Modulating atherosclerosis through inhibition or blockade of angiotensin

Tailored antihypertensive drug therapy prescribed to older women attenuates circulating levels of interleukin-6 and tumor necrosis factor-α

Objective

To test the hypothesis that antihypertensive drug therapy produces anti-inflammatory effects in clinical practice, this study investigated circulating levels of selected proinflammatory mediators (interleukin-6 [IL-6], tumor necrosis factor-alpha [TNF-α], and interferon-γ [INF-γ]) in response to multivariate drug directions for blood pressure (BP) control.

Methods

Prospective study involving 110 hypertensive, community-dwelling older women with different metabolic disorders. A short-term BP-lowering drug therapy was conducted according to current Brazilian guidelines on hypertension, and basal cytokine levels were measured before and after intervention.

Results

Interventions were found to represent current hypertension-management practices in Brazil and corresponded to a significant reduction in systolic and diastolic BP levels in a whole-group analysis, as well as when users and nonusers of the most common therapeutic classes were considered separately. Considering all patients, mean IL-6 and TNF-α levels showed a significant decrease in circulating concentrations (P<0.01) at the endpoint compared with baseline, whereas the mean INF-γ level was not significantly different from baseline values. In separate analyses, only users of antagonists of the renin–angiotensin system and users of diuretics exhibited the same significant treatment-induced reduction in serum IL-6 and TNF-α observed in the whole group.

Conclusion

Our data demonstrates that a clinically guided antihypertensive treatment is effective in reversing the low-grade proinflammatory state of serum cytokines found in postmenopausal women and support extracardiac benefits from diuretics and renin–angiotensin system antagonists.

Taurine and atherosclerosis

Taurine is abundantly present in most mammalian tissues and plays a role in many important physiological functions. Atherosclerosis is the underlying mechanism of cardiovascular disease including myocardial infarctions, strokes and peripheral artery disease and remains a major cause of morbidity and mortality worldwide. Studies conducted in laboratory animal models using both genetic and dietary models of hyperlipidemia have demonstrated that taurine supplementation retards the initiation and progression of atherosclerosis. Epidemiological studies have also suggested that taurine exerts preventive effects on cardiovascular diseases. The present review focuses on the effects of taurine on the pathogenesis of atherosclerosis. In addition, the potential mechanisms by which taurine suppress the development of atherosclerosis will be discussed.

Coagulation and fibrinolysis in diabetes

Atherothrombotic complications are the main cause of mortality in subjects with diabetes. Premature atherosclerosis, increased platelet reactivity and activation of coagulation factors with associated hypofibrinolysis all contribute to increased cardiovascular risk in this population. Blood clot formation represents the last step in the atherothrombotic process, and the structure of the fibrin network has a role in determining predisposition to cardiovascular disease. In this review, we discuss alterations in coagulation factor plasma levels and/or activity in diabetes and clarify their role in predisposition to cardiovascular events. The effect of diabetes on fibrin network structure/fibrinolysis is reviewed and potential mechanisms that modify clot properties are discussed. Finally, modulation of clotting potential by the various therapeutic agents used in diabetes is examined. Understanding the mechanisms by which diabetes influences the coagulation pathway will help to develop more effective treatment strategies to reduce thrombotic events in subjects with this condition.

Cardiovascular disease and heritability of the prothrombotic state

Atherothrombotic disease remains a major cause of mortality worldwide, and family clustering suggests an important contribution of genetic factors to disease pathogenesis. Thrombus formation represents the final step in atherothrombosis, a process influenced by genetic and environmental factors. A major difficulty of investigating the genetic regulation of thrombotic conditions is the complexity of the phenotype and the relatively modest effects of individual genetic variations. We address in this review genetic aspects involved in regulating thrombosis potential and their impact on the development of atherothrombotic disease. The effects of common genetic polymorphisms in clotting factors are discussed and examples of complex gene-gene and gene-environment interactions are highlighted. Understanding the effects of genetic factors on predisposition to thrombotic disease and unravelling the complex gene-environment interactions will help to better understand the pathophysiology of this complex condition, which will enable the development of new preventative and treatment strategies.

Atherosclerosis and oxidant stress: the end of the road for antioxidant vitamin treatment?

Extensive experimental data have revealed a central role for oxidative stress in atherogenesis and suggested a potential role for 'antioxidant' treatment in cardiovascular disease (CVD) [1-11]. Experimental data, however, have not translated into clinical benefit: most antioxidant vitamin trials have failed to reduce cardiovascular morbidity and mortality [12]. Moreover, recent clinical trials have suggested that mono-therapy with certain antioxidant vitamins like vitamin E may, in fact, be detrimental [13]. As a result of the disappointing outcome of 'antioxidant' vitamin trials, some authors have questioned both the utility of 'antioxidant' treatment in CVD and the supposedly central role of oxidative stress in atherogenesis [14-19]. Other investigators, however, sustain that the beneficial effects of lipid lowering and anti-hypertensive treatment are at least, in part, due to their 'antioxidant' properties, in addition to their specific pharmacological properties [20, 21]. Oxidant stress plays a pivotal role in atherogenesis, however, the clinical promise of antioxidant vitamins has failed to translate into clinical benefit. Increasing evidence suggests that more rigorous clinical trial designs are necessary to effectively divulge antioxidant utility and that a multifaceted antioxidant approach to atherosclerosis may yield the most clinical reward. This article reviews currently available evidence on the role of oxidant stress in atherosclerosis, analyzes the results of large anti-oxidant trials, and suggests ways to investigate the true role of antioxidant treatment in the clinical setting.

Coagulation and atherothrombotic disease

Atherothrombotic disease arises secondary to a complex gene-environment interaction. In the initial stages, the condition is clinically silent but with more advanced disease, an occlusive thrombus is formed resulting in the classical clinical manifestations. Both environmental factors and genetic variations in elements of the clotting cascade influence thrombosis risk by inducing quantitative and qualitative changes in the mature protein, which may affect the final structure of the clot and determine its resistance to lysis. Understanding the fine details of gene-environment interactions in relation to thrombus formation will help to shed more light on disease pathogenesis. Consequently, this will allow the development of more efficacious treatment strategies and will also help to identify subjects at risk, thereby enabling the introduction of early preventative measures.

ANG II-induced cardiac molecular and cellular events: role of aldosterone

Chronic elevation of circulating ANG II is associated with cardiac remodeling in patients with hypertension and heart failure. The underlying mechanisms, however, are not completely defined. Herein, we studied ANG II-induced molecular and cellular events in the rat heart as well as their links to the redox state. We also addressed the potential contribution of aldosterone (ALDO) on ANG II-induced cardiac remodeling. In ANG II-treated rats, and compared with controls, we found: 1) the expression of proinflammatory/profibrogenic mediators was significantly increased in the perivascular space and at the sites of microscopic injury in both ventricles; 2) macrophages and myofibroblasts were primary repairing cells at these sites, together with increased fibrillar collagen volume; 3) apoptotic macrophages and myofibroblasts were evident at the same sites; 4) NADPH oxidase (gp91phox) was significantly enhanced at these regions and primarily expressed by macrophages, whereas superoxide dismutase and catalase levels remained unchanged; 5) plasma 8-isoprostane levels were significantly increased; and 6) blood pressure was significantly elevated. Losartan treatment completely prevented cardiac oxidative stress as well as molecular/cellular responses and normalized blood pressure. Spironolactone treatment partially suppressed the cardiac inflammatory/fibrogenic responses and redox state. Thus chronic elevation of circulating ANG II is accompanied by a proinflammatory/profibrogenic phenotype involving vascular and myocardial remodeling in both ventricles. Enhanced reactive oxygen species production at these sites and increased plasma 8-isoprostane indicate the involvement of oxidative stress in ANG II-induced cardiac injury. ALDO contributes, in part, to ANG II-induced cardiac molecular and cellular responses.

Role of Blood Cell–Associated AT1 Receptors in the Microvascular Responses to Hypercholesterolemia

OBJECTIVE

Hypercholesterolemia elicits a proinflammatory and prothrombogenic phenotype in the microvasculature that is characterized by activation and adhesion of blood cells. The angiotensin II receptor-1 antagonist Losartan prevents the induction of these responses. The objective of this study was to determine the relative contributions of blood cell-associated versus endothelium-associated AT1a-R to these hypercholesterolemia-induced microvascular alterations.

METHODS AND RESULTS

Leukocyte adhesion and emigration and platelet adhesion were quantified by intravital microscopy in postcapillary venules. C57Bl/6 mice were placed on a normal (ND) or high-cholesterol (HCD) diet for 2 weeks. AT1a-R bone marrow chimeras that express AT1a-R on the vessel wall but not blood cells and AT1a-R knockouts were placed on HCD. Venular shear rate was comparable in all groups. Platelet and leukocyte adhesion and leukocyte emigration were significantly increased in HCD mice versus ND. Leukocyte recruitment was significantly reduced in the HCD-AT1a-R bone marrow chimera group, whereas platelet adhesion remained at HCD levels. However, in HCD-AT1a-R knockout mice, platelet and leukocyte adhesion were reduced to ND levels.

CONCLUSIONS

These data indicate that the platelet-vessel wall adhesion elicited by hypercholesterolemia is mediated by AT1a-R engagement on the endothelial cell rather than the platelet, whereas leukocyte recruitment is mediated by blood cell-associated AT1a-R.

New strategies in the medical treatment of carotid artery disease

Most patients with ischemic stroke or transient ischemic attack are screened for internal carotid artery stenosis. Although it is important to identify candidates for endarterectomy or stenting, the clinician must realize that most patients are not candidates for revascularization. Therefore, medical therapy remains the cornerstone of treatment. In this article, current thinking on medical therapy for carotid atherosclerosis is outlined, including aggressive use of statins, targeted blood pressure lowering, and antithrombotic therapy. Implementation of these therapies will likely reduce the need for revascularization procedures in the future.

Pharmacological basis of different targets for the treatment of atherosclerosis

The development of atherosclerotic plaque is a highly regulated and complex process which occurs as a result of structural and functional alterations in endothelial cells, smooth muscle cells (SMCs), monocytes/macrophages, T-lymphocytes and platelets. The plaque formation in the coronary arteries or rupture of the plaque in the peripheral vasculature in latter stages of atherosclerosis triggers the onset of acute ischemic events involving myocardium. Although lipid lowering with statins has been established as an important therapy for the treatment of atherosclerosis, partially beneficial effects of statins beyond decreasing lipid levels has shifted the focus to develop newer drugs that can affect directly the process of atherosclerosis. Blockade of renin angiotensin system, augmentation of nitric oxide availability, reduction of Ca(2+) influx, prevention of oxidative stress as well as attenuation of inflammation, platelet activation and SMC proliferation have been recognized as targets for drug treatment to control the development, progression and management of atherosclerosis. A major challenge for future drug development is to formulate a combination therapy affecting different targets to improve the treatment of atherosclerosis.

Angiotensin II Type-1 Receptor Antagonism Attenuates the Inflammatory and Thrombogenic Responses to Hypercholesterolemia in Venules

Hypercholesterolemia elicits an inflammatory response in the microvasculature that is accompanied by an increased expression of angiotensin II type-1 receptors (AT1-R) on platelets, leukocytes, and endothelial cells. AT1-R blockade attenuates inflammatory responses to angiotensin II (eg, adhesion molecule expression and reactive oxygen species production). We investigated whether AT1-R antagonism attenuates the platelet and leukocyte recruitment induced by acute hypercholesterolemia in postcapillary venules. Leukocyte and platelet adhesion and oxidative stress were quantified by intravital microscopy in cremaster muscle, and P-selectin and AT1-R expression was determined in mice placed on a normal diet (ND) or high-cholesterol diet (HCD) for 2 weeks. Platelet and leukocyte adhesion was significantly elevated by hypercholesterolemia. In HCD mice receiving losartan (HCD-Los) in drinking water, platelet and leukocyte recruitment was reduced to ND levels. Increased platelet adhesion was observed in HCD mice receiving platelets from HCD-Los mice, consistent with a direct beneficial action of losartan on the vessel wall. Hypercholesterolemia elicited an oxidative stress in venules and an increased expression of P-selectin and AT1-R. The oxidative stress and AT1-R upregulation were reduced by losartan, but the P-selectin response was not. We propose that AT1-R engagement contributes to the prothrombogenic and proinflammatory state induced in venules by hypercholesterolemia.

Provision of cardiovascular protection by ACE inhibitors: a review of recent trials

This paper reports the rationale for the cardiovascular protective effects of ACE inhibitors (ACEI) and reviews the overall results of recent randomized clinical trials. ACEI improve the vasoconstrictive/vasodilatory balance by blocking the formation of angiotensin II and preventing the degradation of bradykinin. In vitro, animal and human experimental studies have shown that ACEI have several properties: They promote vasodilation, limit neurohormonal activation and vasoconstriction during ischemia, improve endothelial function by reducing oxidative stress, slow down the development of atherosclerosis; improve fibrinolytic balance, inhibit platelet activation and reverse negative vascular remodelling. Previous trials have shown that ACEI reduced cardiovascular events in patients with heart failure or ventricular dysfunction. These findings have recently been extended to trials using lipophilic ACEI with high affinity for tissue ACE i.e. those most likely to have high antiatherosclerotic efficacy. In PROGRESS (n = 6105), a perindopril-based regimen reduced recurrent stroke by 28% and substantially reduced cardiac outcomes among individuals with cerebrovascular disease. In HOPE (n = 9297), ramipril reduced the composite outcome (cardiovascular death, myocardial infarction and cerebrovascular accident) by 22% in patients with high cardiovascular risk. EUROPA (n = 12 218) showed that perindopril reduced cardiovascular mortality, myocardial infarction and cardiac arrest by 20% in coronary artery disease patients whatever their level of risk. The central role of long-acting lipophilic ACEI for cardiovascular protection has been clearly established and they should now be considered as a routine treatment for secondary prevention as aspirin, beta blockers and statins.