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Azzam O, Nejad SH, Carnagarin R, Nolde JM, Galindo-Kiuchi M, Schlaich MP. Taming resistant hypertension: The promise of novel pharmacologic approaches and renal denervation. Br J Pharmacol 2024; 181:319-339. [PMID: 37715452 DOI: 10.1111/bph.16247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 08/11/2023] [Accepted: 09/02/2023] [Indexed: 09/17/2023] Open
Abstract
Resistant hypertension is associated with an exceedingly high cardiovascular risk and there remains an unmet therapeutic need driven by pathophysiologic pathways unaddressed by guideline-recommended therapy. While spironolactone is widely considered as the preferable fourth-line drug, its broad application is limited by its side effect profile, especially off-target steroid receptor-mediated effects and hyperkalaemia in at-risk subpopulations. Recent landmark trials have reported promising safety and efficacy results for a number of novel compounds targeting relevant pathophysiologic pathways that remain unopposed by contemporary drugs. These include the dual endothelin receptor antagonist, aprocitentan, the aldosterone synthase inhibitor, baxdrostat and the nonsteroidal mineralocorticoid receptor antagonist finerenone. Furthermore, the evidence base for consideration of catheter-based renal denervation as a safe and effective adjunct therapeutic approach across the clinical spectrum of hypertension has been further substantiated. This review will summarise the recently published evidence on novel antihypertensive drugs and renal denervation in the context of resistant hypertension.
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Affiliation(s)
- Omar Azzam
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Sayeh Heidari Nejad
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Janis M Nolde
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Marcio Galindo-Kiuchi
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School-Royal Perth Hospital Unit, Royal Perth Hospital Medical Research Foundation, The University of Western Australia, Perth, Western Australia, Australia
- Department of Nephrology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
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2
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Kartchner D, McCoy K, Dubey J, Zhang D, Zheng K, Umrani R, Kim JJ, Mitchell CS. Literature-Based Discovery to Elucidate the Biological Links between Resistant Hypertension and COVID-19. BIOLOGY 2023; 12:1269. [PMID: 37759668 PMCID: PMC10526006 DOI: 10.3390/biology12091269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/11/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023]
Abstract
Multiple studies have reported new or exacerbated persistent or resistant hypertension in patients previously infected with COVID-19. We used literature-based discovery to identify and prioritize multi-scalar explanatory biology that relates resistant hypertension to COVID-19. Cross-domain text mining of 33+ million PubMed articles within a comprehensive knowledge graph was performed using SemNet 2.0. Unsupervised rank aggregation determined which concepts were most relevant utilizing the normalized HeteSim score. A series of simulations identified concepts directly related to COVID-19 and resistant hypertension or connected via one of three renin-angiotensin-aldosterone system hub nodes (mineralocorticoid receptor, epithelial sodium channel, angiotensin I receptor). The top-ranking concepts relating COVID-19 to resistant hypertension included: cGMP-dependent protein kinase II, MAP3K1, haspin, ral guanine nucleotide exchange factor, N-(3-Oxododecanoyl)-L-homoserine lactone, aspartic endopeptidases, metabotropic glutamate receptors, choline-phosphate cytidylyltransferase, protein tyrosine phosphatase, tat genes, MAP3K10, uridine kinase, dicer enzyme, CMD1B, USP17L2, FLNA, exportin 5, somatotropin releasing hormone, beta-melanocyte stimulating hormone, pegylated leptin, beta-lipoprotein, corticotropin, growth hormone-releasing peptide 2, pro-opiomelanocortin, alpha-melanocyte stimulating hormone, prolactin, thyroid hormone, poly-beta-hydroxybutyrate depolymerase, CR 1392, BCR-ABL fusion gene, high density lipoprotein sphingomyelin, pregnancy-associated murine protein 1, recQ4 helicase, immunoglobulin heavy chain variable domain, aglycotransferrin, host cell factor C1, ATP6V0D1, imipramine demethylase, TRIM40, H3C2 gene, COL1A1+COL1A2 gene, QARS gene, VPS54, TPM2, MPST, EXOSC2, ribosomal protein S10, TAP-144, gonadotropins, human gonadotropin releasing hormone 1, beta-lipotropin, octreotide, salmon calcitonin, des-n-octanoyl ghrelin, liraglutide, gastrins. Concepts were mapped to six physiological themes: altered endocrine function, 23.1%; inflammation or cytokine storm, 21.3%; lipid metabolism and atherosclerosis, 17.6%; sympathetic input to blood pressure regulation, 16.7%; altered entry of COVID-19 virus, 14.8%; and unknown, 6.5%.
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Affiliation(s)
- David Kartchner
- Laboratory for Pathology Dynamics, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
| | - Kevin McCoy
- Laboratory for Pathology Dynamics, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
| | - Janhvi Dubey
- Laboratory for Pathology Dynamics, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
| | - Dongyu Zhang
- Laboratory for Pathology Dynamics, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
| | - Kevin Zheng
- Laboratory for Pathology Dynamics, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
| | - Rushda Umrani
- Laboratory for Pathology Dynamics, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
- College of Computing, Georgia Institute of Technology, Atlanta, GA 30332, USA
| | - James J. Kim
- Laboratory for Pathology Dynamics, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
| | - Cassie S. Mitchell
- Laboratory for Pathology Dynamics, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332, USA
- Center for Machine Learning at Georgia Tech, Georgia Institute of Technology, Atlanta, GA 30332, USA
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3
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Loh HH, Lim QH, Chai CS, Goh SL, Lim LL, Yee A, Sukor N. Influence and implications of the renin-angiotensin-aldosterone system in obstructive sleep apnea: An updated systematic review and meta-analysis. J Sleep Res 2023; 32:e13726. [PMID: 36104933 PMCID: PMC10078316 DOI: 10.1111/jsr.13726] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/30/2022] [Accepted: 08/22/2022] [Indexed: 02/03/2023]
Abstract
Obstructive sleep apnea is a chronic, sleep-related breathing disorder, which is an independent risk factor for cardiovascular disease. The renin-angiotensin-aldosterone system regulates salt and water homeostasis, blood pressure, and cardiovascular remodelling. Elevated aldosterone levels are associated with excess morbidity and mortality. We aimed to analyse the influence and implications of renin-angiotensin-aldosterone system derangement in individuals with and without obstructive sleep apnea. We pooled data from 20 relevant studies involving 2828 participants (1554 with obstructive sleep apnea, 1274 without obstructive sleep apnea). The study outcomes were the levels of renin-angiotensin-aldosterone system hormones, blood pressure and heart rate. Patients with obstructive sleep apnea had higher levels of plasma renin activity (pooled wmd+ 0.25 [95% confidence interval 0.04-0.46], p = 0.0219), plasma aldosterone (pooled wmd+ 30.79 [95% confidence interval 1.05-60.53], p = 0.0424), angiotensin II (pooled wmd+ 5.19 [95% confidence interval 3.11-7.27], p < 0.001), systolic (pooled wmd+ 5.87 [95% confidence interval 1.42-10.32], p = 0.0098) and diastolic (pooled wmd+ 3.40 [95% confidence interval 0.86-5.94], p = 0.0086) blood pressure, and heart rate (pooled wmd+ 3.83 [95% confidence interval 1.57-6.01], p = 0.0009) compared with those without obstructive sleep apnea. The elevation remained significant (except for renin levels) when studies involving patients with resistant hypertension were removed. Sub-group analysis demonstrated that levels of angiotensin II were significantly higher only among the Asian population with obstructive sleep apnea compared with those without obstructive sleep apnea. Body mass index accounted for less than 10% of the between-study variance in elevation of the renin-angiotensin-aldosterone system parameters. Patients with obstructive sleep apnea have higher levels of renin-angiotensin-aldosterone system hormones, blood pressure and heart rate compared with those without obstructive sleep apnea, which remains significant even among patients without resistant hypertension.
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Affiliation(s)
- Huai Heng Loh
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia.,Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Malaysia
| | - Quan Hziung Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chee Shee Chai
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Malaysia Sarawak, Kota Samarahan, Malaysia
| | - Siew Li Goh
- Sports and Exercise Medicine Research and Education Group, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Lee-Ling Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Anne Yee
- Department of Psychological Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Norlela Sukor
- Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia
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Barroso WKS, Rodrigues CIS, Bortolotto LA, Mota-Gomes MA, Brandão AA, Feitosa ADDM, Machado CA, Poli-de-Figueiredo CE, Amodeo C, Mion Júnior D, Barbosa ECD, Nobre F, Guimarães ICB, Vilela-Martin JF, Yugar-Toledo JC, Magalhães MEC, Neves MFT, Jardim PCBV, Miranda RD, Póvoa RMDS, Fuchs SC, Alessi A, Lucena AJGD, Avezum A, Sousa ALL, Pio-Abreu A, Sposito AC, Pierin AMG, Paiva AMGD, Spinelli ACDS, Nogueira ADR, Dinamarco N, Eibel B, Forjaz CLDM, Zanini CRDO, Souza CBD, Souza DDSMD, Nilson EAF, Costa EFDA, Freitas EVD, Duarte EDR, Muxfeldt ES, Lima Júnior E, Campana EMG, Cesarino EJ, Marques F, Argenta F, Consolim-Colombo FM, Baptista FS, Almeida FAD, Borelli FADO, Fuchs FD, Plavnik FL, Salles GF, Feitosa GS, Silva GVD, Guerra GM, Moreno Júnior H, Finimundi HC, Back IDC, Oliveira Filho JBD, Gemelli JR, Mill JG, Ribeiro JM, Lotaif LAD, Costa LSD, Magalhães LBNC, Drager LF, Martin LC, Scala LCN, Almeida MQ, Gowdak MMG, Klein MRST, Malachias MVB, Kuschnir MCC, Pinheiro ME, Borba MHED, Moreira Filho O, Passarelli Júnior O, Coelho OR, Vitorino PVDO, Ribeiro Junior RM, Esporcatte R, Franco R, Pedrosa R, Mulinari RA, Paula RBD, Okawa RTP, Rosa RF, Amaral SLD, Ferreira-Filho SR, Kaiser SE, Jardim TDSV, Guimarães V, Koch VH, Oigman W, Nadruz W. Brazilian Guidelines of Hypertension - 2020. Arq Bras Cardiol 2021; 116:516-658. [PMID: 33909761 PMCID: PMC9949730 DOI: 10.36660/abc.20201238] [Citation(s) in RCA: 270] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Weimar Kunz Sebba Barroso
- Universidade Federal de Goiás , Goiânia , GO - Brasil
- Liga de Hipertensão Arterial , Goiânia , GO - Brasil
| | - Cibele Isaac Saad Rodrigues
- Pontifícia Universidade Católica de São Paulo , Faculdade de Ciências Médicas e da Saúde , Sorocaba , SP - Brasil
| | | | | | - Andréa Araujo Brandão
- Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro (FCM-UERJ), Rio de Janeiro , RJ - Brasil
| | | | | | | | - Celso Amodeo
- Universidade Federal de São Paulo (UNIFESP), São Paulo , SP - Brasil
| | - Décio Mion Júnior
- Hospital das Clínicas da Faculdade de Medicina da USP , São Paulo , SP - Brasil
| | | | - Fernando Nobre
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP - Brasil
- Hospital São Francisco , Ribeirão Preto , SP - Brasil
| | | | | | | | - Maria Eliane Campos Magalhães
- Hospital Universitário Pedro Ernesto da Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro , RJ - Brasil
| | - Mário Fritsch Toros Neves
- Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro (FCM-UERJ), Rio de Janeiro , RJ - Brasil
| | | | | | | | - Sandra C Fuchs
- Faculdade de Medicina da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre , RS - Brasil
| | | | | | - Alvaro Avezum
- Hospital Alemão Oswaldo Cruz , São Paulo , SP - Brasil
| | - Ana Luiza Lima Sousa
- Universidade Federal de Goiás , Goiânia , GO - Brasil
- Liga de Hipertensão Arterial , Goiânia , GO - Brasil
| | | | | | | | | | | | | | | | - Bruna Eibel
- Instituto de Cardiologia , Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre , RS - Brasil
- Centro Universitário da Serra Gaúcha (FSG), Caxias do Sul , RS - Brasil
| | | | | | | | | | | | | | - Elizabete Viana de Freitas
- Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro (FCM-UERJ), Rio de Janeiro , RJ - Brasil
- Departamento de Cardiogeriatria da Sociedade Brazileira de Cardiologia , Rio de Janeiro , RJ - Brasil
| | | | | | - Emilton Lima Júnior
- Hospital de Clínicas da Universidade Federal do Paraná (HC/UFPR), Curitiba , PR - Brasil
| | - Erika Maria Gonçalves Campana
- Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro (FCM-UERJ), Rio de Janeiro , RJ - Brasil
- Universidade Iguaçu (UNIG), Rio de Janeiro , RJ - Brasil
| | - Evandro José Cesarino
- Faculdade de Ciências Farmacêuticas de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP - Brasil
- Associação Ribeirãopretana de Ensino, Pesquisa e Assistência ao Hipertenso (AREPAH), Ribeirão Preto , SP - Brasil
| | - Fabiana Marques
- Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo , Ribeirão Preto , SP - Brasil
| | | | | | | | - Fernando Antonio de Almeida
- Pontifícia Universidade Católica de São Paulo , Faculdade de Ciências Médicas e da Saúde , Sorocaba , SP - Brasil
| | | | | | - Frida Liane Plavnik
- Instituto do Coração (InCor), São Paulo , SP - Brasil
- Hospital Alemão Oswaldo Cruz , São Paulo , SP - Brasil
| | | | | | | | - Grazia Maria Guerra
- Instituto do Coração (InCor), São Paulo , SP - Brasil
- Universidade Santo Amaro (UNISA), São Paulo , SP - Brasil
| | | | | | | | | | | | - José Geraldo Mill
- Centro de Ciências da Saúde , Universidade Federal do Espírito Santo , Vitória , ES - Brasil
| | - José Marcio Ribeiro
- Faculdade Ciências Médicas de Minas Gerais , Belo Horizonte , MG - Brasil
- Hospital Felício Rocho , Belo Horizonte , MG - Brasil
| | - Leda A Daud Lotaif
- Instituto Dante Pazzanese de Cardiologia , São Paulo , SP - Brasil
- Hospital do Coração (HCor), São Paulo , SP - Brasil
| | | | | | | | | | | | - Madson Q Almeida
- Hospital das Clínicas da Faculdade de Medicina da USP , São Paulo , SP - Brasil
| | | | | | | | | | | | | | | | | | | | | | | | - Roberto Esporcatte
- Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro (FCM-UERJ), Rio de Janeiro , RJ - Brasil
- Hospital Pró-Cradíaco , Rio de Janeiro , RJ - Brasil
| | - Roberto Franco
- Universidade Estadual Paulista (UNESP), Bauru , SP - Brasil
| | - Rodrigo Pedrosa
- Pronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife , PE - Brasil
| | | | | | | | | | | | | | - Sergio Emanuel Kaiser
- Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro (FCM-UERJ), Rio de Janeiro , RJ - Brasil
| | | | | | - Vera H Koch
- Universidade de São Paulo (USP), São Paulo , SP - Brasil
| | - Wille Oigman
- Faculdade de Ciências Médicas da Universidade do Estado do Rio de Janeiro (FCM-UERJ), Rio de Janeiro , RJ - Brasil
| | - Wilson Nadruz
- Universidade Estadual de Campinas (UNICAMP), Campinas , SP - Brasil
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Fouassier D, Blanchard A, Fayol A, Bobrie G, Boutouyrie P, Azizi M, Hulot J. Sequential nephron blockade with combined diuretics improves diastolic function in patients with resistant hypertension. ESC Heart Fail 2020; 7:2561-2571. [PMID: 32597565 PMCID: PMC7524081 DOI: 10.1002/ehf2.12832] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 04/19/2020] [Accepted: 05/23/2020] [Indexed: 01/13/2023] Open
Abstract
AIMS Hypertension is a major contributor to cardiac diastolic dysfunction. Different therapeutics strategies have been proposed to control blood pressure (BP), but their independent impact on cardiac function remains undetermined. In patients with resistant hypertension, we compared the changes in cardiac parameters between two strategies based on sequential nephron blockade (NBD) with a combination of diuretics or sequential renin-angiotensin system blockade (RASB). METHODS AND RESULTS After a 4-week period where all patients received Irbesartan 300 mg/day + hydrochlorothiazide 12.5 mg/day + amlodipine 5 mg/day, 140 resistant hypertension patients (54.8 ± 11.1 years, 76% men, mean duration with hypertension: 13.1 ± 10.5 years, no previous history of heart failure or current symptoms of congestive heart failure) were randomized 1:1 to the NBD regimen or to the RASB regimen at week 0 (W0, baseline). Treatment intensity was increased at week 4, 8, or 10 if home BP was ≥135/85 mmHg, by sequentially adding 25 mg spironolactone, 20-40 mg furosemide, and 5 mg amiloride (NBD group) or 5-10 mg ramipril and 5-10 mg bisoprolol (RASB group). No other antihypertensive drug was allowed during the study. BP, BNP levels, and echocardiographic parameters were assessed at weeks 0 and 12. The baseline characteristics, laboratory parameters, and plasma hormones (BNP, renin, and aldosterone) and cardiac echocardiographic parameters did not significantly differ between the NBD and the RASB groups. Over 12 weeks, BNP levels significantly decreased in NBD but increased in RASB (mean [CI 95%] change in log-transformed BNP levels: -43% [-67%; -23%] vs. +55% [46%; 62%] in NBD vs. RASB, respectively, P < 0.0001). Similarly, the proportion of patients presenting ≥2 echocardiographic criteria of diastolic dysfunction decreased between baseline and W12 from 31% to 3% in NBD but increased from 19% to 32% in RASB (P = 0.0048). As compared with RASB, NBD induced greater decrease in ambulatory systolic BP (P < 0.0001), pulse pressure (P < 0.0001), and systemic vascular resistance (P < 0.005). In multivariable linear regression analyses, NBD treatment was significantly associated with decreased BNP levels (adjusted ß: -46.41 ± 6.99, P < 0.0001) independent of age, gender, renal function, and changes in BPs or heart rate. CONCLUSIONS In patients with resistant hypertension, nephron blockade with a combination of diuretics significantly improves cardiac markers of diastolic dysfunction independently of BP lowering.
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Affiliation(s)
- David Fouassier
- Centre d'Investigations Cliniques CIC1418, AP‐HPHôpital Européen Georges PompidouParisFrance
- Paris Cardiovascular Research Center PARCC, INSERMUniversité de ParisParisFrance
| | - Anne Blanchard
- Centre d'Investigations Cliniques CIC1418, AP‐HPHôpital Européen Georges PompidouParisFrance
- Paris Cardiovascular Research Center PARCC, INSERMUniversité de ParisParisFrance
| | - Antoine Fayol
- Centre d'Investigations Cliniques CIC1418, AP‐HPHôpital Européen Georges PompidouParisFrance
- Paris Cardiovascular Research Center PARCC, INSERMUniversité de ParisParisFrance
| | - Guillaume Bobrie
- Assistance Publique Hôpitaux de Paris, Hypertension unitHôpital Européen Georges PompidouParisFrance
| | - Pierre Boutouyrie
- Paris Cardiovascular Research Center PARCC, INSERMUniversité de ParisParisFrance
- Assistance Publique Hôpitaux de Paris, Pharmacology departmentHôpital Européen Georges PompidouParisFrance
| | - Michel Azizi
- Centre d'Investigations Cliniques CIC1418, AP‐HPHôpital Européen Georges PompidouParisFrance
- Paris Cardiovascular Research Center PARCC, INSERMUniversité de ParisParisFrance
- Assistance Publique Hôpitaux de Paris, Hypertension unitHôpital Européen Georges PompidouParisFrance
| | - Jean‐Sébastien Hulot
- Centre d'Investigations Cliniques CIC1418, AP‐HPHôpital Européen Georges PompidouParisFrance
- Paris Cardiovascular Research Center PARCC, INSERMUniversité de ParisParisFrance
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6
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Yugar-Toledo JC, Moreno Júnior H, Gus M, Rosito GBA, Scala LCN, Muxfeldt ES, Alessi A, Brandão AA, Moreira Filho O, Feitosa ADDM, Passarelli Júnior O, Souza DDSMD, Amodeo C, Barroso WKS, Gomes MAM, Paiva AMGD, Barbosa ECD, Miranda RD, Vilela-Martin JF, Nadruz Júnior W, Rodrigues CIS, Drager LF, Bortolotto LA, Consolim-Colombo FM, Sousa MGD, Borelli FADO, Kaiser SE, Salles GF, Azevedo MDFD, Magalhães LBNC, Póvoa RMDS, Malachias MVB, Nogueira ADR, Jardim PCBV, Jardim TDSV. Brazilian Position Statement on Resistant Hypertension - 2020. Arq Bras Cardiol 2020; 114:576-596. [PMID: 32267335 PMCID: PMC7792719 DOI: 10.36660/abc.20200198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
| | - Heitor Moreno Júnior
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas, Campinas, SP - Brasil
| | - Miguel Gus
- Hospital Moinhos de Vento, Porto Alegre, RS - Brasil
| | | | | | - Elizabeth Silaid Muxfeldt
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | - Celso Amodeo
- Instituto Dante Pazzanese de Cardiologia,São Paulo, SP - Brasil
| | | | | | | | | | | | | | - Wilson Nadruz Júnior
- Faculdade de Ciências Médicas da Universidade Estadual de Campinas, Campinas, SP - Brasil
| | - Cibele Isaac Saad Rodrigues
- Faculdade de Ciências Médicas e da Saúde Pontifícia Universidade Católica de são Paulo, São Paulo, SP - Brasil
| | - Luciano Ferreira Drager
- Instituto do Coração do Hospital das Clínicas da Faculdade Medicina Universidade de São Paulo,São Paulo, SP - Brasil
| | - Luiz Aparecido Bortolotto
- Instituto do Coração do Hospital das Clínicas da Faculdade Medicina Universidade de São Paulo,São Paulo, SP - Brasil
| | | | | | | | | | - Gil Fernando Salles
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ - Brasil
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Kuzmin OB, Buchneva NN, Zhezha VV, Serdyuk SV. Uncontrolled Arterial Hypertension: Kidney, Neurohormonal Imbalance, and Approaches to Antihypertensive Drug Therapy. ACTA ACUST UNITED AC 2019; 59:64-71. [DOI: 10.18087/cardio.2019.12.n547] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Accepted: 04/29/2019] [Indexed: 11/18/2022]
Abstract
Resistant and refractory arterial hypertensions are two distinct clinical phenotypes of uncontrolled arterial hypertension (AH), which differ in their sensitivity to antihypertensive drug therapy. The review presents data obtained in clinical studies devoted to elucidating the involvement of disorders of neurohormonal status and renal function in the formation of resistant and refractory arterial hypertension, to and the development of new approaches to increasing the effectiveness of antihypertensive therapy in these patient’s populations. The results of these studies have shown that in patients with uncontrolled arterial hypertension, despite prolonged intake ≥ 3 antihypertensive drugs with different mechanisms of action, including a diuretic, excess sodium reabsorption persists in the distal segments of nephron due to increased aldosterone activity and sympathetic nervous system hyperactivity. In this regard, special attention has been paid to the data of PATHWAY-2, PATHWAY-3 and ReHOT trials that in patients with resistant AH tested the clinical efficacy of spironolactone, amiloride, and antiadrenergic drugs bisoprolol, doxazosin and clonidine, suppressing activity of the sympathetic nervous system.
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8
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Bolat I, Pusuroglu H, Demir AR, Ornek V, Erturk M. Decreased neurotensin levels as a biomarker in resistant hypertension. Clin Exp Hypertens 2019; 42:266-270. [PMID: 31204518 DOI: 10.1080/10641963.2019.1632340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: Although neurotensin is found throughout the body including cardiovascular structures, the correlation of plasma neurotensin levels with resistant hypertension (RH) has never been examined. Therefore, we aimed to compare plasma neurotensin concentration, between patients with RH and those with controlled hypertension (CH).Methods: Forty-one patients with RH and 45 patients with CH who had undergone outpatient ambulatory blood pressure measurements were prospectively recruited. RH was defined as uncontrolled blood pressure despite using three antihypertensive agents including a diuretic or need of four or more drugs to control blood pressure. The demographic properties, medications, laboratory parameters including neurotensin levels, and echocardiographic parameters were recorded.Results: There was no significant difference among groups in terms of age, sex, smoking or body mass index. Office and ambulatory blood pressures and mean number of antihypertensive drugs used were significantly higher in patients with RH compared to patients with CH. Plasma neurotensin levels were significantly lower in patients with RH (median: 0.380 ng/ml; interquartile range: 0.292-0.471) than in the patients with controlled blood pressure (median: 0.638 ng/ml; interquartile range: 0.483-0.783). Multivariate and receiver-operating characteristics curve analyses showed that neurotensin is an independent predictor for RH and the optimal cut-off value of neurotensin for RH was lower than 0.509 ng/ml, with a sensitivity of 85.4% and a specificity of 73.3% (area under the curve = 0.793, 95% CI: 0.691-0.894, p < .001)Conclusion: This study is the first to show a correlation between lower neurotensin levels and RH.
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Affiliation(s)
- Ismail Bolat
- Department of Cardiology, Department of Cardiology, Fethiye State Hospital, Muğla, Turkey
| | - Hamdi Pusuroglu
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ali Rıza Demir
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Vesile Ornek
- Department of Biochemistry, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Erturk
- Department of Cardiology, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Gonsalez SR, Ferrão FM, Souza AMD, Lowe J, Morcillo LDSL. Inappropriate activity of local renin-angiotensin-aldosterone system during high salt intake: impact on the cardio-renal axis. ACTA ACUST UNITED AC 2018; 40:170-178. [PMID: 29944159 PMCID: PMC6533978 DOI: 10.1590/2175-8239-jbn-3661] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 01/11/2017] [Indexed: 12/12/2022]
Abstract
Although there is a general agreement on the recommendation for reduced salt
intake as a public health issue, the mechanism by which high salt intake
triggers pathological effects on the cardio-renal axis is not completely
understood. Emerging evidence indicates that the renin-angiotensin-aldosterone
system (RAAS) is the main target of high Na+ intake. An inappropriate
activation of tissue RAAS may lead to hypertension and organ damage. We reviewed
the impact of high salt intake on the RAAS on the cardio-renal axis highlighting
the molecular pathways that leads to injury effects. We also provide an
assessment of recent observational studies related to the consequences of
non-osmotically active Na+ accumulation, breaking the paradigm that
high salt intake necessarily increases plasma Na+ concentration
promoting water retention
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Affiliation(s)
- Sabrina Ribeiro Gonsalez
- Universidade Federal do Rio de Janeiro, Instituto de Ciências Biomédicas, Rio de Janeiro, RJ, Brasil
| | - Fernanda Magalhães Ferrão
- Universidade do Estado do Rio de Janeiro, Instituto de Biologia Roberto Alcântara Gomes, Rio de Janeiro, RJ, Brasil
| | | | - Jennifer Lowe
- Universidade Federal do Rio de Janeiro, Instituto de Biofísica Carlos Chagas Filho, Rio de Janeiro, Brasil
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Abstract
PURPOSE OF REVIEW Resistant hypertension (RHTN) is a condition in which besides the antihypertensive therapy using at least three different drugs (including a diuretics), brachial blood pressure does not reach the target (e.g., 140/90 mmHg). RECENT FINDINGS Despite the diversity of clinical presentations, we divide RHTN in two major groups according to blood pressure and number of drugs taken: controlled (C-RHTN) and uncontrolled (UC-RHTN) resistant hypertension, with refractory hypertension (RfHTN) included in the latter subgroup. Both C-RHTN and UC-RHTN are heterogenic and complex syndromes. To better approach this matter, the some pathophysiological mechanisms (increased volemia, hyperactivity, plasma cortisol, adipocitokines, and other pro-inflammatory factors), have a pivotal clinical role. Some features (African ethnic, obesity, age > 60, LV hypertrophy, and vascular stiffness) increase the risk of refractoriness as well as worst prognosis. Based on increased target organ damage, cardiovascular risk and events will be addressed in this review. Our conclusion is that although both C-RHTN and UC-RHTN are extreme phenotypes of hard-to-control BP, some mechanisms of the disease and clinical expressions are distinct. According to these differences, "UC-RHTN and C-RHTN are not in the same bag."
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11
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Ilan Y. Analogy between non-alcoholic steatohepatitis (NASH) and hypertension: a stepwise patient-tailored approach for NASH treatment. Ann Gastroenterol 2018; 31:296-304. [PMID: 29720855 PMCID: PMC5924852 DOI: 10.20524/aog.2018.0248] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 01/24/2018] [Indexed: 01/18/2023] Open
Abstract
Non-alcoholic steatohepatitis (NASH) is a common liver disorder worldwide. Although there has been improvement in our understanding of the natural history and pathogenesis of the disease, there is still no approved therapy for NASH. NASH shares many similarities with primary hypertension, in that both are extremely common disorders that can easily lead to serious complications if left untreated. Both conditions are viewed as "silent killers", because the disease can progress over a period of time prior to the occurrence of potentially deadly outcomes. While attempts to find the "miracle pill" for NASH are unrealistic, we can make an analogy with the "stepwise combination" approach developed over the last few decades for the treatment of hypertension. In the present review, we summarize some of the similarities in the concepts that underlie NASH and hypertension. The development of a stepwise patient-tailored method for the treatment of NASH is presented.
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Affiliation(s)
- Yaron Ilan
- Gastroenterology and Liver Units, Department of Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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12
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Abstract
Resistant hypertension (RH) is defined as blood pressure (BP) that remains above target levels despite adherence to at least three different antihypertensive medications, typically including a diuretic. Epidemiological studies estimate that RH is increasing in prevalence, and is associated with detrimental health outcomes. The pathophysiology underlying RH is complex, involving multiple, overlapping contributors including activation of the renin-angiotensin aldosterone system and the sympathetic nervous system, volume overload, endothelial dysfunction, behavioural and lifestyle factors. Hypertension guidelines currently recommend specific pharmacotherapy for 1st, 2nd and 3rd-line treatment, however no specific fourth-line pharmacotherapy is provided for those with RH. Rather, five different antihypertensive drug classes are generally suggested as possible alternatives, including: mineralocorticoid receptor antagonists, α1-adrenergic antagonists, α2-adrenergic agonists, β-blockers, and peripheral vasodilators. Each of these drug classes vary in their efficacy, tolerability and safety profile. This review summarises the available data on each of these drug classes as a potential fourth-line drug and reveals a lack of robust clinical evidence for preferred use of most of these classes in the setting of RH. Moreover, there is a lack of direct comparative trials that could assist in identifying a preferred fourth-line pharmacologic approach and in providing evidence for hypertensive guidelines for adequate treatment of RH.
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13
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Abstract
PURPOSE OF REVIEW Emerging evidence suggests that multiple mechanisms may be responsible for the development of treatment-resistant hypertension (TRH). This review aims to summarize recent data on potential mechanisms of resistance and discuss current pharmacotherapeutic options available in the management of TRH. RECENT FINDINGS Excess sodium and fluid retention, increased activation of the renin-angiotensin-aldosterone system, and heightened activity of the sympathetic nervous system appear to play an important role in development of TRH. Emerging evidence also suggests a role for arterial stiffness and, potentially, gut dysbiosis. Therapeutic approaches for TRH should include diuretic optimization and the addition of aldosterone antagonists as the preferred fourth agent in most patients. Further therapeutic approaches may be guided by the suspected underlying mechanism of TRH in conjunction with other patient-specific factors. The pathophysiology of TRH is multifaceted; however, increasing evidence supports several mechanisms that may be targeted to improve blood pressure control among patients with TRH. Further studies are needed to determine whether such approaches may be more effective than usual care.
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Martin-Lorenzo M, Martinez PJ, Baldan-Martin M, Ruiz-Hurtado G, Prado JC, Segura J, de la Cuesta F, Barderas MG, Vivanco F, Ruilope LM, Alvarez-Llamas G. Citric Acid Metabolism in Resistant Hypertension: Underlying Mechanisms and Metabolic Prediction of Treatment Response. Hypertension 2017; 70:1049-1056. [PMID: 28874460 DOI: 10.1161/hypertensionaha.117.09819] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 06/17/2017] [Accepted: 08/09/2017] [Indexed: 12/16/2022]
Abstract
Resistant hypertension (RH) affects 9% to 12% of hypertensive adults. Prolonged exposure to suboptimal blood pressure control results in end-organ damage and cardiovascular risk. Spironolactone is the most effective drug for treatment, but not all patients respond and side effects are not negligible. Little is known on the mechanisms responsible for RH. We aimed to identify metabolic alterations in urine. In addition, a potential capacity of metabolites to predict response to spironolactone was investigated. Urine was collected from 29 patients with RH and from a group of 13 subjects with pseudo-RH. For patients, samples were collected before and after spironolactone administration and were classified in responders (n=19) and nonresponders (n=10). Nuclear magnetic resonance was applied to identify altered metabolites and pathways. Metabolites were confirmed by liquid chromatography-mass spectrometry. Citric acid cycle was the pathway most significantly altered (P<0.0001). Metabolic concentrations were quantified and ranged from ng/mL malate to μg/mL citrate. Citrate and oxaloacetate increased in RH versus pseudoresistant. Together with α-ketoglutarate and malate, they were able to discriminate between responders and nonresponders, being the 4 metabolites increased in nonresponders. Combined as a prediction panel, they showed receiver operating characteristiccurve with area under the curve of 0.96. We show that citric acid cycle and deregulation of reactive oxygen species homeostasis control continue its activation after hypertension was developed. A metabolic panel showing alteration before spironolactone treatment and predicting future response of patients is shown. These molecular indicators will contribute optimizing the rate of control of RH patients with spironolactone.
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Affiliation(s)
- Marta Martin-Lorenzo
- From the Department of Immunology, IIS-Fundacion Jimenez Diaz, REDinREN, Madrid, Spain (M.M.-L., P.J.M., F.V., G.A.-L.); Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.); Hypertension Unit, Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Madrid, Spain (G.R.-H., J.C.P., J.S., L.M.R.); Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, United Kingdom (F.d.l.C.); Department of Biochemistry and Molecular Biology I, Universidad Complutense, Madrid, Spain (F.V.); and Universidad Europea, Madrid, Spain (L.M.R.)
| | - Paula J Martinez
- From the Department of Immunology, IIS-Fundacion Jimenez Diaz, REDinREN, Madrid, Spain (M.M.-L., P.J.M., F.V., G.A.-L.); Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.); Hypertension Unit, Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Madrid, Spain (G.R.-H., J.C.P., J.S., L.M.R.); Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, United Kingdom (F.d.l.C.); Department of Biochemistry and Molecular Biology I, Universidad Complutense, Madrid, Spain (F.V.); and Universidad Europea, Madrid, Spain (L.M.R.)
| | - Montserrat Baldan-Martin
- From the Department of Immunology, IIS-Fundacion Jimenez Diaz, REDinREN, Madrid, Spain (M.M.-L., P.J.M., F.V., G.A.-L.); Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.); Hypertension Unit, Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Madrid, Spain (G.R.-H., J.C.P., J.S., L.M.R.); Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, United Kingdom (F.d.l.C.); Department of Biochemistry and Molecular Biology I, Universidad Complutense, Madrid, Spain (F.V.); and Universidad Europea, Madrid, Spain (L.M.R.)
| | - Gema Ruiz-Hurtado
- From the Department of Immunology, IIS-Fundacion Jimenez Diaz, REDinREN, Madrid, Spain (M.M.-L., P.J.M., F.V., G.A.-L.); Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.); Hypertension Unit, Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Madrid, Spain (G.R.-H., J.C.P., J.S., L.M.R.); Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, United Kingdom (F.d.l.C.); Department of Biochemistry and Molecular Biology I, Universidad Complutense, Madrid, Spain (F.V.); and Universidad Europea, Madrid, Spain (L.M.R.)
| | - Jose Carlos Prado
- From the Department of Immunology, IIS-Fundacion Jimenez Diaz, REDinREN, Madrid, Spain (M.M.-L., P.J.M., F.V., G.A.-L.); Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.); Hypertension Unit, Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Madrid, Spain (G.R.-H., J.C.P., J.S., L.M.R.); Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, United Kingdom (F.d.l.C.); Department of Biochemistry and Molecular Biology I, Universidad Complutense, Madrid, Spain (F.V.); and Universidad Europea, Madrid, Spain (L.M.R.)
| | - Julian Segura
- From the Department of Immunology, IIS-Fundacion Jimenez Diaz, REDinREN, Madrid, Spain (M.M.-L., P.J.M., F.V., G.A.-L.); Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.); Hypertension Unit, Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Madrid, Spain (G.R.-H., J.C.P., J.S., L.M.R.); Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, United Kingdom (F.d.l.C.); Department of Biochemistry and Molecular Biology I, Universidad Complutense, Madrid, Spain (F.V.); and Universidad Europea, Madrid, Spain (L.M.R.)
| | - Fernando de la Cuesta
- From the Department of Immunology, IIS-Fundacion Jimenez Diaz, REDinREN, Madrid, Spain (M.M.-L., P.J.M., F.V., G.A.-L.); Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.); Hypertension Unit, Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Madrid, Spain (G.R.-H., J.C.P., J.S., L.M.R.); Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, United Kingdom (F.d.l.C.); Department of Biochemistry and Molecular Biology I, Universidad Complutense, Madrid, Spain (F.V.); and Universidad Europea, Madrid, Spain (L.M.R.)
| | - Maria G Barderas
- From the Department of Immunology, IIS-Fundacion Jimenez Diaz, REDinREN, Madrid, Spain (M.M.-L., P.J.M., F.V., G.A.-L.); Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.); Hypertension Unit, Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Madrid, Spain (G.R.-H., J.C.P., J.S., L.M.R.); Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, United Kingdom (F.d.l.C.); Department of Biochemistry and Molecular Biology I, Universidad Complutense, Madrid, Spain (F.V.); and Universidad Europea, Madrid, Spain (L.M.R.)
| | - Fernando Vivanco
- From the Department of Immunology, IIS-Fundacion Jimenez Diaz, REDinREN, Madrid, Spain (M.M.-L., P.J.M., F.V., G.A.-L.); Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.); Hypertension Unit, Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Madrid, Spain (G.R.-H., J.C.P., J.S., L.M.R.); Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, United Kingdom (F.d.l.C.); Department of Biochemistry and Molecular Biology I, Universidad Complutense, Madrid, Spain (F.V.); and Universidad Europea, Madrid, Spain (L.M.R.)
| | - Luis Miguel Ruilope
- From the Department of Immunology, IIS-Fundacion Jimenez Diaz, REDinREN, Madrid, Spain (M.M.-L., P.J.M., F.V., G.A.-L.); Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.); Hypertension Unit, Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Madrid, Spain (G.R.-H., J.C.P., J.S., L.M.R.); Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, United Kingdom (F.d.l.C.); Department of Biochemistry and Molecular Biology I, Universidad Complutense, Madrid, Spain (F.V.); and Universidad Europea, Madrid, Spain (L.M.R.)
| | - Gloria Alvarez-Llamas
- From the Department of Immunology, IIS-Fundacion Jimenez Diaz, REDinREN, Madrid, Spain (M.M.-L., P.J.M., F.V., G.A.-L.); Department of Vascular Physiopathology, Hospital Nacional de Paraplejicos SESCAM, Toledo, Spain (M.B.-M., M.G.B.); Hypertension Unit, Instituto de Investigación imas12, Hospital Universitario 12 de Octubre, Madrid, Spain (G.R.-H., J.C.P., J.S., L.M.R.); Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, United Kingdom (F.d.l.C.); Department of Biochemistry and Molecular Biology I, Universidad Complutense, Madrid, Spain (F.V.); and Universidad Europea, Madrid, Spain (L.M.R.).
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