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Serum magnesium and the prevalence of peripheral artery disease

      We read with great interest the work by Sun et al., who observed a strong relationship between peripheral artery disease (PAD) and low serum levels of magnesium (Mg2+) [
      • Sun X.
      • Zhuang X.
      • Huo M.
      • Feng P.
      • Zhang S.
      • et al.
      Serum magnesium and the prevalence of peripheral artery disease: the Atherosclerosis Risk in Communities (ARIC) study.
      ]. Just as interesting is the commentary by Morello et al., who stressed that patients developing PAD were more frequently of Afro-American descent [
      • Morello A.
      • Biondi-Zoccai G.
      • Frati A.
      • Giordano A.
      Association between serum magnesium levels and peripheral artery disease: a leg too short?.
      ]. Moreover, they noted that both in Europe and in the United States, magnesium intake is below the recommended minimum dose [
      • Morello A.
      • Biondi-Zoccai G.
      • Frati A.
      • Giordano A.
      Association between serum magnesium levels and peripheral artery disease: a leg too short?.
      ]. In addition to the lack of dietary intake, we wish to highlight the well-known effect exerted by proton pump inhibitor (PPI) therapies, consisting in reducing the systemic levels of Mg2+ [
      • Florentin M.
      • Elisaf M.S.
      Proton pump inhibitor-induced hypomagnesemia: a new challenge.
      ,
      • Chrysant S.G.
      Proton pump inhibitor-induced hypomagnesemia complicated with serious cardiac arrhythmias.
      ,
      • Lazzerini P.E.
      • Bertolozzi I.
      • Finizola F.
      • Acampa M.
      • Natale M.
      • et al.
      Proton pump inhibitors and serum magnesium levels in patients with torsades de Pointes.
      ]. One of the main reasons for PPI therapy is the presence of upper gastrointestinal (GI) tract symptoms due to gastritis, peptic ulcer and gastroesophageal reflux. The agent of gastritis is Helicobacter pylori, a spiral organism whose habitat is the gastric and the gastric-type mucosa. Peptic ulcerations are most often caused by infection by pathogenic strains of H. pylori, which are characterized by the presence in the chromosome of the cytotoxin-associated gene A (cagA) that encodes the oncogenic protein CagA. The infectious rate in the US is rather high in African-American individuals [
      • Epplein M.
      • Signorello L.B.
      • Zheng W.
      • Peek Jr., R.M.
      • Michel A.
      • et al.
      Race, African ancestry, and Helicobacter pylori infection in a low-income United States population.
      ]. H. pylori infection has been demonstrated to be a contributive cause to atherosclerosis in cynomologous monkeys in the very exhaustive study by Testerman et al. [
      • Testerman T.L.
      • Semino-Mora C.
      • Cann J.A.
      • Qiang B.
      • Peña E.A.
      • et al.
      Both diet and Helicobacter pylori infection contribute to atherosclerosis in pre- and postmenopausal cynomolgus monkeys.
      ]. The correlation between the infection by CagA positive strains and atherosclerosis was quite strong, as reviewed by Shuo et al. [
      • Shuo Z.
      • Yang G.
      • Yan M.A.
      • Yue T.
      Cytoxin-associated gene-A-seropositive virulent strains of Helicobacter pylori and atherosclerotic disease: a systematic review.
      ]; moreover, Testerman et al. cited the many studies reporting the presence of the bacterium in the carotid plaque or in the coronary arteries of patients with ischemic stroke or myocardial infarction (5, ref 24–29). We also wish to report the case of a 46-year old Italian patient who had been referred to surgery due to a femoral artery clot. This patient also suffered from peptic ulcer and H.pylori infection that was deemed better cured before undergoing surgery. Within four months after eradication of the bacterium, also the femoral clot had disappeared, without surgery. We believe that a portion of patients with PAD could benefit from the search of infection by CagA positive strains of H.pylori, at least in countries with high circulation of these strains.
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      References

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        • Zhuang X.
        • Huo M.
        • Feng P.
        • Zhang S.
        • et al.
        Serum magnesium and the prevalence of peripheral artery disease: the Atherosclerosis Risk in Communities (ARIC) study.
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        Association between serum magnesium levels and peripheral artery disease: a leg too short?.
        Atherosclerosis. 2019; 282: 165-166https://doi.org/10.1016/j.atherosclerosis.2019.01.016
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        Proton pump inhibitor-induced hypomagnesemia: a new challenge.
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        Proton pump inhibitor-induced hypomagnesemia complicated with serious cardiac arrhythmias.
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        Proton pump inhibitors and serum magnesium levels in patients with torsades de Pointes.
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        Race, African ancestry, and Helicobacter pylori infection in a low-income United States population.
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        • et al.
        Both diet and Helicobacter pylori infection contribute to atherosclerosis in pre- and postmenopausal cynomolgus monkeys.
        PLoS One. 2019; 14e0222001https://doi.org/10.1371/journal.pone.0222001
        • Shuo Z.
        • Yang G.
        • Yan M.A.
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        Cytoxin-associated gene-A-seropositive virulent strains of Helicobacter pylori and atherosclerotic disease: a systematic review.
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