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Mackenzie IS, Hawkey CJ, Ford I, Greenlaw N, Pigazzani F, Rogers A, Struthers AD, Begg AG, Wei L, Avery AJ, Taggar JS, Walker A, Duce SL, Barr RJ, Dumbleton JS, Rooke ED, Townend JN, Ritchie LD, MacDonald TM. Allopurinol and cardiovascular outcomes in patients with ischaemic heart disease: the ALL-HEART RCT and economic evaluation. Health Technol Assess 2024; 28:1-55. [PMID: 38551218 PMCID: PMC11017142 DOI: 10.3310/attm4092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024] Open
Abstract
Background Allopurinol is a xanthine oxidase inhibitor that lowers serum uric acid and is used to prevent acute gout flares in patients with gout. Observational and small interventional studies have suggested beneficial cardiovascular effects of allopurinol. Objective To determine whether allopurinol improves major cardiovascular outcomes in patients with ischaemic heart disease. Design Prospective, randomised, open-label, blinded endpoint multicentre clinical trial. Setting Four hundred and twenty-four UK primary care practices. Participants Aged 60 years and over with ischaemic heart disease but no gout. Interventions Participants were randomised (1 : 1) using a central web-based randomisation system to receive allopurinol up to 600 mg daily that was added to usual care or to continue usual care. Main outcome measures The primary outcome was the composite of non-fatal myocardial infarction, non-fatal stroke or cardiovascular death. Secondary outcomes were non-fatal myocardial infarction, non-fatal stroke, cardiovascular death, all-cause mortality, hospitalisation for heart failure, hospitalisation for acute coronary syndrome, coronary revascularisation, hospitalisation for acute coronary syndrome or coronary revascularisation, all cardiovascular hospitalisations, quality of life and cost-effectiveness. The hazard ratio (allopurinol vs. usual care) in a Cox proportional hazards model was assessed for superiority in a modified intention-to-treat analysis. Results From 7 February 2014 to 2 October 2017, 5937 participants were enrolled and randomised to the allopurinol arm (n = 2979) or the usual care arm (n = 2958). A total of 5721 randomised participants (2853 allopurinol; 2868 usual care) were included in the modified intention-to-treat analysis population (mean age 72.0 years; 75.5% male). There was no difference between the allopurinol and usual care arms in the primary endpoint, 314 (11.0%) participants in the allopurinol arm (2.47 events per 100 patient-years) and 325 (11.3%) in the usual care arm (2.37 events per 100 patient-years), hazard ratio 1.04 (95% confidence interval 0.89 to 1.21); p = 0.65. Two hundred and eighty-eight (10.1%) participants in the allopurinol arm and 303 (10.6%) participants in the usual care arm died, hazard ratio 1.02 (95% confidence interval 0.87 to 1.20); p = 0.77. The pre-specified health economic analysis plan was to perform a 'within trial' cost-utility analysis if there was no statistically significant difference in the primary endpoint, so NHS costs and quality-adjusted life-years were estimated over a 5-year period. The difference in costs between treatment arms was +£115 higher for allopurinol (95% confidence interval £17 to £210) with no difference in quality-adjusted life-years (95% confidence interval -0.061 to +0.060). We conclude that there is no evidence that allopurinol used in line with the study protocol is cost-effective. Limitations The results may not be generalisable to younger populations, other ethnic groups or patients with more acute ischaemic heart disease. One thousand six hundred and thirty-seven participants (57.4%) in the allopurinol arm withdrew from randomised treatment, but an on-treatment analysis gave similar results to the main analysis. Conclusions The ALL-HEART study showed that treatment with allopurinol 600 mg daily did not improve cardiovascular outcomes compared to usual care in patients with ischaemic heart disease. We conclude that allopurinol should not be recommended for the secondary prevention of cardiovascular events in patients with ischaemic heart disease but no gout. Future work The effects of allopurinol on cardiovascular outcomes in patients with ischaemic heart disease and co-existing hyperuricaemia or clinical gout could be explored in future studies. Trial registration This trial is registered as EU Clinical Trials Register (EudraCT 2013-003559-39) and ISRCTN (ISRCTN 32017426). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 11/36/41) and is published in full in Health Technology Assessment; Vol. 28, No. 18. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Isla S Mackenzie
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | | | - Ian Ford
- The Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Nicola Greenlaw
- The Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Filippo Pigazzani
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Amy Rogers
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Allan D Struthers
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Alan G Begg
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Li Wei
- School of Pharmacy, University College London, London, UK
| | - Anthony J Avery
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jaspal S Taggar
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Suzanne L Duce
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Rebecca J Barr
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | | | - Evelien D Rooke
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Jonathan N Townend
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | | | - Thomas M MacDonald
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
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Arnaud C, Billoir E, de Melo Junior AF, Pereira SA, O'Halloran KD, Monteiro EC. Chronic intermittent hypoxia-induced cardiovascular and renal dysfunction: from adaptation to maladaptation. J Physiol 2023; 601:5553-5577. [PMID: 37882783 DOI: 10.1113/jp284166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/12/2023] [Indexed: 10/27/2023] Open
Abstract
Chronic intermittent hypoxia (CIH) is the dominant pathological feature of human obstructive sleep apnoea (OSA), which is highly prevalent and associated with cardiovascular and renal diseases. CIH causes hypertension, centred on sympathetic nervous overactivity, which persists following removal of the CIH stimulus. Molecular mechanisms contributing to CIH-induced hypertension have been carefully delineated. However, there is a dearth of knowledge on the efficacy of interventions to ameliorate high blood pressure in established disease. CIH causes endothelial dysfunction, aberrant structural remodelling of vessels and accelerates atherosclerotic processes. Pro-inflammatory and pro-oxidant pathways converge on disrupted nitric oxide signalling driving vascular dysfunction. In addition, CIH has adverse effects on the myocardium, manifesting atrial fibrillation, and cardiac remodelling progressing to contractile dysfunction. Sympatho-vagal imbalance, oxidative stress, inflammation, dysregulated HIF-1α transcriptional responses and resultant pro-apoptotic ER stress, calcium dysregulation, and mitochondrial dysfunction conspire to drive myocardial injury and failure. CIH elaborates direct and indirect effects in the kidney that initially contribute to the development of hypertension and later to chronic kidney disease. CIH-induced morphological damage of the kidney is dependent on TLR4/NF-κB/NLRP3/caspase-1 inflammasome activation and associated pyroptosis. Emerging potential therapies related to the gut-kidney axis and blockade of aryl hydrocarbon receptors (AhR) are promising. Cardiorenal outcomes in response to intermittent hypoxia present along a continuum from adaptation to maladaptation and are dependent on the intensity and duration of exposure to intermittent hypoxia. This heterogeneity of OSA is relevant to therapeutic treatment options and we argue the need for better stratification of OSA phenotypes.
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Affiliation(s)
- Claire Arnaud
- Université Grenoble-Alpes INSERM U1300, Laboratoire HP2, Grenoble, France
| | - Emma Billoir
- Université Grenoble-Alpes INSERM U1300, Laboratoire HP2, Grenoble, France
| | | | - Sofia A Pereira
- iNOVA4Health, NOVA Medical School, Universidade NOVA de Lisboa, Lisboa, Portugal
| | - Ken D O'Halloran
- Department of Physiology, School of Medicine, College of Medicine & Health, University College Cork, Cork, Ireland
| | - Emilia C Monteiro
- iNOVA4Health, NOVA Medical School, Universidade NOVA de Lisboa, Lisboa, Portugal
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3
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Svedmyr S, Hedner J, Bailly S, Fanfulla F, Hein H, Lombardi C, Ludka O, Mihaicuta S, Parati G, Pataka A, Schiza S, Tasbakan S, Testelmans D, Zou D, Grote L. Blood pressure control in hypertensive sleep apnoea patients of the European Sleep Apnea Database cohort - effects of positive airway pressure and antihypertensive medication. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead109. [PMID: 38035035 PMCID: PMC10686603 DOI: 10.1093/ehjopen/oead109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/27/2023] [Accepted: 10/10/2023] [Indexed: 12/02/2023]
Abstract
Aims We analysed longitudinal blood pressure (BP) data from hypertensive obstructive sleep apnoea (OSA) patients in the European Sleep Apnea Database cohort. The study investigated the interaction between positive airway pressure (PAP)-induced BP change and antihypertensive treatment (AHT). Methods and results Hypertensive patients with AHT [monotherapy/dual therapy n = 1283/652, mean age 59.6 ± 10.7/60.6 ± 10.3 years, body mass index (BMI) 34.2 ± 6.5/34.8 ± 7.0 kg/m2, apnoea-hypopnoea index 46 ± 25/46 ± 24 n/h, proportion female 29/26%, respectively] started PAP treatment. Office BP at baseline and 2- to 36-month follow-up were assessed. The interaction between AHT drug classes and PAP on BP was quantified and the influences of age, gender, BMI, co-morbidities, BP at baseline, and study site were evaluated. Following PAP treatment (daily usage, 5.6 ± 1.6/5.7 ± 1.9 h/day), systolic BP was reduced by -3.9 ± 15.5/-2.8 ± 17.7 mmHg in mono/dual AHT and diastolic BP by -3.0 ± 9.8/-2.7 ± 10.8 mmHg, respectively, all P < 0.0001. Systolic and diastolic BP control was improved following PAP treatment (38/35% to 54/46% and 67/67% to 79/74%, mono/dual AHT, respectively). PAP treatment duration predicted a larger BP improvement in the monotherapy group. Intake of renin-angiotensin blockers [angiotensin converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB)] alone or in any AHT combination was associated with better BP control. The AHT-dependent BP improvement was independent of confounders. Conclusion In this pan-European OSA patient cohort, BP control improved following initiation of PAP. Longer PAP treatment duration, was associated with a favourable effect on BP. Our study suggests that ACEI/ARB, alone or in combination with other drug classes, provides a particularly strong reduction of BP and better BP control when combined with PAP in OSA.
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Affiliation(s)
- Sven Svedmyr
- Department of Sleep Medicine, Sahlgrenska University Hospital, Blå stråket 5, 413 45 Gothenburg, Sweden
- Center for Sleep and Vigilance Disorders, Sahlgrenska Academy, Gothenburg University, Medicinaregatan 8B, Box 421, 405 30 Gothenburg, Sweden
| | - Jan Hedner
- Department of Sleep Medicine, Sahlgrenska University Hospital, Blå stråket 5, 413 45 Gothenburg, Sweden
- Center for Sleep and Vigilance Disorders, Sahlgrenska Academy, Gothenburg University, Medicinaregatan 8B, Box 421, 405 30 Gothenburg, Sweden
| | - Sebastien Bailly
- Université Grenoble Alpes, INSERM HP2 (U1042) and Grenoble University Hospital, Grenoble, France
| | - Francesco Fanfulla
- Unità Operativa di Medicina del Sonno, Istituto Scientifico di Pavia IRCCS, Pavia, Italy
| | - Holger Hein
- Sleep Disorders Center, St.Adolf Stift, Reinbeck, Germany
| | - Carolina Lombardi
- Cardiology Unit, Sleep Center, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Ondrej Ludka
- Department of Internal Medicine, University Hospital Brno, Brno, Czech Republic
| | - Stefan Mihaicuta
- Center for Research and Innovation in Precision Medicine and Pharmacy, ‘Victor Babes’ University of Medicine and Pharmacy, Timisoara, Romania
| | - Gianfranco Parati
- Cardiology Unit, Sleep Center, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Athanasia Pataka
- Respiratory Failure Unit, G. Papanikolaou Hospital, Aristotle University of Thessalonikii, Thessalonikii, Greece
| | - Sophia Schiza
- Sleep Disorders Unit, Department of Respiratory Medicine, School of Medicine, University of Crete, Crete, Greece
| | - Sezai Tasbakan
- Department of Chest Diseases, Ege University, Izmir, Turkey
| | - Dries Testelmans
- Sleep Disorders Centre, University Hospital Gasthuisberg, Leuven, Belgium
| | - Ding Zou
- Department of Sleep Medicine, Sahlgrenska University Hospital, Blå stråket 5, 413 45 Gothenburg, Sweden
- Center for Sleep and Vigilance Disorders, Sahlgrenska Academy, Gothenburg University, Medicinaregatan 8B, Box 421, 405 30 Gothenburg, Sweden
| | - Ludger Grote
- Department of Sleep Medicine, Sahlgrenska University Hospital, Blå stråket 5, 413 45 Gothenburg, Sweden
- Center for Sleep and Vigilance Disorders, Sahlgrenska Academy, Gothenburg University, Medicinaregatan 8B, Box 421, 405 30 Gothenburg, Sweden
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4
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Mackenzie IS, Hawkey CJ, Ford I, Greenlaw N, Pigazzani F, Rogers A, Struthers AD, Begg AG, Wei L, Avery AJ, Taggar JS, Walker A, Duce SL, Barr RJ, Dumbleton JS, Rooke ED, Townend JN, Ritchie LD, MacDonald TM. Allopurinol versus usual care in UK patients with ischaemic heart disease (ALL-HEART): a multicentre, prospective, randomised, open-label, blinded-endpoint trial. Lancet 2022; 400:1195-1205. [PMID: 36216006 DOI: 10.1016/s0140-6736(22)01657-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/23/2022] [Accepted: 08/23/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Allopurinol is a urate-lowering therapy used to treat patients with gout. Previous studies have shown that allopurinol has positive effects on several cardiovascular parameters. The ALL-HEART study aimed to determine whether allopurinol therapy improves major cardiovascular outcomes in patients with ischaemic heart disease. METHODS ALL-HEART was a multicentre, prospective, randomised, open-label, blinded-endpoint trial done in 18 regional centres in England and Scotland, with patients recruited from 424 primary care practices. Eligible patients were aged 60 years or older, with ischaemic heart disease but no history of gout. Participants were randomly assigned (1:1), using a central web-based randomisation system accessed via a web-based application or an interactive voice response system, to receive oral allopurinol up-titrated to a dose of 600 mg daily (300 mg daily in participants with moderate renal impairment at baseline) or to continue usual care. The primary outcome was the composite cardiovascular endpoint of non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death. The hazard ratio (allopurinol vs usual care) in a Cox proportional hazards model was assessed for superiority in a modified intention-to-treat analysis (excluding randomly assigned patients later found to have met one of the exclusion criteria). The safety analysis population included all patients in the modified intention-to-treat usual care group and those who took at least one dose of randomised medication in the allopurinol group. This study is registered with the EU Clinical Trials Register, EudraCT 2013-003559-39, and ISRCTN, ISRCTN32017426. FINDINGS Between Feb 7, 2014, and Oct 2, 2017, 5937 participants were enrolled and then randomly assigned to receive allopurinol or usual care. After exclusion of 216 patients after randomisation, 5721 participants (mean age 72·0 years [SD 6·8], 4321 [75·5%] males, and 5676 [99·2%] white) were included in the modified intention-to-treat population, with 2853 in the allopurinol group and 2868 in the usual care group. Mean follow-up time in the study was 4·8 years (1·5). There was no evidence of a difference between the randomised treatment groups in the rates of the primary endpoint. 314 (11·0%) participants in the allopurinol group (2·47 events per 100 patient-years) and 325 (11·3%) in the usual care group (2·37 events per 100 patient-years) had a primary endpoint (hazard ratio [HR] 1·04 [95% CI 0·89-1·21], p=0·65). 288 (10·1%) participants in the allopurinol group and 303 (10·6%) participants in the usual care group died from any cause (HR 1·02 [95% CI 0·87-1·20], p=0·77). INTERPRETATION In this large, randomised clinical trial in patients aged 60 years or older with ischaemic heart disease but no history of gout, there was no difference in the primary outcome of non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death between participants randomised to allopurinol therapy and those randomised to usual care. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- Isla S Mackenzie
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK.
| | | | - Ian Ford
- The Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Nicola Greenlaw
- The Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Filippo Pigazzani
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Amy Rogers
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Allan D Struthers
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Alan G Begg
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Li Wei
- School of Pharmacy, University College London, London, UK
| | - Anthony J Avery
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jaspal S Taggar
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Suzanne L Duce
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Rebecca J Barr
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | | | - Evelien D Rooke
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Jonathan N Townend
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | | | - Thomas M MacDonald
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
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Maier LE, Matenchuk BA, Vucenovic A, Sivak A, Davenport MH, Steinback CD. Influence of Obstructive Sleep Apnea Severity on Muscle Sympathetic Nerve Activity and Blood Pressure: a Systematic Review and Meta-Analysis. Hypertension 2022; 79:2091-2104. [PMID: 35766054 DOI: 10.1161/hypertensionaha.122.19288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We conducted meta-analyses to identify relationships between obstructive sleep apnea (OSA) severity, muscle sympathetic nerve activity (MSNA), and blood pressure (BP). We quantified the effect of OSA treatment on MSNA. METHODS Structured searches of electronic databases were performed until June 2021. All observational designs (except reviews) were included: population (individuals with OSA); exposures (OSA diagnosis and direct measures of MSNA); comparator (individuals without OSA or different severity of OSA); outcomes (MSNA, BP, and heart rate). RESULTS Fifty-six studies (N=1872) were included. MSNA burst frequency was higher in OSA (27 studies; n=542) versus controls (n=488; mean differences [MDs], +15.95 bursts/min [95% CI, 12.6-17.6 bursts/min]; I2=86%). As was burst incidence (20 studies; n=357 OSA, n=312 Controls; MD, +22.23 bursts/100 hbs [95% CI, 18.49-25.97 bursts/100 hbs]; I2=67%). Meta-regressions indicated relationships between MSNA and OSA severity (burst frequency, R2=0.489; P<0.001; burst incidence, R2=0.573; P<0.001). MSNA burst frequency was related to systolic pressure (R2=0.308; P=0.016). OSA treatment with continuous positive airway pressure reduced MSNA burst frequency (MD, 11.91 bursts/min [95% CI, 9.36-14.47 bursts/min] I2=15%) and systolic (n=49; MD, 10.3 mm Hg [95% CI, 3.5-17.2 mm Hg]; I2=42%) and diastolic (MD, 6.9 mm Hg [95% CI, 2.3-11.6 mm Hg]; I2=37%) BP. CONCLUSIONS MSNA is higher in individuals with OSA and related to severity. This sympathoexcitation is also related to BP in patients with OSA. Treatment effectively reduces MSNA and BP, but limited data prevents an assessment of the link between these reductions. These data are clinically important for understanding cardiovascular disease risk in patients with OSA. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: CRD42021285159.
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Affiliation(s)
- Lauren E Maier
- Neurovascular Health Laboratory, Faculty of Kinesiology, Sport, and Recreation (L.E.M., A.V., C.D.S.), University of Alberta, Edmonton, Canada
| | - Brittany A Matenchuk
- Program for Pregnancy and Postpartum Health, Faculty of Kinesiology, Sport, and Recreation (B.A.M., M.H.D.), University of Alberta, Edmonton, Canada
| | - Ana Vucenovic
- Neurovascular Health Laboratory, Faculty of Kinesiology, Sport, and Recreation (L.E.M., A.V., C.D.S.), University of Alberta, Edmonton, Canada
| | - Allison Sivak
- H.T. Coutts Education and Physical Education Library (A.S.), University of Alberta, Edmonton, Canada
| | - Margie H Davenport
- Program for Pregnancy and Postpartum Health, Faculty of Kinesiology, Sport, and Recreation (B.A.M., M.H.D.), University of Alberta, Edmonton, Canada
| | - Craig D Steinback
- Neurovascular Health Laboratory, Faculty of Kinesiology, Sport, and Recreation (L.E.M., A.V., C.D.S.), University of Alberta, Edmonton, Canada
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6
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Langner-Hetmańczuk A, Tubek S, Niewiński P, Ponikowski P. The Role of Pharmacological Treatment in the Chemoreflex Modulation. Front Physiol 2022; 13:912616. [PMID: 35774285 PMCID: PMC9237514 DOI: 10.3389/fphys.2022.912616] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/19/2022] [Indexed: 12/20/2022] Open
Abstract
From a physiological point of view, peripheral chemoreceptors (PCh) are the main sensors of hypoxia in mammals and are responsible for adaptation to hypoxic conditions. Their stimulation causes hyperventilation—to increase oxygen uptake and increases sympathetic output in order to counteract hypoxia-induced vasodilatation and redistribute the oxygenated blood to critical organs. While this reaction promotes survival in acute settings it may be devastating when long-lasting. The permanent overfunctionality of PCh is one of the etiologic factors and is responsible for the progression of sympathetically-mediated diseases. Thus, the deactivation of PCh has been proposed as a treatment method for these disorders. We review here physiological background and current knowledge regarding the influence of widely prescribed medications on PCh acute and tonic activities.
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Affiliation(s)
- Anna Langner-Hetmańczuk
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Stanisław Tubek
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
- *Correspondence: Stanisław Tubek,
| | - Piotr Niewiński
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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Abstract
OBJECTIVE Obstructive sleep apnoea (OSA) is a common cause of secondary hypertension. This network meta-analysis (NMA) assessed the effect of different OSA treatments on lowering blood pressure. METHODS PubMed, EMBASE, Web of Science, and Cochrane Library databases were searched for relevant randomized controlled trials. The search strategies included the concepts of OSA, blood pressure, hypertension, and blood pressure-reducing treatments without language or data restriction (from inception to 1 June 2021). The outcomes included office SBP, office DBP, daytime SBP (dSBP) and DBP (dDBP), and night-time SBP (nSBP) and DBP (nDBP). A Bayesian network meta-analysis was performed, and mean differences with 95% credibility intervals were calculated. RESULTS We reviewed 49 randomized controlled trials involving 4893 patients and the following interventions: continuous positive-airway pressure (CPAP), mandibular advancement devices, nocturnal supplemental oxygen, surgery, β-blocker, angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), renal sympathetic denervation (RDN), mineralocorticoid receptor antagonists (MRAs), calcium channel blockers. MRAs were significantly associated with blood pressure reduction followed by ACEI/ARB. RDN could reduce office SBP, office DBP, 24-h SBP, 24-h DBP, dSBP, and dDBP. CPAP also demonstrated modest blood pressure lowering. CONCLUSION MRAs and ACEIs/ARBs can reduce blood pressure effectively in patients with OSA. RDN is a novel hypertension treatment that lowered blood pressure in such patients. CPAP was associated with mild but stable blood pressure reduction, and it might be helpful as an adjunctive therapy in OSA patients with hypertension. REVIEW REGISTRATION This systematic review and meta-analysis was registered in PROSPERO: CRD42021240891.
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Alzahrani AA, Cao LL, Aldossary HS, Nathanael D, Fu J, Ray CJ, Brain KL, Kumar P, Coney AM, Holmes AP. β-Adrenoceptor blockade prevents carotid body hyperactivity and elevated vascular sympathetic nerve density induced by chronic intermittent hypoxia. Pflugers Arch 2021; 473:37-51. [PMID: 33210151 PMCID: PMC7782391 DOI: 10.1007/s00424-020-02492-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/26/2020] [Accepted: 11/06/2020] [Indexed: 12/17/2022]
Abstract
Carotid body (CB) hyperactivity promotes hypertension in response to chronic intermittent hypoxia (CIH). The plasma concentration of adrenaline is reported to be elevated in CIH and our previous work suggests that adrenaline directly activates the CB. However, a role for chronic adrenergic stimulation in mediating CB hyperactivity is currently unknown. This study evaluated whether beta-blocker treatment with propranolol (Prop) prevented the development of CB hyperactivity, vascular sympathetic nerve growth and hypertension caused by CIH. Adult male Wistar rats were assigned into 1 of 4 groups: Control (N), N + Prop, CIH and CIH + Prop. The CIH paradigm consisted of 8 cycles h-1, 8 h day-1, for 3 weeks. Propranolol was administered via drinking water to achieve a dose of 40 mg kg-1 day-1. Immunohistochemistry revealed the presence of both β1 and β2-adrenoceptor subtypes on the CB type I cell. CIH caused a 2-3-fold elevation in basal CB single-fibre chemoafferent activity and this was prevented by chronic propranolol treatment. Chemoafferent responses to hypoxia and mitochondrial inhibitors were attenuated by propranolol, an effect that was greater in CIH animals. Propranolol decreased respiratory frequency in normoxia and hypoxia in N and CIH. Propranolol also abolished the CIH mediated increase in vascular sympathetic nerve density. Arterial blood pressure was reduced in propranolol groups during hypoxia. Propranolol exaggerated the fall in blood pressure in most (6/7) CIH animals during hypoxia, suggestive of reduced sympathetic tone. These findings therefore identify new roles for β-adrenergic stimulation in evoking CB hyperactivity, sympathetic vascular hyperinnervation and altered blood pressure control in response to CIH.
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Affiliation(s)
- Abdulaziz A Alzahrani
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
- Respiratory Care Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Lily L Cao
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Hayyaf S Aldossary
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
- College of Medicine, Basic Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Demitris Nathanael
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Jiarong Fu
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Clare J Ray
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Keith L Brain
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Prem Kumar
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Andrew M Coney
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
| | - Andrew P Holmes
- Institute of Clinical Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
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9
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Prasad B, Morgan BJ, Gupta A, Pegelow DF, Teodorescu M, Dopp JM, Dempsey JA. The need for specificity in quantifying neurocirculatory vs. respiratory effects of eucapnic hypoxia and transient hyperoxia. J Physiol 2020; 598:4803-4819. [PMID: 32770545 DOI: 10.1113/jp280515] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 08/04/2020] [Indexed: 12/24/2022] Open
Abstract
KEY POINTS The carotid chemoreceptor mediates the ventilatory and muscle sympathetic nerve activity (MSNA) responses to hypoxia and contributes to tonic sympathetic and respiratory drives. It is often presumed that both excitatory and inhibitory tests of chemoreflex function show congruence in the end-organ responses. Ventilatory and neurocirculatory (MSNA, blood pressure and heart rate) responses to chemoreflex inhibition elicited by transient hyperoxia and to chemoreflex excitation produced by steady-state eucapnic hypoxia were measured in a cohort of 82 middle-aged individuals. Ventilatory and MSNA responsiveness to hyperoxia and hypoxia were not significantly correlated within individuals. It was concluded that ventilatory responses to hypoxia and hyperoxia do not predict MSNA responses and it is recommended that tests using the specific outcome of interest, i.e. MSNA or ventilation, are required. Transient hyperoxia is recommended as a sensitive and reliable means of quantifying tonic chemoreceptor-driven levels of sympathetic nervous system activity and respiratory drive. ABSTRACT Hypersensitivity of the carotid chemoreceptor leading to sympathetic nervous system activation and ventilatory instability has been implicated in the pathogenesis and consequences of several common clinical conditions. A variety of treatment approaches aimed at lessening chemoreceptor-driven sympathetic overactivity are now under investigation; thus, the ability to quantify this outcome variable with specificity and precision is crucial. Accordingly, we measured ventilatory and neurocirculatory responses to chemoreflex inhibition elicited by transient hyperoxia and chemoreflex excitation produced by exposure to graded, steady-state eucapnic hypoxia in middle-aged men and women (n = 82) with continuous positive airway pressure-treated obstructive sleep apnoea. Progressive, eucapnic hypoxia produced robust and highly variable increases in ventilation (+83 ± 59%) and muscle sympathetic nerve activity (MSNA) burst frequency (+55 ± 31%), whereas transient hyperoxia caused marked reductions in these variables (-35 ± 14% and -42 ± 16%, respectively). Coefficients of variation for ventilatory and MSNA burst frequency responses, indicating test-retest reproducibility, were respectively 9% and 24% for hyperoxia and 35% and 28% for hypoxia. Based on statistical measures of rank correlation or even comparisons across quartiles of corresponding ventilatory and MSNA responses, we found that the magnitudes of ventilatory inhibition with hyperoxia or excitation with eucapnic hypoxia were not correlated with corresponding MSNA responses within individuals. We conclude that, in conscious, behaving humans, ventilatory sensitivities to progressive, steady-state, eucapnic hypoxia and transient hyperoxia do not predict MSNA responsiveness. Our findings also support the use of transient hyperoxia as a reliable, sensitive, measure of the carotid chemoreceptor contribution to tonic sympathetic nervous system activity and respiratory drive.
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Affiliation(s)
- Bharati Prasad
- Department of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Barbara J Morgan
- John Rankin Laboratory of Pulmonary Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.,Department of Orthopedics and Rehabilitation, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Ahana Gupta
- GPPA Medical Scholars Program, University of Illinois at Chicago, Chicago, IL, USA
| | - David F Pegelow
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Mihaela Teodorescu
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - John M Dopp
- Pharmacy Practice Division, School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
| | - Jerome A Dempsey
- John Rankin Laboratory of Pulmonary Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA.,Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, WI, USA
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10
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Aldossary HS, Alzahrani AA, Nathanael D, Alhuthail EA, Ray CJ, Batis N, Kumar P, Coney AM, Holmes AP. G-Protein-Coupled Receptor (GPCR) Signaling in the Carotid Body: Roles in Hypoxia and Cardiovascular and Respiratory Disease. Int J Mol Sci 2020; 21:ijms21176012. [PMID: 32825527 PMCID: PMC7503665 DOI: 10.3390/ijms21176012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 12/17/2022] Open
Abstract
The carotid body (CB) is an important organ located at the carotid bifurcation that constantly monitors the blood supplying the brain. During hypoxia, the CB immediately triggers an alarm in the form of nerve impulses sent to the brain. This activates protective reflexes including hyperventilation, tachycardia and vasoconstriction, to ensure blood and oxygen delivery to the brain and vital organs. However, in certain conditions, including obstructive sleep apnea, heart failure and essential/spontaneous hypertension, the CB becomes hyperactive, promoting neurogenic hypertension and arrhythmia. G-protein-coupled receptors (GPCRs) are very highly expressed in the CB and have key roles in mediating baseline CB activity and hypoxic sensitivity. Here, we provide a brief overview of the numerous GPCRs that are expressed in the CB, their mechanism of action and downstream effects. Furthermore, we will address how these GPCRs and signaling pathways may contribute to CB hyperactivity and cardiovascular and respiratory disease. GPCRs are a major target for drug discovery development. This information highlights specific GPCRs that could be targeted by novel or existing drugs to enable more personalized treatment of CB-mediated cardiovascular and respiratory disease.
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Affiliation(s)
- Hayyaf S. Aldossary
- Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK; (H.S.A.); (A.A.A.); (D.N.); (E.A.A.); (C.J.R.); (P.K.); (A.M.C.)
- College of Medicine, Basic Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia
| | - Abdulaziz A. Alzahrani
- Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK; (H.S.A.); (A.A.A.); (D.N.); (E.A.A.); (C.J.R.); (P.K.); (A.M.C.)
- Respiratory Care Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah 24381, Saudi Arabia
| | - Demitris Nathanael
- Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK; (H.S.A.); (A.A.A.); (D.N.); (E.A.A.); (C.J.R.); (P.K.); (A.M.C.)
| | - Eyas A. Alhuthail
- Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK; (H.S.A.); (A.A.A.); (D.N.); (E.A.A.); (C.J.R.); (P.K.); (A.M.C.)
- Collage of Sciences and Health Professions, Basic Sciences Department, King Saud bin Abdulaziz University for Health Sciences, Riyadh 11481, Saudi Arabia
| | - Clare J. Ray
- Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK; (H.S.A.); (A.A.A.); (D.N.); (E.A.A.); (C.J.R.); (P.K.); (A.M.C.)
| | - Nikolaos Batis
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK;
| | - Prem Kumar
- Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK; (H.S.A.); (A.A.A.); (D.N.); (E.A.A.); (C.J.R.); (P.K.); (A.M.C.)
| | - Andrew M. Coney
- Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK; (H.S.A.); (A.A.A.); (D.N.); (E.A.A.); (C.J.R.); (P.K.); (A.M.C.)
| | - Andrew P. Holmes
- Institute of Clinical Sciences, University of Birmingham, Birmingham B15 2TT, UK; (H.S.A.); (A.A.A.); (D.N.); (E.A.A.); (C.J.R.); (P.K.); (A.M.C.)
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Correspondence: ; Tel.: +44-121-415-8161
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11
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Brown CV, Boulet LM, Vermeulen TD, Sands SA, Wilson RJA, Ayas NT, Floras JS, Foster GE. Angiotensin II-Type I Receptor Antagonism Does Not Influence the Chemoreceptor Reflex or Hypoxia-Induced Central Sleep Apnea in Men. Front Neurosci 2020; 14:382. [PMID: 32410951 PMCID: PMC7198907 DOI: 10.3389/fnins.2020.00382] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 03/27/2020] [Indexed: 12/15/2022] Open
Abstract
Components of the renin-angiotensin system (RAS) situated within the carotid body or central nervous system may promote hypoxia-induced chemoreceptor reflex sensitization or central sleep apnea (CSA). We determined if losartan, an angiotensin-II type-I receptor (AT1R) antagonist, would attenuate chemoreceptor reflex sensitivity before or after 8 h of nocturnal hypoxia, and consequently CSA severity. In a double-blind, randomized, placebo-controlled, crossover protocol, 14 men (age: 25 ± 2 years; BMI: 24.6 ± 1.1 kg/m2; means ± SEM) ingested 3 doses of either losartan (50 mg) or placebo every 8 h. Chemoreceptor reflex sensitivity was assessed during hypoxic and hyperoxic hypercapnic ventilatory response (HCVR) tests and during six-20s hypoxic apneas before and after 8 h of sleep in normobaric hypoxia (FIO2 = 0.135). Loop gain was assessed from a ventilatory control model fitted to the ventilatory pattern of CSA recorded during polysomnography. Prior to nocturnal hypoxia, losartan had no effect on either the hyperoxic (losartan: 3.6 ± 1.1, placebo: 4.0 ± 0.6 l/min/mmHg; P = 0.9) or hypoxic HCVR (losartan: 5.3 ± 1.4, placebo: 5.7 ± 0.68 l/min/mmHg; P = 1.0). Likewise, losartan did not influence either the hyperoxic (losartan: 4.2 ± 1.3, placebo: 3.8 ± 1.1 l/min/mmHg; P = 0.5) or hypoxic HCVR (losartan: 6.6 ± 1.8, placebo: 6.3 ± 1.5 l/min/mmHg; P = 0.9) after nocturnal hypoxia. Cardiorespiratory responses to apnea and participants’ apnea hypopnea indexes during placebo and losartan were similar (73 ± 15 vs. 75 ± 14 events/h; P = 0.9). Loop gain, which correlated with CSA severity (r = 0.94, P < 0.001), was similar between treatments. In summary, in young healthy men, hypoxia-induced CSA severity is strongly associated with loop gain, but the AT1R does not modulate chemoreceptor reflex sensitivity before or after 8 h of nocturnal hypoxia.
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Affiliation(s)
- Courtney V Brown
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Lindsey M Boulet
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Tyler D Vermeulen
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia - Okanagan, Kelowna, BC, Canada
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States
| | - Richard J A Wilson
- Department of Physiology and Pharmacology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Najib T Ayas
- Sleep Disorders Program, University of British Columbia, Vancouver, BC, Canada.,Respiratory and Critical Care Divisions, University of British Columbia, Vancouver, BC, Canada
| | - John S Floras
- University Health Network and Sinai Health System Division of Cardiology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Glen E Foster
- Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia - Okanagan, Kelowna, BC, Canada
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12
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Ayas NT, Foster GE, Shah N, Floras J, Laher I. Could Adjunctive Pharmacology Mitigate Cardiovascular Consequences of Obstructive Sleep Apnea? Am J Respir Crit Care Med 2020; 200:551-555. [PMID: 30875238 DOI: 10.1164/rccm.201811-2097pp] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Najib T Ayas
- Sleep Disorders Program.,Division of Respiratory Medicine and.,Division of Critical Care Medicine, Department of Medicine, and.,Canadian Sleep and Circadian Network and
| | - Glen E Foster
- Canadian Sleep and Circadian Network and.,Centre for Heart, Lung, and Vascular Health, School of Health and Exercise Science, University of British Columbia, Kelowna, British Columbia, Canada
| | - Neomi Shah
- Division of Pulmonary, Critical Care, and Sleep, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - John Floras
- Division of Cardiology, Department of Medicine, University Health Network and Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Ismail Laher
- Department of Anesthesiology, Pharmacology, and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Canadian Sleep and Circadian Network and
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