Hypertension and associated metabolic abnormalities--the role of insulin resistance and the sympathoadrenal system

Medium-term cardiovascular effects of high-dose growth hormone treatment in growth hormone-deficient children

AIM

To investigate the possible cardiac morphofunctional alterations inducd by prolonged and high-dose GH therapy in a group of 14 children with isolated GH deficiency.

PATIENTS AND METHODS

Patients were evaluated at phase 1, after 1.1 +/- 0.6 years of treatment with GH 0.93 +/- 0.13 U/kg/week, and at phase 2, after 5.5 +/- 2.1 years of therapy 0.89 +/- 0.11 U/kg/week. At each phase left ventricular volume, mass and systolic function were evaluated by two-dimensional guided M-mode echocardiography; left ventricular diastolic function was assessed by PW-Doppler sampling of transmitral flow.

RESULTS

Phase 1: diastolic blood pressure was lower (p < 0.05) and fractional shortening was not adequate for the level of afterload (stress shortening index p < 0.05) in patients compared to controls. Phase 2: diastolic blood pressure was lower (p < 0.01) and mass and mass/volume ratio were increased (mass index p < 0.05, mass/ volume ratio p < 0.05) in patients compared to controls. The increased mass/volume ratio, together with the normal systolic blood pressure, explains the reduction in peak systolic stress (p < 0.005). Among the parameters of left ventricular diastolic function, the peak E velocity/total area under mitral valve tracing and the area under E velocity/total area under mitral value tracing ratios were significantly decreased (p < 0.05).

CONCLUSION

After a mean period of 5 years on high-dose GH treatment in GH-deficient children, subclinical morphofunctional alterations in the left ventricle were found.

Management of coronary artery disease: therapeutic options in patients with diabetes

OBJECTIVES

The aim of this review is to discuss the particularities of coronary artery disease (CAD), the effect of intensive medical management and the outcome of percutaneous and surgical revascularization in patients with diabetes mellitus (DM).

BACKGROUND

CAD represents the leading cause of death in patients with DM. Numerous clinical, biological and angiographic risk factors have been shown to be associated with CAD in diabetic patients.

METHODS

Metabolic abnormalities in patients with DM including insulin resistance, hyperglycemia and dyslipidemia are briefly discussed. Then the potential roles of medical management and of percutaneous and surgical coronary revascularization are more extensively reviewed.

RESULTS

More vigorous control of hyperglycemia, hyperlipidemia, hypertension and other risk factors may be of crucial importance for risk reduction. Despite remarkable progress in recent years, the choice of a coronary revascularization strategy remains a challenge in these patients. Diabetic patients with CAD are predisposed to higher cardiovascular events after balloon angioplasty. Whether stenting and new antiplatelet drugs improve the results of percutaneous revascularization in this population needs further evaluation. The superiority of the surgical approach is also not definitely established. Therefore, many aspects of coronary revascularization are still unclear in these patients.

CONCLUSIONS

The results of ongoing randomized trials comparing multiple coronary stents to bypass surgery will likely provide some answers to our questions and additional randomized trials evaluating intensive diabetic control with or without coronary revascularization are needed to determine the best therapeutic approach in these patients.

Signalling in body-weight homeostasis: neuroendocrine efferent signals

Whilst a number of neuroendocrine afferent signals are implicated in body-weight homeostasis, the major efferent pathway is the sympathetic nervous system (SNS), which affects both energy expenditure and substrate utilization. Thyroid hormones and their interactions with the SNS may also have a role to play. Some of the variability in resting energy expenditure can be explained by differences in SNS activity, and beta-blockade can reduce energy expenditure and diet-induced thermogenesis in Caucasians. Excess energy intake leads to SNS activation and increased diet-induced thermogenesis. A relationship has also been demonstrated between spontaneous physical activity and SNS activity. In many animal models the SNS activates brown adipose tissue thermogenesis, hence increasing diet-induced thermogenesis and dissipating excess energy as heat. This effect is mediated via beta3-adrenoceptors and activation of an uncoupling protein unique to brown adipose tissue. Homologous proteins have been identified in human tissues and may play a role in human energy expenditure. How the SNS is implicated in this process is unclear at present. beta3-Adrenoceptor polymorphism has been associated both with lower resting energy expenditure in some populations and with reduced autonomic nervous system activity. SNS effects on substrate cycling may also play a role. In the development of obesity the effects of the SNS in promoting lipolysis and fat oxidation are likely to be at least as important as its effects on thermogenesis. beta-Blockade has relatively small effects on energy expenditure, but more pronounced effects on reducing lipid oxidation, so tending to favour fat storage and weight gain. Low lipid oxidation is a risk factor for weight gain, and there is some evidence that low basal sympathetic nerve activity in muscle is associated with this process. Overall, the relationship between SNS activity and obesity is complex, with evidence of low SNS activity occurring in some, but not all, studies.

Growth hormone therapy for hypopituitary adults: time for re-appraisal

The advent of the production of large quantities of recombinant growth hormone (GH) has made it possible to have sufficient material to assess its efficacy in adult growth hormone deficiency (GHD). Although some studies have shown that patients who are severely deficient benefit from GH therapy, the spectrum of GHD is broad, and the degree of deficiency at times is very difficult to define. In some cases, benefit is not easily quantified, and some studies have claimed benefits that, although statistically significant, are either not clinically important or are so marginal as to be questionable in terms of cost, difficulty of administration and potential risks. The purpose here is to identify the current problems in the diagnosis of GHD, to discuss the rationale for GH therapy and to assess the potential effects of GHD as well as the benefits of GH therapy in GHD adults. We will include a commentary as to which effects appear more robust than others and which are likely to result in the greatest patient benefit. Finally, some attention will be paid to long-term safety issues that should be monitored to ensure that this medication is safe even for the patients with the greatest need.

Different association of hypertension and insulin-related metabolic syndrome between men and women in 8437 nondiabetic Chinese

Insulin resistance may cause a metabolic syndrome but whether insulin resistance causes hypertension is very controversial. Furthermore, it remains unclear whether the link between the insulin-resistance-related metabolic syndrome and hypertension is different between men and women. We examined fasting insulin, glucose, triglyceride and high-density lipoprotein (HDL)-cholesterol levels, systolic blood pressure, body mass index, and waist-to-hip ratio in a dataset from 8437 nondiabetic residents (age range, 30 to 89 years) in Kinmen. Factor analysis, a multivariate correlation statistical technique, was used to investigate the clustering and interdependence of these risk variables. Factor analysis identified two factors for men (n = 3659) and three factors for women (n = 4778, respectively. In men, a cluster of insulin, triglyceride, HDL-cholesterol, body mass index, and waist-to-hip ratio (metabolic syndrome) accounted for 29.7%, and a cluster of systolic blood pressure and glucose (hyperglycemia plus hypertension) accounted for 18.1% of the total variance in all variables considered. In women, a cluster of insulin, triglyceride, body mass index, waist-to-hip ratio, and systolic blood pressure (metabolic syndrome plus hypertension) accounted for 29.4%, a cluster of systolic blood pressure, glucose, and triglyceride (hyperglycemia plus hypertension plus dyslipidemia) accounted for 14.0%, and a cluster of triglyceride and HDL-cholesterol (dyslipidemia) accounted for 16.2% of the total variance. In conclusion, a distinct insulin-resistance-related metabolic syndrome characterized by hyperinsulinemia, dyslipidemia, and obesity was observed for both men and women in this Chinese population. However, hypertension was linked to the metabolic syndrome in women only.

Association between blood pressure, the treatment of hypertension, and cardiovascular risk factors in women

OBJECTIVE

To examine relationships of normal blood pressure (BP), hypertension and degree of BP control with cardiovascular disease (CVD) risk factors and predicted 10-year risks for coronary heart disease (CHD) and stroke.

DESIGN

Cross-sectional survey.

SETTING

107 Marks and Spencer retail stores in the UK.

PARTICIPANTS

14,077 women, aged 30-64 years, screened for CVD risk factors between 1988 and 1991.

MAIN OUTCOME MEASURES

Systolic (SBP) and diastolic (DBP) BP; total, high-(HDL) and low-density lipoprotein (LDL) cholesterol, ratio of total to HDL cholesterol (TC/HDL-C); triglycerides, apolipoprotein A1, apolipoprotein B, lipoprotein (a), glucose, body mass index, antihypertensive medication and predicted risks for CHD and stroke. Hypertension was defined as SBP > or = 140 mmHg and/or DBP > or = 90 mmHg and/or taking anti-hypertensive medication. Subjects were divided into normotensives with optimal (n = 6,599), normal (n = 3,170) and high normal (n = 2,184) BP levels, and hypertensives with adequate BP control (n = 228), untreated (n = 1,729) and inadequate BP control (n = 291).

RESULTS

BP level was associated with other CVD risk factors among both normotensives and hypertensives. Women with inadequately controlled BP had the worst risk profile, followed by untreated hypertensives, those with adequately controlled BP and normotensives. Odds ratios for being in the top quintile of predicted 10-year CHD and stroke risks were 1, 2.7, 4.2, 8.5, 13.0, 18.9 for CHD; 1, 1.1, 5.8, 18.7, 20.6, 756 for stroke, for optimal, normal, high normal, adequate BP control, untreated and inadequate BP control groups respectively.

CONCLUSIONS

Untreated hypertensives and women taking anti-hypertensive medication but with BP > or = 140/90 mmHg have the most atherogenic risk factor profiles. Effective management of BP and the associated CVD risk requires a multi-factorial approach, rather than addressing BP control in isolation.

An insulin receptor gene polymorphism is associated with diastolic blood pressure in Chinese subjects with components of the metabolic syndrome

Insulin resistance has been described as a possible underlying link for the clustering of Type 2 diabetes mellitus, hypertension, obesity, and dyslipidemia, known as the metabolic syndrome. Mutations within the insulin receptor have been associated with hypertension in some white and Oriental populations. We examined the relationship between the insulin receptor NsiI restriction fragment-length polymorphism (RFLP) and biochemical and anthropometric parameters associated with these disorders in 933 Chinese subjects. Of the 933 subjects, 117 were control subjects and 816 had one or more components of the metabolic syndrome: 59.7% hypertension, 64.6% glucose intolerance, 55.3% dyslipidemia, and 53.3% obesity. The prevalences of the N1 allele and N1N1 genotype were 74.4% and 55.8%, respectively, in the whole population. No differences were observed in the genotype and allele frequency distributions between the control group and the cohorts with glucose intolerance, hypertension, or dyslipidemia alone or in combination. Using one-way ANOVA, there was a weak relationship between the insulin receptor genotypes and diastolic blood pressure (DBP), P = .069. The DBP was significantly higher in subjects carrying the N1N1 genotype in both the total population (80 +/- 13 v 76 +/- 12 mm Hg, P = .038) and subjects with glucose intolerance (80 +/- 12 v 76 +/- 10 mm Hg, P = .048). Using stepwise multiple regression, the insulin receptor NsiI polymorphism was found to be an independent predictor of DBP in this Chinese population, P = .018. Age, gender, and body mass index (BMI) were also included in the analysis and were all significantly associated with diastolic DBP. To conclude, the insulin receptor gene NsiI RFLP is associated with DBP in these Chinese subjects.

Quantitative insulin sensitivity check index: a simple, accurate method for assessing insulin sensitivity in humans

Insulin resistance plays an important role in the pathophysiology of diabetes and is associated with obesity and other cardiovascular risk factors. The "gold standard" glucose clamp and minimal model analysis are two established methods for determining insulin sensitivity in vivo, but neither is easily implemented in large studies. Thus, it is of interest to develop a simple, accurate method for assessing insulin sensitivity that is useful for clinical investigations. We performed both hyperinsulinemic isoglycemic glucose clamp and insulin-modified frequently sampled iv glucose tolerance tests on 28 nonobese, 13 obese, and 15 type 2 diabetic subjects. We obtained correlations between indexes of insulin sensitivity from glucose clamp studies (SI(Clamp)) and minimal model analysis (SI(MM)) that were comparable to previous reports (r = 0.57). We performed a sensitivity analysis on our data and discovered that physiological steady state values [i.e. fasting insulin (I(0)) and glucose (G(0))] contain critical information about insulin sensitivity. We defined a quantitative insulin sensitivity check index (QUICKI = 1/[log(I(0)) + log(G(0))]) that has substantially better correlation with SI(Clamp) (r = 0.78) than the correlation we observed between SI(MM) and SI(Clamp). Moreover, we observed a comparable overall correlation between QUICKI and SI(Clamp) in a totally independent group of 21 obese and 14 nonobese subjects from another institution. We conclude that QUICKI is an index of insulin sensitivity obtained from a fasting blood sample that may be useful for clinical research.

Bivariate genetic analysis of fasting insulin and glucose levels

The main aim of this study was to estimate the relative influence of genes and environment on fasting insulin levels, which were considered a proxy of insulin resistance. Possible sex differences in genetic and environmental influences, and the origin of the covariance between fasting insulin and glucose were investigated. Subjects were 209 pairs of middle-aged twins, divided into 5 sex-by-zygosity groups. A general bivariate model and a reciprocal causation model including fasting insulin and glucose were used in the analyses. For both quantitative genetic models, a model specifying additive genetic and unique environmental factors, which were the same in males and females, showed the best fit to the data. Heritability estimates were modest and highly similar in both models: 20-25% of the variance in fasting insulin, and around 50% of the variance in fasting glucose levels could be attributed to genetic factors. The two models could not be discriminated on the basis of their fit to the data. A submodel of the general bivariate model suggested that the covariance between glucose and insulin has a unique environmental basis, whereas for the reciprocal causation model both causal paths were needed to explain the phenotypic correlation between insulin and glucose and estimates of the reciprocal paths were of opposite sign, an indication for the expected negative feedback loop.

Alterations in skeletal muscle morphology in glucose-tolerant elderly hypertensive men: relationship to development of hypertension and heart rate

OBJECTIVE

To compare the muscle morphology in hypertensive subjects with that in controls and to test the hypothesis of a relation between heart rate, development of hypertension and muscle morphology that is independent of glucose intolerance.

PATIENTS AND METHODS

We studied 43 glucose-tolerant, untreated hypertensive subjects and 113 healthy controls in a longitudinal cohort of 70-year-old men. Metabolic status (oral glucose tolerance test and euglycemic, hyperinsulinaemic clamp test), muscle fibre distribution (myosin ATPase staining) and capillary supply (amylase-PAS method) were evaluated. Blood pressure and heart rate data were available from both ages 50 and 70 years.

RESULTS

Hypertensive subjects had a significantly smaller mean number of capillaries per fibre than controls (1.53 versus 1.64; P = 0.04). In hypertensive subjects, the proportions of type I and type II fibres were correlated to mean arterial pressure (r = -0.56 and r= 0.52, respectively, P < 0.05 for both). The increase in mean arterial pressure over 20 years was closely correlated to capillary density in mm2 (r= -0.62; P< 0.0001). Capillary supply was inversely related to resting heart rate both at ages 50 and 70 years.

CONCLUSIONS

Skeletal muscle of glucose tolerant hypertensive subjects showed a lower capillary supply than that of controls. This capillary rarefaction was correlated to increase in mean arterial pressure over two decades and to supine heart rate. This is compatible with the suggestion that higher sympathetic drive might generate structural alterations in muscle capillarization.

Obesity and cardiovascular disease. Pathogenetic role of the metabolic syndrome and therapeutic implications

Since obesity is a major risk factor for cardiovascular disease (CVD), the increasing prevalence and degree of obesity in all developed countries has the potential to significantly offset the current efforts to decrease CVD burden in our population. Obesity is pathogenetically related to several clinical and sub-clinical abnormalities that contribute to the development of atherosclerotic placks and their complication, leading to the onset of cardiovascular events. Obesity seems to interact with inheritable factors in determining the onset of insulin resistance, a metabolic abnormality that is responsible for altered glucose metabolism and predisposition to type 2 diabetes, but that also has a major role in the development of dyslipidemia, hypertension and many other sub-clinical abnormalities that contribute to the atherosclerotic process and onset of cardiovascular events. Inheritable factors seem to modulate the onset of type 2 diabetes, dyslipidemia, hypertension and various insulin resistance-related sub-clinical abnormalities, often in a clustering pattern that is commonly referred to as the "metabolic syndrome." Inheritable factors also are involved in the onset of CVD in a given population or individuals with various components of the metabolic syndrome. Intense research is currently undergoing to better understand the molecular mechanisms that could explain the relationship between environmental and inheritable factors that lead from obesity to atherosclerosis and cardiovascular event. The elucidation of these mechanisms will provide improved therapeutic strategies to reduce cardiovascular risk in the obese patients. However, effective therapeutic tools that control each of the known pathophysiological steps mediating CVD in obese patients are already available and should be used more aggressively. Patient education and coordinated approach of physicians, nurses and other health care providers in a multidisciplinary treatment of the obese patient is of fundamental importance to reduce CVD burden in our population.

Genetic dissection of the syndrome X in the rat

In 1988, Reaven used the term syndrome X to describe a relation between several disorders including hypertension, dyslipidemia, impaired glucose tolerance, obesity, and coronary heart disease. Despite a number of studies dealing with syndrome X, its genetic basis remains poorly understood. Regarding the complexity of this syndrome, it is important to use animal models developing the traits of the disease. Here we show a genetic dissection of syndrome X in the WOKW rat, an animal model of genetically determined syndrome X. We found a major quantitative trait locus (QTL) for glucose metabolism on chromosome 3 and further QTLs influencing obesity and body weight on chromosomes 1 and 5. Genetic determinants of dyslipidemia were mapped to chromosomes 4 and 17. In addition, suggestive linkage for serum insulin was found on chromosome 1 to the region previously shown to be associated with type-1 diabetes mellitus. This is the first study demonstrating independent genetic factors influencing traits of the syndrome X in the rat as well as a possible genetic relationships between syndrome X and diabetes mellitus. Moreover, regarding the close similarities between WOKW rat and human syndrome X, the study could help in a search of genetic factors involved in this complex metabolic disorder in human.

Sleep as a mediator of the relationship between socioeconomic status and health: a hypothesis

This article discusses the hypothesis that the adverse impact of low socioeconomic status (SES) on health may be partly mediated by decrements in sleep duration and quality. Low SES is frequently associated with a diminished opportunity to obtain sufficient sleep or with environmental conditions that compromise sleep quality. In a recent study, we examined carbohydrate metabolism, endocrine function, and sympatho-vagal balance in young, healthy adults studied after restricting sleep to four hours per night for six nights as compared to a fully rested condition obtained by extending the bed-time period to 12 hours per night for six nights. The state of sleep debt was associated with decreased glucose tolerance, elevated evening cortisol levels, and increased sympathetic activity. The alterations in glucose tolerance and hypothalamo-pituitary-adrenal function were qualitatively and quantitatively similar to those observed in normal aging. These results indicate that sleep loss can increase the "allostatic load" and facilitate the development of chronic conditions, such as obesity, diabetes, and hypertension, which have an increased prevalence in low SES groups.

Overweight and hypertension : a 2-way street?

Cross-sectionally, higher weight is associated with higher blood pressure levels; prospectively, baseline weight and weight gain predict higher blood pressure. The loss of weight is frequently associated with a decrease in blood pressure. These findings suggest that weight gain may pathophysiologically contribute to blood pressure elevation. In this review, we present data to indicate that the reverse is also true; persons of equal weight who had higher initial blood pressures gain more weight in the future. We also propose a plausible hypothesis to explain this reverse relationship. Both the blood pressure elevation and the gain of weight may reflect a primary increase in sympathetic tone. It is well known that in a milieu of increased sympathetic tone, the beta-adrenergic responsiveness decreases. Sympathetic overactivity and decreased cardiovascular beta-adrenergic responsiveness have been described in hypertension. beta-Adrenergic receptors mediate increases in energy expenditure. If these metabolic receptors were downregulated in hypertension, the ability of hypertensive patients to dissipate calories would decrease and they would gain more weight. The possible relationship of decreased beta-adrenergic responsiveness to weight in hypertension can be experimentally tested. Such research may contribute to an explanation of why patients with hypertension can rarely lose weight. An understanding of this pathophysiological relationship may open new avenues for therapeutic interventions.

Impairment of insulin-induced vasodilation is associated with muscle insulin resistance in type 2 diabetes

To clarify the association between the actions of insulin on the vascular wall and on the muscles in diabetes, we evaluated insulin-mediated vasodilation and muscle glucose uptake simultaneously using the euglycemic hyperinsulinemic glucose clamp technique and the calculation of total peripheral vascular resistance (TPR) from arterial pulse wave analysis in 19 Japanese patients with type 2 diabetes who had no signs of atherosclerosis. During the clamp study, the plasma norepinephrine (NE) level and plasma renin activity (PRA) increased without showing any significant correlation to the glucose infusion rate (GIR); a marker of muscle insulin sensitivity, and no changes of other plasma vasoactive hormone levels were observed. TPR decreased over time during the clamp study. The decrease of TPR from baseline was 0.88 +/- 0.02 at 1 h (mean +/- S.E.M., P < 0.01) and 0.79 +/- 0.03 at 2 h (P < 0.01), and the relative change in TPR from baseline was negatively correlated with GIR (r = -0.48 at 1 and 2 h; both P < 0.05). Our results suggest that there is also insulin resistance in the vascular wall, and this phenomenon may be associated with muscle insulin resistance in type 2 diabetes.

Metabolic complications of obesity. Pathophysiologic considerations

Given a specific research interest in human fatty acid metabolism, this article focuses primarily on the evidence surrounding the hypothesis that dysregulation of the fuel release function of fat cells (lipolysis) is an important contributing factor to the health hazards of obesity.

Chronic infusion of norepinephrine into the VMH of normal rats induces the obese glucose-intolerant state

Increases in ventromedial hypothalamic (VMH) norepinephrine (NE) levels and/or activities have been observed in a variety of animal models of the obese insulin-resistant condition. This study examined the metabolic effects of chronic NE infusion (25 nmol/h) into the unilateral VMH of normal rats. Within 4 days, VMH NE infusion significantly increased plasma insulin (140%), glucagon (45%), leptin (300%), triglyceride (100%), abdominal fat pad weight (50%), and white adipocyte lipogenic (100%) and lipolytic (100%) activities relative to vehicle-infused rats. Furthermore, isolated islet insulin secretory response to glucose (15 mM) within 4 days of such treatment was increased over twofold (P < 0.05). Among treated animals, fat stores continued to increase over time and plateaued at approximately 2 wk (3-fold increase), remaining elevated to the end of the study (5 wk). By week 4 of treatment, NE infusion induced glucose intolerance as evidenced by a 32% increase in plasma glucose total area under the glucose tolerance test curve (P < 0.01). Whole body fat oxidation rate measured after 5 wk of infusion was significantly increased among treated animals as evidenced by a reduced respiratory quotient (0.87 +/- 0.01) relative to controls (0. 90 +/- 0.01). VMH NE infusion induced hyperphagia (30%) only during the first week and did not affect body weight over the 5-wk period. Increases in VMH NE activity that are common among obese insulin-resistant animal models can cause the development of this obese glucose-intolerant (metabolic) syndrome.

Assessment of human muscle glycogen synthesis and total glucose content by in vivo 13C MRS

BACKGROUND

Obesity is often accompanied by a decreased ability of insulin to stimulate glucose uptake and glycogenesis in skeletal muscle. The aim of this study was to investigate the rate of glycogen formation and of muscular glucose content in relation to insulin sensitivity under euglycemic conditions.

MATERIALS AND METHODS

We applied a hyperinsulinemic (430 pmol m-2 min-1) euglycemic clamp with infusion of 20% glucose (30% enriched with 13C-1-glucose) to 8 subjects with a wide range of insulin sensitivities. Glycogen and glucose levels were monitored simultaneously by in vivo 13C MRS of the calf muscle on a clinical MR system at 1.5T field strength.

RESULTS AND CONCLUSIONS

Glycogen synthesis rate showed a strong correlation with whole body glucose uptake during the clamp (r = 0.93, P < 0.01). With the use of 13C MRS, total muscular glucose content could be determined in vivo, and showed a positive, linear correlation with glycogen synthesis rate (r = 0.85, P < 0.01). 13C MRS provides important information regarding in vivo insulin action. Preliminary results indicate that the glycogen synthesis rate improves after treatment with troglitazone.

Elevated systolic blood pressure as a cardiovascular risk factor

This paper reviews the evolution of attitudes toward the treatment and diagnosis of hypertension. In particular, there is a growing realization that elevated systolic pressure may be a more valuable measurement in evaluating and controlling hypertension than is generally acknowledged. A large number of epidemiologic studies in a wide variety of populations have revealed that systolic blood pressure exerts a stronger influence than diastolic blood pressure. The largest of these, the Framingham Heart Study, showed that in subjects with systolic hypertension, diastolic blood pressure was only weakly related to the risk of cardiovascular events, but in those with diastolic hypertension, the risk of these events was strongly influenced by the level of systolic pressure. Furthermore, cardiovascular event rates were found to increase steeply with systolic pressure and were higher in cases of isolated systolic hypertension than diastolic hypertension. Clinical trials produced similar results, again suggesting that a greater reliance should be placed on systolic pressure in evaluating the risk of cardiovascular problems. This review concludes that the health community needs to be reeducated to consider the importance of systolic and diastolic blood pressure in assessing appropriate management strategies for hypertensive patients.

Lack of effect of insulin on glucose utilization of the hypothalamus in normotensive and hypertensive rats

Hypertension is frequently associated with insulin resistance and enhanced sympathetic activity supposedly mediated by an effect of the hormone on the hypothalamus. In this study we sought to determine whether insulin modifies the functional activity of the hypothalamus and other brain areas of spontaneously hypertensive (SHR) and normotensive WKY rats. The study was carried out in control and hyperinsulinemic, normoglycemic rats. Insulin plasma levels were increased to 198 +/- 10 (WKY) or 220 +/- 10 microunits/ml (SHR). Brain functional activity was evaluated by the 2-[14C]deoxyglucose method for measuring local rates of glucose utilization. The results show that insulin has no effect on any of the brain areas examined including the hypothalamus, of both WKY and SHR rats. The two strains of rats have comparable cerebral metabolic rates also under basal conditions.

Gene-gene interaction in the RAS system in the predisposition to myocardial infarction in elder population of St. Petersburg (Russia)

The aim of this study was to estimate the frequencies of some DNA polymorphisms of two genes of the renin-angiotensin system (RAS), M235T angiotensinogen gene and insertion-deletion polymorphism in angiotensin-converting enzyme gene, in older (>55 years old) myocardial infarction survival and control groups. For this purpose 198 myocardial infarction (MI) patients and 152 randomly selected healthy persons have been analyzed. We have not found any differences in allele and genotype distribution in the above-mentioned genes for either group. However, statistical research showed a significant increase of double homozygotes IITT in the group of MI patients as compared with those in the control group. In this respect we suggested that gene-gene interaction in the RAS system may be considered to be a predisposing factor for MI development.

Relative influence of insulin resistance versus blood pressure on vascular changes in longstanding hypertension. ICARUS, a LIFE sub study. Insulin Carotids US Scandinavia

BACKGROUND

Insulin resistance is associated with hypertension. The relative influences of hyperinsulinaemia and high blood pressure on vascular hypertrophy and carotid distensibility is unclear in patients with longstanding hypertension.

METHODS

In 88 unmedicated patients with stage II-III hypertension and left ventricular hypertrophy on electrocardiogram we measured blood pressure, minimal forearm vascular resistance (MFVR) using plethysmography, intima-media thickness (IMT) and the wall distensibility of the common carotid arteries using ultrasound, and insulin sensitivity using a 2-h isoglycaemic hyperinsulinaemic clamp.

RESULTS

IMT was positively correlated to systolic blood pressure (r= 0.26, P < 0.05), whole body glucose uptake index (M/IG; r= 0.22, P< 0.05), age (r= 0.24, P< 0.05) and negatively correlated to body mass index (r= -0.24, P < 0.05); IMT did not correlate to fasting serum insulin (r= -0.14, NS). In men (n = 64) MFVR was positively correlated to systolic blood pressure (r = 0.30, P < 0.05), but was unrelated to M/G and serum insulin. The distensibility of the common carotid arteries was negatively correlated to systolic blood pressure (r = -0.40, P< 0.001) and in untreated patients (n = 22) positively correlated to M/IG (r = 0.47, P < 0.05).

CONCLUSIONS

High systolic blood pressure was related to vascular hypertrophy, whereas hyperinsulinaemia and insulin resistance were not, suggesting that longstanding high blood pressure is a far more important determinant for structural vascular changes than insulin resistance at this stage of the hypertensive disease. However, hyperinsulinaemia and insulin resistance were associated with low distensibility of the common carotid arteries in the subgroup of never treated hypertensive patients.

Dopaminergic agonists normalize elevated hypothalamic neuropeptide Y and corticotropin-releasing hormone, body weight gain, and hyperglycemia in ob/ob mice

Hypothalamic neuropeptide Y (NPY) and corticotropin-releasing hormone (CRH) influence feeding and levels of plasma glucose, insulin, free fatty acids, and triglycerides. Treatment of genetically obese, ob/ob mice, with dopamine receptor D(1)/D(2) agonists normalizes hyperphagia, body weight gain, hyperglycemia, and hyperlipidemia. We therefore examined whether levels of NPY and CRH immunoreactivity in discrete hypothalamic nuclei are altered in ob/ob mice, and whether dopaminergic treatment reverses this alteration. Female ob/ob mice were treated daily at 1 h after light onset with the D(1)/D(2) agonists, SKF-38393 (20 mg/kg) and bromocriptine (15 mg/kg), respectively or vehicle for 2 weeks. Such treatment, while normalizing body weight gain and hyperglycemia, also significantly reduced elevated NPY immunoreactivity in the suprachiasmatic (by 39%), intergeniculate (by 43%), paraventricular (PVN; by 31%), and arcuate (by 41%) nuclei in obese mice to levels observed in lean mice. This treatment also caused a 45-50% decline in levels of CRH in the PVN and dorsomedial hypothalamus compared to obese controls to levels observed in lean mice. Taken together, these findings suggest that dopaminergic D(1)/D(2) receptor coactivation may improve hyperphagia, hyperglycemia, and obesity in the ob/ob mouse, in part, by normalizing elevated levels of both NPY and CRH.

Diabetes in the elderly population

Type 2 diabetes mellitus has emerged as an important condition of older patients in which both microvascular and macrovascular complications are a common cause of morbidity and mortality. In contrast to type 1 diabetes mellitus, this endocrinopathy is clustered in minority populations and has both strong genetic and environmental factors that influence disease manifestation. A number of physiological alterations of glucose metabolism including hepatic overproduction of glucose, and reduced glucose utilization by peripheral tissues as a result of insulin resistance contribute to the development of the metabolic manifestations of this disease. Ultimately, pancreatic failure and reduced insulin secretion lead to hyperglycemia and the diabetic state. Frequently, many of these metabolic manifestations, or what has been termed Syndrome X, antecede the development of overt diabetes by many years. This syndrome is manifest clinically by such cardiovascular risk factors as hypertension, dyslipidemia, and coagulation abnormalities. This abnormal metabolic milieu contributes to the high prevalence of macrovascular complications including coronary artery disease as well as more generalized atherosclerosis. Microvascular complications have only more recently been recognized as an important and frequent complication of type 2 diabetes. Among the elderly and minority populations, this has become the single most important cause of end-stage renal failure that necessitates renal replacement therapies. The outcome for these patients on hemodialysis, the modality most frequently selected, is poor, with the majority of these patients dying of cardiovascular causes. Unfortunately, interventional strategies to reduce or prevent the microvascular and macrovascular complications have only recently received the needed attention and will require considerable effort and resources to improve the clinical outcomes and life expectancies for these patients.

beta(3)-adrenergic stimulation differentially inhibits insulin signaling and decreases insulin-induced glucose uptake in brown adipocytes

Activity of the sympathetic nervous system is an important factor involved in the pathogenesis of insulin resistance and associated metabolic and vascular abnormalities. In this study, we investigate the molecular basis of cross-talk between beta(3)-adrenergic and insulin signaling systems in mouse brown adipocytes immortalized by SV40 T infection. Insulin-induced tyrosine phosphorylation of the insulin receptor, insulin receptor substrate 1 (IRS-1), and IRS-2 was reduced by prestimulation of beta(3)-adrenergic receptors (CL316243). Similarly, insulin-induced IRS-1-associated and phosphotyrosine-associated phosphatidylinositol 3-kinase (PI 3-kinase) activity, but not IRS-2-associated PI 3-kinase activity, was reduced by beta(3)-adrenergic prestimulation. Furthermore, insulin-stimulated activation of Akt, but not mitogen-activated protein kinase, was diminished. Insulin-induced glucose uptake was completely inhibited by beta(3)-adrenergic prestimulation. These effects appear to be protein kinase A-dependent. Furthermore inhibition of protein kinase C restored the beta(3)-receptor-mediated reductions in insulin-induced IRS-1 tyrosine phosphorylation and IRS-1-associated PI 3-kinase activity. Together, these findings indicate cross-talk between adrenergic and insulin signaling pathways. This interaction is protein kinase A-dependent and, at least in part, protein kinase C-dependent, and could play an important role in the pathogenesis of insulin resistance associated with sympathetic overactivity and regulation of brown fat metabolism.

Inositol phosphoglycans in diabetes and obesity: urinary levels of IPG A-type and IPG P-type, and relationship to pathophysiological changes

Measurements have been made, in adult male diabetic patients and control subjects, of the urinary content of inositol phosphoglycans (IPGs), the IPG A-type and IPG P-type forms, which, among other actions, regulate pathways of glucose utilization, lipogenesis, triglyceride formation, and pyruvate dehydrogenase (PDH) activity. Urine samples from the entire diabetic group showed a 2- to 3-fold increase in IPG A-type, and a fall in the IPG P-type:IPG A-type ratio relative to the control group. Subdivision of the diabetic patients into lean IDDM and obese NIDDM groups revealed significant differences in the IPG P-type:IPG A-type ratio between these groups, this ratio decreasing with increases in the body mass index (BMI). Analysis of the relationships among IPGs and HbA1, blood pressure, and BMI indicated that a fall in the IPG P-type:IPG A-type ratio correlated with a rise in the HbA1 (indicative of impaired glycemic control), with increased systolic blood pressure and increased obesity, all factors linked to Syndrome X. There was a parallism between the profile of the IPG P-type:IPG A-type ratio and the well-established pattern of insulin resistance and BMI. In vitro studies of the effects of alterations in the IPG P-type:IPG A-type ratio on the activation of the pyruvate dehydrogenase complex (PDH complex) at the PDH phosphatase reaction demonstrated that IPG A-type forms antagonized the stimulation of the PDH phosphatase by IPG P-type forms, thus having a negative effect on the conversion of PDH to the active, dephosphorylated, form. This observation could provide a mechanism whereby the shifts in the IPG P-type:IPG A-type ratio reported above could change the metabolic pattern from one directed to glucose oxidation to one more directed toward energy conservation and lipid storage.

Role of the sympathetic adrenal system in the pathogenesis of the insulin resistance syndrome

The pathophysiology of the various manifestations of Syndrome X has been poorly understood. A possible mechanism involves stimulation of the sympathetic nervous system (SNS). Insulin plays an important role in the relationship between dietary intake and SNS activity. Because insulin-mediated glucose uptake in central hypothalamic neurons regulates SNS activity in response to dietary intake, a hypothesis was developed that links the hyperinsulinemia of obesity to sympathetic stimulation, the latter exerting a prohypertensive effect mediated by the kidney, the heart, and the vasculature. Evidence in support of this hypothesis has been obtained from the Normative Aging Study (NAS) in which a relationship between insulin (and glucose) and the SNS, and between insulin and SNS activity and blood pressure was demonstrated. The characteristic dyslipidemia in NAS subjects, moreover, was related to insulin and epinephrine. As reported in other studies, insulin level was directly associated with low HDL and high triglyceride levels. An independent inverse association was also noted between urinary epinephrine excretion and lipid levels: high epinephrine excretion rates were associated with high HDL and low triglyceride levels and, conversely, low epinephrine excretion was associated with low HDL and high triglycerides. In the NAS, therefore, increased SNS activity contributes to hypertension while diminished adrenal medullary activity contributes to the low HDL and high triglyceride levels commonly seen in association with hypertension.

Screening for cardiovascular disease. Concepts, conflicts, and consensus

CVD in the United States is prevalent, costly, and disabling. Wherever in the arterial tree atherosclerosis occurs, the process appears to begin in youth, to develop under the influence of the same risk factors, and to be amenable to the same interventions. The relationship between CVD and its associated risk factors is continuous, is graded, and extends below thresholds previously defined as normal. This observation, in turn, is based on an appreciation that in our society, the gap between normal and optimal can be considerable. CVD is a multifactorial process, often related to modifiable lifestyle choices; we focus on any single risk factor to the exclusion of others puts patients in danger. Because risk factors rarely occur in isolation, risk assessment must be as multifactorial as the underlying disease process. By understanding differences between risk factors in terms of the impact of their modification on the underlying disease, targeted interventions become possible that are tailored to the likelihood of an individual patient acquiring CVD. To change the overall prevalence of an epidemic disease such as CVD, however, such a high-risk approach must be applied in concert with a population strategy that seeks to effect smaller degrees of change in the large segment of society that may be at only moderate risk but--because of their great numbers--bears most of the morbidity and mortality of CVD. Finally, despite the remarkable progress that has been made in our understanding of the pathophysiology of CVD and the effectiveness of risk factor modification, significant gaps remain between knowledge and behavior. Fewer than 50% of diabetics are even aware that they have the disease. Only a third of those whose lipid levels qualify them for treatment receive intervention of any kind, including dietary advice. Only 27% of hypertensives have their blood pressure adequately controlled. The potential impact of more vigorous screening practices in the primary care setting on the health of individuals and communities cannot be overstated.

Plasma leptin level is associated with myocardial wall thickness in hypertensive insulin-resistant men

Leptin, the product of the ob gene, has been shown to increase heart rate and blood pressure through a stimulation of cardiac sympathetic nervous system activity, a phenomenon also involved in the pathogenesis of left ventricular hypertrophy in hypertensives. Thus, we hypothesize that plasma leptin concentration is associated with left ventricular hypertrophy. Forty hypertensive males and 15 healthy male subjects underwent anthropometric and echocardiographic evaluations, assessment of insulin sensitivity through euglycemic glucose clamp combined with indirect calorimetry, and determination of fasting plasma leptin concentration. Fasting plasma leptin levels were higher in hypertensives than in controls (6.48+/-2.9 versus 4. 62+/-1.5 ng/mL, P<0.05); these results were unchanged after adjustment for body mass index (P<0.05). In the whole group of patients (n=55), fasting plasma leptin concentration was correlated with body mass index (r=0.46, P<0.001) and waist/hip ratio (r=0.50, P<0.001); independent of body mass index and waist/hip ratio, fasting plasma leptin concentration was correlated (n=55) with whole-body glucose disposal (r=-0.27, P<0.04), interventricular septum thickness (r=0.34, P<0.001), posterior wall thickness (r=0.38, P<0.003), and the sum of wall thicknesses (r=0.68, P<0.001). In a multivariate analysis (n=55), age, body mass index, fasting plasma leptin concentration, plasma Na(+) concentration, whole-body glucose disposal, and diastolic blood pressure explained 68% of the variability of the sum of wall thicknesses with fasting plasma leptin concentration (P<0.03), whole body glucose disposal (P<0.002), and diastolic blood pressure (P<0.001), which were significantly and independently associated with the sum of wall thicknesses. In conclusion, our study demonstrates that fasting plasma leptin levels are associated with increased myocardial wall thickness independent of body composition and blood pressure levels in hypertensives.

Association of body mass, gender and race with heart failure primarily due to hypertension

OBJECTIVES

This study was performed to determine the association between clinical characteristics, particularly body mass and race, and the likelihood of hypertension as the primary etiology for heart failure (HTNCM).

BACKGROUND

Although held to be important in the development of heart failure, the clinical characteristics predictive of HTNCM have not been well delineated.

METHODS

The study analysis was conducted using 680 patients from the University of North Carolina Heart Failure Database. This data set is racially diverse (44% African-American) and contains data concerning baseline clinical characteristics and cardiac function in patients with and without HTNCM. Logistic regression techniques determined independent predictors of HTNCM among the entire study population as well as the subgroup of study patients with hypertension.

RESULTS

Hypertension was present in 51% of the study patients but was the primary etiology of heart failure in only 25%. Body mass, race, gender and baseline systolic blood pressure were identified as significant independent predictors of the likelihood of HTNCM (all p < 0.001). These characteristics were predictors in the total study population and also in the subgroup of study patients with hypertension.

CONCLUSIONS

Hypertension remains a common etiologic factor for the development of heart failure but was the primary cause of heart failure in a minority of study patients. However, the presence of increased body mass, female gender, African-American ethnic origin or elevated baseline systolic blood pressure significantly increased the likelihood of HTNCM.

Circulating insulin and insulin growth factor-1 are independent determinants of left ventricular mass and geometry in essential hypertension

BACKGROUND

It is unclear whether insulin and insulin-like growth factor-1 (IGF-1) are independent determinants of left ventricular (LV) mass in essential hypertension.

METHODS AND RESULTS

We studied 101 never-treated nondiabetic subjects with essential hypertension. All had 24-hour noninvasive ambulatory blood pressure (ABP) monitoring and a 75-g oral glucose tolerance test. We determined fasting glucose, insulin, and IGF-1 and postload glucose and insulin 2 hours after glucose. Insulin resistance was estimated by the homeostasis model assessment (HOMA(IR)) formula. LV mass showed an association with body mass index (BMI) (r=0.47; P<0.01), postload insulin (r=0.54; P<0.01), HOMA(IR) (r=0.39; P<0.01), and IGF-1 (r=0. 43; P<0.01) and a weaker association with average 24-hour systolic and diastolic ABPs (r=0.29 and r=0.26; P<0.05) and basal insulin (r=0.31; P<0.05). Relative wall thickness was positively related to IGF-1 (r=0.39; P<0.01) but not to fasting or 2-hour postload insulin, HOMA(IR), and glucose. In a multiple regression analysis, the final LV mass model (R(2)=0.64) included IGF-1, postload insulin, average 24-hour systolic ABP, sex, and BMI. IGF-1 and postload insulin accounted for >40% of variability of LV mass. The final model (R(2)=0.36) for relative wall thickness included IGF-1 (16% total explained variability), average 24-hour systolic ABP, sex, BMI, and age but not insulin and HOMA(IR).

CONCLUSIONS

These data indicate that insulin and IGF-1 are powerful independent determinants of LV mass and geometry in untreated subjects with essential hypertension and normal glucose tolerance.

Impact of sleep debt on metabolic and endocrine function

BACKGROUND

Chronic sleep debt is becoming increasingly common and affects millions of people in more-developed countries. Sleep debt is currently believed to have no adverse effect on health. We investigated the effect of sleep debt on metabolic and endocrine functions.

METHODS

We assessed carbohydrate metabolism, thyrotropic function, activity of the hypothalamo-pituitary-adrenal axis, and sympathovagal balance in 11 young men after time in bed had been restricted to 4 h per night for 6 nights. We compared the sleep-debt condition with measurements taken at the end of a sleep-recovery period when participants were allowed 12 h in bed per night for 6 nights.

FINDINGS

Glucose tolerance was lower in the sleep-debt condition than in the fully rested condition (p<0.02), as were thyrotropin concentrations (p<0.01). Evening cortisol concentrations were raised (p=0.0001) and activity of the sympathetic nervous system was increased in the sleep-debt condition (p<0.02).

INTERPRETATION

Sleep debt has a harmful impact on carbohydrate metabolism and endocrine function. The effects are similar to those seen in normal ageing and, therefore, sleep debt may increase the severity of age-related chronic disorders.

Fasting insulin and leptin serum levels are associated with systolic blood pressure independent of percentage body fat and body mass index

OBJECTIVE

To examine the relationship between leptin and insulin serum levels and systolic and diastolic blood pressure in young men.

SETTING

Kobe University of Mercantile Marine, Kobe, Japan.

PARTICIPANTS

One hundred and ninety-eight male students aged 18-20 years (comprising 100% of those eligible).

DESIGN AND MEASUREMENTS

A cross-sectional survey of a sample of male college students was performed, with measurements to include anthropometry, blood pressure and blood tests after overnight fasting.

RESULTS

Compared with 90 men with an optimal blood pressure, 56 men with high-normal and high blood pressure had an increase in body mass index (23.7 +/- 5.2 versus 20.4 +/- 2.2 kg/m2), percentage body fat (21.7 +/- 8.0 versus 16.3 +/- 4.2%) and serum leptin (3.7 +/- 4.7 versus 1.5 +/- 0.8 ng/ml). In addition, they had greater serum insulin (59 +/- 31 versus 43 +/- 12 pmol/l) despite there being no differences in plasma glucose, resulting in a reduction of the ratio of glucose to insulin (x 10(6)) (107 +/- 43 versus 126 +/-, which is an estimate of insulin sensitivity in a nondiabetic population. Furthermore, the 56 men had higher serum triglyceride levels, although there was no difference in low density lipoprotein-cholesterol and high density lipoprotein-cholesterol between men with optimal and high-normal plus high blood pressure. Similar differences were found between men in a top versus low tertile of systolic and diastolic blood pressure. In multiple regression analysis, both log leptin and log insulin emerged as determinants for systolic blood pressure independent of body mass index and percentage body fat, but an association with diastolic blood pressure was only shown for log leptin.

CONCLUSION

Hyperleptinemia and hyperinsulinemia may be regulators of arterial pressure, independent of body mass index or percentage body fat.

Effect of alpha1-adrenoceptor blockade on coronary vasodilator reserve in cardiac syndrome X

We sought to test the response of the coronary microcirculation to alpha-adrenoceptor blockade in patients with syndrome X (angina, ischemia-like stress electrocardiogram, and a normal coronary arteriogram). The response of the microcirculation was assessed by quantification of coronary vasodilator reserve (the ratio of hyperemic to resting myocardial blood flow). We investigated 28 patients with syndrome X [18 women, age 54.4 (7.6) years]. Myocardial blood flow was measured at rest and after dipyridamole by using positron emission tomography with H(2)15O. The measurements were made before and after treatment for 10 days with doxazosin (1 mg o.d. for 3 days, followed by 2 mg o.d. for 7 days) or a matched placebo, similarly administered. Patients were randomized to alpha1-blockade or to placebo in double-blind fashion. No significant differences were demonstrable between syndrome X patients treated with doxazosin and those receiving placebo, with respect to resting myocardial blood flow, myocardial blood flow after dipyridamole, or coronary vasodilator reserve (the ratio of the latter two). In addition, no relations were demonstrable among myocardial blood flow, coronary vasodilator reserve, development of chest pain after dipyridamole, or development of ischemia-like ECG changes. Doxazosin had no effect on the perception of chest pain after dipyridamole. No differences were found between the effects of alpha1-blockade with doxazosin or those of placebo with respect to myocardial blood flow in syndrome X. The values obtained for myocardial blood flow and coronary vasodilator reserve for the patients were within the normal range. The data do not support the case for alpha1-mediated vasoconstriction having an etiologic role in the chest pain of syndrome X.

Radiotelemetric characterization of overweight-associated rises in blood pressure and heart rate

We addressed the hypothesis that hypercaloric diets induce hyperkinetic hypertension irrespective of day-night cycle and locomotor activity that is associated with altered cardiac myosin isozymes. Normotensive rats with implanted radiotelemetry pressure transducers were fed increasing amounts of coconut fat (8, 16, and 24%, each for 2 wk) corresponding to 20-47% of total calories from fat. Thereafter, increasing amounts of sucrose (16, 32, and 50%) and fructose (50%) were added to the 24% fat diet corresponding to 13-40% of total calories from sugar. In contrast to the fat diets, the 32% and 50% sucrose diets as well as the 50% fructose diets increased (P < 0.05) blood pressure (systolic maximum +13 mmHg, diastolic maximum +4 mmHg, mean maximum +7 mmHg) and heart rate (maximum +50 beats/min) irrespective of the day-night cycle and the unaltered locomotor activity. Furthermore, body weight increased (P < 0.05) during the 32% and 50% sucrose feedings. The increased blood pressure and heart rate normalized after rats were fed a regular chow. We concluded that an excessive caloric intake results in hyperkinetic hypertension that increases the myosin V(1) proportion.

Hypotensive effect of low-fat, high-carbohydrate diet can be independent of changes in plasma insulin concentrations

To examine the relationship between diet, blood pressure, and plasma insulin concentrations, we studied 14 healthy males who were prescribed low-fat and high-fat diets. The low-fat diet contained 25% (of energy intake) fat and 54% carbohydrate; the high-fat diet was 45% fat (predominantly saturated fat) and 36% carbohydrate. The diets were consumed over consecutive 2-week periods in random sequence, separated by a 2-week washout period. Resting supine systolic and diastolic blood pressures decreased significantly by 7 and 3 mm Hg, respectively, and plasma total cholesterol, LDL cholesterol, and HDL cholesterol concentrations all fell (by 21.6%, 25.7%, and 18.0%, respectively; all P<0.001) on the low-fat compared with the high-fat diet. Fasting glucose and the glucose area under the curve during the frequently sampled intravenous glucose tolerance test (300 mg/kg glucose load with blood sampling for 180 minutes) were significantly lower, and the glucose disappearance rate tended to be faster after the low-fat diet. In contrast, fasting insulin concentrations and the insulin response (insulin area under the curve) to glucose challenge were unchanged. Insulin sensitivity (defined as the rate of glucose disappearance per unit of insulin increase during the period 0 to 40 minutes after the glucose load) was significantly higher on the low-fat diet. These results suggest that the hypotensive effects of a low-fat, high-carbohydrate diet, although associated with an improvement in insulin sensitivity, are not mediated by changes in plasma insulin concentration.

Bromocriptine improves glycaemic control and serum lipid profile in obese Type 2 diabetic subjects: a new approach in the treatment of diabetes

Bromocriptine, a potent dopamine D(2) receptor agonist, has been shown to reduce insulin resistance, glucose intolerance and hyperlipidaemia in both numerous animal studies and in Phase II studies. Bromocriptine has been used worldwide for over 20 years to treat Parkinson's disease, macroprolactinoma and other disorders; it has been found to be generally safe. We therefore investigated the possible beneficial effects of Ergoset(R) (Ergo Science Corp.), a new quick release formulation of bromocriptine, on glycaemic control and serum lipid profile in obese Type 2 diabetic subjects in two large Phase III studies. A large, randomised, double-blind placebo-controlled study was conducted in which Ergoset was given once daily at 8 am. (4.8 mg maximum dose) for 24 weeks as adjunctive therapy to sulphonylurea (485 subjects) to obese Type 2 diabetics held on a weight- maintaining diet. Treatment efficacy parameters included change from baseline in glycated haemoglobin A(1c) (HbA(1c)), fasting and post-prandial serum glucose, insulin, triglyceride and free fatty acid levels. Baseline glycated haemoglobin, fasting glucose, insulin, triglyceride and free fatty acid levels did not differ between treatment groups. and on average were 9.4 +/- 0.05%, 222 +/- 2 mg/dl, 24 +/- 1 µU/ml, 248 +/- 11 mg/dl, and 850 +/- 32 µEq/l, respectively. A similarly designed study of Ergoset as monotherapy in Type 2 diabetics (154 subjects) with similar baseline clinical characteristics was conducted. Addition of Ergoset treatment to sulphonylurea reduced percent glycated HbA(1c) by 0.55 (P < 0.0001) (approximately 1.0 for responders, 65% of population), fasting and post-prandial glucose by 23 and 26 mg/dl (P < 0.0002), fasting and post-prandial triglycerides by 72 and 63 mg/dl (P < 0.005) and fasting and post-prandial free fatty acids by 150 and 165 µEq/l (P < 0.05), relative to placebo. Twelve percent of all Ergoset subjects, compared to 3% of placebo subjects, withdrew from the study due to adverse events. The most common events causing withdrawal were nausea, dizziness, asthenia, and rhinitis (representing 4.5, 3.3, 2.0, and 0.8% of the total Ergoset populations, respectively). The incidence of serious adverse events did not differ between Ergoset- (3.4%) and placebo- (4.3%) treated subjects. Ergoset as monotherapy also improved glycaemic control (0.56 HbA(1c) decrease relative to placebo after 24 weeks of treatment; P < 0.02). Once daily Ergoset treatment improves glycaemic control and serum lipid profile and is well-tolerated in obese Type 2 diabetics.

Leptin is associated with increased risk of myocardial infarction

OBJECTIVES AND DESIGN

Leptin is involved in the regulation of bodyweight and metabolism in man and might also be involved in the pathophysiology of the insulin resistance syndrome, which is associated with the development of cardiovascular diseases. We tested whether leptin is a risk factor for acute myocardial infarction (AMI) in a nested case-referent study.

SUBJECTS AND METHODS

Sixty-two men with first-ever AMI were identified who, prior to AMI, had participated in population-based health surveys in Northern Sweden. Referents were matched for sex, age, date and type of health survey, and geographical region. Blood pressure, body mass index (BMI) and the presence of smoking, diabetes and hypertension were recorded. Total cholesterol, apolipoprotein A-1 (apo A-1), apolipoprotein B (apo B), plasminogen activator inhibitor (PAI-1), insulin, and leptin were analysed in stored samples. Their influences on first-ever AMI were analysed by conditional logistic regression analysis.

RESULTS

Men with first-ever AMI had higher BMI, plasma insulin and leptin, and diastolic blood pressure than the referents. Furthermore, they had lower plasma apo A-1 and were more often smokers. Smoking, high leptin, PAI-1 and cholesterol, and low apo A-1 levels were significant risk factors for first-ever AMI in univariate analysis. High leptin (OR 8.97; 95% CI: 1.73-46.5) and cholesterol (OR 5.18; 95% CI: 1.34-20.0) levels remained significant risk factors for AMI in a multivariate model. High apo A-1 was protective (OR = 0.13; 95% CI: 0.03-0.55). The combination of high leptin and low apo A-1 was associated with a particularly pronounced increased risk for AMI.

CONCLUSION

Plasma leptin strongly predicts first-ever AMI. Our data support the hypothesis that leptin is an important link in the development of cardiovascular disease in obesity.

Relation between systemic hypertension and blood lipids on the risk of myocardial infarction

We sought to evaluate the potential interactions between systemic hypertension and blood lipids on the risk of myocardial infarction (MI). Recent evidence suggests that hypertension may interact with other risk factors such as dyslipidemia in the development of coronary heart disease. However, the precise nature of that interrelation remains unclear. We selected 340 cases of first MI and an equal number of age-, sex-, and community-matched controls. Data were collected on a large number of coronary risk factors, and fasting blood samples were obtained. Logistic regression was used to calculate the odds ratio (OR) of nonfatal MI. The age- and sex-adjusted OR of MI was 1.61 (95% confidence interval [CI] 1.15 to 2.25) among treated hypertensives compared with nonhypertensives. Further adjustment for coronary risk factors did not materially alter the results (OR 1.67, 95% CI 1.16 to 2.41). To explore the interrelations among hypertension, lipids, and risk of MI, each lipoprotein parameter was individually added to the risk factor-adjusted multivariate model. The apparent risk associated with hypertension was substantially attenuated by the addition of either high-density lipoprotein cholesterol (OR 1.25, 95% CI 0.82 to 1.90) or triglycerides (OR 1.37, 95% CI 0.91 to 2.05). No significant interactions were found between hypertension and any lipoprotein parameter. These data indicate that the risk of MI associated with treated hypertension may have a lipid mechanism involving high-density lipoprotein cholesterol and/or triglycerides.

The altered homeostatic theory: a holistic approach to multiple diseases, including atherosclerosis, ischemic diseases, and hypertension

The altered homeostatic theory proposes that multiple acquired and genetic factors (risk factors) move the basic homeostatic balance in an 'action' direction which 'inappropriately' activates defense mechanisms and thus favors multiple diseases; factors which improve these disorders move the homeostatic balance in the opposite 'rest' direction. Diseases include hypertension, atherosclerosis, and ischemic disorders as ischemic heart disease (IHD), stroke, migraine, and Raynaud's disease. The theory has its origins in the premises of the spasm-of-resistance-vessel (S-RV) concept of ischemic diseases (which attributes symptoms in ischemic diseases to S-RV), and in a study designed to provide more evidence for this concept. The study showed that multiple risk factors for IHD express the combination of S-RV and a tendency toward thrombosis, and are risk factors for hypertension, migraine, Raynaud's disease, and stroke; factors which ameliorate IHD express vasodilation of resistance vessels and are anti-thrombotic, and ameliorate the other disorders.

Relationship between insulin resistance and cardiac sympathetic nervous function in essential hypertension

BACKGROUND

It has been suggested that hyperinsulinemia and insulin resistance participate in the pathogenesis of hypertension, in part by activating sympathetic activity.

OBJECTIVE

We aimed to examine the relationship between insulin resistance and cardiac sympathetic nervous function in patients with essential hypertension using 123I-metaiodobenzylguanidine (MIBG) cardiac scintigraphy.

METHODS AND RESULTS

Twenty-eight patients (18 men) with essential hypertension and 11 (seven men) control individuals with a mean age of 55.8+/-3.3 years were recruited. Patients with diabetes mellitus, congestive heart failure or coronary artery disease were excluded from this study. To evaluate insulin resistance, we used steady-state plasma glucose (SSPG; mg/dl) levels measured by the SSPG method. To evaluate cardiac sympathetic nervous function, we calculated the heart-to-mediastinum ratio from the delayed MIBG image (H:M-D) and the mean washout rate (WOR, %). There were significant differences (P<0.01) in SSPG, H:M-D and WOR between the essential hypertension and control individual groups (125 versus 103 mg/dl, 2.2 versus 2.4, and 32 versus 23%, respectively). Stepwise regression analysis showed that SSPG and plasma norepinephrine level are independent predictors for the cardiac sympathetic nervous function obtained from MIBG scintigraphy.

CONCLUSIONS

These findings indicate that insulin resistance is significantly related to activation of the cardiac sympathetic nervous function associated with left ventricular hypertrophy in patients with essential hypertension.

Insulin resistance in adipocytes from spontaneously hypertensive rats: effect of long-term treatment with enalapril and losartan

Insulin responsiveness was studied in isolated adipocytes from the normotensive Wistar Kyoto (WKY) rat and the spontaneously hypertensive rat (SHR). The effect of insulin (0.1 to 5 nmol/L) on glucose uptake (glucose transport and lipogenesis) was measured, and the maximal effect of insulin (Emax) and the dose of insulin required to elicit 50% of the maximal response (EC50) were calculated. A diminished Emax on lipogenesis without changes in the EC50 was detected in SHRs. The Emax was 0.49 +/- 0.09 (SHR) and 1.16 +/- 0.14 (WKY) micromol/10(5) cells (P < .05), and the EC50 was 0.13 +/- 0.03 and 0.11 +/- 0.02 nmol/L for WKY and SHR, respectively. Similar results were obtained when measuring insulin-stimulated glucose transport. A 30-day long-term treatment with enalapril (20 mg/kg/d) normalized insulin responsiveness in adipocytes from SHRs. The effect of enalapril was suppressed when SHRs were pretreated with enalapril and 150 microg/kg/d of the bradykinin (BK) B2-receptor blocker Hoe 140. Pretreatment with losartan (40 mg/kg/d) did not improve insulin action in the SHR. Since these results were obtained with isolated cells in which glucose availability was not a function of blood flow, and the effect of insulin in the SHR was improved by pretreatment with an angiotensin-converting enzyme (ACE) inhibitor but not with the AT1-receptor blocker, it appears that the insulin resistance linked to the hypertension is not related to changes in blood flow.

Elevated fasting insulin predicts incident hypertension: the ARIC study. Atherosclerosis Risk in Communities Study Investigators

OBJECTIVE

The prospective association of insulin and hypertension has been under debate in the context of the development of the insulin resistance or multiple metabolic syndrome. We examined the predictive associations of fasting serum insulin with incident hypertension occurring alone or as part of the multiple metabolic syndrome.

DESIGN

Analyses were restricted to 5221 middle-aged participants of the Atherosclerosis Risk in Communities Study cohort who were free of component disorders of the multiple metabolic syndrome (hypertension; diabetes; high triglycerides and/or low HDL cholesterol (dyslipidaemias)) at baseline.

OUTCOME

A total of 1018 individuals developed hypertension, 801 in the absence of components of the metabolic syndrome and 217 in combination with diabetes or dyslipidaemias, between 1987 and 1993.

RESULTS

Elevated fasting insulin (top quartile versus lowest quartile) was associated with overall incident hypertension in European Americans [hazard rate ratio (HRR) 2.0, 95% confidence interval (CI) 1.7-2.4] but the results were inconclusive in African Americans (HRR 1.3, 95% CI 0.9-1.8) after adjustment for age, gender and study centre. Among European Americans, body mass index and abdominal girth only partly explained the observed association. Elevated fasting insulin was more strongly predictive of hypertension occurring as a component of the multiple metabolic syndrome (HRR 2.4, 95% CI 1.5-3.9) than of hypertension occurring alone (HRR 1.3, 95% CI 1.0-1.7) adjusting statistically for age, gender, study centre, body mass index and abdominal girth.

CONCLUSIONS

The results are consistent with the concept of an aetiological heterogeneity for hypertension and may explain previously reported inconsistent findings on the association of insulin with incident hypertension.

Imidazoline receptors: from discovery to antihypertensive therapy (facts and doubts)

The hypothesis and indirect evidence of imidazoline receptors has been promoted since some 15 years ago and it gave a substantial impetus for research in this field, resulting in a better understanding of neuronal and cardiovascular regulatory processes. The nomenclature of the imidazoline receptors has been accepted by international forums but no direct proof for the existence of these receptors has been published. Authors summarise the most important available data, including facts and doubts as far as the discovery, characterisation, and function of imidazoline receptors and their subtypes, the differences between imidazoline receptors and alpha-2 adrenoceptors, and also on their participation in regulatory processes.