Addressing the Global Cardiovascular Risk of Hypertension, Dyslipidemia, Diabetes Mellitus, and the Metabolic Syndrome in the Southeastern United States, Part II: Treatment Recommendations for Management of the Global Cardiovascular Risk of Hypertension, Dyslipidemia, Diabetes Mellitus, and the Metabolic Syndrome

Periodontitis and diabetes mellitus co-morbidity: A molecular dialogue

BACKGROUND

Type 2 diabetes mellitus (T2DM) and periodontitis are two biologically linked diseases that often coexist in complex interaction. While periodontitis may lead to insulin receptor desensitization, diabetes may increase the expression of inflammatory cytokines, such as Tumor Necrosis Factor-α (TNF-α) and Interleukin 6 (IL-6), in the gingival crevicular fluid and activate osteoclasts via Receptor activator of nuclear factor kappa-Β ligand (RANK-L) production, leading to bone resorption. However, the association between the two diseases processes, where one may exacerbate the progression of the other, is unclear. In addition, both diseases have similar mechanistic themes, such as chronic inflammation and oxidative stress. This review aimed to investigate the pathophysiological and molecular mechanisms underlying T2DM and periodontitis.

HIGHLIGHT

Uncontrolled diabetes is often associated with severe periodontitis, measured by clinical attachment loss. Alteration in the oral microbiome composition, which may activate the host inflammatory response and lead to irreversible oxidative stress, is a common finding in both diseases. An understanding of the molecular crosstalk between the two disease processes is crucial for developing therapeutic targets that inhibit bone resorption and halt the progression of periodontitis in patients with diabetes.

CONCLUSION

The Oral microbiome composition in T2DM and periodontitis shifts toward dysbiosis, favoring bacterial pathogens, such as Fusobacteria and Porphyromonas species. Both conditions are marked by pro-inflammatory immune activity via the activation of Interleukin 17 (IL-17), Interleukin 1 (IL-1), TNF-α, and Nuclear Factor Kappa Beta (NF-κB). Common molecular crosstalk signaling appears to involve advanced glycation end products (AGEs) and oxidative stress. Thus, future drug targets are multifactorial, ranging from modulatory of host inflammatory response to preventing the accumulation of AGEs and oxidative free radicals.

Chemistry and Effects of Brainstem Acting Drugs

BACKGROUND

Brain is the most sensitive organ, whereas brainstem is the most important part of Central Nervous System (CNS). It connects the brain and the spinal cord. However, a myriad of drugs and chemicals affects CNS with severe resultant effects on the brainstem.

METHODS

In view of this, a number of literature were assessed for information on the most sensitive part of brain, drugs and chemicals that act on the brainstem and clinical benefit and risk assessment of such drugs and chemicals.

RESULTS

Findings have shown that brainstem regulates heartbeat, respiration and because it connects the brain and spinal cord, all the drugs that act on the spinal cord may overall affect the systems controlled by the spinal cord and brain. The message is sent and received by temporal lobe, occipital lobe, frontal lobe, parietal lobe and cerebellum.

CONCLUSION

Hence, the chemical functional groups of the brainstem and drugs acting on brainstem are complementary, and may produce either stimulation or depression of CNS.

The role of noninvasive cardiovascular testing, applied clinical nutrition and nutritional supplements in the prevention and treatment of coronary heart disease

Numerous clinical trials suggest that we have reached a limit in our ability to decrease the incidence of coronary heart disease (CHD) and cardiovascular disease (CVD) utilizing the traditional diagnostic evaluation, prevention and treatment strategies for the top five cardiovascular risk factors of hypertension, diabetes mellitus, dyslipidemia, obesity and smoking. About 80% of heart disease (heart attacks, angina, coronary heart disease and congestive heart failure) can be prevented by optimal nutrition, optimal exercise, optimal weight and body composition, mild alcohol intake and avoiding smoking. Statistics show that approximately 50% of patients continue to have CHD or myocardial infarction (MI) despite presently defined 'normal' levels of the five risk factors listed above. This is often referred to as the 'CHD gap'. Novel and more accurate definitions and evaluations of these top five risk factors are required, such as 24 h ambulatory blood pressure (ABM) results, advanced lipid profiles, redefined fasting and 2 h dysglycemia parameters, a focus on visceral obesity and body composition and the effects of adipokines on cardiovascular risk. There are numerous traumatic insults from the environment that damage the cardiovascular system but there are only three finite vascular endothelial responses, which are inflammation, oxidative stress and immune vascular dysfunction. In addition, the concept of translational cardiovascular medicine is mandatory in order to correlate the myriad of CHD risk factors to the presence or absence of functional or structural damage to the vascular system, preclinical and clinical CHD. This can be accomplished by utilizing advanced and updated CV risk scoring systems, new and redefined CV risk factors and biomarkers, micronutrient testing, cardiovascular genetics, nutrigenomics, metabolomics, genetic expression testing and noninvasive cardiovascular testing.

Determination of mitochondrial metabolic phenotype through investigation of the intrinsic inhibition of succinate dehydrogenase

Many diseases are accompanied by systemic or organ metabolic abnormalities. Therefore, investigation of the roles of mitochondrial dysfunction in the pathogenesis of major diseases requires a methodology that reflects the characteristics of mitochondrial metabolism particular for the organ of origin. We provide evidence that for brain and heart mitochondria the intrinsic inhibition of succinate dehydrogenase (SDH) is a key mechanism for attenuation of mitochondrial respiration and energy production in response to the organ's energy needs. This mechanism also serves to minimize the production of reactive oxygen species when the organ is at rest. Changes in the organ's workloads are accompanied by changes in metabolites that are used by mitochondria as substrates and for modification of energy production at the SDH level. Measurement of the respiratory activity of mitochondria with various substrates and substrate mixtures and use of bovine serum albumin as an SDH inhibitor will be useful for evaluation of metabolic phenotype at the mitochondrial level.

Models for estimating the metabolic syndrome biological age as the new index for evaluation and management of metabolic syndrome

Purpose

This study aims to propose a metabolic syndrome (MS) biological age model, through which overall evaluation and management of the health status and aging state in MS can be done easily. Through this model, we hope to provide a novel evaluation and management health index that can be utilized in various health care fields.

Patient and methods

MS parameters from American Heart Association/National Heart, Lung, and Blood Institute guidelines in 2005 were used as biomarkers for the estimation of MS biological age. MS biological age model development was done by analyzing data of 263,828 participants and clinical application of the developed MS biological age was assessed by analyzing the data of 188,886 subjects.

Results

The principal component accounted for 36.1% in male and 38.9% in female of the total variance in the battery of five variables. The correlation coefficient between corrected biological age and chronological age in males and females were 0.711 and 0.737, respectively. Significant difference for mean MS biological age and chronological age between the three groups, normal, at risk and MS, was seen (P<0.001).

Conclusion

For the comprehensive approach in MS management, MS biological age is expected to be additionally utilized as a novel evaluation and management index along with the traditional MS diagnosis.

Review: The role of noninvasive hemodynamic monitoring in the evaluation and treatment of hypertension

Advances in the understanding of the mechanisms accounting for the elevation of arterial pressure in essential hypertension suggest that there is value in assessing the relative contribution of hemodynamic factors in tailoring specific therapies to control arterial pressure. The non-invasive method of impedance cardiography (ICG) to measure hemodynamic abnormalities in hypertensive patients has emerged as a valuable adjuvant in the decision-making process of selecting antihypertensive agents. The technique is both accurate and reproducible in delineating the hemodynamic mechanisms of hypertension, comparing age-and gender-related changes in hemodynamics, detecting the presence of left ventricular dysfunction, and demonstrating clinically significant improvement in blood pressure control using ICG-guided therapy.

Review: The metabolic syndrome as an endocrine disease: is there an effective pharmacotherapeutic strategy optimally targeting the pathogenesis?

The metabolic syndrome (MetS) represents a combination of cardiovascular risk determinants such as obesity, insulin resistance and lipid abnormalities such as hypertriglyceridemia, increased free fatty acids, low high-density-cholesterol and hypertension. As a multiple component condition it imparts a doubling of relative risk for atherosclerotic cardiovascular disease (ASCVD). It is currently controversial which component of the syndrome carries what weight. There is even a considerable debate whether the risk for ASCVD is greater in patients diagnosed with MetS than that by the individual risk factors. At present, no unifying pathogenetic mechanism can explain the metabolic syndrome and there is no unique treatment for it. This review summarizes and critically reviews the currently available clinical and scientific evidence for the concept that the MetS is causally an endocrine disease and discusses pharmacotherapeutic strategies targeting the pathogenesis rather than single symptoms of the cluster.

Value of a facilitated quality improvement initiative on cardiovascular disease risk: findings from an evaluation of the Aggressively Treating Global Cardiometabolic Risk Factors to Reduce Cardiovascular Events (AT GOAL)

RATIONALE, AIMS AND OBJECTIVES

In the United States, cardiovascular disease (CVD) is the leading cause of death. The US Centers for Disease Control and Prevention contracted an evaluation of the Aggressively Treating Global Cardiometabolic Risk Factors to Reduce Cardiovascular Events (AT GOAL) programme as part of its effort to identify strategies to address CVD risk factors.

METHODS

This study analysed patient-level data from 7527 patients in 43 primary care practices. The researchers assessed average change in control rates for CVD-related measures across practices, and then across patients between baseline and a patient's last visit during the practice's tenure in the programme (referred to as 'end line') using repeated measures analysis of variance and random effects generalized least squares, respectively.

RESULTS

Among non-diabetic patients, there were significant increases in control rates for overall blood pressure (74.3% to 78.0%, P = 0.0002), systolic blood pressure (70.3% to 80.6%, P = 0.0099), diastolic blood pressure (90.1% to 92.7%, P = 0.0001) and low-density lipoprotein (LDL; 48.6% to 53.1%, P = 0.0001) between baseline and end line. Among diabetic patients, there was a significant increase in diastolic blood pressure control (59.8% to 61.9%, P = 0.0141). While continuous CVD-related outcomes show an overall trend between baseline and end line, patients with uncontrolled measures at baseline showed a decrease between baseline and end line relative to their counterparts who were controlled at baseline.

CONCLUSIONS

Findings from the AT GOAL evaluation support the value of a facilitated quality improvement (QI) initiative on managing CVD risk.

The Effectiveness of Mobile Phone-Based Care for Weight Control in Metabolic Syndrome Patients: Randomized Controlled Trial

Background

Overweight and obesity, due to a Westernized diet and lack of exercise, are serious global problems that negatively affect not only personal health, but national economies as well. To solve these problems, preventative-based approaches should be taken rather than medical treatments after the occurrence of disease. The improvement of individual life habits, through continuous care, is thus a paramount, long-term treatment goal. This study describes the effects of ubiquitous health care (uHealth care) or SmartCare services in the treatment of weight loss and obesity.

Objective

The aim of this study is to evaluate the effect of SmartCare services on weight loss compared to the effects of existing outpatient treatments in obese patients with metabolic syndrome.

Methods

Metabolic syndrome patients who met the inclusion/exclusion criteria were enrolled in the study and randomized into an intervention or control group. The intervention group was provided with remote monitoring and health care services in addition to the existing treatment. The control group was provided with only the existing treatment. Pedometers were given to all of the patients. Additionally, mobile phones and body composition monitors were provided to the intervention group while body weight scales were provided to the control group. The patients visited the hospitals at 12 and 24 weeks following the baseline examination to receive efficacy and safety evaluations.

Results

Mean weight reduction from baseline to week 24 was measured as a primary efficacy evaluation parameter and was found to be 2.21 kg (SD 3.60) and 0.77 kg (SD 2.77) in the intervention and control group, respectively. The intervention group had a larger decrement compared to the control group (P<.001). Among the secondary efficacy evaluation parameters, body mass index (BMI) (P<.001), body fat rate (P=.001), decrement of waist measurement (P<.001), and diet habit (P=.012) improvement ratings from baseline to week 24 were found to be superior in the intervention group compared with the control group. The proportion of patients whose body weight decreased by ≥10%, lipid profiles, blood pressure, prevalence of metabolic syndrome, change in the number of metabolic syndrome elements, smoking rate, drinking rate, and physical activity were not statistically significant between the groups.

Conclusions

The efficacy of SmartCare services was confirmed as the intervention group that received both SmartCare services and the existing treatment had superior results compared with the control group that only received the existing treatment. Importantly, no specific problems with respect to safety concerns were observed. SmartCare service is thus an effective way to control the weight of obese patients with metabolic syndrome.

Trial Registration

Clinicaltrials.gov NCT01344811; https://clinicaltrials.gov/ct2/show/NCT01344811 (Archived by Webcite at http://www.webcitation.org/6alT2MmIB)

Relationship between chronic kidney disease and metabolic syndrome: current perspectives

Both metabolic syndrome (MetS) and chronic kidney disease (CKD) are increasing in incidence and lead to significant cardiovascular morbidity and mortality. The relationship between these two entities is complex. Individual components of the MetS are known risk factors for incident kidney disease, but it is not clear how the clustering of these components is linked to the development and progression of kidney disease. Cross-sectional studies show an association of the MetS and prevalent CKD; however, one cannot draw conclusions as to which came first - the MetS or the kidney disease. Observational studies suggest a relationship between MetS and incident CKD, but they also demonstrate the development of MetS in patients with established CKD. These observations suggest a bidirectional relationship. A better understanding of the relationship between components of the MetS and whether and how these components contribute to progression of CKD and incident cardiovascular disease could inform more effective prevention strategies.

An evolving scientific basis for the prevention and treatment of pediatric obesity

The 2013 Pennington Biomedical Research Center's Scientific Symposium focused on the treatment and management of pediatric obesity and was designed to (i) review recent scientific advances in the prevention, clinical treatment and management of pediatric obesity, (ii) integrate the latest published and unpublished findings and (iii) explore how these advances can be integrated into clinical and public health approaches. The symposium provided an overview of important new advances in the field, which led to several recommendations for incorporating the scientific evidence into practice. The science presented covered a range of topics related to pediatric obesity, including the role of genetic differences, epigenetic events influenced by in utero development, pre-pregnancy maternal obesity status, maternal nutrition and maternal weight gain on developmental programming of adiposity in offspring. Finally, the relative merits of a range of various behavioral approaches targeted at pediatric obesity were covered, together with the specific roles of pharmacotherapy and bariatric surgery in pediatric populations. In summary, pediatric obesity is a very challenging problem that is unprecedented in evolutionary terms; one which has the capacity to negate many of the health benefits that have contributed to the increased longevity observed in the developed world.

Nitric oxide production, systemic inflammation and lipid metabolism in periodontitis patients: possible gender aspect

AIM

Nitric oxide (NO) plays a crucial role in vascular tone regulation and is involved in pathogenesis of periodontitis. In this cross-sectional study, we investigated the serum and saliva levels of NO metabolites in periodontal disease and their relationship with serum C-reactive protein (CRP) levels, lipids metabolism and periodontal disease severity.

MATERIAL AND METHODS

Serum and saliva were collected from non-smoking patients with generalized severe periodontitis (n = 89) and healthy controls (n = 56). Serum and salivary levels of NO metabolites, serum levels of high density lipoproteins (HDL), low density lipoproteins (LDL), triglycerides, cholesterol and CRP were measured. Data were analysed in whole population and in different gender groups.

RESULTS

Periodontitis patients exhibited significantly lower serum and saliva levels of NO metabolites and significantly higher LDL, cholesterol and CRP levels than control group. Similar findings were observed within male but not within female population. Serum NO metabolites levels exhibited significant negative correlation with CRP in whole population and in male population. Significant positive correlation of serum NO metabolite levels with HDL levels was observed in whole population.

CONCLUSION

NO production is reduced in periodontitis, especially in male population. Gender might be an important factor in assessing risk of cardiovascular disease in periodontitis.

The COSEHC™ Global Vascular Risk Management quality improvement program: first follow-up report

The Global Vascular Risk Management (GVRM) Study is a 5-year prospective observational study of 87,863 patients (61% females) with hypertension and associated cardiovascular risk factors began January 1, 2010. Data are gathered electronically and cardiovascular risk is evaluated using the Consortium for Southeastern Hypertension Control™ (COSEHC™)-11 risk score. Here, we report the results obtained at the completion of 33 months since study initiation. De-identified electronic medical records of enrolled patients were used to compare clinical indicators, antihypertensive medication usage, and COSEHC™ risk scores across sex and diabetic status subgroups. The results from each subgroup, assessed at baseline and at regular follow-up periods, are reported since the project initiation. Inference testing was performed to look for statistically significant differences between goal attainments rates between sexes. At-goal rates for systolic blood pressure (SBP) were improved during the 33 months of the study, with females achieving higher goal rates when compared to males. On the other hand, at-goal control rates for total and low-density lipoprotein (LDL) cholesterol (chol) were better in males compared to females. Diabetic patients had lower at-goal rates for SBP and triglycerides but higher rates for LDL-chol. The LDL-chol at-goal rates were higher for males, while high-density lipoprotein (HDL)-chol rates were higher for females. Utilization of antihypertensive medications was similar during and after the baseline period for both men and women. Patients taking two or more antihypertensive medications had higher mean COSEHC™-11 scores compared to those on monotherapy. With treatment, hypertensive patients can reach SBP and cholesterol goals; however, population-wide improvement in treatment goal adherence continues to be a challenge for physicians. The COSEHC™ GVRM Study shows, however, that continuous monitoring and feedback to physicians of accurate longitudinal data is an effective tool in achieving better control rates of cardiovascular risk factors.

Incidence of metabolic syndrome and its characteristics of patients attending a diabetic outpatient clinic in a tertiary care hospital

OBJECTIVE

We sought to evaluate the incidence of metabolic syndrome and non-metabolic syndrome among type 2 diabetic patients attending the diabetic outpatient clinic at tertiary care hospital, Warangal.

MATERIALS AND METHODS

A cross-sectional study was conducted in a period of 6 months from January 2011 to June 2011. The study group consisted of 75 type 2 diabetic patients. They were screened for hypertension, hyperlipidemia, obesity, and clinical characteristics, and other co-morbidities were recorded. Metabolic syndrome diagnosis was made as per ATP III guidelines.

RESULTS

The prevalence of metabolic syndrome was significant in men (54.8%) compared to women (45.2%). Incidence of metabolic syndrome was found to be more in normal weight patients (43.56%). Low high density lipoprotein (HDL) levels were observed in both rural (90.63%) and urban (95.65%) patients with metabolic syndrome, followed by increase in waist circumference. The mean HDL level was found to be 23.77 mg/dl. Patients in the age group 51-60 years were found to be more affected with metabolic syndrome. Sedentary household female patients (58.3%) and illiterates (41.8%) were suffering from metabolic syndrome. Patients with metabolic syndrome had been suffering with diabetes (duration of diabetes) from 1 to 5 years. In summary, this cross-sectional study characterizes the metabolic and non-metabolic syndromes of type 2 diabetes patients living in Telangana regions, using ATP III guidelines, and generates a biological resource that enables further investigation of numerous hypotheses related to genetic exposure of both in a population.

CONCLUSION

These results suggest that higher prevalence of metabolic syndrome was observed in non-obese male patients and was significantly associated with aging. Nevertheless, further studies are required to confirm the metabolic syndrome in larger population.

Pharmacotherapy for childhood obesity: present and future prospects

Pediatric obesity is a serious medical condition associated with significant comorbidities during childhood and adulthood. Lifestyle modifications are essential for treating children with obesity, yet many have insufficient response to improve health with behavioral approaches alone. This review summarizes the relatively sparse data on pharmacotherapy for pediatric obesity and presents information on obesity medications in development. Most previously studied medications demonstrated, at best, modest effects on body weight and obesity-related conditions. It is to be hoped that the future will bring new drugs targeting specific obesity phenotypes that will allow clinicians to use etiology-specific, and therefore more effective, anti-obesity therapies.

Metabolic Syndrome: Screening, Diagnosis, and Management

Metabolic syndrome, a growing issue in women's health, is a cluster of health findings that increase the risk of cardiovascular events. The prevalence of metabolic syndrome is higher in women and is linked to several conditions unique to women's health, including polycystic ovary syndrome, gestational diabetes, pregnancy-induced hypertension, and female sexual dysfunction. Risk factors, screening strategies, and therapeutic management of metabolic syndrome in women are discussed.

Adenine nucleotide translocator as a regulator of mitochondrial function: implication in the pathogenesis of metabolic syndrome

Mitochondria play key roles in energy production and intracellular reactive oxygen species (ROS) generation. Lines of evidence have shown that mitochondrial dysfunction contributes to the development of metabolic syndrome. The causes of mitochondrial dysfunction are complex, but overnutrition and sedentary living are among the best known causes of mitochondrial dysfunction. ATP synthesized in the mitochondria is exchanged for cytosolic ADP by adenine nucleotide translocator (ANT) to provide a continuous supply of ADP to mitochondria. We recently found that ANT function is essential for peroxisome proliferator-activated receptor-γ coactivator 1-α (PGC-1α)'s action on endothelial cells. PGC-1α is a transcriptional coactivator of nuclear receptors, playing an important role in fatty acid oxidation and mitochondrial biogenesis. Recent studies have shown that PGC-1α decreases intracellular ROS generation by increasing the expression of antioxidant genes. In our study, PGC-1α reduced cell apoptosis and ROS generation in endothelial cells by increasing ATP/ADP translocase activity of ANT and ANT1 expression. Here we review the role of ANT in maintaining proper mitochondrial function, and possible role of ANT dysfunction in the pathogenesis of metabolic syndrome.

The metabolic syndrome in patients on peritoneal dialysis: prevalence and influence on cardiovascular morbidity

The metabolic syndrome (MS) is a multi-factorial disorder which includes a main risk factors associated with the development of cardiovascular, neurologic, renal and endocrine diseases, especially type 2 diabetes. This study has been conducted to estimate the prevalence of the MS in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) and its association with cardiovascular morbidity. The study included 37 patients (25 type 2 diabetic patients and 12 non-diabetic patients), who had been on peritoneal dialysis for > 3 months. At the beginning of CAPD treatment (baseline) and at the end of follow-up, we measured: body mass index (BMI), blood pressure, fasting blood glucose, triglycerides and high-density lipoprotein cholesterol (HDLC) and defined the prevalence of the MS using the modified National Cholesterol Education Program (NCEP; Adult Treatment Panel III) for peritoneal dialysis patients. The overall prevalence of the MS was 89.2%. The metabolic syndrome was estimated in all (100%) type 2 diabetic patients (vs. 60% patients on the beginning of CAPD treatment). In non-diabetic peritoneal patients, the MS was estimated in 50% cases, according to 33.3% at the beginning CAPD treatment. Development of the MS was significantly higher in the type 2 diabetic patients in compared with non-diabetic patients until the end of follow-up examination (p=0.0005). The prevalence of LVH in type 2 diabetic patients with the MS was significantly higher (p=0.002) than in non-diabetic peritoneal patients with the MS. We didn't found statistical significantly difference in the prevalence of ischemic heart disease between this two category of peritoneal dialysis patients (p=0.076). The results indicate that the metabolic syndrome is presented in high percentage in peritoneal dialysis patients, and it's also important risk factor of high cardiovascular morbidity rate in these patients, especially in type 2 diabetic patients.

Periodontal disease might be associated even with impaired fasting glucose

OBJECTIVE

To determine whether there is an association between fasting plasma glucose level and periodontal condition in a non-diabetic male population.

METHODS

Data of periodic medical examinations of 815 non-diabetic male adults (mean age 38.1 + or - 7.0 years) were analysed. Blood samples were drawn from each subject following a 14-hour fast. The distance between the cement-enamel-junction to alveolar bone crest was measured at inter-proximal sites on two standardised posterior bitewing radiographs.

RESULTS

Higher prevalence of alveolar bone loss was found among individuals with a fasting glucose level of > or = 100 mg/dL than among individuals with <100 mg/dL (p = 0.032) and among individuals with BMI > or = 25 than among individuals with BMI <25 (p = 0.025). Associations were found between bone loss prevalence and serum triglyceride levels of > or = 200mg/dL, total cholesterol level of > or = 200mg/dL and LDL-cholesterol level of > or = 130 mg/dL (p = 0.010, p <0.001, p = 0.009, respectively).

CONCLUSIONS

In the studied non-diabetic adult population, periodontal disease was associated with impaired glucose level. Periodontal disease could serve as a predictor for future diabetes mellitus, or play a possible role in the glucose imbalance and diabetes mellitus development.

COSEHC global vascular risk management quality improvement program: rationale and design

Background:

The Consortium for Southeastern Hypertension Control (COSEHC) promotes global risk factor management in patients with metabolic syndrome. The COSEHC Global Vascular Risk Management Study (GVRM) intends to quantify these efforts on long-term patient outcomes. The objectives of this study were to present baseline demographics of patients enrolled in the GVRM, calculate a modified COSEHC risk score using 11 variables (COSEHC-11), and compare it with the original COSEHC-17 and Framingham, Prospective Cardiovascular Münster (PROCAM), and Systemic Coronary Risk Evaluation (SCORE) risk scores.

Methods:

Deidentified electronic medical records of enrolled patients were used to calculate the risk scores. The ability of the COSEHC-11 score to predict the COSEHC-17 score was assessed by regression analysis. Raw risk scores were converted to probability estimates of fatal coronary heart disease (CHD) and compared with predicted risks from other algorithms.

Results:

Of the 177,404 patients enrolled, 43,676 had data for all 11 variables. The COSEHC-11 score (mean ± standard deviation) of these 43,676 patients was 31.75 ± 11.66, implying a five-year fatal CHD risk of 1.4%. The COSEHC-11 score was highly predictive of the COSEHC-17 score (R² = 0.93; P < 0.0001) and correlated well with the SCORE algorithm.

Conclusion:

The COSEHC-11 risk score is statistically similar to the COSEHC-17 risk score and should be a viable tool for evaluating its ability to predict five-year cardiovascular mortality in the coming years.

Metabolic syndrome in the pediatric population: a short overview

The metabolic syndrome (MS) in adults is defined as a concurrence of obesity, disturbed glucose and insulin metabolism, hypertension and dyslipidemia, and is associated with increased morbidity and mortality from cardiovascular diseases and type 2 diabetes. Studies now indicate that many of its components are also present in children and adolescents. Moreover, the clustering of these risk factors has been documented in some children, who are at increased cardiovascular risk in adulthood. The MS is highly prevalent among overweight children and adolescents. Identifying these children is important for early prevention and treatment of different components of the syndrome. The first-line treatment comprises lifestyle modification consisting of diet and exercise. The most effective tool for prevention of the MS is to stop the development of childhood obesity. The first attempt at consensus-based pediatric diagnostic criteria was published in 2007 by the International Diabetes Federation. Nevertheless, national prevalence data, based on uniform pediatric definition, protocols for prevention, early recognition and effective treatment of pediatric MS are still needed.The aim of this article is to provide a short overview of the diagnosis and treatment options of childhood MS, as well as to present the relationships between MS and its individual components.

Dyslipidemia treatment of patients with diabetes mellitus in a US managed care plan: a retrospective database analysis

Background

To evaluate real-world pharmacologic treatment of mixed dyslipidemia in patients with diabetes mellitus (DM).

Methods

All commercial health plan members in a large US managed care database with complete lipid panel results (HDL-C, LDL-C, TG) between 1/1/2006 and 12/31/2006 were identified (N = 529,236). DM patients (N = 53,679) with mixed dyslipidemia were defined as having any 2 suboptimal lipid parameters (N = 28,728). Lipid treatment status 6 months pre- and post-index date was determined using pharmacy claims for any lipid therapy.

Results

Post-index, 41.1% of DM patients with 2 abnormal lipid parameters and 45.1% with 3 abnormal lipid parameters did not receive lipid-modifying treatment. Post-index treatment rates were 57.4%, 63.6%, and 66.4% for patients with LDL-C, HDL-C, and TG in the most severe quartiles, respectively. Statin monotherapy was the primary lipid-modifying regimen prescribed (54.8% and 47.8% of patients with any 2 and all 3 lipids not at goal, respectively). Less than 30% of treated patients received combination therapy.

Conclusion

Over 40% of DM patients with mixed dyslipidemia received no lipid-modifying therapy during the follow-up period. Those who were treated were primarily prescribed statin monotherapy. This study suggests that DM patients are not being treated to ADA-suggested targets.

Effects of the flaxseed lignans secoisolariciresinol diglucoside and its aglycone on serum and hepatic lipids in hyperlipidaemic rats

The present study involved a comparative analysis of the effects of purified flaxseed lignans, secoisolariciresinol diglucoside (SDG) and its aglycone metabolite (SECO), in hyperlipidaemic rats. For hypercholesterolaemia, female Wistars (six rats per group) were fed a standard or 1 % cholesterol diet and orally administered 0, 3 or 6 mg SDG/kg or 0, 1·6 or 3·2 mg SECO/kg body weight once daily for 4 weeks. Hypertriacylglycerolaemia was induced in male Sprague–Dawley rats (ten rats per group) by supplementing tap water with 10 % fructose. These rats were orally administered 0, 3 or 6 mg SDG/kg body weight once daily for 2 weeks. Fasting blood samples (12 h) were collected predose and at the end of the dosing period for serum lipid analyses. Rats were killed and livers rapidly excised and sectioned for lipid, mRNA and histological analyses. Chronic administration of equimolar amounts of SDG and SECO caused similar dose-dependent reductions in rate of body-weight gain and in serum total and LDL-cholesterol levels and hepatic lipid accumulation. SDG and SECO failed to alter hepatic gene expression of commonly reported regulatory targets of lipid homeostasis. SDG had no effect on serum TAG, NEFA, phospholipids and rate of weight gain in 10 % fructose-supplemented rats. In conclusion, our data suggest that the lignan component of flaxseed contributes to the hypocholesterolaemic effects of flaxseed consumption observed in humans. Future studies plan to identify the biochemical mechanism(s) through which flaxseed lignans exert their beneficial effects and the lignan form(s) responsible.

Goal attainment for multiple cardiovascular risk factors in community-based clinical practice (a Canadian experience)

BACKGROUND

The primary goal in the clinical management of atherosclerotic cardiovascular (CV) disease is to reduce major CV risk factors. A single risk factor approach has been traditionally used for demonstrating effectiveness of therapeutic interventions designed to reduce CV risk in clinical trials, but a global CV risk reduction approach should be adopted when assessing effectiveness in the clinical practice setting.

OBJECTIVES

To explore combined goal achievement for low-density lipoprotein cholesterol (LDL-C), fasting plasma glucose and systolic-diastolic blood pressure, in patients with dyslipidemia on pharmacotherapy in community-based clinical practices across Canada.

METHODS

In a cross-sectional study, patients filling a prescription for any antihyperlipidemia therapy in selected pharmacies in Ontario, Quebec, British Columbia and Nova Scotia were recruited. Family physicians of the participating patients were requested to provide information from the patient's medical record. Ten-year CV risk was identified for each patient according to the Framingham criteria.

RESULTS

High-risk patients comprised 52% of the patient population; 34% were moderate-risk and 14% were low-risk. Patients had a mean of 2.8 CV risk factors; high-risk 3.7, moderate-risk 2.3 and low-risk 1.2. LDL-C goal attainment was observed in 62%, 79% and 96% of patients in high-risk, moderate-risk and low-risk strata respectively. BP goal was achieved in high-risk patients 58%, moderate-risk 83% and low-risk 95%. Glucose levels were below the threshold in 91% of patients. Complete global CV risk reduction was achieved in only 21%, 66% and 92% of high-risk, moderate-risk and low-risk strata respectively.

CONCLUSION

This study illustrates that many patients with dyslipidemia in the Canadian population, and in particular the high-risk patients, did not meet the therapeutic targets for specific CV risk factors according to the Canadian guidelines. Overall, 54% of patients failed to achieve a state of complete global CV risk reduction.

The metabolic syndrome

The "metabolic syndrome" (MetS) is a clustering of components that reflect overnutrition, sedentary lifestyles, and resultant excess adiposity. The MetS includes the clustering of abdominal obesity, insulin resistance, dyslipidemia, and elevated blood pressure and is associated with other comorbidities including the prothrombotic state, proinflammatory state, nonalcoholic fatty liver disease, and reproductive disorders. Because the MetS is a cluster of different conditions, and not a single disease, the development of multiple concurrent definitions has resulted. The prevalence of the MetS is increasing to epidemic proportions not only in the United States and the remainder of the urbanized world but also in developing nations. Most studies show that the MetS is associated with an approximate doubling of cardiovascular disease risk and a 5-fold increased risk for incident type 2 diabetes mellitus. Although it is unclear whether there is a unifying pathophysiological mechanism resulting in the MetS, abdominal adiposity and insulin resistance appear to be central to the MetS and its individual components. Lifestyle modification and weight loss should, therefore, be at the core of treating or preventing the MetS and its components. In addition, there is a general consensus that other cardiac risk factors should be aggressively managed in individuals with the MetS. Finally, in 2008 the MetS is an evolving concept that continues to be data driven and evidence based with revisions forthcoming.

Local adipose tissue renin-angiotensin system

A local renin-angiotensin system (RAS) has been proposed in adipocytes. Adipocytes are a suggested source of components of the RAS, with regulation of their production related to obesity-hypertension. Both angiotensin type 1 and 2 receptors have been localized to adipocytes. Angiotensin II has been demonstrated to regulate adipocyte growth and differentiation, lipid metabolism, and expression and release of adipokines and RAS components, and to promote oxidative stress. Differences in regional expression of RAS components in visceral versus subcutaneous adipose tissue have been suggested as a link between abdominal obesity and cardiovascular disease. Finally, several studies support antihypertensive efficacy of RAS blockade in patients with type 2 diabetes and obesity. Future studies should address the role of adipocyte-specific deficiency of RAS components to definitively determine the relevance of the adipose RAS to normal physiology and to the development of hypertension.

Review: New techniques for assessment of vascular function

The noninvasive measurement of hemodynamic variables associated with hypertension and cardiovascular disease processes needs to be recognized as a viable adjunct to clinical practice. This review traces the history of the inception and development of noninvasive measurement of hemodynamic variable. It then identifies well established, useful, and available devices, and then notes clinical studies verifying the clinical relevance of these measurements. Given the need to intervene earlier in the course of cardiovascular disease processes, tools are needed to assist the medical team to evaluate, prognosticate, and guide their patient's therapy correctly. It is the goal of this review to heighten the awareness and enhance and encourage the implementation of these devices in our armamentarium for the betterment of our patient's health.

Severe periodontitis is associated with systemic inflammation and a dysmetabolic status: a case–control study

BACKGROUND AND AIM

A cluster of metabolic factors defines a syndrome that predisposes to diabetes and cardiovascular disease. Chronic infections such as periodontitis might alter these individual metabolic factors and the systemic inflammatory burden. The aim of this study was to investigate the association between severe periodontitis and increase in inflammatory and metabolic risk factors for cardiovascular disease.

MATERIALS AND METHODS

We examined 302 patients with severe periodontitis and 183 healthy controls, and we collected a blood sample from each subject in order to investigate differences in inflammatory (leukocyte numbers and differential counts) and metabolic markers (lipids and glucose).

RESULTS

After correcting for differences in age, gender, smoking and ethnicity, periodontitis subjects exhibited a low-grade systemic inflammation (increased white cell counts, 1.10+/-1.02 x 10(9)/l, 95%CI 1.05-1.15, p=0.0001), dyslipidemia [lower high-density lipoprotein cholesterol, 1.14+/-1.03 mmol/l, 95%CI 1.08-1.20, p<0.0001 and higher low-density lipoprotein cholesterol, 1.12+/-1.03, 95%CI 1.05-1.19, p<0.0001) and increased non-fasting serum glucose levels (1.04+/-1.01 mmol/l, 95%CI 1.02-1.06, p=0.01) when compared with controls. The associations were confirmed in a subpopulation of Caucasian non-smokers. A trend for a dose dependent effect of the number of periodontal pockets on the tested inflammatory and metabolic markers was observed.

CONCLUSIONS

These data suggest a possible link between severe generalized periodontitis, systemic inflammation and a dysmetabolic state in otherwise healthy individuals.

Metabolic syndrome: treatment of hypertensive patients

Metabolic syndrome (MetSyndr), a constellation of abnormalities [obesity, glucose intolerance, insulin resistance (IR), dyslipidemia (low HDL-cholesterol, high LDL-cholesterol and triglycerides (TG)], and elevated blood pressure (BP)], increases the risk of cardiovascular (CV) disease and premature death. From 10% to 30% of the adult population in industrialized countries has MetSyndr, which effectively predicts the development of type 2 diabetes mellitus (T2D) and CV disease. Because of the complex etiology of MetSyndr, a multi-targeted, integrated therapeutic approach is required to simultaneously treat high BP, obesity, lipid disorders and T2D (if present), to fully protect CV, cerebrovascular and renal systems. If lifestyle modification (weight control, diet, exercise, smoking cessation, moderation of alcohol intake) is ineffective, pharmaco-theraphy should be added to treat simultaneously the lipid- and non-lipid CV risk factors. Patients with HTN and MetSyndr should be started on angiotensin-converting enzyme (ACE) inhibitors, unless contraindicated. The ACE inhibitors and angiotensin receptor blockers (ARBs) reduce the odds of developing new onset T2D and also decrease albuminuria. The ACE inhibitors provide cardioprotective and renoprotective benefits beyond their effect on BP; they also improve IR. The ARBs are renoprotective in addition to being cardioprotective. Long-acting calcium channel blockers are also recommended in hypertensive patients with MetSyndr; these drugs also improve IR. Thiazides (at low doses) and selected ss-blockers can be given to patients with HTN and MetSyndr. Celiprolol in combination with diuretics has a favorable effect on glucose tolerance and IR in patients with HTN and MetSyndr, and spironolactone added to ACE inhibitor or ARB therapy provides additional reno- and CV protective benefits in patients with diabetic nephropathy. Carvedilol, a ss-blocker with vasodilating properties, added to ACE inhibitor or ARB therapy, is effective in preventing worsening of microalbuminuria in patients with HTN and MetSyndr; it also improves IR and glycemic control. Most patients eventually require two or more antihypertensive drugs to reach BP goal. It is recommended that therapy in patients whose BP is more than 20/10 mm Hg above target at diagnosis be initiated with a combination of antihypertensive drugs, administered either as individual drugs or as fixed-dose formulations. Treatment with fixed-dose combinations, such as irbesartan + hydrochlorothiazide provides good BP control in more than two-thirds of hypertensive patients with MetSyndr. Lipid and BP targets are reached in a high percent of patients with HTN and CV disease treated with a combination of amlodipine + atorvastatin. In conclusion, hypertensive patients with the MetSyndr be treated aggressively for each component of the syndrome to provide CV, cerebrovascular and renal protection.

Should Hypertension Guidelines Be Changed for Hypertensive Patients With the Metabolic Syndrome?

The authors analyzed the impact of present guidelines for hypertension management on cardiovascular (CV) risk factors in hypertensive patients with and without the metabolic syndrome (MS). Results in 549 nondiabetic hypertensive patients with a mean follow-up of 3.8+/-1.2 years on usual recommended care were reviewed. At baseline, 231 (42.1%) patients had MS and, per the definition, showed significantly higher values of traditional CV risk factors than non-MS patients. At the end of follow-up, blood pressure levels were similar in both groups; the lipid profile tended to improve in MS patients. Eighteen MS patients (7.8%) and 7 non-MS patients (2.2%) developed diabetes (P<.001). Prevalence of microalbuminuria was reduced in both groups, but it remained significantly higher in MS patients. Usual care of hypertensive patients achieved similar blood pressure and low-density lipoprotein cholesterol goals, both in MS and non-MS patients. Global CV risk, however, remained higher in MS patients, as suggested by a 3-fold higher incidence of new-onset diabetes (absolute increase of 5.6%) and a 2-fold increase in microalbuminuria.

Differential effects of oral hypoglycemic agents on glucose control and cardiovascular risk

Cardiovascular disease (CVD) burden remains the predominant cause of mortality and morbidity in the United States and in most of the developed world. The ongoing twin epidemics of obesity and type 2 diabetes mellitus provide a groundswell source for sustaining this trend for the foreseeable future (increasing the prevalence of CVD by 2-4 times), unless radical changes are made in public health policy. Oral hypoglycemic agents (OHAs) remain a mainstay for management of type 2 diabetes in most practice settings. Although these agents are primarily prescribed to achieve better glycemic control, it is important to evaluate what effects they have on cardiovascular risk and whether there are significant differences in effects among the different OHAs. This review presents the available data on the effects of the various OHAs on cardiovascular risk surrogates and actual events in retrospective and prospective study design settings.

Antihypertensive therapy in patients with metabolic syndrome

PURPOSE OF REVIEW

It is amply recognized that the presence of metabolic syndrome is associated with subclinical cardiac, vascular and kidney damage, with an increased risk for cardiovascular and cerebrovascular disease and type 2 diabetes, and, as a consequence, with higher rates of cardiovascular mortality. Metabolic syndrome can be considered as a prediabetic state very frequently associated with arterial hypertension, requiring pharmacological therapy.

RECENT FINDINGS

All antihypertensive therapies have been shown to reduce the risk of total major cardiovascular events. Recently, the relevance of the type of hypertensive therapy used to treat hypertensive patients in facilitating the development of diabetes has been demonstrated in different trials. The recognition of the risk present in hypertensive patients with metabolic syndrome for developing diabetes reinforces the need to consider the ideal antihypertensive therapy, either mono or combination, in these patients.

SUMMARY

This brief review contains the available evidence showing that an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker is the most suitable therapy to be started in these patients, alone or in combination, due to their capacity to prevent or retard the development of diabetes, and the strong relationship between metabolic syndrome and arterial hypertension, focusing on the advantages and disadvantages of different antihypertensive drugs.

Cholesterol-fed rabbit as a unique model of nonalcoholic, nonobese, non-insulin-resistant fatty liver disease with characteristic fibrosis

BACKGROUND

The number of patients suffering from metabolic syndrome is increasing rapidly. Metabolic syndrome causes severe pathological changes in various organs, including the liver, and its main phenotype is nonalcoholic fatty liver disease (NAFLD). NAFLD has a broad spectrum ranging from simple fatty change to severe steatohepatitis with marked fibrosis. Recently, several experimental animal models for NAFLD have been proposed. However, most were established by rather artificial conditions such as genetic alteration. In the present study, we tried to establish a unique animal model mimicking some of the physiopathological features of NAFLD using high-cholesterol-fed rabbits.

METHODS

Male rabbits fed with standard rabbit food containing 1% cholesterol for 8 weeks and 12 weeks were compared to controls (six rabbits/group). The weight of food was strictly restricted to 100 g/rabbit per day.

RESULTS

Body weights and fasting plasma insulin levels showed no significant differences among the groups. In contrast, characteristic fine fibrosis was extended from perivenular to pericellular areas, and microvesicular fatty change with ballooning degeneration was observed in perivenular areas in livers of the cholesterol-fed rabbits. Increase of serum cholesterol level, activation of hepatic stellate cells, and exposure to oxidative stress were also recognized.

CONCLUSIONS

Cholesterol-fed rabbits share several physiopathological features of NAFLD. Because this model did not show insulin resistance or obesity, it may be useful for elucidating the mechanism of NAFLD related mainly to hyperlipidemia.

Prevalence of the metabolic syndrome in Zhejiang Chinese obese children and adolescents and the effect of metformin combined with lifestyle intervention

OBJECTIVE

We aimed to evaluate the prevalence of metabolic syndrome (MS) in a group of obese children and adolescents in Zhejiang in the south of China, and to compare risk factors such as insulin resistance, adiponectin level and impaired glucose tolerance (IGT) etc with that of simple obese group (SOB) and non-obese healthy group, and also to evaluate the effect of metformin and lifestyle intervention in MS group by up to a 3-month follow-up.

METHODS

Three hundred and forty eight moderately or severely obese adolescents aged between 7 and 16 years were enrolled. Oral glucose tolerance test (OGTT), biochemical indicators, blood pressure and body mass index (BMI) were assessed in all of them. Three subgroups were selected (MS group, SOB and healthy control). Adiponectin levels, Whole body insulin sensitive index (WBISI), homeostasis model of insulin resistance (HOMA-IR), plasma lipid and blood pressure were compared in these three groups. Thirty out of thirty-six MS subjects with age over 10 years received metformin treatment combined with lifestyle modification.

RESULTS

(1) The prevalence of MS was 10.34% among all obese subjects, which increased with the severity of obesity and reached 22.1% in severely obese children and adolescents. The occurrence of more than one complication reached 72.13%. The incidence of type 2 diabetes and IGT were 1.44 and 1.44% respectively. (2) BMI, waist-to-hip ratio (WHR) and HOMA-IR increased stepwise in the control group, SOB and MS group, whereas serum adiponectin and WBISI decreased stepwise (all P<0.01). Systolic pressure, triglyceride, total cholesterol, low-density lipoprotein cholesterol and postprandial 2-h blood glucose in the MS group increased significantly compared to those in control and SOBs (all P<0.01). A correlation analysis showed that serum levels of adiponectin and WBISI were associated with the components of MS (all P<0.05). (3) After metformin and lifestyle intervention, clinical symptoms were ameliorated, serum adiponectin levels were actually increased and HOMA-IR was dropped in 20/30 MS children who had finished a 3-months follow-up (all P<0.01).

CONCLUSION

The prevalence of MS in severely obese children and adolescents in Zhejiang area has reached a high level. Insulin resistance and hypoadiponectinemia were found in these MS children. Metformin combined with lifestyle modification was confirmed to be efficient and safe in treating the obese adolescents with MS.

Reduced acute vascular injury and atherosclerosis in hyperlipidemic mice transgenic for lysozyme

Hyperlipidemia promotes oxidant stress, inflammation, and atherogenesis in apolipoprotein E-deficient (ApoE((-/-))) mice. Mice transgenic for lysozyme (LZ-Tg) are resistant to acute and chronic oxidative stress and have decreased circulating levels of pro-oxidant advanced glycation end-products (AGEs). Herein we report that TIB-186 macrophages transduced with adenovirus-expressing human LZ (AdV-LZ) containing the AGE-binding domain facilitated AGE uptake and degradation and that AdV-LZ-transduced macrophages and peritoneal macrophages from LZ-Tg mice suppressed the AGE-triggered tumor necrosis factor-alpha response. We assessed atherosclerosis in LZ-Tg mice crossed with ApoE((-/-)) mice (LZ/ApoE((-/-))) and found increased serum LZ levels and decreased AGE and 8-isoprostanes levels, although hyperlipidemia remained similar to ApoE((-/-)) controls. Atherosclerotic plaques and neointimal lesions at the aortic root and descending aorta were markedly decreased (by 40% and 80%, respectively) in LZ/ApoE((-/-)) versus ApoE((-/-)) mice, as were inflammatory infiltrates. The arterial lesions following femoral artery injury in LZ/ApoE((-/-)) mice were suppressed (intimal to media ratio decreased by 50%), as were AGE deposits and vascular smooth muscle cell activation, compared to ApoE((-/-)) mice. Despite hyperlipidemia, development of atheroma and occlusive, inflammatory arterial neointimal lesions in response to injury was suppressed in LZ/ApoE((-/-)) mice. This effect may be due to the antioxidant properties of LZ, which is possibly linked to the AGE-binding domain region of the molecule.

Management of Global Risk Across the Continuum of Hypertensive Heart Disease

Identification and management of cardiovascular (CV) risk factors are essential to help prevent CV disease and slow its progression. Long-term epidemiologic data show that hypertension is associated with a two- to four-fold increase in CV morbidity and mortality; moreover, antihypertensive therapy has been proven to significantly reduce the risk of CV events. Clinical trial data also suggest that different antihypertensive agents generally provide similar reductions in CV risks and outcomes. Beta blockers have historically played an integral role in hypertension treatment, particularly among patients at high CV risk; however, a recent meta-analysis, based primarily on the use of atenolol, found that beta blockers may provide less clinical benefit as initial therapy than other classes of antihypertensive agents. Beta blockers are heterogeneous, and atenolol data may not be representative of other beta blockers. Newer beta blockers, which provide both cardioselective beta1-adrenergic receptor blockade and endothelium-dependent vasodilation, may prove to be more effective in reducing CV morbidity and mortality. Intensive strategies to control global CV risk have been shown to significantly reduce CV events. The challenge remains to develop effective risk assessment tools to identify at-risk patients who often go undetected.

Hypertension--a treatable component of the cardiometabolic syndrome: challenges for the primary care physician

Patients with the cardiometabolic syndrome (CMS) have an adverse cardiovascular risk factor profile, placing them at increased risk of stroke, coronary artery disease, chronic kidney disease, and type 2 diabetes mellitus. Although no specific treatments for CMS are available per se, prompt recognition and treatment of the individual components of the condition can prevent or delay the development of comorbidities. Primary care physicians are ideally positioned to identify patients with CMS and implement early intervention strategies. Hypertension contributes to many complications of CMS, and rigorous blood pressure control will help to delay or prevent end-organ vascular damage. Achieving blood pressure control to current guideline standards should be eagerly sought in the majority of patients through a combination of lifestyle modifications and appropriate pharmacologic therapy. Antihypertensive drug choice should be personalized, taking into account the CMS determinants present and any compelling indications for specific agents. As an initial approach, a thiazide diuretic is suitable for most cases of uncomplicated hypertension, although many patients will require additional antihypertensives from other classes to achieve their blood pressure goal. It is predicted that, due to the increase in unhealthy lifestyles, the prevalence of CMS will rise in the coming years. Therefore, by meeting the challenge of attaining and maintaining blood pressure control in patients with CMS, primary care physicians have the unique opportunity to markedly improve the health of the nation.

Managing hypertension in high-risk patients: lessons and promises from the STRATHE and ADVANCE trials

Pharmacological treatment of hypertension represents a cost-effective way of preventing cardiovascular and renal complications. To benefit maximally from antihypertensive treatment, blood pressure should be brought to below 140/90 mmHg in every hypertensive patient, and even lower (< 130/80 mmHg) if diabetes or renal disease co-exists. Such targets cannot usually be reached using monotherapies. This is especially true in patients who present with a high cardiovascular risk. The co-administration of two agents acting by different mechanisms considerably increases the blood pressure control rate. Such combinations are not only efficacious, but are also well tolerated, and some fixed low-dose combinations even have a placebo-like tolerability. This is the case for the preparation containing the angiotensin-converting enzyme inhibitor perindopril (2 mg) and the diuretic indapamide (0.625 mg), a fixed low-dose combination that has been shown in controlled trials to be more effective than monotherapies in reducing albuminuria, regressing cardiac hypertrophy and improving the stiffness of large arteries. Using this combination to initiate antihypertensive therapy has been shown in a double-blind trial (Strategies of Treatment in Hypertension: Evaluation; STRATHE) to normalize blood pressure (< 140/90 mmHg) in significantly more patients (62%) than a sequential monotherapy approach based on atenolol, losartan and amlodipine (49%) and a stepped-care strategy based on valsartan and hydrochlorothiazide (47%), with no difference between the three arm groups in terms of tolerability. An ongoing randomized trial (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation; ADVANCE) is a study with a 2 x 2 factorial design assessing the effects of the fixed-dose perindopril-indapamide combination and of the intensive gliclazide modified release-based glucose control regimen in type 2 diabetic patients, with or without hypertension. A total of 11 140 patients were randomly selected. Within the first 6 weeks of treatment (run-in phase), the perindopril-indapamide combination lowered blood pressure from 145/81 +/- 22/11 mmHg (mean +/- SD) to 137/78 +/- 20/10 mmHg. Fixed-dose combinations are becoming more and more popular for the management of hypertension, and are even proposed by hypertension guidelines as a first-line option to treat hypertensive patients.