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Kokko E, Choudhary MK, Mutanen A, Honkonen M, Tikkakoski A, Koskela JK, Hämäläinen M, Moilanen E, Viukari M, Matikainen N, Nevalainen PI, Pörsti I. Volume overload is a major characteristic in primary aldosteronism: a 3-year follow-up study. J Hypertens 2024; 42:1057-1065. [PMID: 38406920 PMCID: PMC11064919 DOI: 10.1097/hjh.0000000000003696] [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] [Received: 10/31/2023] [Accepted: 02/05/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVES We examined haemodynamics, focusing on volume balance and forward and backward wave amplitudes, before and after 2.8 years of targeted treatment of primary aldosteronism. Patients with essential hypertension and normotensive individuals were examined for comparison ( n = 40 in each group). METHODS Recordings were performed using radial artery pulse wave analysis and whole-body impedance cardiography. Unilateral aldosteronism was treated with adrenalectomy ( n = 20), bilateral aldosteronism with spironolactone-based medication ( n = 20), and essential hypertension with standard antihypertensive agents. RESULTS Aortic SBP and DBP, forward and backward wave amplitudes, and systemic vascular resistance were equally elevated in primary aldosteronism and essential hypertension. All these haemodynamic variables were similarly reduced by the treatments. Primary aldosteronism presented with 1 litre (∼10%) extracellular water excess ( P < 0.001) versus the other groups, and this excess was normalized by treatment. Initial pulse wave velocity (PWV) was similarly increased in primary aldosteronism and essential hypertension, but final values remained higher in primary aldosteronism ( P < 0.001). In regression analyses, significant explanatory factors for treatment-induced forward wave amplitude reduction were decreased systemic vascular resistance ( β = 0.380) and reduced extracellular water volume ( β = 0.183). Explanatory factors for backward wave amplitude reduction were changes in forward wave amplitude ( β = 0.599), heart rate ( β = -0.427), and PWV ( β = 0.252). CONCLUSION Compared with essential hypertension, the principal haemodynamic difference in primary aldosteronism was higher volume load. Volume excess elevated forward wave amplitude, which was subsequently reduced by targeted treatment of primary aldosteronism, along with normalization of volume load. We propose that incorporating extracellular water evaluation alongside routine diagnostics could enhance the identification and diagnosis of primary aldosteronism.
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Affiliation(s)
- Eeva Kokko
- Faculty of Medicine and Health Technology, Tampere University
| | | | - Aapo Mutanen
- Faculty of Medicine and Health Technology, Tampere University
| | - Milja Honkonen
- Faculty of Medicine and Health Technology, Tampere University
| | - Antti Tikkakoski
- Faculty of Medicine and Health Technology, Tampere University
- Department of Clinical Physiology and Nuclear Medicine
| | - Jenni K. Koskela
- Faculty of Medicine and Health Technology, Tampere University
- Department of Internal Medicine, Tampere University Hospital
| | - Mari Hämäläinen
- Faculty of Medicine and Health Technology, Tampere University
- Immunopharmacology Research Group, Tampere University and Tampere University Hospital, Tampere
| | - Eeva Moilanen
- Faculty of Medicine and Health Technology, Tampere University
- Immunopharmacology Research Group, Tampere University and Tampere University Hospital, Tampere
| | - Marianna Viukari
- Endocrinology, Helsinki University Hospital and Research Programs Unit, Clinical and Molecular Medicine, University of Helsinki, Helsinki, Finland
| | - Niina Matikainen
- Endocrinology, Helsinki University Hospital and Research Programs Unit, Clinical and Molecular Medicine, University of Helsinki, Helsinki, Finland
| | | | - Ilkka Pörsti
- Faculty of Medicine and Health Technology, Tampere University
- Department of Internal Medicine, Tampere University Hospital
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Verma S, Pandey A, Pandey AK, Butler J, Lee JS, Teoh H, Mazer CD, Kosiborod MN, Cosentino F, Anker SD, Connelly KA, Bhatt DL. Aldosterone and aldosterone synthase inhibitors in cardiorenal disease. Am J Physiol Heart Circ Physiol 2024; 326:H670-H688. [PMID: 38133623 DOI: 10.1152/ajpheart.00419.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023]
Abstract
Modulation of the renin-angiotensin-aldosterone system is a foundation of therapy for cardiovascular and kidney diseases. Excess aldosterone plays an important role in cardiovascular disease, contributing to inflammation, fibrosis, and dysfunction in the heart, kidneys, and vasculature through both genomic and mineralocorticoid receptor (MR)-mediated as well as nongenomic mechanisms. MR antagonists have been a key therapy for attenuating the pathologic effects of aldosterone but are associated with some side effects and may not always adequately attenuate the nongenomic effects of aldosterone. Aldosterone is primarily synthesized by the CYP11B2 aldosterone synthase enzyme, which is very similar in structure to other enzymes involved in steroid biosynthesis including CYP11B1, a key enzyme involved in glucocorticoid production. Lack of specificity for CYP11B2, off-target effects on the hypothalamic-pituitary-adrenal axis, and counterproductive increased levels of bioactive steroid intermediates such as 11-deoxycorticosterone have posed challenges in the development of early aldosterone synthase inhibitors such as osilodrostat. In early-phase clinical trials, newer aldosterone synthase inhibitors demonstrated promise in lowering blood pressure in patients with treatment-resistant and uncontrolled hypertension. It is therefore plausible that these agents offer protection in other disease states including heart failure or chronic kidney disease. Further clinical evaluation will be needed to clarify the role of aldosterone synthase inhibitors, a promising class of agents that represent a potentially major therapeutic advance.
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Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Avinash Pandey
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Arjun K Pandey
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, United States
- University of Mississippi, Jackson, Mississippi, United States
| | - John S Lee
- LJ Biosciences, LLC, Rockville, Maryland, United States
- PhaseBio Pharmaceuticals, Malvern, Pennsylvania, United States
| | - Hwee Teoh
- Division of Cardiac Surgery, St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
- Division of Endocrinology and Metabolism, St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri, United States
- University of Missouri-Kansas City, Kansas City, Missouri, United States
| | | | - Stefan D Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Kim A Connelly
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, St. Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Deepak L Bhatt
- Mount Sinai Fuster Heart, Icahn School of Medicine at Mount Sinai Health System, New York, New York, United States
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Girard AA, Denney TS, Gupta H, Dell'Italia LJ, Calhoun DA, Oparil S, Sharifov OF, Lloyd SG. Spironolactone improves left atrial function and atrioventricular coupling in patients with resistant hypertension. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024; 40:487-497. [PMID: 38123867 DOI: 10.1007/s10554-023-03013-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/17/2023] [Indexed: 12/23/2023]
Abstract
To determine the blood pressure independent effects of spironolactone on left atrial (LA) size and function in patients with resistant hypertension (RHTN). Patients with RHTN (n = 36, mean age 55 ± 7) were prospectively recruited. Spironolactone was initiated at 25 mg/day and increased to 50 mg/day after 4 weeks. Other antihypertensives were withdrawn to maintain constant blood pressure. Cardiac magnetic resonance imaging was performed at baseline and after 6 months of spironolactone treatment and changes in LA functional metrics were assessed. LA size and function parameters were improved (p < 0.05) from baseline to month-6: LA volumes indexed to body surface area (LAVI) were reduced (LAVImaximum 41.4 ± 12 vs. 33.2±9.7 mL/m2; LAVIpre-A 32.6 ± 9.8 vs. 25.6 ± 8.1 mL/m2; median LAVIminimum 18.5 [13.9-24.8] vs. 14.1 [10.9-19.2] mL/m2); left atrioventricular coupling index was reduced (28.2 ± 11.5 vs. 22.7 ± 9.2%); LA emptying fractions (LAEF) were increased (median total LAEF 52.4 [48.7-60.3] vs. 55.9 [50.3-61.1] %; active LAEF 40.2 ± 8.6 vs. 43.1 ± 7.8%). LA global longitudinal strain in the active phase was increased (16.3 ± 4.1 vs. 17.8 ± 4.2%). The effect of spironolactone was similar in patients with high (N = 18) and normal (N = 18) aldosterone status (defined by plasma renin activity and 24-h urine aldosterone). Treatment of RHTN with spironolactone is associated with improvements in LA size and function, and atrioventricular coupling, regardless of whether aldosterone levels were normal or high at baseline. This study suggests the need for larger prospective studies examining effects of mineralocorticoid receptor antagonists on atrial function and atrioventricular coupling.
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Affiliation(s)
- Andrew A Girard
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Thomas S Denney
- Department of Electrical and Computer Engineering, Auburn University, Auburn, AL, USA
| | | | - Louis J Dell'Italia
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- VA Medical Center, Birmingham, AL, USA
| | - David A Calhoun
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Suzanne Oparil
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- Vascular Biology and Hypertension Program, UAB, Birmingham, AL, USA
| | - Oleg F Sharifov
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, 1808 7th Avenue South, BDB 143, Birmingham, AL, 35294, USA.
| | - Steven G Lloyd
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- VA Medical Center, Birmingham, AL, USA
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Hundemer GL, Leung AA, Kline GA, Brown JM, Turcu AF, Vaidya A. Biomarkers to Guide Medical Therapy in Primary Aldosteronism. Endocr Rev 2024; 45:69-94. [PMID: 37439256 PMCID: PMC10765164 DOI: 10.1210/endrev/bnad024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 07/14/2023]
Abstract
Primary aldosteronism (PA) is an endocrinopathy characterized by dysregulated aldosterone production that occurs despite suppression of renin and angiotensin II, and that is non-suppressible by volume and sodium loading. The effectiveness of surgical adrenalectomy for patients with lateralizing PA is characterized by the attenuation of excess aldosterone production leading to blood pressure reduction, correction of hypokalemia, and increases in renin-biomarkers that collectively indicate a reversal of PA pathophysiology and restoration of normal physiology. Even though the vast majority of patients with PA will ultimately be treated medically rather than surgically, there is a lack of guidance on how to optimize medical therapy and on key metrics of success. Herein, we review the evidence justifying approaches to medical management of PA and biomarkers that reflect endocrine principles of restoring normal physiology. We review the current arsenal of medical therapies, including dietary sodium restriction, steroidal and nonsteroidal mineralocorticoid receptor antagonists, epithelial sodium channel inhibitors, and aldosterone synthase inhibitors. It is crucial that clinicians recognize that multimodal medical treatment for PA can be highly effective at reducing the risk for adverse cardiovascular and kidney outcomes when titrated with intention. The key biomarkers reflective of optimized medical therapy are unsurprisingly similar to the physiologic expectations following surgical adrenalectomy: control of blood pressure with the fewest number of antihypertensive agents, normalization of serum potassium without supplementation, and a rise in renin. Pragmatic approaches to achieve these objectives while mitigating adverse effects are reviewed.
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Affiliation(s)
- Gregory L Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON K1H 8L6, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
| | - Alexander A Leung
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Gregory A Kline
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Vaidya A, Hundemer GL, Nanba K, Parksook WW, Brown JM. Primary Aldosteronism: State-of-the-Art Review. Am J Hypertens 2022; 35:967-988. [PMID: 35767459 PMCID: PMC9729786 DOI: 10.1093/ajh/hpac079] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
We are witnessing a revolution in our understanding of primary aldosteronism (PA). In the past 2 decades, we have learned that PA is a highly prevalent syndrome that is largely attributable to pathogenic somatic mutations, that contributes to cardiovascular, metabolic, and kidney disease, and that when recognized, can be adequately treated with widely available mineralocorticoid receptor antagonists and/or surgical adrenalectomy. Unfortunately, PA is rarely diagnosed, or adequately treated, mainly because of a lack of awareness and education. Most clinicians still possess an outdated understanding of PA; from primary care physicians to hypertension specialists, there is an urgent need to redefine and reintroduce PA to clinicians with a modern and practical approach. In this state-of-the-art review, we provide readers with the most updated knowledge on the pathogenesis, prevalence, diagnosis, and treatment of PA. In particular, we underscore the public health importance of promptly recognizing and treating PA and provide pragmatic solutions to modify clinical practices to achieve this.
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Affiliation(s)
- Anand Vaidya
- Department of Medicine, Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kazutaka Nanba
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Wasita W Parksook
- Department of Medicine, Division of Endocrinology and Metabolism, and Division of General Internal Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Primary aldosteronism is a common cause of hypertension and is a risk factor for cardiovascular and renal morbidity and mortality, via mechanisms mediated by both hypertension and direct insults to target organs. Despite its high prevalence and associated complications, primary aldosteronism remains largely under-recognized, with less than 2% of people in at-risk populations ever tested. Fundamental progress made over the past decade has transformed our understanding of the pathogenesis of primary aldosteronism and of its clinical phenotypes. The dichotomous paradigm of primary aldosteronism diagnosis and subtyping is being redefined into a multidimensional spectrum of disease, which spans subclinical stages to florid primary aldosteronism, and from single-focal or multifocal to diffuse aldosterone-producing areas, which can affect one or both adrenal glands. This Review discusses how redefining the primary aldosteronism syndrome as a multidimensional spectrum will affect the approach to the diagnosis and subtyping of primary aldosteronism.
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Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA.
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
Purpose of Review To update on definition, diagnosis, prevalence, patient characteristics, pathophysiology, and treatment of refractory hypertension (RfHTN). Recent Findings Refractory hypertension (RfHTN) is defined as blood pressure (BP) that is uncontrolled despite using ≥ 5 antihypertensive medications of different classes, including a long-acting thiazide diuretic and a mineralocorticoid receptor antagonist (MRA) at maximal or maximally tolerated doses. This new phenotype is different from resistant hypertension (RHTN), defined as BP that is uncontrolled despite using ≥ 3 medications, commonly a long-acting calcium channel blocker (CCB), a blocker of the renin-angiotensin system (angiotensin-converting enzyme [ACE] inhibitor or angiotensin receptor blocker [ARB]), and a diuretic. The RHTN phenotype includes controlled RHTN, BP that is controlled on 4 or more medications. RfHTN is largely attributable to increased sympathetic activity, unlike RHTN, which is mainly due to increased intravascular fluid volume frequently caused by hyperaldosteronism and chronic excessive sodium ingestion. Compared to those with controlled RHTN, patients with RfHTN have a higher prevalence of target organ damage and do not have elevated aldosterone levels. Ongoing clinical trials are assessing the safety and efficacy of using devices to aid with BP control in patients with RfHTN. Summary RfHTN is a separate entity from RHTN and is generally attributable to increased sympathetic activity.
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Butts B, Brown JA, Denney TS, Ballinger S, Lloyd SG, Oparil S, Sanders P, Merriman TR, Gaffo A, Singh J, Kelley EE, Calhoun DA, Dell'Italia LJ. Racial Differences in XO (Xanthine Oxidase) and Mitochondrial DNA Damage-Associated Molecular Patterns in Resistant Hypertension. Hypertension 2022; 79:775-784. [PMID: 35164526 PMCID: PMC10652275 DOI: 10.1161/hypertensionaha.121.18298] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/22/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND We previously reported increased plasma XO (xanthine oxidase) activity in patients with resistant hypertension. Increased XO can cause mitochondrial DNA damage and promote release of fragments called mitochondrial DNA damage-associated molecular patterns (mtDNA DAMPs). Here, we report racial differences in XO activity and mtDNA DAMPs in Black and White adults with resistant hypertension. METHODS This retrospective study includes 91 resistant hypertension patients (44% Black, 47% female) with blood pressure >140/90 mm Hg on ≥4 medications and 37 normotensive controls (30% Black, 54% female) with plasma XO activity, mtDNA DAMPs, and magnetic resonance imaging of left ventricular morphology and function. RESULTS Black-resistant hypertension patients were younger (mean age 52±10 versus 59±10 years; P=0.001), with higher XO activity and left ventricular wall thickness, and worse diastolic dysfunction than White resistant hypertension patients. Urinary sodium excretion (mg/24 hour per kg) was positively related to left ventricular end-diastolic volume (r=0.527, P=0.001) and left ventricular mass (r=0.394, P=0.02) among Black but not White resistant hypertension patients. Patients with resistant hypertension had increased mtDNA DAMPs versus controls (P<0.001), with Black mtDNA DAMPS greater than Whites (P<0.001). Transmission electron microscopy of skeletal muscle biopsies in resistant hypertension patients demonstrates mitochondria cristae lysis, myofibrillar loss, large lipid droplets, and glycogen accumulation. CONCLUSIONS These data warrant a large study to examine the role of XO and mitochondrial mtDNA DAMPs in cardiac remodeling and heart failure in Black adults with resistant hypertension.
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Affiliation(s)
- Brittany Butts
- Division of Cardiovascular Disease, University of Alabama at Birmingham (UAB) School of Medicine (SOM) (B.B., S.G.L., S.O., P.S., D.A.C., L.J.D.)
| | - Jamelle A Brown
- Center for Free Radical Biology and Department of Pathology, UAB SOM (J.A.B., S.B.)
| | - Thomas S Denney
- Department of Electrical and Computer Engineering, Auburn University (T.S.D.)
| | - Scott Ballinger
- Center for Free Radical Biology and Department of Pathology, UAB SOM (J.A.B., S.B.)
| | - Steven G Lloyd
- Division of Cardiovascular Disease, University of Alabama at Birmingham (UAB) School of Medicine (SOM) (B.B., S.G.L., S.O., P.S., D.A.C., L.J.D.)
- Birmingham Department of Veterans Affairs Health Care System (S.G.L., P.S., A.G., J.S., L.J.D.)
| | - Suzanne Oparil
- Division of Cardiovascular Disease, University of Alabama at Birmingham (UAB) School of Medicine (SOM) (B.B., S.G.L., S.O., P.S., D.A.C., L.J.D.)
| | - Paul Sanders
- Division of Cardiovascular Disease, University of Alabama at Birmingham (UAB) School of Medicine (SOM) (B.B., S.G.L., S.O., P.S., D.A.C., L.J.D.)
- Nephrology Research and Training Center and Division of Nephrology UAB SOM (P.S.)
- Birmingham Department of Veterans Affairs Health Care System (S.G.L., P.S., A.G., J.S., L.J.D.)
| | - Tony R Merriman
- Division of Clinical Immunology and Rheumatology, UAB SOM (T.R.M., A.G., J.S.)
| | - Angelo Gaffo
- Division of Clinical Immunology and Rheumatology, UAB SOM (T.R.M., A.G., J.S.)
- Birmingham Department of Veterans Affairs Health Care System (S.G.L., P.S., A.G., J.S., L.J.D.)
| | - Jasvinder Singh
- Division of Clinical Immunology and Rheumatology, UAB SOM (T.R.M., A.G., J.S.)
- Birmingham Department of Veterans Affairs Health Care System (S.G.L., P.S., A.G., J.S., L.J.D.)
| | - Eric E Kelley
- Department of Physiology and Pharmacology, West Virginia University (E.E.K.)
| | - David A Calhoun
- Division of Cardiovascular Disease, University of Alabama at Birmingham (UAB) School of Medicine (SOM) (B.B., S.G.L., S.O., P.S., D.A.C., L.J.D.)
| | - Louis J Dell'Italia
- Division of Cardiovascular Disease, University of Alabama at Birmingham (UAB) School of Medicine (SOM) (B.B., S.G.L., S.O., P.S., D.A.C., L.J.D.)
- Birmingham Department of Veterans Affairs Health Care System (S.G.L., P.S., A.G., J.S., L.J.D.)
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Gamble FN, Aufan MR, Sharifov OF, Williams LJ, Reighard S, Calhoun DA, Gupta H, Dell'Italia LJ, Denney TS, Lloyd SG. Diastolic function: modeling left ventricular untwisting as a damped harmonic oscillator. Physiol Meas 2022; 43:10.1088/1361-6579/ac4e6e. [PMID: 35073533 PMCID: PMC9066283 DOI: 10.1088/1361-6579/ac4e6e] [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: 07/26/2021] [Accepted: 01/24/2022] [Indexed: 11/11/2022]
Abstract
Objective.We developed a method using cardiovascular magnetic resonance imaging to model the untwisting of the left ventricle (LV) as a damped torsional harmonic oscillator to estimate shear modulus (intrinsic myocardial stiffness) and frictional damping, then applied this method to evaluate the torsional stiffness of patients with resistant hypertension (RHTN) compared to a control group.Approach.The angular displacement of the LV during diastole was measured. Myocardial shear modulus and damping constant were determined by solving a system of equations modeling the diastolic untwisting as a damped, unforced harmonic oscillator, in 100 subjects with RHTN and 36 control subjects.Main Results.Though overall torsional stiffness was increased in RHTN (41.7 (27.1-60.7) versus 29.6 (17.3-35.7) kdyn*cm;p = 0.001), myocardial shear modulus was not different between RHTN and control subjects (0.34 (0.23-0.50) versus 0.33 (0.22-0.46) kPa;p= 0.758). RHTN demonstrated an increase in overall diastolic frictional damping (6.13 ± 3.77 versus 3.35 ± 1.70 kdyn*cm*s;p< 0.001), but no difference in damping when corrected for the overlap factor (74.3 ± 25.9 versus 68.0 ± 24.0 dyn*s/cm3;p = 0.201). There was an increase in the polar moment (geometric component of stiffness; 11.47 ± 6.95 versus 7.58 ± 3.28 cm4;p<0.001).Significance.We have developed a phenomenological method, estimating the intrinsic stiffness and relaxation properties of the LV based on restorative diastolic untwisting. This model finds increased overall stiffness in RHTN and points to hypertrophy, rather than tissue- level changes, as the major factor leading to increased stiffness.
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Affiliation(s)
- Forrest N Gamble
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - M Rifqi Aufan
- Department of Biomedical Engineering, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Oleg F Sharifov
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Lamario J Williams
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Shane Reighard
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - David A Calhoun
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, United States of America
| | - Himanshu Gupta
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, United States of America
- Valley Medical Group, Paramus, New Jersey
| | - Louis J Dell'Italia
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, United States of America
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, United States of America
| | - Thomas S Denney
- Department of Electrical and Computer Engineering, Auburn University, Auburn, AL, United States of America
| | - Steven G Lloyd
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, United States of America
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, United States of America
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Strain Imaging for the Early Detection of Cardiac Remodeling and Dysfunction in Primary Aldosteronism. Diagnostics (Basel) 2022; 12:diagnostics12020543. [PMID: 35204632 PMCID: PMC8871189 DOI: 10.3390/diagnostics12020543] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 12/30/2022] Open
Abstract
Speckle tracking echocardiography is a novel technique to quantify cardiac function and deformation. It has been applied in a series of cardiovascular diseases for the evaluation of early cardiac impairment. We recently used this technique to investigate cardiac structure and function in patients with primary aldosteronism. Cardiac damage usually occurs earlier in patients with primary aldosteronism than those with primary hypertension, probably because aldosterone hypersecretion is more commonly observed in the former than the latter patients. In this article, we will review the imaging studies, especially with speckle tracking echocardiography, for the detection of early cardiac dysfunction in primary aldosteronism as a disease model.
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11
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Karbalaei S, Goldsmith CR. Recent advances in the preclinical development of responsive MRI contrast agents capable of detecting hydrogen peroxide. J Inorg Biochem 2022; 230:111763. [DOI: 10.1016/j.jinorgbio.2022.111763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 01/10/2023]
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12
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Safaryan AS, Nebieridze DV. Sympathetic hyperactivity in patients with hypertension: pathogenesis and treatment. Part II. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2021-2845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
The second part of the review considers different classes of drugs affecting blood pressure in increased activity of the sympathetic nervous system. Additional possibilities are discussed on how to reduce the negative effect of sympathetic hyperactivity on cardiovascular system and improve the prognosis.
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Affiliation(s)
- A. S. Safaryan
- National Medical Research Center for Therapy and Preventive Medicine
| | - D. V. Nebieridze
- National Medical Research Center for Therapy and Preventive Medicine
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13
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Aryal SR, Siddiqui M, Sharifov OF, Coffin MD, Zhang B, Gaddam KK, Gupta H, Denney TS, Dell'Italia LJ, Oparil S, Calhoun DA, Lloyd SG. Spironolactone Reduces Aortic Stiffness in Patients With Resistant Hypertension Independent of Blood Pressure Change. J Am Heart Assoc 2021; 10:e019434. [PMID: 34459249 PMCID: PMC8649301 DOI: 10.1161/jaha.120.019434] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Aortic stiffness is an independent predictor of cardiovascular events in patients with arterial hypertension. Resistant hypertension is often linked to hyperaldosteronism and associated with adverse outcomes. Spironolactone, a mineralocorticoid receptor antagonist, has been shown to reduce both the arterial blood pressure (BP) and aortic stiffness in resistant hypertension. However, the mechanism of aortic stiffness reduction by spironolactone is not well understood. We hypothesized that spironolactone reduces aortic stiffness in resistant hypertension independently of BP change. Methods and Results Patients with uncontrolled BP (≥140/90 mm Hg) despite use of ≥3 antihypertensive medications (including diuretics) were prospectively recruited. Participants were started on spironolactone at 25 mg/d, and increased to 50 mg/d at 4 weeks while other antihypertensive medications were withdrawn to maintain constant mean BP. Phase‐contrast cardiac magnetic resonance imaging of the ascending aorta was performed in 30 participants at baseline and after 6 months of spironolactone treatment to measure aortic pulsatility, distensibility, and pulse wave velocity. Pulse wave velocity decreased (6.3±2.3 m/s to 4.5±1.8 m/s, P<0.001) and pulsatility and distensibility increased (15.9%±5.3% to 22.1%±7.9%, P<0.001; and 0.28%±0.10%/mm Hg to 0.40%±0.14%/mm Hg, P<0.001, respectively) following 6 months of spironolactone. Conclusions Our results suggest that spironolactone improves aortic properties in resistant hypertension independently of BP, which may support the hypothesis of an effect of aldosterone on the arterial wall. A larger prospective study is needed to confirm our findings.
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Affiliation(s)
- Sudeep R Aryal
- Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham AL
| | - Mohammed Siddiqui
- Vascular Biology and Hypertension Program University of Alabama at Birmingham Birmingham AL
| | - Oleg F Sharifov
- Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham AL
| | - Megan D Coffin
- School of Medicine University of Alabama at Birmingham Birmingham AL
| | - Bin Zhang
- Division of Biostatistics and Epidemiology Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Krishna K Gaddam
- Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham AL
| | | | - Thomas S Denney
- Department of Electrical and Computer Engineering Auburn University Auburn AL
| | - Louis J Dell'Italia
- Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham AL.,VA Medical Center Birmingham AL
| | - Suzanne Oparil
- Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham AL.,Vascular Biology and Hypertension Program University of Alabama at Birmingham Birmingham AL
| | - David A Calhoun
- Vascular Biology and Hypertension Program University of Alabama at Birmingham Birmingham AL
| | - Steven G Lloyd
- Division of Cardiovascular Disease University of Alabama at Birmingham Birmingham AL.,VA Medical Center Birmingham AL
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14
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Wu T, Ren Y, Wang W, Cheng W, Zhou F, He S, Liu X, Li L, Tang L, Deng Q, Zhou X, Chen Y, Sun J. Left Ventricular Remodeling in Patients with Primary Aldosteronism: A Prospective Cardiac Magnetic Resonance Imaging Study. Korean J Radiol 2021; 22:1619-1627. [PMID: 34269528 PMCID: PMC8484156 DOI: 10.3348/kjr.2020.1291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 04/07/2021] [Accepted: 04/25/2021] [Indexed: 02/05/2023] Open
Abstract
Objective This study used cardiac magnetic resonance imaging (MRI) to compare the characteristics of left ventricular remodeling in patients with primary aldosteronism (PA) with those of patients with essential hypertension (EH) and healthy controls (HCs). Materials and Methods This prospective study enrolled 35 patients with PA, in addition to 35 age- and sex-matched patients with EH, and 35 age- and sex-matched HCs, all of whom underwent comprehensive clinical and cardiac MRI examinations. The analysis of variance was used to detect the differences in the characteristics of left ventricular remodeling among the three groups. Univariable and multivariable linear regression analyses were used to determine the relationships between left ventricular remodeling and the physiological variables. Results The left ventricular end-diastolic volume index (EDVi) (mean ± standard deviation [SD]: 85.1 ± 13.0 mL/m2 for PA, 75.9 ± 14.3 mL/m2 for EH, and 77.3 ± 12.8 mL/m2 for HC; p = 0.010), left ventricular end-systolic volume index (ESVi) (mean ± SD: 35.2 ± 9.8 mL/m2 for PA, 30.7 ± 8.1 mL/m2 for EH, and 29.5 ± 7.0 mL/m2 for HC; p = 0.013), left ventricular mass index (mean ± SD: 65.8 ± 16.5 g/m2 for PA, 56.9 ± 12.1 g/m2 for EH, and 44.1 ± 8.9 g/m2 for HC; p < 0.001), and native T1 (mean ± SD: 1224 ± 39 ms for PA, 1201 ± 47 ms for EH, and 1200 ± 44 ms for HC; p = 0.041) values were higher in the PA group compared to the EH and HC groups. Multivariable linear regression demonstrated that log (plasma aldosterone-to-renin ratio) was independently correlated with EDVi and ESVi. Plasma aldosterone was independently correlated with native T1. Conclusion Patients with PA showed a greater degree of ventricular hypertrophy and enlargement, as well as myocardial fibrosis, compared to those with EH. Cardiac MRI T1 mapping can detect left ventricular myocardial fibrosis in patients with PA.
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Affiliation(s)
- Tao Wu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Yan Ren
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Wang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Cheng
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Fangli Zhou
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, China
| | - Shuai He
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiumin Liu
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lu Tang
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiao Deng
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China.,Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoyue Zhou
- Department of North Sichuan Medical College, Nanchong, China
| | - Yucheng Chen
- Department of MR Collaboration, Siemens Healthcare, Shanghai, China
| | - Jiayu Sun
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, China.
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15
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Mulè G, Geraci G, Carollo C, Cottone S. Haemodynamics of primary aldosteronism associated with adrenocortical adenoma: insights from bioimpedance cardiography measurements. J Intern Med 2021; 289:134-136. [PMID: 32533871 DOI: 10.1111/joim.13127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/05/2020] [Indexed: 11/29/2022]
Affiliation(s)
- G Mulè
- From the, Unit of Nephrology and Hypertension, European Society of Hypertension Excellence Centre, Dipartimento Di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica Di Eccellenza (PROMISE), Università degli studi di Palermo, Palermo, Italy
| | - G Geraci
- From the, Unit of Nephrology and Hypertension, European Society of Hypertension Excellence Centre, Dipartimento Di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica Di Eccellenza (PROMISE), Università degli studi di Palermo, Palermo, Italy
| | - C Carollo
- From the, Unit of Nephrology and Hypertension, European Society of Hypertension Excellence Centre, Dipartimento Di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica Di Eccellenza (PROMISE), Università degli studi di Palermo, Palermo, Italy
| | - S Cottone
- From the, Unit of Nephrology and Hypertension, European Society of Hypertension Excellence Centre, Dipartimento Di Promozione Della Salute, Materno Infantile, Medicina Interna e Specialistica Di Eccellenza (PROMISE), Università degli studi di Palermo, Palermo, Italy
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16
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Higuchi S, Ota H, Tezuka Y, Seiji K, Takagi H, Lee J, Lee YW, Omata K, Ono Y, Morimoto R, Kudo M, Satoh F, Takase K. Aldosterone-induced cardiac damage in primary aldosteronism depends on its subtypes. Endocr Connect 2021; 10:29-36. [PMID: 33268573 PMCID: PMC7923132 DOI: 10.1530/ec-20-0504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/25/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study compared cardiac function, morphology, and tissue characteristics between two common subtypes of primary aldosteronism (PA) using a 3T MR scanner. DESIGN A retrospective, single-center, observational study. METHODS We retrospectively reviewed 143 consecutive patients with PA, who underwent both adrenal venous sampling and cardiac magnetic resonance. We acquired cine, late gadolinium enhancement, and pre- and postcontrast myocardial T1-mapping images. RESULTS PA was diagnosed as unilateral aldosterone-producing adenoma (APA) in 70 patients and bilateral hyperaldosteronism (BHA) in 73. The APA group showed significantly higher plasma aldosterone concentration (PAC) and aldosterone to renin rate (ARR) than the BHA group. After controlling for age, sex, antihypertensive drugs, systolic and diastolic blood pressure, and disease duration, the parameters independently associated with APA were: left ventricular end-diastolic volume index (EDVI: adjusted odds ratio (aOR) = 1.06 (95% CI: 1.030-1.096), P < 0.01), end-systolic volume index (ESVI: 1.06 (1.017-1.113), P < 0.01), stroke index (SI: 1.07 (1.020-1.121), P < 0.01), cardiac index (CI: 1.001 (1.000-1.001), P < 0.01), and native T1 (1.01 (1.000-1.019), P = 0.038). Weak positive correlations were found between PAC and EDVI (R = 0.28, P < 0.01), ESVI (0.26, P < 0.01), and SI (0.18, P = 0.03); and between ARR and EDVI (0.25, P < 0.01), ESVI (0.24, P < 0.01), and native T1 (0.17, P = 0.047). CONCLUSIONS APA is associated with greater LV volumetric parameters and higher native T1 values, suggesting a higher risk of volume overload and myocardial damage.
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Affiliation(s)
- Satoshi Higuchi
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hideki Ota
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Miyagi, Japan
- Department of Advanced MRI Collaboration Research, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
- Correspondence should be addressed to H Ota:
| | - Yuta Tezuka
- Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
- Department of Radiology, The University of British Columbia, Vancouver, Canada
| | - Kazumasa Seiji
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hidenobu Takagi
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Miyagi, Japan
- Department of Radiology, The University of British Columbia, Vancouver, Canada
| | - Jongmin Lee
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yi-Wei Lee
- Department of Radiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kei Omata
- Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
- Department of Radiology, The University of British Columbia, Vancouver, Canada
| | - Yoshikiyo Ono
- Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
- Department of Radiology, The University of British Columbia, Vancouver, Canada
| | - Ryo Morimoto
- Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Masataka Kudo
- Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Fumitoshi Satoh
- Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine, Tohoku University Hospital, Sendai, Miyagi, Japan
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Miyagi, Japan
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17
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Choudhary MK, Värri E, Matikainen N, Koskela J, Tikkakoski AJ, Kähönen M, Niemelä O, Mustonen J, Nevalainen PI, Pörsti I. Primary aldosteronism: Higher volume load, cardiac output and arterial stiffness than in essential hypertension. J Intern Med 2021; 289:29-41. [PMID: 32463949 DOI: 10.1111/joim.13115] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 05/05/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND The diagnostics of primary aldosteronism (PA) are usually carried out in patients taking antihypertensive medications. We compared haemodynamics between medicated PA, medicated essential hypertension (EH), never-medicated EH and normotensive controls (n = 130 in all groups). METHODS The hypertensive groups were matched for age (53 years), sex (84 male/46 female) and body mass index (BMI) (30 kg m-2 ); normotensive controls had similar sex distribution (age 48 years, BMI 27 kg m-2 ). Haemodynamics were recorded using whole-body impedance cardiography and radial pulse wave analysis, and the results were adjusted as appropriate. Radial blood pressure recordings were calibrated by brachial blood pressure measurements from the contralateral arm. RESULTS Radial and aortic systolic and diastolic blood pressure was similar in PA and never-medicated EH, and higher than in medicated EH and normotensive controls (P ≤ 0.001 for all comparisons). Extracellular water balance was ~ 4% higher in PA than in all other groups (P < 0.05 for all), whilst cardiac output was ~ 8% higher in PA than in medicated EH (P = 0.012). Systemic vascular resistance and augmentation index were similarly increased in PA and both EH groups when compared with controls. Pulse wave velocity was higher in PA and never-medicated EH than in medicated EH and normotensive controls (P ≤ 0.033 for all comparisons). CONCLUSIONS Medicated PA patients presented with corresponding systemic vascular resistance and wave reflection, but higher extracellular water volume, cardiac output and arterial stiffness than medicated EH patients. Whether the systematic evaluation of these features would benefit the clinical diagnostics of PA remains to be studied in future.
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Affiliation(s)
- M K Choudhary
- From the, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - E Värri
- From the, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - N Matikainen
- Endocrinology, Helsinki University Hospital and Research Programs Unit, Clinical and Molecular Medicine, University of Helsinki, Helsinki, Finland
| | - J Koskela
- From the, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - A J Tikkakoski
- From the, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Clinical Physiology, Tampere University Hospital, Tampere, Finland
| | - M Kähönen
- From the, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Clinical Physiology, Tampere University Hospital, Tampere, Finland
| | - O Niemelä
- From the, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Laboratory and Medical Research Unit, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - J Mustonen
- From the, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - P I Nevalainen
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - I Pörsti
- From the, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
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18
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Aldosterone synthase inhibitors for cardiovascular diseases: A comprehensive review of preclinical, clinical and in silico data. Pharmacol Res 2020; 163:105332. [PMID: 33271294 DOI: 10.1016/j.phrs.2020.105332] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/27/2020] [Accepted: 11/23/2020] [Indexed: 01/23/2023]
Abstract
Aldosterone, the main mineralocorticoid hormone, plays a fundamental role in maintaining blood pressure (BP)and volume under hypovolemic conditions. However, in numerous diseases, where it is produced in excess, it plays a detrimental role and contributes to cardiovascular events and ultimately to death in a multitude of patients. The seminal observation that the fungicide-derivative fadrozole blunted steroidogenesis has led to develop several agents to inhibit aldosterone synthase (AS, CYP11B2), the mitochondrial NADH-dependent enzyme that is necessary for aldosterone biosynthesis. Aldosterone synthase inhibitors (ASI) have, thereafter, been conceived and investigated in phase I and phase II studies. We herein reviewed the ASIs available so far considering their chemical structure, the related aldosterone synthase binding and pharmacodynamic properties. We also examined the promising results obtained with ASIs that have already been tested in phase II human studies.
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19
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Kotanidou EP, Giza S, Tsinopoulou VR, Vogiatzi M, Galli-Tsinopoulou A. Diagnosis and Management of Endocrine Hypertension in Children and Adolescents. Curr Pharm Des 2020; 26:5591-5608. [PMID: 33185153 DOI: 10.2174/1381612826666201113103614] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 08/18/2020] [Indexed: 12/12/2022]
Abstract
Hypertension in childhood and adolescence has increased in prevalence. Interest in the disease was raised after the 2017 clinical practice guidelines of the American Academy of Paediatrics on the definition and classification of paediatric hypertension. Among the secondary causes of paediatric hypertension, endocrine causes are relatively rare but important due to their unique treatment options. Excess of catecholamine, glucocorticoids and mineralocorticoids, congenital adrenal hyperplasia, hyperaldosteronism, hyperthyroidism and other rare syndromes with specific genetic defects are endocrine disorders leading to paediatric and adolescent hypertension. Adipose tissue is currently considered the major endocrine gland. Obesity-related hypertension constitutes a distinct clinical entity leading to an endocrine disorder. The dramatic increase in the rates of obesity during childhood has resulted in a rise in obesity-related hypertension among children, leading to increased cardiovascular risk and associated increased morbidity and mortality. This review presents an overview of pathophysiology and diagnosis of hypertension resulting from hormonal excess, as well as obesity-related hypertension during childhood and adolescence, with a special focus on management.
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Affiliation(s)
- Eleni P Kotanidou
- Second Department of Paediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Styliani Giza
- Fourth Department of Paediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Vasiliki-Regina Tsinopoulou
- Second Department of Paediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Maria Vogiatzi
- Division of Endocrinology and Diabetes, Children' s Hospital of Philadelphia, PA 19104, United States
| | - Assimina Galli-Tsinopoulou
- Second Department of Paediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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20
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Legg Ditterline BE, Wade S, Ugiliweneza B, Singam NS, Harkema SJ, Stoddard MF, Hirsch GA. Beneficial Cardiac Structural and Functional Adaptations After Lumbosacral Spinal Cord Epidural Stimulation and Task-Specific Interventions: A Pilot Study. Front Neurosci 2020; 14:554018. [PMID: 33192245 PMCID: PMC7643015 DOI: 10.3389/fnins.2020.554018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/15/2020] [Indexed: 12/22/2022] Open
Abstract
Cardiac myocyte atrophy and the resulting decreases to the left ventricular mass and dimensions are well documented in spinal cord injury. Therapeutic interventions that increase preload can increase the chamber size and improve the diastolic filling ratios; however, there are no data describing cardiac adaptation to chronic afterload increases. Research from our center has demonstrated that spinal cord epidural stimulation (scES) can normalize arterial blood pressure, so we decided to investigate the effects of scES on cardiac function using echocardiography. Four individuals with chronic, motor-complete cervical spinal cord injury were implanted with a stimulator over the lumbosacral enlargement. We assessed the cardiac structure and function at the following time points: (a) prior to implantation; (b) after scES targeted to increase systolic blood pressure; (c) after the addition of scES targeted to facilitate voluntary (i.e., with intent) movement of the trunk and lower extremities; and (d) after the addition of scES targeted to facilitate independent, overground standing. We found significant improvements to the cardiac structure (left ventricular mass = 10 ± 2 g, p < 0.001; internal dimension during diastole = 0.1 ± 0.04 cm, p < 0.05; internal dimension during systole = 0.06 ± 0.03 cm, p < 0.05; interventricular septum dimension = 0.04 ± 0.02 cm, p < 0.05), systolic function (ejection fraction = 1 ± 0.4%, p < 0.05; velocity time integral = 2 ± 0.4 cm, p < 0.001; stroke volume = 4.4 ± 1.5 ml, p < 0.01), and diastolic function (mitral valve deceleration time = -32 ± 11 ms, p < 0.05; mitral valve deceleration slope = 50 ± 25 cm s-1, p < 0.05; isovolumic relaxation time = -6 ± 1.9 ms, p < 0.05) with each subsequent scES intervention. Despite the pilot nature of this study, statistically significant improvements to the cardiac structure, systolic function, and diastolic function demonstrate that scES combined with task-specific interventions led to beneficial cardiac remodeling, which can reverse atrophic changes that result from spinal cord injury. Long-term improvements to cardiac function have implications for increased quality of life and improved cardiovascular health in individuals with spinal cord injury, decreasing the risk of cardiovascular morbidity and mortality.
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Affiliation(s)
- Bonnie E. Legg Ditterline
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
- Department of NeuroSurgery, University of Louisville, Louisville, KY, United States
| | - Shelley Wade
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Beatrice Ugiliweneza
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
- Department of NeuroSurgery, University of Louisville, Louisville, KY, United States
| | - Narayana Sarma Singam
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, Louisville, KY, United States
| | - Susan J. Harkema
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
- Department of NeuroSurgery, University of Louisville, Louisville, KY, United States
| | - Marcus F. Stoddard
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, Louisville, KY, United States
| | - Glenn A. Hirsch
- Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, Louisville, KY, United States
- Division of Cardiology, Department of Medicine, National Jewish Health, Denver, CO, United States
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21
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Left ventricular remodeling and dysfunction in primary aldosteronism. J Hum Hypertens 2020; 35:131-147. [PMID: 33067554 DOI: 10.1038/s41371-020-00426-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 09/24/2020] [Accepted: 10/01/2020] [Indexed: 12/12/2022]
Abstract
Primary aldosteronism (PA) is a common cause of secondary hypertension and is associated with worse cardiovascular outcomes. The elevated aldosterone in PA leads to left ventricular (LV) remodeling and dysfunction. In recent decades, clinical studies have demonstrated worse LV remodeling including increased LV mass and cardiac fibrosis in patients with PA compared to patients with essential hypertension. Several mechanisms may explain the process of aldosterone-induced LV remodeling, including directly profibrotic and hypertrophic effects of aldosterone on myocardium, increased reactive oxygen species and profibrotic molecules, dysregulation of extracellular matrix metabolism, endothelium dysfunction and circulatory macrophages activation. LV remodeling causes LV diastolic and systolic dysfunction, which may consequently lead to clinical complications such as heart failure, atrial fibrillation, ischemic heart disease, and other vascular events. Adequate treatment with adrenalectomy or medical therapy can improve LV remodeling and dysfunction in PA patients. In this review, we discuss the mechanisms of aldosterone-induced LV remodeling and provide an up-to-date review of clinical research about LV remodeling-related heart structural changes, cardiac dysfunction, and their clinical impacts on patients with PA.
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22
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Resolution of drug-resistant hypertension by adrenal vein sampling-guided adrenalectomy: a proof-of-concept study. Clin Sci (Lond) 2020; 134:1265-1278. [DOI: 10.1042/cs20200340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/07/2020] [Accepted: 05/26/2020] [Indexed: 11/17/2022]
Abstract
Abstract
Drug-resistant hypertension (RH) is a very high-risk condition involving many hypertensive patients, in whom primary aldosteronism (PA) is commonly overlooked. Hence, we aimed at determining if (1) adrenal vein sampling (AVS) can identify PA in RH patients, who are challenging because of receiving multiple interfering drugs; (2) AVS-guided adrenalectomy can resolve high blood pressure (BP) resistance to treatment in these patients.
Based on a pilot study we selected from 1016 consecutive patients referred to our Centre for ‘difficult-to-treat’ hypertension those with RH, for an observational prospective cohort study. We excluded those non-adherent to treatment (by therapeutic drug monitoring) and those with pseudo-RH (by 24-h BP monitoring), which left 110 patients who met the European Society of Cardiology/European Society of Hypertension (ESC/ESH) 2013 definition for RH. Of these patients, 77 were submitted to AVS, who showed unilateral PA in 27 (mean age 55 years; male/female 19/8). Therefore, these patients underwent AVS-guided laparoscopic unilateral adrenalectomy, which resolved RH in all: 20% were clinically cured in that they no longer needed any antihypertensive treatment; 96% were biochemically cured. Systolic and diastolic BP fell from 165/100 ± 26/14 mmHg at baseline, to 132/84 ± 14/9 mmHg at 6 months after surgery (P<10−4 for both) notwithstanding the fall of number and defined daily dose (DDD) of antihypertensive drugs required to achieve BP control (P<10−4 for both). A prominent regression of cardiac and renal damage was also observed.
Thus, the present study shows the feasibility of identifying PA by AVS in RH patients, and of resolving high BP resistance to treatment in these patients by AVS-guided adrenalectomy.
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Lau CWZ, Hamers AJP, Rathod KS, Shabbir A, Cooper J, Primus CP, Davies C, Mathur A, Moon JC, Kapil V, Ahluwalia A. Randomised, double-blind, placebo-controlled clinical trial investigating the effects of inorganic nitrate in hypertension-induced target organ damage: protocol of the NITRATE-TOD study in the UK. BMJ Open 2020; 10:e034399. [PMID: 31969369 PMCID: PMC7045137 DOI: 10.1136/bmjopen-2019-034399] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/20/2019] [Accepted: 11/22/2019] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Arterial stiffness and left ventricular (LV) hypertrophy are the key markers of hypertensive target organ damage (TOD) associated with increased cardiovascular morbidity and mortality. We have previously shown that dietary inorganic nitrate supplementation lowers blood pressure (BP) in hypertension, however, whether this approach might also improve markers of hypertensive TOD is unknown. In this study, we will investigate whether daily dietary inorganic nitrate administration reduces LV mass and improves measures of arterial stiffness. METHODS AND DESIGN NITRATE-TOD is a double-blind, randomised, single-centre, placebo-controlled phase II trial aiming to enrol 160 patients with suboptimal BP control on one or more antihypertensives. Patients will be randomised to receive 4 months once daily dose of either nitrate-rich beetroot juice or nitrate-deplete beetroot juice (placebo). The primary outcomes are reduction in LV mass and reduction in pulse wave velocity (PWV) and central BP.The study has a power of 95% for detecting a 9 g LV mass change by cardiovascular MRI (~6% change for a mildly hypertrophied heart of 150 g). For PWV, we have a power of >95% for detecting a 0.6 m/s absolute change. For central systolic BP, we have a>90% power to detect a 5.8 mm Hg difference in central systolic BP.Secondary end points include change in ultrasound flow-mediated dilation, change in plasma nitrate and nitrite concentration and change in BP. ETHICS AND DISSEMINATION The study was approved by the London-City and East Research Ethics Committee (10/H0703/98). Trial results will be published according to the Consolidated Standards of Reporting Trials statement and will be presented at conferences and reported in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03088514.
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Affiliation(s)
- Clement Wai Zhen Lau
- William Harvey Research Institute, Barts & The London, Queen Mary University of London, London, UK
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | | | - Krishnaraj Sinhji Rathod
- William Harvey Research Institute, Barts & The London, Queen Mary University of London, London, UK
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Asad Shabbir
- William Harvey Research Institute, Barts & The London, Queen Mary University of London, London, UK
| | - Jackie Cooper
- William Harvey Research Institute, Barts & The London, Queen Mary University of London, London, UK
| | - Christopher Peter Primus
- William Harvey Research Institute, Barts & The London, Queen Mary University of London, London, UK
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Ceri Davies
- William Harvey Research Institute, Barts & The London, Queen Mary University of London, London, UK
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Anthony Mathur
- William Harvey Research Institute, Barts & The London, Queen Mary University of London, London, UK
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - James C Moon
- Department of Cardiology, Barts Health NHS Trust, London, UK
- UCL Institute of Cardiovascular Science, University College London, London, UK
| | - Vikas Kapil
- William Harvey Research Institute, Barts & The London, Queen Mary University of London, London, UK
- Department of Cardiology, Barts Health NHS Trust, London, UK
| | - Amrita Ahluwalia
- William Harvey Research Institute, Barts & The London, Queen Mary University of London, London, UK
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Abstract
Resistant hypertension (RHTN) is defined as uncontrolled blood pressure despite the use of ≥3 antihypertensive agents of different classes, including a diuretic, usually thiazide-like, a long-acting calcium channel blocker, and a blocker of the renin- angiotensin system, either an ACE (angiotensin-converting enzyme) inhibitor or an ARB (angiotensin receptor blocker), at maximal or maximally tolerated doses. Antihypertensive medication nonadherence and the white coat effect, defined as elevated blood pressure when measured in clinic but controlled when measured outside of clinic, must be excluded to make the diagnosis. RHTN is a high-risk phenotype, leading to increased all-cause mortality and cardiovascular disease outcomes. Healthy lifestyle habits are associated with reduced cardiovascular risk in patients with RHTN. Aldosterone excess is common in patients with RHTN, and addition of spironolactone or amiloride to the standard 3-drug antihypertensive regimen is effective at getting the blood pressure to goal in most of these patients. Refractory hypertension is defined as uncontrolled blood pressure despite use of ≥5 antihypertensive agents of different classes, including a long-acting thiazide-like diuretic and an MR (mineralocorticoid receptor) antagonist, at maximal or maximally tolerated doses. Fluid retention, mediated largely by aldosterone excess, is the predominant mechanism underlying RHTN, while patients with refractory hypertension typically exhibit increased sympathetic nervous system activity.
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Affiliation(s)
- Maria Czarina Acelajado
- From the Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham
| | - Zachary H Hughes
- From the Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham
| | - Suzanne Oparil
- From the Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham
| | - David A Calhoun
- From the Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, University of Alabama at Birmingham
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Rakugi H, Ito S, Itoh H, Okuda Y, Yamakawa S. Long-term phase 3 study of esaxerenone as mono or combination therapy with other antihypertensive drugs in patients with essential hypertension. Hypertens Res 2019; 42:1932-1941. [PMID: 31554937 PMCID: PMC8076031 DOI: 10.1038/s41440-019-0314-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/08/2019] [Accepted: 07/12/2019] [Indexed: 01/30/2023]
Abstract
This study investigated the long-term antihypertensive effects of esaxerenone, a novel nonsteroidal mineralocorticoid receptor blocker, alone or in combination with a calcium channel blocker (CCB) or a renin-angiotensin system (RAS) inhibitor, in Japanese patients with essential hypertension. Patients were treated with esaxerenone starting at 2.5 mg/day increasing to 5 mg/day if required to achieve blood pressure (BP) targets as a monotherapy or with a CCB or RAS inhibitor. After the first 12 weeks of treatment, an additional antihypertensive agent could be added if required to achieve the target BP; the total treatment period was 28 or 52 weeks. The primary endpoint was a change from baseline in sitting BP. Of the 368 enrolled patients, 245 received monotherapy, and 59 and 64, respectively, took a CCB or RAS inhibitor concurrently. Mean changes from baseline in sitting systolic/diastolic BP (95% confidence intervals) at weeks 12, 28 and 52 were -16.1 (-17.3, -14.9)/-7.7 (-8.4, -6.9), -18.9 (-20.2, -17.7)/-9.9 (-10.7, -9.2), and -23.1 (-25.0, -21.1)/-12.5 (-13.6, -11.3) mmHg, respectively (all P < 0.0001 vs baseline). Similar BP reductions at these weeks were observed between all patient subgroups stratified by age, and the observed decreases in 24-h ambulatory BP were consistent with the efficacy observed in sitting BP. Esaxerenone was also well-tolerated with a rate of hyperkalemia at 5.4% (serum potassium ≥5.5 mEq/L), indicating a good safety profile for treatment over the long-term or in combination with a CCB or RAS inhibitor. In conclusion, esaxerenone may be a promising treatment option for patients with hypertension.
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Affiliation(s)
- Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology and Vascular Medicine, Department of Medicine, Tohoku University School of Medicine, 2-1 Seiryo-machi, Aoba, Sendai, Miyagi, 980-8575, Japan
| | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, Keio University, School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo, 160-8582, Japan
| | - Yasuyuki Okuda
- Daiichi Sankyo Co., Ltd., 1-2-58 Hiromachi, Shinagawa, Tokyo, 140-8710, Japan
| | - Satoru Yamakawa
- Daiichi Sankyo Co., Ltd., 1-2-58 Hiromachi, Shinagawa, Tokyo, 140-8710, Japan
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Seccia TM, Caroccia B, Maiolino G, Cesari M, Rossi GP. Arterial Hypertension, Aldosterone, and Atrial Fibrillation. Curr Hypertens Rep 2019; 21:94. [PMID: 31741119 DOI: 10.1007/s11906-019-1001-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE Atrial fibrillation is the most common sustained arrhythmia, with a prevalence of 1-2% in the general population and over 15% in people older than 80 years. Due to aging of the population it imposes an increasing burden on the healthcare system because of the need for life-long pharmacological treatment and the associated increased risk of heart failure and hospitalization. Hence, identification of the factors that predispose to atrial fibrillation it is of utmost relevance. RECENT FINDINGS Several conditions exist that are characterized by inappropriately high levels of aldosterone, mostly primary aldosteronism and the severe or drug-resistant forms of arterial hypertension. In these forms, aldosterone can cause prominent target organ damage, mostly in the heart, vasculature, and kidney. This review examines the experimental data and clinical evidences that support a link between hyperaldosteronism and atrial fibrillation, and how this knowledge should lead to a change in our management of the hypertensive patients presenting with atrial fibrillation.
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Affiliation(s)
- Teresa M Seccia
- Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, Via Giustiniani, 2, 35128, Padova, Italy
| | - Brasilina Caroccia
- Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, Via Giustiniani, 2, 35128, Padova, Italy
| | - Giuseppe Maiolino
- Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, Via Giustiniani, 2, 35128, Padova, Italy
| | - Maurizio Cesari
- Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, Via Giustiniani, 2, 35128, Padova, Italy
| | - Gian Paolo Rossi
- Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, Via Giustiniani, 2, 35128, Padova, Italy.
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Liao MT, Liao CW, Tsai CH, Chang YY, Chen ZW, Pan CT, Lin LC, Wu VC, Kuo SF, Wu XM, Hung CS, Lin YH. U-shaped relationship between left ventricular mass index and estimated glomerular filtration rate in patients with primary aldosteronism. J Investig Med 2019; 68:371-377. [PMID: 31630138 DOI: 10.1136/jim-2019-001057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2019] [Indexed: 11/03/2022]
Abstract
Estimated glomerular filtration rate (eGFR) is an important topic in patients with primary aldosteronism (PA). However, the relationship between left ventricular structure and eGFR is unclear. We conducted a prospective, observational, and cross-sectional study to analyze 168 patients with PA and 168 propensity score-matched patients with essential hypertension (EH) as the control group, matched by age, gender, and systolic blood pressure. In the patients with PA, the eGFR was not correlated with left ventricular mass index (LVMI; r=-0.065, p=0.404), while in the patients with EH, the eGFR was negatively correlated with LVMI (r=-0.309, p<0.001). To test whether eGFR had a non-linear relationship with LVMI among the patients with PA, we stratified the patients with PA according to the tertile of eGFR (low, medium, and high tertile). The medium tertile of patients had a significantly lower LVMI than those in the other two tertiles (LVMI: 143.5±41.6, 120.5±40.5, and 133.1±34.3 g/m2, from the lowest to highest tertile of eGFR; analysis of covariance p=0.032). The medium tertile of eGFR is associated with lowest LVMI. Patients with PA with high and low eGFR were associated with higher LVMI. The findings implied that the reasons for an increased LVMI in patients with PA may be different to those in patients with EH.
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Affiliation(s)
- Min-Tsun Liao
- Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Che-Wei Liao
- Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Cheng-Hsuan Tsai
- Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Yao Chang
- Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Zheng-Wei Chen
- Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Douliou, Taiwan
| | - Chien-Ting Pan
- Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Lung-Chun Lin
- Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Vin-Cent Wu
- Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Fen Kuo
- Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Xue-Ming Wu
- Internal Medicine, Taoyuan General Hospital, Taoyuan, Taiwan
| | - Chi-Sheng Hung
- Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yen-Hung Lin
- Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Stavropoulos K, Papadopoulos C, Koutsampasopoulos K, Lales G, Mitas C, Doumas M. Mineralocorticoid Receptor Antagonists in Primary Aldosteronism. Curr Pharm Des 2019; 24:5508-5516. [DOI: 10.2174/1381612825666190311130138] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/05/2019] [Indexed: 01/21/2023]
Abstract
Background:Primary aldosteronism is the most common causes of secondary hypertension. Patients suffering from this clinical syndrome have an increased cardiovascular risk and target organ damage. Mineralocorticoid receptor antagonists are the optimal pharmaceutical option for the management of such patients.Objectives:The study aimed to assess the effects of mineralocorticoid receptor antagonist in the treatment of patients with primary aldosteronism.Method:We conducted an in-depth review of the literature and comprehensive identification of the clinical studies investigating the efficacy of mineralocorticoid receptor antagonists in individuals with primary aldosteronism.Results:Mineralocorticoid receptor antagonists result in significant improvement in blood pressure and serum potassium level among patients with primary aldosteronism. Moreover, mineralocorticoid receptor antagonists reverse left ventricular hypertrophy, albuminuria, and carotid intima-media thickness. However, a high risk for atrial fibrillation remains among subject with primary aldosteronism in such agents.Conclusion:Mineralocorticoid receptor antagonists are recommended as the first-line treatment in patients with bilateral primary aldosteronism. In patients with unilateral aldosterone-producing adenoma, adrenalectomy should be preferred. However, existing data presents significant limitations and is rather inconclusive. Future randomized control trials are required in order to illustrate the field.
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Affiliation(s)
- Konstantinos Stavropoulos
- Second Propedeutic Department of Internal Medicine, Hippokration Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christodoulos Papadopoulos
- Third Department of Cardiology, Hippokration Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Koutsampasopoulos
- Second Propedeutic Department of Internal Medicine, Hippokration Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Lales
- Second Propedeutic Department of Internal Medicine, Hippokration Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos Mitas
- Second Propedeutic Department of Internal Medicine, Hippokration Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, Hippokration Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Butts B, Calhoun DA, Denney TS, Lloyd SG, Gupta H, Gaddam KK, Aban I, Oparil S, Sanders PW, Patel R, Collawn JF, Dell'Italia LJ. Plasma xanthine oxidase activity is related to increased sodium and left ventricular hypertrophy in resistant hypertension. Free Radic Biol Med 2019; 134:343-349. [PMID: 30695690 PMCID: PMC6588431 DOI: 10.1016/j.freeradbiomed.2019.01.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 12/30/2018] [Accepted: 01/22/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND The extra-renal effects of aldosterone on left ventricular (LV) structure and function are exacerbated by increased dietary sodium in persons with hypertension. Previous studies demonstrated endothelial dysfunction and increased oxidative stress with high salt diet in normotensive salt-resistant subjects. We hypothesized that increased xanthine oxidase (XO), a product of endothelial cells, is related to 24-h urinary sodium and to LV hypertrophy and function in patients with resistant hypertension (RHTN). METHODS The study group included persons with RHTN (n = 91), defined as a blood pressure > 140/90 mmHg on ≥ 3 medications at pharmacologically effective doses. Plasma XO activity and 24-h urine were collected, and cardiac magnetic resonance imaging (MRI) was performed to assess LV function and morphology. Sixty-seven normotensive persons on no cardiovascular medications served as controls. A subset of RHTN (n = 19) received spironolactone without salt restriction for six months with follow-up XO activity measurements and MRI analyses. RESULTS XO activity was increased two-fold in RHTN vs. normal and was positively correlated with LV mass, LV diastolic function, and 24-h urinary sodium. In RHTN patients receiving spironolactone without salt restriction, LV mass decreased, but LV diastolic function and XO activity did not improve. Baseline urinary sodium was positively associated with rate of change of LV mass to volume ratio and the LV E/A ratio. CONCLUSIONS These results demonstrate a potential role of endothelium-derived oxidative stress and excess dietary salt in the pathophysiology of LV hypertrophy and diastolic dysfunction in persons with RHTN unaffected by the addition of spironolactone.
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Affiliation(s)
- Brittany Butts
- Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, USA; Nell Hodgson Woodruff School of Nursing, Emory University, USA
| | - David A Calhoun
- Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, USA
| | - Thomas S Denney
- Department of Electrical and Computer Engineering, Auburn University, USA
| | - Steven G Lloyd
- Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, USA
| | - Himanshu Gupta
- Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, USA; Birmingham Department of Veterans Affairs Medical Center, USA
| | - Krishna K Gaddam
- Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, USA
| | - Inmaculada Aban
- Department of Biostatistics, University of Alabama at Birmingham, USA
| | - Suzanne Oparil
- Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, USA
| | - Paul W Sanders
- Division of Nephrology, University of Alabama at Birmingham School of Medicine, USA
| | - Rakesh Patel
- Center for Free Radical Biology and Department of Pathology, University of Alabama at Birmingham, USA
| | - James F Collawn
- Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, USA
| | - Louis J Dell'Italia
- Division of Cardiovascular Disease, University of Alabama at Birmingham School of Medicine, USA; Birmingham Department of Veterans Affairs Medical Center, USA.
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Eplerenone Versus Spironolactone in Resistant Hypertension: an Efficacy and/or Cost or Just a Men’s Issue? Curr Hypertens Rep 2019; 21:22. [DOI: 10.1007/s11906-019-0924-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hellman P, Björklund P, Åkerström T. Aldosterone-Producing Adenomas. VITAMINS AND HORMONES 2019; 109:407-431. [PMID: 30678866 DOI: 10.1016/bs.vh.2018.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Aldosterone-producing adenomas (APA) are more common than initially anticipated. APA cause primary aldosteronism (PA), which affect 3-10% of the hypertensive population. Research during recent years has led to an increased knowledge of the background dysregulation of the increased aldosterone release, where mutation in the gene encoding the potassium channel GIRK4-KCNJ5-is the most common. Moreover, the discovery of aldosterone-producing cell clusters in apparently normal adenomas has also led to increased understanding of the development of PA, and presumably also APA. A continuum ranging from low-renin hypertension to APA and overt PA is reasoned, and the secondary effects of aldosterone on especially the cardiovascular system have also become more evident. Diagnostics of PA and APA is important in order to reduce cardiovascular morbidity and mortality, but the diagnostic methods are somewhat unspecific and insensitive, indicating the need for novel methods.
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Affiliation(s)
- Per Hellman
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - Peyman Björklund
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Tobias Åkerström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Keeping primary aldosteronism in mind: Deficiencies in screening at-risk hypertensives. Surgery 2019; 165:221-227. [DOI: 10.1016/j.surg.2018.05.085] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 05/02/2018] [Accepted: 05/02/2018] [Indexed: 11/16/2022]
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Nakano Y, Yoshimoto T, Fukuda T, Murakami M, Bouchi R, Minami I, Hashimoto K, Fujii Y, Kihara K, Ogawa Y. Effect of Eplerenone on the Glomerular Filtration Rate (GFR) in Primary Aldosteronism: Sequential Changes in the GFR During Preoperative Eplerenone Treatment to Subsequent Adrenalectomy. Intern Med 2018; 57:2459-2466. [PMID: 29709927 PMCID: PMC6172537 DOI: 10.2169/internalmedicine.0438-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/28/2018] [Indexed: 12/21/2022] Open
Abstract
Objective Eplerenone (EPL) is a mineralo-corticoid receptor antagonist that is highly selective and has few side effects. This study was conducted to examine whether or not EPL treatment was able to reverse glomerular hyperfiltration, as an indicator of aldosterone renal action, in primary aldosteronism (PA) patients. Methods Changes in the estimated glomerular filtration rate (ΔGFR) were examined in 102 PA patients with EPL treatment. Furthermore, the sequential ΔGFR in 40 patients initially treated with EPL followed by adrenalectomy was examined in order to evaluate the extent of the remaining glomerular hyperfiltration in the patients treated with EPL. Results EPL decreased the GFR at 1 month after treatment. The GFR at baseline was the sole significant predictor for the ΔGFR. Patients initially treated by EPL followed by adrenalectomy showed three different ΔGFR patterns during the treatment, despite having comparable doses of EPL and comparable control of blood pressure and serum potassium levels. The urinary aldosterone excretion was significantly different among these three groups, and the group with no decrease in the GFR after EPL treatment showed greater urinary aldosterone excretion. Glomerular hyperfiltration was completely restored only in 17.5% of our unilateral PA patients after EPL treatment. Conclusion The present study revealed that blockade of aldosterone action by EPL could, at least partially, reverse glomerular hyperfiltration in PA. Whether or not these differential effects on the GFR affect the long-term outcome needs to be investigated, especially in patients with unilateral PA who do not want adrenalectomy and choose the EPL treatment option.
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Affiliation(s)
- Yujiro Nakano
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Takanobu Yoshimoto
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Tatsuya Fukuda
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Masanori Murakami
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Ryotaro Bouchi
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Isao Minami
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Koshi Hashimoto
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
- Department of Preemptive Medicine and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Yasuhisa Fujii
- Department of Urology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Kazunori Kihara
- Department of Urology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Yoshihiro Ogawa
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
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Cannone V, Buglioni A, Sangaralingham SJ, Scott C, Bailey KR, Rodeheffer R, Redfield MM, Sarzani R, Burnett JC. Aldosterone, Hypertension, and Antihypertensive Therapy: Insights From a General Population. Mayo Clin Proc 2018; 93:980-990. [PMID: 30077215 PMCID: PMC6203321 DOI: 10.1016/j.mayocp.2018.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/19/2018] [Accepted: 05/25/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To investigate the relationships among aldosterone level, use of antihypertensive (anti-HTN) medications, clinical profile, and atrial natriuretic peptide (ANP) level in individuals with HTN. PARTICIPANTS AND METHODS In a community-based cohort, we analyzed aldosterone plasma levels based on the presence (n=477) or absence (n=1073) of HTN. In individuals with HTN, we evaluated circulating aldosterone levels according to the number of anti-HTN drugs used, analyzed the associated clinical characteristics, and determined the relationship to the counterregulatory cardiac hormone ANP. Data were collected from August 25, 1997, through September 5, 2000. RESULTS Participants with HTN had higher serum aldosterone levels than those without HTN (6.4 vs 4.1 ng/dL [to convert to pmol/L, multiply by 27.74]; P<.001). When individuals with HTN were stratified according to the number of anti-HTN medications used, the increase in number of medications (0, 1, 2, and ≥3) was associated with higher aldosterone levels (4.8, 6.4, 7.10, and 7.9 ng/dL, respectively; P=.002), worse metabolic profile, and higher prevalence of cardiovascular, renal, and metabolic disease. In participants with HTN, ANP plasma levels were inversely related to aldosterone levels when the latter was divided into tertiles. CONCLUSION In this randomly selected general population cohort, aldosterone levels were higher in individuals with HTN compared with normotensive participants. Aldosterone levels increased with anti-HTN medication use. These findings also suggest a relative ANP deficiency with increasing aldosterone levels and anti-HTN drug use. These studies have pathophysiologic and therapeutic implications for targeting aldosterone in the clinical treatment of HTN.
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Affiliation(s)
- Valentina Cannone
- Cardiorenal Research Laboratory, Division of Circulatory Failure, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Clinical Medicine, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Alessia Buglioni
- Cardiorenal Research Laboratory, Division of Circulatory Failure, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - S Jeson Sangaralingham
- Cardiorenal Research Laboratory, Division of Circulatory Failure, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Christopher Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Kent R Bailey
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Margaret M Redfield
- Cardiorenal Research Laboratory, Division of Circulatory Failure, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Riccardo Sarzani
- Internal Medicine and Geriatrics and "Hypertension Excellence Centre" of the European Society of Hypertension, Department of Clinical and Molecular Sciences, University "Politecnica delle Marche", Ancona, Italy; Italian National Research Centre on Aging "U. Sestilli", IRCCS-INRCA, Ancona, Italy
| | - John C Burnett
- Cardiorenal Research Laboratory, Division of Circulatory Failure, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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Verma AK, Sun JL, Hernandez A, Teerlink JR, Schulte PJ, Ezekowitz J, Voors A, Starling R, Armstrong P, O'Conner CM, Mentz RJ. Rate pressure product and the components of heart rate and systolic blood pressure in hospitalized heart failure patients with preserved ejection fraction: Insights from ASCEND-HF. Clin Cardiol 2018; 41:945-952. [PMID: 29781109 DOI: 10.1002/clc.22981] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 05/14/2018] [Accepted: 05/16/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Heart rate and systolic blood pressure (SBP) are prognostic markers in heart failure (HF) with reduced ejection fraction (HFrEF). Their combination in rate pressure product (RPP) as well as their role in heart failure with preserved ejection fraction (HFpEF) remains unclear. HYPOTHESIS RPP and its components are associated with HFpEF outcomes. METHODS We performed an analysis of Acute Study of Clinical Effectiveness of Nesiritide in Subjects With Decompensated Heart Failure (ASCEND-HF; http://www.clinicaltrials.gov NCT00475852), which studied 7141 patients with acute HF. HFpEF was defined as left ventricular ejection fraction ≥40%. Outcomes were assessed by baseline heart rate, SBP, and RPP, as well as the change of these variables using adjusted Cox models. RESULTS After multivariable adjustment, in-hospital change but not baseline heart rate, SBP, and RPP were associated with 30-day mortality/HF hospitalization (hazard ratio [HR]: 1.17 per 5-bpm heart rate, HR: 1.20 per 10-mm Hg SBP, and HR: 1.02 per 100 bpm × mm Hg RPP; all P < 0.05). Baseline SBP was associated with 180-day mortality (HR: 0.88 per 10-mm Hg, P = 0.028). Though change in RPP was associated with 30-day mortality/HF hospitalization, the RPP baseline variable did not provide additional associative information with regard to outcomes when compared with assessment of baseline heart rate and SBP variables alone. CONCLUSIONS An increase in heart rate and SBP from baseline to discharge was associated with increased 30-day mortality/HF hospitalization in HFpEF patients with acute exacerbation. These findings suggest value in monitoring the trend of vital signs during HFpEF hospitalization.
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Affiliation(s)
- Amanda K Verma
- Department of Cardiology, Washington University School of Medicine, St. Louis, Missouri
| | - Jie-Lena Sun
- Department of Statistics, Duke University Medical Center, Durham, North Carolina
| | - Adrian Hernandez
- Department of Cardiology, Duke Clinical Research Institute, Duke Hospital, Durham, North Carolina
| | - John R Teerlink
- Department of Cardiology, School of Medicine, University of California, San Francisco
| | - Phillip J Schulte
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | | | - Adriaan Voors
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Paul Armstrong
- Division of Cardiology, University of Alberta, Edmonton, Canada
| | - Christopher M O'Conner
- Department of Cardiology, Duke Clinical Research Institute, Duke Hospital, Durham, North Carolina
| | - Robert J Mentz
- Department of Cardiology, Duke Clinical Research Institute, Duke Hospital, Durham, North Carolina
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Velasco A, Siddiqui M, Kreps E, Kolakalapudi P, Dudenbostel T, Arora G, Judd EK, Prabhu SD, Lloyd SG, Oparil S, Calhoun DA. Refractory Hypertension Is not Attributable to Intravascular Fluid Retention as Determined by Intracardiac Volumes. Hypertension 2018; 72:343-349. [PMID: 29866740 DOI: 10.1161/hypertensionaha.118.10965] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 02/09/2018] [Accepted: 05/10/2018] [Indexed: 01/01/2023]
Abstract
Refractory hypertension (RfHTN) is an extreme phenotype of antihypertensive treatment failure defined as lack of blood pressure control with ≥5 medications, including a long-acting thiazide and a mineralocorticoid receptor antagonist. RfHTN is a subgroup of resistant hypertension (RHTN), which is defined as blood pressure >135/85 mm Hg with ≥3 antihypertensive medications, including a diuretic. RHTN is generally attributed to persistent intravascular fluid retention. It is unknown whether alternative mechanisms are operative in RfHTN. Our objective was to determine whether RfHTN is characterized by persistent fluid retention, indexed by greater intracardiac volumes determined by cardiac magnetic resonance when compared with controlled RHTN patients. Consecutive patients evaluated in our institution with RfHTN and controlled RHTN were prospectively enrolled. Exclusion criteria included advanced chronic kidney disease and masked or white coat hypertension. All enrolled patients underwent biochemical testing and cardiac magnetic resonance. The RfHTN group (n=24) was younger (mean age, 51.7±8.9 versus 60.6±11.5 years; P=0.003) and had a greater proportion of women (75.0% versus 43%; P=0.02) compared with the controlled RHTN group (n=30). RfHTN patients had a greater left ventricular mass index (88.3±35.0 versus 54.6±12.5 g/m2; P<0.001), posterior wall thickness (10.1±3.1 versus 7.7±1.5 mm; P=0.001), and septal wall thickness (14.5±3.8 versus 10.0±2.2 mm; P<0.001). There was no difference in B-type natriuretic peptide levels and left atrial or ventricular volumes. Diastolic dysfunction was noted in RfHTN. Our findings demonstrate greater left ventricular hypertrophy without chamber enlargement in RfHTN, suggesting that antihypertensive treatment failure is not attributable to intravascular volume retention.
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Affiliation(s)
- Alejandro Velasco
- From the Division of Cardiovascular Disease (A.V., G.A., S.D.P., S.G.L.)
| | - Mohammed Siddiqui
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease (M.S., T.D., S.O., D.A.C.)
| | | | - Pavani Kolakalapudi
- University of Alabama at Birmingham; and Division of Cardiovascular Disease, University of South Alabama, Mobile (P.K.)
| | - Tanja Dudenbostel
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease (M.S., T.D., S.O., D.A.C.)
| | - Garima Arora
- From the Division of Cardiovascular Disease (A.V., G.A., S.D.P., S.G.L.)
| | | | - Sumanth D Prabhu
- From the Division of Cardiovascular Disease (A.V., G.A., S.D.P., S.G.L.)
| | - Steven G Lloyd
- From the Division of Cardiovascular Disease (A.V., G.A., S.D.P., S.G.L.)
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease (M.S., T.D., S.O., D.A.C.)
| | - David A Calhoun
- Vascular Biology and Hypertension Program, Division of Cardiovascular Disease (M.S., T.D., S.O., D.A.C.)
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Calhoun DA. Fluid retention, aldosterone excess, and treatment of resistant hypertension. Lancet Diabetes Endocrinol 2018; 6:431-433. [PMID: 29655878 DOI: 10.1016/s2213-8587(18)30080-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 03/01/2018] [Indexed: 11/15/2022]
Affiliation(s)
- David A Calhoun
- Vascular Biology and Hypertension Program, University of Alabama at Birmingham, Birmingham, AL 35294, USA.
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Abstract
Resistant hypertension (RH) is defined as blood pressure (BP) that remains above target levels despite adherence to at least three different antihypertensive medications, typically including a diuretic. Epidemiological studies estimate that RH is increasing in prevalence, and is associated with detrimental health outcomes. The pathophysiology underlying RH is complex, involving multiple, overlapping contributors including activation of the renin-angiotensin aldosterone system and the sympathetic nervous system, volume overload, endothelial dysfunction, behavioural and lifestyle factors. Hypertension guidelines currently recommend specific pharmacotherapy for 1st, 2nd and 3rd-line treatment, however no specific fourth-line pharmacotherapy is provided for those with RH. Rather, five different antihypertensive drug classes are generally suggested as possible alternatives, including: mineralocorticoid receptor antagonists, α1-adrenergic antagonists, α2-adrenergic agonists, β-blockers, and peripheral vasodilators. Each of these drug classes vary in their efficacy, tolerability and safety profile. This review summarises the available data on each of these drug classes as a potential fourth-line drug and reveals a lack of robust clinical evidence for preferred use of most of these classes in the setting of RH. Moreover, there is a lack of direct comparative trials that could assist in identifying a preferred fourth-line pharmacologic approach and in providing evidence for hypertensive guidelines for adequate treatment of RH.
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Grytaas MA, Sellevåg K, Thordarson HB, Husebye ES, Løvås K, Larsen TH. Cardiac magnetic resonance imaging of myocardial mass and fibrosis in primary aldosteronism. Endocr Connect 2018; 7:413-424. [PMID: 29440130 PMCID: PMC5834771 DOI: 10.1530/ec-18-0039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 02/12/2018] [Indexed: 01/24/2023]
Abstract
BACKGROUND Primary aldosteronism (PA) is associated with increased cardiovascular morbidity, presumably due to left ventricular (LV) hypertrophy and fibrosis. However, the degree of fibrosis has not been extensively studied. Cardiac magnetic resonance imaging (CMR) contrast enhancement and novel sensitive T1 mapping to estimate increased extracellular volume (ECV) are available to measure the extent of fibrosis. OBJECTIVES To assess LV mass and fibrosis before and after treatment of PA using CMR with contrast enhancement and T1 mapping. METHODS Fifteen patients with newly diagnosed PA (PA1) and 24 age- and sex-matched healthy subjects (HS) were studied by CMR with contrast enhancement. Repeated imaging with a new scanner with T1 mapping was performed in 14 of the PA1 and 20 of the HS median 18 months after specific PA treatment and in additional 16 newly diagnosed PA patients (PA2). RESULTS PA1 had higher baseline LV mass index than HS (69 (53-91) vs 51 (40-72) g/m2; P < 0.001), which decreased significantly after treatment (58 (40-86) g/m2; P < 0.001 vs baseline), more with adrenalectomy (n = 8; -9 g/m2; P = 0.003) than with medical treatment (n = 6; -5 g/m2; P = 0.075). No baseline difference was found in contrast enhancement between PA1 and HS. T1 mapping showed no increase in ECV as a myocardial fibrosis marker in PA. Moreover, ECV was lower in the untreated PA2 than HS 10 min post-contrast, and in both PA groups compared with HS 20 min post-contrast. CONCLUSION Specific treatment rapidly reduced LV mass in PA. Increased myocardial fibrosis was not found and may not represent a common clinical problem.
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Affiliation(s)
- Marianne Aa Grytaas
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway
- Department of MedicineHaukeland University Hospital, Bergen, Norway
| | - Kjersti Sellevåg
- Department of Heart DiseaseHaukeland University Hospital, Bergen, Norway
| | - Hrafnkell B Thordarson
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway
- Department of MedicineHaukeland University Hospital, Bergen, Norway
| | - Eystein S Husebye
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway
- Department of MedicineHaukeland University Hospital, Bergen, Norway
| | - Kristian Løvås
- Department of Clinical ScienceUniversity of Bergen, Bergen, Norway
- Department of MedicineHaukeland University Hospital, Bergen, Norway
| | - Terje H Larsen
- Department of Heart DiseaseHaukeland University Hospital, Bergen, Norway
- Department of BiomedicineUniversity of Bergen, Bergen, Norway
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40
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Affiliation(s)
- David A Calhoun
- From the Vascular Biology and Hypertension Program, University of Alabama at Birmingham.
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Seccia TM, Caroccia B, Adler GK, Maiolino G, Cesari M, Rossi GP. Arterial Hypertension, Atrial Fibrillation, and Hyperaldosteronism: The Triple Trouble. Hypertension 2018; 69:545-550. [PMID: 28264920 DOI: 10.1161/hypertensionaha.116.08956] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Teresa M Seccia
- From the Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, Italy (T.M.S., B.C., G.M., M.C., G.P.R.); and Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (G.K.A.)
| | - Brasilina Caroccia
- From the Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, Italy (T.M.S., B.C., G.M., M.C., G.P.R.); and Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (G.K.A.)
| | - Gail K Adler
- From the Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, Italy (T.M.S., B.C., G.M., M.C., G.P.R.); and Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (G.K.A.)
| | - Giuseppe Maiolino
- From the Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, Italy (T.M.S., B.C., G.M., M.C., G.P.R.); and Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (G.K.A.)
| | - Maurizio Cesari
- From the Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, Italy (T.M.S., B.C., G.M., M.C., G.P.R.); and Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (G.K.A.)
| | - Gian Paolo Rossi
- From the Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, Italy (T.M.S., B.C., G.M., M.C., G.P.R.); and Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (G.K.A.).
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Derya MA, Demir V, Ede H. Relationship between neutrophil/lymphocyte ratio and epicardial fat tissue thickness in patients with newly diagnosed hypertension. J Int Med Res 2018; 46:940-950. [PMID: 29332485 PMCID: PMC5972270 DOI: 10.1177/0300060517749130] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective Epicardial fat tissue thickness (EFT) and the neutrophil/lymphocyte ratio (NLR) are associated with atherosclerosis. Few studies have focused on the relationship between these parameters in patients with newly diagnosed hypertension. In this study, we examined the relationship between EFT and the NLR in patients with newly diagnosed hypertension detected by 24-hour ambulatory blood pressure monitoring (ABPM). Methods Eighty consecutive patients without chronic illness who were diagnosed with hypertension according to ABPM results and 80 otherwise healthy subjects were enrolled in the study. EFT of each participant was measured echocardiographically. The C-reactive protein (CRP) concentration and NLR were measured from venous blood samples. Results The 24-hour average systolic blood pressure was significantly higher in the hypertension group than in the control group (143±17 vs. 117±7 mmHg, respectively). There were no significant differences in age, sex, or body mass index between the two groups. EFT, the NLR, and the CRP concentration were significantly higher in the hypertension group than control group. Additionally, a significantly positive correlation between EFT and the NLR was found in both the control group and hypertension group. Conclusion A higher EFT and NLR were detected in patients with newly diagnosed hypertension than in healthy subjects.
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Affiliation(s)
- Mehmet Ali Derya
- Cardiology Department, Faculty of Medicine, 485513 Bozok University, Yozgat , Turkey
| | - Vahit Demir
- Cardiology Department, Faculty of Medicine, 485513 Bozok University, Yozgat , Turkey
| | - Huseyin Ede
- Cardiology Department, Faculty of Medicine, 485513 Bozok University, Yozgat , Turkey
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Yugar-Toledo JC, Modolo R, de Faria AP, Moreno H. Managing resistant hypertension: focus on mineralocorticoid-receptor antagonists. Vasc Health Risk Manag 2017; 13:403-411. [PMID: 29081661 PMCID: PMC5652936 DOI: 10.2147/vhrm.s138599] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Mineralocorticoid-receptor antagonists (MRAs) have proven to be effective in some types of hypertension, especially in resistant hypertension (RHTN). In this phenotype of hypertension, the renin-angiotensin-aldosterone pathway plays an important role, with MRAs being especially effective in reducing blood pressure. In this review, we show the relevance of aldosterone in RHTN, as well as some clinical characteristics of this condition and the main concepts involving its pathophysiology and cardiovascular damage. We analyzed the mechanisms of action and clinical effects of two current MRAs - spironolactone and eplerenone - both of which are useful in RHTN, with special attention to the former. RHTN represents a significant minority (10%-15%) of hypertension cases. However, primary-care physicians, cardiologists, nephrologists, neurologists, and geriatricians face this health problem on a daily basis. MRAs are likely one of the best pharmacological options in RHTN patients; however, they are still underused.
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Affiliation(s)
| | - Rodrigo Modolo
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Ana Paula de Faria
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
| | - Heitor Moreno
- School of Medical Sciences, University of Campinas (UNICAMP), Campinas, Brazil
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Dudenbostel T, Siddiqui M, Gharpure N, Calhoun DA. Refractory versus resistant hypertension: Novel distinctive phenotypes. JOURNAL OF NATURE AND SCIENCE 2017; 3:e430. [PMID: 29034321 PMCID: PMC5640321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Resistant hypertension (RHTN) is relatively common with an estimated prevalence of 10-20% of treated hypertensive patients. It is defined as blood pressure (BP) >140/90 mmHg treated with ≥3 antihypertensive medications, including a diuretic, if tolerated. Refractory hypertension is a novel phenotype of severe antihypertensive treatment failure. The proposed definition for refractory hypertension, i.e. BP >140/90 mmHg with use of ≥5 different antihypertensive medications, including a diuretic and a mineralocorticoid receptor antagonist (MRA) has been applied inconsistently. In comparison to RHTN, refractory hypertension seems to be less prevalent than RHTN. This review focuses on current knowledge about this novel phenotype compared with RHTN including definition, prevalence, mechanisms, characteristics and comorbidities, including cardiovascular risk. In patients with RHTN excess fluid retention is thought to be a common mechanism for the development of RHTN. Recently, evidence has emerged suggesting that refractory hypertension may be more of neurogenic etiology due to increased sympathetic activity as opposed to excess fluid retention. Treatment recommendations for RHTN are generally based on use and intensification of diuretic therapy, especially with the combination of a long-acting thiazide-like diuretic and an MRA. Based on findings from available studies, such an approach does not seem to be a successful strategy to control BP in patients with refractory hypertension and effective sympathetic inhibition in such patients, either with medications and/or device based approaches may be needed.
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Affiliation(s)
- Tanja Dudenbostel
- Corresponding Author: Tanja Dudenbostel, MD, FASH, Assistant Professor of Medicine, Department of Medicine, Division of Cardiovascular Disease, Vascular Biology and Hypertension Program, 933 19 Street South, Room 115, Community Health Services Building, Birmingham, AL 35294, Phone: (205) 934-9281; Fax: (205) 934-1302,
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Clinical characteristics, target organ damage and associate risk factors of resistant hypertension determined by ambulatory blood pressure monitoring in patients aged ≥ 80 years. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2017. [PMID: 28630606 PMCID: PMC5466933 DOI: 10.11909/j.issn.1671-5411.2017.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To investigate clinical characteristics, target organ damage, and the associated risk factors of the patients aged ≥ 80 years with true resistant hypertension (RH). METHODS Patients aged ≥ 80 years with hypertension (n = 1163) were included in this study. The included participants attended a structured clinical examination and an evaluation of RH was carried out. The prevalence, clinical characteristics and target organ damage of patients with RH were assessed. The associated clinical risk factors were analyzed by using logistic regression. RESULTS The prevalence of RH diagnosis by 24-h ambulatory blood pressure monitoring assessment was 21.15%. End-diastolic left ventricular internal dimension, left ventricular mass index as well as prevalence of left ventricular hypertrophy were significantly greater in patients with RH than in control group. The common carotid artery intimal media thickness, carotid walls thickness, common carotid artery diameter and relative wall thickness were significant greater in RH group than in control. A relatively higher level of creatinine, estimated glomerular filtration rate, microalbuminuria and retinal changes was found in RH group than in control. A multivariate analysis showed that patients with a history of diabetes, higher body mass index (BMI) and lipid profiles were independent risk factors of RH. CONCLUSIONS The prevalence of RH in patients aged ≥ 80 years was within the range of reported rates of the general population. Subjects with RH diagnosis showed a higher occurrence of target organ damage than patients with well controlled blood pressure. Patients with diabetes, higher BMI and serum lipid profiles were independent risk factors for RH in patients aged ≥ 80 years.
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Hung CS, Wu XM, Chen CW, Chen YH, Wu VC, Liao CW, Chang YY, Yen RF, Lu CC, Su MYM, Liu KL, Chang CC, Liu LYD, Wu KD, Lin YH. The relationship among cardiac structure, dietary salt and aldosterone in patients with primary aldosteronism. Oncotarget 2017; 8:73187-73197. [PMID: 29069862 PMCID: PMC5641205 DOI: 10.18632/oncotarget.17505] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/05/2017] [Indexed: 01/10/2023] Open
Abstract
Salt intake is highly associated with cardiac structure in patients with primary aldosteronism (PA). We investigated the association among dietary salt intake, aldosterone and left ventricular mass in patients with PA. We enrolled 158 patients with PA and 158 patients with essential hypertension. We measured 24-hour urinary sodium (UNa) and aldosterone (UAldo) level and echocardiography parameters. In patients with PA, the UAldo level was positively correlated with left ventricular mass index (LVMI; r=0.231, p=0.007). The UNa level was not linearly correlated with left ventricular structural parameters in patients with PA. To test if UNa has a non-linear relationship with LVMI among patients with PA, we categorized the participants according to the tertile of UNa (low, median, and high tertile). PA patients with medium tertile of UNa had significant lower LVMI than the other two groups (LVMI: 144.1 ± 42.9, 121.1 ± 33.4, and 136.7 ± 32.8 g/m2, from the lowest to the highest tertile of Una; analysis of variance p=0.006, post-hoc p <0.05). Multifactor analysis of variance confirmed this finding after adjustment for clinical parameters. Post-hoc analyses revealed that the high UNa tertile was associated with higher left ventricular end-diastolic volume compared with medium UNa tertile; while the low UNa tertile was associated with higher mean wall thickness compared with medium UNa tertile. The findings imply the reasons for increased LVMI may be different in patients with the highest and lowest UNa tertile. In conclusion, the medium tertile of 24-hour UNa is associated with lowest LVMI in patients with PA.
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Affiliation(s)
- Chi-Sheng Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Xue-Ming Wu
- Department of Internal Medicine, Taoyuan General Hospital, Taoyuan, Taiwan
| | - Ching-Way Chen
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Ying-Hsien Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Che-Wei Liao
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Yi-Yao Chang
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Ruh-Fang Yen
- Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ching-Chu Lu
- Department of Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Mao-Yuan M Su
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kao-Lang Liu
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chin-Chen Chang
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Li-Yu Daisy Liu
- Department of Agronomy, Biometry Division, National Taiwan University, Taipei, Taiwan
| | - Kwan-Dun Wu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Ghazi L, Oparil S, Calhoun DA, Lin CP, Dudenbostel T. Distinctive Risk Factors and Phenotype of Younger Patients With Resistant Hypertension: Age Is Relevant. Hypertension 2017; 69:827-835. [PMID: 28348010 DOI: 10.1161/hypertensionaha.116.08632] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 11/04/2016] [Accepted: 02/04/2017] [Indexed: 01/11/2023]
Abstract
Resistant hypertension, defined as blood pressure >140/90 mm Hg despite using ≥3 antihypertensive medications, is a well-recognized clinical entity. Patients with resistant hypertension are at an increased risk of cardiovascular disease compared with those with more easily controlled hypertension. Coronary heart disease mortality rates of younger adults are stagnating or on the rise. The purpose of our study was to characterize the phenotype and risk factors of younger patients with resistant hypertension, given the dearth of data on cardiovascular risk profile in this cohort. We conducted a cross-sectional analysis with predefined age groups of a large, ethnically diverse cohort of 2170 patients referred to the Hypertension Clinic at the University of Alabama at Birmingham. Patients (n=2068) met the inclusion criteria and were classified by age groups, that is, ≤40 years (12.7% of total cohort), 41 to 55 years (32.1%), 56 to 70 years (36.1%), and ≥71 years (19.1%). Patients aged ≤40 years compared with those aged ≥71 years had significantly earlier onset of hypertension (24.7±7.4 versus 55.0±14.1 years; P<0.0001), higher rates of obesity (53.4% versus 26.9%; P<0.0001), and significantly higher levels of plasma aldosterone (11.3±9.8 versus 8.9±7.4 ng/dL; P=0.005), plasma renin activity (4.9±10.2 versus 2.5±5.0 ng/mL per hour; P=0.001), 24-hour urinary aldosterone (13.4±10.0 versus 8.2±6.2 µg/24 h; P<0.0001), and sodium excretion (195.9±92.0 versus 146.8±67.1 mEq/24 h; P<0.0001). Among patients with resistant hypertension, younger individuals have a distinct phenotype characterized by overlapping risk factors and comorbidities, including obesity, high aldosterone, and high dietary sodium intake compared with elderly.
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Affiliation(s)
- Lama Ghazi
- From the Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (L.G.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham (S.O., D.A.C., T.D.); Alabama Medicine (S.O., D.A.C., T.D.) and Center for Clinical and Translational Science (C.P.L.), University of Birmingham at Alabama.
| | - Suzanne Oparil
- From the Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (L.G.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham (S.O., D.A.C., T.D.); Alabama Medicine (S.O., D.A.C., T.D.) and Center for Clinical and Translational Science (C.P.L.), University of Birmingham at Alabama
| | - David A Calhoun
- From the Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (L.G.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham (S.O., D.A.C., T.D.); Alabama Medicine (S.O., D.A.C., T.D.) and Center for Clinical and Translational Science (C.P.L.), University of Birmingham at Alabama
| | - Chee Paul Lin
- From the Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (L.G.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham (S.O., D.A.C., T.D.); Alabama Medicine (S.O., D.A.C., T.D.) and Center for Clinical and Translational Science (C.P.L.), University of Birmingham at Alabama
| | - Tanja Dudenbostel
- From the Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis (L.G.); Vascular Biology and Hypertension Program, Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham (S.O., D.A.C., T.D.); Alabama Medicine (S.O., D.A.C., T.D.) and Center for Clinical and Translational Science (C.P.L.), University of Birmingham at Alabama
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Rosa J, Zelinka T, Petrák O, Štrauch B, Holaj R, Widimský J. Should All Patients with Resistant Hypertension Receive Spironolactone? Curr Hypertens Rep 2016; 18:81. [PMID: 27787836 DOI: 10.1007/s11906-016-0690-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Ján Rosa
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic.
- Cardiocenter, University Hospital Královské Vinohrady and Third Faculty of Medicine, Charles University, Prague, Czech Republic.
| | - Tomáš Zelinka
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ondřej Petrák
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Branislav Štrauch
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Robert Holaj
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jiří Widimský
- 3rd Department of Medicine, Center for Hypertension, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
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Dudenbostel T, Ghazi L, Liu M, Li P, Oparil S, Calhoun DA. Body Mass Index Predicts 24-Hour Urinary Aldosterone Levels in Patients With Resistant Hypertension. Hypertension 2016; 68:995-1003. [PMID: 27528066 DOI: 10.1161/hypertensionaha.116.07806] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 07/13/2016] [Indexed: 12/25/2022]
Abstract
Prospective studies indicate that hyperaldosteronism is found in 20% of patients with resistant hypertension. A small number of observational studies in normotensive and hypertensive patients suggest a correlation between aldosterone levels and obesity while others could not confirm these findings. The correlation between aldosterone levels and body mass index (BMI) in patients with resistant hypertension has not been previously investigated. Our objective was to determine whether BMI is positively correlated with plasma aldosterone concentration, plasma renin activity, aldosterone:renin ratio, and 24-hour urinary aldosterone in black and white patients. We performed a cross-sectional analysis of a large diverse cohort (n=2170) with resistant hypertension. The relationship between plasma aldosterone concentration, plasma renin activity, aldosterone:renin ratio, 24-hour urinary aldosterone, and BMI was investigated for the entire cohort, by sex and race (65.3% white, 40.3% men). We demonstrate that plasma aldosterone concentration and aldosterone:renin ratio were significantly correlated to BMI (P<0.0001) across the first 3 quartiles, but not from the 3rd to 4th quartile of BMI. Plasma renin activity was not correlated with BMI. Twenty-four-hour urinary aldosterone was positively correlated across all quartiles of BMI for the cohort (P<0.0001) and when analyzed by sex (men P<0.0001; women P=0.0013) and race (P<0.05), and stronger for men compared with women (r=0.19, P<0.001 versus r=0.05, P=0.431, P=0.028) regardless of race. In both black and white patients, aldosterone levels were positively correlated to increasing BMI, with the correlation being more pronounced in black and white men. These findings suggest that obesity, particularly the abdominal obesity typical of men, contributes to excess aldosterone in patients with resistant hypertension.
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Affiliation(s)
- Tanja Dudenbostel
- From the Division of Cardiovascular Disease, Vascular Biology, and Hypertension Program (T.D., L.G., M.L., S.O., D.A.C.), School of Medicine (M.L.), and Department of Biostatistics, School of Public Health (P.L.), University of Alabama at Birmingham.
| | - Lama Ghazi
- From the Division of Cardiovascular Disease, Vascular Biology, and Hypertension Program (T.D., L.G., M.L., S.O., D.A.C.), School of Medicine (M.L.), and Department of Biostatistics, School of Public Health (P.L.), University of Alabama at Birmingham
| | - Mingchun Liu
- From the Division of Cardiovascular Disease, Vascular Biology, and Hypertension Program (T.D., L.G., M.L., S.O., D.A.C.), School of Medicine (M.L.), and Department of Biostatistics, School of Public Health (P.L.), University of Alabama at Birmingham
| | - Peng Li
- From the Division of Cardiovascular Disease, Vascular Biology, and Hypertension Program (T.D., L.G., M.L., S.O., D.A.C.), School of Medicine (M.L.), and Department of Biostatistics, School of Public Health (P.L.), University of Alabama at Birmingham
| | - Suzanne Oparil
- From the Division of Cardiovascular Disease, Vascular Biology, and Hypertension Program (T.D., L.G., M.L., S.O., D.A.C.), School of Medicine (M.L.), and Department of Biostatistics, School of Public Health (P.L.), University of Alabama at Birmingham
| | - David A Calhoun
- From the Division of Cardiovascular Disease, Vascular Biology, and Hypertension Program (T.D., L.G., M.L., S.O., D.A.C.), School of Medicine (M.L.), and Department of Biostatistics, School of Public Health (P.L.), University of Alabama at Birmingham
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