RESUMEN
BACKGROUND: Interleukin (IL)-18 is a proinflammatory cytokine that is present in chronically inflamed tissues; IL-18 was positively associated with periodontitis and coronary artery disease (CAD). CXC ligand (CXCL) 16, a recently discovered chemokine, was identified in atherosclerotic lesions; its role in periodontal disease is largely unknown. This research study correlates periodontal parameters with systemic levels of IL-18 and CXCL16. METHODS: Fifty-one patients who presented for clinically indicated coronary angiography received full-mouth periodontal examinations. The periodontal status of patients was defined using frequency distributions of probing depth (PD), clinical attachment loss (AL), and bleeding on probing (BOP). Blood samples were collected during cardiac catheterization, and plasma levels of IL-18 and CXCL16 were analyzed. The severity of CAD was determined by the presence and extent of coronary artery stenosis. Correlations between periodontal parameters, levels of inflammatory mediators, and CAD status were analyzed. RESULTS: The extent of BOP exhibited a significant positive correlation with IL-18 in the Spearman rank correlation analysis (P = 0.039), which indicated a correlation between periodontal inflammation and systemic IL-18 levels. When multiple regression analysis was performed, the extent of clinical AL > or =3 mm (P = 0.045) and > or =5 mm (P = 0.024) exhibited an association with IL-18, whereas CXCL16 was associated with clinical AL > or =5 mm (P = 0.040) and PD > or =7 mm (P = 0.047). CONCLUSION: A significant correlation is identified between periodontitis and systemic levels of IL-18 and CXCL16 in patients undergoing diagnostic coronary angiography.
Asunto(s)
Cateterismo Cardíaco , Quimiocinas CXC/sangre , Angiografía Coronaria , Interleucina-18/sangre , Periodontitis/inmunología , Receptores Depuradores/sangre , Adulto , Anciano , Índice de Masa Corporal , Quimiocina CXCL16 , Enfermedad de la Arteria Coronaria/clasificación , Enfermedad de la Arteria Coronaria/inmunología , Estenosis Coronaria/clasificación , Estenosis Coronaria/inmunología , Diabetes Mellitus Tipo 2/complicaciones , Femenino , Hemorragia Gingival/clasificación , Hemorragia Gingival/inmunología , Humanos , Mediadores de Inflamación/sangre , Masculino , Persona de Mediana Edad , Pérdida de la Inserción Periodontal/clasificación , Pérdida de la Inserción Periodontal/inmunología , Índice Periodontal , Bolsa Periodontal/clasificación , Bolsa Periodontal/inmunología , Periodontitis/clasificación , FumarRESUMEN
Delivery of therapeutic agents from self-assembled monolayers (SAMs) on 316L stainless steel (SS) has been demonstrated as a viable method to deliver drugs for localized coronary artery stent application. SAMs are highly-ordered, nano-sized molecular coatings, adding 1-10 nm thickness to a surface. Hydroxyl terminated alkanethiol SAMs of 11-mercapto-1-undecanol (-OH SAM) were formed on 316L SS with 48 hr immersion in ethanolic solutions. Attachment of ibuprofen (a model drug) to the functional SAMs was carried out in toluene for 5 hrs at 60 degrees C using Novozume-435 as a biocatalyst. SAM formation and subsequent attachment of ibuprofen was characterized collectively using X-ray photoelectron spectroscopy (XPS), Fourier transform infrared spectroscopy (FTIR), and contact angle (CA) measure-ments. The quantitative in vitro release of ibuprofen into a "physiological" buffer solution was characterized using reverse phase HPLC. Drug release kinetics showed that 14.1 microg of ibuprofen eluted over a period of 35 days with 2.7microg being eluted in the first day and the remaining being eluted over a period of 35 days. The drug release kinetics showed an increase in ibuprofen elution that occurred during first 14 days (2.7microg in 1 day to 9.5 microg in 14 days), following which there was a decrease in the rate of elution. Thus, functional SAMs on 316L SS could be used as tethers for drug attachment and could serve as a drug delivery mechanism from stainless steel implants such as coronary artery stents.
Asunto(s)
Sistemas de Liberación de Medicamentos/métodos , Stents Liberadores de Fármacos , Nanoestructuras/química , Preparaciones Farmacéuticas/administración & dosificación , Acero Inoxidable/química , Cromatografía Líquida de Alta Presión , Stents Liberadores de Fármacos/normas , Ibuprofeno/administración & dosificación , Ibuprofeno/química , Preparaciones Farmacéuticas/química , Espectroscopía Infrarroja por Transformada de FourierRESUMEN
An inverse correlation between the pro-inflammatory cytokine interleukin-18 and the anti-atherogenic adipokine adiponectin has been reported in the chronic pathological conditions obesity, insulin resistance, coronary artery disease, and metabolic syndrome. We investigated whether this relationship is coincidental or has a causal basis. Here we show that interleukin-18 (IL-18) suppresses adiponectin transcription, mRNA expression, and secretion by 3T3-L1 adipocytes. IL-18 suppresses adiponectin promoter-reporter activity, an effect reversed by deletion or mutation of the NFATc4 core DNA-binding site. IL-18 induces NFATc4 phosphorylation (Ser(676)), nuclear translocation, and in vivo DNA binding. IL-18 induces ERK1/2 phosphorylation and enzyme activity, and pretreatment with the MEK inhibitor U0126, ERK1/2 inhibitor PD98059, or small interference RNA targeted to ERK1/2 attenuates ERK1/2 activation and NFATc4 phosphorylation. Finally, inhibition of ERK1/2 or NFATc4 knockdown reverses IL-18-mediated adiponectin suppression. In contrast to its inhibitory effects on adiponectin expression, IL-18 potently stimulates PAI-1 secretion. These data demonstrate for the first time that IL-18 selectively suppresses adiponectin expression via ERK1/2-dependent NFATc4 activation and suggest that the inverse relationship observed between IL-18 and adiponectin in various chronic pathological conditions is causally related. Thus, targeting IL-18 expression may enhance adiponectin expression and mitigate disease progression.
Asunto(s)
Adipocitos/metabolismo , Adiponectina/metabolismo , Interleucina-18/fisiología , Proteína Quinasa 1 Activada por Mitógenos/metabolismo , Proteína Quinasa 3 Activada por Mitógenos/metabolismo , Factores de Transcripción NFATC/metabolismo , Transducción de Señal/fisiología , Células 3T3-L1 , Adiponectina/genética , Animales , Secuencia de Bases , Inmunoprecipitación de Cromatina , Cartilla de ADN , Ensayo de Inmunoadsorción Enzimática , Genes Reporteros , Ratones , Fosforilación , Regiones Promotoras Genéticas , ARN Interferente PequeñoRESUMEN
Elevated systemic levels of the acute phase C-reactive protein (CRP) are predictors of future cardiovascular events. There is evidence that CRP may also play a direct role in atherogenesis. Here we determined whether the proinflammatory interleukin (IL)-17 stimulates CRP expression in hepatocytes (Hep3B cell line and primary hepatocytes) and coronary artery smooth muscle cells (CASMC). Our results demonstrate that IL-17 potently induces CRP expression in Hep3B cells independent of IL-1beta and IL-6. IL-17 induced CRP promoter-driven reporter gene activity that could be attenuated by dominant negative IkappaBalpha or C/EBPbeta knockdown and stimulated both NF-kappaB and C/EBP DNA binding and reporter gene activities. Targeting NF-kappaB and C/EBPbeta activation by pharmacological inhibitors, small interfering RNA interference and adenoviral transduction of dominant negative expression vectors blocked IL-17-mediated CRP induction. Overexpression of wild type p50, p65, and C/EBPbeta stimulated CRP transcription. IL-17 stimulated p38 MAPK and ERK1/2 activation, and SB203580 and PD98059 blunted IL-17-mediated NF-kappaB and C/EBP activation and CRP transcription. These results, confirmed in primary human hepatocytes and CASMC, demonstrate for the first time that IL-17 is a potent inducer of CRP expression via p38 MAPK and ERK1/2-dependent NF-kappaB and C/EBPbeta activation and suggest that IL-17 may mediate chronic inflammation, atherosclerosis, and thrombosis.
Asunto(s)
Proteína C-Reactiva/genética , Proteína beta Potenciadora de Unión a CCAAT/fisiología , Quinasas MAP Reguladas por Señal Extracelular/fisiología , Hepatocitos/metabolismo , Interleucina-17/farmacología , Músculo Liso Vascular/metabolismo , Miocitos del Músculo Liso/metabolismo , FN-kappa B/fisiología , Proteínas Quinasas p38 Activadas por Mitógenos/fisiología , Línea Celular Tumoral , Humanos , Proteínas I-kappa B/fisiología , Interleucina-1beta/fisiología , Interleucina-6/fisiología , Músculo Liso Vascular/citología , Inhibidor NF-kappaB alfa , Proteínas Serina-Treonina Quinasas/fisiología , ARN Mensajero/análisis , Factor 6 Asociado a Receptor de TNF/fisiología , Quinasa de Factor Nuclear kappa BRESUMEN
Nanotechnology is a new field of science and technology that has already had significant impact in the development of novel products in industry. In medicine, application of nanotechnology has the potential to develop new imaging agents, pharmaceutical drugs and medical devices with unique physical and chemical properties. This article reviews the potential for various nanoparticles in cardiovascular imaging and therapeutics, nanoporous structures for sensing and implant based drug delivery, and self-assembled monolayers for surface modification and implant based drug delivery.
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Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/terapia , Nanomedicina/métodos , Implantes Absorbibles , Materiales Biomédicos y Dentales/farmacología , Materiales Biomédicos y Dentales/uso terapéutico , Sistemas de Liberación de Medicamentos , Diseño de Equipo , Humanos , Sustancias Macromoleculares/farmacología , Sustancias Macromoleculares/uso terapéutico , Nanomedicina/tendencias , Nanoestructuras/uso terapéuticoRESUMEN
CXCL16 is a transmembrane non-ELR CXC chemokine that signals via CXCR6 to induce aortic smooth muscle cell (ASMC) proliferation. While bacterial lipopolysaccharide (LPS) has been shown to stimulate CXCL16 expression in SMC, its effects on CXCR6 are not known. Here, we demonstrate that LPS upregulates CXCR6 mRNA, protein, and surface expression in human ASMC. Inhibition of TLR4 with neutralizing antibodies or specific siRNA interference blocked LPS-mediated CXCR6 expression. LPS stimulated both AP-1 (c-Fos, c-Jun) and NF-kappaB (p50 and p65) activation, but only inhibition of AP-1 attenuated LPS-induced CXCR6 expression. Using dominant negative expression vectors and siRNA interference, we demonstrate that LPS induces AP-1 activation via MyD88, TRAF6, ERK1/2, and JNK signaling pathways. Furthermore, the flavoprotein inhibitor diphenyleniodonium chloride significantly attenuated LPS-mediated AP-1-dependent CXCR6 expression, as did inhibition of NOX4 NADPH oxidase by siRNA. Finally, CXCR6 knockdown inhibited CXCL16-induced ASMC proliferation. These results demonstrate that LPS-TLR4-NOX4-AP-1 signaling can induce CXCR6 expression in ASMC, and suggest that the CXCL16-CXCR6 axis may be an important proinflammatory pathway in the pathogenesis of atherosclerosis.
Asunto(s)
Lipopolisacáridos/farmacología , Músculo Liso Vascular/metabolismo , NADPH Oxidasas/fisiología , Receptores de Quimiocina/biosíntesis , Receptores Virales/biosíntesis , Transducción de Señal/fisiología , Receptor Toll-Like 4/fisiología , Factor de Transcripción AP-1/fisiología , Células Cultivadas , Humanos , Receptores de Lipopolisacáridos/farmacología , Músculo Liso Vascular/citología , Músculo Liso Vascular/efectos de los fármacos , NADPH Oxidasa 4 , Polimixina B/farmacología , Interferencia de ARN , Receptores CXCR6 , Regulación hacia ArribaRESUMEN
The proliferation and migration of arterial smooth muscle cells (SMCs) are key events in the vascular restenosis that frequently follows angioplasty. Furthermore, SMC migration and neointimal hyperplasia are promoted by degradation of the extracellular matrix by matrix metalloproteinases (MMPs). Because we demonstrated previously that the proinflammatory and proatherogenic cytokine interleukin-18 (IL-18) stimulates SMC proliferation (Chandrasekar, B., Mummidi, S., Valente, A. J., Patel, D. N., Bailey, S. R., Freeman, G. L., Hatano, M., Tokuhisa, T., and Jensen, L. E. (2005) J. Biol. Chem. 280, 26263-26277), we investigated whether IL-18 induces SMC migration in an MMP-dependent manner and whether the 3-hydroxy-3-methylglutaryl-CoA reductase inhibitor atorvastatin can inhibit this response. IL-18 treatment increased both mRNA and protein expression of MMP9 in human coronary artery SMCs. Gel shift, enzyme-linked immunosorbent, and chromatin immunoprecipitation assays revealed a strong induction of IL-18-mediated AP-1 (c-Fos, c-Jun, and Fra-1) and NF-kappaB (p50 and p65) activation and stimulation of MMP9 promoter-dependent reporter gene activity in an AP-1- and NF-kappaB-dependent manner. Ectopic expression of p65, c-Fos, c-Jun, and Fra-1 induced MMP9 promoter activity. Specific antisense or small interfering RNA reagents for these transcription factors reduced IL-18-mediated MMP9 transcription. Furthermore, IL-18 stimulated SMC migration in an MMP9-dependent manner. Atorvastatin effectively suppressed IL-18-mediated AP-1 and NF-kappaB activation, MMP9 expression, and SMC migration. Together, our results indicate for the first time that the proatherogenic cytokine IL-18 induces human coronary artery SMC migration in an MMP9-dependent manner. Atorvastatin inhibits IL-18-mediated aortic SMC migration and has therapeutic potential for attenuating the progression of atherosclerosis and restenosis.
Asunto(s)
Vasos Coronarios/efectos de los fármacos , Vasos Coronarios/metabolismo , Interleucina-18/farmacología , Metaloproteinasa 9 de la Matriz/genética , Metaloproteinasa 9 de la Matriz/metabolismo , Músculo Liso Vascular/efectos de los fármacos , Músculo Liso Vascular/metabolismo , FN-kappa B/metabolismo , Factor de Transcripción AP-1/metabolismo , Aterosclerosis/prevención & control , Atorvastatina , Secuencia de Bases , Movimiento Celular/efectos de los fármacos , Proliferación Celular/efectos de los fármacos , Células Cultivadas , Vasos Coronarios/citología , ADN Complementario/genética , Expresión Génica/efectos de los fármacos , Ácidos Heptanoicos/farmacología , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/farmacología , Metaloproteinasa 2 de la Matriz/metabolismo , Músculo Liso Vascular/citología , Fosfatidilinositol 3-Quinasas/metabolismo , Regiones Promotoras Genéticas , Proteínas Proto-Oncogénicas c-akt/metabolismo , Pirroles/farmacología , ARN Mensajero/genética , ARN Mensajero/metabolismo , Proteínas Recombinantes/farmacologíaRESUMEN
Lipase catalyzed esterification of therapeutic drugs to functional self-assembled monolayers (SAMs) on 316L stainless steel (SS) after assembly has been demonstrated. SAMs of 16-mercaptohexadecanoic acid (-COOH SAM) and 11-mercapto-1-undecanol (-OH SAM) were formed on 316L SS, and lipase catalysis was used to attach therapeutic drugs, perphenazine and ibuprofen, respectively, on these SAMs. The reaction was carried out in toluene at 60 degrees C for 5 h using Novozyme-435 as the biocatalyst. The FTIR spectra after surface modification of -OH SAMs showed the presence of the C=O stretching bands at 1745 cm(-1), which was absent in the FTIR spectra of -OH SAMs. Similarly, the FTIR spectra after the reaction of the -COOH SAM with perphenazine showed two peaks in the carbonyl region, a peak at 1764 cm(-1), which is the representative peak for the C=O stretching for esters. The second peak at 1681 cm(-1) is assigned to the C=O stretching of the remaining unreacted terminal COOH. XPS spectra after lipase catalysis with ibuprofen showed a photoelectron peak evolving at 288.5 eV which arises from the carbon (C=O) of the carboxylic acid of the drug (ibuprofen). Similarly for -COOH SAMs, after esterifiation we see a small, photoelectron peak evolving at 286.5 eV which corresponds to the C in the methylene groups adjacent to the oxygen (C-O), which should evolve only after the esterification of perphenazine with the -COOH SAM. Thus, lipase catalysis provides an alternate synthetic methodology for surface modification of functional SAMs after assembly.
Asunto(s)
Lipasa/metabolismo , Acero Inoxidable , Propiedades de Superficie , Catálisis , Espectroscopía Infrarroja por Transformada de FourierRESUMEN
The use of self-assembled monolayers (SAMs) on medical devices offers a methodology for the incorporation of nanotechnology into medicine. SAMs are highly ordered nanosized molecular coatings, adding 1 to 10 nm thickness to a surface. This work is part of an overall goal to deliver therapeutic drugs from the surface of metal coronary stents using SAMs. In this study the oxidative and in vitro stability of functional alkylthiol SAMs on 316L stainless steel (SS) has been demonstrated. SAMs of 11-mercaptoundecanoic acid (-COOH SAM) and 11-mercapto-1-undecanol (-OH SAM) were formed on 316L SS. X-ray photoelectron spectroscopy (XPS), Fourier transform infrared spectroscopy (FTIR), and contact angle (CA) measurements collectively confirmed the formation of functional alkylthiol SAMs on 316L SS. Well-formed SAMs (CA: 82 deg +/- 9 deg) were achieved within 48 hours of immersion in ethanolic solutions, after which no significant improvement in CA was observed. The ratio of the thiolate peak (163.5 eV) to the oxidized sulfur (sulfonates) peak (166.5 eV) gives us an indication of the percentage SAMs that would bind to the metal and serve as a drug reservoir in vivo; which in turn represents the stability and viability of these SAMs, keeping in mind the cardiovascular application under consideration. Oxidative and in vitro stability studies showed that alkanethiol SAMs oxidized completely within 14 days. The SAMs tend to desorb and leave the metal surface after longer time periods (21 days) in phosphate-buffered saline (PBS) immersion, whereas for oxidative exposure the SAMs continue to remain on the metal surface in the form of sulfonates. Although the chemistry of bonding of alkylthiol with the 316L SS is not well understood, the nanosized alkylthiol SAMs demonstrate sufficient stability to justify further study on these systems for potential in vivo drug delivery in the chosen coronary artery stent applications.
Asunto(s)
Prótesis Vascular , Materiales Biocompatibles Revestidos/química , Vasos Coronarios/cirugía , Nanomedicina/instrumentación , Acero Inoxidable/química , Stents , Compuestos de Sulfhidrilo/química , Líquidos Corporales , Cristalización/métodos , Estabilidad de Medicamentos , Análisis de Falla de Equipo , Ensayo de Materiales , Nanomedicina/métodos , Oxidación-Reducción , Propiedades de SuperficieRESUMEN
We recently demonstrated that the chemokine CXCL16 is expressed in aortic smooth muscle cells (ASMC) and induces ASMC adhesion and proliferation (Chandrasekar, B., Bysani, S., and Mummidi, S. (2004) J. Biol. Chem. 279, 3188-3196). Here we reort that interleukin (IL)-18 positively regulates CXCL16 transcription in rat ASMC. We characterized the cis-regulatory region of CXCL16 and identified a functional activator protein-1 (AP-1) binding motif. Deletion or mutation of this site attenuated IL-18-mediated CXCL16 promoter activity. Gel shift, supershift, and chromatin immunoprecipitation assays confirmed AP-1-dependent CXCL16 expression. CXCL16 promoter-reporter activity was increased by constitutively active c-Fos and c-Jun and decreased by dominant negative or antisense c-Fos and c-Jun. Src kinase inhibitors PP1 and PP2, phosphatidylinositol 3-kinase (PI3K) inhibitors wortmannin and LY294002, Akt inhibitor, the c-Jun N-terminal kinase (JNK) inhibitor SP600125, antisense JNK and dominant negative MyD88, interleukin-1 receptor-associated kinase (IRAK)-1, IRAK4, and phosphatidylinositol 3-kinase expression all attenuated IL-18-mediated AP-1 binding and reporter activity, CXCL16 promoter-reporter activity, and CXCL16 expression. Thus IL-18 induced CXCL16 expression via a MyD88 --> IRAK1-IRAK4-TRAF6 (tumor necrosis factor receptor-associated factor 6) --> c-Src--> PI3K --> Akt --> JNK --> AP-1 pathway. Importantly, IL-18 stimulated ASMC proliferation in a CXCL16-dependent manner. These data provide for the first time a mechanism of IL-18-mediated CXCL16 gene transcription and CXCL16-dependent ASMC proliferation and suggest a role for IL-18-CXCL16 cross-talk in atherogenesis and restenosis following angioplasty.
Asunto(s)
Antígenos de Diferenciación/fisiología , Aorta/metabolismo , Quimiocinas CXC/biosíntesis , Regulación de la Expresión Génica , Interleucina-18/fisiología , Proteínas Quinasas JNK Activadas por Mitógenos/fisiología , Proteínas de la Membrana/biosíntesis , Miocitos del Músculo Liso/metabolismo , Fosfatidilinositol 3-Quinasas/fisiología , Proteínas Quinasas/fisiología , Proteínas Serina-Treonina Quinasas/fisiología , Proteínas Tirosina Quinasas/fisiología , Proteínas Proto-Oncogénicas/fisiología , Receptores Inmunológicos/biosíntesis , Receptores Inmunológicos/fisiología , Factor 6 Asociado a Receptor de TNF/fisiología , Factor de Transcripción AP-1/fisiología , Proteínas Adaptadoras Transductoras de Señales , Secuencias de Aminoácidos , Animales , Antígenos de Diferenciación/metabolismo , Apoptosis , Secuencia de Bases , Proteína Tirosina Quinasa CSK , Adhesión Celular , Proliferación Celular , Quimiocinas CXC/metabolismo , Dactinomicina/farmacología , Relación Dosis-Respuesta a Droga , Elementos de Facilitación Genéticos , Inhibidores Enzimáticos/farmacología , Genes Dominantes , Quinasas Asociadas a Receptores de Interleucina-1 , Interleucina-18/metabolismo , Proteínas Quinasas JNK Activadas por Mitógenos/metabolismo , Proteínas de la Membrana/metabolismo , Proteína Quinasa 8 Activada por Mitógenos/metabolismo , Modelos Genéticos , Datos de Secuencia Molecular , Mutagénesis Sitio-Dirigida , Factor 88 de Diferenciación Mieloide , Oligonucleótidos Antisentido/química , Oligonucleótidos Antisentido/farmacología , Fosfatidilinositol 3-Quinasas/metabolismo , Inhibidores de las Quinasa Fosfoinosítidos-3 , Proteínas Quinasas/metabolismo , Proteínas Serina-Treonina Quinasas/metabolismo , Proteínas Tirosina Quinasas/metabolismo , Proteínas Proto-Oncogénicas/metabolismo , Proteínas Proto-Oncogénicas c-akt , Proteínas Proto-Oncogénicas c-fos/metabolismo , ARN Interferente Pequeño/metabolismo , Ratas , Receptores Inmunológicos/metabolismo , Factor 6 Asociado a Receptor de TNF/metabolismo , Factores de Tiempo , Factor de Transcripción AP-1/metabolismo , Familia-src QuinasasRESUMEN
BACKGROUND: Pravastatin and simvastatin prolong survival and reduce transplant-related coronary vasculopathy, although low-density lipoprotein (LDL) lowering with these agents is only modest. The objective of this study was to assess the safety of moderate dose atorvastatin and its efficacy when prior treatment with another statin had failed to lower LDL to < 100 mg/dl. METHODS: Data from 185 patients were retrospectively evaluated for adverse events, duration of exposure (person-days), and the mean atorvastatin dose exposure. Changes in lipid parameters, and prednisone and cyclosporine doses were determined. SAFETY: 48 patients received atorvastatin for 24,240 person-days at a mean dose exposure of 21 +/- 10 mg. Rhabdomyolysis, myositis, myalgias, and hepatotoxicity occurred in 0, 2, 2, and 0 patients, respectively. All events occurred at the 10-mg dose, within the first 3 months, and were rapidly reversible with atorvastatin discontinuation. EFFICACY: Thirty-four patients evaluable for efficacy analyses had a pre-atorvastatin LDL of 145 +/- 38 mg/dl on the following statins: pravastatin (n = 30, 40 +/- 0mg), fluvastatin (n = 3, 33 +/- 12 mg), simvastatin (n = 1, 40 mg). After atorvastatin (21 +/- 9 mg/day) for 133 +/- 67 days, LDL was reduced to 97 +/- 24 mg/dl (relative reduction 31 +/- 20%, p < 0.0001). At the end of the observation period (418 +/- 229 days, atorvastatin final dose 24 +/- 14 mg/day), LDL was further decreased to 88 +/- 23 mg (relative reduction 37 +/- 17%, p < 0.0001). CONCLUSION: Atorvastatin, when used at moderate doses and with close biochemical and clinical monitoring, appears to be safe and is effective in aggressively lowering LDL in heart transplant recipients when treatment with other statins has failed to achieve LDL goals.