Effects of Blood Pressure Lowering Agents on Cardiovascular Outcomes in Weight Excess Patients: A Systematic Review and Meta-analysis

Highlights of mechanisms and treatment of obesity-related hypertension

The prevalence of obesity has increased two to three times from 1975 to 2015. Large-scale epidemiological and longitudinal prospective studies link obesity with hypertension. Research suggests that excessive weight gain, particularly when associated with visceral adiposity, may account for as much as 65% to 75% of the risk of incident hypertension. Also, exercise and bariatric/metabolic surgery significantly lowers blood pressure, whereas weight gain increases blood pressure, thus establishing a firm link between these two factors. The mechanisms underpinning obesity-related hypertension are complex and multifaceted, and include, but are not limited to, renin-angiotensin-aldosterone system/sympathetic nervous system overactivation, overstimulation of adipokines, insulin resistance, immune dysfunction, structural/functional renal, cardiac, and adipocyte changes. Though weight loss is the mainstay of treatment for obesity-related hypertension, it is often not a feasible long-term solution. Therefore, it is recommended that aggressive treatment with multiple antihypertensive medications combined with diet and exercise be used to lower blood pressure and prevent complications. The research regarding the mechanisms and treatment of obesity-related hypertension has moved at a blistering pace over the past ten years. Therefore, the purpose of this expert review is two-fold: to discuss the pathophysiological mechanisms underlying obesity-related hypertension, and to revisit pharmacotherapies that have been shown to be efficacious in patients with obesity-related hypertension.

Association of blood pressure in the first-week of hospitalization and long-term mortality in patients with acute left ventricular myocardial infarction

BACKGROUND

Previous studies have shown that optimal blood pressure (BP) control is necessary to outcomes in patients with acute myocardial infarction (AMI). Acute left ventricular MI is a prevalent type of AMI with poor prognosis. We aimed to analyze the associations between BP control in the first 7 days of hospitalization and long-term mortality specific to patients with isolated left ventricular MI.

METHODS

A total of 3108 acute left ventricular MI patients were included in this analysis. The average BP on the first seven days of hospitalization was categorized into 10-mmHg increments. The primary and secondary outcomes were all-cause death and cardiac death, respectively. Cox models were used to assess the association of outcomes with BP during hospitalization.

RESULTS

The median length-of-stay was 7 (IQR 6-10) days. The relationship between systolic BP (SBP) or diastolic BP (DBP) followed a U-shaped curve association with outcomes. All-cause mortality was higher in patients with lower SBP (≤90 mmHg) (adjusted hazard ratios (HRs) 7.12, 95% confidence interval (CI) 3.13-16.19; p < 0.001) and DBP (<60 mmHg) (HR 1.76, 95% CI 1.14-2.71; p = 0.011) [reference: 110 < SBP ≤120 mmHg; 70 < DBP ≤ 80 mmHg], respectively. Furthermore, primary outcome was higher in patients with higher SBP (>130 mmHg) (HR 1.51, 95% CI 1.12-2.03; p = 0.007) and DBP (>80 mmHg) (HR 1.61, 95% CI 1.20-2.18; p = 0.002), respectively.

CONCLUSION

Maintaining a SBP from 90 to 130 mmHg and a DBP from 60 to 80 mmHg may be beneficial to patients with acute left ventricular MI in the long run.

What Are the Clinical and Systemic Results of Periodontitis Treatment in Obese Individuals?

Purpose of Review

Periodontitis and obesity are characterized by a dysregulated inflammatory state. Obese individuals have a higher chance of presenting periodontitis. Clinical studies in different populations demonstrate that individuals with obesity have worse periodontal conditions. This current review aims to explore recent literature to understand what the impacts of obesity on periodontal treatment outcomes are and to learn whether periodontal treatment can improve systemic biomarkers in obese individuals.

Recent Findings

Short- and long-term evaluations demonstrated that non-surgical periodontal treatment could improve clinical parameters in obese individuals, represented as the reduction in mean probing depth, sites with probing depth ≥ 4 mm, and extension of bleeding on probing. However, obese individuals may have less clinical improvement when compared to normal-weight individuals with a similar periodontal profile. Additionally, periodontal treatment may contribute to a reduction in systemic levels of retinol-binding protein 4 and leptin, while promoting an increase in systemic levels of adiponectin.

Summary

Overall, obese individuals with periodontitis can significantly benefit from non-surgical periodontal treatment. However, clinical improvements seem to be less prominent in obese individuals with periodontitis compared to non-obese individuals with similar periodontal status. Nevertheless, periodontal treatment may impact significantly on the reduction of several biochemical biomarkers of obesity with or without weight reduction. Further investigations are needed to improve our comprehension of the mechanisms underlying those findings.

The Connotation of Variances in the Risk Predictors, Medications, Homocysteine, and Homocysteine Pathway Gene Polymorphisms with CVA/Stroke

Cerebrovascular accidents (CVAs) are vascular multifactorial, multigenic ailments with intricate genetic, environmental risk influences. The present study aimed to establish affiliation of CVAs/stroke with blood parameters, differences in prescribed drugs consumption, and with differences in homocysteine pathway genes polymorphisms. The participants in study included controls n  = 251, transient ischemic attack (TIA) patients n  = 16, and stroke cases n  = 122, respectively, (total participants, n  = 389). The analyzed single nucleotide polymorphisms (SNPs) included C677T(rs1801133), A1298C(rs1801131) of methylene tetrahydrofolate reductase ( MTHFR ), A2756G(rs1805087) of methyl tetrahydrofolate homocysteine methyltransferase/methionine synthase ( MS ), and the A192G(rs662) of paraoxonase 1( PON1 ) genes, all validated by tetra-primer allele refractory mutation system polymerase chain reaction (T-ARMS-PCR). The insertion deletion (I/D; rs4646994) polymorphism in angiotensin converting enzyme ( ACE ) gene was analyzed using routine PCR. All studied traits were scrutinized through analysis of variance (ANOVA), and later through regression analysis. Through ANOVA and multiple comparison, there was association of CVA with serum homocysteine, cholesterol, and with diastolic blood pressure readings. When data was subjected to regression, serum homocysteine and diastolic blood pressure (significant through ANOVA), as well as two additional traits, high-density lipoproteins (HDL), and rs1801133 MTHFR SNP sustained statistical significance and noteworthy odds in relation to CVA and stroke. The ailments affecting cerebral vasculature are mutifactorial, whereby genes, proteins, and environmental cues all exert cumulative effects enhancing CVA risk. The current study emphasizes that SNPs and variation in circulating biomarkers can be used for screening purposes and for reviewing their effects in stroke/CVA-linked risk progression.

The Novel Phosphate and Bile Acid Sequestrant Polymer SAR442357 Delays Disease Progression in a Rat Model of Diabetic Nephropathy

As a gut-restricted, nonabsorbed therapy, polymeric bile acid sequestrants (BAS) play an important role in managing hyperlipidemia and hyperglycemia. Similarly, nonabsorbable sequestrants of dietary phosphate have been used for the management of hyperphosphatemia in end-stage renal disease. To evaluate the potential utility of such polymer sequestrants to treat type 2 diabetes (T2D) and its associated renal and cardiovascular complications, we synthesized a novel polymeric sequestrant, SAR442357, possessing optimized bile acid (BA) and phosphate sequestration characteristics. Long-term treatment of T2D obese ^cZucker fatty/Spontaneously hypertensive heart failure F1 hybrid (ZSF1) with SAR442357 resulted in enhanced sequestration of BAs and phosphate in the gut, improved glycemic control, lowering of serum cholesterol, and attenuation of diabetic kidney disease (DKD) progression. In comparison, colesevelam, a BAS with poor phosphate binding properties, did not prevent DKD progression, whereas losartan, an angiotensin II receptor blocker that is widely used to treat DKD, showed no effect on hyperglycemia. Analysis of hepatic gene expression levels of the animals treated with SAR442357 revealed upregulation of genes responsible for the biosynthesis of cholesterol and BAs, providing clear evidence of target engagement and mode of action of the new sequestrant. Additional hepatic gene expression pathway changes were indicative of an interruption of the enterohepatic BA cycle. Histopathological analysis of ZSF1 rat kidneys treated with SAR442357 further supported its nephroprotective properties. Collectively, these findings reveal the pharmacological benefit of simultaneous sequestration of BAs and phosphate in treating T2D and its associated comorbidities and cardiovascular complications. SIGNIFICANCE STATEMENT: A new nonabsorbed polymeric sequestrant with optimum phosphate and bile salt sequestration properties was developed as a treatment option for DKD. The new polymeric sequestrant offered combined pharmacological benefits including glucose regulation, lipid lowering, and attenuation of DKD progression in a single therapeutic agent.

Angiotensin-(3-4) normalizes blood pressure, decreases Na+ and energy intake, but preserves urinary Na+ excretion in overweight hypertensive rats

Hypertension, one of the most common and severe comorbidities of obesity and overweight, is a worldwide epidemic affecting over 30% of the population. We induced overweight in young male rats (aged 58 days) by exposure to a hypercaloric high lipid (HL) diet in which 70% of the calories originated from fat. The HL diet also contained 33 or 57% higher Na⁺ than the control (CTR) diet. Over the following weeks the HL rats gradually became overweight (490 ± 12 g vs 427 ± 7 g in the CTR group after 15 weeks) with high visceral fat. They developed elevated systolic blood pressure (SBP) (141 ± 1.9 mmHg), which was fully restored to CTR values (128 ± 1.1 mmHg) by oral administration of Ang-(3-4) (Val-Tyr), the shortest renin-angiotensin-derived peptide. The overweight rats had lower plasma Na⁺ concentration that augmented to CTR values by Ang-(3-4) treatment. Na⁺ ingestion was depressed by 40% as result of the Ang-(3-4) treatment, whereas the urinary excretion of Na⁺ (U_NaV) remained unmodified. The preservation of U_NaV after Ang-(3-4) treatment - despite the sharp decrease in the dietary Na⁺ intake - can be ascribed to the normalization of renal type 1 angiotensin II receptors and Na⁺-transporting ATPases, both up-regulated in overweight rats. These renal effects complete a counterregulatory action on elevated renin-angiotensin activity that allows the high SBP to be normalized and body Na⁺ homeostasis to be restored concomitantly in overweight rats.