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Subclinical Kidney Damage in Hypertensive Patients: A Renal Window Opened on the Cardiovascular System. Focus on Microalbuminuria. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 956:279-306. [PMID: 27873229 DOI: 10.1007/5584_2016_85] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The kidney is one of the major target organs of hypertension.Kidney damage represents a frequent event in the course of hypertension and arterial hypertension is one of the leading causes of end-stage renal disease (ESRD).ESRD has long been recognized as a strong predictor of cardiovascular (CV) morbidity and mortality. However, over the past 20 years a large and consistent body of evidence has been produced suggesting that CV risk progressively increases as the estimated glomerular filtration rate (eGFR) declines and is already significantly elevated even in the earliest stages of renal damage. Data was supported by the very large collaborative meta-analysis of the Chronic Kidney Disease Prognosis Consortium, which provided undisputable evidence that there is an inverse association between eGFR and CV risk. It is important to remember that in evaluating CV disease using renal parameters, GFR should be assessed simultaneously with albuminuria.Indeed, data from the same meta-analysis indicate that also increased urinary albumin levels or proteinuria carry an increased risk of all-cause and CV mortality. Thus, lower eGFR and higher urinary albumin values are not only predictors of progressive kidney failure, but also of all-cause and CV mortality, independent of each other and of traditional CV risk factors.Although subjects with ESRD are at the highest risk of CV diseases, there will likely be more events in subjects with mil-to-moderate renal dysfunction, because of its much higher prevalence.These findings are even more noteworthy when one considers that a mild reduction in renal function is very common in hypertensive patients.The current European Society of Hypertension (ESH)/European Society of Cardiology (ESC) guidelines for the management of arterial hypertension recommend to sought in every patient signs of subclinical (or asymptomatic) renal damage. This was defined by the detection of eGFR between 30 mL/min/1.73 m2 and 60 mL/min/1.73 m2 or the presence of microalbuminuria (MAU), that is an amount of albumin in the urine of 30-300 mg/day or an albumin/creatinine ratio, preferentially on morning spot urine, of 30-300 mg/g.There is clear evidence that urinary albumin excretion levels, even below the cut-off values used to define MAU, are associated with an increased risk of CV events. The relationships of MAU with a variety of risk factors, such as blood pressure, diabetes and metabolic syndrome and with several indices of subclinical organ damage, may contribute, at least in part, to explain the enhanced CV risk conferred by MAU. Nonetheless, several studies showed that the association between MAU and CV disease remains when all these risk factors are taken into account in multivariate analyses. Therefore, the exact pathophysiological mechanisms explaining the association between MAU and CV risk remain to be elucidated. The simple search for MAU and in general of subclinical renal involvement in hypertensive patients may enable the clinician to better assess absolute CV risk, and its identification may induce physicians to encourage patients to make healthy lifestyle changes and perhaps would prompt to more aggressive modification of standard CV risk factors.
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Völzke H, Fung G, Ittermann T, Yu S, Baumeister SE, Dörr M, Lieb W, Völker U, Linneberg A, Jørgensen T, Felix SB, Rettig R, Rao B, Kroemer HK. A new, accurate predictive model for incident hypertension. J Hypertens 2015; 31:2142-50; discussion 2150. [PMID: 24077244 DOI: 10.1097/hjh.0b013e328364a16d] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Data mining represents an alternative approach to identify new predictors of multifactorial diseases. This work aimed at building an accurate predictive model for incident hypertension using data mining procedures. METHODS The primary study population consisted of 1605 normotensive individuals aged 20-79 years with 5-year follow-up from the population-based study, that is the Study of Health in Pomerania (SHIP). The initial set was randomly split into a training and a testing set. We used a probabilistic graphical model applying a Bayesian network to create a predictive model for incident hypertension and compared the predictive performance with the established Framingham risk score for hypertension. Finally, the model was validated in 2887 participants from INTER99, a Danish community-based intervention study. RESULTS In the training set of SHIP data, the Bayesian network used a small subset of relevant baseline features including age, mean arterial pressure, rs16998073, serum glucose and urinary albumin concentrations. Furthermore, we detected relevant interactions between age and serum glucose as well as between rs16998073 and urinary albumin concentrations [area under the receiver operating characteristic (AUC 0.76)]. The model was confirmed in the SHIP validation set (AUC 0.78) and externally replicated in INTER99 (AUC 0.77). Compared to the established Framingham risk score for hypertension, the predictive performance of the new model was similar in the SHIP validation set and moderately better in INTER99. CONCLUSION Data mining procedures identified a predictive model for incident hypertension, which included innovative and easy-to-measure variables. The findings promise great applicability in screening settings and clinical practice.
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Affiliation(s)
- Henry Völzke
- aInstitute for Community Medicine, Ernst Moritz Arndt University, Greifswald, Germany bSiemens Healthcare, Malvern, Pennsylvania, USA cClinic of Internal Medicine B, Ernst Moritz Arndt University, Greifswald dInstitute of Epidemiology, Christian Albrechts University, Kiel eInterfaculty Institute of Functional Genomics, Ernst Moritz Arndt University, Greifswald, Germany fResearch Centre for Prevention and Health, Glostrup University Hospital, Glostrup gFaculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark hInstitute of Physiology, University Medicine, Ernst Moritz Arndt University, Greifswald iUniversity Medical Center, Göttingen, Germany *Henry Völzke and Glenn Fung contributed equally to the writing of this article
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Xu B, Dai M, Li M, Sun K, Zhang J, Wang T, Sun J, Chen Y, Xu M, Lu J, Bi Y. Low-grade albuminuria is associated with peripheral artery disease in Chinese diabetic patients. Atherosclerosis 2014; 232:285-8. [DOI: 10.1016/j.atherosclerosis.2013.11.046] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 11/13/2013] [Accepted: 11/13/2013] [Indexed: 10/25/2022]
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The progressive pathway of microalbuminuria: from early marker of renal damage to strong cardiovascular risk predictor. J Hypertens 2011; 28:2357-69. [PMID: 20842046 DOI: 10.1097/hjh.0b013e32833ec377] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
There is clear evidence that urinary albumin excretion levels, even below the cut-off values currently used to diagnose microalbuminuria, are associated with an increased risk of cardiovascular events. The relationships of microalbuminuria with a variety of risk factors, such as hypertension, diabetes and metabolic syndrome and with several indices of subclinical organ damage, may contribute, at least in part, to explain the enhanced cardiovascular risk conferred by microalbuminuria. Nonetheless, several studies showed that the association between microalbuminuria and cardiovascular disease remains when all these risk factors are taken into account in multivariate analyses. Therefore, the exact pathophysiological mechanisms explaining the association between microalbuminuria and cardiovascular risk remain incompletely understood. The simple search for microalbuminuria in hypertensive patients may enable the clinician to better assess absolute cardiovascular risk, and its identification may induce physicians to encourage patients to make healthy lifestyle changes and perhaps would prompt to more aggressive modification of standard cardiovascular risk factors.
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Resistin: a new marker of cardiorenal risk? Am J Hypertens 2010; 23:585. [PMID: 20479719 DOI: 10.1038/ajh.2010.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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The association of microalbuminuria with aortic stiffness is independent of C-reactive protein in essential hypertension. Am J Hypertens 2009; 22:1041-7. [PMID: 19629049 DOI: 10.1038/ajh.2009.132] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND It has not been fully elucidated whether microalbuminuria (MAU) and high-sensitivity C-reactive protein (hsCRP) are associated with aortic distensibility independently of each other. Our study was aimed to evaluate the independent relationships of urinary albumin excretion rate (AER) and hsCRP with aortic stiffness in hypertensive patients. METHODS We enrolled 140 untreated nondiabetic essential hypertensives (mean age: 48 +/- 12 years). In all subjects, 24-hour AER and plasma levels of hsCRP were determined by immunoenzymatic assay. MAU was defined as an AER of 20-200 microg/min. Aortic stiffness was assessed by measurement of carotid-femoral pulse wave velocity (PWV). RESULTS Carotid-femoral PWV, adjusted for age and mean arterial pressure (MAP), was higher in subjects with MAU (n = 41) than in those without it (n = 99) (11.6 +/- 2.3 vs. 9.9 +/- 1.8 m/s; P < 0.001) and in subjects with hsCRP above the median value when compared to those with lower levels of hsCRP (10.8 +/- 2.1 vs. 10 +/- 2.1 m/s; P = 0.026). In multiple regression analysis, AER and hsCPR remained independent predictors of aortic stiffness (beta = 0.24; P < 0.001 and beta = 0.15; P = 0.03, respectively). CONCLUSIONS Our results suggest that in patients with essential hypertension, MAU and CRP are independently associated with an increased aortic stiffness.
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Zimering MB, Anderson RJ, Moritz TE, Ge L. Low plasma basic fibroblast growth factor is associated with laser photocoagulation treatment in adult type 2 diabetes mellitus from the Veterans Affairs Diabetes Trial. Metabolism 2009; 58:393-400. [PMID: 19217457 DOI: 10.1016/j.metabol.2008.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2008] [Accepted: 10/20/2008] [Indexed: 10/21/2022]
Abstract
Basic fibroblast growth factor (bFGF) is a potent endothelial cell mitogen that does not normally circulate. Yet plasma bFGF-like bioactivity was increased in association with persistent microalbuminuria and retinopathy in adult type 2 diabetes mellitus. In the present study, we tested whether plasma bFGF immunoreactivity (IR) could predict the need for laser treatment of diabetic retinopathy in a baseline subset of advanced type 2 diabetes mellitus from the Veterans Affairs Diabetes Trial (mean: age, 59 years; diabetes duration, 11 years; baseline glycosylated hemoglobin, 9.5%). Plasma bFGF-IR was determined with a sensitive and specific 2-site enzyme-linked immunoassay in 172 patients at the baseline visit. Results were dichotomized at 4.5 pg/mL, the upper limit in healthy men. There was an unexpected significant association between low baseline plasma bFGF-IR level and the interim (4 years) need for laser treatment. First laser treatment was significantly more likely to be required in patients with low compared with high baseline bFGF (19% vs 6%, P = .03 for the difference). After adjusting for clinical risk factors, low vs high bFGF (hazard ratio [HR], 5.01; P = .012), duration of diabetes (HR, 1.05; P = .050), and low-density lipoprotein cholesterol concentration (HR, 0.98; P = .027) were all significantly associated with time to first laser occurrence. These and our prior results suggest that low plasma bFGF-IR may be a marker for the presence of anti-endothelial cell autoantibodies that may contribute to the need for laser photocoagulation treatment in adult men with advanced type 2 diabetes mellitus.
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Affiliation(s)
- Mark B Zimering
- Medical Service, Department of Veterans Affairs New Jersey Health Care System, Lyons, NJ 07939, USA.
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Cottone S, Mulè G, Nardi E, Lorito MC, Guarneri M, Arsena R, Briolotta C, Vadalà A, Cerasola G. Microalbuminuria and early endothelial activation in essential hypertension. J Hum Hypertens 2006; 21:167-72. [PMID: 17051235 DOI: 10.1038/sj.jhh.1002109] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We hypothesized that in essential hypertensive patients (EHs), plasma levels of pro-atherogenic adhesion molecules would be increased and related with urine albumin excretion (UAE). Thus, this study was aimed at evaluating biochemical markers of endothelial activation and their relationship with UAE in a group of patients with uncomplicated EH. In basal condition soluble forms of adhesion molecules intercellular adhesion molecule (ICAM)-1 and vascular cell adhesion molecule (VCAM)-1, as well as 24-h UAE were assayed. One hundred patients with essential hypertension and no diabetes or ultrasonographic evidence of atherosclerosis were included in the study. Seventy normotensive healthy subjects served as controls. EHs were first studied overall, than were divided into two subgroups: those with UAE > or =20 mcg/min MAUs and those with UAE <20 mcg/min (non-MAUs). ICAM-1 (P<0.001) and VCAM-1 (P<0.0001) plasma concentrations were higher in EHs than in controls. Microalbuminuric EHs had greater levels of adhesion molecules than non-MAUs (ICAM-1 P=0.04; VCAM-1 P=0.02, respectively). In EHs UAE was correlated with ICAM-1 (r=0.29, P=0.003), and VCAM-1 (r=0.30, P=0.002). These associations were confirmed in multiple regression models (P=0.02 for both ICAM-1 and VCAM-1) including, along with adhesion molecules, age, body mass index and blood pressures. Our findings show that in essential hypertension there is a very early activation of endothelial adhesion molecules favouring atherosclerosis.
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Affiliation(s)
- S Cottone
- Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefrourologiche, Cattedra di Medicina Interna ed Unità Operativa di Medicina Interna, Nefrologia ed Ipertensione, Università di Palermo, Palermo, Italy
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Mulè G, Cottone S, Mongiovì R, Cusimano P, Mezzatesta G, Seddio G, Volpe V, Nardi E, Andronico G, Piazza G, Cerasola G. Influence of the metabolic syndrome on aortic stiffness in never treated hypertensive patients. Nutr Metab Cardiovasc Dis 2006; 16:54-59. [PMID: 16399492 DOI: 10.1016/j.numecd.2005.03.005] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2004] [Revised: 02/28/2005] [Accepted: 03/03/2005] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIM Metabolic syndrome (MS) carries an increased risk for cardiovascular events and there is a growing awareness that large artery stiffening is a powerful predictor of cardiovascular morbidity and mortality. Little is known about the relationship of MS with aortic stiffness. The aim of our study was to analyze, in patients with essential hypertension, the influence of MS, defined according to the criteria proposed by the Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP-ATP III), on carotid-femoral pulse wave velocity (PWV), a measure of aortic stiffness. METHODS Ninety-three untreated essential hypertensives, aged between 23 and 61 years, without diabetes mellitus, were studied. All subjects underwent routine blood chemistry, oral glucose tolerance test with glucose and insulin determinations, albumin excretion rate (AER) measurement, 24-h ambulatory blood pressure monitoring, and measurement of carotid-femoral PWV, by means of a computerized method. RESULTS Patients with MS (n = 28) showed higher age-adjusted carotid-femoral PWV (10.1 +/- 1.4 vs 9.3 +/- 1.4 m/s; p = 0.01) when compared to subjects without MS. This difference held after controlling for gender and for 24-h mean blood pressure (MBP) (p = 0.02) and lost its statistical significance after further adjustment for AER. In a multiple regression model, excluding the individual components of MS, in which metabolic syndrome was added along with age, gender, smoking habit, LDL cholesterol, HOMA index, 24-h MBP and 24-h heart rate, MS remained independently associated with carotid-femoral PWV (beta = 0.29; p = 0.002). The statistical significance of this association disappeared after the inclusion into this model of AER. CONCLUSIONS Metabolic syndrome is associated with an increased aortic stiffness. Main explanatory factors of this association are age, systolic blood pressure and albumin excretion rate.
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Affiliation(s)
- Giuseppe Mulè
- Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefrourologiche, Cattedra di Medicina Interna e Centro Ipertensione, Università di Palermo, Italy.
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Sane DC, Anton L, Brosnihan KB. Angiogenic growth factors and hypertension. Angiogenesis 2005; 7:193-201. [PMID: 15609074 DOI: 10.1007/s10456-004-2699-3] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2004] [Accepted: 08/06/2004] [Indexed: 01/08/2023]
Abstract
Emerging evidence supports a novel view of hypertension as a disease of inadequate or aberrant responses to angiogenic growth factors (AGF). Patients with hypertension have reduced microvascular density, with some evidence supporting a primary role for rarefaction in causing hypertension. Two clinical models have demonstrated a link between inhibition of AGF activity and hypertension. A major side effect of bevacizumab, a monoclonal antibody to vascular endothelial growth factor (VEGF), is hypertension. Pre-eclampsia is accompanied by high circulating levels of soluble VEGF receptor-1, which forms inactive complexes with VEGF and placental growth factor (PlGF). Paradoxically, early studies have demonstrated high circulating levels of AGF in hypertension. Several mechanisms may account for this finding including increased vascular stretch, tissue ischemia, compensatory responses, decreased clearance or a combination of these mechanisms. High AGF in hypertension could contribute to clinical sequelae such as peripheral and pulmonary edema, microalbuminuria, and progression of atherosclerosis. However, a role for altered angiogenesis in the pathogenesis of hypertension or its sequelae has not been established. Novel studies to understand the roles of AGF in hypertensive patients are warranted.
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Affiliation(s)
- David C Sane
- Department of Internal Medicine, Section of Cardiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1045, USA.
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Mulè G, Cottone S, Vadalà A, Volpe V, Mezzatesta G, Mongiovì R, Piazza G, Nardi E, Andronico G, Cerasola G. Relationship between albumin excretion rate and aortic stiffness in untreated essential hypertensive patients. J Intern Med 2004; 256:22-9. [PMID: 15189362 DOI: 10.1111/j.1365-2796.2004.01338.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate, in a group of nondiabetic essential hypertensive patients with normal renal function, the relationship between albumin excretion rate (AER) and carotid-femoral pulse wave velocity (PWV), as an index of aortic stiffness. DESIGN Cross-sectional study. SETTING Outpatient hypertension clinic. SUBJECTS Seventy patients with mild-to-moderate essential hypertension, aged 42 +/- 8 years, never pharmacologically treated. All subjects underwent routine laboratory tests, 24-h ambulatory blood pressure (BP) monitoring, measurement of carotid-femoral PWV, by means of a computerized method, and AER. RESULTS Microalbuminuric patients (AER > or = 20 microg min(-1); n = 19), when compared with normoalbuminuric subjects, showed more elevated 24-h BP (136/88 +/- 10/10 vs. 128/83 +/- 7/6 mmHg; P < 0.001 and P = 0.013, for systolic and diastolic BP respectively) and higher values of carotid-femoral PWV (10.4 +/- 2 m s(-1) vs. 9.2 +/- 1.3; P = 0.006). This latter difference remained statistically significant, even after correction by ancova for 24-h systolic and diastolic BP, and body mass index (BMI, P = 0.016). Univariate regression analysis disclosed a tight correlation between AER and carotid-femoral PWV (r = 0.42; P = 0.0003). This association was confirmed in a multiple regression model (beta = 0.35; P = 0.009) in which, as independent variables, besides PWV, 24-h BP, age, serum glucose values, smoking status, gender and BMI, were added. CONCLUSIONS Our results seem to confirm that microalbuminuria may represent the early renal manifestation of a widespread vascular dysfunction, and therefore it is an integrated marker of cardiovascular risk.
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Affiliation(s)
- G Mulè
- Dipartimento di Medicina Interna, Malattie Cardiovascolari e Nefrourologiche, Cattedra di Medicina Interna e Centro Ipertensione, Università di Palermo, Palermo, Italy.
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Armario P, Hernández del Rey R, Martín-Baranera M, Andreu Valls N, Almendros M, Ruigómez J. Relación entre frecuencia cardíaca y excreción urinaria de albúmina en sujetos normotensos y en hipertensos grados 1-2 nunca tratados. HIPERTENSION Y RIESGO VASCULAR 2004. [DOI: 10.1016/s1889-1837(04)71456-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Pedrinelli R, Dell'Omo G, Penno G, Mariani M. Non-diabetic microalbuminuria, endothelial dysfunction and cardiovascular disease. Vasc Med 2001; 6:257-64. [PMID: 11958393 DOI: 10.1177/1358836x0100600410] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Subclinical increases in albuminuria (microalbuminuria) predict morbid events, but the reasons for that are still not understood in full. This paper reviews the existing evidence regarding the relationships of non-diabetic microalbuminuria and cardiovascular disease, the underlying assumption being that endothelial dysfunction contributes both to atherosclerotic macrovascular disease and renal microvascular disease of which albuminuria is a marker. Much data support that concept, and suggest a preferential link with endothelial activation in response to acute and subclinical inflammatory stimulation, although further studies are needed to establish the exact cause-effect mechanisms. Epidemiological studies also show associations with cardiovascular events, and some recent prospective results also indicate the power of microalbuminuria to predict risk independently from conventional atherogenic factors. Thus, microalbuminuria might be considered as an integrated marker of cardiovascular risk sensitive to systemic vascular status in addition to other parameters such as blood pressure levels, glucose metabolism, smoking habits, a profile rather unique among the prognostic predictors available to stratify risk in hypertensive patients.
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Affiliation(s)
- R Pedrinelli
- Dipartimento Cardio Toracico, Università di Pisa, Italy.
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Schiffrin EL. Effects of antihypertensive drugs on vascular remodeling: do they predict outcome in response to antihypertensive therapy? Curr Opin Nephrol Hypertens 2001; 10:617-24. [PMID: 11496055 DOI: 10.1097/00041552-200109000-00011] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Remodeling of large and small arteries in hypertension contributes to elevation of blood pressure, and may participate in the complications of hypertension. Large arteries exhibit increased lumen size, thickened media with increased collagen deposition, and decreased compliance, which contributes to raised systolic blood pressure and pulse pressure. In small (resistance) arteries smooth muscle cells are restructured around a smaller lumen, without true hypertrophy, particularly in milder forms of hypertension, whereas in severe forms and in secondary hypertension hypertrophic remodeling has been reported. Endothelial dysfunction occurs in many patients, with prevalence similar to that of left ventricular hypertrophy. Treatment with angiotensin-converting enzyme inhibitors, angiotensin receptor subtype 1 antagonists and long-acting calcium channel blockers has corrected changes in large and small arteries in hypertensive patients. Treatment with beta-blockers did not modify either structure or function of small arteries. Improved outcomes were reported in clinical trials with drugs that exert vascular protective effects, such as angiotensin-converting enzyme inhibitors and angiotensin receptor subtype 1 antagonists, as well as with those that do not appear to improve vascular structure or function. Recent trials suggest that these different drugs may provide similar benefits essentially through blood pressure lowering, although some minor differences between drugs have been noted. For example, the alpha-blocker doxasozin has been associated with worse outcomes (heart failure) than have diuretics. That hard end-point clinical trials have not demonstrated any advantages of agents with vasculoprotective properties may relate in part to the relatively short duration of some of these multicenter trials (3-5 years). Another contributing factor may be the low number of events with each drug class in the longer trials. Thus, current evidence does not support the rational expectation that vasculoprotective antihypertensive agents will be associated with better outcomes in hypertensive patients, possibly because of limitations of these trials.
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Affiliation(s)
- E L Schiffrin
- Multidisciplinary Research Group on Hypertension, Clinical Research Institute of Montreal, Montréal, Québec, Canada.
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Armario P, Hernández del Rey R, Martín-Baranera M, Almendros M, Andreu N, Ruigómez J, Ceresuela L, Pardell H. Ausencia de relación entre insulinemia y afectación orgánica en hipertensos no tratados grados 1-2. HIPERTENSION Y RIESGO VASCULAR 2001. [DOI: 10.1016/s1889-1837(01)71792-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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