Clinical Evaluation of a Noninvasive, Widely Applicable Method for
Assessing Endothelial Function
Ian B. Wilkinson, Ian R. Hall, Helen MacCallum, Isla S. Mackenzie, Carmel M. McEniery, Bart J. van der Arend, Yae-Eun Shu, Laura S. MacKay, David J. Webb, John R. Cockcroft Abstract—Current methods for assessing vasomotor endothelial function are impractical for use in large studies. We tested
the hypothesis that pulse-wave analysis (PWA) combined with provocative pharmacological testing might provide analternative method. Radial artery waveforms were recorded and augmentation index (AIx) was calculated from derivedaortic waveforms. Thirteen subjects received sublingual nitroglycerin (NTG), inhaled albuterol, or placebo. Twelvesubjects received NTG, albuterol, and placebo separately during an infusion of NG-monomethyl-L-arginine (LNMMA)or norepinephrine. Twenty-seven hypercholesterolemic subjects and 27 controls received NTG followed by albuterol.
Endothelial function was assessed by PWA and forearm blood flow in 27 subjects. Albuterol and NTG both significantlyand repeatably reduced AIx (P⬍0.001). Only the response to albuterol was inhibited by LNMMA (⫺9.8⫾5.5% vs ⫺4.7⫾2.7%; P⫽0.02). Baseline AIx was higher in the hypercholesterolemic subjects, who exhibited a reduced response
to albuterol (P⫽0.02) but not to NTG when compared with matched controls. The responses to albuterol and
acetylcholine were correlated (r⫽0.5, P⫽0.02). Consistent with an endothelium-dependent effect, the response to
albuterol was substantially inhibited by LNMMA. Importantly, the response to albuterol was reduced in subjects with
hypercholesterolemia and was correlated to that of intra-arterial acetylcholine. This methodology provides a simple,
repeatable, noninvasive means of assessing endothelial function in vivo. (Arterioscler Thromb Vasc Biol. 2002;22:147-

Key Words: hypercholesterolemia 䡲 nitric oxide 䡲 pulse-wave analysis 䡲 augmentation index
䡲 endothelial function The vascular endothelium releases a number of biologi- (SNP) or nitroglycerin (NTG). However, current methods are cally active mediators, including nitric oxide (NO), that not suitable for inclusion in large-scale trials. Therefore, new regulate vessel tone and prevent the development of athero- and relatively simple, noninvasive techniques are required to ma.1 Endothelial dysfunction is associated with a range of assess the predictive value of endothelial dysfunction.7 risk factors for cardiovascular disease, including hypercho- Arterial stiffness depends, in part, on smooth muscle tone.8 lesterolemia,2,3 and some therapies that improve clinical The shape of the arterial pressure waveform provides a outcome also reverse endothelial dysfunction.4 Vasomotor measure of systemic arterial stiffness9 and can be assessed responses in the peripheral and coronary circulations are noninvasively by using the technique of pulse-wave analysis correlated,5 and coronary endothelial dysfunction is associ- (PWA).10 We hypothesized that PWA might provide a simple ated with cardiovascular risk.6 However, no direct link method for assessing endothelial vasomotor function. Chow- between improved endothelial function and reduced risk has ienczyk et al11 demonstrated that albuterol, a ␤2-agonist, in been made, and the prognostic significance of endothelial part reduces wave reflection by activation of the L-argi- dysfunction has not been assessed in a major observational nine–NO pathway and suggested that such methodology might be applied to the assessment of endothelial function.
Established methods for assessing vasomotor endothelial The aim of this series of experiments was to provide robust function center on measuring the response to an endotheli- validation of the noninvasive assessment of endothelial func- um-dependent, NO-mediated stimulus such as acetylcholine tion by PWA combined with provocative administration of (Ach)2,3 or reactive hyperemia, and a direct (endothelium- NTG and albuterol. In particular, we wanted to define the independent) nitrovasodilator, like sodium nitroprusside repeatability of the responses to albuterol and NTG; to Received September 5, 2001; revision accepted October 29, 2001.
From the Clinical Pharmacology Units, University of Cambridge (I.B.W., I.S.M., C.M.M.), Addenbrooke's Hospital, Cambridge, England, and the University of Edinburgh (H.M., B.J.v.d.A., Y.-E.S., L.S.M., D.J.W.), Western General Hospital, Edinburgh, Scotland, and the Department of Cardiology(I.R.H., J.R.C.), University of Wales College of Medicine, University Hospital, Cardiff, Wales.
Correspondence to Dr I.B. Wilkinson, Clinical Pharmacology Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK.
E-mail [email protected] 2002 American Heart Association, Inc.
Arterioscler Thromb Vasc Biol. is available at
Arterioscler Thromb Vasc Biol.
January 2002
determine whether albuterol acts via the L-arginine–NO pathway; to apply the technique to a large cohort of healthy Subjects were studied in the morning after an overnight fast. Subjects controls and hypercholesterolemic subjects, the latter of with an elevated blood pressure at screening (⬎160/100 mm Hg),diabetes mellitus, or a clinical history of cardiovascular disease were whom are known to exhibit endothelial dysfunction2; and excluded, as were individuals receiving medication. Studies were then to compare the technique with the "gold standard" of conducted in a double-blind fashion (where appropriate) in a quiet, forearm venous occlusion plethysmography.3 temperature-controlled room (22⫾2°C). All hemodynamic record-ings were made in duplicate. Three sets of recordings were madeduring a 45-minute period of supine rest, and the last was taken as a baseline. Recordings were made 3, 5, 10, 15, and 20 minutes after All studies were conducted at the Clinical Pharmacology Unit, NTG administration and 5, 10, 15, and 20 minutes after albuterol or University of Edinburgh; the Clinical Pharmacology Unit, University aerosol placebo. Pilot studies had confirmed that 20 minutes was of Cambridge, and the Wales Heart Research Institute, University of sufficient for the hemodynamic changes after NTG to return to Wales, Cardiff. Healthy subjects were enrolled from community baseline but that a longer period was required for albuterol. There- databases of volunteers, and patients were recruited from cardiovas- fore, NTG was always administered first, followed by albuterol 25 cular risk clinics and family practices local to all institutions.
minutes later.
Approval for all studies was obtained from the respective localresearch ethics committees, and informed consent was obtained from Study 1: Repeatability
each participant.
Thirteen healthy subjects (11 male) were studied on 3 occasions,separated by 1 week. After baseline recordings of heart rate, blood pressure, CI, and radial artery waveforms were made, subjectsreceived sublingual NTG. This was followed by albuterol (on 2 Blood pressure was recorded in duplicate in the dominant arm by occasions) or matching placebo (once) in random order. Blood was using a validated oscillometric technique (HEM-705CP, Omron taken for estimation of plasma albuterol at baseline and at 5-minute Corp). Cardiac index (CI) was assessed noninvasively by using a validated12 transthoracic electrical bioimpedance technique (BoMedNCCOM3-R7), and peripheral vascular resistance (PVR) was calcu- Study 2: Inhibition of NO Synthase
lated as mean arterial pressure (MAP) divided by CI.
Twelve healthy males were studied on 6 occasions, separated by 1 Radial artery waveforms were recorded with a high-fidelity week. An 18-gauge cannula was sited in the nondominant arm and micromanometer (SPC-301, Millar Instruments) from the wrist of saline infused for 30 minutes. After baseline recordings of heart rate, the dominant arm. PWA (SCOR 6.1, PWV) was then used to blood pressure, CI, and radial artery waveforms were made, generate a corresponding central waveform by using a validated LNMMA was then infused for 15 minutes alone, on 3 occasions, transfer function,13–15 as previously described.16 From this, augmen- followed by administration of NTG, albuterol, or matching aerosol tation index (AIx) and heart rate were determined by using the placebo. On the other 3 visits, NE was infused in place of LNMMA.
integral software. AIx, a measure of systemic arterial stiffness,9 was The order of administration of all drugs was fully randomized.
calculated as the difference between the second and first systolicpeaks, expressed as a percentage of the pulse pressure.
Study 3: Hypercholesterolemia
Twenty-seven hypercholesterolemic subjects (total cholesterol
⬎6.0 mmol · L⫺1) and 27 matched normocholesterolemics Venous Occlusion Plethysmography
(⬍6.0 mmol · L⫺1) were studied. Heart rate, blood pressure, and The brachial artery of the nondominant arm was cannulated with a radial artery waveforms were assessed at baseline and after NTG and 27-gauge steel needle (Coopers Needle Works) under local anesthe- albuterol administration. Twenty minutes after albuterol was given, sia, and blood flow was measured simultaneously in both arms by blood was taken for determination of cholesterol (total, LDL, and venous occlusion plethysmography, with temperature-compensated, HDL), glucose, and albuterol concentrations.
indium/gallium-in–silicone elastomer strain gauges, as previouslydescribed.17 Blood flows were recorded during the final 3 minutes of Study 4: Comparison With Venous Occlusion Plethysmography
each infusion period, and the mean of the final 5 measurements was Twenty-seven subjects with a range of serum cholesterol values (3 to used for analysis.
8.6 mmol · L⫺1; 12 subjects ⬎6.0) but no other cardiovascular riskfactors were studied on a single occasion. Endothelial function was Plasma Albuterol Assay
first assessed invasively by venous occlusion plethysmographycoupled with an intra-arterial infusion of SNP and ACh (after 30 Venous blood (10 mL) was taken from the antecubital fossa into minutes of saline infusion and a 20-minute washout between drugs).
lithium-heparin tubes and centrifuged immediately at 4°C (2000g for After a further 30 minutes, endothelial function was then assessed by 10 minutes). The plasma was then removed and stored at ⫺80°C for PWA coupled with administration of NTG and albuterol.
later analysis by a chiral liquid chromatography/tandem mass spec-trometry technique.18 The lower limit of detection for the assay was 0.05 ng · mL⫺1, and the coefficient of variation was ⬍10%.
The response to albuterol, placebo, or NTG was defined as themaximum change in each parameter after drug administration (an a priori summary measure). Forearm blood flow was calculated as Albuterol (Allen and Hanbury's) was given by inhalation with a mL · min⫺1 · 100 mL⫺1 tissue, and the ratio of blood flow in the spacer device (2⫻ 200 ␮g). A 500-␮g tablet of NTG (Cox) was infused to the noninfused arm was used to reduce blood flow placed under the tongue for 3 minutes and then removed. Norepi- variability in response to extraneous stimuli such as temperature nephrine (NE, Abbott Laboratories) and NG-monomethyl-L-arginine fluctuations.21 Again, the maximum responses to albuterol and to (LNMMA, Clinalfa) were prepared aseptically with 0.9% saline as a ACh were used as a priori summary measures. Data were analyzed diluent and infused intravenously at 1 mL · min⫺1. LNMMA was by SPSS software (version 9.0) and unpaired or paired, 2-tailed given as a bolus of 3 mg · kg⫺1 (5 minutes) and then continuously at Student's t tests or ANOVA, as appropriate. Multiple regression 3 mg · kg⫺1 · h⫺1 for 45 min. NE was infused at 50 ng · kg⫺1 · h⫺1 for analysis was conducted by using the "enter method." Repeatability 45 min as a control constrictor; the dose was chosen from pilot was assessed by constructing Bland-Altman plots and reported as the studies and published literature to produce an elevation of MAP and mean⫾SD of the differences between samples.22 All values repre- AIx similar to that effected by LNMMA.19,20 SNP (David Bull sent mean⫾SD, and a P value ⬍0.05 was considered significant. All Laboratories) at 3 and 10 ␮g · min⫺1 and ACh (Novartis) at 7.5 and changes cited represent absolute differences, rather than percentage 15 ␮g · min⫺1 were infused intra-arterially, each for 6 minutes.
Wilkinson et al
Assessment of Endothelial Function
Hemodynamic Changes in Study 1
CI, L 䡠 min⫺1 䡠 m⫺2 HR, beats 䡠 min⫺1 Changes in AIx, MAP, CI, PVR, and heart rate (HR) after albuterol, matching placebo, or NTG. Numbers in parentheses refer to visit number. AU indicates arbitrary units.
Values represent means⫾SD, and significant changes from baseline are indicated by *P⬍0.0.5, †P⬍0.01, ‡P⬍0.001. Significant differences in the response between albuterol and placebo are indicated in column by §P⬍0.05, 㛳P⬍0.001; n⫽13.
or albuterol in either group. AIx fell significantly after adminis-tration of albuterol, but the response was significantly reduced in hypercholesterolemics compared with controls (⫺7.4⫾5.7% vs The mean age of the subjects was 37 years (range, 25 to 56).
There were no significant differences in baseline values 11.9⫾7.7%, respectively; P⫽0.02). Despite this disparity, the between the 3 visits. The hemodynamic changes are shown in time to maximum change (12⫾3 vs 11⫾3 minutes, P⫽0.2) and Table 1. Only AIx (P⬍0.001) and CI (P⫽0.01) changed peak plasma albuterol concentrations (1.2⫾0.6 vs 1.1⫾0.5 ng · significantly after albuterol. There was no difference in the mL⫺1, P⫽0.5) were similar in both groups. Moreover, the mean response to albuterol compared with NTG for any maximum change in AIx after NTG (⫺14.8⫾8.4% vs parameter except CI (P⫽0.02). The response to albuterol or ⫺10.2⫾9.0%, P⫽0.1) did not differ significantly.
NTG did not differ between visits. The mean difference in the To investigate further the factors influencing the response to AIx response between visits was ⫺2.3⫾3.0% and albuterol, a multiple linear regression model was constructed, ⫺0.2⫾6.5% for albuterol and NTG, respectively.
with change in AIx as the dependent variable. Age, sex, weight, Plasma albuterol was below the level of detection at smoking status, baseline MAP and AIx, LDL and HDL choles- baseline and after administration of placebo. Plasma albuterol terol, triglycerides, glucose, and change in MAP and heart rate increased after administration of the active drug (P⬍0.001 on were entered into the model. Variables with a significance both occasions, Figure 1), and there was no difference in the ⬎0.25 were then removed and the analysis repeated. The final peak albuterol concentration between visits (mean difference model (Table 4) explained ⬇60% of the variability in the of ⫺0.12⫾0.55 ng · mL⫺1, P⫽0.9).
response to albuterol. Change in AIx was negatively associatedwith plasma LDL and glucose and positively correlated with plasma albuterol concentration and fall in heart rate.
The mean age of the subjects was 32 years (range, 22 to 52).
There were no significant differences in baseline values across the 6 visits. Hemodynamic changes are summarized in Resting forearm blood flow did not differ between the 2 arms, Table 2. The effects of NE and LNMMA did not differ and there was no change in blood flow in the noninfused arm significantly between visits. Both drugs had similar effects on during the study (data not shown). As expected, blood flow AIx, MAP, and heart rate, but there was a greater change in increased significantly during infusion of SNP and ACh CI (P⬍0.001) and PVR (P⬍0.001) with LNMMA. The (P⬍0.001 for both, ANOVA). However, the response to ACh responses to NTG and placebo with LNMMA did not differ (7.5 ␮g · min⫺1: 1.6⫾1.0 vs 3.4⫾1.0 mL · min⫺1 · 100 mL⫺1, significantly from those during coinfusion of NE. However, P⫽0.003; and 15.0 ␮g · min⫺1: 2.0⫾0.3 vs 5.8⫾0.3 mL · albuterol had less effect on AIx during infusion of LNMMA min⫺1 · 100 mL⫺1, P⫽0.04) but not to SNP was reduced in (P⫽0.02, Figure 2A), despite causing a greater reduction in subjects with a cholesterol level ⬎6.0 mmol · L⫺1. NTG and MAP (P⬍0.001) and PVR (P⬍0.001).
albuterol both significantly reduced AIx (P⬍0.001), and theresponse to albuterol (r⫽0.5, P⫽0.02) was related to serum cholesterol. There was a significant, linear relationship be- The baseline characteristics of the subjects are given in Table 3.
tween the absolute change in AIx after albuterol and the There was no significant change in MAP or heart rate after NTG change in the forearm blood flow ratio during infusion ofACh at 15 ␮g · min⫺1 (Figure 2B). There was no relationshipbetween the response to SNP and to NTG.
This study describes the effects of albuterol and NTG on theaortic pressure waveform. AIx, a quantitative index of systemicarterial stiffness,9 was calculated from aortic waveforms gener-ated by PWA.10 Our main novel findings are that albuterol andNTG produce qualitatively and quantitatively similar and repeat-able effects on AIx, that the effect of albuterol but not of NTGis inhibited by LNMMA and reduced in hypercholesterolemic Figure 1. Changes in plasma albuterol concentration after visits
1 (䡩) and 2 (▫); n⫽13.
subjects, and that the response to albuterol is correlated with the Arterioscler Thromb Vasc Biol.
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Hemodynamic Changes in Study 2
CI, L 䡠 min⫺1 䡠 m⫺2 HR, beats 䡠 min⫺1 Changes (means⫾SD) in AIx, MAP, CI, PVR, and heart rate (HR) during study 2. NE or LNMMA was infused, and then albuterol, matching placebo, or NTG was administered. AU indicates arbitrary unit.
effect of ACh in the forearm vascular bed. These data indicate lium-dependent NO dilators has not been reported. Neverthe- that the effect of albuterol is, in part, NO and endothelium less, comparable changes in the volume waveform after dependent and are constistent with the presence of endothelial infusion of ACh into rabbits30 and of NTG and albuterol into dysfunction in hypercholesterolemic subjects. Moreover, they humans11 have been described. However, unlike Chowienc- suggest that PWA and administration of albuterol and NTG zyk et al11 and relevant to wider application of the present provide a simple, reliable, noninvasive method for assessing technique, we included a suitable placebo and showed that the endothelial function, as we and others have previously responses to albuterol and NTG are repeatable. We also measured plasma albuterol concentrations, which were rela- As expected, inhalation of albuterol at the dose used tively stable between 5 and 20 minutes (Figure 1). This reduced AIx without any accompanying alteration in heart pharmacokinetic profile is in keeping with the pharmacody- rate or MAP, compared with placebo, which is important namic response to albuterol. Peak plasma levels did not differ because AIx is influenced by both.20,25 The magnitude of the significantly between visits, confirming that inhalation of response to both drugs was comparable, and the repeatability, albuterol with a spacer device provides a repeatable method high. Indeed, the repeatability is similar to what we previ- of drug delivery. As might be expected, the results of the ously reported for PWA16 and to values quoted for other multiple regression analysis from study 3 (Table 4) demon- techniques of assessing endothelial function, such as intra-ar- strated a significant relationship between plasma albuterol terial infusion of ACh26 and flow-mediated dilatation.27 and the maximum change in AIx. Therefore, some of the Previous studies have shown similar changes in the arterial variability in the response to albuterol between subjects may pressure waveform after NTG,28,29 but the effect of endothe- have been due to differences in drug absorption and peakplasma concentrations. Such an effect may be important whenmaking comparisons between subjects groups, especiallywhen relatively small numbers of subjects are studied orsmokers are included, when plasma albuterol values mayimprove the reliability of data interpretation.
To investigate the NO dependence of albuterol, we infused LNMMA, a specific substrate-analogue inhibitor of NOsynthase. However, because systemic LNMMA infusion Subject Characteristics in Study 3
Cholesterol, mmol 䡠 L⫺1 LDL, mmol 䡠 L⫺1 HDL, mmol 䡠 L⫺1 Triglycerides, mmol 䡠 L⫺1 Figure 2. A, Effect of inhibition of NO synthase on the response
Glucose, mmol 䡠 L⫺1 to NTG, albuterol, and placebo. Changes in AIx after albuterol, NTG, and placebo during infusion of NE ( ) and NG-monometh-yl-L-arginine (䡲); n⫽12, *P⬍0.05. B, Relationship between the Heart rate, beats 䡠 min⫺1 response to albuterol and ACh. Change in AIx after albuterol and change in forearm blood flow (FBF) after ACh. A regressionline is shown, for which r⫽0.5, P⫽0.02, slope⫽⫺9.8, n⫽27.
Values represent means⫾SD.
Wilkinson et al
Assessment of Endothelial Function
Results of the Regression Analysis for Study 3, With
and with acute hyperglycemia in normal subjects.39 However, Change in AIx After Albuterol as the Dependent Variable
any relationship between insulin sensitivity and endothelialfunction in nondiabetic subjects is controversial.40,41 More- over, data concerning cardiovascular risk and plasma glucose in normal subjects are divided.42 Nevertheless, glycosylated hemoglobin is positively associated with the risk of future coronary heart disease risk in a linear, stepwise manner,43 suggesting a continuum of risk across the glycemic range, Change in heart rate beats 䡠 min⫺1 which may be explained by the inverse relationship between endothelial function and plasma glucose in the present study.
Biochemical parameters were derived from plasma samples, and the R2 for To compare our novel methodology for noninvasive as- the entire group was 0.61, P⫽0.001, n⫽54.
sessment of endothelial function with a more established one,we assessed endothelial function by both PWA and forearm alters MAP and heart rate,19 we used NE as a control vasocon- blood flow in 27 individuals with a wide range of serum strictor to produce comparable hemodynamic changes.20 As cholesterol values. As previously noted,3 we observed a expected, but not previously reported, we observed a significant significant blunting of the vasodilator effect of ACh, but not increase in AIx with administration of LNMMA. However, both of SNP, in subjects with a serum cholesterol value ⬎6 mmol drugs had similar effects on AIx, heart rate, and MAP, but the · L⫺1. Moreover, as in study 3, the response to albuterol but response to albuterol was significantly attenuated by LNMMA, not to NTG was related to serum cholesterol. The main novel despite a greater reduction in MAP and PVR. Moreover, the finding, however, was that there was a significant and linear responses to NTG and placebo were not affected by LNMMA.
correlation between the effect of albuterol on AIx and of ACh This indicates that NO mediates a significant part of the response on forearm blood flow (Figure 2). This suggests that differ- to inhaled albuterol. Furthermore, the degree of inhibition ences in the response to albuterol are likely to be caused by produced by LNMMA, ⬇50%, is consistent with data from the differences in endothelial function and that PWA provides a forearm vascular bed31 and systemic studies on the volume reasonable means of assessing endothelial function noninva- waveform.11 However, in the present study, we included a sively. Although the correlation between the 2 methods in the suitable placebo aerosol and control vasoconstrictor to investi- present study was not absolute, the strength of the relation- gate the potential confounding effect of baseline changes in heart ship is greater than that reported previously when endothelial rate, MAP, and AIx after LNMMA.
function was compared in different vascular beds.5 Thus,PWA may be suitable for use in large studies investigating Hypercholesterolemia is the condition most consistently associ- the predictive value of endothelial function.
ated with endothelial dysfunction.2,3,32 Therefore, we investigated Based on our previous data,20,25 it is unlikely that the small the response to albuterol and NTG in a group of 27 hypercholes- alterations in MAP and heart rate observed in the present terolemics and matched controls and, in a separate cohort, compared study could account for the effect of the 2 drugs on AIx.
endothelial function as assessed by PWA with that measured by Moreover, in study 2 the changes in MAP and heart rate with intra-arterial infusion of ACh and SNP in the forearm. Baseline AIx albuterol were greater during infusion of NE, which would was significantly higher in the hypercholesterolemic subjects, indi- tend to reduce the observed difference between LNMMA and cating increased arterial stiffness. This is the first time that increased NE. Furthermore, in study 3 the changes in MAP and heart aortic AIx has been reported in hypercholesterolemics, but in- rate were similar between the 2 groups. Therefore, it seems creased stiffness has been previously demonstrated by several other likely that NTG and albuterol altered the waveform, in part by techniques,33,34 although this is not a universal finding.35 However, a direct effect of NO on large-artery mechanics.
the higher AIx may have been due to the slightly higher MAP20 in In summary, albuterol and NTG produce repeatable changes the hypercholesterolemics, arterial stiffening per se, or a combina- in the arterial waveform. The response to albuterol but not to tion of both.34,36 AIx fell less after albuterol in the hypercholester- NTG can be substantially inhibited by LNMMA, indicating that olemics than in controls, despite their being well matched. More- albuterol reduces AIx in part through generation of NO. There- over, mean plasma albuterol concentration was similar in both fore, albuterol can be considered an endothelium-dependent, groups, as were the effects of albuterol and NTG on other hemo- NO-mediated vasodilator and NTG, endothelium independent.
dynamic variables, suggesting blunting of a direct effect of albuterol Moreover, hypercholesterolemics exhibit a reduced response to on AIx in the hypercholesterolemic subjects, rather than, for albuterol but not to NTG, consistent with the presence of example, an indirect mechanism through changes in heart rate or endothelial dysfunction. Finally, the response to albuterol was MAP. Moreover, in the multiple regression model, which included correlated with the reponse to ACh in the forearm, suggesting known and potential confounding variables, LDL cholesterol was that there is good agreement between the 2 methods of assessing inversely and independently correlated with the change in AIx.
endothelial function. These data support the view that PWA Interestingly, although endothelial function declines with age, we coupled with administration of albuterol and NTG provides a were unable to show any relationship between age and the albuterol simple, noninvasive, repeatable method for assessing endothelial response in our multiple regression model. However, this is likely function. We believe that this technique provides a suitable due to the relatively narrow age range of the study subjects and the means for assessing endothelial function in large numbers of small sample size.
patients and thus, answers the important question of the predic- The inverse association between the response to albuterol tive value of endothelial function. PWA has already been and plasma glucose is of considerable interest. Endothelial included in substudies of the ASCOT, SEARCH, and FIELD dysfunction is associated with type 137 and type 2 diabetes38 investigations. This will address the importance of stiffness as a Arterioscler Thromb Vasc Biol.
January 2002
predictor of risk, but we now need to include the noninvasive 20. Wilkinson IB, MacCallum H, Hupperetz PC, Van Thoor CJ, Cockcroft assessment of endothelial function by PWA in such studies.
JR, Webb DJ. Changes in the derived central pressure waveform andpulse pressure in response to angiotensin II and noradrenaline in man.
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Microsoft word - asphsharedcareatomoxetine1.doc

Shared Care Protocol for the use of Atomoxetine (Strattera®) in Attention Deficit Hyperactivity Disorder in Childhood Surrey PCT's Medicines Management Committee classification: A * :: Drugs that require initiation by a specialist in secondary/tertiary care but due to more widespread experience in primary care GPs are generally happy to prescribe on specialist advice without the need for a formal shared care protocol. This information sheet is available on the internet ( forming part of Surrey's PCT's traffic light document giving GPs appropriate advice / guidance and is not required to be sent to the GP with the clinic letter. A minimum of one month supply of medication will be provided by the initiating consultant.

Programme officiel.qxd

90eanniversaire de la Station de recherche 3 au 5 octobre 2008 Nos commanditaires Nos commanditaires Mot du ministre C'est avec plaisir que je joins ma voix à l'ensemble des acteurs du milieu pour marquerle 90e anniversaire du Centre de recherche en sciences animales de Deschambault(CRSAD). Il s'agit là d'une réussite qui mérite d'être soulignée. Depuis sa fondation en1918, le Centre a grandement évolué et il est devenu une véritable institution, une orga-nisation influente et moderne qui jouit d'une réputation enviable au Canada en matièrede recherche en productions animales.