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Latest hypertension research to inform clinical practice in Asia. Hypertens Res 2022; 45:555-572. [DOI: 10.1038/s41440-022-00874-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 12/16/2022]
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Timing of procedural interventions in childhood renovascular hypertension. Pediatr Nephrol 2021; 36:3089-3096. [PMID: 34143295 DOI: 10.1007/s00467-021-05152-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 05/04/2021] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Renovascular hypertension (RVHTN) is a rare, often complex condition due to multiple etiologies including congenital stenoses, vasculitides, and fibromuscular dysplasia. Among children with RVHTN who require multiple and escalating medications to control blood pressure, the optimal timing of a procedural intervention involves a balance of numerous factors. CASE-DIAGNOSIS/TREATMENT In this presentation of a 1-month-old girl with RVHTN, the treating medical team had to consider multiple factors in the initial management and timing of interventions to treat her underlying cause of RVHTN, including concerns for kidney health, degree of hypertension, age and size of the patient, and potential methods of procedural intervention. Initially, she was treated conservatively until concern for poor renal growth arose and a durable surgical intervention was thought feasible and safe. CONCLUSION The evidence regarding the timing of non-medical interventions in pediatric RVHTN is limited. Considerations should include patient age, size, disease severity, comorbid conditions, and degree of medical management required to maintain safe blood pressures that allow for growth and reverse cardiac damage. The optimal interventions have not been evaluated by controlled trials and should be decided on a case-by-case basis with consideration of center expertise and family preferences.
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Toyama K, Furuie H, Kuroda K, Ishizuka T, Okuda Y, Shimizu T, Kato M, Igawa Y, Nishikawa Y, Ishizuka H. Effects of Repeated Oral Administration of Esaxerenone on the Pharmacokinetics of Midazolam in Healthy Japanese Males. Eur J Drug Metab Pharmacokinet 2021; 46:685-694. [PMID: 34383278 PMCID: PMC8397627 DOI: 10.1007/s13318-021-00701-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Esaxerenone showed the potential to inhibit and induce activity against cytochrome P450 (CYP) 3A in in vitro studies. We investigated whether repeated administration of 5 mg/day esaxerenone for 14 days influences the pharmacokinetics of midazolam, a sensitive CYP3A substrate, in healthy Japanese males. METHODS This single-centre, open-label, single-sequence study had two administration periods: period 1: single oral dose of 2 mg midazolam (day 0); period 2: repeated oral doses of 5 mg/day esaxerenone for 14 days, with a single oral dose of 2 mg midazolam on day 14. Full pharmacokinetic profiles of midazolam and 1-hydroxymidazolam on days 0 and 14 and safety data were obtained. Primary pharmacokinetic endpoints for midazolam were area under the plasma concentration-time curve (AUC) from zero to time of the last measurable concentration (AUClast), AUC from zero to infinity (AUCinf), and peak plasma concentration (Cmax). RESULTS The study included 28 male subjects. One subject was withdrawn because of a mild adverse event (increased hepatic enzyme levels) that resolved without intervention. Repeated administration of esaxerenone increased midazolam AUClast, AUCinf, and Cmax by about 1.2-fold (1.201, 1.201, and 1.224, respectively) compared with administration of midazolam alone. However, repeated administration of esaxerenone did not affect the elimination half-life of midazolam (2.86 versus 2.63 h with and without esaxerenone). There were no safety concerns associated with concomitant administration of esaxerenone and midazolam. CONCLUSIONS Esaxerenone 5 mg/day had no clinically significant effect on midazolam pharmacokinetics and was not associated with any safety issues. Esaxerenone can be concomitantly administered with drugs of CYP3A substrates without dose adjustments. CLINICAL TRIAL REGISTRATION JapiCTI-152832.
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Woodhams L, Sim TF, Chalmers L, Yeap B, Green D, Schlaich M, Schultz C, Hillis G. Diabetic kidney disease in type 2 diabetes: a review of pathogenic mechanisms, patient-related factors and therapeutic options. PeerJ 2021; 9:e11070. [PMID: 33976959 PMCID: PMC8061574 DOI: 10.7717/peerj.11070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 02/16/2021] [Indexed: 12/23/2022] Open
Abstract
The global prevalence of diabetic kidney disease is rapidly accelerating due to an increasing number of people living with type 2 diabetes. It has become a significant global problem, increasing human and financial pressures on already overburdened healthcare systems. Interest in diabetic kidney disease has increased over the last decade and progress has been made in determining the pathogenic mechanisms and patient-related factors involved in the development and pathogenesis of this disease. A greater understanding of these factors will catalyse the development of novel treatments and influence current practice. This review summarises the latest evidence for the factors involved in the development and progression of diabetic kidney disease, which will inform better management strategies targeting such factors to improve therapeutic outcomes in patients living with diabetes.
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Affiliation(s)
- Louise Woodhams
- Curtin Medical School, Curtin University of Technology, Perth, Western Australia, Australia
| | - Tin Fei Sim
- Curtin Medical School, Curtin University of Technology, Perth, Western Australia, Australia
| | - Leanne Chalmers
- Curtin Medical School, Curtin University of Technology, Perth, Western Australia, Australia
| | - Bu Yeap
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Daniel Green
- School of Human Sciences (Exercise and Sport Sciences), The University of Western Australia, Perth, Western Australia, Australia
| | - Markus Schlaich
- Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Department of Cardiology and Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia.,Neurovascular Hypertension and Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit/Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Carl Schultz
- Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Graham Hillis
- Medical School, The University of Western Australia, Perth, Western Australia, Australia.,Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
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Morgan ES, Tami Y, Hu K, Brambatti M, Mullick AE, Geary RS, Bakris GL, Tsimikas S. Antisense Inhibition of Angiotensinogen With IONIS-AGT-L Rx: Results of Phase 1 and Phase 2 Studies. ACTA ACUST UNITED AC 2021; 6:485-496. [PMID: 34222719 PMCID: PMC8246029 DOI: 10.1016/j.jacbts.2021.04.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 04/28/2021] [Accepted: 04/28/2021] [Indexed: 01/04/2023]
Abstract
Targeting angiotensinogen (AGT) may provide a novel approach to more optimally inhibit the renin-angiotensin-aldosterone system pathway. Double-blind, placebo-controlled clinical trials were performed in subjects with hypertension as monotherapy or as an add-on to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers with IONIS-AGT-LRx versus placebo up to 2 months. IONIS-AGT-LRx was well tolerated with no significant changes in platelet count, potassium levels, or liver and renal function. IONIS-AGT-LRx significantly reduced AGT levels compared with placebo in all 3 studies. Although not powered for this endpoint, trends were noted in blood pressure reduction. In conclusion, IONIS-AGT-LRx significantly reduces AGT with a favorable safety, tolerability, and on-target profile. (A Study to Assess the Safety, Tolerability and Efficacy of IONIS-AGT-LRx; NCT04083222; A Study to Assess the Safety, Tolerability and Efficacy of IONIS-AGT-LRx, an Antisense Inhibitor Administered Subcutaneously to Hypertensive Subjects With Controlled Blood Pressure; NCT03714776; Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of Ionis AGT-LRx in Healthy Volunteers; NCT03101878).
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Key Words
- ACEi/ARB, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker
- AGT, angiotensinogen
- ASO, antisense oligonucleotide
- CI, confidence interval
- DBP, diastolic blood pressure
- EDTA, ethylenediaminetetraacetic acid
- GalNAc3, triantennary N-acetyl galactosamine
- K+, potassium
- PS, phosphorothioate
- RAAS
- RAAS, renin-angiotensin-aldosterone system
- SBP, systolic blood pressure
- angiotensinogen
- antisense
- hepatocyte
- hypertension
- oligonucleotide
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Affiliation(s)
| | - Yvonne Tami
- Ionis Pharmaceuticals, Carlsbad, California, USA
| | - Kuolung Hu
- Ionis Pharmaceuticals, Carlsbad, California, USA
| | | | | | | | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Sotirios Tsimikas
- Ionis Pharmaceuticals, Carlsbad, California, USA.,Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, California, USA
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DNA Methylation of the Angiotensinogen Gene, AGT, and the Aldosterone Synthase Gene, CYP11B2 in Cardiovascular Diseases. Int J Mol Sci 2021; 22:ijms22094587. [PMID: 33925539 PMCID: PMC8123855 DOI: 10.3390/ijms22094587] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/20/2022] Open
Abstract
Angiotensinogen (AGT) and aldosterone play key roles in the regulation of blood pressure and are implicated in the pathogenesis of cardiovascular diseases. DNA methylation typically acts to repress gene transcription. The aldosterone synthase gene CYP11B2 is regulated by angiotensin II and potassium. DNA methylation negatively regulates AGT and CYP11B2 expression and dynamically changes in response to continuous promoter stimulation of each gene. High salt intake and excess circulating aldosterone cause DNA demethylation around the CCAAT-enhancer-binding-protein (CEBP) sites of the ATG promoter region, thereby converting the phenotype of AGT expression from an inactive to an active state in visceral adipose tissue and heart. A close association exists between low DNA methylation at CEBP-binding sites and increased AGT expression in salt-sensitive hypertensive rats. Salt-dependent hypertension may be partially affected by increased cardiac AGT expression. CpG dinucleotides in the CYP11B2 promoter are hypomethylated in aldosterone-producing adenomas. Methylation of recognition sequences of transcription factors, including CREB1, NGFIB (NR4A1), and NURR1 (NR4A2) diminish their DNA-binding activity. The methylated CpG-binding protein MECP2 interacts directly with the methylated CYP11B2 promoter. Low salt intake and angiotensin II infusion lead to upregulation of CYP11B2 expression and DNA hypomethylation in the adrenal gland. Treatment with the angiotensin II type 1 receptor antagonist decreases CYP11B2 expression and leads to DNA hypermethylation. A close association between low DNA methylation and increased CYP11B2 expression are seen in the hearts of patients with hypertrophic cardiomyopathy. These results indicate that epigenetic regulation of both AGT and CYP11B2 contribute to the pathogenesis of cardiovascular diseases.
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Aliskiren Reduces the Adrenal Zona Glomerulosa Apoptosis and Autophagy in Wistar Rats with 2K1C Hypertension. Int J Hypertens 2020; 2020:7684849. [PMID: 33145109 PMCID: PMC7596424 DOI: 10.1155/2020/7684849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/21/2020] [Accepted: 09/04/2020] [Indexed: 11/18/2022] Open
Abstract
Hypertension is a disease classified as primary or secondary, manifested not only by elevation of blood pressure but also involved in structural and functional changes of target organs. Renal artery stenosis is a leading factor of secondary hypertension, and its progress is associated with overactivation of the renin-angiotensin-aldosterone system (RAAS). Aliskiren is a renin inhibiting drug that suppresses RAAS and culminates in decreased renin release, plasma angiotensin II concentration, and inhibition of aldosterone secretion. In this sense, the aim of the present study was to analyze the structural and ultrastructural morphophysiology of the adrenal glomerular zone, after treatment with aliskiren in Wistar rats with 2K1C hypertension. Parameters as structure and ultrastructure of the adrenal glomerular zone, cellular apoptosis, nuclear cell proliferation, and AT1 receptor expression were analyzed by immunostaining and electron microscopy. Our results showed that the hypertensive animals treated with aliskiren presented a reestablishment of AT1 receptor expression and decrease in apoptosis and autophagy. In addition, treatment with aliskiren improves the cell aspects in the adrenal glomerular zone, evidenced by ultrastructural analysis through preserved nuclei and well-developed mitochondria. Therefore, our evidence suggests that aliskiren has a beneficial effect on the adrenal glomerular zone remodeling in animals with renovascular hypertension.
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Morimoto S, Ichihara A. Management of primary aldosteronism and mineralocorticoid receptor-associated hypertension. Hypertens Res 2020; 43:744-753. [PMID: 32424201 DOI: 10.1038/s41440-020-0468-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 04/11/2020] [Accepted: 04/11/2020] [Indexed: 12/31/2022]
Abstract
Resistant hypertension is associated with a poor prognosis due to organ damage caused by prolonged suboptimal blood pressure control. The concomitant use of mineralocorticoid receptor (MR) antagonists with other antihypertensives has been shown to improve blood pressure control in some patients with resistant hypertension, and such patients are considered to have MR-associated hypertension. MR-associated hypertension is classified into two subtypes: one with a high plasma aldosterone level, which includes primary aldosteronism (PA), and the other with a normal aldosterone level. In patients with unilateral PA, adrenalectomy may be the first-choice procedure, while in patients with bilateral PA, MR antagonists are selected. In addition, in patients with other types of MR-associated hypertension with high aldosterone levels, MR antagonists may be selected as a first-line therapy. In patients with normal aldosterone levels, ARBs or ACE inhibitors are used as a first-line therapy, and MR antagonists may be used as an add-on agent. Since MR antagonist therapy may have efficacy as a first-line or add-on agent in these patients, it is important to recognize this type of hypertension. Further studies are needed to elucidate the pathogenesis and management of MR-associated hypertension in more detail to improve the clinical outcomes of patients with MR-associated hypertension.
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Affiliation(s)
- Satoshi Morimoto
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo, Japan.
| | - Atsuhiro Ichihara
- Department of Endocrinology and Hypertension, Tokyo Women's Medical University, Tokyo, Japan
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Kurata A, Furuie H, Ishizuka T, Nakatsu T, Shimizu T, Kato M, Nishikawa Y, Ishizuka H. Absolute Bioavailability of Esaxerenone and Food Effects on its Pharmacokinetics After a Single Oral Dose in Healthy Japanese Subjects: An Open-Label Crossover Study. Adv Ther 2019; 36:1618-1627. [PMID: 31119692 PMCID: PMC6824388 DOI: 10.1007/s12325-019-00956-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Indexed: 12/19/2022]
Abstract
Introduction To investigate the absolute bioavailability of esaxerenone and the effects of food on its pharmacokinetics (PK) after a single oral dose in healthy Japanese subjects. Methods Twenty-four Japanese males aged 20–45 years were randomised to six groups (each n = 4) in this single-centre, open-label, three-way, three-period crossover study. Esaxerenone (5 mg) was administered in the fasting state as a single oral dose, single intravenous infusion over 1 h, or in the postprandial state as a single oral dose. Plasma samples were taken before and during the 96 h after drug administration. Drug concentrations were measured using liquid chromatography-tandem mass spectrometry. PK parameters were calculated using noncompartmental analysis, and safety was assessed. Results After fasting intravenous administration, total body clearance was 3.69 L h−1 and volume of distribution was 92.7 L. The plasma concentration–time profile of esaxerenone was similar after fasting and postprandial administration. Absolute bioavailability of a single oral 5-mg dose of esaxerenone was 89.0% in the fasting state and 90.8% postprandially. Point estimates (1.010 and 1.019, respectively) and 90% confidence intervals for geometric least squares mean peak plasma concentrations and area under the plasma concentration–time curve ratios after postprandial versus fasting oral esaxerenone were within the prespecified range (0.80, 1.25). No severe adverse events occurred throughout the study. Conclusions Esaxerenone has a high absolute bioavailability of approximately 90% and food has no effect on esaxerenone PK after a single oral dose of 5 mg in healthy Japanese subjects. Additionally, no safety concerns were identified. Clinical Trial Registration JapicCTI No. 163452. Funding Daiichi Sankyo Co., Ltd.
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Efficacy and safety of esaxerenone (CS-3150) for the treatment of essential hypertension: a phase 2 randomized, placebo-controlled, double-blind study. J Hum Hypertens 2019; 33:542-551. [PMID: 31113987 PMCID: PMC6760614 DOI: 10.1038/s41371-019-0207-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 03/25/2019] [Accepted: 04/08/2019] [Indexed: 12/16/2022]
Abstract
This was a phase 2, multicenter, randomized, double-blind, placebo-controlled, open-label comparator study to investigate the efficacy and safety of esaxerenone (CS-3150), a novel non-steroidal mineralocorticoid receptor blocker, in Japanese patients with essential hypertension. Eligible patients (n = 426) received esaxerenone (1.25, 2.5, or 5 mg/day), placebo, or eplerenone (50–100 mg/day) for 12 weeks. The primary efficacy endpoint was the change from baseline in sitting systolic and diastolic blood pressure (BP). Safety endpoints included adverse events and serum K+ elevation. There were significant dose–response reductions in the 2.5 and 5 mg/day esaxerenone groups for sitting BP (both p < 0.001) and 24-h BP (both p < 0.0001) compared with placebo, with a mean (95% confidence interval) change in sitting BP of −7.0 (−9.5 to −4.6)/−3.8 (−5.2 to −2.4) mmHg in the placebo group, and −10.7 (−13.2 to −8.2)/−5.0 (−6.4 to −3.6) mmHg, −14.3 (−16.8 to −11.9)/−7.6 (−9.1 to −6.2) mmHg, and −20.6 (−23.0 to −18.2)/ −10.4 (−11.8 to −9.0) mmHg for the 1.25, 2.5, and 5 mg/day esaxerenone groups, respectively, while the change was −17.4 (−19.9 to −15.0)/−8.5 (−9.9 to −7.1) mmHg for eplerenone. The incidence of adverse events was similar in all treatment groups. Serum K+ levels initially increased in proportion with esaxerenone dose but were stable from week 2 until week 12. Plasma esaxerenone concentration increased in proportion with the dose. In conclusion, esaxerenone is an effective and tolerable treatment option for patients with essential hypertension.
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Affiliation(s)
- I. V. Leontyeva
- Veltischev Research and Clinical Institute for Pediatrics of the Pirogov Russian National Research Medical University
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12
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Methodological and reporting quality of systematic reviews referenced in the clinical practice guideline for pediatric high-blood pressure. J Hypertens 2019; 37:488-495. [DOI: 10.1097/hjh.0000000000001870] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Pathophysiological mechanisms of mineralocorticoid receptor-dependent cardiovascular and chronic kidney disease. Hypertens Res 2018; 42:293-300. [PMID: 30523293 DOI: 10.1038/s41440-018-0158-6] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/27/2018] [Accepted: 07/27/2018] [Indexed: 01/02/2023]
Abstract
Accumulating evidence has indicated the potential contributions of aldosterone and mineralocorticoid receptor (MR) to the pathophysiology of cardiovascular disease (CVD) and chronic kidney disease (CKD). Patients with primary aldosteronism have a higher risk of CVD and CKD than those with essential hypertension. MR is strongly expressed in endothelial cells, vascular smooth muscle cells, cardiomyocytes, fibroblasts, macrophages, glomerular mesangial cells, podocytes, and proximal tubular cells. In these cardiovascular and renal cells, aldosterone-induced cell injury is prevented by MR blockade. Interestingly, MR antagonists elicit beneficial effects on CVD and CKD in subjects with low or normal plasma aldosterone levels. Recent studies have shown that during development of CVD and CKD, cardiovascular and renal MR is activated by glucocorticoid and ligand-independent mechanisms, such as Rac1 signaling pathways. These data indicate that inappropriate activation of local MR contributes to cardiovascular and renal tissue injury through aldosterone-dependent and -independent mechanisms. In this review, recent findings on the specific role of cardiovascular and renal MR in the pathogenesis of CVD and CKD are summarized.
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Agarwal R, Rossignol P, Garza D, Mayo MR, Warren S, Arthur S, Romero A, White WB, Williams B. Patiromer to Enable Spironolactone Use in the Treatment of Patients with Resistant Hypertension and Chronic Kidney Disease: Rationale and Design of the AMBER Study. Am J Nephrol 2018; 48:172-180. [PMID: 30176673 DOI: 10.1159/000492622] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/01/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND While chronic kidney disease (CKD) is common in resistant hypertension (RHTN), prior studies -evaluating mineralocorticoid receptor antagonists excluded patients with reduced kidney function due to risk of hyperkalemia. AMBER (ClinicalTrials.gov identifier NCT03071263) will evaluate if the potassium-binding polymer patiromer used concomitantly with spironolactone in patients with RHTN and CKD prevents hyperkalemia and allows more persistent spironolactone use for hypertension management. METHODS Randomized, double-blind, placebo-controlled parallel group 12-week study of patiromer and spironolactone versus placebo and spironolactone in patients with uncontrolled RHTN and CKD. RHTN is defined as unattended systolic automated office blood pressure (AOBP) of -135-160 mm Hg during screening despite taking ≥3 antihypertensives, including a diuretic, and an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker -(unless not tolerated or contraindicated). The CKD inclusion criterion is an estimated glomerular filtration rate (eGFR) of 25 to ≤45 mL/min/1.73 m2. Screening serum potassium must be 4.3-5.1 mEq/L. The primary efficacy endpoint is the between-group difference (spironolactone plus patiromer versus spironolactone plus placebo) in the proportion of patients remaining on spironolactone at Week 12. RESULTS Baseline characteristics have been analyzed as of March 2018 for 146 (of a targeted 290) patients. Mean (SD) baseline age is 69.3 (10.9) years; 52.1% are male, 99.3% White, and 47.3% have diabetes. Mean (SD) baseline serum potassium is 4.68 (0.25) mEq/L, systolic AOBP is 144.3 (6.8) mm Hg, eGFR is 35.7 (7.7) mL/min/1.73 m2. CONCLUSION AMBER will define the ability of patiromer to facilitate the use of spironolactone, an effective antihypertensive therapy for patients with RHTN and CKD.
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Affiliation(s)
- Rajiv Agarwal
- Department of Medicine, Division of Nephrology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Patrick Rossignol
- Inserm 1433 CIC-P CHRU de Nancy, University of Lorraine and FCRIN INI-CRCT, Nancy, France
| | - Dahlia Garza
- Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, California, USA
| | - Martha R Mayo
- Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, California, USA
| | - Suzette Warren
- Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, California, USA
| | - Susan Arthur
- Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, California, USA
| | - Alain Romero
- Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, California, USA
| | - William B White
- Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Bryan Williams
- Institute of Cardiovascular Sciences University College London (UCL) and National Institute for Health Research (NIHR) UCL/UCL Hospitals Biomedical Research Centre, London, United Kingdom
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Good ME, Chiu YH, Poon IKH, Medina CB, Butcher JT, Mendu SK, DeLalio LJ, Lohman AW, Leitinger N, Barrett E, Lorenz UM, Desai BN, Jaffe IZ, Bayliss DA, Isakson BE, Ravichandran KS. Pannexin 1 Channels as an Unexpected New Target of the Anti-Hypertensive Drug Spironolactone. Circ Res 2017; 122:606-615. [PMID: 29237722 DOI: 10.1161/circresaha.117.312380] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 12/06/2017] [Accepted: 12/12/2017] [Indexed: 12/16/2022]
Abstract
RATIONALE Resistant hypertension is a major health concern with unknown cause. Spironolactone is an effective antihypertensive drug, especially for patients with resistant hypertension, and is considered by the World Health Organization as an essential medication. Although spironolactone can act at the mineralocorticoid receptor (MR; NR3C2), there is increasing evidence of MR-independent effects of spironolactone. OBJECTIVE Here, we detail the unexpected discovery that Panx1 (pannexin 1) channels could be a relevant in vivo target of spironolactone. METHODS AND RESULTS First, we identified spironolactone as a potent inhibitor of Panx1 in an unbiased small molecule screen, which was confirmed by electrophysiological analysis. Next, spironolactone inhibited α-adrenergic vasoconstriction in arterioles from mice and hypertensive humans, an effect dependent on smooth muscle Panx1, but independent of the MR NR3C2. Last, spironolactone acutely lowered blood pressure, which was dependent on smooth muscle cell expression of Panx1 and independent of NR3C2. This effect, however, was restricted to steroidal MR antagonists as a nonsteroidal MR antagonist failed to reduced blood pressure. CONCLUSIONS These data suggest new therapeutic modalities for resistant hypertension based on Panx1 inhibition.
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Affiliation(s)
- Miranda E Good
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Yu-Hsin Chiu
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Ivan K H Poon
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Christopher B Medina
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Joshua T Butcher
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Suresh K Mendu
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Leon J DeLalio
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Alexander W Lohman
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Norbert Leitinger
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Eugene Barrett
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Ulrike M Lorenz
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Bimal N Desai
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Iris Z Jaffe
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Douglas A Bayliss
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
| | - Brant E Isakson
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.).
| | - Kodi S Ravichandran
- From the Department of Molecular Physiology and Biophysics, Robert M. Berne Cardiovascular Research Center (M.E.G., J.T.B., L.J.D., A.W.L., B.E.I.), Department of Pharmacology (Y.-H.C., S.K.M., N.L., B.N.D., D.A.B.), Department of Microbiology, Immunology and Cancer Biology, the Center for Cell Clearance, and the Beirne B. Carter Center for Immunology Research (C.B.M., U.M.L., K.S.R.), and Division of Endocrinology (E.B.), University of Virginia School of Medicine, Charlottesville; Department of Biochemistry and Genetics, La Trobe University, Melbourne, Australia (I.K.H.P.); and Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA (I.Z.J.)
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16
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Yugar-Toledo JC, Modolo R, de Faria AP, Moreno H. Managing resistant hypertension: focus on mineralocorticoid-receptor antagonists. Vasc Health Risk Manag 2017; 13:403-411. [PMID: 29081661 PMCID: PMC5652936 DOI: 10.2147/vhrm.s138599] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Mineralocorticoid-receptor antagonists (MRAs) have proven to be effective in some types of hypertension, especially in resistant hypertension (RHTN). In this phenotype of hypertension, the renin-angiotensin-aldosterone pathway plays an important role, with MRAs being especially effective in reducing blood pressure. In this review, we show the relevance of aldosterone in RHTN, as well as some clinical characteristics of this condition and the main concepts involving its pathophysiology and cardiovascular damage. We analyzed the mechanisms of action and clinical effects of two current MRAs - spironolactone and eplerenone - both of which are useful in RHTN, with special attention to the former. RHTN represents a significant minority (10%-15%) of hypertension cases. However, primary-care physicians, cardiologists, nephrologists, neurologists, and geriatricians face this health problem on a daily basis. MRAs are likely one of the best pharmacological options in RHTN patients; however, they are still underused.
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Affiliation(s)
| | - Rodrigo Modolo
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Ana Paula de Faria
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Heitor Moreno
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
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17
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Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140:peds.2017-1904. [PMID: 28827377 DOI: 10.1542/peds.2017-1904] [Citation(s) in RCA: 1857] [Impact Index Per Article: 265.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.
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Affiliation(s)
- Joseph T Flynn
- Dr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - David C Kaelber
- Departments of Pediatrics, Internal Medicine, Population and Quantitative Health Sciences, Center for Clinical Informatics Research and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio
| | - Carissa M Baker-Smith
- Division of Pediatric Cardiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Douglas Blowey
- Children's Mercy Hospital, University of Missouri-Kansas City and Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado-Denver and Pediatrician in Chief, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah D de Ferranti
- Director, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan K Flinn
- Consultant, American Academy of Pediatrics, Washington, District of Columbia
| | - Samuel S Gidding
- Cardiology Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Celeste Goodwin
- National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine and Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Corinna Rea
- Associate Director, General Academic Pediatric Fellowship, Staff Physician, Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts
| | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern Medical School, University of Texas, Houston, Texas
| | - Madeline Simasek
- Pediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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18
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Downey RM, Mizuno M, Mitchell JH, Vongpatanasin W, Smith SA. Mineralocorticoid receptor antagonists attenuate exaggerated exercise pressor reflex responses in hypertensive rats. Am J Physiol Heart Circ Physiol 2017; 313:H788-H794. [PMID: 28733447 DOI: 10.1152/ajpheart.00155.2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 07/07/2017] [Accepted: 07/17/2017] [Indexed: 01/19/2023]
Abstract
Exaggerated heart rate (HR) and blood pressure responses to exercise in hypertension are mediated, in part, by overactivity of the exercise pressor reflex (EPR). The mechanisms underlying this EPR dysfunction have not been fully elucidated. Previous studies have shown that stimulation of mineralocorticoid receptors (MRs) with exogenous administration of aldosterone in normal, healthy rats reproduces the EPR overactivity characteristic of hypertensive animals. Conversely, the purpose of this study was to examine whether antagonizing MR with spironolactone (SPIR) or eplerenone (EPL) in decerebrated hypertensive rats ameliorates abnormal EPR function. Changes in mean arterial pressure (MAP) and HR induced by EPR or muscle mechanoreflex (a component of EPR) activation were assessed in normotensive Wistar-Kyoto rats and spontaneously hypertensive rats (SHRs) fed normal chow (NC) or a customized diet containing either SPIR or EPL for 3 wk. SHRs treated with SPIR or EPL had significantly attenuated MAP responses to EPR (NC: 45 ± 7 mmHg, SPIR: 26 ± 4 mmHg, and EPL: 24 ± 5 mmHg, P = 0.02) and mechanoreflex (NC: 34 ± 9 mmHg, SPIR: 17 ± 3 mmHg, and EPL: 15 ± 3 mmHg, P = 0.03) activation. SHRs treated with SPIR or EPL also showed significantly attenuated HR responses to EPR (NC: 17 ± 3 beats/min, SPIR: 9 ± 1 beats/min, and EPL: 9 ± 2 beats/min, P = 0.01) and mechanoreflex (NC: 15 ± 3 beats/min, SPIR: 6 ± 1 beats/min, and EPL: 7 ± 1 beats/min, P = 0.01) activation. Wistar-Kyoto rats treated with SPIR did not demonstrate significant differences in MAP or HR responses to EPR or mechanoreflex activation. The data suggest that antagonizing MRs may be an effective strategy for the treatment of EPR overactivity in hypertension.NEW & NOTEWORTHY Exaggerated cardiovascular responses to exercise in hypertensive patients are linked with overactive exercise pressor reflexes (EPRs). Administration of low-dose mineralocorticoid receptor antagonists (spironolactone or eplerenone) effectively ameliorates abnormal EPR function in hypertension. Effective treatment of EPR overactivity may reduce the cardiovascular risks associated with physical activity in hypertension.
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Affiliation(s)
- Ryan M Downey
- Department of Health Care Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Masaki Mizuno
- Department of Health Care Sciences, University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Jere H Mitchell
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
| | - Wanpen Vongpatanasin
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and.,Hypertension Section, Cardiology Division, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Scott A Smith
- Department of Health Care Sciences, University of Texas Southwestern Medical Center, Dallas, Texas; .,Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; and
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19
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Mullick AE, Yeh ST, Graham MJ, Engelhardt JA, Prakash TP, Crooke RM. Blood Pressure Lowering and Safety Improvements With Liver Angiotensinogen Inhibition in Models of Hypertension and Kidney Injury. Hypertension 2017; 70:566-576. [PMID: 28716988 DOI: 10.1161/hypertensionaha.117.09755] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 06/04/2017] [Accepted: 06/07/2017] [Indexed: 01/16/2023]
Abstract
Uncontrolled hypertension is an important contributor to cardiovascular disease. Despite the armamentarium of antihypertensive treatments, there remains a need for novel agents effective in individuals who cannot reach acceptable blood pressure levels. Inhibitors targeting the renin-angiotensin-aldosterone system (RAAS) are widely used but may not optimally inhibit RAAS and demonstrate an acceptable safety profile. Experiments were conducted to characterize a series of AGT (angiotensinogen) antisense oligonucleotides (ASOs) and compare their efficacy and tolerability to traditional RAAS blockade. AGT ASOs which target multiple systemic sites of AGT versus an N-acetylgalactosamine-conjugated AGT ASO that targets the liver were compared with captopril and losartan. Spontaneously hypertensive rats fed an 8% NaCl diet, a model of malignant hypertension resistant to standard RAAS inhibitors, demonstrated robust and durable blood pressure reductions with AGT ASO treatments, which was not observed with standard RAAS blockade. Studies in rat models of acute kidney injury produced by salt deprivation revealed kidney injury with ASO treatment that reduced kidney-expressed AGT, but not in animals treated with the N-acetylgalactosamine AGT ASO despite comparable plasma AGT reductions. Administration of either captopril or losartan also produced acute kidney injury during salt deprivation. Thus, intrarenal RAAS derived from kidney AGT, and inhibited by the standard of care, contributes to the maintenance of renal function during severe RAAS challenge. Such improvements in efficacy and tolerability by a liver-selective AGT inhibitor could be desirable in individuals not at their blood pressure goal with existing RAAS blockade.
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Affiliation(s)
| | - Steve T Yeh
- From the Ionis Pharmaceuticals, Inc, Carlsbad, CA
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21
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Abstract
Hypertension, or high blood pressure, is a prevalent yet modifiable risk factor for cardiovascular disease. While there are many effective treatments available to combat hypertension, patients often require at least two to three medications to control blood pressure, although there are patients who are resistant to such therapies. This short review will briefly update on recent clinical advances and potential emerging therapies and is intended for a cross-disciplinary readership.
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Affiliation(s)
- Andrew J. Freeman
- Department of Pharmacology and Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria 3800, Australia
| | - Antony Vinh
- Department of Pharmacology and Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria 3800, Australia
| | - Robert E. Widdop
- Department of Pharmacology and Monash Biomedicine Discovery Institute, Monash University, Clayton, Victoria 3800, Australia
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22
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A meta-analysis of add-on use of spironolactone in patients with resistant hypertension. Int J Cardiol 2016; 233:113-117. [PMID: 28089457 DOI: 10.1016/j.ijcard.2016.12.158] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 11/15/2016] [Accepted: 12/20/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The efficacy of add-on use of spironolactone in patients with resistant hypertension has been investigated in several small studies. We performed this meta-analysis evaluating the efficacy of add-on use of spironolactone in these patients. METHODS We searched Pubmed, Web of Science, and Cochrane Central for all published studies evaluating add-on use of spironolactone in patients with resistant hypertension. Only randomized controlled trials determining antihypertensive effects of spironolactone were considered. RESULTS The antihypertensive effects were assessed in 869 patients included in 4 trials with a mean follow-up of 12±3weeks. The reduction of systolic blood pressure (SBP) and diastolic BP (DBP) in patients treated with spironolactone was greater than placebo (weighted mean differences (WMD) for SBP -16.67mmHg (95% confidence interval (CI), -27.54, -5.80), p<0.01; WMD for DBP -6.11mmHg (95% CI, -9.34, -2.88), p<0.001), respectively. The rates of serious adverse effects or patient withdrawals from the trials tended to be higher in patients treated with spironolactone than placebo (WMD for odds ratio 2.11 (95% CI, 0.98, 4.53), p=0.05). CONCLUSIONS This meta-analysis provides the evidence that add-on use of spironolactone in patients with resistant hypertension is effective in lowering SBP and DBP, suggesting an add-on use of spironolactone as fourth line therapy in patients with resistant hypertension.
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