Hypertension and Organ Damage in Women

Rationale and design of the PACIFIC-PRESERVED (PhenomApping, ClassIFication and Innovation for Cardiac dysfunction in patients with heart failure and PRESERVED left ventricular ejection fraction) study

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome that is poorly defined, reflecting an incomplete understanding of its pathophysiology.

AIM

To redefine the phenotypic spectrum of HFpEF.

METHODS

The PACIFIC-PRESERVED study is a prospective multicentre cohort study designed to perform multidimensional deep phenotyping of patients diagnosed with HFpEF (left ventricular ejection fraction≥50%), patients with heart failure with reduced ejection fraction (left ventricular ejection fraction≤40%) and subjects without overt heart failure (3:2:1 ratio). The study proposes prospective investigations in patients during a 1-day hospital stay: physical examination; electrocardiogram; performance-based tests; blood samples; cardiac magnetic resonance imaging; transthoracic echocardiography (rest and low-level exercise); myocardial shear wave elastography; chest computed tomography; and non-invasive measurement of arterial stiffness. Dyspnoea, depression, general health and quality of life will be assessed by dedicated questionnaires. A biobank will be established. After the hospital stay, patients are asked to wear a connected garment (with digital sensors) to collect electrocardiography, pulmonary and activity variables in real-life conditions (for up to 14 days). Data will be centralized for machine-learning-based analyses, with the aim of reclassifying HFpEF into more distinct subgroups, improving understanding of the disease mechanisms and identifying new biological pathways and molecular targets. The study will also serve as a platform to enable the development of innovative technologies and strategies for the diagnosis and stratification of patients with HFpEF.

CONCLUSIONS

PACIFIC-PRESERVED is a prospective multicentre phenomapping study, using novel analytical techniques, which will provide a unique data resource to better define HFpEF and identify new clinically meaningful subgroups of patients.

Roxadustat reduces left ventricular mass index compared to rHuEPO in haemodialysis patients in a randomized controlled trial

BACKGROUND

Left ventricular hypertrophy (LVH) is highly prevalent in haemodialysis (HD) patients and is associated with an increased risk of death. Roxadustat and recombinant human erythropoietin (rHuEPO, abbreviated as EPO) are the main treatment strategies for renal anaemia in HD patients, but it has not been clear whether there is a difference in their effect on LVH.

METHODS

In this multi-centre, prospective, randomized trial of 12-month duration, study participants were randomized in a 1:1 ratio to the roxadustat group or the EPO group. The doses of both treatment regimens were adjusted so that the patients had a haemoglobin level of 10.0-12.0 g per dL. The primary study endpoint was the change from baseline to 12 months in the left ventricular mass index (LVMI, g/m2) measured by echocardiography.

RESULTS

In total, 114 patients were enrolled. The mean age was 50 years, and the median dialysis duration was 33 months. Sixty-one patients were men, and 24 were diabetic. LVMI decreased from 116.18 ± 27.84 to 110.70 ± 25.74 g/m2 in the roxadustat group. However, it increased from 109.35 ± 23.41 to 114.99 ± 28.46 g/m2 in the EPO group, with a significant difference in the change in LVMI between the two groups [-5.48 (-11.60 to 0.65) vs. 5.65 (0.74 to 10.55), p < 0.05]. Changes in left ventricular mass, end-diastolic volume and 6-min walk test seemed superior in the roxadustat group. There were no significant differences in other cardiac geometry, biochemical parameters and major adverse cardiovascular events between the two groups.

CONCLUSIONS

Compared to EPO, roxadustat is more helpful in the regression of LVH in HD patients.

Gender Differences in Cardiac Organ Damage in Arterial Hypertension: Assessing the Role of Drug Nonadherence

INTRODUCTION

Cardiac organ damage like left ventricular (LV) hypertrophy and left atrial (LA) enlargement is more prevalent in women than men with hypertension, but the mechanisms underlying this gender difference remain unclear.

METHODS

We tested the association of drug nonadherence with the presence of LV hypertrophy and LA enlargement by echocardiography in 186 women and 337 men with uncontrolled hypertension defined as daytime systolic blood pressure (BP) ≥ 135mmHg despite the prescription of at least two antihypertensive drugs. Drug adherence was assessed by measurements of serum drug concentrations interpreted by an experienced pharmacologist. Aldosterone-renin-ratio (ARR) was measured on actual medication.

RESULTS

Women had a higher prevalence of LV hypertrophy (46% vs. 33%) and LA enlargement (79% vs 65%, both p < 0.05) than men, while drug nonadherence (8% vs. 9%, p > 0.514) did not differ. Women were older and had lower serum renin concentration and higher ARR than men, while 24-h systolic BP (141 ± 9 mmHg vs. 142 ± 9 mmHg), and the prevalences of obesity (43% vs. 50%) did not differ (all p > 0.10). In multivariable analyses, female gender was independently associated with a two-fold increased risk of LV hypertrophy (OR 2.01[95% CI 1.30-3.10], p = 0.002) and LA enlargement (OR 1.90 [95% CI 1.17-3.10], p = 0.010), while no association with drug nonadherence was found. Higher ARR was independently associated with LV hypertrophy in men only (OR 2.12 [95% CI 1.12-4.00] p = 0.02).

CONCLUSIONS

Among patients with uncontrolled hypertension, the higher prevalence of LV hypertrophy and LA enlargement in women was not explained by differences in drug nonadherence.

REGISTRATION

URL:  https://www.

CLINICALTRIALS

gov ; Unique identifier: NCT03209154.

Vascular function in hypertension: does gender dimension matter?

Blood pressure and vascular ageing trajectories differ between men and women. These differences develop due to sex-related factors, attributable to sex chromosomes or sex hormones, and due to gender-related factors, mainly related to different sociocultural behaviors. The present review summarizes the relevant facts regarding gender-related differences in vascular function in hypertension. Among sex-related factors, endogenous 17ß-estradiol plays a key role in protecting pre-menopausal women from vascular ageing. However, as vascular ageing (preceding and inducing hypertension) has a steeper increase in women than in men starting already from the third decade, it is likely that gender-related factors play a prominent role, especially in the young. Among gender-related factors, psychological stress (including that one related to gender-based violence and discrimination), depression, some psychological traits, but also low socioeconomic status, are more common in women than men, and their impact on vascular ageing is likely to be greater in women. Men, on the contrary, are more exposed to the vascular adverse consequences of alcohol consumption, as well as of social deprivation, while "toxic masculinity" traits may result in lower adherence to lifestyle and preventive strategies. Unhealthy diet habits are more prevalent in men and smoking is equally prevalent in the two sexes, but have a disproportional negative effect on women's vascular health. In conclusion, given the major and complex role of gender-related factors in driving vascular alterations and blood pressure patterns, gender dimension should be systematically integrated into future research on vascular function and hypertension and to tailor cardiovascular prevention strategies.

Soluble Urokinase-Type Plasminogen Activator Receptor (suPAR) Is a Biomarker Associated with Left Ventricular Hypertrophy in the Elderly, Specifically in Women

Left ventricular hypertrophy (LVH) may result in the development of heart failure, which is widespread among people of advanced age. The pathophysiology of LVH is complex and its biochemical pathways are not fully understood in this group. Elevated soluble urokinase-type plasminogen activator receptor (suPAR), a biomarker of immune activation, including fibrosis, reflects subclinical organ damage in systematic diseases. The present study assesses the clinical role of suPAR measurement in determination of LVH-associated cardiac disorders in the elderly. The studied population consisted of 238 individuals aged 76-91 years; of these, 139 (58%) were diagnosed with LVH. Serum biomarkers measurement (suPAR, troponin T, NT-proBNP and CRP) and echocardiography were performed in all subjects. The suPAR level was significantly higher in the LVH group (4.01 vs. 3.82 ng/mL, p = 0.033) and correlated with the parameters of cardiac diastolic function. Stepwise logistic regression found suPAR level (OR = 1.55, p = 0.016), BMI (OR = 1.17, p = 0.0003) and hypertension (OR = 2.42, p = 0.046) to be independently associated with LVH in women. In men, the strongest predictors of LVH were hypertension (OR = 7.52, p = 0.014) and BMI (OR = 1.42, p = 0.032). The observations indicate suPAR as a promising marker reflecting LVH, especially in women at advanced age, independent of age-associated cardiac remodeling.

Sex and gender differences in the treatment of arterial hypertension

INTRODUCTION

Arterial hypertension represents the leading modifiable risk factor for all-cause death and early development of cardiovascular disease in women. Current clinical guidelines for the treatment of hypertension noted that women respond to antihypertensive drugs similarly to men and, therefore, treatment recommendations remain the same for both sexes. However, clinical evidence suggests the existence of sex- and gender-related differences (SGRD) in the prevalence, pathophysiology, pharmacodynamics (efficacy and safety) and pharmacokinetics of antihypertensive drugs.

AREAS COVERED

This review summarizes SGRD in the prevalence of hypertension, hypertension-mediated organ damage and blood pressure control, prescription patterns, and pharmacokinetics/ pharmacodynamics and doses of antihypertensive drugs.

EXPERT OPINION

There is limited information on SGRD in antihypertensive drug efficacy because of the underrepresentation of women in randomized clinical trials and, more important, because few trials reported results stratified by sex or performed sex-specific analyses. However, there are SGRD in hypertension-mediated organ damage, drug pharmacokinetics and, particularly, in drug safety. Prospective trials specifically designed to better understand the basis for SGRD in the pathophysiology of hypertension and in the efficacy and safety of antihypertensive drugs are needed to achieve a more personalized treatment of hypertension and hypertension-mediated organ damage in women.

Role of Arterial Hypertension and Hypertension-Mediated Organ Damage in Cardiotoxicity of Anticancer Therapies

PURPOSE OF THE REVIEW

Arterial hypertension (AH) is the most common cardiovascular (CV) risk factor in the community and in oncologic patients. It also represents the most important CV condition predisposing to anticancer treatment-related cardiotoxicity. This risk is heightened in the presence of cardiac AH-mediated organ damage (HMOD). Influence of AH and HMOD on the development of cardiotoxicity will be reviewed, with a focus on specific scenarios and implications for management of oncologic patients.

RECENT FINDINGS

Not adequately controlled AH before or during anticancer treatments and/or development of AH during or after completion of such therapies have detrimental effects on the clinical course of oncologic patients, particularly if HMOD is present. As overlooking CV health can jeopardize the success of anticancer treatments, the goal for clinicians caring for the oncologic patient should include the treatment of AH and HMOD.

Serum testosterone level correlates with left ventricular hypertrophy in older women

Introduction

Sex hormones may play an important role in age-related cardiac remodeling. However, their impact on cardiac structure and function in females of advanced age still remains unclear. The aim of this study is to evaluate the relationship between sex hormones level and echocardiographic parameters in older women with concomitant cardiovascular diseases.

Materials and Methods

The study group included 52 community-dwelling women with mean age 79.5 ± 2.8 years, consecutive patients of an outpatient geriatric clinic. In all the subjects, a transthoracic echocardiogram was performed and serum testosterone, estradiol, follicle-stimulating hormone, luteinising hormone, dehydroepiandrosterone sulphate, and cortisol levels were determined.

Results

Testosterone level correlated positively with interventricular septum diastolic dimension (IVSd) (rS=0.293, p<0.05), left ventricular mass index (rS=0.285, p<0.05), E/E' ratio (rS=0.301, p<0.05), and negatively with E' (rS=-0.301, p<0.05). Estradiol level showed a positive correlation with the posterior wall dimension (rS=0.28, p<0.05). Besides, no significant correlations between clinical or echocardiographic parameters and other hormones were observed. Female subjects with diagnosed left ventricular hypertrophy (LVH) (n=34) were characterized by a significantly higher rate of hypertension (p=0.011), higher waist-to-height ratio (p=0.009), higher testosterone level (0.82 vs. 0.48 nmol/L, p=0.024), higher testosterone/estradiol ratio (16.4 vs. 9.9, p=0.021), and received more anti-hypertensive drugs (p=0.030). In a multiple stepwise logistic regression, the best determinants of LVH were the presence of hypertension (OR=6.51; 95% CI 1.62-26.1), and testosterone level (OR= 6.6; 95% CI 1.19-36.6).

Conclusions

Higher serum testosterone levels may contribute to pathological cardiac remodeling, especially in hypertensive women. Estradiol, gonadotropins, DHEAS, and cortisol were not related to echocardiographic parameters.

Update on Management of Cardiovascular Diseases in Women

Cardiovascular diseases (CVD) have a lower prevalence in women than men; although, a higher mortality rate and a poorer prognosis are more common in women. However, there is a misperception of CVD female risk since women have commonly been considered more protected so that the real threat is vastly underestimated. Consequently, female patients are more likely to be treated less aggressively, and a lower rate of diagnostic and interventional procedures is performed in women than in men. In addition, there are substantial sex differences in CVD, so different strategies are needed. This review aims to evaluate the main gender-specific approaches in CVD.

Angiotensin-converting enzyme inhibitors increase anti-fibrotic biomarkers in African Americans with left ventricular hypertrophy

Angiotensin‐converting enzyme inhibitors (ACEi) are part of the indicated treatment in hypertensive African Americans. ACEi have blood pressure‐independent effects that may make them preferred for certain patients. We aimed to evaluate the impact of ACEi on anti‐fibrotic biomarkers in African American hypertensive patients with left ventricular hypertrophy (LVH). We conducted a post hoc analysis of a randomized controlled trial in which hypertensive African American patients with LVH and vitamin D deficiency were randomized to receive intensive antihypertensive therapy plus vitamin D supplementation or placebo. We selected patients who had detectable lisinopril (lisinopril group) in plasma using liquid‐chromatography/mass spectrometry analysis and compared them to subjects who did not (comparison group) at the one‐year follow‐up. The pro‐fibrotic marker type 1 procollagen C‐terminal propeptide (PICP) and the anti‐fibrotic markers matrix metalloproteinase‐1 (MMP‐1), tissue inhibitor of metalloproteinases 1 (TIMP‐1), telopeptide of collagen type I (CITP), and N‐acetyl‐seryl‐aspartyl‐lysyl‐proline (Ac‐SDKP) peptide were measured. Sixty‐six patients were included, and the mean age was 46.2 ± 8 years. No difference was observed in the number and intensity of antihypertensive medications prescribed in each group. Patients with detectable lisinopril had lower blood pressure than those in the comparison group. The anti‐fibrotic markers Ac‐SDKP, MMP‐1, and MMP‐1/TIMP‐1 ratio were higher in patients with detectable ACEi (all p < .05). In a model adjusted for systolic blood pressure, MMP‐1/TIMP‐1 (p = .02) and Ac‐SDKP (p < .001) levels were associated with lisinopril. We conclude that ACEi increase anti‐fibrotic biomarkers in hypertensive African Americans with LVH, suggesting that they may offer added benefit over other agents in such patients.

The strain and strain rate imaging paradox in echocardiography: overabundant literature in the last two decades but still uncertain clinical utility in an individual case

Almost two decades ago strain and strain rate imaging were proposed as a new, potentially more sensitive modality for quantifying both regional and global myocardial function. Until now, however, strain and strain rate imaging have been slow to be incorporated into everyday clinical practice. More recently, two dimensional strain has been claimed as of greater clinical utility, given that it is angle independent, with improved feasibility and reproducibility as compared to tissue Doppler strain. Nevertheless, speckle tracking strain is reliant on 2D image quality and frame rates. Three dimensional speckle tracking could eliminate the problem of through-plane motion inherent in 2D imaging, but 3D strain is currently limited by low frame rates. Another limitation of strain imaging is that the results are dependent on the ultrasound machine on which analyses are performed, with variability in measurements between different vendors. Despite the diagnostic and prognostic advantages of 2D strain, there is a lack of specific therapeutic interventions based on strain and a paucity of long-term large-scale randomized trial evidence on cardiovascular outcomes. After overabundant literature the same definition of normal cut-off values is controversial and not univocal. Further studies are needed, involving both manufacturers and medical professionals, on the additive contribution, possibly different case by case, of interfering and artifactual factors, aside from myocardial function per se. These artifactual determinants and motion artifacts components could be dominant in individual cases and should always be taken into account in the clinical decision making process in a single case.

Covariables of Myocardial Function in Women and Men with Increased Body Mass Index

Introduction

Sex-difference in types of cardiac organ damage has been reported in subjects with increased body mass index (BMI). However less is known about sex-differences in left ventricular (LV) myocardial function assessed by global longitudinal strain (GLS) in these subjects.

Methods

493 subjects (mean age 47 ± 9 years, 61% women) with BMI > 27.0 kg/m² and without known cardiac disease underwent 24-hour (24h) ambulatory blood pressure (BP) recording, body composition analysis, carotid-femoral pulse wave velocity (PWV) measurement and echocardiography. LV peak systolic GLS was measured by two-dimensional speckle tracking echocardiography and LV ejection fraction (EF) by biplane Simpson’s method. Insulin sensitivity was assessed by homeostatic model of insulin resistance (HOMA-IR).

Results

Women had higher prevalence of increased waist circumference (99% vs. 82%), lower prevalence of hypertension (59 vs. 74%), and lower serum triglycerides (1.3 ± 0.7 vs. 1.7 ± 0.9 mmol/L) and carotid-femoral PWV (7.3 ± 1.6 vs. 7.7 ± 1.6 m/s) compared to men (all p < 0.05). Women also had higher (more negative) GLS compared to men (− 19.9 ± 3.0 vs. − 18.6 ± 3.0%, p < 0.001), while EF did not differ between sexes. In multivariable linear regression analyses, lower GLS in women was associated with higher waist circumference and PWV and with lower EF (all p < 0.05). In men, lower GLS was associated with higher waist circumference and HOMA-IR, and with lower EF (all p < 0.05).

Conclusions

Among subjects with increased BMI, GLS was higher in women than men. Lower GLS was associated with abdominal obesity in both sexes, and with impaired glucose metabolism in men, and with higher arterial stiffness in women.

Trial registration

https://www.clinicaltrials.gov NCT02805478, first registered 20.06.16.

Ambulatory blood pressure variability and combined exercise training: comparison between hypertensive and normotensive postmenopausal women

AIM

The aim of the study was to verify the effects of moderate combined aerobic and resistance exercises training in ambulatory blood pressure (ABPM) and its variability in hypertensive and normotensive postmenopausal women.

METHODS

Twenty-six participants were divided into two groups: hypertensive (HT = 13) and normotensive (NT = 13). They performed 30 sessions of combined exercises (aerobic and resistance exercises at same session) over 10 weeks. We evaluated: resting BP and 24-h ABPM with systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP), and heart rate (HR). To evaluate blood pressure variability (BPV), the following were considered: 24-h SD (SD24), the mean diurnal and nocturnal deviations (SDdn), average real variability (ARV24).

RESULTS

The two-way analysis of variance showed no difference in ABPM nor BPV responses after training between groups. Both HT and NT groups had similar BP reductions in 24-h DBP (P < 0.01; ΔNT = -3.1 ± 1.1, ΔHT = -1.8 ± 1.2 mmHg), 24-h area under the curve of DBP (P = 0.01; ΔNT = -73±105, ΔHT = -44 ± 115 mmHg), and wake DBP (P < 0.01; ΔNT = -3.4 ± 1.2, ΔHT = -1.8 ± 1.3 mmHg), without differences in BPV responses. Moreover, HT women had higher overall SBP SDdn (P = 0.01), SBP ARV (P = 0.02), and MBP ARV (P < 0.01) than NT women.

CONCLUSION

Ten-week combined exercise training resulted in similar BP reductions in hypertensive and normotensive postmenopausal women, but not in BPV responses.

The influence of sex on left ventricular remodeling in arterial hypertension

Hypertension represents one of the most important and most frequent cardiovascular risk factors responsible for heart failure (HF) development. Both sexes are equally affected by arterial hypertension. The difference is lying in the fact that prevalence of hypertension as well as hypertension-induced target organ damage varies during lifetime due to substantial variation of sex hormones in women. Left ventricular (LV) structural, functional, and mechanical changes induced by hypertension are well-known complications that occur in both sexes and they are responsible for HF development. However, their prevalence is significantly different between women and men, which could potentially explain the variation in HF occurrence and prognosis between the sexes. Studies have shown that the prevalence of left ventricular hypertrophy is higher in men. The data are not consistent regarding LV diastolic dysfunction and a similar report has been given for LV mechanical changes. Most investigations agree that LV longitudinal strain is lower among hypertensive men. However, even in the healthy population, men have lower LV longitudinal strain and the cutoff values are still missing. Therefore, it would be difficult to draw the conclusion that LV mechanical dysfunction is more prevalent among men. The main mechanisms responsible for sex-related LV remodeling are sex hormones and their influence on biohumoral systems. This review provides an updated overview of the available data about sex-related LV remodeling, as well as potential mechanisms for these changes, in the patients with arterial hypertension.

Cardiovascular prevention in women: a narrative review from the Italian Society of Cardiology working groups on 'Cardiovascular Prevention, Hypertension and peripheral circulation' and on 'Women Disease'

: Cardiovascular disease (CVD) is the leading cause of mortality and morbidity in women.Some authors highlighted that the female risk profile consists of traditional and emerging risk factors. Despite the lower prevalence of type 2 diabetes, years of life lost owing to the disease for women are substantially higher compared with men. In addition, pregnancy complicated by gestational diabetes represents a risk factor for CVD. Women with gestational diabetes have a higher prevalence of coronary artery disease that occur at a younger age and are independent of T2DM.Hypertension is an important cardiovascular risk factor in women. Estrogens and progesterone, known to have an impact on blood pressure levels, have also been proposed to be protective against sleep-disordered breathing. It is very difficult to understand whereas obstructive sleep apnea in women is independently associated with hypertension or if many confounders acting at different stages of the woman lifespan mediate this relation.The cardioprotective effect of physical activity in women of all ages is well known. Women are generally more physically inactive than men. During and after menopause, most women tend to reduce their physical activity levels and together with the reduction in basal metabolic rate, women experience loss of skeletal muscle mass with a negative change in the ratio of fat-to-lean mass.In conclusion, sex differences in the cardiovascular system are because of dissimilarities in gene expression and sex hormones; these result in variations in prevalence and presentation of CVD and associated conditions, such as diabetes, hypertension and vascular and cardiac remodeling.Changes in lifestyle and increase in physical activity could help in prevention of cardiovascular disease in women.

Effects of imperatorin in the cardiovascular system and cancer

Patients with cancer survivors are at increased risk of cardiovascular disease(CVD). Cardio-oncology has developed as a new discipline with the advances in cancer treatment. There are many new challenges for the clinician and a new frontier for research and investigation. There is an urgent need for further study on the prevention of cardiovascular toxicity. Imperatorin (IMP) is a natural form of coumarin and extract from several plants with diver's pharmacokinetic effects, including antioxidant and anti-inflammatory properties. This review focus on the molecular mechanisms and pharmacological effects of Imperatorin maybe provide potential cancer and cardiovascular protection that targets IMP. Further studies are required to elucidate the entire spectrum of cytotoxic activities of these compounds to validate and expand their preclinical and clinical applications and to clarify the potential role of IMP.