Flow-mediated vasodilation and the risk of developing hypertension in healthy postmenopausal women

Endothelial dysfunction influences augmented aortic hemodynamic responses to metaboreflex activation in postmenopausal women

PURPOSE

Postmenopausal women experience augmented aortic hemodynamic responses to isometric handgrip (IHG) exercise and metaboreflex activation post-exercise muscle ischemia (PEMI). Relationships between endothelial function brachial artery flow-mediated dilation (FMD) and aortic stiffness carotid-femoral pulse wave velocity (cfPWV) with aortic pulsatile hemodynamics during IHG and PEMI have not been determined. The relationships between aortic hemodynamic responses to PEMI were evaluated.

METHODS

Aortic blood pressure (BP), wave reflection, and pressure of forward (Pf) and backward (Pb) waves were measured using arterial tonometry at rest, IHG at 30% maximal force, and PEMI in 30 (15/group) postmenopausal women with low (≤ 4.5%) and normal (≥ 5.5%) FMD. Hemodynamic responses were analyzed as the change (Δ) from rest to the last minute of IHG and PEMI.

RESULTS

Brachial and aortic systolic BP (SBP) responses to IHG were higher in the low vs normal FMD group (P < 0.05). Aortic SBP (Δ20 ± 8 vs Δ11 ± 7 mmHg), pulse pressure (PP) (Δ12 ± 8 vs Δ6 ± 4 mmHg), augmented pressure (AP) (Δ5 ± 3 vs Δ2 ± 2 mmHg), and Pb (Δ6 ± 4 vs Δ3 ± 2 mmHg) responses to PEMI were greater (P < 0.05) in women with low vs. normal FMD. FMD was negatively correlated with aortic SBP, PP, AP, and Pb (P < 0.05) responses to PEMI. cfPWV was not correlated with responses to PEMI.

CONCLUSION

Endothelial dysfunction relates to augmented aortic pulsatile load during metaboreflex activation, which may increase cardiovascular risk in postmenopausal women.

Deletion of adipocyte NOS3 potentiates high-fat diet-induced hypertension and vascular remodelling via chemerin

AIMS

Obesity is an epidemic that is a critical contributor to hypertension and other cardiovascular diseases. Current paradigms suggest that endothelial nitric oxide synthase (eNOS/NOS3) in the vessel wall is the primary regulator of vascular function and blood pressure. However, recent studies have revealed the presence of eNOS/NOS3 in the adipocytes of white adipose tissues and perivascular adipose tissues (PVATs). The current understanding of the role of adipocyte NOS3 is based mainly on studies using global knockout models. The present study aimed to elucidate the functional significance of adipocyte NOS3 for vascular function and blood pressure control.

METHODS AND RESULTS

We generated an adipocyte-specific NOS3 knockout mouse line using adiponectin promoter-specific Cre-induced gene inactivation. Control and adipocyte-specific NOS3 knockout (A-NOS3 KO) mice were fed a high-fat diet (HFD). Despite less weight gain, A-NOS3 KO mice exhibited a significant increase in blood pressure after HFD feeding, associated with exacerbated vascular dysfunction and remodelling. A-NOS3 KO mice also showed increased expression of signature markers of inflammation and hypoxia in the PVATs. Among the differentially expressed adipokines, we have observed an upregulation of a novel adipokine, chemerin, in A-NOS3 KO mice. Chemerin was recently reported to link obesity and vascular dysfunction. Treatment with chemerin neutralizing antibody normalized the expression of remodelling markers in the aorta segments cultured in serum from HFD-fed A-NOS3 KO mice ex vivo.

CONCLUSION

These data suggest that NOS3 in adipocytes is vital in maintaining vascular homeostasis; dysfunction of adipocyte NOS3 contributes to obesity-induced vascular remodelling and hypertension.

The acute effects of exercise intensity and inorganic nitrate supplementation on vascular health in females after menopause

Menopause is associated with reduced nitric oxide bioavailability and vascular function. Although exercise is known to improve vascular function, this is blunted in estrogen-deficient females post-menopause (PM). Here, we examined the effects of acute exercise at differing intensities with and without inorganic nitrate (NO3-) supplementation on vascular function in females PM. Participants were tested in a double-blinded, block-randomized design, consuming ∼13 mmol NO3- in the form of beetroot juice (BRJ; n = 12) or placebo (PL; n = 12) for 2 days before experimental visits and 2 h before testing. Visits consisted of vascular health measures before (time point 0) and every 30 min after (time points 60, 90, 120, 150, and 180) calorically matched high-intensity exercise (HIE), moderate-intensity exercise (MIE), and a nonexercise control (CON). Blood was sampled at rest and 5-min postexercise for NO3-, NO2-, and ET-1. BRJ increased N-oxides and decreased ET-1 compared with PL, findings which were unchanged after experimental conditions (P < 0.05). BRJ improved peak Δflow-mediated dilation (FMD) compared with PL (P < 0.05), defined as the largest ΔFMD for each individual participant across all time points. FMD across time revealed an improvement (P = 0.05) in FMD between BRJ + HIE versus BRJ + CON, while BRJ + MIE had medium effects compared with BRJ + CON. In conclusion, NO3- supplementation combined with HIE improved FMD in postmenopausal females. NO3- supplementation combined with MIE may offer an alternative to those unwilling to perform HIE. Future studies should test whether long-term exercise training at high intensities with NO3- supplementation can enhance vascular health in females PM.NEW & NOTEWORTHY This study compared exercise-induced changes in flow-mediated dilation after acute moderate- and high-intensity exercise in females postmenopause supplementing either inorganic nitrate (beetroot juice) or placebo. BRJ improved peak ΔFMD postexercise, and BRJ + HIE increased FMD measured as FMD over time. Neither PL + MIE nor PL + HIE improved FMD. These findings suggest that inorganic nitrate supplementation combined with high-intensity exercise may benefit vascular health in females PM.

Endocan as a marker of endothelial dysfunction in hypertension: a systematic review and meta-analysis

Hypertension is one of the foremost risk factors for cardiovascular disease and a significant cause of death worldwide. Importantly, endothelial dysfunction (ED) is one of the primary manifestations that may precede the development of hypertension. Endocan is a novel endothelial dysfunction and inflammation biomarker secreted from endothelial cells. Whether endocan may serve as a biomarker of hypertension is currently debated. This systematic review and meta-analysis aimed at linking endocan to ED in hypertensive patients. International databases, including PubMed, Scopus, Embase, and Web of Science, were systematically searched for studies investigating Endocan serum or plasma levels in hypertensive patients and healthy controls. Random effect meta-analysis was performed to calculate the standardized mean difference (SMD) and 95% confidence interval (CI). A total of 20 studies assessing the association between endocan levels and hypertension were included in which 3130 individuals with a mean age of 50.48 ± 8.45 years were assessed. Hypertensive patients presented with higher circulating endocan levels (SMD 0.91, 95% CI 0.44-1.38, p-value < 0.01) compared with healthy controls. Interestingly, our data demonstrated that removing three studies assessing endocan levels in hypertensive patients with different comorbidities or special populations resulted in the same statistically higher endocan levels (SMD 1.16, 95% CI 0.66-1.65, p-value < 0.01). Overall, this systematic review and meta-analysis indicated that in hypertensive patients circulating endocan levels are significantly elevated. Thus, suggesting endocan as an easy-to-use biomarker to detect ED in hypertension. Despite this, more research is warranted to address this potential ability specifically.

Reprogramming endothelial and vascular smooth muscle cells to prevent and treat hypertension

The major pathophysiological characteristic of hypertension is the occurrence of small artery remodeling and endothelial dysfunction. There is also solid evidence showing that microcirculation abnormalities occur prior to the onset of hypertension. However, the mechanism(s) that trigger these changes prior to the elevation of blood pressure are unknown, and this may limit our ability to identify the cause of this disease and effectively treat it. In hypertension, as with aging, the vasculature becomes less susceptible to repair. One of the reasons is because endothelial cells start to deteriorate and present with exacerbated endothelial-to-mesenchymal transition (EndMT). Likewise, vascular smooth muscle cells (VSMC) also dedifferentiate into a synthetic phenotype, whereby they start to produce and secrete extracellular vesicles with a high migration and proliferation capacity for repairing vascular injury. Uncontrolled EndMT and/or VSMC phenotype switching contributes to vascular diseases, but the initial trigger for these conditions is unidentified. Importantly, EndMT and synthetic VSMC exhibit plasticity and can return to adopt an endothelial cell-like fate and present contractile phenotype again, respectively. Therefore, in this hypothesis we will take advantage of this plasticity, and we propose to manipulate this fate by inducing partial cellular reprogramming without passing through the pluripotent state. Specifically, we suggest that activation of the three master transcription factors, Oct-4, Sox-2, and Klf-4 (collectively termed OSK) will reprogram endothelial cells and prevent and reduce EndMT and VSMC synthetic phenotype. It was recently shown that activation of OSK was able to restore lost vision in old mice, and cancer risk was reduced by excluding c-Myc. Therefore, OSK treatment could provide new possibilities for vascular rejuvenation and treatment of hypertension.

Effect of Exercise Training on Blood Pressure in Healthy Postmenopausal Females: A Systematic Review with Meta-analysis

INTRODUCTION

The prevalence of hypertension is greater in postmenopausal females compared with males of similar age. Previous meta-analyses of normotensive and hypertensive adults have shown that aerobic exercise training reduces systolic blood pressure (SBP) and/or diastolic blood pressure (DBP). However, the effect of aerobic exercise training on blood pressure specifically within healthy postmenopausal females remains unclear. This systematic review with meta-analysis quantified the effect of aerobic exercise training on resting SBP and DBP in healthy postmenopausal females.

METHODS

The systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Review and Meta-analyses guidelines and was registered in PROSPERO (CRD42020198171). The literature search was done in MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL Plus, and SPORTDiscus. Randomized controlled trials involving healthy postmenopausal females with normal or high normal blood pressure and undergoing ≥4 wk of aerobic exercise training were included. The total weighted mean change in SBP and DBP was compared between the exercise and the control interventions. A random-effects model was used to calculate the overall effect sizes of the weighted mean differences and the 95% confidence interval (CI).

RESULTS

Twelve studies were included in the meta-analysis (exercise interventions: n = 357, age = 60 ± 4 yr, baseline SBP/DBP = 128 ± 13/79 ± 8 mm Hg; control interventions: n = 330, age = 60 ± 4 yr, baseline SBP/DBP = 126 ± 11/77 ± 6 mm Hg). Compared with the change observed in response to the control interventions, exercise training significantly reduced SBP (-0.43 mm Hg, 95% CI = -0.78 to -0.09, P = 0.02) and DBP (-0.39 mm Hg, 95% CI = -0.73 to -0.05, P = 0.05).

CONCLUSIONS

Aerobic exercise training significantly reduces resting SBP and DBP in healthy postmenopausal females with normal or high normal blood pressure. However, this reduction is small and of uncertain clinical significance.

Targeting cytokine-like protein FAM3D lowers blood pressure in hypertension

Current antihypertensive options still incompletely control blood pressure, suggesting the existence of uncovered pathogenic mechanisms. Here, whether cytokine-like protein family with sequence similarity 3, member D (FAM3D) is involved in hypertension etiology is evaluated. A case-control study exhibits that FAM3D is elevated in patients with hypertension, with a positive association with odds of hypertension. FAM3D deficiency significantly ameliorates angiotensin II (AngII)-induced hypertension in mice. Mechanistically, FAM3D directly causes endothelial nitric oxide synthase (eNOS) uncoupling and impairs endothelium-dependent vasorelaxation, whereas 2,4-diamino-6-hydroxypyrimidine to induce eNOS uncoupling abolishes the protective effect of FAM3D deficiency against AngII-induced hypertension. Furthermore, antagonism of formyl peptide receptor 1 (FPR1) and FPR2 or the suppression of oxidative stress blunts FAM3D-induced eNOS uncoupling. Translationally, targeting endothelial FAM3D by adeno-associated virus or intraperitoneal injection of FAM3D-neutralizing antibodies markedly ameliorates AngII- or deoxycorticosterone acetate (DOCA)-salt-induced hypertension. Conclusively, FAM3D causes eNOS uncoupling through FPR1- and FPR2-mediated oxidative stress, thereby exacerbating the development of hypertension. FAM3D may be a potential therapeutic target for hypertension.

Combined Citrulline and Glutathione Supplementation Improves Endothelial Function and Blood Pressure Reactivity in Postmenopausal Women

Postmenopausal women (PMW) may experience endothelial dysfunction associated with arginine (ARG) deficiency relative to asymmetric dimethylarginine (ADMA) caused by oxidative stress. Endothelial dysfunction contributes to increased blood pressure (BP) responsiveness to sympathoexcitation induced by the cold pressor test (CPT). We investigated the effects of citrulline alone (CIT) and combined with the antioxidant glutathione (CIT+GSH) on vascular function. Forty-four healthy PMW were randomized to CIT (6 g), CIT+GSH (2 g + 200 mg: Setria^®) or placebo (PL) for 4 weeks. Brachial artery flow-mediated dilation (FMD), aortic stiffness (pulse wave velocity, PWV), brachial and aortic BP reactivity to CPT, and serum fasting blood glucose (FBG), ARG, and ARG/ADMA ratio were measured. Baseline FBG was higher in CIT+GSH vs. PL. FMD increased after CIT+GSH vs. PL (p < 0.05). CIT and CIT+GSH increased ARG/ADMA (p < 0.05), but did not affect aortic PWV. CIT+GSH attenuated the brachial and aortic systolic BP and mean arterial pressure (MAP) responses to CPT vs. PL and CIT (p < 0.05). The improvements in FMD were related to baseline FMD (r = -0.39, p < 0.05) and aortic MAP response to CPT (r = -0.33, p < 0.05). This study showed that CIT+GSH improved FMD and attenuated systolic BP and MAP reactivity in PMW. Although CIT increased ARG/ADMA, it did not improve FMD in healthy PMW.

Women and Ischemic Stroke

Although men are at higher risk of stroke throughout most of their lifespan, the incidence of stroke in women climbs with age, increasing after menopause and rising sharply after 85 years. This, combined with women's longer life expectancy, results in most of the stroke deaths occurring in women. In addition to accounting for a larger proportion of strokes, women may also suffer a survival disadvantage, which may be due to several factors. In many families, women are the primary caretakers. When they become disabled, there may be limited options to care for them. Others suggest that some of the disparities in stroke outcomes in women may be related to age, pre-stroke functional status, and comorbidities. Regardless of the cause, the increased disability and post-stroke care requirements of women, particularly in our aging population, highlight the importance of determining successful strategies for stroke prevention, acute stroke treatments, optimization of stroke rehabilitation, and effective secondary prevention measures in women.

Hypertension Across a Woman's Life Cycle

PURPOSE OF REVIEW

We reviewed the effects of hypertension and the means to prevent and treat it across the spectrum of a woman's lifespan and identified gaps in sex-specific mechanisms contributing to hypertension in women that need to be addressed.

RECENT FINDINGS

Hypertension continues to be an important public health problem for women across all life stages from adolescence through pregnancy, menopause, and older age. There remain racial, ethnic, and socioeconomic differences in hypertension rates not only overall but also between the sexes. Blood pressure cutoffs during pregnancy have not been updated to reflect the 2017 ACC/AHA changes due to a lack of data. Additionally, the mechanisms behind hypertension development in menopause, including sex hormones and genetic factors, are not well understood. In the setting of increasing inactivity and obesity, along with an aging population, hypertension rates are increasing in women. Screening and management of hypertension throughout a women's lifespan are necessary to reduce the burden of cardiovascular disease, and further research to understand sex-specific hypertension mechanisms is needed.

Associations between noninvasive upper- and lower-limb vascular function assessments: extending the evidence to young women

Brachial artery (BA) flow-mediated dilation (FMD) is a well-established measure of peripheral vascular function prognostic of future cardiovascular events. The vasodilatory response to FMD (FMD%) reflects upper-limb conduit artery function, whereas reactive hyperemia (RH) following cuff-occlusion release reflects upper-limb resistance artery function. Comparatively, passive leg movement (PLM) is a newer, increasingly utilized assessment of lower-limb resistance artery function. To increase its clinical utility, PLM-induced leg blood flow (LBF) responses have been compared with hemodynamic responses to FMD, but only in men. Therefore, the purpose of this study was to retrospectively compare LBF responses to FMD% and RH responses in women. We hypothesized that LBF responses would be positively associated with both FMD% and RH, but to a greater extent with RH. FMD and PLM were performed on 72 women (23 ± 4 yr). Arterial diameter and blood velocity were assessed using Doppler ultrasound. Pearson correlation coefficients were used to evaluate associations. Measures of resistance artery function were weakly positively associated: change in BA blood flow ΔBABF and ΔLBF (r = 0.33, P < 0.01), BABF area under the curve (BABF AUC) and LBF AUC (r = 0.33, P < 0.01), and BABFpeak and LBFpeak (r = 0.37, P < 0.01). However, FMD% was not associated with any index of PLM (all P > 0.30). In women, indices of resistance artery function in the upper- and lower limbs were positively associated. However, contrary to the previous work in men, upper-limb conduit artery function was not associated with lower-limb resistance artery function suggesting these assessments capture different aspects of vascular function and should not be used interchangeably in women.NEW & NOTEWORTHY Upper- and lower-limb indices of resistance artery function are positively associated in young women when assessed by reactive hyperemia following brachial artery flow-mediated dilation (FMD) cuff-occlusion release and leg blood flow responses to passive leg movement (PLM), respectively. However, despite previous data demonstrating a positive association between upper-limb conduit artery function assessed by FMD and lower-limb resistance artery function assessed by PLM in young men, these measures do not appear to be related in young women.

Comparison of Blood Pressure and Vascular Health in Physically Active Late Pre- and Early Postmenopausal Females

PURPOSE

The benefits of exercise on vascular health are inconsistent in postmenopausal females. We investigated if blood pressure and markers of vascular function differ between physically active early post- and late premenopausal females.

METHODS

We performed a cross-sectional comparison of 24-h blood pressure, brachial artery flow-mediated dilation, microvascular reactivity (reactive hyperemia), carotid-femoral pulse wave velocity, and cardiac baroreflex sensitivity between physically active late premenopausal (n = 16, 48 ± 2 yr) and early postmenopausal (n = 14, 53 ± 2 yr) females.

RESULTS

Physical activity level was similar between premenopausal (490 ± 214 min·wk-1) and postmenopausal (550 ± 303 min·wk-1) females (P = 0.868). Brachial artery flow-mediated dilation (pre, 4.6 ± 3.9, vs post, 4.7% ± 2.2%; P = 0.724), 24-h systolic (+5 mm Hg, 95% confidence interval [CI] = -1 to +10, P = 0.972) and diastolic (+4 mm Hg, 95% CI = -1 to +9, P = 0.655) blood pressures, total reactive hyperemia (pre, 1.2 ± 0.5, vs post, 1.0 ± 0.5 mL·mm Hg-1; P = 0.479), carotid-femoral pulse wave velocity (pre, 7.9 ± 1.7, vs post, 8.1 ± 1.8 m·s-1; P = 0.477), and cardiac baroreflex sensitivity (-8 ms·mm Hg-1, 95% CI = -20.55 to 4.62, P = 0.249) did not differ between groups. By contrast, peak reactive hyperemia (-0.36 mL·min-1⋅mm Hg-1, 95% CI = -0.87 to +0.15, P = 0.009) was lower in postmenopausal females.

CONCLUSIONS

These results suggest that blood pressure and markers of vascular function do not differ between physically active late pre- and early postmenopausal females.

Hypertension and retinal microvascular dysfunction (HyperVasc): protocol of a randomised controlled exercise trial in patients with hypertension

INTRODUCTION

Hypertension is a global healthcare burden that affects the structure and function of the macrocirculation and microcirculation and induces disease-specific end-organ damage. Vascular biomarkers are essential to timely diagnose this end-organ damage to improve cardiovascular (CV) risk stratification and medical decision making. Exercise therapy is an effective means to improve vascular health and reduce overall CV risk. However, it is still not clear whether high-intensity interval training (HIIT) is recommendable for patients with hypertension to reduce blood pressure, increase cardiorespiratory fitness and ameliorate vascular health.

METHODS AND ANALYSIS

The 'Hypertension and retinal microvascular dysfunction' trial will investigate macrovascular and microvascular impairments in hypertensive patients compared with healthy controls to investigate hypertension-induced end-organ damage by using gold-standard methods as well as newly developed unique retinal microvascular biomarkers. In addition, this trial will investigate the reversibility of retinal end-organ damage by assessing the effects of an 8-week supervised and walking based HIIT on blood pressure, cardiorespiratory fitness as well as macrovascular and microvascular health, compared with a control group following standard physical activity recommendations. Primary outcome will be the arteriolar-to-venular diameter ratio. Secondary outcomes will be arteriolar and venular diameters as well as the flicker-light-induced dilation. Further outcomes will be other retinal microvascular biomarkers, flow-mediated dilation of the brachial artery as well as blood pressure, cardiorespiratory fitness, microalbuminuria, hypertensive retinopathy and classical CV risk markers. Analysis of variance and analysis of covariance will be used to investigate group differences between healthy controls and hypertensive patients and training effects in hypertensive patients, respectively.

ETHICS AND DISSEMINATION

The Ethics Committee of Northwestern and Central Switzerland approved this study (EKNZ-2021-00086). All participants will give informed consent.

TRIAL REGISTRATION NUMBER

NCT04763005.

High Normal Urinary Albumin-Creatinine Ratio Is Associated With Hypertension, Type 2 Diabetes Mellitus, HTN With T2DM, Dyslipidemia, and Cardiovascular Diseases in the Chinese Population: A Report From the REACTION Study

Background

Albuminuria has been widely considered a risk factor for cardiovascular diseases (CVDs), which is associated with hypertension (HTN), type 2 diabetes mellitus (T2DM), HTN with T2DM, and dyslipidemia. However, the associations between albuminuria and HTN, T2DM, HTN with T2DM, dyslipidemia, and CVDs are still unclear. Thus, this study aimed to explore the association of albuminuria thoroughly, especially within the normal range, with the abovementioned diseases in the Chinese population.

Methods

This study included 40,188 participants aged over 40 years from seven centers across China. Urinary albumin-creatinine ratio (UACR) was firstly divided into the ≥30-mg/g group, indicating kidney damage, and <30-mg/g group. Furthermore, UACR was divided into five groups: the <20%, 20%-39%, 40%-59%, 60%-79%, and ≥80% groups, according to the quintile division of participants within the normal range. Propensity score matching was used to reduce bias, and multiple logistic regression models were conducted to examine the association between UACR and HTN, T2DM, HTN with T2DM, dyslipidemia, and CVDs.

Results

Multivariable regression analysis revealed that UACR, even within the normal range, is significantly associated with HTN, T2DM, HTN with T2DM, dyslipidemia, and CVDs, and the association between UACR and HTN with T2DM was the most significant in model 3 even after adjusting for confounding factors (HTN: OR = 1.56 (95% CI = 1.45-1.68), p < 0.0001; T2DM: OR = 1.78 (95% CI = 1.60-1.97), p < 0.0001; HTN with T2DM: OR = 1.76 (95% CI = 1.59-1.95), p < 0.0001; dyslipidemia: OR = 1.08 (95% CI = 1.01-1.14), p = 0.0146; CVDs: OR = 1.12 (95% CI = 1.00-1.25), p = 0.0475). In the stratified analysis, high normal UACR was significantly associated with HTN, T2DM, HTN with T2DM, and dyslipidemia in subgroups.

Conclusions

In summary, we observe a higher prevalence of HTN, T2DM, HTN with T2DM, dyslipidemia, and CVDs in abnormal UACR and reveal a significant association of UACR, even within the normal range, with HTN, T2DM, HTN with T2DM, dyslipidemia, and CVDs.

Mechanisms and Clinical Implications of Endothelial Dysfunction in Arterial Hypertension

The endothelium is composed of a monolayer of endothelial cells, lining the interior surface of blood and lymphatic vessels. Endothelial cells display important homeostatic functions, since they are able to respond to humoral and hemodynamic stimuli. Thus, endothelial dysfunction has been proposed as a key and early pathogenic mechanism in many clinical conditions. Given the relevant repercussions on cardiovascular risk, the complex interplay between endothelial dysfunction and systemic arterial hypertension has been a matter of study in recent years. Numerous articles have been published on this issue, all of which contribute to providing an interesting insight into the molecular mechanisms of endothelial dysfunction in arterial hypertension and its role as a biomarker of inflammation, oxidative stress, and vascular disease. The prognostic and therapeutic implications of endothelial dysfunction have also been analyzed in this clinical setting, with interesting new findings and potential applications in clinical practice and future research. The aim of this review is to summarize the pathophysiology of the relationship between endothelial dysfunction and systemic arterial hypertension, with a focus on the personalized pharmacological and rehabilitation strategies targeting endothelial dysfunction while treating hypertension and cardiovascular comorbidities.

Association of plasma endothelin-1 with blood pressure progression among Blacks: The Jackson Heart Study

BACKGROUND

Despite pathophysiological links between endothelin (ET)-1 and hypertension in Black adults, there is no population-based data appraising the association of plasma ET-1 with longitudinal blood pressure (BP) changes in Blacks.

METHODS

We analyzed data from 1197 Jackson Heart Study participants without hypertension (mean age 47.8 years [SD: 12.0]; 64.2% women), with plasma ET-1 available at the baseline examination (2000-2004). Poisson regression with robust variance was used to generate risk ratios (RRs) and 95% confidence intervals (CIs) of BP progression (an increase by ≥1 BP category based on the 2017 American College of Cardiology/American Heart Association classification) and incident hypertension (BP ≥ 130/80 mm Hg or use of antihypertensive medication) at follow-up (2005-2008 or 2009-2013).

RESULTS

Over a median follow-up of 7 years (range: 4-11), 71.2% (n = 854) progressed to a higher BP stage and 64.6% (n = 773) developed hypertension. After adjusting for possible confounders, each unit increment in baseline log (ET-1) was associated with higher risks of BP progression (RR 1.15 [95% CI 1.03-1.29], P = .016) and incident hypertension (RR 1.15 [95% CI 1.01-1.31], P = .032). Compared to those in the lowest ET-1 quartile, participants in the highest quartile had significantly higher risks of BP progression (RR 1.20 [95% CI 1.05-1.37], P = .007) and incident hypertension (RR 1.16 [95% CI 1.00-1.36], P = .052).

CONCLUSIONS

In a large, community-based sample of African Americans, higher plasma ET-1 concentrations were associated with higher risks of BP progression and incident hypertension.

Association between satellite-based estimates of long-term PM2.5 exposure and cardiovascular disease: evidence from the Indonesian Family Life Survey

Exposure to particulate matter with a diameter < 2.5 µm (PM2.5) increases the risk of cardiovascular disease (CVD), which is the leading cause of both morbidity and mortality in Indonesia, accounting for one-third of all deaths. Indonesian authorities started to monitor PM2.5 levels in urban areas in 2015. However, there is still no study examining the association between long-term PM2.5 exposure and CVD in Indonesia. In this study, we combined PM2.5 data and health survey data. Long-term (2000-2007) exposure to PM2.5 was measured based on satellite-derived aerosol optical depth measurements (1 × 1 km2) that could be used to predict ground-level PM2.5 concentrations. Population data on residents of Sumatra Island were obtained from the fourth wave of the Indonesian Family Life Survey (IFLS). A cross-sectional study was performed with 2324 participants who were aged ≥ 40 years old, and a report of doctor-diagnosed CVD determined CVD status. We used logistic regression to analyze the association between PM2.5 and CVD prevalence, adjusting for multiple covariates. Of the sample, 52.1% were women, and 47.9% were men. The sample was divided into those aged 40-59 (adults) and those ≥ 60 (older adults). The CVD prevalence was 4.05% (n = 94), with a mean (standard deviation) PM2.5 concentration of 14.4 (6.4) µg/m3. In adjusted models, a 10-µg/m3 increase in annual average PM2.5 levels was associated with 29% higher odds of having CVD (odds ratio = 1.29; 95% confidence interval: 1.02, 1.47). In this population-based IFLS data, long-term exposure to PM2.5 is associated with a higher prevalence of CVD in Sumatera, Indonesia.

Association Between Serum Calcium and the Prevalence of Hypertension Among US Adults

Background: Hypertension is a significant risk factor of cardiovascular diseases, posing a serious threat to global health. Calcium plays an important role in regulating body homeostasis. The association of calcium with hypertension remains uncertain in the general population.

Methods and Results: Cross-sectional data from the 2007–2018 National Health and Nutrition Examination Survey (NHANES) were analyzed. Adjusted multivariable logistic regression analysis and restricted cubic spline were used to investigate the association of serum calcium with the prevalence of hypertension. A total of 26,778 participants were included. The increase in calcium levels showed a positive association with the prevalence of hypertension in all three models with ORs of 1.347 (1.249–1.454), 1.522 (1.401–1.654), and 1.438 (1.306–1.583). The further subgroup analysis demonstrated a robust trend across all categories by sex, age, race, BMI, and eGFR. The restricted cubic spline plot exhibited an S-curve relationship between calcium and hypertension.

Conclusion: Our cross-sectional study demonstrated a positive association between higher serum calcium level and the prevalence of hypertension. Our findings highlighted serum calcium level in hypertensive patients.

Influence of dietary intervention on microvascular endothelial function in coronary patients and atherothrombotic risk of recurrence

Endothelial dysfunction is a key player in both the onset and development of atherosclerosis. No study has examined whether healthy dietary patterns can improve microvascular endothelial function in patients with coronary heart disease (CHD) in the long-term and whether this relationship can affect patient's risk of CHD recurrence. In the CORDIOPREV study, a randomized, double-blind, controlled trial, dietary intervention with either the Mediterranean diet or a low-fat diet was implemented in 1,002 CHD patients. A laser-doppler flowmetry was performed at baseline and after 6 years of follow up in 664 patients, evaluating the effects of this dietary intervention on microvascular basal flow and reactive hyperaemia area, as well as on the risk of CHD recurrence, based on the TRS2P risk score. Basal flow (97.78 ± 2.79 vs. 179.31 ± 5.06 arbitrary perfusion units, 83.38% increase, p < 0.001) and reactive hyperaemia area (4233.3 ± 127.73 vs. 9695.9 ± 205.23 arbitrary perfusion units per time, 129.04% increase, p < 0.001) improved after the dietary intervention in the cohort, without finding differences due to the diet (p > 0.05 for the diet-effect). When patients were stratified to low, moderate or high-risk of recurrence, basal flow was similarly increased in all three groups. However, reactive hyperaemia area was improved to a greater extent in patients at the low-risk group compared with those at moderate or high-risk. No differences were observed between diets. Healthy dietary patterns can improve microvascular endothelial function and this improvement persists in the long-term. Patients with a low-risk of CHD recurrence show a greater improvement in reactive vasodilation to ischemia than patients in the moderate or high-risk groups.

A Pilot Study: Hypertension, Endothelial Dysfunction and Retinal Microvasculature in Rheumatic Autoimmune Diseases

Background: The etiology of autoimmune rheumatic diseases is unknown. Endothelial dysfunction and premature atherosclerosis are commonly seen in these patients. Atherosclerosis is considered one of the main causes of cardiovascular diseases. Hypertension is considered the most important traditional cardiovascular risk. This case-control study aimed to investigate the relationship between autoimmune diseases and cardiovascular risk. Methods: This study was carried out in patients with rheumatoid arthritis, RA (n = 10), primary Sjögren syndrome, PSS (n = 10), and healthy controls (n = 10). Mean blood pressure (MBP), systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse wave velocity (PWV, an indicator of arterial stiffness) were assessed via a Vicorder device. Asymmetric dimethylarginine (ADMA) was measured via ELISA. Retinal photos were taken via a CR-2 retinal camera, and retinal microvasculature analysis was carried out. T-tests were conducted to compare the disease and control groups. ANOVA and ANOVA—ANCOVA were also used for the correction of covariates. Results: A high prevalence of hypertension was seen in RA (80% of cases) and PSS (40% of cases) compared to controls (only 20% of cases). Significant changes were seen in MBP (RA 101 ± 11 mmHg; PSS 93 ± 10 mm Hg vs. controls 88 ± 7 mmHg, p = 0.010), SBP (148 ± 16 mmHg in RA vs. 135 ± 16 mmHg in PSS vs. 128 ± 11 mmHg in control group; p = 0.007), DBP (77 ± 8 mmHg in RA, 72 ± 8 mmHg in PSS vs. 67 ± 6 mmHg in control; p = 0.010 in RA compared to the controls). Patients with PSS showed no significant difference as compared to controls (MBP: p = 0.240, SBP: p = 0.340, DBP: p = 0.190). Increased plasma ADMA was seen in RA (0.45 ± 0.069 ng/mL) and PSS (0.43 ± 0.060 ng/mL) patients as compared to controls (0.38 ± 0.059 ng/mL). ADMA in RA vs. control was statistically significant (p = 0.022). However, no differences were seen in ADMA in PSS vs. controls. PWV and retinal microvasculature did not differ across the three groups. Conclusions: The prevalence of hypertension in our cohort was very high. Similarly, signs of endothelial dysfunction were seen in autoimmune rheumatic diseases. As hypertension and endothelial dysfunction are important contributing risk factors for cardiovascular diseases, the association of hypertension and endothelial dysfunction should be monitored closely in autoimmune diseases.

Cardiovascular Risk and Endothelial Dysfunction in Primary Sjogren Syndrome Is Related to the Disease Activity

The aim of our study was to evaluate if endothelial-dysfunction (ED) occurs in patients with primary Sjogren syndrome (pSS) and whether it is associated with the disease characteristics and activity. A total of 46 patients with pSS and 30 controls, without known cardiovascular disease, were enrolled in this study. A flow-mediated-dilation (FMD) of the brachial artery, plasma concentrations of the nitric oxide (NO) metabolic pathway (ADMA, L-arginine, SDMA, cGMP), and markers of endothelial inflammatory function (PAI-1, sE-selectin) and angiogenesis (angiostatin, VEGF) were analyzed. The FMD was significantly lower in pSS patients (7.56 ± 3.08 vs. 10.91 ± 1.02%, p = 0.043) and positively correlated with the Ro/SS-A-antibodies (r = 0.34, p = 0.03), pulmonary involvement (r = 0.52, p = 0.001) and inversely with ADMA (r = −0.35, p = 0.04). Plasma ADMA, L-arginine and angiostatin levels were significantly higher in pSS patients (0.39 ± 0.08 vs. 0.36 ± 0.06 µmol/L, p = 0.05; 29.07 ± 6.7 vs. 25.4 ± 5.23 µmol/L, p = 0.01; 152.25 ± 60.99 vs. 120.07 ± 38.7 pg/mL, p = 0.0, respectively). ADMA was associated with ESSDAI (r = 0.33, p = 0.02), SCORE (r = 0.57, p = 0.00003) and focus score (r = 0.38, p = 0.04). In the multiple regression analysis, the ESSDAI was significantly and independently associated with plasma ADMA levels (β = 0.24, p = 0.04). Moreover, plasma cGMP concentrations were negatively correlated with the disease duration (r = −0.31, p = 0.03). Endothelial function is impaired in patients with pSS and associated with the measures of disease activity, which supports the key-role of inflammation in developing and maintaining accelerated atherosclerosis.

Different Influence of Blood Pressure on New-Onset Atrial Fibrillation in Pre- and Postmenopausal Women: A Nationwide Population-Based Study

[Figure: see text].

Young healthy adults with a family history of hypertension have increased microvascular reactivity but decreased macrovascular function

OBJECTIVE

To determine whether, like hypertensives, normotensive adults with a family history of hypertension (+FHH) display lower microvascular reactivity and conduit artery function than normotensive adults without a family history of hypertension (-FHH).

METHODS

A forearm vascular occlusion test was performed on healthy normotensive adults while resting in the supine position. A near-infrared spectroscopy sensor placed on the forearm measured skeletal muscle oxygen saturation kinetics to determine microvascular reactivity. Simultaneously, an ultrasound probe placed on the brachial artery above the occlusion cuff was used to assess flow-mediated dilation; a test of macrovascular function.

RESULTS

Twenty-two participants were included in this investigation (-FHH n = 13, +FHH n = 9). Following cuff release, the resaturation slope (1st 10 s median ± SD, -FHH 2.76 ± 2.10, +FHH 5.59 ± 2.47%/s; p = .036) was greater in +FHH when accounting for the magnitude and rate of the decrease in skeletal muscle oxygen saturation during occlusion. Conversely, flow-mediated dilation (median ± SD, -FHH 5.96 ± 5.22, +FHH 4.10 ± 3.17%∆; p = .031) was lower in +FHH when accounting for baseline artery diameter and shear rate.

CONCLUSIONS

Young +FHH adults have altered microvascular and macrovascular reactivity compared with young -FHH adults.

Endocan: A novel biomarker for risk stratification, prognosis and therapeutic monitoring in human cardiovascular and renal diseases

The vascular endothelium is localized at the interface between the blood and surrounding tissues, playing a pivotal role in the maintenance of tissue-fluid homeostasis and in the regulation of host defense, inflammation, vascular tone and remodeling, angiogenesis and haemostasis. The dysfunctional endothelium was shown to be implicated in the pathophysiology of several endothelial-dependent disorders, such as arterial hypertension, coronary artery disease, heart failure and chronic kidney disease, in which it is an early predictor of cardiovascular events. Endocan is a soluble dermatan sulphate proteoglycan mainly secreted by the activated endothelium. It is upregulated by several proinflammatory cytokines and proangiogenic factors and may itself contribute to the inflammatory status. In addition of being a surrogate marker of inflammation and endothelial dysfunction, it seems to be involved in the regulation of several proliferative and neovascularization processes. Therefore, its utility as a biomarker in a wide spectrum of diseases has been increasingly explored. Here, we review the current evidence concerning the role of endocan in several human cardiovascular and renal diseases, where it seems to be a promising biomarker for risk stratification, prognosis and therapeutic monitoring.

Effects of nebivolol versus other antihypertensive drugs on the endothelial dysfunction in patients with essential hypertension

We aim to determine whether nebivolol has a better effect on endothelial dysfunction compared with other β-blockers or other classes of antihypertensive drugs. Searches of the PubMed, Embase etc. were performed to analyze all the randomized controlled trials using nebivolol to treat essential hypertension. The primary end points included a measurement of peripheral endothelial function by brachial flow mediated vasodilatation (FMD) or forearm blood flow (FBF). A random-effect model was used to perform the meta-analysis when the studies showed significant heterogeneity, otherwise a descriptive analysis was conducted. Ten studies (689 patients) were included in qualitative analysis, four of which were included in quantitative synthesis. Meta-analysis showed that the changed FMD value before and after treatment with nebivolol was not statistically different from those treated with other β-blockers [mean difference = 1.12, 95% confidence interval (CI): −0.56, 2.81, P=0.19]. Descriptive analysis indicated that nebivolol did not have a better endothelium-protective effect than other classes of antihypertensive drugs including olmesartan and perindopril. Nebivolol is not a unique endothelial function-protective agent distinguished from other β-blockers or other classes of antihypertensive drugs. Reversal of endothelial dysfunction is a key point in the prevention and therapy of essential hypertension.

Impact of pulsed electromagnetic field therapy on vascular function and blood pressure in hypertensive individuals

The present study investigated the impact of 12 weeks of pulsed electromagnetic field (PEMF) therapy on peripheral vascular function, blood pressure (BP), and nitric oxide in hypertensive individuals. Thirty hypertensive individuals (SBP > 130 mm Hg and/or MAP > 100 mm Hg) were assigned to either PEMF group (n = 15) or control group (n = 15). During pre-assessment, participants underwent measures of flow-mediated dilation (FMD), BP, and blood draw for nitric oxide (NO). Subsequently, they received PEMF therapy 3x/day for 12 weeks and, at conclusion, returned to the laboratory for post-assessment. Fifteen participants from the PEMF group and 11 participants from the control group successfully completed the study protocol. After therapy, the PEMF group demonstrated significant improvements in FMD and FMD_NOR (normalized to hyperemia), but the control group did not (P = .05 and P = .04, respectively). Moreover, SBP, DBP, and MAP were reduced, but the control group did not (P = .04, .04, and .03, respectively). There were no significant alterations in NO in both groups (P > .05). Twelve weeks of PEMF therapy may improve BP and vascular function in hypertensive individuals. Additional studies are needed to identify the mechanisms by which PEMF affects endothelial function.

Association of combined genetic variations in SOD3, GPX3, PON1, and GSTT1 with hypertension and severity of coronary artery disease

Oxidative stress plays a critical role in the pathophysiology of hypertension (HT) and the progression of atherosclerotic coronary artery disease (CAD). Genetic variations in superoxide dismutase (SOD), glutathione peroxidase 3 (GPX3), paraoxonase 1 (PON1) and glutathione S-transferase theta 1 (GSTT1) may modulate their gene functions, affecting protein functions. These changes could have an impact on the pathogenesis of HT and progression of CAD. The present study investigated the associations of individual and combined antioxidant-related gene polymorphisms with the incidence of HT and severity of CAD. Two study populations were enrolled. The HT-associated study comprised 735 control and 735 hypertensive subjects (mean age 59.3 ± 9.0 years), matched for age and sex. The CAD study, hospital-based subjects (mean age 62.1 ± 9.5 years), included 279 CAD patients and 165 non-CAD subjects. Gene polymorphisms were identified in genomic DNA using polymerase chain reaction (PCR)-based technique. Genetic variations were assessed for their associations with HT and severity of CAD. Antioxidant gene variants, SOD3 rs2536512-GG, GPX3 rs3828599-GG, PON1 rs705379-TT, and GSTT1^{-/- and +/-}, were independently associated with the incidence of HT. A combination of four HT-associated genotypes, as a genetic risk score (GRS), revealed an association of GRS 5 and GRS ≥ 6 with increased susceptibility to HT and CAD, and further with multivessel coronary atherosclerosis (multivessel CAD) compared with GRS 0-2 [respective ORs(95% CI) for GRS ≥ 6 = 2.37 (1.46-3.85), 3.26 (1.29-8.25), and 4.36 (1.36-14.0)]. Combined polymorphisms in these four antioxidant-related genes were associated with the incidences of HT and CAD, and with the severity of coronary atherosclerosis.

Aging women and their endothelium: probing the relative role of estrogen on vasodilator function

Despite significant decreases in cardiovascular disease (CVD) mortality in the past three decades, it still remains the leading cause of death in women. Following menopause and the accompanying loss of estrogen, women experience a unique, accelerated rise in CVD risk factors. Dysfunction of the endothelium represents an important antecedent to CVD development, with rapid declines in endothelial vasodilator function reportedly taking place across the menopause transition. Importantly, the decline in endothelial function is independent of chronological age and is associated with estrogen deficiency. Estrogen-mediated effects, including increasing nitric oxide bioavailability and attenuating oxidative stress and inflammation, contribute to preserving endothelial health. This review will discuss studies that have probed the role of estrogen on endothelial vasodilator function in women at discrete stages of the menopause transition and the effects of estradiol supplementation in postmenopausal women. Estrogen receptor signaling is also an important aspect of endothelial function in women, and studies suggest that expression is reduced with both acute and prolonged estrogen deficiency. Changes in regulatory mechanisms of estrogen receptor-α expression as well as sensitivity to estrogen may underlie the differential effects of estrogen therapy in early (≤5 yr past final menstrual period) and late postmenopausal women (>5 yr past final menstrual period). Lastly, this review presents potential therapeutic targets that include increasing l-arginine bioavailability and estrogen receptor activation to prevent endothelial dysfunction in postmenopausal women as a strategy for decreasing CVD mortality in this high-risk population.

Genetic Association of Albuminuria with Cardiometabolic Disease and Blood Pressure

Excretion of albumin in urine, or albuminuria, is associated with the development of multiple cardiovascular and metabolic diseases. However, whether pathways leading to albuminuria are causal for cardiometabolic diseases is unclear. We addressed this question using a Mendelian randomization framework in the UK Biobank, a large population-based cohort. We first performed a genome-wide association study for albuminuria in 382,500 individuals and identified 32 new albuminuria loci. We constructed albuminuria genetic risk scores and tested for association with cardiometabolic diseases. Genetically elevated albuminuria was strongly associated with increased risk of hypertension (1.38 OR; 95% CI, 1.27-1.50 per 1 SD predicted increase in albuminuria, p = 7.01 × 10-14). We then examined bidirectional associations of albuminuria with blood pressure which suggested that genetically elevated albuminuria led to higher blood pressure (2.16 mmHg systolic blood pressure; 95% CI, 1.51-2.82 per 1 SD predicted increase in albuminuria, p = 1.22 × 10-10) and that genetically elevated blood pressure led to more albuminuria (0.005 SD; 95% CI 0.004-0.006 per 1 mmHg predicted increase in systolic blood pressure, p = 2.45 × 10-13). These results support the existence of a feed-forward loop between albuminuria and blood pressure and imply that albuminuria could increase risk of cardiovascular disease through blood pressure. Moreover, they suggest therapies that target albuminuria-increasing processes could have antihypertensive effects that are amplified through inhibition of this feed-forward loop.

Association of Impaired Vascular Endothelial Function with Increased Cardiovascular Risk in Asymptomatic Adults

Impaired vascular endothelial function has attracted attention as a prognostic indicator of cardiovascular prevention. The association between impaired endothelial function and cardiovascular risk in the asymptomatic population, however, has been poorly explored. We evaluated the association of brachial artery flow-mediated dilation (FMD) with Framingham-estimated 10-year cardiovascular disease (CVD) risk in subjects free of CVD, especially by cardiovascular risk profiles. In total, 680 adults aged 30-74 years were enrolled from Rongan and Rongshui of Liuzhou, Guangxi, China, through a cross-sectional study in 2015. In the full-adjusted model, the odds ratio for the estimated 10-year CVD risk comparing the low FMD (<6%) with the high FMD (≥10%) was 2.81 (95% confidence interval [CI]: 1.21, 6.53; P for trend = 0.03). In subgroup analyses, inverse associations between FMD and the estimated 10-year CVD risk were found in participants with specific characteristics. The adjusted odds ratios, comparing the 25th and the 75th percentiles of FMD, were 2.77 (95% CI: 1.54, 5.00) for aged ≥60 years, 1.77 (95% CI: 1.16, 2.70) for female, 1.59 (95% CI: 1.08, 2.35) for nonsmokers, 1.74 (95% CI: 1.02, 2.97) for hypertension, 1.59 (95% CI: 1.04, 2.44) for normal glycaemia, 2.03 (95% CI: 1.19, 3.48) for C-reactive protein ≥10 mg/L, and 1.85 (95% CI: 1.12, 3.06) for eGFR <106 mL/minute per 1.73 m². Therefore, impaired endothelial function is associated with increased CVD risk in asymptomatic adults. This inverse association is more likely to exist in subjects with higher cardiovascular risk.

Activation of PI3K/Akt pathway mediated by estrogen receptors accounts for estrone-induced vascular activation of cGMP signaling

Estrone (E1) produces remarkable vascular effects, including relaxation, modulation of proliferation, apoptosis and cell adhesion. This study investigated the role of estrogen receptors and endothelial signaling pathways in the vascular relaxation promoted by E1. Aortic rings from male Wistar rats (250-300 g) were contracted with phenylephrine and stimulated with graded concentrations of E1. The concentration-dependent relaxation induced by E1 was abolished after removal of the endothelium or incubation with the estrogen receptor antagonist ICI 182,780. G protein-coupled estrogen receptor antagonism did not alter the E1 effect. Pretreatment of endothelium-intact arteries with inhibitors of nitric oxide synthase, guanylyl cyclase, calmodulin (CaM) and PI3K reduced the E1-induced vasorelaxation. Incubation with inhibitors of the MEK/ERK1/2 or p38MAPK pathways did not alter the E1 vasorelaxation. Similarly, inhibition of cyclooxygenase or blockade of potassium channels did not change the E1 effect. Western blot analysis evidenced that E1 induces phosphorylation of eNOS, PI3K and Akt in rat aorta. Our data demonstrate that E1 induces aortic vascular relaxation through classic estrogen receptors activation on the endothelium. We also identify CaM and PI3K/Akt pathways as critical mediators of the NO-cGMP signaling activation by E1. These findings contribute to the notion that this estrogen regulates arterial function and represents another link, besides 17β-estradiol (E2), between postmenopause and vascular dysfunction.

Hypertension Across a Woman's Life Cycle

Hypertension accounts for 1 in 5 deaths among American women, posing a greater burden for women than men, and is among their most important risk factors for death and development of cardiovascular and other diseases. Hypertension affects women in all phases of life, with specific characteristics relating to risk factors and management for primary prevention of hypertension in teenage and young adult women; hypertension in pregnancy; hypertension during use of oral contraceptives and assisted reproductive technologies, lactation, menopause, or hormone replacement; hypertension in elderly women; and issues of race and ethnicity. All are detailed in this review, as is information relative to women in clinical trials of hypertension and medication issues. The overarching message is that effective treatment and control of hypertension improves cardiovascular outcomes. But many knowledge gaps persist, including the contribution of hypertensive disorders of pregnancy to cardiovascular disease risk, the role of hormone replacement, blood pressure targets for elderly women, and so on.

Evaluating Periodontal Treatment to Prevent Cardiovascular Disease: Challenges and Possible Solutions

PURPOSE OF REVIEW

Periodontal disease is correlated with cardiovascular disease (CVD) in observational studies, but a causal connection has not been established. The empirical evidence linking periodontal disease and CVD consists of a large body of observational and mechanistic studies, but a limited number of clinical trials evaluating the effects of periodontal treatment on surrogate CVD endpoints.

RECENT FINDINGS

No randomized controlled trial has been conducted to evaluate the effect of periodontal treatment on CVD risk. In this review, we have summarized these data, described possible biological mechanisms linking periodontal disease and CVD, discussed barriers to conducting a randomized controlled trial to evaluate this hypothesis, and provided an alternative analytical approach using causal inference methods to answer the question. The public health implications of addressing this question can be significant because periodontal disease is under-treated, and highly prevalent among adults at risk of CVD. Even a small beneficial effect of periodontal treatment on CVD risk can be important.

Circulating Total Bilirubin and Future Risk of Hypertension in the General Population: The Prevention of Renal and Vascular End-Stage Disease (PREVEND) Prospective Study and a Mendelian Randomization Approach

BACKGROUND

Circulating total bilirubin is known to be inversely and independently associated with future risk of cardiovascular disease. However, the relationship of circulating total bilirubin with incident hypertension is uncertain. We aimed to assess the association of total bilirubin with future hypertension risk and supplemented this with a Mendelian randomization approach to investigate any causal relevance to the association.

METHODS AND RESULTS

Plasma total bilirubin levels were measured at baseline in the PREVEND (Prevention of Renal and Vascular End-Stage Disease) prospective study of 3989 men and women without hypertension. Hazard ratios (95% confidence intervals) of total bilirubin with incident hypertension were assessed. New-onset hypertension was recorded in 1206 participants during a median follow-up of 10.7 years. Baseline total bilirubin was approximately log-linearly associated with hypertension risk. Age- and sex-adjusted hazard ratio for hypertension per 1-SD increase in loge total bilirubin was 0.86 (0.81-0.92; P<0.001), which was attenuated to 0.94 (0.88-0.99; P=0.040) after further adjustment for established risk factors and other potential confounders. The association was marginally significant on further adjustment for high-sensitivity C-reactive protein (0.94; 0.88-1.00; P=0.067). A genetic variant at the UGT1A1*28 locus consistently shown to be strongly associated with circulating bilirubin levels-rs6742078-was not significantly associated with blood pressure or hypertension (P>0.05 for all), arguing against a strong causal association of circulating bilirubin with blood pressure.

CONCLUSIONS

The weak and inverse association of circulating total bilirubin with future hypertension risk may be driven by biases such as unmeasured confounding and/or reverse causation. Further evaluation is warranted.

Selective impairment of blood pressure reduction by endothelial nitric oxide synthase dimer destabilization in mice

OBJECTIVES

Endothelial dysfunction and oxidative stress are associated with hypertension but whether endothelial superoxide may play a role in the early development of essential hypertension remains uncertain. We investigated whether endothelial nitric oxide synthase (eNOS)-derived endothelial oxidative stress is involved in the regulation of SBP.

METHODS

Wild-type eNOS [mice with endothelium-specific overexpression of bovine endothelial NO-synthase (eNOS-Tg)] or a novel dimer-destabilized eNOS-mutant harboring a partially disrupted zinc-finger [mice with endothelium-specific overexpression of destabilized bovine eNOS destabilized by replacement of Cys 101 to Ala (C101A-eNOS-Tg)] was introduced in C57BL/6 in an endothelial-specific manner. Mice were monitored for aortic endothelium-dependent relaxation, SBP, levels of superoxide and several posttranslational modifications indicating activity and/or increased vascular oxidative stress. Some groups of mice underwent voluntary exercise training for 4 weeks or treatment with the superoxide dismutase mimetic Tempol.

RESULTS

C101A-eNOS-Tg showed significantly increased superoxide generation, protein-tyrosine-nitration and eNOS-tyrosine-nitration, eNOS-S-glutathionylation, eNOS phosphorylation and AMP kinase-α phosphorylation at Thr172 in aorta, skeletal muscle, left ventricular myocardium and lung as compared with eNOS-Tg and wild-type controls. Exercise training increased phosphorylation of eNOS at Ser and AMP kinase-α in wild-type. These physiologic adaptations were absent in C101A-eNOS-Tg. Maximal aortic endothelium-dependent relaxation was similar in all strains. C101A-eNOS-Tg displayed normal SBP despite higher levels of eNOS, whereas eNOS-Tg showed significant hypotension. Tempol completely reversed the occurring protein modifications and significantly reduced SBP in C101A-eNOS-Tg but not in wild-type.

CONCLUSION

Oxidative stress generated by endothelial-specific expression of genetically destabilized C101A-eNOS selectively prevents SBP-reducing activity of vascular eNOS, while having no effect on aortic endothelium-dependent relaxation. These data suggest that oxidative stress in microvascular endothelium may play a role for the development of essential hypertension.

Endothelial dysfunction in human essential hypertension

Although the endothelium has a number of important functions, the term endothelial dysfunction is commonly used to describe impairment in its vasodilatory capacity. It is increasingly recognized that this is related to hypertension, although whether it predates essential hypertension or is a consequence of it is still unknown. In this review, we explore the mechanisms of endothelial dysfunction in essential hypertension, its prognostic significance and methods of pharmacological reversal.

Impaired Muscle Oxygenation and Elevated Exercise Blood Pressure in Hypertensive Patients: Links With Vascular Stiffness

This study examined in vivo (1) skeletal muscle oxygenation and microvascular function, at rest and during handgrip exercise, and (2) their association with macrovascular function and exercise blood pressure (BP), in newly diagnosed, never-treated patients with hypertension and normotensive individuals. Ninety-one individuals (51 hypertensives and 40 normotensives) underwent office and 24-hour ambulatory BP, arterial stiffness, and central aortic BP assessment, followed by a 5-minute arterial occlusion and a 3-minute submaximal handgrip exercise. Changes in muscle oxygenated and deoxygenated hemoglobin and tissue oxygen saturation were continuously monitored by near-infrared spectroscopy and beat-by-beat BP by Finapres. Hypertensives had higher (P<0.001) central aortic BP and pulse wave velocity versus normotensives and exhibited (1) a blunted tissue oxygen saturation response during occlusion, with slower (P=0.006) deoxygenation rate, suggesting reduced muscle oxidative capacity, and (2) a slower reoxygenation rate and blunted hyperemic response (P<0.05), showing reduced microvascular reactivity. Muscle oxygenation responses were correlated with aortic systolic and pulse pressure and augmentation index (P<0.05; age and body mass index (BMI) adjusted). When exercising at the same submaximal intensity, hypertensives required a significantly greater (P<0.001) increase in BP for achieving similar muscle oxygenation levels as normotensives. This response was correlated with the magnitude of microvascular hyperemia and aortic BP. In conclusion, nontreated patients with hypertension exhibit prominent reductions in in vivo indices of skeletal muscle oxidative capacity, suggestive of mitochondrial dysfunction, and blunted muscle microvascular reactivity. These dysfunctions were associated with higher aortic systolic BP and arterial stiffness. Dysregulations in muscle oxygen delivery/utilization and microvascular stiffness, in hypertensive patients, partially contribute to their exaggerated BP during exercise.

Urine Albumin/Creatinine Ratio Below 30 mg/g is a Predictor of Incident Hypertension and Cardiovascular Mortality

BACKGROUND

Microalbuminuria is associated with cardiovascular disease (CVD) mortality, but whether lower levels of urine albumin excretion similarly predict CVD is uncertain. We investigated associations between urine albumin:creatinine ratio (UACR) <30 mg/g, and incident hypertension, incident diabetes mellitus, and all-cause and CVD mortality, during a maximum of 11 years of follow-up.

METHODS AND RESULTS

Individuals (37 091) in a health screening program between 2002 and 2012 with baseline measurements of UACR were studied. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% CIs for incident hypertension, incident diabetes mellitus, and mortality outcomes (lowest UACR quartile as reference) at follow-up. For linear risk trends, the quartile rank was used as a continuous variable in regression models. Nine-hundred sixty-three cases of incident hypertension, 511 cases of incident diabetes mellitus, and 349 deaths occurred during follow-up. In the fully adjusted models, there was a significant HR for the association between UACR and incident hypertension (highest UACR quartile HR 1.95 [95% CI 1.51, 2.53], P-value for trend across UACR quartiles P<0.001). In contrast, the association between UACR and incident diabetes mellitus was not significant (highest UACR quartile, HR 1.15 [95% CI 0.79, 1.66], P-value for trend P=0.20). For CVD mortality, with increasing UACR quartiles, there was a significant increase in HR across quartiles, P=0.029, (for all-cause mortality, P=0.078).

CONCLUSIONS

Low levels of albuminuria, UACR below 30 mg/g, are associated with increased risk of incident hypertension and CVD mortality at follow-up, but are not associated with increased risk of incident diabetes mellitus.

The effects of urate lowering therapy on inflammation, endothelial function, and blood pressure (SURPHER) study design and rationale

BACKGROUND

The association between hyperuricemia and hypertension is controversial. Animal models, epidemiological data, and small clinical trials have favored a causative role for hyperuricemia in hypertension but more studies are necessary to elucidate putative mechanisms, population susceptibility, and potential for urate-lowering therapies (ULT) to decrease blood pressure (BP).

PURPOSE

To describe the background and design of the Serum Urate Reduction to Prevent Hypertension (SURPHER) study.

METHODS

SURPHER is a single center, double-blinded, crossover trial in which participants are randomly assigned to allopurinol (300mg) or placebo. Enrollment focused on adults 18-40years old with baseline systolic blood pressure≥120 and <160mmHg or diastolic blood pressure≥80 and <100mmHg, and serum urate ≥5.0mg/dL or ≥4.0mg/dL for men or women, respectively. SURPHER recruitment targets participants without chronic kidney disease (estimated glomerular filtration rate>60mL/min/1.73m2), and without prior diagnosis of gout or use of ULT to treat gout. The primary outcome is change from baseline in blood pressure assessed by 24hour ambulatory blood pressure monitoring and mechanistic outcomes include changes in endothelial function as measured by flow-mediated dilation, as well as C-reactive protein levels.

RESULTS

Since June 16, 2014 until present, SURPHER is recruiting participants in the city of Birmingham, Alabama.

LIMITATIONS

The study aims to enroll otherwise healthy young adults for a pharmacological intervention study with multiple study-related procedures. Challenges related to recruitment are anticipated and multiple strategies for increasing recruitment and retention are planned if necessary.

Early Postmenopausal Phase Is Associated With Reduced Prostacyclin-Induced Vasodilation That Is Reversed by Exercise Training: The Copenhagen Women Study

The postmenopausal phase is associated with an accelerated rate of rise in the prevalence of vascular dysfunction and hypertension; however, the mechanisms underlying these adverse vascular changes and whether exercise training can reverse the decline in vascular function remains unclear. We examined the function of the vascular prostanoid system in matched pre- and postmenopausal women before and after 12 weeks of exercise training. Twenty premenopausal and 16 early postmenopausal (3.1±0.5 [mean±SE] years after final menstrual period) women only separated by 4 (50±0 versus 54±1) years of age were included. Before the training period, the vasodilator response to intra-arterial infusion of either the prostacyclin analog epoprostenol or acetylcholine was lower (≈13%-41%; P<0.05) in the postmenopausal compared with the premenopausal women. Acetylcholine infusion induced a similar release of prostacyclin (6-keto prostaglandin F1a). To elucidate the role of vasoconstrictor prostanoids, acetylcholine infusion was combined with the cyclooxygenase inhibitor ketorolac and here the vascular response to acetylcholine was reduced to a similar extent in pre- and postmenopausal women. Exercise training increased (P<0.05) the vasodilator response to epoprostenol (≈100%-150%) and acetylcholine (≈100%-120%) infusion in the postmenopausal group. These findings demonstrate that the early postmenopausal phase is associated with a marked reduction in vascular function. Despite of a reduced sensitivity to prostacyclin, the overall balance between vasodilator and vasoconstrictor prostanoids does not seem to be altered. Exercise training can reverse the decline in vascular sensitivity to epoprostenol and acetylcholine, suggesting that beneficial vascular adaptations with exercise training are preserved in recent postmenopausal women.

Chitinase-3-like protein-1 (YKL-40) as a marker of endothelial dysfunction in obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) is a highly prevalent disorder affecting 15-24% of adults and triples the risk for hypertension independent of other risk factors. The exact mechanisms of endothelial dysfunction and variable susceptibility to hypertension in OSA are not entirely clear. No biomarker to date has been found to be associated with hypertension in OSA. Chitinase-3-like protein-1(YKL-40) is a circulating moiety with roles in injury, repair and angiogenesis that is dysregulated in atherosclerosis and correlates with increased cardiovascular morbidity and mortality. We sought to determine the role of YKL-40, as a biomarker, for endothelial dysfunction and hypertension in OSA.

METHODS

All subjects underwent polysomnography for suspected sleep-disordered breathing. Endothelial-dependent vasodilatory capacity was assessed using flow-mediated vasodilation (FMD). YKL-40 was measured in plasma using ELISA methodology.

RESULTS

We studied 95 subjects in four groups according to OSA and hypertension status. FMD was markedly impaired in hypertensive OSA (8.0% ± 0.5 vasodilation) compared to normotensive OSA (13.5% ± 0.5, P <0.0001) and non-OSA with hypertension (10.5% ± 0.8, P <0.01) and without hypertension (16.1% ± 1.0, P <0.0001). YKL-40 was significantly elevated only in hypertensive OSA compared to other three groups and had a negative correlation with FMD (r=-0.37, P = 0.0008). Receiver operating characteristic (ROC) curve analysis for YKL-40 in predicting endothelial dysfunction had a sensitivity of 71% and a specificity of 64% with AUC = 0.68, 0.57 to 0.80, P = 0.004.

CONCLUSIONS

Elevated circulating levels of YKL-40 are observed in only hypertensive OSA and have a significant negative correlation with endothelial function. This specificity suggests YKL-40 could be a potential biomarker for endothelial dysfunction in OSA.

Review: The role of noninvasive hemodynamic monitoring in the evaluation and treatment of hypertension

Advances in the understanding of the mechanisms accounting for the elevation of arterial pressure in essential hypertension suggest that there is value in assessing the relative contribution of hemodynamic factors in tailoring specific therapies to control arterial pressure. The non-invasive method of impedance cardiography (ICG) to measure hemodynamic abnormalities in hypertensive patients has emerged as a valuable adjuvant in the decision-making process of selecting antihypertensive agents. The technique is both accurate and reproducible in delineating the hemodynamic mechanisms of hypertension, comparing age-and gender-related changes in hemodynamics, detecting the presence of left ventricular dysfunction, and demonstrating clinically significant improvement in blood pressure control using ICG-guided therapy.

Cardiovascular Safety in Drug Development

As drug development becomes a long and demanding process, it might also become a barrier to medical progress. Drug safety concerns are responsible for many of the resources consumed in launching a new drug. Despite the money and time expended on it, a significant number of drugs are withdrawn years or decades after being in the market. Cardiovascular toxicity is one of the major reasons for those late withdrawals, meaning that many patients are exposed to unexpected serious cardiovascular risks. It seems that current methods to assess cardiovascular safety are imperfect, so new approaches to avoid the exposure to those undesirable effects are quite necessary. Endothelial dysfunction is the earliest detectable pathophysiological abnormality, which leads to the development of atherosclerosis, and it is also an independent predictor for major cardiovascular events. Endothelial toxicity might be the culprit of the cardiovascular adverse effects observed with a significant number of drugs. In this article, we suggest the regular inclusion of the best validated and less invasive endothelial function tests in the clinical phases of drug development in order to facilitate the development of drugs with safer cardiovascular profiles.