External Counterpulsation Improves Angiogenesis by Preserving Vascular Endothelial Growth Factor-A and Vascular Endothelial Growth Factor Receptor-2 but Not Regulating MicroRNA-92a Expression in Patients With Refractory Angina

Ade Meidian Ambari, Gracia Lilihata, Ervan Zuhri, Elok Ekawati, Shoma Adhi Wijaya, Bambang Dwiputra, Renan Sukmawan, Basuni Radi, Sofia Mubarika Haryana, Suko Adiarto, Dicky A Hanafy, Dian Zamroni, Elen Elen, Arwin S Mangkuanom, Anwar Santoso, Ade Meidian Ambari, Gracia Lilihata, Ervan Zuhri, Elok Ekawati, Shoma Adhi Wijaya, Bambang Dwiputra, Renan Sukmawan, Basuni Radi, Sofia Mubarika Haryana, Suko Adiarto, Dicky A Hanafy, Dian Zamroni, Elen Elen, Arwin S Mangkuanom, Anwar Santoso

Abstract

Objective: External counterpulsation (ECP) provides long-term benefits of improved anginal frequency and exercise tolerance in patients with refractory angina (RA). This is postulated as a result of improved angiogenesis and endothelial function through an increase in shear stress. Angiogenesis is mainly represented by vascular endothelial growth factor-A (VEGF-A) and its receptor, vascular endothelial growth factor receptor-2 (VEGFR-2). The microRNA-92a (miR-92a) is a flow-sensitive miRNA that regulates atherosclerosis and angiogenesis in response to shear stress. Thus, ECP beneficial effect might be achieved through interaction between VEGF-A, VEGFR-2, and miR-92a. This study aims to evaluate the ECP effect on VEGF-A, VEGFR-2, and miR-92a in patients with RA in a sham-controlled manner. Methods: This was a randomized sham-controlled trial, enrolling 50 patients with RA who have coronary artery disease (CAD). Participants were randomized (1:1 ratio) to 35 sessions of either ECP (n = 25) or sham (n = 25), each session lasting for 1 h. Plasma levels of VEGF-A and VEGFR-2 were assayed by the ELISA technique. The quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was performed to measure miR-92a circulating levels in plasma. Result: External counterpulsation significantly preserved VEGF-A and VEGFR-2 level compared to sham [ΔVEGF-A: 1 (-139 to 160) vs.-136 (-237 to 67) pg/ml, p = 0.026; ΔVEGFR-2: -171(-844 to +1,166) vs. -517(-1,549 to +1,407) pg/ml, p = 0.021, respectively]. Circulating miR-92a increased significantly in ECP [5.1 (4.2-6.4) to 5.9 (4.8-6.4), p < 0.001] and sham [5.2 (4.1-9.4) to 5.6 (4.8-6.3), p = 0.008] post-intervention. The fold changes tended to be higher in ECP group, although was not statistically different from sham [fold changes ECP = 4.6 (0.3-36.5) vs. sham 2.8 (0-15), p = 0.33)]. Conclusion: External counterpulsation improved angiogenesis by preserving VEGF-A and VEGFR-2 levels. Both ECP and sham increased miR-92a significantly, yet the changes were not different between the two groups. (Study registered on www.clinicaltrials.gov, no: NCT03991871, August 8, 2019, and received a grant from the National Health Research and Development of Ministry of Health of Indonesia, No: HK.02.02/I/27/2020).

Keywords: angiogenesis; external counter pulsation (ECP); micro RNA-92a (miR-92a); vascular endothelial growth factor (VEGF); vascular endothelial growth factor receptor-2 (VEGFR-2); vascular endothelial growth factor-A (VEGF-A).

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Ambari, Lilihata, Zuhri, Ekawati, Wijaya, Dwiputra, Sukmawan, Radi, Haryana, Adiarto, Hanafy, Zamroni, Elen, Mangkuanom and Santoso.

Figures

Figure 1
Figure 1
CONSORT flow diagram.
Figure 2
Figure 2
Boxplot of vascular endothelial growth factor receptor-2 (VEGFR-2) concentration before and after intervention in external counter pulsation (ECP) group (A) and sham group (B). *Analysis by Wilcoxon test.
Figure 3
Figure 3
Boxplot of microRNA-92a (miR-92A) expression before and after intervention in ECP group (A) and sham group (B). *Analysis by Wilcoxon test.

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