The cardiovascular disease continuum validated: clinical evidence of improved patient outcomes: part I: Pathophysiology and clinical trial evidence (risk factors through stable coronary artery disease)

Evaluation of the cardiovascular effects of methylmercury exposures: current evidence supports development of a dose-response function for regulatory benefits analysis

BACKGROUND

The U.S. Environmental Protection Agency (U.S. EPA) has estimated the neurological benefits of reductions in prenatal methylmercury (MeHg) exposure in past assessments of rules controlling mercury (Hg) emissions. A growing body of evidence suggests that MeHg exposure can also lead to increased risks of adverse cardiovascular impacts in exposed populations.

DATA EXTRACTION

The U.S. EPA assembled the authors of this article to participate in a workshop, where we reviewed the current science concerning cardiovascular health effects of MeHg exposure via fish and seafood consumption and provided recommendations concerning whether cardiovascular health effects should be included in future Hg regulatory impact analyses.

DATA SYNTHESIS

We found the body of evidence exploring the link between MeHg and acute myocardial infarction (MI) to be sufficiently strong to support its inclusion in future benefits analyses, based both on direct epidemiological evidence of an MeHg-MI link and on MeHg's association with intermediary impacts that contribute to MI risk. Although additional research in this area would be beneficial to further clarify key characteristics of this relationship and the biological mechanisms that underlie it, we consider the current epidemiological literature sufficiently robust to support the development of a dose- response function.

CONCLUSIONS

We recommend the development of a dose- response function relating MeHg exposures with MIs for use in regulatory benefits analyses of future rules targeting Hg air emissions.

The role of nitric oxide in improving endothelial function andcardiovascular health: focus on nebivolol

Although β-blockers have been endorsed by guidelines committees for the treatment of patients with hypertension, particularly those with significant CVD and high CVD risk, there are concerns about conventional β-blockers related to poorer clinical outcomes compared with other classes of antihypertensive agents, as well as deleterious effects on quality of life and lipid and carbohydrate metabolism. β-blockers comprise a heterogeneous group of antihypertensive agents, including nonselective agents, cardioselective, nonvasodilating agents, and vasodilating agents that either combine β-nonselectivity with β-blockade or possess cardioselectivity without β-blockade. The pharmacologic, mechanistic, and hemodynamic differences between conventional, nonvasodilating β-blockers and vasodilating β-blockers are discussed in this review, with a focus on the cardioselective vasodilating β-blocker nebivolol. These differences may have important clinical implications, particularly in the treatment of complicated hypertension, such as that associated with patients with diabetes or cardiometabolic syndrome, elderly patients, and African American patients, suggesting that mechanism of action may be an important consideration when choosing a β-blocker.

Stagnant in cardiovascular prevention: alarming trends and persistent socioeconomic obstacles

Recently it has been suggested that the decline in cardiovascular mortality observed over the last 50 years may be coming to an end. This alarming trend, which has been noted mainly in younger adults from lower socioeconomic strata, may be linked to other changes, namely the increasing prevalence of modifiable risk factors, the most important of which is obesity. In contrast, our ability to predict cardiovascular risk continues to improve steadily, although it is unclear which will be its ability in designing more effective global preventive measures. Coronary heart disease appears to develop through multiple pathways, whose association with cardiovascular risk is mediated by complex processes involving numerous factors ranging from genetic predisposition to unfavorable socioeconomic circumstances. Although some attention has been paid to the latter, more effort has been put into controlling isolated risk factors. For example, numerous large studies have involved looking at the effect of single-drug therapies aimed at specific targets rather than examining more comprehensive approaches to managing multiple risk factors. In conclusion, an effective strategy for controlling modifiable risk factors in both individuals and populations must address this complex scenario and should consider significant socioeconomic factors such as education, income and the built environment. The unfavorable trend observed in cardiovascular health makes it essential that current preventive strategies are reassessed.

Cardiac benefits of renal artery stenting

AIMS

The aims of this study were to evaluate the effects of renal stenting on cardiac function using echocardiographic parameters, and to clarify whether changes in clinical and echocardiographic variables after renal stenting differ between atherosclerotic renal artery stenosis (ARAS) patients with and without cardiac symptoms.

METHODS AND RESULTS

A total of 61 patients who underwent renal stenting and echocardiography were included in the study. Left ventricular (LV) filling pressure and LV relaxation were evaluated with tissue Doppler imaging. The ratio of the peak early diastolic mitral inflow velocity to the peak early mitral annular velocity (E/e' ratio) and the e'-velocity were measured to assess diastolic function. LV ejection fraction remained unchanged, but the E/e' ratio (P<0.001) and the e'-velocity (P=0.004) improved after renal stenting. In particular, the E/e' ratio improved from 13.7±5.6 to 11.9±4.0 (P=0.002) within 24 hours after renal stenting and remained low at 11.2±3.8 after a mean follow-up period of 7±4 months (P=0.001). Patients with cardiac symptoms showed significantly better change in E/e' ratio (P=0.002) and E-velocity (P=0.005) compared to those without cardiac symptoms. Cardiac symptoms also significantly improved after renal stenting (New York Heart Association functional class: 2.5±0.6 at baseline to 1.4±0.6 at follow-up; P<0.001).

CONCLUSIONS

Renal stenting improved echocardiographic parameters that reflect LV diastolic function, and yielded a higher benefit for E/e' ratio and E-velocity in patients with cardiac symptoms than in those without cardiac symptoms.

An antioxidant probiotic reduces postprandial lipemia and oxidative stress

Reducing postprandial oxidative stress (OxS), decreasing postprandial blood triglyceride level (TG) and improving lipoprotein status is likely to have a preventive impact on the development of cardiovascular disease (CVD). Previously we have shown that the antioxidant probiotic Lactobacillus fermentum ME-3 (DSM14241) is characterized by antiatherogenic effects. This randomized double-blind placebo-controlled study evaluated the influence of kefir enriched with an antioxidative probiotic L. fermentum ME-3 (LfKef) on postprandial OxS, blood TG response and lipoprotein status. 100 clinically healthy subjects were recruited into the study. Blood parameters of postprandial OxS, TG and lipoprotein status were determined by oxidized LDL, baseline diene conjugation in LDL (BDC-LDL), oxidized LDL complex with beta-2 glycoprotein (Beta2-GPI-oxLDL), paraoxonase (PON) activity, LDL-Chol, HDL-Chol and TG. To evaluate general body postprandial OxS-load we measured 8-isoprostanes (8-EPI) in the urine. Consumption of LfKef significantly reduced the postprandial level of oxidized LDL, BDC-LDL, Beta2-GPI-oxLDL, urinary 8-isoprostanes and postprandial TG and caused a significant increase in HDL-Chol and PON activity. This is the first evidence that kefir enriched with an antioxidant probiotic may have a positive effect on both postprandial OxS and TG response as well as on lipoprotein status.

The physiological roles of phosducin: from retinal function to stress-dependent hypertension

In the time since its discovery, phosducin's functions have been intensively studied both in vivo and in vitro. Phosducin's most important biochemical feature in in vitro studies is its binding to heterotrimeric G protein βγ-subunits. Data on phosducin's in vivo relevance, however, have only recently been published but expand the range of biological actions, as shown both in animal models as well as in human studies. This review gives an overview of different aspects of phosducin biology ranging from structure, phylogeny of phosducin family members, posttranscriptional modification, biochemical features, localization and levels of expression to its physiological functions. Special emphasis will be placed on phosducin's function in the regulation of blood pressure. In the second part of this article, findings concerning cardiovascular regulation and their clinical relevance will be discussed on the basis of recently published data from gene-targeted mouse models and human genetic studies.

The Cardiovascular Continuum extended: Aging effects on the aorta and microvasculature

The ‘Cardiovascular Continuum’ was described by Dzau and colleagues in 2006 to explain the development over many years of coronary disease with its complications, then end-stage heart failure. The Continuum identified different points along the way where the process could be interrupted by drug therapies or interventions, then described the trials that have been undertaken over the last three decades to establish their value. The approach summarized the major steps in cardiology through modern times, but it had an emphasis on coronary atherosclerosis in prosperous nations, and did not account fully for the problems of aging, which occur in all societies. Aging of the aorta and elastic arteries causes arterial stiffening and leads to development of cardiac failure and microvascular disease in highly perfused organs such as the brain and kidneys. The ‘Vascular Aging Continuum’ which we introduce, dovetails with the late phases of the Cardiovascular Continuum and provides a more comprehensive explanation, especially for vascular diseases in nations with little atherosclerosis. It will become more common in the Western World where attention to risk factors and widespread use of statins are responsible for a decrease in atherosclerotic disease, prolongation of life, and dominance of macrovascular and microvascular arterial disease, as well as of cardiac failure.

Aliskiren and valsartan combination therapy for the management of hypertension

Combination therapy is necessary for most patients with hypertension, and agents that inhibit the renin-angiotensin-aldosterone system (RAAS) are mainstays in hypertension management, especially for patients at high cardiovascular and renal risk. Single blockade of the RAAS with an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) confers some cardiorenal protection; however, these agents do not extinguish the RAAS as evidenced by a reactive increase in plasma renin activity (PRA), a cardiovascular risk marker, and incomplete cardiorenal protection. Dual blockade with an ACE inhibitor and an ARB offers no additional benefit in patients with hypertension and normal renal and left ventricular function. Indeed, PRA increases synergistically with dual blockade. Aliskiren, the first direct renin inhibitor (DRI) to become available has provided an opportunity to study the merit of DRI/ARB combination treatment. By blocking the first and rate-limiting step in the RAAS, aliskiren reduces PRA by at least 70% and buffers the compensatory increase in PRA observed with ACE inhibitors and ARBs. The combination of a DRI and an ARB or an ACE inhibitor is an effective approach for lowering blood pressure; available data indicate that such combinations favorably affect proteinuria, left ventricular mass index, and brain natriuretic peptide in patients with albuminuria, left ventricular hypertrophy, and heart failure, respectively. Ongoing outcome studies will clarify the role of aliskiren and aliskiren-based combination RAAS blockade in patients with hypertension and those at high cardiorenal risk.

Metabolic syndrome, dyslipidemia, hypertension and type 2 diabetes in youth: from diagnosis to treatment

Overweight and obesity in youth is a worldwide public health problem. Overweight and obesity in childhood and adolescents have a substantial effect upon many systems, resulting in clinical conditions such as metabolic syndrome, early atherosclerosis, dyslipidemia, hypertension and type 2 diabetes (T2D). Obesity and the type of body fat distribution are still the core aspects of insulin resistance and seem to be the physiopathologic links common to metabolic syndrome, cardiovascular disease and T2D. The earlier the appearance of the clustering of risk factors and the higher the time of exposure, the greater will be the chance of developing coronary disease with a more severe endpoint. The age when the event may occur seems to be related to the presence and aggregation of risk factors throughout life.The treatment in this age-group is non pharmacological and aims at promoting changes in lifestyle. However, pharmacological treatments are indicated in special situations.The major goals in dietary treatments are not only limited to weight loss, but also to an improvement in the quality of life. Modification of risk factors associated to comorbidities, personal satisfaction of the child or adolescent and trying to establish healthy life habits from an early age are also important. There is a continuous debate on the best possible exercise to do, for children or adolescents, in order to lose weight. The prescription of physical activity to children and adolescents requires extensive integrated work among multidisciplinary teams, patients and their families, in order to reach therapeutic success.The most important conclusion drawn from this symposium was that if the growing prevalence of overweight and obesity continues at this pace, the result will be a population of children and adolescents with metabolic syndrome. This would lead to high mortality rates in young adults, changing the current increasing trend of worldwide longevity. Government actions and a better understanding of the causes of this problem must be implemented worldwide, by aiming at the prevention of obesity in children and adolescents.

The role of nitric oxide in improving endothelial function and cardiovascular health: focus on nebivolol

Although beta-blockers have been endorsed by guidelines committees for the treatment of patients with hypertension, particularly those with significant CVD and high CVD risk, there are concerns about conventional beta-blockers related to poorer clinical outcomes compared with other classes of antihypertensive agents, as well as deleterious effects on quality of life and lipid and carbohydrate metabolism. beta-Blockers comprise a heterogeneous group of antihypertensive agents, including nonselective agents, cardioselective, nonvasodilating agents, and vasodilating agents that either combine beta-nonselectivity with alpha-blockade or possess cardioselectivity without alpha-blockade. The pharmacologic, mechanistic, and hemodynamic differences between conventional, nonvasodilating beta-blockers and vasodilating beta-blockers are discussed in this review, with a focus on the cardioselective vasodilating beta-blocker nebivolol. These differences may have important clinical implications, particularly in the treatment of complicated hypertension, such as that associated with patients with diabetes or the cardiometabolic syndrome, elderly patients, and African American patients, suggesting that mechanism of action may be an important consideration when choosing a beta-blocker.

Syntropy, genetic testing and personalized medicine

The concept of syntropic diseases was proposed at the beginning of the last century to emphasize the phenomenon of nonrandom co-occurrence of human disorders. Common genes underlying specific syntropic diseases were called syntropic genes. The application of this concept to contemporary genomic studies will facilitate the understanding of the molecular basis of complex diseases, provide future direction for discovering new targets for therapy and prognosis, and may even lead to the reassessment of disease classification for the practice of more precise personalized medicine. With the acceptance of the syntropic genes theory, new genetic tests, focused on markers pointing to a set of pathogenetically linked diseases rather than to a single nosology, can be developed.

Should we screen for masked hypertension in patient with vascular disease?

Background:

The influence of hypertension on cardiovascular risk is well known. Ambulatory blood pressure measurement (ABPM) is able to identify patients with masked hypertension (MH) underdetected by clinical BP measurement. The benefit of screening for MH in a high-risk population was investigated.

Aims:

To detect MH in a population with no prior history of hypertension and medically treated for peripheral or coronary arterial disease.

Methods:

Thirty-eight consecutive patients with peripheral or coronary artery disease documented with arteriography, without a history of hypertension, and with an admission BP < 140/90 mmHg underwent ABPM after discharge. Ambulatory BP ≥ 125/80 mmHg were defined as MH.

Results:

MH was found in 11 patients (28.9%). The MH group had a mean systolic and diastolic hospitalization BP significantly higher (127 versus 115 mmHg, respectively, P = 0.002 and 76 versus 66 mmHg, P = 0.01), and tended to have a higher admission systolic BP and pulse pressure (127 versus 121 mmHg, respectively, P = 0.07; and 54 versus 46 mmHg, P = 0.06). The first BP measurement on the 24-hour ABPM was significantly higher in the MH group 140 versus 121 mmHg, P = 0.001, for systolic BP and 84 versus 74 mmHg, P = 0.03, for diastolic BP.

Conclusions:

MH was found in patients with documented and medically treated vascular disease. BP in the prehypertensive range is associated with MH. Systematic screening for MH in this high-risk population requires further investigation.

Evidence for the efficacy of ARBs across the cardiovascular continuum

INTRODUCTION

Angiotensin II receptor blockers (ARBs) are antihypertensive agents with considerable evidence of efficacy and safety for the reduction of cardiovascular (CV) disease risk in numerous patient populations from one end of the CV continuum (i.e., primary prevention among patients with CV risk factors) to the other (i.e., secondary prevention in the post-MI setting). There are several agents within the ARB class, all of which have contributed to various degrees to this evidence base.

SCOPE

This review presents the design and main results of large, well designed studies examining the CV risk-reducing properties of ARBs. The authors searched major literature databases (Embase, Medline, PubMed) for randomized, controlled studies published between January, 1995 and October, 2009 that compared ARBs with placebo or active controls and reported major CV outcomes (e.g., myocardial infarction, stroke) and/or mortality as the primary study endpoint(s).

LIMITATIONS

Although many trials evaluating similar agents are presented, between-trial comparisons are inappropriate. The results of each study stand on their own merits and weaknesses, but do not provide any additional insight into the results of the other studies.

RESULTS

Agents in the ARB class have demonstrated efficacy in reducing CV events and/or mortality in a number of different patient populations, from primary prevention studies in patients with pre-specified risk factors (e.g., hypertension and left-ventricular hypertrophy in the LIFE study) to secondary prevention (i.e., post-MI patients in the VALIANT study). Some studies have also demonstrated the statistical equivalence of ARBs to ACE inhibitors in certain populations (e.g., among post-MI patients in VALIANT and among a broad population of patients with vascular disease or diabetes in the ONTARGET). There are several major studies currently underway that will provide further information on the risk-reducing properties of ARBs in additional populations (e.g., patients with impaired glucose tolerance in the NAVIGATOR study).

CONCLUSIONS

ARBs have demonstrated efficacy in reducing CV morbidity and mortality in a broad spectrum of CV disease states across the CV continuum. Ongoing research continues to provide additional evidence, with ongoing trials investigating their role in additional patient populations.

The relationship between retinal microvascular abnormalities and coronary heart disease: a review

Heart disease remains the leading cause of death in the United States despite decades of advancement in its diagnosis and treatment. Because of the limitations of traditional risk stratification for heart disease, evaluation of the retinal vasculature has been proposed as an easily and safely measured adjunct to commonly used screening methods. This article provides a comprehensive review of the literature concerning the relationships between retinal microvascular abnormalities and coronary heart disease. We outline details of the most recent large epidemiologic studies and discuss their potential implications for clinical practice. Finally, we propose a change to the current guidelines regarding the screening of "low-risk" women, a group that is often failed by traditional evaluation algorithms.

Stopping the cardiovascular disease continuum: Focus on prevention

The cardiovascular disease continuum (CVDC) is a sequence of events, which begins from a host of cardiovascular risk factors that consists of diabetes mellitus, dyslipidemia, hypertension, smoking and visceral obesity. If it is not intervened with early, it inexorably progresses to atherosclerosis, coronary artery disease, myocardial infarction, left ventricular hypertrophy, and left ventricular dilatation, which lead to left ventricular diastolic or systolic dysfunction and eventually end-stage heart failure and death. Treatment intervention at any stage during its course will either arrest or delay its progress. In this editorial, the cardiovascular risk factors that initiate and perpetuate the CVDC are briefly discussed, with an emphasis on their early prevention or aggressive treatment.

Telmisartan: a different angiotensin II receptor blocker protecting a different population?

The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET()) showed that the angiotensin II receptor blocker (ARB) telmisartan was as protective as the reference-standard ramipril in a broad cross-section of patients at increased cardiovascular risk, but was better tolerated. Telmisartan has a unique profile among ARBs, with a high affinity for the angiotensin II type 1 receptor, a long duration of receptor binding, a high lipophilicity and a long plasma half life. This leads to sustained and powerful blood pressure lowering when compared with the first marketed ARBs, such as losartan and valsartan. Some pharmacological properties of telmisartan clearly distinguish it from other members of the ARB class and may contribute to the clinical effects seen with telmisartan. A class effect for ARBs cannot be assumed. To date, telmisartan is the only ARB that has been shown to reduce cardiovascular risk in at-risk cardiovascular patients.

Increased prevalence of metabolic syndrome in individuals with osteoarthritis: an analysis of NHANES III data

BACKGROUND

Osteoarthritis (OA) and cardiovascular disease (CVD) share age and obesity as risk factors, but may also be linked by pathogenic mechanisms involving metabolic abnormalities and systemic inflammation. This study compared the prevalence of OA and metabolic syndrome (MetS) in subjects with OA versus the general population without OA to determine whether having OA predicts increased cardiovascular risk.

METHODS

National Health and Nutrition Examination Survey III data were used as a representative sample of the general US population. Subjects included adults aged > or = 18 years with records of history, physical, radiographic, and laboratory data adequate to assess for diagnoses of MetS and OA. Logistic regression was used to examine the association between MetS and population-weighted variables.

RESULTS

The general population sample included 7714 subjects (weighted value representing 174.9 million population), of whom 975 subjects had OA (weighted value 17.5 million) and 6739 did not (weighted value 157.4 million). Metabolic syndrome was prevalent in 59% of the OA population and 23% of the population without OA. Each of the 5 cardiovascular risk factors that comprise MetS was more prevalent in the OA population versus the population without OA: hypertension (75% vs 38%), abdominal obesity (63% vs 38%), hyperglycemia (30% vs 13%), elevated triglycerides (47% vs 32%), and low high-density lipoprotein cholesterol (44% vs 38%). Metabolic syndrome was more prevalent in subjects with OA regardless of sex or race. The association between OA and MetS was greater in younger subjects and diminished with increasing age. Having OA at age 43.8 years (mean age of the general population) was associated with a 5.26-fold (SE = 1.58, P < 0.001) increased risk of MetS. This association remained strong when obesity was controlled for in additional regression models.

CONCLUSIONS

Osteoarthritis is associated with an increased prevalence of MetS, particularly in younger individuals. Global cardiovascular risk should be assessed in individuals aged < or = 65 years with OA, and should be considered when prescribing analgesics for OA patients.

Cardiovascular disease risk factors: epidemiology and risk assessment

Current epidemiologic predictions show that the world is heading for a vascular tsunami of pandemic proportions. The number of people at high risk from cardiovascular disease is increasing; recent cohort studies suggest that only 2%-7% of the general population have no risk factors at all, and >70% of at-risk individuals have multiple risk factors. The recently published Ongoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) study, which showed that telmisartan was as effective as ramipril in the prevention of a range of cardiovascular outcomes, enrolled a broad cross section of high-risk patients. This population was chosen to reflect the type of patients encountered in general practice, and because the proportion of high-risk individuals is increasing worldwide, the ONTARGET results will be relevant for most at-risk patients. Further analysis of the ONTARGET results may also aid in the development of risk estimation scores populated with real-life data and could also determine the impact of treatment on the long-term reduction of total cardiovascular burden (ie, absolute risk reduction). This may be a particularly useful exercise because current risk estimation charts have limitations in their scope, sensitivity, and the ability to reflect changes in risk.

Impact of olmesartan on blood pressure, endothelial function, and cardiovascular outcomes

The vascular endothelium, the largest "organ" in the body, synthesizes and releases a wide spectrum of vasoactive substances into the circulation. Endothelial dysfunction links hypertension and other cardiovascular (CV) risk factors that promote the development of atherosclerotic plaque, CV disease, and fatal and nonfatal CV events. Blood pressure (BP) reduction is the most effective way to reduce CV risk in patients with hypertension, but it is unknown whether endothelial dysfunction is a cause or consequence of hypertension. Renin-angiotensin-aldosterone system blockers improve endothelial function and have favorable vascular, metabolic, cardiac, and renoprotective effects that are independent of BP reduction. Olmesartan effectively reduces BP and also has vasoprotective properties, including reductions in endothelial dysfunction and inflammation, prevention of microalbuminuria, and reversal of vascular remodeling. Large-scale, long-term studies are needed to confirm that olmesartan has vasoprotective effects that are independent of BP control and to determine whether these pleiotropic effects translate into improved CV disease outcomes.

Lessons in hypertension from new clinical trials

Three important principles have emerged from recent epidemiologic and clinical studies in hypertension. First, patients with hypertension most often have other cardiovascular risk factors such as obesity and diabetes. Second, hypertension remains grossly undertreated. Third, at blood pressure levels once considered "high-normal," early organ damage may already be taking place in patients with multiple risk factors that, without treatment, can eventually lead to cardiovascular morbidity and mortality. The concept of evaluating global or overall risk is gaining wide acceptance, and US treatment guidelines may soon reflect these findings and assist clinicians in identifying individuals who are most likely to benefit from therapy. Results from clinical trials suggest that among the various pharmacologic agents available to treat hypertension, blockers of the renin-angiotensin system are effective in type 2 diabetes and chronic kidney disease, conditions that often occur in conjunction with hypertension.

Comparative assessment of angiotensin receptor blockers in different clinical settings

Cardiovascular and renal disease can be regarded as progressing along a sort of continuum which starts with cardiovascular risk factors (hypertension, diabetes, dyslipidemia, smoking, etc), evolves with progression of atherosclerotic lesions and organ damage, and then becomes clinically manifest with the major clinical syndromes (myocardial infarction, stroke, heart failure, end-stage renal disease). The blood pressure control remains a fundamental mechanism for prevention of cardiovascular disease. The renin–angiotensin system is believed to play an important role along different steps of the cardiovascular disease continuum. Convincing evidence accumulated over the last decade that therapeutic intervention with angiotensin receptor blockers (ARBs) is effective to slow down or block the progression of cardiovascular disease at different steps of the continuum, with measurable clinical benefits. However, despite the shared mechanism of action, each ARB is characterized by specific pharmacological properties that may influence its clinical efficacy. Indeed, important differences among available ARBs emerged from clinical studies. Therefore, generalization of results obtained with a specific ARB to all available ARBs may be misleading. The present review provides a comparative assessment of the different ARBs in their efficacy on major clinical endpoints along the different steps of the cardiovascular disease continuum.

Should diuretics always be included as initial antihypertensive management in early-stage CKD?

PURPOSE OF REVIEW

This review focuses on the need for combined antihypertensive therapy drugs in patients with chronic kidney disease and the relevance of diuretics.

RECENT FINDINGS

Chronic kidney disease is a high-risk situation characterized by the presence of volume overload-related hypertension, micro/macroalbuminuria and other traditional and nontraditional risk factors. To achieve the blood pressure goal in these patients, combined antihypertensive therapy (including diuretics) is usually required.

SUMMARY

Extracellular volume expansion is an important, if not the most important, contributing factor to hypertension seen in chronic kidney disease. Protection against progression of renal dysfunction has two main requirements: strict blood pressure control and lowering proteinuria to values as near to normal as possible. Diuretics have been a useful tool to manage volume overload and to achieve strict blood pressure control in patients with chronic kidney disease. Albeit other blood pressure-lowering agents offer additional favorable effects independently of blood pressure changes, diuretics will continue to be used in these patients.

Cardiovascular disease risk, vascular health and erectile dysfunction among middle-aged, clinically depressed men

Erectile dysfunction (ED) is especially common in men with major depressive disorder (MDD). This study examined the extent to which risk factors for cardiovascular disease (CVD) and vascular endothelial dysfunction were associated with ED severity in MDD patients. The sample included 46 middle-aged [M (s.d.)=53 (7) years], sedentary men diagnosed with MDD. ED severity was assessed by the Arizona Sexual Experiences Scale (ASEX), item 3. Depression severity was measured by the Beck Depression Inventory-II (BDI). The Framingham risk score was calculated as a composite measure of CVD risk factors. Vascular endothelial function was measured by flow-mediated dilation (FMD) of the brachial artery. Regression analysis showed that ASEX scores were predicted by the greater Framingham risk score (beta=0.41, P=0.008) and lower FMD (beta=-0.38, P=0.01), but not by BDI scores (beta=0.00, P=0.99). When FMD was included in the regression model, the relationship between Framingham risk and ASEX scores was partially attenuated (beta=0.27, P=0.08). ED was associated with greater CVD risk and impaired vascular endothelial function in depressed men. CVD risk factors may affect ED through impairment of vascular endothelial function.

Target organ damage in patients with rheumatoid arthritis: the role of blood pressure and heart rate

BACKGROUND

Rheumatoid arthritis (RA) is characterised by increased cardiovascular morbidity and mortality. Even though hypertension (HT) is highly prevalent in RA, the extent of target organ damage (TOD) caused by it remains unknown. Inflammation and sympathetic overdrive may also associate with TOD. We investigated the prevalence and associations of TOD in RA.

METHODS

In this cross-sectional, observational study, 251 RA patients with no overt cardiovascular or renal disease had extensive clinical and laboratory evaluations, including a 12-lead electrocardiogram and urine albumin:creatinine ratio. Pulse pressure (PP) was used as a proxy of arterial stiffness and heart rate (HR) of autonomic activity. TOD was defined as described in the European guidelines for the management of arterial hypertension. Binary logistic regression analysis was used to evaluate the independence of the variables that associated with the presence of TOD.

RESULTS

TOD prevalence was 23.5% (59/251). Of the 59 patients with TOD, 45.8% had suboptimally controlled HT, whereas 32.3% had undiagnosed HT. In univariable analysis, TOD was significantly associated with higher age (64.2+/-11.7 years vs. 58.0+/-12.4 years, p=0.001), HT prevalence (89.8% vs. 60.4%, p<0.001), systolic blood pressure (SBP) (150.3+/-18.8mmHg vs. 139.7+/-20.7mmHg, p=0.001), PP (70.6+/-16.6mmHg vs. 60.3+/-17.3mmHg, p<0.001), HR (77.1+/-15.4bpm vs. 72.2+/-12.2bpm, p<0.001), serum uric acid (320.6+/-88.8mumol/l vs. 285.0+/-74.9mumol/l, p=0.03) and type 2 diabetes mellitus prevalence (13.6% vs. 4.7%, p=0.019). Binary logistic regression analysis revealed that only hypertension indices and HR associated independently with TOD.

CONCLUSIONS

TOD is highly prevalent in patients with RA and associates independently with hypertension, arterial stiffness and heart rate. Further prospective studies are needed to confirm these findings and examine the role of beta-blockers in this particular population.

Kidney protection: a key target in the management of patients with diabetes

The need to prevent the development of renal damage and its associated increase in cardiovascular risk in patients with type 2 diabetes is well established. Early intervention to maintain strict blood pressure control and to prevent the development of microalbuminuria is mandatory and will constitute the primary aim of intervention in patients with diabetes and also in prediabetes, characterized by the presence of cardiometabolic risk. If microalbuminuria is already present, similar blood pressure control and normalized urinary albumin excretion are required. If diabetic nephropathy is established, similar blood pressure and albumin targets must be achieved. In this regard, data from the ADVANCE study suggest that the combination of perindopril and indapamide can greatly help clinicians to achieve these targets. This combination on top of standard treatment significantly reduced the risk of renal events by 21% (P < 0.0001), the progression of albuminuria by 22% (P < 0.0001), and increased the regression of albuminuria by 16% (P = 0.002). Furthermore, the rate of renal events decreased log-linearly with decreasing follow-up blood pressure, down to systolic blood pressure below 110 mmHg. According to the ADVANCE results, treatment with the perindopril/indapamide fixed combination on top of contemporary cardiovascular care prevents one renal event in 20 patients with type 2 diabetes treated over 5 years. Evidence of renal protection is added to the reduction in total and cardiovascular mortality in the main ADVANCE trial.

[Civilization stress, cardiovascular risk, evidence-based medicine, guidelines]

Cardiovascular diseases have the pole-position on the list of morbidity and mortality statistics. Despite the great advances have been made in management of cardiovascular diseases, prevalence of these disorders increases worldwide, and even younger and younger ages are threatened. This phenomenon is strongly related to obesity and type 2 diabetes pandemic, which shows an unequivocal association with expansion of modernized life-style. The pathomechanism proposed to have central role is the chronic stress induced by civilized life-conduct. The authors criticizes the everyday practice suggested for management of cardiovascular diseases, focusing on normalization of cardiovascular risk factors, instead of fighting against the primary cause ie. chronic stress. There is growing evidence, that achieving the target values defined in guide-lines will not necessarily result in improvement of patient related clinical outcomes. The statistical approach generally practiced in randomized clinical trials is primarily striving for the drug-sale, instead of discovering novel pathophysiological relations. Pharmaceutical industry having decisive role in research and patient-care is mainly interested in profit-sharing, therefore patients' interest can not be optimally realized, and costs are unnecessarily augmented. Separation of patient-, and business-oriented medical care is an ethical question of fundamental importance.

Devil and angel in the renin-angiotensin system: ACE-angiotensin II-AT1 receptor axis vs. ACE2-angiotensin-(1-7)-Mas receptor axis

Recent studies have established a new regulatory axis in the renin–angiotensin system (RAS). In this axis, angiotensin (Ang)-(1–7) is finally produced from Ang I or Ang II by the catalytic activity of angiotensin-converting enzyme 2 (ACE2). Ang-(1–7) shows actions different from those of AT₁ receptor stimulation, such as vasodilatation, natriuresis, anti-proliferation and an increase in the bradykinin–NO (nitric oxide) system. As the catalytic efficiency of ACE2 is approximately 400-fold higher with Ang II as a substrate than with Ang I, this axis is possibly acting as a counter-regulatory system against the ACE/Ang II/AT₁ receptor axis. The signaling pathway of the ACE2–Ang-(1–7) axis has not yet been totally and clearly understood. However, a recent report suggests that the Mas oncogene acts as a receptor for Ang-(1–7). Intracellular signaling through Mas is not clear yet. Several factors such as Akt phosphorylation, protein kinase C activation and mitogen-activated protein (MAP) kinase inhibition seem to be involved in this signaling pathway. Further investigations are needed to clarify the regulation and mechanism of action of ACE2 and Ang-(1–7). However, this second axis through ACE2 and Ang-(1–7) in RAS can be an important target for the therapy of cardiovascular and metabolic disorders.

Lactobacillus fermentum ME-3 - an antimicrobial and antioxidative probiotic

The paper lays out the short scientific history and characteristics of the new probiotic Lactobacillus fermentum strain ME-3 DSM-14241, elaborated according to the regulations of WHO/FAO (2002). L. fermentum ME-3 is a unique strain of Lactobacillus species, having at the same time the antimicrobial and physiologically effective antioxidative properties and expressing health-promoting characteristics if consumed. Tartu University has patented this strain in Estonia (priority June 2001, patent in 2006), Russia (patent in 2006) and the USA (patent in 2007). The paper describes the process of the identification and molecular typing of this probiotic strain of human origin, its deposition in an international culture collection, and its safety assessment by laboratory tests and testing on experimental animals and volunteers. It has been established that L. fermentum strain ME-3 has double functional properties: antimicrobial activity against intestinal pathogens and high total antioxidative activity (TAA) and total antioxidative status (TAS) of intact cells and lysates, and it is characterized by a complete glutathione system: synthesis, uptake and redox turnover. The functional efficacy of the antimicrobial and antioxidative probiotic has been proven by the eradication of salmonellas and the reduction of liver and spleen granulomas in Salmonella Typhimurium-infected mice treated with the combination of ofloxacin and L. fermentum strain ME-3. Using capsules or foodstuffs enriched with L. fermentum ME-3, different clinical study designs (including double-blind, placebo-controlled, crossover studies) and different subjects (healthy volunteers, allergic patients and those recovering from a stroke), it has been shown that this probiotic increased the antioxidative activity of sera and improved the composition of the low-density lipid particles (LDL) and post-prandial lipids as well as oxidative stress status, thus demonstrating a remarkable anti-atherogenic effect. The elaboration of the probiotic L. fermentum strain ME-3 has drawn on wide international cooperative research and has taken more than 12 years altogether. The new ME-3 probiotic-containing products have been successfully marketed and sold in Baltic countries and Finland.

Supramaximal dose of candesartan in proteinuric renal disease

High levels of proteinuria predict renal deterioration, suggesting that interventions to reduce proteinuria may postpone the development of severe renal impairment. This multicenter Canadian trial evaluated whether supramaximal dosages of candesartan would reduce proteinuria to a greater extent than the maximum approved antihypertensive dosage. The authors randomly assigned 269 patients who had persistent proteinuria (> or =1 g/d) despite 7 wk of treatment with the highest approved dosage of candesartan (16 mg/d) to 16, 64, or 128 mg/d candesartan for 30 wk. The median serum creatinine level was 130.0 micromol/L (1.47 mg/dl), and the median urinary protein excretion was 2.66 g/d; most (53.9%) patients had diabetic nephropathy. The mean difference of the percentage change in proteinuria for patients receiving 128 mg/d candesartan compared with those receiving 16 mg/d candesartan was -33.05% (95% confidence interval -45.70 to -17.44; P < 0.0001). Reductions in BP were not different across the three treatment groups. Elevated serum potassium levels (K+ > 5.5 mEq/L) led to the early withdrawal of 11 patients, but there were no dosage-related increases in adverse events. In conclusion, proteinuria that persists despite treatment with the maximum recommended dosage of candesartan can be reduced by increasing the dosage of candesartan further, but serum potassium levels should be monitored during treatment.

Heart rate as a treatable cardiovascular risk factor

BACKGROUND

Although several epidemiological studies demonstrate the association between resting heart rate (HR) and cardiovascular morbidity and mortality, an elevated HR remains a neglected cardiovascular risk factor.

SOURCES OF DATA

This review summarizes the results of published studies on the relationship between elevated HR and cardiovascular risk.

AREAS OF AGREEMENT

The role of HR in myocardial ischaemia in coronary patients is well known. Experimental data and clinical observations support the importance of HR in the pathophysiology of atherosclerosis and plaque rupture. A large body of evidence points to high resting HR as a risk factor for mortality in various populations, including coronary patients.

AREAS OF CONTROVERSY

HR reduction is suggested to be a mechanism explaining the prognostic benefit of beta-blockers after myocardial infarction or in heart failure patients. However, it was unclear whether HR reduction per se directly affects cardiovascular prognosis. Treatment with ivabradine, a pure HR-reducing agent, provides an opportunity to assess the effects of selectively lowering HR without altering other aspects of cardiac function.

GROWING POINTS

The results of the recent Morbidity-Mortality Evaluation of the I(f) Inhibitor Ivabradine in Patients with Coronary Disease and Left Ventricular Dysfunction study underline the importance of HR reduction in the management of stable coronary artery disease. The prospective analysis of data from the placebo arm demonstrated that elevated resting HR (>or=70 bpm) is a strong independent predictor of clinical outcomes. Consistent with these data, ivabradine significantly improved coronary outcomes in patients with a HR of 70 bpm or more. AREAS TIMELY FOR DEVELOPMENT: These data support the importance of HR in the management of stable coronary artery disease to assess prognosis and to guide optimal therapy.

Hypertension and heart failure: a dysfunction of systole, diastole or both?

The pathological myocardial hypertrophy associated with hypertension contains the seed for further maladaptive development. Increased myocardial oxygen consumption, impaired epicardial coronary perfusion, ventricular fibrosis and remodelling, abnormalities in long-axis function and torsion, cause, to a varying degree, a mixture of systolic and diastolic abnormalities. In addition, chronotropic incompetence and peripheral factors such as lack of vasodilator reserve and reduced arterial compliance further affect cardiac output particularly on exercise. Many of these factors are common to hypertensive heart failure with a normal ejection fraction as well as systolic heart failure. There is increasing evidence that these apparently separate phenotypes are part of a spectrum of heart failure differing only in the degree of ventricular remodelling and volume changes. Furthermore, dichotomizing heart failure into systolic and diastolic clinical entities has led to a paucity of clinical trials of therapies for heart failure with a normal ejection fraction. Therapies aimed at reversing myocardial fibrosis, and targets outside the heart such as enhancing vasodilator reserve and improving chronotropic incompetence deserve further study and may improve the exercise capacity of hypertensive heart failure patients. Hypertension heart disease with heart failure is simply not a dysfunction of systole and diastole. Other peripheral factors including heart rate and vasodilator response with exercise may deserve equal attention in an attempt to develop more effective treatments for this disorder.

Therapeutic angiogenesis: a new treatment approach for ischemic heart disease--part I

Angiogenesis is the biologic process of forming new blood vessels and is being investigated as an innovative therapeutic approach to help manage ischemic heart disease and peripheral vascular disease. Research studies have identified various angiogenic growth factors and progenitor cells that can enhance new blood vessel formation. Preclinical investigations in animal models have explored the potential use of growth factors with and without progenitor cells to treat myocardial ischemia. The results of clinical trials with growth factor infusions and gene therapy techniques to enhance growth factor production have shown some promise, but therapeutic angiogenesis remains at an early stage of development.

Antioxidant plasma concentration and supplementation in carotid intima media thickness

Cerebrovascular diseases represent a major problem in Western countries. Oxidative stress, an important condition of increased amounts of reactive oxygen species, is now recognized to be a prominent feature of many acute and chronic diseases, and even of the normal aging process. Carotid intima media thickness is an important marker of atherosclerosis that correlates with established coronary heart disease. Changes in carotid intima media thickness, measured by B-mode high-resolution carotid ultrasonography, represent an important and early step in carotid plaque formation and progression and are the most common currently used marker to evaluate the progression of atherosclerotic processes. Several therapeutic strategies have been adopted to slow the early atherosclerotic process in asymptomatic subjects in order to reduce the risk of cardiovascular events. An additional step to slow the atherosclerotic process may include interventions to decrease newly emerging coronary risk factors, such as oxidative stress and inflammation. Consuming a diet rich in fruits and vegetables will provide antioxidant vitamins, and carotenoids, which are believed to inhibit tissue damage derived from oxidative processes and may slow the progression of early atherosclerosis, modify the increase in carotid intima media thickness and, consequently, reduce cardiovascular events. This review synthesizes the published literature regarding antioxidant vitamins plasma concentration and supplementation and carotid intima media thickness.

Astaxanthin: a novel potential treatment for oxidative stress and inflammation in cardiovascular disease

Oxidative stress and inflammation are implicated in several different manifestations of cardiovascular disease (CVD). They are generated, in part, from the overproduction of reactive oxygen species (ROS) and reactive nitrogen species (RNS) that activate transcriptional messengers, such as nuclear factor-kappaB, tangibly contributing to endothelial dysfunction, the initiation and progression of atherosclerosis, irreversible damage after ischemic reperfusion, and even arrhythmia, such as atrial fibrillation. Despite this connection between oxidative stress and CVD, there are currently no recognized therapeutic interventions to address this important unmet need. Antioxidants that provide a broad, "upstream" approach via ROS/RNS quenching or free radical chain breaking seem an appropriate therapeutic option based on epidemiologic, dietary, and in vivo animal model data. However, human clinical trials with several different well-known agents, such as vitamin E and beta-carotene, have been disappointing. Does this mean antioxidants as a class are ineffective, or rather that the "right" compound(s) have yet to be found, their mechanisms of action understood, and their appropriate targeting and dosages determined? A large class of potent naturally-occurring antioxidants exploited by nature-the oxygenated carotenoids (xanthophylls)-have demonstrated utility in their natural form but have eluded development as successful targeted therapeutic agents up to the present time. This article characterizes the mechanism by which this novel group of antioxidants function and reviews their preclinical development. Results from multiple species support the antioxidant/anti-inflammatory properties of the prototype compound, astaxanthin, establishing it as an appropriate candidate for development as a therapeutic agent for cardiovascular oxidative stress and inflammation.