Beneficial Effects of Valsartan in Asymptomatic Individuals With Vascular or Cardiac Abnormalities

Effect of low-dose terazosin on arterial stiffness improvement: A pilot study

Arterial stiffness, a prominent hallmark of ageing arteries, is a predictor of all-cause mortality. Strategies for promoting healthy vascular ageing are encouraged. Here we conducted a pilot study to evaluate the potential effects of low-dose Terazosin on arterial stiffness. We enrolled patients aged over 40 with elevated arterial stiffness, defined as a brachial-ankle pulse wave velocity (baPWV) ≥1400 cm/s, who were administered Terazosin (0.5 and 1.0 mg/day) from December 2020 to June 2023. Treatment responses were assessed every 3 months. Linear regression analysis was used to characterise the improvement. We matched cases who took Terazosin for 1 year with Terazosin-free controls using propensity score matching (PSM). Our findings demonstrate that Terazosin administration significantly affected arterial stiffness. (1) Arterial stiffness significantly improved (at least a 5% reduction in baPWV) in 50.0% of patients at 3 months, 48.6% at 6 months, 59.3% at 9 months, and 54.4% at 12 months, respectively. (2) Those with higher baseline baPWV and hypertension exhibited a significantly reduced risk of non-response. (3) Terazosin was associated with a reduction of baPWV at 1-year follow-up (linear regression: β = -165.16, p < 0.001). This pilot study offers valuable insights into the potential significance of Terazosin in improving arterial stiffness and paves the way for future randomised clinical trials in combating vascular ageing.

Cardiovascular Disease Progression: A Target for Therapy?

Clinical research aimed at preventing cardiovascular disease has focused on the effect of interventions to reduce risk factors on the incidence of future morbid events. Disease progression, which likely serves as a necessary prerequisite for morbid events, has not served as a target for therapy. The Rasmussen Center at the University of Minnesota has, for the past 18 years, been performing a noninvasive cardiovascular evaluation in individuals with no history of cardiovascular disease. The studies, performed in 1 hour in one room, provide a comprehensive noninvasive assessment of the severity of functional and structural abnormalities in the small arteries, the large arteries and the left ventricle, the target organs for most cardiovascular morbid events. Preliminary follow-up data have revealed a striking relationship between the Disease Score, which represents the sum of the abnormal tests, and the risk of future morbid events. In order to develop strategies to prolong cardiovascular disease-free life expectancy, studies in early stages of disease aimed at slowing disease progression should be encouraged.

Echocardiographic indices of age- and gender-dependent cardiac remodeling over the adult lifespan in Irish Wolfhounds

INTRODUCTION

Characterizing age- and gender-dependent cardiac remodeling over the adult lifespan in Irish Wolfhounds (IWs) by echocardiography. In people, a life-long cardiac remodeling process has been demonstrated.

ANIMALS, MATERIALS, METHODS

Irish Wolfhounds (56 males, 90 females) with no indication of cardiac disease at final assessment (>7.0 years old). For each dog, four transthoracic echocardiographic studies were analyzed. Left ventricular (LV) systolic and diastolic internal dimensions (LVIDs, LVIDd), LV fractional shortening (FS) and ejection fraction (EF), LV free wall and interventricular septal thickness, right ventricular diastolic dimension, and left atrial (LA) and right atrial systolic diameters were compared at time points in the following age categories (years): 1.0-2.5; 3.0-4.0; 4.5-6.0; and 7.0-10.5 and related to age, body weight, and heart rate.

RESULTS

Over the adult life course, males had statistically significant increases in LV internal dimensions, atrial diameters, and decreases of FS and EF. From youngest to oldest age of examination means ± standard deviations were as follows: LVIDs, 32.7 ± 2.9 vs. 36.5 ± 2.9 mm; LVIDd, 49.6 ± 4.7 vs. 53.4 ± 3.8 mm; right atrial diameter, 36.8 ± 3.3 vs. 42.6 ± 3.3 mm; LA, 49.0 ± 3.6 vs. 55.0 ± 3.7 mm; and FS, 34.6 ± 3.7 vs. 31.0 ± 3.2. In females, LV internal dimensions did not change significantly, increases in right atrial (38.1 ± 3.7 mm to 40.0 ± 5.2 mm) and LA diameter (48.8 ± 3.6 to 52.4 ± 4.3 mm) were attenuated, as were decreases of FS (33.4 ± 3.7 to 31.5 ± 4.4, p = 0.02). LV wall thicknesses did not significantly change in both genders.

DISCUSSION AND CONCLUSIONS

Over the adult life course, echocardiography demonstrated increasing LV dimensions in male IWs only. In both genders, FS and EF decreased, and atrial diameters increased. Females showed an attenuated remodeling process.

Inflammation Associates With Impaired Small Arterial Elasticity Early in HIV Disease

We estimated small arterial elasticity and used linear regression to evaluate its association with inflammatory biomarkers among antiretroviral therapy–naïve, HIV-positive patients with high CD4+ counts. After adjustment, high-sensitivity C-reactive protein and interleukin-6 were inversely associated with small arterial elasticity. These data suggest that systemic inflammation may contribute to vascular dysfunction even in very early HIV disease.

Early Antiretroviral Therapy at High CD4 Counts Does Not Improve Arterial Elasticity: A Substudy of the Strategic Timing of AntiRetroviral Treatment (START) Trial

Background.

Both human immunodeficiency virus (HIV) infection and antiretroviral therapy (ART) may increase cardiovascular disease (CVD) risk. Vascular function assessments can be used to study CVD pathogenesis. We compared the effect of immediate versus deferred ART initiation at CD4 counts >500 cells/mm³ on small arterial elasticity (SAE) and large artery elasticity (LAE).

Methods.

Radial artery blood pressure waveforms were recorded noninvasively. Small arterial elasticity and LAE were derived from analysis of the diastolic pulse waveform. Randomized treatment groups were compared with linear models at each visit and longitudinal mixed models.

Results.

Study visits involved 332 participants in 8 countries: mean (standard deviation [SD]) age 35 (10), 70% male, 66% nonwhite, 30% smokers, and median CD4 count 625 cells/mm³ and 10-year Framingham risk score for CVD 1.7%. Mean (SD) SAE and LAE values at baseline were 7.3 (2.9) mL/mmHg × 100 and 16.6 (4.1) mL/mmHg × 10, respectively. Median time on ART was 47 and 12 months in the immediate and deferred ART groups, respectively. The treatment groups did not demonstrate significant within-person changes in SAE or LAE during the follow-up period, and there was no difference in mean change from baseline between treatment groups. The lack of significant differences persisted after adjustment, when restricted to early or late changes, after censoring participants in deferred group who started ART, and among subgroups defined by CVD and HIV risk factors.

Conclusions.

Among a diverse global population of HIV-positive persons with high CD4 counts, these randomized data suggest that ART treatment does not have a substantial influence on vascular function among younger HIV-positive individuals with preserved immunity.

Vascular Disease in Young Indians (20-40 years): Role of Hypertension

Hypertension (HTN) being one of the important risk factors for cardiovascular disease (CVD) is a significant health concern, especially in India. With age, prevalence of HTN, especially systolic HTN increases. Special attention needs to be directed to HTN in young ages (20-40 years) due to lower awareness, need for early treatment and better control of HTN. HTN in the age group of 20-40 years needs critical reappraisal. Given the high prevalence of HTN in the general population in India, in this review we attempt to provide current evidence and expert opinion on epidemiology, aetiopathogenesis and treatment of HTN in young (20-40 years) Indians.

Screening for asymptomatic coronary heart disease in the young 'at risk' population: Who and how?

Deaths due to coronary heart disease (CHD) remain high worldwide, despite recent achievements. An effective screening strategy may improve outcomes further if implemented in a high or ‘at risk’ cohort. Asymptomatic CHD in the young maybe underappreciated and applying an effective screening strategy to a young cohort may lead to improved outcomes due to significant socioeconomic impact from the consequences of CHD in this sub-group. A positive family history of CHD, which is known to be associated with an increased risk of future myocardial events, could aid in identifying the ‘at risk’ young cohort.

Traditional cardiovascular risk scoring systems are in wide use but lack the sensitivity or specificity required to estimate risk in an individual. Rather their use is limited to predicting population attributable risk. Functional studies such as exercise stress tests are readily available and cost effective but do not have the required sensitivity required to suggest their use as part of a screening protocol. Coronary CT angiography has been demonstrated to have high sensitivity for the detection of CHD and therefore may be suitable for screening purposes but there are concerns regarding radiation exposure.

Here we review the evidence for the use of potential screening strategies and the suitability of using such strategies to estimate risk of CHD in a young ‘at risk’ population.

Prevention of cardiovascular disease

Meaningful prevention of cardiovascular disease (CVD) requires prolongation of life to age 90 or 100 free of morbid events. This requires early detection of the CVD phenotypes and effective treatment to slow their progression. We present a strategy for screening and evaluation of the population that should accomplish that goal with potential benefits on both cost and cardiovascular health. Studies to document the effectiveness of this strategy are urgently needed.

Exercise testing in hypertensive patients for assessing the cardiovascular protective potential of antihypertensive drugs

Exercise testing is an established noninvasive tool in cardiology used to diagnose and guide treatment in individuals with suspected or confirmed coronary artery disease. Owing to the wealth of information it provides, exercise testing is also being utilized to evaluate prehypertensive stages, characterize hypertension, assess tolerance to exercise and the efficacy of antihypertensive therapies, and predict target organ damage and cardiovascular risk. The literature on exercise tolerance tests is relatively limited since these studies are difficult to conduct although they represent a valuable test for evaluating the benefits of antihypertensive therapies beyond their blood-pressure-lowering efficacy at rest or during exercise. Such a setting can be immensely useful for the evaluation and for the differentiation of treatments, especially in patients with evident rises in systolic blood pressure and with concomitant diseases, who are at higher risk of stroke. Exercise-induced increase in systolic blood pressure from rest to peak exercise should therefore be used as the primary efficacy variable. There is growing evidence that central pressure is a better predictor for cardiovascular risk than peripheral blood pressure, since this variable takes into account the overall effect of vascular aging and increased arterial stiffness that age and other concomitant diseases may induce. It is also important to include central aortic blood pressure and biomarkers of hypertension and cardiac disease in the overall assessment.

Blood pressure and plasma renin activity responses to different strategies to inhibit the renin-angiotensin-aldosterone system during exercise

OBJECTIVE

The effect of two different strategies for renin-angiotensin-aldosterone system (RAAS) blockade; direct renin inhibition (DRI) versus angiotensin receptor blockade (ARB) on blood pressure (BP) and plasma renin activity (PRA) was compared during exercise.

METHODS

Hypertensive adults were randomised to aliskiren (300 mg once daily, n=33) or valsartan (320 mg once daily, n=35). BP and PRA were measured during treadmill exercise (Bruce protocol), at baseline, end of treatment (eight weeks), and after treatment withdrawal (48 hours after last dose).

RESULTS

After eight weeks treatment, Aliskiren inhibited PRA (>80%) at rest and during exercise, with inhibition remaining undiminished 48 hours after treatment withdrawal. In contrast, valsartan increased PRA at rest, and more-so during exercise (>400%). Angiotensin receptor blockade, as indicated by PRA increase, was reduced, 48 hours after valsartan treatment withdrawal, suggesting more sustained RAAS blockade with aliskiren. Despite divergent effects on PRA, similar exercise-induced changes in BP were seen. The primary outcome, the rise in systolic BP from rest to peak exercise (baseline to after treatment withdrawal) did not differ between treatments (p=0.25).

CONCLUSION

Measurement of PRA is a more sensitive index of RAAS blockade than the BP response during exercise. Furthermore, after treatment withdrawal, aliskiren provides more sustained RAAS inhibition than valsartan at rest and during exercise.

Stage B heart failure: rationale for screening

To adequately address the burden imposed by heart failure, a combined approach to prevention, early detection, and management is required. Failure to adequately consider the presymptomatic pool of subjects largely accounts for the continuing burden of incident cases of symptomatic heart failure. This article reviews the rationale for the early detection and management of stage B heart failure with specific reference to asymptomatic left ventricular systolic dysfunction as a potentially modifiable heart failure antecedent. Provided one can safely and reliably detect these individuals, a strong case can be made for screening given the evidence from treatment efficacy studies that clinicians can improve patient outcomes.

Arterial stiffness/elasticity in the contribution to progression of heart failure

Arterial stiffness/elasticity plays a major role in the pathogenesis of heart failure beyond arterial blood pressure. Arterial wave reflections are generated from the periphery of the vascular system, especially at the level of the small arteries. The pattern change of the arterial wave reflections can alter the ventricular-vascular coupling in a pathologic manner, leading to heart failure. Several noninvasive techniques are used to estimate arterial stiffness/elasticity. Small artery elasticity has important predictive value for the diagnosis of heart failure. The beneficial effect of some cardiovascular therapy on arterial stiffness/elasticity has potential to prevent or delay the progression of heart failure.

Is vascular stiffness a target for therapy?

BACKGROUND

Early cardiovascular disease starts in the endothelium leading to functional changes in the vasculature. These changes can be depicted by assessment of arterial stiffness or elasticity. There are several techniques to assess arterial stiffness. Increased arterial stiffness or decreased arterial elasticity has been associated with cardiovascular risk factors. There is now evidence that small artery elasticity is a strong predictor for arterial hypertension. Moreover arterial elasticity provides extra prognostic information beyond arterial blood pressure measurement. Arterial stiffness attenuation may reflect the true reduction of arterial wall damage.

RESULTS

ACE-inhibitors, angiotensin II receptor blockers, aldosterone antagonists and calcium antagonists have favorable effects in improving arterial elasticity, while beta-blockers have an inverse effect. Diuretics have not been evaluated. Lipid lowering therapy, some antidiabetic therapy have shown to reduce arterial stiffness. Inflammatory and infectious diseases have been associated with vascular inflammation and consequently increase in arterial stiffness. The effect of anti-inflammatory agents and antiretroviral therapy on arterial stiffness is under investigation.

CONCLUSIONS

Measurement of arterial stiffness will not only be helpful in the detection of early vascular disease but also as a tool in the selection and follow-up monitoring of therapeutic strategies aimed at preventing or delaying progression of vascular disease.

Evidence for aggressive blood pressure-lowering goals in patients with coronary artery disease

Lowering blood pressure (BP) reduces the risk of major cardiovascular mortality and morbidity. Current consensus targets for BP reduction are less than 140/90 mm Hg in uncomplicated hypertension and less than 130/80 mm Hg in those patients with diabetes, chronic kidney disease, and coronary artery disease or in those who are at high risk for developing coronary artery disease (defined as a Framingham risk score of > or = 10%). There is solid epidemiologic evidence for lower BP targets, supported by some clinical studies with surrogate end points. On the other hand, there are meager data from clinical trials using hard end points, and there is a concern that overly aggressive BP lowering, especially of diastolic BP, may impair coronary perfusion, particularly in patients with left ventricular hypertrophy and/or coronary artery disease. This review evaluates the evidence for the benefit of lower BP targets in hypertension management.

Comprehensive noninvasive arterial vascular evaluation

Noninvasive evaluation of the health of the vasculature is an increasingly important approach to identifying individuals at risk for cardiovascular morbid events. Vascular health assessment involves functional and structural examination of the large and small arteries. Endothelial dysfunction, which alters small artery function, is a key contributor to progressive structural vascular changes. Ultrasonography of conduit arteries and aortic pulse-wave velocity provide information limited to structural changes in large arteries. Comprehensive assessment of the large and small arteries is best carried out by pulse-contour analysis. This can provide insight into functional and structural abnormalities in the small as well as the large arteries, and may be useful in monitoring response to therapy.

Prehypertension and black-white contrasts in cardiovascular risk in young adults: Bogalusa Heart Study

OBJECTIVE

The aim of this study was to examine the association of prehypertension with measures of cardiovascular disease risk in a biracial (black-white) population of young adults.

METHODS

As part of the Bogalusa Heart Study, echocardiography and carotid ultrasonography were performed along with cardiovascular risk factor measurements in 1379 young adult participants (age range 20-44 years, average 36 years; 43% men, 70% white). Participants were categorized as normotensives (60%), prehypertensives (27%) and hypertensives (13%).

RESULTS

The prevalence of prehypertension was significantly higher among men than women (35 vs. 22%) and among blacks than whites (29 vs. 27%). Compared with normotensives, prehypertensives had a greater adverse cardiovascular risk factor profile. Male sex and BMI equally and significantly contributed to the prehypertension status in both whites [odds ratio (OR) and 95% confidence interval 2.66 (1.88-3.74) and 1.10 (1.07-1.14)] and blacks [OR: 2.56 (1.51-4.33) and 1.05 (1.01-1.09)]. Additionally, prehypertensives compared with normotensives had significantly higher left ventricular (LV) mass index, LV internal diameter, and carotid artery intima-media thickness.

CONCLUSION

The condition of prehypertension in young adults shows men>women and black women>white women, and participants with prehypertension already have adverse profiles of risk factors and indices of subclinical cardiovascular disease. A greater percentage of blacks at a relatively young age fall into the hypertensive category. These findings underscore the need for aggressive management of cardiovascular risk in youth at levels below those considered as hypertension.

Unconventional end points in cardiovascular clinical trials: should we be moving away from morbidity and mortality?

BACKGROUND

Mortality and irreversible or major morbid events are the end points conventionally chosen for cardiovascular clinical trials because they are considered to reflect the effects of intervention on the natural history of disease. Other end points are now being considered and implemented because of the recognized limitations associated with using mortality and morbidity as the sole measures of therapeutic efficacy.

METHODS AND RESULTS

This article reflects the discussion and recommendations regarding nontraditional end points for cardiovascular trials generated from a meeting of clinical trial experts convened to discuss this issue. Less common end points that have been used in cardiovascular clinical trials include composite clinical scores integrating measures of quality of life with mortality and morbidity or using the function of vital organs as end points. Appropriate measurement and applications of such end points is controversial.

CONCLUSIONS

More experience is needed in applying and analyzing results with these nontraditional end points to enable their optimal use in clinical trials in cardiology, but such approaches have the potential to redress many of the conceptual and actual deficiencies inherent in conventional measures of outcome.

Establishing a new option for target-organ protection: rationale for ARB plus ACE inhibitor combination therapy

Activation of the renin-angiotensin system (RAS) plays an important role in the promotion of cardiovascular disease and target-organ damage, mediated in part by hypertension. Combination therapy targeting RAS activation may reduce target-organ damage and provide superior blood pressure (BP) control; combining angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) represents one possible approach. In monotherapy studies, both ACE inhibitors and ARBs have demonstrated similar positive effects on BP and on RAS-related target-organ damage, including nephropathy and congestive heart failure. Studies of combination therapy, most of which involved addition of an ARB to existing ACE inhibitor therapy, have demonstrated benefits among patients with congestive heart failure and renal disease. However, variances in study design and populations, dosing and titration methods, and clinical end points, in addition to inherent differences between agents, limit the ability to reach clinically meaningful conclusions about the value of dual RAS inhibition. Trials designed to document such efficacy are currently underway.

Cardiovascular responses and neurotransmitter changes during blockade of angiotensin II receptors within the ventrolateral medulla

Angiotensin II (Ang II) receptors are located in different regions of the brain, particularly within the cardiovascular control centers in the brainstem. These Ang II receptors are divided into AT1 and AT2 subtypes. We investigated the role of AT1 receptor subtype within the rostral (RVLM) and caudal (CVLM) ventrolateral medulla on cardiovascular responses and glutamate/GABA neurotransmission during static exercise using microdialysis in anesthetized rats. Bilateral microdialysis of a selective AT1 receptor antagonist, ZD7155 (10 microM), for 30 min into the RVLM attenuated increases in mean arterial pressure (MAP) and heart rate (HR) during a static muscle contraction. Glutamate concentrations within the RVLM decreased while GABA levels increased simultaneously during the contraction period when compared to those before ZD7155. After 60 min of discontinuation of ZD7155, MAP, HR, glutamate, and GABA levels in response to another muscle contraction returned to baseline levels. Conversely, bilateral microdialysis of ZD7155 into the CVLM potentiated cardiovascular responses during a static muscle contraction; glutamate concentrations increased while GABA levels within the CVLM decreased. All responses recovered after 60 min of discontinuation of ZD7155. These results demonstrate that medullary AT1 receptors play an important role in modulating both neurotransmission and cardiovascular function during static exercise.