Therapeutic Modulation of Aortic Stiffness

Use of Antihypertensive Drugs and Arterial Stiffness in the Longitudinal Study of Adult Health (ELSA-Brasil)

OBJECTIVE

Evaluate the longitudinal association between BP control and the use of antihypertensive classes with arterial stiffness (AS) in Brazilian adults.

METHODS

This study included 1830 participants with arterial hypertension (1092 participants with controlled BP and 738 participants with uncontrolled BP) from the Longitudinal Study of Adult Health (ELSA-Brasil). AS was assessed by pulse wave velocity (PWV) and pulse pressure (PP) at baseline and repeated after approximately 9 years. Associations between AS and BP control and the use of antihypertensives, diuretics, angiotensin-converting enzyme inhibitors (ACEI), AT1 receptor blockers (ARB), calcium channel blockers (CCB), and beta blockers (in the population with controlled BP), at baseline were investigated using linear mixed-effects models.

RESULTS

Uncontrolled BP was associated with worse PWV and PP trajectory, respectively (β = 0.026 [0.008 to 0.036] / β = 0.273 [0.216 to 0.330]). Among the participants with controlled BP, using CCB (β = 0.031 [0.011 to 0.051]) was associated with a worse PWV trajectory, compared to not using this class and this combination, respectively.

CONCLUSION

BP control, regardless of the class of antihypertensive used is associated with a better AS trajectory, as assessed by PWV and PP. Among participants with controlled BP, the use of BCC, compared to not using this class, seems to be worse for the trajectory of PWV in individuals with arterial hypertension without cardiovascular disease. Further studies are needed to assess whether this effect results in a better prognosis for patients with arterial hypertension.

Role of arterial impairment in preeclampsia: should the paradigm shift?

Preeclampsia is a worldwide pregnancy complication with serious short- and long-term maternal and neonatal consequences. Our understanding of preeclampsia pathophysiology has significantly evolved over the last decades with the recognition that impaired arterial function and structure may occur early in the course of pregnancy, preceding the clinic-humoral syndrome and driving long-term cardiovascular disease risk in the future of these patients. Although an early abnormal placentation may be the inciting event for a large proportion of cases, there is growing evidence that challenges the placental hypothesis in all affected women, since placental histopathology lesions thought to be characteristic are neither sensitive nor specific markers for the disorder. Recent hemodynamic investigations and studies on left ventricular function and structure in women with preeclampsia further challenge this universal paradigm and propose that placental dysfunction could be secondary to a maternal cardiovascular maladaptation to pregnancy in certain patients. Supporting this hypothesis, certain vascular features, which are characteristically enhanced in normal pregnancy allowing a healthy vascular adaptation, are absent in preeclampsia and comparable to the nonpregnant population. However, arterial biomechanics in preeclampsia may only not cope with hemodynamic demands of pregnancy but also impose additional detrimental loads to the maternal heart ("impaired left-ventricle-aorta coupling") and transmit pressure and flow disturbances into the fetoplacental circulation ("impaired large arteries-microcirculation coupling"). In this review, we analyze the major role of the arterial dysfunction in the cardiovascular maladaptation hypothesis of preeclampsia, shed light on its potential etiopathogenic link, and discuss the complementary nature of the placental and cardiovascular theories.

Decreased biventricular function following thoracic endovascular aortic repair

OBJECTIVES

Preclinical studies have suggested acute stiffening of the aorta following experimental thoracic endovascular aortic repair (TEVAR), resulting in acute elevated pulse pressure, hypertension and possibly heart failure. The aim of this study was to evaluate cardiac remodelling following TEVAR.

METHODS

From 2005 to 2018, 519 TEVAR procedures were performed at a single centre. Transthoracic echocardiography was performed pre- and post-TEVAR in 31 patients without previous replacement of the thoracic aorta. Patient characteristics, drug information, radiographic and follow-up data were evaluated. Aortic details were measured in multiplanar reconstruction.

RESULTS

Transthoracic echocardiography was performed 2 ± 2 years after TEVAR. At this time, patients received significantly more antihypertensive drugs compared to the pre-TEVAR intake (beta-blocker therapy: P = 0.037; calcium channel blocker: P = 0.022). Compared to pre-TEVAR, there was a significant reduction in the left ventricular ejection fraction (P = 0.008) and tricuspid annular plane systolic excursion (P = 0.013) post-TEVAR. A significant increase in the left ventricular mass was not detected in this study (P = 0.95). The mean distance of 163 ± 66 mm of the descending aorta was covered.

CONCLUSIONS

This study suggests negative cardiac remodelling with a decrease in the left and right ventricular function following TEVAR despite an increase in oral antihypertensive medication. The impact of stiffer endovascular grafts compared with the native aortic wall should be considered by endovascular specialists and manufacturers.

Association of Low Serum Adiponectin Levels with Aortic Arterial Stiffness in Patients with Type 2 Diabetes

Adiponectin, an anti-inflammatory and anti-atherogenic protein, affects glucose metabolism. High serum adiponectin levels are associated with decreased diabetes mellitus (DM) risks. Aortic arterial stiffness (AS) is associated with cardiovascular disease and mortality in type 2 DM patients. We assessed the association between adiponectin levels and aortic AS in type 2 DM patients. We measured serum adiponectin levels in 140 volunteers with type 2 DM and assigned patients with carotid–femoral pulse wave velocity (cfPWV) >10 m/s to the aortic AS group (n = 54, 38.6%). These patients had higher systolic (p = 0.001) and diastolic (p = 0.010) blood pressures; body fat masses (p = 0.041); serum triglyceride (p = 0.026), phosphorus (p = 0.037), and insulin (p = 0.040) levels; and homeostasis model assessment of insulin resistance values (p = 0.029) and lower estimated glomerular filtration rates (p = 0.009) and serum adiponectin levels (p = 0.001) than controls. Multivariable logistic regression analysis adjusted for confounders showed serum adiponectin levels (OR 0.922; 95% CI, 0.876–0.970; p = 0.002) as an independent predictor of aortic AS. Multivariable forward stepwise linear regression analyses showed that serum adiponectin levels (β = −0.283, adjusted R² change: 0.054, p < 0.001) were negatively associated with cfPWV. Thus, serum adiponectin level is an independent predictor of aortic AS in type 2 DM patients.

Effect of carbohydrate restriction-induced weight loss on aortic pulse wave velocity in overweight men and women

Increased aortic stiffness, measured by carotid-to-femoral pulse wave velocity (PWV), is an independent predictor of cardiovascular disease, and past data have shown that low-fat and low-energy diets, fed for 8–24 weeks, lower PWV. The purpose of this study was to determine whether a reduction in PWV would be achieved by dietary carbohydrate (CHO) restriction, shown to bring about weight loss over a shorter timeframe. Men (n = 10, age: 41.8 ± 10.2 years, BMI: 34.2 ± 3.0 kg/m2 (mean ± SD)) and women (n = 10, age: 38.6 ± 6.1 years, BMI: 33.5 ± 3.8 kg/m2) with characteristics of insulin resistance and the metabolic syndrome consumed a structured, CHO-restricted diet for 4 weeks (energy deficit, 645 kcal/day). For the whole group, subjects lost 5.4% ± 0.5% (P < 0.001) of body weight and experienced significant reductions in blood pressure (6%–8%), plasma insulin (34%), and triglycerides (34%). PWV was reduced by 6% ± 2% (7.1 ± 0.2 m/s to 6.7 ± 0.2 m/s, P = 0.008) and surprisingly, in women, it fell significantly (from 7.2 ± 0.3 m/s to 6.3 ± 0.3 m/s, P = 0.028), while no changes were observed in men (7.2 ± 0.3 vs. 7.0 ± 0.3 m/s, P = 0.144). This is the first study to demonstrate that weight loss can improve PWV in as little as 4 weeks and that dietary CHO restriction may be an effective treatment for reducing aortic stiffness in women. Future studies are needed to establish the mechanisms by which dietary CHO restriction may confer more cardiovascular benefits to women than to men.

Impact of antihypertensive agents on arterial stiffness in hypertensive patients

AIMS

The present network meta-analysis was performed to comprehensively compare the ability of different types of antihypertensive agents to ameliorate arterial stiffness in hypertensive patients.

METHODS AND RESULTS

To conduct this network meta-analysis, we searched PubMed, the Embase database, and the https://clinicaltrials.gov/ website for all relevant articles concerning clinical trials on hypertension therapy. The last search date was 10 August 2017. As a result, 28 eligible articles were enrolled in our meta-analysis. According to the included studies, there was no significant difference in pulse wave velocity (PWV) between these treatments. The eight types of antihypertension agents outperformed placebo in controlling systolic blood pressure (SBP). Angiotensin-converting enzyme inhibitor (ACEI) outperformed angiotensin II receptor blocker (ARB) in SBP; and angiotensin receptor-neprilysin inhibitor (ARNI) outperformed diuretic (D)in SBP.

CONCLUSIONS

This study found that the eight antihypertensive agents show obvious effect on reducing SBP other than arterial stiffness.

Inflammatory Markers for Arterial Stiffness in Cardiovascular Diseases

Arterial stiffness predicts an increased risk of cardiovascular events. Inflammation plays a major role in large arteries stiffening, related to atherosclerosis, arteriosclerosis, endothelial dysfunction, smooth muscle cell migration, vascular calcification, increased activity of metalloproteinases, extracellular matrix degradation, oxidative stress, elastolysis, and degradation of collagen. The present paper reviews main mechanisms explaining the crosstalk between inflammation and arterial stiffness and the most common inflammatory markers associated with increased arterial stiffness, considering the most recent clinical and experimental studies. Diverse studies revealed significant correlations between the severity of arterial stiffness and inflammatory markers, such as white blood cell count, neutrophil/lymphocyte ratio, adhesion molecules, fibrinogen, C-reactive protein, cytokines, microRNAs, and cyclooxygenase-2, in patients with a broad variety of diseases, such as metabolic syndrome, diabetes, coronary heart disease, peripheral arterial disease, malignant and rheumatic disorders, polycystic kidney disease, renal transplant, familial Mediterranean fever, and oral infections, and in women with preeclampsia or after menopause. There is strong evidence that inflammation plays an important and, at least, partly reversible role in the development of arterial stiffness, and inflammatory markers may be useful additional tools in the assessment of the cardiovascular risk in clinical practice. Combined assessment of arterial stiffness and inflammatory markers may improve non-invasive assessment of cardiovascular risk, enabling selection of high-risk patients for prophylactic treatment or more regular medical examination. Development of future destiffening therapies may target pro-inflammatory mechanisms.