Nitric Oxide Bioavailability in Chronic Obstructive Pulmonary Disease (COPD)

This study has been completed.

Sponsor:

Collaborator:

American Heart Association

Information provided by (Responsible Party):

Ryan Harris, Augusta University

ClinicalTrials.gov Identifier:

NCT01398943

First received: July 19, 2011

Last updated: June 27, 2017

Last verified: June 2017

History of Changes

Purpose

More patients with chronic obstructive pulmonary disease (COPD) die from cardiovascular disease than direct pulmonary complications. Inflammation and oxidative stress, characteristic in COPD, are likely contributors to the reduction in nitric oxide (NO) bioavailability and vascular endothelial dysfunction in COPD patients; however, this has yet to be determined. Thus, the overall objective of this proposal is to identify the role of NO bioavailability in contributing to vascular endothelial dysfunction in patients with COPD and to provide insight into the molecular mechanisms involved. Our central hypothesis is that inflammation and oxidative stress, both independently, contribute to the reduction in NO bioavailability and vascular endothelial dysfunction in patients with COPD.

Condition	Intervention
Pulmonary Disease, Chronic Obstructive	Drug: Tetrahydrobiopterin (BH4) Dietary Supplement: Antioxidant Cocktail


Study Type:	Interventional
Study Design:	Allocation: Randomized Intervention Model: Crossover Assignment Masking: Participant, Investigator Primary Purpose: Prevention
Official Title:	Regulation of Nitric Oxide Bioavailability in Chronic Obstructive Pulmonary Disease: A Mechanistic Approach

Resource links provided by NLM:

MedlinePlus related topics: COPD Lung Diseases

Drug Information available for: Nitric oxide

U.S. FDA Resources

Further study details as provided by Ryan Harris, Augusta University:

Primary Outcome Measures:

Flow-Mediated Dilation (FMD) [ Time Frame: Post FMD was taken approximately 110 min after baseline ]
Brachial artery FMD induced by reactive hyperemia will be used to assess vascular endothelial function at baseline and several hours after each experimental intervention.

Secondary Outcome Measures:

Pulse Wave Velocity [ Time Frame: Post PWV was taken approximately 90 min after baseline ]
A measure of vascular stiffness at baseline and several hours after each experimental intervention.


Enrollment:	60
Study Start Date:	September 2010
Study Completion Date:	June 2015
Primary Completion Date:	June 2015 (Final data collection date for primary outcome measure)

Arms	Assigned Interventions
Experimental: COPD Patients Patients with COPD AOC protocol: Brachial artery flow-mediated dilation, direct assessment of oxidative stress via EPR spectroscopy (O2-) and biomarkers of oxidative stress (8-isoprostane, LH, SOD) will be assessed at baseline and 2 hours following ingestion of a single oral antioxidant cocktail (1g of vitamin C, 600 IU of vitamin E, and 600 mg of alpha-lipoic acid.) Antioxidant Cocktail: 1g of vitamin C, 600 IU of vitamin E, and 600 mg of alpha-lipoic acid BH4 protocol: Brachial artery flow-mediated dilation (FMD), markers of inflammation, and markers of oxidative stress will be assessed at baseline and following an increase in nitric oxide bioavailability after administering a single dose = 5 mg/kg of Tetrahydrobiopterin (BH4)	Drug: Tetrahydrobiopterin (BH4) single dose = 5 mg/kg Other Name: Kuvan (Sapropterin Dihydrochloride) Dietary Supplement: Antioxidant Cocktail 1g of vitamin C, 600 IU of vitamin E, and 600 mg of alpha-lipoic acid
Experimental: Controls Healthy age- and sex- matched controls AOC protocol: Brachial artery flow-mediated dilation, direct assessment of oxidative stress via EPR spectroscopy (O2-) and biomarkers of oxidative stress (8-isoprostane, LH, SOD) will be assessed at baseline and 2 hours following ingestion of a single oral antioxidant cocktail (1g of vitamin C, 600 IU of vitamin E, and 600 mg of alpha-lipoic acid.) Antioxidant Cocktail: 1g of vitamin C, 600 IU of vitamin E, and 600 mg of alpha-lipoic acid BH4 protocol: Brachial artery flow-mediated dilation (FMD), markers of inflammation, and markers of oxidative stress will be assessed at baseline and following an increase in nitric oxide bioavailability after administering a single dose = 5 mg/kg of Tetrahydrobiopterin (BH4)	Drug: Tetrahydrobiopterin (BH4) single dose = 5 mg/kg Other Name: Kuvan (Sapropterin Dihydrochloride) Dietary Supplement: Antioxidant Cocktail 1g of vitamin C, 600 IU of vitamin E, and 600 mg of alpha-lipoic acid

Arms

Assigned Interventions

Experimental: COPD Patients

Patients with COPD

AOC protocol: Brachial artery flow-mediated dilation, direct assessment of oxidative stress via EPR spectroscopy (O2-) and biomarkers of oxidative stress (8-isoprostane, LH, SOD) will be assessed at baseline and 2 hours following ingestion of a single oral antioxidant cocktail (1g of vitamin C, 600 IU of vitamin E, and 600 mg of alpha-lipoic acid.) Antioxidant Cocktail: 1g of vitamin C, 600 IU of vitamin E, and 600 mg of alpha-lipoic acid

BH4 protocol: Brachial artery flow-mediated dilation (FMD), markers of inflammation, and markers of oxidative stress will be assessed at baseline and following an increase in nitric oxide bioavailability after administering a single dose = 5 mg/kg of Tetrahydrobiopterin (BH4)

Drug: Tetrahydrobiopterin (BH4)

single dose = 5 mg/kg

Other Name: Kuvan (Sapropterin Dihydrochloride)

Dietary Supplement: Antioxidant Cocktail

1g of vitamin C, 600 IU of vitamin E, and 600 mg of alpha-lipoic acid

Experimental: Controls

Healthy age- and sex- matched controls

Drug: Tetrahydrobiopterin (BH4)

single dose = 5 mg/kg

Other Name: Kuvan (Sapropterin Dihydrochloride)

Dietary Supplement: Antioxidant Cocktail

1g of vitamin C, 600 IU of vitamin E, and 600 mg of alpha-lipoic acid

Detailed Description:

Flow-Mediated Dilation (FMD) - Subjects will lie in the supine position for 20 minutes to obtain hemodynamic steady state. A blood pressure cuff (Hokanson) will be placed around the forearm (distal to the Doppler transducer) and rapidly inflated to 250 mmHg for 5 minutes (circulatory arrest). Simultaneous ultrasound images of the vessel (B-mode) and Doppler waveforms will be collected 10 seconds prior to and for 2 minutes following deflation of the cuff. All B-mode images will be analyzed using automated edge detection software (Medical Imaging Applications), while intensity weighted velocity spectra segments will be saved to the GE Logiq 7 hard drive for off-line blood velocity waveform analysis. P.I. has utilized the traditional method of brachial artery flow-mediated dilation (FMD) induced by reactive hyperemia to assess vascular endothelial function in populations ranging from young healthy adults to older adults with pathological conditions.

Spygmocor - Pulse Wave Velocity (PWV) - A Spygmocor® device will be used at baseline and following each protocol to assess PWV. PWV analysis provides a non-invasive assessment of arterial stiffness. Increased arterial stiffness is known to be associated with cardiovascular disease. The participant is required to lie in a resting position for approximately 30-45 minutes. The research assistant will place ECG electrode sensors at the carotid, femoral, radial and distal artery locations. A highly sensitive pen-like device, called a tonometer, is then gently applied to record the velocity of the blood flow between each of the points.

Eligibility


Ages Eligible for Study:	18 Years and older (Adult, Senior)
Sexes Eligible for Study:	All
Accepts Healthy Volunteers:	Yes

Criteria

Inclusion Criteria:

Patients with COPD (GOLD stages II-IV) and matched healthy controls
Caucasian or African American
Both men and women
Current and former smokers

Exclusion Criteria:

GOLD Stage I
Clinical diagnosis of heart disease, hypertension, or metabolic disease
Vasoactive medications (i.e. nitrates, beta-blockers, ACE inhibitors, Viagra, etc.)
Pulmonary hypertension
Hypothyroidism
Hyper-homocysteinemia
Interstitial lung disease
Phenylketonuria
Pregnancy
Sleep apnea
Anemia
Raynod's phenomenon
Gangrene of the digits
History of low platelets or coagulopathies
Aspirin sensitivity or allergy

Contacts and Locations

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT01398943

Locations


United States, Georgia
Georgia Health Sciences University
Augusta, Georgia, United States, 30912

Sponsors and Collaborators

Augusta University

American Heart Association

Investigators


Principal Investigator:	Ryan A Harris, PhD	Augusta University

More Information

Publications:

Selvaraj CL, Gurm HS, Gupta R, Ellis SG, Bhatt DL. Chronic obstructive pulmonary disease as a predictor of mortality in patients undergoing percutaneous coronary intervention. Am J Cardiol. 2005 Sep 15;96(6):756-9.

Anthonisen NR, Connett JE, Enright PL, Manfreda J; Lung Health Study Research Group. Hospitalizations and mortality in the Lung Health Study. Am J Respir Crit Care Med. 2002 Aug 1;166(3):333-9.

Schächinger V, Britten MB, Zeiher AM. Prognostic impact of coronary vasodilator dysfunction on adverse long-term outcome of coronary heart disease. Circulation. 2000 Apr 25;101(16):1899-906.

Suwaidi JA, Hamasaki S, Higano ST, Nishimura RA, Holmes DR Jr, Lerman A. Long-term follow-up of patients with mild coronary artery disease and endothelial dysfunction. Circulation. 2000 Mar 7;101(9):948-54.

Wheatcroft SB, Williams IL, Shah AM, Kearney MT. Pathophysiological implications of insulin resistance on vascular endothelial function. Diabet Med. 2003 Apr;20(4):255-68. Review.

Knowles RG, Moncada S. Nitric oxide synthases in mammals. Biochem J. 1994 Mar 1;298 ( Pt 2):249-58. Review.

Green D. Point: Flow-mediated dilation does reflect nitric oxide-mediated endothelial function. J Appl Physiol (1985). 2005 Sep;99(3):1233-4; discussion 1237-8.

Uehata A, Lieberman EH, Gerhard MD, Anderson TJ, Ganz P, Polak JF, Creager MA, Yeung AC. Noninvasive assessment of endothelium-dependent flow-mediated dilation of the brachial artery. Vasc Med. 1997;2(2):87-92.

Celermajer DS, Sorensen KE, Gooch VM, Spiegelhalter DJ, Miller OI, Sullivan ID, Lloyd JK, Deanfield JE. Non-invasive detection of endothelial dysfunction in children and adults at risk of atherosclerosis. Lancet. 1992 Nov 7;340(8828):1111-5.

Verma S, Buchanan MR, Anderson TJ. Endothelial function testing as a biomarker of vascular disease. Circulation. 2003 Oct 28;108(17):2054-9. Review.

Maiorana A, O'Driscoll G, Taylor R, Green D. Exercise and the nitric oxide vasodilator system. Sports Med. 2003;33(14):1013-35. Review.

Edwards DG, Schofield RS, Lennon SL, Pierce GL, Nichols WW, Braith RW. Effect of exercise training on endothelial function in men with coronary artery disease. Am J Cardiol. 2004 Mar 1;93(5):617-20.

Guerci B, Kearney-Schwartz A, Böhme P, Zannad F, Drouin P. Endothelial dysfunction and type 2 diabetes. Part 1: physiology and methods for exploring the endothelial function. Diabetes Metab. 2001 Sep;27(4 Pt 1):425-34. Review.

Zarubina EG, Mishina EA, Osadchuk MA. [The role of endothelial dysfunction in the pathogenesis of combined cardiopulmonary diseases]. Klin Med (Mosk). 2006;84(5):31-4. Russian.

Barr RG, Mesia-Vela S, Austin JH, Basner RC, Keller BM, Reeves AP, Shimbo D, Stevenson L. Impaired flow-mediated dilation is associated with low pulmonary function and emphysema in ex-smokers: the Emphysema and Cancer Action Project (EMCAP) Study. Am J Respir Crit Care Med. 2007 Dec 15;176(12):1200-7. Epub 2007 Aug 29.

Moro L, Pedone C, Scarlata S, Malafarina V, Fimognari F, Antonelli-Incalzi R. Endothelial dysfunction in chronic obstructive pulmonary disease. Angiology. 2008 Jun-Jul;59(3):357-64. doi: 10.1177/0003319707306141. Epub 2008 Apr 2.

Eickhoff P, Valipour A, Kiss D, Schreder M, Cekici L, Geyer K, Kohansal R, Burghuber OC. Determinants of systemic vascular function in patients with stable chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2008 Dec 15;178(12):1211-8. doi: 10.1164/rccm.200709-1412OC. Epub 2008 Oct 3.

Fukai T. Endothelial GTPCH in eNOS uncoupling and atherosclerosis. Arterioscler Thromb Vasc Biol. 2007 Jul;27(7):1493-5.

Channon KM. Tetrahydrobiopterin: regulator of endothelial nitric oxide synthase in vascular disease. Trends Cardiovasc Med. 2004 Nov;14(8):323-7. Review.

Heitzer T, Brockhoff C, Mayer B, Warnholtz A, Mollnau H, Henne S, Meinertz T, Münzel T. Tetrahydrobiopterin improves endothelium-dependent vasodilation in chronic smokers : evidence for a dysfunctional nitric oxide synthase. Circ Res. 2000 Feb 4;86(2):E36-41.

Nandi M, Miller A, Stidwill R, Jacques TS, Lam AA, Haworth S, Heales S, Vallance P. Pulmonary hypertension in a GTP-cyclohydrolase 1-deficient mouse. Circulation. 2005 Apr 26;111(16):2086-90. Epub 2005 Apr 11.

Khoo JP, Zhao L, Alp NJ, Bendall JK, Nicoli T, Rockett K, Wilkins MR, Channon KM. Pivotal role for endothelial tetrahydrobiopterin in pulmonary hypertension. Circulation. 2005 Apr 26;111(16):2126-33. Epub 2005 Apr 11.

Barnes PJ, Karin M. Nuclear factor-kappaB: a pivotal transcription factor in chronic inflammatory diseases. N Engl J Med. 1997 Apr 10;336(15):1066-71. Review.

De Boer WI. Cytokines and therapy in COPD: a promising combination? Chest. 2002 May;121(5 Suppl):209S-218S. Review.

Keatings VM, Collins PD, Scott DM, Barnes PJ. Differences in interleukin-8 and tumor necrosis factor-alpha in induced sputum from patients with chronic obstructive pulmonary disease or asthma. Am J Respir Crit Care Med. 1996 Feb;153(2):530-4.

Shapiro SD, Senior RM. Matrix metalloproteinases. Matrix degradation and more. Am J Respir Cell Mol Biol. 1999 Jun;20(6):1100-2. Review.

Read MA, Whitley MZ, Williams AJ, Collins T. NF-kappa B and I kappa B alpha: an inducible regulatory system in endothelial activation. J Exp Med. 1994 Feb 1;179(2):503-12.

Yin MJ, Yamamoto Y, Gaynor RB. The anti-inflammatory agents aspirin and salicylate inhibit the activity of I(kappa)B kinase-beta. Nature. 1998 Nov 5;396(6706):77-80.

Atkinson MH, Ménard HA, Kalish GH. Assessment of salsalate, a nonacetylated salicylate, in the treatment of patients with arthritis. Clin Ther. 1995 Sep-Oct;17(5):827-37.

Bombardier C, Peloso PM, Goldsmith CH. Salsalate, a nonacetylated salicylate, is as efficacious as diclofenac in patients with rheumatoid arthritis. Salsalate-Diclofenac Study Group. J Rheumatol. 1995 Apr;22(4):617-24.

Pierce GL, Lesniewski LA, Lawson BR, Beske SD, Seals DR. Nuclear factor-{kappa}B activation contributes to vascular endothelial dysfunction via oxidative stress in overweight/obese middle-aged and older humans. Circulation. 2009 Mar 10;119(9):1284-92. doi: 10.1161/CIRCULATIONAHA.108.804294. Epub 2009 Feb 23.

Halliwell B. Free radicals and antioxidants: a personal view. Nutr Rev. 1994 Aug;52(8 Pt 1):253-65. Review.

Celermajer DS, Adams MR, Clarkson P, Robinson J, McCredie R, Donald A, Deanfield JE. Passive smoking and impaired endothelium-dependent arterial dilatation in healthy young adults. N Engl J Med. 1996 Jan 18;334(3):150-4.

Celermajer DS, Sorensen KE, Georgakopoulos D, Bull C, Thomas O, Robinson J, Deanfield JE. Cigarette smoking is associated with dose-related and potentially reversible impairment of endothelium-dependent dilation in healthy young adults. Circulation. 1993 Nov;88(5 Pt 1):2149-55.

Raitakari OT, Adams MR, McCredie RJ, Griffiths KA, Celermajer DS. Arterial endothelial dysfunction related to passive smoking is potentially reversible in healthy young adults. Ann Intern Med. 1999 Apr 6;130(7):578-81.

Macnee W. Pathogenesis of chronic obstructive pulmonary disease. Clin Chest Med. 2007 Sep;28(3):479-513, v. Review.

Rubanyi GM, Vanhoutte PM. Superoxide anions and hyperoxia inactivate endothelium-derived relaxing factor. Am J Physiol. 1986 May;250(5 Pt 2):H822-7.

Neunteufl T, Kostner K, Katzenschlager R, Zehetgruber M, Maurer G, Weidinger F. Additional benefit of vitamin E supplementation to simvastatin therapy on vasoreactivity of the brachial artery of hypercholesterolemic men. J Am Coll Cardiol. 1998 Sep;32(3):711-6.

Plantinga Y, Ghiadoni L, Magagna A, Giannarelli C, Franzoni F, Taddei S, Salvetti A. Supplementation with vitamins C and E improves arterial stiffness and endothelial function in essential hypertensive patients. Am J Hypertens. 2007 Apr;20(4):392-7.

Title LM, Cummings PM, Giddens K, Genest JJ Jr, Nassar BA. Effect of folic acid and antioxidant vitamins on endothelial dysfunction in patients with coronary artery disease. J Am Coll Cardiol. 2000 Sep;36(3):758-65.

Williams TJ, Howard M, Roget J, Esmore DS. Exercise capacity after combined heart-lung transplantation. Transplant Proc. 1992 Oct;24(5):2018.

Richardson RS, Secher NH, Tschakovsky ME, Proctor DN, Wray DW. Metabolic and vascular limb differences affected by exercise, gender, age, and disease. Med Sci Sports Exerc. 2006 Oct;38(10):1792-6.

Eskurza I, Myerburgh LA, Kahn ZD, Seals DR. Tetrahydrobiopterin augments endothelium-dependent dilatation in sedentary but not in habitually exercising older adults. J Physiol. 2005 Nov 1;568(Pt 3):1057-65. Epub 2005 Sep 1.

Ueda S, Matsuoka H, Miyazaki H, Usui M, Okuda S, Imaizumi T. Tetrahydrobiopterin restores endothelial function in long-term smokers. J Am Coll Cardiol. 2000 Jan;35(1):71-5.

Padilla J, Harris RA, Fly AD, Rink LD, Wallace JP. A comparison between active- and reactive-hyperaemia-induced brachial artery vasodilation. Clin Sci (Lond). 2006 Mar;110(3):387-92.

Plotnick GD, Corretti MC, Vogel RA. Effect of antioxidant vitamins on the transient impairment of endothelium-dependent brachial artery vasoactivity following a single high-fat meal. JAMA. 1997 Nov 26;278(20):1682-6.

Padilla J, Harris RA, Fly AD, Rink LD, Wallace JP. The effect of acute exercise on endothelial function following a high-fat meal. Eur J Appl Physiol. 2006 Oct;98(3):256-62. Epub 2006 Aug 3.

Tsai WC, Li YH, Lin CC, Chao TH, Chen JH. Effects of oxidative stress on endothelial function after a high-fat meal. Clin Sci (Lond). 2004 Mar;106(3):315-9.

Mullen MJ, Kharbanda RK, Cross J, Donald AE, Taylor M, Vallance P, Deanfield JE, MacAllister RJ. Heterogenous nature of flow-mediated dilatation in human conduit arteries in vivo: relevance to endothelial dysfunction in hypercholesterolemia. Circ Res. 2001 Feb 2;88(2):145-51.

Kingwell BA, Formosa M, Muhlmann M, Bradley SJ, McConell GK. Nitric oxide synthase inhibition reduces glucose uptake during exercise in individuals with type 2 diabetes more than in control subjects. Diabetes. 2002 Aug;51(8):2572-80.

Lieberman EH, Gerhard MD, Uehata A, Selwyn AP, Ganz P, Yeung AC, Creager MA. Flow-induced vasodilation of the human brachial artery is impaired in patients <40 years of age with coronary artery disease. Am J Cardiol. 1996 Dec 1;78(11):1210-4.

Harris RA, Nishiyama SK, Wray DW, Tedjasaputra V, Bailey DM, Richardson RS. The effect of oral antioxidants on brachial artery flow-mediated dilation following 5 and 10 min of ischemia. Eur J Appl Physiol. 2009 Nov;107(4):445-53. doi: 10.1007/s00421-009-1147-x. Epub 2009 Aug 11.

Bleeker MW, Kooijman M, Rongen GA, Hopman MT, Smits P. Preserved contribution of nitric oxide to baseline vascular tone in deconditioned human skeletal muscle. J Physiol. 2005 Jun 1;565(Pt 2):685-94. Epub 2005 Mar 31.

Mercier JG, Hokanson JF, Brooks GA. Effects of cyclosporine A on skeletal muscle mitochondrial respiration and endurance time in rats. Am J Respir Crit Care Med. 1995 May;151(5):1532-6.

Casaburi R. Skeletal muscle function in COPD. Chest. 2000 May;117(5 Suppl 1):267S-71S. Review.

Harris RA, Padilla J, Rink LD, Wallace JP. Variability of flow-mediated dilation measurements with repetitive reactive hyperemia. Vasc Med. 2006 Feb;11(1):1-6.

Harris RA, Padilla J, Hanlon KP, Rink LD, Wallace JP. Reproducibility of the flow-mediated dilation response to acute exercise in overweight men. Ultrasound Med Biol. 2007 Oct;33(10):1579-85. Epub 2007 Jun 27.

Vogel RA, Corretti MC, Plotnick GD. Effect of a single high-fat meal on endothelial function in healthy subjects. Am J Cardiol. 1997 Feb 1;79(3):350-4.

Sander M, Chavoshan B, Victor RG. A large blood pressure-raising effect of nitric oxide synthase inhibition in humans. Hypertension. 1999 Apr;33(4):937-42.

Goldfine AB, Silver R, Aldhahi W, Cai D, Tatro E, Lee J, Shoelson SE. Use of salsalate to target inflammation in the treatment of insulin resistance and type 2 diabetes. Clin Transl Sci. 2008 May;1(1):36-43. doi: 10.1111/j.1752-8062.2008.00026.x.

Bailey DM, Davies B, Young IS, Jackson MJ, Davison GW, Isaacson R, Richardson RS. EPR spectroscopic detection of free radical outflow from an isolated muscle bed in exercising humans. J Appl Physiol (1985). 2003 May;94(5):1714-8. Epub 2003 Mar 7.


Responsible Party:	Ryan Harris, Assistant Professor, Director Laboratory of Integrative Vascular and Exercise Physiology, Augusta University
ClinicalTrials.gov Identifier:	NCT01398943 History of Changes
Other Study ID Numbers:	AHA00115CS
Study First Received:	July 19, 2011
Results First Received:	November 17, 2016
Last Updated:	June 27, 2017
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD:	Yes

Keywords provided by Ryan Harris, Augusta University:


flow-mediated dilation arterial stiffness intima-media thickness pulse wave velocity dual energy x-ray absorptiometry inflammatory markers blood lipids tetrahydrobiopterin	body mass index hemoglobin A1c complete blood count oxidative stress biomarkers pulmonary function test lung COPD

Additional relevant MeSH terms:


Lung Diseases Lung Diseases, Obstructive Pulmonary Disease, Chronic Obstructive Chronic Disease Respiratory Tract Diseases Disease Attributes Pathologic Processes Vitamins Vitamin E Thioctic Acid Nitric Oxide Antioxidants Micronutrients Growth Substances	Physiological Effects of Drugs Bronchodilator Agents Autonomic Agents Peripheral Nervous System Agents Anti-Asthmatic Agents Respiratory System Agents Free Radical Scavengers Molecular Mechanisms of Pharmacological Action Neurotransmitter Agents Endothelium-Dependent Relaxing Factors Vasodilator Agents Gasotransmitters Protective Agents Vitamin B Complex

ClinicalTrials.gov processed this record on July 28, 2017

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