Pulsed electromagnetic fields treatment ameliorates cardiac function after myocardial infarction in mice and pigs

Shiqi Wang; Gaiqin Pei; Jiayu Shen; Zhi Fang; Tingyu Chen; Lu Wang; Hongxin Cheng; Hanbin Li; Hongliang Pei; Qipu Feng; Qingwen Fan; Chengqi He; Chenying Fu; Yingqiang Guo; Quan Wei

doi:10.1016/j.jare.2025.04.019

. 2025 Apr 16;80:1139–1153. doi: 10.1016/j.jare.2025.04.019

Pulsed electromagnetic fields treatment ameliorates cardiac function after myocardial infarction in mice and pigs

Shiqi Wang ^a,^b,¹, Gaiqin Pei ^a,^b,¹, Jiayu Shen ^c,¹, Zhi Fang ^c, Tingyu Chen ^d, Lu Wang ^a,^b, Hongxin Cheng ^a,^b, Hanbin Li ^a,^b, Hongliang Pei ^e, Qipu Feng ^f, Qingwen Fan ^e, Chengqi He ^a,^b, Chenying Fu ^g,^h,^⁎, Yingqiang Guo ^c,^⁎, Quan Wei ^a,^b,^⁎

PMCID: PMC12869239 PMID: 40250556

Graphical abstract

Keywords: Pulsed electromagnetic fields treatment, Myocardial infarction, Ischemic heart disease, TLR4, TGF-β1

Highlights

•
PEMF treatment can ameliorate cardiac function and reduce scar size in post-MI mice and pigs.
•
The benefits of PEMF in the treatment of MI are supported by reduced inflammatory responses, improved cell survival, and decreased collagen secretion.
•
The underlying molecular mechanism of PEMF treatment is associated with the inhibition of the TLR4/MyD88/NF-κB and TGF-β1/SMAD3 signaling pathways.
•
From the perspective of safety, the process of PEMF treatment is safe. No adverse events occur. PEMF treatment does not cause damage to liver or kidney function and does not lead to the growth of harmful intestinal flora.
•
PEMF treatment holds significant promise as a noninvasive physical therapy modality, justifying further exploration of its potential implications for managing patients with IHD.

Abstract

Introduction

Ischemic heart disease (IHD) is a prominent contributor to mortality worldwide, with myocardial infarction (MI) representing its most severe manifestation. Pulsed electromagnetic fields (PEMF) treatment shows promise for treating IHD. Nevertheless, the therapeutic impact and underlying mechanism of PEMF in MI are not fully understood.

Objectives

To investigate the efficacy, safety, and mechanisms of PEMF for MI.

Methods

We established MI models in both mice and pigs and performed serial echocardiography and cardiac magnetic resonance follow-up to demonstrate the benefit of PEMF treatment after MI. The pathological environment after myocardial infarction was simulated in vitro to observe changes in various cells exposed to PEMF. Gene knockout (TLR4^-/-) mice and inhibitors were used to compare the differences in the efficacy of PEMF treatment relative to that of gene knockout/inhibitor treatments. Agonists were used to further explore the mechanism of PEMF treatment.

Results

In post-MI mice, PEMF treatment enhanced cardiac function and reduced scar formation. PEMF reduced the macrophage inflammatory response, improved cardiomyocyte survival in an inflammatory environment, and decreased collagen secretion by fibroblasts in vitro. Importantly, in the clinically relevant porcine model, PEMF treatment inhibited the inflammatory response and alleviated adverse left ventricular remodeling. Moreover, PEMF could exert therapeutic effects similar to those of gene knockout or inhibitor treatments. In the presence of TLR4 knockout or pyrrolidine dithiocarbamate (an NF-κB inhibitor) administration, PEMF could still improve cardiac function in post-MI mice. Mechanistically, the anti-inflammatory effect of PEMF was reversed when RS09 (a TLR4 agonist) was administered, and the antifibrotic effect of PEMF was attenuated after treatment with SRI-011381 (a TGF-β signaling pathway agonist).

Conclusions

PEMF treatment exhibits considerable promise as a noninvasive physical therapy modality, warranting further investigation into its potential implications for managing patients with IHD.

Introduction

Ischemic heart disease (IHD) is a prominent contributor to global mortality, with myocardial infarction (MI) representing its most severe manifestation [1]. Reperfusion therapies, including coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), serve as primary interventions aimed at diminishing the extent of infarction [2]. However, certain patients with MI may not be suitable candidates for PCI and CABG, particularly if they suffer from hemorrhagic disease, degenerative diffuse vascular stenosis, or occlusion of the great saphenous vein bypass [3]. Additionally, the effectiveness of reperfusion therapy is limited due to potential complications such as reperfusion injury and vascular restenosis [4]. Therefore, there is a pressing need to develop novel strategies for myocardial protection in post-MI patients.

Electromagnetic fields (EMF) are omnipresent, and among them, pulsed electromagnetic fields (PEMF) have demonstrated efficacy as a noninvasive physical therapy modality in various domains, as evidenced by multiple studies [[5], [6], [7], [8]]. The underlying mechanism behind the potential impact of PEMF on biological processes is postulated to involve alterations in the cellular microenvironment and subsequent modulation of intracellular signaling pathways through mechanical stress [9,10]. A prior study indicated that EMF treatment is safe and tolerable in patients with acute stroke, suggesting the potential efficacy of this physical therapy modality in ameliorating ischemic conditions [11]. In 1999, Albertini et al. initially demonstrated that PEMF exposure could mitigate the necrotic area following acute ischemic injury induced by permanent ligation of the left anterior descending artery [12]. Moreover, our previous study revealed that PEMF can reduce cell death at the MI border and promote angiogenesis in post-MI mice [13,14].

The pathophysiological mechanism of MI is highly intricate [15]. After MI, the activation of signaling pathways, such as the Toll-like receptor (TLR) and transforming growth factor beta (TGF-β) signaling pathways, leads to the infiltration of inflammatory cells and the proliferation and differentiation of cardiac fibroblasts in the infarct region [16]. Although inflammation is crucial to wound healing and cardiac remodeling, a significant proportion of cardiomyocytes fail to regenerate and undergo cell death [17,18]. Moreover, the inflammation that occurs after MI exacerbates left ventricular (LV) remodeling and contributes to the development of heart failure [19]. Thus, for optimal cardiac tissue repair following MI, inflammation and excessive fibrosis need to be contained and resolved as soon as possible. However, few studies have investigated the impact of PEMF treatment on post-MI fibrosis and inflammation.

Here, we established permanent coronary artery ligation models in both mice and pigs and performed serial echocardiography (Echo) and cardiac magnetic resonance (CMR) follow-up to demonstrate the benefit of PEMF treatment after MI. Our findings indicated that PEMF treatment ameliorated cardiac function and reduced infarct size after MI. Furthermore, PEMF could exert therapeutic effects similar to those of gene knockout or inhibitor treatments. Mechanistically, we revealed that the anti-inflammatory and antifibrotic effects of PEMF were mediated by the TLR4/MyD88/NF-κB and TGF-β1/SMAD3 signaling pathways. Moreover, the biochemical parameters and intestinal flora of the experimental animals were dynamically monitored throughout the study to ensure the safety of the PEMF. The therapeutic effects and mechanisms of PEMF revealed in our study provide preclinical insights for reducing infarct size and promoting infarct healing and are conducive to the development of therapeutic strategies for IHD based on physical therapy modalities.

Materials and methods

Additional methods are provided in the Supplementary Materials.

Ethics statement

The animal experimental procedures were reviewed and approved by the Institutional Animal Care and Use Committees of West China Hospital, Sichuan University (Registration numbers: 20220228075 and 20211445A). All experiments involving animals were performed in accordance with the National Institutes of Health Guide for the Care and Use of Laboratory Animals. Furthermore, this study was committed to the “3R” principle of experimental animal research and therefore used the minimum number of animals to draw statistical conclusions.

MI induction and grouping

Mice

Wild-type (WT) and TLR4 knockout (TLR4^-/-) mice aged 8–12 weeks were used for MI induction. The induction procedure was consistent with that in our previous study. Briefly, under 2 % isoflurane inhalation anesthesia, after tracheal intubation and thoracotomy, the left anterior descending coronary artery was ligated approximately 2 mm below the left auricle with an 8–0 nylon surgical suture. After successful ligation, the anterior wall of the left ventricle became white, and Echo revealed that the left ventricular ejection fraction (LVEF) was lower than 50 %. MI mice were randomly divided into the MI group (control group), PEMF group (treatment group), T^-/- group (TLR4^-/- MI group), T^-/- PEMF group (TLR4^-/- treated group), PDTC group (NF-κB inhibitor group), and PDTC PEMF group (PDTC treatment group). MI was induced in all groups of mice. In the NF-κB inhibitor group and PDTC treatment group, the NF-κB inhibitor pyrrolidine dithiocarbamate (PDTC) (100 mg/kg) was injected intraperitoneally 1 h before MI induction, and each treatment group received PEMF treatment after MI induction. Relevant imaging examinations were performed as planned. After the last Echo (day 14), the animals were sacrificed under isoflurane anesthesia by increasing the dosage of the anesthetic. Tissue and blood samples were collected for subsequent pathological and molecular experiments.

Pigs

Bama miniature pigs weighing 25 to 30 kg were used in the experiment. Before the operation, the experimental animals underwent a one-week adaptation period to acclimate to the environment and were then randomly assigned to either the MI group or the PEMF group. Routine skin preparation was performed before the operation. Zoletil 50 (0.1 mg/kg) was used for basic anesthesia. The animals were anesthetized via intravenous bolus injection of propofol (5 mg/kg) and the muscle relaxant vecuronium bromide (2 mg/kg). Isoflurane was used to maintain anesthesia after endotracheal intubation. After thoracotomy, the distal 1/3 of the left anterior descending (LAD) branch was ligated. The success of the MI model was preliminarily determined on the basis of electrocardiogram (ECG) manifestations and local macroscopic changes in the heart after coronary artery ligation (Fig. S1). Standard postoperative care was provided until the animals were fed normally. Pigs were treated with PEMF starting on the first postoperative day. Relevant imaging examinations were performed as planned, and blood samples were collected. After the last CMR imaging examination (day 28), the animals were sacrificed by pentobarbital (200 mg/kg). Tissue, blood, and fecal samples were collected for subsequent pathological and molecular experiments.

PEMF treatment

PEMF equipment suitable for mice and pigs was jointly developed by the West China Clinical Medical College of Sichuan University and the School of Mechanical Engineering of Sichuan University. The PEMF equipment we used for the mice was the same as that used in our previous studies, which utilized a standard Helmholtz coil for a uniform magnetic field (Fig. S2A-C) [13]. For the treatment of pigs, we increased the size of the device and used 3 Helmholtz coils to expand the scope of the magnetic field, ensuring the uniformity of the magnetic field (Fig. S2D). Pigs need to be transported to PEMF equipment with the assistance of animal center staff. During the whole transport process, rough movements that caused the experimental animals to be irritable and uneasy were avoided. A cuboid movement area (wooden fence) was set up inside the instrument to limit the range of movement of the pigs so that they could stay in the magnetic field during the treatment (Fig. S2E). A Gaussian meter was used to measure the strength of the magnetic field for each treatment to maintain equipment stability (Fig. S2C and F). Because our previous study revealed that 30 Hz, 3.0 mT PEMF treatment was beneficial for the treatment of MI, this study used this parameter for intervention, and the treatment time was 45 min per day [13]. Post-MI mice were treated with PEMF for a total of 14 days. Post-MI pigs received PEMF treatment for a total of 28 days. Notably, mice in the MI, T^-/-, and PDTC groups, as well as pigs in the MI group, received sham PEMF stimulation for 45 min per day, during which the equipment did not provide any EMF output.

Echocardiography

The mice were examined by Echo at 1, 7, and 14 days after MI. A parasternal short-axis two-dimensional M−mode diagram was used to detect the LVEF, left ventricular fractional shortening (LVFS), left ventricular end of diastole volume (LVEDV), and left ventricular end of systole volume (LVESV). The pigs were examined at 1, 7, 14, and 28 days after MI. The probe was placed after the right intercostal space touched the heartbeat to obtain the four-chamber image, and the M−mode map was obtained. The detection contents included left ventricular internal dimension systole (LVIDs), left ventricular internal dimension diastole (LVIDd), LVEF, and LVFS.

CMR imaging

A total of 10 pigs (5 in each group) were subjected to CMR imaging at 14 and 28 days after MI. In this study, the acquisition was performed on a Philips Ingenia 3.0 T scanner, and the CMR was set in the supine position with the head facing forward to acquire cardiac images. The collection methods were similar to those used in previous studies [20,21]. The following CMR sequences were collected from experimental animals: the cine sequence to evaluate cardiac function and wall motion (WM) and late gadolinium enhancement (LGE) to evaluate the number and extent of myocardial lesions. All CMR studies followed the same scheme. First, scout images were acquired to locate the true axis of the heart and define a field of view involving the entire heart. Subsequently, from the short-axis movie sequence, we obtained cardiac phases at each level to ensure the correct assessment of cardiac function and WM. Then, gadopentetate dimeglumine (Magnevist) (Gd-GTPA, Bayer Schering Pharma AG, Germany) (0.1 mmol/kg) was injected intravenously. LGE sequences were obtained 10 min after contrasting medium injection. The scan parameters were as follows: cine: TR: shortest, TE: shortest, FA 45°, and layer thickness 8 mm. LGE: TR shortest, TE 3 ms, FA 25°, and layer thickness 8 mm.

CMR image processing and analysis

After scanning was completed, the data were imported into postprocessing analysis software (Circle cvi42). The software obtained 16 segments of data for each parameter according to the American Heart Association (AHA) segmentation method. Briefly, the endocardial and epicardial contours of the cine sequence were sketched to obtain the left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), LVEF, and WM. The wall motion score index (WMSI) was used to evaluate the WM of the territory supplied by the LAD [22]. Subsequently, normal myocardial ROIs were sketched on the LGE sequence, the area that was 3 standard deviations greater than the mean value of the normal myocardium was defined as the enhanced area, and the number of LGE-positive segments for each case was calculated.

Statistical analysis

All values in the box plots are presented as medians (interquartile range), and the values in the bar plots are presented as the means ± standard error (mean ± SEM). All the data in the table are presented as the means ± standard deviation (mean ± SD). Student's t test, ANOVA, or nonparametric multiple comparison tests were used for statistical analysis. Spearman's rank correlation coefficient was used to analyze correlations between the data. The differences in the box plots are marked by “*” or “#”. The differences in the bar plots are marked by the alphabet mark method. A p value less than 0.05 was considered to indicate statistical significance. Statistical analysis was performed via GraphPad Prism v9 software or R version 3.6.1.

Results

PEMF ameliorated cardiac function and decreased infarct size after MI in mice

WT mice received PEMF treatment after the operation. The Echo was performed every week to evaluate cardiac function. The detailed experimental procedure is illustrated in Fig. 1A. The Echo results indicated that the LVEF and LVFS of post-MI mice in the PEMF group were greater than those in the MI group, whereas the LVEDV and LVESV were lower (Fig. 1B-F). The detailed echocardiographic results are shown in Table S1. These results indicated that PEMF can effectively improve impaired cardiac function in post-MI mice. Furthermore, Western blotting results demonstrated that PEMF reduced inducible iNOS expression in the inflammatory environment of MI (Fig. 1G-H). The concentration of TNF-α in murine serum measured by ELISA in the PEMF group was lower than that in the MI group (Fig. 1I). In addition, Masson staining revealed that the infarct size in the PEMF group was significantly reduced at 14 days after MI (Fig. 1J-K).

Fig. 1 — **PEMF ameliorates cardiac function and decreases infarct size after MI in mice. (A)** Animal experimental design. **(B)** Representative echocardiograms of each group at 14 days after MI. **(C-F)** The LVEF (p = 0.006), LVFS (p < 0.001), LVEDV (p = 0.003), and LVESV (p < 0.001) are significantly different between the two groups at 14 days after MI. n = 9 in each group. **(G)** Representative Western blotting results of iNOS in each group at 14 days after MI. **(H)** The relative protein expression of iNOS in murine myocardial tissue after MI is significantly different between the two groups (p = 0.003). n = 3 in each group. **(I)** The concentration of TNF-α in the serum at 14 days after MI is significantly different between the two groups (p < 0.001). n = 6 in each group. **(J)** Representative Masson staining of mice after MI for 14 days. Scale bar = 1 mm. **(K)** Statistics of infarct size in mice after MI for 14 days. The difference between the two groups was statistically significant (p = 0.002). n = 6 in each group. All the sample numbers provided represent biological replicates. Comparisons of parameters were performed with Student’s t test or nonparametric tests. The values in the box plots are presented as medians (interquartile range), and the values in the bar plots are presented as the means ± SEM. The differences in the box plots are marked by “*”. ** p < 0.01, *** p < 0.001 vs. the MI group. The differences in the bar plots are marked by the alphabet mark method. The means with different letters above the bars are significantly different from each other. Differences with a p value < 0.05 were considered statistically significant. iNOS, inducible nitric oxide synthase; LVEF, left ventricular ejection fraction; LVEDV, left ventricular end of diastole volume; LVESV, left ventricular end of systole volume; LVFS, left ventricular fractional shortening; MI, myocardial infarction; PEMF, pulsed electromagnetic fields; TNF-α, tumor necrosis factor-α.

PEMF reduced the macrophage inflammatory response, improved cardiomyocyte survival in an inflammatory environment, and decreased collagen secretion in vitro

Given the effectiveness of PEMF treatment in mice, we further explored the effects of PEMF exposure on various cells in vitro. Inflammation and tissue repair are influenced by inflammatory factors in heart macrophages after MI. We directly exposed macrophages induced by LPS and IFN-γ to PEMF to clarify the effects of PEMF on RAW 264.7 macrophages. PEMF reduced the LPS + INF-γ-induced release of TNF-α from macrophages (Fig. S3). Immunofluorescence staining revealed that compared with the LPS + IFN-γ treatment, the PEMF treatment significantly reduced the number of iNOS-positive macrophages (Fig. 2A-B). Western blotting further confirmed that PEMF intervention inhibited the expression of nitric oxide synthase (iNOS) (Fig. 2C-D).

Fig. 2 — PEMF reduces inflammation, cell death, and fibrosis *in vitro*. **(A)** Representative immunofluorescence staining (iNOS) of RAW 264.7 macrophages. Scale bar = 50 μm. **(B)** Statistics of the relative number of iNOS-positive cells in each group. The difference between the LPS + IFN-γ group and the PEMF group was statistically significant (p < 0.001). n = 4 in each group. **(C)** Representative Western blotting results of iNOS in RAW 264.7 macrophages. **(D)** The relative protein expression of iNOS in RAW 264.7 macrophages is significantly different between the LPS + IFN-γ group and the PEMF group (p = 0.029). n = 3 in each group. **(E)** Representative Hoechst/PI staining of H9C2 cardiomyocytes. Scale bar = 100 μm. **(F)** Statistics of the relative number of PI-positive cells in each group. The difference between the MCM group and the PEMF group was statistically significant (p = 0.0006). n = 4 in each group. **(G)** Statistics of the relative viability of H9C2 cardiomyocytes via the CCK-8 assay. The difference between the MCM group and the PEMF group was statistically significant (p = 0.005). n = 4 in each group. **(H)** Statistics of the relative LDH release in H9C2 cardiomyocyte supernatants. The difference between the MCM group and the PEMF group was statistically significant (p = 0.005). n = 5 in each group. **(I)** Representative immunofluorescence staining (Col 1) of NIH3T3 fibroblasts. Scale bar = 100 μm. **(J)** Statistics of the relative number of Col 1-positive cells in each group. n = 3 in each group. **(K)** Representative Western blotting results of Col 1 and α-SMA in NIH3T3 fibroblasts after exposure to PEMF. **(L-M)** The relative protein expression levels of Col 1 (p < 0.001) and α-SMA (p = 0.019) in NIH3T3 fibroblasts are significantly different between the two groups. n = 3 in each group. **(N)** Representative Western blotting results of Col 1 and α-SMA in NIH3T3 fibroblasts treated with TGF-β1 after exposure to PEMF. **(O-P)** The relative protein expression levels of Col 1 (p = 0.041) and α-SMA (p = 0.033) in NIH3T3 fibroblasts are significantly different between the TGF-β1 group and the PEMF group. n = 4 in each group. All the sample numbers provided represent biological replicates. Comparisons of parameters were performed with Student’s t test or ANOVA. All values are presented as the means ± SEM. The differences in the bar plots are marked by the alphabet mark method. The means with different letters above the bars are significantly different from each other. Differences with a p value < 0.05 were considered statistically significant. α-SMA, alpha smooth muscle actin; Col 1, collagen type Ⅰ; iNOS, inducible nitric oxide synthase; MCM, macrophage-conditioned medium; PEMF, pulsed electromagnetic fields; TGF-β1, transforming growth factor beta 1.

We used the supernatant of macrophages induced by LPS and IFN-γ as MCM to treat H9C2 cardiomyocytes to simulate the pathological environment of myocardial cells after MI. Hoechst/PI staining further suggested that PEMF exposure reduced MCM-induced myocardial cell death (Fig. 2E-F). In addition, MCM-treated H9C2 cardiomyocytes presented significantly decreased viability and significantly increased LDH release in the supernatant, both of which could be improved by PEMF (Fig. 2G-H).

To further assess the effects of PEMF on fibrosis in vitro, we exposed NIH3T3 fibroblasts with or without TGF-β1 induction to PEMF. The immunofluorescence staining results suggested that the expression of the fibroblast-to-myofibroblast transition (FMT) marker Col 1 decreased after PEMF exposure (Fig. 2I-J). The Western blotting results revealed that the relative expression levels of Col1 and α-SMA in the PEMF group were lower than those in the control group or the TGF-β1 group (Fig. 2K-P).

PEMF ameliorated cardiac function and decreased infarct size after MI in pigs

We proceeded to establish the MI model in pigs, aiming to ascertain the potential of PEMF treatment for clinical translation in IHD (Fig. 3A) [23]. The Echo results indicated that the LVEF and LVFS of post-MI pigs in the PEMF group both improved at 28 days (Fig. 3B-D). Table S2 shows the detailed echocardiographic results. Similar results were obtained when CMR was used to evaluate cardiac function (Fig. S4A-D). In addition, the LGE sequence of CMR was used to analyze the changes in the infarct area after MI in pigs. The infarction size in the PEMF group was significantly lower than that in the MI group (Fig. 3E-G). The detailed anatomical function parameters are shown in Table S3. Moreover, we evaluated the WM of the myocardium supplied by the LAD through the WMSI. Overall, there were varying degrees of WM abnormalities in both groups, but we still found that the WMSI of the myocardium was lower in the PEMF group than in the MI group (Fig. S4E).

Notably, pathological testing further supported the functional improvement and efficacy of PEMF treatment. HE staining revealed a disordered structure in the border zone of the myocardial tissue in the MI group, in contrast to the distinct and orderly structure observed in the PEMF group (Fig. 3H). Hypertrophy and fibrosis are important links to pathological remodeling. Myocardial size was evaluated by WGA staining, and the results revealed that PEMF decreased myocardial hypertrophy at the infarct junction. The Masson and Sirius Red staining results revealed that PEMF significantly reduced fibrosis in the border zone (Fig. 3H-K).

PEMF reduced apoptosis and proinflammatory factor levels after MI in pigs

TUNEL staining revealed that PEMF reduced the number of TUNEL-positive cells after MI (Fig. 4A and C). In addition, immunohistochemical staining revealed that PEMF significantly reduced the expression of TNF-α in the border zone of the heart in post-MI pigs (Fig. 4B and D). After 28 days, the serum LDH levels were significantly lower in the PEMF group (Fig. 4E). The concentrations of IL-1β and TNF-α in the serum of pigs at 1 and 28 days after MI were detected via ELISA, and the decrease in proinflammatory factor levels was greater in the PEMF group (Fig. 4F-G).

PEMF treatment affected the TLR4/MyD88/NF-κB and TGF-β1/SMAD3 signaling pathways in the myocardial tissue of pigs

To elucidate the biological function of PEMF in MI, mRNA-seq was conducted on two groups of porcine myocardial tissue. The results of mRNA-seq of myocardial tissue from pigs after MI suggested that 250 upregulated and 1,116 downregulated genes were observed in the PEMF group compared with the MI group (Fig. S5A). Interestingly, we observed extracellular matrix, collagen-containing extracellular matrix, and inflammatory response in the GO enrichment of DEGs, which further confirmed that inflammation and fibrosis differed between the two groups (Fig. S5B). KEGG enrichment analysis revealed alterations in the TLR and TGF-β signaling pathways (Fig. S5C). Therefore, the follow-up of this study focused on these two important signaling pathways in terms of mechanistic exploration.

The TLR4/MyD88/NF-κB signaling pathway plays an important role in PEMF treatment to reduce inflammatory

We found that the expression of the TLR4/MyD88/NF-κB signaling pathway was downregulated in the border zone in pigs and mice after PEMF treatment (Fig. 5A-H). In addition, after LPS- and IFN-γ-induced macrophages were exposed to PEMF, the expression of this pathway molecule was also significantly downregulated (Fig. 5I-L). More importantly, after pretreatment of RAW 264.7 macrophages with RS09 (a TLR4 agonist), the regulatory effect of PEMF on this pathway was reversed (Fig. 5M-P). Additionally, both the down-regulation of iNOS expression and the inhibitory effect on TNF-α release of PEMF were counteracted (Fig. 5Q-S). These results indicate that PEMF could reduce inflammation by regulating the TLR4/MyD88/NF-κB signaling pathway in vitro. Notably, after pretreatment of RAW264.7 macrophages with TAK-242 (a TLR4 inhibitor) and PDTC (an NF-κB inhibitor), PEMF still inhibited iNOS expression (Fig. S6A-C) and decreased TNF-α release from the macrophage supernatant (Fig. S3), which illustrated that PEMF might have additive effects when PEMF was used in combination with TLR4 or NF-κB inhibitors.

Fig. 5 — **PEMF alleviates inflammation through the TLR4/MyD88/NF-κB signaling pathway *in vitro*. (A)** Representative Western blotting results of TLR4, MyD88, and NF-κB p-P65 in pigs in each group at 28 days after MI. **(B-D)** The relative protein expression levels of TLR4 (p = 0.028), MyD88 (p = 0.033), and NF-κB p-P65 (p = 0.040) in porcine myocardial tissue after MI are significantly different between the two groups. n = 4 in each group. **(E)** Representative Western blotting results of TLR4, MyD88, and NF-κB p-P65 in the mice in each group at 14 days after MI. **(F-H)** The relative protein expression levels of TLR4 (p = 0.035), MyD88 (p = 0.031), and NF-κB p-P65 (p = 0.011) in murine myocardial tissue after MI are significantly different between the two groups. n = 3 in each group. **(I)** Representative Western blotting results of TLR4, MyD88, and NF-κB p-P65 in RAW 264.7 macrophages. **(J-L)** The relative protein expression levels of TLR4 (p = 0.038), MyD88 (p = 0.018), and NF-κB p-P65 (p = 0.024) in RAW 264.7 macrophages in the two groups are significantly different. n = 3 in each group. **(M)** Representative Western blotting results of TLR4, MyD88, and NF-κB p-P65 in RAW 264.7 macrophages treated with RS09. **(N-P)** The relative protein expression of TLR4, MyD88, and NF-κB p-P65 in RAW 264.7 macrophages in the three groups. There is no significant difference between the LPS + INF-γ group and the RS09 PEMF group (p > 0.05). n = 4 in each group. **(Q)** Representative Western blotting results of iNOS in RAW 264.7 macrophages treated with RS09. **(R)** Relative protein expression of iNOS in RAW 264.7 macrophages treated with RS09. There is no significant difference between the LPS + INF-γ group and the RS09 PEMF group (p > 0.05). n = 4 in each group. **(S)** TNF-α concentration in the supernatants of RAW 264.7 macrophages in three groups. There is no significant difference between the LPS + INF-γ group and the RS09 PEMF group (p > 0.05). n = 5 in each group. All the sample numbers provided represent biological replicates. Comparisons of parameters were performed with Student’s t test or ANOVA. All values are presented as the means ± SEM. The differences in the bar plots are marked by the alphabet mark method. The means with different letters above the bars are significantly different from each other. Differences with a p value < 0.05 were considered statistically significant. MyD88, myeloid differentiation primary response gene 88; MI, myocardial infarction; NF-κB, nuclear factor kappa-B; PDTC, pyrrolidine dithiocarbamate; PEMF, pulsed electromagnetic fields; RS09, TLR4 agonist; TAK-242, Resatorvid; TLR4, Toll-like receptor 4.

Given the pivotal role of the TLR4/MyD88/NF-κB signaling pathway in the anti-inflammatory effects of PEMF, we used WT mice, TLR4^-/- mice, and mice preconditioned with PDTC for subsequent experiments after MI induction, aiming to compare the differences in the efficacy of PEMF treatment relative to that of gene knockout/inhibitor treatments, as well as to investigate potential changes in the efficacy and possible additive effects of PEMF treatment in the context of gene knockout or inhibitor use (Fig. 6A). In terms of cardiac function improvement, the efficacy of PEMF treatment was similar to that of TLR4^-/- or PDTC treatments. In particular, the combination of TLR4^-/- with PEMF treatment demonstrated superior outcomes compared to PEMF alone (Fig. 6B-D). The detailed echocardiographic results are shown in Table S4. In addition, the expression of iNOS in the T^-/- PEMF group was lower than that in the PEMF group (Fig. 6E-G). Furthermore, the Masson staining results suggested that the original myocardial tissue was replaced by fibrous tissue after MI. The infarct size was notably diminished in the mice following PEMF intervention, with a pronounced effect observed in the T^-/- PEMF group (Fig. 6H-I and Table S5). The concentration of TNF-α in murine serum also showed a similar trend. Specifically, TNF-α concentrations were significantly lower in the T^-/- PEMF and PDTC PEMF groups than in the PEMF group (Fig. 6J and Table S5).

Fig. 6 — **PEMF treatment exerts therapeutic effects similar to those of gene knockout or inhibitor treatments *in vivo*. (A)** Animal experimental design. **(B)** Representative echocardiograms of each group at 14 days after MI. **(C-D)** The LVEF **(C)** and LVFS **(D)** in each group at 14 days after MI. The LVEF (p = 0.04) and LVFS (p = 0.01) of the post-MI mice are significantly different between the PEMF group and the T^-/- PEMF group. n = 8–11 in each group. **(E)** Representative Western blotting results of iNOS in each group at 14 days after MI. **(F-G)** Relative protein expression of iNOS in murine myocardial tissue after MI. The relative protein expression of iNOS in post-MI mice is significantly different between the PEMF group and the T^-/- PEMF group (p = 0.022). n = 3 in each group. **(H)** Representative Masson staining of the mice in each group after MI at 14 days. Scale bar = 1 mm. **(I)** Statistics of infarct size in mice after MI for 14 days. The infarct size is significantly different between the PEMF group and the T^-/- PEMF group (p = 0.034). n = 5–7 in each group. **(J)** TNF-α concentration in the serum at 14 days after MI. Compared with that in the PEMF group, the TNF-α concentration in the T^-/- PEMF group (p = 0.001) and the PDTC group (p < 0.001) is significantly different. n = 6–13 in each group. All the sample numbers provided represent biological replicates. Comparisons of parameters were performed with ANOVA or nonparametric tests. The values in the box plots are presented as medians (interquartile range), and the values in the bar plots are presented as the means ± SEM. The differences in the box plots are marked by “*” and “#”. * p < 0.05, ** p < 0.01 vs. the MI group; # p < 0.05 vs. the PEMF group. The differences in the bar plots are marked by the alphabet mark method. The means with different letters above the bars are significantly different from each other. Differences with a p value < 0.05 were considered statistically significant. iNOS, inducible nitric oxide synthase; LVEF, left ventricular ejection fraction; LVFS, left ventricular fractional shortening; MI, myocardial infarction; PDTC, pyrrolidine dithiocarbamate; PEMF, pulsed electromagnetic fields; TAK-242, Resatorvid; T^-/-, TLR4 knockout; TLR4, Toll-like receptor 4; TNF-α, tumor necrosis factor-α.

PEMF played an antifibrotic role by regulating TGF-β1/SMAD3

The protein expression level of TGF-β1 and the phosphorylation level of p-SMAD3 in the myocardial tissue of pigs in the PEMF group were decreased (Fig. S7A-C). We further verified whether PEMF was able to down-regulate the TGF-β1/SMAD3 pathway in vitro. Consistent with the protein expression results in the myocardium of pigs, PEMF downregulated the protein expression level of TGF-β1 and the phosphorylation level of p-SMAD3 of NIH3T3 fibroblasts (Fig. S7D-F). To verify that the reduction in fibrosis induced by PEMF was mediated by the TGF-β1/SMAD3 signaling pathway, we treated these fibroblasts with or without SRI-011381 hydrochloride (a TGF-β signaling pathway agonist). PEMF exposure resulted in down-regulation of SRI-011381-induced Col1, α-SMA, and TGF-β1 expression and p-SMAD3 phosphorylation. However, these changes were not significantly different from those observed in the control group. These findings suggested that SRI-011381 could attenuate the antifibrotic effects of PEMF on fibroblasts. Briefly, PEMF alleviated fibroblast fibrosis by inhibiting the TGF-β1/SMAD3 signaling pathway (Fig. S7G-L).

PEMF treatment was safe and well tolerated

During the study, we carefully monitored the post-MI pigs to determine the adverse events associated with PEMF treatment. We tested the relevant biochemical parameters of the blood supernatant. One day before the operation, all the measured parameters were within the healthy range. One day after modeling, changes caused by MI were observed in both groups. After 28 days of treatment, there was no difference in the biochemical parameters between the two groups. (Fig. 7A-F).

Fig. 7 — **PEMF treatment is safe and well tolerated. (A-F)** Changes in blood biochemical parameters over time between the two groups. There is no significant difference in blood biochemical parameters between the two groups before the operation or on the first or the 28th day after MI (p > 0.05). n = 5–6 in each group. (G) Heatmap of the microbial composition at the genus level. Compared with those in the MI group, the relative abundances of *Anaerostipes* (p = 0.003), *Intestinimonas* (p = 0.023), and *Blautia* (p = 0.025) in pigs in the PEMF group are lower. n = 3 in each group. **(H)** Heatmap of the microbial composition at the species level. Compared with those in the MI group, the relative abundances of *uncultured rumen bacterium* (p = 0.015), *Clostridiales bacterium NK3B98* (p = 0.027), *and unidentified rumen bacterium RFN28* (p = 0.01) in pigs in the PEMF group are decreased, whereas *uncultured Firmicutes bacterium* (p = 0.015) and *uncultured Clostridiales bacterium* (p = 0.005) in pigs in the PEMF group are increased. n = 3 in each group. **(I)** Association heatmap for correlation analysis between the intestinal flora and the Toll-like receptor signaling pathway. The relative abundance of *uncultured Firmicutes bacterium* is negatively correlated with the expression of TLR2 (p = 0.005) and MyD88 (p = 0.019). The relative abundance of the *unidentified rumen bacterium RFN28* is positively correlated with the expression of TLR4 (p = 0.036) and MyD88 (p = 0.036). The relative abundance of *Intestinimonas* is positively correlated with the expression of MyD88 (p = 0.042). n = 3 in each group. All the sample numbers provided represent biological replicates. Comparisons of parameters were performed with Student’s t test, ANOVA, or a nonparametric test. Correlation analysis was performed with Spearman's rank test. Differences with a p value < 0.05 were considered statistically significant. * p < 0.05, *** p < 0.001 vs. before operation. ^##p < 0.01, ^###p < 0.001 vs. Day 28. All values are presented as the means ± SEM. ALT, glutamic-pyruvic transaminase; AST, aspartate aminotransferase; CK, creatine kinase; CREA, creatinine; GGT, glutamyl transpeptidase; MyD88, myeloid differentiation primary response gene 88; TLR2, Toll-like receptor 2; TLR4, Toll-like receptor 4; TRIGL, triglyceride.

To ensure that the PEMF treatment did not lead to the growth of harmful flora, we performed further analysis of the microbial composition and abundance in the pig fecal samples. Fortunately, we did not observe changes in the diversity of the intestinal flora in the pigs (Fig. S8A-F). Although the composition of some intestinal flora was altered at the level of genus and species (Fig. 7G-H, Fig. S9A-H), these altered intestinal flora favored the downregulation of the TLR-like receptor signaling pathway (Fig. 7I). In brief, PEMF treatment was safe with no adverse events, and no treatment-related adverse hematological or laboratory chemical changes were observed, further supporting the safety of this physical therapy modality.

Discussion

In this study, an innovative physical therapy modality was employed in mice and pigs after MI to assess the benefits and safety of PEMF treatment in terms of cardiac anatomical and functional parameters, histopathology, and cellular and molecular responses. Additionally, the mechanisms of PEMF in mitigating inflammation and ameliorating fibrosis were investigated. We demonstrate that i) PEMF treatment can ameliorate cardiac function and reduce scar formation in post-MI mice; ii) PEMF exposure can reduce the macrophage inflammatory response, reduce cardiomyocyte death in an inflammatory environment, and diminish collagen secretion by fibroblasts in vitro; iii) in a clinically relevant porcine model, PEMF treatment has demonstrated the ability to inhibit MI-induced inflammation, reduce cell apoptosis, and alleviate adverse LV remodeling, and the treatment process is safe, with no reported adverse events; and iv) we also revealed that the anti-inflammatory and antifibrotic effects of PEMF treatment are mediated through the TLR4/MyD88/NF-κB and TGF-β1/SMAD3 signaling pathways.

Our study demonstrates that PEMF ameliorates cardiac function in mice following MI, which is consistent with the findings of previous studies [13,14,24]. In addition, many previous studies have shown that EMF can improve oxidative stress by regulating mitochondrial function [25,26]. For example, mitochondriogenesis and respiratory capacity can be enhanced by PEMF exposure [27]. Given the link between oxidative stress and inflammation, these previous findings imply that PEMF has the potential to control inflammation after MI. Notably, our findings in mice indicate that PEMF can alleviate inflammation after MI, which has not been reported in previous MI-related studies. Given the crucial role of timely inflammation control in MI recovery, particularly in the context of irreversible pathological remodeling during advanced stages, our innovative findings provide a key preclinical basis for physical therapy modalities for IHD [28,29]. Moreover, PEMF exposure can reduce the macrophage inflammatory response, decrease cardiomyocyte death, and ameliorate fibrosis in vitro, which further increases our confidence in conducting translational preclinical experiments in large animals.

To achieve clinical translation of PEMF in the treatment of MI, the same efficacy needs to be verified in large animals. Although studies in mice have provided a wider understanding of the treatment of MI with PEMF, the hearts of mice are different from those of humans [30]. In contrast, the pig heart has many similarities with the human heart, both in healthy and MI states [17,31]. There have been many reports on the use of physical therapy modalities, such as low-energy lasers and extracorporeal cardiac shock waves, for the treatment of MI in large animals [32,33]. Of note, there is a dearth of literature pertaining to the impact of PEMF treatment on inflammation and fibrosis in large animals, and our research endeavors to bridge this gap in knowledge. Our study revealed that PEMF treatment modulates systemic and local inflammatory mediators, improves LV function, reduces myocardial scar size, and prevents LV hypertrophy, which is consistent with findings in small animals.

Mechanistically, the anti-inflammatory and antifibrotic effects of PEMF are mediated by two classic signaling pathways, the TLR4/MyD88/NF-κB and TGF-β1/SMAD3 pathways. Multiple lines of evidence support our conclusion: i) The mRNA-seq results of porcine infarct border myocardium suggest that the TLR-like receptor and the TGF-β pathway are critically involved in the therapeutic effects of PEMF; ii) molecular changes in TLR4/MyD88/NF-κB and TGF-β1/SMAD3 were observed at both the cellular and animal levels; iii) The anti-inflammatory effect of PEMF was reversed upon the administration of RS09; and iv) the antifibrotic effect of PEMF was attenuated after the use of SRI-011381.

Inflammation is a key process after MI and is characterized by extensive cell death and inflammatory cell infiltration [34,35]. While an initial surge of inflammation can facilitate the healing process of necrotic myocardium, persistent and elevated levels of inflammation can result in myocardial interstitial remodeling and potentially lead to heart failure [36]. Previous studies have highlighted the therapeutic potential of PEMF treatment for regulating inflammation [37]. Katia Varani et al. have reported significant alterations in both the expression and function of adenosine A2A receptors in human neutrophils treated with PEMF [38]. Furthermore, evidence indicates that PEMF exposure mitigates inflammatory damage in neuron-like cells and microglia [39]. However, the underlying mechanisms and molecular targets of PEMF treatment remain poorly understood. Several in vitro studies reported that magnetic field exposure could reduce inflammatory responses in HEK-Blue™ hTLR4 cells [40,41]. Indeed, the role of TLR4 in inflammation and injury responses, such as those caused by myocardial ischemia, has been demonstrated in many studies using TLR4^-/- mice or targeted gene silencing of TLR4 [[42], [43], [44]]. Therefore, in addition to validating the mechanism at the cellular level, we performed a comparative analysis of the efficacy of PEMF and gene knockout/inhibitor in vivo. These results indicate that PEMF can elicit therapeutic effects comparable to those achieved through gene knockout or inhibitor treatment and may have additive benefits when combined with TLR4 knockout or NF-κB inhibitors.

Furthermore, the TGF-β1/SMAD3 signaling pathway plays a crucial role in tissue repair in the early stage of MI, but persistent high expression can lead to the activation of inflammatory factors, angiotensin-II, and other profibrotic cytokines, thereby aggravating cardiac fibrosis [16,45]. The persistent fibrotic response subsequently contributes to cardiac remodeling and the eventual development of heart failure [46,47]. There are currently no studies elucidating the mechanism by which PEMF for fibrosis after MI. The results of mRNA-seq and the trend toward improvement in the WM situation have aroused our interest, illustrating that PEMF may play a role in pathological remodeling. Our study demonstrated that PEMF treatment during MI can efficiently inhibit the TGF-β1/SMAD3 signaling pathway, leading to a reduction in collagen deposition in the border zone of the heart. Both Sirius and Masson staining also revealed a decrease in extracellular collagen. Moreover, the release of TGF-β1 regulates the differentiation of cardiac fibroblasts into myofibroblasts after MI [48]. TGF-β1 is responsible for regulating the transcription of the extracellular matrix gene Col 1 together with the downstream effector SMAD3 [49,50]. We found that the levels of α-SMA (a marker for mature myofibroblasts) and Col 1 were significantly decreased after PEMF exposure in vitro. The underlying mechanism involves the role of the TGF-β1/SMAD3 signaling pathway in the regulation of fibrosis-related proteins.

Importantly, a new treatment should not only have definite efficacy but also safety, which is the key to the clinical translation of treatment. In 2022, the Mayo Clinic commenced a trial aimed at investigating the potential of wearable PEMF equipment to alleviate the burden of myocardial ischemia, which also provides us with the confidence to further explore the clinical efficacy and safety of PEMF [14]. Although the PEMF equipment used in this study is a whole-body intervention, no PEMF-induced adverse events or changes in biochemical parameters were observed. Notably, an increasing number of studies have revealed strong associations between CVDs and the intestinal flora and its metabolites. This connection arises from the fact that metabolites produced by the intestinal flora can elicit an immune response [[51], [52], [53]]. Indeed, the frequency and strength of a magnetic field can influence the growth of the intestinal flora [54]. A previous study revealed that PEMF can induce relevant metabolic adaptations independent of exercise, which is related to their ability to modulate the composition of the intestinal flora [55]. If PEMF treatment leads to the growth of harmful bacteria, it not only affects the efficacy of the PEMF itself but also may cause unnecessary harm to the body [[56], [57], [58]]. Hence, to avoid changes in the intestinal flora during PEMF treatment that might affect the safety of instrument use, we further monitored changes in the intestinal flora of the experimental animals. This also led us to an unexpected discovery of the potential effects of PEMF on intestinal microbial communities in post-MI pigs.

In the present study, we observed that PEMF did not alter intestinal flora diversity in pigs. Nevertheless, PEMF influences the relative abundance of some intestinal flora. Interestingly, these alterations may have positive implications for cardiovascular health. For example, low-density lipoprotein (LDL) cholesterol, a significant risk factor for cardiovascular disease, is positively correlated with Blautia. The relative abundance of Blautia is reduced in the intestines of post-MI pigs following PEMF treatment, implying that PEMF-induced modulation of this bacterium might contribute to improved MI recovery [59]. It has also been reported that the relative abundance of Anaerostipes can increase in individuals with inflammatory diseases, whereas in our study, the relative abundance of Anaerostipes in the intestine of post-MI pigs following PEMF treatment decreased [60]. In addition, Firmicutes and Clostridia have been identified as having a significant correlation with the TLR signaling pathway. The regulation of these microbiotas through fecal microbiota transplantation might downregulate the expression of associated molecules in the TLR signaling pathway, thereby achieving the objective of diminishing inflammation [[61], [62], [63], [64]]. Crucially, correlation analysis in our study also revealed that some intestinal flora with changes in relative abundance were significantly associated with TLR signaling pathway expression. In other words, our findings indicate that the PEMF-regulated intestinal flora may be beneficial for the resolution of inflammation. While this discovery offers a novel perspective, subsequent research is needed to elucidate the precise impacts of PEMF on the intestinal flora and the interconnectedness of this effect with MI.

This study has several limitations. The number of animals used in this study was limited, necessitating further enlargement of the sample size to facilitate clinical translation. Moreover, PEMF-induced cardioprotection may not be explained solely by reducing inflammation and improving remodeling, so other potential mechanisms contributing to the therapeutic effects of PEMF require further investigation. In addition, aminoglycoside antibiotics have been found to attenuate the response to magnetic exposure as well as the potency of the induced secretome [65,66]. The impact of various cellular medium components on PEMF exposure was not evaluated in this study; thus, future in vitro experiments on the magnetic field should place greater emphasis on the design of culture conditions.

Conclusions

In summary, PEMF treatment can ameliorate cardiac function and reduce scar size in post-MI mice and pigs. The benefits of PEMF in the treatment of MI are supported by reduced inflammatory responses, improved cell survival, and decreased collagen secretion. The underlying molecular mechanism of PEMF treatment is associated with the inhibition of the TLR4/MyD88/NF-κB and TGF-β1/SMAD3 signaling pathways. We believe that PEMF treatment holds significant promise as a noninvasive physical therapy modality, justifying further exploration of its potential implications for managing patients with IHD.

Compliance with Ethics Requirements

All Institutional and National Guidelines for the care and use of animals (fisheries) were followed.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

This work was supported by National Key R&D Program of China (Grant No. 2023YFC3603800 and 2023YFC3603801), National Natural Science Foundation of China (Grant No. 82172534, 82372574, and 82202793), Natural Science Foundation of Sichuan Province (Grant No. 2023NSFSC1999, 2023NSFSC1654, and 2023NSFSC1495), Young and Middle-Aged Leading Talent Cultivation Project of Sichuan University (Grant No. JH20231160), 1·3·5 Project for Disciplines of Excellence, West China Hospital, Sichuan University (Grant No. ZYJC21038), China Postdoctoral Science Foundation (Grant No. 2023M732452), and Zero to One, Innovative research project, Sichuan University (Grant No. 2023SCUH0048). The illustrations were created with BioRender.com.

Footnotes

^{Appendix A}

Supplementary data to this article can be found online at https://doi.org/10.1016/j.jare.2025.04.019.

Contributor Information

Chenying Fu, Email: fcying_2004@163.com.

Yingqiang Guo, Email: drguoyq@wchscu.com.

Quan Wei, Email: weiquan@scu.edu.cn.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

Supplementary Data 1

mmc1.docx^{(4.3MB, docx)}

Data availability

All the data are available from the corresponding authors upon reasonable request.

References

1.Tsao C.W., Aday A.W., Almarzooq Z.I., Anderson C.A.M., Arora P., Avery C.L., et al. Heart disease and stroke statistics-2023 update: a report from the american heart association. Circulation. 2023;147(8):e93–e621. doi: 10.1161/CIR.0000000000001123. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.Doenst T., Haverich A., Serruys P., Bonow R.O., Kappetein P., Falk V., et al. PCI and CABG for treating stable coronary artery disease: JACC review topic of the week. J Am Coll Cardiol. 2019;73(8):964–976. doi: 10.1016/j.jacc.2018.11.053. [DOI] [PubMed] [Google Scholar]
3.Quin J.A., Wagner T.H., Hattler B., Carr B.M., Collins J., Almassi G.H., et al. Ten-year outcomes of off-pump vs on-pump coronary artery bypass grafting in the department of veterans affairs: a randomized clinical trial. JAMA Surg. 2022;157(4):303–310. doi: 10.1001/jamasurg.2021.7578. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Doenst T., Thiele H., Haasenritter J., Wahlers T., Massberg S., Haverich A. The treatment of coronary artery disease. Dtsch Arztebl Int. 2022;119(42):716–723. doi: 10.3238/arztebl.m2022.0277. [DOI] [PMC free article] [PubMed] [Google Scholar]
5.Yabroudi M.A., Aldardour A., Nawasreh Z.H., Obaidat S.M., Altubasi I.M., Bashaireh K. Effects of the combination of pulsed electromagnetic field with progressive resistance exercise on knee osteoarthritis: a randomized controlled trial. J Back Musculoskelet Rehabil. 2023 doi: 10.3233/BMR-220261. [DOI] [PubMed] [Google Scholar]
6.Mayer Y., Khoury J., Horwitz J., Ginesin O., Canullo L., Gabay E., et al. A novel nonsurgical therapy for peri-implantitis using focused pulsed electromagnetic field: a pilot randomized double-blind controlled clinical trial. Bioelectromagnetics. 2023;44(7–8):144–155. doi: 10.1002/bem.22481. [DOI] [PubMed] [Google Scholar]
7.Kandemir O., Adar S., Dündar Ü., Toktaş H., Yeşil H., Eroğlu S., et al. Effectiveness of pulse electromagnetic field therapy in patients with subacromial impingement syndrome: a double-blind randomized sham controlled study. Arch Phys Med Rehabil. 2023 doi: 10.1016/j.apmr.2023.09.020. [DOI] [PubMed] [Google Scholar]
8.Dias A.R., Bitsaktsis C., Emdin D., Bosman L., Smith A.H., Merhi Z. Ozone sauna therapy and pulsed electromagnetic field therapy could potentially improve outcome in women with diminished ovarian reserve undergoing assisted reproductive technology. Med Gas Res. 2023;13(4):202–207. doi: 10.4103/2045-9912.350862. [DOI] [PMC free article] [PubMed] [Google Scholar]
9.Goodman R., Bassett C.A., Henderson A.S. Pulsing electromagnetic fields induce cellular transcription. Science. 1983;220(4603):1283–1285. doi: 10.1126/science.6857248. [DOI] [PubMed] [Google Scholar]
10.Flatscher J., Pavez Loriè E., Mittermayr R., Meznik P., Slezak P., Redl H., et al. Pulsed Electromagnetic Fields (PEMF)-physiological response and its potential in trauma treatment. Int J Mol Sci. 2023;24(14) doi: 10.3390/ijms241411239. [DOI] [PMC free article] [PubMed] [Google Scholar]
11.Capone F., Liberti M., Apollonio F., Camera F., Setti S., Cadossi R., et al. An open-label, one-arm, dose-escalation study to evaluate safety and tolerability of extremely low frequency magnetic fields in acute ischemic stroke. Sci Rep. 2017;7(1):12145. doi: 10.1038/s41598-017-12371-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
12.Albertini A., Zucchini P., Noera G., Cadossi R., Pace Napoleone C., Pierangeli A. Protective effect of low frequency low energy pulsing electromagnetic fields on acute experimental myocardial infarcts in rats. Bioelectromagnetics. 1999;20(6):372–377. doi: 10.1002/(sici)1521-186x(199909)20:6<372::aid-bem6>3.0.co;2-l. [DOI] [PubMed] [Google Scholar]
13.Peng L., Fu C., Liang Z., Zhang Q., Xiong F., Chen L., et al. Pulsed electromagnetic fields increase angiogenesis and improve cardiac function after myocardial ischemia in mice. Circ J. 2020;84(2):186–193. doi: 10.1253/circj.CJ-19-0758. [DOI] [PubMed] [Google Scholar]
14.Wang Y., Chen L., Wang L., Pei G., Cheng H., Zhang Q., et al. Pulsed electromagnetic fields combined with adipose-derived stem cells protect ischemic myocardium by regulating miR-20a-5p/E2F1/p73 signaling. Stem Cells. 2023;41(7):724–737. doi: 10.1093/stmcls/sxad037. [DOI] [PubMed] [Google Scholar]
15.Gao L., Qiu F., Cao H., Li H., Dai G., Ma T., et al. Therapeutic delivery of microRNA-125a-5p oligonucleotides improves recovery from myocardial ischemia/reperfusion injury in mice and swine. Theranostics. 2023;13(2):685–703. doi: 10.7150/thno.73568. [DOI] [PMC free article] [PubMed] [Google Scholar]
16.Zhang Q., Wang L., Wang S., Cheng H., Xu L., Pei G., et al. Signaling pathways and targeted therapy for myocardial infarction. Signal Transduct Target Ther. 2022;7(1):78. doi: 10.1038/s41392-022-00925-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Liu S., Li K., Wagner Florencio L., Tang L., Heallen T.R., Leach J.P., et al. Gene therapy knockdown of Hippo signaling induces cardiomyocyte renewal in pigs after myocardial infarction. Sci Transl Med. 2021;13(600) doi: 10.1126/scitranslmed.abd6892. [DOI] [PMC free article] [PubMed] [Google Scholar]
18.van Hout G.P., van Solinge W.W., Gijsberts C.M., Teuben M.P., Leliefeld P.H., Heeres M., et al. Elevated mean neutrophil volume represents altered neutrophil composition and reflects damage after myocardial infarction. Basic Res Cardiol. 2015;110(6):58. doi: 10.1007/s00395-015-0513-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
19.Majmudar M.D., Keliher E.J., Heidt T., Leuschner F., Truelove J., Sena B.F., et al. Monocyte-directed RNAi targeting CCR2 improves infarct healing in atherosclerosis-prone mice. Circulation. 2013;127(20):2038–2046. doi: 10.1161/CIRCULATIONAHA.112.000116. [DOI] [PMC free article] [PubMed] [Google Scholar]
20.Mendieta G., Ben-Aicha S., Gutiérrez M., Casani L., Aržanauskaitė M., Carreras F., et al. Intravenous statin administration during myocardial infarction compared with oral post-infarct administration. J Am Coll Cardiol. 2020;75(12):1386–1402. doi: 10.1016/j.jacc.2020.01.042. [DOI] [PubMed] [Google Scholar]
21.Monguió-Tortajada M., Prat-Vidal C., Martínez-Falguera D., Teis A., Soler-Botija C., Courageux Y., et al. Acellular cardiac scaffolds enriched with MSC-derived extracellular vesicles limit ventricular remodelling and exert local and systemic immunomodulation in a myocardial infarction porcine model. Theranostics. 2022;12(10):4656–4670. doi: 10.7150/thno.72289. [DOI] [PMC free article] [PubMed] [Google Scholar]
22.Klein P., Holman E.R., Versteegh M.I., Boersma E., Verwey H.F., Bax J.J., et al. Wall motion score index predicts mortality and functional result after surgical ventricular restoration for advanced ischemic heart failure. Eur J Cardiothorac Surg. 2009;35(5):847–852. doi: 10.1016/j.ejcts.2008.12.046. discussion 52–3. [DOI] [PubMed] [Google Scholar]
23.Huang Z., Ge J., Sun A., Wang Y., Zhang S., Cui J., et al. Ligating LAD with its whole length rather than diagonal branches as coordinates is more advisable in establishing stable myocardial infarction model of swine. Exp Anim. 2010;59(4):431–439. doi: 10.1538/expanim.59.431. [DOI] [PubMed] [Google Scholar]
24.Hao C.N., Huang J.J., Shi Y.Q., Cheng X.W., Li H.Y., Zhou L., et al. Pulsed electromagnetic field improves cardiac function in response to myocardial infarction. Am J Transl Res. 2014;6(3):281–290. [PMC free article] [PubMed] [Google Scholar]
25.Franco-Obregón A. Harmonizing magnetic mitohormetic regenerative strategies: developmental implications of a calcium-mitochondrial axis invoked by magnetic field exposure. Bioengineering (Basel) 2023;10(10) doi: 10.3390/bioengineering10101176. [DOI] [PMC free article] [PubMed] [Google Scholar]
26.Zhai M., Zhang C., Cui J., Liu J., Li Y., Xie K., et al. Electromagnetic fields ameliorate hepatic lipid accumulation and oxidative stress: potential role of CaMKKβ/AMPK/SREBP-1c and Nrf2 pathways. Biomed Eng Online. 2023;22(1):51. doi: 10.1186/s12938-023-01114-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
27.Yap J.L.Y., Tai Y.K., Fröhlich J., Fong C.H.H., Yin J.N., Foo Z.L., et al. Ambient and supplemental magnetic fields promote myogenesis via a TRPC1-mitochondrial axis: evidence of a magnetic mitohormetic mechanism. Faseb j. 2019;33(11):12853–12872. doi: 10.1096/fj.201900057R. [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Zhou F., Mei J., Han X., Li H., Yang S., Wang M., et al. Kinsenoside attenuates osteoarthritis by repolarizing macrophages through inactivating NF-κB/MAPK signaling and protecting chondrocytes. Acta Pharm Sin B. 2019;9(5):973–985. doi: 10.1016/j.apsb.2019.01.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
29.Zacchigna S., Martinelli V., Moimas S., Colliva A., Anzini M., Nordio A., et al. Paracrine effect of regulatory T cells promotes cardiomyocyte proliferation during pregnancy and after myocardial infarction. Nat Commun. 2018;9(1):2432. doi: 10.1038/s41467-018-04908-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
30.Lunney J.K., Van Goor A., Walker K.E., Hailstock T., Franklin J., Dai C. Importance of the pig as a human biomedical model. Sci Transl Med. 2021;13(621) doi: 10.1126/scitranslmed.abd5758. [DOI] [PubMed] [Google Scholar]
31.Sharma A., Sances S., Workman M.J., Svendsen C.N. Multi-lineage human iPSC-derived platforms for disease modeling and drug discovery. Cell Stem Cell. 2020;26(3):309–329. doi: 10.1016/j.stem.2020.02.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
32.Oron U., Yaakobi T., Oron A., Mordechovitz D., Shofti R., Hayam G., et al. Low-energy laser irradiation reduces formation of scar tissue after myocardial infarction in rats and dogs. Circulation. 2001;103(2):296–301. doi: 10.1161/01.cir.103.2.296. [DOI] [PubMed] [Google Scholar]
33.Uwatoku T., Ito K., Abe K., Oi K., Hizume T., Sunagawa K., et al. Extracorporeal cardiac shock wave therapy improves left ventricular remodeling after acute myocardial infarction in pigs. Coron Artery Dis. 2007;18(5):397–404. doi: 10.1097/MCA.0b013e328089f19b. [DOI] [PubMed] [Google Scholar]
34.Cai S., Zhao M., Zhou B., Yoshii A., Bugg D., Villet O., et al. Mitochondrial dysfunction in macrophages promotes inflammation and suppresses repair after myocardial infarction. J Clin Invest. 2023;133(4) doi: 10.1172/JCI159498. [DOI] [PMC free article] [PubMed] [Google Scholar]
35.Ziegler K.A., Ahles A., Wille T., Kerler J., Ramanujam D., Engelhardt S. Local sympathetic denervation attenuates myocardial inflammation and improves cardiac function after myocardial infarction in mice. Cardiovasc Res. 2018;114(2):291–299. doi: 10.1093/cvr/cvx227. [DOI] [PMC free article] [PubMed] [Google Scholar]
36.Ong S.B., Hernández-Reséndiz S., Crespo-Avilan G.E., Mukhametshina R.T., Kwek X.Y., Cabrera-Fuentes H.A., et al. Inflammation following acute myocardial infarction: multiple players, dynamic roles, and novel therapeutic opportunities. Pharmacol Ther. 2018;186:73–87. doi: 10.1016/j.pharmthera.2018.01.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
37.Lee C.G., Park C., Hwang S., Hong J.E., Jo M., Eom M., et al. Pulsed Electromagnetic Field (PEMF) treatment reduces lipopolysaccharide-induced septic shock in mice. Int J Mol Sci. 2022;23(10) doi: 10.3390/ijms23105661. [DOI] [PMC free article] [PubMed] [Google Scholar]
38.Varani K., Gessi S., Merighi S., Iannotta V., Cattabriga E., Spisani S., et al. Effect of low frequency electromagnetic fields on A2A adenosine receptors in human neutrophils. Br J Pharmacol. 2002;136(1):57–66. doi: 10.1038/sj.bjp.0704695. [DOI] [PMC free article] [PubMed] [Google Scholar]
39.Vincenzi F., Ravani A., Pasquini S., Merighi S., Gessi S., Setti S., et al. Pulsed electromagnetic field exposure reduces hypoxia and inflammation damage in neuron-like and microglial cells. J Cell Physiol. 2017;232(5):1200–1208. doi: 10.1002/jcp.25606. [DOI] [PubMed] [Google Scholar]
40.Ronniger M., Aguida B., Stacke C., Chen Y., Ehnert S., Erdmann N., et al. A novel method to achieve precision and reproducibility in exposure parameters for low-frequency pulsed magnetic fields in human cell cultures. Bioengineering (Basel) 2022;9(10) doi: 10.3390/bioengineering9100595. [DOI] [PMC free article] [PubMed] [Google Scholar]
41.Pooam M., Aguida B., Drahy S., Jourdan N., Ahmad M. Therapeutic application of light and electromagnetic fields to reduce hyper-inflammation triggered by COVID-19. Commun Integr Biol. 2021;14(1):66–77. doi: 10.1080/19420889.2021.1911413. [DOI] [PMC free article] [PubMed] [Google Scholar]
42.Yang J.C., Wu S.C., Rau C.S., Lu T.H., Wu Y.C., Chen Y.C., et al. Inhibition of the phosphoinositide 3-kinase pathway decreases innate resistance to lipopolysaccharide toxicity in TLR4 deficient mice. J Biomed Sci. 2014;21(1):20. doi: 10.1186/1423-0127-21-20. [DOI] [PMC free article] [PubMed] [Google Scholar]
43.Theobald D., Nair A.R., Sriramula S., Francis J. Cardiomyocyte-specific deletion of TLR4 attenuates angiotensin II-induced hypertension and cardiac remodeling. Front Cardiovasc Med. 2023;10 doi: 10.3389/fcvm.2023.1074700. [DOI] [PMC free article] [PubMed] [Google Scholar]
44.Cao C., Qi Y.T., Wang A.A., Wang Z.Y., Liu Z.X., Meng H.X., et al. Huoxin pill reduces myocardial ischemia reperfusion injury in rats via TLR4/NFκB/NLRP3 signaling pathway. Chin J Integr Med. 2023;29(12):1066–1076. doi: 10.1007/s11655-023-3640-1. [DOI] [PubMed] [Google Scholar]
45.Huo L., Shi W., Chong L., Wang J., Zhang K., Li Y. Asiatic acid inhibits left ventricular remodeling and improves cardiac function in a rat model of myocardial infarction. Exp Ther Med. 2016;11(1):57–64. doi: 10.3892/etm.2015.2871. [DOI] [PMC free article] [PubMed] [Google Scholar]
46.Cheng X., Wang L., Wen X., Gao L., Li G., Chang G., et al. TNAP is a novel regulator of cardiac fibrosis after myocardial infarction by mediating TGF-β/Smads and ERK1/2 signaling pathways. EBioMedicine. 2021;67 doi: 10.1016/j.ebiom.2021.103370. [DOI] [PMC free article] [PubMed] [Google Scholar]
47.Stratton M.S., Bagchi R.A., Felisbino M.B., Hirsch R.A., Smith H.E., Riching A.S., et al. Dynamic chromatin targeting of BRD4 stimulates cardiac fibroblast activation. Circ Res. 2019;125(7):662–677. doi: 10.1161/CIRCRESAHA.119.315125. [DOI] [PMC free article] [PubMed] [Google Scholar]
48.Katwa L.C., Mendoza C., Clements M. CVD and COVID-19: emerging roles of cardiac fibroblasts and myofibroblasts. Cells. 2022;11(8) doi: 10.3390/cells11081316. [DOI] [PMC free article] [PubMed] [Google Scholar]
49.Wang H., Jiang W., Hu Y., Wan Z., Bai H., Yang Q., et al. Quercetin improves atrial fibrillation through inhibiting TGF-β/Smads pathway via promoting MiR-135b expression. Phytomedicine. 2021;93 doi: 10.1016/j.phymed.2021.153774. [DOI] [PubMed] [Google Scholar]
50.Wang J., Ge S., Wang Y., Liu Y., Qiu L., Li J., et al. Puerarin alleviates UUO-induced inflammation and fibrosis by regulating the NF-κB P65/STAT3 and TGFβ1/smads signaling pathways. Drug Des Devel Ther. 2021;15:3697–3708. doi: 10.2147/DDDT.S321879. [DOI] [PMC free article] [PubMed] [Google Scholar]
51.Tang W.H., Kitai T., Hazen S.L. Gut microbiota in cardiovascular health and disease. Circ Res. 2017;120(7):1183–1196. doi: 10.1161/CIRCRESAHA.117.309715. [DOI] [PMC free article] [PubMed] [Google Scholar]
52.Wang Z., Zhao Y. Gut microbiota derived metabolites in cardiovascular health and disease. Protein Cell. 2018;9(5):416–431. doi: 10.1007/s13238-018-0549-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
53.Witkowski M., Weeks T.L., Hazen S.L. Gut microbiota and cardiovascular disease. Circ Res. 2020;127(4):553–570. doi: 10.1161/CIRCRESAHA.120.316242. [DOI] [PMC free article] [PubMed] [Google Scholar]
54.Al-Harbi F.F., Alkhalifah D.H.M., Elqahtani Z.M., Ali F.M., Mohamed S.A., Abdelbacki A.M.M. Nonthermal control of Escherichia coli growth using extremely low frequency electromagnetic (ELF-EM) waves. Biomed Mater Eng. 2018;29(6):809–820. doi: 10.3233/BME-181025. [DOI] [PubMed] [Google Scholar]
55.Tai Y.K., Ng C., Purnamawati K., Yap J.L.Y., Yin J.N., Wong C., et al. Magnetic fields modulate metabolism and gut microbiome in correlation with Pgc-1α expression: follow-up to an in vitro magnetic mitohormetic study. Faseb j. 2020;34(8):11143–11167. doi: 10.1096/fj.201903005RR. [DOI] [PubMed] [Google Scholar]
56.Smirnov K.S., Maier T.V., Walker A., Heinzmann S.S., Forcisi S., Martinez I., et al. Challenges of metabolomics in human gut microbiota research. Int J Med Microbiol. 2016;306(5):266–279. doi: 10.1016/j.ijmm.2016.03.006. [DOI] [PubMed] [Google Scholar]
57.Wang B., Chen X., Chen Z., Xiao H., Dong J., Li Y., et al. Stable colonization of Akkermansia muciniphila educates host intestinal microecology and immunity to battle against inflammatory intestinal diseases. Exp Mol Med. 2023;55(1):55–68. doi: 10.1038/s12276-022-00911-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
58.Zhao W., Han Y., Shao D., Han C., Tian Y., Huang Q. Effects of ultra-strong static magnetic field on the gut microbiota of humans and mice. Bioelectromagnetics. 2023;44(7–8):211–220. doi: 10.1002/bem.22482. [DOI] [PubMed] [Google Scholar]
59.Liu Z., Li J., Liu H., Tang Y., Zhan Q., Lai W., et al. The intestinal microbiota associated with cardiac valve calcification differs from that of coronary artery disease. Atherosclerosis. 2019;284:121–128. doi: 10.1016/j.atherosclerosis.2018.11.038. [DOI] [PubMed] [Google Scholar]
60.Xu N., Bai X., Cao X., Yue W., Jiang W., Yu Z. Changes in intestinal microbiota and correlation with TLRs in ulcerative colitis in the coastal area of northern China. Microb Pathog. 2021;150 doi: 10.1016/j.micpath.2020.104707. [DOI] [PubMed] [Google Scholar]
61.Demirci M., Bahar Tokman H., Taner Z., Keskin F.E., Çağatay P., Ozturk Bakar Y., et al. Bacteroidetes and Firmicutes levels in gut microbiota and effects of hosts TLR2/TLR4 gene expression levels in adult type 1 diabetes patients in Istanbul, Turkey. J Diabetes Complications. 2020;34(2) doi: 10.1016/j.jdiacomp.2019.107449. [DOI] [PubMed] [Google Scholar]
62.Robles-Vera I., Toral M., de la Visitación N., Sánchez M., Gómez-Guzmán M., Romero M., et al. Probiotics prevent dysbiosis and the rise in blood pressure in genetic hypertension: role of short-chain fatty acids. Mol Nutr Food Res. 2020;64(6) doi: 10.1002/mnfr.201900616. [DOI] [PubMed] [Google Scholar]
63.Sun M.F., Zhu Y.L., Zhou Z.L., Jia X.B., Xu Y.D., Yang Q., et al. Neuroprotective effects of fecal microbiota transplantation on MPTP-induced Parkinson's disease mice: gut microbiota, glial reaction and TLR4/TNF-α signaling pathway. Brain Behav Immun. 2018;70:48–60. doi: 10.1016/j.bbi.2018.02.005. [DOI] [PubMed] [Google Scholar]
64.Shi H., Huang X., Yan Z., Yang Q., Wang P., Li S., et al. Effect of Clostridium perfringens type C on TLR4/MyD88/NF-κB signaling pathway in piglet small intestines. Microb Pathog. 2019;135 doi: 10.1016/j.micpath.2019.103567. [DOI] [PubMed] [Google Scholar]
65.Tai Y.K., Iversen J.N., Chan K.K.W., Fong C.H.H., Abdul Razar R.B., Ramanan S., et al. Secretome from magnetically stimulated muscle exhibits anticancer potency: novel preconditioning methodology highlighting HTRA1 action. Cells. 2024;13(5) doi: 10.3390/cells13050460. [DOI] [PMC free article] [PubMed] [Google Scholar]
66.Wong C.J.K., Tai Y.K., Yap J.L.Y., Fong C.H.H., Loo L.S.W., Kukumberg M., et al. Brief exposure to directionally-specific pulsed electromagnetic fields stimulates extracellular vesicle release and is antagonized by streptomycin: a potential regenerative medicine and food industry paradigm. Biomaterials. 2022;287 doi: 10.1016/j.biomaterials.2022.121658. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Data 1

mmc1.docx^{(4.3MB, docx)}

Data Availability Statement

All the data are available from the corresponding authors upon reasonable request.

[b0005] 1.Tsao C.W., Aday A.W., Almarzooq Z.I., Anderson C.A.M., Arora P., Avery C.L., et al. Heart disease and stroke statistics-2023 update: a report from the american heart association. Circulation. 2023;147(8):e93–e621. doi: 10.1161/CIR.0000000000001123. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0010] 2.Doenst T., Haverich A., Serruys P., Bonow R.O., Kappetein P., Falk V., et al. PCI and CABG for treating stable coronary artery disease: JACC review topic of the week. J Am Coll Cardiol. 2019;73(8):964–976. doi: 10.1016/j.jacc.2018.11.053. [DOI] [PubMed] [Google Scholar]

[b0015] 3.Quin J.A., Wagner T.H., Hattler B., Carr B.M., Collins J., Almassi G.H., et al. Ten-year outcomes of off-pump vs on-pump coronary artery bypass grafting in the department of veterans affairs: a randomized clinical trial. JAMA Surg. 2022;157(4):303–310. doi: 10.1001/jamasurg.2021.7578. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0020] 4.Doenst T., Thiele H., Haasenritter J., Wahlers T., Massberg S., Haverich A. The treatment of coronary artery disease. Dtsch Arztebl Int. 2022;119(42):716–723. doi: 10.3238/arztebl.m2022.0277. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0025] 5.Yabroudi M.A., Aldardour A., Nawasreh Z.H., Obaidat S.M., Altubasi I.M., Bashaireh K. Effects of the combination of pulsed electromagnetic field with progressive resistance exercise on knee osteoarthritis: a randomized controlled trial. J Back Musculoskelet Rehabil. 2023 doi: 10.3233/BMR-220261. [DOI] [PubMed] [Google Scholar]

[b0030] 6.Mayer Y., Khoury J., Horwitz J., Ginesin O., Canullo L., Gabay E., et al. A novel nonsurgical therapy for peri-implantitis using focused pulsed electromagnetic field: a pilot randomized double-blind controlled clinical trial. Bioelectromagnetics. 2023;44(7–8):144–155. doi: 10.1002/bem.22481. [DOI] [PubMed] [Google Scholar]

[b0035] 7.Kandemir O., Adar S., Dündar Ü., Toktaş H., Yeşil H., Eroğlu S., et al. Effectiveness of pulse electromagnetic field therapy in patients with subacromial impingement syndrome: a double-blind randomized sham controlled study. Arch Phys Med Rehabil. 2023 doi: 10.1016/j.apmr.2023.09.020. [DOI] [PubMed] [Google Scholar]

[b0040] 8.Dias A.R., Bitsaktsis C., Emdin D., Bosman L., Smith A.H., Merhi Z. Ozone sauna therapy and pulsed electromagnetic field therapy could potentially improve outcome in women with diminished ovarian reserve undergoing assisted reproductive technology. Med Gas Res. 2023;13(4):202–207. doi: 10.4103/2045-9912.350862. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0045] 9.Goodman R., Bassett C.A., Henderson A.S. Pulsing electromagnetic fields induce cellular transcription. Science. 1983;220(4603):1283–1285. doi: 10.1126/science.6857248. [DOI] [PubMed] [Google Scholar]

[b0050] 10.Flatscher J., Pavez Loriè E., Mittermayr R., Meznik P., Slezak P., Redl H., et al. Pulsed Electromagnetic Fields (PEMF)-physiological response and its potential in trauma treatment. Int J Mol Sci. 2023;24(14) doi: 10.3390/ijms241411239. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0055] 11.Capone F., Liberti M., Apollonio F., Camera F., Setti S., Cadossi R., et al. An open-label, one-arm, dose-escalation study to evaluate safety and tolerability of extremely low frequency magnetic fields in acute ischemic stroke. Sci Rep. 2017;7(1):12145. doi: 10.1038/s41598-017-12371-x. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0060] 12.Albertini A., Zucchini P., Noera G., Cadossi R., Pace Napoleone C., Pierangeli A. Protective effect of low frequency low energy pulsing electromagnetic fields on acute experimental myocardial infarcts in rats. Bioelectromagnetics. 1999;20(6):372–377. doi: 10.1002/(sici)1521-186x(199909)20:6<372::aid-bem6>3.0.co;2-l. [DOI] [PubMed] [Google Scholar]

[b0065] 13.Peng L., Fu C., Liang Z., Zhang Q., Xiong F., Chen L., et al. Pulsed electromagnetic fields increase angiogenesis and improve cardiac function after myocardial ischemia in mice. Circ J. 2020;84(2):186–193. doi: 10.1253/circj.CJ-19-0758. [DOI] [PubMed] [Google Scholar]

[b0070] 14.Wang Y., Chen L., Wang L., Pei G., Cheng H., Zhang Q., et al. Pulsed electromagnetic fields combined with adipose-derived stem cells protect ischemic myocardium by regulating miR-20a-5p/E2F1/p73 signaling. Stem Cells. 2023;41(7):724–737. doi: 10.1093/stmcls/sxad037. [DOI] [PubMed] [Google Scholar]

[b0075] 15.Gao L., Qiu F., Cao H., Li H., Dai G., Ma T., et al. Therapeutic delivery of microRNA-125a-5p oligonucleotides improves recovery from myocardial ischemia/reperfusion injury in mice and swine. Theranostics. 2023;13(2):685–703. doi: 10.7150/thno.73568. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0080] 16.Zhang Q., Wang L., Wang S., Cheng H., Xu L., Pei G., et al. Signaling pathways and targeted therapy for myocardial infarction. Signal Transduct Target Ther. 2022;7(1):78. doi: 10.1038/s41392-022-00925-z. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0085] 17.Liu S., Li K., Wagner Florencio L., Tang L., Heallen T.R., Leach J.P., et al. Gene therapy knockdown of Hippo signaling induces cardiomyocyte renewal in pigs after myocardial infarction. Sci Transl Med. 2021;13(600) doi: 10.1126/scitranslmed.abd6892. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0090] 18.van Hout G.P., van Solinge W.W., Gijsberts C.M., Teuben M.P., Leliefeld P.H., Heeres M., et al. Elevated mean neutrophil volume represents altered neutrophil composition and reflects damage after myocardial infarction. Basic Res Cardiol. 2015;110(6):58. doi: 10.1007/s00395-015-0513-6. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0095] 19.Majmudar M.D., Keliher E.J., Heidt T., Leuschner F., Truelove J., Sena B.F., et al. Monocyte-directed RNAi targeting CCR2 improves infarct healing in atherosclerosis-prone mice. Circulation. 2013;127(20):2038–2046. doi: 10.1161/CIRCULATIONAHA.112.000116. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0100] 20.Mendieta G., Ben-Aicha S., Gutiérrez M., Casani L., Aržanauskaitė M., Carreras F., et al. Intravenous statin administration during myocardial infarction compared with oral post-infarct administration. J Am Coll Cardiol. 2020;75(12):1386–1402. doi: 10.1016/j.jacc.2020.01.042. [DOI] [PubMed] [Google Scholar]

[b0105] 21.Monguió-Tortajada M., Prat-Vidal C., Martínez-Falguera D., Teis A., Soler-Botija C., Courageux Y., et al. Acellular cardiac scaffolds enriched with MSC-derived extracellular vesicles limit ventricular remodelling and exert local and systemic immunomodulation in a myocardial infarction porcine model. Theranostics. 2022;12(10):4656–4670. doi: 10.7150/thno.72289. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0110] 22.Klein P., Holman E.R., Versteegh M.I., Boersma E., Verwey H.F., Bax J.J., et al. Wall motion score index predicts mortality and functional result after surgical ventricular restoration for advanced ischemic heart failure. Eur J Cardiothorac Surg. 2009;35(5):847–852. doi: 10.1016/j.ejcts.2008.12.046. discussion 52–3. [DOI] [PubMed] [Google Scholar]

[b0115] 23.Huang Z., Ge J., Sun A., Wang Y., Zhang S., Cui J., et al. Ligating LAD with its whole length rather than diagonal branches as coordinates is more advisable in establishing stable myocardial infarction model of swine. Exp Anim. 2010;59(4):431–439. doi: 10.1538/expanim.59.431. [DOI] [PubMed] [Google Scholar]

[b0120] 24.Hao C.N., Huang J.J., Shi Y.Q., Cheng X.W., Li H.Y., Zhou L., et al. Pulsed electromagnetic field improves cardiac function in response to myocardial infarction. Am J Transl Res. 2014;6(3):281–290. [PMC free article] [PubMed] [Google Scholar]

[b0125] 25.Franco-Obregón A. Harmonizing magnetic mitohormetic regenerative strategies: developmental implications of a calcium-mitochondrial axis invoked by magnetic field exposure. Bioengineering (Basel) 2023;10(10) doi: 10.3390/bioengineering10101176. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0130] 26.Zhai M., Zhang C., Cui J., Liu J., Li Y., Xie K., et al. Electromagnetic fields ameliorate hepatic lipid accumulation and oxidative stress: potential role of CaMKKβ/AMPK/SREBP-1c and Nrf2 pathways. Biomed Eng Online. 2023;22(1):51. doi: 10.1186/s12938-023-01114-x. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0135] 27.Yap J.L.Y., Tai Y.K., Fröhlich J., Fong C.H.H., Yin J.N., Foo Z.L., et al. Ambient and supplemental magnetic fields promote myogenesis via a TRPC1-mitochondrial axis: evidence of a magnetic mitohormetic mechanism. Faseb j. 2019;33(11):12853–12872. doi: 10.1096/fj.201900057R. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0140] 28.Zhou F., Mei J., Han X., Li H., Yang S., Wang M., et al. Kinsenoside attenuates osteoarthritis by repolarizing macrophages through inactivating NF-κB/MAPK signaling and protecting chondrocytes. Acta Pharm Sin B. 2019;9(5):973–985. doi: 10.1016/j.apsb.2019.01.015. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0145] 29.Zacchigna S., Martinelli V., Moimas S., Colliva A., Anzini M., Nordio A., et al. Paracrine effect of regulatory T cells promotes cardiomyocyte proliferation during pregnancy and after myocardial infarction. Nat Commun. 2018;9(1):2432. doi: 10.1038/s41467-018-04908-z. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0150] 30.Lunney J.K., Van Goor A., Walker K.E., Hailstock T., Franklin J., Dai C. Importance of the pig as a human biomedical model. Sci Transl Med. 2021;13(621) doi: 10.1126/scitranslmed.abd5758. [DOI] [PubMed] [Google Scholar]

[b0155] 31.Sharma A., Sances S., Workman M.J., Svendsen C.N. Multi-lineage human iPSC-derived platforms for disease modeling and drug discovery. Cell Stem Cell. 2020;26(3):309–329. doi: 10.1016/j.stem.2020.02.011. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0160] 32.Oron U., Yaakobi T., Oron A., Mordechovitz D., Shofti R., Hayam G., et al. Low-energy laser irradiation reduces formation of scar tissue after myocardial infarction in rats and dogs. Circulation. 2001;103(2):296–301. doi: 10.1161/01.cir.103.2.296. [DOI] [PubMed] [Google Scholar]

[b0165] 33.Uwatoku T., Ito K., Abe K., Oi K., Hizume T., Sunagawa K., et al. Extracorporeal cardiac shock wave therapy improves left ventricular remodeling after acute myocardial infarction in pigs. Coron Artery Dis. 2007;18(5):397–404. doi: 10.1097/MCA.0b013e328089f19b. [DOI] [PubMed] [Google Scholar]

[b0170] 34.Cai S., Zhao M., Zhou B., Yoshii A., Bugg D., Villet O., et al. Mitochondrial dysfunction in macrophages promotes inflammation and suppresses repair after myocardial infarction. J Clin Invest. 2023;133(4) doi: 10.1172/JCI159498. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0175] 35.Ziegler K.A., Ahles A., Wille T., Kerler J., Ramanujam D., Engelhardt S. Local sympathetic denervation attenuates myocardial inflammation and improves cardiac function after myocardial infarction in mice. Cardiovasc Res. 2018;114(2):291–299. doi: 10.1093/cvr/cvx227. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0180] 36.Ong S.B., Hernández-Reséndiz S., Crespo-Avilan G.E., Mukhametshina R.T., Kwek X.Y., Cabrera-Fuentes H.A., et al. Inflammation following acute myocardial infarction: multiple players, dynamic roles, and novel therapeutic opportunities. Pharmacol Ther. 2018;186:73–87. doi: 10.1016/j.pharmthera.2018.01.001. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0185] 37.Lee C.G., Park C., Hwang S., Hong J.E., Jo M., Eom M., et al. Pulsed Electromagnetic Field (PEMF) treatment reduces lipopolysaccharide-induced septic shock in mice. Int J Mol Sci. 2022;23(10) doi: 10.3390/ijms23105661. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0190] 38.Varani K., Gessi S., Merighi S., Iannotta V., Cattabriga E., Spisani S., et al. Effect of low frequency electromagnetic fields on A2A adenosine receptors in human neutrophils. Br J Pharmacol. 2002;136(1):57–66. doi: 10.1038/sj.bjp.0704695. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0195] 39.Vincenzi F., Ravani A., Pasquini S., Merighi S., Gessi S., Setti S., et al. Pulsed electromagnetic field exposure reduces hypoxia and inflammation damage in neuron-like and microglial cells. J Cell Physiol. 2017;232(5):1200–1208. doi: 10.1002/jcp.25606. [DOI] [PubMed] [Google Scholar]

[b0200] 40.Ronniger M., Aguida B., Stacke C., Chen Y., Ehnert S., Erdmann N., et al. A novel method to achieve precision and reproducibility in exposure parameters for low-frequency pulsed magnetic fields in human cell cultures. Bioengineering (Basel) 2022;9(10) doi: 10.3390/bioengineering9100595. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0205] 41.Pooam M., Aguida B., Drahy S., Jourdan N., Ahmad M. Therapeutic application of light and electromagnetic fields to reduce hyper-inflammation triggered by COVID-19. Commun Integr Biol. 2021;14(1):66–77. doi: 10.1080/19420889.2021.1911413. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0210] 42.Yang J.C., Wu S.C., Rau C.S., Lu T.H., Wu Y.C., Chen Y.C., et al. Inhibition of the phosphoinositide 3-kinase pathway decreases innate resistance to lipopolysaccharide toxicity in TLR4 deficient mice. J Biomed Sci. 2014;21(1):20. doi: 10.1186/1423-0127-21-20. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0215] 43.Theobald D., Nair A.R., Sriramula S., Francis J. Cardiomyocyte-specific deletion of TLR4 attenuates angiotensin II-induced hypertension and cardiac remodeling. Front Cardiovasc Med. 2023;10 doi: 10.3389/fcvm.2023.1074700. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0220] 44.Cao C., Qi Y.T., Wang A.A., Wang Z.Y., Liu Z.X., Meng H.X., et al. Huoxin pill reduces myocardial ischemia reperfusion injury in rats via TLR4/NFκB/NLRP3 signaling pathway. Chin J Integr Med. 2023;29(12):1066–1076. doi: 10.1007/s11655-023-3640-1. [DOI] [PubMed] [Google Scholar]

[b0235] 45.Huo L., Shi W., Chong L., Wang J., Zhang K., Li Y. Asiatic acid inhibits left ventricular remodeling and improves cardiac function in a rat model of myocardial infarction. Exp Ther Med. 2016;11(1):57–64. doi: 10.3892/etm.2015.2871. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0240] 46.Cheng X., Wang L., Wen X., Gao L., Li G., Chang G., et al. TNAP is a novel regulator of cardiac fibrosis after myocardial infarction by mediating TGF-β/Smads and ERK1/2 signaling pathways. EBioMedicine. 2021;67 doi: 10.1016/j.ebiom.2021.103370. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0245] 47.Stratton M.S., Bagchi R.A., Felisbino M.B., Hirsch R.A., Smith H.E., Riching A.S., et al. Dynamic chromatin targeting of BRD4 stimulates cardiac fibroblast activation. Circ Res. 2019;125(7):662–677. doi: 10.1161/CIRCRESAHA.119.315125. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0250] 48.Katwa L.C., Mendoza C., Clements M. CVD and COVID-19: emerging roles of cardiac fibroblasts and myofibroblasts. Cells. 2022;11(8) doi: 10.3390/cells11081316. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0255] 49.Wang H., Jiang W., Hu Y., Wan Z., Bai H., Yang Q., et al. Quercetin improves atrial fibrillation through inhibiting TGF-β/Smads pathway via promoting MiR-135b expression. Phytomedicine. 2021;93 doi: 10.1016/j.phymed.2021.153774. [DOI] [PubMed] [Google Scholar]

[b0260] 50.Wang J., Ge S., Wang Y., Liu Y., Qiu L., Li J., et al. Puerarin alleviates UUO-induced inflammation and fibrosis by regulating the NF-κB P65/STAT3 and TGFβ1/smads signaling pathways. Drug Des Devel Ther. 2021;15:3697–3708. doi: 10.2147/DDDT.S321879. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0265] 51.Tang W.H., Kitai T., Hazen S.L. Gut microbiota in cardiovascular health and disease. Circ Res. 2017;120(7):1183–1196. doi: 10.1161/CIRCRESAHA.117.309715. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0270] 52.Wang Z., Zhao Y. Gut microbiota derived metabolites in cardiovascular health and disease. Protein Cell. 2018;9(5):416–431. doi: 10.1007/s13238-018-0549-0. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0275] 53.Witkowski M., Weeks T.L., Hazen S.L. Gut microbiota and cardiovascular disease. Circ Res. 2020;127(4):553–570. doi: 10.1161/CIRCRESAHA.120.316242. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0280] 54.Al-Harbi F.F., Alkhalifah D.H.M., Elqahtani Z.M., Ali F.M., Mohamed S.A., Abdelbacki A.M.M. Nonthermal control of Escherichia coli growth using extremely low frequency electromagnetic (ELF-EM) waves. Biomed Mater Eng. 2018;29(6):809–820. doi: 10.3233/BME-181025. [DOI] [PubMed] [Google Scholar]

[b0285] 55.Tai Y.K., Ng C., Purnamawati K., Yap J.L.Y., Yin J.N., Wong C., et al. Magnetic fields modulate metabolism and gut microbiome in correlation with Pgc-1α expression: follow-up to an in vitro magnetic mitohormetic study. Faseb j. 2020;34(8):11143–11167. doi: 10.1096/fj.201903005RR. [DOI] [PubMed] [Google Scholar]

[b0290] 56.Smirnov K.S., Maier T.V., Walker A., Heinzmann S.S., Forcisi S., Martinez I., et al. Challenges of metabolomics in human gut microbiota research. Int J Med Microbiol. 2016;306(5):266–279. doi: 10.1016/j.ijmm.2016.03.006. [DOI] [PubMed] [Google Scholar]

[b0295] 57.Wang B., Chen X., Chen Z., Xiao H., Dong J., Li Y., et al. Stable colonization of Akkermansia muciniphila educates host intestinal microecology and immunity to battle against inflammatory intestinal diseases. Exp Mol Med. 2023;55(1):55–68. doi: 10.1038/s12276-022-00911-z. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0300] 58.Zhao W., Han Y., Shao D., Han C., Tian Y., Huang Q. Effects of ultra-strong static magnetic field on the gut microbiota of humans and mice. Bioelectromagnetics. 2023;44(7–8):211–220. doi: 10.1002/bem.22482. [DOI] [PubMed] [Google Scholar]

[b0305] 59.Liu Z., Li J., Liu H., Tang Y., Zhan Q., Lai W., et al. The intestinal microbiota associated with cardiac valve calcification differs from that of coronary artery disease. Atherosclerosis. 2019;284:121–128. doi: 10.1016/j.atherosclerosis.2018.11.038. [DOI] [PubMed] [Google Scholar]

[b0310] 60.Xu N., Bai X., Cao X., Yue W., Jiang W., Yu Z. Changes in intestinal microbiota and correlation with TLRs in ulcerative colitis in the coastal area of northern China. Microb Pathog. 2021;150 doi: 10.1016/j.micpath.2020.104707. [DOI] [PubMed] [Google Scholar]

[b0315] 61.Demirci M., Bahar Tokman H., Taner Z., Keskin F.E., Çağatay P., Ozturk Bakar Y., et al. Bacteroidetes and Firmicutes levels in gut microbiota and effects of hosts TLR2/TLR4 gene expression levels in adult type 1 diabetes patients in Istanbul, Turkey. J Diabetes Complications. 2020;34(2) doi: 10.1016/j.jdiacomp.2019.107449. [DOI] [PubMed] [Google Scholar]

[b0320] 62.Robles-Vera I., Toral M., de la Visitación N., Sánchez M., Gómez-Guzmán M., Romero M., et al. Probiotics prevent dysbiosis and the rise in blood pressure in genetic hypertension: role of short-chain fatty acids. Mol Nutr Food Res. 2020;64(6) doi: 10.1002/mnfr.201900616. [DOI] [PubMed] [Google Scholar]

[b0325] 63.Sun M.F., Zhu Y.L., Zhou Z.L., Jia X.B., Xu Y.D., Yang Q., et al. Neuroprotective effects of fecal microbiota transplantation on MPTP-induced Parkinson's disease mice: gut microbiota, glial reaction and TLR4/TNF-α signaling pathway. Brain Behav Immun. 2018;70:48–60. doi: 10.1016/j.bbi.2018.02.005. [DOI] [PubMed] [Google Scholar]

[b0330] 64.Shi H., Huang X., Yan Z., Yang Q., Wang P., Li S., et al. Effect of Clostridium perfringens type C on TLR4/MyD88/NF-κB signaling pathway in piglet small intestines. Microb Pathog. 2019;135 doi: 10.1016/j.micpath.2019.103567. [DOI] [PubMed] [Google Scholar]

[b0335] 65.Tai Y.K., Iversen J.N., Chan K.K.W., Fong C.H.H., Abdul Razar R.B., Ramanan S., et al. Secretome from magnetically stimulated muscle exhibits anticancer potency: novel preconditioning methodology highlighting HTRA1 action. Cells. 2024;13(5) doi: 10.3390/cells13050460. [DOI] [PMC free article] [PubMed] [Google Scholar]

[b0340] 66.Wong C.J.K., Tai Y.K., Yap J.L.Y., Fong C.H.H., Loo L.S.W., Kukumberg M., et al. Brief exposure to directionally-specific pulsed electromagnetic fields stimulates extracellular vesicle release and is antagonized by streptomycin: a potential regenerative medicine and food industry paradigm. Biomaterials. 2022;287 doi: 10.1016/j.biomaterials.2022.121658. [DOI] [PubMed] [Google Scholar]

PERMALINK

Pulsed electromagnetic fields treatment ameliorates cardiac function after myocardial infarction in mice and pigs

Shiqi Wang

Gaiqin Pei

Jiayu Shen

Zhi Fang

Tingyu Chen

Lu Wang

Hongxin Cheng

Hanbin Li

Hongliang Pei

Qipu Feng

Qingwen Fan

Chengqi He

Chenying Fu

Yingqiang Guo

Quan Wei

Graphical abstract

Highlights

Abstract

Introduction

Objectives

Methods

Results

Conclusions

Introduction

Materials and methods

Ethics statement

MI induction and grouping

Mice

Pigs

PEMF treatment

Echocardiography

CMR imaging

CMR image processing and analysis

Statistical analysis

Results

PEMF ameliorated cardiac function and decreased infarct size after MI in mice

Fig. 1.

PEMF reduced the macrophage inflammatory response, improved cardiomyocyte survival in an inflammatory environment, and decreased collagen secretion in vitro

Fig. 2.

PEMF ameliorated cardiac function and decreased infarct size after MI in pigs

Fig. 3.

PEMF reduced apoptosis and proinflammatory factor levels after MI in pigs

Fig. 4.

PEMF treatment affected the TLR4/MyD88/NF-κB and TGF-β1/SMAD3 signaling pathways in the myocardial tissue of pigs

The TLR4/MyD88/NF-κB signaling pathway plays an important role in PEMF treatment to reduce inflammatory

Fig. 5.

Fig. 6.

PEMF played an antifibrotic role by regulating TGF-β1/SMAD3

PEMF treatment was safe and well tolerated

Fig. 7.

Discussion

Conclusions

Compliance with Ethics Requirements

Declaration of competing interest

Acknowledgments

Footnotes

Contributor Information

Appendix A. Supplementary data

Data availability

References

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases