The cardiovascular system

Pharmacokinetic and pharmacodynamic alterations in older people: what we know so far

INTRODUCTION

Healthcare professionals face increasing challenges when managing older patients, a group characterized by significant interindividual variability in comorbidity patterns, homeostatic capacity, frailty status, cognitive function, and life expectancy. Complex therapeutic decisions may increase the risk of inappropriate polypharmacy, drug-drug, and drug-disease interactions in the context of age-associated pharmacokinetic and pharmacodynamic alterations, with consequent drug accumulation and toxicity.

AREAS COVERED

This state-of-the-art narrative review article summarizes and critically appraises the results of original research studies and reviews published in PubMed, Scopus, and Web of Science, from inception to 9 April 2025, on age-associated changes in critical organs and systems and relevant pharmacokinetic and pharmacodynamic alterations. It also discusses the emerging role of frailty and the gut microbiota in influencing such alterations and the potential utility of machine learning techniques in identifying new signals of drug efficacy and toxicity in older patients.

EXPERT OPINION

The available knowledge regarding specific age-associated pharmacokinetic and pharmacodynamic alterations applies to a limited number of drugs, some of which are not frequently prescribed in contemporary practice. Future studies investigating a wider range of drugs and their patterns of use will likely enhance therapeutic efficacy and minimize toxicity in the older patient population.

The Effects of Resistance Exercise With Blood Flow Restriction on Flow-Mediated Dilation and Arterial Stiffness in Elderly People With Low Gait Speed: Protocol for a Randomized Controlled Trial

Background

During aging, a significant loss of muscle mass, strength, and power is associated with a decline in daily functional capacities. Traditionally, resistance training is prescribed to prevent or reverse the skeletal muscle weakness, but the required training intensity may be too demanding for older people with poor physical performance. Resistance exercise with blood flow moderation (KAATSU training), originally developed in Japan, combines resistance exercise with blood flow restriction. It has been reported that KAATSU training enhances muscle hypertrophy in many populations. However, few studies have evaluated the effects of resistance exercises with blood flow restriction in elderly people and how this affects vascular structure and function.

Objective

The aim of this study was to evaluate (1) the acute and chronic effects of resistance exercise with blood flow restriction on vascular health in elderly people with low gait speed and (2) whether low-load resistance training with blood flow restriction elicits similar strength and gait speed gains to those elicited by conventional resistance training without blood flow restriction.

Methods

This is an ongoing randomized controlled trial in elderly people with low gait speed. Overall, two study arms of 13 participants each perform resistance exercise with and without blood flow restriction. The 2 groups are as follows: the control group will perform conventional resistance exercise (60% of 1 repetition maximum) and the KAATSU group will perform the low-load resistance exercise with blood flow restriction (20% of 1 repetition maximum) for 12 weeks. Pulse wave velocity, venous occlusion plethysmography, and flow-mediated dilation are used to assess arterial stiffness, muscle blood flow, and endothelial function, respectively. The secondary outcomes are gait speed, strength, and quality of life. All measures will be performed before and after the training program.

Results

This research study is in progress. Recruitment has started, and data collection is expected to finish in August 2020.

Conclusions

The findings of this study will have important implications for the rehabilitation of elderly people.

Trial Registration

ClinicalTrials.gov NCT03272737; https://clinicaltrials.gov/ct2/show/NCT03272737

International Registered Report Identifier (IRRID)

DERR1-10.2196/14691

Predictors of anti-VEGF drug-induced hypertension using different hypertension criteria: a secondary analysis of the COMPARZ study

Background

There is inconsistency in the criteria used to define anti-vascular endothelial growth factor (VEGF) drug-induced hypertension (AVEGF-HT) in published studies. It is unknown whether specific patient characteristics similarly predict AVEGF-HT using different criteria.

Methods

We assessed the associations between clinical and demographic factors (n = 22) and AVEGF-HT, using six criteria based on predefined on-treatment blood pressure (BP) thresholds or absolute BP elevations versus baseline, in a post hoc analysis of a phase III trial of 1102 patients with renal cell carcinoma (RCC) randomized to pazopanib or sunitinib (COMPARZ study).

Results

The cumulative incidence of AVEGF-HT at any time while on treatment ranged between 14.8% [criterion: grade ⩾3 toxicity, National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) v3.0] and 58.8% (criterion: absolute systolic BP increase ⩾20 mmHg versus baseline). After adjusting for anti-VEGF treatment and baseline BP, the number of significant (p < 0.05) predictors ranged between one (criterion: absolute systolic BP increase ⩾20 mmHg, on-treatment systolic BP ⩾140 mmHg and diastolic BP ⩾90 mmHg) and nine (criterion: grade ⩾3 toxicity, NCI CTCAE v3.0). Age, use of antidiabetic drugs and use of antihypertensive drugs each significantly predicted four AVEGF-HT criteria. By contrast, sex, smoking, heart rate, proteinuria, Karnofsky performance status, and use of thiazide diuretics did not predict any criterion.

Conclusions

There was a significant variability in the incidence, number and type of predictors of AVEGF-HT, using six different criteria, in a post hoc analysis of the COMPARZ study. The use of specific criteria might affect the assessment of the interaction between anti-VEGF drugs, AVEGF-HT and cancer outcomes.

Differences in Cardiovascular Aging in Men and Women

Cardiovascular diseases increase dramatically with age in both men and women. While it is clear that advanced age allows more time for individuals to be exposed to risk factors in general, there is strong evidence that age itself is a major independent risk factor for cardiovascular disease. Indeed, there are distinct age-dependent cellular, structural, and functional changes in both the heart and blood vessels, even in individuals with no clinical evidence of cardiovascular disease. Studies in older humans and in animal models of aging indicate that this age-related remodeling is maladaptive. An emerging view is that the heart and blood vessels accumulate cellular and subcellular deficits with age and these deficits increase susceptibility to disease in older individuals. Aspects of this age-dependent remodeling of the heart and blood vessels differ between the sexes. There is also new evidence that these maladaptive changes are more prominent in older animals and humans with a high degree of frailty. These observations may help explain why men and women are susceptible to different cardiovascular diseases as they age and why frail older adults are most often affected by these diseases.

Activation of α1A -adrenoceptors desensitizes the rat aorta response to phenylephrine through a neuronal NOS pathway, a mechanism lost with ageing

BACKGROUND AND PURPOSE

A NO-mediated desensitization of vasoconstrictor responses evoked by stimulation of α₁ -adrenoceptors has been reported in different vessels. We investigated the involvement of each α₁ -adrenoceptor subtype and constitutive NOS isoforms and the influence of ageing and hypertension on this process.

EXPERIMENTAL APPROACH

Wistar and spontaneously hypertensive rats (SHR), 16, 32, 52 and 72 weeks-old, were used to evaluate the desensitization process. Expression of α₁ -adrenoceptor subtypes, endothelial NOS (eNOS) and neuronal NOS (nNOS) were determined in rat aorta and left ventricle (LV). Expression levels were also evaluated in LV of a group of heart failure patients with a wide age range.

KEY RESULTS

Repeated application of phenylephrine decreased subsequent α₁ -adrenoceptor-mediated vasoconstriction by increasing nNOS protein expression in aorta, but not in tail or mesenteric resistance arteries, where mRNA levels of nNOS were undetectable. This desensitization process disappeared in the absence of endothelium or in the presence of L-NAME (100 μM), nNOS inhibitors, SMTC (1 μM) and TRIM (100 μM), and 5-methylurapidil (100 nM, α_1A -antagonist), but not BMY7378 (10 nM, α_1D -antagonist). The α_1A /nNOS-mediated desensitization was absent in aged SHR and Wistar animals, where the expression of α_1A -adrenoceptors was reduced in aorta and LV. In human LV, a negative correlation was found between age and α_1A -adrenoceptor expression.

CONCLUSIONS AND IMPLICATIONS

The α_1A -adrenoceptor subtype, through endothelial nNOS-derived NO, may act as a physiological 'brake' against the detrimental effects of excessive α₁ -adrenoceptor-mediated vasoconstriction. Reduced α_1A -adrenoceptor- and nNOS-mediated desensitization in aged patients could be involved in the age-dependent elevation of adrenergic activity.

Contrasting Patterns of Agonist-induced Store-operated Ca2+ Entry and Vasoconstriction in Mesenteric Arteries and Aorta With Aging

Ca is a crucial factor in the regulation of smooth muscle contraction. Store-operated Ca entry (SOCE) is one pathway that mediates Ca influx and smooth muscle contraction. Vessel contraction function usually alters with aging to cause severe vascular-related diseases. However, the underlying mechanism is still not fully understood. Here, we assessed intracellular Ca and vessel tension and found that SOCE and SOCE-mediated contraction of vascular smooth muscle cells (VSMCs) was reduced in aorta but increased in mesenteric arteries from aged rats. The results of Western blot and immunofluorescence staining show that the expression levels of Orai1, a store-operated Ca channel, were increased in VSMCs of mesenteric arteries but were reduced in VSMCs of aorta with aging. In conclusion, we demonstrated that the changing pattern of SOCE and SOCE-mediated contraction of VSMCs is completely reversed in mesenteric arteries and aorta with aging, providing a potential therapeutic target for clinical treatment in age-related vascular diseases.

Effect of Advanced Maternal Age on Pregnancy Outcomes and Vascular Function in the Rat

Advanced maternal age is becoming increasingly common in Western societies and is associated with increased maternal and fetal morbidity and mortality. We hypothesized that aging results in impaired vascular function in pregnancy because of increased vascular oxidative stress and resultant scavenging of nitric oxide in both uterine and systemic arteries, causing reduced uteroplacental perfusion and poor pregnancy outcomes. Using aged rats (9.5 months), we investigated the effect of a delayed first natural pregnancy on pregnancy outcomes and uterine and mesenteric artery function on gestational day 20. Delayed pregnancy in the rat reduced fertility by 46%, reduced litter size by 36%, caused fetal growth restriction, increased placental weight, and increased maternal systolic blood pressure (by 16 mm Hg). Uterine arteries from aged dams displayed reduced constriction to phenylephrine (young: 14.3±0.94 mN/mm versus aged: 11.4±0.5 mN/mm, P =0.02) and potassium chloride (124 mmol/L; young: 21.8±1.27 mN/mm versus aged: 14.2±1.7 mN/mm; P =0.01). Methacholine-induced vasodilation was similar in uterine arteries from young and aged dams. However, mesenteric arteries from aged dams had a greater nitric oxide and a reduced endothelial-derived hyperpolarization contribution to methacholine-mediated vasodilation compared with young dams. Both uterine and mesenteric arteries from aged dams had greater active myogenic responses, with area under the curve increased by 228% and 151%, in aged uterine and mesenteric arteries, respectively. These results demonstrate that vascular function is altered at an advanced maternal age and provides further insights into the risks of poor pregnancy outcomes observed in women who delay pregnancy.

Attenuation of L-type Ca²⁺ channel expression and vasomotor response in the aorta with age in both Wistar-Kyoto and spontaneously hypertensive rats

Age-related vascular diseases are induced by vascular dysfunction, which involves changes in the vasomotor response. The voltage-dependent L-type calcium channel (VDCC) protein is involved in the regulation of vessel function (contraction/relaxation action). In the present study, we evaluated age-related vasomotor function and expression of the signal-related target proteins, including VDCC, using thoracic aorta from both 8- and 40-week old Wistar-Kyoto (WKY) and spontaneously hypertensive rats (SHR). In contraction experiments using aortic rings, vasomotor responses of both phenylephrine-induced contraction and acetylcholine-induced relaxation were significantly attenuated with age in SHR, whereas WKY did not lose activity with age. Contraction induced by angiotensin II was impaired only for the 40-week old SHR among all the rat groups tested, although enhanced AT1R/reduced AT2R expression with age was observed for both WKY and SHR. In contrast, a vasomotor responsiveness to Bay K 8644 (a VDCC agonist) at the initial contraction phase was significantly attenuated in both 40-week WKY and SHR with significant reduction of VDCC protein expression. The reduced VDCC expression in 40-week old rats significantly lowered the relaxation activity of VDCC blockers, such as verapamil and Trp-His, but did not affect that of nifedipine. Taken together, we provided the first evidence that aging caused a reduction of VDCC expression in rat aorta, irrespective of the rat strain, along with diminishment of the therapeutic potential of VDCC blockers.

Double-leg isometric exercise training in older men

Double-leg isometric training has been demonstrated to reduce resting blood pressure in young men when using electromyographic activity (EMG) to regulate exercise intensity. This study assessed this training method in healthy older (45–60 years.) men. Initially, 35 older men performed an incremental isometric exercise test to determine the linearity of the heart rate versus percentage peak EMG (%EMG_peak) and systolic blood pressure versus %EMG_peak relationship. Thereafter, 20 participants were allocated to a training or control group. The training group performed three double-leg isometric sessions per week for 8 weeks, at 85% of peak heart rate. The training resulted in a significant reduction in resting systolic (11 ± 8 mmHg, P < 0.05) and mean arterial (5 ± 7 mmHg, P < 0.05) blood pressure. There was no significant change in resting systolic blood pressure for the control group or diastolic blood pressure in either group (all P > 0.05). These findings show that this training method, used previously in young men, is also effective in reducing resting systolic and mean arterial blood pressure in older men.

Are older adults less or more physiologically reactive? A meta-analysis of age-related differences in cardiovascular reactivity to laboratory tasks

In this meta-analytic review of 31 laboratory studies, we examined if relatively older adults showed lower or higher cardiovascular reactivity compared with relatively younger adults. Results revealed that age was associated with lower heart rate reactivity but higher systolic blood pressure (SBP) reactivity during emotionally evocative tasks. Consistent with the predictions of dynamic integration theory, the result for SBP was moderated by the degree of task activation. These data are discussed in light of existing self-regulatory models and important future research directions.

Arterial Compliance in Multiple Sclerosis: A Pilot Study

A reduction in arterial compliance in patients with autoimmune diseases such as rheumatoid arthritis and systemic lupus erythematosus has been previously reported. It is caused by the effect that systemic inflammation has on the cardiovascular system. Multiple sclerosis (MS), an immune-mediated disease that exclusively affects the central nervous system (CNS), has a significant inflammatory component that is limited to that compartment. The potential effects of its inflammatory mediators in the cardiovascular system are largely unknown. Purpose: To examine large (C1) and small arterial compliance (C2) in patients with MS and compare them with healthy age-matched controls. To also determine whether any differences in C1 and C2 indices between participants diagnosed with relapsing remitting MS (RR-MS), secondary progressive MS (SP-MS), and controls exist. Methods: A total of 26 men and women between the ages of 18 and 64 diagnosed with MS and 25 healthy controls volunteered for this study. Arterial compliance was measured by using pulse contour analysis (PCA), which records and analyzes the blood pressure waveform data from the Arterial Pulse Wave Sensors. Results: Significant differences in C1 and C2 were found between young RR-MS and healthy young controls (P < .05), with the MS group showing lower arterial C1 and C2 compliance. No significant differences (P > .05) were seen for C1 or C2 values between older RR-MS, SP-MS, and healthy controls. Conclusion: Arterial compliance is significantly compromised in young individuals with MS, compared with age-matched controls, but not for older individuals, suggesting a systemic effect of an inflammatory process that predominantly affects the CNS.

Longitudinal assessment of the effects of oestrogen on blood pressure and cardiovascular autonomic activity in female rats

1. Published data concerning the effects of ovarian hormones on haemodynamic variability are contradictory. For the first time, the present study used radiotelemetric haemodynamic monitoring to investigate the long-term effects of chronic oestrogen depletion and repletion on cardiovascular autonomic control and arterial baroreflex sensitivity (BRS) in female rats. 2. Blood pressure (BP), heart rate (HR) and +dP/dt(max) of arterial pressure (an estimate of myocardial contractility) were monitored in sham-operated (SO), ovariectomized (OVX) and oestrogen-replaced OVX rats (OVXE2) for 16 weeks. Cardiovascular autonomic control and baroreflexes were assessed by frequency domain analysis of interbeat intervals (IBI) and systolic BP (SBP). 3. Compared with SO rats, OVX rats exhibited no changes in BP, short-lived decreases in HR and sustained reductions in +dP/dt(max) of arterial pressure. The high- (HF; 0.75-3 Hz) and low-frequency (LF; 0.25-0.75 Hz) components of spectral power of IBI were significantly decreased and increased, respectively, by ovariectomy. An increase in the IBI(LF/HF) ratio in OVX rats suggests a shift in the cardiac sympathovagal balance towards sympathetic dominance. Index alpha, the spectral index of spontaneous BRS, was reduced by OVX. 4. Oestrogen replacement caused significant reductions in BP and HR and reversed OVX-induced changes in +dP/dt(max) of arterial pressure and cardiac autonomic activity. The LF oscillations of SBP were reduced in OVXE2 rats, suggesting a reduction in vascular sympathetic tone by oestrogen. 5. These findings highlight the importance of long-term oestrogen therapy in rectifying the detrimental effects of depletion of ovarian hormones on the cardiovascular system and baroreflex.

Extracellular matrix fibronectin mechanically couples skeletal muscle contraction with local vasodilation

During exercise, local mechanisms in tissues cause arterioles to rapidly dilate to increase blood flow to tissues to meet the metabolic demands of contracting muscle. Despite decades of study, the mechanisms underlying this important aspect of blood flow control are still far from clear. We now report a novel mechanism wherein fibronectin fibrils in connective tissue matrices transduce signals from contracting skeletal muscle to local blood vessels to increase blood flow. Using intravital microscopy, we show that local vasodilation in response to skeletal muscle contraction is specifically inhibited by an antibody that recognizes the matricryptic site in the first type III repeat of fibronectin (FNIII-1). In the absence of skeletal muscle contraction, direct application of FNIII-1-containing fibronectin fragments to cremaster muscle arterioles in situ, triggered a rapid, specific, and reversible local dilation that was mediated by nitric oxide and required the cryptic, heparin-binding sequence of FNIII-1. Furthermore, application of function-blocking FNIII-1 peptides to cremaster muscle arterioles rapidly and specifically decreased their diameter, indicating that the matricryptic site of fibronectin also contributes to resting vascular tone. Alexa fluor 488-labeled fibronectin, administered intravenously, was rapidly assembled into elongated, branching fibrils in the extracellular matrix of intact cremaster muscle, demonstrating active polymerization of fibronectin in areas adjacent to blood vessels. Together, these data provide the first evidence that a matricryptic, heparin-binding site within fibronectin fibrils of adult connective tissue plays a dynamic role in regulating both vascular responses and vascular tone.

Pharmacokinetic-Pharmacodynamic Crisis in the Elderly

Advances in medical technology have led to improved survival after catastrophic illnesses. Many of the survivors require ongoing care including tracheostomy, mechanical ventilation, tube feedings, and indwelling venous catheters. Repeated hospitalizations may be necessary to treat infectious complications resulting from resistant organisms requiring intravenous antibiotic therapy. Because prolonged intravenous access may be difficult or even impossible in these patients, alternative means of therapy are necessary. Linezolid is the first of a new class of antimicrobial agents known as the oxazolidinones with activity against gram-positive bacteria similar to that of vancomycin and yet its oral bioavailability allows for enteral administration. We present our retrospective experience with oral linezolid in a cohort of pediatric intensive care unit patients. Primary infectious disease issues included endocarditis, tracheitis, pneumonia, or central line sepsis resulting from Staphylococcus epidermidis, methicillin-resistant Staphylococcus aureus, and Enterococcus. Treatment was initiated with vancomycin and changed to enteral linezolid (10 mg/kg every 12 hours). The duration of therapy with linezolid varied from 7 days to 6 weeks. All of the patients were discharged home to complete their course of enteral linezolid. No complications related to linezolid therapy were noted, and all of the patients completed their prescribed course of therapy without the need for rehospitalization. Our preliminary experience suggests that oral linezolid offers an effective alternative to intravenous vancomycin for the treatment of infections resulting from gram-positive bacteria and avoids the need for prolonged vascular access.

Involvement of RhoA/Rho kinase pathway in myogenic tone in the rabbit facial vein

Myogenic tone (MT), a fundamental stretch-sensitive vasoconstrictor property of resistance arteries and veins, is a key determinant of local blood flow regulation. We evaluated the pathways involved in MT development. The role of the RhoA/Rho kinase, p38 MAP kinase, and HSP27 in MT was investigated in the rabbit facial vein (RFV), previously shown to possess MT at a pressure level equivalent to 20 mm Hg. Venous MT is poorly understood, although venous diseases affect a large proportion of the population. Stretched RFV are characterized by a temperature-sensitive MT, which is normal at 39 degrees C but fails to develop at 33 degrees C. This allows for the discrimination of the pathways involved in MT from the multiple pathways activated by stretch. Isolated RFV segments were mounted in organ baths and stretched. Temperature was then set at 33 degrees C or 39 degrees C. MT was associated to the translocation of RhoA to the plasma membrane and the Rho kinase inhibitor Y27632 decreased stretch-induced MT by 93.1+/-4.9%. MT was also associated to an increase in p38 (131.0+/-12.5% at 39 degrees C versus 100% at 33 degrees C) and HSP27 phosphorylation (196.1+/-13.3% versus 100%), and the p38 MAP kinase inhibitor SB203580 decreased MT by 36.5+/-8.1%. (39 degrees C, compared with RFV stretched at 33 degrees C). Finally, phosphorylation of p38 was blocked by Y27632 and HSP27 phosphorylation was inhibited by SB203580 and Y27632. Thus, MT and the associated p38 and HSP27 phosphorylation seem to depend on RhoA/Rho kinase activation in stretch RFV.

Treatment of vasodepressor carotid sinus syndrome with midodrine: a randomized, controlled pilot study

OBJECTIVES

To evaluate the efficacy of treatment of the vasodepressor form of carotid sinus hypersensitivity (carotid sinus syndrome (CSS)) with midodrine.

DESIGN

A prospective, double-blind, randomized, controlled trial of crossover design.

SETTING

A dedicated outpatient facility with access to tilt-table, digital arterial photoplethysmography, and 24-hour ambulatory blood pressure (BP) monitoring equipment.

PARTICIPANTS

Ten older adults (4 male, 6 female, mean age 75, range 66-86 years) with a history of unexplained syncope who displayed an asymptomatic decrease in systolic BP (SBP) of more than 50 mmHg or a symptomatic decrease of more than 30 mmHg within 30 seconds of carotid sinus massage (CSM).

MEASUREMENTS

Symptom reproduction and BP and heart rate changes were evaluated after CSM in supine and semierect positions on the right and then left sides. These measurements were performed on the final day of placebo and active-treatment phases. Ambulatory 24-hour BP monitoring took place on the penultimate and final days of each treatment phase.

RESULTS

Eight patients were symptomatic after their initial CSM. The mean+/-standard deviation SBP decrease after initial CSM was 54+/-22 mmHg. Initial mean 24-hour ambulatory BP was 127/70+/-7/5 mmHg. Eight patients reported symptoms after CSM at the end of the placebo phase. The mean SBP decrease at the end of the placebo phase was 49+/-12 mmHg. The mean 24-hour ambulatory BP was 127/69+/-9/7 mmHg. One patient reported symptoms after CSM at the end of the active-treatment phase. The mean SBP decrease at the end of the active-treatment phase was 36+/-9 mmHg. The mean 24-hour ambulatory BP at the end of the treatment phase was 133/75+/-7/6 mmHg. The differences in symptom reporting and mean SBP decrease after CSM were both significant (P<.01 and P=.03, respectively).

CONCLUSION

The results of this pilot study suggest that treatment of vasodepressor CSS with midodrine significantly reduced the rate of symptom reporting and attenuated SBP decreases after CSM but increased mean 24-hour ambulatory BP.

Cardiovascular Drug Therapy in Elderly Patients

An increasing number of elderly patients are exposed to cardiovascular drugs for the treatment of acute and/or chronic conditions. This is a result of the progressive aging of the population, a common feature in most industrialised countries, and an improvement in primary and secondary cardiovascular prevention strategies with increased survival rates. Traditionally, most elderly patients receiving cardiovascular drugs had advanced cardiac, liver and kidney disease that significantly influenced drug pharmacokinetic and pharmacodynamic parameters. Currently, however, many patients without significant organ impairment receive cardiovascular therapy for primary or early secondary prevention (i.e. increased vascular risk, asymptomatic left ventricular dysfunction, poststroke phase, type 2 diabetes mellitus), highlighting the need for a better understanding of specific age-related pharmacokinetic and pharmacodynamic effects. A systematic review has been conducted on the specific effects of aging, in the absence of major co-morbidities, on the pharmacokinetic and pharmacodynamic properties of traditional and newer cardiovascular drugs. Currently, the evidence available is poor or nonexisting for several drugs and mainly derived from very small and underpowered studies, thus limiting data interpretation. In particular, there is very little information on patients >80 years of age, thus raising important concerns about the correct use of these drugs in this constantly growing population.