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Smoking and Female Sex: Independent Predictors of Human Vascular Smooth Muscle Cells Stiffening

  • Carla Luana Dinardo ,

    caludinardo@gmail.com

    Affiliation Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil

  • Hadassa Campos Santos,

    Affiliation Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil

  • André Ramos Vaquero,

    Affiliation Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil

  • André Ricardo Martelini,

    Affiliation Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil

  • Luis Alberto Oliveira Dallan,

    Affiliation Coronary Surgery Unit, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil

  • Adriano Mesquita Alencar,

    Affiliation Laboratory of Microrheology and Molecular Physiology, Physics Institute, University of São Paulo, São Paulo, Brazil

  • José Eduardo Krieger,

    Affiliation Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil

  • Alexandre Costa Pereira

    Affiliation Laboratory of Genetics and Molecular Cardiology, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil

Smoking and Female Sex: Independent Predictors of Human Vascular Smooth Muscle Cells Stiffening

  • Carla Luana Dinardo, 
  • Hadassa Campos Santos, 
  • André Ramos Vaquero, 
  • André Ricardo Martelini, 
  • Luis Alberto Oliveira Dallan, 
  • Adriano Mesquita Alencar, 
  • José Eduardo Krieger, 
  • Alexandre Costa Pereira
PLOS
x

Abstract

Aims

Recent evidence shows the rigidity of vascular smooth muscle cells (VSMC) contributes to vascular mechanics. Arterial rigidity is an independent cardiovascular risk factor whose associated modifications in VSMC viscoelasticity have never been investigated. This study’s objective was to evaluate if the arterial rigidity risk factors aging, African ancestry, female sex, smoking and diabetes mellitus are associated with VMSC stiffening in an experimental model using a human derived vascular smooth muscle primary cell line repository.

Methods

Eighty patients subjected to coronary artery bypass surgery were enrolled. VSMCs were extracted from internal thoracic artery fragments and mechanically evaluated using Optical Magnetic Twisting Cytometry assay. The obtained mechanical variables were correlated with the clinical variables: age, gender, African ancestry, smoking and diabetes mellitus.

Results

The mechanical variables Gr, G’r and G”r had a normal distribution, demonstrating an inter-individual variability of VSMC viscoelasticity, which has never been reported before. Female sex and smoking were independently associated with VSMC stiffening: Gr (apparent cell stiffness) p = 0.022 and p = 0.018, R2 0.164; G’r (elastic modulus) p = 0.019 and p = 0.009, R2 0.184 and G”r (dissipative modulus) p = 0.011 and p = 0.66, R2 0.141.

Conclusion

Female sex and smoking are independent predictors of VSMC stiffening. This pro-rigidity effect represents an important element for understanding the vascular rigidity observed in post-menopausal females and smokers, as well as a potential therapeutic target to be explored in the future. There is a significant inter-individual variation of VSMC viscoelasticity, which is slightly modulated by clinical variables and probably relies on molecular factors.

Introduction

Recent studies have demonstrated VSMC viscoelasticity contributes to the vessels’ overall mechanics, contradicting the previous paradigm which associated vascular compliance only with extracellular matrix composition (ECM) [1]. Under physiological conditions, it has been shown the VSMC mechanical behavior varies according to the position in arterial tree and intensity of regional mechanical forces. As the variations of VSMC mechanical phenotype were in accordance with the variations of vascular compliance, the association between these two variables was suggested [2]. In pathological scenario, VSMC cytoplasm stiffening has already been associated with aging and arterial hypertension, causing arterial rigidity in the absence of ECM modifications [3, 4].

Arterial rigidity is an independent cardiovascular risk factor caused by diverse pathological clinical variables: hyperlipidemia [5], diabetes mellitus [6], arterial systemic hypertension [7] and smoking [8], as well as by some physiological factors: aging, female sex and black race [9, 10]. Proteomics studies show almost one-third of the differences found between stiff and distensible vessels are due to the differential expression of proteins involved in the mechanical regulation of vascular function, especially the components of VSMC cytoskeleton and ECM [11]. Even though this difference exists, the ability of most arterial rigidity risk factors to modify neither VSMC mechanical phenotype nor ECM composition has been properly explored, limiting our understanding of the pathophysiological steps that lead to the reduction of vascular compliance. Exceptionally, hypertension and aging have been associated with VSMCs stiffening and hypertrophy [3, 12], and with VSMCs stiffening [4] and collagen deposit [13], respectively.

The finding that the arterial rigidity risk factors cause VSMC stiffness would not only help in explaining the pathophysiology of the disease, but would also represent a therapeutic option, since the VSMC mechanical phenotype is extremely plastic [14]. Based on what was exposed, the main objective of this study was to evaluate if the arterial rigidity risk factors: aging, African ancestry, female sex, smoking and diabetes mellitus are associated with VMSC stiffening.

Methods

Patient recruitment

The study and its consent procedure were approved by our local ethics committee (Comissão de Ética para Análise de Projetos de Pesquisa—CAPPesq USP, number of the project 0272/11). The study was conducted in accordance to the Declaration of Helsinki. All patients included in the study were subjected to coronary artery bypass surgery between 2012 and 2014. The participants were aware of the study objectives and signed the informed consent approved by our local ethics committee. A sample of blood and a fragment of the internal thoracic artery were obtained during the surgical act. All clinical data were obtained using electronic medical records and, in case of dubious information, the patient was contacted for clarification. Estimated glomerular filtration rate (eGFR) was calculated using Cockroft-Gault formula and body mass index (BMI) was calculated using patients’ weight and height measured immediately before the surgery.

Primary culture (VSMCs isolation)

The chosen experimental set up involved the use of a large repository of primary cell lines mechanically evaluated at low culture passaging using Optical Magnetic Twisting Cytometry assay. This was an attempt to maximize the preservation of VSMCs in vivo characteristics, as well as to perform the mechanical measurements without cell detachment from the substrate, keeping the cytoskeleton organization.

Internal thoracic artery fragments were used to isolate VSMCs using the primary explant technique. Briefly, the vessel’s lumen was opened and a mechanical friction was applied in order to remove the endothelium. The vessel was then cut into small fragments (approximately 3mm x 3mm), which were placed on a 6-well plastic plate (one or two fragments per well), with the luminal face down. Dulbecco’s Modified Eagle’s Medium with high glucose (Sigma Aldrich®, catalog number D0572) supplemented with 20% fetal bovine serum (Gibco®) and 1% of Penicillin-Streptomycin solution (Sigma-Aldrich®, catalog number P4333) was added to the wells (1cc per well). Isolated VSMCs were characterized using immunofluorescence microscopy with the following primary antibodies: alpha- smooth muscle actin (Sigma Aldrich®, catalog number A2547), anti-myosin heavy chain (Abcam®, catalog number ab683) and calponin (Sigma Aldrich®, catalog number C6047). The obtained primary cultures exhibited more than 90% of cells positive for alpha-smooth muscle actin, myosin heavy chain and calponin (Fig 1). When 90% of cellular confluence was achieved in the 6-well plate, cells underwent tripsinization and were seeded on a T25 bottle. There, when 90% of confluence was reached, cells were prepared for the mechanical measurement as it will be described later.

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Fig 1. VSMCs characterization.

VSMCs obtained using the primary explant technique were characterized using immunofluorescence microscopy with the following primary antibodies: alpha- smooth muscle actin (A2547, Sigma Aldrich®), anti-myosin heavy chain (ab683, Abcam®) and calponin (C6047, Sigma Aldrich®) before the beginning of the experiments. The obtained primary cultures exhibited more than 90% of cells positive for alpha-smooth muscle actin, myosin heavy chain and calponin. (A and B): VSMCs exhibiting positive staining for calponin (blue) and myosin heavy chain (green). Red: nucleus. (C and D): VSMCs exhibiting positive staining for calponin (blue) and alpha- smooth muscle cell actin (green). Red: nucleus. This characterization protocol has a high capability of identifying SMCs amongst possible contaminants.

https://doi.org/10.1371/journal.pone.0145062.g001

For the mechanical experiments, VSMCs in second culture passage were used, as previous standardized for Optical Magnetic Twisting Cytometry (OMTC) assay [15]. The internal thoracic artery was chosen as object of study since the mechanical properties of its VSMCs, under physiological conditions, are similar to that presented by thoracic aorta VSMCs, as previously demonstrated by our group [2].

Optical Magnetic Twisting Cytometry (OMTC)

OMTC assay is a method used to measure cell viscoelasticity based on the application of a sinusoidal magnetic torque to ferromagnetic beads, which are intrinsically attached to the cytoskeleton stress fibers [16, 17]. VSMCs (2nd culture passage) were plated on a 96-well plate (Corning®, catalog number 9102) previously coated with 3% porcine gelatin (Sigma Aldrich®, catalog number G9136) at a concentration of 1 x 104 cells per well. Twelve hours after plating, VSMCs were serum-deprived for 24h and, then, RGD-coated ferromagnetic beads were added at a concentration of 10μg per well. VSMCs were then incubated for 20 minutes and washed once to remove loosely bound beads before the performance of mechanical measurements.

Beads were first magnetized horizontally (9,000 Gauss) and, then, a vertical magnetic field oscillating at 0.75 Hz was put into action (90 Gauss). The resulting bead displacement was optically registered by a charge-coupled device camera mounted on an inverted microscope (Leica DMI-4000). The ratio between the Fourier transformation of the specific torque and bead displacement defined a complex apparent stiffness of the cell, g*(f), measured in units of Pa nm-1. The apparent stiffness g*(f) was converted into a shear modulus G* after taking into consideration the shape and thickness of the cell and the degree of bead embedding [18]. |G*| at 0.75Hz was labeled G. Based on this value, it was possible to also compute the elastic modulus G’ and the loss modulus G” for the cell.

Genetic ancestry determination

DNA was extracted using QIAamp DNA Mini-kit® and genotyped using Affymetrix GeneChip Human Mapping SNP Array®, according to manufacturer instructions. The evaluation of genomic ancestry was conducted using the Admixture program [19]. Admixture is a software tool for maximum likelihood estimation of individual ancestries from multilocus SNP genotype datasets. Specifically, Admixture uses a block relaxation approach to alternately update allele frequency and ancestry fraction. This software estimates parameter standard errors using bootstrapping. Since the contributions of different ancestral genomes have previously been described by our group, as well as others, we used a supervised approach for ancestry determination [20]. We used 200 bootstrap replicates (default) and k = 3 (number of populations assumed for the analysis). This analysis was done using all 101.348 common autosomal SNPs between the study population and reference. We assumed as reference ancestral populations individuals from the Human Genome Diversity Project (HGDP) [21]: Pima, Maya as Amerindians and from HapMap project [22]: Africans—YRI (Yoruba in Ibadan, Nigeria), LWK (Luhya in Webuye, Kenya), ASW (Americans of African Ancestry in SW, USA); European—CEU (Utah Residents (CEPH) with Northern and Western European ancestry) and TSI (Tuscan in Italia).

Statistical analysis

Any potential bias due to different bead batches was corrected using a linear regression method and the non-standardized residues (named Gr, G’r and G”r) were used as the variables of comparison between the groups. Univariate analysis was performed using t-Student test for the categorical variables and Pearson correlation test for the numerical variables. Multivariate analysis was done using multiple linear regression, considering as dependent variables: Gr, G’r and G”r and, as independent variables: age, sex, African ancestry, diabetes mellitus, smoking and any clinical variable whose association with the mechanical variables resulted a p value of 0.2 or less in the univariate analysis. A p value less than 0.05 was considered significant in the multivariate analysis. All statistical tests were held in SPSS software, 18th version.

Results

Eighty patients with chronic coronary heart disease subjected to revascularization surgery were included in the study. The studied population exhibited a predominance of men and European ancestry (Fig 2), besides being homogeneous for the presence of systemic hypertension and hyperlipidemia (Table 1). All women included in this study were post-menopausal. For each included patient, six replicates of the OMTC experiment were performed and the median value of G, G” and G’ obtained from these assays was used in the statistical analyses. The mechanical variables Gr, G’r and G”r had a normal distribution (Kolmogorov-Smirnov test: p = 0.2, p = 0.2 and p = 0.089, respectively), as exposed on Fig 3. This distribution pattern demonstrates an inter-individual variability of VSMC viscoelasticity, which has never been reported before.

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Fig 2. Dispersion of genetic ancestry within the studied population.

The graph highlights that all included patients had a predominance of European genetic ancestry in comparison to both African and Amerindian genetic ancestry.

https://doi.org/10.1371/journal.pone.0145062.g002

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Fig 3. Distribution of the mechanical variables that reflect VSMC viscoelasticity amongst the studied population.

The graphs outline that Gr (apparent cell stiffness), G’r (elastic modulus) and G”r (dissipative modulus) present a normal distribution (Kolmogorov-Smirnov test: p = 0.2, p = 0.2 and p = 0.089, respectively) and also highlight the inter-individual variability of this biological trait, never described before.

https://doi.org/10.1371/journal.pone.0145062.g003

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Table 1. Clinical characteristics of the patients included in the study.

https://doi.org/10.1371/journal.pone.0145062.t001

In univariate analysis, the variables Gr and G’r differed between women and men (p = 0.042 and 0.04, respectively) and ever-smokers and non-smokers (p = 0.023 and 0.012, respectively). The other variables of interest (diabetes mellitus, African ancestry, age) were not significantly associated with the studied cellular phenotypes. Also, in univariate analysis, the confounder variables hypertension, hyperlipidemia, chronic renal failure, acute coronary syndrome, symptomatic angina, eGFR, BMI, educational status, medications in use and chronic obstructive pulmonary disease were not significantly associated with any mechanical variables and exhibited a p value greater than 0.2. Men and women presented similar rates of diabetes mellitus (p = 0.62). Multivariate analysis was then performed using multiple linear regression including the dependent variables (Gr, G”r and G’r) and the independent variables age, gender, African ancestry, diabetes mellitus and smoking (Table 2). Female sex was found to be a significant predictor of Gr (p = 0.022), G’r (p = 0.019) and G”r (p = 0.011), while smoking was a significant predictor of Gr (p = 0.018) and G’r (p = 0.009) (Table 2). The positive effect of female sex and smoking on the cellular mechanical variables Gr and G’r occurred independently of the variables age, African ancestry and diabetes mellitus.

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Table 2. Statistical model obtained when evaluating factors capable of modifying VSMC viscoelasticity (multivariate analyses).

https://doi.org/10.1371/journal.pone.0145062.t002

This result demonstrates the influence of the variables female sex and smoking on the increase of VSMC apparent stiffness (G) and its elastic component (G’r), the latter representing cell rigidity (Fig 4A and 4B). Female sex was also associated, in a smaller proportion, to an increase of the mechanical dissipative modulus (G”r), which represents cell viscosity (Fig 4A). The other clinical variables of interest (diabetes mellitus, African ancestry and age) were not significantly associated with none of the mechanical variables (Table 2). The fact that the resulting multivariate model exhibited a R2 of 0.164 (p = 0.042) for Gr, 0.184 (p = 0.023) for G’r and 0.141 (p = 0.082) for G”r is important to highlight. This finding shows that most of observed inter-individual variability of VSMC viscoelasticity (more than 80%) is not explained by our studied clinical variables and probably relies on other modulators, as it will be discussed later.

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Fig 4. Comparison of VSMC mechanics between men and women / ever smokers and non-smokers.

(A) Graph outlining the statistical comparison between men and women regarding VSMC mechanics. Women presented a significant higher apparent VSMC stiffness (Gr) in comparison to men, mainly due to its elastic modulus (G’r). (B) Similarly to what was observed with women, ever smokers presented a significant higher apparent VSMC stiffness (Gr) in comparison to non-smokers, mainly due to its elastic modulus (G’r). Error bars represent 95% CI and their size is compatible with other OMTC experiments in which a per-well analysis was performed. For each patient, 6 replicates of OMTC experiment were performed.

https://doi.org/10.1371/journal.pone.0145062.g004

Discussion

Our results demonstrate, for the first time, the inter-individual variation of VSMC viscoelasticity and the association between smoking / female sex and VSMC stiffening. The pro-stiffening effect of these clinical variables represents an important element for understanding the vascular rigidity observed in post-menopausal females and smokers, since significant changes in both ECM and VSMC have never been described in these conditions [8, 23]. Also, VSMC stiffening was observed in the absence of endothelium, what is especially relevant in the case of smoking, whose resulting arterial rigidity was always associated only with the dysfunction of endothelial cells [24]. Finally, it was demonstrated most of observed inter-individual variability of VSMC viscoelasticity is not explained by clinical variables of risk for arterial rigidity, probably relying on molecular modulators.

The role played by VSMCs on the vessel mechanics has been shed to light only recently, contradicting the classical concept that associated vascular compliance only with ECM composition [1]. In this regard, there are two experimental situations in which the VSMC cytoplasm rigidity was associated with an increase of vascular tone: arterial hypertension [3] and senile arterial rigidity [4]. In the first situation, it was demonstrated the VSMCs from spontaneously hypertensive rats were stiffer than the VSMCs from non-hypertensive controls, using atomic force microscopy to measure cell rigidity and an engineered aortic tissue model to evaluate the impact of stiffer VSMCs on vascular tone. In the second situation, the VSMCs from aged monkeys with arterial rigidity proved to be stiffer than the VSMCs from young animals using the same previously described methodology. In both studies, no ECM abnormalities were identified.

The present study is the first to assess the viscoelasticity of human primary VSMCs and correlate this biological trait with five important clinical factors of risk for arterial rigidity (age, gender, race, diabetes mellitus and smoking). It was found smoking and female sex are independent predictors of VSMCs stiffness. Considering that there are no studies showing significant changes in ECM and VSMCs of smokers and women, as it will be explored later, this represents the first description of a vascular abnormality of significance associated with these clinical variables. Even though it is difficult to quantify the relative contribution of VSMC mechanics and ECM for the arterial phenotype in these patients, our data suggest VSMC stiffening represents one possible contributory factor for the abnormal mechanical phenotype observed in association with smoking and female sex [3, 4].

It has already been demonstrated post-menopausal women exhibit higher aortic rigidity and lower vascular compliance in relation to men [23], situation associated with a significant impact on their mortality [25] and probably caused by estrogen deprival [2628]. Even though some authors argue that the smaller diameter of aortic root is responsible for women increased pulse pressure [29], there are strong evidences pointing out that the vascular wall composition is the most important factor responsible for it [23]. Gender differences concerning neither the ECM composition nor the VSMCs were previously evaluated. Our finding that women VSMCs are stiffer irrespective of other clinical variables (age, race, smoking, diabetes, hypertension and hyperlipidemia) represents the first evidence of vascular structural differences between male and female gender and offers a therapeutic possibility to be further evaluated.

The exposure to tobacco is also an independent risk factor for arterial rigidity [30, 31] and the exposure removal is incapable of completely reversing the established vascular mechanical modifications [32]. The abnormal vascular contractility observed in smokers has been always extensively associated with the injury of endothelial cells due to oxidative and inflammatory stress [24, 33]. That means that the physiological response of VSMCs to the dysfunctional endothelium was the only responsible for arterial rigidity [24]. Contradicting this fact, our study shows that smokers’ VMSCs are stiffer than non-smokers’ VSMCs regardless of the presence of the endothelium, suggesting a direct action of smoking on VSMCs or a final scenario of chronic VSMC modifications which could have been once deflagrated by the endothelium or by changes in ECM. The literature is scarce regarding smoking-associated ECM / VSMC abnormalities. There are evidences of increased activity of the matrix metalloproteinases MMP-2 and MMP-9 in association with nicotine exposure [34] and of increased production of PDGF, leading to chronic modifications in VSMC cytoskeleton, following tobacco exposure [35]. However, none of these studies have evaluated if the amount /composition of ECM is altered in smokers, as well as if the VSMC cytoplasm is more rigid in the same patients. Our finding that VMSC mechanics is affected by smoking helps to explain its association with arterial rigidity.

The finding that VSMCs are stiffer in women and in smokers is of great interest because it may represent a future therapeutic option to their associated arterial rigidity, given the plasticity of VSMC mechanical phenotype [14]. ECM composition and regional mechanical forces are factors known to modulate VSMC mechanics, but difficult to be modified in vivo [2]. In contrast, there are peptides capable of directly increasing VSMC tone, namely angiotensin 2 [36] and aldosterone [37], both associated with arterial rigidity and whose blockage may ameliorate the vascular compliance. Moreover, drugs that increase the endothelium production of nitric oxide, such as the 3-hydroxi-3-methylglutaryl coenzyme A reductase inhibitor fluvastatin, are also capable of indirectly reducing VSMC tone [38]. The ability of those options in reducing the stiffening of large arteries observed in women and smokers needs to be explored in the future.

Finally, this is the first study to demonstrate the presence of significant inter-individual variability of VSMC viscoelasticity. Even though it was stated that female sex and smoking affect this phenotype, our resulting statistical model was capable of explaining less than 20% of the trait’s variation. Knowing which factors are capable of modulating VSMC mechanics is of great importance, especially considering the growing evidences linking this phenotype with the vessels overall mechanical behavior. Considering this, future studies targeting possible genetic modulators of this trait are warranted as they can provide significant insight into the biology of vascular rigidity.

The present study has some limitations. Even though the variable ancestry was assessed using genetic tools, there was a strong predominance of patients with European origin, hampering the evaluation of a possible influence of the African heritage on VSMC rigidity. Similarly, the dispersion of the variable age within the sample was small, reducing the power of the correlation between this variable and the VSMC viscoelasticity. Even though the association between arterial hypertension and VSMC stiffening has already been demonstrated in the experimental scenario using animal models, in this study, the pro-stiffening effect of this variable could not be evaluated because of its universal presence in the studied sample. Last, the vascular properties of coronary arterial disease patients may vary [39] and, as the pulse wave velocity was not measured in our patients, the direct correlation between VSMC viscoelasticity and arterial rigidity could not be made.

In conclusion, female sex and smoking are independent predictors of VSMC stiffening. The described VSMC rigidity represents a significant change of the vascular media layer of smokers and post-menopausal females, thus becoming an important element in understanding the vascular rigidity observed in this population. Also, considering the plasticity of VSMC mechanical phenotype, this finding is a potential therapeutic target to be explored in the future. There is a significant inter-individual variation of VSMC viscoelasticity, which is slightly modulated by clinical variables and probably relies on molecular factors.

Author Contributions

Conceived and designed the experiments: CLD JEK AMA ACP. Performed the experiments: CLD HCS ARV ARM LAOD. Analyzed the data: CLD HCS ACP. Contributed reagents/materials/analysis tools: LAOD AMA JEK. Wrote the paper: CLD HCS ACP. Recruited the patients: LAOD.

References

  1. 1. Wagenseil JE, Mecham RP. Vascular extracellular matrix and arterial mechanics. Physiol Rev. 2009;89(3):957–89. pmid:19584318
  2. 2. Dinardo CL, Venturini G, Zhou EH, Watanabe IS, Campos LC, Dariolli R, et al. Variation of mechanical properties and quantitative proteomics of VSMC along the arterial tree. Am J Physiol Heart Circ Physiol. 2014;306(4):H505–16. pmid:24337458
  3. 3. Sehgel NL, Zhu Y, Sun Z, Trzeciakowski JP, Hong Z, Hunter WC, et al. Increased vascular smooth muscle cell stiffness: a novel mechanism for aortic stiffness in hypertension. Am J Physiol Heart Circ Physiol. 2013;305(9):H1281–7. pmid:23709594
  4. 4. Qiu H, Zhu Y, Sun Z, Trzeciakowski JP, Gansner M, Depre C, et al. Short communication: vascular smooth muscle cell stiffness as a mechanism for increased aortic stiffness with aging. Circ Res. 2010;107(5):615–9. pmid:20634486
  5. 5. Giannattasio C, Mangoni AA, Failla M, Carugo S, Stella ML, Stefanoni P, et al. Impaired radial artery compliance in normotensive subjects with familial hypercholesterolemia. Atherosclerosis. 1996;124(2):249–60. pmid:8830937
  6. 6. Salomaa V, Riley W, Kark JD, Nardo C, Folsom AR. Non-insulin-dependent diabetes mellitus and fasting glucose and insulin concentrations are associated with arterial stiffness indexes. The ARIC Study. Atherosclerosis Risk in Communities Study. Circulation. 1995;91(5):1432–43. pmid:7867184
  7. 7. Blacher J, Asmar R, Djane S, London GM, Safar ME. Aortic pulse wave velocity as a marker of cardiovascular risk in hypertensive patients. Hypertension. 1999;33(5):1111–7. pmid:10334796
  8. 8. Levenson J, Simon AC, Cambien FA, Beretti C. Cigarette smoking and hypertension. Factors independently associated with blood hyperviscosity and arterial rigidity. Arteriosclerosis. 1987;7(6):572–7. pmid:3689203
  9. 9. Santos PC, Alvim Rde O, Ferreira NE, de Sa Cunha R, Krieger JE, Mill JG, et al. Ethnicity and arterial stiffness in Brazil. Am J Hypertens. 2011;24(3):278–84. pmid:21183929
  10. 10. Segers P, Rietzschel ER, De Buyzere ML, Vermeersch SJ, De Bacquer D, Van Bortel LM, et al. Noninvasive (input) impedance, pulse wave velocity, and wave reflection in healthy middle-aged men and women. Hypertension. 2007;49(6):1248–55. pmid:17404183
  11. 11. Durier S, Fassot C, Laurent S, Boutouyrie P, Couetil JP, Fine E, et al. Physiological genomics of human arteries: quantitative relationship between gene expression and arterial stiffness. Circulation. 2003;108(15):1845–51. pmid:14530203
  12. 12. Atef ME, Anand-Srivastava MB. Enhanced expression of Gqalpha and PLC-beta1 proteins contributes to vascular smooth muscle cell hypertrophy in SHR: role of endogenous angiotensin II and endothelin-1. Am J Physiol Cell Physiol. 2014;307(1):C97–106. pmid:24760983
  13. 13. Osborne-Pellegrin M, Labat C, Mercier N, Challande P, Lacolley P. Changes in aortic stiffness related to elastic fiber network anomalies in the Brown Norway rat during maturation and aging. Am J Physiol Heart Circ Physiol. 2010;299(1):H144–52. pmid:20435849
  14. 14. Liu WF. Mechanical regulation of cellular phenotype: implications for vascular tissue regeneration. Cardiovasc Res. 2012;95(2):215–22. pmid:22628449
  15. 15. Dinardo CL, Venturini G, Omae SV, Zhou EH, da Motta-Leal-Filho JM, Dariolli R, et al. Vascular smooth muscle cells exhibit a progressive loss of rigidity with serial culture passaging. Biorheology. 2012;49(5–6):365–73. pmid:23380902
  16. 16. Park CY, Tambe D, Alencar AM, Trepat X, Zhou EH, Millet E, et al. Mapping the cytoskeletal prestress. Am J Physiol Cell Physiol. 2010;298(5):C1245–52. pmid:20164383
  17. 17. Fabry B, Maksym GN, Shore SA, Moore PE, Panettieri RA Jr., Butler JP, et al. Selected contribution: time course and heterogeneity of contractile responses in cultured human airway smooth muscle cells. J Appl Physiol (1985). 2001;91(2):986–94.
  18. 18. Zhou EH, Krishnan R, Stamer WD, Perkumas KM, Rajendran K, Nabhan JF, et al. Mechanical responsiveness of the endothelial cell of Schlemm's canal: scope, variability and its potential role in controlling aqueous humour outflow. Journal of the Royal Society, Interface / the Royal Society. 2012;9(71):1144–55. pmid:22171066
  19. 19. Alexander DH, Novembre J, Lange K. Fast model-based estimation of ancestry in unrelated individuals. Genome research. 2009;19(9):1655–64. pmid:19648217
  20. 20. Cardena MM, Ribeiro-dos-Santos A, Santos S, Mansur AJ, Pereira AC, Fridman C. Amerindian genetic ancestry is associated with higher survival rates compared to African and European ancestry in Brazilian patients with heart failure. Int J Cardiol. 2014;176(2):527–8. pmid:25088152
  21. 21. Center SHG. Human Genome Diversity Project [cited 2014 July, 15]. Available from: http://www.hagsc.org/hgdp/.
  22. 22. International HapMap Project [cited 2014 July, 15]. Available from: http://hapmap.ncbi.nlm.nih.gov/index.html.en.
  23. 23. Coutinho T, Borlaug BA, Pellikka PA, Turner ST, Kullo IJ. Sex differences in arterial stiffness and ventricular-arterial interactions. J Am Coll Cardiol. 2013;61(1):96–103. pmid:23122799
  24. 24. Ambrose JA, Barua RS. The pathophysiology of cigarette smoking and cardiovascular disease: an update. J Am Coll Cardiol. 2004;43(10):1731–7. pmid:15145091
  25. 25. Regnault V, Thomas F, Safar ME, Osborne-Pellegrin M, Khalil RA, Pannier B, et al. Sex difference in cardiovascular risk: role of pulse pressure amplification. J Am Coll Cardiol. 2012;59(20):1771–7. pmid:22575315
  26. 26. Waddell TK, Dart AM, Gatzka CD, Cameron JD, Kingwell BA. Women exhibit a greater age-related increase in proximal aortic stiffness than men. Journal of hypertension. 2001;19(12):2205–12. pmid:11725165
  27. 27. Mullick AE, Walsh BA, Reiser KM, Rutledge JC. Chronic estradiol treatment attenuates stiffening, glycoxidation, and permeability in rat carotid arteries. Am J Physiol Heart Circ Physiol. 2001;281(5):H2204–10. pmid:11668084
  28. 28. Stefanadis C, Tsiamis E, Dernellis J, Toutouzas P. Effect of estrogen on aortic function in postmenopausal women. Am J Physiol. 1999;276(2 Pt 2):H658–62. pmid:9950868
  29. 29. Mitchell GF, Gudnason V, Launer LJ, Aspelund T, Harris TB. Hemodynamics of increased pulse pressure in older women in the community-based Age, Gene/Environment Susceptibility-Reykjavik Study. Hypertension. 2008;51(4):1123–8. pmid:18259005
  30. 30. Takami T, Saito Y. Effects of smoking cessation on central blood pressure and arterial stiffness. Vasc Health Risk Manag. 2011;7:633–8. pmid:22102787
  31. 31. Tomiyama H, Hashimoto H, Tanaka H, Matsumoto C, Odaira M, Yamada J, et al. Continuous smoking and progression of arterial stiffening: a prospective study. J Am Coll Cardiol. 2010;55(18):1979–87. pmid:20430271
  32. 32. Hata K, Nakagawa T, Mizuno M, Yanagi N, Kitamura H, Hayashi T, et al. Relationship between smoking and a new index of arterial stiffness, the cardio-ankle vascular index, in male workers: a cross-sectional study. Tob Induc Dis. 2012;10(1):11. pmid:22839736
  33. 33. Barua RS, Ambrose JA, Srivastava S, DeVoe MC, Eales-Reynolds LJ. Reactive oxygen species are involved in smoking-induced dysfunction of nitric oxide biosynthesis and upregulation of endothelial nitric oxide synthase: an in vitro demonstration in human coronary artery endothelial cells. Circulation. 2003;107(18):2342–7. pmid:12707237
  34. 34. Jacob-Ferreira AL, Palei AC, Cau SB, Moreno H Jr., Martinez ML, Izidoro-Toledo TC, et al. Evidence for the involvement of matrix metalloproteinases in the cardiovascular effects produced by nicotine. Eur J Pharmacol. 2010;627(1–3):216–22. pmid:19879865
  35. 35. Cucina A, Sapienza P, Corvino V, Borrelli V, Randone B, Santoro-D'Angelo L, et al. Nicotine induces platelet-derived growth factor release and cytoskeletal alteration in aortic smooth muscle cells. Surgery. 2000;127(1):72–8. pmid:10660761
  36. 36. Louis H, Kakou A, Regnault V, Labat C, Bressenot A, Gao-Li J, et al. Role of alpha1beta1-integrin in arterial stiffness and angiotensin-induced arterial wall hypertrophy in mice. Am J Physiol Heart Circ Physiol. 2007;293(4):H2597–604. pmid:17660399
  37. 37. Galmiche G, Pizard A, Gueret A, El Moghrabi S, Ouvrard-Pascaud A, Berger S, et al. Smooth muscle cell mineralocorticoid receptors are mandatory for aldosterone-salt to induce vascular stiffness. Hypertension. 2014;63(3):520–6. pmid:24296280
  38. 38. Ichihara A, Hayashi M, Ryuzaki M, Handa M, Furukawa T, Saruta T. Fluvastatin prevents development of arterial stiffness in haemodialysis patients with type 2 diabetes mellitus. Nephrol Dial Transplant. 2002;17(8):1513–7. pmid:12147804
  39. 39. Tarnoki A, Tarnoki DL, Godor E, Littvay L, Horvath T, Jermendy A, et al. 2d.05: Relationship of Coronary Atherosclerosis with Arterial Stiffness and Central Systolic Blood Pressure. Journal of hypertension. 2015;33 Suppl 1:e29.