Gender considerations in hypertension pathophysiology and treatment

Lower Post Myocardial Infarction Mortality Among Women Treated at Veterans Affairs Hospitals Compared to Men

BACKGROUND

There is conflicting evidence about whether mortality after myocardial infarction is higher among women than among men. This study aimed to compare sex differences in post myocardial infarction mortality in the Veterans Affairs system, a setting where the predominant subjects are men.

MATERIALS AND METHODS

The Veterans Affairs Corporate Data Warehouse inpatient and laboratory chemistry databases were used to identify patients diagnosed with acute myocardial infarction from inpatient records from January 1st, 2005 to April 25th, 2015. Mortality data was obtained through the Veterans Affairs death registry.

RESULTS

A total of 130,241 patients were identified; 127,711 men (98%) and 2,530 women (2%). Men typically had more comorbidities including congestive heart failure (54% vs. 46%, P value < 0.001), diabetes mellitus (54% vs. 48%, P value < 0.001), and chronic kidney disease (39% vs. 28%, P value < 0.001). The peak troponin-I was significantly higher among men (16.0 vs. 10.7 ng/mL, P value = 0.03). The mean follow-up time was 1490.67 ± 8 days. After adjusting for differences in demographics and comorbidities, women had a significantly lower risk of mortality (hazard ration [HR]: 0.747, P value < 0.0001) as compared to men.

CONCLUSIONS

In a health care system where the predominant subjects are men, women had better short- and long-term survival than men after an acute myocardial infarction. Further investigation is warranted to determine the reasons behind the improved outcomes in women post myocardial infarction in the veteran population.

Burden of Disease Attributable to Obesity and Overweight in Colombia

OBJECTIVES

To estimate the burden of disease attributable to obesity and overweight conditions using disability-adjusted life-years (DALYs) in Colombia.

METHODS

The burden of disease was estimated following an adapted methodology published by the World Health Organization. A selection of diseases was performed in which overweight and obesity are risk factors. DALYs were calculated by obtaining the proportion of cases and deaths of every disease that can be attributable to obesity and overweight conditions. The economic impact of obesity was calculated by multiplying the cost of care per patient for each comorbidity by the number of cases attributable exclusively to obesity.

RESULTS

A total of 997 371 DALYs were estimated, 45% of which corresponded to men; 81% of DALYs corresponded to years lived with disability. Conditions with greater attributable DALYs are, in order, hypertension (31.6% of the total DALYs), type 2 diabetes mellitus (28.0%), cardiac ischemic disease (14.6%), and lower back pain (11.2%). An estimation of 20.5 DALYs per 1000 inhabitants was made. The economic impact of care for comorbidities associated with obesity could amount to $2158 million.

CONCLUSIONS

Obesity and overweight conditions are related to higher mortality and disability than previously estimated; effective interventions aimed at prevention and treatment will have a high impact on quality of life.

Clinical predictors of the estimated glomerular filtration rate 1 year after radical nephrectomy in Japanese patients

Purpose

To evaluate renal function 1 year after radical nephrectomy (RN) for renal cell carcinoma, the preoperative predictors of postnephrectomy renal function were investigated by sex, and equations to predict the estimated glomerular filtration rate (eGFR) 1 year after RN were developed.

Materials and Methods

A total of 525 patients who underwent RN between May 2007 and August 2011 at Tohoku University Hospital and its affiliated hospitals were prospectively evaluated. Overall, 422 patients were analyzed in this study.

Results

Independent preoperative factors associated with postnephrectomy renal function were different in males and females. Preoperative eGFR, age, tumor size, and body mass index (BMI) were independent factors in males, while tumor size and BMI were not independent factors in females. The equations developed to predict eGFR 1 year after RN were: Predicted eGFR in males (mL/min/1.73 m²)=27.99−(0.196×age)+(0.497×eGFR)+(0.744×tumor size)−(0.339×BMI); and predicted eGFR in females=44.57−(0.275×age)+(0.298×eGFR). The equations were validated in the validation dataset (R²=0.63, p<0.0001 and R²=0.31, p<0.0001, respectively).

Conclusions

The developed equations by sex enable better prediction of eGFR 1 year after RN. The equations will be useful for preoperative patient counseling and selection of the type of surgical procedure in elective partial or RN cases.

Proteomics in investigation of protein nitration in kidney disease: technical challenges and perspectives from the spontaneously hypertensive rat

Kidneys are the mammalian organs with widest range of oxidative status ranging from the well-perfused cortex to the relatively anoxic medulla. This organ is of key interest from the perspective of hypertension, an important contributor to human mortality, and there has been growing use of the spontaneously hypertensive rat (SHR) as a model to explore oxidative stress in hypertensive kidney. Nitrosative stress is often associated with oxidative stress and, like oxidative stress, can lead to covalent modification of protein side-chains. It is especially relevant to kidney because of high levels of both nitrite/nitrate and nitric oxide synthase in medulla. Because of their relatively low abundance and their well-known role in signal transduction, nitration of tyrosines to 3-nitrotyrosines (3NT) is of particular interest in this regard. This modification has the potential to contribute to changes in regulation, in protein activity and may provide a means of specific targeting of key proteins. Mass spectrometry (MS) offers a promising route to detecting this modification. This review surveys protein nitration in kidney disease and highlights opportunities for MS detection of nitrated residues in the SHR.

Paradoxical lower postmyocardial infarction mortality among veteran women--does a sex bias exist in the Veterans Affairs medical system?

BACKGROUND

Outcomes after acute coronary disease are reportedly worse among women in general and more so among women with diabetes compared with men. Sex differences were evaluated in postmyocardial infarction (MI) mortality among veterans (who are predominantly male) to determine whether evaluation and treatment in Veterans Affairs hospitals amplifies sex differences in outcome.

METHODS

All patients discharged with the primary diagnosis of acute MI from any Veterans hospitals in the United States between October 1990 and September 1997 were identified. Demographic, comorbidity, inpatient, outpatient, mortality and readmission data were extracted. Mortality, revascularization and readmissions were compared between male and female patients using Cox regression models.

RESULTS

The authors identified 67,889 patients with MI, 17,756 (26%) of whom had diabetes. There were 951 women, 280 (29%) of whom had diabetes, and 66,938 men, 17,476 (26%) of whom had diabetes. Over the entire follow-up period, adjusted mortality was higher in men than women (hazard ratio [HR] 1.5, 95% CI 1.3 to 1.7). Cardiac procedures were significantly higher among men: HR for coronary bypass surgery was 2.1 (95% CI 1.6 to 2.8; P<0.001) for all men, while HR for catheterization and percutaneous coronary intervention were higher for men among nondiabetics only--1.5 (95% CI 1.2 to 1.8; P<0.001) and 2.0 (95% CI 1.4 to 2.9; P<0.001). Interaction between sex and diabetes was not significant.

CONCLUSIONS

Contrary to previous observations in the nonveteran population, long-term mortality post-MI was lower among veteran women, despite higher procedure rates in men. The present study also failed to show increased mortality in women with diabetes.

Estrogen replacement suppresses stress-induced cardiovascular responses in ovariectomized rats

We assessed the hypothesis that chronic estrogen replacement in ovariectomized rats has the beneficial effect of suppressing stress-induced cardiovascular responses through endothelial nitric oxide synthase (eNOS). We employed a radiotelemetry system to measure blood pressure and heart rate (HR). Female Wistar rats aged 11 wk were ovariectomized and implanted with radiotelemetry devices. After 4 wk, the rats were assigned either to a placebo-treated group (Placebo; n = 6) or a group treated with 17β-estradiol (Estrogen; n = 8) subcutaneously implanted with either placebo- or 17β-estradiol (1.5 mg/60-day release) pellets under anesthesia. These rats underwent either of the two types of stress after 4 wk of estrogen or placebo treatment. Cage-switch stress and restraint stress rapidly and continuously elevated the mean arterial pressure (MAP) and HR both in the Placebo and Estrogen groups. However, the MAP and HR responses to cage-switch stress and the MAP but not HR response to restraint stress were attenuated significantly in the Estrogen group compared with the Placebo group. A NOS inhibitor, NG-nitro-l-arginine methyl ester, given in drinking water, reduced the difference in the pressor response to cage-switch between the Estrogen and Placebo groups. In addition, Western blot analysis showed that eNOS expression in the mesentery was increased in the Estrogen group compared with the Placebo group. Thus for the first time we showed that mesenteric eNOS overexpression could explain at least partly why chronic estrogen treatment suppressed the enhanced cardiovascular responses to psychological stress in the ovariectomized rat.

The effect of estrogen on serum nitric oxide concentrations in normotensive and DOCA Salt hypertensive ovariectomized rats

BACKGROUND

Cardiovascular disease (CVD) is less prevalent in premenopausal women and women receiving estrogen replacement therapy (ERT) than in postmenopausal women or men. It proposed that the cardiovascular effects of estrogen are mediated, at least in part, through the ability of estrogen to increase nitric oxide (NO) synthesis. This study investigated the effect of estrogen on serum NO concentrations in normotensive and deoxycorticostrone acetate (DOCA) Salt hypertensive ovariectomized rats.

METHODS

Forty-eight female rats were ovariectomized and randomly divided into six groups. Hypertension was induced by DOCA Salt method. DOCA was injected 30 mg/kg of body weight subcutaneously, twice a week with NaCl 1% instead of tap water for drinking throughout the treatment period. Estradiol valerate (Es) was injected i.m. once a week. The groups were as follows: (2) DOCA (4 weeks) and DOCA+Es (6 weeks), (22) DOCA (10 weeks), (222) normal saline (N/S) (4 weeks)+Es (6 weeks), (2V) N/S (10 weeks), (V) DOCA (4 weeks), and (V2) N/S (4 weeks). Serum NO concentrations were measured in groups 1, 3 and 4 before and after treatment. Other groups were used as control.

RESULTS

Results showed that in normotensive animals, serum NO concentrations were increased after estrogen treatment significantly (90.20 +/- 18.67 vs. 19.11 +/- 1.78 micromol/l) (p < 0.05). Also, estrogen increased serum NO concentrations in DOCA Salt hypertensive rats (73.54 +/- 22.55 vs. 36.94 +/- 10.73 micromol/l) (p = 0.06).

CONCLUSION

Estrogen can increase serum NO concentrations in normotensive and DOCA Salt hypertensive animals and it may be important in cardiovascular effects of estrogen.

Specific regulation of lipocalin-type prostaglandin D synthase in mouse heart by estrogen receptor beta

Estrogens have important physiological roles in the cardiovascular system. We use DNA microarray technology to study the molecular mechanism of estrogen action in the heart and to identify novel estrogen-regulated genes. In this investigation we identify genes that are regulated by chronic estrogen treatment of mouse heart. We present our detailed characterization of one of these genes, lipocalin-type prostaglandin D synthase (L-PGDS). Northern and Western blot analysis revealed that L-PGDS was induced both by acute and chronic estrogen treatment. Northern blot analysis, using estrogen receptor (ER)-disrupted mice, suggests that L-PGDS is specifically induced by ERbeta in vivo. In further support of ERbeta-selective regulation, we identify a functional estrogen-responsive element in the L-PGDS promoter, the activity of which is up-regulated by ERbeta, but not by ERalpha. We demonstrate that a one-nucleotide change (A to C) in the L-PGDS estrogen-responsive element affects receptor selectivity.

Mean arterial pressure and pulse pressure are associated with different clinical parameters in chronic haemodialysis patients

The mean arterial pressure (MAP) usually serves as an expression of blood pressure in patients on chronic haemodialysis (PCHD), instead of using solely systolic or diastolic pressure. Pulse pressure (PP) has been recognized as an important correlate of mortality in PCHD. We conducted this study in order to demonstrate clinical and biochemical determinants and variability of predialysis and postdialysis MAP and PP values. A total of 136 single haemodialysis (HD) treatments in 23 subjects (PCHD, 11 male and 12 female patients) were processed during 15 months. MAP before HD was in negative correlation with haemoglobin (P<0.001) and body mass index (BMI) (P<0.001), and in positive correlation with weekly erythropoietin dosage (P=0.017). MAP after HD was in negative correlation with haemoglobin (P<0.001), ultrafiltration per HD (P=0.015), and BMI (P=0.001), and in positive correlation with weekly erythropoietin dosage (P=0.003). PP before HD was in negative correlation with parathyroid hormone (PTH) level (P=0.020), haemoglobin (P<0.001), ultrafiltration per HD (P=0.001), and years on the chronic HD treatment (P=0.001), and in positive correlation with weekly erythropoietin dosage (P<0.001) and age (P<0.001). PP after HD was in significant negative correlation with PTH (P=0.015), haemoglobin (P=0.005), ultrafiltration per HD (P<0.001), BMI (P=0.003), and in positive correlation with weekly erythropoietin dosage (P<0.001) and age (P=0.004). Multiple regression analyses unveiled the strongest and negative correlations between MAP before HD and BMI (beta=-0.37, P=0.01); MAP after HD and haemoglobin (beta=-0.36, P=0.01); PP after HD and ultrafiltration/body weight ratio (beta=-0.41, P<0.001). The strongest and positive correlation was found between PP before HD and erythropoietin dosage per week (beta=0.51, P&<0.001). In conclusion, our findings support the assumption that PP and MAP are associated with different clinical parameters. PP values have advantages as the method of blood pressure expression.

Angiotensin II type 1 receptor blocker irbesartan ameliorates vascular function in spontaneously hypertensive rats regardless of oestrogen status

BACKGROUND

Angiotensin II type 1 (AT1) receptor overexpression may play a decisive role in endothelial dysfunction during oestrogen deficiency in spontaneously hypertensive rats (SHRs). Similarly, exaggerated production of angiotensin II and enhanced expression of AT1 receptor have been reported in vessels of SHRs compared with normotensive rats.

OBJECTIVE

To test the hypothesis that antihypertensive treatment with the AT1 receptor antagonist, irbesartan, could not only decrease blood pressure but also ameliorate endothelial dysfunction associated with both hypertension and oestrogen deficiency.

METHODS

Ovariectomized and sham-ovariectomized SHRs were treated with 50 mg/kg irbesartan per day, administered with chow for 30 weeks. Sham-ovariectomized and ovariectomized rats receiving no treatment were used as control groups. At the end of the treatment period, the vascular reactivity of aortic rings was studied.

RESULTS

In the irbesartan-treated groups, vasoconstriction induced by Nomega-nitro-l-arginine methyl ester (l-NAME) was increased and the response to phenylephrine exhibited greater potentiation in the presence of l-NAME, demonstrating a greater availability of basal nitric oxide in these groups. In addition, chronic treatment with irbesartan similarly enhanced the responsiveness of aortic rings from ovariectomized or sham-ovariectomized rats to acetylcholine and sodium nitroprusside. Incubation with indomethacin did not significantly alter acetylcholine- and sodium nitroprusside-induced relaxations in the irbesartan-treated rats. However, relaxations induced by acetylcholine and sodium nitroprusside in aortic rings from non-treated rats were significantly greater in the presence of indomethacin.

CONCLUSION

Our data suggest that irbesartan enhances basal nitric oxide availability and ameliorates vascular relaxations in SHRs, by decreasing the production of cyclooxygenase-dependent contracting factors in smooth muscle cells, regardless of oestrogen status.

Renal function and renal disease in the elderly: Part I

In all industrialized countries, life expectancy has risen in the past 100 years. The incidence of elderly patients reaching end-stage renal disease (ESRD) and requiring renal replacement therapy has also increased. During the past few decades, the pattern of ESRD has changed significantly with the emerging predominance of elderly patients. The causes of this phenomenon are manifold and include an increasing number of chronic diseases typical of the 'third age', such as type 2 diabetes mellitus and vascular disease. In many species, a consequence of aging includes deterioration of renal function, partly due to structural alterations, and partly as the result of a diminishing blood flow. In humans, the aging kidney is characterized by modifications resulting from organic and functional disturbances. In particular, type 2 diabetes mellitus has emerged as an important condition, the microvascular and macrovascular complications of which are a common cause of morbidity and mortality in older patients. In part I of this review, the morphological and functional changes of the aging kidney will be reviewed, as well as the pathological conditions leading to the loss of renal function in the elderly.

Gender differences in sensitivity to adrenergic agonists of forearm resistance vasculature

OBJECTIVES

The goal of this study was to investigate the mechanism of reduced vasoconstrictor sensitivity to norepinephrine in women compared with men.

BACKGROUND

beta2-adrenergic agonists such as albuterol dilate forearm resistance vessels, partly by activating the L-arginine/nitric oxide pathway. Norepinephrine (which acts as beta- as well as alpha-adrenergic receptors) causes less forearm vasoconstriction in women than it does in men. This could be explained by a greater sensitivity to beta2-receptor stimulation in women than in men.

METHODS

Forearm blood flow was measured by venous occlusion plethysmography in healthy women (days 10 to 14 of the menstrual cycle) and in men. Drugs were administered via the brachial artery in three separate protocols: albuterol +/- NG-monomethyl-L-arginine (an inhibitor of nitric oxide synthase); substance P, nitroprusside and verapamil (control vasodilators); norepinephrine (+/- propranolol, a beta-adrenergic receptor antagonist).

RESULTS

Vasodilator responses to albuterol were greater in women than they were in men (p = 0.02 by analysis of variance). NG-monomethyl-L-arginine reduced these similarly in men and women. Responses to control vasodilators were less in women than they were in men (each p < 0.05). Norepinephrine caused less vasoconstriction in women than it did in men (p = 0.02). Propranolol did not influence basal flow in either gender nor responses of men to norepinephrine but increased vasoconstriction to each dose of norepinephrine in women (p < 0.0001 for interaction between gender and propranolol). Responses to norepinephrine coinfused with propranolol were similar in men and women.

CONCLUSIONS

Stimulation of beta2-adrenergic receptors causes greater forearm vasodilation in premenopausal women, at midmenstrual cycle, than it does in men. This is sufficient to explain why vasoconstriction to brachial artery norepinephrine is attenuated in such women.

Heart disease in women

Women face a disparity in the evaluation and treatment of coronary artery disease, even though coronary artery disease is the leading cause of death for women in the United States. Primary care physicians play an important role in the identification and treatment of risk factors and comorbidities. It is their obligation to ensure that women receive equal and appropriate care, and to advocate for their patients.

Hypertension, hormones, and aging

The most rapidly growing segment of the United States population is the geriatric group, especially those above 75 years of age. Hypertension, diabetes mellitus, and dyslipidemia increase with advancing years in Westernized, industrialized societies such as the United States. These disorders contribute significantly to strokes and myocardial infarctions and associated morbidity and mortality in our elderly population. The increase in these chronic disease processes with aging is related, in part, to increasing obesity, reductions in physical activity, and medications that predispose to these conditions (ie, nonsteroidal inflammatory agents and hypertension). Hypertension in the elderly is characterized by high peripheral vascular resistance/reduced cardiac output, impaired baroflex sensitivity, relatively greater systolic pressures, increased blood pressure variability, and a propensity to salt sensitivity. Type 2 diabetes in the elderly is related to alterations in body composition (ie, increased central adiposity and decreased lean body mass) and to reduced physical activity. There is an increasing body of evidence that aggressive treatment of hypertension and dyslipidemia in the elderly results in comparable, if not greater, reductions in cardiovascular morbidity and mortality in the elderly as in younger counterparts.

Physical activity and incident hypertension in black and white adults: the Atherosclerosis Risk in Communities Study

BACKGROUND

The epidemiologic observation that physical activity reduces the risk for hypertension has only been made for white men who self-reported hypertension. This study examined physical activity and clinically determined incident hypertension in black and white men and women of the Atherosclerosis Risk in Communities (ARIC) Study.

METHODS

ARIC is a population-based prospective study with four U.S. clinic centers. The present analyses included 7,459 black and white adults 45-65 years of age. Hypertension (systolic/diastolic blood pressure >/= 140/90 mm Hg) was defined by blood pressure measured by a random-zero device or medication use. Physical activity was assessed with the Baecke questionnaire.

RESULTS

After adjustment for age, baseline blood pressure, ARIC center, education, body mass index, waist-hip ratio, parental history of hypertension, cigarette smoking, alcohol consumption, and diet, white men in the highest quartile of leisure activity (primarily cycling and walking) had a 34% lower odds of developing hypertension over 6 years compared to the least active (OR = 0.66, 95% CI = 0.47-0.94; P for quartile trend = 0.01). Baseline activity was not associated with incident hypertension in white women or blacks.

CONCLUSIONS

Leisure-time physical activity reduces the odds of hypertension in middle-aged white men. Additional studies in women and blacks are needed.

Racial differences in renal kallikrein excretion: effect of the ovulatory cycle

BACKGROUND

Renal kallikrein excretion is diminished in essential hypertension, especially in African-Americans, and evidence exists for a major gene effect on the kallikrein phenotype. In addition, urinary kallikrein excretion differs by gender, with ovulating females having greater kallikrein excretion than males or postmenopausal females. Recent studies have shown that renal kallikrein excretion varies in females during the ovulatory cycle, with levels rising during the luteal phase and returning during the follicular phase to levels that are similar to those of males. In family studies, gender differences in urinary kallikrein excretion were present in white subjects, but not black subjects. We therefore hypothesized dysregulation of kallikrein biosynthetic responses in African-Americans.

METHODS

We determined urinary kallikrein activity [chromogenic substrate S2266 (D-val-leu-arg-paranitroanilide) assay; in microU/mg creatinine] in white (N = 15) and black (N = 11) ovulating females during the ovulatory cycle. Serum progesterone, estrogen, plasma renin activity as well as urinary aldosterone, and urinary electrolytes were determined to investigate changes between mid-follicular and mid-luteal phases in the two groups.

RESULTS

White and black groups were matched for age, body mass index, blood pressure, heart rate and renal function. Ovulatory cycle phases were confirmed by serum progesterone determinations, which increased significantly in whites and blacks to a comparable degree [0.84 +/- 0.14 nmol/liter (mid-follicular) to 29.77 +/- 4.70 nmol/liter (mid-luteal) in whites, 0.67 +/- 0.08 nmol/liter (mid-follicular) to 28.62 +/- 5.83 nmol/liter (mid-luteal) in blacks; P < 0.001 for cycle effect, P = NS for race effect and race X cycle interaction]. Urinary kallikrein activity increased from 623 +/- 86 microU/mg creatinine (mid-follicular) to 948 +/- 142 microU/mg creatinine (mid-luteal) in whites, but did not change in blacks during the ovulatory cycle [239 +/- 73 microU/mg creatinine (mid-follicular] to 244 +/- 41 microU/mg creatinine (mid-luteal)]. Two-way ANOVA revealed significant effects on urinary kallikrein for race (P < 0.001), cycle (P < 0.05), and race X cycle interaction (P < 0.05). Thus, white females had higher urinary kallikrein than black females, and demonstrated a significant increase in urinary kallikrein excretion during the ovulatory cycle, whereas no significant change in urinary kallikrein activity was seen in the black group. Enzyme kinetic studies and mixing studies demonstrated that these racial differences in renal kallikrein excretion were quantitative, rather than due to qualitative differences in the renal kallikrein enzyme or due to the presence of a kallikrein inhibitor.

CONCLUSIONS

These results suggest pronounced blunting of menstrual cycle changes in urinary kallikrein excretion in black females. Blunted urinary kallikrein responses during the ovulatory cycle are consistent with dysregulation of renal kallikrein biosynthetic responses in African-Americans, a group at increased risk for hypertension.