Preventing left ventricular hypertrophy by ACE inhibition in hypertensive patients with type 2 diabetes: a prespecified analysis of the Bergamo Nephrologic Diabetes Complications Trial (BENEDICT)

Prevention and treatment of hypertensive left ventricular hypertrophy

PURPOSE OF REVIEW

Left ventricular (LV) hypertrophy (LVH) is a well recognized target organ adaptation to longstanding uncontrolled hypertension and other cardiovascular risk factors. It is also a strong and independent predictor of many cardiovascular disorders.

RECENT FINDINGS

This focused review explores the current concepts in screening, diagnosis, prevention, and treatment of LVH in patients with hypertension. Currently, the primary screening and diagnostic tools for LVH are ECG and 2D echocardiography. Implementing machine learning in the diagnostic modalities can improve sensitivity in the detection of LVH. Lifestyle modifications, blood pressure control with antihypertensive therapy, and management of comorbidities aid in preventing and reversing LV remodeling.

SUMMARY

LVH is a common and often silent complication of hypertension. Prevention and reversal of LV remodeling are crucial for cardiovascular risk reduction in patients with hypertension.

Effect of active vitamin-D on left ventricular mass index: Results of a randomized controlled trial in type 2 diabetes and chronic kidney disease

BACKGROUND

Active vitamin-D deficiency is a potential modifiable risk factor for increased ventricular mass. We explored the effects of active vitamin-D (calcitriol) treatment on left ventricular mass in patients with type-2 diabetes (T2D) and chronic kidney disease (CKD).

METHODS

We performed a 48-week duration single center randomized double-blind parallel group trial examining the impact of calcitriol, 0.5 mcg once daily, as compared to placebo on a primary endpoint of change from baseline in left ventricular mass index (LVMI) measured by magnetic resonance imaging . Patients with T2D, CKD stage-3 and raised left ventricular mass on stable renin angiotensin aldosterone system blockade, who all had elevated intact parathyroid hormone were eligible. Secondary endpoints included interstitial myocardial fibrosis, assessed with cardiac magnetic resonance imaging. In total, 45 (male 73%) patients with T2D and stage-3 CKD were studied (calcitriol n = 19, placebo n = 26).

RESULTS

Following 48-weeks calcitriol treatment, the median difference and the (95% CI) of LVMI between the 2 treatment arms was 1.84 (-1.28, 4.96), similar between the 2 groups studied. Intact parathyroid hormone fell only in the calcitriol group from 142 pg/mL (80-293) to 76 pg/mL (41-204)(median, interquartile range, P= .04). No significant differences were observed in interstitial myocardial fibrosis or other secondary endpoints.

CONCLUSIONS

The study did not provide evidence that treatment with calcitriol as compared to placebo might improve LVMI in patients with T2D, mild left ventricular hypertrophy and stable CKD. Our data does not support the routine use of active vitamin-D for LVMI regression and cardiovascular protection in patients with T2D and stage-3 CKD.

Association of Renin-Angiotensin System Blockers with Survival in Patients on Maintenance Hemodialysis

Additional studies are needed to confirm whether the use of renin-angiotensin system blockers (RASBs) induces survival benefits in patients on hemodialysis (HD). This study aimed to evaluate patient survival with the use of RASBs in a large sample of maintenance HD patients. This study used data from the national HD quality assessment program and claim data from South Korea (n = 54,903). A patient using RASBs was defined as someone who had received more than one prescription during the 6 months of each HD quality assessment period. The patients were divided into three groups as follows: Group 1, no prescription for anti-hypertensive drugs; Group 2, prescription for anti-hypertensive drugs other than RASBs; and Group 3, prescription for RASBs. The five-year survival rates in Groups 1, 2, and 3 were 72.1%, 64.5%, and 66.6%, respectively (p < 0.001 for Group 1 vs. Group 2 or 3; p = 0.001 for Group 2 vs. Group 3). Group 1 had the highest patient survival rates among the three groups, and Group 3 had higher patient survival rates compared to Group 2. Group 3 had higher patient survival rates than Group 2; however, the difference in patient survival rates between Group 2 and Group 3 was relatively small. Multivariate Cox regression analyses showed similar trends as those of univariate analyses. The highest survival rates from our study were those of patients who had not used anti-hypertensive drugs. Between patients treated with RASBs and those with other anti-hypertensive drugs, patient survival rates were higher in patients treated with RASBs.

Ramipril and Cardiovascular Outcomes in Patients on Maintenance Hemodialysis: The ARCADIA Multicenter Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Renin-angiotensin system (RAS) inhibitors reduce cardiovascular morbidity and mortality in patients with CKD. We evaluated the cardioprotective effects of the angiotensin-converting enzyme inhibitor ramipril in patients on maintenance hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this phase 3, prospective, randomized, open-label, blinded end point, parallel, multicenter trial, we recruited patients on maintenance hemodialysis with hypertension and/or left ventricular hypertrophy from 28 Italian centers. Between July 2009 and February 2014, 140 participants were randomized to ramipril (1.25-10 mg/d) and 129 participants were allocated to non-RAS inhibition therapy, both titrated up to the maximally tolerated dose to achieve predefined target BP values. The primary efficacy end point was a composite of cardiovascular death, myocardial infarction, or stroke. Secondary end points included the single components of the primary end point, new-onset or recurrence of atrial fibrillation, hospitalizations for symptomatic fluid overload, thrombosis or stenosis of the arteriovenous fistula, and changes in cardiac mass index. All outcomes were evaluated up to 42 months after randomization.

RESULTS

At comparable BP control, 23 participants on ramipril (16%) and 24 on non-RAS inhibitor therapy (19%) reached the primary composite end point (hazard ratio, 0.93; 95% confidence interval, 0.52 to 1.64; P=0.80). Ramipril reduced cardiac mass index at 1 year of follow-up (between-group difference in change from baseline: -16.3 g/m2; 95% confidence interval, -29.4 to -3.1), but did not significantly affect the other secondary outcomes. Hypotensive episodes were more frequent in participants allocated to ramipril than controls (41% versus 12%). Twenty participants on ramipril and nine controls developed cancer, including six gastrointestinal malignancies on ramipril (four were fatal), compared with none in controls.

CONCLUSIONS

Ramipril did not reduce the risk of major cardiovascular events in patients on maintenance hemodialysis.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

ARCADIA, NCT00985322 and European Union Drug Regulating Authorities Clinical Trials Database number 2008-003529-17.

Regulation of connexins genes expression contributes to reestablishes tissue homeostasis in a renovascular hypertension model

Connexins (Cx) are essential for cardiovascular regulation and maintenance of cardio-renal response involving the natriuretic peptide family. Changes in the expression of connexins promote intercellular communication dysfunction and may induce hypertension, atherosclerosis, and several other vascular diseases. This study analyzed the expression of the genes involved in the renin-angiotensin system (RAS) and the relation of the connexins gene expression with the renovascular hypertension 2K1C in different tissues. The insertion of a silver clip induced renovascular hypertension 2K1C into the left renal artery. Biochemical measurements were made using commercial kits. Gene expression was evaluated in the liver, heart, and kidneys by RT-PCR. The genes investigated were LDLr, Hmgcr, Agt, Ren, Ace, Agtr1a, Anp, Bnp, Npr1, Cx26, Cx32, Cx37, Cx40 and Cx43. All genes involved in the RAS presented increased transcriptional levels in the 2K1C group, except hepatic Agt. The natriuretic peptides (Anp; Bnp) and the receptor genes (Npr1) appeared to increase in the heart, however, Npr1 decreased in the kidneys. In hepatic tissue, hypertension promoted increased expression of Cx32, Cx37, and Cx40 genes however, Cx26 and Cx43 genes were not influenced. Expression was upregulated for Cx37 and Cx43 in cardiac tissue in the 2K1C group, but Cx40 did not demonstrate any difference between groups. The stenotic kidney showed an upregulated expression for Cx37 vs Sham and contralateral kidney, although Cx40 and Cx43 were downregulated. Hypertension did not modify the transcriptional expression of Cx26 and Cx32. Therefore, this study indicated that RAS and cardiac response were regulated transcriptionally by renovascular hypertension 2K1C. Moreover, the results of connexin gene expression demonstrated differential transcriptional regulation in different tissues studied and suggest a relationship between cardiac and renal physiological changes as an adaptive mechanism to the hypertensive state.

The Gene Polymorphism of Angiotensin-Converting Enzyme Intron Deletion and Angiotensin-Converting Enzyme G2350A in Patients With Left Ventricular Hypertrophy: A Meta-analysis

Objectives

The aim of the study was to evaluate the correlation between left ventricular hypertrophy and the gene polymorphism of angiotensin-converting enzyme (ACE) intron deletion (I/D) and ACE G2350A.

Methods

Information related to the sample size and genotype frequencies was extracted from each study.

Results

Our results found that the D allele (p = 0.0180) and DD genotype (p = 0.0110) of ACE I/D had a significant association with increasing the risk of left ventricular hypertrophy, whereas the I allele (p = 0.0180), but not II (p = 0.1660) and ID genotypes (p = 0.1430), was associated with decreasing the risk of left ventricular hypertrophy. On other hand, we found that the A allele (p = 0.0020) and GA genotype of ACE G2350A (p = 0.0070) had the correlation with increasing the risk of left ventricular hypertrophy.

Conclusions

Our meta-analysis reveals that the D allele of ACE I/D and the A allele of ACE G2350A are associated with increasing the risk of left ventricular hypertrophy.

Current Perspectives on Systemic Hypertension in Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a prevalent but incompletely understood syndrome. Traditional models of HFpEF pathophysiology revolve around systemic HTN and other causes of increased left ventricular afterload leading to left ventricular hypertrophy (LVH) and diastolic dysfunction. However, emerging models attribute the development of HFpEF to systemic proinflammatory changes secondary to common comorbidities which include HTN. Alterations in passive ventricular stiffness, ventricular-arterial coupling, peripheral microvascular function, systolic reserve, and chronotropic response occur. As a result, HFpEF is heterogeneous in nature, making it difficult to prescribe uniform therapies to all patients. Nonetheless, treating systemic HTN remains a cornerstone of HFpEF management. Antihypertensive therapies have been linked to LVH regression and improvement in diastolic dysfunction. However, to date, no therapies have definitive mortality benefit in HFpEF. Non-pharmacologic management for HTN, including dietary modification, exercise, and treating sleep disordered breathing, may provide some morbidity benefit in the HFpEF population. Future research is need to identify effective treatments, perhaps in more specific subgroups, and focus may need to shift from reducing mortality to improving exercise capacity and symptoms. Tailoring antihypertensive therapies to specific phenotypes of HFpEF may be an important component of this strategy.

Is hepatic steatosis associated with left ventricular mass index increase in the general population?

AIM

To investigate the association between hepatic steatosis and change in left ventricular mass index (LVMI) over five years, and examine whether systolic and diastolic blood pressures are mediators of the association between hepatic steatosis and LVMI using a general population sample.

METHODS

We analyzed data from the Study of Health in Pomerania. The study population comprised 1298 individuals aged 45 to 81 years. Hepatic steatosis was defined as the presence of a hyperechogenic pattern of the liver together with elevated serum alanine transferase levels. Left ventricular mass was determined echocardiographically and indexed to height^2.7. Path analyses were conducted to differentiate direct and indirect paths from hepatic steatosis to LVMI encompassing systolic and diastolic blood pressure as potential mediating variables.

RESULTS

Hepatic steatosis was a significant predictor for all measured echocardiographic characteristics at baseline. Path analyses revealed that the association of hepatic steatosis with LVMI change after five years was negligibly small (β = -0.12, s.e. = 0.21, P = 0.55). Systolic blood pressure at baseline was inversely associated with LVMI change (β = -0.09, s.e. = 0.03, P < 0.01), while no association between diastolic blood pressure at baseline and LVMI change was evident (β = 0.03, s.e. = 0.05, P = 0.56). The effect of the indirect path from hepatic steatosis to LVMI via systolic baseline blood pressure was small (β = -0.20, s.e. = 0.10, P = 0.07). No indirect effect was observed for the path via diastolic baseline blood pressure (β = 0.03, s.e. = 0.06, P = 0.60). Similar associations were observed in the subgroup of individuals not receiving beta-blockers, calcium channel blockers, or drugs acting on the renin-angiotensin system.

CONCLUSION

Baseline associations between hepatic steatosis and LVMI do not extend to associations with LVMI change after five years. More studies are needed to study the longitudinal effects of hepatic steatosis on LVMI.

Baseline characteristics of patients with heart failure and preserved ejection fraction at admission with acute heart failure in Saudi Arabia

Heart failure and preserved ejection fraction (HFpEF) is defined as heart failure symptoms and signs with a normal or near-normal ejection fraction (EF) with evidence of diastolic dysfunction. The few Middle Eastern studies that have been conducted were designed to compare patients with heart failure reduced ejection fraction (HFrEF) and HFpEF.The aim of this study was to study Saudi patients with HFpEF who presented with acute heart failure, and define their clinical characteristics and the signs and symptoms of heart failure, echocardiographic findings and medications at admission and at hospital discharge.

Methods

This is a prospective observational study in which patients were included following an acute heart failure presentation with N-terminal pro-BNP (NT-proBNP) > 300 ng/L and left ventricular ejection fraction (LVEF) > 50%. They were admitted to the coronary care unit of king Saud medical city from the period of March 2015 to September 2015.

Results

114 patients were enrolled in the study and assessed at acute admission. Of these, 4% died on day one of admission.The mean ± SD age of 109 included patients was 59 ± 8 years and 55% were women. Hypertension (64%), dyslipidemia (76%), atrial tachyarrhythmia (38%), prior heart failure (33%) and anemia (35%), median NT-proBNP was 2490 ± 125 ng/l at admission. Mean (LVEF) was 61 ± 3, mean LV mass index was 118 ± 11, mean E/e' was 12.2 ± 2, and left atrial volume index was 47 ± 7 mL/m². Mean global left ventricular strain was -13.5 ± 1.5. At discharge the majority of patients were still symptomatic with high NT-proBNP 542 ± 266.

Conclusions

Patients with HFpEF were old with slight female dominance, a high rate of hypertension, diabetes, dyslipidemia and much comorbidity. LVEF was preserved despite depressed left ventricular longitudinal and diastolic functions with high filling pressure. At discharge the patients were still symptomatic calling for further research to reach the best strategy for proper management.

Renin-angiotensin-aldosterone system blockade in chronic kidney disease: current strategies and a look ahead

The Renin-Angiotensin-Aldosterone System (RAAS) is profoundly involved in the pathogenesis of renal and cardiovascular organ damage, and has been the preferred therapeutic target for renal protection for over 30 years. Monotherapy with either an Angiotensin Converting Enzime Inhibitor (ACE-I) or an Angiotensin Receptor Blocker (ARB), together with optimal blood pressure control, remains the mainstay treatment for retarding the progression toward end-stage renal disease. Combining ACE-Is and ARBs, or either one with an Aldosterone Receptor Antagonist (ARA), has been shown to provide greater albuminuria reduction, and to possibly improve renal outcome, but at an increased risk of potentially severe side effects. Moreover, combination therapy has failed to provide additional cardiovascular protection, and large prospective trials on hard renal endpoints are lacking. Therefore this treatment should, at present, be limited to selected patients with residual proteinuria and high renal risk. Future studies with novel agents, which directly act on the RAAS at multiple levels or have a more favourable side effect profile, are greatly needed to further explore and define the potential for and the limitations of profound pharmacologic RAAS inhibition.

Accepting Medication Therapy Management Recommendations to Add ACEIs or ARBs in Diabetes Care

BACKGROUND

National guidelines and initiatives have promoted the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) for patients with diabetes. The University of Arizona Medication Management Center (UA-MMC) is contracted by Medicare health plans, pharmacy benefit managers (PBMs), and multiple commercial health insurance plans to provide medication therapy management (MTM) services for plan members. As part of the MTM program, recommendations have been made for those patients who may benefit from the addition of an ACEI/ARB. Although the intervention benefits and guidelines for using ACEIs/ARBs are clear, real-world evidence is needed to understand and potentially increase uptake of guideline interventions among eligible patients.

OBJECTIVES

To (a) identify patient characteristics that predict acceptance of guideline recommendations to add ACEI/ARB medications to diabetic treatment via MTM services and (b) examine how well different case characteristics (i.e., patient age and sex, type and number of recommendation attempts, type of health care plan) predict the odds of adding ACEI/ARB medications to diabetic regimens when recommended through an MTM call center.

METHODS

This was a retrospective analysis of secondary data provided by the UA-MMC. The de-identified national data included adult plan members with diabetes who the UA-MMC recommended adding an ACEI/ARB prescription based on 2012 national guidelines. The UA-MMC made recommendations by either patient letters, patient phone calls, physician faxes, or any combination thereof. We conducted a binary logistic regression analysis to assess the impact of case characteristics on the likelihood of accepting recommendations to add ACEI/ARB medications. The outcome variable was recommendation acceptance (yes/no), defined as new prescription claims for an ACEI/ARB within 120 days following the recommendation. Five predictor variables were assessed: (1) patient's age quartile; (2) method of communicating recommendations (letter, phone call, fax, or some combination thereof); (3) whether recommendations were made once or twice on separate dates; (4) patient's sex; and (5) type of health care plan.

RESULTS

Recommendations were made for 31,495 members of health plans or PBMs that contracted with the UA-MMC. Patients' ages ranged from 19-90 (Mean =72.01; SD =10.21), with females comprising 56% of the sample. The recommendation to add ACEI/ARB medications was accepted for 14.5% (4,559) of patients. In most cases (73%), recommendations occurred via a letter to patients together with a fax to their providers. The fitted model, containing 3 predictor variables (age quartile, type of contact to communicate the recommendations, and whether recommendation contacts were made twice), was statistically significant, χ(2) (10; N = 31,495) = 112.82 (P < 0.001), indicating that the model was able to distinguish between those who did and did not accept UA-MMC's recommendations to add ACEI/ARB medications. The likelihood of recommendation acceptance decreased as patient age increased compared with patients in the first age quartile (ages 19-67; P ≤ 0.005 at all levels). Compared with sending only a provider fax, patients who received all 3 types of contact (provider fax with patient phone call and letter) were estimated to be 1.34 times more likely (34% increase) to have recommendation acceptance ( P = 0.004; 95% CI = 1.10-1.63). Similarly, patients who received only letters were also 1.32 times more likely (32% increase) than provider faxes alone to result in recommendation acceptance ( P = 0.003; 95% CI = 1.10-1.59). Patients for whom recommendations were made twice were less likely to have recommendation acceptance than for those contacted once, controlling for all other predictor variables in the model ( P < 0.001; OR = 0.77; 95% CI = 0.69-0.86).

CONCLUSIONS

Recommendations to add an ACEI/ARB to diabetic regimens are more likely to be accepted for younger patients and those who receive recommendations through all 3 communication types (provider fax combined with patient phone call and letter) or just letters than provider faxes alone. Further research is needed to understand why prescribers are not accepting MTM recommendations.

44-h ambulatory blood pressure monitoring: revealing the true burden of hypertension in pediatric hemodialysis patients

BACKGROUND

The blood pressure (BP) burden is high in pediatric hemodialysis (HD) patients and adversely affects prognosis. The aim of this study was to examine whether 44-h ambulatory BP monitoring (ABPM) provides additional relevant BP data compared with 24-h ABPM.

METHODS

ABPM was initiated at the end of the mid-week dialysis run in 13 stable pediatric HD patients and continued until the next run for 44 h. Day 1 was defined as the initial 24-h ABPM and Day 2 as the time period after that until the next dialysis run. All patients had an echocardiogram to calculate the left ventricular mass index (LVMI).

RESULTS

A higher percentage of patients were diagnosed with hypertension from the 44-h ABPM than from the 24-h ABPM. All BP indexes and loads (except nighttime diastolic load) were significantly higher on Day 2 than on Day 1. Patients with BP loads of ≥ 25 % on 44-h ABPM had significantly higher LVMI than those patients with normal BP loads. No such association was found with 24-h ABPM and LVMI. Higher interdialytic weight gain was associated with higher Day-2 nighttime systolic BP load.

CONCLUSIONS

The 44-h ABPM provides more information than the 24-h ABPM in terms of diagnosing and assessing the true burden of hypertension in pediatric HD patients. Elevated BP loads from 44-h ABPM correlate with a higher LVMI on the echocardiogram.

Diabetic cardiomyopathy: mechanisms and new treatment strategies targeting antioxidant signaling pathways

Cardiovascular disease is the primary cause of morbidity and mortality among the diabetic population. Both experimental and clinical evidence suggest that diabetic subjects are predisposed to a distinct cardiomyopathy, independent of concomitant macro- and microvascular disorders. 'Diabetic cardiomyopathy' is characterized by early impairments in diastolic function, accompanied by the development of cardiomyocyte hypertrophy, myocardial fibrosis and cardiomyocyte apoptosis. The pathophysiology underlying diabetes-induced cardiac damage is complex and multifactorial, with elevated oxidative stress as a key contributor. We now review the current evidence of molecular disturbances present in the diabetic heart, and their role in the development of diabetes-induced impairments in myocardial function and structure. Our focus incorporates both the contribution of increased reactive oxygen species production and reduced antioxidant defenses to diabetic cardiomyopathy, together with modulation of protein signaling pathways and the emerging role of protein O-GlcNAcylation and miRNA dysregulation in the progression of diabetic heart disease. Lastly, we discuss both conventional and novel therapeutic approaches for the treatment of left ventricular dysfunction in diabetic patients, from inhibition of the renin-angiotensin-aldosterone-system, through recent evidence favoring supplementation of endogenous antioxidants for the treatment of diabetic cardiomyopathy. Novel therapeutic strategies, such as gene therapy targeting the phosphoinositide 3-kinase PI3K(p110α) signaling pathway, and miRNA dysregulation, are also reviewed. Targeting redox stress and protective protein signaling pathways may represent a future strategy for combating the ever-increasing incidence of heart failure in the diabetic population.

Angiotensin-converting enzyme inhibitor, angiotensin receptor blocker use, and mortality in patients with chronic kidney disease

OBJECTIVES

The study objective was to assess the association between angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB) use and mortality in patients with chronic kidney disease (CKD).

BACKGROUND

There is insufficient evidence about the association of ACEI or ARBs with mortality in patients with CKD.

METHODS

A logistic regression analysis was used to calculate the propensity of ACEI/ARB initiation in 141,413 U.S. veterans with nondialysis CKD who were previously unexposed to ACEI/ARB treatment. We examined the association of ACEI/ARB administration with all-cause mortality in patients matched by propensity scores using the Kaplan-Meier method and Cox models in "intention-to-treat" analyses and in generalized linear models with binary outcomes and inverse probability of treatment weights in "as-treated" analyses.

RESULTS

The age of the patients at baseline was 75 ± 10 years, 8% of patients were black, and 22% were diabetic. ACEI/ARB administration was associated with a significantly lower risk of mortality both in the intention-to-treat analysis (hazard ratio: 0.81, 95% confidence interval: 0.78 to 0.84; p < 0.001) and the as-treated analysis with inverse probability of treatment weights (odds ratio: 0.37, 95% confidence interval: 0.34 to 0.41; p < 0.001). The association of ACEI/ARB treatment with lower risk of mortality was present in all examined subgroups.

CONCLUSIONS

In this large contemporary cohort of nondialysis-dependent patients with CKD, ACEI/ARB administration was associated with greater survival.

Targeting the upregulation of reactive oxygen species subsequent to hyperglycemia prevents type 1 diabetic cardiomyopathy in mice

Cardiac oxidative stress is an early event associated with diabetic cardiomyopathy, triggered by hyperglycemia. We tested the hypothesis that targeting left-ventricular (LV) reactive oxygen species (ROS) upregulation subsequent to hyperglycemia attenuates type 1 diabetes-induced LV remodeling and dysfunction, accompanied by attenuated proinflammatory markers and cardiomyocyte apoptosis. Male 6-week-old mice received either streptozotocin (55mg/kg/day for 5 days), to induce type 1 diabetes, or citrate buffer vehicle. After 4 weeks of hyperglycemia, the mice were allocated to coenzyme Q10 supplementation (10mg/kg/day), treatment with the angiotensin-converting-enzyme inhibitor (ACE-I) ramipril (3mg/kg/day), treatment with olive oil vehicle, or no treatment for 8 weeks. Type 1 diabetes upregulated LV NADPH oxidase (Nox2, p22(phox), p47(phox) and superoxide production), LV uncoupling protein UCP3 expression, and both LV and systemic oxidative stress (LV 3-nitrotyrosine and plasma lipid peroxidation). All of these were significantly attenuated by coenzyme Q10. Coenzyme Q10 substantially limited type 1 diabetes-induced impairments in LV diastolic function (E:A ratio and deceleration time by echocardiography, LV end-diastolic pressure, and LV -dP/dt by micromanometry), LV remodeling (cardiomyocyte hypertrophy, cardiac fibrosis, apoptosis), and LV expression of proinflammatory mediators (tumor necrosis factor-α, with a similar trend for interleukin IL-1β). Coenzyme Q10's actions were independent of glycemic control, body mass, and blood pressure. Coenzyme Q10 compared favorably to improvements observed with ramipril. In summary, these data suggest that coenzyme Q10 effectively targets LV ROS upregulation to limit type 1 diabetic cardiomyopathy. Coenzyme Q10 supplementation may thus represent an effective alternative to ACE-Is for the treatment of cardiac complications in type 1 diabetic patients.

Antihypertensive agents for preventing diabetic kidney disease

BACKGROUND

Various blood pressure-lowering agents, and particularly inhibitors of the renin-angiotensin system (RAS), are widely used for people with diabetes to prevent the onset of diabetic kidney disease (DKD) and adverse cardiovascular outcomes. This is an update of a Cochrane review first published in 2003 and updated in 2005.

OBJECTIVES

This systematic review aimed to assess the benefits and harms of blood pressure lowering agents in people with diabetes mellitus and a normal amount of albumin in the urine (normoalbuminuria).

SEARCH METHODS

In January 2011 we searched the Cochrane Renal Group's Specialised Register through contact with the Trials Search Co-ordinator.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any antihypertensive agent with placebo or another agent in hypertensive or normotensive patients with diabetes and no kidney disease (albumin excretion rate < 30 mg/d) were included.

DATA COLLECTION AND ANALYSIS

Two investigators independently extracted data on kidney and other patient-relevant outcomes (all-cause mortality and serious cardiovascular events), and assessed study quality. Analysis was by a random effects model was applied to analyse results which were expressed as risk ratio (RR) and 95% confidence intervals (CI).

MAIN RESULTS

We identified 26 studies that enrolling 61,264 participants. Angiotensin-converting enzyme inhibitors (ACEi) reduced the risk of new onset of microalbuminuria, macroalbuminuria or both when compared to placebo (8 studies, 11,906 patients: RR 0.71, 95% CI 0.56 to 0.89), with similar benefits in people with and without hypertension (P = 0.74), and when compared to calcium channel blockers (5 studies, 1253 participants: RR 0.60, 95% CI 0.42 to 0.85). ACEi reduced the risk of death when compared to placebo (6 studies, 11,350 participants: RR 0.84, 95% CI 0.73 to 0.97). No effect was observed for angiotensin receptor blockers (ARB) when compared to placebo for new microalbuminuria, macroalbuminuria or both (5 studies, 7653 participants: RR 0.90, 95% CI 0.68 to 1.19) or death (5 studies, 7653 participants: RR 1.12, 95% CI 0.88 to 1.41); however, meta-regression suggested possible benefits from ARB for preventing kidney disease in high risk patients. There was a trend towards benefit from use of combined ACEi and ARB for prevention of DKD compared with ACEi alone (2 studies, 4171 participants: RR 0.88, 95% CI 0.78 to 1.00).The risk of cough was significantly increased with ACEi when compared to placebo (6 studies, 11,791 patients: RR 1.84, 95% CI 1.24 to 2.72), however there was no significant difference in the risk of headache or hyperkalaemia. There was no significant difference in the risk of cough, headache or hyperkalaemia when ARB was to placebo. On average risk of bias was judged to be either low (27% to 69%) or unclear (i.e. no information available) (8% to 73%). Blinding of participants, incomplete outcome data and selective reporting were judged to be high in 23%, 31% and 31% of studies, respectively.

AUTHORS' CONCLUSIONS

ACEi were found to prevent new onset DKD and death in normoalbuminuric people with diabetes, and could therefore be used in this population. More data are needed to clarify the role of ARB and other drug classes in preventing DKD.

Cardiorenal disease development under chronic renin–angiotensin–aldosterone system suppression

Drugs suppressing the renin-angiotensin-aldosterone system (RAAS) are now widely used to treat patients all along the cardiorenal continuum. It supposes that many patients, in particular those with arterial hypertension are treated with converting-enzyme inhibitors and angiotensin receptor blockers for years during which the development and prograssion of cardiorenal disease can be observed. The meaning of this progression in the presence of RAAS suppression requires to be clarified and to be treated in order to diminish the velocity of progression of cardiorenal disease.

Current challenges in the clinical management of hypertension

Elevated blood pressure (BP) is probably the most-important modifiable risk factor for cardiovascular disease (CVD). BP influences the development of CVD, even if levels of BP are well below the usual cut-off point that defines the presence of arterial hypertension. Adequate measurement of BP is the most-important requirement for the diagnosis and treatment of patients with suspected hypertension. The use of methodologies such as ambulatory and home BP monitoring have become powerful tools for defining the 'real' BP of patients, discarding the white-coat effect, and discovering masked hypertension. Early intervention with life-style changes and antihypertensive drugs is required to obtain the best outcome for the patient. In this sense, early use of combination antihypertensive drug therapy is recommended. The treatment of resistant hypertension-the type of elevated BP that is most difficult to control-has clearly improved over the past decade. Further studies are required to define how antihypertensive therapy should be used in the earliest stages of hypertension and for the treatment of patients with a mild-to-moderate increase in global cardiovascular risk.

The diabetic CKD patient--a major cardiovascular challenge

The diabetic patient with chronic kidney disease (CKD) is at very high risk of cardiovascular disease (CVD). Primary and secondary CVD prevention is of major importance and should be targeted at both traditional cardiovascular risk factors and risk factors specific for patients with CKD, such as albuminuria, anaemia and CKD--mineral and bone disorder. However, treatment goals have largely been derived from clinical trials including patients with no or only mild CKD and may not be generalizable to patients with advanced renal disease. Moreover, in patients on renal replacement therapy, the association between traditional CVD risk factors and the incidence of CVD may be reversed, and pharmaceutical interventions that are beneficial in the general population may be ineffective or even harmful in this high-risk population. Those involved in the delivery of care to patients with diabetes and CKD need to be aware of these issues and should adopt an individualised approach to treatment.

Proteinuria in diabetes: bystander or pathway to cardiorenal disease?

The development of albuminuria in diabetics is closely associated with an enhanced risk of renal and cardiovascular disease. However, the role of albuminuria in the pathogenesis of these clinical conditions remains controversial. Whether albuminuria is simply a biomarker or qualifies as a surrogate endpoint for cardiorenal disease has wide-ranging implications from the monitoring and treatment of patients to the design of clinical trials and drug development. We critically review available data to determine whether the association between albuminuria and cardiorenal disease is causative. Current evidence suggests the significance of albuminuria depends on its severity (degree or level) and on the specific clinical outcome under consideration. For diabetic kidney disease, there is convincing epidemiologic and experimental evidence to assign clinical albuminuria status as a surrogate endpoint, but for lower levels of albuminuria (microalbuminuria and normoalbuminuria), the evidence is inconclusive or not available. Albuminuria of any degree is unlikely to be causally related to diabetic cardiovascular disease, but its onset might be useful to identify those subjects at cardiovascular risk and to detect and treat other modifiable risk factors.

Cardiovascular effects of angiotensin converting enzyme inhibition or angiotensin receptor blockade in hemodialysis: a meta-analysis

BACKGROUND AND OBJECTIVES

Cardiovascular (CV) disease causes significant morbidity and mortality among the hemodialysis (HD) population. This meta-analysis was performed to determine whether angiotensin converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) reduce fatal and nonfatal CV events and left ventricular (LV) mass in patients receiving HD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Studies were identified by searching electronic databases, bibliographies, and conference proceedings. Two reviewers independently selected randomized controlled trials using ACEIs or ARBs compared with control among patients receiving HD. Studies were independently assessed for inclusion, quality, and data extraction. Random-effects models were used to estimate the pooled relative risk (RR) for CV outcomes and the weighted mean difference (WMD) for pooled change-from-baseline comparisons for LV mass for ACEI or ARB treated patients compared with control.

RESULTS

Compared with control, the RR of CV events associated with ACEI or ARB use was 0.66 [95% confidence interval (CI) 0.35 to 1.25; P = 0.20]. ACEI or ARB use resulted in a statistically significant reduction in LV mass, with a WMD of 15.4 g/m(2) (95% CI 7.4 to 23.3; P < 0.001).

CONCLUSIONS

Treatment with an ACEI or ARB reduced LV mass in patients receiving HD. However, their use was not associated with a statistically significant reduction in the risk of fatal and nonfatal CV events. Larger, high-quality trials in the HD population are required to determine if the effects of ACEI or ARB therapy on LV mass translate into decreased CV morbidity and mortality.

Exploiting cGMP-based therapies for the prevention of left ventricular hypertrophy: NO* and beyond

Left ventricular hypertrophy (LVH), an increased left ventricular (LV) mass, is common to many cardiovascular disorders, initially developing as an adaptive response to maintain myocardial function. In the longer term, this LV remodelling becomes maladaptive, with progressive decline in LV contractility and diastolic function. Indeed LVH is recognised as an important blood-pressure independent predictor of cardiovascular morbidity and mortality. The clinical efficacy of current treatments for LVH is reduced, however, by their tendency to slow disease progression rather than induce its reversal, and thus the development of new therapies for LVH is paramount. The signalling molecule cyclic guanosine-3',5'-monophosphate (cGMP), well-recognised for its role in regulating vascular tone, is now being increasingly identified as an important anti-hypertrophic mediator. This review is focused on the various means by which cGMP can be stimulated in the heart, such as via the natriuretic peptides, to exert anti-hypertrophic actions. In particular we address the limitations of traditional nitric oxide (NO*) donors in the face of the potential therapeutic advantages offered by novel alternatives; NO* siblings, ligands of the cGMP-generating enzymes, soluble (sGC) and particulate guanylyl cyclases (pGC), and phosphodiesterase inhibitors. Further impact of cGMP within the cardiovascular system is also discussed with a view to representing cGMP-based therapies as innovative pharmacotherapy, alone or concurrent with standard care, for the management of LVH.