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Kim DH, Tatsuoka C, Chen Z, Wright JT, Odden MC, Beddhu S, Bellows BK, Bress A, Carson T, Cushman WC, Johnson KC, Morisky DE, Punzi H, Tamariz L, Yang S, Wei LJ. Intensive Versus Standard Blood Pressure Lowering and Days Free of Cardiovascular Events and Serious Adverse Events: a Post Hoc Analysis of Systolic Blood Pressure Intervention Trial. J Gen Intern Med 2022; 37:3797-3804. [PMID: 35945470 PMCID: PMC9640478 DOI: 10.1007/s11606-022-07753-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 07/27/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Communication of the benefits and harms of blood pressure lowering strategy is crucial for shared decision-making. OBJECTIVES To quantify the effect of intensive versus standard systolic blood pressure lowering in terms of the number of event-free days DESIGN: Post hoc analysis of the Systolic Blood Pressure Intervention Trial PARTICIPANTS: A total of 9361 adults 50 years or older without diabetes or stroke who had a systolic blood pressure of 130-180 mmHg and elevated cardiovascular risk INTERVENTIONS: Intensive (systolic blood pressure goal <120 mmHg) versus standard blood pressure lowering (<140 mmHg) MAIN MEASURES: Days free of major adverse cardiovascular events (MACE), serious adverse events (SAE), and monitored adverse events (hypotension, syncope, bradycardia, electrolyte abnormalities, injurious falls, or acute kidney injury) over a median follow-up of 3.33 years KEY RESULTS: The intensive treatment group gained 14.7 more MACE-free days over 4 years (difference, 14.7 [95% confidence interval: 5.1, 24.4] days) than the standard treatment group. The benefit of the intensive treatment varied by cognitive function (normal: difference, 40.7 [13.0, 68.4] days; moderate-to-severe impairment: difference, -15.0 [-56.5, 26.4] days; p-for-interaction=0.009) and self-rated health (excellent: difference, -22.7 [-51.5, 6.1] days; poor: difference, 156.1 [31.1, 281.2] days; p-for-interaction=0.001). The mean overall SAE-free days were not significantly different between the treatments (difference, -14.8 [-35.3, 5.7] days). However, the intensive treatment group had 28.5 fewer monitored adverse event-free days than the standard treatment group (difference, -28.5 [-40.3, -16.7] days), with significant variations by frailty status (non-frail: difference, 38.8 [8.4, 69.2] days; frail: difference, -15.5 [-46.6, 15.7] days) and self-rated health (excellent: difference, -12.9 [-45.5, 19.7] days; poor: difference, 180.6 [72.9, 288.4] days; p-for-interaction <0.001). CONCLUSIONS Over 4 years, intensive systolic blood pressure lowering provides, on average, 14.7 more MACE-free days than standard treatment, without any difference in SAE-free days. Whether this time-based effect summary improves shared decision-making remains to be elucidated. TRIAL REGISTRATION ClinicalTrials.gov Registration: NCT01206062.
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Affiliation(s)
- Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA.
| | - Curtis Tatsuoka
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Zhengyi Chen
- Department of Population and Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH, USA
- Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Jackson T Wright
- Department of Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Michelle C Odden
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Srinivasan Beddhu
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | | | - Adam Bress
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Thaddeus Carson
- Department of Medicine, Medical College of Georgia, Augusta, GA, USA
| | - William C Cushman
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Karen C Johnson
- Department of Preventive Medicine, The University of Tennessee Health Science Center, Memphis, TN, USA
| | - Donald E Morisky
- Department of Community Health Sciences, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | | | - Leonardo Tamariz
- Division of Population Health and Computational Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Song Yang
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Lee-Jen Wei
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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2
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Upadhya B, Pajewski NM, Rocco MV, Hundley WG, Aurigemma G, Hamilton CA, Bates JT, He J, Chen J, Chonchol M, Glasser SP, Hung AM, Pisoni R, Punzi H, Supiano MA, Toto R, Taylor A, Kitzman DW. Effect of Intensive Blood Pressure Control on Aortic Stiffness in the SPRINT-HEART. Hypertension 2021; 77:1571-1580. [PMID: 33775127 DOI: 10.1161/hypertensionaha.120.16676] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
[Figure: see text].
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Affiliation(s)
- Bharathi Upadhya
- Cardiovascular Medicine Section (B.U., D.W.K.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Nicholas M Pajewski
- Department of Biostatistics and Data Science (N.M.P.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael V Rocco
- Nephrology Section, Department of Internal Medicine (M.V.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - W Gregory Hundley
- Pauley Heart Center Department of Internal Medicine at Virginia Commonwealth University Health Sciences Richmond (W.G.H.)
| | - Gerard Aurigemma
- Cardiovascular Medicine Section, University of Massachusetts Medical School, Worcester (G.A.)
| | - Craig A Hamilton
- Biomedical Engineering (C.A.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jeffrey T Bates
- Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX (J.T.B., A.T.)
| | - Jiang He
- Division of Nephrology & Hypertension, Tulane University School of Public Health and Tropical Medicine, Department of Medicine, Tulane University, New Orleans, LA (J.H., J.C.)
| | - Jing Chen
- Division of Nephrology & Hypertension, Tulane University School of Public Health and Tropical Medicine, Department of Medicine, Tulane University, New Orleans, LA (J.H., J.C.)
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora (M.C.)
| | - Steve P Glasser
- UAB School of Public Health, University of Alabama, Birmingham (S.P.G.)
| | - Adriana M Hung
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (A.M.H.)
| | - Roberto Pisoni
- Nephrology Section, Medical University of South Carolina, Ralph H. Johnson VA Medical Center, Charleston (R.P.)
| | - Henry Punzi
- Internal Medicine, Trinity Hypertension and Metabolic Research Institute, Punzi Medical Center, Carrollton, TX (H.P.)
| | - Mark A Supiano
- Geriatrics Division, VA Salt Lake City Geriatric Research, Education, and Clinical Center, University of Utah School of Medicine University of Utah School of Medicine, Salt Lake City (M.A.S.)
| | - Robert Toto
- Nephrology Section, University of Texas Southwestern Medical Center, Dallas (R.T.)
| | - Addison Taylor
- Department of Medicine, Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, TX (J.T.B., A.T.)
| | - Dalane W Kitzman
- Cardiovascular Medicine Section (B.U., D.W.K.), Wake Forest School of Medicine, Winston-Salem, NC
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3
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Beddhu S, Boucher RE, Sun J, Balu N, Chonchol M, Navaneethan S, Chertow GM, Townsend R, Haley W, Cheung AK, Conroy MB, Raj DS, Xu D, George T, Yunis R, Wei G, Canton G, Bates J, Chen J, Papademetriou V, Punzi H, Wiggers A, Wright JT, Greene T, Yuan C. Chronic kidney disease, atherosclerotic plaque characteristics on carotid magnetic resonance imaging, and cardiovascular outcomes. BMC Nephrol 2021; 22:69. [PMID: 33627066 PMCID: PMC7905597 DOI: 10.1186/s12882-021-02260-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 02/04/2021] [Indexed: 12/13/2022] Open
Abstract
Background It is unclear whether faster progression of atherosclerosis explains the higher risk of cardiovascular events in CKD. The objectives of this study were to 1. Characterize the associations of CKD with presence and morphology of atherosclerotic plaques on carotid magnetic resonance imaging (MRI) and 2. Examine the associations of baseline CKD and carotid atherosclerotic plaques with subsequent cardiovascular events. Methods In a subgroup (N = 465) of Systolic Blood Pressure Intervention Trial. (SPRINT) participants, we measured carotid plaque presence and morphology at baseline and after 30-months with MRI. We examined the associations of CKD (baseline eGFR < 60 ml/min/1.73m2) with progression of carotid plaques and the SPRINT cardiovascular endpoint. Results One hundred and ninety six (42%) participants had CKD. Baseline eGFR in the non-CKD and CKD subgroups were 77 ± 14 and 49 ± 8 ml/min/1.73 m2, respectively. Lipid rich necrotic-core plaque was present in 137 (29.5%) participants. In 323 participants with both baseline and follow-up MRI measurements of maximum wall thickness, CKD was not associated with progression of maximum wall thickness (OR 0.62, 95% CI 0.36 to 1.07, p = 0.082). In 96 participants with necrotic core plaque at baseline and with a valid follow-up MRI, CKD was associated with lower odds of progression of necrotic core plaque (OR 0.41, 95% CI 0.17 to 0.95, p = 0.039). There were 28 cardiovascular events over 1764 person-years of follow-up. In separate Cox models, necrotic core plaque (HR 2.59, 95% CI 1.15 to 5.85) but not plaque defined by maximum wall thickness or presence of a plaque component (HR 1.79, 95% CI 0.73 to 4.43) was associated with cardiovascular events. Independent of necrotic core plaque, CKD (HR 3.35, 95% CI 1.40 to 7.99) was associated with cardiovascular events. Conclusions Presence of necrotic core in carotid plaque rather than the presence of plaque per se was associated with increased risk of cardiovascular events. We did not find CKD to be associated with faster progression of necrotic core plaques, although both were independently associated with cardiovascular events. Thus, CKD may contribute to cardiovascular disease principally via mechanisms other than atherosclerosis such as arterial media calcification or stiffening. Trial Registration NCT01475747, registered on November 21, 2011. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02260-x.
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Affiliation(s)
- Srinivasan Beddhu
- Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, USA. .,Division of Nephrology & Hypertension, University of Utah School of Medicine, 85 North Medical Drive East, Room 201, Salt Lake City, UT, 84112, USA.
| | - Robert E Boucher
- Division of Nephrology & Hypertension, University of Utah School of Medicine, 85 North Medical Drive East, Room 201, Salt Lake City, UT, 84112, USA
| | - Jie Sun
- Department of Radiology, Vascular Imaging Lab, University of Washington, Seattle, WA, USA
| | - Niranjan Balu
- Department of Radiology, Vascular Imaging Lab, University of Washington, Seattle, WA, USA
| | - Michel Chonchol
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sankar Navaneethan
- Section of Nephrology, Baylor College of Medicine, Houston, TX, USA.,Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Glenn M Chertow
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Raymond Townsend
- Division of Nephrology, University of Pennsylvania, Philadelphia, PA, USA
| | - William Haley
- Division of Nephrology, Mayo Clinic, Jacksonville, FL, USA
| | - Alfred K Cheung
- Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, USA.,Division of Nephrology & Hypertension, University of Utah School of Medicine, 85 North Medical Drive East, Room 201, Salt Lake City, UT, 84112, USA
| | - Molly B Conroy
- Division of General Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Dominic S Raj
- Division of Nephrology, George Washington University, Washington, DC, USA
| | - Dongxiang Xu
- Department of Radiology, Vascular Imaging Lab, University of Washington, Seattle, WA, USA
| | - Thomas George
- Division of Nephrology, Cleveland Clinic, Cleveland, OH, USA
| | - Reem Yunis
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Guo Wei
- Division of Nephrology & Hypertension, University of Utah School of Medicine, 85 North Medical Drive East, Room 201, Salt Lake City, UT, 84112, USA
| | - Gador Canton
- Department of Radiology, Vascular Imaging Lab, University of Washington, Seattle, WA, USA
| | - Jeffrey Bates
- Medical Care Line, Michael E. DeBakey VA Medical Center, Houston, TX, USA.,Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jing Chen
- Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Henry Punzi
- Department of Medicine & Clinical Research, Punzi Medical Center, Carrollton, TX, USA
| | - Alan Wiggers
- Division of Nephrology and Hypertension, Case Western Reserve University, Cleveland, OH, USA
| | - Jackson T Wright
- Division of Nephrology and Hypertension, Case Western Reserve University, Cleveland, OH, USA
| | - Tom Greene
- Division of Biostatistics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Chun Yuan
- Department of Radiology, Vascular Imaging Lab, University of Washington, Seattle, WA, USA
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4
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Jovanovich A, Ginsberg C, You Z, Katz R, Ambrosius WT, Berlowitz D, Cheung AK, Cho M, Lee AK, Punzi H, Rehman S, Roumie C, Supiano MA, Wright CB, Shlipak M, Ix JH, Chonchol M. FGF23, Frailty, and Falls in SPRINT. J Am Geriatr Soc 2020; 69:467-473. [PMID: 33289072 DOI: 10.1111/jgs.16895] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND/OBJECTIVES Chronic kidney disease (CKD) is associated with frailty. Fibroblast growth factor 23 (FGF23) is elevated in CKD and associated with frailty among non-CKD older adults and individuals with human immunodeficiency virus. Whether FGF23 is associated with frailty and falls in CKD is unknown. DESIGN Cross-sectional and longitudinal observational study. SETTING Systolic Blood Pressure Intervention Trial (SPRINT), a randomized trial evaluating standard (systolic blood pressure [SBP] <140 mm Hg) versus intensive (SBP <120 mm Hg) blood pressure lowering on cardiovascular and cognitive outcomes among older adults without diabetes mellitus. PARTICIPANTS A total of 2,376 participants with CKD (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2 ). MEASUREMENTS The exposure variable was intact FGF23. We used multinomial logistic regression to determine the cross-sectional association of intact FGF23 with frailty and Cox proportional hazards analysis to determine the longitudinal association with incident falls. Models were adjusted for demographics, comorbidities, randomization group, antihypertensives, eGFR, mineral metabolism markers, and frailty. RESULTS After adjustment, the odds ratio for prevalent frailty versus non-frailty per twofold higher FGF23 was 1.34 (95% confidence interval [CI] = 1.01-1.77). FGF23 levels in the highest quartile versus the lowest quartile demonstrated more than a twofold increased fall risk (hazard ratio [HR] = 2.32; 95% CI = 1.26-4.26), and the HR per twofold higher FGF23 was 1.99 (95% CI = 1.48-2.68). CONCLUSION Among SPRINT participants with CKD, FGF23 was associated with prevalent frailty and falls.
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Affiliation(s)
- Anna Jovanovich
- VA Eastern Colorado Healthcare System, Aurora, Colorado.,University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Zhiying You
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Ronit Katz
- University of Washington, Seattle, Washington
| | | | | | - Alfred K Cheung
- University of Utah, Salt Lake City, Utah.,Salt Lake City VA Medical Center, Salt Lake City, Utah
| | - Monique Cho
- Salt Lake City VA Medical Center, Salt Lake City, Utah
| | - Alexandra K Lee
- University of California, San Francisco, San Francisco, California
| | | | - Shakaib Rehman
- Phoenix VA Healthcare System, Phoenix, Arizona.,University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | | | - Mark A Supiano
- University of Utah, Salt Lake City, Utah.,Salt Lake City VA Medical Center, Salt Lake City, Utah
| | - Clinton B Wright
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - Michael Shlipak
- University of California, San Francisco, San Francisco, California
| | - Joachim H Ix
- University of California San Diego, San Diego, California.,Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Michel Chonchol
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
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5
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Jotwani V, Garimella PS, Katz R, Malhotra R, Bates J, Cheung AK, Chonchol M, Drawz PE, Freedman BI, Haley WE, Killeen AA, Punzi H, Sarnak MJ, Segal MS, Shlipak MG, Ix JH. Tubular Biomarkers and Chronic Kidney Disease Progression in SPRINT Participants. Am J Nephrol 2020; 51:797-805. [PMID: 32906135 DOI: 10.1159/000509978] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/05/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Kidney tubular atrophy on biopsy is a strong predictor of chronic kidney disease (CKD) progression, but tubular health is poorly quantified by traditional measures including estimated glomerular filtration rate (eGFR) and albuminuria. We hypothesized that urinary biomarkers of impaired tubule function would be associated with faster eGFR declines in persons with CKD. METHODS We measured baseline urine concentrations of uromodulin, β2-microglobulin (β2m), and α1-microglobulin (α1m) among 2,428 participants of the Systolic Blood Pressure Intervention Trial with an eGFR <60 mL/min/1.73 m2. We used linear mixed models to evaluate biomarker associations with annualized relative change in eGFR, stratified by randomization arm. RESULTS At baseline, the mean age was 73 ± 9 years and eGFR was 46 ± 11 mL/min/1.73 m2. In the standard blood pressure treatment arm, each 2-fold higher urinary uromodulin was associated with slower % annual eGFR decline (0.34 [95% CI: 0.08, 0.60]), whereas higher urinary β2m was associated with faster % annual eGFR decline (-0.10 [95% CI: -0.18, -0.02]) in multivariable-adjusted models including baseline eGFR and albuminuria. Associations were weaker and did not reach statistical significance in the intensive blood pressure treatment arm for either uromodulin (0.11 [-0.13, 0.35], p value for interaction by treatment arm = 0.045) or β2m (-0.01 [-0.08, 0.08], p value for interaction = 0.001). Urinary α1m was not independently associated with eGFR decline in the standard (0.01 [-0.22, 0.23]) or intensive (0.03 [-0.20, 0.25]) arm. CONCLUSIONS Among trial participants with hypertension and CKD, baseline measures of tubular function were associated with subsequent declines in kidney function, although these associations were diminished by intensive blood pressure control.
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Affiliation(s)
- Vasantha Jotwani
- Department of Medicine, San Francisco VA Medical Health Care System, San Francisco, California, USA,
- Kidney Health Research Collaborative, San Francisco VA Medical Center and University of California, San Francisco, California, USA,
| | - Pranav S Garimella
- Department of Medicine, University of California, San Diego, California, USA
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
| | - Ronit Katz
- Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Rakesh Malhotra
- Department of Medicine, University of California, San Diego, California, USA
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
| | - Jeffrey Bates
- Michael E. DeBakey VA Medical Center and Baylor College of Medicine, Houston, Texas, USA
| | - Alfred K Cheung
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Michel Chonchol
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Paul E Drawz
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Barry I Freedman
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - William E Haley
- Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Anthony A Killeen
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Henry Punzi
- Punzi Medical Center, Trinity Hypertension Research Institute, Carollton, Texas, USA
| | - Mark J Sarnak
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | - Mark S Segal
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Michael G Shlipak
- Department of Medicine, San Francisco VA Medical Health Care System, San Francisco, California, USA
- Kidney Health Research Collaborative, San Francisco VA Medical Center and University of California, San Francisco, California, USA
| | - Joachim H Ix
- Department of Medicine, University of California, San Diego, California, USA
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
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6
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Chang AR, Kramer H, Wei G, Boucher R, Grams ME, Berlowitz D, Bhatt U, Cohen DL, Drawz P, Punzi H, Freedman BI, Haley W, Hawfield A, Horwitz E, McLouth C, Morisky D, Papademetriou V, Rocco MV, Wall B, Weiner DE, Zias A, Beddhu S. Effects of Intensive Blood Pressure Control in Patients with and without Albuminuria: Post Hoc Analyses from SPRINT. Clin J Am Soc Nephrol 2020; 15:1121-1128. [PMID: 32669306 PMCID: PMC7409741 DOI: 10.2215/cjn.12371019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 06/12/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES It is unclear whether the presence of albuminuria modifies the effects of intensive systolic BP control on risk of eGFR decline, cardiovascular events, or mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Systolic Blood Pressure Intervention Trial randomized nondiabetic adults ≥50 years of age at high cardiovascular risk to a systolic BP target of <120 or <140 mm Hg, measured by automated office BP. We compared the absolute risk differences and hazard ratios of ≥40% eGFR decline, the Systolic Blood Pressure Intervention Trial primary cardiovascular composite outcome, and all-cause death in those with or without baseline albuminuria (urine albumin-creatinine ratio ≥30 mg/g). RESULTS Over a median follow-up of 3.1 years, 69 of 1723 (4%) participants with baseline albuminuria developed ≥40% eGFR decline compared with 61 of 7162 (1%) participants without albuminuria. Incidence rates of ≥40% eGFR decline were higher in participants with albuminuria (intensive, 1.74 per 100 person-years; standard, 1.17 per 100 person-years) than in participants without albuminuria (intensive, 0.48 per 100 person-years; standard, 0.11 per 100 person-years). Although effects of intensive BP lowering on ≥40% eGFR decline varied by albuminuria on the relative scale (hazard ratio, 1.48; 95% confidence interval, 0.91 to 2.39 for albumin-creatinine ratio ≥30 mg/g; hazard ratio, 4.55; 95% confidence interval, 2.37 to 8.75 for albumin-creatinine ratio <30 mg/g; P value for interaction <0.001), the absolute increase in ≥40% eGFR decline did not differ by baseline albuminuria (incidence difference, 0.38 events per 100 person-years for albumin-creatinine ratio ≥30 mg/g; incidence difference, 0.58 events per 100 person-years for albumin-creatinine ratio <30 mg/g; P value for interaction =0.60). Albuminuria did not significantly modify the beneficial effects of intensive systolic BP lowering on cardiovascular events or mortality evaluated on relative or absolute scales. CONCLUSIONS Albuminuria did not modify the absolute benefits and risks of intensive systolic BP lowering.
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Affiliation(s)
- Alex R Chang
- Kidney Health Research Institute, Department of Population Health Sciences, Geisinger Health System, Danville, Pennsylvania
| | - Holly Kramer
- Division of Nephrology, Loyola University Medical Center, Maywood, Illinois
| | - Guo Wei
- Division of Nephrology & Hypertension, University of Utah School of Medicine, Salt Lake City, Utah
| | - Robert Boucher
- Division of Nephrology & Hypertension, University of Utah School of Medicine, Salt Lake City, Utah
| | - Morgan E Grams
- Division of Nephrology, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Dan Berlowitz
- Department of Public Health, University of Massachusetts-Lowell, Lowell, Massachusetts
| | - Udayan Bhatt
- Division of Nephrology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Debbie L Cohen
- Renal Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul Drawz
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, Minnesota
| | - Henry Punzi
- Punzi Medical Center, Trinity Hypertension and Metabolic Research Institute, Carollton, Texas
| | - Barry I Freedman
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - William Haley
- Division of Nephrology, Mayo Clinic, Jacksonville, Florida
| | - Amret Hawfield
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Edward Horwitz
- Division of Nephrology, MetroHealth Medical Center, Cleveland, Ohio
| | - Christopher McLouth
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest Health Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Don Morisky
- Department of Community Health Sciences, University of California, Los Angeles Fielding School of Public Health, Los Angeles, California
| | - Vasilios Papademetriou
- Department of Cardiology, Veterans Affairs Medical Center, Georgetown University, Washington, DC
| | - Michael V Rocco
- Section on Nephrology, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Barry Wall
- Division of Nephrology, Veterans Affairs Medical Center, Memphis, Tennessee
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Athena Zias
- Stony Brook University School of Medicine, Stony Brook, New York
| | - Srinivasan Beddhu
- Division of Nephrology & Hypertension, University of Utah School of Medicine, Salt Lake City, Utah.,Medical Service, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
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7
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Ginsberg C, Katz R, Chonchol MB, Bullen AL, Raphael KL, Zhang WR, Ambrosius WT, Bates JT, Neyra JA, Killeen AA, Punzi H, Shlipak MG, Ix JH. The Effects of Intensive Blood Pressure Lowering on Markers of Mineral Metabolism in Persons with CKD in SPRINT. Clin J Am Soc Nephrol 2020; 15:852-854. [PMID: 32376678 PMCID: PMC7274286 DOI: 10.2215/cjn.01400220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Charles Ginsberg
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California .,Division of Nephrology-Hypertension, University of California, San Diego, California
| | - Ronit Katz
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Michel B Chonchol
- Division of Renal Diseases and Hypertension, University of Anschutz Medical Center, Aurora, Colorado
| | - Alexander L Bullen
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California.,Division of Nephrology-Hypertension, University of California, San Diego, California
| | - Kalani L Raphael
- Division of Nephrology and Hypertension, University of Utah Health, Salt Lake City, Utah
| | - William R Zhang
- Kidney Health Research Collaborative, Veterans Affairs Medical Center, San Francisco, California.,Department of Dermatology, University of California, San Francisco, California
| | - Walter T Ambrosius
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jeffrey T Bates
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas
| | - Javier A Neyra
- Division of Nephrology, Bone and Mineral Metabolism, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Anthony A Killeen
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | | | - Michael G Shlipak
- Kidney Health Research Collaborative, Veterans Affairs Medical Center, San Francisco, California.,Department of Medicine, University of California, San Francisco, California
| | - Joachim H Ix
- Nephrology Section, Veterans Affairs San Diego Healthcare System, San Diego, California.,Division of Nephrology-Hypertension, University of California, San Diego, California
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8
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Malhotra R, Katz R, Jotwani V, Ambrosius WT, Raphael KL, Haley W, Rastogi A, Cheung AK, Freedman BI, Punzi H, Rocco MV, Ix JH, Shlipak MG. Urine Markers of Kidney Tubule Cell Injury and Kidney Function Decline in SPRINT Trial Participants with CKD. Clin J Am Soc Nephrol 2020; 15:349-358. [PMID: 32111704 PMCID: PMC7057300 DOI: 10.2215/cjn.02780319] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 01/17/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES eGFR and albuminuria primarily reflect glomerular function and injury, whereas tubule cell atrophy and interstitial fibrosis on kidney biopsy are important risk markers for CKD progression. Kidney tubule injury markers have primarily been studied in hospitalized AKI. Here, we examined the association between urinary kidney tubule injury markers at baseline with subsequent loss of kidney function in persons with nondiabetic CKD who participated in the Systolic Blood Pressure Intervention Trial (SPRINT). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Among 2428 SPRINT participants with CKD (eGFR<60 ml/min per 1.73 m2) at baseline, we measured urine markers of tubule injury (IL-18, kidney injury molecule-1 [KIM-1], neutrophil gelatinase-associated lipocalin [NGAL]), inflammation (monocyte chemoattractant protein-1 [MCP-1]), and repair (human cartilage glycoprotein-40 [YKL-40]). Cox proportional hazards models evaluated associations of these markers with the kidney composite outcome of 50% eGFR decline or ESKD requiring dialysis or kidney transplantation, and linear mixed models evaluated annualized change in eGFR. RESULTS Mean participant age was 73±9 (SD) years, 60% were men, 66% were white, and mean baseline eGFR was 46±11 ml/min per 1.73 m2. There were 87 kidney composite outcome events during a median follow-up of 3.8 years. Relative to the respective lowest quartiles, the highest quartiles of urinary KIM-1 (hazard ratio, 2.84; 95% confidence interval [95% CI], 1.31 to 6.17), MCP-1 (hazard ratio, 2.43; 95% CI, 1.13 to 5.23), and YKL-40 (hazard ratio, 1.95; 95% CI, 1.08 to 3.51) were associated with higher risk of the kidney composite outcome in fully adjusted models including baseline eGFR and urine albumin. In linear analysis, urinary IL-18 was the only marker associated with eGFR decline (-0.91 ml/min per 1.73 m2 per year for highest versus lowest quartile; 95% CI, -1.44 to -0.38), a finding that was stronger in the standard arm of SPRINT. CONCLUSIONS Urine markers of tubule cell injury provide information about risk of subsequent loss of kidney function, beyond the eGFR and urine albumin.
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Affiliation(s)
- Rakesh Malhotra
- Division of Nephrology and Hypertension, Department of Medicine and.,Division of Nephrology and Hypertension, Imperial Valley Family Care Medical Group, El Centro, California
| | - Ronit Katz
- Kidney Research Institute, University of Washington, Seattle, Washington
| | - Vasantha Jotwani
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, California
| | - Walter T Ambrosius
- Department of Biostatistics and Data Science, Division of Public Health Sciences and
| | - Kalani L Raphael
- Division of Nephrology and Hypertension, University of Utah Health and Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - William Haley
- Division of Nephrology, Mayo Clinic, Jacksonville, Florida
| | - Anjay Rastogi
- Division of Nephrology, University of California Los Angeles, Los Angeles, California
| | - Alfred K Cheung
- Division of Nephrology and Hypertension, University of Utah Health and Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Henry Punzi
- Trinity Hypertension and Metabolic Research Instititute, Punzi Medical Center, Carrollton, Texas
| | - Michael V Rocco
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Joachim H Ix
- Division of Nephrology and Hypertension, Department of Medicine and .,Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego, San Diego, California.,Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, California; and
| | - Michael G Shlipak
- Kidney Health Research Collaborative, San Francisco Veterans Affairs Medical Center and University of California, San Francisco, California.,Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, California
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9
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Garimella PS, Lee AK, Ambrosius WT, Bhatt U, Cheung AK, Chonchol M, Craven T, Hawfield AT, Jotwani V, Killeen A, Punzi H, Sarnak MJ, Wall BM, Ix JH, Shlipak MG. Markers of kidney tubule function and risk of cardiovascular disease events and mortality in the SPRINT trial. Eur Heart J 2019; 40:3486-3493. [PMID: 31257404 PMCID: PMC6837159 DOI: 10.1093/eurheartj/ehz392] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/11/2019] [Accepted: 05/21/2019] [Indexed: 12/31/2022] Open
Abstract
AIMS Biomarkers of kidney tubule injury, inflammation and fibrosis have been studied extensively and established as risk markers of adverse kidney and cardiovascular disease (CVD) outcomes. However, associations of markers of kidney tubular function with adverse clinical events have not been well studied, especially in persons with chronic kidney disease (CKD). METHODS AND RESULTS Using a sample of 2377 persons with CKD at the baseline Systolic Blood Pressure Intervention Trial (SPRINT) visit, we evaluated the association of three urine tubular function markers, alpha-1 microglobulin (α1m), beta-2 microglobulin (β2m), and uromodulin, with a composite CVD endpoint (myocardial infarction, acute coronary syndrome, stroke, acute decompensated heart failure, or death from cardiovascular causes) and mortality using Cox proportional hazards regression, adjusted for baseline estimated glomerular filtration rate (eGFR), albuminuria, and CVD risk factors. In unadjusted analysis, over a median follow-up of 3.8 years, α1m and β2m had positive associations with composite CVD events and mortality, whereas uromodulin had an inverse association with risk for both outcomes. In multivariable analysis including eGFR and albuminuria, a two-fold higher baseline concentration of α1m was associated with higher risk of CVD [hazard ratio (HR) 1.25; 95% confidence interval (CI): 1.10-1.45] and mortality (HR 1.25; 95% CI: 1.10-1.46), whereas β2m had no association with either outcome. A two-fold higher uromodulin concentration was associated with lower CVD risk (HR 0.79; 95% CI: 0.68-0.90) but not mortality (HR 0.86; 95% CI: 0.73-1.01) after adjusting for similar confounders. CONCLUSION Among non-diabetic persons with CKD, biomarkers of tubular function are associated with CVD events and mortality independent of glomerular function and albuminuria.
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Affiliation(s)
- Pranav S Garimella
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, CA, USA
| | - Alexandra K Lee
- Division of General Internal Medicine, San Francisco VA Medical Center, San Francisco, CA, USA
| | - Walter T Ambrosius
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Udayan Bhatt
- Division of Nephrology, Ohio State University, Columbus, OH, USA
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, Department of Internal Medicine, Medical Service, University of Utah, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Michel Chonchol
- Division of Nephrology & Hypertension, Department of Medicine, University of Colorado, Denver, CO, USA
| | - Timothy Craven
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Amret T Hawfield
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Vasantha Jotwani
- Kidney Health Research Collaborative, San Francisco VA Medical Center, University of California, San Francisco, CA, USA
| | - Anthony Killeen
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | | | - Mark J Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
| | - Barry M Wall
- Division of Nephrology, University of Tennessee, Memphis, TN, USA
| | - Joachim H Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, CA, USA
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California San Diego, San Diego, CA, USA
- Nephrology Section, Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA
| | - Michael G Shlipak
- Division of General Internal Medicine, San Francisco VA Medical Center, San Francisco, CA, USA
- Kidney Health Research Collaborative, San Francisco VA Medical Center, University of California, San Francisco, CA, USA
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10
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Lee AK, Katz R, Jotwani V, Garimella PS, Ambrosius WT, Cheung AK, Gren LH, Neyra JA, Punzi H, Raphael KL, Shlipak MG, Ix JH. Distinct Dimensions of Kidney Health and Risk of Cardiovascular Disease, Heart Failure, and Mortality. Hypertension 2019; 74:872-879. [PMID: 31378102 PMCID: PMC6739187 DOI: 10.1161/hypertensionaha.119.13339] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Chronic kidney disease is a strong risk factor for cardiovascular disease (CVD), but clinical kidney measures (estimated glomerular filtration rate and albuminuria) do not fully reflect the multiple aspects of kidney tubules influencing cardiovascular health. Applied methods are needed to integrate numerous tubule biomarkers into useful prognostic scores. In SPRINT (Systolic Blood Pressure Intervention Trial) participants with chronic kidney disease at baseline (estimated glomerular filtration ratecr&cys <60 mL/minute per 1.73 m2), we measured 8 biomarkers from urine (α1M [α1M microglobulin], β2M [β2M microglobulin], umod [uromodulin], KIM-1 [kidney injury molecule-1], MCP-1 [monocyte chemoattractant protein-1], YKL-40 [chitinase-3-like protein-1], NGAL [neutrophil gelatinase-associated lipocalin], and IL-18 [interleukin 18]) and 2 biomarkers from serum (intact parathyroid hormone, iFGF-23 [intact fibroblast growth factor-23]). We used an unsupervised method, exploratory factor analysis, to create summary scores of tubule health dimensions. Adjusted Cox models evaluated each tubule score with CVD events, heart failure, and all-cause mortality. We examined CVD discrimination using Harrell C-statistic. Factor analysis of 10 biomarkers from 2376 SPRINT-chronic kidney disease participants identified 4 unique dimensions of tubular health: tubule injury/repair (NGAL, IL-18, YKL-40), tubule injury/fibrosis (KIM-1, MCP-1), tubule reabsorption (α1M, β2M), and tubular reserve/mineral metabolism (umod, intact parathyroid hormone, iFGF-23). After adjustment for CVD risk factors, estimated glomerular filtration rate, and albumin-to-creatinine ratio, 2 of the 4 tubule scores were associated with CVD (hazard ratio per SD; reabsorption, 1.21 [1.06-1.38]; reserve, 1.24 (1.08-1.38]), 1 with heart failure (reserve, 1.41 [1.13-1.74]), and none with mortality. Compared with a base model (C-statistic=0.674), adding estimated glomerular filtration rate and albumin-to-creatinine ratio improved the C-statistic (C=0.704; P=0.001); further adding tubule scores additionally improved the C-statistic (C=0.719; P=0.009). In the setting of chronic kidney disease, dimensions of tubule health quantified using factor analysis improved CVD discrimination beyond contemporary kidney measures. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01206062.
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Affiliation(s)
| | | | | | | | | | - Alfred K. Cheung
- University of Utah
- Veterans Affairs Salt Lake City Healthcare System
| | | | - Javier A. Neyra
- University of Texas Southwestern, Dallas
- University of Kentucky, Lexington
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11
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Bullen AL, Katz R, Lee AK, Anderson CAM, Cheung AK, Garimella PS, Jotwani V, Haley WE, Ishani A, Lash JP, Neyra JA, Punzi H, Rastogi A, Riessen E, Malhotra R, Parikh CR, Rocco MV, Wall BM, Bhatt UY, Shlipak MG, Ix JH, Estrella MM. The SPRINT trial suggests that markers of tubule cell function in the urine associate with risk of subsequent acute kidney injury while injury markers elevate after the injury. Kidney Int 2019; 96:470-479. [PMID: 31262489 PMCID: PMC6650383 DOI: 10.1016/j.kint.2019.03.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 03/26/2019] [Accepted: 03/28/2019] [Indexed: 01/19/2023]
Abstract
Urine markers can quantify tubular function including reabsorption (α-1 microglobulin [α1m]) and β-2-microglobulin [β2m]) and protein synthesis (uromodulin). Individuals with tubular dysfunction may be less able to compensate to insults than those without, despite similar estimated glomerular filtration rate (eGFR) and albuminuria. Among Systolic Blood Pressure Intervention Trial (SPRINT) participants with an eGFR under 60 ml/min/1.73m2, we measured urine markers of tubular function and injury (neutrophil gelatinase-associated lipocalin [NGAL], kidney injury molecule-1 [KIM-1], interleukin-18 [IL-18], monocyte chemoattractant protein-1, and chitinase-3-like protein [YKL-40]) at baseline. Cox models evaluated associations with subsequent acute kidney injury (AKI) risk, adjusting for clinical risk factors, baseline eGFR and albuminuria, and the tubular function and injury markers. In a random subset, we remeasured biomarkers after four years, and compared changes in biomarkers in those with and without intervening AKI. Among 2351 participants, 184 experienced AKI during 3.8 years mean follow-up. Lower uromodulin (hazard ratio per two-fold higher (0.68, 95% confidence interval [0.56, 0.83]) and higher α1m (1.20; [1.01, 1.44]) were associated with subsequent AKI, independent of eGFR and albuminuria. None of the five injury markers were associated with eventual AKI. In the random subset of 947 patients with repeated measurements, the 59 patients with intervening AKI versus without had longitudinal increases in urine NGAL, IL-19, and YKL-40 and only 1 marker of tubule function (α1m). Thus, joint evaluation of tubule function and injury provided novel insights to factors predisposing to AKI, and responses to kidney injury.
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Affiliation(s)
- Alexander L Bullen
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Ronit Katz
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Alexandra K Lee
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, California, USA
| | - Cheryl A M Anderson
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA; Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California-San Diego, San Diego, California, USA
| | - Alfred K Cheung
- Division of Nephrology & Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA; Medical Service, Veterans Affairs, Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Pranav S Garimella
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Vasantha Jotwani
- Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA; Department of Epidemiology and Biostatistics, University of California, San Francisco, California, USA
| | - William E Haley
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida, USA
| | - Areef Ishani
- Division of Medicine, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota, USA
| | - James P Lash
- Division of Nephrology, Department of Medicine, College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Javier A Neyra
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky Medical Center, Lexington, Kentucky, USA; Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern, Dallas, Texas, USA
| | - Henry Punzi
- UT Southwestern Medical Center, Carrollton, Texas, USA
| | - Anjay Rastogi
- Division of Pulmonary and Critical Care, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles (UCLA), Los Angeles, California, USA
| | - Erik Riessen
- Medical Service, Veterans Affairs, Salt Lake City Healthcare System, Salt Lake City, Utah, USA
| | - Rakesh Malhotra
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Chirag R Parikh
- Department of Medicine, Section of Nephrology, Yale University, New Haven, Connecticut, USA
| | - Michael V Rocco
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Barry M Wall
- Division of Nephrology, Veterans Affairs Medical Center, Memphis, Tennessee, USA
| | - Udayan Y Bhatt
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Michael G Shlipak
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, California, USA; Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA
| | - Joachim H Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, San Diego, California, USA; Nephrology Section, Veterans Affairs, San Diego Healthcare System, La Jolla, California, USA
| | - Michelle M Estrella
- Kidney Health Research Collaborative, Department of Medicine, University of California, San Francisco, California, USA; Department of Medicine, San Francisco VA Medical Center, San Francisco, California, USA.
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12
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Jotwani VK, Lee AK, Estrella MM, Katz R, Garimella PS, Malhotra R, Rifkin DE, Ambrosius W, Freedman BI, Cheung AK, Raphael KL, Drawz P, Neyra JA, Oparil S, Punzi H, Shlipak MG, Ix JH. Urinary Biomarkers of Tubular Damage Are Associated with Mortality but Not Cardiovascular Risk among Systolic Blood Pressure Intervention Trial Participants with Chronic Kidney Disease. Am J Nephrol 2019; 49:346-355. [PMID: 30939472 DOI: 10.1159/000499531] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/11/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Kidney tubulointerstitial fibrosis on biopsy is a strong predictor of chronic kidney disease (CKD) progression, and CKD is associated with elevated risk of cardiovascular disease (CVD). Tubular health is poorly quantified by traditional kidney function measures, including estimated glomerular filtration rate (eGFR) and albuminuria. We hypothesized that urinary biomarkers of tubular injury, inflammation, and repair would be associated with higher risk of CVD and mortality in persons with CKD. METHODS We measured urinary concentrations of interleukin-18 (IL-18), kidney injury molecule-1, neutrophil gelatinase-associated lipocalin, monocyte chemoattractant protein-1, and chitinase-3-like protein-1 (YKL-40) at baseline among 2,377 participants of the Systolic Blood Pressure Intervention Trial who had an eGFR < 60 mL/min/1.73 m2. We used Cox proportional hazards models to evaluate biomarker associations with CVD events and all-cause mortality. RESULTS At baseline, the mean age of participants was 72 ± 9 years, and eGFR was 48 ± 11 mL/min/1.73 m2. Over a median follow-up of 3.8 years, 305 CVD events (3.6% per year) and 233 all-cause deaths (2.6% per year) occurred. After multivariable adjustment including eGFR, albuminuria, and urinary creatinine, none of the biomarkers showed statistically significant associations with CVD risk. Urinary IL-18 (hazard ratio [HR] per 2-fold higher value, 1.14; 95% CI 1.01-1.29) and YKL-40 (HR per 2-fold higher value, 1.08; 95% CI 1.02-1.14) concentrations were each incrementally associated with higher mortality risk. Associations were similar when stratified by randomized blood pressure arm. CONCLUSIONS Among hypertensive trial participants with CKD, higher urinary IL-18 and YKL-40 were associated with higher risk of mortality, but not CVD.
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Affiliation(s)
- Vasantha K Jotwani
- Department of Medicine, San Francisco VA Medical Health Care System, San Francisco, California, USA,
- Kidney Health Research Collaborative, San Francisco VA Medical Center and University of California, San Francisco, California, USA,
| | - Alexandra K Lee
- Kidney Health Research Collaborative, San Francisco VA Medical Center and University of California, San Francisco, California, USA
| | - Michelle M Estrella
- Department of Medicine, San Francisco VA Medical Health Care System, San Francisco, California, USA
- Kidney Health Research Collaborative, San Francisco VA Medical Center and University of California, San Francisco, California, USA
| | - Ronit Katz
- Kidney Research Institute, University of Washington, Seattle, Washington, USA
| | - Pranav S Garimella
- Department of Medicine, University of California, San Diego, California, USA
| | - Rakesh Malhotra
- Department of Medicine, University of California, San Diego, California, USA
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
| | - Dena E Rifkin
- Department of Medicine, University of California, San Diego, California, USA
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
| | - Walter Ambrosius
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Barry I Freedman
- Department of Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Alfred K Cheung
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kalani L Raphael
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Paul Drawz
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Javier A Neyra
- Department of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Suzanne Oparil
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Henry Punzi
- Punzi Medical Center, Trinity Hypertension Research Institute, Carollton, Texas, USA
| | - Michael G Shlipak
- Department of Medicine, San Francisco VA Medical Health Care System, San Francisco, California, USA
- Kidney Health Research Collaborative, San Francisco VA Medical Center and University of California, San Francisco, California, USA
| | - Joachim H Ix
- Department of Medicine, University of California, San Diego, California, USA
- Veterans Affairs San Diego Healthcare System, San Diego, California, USA
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13
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Basile J, Egan B, Punzi H, Ali S, Li Q, Patel M, Neutel J. Risk of Hospitalization for Cardiovascular Events with β-Blockers in Hypertensive Patients: A Retrospective Cohort Study. Cardiol Ther 2018; 7:173-183. [PMID: 30191469 PMCID: PMC6251822 DOI: 10.1007/s40119-018-0117-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION β-Blockers are a heterogenous class of drugs that are no longer recommended for initial antihypertension monotherapy due to unfavorable long-term cardiovascular events observed with non-vasodilatory β-blockers. However, the comparative cardiovascular event risk between the vasodilatory β1-selective antagonist/β3 agonist nebivolol and non-vasodilatory β1-blockers, atenolol and metoprolol, is unknown. METHODS Incident nebivolol, atenolol, or metoprolol monotherapy users with hypertension were identified using US claims data (2007-2014). The first β-blocker claim on/after 1/1/2008 defined the index drug/date. Hypertensive patients without pre-index cardiovascular history were followed until index drug discontinuation (> 90 day supply gap), use of other β-blockers, or end of continuous plan enrollment. Patients were pair-wise propensity score-matched using logistic regression, adjusted for baseline demographics, Charlson Comorbidity Index score, comorbid chronic pulmonary disease, rheumatic disease, renal disease, and diabetes, and use of other antihypertensive drugs during baseline. Time to first hospital claim for a cardiovascular event was assessed via Cox proportional hazards regression, adjusted for the variables above. RESULTS Inclusion criteria were met by 81,402 patients (n = 27,134 in each matched treatment cohort), with no between-cohort differences in baseline characteristics, comorbid conditions, or average follow-up duration. Atenolol and metoprolol cohorts had greater risk of hospitalization for a composite event (myocardial infarction, angina, congestive heart failure, stroke) than nebivolol users (adjusted hazard ratios [95% confidence interval] atenolol: 1.68 [1.29, 2.17]; metoprolol: 2.05 [1.59, 2.63]; P < 0.001, both). Risks of most individual cardiovascular events were also lower with nebivolol, including myocardial infarction and angina versus atenolol, and myocardial infarction, congestive heart failure, and angina versus metoprolol (P < 0.05, all). CONCLUSIONS Nebivolol was associated with significantly lower risk of hospitalization due to composite cardiovascular events than atenolol or metoprolol in this large retrospective cohort study of monotherapy with three different β1-selective blockers in hypertensive patients. FUNDING Allergan plc, Madison, NJ, USA.
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Affiliation(s)
- Jan Basile
- Medical University of South Carolina, Charleston, SC, USA.
| | - Brent Egan
- The Care Coordination Institute, University of South Carolina School of Medicine, Greenville, SC, USA
| | - Henry Punzi
- UT Southwestern Medical Center, Carrollton, TX, USA
| | | | | | | | - Joel Neutel
- Orange County Research Center, Tustin, CA, USA
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14
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Punzi H, Ali S, Li Q, Patel M, Neutel J. Abstract 208: A Large, Retrospective Cohort Study Comparing Cardiovascular Outcomes With β-blocker Combination Treatment in Patients With Hypertension. Circ Cardiovasc Qual Outcomes 2018. [DOI: 10.1161/circoutcomes.11.suppl_1.208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives:
Hypertension is a major risk factor for cardiovascular (CV) events. While β-blockers (BBs) lower blood pressure and reduce CV event risk, the comparative CV event risk and rate of hospitalization due to CV events between hypertensive patients treated with vasodilatory β
1
-selective antagonist/β
3
agonist, nebivolol (NEB), and non-vasodilatory β
1
-selective BBs, atenolol (ATN) and metoprolol (MET), is unknown.
Methods:
Incident users of NEB, ATN or MET receiving ≥1 additional antihypertensive were identified from US claims data (2007-2014). First BB claim on/after 1/1/2008 defined index drug and date. Follow-up lasted ≥6 months, until index drug cessation or other BB use. Treatment cohorts (N=16,787 each) were matched by the number of antihypertensive drug classes used in follow-up and on propensity score (1:1) to balance confounders (follow-up duration, baseline demographics and clinical characteristics). Clinical outcomes based on matched cohorts were: hospitalization risk for composite CV outcome (myocardial infarction [MI], congestive heart failure, stroke, and angina; assessed by Cox proportional hazards regression) and event rate ratio for CV-related hospitalizations (assessed by count regression with negative binomial distribution) comparing ATN and MET with NEB. Both regressions were adjusted for concomitant antihypertension medication possession ratios (≥75%) and baseline confounders balanced in matching.
Results:
Compared with NEB, hospitalization risk due to composite CV events, MI, and angina was significantly higher with ATN and MET (Table). The unadjusted rate of all hospitalizations due to composite CV events per 1,000 persons per year was significantly greater in ATN and MET users compared with NEB users, while the adjusted ratio of composite CV event rate was significantly greater with MET, but not ATN (Table).
Conclusions:
In adults receiving combination antihypertension therapy, NEB treatment was associated with a lower risk for CV-related hospitalization than either ATN or MET. Lower risk of hospitalization was supported by event rate data, as patients receiving NEB combined with other antihypertensives were hospitalized less frequently than patients receiving combination therapy with either ATN or MET.
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Ishak J, Rael M, Punzi H, Gradman A, Anderson LM, Patel M, Ali S, Ferguson W, Neutel J. Additivity of nebivolol/valsartan single-pill combinations versus other single-pill combinations for hypertension. J Clin Hypertens (Greenwich) 2017; 20:143-149. [PMID: 29105958 PMCID: PMC5813198 DOI: 10.1111/jch.13132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 08/09/2017] [Accepted: 08/28/2017] [Indexed: 11/29/2022]
Abstract
The single‐pill combination (SPC) comprising nebivolol (5 mg), a vasodilatory β1‐selective antagonist/β3‐agonist, and valsartan (80 mg), a renin‐angiotensin‐aldosterone system inhibitor, is the only Food and Drug Administration–approved β‐blocker/renin‐angiotensin‐aldosterone system inhibitor SPC for hypertension. Additive effects of four nebivolol/valsartan SPC doses (5 mg/80 mg, 5/160 mg, 10/160 mg, 10/320 mg nebivolol/valsartan) were compared with five Food and Drug Administration–approved non–β‐blocker/renin‐angiotensin‐aldosterone system inhibitor SPCs (aliskiren/hydrochlorothiazide, aliskiren/amlodipine, valsartan/amlodipine, aliskiren/valsartan, and telmisartan/amlodipine). Additivity is the ratio of placebo‐adjusted SPC blood pressure (BP) reduction to the placebo‐adjusted monotherapy component BP reduction sums. A weighted average of comparator scores was calculated and compared vs nebivolol/valsartan. Additivity ratio scores for nebivolol/valsartan SPCs (diastolic BP range: 0.735–0.866; systolic BP range: 0.717–0.822) were similar to the comparator weighted average (diastolic BP: 0.837; systolic BP: 0.825). Among the nebivolol/valsartan SPCs, 5/80 mg had the greatest additivity (diastolic BP: 0.866; systolic BP: 0.822). BP reduction contributions with monotherapy were similar for nebivolol/valsartan 5/80 mg SPC. Additivity scores for nebivolol/valsartan and select non–β‐blocker/renin‐angiotensin‐aldosterone system inhibitor SPCs were comparable.
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Affiliation(s)
| | | | - Henry Punzi
- UT Southwestern Medical Center, Dallas, TX, USA
| | - Alan Gradman
- Temple University School of Medicine, Pittsburgh, PA, USA
| | | | - Mehul Patel
- Allergan plc, Harborside Financial Center, Jersey City, NJ, USA
| | - Sanjida Ali
- Allergan plc, Harborside Financial Center, Jersey City, NJ, USA
| | | | - Joel Neutel
- Orange County Research Center, Tustin, CA, USA
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Ishak J, Rael M, Punzi H, Gradman A, Anderson LM, Patel MD, Ali S, Ferguson W, Neutel J. ADDITIVITY OF NEBIVOLOL/VALSARTAN SINGLE-PILL COMBINATIONS VERSUS OTHER APPROVED SINGLE-PILL COMBINATIONS FOR HYPERTENSION. J Am Coll Cardiol 2017. [DOI: 10.1016/s0735-1097(17)35081-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Rodriguez CJ, Still CH, Garcia KR, Wagenknecht L, White S, Bates JT, Del Cid MV, Lioudis M, Lopez Barrera N, Moreyra A, Punzi H, Ringer RJ, Cushman WC, Contreras G, Servilla K, Rocco M. Baseline blood pressure control in Hispanics: characteristics of Hispanics in the Systolic Blood Pressure Intervention Trial. J Clin Hypertens (Greenwich) 2016; 19:116-125. [PMID: 27862904 DOI: 10.1111/jch.12942] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 08/19/2016] [Accepted: 08/22/2016] [Indexed: 11/30/2022]
Abstract
The Systolic Blood Pressure Intervention Trial (SPRINT) tested whether a systolic blood pressure (SBP) value <120 mm Hg reduces adverse clinical outcomes compared with the goal of <140 mm Hg. Here the authors describe the baseline characteristics of Hispanic participants in SPRINT. Nondiabetic hypertensive patients 50 years and older with SBP 130-180 mm Hg taking zero to four blood pressure (BP) medications were enrolled from the mainland United States and Puerto Rico. Cross-sectional, bivariate analysis was employed comparing sociodemographic and clinical factors in Hispanics vs non-Hispanics. Multivariable logistic regression models restricted to Hispanics were used to identify factors associated with achieved BP control (SBP <140 mm Hg and diastolic BP <90 mm Hg) at baseline. Eleven percent (n=984) of SPRINT participants were Hispanic; 56% (n=549) of Hispanics were living in Puerto Rico and the remainder were living on the US mainland. Hispanics overall were younger, more often female, less likely to live alone, and more likely to have lower education and be uninsured, although just as likely to be employed compared with non-Hispanics. BP control was not different between Hispanics vs non-Hispanics at baseline. However, a significantly higher percentage of Hispanics on the US mainland (compared with Hispanics in Puerto Rico) had controlled BP. BP control was independently associated with cardiovascular disease history and functional status among Hispanics, specifically those living in Puerto Rico, whereas functional status was the only independent predictor of BP control identified among mainland Hispanics. These findings highlight the diversity of the SPRINT population. It remains to be seen whether factors identified among Hispanics impact intervention goals and subsequent clinical outcomes.
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Affiliation(s)
- Carlos J Rodriguez
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Internal Medicine - Cardiovascular Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Carolyn H Still
- Division of Nephrology and Hypertension, Clinical Hypertension Program, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Katelyn R Garcia
- Department of Biostatistics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lynne Wagenknecht
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Suzanne White
- Department of Internal Medicine, NEON Health Centers, Cleveland, OH, USA
| | - Jeffrey T Bates
- Department of Internal Medicine, Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | | | - Michael Lioudis
- Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, OH, USA
| | | | - Abel Moreyra
- Division of Cardiovascular Disease, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Henry Punzi
- Department of Medicine, Punzi Medical Center, Carrollton, TX, USA
| | - Robert J Ringer
- Department of Pharmacology, Veterans Affairs Medical Center, Albuquerque, NM, USA
| | | | - Gabriel Contreras
- Department of Nephrology - Internal Medicine, University of Miami, Miami, FL, USA
| | - Karen Servilla
- Department of Medicine - Nephrology, Veterans Affairs Medical Center, Albuquerque, NM, USA
| | - Michael Rocco
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC, USA.,Department of Internal Medicine - Nephrology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Varagic J, Punzi H, Ferrario CM. Clinical utility of fixed-dose combinations in hypertension: evidence for the potential of nebivolol/valsartan. Integr Blood Press Control 2014; 7:61-70. [PMID: 25473311 PMCID: PMC4251532 DOI: 10.2147/ibpc.s50954] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Despite significant advances in pharmacologic approaches to treat hypertension during the last decades, hypertension- and hypertension-related organ damage are still a high health and economic burden because a large proportion of patients with hypertension do not achieve optimal blood pressure control. There is now general agreement that combination therapy with two or more antihypertensive drugs is required for targeted blood pressure accomplishment and reduction of global cardiovascular risk. The goals of combination therapies are to reduce long-term cardiovascular events by targeting different mechanism underlying hypertension and target organ disease, to block the counterregulatory pathways activated by monotherapies, to improve tolerability and decrease the adverse effects of up-titrated single agents, and to increase persistence and adherence with antihypertensive therapy. Multiple clinical trials provide evidence that fixed-dose combinations in a single pill offer several advantages when compared with loose-dose combinations. This review discusses the advances in hypertension control and associated cardiovascular disease as they relate to the prospect of combination therapy targeting a third-generation beta (β) 1-adrenergic receptor (nebivolol) and an angiotensin II receptor blocker (valsartan) in fixed-dose single-pill formulations.
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Affiliation(s)
- Jasmina Varagic
- Hypertension and Vascular Research Center, Wake Forest University, Winston-Salem, NC USA ; Division of Surgical Sciences, Wake Forest University, Winston-Salem, NC USA ; Department of Physiology and Pharmacology, Wake Forest University, Winston-Salem, NC USA
| | - Henry Punzi
- Trinity Hypertension and Diagnostic Research Center, Carrollton, TX, USA ; Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Carlos M Ferrario
- Division of Surgical Sciences, Wake Forest University, Winston-Salem, NC USA ; Department of Physiology and Pharmacology, Wake Forest University, Winston-Salem, NC USA ; Department of Internal Medicine and Nephrology, Wake Forest University, Winston-Salem, NC, USA
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19
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Lewin A, Punzi H, Luo X, Stapff M. Nebivolol monotherapy for patients with systolic stage II hypertension: results of a randomized, placebo-controlled trial. Clin Ther 2013; 35:142-52. [PMID: 23332366 DOI: 10.1016/j.clinthera.2012.12.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 11/20/2012] [Accepted: 12/20/2012] [Indexed: 01/13/2023]
Abstract
BACKGROUND Elevated systolic blood pressure (SBP) is an independent risk factor for cardiovascular events and mortality. OBJECTIVE The goal of this study was to assess whether nebivolol (NEB), a vasodilatory β(1)-selective blocker, is a safe and efficacious monotherapy for individuals with systolic stage II hypertension. METHODS In this multicenter trial, 18- to 64-year-olds who had not used antihypertensive treatment for at least 4 weeks and had SBP/diastolic blood pressure (DBP) of 160 to 180/90 to 110 mm Hg were randomized to receive double-blind medication for 6 weeks (NEB, n = 290; placebo [PBO], n = 142). Depending on response, the starting dose (5 mg/d) could be increased directly to 20 mg/d. Primary parameters were baseline-end point changes in trough seated SBP and DBP (intent-to-treat [ITT] population); the Hochberg method was used to control the type I error (α = 0.05). Responder analysis was also performed. Safety and tolerability assessment included monitoring of adverse events (AEs). RESULTS Mean age at baseline (ITT) was 50.7 years, and the mean SBP/DBP values were 167/101 mm Hg; 202 (47.3%) participants were women, 276 (63.9%) had body mass index ≥30 kg/m(2), 152 (35.2%) were black, and 161 (37.3%) were Hispanic. Completion rates were 79.7% (PBO) and 90.3% (NEB). After 2 weeks of treatment, 92% and 95% participants in the NEB and PBO groups, respectively, had SBP in the range of 130 to 180 mm Hg and were titrated to the 20-mg/d NEB dose or its matching PBO tablet. After 6 weeks of treatment, the NEB group experienced significant mean reductions compared with the PBO group for both SBP (-18.2 vs -12.3 mm Hg; P < 0.001) and DBP (-12.3 vs -5.7 mm Hg; P < 0.001), down to mean SBP/DBP values of 149/89 mm Hg and 155/95 mm Hg, respectively, and had a significantly higher percentage of individuals who achieved BP control (SBP/DBP <140/90 mm Hg, 30.6% vs 17.3%; P = 0.004). Post hoc analyses suggest that NEB was not efficacious in reducing SBP in black participants. Mean changes in pulse rate were -12.8 beats/min for the NEB group and -1.6 beats/min for the PBO group (P < 0.001). Rates of discontinuations due to an AE (NEB vs PBO) were 1.4% in both groups, rates of any treatment-emergent AEs were 19.7% versus 19.0%, and rates of serious AEs were 0.3% versus 2.1%. The most common AEs (NEB vs PBO) were headache (2.1% vs 2.8%) and hypertension (0.7% vs 2.1%). CONCLUSIONS NEB monotherapy was an efficacious and well-tolerated treatment option for these study individuals with systolic stage II hypertension, but most of them would need combination therapy to achieve BP control.
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Affiliation(s)
- Andrew Lewin
- National Research Institute, Los Angeles, CA 90057, USA.
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20
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Punzi H, Shojaee A, Maa JF. Efficacy and tolerability of fixed-dose amlodipine/olmesartan medoxomil with or without hydrochlorothiazide in Hispanic and non-Hispanic patients whose blood pressure is uncontrolled on antihypertensive monotherapy. Ther Adv Cardiovasc Dis 2012; 6:149-61. [PMID: 22855062 PMCID: PMC3546644 DOI: 10.1177/1753944712452190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Objectives: This is a prespecified subgroup analysis in Hispanic and non-Hispanic patients of a study that evaluated blood pressure (BP) control with fixed-dose amlodipine/olmesartan medoxomil (AML/OM)-based therapy in patients whose condition was uncontrolled on prior monotherapy. Methods: In this prospective, open-label, dose-titration study, patients with uncontrolled BP after at least 1 month of antihypertensive monotherapy were switched to fixed-dose AML/OM 5/20 mg. Patients were uptitrated to AML/OM 5/40 and 10/40 mg, with uptitration to AML/OM + hydrochlorothiazide 10/40 + 12.5 mg and 10/40 + 25 mg to achieve target BP. The primary efficacy endpoint was the cumulative proportion of patients achieving seated cuff systolic BP (SeSBP) less than 140 mmHg (<130 mmHg in patients with diabetes mellitus) at 12 weeks. Secondary endpoints included SeBP goal rates, ambulatory BP (ABP) target rates, and mean change from baseline in seated cuff BP (SeBP) and ABP at weeks 12 and 20. Results: Mean baseline BP was similar in Hispanics (153.6/92.8 mmHg; n = 105) and non-Hispanics (153.7/91.8 mmHg; n = 894). At 12 weeks, 72.0% of Hispanics and 76.3% of non-Hispanics achieved the primary endpoint. At week 12, goal rates for cumulative SeBP (<140/90 mmHg or <130/80 mmHg in patients with diabetes) were 69.0% and 71.5% in Hispanic and non-Hispanic patients, respectively. Mean change in SeBP in Hispanics ranged from −15.3/−7.3 mmHg for AML/OM 5/20 mg to −23.2/−13.8 mmHg for AML/OM 10/40 mg + hydrochlorothiazide 25 mg, and in non-Hispanics from −14.1/−7.8 mmHg to −25.4/−13.7 mmHg (all p < 0.0001 versus baseline). A majority of patients achieved mean 24 h, daytime, and nighttime ABP targets in both subgroups. Greater proportions of Hispanics achieved ABP targets versus non-Hispanics at week 12; however, this trend was reversed at week 20. Treatment was well tolerated. Conclusions: Switching to a fixed-dose combination of AML/OM ± hydrochlorothiazide provided significant BP lowering and effectively controlled BP in a large proportion of Hispanic and non-Hispanic patients with hypertension uncontrolled on previous monotherapy.
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Affiliation(s)
- Henry Punzi
- Punzi Medical Center, 1932 Walnut Plaza, Carrollton, TX 75006, USA.
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Papademetriou V, Tsioufis K, Gradman A, Punzi H. Difficult-to-Treat or Resistant Hypertension: Etiology, Pathophysiology, and Innovative Therapies. Int J Hypertens 2011; 2011:438198. [PMID: 21822477 PMCID: PMC3124360 DOI: 10.4061/2011/438198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 03/23/2011] [Indexed: 11/20/2022] Open
Abstract
Despite the many therapeutic options available today for the treatment of hypertension, a sizable number of patients still remain resistant to treatment. The prevalence of resistant hypertension in the general population under optimal conditions is about 3–5%. Although several factors and conditions can be identified and corrected a percentage of hypertensive patients remain with unacceptably high blood pressure levels. The high prevalence of hypertension in the general population renders this small percentage significant, in terms of actual patient numbers. This special issue of the journal expoars a whole spectrum of topics related to resistant hypertension: several articles address pathophysiolog and secondary causes of resistant hypertension and modern approaches to therapy. Of interest is the referance to the newer interventional approaches, that is, Baroreceptor stimulation therapy and catheter based sympathetic renal denervation.
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Affiliation(s)
- Vasilios Papademetriou
- Cardiovascular Research, VA Medical Center, 50 Irving Street NW, Washington, DC 20422, USA
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Punzi H, Lewin A, Lukić T, Goodin T, Wei Chen. Efficacy and safety of nebivolol in Hispanics with stage I-II hypertension: a randomized placebo-controlled trial. Ther Adv Cardiovasc Dis 2011; 4:349-57. [PMID: 21088095 DOI: 10.1177/1753944710387629] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Hispanics have lower rates of hypertension control compared with black and white patients. Nebivolol is a vasodilatory β1-selective blocker, with neutral metabolic effects. This phase IV trial evaluated the efficacy and safety of nebivolol in Hispanics with stage I-II hypertension. METHODS Self-identified Hispanics with stage I-II hypertension were randomized to receive a double-blind treatment: placebo (n = 136) or nebivolol (n = 141, starting dose 5 mg/day) for 8 weeks. Nebivolol dosage could be uptitrated at 2-week intervals to 10, 20, or 40 mg/day, as needed to achieve diastolic blood pressure (DBP) control (JNC7 criteria). Efficacy outcome measures were the mean changes from baseline to the end of week 8 in trough-seated DBP (primary) and systolic blood pressure (SBP) (secondary). Safety and tolerability were also assessed. RESULTS Baseline SBP/DBP (mmHg) was similar in both treatment groups (nebivolol: 156/100; placebo: 157/101). A total of 135 (96%) and 121 (89%) nebivolol- and placebo-treated participants completed the double-blind phase, respectively. Compared with the placebo, nebivolol treatment was associated with significant mean reductions in both trough-seated DBP and SBP (DBP: -11.1 mmHg vs. -7.3 mmHg, p < 0.0001; SBP: -14.1 mmHg vs. -9.3 mmHg; p = 0.001). Treatment-emergent adverse event (TEAE) rates were 17% (nebivolol) and 22% (placebo); the most frequent TEAEs were headache (4% vs. 6%, respectively), upper respiratory tract infection (2% vs. 2%), and dizziness (1% vs. 3%). CONCLUSIONS In Hispanics with stage I-II hypertension, 8-week nebivolol monotherapy resulted in significant reductions in blood pressure. The safety and tolerability profile of nebivolol was similar to that of placebo.
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Affiliation(s)
- Henry Punzi
- Trinity Hypertension & Metabolic Research Institute, 1932 Walnut Plaza, Carrollton, TX 75006, USA.
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Punzi H, Shojaee A, Waverczak WF, Maa JF. Efficacy of amlodipine and olmesartan medoxomil in hypertensive patients with diabetes and obesity. J Clin Hypertens (Greenwich) 2011; 13:422-30. [PMID: 21649842 DOI: 10.1111/j.1751-7176.2010.00422.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A subgroup analysis of a prospective, open-label, single-arm titration study in patients with hypertension and type 2 diabetes or obesity is reported. The primary end point was the change from baseline in mean 24-hour ambulatory systolic blood pressure (BP) after 12 weeks. Patients received amlodipine 5 mg/d and were uptitrated (if seated [Se] BP was ≥ 120/80 mm Hg) at 3-week intervals to amlodipine/olmesartan medoxomil 5/20 mg/d, 5/40 mg/d, and 10/40 mg/d. In patients with diabetes and obesity, baseline 24-hour ambulatory BP (± standard deviation) was 145.6 ± 10.4/83.1 ± 9.0 mm Hg and 143.7 ± 9.8/84.9 ± 8.2 mm Hg, respectively, and baseline SeBP was 159.1 ± 11.3/90.3 ± 9.2 mm Hg and 158.2 ± 12.5/94.2 ± 8.5mm Hg, respectively. Changes from baseline in mean 24-hour ambulatory BP (± standard error of the mean) were -21.5 ± 1.8/-12.6 ± 1.1 mm Hg and 21.6 ± 1.1/13.4 ± 0.8 mm Hg in patients with diabetes and obesity, respectively. Prespecified 24-hour ambulatory BP targets of < 130/80 mm Hg, < 125/75 mm Hg, and < 120/80 mm Hg were achieved by 79.1%, 53.5%, and 39.5% of patients with diabetes and 75.3%, 58.4%, and 43.8% of obese patients, respectively. The SeBP goal of < 130/80 mm Hg was achieved by 26.1% of patients with diabetes and <140/90 mm Hg was achieved by 78.1% of obese patients.
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Affiliation(s)
- Henry Punzi
- Trinity Hypertension Research Institute, Punzi Medical Center, Carrollton, TX, USA
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24
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Punzi H, Neutel JM, Kereiakes DJ, Shojaee A, Waverczak WF, Dubiel R, Maa JF. Efficacy of amlodipine and olmesartan medoxomil in patients with hypertension: the AZOR Trial Evaluating Blood Pressure Reductions and Control (AZTEC) study. Ther Adv Cardiovasc Dis 2010; 4:209-21. [PMID: 20519261 DOI: 10.1177/1753944710374745] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
The aim of the present study was to use ambulatory blood pressure (BP) monitoring (ABPM) to determine the efficacy of a fixed-dose combination of amlodipine (AML) and olmesartan medoxomil (OM) over the 24-hour dosing interval. This 12-week, titrate-to-goal study was conducted in 185 patients with hypertension. Patients were initially treated with AML 5 mg/ day and uptitrated to AML/OM 5/20, 5/40, and 10/40 mg/day every 3 weeks if mean seated BP (SeBP) was ≥120/80 mmHg. The primary efficacy endpoint was the change from baseline in mean 24-hour systolic BP at week 12 as assessed by ABPM. At baseline, the mean 24-hour ambulatory BP (±standard deviation [SD]) was 144.8±11.1/85.7±7.9 mmHg. At week 12, the change from baseline in mean 24-hour ambulatory BP (±standard error of the mean [SEM]) was -21.4±0.8/-12.7±0.5 mmHg (p < 0.0001 versus baseline). At baseline, the mean SeBP (±SD) was 158.2±12.6/92.8±8.6 mmHg and at week 12, the mean SeBP change (±SEM) from baseline (last observation carried forward) was -24.1±1.1/-12.1±0.7 mmHg (p < 0.0001 versus baseline). Proportions of patients achieving mean 24-hour ambulatory BP prespecified study targets were 70.9% (<130/80 mmHg), 48.3% (<125/75 mmHg), and 40.7% (<120/80 mmHg). Cumulatively, 76.8% of patients uptitrated to AML/OM 10/40 mg/day attained an SeBP goal of <140/90 mmHg. The study drug was well tolerated with few adverse events (peripheral edema, 2.2%; dizziness, 1.1%). An AML/OM-based titration regimen effectively reduces BP in patients with hypertension.
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Affiliation(s)
- Henry Punzi
- Trinity Hypertension Research Institute and Metabolic Research Institute, Punzi Medical Center, 1932 Walnut Plaza, Carrollton, TX 75006, USA
| | | | - Dean J. Kereiakes
- The Christ Hospital Heart and Vascular Center and The Carl and Edith Lindner Center for Research and Education at The Christ Hospital, Cincinnati, OH, USA
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Thakkar R, Punzi H, Davidson M, Jiang P, Padley R. Abstract: P1444 ASPIRIN IN ADDITION TO NIACIN PROMOTES A MORE RAPID TOLERANCE TO FLUSHING. ATHEROSCLEROSIS SUPP 2009. [DOI: 10.1016/s1567-5688(09)71452-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Gradman AH, Gray J, Maggiacomo F, Punzi H, White WB. Assessment of once-daily eprosartan, an angiotensin II antagonist, in patients with systemic hypertension. Eprosartan Study Group. Clin Ther 1999; 21:442-53. [PMID: 10321414 DOI: 10.1016/s0149-2918(00)88300-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A multicenter, randomized, double-masked, placebo-controlled trial was conducted to assess the efficacy of once-daily eprosartan, a nonbiphenyl, nontetrazole angiotensin II-receptor antagonist, in 243 patients with mild-to-moderate systemic hypertension (sitting diastolic blood pressure [SitDBP], 95-114 mm Hg). After a 3-to 5-week single-masked placebo run-in period to obtain baseline values, patients were randomly allocated to receive 600 mg eprosartan once daily or placebo for 8 weeks. All clinic blood pressure measurements were made 24 hours +/-90 minutes after dosing. Eprosartan produced statistically and clinically significant reductions in SitDBP(-7.5+/-0.8 mm Hg) and sitting systolic blood pressure (SitSBP) (-6.0+/-1.3 mm Hg) compared with placebo (SitDBP -1.9+/-0.7 mm Hg; SitSBP 0.8+/-1.2 mm Hg). The 95% confidence intervals for the difference from placebo were -8.1 to 4.1 for SitDBP and -11.0 to -4.0 for SitSBP (both, P<0.0001). The proportion of patients responding (SitDBP was <90 mm Hg or had decreased by > or =10 mm Hg from baseline at study end point) to eprosartan was significantly higher than the proportion of those responding to placebo (42% vs. 21%, respectively; P = 0.0003). Similar results were obtained in a subgroup analysis comparing patients aged <65 years with those aged > or =65 years. The total number of adverse events was similar in the eprosartan and placebo groups. Eprosartan 600 mg once daily was both well tolerated and effective, providing significant blood pressure reduction 24 hours after dosing in patients with mild-to-moderate systemic hypertension, regardless of age.
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Affiliation(s)
- A H Gradman
- Western Pennsylvania Hospital, Pittsburgh 15224, USA
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Wilford Germino F, Lastra J, Pool P, Punzi H, Spinowitz B, Smith W, Wallace S, Willett M, Mills D, De Silva J, Cryer D. Evaluation of the cough profile of fosinopril in hypertensive patients with ACE inhibitor-associated cough—A pilot study. Curr Ther Res Clin Exp 1993. [DOI: 10.1016/s0011-393x(05)80665-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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