Management of Hypertension among Patients with Coronary Heart Disease

Prevalence and predictors of coronary heart disease among individuals with and without obesity in North Dakota

INTRODUCTION

Coronary heart disease (CHD) is the most common cardiovascular disease in the United States and heart disease is the leading cause of death in North Dakota. Although obesity is a major risk factor for CHD, some studies have reported an inverse relationship between body mass index (BMI) and CHD outcomes. Understanding the epidemiology of CHD among individuals with and without obesity is essential to guide health planning. Therefore, the objectives of this study were to estimate the prevalence and identify predictors of CHD among North Dakota adults with and without obesity.

METHODS

Behavioral Risk Factor Surveillance System data from 2017 to 2021 were provided by the North Dakota Department of Health and Human Services. Weighted prevalence estimates and 95% confidence intervals (CIs) were computed for CHD and potential risk factors among respondents with and without obesity (BMI ≥30 kg/m2). Multivariable logistic regression was used to identify significant predictors of CHD in both groups.

RESULTS

A total of 17,092 respondents were included in the study. Respondents with obesity had a higher prevalence of CHD (4.7%, 95% CI: 4.2-5.4) than those without obesity (3.0%, 95% CI: 2.7-3.4). Predictors of CHD among both groups included age, sex, self-reported general health, high blood pressure, high cholesterol, chronic obstructive pulmonary disease, and diabetes. Having a personal doctor (Odds Ratio [OR] = 1.91, 95% CI: 1.13-3.23) and arthritis (OR = 1.72, 95% CI: 1.34-2.22) were significant predictors of CHD among respondents without obesity, but not among those without obesity.

CONCLUSION

While the prevalence of CHD was significantly higher among adults with obesity compared to those without obesity, the findings of the stratified analysis indicated that predictors of the condition tended to be similar for the two groups. This study provides useful information to guide health planning and control programs that aim to reduce the burden of CHD in North Dakota.

SLCO1B1 and ABCG2 genotype-informed phenotypes are related to variation in ramipril exposure

Ramipril is an angiotensin-converting enzyme inhibitor used for hypertension and heart failure management. To date, scarce literature is available on pharmacogenetic associations affecting ramipril. The goal of this study was to investigate the effect of 120 genetic variants in 34 pharmacogenes (i.e., genes encoding for enzymes like CYPs or UGTs and transporters like ABC or SLC) on ramipril pharmacokinetic variability and adverse drug reaction (ADR) incidence. Twenty-nine healthy volunteers who had participated in a single-dose bioequivalence clinical trial of two formulations of ramipril were recruited. A univariate and multivariate analysis searching for associations between genetic variants and ramipril pharmacokinetics was performed. SLCO1B1 and ABCG2 genotype-informed phenotypes strongly predicted ramipril exposure. Volunteers with the SLCO1B1 decreased function (DF) phenotype presented around 1.7-fold higher dose/weight-corrected area under the curve (AUC/DW) than volunteers with the normal function (NF) phenotype (univariate p-value [puv] < 0.001, multivariate p-value [pmv] < 0.001, β = 0.533, R2 = 0.648). Similarly, volunteers with ABCG2 DF + poor function (PF) phenotypes presented around 1.6-fold higher AUC/DW than those with the NF phenotype (puv = 0.011, pmv < 0.001, β = 0.259, R2 = 0.648). Our results suggest that SLCO1B1 and ABCG2 are important transporters to ramipril pharmacokinetics, and their genetic variation strongly alters its pharmacokinetics. Further studies are required to confirm these associations and their clinical relevance.

The Effectiveness of Telemedicine in the Management of Chronic Diseases (Diabetes, Hypertension, and Coronary Heart Disease) at Primary Care Facilities in Eastern Trinidad During the COVID-19 Pandemic

Introduction: During the COVID-19 pandemic, Trinidad and Tobago's government implemented lockdowns and limited the availability of outpatient clinics to curb virus transmission. Subsequently, telemedicine via telephone calls was utilized to address infection control and continuity of care for chronic disease patients. Methods: An observational study was conducted at three primary care facilities in Eastern Trinidad using convenience sampling to review retrospectively telemedicine patients' medical records from October 2019 to February 2020 (before telemedicine) and from March 2020 to September 2020 (during telemedicine) for comparative analysis. Data were analyzed using IBM SPSS Statistics 28.0 software and Microsoft Excel. Results: A total of 199 patient files were analyzed; 57.3% of these were female; 52.3% were 60 years and older. A Wilcoxon signed-rank test demonstrated no statistically significant differences between random blood sugar (RBS) readings (0.355), weight (0.621), or systolic and diastolic blood pressure (BP; 0.239 and 0.232, respectively) before and during the 6-month period of telemedicine consultation. Patients compliant with medication before the use of telemedicine were 14 times more likely to attain target BPs. There was no significant association between compliance with prescribed therapy and BP control (0.335) during the period of telemedicine. Discussion: The findings support the use of telemedicine to manage chronic diseases such as hypertension, diabetes mellitus, and coronary heart disease, as the standard of care was preserved, and no inferiority of recorded outcomes was demonstrated. Although there was an overall decrease in compliance during the telemedicine period compared with before, comparative analysis exhibited no statistically significant differences in BP or RBS readings.

Targeting Hypertension: A Review on Pathophysiological Factors and Treatment Strategies

Hypertension is one of the primary causes of cardiovascular diseases and death, with a higher prevalence in low- and middle-income countries. The pathophysiology of hypertension remains complex, with 2% to 5% of patients having underlying renal or adrenal disorders. The rest are referred to as essential hypertension, with derangements in various physiological mechanisms potentially contributing to the development of essential hypertension. Hypertension elevates the risk of cardiovascular disease (CVD) events (coronary heart disease, heart failure, and stroke) and mortality. First-line therapy for hypertension is lifestyle change, which includes weight loss, a balanced diet that includes low salt and high potassium intake, physical exercise, and limitation or elimination of alcohol use. Blood pressure-lowering effects of individual lifestyle components are partially additive, enhancing the efficacy of pharmaceutical treatment. The choice to begin antihypertensive medication should be based on the level of blood pressure and the existence of a high atherosclerotic CVD risk. First-line hypertension treatment includes a thiazide or thiazide-like diuretic, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a calcium channel blocker. Addressing hypertension will require continued efforts to improve access to diagnosis, treatment, and lifestyle interventions.

Hypertensive heart disease: risk factors, complications and mechanisms

Hypertensive heart disease constitutes functional and structural dysfunction and pathogenesis occurring primarily in the left ventricle, the left atrium and the coronary arteries due to chronic uncontrolled hypertension. Hypertensive heart disease is underreported and the mechanisms underlying its correlates and complications are not well elaborated. In this review, we summarize the current understanding of hypertensive heart disease, we discuss in detail the mechanisms associated with development and complications of hypertensive heart disease especially left ventricular hypertrophy, atrial fibrillation, heart failure and coronary artery disease. We also briefly highlight the role of dietary salt, immunity and genetic predisposition in hypertensive heart disease pathogenesis.

Genetic Factors for Coronary Heart Disease and Their Mechanisms: A Meta-Analysis and Comprehensive Review of Common Variants from Genome-Wide Association Studies

Genome-wide association studies (GWAS) have discovered 163 loci related to coronary heart disease (CHD). Most GWAS have emphasized pathways related to single-nucleotide polymorphisms (SNPs) that reached genome-wide significance in their reports, while identification of CHD pathways based on the combination of all published GWAS involving various ethnicities has yet to be performed. We conducted a systematic search for articles with comprehensive GWAS data in the GWAS Catalog and PubMed, followed by a meta-analysis of the top recurring SNPs from ≥2 different articles using random or fixed-effect models according to Cochran Q and I2 statistics, and pathway enrichment analysis. Meta-analyses showed significance for 265 of 309 recurring SNPs. Enrichment analysis returned 107 significant pathways, including lipoprotein and lipid metabolisms (rs7412, rs6511720, rs11591147, rs1412444, rs11172113, rs11057830, rs4299376), atherogenesis (rs7500448, rs6504218, rs3918226, rs7623687), shared cardiovascular pathways (rs72689147, rs1800449, rs7568458), diabetes-related pathways (rs200787930, rs12146487, rs6129767), hepatitis C virus infection/hepatocellular carcinoma (rs73045269/rs8108632, rs56062135, rs188378669, rs4845625, rs11838776), and miR-29b-3p pathways (rs116843064, rs11617955, rs146092501, rs11838776, rs73045269/rs8108632). In this meta-analysis, the identification of various genetic factors and their associated pathways associated with CHD denotes the complexity of the disease. This provides an opportunity for the future development of novel CHD genetic risk scores relevant to personalized and precision medicine.

The Endothelium as a Target for Anti-Atherogenic Therapy: A Focus on the Epigenetic Enzymes EZH2 and SIRT1

Endothelial cell inflammatory activation and dysfunction are key events in the pathophysiology of atherosclerosis, and are associated with an elevated risk of cardiovascular events. Yet, therapies specifically targeting the endothelium and atherosclerosis are lacking. Here, we review how endothelial behaviour affects atherogenesis and pose that the endothelium may be an efficacious cellular target for antiatherogenic therapies. We discuss the contribution of endothelial inflammatory activation and dysfunction to atherogenesis and postulate that the dysregulation of specific epigenetic enzymes, EZH2 and SIRT1, aggravate endothelial dysfunction in a pleiotropic fashion. Moreover, we propose that commercially available drugs are available to clinically explore this postulation.

Interactive effects of interferon-gamma functional single nucleotid polymorphism (+874 T/A) with cardiovascular risk factors in coronary heart disease and early myocardial infarction risk

Atherosclerosis is an inflammatory disease characterized by extensive lipid accumulation in the artery wall. Throughout the atherosclerotic process, interferon-gamma (IFN-γ), which is an important pro-inflammatory cytokine, plays a central role in atherosclerotic plaque instability and the occurrence of myocardial infarction (MI). In this study, we aimed to investigate the relationship between IFN-γ +874 T/A (rs2430561) polymorphism and coronary heart disease (CHD) as well as its effects on MI and CHD. Three hundred and ninety patients with CHD (229 with MI, 161 without MI) and 233 healthy controls were screened by the amplification refractory mutation system (ARMS) PCR method for IFN-γ +874 T/A polymorphism. For MI risk, early adult age was important risk factors and the risk was increased with IFN-γ +874 T/A polymorphism. IFN-γ T allele was significantly increased in the CHD patients with age≤45 (p = 0.048) and patients with history of MI (p = 0.007). As IFN-γ is an inflammatory cytokine with an emerging role in the atherosclerotic process, it was suggested that inhibition of IFN-γ activity could be a therapeutic strategy to stabilize human atherosclerotic plaque. Our findings support the association between MI risk and IFN-γ +874 T/A polymorphism in the Turkish population, particularly by increasing the level of IFN-γ in young patients, thereby causing rupture of vulnerable plaques in atherosclerotic lesions. Identification of the IFN-γ +874 T/A gene variants as risk factors for early CHD and MI development may be a practical biomarker to guide the MI risk process and determine the ideal therapeutic approach.

Perindopril regulates the inflammatory mediators, NF-κB/TNF-α/IL-6, and apoptosis in cisplatin-induced renal dysfunction

Cisplatin (CP) is an essential chemotherapeutic drug used over the world against many types of cancer. It has several side effects such as ototoxicity, myelosuppression, and nephrotoxicity. Nephrotoxicity is the most dangerous and is considered a dose-limiting one. Oxidative stress, inflammation, and apoptosis are involved in this toxicity. This study was conducted to focus on the impact of perindopril (PER) against CP-induced nephrotoxicity in rat. Male albino rats were divided to control, rats received a single dose of CP, rats received PER, and rats co-received PER and CP. Nephrotoxicity evoked by CP challenge was characterized histologically and biochemically including significant increase in relative kidney/body weight ratio and serum urea and creatinine. Additionally, CP markedly increased renal tissue content of malondialdehyde (MDA) while decreased reduced glutathione (GSH) and depleted glutathione-S-transferase (GST) activity. CP produced significant increase in the inflammation biomarkers; nuclear factor-κB (NF-κB), tumor necrosis factor-α (TNF-α), and interlukine-6 (IL-6). Administration of CP clearly upregulated caspase-3, while it downregulated B-cell lymphoma-2 (BCL-2) gene expressions. Perindopril treatment showed a significant restoration in the pathological alterations histologically and biochemically, which are provoked by CP administration. Altogether, these results suggested a good therapeutic role of PER against CP-induced nephrotoxicity through its influence on oxidative stress, inflammation, and apoptosis pathway.

PGC-1α (Peroxisome Proliferator-Activated Receptor γ Coactivator 1-α) Overexpression in Coronary Artery Disease Recruits NO and Hydrogen Peroxide During Flow-Mediated Dilation and Protects Against Increased Intraluminal Pressure

Blood flow through healthy human vessels releases NO to produce vasodilation, whereas in patients with coronary artery disease (CAD), the mediator of dilation transitions to mitochondria-derived hydrogen peroxide (_mtH₂O₂). Excessive _mtH₂O₂ production contributes to a proatherosclerotic vascular milieu. Loss of PGC-1α (peroxisome proliferator-activated receptor γ coactivator 1α) is implicated in the pathogenesis of CAD. We hypothesized that PGC-1α suppresses _mtH₂O₂ production to reestablish NO-mediated dilation in isolated vessels from patients with CAD. Isolated human adipose arterioles were cannulated, and changes in lumen diameter in response to graded increases in flow were recorded in the presence of PEG (polyethylene glycol)-catalase (H₂O₂ scavenger) or L-NAME (N^G-nitro-l-arginine methyl ester; NOS inhibitor). In contrast to the exclusively NO- or H₂O₂-mediated dilation seen in either non-CAD or CAD conditions, respectively, flow-mediated dilation in CAD vessels was sensitive to both L-NAME and PEG-catalase after PGC-1α upregulation using ZLN005 and α-lipoic acid. PGC-1α overexpression in CAD vessels protected against the vascular dysfunction induced by an acute increase in intraluminal pressure. In contrast, downregulation of PGC-1α in non-CAD vessels produces a CAD-like phenotype characterized by _mtH₂O₂-mediated dilation (no contribution of NO). Loss of PGC-1α may contribute to the shift toward the _mtH₂O₂-mediated dilation observed in vessels from subjects with CAD. Strategies to boost PGC-1α levels may provide a therapeutic option in patients with CAD by shifting away from _mtH₂O₂-mediated dilation, increasing NO bioavailability, and reducing levels of _mtH₂O₂ Furthermore, increased expression of PGC-1α allows for simultaneous contributions of both NO and H₂O₂ to flow-mediated dilation.

Renalase, kidney and cardiovascular disease: are they related or just coincidentally associated?

Cardiovascular diseases, including hypertension are the leading cause of death in the developed countries. Diabetes and chronic kidney disease became also more prevalent reaching almost the level of epidemy. Researchers are looking eagerly for the new risk and/or pathogenetic factors, as well as therapeutic option in these disease. It has been suggested that human kidney releases a protein named renalase into the bloodstream. It is supposed to be an enzyme which breaks down catecholamines in the blood circulation and regulate blood pressure. However, there were several doubts whether renalase exerts monoaminooxidase activity, or if it is monoaminooxidase at all. Recently, a hypothesis that it is also a cytokine was postulated. Studies on renalase polymorphisms in hypertension, cardiovascular disease or diabetes are inconsistent. Similarly, there are several discrepancies in the animal on the possible role of renalase in hypertension and cardiovascular diseases. Some studies report a protective role of renalase in acute kidney injury, whereas others showed that renalase levels were mainly dependent on kidney function, indicating rather a role of kidney in excretion of this substance. Moreover, validated assays are needed to evaluate renalase levels and activity. On one hand a deeper and more accurate link between renalase and cardiovascular diseases require further profound research, on the other hand whether or not renalase protein could be a new therapeutic target in these pathologies should also be considered. Whether renalase, discovered in 2005, might be a Holy Grail of hypertension, linking kidney and cardiovascular diseases, remains to be proven.

Renalase gene polymorphism in patients with hypertension and concomitant coronary heart disease

BACKGROUND/AIMS

This study aimed to investigate renalase gene polymorphism in patients with hypertension and concomitant coronary heart disease (CHD) and to evaluate the risk for CHD in hypertensive patients from the view of genetics.

METHODS

NCBI and HapMap genome database were employed to screen the Single nucleotide polymorphisms (SNP). These SNPs were detected in hypertensive and CHD patients (n=791), hypertensive patients (n=802) and healthy controls (n=812), and the genotypes were recorded. Haploview 4.2 software was used to determine the genotypes, allele frequency, haplotypes, linkage disequilibrium and Hardy-Weinberg (HWE) equilibrium, and odds ratio (OR) was calculated with non-conditioned logistic regression analysis.

RESULTS

The frequency of allele A of rs2576178 in patients with hypertensive and CHD was markedly higher than that in hypertensive patients (p=0.001, OR=1.625,95% CI 1.221-2.160). The frequency of allele C of rs2296545 in hypertensive patients was significantly higher than that in healthy controls (P=0.009, OR=1.436, 95% CI 1.095-1.883).

CONCLUSION

The allele A of rs2576178 may be a predisposing factor of CHD in hypertensive patients, and hypertensive patients with AA genotype are susceptible to develop CHD. The allele C of rs2296545 may be a predisposing factor of hypertension and patients with CC genotype are susceptible to develop hypertension.

Hypertension management in the high cardiovascular risk population

The incidence of hypertension is increasing every year. Blood pressure (BP) control is an important therapeutic goal for the slowing of progression as well as for the prevention of Cardiovascular disease. The management of hypertension in the high cardiovascular risk population remains a real challenge as the population continues to age, the incidence of diabetes increases, and more and more people survive acute myocardial infarction. We will review hypertension management in the high cardiovascular risk population: patients with coronary heart disease (CHD) and heart failure (HF) as well as in diabetic patients.

Overweight, air and noise pollution: Universal risk factors for pediatric pre-hypertension

Pediatric pre-hypertension (pre-HTN) has a complex multifactorial etiology. Although most cases are secondary to other disorders, a substantial number of children and adolescents have primary or essential HTN and pre-HTN. The gene-gene and gene-environment interactions should be considered in this context. The strong relationship of pre-HTN with environmental factors such as air pollution, noise pollution and passive smoking and obesity suggest that its prevalence will be escalating.Exposure to ambient particulate matters may increase blood pressure (BP) within hours to days. The underlying biologic pathways include autonomic nervous system imbalance and arterial vascular dysfunction or vasoconstriction because of systemic oxidative stress and inflammation. Likewise, tobacco smoke exposure of pregnant mothers increases systolic BP of their offspring in early infancy. Parental smoking also independently affects systolic BP among healthy preschool children. Noise exposure, notably in night, is associated with catecholamine secretion, increased BP and a pre-HTN state even in pre-school age children.Excess weight is associated with dysfunction of the adipose tissue, consisting of enlarged hypertrophied adipocytes, increased infiltration by macrophages and variations in secretion of adipokines and free fatty acids. These changes would result in chronic vascular inflammation, oxidative stress, activation of the renin-angiotensin-aldosterone system and sympathetic response, and ultimately to pre-HTN from childhood.Prevention and control of the modifiable risk factors of pre-HTN from prenatal period can have long-term health impact on primordial and primary prevention of chronic non-communicable diseases. This review presents a general view on the diagnosis, prevalence and etiology of pre-HTN along with practical measures for its prevention and control.