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Free Radic Biol Med. Author manuscript; available in PMC 2012 March 1.
Published in final edited form as:
PMCID: PMC3058898

F2-isoprostanes as an indicator and risk factor for coronary heart disease


Coronary heart disease (CHD) is the leading single cause of death in the United States and most Western countries, killing more than 400,000 Americans per year. Although CHD often manifests suddenly as a fatal myocardial infarction, the atherosclerosis that gives rise to the infarction develops gradually and can be markedly slowed or even reversed through pharmacological and lifestyle interventions. These same atherosclerotic processes also drive related vascular diseases such as stroke and peripheral artery disease, and individuals surviving occlusive events often develop additional complications including ischemic cardiomyopathy and heart failure. Therefore, better detection of subclinical atherosclerosis, along with more effective treatments, could significantly reduce the rate of death from CHD and related vascular diseases in the United States. In recent years, oxidation of polyunsaturated fatty acids (PUFA) in plasma lipoproteins has been postulate to be a critical step in the development atherosclerosis. If so, then monitoring lipid peroxidation should be a useful indicator of disease risk and progression. This review will focus on the evidence that specific PUFA peroxidation products, the F2-isoprostanes, are useful biomarkers that could potentially be utilized as indicators of CHD.

Keywords: isoprostanes, lipid peroxidation, coronary heart disease, cardiovascular disease, oxidative stress, biomarkers, antioxidants, polyunsaturated fatty acids, atherosclerosis


For many years, screening and treatment of atherosclerosis focused on cholesterol levels in lipoproteins rather than reducing the peroxidation of the polyunsaturated fatty acid (PUFA) in these lipoproteins. The focus on cholesterol reduction was based on the two seminal discoveries by Brown and Goldstein: the first, in 1974, was that persons with familial hypercholesterolemia lacked the cell surface receptor for low density lipoprotein (LDL) [1] and therefore failed to regulate cholesterol synthesis and the second, in 1979, was that macrophages possessed scavenger receptors that bound and internalized acetylated LDL, producing massive cholesterol deposition similar to those found in the foam cells of atherosclerotic fatty streak lesions [2]. The notion that oxidation of PUFA in lipoproteins might be important to atherosclerosis arose in 1987, when Parthasarathy et al showed that LDL exposed to oxidants (oxidized LDL) was also taken up by macrophage scavenger receptors [3, 4]. Recognition of oxidized LDL by scavenger receptors was postulated to result from modification of the apoB-100 protein in LDL in a similar manner as with acetylation, except that modification was due to lipid aldehydes such as malondialdehyde that were generated during PUFA oxidation. Oxidized LDL was suggested to form in vivo by penetration of LDL into the subintimal space of the vascular wall where it was oxidized by redox metals. Evidence that LDL oxidized in vitro could induce many proatherogenic effects in cultured cells led to the incorporation of oxidized LDL into some models of atherogenesis [5]. Some of these proatherogenic effects of oxidized LDL could also be induced by organic phase extracts of the oxidized LDL, suggesting that oxidized lipid themselves were proatherogenic, in addition to oxidatively modified ApoB. Therefore, even lipid peroxidation products in the vasculature that did not arise directly from LDL could contribute to atherogenesis. The current oxidative injury model of atherosclerosis posits that various risk factors for atherosclerosis promote the oxidation of LDL and other lipoproteins which creates proinflammatory lipid mediators that drive a chronic inflammatory state. In time, this chronic inflammatory state leads to complex plaque formation, rupture, and vessel occlusion. This model predicts: that risk factors for CHD should increase lipid peroxidation, that high concentrations of lipid peroxidation products are risk indicators for onset and severity of disease, and that interventions that lower lipid peroxidation should also modulate disease.

Measuring lipid peroxidation in vivo

In order to assess the extent to which clinical studies in humans support the hypothesis that lipid peroxidation mediates atherogenesis and that oxidized PUFA products can be used as indices of CHD, we must first identify appropriate in vivo biomarkers of lipid peroxidation. Peroxidation of the various PUFA esterified in the phospholipids, triglycerides, and cholesterols of lipoproteins generate literally hundreds of compounds including hydroxy-, hydroperoxy-, and epoxy- fatty acids, hydroxyalkenals, various dicarbonyl products, oxysterols, and fragmented phospholipids. Many of these oxidation products have biological activities that could contribute to atherogenesis. Ideally, clinic studies should measure the lipoxidation products deemed most likely to mediate inflammation and atherogenesis. However, no current consensus exists on which lipoxidation products are most important in terms of mediating disease. Therefore, most clinical trials simply measure one or two established indicators of lipid peroxidation in vivo, with the assumption that their levels reflect other lipid peroxidation products as well. Over the past few years, the measurement of F2-isoprostanes (IsoPs) have emerged as one of the most sensitive and reliable biomarkers of lipid peroxidation in vivo [6, 7]. For this reason, the measurement of IsoPs has been incorporated into a wide number of clinical trials. The results of these trials provide significant insights into the role of lipid peroxidation in disease.

To appropriately interpret the results of these clinical studies, several key features of the biochemistry of IsoPs and their measurements should be kept in mind. The vast majority of arachidonic acid is esterified in tissue phospholipids. Accordingly, IsoPs are predominantly formed initially esterified in phospholipids and are then subsequently hydrolyzed to their free acid form by platelet-activating factor acetylhydrolase [8]and possibly other phospholipases. The free IsoPs are released from tissue into the circulation, where they undergo partial metabolism, predominantly in the liver. Therefore, both unmetabolized IsoPs and IsoP metabolites are excreted into the urine [9-11]. Total body IsoP production can be assessed by quantifying unmetabolized free IsoPs in plasma or unmetabolized free IsoPs and IsoP metabolites in urine. Individual organ IsoP production is assessed by quantifying esterified IsoPs. Caution must be applied when interpreting changes in unmetabolized IsoPs from urine as evidence for overall systemic increases in lipid peroxidation. This is because the IsoPs formed in the kidney are directly excreted into the urine without metabolism, so that if renal disease associated with oxidative damage is present, then the total levels of unmetabolized IsoPs in the urine could increase disproportionately to the total body change in lipid peroxidation. In this case, urinary levels of IsoP metabolites should better reflect actual changes in total body lipid peroxidation.

Valid clinical studies utilizing IsoPs require appropriate collection and storage procedures. Hemolysis of blood samples can release free iron and hemoglobin, both of which can catalyze artifactual oxidation of lipids during storage. To minimize this, a large bore needle should be used and blood manually collected using very gentle suction to ensure that no frothing and hemolysis occurs. Collected blood should be immediately transferred to tubes containing anticoagulants such as EDTA or citrate (but not heparin) and kept chilled until centrifugation which should be performed as soon as possible. Plasma should be aliquoted and stored at −80°C. Tissue samples should be flash frozen immediately after collection and also stored at −80°C. Long-term storage of plasma and tissue samples at −20°C or repeated freezing and thawing of samples will artifactually generate IsoPs via auto-oxidation of arachidonate. Because urine contains relatively little arachidonate, urine samples can be stored at −20°C. In general, even though IsoPs are chemically quite stable, long term storage of biological samples should still be avoided if possible.

The most reliable method for measurement of IsoPs is stable isotope dilution mass spectrometry. Several features of this assay make it more reliable than immunoassays. Directly adding the stable isotope internal standard to sample at the beginning of the assay greatly increases the reliability of these assays by preventing analytical error due to sample to sample variation in the efficiency o f extraction, derivitization, or ionization. Appropriate solid phase extraction of the IsoP at the beginning of the work-up removes potentially interfering substances from the sample, particularly arachidonate that could lead to artifactual formation of IsoP by autooxidation during the work-up procedure. Finally, coupling appropriate chromatography to selectively monitoring only the specific mass of the IsoP (and its internal standard) ensures that closely related arachidonate metabolites including prostaglandins do not interfere with quantitation. As plasma levels of free IsoPs in healthy humans are quite low (in the range of 30-40 pg/ml for healthy humans), mass spectrometry coupled to gas chromatography (GC/MS) rather than liquid chromatography (LC/MS) is generally employed because of its greater sensitivity. The urinary levels of unmetabolized IsoPs and metabolites of IsoPs are much higher (~ngs/ml), so that both GC/MS and LC/MS have been widely utilized for these measurements.

Because of the equipment costs associated with mass spectrometry assays, immunoassays have also been developed for measuring IsoPs. However, great care must be used in interpreting the results of IsoP immunoassays without adequate validation. Because IsoPs have limited antigenic structures, their immunoassays are carried out by competitive displacement of a labeled conjugate of IsoP from surface bound antibody, rather than by the more selective method of sandwich ELISA. Thus, compounds in the sample that non-specifically interfere with antigen-antibody binding will lead to aberrantly high values. Of particular concern are the fatty acids that are present at more than 10,000-fold greater concentration than IsoPs, and that can be released from albumin by standard partial purification strategies employed during immunoassay such as protein precipitation [12]. Other interfering contaminants may be released from solid phase cartridges or from plastics used in the assay [12]. Studies comparing the values obtained by immunoassay and GC/MS measurements have shown very different results depending on the antibodies used, the extent of sample purification, and the fluid measured, with some studies finding excellent correlation [10, 13, 14] and other finding either modest [15] or very poor correlation [16-18]. Because of the poorer precision of immunoassays, larger numbers of subjects may be required to detect significant differences between populations when using immunoassays than when using mass spectrometric assays and validation by mass spectrometry of the results obtained by immunoassay, at least in a subset of samples, improves confidence in the overall conclusions.

As will be discussed in detail below, clinical studies that have measured IsoP levels by a variety of methods provide a significant body of evidence that many risk factors for CHD increase overall lipid peroxidation, that higher IsoP levels correlate with greater extent of CHD, that IsoP levels predict disease outcomes, and that IsoP levels can be used to assess the effectiveness of various therapies aimed at reducing the level of lipid peroxidation.

Risk factors for CHD increase lipid peroxidation

Well-established risk factors for CHD include older age, male gender, high LDL cholesterol levels, low HDL cholesterol levels, obesity, diabetes, smoking, and hypertension. Other risk factors include elevated levels of high sensitivity C-reactive protein (hs-CRP) and homocysteine. Although each of these risk factors may contribute to cardiovascular disease by mechanisms independent of their effects on lipid peroxidation, there is significant evidence that many of these risk factors also increase lipid peroxidation (Table 1). For instance, smoking is associated with 2 to 3-fold higher IsoP levels in numerous studies [19-23]. Many studies have also shown that adult subjects with high levels of the proatherogenic LDL cholesterol have about two-fold higher levels of IsoPs compared to aged matched controls [24-28]. Similar two-fold elevations in IsoP levels were seen in persons with low levels of the protective lipoprotein HDL [29]. Both type 1 and type 2 diabetes are associated with a 2 to 3-fold increases in IsoP levels [30-34], and obesity correlates with increased IsoP levels even when adjusting for blood glucose levels [35-38].

Table 1
Studies Assessing the Effect of Risk Factors on IsoP Levels

Other risk factors have more subtle effects on IsoP levels and may therefore make lesser contributions to the overall extent of lipid peroxidation in disease. Several studies looking at IsoP levels in normotensive versus hypertensive persons have found somewhat higher IsoP levels with hypertension [39-42]. IsoP levels also positively correlate with CRP levels [43, 44] and with homocysteine levels [45]. Although IsoP levels are generally not increased in healthy older individuals under resting conditions [35, 46], even apparently healthy older adults have significantly increased IsoP levels compared to young adults when subjected to short bouts of ischemia/reperfusion [47]. IsoP levels are generally similar or slightly higher in healthy women than men [35, 48], so that the gender differences in risk for CHD are most likely to be due to factors other than lipid peroxidation.

Overall, the finding that many risk factors for the CHD associate with increased IsoP levels in various clinical studies supports the notion that lipid peroxidation is an important contributor to the process of atherogenesis. The additive effect of various risk factors for CHD can also be explained by this mechanism, because of their additive effect on the extent of lipid peroxidation.

Lipid peroxidation as an independent risk factor for CHD

If lipid peroxidation contributes to atherogenesis, then identifying patients with high lipid peroxidation levels should tell us who is at risk for CHD and who would therefore benefit from therapeutic intervention (Table 2). To determine if IsoP values were an independent predictor of CHD, Schwedhelm et al performed a case-control studies with 93 subjects with verified CHD and 93 age- and sex-matched healthy controls [49]. They measured IsoPs along with more traditional markers such as hypercholesterolemia, low HDL, body mass index, diabetes, systolic blood pressure, hs-CRP, and smoking status. Patients with a greater number of risk factors had higher IsoP values. Each biomarker was associated with a higher odd ratio for CHD in univariate analysis, but only two biomarkers (IsoPs and hs-CRP) were associated with higher odd ratios for CHD when multivariate analysis was applied in a stepwise regression model. This finding established IsoP values as a potential independent risk factor for CHD.

Table 2
Studies Assessing Relationship Between IsoP Levels and Presence or Extent of CHD

A subsequent study further established IsoPs values as an independent risk factor for CHD [50]. In this study, nine different lipid peroxidation products (IsoPs and eight different hydroxy fatty acids) were each measured by mass spectrometry in the plasma of consecutive patients who underwent diagnostic coronary angiography. Two of the nine lipoxidation products (IsoPs and 9-HETE) were significantly higher in those diagnosed with CHD compared to those without. The other lipoxidation products did not reach statistical significance. When all patients were stratified by IsoP quartile, the odds ratio for patients in the highest IsoP quartile to have angiographic evidence of CHD was 9.7 compared to subjects in the lowest IsoP quartile. Adding IsoP (or 9-HETE) values to the standard Framingham global risk score significantly improved the ability to predict angiographic CHD compared to using the Framingham risk score alone, demonstrating the potential clinical utility of these measurements.

The potential utility of IsoP values as an independent risk indicator for CHD found in these small pilot studies have been subsequently confirmed in larger populations. For instance, Gross et al compared IsoP values and the extent of coronary artery calcification (CAC) in a biracial cohort of 2850 young healthy men and women [48]. Approximately 23% of the men in the highest IsoP quartile manifested calcification compared to only about 12% of the men in the lowest IsoP quartile. Although prevalence of calcification was much lower in women overall, they still found that a greater percentage of women in the highest IsoP quartile manifested calcification than those in the lowest IsoP quartile. Another case control study with 799 patients with angiographically confirmed CHD and 925 healthy controls found similar two-fold increases in odds ratios for the highest IsoP quartile compared to the lowest quartile [51].

Although almost all studies to date indicate a correlation between IsoP values and CHD, we are aware of two studies that have failed to find such a relationship. Ruef et al reported (but did not show data) that IsoP levels were not significantly higher in 162 patients with stable angina or acute coronary syndromes compared to 46 control patient [52] . These measurements were performed by immunoassay, which may have meant the study was simply underpowered. No differences were also found in a nested case-control study that included 647 patients even though a GC/MS assay method was used measure IsoP levels [53]; however, IsoP values in the matched control patients ranged from 0.3 nM to 65 nM. From our extensive experience measuring IsoP levels in humans, this 200-fold variation is highly unusual for normal healthy patients and therefore suggests that a significant portion of the matched control subjects may in fact have had subclinical disease at the time of the study. Thus, in our opinion, the results of these two studies do not significantly alter the conclusion that high IsoP values are an independent risk factor for CHD.

Isoprostanes as an indicator of disease severity and outcome

In addition to signifying an increased risk for disease, high IsoP values may also provide information about the severity of disease. Vassalle et al compared plasma IsoP levels in 38 patients with angiographically measured CHD and 30 healthy control subjects[54]. They not only found that plasma levels of IsoP increased with the number of risk factors, but also that subjects with greater number of diseased vessels had higher plasma IsoP levels. This finding was confirmed by a larger study comparing IsoP levels and severity of coronary artery stenosis in 241 consecutive patients undergoing coronary angiography for suspected coronary artery disease [55]. Once again, IsoP levels correlated with the number of risk factors and the number of affected vessels.

If there is a relationship between IsoP values and severity of coronary disease, then do IsoP values predict clinical outcome of patients diagnosed with CHD? One of the first studies to address this question measured IsoP and other biomarkers in 108 patients admitted to the emergency room with chest pain and subsequently diagnosed with acute coronary syndrome (ACS) based on changes in their echocardiogram or elevated troponin levels [56]. IsoP levels at admission were more than 3-fold higher in patients diagnosed with ACS than the 101 age- and gendered-matched patients who did not have ACS. The ACS patients were then tracked over the next 30 days for four primary endpoints (nonfatal myocardial infarction, heart failure, revascularization or death). 42% of patients in the highest IsoP tertile at admission had reached one or more of these endpoints by 30 days, compare to only 14% and 17% of patients in the lowest and middle IsoP tertiles, respectively. Using this data to create receiver operating characteristic curves, the optimal cutoff point for IsoP levels was 124.5 pg/ml (74% sensitive, 81% specific in predicting cardiac events ; 57% positive predictive value, 90% negative predictive value.) Interestingly, IsoP values had greater predictive power than hs-CRP values. Thus, high IsoP values appear to be a useful indicator that a patient is at high risk and that greater vigilance and intervention are needed.

The relationship between CHD and IsoP levels suggests that atherosclerotic tissue is a significant source of the increased IsoPs found in circulation and in urine. Evidence that formation of IsoPs occurs in atherosclerotic vascular tissue to a greater extent than in normal vascular tissues comes from a study that used directional coronary atherectomy [57]. Mean IsoP levels in lesion specimens from patients with unstable angina pectoris or recent myocardial infarction were approximately 16-fold higher than in specimens from apparently normal peripheral artery. Lesions from patients with stable angina were 7-fold higher than the control tissue. Therefore, the increased circulating or urinary IsoP levels for in CHD seems to directly reflect increased lipid peroxidation that occurs in blood vessels undergoing atherogenesis.

Isoprostanes as an endpoint in interventional trials

If increased IsoP values directly reflect lipid peroxidation in vessel walls that is driving atherogenesis, then a reduction in IsoP values should indicate successful intervention and modulation of disease progression (Table 3). Can IsoP values be used as a surrogate endpoint in interventional studies? Several clinical studies for therapeutic agents that are effective at ameliorating disease and that may target lipid peroxidation indirectly have shown reduction in IsoP values after intervention. For instance, statins, which lower LDL levels by inhibition cholesterol synthesis, have been consistently shown to reduce IsoP levels in hypercholesterolemic patients [27, 28, 58-60]. Smoking cessation also rapidly reduces IsoP levels [21, 61, 62]. AT1 receptor blockers, used to treat hypertension, also significantly reduce IsoP levels in hyperholesterolemic patients [63]. Weight loss in obese subjects also profoundly lowers IsoP levels [64-69]. These results strongly suggest that effective interventions for CHD will either directly or indirectly lower IsoP values, so that measurement of IsoP values should be a highly useful surrogate endpoint in clinical trials.

Table 3
Interventions That Significantly Reduce IsoP Levels in Human Clinical Studies

The lack of such surrogate endpoint clouds the interpretation of an entire group of therapeutic trials involving vitamin E supplementation that have been used as evidence that lipid peroxidation does not mediate CHD. These trials were initiated based on epidemiological studies that suggested an inverse relationship between intake of the dietary antioxidant vitamin E and CHD [70, 71] and on animal studies showing a reduction of atherosclerosis with vitamin E supplementation[72-77]. However, in a large number of placebo controlled clinical trials, vitamin E supplementation failed to reduce CHD [78-85]. One key, but untested, assumption of these trials was that the doses of vitamin E used were sufficient to reduce lipid peroxidation in hypercholesterolemic subjects. A recent pharmacokinetic /pharmacodynamic studies for vitamin E using hypercholesterolemic subjects with elevated plasma IsoP values suggest this key assumption was not correct [86]. Sixteen weeks of vitamin E supplementation at 1600 IU/day or greater were required to significantly reduced plasma IsoP levels. The typical dose of vitamin E used in clinical trials has been 400 IU/day or less, so that the doses of vitamin E used in almost every clinical trial for CHD to date appear to have been too low to significantly alter lipid peroxidation. Therefore, while these trials provide clear evidence that low dose vitamin E is not an effective treatment for CHD, they do not provide evidence about the effectiveness of lowering lipid peroxidation as a treatment for CHD.

Limitations of current knowledge and future studies needed

Clinical studies in the past decade have greatly strengthened the evidence that lipid peroxidation plays a key role in atherogenesis. While the consistent findings that high IsoP values are independent risk factors for CHD and correlate with severity of disease suggest the potential clinical utility of measuring IsoP levels, this remains to be demonstrated with appropriate clinical studies. For instance, there clearly need to be more studies to determine whether IsoP levels at admittance to the emergency room for chest pain or acute coronary syndrome are a useful predictor of short and long-term outcomes and if applying more aggressive treatments based on high IsoP levels actually improves outcomes. In a similar manner, there need to be large scale clinical studies to determine if initiating or escalating preventative treatments (e.g. statins or antihypertensives) based on IsoP levels in patients with otherwise borderline indicators significantly reduces the incidence of CHD. A key aspect of these trials should be the establishment of what specific IsoP values should trigger intervention, along with identifying what level of reduction is required for efficacy. We believe that the use of mass spectrometry based methods rather than immunoassay to quantify IsoP levels in these studies is critical to establishing appropriate treatment guidelines. Although this may slightly add to the cost of conducting large scale trials, this seems to be the only reasonable way to ensure that measurements conducted at multiple testing centers can be reliably compared to one another, be free of artifacts, and be subsequently standardized for widespread use.

The results of the past decade also demonstrate that many pharmacological interventions that reduce risk factors of CHD (e.g. elevated cholesterol levels, diabetes, etc…) concomitantly reduce lipid peroxidation. It remains to be established whether lowering lipid peroxidation is by itself clinically relevant and how significant of reductions in lipid peroxidation levels are required to provide maximum clinical benefit. An important aspect of such studies would be to determine if mechanistically unrelated interventional strategies that achieve similar reductions in IsoP levels provide similar benefits in terms of outcome. It must also be determined whether reduction of lipid peroxidation must be achieved very early in atherogenesis to be beneficial, or whether reduction in later stages of disease is also beneficial. In addition to high dose vitamin E, there are a number of novel dietary antioxidants (e.g. pomegranate juice [87-89]) and synthetic antioxidant interventions that have been proposed to reduce lipid peroxidation and that might merit use in clinical trials. However, defining the clinical pharmacology and the doses needed to suppress lipid peroxidation by these agents is needed prior to initiating trials. To appropriately test the efficacy of such antioxidant strategies in the prevention of CHD, we suggest that a minimum IsoP value of more than 2 SD above the normal mean (i.e. plasma IsoP >47 pg/ml as measured by GC/MS assay) be used as the inclusion criteria for subjects [86] and that treatment doses be titrated to reduce IsoP values to within 1SD of the normal range (i.e. plasma IsoPs <41 pg/ml). Such studies should provide a clear test of the hypothesis that reducing lipid peroxidation is an effective strategy in the treatment of CHD and if successful, would establish appropriate target levels for physicians to use in treating their patients, in the same manner that target cholesterol and blood pressure levels are currently used.

In addition to more clinical trials, the results of the past decades also provide the rationale for continuing animal and cell culture studies to fully elucidate how lipoxidation products contribute to atherosclerosis. Although IsoPs clearly serve as excellent markers of lipid peroxidation, this should not distract from efforts to identify the lipoxidation products that are the most important contributors to atherosclerosis and to perform clinical studies to test their usefulness as biomarkers. With such studies in hand, the questions of whether lipid peroxidation is a critical component of CHD and if lipid peroxidation is a suitable target for intervention in CHD should finally be satisfactorily answered.


We are grateful for financial support from the National Institute of Health OD003137 (SSD), HL079365 (LJR), GM15431 (LJR) and GM42056 (LJR).

List of Abbreviations

Acute coronary syndrome
coronary heart disease
gas chromatography/mass spectrometry
high density lipoprotein
high sensitivity C-reactive protein
liquid chromatography/mass spectrometry
low density lipoprotein
polyunsaturated fatty acids


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1. Brown MS, Goldstein JL. Expression of the familial hypercholesterolemia gene in heterozygotes: mechanism for a dominant disorder in man. Science. 1974;185:61–63. [PubMed]
2. Goldstein JL, Ho YK, Basu SK, Brown MS. Binding site on macrophages that mediates uptake and degradation of acetylated low density lipoprotein, producing massive cholesterol deposition. Proc Natl Acad Sci U S A. 1979;76:333–337. [PubMed]
3. Quinn MT, Parthasarathy S, Fong LG, Steinberg D. Oxidatively modified low density lipoproteins: a potential role in recruitment and retention of monocyte/macrophages during atherogenesis. Proceedings of the National Academy of Sciences of the United States of America. 1987;84:2995–2998. [PubMed]
4. Parthasarathy S, Fong LG, Otero D, Steinberg D. Recognition of solubilized apoproteins from delipidated, oxidized low density lipoprotein (LDL) by the acetyl-LDL receptor. Proceedings of the National Academy of Sciences of the United States of America. 1987;84:537–540. [PubMed]
5. Jurgens G, Hoff HF, Chisolm GM, 3rd, Esterbauer H. Modification of human serum low density lipoprotein by oxidation--characterization and pathophysiological implications. Chem Phys Lipids. 1987;45:315–336. [PubMed]
6. Morrow JD, Hill KE, Burk RF, Nammour TM, Badr KF, Roberts LJ., 2nd A series of prostaglandin F2-like compounds are produced in vivo in humans by a noncyclooxygenase, free radical-catalyzed mechanism. Proc Natl Acad Sci U S A. 1990;87:9383–9387. [PubMed]
7. Kadiiska MB, Gladen BC, Baird DD, Germolec D, Graham LB, Parker CE, Nyska A, Wachsman JT, Ames BN, Basu S, Brot N, Fitzgerald GA, Floyd RA, George M, Heinecke JW, Hatch GE, Hensley K, Lawson JA, Marnett LJ, Morrow JD, Murray DM, Plastaras J, Roberts LJ, 2nd, Rokach J, Shigenaga MK, Sohal RS, Sun J, Tice RR, Van Thiel DH, Wellner D, Walter PB, Tomer KB, Mason RP, Barrett JC. Biomarkers of Oxidative Stress Study II: Are oxidation products of lipids, proteins, and DNA markers of CCl(4) poisoning? Free Radic Biol Med. 2005;38:698–710. [PubMed]
8. Stafforini DM, Sheller JR, Blackwell TS, Sapirstein A, Yull FE, McIntyre TM, Bonventre JV, Prescott SM, Roberts LJ., 2nd Release of free F2-isoprostanes from esterified phospholipids is catalyzed by intracellular and plasma platelet-activating factor acetylhydrolases. J Biol Chem. 2006;281:4616–4623. [PubMed]
9. Awad JA, Morrow JD, Takahashi K, Roberts LJ., 2nd Identification of noncyclooxygenase-derived prostanoid (F2-isoprostane) metabolites in human urine and plasma. J Biol Chem. 1993;268:4161–4169. [PubMed]
10. Wang Z, Ciabattoni G, Créminon C, Lawson J, Fitzgerald GA, Patrono C, Maclouf J. Immunological characterization of urinary 8-epi-prostaglandin F2 alpha excretion in man. Journal of Pharmacology and Experimental Therapeutics. 1995;275:94–100. [PubMed]
11. Roberts LJ, 2nd, Moore KP, Zackert WE, Oates JA, Morrow JD. Identification of the major urinary metabolite of the F2-isoprostane 8-iso-prostaglandin F2alpha in humans. J Biol Chem. 1996;271:20617–20620. [PubMed]
12. Granström E, Kindahl H. Quality control of antibodies with special reference to prostaglandins. Journal of Pharmaceutical and Biomedical Analysis. 1987;5:759–765. [PubMed]
13. Devaraj S, Hirany SV, Burk RF, Jialal I. Divergence between LDL oxidative susceptibility and urinary F(2)-isoprostanes as measures of oxidative stress in type 2 diabetes. Clin Chem. 2001;47:1974–1979. [PubMed]
14. Sasaki DM, Yuan Y, Gikas K, Kanai K, Taber D, Morrow JD, Roberts LJ, 2nd, Callewaert DM. Enzyme immunoassays for 15-F2T isoprostane-M, an urinary biomarker for oxidant stress. Adv Exp Med Biol. 2002;507:537–541. [PubMed]
15. Proudfoot J, Barden A, Mori TA, Burke V, Croft KD, Beilin LJ, Puddey IB. Measurement of urinary F(2)-isoprostanes as markers of in vivo lipid peroxidation-A comparison of enzyme immunoassay with gas chromatography/mass spectrometry. Anal Biochem. 1999;272:209–215. [PubMed]
16. Bessard J, Cracowski JL, Stanke-Labesque F, Bessard G. Determination of isoprostaglandin F2alpha type III in human urine by gas chromatography-electronic impact mass spectrometry. Comparison with enzyme immunoassay. J Chromatogr B Biomed Sci Appl. 2001;754:333–343. [PubMed]
17. Il'yasova D, Morrow JD, Ivanova A, Wagenknecht LE. Epidemiological marker for oxidant status: comparison of the ELISA and the gas chromatography/mass spectrometry assay for urine 2,3-dinor-5,6-dihydro-15-F2t-isoprostane. Ann Epidemiol. 2004;14:793–797. [PubMed]
18. Soffler C, Campbell VL, Hassel DM. Measurement of urinary F2-isoprostanes as markers of in vivo lipid peroxidation: a comparison of enzyme immunoassays with gas chromatography-mass spectrometry in domestic animal species. J Vet Diagn Invest. 2010;22:200–209. [PubMed]
19. Morrow JD, Frei B, Longmire AW, Gaziano JM, Lynch SM, Shyr Y, Strauss WE, Oates JA, Roberts LJ., 2nd Increase in circulating products of lipid peroxidation (F2-isoprostanes) in smokers. Smoking as a cause of oxidative damage. N Engl J Med. 1995;332:1198–1203. [PubMed]
20. Bachi A, Zuccato E, Baraldi M, Fanelli R, Chiabrando C. Measurement of urinary 8-Epi-prostaglandin F2alpha, a novel index of lipid peroxidation in vivo, by immunoaffinity extraction/gas chromatography-mass spectrometry. Basal levels in smokers and nonsmokers. Free Radic Biol Med. 1996;20:619–624. [PubMed]
21. Reilly M, Delanty N, Lawson JA, FitzGerald GA. Modulation of oxidant stress in vivo in chronic cigarette smokers. Circulation. 1996;94:19–25. [PubMed]
22. Obwegeser R, Oguogho A, Ulm M, Berghammer P, Sinzinger H. Maternal cigarette smoking increases F2-isoprostanes and reduces prostacyclin and nitric oxide in umbilical vessels. Prostaglandins Other Lipid Mediat. 1999;57:269–279. [PubMed]
23. Montuschi P, Collins JV, Ciabattoni G, Lazzeri N, Corradi M, Kharitonov SA, Barnes PJ. Exhaled 8-isoprostane as an in vivo biomarker of lung oxidative stress in patients with COPD and healthy smokers. Am J Respir Crit Care Med. 2000;162:1175–1177. [PubMed]
24. Davi G, Alessandrini P, Mezzetti A, Minotti G, Bucciarelli T, Costantini F, Cipollone F, Bon GB, Ciabattoni G, Patrono C. In vivo formation of 8-Epi-prostaglandin F2 alpha is increased in hypercholesterolemia. Arterioscler Thromb Vasc Biol. 1997;17:3230–3235. [PubMed]
25. Reilly MP, Pratico D, Delanty N, DiMinno G, Tremoli E, Rader D, Kapoor S, Rokach J, Lawson J, FitzGerald GA. Increased formation of distinct F2 isoprostanes in hypercholesterolemia. Circulation. 1998;98:2822–2828. [PubMed]
26. Li H, Lawson JA, Reilly M, Adiyaman M, Hwang S-W, Rokach J, FitzGerald GA. Quantitative high performance liquid chromatography/tandem mass spectrometric analysis of the four classes of F2-isoprostanes in human urine. Proceedings of the National Academy of Sciences of the United States of America. 1999;96:13381–13386. [PubMed]
27. Lee TM, Chou TF, Tsai CH. Association of pravastatin and left ventricular mass in hypercholesterolemic patients: role of 8-iso-prostaglandin f2alpha formation. J Cardiovasc Pharmacol. 2002;40:868–874. [PubMed]
28. Desideri G, Croce G, Tucci M, Passacquale G, Broccoletti S, Valeri L, Santucci A, Ferri C. Effects of Bezafibrate and Simvastatin on Endothelial Activation and Lipid Peroxidation in Hypercholesterolemia: Evidence of Different Vascular Protection by Different Lipid-Lowering Treatments. J Clin Endocrinol Metab. 2003;88:5341–5347. [PubMed]
29. Kontush A, de Faria EC, Chantepie S, Chapman MJ. A normotriglyceridemic, low HDL-cholesterol phenotype is characterised by elevated oxidative stress and HDL particles with attenuated antioxidative activity. Atherosclerosis. 2005;182:277–285. [PubMed]
30. Gopaul NK, Anggard EE, Mallet AI, Betteridge DJ, Wolff SP, Nourooz-Zadeh J. Plasma 8-epi-PGF2 alpha levels are elevated in individuals with non-insulin dependent diabetes mellitus. FEBS Lett. 1995;368:225–229. [PubMed]
31. Davi G, Ciabattoni G, Consoli A, Mezzetti A, Falco A, Santarone S, Pennese E, Vitacolonna E, Bucciarelli T, Costantini F, Capani F, Patrono C. In vivo formation of 8-iso-prostaglandin f2alpha and platelet activation in diabetes mellitus: effects of improved metabolic control and vitamin E supplementation. Circulation. 1999;99:224–229. [PubMed]
32. Moussavi N, Renier G, Roussin A, Mamputu JC, Buithieu J, Serri O. Lack of concordance between plasma markers of cardiovascular risk and intima-media thickness in patients with type 2 diabetes. Diabetes Obes Metab. 2004;6:69–77. [PubMed]
33. Flores L, Rodela S, Abian J, Claria J, Esmatjes E. F2 isoprostane is already increased at the onset of type 1 diabetes mellitus: effect of glycemic control. Metabolism. 2004;53:1118–1120. [PubMed]
34. Nakanishi S, Suzuki G, Kusunoki Y, Yamane K, Egusa G, Kohno N. Increasing of oxidative stress from mitochondria in type 2 diabetic patients. Diabetes Metab Res Rev. 2004;20:399–404. [PubMed]
35. Keaney JF, Jr., Larson MG, Vasan RS, Wilson PW, Lipinska I, Corey D, Massaro JM, Sutherland P, Vita JA, Benjamin EJ. Obesity and systemic oxidative stress: clinical correlates of oxidative stress in the Framingham Study. Arterioscler Thromb Vasc Biol. 2003;23:434–439. [PubMed]
36. Urakawa H, Katsuki A, Sumida Y, Gabazza EC, Murashima S, Morioka K, Maruyama N, Kitagawa N, Tanaka T, Hori Y, Nakatani K, Yano Y, Adachi Y. Oxidative stress is associated with adiposity and insulin resistance in men. J Clin Endocrinol Metab. 2003;88:4673–4676. [PubMed]
37. Hansel B, Giral P, Nobecourt E, Chantepie S, Bruckert E, Chapman MJ, Kontush A. Metabolic syndrome is associated with elevated oxidative stress and dysfunctional dense high-density lipoprotein particles displaying impaired antioxidative activity. J Clin Endocrinol Metab. 2004;89:4963–4971. [PubMed]
38. Araki S, Dobashi K, Yamamoto Y, Asayama K, Kusuhara K. Increased plasma isoprostane is associated with visceral fat, high molecular weight adiponectin, and metabolic complications in obese children. Eur J Pediatr. 2010;169:965–970. [PubMed]
39. Minuz P, Patrignani P, Gaino S, Degan M, Menapace L, Tommasoli R, Seta F, Capone ML, Tacconelli S, Palatresi S, Bencini C, Del Vecchio C, Mansueto G, Arosio E, Santonastaso CL, Lechi A, Morganti A, Patrono C. Increased Oxidative Stress and Platelet Activation in Patients With Hypertension and Renovascular Disease. Circulation. 2002;106:2800–2805. [PubMed]
40. Zhou L, Xiang W, Potts J, Floyd M, Sharan C, Yang H, Ross J, Nyanda AM, Guo Z. Reduction in extracellular superoxide dismutase activity in African-American patients with hypertension. Free Radical Biology and Medicine. 2006;41:1384–1391. [PubMed]
41. Romero JC, Reckelhoff JF. State-of-the-Art lecture. Role of angiotensin and oxidative stress in essential hypertension. Hypertension. 1999;34:943–949. [PubMed]
42. Cracowski JL, Cracowski C, Bessard G, Pepin JL, Bessard J, Schwebel C, Stanke-Labesque F, Pison C. Increased lipid peroxidation in patients with pulmonary hypertension. Am J Respir Crit Care Med. 2001;164:1038–1042. [PubMed]
43. Il'yasova D, Ivanova A, Morrow JD, Cesari M, Pahor M. Correlation between two markers of inflammation, serum C-reactive protein and interleukin 6, and indices of oxidative stress in patients with high risk of cardiovascular disease. Biomarkers. 2008;13:41–51. [PubMed]
44. Dohi Y, Takase H, Sato K, Ueda R. Association among C-reactive protein, oxidative stress, and traditional risk factors in healthy Japanese subjects. International Journal of Cardiology. 2007;115:63–66. [PubMed]
45. Voutilainen S, Morrow JD, Roberts LJ, 2nd, Alfthan G, Alho H, Nyyssonen K, Salonen JT. Enhanced in vivo lipid peroxidation at elevated plasma total homocysteine levels. Arterioscler Thromb Vasc Biol. 1999;19:1263–1266. [PubMed]
46. Frisard MI, Broussard A, Davies SS, Roberts LJ, 2nd, Rood J, de Jonge L, Fang X, Jazwinski SM, Deutsch WA, Ravussin E. Aging, resting metabolic rate, and oxidative damage: results from the Louisiana Healthy Aging Study. J Gerontol A Biol Sci Med Sci. 2007;62:752–759. [PMC free article] [PubMed]
47. Davies SS, Traustadottir T, Stock AA, Ye F, Shyr Y, Harman SM, Roberts LJ., 2nd Ischemia/reperfusion unveils impaired capacity of older adults to restrain oxidative insult. Free Radic Biol Med. 2009;47:1014–1018. [PMC free article] [PubMed]
48. Gross M, Steffes M, Jacobs DR, Jr., Yu X, Lewis L, Lewis CE, Loria CM. Plasma F2-Isoprostanes and Coronary Artery Calcification: The CARDIA Study. Clin Chem. 2005;51:125–131. [PubMed]
49. Schwedhelm E, Bartling A, Lenzen H, Tsikas D, Maas R, Brummer J, Gutzki F-M, Berger J, Frolich JC, Boger RH. Urinary 8-iso-Prostaglandin F2{alpha} as a Risk Marker in Patients With Coronary Heart Disease: A Matched Case-Control Study. Circulation. 2004;109:843–848. [PubMed]
50. Shishehbor MH, Zhang R, Medina H, Brennan M-L, Brennan DM, Ellis SG, Topol EJ, Hazen SL. Systemic elevations of free radical oxidation products of arachidonic acid are associated with angiographic evidence of coronary artery disease. Free Radical Biology and Medicine. 2006;41:1678–1683. [PMC free article] [PubMed]
51. Kim JY, Hyun YJ, Jang Y, Lee BK, Chae JS, Kim SE, Yeo HY, Jeong T-S, Jeon DW, Lee JH. Lipoprotein-associated phospholipase A2 activity is associated with coronary artery disease and markers of oxidative stress: a case-control study. Am J Clin Nutr. 2008;88:630–637. [PubMed]
52. Ruef J, März W, Winkelmann BR. Markers for endothelial dysfunction, but not markers for oxidative stress correlate with classical risk factors and the severity of coronary artery disease. Scandinavian Cardiovascular Journal. 2006;40:274–279. [PubMed]
53. Woodward M, Croft KD, Mori TA, Headlam H, Wang XS, Suarna C, Raftery MJ, MacMahon SW, Stocker R. Association between both lipid and protein oxidation and the risk of fatal or non-fatal coronary heart disease in a human population. Clinical Science. 2009;116:53–60. [PubMed]
54. Vassalle C, Petrozzi L, Botto N, Andreassi MG, Zucchelli GC. Oxidative stress and its association with coronary artery disease and different atherogenic risk factors. Journal of Internal Medicine. 2004;256:308–315. [PubMed]
55. Wang B, Pan J, Wang L, Zhu H, Yu R, Zou Y. Associations of plasma 8-isoprostane levels with the presence and extent of coronary stenosis in patients with coronary artery disease. Atherosclerosis. 2006;184:425–430. [PubMed]
56. LeLeiko RM, Vaccari CS, Sola S, Merchant N, Nagamia SH, Thoenes M, Khan BV. Usefulness of elevations in serum choline and free F2)-isoprostane to predict 30-day cardiovascular outcomes in patients with acute coronary syndrome. Am J Cardiol. 2009;104:638–643. [PubMed]
57. Nishibe A, Kijima Y, Fukunaga M, Nishiwaki N, Sakai T, Nakagawa Y, Hata T. Increased isoprostane content in coronary plaques obtained from vulnerable patients. Prostaglandins, Leukotrienes and Essential Fatty Acids. 78:257–263. [PubMed]
58. De Caterina R, Cipollone F, Filardo FP, Zimarino M, Bernini W, Lazzerini G, Bucciarelli T, Falco A, Marchesani P, Muraro R, Mezzetti A, Ciabattoni G. Low-Density Lipoprotein Level Reduction by the 3-Hydroxy-3-Methylglutaryl Coenzyme-A Inhibitor Simvastatin Is Accompanied by a Related Reduction of F2-Isoprostane Formation in Hypercholesterolemic Subjects: No Further Effect of Vitamin E. Circulation. 2002;106:2543–2549. [PubMed]
59. Viviana N, Christian P, María Pilar S, Mario C, Marcelo L, Sergio L, Juan Carlos P. (TTA)n Polymorphism in 3-Hydroxy-3-Methylglutaryl-Coenzyme A and Response to Atorvastatin in Coronary Artery Disease Patients. Basic & Clinical Pharmacology & Toxicology. 2009;104:211–215. [PubMed]
60. Kishimoto N, Hayashi T, Sakuma I, Kano-Hayashi H, Tsunekawa T, Osawa M, Ina K, Iguchi A. A hydroxymethylglutaryl coenzyme a reductase inhibitor improves endothelial function within 7 days in patients with chronic hemodialysis. International Journal of Cardiology. In Press, Corrected Proof. [PubMed]
61. Pilz H, Oguogho A, Chehne F, Lupattelli G, Palumbo B, Sinzinger H. Quitting cigarette smoking results in a fast improvement of in vivo oxidation injury (determined via plasma, serum and urinary isoprostane) Thromb Res. 2000;99:209–221. [PubMed]
62. Chehne F, Oguogho A, Lupattelli G, Palumbo B, Sinzinger H. Effect of giving up cigarette smoking and restarting in patients with clinically manifested atherosclerosis. Prostaglandins Leukot Essent Fatty Acids. 2002;67:333–339. [PubMed]
63. Wassmann S, Hilgers S, Laufs U, Bohm M, Nickenig G. Angiotensin II Type 1 Receptor Antagonism Improves Hypercholesterolemia-Associated Endothelial Dysfunction. Arterioscler Thromb Vasc Biol. 2002;22:1208–1212. [PubMed]
64. Davi G, Guagnano MT, Ciabattoni G, Basili S, Falco A, Marinopiccoli M, Nutini M, Sensi S, Patrono C. Platelet activation in obese women: role of inflammation and oxidant stress. JAMA. 2002;288:2008–2014. [PubMed]
65. Montine TJ, Neely MD, Quinn JF, Beal MF, Markesbery WR, Roberts LJ, Morrow JD. Lipid peroxidation in aging brain and Alzheimer's disease. Free Radic Biol Med. 2002;33:620–626. [PubMed]
66. Bougoulia M, Triantos A, Koliakos G. Effect of weight loss with or without orlistat treatment on adipocytokines, inflammation, and oxidative markers in obese women. Hormones (Athens) 2006;5:259–269. [PubMed]
67. Johnson JB, Summer W, Cutler RG, Martin B, Hyun DH, Dixit VD, Pearson M, Nassar M, Telljohann R, Maudsley S, Carlson O, John S, Laub DR, Mattson MP. Alternate day calorie restriction improves clinical findings and reduces markers of oxidative stress and inflammation in overweight adults with moderate asthma. Free Radic Biol Med. 2007;42:665–674. [PMC free article] [PubMed]
68. Crujeiras AB, Parra D, Abete I, Martinez JA. A hypocaloric diet enriched in legumes specifically mitigates lipid peroxidation in obese subjects. Free Radic Res. 2007;41:498–506. [PubMed]
69. Elizondo A, Araya J, Rodrigo R, Signorini C, Sgherri C, Comporti M, Poniachik J, Videla LA. Effects of weight loss on liver and erythrocyte polyunsaturated fatty acid pattern and oxidative stress status in obese patients with non-alcoholic fatty liver disease. Biol Res. 2008;41:59–68. [PubMed]
70. Rimm EB, Stampfer MJ, Ascherio A, Giovannucci E, Colditz GA, Willett WC. Vitamin E consumption and the risk of coronary heart disease in men. N Engl J Med. 1993;328:1450–1456. [PubMed]
71. Stampfer MJ, Hennekens CH, Manson JE, Colditz GA, Rosner B, Willett WC. Vitamin E consumption and the risk of coronary disease in women. N Engl J Med. 1993;328:1444–1449. [PubMed]
72. Crawford RS, Kirk EA, Rosenfeld ME, LeBoeuf RC, Chait A. Dietary antioxidants inhibit development of fatty streak lesions in the LDL receptor-deficient mouse. Arterioscler Thromb Vasc Biol. 1998;18:1506–1513. [PubMed]
73. Pratico D, Tangirala RK, Rader DJ, Rokach J, FitzGerald GA. Vitamin E suppresses isoprostane generation in vivo and reduces atherosclerosis in ApoE-deficient mice. Nat Med. 1998;4:1189–1192. [PubMed]
74. Thomas SR, Leichtweis SB, Pettersson K, Croft KD, Mori TA, Brown AJ, Stocker R. Dietary cosupplementation with vitamin E and coenzyme Q(10) inhibits atherosclerosis in apolipoprotein E gene knockout mice. Arterioscler Thromb Vasc Biol. 2001;21:585–593. [PubMed]
75. Peluzio MC, Homem AP, Cesar GC, Azevedo GS, Amorim R, Cara DC, Saliba H, Vieira EC, Arantes RE, Alvarez-Leite J. Influences of alpha-tocopherol on cholesterol metabolism and fatty streak development in apolipoprotein E-deficient mice fed an atherogenic diet. Braz J Med Biol Res. 2001;34:1539–1545. [PubMed]
76. Cyrus T, Yao Y, Rokach J, Tang LX, Pratico D. Vitamin E reduces progression of atherosclerosis in low-density lipoprotein receptor-deficient mice with established vascular lesions. Circulation. 2003;107:521–523. [PubMed]
77. Otero P, Bonet B, Herrera E, Rabano A. Development of atherosclerosis in the diabetic BALB/c mice. Prevention with Vitamin E administration. Atherosclerosis. 2005;182:259–265. [PubMed]
78. Virtamo J, Rapola JM, Ripatti S, Heinonen OP, Taylor PR, Albanes D, Huttunen JK. Effect of vitamin E and beta carotene on the incidence of primary nonfatal myocardial infarction and fatal coronary heart disease. Arch Intern Med. 1998;158:668–675. [PubMed]
79. Rapola JM, Virtamo J, Ripatti S, Huttunen JK, Albanes D, Taylor PR, Heinonen OP. Randomised trial of alpha-tocopherol and beta-carotene supplements on incidence of major coronary events in men with previous myocardial infarction. Lancet. 1997;349:1715–1720. [PubMed]
80. de Gaetano G. Low-dose aspirin and vitamin E in people at cardiovascular risk: a randomised trial in general practice. Collaborative Group of the Primary Prevention Project. Lancet. 2001;357:89–95. [PubMed]
81. Lonn E, Yusuf S, Dzavik V, Doris C, Yi Q, Smith S, Moore-Cox A, Bosch J, Riley W, Teo K. Effects of ramipril and vitamin E on atherosclerosis: the study to evaluate carotid ultrasound changes in patients treated with ramipril and vitamin E (SECURE) Circulation. 2001;103:919–925. [PubMed]
82. Lonn E, Bosch J, Yusuf S, Sheridan P, Pogue J, Arnold JM, Ross C, Arnold A, Sleight P, Probstfield J, Dagenais GR. Effects of long-term vitamin E supplementation on cardiovascular events and cancer: a randomized controlled trial. JAMA. 2005;293:1338–1347. [PubMed]
83. Stephens NG, Parsons A, Schofield PM, Kelly F, Cheeseman K, Mitchinson MJ. Randomised controlled trial of vitamin E in patients with coronary disease: Cambridge Heart Antioxidant Study (CHAOS) Lancet. 1996;347:781–786. [PubMed]
84. MRC/BHF Heart Protection Study of antioxidant vitamin supplementation in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002;360:23–33. [PubMed]
85. Vivekananthan DP, Penn MS, Sapp SK, Hsu A, Topol EJ. Use of antioxidant vitamins for the prevention of cardiovascular disease: meta-analysis of randomised trials. Lancet. 2003;361:2017–2023. [PubMed]
86. Roberts LJ, 2nd, Oates JA, Linton MF, Fazio S, Meador BP, Gross MD, Shyr Y, Morrow JD. The relationship between dose of vitamin E and suppression of oxidative stress in humans. Free Radic Biol Med. 2007;43:1388–1393. [PMC free article] [PubMed]
87. Aviram M, Dornfeld L, Rosenblat M, Volkova N, Kaplan M, Coleman R, Hayek T, Presser D, Fuhrman B. Pomegranate juice consumption reduces oxidative stress, atherogenic modifications to LDL, and platelet aggregation: studies in humans and in atherosclerotic apolipoprotein E-deficient mice. Am J Clin Nutr. 2000;71:1062–1076. [PubMed]
88. Aviram M, Dornfeld L. Pomegranate juice consumption inhibits serum angiotensin converting enzyme activity and reduces systolic blood pressure. Atherosclerosis. 2001;158:195–198. [PubMed]
89. Aviram M, Rosenblat M, Gaitini D, Nitecki S, Hoffman A, Dornfeld L, Volkova N, Presser D, Attias J, Liker H, Hayek T. Pomegranate juice consumption for 3 years by patients with carotid artery stenosis reduces common carotid intima-media thickness, blood pressure and LDL oxidation. Clin Nutr. 2004;23:423–433. [PubMed]