Effect of amlodipine on the progression of atherosclerosis and the occurrence of clinical events. PREVENT Investigators

Polygenic scores for cardiovascular risk factors improve estimation of clinical outcomes in CCB treatment compared to pharmacogenetic variants alone

Pharmacogenetic variants are associated with clinical outcomes during Calcium Channel Blocker (CCB) treatment, yet whether the effects are modified by genetically predicted clinical risk factors is unknown. We analyzed 32,000 UK Biobank participants treated with dihydropiridine CCBs (mean 5.9 years), including 23 pharmacogenetic variants, and calculated polygenic scores for systolic and diastolic blood pressures, body fat mass, and other patient characteristics. Outcomes included treatment discontinuation and heart failure. Pharmacogenetic variant rs10898815-A (NUMA1) increased discontinuation rates, highest in those with high polygenic scores for fat mass. The RYR3 variant rs877087 T-allele alone modestly increased heart failure risks versus non-carriers (HR:1.13, p = 0.02); in patients with high polygenic scores for fat mass, lean mass, and lipoprotein A, risks were substantially elevated (HR:1.55, p = 4 × 10-5). Incorporating polygenic scores for adiposity and lipoprotein A may improve risk estimates of key clinical outcomes in CCB treatment such as treatment discontinuation and heart failure, compared to pharmacogenetic variants alone.

Cav3.1 T-type calcium channel blocker NNC 55-0396 reduces atherosclerosis by increasing cholesterol efflux

Calcium channel blockers (CCBs) are commonly used as antihypertensive agents. While certain L-type CCBs exhibit antiatherogenic effects, the impact of Cav3.1 T-type CCBs on antiatherogenesis and lipid metabolism remains unexplored. NNC 55-0396 (NNC) is a highly selective blocker of T-type calcium channels (Cav3.1 channels). We investigated the effects of NNC on relevant molecules and molecular mechanisms in human THP-1 macrophages. Cholesterol efflux, an indicator of reverse cholesterol transport (RCT) efficiency, was assessed using [3H]-labeled cholesterol. In vivo, high cholesterol diet (HCD)-fed LDL receptor knockout (Ldlr-/-) mice, an atherosclerosis-prone model, underwent histochemical staining to analyze plaque burden. Treatment of THP-1 macrophages with NNC facilitated cholesterol efflux and reduced intracellular cholesterol accumulation. Pharmacological and genetic interventions demonstrated that NNC treatment or Cav3.1 knockdown significantly enhanced the protein expression of scavenger receptor B1 (SR-B1), ATP-binding cassette transporter A1 (ABCA1), ATP-binding cassette transporter G1 (ABCG1), and liver X receptor alpha (LXRα) transcription factor. Mechanistic analysis revealed that NNC activates p38 and c-Jun N-terminal kinase (JNK) phosphorylation, leading to increased expression of ABCA1, ABCG1, and LXRα-without involving the microRNA pathway. LXRα isrequired for NNC-induced ABCA1 and ABCG1 expression. Administering NNC diminished atherosclerotic lesion area and lipid deposition in HCD-fed Ldlr-/- mice. NNC's anti-atherosclerotic effects, achieved through enhanced cholesterol efflux and inhibition of lipid accumulation, suggest a promising therapeutic approach for hypertensive patients with atherosclerosis. This research highlights the potential of Cav3.1 T-type CCBs in addressing cardiovascular complications associated with hypertension.

Utility of Cilefa Pink B, a foodstuff dye as a fluoro-substrate in the devising of the first facile green Molecular-mass-Related Fluorescence Sensor for quantifying amlodipine in batched material and dosage forms; content uniformity evaluation

This study introduces the first and unique Molecular-mass-Related Fluorescence Sensor as the first fluorimetric strategy for determining amlodipine. An environmentally friendly, single-step, and direct spectrofluorimetric approach was utilized to evaluate the analyte. In an acidic setting, combining the amlodipine medication and the fluorescent dye Cilefa Pink B generated an instantaneous ultra-fluorescent product. An increase in dye response after adding amlodipine was proportional to the molecular weight of the generated complex, as measured at 329 nm. was the idea ofthe applied fluorimetric analysis. The complexing process increased the molecular mass from 879.86 to 1288.739 g mol-1. The medication's range of 0.050-1.00 µg mL-1 is directly correlated with this molecular massenlargement. The ideal settings for the changeable parameters of the system were established through an analysis of the response of the amlodipine-Cilefa Pink B system. Furthermore, the developed sensor complied with ICH (International Council for Harmonization) standards. The sensitivity limits were 0.0139 µg mL-1 (for the detection limit, LOD) and 0.042 µg mL-1 (for the quantification limit, LOQ). Additionally, this method effectively recovered the drug in its original and therapeutic dosage forms. Finally, the proposed process's environmental impact was also assessed through different modern greenness evaluation tools.

Long-term recurrence of ischemic events in patients with intracranial atherosclerotic stenosis stratified by symptoms and pathogenesis

BACKGROUND

Intracranial atherosclerotic stenosis (ICAS) can cause either transient ischemic attack (TIA) or acute ischemic stroke (AIS). Pathogenesis of ICAS-AIS can be divided into artery-to-artery embolism(A-A), hypoperfusion(HP), and parent-artery atherosclerosis occluding penetrating artery(POPA). However, the prognosis of each type remains uncertain. Our study aimed to investigate potential disparities in the recurrent risk among these four subtypes of symptomatic ICAS.

METHODS

From a prospective, single-center cohort study of acute cerebrovascular diseases from January 2017 to November 2021, we recruited 120 ICAS patients and classified them into four groups based on diffusion weighted imaging. Patients were retrospectively followed up for recurrence in December 2022. The primary outcome was recurrent cerebral vascular events (RCVE) in the same territory.

RESULTS

Among 120 recruited patients, POPA(33%) was the most common subtype, followed by A-A(32%), HP(29%), and TIA(6%). Cumulative recurrent rate was 31.2% with median months of follow-up as 27(20-45.5). There was no significant difference in the risk of RCVE in the same territory among four subgroups within three months. However, when considering the risk after three months, TIA(57%) had the highest risk of RCVE, followed by A-A(26%), while HP(4%) and POPA(8%) had lower risks (P = 0.001). Cox regression model indicated that symptom and pathogenesis was an independent risk factor for RCVE in long-term prognosis (P = 0.022), after adjusting for a history of hypertension and cerebral infarction.

CONCLUSIONS

Distinctive symptoms and pathogenesis of ICAS exhibit varying risks of RCVE in long-term prognosis. The differentiation in recurrent risk may provide valuable insights for guiding secondary prevention strategies.

Differential Cardiovascular Outcomes of Each Antihypertensive Drug Class in Patients With Hypertension and Breast Cancer Undergoing Doxorubicin-Containing Chemotherapy

PURPOSE

The preemptive use of renin-angiotensin system (RAS) inhibitors may reduce doxorubicin (DOX)-related cardiotoxicity. Using the national insurance claims data of Korea, this study compared cardiovascular (CV) outcomes following the use of four major antihypertensive drug classes in patients with hypertension and breast cancer who underwent DOX-containing chemotherapy.

METHODS

A total of 4,722 patients with hypertension and breast cancer who underwent DOX-containing chemotherapy were included. The outcomes were compared between patients who used RAS inhibitors, calcium channel blockers (CCBs), beta-blockers (BBs), and thiazide and thiazide-like diuretics (TDs). The primary outcome was a composite of incident heart failure and serious ventricular arrhythmias, including ventricular tachycardia and fibrillation, ischemic heart disease, and stroke.

RESULTS

In the propensity score-matched population, there were no significant differences in the primary outcome between RAS inhibitor and CCB users; however, patients with diabetes who used CCBs had a worse primary outcome than those who used RAS inhibitors (adjusted hazard ratio [aHR], 1.93; 95% confidence interval [CI], 1.06-3.51). BB and TD users had a worse primary outcome compared with RAS inhibitor (aHR, 1.88; 95% CI, 1.30-2.71 in BB users and aHR, 2.55; 95% CI, 1.37-4.75 in TD users) or CCB (aHR, 1.54; 95% CI, 1.09-2.16 in BB users and aHR, 2.08; 95% CI, 1.13-3.82 in TD users) users.

CONCLUSION

RAS inhibitors are preferred for the treating hypertension and improving CV outcomes in patients with hypertension and breast cancer undergoing DOX-containing chemotherapy, particularly in patients with comorbid diabetes. However, CCBs are equivalent to RAS inhibitors and are more favorable than BBs and TDs in terms of improving CV outcomes.

Amlodipine in the current management of hypertension

Hypertension is the leading cause of death worldwide, affecting 1.4 billion people. Treatment options include the widely used calcium channel blockers, among which amlodipine, a dihydropyridine, has unique characteristics that distinguish it from other drugs within this class. This review aims to provide an updated overview of the evidence supporting the use of amlodipine over the past 30 years and highlights its cardiovascular benefits in current hypertension management. Amlodipine has low renal clearance (7 mL/min/mg) and long half-life (35-50 h) and duration of action, which allows it to sustain its anti-hypertensive effect for more than 24 h following a single dose. Additionally, blood pressure (BP) control is maintained even when a dose has been missed, providing continuous protection in case of incidental noncompliance. It has proven to reduce BP variability and successfully lower BP. Amlodipine also controls BP in patients with a systolic/diastolic BP of 130/80 mm Hg or higher, diabetes, or chronic kidney disease without worsening glycemic or kidney function. Additionally, amlodipine is a wise choice for older adults due to its ability to control BP and protect against stroke and myocardial infarction. Side effects of amlodipine include edema, palpitations, dizziness, and flushing, which are more common with the higher dose of 10 mg. Amlodipine is cost effective and predicted to be cost saving when compared with usual care.

Incident Stroke Events in Clinical Trials of Antihypertensive Drugs in Cardiovascular Disease Patients: A Network Meta-analysis of Randomized Controlled Trials

Antihypertensive drugs are commonly used in cardiovascular diseases (CVD), less is known about the comparative effectiveness of different antihypertensive drugs on stroke events in CVD patients. We searched MEDLINE, EMBASE, the Cochrane Library, and the Web of Science for randomized controlled trails comparing the different antihypertensive drugs for stroke events in CVD patients from inception until November, 2022. Pairwise and network meta-analysis were performed to compare of different antihypertensive drugs for the incidence of stroke events in CVD patients. The protocol was registered on the PROSPERO database (CRD42022375038). 33 trials involving 141,217 CVD patients were included. The incidence of stroke in CVD patients for each antihypertensive drugs was placebo (3.0%), ACEI (2.4%), ARB (4.1%), CCB (1.8%), β blocker (1.3%), and diuretic (3.6%). Antihypertensive drug was significantly reducing stroke events in CVD patients when compared with placebo (OR 0.82; 95% CI 0.75 to 0.89). Specifically, ACEI (OR 0.82; 95% CI, 0.69-0.97), ARB (OR 0.87; 95% CI, 0.77-0.98), CCB (OR 0.69; 95% CI, 0.54-to 0.87), and diuretic (OR 0.74; 95% CI, 0.57-0.95) were significantly reducing stroke events in CVD patients when compared with placebo. Network meta-analysis suggested CCB and diuretic ranked the first and second in reducing the incidence of stroke events in CVD patients with the SUCRA value of 90.9% and 73.8%. CCB and diuretic had the greatest possibility to reduce the incidence of stroke events in CVD patients, while, ACEI was the worst antihypertensive agents in reducing the incidence of stroke events in CVD patients.

Intravascular imaging assessment of pharmacotherapies targeting atherosclerosis: advantages and limitations in predicting their prognostic implications

Intravascular imaging has been often used over the recent years to examine the efficacy of emerging therapies targeting plaque evolution. Serial intravascular ultrasound, optical coherence tomography, or near-infrared spectroscopy-intravascular ultrasound studies have allowed us to evaluate the effects of different therapies on plaque burden and morphology, providing unique mechanistic insights about the mode of action of these treatments. Plaque burden reduction, a decrease in necrotic core component or macrophage accumulation-which has been associated with inflammation-and an increase in fibrous cap thickness over fibroatheromas have been used as surrogate endpoints to assess the value of several drugs in inhibiting plaque evolution and improving clinical outcomes. However, some reports have demonstrated weak associations between the effects of novel treatments on coronary atheroma and composition and their prognostic implications. This review examines the value of invasive imaging in assessing pharmacotherapies targeting atherosclerosis. It summarizes the findings of serial intravascular imaging studies assessing the effects of different drugs on atheroma burden and morphology and compares them with the results of large-scale trials evaluating their impact on clinical outcome. Furthermore, it highlights the limited efficacy of established intravascular imaging surrogate endpoints in predicting the prognostic value of these pharmacotherapies and introduces alternative imaging endpoints based on multimodality/hybrid intravascular imaging that may enable more accurate assessment of the athero-protective and prognostic effects of emerging therapies.

A reference-free R-learner for treatment recommendation

Assigning optimal treatments to individual patients based on their characteristics is the ultimate goal of precision medicine. Deriving evidence-based recommendations from observational data while considering the causal treatment effects and patient heterogeneity is a challenging task, especially in situations of multiple treatment options. Herein, we propose a reference-free R-learner based on a simplex algorithm for treatment recommendation. We showed through extensive simulation that the proposed method produced accurate recommendations that corresponded to optimal treatment outcomes, regardless of the reference group. We used the method to analyze data from the Systolic Blood Pressure Intervention Trial (SPRINT) and achieved recommendations consistent with the current clinical guidelines.

Benefits and risks of antihypertensive medication in adults with different systolic blood pressure: A meta-analysis from the perspective of the number needed to treat

Background

The blood pressure (BP) threshold for initial pharmacological treatment remains controversial. The number needed to treat (NNT) is a significant indicator. This study aimed to explore the benefits and risks of antihypertensive medications in participants with different systolic BPs (SBPs), and cardiovascular disease status from the perspective of the NNT.

Methods

We conducted a meta-analysis of 52 randomized placebo-controlled trials. The data were extracted from published articles and pooled to calculate NNTs. The participants were divided into five groups, based on the mean SBP at entry (120–129.9, 130–139.9, 140–159.9, 160–179.9, and ≥180 mmHg). Furthermore, we stratified patients into those with and without cardiovascular disease. The primary outcomes were the major adverse cardiovascular events (MACEs), and adverse events (AEs) leading to discontinuation.

Results

Antihypertensive medications were not associated with MACEs, however, it increased AEs, when the SBP was <140 mmHg. For participants with cardiovascular disease or at a high risk of heart failure and stroke, antihypertensive treatment reduced MACEs when SBP was ≥130 mmHg. Despite this, only 2–4 subjects had reduced MACEs per 100 patients receiving antihypertensive medications for 3.50 years. The number of individuals who needed to treat to avoid MACEs declined with an increased cardiovascular risk.

Conclusion

Pharmacological treatment could be activated when SBP reaches 140 mmHg. For people with cardiovascular disease or at a higher risk of stroke and heart failure, 130 mmHg may be a better therapeutic threshold. It could be more cost-effective to prioritize antihypertensive medications for people with a high risk of developing cardiovascular disease.

Effects of elevated systolic blood pressure on ischemic heart disease: a Burden of Proof study

High systolic blood pressure (SBP) is a major risk factor for ischemic heart disease (IHD), the leading cause of death worldwide. Using data from published observational studies and controlled trials, we estimated the mean SBP-IHD dose-response function and burden of proof risk function (BPRF), and we calculated a risk outcome score (ROS) and corresponding star rating (one to five). We found a very strong, significant harmful effect of SBP on IHD, with a mean risk-relative to that at 100 mm Hg SBP-of 1.39 (95% uncertainty interval including between-study heterogeneity 1.34-1.44) at 120 mm Hg, 1.81 (1.70-1.93) at 130 mm Hg and 4.48 (3.81-5.26) at 165 mm Hg. The conservative BPRF measure indicated that SBP exposure between 107.5 and 165.0 mm Hg raised risk by 101.36% on average, yielding a ROS of 0.70 and star rating of five. Our analysis shows that IHD risk was already increasing at 120 mm Hg SBP, rising steadily up to 165 mm Hg and increasing less steeply above that point. Our study endorses the need to prioritize and strengthen strategies for screening, to raise awareness of the need for timely diagnosis and treatment of hypertension and to increase the resources allocated for understanding primordial prevention of elevated blood pressure.

[Pharmacotherapy optimization opportunities using fixed combinations in patients with high cardiovascular risk]

This review focuses on the role of arterial hypertension and hyperlipidemia as the most important risk factors of early disability and death. The facts are provided that many persons with those risk factors do not have the adequate control of blood pressure and atherogenic fractions of blood serum lipoproteins. The review addresses prospects for optimizing pharmacotherapy with fixed combinations of drugs for arterial hypertension and dyslipidemia. From the perspective of effective clinical guidelines and the available evidence base, the authors reviewed possibilities for improving the treatment compliance by using combinations of antihypertensive and hypolipidemic drugs in a single dosage form. Implementation of such complex, optimized treatment using a three-component fixed-dose combination is considered.

24-Hour Blood Pressure Control with Amlodipine: A Review of the Current Scenario

Introduction Hypertension is the leading cause of cardiovascular diseases and premature death worldwide. Antihypertensive therapy using calcium channel blockers (CCBs) is one of the preferred choices to treat blood pressure (BP) and control blood pressure variability (BPV). In contrast to clinic BP, 24-hour ambulatory BP monitoring (ABPM) has evolved into an accurate and reproducible tool for the assessment and management of hypertension. Amlodipine, a longer acting dihydropyridine CCB is effective for 24 hours BP control and also minimizing BPV. The present article is the comprehensive review highlighting the efficacy of amlodipine in controlling 24-hour BP and minimizing BPV from the review of recent studies.

Materials and Methods The literature search was done using PubMed, Google Scholar, and MEDLINE databases. The studies to be included for review, were identified through the keywords: “amlodipine,” “ambulatory BP monitoring (ABPM),”“blood pressure variability (BPV),” “CCBs,” and filtering articles published in English language only.

Results Pharmacological evidence suggests that amlodipine has the ability to block all the subtypes of CCBs such as L-, N-, P-, Q-, R-, and T-type. Various clinical studies reported that amlodipine is a powerful, well-tolerated, and safe antihypertensive agent which is widely used either alone or as a key component of combination therapy for control of 24 hours BP.

Conclusion Overall, amlodipine is a proven and effective antihypertensive drug and helpful in controlling 24-hour BP, minimizing BP variability and hence reducing the risk of cardiovascular complications.

Effectiveness of indapamide/amlodipine single-pill combination in patients with isolated systolic hypertension: post-hoc analysis of the ARBALET study

BACKGROUND

This study evaluated the effectiveness of treatment with an indapamide/amlodipine single-pill combination (SPC) in outpatients with uncontrolled isolated systolic hypertension (ISH) aged over 55 years in real-life clinical practice.

METHODS

This was a post-hoc analysis of the subgroup of patients with ISH from ARBALET, a 3-month, multicenter, observational, open-label study conducted in Russia among patients with grade I or II hypertension who were either uncontrolled on previous antihypertensive treatment or treatment-naïve. The effectiveness of indapamide/amlodipine SPC was assessed by the change in office systolic blood pressure (SBP) and the rate of target SBP (< 140 mmHg) achievement at 2 weeks, 1 month and 3 months, in four age groups: 55-59 years, 60-69 years, 70-79 years, and 80 years or older.

RESULTS

The ARBALET study recruited 2217 patients, of whom 626 had ISH and were included in this post-hoc analysis (mean age 66.1 ± 7.8 years; 165 men [26.4%] and 461 women [73.6%]). Target SBP < 140 mmHg was achieved in 43%, 75% and 93% of patients at 2 weeks, 1 and 3 months, respectively. SBP decreased from baseline by 18.8 ± 10.5 mmHg, 27.2 ± 10.6 mmHg and 31.8 ± 9.9 mmHg at 2 weeks, 1 month and 3 months, respectively. In the groups of patients aged 55-59, 60-69, 70-79, and ≥ 80 years, SBP reductions at 3 months compared with baseline were - 30.3 ± 9.4, - 32.4 ± 9.7, - 32.5 ± 10.7, and - 28.9 ± 9.6 mmHg, respectively.

CONCLUSION

This post-hoc analysis of the observational ARBALET study showed that indapamide/amlodipine SPC was associated with significant reductions in BP and high rates of target BP achievement in a broad age range of patients with ISH treated in routine clinical practice.

STUDY REGISTRATION NUMBER

ISRCTN40812831.

Perindopril/Indapamide/Amlodipine in Hypertension: A Profile of Its Use

The single-pill combination (SPC) of perindopril (PER)/indapamide (IND)/amlodipine (AML) is a valuable and convenient treatment option for patients with hypertension controlled with two-drug SPC of PER/IND + AML given as two separate pills at the same dose level. PER [an angiotensin-converting enzyme (ACE) inhibitor], IND (a thiazide-like diuretic) and AML (a calcium channel blocker) are well established antihypertensive agents, which have been available for a long time as monotherapies and dual SPCs and have complementary mechanisms of action. Once-daily PER/IND/AML provided effective BP control, with good tolerability, in patients with uncontrolled hypertension in clinical trials and in large observational prospective studies. The efficacy and tolerability of PER/IND/AML was similar to that of PER/IND + AML in a randomized clinical trial. The therapeutic effect of PER/IND/AML was associated with improved health-related quality of life. Thus, switching from the two-pill PER/IND + AML regimen to single-pill PER/IND/AML reduces pill burden and simplifies drug administration, which may improve adherence to treatment, leading to better BP control and clinical outcomes.

Increased Ca2+ influx through CaV1.2 drives aortic valve calcification

Calcific aortic valve disease (CAVD) is heritable as revealed by recent genome wide association studies. While polymorphisms linked to increased expression of CACNA1C, encoding the CaV1.2 L-type voltage-gated Ca2+ channel, and increased Ca2+ signaling are associated with CAVD, whether increased Ca2+ influx through the druggable CaV1.2 is causal for calcific aortic valve disease is unknown. With surgically removed aortic valves from patients, we confirmed the association between increased CaV1.2 expression and CAVD. We extended our studies with a transgenic mouse model that mimics increased CaV1.2 expression in within aortic valve interstitial cells (VICs). In young mice maintained on normal chow, we observed dystrophic valve lesions that mimic changes found in pre-symptomatic CAVD, and showed activation of chondrogenic and osteogenic transcriptional regulators within these valve lesions. Chronic administration of verapamil, a clinically used CaV1.2 antagonist, slowed the progression of lesion development in vivo. Exploiting VIC cultures we demonstrated that increased Ca2+ influx through CaV1.2 drives signaling programs that lead to myofibroblast activation of VICs and upregulation of genes associated with aortic valve calcification. Our data support a causal role for Ca2+ influx through CaV1.2 in CAVD and suggest that early treatment with Ca2+ channel blockers is an effective therapeutic strategy.

Effect of Amlodipine in Stroke and Myocardial infarction: A Systematic Review and Meta-analysis

INTRODUCTION

Hypertension is a progressive cardiovascular condition arising from complex aetiologies. Progression is strongly associated with functional and structural abnormalities that lead to multi-organ dysfunction. Stroke and myocardial infarction are two of the major complications of hypertension in India. Various anti-hypertensive drugs, such as calcium channel blockers (CCBs), beta-blockers, diuretics, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, have been the medications of choice for disease management and are known to be effective in reducing the complications of hypertension. CCBs, such as amlodipine, are also currently being used and proven to be effective, although their beneficial effects in the management of complications of hypertension like stroke and myocardial infarction (MI) have yet to be proven. Therefore, the aim of this systematic review was to evaluate the effect of amlodipine on stroke and MI in hypertensive patients.

METHODS

A systematic search of English electronic databases was performed for studies with sufficient statistical power that were published between 2000 andl 30 August 2020, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. A total of 676 papers were screened, and 13 were found eligible to be included in the meta-analysis. Studies that included patients who suffered from MI or stroke and were under amlodipine treatment were included in the analysis. The odds ratio and the risk ratio of amlodipine compared to active control/placebo were noted from the studies and statistically analyzed.

RESULTS

Amlodipine had a significant effect in reducing stroke and MI in hypertensive patients. Similar to results published in reports, this systematic review proved that the hazard ratio for amlodipine was < 1 for stroke (0.69-1.04) and MI (0.77-0.98), showing that amlodipine accounted for better prevention of stroke and MI.

CONCLUSION

In the pooled analysis of data from 12 randomised controlled trials and one double-blinded cohort study measuring the effect of CCBs, we found that the CCB amlodipine reduced the risk of stroke and MI in hypertensive patients. Superior results for amlodipine were found in ten of the 13 studies included in this meta-analysis.

Gut Microbiome, Functional Food, Atherosclerosis, and Vascular Calcifications-Is There a Missing Link?

The gut microbiome is represented by the genome of all microorganisms (symbiotic, potential pathogens, or pathogens) residing in the intestine. These ecological communities are involved in almost all metabolic diseases and cardiovascular diseases are not excluded. Atherosclerosis, with a continuously increasing incidence in recent years, is the leading cause of coronary heart disease and stroke by plaque rupture and intraplaque hemorrhage. Vascular calcification, a process very much alike with osteogenesis, is considered to be a marker of advanced atherosclerosis. New evidence, suggesting the role of dietary intake influence on the diversity of the gut microbiome in the development of vascular calcifications, is highly debated. Gut microbiota can metabolize choline, phosphatidylcholine, and L-carnitine and produce vasculotoxic metabolites, such as trimethylamine-N-oxide (TMAO), a proatherogenic metabolite. This review article aims to discuss the latest research about how probiotics and the correction of diet is impacting the gut microbiota and its metabolites in the atherosclerotic process and vascular calcification. Further studies could create the premises for interventions in the microbiome as future primary tools in the prevention of atherosclerotic plaque and vascular calcifications.

Effects of different enantiomers of amlodipine on lipid profiles and vasomotor factors in atherosclerotic rabbits

This research aimed to describe the functions of vascular endothelial cells (VECs) in protecting target organs and the anti-atherosclerotic effects of different enantiomers of amlodipine on a rabbit model of atherosclerosis. Thirty male New Zealand white rabbits were randomly allocated to four groups (nA = 9, nB = 7, nC = 7, and nD = 7 rabbits): rabbits in group-A (control group) were fed a high-fat diet, group-B rabbits were fed a high-fat diet plus 2.5 mg/kg/day S-amlodipine, group-C rabbits were fed a high-fat diet plus 2.5 mg/kg/day R-amlodipine, and group-D rabbits were fed a high-fat diet plus 5 mg/kg/day racemic amlodipine. Different enantiomers of amlodipine did not influence lipid profiles and serum level of eNOS in the rabbit atherosclerosis model but decreased ET-1 expression to some extent. The serum NO and iNOS levels in the drug intervention groups were significantly reduced. No significant differences in the rabbits' body weights were observed. At the 4th and 8th weeks, the serum lipid profiles significantly increased in high cholesterol diet groups. The serum ET-1 level was significantly increased in each group of rabbits at the 8th week. Both S-amlodipine and R-amlodipine may protect the endothelium by reducing the serum ET-1 level, downregulating iNOS expression.

Calcium channel blockers, survival and ischaemic stroke in patients with dementia: a Swedish registry study

BACKGROUND

The effect of calcium channel blockers (CCB) on mortality and ischaemic stroke risk in dementia patients is understudied.

OBJECTIVES

To calculate the risk of death and ischaemic stroke in dementia patients treated with CCBs, considering individual agents and dose response.

METHODS

Longitudinal cohort study with 18 906 hypertensive dementia patients from the Swedish Dementia Registry (SveDem), 2008-2014. Other Swedish national registries contributed information on comorbidities, dispensed medication and outcomes. Individual CCB agents and cumulative defined daily doses (cDDD) were considered.

RESULTS

In patients with hypertension and dementia, nifedipine was associated with increased mortality risk (aHR 1.32; CI 1.01-1.73; P < 0.05) compared to non-CCB users. Patients diagnosed with Alzheimer's dementia (AD) or dementia with Lewy bodies/Parkinson's disease dementia (DLB-PDD) taking amlodipine had lower mortality risk (aHR, 0.89; CI, 0.80-0.98; P < 0.05 and aHR 0.58; CI, 0.38-0.86; P < 0.01, respectively), than those taking other CCBs. Amlodipine was associated with lower stroke risk in patients with Alzheimer's dementia compared to other CCBs (aHR 0.63; CI, 0.44-0.89; P < 0.05). Sensitivity analyses with propensity score-matched cohorts repeated the results for nifedipine (aHR 1.35; 95% CI, 1.02-1.78; P < 0.05) and amlodipine in AD (aHR, 0.87; CI, 0.78-0.97; P < 0.05) and DLB-PDD (aHR, 0.56, 95%CI, 0.37-0.85; P < 0.05).

CONCLUSION

Amlodipine was associated with reduced mortality risk in dementia patients diagnosed with AD and DLB-PDD. AD patients using amlodipine had a lower risk of ischaemic stroke compared to other CCB users.

Antihypertensive treatment and risk of cancer: an individual participant data meta-analysis

BACKGROUND

Some studies have suggested a link between antihypertensive medication and cancer, but the evidence is so far inconclusive. Thus, we aimed to investigate this association in a large individual patient data meta-analysis of randomised clinical trials.

METHODS

We searched PubMed, MEDLINE, The Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from Jan 1, 1966, to Sept 1, 2019, to identify potentially eligible randomised controlled trials. Eligible studies were randomised controlled trials comparing one blood pressure lowering drug class with a placebo, inactive control, or other blood pressure lowering drug. We also required that trials had at least 1000 participant years of follow-up in each treatment group. Trials without cancer event information were excluded. We requested individual participant data from the authors of eligible trials. We pooled individual participant-level data from eligible trials and assessed the effects of angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), β blockers, calcium channel blockers, and thiazide diuretics on cancer risk in one-stage individual participant data and network meta-analyses. Cause-specific fixed-effects Cox regression models, stratified by trial, were used to calculate hazard ratios (HRs). The primary outcome was any cancer event, defined as the first occurrence of any cancer diagnosed after randomisation. This study is registered with PROSPERO (CRD42018099283).

FINDINGS

33 trials met the inclusion criteria, and included 260 447 participants with 15 012 cancer events. Median follow-up of included participants was 4·2 years (IQR 3·0-5·0). In the individual participant data meta-analysis comparing each drug class with all other comparators, no associations were identified between any antihypertensive drug class and risk of any cancer (HR 0·99 [95% CI 0·95-1·04] for ACEIs; 0·96 [0·92-1·01] for ARBs; 0·98 [0·89-1·07] for β blockers; 1·01 [0·95-1·07] for thiazides), with the exception of calcium channel blockers (1·06 [1·01-1·11]). In the network meta-analysis comparing drug classes against placebo, we found no excess cancer risk with any drug class (HR 1·00 [95% CI 0·93-1·09] for ACEIs; 0·99 [0·92-1·06] for ARBs; 0·99 [0·89-1·11] for β blockers; 1·04 [0·96-1·13] for calcium channel blockers; 1·00 [0·90-1·10] for thiazides).

INTERPRETATION

We found no consistent evidence that antihypertensive medication use had any effect on cancer risk. Although such findings are reassuring, evidence for some comparisons was insufficient to entirely rule out excess risk, in particular for calcium channel blockers.

FUNDING

British Heart Foundation, National Institute for Health Research, Oxford Martin School.

Optimization of Pharmacotherapy Within the Framework of a Patient-oriented Approach in the Treatment of Hypertension in Multimorbidity Patients (Clinical Case and Literature Review)

Arterial hypertension (AH) remains one of the main causes of disability and death worldwide, including in Russia. At the same time, the risks of coronary and cerebrovascular events increase in the presence of additional risk factors. The most common modifiable risk factors are metabolic disorders, including pre-diabetes, dyslipidemia, peripheral arterial atherosclerosis, and obesity, which also imposes certain features on the choice of optimal pharmacotherapy. Currently, the terminology of comorbid conditions continues to be discussed depending on their pathogenesis and the presence or absence of dominance of one disease over others, i.e. polymorbidity, comorbidity and multimorbidity. At the same time, “associative polymorbidity” is distinguished with a certain set of diseases that often occur in conjunction with each other with individual susceptibility of the body. One of the most common phenotypes of polymorbidity occurring in all age groups in both sexes is cardiometabolic, which is based on the formation of insulin resistance, sympathetic overactivity and chronic inflammation. This article provides a clinical example of the use of a fixed combination of angiotensin II receptor blocker telmisartan and calcium channel blocker amlodipine with the addition of an I1-imidazoline receptor agonist moxonidine in real clinical practice in a polymorbid cardiometabolic patient with target organ damage (left ventricular hypertrophy and microalbuminuria). High antihypertensive (favorable effect on 24-hour blood pressure, especially in the early morning) and organoprotective effectiveness of this combination, its possibilities in correcting additional risk factors (reduced heart rate, body weight and a positive effect on metabolic parameters), due to a synergistic effect on the central pathogenetic mechanisms of hypertension and obesity – insulin resistance and sympathetic overactivity.

Voltage-Gated Calcium Channels in Nonexcitable Tissues

The identification of a gain-of-function mutation in CACNA1C as the cause of Timothy syndrome, a rare disorder characterized by cardiac arrhythmias and syndactyly, highlighted roles for the L-type voltage-gated Ca2+ channel CaV1.2 in nonexcitable cells. Previous studies in cells and animal models had suggested that several voltage-gated Ca2+ channels (VGCCs) regulated critical signaling events in various cell types that are not expected to support action potentials, but definitive data were lacking. VGCCs occupy a special position among ion channels, uniquely able to translate membrane excitability into the cytoplasmic Ca2+ changes that underlie the cellular responses to electrical activity. Yet how these channels function in cells not firing action potentials and what the consequences of their actions are in nonexcitable cells remain critical questions. The development of new animal and cellular models and the emergence of large data sets and unbiased genome screens have added to our understanding of the unanticipated roles for VGCCs in nonexcitable cells. Here, we review current knowledge of VGCC regulation and function in nonexcitable tissues and cells, with the goal of providing a platform for continued investigation.

Impact of visit-to-visit variability in blood pressure on coronary plaque as assessed by integrated backscatter intravascular ultrasound

INTRODUCTION

Visit-to-visit variability (VVV) in blood pressure (BP) has been reported to be a strong predictor of cardiovascular disease. However, the association between VVV in BP and coronary plaque composition has not been fully elucidated.

METHODS

One hundred-two consecutive patients with coronary artery disease (CAD) who underwent percutaneous coronary intervention (PCI) using integrated backscatter (IB) intravascular ultrasound (IVUS), and who had at least six clinic visits a year before PCI were included. We measured systolic and diastolic BP (SBP and DBP) at each visit and determined VVV in BP expressed as the standard deviation of the average BP. Grayscale and IB IVUS examinations were performed for the culprit lesion of a coronary artery just before PCI.

RESULTS

There were no significant associations between the average SBP or DBP and various IVUS parameters. However, VVV in SBP was positively correlated with both the percentage (%) of atheroma volume (β = 0.23, p = .02) and % lipid volume (β = 0.53, p < .0001). VVV in DBP was positively correlated with % lipid volume (β = 0.24, p = .01), while there was no significant correlation between VVV in DBP and % atheroma volume. A  multivariable linear regression analysis showed that VVV in SBP was independently associated with % atheroma volume (p = .04) and % lipid volume (p < .001).

CONCLUSIONS

Larger VVV in SBP was significantly associated with an increased plaque burden and lipid composition at the culprit lesion of a coronary artery in CAD patients. The improvement of VVV in SBP may contribute to the regression and stabilization of coronary plaques.

Carotid Intima-Media Thickness Progression as Surrogate Marker for Cardiovascular Risk: Meta-Analysis of 119 Clinical Trials Involving 100 667 Patients

BACKGROUND

To quantify the association between effects of interventions on carotid intima-media thickness (cIMT) progression and their effects on cardiovascular disease (CVD) risk.

METHODS

We systematically collated data from randomized, controlled trials. cIMT was assessed as the mean value at the common-carotid-artery; if unavailable, the maximum value at the common-carotid-artery or other cIMT measures were used. The primary outcome was a combined CVD end point defined as myocardial infarction, stroke, revascularization procedures, or fatal CVD. We estimated intervention effects on cIMT progression and incident CVD for each trial, before relating the 2 using a Bayesian meta-regression approach.

RESULTS

We analyzed data of 119 randomized, controlled trials involving 100 667 patients (mean age 62 years, 42% female). Over an average follow-up of 3.7 years, 12 038 patients developed the combined CVD end point. Across all interventions, each 10 μm/y reduction of cIMT progression resulted in a relative risk for CVD of 0.91 (95% Credible Interval, 0.87-0.94), with an additional relative risk for CVD of 0.92 (0.87-0.97) being achieved independent of cIMT progression. Taken together, we estimated that interventions reducing cIMT progression by 10, 20, 30, or 40 μm/y would yield relative risks of 0.84 (0.75-0.93), 0.76 (0.67-0.85), 0.69 (0.59-0.79), or 0.63 (0.52-0.74), respectively. Results were similar when grouping trials by type of intervention, time of conduct, time to ultrasound follow-up, availability of individual-participant data, primary versus secondary prevention trials, type of cIMT measurement, and proportion of female patients.

CONCLUSIONS

The extent of intervention effects on cIMT progression predicted the degree of CVD risk reduction. This provides a missing link supporting the usefulness of cIMT progression as a surrogate marker for CVD risk in clinical trials.

Meta-Analysis Evaluating Calcium Channel Blockers and the Risk of Peripheral Arterial Disease in Patients With Hypertension

Clinical studies have shown that calcium channel blockers (CCB) can mitigate the progression of atherosclerosis. Their role in the primary prevention of peripheral artery disease (PAD) is unclear. We conducted a meta-analysis of randomized control trials (RCT) to compare the impact of CCB on the incidence of PAD in patients with hypertension. A comprehensive review of the literature was performed in PubMed and Cochrane registry. Studies were included if they were RCT and had outcome data on PAD with a follow-up duration of at least 6 months. CCB formed the intervention group, whereas the control group was constituted by either placebo or active treatment with any of the other antihypertensive medications. A random-effects meta-analysis was performed, and we report odds ratio as a measure of treatment effect. Our search identified 934 trials, of which 7 RCTs with 71,971 patients fulfilled the inclusion criteria. The mean duration of follow-up was 3.8 years. In patients receiving CCB, PAD events occurred in 547 out of 27,502 patients (2%) compared with 1,263 out of 42,659 patients in the control group (3%). Based on the random-effect model, the odds for development of PAD in hypertensive patients treated with CCB compared with the control group was 0.70 (95% confidence interval of 0.58 to 0.86, p = 0.0005). In conclusion, this meta-analysis of RCTs of hypertensive patients, we found that treatment with CCB was strongly associated with a decrease in the PAD compared with other antihypertensive agents or placebo.

Current Trends in the Treatment of Hypertension: Focus on Improving Prognosis. The Capabilities of an Amlodipine/Telmisartan Single-Pill Combination

Nowadays, the modern approach to antihypertensive therapy is to prescribe in the most hypertensive patients fixed-dose combinations of antihypertensive drugs as initial therapy. This concept is reflected in the latest revisions of European and Russian guidelines for the management of arterial hypertension (AH). Above mentioned principle is referred as “single-pill combination” strategy and is given high priority in clinical practice with a high evidence level. According to this approach, one of the possible first line single-pill combinations is the combination of an angiotensin II receptor blocker and a calcium channel blocker. In both classes, the reference and the best representatives include, respectively, telmisartan and amlodipine, as a result of broad experience in their practical application and, most importantly, extensive body of evidence regarding to its effectiveness and safety. Both antihypertensive drugs are distinguished by an extra-longstanding antihypertensive effect that exceeds such one of other representatives in their classes, thereby a stable blood pressure control throughout the day is realized, and most importantly, in the early morning hours, that are the most dangerous in terms of adverse cardiovascular and cerebrovascular events. Another important telmisartan and amlodipine characteristics is their targetorgan protective properties, which is realized at all the levels. In addition, telmisartan has a unique ability to activate PPAR-у-receptors and improves the carbohydrate metabolism and lipid profile, which is advantageous in patients with concomitant metabolic syndrome and diabetes mellitus. The telmisartan and amlodipine features and their proven ability to improve prognosis in hypertensive patients served as background for creating a singlepill combination of these antihypertensive drugs, which fully meet with the requirements of current clinical guidelines for AH management and in which these drugs synergistically coupling resulting in more effective blood pressure control, increases the reliability of target-organ protection, and also improves the therapy safety profile.

Pharmacological and Nutritional Modulation of Vascular Calcification

Vascular calcification is an independent predictor of cardiovascular disease, and therefore, inhibition or regression of this processes is of clinical importance. The standard care regarding prevention and treatment of cardiovascular disease at this moment mainly depends on drug therapy. In animal and preclinical studies, various forms of cardiovascular drug therapy seem to have a positive effect on vascular calcification. In particular, calcium channel blockers and inhibitors of the renin-angiotensin-aldosteron system slowed down arterial calcification in experimental animals. In humans, the results of trials with these drugs are far less pronounced and often contradictory. There is limited evidence that the development of new atherosclerotic lesions may be retarded in patients with coronary artery disease, but existing lesions can hardly be influenced. Although statin therapy has a proven role in the prevention and treatment of cardiovascular morbidity and mortality, it is associated with both regression and acceleration of the vascular calcification process. Recently, nutritional supplements have been recognized as a potential tool to reduce calcification. This is particularly true for vitamin K, which acts as an inhibitor of vascular calcification. In addition to vitamin K, other dietary supplements may also modulate vascular function. In this narrative review, we discuss the current state of knowledge regarding the pharmacological and nutritional possibilities to prevent the development and progression of vascular calcification.

[Mechanisms for the Development of Blood Pressure Variability and the Potential of Antihypertensive Drugs in Their Correction]

Blood pressure variability (BPV) is the fluctuations of blood pressure over a certain period of time under the influence of various factors. The issue of increased BPV is of particular clinical importance due to high predictive value of this parameter as a risk factor for fatal and non-fatal cardiovascular, cerebrovascular and renal events. It is proved that in the BPV increasing, the key role is played by impairments in arterial baroreflexes, which, in turn, are mediated by increased vascular stiffness, impact of angiotensin II and the sympathetic nervous system, endothelial dysfunction, nitric oxide deficiency and aging, including the vascular aging. Antihypertensive drugs that targeting largest amount of pathophysiological mechanisms in BPV increasing have a most advantages in correcting excessive pressure fluctuations. In this regard such drugs are perindopril and amlodipine, which can eliminate almost the entire spectrum of increased BPV causes and, therefore, optimally reduce the cardiovascular risk.

Magnitude of and Characteristics Associated With the Treatment of Calcium Channel Blocker-Induced Lower-Extremity Edema With Loop Diuretics

IMPORTANCE

Calcium channel blockers, specifically dihydropyridine calcium channel blockers (DH CCBs, eg, amlodipine), may cause lower-extremity edema. Anecdotal reports suggest this may result in a prescribing cascade, where DH CCB-induced edema is treated with loop diuretics.

OBJECTIVE

To assess the magnitude and characteristics of the DH CCB prescribing cascade.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used a prescription sequence symmetry analysis to assess loop diuretic initiation before and after the initiation of DH CCBs among patients aged 20 years or older without heart failure. Data from a private insurance claims database from 2005 to 2017 was analyzed. Use of loop diuretics associated with initiation of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and other commonly used medications was used as negative controls. Data were analyzed from March 2019 through October 2019.

EXPOSURES

Initiation of DH CCB or negative control medications.

MAIN OUTCOMES AND MEASURES

The temporality of loop diuretic initiation relative to DH CCB or negative control initiation. Secular trend-adjusted sequence ratios (aSRs) with 95% CIs were calculated using data from 360 days before and after initiation of DH CCBs.

RESULTS

Among 1 206 093 DH CCB initiators, 55 818 patients (4.6%) (33 100 [59.3%] aged <65 years; 32 916 [59.0%] women) had a new loop diuretic prescription 360 days before or after DH CCB initiation, resulting in an aSR of 1.87 (95% CI, 1.84-1.90). An estimated 1.44% of DH CCB initiators experienced the prescribing cascade. The aSR was disproportionately higher among DH CCB initiators who were prescribed high doses (aSR, 2.20; 95% CI, 2.13-2.27), initiated amlodipine (aSR, 1.89; 95% CI, 1.86-1.93), were men (aSR, 1.96; 95% CI, 1.91-2.01), and used fewer antihypertensive classes (aSR, 2.55; 95% CI, 2.47-2.64). The evaluation of ACE inhibitors or ARBs as negative controls suggested hypertension progression may have tempered the incidence of the prescribing cascade (aSR for ACE inhibitors and ARBs, 1.27; 95% CI, 1.24-1.29).

CONCLUSIONS AND RELEVANCE

This study found an excessive use of loop diuretics following initiation of DH CCBs that cannot be completely explained by secular trends or hypertension progression. The prescribing cascade was more pronounced among those initially prescribed a high dose of DH CCBs.

Resistant Hypertension: Questions and Contemporary Answers

The review presents the important problem of resistant hypertension. Its real prevalence is unknown. According to population studies and metaanalyzes of clinical studies, the prevalence of this most severe form of hypertension reaches 12-15% in the general population and 15-18% in clinical cohorts. Over the past decades, an increase in its frequency among patients with hypertension has been noted. Based on the results of large-scale studies, risk factors are detected that allow to assess the risk for the resistance to antihypertensive drugs. Adherence to ongoing antihypertensive therapy is crucial to addressing the issue of hypertension resistance; there are acceptable ways to evaluate it in clinical practice. The review discusses the most common mistakes in the choice of therapy, which can cause resistance to antihypertensive treatment, namely irrational drug combinations, insufficient dosage of the drug, and the use of non-prolonged forms of drugs. The latest recommendations for the diagnosis and treatment of hypertension, including its resistant form, are analyzed. The review contains a rationale based on the results of randomized clinical trials, the choice antihypertensive strategy in this variant of arterial hypertension. The importance of fixed combination antihypertensive drugs, as well as thiazine-like diuretics and amlodipine is stressed. The results of studies demonstrate the rational for the use of antimineralcorticoid drugs, namely spironolactone, for this category of patients. The authors offer an updated algorithm for the diagnosis and treatment of resistant hypertension, based on the sections of the latest clinical recommendations on this problem.

Treatment of Hypertensive and Hypercholesterolaemic Patients with the Triple Fixed Combination of Atorvastatin, Perindopril and Amlodipine: The Results of the CORAL Study

INTRODUCTION

Hypertension and hypercholesterolaemia are important contributors to the development and progression of atherosclerosis. The coexistence of these two conditions is rather common: hypercholesterolaemia is present in 40-60% of hypertensive patients. Remarkably, patient compliance with antihypertensive regimens is better than with statin therapy. Thus, the inclusion of statins and blood pressure-lowering agents into a fixed combination might even double the effectiveness of statin therapy, and thereby achieve significantly greater reduction of cardiovascular risk. The CORAL study was a 3-month, prospective, multicentre, observational, non-interventional survey, which evaluated the blood pressure- and lipid-lowering efficacy of the triple fixed combination of atorvastatin/perindopril/amlodipine, administered in various dose combinations.

METHODS

The efficacy of the triple fixed combination was reflected by the changes of the blood pressure readings taken in the office and during 24-h blood pressure monitoring (3 months elapsed between visits 1 and 3). The laboratory parameters obtained during data acquisition were also recorded.

RESULTS

After 3 months of therapy, mean office blood pressure decreased from 158.5 ± 16.7/91.7 ± 9.4 to 132.2 ± 8.3/80.1 ± 6.8 mmHg (p < 0.0001), whereas mean 24-h blood pressure decreased from 146.0 ± 14.5/82.5 ± 12.1 to 132.1 ± 13.2/75.6 ± 9.9 mmHg. With regard to metabolic parameters, the inclusion of pre-existing statin therapy in the fixed combination led to further, significant reduction of lipid parameters as follows: total cholesterol level from 6.18 ± 1.15 to 5.16 ± 0.88 mmol/L, LDL-cholesterol from 3.41 ± 1.01 to 2.80 ± 0.82 mmol/L and triglyceride level from 2.26 ± 1.17 to 1.82 ± 0.83 mmol/L (all p < 0.0001).

CONCLUSION

Treatment with the fixed triple combination of atorvastatin, perindopril and amlodipine might take us closer to the optimal therapy for hypertensive patients with hypercholesterolaemia. The expected improvement of patient adherence to treatment may result in an increase of the percentage patients who achieve both blood pressure control and the LDL-cholesterol targets recommended in guidelines. Moreover, this may translate into the further decline of the risk of prospective cardiovascular events.

FUNDING

Egis Pharmaceuticals.

Advances in small-molecule therapy for managing angina pectoris in the elderly

Introduction: As our population ages, the prevalence of angina is growing, leading to increased morbidity and decreased quality of life. The management of angina in the elderly is challenging due to drug intolerance and/or drug resistance as well as frailty. Over the past decades, many new therapeutic small molecules have been investigated for the management of angina. Although none of these studies have specifically focused on the therapies for the elderly, they offer promising new avenues for the treatment of angina in the elderly. Areas covered: Herein, the authors provide a review of the recently published literature on the use of small-molecule therapies for angina management in the elderly and provide a brief overview of these therapies. Expert opinion: A variety of therapeutic classes of existing and newer small molecules are emerging for the management of angina in the elderly. An individualized approach to the management of angina in this growing population is critical for good outcomes. Many small molecules are in their initial stages of clinical use, and further research should be conducted on their utility, especially in the elderly.

Amlodipine induces vasodilation via Akt2/Sp1-activated miR-21 in smooth muscle cells

BACKGROUND AND PURPOSE

The calcium antagonist amlodipine exerts important cardioprotective effects by modulating smooth muscle and endothelial functions. However, the mechanisms underlying these effects are incompletely understood.

EXPERIMENTAL APPROACH

Western blotting was used to compare the expression of key genes involved in vascular smooth muscle cell (VSMC) phenotype conversion. Recombinant adeno-associated virus system was used to regulate miRNA expression in rats via tail vein. Bioinformatics was used to predict the transcriptional regulation of miR-21 upstream followed by biochemical validation using quantitative real-time polymerase chain reaction, ChIP-qPCR and EMSA assays.

KEY RESULTS

Only the calcium antagonist amlodipine, and no other type of anti-hypertensive drug, induced miR-21 overexpression in plasma and aortic vessels in the animal model. Real-time PCR and luciferase assays showed that amlodipine induced miR-21 overexpression in vascular smooth muscle cells. Western blot and immunofluorescence assays demonstrated that amlodipine activated Akt2, rather than Akt1, followed by activation of transcription factor Sp1, which regulated VSMC phenotype conversion via binding to the miR-21 promoter. Furthermore, bioinformatic analyses and luciferase assays demonstrated that amlodipine activated miR-21 transcription at the -2034/-2027 Sp1-binding site, which was further demonstrated by ChIP-qPCR and EMSA assays. Consistently, small-interfering RNA-mediated knockdown of Akt2 and Sp1 significantly attenuated the effects of amlodipine on miR-21 expression in smooth muscle cells.

CONCLUSION AND IMPLICATIONS

These results indicate that amlodipine induces smooth muscle cell differentiation via miR-21, which is regulated by p-Akt2 and Sp1 nuclear translocation, thereby providing a novel target for cardiovascular diseases.

Effects of lowering diastolic blood pressure to <80 mmHg on cardiovascular mortality and events in patients with coronary artery disease: a systematic review and meta-analysis

The target of diastolic blood pressure (DBP) remains controversial in patients with coronary artery disease (CAD). We systematically searched PubMed/Medline and the Cochrane Central database for randomized controlled trials (RCTs) assessing the efficacy and safety of reducing DBP in CAD patients from January 1965 to July 2017. Seven placebo-controlled RCTs enrolling 34,814 CAD patients who achieved DBP <80 mmHg were included in the drug-intervention group. The average achieved blood pressures (BPs) were 126.3/75.1 and 131.5/77.8 mmHg in the drug-intervention and placebo-control groups, respectively. Drug intervention was associated with an 11% reduction in coronary revascularization and a 31% reduction in heart failure. In the drug-intervention group, all-cause death, myocardial infarction, angina pectoris, and stroke were reduced with marginal significance, whereas hypotension was increased by 123%. A meta-analysis of four RCTs, in which the achieved DBP was <75 mmHg, showed that the drug intervention was associated with a 22% reduction in heart failure. These results suggest that reducing DBP to 80 mmHg or less would significantly reduce coronary revascularization and heart failure but at the expense of causing hypotension in CAD patients. Further trials are warranted to prove this issue.

Antihypertensive Efficacy of Fixed Combination of Amlodipine and Ramipril in Patients with Arterial Hypertension and Very High Cardiovascular Risk

Aim. To evaluate the antihypertensive efficacy and tolerability of a fixed combination of amlodipine and ramipril in hypertensive patients with very high cardiovascular risk. Material and methods. A retrospective cohort study of real clinical practice of prescribing antihypertensive drugs according to 255 medical records of outpatient hypertensive patients with a history of acute coronary syndrome (ACS) and coronary artery stenting was performed in the first part. An open observational study was performed in the second part. 69 people older than 18 years with a history of ACS and coronary artery stenting, without reaching the target blood pressure (BP) level while using free combinations of antihypertensive drugs and with indications for a fixed combination of ramipril and amlodipine were included into the study. Analysis of self-monitoring of BP, office BP, daily BP monitoring (ABPM) and patients’ adherence to treatment (Morisky-Green test) initially, after 4 and after 12 weeks of taking the fixed combination of ramipril and amlodipine was performed to assess the clinical efficacy of the studied drug. Results. It was found that 42.0% of patients did not follow the recommendations for regular intake of antihypertensive drugs. So, hypertension of all patients regarded as false-refractory, which was the basis for the prescription of the fixed combination of ramipril and amlodipine in accordance with clinical guidelines for the diagnosis and treatment of hypertension. After 4 weeks of therapy, there was significant decrease in office BP with the achievement and preservation of the target level by the 12th week, normalization to the 12th week of day and night BP variability in 54.9% of patients. 78.0% of patients followed medical recommendations for regular administration of antihypertensive drugs, none of the patients had adverse events. Conclusion. The use of fixed combinations of drugs, in particular, amlodipine and ramipril as a part of multicomponent therapy in hypertensive patients with very high cardiovascular risk, led to the achievement of target BP by the 4th week of therapy and stable preservation of antihypertensive effect in 12 weeks of treatment as well as gradual normalization of day and night BP variability in more than half of patients. Fixed combination of ramipril and amlodipine allowed to improve adherence of patients to cardiovascular diseases.

Comparison of fimasartan and amlodipine therapy on carotid atherosclerotic plaque inflammation

Background

The renin‐angiotensin system plays an important role in promoting atherosclerotic plaque inflammation, which may be inhibited by angiotension‐II receptor blockers.

Hypothesis

We investigated the effects of fimasartan and amlodipine therapy on carotid atherosclerotic plaque inflammation using ¹⁸F‐fluorodeoxyglucose (¹⁸FDG) positron emission tomography (PET) imaging.

Methods

Fifty patients with acute coronary syndrome (ACS) and at least one lesion with ¹⁸FDG uptake in the carotid artery (target‐to‐background ratio [TBR] ≥ 1.6) were randomly assigned to receive either fimasartan (60 mg once a day) or amlodipine (5 mg once a day). ¹⁸FDG PET examinations were performed in all patients at baseline and 6 months. The primary endpoint was the percent change in the index vessel TBR for the most diseased segment (MDS TBR).

Results

The two groups had similar baseline characteristics. At the 6‐month follow‐up, index vessel and aorta MDS TBR significantly decreased in both groups. However, the percent change in index vessel MDS TBR was similar between the two groups (−9.33 ± 14.2% vs −7.73 ± 19.1%, respectively, P = 0.9). No significant difference was found for the percent change in the whole vessel TBR for the index vessel between the two groups, with similar findings for changes in MDS TBR or whole vessel TBR for the aorta. Total cholesterol, low‐density lipoprotein cholesterol levels, and blood pressure improved to a similar degree in both groups.

Conclusions

Fimasartan and amlodipine reduce carotid atherosclerotic plaque inflammation similarly in patients with ACS, offering the same level of effectiveness.

Nitrendipine and Dementia: Forgotten Positive Facts?

Nowadays, there are about 50 million people suffering from dementia worldwide. In 2030, it is expected that there will be 82 million people living with dementia and in 2050, their number should reach 152 million. This increase in the number of people with dementia results in significant social and economic problems. Therefore, researchers attempt to reduce risk factors causing the development of dementia such as high blood pressure. Epidemiological studies have shown that hypertension increases the risk of dementia at an older age. It can, therefore, be assumed that hypertension therapy will reduce the risk of dementia. However, previous clinical studies have shown that the efficacy of different antihypertensive drugs differs in this respect. The drug group that appears to be the most effective in these analyses is calcium channel blockers (CCBs). The most significant preventive efficacy in terms of protection against dementia has been demonstrated with nitrendipine. Its use is, therefore, particularly advantageous in elderly patients with systolic hypertension who are at high risk of dementia. The purpose of this study is to restore the discussion on the prevention of vascular dementia and Alzheimer’s dementia with nitrendipine in indicated hypertonic patients. The authors performed a literature search of available sources describing the issue of dementia, hypertension and its treatment with nitrendipine. In addition, they made a comparison and evaluation of relevant findings. The results of the detected research studies indicate that nitrendipine is able to reduce the incidence of dementia [Alzheimer’s disease (AD), vascular and mixed] by 55%. The treatment of 1,000 patients with nitrendipine for 5 years may prevent 20 cases of dementia. However, what has not yet been explained is the temporal link between hypertension and dementia due to the long-time intervals between hypertension and the development of dementia.

Effect of inter-individual blood pressure variability on the progression of atherosclerosis in carotid and coronary arteries: a post hoc analysis of the NORMALISE and PREVENT studies

Aims

To investigate the relationship between visit-to-visit blood pressure variability (BPV) and the progression of both carotid and coronary artery disease (CAD).

Methods and results

Data from two cardiovascular endpoint studies [Norvasc for Regression of Manifest Atherosclerotic Lesions by Intravascular Sonographic Evaluation (NORMALISE) and Prospective Randomized Evaluation of the Vascular Effects of Norvasc Trial (PREVENT)] were analysed separately. Systolic BPV was assessed as within-subject standard deviation of systolic BP across visits from 12-weeks onwards. Follow-up was 24 months (NORMALISE) or 36 months (PREVENT). Any association between BPV and progression of atherosclerosis was assessed using quantitative coronary angiography (QCA), intravascular ultrasound (IVUS), or B-mode ultrasound (depending on study). Patients from NORMALISE (n = 261) and PREVENT (n = 688 for QCA; n = 364 for ultrasound) were stratified within study according to median systolic BPV. No significant difference in change of minimal luminal diameter (by QCA in PREVENT) or change in percent atheroma volume or normalized total atheroma volume (by IVUS in NORMALISE) was detected for subjects with low BPV (BPV < median) compared with high BPV (BPV ≥ median), regardless of treatment. In PREVENT, a significantly greater reduction in maximum carotid intima-media thickness (IMT) (left and right common carotid artery far wall) was observed for patients with BPV < median compared with those with BPV ≥ median [least squares mean difference 0.06 (95% confidence interval 0.01, 0.11); P = 0.0271], after adjusting for treatment, carotid artery segment (left or right), baseline maximum carotid IMT, and other baseline and cardiovascular risk factors/covariates.

Conclusions

In patients with existing CAD and well-controlled BP, visit-to-visit BPV was not associated with progression of coronary atherosclerosis; however, a significantly greater reduction in maximum carotid IMT was observed for patients with low BPV.

TRIPLE ANTIHYPERTENSIVE THERAPY: FOCUS ON EFFICACY AND PROGNOSIS

In the article, with regard to current clinical recommendations, the place of combined antihypertensive therapy, especially triple drugs regimens, is considered in the treatment of patients with arterial hypertension. Special focus is given to the body of evidence for the efficacy of valsartan and amlodipine, as the reference drug of angiotensin II receptor blockers and calcium channel blockers, respectively. Not only their high antihypertensive properties are demonstrated, but also a favorable effect on target-organ protection and prognosis is described. In particular, the possibilities of valsartan in reducing the severity of left ventricular hypertrophy and microalbuminuria are described, and its unique properties in the class of sartans that allow the use of this drug in patients with ischemic heart disease and chronic heart failure are emphasized. Data on the antiatherosclerotic effects of amlodipine and its proven ability to reduce cardiovascular risk are presented. Current data are presented about their use in a fixed-dose combination with hydrochlorothiazide, including real clinical practice settings. The evidence base of high clinical efficacy, safety and metabolic neutrality of the triple combination of antihypertensive drugs valsartan, amlodipine and hydrochorothiazide is presented. The issues of increasing adherence of patients to treatment when prescribing fixed-dose combinations are considered. An algorithm for the selection of antihypertensive drugs in the form of monotherapy and combination therapy of two or three drugs depending on the clinical situation (the presence of certain target-organs damages and associated clinical conditions, primarily ischemic heart disease, atherosclerosis of carotid arteries and chronic heart failure) and the severity of the additional risk of cardiovascular complications.

Effects of Cilnidipine, an L/N-Type Calcium Channel Blocker, on Carotid Atherosclerosis in Japanese Post-Stroke Hypertensive Patients: Results from the CA-ATTEND Study

Aims: Although several antihypertensive agents reduced the carotid intima-media thickness (IMT), it remains unclear whether those agents affect the interadventitial diameter (IAD). We aimed to examine whether cilnidipine, an L/N-type calcium channel blocker, reduced the common carotid IMT or IAD in post-stroke hypertensive patients.

Methods: The common carotid IMT and IAD were measured at the start of cilnidipine treatment and 12 months from that. The changes in the mean max-IMT or IAD between baseline and the 12-month follow-up were evaluated and compared between the thick group (max-IMT ≥ 1.1 mm) and the normal group (max-IMT < 1.1 mm).

Results: A total of 603 post-stroke hypertensive subjects (mean age = 69.3 yr, 378 males) were included in the analysis. At baseline, IAD was increased stepwise according to the value of max-IMT (p for trend < 0.001). Among them, 326 subjects were followed up for 12 months. The mean max-IMT from baseline to 12 months did not change in the normal group (−0.01 mm, 95% confidence interval [CI] −0.03 to 0.01, n = 170), whereas a significant reduction was observed in the thick group (−0.09 mm, 95% CI −0.13 to −0.05, n = 156). The mean IAD was significantly reduced during the study period in the normal group (−0.14 mm, 95% CI −0.22 to −0.05) as well as in the thick group (−0.12 mm, 95% CI −0.21 to −0.03).

Conclusions: Cilnidipine promoted the regression of common carotid IMT in post-stroke hypertensive patients, especially in the thick group. Cilnidipine also reduced the IAD in both normal and thick groups.

Blood pressure-lowering treatment strategies based on cardiovascular risk versus blood pressure: A meta-analysis of individual participant data

BACKGROUND

Clinical practice guidelines have traditionally recommended blood pressure treatment based primarily on blood pressure thresholds. In contrast, using predicted cardiovascular risk has been advocated as a more effective strategy to guide treatment decisions for cardiovascular disease (CVD) prevention. We aimed to compare outcomes from a blood pressure-lowering treatment strategy based on predicted cardiovascular risk with one based on systolic blood pressure (SBP) level.

METHODS AND FINDINGS

We used individual participant data from the Blood Pressure Lowering Treatment Trialists' Collaboration (BPLTTC) from 1995 to 2013. Trials randomly assigned participants to either blood pressure-lowering drugs versus placebo or more intensive versus less intensive blood pressure-lowering regimens. We estimated 5-y risk of CVD events using a multivariable Weibull model previously developed in this dataset. We compared the two strategies at specific SBP thresholds and across the spectrum of risk and blood pressure levels studied in BPLTTC trials. The primary outcome was number of CVD events avoided per persons treated. We included data from 11 trials (47,872 participants). During a median of 4.0 y of follow-up, 3,566 participants (7.5%) experienced a major cardiovascular event. Areas under the curve comparing the two treatment strategies throughout the range of possible thresholds for CVD risk and SBP demonstrated that, on average, a greater number of CVD events would be avoided for a given number of persons treated with the CVD risk strategy compared with the SBP strategy (area under the curve 0.71 [95% confidence interval (CI) 0.70-0.72] for the CVD risk strategy versus 0.54 [95% CI 0.53-0.55] for the SBP strategy). Compared with treating everyone with SBP ≥ 150 mmHg, a CVD risk strategy would require treatment of 29% (95% CI 26%-31%) fewer persons to prevent the same number of events or would prevent 16% (95% CI 14%-18%) more events for the same number of persons treated. Compared with treating everyone with SBP ≥ 140 mmHg, a CVD risk strategy would require treatment of 3.8% (95% CI 12.5% fewer to 7.2% more) fewer persons to prevent the same number of events or would prevent 3.1% (95% CI 1.5%-5.0%) more events for the same number of persons treated, although the former estimate was not statistically significant. In subgroup analyses, the CVD risk strategy did not appear to be more beneficial than the SBP strategy in patients with diabetes mellitus or established CVD.

CONCLUSIONS

A blood pressure-lowering treatment strategy based on predicted cardiovascular risk is more effective than one based on blood pressure levels alone across a range of thresholds. These results support using cardiovascular risk assessment to guide blood pressure treatment decision-making in moderate- to high-risk individuals, particularly for primary prevention.