Inhibitory effect of glucocorticoid on coronary artery endothelial function

β-Adrenergic Stimulation-Induced PVAT Dysfunction in Male Sex: A Role for 11β-Hydroxysteroid Dehydrogenase-1

Long-term β-adrenoceptor (β-AR) stimulation is a pathological mechanism associated with cardiovascular diseases resulting in endothelial and perivascular adipose tissue (PVAT) dysfunction. In this study, we aimed to identify whether β-adrenergic signaling has a direct effect on PVAT. Thoracic aorta PVAT was obtained from male Wistar rats and cultured ex vivo with the β-AR agonist isoproterenol (Iso; 1 µM) or vehicle for 24 hours. Conditioned culture medium (CCM) from Iso-treated PVAT induced a marked increase in aorta contractile response, induced oxidative stress, and reduced nitric oxide production in PVAT compared to vehicle. In addition, Iso-treated PVAT and PVAT-derived differentiated adipocytes exhibited higher corticosterone release and protein expression of 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1), an enzyme responsible for de novo synthesis of corticosterone. Macrophages exposed to Iso also exhibited increased corticosterone release in response to β-AR stimulation. Incubation of Iso-treated PVAT and PVAT-derived differentiated adipocytes with β3-AR antagonist restored aorta contractile function modulated by Iso-CCM and normalized 11β-HSD1 protein expression. These results show that β3-AR signaling leads to upregulation of 11β-HSD1 in PVAT, thus increasing corticosterone release and contributing to impair the anticontractile function of this tissue.

Metabolomic Profiling of Hormonal Contraceptive Use in Young Females Using a Commercially Available LC-MS/MS Kit

Oral hormonal contraceptive users carry the risk of venous thrombosis and increased mortality. This study aimed to comprehensively profile the serum metabolome of participants using a combination of drospirenone (DRSP) and ethinyl estradiol (EE) containing oral contraceptives (COCs). The MxP Quant 500 kit for liquid chromatography mass tandem spectrometry (LC-MS/MS) was used to analyse the 22 controls and 44 COC users (22 on a low EE dose (DRSP/20EE) and 22 on a higher EE dose (DRSP/30EE)). The kit's results were compared to our internally developed untargeted and targeted metabolomics methods previously applied to this cohort. Of the 630 metabolites included in the method, 277 provided desirable results (consistently detected above their detection limits), and of these, 5 had p-values < 0.05, including betaine, glutamine, cortisol, glycine, and choline. Notably, these variations were observed between the control and COC groups, rather than among the two COC groups. Partial least squares-discriminant analysis revealed 49 compounds with VIP values ≥ 1, including amino acids and their derivatives, ceramides, phosphatidylcholines, and triglycerides, among others. Ten differential compounds were consistent with our previous studies, reinforcing the notion of COCs inducing a prothrombotic state and increased oxidative stress. Although only a limited number of compounds were deemed usable, these were quantified with high reliability and facilitated the identification of meaningful biological differences among the sample groups. In addition to substantiating known drug-induced variations, new hypotheses were also generated.

Endothelial Cell Response in Kawasaki Disease and Multisystem Inflammatory Syndrome in Children

Although Kawasaki disease (KD) and multisystem inflammatory syndrome in children (MIS-C) share some clinical manifestations, their cardiovascular outcomes are different, and this may be reflected at the level of the endothelial cell (EC). We performed RNA-seq on cultured ECs incubated with pre-treatment sera from KD (n = 5), MIS-C (n = 7), and healthy controls (n = 3). We conducted a weighted gene co-expression network analysis (WGCNA) using 935 transcripts differentially expressed between MIS-C and KD using relaxed filtering (unadjusted p < 0.05, >1.1-fold difference). We found seven gene modules in MIS-C, annotated as an increased TNFα/NFκB pathway, decreased EC homeostasis, anti-inflammation and immune response, translation, and glucocorticoid responsive genes and endothelial-mesenchymal transition (EndoMT). To further understand the difference in the EC response between MIS-C and KD, stringent filtering was applied to identify 41 differentially expressed genes (DEGs) between MIS-C and KD (adjusted p < 0.05, >2-fold-difference). Again, in MIS-C, NFκB pathway genes, including nine pro-survival genes, were upregulated. The expression levels were higher in the genes influencing autophagy (UBD, EBI3, and SQSTM1). Other DEGs also supported the finding by WGCNA. Compared to KD, ECs in MIS-C had increased pro-survival transcripts but reduced transcripts related to EndoMT and EC homeostasis. These differences in the EC response may influence the different cardiovascular outcomes in these two diseases.

Meta-Analysis of Glucocorticoids for Covid-19 Patients Not Receiving Oxygen

BACKGROUND: Glucocorticoids reduce mortality in hospitalized patients with severe and critical coronavirus disease 2019 (Covid-19), although a possible harm was documented in patients with Covid-19 not requiring oxygen. METHODS: We searched Embase, BioMed Central, medRxiv, bioRxiv, PubMed, and the Cochrane Central Register of Controlled Trials for any randomized trial or matched study ever performed on adult patients with Covid-19 not receiving oxygen therapy treated with intravenous or oral glucocorticoids versus any comparator (standard therapy or placebo); there were no restrictions on dose or time of administration. The primary end point was all-cause mortality at the longest available follow-up. RESULTS: Five randomized trials and one propensity-matched study involving 6634 hospitalized patients not on oxygen were finally included (3704 received glucocorticoids and 2930 received standard treatment). The overall mortality of patients treated with glucocorticoids was significantly higher than the mortality of patients in the control group (509 of 3704 [14%] in the glucocorticoid group vs. 294 of 2930 [10%] in the control group; odds ratio, 1.56 [95% confidence interval, 1.27 to 1.92], with three articles reporting mortality events and contributing to the combined odds ratio; P<0.001; number needed to harm=27). CONCLUSIONS: Glucocorticoid use likely increases mortality in hospitalized patients with Covid-19 not receiving oxygen, with a number needed to harm of 27. (PROSPERO number CRD42022342996.)

Home as the new frontier for the treatment of COVID-19: the case for anti-inflammatory agents

COVID-19, caused by SARS-CoV-2, is characterised by a broad spectrum of symptom severity that requires varying amounts of care according to the different stages of the disease. Intervening at the onset of mild to moderate COVID-19 symptoms in the outpatient setting would provide the opportunity to prevent progression to a more severe illness and long-term complications. As early disease symptoms variably reflect an underlying excessive inflammatory response to the viral infection, the use of anti-inflammatory drugs, especially non-steroidal anti-inflammatory drugs (NSAIDs), in the initial outpatient stage of COVID-19 seems to be a valuable therapeutic strategy. A few observational studies have tested NSAIDs (especially relatively selective COX-2 inhibitors), often as part of multipharmacological protocols, for early outpatient treatment of COVID-19. The findings from these studies are promising and point to a crucial role of NSAIDs for the at-home management of people with initial COVID-19 symptoms.

The sex-dependent response to psychosocial stress and ischaemic heart disease

Stress is an important risk factor for modern chronic diseases, with distinct influences in males and females. The sex specificity of the mammalian stress response contributes to the sex-dependent development and impacts of coronary artery disease (CAD). Compared to men, women appear to have greater susceptibility to chronic forms of psychosocial stress, extending beyond an increased incidence of mood disorders to include a 2- to 4-fold higher risk of stress-dependent myocardial infarction in women, and up to 10-fold higher risk of Takotsubo syndrome-a stress-dependent coronary-myocardial disorder most prevalent in post-menopausal women. Sex differences arise at all levels of the stress response: from initial perception of stress to behavioural, cognitive, and affective responses and longer-term disease outcomes. These fundamental differences involve interactions between chromosomal and gonadal determinants, (mal)adaptive epigenetic modulation across the lifespan (particularly in early life), and the extrinsic influences of socio-cultural, economic, and environmental factors. Pre-clinical investigations of biological mechanisms support distinct early life programming and a heightened corticolimbic-noradrenaline-neuroinflammatory reactivity in females vs. males, among implicated determinants of the chronic stress response. Unravelling the intrinsic molecular, cellular and systems biological basis of these differences, and their interactions with external lifestyle/socio-cultural determinants, can guide preventative and therapeutic strategies to better target coronary heart disease in a tailored sex-specific manner.

Non-ST-Segment Elevation Myocardial Infarction Shortly After Starting Steroid Replacement Therapy in a Patient With Adrenal Insufficiency

Adrenal insufficiency is a rare disorder that results from etiological factors affecting either the hypothalamic-pituitary axis or the adrenal gland itself. Studies have associated an inherently increased risk of cardiovascular events with this condition. It is treated with exogenous steroid supplementation. However, in recent years, there have been an increasing number of reports regarding the potential of steroid therapy to precipitate acute cardiac events. However, this risk is generally assumed to be dose-dependent and could be absent in patients receiving low-dose glucocorticoid treatment. We present a case of a 71-year-old woman who was admitted to our institution with bilateral lower limb swelling. Blood investigation revealed hypoalbuminemia and hyponatremia. Upon further evaluation she was diagnosed to have adrenal insufficiency and was started on hydrocortisone replacement therapy; however, the patient developed non-ST-segment elevation myocardial infarction (NSTEMI) and acute pulmonary edema a few days after starting steroid replacement therapy. Here, we discuss the possible association between hydrocortisone use and the development of acute cardiac events.

Cardiovascular signatures of COVID-19 predict mortality and identify barrier stabilizing therapies

Background

Endothelial cell (EC) activation, endotheliitis, vascular permeability, and thrombosis have been observed in patients with severe coronavirus disease 2019 (COVID-19), indicating that the vasculature is affected during the acute stages of SARS-CoV-2 infection. It remains unknown whether circulating vascular markers are sufficient to predict clinical outcomes, are unique to COVID-19, and if vascular permeability can be therapeutically targeted.

Methods

Prospectively evaluating the prevalence of circulating inflammatory, cardiac, and EC activation markers as well as developing a microRNA atlas in 241 unvaccinated patients with suspected SARS-CoV-2 infection allowed for prognostic value assessment using a Random Forest model machine learning approach. Subsequent ex vivo experiments assessed EC permeability responses to patient plasma and were used to uncover modulated gene regulatory networks from which rational therapeutic design was inferred.

Findings

Multiple inflammatory and EC activation biomarkers were associated with mortality in COVID-19 patients and in severity-matched SARS-CoV-2-negative patients, while dysregulation of specific microRNAs at presentation was specific for poor COVID-19-related outcomes and revealed disease-relevant pathways. Integrating the datasets using a machine learning approach further enhanced clinical risk prediction for in-hospital mortality. Exposure of ECs to COVID-19 patient plasma resulted in severity-specific gene expression responses and EC barrier dysfunction, which was ameliorated using angiopoietin-1 mimetic or recombinant Slit2-N.

Interpretation

Integration of multi-omics data identified microRNA and vascular biomarkers prognostic of in-hospital mortality in COVID-19 patients and revealed that vascular stabilizing therapies should be explored as a treatment for endothelial dysfunction in COVID-19, and other severe diseases where endothelial dysfunction has a central role in pathogenesis.

Funding Information

This work was directly supported by grant funding from the Ted Rogers Center for Heart Research, Toronto, Ontario, Canada and the Peter Munk Cardiac Center, Toronto, Ontario, Canada.

Glucocorticoids: Fuelling the Fire of Atherosclerosis or Therapeutic Extinguishers?

Glucocorticoids are steroid hormones with key roles in the regulation of many physiological systems including energy homeostasis and immunity. However, chronic glucocorticoid excess, highlighted in Cushing's syndrome, is established as being associated with increased cardiovascular disease (CVD) risk. Atherosclerosis is the major cause of CVD, leading to complications including coronary artery disease, myocardial infarction and heart failure. While the associations between glucocorticoid excess and increased prevalence of these complications are well established, the mechanisms underlying the role of glucocorticoids in development of atheroma are unclear. This review aims to better understand the importance of glucocorticoids in atherosclerosis and to dissect their cell-specific effects on key processes (e.g., contractility, remodelling and lesion development). Clinical and pre-clinical studies have shown both athero-protective and pro-atherogenic responses to glucocorticoids, effects dependent upon their multifactorial actions. Evidence indicates regulation of glucocorticoid bioavailability at the vasculature is complex, with local delivery, pre-receptor metabolism, and receptor expression contributing to responses linked to vascular remodelling and inflammation. Further investigations are required to clarify the mechanisms through which endogenous, local glucocorticoid action and systemic glucocorticoid treatment promote/inhibit atherosclerosis. This will provide greater insights into the potential benefit of glucocorticoid targeted approaches in the treatment of cardiovascular disease.

Efficacy of synthetic glucocorticoids in COVID-19 endothelites

Since March 2020, the world has been fighting a global pandemic caused by a new coronavirus SARS-CoV-2 (COVID-19). SARS-CoV-2 is responsible for severe acute respiratory syndrome, an airway disease that can be severe and fatal in a percentage of cases. Patients with severe COVID-19 can develop extrapulmonary lesions, with renal, hepatic, cardiac, neurological, and tissue involvement that can cause further severe complications. On December 21, 2021, the European Medicines Agency (EMA) authorized the marketing of the first COVID-19 vaccine. However, several randomized trials are ongoing to find effective, safe, and widely available treatments. The most severe stages of COVID-19 infection are characterized by a multi-system inflammatory state induced by a cytokine storm causing multi-organ injury. Epidemiologic evidence has shown that glucocorticoids (GCs), particularly dexamethasone, are used in severe, hospitalized patients with COVID-19 with good therapeutic benefit. COVID-19 can also damage the endothelial system, causing microcirculatory disturbances and consequently leading to functional organ disorders. The combination of endothelial dysfunction with a generalized inflammatory state may contribute to the general pro-coagulative state described in patients with COVID-19 with increased risk of venous and arterial occlusions. The aim of this article is to describe the therapeutic utility of GCs in stabilizing the vascular endothelial barrier in COVID-19 infection. Indeed, we believe that the stabilization of the endothelial barrier and the anti-inflammatory effect of GCs could be the main effect underlying the therapeutic efficacy in COVID-19 patients.

A brief positive psychological intervention prior to a potentially stressful task facilitates more challenge-like cardiovascular reactivity in high trait anxious individuals

When confronted with stress, anxious individuals tend to evaluate the demands of an upcoming encounter as higher than the available resources, thus, indicating threat evaluations. Conversely, evaluating available resources as higher than the demands signals challenge. Both types of evaluations have been related to specific cardiovascular response patterns with higher cardiac output relative to peripheral resistance indicating challenge and higher peripheral resistance relative to cardiac output signaling threat. The aim of this research was to evaluate whether a brief positive psychological exercise (best possible selves intervention) prior to a potentially stress‐evoking task shifted the cardiovascular profile in trait anxious individuals from a threat to a challenge type. We randomly assigned 74 participants to either a best possible selves or a control exercise prior to performing a sing a song stress task and assessed their level of trait anxiety. Cardiac output (CO) and total peripheral resistance (TPR) were continuously recorded through baseline, preparation, stress task, and recovery, respectively, as well as self‐reported affect. Trait anxiety was related to higher CO in the best possible selves group and lower CO in the control group. While high trait anxious individuals in the control group showed increasing TPR reactivity, they exhibited a nonsignificant change in the best possible selves group. Moreover, in the latter group a stress‐related decrease in positive affect in high trait anxious participants was prevented. Findings suggest that concentrating on strengths and positive assets prior to a potentially stressful encounter could trigger a more adaptive coping in trait anxious individuals.

According to the biopsychosocial model anxious individuals may evaluate motivated performance tasks as threatening, resulting in stronger vascular than cardiac responding. We found that a positive writing exercise (best possible selves‐intervention) prior to a laboratory stress task led to a more challenge‐type response profile (i.e., higher cardiac output relative to peripheral resistance) in trait anxious individuals, suggesting that positive psychological micro‐interventions could foster more adaptive coping.

Impact of Acute and Chronic Stress on Thrombosis in Healthy Individuals and Cardiovascular Disease Patients

Psychological stress induces different alterations in the organism in order to maintain homeostasis, including changes in hematopoiesis and hemostasis. In particular, stress-induced hyper activation of the autonomic nervous system and hypothalamic–pituitary–adrenal axis can trigger cellular and molecular alterations in platelets, coagulation factors, endothelial function, redox balance, and sterile inflammatory response. For this reason, mental stress is reported to enhance the risk of cardiovascular disease (CVD). However, contrasting results are often found in the literature considering differences in the response to acute or chronic stress and the health condition of the population analyzed. Since thrombosis is the most common underlying pathology of CVDs, the comprehension of the mechanisms at the basis of the association between stress and this pathology is highly valuable. The aim of this work is to give a comprehensive review of the studies focused on the role of acute and chronic stress in both healthy individuals and CVD patients, focusing on the cellular and molecular mechanisms underlying the relationship between stress and thrombosis.

Interventions to promote cardiometabolic health and slow cardiovascular ageing

Cardiovascular ageing and the atherosclerotic process begin very early in life, most likely in utero. They progress over decades of exposure to suboptimal or abnormal metabolic and hormonal risk factors, eventually culminating in very common, costly, and mostly preventable target-organ pathologies, including coronary heart disease, stroke, heart failure, aortic aneurysm, peripheral artery disease, and vascular dementia. In this Review, we discuss findings from preclinical and clinical studies showing that calorie restriction (CR), intermittent fasting, and adjusted diurnal rhythm of feeding, with adequate intake of specific macronutrients and micronutrients, are powerful interventions not only for the prevention of cardiovascular disease but also for slowing the accumulation of molecular damage leading to cardiometabolic dysfunction. Furthermore, we discuss the mechanisms through which a number of other nondietary interventions, such as regular physical activity, mindfulness-based stress-reduction exercises, and some CR-mimetic drugs that target pro-ageing pathways, can potentiate the beneficial effects of a healthy diet in promoting cardiometabolic health.

PTSD and Physical Health

PURPOSE OF REVIEW

We review evidence linking PTSD to physical health symptoms and specific disorders, highlighting areas with multiple studies and objective measures of disease states when available. We also examine evidence for biological, behavioral, and psychosocial mechanisms underlying these associations and discuss the clinical implications of recent research.

RECENT FINDINGS

Recent meta-analyses have found that evidence is particularly strong for increased risk of cardiovascular, metabolic, and musculoskeletal disorders among patients with PTSD. Numerous studies have found alterations in the hypothalamic-pituitary-adrenal axis, sympathetic nervous system, inflammation, and health behaviors that could increase risk of illness, but few studies have simultaneously incorporated measures of mechanisms and disease outcomes. Future research should focus on expanding the diversity of populations studied, particularly with respect to underrepresented racial and ethnic groups. Longitudinal studies that incorporate repeated measures of PTSD, pathogenic mechanisms of disease, and physical health outcomes and the addition of physical health outcomes to PTSD treatment trials will be most informative for the field.

Blood pressure regulation in stress: focus on nitric oxide-dependent mechanisms

Stress is considered a risk factor associated with the development of various civilization diseases including cardiovascular diseases, malignant tumors and mental disorders. Research investigating mechanisms involved in stress-induced hypertension have attracted much attention of physicians and researchers, however, there are still ambiguous results concerning a causal relationship between stress and long-term elevation of blood pressure (BP). Several studies have observed that mechanisms involved in the development of stress-induced hypertension include increased activity of sympathetic nervous system (SNS), glucocorticoid (GC) overload and altered endothelial function including decreased nitric oxide (NO) bioavailability. Nitric oxide is well known neurotransmitter, neuromodulator and vasodilator involved in regulation of neuroendocrine mechanisms and cardiovascular responses to stressors. Thus NO plays a crucial role in the regulation of the stress systems and thereby in the BP regulation in stress. Elevated NO synthesis, especially in the initial phase of stress, may be considered a stress-limiting mechanism, facilitating the recovery from stress to the resting levels via attenuation of both GC release and SNS activity as well as by increased NO-dependent vasorelaxation. On the other hand, reduced levels of NO were observed in the later phases of stress and in subjects with genetic predisposition to hypertension, irrespectively, in which reduced NO bioavailability may account for disruption of NO-mediated BP regulatory mechanisms and accentuated SNS and GC effects. This review summarizes current knowledge on the role of stress in development of hypertension with a special focus on the interactions among NO and other biological systems affecting blood pressure and vascular function.

Left ventricular geometry and 24-h blood pressure profile in Cushing's syndrome

Cushing's syndrome (CS) is associated with cardiovascular disease. The impact of the hemodynamic load on left ventricular mass (LVM) in patients with CS is not well known. In fact, the effects of 24-h blood pressure (BP) load and BP circadian rhythm on cardiac structure and function have not been studied. Aim of the present study has thus been to assess the presence of cardiac remodeling in patients with newly diagnosed CS, combining evaluation of cardiac remodeling and assessment of BP burden derived by 24-h ambulatory blood pressure monitoring (ABPM). 25 patients (4 M, 21 F) with CS underwent echocardiography in order to assess cardiac morphology and geometry (relative wall thickness-RWT). As controls, 25 subjects similar for demographic characteristics and 24-h BP were used. CS Patients were similar to controls by age, sex, mean 24-h BP, and body mass index. There was a significant increase in left ventricular mass (LVM; 44.4 ± 14.7 vs. 36.9 ± 10 g/m^2.7, p = 0.03) and a significant increase in RWT (0.46 ± 0.07 vs. 0.41 ± 0.08, p = 0.02) in CS patients compared to controls. The prevalence of CS patients with pressure non-dipping profile was greater than that of controls (56 vs. 16 %, p < 0.05), with no significant association with LVM or geometry. 24-h urinary cortisol was not associated with LVM (r = 0.1, p = 0.5) or RWT (r = 0.02, p = 0.89) in the CS group. In conclusion, LVM and the concentric pattern of the left ventricle are relatively independent from 24-h BP load and profile (dipping/non-dipping) in CS patients.

Glucocorticoids and endothelial function in inflammatory diseases: focus on rheumatoid arthritis

Rheumatoid arthritis (RA) is the most common systemic autoimmune disease characterized by articular and extra-articular manifestations involving cardiovascular (CV) diseases. RA increases the CV mortality by up to 50 % compared with the global population and CV disease is the leading cause of death in patients with RA. There is growing evidence that RA favors accelerated atherogenesis secondary to endothelial dysfunction (ED) that occurs early in the course of the disease. ED is a functional and reversible alteration of endothelial cells, leading to a shift of the actions of the endothelium towards reduced vasodilation, proinflammatory state, proliferative and prothrombotic properties. The mechanistic links between RA and ED have not been fully explained, but growing evidence suggests a role for traditional CV factors, auto-antibodies, genetic factors, oxidative stress, inflammation and iatrogenic interventions such as glucocorticoids (GCs) use. GCs have been used in RA for several decades. Whilst their deleterious CV side effects were described in the 1950s, their effect on CV risk associated with inflammatory arthritis remains subject for debate. GC might induce negative effects on endothelial function, via a direct effect on endothelium or via increasing CV risk factors. Conversely, they might actually improve endothelial function by decreasing systemic and/or vascular inflammation. The present review summarizes the available data on the impact of GCs on endothelial function, both in normal and inflammatory conditions, with a special focus on RA patients.

Dexamethasone Associated ST Elevation Myocardial Infarction Four Days after an Unremarkable Coronary Angiogram-Another Reason for Cautious Use of Steroids: A Case Report and Review of the Literature

Drug induced myocardial infarction is a known entity with different forms of steroids linked to coronary artery disease (CAD) either through promoting its traditional risk factors, inducing coronary spasm, or by other unidentified mechanisms. Dexamethasone is known to promote an atherogenic and hypercoagulable state. We report a case of a 75-year-old woman who had ST elevation myocardial infarction (STEMI) associated with dexamethasone use just 4 days following an angiogram showing minor luminal irregularities.

Moderate hyperoxic versus near-physiological oxygen targets during and after coronary artery bypass surgery: a randomised controlled trial

Background

The safety of perioperative hyperoxia is currently unclear. Previous studies in patients undergoing coronary artery bypass surgery suggest reduced myocardial damage when avoiding extreme perioperative hyperoxia (>400 mmHg). In this study we investigated whether an oxygenation strategy from moderate hyperoxia to a near-physiological oxygen tension reduces myocardial damage and improves haemodynamics, organ dysfunction and oxidative stress.

Methods

This was a single-blind, single-centre, open-label, randomised controlled trial in patients undergoing elective coronary artery bypass surgery. Fifty patients were randomised to a partial pressure of oxygen in arterial blood (P_aO₂) target of 200–220 mmHg during cardiopulmonary bypass and 130–150 mmHg during intensive care unit (ICU) admission (control group) versus lower targets of 130–150 mmHg during cardiopulmonary bypass and 80–100 mmHg at the ICU (conservative group). Primary outcome was myocardial injury (CK-MB and Troponin-T) at ICU admission and 2, 6 and 12 hours thereafter.

Results

Weighted P_aO₂ during cardiopulmonary bypass was 220 mmHg (interquartile range (IQR) 211–233) vs. 157 (151–162) in the control and conservative group, respectively (P < 0.0001). During ICU admission, weighted P_aO₂ was 107 mmHg (86–141) vs. 90 (84–98) (P = 0.03), respectively. Area under the curve of CK-MB was median 23.5 μg/L/h (IQR 18.4–28.1) vs. 21.5 (15.8–26.6) (P = 0.35) and 0.30 μg/L/h (0.25–0.44) vs. 0.39 (0.24–0.43) (P = 0.81) for Troponin-T. Cardiac index, systemic vascular resistance index, creatinine, lactate and F2-isoprostane levels were not different between groups.

Conclusions

Compared to moderate hyperoxia, a near-physiological oxygen strategy does not reduce myocardial damage in patients undergoing coronary artery bypass surgery. Conservative oxygen administration was not associated with increased lactate levels or hypoxic events.

Trial registration

Netherlands Trial Registry NTR4375, registered on 30 January 2014

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1240-6) contains supplementary material, which is available to authorized users.

Chronic stress impacts the cardiovascular system: animal models and clinical outcomes

Psychological stresses are associated with cardiovascular diseases to the extent that cardiovascular diseases are among the most important group of psychosomatic diseases. The longstanding association between stress and cardiovascular disease exists despite a large ambiguity about the underlying mechanisms. An array of possibilities have been proposed including overactivity of the autonomic nervous system and humoral changes, which then converge on endothelial dysfunction that initiates unwanted cardiovascular consequences. We review some of the features of the two most important stress-activated systems, i.e., the humoral and nervous systems, and focus on alterations in endothelial function that could ensue as a result of these changes. Cardiac and hematologic consequences of stress are also addressed briefly. It is likely that activation of the inflammatory cascade in association with oxidative imbalance represents key pathophysiological components of stress-induced cardiovascular changes. We also review some of the commonly used animal models of stress and discuss the cardiovascular outcomes reported in these models of stress. The unique ability of animals for adaptation under stressful conditions lessens the extrapolation of laboratory findings to conditions of human stress. An animal model of unpredictable chronic stress, which applies various stress modules in a random fashion, might be a useful solution to this predicament. The use of stress markers as indicators of stress intensity is also discussed in various models of animal stress and in clinical studies.

Coronary Slow Flow Accompanying Exertional Blurred Vision and Effects of Corticosteroids

Patient: Male, 44

Final Diagnosis: Coronary slow flow

Symptoms: Blurring of vision • chest pain

Medication: —

Clinical Procedure: Medical treatment

Specialty: Cardiology

Acute psychological and physical stress transiently enhances brachial artery flow-mediated dilation stimulated by exercise-induced increases in shear stress

Exercise elevates conduit artery shear stress and stimulates flow-mediated dilation (FMD). However, little is known regarding the impact of acute psychological and physical stress on this response. The purpose of this study was to examine the impact of the Trier Social Stress Test (TSST (speech and arithmetic tasks)) and a cold pressor test (CPT) with and without social evaluation (SE) on exercise-induced brachial artery FMD (EX-FMD). A total of 59 healthy male subjects were randomly assigned to 1 of 3 conditions: TSST, CPT, or CPT with SE. During 6 min of handgrip exercise, brachial artery EX-FMD was assessed before and 15 and 35 min poststress with echo and Doppler ultrasound. Shear stress was estimated as shear rate, calculated as brachial artery mean blood velocity/brachial artery diameter. Results are means ± SD. All conditions elicited significant physiological stress responses. Salivary cortisol increased from 4.6 ± 2.4 nmol/L to 10.0 ± 5.0 nmol/L (p < 0.001; condition effect: p = 0.292). Mean arterial pressure increased from 98.6 ± 12.1 mm Hg to 131.9 ± 18.7 mm Hg (p < 0.001; condition effect: p = 0.664). Exercise shear rate did not differ between conditions (p = 0.592), although it was modestly lower poststress (prestress: 72.3 ± 4.5 s−1; 15 min poststress: 70.8 ± 5.4 s−1; 35 min poststress: 70.6 ± 6.1 s−1; trial effect: p = 0.011). EX-FMD increased from prestress to 15 min poststress in all conditions (prestress: 6.2% ± 2.8%; 15 min poststress: 7.9% ± 3.2%; 35 min poststress: 6.6% ± 2.9%; trial effect: p < 0.001; condition effect: p = 0.611). In conclusion, all conditions elicited similar stress responses that transiently enhanced EX-FMD. This response may help to support muscle perfusion during stress.

Endothelial dysfunction in experimental models of arterial hypertension: cause or consequence?

Hypertension is a risk factor for other cardiovascular diseases and endothelial dysfunction was found in humans as well as in various commonly employed animal experimental models of arterial hypertension. Data from the literature indicate that, in general, endothelial dysfunction would not be the cause of experimental hypertension and may rather be secondary, that is, resulting from high blood pressure (BP). The initial mechanism of endothelial dysfunction itself may be associated with a lack of endothelium-derived relaxing factors (mainly nitric oxide) and/or accentuation of various endothelium-derived constricting factors. The involvement and role of endothelium-derived factors in the development of endothelial dysfunction in individual experimental models of hypertension may vary, depending on the triggering stimulus, strain, age, and vascular bed investigated. This brief review was focused on the participation of endothelial dysfunction, individual endothelium-derived factors, and their mechanisms of action in the development of high BP in the most frequently used rodent experimental models of arterial hypertension, including nitric oxide deficient models, spontaneous (pre)hypertension, stress-induced hypertension, and selected pharmacological and diet-induced models.

Endothelial dysfunction in experimental models of arterial hypertension: cause or consequence?

Hypertension is a risk factor for other cardiovascular diseases and endothelial dysfunction was found in humans as well as in various commonly employed animal experimental models of arterial hypertension. Data from the literature indicate that, in general, endothelial dysfunction would not be the cause of experimental hypertension and may rather be secondary, that is, resulting from high blood pressure (BP). The initial mechanism of endothelial dysfunction itself may be associated with a lack of endothelium-derived relaxing factors (mainly nitric oxide) and/or accentuation of various endothelium-derived constricting factors. The involvement and role of endothelium-derived factors in the development of endothelial dysfunction in individual experimental models of hypertension may vary, depending on the triggering stimulus, strain, age, and vascular bed investigated. This brief review was focused on the participation of endothelial dysfunction, individual endothelium-derived factors, and their mechanisms of action in the development of high BP in the most frequently used rodent experimental models of arterial hypertension, including nitric oxide deficient models, spontaneous (pre)hypertension, stress-induced hypertension, and selected pharmacological and diet-induced models.

Three cases of vasospastic angina that developed following the initiation of corticosteroid therapy

Three patients diagnosed as having remitting seronegative symmetrical synovitis with pitting edema syndrome, pemphigus erythematosus and idiopathic interstitial pneumonia were treated with oral prednisolone. Several weeks after starting the treatment, they experienced repeated chest pain attacks between midnight and early morning, although none of the patients had a past history of ischemic heart disease. One of the patients exhibited aggravation of symptoms soon after increasing the dose of prednisolone. A definitive diagnosis of vasospastic angina was made using electrocardiograms, coronary angiography and vasospasm provocation tests. These cases emphasize that clinicians should be aware of the possible occurrence of vasospastic angina following the initiation of corticosteroid therapy.

Glucocorticoids and estrogens modulate the NF-κB pathway differently in the micro- and macrovasculature

Estrogens and glucocorticoids have synergistic effects in the micro and macrovasculature of endothelial cells (ECs), having pro-inflammatory effects in the former and inhibiting the expression of adhesion molecules in the latter. The molecular basis of these effects in the endothelium has not yet been clarified. We postulate that the ECs of the micro- and macrovasculature have different non-genomic mechanisms that regulate levels of preexisting complexes of glucocorticoids and estrogens with their respective receptors. Since these receptors are regulated by NF-κB, their expression could be critical to the activation of a pro- or anti-inflammatory response. In the macrovasculature the synergistic effects of estrogens and glucocorticoids on ECs may be through the inhibition of NF-κB, leading to the inhibition of the expression of inflammatory molecules. It seems likely that glucocorticoid-receptor and estrogen-receptor complexes directly bind to NF-κB proteins in the macrovasculature, resulting in the inhibition of an excessive proinflammatory response. Further insights into these processes may help clarify the role of the endothelial cells of different vascular beds during the inflammatory response and chronic inflammation, and thus contribute to the design of more effective therapeutic strategies for the prevention of diseases related to inflammation, including atherosclerosis, systemic lupus erythematosus and rheumatoid arthritis.

Evaluation of circulation disorder in coronary slow flow by fundus fluorescein angiography

Coronary slow flow (CSF) may be a reflection of a systemic slow-flow phenomenon in the coronary arterial tree. In this study, the CSF group consisted of 24 men (77.4%) and 7 women (22.5%). An age- and gender-matched normal coronary artery (control) group was composed of 21 men (72.4%) and 8 women (27.5%). Retinal arteriovenous circulation time was measured using fundus fluorescein angiography as a part of the microcirculation and the circulation time between the antecubital vein and the retina as a part of the systemic circulation in patients with CSF and controls with normal coronary arteries. The mean arm-retina circulation time was 19.0 ± 5.7 seconds in the CSF group and 14.1 ± 3.1 seconds in the control group (p <0.001). The mean retinal arteriovenous passage time was 2.6 ± 0.9 seconds in the CSF group and 2.1 ± 0.7 seconds in the control group (p = 0.001). Strikingly, retinal findings of chronic central serous retinopathy were observed in 3 patients in the CSF group. In conclusion, CSF may indeed be a part of a systemic slow-flow phenomenon. The association of central serous retinopathy with this condition suggests that corticosteroids and the sympathetic system may play important roles in the pathogenesis of the disease by causing or contributing to increases in microvascular resistance and tonus.

Posttraumatic stress disorder and cardiovascular disease

Posttraumatic stress disorder (PTSD) is an anxiety disorder initiated by exposure to a traumatic event and characterized by intrusive thoughts about the event, attempts to avoid reminders of the event, and physiological hyperarousal. In a number of large prospective observational studies, PTSD has been associated with incident cardiovascular disease (CVD) and mortality. Also, in recent years, a number of studies have shown that cardiovascular events can themselves cause PTSD in more than 1 in 8 patients with acute coronary syndrome. Further, a few small studies suggest that PTSD secondary to an acute CVD event then places patients at increased risk for subsequent CVD events and mortality. In this article, we review the evidence for a link between PTSD and CVD, and discuss potential mechanisms for that association as well as future directions for research.

The impact of acute mental stress on vascular endothelial function: evidence, mechanisms and importance

Cardiovascular disease is a principle cause of morbidity and mortality worldwide, and it has a complex etiology that involves lifestyle factors such as psychosocial stress. Recent evidence suggests that temporary impairments in vascular endothelial cell function may contribute to the relationship between stress and cardiovascular disease. Indeed, impaired endothelial function has been observed to occur transiently (lasting up to 1.5h) following mental stress, and such periods of impairment could accumulate to become clinically relevant over the long term. The finding of acute stress induced endothelial dysfunction is not universal however, and both physiological (e.g. sympathetic nervous system and hypothalamic-pituitary-adrenal axis reactivity), and methodological factors contribute to the conflicting results. A clear understanding of the interaction between stress response activation and endothelial function is critical to elucidating the complexities of the relationship between psychosocial stress and cardiovascular disease. Therefore, the purpose of this review is: 1) to briefly describe the importance of vascular endothelial function and how it is assessed, 2) to review the literature investigating the impact of acute mental stress on endothelial function in humans, identifying factors that may explain contradictory results, and 3) to summarize our current understanding of the mechanisms that may mediate an acute mental stress-endothelial function interaction.

Chronic glucocorticoid exposure potentiates placental chorionic plate artery constriction: implications for aberrant fetoplacental vascular resistance in fetal growth restriction

Fetal growth restriction (FGR) is a serious pregnancy complication, resulting in significant perinatal morbidity and mortality. Increased vascular resistance in the fetoplacental circulation is a hallmark of FGR and is associated with enhanced vasoconstriction of the resistance arteries in the placenta, the chorionic plate arteries (CPAs). Although the cause is unknown, FGR is associated with excess exposure to glucocorticoids (GCs), key mediators of vascular resistance in the systemic circulation. We hypothesized that GCs alter CPA reactivity, thereby contributing to the altered blood flow dynamics seen in FGR. We aimed to examine the acute and chronic effects of GCs on CPA reactivity and the operational mechanisms. Glucocorticoid receptors were highly expressed by CPA. 11β-Hydroxysteroid isoenzyme type 2 was detected within the endothelium, whereas 11β-hydroxysteroid isoenzyme type 1 was absent. Acute GC treatment significantly attenuated U46619-induced constriction. This effect was reversed by cotreatment with mifepristone or an endothelial NOS inhibitor. In contrast, chronic GC treatment potentiated U46619 constriction in a dose-dependent manner, which was partially abolished by mifepristone cotreatment. Similar effects were observed using a novel nonsteroidal glucocorticoid receptor-specific agonist. Chronic treatment with GCs altered the expression of several vasoactive factors, including thromboxane and bradykinin receptors, prokineticin-1, cyclooxygenase-2, and endothelial NOS. In summary, acute and chronic GC treatment exerts contrasting effects on CPA vasoreactivity. These opposing effects are consistent with temporal actions in other vascular beds and reflect activation of distinct nongenomic and genomic pathways. Chronic exposure to elevated GCs may contribute to the raised vascular resistance observed in the fetoplacental circulation in FGR.

Coronary microvascular function in patients with Cushing's syndrome

The aim of the study was to evaluate patients with Cushing's syndrome the coronary flow reserve (CFR), an index of coronary microvascular function. Fifteen newly diagnosed patients with Cushing's syndrome (1 male/14 females; mean age 45 ± 11 years), were selected for having no clinical evidence of ischemic heart disease. Twelve patients had pituitary-dependent Cushing's disease and three had an adrenal adenoma. Fifteen subjects matched for age, sex, and major cardiovascular risk factors were used as controls. Coronary flow velocity in the left anterior descending coronary artery was investigated by transthoracic Doppler echocardiography at rest and during adenosine infusion. CFR was obtained as the ratio hyperemic/resting diastolic flow velocity. A reduced coronary reserve (hyperemic/resting ratio ≤ 2.5) was found in 5/15 Cushing patients and 4/15 controls. In all patients with abnormal CFR, epicardial coronary stenosis was excluded by multi-slice computed tomographic coronary angiography. CFR was inversely related to urinary cortisol in patients with endogenous hypercortisolism (Spearman's rho = -0.57, P = 0.03), while no correlation was found in controls. Coronary microvascular function, as assessed by CFR, is pathologically reduced in a considerable number of patients with Cushing's syndrome without clinical symptoms of ischemic heart disease and in the absence of epicardial coronary artery lesions, as well as in controls matched for cardiovascular risk factors. The presence of comorbidities can explain this early coronary abnormality in both patients and controls. Whether urinary cortisol may be a predictor of coronary microvascular function in the setting of patients with Cushing's syndrome, needs further investigation.

The association between cortisol dynamics and the course of aneurysmal subarachnoid hemorrhage

Context:

One of aneurysmal subarachnoid hemorrhage complication is delayed ischemic neurological deficits (DIND). It is postulated that cortisol dynamics might be associated with the severity of this complication.

Aims:

The goal of the study is to investigate whether the peak of morning serum cortisol levels are associated with the severity of its complication during the course of the disease.

Settings and Design:

This is a prospective cohort study conducted from January 2009 to June 2011, at our institution.

Materials and Methods:

The study follows a consecutive cohort of patients for 14 days after the aneurysmal subarachnoid hemorrhage. Serum cortisols, cortisol binding globulin, adenocorticotrophic hormone (ACTH) were measured pre operatively and then on post operative days (POD) 2, 4, 7, and 10. Blood was drawn to coincide with peak cortisol levels between 08.00-09.00 hours. Neurological examinations were conducted at least twice daily and patient outcome were graded according to modified Ranklin Scale. DIND was defined by a decrease in the Glasgow Coma Scale of two or more points compared to the status on POD 1.

Statistical Analysis:

All the results were analyzed using statistical software, Statistical Package for Social Sciences (SPSS v61; SPSS, Inc., Chicago, IL). Logistic regression analysis was used to compare the relationship between the variables.

Results:

Thirty six consecutive patients are collected, but only 28 patients (12 M and 16 F) were eligible for the cohort analysis. Average patient age is 50.75 years old (50.75±12.27), and more than 50% (15/28) arrived with World Federation of Neurologic Surgeons grade 3 or better. Elevated total cortisol levels of more than 24 mg/dl on day 2, 4, and 10 were associated with DIND, and the most significant being on day 4 (P=0.011). These patients also had a higher grade on the modified Ranklin scale of disability.

Conclusions:

This study shows that the elevated levels of morning total cortisol in the serum are associated with the onset of DIND during the disease course, and it's also associated with bad outcomes.

Glucocorticoid-induced hypertension and the nitric oxide system

Glucocorticoid hormones, both naturally occurring and synthetic, have long been recognized as a major cause of hypertension. There are well-described experimental models of glucocorticoid-induced hypertension, such as adrenocorticotropic hormone- and dexamethasone-induced hypertension in rats, although the exact mechanism of glucocorticoid-induced hypertension remains unclear. It was initially considered to be due to mineralocorticoid receptor activation but more recent studies have not supported this notion. Current evidence demonstrates the importance of the nitric oxide (NO) system and interactions between NO and reactive oxygen species in the development of glucocorticoid-induced hypertension. This review highlights the pathways contributing to NO deficiency, which encompass the availability of l-arginine, endothelial NO synthase function and the extent of NO inactivation during oxidative stress.

Biological understanding of the cardiovascular risk associated with major depression and panic disorder is important

INTRODUCTION

Panic disorder (PD) and major depressive disorders (MDD) are serious mental disorders but the mechanisms underlying the pathophysiology are poorly understood. Nitric oxide (NO) is a gas considered to play an important role in mediating anxiety and stress response and is synthesised from nitric oxide synthase (NOS). The endothelial isoform (eNOS) has been found also in platelets. Homocysteine (Hcy) is an amino acid which naturally occurs in the human body. Elevated levels are linked to increased risk of cardiovascular, neurological and psychiatric diseases. In this study we aimed to evaluate NO, platelet aggregation and Hcy levels in PD and MDD patients.

MATERIALS AND METHODS

Nineteen PD and 18 MDD patients participated in this study. NO levels were measured spectrophotometrically, platelet aggregation levels were measured in an aggregometer and Hcy levels were measured by HPLC.

RESULTS

NO levels were significantly lower in patients with MDD and PD than in control subjects (P < 0.05). Hcy and platelet aggregation levels were significantly higher in patients with MDD and PD than in control subjects (P < 0.05).

CONCLUSION

Further more detailed studies are needed to find out the effects of drugs on these parameters or to disclose the exact mechanism underlying the alteration of these parameters.

How mental stress affects endothelial function

Mental stress is an important factor contributing to recognized mechanisms underlying cardiovascular events. Among these, stress-related endothelial dysfunction is an early risk factor that predicts future development of severe cardiovascular disorders. Acute mental stress by a variety of tests impairs endothelial function in humans, although the opposite results have been reported by some investigators. Chronic stress always deteriorates endothelial function in humans and experimental animals. Stress hormones, such as glucocorticoids and pro-inflammatory cytokines, and endothelin-1 liberated in response to mental stress participate in endothelial dysfunction possibly via downregulation of endothelial nitric oxide synthase (eNOS) expression, eNOS inactivation, decreased nitric oxide (NO) actions, and increased NO degradation, together with vasoconstriction counteracting against NO-induced vasodilatation. Catecholamines do not directly affect endothelial function but impair its function when blood pressure elevation by the amines is sustained. Endogenous opioids favorably affect endothelial function, which counteract deteriorating effects of other stress hormones and mediators. Inhibition of cortisol and endothelin-1 production, prevention of pro-inflammatory mediator accumulation, hypnotics, mirthful laughter, humor orientation, and lifestyle modification would contribute to the prevention and treatment for stress-related endothelial dysfunction and future serious cardiovascular disease.

Spontaneous perirenal hematoma due to Wegener's granulomatosis after initiation of immunosuppressant

Spontaneous perirenal hematoma (SPH) is a rare, life-threatening condition. We present a patient with Wegener's granulomatosis (WG) who developed SPH soon after the initiation of immunosuppressant therapy. Few cases of SPH as a complication of WG have been reported, though a rupture of an aneurysm in patients with polyarteritis nodosa can lead to SPH. Though immunosuppressant therapy is considered to be the first-line therapy for SPH with vasculitis, SPH could still occur after the initiation of an adequate treatment regimen.

Effects of antidepressants on plasma metabolites of nitric oxide in major depressive disorder: comparison between milnacipran and paroxetine

Depression is a risk factor for coronary heart disease (CHD). It has been demonstrated that there is a potential role of nitric oxide (NO) in the relationship between depression and CHD risk as well as an effect of antidepressants on NO production. This study included 40 in- or outpatients in our university hospital who met the DSM-IV-TR criteria for major depressive disorder (M/F: 15/25, age: 47+/-19 years) and 30 age- and sex-matched healthy controls (M/F: 10/20, age: 45+/-15 years), and also examined the effects of the antidepressants on the plasma NOx levels in depressed patients. The baseline plasma NOx levels were significantly lower in the whole depressed group than in the control group (p<0.01). Treatment with milnacipran, but not paroxetine, significantly increased the plasma NOx levels by 4 and 8 weeks. These results suggest that decreased plasma NOx levels might be partially associated with the pathophysiology of depression, and that treatment with milnacipran, a serotonin noradrenaline reuptake inhibitor, might increase those levels in depressed patients.

Interaction of hydrocortisone with ATP and adenosine on nerve-mediated contractions of frog skeletal muscle

The inhibitory effects of ATP and adenosine on the nerve-mediated contractile responses of isolated sartorius muscle of the frog, Rana ridibunda, evoked by electrical field stimulation (EFS) were studied using pharmacological organ-bath technique. The effects of hydrocortisone applied in vitro and in vivo on contractility of sartorius muscle were also examined. ATP (100 microM) significantly reduced the amplitude of contraction to EFS of sartorius muscle, while pyridoxalphosphate-6-azonphenyl-2',4'-disulfonic acid (PPADS; 10 microM), a P2 receptor antagonist, abolished inhibitory effect of ATP. A similar inhibitory effect of adenosine (100 microM) was fully antagonized by 8-(p-sulfophenyl)-theophylline (8-SPT, 100 microM), a P1 receptor antagonist. Incubation of the tissue with hydrocortisone (10 microM) caused a slight, but significant, decrease of muscle contractions. After incubation of muscle preparations with both hydrocortisone and ATP, no inhibition of muscle contractility was registered. A single injection of hydrocortisone (100 mg/kg) 12 h prior to experiments to frogs did not significantly change the nerve-mediated contractility of isolated sartorius muscle; however, it abolished the inhibitory action of ATP without changing inhibitory activity of adenosine. After treatment of frogs with hydrocortisone for 14 days (100 mg/kg/day), both ATP and adenosine retained their inhibitory action on EFS-induced contractions of the muscle, and their effects were antagonized by PPADS and 8-SPT, respectively. It is concluded that hydrocortisone has antagonistic actions against the inhibitory effects of ATP at the frog neuromuscular junction, although this effect is lost following long-term treatment with hydrocortisone.

Effects of a low-salt diet on flow-mediated dilatation in humans

BACKGROUND

The effect of salt reduction on vascular function, assessed by brachial artery flow-mediated dilatation (FMD), is unknown.

OBJECTIVE

Our aim was to compare the effects of a low-salt (LS; 50 mmol Na/d) diet with those of a usual-salt (US; 150 mmol Na/d) diet on FMD.

DESIGN

This was a randomized crossover design in which 29 overweight and obese normotensive men and women followed an LS diet and a US diet for 2 wk. Both diets had similar potassium and saturated fat contents and were designed to ensure weight stability. After each intervention, FMD, pulse wave velocity, augmentation index, and blood pressure were measured.

RESULTS

FMD was significantly greater (P = 0.001) with the LS diet (4.89 +/- 2.42%) than with the US diet (3.37 +/- 2.10%), systolic blood pressure was significantly (P = 0.02) lower with the LS diet (112 +/- 11 mm Hg) than with the US diet (117 +/- 13 mm Hg), and 24-h sodium excretion was significantly lower (P = 0.0001) with the LS diet (64.1 +/- 41.3 mmol) than with the US diet (156.3 +/- 56.7 mmol). There was no correlation between change in FMD and change in 24-h sodium excretion or change in blood pressure. No significant changes in augmentation index or pulse wave velocity were observed.

CONCLUSIONS

Salt reduction improves endothelium-dependant vasodilation in normotensive subjects independently of the changes in measured resting clinic blood pressure. These findings suggest additional cardioprotective effects of salt reduction beyond blood pressure reduction. The trial is registered with the Australian and New Zealand Clinical Trials Registry (unique identifier: ANZCTR12607000381482; http://www.anzctr.org.au/trial_view.aspx?ID=82159).

Glucocorticoid response elements and 11 beta-hydroxysteroid dehydrogenases in the regulation of endothelial nitric oxide synthase expression

AIMS

Hypertensive and other effects of excess glucocorticoids might be in part mediated by the suppression of endothelial nitric oxide synthase (eNOS) expression. We studied the transcriptional and biochemical mechanisms that mediate or modulate the suppression of eNOS expression by glucocorticoids.

METHODS AND RESULTS

We found that a mere three-fold increase in the concentration of the natural glucocorticoid cortisol (from 30 to 100 nmol/L) significantly decreased the expression level of eNOS in human endothelial cells. Deletion analysis of the eNOS promoter indicated that the segment within -119 bp upstream from the transcription start site was significantly involved in the effect of cortisol. Site-directed mutagenesis and chromatin immunoprecipitation analyses demonstrated the presence of a suppressive glucocorticoid response element (GRE) at -111 to -105 bp. 11 beta-hydroxysteroid dehydrogenases (11 beta-HSD) catalyse the interconversion of active and inactive glucocorticoids. The suppression of 11 beta-HSD2 using small interfering RNA markedly exacerbated the inhibition of eNOS by cortisol. The suppression of 11 beta-HSD1 abolished the inhibition of eNOS expression by cortisol.

CONCLUSION

We identified the first GRE in the eNOS promoter region and demonstrated that endogenous 11 beta-HSD1 and 11 beta-HSD2 play significant and distinct roles in modulating the effect of glucocorticoids on eNOS expression.

Soluble adhesion molecules levels in patients with Cushing's syndrome before and after cure

OBJECTIVE

Patients with Cushing's syndrome (CS) show a high prevalence of cardiovascular risk factors and atherosclerosis, persisting even after cure. Soluble intercellular adhesion molecule-1 (sICAM-1) and vascular cell adhesion molecule-1 (sVCAM-1) are surrogate markers of endothelial function involved in the initiation of atherosclerosis. This study aimed to evaluate sICAM-1 and sVCAM-1 levels in patients with CS before and after successful cure.

SUBJECTS AND METHODS

sICAM-1 and sVCAM-1 levels were evaluated in 28 patients with active CS and in 12 patients with Cushing's disease (CD), 6-12 months after disease remission. Body mass index (BMI), blood pressure, glucose, serum lipids, ACTH, cortisol and urinary free cortisol (UFC) were measured in basal conditions in all patients.

RESULTS

At baseline, sICAM-1 levels positively correlated with BMI (r=0.443, p<0.01), while no correlations between sICAM/sVCAM levels and ACTH, cortisol or UFC were found. Plasma ACTH, serum cortisol, and UFC levels significantly decreased in 12 cured patients, but ICAM-1 and VCAM-1 levels were unchanged (12.7+/-1.8 vs 10.1+/-0.9 ng/ml and 33.5+/-4.4 vs 35.8+/-4.0 ng/ml, respectively). Obesity, hypertension, and impaired glucose metabolism persisted 1 yr after the biochemical cure of hypercortisolism. A significant reduction in ICAM-1 levels was observed in 4 out of 12 cured patients as well as a remission from diabetes, hypertension or obesity.

CONCLUSIONS

ICAM/VCAM-1 levels show a great variability in patients with active CS, not correlated with cortisol levels, and are slightly modified in some cured patients with CD. The persistence of obesity, hypertension, and impaired glucose metabolism may be responsible for the maintenance of a subclinical endothelial dysfunction, making these subjects still at high cardiovascular risk and needing a long-term follow-up.

Chronic administration of an angiotensin II receptor antagonist resets the hypothalamic-pituitary-adrenal (HPA) axis and improves the affect of patients with diabetes mellitus type 2: preliminary results

Diabetes mellitus type 2 (DM type 2) is associated with depressive symptomatology and intermittent hyperfunction of the hypothalamic-pituitary-adrenal (HPA) axis. DM type 2 is also accompanied by increased tissue levels of angiotensin II (Ang II), which stimulates the HPA axis through the Ang II type 1 receptors (AT1). We investigated the effect of candesartan, an angiotensin receptor blocker (ARB) that crosses the blood brain barrier, on the activity of the HPA axis and on the affect of 17 patients with DM type 2, aged 40-65 years, who were treated with 4 mg/day candesartan per os for at least 3 months. Before and after candesartan administration, a corticotropin-releasing hormone (CRH) stimulation test and psychological tests were performed. In response to hCRH, time-integrated secretion of ACTH was not altered by candesartan administration, however, the cortisol response was decreased significantly compared to baseline (mean +/- SEM, 2327 +/- 148.3 vs. 1943 +/- 131.9 microg/dl, P = 0.005) suggesting reduced sensitivity of the adrenals to ACTH. In parallel, there was a significant improvement in interpersonal sensitivity (0.91 +/- 0.16 vs. 0.70 +/- 0.15, P = 0.027) and depression scores (0.96 +/- 0.15 vs. 0.71 +/- 0.10, P = 0.026). We suggest that candesartan resets the HPA axis of patients with DM type 2 and improves their affect.

Adrenalectomy alters regulation of blood pressure and endothelial nitric oxide synthase in sheep: modulation by estradiol

Hypoadrenocorticism produces more severe hypotension during the peripartal period in pregnant ewes and women. We hypothesized that estradiol increases the severity of hypotension after withdrawal of corticosteroids and that this results from combined effects of adrenalectomy and estradiol to increase endothelial nitric oxide synthase (eNOS). In study I, blood pressure and eNOS mRNA and protein in aorta, uterine, renal, and mesenteric arteries were measured in intact ewes or adrenalectomized ewes 18–20 h after cessation of infusion of cortisol and aldosterone; half of each group ewes were treated with estradiol. In study II, adrenalectomized ewes were similarly studied 22–28 h after withdrawal of corticosteroids. Estradiol treatment in both studies significantly increased eNOS mRNA and protein in uterine artery, whereas corticosteroid withdrawal decreased expression of eNOS mRNA and protein in uterine artery. In both studies, adrenalectomy and steroid withdrawal decreased mean arterial pressure. In study II, four of six adrenalectomized ewes not treated with estradiol showed dramatic phasic variations in blood pressure and heart rate with a period of ∼20 s, developing within 22–28 h after corticosteroid withdrawal. Although there was no effect of estradiol on blood pressure in study I, in study II, ewes treated with estradiol did not develop this pattern. Estradiol also slowed both the decline in plasma sodium and the rise in plasma potassium after corticosteroid withdrawal. These results disprove the hypothesis that estradiol increases the severity of hypotension during hypoadrenocorticism. However, the study reveals an important effect of corticosteroid withdrawal on blood pressure, consistent with corticosteroid modulation of baroreflex responsiveness.

Urinary cortisol is inversely associated with capillary recruitment in women: a potential explanation for the cortisol–blood pressure relationship

The relationships of cortisol with elevated blood pressure and insulin resistance are likely to be the result of a complex interplay of different mechanisms. We hypothesize that cortisol is associated with impaired microvascular function and that this contributes to cortisol-associated high blood pressure and insulin resistance. We examined 24 h urinary free cortisol excretion in 56 healthy adults (26 women). Blood pressure was assessed by 24 h ambulatory measurements. Insulin sensitivity was determined using the hyperinsulinaemic euglycaemic clamp technique. Skin capillary recruitment after arterial occlusion was visualized with videomicroscopy and endothelium-(in)dependent vasodilation was evaluated with iontophoresis of acetylcholine and sodium nitroprusside combined with laser Doppler fluxmetry. Men were characterized by higher urinary cortisol excretion [median (interquartile range), 162 (130–194) compared with 118 (99–156) nmol/24 h, P<0.05]. In women, but not in men, urinary cortisol excretion was associated with impaired capillary recruitment (r=−0.66, P<0.001), higher systolic blood pressure (r=0.64, P<0.001) and lower insulin sensitivity (r=−0.43, P<0.05). Urinary cortisol excretion was not associated with endothelium-(in)dependent vasodilation in men or women. Regression analysis demonstrated that capillary recruitment statistically explained 37% of the association between urinary cortisol and blood pressure in women. Capillary recruitment did not explain part of the association between urinary cortisol and insulin sensitivity. In conclusion, urinary cortisol excretion is inversely associated with capillary recruitment in women, but not in men, and capillary recruitment explains part of the cortisol–blood pressure relationship. These data suggest that, in women, impairment of capillary function mediates some of the adverse effects of cortisol and thus may provide a target to prevent such adverse effects.