular endothelial growth factor acts as a survival factor for newly formed retinal vessels and has implications for retinopathy of prematurity. Nat Med. 1995;1:10241028.[Medline] [Order article via Infotrieve]
33. Darland DC, DAmore PA. Blood vessel maturation: vascular development comes of age. J Clin Invest. 1999;103:157158.[Medline] [Order article via Infotrieve]
This article has been cited by other articles:
![]() |
J. Chen, J. Olsen, S. Ford, S. Mirza, A. Walker, J. M. Murphy, and I. G. Young A New Isoform of Interleukin-3 Receptor {alpha} with Novel Differentiation Activity and High Affinity Binding Mode J. Biol. Chem., February 27, 2009; 284(9): 5763 - 5773. [Abstract] [Full Text] [PDF] |
||||
![]() |
A. Zeoli, P. Dentelli, A. Rosso, G. Togliatto, A. Trombetta, L. Damiano, P. F. di Celle, L. Pegoraro, F. Altruda, and M. F. Brizzi Interleukin-3 promotes expansion of hemopoietic-derived CD45+ angiogenic cells and their arterial commitment via STAT5 activation Blood, July 15, 2008; 112(2): 350 - 361. [Abstract] [Full Text] [PDF] |
||||
![]() |
H. Oren, A. R. Erbay, M. Balci, and S. Cehreli Role of Novel Biomarkers of Inflammation in Patients With Stable Coronary Heart Disease Angiology, April 1, 2007; 58(2): 148 - 155. [Abstract] [PDF] |
||||
![]() |
A. Tedgui and Z. Mallat Cytokines in Atherosclerosis: Pathogenic and Regulatory Pathways Physiol Rev, April 1, 2006; 86(2): 515 - 581. [Abstract] [Full Text] [PDF] |
||||
![]() |
D. H. Walter, J. Haendeler, J. Reinhold, U. Rochwalsky, F. Seeger, J. Honold, J. Hoffmann, C. Urbich, R. Lehmann, F. Arenzana-Seisdesdos, et al. Impaired CXCR4 Signaling Contributes to the Reduced Neovascularization Capacity of Endothelial Progenitor Cells From Patients With Coronary Artery Disease Circ. Res., November 25, 2005; 97(11): 1142 - 1151. [Abstract] [Full Text] [PDF] |
||||
![]() |
E. W. Raines and N. Ferri Thematic Review Series: The Immune System and Atherogenesis. Cytokines affecting endothelial and smooth muscle cells in vascular disease J. Lipid Res., June 1, 2005; 46(6): 1081 - 1092. [Abstract] [Full Text] [PDF] |
||||
![]() |
P. Defilippi, A. Rosso, P. Dentelli, C. Calvi, G. Garbarino, G. Tarone, L. Pegoraro, and M. F. Brizzi {beta}1 integrin and IL-3R coordinately regulate STAT5 activation and anchorage-dependent proliferation J. Cell Biol., March 28, 2005; 168(7): 1099 - 1108. [Abstract] [Full Text] [PDF] |
||||
![]() |
C. Calvi, P. Dentelli, M. Pagano, A. Rosso, M. Pegoraro, S. Giunti, G. Garbarino, G. Camussi, L. Pegoraro, and M. F. Brizzi Angiopoietin 2 Induces Cell Cycle Arrest in Endothelial Cells: A Possible Mechanism Involved in Advanced Plaque Neovascularization Arterioscler Thromb Vasc Biol, March 1, 2004; 24(3): 511 - 518. [Abstract] [Full Text] |
||||
![]() |
A. Ruiz-Torres, R. Lozano, J. Melon, and R. Carraro Age-Dependent Decline of In Vitro Migration (Basal and Stimulated by IGF-1 or Insulin) of Human Vascular Smooth Muscle Cells J. Gerontol. A Biol. Sci. Med. Sci., December 1, 2003; 58(12): B1074 - 1077. [Abstract] [Full Text] [PDF] |
||||
![]() |
J. Modi, A. Patel, R. Terrell, R. M. Tuttle, and G. L. Francis Papillary Thyroid Carcinomas from Young Adults and Children Contain a Mixture of Lymphocytes J. Clin. Endocrinol. Metab., September 1, 2003; 88(9): 4418 - 4425. [Abstract] [Full Text] [PDF] |
||||
![]() |
J. H. Von der Thusen, J. Kuiper, T. J. C. Van Berkel, and E. A. L. Biessen Interleukins in Atherosclerosis: Molecular Pathways and Therapeutic Potential Pharmacol. Rev., March 1, 2003; 55(1): 133 - 166. [Abstract] [Full Text] [PDF] |
||||
![]() |
A. Jacob, J. D. Molkentin, A. Smolenski, S. M. Lohmann, and N. Begum Insulin inhibits PDGF-directed VSMC migration via NO/ cGMP increase of MKP-1 and its inactivation of MAPKs Am J Physiol Cell Physiol, September 1, 2002; 283(3): C704 - C713. [Abstract] [Full Text] [PDF] |
||||
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Circulation Home | Subscriptions | Archives | Feedback | Authors | Help | AHA Journals Home | Search Copyright © 2001 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited. |