Dormant bacterial spores encrypt a long-lasting transcriptional program to be executed during revival

Sporulating bacteria can retreat into long-lasting dormant spores that preserve the capacity to germinate when propitious. However, how the revival transcriptional program is memorized for years remains elusive. We revealed that in dormant spores, core RNA polymerase (RNAP) resides in a central chromosomal domain, where it remains bound to a subset of intergenic promoter regions. These regions regulate genes encoding for most essential cellular functions, such as rRNAs and tRNAs. Upon awakening, RNAP recruits key transcriptional components, including sigma factor, and progresses to express the adjacent downstream genes. Mutants devoid of spore DNA-compacting proteins exhibit scattered RNAP localization and subsequently disordered firing of gene expression during germination. Accordingly, we propose that the spore chromosome is structured to preserve the transcriptional program by halting RNAP, prepared to execute transcription at the auspicious time. Such a mechanism may sustain long-term transcriptional programs in diverse organisms displaying a quiescent life form.

The Impact of the Renin-Angiotensin-Aldosterone System on Inflammation, Coagulation, and Atherothrombotic Complications, and to Aggravated COVID-19

Atherosclerosis is considered a disease caused by a chronic inflammation, associated with endothelial dysfunction, and several mediators of inflammation are up-regulated in subjects with atherosclerotic disease. Healthy, intact endothelium exhibits an antithrombotic, protective surface between the vascular lumen and vascular smooth muscle cells in the vessel wall. Oxidative stress is an imbalance between anti- and prooxidants, with a subsequent increase of reactive oxygen species, leading to tissue damage. The renin-angiotensin-aldosterone system is of vital importance in the pathobiology of vascular disease. Convincing data indicate that angiotensin II accelerates hypertension and augments the production of reactive oxygen species. This leads to the generation of a proinflammatory phenotype in human endothelial and vascular smooth muscle cells by the up-regulation of adhesion molecules, chemokines and cytokines. In addition, angiotensin II also seems to increase thrombin generation, possibly via a direct impact on tissue factor. However, the mechanism of cross-talk between inflammation and haemostasis can also contribute to prothrombotic states in inflammatory environments. Thus, blocking of the renin-angiotensin-aldosterone system might be an approach to reduce both inflammatory and thrombotic complications in high-risk patients. During COVID-19, the renin-angiotensin-aldosterone system may be activated. The levels of angiotensin II could contribute to the ongoing inflammation, which might result in a cytokine storm, a complication that significantly impairs prognosis. At the outbreak of COVID-19 concerns were raised about the use of angiotensin converting enzyme inhibitors and angiotensin receptor blocker drugs in patients with COVID-19 and hypertension or other cardiovascular comorbidities. However, the present evidence is in favor of continuing to use of these drugs. Based on experimental evidence, blocking the renin-angiotensin-aldosterone system might even exert a potentially protective influence in the setting of COVID-19.

Heart failure events in a clinical trial of arterial hypertension. The acquittal of the SPRINT trial

Introduction

The Systolic Blood Pressure Intervention Trial (SPRINT) was a randomized trial showing that intensive lowering of systolic blood pressure (BP), as compared to standard treatment (i.e. <120 vs <140 mm Hg) was associated with a reduced risk (HR 0.75 [95% CI 0.64–0.79], p<0.001) for the primary composite outcome (CE), defined as myocardial infarction, an acute coronary syndrome other than myocardial infarction, stroke, acute exacerbation of heart failure and cardiovascular death. primary outcome event in subjects at high cardiovascular risk. However, the primary endpoint events in the intensive treatment arm were only 76 fewer than in the standard treatment arm (243 vs 319 events), and he reduction in heart failure events was responsible for half of the effect (62 vs 100 events, i.e. 38 events fewer). Thus, several experts in hypertension argued that these results were mainly driven by a reduction of heart failure events, and questioned the main conclusion of the study.

Aim

To assess the effect of SPRINT intervention on a redefined CE: the primary SPRINT endpoint with HF events excluded.

Material and methods

We used limited SPRINT data, available from the NHLBI Biologic Specimen and Data Repository to assess the impact of BP intervention in SPRINT on a redefined CE excluding HF events. The Chi-square test, Cox proportional model and survival analysis were applied.

Results

Among 9361 SPRINT participants (mean age 67.9±9.5 years, 35.6% female, 20% with previous cardiovascular disease), there was 461 CE events. There were fewer CE events in the intensive treatment arm than in the standard treatment arm (204 [4.4%] vs 257 [5.5%], p=0.0117, respectively). Intensive systolic BP lowering was associated with lower risk for CE than standard treatment (HR 0.79 [95% CI 0.66–0.95], p=0.0115). Kaplan-Meier curves show that intensive treatment was associated with better outcome (Figure 1). Analyses in subgroups (age >75 vs <75 years, female vs male, black vs non-black, prior cardiovascular disease vs no cardiovascular disease, prior chronic kidney disease vs no chronic kidney disease) showed no difference in benefit of intensive treatment (p for interaction >0.05 in all subgroup).

Conclusion

The reduction in cardiovascular events by intensive BP lowering in SPRINT was not explained by a difference in heart failure events. This supports the concept that more intensive BP reduction may provide benefit in reducing cardiovascular event risk.

Figure 1. Kaplan-Meier curves

Funding Acknowledgement

Type of funding source: None

Use of proteomics to identify biomarkers associated with chronic kidney disease and long-term outcomes in patients with myocardial infarction

BACKGROUND

Patients with chronic kidney disease (CKD) have poor outcomes following myocardial infarction (MI). We performed an untargeted examination of 175 biomarkers to identify those with the strongest association with CKD and to examine the association of those biomarkers with long-term outcomes.

METHODS

A total of 175 different biomarkers from MI patients enrolled in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies (SWEDEHEART) registry were analysed either by a multiple reaction monitoring mass spectrometry assay or by a multiplex assay (proximity extension assay). Random forests statistical models were used to assess the predictor importance of biomarkers, CKD and outcomes.

RESULTS

A total of 1098 MI patients with a median estimated glomerular filtration rate of 85 mL min^-1 /1.73 m² were followed for a median of 3.2 years. The random forests analyses, without and with adjustment for differences in demography, comorbidities and severity of disease, identified six biomarkers (adrenomedullin, TNF receptor-1, adipocyte fatty acid-binding protein-4, TNF-related apoptosis-inducing ligand receptor 2, growth differentiation factor-15 and TNF receptor-2) to be strongly associated with CKD. All six biomarkers were also amongst the 15 strongest predictors for death, and four of them were amongst the strongest predictors of subsequent MI and heart failure hospitalization.

CONCLUSION

In patients with MI, a proteomic approach could identify six biomarkers that best predicted CKD. These biomarkers were also amongst the most important predictors of long-term outcomes. Thus, these biomarkers indicate underlying mechanisms that may contribute to the poor prognosis seen in patients with MI and CKD.

P1539Aortic pulse wave velocity measured by an oscillometric device independently predicts all-cause mortality in a cohort of 4146 subjects

Objectives

Assessment of carotid-femoral pulse wave velocity by applanation tonometry independently predicts all-cause and cardiovascular mortality. However, there has been a need for a simpler, user-independent measurement with a validated device, that is applicable even in the primary care setting.

Methods and subjects

4146 subjects (49% men) aged 35–75 years were measured in multiple centers in Hungary. Subjects visited the outpatient department of these centers on their own initiative. The measurement of aortic pulse wave velocity (PWVao) with Arteriograph was performed in addition to taking past medical history, physical examination and laboratory tests. The mean follow-up time of the study was 5.5 years. The number of events (all cause mortality) were provided by the Hungarian National Health Insurance Fund. Cox regression analyses were used to identify predictive factors for this endpoint.

Results

The mean age of the study population was 53 years, brachial systolic and diastolic blood pressure were 137±20 and 82±11 mmHg, and heart rate was 70±10 1/min. The mean value of SCORE was 3 in this large cohort. 410 subjects had a registered cerebro-or cardiovascular event before the measurement, the number of smokers was 656 (16%), 1974 subjects were treated with at least one anti-hypertensive drug (48%), while the number of subjects on lipid-lowering, antidiabetic or antiplatelet medication were 807 (19%), 352 (8%) and 398 (17%), respectively. There were 116 fatal events during a mean follow-up of 5.5 years. According to the Cox regression, PWVao is a significant and independent predictor of all cause-mortality and in univariate analysis, a 1.0 m/s increase in PWVao was associated with HR 1.7 [1.47–1.98; p<0.001], for this endpoint.

Conclusion

Aortic pulse wave velocity measured by an invasively validated, simple, oscillometric device predicted all-cause mortality in a large cohort of relatively young subjects of the general population that may improve risk stratification even in the everyday clinical practice or primary care setting.

Epigenetic mechanism of FMR1 inactivation in Fragile X syndrome

Fragile X syndrome is the most frequent cause of inherited intellectual disability. The primary molecular defect in this disease is the expansion of a CGG repeat in the 5' region of the fragile X mental retardation1 (FMR1) gene, leading to de novo methylation of the promoter and inactivation of this otherwise normal gene, but little is known about how these epigenetic changes occur during development. In order to gain insight into the nature of this process, we have used cell fusion technology to recapitulate the events that occur during early embryogenesis. These experiments suggest that the naturally occurring Fragile XFMR1 5' region undergoes inactivation post implantation in a Dicer/Ago-dependent targeted process which involves local SUV39H-mediated tri-methylation of histone H3K9. It thus appears that Fragile X syndrome may come about through inadvertent siRNA-mediated heterochromatinization.

Pregnancy-associated plasma protein-A is positively correlated with first-trimester skin microvascular reactivity

OBJECTIVE

To investigate the relationship between levels of circulating maternal pregnancy-associated plasma protein-A (PAPP-A) and first-trimester maternal vascular function.

METHODS

This was a cross-sectional study of 53 healthy, non-smoking, nulliparous pregnant women in Stockholm, Sweden. PAPP-A levels and vascular function were assessed during gestational weeks 11-14. Forearm skin microcirculation was investigated by laser Doppler perfusion imaging during iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP) to assess endothelium-dependent and -independent microvascular vasodilatation, respectively. Microvascular endothelial function index was calculated as peak ACh/peak SNP. Endothelium-dependent and -independent vasodilatation in the brachial artery was evaluated, respectively, by postischemic hyperemia-induced flow-mediated vasodilatation (FMD) and by response to sublingual intake of glyceryl trinitrate (GTN).

RESULTS

PAPP-A was correlated with skin microvascular endothelial function index (β = 1.008 (95% CI, 0.34-1.68), r²  = 0.17, P = 0.004). PAPP-A also correlated inversely with FMD (β = -0.052 (95% CI, -0.094 to -0.011), r²  = 0.13, P = 0.014) but did not relate to forearm endothelial function index (i.e. FMD/GTN). The results were retained in multivariate analyses including known confounding factors.

CONCLUSIONS

First-trimester endothelium-dependent skin microvascular reactivity was positively related to PAPP-A levels. If confirmed, these novel findings suggest that first-trimester skin microvascular reactivity could be a useful early pregnancy marker of placental function. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Longitudinal study of vascular structure and function during normal pregnancy

OBJECTIVE

To examine alterations in maternal vascular structure and function during normal pregnancy.

METHODS

We assessed brachial and central blood pressure, pulse-wave velocity and augmentation index (by pulse-wave analysis and applanation tonometry), common carotid artery structure (by ultrasonography) and endothelial function in the brachial artery (by postischemic hyperemia-induced flow-mediated vasodilatation by glyceryl trinitrate) and in the forearm skin microcirculation (by laser Doppler perfusion imaging during iontophoretic administration of acetylcholine and sodium nitroprusside) in 52 healthy nulliparous women at 14, 24 and 34 weeks' gestation, and at 9 months postpartum.

RESULTS

During pregnancy, brachial and central systolic and diastolic blood pressures initially decreased but subsequently increased (all P < 0.05). Flow-mediated vasodilatation in the brachial artery increased during early pregnancy (P < 0.05), whereas non-specific vasodilatation by glyceryl trinitrate decreased (P < 0.01), indicating improved endothelial function. Thus, endothelial function index (forearm blood flow/glyceryl trinitrate) increased during pregnancy (0.30 ± 0.18 in the non-pregnant state at 9 months postpartum and 0.51 ± 0.19, 0.61 ± 0.39 and 0.49 ± 0.30 in the first, second and third trimesters, respectively) (P < 0.001). Endothelium-dependent skin microvascular reactivity to acetylcholine also increased (P < 0.01). Carotid-femoral pulse-wave velocity decreased during pregnancy (5.88 ± 0.91 m/s in the non-pregnant state and 5.55 ± 0.67, 5.12 ± 0.66 and 5.62 ± 0.74 m/s in the first, second and third trimesters, respectively) (P < 0.001).

CONCLUSION

During normal pregnancy, the blood volume expansion necessary for sufficient fetal growth is accommodated by early and marked changes in the matvascular system. This seems to be dependent on normal adaptive endothelial and vascular function. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Fetal growth is associated with first-trimester maternal vascular function

OBJECTIVE

To investigate the relationship between maternal endothelial function in the first trimester, assessed in both the brachial artery and the forearm skin microcirculation, and fetal growth.

METHODS

Vascular function was assessed in 56 pregnant women during gestational weeks 11-14. Vascular reactivity in the brachial artery was evaluated by postischemic hyperemia-induced flow-mediated vasodilatation (FMD) and by vasodilatation following administration of sublingual glyceryl trinitrate (GTN). Forearm skin microcirculation was investigated by laser Doppler perfusion imaging during iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP) to assess endothelium-dependent and -independent microvascular vasodilatation, respectively. Fetal growth was measured at study inclusion and birth-weight centile was calculated after delivery.

RESULTS

FMD and GTN-induced vasodilatation were both associated with birth-weight centile. On multivariate analysis (adjusted for brachial artery diameter at rest, blood pressure, maternal age and heart rate), for FMD β = 1.7 (95% CI, 0.06-3.34), r²  = 0.26 and P = 0.042, and for GTN-induced vasodilatation β = 2.6 (95% CI, 0.44-4.68), r²  = 0.15 and P = 0.02. Endothelium-dependent and -independent microvascular reactivity were also associated with birth-weight centile: for ACh β = 7.82 (95% CI, 1.81-13.83), r²  = 0.12 and P = 0.029, and for SNP β = 6.27 (95% CI, 1.20-11.34), r²  = 0.11 and P = 0.016.

CONCLUSION

First-trimester maternal vascular dilatation capacity (rather than endothelial function alone) is associated with fetal growth. These findings were consistent in both the brachial artery and the forearm skin microcirculation. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

The p53 C terminus controls site-specific DNA binding and promotes structural changes within the central DNA binding domain

DNA binding by numerous transcription factors including the p53 tumor suppressor protein constitutes a vital early step in transcriptional activation. While the role of the central core DNA binding domain (DBD) of p53 in site-specific DNA binding has been established, the contribution of the sequence-independent C-terminal domain (CTD) is still not well understood. We investigated the DNA-binding properties of a series of p53 CTD variants using a combination of in vitro biochemical analyses and in vivo binding experiments. Our results provide several unanticipated and interconnected findings. First, the CTD enables DNA binding in a sequence-dependent manner that is drastically altered by either its modification or deletion. Second, dependence on the CTD correlates with the extent to which the p53 binding site deviates from the canonical consensus sequence. Third, the CTD enables stable formation of p53-DNA complexes to divergent binding sites via DNA-induced conformational changes within the DBD itself.

The race to decipher the top secrets of TOP mRNAs

Cells encountering hostile growth conditions, like those residing in the middle of a newly developing solid tumor, conserve resources and energy by downregulating protein synthesis. One mechanism in this response is the translational repression of multiple mRNAs that encode components of the translational apparatus. This coordinated translational control is carried through a common cis-regulatory element, the 5' Terminal OligoPyrimidine motif (5'TOP), after which these mRNAs are referred to as TOP mRNAs. Subsequent to the initial structural and functional characterization of members of this family, the research of TOP mRNAs has progressed in three major directions: a) delineating the landscape of the family; b) establishing the pathways that transduce stress cues into selective translational repression; and c) attempting to decipher the most proximal trans-acting factor(s) and defining its mode of action--a repressor or activator. The present chapter critically reviews the development in these three avenues of research with a special emphasis on the two "top secrets" of the TOP mRNA family: the scope of its members and the identity of the proximal cellular regulator(s). This article is part of a Special Issue entitled: Translation and Cancer.

PP037. Family history of cardiovascular disease and maternal vascular function during early pregnancy

INTRODUCTION

Women with a family history of cardiovascular disease (CVD) have an increased risk of hypertensive disorders during pregnancy. Pregnancy is associated with increased physical demands on the cardiovascular system and hemodynamic changes. Cardiac output increases by about 40-50%, blood volume by 10-20% and vascular resistance decreases.

OBJECTIVES

Our hypotheses was that women with a family history of CVD fail to have an adequate cardiovascular adaptation during pregnancy.

METHODS

Fifty healthy women with singleton viable pregnancies were included in the study who were recorded in the Ultrasound Department of UltraGyn Stockholm, Sweden for ultrasound dating in gestational week of 11-14. Of these, 25 women had a family history of CVD which was defined as having at least one first degree relative with the diagnosis of premature hypertension, myocardial infarct or stroke before the age of 55 (men) or 65 (women). Twenty five healthy women without a family history were included as controls. Smokers were excluded. Blood pressure was measured in the upper left arm in a conventional way. The pulse wave was registered in the radial artery (SphygmoCor Px and Vx, PWV Medical). The central blood pressure was calculated with a validated algorithm. The pulse wave was then registered in the femoral artery, the velocity was calculated and the arterial stiffness estimated. Flow mediated vasodilation was studied in the radial artery through measurement with ultrasound of diameter changes and blood flow before and after ischemia (Vivid 7, GE, 10MHz transducer).

RESULTS

Systolic blood pressure in the upper left arm was significantly higher in women with a family history of CVD (median 109.5mmHg versus 105mmHg, p=0.04). Diastolic blood pressure did not differ. Aortic blood pressure also differed significantly in women with a family history of CVD, both systolic (median 95mmHg versus 86.3mmHg, p=0.0005) and diastolic (median 66mmHg versus 59.3mmHg, p=0.0024). No other results were significantly different. All values refer to examinations at gestational weeks 11-14.

CONCLUSION

Changes in vascular function during the first trimester reflect important adaptations that are necessary for a normal pregnancy. Women with a family history of CVD had a significantly higher blood pressure at 11-14weeks of gestation although the values were within normal range. The pregnancy related decrease of vascular resistance may be less pronounced in women with a family history of CVD. Vascular function will be followed longitudinally during pregnancy and related to obstetric outcome in this group.

A randomized controlled trial on very early speech and language therapy in acute stroke patients with aphasia

Background

Aphasia affects one third of acute stroke patients. There is a considerable spontaneous recovery in aphasia, but impaired communication ability remains a great problem. Communication difficulties are an impediment to rehabilitation. Early treatment of the language deficits leading to increased communication ability would improve rehabilitation. The aim of this study is to elucidate the efficacy of very early speech and language therapy (SLT) in acute stroke patients with aphasia.

Methods

A prospective, open, randomized, controlled trial was carried out with blinded endpoint evaluation of SLT, starting within 2 days of stroke onset and lasting for 21 days. 123 consecutive patients with acute, first-ever ischemic stroke and aphasia were randomized. The SLT treatment was Language Enrichment Therapy, and the aphasia tests used were the Norsk grunntest for afasi (NGA) and the Amsterdam-Nijmegen everyday language test (ANELT), both performed by speech pathologists, blinded for randomization.

Results

The primary outcome, as measured by ANELT at day 21, was 1.3 in the actively treated patient group and 1.2 among controls. NGA led to similar results in both groups. Patients with a higher level of education (>12 years) improved more on ANELT by day 21 than those with <12 years of education (3.4 vs. 1.0, respectively). In 34 patients in the treatment group and 19 in the control group improvement was ≥1 on ANELT (p < 0.05). There was no difference in the degree of aphasia at baseline except for fluency, which was higher in the group responding to treatment.

Conclusions

Very early intensive SLT with the Language Enrichment Therapy program over 21 days had no effect on the degree of aphasia in unselected acute aphasic stroke patients. In aphasic patients with more fluency, SLT resulted in a significant improvement as compared to controls. A higher educational level of >12 years was beneficial.

The economic consequences of non-adherence to lipid-lowering therapy: results from the Anglo-Scandinavian-Cardiac Outcomes Trial

BACKGROUND

Adherence to lipid-lowering therapy in clinical practice is less than ideal. Analysis of registry data has indicated that this is associated with poor outcomes. The objective of the present analysis was to assess the impact of high adherence to drug (defined as > 80% of days covered), compared with low adherence to drug (< 50% of days covered) in terms of risk of events and long-term economic consequences.

DESIGN

Open-label follow up of a randomised placebo-controlled trial in hypertensive patients.

METHODS

Cox proportional hazards and Poisson regression models were used to assess the hazard ratio of patients with high adherence compared with low adherence while controlling for cardiovascular risk. A Markov model was used to predict the long-term costs and health outcomes associated with poor adherence during the follow-up period.

RESULTS

Both statistical models indicated that high adherence is associated with improved prognosis [Cox model: 0.75; 95% confidence interval (CI): 0.56-0.98, Poisson model hazard ratio: 0.73; 95% CI: 0.58-0.98]. Discounted at 3.5% per year, the Markov model predicts that as a consequence of higher adherence during the follow-up period, costs would be higher (1689 pounds per patient compared with 1323 pounds per patient) because of higher drug costs, but the projected survival and quality-adjusted survival (QALY) would also be longer (10.83 compared with 10.81 life years and 8.13 compared with 8.11 QALYs).

CONCLUSION

Given the higher risk of cardiovascular events associated with low adherence shown here, measures to improve adherence are an important part of the prevention of cardiovascular disease.

A single nucleotide polymorphism in the promoter region of the osteoprotegerin gene is related to intima‐media thickness of the carotid artery in hypertensive patients. The Swedish irbesartan left ventricular hypertrophy investigation vs atenolol (SILVHIA)

Osteoprotegerin (OPG) is a secreted member of the tumor necrosis factor receptor family, and in previous studies has been shown to regulate osteoclast activity and differentiation. Ablation of the OPG gene in mice results in calcification of the aorta and renal arteries. We have previously reported an association between a single nucleotide polymorphism in the promoter region of OPG and vascular morphology and function in healthy humans. The objective with this study was to confirm our previous results in a larger population, and in addition, to study subjects with hypertension. The OPG genotype was determined by restriction fragment length and the intima-media thickness (IMT) of the common carotid artery was measured by ultrasound in 100 patients with hypertension and left ventricular hypertrophy, and 75 healthy normotensive control subjects. In the hypertensive group subjects with the CC genotype (n=24) showed a significantly increased IMT compared to those with the TC (n=52, p=0.007) and TT (n=24, p=0.009) genotype, in the hypertensive group only (mean +/- SD for TT=0.88 +/- 0.21 mm, TC=0.90 +/- 0.16 mm, CC=1.05 +/- 0.31 mm). The allele distribution did not differ between hypertensive and control individuals. The present study confirms our previous finding and shows that polymorphism in the promoter region of OPG is associated with vascular morphology in hypertensive subjects.

Economic evaluation of ASCOT-BPLA: antihypertensive treatment with an amlodipine-based regimen is cost effective compared with an atenolol-based regimen

OBJECTIVE

To compare the cost effectiveness of an amlodipine-based strategy and an atenolol-based strategy in the treatment of hypertension in the UK and Sweden.

DESIGN

A prospective, randomised trial complemented with a Markov model to assess long-term costs and health effects.

SETTING

Primary care.

PATIENTS

Patients with moderate hypertension and three or more additional risk factors.

INTERVENTIONS

Amlodipine 5-10 mg with perindopril 4-8 mg added as needed or atenolol 50-100 mg with bendroflumethiazide 1.25-2.5 mg and potassium added as needed

MAIN OUTCOME MEASURES

Cost per cardiovascular event and procedure avoided, and cost per quality-adjusted life-year gained.

RESULTS

In the UK, the cost to avoid one cardiovascular event or procedure would be euro18 965, and the cost to gain one quality-adjusted life-year would be euro21 875. The corresponding figures for Sweden were euro13 210 and euro16 856.

CONCLUSIONS

Compared with the thresholds applied by NICE and in the Swedish National Board of Health and Welfare's Guidelines for Cardiac Care, an amlodipine-based regimen is cost effective for the treatment of hypertension compared with an atenolol-based regimen in the population studied.

Cardiac repolarization and its relation to ventricular geometry and rate in reverse remodelling during antihypertensive therapy with irbesartan or atenolol: results from the SILVHIA study

Hypertensive left ventricular (LV) hypertrophy is associated with a substantial risk for malignant arrhythmias and sudden death. According to recent results, antihypertensive therapy with the angiotensin II type 1 receptor blocker irbesartan reverses both structural and electrical remodelling. However, the relation between the LV geometric pattern (concentric vs eccentric) and electrical reverse remodelling has not been characterized, neither has the relation between repolarization and rate (QT/RR and JT/RR relation), which presumably reflects the propensity for bradycardia-dependent ventricular arrhythmia. In this study, repeat echocardiographic and electrocardiographic measurements were performed in hypertensive patients with LV hypertrophy, randomized to double-blind therapy with irbesartan (n = 44) or the beta(1)-adrenoceptor blocker atenolol (n = 48) for 48 weeks; 53 patients had concentric and 39 eccentric LV hypertrophy. In addition, 37 matched hypertensive subjects without LV hypertrophy and no current therapy served as controls. Irbesartan induced structural and electrophysiological reverse remodelling, independent of LV geometry. In contrast, atenolol had similar beneficial effect only in patients with concentric LV hypertrophy, while the response in those with eccentric hypertrophy was unfavourable with both prolonged repolarization time and an increased QT/RR slope (suggesting reverse-use dependence). In conclusion, there is a significant geometry-related difference in the reverse remodelling processes induced by irbesartan and atenolol. Echocardiographic characterization of the geometry in hypertension-induced LV hypertrophy might become an important step in the selection of optimal antihypertensive therapy.

Recognition of Depression in Aphasic Stroke Patients

BACKGROUND

Data on post-stroke depression in aphasia are scarce.

METHODS

Eighty-nine acute stroke patients with aphasia of all types were followed for 6 months to investigate if depression can be reliably diagnosed (DSM-IV criteria) and validly assessed by the verbal Montgomery-Asberg Depression Rating Scale (MADRS) and a global technique (Clinical Global Impressions Rating Scale for Severity). A standard aphasia test was performed.

RESULTS

In 60 patients (67%) at baseline and in 100% at 6 months, comprehension allowed a reliable DSM-IV diagnosis. Among these patients MADRS was feasible in 95% at baseline and in 100% at 6 months. The assistance of relatives and staff increases the feasibility and decreases the validity. Depression was identified in 24% during the 6 months.

CONCLUSION

Depression diagnosis and severity rating can reliably be made in the acute phase in at least two thirds of aphasic patients, and feasibility increases over time.

Irbesartan reduces common carotid artery intima-media thickness in hypertensive patients when compared with atenolol: the Swedish Irbesartan Left Ventricular Hypertrophy Investigation versus Atenolol (SILVHIA) study

BACKGROUND AND PURPOSE

Angiotensin II promotes cell growth and has been implicated in the development and maintenance of left ventricular (LV) hypertrophy and of structural vascular changes. We wished to examine whether an angiotensin receptor blocker (ARB) would influence structural vascular changes beyond the effects of blood pressure reduction.

METHODS

Hypertensive patients with LV hypertrophy (age 55 +/- 9 years, blood pressure 162 +/- 19/104 +/- 8 mmHg, LV mass index 148 +/- 31 g m(-2); mean +/- SD) were randomized double-blind to the ARB irbesartan (n=52) or the beta(1) receptor blocker atenolol (n=56) for 48 weeks. Ultrasonography of the left and right common carotid artery (CCA) and echocardiography were performed at week 0 and 48.

RESULTS

With similar reductions in blood pressure, CCA intima-media thickness (IMT) was reduced by irbesartan (from 0.92 +/- 0.14 by 0.01 +/- 0.10 mm, NS), whereas it was increased by atenolol (from 0.94 +/- 0.21 by 0.03 +/- 0.12 mm, P=0.018; P=0.002 between groups). CCA lumen diameter was less reduced by irbesartan than by atenolol. Thus, CCA intima-media area was reduced by irbesartan (from 21.3 +/- 5.0 by 0.90 +/- 2.45 mm(2), P=0.034) but not by atenolol (from 21.3 +/- 6.1 by 0.18 +/- 2.71 mm(2), NS; P=0.037 between groups). Changes in CCA IMT or area did not relate to changes in LV mass.

CONCLUSIONS

The favourable effects by irbesartan on CCA IMT with an outward vascular remodelling suggest that angiotensin II mediates structural vascular changes, beyond the effects of blood pressure. This may be important in the prevention of cerebrovascular events.

Interaction of Epe1 with the heterochromatin assembly pathway in Schizosaccharomyces pombe

Epe1 is a JmjC domain protein that antagonizes heterochromatization in Schizosaccharomyces pombe. Related JmjC domain proteins catalyze a histone demethylation reaction that depends on Fe(II) and alpha-ketoglutarate. However, no detectable demethylase activity is associated with Epe1, and its JmjC domain lacks conservation of Fe(II)-binding residues. We report that Swi6 recruits Epe1 to heterochromatin and that overexpression of epe1+, like mutations in silencing genes or overexpression of swi6+, upregulates expression of certain genes. A significant overlap was observed between the lists of genes that are upregulated by overexpression of epe1+ and those that are upregulated by mutations in histone deacetylase genes. However, most of the common genes are not regulated by Clr4 histone methyltransferase. This suggests that Epe1 interacts with the heterochromatin assembly pathway at the stage of histone deacetylation. Mutational inactivation of Epe1 downregulates approximately 12% of S. pombe genes, and the list of these genes overlaps significantly with the lists of genes that are upregulated by mutations in silencing genes and genes that are hyperacetylated at their promoter regions in clr6-1 mutants. We propose that an interplay between the repressive HDACs activity and Epe1 helps to regulate gene expression in S. pombe.

Mechanisms of exercise-induced ST-segment depression in patients without typical angina pectoris

OBJECTIVE

To evaluate if exercise-induced ST-segment depression without typical angina pectoris is related to increases in sympatho-adrenal activity or beta-adrenoceptor sensitivity.

PATIENTS

Thirteen patients (four men) aged 35-62 years with ST-segment depression during exercise but atypical symptoms and normal myocardial scintigraphy, and 13 matched controls.

DESIGN AND INTERVENTIONS

Patients and controls were compared regarding responses with: (i) exercise testing without treatment, (ii) exercise testing following beta-adrenoceptor blockade by propranolol (0.15 mg kg(-1) i.v.), (iii) incremental adrenaline infusions (0.1, 0.2, 0.4 and 0.8 nmol kg(-1) min(-1)) and (iv) adrenaline infusions during alpha-adrenoceptor blockade by phentolamine (0.5 mg min(-1)).

MAIN OUTCOME MEASURES

ST-segment depression and tissue Doppler parameters reflecting contractility.

RESULTS

Exercise lowered the ST-segment by 2.44 mm without and 0.87 mm with beta-adrenoceptor blockade (P < 0.001 for difference) amongst patients, but not amongst controls. Maximal heart rate was slightly higher amongst patients (P < 0.05), despite similar loads and plasma catecholamine responses to exercise in the two groups; this difference disappeared after beta-adrenoceptor blockade with propranolol. ST-segment depression during adrenaline infusion was greater in patients compared with controls (P < 0.01) despite similar increases in heart rate. alpha-Blockade enhanced the ST-segment depression (P < 0.001) and heart rate (P < 0.001) responses to adrenaline infusion more markedly amongst patients. Tissue Doppler imaging showed similar contractility and diastolic relaxation responses of patients and controls to adrenaline, but early diastolic movements did not increase amongst patients after phentolamine (P < 0.01).

CONCLUSIONS

Exercise-induced ST-segment depression in patients with a low likelihood of ischaemic heart disease is related to increased beta-adrenergic sensitivity regarding chronotropic and electrophysiological, but not inotropic responses.

Cyprinid herpes virus-3 (CyHV-3) bears genes of genetically distant large DNA viruses

A large DNA virus, designated koi herpes virus (KHV), carp interstitial nephritis gill necrosis virus (CNGV) and Cyprinid herpes virus-3 (CyHV-3), causes massive mortality of carp. Morphologically, the virus resembles herpes viruses, but it contains a genome of ca 295 kbp, larger than that of any Herpesviridae member. Interestingly, three CyHV-3 genes, thymidylate monophosphate kinase (TmpK), ribonucleotide reductase and thymidine kinase, which are involved in deoxynucleotide tri-phosphate synthesis, resemble those of pox viruses. In addition to the TmpK gene, which is nonexistent in the genome of herpes viruses, CyHV-3 contains a B22R-like gene, exclusively expressed by pox viruses. These results raise questions on the phylogenic origin of CyHV-3.

Predicting readmissions and cardiovascular events in heart failure patients

AIMS

To analyse measures of clinical data, functional capacity, left ventricular function and neurohormonal activation for the ability to predict mortality and morbidity in patients after a hospitalisation for heart failure.

METHODS

In a prospective study, patients 60 years or above with systolic heart failure NYHA II-IV were followed for at least 18 months. At study start, a physical examination, echocardiography, blood samples and measurements of quality of life (QoL) by Nottingham Health Profile were obtained. Data on mortality and readmission rates were collected.

RESULTS

208 patients, 58% men, with a mean age of 76 years, and an ejection fraction of 0.34 were included and followed for a mean of 1,122 days. In all, 74 (36%) patients died and 171 (82%) were readmitted. By univariate analysis, readmissions were predicted by poor QoL (169 +/- 118 vs. 83 +/- 100, p < 0.001), age, creatinine, haemoglobin (p < 0.01 all) and diabetes (p < 0.1). By multivariate analyses, QoL at study start was the only independent predictor of readmissions (chi(2) = 25.2, p < 0. 001). Mortality was univariately associated with QoL (183 +/- 117 vs. 142 +/- 115, p < 0.05) and in multivariate analyses to traditional variables: age, male gender, systolic function, BNP and serum creatinine (chi(2) = 48.9, p < 0.001).

CONCLUSIONS

Measurements representing different aspects of the heart failure syndrome can easily be obtained to stratify long-term risks of mortality and morbidity in hospitalised heart failure patients. Poor QoL was a univariate predictor for mortality and a strong multivariate predictor for the important outcome of readmission, pointing to the need for a simple assessment of QoL.

Nurse-recorded clinic and ambulatory blood pressures correlate equally well with left ventricular mass and carotid intima-media thickness

OBJECTIVE

To assess relationships between noninvasive ambulatory blood pressure (BP), clinic BP (mean value of three readings in the seated position measured by nurses), structural cardiac indices, intima-media thickness of the common carotid artery and several hormones.

DESIGN

Cross-sectional study of 75 subjects with hypertension and left ventricular hypertrophy (HTH) according to echocardiography, 35 subjects with hypertension and normal left ventricular dimensions (HT) and 23 normotensive subjects (NT).

RESULTS

We found an excellent correlation between mean 24-h ambulatory BP and clinic BP, the r-value for systolic BP being 0.82 and for diastolic levels 0.78 (both P < 0.0001). Clinic and ambulatory BP correlated equally well with left ventricular (LV) mass index (r-values between 0.55 and 0.64, all P < 0.0001) and to intima-media thickness of the carotid artery (r = 0.18-0.34, P < 0.01). The systolic white-coat effect (clinic BP - day-time BP) was higher in the HTH and HT compared with NT and was weakly correlated to LV mass index (r = 0.18, P = 0.04). Nondippers (mean arterial night/day BP ratio of > 0.9) had higher brain (6.1 +/- 7.5 pmol L(-1) vs. 3.7 +/- 3.2 pmol L(-1), P = 0.01) and atrial (14 +/- 3.4 pmol L(-1) vs. 9.3 +/- 5.4 pmol L(-1), P = 0.04) natriuretic peptide levels, and also exhibited a lower ejection fraction (49 +/- 8% vs. 57 +/- 9%, P = 0.006), than dippers.

CONCLUSION

Clinic BP recordings performed by nurses as three measurements 1 min apart provide excellent relationship to target organ damage. Nondippers exhibited signs of a more advanced hypertensive organ damage than dippers which corresponds well with the poor prognosis linked to this condition.

Long-Term Antidepressant Treatment with Moclobemide for Aphasia in Acute Stroke Patients: A Randomised, Double-Blind, Placebo-Controlled Study

BACKGROUND AND PURPOSE

Pharmacotherapy aimed at stroke rehabilitation through direct central nervous effects may be assumed to work in a similar way for language recovery and sensory-motor recovery. Some data suggest that antidepressant drugs could be beneficial also for functional improvement. This prompted us to investigate whether regression from aphasia after acute stroke could be enhanced by antidepressive drug therapy.

METHODS

We randomised 90 acute stroke patients with aphasia to either 600 mg moclobemide or placebo daily for 6 months, within 3 weeks of the onset of stroke. Aphasia was assessed prior to treatment and at 6 months, using Reinvang's 'Grunntest for afasi' and the Amsterdam-Nijmegen-Everyday-Language-Test (ANELT).

RESULT

The degree of aphasia decreased significantly at 6 months, with no difference between the moclobemide- and the placebo-treated groups. Multivariate regression analysis including treatment group, activities of daily living, aetiology of stroke, ANELT, and Reinvang's coefficient at baseline, and neurological deficit confirmed these results. In all, 13 in the moclobemide and 10 in the placebo group stopped taking the study medication. No further change was found in the 56 aphasic patients followed up for another 6 months with no medication.

CONCLUSIONS

Compared to placebo, treatment with moclobemide for 6 months did not enhance the regression of aphasia following an acute stroke.

Beta1-adrenergic receptor gene polymorphisms and response to beta1-adrenergic receptor blockade in patients with essential hypertension

BACKGROUND

Studies suggest that the Ser49Gly and Arg389Gly polymorphisms in the beta1-adrenergic receptor might be of functional importance for the cardiovascular system. Both have been associated with altered receptor activity in vitro, and with hypertension and cardiac failure in vivo.

HYPOTHESIS

The aim of this study was to test whether these polymorphisms were associated with the change in heart rate or blood pressure in patients with essential hypertension and left ventricular (LV) hypertrophy treated with the beta1-adrenergic receptor blocker atenolol.

METHODS

Blood pressure and heart rate were measured in 101 hypertensive patients with echocardiographically verified LV hypertrophy, randomized in a double-blind study to treatment with either the beta1-adrenergic receptor blocker atenolol or the angiotensin II type I receptor antagonist irbesartan. Changes in blood pressure and heart rate were evaluated after 12 weeks. Beta1-adrenergic receptor genotyping was performed using polymerase chain reaction and restriction fragment length polymorphism.

RESULTS

We found no significant associations between the changes in the measured variables and either of the two polymorphisms. However, carriers of the 49Gly allele showed a tendency toward a greater reduction in heart rate compared with patients with the Ser/Ser49 genotype (p = 0.06).

CONCLUSIONS

The Ser49Gly and Arg389Gly beta1-adrenergic receptor polymorphisms do not seem to exert a major effect on the changes in heart rate and blood pressure during 12 weeks of treatment with atenolol in patients with essential hypertension and LV hypertrophy.

Gender-specific association between preproendothelin-1 genotype and reduction of systolic blood pressure during antihypertensive treatment--results from the Swedish Irbesartan Left Ventricular Hypertrophy Investigation versus Atenolol (SILVHIA)

BACKGROUND

Studies suggest that endothelin-1 contributes to the pathogenesis of hypertension. A G5665T gene polymorphism of preproendothelin-1 has been shown to be associated with higher blood pressure in overweight patients. No study has yet determined the effect of this polymorphism on the change in blood pressure during antihypertensive treatment.

HYPOTHESIS

This study aimed to determine this effect in hypertensive patients with left ventricular (LV) hypertrophy during antihypertensive treatment with either irbesartan or atenolol.

METHODS

We determined the preproendothelin-1 genotype using minisequencing in 102 patients with essential hypertension and LV hypertrophy verified by echocardiography, randomized in a double-blind fashion to treatment with either the AT1-receptor antagonist irbesartan or the beta1-adrenoceptor antagonist atenolol.

RESULTS

The change in systolic blood pressure (SBP) after 12 weeks of treatment was related to the preproendothelin-1 genotype in men; after adjustment for potential covariates (age, blood pressure, and LV mass index at study entry, dose of irbesartan/atenolol, and type of treatment), those carrying the T-allele responded on average with a more than two-fold greater reduction than those with the G/G genotype (-21.9 mmHg 13.9] vs. -8.9 [2.3], p = 0.007). No significant differences in blood pressure change between G/G and carriers of the T-allele were seen among women.

CONCLUSIONS

Our finding suggests a gender-specific relationship between the G5665T preproendothelin-1 polymorphism and change in SBP in response to antihypertensive treatment with irbesartan or atenolol, suggesting the endothelin pathway to be a common mechanism included in the hypertensive action of the drugs.

Limited long term effects of a management programme for heart failure

OBJECTIVE

To evaluate the effects of a nurse based outpatient management programme for elderly patients discharged with heart failure from a university hospital.

DESIGN

Patients with heart failure (New York Heart Association class II-IV) and left ventricular systolic dysfunction aged 60 years or more were randomly assigned to follow up within the management programme or to conventional follow up, usually in primary care. Of the 208 participants, 58% were men, mean age was 75 years, and mean ejection fraction 34%. All patients were scheduled for three observational study visits at six month intervals. The primary end point was quality of life (QoL) and secondary end points were hospitalisation and mortality.

RESULTS

More patients achieved target doses of angiotensin converting enzyme (ACE) inhibitors in the intervention group than in the control group (82% v 69%, 88% v 69%, and 88% v 74% of recommended target doses at 6, 12, and 18 months of follow up, respectively, p < 0.05 for all). Patients with initial low QoL had a poor prognosis. After a mean 1122 days of follow up, 82% of all patients had been readmitted. There were on average 4.7 readmissions per patient and 66% were due to non-cardiac diagnoses. There were no differences in QoL or health care consumption between the two study groups during follow up.

CONCLUSION

A nurse based management programme is more effective than follow up in primary care in optimising medication for elderly patients with heart failure. However, such a programme does not seem to have a favourable influence on QoL or readmission rate during long term follow up.

Blood pressure and left ventricular geometric pattern determine diastolic function in hypertensive myocardial hypertrophy

Abnormal left ventricular (LV) diastolic relaxation is an early sign of hypertensive heart disease. Whether LV diastolic dysfunction is caused directly by raised blood pressure, or by structural changes related to LV hypertrophy remains controversial. We examined 115 hypertensive patients with LV hypertrophy, and two age- and gender-matched groups (38 hypertensive patients without LV hypertrophy and 38 normotensive subjects) by echocardiography to assess determinants of LV diastolic function, and the relation between diastolic function and LV geometric pattern. Diastolic function was evaluated by the E/A-ratio, E wave deceleration time (E-dec), isovolumic relaxation time (IVRT), and the atrioventricular plane displacement method (AV-LA/AV-mean). A multivariate analysis (including gender, age and body mass index) shows diastolic function to be inversely related to blood pressure, LV wall thickness and LV mass, but not to LV end diastolic diameter. The E/A-ratio generally showed the strongest relations. Only the E/A-ratio and AV-LA/AV-mean were related to heart rate. By stepwise regression analysis, age was the strongest determinant for the E/A-ratio, E-dec and AV-LA/AV-mean, followed by systolic blood pressure, heart rate and LV wall thickness. For IVRT, however, LV wall thickness appeared strongest, followed by systolic blood pressure and age. In conclusion, blood pressure and LV wall thickness both have independent influence on LV diastolic function. Age and blood pressure are the most important factors to determine the E/A-ratio and E-dec, whereas LV geometry and blood pressure are most important when IVRT is used. AV-LA/AV-mean may not be useful in hypertensive LV hypertrophy.

A novel jmjC domain protein modulates heterochromatization in fission yeast

The heterochromatin domain at the mat locus of Schizosaccharomyces pombe is bounded by the IR-L and IR-R barriers. A genetic screen for mutations that promote silencing beyond IR-L revealed a novel gene named epe1, encoding a conserved nuclear protein with a jmjC domain. Disruption of epe1 promotes continuous spreading of heterochromatin-associated histone modifications and Swi6 binding to chromatin across heterochromatic barriers. It also enhances position effect variegation at heterochromatic domains, suppresses mutations in silencing genes, and stabilizes the repressed epigenetic state at the mat locus. However, it does not enhance silencing establishment. Our analysis suggests that the jmjC domain is essential for Epe1 activity and that Epe1 counteracts transcriptional silencing by negatively affecting heterochromatin stability. Consistent with this proposition, the meiotic stability of established heterochromatin beyond IR-L is diminished by Epe1 activity, and overexpression of Epe1 disrupts heterochromatin through acetylation of H3-K9 and H3-K14 and methylation of H3-K4. Furthermore, overexpression of Epe1 elevates the rate of chromosome loss. We propose that Epe1 helps control chromatin organization by down-regulating the stability of epigenetic marks that govern heterochromatization.

Soluble intercellular adhesion molecule-1 is related to endothelial vasodilatory function in healthy individuals

OBJECTIVE

To investigate the associations between markers of systemic and vascular inflammation, and indicators of vascular morphology and function.

METHODS

In 59 apparently healthy individuals, we measured serum levels of highly sensitive C-reactive protein (hsCRP), intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and E-selectin. Endothelium-dependent (EDV) and -independent (EIDV) vasodilatation was evaluated in the forearm by venous occlusion plethysmography and local infusions of methacholine and sodium nitroprussid. Endothelial function index (EFI) was expressed as the EDV/EIDV ratio. The intima-media thickness (IMT) of the common carotid artery was investigated with ultrasound (far wall).

RESULTS

EFI was inversely related only to ICAM-1 (r=-0.31, P<0.02) by univariate analysis. This association remained significant after adjustment for age, sex, blood pressure, smoking and serum cholesterol. EFI did not relate to hsCRP, VCAM-1 or E-selectin. Neither hsCRP, nor the adhesion molecules were significantly related to carotid artery IMT.

CONCLUSION

ICAM-1 was related to endothelial vasodilatory function, but not to IMT, suggesting that endothelial inflammatory activation is related to an impaired vascular relaxation in apparently healthy individuals.

Relationships between left ventricular mass and the renin-angiotensin system, catecholamines, insulin and leptin

OBJECTIVES

Several neurohormonal systems have been suggested to stimulate myocardial cell growth, and thus take part in the development of left ventricular (LV) hypertrophy. We studied associations between LV mass and markers of the renin-angiotensin-aldosterone system (RAAS), the sympathetic nervous system, glucose homeostasis and leptin.

DESIGN

A total of 115 hypertensive patients with LV hypertrophy and two age- and gender-matched control groups consisting of 38 hypertensive patients without LV hypertrophy and 38 normotensive subjects were included. We examined determinants of the RAAS, plasma levels and 24-h urinary excretions of noradrenaline and adrenaline, plasma proinsulin, insulin, glucose, leptin and LV mass by echocardiography.

RESULTS

Plasma renin activity (PRA) and serum aldosterone were higher (both P < 0.001) in the LV hypertrophy group than in patients without LV hypertrophy and normotensive subjects (1.0 +/- 0.8, 0.2 +/- 0.2 and 0.2 +/- 0.2 ng mL(-1) h(-1), and 327 +/- 126, 269 +/- 146 and 221 +/- 80 pmol L(-1), respectively). PRA and aldosterone both related (P < 0.001) to LV mass index (r = 0.44 and 0.27, respectively). Catecholamine levels and excretions were similar in all three groups and did not relate to LV mass index. Proinsulin, insulin and leptin levels were all elevated in the hypertensive patients (P < 0.01), but proinsulin, insulin, insulin sensitivity (by the homeostasis model assessment) and leptin did not relate to LV geometry, when indexed for body size.

CONCLUSIONS

Plasma renin activity and serum aldosterone levels are elevated in hypertensive LV hypertrophy and relate to LV mass index. In addition to blood pressure, activation of the RAAS may be an important nonhaemodynamic mechanism in the control of LV hypertrophy.

Ventilatory variables are strong prognostic markers in elderly patients with heart failure

OBJECTIVE

To evaluate the safety and prognostic capacity of cardiopulmonary exercise testing in patients > or = 60 years old who are hospitalised with heart failure caused by left ventricular dysfunction.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENTS

Study participants were 67 patients (66% men) with clinical heart failure stabilised on medical treatment. The study is a part of a nursing intervention study. Mean (SD) age was 74 (6) years, New York Heart Association functional class II-III, and ejection fraction 0.36 (0.11).

INTERVENTIONS

Cardiopulmonary exercise testing and echocardiography.

MAIN OUTCOME MEASURES

Peak oxygen consumption (VO2), peak ventilatory equivalents for carbon dioxide (VE/VCO2) and oxygen (VE/VO2), left ventricular volumes, and mortality.

RESULTS

Mean (SD) peak VO2 was 11.7 (3.7) ml/kg/min, peak VE/VCO2 43 (9), and peak VE/VO2 46 (11). During 12-59 months of follow up, 14 patients died. In univariate analyses peak VO2, VE/VO2, and VE/VCO2 were all strongly related (p < 0.01) to mortality. In a multivariate Cox regression analysis, peak VE/VCO2 was the strongest predictor of mortality (p < 0.001), followed by left ventricular end systolic volume (p < 0.001). A cut off of peak VE/VCO2 at > or = 45 gave a univariate hazard ratio of 6.7 for death during follow up. No adverse events occurred during the exercise test.

CONCLUSION

These findings extend results found in selected middle aged patients to elderly patients with heart failure and show that ventilatory parameters from a cardiopulmonary exercise test, such as peak VO2, VE/O2, and VE/VCO2 are powerful predictors of mortality.

Cloning and characterization of a novel human gene RNF38 encoding a conserved putative protein with a RING finger domain

RING finger (C3HC4-type zinc finger) is a variant zinc finger motif present in a large family of functionally distinct proteins. We describe the cloning and characterization of a novel human transcript RNF38 encoding a new member of the RING finger protein family. The complete mRNA consists of about 6.8 kb widely expressed in human tissues as a single transcript, most abundantly in testis. The predicted proline-rich protein consists of 432 amino acid residues with a coiled-coil motif and a RING-H2 motif (C3H2C2) at its carboxy-terminus. High degree homology was found between the human protein and hypothetical peptides from several other species including Rattus norvegicus, Mus musculus, and Drosophila melanogaster, indicating a significant conservation throughout evolution. The RNF38 genomic structure was determined and comprises at least 13 exons extending over more than 65 kb in the genome, 78 kb centromeric to the GNE gene on human chromosome 9p12-p13. The involvement of this chromosomal segment in a large number of human diseases and in particular in various types of malignancies urges the assessment of the potential functional role of RNF38 in these disorders.

Cloning and characterization of a human novel gene C9orf19 encoding a conserved putative protein with an SCP-like extracellular protein domain

A novel human transcript, C9orf19, mapped to the genomic region involved in hereditary inclusion body myopathy (IBM2) at chromosome 9p12-p13, has been cloned and characterized. A single cDNA clone consisting of the full-length 1.9 kb transcript has been isolated from a human placenta cDNA library and further analyzed. Genomic characterization of the C9orf19 gene identified five exons extending over 27.2 kb of genomic DNA, located 12 kb centromeric to the tumor suppressor RECK gene. C9orf19 mRNA is expressed in a wide range of adult tissues as a single transcript, most abundantly in lung and peripheral blood leukocytes. The predicted protein contains the SCP-like extracellular protein signature classified to IPR001283, a family of evolutionary related proteins with extracellular domains, which includes the human glioma pathogenesis-related protein (GliPR), the human testis specific glycoprotein (TPX-1), and several other extracellular proteins from rodents (SCP), insects venom allergens (Ag5, Ag3), plants pathogenesis proteins (PR-1) and yeast hypothetical proteins. Homology searches with the deduced 154 amino acid protein sequence of C9orf19 revealed highly similar proteins in mouse, drosophila, nematode and yeast. Mutation analysis of C9orf19 in IBM2 patients excluded it as the disease causing gene and revealed four single nucleotide polymorphisms within and in the vicinity of the gene, which will certainly be useful tools to study its potential role in several human diseases mapped to chromosome 9p12-p13. Parallel to this study, the gene termed GNE, approximately 50 kb centromeric to C9orf19, was shown to be the disease causing gene in IBM2.

The cost-effectiveness of ramipril in the treatment of patients at high risk of cardiovascular events: a Swedish sub-study to the HOPE study

OBJECTIVE

To evaluate if long-term treatment with ramipril is cost-effective in patients at high risk of cardiovascular events.

DESIGN

Randomized double-blind and placebo controlled. Information was gathered prospectively for a number of direct medical, direct nonmedical and indirect costs.

SETTING AND SUBJECT

This is a sub-study to the Heart Outcomes Prevention Evaluation (HOPE) study performed in Swedish patients. All Swedish centres (19; n= 554) were invited to take part and 18 centres agreed to do so (n=537). The patients were managed in a specialist setting with a mean follow-up period of 4.5 years. Main outcome measures. The number of life-years saved was derived from the global HOPE study (n=9297) and subsequently the estimated life expectancy of those who completed the clinical study alive was added to the calculation. Direct medical costs related to cardiovascular disease only were considered in the primary analysis, whilst all kinds of costs and costs for all kinds of diseases were included in subsequent analyses. The cost of added years of life, according to the future cost method, was included in sensitivity analyses.

RESULTS

The cost per life-year gained was SEK 16 600 (Euro 1940) when direct medical costs for cardiovascular reasons only were considered and SEK 45 400 (Euro 5300) when direct medical costs for all diseases were considered. The corresponding costs when direct nonmedical and indirect cost were added to the estimate were SEK 16 100 (Euro 1880) and SEK 54 600 (Euro 6380), respectively. When the future cost method was applied, the cost per life-year gained was SEK 208 300 (Euro 24 300).

CONCLUSION

Ramipril is highly cost-effective in the treatment of patients at high risk of cardiovascular events.

Prognostic implications of autonomic function assessed by analyses of catecholamines and heart rate variability in stable angina pectoris

OBJECTIVE

To assess the prognostic impact of autonomic activity, as reflected by catecholamines and heart rate variability (HRV), in patients with stable angina pectoris.

DESIGN

Double blind, randomised treatment with metoprolol or verapamil. 24 hour ambulatory ECG, used for frequency domain analyses of HRV, and symptom limited exercise tests at baseline and after one month of treatment. Catecholamine concentrations were measured in plasma (rest and exercise) and urine.

SETTING

Single centre at a university hospital.

PATIENTS

641 patients (449 men) with stable angina pectoris.

MAIN OUTCOME MEASURES

Cardiovascular (CV) death, non-fatal myocardial infarction (MI).

RESULTS

During follow up (median 40 months) there were 27 CV deaths and 26 MIs. Patients who died of CV causes had lower total power and high (HF), low (LF), and very low (VLF) frequency components of HRV. HRV was not altered in patients who suffered non-fatal MI. Catecholamines did not differ between patients with and those without events. Metoprolol increased HRV. Verapamil decreased noradrenaline (norepinephrine) excretion. Multivariate Cox analyses showed that total power, HF, LF, and VLF independently predicted CV death (also non-sudden death) but not MI. LF:HF ratios and catecholamines were not related to prognosis. Treatment effects on HRV did not influence prognosis.

CONCLUSIONS

Low HRV predicted CV death but not non-fatal MI. Neither the LF:HF ratio nor catecholamines carried any prognostic information. Metoprolol and verapamil influenced LF, HF, and catecholamines differently but treatment effects were not related to prognosis.

Regression of left ventricular mass with captopril and metoprolol, and the effects on glucose and lipid metabolism

OBJECTIVE

Angiotensin II and insulin have been suggested to promote the development of hypertensive left ventricular (LV) hypertrophy. We compared the effects of captopril and metoprolol on the regression of LV mass and the relation to insulin sensitivity.

DESIGN

51 previously untreated non-diabetic hypertensive patients (mean age 51 +/- 8 years, body mass index, BMI 25.9 +/- 3.2 kg/m2, office blood pressure, 158/102 mmHg) were randomized to captopril or metoprolol; a low-dose diuretic and/or a calcium cannel antagonist were added, if needed.

INTERVENTIONS

LV mass index (LVMI; by echocardiography) and 24-h ambulatory blood pressure were examined at baseline, 6 and 12 months. At baseline and 12 months, insulin sensitivity index (MI) was calculated by a hyperinsulinemic-euglycemic insulin clamp technique.

RESULTS

Blood pressures were reduced similarly in both groups. LVMI (115 +/- 21 g/m2 at baseline) was reduced in both groups (p < 0.01), but more with captopril than with metoprolol (e.g. -16 vs -7 g/m2, i.e. -13 vs -6%, at 12 months, p < 0.01). MI decreased by 6% with captopril (p = 0.05) and by 23% with metoprolol (p < 0.01), with no difference between the groups. Changes in LVMI were not related to changes in MI in the two groups, or when all patients were analyzed together. High-density lipoprotein (HDL)-cholesterol decreased (p < 0.05) by both drugs, with small effects on low-density lipoprotein (LDL), and triglycerides increased by 30% with metoprolol (p < 0.01).

CONCLUSION

Blockade of the renin-angiotensin-aldosterone system has a role beyond that of blood pressure reduction in the regression of LV mass. There was no relationship between regression of LV mass and improvement in insulin sensitivity. We could not confirm a beneficial effect of ACE inhibition on insulin sensitivity. Thus, our results do not support the importance of insulin in the control of LV geometry.

A national record linkage to study acute myocardial infarction incidence and case fatality in Sweden

BACKGROUND

During the last decades substantial temporal changes, as well as population differences, in coronary heart disease mortality have occurred in Sweden. There is little information to what extent these changes and differences also apply to myocardial infarction incidence. The aim of this paper was to describe the methods used to identify cases in a recently developed National Acute Myocardial Infarction Register in Sweden, and to present estimates of incidence and case fatality in Sweden.

MATERIAL AND METHODS

Incident cases of acute myocardial infarction (AMI) were identified by record linkage of routinely collected data on hospital discharges and deaths. Case fatality within 28 days was ascertained by linkage of incident cases to the National Cause of Death Register.

RESULTS

About 40 000 new cases of AMI per year were recorded in Sweden during 1987-1995. Well-known differences in incidence with regard to age and gender were observed, as well as a decline in incidence between 1987 and 1995. A similar case fatality was seen in men and women aged 30-89 among hospitalized cases. When fatal cases outside hospital were also considered the case fatality was somewhat higher in men. Examination of medical records for a national sample of ischaemic heart disease patients suggested a high sensitivity (94%) and a high positive predictive value (86%) for ICD-9 code 410 in hospital discharge data with regard to definite AMI.

CONCLUSIONS

The National Acute Myocardial Infarction Register offers a new possibility to study the incidence of AMI, as well as case fatality, in Sweden.

Angiotensin converting enzyme gene polymorphism predicts blood pressure response to angiotensin II receptor type 1 antagonist treatment in hypertensive patients

OBJECTIVES

To determine whether polymorphisms in the renin-angiotensin system can predict blood pressure-lowering response to antihypertensive treatment; more specifically, in response to treatment with irbesartan or atenolol.

DESIGN AND METHODS

Eighty-six patients with hypertension were randomized to double-blind treatment with either the angiotensin II type 1 receptor antagonist irbesartan or the beta1 adrenergic receptor blocker atenolol and followed for 3 months. We analysed angiotensinogen T174M and M235T, angiotensin converting enzyme (ACE) I/D and angiotensin II type 1 receptor A1166C polymorphisms and related them to blood pressure reduction.

RESULTS

The mean reductions in blood pressure were similar for both treatments. In the irbesartan group, individuals homozygous for the ACE gene I allele showed a greater reduction in diastolic blood pressure, exceeding those with the D allele (-18 +/- 11 SD versus -7 +/- 10 mmHg, P = 0.0096). This was not the case during treatment with atenolol, and the interaction term between type of treatment and ACE II genotype was significant (P = 0.0176). The angiotensinogen and angiotensin II type 1 receptor polymorhisms were not related to the response to treatment.

CONCLUSIONS

ACE genotyping predicted the blood pressure-lowering response to antihypertensive treatment with irbesartan but not atenolol. Thus, specific genotypes might predict the response to specific antihypertensive treatment.

Treatment with irbesartan or atenolol improves endothelial function in essential hypertension

OBJECTIVES

To investigate if antihypertensive treatment could improve endothelium-dependent vasodilatation in hypertensive patients, and whether the angiotensin II subtype-1 (AT1)-receptor antagonist irbesartan and the beta1-receptor antagonist atenolol would differ in this respect.

SUBJECTS AND METHODS

Thirty-four patients (28 men and six women) with mild-to-moderate essential hypertension (diastolic blood pressure 90-120 mmHg) were randomized to once daily 150-300 mg irbesartan or 50-100 mg atenolol in a double-blind fashion, preceded by a placebo run-in period. Forearm blood flow (FBF) was assessed by venous occlusion plethysmography during local intra-arterial infusions of methacholine and sodium nitroprusside, to evaluate endothelium-dependent and endothelium-independent vasodilatation, respectively. Measurements of FBF were undertaken at the end of the run-in placebo period and repeated after 3 months of active antihypertensive treatment.

RESULTS

Irbesartan and atenolol induced a similar decline in blood pressure (from 171/107 to 158/98 mmHg, P < 0.05), and improved endothelium-dependent vasodilatation (e.g. an increase in FBF response to 4 microg/min methacholine from 325 +/- 29% to 411 +/- 41%, P < 0.05), with no difference between the two study drugs. No significant changes in endothelium-independent vasodilatation were induced by irbesartan or by atenolol.

CONCLUSIONS

The present study shows that 3 months of antihypertensive therapy with irbesartan or atenolol improves endothelium-dependent vasodilatation.