HEARTS in the Americas: Targeting Health System Change to Improve Population Hypertension Control

PURPOSE OF REVIEW

HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation.

RECENT FINDINGS

Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation. Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.

[HEARTS in the Americas: targeting health system change to improve population hypertension controlHEARTS nas Américas: impulsionar mudanças no sistema de saúde para melhorar o controle da hipertensão arterial na população]

Purpose of review

HEARTS in the Americas is the regional adaptation of Global Hearts, the World Health Organization initiative for cardiovascular disease (CVD) prevention and control. Its overarching goal is to drive health services to change managerial and clinical practice in primary care settings to improve hypertension control and CVD risk management. This review describes the HEARTS in the Americas initiative. First, the regional epidemiological situation of CVD mortality and population hypertension control trends are summarized; then the rationale for its main intervention components: the primary care-oriented management system and the HEARTS Clinical Pathway are described. Finally, the key factors for accelerating the expansion of HEARTS are examined: medicines, team-based care, and a system for monitoring and evaluation.

Recent findings

Thus far, 33 countries in Latin America and the Caribbean have committed to integrating this program across their primary healthcare network by 2025. The increase in hypertension coverage and control in primary health care settings compared with the traditional model is promising and confirms that the interventions under the HEARTS umbrella are feasible and acceptable to communities, patients, providers, decision-makers, and funders. This review highlights some cases of successful implementation.

Summary

Scaling up effective treatment for hypertension and optimization of CVD risk management is a pragmatic way to accelerate the reduction of CVD mortality while strengthening primary healthcare systems to respond effectively, with quality, and equitably, to the challenge of non-communicable diseases, not only in low-middle income countries but in all communities globally.

HEARTS in the Americas clinical pathway. Strengthening the decision support system to improve hypertension and cardiovascular disease risk management in primary care settings

Background

HEARTS in the Americas is the regional adaptation of the WHO Global HEARTS Initiative. It is implemented in 24 countries and over 2,000 primary healthcare facilities. This paper describes the results of a multicomponent, stepwise, quality improvement intervention designed by the HEARTS in the Americas to support advances in hypertension treatment protocols and evolution towards the Clinical Pathway.

Methods

The quality improvement intervention comprised: 1) the use of the appraisal checklist to evaluate the current hypertension treatment protocols, 2) a peer-to-peer review and consensus process to resolve discrepancies, 3) a proposal of a clinical pathway to be considered by the countries, and 4) a process of review, adopt/adapt, consensus and approval of the clinical pathway by the national HEARTS protocol committee. A year later, 16 participants countries (10 and 6 from each cohort, respectively) were included in a second evaluation using the HEARTS appraisal checklist. We used the median and interquartile scores range and the percentages of the maximum possible total score for each domain as a performance measure to compare the results pre and post-intervention.

Results

Among the eleven protocols from the ten countries in the first cohort, the baseline assessment achieved a median overall score of 22 points (ICR 18 -23.5; 65% yield). After the intervention, the overall score reached a median of 31.5 (ICR 28.5 -31.5; 93% yield). The second cohort of countries developed seven new clinical pathways with a median score of 31.5 (ICR 31.5 -32.5; 93% yield). The intervention was effective in three domains: 1. implementation (clinical follow-up intervals, frequency of drug refills, routine repeat blood pressure measurement when the first reading is off-target, and a straightforward course of action). 2. treatment (grouping all medications in a single daily intake and using a combination of two antihypertensive medications for all patients in the first treatment step upon the initial diagnosis of hypertension) and 3. management of cardiovascular risk (lower BP thresholds and targets based on CVD risk level, and the use of aspirin and statins in high-risk patients).

Conclusion

This study confirms that this intervention was feasible, acceptable, and instrumental in achieving progress in all countries and all three domains of improvement: implementation, blood pressure treatment, and cardiovascular risk management. It also highlights the challenges that prevent a more rapid expansion of HEARTS in the Americas and confirms that the main barriers are in the organization of health services: drug titration by non-physician health workers, the lack of long-acting antihypertensive medications, lack of availability of fixed-doses combination in a single pill and cannot use high-intensity statins in patients with established cardiovascular diseases. Adopting and implementing the HEARTS Clinical Pathway can improve the efficiency and effectiveness of hypertension and cardiovascular disease risk management programs.

[Integrating hypertension and diabetes management in primary health care settings: HEARTS as a toolIntegrando o manejo da hipertensão e do diabetes na atenção primária à saúde: uso do HEARTS como instrumento]

Hypertension and diabetes are modifiable cardiovascular disease (CVD) risk factors that contribute to nearly one-third of all deaths in the Americas Region each year (2.3 million deaths). Despite advances in the detection and clinical management of hypertension and diabetes, there are substantial gaps in their implementation globally and in the Region. The considerable overlap in risk factors, prognosis, and treatment of hypertension and diabetes creates a unique opportunity for a unified implementation model for management at the population level. This report highlights one such high-profile effort, the Pan American Health Organization's "HEARTS in the Americas" program, based on the World Health Organization's HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care. The HEARTS program aims to improve the implementation of preventive CVD care in primary health systems using six evidence-based, pragmatic components: Healthy-lifestyle counseling, Evidence-based protocols, Access to essential medicines and technology, Risk-based CVD management, Team-based care, and Systems for monitoring. To date, HEARTS implementation projects have focused primarily on hypertension given that it is the leading modifiable CVD risk factor and can be treated cost-effectively. The objective of this report is to describe opportunities for integration of diabetes clinical care and policy within the HEARTS hypertension framework. A substantial global burden of disease could be averted with integrated primary care management of these conditions. Thus, there is an urgency in applying lessons from HEARTS to close these implementation gaps and improve the integrated detection, treatment, and control of diabetes and hypertension.

HEARTS en las Américas: innovaciones para mejorar el manejo de la hipertensión y del riesgo cardiovascular en la atención primaria

La Iniciativa Mundial HEARTS. es la iniciativa emblemática de la Organización Mundial de la Salud para reducir la carga de las enfermedades cardiovasculares, la principal causa de muerte y discapacidad en todo el mundo. La Iniciativa HEARTS en las Américas es la adaptación regional que propone usar HEARTS como modelo para el manejo del riesgo de enfermedades cardiovasculares, incluida la hipertensión, y la diabetes en la atención primaria de salud en la Región de las Américas para el año 2025. Esta iniciativa está iniciando su sexto año de aplicación y ya incluye a 22 países y 1 380 centros de atención primaria de salud. Este informe tiene tres objetivos. En primer lugar, describir cómo surgió la Iniciativa HEARTS en las Américas y cuáles son sus principales elementos. En segundo lugar, resumir las principales innovaciones logradas para catalizar la iniciativa y mantener su aplicación. Entre estas innovaciones se encuentran: a) la introducción de factores impulsores del control de la hipertensión; b) el desarrollo de una vía clínica integral y práctica; c) la elaboración de una estrategia para mejorar la precisión de la medición de la presión arterial; d) la creación de un marco de seguimiento y evaluación; y e) la elaboración de un conjunto estandarizado de recursos de capacitación y formación. En tercer lugar, en este informe se examinan las futuras prioridades de la iniciativa. El objetivo de poner en marcha estas soluciones innovadoras y pragmáticas es crear un sistema de salud más efectivo y trasladar el enfoque de los programas cardiovasculares y de hipertensión del nivel de atención altamente especializada a la atención primaria de salud. Además, HEARTS en las Américas puede servir como modelo para unas prácticas más integrales, efectivas y sostenibles en la prevención y el tratamiento de las enfermedades no transmisibles.

Developing population-based hypertension control programs

Hypertension remains the leading cause of cardiovascular disease globally despite the availability of safe and effective treatments. Unfortunately, many barriers exist to controlling hypertension, including a lack of effective screening and awareness, an inability to access treatment and challenges with its management when it is treated. Addressing these barriers is complex and requires engaging in a systematic and sustained approach across communities over time. This analysis aims to describe the key elements needed to create an effective delivery system for hypertension control. A successful system requires political will and supportive leadership at all levels of an organization, including at the point of care delivery (office or clinic), in the health care system, and at regional, state and national levels. Effective screening and outreach systems are necessary to identify individuals not previously diagnosed with hypertension, and a system for follow up and tracking is needed after people are diagnosed. Implementing simple protocols for treating hypertension can reduce confusion among providers and increase treatment efficiency. Ensuring easy access to safe, effective and affordable medications can increase blood pressure control and potentially decrease health care system costs. Task-sharing among members of the health care team can expand the services that are delivered. Finally, monitoring of and reporting on the performance of the health care team are needed to learn from those who are doing well, disseminate ideas to those in need of improvement and identify individual patients who need outreach or additional care. Successful large-scale hypertension programs in different settings share many of these key elements and serve as examples to improve systems of hypertension care delivery throughout the world.

Integrating hypertension and diabetes management in primary health care settings: HEARTS as a tool

Hypertension and diabetes are modifiable cardiovascular disease (CVD) risk factors that contribute to nearly one-third of all deaths in the Americas Region each year (2.3 million deaths). Despite advances in the detection and clinical management of hypertension and diabetes, there are substantial gaps in their implementation globally and in the Region. The considerable overlap in risk factors, prognosis, and treatment of hypertension and diabetes creates a unique opportunity for a unified implementation model for management at the population level. This report highlights one such high-profile effort, the Pan American Health Organization's "HEARTS in the Americas" program, based on the World Health Organization's HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care. The HEARTS program aims to improve the implementation of preventive CVD care in primary health systems using six evidence-based, pragmatic components: Healthy-lifestyle counseling, Evidence-based protocols, Access to essential medicines and technology, Risk-based CVD management, Team-based care, and Systems for monitoring. To date, HEARTS implementation projects have focused primarily on hypertension given that it is the leading modifiable CVD risk factor and can be treated cost-effectively. The objective of this report is to describe opportunities for integration of diabetes clinical care and policy within the HEARTS hypertension framework. A substantial global burden of disease could be averted with integrated primary care management of these conditions. Thus, there is an urgency in applying lessons from HEARTS to close these implementation gaps and improve the integrated detection, treatment, and control of diabetes and hypertension.

HEARTS in the Americas: innovations for improving hypertension and cardiovascular disease risk management in primary care

Global Hearts is the flagship initiative of the World Health Organization to reduce the burden of cardiovascular diseases, the leading cause of death and disability worldwide. HEARTS in the Americas Initiative is the regional adaptation that envisions HEARTS as the model for cardiovascular disease risk management, including hypertension and diabetes, in primary health care in the Americas by 2025. This initiative is entering its sixth year of implementation and now includes 22 countries and 1 380 primary health care centers. The objectives of this report are three-fold. First, it describes the emergence and the main elements of HEARTS in the Americas. Secondly, it summarizes the main innovations developed to catalyze and sustain implementation of the initiative. These innovations include: a) introduction of hypertension control drivers; b) development of a comprehensive and practical clinical pathway; c) development of a strategy to improve the accuracy of blood pressure measurement; d) creation of a monitoring and evaluation platform; and e) development of a standardized set of training and education resources. Thirdly, this report discusses future priorities of the initiative. The goal of implementing these innovative and pragmatic solutions is to create a more effective health system and shift the focus of cardiovascular and hypertension programs from the highly specialized care level to primary health care. In addition, HEARTS in the Americas can serve as a model for more comprehensive, effective, and sustainable noncommunicable disease prevention and treatment practices.

Alpha-Calcitonin Gene Related Peptide: New Therapeutic Strategies for the Treatment and Prevention of Cardiovascular Disease and Migraine

Alpha-calcitonin gene-related peptide (α-CGRP) is a vasodilator neuropeptide of the calcitonin gene family. Pharmacological and gene knock-out studies have established a significant role of α-CGRP in normal and pathophysiological states, particularly in cardiovascular disease and migraines. α-CGRP knock-out mice with transverse aortic constriction (TAC)-induced pressure-overload heart failure have higher mortality rates and exhibit higher levels of cardiac fibrosis, inflammation, oxidative stress, and cell death compared to the wild-type TAC-mice. However, administration of α-CGRP, either in its native- or modified-form, improves cardiac function at the pathophysiological level, and significantly protects the heart from the adverse effects of heart failure and hypertension. Similar cardioprotective effects of the peptide were demonstrated in pressure-overload heart failure mice when α-CGRP was delivered using an alginate microcapsules-based drug delivery system. In contrast to cardiovascular disease, an elevated level of α-CGRP causes migraine-related headaches, thus the use of α-CGRP antagonists that block the interaction of the peptide to its receptor are beneficial in reducing chronic and episodic migraine headaches. Currently, several α-CGRP antagonists are being used as migraine treatments or in clinical trials for migraine pain management. Overall, agonists and antagonists of α-CGRP are clinically relevant to treat and prevent cardiovascular disease and migraine pain, respectively. This review focuses on the pharmacological and therapeutic significance of α-CGRP-agonists and -antagonists in various diseases, particularly in cardiac diseases and migraine pain.

Abstract P106: Development Of An Oral Drug Delivery System For The Cardio-protective Neuropeptide Alpha-calcitonin Gene Related Peptide

Alpha-calcitonin gene related peptide (α-CGRP) is a promising neuropeptide for the treatment of cardiovascular disease. We have developed an alginate biomaterial-based delivery system which increases the peptide’s bioavailability and have shown that subcutaneous delivery of alginate-CGRP microcapsules significantly improved cardiac function in pressure overload-induced heart failure in mice. The goal of this study is to develop efficient alginate microcapsule formulations for oral delivery of α-CGRP. An electrospray method was used to prepare four different formulations of alginate-CGRP microcapsules all of 200 μm diameter- i)- alginate-CGRP microcapsules, ii)- alginate-CGRP microcapsules with UV-light exposure, iii)- poly-L-ornithine (PLO) coated alginate-CGRP microcapsules, and iv)- PLO alginate-CGRP microcapsules with UV-light exposure. The stability of the microcapsules in the digestive tract was evaluated in deionized water, simulated gastric fluid (SGF; pH 1.2), and simulated intestinal fluid (SIF; pH 6.8). Over time, the size of all four microcapsule formulations remained almost unchanged in SGF, however all four of the microcapsule formulations swelled in presence of SIF. Compared to deionized water, the size of alginate-CGRP microcapsules after 6 h incubation in SIF increased by 1.7 fold. Since all four formulations yielded similar results, we chose to further study the alginate-CGRP microcapsules in vivo . To determine the bioactive nature of the released peptide, alginate microcapsules containing α-CGRP in doses of 1, 3, and 10 (mg/kg b.wt) were fed to male C57BL/6 mice via oral gavage. Systolic blood pressure (SBP) was subsequently measured by a tail-cuff method. α-CGRP microcapsules reduced SBP in a time-dependent manner. Alginate-CGRP at 1 and 3 mg/kg lowered the SBP by 25 mmHg for up to 4 h and 48 h, respectively. However, 10 mg/kg alginate-CGRP initially reduced SBP to undetectable levels which ultimately returned to baseline level by day 7. These studies indicate that alginate microcapsules can withstand the low pH of the stomach and the release of the peptide is bioactive in vivo . Thus, alginate microcapsules may provide an ideal formulation to deliver α-CGRP orally for the long-term treatment of cardiac diseases.

Mapping stages, barriers and facilitators to the implementation of HEARTS in the Americas initiative in 12 countries: A qualitative study

The World Health Organization (WHO) Global Hearts Initiative offers technical packages to reduce the burden of cardiovascular diseases through population-wide and targeted health services interventions. The Pan American Health Organization (PAHO) has led implementation of the HEARTS in the Americas Initiative since 2016. The authors mapped the developmental stages, barriers, and facilitators to implementation among the 371 primary health care centers in the participating 12 countries. The authors used the qualitative method of document review to examine cumulative country reports, technical meeting notes, and reports to regional stakeholders. Common implementation barriers include segmentation of health systems, overcoming health care professionals' scope of practice legal restrictions, and lack of health information systems limiting operational evaluation and quality improvement mechanisms. Main implementation facilitators include political support from ministries of health and leading scientific societies, PAHO's role as a regional catalyst to implementation, stakeholder endorsement demonstrated by incorporating HEARTS into official documents, and having a health system oriented to primary health care. Key lessons include the need for political commitment and cultivating on-the-ground leadership to initiate a shift in hypertension care delivery, accompanied by specific progress in the development of standardized treatment protocols and a set of high-quality medicines. By systematizing an implementation strategy to ease integration of interventions into delivery processes, the program strengthened technical leadership and ensured sustainability. These study findings will aid the regional approach by providing a staged planning model that incorporates lessons learned. A systematic approach to implementation will enhance equity, efficiency, scale-up, and sustainability, and ultimately improve population hypertension control.

A Novel Alginate-Based Delivery System for the Prevention and Treatment of Pressure-Overload Induced Heart Failure

Background: α-CGRP (alpha-calcitonin gene related peptide) is a cardioprotective neuropeptide. Our recent study demonstrated that the administration of native α-CGRP, using osmotic mini-pumps, protected against transverse aortic constriction (TAC) pressure-induced heart failure in mice. However, the short half-life of peptides and the non-applicability of osmotic pumps in humans limits the use of α-CGRP as a therapeutic agent for heart failure (HF). Here, we sought to comprehensively study a novel α-CGRP delivery system using alginate microcapsules to determine its bioavailability in vivo and to test for cardioprotective effects in HF mice.

Methods: Native α-CGRP filled alginate microcapsules (200 µm diameter) were prepared using an electrospray method. The prepared alginate-α-CGRP microcapsules were incubated with rat cardiac H9c2 cells, mouse cardiac HL-1 cells, and human umbilical vein endothelial cells (HUVECs), and the cytotoxicity of the alginate-α-CGRP microcapsules was measured by a trypan-blue cell viability assay and a calcium dye fluorescent based assay. The efficacy of the alginate-α-CGRP microcapsules was tested in a TAC-pressure overload mouse model of heart failure. Male C57BL6 mice were divided into four groups: sham, sham-alginate-α-CGRP, TAC-only, and TAC-alginate-α-CGRP, and the TAC procedure was performed in the TAC-only and TAC-alginate-α-CGRP groups of mice to induce pressure-overload heart failure. After 2 or 15 days post-TAC, alginate-α-CGRP microcapsules (containing an α-CGRP dose of 6 mg/kg/mouse) were administered subcutaneously on alternate days, for 28 days, and echocardiography was performed weekly. After 28 days of peptide delivery, the mice were sacrificed and their hearts were collected for histological and biochemical analyses.

Results: Our in vitro cell culture assays showed that alginate-α-CGRP microcapsules did not affect the viability of the cell lines tested. The alginate-α-CGRP microcapsules released their peptides for an extended period of time. Our echocardiography, biochemical, and histology data from HF mice demonstrated that the administration of alginate-α-CGRP microcapsules significantly improved all cardiac parameters examined in TAC-mice. When compared to sham mice, TAC significantly decreased cardiac functions (as determined by fraction shortening and ejection fraction) and markedly increased heart and lung weight, left ventricle (LV) cardiac cell size, cardiac apoptosis, and oxidative stress. In contrast, the administration of alginate-α-CGRP microcapsules significantly attenuated the increased heart and lung weight, LV cardiac cell size, apoptosis, and oxidative stress in TAC mice.

Conclusion: Our results demonstrate that the encapsulation of α-CGRP in an alginate polymer is an effective strategy to improve peptide bioavailability in plasma and increase the duration of the therapeutic effect of the peptide throughout the treatment period. Furthermore, alginate mediates α-CGRP delivery, either prior to the onset or after the initiation of the symptom progression of pressure-overload, improves cardiac function, and protects hearts against pressure-induced HF.

Implementation of a Vertically Integrated Trainee Program (VITP): Progress and Lessons Learned

Mentorship is vital in the effective progression of a physician's educational training. This journey often begins during a physician's undergraduate career prior to advancing on to medical school, residency, and fellowship training. These levels of training distinguish different tiers of mastery, and collaboration among these tiers is integral in order to facilitate a meaningful transition into an independent physician.

Standardized treatment to improve hypertension control in primary health care: The HEARTS in the Americas Initiative

Hypertension is the leading risk factor for cardiovascular disease (CVD) worldwide. Despite the availability of effective antihypertensive medications, the control of hypertension at a global level is dismal, and consequently, the CVD burden continues to increase. In response, countries in Latin America and the Caribbean are implementing the HEARTS in the Americas, a community-based program that focuses on increasing hypertension control and CVD secondary prevention through risk factor mitigation. One key pillar is the implementation of a standardized hypertension treatment protocol supported by a small, high-quality formulary. This manuscript describes the methodology used by the HEARTS in the Americas program to implement a population-based standardized hypertension treatment protocol. It is rooted in a seamless transition from existing treatment practices to best practice using pharmacologic protocols built around a core set of ideal antihypertensive medications. In alignment with recent major hypertension guidelines, the HEARTS in the Americas protocols call for the rapid control of blood pressure, through the use of two antihypertensive medications, preferably in the form of a single pill, fixed-dose combination, in the initial treatment of hypertension. To date, the HEARTS in the Americas program has seen the improvement in antihypertensive medication formularies and the establishment of pharmacologic treatment protocols tailored to individual participating countries. This has translated to significant increases in hypertension control rates post-program implementation in these jurisdictions. Thus, the HEARTS in the Americas program could serve as a model, for not only the Americas Region but globally, and ultimately decrease the burden of CVD.

Approaches to the Management of Hypertension in Resource-Limited Settings: Strategies to Overcome the Hypertension Crisis in the Post-COVID Era

The COVID-19 pandemic has changed most aspects of everyday life in both the non-medical and medical settings. In the medical world, the pandemic has altered how healthcare is delivered and has necessitated an aggressive and new coordinated public health approach to limit its spread and reduce its disease burden and socioeconomic impact. This pandemic has resulted in a staggering morbidity and mortality and massive economic and physical hardships. Meanwhile, non-communicable diseases such as hypertension, diabetes mellitus, and cardiovascular disease in general continue to cause significant disease burden globally in the background. Though presently receiving less attention in the public eye than the COVID-19 pandemic, the hypertension crisis cannot be separated from the minds of healthcare providers, policymakers and the general public, as it continues to wreak havoc, particularly in vulnerable populations in resource limited settings. On this background, many of the strategies being employed to combat the COVID-19 pandemic can be used to re-energize and galvanize the fight against hypertension and hopefully bring the public health crisis associated with uncontrolled hypertension to an end.

Abstract P102: Generation Of A Novel Peptoid-peptide Analog Of Alpha-calcitonin Gene Related Peptide (α-CGRP) For The Treatment And Prevention Of Cardiovascular Diseases

Alpha-calcitonin gene related peptide (α-CGRP) is a 37-amino acid cardioprotective neuropeptide. Studies carried out in our laboratory and others establish α-CGRP as a potential therapeutic agent against a variety of cardiovascular diseases. However, the short half-life of α-CGRP limits its use in any long-term treatment regime. The goal of the present study is to develop an α-CGRP agonist analog with extended bioavailability using peptoid chemistry. A peptoid is a N -substituted glycine peptidomimetic molecule and is identical to α-amino acid except that the side chain in a peptoid is attached on the nitrogen rather than the α-carbon atom. Inclusion of a peptoid makes the native peptide protease-resistant and thus biostable in vivo . Using a solid-phase submonomer method, we synthesized a novel human α-CGRP analog containing two monomers of N -methoxyethylglycine (NMEG) peptoid at the N-terminus. Electrospray mass spectrometry (MALDI-TOF) analysis showed that the molecular mass of synthesized peptoid-peptide hybrid, NMEG-α-CGRP, was 4044 that is ~6.7% more than native peptide. An in vitro trypan blue cell exclusion assay demonstrated that incubation of NMEG-α-CGRP (5 μM) for 7 days did not affect the viability of rat H9C2 and mouse HL-1 cardiac cells. To evaluate the biological activity of NMEG-α-CGRP, a subcutaneous injection of human α-CGRP (10 μg/mice) and NMEG-α-CGRP (1, 3, 10, and 30 μg/mice) were given in 9-week-old C57BL6 mice (n=2 mice/dose), and blood pressure (BP) was measured using a tail-cuff method. A dose response curve showed that NMEG-α-CGRP decreased BP in mice in a time-dependent manner. Beginning with and injection of 3 μg of NMEG-α-CGRP, a dip in BP (85 ± 1 mmHg; in ±SD) was observed at 10 min after injection, and BP returned to baseline (125 mmHg) by 6 h, 18 h, and 24 h when injected with 3, 10, and 30 μg doses, respectively. Moreover, 10 μg of human-α-CGRP and NMEG-α-CGRP lowered BP from baseline for 2 h and 18 h, respectively, suggesting that NMEG addition increased stability, and thus bioavailability, of α-CGRP in vivo . In summary, our results show that a NMEG based α-CGRP modification is an effective approach to increase stability and, thus, bioavailability of α-CGRP in vivo making α-CGRP a viable therapeutic drug to treat cardiovascular diseases.

Alpha-calcitonin gene-related peptide prevents pressure-overload induced heart failure: role of apoptosis and oxidative stress

Alpha-calcitonin gene-related peptide (α-CGRP) is a 37-amino acid neuropeptide that plays an important protective role in modulating cardiovascular diseases. Deletion of the α-CGRP gene increases the vulnerability of the heart to pressure-induced heart failure and the administration of a modified α-CGRP agonist decreases this vulnerability. Systemic administration of α-CGRP decreases blood pressure in normotensive and hypertensive animals and humans. Here we examined the protective effect of long-term administration of native α-CGRP against pressure-overload heart failure and the likely mechanism(s) of its action. Transverse aortic constriction (TAC) was performed to induce pressure-overload heart failure in mice. We found that TAC significantly decreased left ventricular (LV) fractional shortening, ejection fraction, and α-CGRP content, and increased hypertrophy, dilation, and fibrosis compared to sham mice. Administration of α-CGRP-filled mini-osmotic pumps (4 mg/kg bwt/day) in TAC mice preserved cardiac function and LV α-CGRP levels, and reduced LV hypertrophy, dilation, and fibrosis to levels comparable to sham mice. Additionally, TAC pressure-overload significantly increased LV apoptosis and oxidative stress compared to the sham mice but these increases were prevented by α-CGRP administration. α-CGRP administration in TAC animals decreased LV AMPK phosphorylation levels and the expression of sirt1, both of which are regulatory markers of oxidative stress and energy metabolism. These results demonstrate that native α-CGRP is protective against pressure-overload induced heart failure. The mechanism of this cardio-protection is likely through the prevention of apoptosis and oxidative stress, possibly mediated by sirt1 and AMPK. Thus, α-CGRP is a potential therapeutic agent in preventing the progression to heart failure, and the cardio-protective action of α-CGRP is likely the result of a direct cellular effect; however, a partial vasodilatory blood pressure-dependent mechanism of α-CGRP cannot be excluded.

Implementation of a community-based hypertension control program in Matanzas, Cuba

Increased blood pressure is a leading risk factor for death worldwide, and improving the control of hypertension is a major health goal to reduce non-communicable disease. Thus, in 2016, as part of a regional effort between the Pan American Health Organization and Cuban Ministry of Public Health to reduce cardiovascular risk and disease, a community demonstration project was implemented to enhance hypertension control. The intervention project was in a population of 25 868 people served by the Carlos Verdugo Martínez Polyclinic in Matanzas, Cuba. The project implemented interventions currently recommended in the World Health Organization HEARTS modules, including a standardized clinical training program with certification for blood pressure measurement, routine screening for hypertension in clinics and in the community, a simple directive pharmacologic treatment algorithm, and a registry with performance reporting and feedback. Qualitative and quantitative program monitoring and evaluation was established. In a 2010 national survey, the prevalence of hypertension and the rate of hypertension control were estimated to be 31% and 36%, respectively. Following less than one year of the full implementation of the program, the prevalence of hypertension, proportion of the hypertensive population registered as having hypertension, proportion of those drug-treated who were controlled, and estimated population rate of control were 30%, 90%, 68%, and 58%, respectively. Based on these positive results, the program has been expanded to include another demonstration program initiated in a second region. In addition, preliminary efforts to disseminate and scale-up aspects of the program to the full Cuban population have started.

Protective Role of α-Calcitonin Gene-Related Peptide in Cardiovascular Diseases

α-Calcitonin gene-related peptide (α-CGRP) is a regulatory neuropeptide of 37 amino acids. It is widely distributed in the central and peripheral nervous system, predominantly in cell bodies of the dorsal root ganglion (DRG). It is the most potent vasodilator known to date and has inotropic and chronotropic effects. Using pharmacological and genetic approaches, our laboratory and other research groups established the protective role of α-CGRP in various cardiovascular diseases such as heart failure, experimental hypertension, myocardial infarction, and myocardial ischemia/reperfusion injury (I/R injury). α-CGRP acts as a depressor to attenuate the rise in blood pressure in three different models of experimental hypertension: (1) DOC-salt, (2) subtotal nephrectomy-salt, and (3) L-NAME-induced hypertension during pregnancy. Subcutaneous administration of α-CGRP lowers the blood pressure in hypertensive and normotensive humans and rodents. Recent studies also demonstrated that an α-CGRP analog, acylated α-CGRP, with extended half-life (~7 h) reduces blood pressure in Ang-II-induced hypertensive mouse, and protects against abdominal aortic constriction (AAC)-induced heart failure. Together, these studies suggest that α-CGRP, native or a modified form, may be a potential therapeutic agent to treat patients suffering from cardiac diseases.

Abstract 007: Exogenous Delivery of Alpha-Calcitonin Gene Related Peptide Inhibits Apoptosis and Oxidative Stress and Protects Against Pressure-Induced Congestive Heart Failure

Congestive heart failure (CHF) is the leading cause of mortality in men and women world-wide, despite multiple but limited treatment modalities. Our laboratory and others have established that α-calcitonin gene-related peptide (αCGRP) plays a significant protective role in several cardiovascular diseases. αCGRP is a 37-amino acid neuropeptide and potent vasodilator. In αCGRP-knockout mice, pressure overload significantly exacerbates cardiac hypertrophy, dysfunction and fibrosis. The present study was performed to determine if exogenous delivery of native αCGRP was cardio-protective against pressure overload-induced CHF. Transverse aortic constriction (TAC) was performed to induce pressure overload CHF in nine week old C57/BL6 mice. One group were sham-treated, one TAC alone, and one TAC plus αCGRP (4 mg/kg bwt/day) via an implanted mini-osmotic pump. All mice had serial echocardiography performed and were sacrificed and hearts collected after 28 days. ELISA data showed that αCGRP levels in the TAC left ventricle (LV) were significantly lower compared to sham LV, while αCGRP in the TAC-CGRP LVs was similar to sham levels. TAC alone significantly decreased fractional shortening (FS) and ejection fraction (EF), and increased cardiac hypertrophy, apoptosis, and fibrosis in the LV compared to sham mice. αCGRP in the TAC mice significantly preserved LV FS and EF, (FS ±SEM: sham 46.2±1.8%, TAC 25.4±1.1%, and TAC-CGRP 36.6±1.2%; EF ±SEM: sham 78±1.9%, TAC 51.3±1.5%, and TAC-CGRP 67.4±1.5%) and attenuated apoptosis (measured by cleaved caspase-3 and TUNEL staining), fibrosis, and oxidative stress (measured by lipid peroxidation, glutathione, and 8-OHdG levels) compared to TAC alone. Moreover, TAC increased the expression of sirtuin proteins (Sirt1, 2, 3, 5, and 7) and phosphorylation of AMPK, both of which are involved in oxidative stress and energy metabolism. This increase in Sirt-1 and -2 protein level was significantly attenuated by αCGRP. In addition, αCGRP markedly reduced phospho-AMPK level in the TAC LV back to control levels. Our results show that αCGRP protects against pressure-induced CHF which may be mediated by the inhibition of myocyte apoptosis and reduction in oxidative stress. Thus, αCGRP is an exciting therapeutic agent in CHF.

Monitoring and evaluation framework for hypertension programs. A collaboration between the Pan American Health Organization and World Hypertension League

The Pan American Health Organization (PAHO)-World Hypertension League (WHL) Hypertension Monitoring and Evaluation Framework is summarized. Standardized indicators are provided for monitoring and evaluating national or subnational hypertension control programs. Five core indicators from the World Health Organization hearts initiative and a single PAHO-WHL core indicator are recommended to be used in all hypertension control programs. In addition, hypertension control programs are encouraged to select from 14 optional qualitative and 33 quantitative indicators to facilitate progress towards enhanced hypertension control. The intention is for hypertension programs to select quantitative indicators based on the current surveillance mechanisms that are available and what is feasible and to use the framework process indicators as a guide to program management. Programs may wish to increase or refine the number of indicators they use over time. With adaption the indicators can also be implemented at a community or clinic level. The standardized indicators are being pilot tested in Cuba, Colombia, Chile, and Barbados.

Controlling hypertension and reducing its associated morbidity and mortality in the Caribbean: implications of race and ethnicity

Cardiovascular diseases and stroke, especially hypertension, represent a significant global disease burden for both morbidity and mortality, with a disproportionately higher impact in vulnerable low- to middle-income countries. International initiatives such as the Centers for Disease and Prevention and the Pan American Health Organization Standardized Hypertension Treatment Project have been developed to address this burden on the Caribbean and Latin America populations. The disparity in disease burden observed in low- to middle-income countries is explained, in part, by differences in disease risks for different racial and ethnic groups with high blood pressure more prevalent and hypertension-related morbidity significantly higher in men and women of African heritage. In addition to the race and ethnic differences in indicators of socioeconomic status, access to care and health service delivery, the physiologic mechanism of high blood pressure including salt-sensitivity, may also play a significant role in the disparities in hypertension and hypertension-related outcomes. This article focuses on potential racial and ethnic differences in influences on the pathophysiology of hypertension in the Caribbean region of the world. The identification of such differences may be used in the development of population hypertension control strategies and treatment approach that address the excess disease burden in these populations. The consideration of strategies, such as salt reduction and hypertension awareness and treatment, are particularly relevant to the high-risk Caribbean region.

Implementing standardized performance indicators to improve hypertension control at both the population and healthcare organization levels

The ability to reliably evaluate the impact of interventions and changes in hypertension prevalence and control is critical if the burden of hypertension-related disease is to be reduced. Previously, a World Hypertension League Expert Committee made recommendations to standardize the reporting of population blood pressure surveys. We have added to those recommendations and also provide modified recommendations from a Pan American Health Organization expert meeting for "performance indicators" to be used to evaluate clinical practices. Core indicators for population surveys are recommended to include: (1) mean systolic blood pressure and (2) mean diastolic blood pressure, and the prevalences of: (3) hypertension, (4) awareness of hypertension, (5) drug-treated hypertension, and (6) drug-treated and controlled hypertension. Core indicators for clinical registries are recommended to include: (1) the prevalence of diagnosed hypertension and (2) the ratio of diagnosed hypertension to that expected by population surveys, and the prevalences of: (3) controlled hypertension, (4) lack of blood pressure measurement within a year in people diagnosed with hypertension, and (5) missed visits by people with hypertension. Definitions and additional indicators are provided. Widespread adoption of standardized population and clinical hypertension performance indicators could represent a major step forward in the effort to control hypertension.

Abstract 2605: Metformin reduces growth of tumors generated from neuroblastoma stem cells in a xenograft mouse model; role of Cdc42 in mediating the effects

Neuroblastoma, the most common malignant childhood cancer of the postganglionic sympathetic nervous system, is derived from the neural crest cells. Despite the standard therapy, the mortality rate remains high in children with neuroblastoma. Growing evidence confirm that cancer stem cells are responsible for drug resistance, and disease relapse. Hence targeting of cancer stem cells is an effective strategy to cure cancer. In the present study we tested if anti-diabetic drug metformin (N’, N’-dimethylbiguanide) has anti-survival effects against neuroblastoma stem cells.

Using a panel of human neuroblastoma cell lines of different genetics- SH-SY5Y, SK-N-BE(2), IMR-32, NGP, and SK-N-F1 cells, we demonstrated that metformin dose-dependently reduced the protein expression of stem cell-specific transcription factors- sox2, oct4 and nanog. Neuroblastoma cells, in stem cell specific medium, formed compact and distinct spheroids which were enriched in stem cells. Addition of metformin (0.5 mM and onwards) significantly inhibited initiation of spheroids, and no spheroid formation was observed at 20 mM metformin. We further examined if metformin interfered with self-renewal and differentiation capacity of neuroblastoma stem cells. Our results demonstrated that metformin-treated primary spheroids lost their ability to form secondary spheroids in a metformin depleted medium (drug withdrawal experiment). However, addition of pharmacological inhibitor of Cdc42 (ML141) along with metformin increased the numbers of spheroids suggesting involvement of Cdc42 in spheroid formation. To further test the inhibitory effect of metformin on the tumorigenicity of neuroblastoma stem cells, we generated subcutaneous tumors by inoculating spheroids in athymic mice. Metformin (10, 30, and 100 mg/kg per mouse) was given daily by oral gavage, and tumor volume was measured. The size of tumors collected from mice fed with 30 and 100 mg/kg metformin was significantly reduced compared to tumors from metformin-untreated mice. In these tumors, metformin induced DNA fragmentation and apoptosis by activating caspase-3. The presence of cleaved caspase-3 signal in both sox2-expressing and sox2-nonexpressing cells indicated that metformin induced cell death in both normal tumor cells and tumor stem cells. These data validate the anti-survival activity of metformin against neuroblastoma stem cells.

The fact that metformin is non-toxic and already approved by FDA to treat type 2 diabetes in children suggest metformin is a novel therapeutic drug to treat neuroblastoma.

Citation Format: Ambrish Kumar, Donald J. DiPette, Ugra S. Singh. Metformin reduces growth of tumors generated from neuroblastoma stem cells in a xenograft mouse model; role of Cdc42 in mediating the effects. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2605.

Abstract A56: Metformin targets Rho GTPases to inhibit neuroblastoma cell growth; implications in the treatment of neuroblastoma

In recent years, oncologists are paying considerable attention to metformin (N', N'-dimethylbiguanide) in the treatment of various types of cancers, as some population-based studies have shown low cancer incidences and mortalities among diabetic-patients treated with metformin. In the present study, using neuroblastoma cells, we explored the anti-tumor activity and the underlying mechanisms of metformin. Neuroblastoma is a malignant cancer of the postganglionic sympathetic nervous system; it develops in the adrenal gland and metastasizes to liver, bone, bone marrow, lymph nodes, neck and chest. It is the most common cancer in infants younger than one and second most common tumors in children. In the United States of America, it accounts for 7% of all childhood cancers, and is responsible for 15% of all cancer deaths in children younger than 15 years. Various genetic and cytological alterations allow cells to develop drug resistance and help neuroblastoma tumors to escape most available therapies.

Using human neuroblastoma cells of different genotypes (SH-SY5Y, MYCN-nonamplified; and SK-N-BE(2), MYCN-amplified cells), we generated subcutaneous xenograft mice models, and metformin (50, 100 and 250 mg/kg body weight per mice) was given daily by oral gavage to tumor-bearing mice. Our in vivo results demonstrated that metformin (100 and 250 mg/kg body weight) significantly inhibited the growth of tumors in both mice models. Immunofluorescence and Western blot results indicated reduction in tumor growth was due to the increased DNA fragmentation and apoptotic cell death that occur via activation of caspase-3. Metformin also inhibited the initiation of spheroid formation in 3-D cultures (hanging drop assay). In xenograft tumors, metformin affected the phosphorylation of mitogen-activated protein kinases (MAPKs). Metformin induced the phosphorylation of JNK1/2 and inhibited the phosphorylation of ERK1/2 without affecting p38 MAP Kinase. Since ERK1/2 is involved in cell proliferation and JNK1/2 promotes cell death, our observations clearly indicated that MAP kinases are involved in metformin-induced cell death.

Rho-GTPases (RhoA, Rac1 and Cdc42), a family of small G-proteins, act as molecular switches to regulate cellular functions- cell division, motility and cell survival. These small G-proteins exist either as a GTP-bound active form or an inactive GDP-bound form. The aberrant expression and/or activity of Rho-GTPases are associated with the progression of various cancers. Our glutathione-S-transferase (GST)-pull down assays showed that metformin significantly increased activation of Rac1 (GTP-Rac1) and Cdc42 (GTP-Cdc42) while it decreased activation of RhoA (GTP-RhoA) in these tumors. Infection of neuroblastoma cells by adenoviruses expressing dominant negative Rac1, Cdc42 (Rac1-N17 and Cdc42-N17, respectively) and constitutively active RhoA (RhoA-V14), or incubation with pharmacological inhibitors of Rac1 (NSC23766) or Cdc42 (ML141) significantly protected cells from metformin-induced apoptosis. Additionally, inhibition of JNK activity with Rac1 or Cdc42 attenuated cytotoxic effects of metformin. These gain-in and loss-off function studies suggested that metformin impairs Rho-GTPase signaling to initiate apoptosis via JNK pathway.

Together, our results reported the inhibitory effects of metformin against neuroblastoma, and demonstrated the role of Rho-GTPases in metformin-mediated apoptotic cell death. The cytotoxic effects of metformin against MYCN-nonamplified and MYCN-amplified multidrug resistant neuroblastoma cells in our studies further signifies that metformin can be a promising drug candidate for neuroblastoma therapy.

Citation Format: Ambrish Kumar, Nadia Al-Sammarraie, Donald J. DiPette, Ugra S. Singh. Metformin targets Rho GTPases to inhibit neuroblastoma cell growth; implications in the treatment of neuroblastoma. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr A56.