Elastase, a proteolytic enz granules of neutrophils, tissue injury in emphyse phils in the pathophysiology of Neutrophils play a critical role in ischemia, the stunning of potentially viable myocardiumand elusion in animalmodels the genesis of a~hythmias vision-related myocardial of myocardial ischemia (2
From the Departments of Medicine and Biostatistics. University of Florida, College of Medicine. Veterans Affairs Medical Center, Gainesville. Florida and *Department of Forensic Medicine, University of Uppsala, Uppsala, Sweden. These studies were supported by grants from the Department of Veterans Affairs, Washiagton D.C., the American Heart Association. Florida Affiliate, St. Petersburg, Florida and the Afa Fund, Stockholm. Sweden. Dr. Mehta is a Clinical investigator of the Department of Veterans rs Central Office. Washington D.C. Manuscript received September 18. 1989, revised manuscript received January 3,19!JO, accepted February 7, K&O. : Jawahar L. Mehta, MD, WD. Department of Medicine, University of Florida, Box J-277, JHMHC. Gainesville, Florida 32610. Q 1990 by the American College of Cardiology
tinent in interventions (such as thrombolys~s)that restore blood flow to jeopardized myocardium and cause entry of neutrophils into the ischemic tissue. To characterize ne~trophil elastase activity in human ischemic heart disease, plasma levels of neutrophil elastase-derived fibrin0 measured in peripheral blood angina pectoris, unstable angina infarctionas well as arent cardiovascular
ts. Ali patients and control subjects were Stu male. Patients were recwited consecutively from those 07351097/9oL$3.50
1560
JACC Vol. IS. No. 7 June mml559-63
DINERMAN ET AL. ELASTASE AND ISCHEMIC HEART DISEASE
presenting for care to the cardiology inpatient or outpatient service at the Veterans Affairs Medical Center, Gainesville, Florida. Control subjects (n = 22) were outpatients without clinical evidence of vascular disease or inpatients hospitalized for evaluation of chest pain, which after evaluation, including exercise tolerance testing or CorOnarYangiography, or both, was believed to be noncardiac in origin. Diagnosisof stable angina pectoris (n = 25) was based on a positive exercise tolerance test and significant coronary artery disease documented by coronary angiographywithout recent change in the character, frequency or severity of anginal pain. Unstable angina pectoris (n = 29) was defined as a change in the pattern of chest pain (recent increase in severity or frequency, or both) or new onset of symptoms typical of myocardialischemia, with or without ST changes on the electrocardiogram (ECG) and without significant elevation in serum creatine kinase (CK). All patients included in the unstable angina pectoris group had typical anginal pain at rest. Patients with acute myocardial infarction (n = 17) had either elevation in serum CK (>2 times normal) or appearance of a new Q wave on the ECG. None of the subjects had smoked within 2 h of blood collection. Patients taking antibiotics or with a clinical history suggestive of underlying infection were not included in the study. Written consent to participate in this study, which was approved by the Institutional Review Board of the University of Florida College of Medicine, was obtained from all subjects. Blood collection. Peripheral venous blood was collected in an acid-citrate-dextrose solution, and the plasma was isolated by centrifugation. Blood was collected from all subjects within 4 h of hospitalization for peptide BP 30-43 measurement. In eight patients with acute myocardial infarction, blood was collected at admission and again at 8 and 16h after admission for peptide B/330-43 and CK measurements. Total leukocyte and absolute neutrophil counts were also determined. Assaymethods. A radioimmunoassay was developed for measurement of a unique fibrinopeptide. Antibodies to the peptide Arg-Pro-Ala-Pro.Pro-Pro-Ile-Ser-Gly-Gl~-Gly-TyrArg-Ala, produced by the enzymziic cleavage of fibrin or fibrinogenby human neutrophil elastase and corresponding to the amino acids 30 to 43 of the fibrinogenBP chain (BP 30-43), were raised in rabbits (5,6).These antibodiesexhibit high specificity and sensitivity for a fibrinopeptidereleased by the enzymatic degradation of the B/? chain of fibrin or fibrinogenby neutrophil elastase (6). Significantreactivity of this antibody was noted against a largerfibrinopeptide(molecularweight approximately 13kd) released by the action of human neutrophil elastase. This peptide is a precursor to the peptide B/l 30-43, is very stable in piasma and accounts for most (or all) of the immunoreacGvitYin human plasma. Purified human neutrophil elastase, but not Plasmin, liberates this peptide in vitro from both
1
6
16
10 Incubelion
time
20
24
Omurs~
Figure 1. Releaseof peptideB/330-43(~molfiiter)when fibrinogen (Fbg) or fibrin (Fib) is incubated with either human neutrophil elastase (E) or plasmin(P).
fibrinogenand fibrin (Fig. 1).The release of i~~~noreactive materialis fairly slow and increases with time. Releaseof the 13 kd peptide, however, occurs during the first part of the incubation period. When elastase is added to normal plasma (1450 dml), no release of BP 30-43 peptide precursor is obse However, after incubation of neutrophil elastase in al protease inhibitor-deficient plasma, large amounts of the peptide are formed, suggestingthat the release of the peptide is dependent on this natural inhibitor of elastase. Furthermore, a synthetic elastase inhibitor, U 25,651(Stuart Pharmaceuticals), strongly inhibits ehe release of the peptide in vitro (Fig. 2), demonstratitlg specificityof the radioimmunoassay. The antibody has a very low (0. 2%) cross-reactivity with fibrinogen. Cross-reactivity with peptides released by chymotvypsin, collagen, pancreatic elastase, plasmin, thrombin or trypsin is ~0.2%. Figure 2. In vitro release of peptide B/330-43 is inhibited in the presenceof U 25,651,a syntheticinhibitorof elastase;9.4nmol of $asminogen-freefibrinogenwas incubatedat 37°Cwith 460pmol of hunlay neutrophil elastase and various concentrations (Cone) of inhibitor.
JAW Vol. 15, No. 7 June I :1559-63
e 1. Clinical
~~~acte~i~tic§
Hypertension (%) Diabetes mellitus (%j edication* (%) Nitrates Beta-blockers Calcium antagonists Aspirin Heparin (iv) Streptokinase
of Control
COIWOI
Stable
Subjects
Aagina
(n = 22)
rin = 25,
and Stu Lkmlble hgina (n = 79)
AMl In =
879
9 5
16 8
‘1 17
I 2 2.6 41 35 17
14 9 14 9 14 0
60 32 9 48 0 0
16 48 72 66 48 tl
88 47 29 35 53 18
*Medication taken within 24 h of blood collection. AMI = acute myocardial infarction; iv = intwcwusly.
10 1 conlrol subjects
stable angIna patients
unstable engIna
my!xardtet lnltwctlon
patients
patlWltS
30-43 levels in myocardial &hernia. is increased in patients with unstable a yocardial
infarction
as compared
wit
Total leukocyte counts wer aspirin, heparin, beta~adre~er~c blockers, nitrates, calcium channel antagonists or strepto~i~ase, was assessed in the ultiple linear regression. ~onparametric Duskal-Wallis and bang-Whitney tests were then used to corroborate the findings of the al theory tests. Data are expressed as mean values -CS
Patient characteristics and treatments able 1. Approx~~~ately third of all of patients rs. Twenty percent to and the ~ropo~io~ was similar had hype~e~sion or d Iintake of cardiac medication s than in the control group (p < 0.M). Patients in the control group were younger than those in the other study groups (p < 0.05). Analysisof relations among factors such as smoking, hypertension,
control subjects (4.9 -C0.3 x ?+06/ml, p < O.OI for both). Absolute neutrophil counts were unstable angina (6.6 + 0.7 X 10 le angina (p < 0.01) but the ects did not reach statistical There was no significantrelation between pep levels and total leukocyte count
p 30-43 levels over 16h in patients with acute myocardial infarction demonstrated a trend toward a decrease over
1562
JACC Vol. 15. No. 7 June I :1559-63
DINERMAN ET AL. ELASTASE AND ISCHEMIC HEART DISEASE
time. Mean peptide B/3 30-43 levels were 1,420 + 669 pmol/literat admission,1,130f 486pmolfliterat 8 h and898 2 401 pmol/l/terat 16 h for this group. levels were 783 + 570 Wliter at admission, 814 2 331 W/literat 8 h and 1,022+ 441 W/literat 16 h. There was, however, no significantrelationbetweenpeptideB/330-43 levels and serumCK levels at any given timeor overall(I’= 0.15).
values(5-7). Hypertension. diabetes me~~itMs treatments,which ma were also common emphysema aud smokiNg (1,12). 30-43 levels were markedly incr our patientswith unstable angina
NeutroT:& .I(.; i_. Roleof ncutropbi in acute isc myocardiumand in large number resultin capillarypluggingandthe “no reflow” phenomenon mulate
(2,8-1(t). These neutrophils undergo activation in response to complement fragments and release oxygen free radicals, arachidonatemetabolitesand elastase (2). Tissue damage caused by neutrophils during acute ischemic events is characterized by proteolysis secondary to release of granule constituents and free radicals. Specifically, neutrophil elastase has been shown to mediate both degradation of basementmembraneconstituents(2) and damage of endothelium (3). Although much research has focused on the role of neutrophil-derived free radical release, the time course of neutrophil-mediated endothelial damage more closely resembles that of the injury caused by neutrophil elastase than by oxygen free radicals (4). In this context, our observations of significant, severalfold elevations in plasma levels of peptide B/3 30-O soon after the onset of unstable angina or acute myocardial infarction may have important pathophysiologic implications. Relatively higher plasma levels of noted in our patients with unstable angi pared with those with acute myocardial likely due to episodic occlusion and reperfusion of the offending coronary artery (1 I), resulting in repetitive entry of neutrophils into the ischemic myocardium and their activation. In patients with acute myocardial infarction, pharmacologic (in response to streptokinase) or spontaneous reperfusion may cause entry of neutrophils into the ischemic tissues. As our study shows, elastase release gradually declines over the next 8 to 16 h in patients with myocardial infarction, but has no relation to CK release. tiitions of the study. Wide variations in the plasma levels of peptide B/3 30-43 were observed among our study groups, which may relate to the nature of our controlgrou and vagaries inherent in the assignment of clinical labels, such as stable and unstable angina pectotis. Subjects in our control group, with a ~l”re~nage of 54 years and a 32% incidence rate of smoking, are likely to have subclinical cardiovascular or pulmonary disease. Previousnormatvalues for peptideB/330-43 were obtained from normal subjects, rather than our control patients. This and the assignment of a value of 50 pmoYliter to all measurementsc 100
nn deposits where close contact between fiber and elastase may overcome the activity of alohas-protease inhibitor). With one exception, our used for the determination of h derived fibrinopeptide in plasma. a method for determination of peptide A l-21, derived from elastase degradation of fibrino8en. Their method may not be generally useful, however, because the antibodies crossreact with various other molecul Therefore, the peptide has to be is liquid chromatography before it ca AlthoMgb the elevations in peptide BP 30-43 levels in p&ma represent increased formation of unique fibrin or ~~~nogen degradation products through the a&on of neutrophil elastase, whether this increase results from increased substrate (fi-
4. SmedPy LA. ‘Tonnesen
injury lo endothePialse91
endok~in and essemial role OF
~eu~~opb~~elastase. J Clin Invest ~9~6;77:~233-~3. 5.
tin R. Saldeen T. A specific r~~~oirnrnM~l~ss~~y for ~e~errni~a~~~~~of erived From elastase ~legri~da~~o~of hunran ~br~~~ogea]. Acca Univ Ups&asis ~Yg7~1~2:1~26.
6. Saldeen T. Wallin N. A specific ~dioimm~noassay For deterrn~~a~~o~ of peplides drrived From ~~rn~~ leo~~yle elestase degradai~on of human ~br~~~o~e~~ Iabs?rl ~irc~~~l~i~~~ 1987:7fr:snppl BV):!V-339. eh~a J.
ehta P. et al. Neutrophil
Function in ischemic
da R. Leukocyle capiljury sion in the dog. Am J Parbol
Mehia
J. Nichols
CrowelI ED. Rowe GC. Plalelel a~grega~~o~ in partially 365-70. eitz JI. Crowjey KA. Landmaa SL. Lipman t!;ophil clastase activity in smokers. Ann Bmern riiner s. %krrousky !k i_aMie 6. Pinkhas J. Aronson h!. Agmon J. ‘Fhe leubergy lest in pa!ienls whh ischemic heart disease. Am 1986:111:19-22.
. CommerFord PJ. Franks JJ. Kirsch anligens in patients with stable and u disease. PI Engl J Med 19#7:317:1361-5. Mclrta 3. Mehta P. Conti CR. Platelet Function studies in coronary bean disease. X1. increased phclc: pros~~~~~andi~generation and abnormal n~o~r~xi~e analog in angina
disease.
he help of the nurses ary Care Uni LaVernf A.
: current
J Am Co!! Cardiol
Veterans ALfdirs esville. Florida in Iph For assistance
of the prokace-
, ~ee~~erna~ P. Effects of rphree S. Saffitz SE. Jak xane. and ~roslag~a~dios produced leukotrienes. on coronary vascular resistance in rabbit myocardi~l infarction. J Clin lnvesl lY85:75:9Y2-9.
Mehh L. Nichols WW, Doidly W dismufase from myocardial dysfuncti reserve Following coronary occiusion and reperFusion in dog. lYgY:b5:1283-95. hida S. Suzuki K. cl al. PoiymorphonMclear !eUkyle Kuzuya T. trjcuiar arr~y~~m~a in acute myocardial inFarclioa. Am J activity and Cardioi ~9~~~6~~~4K-7~. epine R.Cheronis JC, Sandhaus JE. O2 metaboliles and neu~~opbil elaslilse sy~er~islic~~~y cause edem& tous ifl@q in isolated ral lungs. J Appl Physiol ~9~6~6~:~~~4-9.
From the Departments of Medicine and Biostatistics. University of Florida, College of Medicine. Veterans Affairs Medical Center, Gainesville. Florida and *Department of Forensic Medicine, University of Uppsala, Uppsala, Sweden. These studies were supported by grants from the Department of Veterans Affairs, Washiagton D.C., the American Heart Association. Florida Affiliate, St. Petersburg, Florida and the Afa Fund, Stockholm. Sweden. Dr. Mehta is a Clinical investigator of the Department of Veterans rs Central Office. Washington D.C. Manuscript received September 18. 1989, revised manuscript received January 3,19!JO, accepted February 7, K&O. : Jawahar L. Mehta, MD, WD. Department of Medicine, University of Florida, Box J-277, JHMHC. Gainesville, Florida 32610. Q 1990 by the American College of Cardiology
tinent in interventions (such as thrombolys~s)that restore blood flow to jeopardized myocardium and cause entry of neutrophils into the ischemic tissue. To characterize ne~trophil elastase activity in human ischemic heart disease, plasma levels of neutrophil elastase-derived fibrin0 measured in peripheral blood angina pectoris, unstable angina infarctionas well as arent cardiovascular
ts. Ali patients and control subjects were Stu male. Patients were recwited consecutively from those 07351097/9oL$3.50
1560
JACC Vol. IS. No. 7 June mml559-63
DINERMAN ET AL. ELASTASE AND ISCHEMIC HEART DISEASE
presenting for care to the cardiology inpatient or outpatient service at the Veterans Affairs Medical Center, Gainesville, Florida. Control subjects (n = 22) were outpatients without clinical evidence of vascular disease or inpatients hospitalized for evaluation of chest pain, which after evaluation, including exercise tolerance testing or CorOnarYangiography, or both, was believed to be noncardiac in origin. Diagnosisof stable angina pectoris (n = 25) was based on a positive exercise tolerance test and significant coronary artery disease documented by coronary angiographywithout recent change in the character, frequency or severity of anginal pain. Unstable angina pectoris (n = 29) was defined as a change in the pattern of chest pain (recent increase in severity or frequency, or both) or new onset of symptoms typical of myocardialischemia, with or without ST changes on the electrocardiogram (ECG) and without significant elevation in serum creatine kinase (CK). All patients included in the unstable angina pectoris group had typical anginal pain at rest. Patients with acute myocardial infarction (n = 17) had either elevation in serum CK (>2 times normal) or appearance of a new Q wave on the ECG. None of the subjects had smoked within 2 h of blood collection. Patients taking antibiotics or with a clinical history suggestive of underlying infection were not included in the study. Written consent to participate in this study, which was approved by the Institutional Review Board of the University of Florida College of Medicine, was obtained from all subjects. Blood collection. Peripheral venous blood was collected in an acid-citrate-dextrose solution, and the plasma was isolated by centrifugation. Blood was collected from all subjects within 4 h of hospitalization for peptide BP 30-43 measurement. In eight patients with acute myocardial infarction, blood was collected at admission and again at 8 and 16h after admission for peptide B/330-43 and CK measurements. Total leukocyte and absolute neutrophil counts were also determined. Assaymethods. A radioimmunoassay was developed for measurement of a unique fibrinopeptide. Antibodies to the peptide Arg-Pro-Ala-Pro.Pro-Pro-Ile-Ser-Gly-Gl~-Gly-TyrArg-Ala, produced by the enzymziic cleavage of fibrin or fibrinogenby human neutrophil elastase and corresponding to the amino acids 30 to 43 of the fibrinogenBP chain (BP 30-43), were raised in rabbits (5,6).These antibodiesexhibit high specificity and sensitivity for a fibrinopeptidereleased by the enzymatic degradation of the B/? chain of fibrin or fibrinogenby neutrophil elastase (6). Significantreactivity of this antibody was noted against a largerfibrinopeptide(molecularweight approximately 13kd) released by the action of human neutrophil elastase. This peptide is a precursor to the peptide B/l 30-43, is very stable in piasma and accounts for most (or all) of the immunoreacGvitYin human plasma. Purified human neutrophil elastase, but not Plasmin, liberates this peptide in vitro from both
1
6
16
10 Incubelion
time
20
24
Omurs~
Figure 1. Releaseof peptideB/330-43(~molfiiter)when fibrinogen (Fbg) or fibrin (Fib) is incubated with either human neutrophil elastase (E) or plasmin(P).
fibrinogenand fibrin (Fig. 1).The release of i~~~noreactive materialis fairly slow and increases with time. Releaseof the 13 kd peptide, however, occurs during the first part of the incubation period. When elastase is added to normal plasma (1450 dml), no release of BP 30-43 peptide precursor is obse However, after incubation of neutrophil elastase in al protease inhibitor-deficient plasma, large amounts of the peptide are formed, suggestingthat the release of the peptide is dependent on this natural inhibitor of elastase. Furthermore, a synthetic elastase inhibitor, U 25,651(Stuart Pharmaceuticals), strongly inhibits ehe release of the peptide in vitro (Fig. 2), demonstratitlg specificityof the radioimmunoassay. The antibody has a very low (0. 2%) cross-reactivity with fibrinogen. Cross-reactivity with peptides released by chymotvypsin, collagen, pancreatic elastase, plasmin, thrombin or trypsin is ~0.2%. Figure 2. In vitro release of peptide B/330-43 is inhibited in the presenceof U 25,651,a syntheticinhibitorof elastase;9.4nmol of $asminogen-freefibrinogenwas incubatedat 37°Cwith 460pmol of hunlay neutrophil elastase and various concentrations (Cone) of inhibitor.
JAW Vol. 15, No. 7 June I :1559-63
e 1. Clinical
~~~acte~i~tic§
Hypertension (%) Diabetes mellitus (%j edication* (%) Nitrates Beta-blockers Calcium antagonists Aspirin Heparin (iv) Streptokinase
of Control
COIWOI
Stable
Subjects
Aagina
(n = 22)
rin = 25,
and Stu Lkmlble hgina (n = 79)
AMl In =
879
9 5
16 8
‘1 17
I 2 2.6 41 35 17
14 9 14 9 14 0
60 32 9 48 0 0
16 48 72 66 48 tl
88 47 29 35 53 18
*Medication taken within 24 h of blood collection. AMI = acute myocardial infarction; iv = intwcwusly.
10 1 conlrol subjects
stable angIna patients
unstable engIna
my!xardtet lnltwctlon
patients
patlWltS
30-43 levels in myocardial &hernia. is increased in patients with unstable a yocardial
infarction
as compared
wit
Total leukocyte counts wer aspirin, heparin, beta~adre~er~c blockers, nitrates, calcium channel antagonists or strepto~i~ase, was assessed in the ultiple linear regression. ~onparametric Duskal-Wallis and bang-Whitney tests were then used to corroborate the findings of the al theory tests. Data are expressed as mean values -CS
Patient characteristics and treatments able 1. Approx~~~ately third of all of patients rs. Twenty percent to and the ~ropo~io~ was similar had hype~e~sion or d Iintake of cardiac medication s than in the control group (p < 0.M). Patients in the control group were younger than those in the other study groups (p < 0.05). Analysisof relations among factors such as smoking, hypertension,
control subjects (4.9 -C0.3 x ?+06/ml, p < O.OI for both). Absolute neutrophil counts were unstable angina (6.6 + 0.7 X 10 le angina (p < 0.01) but the ects did not reach statistical There was no significantrelation between pep levels and total leukocyte count
p 30-43 levels over 16h in patients with acute myocardial infarction demonstrated a trend toward a decrease over
1562
JACC Vol. 15. No. 7 June I :1559-63
DINERMAN ET AL. ELASTASE AND ISCHEMIC HEART DISEASE
time. Mean peptide B/3 30-43 levels were 1,420 + 669 pmol/literat admission,1,130f 486pmolfliterat 8 h and898 2 401 pmol/l/terat 16 h for this group. levels were 783 + 570 Wliter at admission, 814 2 331 W/literat 8 h and 1,022+ 441 W/literat 16 h. There was, however, no significantrelationbetweenpeptideB/330-43 levels and serumCK levels at any given timeor overall(I’= 0.15).
values(5-7). Hypertension. diabetes me~~itMs treatments,which ma were also common emphysema aud smokiNg (1,12). 30-43 levels were markedly incr our patientswith unstable angina
NeutroT:& .I(.; i_. Roleof ncutropbi in acute isc myocardiumand in large number resultin capillarypluggingandthe “no reflow” phenomenon mulate
(2,8-1(t). These neutrophils undergo activation in response to complement fragments and release oxygen free radicals, arachidonatemetabolitesand elastase (2). Tissue damage caused by neutrophils during acute ischemic events is characterized by proteolysis secondary to release of granule constituents and free radicals. Specifically, neutrophil elastase has been shown to mediate both degradation of basementmembraneconstituents(2) and damage of endothelium (3). Although much research has focused on the role of neutrophil-derived free radical release, the time course of neutrophil-mediated endothelial damage more closely resembles that of the injury caused by neutrophil elastase than by oxygen free radicals (4). In this context, our observations of significant, severalfold elevations in plasma levels of peptide B/3 30-O soon after the onset of unstable angina or acute myocardial infarction may have important pathophysiologic implications. Relatively higher plasma levels of noted in our patients with unstable angi pared with those with acute myocardial likely due to episodic occlusion and reperfusion of the offending coronary artery (1 I), resulting in repetitive entry of neutrophils into the ischemic myocardium and their activation. In patients with acute myocardial infarction, pharmacologic (in response to streptokinase) or spontaneous reperfusion may cause entry of neutrophils into the ischemic tissues. As our study shows, elastase release gradually declines over the next 8 to 16 h in patients with myocardial infarction, but has no relation to CK release. tiitions of the study. Wide variations in the plasma levels of peptide B/3 30-43 were observed among our study groups, which may relate to the nature of our controlgrou and vagaries inherent in the assignment of clinical labels, such as stable and unstable angina pectotis. Subjects in our control group, with a ~l”re~nage of 54 years and a 32% incidence rate of smoking, are likely to have subclinical cardiovascular or pulmonary disease. Previousnormatvalues for peptideB/330-43 were obtained from normal subjects, rather than our control patients. This and the assignment of a value of 50 pmoYliter to all measurementsc 100
nn deposits where close contact between fiber and elastase may overcome the activity of alohas-protease inhibitor). With one exception, our used for the determination of h derived fibrinopeptide in plasma. a method for determination of peptide A l-21, derived from elastase degradation of fibrino8en. Their method may not be generally useful, however, because the antibodies crossreact with various other molecul Therefore, the peptide has to be is liquid chromatography before it ca AlthoMgb the elevations in peptide BP 30-43 levels in p&ma represent increased formation of unique fibrin or ~~~nogen degradation products through the a&on of neutrophil elastase, whether this increase results from increased substrate (fi-
4. SmedPy LA. ‘Tonnesen
injury lo endothePialse91
endok~in and essemial role OF
~eu~~opb~~elastase. J Clin Invest ~9~6;77:~233-~3. 5.
tin R. Saldeen T. A specific r~~~oirnrnM~l~ss~~y for ~e~errni~a~~~~~of erived From elastase ~legri~da~~o~of hunran ~br~~~ogea]. Acca Univ Ups&asis ~Yg7~1~2:1~26.
6. Saldeen T. Wallin N. A specific ~dioimm~noassay For deterrn~~a~~o~ of peplides drrived From ~~rn~~ leo~~yle elestase degradai~on of human ~br~~~o~e~~ Iabs?rl ~irc~~~l~i~~~ 1987:7fr:snppl BV):!V-339. eh~a J.
ehta P. et al. Neutrophil
Function in ischemic
da R. Leukocyle capiljury sion in the dog. Am J Parbol
Mehia
J. Nichols
CrowelI ED. Rowe GC. Plalelel a~grega~~o~ in partially 365-70. eitz JI. Crowjey KA. Landmaa SL. Lipman t!;ophil clastase activity in smokers. Ann Bmern riiner s. %krrousky !k i_aMie 6. Pinkhas J. Aronson h!. Agmon J. ‘Fhe leubergy lest in pa!ienls whh ischemic heart disease. Am 1986:111:19-22.
. CommerFord PJ. Franks JJ. Kirsch anligens in patients with stable and u disease. PI Engl J Med 19#7:317:1361-5. Mclrta 3. Mehta P. Conti CR. Platelet Function studies in coronary bean disease. X1. increased phclc: pros~~~~~andi~generation and abnormal n~o~r~xi~e analog in angina
disease.
he help of the nurses ary Care Uni LaVernf A.
: current
J Am Co!! Cardiol
Veterans ALfdirs esville. Florida in Iph For assistance
of the prokace-
, ~ee~~erna~ P. Effects of rphree S. Saffitz SE. Jak xane. and ~roslag~a~dios produced leukotrienes. on coronary vascular resistance in rabbit myocardi~l infarction. J Clin lnvesl lY85:75:9Y2-9.
Mehh L. Nichols WW, Doidly W dismufase from myocardial dysfuncti reserve Following coronary occiusion and reperFusion in dog. lYgY:b5:1283-95. hida S. Suzuki K. cl al. PoiymorphonMclear !eUkyle Kuzuya T. trjcuiar arr~y~~m~a in acute myocardial inFarclioa. Am J activity and Cardioi ~9~~~6~~~4K-7~. epine R.Cheronis JC, Sandhaus JE. O2 metaboliles and neu~~opbil elaslilse sy~er~islic~~~y cause edem& tous ifl@q in isolated ral lungs. J Appl Physiol ~9~6~6~:~~~4-9.
