Insulin resistance and sympathetic overactivity in women

The association of triglyceride-glucose index with major adverse cardiovascular and cerebrovascular events after acute myocardial infarction: a meta-analysis of cohort studies

BACKGROUND

Insulin resistance (IR) is indicated to be linked with adverse outcomes of acute myocardial infarction (AMI), for its pro-inflammatory and pro-thromboplastic function. The triglyceride-glucose (TyG) index is a newly developed substitute marker for IR. The aim of this pooled analysis was to provide a summary of the relationship of TyG index with occurrences of major adverse cardiovascular and cerebrovascular events (MACCEs) among populations suffering from AMI.

METHODS

Cohorts reporting multivariate-adjusted hazard ratios of TyG index with MACCEs or its independent events were identified through systematically searching PubMed, MEDLINE, Web of science, Embase and Cochrane databases. Results were combined using a random-effects model.

RESULTS

21 cohorts comprising 20403 individuals were included. Compared to individuals in the lowest TyG category, patients in the highest TyG category exhibited elevated risks of both MACCEs (P < 0.00001) and all-cause death (P < 0.00001). These findings were in line with the results as TyG analyzed as continuous variables (MACCEs: P = 0.006; all-cause death: P < 0.00001). Subgroup analysis demonstrated that diabetic status, type of AMI, nor the reperfusion therapy did not destruct this correlation (for subgroups, all P < 0.05).

CONCLUSION

All these indicated that higher TyG index could potentially predict MACCEs and all-cause death in patients with AMI as an independent indicator.

Relationship Between the Triglyceride-Glucose Index and Type 2 Diabetic Macroangiopathy: A Single-Center Retrospective Analysis

PURPOSE

The research explores the relationship between the triglyceride-glucose index (TyG index) and the macroangiopathy risk in single-center hospitalized type 2 diabetes mellitus (T2DM) patients and develops a risk prediction nomogram model.

PATIENTS AND METHODS

A total of 858 patients with T2DM were studied retrospectively. Lasso regression was used to eliminate unimportant factors, and multivariate logistic regression analysis was used to investigate the association between the TyG index and macrovascular disease in T2DM. A nomogram model was constructed to predict macrovascular disease in T2DM and tested using the bootstrap technique, and the efficacy of the nomogram model was investigated using ROC curves. The multivariate Cox proportional hazards model estimated the association between the TyG index and all-cause mortality.

RESULTS

TyG index, high-density lipoprotein, red blood cell count, hypertension, history of taking ACEI/ARB drugs, and aortic calcification were closely related to macrovascular complications. In Cox proportional hazard model, the HRs of TyG index were 1.89 (95% confidence interval (CI) 1.29-2.76, p < 0.001) after adjusting for covariates. The risk of all-cause mortality in T2DM with macrovascular complications was significantly higher than in diabetic patients without vascular disease. In the ROC curve analysis, the cut-off value of the TyG index for macrovascular complications of T2DM was 9.31 (AUC: 0.702, 95% CI 0.67-0.74, p < 0.001).

CONCLUSION

TyG index predicts future macrovascular disease in diabetic patients independently of known cardiovascular risk factors, suggesting that TyG index may be a useful marker for prognosis in diabetic patients.

Triglyceride-glucose index and the incidence of atherosclerotic cardiovascular diseases: a meta-analysis of cohort studies

Background

Insulin resistance has been demonstrated to be involved in the pathogenesis of atherosclerotic cardiovascular diseases (ASCVDs). This study evaluated the association between the triglyceride–glucose (TyG) index, a novel surrogate indicator of insulin resistance, and the incidence of ASCVDs in people without ASCVDs at baseline by performing a meta-analysis.

Methods

Cohort studies reporting the multivariate-adjusted association between the TyG index and the incidence of ASCVDs were obtained by searching the PubMed and Embase databases. A random-effects model incorporating intra-study heterogeneity was applied to combine the results.

Results

Eight cohort studies comprising 5,731,294 participants were included in this meta-analysis. The results showed that compared to those with the lowest TyG index category, participants with the highest TyG index category were independently associated with a higher risk of ASCVDs [hazard ratio (HR): 1.61, 95% confidence interval (CI) 1.29–2.01, I² = 80%, P < 0.001]. This finding was consistent with the meta-analysis results with the TyG index analyzed as a continuous variable (HR per 1-unit increment of the TyG index: 1.39, 95% CI 1.18–1.64, I² = 89%, P < 0.001). Subgroup analyses suggested that the age, sex, and diabetic status did not significantly affect the association (for subgroup analyses, all P > 0.05). Moreover, participants with the highest TyG index category were independently associated with a higher risk of coronary artery disease [(CAD), HR: 1.95, 95% CI 1.47–2.58, I² = 92%, P < 0.001] and stroke (HR: 1.26, 95% CI 1.23–1.29, I² = 0%, P < 0.001).

Conclusions

A higher TyG index may be independently associated with a higher incidence of ASCVDs, CAD, and stroke in people without ASCVDs at baseline.

Expression of ADR-α1, 2 and ADR-β2 in cumulus cell culture of infertile women with polycystic ovary syndrome and poor responder who are a candidate for IVF: the novel strategic role of clonidine in this expression

OBJECTIVE

Alpha and beta-adrenoceptors (ADR-α1, 2, and β2) play a regulatory role in the folliculogenesis and steroidogenesis in the ovarian follicles. This study aimed to measure these adrenoceptors mRNA and its protein levels in cumulus cells (CCs) culture of poor ovarian reserve (POR) and polycystic ovarian syndrome (PCOS) infertile women (IVF candidate) and the effect of clonidine treatment at CCs culture.

METHODS

This case/control study was conducted in 2017 includes a control (donation oocytes) and two studies (PCO and POR) groups. The ovulation induction drugs were prescribed in all groups. After the oocyte puncture, the follicular fluid was collected and CCs were isolated were cultured. RNA was extracted and cDNA was synthesized and designed the primer for the ADR-α1, 2 and ADR-β2 gene expression. The protein levels were investigated by Western Blot.

RESULTS

The results showed a high level of three adrenergic expressions in PCO women compared to the control group (p-value <.001), which can be reduced by clonidine. POR group showed a significant decrease in the gene expression of ADR-α1 (p-value = .004) and ADR-α2 (p-value = .003) compared to the control group and clonidine treatment had no effect.

CONCLUSION

The significant increase of three adrenoceptors gene expression and protein levels in CCs culture indicate to the hyperactivity of the ovarian sympathetic nervous system at the receptor levels in women with PCOS, and clonidine confirmed it by reducing this expression. In POR women, the reduction of ADR-α1, 2 expressions maybe lead to the aging process in the ovary.

Left ventricular myocardial mass index and its correlates as an early marker of cardiovascular risk among nonobese normotensive Indian women with polycystic ovary syndrome: lessons from a cross-sectional study

OBJECTIVE

To quantitate left ventricular mass index (LVMI) and correlate it with inflammation, insulin resistance (IR) and serum androgen levels among nonobese normotensive women with polycystic ovary syndrome (PCOS).

DESIGN

Cross-sectional study SETTING: Tertiary care institute in North India PATIENTS: A total of 260 drug-naive women qualifying the Rotterdam 2003 criteria for diagnosis of PCOS and 250 apparently healthy women matched for age and body mass index (BMI).

INTERVENTIONS

Clinical, biochemical, hormonal, and inflammatory marker assessment was followed by estimation of LVM and LVMI by 2-dimensional echocardiography.

MAIN OUTCOME MEASURES

LVM and LVMI in nonobese, normotensive women with PCOS and its correlation with subinflammation, IR, and androgen excess.

RESULTS

Mean ages (28.08 ± 4.18 vs. 29.44 ± 6.33 years) and BMI (24.43 ± 4.15 vs. 23.92 ± 4.21 kg/m²) of cases vs. controls were comparable, as was blood pressure and plasma glucose (1 hour after oral glucose tolerance test [OGTT]). Women with PCOS had fewer menstrual cycles per year and higher Ferriman-Gallwey scores, plasma insulin, homeostasis model assessment of IR, total testosterone, plasma glucose (fasting and 2 hours after OGTT), serum high-sensitive C-reactive protein, tumor necrosis factor-α, and interleukin-6 than did the controls (P<.001). Significant differences were observed in LVM (101.50 ± 30.19 vs. 89.35 ± 27.57 g) and LVMI (63.60 ± 16.67 vs. 56.32 ± 10.84 g/m²) between women with PCOS and the controls (P<.001). Multivariate analysis revealed that proinflammatory markers and IR rather than hyperandrogenism correlated with LVMI.

CONCLUSION

We conclude that normotensive nonobese women with PCOS were more likely to have elevated mean LVMI than were healthy controls and it was positively correlated with proinflammatory markers and IR but not with androgen excess. Well-designed long-term follow-up studies with a larger cohort of subjects with comprehensive cardiovascular risk assessment are warranted to conclusively answer the question.

The Fate of Older Diabetic Patients on Peritoneal Dialysis: Myths and Mysteries and Suggestions for Further Research

The outcome of older and especially of female diabetic patients appears to be worse on peritoneal dialysis (PD) than on hemodialysis (HD). This opinion is based mostly on data coming from the USA, whereas data from other regions seem to give a more balanced picture. The questions arise whether indeed outcome is worse in this patient group, and what might be the underlying reasons for this; further research to unravel this phenomenon is warranted. This review proposes several suggestions for further exploration. The observed differences in outcome might be attributable to differences in treatment practices and experience with PD versus HD. As cardiovascular mortality is a major killer in end-stage renal disease patients, differences in fluid homeostasis and how it is achieved are potential explanations. Fluid balance is potentially more difficult to obtain in PD patients, especially as in the past it was spuriously suggested that fluid restriction was less important in PD patients. PD and HD might also have different impacts on factors related to inflammation, insulin resistance, and hormone balance. The adipocytokine network is of special interest in this respect. It is also possible that bias introduced by the way we measure body composition might have a more negative impact on PD than on HD patients. Finally, it still is not fully established that if diabetic patients are treated appropriately, their outcome on PD is worse than that on HD; further observational trials in this respect are needed. All these topics require further clarification and investigation.

Genetics and Epigenetics of Infertility and Treatments on Outcomes

CONTEXT

Infertility affects 10% of the reproductive-age population. Even the most successful treatments such as assisted reproductive technologies still result in failed implantation. In addition, adverse pregnancy outcomes associated with infertility have been attributed to these fertility treatments owing to the presumed epigenetic modifications of in vitro fertilization and in vitro embryo development. However, the diagnosis of infertility has been associated with adverse outcomes, and the etiologies leading to infertility have been associated with adverse pregnancy and long-term outcomes.

EVIDENCE ACQUISITION

We have comprehensively summarized the data available through observational, experimental, cohort, and randomized studies to better define the effect of the underlying infertility diagnosis vs the epigenetics of infertility treatments on treatment success and overall outcomes.

EVIDENCE SYNTHESIS

Most female infertility results from polycystic ovary syndrome, endometriosis, and unexplained infertility, with some cases resulting from a polycystic ovary syndrome phenotype or underlying endometriosis. In addition to failed implantation, defective implantation can lead to problems with placentation that leads to adverse pregnancy outcomes, affecting both mother and fetus.

CONCLUSION

Current research, although limited, has suggested that genetics and epigenetics of infertility diagnosis affects disease and overall outcomes. In addition, other fertility treatments, which also lead to adverse outcomes, are aiding in the identification of factors, including the supraphysiologic hormonal environment, that might affect the overall success and healthy outcomes for mother and child. Further studies, including genome-wide association studies, epigenomics studies, and experimental studies, are needed to better identify the factors leading to these outcomes.

Hypertensive Disorders of Pregnancy

Hypertensive disorders of pregnancy are common and contribute inordinately to maternal and fetal morbidity and mortality. Although not completely understood, recent clinical trials have provided important insights into pathogenesis of preeclampsia. Preeclampsia is considered a systemic disease with generalized endothelial dysfunction and risk of future cardiovascular disease. This review revisits the definitions and classifications of hypertensive disorders of pregnancy; discusses updates on pathophysiology, prevention, and early prediction of preeclampsia; reviews current management guidelines; and discusses potential risks and benefits associated with treatment. Improvement in management and outcomes of women with hypertensive disorders of pregnancy seems in sight in the near future.

Inter-related effects of insulin resistance, hyperandrogenism, sympathetic dysfunction and chronic inflammation in PCOS

OBJECTIVE

Insulin resistance, hyperandrogenism, sympathetic dysfunction and chronic low-grade inflammation may act together in a vicious cycle in the pathophysiology of PCOS. However, the inter-relationships of these components are not fully understood. We aimed to study these mechanisms in the pathophysiology of PCOS.

PARTICIPANTS AND METHODS

Premenopausal women with PCOS (Rotterdam diagnostic criteria) and without PCOS were recruited from a community setting into a cross-sectional substudy within a randomized control trial. Insulin resistance (fasting insulin and glucose), hyperandrogenism (testosterone, sex hormone-binding globulin [SHBG] and Free Androgen Index [FAI]), muscle sympathetic nerve activity (MSNA) and markers of chronic low-grade inflammation (high sensitivity C-reactive protein [hs-CRP] and high molecular weight adiponectin [HMW-adiponectin]) were measured.

RESULTS

Forty-nine women with PCOS (mean age 30 ± 6 mean BMI 29 ± 5) and 23 controls (mean age 29 ± 8 mean BMI 33 ± 7) with included in this analysis. MSNA and testosterone level were most significantly associated with PCOS status, after adjustment for age and BMI. In women with PCOS, markers of sympathetic activity correlated inversely with HMW-adiponectin and HMW-adiponectin correlated inversely with FAI. Testosterone and FAI both correlated positively with insulin resistance in women PCOS.

CONCLUSION

Sympathetic dysfunction and hyperandrogenism are significantly associated with PCOS. Chronic low-grade inflammation potentially mediates the effect of sympathetic dysfunction on hyperandrogenism and insulin resistance.

Effect of Central Sympathoinhibition With Moxonidine on Sympathetic Nervous Activity in Polycystic Ovary Syndrome-A Randomized Controlled Trial

Sympathetic nervous system (SNS) activity is increased in polycystic ovary syndrome (PCOS). Moxonidine is a centrally acting sympatholytic drug with known beneficial effects on hypertension, insulin sensitivity, dyslipidemia and inflammation. In this double-blind placebo controlled randomized clinical trial we examined the effect of moxonidine on modulating sympathetic activity and downstream metabolic abnormalities in 48 pre-menopausal women with PCOS (Rotterdam diagnostic criteria), recruited from the community (January 2013-August 2015). Participants received moxonidine (0.2 mg daily initially, up titrated to 0.4 mg daily in 2 weeks) (n = 23) or placebo (n = 25) for 12 weeks. Multiunit muscle sympathetic activity (by microneurography) and plasma noradrenaline levels were measured (primary outcomes). Fasting lipids, insulin resistance, serum androgens, and inflammatory markers were measured as secondary outcomes. Forty three women completed the trial (19 moxonidine, 24 placebo). Mean change in burst frequency (-3 ± 7 vs. -3 ± 8 per minute) and burst incidence (-3 ± 10 vs. -4 ± 12 per 100 heartbeat) did not differ significantly between moxonidine and placebo groups. Women on moxonidine had a significant reduction in hs-CRP compared to placebo group (-0.92 ± 2.3 vs. -0.04 ± 1.5) which did not persist post Bonferroni correction. There was a significant association between markers of insulin resistance at baseline and reduction in sympathetic activity with moxonidine. Moxonidine was not effective in modulating sympathetic activity in PCOS. Anti-inflammatory effects of moxonidine and a relationship between insulin resistance and sympathetic response to moxonidine are suggested which need to be further explored. Clinical Trial Registration Number: (NCT01504321).

Sympathetic neurotransmission in spleens from aging Brown-Norway rats subjected to reduced sympathetic tone

Senescence of innate and adaptive responses and low-grade inflammation (inflammaging) hallmarks normal aging, which increases vulnerability to infectious diseases, autoimmunity and cancer. In normal aging, sympathetic dysregulation contributes to the dysregulation of innate and adaptive immunity and inflammaging. Sympathetic innervation of immune cells in secondary immune organs regulates immune responses. Previously in Fischer 344 (F344) rats, we reported an age-related increase in sympathetic tone and sympathetic dysfunction in beta-adrenergic receptor (AR) signaling of splenic lymphocytes that contributes to immune senescence, although the responsible mechanisms remains unexplored. In this study, we extend our previous findings using the much longer-lived Brown-Norway (BN) rats, whose behavior and immune response profile differ strikingly from F344 rats. Here, we investigated whether increased sympathetic nerve activity (SNA) in the aging spleen contributes to age-related sympathetic neuropathy and altered neurotransmission in splenic lymphocytes in BN rats. Fifteen-month male BN rats received 0, 0.5 or 1.5 μg/kg/day rilmenidine intraperitoneally for 90 days to lower sympathetic tone. Untreated young and age-matched rats controlled for effects of age. We found that elevated SNA in the aging BN rat spleen does not contribute significantly to sympathetic neuropathy or the aging-induced impairment of canonical β-AR signal transduction. Despite the rilmenidine-induced increase in β-AR expression, splenocyte c-AMP production was comparable with age-matched controls, thus dampening nerve activity had no effect on receptor coupling to adenylate cyclase. Understanding how aging affects neuroimmune regulation in healthy aging rodent models may eventually lead to strategies that improve health in aging populations vulnerable to immunosenescence and low-grade systemic inflammation.

Visit-to-visit HbA1c variability is inversely related to baroreflex sensitivity independently of HbA1c value in type 2 diabetes

BACKGROUND

The relationship between long-term glycemic variability (GV) represented by visit-to-visit HbA1c variability and baroreflex sensitivity (BRS) in type 2 diabetes mellitus (T2DM) has not been clarified by previous literature. The present study is the first to examine the relationships between visit-to-visit HbA1c variability and BRS.

METHODS

This retrospective study initially analyzed data on 94 patients with T2DM. Visit-to-visit HbA1c variability was evaluated using the intrapersonal coefficient of variation (CV), standard deviation (SD), and adjusted SD of 8 or more serial measurements of HbA1c during a 2-year period. The BRS was analyzed using the sequence method. Short-term GV was assessed by measuring the glucose CV during 24-h continuous glucose monitoring (CGM). The primary objective was to determine if there was a relationship between visit-to-visit HbA1c variability (HbA1c CV) and BRS. Secondary objectives were to examine the relationship between other variables and BRS and the respective and combined effects of long-term GV (HbA1c CV) and short-term GV (CGM CV) on BRS.

RESULTS

A total of 57 patients (mean age 67.2 ± 7.7 years, mean HbA1c 7.3 ± 1.0%) who met this study's inclusion criteria were finally analyzed. In the univariate analysis, HbA1c CV (r = - 0.354, p = 0.007), HbA1c SD (r = - 0.384, p = 0.003), and adjusted HbA1c SD (r = - 0.391, p = 0.003) were significantly related to low levels of BRS. Multiple regression analysis showed that HbA1c CV, HbA1c SD, and adjusted HbA1c SD were inversely related to BRS. Furthermore, although the increase in either long-term GV (HbA1c CV) or short-term GV (CGM CV) as determined by 24-h CGM was inversely correlated with BRS, additional reductions in BRS were not shown in participants with both HbA1c CV and CGM CV values above the median.

CONCLUSIONS

Visit-to-visit HbA1c variability was inversely related to BRS independently of the mean HbA1c in patients with T2DM. Therefore, visit-to-visit HbA1c variability might be a marker of reduced BRS in T2DM.

Effects of sympathectomy on ovarian follicular development and steroid secretion

Recently, the influence of adrenergic activity over ovarian function, and thus fertility, has begun to gain importance. Previous studies have shown that adrenergic activity through norepinephrine (NE) participates in the control of follicular development and steroidal secretion from the ovary, among other functions. To examine this phenomenon, the denervation of the gonad has been widely used to observe changes in the ovary’s performance. Nevertheless, the effect of the absence of adrenergic nerves in the ovary has only been studied in short times periods. In the present work, we used guanethidine (a drug that produces an irreversible sympathectomy) during the infantile period of rats, and we observed its effects in the adult rat (6 months old). Our results indicate that ovarian NE content is recovered at 6 months old, alongside with an increase of the adrenal content of NE and a dysfunctional celiac ganglion. Together, these results suggest that the recovery of ovarian NE does not come from a neural origin. In addition, ovarian performance was impaired because the changes in follicular development and steroidal secretion are not recovered despite the recovery of ovarian NE content. In conclusion, these results suggest that the nerve–ovarian connections, which are established during infantile development, are necessary for the accurate response of the ovary to sympathetic stimulation.

Association of insulin resistance and autonomic tone in patients with pregnancy-induced hypertension

Pregnancy-induced hypertension (PIH) remains the main cause of maternal and fatal mortality. Insulin resistance (IR) and autonomic nervous system (ANS) imbalance are two principal drivers of PIH development. Few previous researches investigated the association between IR and ANS imbalance in Chinese PIH patients. 120 pregnant women were enrolled in our study, sixty healthy pregnant women (control group), fourty one gestational hypertension (GH group) and nineteen preeclampsia patients (PE group). The homeostasis model assessment of IR (HOMA-IR) and markers of ANS (plasma biomarkers and heart rate variability (HRV) components) were collected. Body mass index (BMI), Ln(HOMA-IR), noradrenaline level, LnTP (total power), Ln SDNN (standard deviation of the normal-to-normal interval), LnLF (low frequency), LnLF/LnHF (low frequency/high frequency) were different in the GH and PE groups compared with the controls. Significant correlations were observed between Ln (HOMA-IR) and gestational duration (r = 0.237, P = 0.031), BMI（r = 0.314, P = 0.002), systolic blood pressure (r = 0.108, P = 0.016), noradrenaline (r = 0.451, P = 0.009), LnTP (r = -0.269, P = 0.015) and LnLF/HF (r = 0.183, P = 0.026) in those PIH patients. Furthermore, BMI, noradrenaline and LnTP were independent determinants of Ln(HOMA-IR) in PIH patients by multiple regression analysis. Our finding verified both IR and ANS imbalance were more severe in PIH patients than healthy pregnant women. Moreover, IR had a close association with ANS parameters in PIH patients, suggesting that they probably had contributory effects on the occurrence and development of PIH. We propose that these parameters could be added to the traditional indexes for individualized treatment of PIH patients in the future.

Variation in the α2A-adrenergic receptor gene and risk of gestational diabetes

AIM

Sympathetic activation suppresses insulin secretion via pancreatic ADRA2A.  Because sympathetic activity and insulin demand increase during pregnancy, we tested the hypothesis  that ADRA2A variants are associated with gestational diabetes (GDM).

PATIENTS & METHODS

Among Caucasian pregnant women without pre-existing diabetes, we genotyped 458 who had GDM and 1537 without GDM for seven ADRA2A variants.

RESULTS

rs1800038 (OR: 2.34; p = 0.020) and rs3750625 (OR: 1.56; p = 0.010) increased the risk of GDM, and rs11195418 decreased it (OR: 0.62; p = 0.025). The associations remained significant after adjustment for maternal age, maternal BMI, parity and a genetic risk score that included variants previously associated with Type 2 diabetes mellitus and GDM.

CONCLUSION

ADRA2A genetic variation contributes independently to the risk of GDM in Caucasian women.

Lifestyle in progression from hypertensive disorders of pregnancy to chronic hypertension in Nurses' Health Study II: observational cohort study

Objectives To study the association between lifestyle risk factors and chronic hypertension by history of hypertensive disorders of pregnancy (HDP: gestational hypertension and pre-eclampsia) and investigate the extent to which these risk factors modify the association between HDP and chronic hypertension.Design Prospective cohort study.Setting Nurses' Health Study II (1991-2013).Participants 54 588 parous women aged 32 to 59 years with data on reproductive history and without previous chronic hypertension, stroke, or myocardial infarction.Main outcome measure Chronic hypertension diagnosed by a physician and indicated through nurse participant self report. Multivariable Cox proportional hazards models were used to investigate the development of chronic hypertension contingent on history of HDP and four lifestyle risk factors: post-pregnancy body mass index, physical activity, adherence to the Dietary Approaches to Stop Hypertension (DASH) diet, and dietary sodium/potassium intake. Potential effect modification (interaction) between each lifestyle factor and previous HDP was evaluated with the relative excess risk due to interaction.Results 10% (n=5520) of women had a history of HDP at baseline. 13 971 cases of chronic hypertension occurred during 689 988 person years of follow-up. Being overweight or obese was the only lifestyle factor consistently associated with higher risk of chronic hypertension. Higher body mass index, in particular, also increased the risk of chronic hypertension associated with history of HDP (relative excess risk due to interaction P<0.01 for all age strata). For example, in women aged 40-49 years with previous HDP and obesity class I (body mass index 30.0-34.9), 25% (95% confidence interval 12% to 37%) of the risk of chronic hypertension was attributable to a potential effect of obesity that was specific to women with previous HDP. There was no clear evidence of effect modification by physical activity, DASH diet, or sodium/potassium intake on the association between HDP and chronic hypertension.Conclusion This study suggests that the risk of chronic hypertension after HDP might be markedly reduced by adherence to a beneficial lifestyle. Compared with women without a history of HDP, keeping a healthy weight seems to be especially important with such a history.

Abnormal Placentation Associated with Infertility as a Marker of Overall Health

Infertility and fertility treatments utilized are associated with abnormal placentation leading to adverse pregnancy outcomes related to placentation, including preterm birth, low birth weight, placenta accrete, and placenta previa. This may be due to the underlying genetics predisposing to infertility or the epigenetic changes associated with the fertility treatments utilized, as specific disease states leading to infertility are at increased risk of adverse outcomes, including placental abruption, fetal loss, gestational diabetes mellitus, and outcomes related to placentation, as well as the treatments utilized including in vitro fertilization (IVF) and non-IVF fertility treatment. Placentation defects, leading to adverse maternal and fetal outcomes, which are more pronounced in the infertile population, occur due to changes in trophoblast invasion, vascular defects, changes in the environmental milieu, chronic inflammation, and oxidative stress. These similar processes are recognized as major contributors to lifelong risk of cardiovascular and metabolic disease for both the mother and her offspring. Thus, abnormal placentation, found to be more prevalent in the infertile population, may be the key to better understand how infertility affects overall and long-term health.

Heart rate variability in normal-weight patients with polycystic ovary syndrome

Objective:

Polycystic ovary syndrome (PCOS) is an endocrine disease closely related to several risk factors of cardiovascular disease. Obese women with PCOS show altered autonomic modulation. The results of studies investigating cardiac autonomic functions of normal-weight women with PCOS are conflicting. The aim of the study was to assess the reactivity of cardiac sympathovagal balance in normal-weight women with PCOS by heart rate variability analysis.

Methods:

We examined the heart rate variability in 60 normal-weight women with PCOS and compared them with that in 60 age-matched healthy women having a similar metabolic profile. Time and frequency domain parameters of heart rate variability were analyzed based on 5-min-long continuous electrocardiography recordings for the following 3 periods: (1) during rest in supine position, (2) during controlled breathing, and (3) during isometric handgrip exercise.

Results:

Time and frequency domain parameters of heart rate variability for the 3 periods assessed were similar in the two groups. Although modified Ferriman–Gallwey score and serum testosterone and luteinizing hormone levels were significantly higher in women with PCOS, homeostatic model assessment-insulin resistance (HOMA-IR) was not different the between the PCOS and control groups. There were no significant correlations between serum testosterone levels and heart rate variability parameters among the study population.

Conclusion:

The findings of this study suggest that the reactivity of cardiac sympathovagal balance is not altered in normal-weight women with PCOS having a normal HOMA-IR.

Metabolic syndrome and the hepatorenal reflex

Insufficient hepatic O₂ in animal and human studies has been shown to elicit a hepatorenal reflex in response to increased hepatic adenosine, resulting in the stimulation of renal as well as muscle sympathetic nerve activity and activating the renin angiotensin system. Low hepatic ATP, hyperuricemia, and hepatic lipid accumulation reported in metabolic syndrome (MetS) patients may reflect insufficient hepatic O₂ delivery, potentially accounting for the sympathetic overdrive associated with MetS. This theoretical concept is supported by experimental results in animals fed a high fructose diet to induce MetS. Hepatic fructose metabolism rapidly consumes ATP resulting in increased adenosine production and hyperuricemia as well as elevated renin release and sympathetic activity. This review makes the case for the hepatorenal reflex causing sympathetic overdrive and metabolic syndrome in response to exaggerated splanchnic oxygen consumption from excessive eating. This is strongly reinforced by the fact that MetS is cured in a matter of days in a significant percentage of patients by diet, bariatric surgery, or endoluminal sleeve, all of which would decrease splanchnic oxygen demand by limiting nutrient contact with the mucosa and reducing the nutrient load due to loss of appetite or dietary restriction.

Metabolic syndrome and the hepatorenal reflex

Insufficient hepatic O₂ in animal and human studies has been shown to elicit a hepatorenal reflex in response to increased hepatic adenosine, resulting in stimulation of renal as well as muscle sympathetic nerve activity and activating the renin angiotensin system. Low hepatic ATP, hyperuricemia, and hepatic lipid accumulation reported in metabolic syndrome (MetS) patients may reflect insufficient hepatic O₂ delivery, potentially accounting for the sympathetic overdrive associated with MetS. This theoretical concept is supported by experimental results in animals fed a high fructose diet to induce MetS. Hepatic fructose metabolism rapidly consumes ATP resulting in increased adenosine production and hyperuricemia as well as elevated renin release and sympathetic activity. This review makes the case for the hepatorenal reflex causing sympathetic overdrive and metabolic syndrome in response to exaggerated splanchnic oxygen consumption from excessive eating. This is strongly reinforced by the fact that MetS is cured in a matter of days in a significant percentage of patients by diet, bariatric surgery, or endoluminal sleeve, all of which would decrease splanchnic oxygen demand by limiting nutrient contact with the mucosa and reducing the nutrient load due to the loss of appetite or dietary restriction.

Autonomic dysfunction in patients with polycystic ovary syndrome

OBJECTIVE

To assess the autonomic system in patients with polycystic ovary syndrome (PCOS).

MATERIALS AND METHODS

Thirty-seven adult patients with PCOS and 33 healthy controls were enrolled in the study. The electrophysiological assessments of the autonomic nervous system function were performed using sympathetic skin response and R-R interval variation tests.

RESULTS

The mean latency of sympathetic skin response in PCOS patients was significantly delayed compared with the controls (p = 0.001). The mean amplitude of sympathetic skin response was significantly lower in comparison with the controls (p = 0.01). Mean R-R interval variation during deep breathing was also significantly delayed (p = 0.04).

CONCLUSION

There are parasympathetic dysfunction and sympathetic dysfunction in patients with PCOS. This may be easily demonstrated with sympathetic skin response and R-R interval variation tests.

Recurrent pre-eclampsia in women with metabolic syndrome and low plasma volume: a retrospective cohort study

OBJECTIVE

To determine the prevalence of recurrent pre-eclampsia in women with a history of pre-eclampsia with both metabolic syndrome and low plasma volume postpartum, as compared with women without either entity.

DESIGN

Retrospective cohort study.

SETTING

Three tertiary referral hospitals in the Netherlands.

POPULATION

Women with a history of pre-eclampsia.

METHODS

In 196 women with a history of pre-eclampsia we determined the presence or absence of metabolic syndrome using the World Health Organization criteria and measured plasma volume with the (125) I-human serum albumin indicator dilution technique. We compared the prevalence of recurrent pre-eclampsia in four groups, classified according to presence or absence of metabolic syndrome and low or normal plasma volume, calculating odds ratios (OR), adjusted for confounders.

MAIN OUTCOME MEASURE

Recurrence of pre-eclampsia in the subsequent pregnancy.

RESULTS

The prevalence of recurrent pre-eclampsia was 12% (12/99) in women without metabolic syndrome with normal plasma volume, versus 47% (8/17) in women with both metabolic syndrome and low plasma volume: OR 6.44 (95% CI 2.09-19.90), adjusted OR 7.90 (95% CI 2.30-27.16). Recurrent pre-eclampsia was present in 44% (10/23) and 25% (14/57) of women with isolated metabolic syndrome and low plasma volume, respectively.

CONCLUSIONS

In the concomitant presence of metabolic syndrome and low plasma volume, the prevalence of recurrent pre-eclampsia was nearly 50%, which is four times as high as the prevalence in women without either entity.

TWEETABLE ABSTRACT

Metabolic syndrome and low plasma volume raise the risk of recurrent pre-eclampsia to nearly 50%.

The Relationship of Restless Legs Syndrome to History of Pregnancy-Induced Hypertension

BACKGROUND

Restless legs syndrome (RLS), a burdensome sleep disorder, has been associated with cardiovascular disease (CVD), hypertension, diabetes, and related disorders. However, the relationship of RLS to history of pregnancy-induced hypertension (PIH), a predictor of subsequent CVD, diabetes, and associated conditions, remains little explored. In this study, we investigated the relationship of RLS to history of PIH in a sample of primary care patients.

METHODS

Participants were women aged ≥40 years drawn from an anonymous survey study of West Virginia primary care patients. Data collected included detailed information on demographics, lifestyle factors, sleep patterns, and reproductive/medical history; the survey also included an RLS diagnostic questionnaire. Women who were pregnant or unsure about their pregnancy status were excluded from the analyses.

RESULTS

Of the 498 participants in the final analytic sample, 24.5% met diagnostic criteria for RLS (17.9% with symptoms ≥once/week, 11.9% with symptoms ≥3 times/week); 73 (16.5% of parous women) reported a history of PIH, defined as physician-diagnosed preeclampsia or gestational hypertension. After adjustment for demographics, lifestyle characteristics, obesity, reproductive history, health conditions, and other factors, those reporting a history of PIH were approximately twice as likely to meet criteria for RLS (odds ratio [OR] = 1.9; 95% confidence interval [CI] = 1.1, 3.6). These associations increased in magnitude with increasing symptom frequency (adjusted OR for RLS with symptoms ≥3 times/week = 3.8; CI 1.9, 7.6; p for trend = 0.003).

CONCLUSIONS

History of PIH was strongly and positively related to current RLS in this study of primary care patients; these findings further support a possible role for metabolic dysregulation in RLS etiology.

Hypothalamic Paraventricular and Arcuate Nuclei Contribute to Elevated Sympathetic Nerve Activity in Pregnant Rats: Roles of Neuropeptide Y and α-Melanocyte-Stimulating Hormone

Pregnancy increases sympathetic nerve activity (SNA), but the mechanisms are unknown. Here, we investigated the contributions of the hypothalamic paraventricular and arcuate nuclei in α-chloralose-anesthetized pregnant and nonpregnant rats. Baseline arterial pressure (AP) was lower, and heart rate (HR), lumbar sympathetic activity, and splanchnic SNA were higher in pregnant rats compared with nonpregnant rats. Inhibition of the paraventricular nucleus via bilateral muscimol nanoinjections decreased AP and HR more in pregnant rats than in nonpregnant rats and decreased lumbar SNA only in pregnant rats. Similarly, after arcuate muscimol nanoninjections, the decreases in AP, HR, and lumbar, renal, and splanchnic sympathetic nerve activities were greater in pregnant rats than in nonpregnant rats. Major arcuate neuronal groups that project to the paraventricular nucleus express inhibitory neuropeptide Y (NPY) and excitatory α-melanocyte-stimulating hormone. Inhibition of paraventricular melanocortin 3/4 receptors with SHU9119 also decreased AP, HR, and lumbar SNA in pregnant rats but not in nonpregnant rats. Conversely, paraventricular nucleus NPY expression was reduced in pregnant animals, and although blockade of paraventricular NPY Y1 receptors increased AP, HR, and lumbar sympathetic activity in nonpregnant rats, it had no effects in pregnant rats. Yet, the sympathoinhibitory, depressor, and bradycardic effects of paraventricular NPY nanoinjections were similar between groups. In conclusion, the paraventricular and arcuate nuclei contribute to increased basal SNA during pregnancy, likely due in part to decreased tonic NPY inhibition and increased tonic α-melanocyte-stimulating hormone excitation of presympathetic neurons in the paraventricular nucleus.

Cardiovascular effects of aerobic exercise training in formerly preeclamptic women and healthy parous control subjects

OBJECTIVE

Women who have had preeclampsia demonstrate higher prevalence of metabolic syndrome (MetS), impaired vascular function, and increased sympathetic activity and are at increased risk of cardiovascular disease. The aim of this study was to assess the effects of 12 weeks of exercise training (70-80% maximum volume of oxygen utilization) in women who had had preeclampsia on physical fitness, components of MetS, vasculature, and autonomic functions compared with healthy control subjects.

STUDY DESIGN

Our prospective case-control study included 24 normotensive women who had had preeclampsia and 20 control subjects who were matched for age and postpartum interval (all 6-12 months after delivery). Before and after training, we measured all components of MetS (ie, BP, lipids, glucose/insulin, and albuminuria), carotid intima media thickness (IMT) and brachial and superficial femoral artery endothelial function that used flow-mediated dilation (FMD). Autonomic activity was quantified with power spectral analysis (low-frequency/high-frequency power [LF/HF] ratio).

RESULTS

At baseline, women who had had preeclampsia demonstrated higher values of most components of MetS. Compared with the control subjects, women who had had preeclampsia had increased IMT (580 ± 92 μm vs 477 ± 65 μm, respectively), impaired endothelial function (FMD brachial artery, 5.3% ± 2.2% vs 10.8% ± 3.5%, respectively; FMD superficial femoral artery, 4.9% ± 2.1% vs 8.7% ± 3.2%, respectively) and increased LF/HF power ratio (2.2 ± 1.0 vs 1.3 ± 0.4, respectively; all P < .05). In both groups, exercise training decreased values of most components of MetS and IMT, improved FMD, and concurrently reduced LF/HF. Despite these improvements, vascular and autonomic variables did not normalize by 12 weeks of training in women who had had preeclampsia.

CONCLUSION

This study demonstrates that exercise training in women who had had preeclampsia and control subjects improves components of MetS, endothelial function, vascular wall thickness, and autonomic control. Nonetheless, trained women who had had preeclampsia only reached a cardiovascular status that is comparable with sedentary healthy control subjects.

Impaired baroreflex sensitivity in subjects with impaired glucose tolerance, but not isolated impaired fasting glucose

Impaired baroreflex sensitivity (BRS) is associated with adverse cardiovascular outcomes. There are currently no studies on BRS changes in subjects with different glycemic statuses, including normal glucose tolerance (NGT), isolated impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and newly diagnosed diabetes (NDD). The aim of this study was to investigate the effects of NDD, IGT and isolated IFG on BRS, based on a community-based data. A total of 768 subjects were classified as NGT (n = 498), isolated IFG (n = 61), IGT (n = 126) and NDD (n = 83). Spontaneous BRS was determined by the spectral α coefficient method, i.e., the square root of the ratio between the power of the RR interval and the power of systolic blood pressure in the LF frequency region (0.04-0.15 Hz) after the subjects had rested in a supine position for 5 min. Valsalva ratio was calculated as the longest RR interval after release of the Valsalva maneuver, divided by the shortest RR interval during the maneuver. As compared with NGT subjects, NDD (p = 0.039) and IGT (p = 0.041) subjects had a reduced spontaneous BRS in multivariate analysis based on analysis of covariance. NDD subjects exhibited a lower Valsalva ratio than NGT subjects (p = 0.043). However, there were no significant differences in spontaneous BRS and Valsalva ratio between subjects with isolated IFG and NGT. In conclusion, NDD and IGT subjects had an impaired BRS as compared to NGT subjects. However, reduced BRS was not apparent in subjects with isolated IFG.

Elevated serum angiopoietin-like protein 6 in women with subsequent pregnancy-induced hypertension: a preliminary study

OBJECTIVE

Association of maternal angiopoietin-like protein 6 (Angptl6) levels with subsequent development of pregnancy-induced hypertension (PIH).

METHODS

At 24 and 32 weeks of gestation in 47 relatively overweight (BMI ≥ 24 kg/m(2)), nulliparous pregnant women serum concentrations of Angptl6 were quantified prospectively. Insulin sensitivity and lipids were measured at 24 weeks.

RESULTS

Angptl6 levels at 24 weeks, but not at 32 weeks, were significantly higher in women with subsequent PIH. Metabolic factors at 24 weeks did not correlate with Angptl6 levels.

CONCLUSION

This preliminary study suggests that in the second trimester, Angptl6 levels are higher in women with subsequent PIH.

Retrograde shear rate in formerly preeclamptic and healthy women before and after exercise training: relationship with endothelial function

Blood flow patterns in conduit arteries characterized by high levels of retrograde shear stress can be detrimental for vascular health. In this study we examined whether retrograde shear rate and endothelial function are related in healthy and formerly preeclamptic (PE) women and whether this relationship is altered by exercise training. Formerly PE women (32 ± 4 yr, n = 20) and controls (32 ± 4 yr, n = 20), all 6-12 mo postpartum, performed 12-wk aerobic exercise training. We measured brachial artery shear rate (SR) and endothelial function by flow-mediated dilation (FMD, echo-Doppler). We additionally performed power spectral analysis of heart rate variability and calculated low-frequency/high-frequency (LF/HF) ratio. Antegrade SR was not different between groups, while retrograde SR was significantly higher and FMD% lower in PE women compared with controls (both P < 0.05). Retrograde shear correlated strongly with FMD% in PE women and controls (P < 0.05). LF/HF ratio inversely correlated with brachial artery retrograde SR and FMD% (both P < 0.05) in PE women and controls. Exercise training reduced retrograde shear, improved FMD%, and reduced LF/HF ratios similarly in both groups (all P < 0.05). Training-induced changes in retrograde SR correlated with changes in FMD% and LF/HF ratio. A higher brachial artery retrograde SR relates to lower brachial artery endothelial function, in both controls and formerly PE women. Exercise training improves retrograde SR, while the magnitude of this change correlated strongly with improvements in FMD and reductions in LF/HF ratio. Therefore, the impact of PE and exercise training on endothelial health may, at least partly, be related to retrograde shear rate.

The Relationship between Vascular Function and the Autonomic Nervous System

Endothelial dysfunction and autonomic nervous system dysfunction are both risk factors for atherosclerosis. There is evidence demonstrating that there is a close interrelationship between these two systems. In hypertension, endothelial dysfunction affects the pathologic process through autonomic nervous pathways, and the pathophysiological process of autonomic neuropathy in diabetes mellitus is closely related with vascular function. However, detailed mechanisms of this interrelationship have not been clearly explained. In this review, we summarize findings concerning the interrelationship between vascular function and the autonomic nervous system from both experimental and clinical studies. The clarification of this interrelationship may provide more comprehensive risk stratification and a new effective therapeutic strategy against atherosclerosis.

Cardiac autonomic function and insulin resistance for the development of hypertension: a six-year epidemiological follow-up study

BACKGROUND AND AIMS

To explore the impact of cardiac autonomic function (CAF) and insulin resistance (IR) on incident hypertension.

METHODS AND RESULTS

In 1996, 1638 subjects finished baseline examination, which included anthropometry, blood pressures, CAF, blood biochemistry, plasma insulin, urine examination and electrocardiogram. CAF included standard deviation of normal-to-normal intervals or RR intervals (SDNN), low- and high-frequency power spectrum (LF and HF), and LF/HF ratio at supine for 5 min, the RR interval changes during lying-to-standing maneuver, and the ratio between the longest RR interval during expiration and the shortest RR interval during inspiration (E/I ratio). We used homeostasis model assessment to define beta cell function (HOMA-B) and insulin resistance (HOMA-IR). In total, 992 non-hypertensive participants completed the follow-up assessment in 2003 and 959 participants were included for the final analysis. Incident hypertension was determined by blood pressure status at follow-up. In unadjusted model, both square root of HOMA-IR (OR:3.37, 95%CI: 2.10-6.64) and HOMA-B (OR:0.996, 95%CI: 0.992-0.999) were related to incident hypertension. In multivariate model, square root of HOMA-IR (OR:1.97, 95%CI: 1.05-3.70), but not HOMA-B, was associated with incident hypertension. After further adjustment for baseline CAF, the positive relationship between the square root of HOMA-IR and incident hypertension disappeared. In contrast, LF/HF ratio (OR:1.18, 95%CI: 1.01-1.37), HF power (OR:0.98, 95%CI: 0.96-0.999), and E/I ratio (OR:0.71, 95%CI: 0.54-0.95) were each independently associated with incident hypertension after further adjustment for HOMA measures.

CONCLUSION

Sympathovagal imbalance with an apparently decreased parasympathetic tone is an important predictor of incident hypertension independent of IR.

Gender influence on left ventricular structure and function in metabolic syndrome. Are women at greater risk?

PURPOSE

The aim of this study was to investigate the influence of metabolic syndrome (MS) on left ventricular (LV) structure and function depending on gender.

METHODS

The study included 235 never-treated MS subjects and 138 controls. MS was defined as the presence of three or more National Cholesterol Education Program's Adult Treatment Panel III criteria. All the subjects underwent laboratory blood tests and complete two-dimensional, pulsed, and tissue Doppler echocardiography.

RESULTS

LV structure, diastolic function, and global function were significantly impaired in all MS subjects. Multivariate analysis of individual MS factors showed that increased blood pressure (BP) and impaired fasting glucose were independently associated with LV hypertrophy in women, whereas the only independent predictor in men was increased BP. The same analysis revealed that the combination of impaired glucose level, abdominal obesity, and dyslipidemia was associated with LV hypertrophy only in women. Higher BP, impaired fasting glucose, and triglycerides level were independently associated with LV diastolic dysfunction in women, whereas higher BP was the only independent predictor in men. The combination of increased BP, fasting glucose, and dyslipidemia was independently associated with LV diastolic dysfunction only in women.

CONCLUSIONS

Different MS factors are responsible for LV remodeling in women and men. The metabolic sequence of MS is more important for LV remodeling in women.

Cardiovascular and metabolic characteristics 40 years after hypertensive pregnancies: a long-term follow-up study of mothers

OBJECTIVES

Maternal cardiovascular morbidity is increased after hypertensive pregnancies (HTP). The pathways from complicated pregnancies to future cardiovascular disease are complex. The aim of the present study was to test the hypothesis that different cardiovascular mechanisms are changed in women who experienced HTP four decades earlier in comparison to women with normotensive pregnancies.

METHODS

One hundred and five women (50 with hypertensive and 55 with normal pregnancies) were examined with anthropometric measurements; office blood pressure, ambulatory blood pressure and central blood pressure, pulse wave velocity, augmentation index, intimal-media thickness, echocardiography and laboratory measurements. In addition another 204 women were followed-up by a questionnaire regarding their pregnancy 40 years ago, as well as their present health status and medications.

RESULTS

Women with HTP had more often diagnosed hypertension when compared with women with normal pregnancies (50 vs. 31%, respectively; P = 0.046), but the groups did not differ in any blood pressure levels. HTP were associated with higher pulse wave velocity (8.8 m/s vs. 7.8 m/s, P = 0.021), and higher levels of P-glucose (5.7 mmol/l vs. 5.2 mmol/l, P = 0.022), P-HbA1c (4.4% vs. 4.2%, P = 0.010) and noradrenaline (2.45 mmol/l vs. 2.11 mmol/l, P = 0.040) when compared with normotensive pregnancies. Women followed up with a questionnaire reported deteriorated cardiovascular health compared to women attending the clinical investigations of the study.

CONCLUSION

HTP are associated with impairment in vascular function and metabolic status 40 years postpartum despite well controlled blood pressure levels.

Growth factors in preeclampsia: a vascular disease model. A failed vasodilation and angiogenic challenge from pregnancy onwards?

Preeclampsia is the major cause of maternofetal and neonatal morbi-mortality including intrauterine growth retardation, miscarriages and stillbirths. Inadequate vascular dilation and angiogenesis represent the crucial underlying defect of gravidic hypertension, denoting a failed response to the vasodilatory and pro-angiogenic challenge imposed by pregnancy, especially if multifetal. A similar pathogenesis appears involved in gestational diabetes. In this review we aimed to provide a hint on understanding the deeply involved angiogenic disorders which eventually culminate in utero-placental failure. The key players in these complex processes may be found in an intricate network of growth factors (GFs) and GF inhibitors, controlled by several vascular risk factors modulated by environment and genes, which eventually impact on early and late cardiovascular outcomes of mother and fetus.

The sympathetic nervous system in polycystic ovary syndrome: a novel therapeutic target?

Polycystic ovary syndrome (PCOS) is a common endocrine condition associated with long-term health risks, including type 2 diabetes and vascular dysfunction in addition to reproductive sequelae. Many of the common features of PCOS, such as central obesity, hyperinsulinaemia and obstructive sleep apnoea (OSA), are associated with chronic sympathetic overactivity, suggesting that sympathoexcitation may be involved in the pathogenesis of this condition. Rodent models of polycystic ovaries have shown that ovarian sympathetic outflow may be increased, accompanied by elevated intra-ovarian synthesis of nerve growth factor (NGF) which may be involved in initiation of ovarian pathology. Patients with PCOS have evidence of increased muscle sympathetic nerve activity (MSNA), altered heart rate variability and attenuated heart rate recovery postexercise, compared with age- and BMI-matched controls, suggesting a generalized increase in sympathetic nerve activity. Active weight loss can reduce MSNA and whole body noradrenaline spillover, whereas low-frequency electroacupuncture decreased MSNA in overweight women with PCOS. Treatment of OSA with continuous positive airways pressure may reduce plasma noradrenaline levels and diastolic blood pressure and improve cardiac sympathovagal balance. Renal sympathetic denervation also reduced MSNA, noradrenaline spillover and blood pressure in two PCOS subjects with hypertension, accompanied by improved insulin sensitivity. The sympathetic nervous system may thus offer a new therapeutic target in PCOS but larger and longer-term studies are needed before these treatments can be considered in clinical practice.

Pre-eclampsia and long-term maternal health

Pre-eclampsia is a syndrome of pregnancy, defined by the gestational-onset of hypertension and proteinuria, which resolves postpartum. This definition does not consider the variable multiorgan involvement of a syndrome that can include seizures, fulminating hepatic necrosis and a consumptive coagulopathy. These disparate clinical features are a consequence of an accelerated but transient metabolic syndrome with widespread maternal endothelial dysfunction and inflammation. A trigger to this maternal state is the relatively ischaemic placenta. As pregnancy progresses, the concentration of vaso-toxic factors released by the relatively ischaemic placenta gradually builds up in the maternal circulation. Those predisposed to endothelial dysfunction, e.g. women with risk factors for cardiovascular disease, are more sensitive to these placental derived factors and will develop pre-eclampsia before natural onset of labour. A woman's vulnerability to pre-eclampsia is therefore composed of a unique balance between her pre-existing maternal endothelial and metabolic health and the concentration of placental derived factors toxic to maternal endothelium. Delivery of the placenta remains the only cure. Years later, women who had pre-eclampsia are at increased risk of chronic hypertension, ischaemic heart disease, cerebrovascular disease, kidney disease, diabetes mellitus, thromboembolism, hypothyroidism and even impaired memory. This article describes how a brief, usually single episode of this acute pregnancy syndrome might both identify those vulnerable to chronic disease in later life and in some cases initiate chronic disease.

Autonomic neural control of the cardiovascular system in patients with Behçet's disease in the absence of neurological involvement

Behçet's disease (BD) is a chronic multi-system disease presenting with recurrent oral and genital ulceration, and relapsing uveitis. Heart rate recovery (HRR) after exercise is a marker of parasympathetic activity. A delayed recovery of systolic blood pressure (SBP) after exercise might reflect sympathetic hyperactivity. The analysis of variations in heart rate has also been used to determine the balance between sympathetic and vagal nerve activities in the heart. Our objective was to determine HRR, the SBP response to exercise and heart rate variability (HRV) in patients with BD in the absence of neurological involvement. The study population consisted of 32 patients with BD and 30 healthy controls who were matched with respect to age, sex, and physical activity. Heart rate recovery was calculated as the difference between heart rate at peak exercise and heart rate at 1, 2, and 3 min of recovery. Blood pressure recovery indexes were determined by dividing the systolic blood pressure at 2 and 3 min in recovery to the systolic blood pressure at peak exercise. In patients with BD, mean HRR at 1 min (HRR1) were not significantly different than that of controls (21 ± 7 vs 20 ± 7 bpm, p = 0.50). Although, resting mean SBP of patients with BD was higher than controls (121 ± 13 vs 115 ± 12 mmHg, p = 0.039), the SBP recovery indices of the patients with BD at 2 and 3 min were similar to those of controls (0.84 ± 0.07 vs 0.84 ± 0.09, p = 0.89 and 0.78 ± 0.09 vs 0.78 ± 0.08, p = 0.93, respectively). Both time domain and frequency domain parameters of patients with BD were similar to that of controls. This study shows that the patients with BD have normal HRR1 and normal SBP response to exercise and normal HRV. These findings might suggest unaltered autonomic neural control of the cardiovascular system in this disorder in the absence of neurological involvement.

Fetal cardiac autonomic control during breathing and non-breathing epochs: the effect of maternal exercise

We explored whether maternal exercise during pregnancy moderates the effect of fetal breathing movements on fetal cardiac autonomic control assessed by metrics of heart rate (HR) and heart rate variability (HRV). Thirty women were assigned to Exercise or Control group (n=15/group) based on the modifiable physical activity questionnaire (MPAQ). Magnetocardiograms (MCG) were recorded using a dedicated fetal biomagnetometer. Periods of fetal breathing activity and apnea were identified using the fetal diaphragmatic magnetomyogram (dMMG) as a marker. MCG R-waves were marked. Metrics of fetal HR and HRV were compared using 1 breathing and 1 apneic epoch/fetus. The main effects of group (Exercise vs. Control) and condition (Apnea vs. Breathing) and their interactions were explored. Fetal breathing resulted in significantly lower fetal HR and higher vagally-mediated HRV. Maternal exercise resulted in significantly lower fetal HR, higher total HRV and vagally-mediated HRV with no difference in frequency band ratios. Significant interactions between maternal exercise and fetal breathing were found for metrics summarizing total HRV and a parasympathetic metric. Post hoc comparison showed no group difference during fetal apnea. Fetal breathing was associated with a loss of Total HRV in the Control group and no difference in the Exercise group. Both groups show enhanced vagal function during fetal breathing; greater in the Exercise group. During in utero breathing movements, the fetus of the exercising mother has enhanced cardiac autonomic function that may give the offspring an adaptive advantage.

A comprehensive review of hypertension in pregnancy

Hypertension is the most common medical disorder encountered during pregnancy. Hypertensive disorders are one of the major causes of pregnancy-related maternal deaths in the United States. We will present a comprehensive update of the literature pertinent to hypertension in pregnancy. The paper begins by defining and classifying hypertensive disorders in pregnancy. The normal vascular and renal physiological changes which occur during pregnancy are detailed. We will summarize the intriguing aspects of pathophysiology of preeclampsia, emphasizing on recent advances in this field. The existing diagnostic tools and the tests which have been proposed for screening preeclampsia are comprehensively described. We also highlight the short- and long-term implications of preeclampsia. Finally, we review the current management guidelines, goals of treatment and describe the potential risks and benefits associated with various antihypertensive drug classes. Preeclampsia still remains an enigma, and the present management focuses on monitoring and treatment of its manifestations. We are hopeful that this in depth critique will stimulate the blossoming research in the field and assist practitioners to identify women at risk and more effectively treat affected individuals.

Sirtuin 1 (SIRT1) and steroid hormone receptor activity in cancer

Sirtuins, which are class III NAD-dependent histone deacetylases that regulate a number of physiological processes, play important roles in the regulation of metabolism, aging, oncogenesis, and cancer progression. Recently, a role for the sirtuins in the regulation of steroid hormone receptor signaling is emerging. In this mini-review, we will summarize current research into the regulation of estrogen, androgen, progesterone, mineralocorticoid, and glucocorticoid signaling by sirtuins in cancer. Sirtuins can regulate steroid hormone signaling through a variety of molecular mechanisms, including acting as co-regulatory transcription factors, deacetylating histones in the promoters of genes with nuclear receptor-binding sites, directly deacetylating steroid hormone nuclear receptors, and regulating pathways that modify steroid hormone receptors through phosphorylation. Furthermore, disruption of sirtuin activity may be an important step in the development of steroid hormone-refractory cancers.

Chronic kidney disease in postmenopausal women

Menopause is derived from the Greek words men (month) and pauses (cessation) and means permanent cessation of menstruation after the loss of ovarian activity. Chronic kidney disease (CKD) has recently been associated with cardiovascular events in several studies. CKD patients have a heavy burden of traditional cardiovascular risk factors in addition to a range of nontraditional risk factors such as inflammation and abnormal metabolism of calcium and phosphate. In this review, the association of CKD and cardiovascular disease (CVD), as well as of osteoporosis in postmenopausal women is discussed. CKD mineral and bone disorder, characterized by disturbances of calcium/phosphate/parathyroid hormone, bone abnormalities and vascular and soft tissue calcification, is highly prevalent in CKD and is a strong, independent predictor of bone fracture, CVD and death. Estrogen has been shown to: (a) decrease the expression of angiotensin type 1 receptors in vasculature and kidneys; (b) reduce the expression and activity of angiotensin-converting enzyme, and (c) cause the release of angiotensinogen substrate from the liver. However, the degree of activation or suppression of the renin-angiotensin-aldosterone system by estrogen has not been clearly established. Clinical data on the effects of estrogen therapy on bone mineral densities are extremely limited in the ESRD population. CVD is the most common cause of death in postmenopausal women with CKD and many contributing factors have been explored. Future research for prevention of CVD in postmenopausal women with CKD would focus on the biology of vascular calcification as well as bone loss.