Note: Descriptions are shown in the official language in which they were submitted.
CA 02484691 2004-11-15
A NUTRICEUTICAL COMPOSITION FOR THE CORRECTION OF IMPAIRED
ENDOTHELIUM-DEPENDENT ARTERIAL VASOMOTOR RESPONSE
SPECIFICATION
Technical Field of the Invention
This invention pertains to a composition of nutritional elements that have
been specifically
chosen to be mixed in specific proportions in order to provide a particular
daily dose, or dose
range, for the purpose of reversing impaired endothelium-dependent arterial
vasomotor response,
or "endothelial dysfunction". The vascular endothelium is a single cell layer
comprising the inner
wall of blood vessels. Underneath the endothelial layer is the layer of smooth
muscle cells which,
upon contraction, cause the constriction of the blood vessel lumen, and upon
relaxing, brings
about its vasodilation. One of the critical functions of the endothelial
layer, upon sensing blood
flow shear stress, or other stimuli, such as acetylcholine, is to signal to
the smooth muscle cells to
relax, thereby increasing the blood vessel's diameter in order to accommodate
the increased
demands of rapid blood flow. When this vasomotor response of the arterial
endothelium fails to
occur, or worse, is even reversed - that is, responding instead with
vasoconstriction - then the
endothelium-dependent arterial vasomotor response is said to be impaired.
The endothelial layer is also responsible for other functions: By the
inhibiting of leukocyte
adhesion to the endothelium and of smooth muscle cell proliferation, it
prevents inflammatory
processes from occurring in blood vessel walls. It has an anti-coagulant
influence by virtue of its
inhibition of platelet aggregation and its promotion of fibrinolysis. Impaired
endothelial
functioning manifests a failure also of these actions, resulting in the
accumulation and
proliferation of cell mass in the blood vessel wall. Monocyte leukocytes,
attracted into the
interstices of the blood vessel wall and transformed into macrophages, become
engorged with
oxidized low density lipoprotein (LDL) cholesterol and, having become
immobilized there, form
the major cellular component of the atherosclerotic plaque, or atheroma. The
blood vessel wall
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CA 02484691 2004-11-15
becomes thickened at the expense of lumen volume, and, with a diminished lumen
volume
(stenosis), blood flow is constricted. The constriction to blood flow is
called ischemia. If an
increased blood supply is needed for, say, the heart's myocardium during
vigorous exercise, the
constriction to blood flow in the narrowed coronary artery vessels will
prevent a sufficient supply
of oxygen to the taxed heart. Further, if proper vasomotor response to the
increased blood flow is
absent, vasodilation for the purpose of accommodating the increased blood flow
will not occur,
further taxing the heart. The painful clinical manifestation of this state of
affairs is termed angina
pectoris. Atherosclerotic occlusion of the arteries in the leg can also occur
and it results in
intermittent claudication, muscle pain that limits walking. (1-3)
In advanced atherosclerosis, the atherosclerotic plaque may rupture due to
mechanical flow
stresses or oxidative degradation of the plaque coating. The exposed atheroma
attracts platelets
which aggregate and adhere to the site of rupture producing a thrombus.
Occurring in the
coronary artery, thrombosis can block blood supply to the heart myocardium
with resulting
myocardial cell death (myocardial infarction). A patch of dead myocardial
tissue breaks electrical
contiguity and communication in the myocardium and the heart thereby fails to
contract
synchronously. Arrhythmias may set in. If a significant region of the
myocardium is affected,
effective blood pumping no longer occurs, resulting in congestive heart
failure. Atherosclerosis
in the arteries to the brain can lead to cerebrovascular disease and, when an
atherosclerotic
plaque ruptures causing blockage within the arteries supplying the brain, a
stroke occurs, which
entails brain cell death due to oxygen deprivation.(4)
Clinical researchers have demonstrated by angiography that the locus of failed
vasomotor
response in subjects bearing one or more of the risk factors for
atherosclerotic disease, but who
are otherwise healthy, is the site years later of atherosclerotic stenosis.
This implies that
endothelial dysfunction is not only a hallmark of fully entrenched
atherosclerosis, but is also an
early warning sign and a predictor of future disease.(5,6) It is, therefore, a
desideratum not only
to treat endothelial dysfunction in patients diagnosed with any of the
diseases caused by
atherosclerosis, but also in healthy, asymptomatic individuals who are at
risk.
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At the crossroads of all these manifestations of endothelial dysfunction lies
the gaseous signaler,
nitric oxide (NO), and the enzyme that produces it, endothelial nitric oxide
synthase (eNOS).
Nitric oxide signals smooth muscle cells to relax; inhibits the expression on
endothelial cell
surfaces of vascular cell adhesion molecules, which are the "anchors" by which
monocyte
leukocytes and platelets adhere to the endothelium; and it inhibits the
proliferation of smooth
muscle cells. Nitric oxide is, hence, anti-atherogenic, and diminished bio-
availability of nitric
oxide results in pro-atherogenic endothelial dysfunction - in all its
manifestations. It has been
observed that the risk factors for atheroselerosis - dyslipidemia,
hyperhomocyst(e)inemia,
hypertension, diabetes, cigarette smoking - are associated with endothelial
dysfunction and with
oxidative stress in the environment of the endothelium. This oxidative stress
is the likely cause of
the impaired eNOS bio-availability, presumably due to increased oxidative
destruction of NO
and the inactivation of endothelial nitric oxide synthase. (7)
Notwithstanding the aforementioned explanatory mechanism for endothelial
dysfunction which
centres on the mediation of nitric oxide and the functioning of endothelial
nitric oxide synthase,
the claims of this invention do not rely on that mechanism, nor on any other
mechanism, but
rather, on the empirical evidence alone that the fact of the reversal of
impaired arterial vasomotor
response is effected by the administering of the ingredients of the
invention's composition, as
described below.
References to Technical Field of the Invention
(1) "Atherogenic Lipids and Endothelial Dysfunction: Mechanisms in the Genesis
of Ischemic
Syndromes" by Adams, M.A., et al. in Annu. Rev. Med. 51:149-167, 2000.
(2) "Endothelial Dysfunction: A Marker for Atherosclerosis Risk" by Bonetti.
PØ, Lerman,
L.O. and Lerman, A. in Arterioscler. Thromb. Vasc. Biol. 22:1065-1074, 2003.
(3) "Endothelium and the Lipid Metabolism: The Current Understanding" by
Laroia, S.T. et al. in
International Journal of Cardiology 88:1-9, 2003.
(4) "Inflammation and Atherothrombosis" by Robbie, L. and Libby, P. in Ann.
N.Y. Acad. Sci.
947:167-180, Dec. 2001.
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CA 02484691 2004-11-15
(5) "Prognostic Impact of Coronary Vasodilator Dysfunction in Adverse Long-
Term Outcome of
Coronary Heart Disease" by Schachinger, V. et al. in Circulation 101:1899-
1906, 2000.
(6) "Long-Term Follow-Up of Patients With Mild Coronary Artery Disease and
Endothelial
Dysfunction: A Marker of Atherosclerosis Risk" by Bonetti, P.O., Lerman, L.O.
and
Lerman, A. in Arterioscler. Thromb. Vasc. Biol. 23:168-175, 2003.
(7) "Endothelial Dysfunction in Cardiovascular Disease: The Role of Oxidant
Stress" by Cai, H.
and Harrison, D.G. in Circulation Research x:840-844, 2000.
Background Art
A functional food product, called "HeartBarTm" (Unither Pharma, Silver Spring,
MD, U.S.A.),
contains a nutritional formulation intended to correct endothelial dysfunction
in patients with the
diseases of atherosclerosis. The key ingredient in HeartBarT'" is L-arginine,
the substrate of
endothelial nitric oxide synthase (eNOS), and is supplied in up to six grams
per bar. It is
recommended that two bars per day be ingested for effective treatment.
HeartBarTm is protected
by U.S. patent 6,063,432, "Arginine or Lysine Containing Fruit HealthBar
Formulation". This
product is based on published research that has demonstrated that, by
promoting eNOS activity,
L-arginine can reverse endothelial dysfunction in patients with coronary
artery disease, stable
angina and heart failure, and in healthy subjects with the risk factors for
atherosclerosis:
hypercholesterolemia, hypertension, advanced age, smoking, and diabetes.( 1 )
The reality,
however, is that results with arginine supplementation are inconsistent.
Negative results with
arginine have been reported in coronary artery disease (2); stable angina (3),
and heart failure (4).
The contradictory results with arginine supplementation is paralleled by
contradictory reports on
HeartBarTm itself-. Positive results with HeartBarTm (5,6) stand in contrast
with negative results
(7). It has been suggested that not enough is known about the complexities of
eNOS to
recommend arginine's use, and that the catabolic relationship between arginine
and the
competitive inhibitor of eNOS, asymmetric dimethylarginine (ADMA), may result
in opposing,
undesirable results.(8)
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The use of arginine in combination with HMG-CoA reductase inhibitors (statins)
in the treatment
of the diseases of atherosclerosis by promoting nitric oxide synthesis is
described in Canadian
patent CA2286671, "Method and Formulation for Treating Vascular Disease". The
use of
arginine and derivatives of arginine is claimed in Canadian patent CA2404909,
"Pharmacotherapy for Vascular Dysfunction Associated with Deficient Nitric
Oxide Bioactivity".
These would also have to contend with the inconsistent clinical findings as
described above.
A practical disadvantage to arginine therapy is that, because of the large
amounts required - about
grams per day - a large number of pills must be taken each day. To avoid that
inconvenience,
10 the arginine can be provided in alternate dosage forms, for instance, in a
drink powder or a
nutritional "snack bar".
An alternative to both the inconsistent clinical trials with arginine and the
practical restrictions to
dosage forms is to seek out other nutritional modulators of endothelial
function.
References to Background Art
( 1 ) "Arginine Nutrition and Cardiovascular Function" by Wu, G. and
Meininger, C.J. in J. Nutr.
130:2626-2629, 2000.
(2) "Oral L-Arginine in Patients With Coronary Artery Disease on Medical
Management" by
Blum, A. et al. in Circulation 101:2160-2164, 2000.
(3) "Endothelium-dependent Vasodilation is Independent of the Plasma L-
Arginine/ADMA
Ratio in Men With Stable Angina: Lack of Effect of Oral L-Arginine on
Endothelial
Function, Oxidative Stress and Exercise Performance" by Walker, H.A. et al. in
M. Am.
Coll. Cardiol. 38(2):499-505, 2001.
(4) "Dietary Supplementation With L-Arginine Fails To Restore Endothelial
Function in Forearm
Resistance Arteries of Patients with Severe Heart Failure" by Chin-Dusting,
J.P. et al. in
J. Am. Coll. Cardiol. 27(5):1207-1213; 1996.
(5) "Nutritional Therapy For Peripheral Arterial Disease: A Double-blind,
Placebo-controlled,
Randomized Trial of HeartBar" by Maxwell, A.J., Anderson, B.E. and Cooke, J.P.
in
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Vasc. Med. 5_(1):11-19, 2000.
(6) "Randomized Trial of a Medical Food for the Dietary Management of Chronic,
Stable
Angina" by Maxwell, A.J. et al. in J. Am. Coll. Cardiol. 39:37-45, 2002.
(7) "No Effect of an L-Arginine-enriched Medical Food (HeartBars) on
Endothelial Function and
Platelet Aggregation in Subjects with Hypercholesterolemia" by Abdelhamed,
A.I. et al.
in Am. Heart. J. 145(3):E15, Mar. 2003.
(8) "Adverse Effects of Supplemental L-Arginine in Atherosclerosis:
Consequences of
Methylation Stress in a Complex Catabolism?" by Loscalzo, J. in Arterioscler.
Thromb.
Vasc. Biol. 23: 3-5, 2003.
Disclosure of the Invention
Of the various functions associated with a healthy endothelium - arterial
vasomotor dilation and
inhibitory control of coagulation and inflammatory processes - as described
above in "Technical
Field of the Invention", the easiest activity to monitor clinically is
arterial vasodilation. It has
been shown that a reliable proxy for coronary artery vasomotor dilation is
that of the brachial
artery, which means that experiments can be done non-invasively. In one
technique that measures
vasomotor response, the brachial artery diameter is monitored by ultrasound
imaging before
(baseline) and after inducing rapid blood flow. Rapid blood flow is induced by
applying a
pneumatic tourniquet on the lower arm beyond the position of the ultrasound
transducers and
then suddenly releasing it, thereby producing reactive hyperemia in the
artery.(1) This technique
is called Flow Mediated Dilatation (FMD). Healthy vasomotor response to
hyperemia amounts,
approximately, to a 12% increase in arterial diameter.(2) Individuals with
proven coronary artery
disease are measured to have an average FMD response of 3% with a large inter-
subject
variability that even encompasses null vasodilation response in some
patients.(3) Individuals that
are otherwise healthy but who bear (a) risk factors) for atherosclerosis
manifest FMD responses
intermediate to these values. Improvements to FMD response brought about by
various
nutritional elements are described below:
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CA 02484691 2004-11-15
(1) "Passive Smoking and Impaired Endothelium-Dependent Arterial Dilatation in
Healthy
Young Adults" by Celermajer, D. et al. in The New England Journal of Medicine.
Jan.
18, 1996; 334:150-154.
{2) "ADMA and Oxidative Stress Are Responsible for Endothelial Dysfunction in
Hyperhomocyst{e)inemia" by Sydow; K. et al. in Cardiovascular Research ,7:244-
252,
2003.
(3) "Effect of Folic Acid and Antioxidant Vitamins on Endothelial Dysfunction
in Patients With
Coronary Artery Disease" by Title, L.M. et al. in Journal of the American
College of
IO Cardiology x_6:758-765, 2000.
Folic Acid
At a folic acid dose of at least 5 mg/d impaired vasomotor response can be
improved. For
instance, in subjects with coronary artery disease the flow-mediated
dilatation was raised from an
average of 3.2% to an average of 5.2% using a dose of 5 mg.(1) Folic acid
administered at a dose
of I O mg/d to healthy subjects with the risk factor of hyperhomocyst(e)inemia
raised
endothelium-dependent vasodilation from 6% to 8.2°/a.(2) Healthy
subjects with
hypercholesterolemia demonstrated impaired FMD which could be reversed with S
mg/d of folic
acid.(3) However, while a majority of studies found improvements in
endothelial functioning
following high-dose folic acid supplementation, one study reported negative
results, which
suggests that some, as yet uncharacterized sub-populations may not respond to
folic acid.(4)
An additional benefit of folic acid on endothelial dysfunction is its ability
to reverse nitrate
tolerance in long term users of nitroglycerin.(5)
(1) "Effect of Folic Acid and Antioxidant Vitamins on Endothelial Dysfunction
in Patients With
Coronary Artery Disease" by Title, L.M. et al. in Journal of the American
College of
Cardiology 36:758-765, 2000.
(2) "Folic Acid Improves Arterial Endothelial Function in Adults With
Hyperhomocystinemia"
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CA 02484691 2004-11-15
by Woo, K.S. et al. in Journal of the American College of Cardiology 34:2002-
2006,
1999.
(3) "Effects of Folic Acid Supplementation on Endothelial Function in Familial
Hypercholesterolemia" by Verhaar, M.C. et al. in Circulation 100:335-338,
1999.
(4) "ADMA and Oxidative Stress Are Responsible for Endothelial Dysfunction in
Hyperhomocyst(e)inemia: Effects of L-Arginine and B Vitamins" by Sydow, K. et
al. in
Cardiovascular Research x:244-252, 2003.
(5) "Folic Acid Prevents Nitroglycerin-Induced Nitric Oxide Synthase
Dysfunction and Nitrate
Tolerance" by Gori. T. et al. in Circulation 104:1119-1123, 2001.
N'acin
Niacin, in the form of its free acid, nicotinic acid, lowers low density
lipoprotein (LDL) and
raises high density lipoprotein (HDL).(1) Nicotinic acid can also be
administered in its esterified
forms, such as inositol hexanicotinate, since esters of nicotinic acid
hydrolyze readily to the free
acid form.(2,3)
In line with the knowledge that LDL cholesterol, being highly susceptible to
oxidation, causes
injurious oxidative stress in the environment of the endothelium, endothelium-
dependent arterial
vasomotor function is impaired by elevated plasma LDL levels.(4) Fortunately,
impaired
vasomotor response in hypercholesterolemic subjects, both those with and
without coronary
artery disease, can be reversed by cholesterol reduction therapy. Out of 15
trials, using various
lipid lowering agents including niacin, only 2 failed to show improvement.(5)
High density lipoprotein (HDL), on the other hand, is protective against
atherogenesis by virtue
of its functioning in reverse transport of cholesterol (the main atheroma
material) and of
phospholipids out of the endothelium and to the liver (6), its ability to
protect lipids from
peroxidation, and its anti-thrombotic and anti-inflammatory activities (7). A
low plasma HDL
level is an independent risk factor for developing coronary artery disease,
and low HDL levels in
healthy male subjects are correlated with poor endothelial function.(8)
Proving the cause and
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CA 02484691 2004-11-15
effect linkage between HDL and endothelial dysfunction is the demonstration
that intravenous
infusion of reconstituted HDL particles into healthy subjects with
hypercholesterolemia brings
about an improvement in FMD from 2.7% to 4.5%.(9) Proof that FMD can be
improved
nutritionally using niacin and that the improvement derives from niacin's
ability to correct low
S HDL levels comes from a study of coronary artery disease patients whose LDL
levels had been
kept low through prior and continuing statin treatment while niacin was
administered at doses of
up to 1.5 mg/d. Along with raising HDL values, FMD was improved by the
administered niacin
to an average of 11.8% from a pretreatment average of 6.5%, and the FMD
percentage
improvements of individual patients were correlated to their post-treatment
plasma HDL
values.{10)
(1) Compendium of Pharmaceuticals and Specialties, 34'" edition, 1999,
published by Canadian
Pharmacists Association, pg. 1169.
(2) "Nocturnal Inhibition of Lipolysis in Man by Nicotinic Acid and
Derivatives" by Kruse, W.
et al. in Eur. J. Clin. Pharmacol. ,x_6:11-15, 1979.
(3) "Comparative Evaluation of Some Pharmacological Properties and Side
Effects of D-glucitol
Hexanicotinate and Nicotinic Acid Correlated With the Plasma Concentration of
Nicotinic Acid" by Subissi, A. et al. in Atherosclerosis 36(1):135-148, May,
1980.
(4) "Atherogenic Lipids and Endothelial Dysfunction: Mechanisms in the Genesis
of Ischemic
Syndromes" by Adams, M.R. et al. in Annu. Rev. Med. 51:149-167, 2000.
(5) "Cholesterol Lowering and Endothelial Function" by Vogel R.A. in Am. J.
Med. 107:479-
487, 1999.
(6) "High Density Lipoproteins and Arteriosclerosis: Role of Cholesterol
Efflux and Reverse
Cholesterol Transport" by von Eckardstein, A., Nofer, J-R., and Assmann, G. in
Arterioscler. Thromb. Vasc. Biol. 21:13-27, 2001.
(7) "Endothelial Protection by High-Density Lipoproteins: From Bench to
Bedside" by Calabresi,
L., Gomaraschi, M., and Franceschini, G. in Arterioscler. Thromb. Vasc. Biol.
23:1724-
1731, 2003.
(8) "Endothelial Nitric Oxide Synthase Gene Polymorphism, Homocysteine,
Cholesterol and
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CA 02484691 2004-11-15
Vascular Endothelial Function" by Bilsborough, W. et al. in Atherosclerosis
169:131-
138, 2003.
(9) "High-Density Lipoprotein Restores Endothelial Function in
Hypercholesterolemic Men" by
Spieker, L.E. et al. in Circulation 105:1399-1402.
S (10) "A Novel Mechanism for the Beneficial Vascular Effects of High-Density
Lipoprotein
Cholesterol: Enhanced Vasorelaxation and Increased Endothelial Nitric Oxide
Synthase
Expression" by Kuvin, J.T. et al. in American Heart Journal 144:165-172, 2002.
Vitamin C
I O As stated above, in Technical Field of the Invention, oxidative stress is
associated with the risk
factors for atherosclerosis, and manifests itself at the molecular level with
decreased
bioavailability of NO, probably through oxidation of NO to nitrite and
nitrate. To counteract
oxidative stress, experiments have been carried out to investigate the effect
on FMD of the water-
soluble antioxidant, vitamin C (ascorbic acid). In the majority of clinical
studies, patients with
15 coronary heart disease as well as subjects who were otherwise healthy but
were at risk due to
diabetes, smoking, hypercholesterolemia, and hyperhomocysteinemia had their
impaired
endothelial vasomotor responses improved by vitamin C. The methods of
administration in these
experiments consisted of oral chronic dosing at 0.5 - 2 grams per day, acute
oral dosing at 2
grams, and intravenous infusion with 1-3 grams. (1-14) A minority of studies,
however, failed to
20 demonstrate improvement in FMD: one study on coronary artery disease
patients (15) against
seven positive studies on diseased subjects; one study on healthy smokers (16}
against three
successful reports on smokers; and one study on hypertensive, healthy subjects
(17). (The
hypertensive subjects of the last study, however, did benefit from lowered
blood pressure, which
is another aspect of endothelial function.) These exceptions suggest that
there may be sub-
25 populations, yet unrecognized, that are resistant to the otherwise
beneficial effect of vitamin C.
An additional benefit of vitamin C on endothelial dysfunction is its ability
to counteract tolerance
adaptation to long-term, continuous use of nitroglycerin. ( 18)
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CA 02484691 2004-11-15
(1 ) "Vitamin C Improves Endothelium-dependent Vasodilation in Patients With
Non-Insulin-
Dependent Diabetes Mellitus" by Ting, H.H. et al. in J. Clinical Investigation
92(1):22-
28, 1996.
(2) "Ascorbic Acid Reverses Endothelial Vasomotor Dysfunction in Patients With
Coronary
Artery Disease" by Levine. G.N. et al. in Circulation 93:1107-1113, 1996.
(3) "Antioxidant Vitamin C Improves Endothelial Dysfunction in Chronic
Smokers" by Heitzer,
T., Just, H. and Munzel, T. in Circulation 94(1):6-9, 1996.
(4) "Vitamin C Improves Endothelial Function of Conduit Arteries in Patients
With Chronic
Heart Failure" by Hornig, B. et al. in Circulation 97:363-368, 1998.
(5) "Vitamin C Improves Endothelium-Dependent Vasodilation in Forearm
Resistance Vessels
of Humans With Hypercholesterolemia" by Ting. H.H. et al. in Circulation
95:2617-
2622, 1997.
(6) "Long-Term Ascorbic Acid Administration Reverses Endothelial Vasomotor
Dysfunction in
Patients With Coronary Artery Disease" by Gokce, N. et al. in Circulation
99:3234-3240,
1999.
{7) "Demonstration of Rapid Onset Vascular Endothelial Dysfunction After
Hyperhomocysteinemia: An Effect Reversible With Vitamin C Therapy" by
Chambers,
J.C. et al. in Circulation 99:1156-1160, 1999.
{8) "Role of Oxidant Stress in Endothelial Dysfunction Produced by
Experimental
Hyperhomocyst(e)inemia in Humans" by Kanani, P.M. et al. in Circulation
100:1161-
1168, 1999.
(9) "Endothelial Dysfunction, Oxidative Stress, and Risk of Cardiovascular
Events in Patients
With Coronary Artery Disease" by Heitzer, T. et al. in Circulation 104:2673-
2678, 2001.
(10) "Acute Effects of Vitamin C on Platelet Responsiveness to Nitric Oxide
Donors and
Endothelial Function in Patients with Chronic Heart Failure" by Ellis, G.R. et
al. in J.
Cardiovascular Pharmacology 37:564-570, 2001.
(11) "Impaired Endothelium-Dependent Vasodilation in the Brachial Artery in
Variant Angina
Pectoris and the Effect of Intravenous Administration of Vitamin C" by Hamabe,
A. et al.
in American Journal of Cardiology 87:1154-1159, 2001.
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CA 02484691 2004-11-15
(12) "Reversibility of Coronary Endothelial Vasomotor Dysfunction in
Idiopathic Dilated
Cardiomyopathy: Acute Effects of Vitamin C" by Richartz, B.M. et al. in
American
Journal of Cardiology 88:1001-1005, 2001.
(13) "Taurine and Vitamin C Modify Monocyte and Endothelial Dysfunction in
Young Smokers"
by Fennessy, F.M. et al. in Circulation 107:410-415, 2003.
(14) "Oral Administration of Ascorbic Acid Attenuates Endothelial Dysfunction
After Short-
Term Cigarette Smoking" by Stamatelopoulos, K.S. et al. in International
Journal of
Nutrition Research 73(6):417-422, 2003.
(15) "Coronary Endothelial Dysfunction Is Not Rapidly Reversible With Ascorbic
Acid" by
Widlansky M.E. et al. in Free Radical Biology and Medicine 36(1):123-130,
2004.
(16) "Vitamin C Has No Effect on Endothelium-Dependent Vasomotion and Acute
Endogenous
Fibrinolysis in Healthy Smokers" by Pellegrini, M.P. et al. in J.
Cardiovascular
Pharmacology 44(1):117-124, 2004.
(17) "Effect of Ascorbic Acid Treatment On Conduit Vessel Endothelial
Dysfunction in Patients
With Hypertension" by Duffy, S.J. et al. in Am. J. Physiol. Heart Circ.
Physiol.
280:H528-H534, 2001.
(18) "Dietary Supplement with Vitamin C Prevents Nitrate Tolerance" by
Bassenge, E. et al. in J.
Clin. Invest. 102:67-71, 1998.
Vitamin E
Vitamin E is the major lipid-soluble antioxidant and is found in LDL particles
where it is well-
positioned to protect the cholesterol and phospholipids in the particles
against oxidation.(1) This
is important vis a vis endothelial function because oxidized LDL induces
apoptosis in cultured
human endothelial cells. Indeed, when LDL is incubated with the antioxidants,
vitamin C and
vitamin E, apoptosis was prevented.(2) Clinical trials testing vitamin E
administration at dosages
ranging from 300 to 1,200 IU per day, both on subjects with heart disease and
on otherwise
healthy subjects with risk factors for atherosclerosis, revealed mixed
results: One half of these
studies demonstrated improved endothelial functioning.(3) One possible
explanation for the
negative findings is that some risk factors, such as smoking, cannot be
compensated for with
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CA 02484691 2004-11-15
vitamin E; though it can be compensated for with vitamin C (See above, under
Vitamin C,).
Another possibility is that within one risk factor category there exist
different sub-populations,
some of which are benefitted by vitamin E, while the others are not.
Vitamin E also has the positive effect on endothelial dysfunction in terms of
its ability to
counteract tolerance adaptation to long-term, continuous use of
nitroglycerin.(4)
(1) "Vitamin E and Heart Disease: Basic Science To Clinical Investigation
Trials" by Pryor,
W.A. in Free Radical Biology & Medicine x(1):141-164, 2000.
(2) "Vascular Thrombogenicity Induced by Progressive LDL Oxidation: Protection
by
Antioxidants" by Banfi, C. et al. in Thromb. Haemost. 89:544-SS3, 2003.
(3) "Effect of Anti-oxidant Treatment and Cholesterol Lowering On Resting
Arterial Tone,
Metabolic Vasodilation and Endothelial Function in the Human Forearm" by
Duffy, S.J.
et al. in Clinical and Experimental Pharmacology and Physiology 28:409-418,
2001.
I S (4) "Randomized, Double-Blind, Placebo-Controlled Study of Supplemental
Vitamin E on
Attenuation of the Development of Nitrate Tolerance" by Watanabe, H. et al. in
Circulation 96:2545-2550, 1997.
Coenzyme O
As stated above, in Technical Field of the Invention, oxidative stress,
impaired eNOS activity
and the risk factors for atherosclerosis are tied together in cause-and-effect
relationships.
Coenzyme Q10 is a strong antioxidant and it has been shown, at a dose of 200
mg per day, to
mildly improve endothelial dysfunction in dyslipidemic patients with Type II
diabetes.(I) In
another study, coenzyme Q10, also at 200 mg per day, but in combination with
the lipid lowering
agent, fenofibrate, brought about a marked improvement in vasodilation
response.(2)
(1) "Coenzyme Q10 Improves Endothelial Dysfunction of the Brachial Artery in
Type II Diabetes
Mellitus" by Watts, G.F. et al. in Diabetologia 45:420-426, 2002.
(2) "Combined Effect of Coenzyme Ql O and Fenofibrate on Forearm
Microcirculatory Function
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in Type 2 Diabetes" by Playford, D.A. et al. in Atherosclerosis I68(1):169-
179, 2003.
Omega-3 Polyunsaturated Fatt~Aqids (,n-3 PUFAI
Both in vitro (1) and in vivo research (2,3) have demonstrated that
supplementation with fish oil,
S as a source of the omega-3 fatty acids, DHA (docosahexa.enoic acid) and EHA
(eicosapentaenoic
acid), can significantly improve vasomotor impairment due to
hypercholesterolemia. After four
months of supplementation, flow mediated dilatation was raised from the
pretreatment
percentage diameter increase of 1:2% to 3.0% (calculated from Table 2 of
Reference 3). The
mechanism of the effect has not been determined, but it may be due to the
altering of endothelial
cell membrane fluidity and its subsequent favourable influence on eNOS
activity when the
omega-3 polyunsaturated fatty acids are incorporated into the endothelial cell
membranes.
(1) "Dietary Supplementation With Marine Fish Oil Improves In Vitro Small
Artery Endothelial
Function in Hypercholesterolemic Patients" by Goode, G.K., Garcia, S. and
Heagerty,
A.N. in Circulation 96:2802-2807, 1997.
(2) "Therapeutic Restoration of Endothelial Function in Hypercholesterolemic
Subjects: Effects
of Fish Oil" by Chin, J.P. and Dart; A.M. in Clin. Exp. Pharmacol. Physiol.
21(10):749-
755, 1994.
(3) "Dietary Supplementation With Marine Omega-3 Fatty Acids Improve Systemic
Large Artery
Endothelial Function in Subjects With Hypercholesterolemia" by Goodfellow, J.
et al. in
Journal of the American College of Cardiology ,~S_:265-270, 2000.
Magnesium
By means of a mechanism that is yet to be established, endothelium-dependent
vasodilation can
be enhanced in healthy, young subjects by infusing magnesium salt ( 1 ) and in
patients with
coronary artery disease by means of oral adminstration of magnesium (2).
{ 1 ) "Magnesium Infusion Improves Endothelium-Dependent Vasodilation in the
Human
Forearm" by Haenni, A. et al. in American Journal of Hypertension 15:10-15,
2002.
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CA 02484691 2004-11-15
(2) "Oral Magnesium Therapy Improves Endothelial Function in Patients With
Coronary Artery
Disease" by Shechter, M. et al. in Circulation X02:2353-2358, 2000.
The utility of the invention inheres in the fact that it is a combination
product. Any individual
whose endothelial dysfunction is not reversed by one component of the
combination - a
possibility realized in about one half of the trials with vitamin E and in a
minority of trials using
folic acid and vitamin C - may gain benefit from any one or more of the other
components that
are active in that individual. That individual may belong to a sub-population
within a population
bearing a common risk factor but which is refractory, for some yet unknown
reason, to one or
more of the agents while being responsive to the others. Since we cannot
identify who is a
member of such a sub-population, a complete combination product which includes
all potentially
active compounds "hedges our bets" and promises a measure of success.
Combination therapy also makes possible additive effects in individuals who
are responsive, but
only partially so, to each of several components. For instance, we have seen
that endothelial
dysfunction can be partially corrected in hypercholesterolemic individuals by
lowering
cholesterol with niacin. We have also seen that there are a number of agents
that correct
endothelial dysfunction in hypercholesterolemic subjects without altering
lipid profiles; that is,
the patients remain hypercholesterolemic throughout the treatment. However, if
the treatment
regimen includes niacin, then partial correction of endothelial dysfunction
will be accomplished
by virtue of LDL cholesterol lowering, and the residual endothelial
dysfunction, which is left
uncorrected due to incomplete cholesterol lowering, will be subsequently
corrected by the other
agents which operate in a hypercholesterolemic environment.
In addition to such additive effects, the possibility also exists of synergy
of action, that is, when
the overall effect of the mixture is determined by the multiplication of
individual effects. It is
known that ingestion of large amounts of arginine, the substrate of eNOS,
results in improved
endothelial vasomotor functioning in responding individuals. The more
arginine, the faster is NO
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production. (See above under Background Art.) If other agents are added,
specifically, those of
this invention which act either by increasing the biosynthesis of the enzyme
or by switching the
inactive into the active form of the enzyme, that would be effectively the
same as increasing the
enzyme's concentration. Hence, the net increase in NO production is determined
by multiplying
the fractional increase in active enzyme concentration by the fractional
increase in substrate
concentration. From these theoretical considerations, the administration of
the composition of
this invention together with large amounts of arginine could result in a
powerful synergistic
improvement on endothelial vasomotor functioning.
Any synergy of action that may exist among the ingredients of the invention
itself, however,
cannot be predicted for the reason that we lack knowledge concerning the
detailed mechanisms
of action of all of the individual ingredients. In any case, the utility of
the invention does not
depend on the ingredients' mechanisms of action but rather on the purely
empirical findings of
their efficacy in human subjects.
It is expected that this invention, by being capable of reversing impaired
endothelium-dependent
arterial vasomotor response in at-risk, disease-free individuals, can block
the earliest step of
atherogenesis and thereby prevent disease development. In addition to its
utility in primary
prevention, by treating individuals with any one of the diseases of
atherosclerosis, namely,
coronary artery disease, cerebrovascular disease or peripheral vascular
disease, the chance of
ischemic attacks can be reduced. Hence, it has utility also in secondary
intervention.
A Preferred Mode of Executing the Invention
The following table suggests a preferred, but not limiting, embodiment of the
invention:
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COMPOUND DAILY DOSE
Folic acid 5 milligrams
Inositol hexanicotinate 2.2 grams (2 grams niacin equivalents)
Vitamin C 1.0 gram
Vitamin E 400 International Units
Coenzyme Q 10 120 milligrams
Fish oil concentrate 48/25 (73% 1.37 grams (1.0 gram n-3 PUFA)
n-3 PUFA)
Magnesium oxide 1.21 grams (730 milligrams Mg)
_1~_
