Journal of American Science

2010; 6(12)

Modulating Effect of Carvedilol on Doxorubicin-Induced

Cardiomyopathy and Hepatic Damage
Safinaz S. Ibrahim*, Maged A. Barakat and HebaTullah S. Helmy
Biochemistry Department, Faculty of Pharmacy, Cairo University, Cairo, Egypt
* dr_safinaz_747@hotmail.com
Abstract: Background: Doxorubicin is an anthracyclin antibiotic that is considered as one of the most effective
antitumor agents. The clinical use of doxorubicin soon proved to be hampered by such serious problems as
hepatotoxicity and most notably cardiomyopathy. Objectives: The current study aims at evaluating the efficiency of
carvedilol as an adjuvant therapy with doxorubicin to protect against doxorubicin - induced cardiomyopathy and
hepatic damage. Materials and Methods: Animals were divided into normal group and doxorubicin -treated group
injecting doxorubicin as a dose of 2.5 mg/kg/twice weekly/ 3 weeks. Doxorubicin - treated animals were divided
into two groups, one kept without further treatment (doxorubicin group) and second group, (doxorubicin +
carvedilol), received carvedilol 1mg/kg/ 7 times over a period of 4 weeks including a dose before doxorubicin 1st
dose. Creatine phosphokinase, lactate dehydrogenase, as cardiac damage markers, and alanine aminotransferase, as
indicator of hepatic damage, were measured. Malondialdehyde and nitric oxide levels, as cardiac oxidative status
indices, glutathione content, glutathione peroxidase, glutathione-Stransferase and superoxide dismutase activities,
as measures for cardiac antioxidant capacity, were also investigated. Histopathological changes in cardiac and
hepatic tissues of all groups were examined. Results and Conclusions: Our results revealed that doxorubicin caused
oxidative stress which plays a major role in doxorubicin -induced cardiomyopathy and hepatic damage. Coadministration of carvedilol in concomitant with doxorubicin caused protection against doxorubicininduced
cardiomyopathy; however, it augmented doxorubicin -induced hepatic damage. Histopathological examination of
cardiac and hepatic tissues supported the previous biochemical results. [Journal of American Science.
2010;6(12):20-32]. (ISSN: 1545-1003).
Keywords: Doxorubicin, carvedilol, cardiomyopathy, hepatic damage.
was examined in a variety of in vitro and in vivo assay
systems, including physicochemical, biochemical and
cellular models. The data indicate that carvedilol
prevents electron adduct formation in both aqueous or
lipid environments containing either superoxide- or
hydroxyl-radical
generating
systems
(10).
Furthermore, carvedilol and several of its metabolites
are as effective in inhibiting lipid peroxidation in brain
and heart membranes (11). The cardioprotective effect
of carvedilol has been shown in a variety of in vitro
and in vivo models. The efficacy of carvedilol has
been observed with anthracyclin cardiomyopathy and
ischemia/ reperfusion (12). One most likely
mechanism of cardioprotection by carvedilol is the
antioxidant effect (13-15).
The current study aims at evaluating the
efficiency of carvedilol as a protective agent against
cardiomyopathy and hepatic damage induced by Dox.

1. Introduction
Almost all clinically used antitumor drugs
exhibit toxic side effects affecting heart function.
Because of cardiotoxicity during anticancer
chemotherapy, effective doses of cytostatics have to
be limited, which may worsen antitumor efficacy.
Doxorubicin (Dox) is an anthracyclin antibiotic that is
considered as one of the most effective antitumor
agents. Dox is an essential component of treatment of
breast cancer (1), soft tissue sarcomas (2) and many
other cancers (3). The immense value of Dox in
treating a variety of malignant conditions is
unquestioned. However, the clinical use of Dox soon
proved to be hampered by such serious problems as
the development of resistance in tumor cells (4) and
toxicity in healthy tissues, in the form of central
nervous system toxicity (5), nephrotoxicity (6) and
most notably in the form of cardiomyopathy and
congestive heart failure (7). These adverse effects of
the drug can preclude its use in some patients and
limit the duration of its use in many others (8).
Carvedilol is non cardioselective -blocker
which lacks intrinsic sympathomimetic activity. In
addition, it has blocking effects at vascular 1receptors, antioxidant, and calcium antagonist
properties (9). The antioxidant activity of carvedilol

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2. Materials and Methods:

A- Animals:
We used a total of 32 male albino rats of the
Wister strain, weighing 170-200 g, that were obtained
from the central animal facility at the Faculty of
Pharmacy, Cairo University, Cairo, Egypt. All rats
were housed in a room with a controlled environment,

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Journal of American Science

2010; 6(12)

at a constant temperature of 23 10 C, humidity of

60% 10%, and a 12 hr light/dark cycle. The animals
were housed in groups and kept at constant nutritional
conditions throughout the experimental period. The
experimental protocols were approved by the Ethical
Committee of Faculty of Pharmacy, Cairo University.

prepared for sectioning at 4 microns thickness by

sledge microtome. The obtained tissue sections were
collected on glass slides, deparaffinized and stained by
hematoxylin
and
eosin
stains
(21)
for
histopathological
examinations
using
light
microscope.

B- Drugs and chemicals:

Doxorubicin HCL was obtained from
Pharmacia & Upjohn, Milan, Italy. Carvedilol was
obtained from Cadila Pharmaceuticals Limited, India.
Other chemicals in the experiments were of analytical
pure grade and supplied by British Drug House (BDH,
UK) and Sigma Chemical Company (USA).

Biochemical parameters:
The remainder of heart tissue of each rat was
weighed and homogenized in ice-cold saline for 1
minute, using an ice-cold Potter Elvejhem glass
homogenizer, forming 10% w/v homogenate.
Estimation of cardiac glutathione (GSH) content
A portion of homogenate was mixed with
ice-cold 7.5% sulfosalicylic acid in a ratio 1:1 and
centrifuged at 3000 r.p.m/15 minutes. The resulted
supernatant was used for the determination of GSH
(22), depending on the reaction between GSH and 5,
5'- dithio-bis, 2-nitrobenzoic acid to yield a stable
yellow
colour
which
can
be
measured
colourimetrically.

C- Experimental design:
Animals were divided into a normal control
group (10 rats), receiving the appropriate volume of
saline i.p, and Dox-treated group (22 rats). Dox was
dissolved in saline and injected i.p. as total cumulative
dose of 15 mg/kg, divided into 6 equal doses, each of
2.5 mg/kg. They were injected twice weekly/ 3 weeks
(16). The Dox-treated animals were divided into two
groups, one was kept without further treatment termed
Dox-group(12 rats), and a second group (10 rats),
termed Dox + carvedilol group, received carvedilol as
an i.p dose of 1mg/kg / 7 times over a period of 4
weeks including a dose before the 1st Dox dose (17).

Estimation of cardiac malondialdehyde (MDA)

level:
Another portion of homogenate was mixed
with ice-cold 2.3% KCL (1:1), centrifuged at 3000
r.p.m/15 minutes. The level of MDA was determined
in the supernatant depending on measuring the
coloured complex formed between thiobarbituric acid
reagent and MDA in acidic medium (23).

D- Serum and Tissue sampling:

Twenty four hours following the last Dox
injection, rates were sacrificed by decapitation. A
blood sample of each animal was collected into a dry
centrifuge tube. Serum was separated by
centrifugation at 3000 r.p.m/15 minutes and used to
determine creatine phosphokinase (CPK), lactate
dehydrogenase (LDH) and alanine aminotransferase
(ALT). Serum CPK activity was determined using a
kit provided by STANBIO, USA (18). Serum LDH
activity was determined using a kit provided also by
STANBIO, USA (19). Serum ALT activity was
determined, using kit provided by Quimica Clinica
Aplicada, Spain (20).
For determination of the biochemical
parameters and histopathological changes, hearts and
livers were removed by dissection, washed by ice-cold
saline and blotted between filter papers.

Preparation of cytosolic fraction for the estimation

of glutathione peroxidase (GPx), glutathione-S
transferase (GST) and superoxide
dismutase
(SOD) activities:
Part of the homogenate was mixed with equal
volume of ice-cold Tris- EDTA buffer (pH=7.6),
centrifuged at 39.000 r.p.m/4C/ 20 minutes. The
resulted supernatant was used for the determination of
GST; GPx and SOD activities. Determination of GST
activity (24, 25) depends on the ability of GST to
catalyze the formation of GSH- adduct with 1-chloro2,4- dinitrobenzene(CDNB). This adduct was
measured by noting the net increase in absorbance at
340 nm. Determination of GPx activity (26) is based
on following the rate of oxidation of GSH by H2O2 in
the presence of GPx. Oxidized GSH was determined
by following up the decrease in absorbance of the
reaction medium at 340 nm, as NADPH was
converted to NADP. SOD activity was determined
(27) depending on the fact that the spontaneous
autoxidation of pyrogallol, at alkaline pH less than
9.5, produces superoxide anion, which in turn
enhances further oxidation of pyrogallol with a
resultant increase in the absorbance at 420 nm. The

Histopathological study:
Samples were taken from hearts and livers of rats in
different groups and fixed in 10% formol saline for 24
hours. Washing was done in tap water, then serial
dilutions of alcohol (methyl, ethyl and absolute ethyl)
were used for dehydration. Specimens were cleared in
xylene, embedded in paraffin at 56O C in hot air oven
for 24 hours. Paraffin bees wax tissue blocks were

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Journal of American Science

2010; 6(12)

presence of SOD in the reaction medium inhibits

pyrogallol autoxidation by scavenging the formed
superoxide anion. Protein content of the supernatant
was determined (28) using bovine serum albumin as
standard.

Table (2) illustrated that, Dox caused

significant increase in MDA and NO levels amounting
to 183.36% and 177.7%, respectively, of the control
values.
Carvedilol
co-administration
caused
normalization of both MDA and NO levels.

Estimation of nitric oxide (NO) (NO2- / NO3-):

An aliquot of the homogenate was
centrifuged at 17.000 r.p.m/ 4C/ 20 minutes. The
resulted supernatant was used for the determination of
NO. Determination of NO radical itself is difficult
because of its radical nature and very short half-life.
Therefore, determination of the stable oxidation
products of NO radical, nitrite (N02-) and nitrate (N03-)
concentrations is used as a measure for the production
of NO radical. NO content was determined (29, 30)
depending on the colourimetric detection of nitrite
with Griess reagent after the enzymatic reduction of
nitrate to nitrite using nitrate reductase enzyme. The
Griess reaction involves the reaction of nitrite with
sulfanilamide in an acidic solution to yield a
diazonium salt, followed by coupling with N-(1naphthyl) ethylenediamine to yield a colored azo dye
that can be measured colourimetrically at 540 nm.

Effect of doxorubicin (Dox), separately or in

combination with carvedilol,
on cardiac
glutathione (GSH) content, glutathione peroxidase
(GPx), glutathione-S-tranferase (GST) and
superoxide dismutase (SOD) activities in rats:
As shown in table (3), Dox administration
caused a significant decrease in cardiac GSH level
reaching to 64% of the normal value. Coadministration of carvedilol significantly raised GSH
content to about 92% compared to the control value.
Results of the same table showed significant increase
in cardiac activities of GPx, GST and SOD in the
Dox-treated rats amounting to 410%, 184% and
225%, respectively, compared to the normal values.
Co-administration
of
carvedilol
produced
normalization of GST and significant decrease in GPx
and SOD activities, accounting to157%, 151%
respectively, compared to the control values.

Statistical analysis
Results were analyzed statistically by oneway analysis of variance (ANOVA test) with
subsequent multiple comparisons using Tukey test.
Differences were considered statistically significant at
p less than 0.05. Results are presented as the mean
standard error of the mean (SEM), with the number of
observations (n) given in parentheses. All data
obtained were submitted to a computerized statistical
treatment using SPSS statistical package, version 17.
Tables were represented by Microsoft Excel computer
program.

Effect of doxorubicin (Dox), separately or in

combination with carvedilol, on serum alanine
aminotransferase (ALT) activity in rats:
Results of table (4) revealed that Dox
administration caused significant elevation in the
serum ALT level to reach 118% of the normal value.
Co-administration of carvedilol caused significant
elevation in the same enzyme level compared to both
Dox-treated and normal group values, reaching
128.8% of the normal control level.
Histopathological examination of the cardiac
tissues:
Histopathological examination of the control
cardiac section showed normal structure of the
myocardium (Figure 1). Sections obtained from rats
administrated Dox showed hyalinization the
myocardial
bundles
associated
with
either
inflammatory cells infiltration only or inflammatory
cells and oedema in focal manner in between the
bundles (Figures 2, 3). With respect to cardiac
sections obtained from rats administrated combined
therapy of Dox+ carvedilol, no histopathological
alterations, compared to normal section, were
observed (Figure 4).

3. Results:
Effect of doxorubicin (Dox), separately or in
combination with carvedilol, on serum lactate
dehydrogenase (LDH) and creatine phosphokinase
(CPK) activities in rats:
Results of table (1) revealed that Dox caused
significant increase in serum levels of LDH and CPK
amounting to 182.4% and 183.6%, respectively, as
compared to the normal values. Carvedilol coadministration caused normalization of LDH as well
as significant decrease in CPK serum levels reaching
119.4% of the control value.
Effect of doxorubicin (Dox), separately or in
combination with carvedilol,
on cardiac
malondialdehyde (MDA) and nitric oxide (NO)
levels in rats:

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Histopathological examination of hepatic tissues:

Examination of liver sections of the different
groups illustrated that liver tissue of the normal group
showed hepatic lobules with normal architecture
(Figure 5). In case of liver sections of rats

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2010; 6(12)

administrated Dox, congestion was observed in the

central vein in addition to kupffer cells proliferation in
diffuse manner between the fatty degenerated
hepatocytes (Figures 6, 7). In rats administrated Dox +
carvedilol, livers were most affected, congestion was

observed in both the central and portal veins

associated with diffuse kupffer cells proliferation in
between the hepatocytes. Moreover, the portal area
showed inflammatory cells infiltration (Figures 8, 9).

Table (1): Effect of doxorubicin, separately or in combination with carvedilol, on serum lactate dehydrogenase
(LDH) and creatine phosphokinase (CPK) activities in rats:
Group
LDH( U/L)
CPK(U/L)
Control
581.1713 (9)
616.520.8 (9)
Doxorubicin
1060.229.4 a, c (10)
1131.932 a, c (10)
Doxorubicin + Carvedilol
598.523.6 b (9)
736.341.2 a, b (9)
Values are given as means SEM (No. of observations are given in parentheses)
a: Significant difference from control group at P<0.05
b: Significant difference from doxorubicin group at P<0.05
c: Significant difference from doxorubicin+
carvedilol group at P<0.05
Table (2): Effect of doxorubicin, separately or in combination with carvedilol, on cardiac malondialdehyde
(MDA) and nitric oxide (NO) levels in rats:
Group
MDA nmole /gm tissue
NO nmole / gm tissue
Control
57.61.9 (9)
17511 (9)
Doxorubicin
105.84.6 a, c (10)
31118 a, c (10)
Doxorubicin + Carvedilol
59.13.5 b (9)
1848 b (9)
Values are given as means SEM (No. of observations are given in parentheses)
a: Significant difference from control group at P<0.05
b: Significant difference from doxorubicin group at P<0.05
c: Significant difference from doxorubicin + carvedilol group at P<0.05
Table (3): Effect of doxorubicin, separately or in combination with carvedilol, on cardiac glutathione (GSH) content,
glutathione peroxidase (GPx), glutathione-S-tranferase (GST) and superoxide dismutase (SOD) activities in rats:
GSH
GPx
GST
SOD
Group
g/gm tissue
nmoles /min /mg protein
nmoles /min/mg protein U/mg protein
Control
64.31.5 (9)
33.61.9 (9)
29.61.0 (9)
21.31.4 (8)
Doxorubicin
41.21.1a,c (9)
137.87.1a,c (10)
54.72.9a,c (9)
48.12.2a,c (10)
Doxorubicin +Carvedilol
59.72.0a,b (9)
53.02.7a,b (8)
36.61.59 b (9)
32.31.8a,b (9)
Values are given as means SEM (No. of observations are given in parentheses)
a: Significant difference from control group at P<0.05
b: Significant difference from doxorubicin group at P<0.05
c: Significant difference from doxorubicin + carvedilol group at P<0.05
Table (4): Effect of doxorubicin, separately or in combination with carvedilol, on serum alanine aminotransferase
(ALT) activity in rats:
Group
ALT (U/L)
Control
52.41.8 (9)
Doxorubicin
60.21.5a,c (10)
Doxorubicin + Carvedilol
69.62.6a,b (9)
Values are given as means SEM (No. of observations are given in parentheses)
a: Significant difference from control group at P<0.05
b: Significant difference from doxorubicin group at P<0.05
c: Significant difference from doxorubicin + carvedilol group at P<0.05

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2010; 6(12)

Figure(3): A photomicrograph of cardiac muscle

fibers of Dxo group showing oedema(o)
with inflammatory cells infiltration
(arrow) in focal manner between the
myocardial bundles (h). (H&E 160)

Figure(1): A photomicrograph of cardiac muscle

fibers of control group showing normal
histological structure of myocardium(M)
(H&E 160)

Figure(4): A photomicrograph of cardiac muscle

fibers of Dox+ carvedilol group showing
intact
histological
structure
of
myocardium (m) (H&E 160)

Figure(2): A photomicrograph of cardiac muscle

fibers of
Dox group showing the
inflammatory cells infiltration (arrow)
inbetween
the
hyalinized
myocardial
bundles(h) (H&E 160)

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2010; 6(12)

Figure(5): Photomicrograph of liver of normal group

showed hepatic lobules (h) and portal vein (p)
with normal architecture (H&E 64)

Figure(7): Photomicrograph of liver of Dox

group showing
diffuse kuffer cells
proliferation (k) inbetween the fatty
degenrated hepatocytes (arrow) (H&E
160)

Figure(6): Photomicrograph of liver of Dox group

showing congestion in central vien(c) (H&E
64)

Figure(8 ): Photomicrograph of liver of Dox +

carvedilol group showing congestion in
the central (c) and portal(p) viens. (H&E
64)

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2010; 6(12)

Figure(9): Photomicrograph of liver of Dox +

carvedilol group showing inflammatory
cells infiltration in the portal area (m)
around the portal vein (p) with diffuse
kuffer cells proliferation (k) inbetween the
hepatocyte. (H&E 160)

cardiomyocyte apoptosis or death (39). This effect

would compromise the cellular integrity and
potentially account for the leakage of heart enzymes,
LDH and CPK, through the membranes and increase
their serum activity.
Regarding the effect of Dox administration
on cardiac oxidative status, Dox caused significant
increase in MDA level (table 2), which is in
agreement with previous study (40) who used similar
drug regimen. This elevation might be attributed to
Dox mediated oxidative stress. The first targets of
Dox-mediated free radical damage are various cellular
membranes, which are rich in lipids prone to
peroxidation. This radical damage results in
production of many relatively stable and highly toxic
aldehydes, such as MDA. These aldehydes can easily
diffuse within the cell, or even cross the plasma
membrane, and attack macromolecular targets far
from where they were generated and thus act as
second cytotoxic messengers (41). Table (2)
revealed also a marked increase in cardiac NO level in
those rats received Dox. This finding is in harmony
with previous study (42), which used a model of Doxinduced cardiomyopathy similar to that used in our
study. The increase in NO level can be explained on
the basis of the ability of Dox to mediate the induction
of nitric oxide synthase (NOS) expression and, hence,
NO release in heart (43). Previous studies suggested
that stimulation of endothelial cells with calciummobilizing agents activates and dissociates the
membrane-bound eNOS (44). Because Dox-induced
toxicity is mediated by intracellular H2O2 as well as
calcium influx, Dox treatment causes an increase in
eNOS transcription and protein activity in aortic
endothelial cells and thus NO synthesis.
Dox administration, as shown in table (3),
caused a significant decrease in cardiac GSH content,
which is quiet compatible with previous studies (40,
45). The overproduction of ROS, caused by Dox
administration, can account for this decrease in GSH

4. Discussion:
Doxorubicin (Dox) is a potent anticancer
drug that is used in treating both hematological and
solid tumors. However, severe cardiomyopathy and
heart failure have been observed in Dox-treated cancer
patients, which limit the clinical dosage of Dox in
cancer treatments (31). Oxidative stress is generally
held as the mediating mechanism in the multiple
biological processes leading to Dox cardiomyopathy,
e.g. redox mediated superoxide radical production
(32), tissue-specific mitochondrial DNA damage (33)
and disturbances of calcium (34) or iron (35). Results
of the present study revealed that 15 mg/kg total
cumulative dose of Dox induced cardiomyopathy and
hepatotoxicity manifested biochemically as significant
increase in serum levels of LDH; CPK and ALT. In
addition, Dox caused elevation in cardiac NO, MDA
levels, SOD, GPx, GST activities, and reduction in
GSH content. Histopathological examination of heart
and liver sections of Dox-treated animals supported
these biochemical results.
Results of table (1) revealed that Dox caused
significant increase in the serum levels of LDH and
CPK, considered as important markers of cardiac
injury. Many previous studies have demonstrated
similar elevations in cardiac enzymes activities in rats
following Dox administration (36, 37). Leakage of
cardiac enzymes directly correlates to ultrastructure
damage of heart tissues examined by electron
microscope. Dox-induced cardiomyopathy is mainly
attributed to increase oxidant production in heart.
Dox may undergo a one-electron reduction through a
metabolic activation by NADPH-cytochrome P-450
reductase. This reduction leads to the formation of the
free radical semiquinone, which in turn can produce a
variety of active ROS/RNS, including H2O2, OH and
ONOO (38). These species can attack the
cardiomyocyte
membrane,
damage
several
macromolecular cellular components, cause protein
and lipid peroxidation and consequently lead to

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2010; 6(12)

content, as these species are detoxified by endogenous

antioxidants mainly GSH causing their cellular stores
to be depleted (46). The observed decrease of cardiac
GSH content may also be attributed to the enhanced
activities of GSH metabolizing enzymes, as shown in
the present study. One is GPx which reduces H2O2 and
various peroxides using GSH as reducing agent, the
other is GST which consumes GSH in the conjugation
of Dox toxic metabolites (47).
Table (3) showed, also, significant increase
in cardiac activity of SOD in the Dox-treated rats,
which is consistent with some studies (40, 48). The
increase in SOD activity can be explained on the basis
that the redox cycling of Dox between quinone and
semiquinone forms generates large amounts of O2
(38), which in turn stimulate SOD as an adaptive
response to counteract oxidative stress (49). Also, it
was previously showed that ROS can upregulate and
induce the synthesis of SOD protein (50). The
observed increase in SOD activity might lead to
overproduction of hydroperoxides. In consequence,
cardiac GPx activity might be stimulated in response
to the accumulated peroxides which can subsequently
lead to the formation of highly toxic OH radical
through Fenton reaction catalyzed by iron (51). This
assumption was supported by our results which
showed a significant enhancement in cardiac GPx
activity in the Dox-treated group. Another assumed
explanation for such increased GPx activity is that
multiple doses of Dox alter the activities of
antioxidant enzymes in the heart so as to protect
against Dox cardiotoxicity (42, 49). Additionally, GPx
have been reported to be over expressed in Doxtreated cells, especially those tumor resistant ones
(52). This can be considered as intracellular
detoxification process for free radical end products
(53). In our study, we assumed that this detoxification
mechanism can occur also in cardiac myocytes,
exposed to Dox administration, to prevent the
accumulation of peroxides and the propagation of
peroxidation. Table (3), additionally, revealed
significant increase in cardiac GST activity in rats
treated with Dox, which is in agreement with
previously reported results (54). The increase in
cardiac GST activity might be related to the fact that
GSTs are family of dimeric proteins that posses a
multitude of functions including the enzymatic
conjugation of GSH to electrophilic xenobiotics (55).
It has been reported that cellular exposure to
xenobiotics and antioxidants leads to coordinated
induction of a battery of genes encoding detoxifying
enzymes including GST (56). Indeed, it has been
known that Dox is metabolized, via alkedoreductases,
yielding C13 hydroxyl derivative, doxorubicinol. This
metabolite is actually more polar and toxic than Dox
itself. Doxorubicinol accumulates in the heart and

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contributes significantly to chronic cumulative

cardiotoxicity induced by Dox (57). In brief, GST has
showed elevation after Dox injection to detoxify Dox
and its metabolites and to attenuate the elevated
oxidative stress (58). Moreover, Dox-treated cancer
cell lines often show elevated GST expression and
activity, which is in consistence with our result. Such
increased activity of GST enzyme almost certainly
leads to increased resistance to Dox treatment, and
hence, creation of one of the most problems of Dox
therapy (59).
Our results showed also an elevation in
serum ALT upon Dox administration (table 4). This
result agrees with previous study (60). Leakage of
hepatic ALT into the serum is due to Dox-induced
oxidative damage to hepatocytes (61). Dox-induced
hepatotoxicity may be less severe than its
cardiotoxicity. This can be related to the fact that liver
mitochondria, unlike cardiac mitochondria, lack the
NADH-related pathway of reducing equivalents from
the cytosol to the respiratory chain, as a result, liver
mitochondria do not generate significant amounts of
Dox semiquinones (62).
The previously mentioned biochemical
results produced by Dox administration are supported
by the obtained cardiac histopathological results
which showed that in the cardiac sections of the Doxtreated rats, serious morphological changes were
observed in the myocardium. Also, the examination of
liver sections of the same group illustrated that
congestion was observed in the central vein in
addition to kupffer cells proliferation in diffuse
manner between the fatty degenerated hepatocytes.
From the previously mentioned discussion, it
has been well established that oxidative stress plays a
major role in Dox-induced cardiomyopathy and
hepatotoxicity. Thus, the importance of antioxidant
co-administration as an adjuvant therapy with Dox in
preventing these damages has been emphasized.
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27

editor@americanscience.org

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5. References:
1
. Bo
na
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l
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a P: Se
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na
nd CMF r
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g
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me
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n
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hmo
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v
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r
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p
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fe
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t
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eDW,Ho
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mi
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:
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4
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4
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l
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s wi
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r
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.
Br J Cancer 2000;
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n. J.
Neurochem. 2
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o
lv
sme
t
o
p
r
o
l
o
li
n pa
t
i
e
nt
s
wi
t
ht
y
p
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i
a
b
e
t
e
sme
l
l
i
t
u
sa
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p
e
r
t
e
ns
i
o
n:a
r
a
nd
o
mi
z
e
dc
o
nt
r
o
l
l
e
dt
r
i
a
l
.JAMA. 2
0
0
4;292:
2
2
2
7

3
6
1
2
.Sp
a
l
l
a
r
o
s
s
aP,Ga
r
i
b
a
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d
iS,Al
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i
e
r
iP:Ca
r
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e
di
l
o
l
p
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e
v
e
nt
sd
o
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b
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c
i
ni
nd
u
c
e
df
r
e
er
a
d
i
c
a
lr
e
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e
a
s
e
a
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p
o
p
t
o
s
i
si
nc
a
r
d
i
o
my
o
c
y
t
e
si
nv
i
t
r
o
.J. Mol.
Cell. Cardiol.2
0
0
4
;3
7
(
4
)
:
8
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1
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s
a
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Ca
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l
o
l
d
e
c
r
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v
a
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e
do
x
i
d
a
t
i
v
es
t
r
e
s
si
n huma
n

5. Conclusion:
Ox
i
da
t
i
v
es
t
r
e
s
spl
a
y
sama
j
o
rr
o
l
ei
nDo
x
i
nd
u
c
e
d c
a
r
d
i
o
my
o
pa
t
hy a
nd he
p
a
t
i
c d
a
ma
g
e
.
Ca
r
v
e
d
i
l
o
l c
o
ul
d e
f
f
e
c
t
i
ve
l
y a
t
t
e
nu
a
t
e t
he
c
a
r
d
i
o
my
o
c
y
t
eda
ma
gec
a
us
e
dbyDo
xa
se
v
i
d
e
nc
e
d
b
y t
he b
i
o
c
he
mi
c
a
l me
a
s
u
r
e
me
nt
s a
nd
h
i
s
t
o
p
a
t
ho
l
o
g
i
c
a
le
xa
mi
na
t
i
o
n o
fc
a
r
di
a
ct
i
s
s
u
e
.
Unf
o
u
r
t
i
o
nt
l
y
,c
a
r
v
e
di
l
o
la
ugme
nt
e
d Do
x
i
nd
u
c
e
d
he
p
a
t
i
c d
a
ma
ge a
se
v
i
de
nc
e
d by t
he p
r
e
s
e
nt
b
i
o
c
he
mi
c
a
l r
e
s
ul
t a
nd t
he hi
s
t
o
pa
t
ho
l
o
g
i
c
a
l
e
x
a
mi
n
a
t
i
o
no
ft
hehe
p
a
t
i
ct
i
s
s
ue
.
Competing Interests:
The a
u
t
ho
r
s de
c
l
a
r
et
ha
tt
he
y ha
v
e no
c
o
mp
e
t
i
ngi
n
t
e
r
e
s
t
s
.
Authors' Contributions:
SSI
:pa
r
t
i
c
i
pa
t
e
di
nde
s
i
gni
ngt
hep
o
i
nto
f
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s
e
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c
ha
ndt
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a
no
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he
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a
c
t
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x
pe
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s
; r
e
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e
we
d t
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t
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s
t
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y
s
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s
;p
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c
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na
na
l
y
s
i
sa
ndi
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e
t
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s
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o
n
t
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ep
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l
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s
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d.
MMB:p
a
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c
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pa
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di
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gni
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e
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e
a
r
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h
a
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a
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r
s
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o
b
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u
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l
i
s
he
d
.
HSH: c
a
r
r
i
e
do
ut t
he e
xpe
r
i
me
nt
a
l wo
r
k
sa
nd
p
e
r
f
o
r
me
dt
hes
t
a
t
i
s
t
i
c
a
la
na
l
y
s
i
s
.
Acknowledgements:
Wea
r
et
ha
nkf
ult
o Dr
.Mo
ha
me
d A Al
i
,
As
s
i
s
t
a
ntp
r
o
f
e
s
s
o
ro
fHi
s
t
o
l
o
gy
,Fa
c
ul
t
yo
fMe
d
i
c
i
ne
,
Ca
i
r
oUni
v
e
r
s
i
t
y
,f
o
rhi
sp
r
o
f
e
s
s
i
o
na
lhe
l
pi
nc
a
r
r
y
i
ng
o
u
tt
heh
i
s
t
o
p
a
t
ho
l
o
gi
c
a
le
xa
mi
na
t
i
o
n.
Corresponding author
Sa
f
i
na
zS.I
b
r
a
hi
m
Bi
o
c
he
mi
s
t
r
yDe
pa
r
t
me
nt
,Fa
c
ul
t
yo
fPha
r
ma
c
y
,
Ca
i
r
o
Uni
v
e
r
s
i
t
y
,Ca
i
r
o
,Egy
pt

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:
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2
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2
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;6(
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f
a
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l
i
ng my
o
c
a
r
di
um. Circulation.200
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0
5
:
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6
7
2
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71.
1
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e Gr
o
o
tAA,Ma
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b
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v
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l
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nt
her
a
t
a
o
r
t
a
.
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.
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5
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o
r
d
a
noFJ
:Oxy
ge
n,o
xi
da
t
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s
s
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x
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1
5
:5
0
0
5
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8
.
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6
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t
s
u
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r
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s
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maI
,Numa
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ns
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nd
u
c
e
d
c
a
r
d
i
o
my
o
pa
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t
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r
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,Le
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c
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a
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a
l
k
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ne
t
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c Me
t
ho
d f
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r t
he
De
t
e
r
mi
na
t
i
o
no
fSe
r
um CPK.J Lab Clin Chem.
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9
7
7
;2
3
:
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1
9
.Bu
hlSN ,
J
a
c
ks
o
nKY:Ki
ne
t
i
cMe
t
ho
df
o
rt
he
De
t
e
r
mi
na
t
i
o
no
fSe
r
um LDH.Clin Chem.1
9
7
8
;
2
4
:
8
2
8
8
32.
2
0
.Re
i
t
ma
n,
Sa
ndFr
a
nke
l
,
S:A c
o
l
o
r
me
t
r
i
cme
t
ho
d
f
o
r t
he de
t
e
r
mi
na
t
i
o
n o
fs
e
r
um g
l
u
t
a
mi
c
o
x
a
l
o
a
c
e
t
i
c a
c
i
d a
nd gl
ut
a
mi
c p
y
r
u
v
i
c
t
r
a
ns
a
mi
na
s
e
s
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.Ba
nc
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o
f
tJ
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e
v
e
nsA,Tur
ne
rD:The
o
r
ya
nd
p
r
a
c
t
i
c
eo
fhi
s
t
o
pa
t
ho
l
o
gi
c
a
lt
e
c
hni
que
s
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c
hi
l Li
v
i
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t
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ne
, Ne
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u
t
l
e
rE,Dur
o
nO,Ke
l
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yB:I
mpr
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v
e
dme
t
ho
d
f
o
rt
hed
e
t
e
r
mi
na
t
i
o
no
fb
l
o
o
dgl
ut
a
t
hi
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ne
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y
a
ma M,
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r
a M: De
t
e
r
mi
na
t
i
o
n o
f
ma
l
o
nd
i
a
l
de
hude pr
e
c
ur
s
o
r i
n t
i
s
s
u
e
s b
y
t
hi
o
b
a
r
b
i
t
ur
i
ca
c
i
dt
e
s
t
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.Ha
b
i
gW,Pa
b
s
tM,J
a
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b
yW:Gl
ut
a
t
hi
o
neSt
r
a
ns
f
e
r
a
s
e
: The f
i
r
s
t e
nz
y
ma
t
i
c s
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e
p i
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r
c
a
p
t
u
r
i
ca
c
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df
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r
ma
t
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i
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nd
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t
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lt
r
e
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t
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dr
a
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t
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l
i
a DE,
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t
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udi
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n t
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e
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rs
u
p
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r
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x
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mu
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e
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.
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.Lo
wr
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e
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ughNJ
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r
rAL,Ra
na
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RJ
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ur
e
me
ntwi
t
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hef
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9
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.Eur Heart J. 2006;
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