Effects of Ramipril on Endothelial Function and the Expression of Proinflammatory Cytokines and Adhesion Molecules in Young Normotensive Subjects With Successfully Repaired Coarctation of Aorta

Protective Effect of Ramipril Against Oxidant and Proinflammatory Cytokine Damage Induced by Ischemia-Reperfusion in Ovarian Tissue in Rats

BACKGROUND

It is known that the increase in oxidants and proinflammatory cytokines, as well as the decrease in antioxidants, play a role in ovarian ischemia-reperfusion (I/R) injury. The antioxidant and anti-inflammatory properties of ramipril have been studied in various diseases. This study aims to investigate the effect of ramipril on I/R-induced ovarian damage in rats.

METHODS

Rats were divided into healthy (HG), sham (SG), ovary I/R (OIR), and ramipril + ovary I/R (ROIR) groups (n = 6/each group). One hour before the surgical procedures, ROIR was given 2 mg/kg ramipril. The lower abdomen of the SG, OIR, and ROIR was surgically opened. Right ovarian tissues of OIR and ROIR were subjected to 2 hours of ischemia and 6 hours of reperfusion. Then, all animals were euthanized, and their right ovaries were removed. Ovarian tissues were examined for oxidants (malondialdehyde), antioxidants (total glutathione, superoxide dismutase, and catalase), and proinflammatory cytokines (nuclear factor kappa-B, tumor necrosis factor-alpha, interleukin 1 beta, and interleukin-6) analysis was performed. Tissues were examined histopathologically.

RESULTS

The ovarian tissue of the OIR, which underwent the I/R procedure, exhibited a significant increase in oxidant and proinflammatory cytokine levels, along with a decrease in antioxidant levels (P < .001). Ramipril suppressed the I/R-induced increase in oxidants and pro-inflammatory cytokines and the decrease in antioxidants (P < .001). Ramipril also attenuated I/R-induced histopathological damage in ovarian tissue (P < .05).

CONCLUSION

Ramipril treatment may be a treatment strategy to protect ovarian tissue against oxidative and inflammatory damage of I/R.

Peripheral Microvascular Dysfunction in Children and Adults with Congenital Heart Disease: A Literature Review

Although there is a continually growing number of patients with congenital heart disease (CHD) due to medical and surgical advances, these patients still have a poorer prognosis compared to healthy individuals of similar age. In patients with heart failure, microvascular dysfunction (MVD) has recently emerged as a crucial modulator of disease initiation and progression. Because of the substantial pathophysiological overlap between CHD and heart failure induced by other etiologies, MVD could be important in the pathophysiology of CHD as well. MVD is believed to be a systemic disease and may be manifested in several vascular beds. This review will focus on what is currently known about MVD in the peripheral vasculature in CHD. Therefore, a search on the direct assessment of the vasodilatory capacity of the peripheral microcirculation in patients with CHD was conducted in the PubMed database. Since there is little data available and the reported studies are also very heterogeneous, peripheral MVD in CHD is not sufficiently understood to date. Its exact extent and pathophysiological relevance remain to be elucidated in further research.

Antihypertensive therapy of late arterial hypertension in children following successful coarctation correction

BACKGROUNG

Late arterial hypertension (AH) is the most significant complication of coarctation of the aorta (CoA). Only a few clinical studies described antihypertensive treatment of late AH following successful CoA repair. The primary objective of this multicentre cross-sectional study was to describe real-life antihypertensive therapy for late AH in children after hemodynamically successful CoA repair. The secondary objective was to describe antihypertensive therapy used within different haemodynamic phenotypes of AH.

METHOD

Blood pressure status, echocardiographic parameters and central blood pressure measurements were evaluated in 110 children aged 6-18 years following successful CoA repair with right arm blood pressure not exceeding leg blood pressure by at least 20 mmHg.

RESULTS

AH was found in 62 (56%) patients including 47 who were already treated and 15 with new diagnosed AH of whom seven presented with masked hypertension. Among treated patients, 10 presented with masked hypertension. The dominant phenotype of AH among patients with uncontrolled AH was isolated systolic hypertension (32 patients out of 37; 87.5%). AH was controlled in 53% of treated patients. Fifty-three percent of hypertensive patients had elevated central SBP and 39% had left ventricular hypertrophy with various left ventricle geometry patterns, 23% of them had both. β-adrenergic receptor blockers were the most used antihypertensive drugs followed by angiotensin-converting enzyme inhibitors with doses within the lower recommended range.

CONCLUSION

High prevalence of uncontrolled AH despite successful CoA repair and use of relatively low doses of antihypertensive drugs indicates the need of close blood pressure monitoring and more intensive and combined antihypertensive therapy.

Immunomodulatory Activity of the Most Commonly Used Antihypertensive Drugs-Angiotensin Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers

This review article is focused on antihypertensive drugs, namely angiotensin converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB), and their immunomodulatory properties reported in hypertensive patients as well as in experimental settings involving studies on animal models and cell lines. The immune regulatory action of ACEI and ARB is mainly connected with the inhibition of proinflammatory cytokine secretion, diminished expression of adhesion molecules, and normalization of CRP concentration in the blood plasma. The topic has significant importance in future medical practice in the therapy of patients with comorbidities with underlying chronic inflammatory responses. Thus, this additional effect of immune regulatory action of ACEI and ARB may also benefit the treatment of patients with metabolic syndrome, allergies, or autoimmune disorders.

Carotid atherosclerosis, changes in tissue remodeling and repair in patients with aortic coarctation

BACKGROUND AND AIMS

After aortic coarctation (CoA) repair, patients still suffer from cardiovascular complications. The aim of this study was to measure cardiovascular markers, intima-media thickness (IMT) and plaques in controls and patients with CoA.

METHODS

Sixty-four patients with CoA (66% male, mean age 48 ± 15 years) and controls (54% men, mean age 47 ± 16 years) underwent ultrasound of their arteries. A multiplex platform to analyze circulating blood levels biomarkers reflecting inflammation, tissue remodeling and repair was used.

RESULTS

In men following CoA repair, a significantly increased carotid bulb IMT was observed in comparison to the control group (1.05 [0.72-1.24] vs. 0.67 [0.59-0.95] mm; p = 0.003). Median common carotid artery (CCA) IMT was increased in men compared to controls (0.82 [0.61-0.97] mm vs. 0.58 [0.53-0.76] mm, p < 0.003) and in women compared to controls (0.83 [0.70-0.92] vs. 0.60 [0.55-0.69], p < 0.004). CoA demonstrated an independent association with IMT in both men and women. Men with CoA were also more likely to have a plaque in their carotid arteries (p = 0.010). In women with CoA, we observed significantly lower levels of stem cell factor (SCF, p = 0.004) while in men with CoA we observed significantly lower levels of matrix metalloproteinase-3 (MMP-3, p = 0.048), tumor necrosis factor receptor 1 (TNF-R1, p = 0.032), tumor necrosis factor receptor superfamily member 10B (TRAIL-R2, p = 0.019) and monocyte chemotactic protein 1 (MCP-1, p = 0.015).

CONCLUSIONS

This is the first study to show that despite successful CoA repair, patients have more carotid atherosclerosis than can be explained by changes in tissue remodeling and repair.

Aortic Coarctation

Aortic coarctation is a discrete narrowing of the thoracic aorta. In addition to anatomic obstruction, it can be considered an aortopathy with abnormal vascular properties characterized by stiffness and impaired relaxation. There are surgical and transcatheter techniques to address the obstruction but, despite relief, patients with aortic coarctation are at risk for hypertension, aortic complications, and abnormalities with left ventricular performance. This review covers the etiology, pathophysiology, diagnosis, and management of adults with aortic coarctation, with emphasis on multimodality imaging characteristics and lifelong surveillance to identify long-term complications.

Right Ventricular Strain Impairment in Adults and Adolescents with Repaired Aortic Coarctation

This study examines the function of the right ventricle (RV) using two-dimensional (2D) strain analysis after aortic coarctation (CoA) repair, as well as relationships between potential RV strain abnormalities and patient characteristics. The study examined 39 patients (61% male, age 32 ± 16 years) with CoA repair (33 post end-to-end anastomosis/sub-clavian flap, 6 post stenting/bypass/Teflon patch) and 42 controls. The structure and function of the left ventricle (LV), left atrium (LA), and RV were assessed using 2D standard echocardiography, tissue Doppler imaging, and 2D strain imaging. The characteristics examined included global RV longitudinal strain (RV-GLS), global LV longitudinal strain (LV-GLS), and LA longitudinal strain (LA strain). RV dysfunction was defined by RV-GLS lower than the mean minus 2 standard deviations (SDs) of the control group value. LV mass and mitral E/E_a were significantly higher in the CoA group. Septal E_a, LV-GLS, and LA strain were significantly lower in the CoA group. RV dysfunction (RV-GLS >  - 16%) was present in 10 (25.6%) CoA patients. RV-GLS was correlated with lateral E_a, LV-GLS, and LA strain (r =  - 0.35, p = 0.02; r =  - 0.54, p < 0.001; and r =  - 0.44, p = 0.005, respectively). Patients who had a stenting/bypass/Teflon patch as the first initial repair exhibited significantly lower RV-GLS. RV systolic strain abnormalities may occur in patients late after CoA repair. RV strain was correlated with parameters of LV dysfunction. Further large-scale studies are required to confirm these findings and to determine the mechanisms and prognostic implications of RV strain in such patients.

Pro-inflammatory Cytokines and Resistant Hypertension: Potential for Novel Treatments?

PURPOSE OF REVIEW

To gather data from studies evaluating the pro-inflammatory profile of individuals with resistant hypertension (RH), and bring a clinical update of new and potential complementary therapies to treat inflammation in RH.

RECENT FINDINGS

Increases in pro-inflammatory cytokines are related to elevated blood pressure and target organ damage in RH patients. Clinical and experimental studies have shown that some biological therapies, especially TNF-α inhibitors, regulated pro- and anti-inflammatory cytokines associated with improvements in clinical outcomes, although they are not yet reported in RH. New emerging therapies to treat inflammation in RH, although promising, are still hypotheses that have not been scientifically confirmed in clinical trials. For this reason, inflammation-target treatments, such as the TNF-α and IL-6 inhibitors, should be encouraged for testing as complementary therapies in RH in order to elucidate their potential benefits.

Subclinical Burden of Coronary Artery Calcium in Patients With Coarctation of the Aorta

Coronary computed tomography (CT) angiography is often performed in adults with coarctation of the aorta (CoA) for anatomic assessment. As this population ages, assessment of atherosclerotic cardiovascular disease burden is important. Thus, quantitative and qualitative coronary artery calcium (CAC) scores were assessed for patients with CoA ≥16 years of age, who were seen at a referral center. CoA patients had either coronary CT angiography or chest CT with interpretable coronary information performed for clinical indications (follow-up, preoperative, or for symptoms) from 2004 to 2017. Qualitative CAC was determined based on low-dose CT and lung cancer screening protocols. Quantitative CAC scores were compared with an age- and gender-matched control cohort of patients chosen from an emergency department database of patients who received coronary CT angiography for chest pain evaluation. Atherosclerotic cardiovascular disease 10-year predicted risk scores were calculated for both cohorts. Out of 131 patients with CoA (mean age 46.1 ± 15.3 years), 22 patients (17%) had multivessel atherosclerotic disease on qualitative assessment. In the subgroup of patients ≥40 years, those with CoA were more likely to have a quantitative CAC score ≥400 compared with those without CoA (14% vs 4%, p = 0.02). Median atherosclerotic cardiovascular disease risk score was 8% (interquartile range 2% to 12%) for CoA patients ≥40 years, and 5% (interquartile range 2% to 9%) for patient without CoA ≥40 years. In conclusion, we determined that CoA patients have subclinical atherosclerosis identifiable on CT in high rates when compared with patients without CoA. Atherosclerotic cardiovascular disease should be assessed in these patients for prevention and treatment.

Hypertension in Coarctation of the Aorta: Challenges in Diagnosis in Children

Evidence indicates that patients with coarctation of the aorta (COA) suffer from increased cardiovascular morbidity and mortality in later life despite successful repair of COA in childhood. Systolic arterial hypertension is common, presenting in up to one-third of patients, and is regarded as the main driver of premature cardiovascular events in this group of patients. In this review, we discuss the prevalence and pathophysiology of hypertension in children following successful COA repair with no residual arch obstruction. The challenges in accurate blood pressure assessment at this early phase are considered and non-invasive measures of central blood pressure are discussed. Although the pathways for investigations in adults are well defined, we highlight the need to address the issues of cardiovascular surveillance in children and describe techniques which can provide complementary information for cardiovascular assessment in this group of patients such that timely treatment can occur.

Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association

Life expectancy and quality of life for those born with congenital heart disease (CHD) have greatly improved over the past 3 decades. While representing a great advance for these patients, who have been able to move from childhood to successful adult lives in increasing numbers, this development has resulted in an epidemiological shift and a generation of patients who are at risk of developing chronic multisystem disease in adulthood. Noncardiac complications significantly contribute to the morbidity and mortality of adults with CHD. Reduced survival has been documented in patients with CHD with renal dysfunction, restrictive lung disease, anemia, and cirrhosis. Furthermore, as this population ages, atherosclerotic cardiovascular disease and its risk factors are becoming increasingly prevalent. Disorders of psychosocial and cognitive development are key factors affecting the quality of life of these individuals. It is incumbent on physicians who care for patients with CHD to be mindful of the effects that disease of organs other than the heart may have on the well-being of adults with CHD. Further research is needed to understand how these noncardiac complications may affect the long-term outcome in these patients and what modifiable factors can be targeted for preventive intervention.

Primary-care management of patients with coarctation of the aorta

Coarctation of the aorta is a congenital cardiac defect that results in a variable degree of obstruction to the left side of the heart. It can present with either acute shock in the neonatal period as a critical lesion or it can appear more insidiously with hypertension or other findings later in life. This article summarises aspects of outpatient care of patients with this lesion, including clinical history and physical examination, ancillary testing, and issues associated with long-term follow-up and management. Increasing knowledge and experience with this group of patients have allowed for a higher level of evidence-based care over the long term.

Effect of Atorvastatin and Pioglitazone on Plasma Levels of Adhesion Molecules in Non-Diabetic Patients With Hypertension or Stable Angina or Both

BACKGROUND

It was to study the effect of atorvastatin, pioglitazone and their combination on plasma levels of adhesion molecules in patients with hypertension or stable angina or both.

METHODS

It was an open-label, randomized parallel-group study. Forty-five atorvastatin-naive patients with hypertension or stable angina or both, were randomized to receive either atorvastatin (19 patients; 10 mg OD for 12 weeks) or pioglitazone (26 patients; 30 mg OD for 12 weeks). Another group of 30 patients who were already on atorvastatin were put on add-on pioglitazone therapy (pioglitazone (15 mg OD) + atorvastatin (10 mg OD) for 12 weeks). Plasma high-sensitivity C-reactive protein (hsCRP), soluble intercellular adhesion molecule-1 (sICAM-1) and soluble vascular cell adhesion molecule-1 (sVCAM-1) levels were measured at baseline and after 12 weeks of therapy.

RESULTS

Atorvastatin monotherapy significantly reduced plasma sICAM-1, but pioglitazone monotherapy did not produce any significant effect. Addition of pioglitazone in patients already receiving atorvastatin also significantly reduced plasma sICAM-1 level. However, there was no significant change in plasma hsCRP and sVCAM-1 levels in any of the groups after 12 weeks of therapy.

CONCLUSION

There is therapeutic advantage of combining pioglitazone and atorvastatin on plasma sICAM-1 levels.

Late hypertension in patients with repaired aortic coarctation

Coarctation of the aorta represents more than a simple obstructive lesion, as there is often evidence of hypertension and vascular dysfunction despite successful surgery at an early age. There are ample data showing that a large proportion of patients develop arterial hypertension, and this appears to increase with age. Our understanding of the pathogenesis of late hypertension is incomplete, and there is limited information on which drugs are most appropriate. Increased arterial rigidity is now well described in this patient group, although it is not known how this should influence therapy. The increase in afterload associated with this increased rigidity has been found to have an impact on the left ventricle at an early stage, and the interaction between the vascular dysfunction and the ventricle is an area of interest and active research. This article reviews some recent studies and highlights areas where research questions remain.

Increased arterial stiffness in resistant hypertension is associated with inflammatory biomarkers

BACKGROUND

Increased levels of inflammatory biomarkers such as interleukin-6 (IL-6), 10 (IL-10), 1β (IL-1β), tumor necrosis factor-α (TNF-α) high-sensitivity C-reactive protein (hs-CRP) are associated with arterial stiffness in hypertension. Indeed, resistant hypertension (RHTN) leads to unfavorable prognosis attributed to poor blood pressure (BP) control and target organ damage. This study evaluated the potential impact of inflammatory biomarkers on arterial stiffness in RHTN.

METHODS

In this cross-sectional study, 32 RHTN, 20 mild hypertensive (HTN) and 20 normotensive (NT) patients were subjected to office BP and arterial stiffness measurements assessed by pulse wave velocity (PWV). Inflammatory biomarkers were measured in plasma samples.

RESULTS

PWV was increased in RHTN compared with HTN and NT (p < 0.05). TNF-α levels were significantly higher in RHTN and HTN than NT patients. No differences in IL-6 levels were observed. RHTN patients had a higher frequency of subjects with increased levels of IL-10 and IL-1β compared with HTN and NT patients. Finally, IL-1β was independently associated with PWV (p < 0.001; R(2) = 0.5; β = 0.077).

CONCLUSION

RHTN subjects have higher levels of inflammatory cytokines (TNF-α, IL-1β and IL-10) as well as increased arterial stiffness, and detectable IL-1β levels are associated arterial stiffness. These findings suggest that inflammation plays a possible role in the pathophysiology of RHTN.

Rational use of antihypertensive medications in children

Hypertension has traditionally been regarded as an uncommon diagnosis in childhood and adolescence; however, there is compelling evidence to suggest that its prevalence is on the rise, particularly in those with obesity. As a result, pediatricians increasingly are asked to evaluate and manage patients with elevated blood pressure. An increased emphasis on conducting drug trials in children over the last 15 years has yielded important advances with respect to evidence-based data regarding the efficacy and safety of antihypertensive medications in children and adolescents. Unfortunately, data to definitively guide selection of initial agents is lacking. This article will present guidelines for the appropriate use of antihypertensive medications in the pediatric population, including the rational approach to selecting an appropriate medication with respect to pathophysiology, putative benefit, and likelihood for side effects.

Cytokines: monitors of disease severity for the clinic

BACKGROUND

Cytokines communicate between the cells of the immune system and its targets to maintain homeostasis after injury or pathogenic events. They are involved in almost any pathological situation imaginable.

OBJECTIVE

To verify the importance of cytokines as biomarkers in current preclinical (aetiopathogenic, development of new therapies) and clinical studies (diagnosis, disease severity, prognosis and response to therapy).

METHOD/RESULTS

A Medline search with the query 'cytokine' AND 'biomarker' AND a variable for a variety of biomedical fields, followed by deeper-level searches, demonstrated the immense popularity of cytokines as biomarkers in almost any biomedical field.

CONCLUSION

As cytokines are not disease-specific they do not serve as single diagnostic biomarkers. The strength of the cytokines resides in monitoring disease severity, prognosis and response to treatment.

Hypertension after repair of aortic coarctation--a systematic review

Hypertension continues to be a common and potentially serious problem in patients who have undergone anatomically successful repair of aortic coarctation.

OBJECTIVE

To assess the prevalence of hypertension after aortic coarctation repair, the factors that affect the prevalence and the hypotheses behind hypertension in this cohort of patients.

DESIGN

A systematic review of all articles reporting on systolic blood pressure (SBP) in patients who have undergone aortic coarctation repair.

DATA SOURCES

An electronic search of all English articles using PUBMED and The Cochrane Controlled Trials Register was performed. A manual search of references lists of relevant studies and a search of conference abstracts were also conducted.

INCLUSION CRITERIA

We restricted inclusion to articles published between 1987 and 2012 that reported on SBP in patients who have undergone aortic coarctation repair.

DATA EXTRACTION

Independent extraction of articles was performed by two authors using predefined data fields. One author then proceeded to extract information of interest from these articles.

RESULTS

The first search yielded 12,914 articles. After screening titles, abstracts and full text articles 26 articles were included in this review article. In papers reporting the prevalence of hypertension late after anatomically satisfactory coarctation repair, the median prevalence was 32.5% (range 25-68%).

CONCLUSION

Hypertension remains a common complication following aortic coarctation repair. Factors that influence the reported prevalence of hypertension include the age at the time of surgery, age at follow up, the method used to measure blood pressure and the type of intervention performed.

Altered hemodynamics, endothelial function, and protein expression occur with aortic coarctation and persist after repair

Coarctation of the aorta (CoA) is associated with substantial morbidity despite treatment. Mechanically induced structural and functional vascular changes are implicated; however, their relationship with smooth muscle (SM) phenotypic expression is not fully understood. Using a clinically representative rabbit model of CoA and correction, we quantified mechanical alterations from a 20-mmHg blood pressure (BP) gradient in the thoracic aorta and related the expression of key SM contractile and focal adhesion proteins with remodeling, relaxation, and stiffness. Systolic and mean BP were elevated for CoA rabbits compared with controls leading to remodeling, stiffening, an altered force response, and endothelial dysfunction both proximally and distally. The proximal changes persisted for corrected rabbits despite >12 wk of normal BP (~4 human years). Computational fluid dynamic simulations revealed reduced wall shear stress (WSS) proximally in CoA compared with control and corrected rabbits. Distally, WSS was markedly increased in CoA rabbits due to a stenotic velocity jet, which has persistent effects as WSS was significantly reduced in corrected rabbits. Immunohistochemistry revealed significantly increased nonmuscle myosin and reduced SM myosin heavy chain expression in the proximal arteries of CoA and corrected rabbits but no differences in SM α-actin, talin, or fibronectin. These findings indicate that CoA can cause alterations in the SM phenotype contributing to structural and functional changes in the proximal arteries that accompany the mechanical stimuli of elevated BP and altered WSS. Importantly, these changes are not reversed upon BP correction and may serve as markers of disease severity, which explains the persistent morbidity observed in CoA patients.

From hypertension to stroke: mechanisms and potential prevention strategies

Stroke is a major cause of disability and death worldwide. Prevention aimed at risk factors of stroke is the most effective strategy to curb the stroke pandemic. Hypertension is one of the most important risk factors for stroke. Despite the substantial evidence of the benefits of lowering blood pressure, conventional treatment does not normalize the burden of major cardiovascular events in patients with hypertension. Fully understanding the factors involved in the hypertension-induced stroke helps to develop new strategies for stroke prevention. Antihypertensive therapies selected should have positive blood pressure-independent effects on stroke risk. This review summarizes the factors involved in the hypertension-induced stroke, such as oxidative stress, inflammation, and arterial baroreflex dysfunction, and potential strategies for its prevention, therefore, provides clues for clinicians.

Secondary arterial hypertension: improvements in diagnosis and management in the last 10 years

The diagnosis and management of secondary hypertension has improved in the last decade as a result of the advances in the acknowledgment of some physiopathologic mechanisms and mainly by the development of new diagnostic methods. Furthermore, the treatment of some types of secondary hypertension may be solved by noninvasive techniques. Hypertension of renal and renovascular origin, coarctation of the aorta, primary hyperaldosteronism, and adrenal medullary tumors are analyzed. The main results of some relevant studies on diagnostic and treatment of those diseases are presented. Also, some experimental methods are mentioned, taking into account the possibility of clinical use in the near future.

Vascular effects of glycoprotein130 ligands--part II: biomarkers and therapeutic targets

Glycoprotein130 (gp130) ligands are defined by the use of the common receptor subunit gp130 and comprise interleukin (IL)-6, oncostatin M (OSM), IL-11, leukemia inhibitory factor (LIF), cardiotrophin-1 (CT-1), cardiotrophin-like cytokine (CLC), ciliary neurotrophic factor (CNTF), IL-27 and neuropoietin (NP). In part I of this review we addressed the pathophysiological functions of gp130 ligands with respect to the vascular wall. In part II of this review on the vascular effects of gp130 ligands we will discuss data about possible use of these molecules as biomarkers to predict development or progression of cardiovascular diseases. Furthermore, the possibility to modulate circulating levels of gp130 ligands or their tissue expression by specific antibodies, soluble gp130 protein, renin-angiotensin-aldosterone system (RASS) inhibitors, statins, agonists of peroxisome proliferator-activated receptors (PPAR), hormone replacement therapy, nonsteroidal anti-inflammatory drugs (NSAID) or lifestyle modulating strategies are presented. Recent knowledge about the application of recombinant cytokines from the gp130 cytokine family as therapeutic agents in obesity or atherosclerosis is also summarized. Thus the purpose of this review is to cover a possible usefulness of gp130 ligands as biomarkers and targets for therapy in cardiovascular pathologies.

Treatment recommendations to prevent myocardial ischemia and infarction in patients undergoing vascular surgery

During major vascular surgery (MVS), patients are at high risk for developing unrecognized myocardial infarction (MI) and myocardial ischemia. In reducing postoperative morbidity and mortality, preoperative cardiac risk stratification and adequate medical therapy play a pivotal role. Based on literature and current opinions, medical treatment should comprise at least a combination of beta-blockers, aspirin, and statins. beta-Blockers exert their beneficial effects predominantly through heart rate control, leading to reduced oxygen demand during surgery. A heart rate between 65 and 70 bpm should be achieved. Irrespective of their lipid-lowering effects, statins seem to improve postoperative cardiac outcome by stabilizing coronary artery plaques, thereby preventing atherosclerotic plaque rupture. Aspirin reduces platelet activation and vasoconstriction, thereby limiting ischemic events and reducing nonfatal MI by 34%. Adding clopidogrel to low-dose aspirin might be beneficial toward postoperative cardiac outcomes; however, the effect on the incidence of postoperative bleeding complications may be a problem for future studies to resolve. Whereas beta-blockers inhibit the effect of catecholamines, alpha(2)-agonists inhibit catecholamine release and may be used in the perioperative setting when beta-blockers are contraindicated. Despite the blood pressure-lowering effect and anti-inflammatory properties of angiotensin-converting enzyme inhibitors, the literature does not support their use in patients undergoing MVS. The possible use of calcium antagonists before MVS should be further evaluated in high-risk patients with contraindications to beta-blockers, such as asthma, conduction abnormalities, or a history of stroke. Although nitrates are widely used for treating angina pectoris, the beneficial effect of their use in patients undergoing MVS remains controversial. Therefore, nitrates are not routinely used in the perioperative setting. The current American College of Cardiology/American Heart Association guidelines do not recommend prophylactic coronary revascularization before noncardiac surgery in patients with stable coronary artery disease.

Hypertension and coarctation of the aorta: an inevitable consequence of developmental pathophysiology

Patients with coarctation of the aorta develop early onset hypertension in spite of early effective repair. This is associated with significant morbidity and is arguably the single most important outcome variable in this patient group. We discuss the potential pathophysiological mechanisms involved in the development of hypertension with clinical reference to monozygotic twins, and review potential strategies for therapy and prevention in this setting.

Left ventricular and ascending aortic function after stenting of native coarctation of aorta

Patients with surgically corrected aortic coarctation have increased proximal aortic stiffness that might contribute to the known worse cardiovascular outcomes. We examined the effect of stenting on the mid-term ascending aortic elastic properties and its relation to cardiac structure and function in adults with native coarctation of the aorta. A total of 20 consecutive patients (13 men, age at stenting 30 + or - 8 years) were prospectively studied before and 14 + or - 2 months after coarctation stenting. The aortic stiffness index was calculated using the ascending aortic diameters and right arm blood pressure values. The ventricular long-axis function was assessed using pulsed-wave tissue Doppler imaging at the septal site. The results were compared to those from 31 normal controls. Statistically significant improvement was found in aortic narrowing (catheter-derived gradient 32 + or - 11 vs 10 + or - 6 mm Hg), left ventricular mass index (132.8 + or - 50.1 vs 114.7 + or - 47.7 g/m(2)), long-axis function, and left atrial volume index (26.5 + or - 5.3 vs 23.7 + or - 5.6 mm(3)/m(2)). The patients continued to have a thicker left ventricle, reduced long-axis function, and larger left atrium after intervention than did the controls. They also had impaired proximal aortic function with respect to the controls that remained unchanged after stenting (aortic stiffness index 10.7 + or - 4.5 to 10.1 + or - 3.0). The poststenting aortic stiffness index correlated modestly with the left ventricular mass index and reduced long-axis velocity. In conclusion, aortic stenting resulted in partial mid-term improvement in cardiac structure and function in adults with coarctation of aorta but the ascending aortic elastic properties remained abnormal. Such a degree of impairment was related to residual left ventricular hypertrophy and dysfunction. Early identification of such patients and optimum management might avoid these irreversible ventriculoaortic disturbances and their known consequences.

Coarctation of the aorta: evaluation and management

PURPOSE OF REVIEW

Coarctation of the aorta is the discrete narrowing of the proximal descending aorta and is the sixth most common lesion in congenital heart disease. Repair of the coarctation can relieve the obstruction, but recurrent coarctation and future aneurysm formation can occur, and a heightened risk of vascular disease is present. This review focuses on advances in the management of native and previously treated coarctation and provides insights into future vascular risk.

RECENT FINDINGS

Coarctation of the aorta is associated with other left heart obstructive lesions, and advances in the genetic basis of these conditions have been made. Recurrent coarctation and aneurysm formation are common after surgical and endovascular repair of coarctation of the aorta. Endovascular treatment is an acceptable alternative to surgical repair of native and recurrent coarctation. Covered stents and stent grafts can be used to treat arch complications with a low risk of complications. In spite of repair of the obstruction, hypertension persists and appears to be multifactorial due to a variety of factors, including endothelial dysfunction, aortic stiffness, altered arch morphology and increased ventricular stiffness.

SUMMARY

People with previously repaired coarctation of the aorta require long-term surveillance for local complications with aortic imaging and surveillance and management of hypertension to prevent vascular disease.

Genetic polymorphism on type 2 receptor of angiotensin II, modifies cardiovascular risk and systemic inflammation in hypertensive males

BACKGROUND

Angiotensin type 2 receptor (AT2R), plays a crucial role in blood pressure regulation and atherogenesis. AT2R gene is located on chromosome X and the biological effect of polymorphism A1675G in this gene needs to be further specified. We examined the impact of A1675G on the risk and the severity of coronary artery disease (CAD), and the expression of proatherogenic inflammatory molecules in hypertensive patients.

METHODS

The study population consisted of 146 with CAD (102 with hypertension) and 266 age-matched individuals without CAD (114 with hypertension). The presence of A1675G polymorphism on AT2R gene was determined by PCR. Serum levels of C-reactive protein (CRP), fibrinogen, interleukin-6 (IL-6) and soluble vascular cell adhesion molecule-1 (sVCAM-1) were measured in all the participants.

RESULTS

The G allele was associated with decreased risk of CAD among hypertensives (odds ratio (OR) (95% confidence interval (CI))): 0.4 (0.2-0.9), P = 0.01) and less aggressive angiographic CAD (P < 0.001). The G allele was associated with lower IL-6 (median (25-75th percentile): 1.4 (0.6-3.8)), sVCAM-1 (621 (476-799)), CRP (1.2 (0.6-1.7)), and fibrinogen (369 (320-416)) vs. A allele (IL-6: 2.4 (1.1-4.5) P < 0.01, sVCAM-1: 702 (548-925) P < 0.05, CRP: 3.5 (2.0-6.1) P < 0.001, and fibrinogen: 407 (348-514) P < 0.01). The effect of A1675G on serum IL-6, sVCAM-1, and fibrinogen was driven by its effect among hypertensives (IL-6 3.1 (2.1-5.6 in A vs. 1.2 (0.3-3.4) in G P < 0.001, sVCAM-1: 890 (560-1000) in A vs. 556 (377-788) in G P < 0.01, and fibrinogen: 408 (354-510) in A vs. 369 (324-418) in G P < 0.001) whereas it had no effect among nonhypertensives.

CONCLUSIONS

Genetic polymorphism A1675G on AT2R gene affects cardiovascular risk and the severity of atherosclerosis by modifying systemic inflammation, especially in hypertensive males.

Essential hypertension: is there a role for inflammatory mechanisms?

Inflammation is a key feature in the initiation, progression, and clinical implications of cardiovascular disorders, including essential hypertension. Increasing evidence shows that activation of renin-angiotensin-aldosterone system and enhanced local production of angiotensin II have been implicated in the pathophysiology of inflammation. Besides being a potent vasoactive peptide, angiotensin II regulates the inflammatory process. Specifically, it increases vascular permeability, participates in the recruitment of inflammatory cells and their adhesion to the activated endothelium, and regulates cell growth and fibrosis. Reactive oxygen species are implicated at every stage in inflammation and activate multiple intracellular signaling molecules and transcription factors associated with inflammatory responses, such as nuclear factor-kappa B and activator protein-1. Other components of the renin-angiotensin-aldosterone system, including aldosterone and/or mineralocorticoid receptor, induce the production of reactive oxygen species and participate in vascular inflammation. Several studies suggest a role of endothelin-1 as an important mediator of chronic inflammation and there is an increasing interest in the relationship between endothelin-1 and reactive oxygen species. These data may have great impact on future therapeutic strategies.

The CD40/CD40 ligand system: linking inflammation with atherothrombosis

The role of CD40/CD40 ligand (CD40L) in atherothrombosis is now widely accepted. However, the exact mechanisms linking the CD40/CD40L system and the soluble form of CD40 ligand (sCD40L) with atherothrombosis are currently a topic of intensive research. CD40L and sCD40L belong to the tumor necrosis factor superfamily, and they are molecules with a dual prothrombotic and proinflammatory role. They are expressed in a variety of tissues such as the immune system (in both B and T cells), the vascular wall, and activated platelets. Soluble CD40L has multiple autocrine, paracrine, and endocrine actions, and it may trigger key mechanisms participating in atherothrombosis. CD40/CD40L may participate in the development of coronary atherosclerosis and the triggering of acute coronary syndromes, while sCD40L seems to have a prognostic role not only in subjects with advanced atherosclerosis but also in the general population. Although conventional cardiovascular medication such as antiplatelet therapy, statins, angiotensin-converting enzyme inhibitors, and many others have been shown to reduce both sCD40L and cardiovascular risk, it is still unclear whether specific treatments targeting the CD40/CD40L system will prove to be beneficial against atherothrombosis in the near future.

A controlled comparison of brachial artery flow mediated dilation (FMD) and digital pulse amplitude tonometry (PAT) in the assessment of endothelial function in systemic lupus erythematosus

The utility of flow mediated dilation (FMD) a measure of endothelial function is limited by operator dependence. Pulse amplitude tonometry (PAT) is a novel, less operator-dependent technique to assess endothelial function. This study compares PAT to FMD in SLE and controls. Thirty women with SLE and 31 controls were enrolled. Medications, cardiovascular disease and risk factors, SLE activity (SLAM-R) and damage (SLICC-DI) were recorded. FMD and PAT were performed simultaneously. Endothelium-independent function was assessed with nitroglycerin. Average age was 48.3 +/- 10.1 years, SLE duration 16.2 years, SLAM-R 8.3 and SLICC-DI 1.0. Framingham Risk Scores were < or =2% in most subjects. There were no differences between SLE cases and controls in FMD, PAT or response to nitroglycerin. This study found no association between FMD and PAT in SLE or controls. In the 17 SLE cases with a history of Raynaud's, correlation between FMD and PAT was 0.50 (P = 0.04). There was no difference in endothelial function assessed by FMD or PAT in SLE cases versus controls. FMD did not correlate with PAT except in SLE cases with a history of Raynaud's. Correlation between FMD and PAT may be stronger in populations with greater variation in endothelial function and more cardiovascular risk factors.