Beneficial effects of polyphenols on cardiovascular disease

Pharmacological Research 68 (2013) 125–131 Contents lists available at SciVerse ScienceDirect Pharmacological Research journal homepage: www.elsevier.com/locate/yphrs Review Beneficial effects of polyphenols on cardiovascular disease Mar Quiñones a , Marta Miguel b,∗ , Amaya Aleixandre a a b Department of Pharmacology, Faculty of Medicine, Universidad Complutense de Madrid, Avda. Complutense s/n, 28040 Madrid, Spain Institut of Food Science Research, (CSIC-UAM, CEI UAM+CSIC), C/Nicolás Cabrera, 9, 28049 Madrid, Spain a r t i c l e i n f o Article history: Received 19 April 2012 Received in revised form 15 October 2012 Accepted 30 October 2012 Keywords: Cardiovascular disease Polyphenols a b s t r a c t In recent years, numerous studies have demonstrated the health benefits of polyphenols, and special attention has been paid to their beneficial effects against cardiovascular disease, the leading cause of death in the world today. Polyphenols present vasodilator effects and are able to improve lipid profiles and attenuate the oxidation of low density lipoproteins. In addition, they present clear anti-inflammatory effects and can modulate apoptotic processes in the vascular endothelium. It has been suggested that most of these effects are a consequence of the antioxidant properties of polyphenols, but this idea is not completely accepted, and many other mechanisms have been proposed recently to explain the health effects of these compounds. In fact, different signaling pathways have been linked to polyphenols. This review brings together some recent studies which establish the beneficial properties of polyphenols for cardiovascular disease and analyzes the mechanisms involved in these properties. © 2012 Elsevier Ltd. All rights reserved. Contents 1. 2. 3. 4. 5. 6. 7. 8. Introduction: polyphenols and cardiovascular disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Vasodilator effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anti-inflammatory effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Antiatherogenic effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Antithrombotic effect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Effect on apoptosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other beneficial effects of polyphenols on health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. Introduction: polyphenols and cardiovascular disease Cardiovascular disease is the leading cause of mortality in the world today. According to World Health Organization data published in September 2009, 17.5 million people died as a result of cardiovascular disease in 2005, representing 30% of the total number of deaths registered worldwide. It is estimated that by 2015, approximately 20 million people will die annually of this disease. Phenolic compounds form the largest group of non-energetic substances present in foods of plant origin. In the last few years, a diet rich in plant polyphenols has been shown to improve health and to decrease the incidence of cardiovascular disease [1,2]. ∗ Corresponding author at: Instituto de Investigación en Ciencias de Alimentación (CIAL, CSIC-UAM), C/Nicolás Cabrera, 9, 28049 Madrid, Spain. Tel.: +34 91 0017931; fax: +34 91 0017905. E-mail address: [email protected] (M. Miguel). 1043-6618/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.phrs.2012.10.018 125 126 127 128 128 128 129 129 129 129 The ability of polyphenols to modulate the activity of various enzymes and thus to interfere in signaling mechanisms in various cellular processes may be ascribed in part to the physiochemical properties of these compounds that allow them to participate in different metabolic cellular oxidation–reduction reactions. Therefore, the antioxidant properties of polyphenols may explain some of their beneficial effects. Polyphenols are the most abundant antioxidants in the diet; their intake is 10 times greater than that of vitamin C and 20 times that of vitamin E or the carotenoids [3]. Some foods such as tea, wine and cocoa are extremely rich in polyphenols, and the polyphenols contained in these foods are highly effective as antioxidant defenses [4]. Animal and clinical experiments have shown that polyphenols decrease cardiac levels of reactive oxygen species (ROS) and malondialdehyde (MDA), a metabolite which forms when ROS and oxidized low density lipoproteins (LDL) attack fatty acids in cell membranes [5,6]. Flavonoids such as catechin or quercetin may directly capture ROS, such as O2 , H2 O2 [7] or HClO [8]. Quercetin and M. Quiñones et al. / Pharmacological Research 68 (2013) 125–131 126 A O+ OH OH R+ OH RH O O+ OH R+ OH RH polyphenols is poorly conserved following digestion because polyphenols are rapidly metabolized to other chemically modified intermediates destined for rapid excretion [26]. Many different molecular targets and mechanisms may be implicated in the biological effects of polyphenols, and all of them could contribute to the observed cardiovascular benefits. Moreover, some studies have shown that these compounds may even inhibit the angiotensinconverting enzyme, which could also explain their vasodilator and cardioprotective effects [29,30]. In this review, we discuss some of the studies that have demonstrated the protective effects of polyphenols in cardiovascular disease, and we comment on their targets and the implicated mechanisms. Fig. 2 shows a sketch summarizing the provided information. 2. Vasodilator effect B Fe2++H 2O2 Fe3++H2O2 Fe3++·OH+OH- Fe2++·OOH+OH+ Fig. 1. Formation of flavinic radical by free radical scavenging of polyphenols, A; Fenton reaction, B. myricetin, followed by kaempferol, are the flavonoids with greatest free radical neutralizing activity. This group of phenols can act directly by capturing unpaired ROS electrons, thereby generating less reactive species [9]. Basically, flavonoids act as buffers, scavenging free radicals to generate the flavin radical, which is much less reactive because its unpaired electrons are more dislocated (Fig. 1A). Flavonols such as quercetin may also chelate and remove transition metal ions such as iron or copper, thus avoiding the formation of ROS produced by the Fenton reaction [10] (Fig. 1B). Polyphenols may also potentiate cell detoxification systems, such as the superoxide dismutase, catalase or glutathione peroxidase [11] systems, and inhibit ROS-generating enzymes, such as xanthine oxidase and nicotinamide adenine dinucleotide phosphate (NADP) oxidase [11]. Polyphenols in tea display marked antioxidant properties in vitro and are up to 5 times more effective than vitamin C or vitamin E [12,13]. It has recently been observed that the flavonoid epigallocatechin gallate, found in tea, may regulate ROS production by modulating the activity of glutathione and the enzyme cytochrome P450 [13]. Wine is another rich source of antioxidant polyphenols, mainly phenolic acids, resveratrol, flavonols, flavanols, procyanidins and anthocyanins [14]. The induction of SOD enzymes by resveratrol has been shown in endothelial cells [15–17] and in cardiac myoblasts [18]. Resveratrol also upregulates catalase or glutathione peroxidase in aortic segments and in vascular smooth muscle cells [19,20]. Cocoa stands out among polyphenol-enriched foods because of its high flavonoid content, principally epicatechin and catechin [21]. Studies of cocoa and its derivatives have aroused great interest among scientists, as the composition of these products makes them strong candidates for use as functional foods in the prevention and/or treatment of cardiovascular disease and pathologies linked to oxidative stress. The antioxidant action of polyphenols could potentially result in vasodilator, antithrombotic, anti-inflammatory, antiapoptotic, hypolipemic or antiatherogenic effects [1,22–28] that have been associated with decreased cardiovascular risk. Nevertheless, it is important to have in mind that the antioxidant capacity of dietary Vascular homeostasis is achieved when production and bioavailability of nitric oxide (NO) are adequate. NO plays a fundamental role in the regulation of vascular tone. It is important to report that the antioxidant effect which flavonoids produce by neutralizing the O2 − radical and diminishing its concentration may improve NO bioavailability, given that this radical is often mainly responsible for the destruction of NO. The decreased levels of NO-destroying oxygen radicals could therefore contribute to the beneficial effects of polyphenols at the vascular level. Nevertheless, different pathways can be implicated in the vasodilator effects of polyphenols [31–35]. Studies carried out on rat aorta rings and mesenteric arteries show that polyphenolic compounds present in red wine may induce endothelium-dependent relaxation [36,37]. This effect is mainly mediated by NO production [38,39], and it has been shown that polyphenols modulate NO production in endothelial cells by means of an extracellular calcium-dependent mechanism [40]. Resveratrol and quercetin induce an increase in intracellular calcium concentration in endothelial cells by activating K+ channels or by inhibiting Ca++ -ATPase in the endoplasmic reticulum [41,42]. Delphinidin, an anthocyanin found in red wine, is also able to stimulate endothelial cells and induce in them an increase in intracellular Ca++ . All these studies have shown that the vasodilator effect of flavonoids can be ascribed chiefly to endothelial NO production and to the increase of cyclic guanosine monophosphate (cGMP) [43] in vascular smooth muscle. It has also recently been shown that improvement in vascular function is linked to soluble guanylyl cyclase-dependent mechanisms [44]. Mukai and Sato established in 2009 that a quercetin-rich diet brings about an increase in endothelial NO synthase (eNOS) activity, thereby raising NO and cGMP production. According to these researchers, the absence of overexpression of the eNOS gene indicates that the mechanisms implicated in the eNOS activation are non-transcriptional [45]. Nevertheless, other researchers have also concluded that some polyphenols might modulate eNOS expression, while at the same time transcriptionally inhibiting expression of the inducible (iNOS) gene [46,47]. In addition, recent studies indicate that upregulation of eNOS expression is, at least in part, mediated by deacetylase sirtuin 1 (SIRT1). In particular, resveratrol enhances eNOS activity by inducing SIRT1-mediated deacetylation of lysines 496 and 506 in the calmoduling-binding domain of eNOS [48]. In any case, the effect of resveratrol on SIRT1 has been hotly debated. Some authors have even claimed that activation of SIRT1 by resveratrol was an experimental artifact [49], and other researchers have proposed that resveratrol is not a direct SIRT1 activator [50]. More recently, Park et al. have proposed that resveratrol directly inactivates phosphodiesterases (PDEs), leading to a signaling cascade involving cyclic adenosine monophosphate that activates SIRT1 [51]. It has also been shown elsewhere that polyphenolic compounds present in red wine may modulate NO M. Quiñones et al. / Pharmacological Research 68 (2013) 125–131 127 Fig. 2. Beneficial effects of polyphenols on cardiovascular disease. ACE = angiotensin converting enzyme; ADMA = dimethylarginine; COX = cyclooxygenase; CVD = cardiovascular disease; eNOS = endothelial nitric oxide synthase; ␥GCS = ␥-glutamylcysteine synthetase; GPx = glutathione peroxidase; HDL = high density lipoproteins; cGMP = cyclic guanosine monophosphate; iNOS = inducible nitric oxide synthase; LDL = low density lipoproteins; LPO = lipooxygenase; NADP = nicotinamide adenine dinucleotide phosphate; NO = nitric oxide; NF-kB = nuclear-factor-kappa beta; PDE = phosphodiesterase; PGI2 = prostaglandin I2; ROS = reactive oxygen species; SIRT1 = deacetylase sirtuin; SOD = superoxide dismutase; TXA2 = thromboxane A2; VSMC = vascular smooth muscle cell. levels by acting on PDE [52]. Specifically, polyphenols found in wine have been shown to inhibit PDE5A1, which catalyses cGMP degradation [53]. Moreover, it has been demonstrated that resveratrol enhances eNOS activity by stimulating eNOS phosphorylation at the serine 1177 residue; this effect is mediated by the estrogen receptor ER␣ and a signaling pathway involving the ␣ subunit of G-protein, caveolin-1 and different kinases [54,55]. Resveratrol also enhances eNOS activity by decreasing the intracellular levels of the endogenous eNOS inhibitor asymmetric dimethylarginine (ADMA) [56]. It is, in any case, true that the direct antioxidant effects of resveratrol are rather poor. This compound is less potent than other well-established antioxidants such as ascorbate and cysteine [57], and its effects against oxidative injury may be mediated by the upregulation of endogenous antioxidant systems rather than by direct ROS-scavenging activity. Indeed, resveratrol induces antioxidant enzymes, such as SOD, GPx1 and catalase, in cardiovascular tissue [15,19,58,20,59,17]. Polyphenols may also decrease the production of endogenous pro-oxidants such as NADP oxidase, thus manifesting an indirect increase in antioxidant activity [60]. Moreover, the increased expression of ␥-glutamylcysteine synthetase (the rate-limiting enzyme for glutathione synthesis) has been proposed to explain the effects of polyphenols [58,20,61]. 3. Anti-inflammatory effect We know that an important inflammatory process takes place during cardiovascular disease [62]. Many published studies implicate inflammatory and immune responses in the vascular damage associated with atherosclerosis [63,64]. Oxidative stress produces an increase in enzymes such as cyclooxygenase (COX) and lipooxygenase (LPO) which are implicated in the release of factors such as interleukins and chemokines, and it has been shown that polyphenols, quercetin in particular, inhibit COX and LPO [65]. Resveratrol is also considered a molecule with anti-inflammatory action, as it is able to inhibit biosynthesis of prostaglandins [65]. Badia et al. observed in 2004 that moderate red wine consumption in humans can reduce monocyte adhesion to endothelial cells and associated this effect with the regulation of adhesion molecules located on the surface of the monocyte [66]. Cocoa polyphenols also have anti-inflammatory properties and can modulate inflammatory mediators in patients with a high risk of cardiac disease [67–69]. Nuclear factor kappa beta (NF-kB) can regulate the inflammatory process by modulating expression of proinflammatory genes. This protein is likely the major molecular target for the antiinflammatory effects of polyphenols in the vasculature. 128 M. Quiñones et al. / Pharmacological Research 68 (2013) 125–131 Several mechanisms may be involved in the inhibition of NF-kB by polyphenols, and these compounds may inhibit ROS-mediated NF-kB activation [70]. The efficient transcriptional activation of NF-kB depends on the phosphorylation of its active subunit P65, and polyphenols may block P65 phosphorylation, rendering NFkB trancriptionally inactive [71,72]. Moreover, overexpression of SIRT1 mimics the effects of some polyphenols, including resveratrol [73], and it has been shown that resveratrol can also promote the deacetylation of P65 by SIRT1 [74]. Synergistic effects of procyanindins and polyunsaturated fatty acids over inflammation have also been proposed [75]. 4. Antiatherogenic effect One of the most frequently studied beneficial effects of polyphenols is their ability to improve lipid profile [76]. This may lead to the prevention of onset and development of lipid accumulation in the arterial wall and concomitant progressive artery obstruction, or atherosclerosis. These lipids cross into the endothelium and oxidize in endothelial and vascular smooth muscle cells and in macrophages [77]. LDL and high density lipoprotein (HDL) oxidation may be intensified by ROS and reactive nitrogen species production and is accompanied by endothelial cell dysfunction and macrophage foam cell recruitment. Another result is the migration of smooth muscle cells from the tunica media to the intima, with the resulting proliferation of smooth muscle cells in the neointima area. All this causes an excessive deposition of extracellular matrix and the adhesion of leucocytes, monocytes and T lymphocytes to the vascular endothelium. The accumulation of macrophages in this area eliminates the oxidized LDL molecules but also provokes an inflammatory response, with the requisite cell recruitment and proliferation accompanied by migration of smooth muscle cells. Extracellular matrix deposits increase around the inflamed area, and this permits the formation of so-called atheroma plaque, which more or less blocks the vessel [78]. The final stage of the atherogenic process is the rupture of the atherosclerotic plaque and platelet activation which causes thrombosis [79]. All these processes go hand in hand with vasoconstriction episodes, caused by inhibition of NO formation and loss of the arteries’ natural relaxation capacity [66]. The beneficial effects of polyphenols on atherosclerosis have been studied widely. It was proposed that these compounds are able to attenuate the onset and development of the disease thanks to their ability to limit LDL oxidation. Numerous studies speak of the protective effect which flavanols, both monomeric and oligomeric, have against LDL oxidation [61,67]. We know that moderate wine consumption can be beneficial, a fact at one time known as the “French paradox” [80]; specifically, it has been demonstrated that resveratrol, one of the main polyphenols found in wine, impedes LDL oxidation and lessens cytotoxicity caused by oxidized LDL in endothelial cells [81]. Several clinical experiments have also established that procyanidin supplements significantly reduce oxidized LDL values in diabetic patients [82]. Red wine and grape juice polyphenols reduce plasma lipid concentration [83], and red wine polyphenols have an immediate effect on postprandial lipemia. There is a much smaller increase in lipid hydroperoxides, which are highly atherogenic and typically present after eating, when red wine is taken with meals [84]. In addition, the oral administration of polyphenols reduces neointima growth and lipid deposits in the iliac artery of hypercholesterolemic rabbits [85]. Cocoa flavanoids have a very favorable effect on lipoprotein profile [86,87]. It has been shown that chronic administration of cocoa procyanidins to rabbits fed on a hypercholesterolemic diet decreases plasma lipid hydroperoxide levels with a concomitant increase in plasma antioxidant capacity. Procyanidin administration prevented the appearance of atherosclerosis in the rabbits and inhibited its progress [88]. Moreover, in hamsters fed on a hypercholesterolemic diet and bearing atherogenic lipid deposits similar to those in humans, the chronic administration of grape polyphenols reduced plasma cholesterol, triglyceride, apolipoprotein B and MDA levels. This effect was associated with a decrease in foam cell deposits in the hamsters’ arterial walls and with an inhibition of the development of atherosclerotic plaque [89]. Polyphenols can also increase plasma HDL cholesterol concentration, [67,90]. Acute administration of procyanidins to normolipemic rats fed on a standard diet produced a dramatic drop in triglyceride, free fatty acid and apolipoprotein B levels, as well as an increase in plasma HDL cholesterol/LDL cholesterol quotient, which represents a clearly antiatherogenic postprandial lipemia situation [91]. The reduction of vascular inflammation, the prevention of leukocyte adhesion [92], the inhibition of vascular smooth muscle proliferation [93–96] and the stimulation of NO production [97] may also contribute to the antiatherosclerotic effects of polyphenols. Cocoa procyanidins inhibit tumor necrosis factor alpha (TNF␣), a pro-inflammatory marker in vascular endothelial cells, thus reducing the adhesion of T-lymphocytes to the endothelium [98]. In addition, epigallocatechin-3 gallate and catechin-3 gallate bind to the platelet-derived growth factor receptor and inhibit the proliferative signal. This effect impedes one of the principal components of chronic inflammation of the blood vessels which causes atherosclerosis [99,100]. Avenanthramides are polyphenols found exclusively in oats (Avena sativa L.), and according to Nie et al., these polyphenols may contribute to the prevention of atherosclerosis through inhibition of smooth muscle proliferation and increasing NO production [101]. In addition, the production of mRNA for endothelin-1 can be decreased, and kruppel-like factor 2 increased, by food-derived procyanindins. Both effects are associated with lower risk of atherosclerosis [102]. 5. Antithrombotic effect Polyphenols exhibit an antithrombotic effect that may be related, at least in part, to antiinflammatory and antiatherogenic properties. Platelet aggregation plays a fundamental role in the development of atherosclerosis, and the antiaggregant effect of polyphenols may be linked to a lower incidence and prevalence of cardiovascular disease. A study carried out with anthocyanins showed that these compounds can inhibit platelet function [103]. The antithrombotic effect of polyphenols may be explained by their capacity to inhibit enzymes implicated in the synthesis of eicosanoids such as thromboxane A2 (TXA2 ), COX and LPO. These compounds therefore inhibit the synthesis of molecules derived from arachidonic acid which are directly involved in vascular homeostasis regulation [104]. It has also been shown that cocoa procyanidins stimulate the formation of prostacyclin (PGI2 ), a platelet aggregation inhibitor, and that these compounds also inhibit the formation of leukotrienes, which are vasoconstrictor agents and inflammation stimulants [105]. We can therefore say that cocoa polyphenols inhibit coagulation and favor blood flow, thereby preventing thrombosis. As a result, they lessen the risk of vascular accident [106,107]. However, cocoa polyphenols act via different mechanisms from those of aspirin, and thus their combined effect is complementary [108]. 6. Effect on apoptosis Apoptosis or “programmed cell death” is a type of genetically defined cell suicide, which takes place physiologically during morphogenesis and tissue renewal and also in regulation processes of M. Quiñones et al. / Pharmacological Research 68 (2013) 125–131 the immune system. Programmed cell death is an integral part of the development of tissue in living beings. When a cell dies through apoptosis, it packs its genetic content and impedes the inflammatory response characteristic of accidental death or necrosis. Cells undergoing apoptosis shrink and fragment their genetic content and thus can be efficiently consumed by phagocytosis; as a result, their components are re-used by macrophages or by cells in adjacent tissue. Disruption of the regulation of genes responsible for the apoptotic process may contribute to the development of a range of diseases such as tumors and autoimmune or neurodegenerative disease [109,110]. In the last few years, studies have been published which suggest that alterations in apoptotic processes may be linked to cardiovascular disease [111–113]. The regulation of cell proliferation and cell death by apoptosis in vascular smooth muscle cells is an important factor when configuring the normal structure of the vascular wall under physiological conditions. When cell proliferation in vascular smooth muscle cells exceeds the rate of apoptosis, cells accumulate and thicken the tunica media and small artery walls; this is characteristic of high blood pressure [114,115]. Apoptosis is also the chief mechanism of cell death in endothelial cells under physiological conditions. The proliferation-apoptosis balance in endothelial cells plays a vital role in the formation and regression of blood vessels, particularly in the arterioles and capillaries. Excessive apoptosis in these cells may produce the endothelial dysfunction typical of cardiovascular diseases. Moreover, endothelial apoptosis warrants special consideration during the onset of atherosclerosis [116]. Flavonoids modulate apoptosis in different ways. Some flavonoids, such as resveratrol, may induce apoptosis in the endothelial cells of the human umbilical vein [117]. Studies have also shown that theasinensin A, a polymer formed by antocyanidin units from oolong tea, induces apoptosis in tumor cells [118]. Polyphenols may also modulate expression levels of different proapoptotic factors. It has been demonstrated that resveratrol induces apoptotic processes by regulating pro-apoptotic factors [119,120]. In vitro studies in endothelial cells from rabbit aorta and fibroblasts have also shown that polyphenols have an inhibitory effect on LDL and H2 O2 -induced apoptosis [121]. 7. Other beneficial effects of polyphenols on health Several studies have shown that polyphenols from chocolate or cocoa extracts have certain effects on animal tumor cells [122,123], alcohol-induced gastric and liver injury [124], intestine protection [125,126], red blood cell stability [127] and diabetes-induced cataracts [128]. All these studies demonstrate the beneficial effect of polyphenols on health. 8. Conclusions Owing to their pleiotropic properties and synergic potential for action on the vascular endothelium, polyphenols can be considered good candidates for the prevention and treatment of cardiovascular disease. Their beneficial action on different organic systems is unquestionable today, and studies continue to be carried out to further demonstrate the health potential of these compounds and to completely establish the implicated mechanisms. Acknowledgements M. Miguel is the recipient of a Ramón y Cajal grant from Ministerio de Ciencia e Innovación. This work was supported by the Project Consolider Ingenio 2010 (CSD-2007-00063). 129 References [1] Schroeter H, Heiss C, Balzer J, Kleinbongard P, Keen CL, Hollenberg NK, et al. (−)-Epicatechin mediates beneficial effects of flavanol-rich cocoa on vascular function in humans. Proceedings of the National Academy of Sciences of the United States of America 2006;103:1024–9. [2] Perez-Vizcaino F, Duarte J, Jimenez R, Santos-Buelga C, Osuna A. Antihypertensive effects of the flavonoid quercetin. Pharmacological Reports 2009;61:67–75. [3] Rice-Evans CA, Miller NJ. Antioxidant activities of flavonoids as bioactive components of food. Biochemical Society Transactions 1996;24:790–5. [4] Pannala AS, Rice-Evans CA, Halliwell B, Singh S. Inhibition of peroxynitritemediated tyrosine nitration by catechin polyphenols. Biochemical and Biophysical Research Communications 1997;232:164–8. [5] Fenercioglu AK, Saler T, Genc E, Sabuncu H, Altuntas Y. The effects of polyphenol-containing antioxidants on oxidative stress and lipid peroxidation in Type 2 diabetes mellitus without complications. Journal of Endocrinological Investigation 2010;33:118–24. [6] Fuhrman B, Aviram M. Flavonoids protect LDL from oxidation and attenuate atherosclerosis. Current Opinion in Lipidology 2001;12:41–8. [7] Binsack R, Boersma BJ, Patel RP, Kirk M, White CR, Darley-Usmar V, et al. Enhanced antioxidant activity after chlorination of quercetin by hypochlorous acid. Alcoholism, Clinical and Experimental Research 2001;25:434–43. [8] Korkina LG, Afanas’ev IB. Antioxidant and chelating properties of flavonoids. Advances in Pharmacology 1997;38:151–63. [9] Cotelle N, Bernier JL, Catteau JP, Pommery J, Wallet JC, Gaydou EM. Antioxidant properties of hydroxy-flavones. Free Radical Biology and Medicine 1996;20:35–43. [10] Krinsky NI. Mechanism of action of biological antioxidants. Proceedings of the Society for Experimental Biology and Medicine 1992;200:248–54. [11] Nijveldt RJ, van Nood E, van Hoorn DE, Boelens PG, van Norren K, van Leeuwen PA. Flavonoids: a review of probable mechanisms of action and potential applications. American Journal of Clinical Nutrition 2001;74:418–25. [12] Orallo F, Alvarez E, Camiña M, Leiro JM, Gómez E, Fernández P. The possible implication of trans-Resveratrol in the cardioprotective effects of long-term moderate wine consumption. Molecular Pharmacology 2002;61:294–302. [13] Dreosti IE. Bioactive ingredients: antioxidants and polyphenols in tea. Nutrition Reviews 1996;54:S51–8. [14] Leifert WR, Abeywardena MY. Cardioprotective actions of grape polyphenols. Nutrition Research 2008;28:729–37. [15] Xia N, Daiber A, Habermeier A, Closs EI, Thum T, Spanier G, et al. Resveratrol reverses endothelial nitric-oxide synthase uncoupling in apolipoprotein E knockout mice. Journal of Pharmacology and Experimental Therapeutics 2010;335:149–54. [16] Spanier G, Xu H, Xia N, Tobias S, Deng S, Wojnowski L, et al. Resveratrol reduces endothelial oxidative stress by modulating the gene expression of superoxide dismutase 1 (SOD1), glutathione peroxidase 1 (GPx1) and NADPH oxidase subunit (Nox4). Journal of Physiology and Pharmacology 2009;60(Suppl. 4):111–6. [17] Ungvari Z, Labinskyy N, Mukhopadhyay P, Pinto JT, Bagi Z, Ballabh P, et al. Resveratrol attenuates mitochondrial oxidative stress in coronary arterial endothelial cells. American Journal of Physiology: Heart and Circulatory Physiology 2009;297:H1876–81. [18] Tanno M, Kuno A, Yano T, Miura T, Hisahara S, Ishikawa S, et al. Induction of manganese superoxide dismutase by nuclear translocation and activation of SIRT1 promotes cell survival in chronic heart failure. Journal of Biological Chemistry 2010;285:8375–82. [19] Ungvari Z, Orosz Z, Rivera A, Labinskyy N, Xiangmin Z, Olson S, et al. Resveratrol increases vascular oxidative stress resistance. American Journal of Physiology: Heart and Circulatory Physiology 2007;292:H2417–24. [20] Li Y, Cao Z, Zhu H. Upregulation of endogenous antioxidants and phase 2 enzymes by the red wine polyphenol, resveratrol in cultured aortic smooth muscle cells leads to cytoprotection against oxidative and electrophilic stress. Pharmacological Research 2006;53:6–15. [21] Lee KW, Kim YJ, Lee HJ, Lee CY. Cocoa has more phenolic phytochemicals and higher antioxidant capacity than teas and red wines. Journal of Agricultural and Food Chemistry 2003;51:7292–5. [22] Pérez-Vizcaíno F, Ibarra M, Cogolludo AL, Duarte J, Zaragozá-Arnáez F, Moreno L, et al. Endothelium-independent vasodilator effects of the flavonoid quercetin and its methylated metabolites in rat conductance and resistance arteries. Journal of Pharmacology and Experimental Therapeutics 2002;302:66–72. [23] Dell’Agli M, Buscialà A, Bosisio E. Vascular effects of wine polyphenols. Cardiovascular Research 2004;63:593–602. [24] Williams MJ, Sutherland WH, Whelan AP, McCormick MP, de Jong SA. Acute effect of drinking red and white wines on circulating levels of inflammationsensitive molecules in men with coronary artery disease. Metabolism: Clinical and Experimental 2004;53:318–23. [25] Ruf JC. Wine and polyphenols related to platelet aggregation and atherothrombosis. Drugs Under Experimental and Clinical Research 1999;25:125–31. [26] Williams RJ, Spencer JPE, Rice-Evans C. Flavonoids: antioxidants or signalling molecules? Free Radical Biology and Medicine 2004;36:838–49. [27] Pal S, Ho N, Santos C, Dubois P, Mamo J, Croft K, et al. Red wine polyphenolics increase LDL receptor expression and activity and suppress the secretion of ApoB100 from human HepG2 cells. Journal of Nutrition 2003;133:700–6. 130 M. Quiñones et al. / Pharmacological Research 68 (2013) 125–131 [28] Wilcox LJ, Borradaile NM, de Dreu LE, Huff MW. Secretion of hepatocyte apoB is inhibited by the flavonoids, naringenin and hesperetin, via reduced activity and expression of ACAT2 and MTP. Journal of Lipid Research 2001;42:725–34. [29] Actis-Goretta L, Ottaviani JI, Fraga CG. Inhibition of angiotensin converting enzyme activity by flavanol-rich foods. Journal of Agricultural and Food Chemistry 2006;54:229–34. [30] Ojeda D, Jiménez-Ferrer E, Zamilpa A, Herrera-Arellano A, Tortoriello J, Alvarez L. Inhibition of angiotensin convertin enzyme (ACE) activity by the anthocyanins delphinidin- and cyanidin-3-O-sambubiosides from Hibiscus sabdariffa. Journal of Ethnopharmacology 2010;127:7–10. [31] Andriambeloson E, Kleschyov AL, Muller B, Beretz A, Stoclet JC, Andriantsitohaina R. Nitric oxide production and endothelium-dependent vasorelaxation induced by wine polyphenols in rat aorta. British Journal of Pharmacology 1997;120:1053–8. [32] Wallerath T, Deckert G, Ternes T, Anderson H, Li H, Witte K, et al. Resveratrol, a polyphenoic phytoalexin present in red wine, enhances expression and activity of endothelial nitric oxide synthase. Circulation 2002;106:1652–8. [33] Mattagajasingh I, Kim CS, Naqvi A, Yamamori T, Hoffman TA, Jung SB, et al. SIRT1 promotes endothelium-dependent vascular relaxation by activating endothelial nitric oxide sybthase. Proceedings of the National Academy of Sciences of the United States of America 2007;104:14955–60. [34] Zhang QJ, Wang Z, Chen HZ, Zhou S, Zheng W, Liu G, et al. Endothelium specific overexpression of calss III deacetylase SIRT1 decreases atherosclerosis in apolipoprotein E-deficient mice. Cardiovascular Research 2008;80:191–9. [35] Li H, Xia N, Fostermann U. Cardiovascular effects and nolecular targets of resveratrol. Nitric Oxide 2012;26:102–10. [36] Perez-Vizcaino F, Duarte J, Andriantsitohaina R. Endothelial function and cardiovascular disease: effects of quercetin and wine polyphenols. Free Radical Research 2006;40:1054–65. [37] Zenebe W, Pechánová O, Andriantsitohaina R. Red wine polyphenols induce vasorelaxation by increased nitric oxide bioactivity. Physiological Research 2003;52:425–32. [38] Andriambeloson E, Stoclet JC, Andriantsitohaina R. Mechanism of endothelial nitric oxide-dependent vasorelaxation induced by wine polyphenols in rat thoracic aorta. Journal of Cardiovascular Pharmacology 1999;33:248–54. [39] Duarte J, Andriambeloson E, Diebolt M, Andriantsitohaina R. Wine polyphenols stimulate superoxide anion production to promote calcium signaling and endothelial-dependent vasodilatation. Physiological Research 2004;53:595–602. [40] Li HF, Chen SA, Wu SN. Evidence for the stimulatory effect of resveratrol on Ca(2+)-activated K+ current in vascular endothelial cells. Cardiovascular Research 2000;45:1035–45. [41] McKenna E, Smith JS, Coll KE, Mazack EK, Mayer EJ, Antanavage J, et al. Dissociation of phospholamban regulation of cardiac sarcoplasmic reticulum Ca2+ATPase by quercetin. Journal of Biological Chemistry 1996;271:24517–25. [42] Martin S, Andriantsitohaina R. Cellular mechanism of vasculo-protection induced by polyphenols on the endothelium. Annales de Cardiologie et d Angeiologie 2002;51:304–15. [43] Botden IP, Langendonk JG, Meima ME, Boomsma F, Seynhaeve AL, ten Hagen TL, et al. Daily red wine consumption improves vascular function by a soluble guanylyl cyclase-dependent pathway. American Journal of Hypertension 2011;24:162–8. [44] Benito S, Lopez D, Sáiz MP, Buxaderas S, Sánchez J, Puig-Parellada P, et al. A flavonoid-rich diet increases nitric oxide production in rat aorta. British Journal of Pharmacology 2002;135:910–6. [45] Mukai Y, Sato S. Polyphenol-containing azuki bean (Vigna angularis) extract attenuates blood pressure elevation and modulates nitric oxide synthase and caveolin-1 expressions in rats with hypertension. Nutrition Metabolism and Cardiovascular Diseases 2009;19:491–7. [46] Kim YW, Zhao RJ, Park SJ, Lee JR, Cho IJ, Yang CH, et al. Anti-inflammatory effects of liquiritigenin as a consequence of the inhibition of NF-kappaBdependent iNOS and proinflammatory cytokines production. British Journal of Pharmacology 2008;154:165–73. [47] Ndiaye M, Chataigneau M, Lobysheva I, Chataigneau T, Schini-Kerth VB. Red wine polyphenol-induced, endothelium-dependent NO-mediated relaxation is due to the redox-sensitive PI3-kinase/Akt-dependent phosphorylation of endothelial NO-synthase in the isolated porcine coronary artery. FASEB Journal 2005;19:455–7. [48] Mattagajasingh I, Kim CS, Naqvi A, Yamamori T, Hoffman TA, Jung SB, et al. SIRT1 promotes endothelium-dependent vascular relaxation by activating endothelial nitric oxide synthase. Proceedings of the National Academy of Sciences of the United States of America 2007;104:14855–60. [49] Klinge CM, Blankenship KA, Risinger KE, Bhatnagar S, Noisin EL, Sumanasekera WK, et al. Resveratrol and estradiol rapidly activate MAPK signaling through estrogen receptors alpha and beta in endothelial cells. Journal of Biological Chemistry 2005;280:7460–8. [50] Klinge CM, Wickramasinghe NS, Ivanova MM, Dougherty SM. Resveratrol stimulates nitric oxide production by increasing estrogen receptor alphaSrc–caveolin-1 interaction and phosphorylation in human umbilical vein endothelial cells. FASEB Journal 2008;22:2185–97. [51] Frombaum M, Therond P, Djelidi R, Beaudeux JL, Bonnefont-Rousselot D, Borderie D. Piceatannol is more effective than resveratrol in restoring endothelial cell dimethyilarginine dimethylaminohydrolase expression and activity after high-glucose oxidative stress. Free Radical Research 2011;45:293–302. [52] Kaeberlein M, McDonagh T, Heltweg B, Hixon J, Westman EA, Caldwell SD, et al. Substrate-specific activation of sirtuins by resveratrol. Journal of Biological Chemistry 2005;280:17038–45. [53] Beher D, Wu J, Cumine S, Kim KW, Lu SC, Atangan L, et al. Resveratrol is not a direct activator of SIRT1 enzyme activity. Chemical Biology & Drug Design 2009;74:619–24. [54] Park SJ, Ahmad F, Philp A, Baar K, Williams T, Luo H, et al. Resveratrol ameliorates aging-related metabolic phenotypes by inhibiting cAMP phosphodiesterases. Cell 2012;148:421–33. [55] Dell’Agli M, Galli GV, Vrhovsek U, Mattivi F, Bosisio E. In vitro inhibition of human cGMP-specific phosphodiesterase-5 by polyphenols from red grapes. Journal of Agricultural and Food Chemistry 2005;53:1960–5. [56] Bagchi D, Sen CK, Ray SD, Das DK, Bagchi M, Preuss HG, et al. Molecular mechanisms of cardioprotection by a novel grape seed proanthocyanidin extract. Mutation Research 2003;523–524:87–97. [57] Bradamante S, Barenghi L, Villa A. Cardiovascular protective effects of resveratrol. Cardiovascular Drug Reviews 2004;22:169–88. [58] Cao Z, Li Y. Potent induction of cellular antioxidants and phase 2 enzymes by resveratrol in cardiomyocytes: protection against oxidative and electrophilic injury. European Journal of Pharmacology 2004;489:39–48. [59] Spanier G, Xu H, Xia N, Tobias S, Deng S, Wojnowski L, et al. Resveratrol reduces endothelial oxidative stress by modulating the gene expression of superoxide dismutase 1 (SOD1), glutathione peroxidase 1 (GPx1) and NADPH oxidase subunit (Nox4). Journal of Physiology and Pharmacology 2009;60:111–6. [60] Sies H. Polyphenols and health: update and perspectives. Archives of Biochemistry and Biophysics 2010;501:2–5. [61] Li H, Xia N, Förstermann U. Cardiovascular effects and molecular targets of resveratrol. Nitric Oxide 2012;26:102–10. [62] Aviram M, Rosenblat M. Macrophage-mediated oxidation of extracellular low density lipoprotein requires an initial binding of the lipoprotein to its receptor. Journal of Lipid Research 1994;35:385–98. [63] Abu-Amsha R, Croft KD, Puddey IB, Proudfoot JM, Beilin LJ. Phenolic content of various beverages determines the extent of inhibition of human serum and low-density lipoprotein oxidation in vitro: identification and mechanism of action of some cinnamic acid derivatives from red wine. Clinical Science (London) 1996;91:449–58. [64] Ross R. Atherosclerosis an inflammatory disease. New England Journal of Medicine 1999;340:115–26. [65] Ridker PM, Brown NJ, Vaughan DE, Harrison DG, Mehta JL. Established and emerging plasma biomarkers in the prediction of first atherothrombotic events. Circulation 2004;109:6–19. [66] Mellor DD, Sathyapalan T, Kilpatrick ES, Beckett S, Atkin SL. High-cocoa polyphenol-rich chocolate improves HDL cholesterol in Type 2 diabetes patients. Diabetic Medicine 2010;27:1318–21. [67] Abe R, Beckett J, Abe R, Nixon A, Rochier A, Yamashita N, et al. Olive oil polyphenol oleuropein inhibits smooth muscle cell proliferation. European Journal of Vascular and Endovascular Surgery 2011;41:814–20. [68] Osakabe N, Baba S, Yasuda A, Iwamoto T, Kamiyama M, Takizawa T, et al. Daily cocoa intake reduces the susceptibility of low-density lipoprotein to oxidation as demonstrated in healthy human volunteers. Free Radical Research 2001;34:93–9. [69] Yang MY, Huang CN, Chan KC, Yang YS, Peng CH, Wang CJ. Mulberry leaf polyphenols possess antiatherogenesis effect via inhibiting LDL oxidation and foam cell formation. Journal of Agricultural and Food Chemistry 2011;59:1985–95. [70] Renaud S, de Lorgeril M. Wine, alcohol, platelets, and the French paradox for coronary heart disease. Lancet 1992;339:1523–6. [71] Ou HC, Chou FP, Sheen HM, Lin TM, Yang CH, Huey-Herng Sheu W. Resveratrol, a polyphenolic compound in red wine, protects against oxidized LDL-induced cytotoxicity in endothelial cells. Clinica Chimica Acta 2006;364: 196–204. [72] Vinson JA, Teufel K, Wu N. Red wine, dealcoholized red wine, and especially grape juice, inhibit atherosclerosis in a hamster model. Atherosclerosis 2001;156:67–72. [73] Ursini F, Zamburlini A, Cazzolato G, Maiorino M, Bon GB, Sevanian A. Postprandial plasma lipid hydroperoxides: a possible link between diet and atherosclerosis. Free Radical Biology and Medicine 1998;25:250–2. [74] Elbaz M, Roul G, Alvès A, Andriantsitohaina R. Provinols, a polyphenolic extract of red wine inhibits in-stent neointimal growth in cholesterol-fed rabbit. Archives des Maladies du Coeur et des Vaisseaux 2005;98:406. [75] Baba S, Natsume M, Yasuda A, Nakamura Y, Tamura T, Osakabe N, et al. Plasma LDL and HDL cholesterol and oxidized LDL concentrations are altered in normo- and hypercholesterolemic humans after intake of different levels of cocoa powder. Journal of Nutrition 2007;137:1436–41. [76] Steffen Y, Schewe T, Sies H. Myeloperoxidase-mediated LDL oxidation and endothelial cell toxicity of oxidized LDL: attenuation by (−)-epicatechin. Free Radical Research 2006;40:1076–85 [Review]. [77] Kurosawa T, Itoh F, Nozaki A, Nakano Y, Katsuda S, Osakabe N, et al. Suppressive effects of cacao liquor polyphenols (CLP) on LDL oxidation and the development of atherosclerosis in Kurosawa and Kusanagihypercholesterolemic rabbits. Atherosclerosis 2005;179:237–46. [78] Auger C, Gérain P, Laurent-Bichon F, Portet K, Bornet A, Caporiccio B, et al. Phenolics from commercialized grape extracts prevent early atherosclerotic lesions in hamsters by mechanisms other than antioxidant effect. Journal of Agricultural and Food Chemistry 2004;52:5297–302. M. Quiñones et al. / Pharmacological Research 68 (2013) 125–131 [79] Del Bas JM, Fernández-Larrea J, Blay M, Ardèvol A, Salvadó MJ, Arola L, et al. Grape seed procyanidins improve atherosclerotic risk index and induce liver CYP7A1 and SHP expression in healthy rats. FASEB Journal 2005;19:479–81. [80] Wang Z, Chen Y, Labinskyy N, Hsieh TC, Ungvari Z, Wu JM. Regulation of proliferation and gene expression in cultured human aortic smooth muscle cells by resveratrol and standardized grape extracts. Biochemical and Biophysical Research Communications 2006;346:367–76. [81] Kim JW, Lim SC, Lee MY, Lee JW, Oh WK, Kim SK, et al. Inhibition of neointimal formation by trans-resveratrol: role of phosphatidyl inositol 3kinase-dependent Nrf2 activation in heme oxygenase-1 induction. Molecular Nutrition & Food Research 2010;54:1497–505. [82] Brito PM, Devillard R, Negre-Salvayre A, Almeida LM, Dinis TC, Salvayre R, et al. Resveratrol inhibits the mTOR mitogenic signaling evoked by oxidized LDL in smooth muscle cells. Atherosclerosis 2009;205:126–34. [83] Khandelwal AR, Hebert VY, Dugas TR. Essential role of ER-alpha-dependent NO production in resveratrol-mediated inhibition of restenosis. American Journal of Physiology: Heart and Circulatory Physiology 2010;299:H1451–8. [84] Kim JE, Son JE, Jung SK, Kang NJ, Lee CY, Lee KW, et al. Cocoa polyphenols suppress TNF-␣-induced vascular endothelial growth factor expression by inhibiting phosphoinositide 3-kinase (PI3K) and mitogen-activated protein kinase kinase-1 (MEK1) activities in mouse epidermal cells. British Journal of Nutrition 2010;104:957–64. [85] Sakata R, Ueno T, Nakamura T, Sakamoto M, Torimura T, Sata M. Green tea polyphenol epigallocatechin-3-gallate inhibits platelet-derived growth factor-induced proliferation of human hepatic stellate cell line LI90. Journal of Hepatology 2004;40:52–9. [86] Rechner AR, Kroner C. Anthocyanins and colonic metabolites of dietary polyphenols inhibit platelet function. Thrombosis Research 2005;116:327–34. [87] Nie L, Wise ML, Peterson DM, Meydani M. Atherosclerosis. Avenanthramide, a polyphenol from oats, inhibits vascular smooth muscle cell proliferation and enhances nitric oxide production. Atherosclerosis 2006;186:260–6. [88] Caton PW, Pothecary MR, Lees DM, Khan NQ, Wood EG, Shoji T, et al. Regulation of vascular endothelial function by procyanidin-rich foods and beverages. Journal of Agricultural and Food Chemistry 2010;58:4008–13. [89] de Gaetano G, De Curtis A, di Castelnuovo A, Donati MB, Iacoviello L, Rotondo S. Antithrombotic effect of polyphenols in experimental models: a mechanism of reduced vascular risk by moderate wine consumption. Annals of the New York Academy of Sciences 2002;957:174–88. [90] Murphy KJ, Chronopoulos AK, Singh I, Francis MA, Moriarty H, Pike MJ, et al. Dietary flavanols and procyanidin oligomers from cocoa (Theobroma cacao) inhibit platelet function. American Journal of Clinical Nutrition 2003;77:1466–73. [91] Schramm DD, Wang JF, Holt RR, Ensunsa JL, Gonsalves JL, Lazarus SA, et al. Chocolate procyanidins decrease the leukotriene-prostacyclin ratio in humans and human aortic endothelial cells. American Journal of Clinical Nutrition 2001;73:36–40. [92] Schewe T, Sadik C, Klotz LO, Yoshimoto T, Kühn H, Sies H. Polyphenols of cocoa: inhibition of mammalian 15-lipoxygenase. Biological Chemistry 2001;382:1687–96. [93] Pearson DA, Paglieroni TG, Rein D, Wun T, Schramm DD, Wang JF, et al. The effects of flavanol-rich cocoa and aspirin on ex vivo platelet function. Thrombosis Research 2002;106:191–7. [94] Pate M, Damarla V, Chi DS, Negi S, Krishnaswamy G. Endothelial cell biology: role in the inflammatory response. Advances in Clinical Chemistry 2010;52:109–30. [95] Uno K, Nicholls SJ. Biomarkers of inflammation and oxidative stress in atherosclerosis. Biomarkers in Medicine 2010;4:361–73. [96] Hansson GK, Hermansson A. The immune system in atherosclerosis. Nature Immunology 2011;12:204–12. [97] Crescente M, Jessen G, Momi S, Höltje HD, Gresele P, Cerletti C, et al. Interactions of gallic acid, resveratrol, quercetin and aspirin at the platelet cyclooxygenase-1 level. Functional and modelling studies. Thrombosis and Haemostasis 2009;102:336–46. [98] Fan E, Zhang L, Jiang S, Bai Y. Beneficial effects of resveratrol on atherosclerosis. Journal of Medicinal Food 2008;11:610–4. [99] Badía E, Sacanella E, Fernández-Solá J, Nicolás JM, Antúnez E, Rotilio D, et al. Decreased tumor necrosis factor-induced adhesion of human monocytes to endothelial cells after moderate alcohol consumption. American Journal of Clinical Nutrition 2004;80:225–30. [100] Monagas M, Khan N, Andres-Lacueva C, Casas R, Urpí-Sardà M, Llorach R, et al. Effect of cocoa powder on the modulation of inflammatory biomarkers in patients at high risk of cardiovascular disease. American Journal of Clinical Nutrition 2009;90:1144–50. [101] Selmi C, Cocchi CA, Lanfredini M, Keen CL, Gershwin ME. Chocolate at heart: the anti-inflammatory impact of cocoa flavanols. Molecular Nutrition & Food Research 2008;52:1340–8. [102] Selmi C, Mao TK, Keen CL, Schmitz HH, Eric Gershwin M. The antiinflammatory properties of cocoa flavanols. Journal of Cardiovascular Pharmacology 2006;47:S163–71. [103] Labinskyy N, Csiszar A, Veress G, Stef G, Pacher P, Oroszi G, et al. Vascular dysfunction in aging: potential effects of resveratrol, an anti-inflammatory phytoestrogen. Current Medicinal Chemistry 2006;13:989–96. 131 [104] Kundu JK, Shin YK, Kim SH, Surh YJ. Resveratrol inhibits phorbol ester-induced expression of COX-2 and activation of NF-kappaB in mouse skin by blocking IkappaB kinase activity. Carcinogenesis 2006;27:1465–74. [105] Manna SK, Mukhopadhyay A, Aggarwal BB. Resveratrol suppresses TNFinduced activation of nuclear transcription factors NF-kappa B, activator protein-1, and apoptosis: potential role of reactive oxygen intermediates and lipid peroxidation. Journal of Immunology 2000;164:6509–19. [106] Csiszar A, Labinskyy N, Podlutsky A, Kaminski PM, Wolin MS, Zhang C, et al. Vasoprotective effects of resveratrol and SIRT1: attenuation of cigarette smoke-induced oxidative stress and proinflammatory phenotypic alterations. American Journal of Physiology: Heart and Circulatory Physiology 2008;294:H2721–35. [107] Yeung F, Hoberg JE, Ramsey CS, Keller MD, Jones DR, Frye RA, et al. Modulation of NF-kappaB-dependent transcription and cell survival by the SIRT1 deacetylase. EMBO Journal 2004;23:2369–80. [108] Pallarés V, Calay D, Cedó L, Castell-Auví A, Raes M, Pinent M, et al. Enhanced anti-inflammatory effect of resveratrol and EPA in treated endotoxinactivated RAW 264.7 macrophages. British Journal of Nutrition 2012;6:1–12. [109] Hajji N, Joseph B. Epigenetic regulation of cell life and death decisions and deregulation in cancer. Essays in Biochemistry 2010;48:121–46. [110] Erusalimsky JD. Vascular endothelial senescence: from mechanisms to pathophysiology. Journal of Applied Physiology 2009;106:326–32. [111] Tedgui A, Mallat Z. Apoptosis, a major determinant of atherothrombosis. Archives des Maladies du Coeur et des Vaisseaux 2003;96:671–5. [112] González A, Fortuño MA, Querejeta R, Ravassa S, López B, López N, et al. Cardiomyocyte apoptosis in hypertensive cardiomyopathy. Cardiovascular Research 2003;59:549–62. [113] Hamet P. Proliferation and apoptosis of vascular smooth muscle in hypertension. Current Opinion in Nephrology and Hypertension 1995;4:1–7. [114] Quadrilatero J, Bloemberg D. Apoptosis repressor with caspase recruitment domain is dramatically reduced in cardiac, skeletal, and vascular smooth muscle during hypertension. Biochemical and Biophysical Research Communications 2010;391:1437–42. [115] Karsan A, Harlan JM. Modulation of endothelial cell apoptosis: mechanisms and pathophysiological roles. Journal of Atherosclerosis and Thrombosis 1996;3:75–80. [116] Ebert T, Fasshauer M. Tumor necrosis factor-related apoptosis-inducing ligand and cardiovascular disease. Atherosclerosis 2011;215:279–80. [117] Szende B, Tyihák E, Király-Véghely Z. Dose-dependent effect of resveratrol on proliferation and apoptosis in endothelial and tumor cell cultures. Experimental and Molecular Medicine 2000;32:88–92. [118] Pan MH, Liang YC, Lin-Shiau SY, Zhu NQ, Ho CT, Lin JK. Induction of apoptosis by the oolong tea polyphenol theasinensin A through cytochrome c release and activation of caspase-9 and caspase-3 in human U937 cells. Journal of Agricultural and Food Chemistry 2000;48:6337–46. [119] Tinhofer I, Bernhard D, Senfter M, Anether G, Loeffler M, Kroemer G, et al. Resveratrol, a tumor-suppressive compound from grapes, induces apoptosis via a novel mitochondrial pathway controlled by Bcl-2. FASEB Journal 2001;15:1613–5. [120] Delmas D, Solary E, Latruffe N. Resveratrol, a phytochemical inducer of multiple cell death pathways: apoptosis, autophagy and mitotic catastrophe. Current Medicinal Chemistry 2011;18:1100–2. [121] Vieira O, Escargueil-Blanc I, Meilhac O, Basile JP, Laranjinha J, Almeida L, et al. Effect of dietary phenolic compounds on apoptosis of human cultured endothelial cells induced by oxidized LDL. British Journal of Pharmacology 1998;123:565–73. [122] Yamagishi M, Natsume M, Osakabe N, Nakamura H, Furukawa F, Imazawa T, et al. Effects of cacao liquor proanthocyanidins on PhIP-induced mutagenesis in vitro, and in vivo mammary and pancreatic tumorigenesis in female Sprague-Dawley rats. Cancer Letters 2002;185:123–30. [123] Yamagishi M, Natsume M, Osakabe N, Okazaki K, Furukawa F, Imazawa T, et al. Chemoprevention of lung carcinogenesis by cacao liquor proanthocyanidins in a male rat multi-organ carcinogenesis model. Cancer Letters 2003;191:49–57. [124] McKim SE, Konno A, Gäbele E, Uesugi T, Froh M, Sies H, et al. Cocoa extract protects against early alcohol-induced liver injury in the rat. Archives of Biochemistry and Biophysics 2002;406:40–6. [125] Scalbert A, Déprez S, Mila I, Albrecht AM, Huneau JF, Rabot S. Proanthocyanidins and human health: systemic effects and local effects in the gut. Biofactors 2000;13:115–20. [126] Martin FP, Rezzi S, Peré-Trepat E, Kamlage B, Collino S, Leibold E, et al. Metabolic effects of dark chocolate consumption on energy, gut microbiota, and stress-related metabolism in free-living subjects. Journal of Proteome Research 2009;8:5568–79. [127] Zhu QY, Schramm DD, Gross HB, Holt RR, Kim SH, Yamaguchi T, et al. Influence of cocoa flavanols and procyanidins on free radical-induced human erythrocyte hemolysis. Clinical & Developmental Immunology 2005;12: 27–34. [128] Osakabe N, Yamagishi M, Natsume M, Yasuda A, Osawa T. Ingestion of proanthocyanidins derived from cacao inhibits diabetes-induced cataract formation in rats. Experimental Biology and Medicine (Maywood) 2004;229:33–9.