Angiotensin Receptor Blockade Improves Vascular Compliance in Healthy Normotensive Elderly Individuals: Results From a Randomized Double‐Blind Placebo‐Controlled Trial

Differential Sex-Specific Effects of Angiotensin-Converting Enzyme Inhibition and Angiotensin Receptor Blocker Therapy on Arterial Function in Hypertension: CALIBREX Trial

BACKGROUND

Increased arterial stiffness is associated with adverse cardiovascular outcomes. We studied the sex-specific impact of angiotensin antagonists on vascular function in hypertension with the hypothesis that their effects on arterial stiffness may be variable in men and women.

METHODS

In 141 hypertensive participants with mild cognitive impairment (age 65.9±7.7, 57% female), candesartan (up to 32 mg, n=77) or lisinopril (up to 40 mg, n=64) were administered to achieve blood pressure <140/90 mm Hg. Pulse wave velocity, central pulse pressure, and central augmentation index were measured using applanation tonometry (SphygmoCor, Australia). Multivariate linear regression and mixed model analyses were performed using intention-to-treat and per protocol analyses for those completing the study.

RESULTS

Blood pressure reduction was similar among candesartan and lisinopril groups. Compared with candesartan, lisinopril therapy resulted in lower pulse wave velocity (0.5±0.8 versus -0.7±0.4 m/s, respectively; P=0.003) and central pulse pressure (-1±3 versus -7±4 mm Hg; P=0.03) after 1 year. There was a significant interaction by sex whereby the improvements in pulse wave velocity and central pulse pressure with lisinopril compared with candesartan were only observed in women. In contrast, there was greater improvement in augmentation index with candesartan compared with lisinopril (-4±7% versus -1.5±8%; P=0.05), with no sex differences.

CONCLUSIONS

Despite equipotent antihypertensive effects, lisinopril was more effective than candesartan at lowering arterial stiffness in women. In contrast, candesartan was more effective than lisinopril in improving pulse wave reflections in both sexes. These findings demonstrate differential sex-specific effects of renin-angiotensin system antagonists on arterial function in hypertension that may contribute to long-term cardiovascular and neurocognitive outcomes in this population.

Improvement in Hypertension Management with Pharmacological and Non- Pharmacological Approaches: Current Perspectives

PURPOSE

Improving hypertension management is still one of the biggest challenges in public health worldwide. Existing guidelines do not reach a consensus on the optimal Blood Pressure (BP) target. Therefore, how to effectively manage hypertension based on individual characteristics of patients, combined with the pharmacological and non-pharmacological approach, has become a problem to be urgently considered.

METHODS

Reports published in PubMed that covered Pharmacological and Non-Pharmacological Approaches in subjects taking hypertension management were reviewed by the group independently and collectively. Practical recommendations for hypertension management were established by the panel.

RESULTS

Pharmacological mechanism, action characteristics, and main adverse reactions varied across different pharmacological agents, and patients with hypertension often require a combination of antihypertensive medications to achieve the target BP range. Non-pharmacological treatment provides an additional effective method for improving therapy adherence and long-term BP control, thus reducing the risk of cardiovascular diseases, and slowing down the progression of the disease.

CONCLUSION

This review summarizes the available literature on the most convincing guideline principles, pharmacological treatment, biotechnology interference, interventional surgical treatment, managing hypertension with technical means of big data, Artificial Intelligence and Behavioral Intervention, as well as providing future directions, for facilitating Current and Developing knowledge into clinical implementation.

The impact of the 24-h movement spectrum on vascular remodeling in older men and women: a review

Aging is associated with increased risk of cardiovascular and cerebrovascular events, which are preceded by early, negative remodeling of the vasculature. Low physical activity is a well-established risk factor associated with the incidence and development of disease. However, recent physical activity literature indicates the importance of considering the 24-h movement spectrum. Therefore, the purpose of this review was to examine the impact of the 24-h movement spectrum, specifically physical activity (aerobic and resistance training), sedentary behavior, and sleep, on cardiovascular and cerebrovascular outcomes in older adults, with a focus on recent evidence (<10 yr) and sex-based considerations. The review identifies that both aerobic training and being physically active (compared with sedentary) are associated with improvements in endothelial function, arterial stiffness, and cerebrovascular function. Additionally, there is evidence of sex-based differences in endothelial function: a blunted improvement in aerobic training in postmenopausal women compared with men. While minimal research has been conducted in older adults, resistance training does not appear to influence arterial stiffness. Poor sleep quantity or quality are associated with both impaired endothelial function and increased arterial stiffness. Finally, the review highlights mechanistic pathways involved in the regulation of vascular and cerebrovascular function, specifically the balance between pro- and antiatherogenic factors, which mediate the relationship between the 24-h movement spectrum and vascular outcomes. Finally, this review proposes future research directions: examining the role of duration and intensity of training, combining aerobic and resistance training, and exploration of sex-based differences in cardiovascular and cerebrovascular outcomes.

Characterizing the relationship between flow-mediated vasodilation and radial artery tonometry in peripheral artery disease

BACKGROUND

Arterial stiffness, measured by the augmentation index (AIX) from radial artery tonometry, and endothelial dysfunction, measured by brachial-artery flow-mediated vasodilation (FMD), have each been associated with increased risk of cardiovascular events. However, their interrelationship in peripheral artery disease (PAD) patients is poorly understood.

MATERIALS AND METHODS

In a cross-sectional analysis of 123 vascular surgery outpatients, the association between FMD and AIX was examined in controls with atherosclerotic risk factors (n = 32) and patients with PAD (n = 91). PAD was defined as claudication symptoms with an ankle-brachial index of <0.9 or a history of revascularization for symptomatic PAD. Controls had an ankle-brachial index ≥0.9 and no history of atherosclerotic vascular disease.

RESULTS

Compared to controls, patients with PAD had lower FMD (6.3 ± 3.8 versus 8.4 ± 3.7, P = 0.008), while central AIX normalized to 75 beats per minute (25.5 ± 9.0 versus 19.3 ± 8.6, P = 0.001) and peripheral AIX (91.3 ± 14.5 versus 81.3 ± 11.4, P = 0.001) were higher. FMD was not significantly correlated with either central or peripheral AIX (central AIX: P = 0.58; peripheral AIX: P = 0.89) across the entire cohort, or in either the patients with PAD (central AIX: P = 0.48; peripheral AIX: P = 0.23) or controls (central AIX: P = 0.43; peripheral AIX: P = 0.92). In a multivariate model including FMD, higher AIX remained independently associated with PAD.

CONCLUSIONS

In an analysis of vascular surgery outpatients, no correlation between FMD and AIX was detected. Larger prospective studies are needed to determine whether the inclusion of both parameters improves predictive models for the early identification and potential risk stratification of PAD patients.

Recent Progress in Vascular Aging: Mechanisms and Its Role in Age-related Diseases

As with many age-related diseases including vascular dysfunction, age is considered an independent and crucial risk factor. Complicated alterations of structure and function in the vasculature are linked with aging hence, understanding the underlying mechanisms of age-induced vascular pathophysiological changes holds possibilities for developing clinical diagnostic methods and new therapeutic strategies. Here, we discuss the underlying molecular mediators that could be involved in vascular aging, e.g., the renin-angiotensin system and pro-inflammatory factors, metalloproteinases, calpain-1, monocyte chemoattractant protein-1 (MCP-1) and TGFβ-1 as well as the potential roles of testosterone and estrogen. We then relate all of these to clinical manifestations such as vascular dementia and stroke in addition to reviewing the existing clinical measurements and potential interventions for age-related vascular dysfunction.

Design of the Magnetic Resonance Imaging Evaluation of Mineralocorticoid Receptor Antagonism in Diabetic Atherosclerosis (MAGMA) Trial

Mineralocorticoid receptor (MR) activation plays an essential role in promoting inflammation, fibrosis, and target organ damage. Currently, no studies are investigating MR antagonism in patients with type 2 diabetes mellitus (T2DM) with chronic kidney disease, at high risk for cardiovascular complications, who are otherwise not candidates for MR antagonism by virtue of heart failure. Further, there is limited information on candidate therapies that may demonstrate differential benefit from this therapy. We hypothesized that MR antagonism may provide additional protection from atherosclerosis progression in higher-risk patients who otherwise may not be candidates for such a therapeutic approach. In this double-blind, randomized, placebo-controlled trial, subjects with T2DM with chronic kidney disease (≥ stage 3) will be randomized in a 1:1 manner to placebo or spironolactone (12.5 mg with eventual escalation to 25 mg daily over a 4-week period). The co-primary efficacy endpoint will be percentage change in total atheroma volume in thoracic aorta and left ventricular mass at 52 weeks in patients treated with spironolactone vs placebo. Secondary outcomes include 24-hour mean systolic blood pressure, central aortic blood pressure, and insulin resistance (HOMA-IR) at 6 weeks. A novel measure in the study will be changes in candidate miRNAs that regulate expression of NR3C2 (MR gene) as well as measuring monocyte/macrophage polarization in response to therapy with spironolactone. We envision that our strategy of simultaneously probing the effects of a drug combined with analysis of mechanisms of action and predictive response will likely provide key information with which to design event-based trials.

Vascular Aging: Implications for Cardiovascular Disease and Therapy

The incidence and prevalence of cardiovascular disease is highest among the elderly, in part, due to deleterious effects of advancing age on the heart and blood vessels. Aging, a known cardiovascular risk factor, is progressively associated with structural and functional changes to the vasculature including hemodynamic disturbance due to increased oxidative stress, premature cellular senescence and impairments in synthesis and/or secretion of endothelium-derived vasoactive molecules. These molecular and physiological changes lead to vessel wall stiffening and thickening, as well as other vascular complications that culminate to loss of vascular tone regulation and endothelial function. Intriguingly, the vessel wall, a biochemically active structure composed of collagen, connective tissue, smooth muscle and endothelial cells, is adversely affected by processes involved in premature or normal aging. Notably, the inner most layer of the vessel wall, the endothelium, becomes senescent and dysfunctional with advancing age. As a result, its ability to release vasoactive molecules such as acetylcholine (ACh), prostacyclin (PGI2), endothelium-derived hyperpolarizing factor (EDHF), and nitric oxide (NO) is reduced and the cellular response to these molecules is also impaired. By contrast, the vascular endothelium increases its generation and release of reactive oxygen (ROS) and nitrogen (RNS) species, vasoconstrictors such as endothelin (ET) and angiotensin (AT), and endogenous inhibitors of NO synthases (NOSs) to block NO. This skews the balance of the endothelium in favor of the release of highly tissue reactive and harmful molecules that promote DNA damage, telomere erosion, senescence, as well as stiffened and hardened vessel wall that is prone to the development of hypertension, diabetes, atherosclerosis and other cardiovascular risk factors. This Review discusses the impact of advancing age on cardiovascular health, and highlights the cellular and molecular mechanisms that underlie age-associated vascular changes. In addition, the role of pharmacological interventions in preventing or delaying age-related cardiovascular disease is discussed.

Impact of Antihypertensive Agents on Central Systolic Blood Pressure and Augmentation Index: A Meta-Analysis

BACKGROUND

New evidence suggests that central systolic blood pressure (cSBP) and augmentation index (AI) are superior predictors of adverse cardiovascular outcomes compared to peripheral systolic BP (pSBP). We performed a meta-analysis assessing the impact of antihypertensives on cSBP and AI.

METHODS

PubMed, Cochrane Library, and CINAHL were searched until September 2014 to identify eligible articles. A DerSimonian and Laird random-effects model was used to calculate the weighted mean difference (WMD) and its 95% confidence interval (CI). Fifty-two and 58 studies incorporating 4,381 and 3,716 unique subjects were included for cSBP and AI analysis, respectively.

RESULTS

Overall, antihypertensives reduced pSBP more than cSBP (WMD 2.52 mm Hg, 95% CI 1.35 to 3.69; I (2) = 21.9%). β-Blockers (BBs) posed a significantly greater reduction in pSBP as compared to cSBP (WMD 5.19 mm Hg, 95% CI 3.21 to 7.18). α-Blockers, angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, diuretics, renin-angiotensin aldosterone system inhibitors and nicorandil reduced cSBP and pSBP in a similar manner. The overall reduction in AI from baseline was 3.09% (95% CI 2.28 to 3.90; I (2) = 84.5%). A significant reduction in AI was seen with angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, diuretics, renin-angiotensin aldosterone system inhibitors, BBs, α-blockers (ABs), nicorandil, and moxonidine reduced AI nonsignificantly.

CONCLUSIONS

BBs are not as beneficial as the other antihypertensives in reducing cSBP and AI.

Effects of different types of antihypertensive agents on arterial stiffness: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

This system review and meta-analysis was conducted to systematically review and analyze the clinical benefits of different antihypertensive agents in improving arterial stiffness in hypertensive patients.

METHODS

PubMed database was searched for randomized controlled trials (RCTs) evaluating the effects of angiotensin receptor blockers (ARB) or other types of antihypertensive agents on pulse wave velocity (PWV). The main indicators were the improvements of PWV and augmentation index (AI) before and after randomized treatments with antihypertensive agents. For the studies that only provided the mean and standard deviation of the indicators before and after randomization, the standardized mean difference (SMD) method was directly applied to combine the mean and standard deviation of various indicators after the treatment. For the studies provided the mean and standard deviation of the changes of the indicators, the weighted mean difference (MD) method was applied to combine the mean and standard deviation of the therapeutic effect.

RESULTS

Ten RCT studies were included and the sample sizes range from 40 to 201 (total: 938). Four studies provided the changes of PWV before and after randomization, the pooled analysis showed that the changes of PWV in ARB group were not significantly higher than other antihypertensive agents [MD: 125.76, 95% confidence interval (CI): -78.70 to 330.23, P=0.23]; 4 studies provided the PWV values before and after randomization, the PWV values in ARB group were not significantly superior (SMD: 0.04, 95% CI: -0.16 to 0.24, P=0.71). Three studies provided the changes of AI before and after randomization, the ability of ARB to lower the level of the AI was superior to other antihypertensive agents (MD: 8.94, 95% CI: 2.18-5.71, P=0.01); 2 studies provided the AI value after randomization, the abilities of ARB and other anti-hypertensive agents to improve the AI were similar (SMD: 0.03, 95% CI: -1.20 to 1.26, P=0.06).

CONCLUSIONS

The effect of ARB on the improvement of the PWV level is not superior to other types of antihypertensive agents, but ARB is superior to other types of antihypertensive agents for improving the AI level. Overall, to improve of arterial stiffness, ARB maybe is superior to other antihypertensive agents.

The impact of angiotensin receptor blockers on arterial stiffness: a meta-analysis

Some studies reported a protective role of angiotensin receptor blockers (ARBs) against arterial stiffness. Therefore, we performed a meta-analysis of published clinical trials to systematically assess the impact of ARBs on arterial stiffness as measured by using pulse wave velocity (PWV). Eligible articles were identified by searching PubMed, EMBASE, Cochrane, Wanfang and CNKI databanks before 31 July 2014. The data were extracted independently and in duplicate. Forty articles including 53 clinical trials qualified, including 1650 and 1659 subjects in ARB treatment and control groups, respectively. Overall reductions in carotid-femoral PWV (cfPWV) and brachial-ankle PWV (baPWV) were statistically significant, with an average of -42.52 cm s(-1) (95% CI: -81.82 to -3.21; P=0.034) and -107.08 cm s(-1) (95% CI: -133.98 to -80.18; P<0.0005), respectively, after receiving ARBs. Subgroup analysis by ARB type revealed that telmisartan (weighted mean difference or WMD=-100.82 cm s(-1); P<0.0005) and valsartan (WMD=-104.59 cm s(-1); P<0.0005) significantly reduced baPWV, but only valsartan reduced cfPWV (WMD=-65.58; P=0.030). cfPWV was significantly reduced in comparisons of ARBs with placebo (WMD=-79.65 cm s(-1); P=0.001), and baPWV was significantly reduced with calcium channel blockers (WMD=-130.74 cm s(-1); P<0.0005). There were low probabilities of publication bias. Taken together, our findings support the important role of ARB treatment in improving arterial stiffness.

Effect of Angiotensin Receptor Blockers on Flow-Mediated Vasodilation: A Meta-Analysis of Randomized Controlled Trials

Background: In a meta-analysis, we investigated the effects of angiotensin receptor blockers (ARBs) in comparison to placebo or other classes of antihypertensive drugs on endothelial function, which was measured by brachial flow-mediated vasodilation (FMD). Methods: We searched for randomized controlled trials that compared ARBs with placebo or other classes of antihypertensive drugs in improving FMD. A random-effect model was used to compute pooled estimates. Results: In 13 trials (n = 529), ARBs were more efficacious in improving brachial FMD than placebo [pooled weighted mean change difference (WMD) 1.34%, 95% CI, 0.93-1.75%, p < 0.001]. In 15 trials (n = 918), treatment with ARBs had a significant effect on brachial FMD when compared with other antihypertensive drugs (pooled WMD 0.59%, 95% CI, 0.20-0.98%, p = 0.003 with significant heterogeneity). ARBs were also more efficacious in improving brachial FMD than calcium channel blockers (CCBs; pooled WMD 1.61%, 95% CI, 0.72-2.49%, p < 0.001) but not the other classes of drugs (p ≥ 0.072). Conclusions: This meta-analysis shows that ARBs improve brachial FMD, a marker of endothelial function, and that they are superior to placebo and CCBs. There was no significant difference in the effect on brachial FMD between ARBs and the other antihypertensive drugs.

Angiotensin II receptor blockers improve peripheral endothelial function: a meta-analysis of randomized controlled trials

OBJECTIVE(S)

Several studies have assessed the effect of angiotensin II receptor blockers (ARBs) on peripheral endothelial dysfunction as measured by flow-mediated vasodilatation (FMD), a widely-used indicator for endothelial function. We conducted a meta-analysis to investigate the effect in comparison to placebo or no treatment and other antihypertensives.

METHODS

MEDLINE, Cochrane library and EMBASE were searched to September 2013 for randomized controlled trials (RCTs) that assessed the effect of ARBs versus placebo or no treatment and other antihypertensives (angiotensin-converting enzyme inhibitors (ACEIs), calcium channel blockers (CCBs), β-blockers, diuretics) by forearm FMD. Furthermore, we also use meta-regression to analyze the relationship between the endothelial function and the duration of ARBs treatments.

RESULTS

In 11 trials including 590 patients, ARBs (n = 315) significantly improved FMD (1.36%, 95% confidence internal [CI]:1.28 to 1.44) versus placebo or no treatment (n = 275). In 16 trials that included 1028 patients, ARBs (n = 486) had a significant effect (0.59%, 95% CI: 0.25 to 0.94) on FMD when compared with other antihypertensives (n = 542). In 8 trials, ARBs (n = 174) had no significant effect (-0.14%, 95% CI: -0.32 to 0.03) compared with ACEI (n = 173). Compared with others, the benefits of ARBs, respectively, were 1.67% (95% CI: 0.65 to 0.93) in 7 trials with CCBs, 0.79% (95% CI: 0.42 to 1.01) with β-blockers in 3 trials and 0.9% (95% CI: 0.77 to 1.03) with diuretics in 3 trials. Importantly, we found ARBs were less effective in a long time span (95% CI: -1.990 to -0.622) than the first 6 months (95% CI: -0.484 to 0.360).

CONCLUSIONS

This study shows that ARBs improve peripheral endothelial function and are superior to CCBs, β-blockers and diuretics. However, the effect couldn't be maintained for a long time. In addition, there was no significant difference between ARBs and ACEI.

Oxidative stress and vascular inflammation in aging

Vascular aging, a determinant factor for cardiovascular disease and health status in the elderly, is now viewed as a modifiable risk factor. Impaired endothelial vasodilation is a early hallmark of arterial aging that precedes the clinical manifestations of vascular dysfunction, the first step to cardiovascular disease and influencing vascular outcomes in the elderly. Accordingly, the preservation of endothelial function is thought to be an essential determinant of healthy aging. With special attention on the effects of aging on the endothelial function, this review is focused on the two main mechanisms of aging-related endothelial dysfunction: oxidative stress and inflammation. Aging vasculature generates an excess of the reactive oxygen species (ROS), superoxide and hydrogen peroxide, that compromise the vasodilatory activity of nitric oxide (NO) and facilitate the formation of the deleterious radical, peroxynitrite. Main sources of ROS are mitochondrial respiratory chain and NADPH oxidases, although NOS uncoupling could also account for ROS generation. In addition, reduced antioxidant response mediated by erythroid-2-related factor-2 (Nrf2) and downregulation of mitochondrial manganese superoxide dismutase (SOD2) contributes to the establishment of chronic oxidative stress in aged vessels. This is accompanied by a chronic low-grade inflammatory phenotype that participates in defective endothelial vasodilation. The redox-sensitive transcription factor, nuclear factor-κB (NF-κB), is upregulated in vascular cells from old subjects and drives a proinflammatory shift that feedbacks oxidative stress. This chronic NF-κB activation is contributed by increased angiotensin-II signaling and downregulated sirtuins and precludes adequate cellular response to acute ROS generation. Interventions targeted to recover endogenous antioxidant capacity and cellular stress response rather than exogenous antioxidants could reverse oxidative stress-inflammation vicious cycle in vascular aging. Lifestyle attitudes such as caloric restriction and exercise training appear as effective ways to overcome defective antioxidant response and inflammation, favoring successful vascular aging and decreasing the risk for cardiovascular disease.

Effects of Various Antihypertensive Drugs on Arterial Stiffness and Wave Reflections

We reviewed trials that tested the efficacy of antihypertensive drugs in reducing arterial stiffness and wave reflections as assessed by pulse wave velocity and augmentation index, respectively. Regardless of cross-over or parallel-group comparison design, placebo-controlled trials demonstrated that antihypertensive drugs were effective in reducing pulse wave velocity. In actively-controlled parallel-group comparison studies, this effect on arterial stiffness was more evident for angiotensin-converting enzyme inhibitors or angiotensin receptor blockers than other classes of antihypertensive drugs, particularly when brachial-ankle pulse wave velocity was measured. Regardless of cross-over or parallel-group comparison or placebo- or actively-controlled design, the reviewed trials showed that β-blockers were inferior to all the other classes of antihypertensive drugs in reducing augmentation index. However, these studies had a small sample size and a short follow-up time and did not link the changes in measurements of arterial function with cardiovascular events. Whether the superiority or inferiority is clinically relevant for cardiovascular protection and prevention remains to be investigated.

Mechanisms involved in the aging-induced vascular dysfunction

Vascular aging is a key process determining health status of aged population. Aging is an independent cardiovascular risk factor associated to an impairment of endothelial function, which is a very early and important event leading to cardiovascular disease. Vascular aging, formerly being considered an immutable and inexorable risk factor, is now viewed as a target process for intervention in order to achieve a healthier old age. A further knowledge of the mechanisms underlying the age-related vascular dysfunction is required to design an adequate therapeutic strategy to prevent or restore this impairment of vascular functionality. Among the proposed mechanisms that contribute to age-dependent endothelial dysfunction, this review is focused on the following aspects occurring into the vascular wall: (1) the reduction of nitric oxide (NO) bioavailability, caused by diminished NO synthesis and/or by augmented NO scavenging due to oxidative stress, leading to peroxynitrite formation (ONOO(-)); (2) the possible sources involved in the enhancement of oxidative stress; (3) the increased activity of vasoconstrictor factors; and (4) the development of a low-grade pro-inflammatory environment. Synergisms and interactions between all these pathways are also analyzed. Finally, a brief summary of some cellular mechanisms related to endothelial cell senescence (including telomere and telomerase, stress-induced senescence, as well as sirtuins) are implemented, as they are likely involved in the age-dependent endothelial dysfunction, as well as in the lower vascular repairing capacity observed in the elderly. Prevention or reversion of those mechanisms leading to endothelial dysfunction through life style modifications or pharmacological interventions could markedly improve cardiovascular health in older people.

Is acute high-dose secondhand smoke exposure always harmful to microvascular function in healthy adults?

Prev Cardiol. Long-term exposure to secondhand smoke (SHS) is associated with impaired vascular function. The authors investigated the vascular and blood pressure (BP) reactions to acute SHS exposure. Twenty-five healthy nonsmoking adults underwent a 1-hour exposure to SHS (mean fine particulate matter < 2.5 μm level = 315 ± 116 μg/m(3) ). Microvascular endothelial-dependent vasodilatation (EDV) (EndoPAT, Itamar Medical, Caesarea, Israel) and aortic hemodynamics/compliance (SphygmoCor, AtCor Medical, West Ryde, Australia) were measured before and after the SHS exposure with BP measured every 15 minutes during and for a 24-hour period before and after the exposure. SHS exposure did not change EDV, aortic hemodynamics, arterial compliance, or 24-hour BP. However, diastolic BP significantly increased during the SHS exposure period by 3.4 ± 5.6 mm Hg. Our brief SHS exposure did not impair microvascular endothelial function or arterial compliance in healthy nonsmoking adults, but brachial diastolic BP increased.

The Global Burden of Cardiovascular Disease: The Role of Endothelial Function and Arterial Elasticity in Cardiovascular Disease as Novel and Emerging Biomarkers

Some consider the measurements of arterial elasticity and flow-mediated dilation to be an indirect "biomarker" of endothelial dysfunction. As such, we describe the various uses of these techniques in the evaluation of the natural history of vascular disease. These measures are potential markers of disease, as abnormalities reflect changes in the integrity of vascular structure but occur prior to the manifestation of symptomatic cardiovascular events. In this review, the natural history of arterial elasticity is discussed, and the effects of aging and inflammation are reviewed. The role that arterial elasticity and flow-mediated dilation have in predicting future cardiovascular disease, and the effects of pharmacologic agents on these measures, is also reviewed.

Longitudinal changes in central artery stiffness with lifestyle modification, washout, and drug treatment in individuals at risk for cardiovascular disease

We assessed 17 middle-aged and older individuals (58.0 +/- 7.9 years, 7 females) at risk for cardiovascular disease regarding: (1) Whether carotid artery stiffness (cAS) would be reduced with a 1-year lifestyle modification program, (2) to what degree cAS would return following washout (mean of 26.9 +/- 4.0 months) from the active intervention, and (3) whether a 24-week telmisartan treatment would reduce cAS more than our lifestyle modification program. cAS by Doppler ultrasound, cardiovascular disease risk factors, and exercise capacity were assessed at three points: Following the 1-year lifestyle modification, following the washout period, and following a 24-week telmisartan treatment. Following telmisartan, systolic blood pressure (SBP) was significantly decreased (114.8 +/- 12.3 mmHg) compared to baseline (127.9 +/- 12.7 mmHg) and following the washout period (126.1 +/- 14.9 mmHg). Similarly, diastolic blood pressure (DBP) was significantly lower following telmisaratn than following the washout period. Exercise capacity was increased following lifestyle modification but returned to the baseline level following the washout period. Following the lifestyle modification program, cAS was significantly reduced, and this reduction was maintained following the washout period. Conversely, the subsequent telmisartan treatment did not change cAS despite a significant blood pressure reduction. These results suggest that the reduced cAS achieved with lifestyle modification may not necessarily disappear following a cessation of the active program, indicating a possible role that family physicians can play in their clinical practice, and also providing a further rationale to promote lifestyle modification as an initial therapy for this population. In contrast, no additional benefit of telmisartan beyond our lifestyle intervention was observed in this study.

Renal protective effect of RAAS blockade across the renal continuum, with a review of the efficacy and safety of valsartan

Abstract Objective: The purpose of this report is to review key data on the angiotensin receptor blocker (ARB) valsartan, along with data from several pivotal studies with other ARBs and angiotensin-converting enzyme (ACE) inhibitors, to highlight the beneficial class effects of renin-angiotensin-aldosterone system (RAAS) blockade throughout the renal continuum.

METHODS

The selection of articles was based on a search of PubMed for clinical trials published between 1997 (the year in which valsartan was approved for sale in the US) and 2009 that involved valsartan and reported effects on renal function, plus a select range of articles on other agents acting on the RAAS, including key guidance documents issued during this time.

SUMMARY

Valsartan has been studied extensively and is widely used for the management of hypertension. Data from clinical studies involving valsartan and other ARBs and ACE inhibitors provide evidence of an additional renal protective effect. This renal protection apparently arises from hemodynamic, endothelial, and anti-inflammatory actions.

LIMITATIONS

Given the extent of the available literature on this topic, this review included only a subset of available publications. This report may reflect inherent heterogeneity between patient populations from these studies and also incorporate the limitations of these individual publications. The inclusion of guidance documents from several organizations may have resulted in apparent minor conflicts in the approaches of the different groups.

Smoking and Aortic Diseases

Cigarette smoking is a major vascular risk factor and in this context, it is an independent risk factor for the development of aortic disease, especially the formation and growth of abdominal aortic aneurysms (AAA). Medline was searched up to January 31, 2007 for the relevant literature for this review of the mechanisms by which smoking causes aortic wall damage and its subsequent impact on the clinical manifestation of this process. Idiopathic AAAs and aortic dissection are considered, as well as other aortic diseases (eg, Takayasu, Kawasaki, Behcet and Buerger). There is evidence suggesting an abnormal homeostasis between proteolytic and antiproteolytic activity in the vascular wall during the development of AAAs, and these mechanisms can be influenced by smoking. Smoking cessation plays an important role in the management of aortic disease.