Use of beta-blockers in obesity hypertension: potential role of weight gain

From "contraindicated" to "first line" - Current mechanistic insights beyond canonical β-receptor signaling

β-blockers are a solid pillar in the treatment of cardiovascular diseases. However, they are highly discussed regarding effectiveness for certain indications and side-effects. Even though there are up to 20 licensed compounds, only four are used for heart failure (HF) therapy. On the receptor level several key characteristics seem to influence the clinical outcome: subtype selectivity, antagonistic vs (inverse/biased) agonistic properties and -in particular- ancillary capacities. On a molecular level, divergent and novel signaling patterns are being identified and extra-cardiac effects on e.g. inflammation, metabolism and oxidative stress are highlighted. This review discusses different well-known and newly discovered characteristics that need to be considered for HF therapy and in the context of co-morbidities.

Effect of beta-blocker therapy on weight loss outcomes after sleeve gastrectomy & Roux-en-Y gastric bypass

BACKGROUND

Patients taking beta-blockers (BBs) commonly experience weight gain. There is limited research exploring how BBs impact weight loss after bariatric surgery.

OBJECTIVES

We examined how BBs impact 12-month weight loss in patients undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB).

SETTING

Large midwest health system.

METHODS

We reviewed health records of SG and RYGB patients (2011-2022) and categorized them by BB usage (none, pre-, post-, or pre- and postoperative). Multivariable linear regression models examined the relation between BB use, percent total body weight loss (%TBWL), and percent excess body mass index lost (%EBMIL).

RESULTS

A total of 889 individuals (SG, n = 485; RYGB, n = 404) had complete data. RYGB led to greater %TBWL compared to SG (31% versus 26%, P < .01) and greater %EBMIL (79% versus 64%, P < .01). BB status did not significantly affect 12-month %TBWL or %EBMIL.

CONCLUSIONS

BB use may not significantly affect weight loss 12 months after bariatric surgery. This finding could enable physicians to prescribe BBs for improved blood pressure control in bariatric surgery patients with less concern of blunting weight loss. Longer term follow-up with a larger sample size would be an important next step to better characterize the relationship between BB usage and bariatric surgery.

Management of Medication-Induced Weight Gain

Several medications can contribute to weight gain. Medication-induced weight gain can have severe health consequences leading to overweight or obesity, or exacerbation of preexisting obesity and the plethora of obesity-related comorbidities. Weight gain due to medications is potentially avoidable by prescribing medications that are either weight neutral or that lead to weight loss, when appropriate. This article reviews the common classes of medications that contribute to weight gain and discusses alternatives to consider.

American Association of Clinical Endocrinology Consensus Statement: Comprehensive Type 2 Diabetes Management Algorithm - 2023 Update

OBJECTIVE

This consensus statement provides (1) visual guidance in concise graphic algorithms to assist with clinical decision-making of health care professionals in the management of persons with type 2 diabetes mellitus to improve patient care and (2) a summary of details to support the visual guidance found in each algorithm.

METHODS

The American Association of Clinical Endocrinology (AACE) selected a task force of medical experts who updated the 2020 AACE Comprehensive Type 2 Diabetes Management Algorithm based on the 2022 AACE Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan and consensus of task force authors.

RESULTS

This algorithm for management of persons with type 2 diabetes includes 11 distinct sections: (1) Principles for the Management of Type 2 Diabetes; (2) Complications-Centric Model for the Care of Persons with Overweight/Obesity; (3) Prediabetes Algorithm; (4) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Dyslipidemia; (5) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Hypertension; (6) Complications-Centric Algorithm for Glycemic Control; (7) Glucose-Centric Algorithm for Glycemic Control; (8) Algorithm for Adding/Intensifying Insulin; (9) Profiles of Antihyperglycemic Medications; (10) Profiles of Weight-Loss Medications (new); and (11) Vaccine Recommendations for Persons with Diabetes Mellitus (new), which summarizes recommendations from the Advisory Committee on Immunization Practices of the U.S. Centers for Disease Control and Prevention.

CONCLUSIONS

Aligning with the 2022 AACE diabetes guideline update, this 2023 diabetes algorithm update emphasizes lifestyle modification and treatment of overweight/obesity as key pillars in the management of prediabetes and diabetes mellitus and highlights the importance of appropriate management of atherosclerotic risk factors of dyslipidemia and hypertension. One notable new theme is an emphasis on a complication-centric approach, beyond glucose levels, to frame decisions regarding first-line pharmacologic choices for the treatment of persons with diabetes. The algorithm also includes access/cost of medications as factors related to health equity to consider in clinical decision-making.

Challenges in Cardiovascular Evaluation and Management of Obese Patients: JACC State-of-the-Art Review

Many unique clinical challenges accompany the diagnosis and treatment of cardiovascular disease (CVD) in people living with overweight/obesity. Similarly, physicians encounter numerous complicating factors when managing obesity among people with CVD. Diagnostic accuracy in CVD medicine can be hampered by the presence of obesity, and pharmacological treatments or cardiac procedures require careful adjustment to optimize efficacy. The obesity paradox concept remains a source of confusion within the clinical community that may cause important risk factors to go unaddressed, and body mass index is a misleading measure that cannot account for body composition (eg, lean mass). Lifestyle modifications that support weight loss require long-term commitment, but cardiac rehabilitation programs represent a potential opportunity for structured interventions, and bariatric surgery may reduce CVD risk factors in obesity and CVD. This review examines the key issues and considerations for physicians involved in the management of concurrent obesity and CVD.

Drug Safety in Episodic Migraine Management in Adults. Part 2: Preventive Treatments

PURPOSE OF REVIEW

The aim of this review is to aid in decision-making when choosing safe and effective options for preventive migraine medications.

RECENT FINDINGS

In Part 2, we have compiled clinically relevant safety considerations for commonly used migraine prophylactic treatments. Preventive treatment of episodic migraine includes nonspecific and migraine-specific drugs. While medications from several pharmacological classes-such as anticonvulsants, beta-blockers, and antidepressants-have an established efficacy in migraine prevention, they are associated with a number of side effects. The safety of migraine-specific treatments such as anti-CGRP monoclonal antibodies and gepants are also discussed. This review highlights safety concerns of commonly used migraine prophylactic agents and offers suggestions on how to mitigate those risks.

INDY as a Therapeutic Target for Cardio-Metabolic Disease

Decreased expression of the plasma membrane citrate transporter INDY (acronym I’m Not Dead, Yet) promotes longevity and protects from high-fat diet- and aging-induced metabolic derangements. Preventing citrate import into hepatocytes by different strategies can reduce hepatic triglyceride accumulation and improve hepatic insulin sensitivity, even in the absence of effects on body composition. These beneficial effects likely derive from decreased hepatic de novo fatty acid biosynthesis as a result of reduced cytoplasmic citrate levels. While in vivo and in vitro studies show that inhibition of INDY prevents intracellular lipid accumulation, body weight is not affected by organ-specific INDY inhibition. Besides these beneficial metabolic effects, INDY inhibition may also improve blood pressure control through sympathetic nervous system inhibition, partly via reduced peripheral catecholamine synthesis. These effects make INDY a promising candidate with bidirectional benefits for improving both metabolic disease and blood pressure control.

Obesity across the lifespan in congenital heart disease survivors: Prevalence and correlates

BACKGROUND

Congenital heart disease (CHD) survivors are at risk for cardiovascular comorbidities exacerbated by obesity.

OBJECTIVES

Determine relationships between overweight/obesity and medical factors across the lifespan of CHD.

METHODS

Lesion severity, weight, blood pressure, cardiac and other comorbidities, and cardiac medications were abstracted from the medical records of 3790 CHD patients, aged ≥6 years, who attended CHD care in the Midwestern U.S.

RESULTS

The proportion of patients with overweight/obesity increased across the lifespan, with 73% of adults affected by overweight/obesity. Obesity was more prevalent among patients with moderate lesions (29%). Overweight/obesity was associated with elevated blood pressure across age and lesion severity. Young adults with obesity and simple or moderate lesions had more comorbidities (simple: IRR = 3.1, moderate: IRR = 2.3) and cardiac medications (simple: IRR = 2.2, moderate: IRR = 1.7).

CONCLUSIONS

Obesity and its cardiovascular correlates are present across the lifespan for CHD survivors, highlighting the need for early prevention and intervention.

The importance of bone marrow and the immune system in driving increases in blood pressure and sympathetic nerve activity in hypertension

NEW FINDINGS

What is the topic of this review? This manuscript provides a review of the current understanding of the role of the sympathetic nervous system in regulation of bone marrow-derived immune cells and the effect that the infiltrating bone marrow cells may have on perpetuation of the sympathetic over-activation in hypertension. What advances does it highlight? We highlight the recent advances in understanding of the neuroimmune interactions both peripherally and centrally as they relate to blood pressure control.

ABSTRACT

The sympathetic nervous system (SNS) plays a crucial role in maintaining physiological homeostasis, in part by regulating, integrating and orchestrating processes between many physiological systems, including the immune system. Sympathetic nerves innervate all primary and secondary immune organs, and all cells of the immune system express β-adrenoreceptors. In turn, immune cells can produce cytokines, chemokines and neurotransmitters capable of modulating neuronal activity and, ultimately, SNS activity. Thus, the essential role of the SNS in the regulation of innate and adaptive immune functions is mediated, in part, via β-adrenoreceptor-induced activation of bone marrow cells by noradrenaline. Interestingly, both central and systemic inflammation are well-established hallmarks of hypertension and its co-morbidities, including an inflammatory process involving the transmigration and infiltration of immune cells into tissues. We propose that physiological states that prolong β-adrenoreceptor activation in bone marrow can disrupt neuroimmune homeostasis and impair communication between the immune system and SNS, leading to immune dysregulation, which, in turn, is sustained via a central mechanism involving neuroinflammation.

Iatrogenic Obesity

Obesity has been identified as a multifactorial disease with several determinants, including genetic predisposition, environmental influences, dietary patterns, and physical activity factors. Iatrogenic obesity, most commonly medication-induced weight gain, is often overlooked as a contributing factor to a patient's obesity. This article highlights medications known to cause weight gain.

Metabolic Syndrome in Children and Adolescents: Diagnostic Criteria, Therapeutic Options and Perspectives

PURPOSE OF REVIEW

This review summarizes our current understanding of the metabolic syndrome (MetS) in children and adolescents. Special emphasis is given towards diagnostic criteria and therapeutic options.

RECENT FINDINGS

Consistent diagnostic criteria to define MetS in childhood and adolescence are not available to date. There is common agreement that the main features defining MetS include (1) disturbed glucose metabolism, (2) arterial hypertension, (3) dyslipidemia, and (4) abdominal obesity. However, settings of cut-off values are still heterogeneous in the pediatric population. Additional features that may define cardiometabolic risk, such as non-alcoholic fatty liver disease (NAFDL) or hyperuricemia, are not considered to date. Prevalence of childhood obesity has more than doubled since 1980, and 6-39% of obese children and adolescents already present with MetS, depending on the definition applied. There is common agreement that a consistent definition of MetS is urgently needed for children to identify those at risk as early as possible. Such definition criteria should consider age, gender, pubertal stage, or ethnicity. Additional features such as NAFDL or hyperuricemia should also be included in MetS criteria. Lifestyle modification is still the main basis to prevent or treat childhood obesity and MetS, as other therapeutic options (pharmacotherapy, bariatric surgery) are not available or not recommended for the majority of affected youngster.

Achievement of weight loss in patients with overweight during dietetic treatment in primary health care

Introduction

Dietitians are the preferred primary health care professionals for nutritional care in overweight patients. Guidelines for dietitians recommend a weight reduction of ≥ 5% of initial body weight after one year of treatment. The purpose of this study was to evaluate weight change in patients with overweight who were treated by dietitians in Dutch primary health care, and to identify patient characteristics that were associated with it.

Materials and methods

This observational study data was based on real life practice data of patients with overweight during the period 2013–2017, derived from dietetic practices that participated in the Nivel Primary Care Database. Multilevel linear regression analyses were performed to investigate weight change after dietetic treatment and to explore associations with patient characteristics.

Results

In total, data were evaluated from 56 dietetic practices and 4722 patients with a body mass index (BMI) ≥ 25 kg/m². The mean treatment time was 3 hours within an average timeframe of 5 months. Overall, patients had a mean weight change of -3.5% (95% CI: -3.8; -3.1) of their initial body weight, and a quarter of the patients reached a weight loss of 5% or more, despite the fact that most patients did not meet the recommended treatment duration of at least one year. The mean BMI change was -1.1 kg/m² (95% CI: -1.2; -1.0). Higher weight reductions were shown for patients with a higher initial BMI and for patients with a longer treatment time. Sex and age were not associated with weight change, and patients with other dietetic diagnoses, such as diabetes, hypertension, and hypercholesterolemia, had lower weight reductions.

Conclusions

This study showed that dietetic treatment in primary health care coincided with modest weight reduction in patients with overweight. The weight loss goals were not reached for most patients, which was possibly due to a low treatment adherence.

Primary Prevention of ASCVD and T2DM in Patients at Metabolic Risk: An Endocrine Society* Clinical Practice Guideline

OBJECTIVE

To develop clinical practice guidelines for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) and type 2 diabetes mellitus (T2DM) in individuals at metabolic risk for developing these conditions.

CONCLUSIONS

Health care providers should incorporate regular screening and identification of individuals at metabolic risk (at higher risk for ASCVD and T2DM) with measurement of blood pressure, waist circumference, fasting lipid profile, and blood glucose. Individuals identified at metabolic risk should undergo 10-year global risk assessment for ASCVD or coronary heart disease to determine targets of therapy for reduction of apolipoprotein B-containing lipoproteins. Hypertension should be treated to targets outlined in this guideline. Individuals with prediabetes should be tested at least annually for progression to diabetes and referred to intensive diet and physical activity behavioral counseling programs. For the primary prevention of ASCVD and T2DM, the Writing Committee recommends lifestyle management be the first priority. Behavioral programs should include a heart-healthy dietary pattern and sodium restriction, as well as an active lifestyle with daily walking, limited sedentary time, and a structured program of physical activity, if appropriate. Individuals with excess weight should aim for loss of ≥5% of initial body weight in the first year. Behavior changes should be supported by a comprehensive program led by trained interventionists and reinforced by primary care providers. Pharmacological and medical therapy can be used in addition to lifestyle modification when recommended goals are not achieved.

Obesity trends in children, adolescents, and young adults with congenital heart disease

OBJECTIVES

To determine the prevalence, age of onset, and risk factors for overweight and obesity in children with congenital heart disease (CHD).

STUDY DESIGN

Children with CHD who were seen at our institution from 1996 to 2017 were studied. Patients were full-time residents of the United States and were receiving all cardiac care at our institution. Patients were categorized by age and CHD diagnosis. The date of last normal weight for age and the date of first recorded weight in the range of overweight and obese were documented.

RESULTS

Nine hundred sixty-eight patients with CHD were included. The prevalence of overweight and obesity was 31.5% and 16.4%, respectively. For patients who became overweight or obese, the last recorded normal weight was between 6 and 10 years of age. Electrophysiologic disease and older age were risk factors for obesity.

CONCLUSIONS

Children with CHD have an increasing risk of becoming overweight and obese in early childhood. This study provides important information and identifies critical period to implement preventative measures and counsel families about the risk of obesity in CHD.

The Time Point-Specific Effect of Beta-Adrenergic Blockade in Attenuating High Fat Diet-Induced Obesity and Bone Loss

We aimed to clarify the key factor determining the effect of beta blocker attenuating high fat diet- induced obesity and bone loss. Six-week-old C57BL/6 male mice were assigned to groups reflecting different relative onset of obesity and beta blocker administration, different diet (control vs. high fat), and treatment (vehicle vs. beta blocker: propranolol). Mice in Group 1 were fed a control diet (CON) or high fat diet (HIGH) with vehicle or propranolol for 12 weeks. Mice in Group 2 were fed a CON or HIGH without pharmaceutical treatment for the first 12 weeks, followed by another 12 weeks of treatment with vehicle or propranolol. Mice in Group 3 were fed a CON without pharmaceutical treatment for the first 12 weeks, followed by stratification into diet-based subgroups and another 12 weeks of treatment with vehicle or propranolol. Propranolol attenuated the HIGH-induced increase in body weight/fat mass in Group 1 mice and in Group 3 mice, but not in Group 2 mice. Propranolol mitigated HIGH-induced reduction in femoral trabecular bone mineral density and bone architecture deterioration in Group 1 mice but not in Group 2 mice. HIGH feeding in Group 3 did not compromise skeletal integrity. Taken together, propranolol attenuates HIGH-induced body weight increases while weight gain is in progress but not once obesity has already been established. HIGH feeding during the growth period results in compromised bone mass/architecture; which can be attenuated by propranolol administration during the growth period, but not by propranolol administration after obesity has already been established.

Obesity in Women: Insights for the Clinician

As a leading cause of morbidity and mortality in the United States and worldwide, obesity is a disease that is frequently encountered in clinical practice today and requires a range of medical interventions. While obesity affects both men and women across all ages, multiple issues are particularly germane to women's health, particularly as obesity is more prevalent among women than men in the United States and obesity among women of reproductive health relates to the growing issue of childhood obesity. Discussed herein are the epidemiology and pathophysiology of obesity along with the impact of perinatal obesity on fetal programming. Guidance on screening and management of obesity through lifestyle intervention, pharmacologic therapy, and bariatric surgery, as well as avoidance of weight-promoting medications wherever possible, is elaborated. Particular attention is paid to the contribution of these modalities to weight loss as well as their impact on obesity-related comorbidities that affect a woman's overall health, such as type 2 diabetes and hypertension, and her reproductive and gynecologic health. With modest weight loss, women with obesity can achieve notable improvements in chronic medical conditions, fertility, pregnancy outcomes, and symptoms of pelvic floor disorders. Moreover, as children born to women after bariatric surgery-induced weight loss show improved metabolic outcomes, this demonstrates a role for maternal weight loss in reducing risk of development of metabolic disturbances in children. In light of the immense cost burden and mortality from obesity, it is important to emphasize the role of lifestyle intervention, pharmacologic management, and bariatric surgery for weight loss in clinical practice to mitigate the impact of obesity on women's health.

Blocking β₁/β₂-Adrenergic Signaling Reduces Dietary Fat Absorption by Suppressing Expression of Pancreatic Lipase in High Fat-Fed Mice

We investigated whether β-adrenergic antagonists attenuates dietary fat absorption through the regulation of pancreatic lipase (PNLIP) expression in pancreatic acinar cells in the context of high fat diet feeding. Male six-week-old C57BL/6 mice were assigned into an ad libitum fed control diet (CON) and a high fat diet (HIGH). Within each diet group, subgroups of mice were treated with vehicle (VEH) or propranolol, a β-adrenergic antagonist (BB). Over 12 weeks, body weight gain observed in HIGHVEH was mitigated in HIGHBB (+103% vs. +72%). Increase in fecal fat amount observed in HIGHVEH was further increased in HIGHBB. Increase in PNLIP expressions observed in HIGHVEH pancreatic tissues was abolished in HIGHBB. PNLIP expression in mouse primary pancreatic acinar cells and 266-6 cell lines increased with isoproterenol treatment, which was blocked by propranolol. Isoproterenol increased PNLIP expression in a cAMP/protein kinase A/ cyclic AMP response element binding protein (CREB)-dependent manner. CREB directly bound to the CRE on the mouse PNLIP promoter and transactivated PNLIP expression. These results suggest that sympathetic activation increases dietary fat absorption through the upregulation of PNLIP expression and that a β-adrenergic antagonist attenuates obesity development partly through the downregulation of PNLIP expression and inhibition of dietary fat absorption in the context of high fat diet feeding.

Practical Use of Pharmacotherapy for Obesity

Obesity management requires a multidisciplinary approach, as there are many factors that contribute to the development of obesity, as well as the preservation of excess weight once it has been gained. Diet, exercise, and behavior modification are key components of treatment. In addition to lifestyle changes, weight gain secondary to medications is an important modifiable risk factor. Even after appropriate lifestyle modification, and medication adjustments (where possible) to avoid agents that can contribute to weight gain, many patients are still unable to achieve clinically meaningful weight loss. Pharmacotherapy for obesity management can fill an important role for these patients. This article will review medications that can lead to weight gain and potential alternatives, currently approved anti-obesity medications and best practices to individualize the selection process, and the use of testosterone in men with hypogonadism and obesity.

Obesity: A Perspective from Hypertension

The prevalence of obesity-related hypertension is high worldwide and has become a major health issue. The mechanisms by which obesity relates to hypertensive disease are still under intense research scrutiny, and include altered hemodynamics, impaired sodium homeostasis, renal dysfunction, autonomic nervous system imbalance, endocrine alterations, oxidative stress and inflammation, and vascular injury. Most of these contributing factors interact with each other at multiple levels. Thus, as a multifactorial and complex disease, obesity-related hypertension should be recognized as a distinctive form of hypertension, and specific considerations should apply in planning therapeutic approaches to treat obese individuals with high blood pressure.

Perivascular adipose tissue as a regulator of vascular disease pathogenesis: identifying novel therapeutic targets

Adipose tissue (AT) is an active endocrine organ with the ability to dynamically secrete a wide range of adipocytokines. Importantly, its secretory profile is altered in various cardiovascular disease states. AT surrounding vessels, or perivascular AT (PVAT), is recognized in particular as an important local regulator of vascular function and dysfunction. Specifically, PVAT has the ability to sense vascular paracrine signals and respond by secreting a variety of vasoactive adipocytokines. Due to the crucial role of PVAT in regulating many aspects of vascular biology, it may constitute a novel therapeutic target for the prevention and treatment of vascular disease pathogenesis. Signalling pathways in PVAT, such as those using adiponectin, H₂ S, glucagon-like peptide 1 or pro-inflammatory cytokines, are among the potential novel pharmacological therapeutic targets of PVAT.

LINKED ARTICLES

This article is part of a themed section on Molecular Mechanisms Regulating Perivascular Adipose Tissue - Potential Pharmacological Targets? To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.20/issuetoc.

Utilization of antihypertensive drugs in obesity-related hypertension: a retrospective observational study in a cohort of patients from Southern Italy

Background

Although the pathophysiological mechanisms of arterial hypertension are different in obese and lean patients, hypertension guidelines do not include specific recommendations for obesity-related hypertension and, therefore, there is a considerable uncertainty on which antihypertensive drugs should be used in this condition. Moreover, studies performed in general population suggested that some antihypertensive drugs may increase body weight, glycemia and LDL-cholesterol but it is unclear how this impact on drug choice in clinical practice in the treatment of obese hypertensive patients. Therefore, in order to identify current preferences of practitioners for obesity-related hypertension, in the present work we evaluated antihypertensive drug therapy in a cohort of 129 pharmacologically treated obese hypertensive patients (46 males and 83 females, aged 51.95 ± 10.1 years) that came to our observation for a nutritional consultation.

Methods

Study design was retrospective observational. Differences in the prevalence of use of the different antihypertensive drug classes among groups were evaluated with χ² square analysis. Threshold for statistical significance was set at p < 0.05.

Results

41.1 % of the study sample was treated with one, 36.4 % with two and the remaining 22.5 % with three or more antihypertensive drugs. In patients under single drug therapy, β-blockers, ACEIs and ARBs accounted each for about 25 % of prescriptions. The prevalence of use of β-blockers was about sixfold higher in females than males. Diuretics were virtually never used in monotherapy regimens but were used in more than 60 % of patients on dual antihypertensive therapy and in all patients assuming three or more drugs. There was no significant difference in the prevalence of use of any of the aforementioned drugs among patients with obesity of type I, II and III or between patients with or without metabolic syndrome.

Conclusions

Our data show that no first choice protocol seems to be adopted in clinical practice for the treatment of obesity-related hypertension. Importantly, physicians do not seem to differentiate drug use according to the severity of obesity or to the presence of metabolic syndrome or to avoid drugs known to detrimentally affect body weight and metabolic profile in general population.

Adverse Effects of β-Blocker Therapy on Weight Loss in Response to a Controlled Dietary Regimen

BACKGROUND

The effects of β-blockers on metabolic parameters including weight loss are poorly understood.

METHODS

From a database of 3582 patients who completed The Ottawa Hospital Weight Management Program between 1992 and 2011, a total of 173 patients were receiving β-blockers and were eligible for the study. We determined differences in rate of weight loss in the first 6 weeks of this 900 kcal/d Optifast (Nestlé Health Science, Vevey, Switzerland) meal replacement program for patients treated with β-blockers compared with (1) matched controls and (2) all participants in the program not being treated with β-blockers. Secondary outcomes included changes in waist circumference.

RESULTS

Mean percent weight loss in the β-blocker group was reduced compared with the rest of the group (9.7% vs 10.0%; P = 0.0001) as well as with matched controls (9.7% vs 10.3%; P = 0.004). Results were the same after adjusting for prevalent cardiovascular disease (9.7% vs 10.0%; P = 0.006). Similarly, a smaller decrease in waist circumference at 6 weeks was observed in the β-blocker-treated group compared with the rest of the group (-24.2 vs -26.3 cm; P = 0.002) and with matched controls (-24.2 vs -25.2 cm; P = 0.04) and was not altered by adjustment for cardiovascular disease (-24.2 vs 26.3 cm; P = 0.004).

CONCLUSIONS

In the absence of a clear medical indication, alternatives to β-blockers should be considered for the treatment of hypertension in obese individuals.

Anti-hypertensive treatment preserves appetite suppression while preventing cardiovascular adverse effects of tesofensine in rats

OBJECTIVE

Tesofensine is a novel triple monoamine reuptake inhibitor which is in development for the treatment of obesity. Preclinical and clinical data suggest that appetite suppression is an important mechanism by which tesofensine exerts its robust weight reducing effect. Notably, the strong hypophagic response to tesofensine treatment is demonstrated to be linked to central stimulation of noradrenergic and dopaminergic neurotransmission. The sympathomimetic mode of action of tesofensine may also associate with the elevated heart rate and blood pressure observed in clinical settings, and we therefore sought experimentally to address this issue.

DESIGN AND METHODS

The anorexigenic and cardiovascular effects of tesofensine were studied simultaneously in telemetrized conscious rats in a combined real-time food intake and cardiovascular telemetry monitoring system.

RESULTS

Acute administration of tesofensine caused a dose-dependent hypophagic effect as well as increased heart rate and blood pressure. Interestingly, combined treatment with metoprolol (b1 adrenoceptor blocker, 10-20 mg/kg, p.o.) fully prevented the cardiovascular sympathetic effects of tesofensine while leaving the robust inhibitory efficacy on food intake unaffected. Similarly, the angiotensin AT1 receptor antagonist telmisartan (1.0-3.0 mg/kg, p.o.) did not interfere with the anti-obesity effects of tesofensine, however, telmisartan only partially reversed the increase in systolic blood pressure and had no effect on the elevated heart rate induced by tesofensine.

CONCLUSION

These data suggests that tesofensine causes elevations in heart rate and blood pressure by increasing sympathetic activity, and that different adrenoceptor subtypes may be responsible for the anti-obesity and cardiovascular effects of tesofensine.

The role of Beta-blockers as first-line therapy in hypertension

National and international guidelines still recommend β-blockers (BBs) as first-line agents in uncomplicated prevention of hypertension. However, it has been shown that BBs reduce blood pressure less than other drugs, specifically with regard to central aortic pressure. More importantly, recent meta-analyses have highlighted that in primary prevention BBs are associated with a relatively weak effect in reducing stroke compared to placebo or no treatment and, compared with other drugs, show evidence of a worse cardiovascular outcome. Several reasons might explain their mild cardioprotective effect, such as their unfavorable metabolic properties, a lack of efficacy on left ventricular hypertrophy regression and endothelial dysfunction, and reduced patient compliance. Thus, the available evidence does not support the use of BBs as first-line drugs in the treatment of uncomplicated hypertension. It remains to be determined whether newer BBs, such as nebivolol and carvedilol, will be more effective than older compounds in improving cardiovascular prognosis.

Mechanisms of obesity-induced hypertension

The relationship between obesity and hypertension is well established both in children and adults. The mechanisms through which obesity directly causes hypertension are still an area of research. Activation of the sympathetic nervous system has been considered to have an important function in the pathogenesis of obesity-related hypertension. The arterial-pressure control mechanism of diuresis and natriuresis, according to the principle of infinite feedback gain, seems to be shifted toward higher blood-pressure levels in obese individuals. During the early phases of obesity, primary sodium retention exists as a result of increase in renal tubular reabsorption. Extracellular-fluid volume is expanded and the kidney-fluid apparatus is resetted to a hypertensive level, consistent with a model of hypertension because of volume overload. Plasma renin activity, angiotensinogen, angiotensin II and aldosterone values display significant increase during obesity. Insulin resistance and inflammation may promote an altered profile of vascular function and consequently hypertension. Leptin and other neuropeptides are possible links between obesity and the development of hypertension. Obesity should be considered as a chronic medical condition, which is likely to require long-term treatment. Understanding of the mechanisms associated with obesity-related hypertension is essential for successful treatment strategies.

Metoprolol compared to carvedilol deteriorates insulin-stimulated endothelial function in patients with type 2 diabetes - a randomized study

AIM

Studies of beta blockade in patients with type 2 diabetes have shown inferiority of metoprolol treatment compared to carvedilol on indices of insulin resistance. The aim of this study was to examine the effect of metoprolol versus carvedilol on endothelial function and insulin-stimulated endothelial function in patients with type 2 diabetes.

METHOD

24 patients with type 2 diabetes were randomized to receive either 200 mg metoprolol succinate or 50 mg carvedilol daily. Endothelium-dependent vasodilation was assessed by using venous occlusion plethysmography with increasing doses of intra-arterial infusions of the agonist serotonin. Insulin-stimulated endothelial function was assessed after co-infusion of insulin for sixty minutes. Vaso-reactivity studies were done before and after the two-month treatment period.

RESULTS

Insulin-stimulated endothelial function was deteriorated after treatment with metoprolol, the percentage change in forearm blood-flow was 60.19% +/- 17.89 (at the highest serotonin dosages) before treatment and -33.80% +/- 23.38 after treatment (p = 0.007). Treatment with carvedilol did not change insulin-stimulated endothelial function. Endothelium-dependent vasodilation without insulin was not changed in either of the two treatment groups.

CONCLUSION

This study shows that vascular insulin sensitivity was preserved during treatment with carvedilol while blunted during treatment with metoprolol in patients with type 2 diabetes.

TRIAL REGISTRATION

Current Controlled Trials NCT00497003.

Why beta-blockers should not be used as first choice in uncomplicated hypertension

In the past 4 decades, beta blockers (BBs) have been widely used in the treatment of uncomplicated hypertension and are still recommended as first-line agents in national and international guidelines. Their putative cardioprotective properties, however, derive from the extrapolation into primary prevention of data relative to the reduction of mortality observed in the 1970s in patients with previous myocardial infarctions. In the past 5 years, a critical reanalysis of older trials, together with several meta-analyses, has shown that in patients with uncomplicated hypertension BBs exert a relatively weak effect in reducing stroke compared to placebo or no treatment, do not have any protective effect with regard to coronary artery disease and, compared to other drugs, such as calcium channel blockers, renin-angiotensin-aldosterone system inhibitors or thiazide diuretics, show evidence of worse outcomes, particularly with regard to stroke. Several reasons can explain their reduced cardioprotection: their suboptimal effect in lowering blood pressure compared to other drugs; their "pseudoantihypertensive" efficacy (failure to lower central aortic pressure); their undesirable adverse effects, which reduce patients' compliance; their unfavorable metabolic effects; their lack of an effect on regression of left ventricular hypertrophy and endothelial dysfunction. In conclusion, the available evidence does not support the use of BBs as first-line drugs in the treatment of hypertension. Whether newer BBs, such as nebivolol and carvedilol, which show vasodilatory properties and a more favorable hemodynamic and metabolic profile, will be more efficacious in reducing morbidity and mortality remains to be determined.

Sympathetic nervous system overactivity and its role in the development of cardiovascular disease

This review examines how the sympathetic nervous system plays a major role in the regulation of cardiovascular function over multiple time scales. This is achieved through differential regulation of sympathetic outflow to a variety of organs. This differential control is a product of the topographical organization of the central nervous system and a myriad of afferent inputs. Together this organization produces sympathetic responses tailored to match stimuli. The long-term control of sympathetic nerve activity (SNA) is an area of considerable interest and involves a variety of mediators acting in a quite distinct fashion. These mediators include arterial baroreflexes, angiotensin II, blood volume and osmolarity, and a host of humoral factors. A key feature of many cardiovascular diseases is increased SNA. However, rather than there being a generalized increase in SNA, it is organ specific, in particular to the heart and kidneys. These increases in regional SNA are associated with increased mortality. Understanding the regulation of organ-specific SNA is likely to offer new targets for drug therapy. There is a need for the research community to develop better animal models and technologies that reflect the disease progression seen in humans. A particular focus is required on models in which SNA is chronically elevated.

Clinical Review: Is the Perioperative Use of β-Blockers Still Recommended? A Critical Review of Recent Controversies

The optimal role of β-adrenergic receptor blockade in the perioperative period remains unclear in patients at risk for cardiovascular events. Cardiovascular complications continue to be the most common cause of perioperative morbidity and mortality, and cardioprotective properties of β-blockers are widely recognized, yet the results of the clinical trials investigating the use of different β-blockers in the perioperative period are controversial. The discrepancy might be related to differences in the design of studies, use of different agents, administration by different routes, and continuation for different time intervals. Evidently, perioperative mortality and morbidity seem to be related to heart rate, and the majority of complications are related to β-blockers’ side effects. Based on the observations from different studies, we propose an algorithm for perioperative β blockade.

Elevated heart rate in cardiovascular diseases: a target for treatment?

Heart rate is a major determinant of myocardial oxygen consumption and of cardiac work, and thus reduction of heart rate may represent an important strategy for the treatment of patients with a wide range of cardiac disorders. In addition, several experimental lines of research point to high heart rate as an important risk factor for atherosclerosis and, thus, pharmacologic heart rate reduction could prevent or retard the development of atherosclerotic plaques and increase survival. Today, in patients with acute or chronic coronary syndromes or with congestive heart failure, reducing heart rate is a generally accepted treatment modality. Up to now, no human study has been performed to demonstrate the efficacy and the risk-benefit ratio of cardiac slowing in patients without cardiac disorders. However, recent retrospective analyses of the INternational VErapamil-SR/trandolapril STudy and the Paris Prospective Study 1 provided promising results. Treatment of high heart rate in healthy subjects appears to be premature, but in clinical conditions such as hypertension or diabetes, the reduction of elevated heart rate appears a desirable additional goal of therapy.

Beta3-adrenoceptor function and long-term changes in body weight

BACKGROUND

The endogenous factors contributing to long-term changes in body weight are not known but the regulation of energy metabolism by different beta-adrenoceptors (beta(1)-AR, beta(2)-AR, beta(3)-AR) or alpha-adrenoceptors (alpha(2)-AR) may play a role.

METHODS

In a prospective study, we investigated beta-AR and alpha(2)-AR subtype function in subcutaneous fat cells of 85 healthy, non-obese women by using a standardized bioassay of lipolysis. Of these 73 were re-investigated on an average 10 years later to compare baseline function of beta(1)-AR, beta(2)-AR, beta(3)-AR and alpha(2)-AR with longitudinal weight changes.

RESULTS

Weight change over time was normally distributed ranging from-4 kg/m(2) to +6 kg/m(2) in body mass index. Long-term changes in body weight correlated inversely with beta(3)-AR function at base line (r=0.5, P=0.001). Those with low beta(3)-AR function gained weight, whereas the opposite was observed with those who had a high beta(3)-AR function. Nineteen percent of weight changes could be explained by beta(3)-AR status. No relationship with weight changes was observed as regards the function of alpha(2)-AR, beta(1)-AR or beta(2)-AR function.

CONCLUSIONS

Beta(3)-ARs are important for long-term changes in body weight putting energy metabolism in adipose tissue in frontline among endogenous factors that regulate body weight in adulthood.

Prevalence and correlates of eating disorder co-morbidity in patients with bipolar disorder

This study was designed to document eating disorder symptoms in a well-defined sample of patients with bipolar disorder and to evaluate the relationship of current loss of control over eating (LOC) to demographic and clinical features hypothesized to characterize bipolar patients at risk for disordered eating. Eighty-one patients enrolled in the Bipolar Disorder Center for Pennsylvanians provided demographic information and completed the Structured Clinical Interview for DSM-IV Axis I Disorders. The Eating Disorder Examination was administered by independent clinicians to evaluate current and lifetime eating disorder symptomatology. Twenty-one percent of participants met DSM-IV criteria for a lifetime eating disorder, and 44% reported a history of LOC. Patients who endorsed weekly LOC during the past six months (n=18) were heavier, had more atypical depressive symptoms, and were more likely to have a lifetime substance use disorder compared to patients in the rest of the sample (n=63). These findings indicate that eating disorder symptoms are prevalent in patients with bipolar disorder and are associated with obesity and other psychiatric morbidity. Screening for eating disorders in bipolar patients is warranted, as intervention may minimize distress and improve treatment outcome.

Changes in lifestyle after hypertension diagnosis in Canada

Lifestyle modification should be an important part of therapy when hypertension is first diagnosed, with or without starting antihypertensive medication. The objective of the present study was to determine the extent to which recently diagnosed hypertensive Canadians modify their lifestyles and to examine how lifestyle modification relates to antihypertensive medication use. The longitudinal National Population Health Survey in Canada was conducted between 1994 and 2002, including five interview cycles at two-year intervals. During this time, 1281 persons reported hypertension in one cycle but not in the previous cycle, and were considered to be new hypertensive patients. Information collected included body mass index, smoking, alcohol consumption, physical inactivity and medication use. The main lifestyle modification associated with newly diagnosed hypertensive patients was smoking cessation, with a 18.6% relative risk reduction (RRR). A smaller change was seen in decreasing physical inactivity (RRR 6.2%). Persons not taking antihypertensive medication were not more likely to make lifestyle improvements. Paradoxically, new hypertensive patients showed increased numbers in the obese category (RRR -9.6%). Weight gain was especially marked among antihypertensive medication users and largest in female beta-blocker users (RRR -36.6%). If confirmed, this needs to be considered when prescribing to overweight people. In general, a greater effort is required to manage hypertension by lifestyle risk modification with or without antihypertensive medication.

Barriers to obesity treatment

Obesity, one of the most prevalent health problems in the Western world, is a chronic and progressive condition. Therefore, as with other chronic diseases, patients with obesity require lifelong treatment. Long-term efficacy and effectiveness of obesity treatments is notoriously poor. This may in part be attributable to the substantial barriers that undermine long-term obesity management strategies. These can include lack of recognition of obesity as a chronic condition, low socioeconomic status, time constraints, intimate saboteurs, and a wide range of comorbidities including mental health, sleep, chronic pain, musculoskeletal, cardiovascular, respiratory, digestive and endocrine disorders. Furthermore, medications used to treat some of these disorders may further undermine weight-loss efforts. Lack of specific obesity training of health professionals, attitudes and beliefs as well as coverage and availability of obesity treatments can likewise pose important barriers. Health professionals need to take care to identify, acknowledge and address these barriers where possible to increase patient success as well as compliance and adherence with treatments. Failure to do so may further undermine the sense of failure, low self esteem and self efficacy already common among obese individuals. Addressing treatment barriers can save resources and increase the prospect of long-term success.

Cardiovascular protection using beta-blockers: a critical review of the evidence

For more than 3 decades, beta-blockers have been widely used in the treatment of hypertension and are still recommended as first-line agents by national and international guidelines. Recent meta-analyses indicate that, in patients with uncomplicated hypertension, compared with other antihypertensive agents, first-line therapy with beta-blockers was associated with an increased risk of stroke, especially in the elderly cohort with no benefit for the end points of all-cause mortality, cardiovascular morbidity, and mortality. In this review, we critically analyze the evidence supporting the use of beta-blockers in patients with hypertension and evaluate evidence for its role in other indications. The review of the currently available literature shows that in patients with uncomplicated hypertension, there is a paucity of data or absence of evidence to support use of beta-blockers as monotherapy or as first-line agents. Given the increased risk of stroke, their "pseudo-antihypertensive" efficacy (failure to lower central aortic pressure), lack of effect on regression of target end organ effects like left ventricular hypertrophy and endothelial dysfunction, and numerous adverse effects, the risk benefit ratio for beta-blockers is not acceptable for this indication. However, beta-blockers remain very efficacious agents for the treatment of heart failure, certain types of arrhythmia, hypertropic obstructive cardiomyopathy, and in patients with prior myocardial infarction.

The relationship of body mass index to outcomes after percutaneous coronary intervention

OBJECTIVES

To evaluate the effect of body mass index (BMI) on in-hospital outcomes in patients undergoing percutaneous coronary intervention (PCI) at a tertiary care hospital center in Ontario, Canada.

BACKGROUND

Obesity is present in a large population of patients undergoing revascularization with PCI.

METHODS

Retrospective analysis of 4,631 patients aged 62.0 +/- 12 years, stratified by BMI into five groups: nonobese (<25 kg/m2); overweight (25-29.9 kg/m2); class I obese (30-34.9 kg/m2); class II obese (35-39.9 kg/m2); and class III obese (> or =40 kg/m2).

RESULTS

A BMI >25 kg/m2 was present in 79% of patients, and 35% were obese (BMI > or =30 kg/m2). Obese patients, particularly the class III obese, were significantly younger and had higher prevalence of diabetes, hypertension, and dyslipidemia (P < 0.0001). After adjustment for several covariates, lower BMI was independently associated with higher risk of major bleeding requiring transfusion (adjusted odds ratio [OR]= 1.40, 95% confidence interval [CI] 1.04-1.88, P = 0.025), and femoral hematoma (adjusted OR = 1.14, 95% CI 1.05-1.25, P = 0.003) in lean (<20 kg/m2) and normal BMI (20-24.9 kg/m2) patients. Obesity was not associated with death, myocardial infarction, repeat PCI, coronary artery bypass grafting, or major adverse cardiac event.

CONCLUSIONS

Obesity is not associated with increased risk of adverse postprocedural in-hospital outcomes. These findings, however, do not discount the need for sustained efforts in secondary prevention of obesity and its consequences.

A Re-examination of the Metabolic Equivalent Concept in Individuals With Coronary Heart Disease

OBJECTIVE

The metabolic equivalent (MET) is a commonly used method of quantifying the energy cost and intensity of physical activity. Recent studies have questioned the accuracy of the well-accepted value of a MET of 3.5 mL O2.kg(-1).min(-1). The goal of the present study was to compare the traditionally accepted value for 1 MET to direct measures of resting metabolic rate in a group of stable individuals with coronary heart disease (CHD).

METHODS

The primary cohort consisted of 109 (60 men and 49 women) subjects with documented coronary heart disease and a body mass index >or=25 kg/m2. Measurements included indirect calorimetry, body composition, and exercise capacity (peak oxygen uptake [VO2]). In a substudy of 17 (10 men, 7 women) normal weight subjects (body mass index <25 kg/m2), metabolic rate in the seated position was also measured.

RESULTS

Mean resting value for 1 MET was a VO2 value of 2.58 +/- 0.4 mL O2.kg(-1).min(-1) for overweight subjects measured in the supine position and 2.84 +/- 0.59 mL O2.kg(-1).min(-1) for normal weight individuals measured in the seated position. Caloric expenditure value was 0.74 +/- 0.12 kcal.kg(-1).h(-1) rather than the expected value of 1 kcal.kg(-1).h(-1). Values were similar between men and women. Women on beta-blockers had a lower resting metabolic rate (2.47 +/- 0.27 vs. 2.71 +/- 0.38 mL O2.kg(-1).min(-1)) (P < .05) than women not on beta-blocker therapy, whereas there was no effect of beta-blockers in men.

CONCLUSIONS

Findings confirm recent studies of otherwise healthy individuals and indicate that the average resting metabolic rate in subjects with coronary heart disease is 23% to 36% lower than the widely accepted value of 3.5 mL O2.kg(-1).min(-1). Results demonstrate the limitation of the convention of expressing energy expenditure in multiples of an assumed constant.

Bosentan: a review of its use in pulmonary arterial hypertension and systemic sclerosis

Bosentan (Tracleer), an orally administered dual endothelin (ET)(A) and ET(B) receptor antagonist, is indicated in the treatment of pulmonary arterial hypertension (PAH). The efficacy of oral bosentan 125 mg twice daily in improving exercise capacity has been demonstrated in well designed trials in adult patients with idiopathic PAH or PAH associated with connective tissue disease or congenital systemic-to-pulmonary shunts, and in other trials in patients with idiopathic PAH or PAH associated with congenital heart disease or HIV infection. The beneficial effects of first-line bosentan treatment may be maintained for up to 1 year in patients with idiopathic PAH or PAH associated with connective tissue disease. Despite the potential for treatment-related teratogenicity and hepatotoxicity, long-term data indicate that bosentan is generally well tolerated at the approved dosages. Although well designed trials are required to establish the efficacy of bosentan versus or in combination with other specific PAH therapies, especially sildenafil, the convenient oral administration and lack of serious injection-related adverse effects may render bosentan preferable to other PAH therapies. Preliminary data indicate that bosentan may be effective in pediatric PAH patients, although randomized trials are required. Furthermore, bosentan may be a useful option for the prevention of digital ulcer development in patients with systemic sclerosis. Thus, in accordance with current clinical guidelines, bosentan is a convenient, effective, and generally well tolerated agent for use in the first-line treatment of class III PAH or second-line treatment of class IV PAH.