Incidence of new-onset hypertension before, during, and after the COVID-19 pandemic: a 7-year longitudinal cohort study in a large population

BACKGROUND

While the augmented incidence of diabetes after COVID-19 has been widely confirmed, controversial results are available on the risk of developing hypertension during the COVID-19 pandemic.

METHODS

We designed a longitudinal cohort study to analyze a closed cohort followed up over a 7-year period, i.e., 3 years before and 3 years during the COVID-19 pandemic, and during 2023, when the pandemic was declared to be over. We analyzed medical records of more than 200,000 adults obtained from a cooperative of primary physicians from January 1, 2017, to December 31, 2023. The main outcome was the new diagnosis of hypertension.

RESULTS

We evaluated 202,163 individuals in the pre-pandemic years and 190,743 in the pandemic years, totaling 206,857 when including 2023 data. The incidence rate of new hypertension was 2.11 (95% C.I. 2.08-2.15) per 100 person-years in the years 2017-2019, increasing to 5.20 (95% C.I. 5.14-5.26) in the period 2020-2022 (RR = 2.46), and to 6.76 (95% C.I. 6.64-6.88) in 2023. The marked difference in trends between the first and the two successive observation periods was substantiated by the fitted regression lines of two Poisson models conducted on the monthly log-incidence of hypertension.

CONCLUSIONS

We detected a significant increase in new-onset hypertension during the COVID-19 pandemic, which at the end of the observation period affected ~ 20% of the studied cohort, a percentage higher than the diagnosis of COVID-19 infection within the same time frame. This observation suggests that increased attention to hypertension screening should not be limited to individuals who are aware of having contracted the infection but should be extended to the entire population.

Adherence to Mediterranean diet among patients with acute cardiovascular events admitted in Cardiac Rehabilitation unit

The Mediterranean Diet plays a critical role in the prevention of primary cardiovascular disease (CVD). Actually, there is a scarcity of evidence for secondary prevention. The current study aims to assess adherence to the Mediterranean diet (MD) in patients recently admitted to the Cardiac Rehabilitation Unit following acute cardiovascular disease. Adherence to MD was assessed in 111 patients admitted to the Cardiac Rehabilitation Unit of the Federico II Hospital in Naples. The Medi-Lite score was used to assess adherence to MD. The main determinant of reduced MD compliance was assessed using Pearson's correlation analysis and a multivariable regression model. The population had a median MD adherence score of 11 and a mean score of 10.9. The lowest possible score was 5 (indicating poor adherence), and the highest possible score was 15 (excellent adherence index). There were 3 participants with a poor score (<7), 82 with a good score (7-12), and 26 with an excellent score (³13). Lower Medi-Lite score was associated with younger age and being an active worker in a multivariate regression model (both p<0.05). Our findings show that among patients admitted to the Cardiac Rehabilitation Unit after a major CV event, young active workers have the lowest adherence to MD, requiring an individualized and multidisciplinary approach to improve their adherence to MD for secondary CV prevention.

Lung ultrasound: a narrative review and proposed protocol for patients admitted to Cardiac Rehabilitation Unit

Lung ultrasonography (LUS) has become in the last 10 years a technique that has reduced the need of second level diagnostic methods such as chest X-ray (CXR) and computerize tomography (CT) for the diagnostic imaging of lung and pleural space, throughout its diagnostic accuracy, radiation free, low cost, real time and bedside approach. The common use of LUS has been recently extend to cardiac and pulmonary disease even in context of Cardiac Rehabilitation Unit and it could be an additional tool for physiotherapist for the management of patients during Rehabilitation course. The authors performed a literature review in PubMed and suggested a new standardize protocol for LUS, based on guidelines and expert consensus document, for patients admitted to Cardiac Rehabilitation Unit. In this protocol, LUS should be performed in six scan each hemithorax, covering twelve imagine regions. For each scan will be noted a specific physiologic or pathological patterns. Furthermore, we suggest for each patient, the use of the Lung Ultrasound Score (LUS score) to obtain a global view of lung aeration and to monitor any changes during the hospitalization. An increase in score range indicates a more severe condition. This Lung Ultrasonography Protocol should be performed in all patients at the time of admission to Cardiac Rehabilitation Unit to monitoring the aeration of the lungs and the possible lung and/or pleura complications after a cardiac disease avoiding the use of second level surveys.

Serum Uric Acid and Left Ventricular Mass in Essential Hypertension

Serum uric acid (sUA) has been associated with cardiovascular risk. Although the recent mechanistic hypothesis poses the basis for the association between sUA and left ventricular mass index (LVMi), the issue remains poorly investigated in a clinical setup. Through a retrospective analysis of the database of the departmental Hypertension Clinic of University Hospital of Salerno Medical School, we identified 177 essential hypertensives (age 60.3 ± 13.3 years; 85 men), free from uric acid-modulating medications and severe chronic kidney disease, and whose sUA values, anthropometric, clinical, and echocardiographic data were available. In the studied cohort, the average duration of hypertension was 8.4 ± 7.1 years. LVMi associated with classical determinants, such as age, blood pressure, and kidney function, although after multivariate correction, only age remained significant. Also, sUA correlated positively with LVMi, as well as body size, metabolism, and kidney function. In a multivariate analysis, sUA confirmed the independent association with LVMi. Also, levels of sUA >5.6 mg/dl are associated with larger cardiac size. We confirmed our data in a replicate analysis performed in a larger population (1,379 hypertensives) from an independent clinic. Our results demonstrate that sUA increases with LVMi, and a cutoff of 5.6 mg/dl predict larger LV sizes. Our data suggest that hyperuricemia might help to stratify the risk of larger cardiac size in hypertensives.

Warranty period of normal stress myocardial perfusion imaging in hypertensive patients: A parametric survival analysis

BACKGROUND

We evaluated the warranty period of a normal stress myocardial perfusion single-photon emission computed tomography (MPS) in hypertensive patients.

METHODS AND RESULTS

A total of 471 consecutive hypertensive patients with suspected coronary artery disease and normal perfusion at stress MPS were followed for a mean of 76 ± 21 months. Endpoint events were cardiac death or nonfatal myocardial infarction. With Cox analysis, age (hazard ratio 1.1, P < .005) and stress test type (hazard ratio 2.7, P < .005) were independent predictors of events. With parametric Weibull analysis, patients ≤60 years old undergoing exercise stress test remained at low risk for the entire length of follow-up, while the highest probability of events and the major risk acceleration were observed in those > 60 years old who underwent pharmacologic stress test. In patients undergoing exercise test, peak systolic blood pressure (BP; hazard ratio 1.1, P < .005) emerged as predictor of events, and only subjects with peak systolic BP < 160 mmHg remained at low risk for the entire length of follow-up. In contrast, for patients with peak systolic BP ≥180 mmHg, the time to achieve a cumulative cardiac risk level of 3% was 18 months.

CONCLUSIONS

In hypertensive patients, the warranty period of a normal stress MPS varies according to stress type and peak systolic BP. A normal stress MPS can be considered reassuring in subjects ≤60 years old who performed exercise stress test and a peak systolic BP < 160 mmHg.

Cardiopulmonary exercise testing and echocardiographic exam: an useful interaction

Cardiopulmonary exercise test (CPET) is a functional assessment that helps to detect disorders affecting the system involved in oxygen transport and utilization through the analysis of the gas exchange during exercise. The clinical application of CPET is various, it including training prescription, evaluation of treatment efficacy and outcome prediction in a broad spectrum of conditions. Furthermore, in patients with shortness of breath it provides pivotal information to bring out an accurate differential diagnosis between physical deconditioning, cardiopulmonary disease and muscular diseases. Modern software allows the breath-by-breath analysis of the volume of oxygen intake (VO₂), volume of carbon dioxide output (VCO₂) and expired air (VE). Through this analysis, CPET provides a series of additional parameters (peak VO₂, ventilatory threshold, VE/VCO₂ slope, end-tidal carbon dioxide exhaled) that characterize different patterns, helping in diagnosis process. Limitations to the routine use of CPET are mainly represented from the lack of measurement standardization and limited data from randomized multicentric studies. The integration of CPET with exercise stress echocardiography has been recently introduced in the clinical practice by integrating the diagnostic power offered by both the tools. This combined approach has been demonstrated to be valuable for diagnosing several cardiac diseases, including heart failure with preserved or reduced ejection fraction, cardiomyopathies, pulmonary arterial hypertension, valvular heart disease and coronary artery disease. Future investigations are needed to further promote this intriguing combination in the clinical and research setting.

P5457Assessment of carotid cross sectional area in hypertensive patients: phenotyping and prognostic validation in the campania salute network

Background

Increased intima media thickness (IMT) of common carotid artery (CA) is considered the hallmark of vascular hypertension-mediated target organ damage, even though vessel remodeling due to mechanical stress can be accompanied also by changes in diameter.

Purpose

We developed a method computing both diameter and IMT of CA, and assessed correlates and prognostic impact of carotid cross sectional area (CCSA) in a large registry of treated hypertensive patients.

Methods

We selected 7049 hypertensive patients of the Campania Salute Network registry free of overt cardiovascular (CV) disease and with available CA ultrasound (54±11 yrs; 57% male). CCSA was computed as:

π × [((CA diameter + 2 × (mean IMT)) / 2)]2 − π × [((CA diameter) / 2)]2.

Results

CCSA was considered high if >90th percentile of the sex-specific distribution (>48 mm2 in men and >41 mm2 in women). Higher CCSA correlated with older age, male sex, higher pulse pressure (PP), higher total and LDL cholesterol and presence of diabetes (p<0.01 for all). During a median follow-up of 45 months (IQR 19–92), 324 incident composite major and minor CV events occurred. In Cox regression analysis high CCSA was associated with more than 100% increased risk of incident CV events (p<0.0001, figure), independently of the effect of older age, male sex, PP>60mmHg, presence of left ventricular hypertrophy (LVH), carotid plaque (CP), and less anti-RAS therapy (p<0.05 for all).

Conclusions

In treated hypertensive patients, increased CCSA is associated with worse metabolic and lipid profile and predict incident CV events, independently of high PP, presence of LVH and CP.

Coronary vascular function in patients with resistant hypertension and normal myocardial perfusion: a propensity score analysis

Aims

Impaired myocardial perfusion reserve (MPR) may occur earlier than coronary atherosclerosis and it may be an early manifestation of developing coronary artery disease (CAD) in patients with resistant hypertension (RH). We evaluated the relationship between RH and MPR in patients with systemic arterial hypertension after balancing for coronary risk factors.

Methods and results

We studied 360 subjects without overt CAD and normal myocardial perfusion at stress-rest 82Rb positron emission tomography/computed tomography. To account for differences in baseline characteristics between patients with resistant and controlled hypertension, we created a propensity score-matched cohort considering clinical variables and coronary risk factors. Before matching, patients with RH were significantly older, had higher prevalence of male gender and hypercholesterolaemia, and showed significantly lower global hyperaemic myocardial blood flow (MBF) and MPR compared with those with controlled hypertension, while baseline MBF and coronary artery calcium (CAC) content were similar in both groups. After matching, there were no significant differences in clinical variables and coronary risk factors between patients with resistant and controlled hypertension, but patients with RH still had lower hyperaemic MBF and MPR (both P < 0.001). At univariable and multivariable linear regression analyses, age, RH, and CAC resulted significant predictors of lower MPR values (all P < 0.05).

Conclusion

After balancing clinical characteristic by propensity score analysis, patients with RH had a blunted hyperaemic MBF and MPR compared with patients with controlled hypertension. The identification of impaired MPR could help to identify early structural alterations of the arterial walls in patients with RH.

Different age-independent effects of nutraceutical combinations on endothelium-mediated coronary flow reserve

Background

Some components of Nutraceuticals (NUT) such as red yeast rice and Morus alba have demonstrated positive effects on the endothelial function in hypercholesterolemic subjects. Our aim was to compare the effects of two different NUT combinations on cold pressure test (CPT) derived coronary flow reserve (CFR) assessed by transthoracic echo-Doppler.

Results

In a randomized, single-blind study, 28 consecutive patients with a variety of cardiovascular risk factors received NUT A (LopiGLIK®: berberine, red yeast rice powder, and leaf extract of Morus alba) or B (Armolipid Plus®: policosanol, red yeast rice, berberine, astaxantine, folic acidandcoenzyme Q10). An echo-Doppler exam with evaluation of CFR was performed at baseline, 2 h (acute test) and 30 days after daily NUT assumption. Blood sampling for metabolic profile and platelet aggregometry was performed at baseline and after 30 days of daily NUT assumption. CFR was not significantly modified at the acute test. After 30 days, CFR improved with NUT A (p < 0.0001), because of the increase of hyperemic flow velocity (p = 0.007), but not with NUT B. CFR was comparable between the two groups at baseline but became significantly higher after 30 days in NUT A (p < 0.02), with a higher CFR percent variation versus baseline (p = 0.008). Total cholesterol and LDL-cholesterol were reduced with both NUT A (p < 0.001 and p < 0.002, respectively) and B (both p < 0.02), whereas platelet aggregation did not significantly change. In the pooled group of patients, after adjusting for age and percent changes of systolic blood pressure, heart rate, LDL-cholesterol and glycemia, NUT A – but not NUT B - was independently associated with CFR changes (β = 0.599, p = 0.003).

Conclusions

LopiGLIK® improved endothelial-derived CFR, independently of the beneficial effects exerted on the lipid profile. These findings can have clinical reflections on the prevention of age-related inflammatory diseases including coronary artery disease.

Trial registration

(NUTRENDO)″(ClinicalTrials.gov, NCT02969070).

A single blind, multicenter, randomized controlled trial to evaluate the effectiveness and cost of a novel nutraceutical (LopiGLIK®) lowering cardiovascular disease risk

Context

Cardiovascular disease (CVD) costs the economy €210 billion per year in Europe. There is an association between low-density lipoprotein cholesterol (LDL-C) and CVD risk.

Objective

To evaluate the cost and effectiveness of LopiGLIK^® (LOPI) in lowering LDL-C and CVD risk.

Design

Single blind multicenter randomized controlled trial; patients were divided into two groups, subjected to centralized randomization.

Setting

Four Italian regions.

Participants

Thirty-one physicians enrolled 573 adult patients with mild hypercholesterolemia between January 2016 and January 2018.

Intervention

Patients were treated for 16 weeks either with LOPI (intervention) or Armolipid Plus^® (AP; control).

Outcome measures

Primary outcome: percentage of patients who achieved LDL-C <130 mg/dL. Secondary outcomes: reduction of HbA1c, survival analysis and HR linked to 38.67 mg/dL reduction of LDL-C and 1% reduction of HbA1c. Costs were assessed per unit and cure.

Results

Three hundred and seventy patients treated with LOPI and 203 treated with AP were randomized and completed the study. At baseline 8.9% (n=18) patients treated with AP and 9.5% (n=35) treated with LOPI had LDL-C levels <130 mg/dL (P=0.815). At the 16-week follow-up, 41.4% (n=84) of patients treated with AP and 67.6% (n=250) with LOPI achieved LDL-C levels <130 mg/dL (P<0.001). LOPI patients were three times more likely to achieve LDL-C levels <130 mg/dL; adjusted OR 2.97 (95% CI; 2.08-4.24; P<0.001), number needed to treat was four (95% CI; 5.60-2.90; P<0.001). Survival analysis demonstrated the superiority of LOPI vs AP relative to 38.67 mg/dL LDL-C reduction (P<0.002); HR was 0.761 (95% CI; 0.62-0.94; P<0.001). Both products reduced the HbA1c without a significant difference between them (P=0.156). Survival analysis and HR (0.91; 95% CI; 0.70-1.18) estimated for 1% HbA1c reduction, showed differences between LOPI and AP, which were not significant (P=0.411; P=0.464). The cost of LOPI was €2.11 (unit), €211 (cure), and AP €3.77 and €377, respectively.

Conclusion

LOPI appeared more effective and less expensive than AP in lowering LDL-C and CVD risk.

Trial registration

NCT02898805, September 8, 2016.

Is increased uric acid a risk factor or a defensive response? The Campania Salute Network

BACKGROUND AND AIMS

Circulating uric acid (UA) is positively associated with body mass index (BMI), blood glucose, blood pressure (BP), markers of inflammation, and altered lipid profile. UA has also anti-oxidative properties which might be beneficial for cardiovascular (CV) system. It is still debated whether or not UA is independently associated with increased CV morbidity and/or mortality.

METHODS AND RESULTS

We studied prognostic impact of UA in 8833 hypertensive adults (mean age 53 ± 12 yrs, 3857 women) from the Campania Salute Network, without prevalent CV disease and more than stage 3 CKD. We calculated standardized UA Z-score, adjusted for age, sex, glomerular filtration rate, and BMI. Low and high UA and UA Z-score quartiles were compared to the 2 middle quartiles assumed to be "normal". Prevalence of obesity and diabetes was higher in low and high than in normal UA Z-score group (all p < 0.001). Systolic BP, left ventricular mass, carotid intima thickness were significantly higher and ejection fraction was reduced in the presence of high UA Z-score (all p < 0.001). Over 33-months average follow-up, incident major CV end-points (MACE) were not significantly different among low, normal and high UA or UA Z-score. In the latter analysis, however, incident MACE tended to be more frequent in the low than the high UA Z-score. Despite the results of multivariable analyses, the effect of less aggressive therapy in low UA Z-score cannot be excluded with certainty.

CONCLUSION

In treated hypertensive patients, high levels of UA normalized for major biological determinants do not independently predict CV outcome. CLINICALTRIALS.

GOV IDENTIFIER

NCT02211365.

Cardiac eccentric remodeling in patients with rheumatoid arthritis

It is known that patients with rheumatoid arthritis (RA) have a higher risk of coronary heart disease and sudden cardiac death. Abnormalities in cardiac geometry appear to be involved in the setting of the cardiovascular risk, but it has never been specifically investigated in RA. We enrolled 44 patients with RA compared to 131 subjects without RA (normal, N): The RA aged between 18 and 70 years (mean 48.3 ± 2.1), 25 females, BMI 27.6 ± 0.9; N, of equal age (48.6 ± 1.2, n.s.), included 80 females (BMI 26.7 ± 0.2, ns). Cardiac Ultrasounds showed an increase of the diameter of the left ventricle but not in the septum with reduction of relative wall thickness (RWT) in the RA population compared to N. Relative wall thickness inversely correlates with biochemical parameters of inflammatory response (gamma globulin, p < 0.03; F = 5,660) and anti citrullinated peptides antibody (anti-CCP Ab) (p < 0.02; F = 7,1620) We conclude that unfavorable cardiac remodeling can increase cardiovascular risk in patients with RA.

Predictive value for cardiovascular events of common carotid intima media thickness and its rate of change in individuals at high cardiovascular risk - Results from the PROG-IMT collaboration

AIMS

Carotid intima media thickness (CIMT) predicts cardiovascular (CVD) events, but the predictive value of CIMT change is debated. We assessed the relation between CIMT change and events in individuals at high cardiovascular risk.

METHODS AND RESULTS

From 31 cohorts with two CIMT scans (total n = 89070) on average 3.6 years apart and clinical follow-up, subcohorts were drawn: (A) individuals with at least 3 cardiovascular risk factors without previous CVD events, (B) individuals with carotid plaques without previous CVD events, and (C) individuals with previous CVD events. Cox regression models were fit to estimate the hazard ratio (HR) of the combined endpoint (myocardial infarction, stroke or vascular death) per standard deviation (SD) of CIMT change, adjusted for CVD risk factors. These HRs were pooled across studies. In groups A, B and C we observed 3483, 2845 and 1165 endpoint events, respectively. Average common CIMT was 0.79mm (SD 0.16mm), and annual common CIMT change was 0.01mm (SD 0.07mm), both in group A. The pooled HR per SD of annual common CIMT change (0.02 to 0.43mm) was 0.99 (95% confidence interval: 0.95-1.02) in group A, 0.98 (0.93-1.04) in group B, and 0.95 (0.89-1.04) in group C. The HR per SD of common CIMT (average of the first and the second CIMT scan, 0.09 to 0.75mm) was 1.15 (1.07-1.23) in group A, 1.13 (1.05-1.22) in group B, and 1.12 (1.05-1.20) in group C.

CONCLUSIONS

We confirm that common CIMT is associated with future CVD events in individuals at high risk. CIMT change does not relate to future event risk in high-risk individuals.

Effect of a novel nutraceutical combination on serum lipoprotein functional profile and circulating PCSK9

Background

A beneficial effect on cardiovascular risk may be obtained by improving lipid-related serum lipoprotein functions such as high-density lipoproteins (HDLs) cholesterol efflux capacity (CEC) and serum cholesterol loading capacity (CLC) and by reducing proprotein convertase subtilisin kexin type 9 (PCSK9), independently of lipoprotein concentrations.

Aim

We aimed to evaluate the effect of an innovative nutraceutical (NUT) combination containing red yeast rice (monacolin K 3.3 mg), berberine 531.25 mg and leaf extract of Morus alba 200 mg (LopiGLIK^®), on HDL-CEC, serum CLC and on circulating PCSK9 levels.

Materials and methods

Twenty three dyslipidemic subjects were treated for 4 weeks with the above NUT combination. HDL-CEC was measured using specific cell-based radioisotopic assays; serum CLC and PCSK9 concentrations were measured fluorimetrically and by enzyme-linked immunosorbent assay, respectively.

Results

The NUT combination significantly reduced plasma level of the total cholesterol and low-density lipoprotein cholesterol (−9.8% and −12.6%, respectively). Despite no changes in HDL-cholesterol, the NUT combination improved total HDL-CEC in 83% of the patients, by an average of 16%, as a consequence of the increase mainly of the ATP-binding cassette A1-mediated CEC (+28.5%). The NUT combination significantly reduced serum CLC (−11.4%) while it did not change PCSK9 plasma levels (312.9±69.4 ng/mL vs 334.8±103.5 mg/L, before and after treatment, respectively).

Conclusion

The present NUT combination improves the serum lipoprotein functional profile providing complementary beneficial effects, without any detrimental increase of PCSK9 plasma levels.

Hypertension Survey in Italy: Novel Findings from the Campania Salute Network

The "Campania Salute" (CS) is a network system aimed at improving the management of essential hypertension by integrating the activity of general practitioners (GPs) with that of the hypertension specialists. It involves 23 outpatient hypertensive clinics distributed in different community hospitals of the Napoli's metropolitan area, 60 randomly selected GPs homogeneously distributed in the same area, and the Hypertension Clinic of the Federico II University in Naples (co-ordinating centre). Through the CS system it is possible to share clinical data collected during each visit at peripheral units (general practitioners and community hospitals hypertensive clinics), which manage low-risk hypertensive patients, and the co-ordinating centre, which mainly manages high-risk hypertensive patients. The co-ordinating centre works in co-operation with the peripheral units in the treatment and follow-up of all hypertensive patients. Since the first reports on the CS network activity, it has been evident the effectiveness of this network in ameliorating the clinical management of the hypertensive disease. CS network is also a large prospective registry that generated several scientific reports based on the longitudinal assessment of hypertensive patients during their treatment. Nowadays, as observed in the Health Search Database, the rate of BP control in Campania was 69.5%, almost reaching the "Objective 70%", a result that could be in part linked to the activity of the CS network.

Effects of a new combination of nutraceuticals on postmenopausal symptoms and metabolic profile: a crossover, randomized, double-blind trial

Objectives

This study was designed to measure the beneficial effects of a combination of nutraceutics (NUT; AkP04, Morestril^®, Akademy Pharma) containing soy isoflavones (80 mg), dry extract of Angelica sinensis (50 mg), dry extract of Morus alba leaf (200 mg) and magnesium (56.25 mg) in the relief of somatic, psychological, and urogenital symptoms in postmenopausal patients, using the validated Menopause Rating Scale (MRS) and cardiovascular risk factors.

Materials and methods

A total of 43 symptomatic postmenopausal women (MRS ≥20) were enrolled in a crossover trial. After a 2-week run-in period, patients were randomized into two arms. One arm received probiotics plus placebo over 4 weeks, followed by a 4-week treatment with probiotics plus NUT. The second arm received probiotics plus NUT for 4 weeks, followed by a 4-week treatment with probiotics plus placebo.

Results

After the NUT period, participants showed a significant reduction in MRS score (18.4±5.4) in comparison to baseline (28.4±5) and the placebo period (28±5.2) (P<0.0001 for both comparisons). Furthermore, at the end of the active-treatment period, we observed a significant reduction in triglycerides, total and low-density lipoprotein cholesterol plasma levels and an increase in high-density lipoprotein cholesterol plasma concentration versus baseline and versus placebo (all P<0.04). Moreover, during the NUT period, we detected a significant reduction in diastolic blood pressure in comparison to baseline, but not in comparison to the placebo period.

Conclusion

This NUT combination was effective for the relief of menopause symptoms in postmenopausal patients and improved their cardiovascular risk profile.

Morus alba extract modulates blood pressure homeostasis through eNOS signaling

SCOPE

Morus alba is a promising phytomedicine cultivated in oriental countries that is extensively used to prevent and treat various cardiovascular problems. To date, despite its beneficial effects, the molecular mechanisms involved remain unclear. Thus, we investigate the vascular and haemodynamic effects of Morus alba extract in an experimental model focusing our attention on the molecular mechanisms involved.

METHODS AND RESULTS

Through vascular reactivity studies, we demonstrate that Morus alba extract evokes endothelial vasorelaxation through a nitric oxide-dependent pathway. Our molecular analysis highlights an increase in endothelial nitric oxide synthase (eNOS) phosphorylation. In vivo administration of Morus alba extract reduces blood pressure levels exclusively in wild-type mice, whereas it fails to evoke any haemodynamic effects in eNOS-deficient mice. Molecular analyses revealed that its beneficial action on vasculature is mediated by the activation of two important proteins that act as stress sensors and chaperones: PERK and heat shock protein 90. Finally, Morus alba extract exerts antihypertensive action in an experimental model of arterial hypertension.

CONCLUSION

Through its action on eNOS signaling, Morus alba extract could act as a food supplement for the regulation of cardiovascular system, mainly in clinical conditions characterized by eNOS dysfunction, such as arterial hypertension.

Real Data on Effectiveness, Tolerability and Safety of New Oral Anticoagulant Agents: Focus on Dabigatran

Vitamin K-dependent antagonists (VKAs) are the most commonly used oral anticoagulants. Non-VKA oral anticoagulants (NOACs), directly target factor IIa (dabigatran) or Xa (rivaroxaban, apixaban, and edoxaban) have predictable pharmacological effects and relatively few drug and food interactions compared with VKA. Among NOACs, dabigatran has been extensively tested for stroke prevention in patients with non-valvular atrial fibrillation eligible for oral anticoagulation with VKA. Dabigatran is at least as effective as warfarin at preventing stroke with advantages of less serious bleeding except for gastrointestinal bleeding, which occurs more often than with warfarin. The findings of dabigatran use in randomized trials, post market registries and specific clinical settings are discussed in this article.

Functional foods and cardiometabolic diseases* International Task Force for Prevention of Cardiometabolic Diseases

Mounting evidence supports the hypothesis that functional foods containing physiologically-active components may be healthful. Longitudinal cohort studies have shown that some food classes and dietary patterns are beneficial in primary prevention, and this has led to the identification of putative functional foods. This field, however, is at its very beginning, and additional research is necessary to substantiate the potential health benefit of foods for which the diet-health relationships are not yet scientifically validated. It appears essential, however, that before health claims are made for particular foods, in vivo randomized, double-blind, placebo controlled trials of clinical end-points are necessary to establish clinical efficacy. Since there is need for research work aimed at devising personalized diet based on genetic make-up, it seems more than reasonable the latter be modeled, at present, on the Mediterranean diet, given the large body of evidence of its healthful effects. The Mediterranean diet is a nutritional model whose origins go back to the traditional dietadopted in European countries bordering the Mediterranean sea, namely central and southern Italy, Greece and Spain; these populations have a lower incidence of cardiovascular diseases than the North American ones, whose diet is characterized by high intake of animal fat. The meeting in Naples and this document both aim to focus on the changes in time in these two different models of dietary habits and their fall out on public health.

Nutraceuticals for treatment of high blood pressure values in patients with metabolic syndrome

AIM

To assess whether the association of a dietary supplement with a correct diet can decrease the incidence of metabolic syndrome. In particular, we studied the effect of a combination of Ortosiphon staminensis, which in rats exerts a diuretic effect, with policosanol, red yeast rice extract, berberine, folic acid and coenzyme Q(10) on the determinants of metabolic syndrome diagnosis.

METHODS

The analysed sample consisted of 21 males and 9 females, who were comparable in age, in order to obtain an adequate comparison between groups with similar demographic characteristics. Thirty patients with metabolic syndrome were divided into two study arms. Both groups received the usual diet recommended by the doctor according to their clinical conditions and placebo for 2 weeks before the beginning of the study, and then they were randomly assigned to two different drug regimens: placebo or the combination of nutraceuticals previously described, and were followed-up for 6 weeks.

RESULTS

At baseline, there were no significant differences between the study and control groups for age, sex distribution, waist measurement, body mass index, systolic and diastolic blood pressure, familiarity for cardiovascular events, smoking habit, fasting glucose and lipid profile.At the end of the follow-up, only in the study group was there a significant reduction in systolic and diastolic blood pressure (-19.6±9.7 vs -3.6±8.1 mmHg and -13.6±5.5 vs -2.3±5.3 mmHg; all p < 0.0001) associated with amarked decrease in low-density lipoprotein cholesterol and triglyceride plasma levels. Consequently, 10 of 15 patients in this group no longer satisfied the criteria for metabolic syndrome, while in the control group the ratio was of 2 of 15.

CONCLUSIONS

The addition of Ortosiphon staminensis to the combination of policosanol, red yeast rice extract, berberine, folic acid and coenzyme Q(10) provides an antihypertensive effect, which allows an effective control of blood pressure in patients with metabolic syndrome.

Insufficient control of blood pressure and incident diabetes

OBJECTIVE

Incidence of type 2 diabetes might be associated with preexisting hypertension. There is no information on whether incident diabetes is predicted by blood pressure control. We evaluated the hazard of diabetes in relation to blood pressure control in treated hypertensive patients.

RESEARCH DESIGN AND METHODS

Nondiabetic, otherwise healthy, hypertensive patients (N = 1,754, mean +/- SD age 52 +/- 11 years, 43% women) participated in a network over 3.4 +/- 1 years of follow-up. Blood pressure was considered uncontrolled if systolic was >or=140 mmHg and/or diastolic was >or=90 mmHg at the last outpatient visit. Diabetes was defined according to American Diabetes Association guidelines.

RESULTS

Uncontrolled blood pressure despite antihypertensive treatment was found in 712 patients (41%). At baseline, patients with uncontrolled blood pressure were slightly younger than patients with controlled blood pressure (51 +/- 11 vs. 53 +/- 12 years, P < 0.001), with no differences in sex distribution, BMI, duration of hypertension, baseline blood pressure, fasting glucose, serum creatinine and potassium, lipid profile, or prevalence of metabolic syndrome. During follow-up, 109 subjects developed diabetes. Incidence of diabetes was significantly higher in patients with uncontrolled (8%) than in those with controlled blood pressure (4%, odds ratio 2.08, P < 0.0001). In Cox regression analysis controlling for baseline systolic blood pressure and BMI, family history of diabetes, and physical activity, uncontrolled blood pressure doubled the risk of incident diabetes (hazard ratio [HR] 2.10, P < 0.001), independently of significant effects of age (HR 1.02 per year, P = 0.03) and baseline fasting glucose (HR 1.10 per mg/dl, P < 0.001).

CONCLUSIONS

In a large sample of treated nondiabetic hypertensive subjects, uncontrolled blood pressure is associated with twofold increased risk of incident diabetes independently of age, BMI, baseline blood pressure, or fasting glucose.

Smoking selectively accelerates carotid atherosclerosis in hypertensive patients

BACKGROUND AND OBJECTIVES

Left ventricular hypertrophy, carotid atherosclerosis and renal dysfunction are indicators of target organ damage in hypertension, and independent risk factors for both fatal and non-fatal cardio- and cerebrovascular events. In the general population, smoking is associated with increases in left ventricular mass and carotid intima-media thickness (IMT), and impaired renal function. The aim of the present study was to evaluate whether smoking affects the development of target organ damage in patients with arterial hypertension.

METHODS

3192 hypertensive patients referred to the Hypertension Clinic of the "Federico II" University of Naples from January 2000 to July 2006 were retrospectively analysed. Subjects were aged from 18 to 75 years. Among these patients, 1391 were smokers and 1801 non-smokers.

RESULTS

The duration and severity of hypertension was significantly shorter in smokers when compared with non-smokers. The maximum arterial IMT was significantly higher in smokers compared with non-smokers (1.7 ± 0.1 mm vs 1.5 ± 0.1, p < 0.0001), while left ventricular mass index was comparable between the two groups. In contrast, glomerular filtration rate was observed to be higher in smokers compared with non-smokers. Logistic regression analysis showed that smoking, age, sex, duration of hypertension, systolic blood pressure and diastolic blood pressure were significantly correlated with IMT. Furthermore, a strong correlation was found between the number of cigarettes smoked per day and IMT.

CONCLUSIONS

Together, these data indicate that in hypertensive patients who have a high risk of developing atherosclerosis, smoking could potentiate the development of atherosclerotic plaques.

[Renin-angiotensin system modulation: instructions for use]

Angiotensin-converting enzyme (ACE) inhibitors and AT1 receptor blockers have long been considered as two classes of drugs with strictly comparable effect in cardiovascular diseases, on the assumption that both classes act on the renin-angiotensin-aldosterone system. The results of large clinical intervention trials, which failed to demonstrate any significant difference between the effects of these two pharmacological classes in patients with essential hypertension, acute myocardial infarction and heart failure, supported this concept. The recent observation that a combination of ACE-inhibitors and AT1 receptor blockers improves the prognosis of these pathological conditions better than monotherapy at higher doses focused on the difference between their mechanisms of action. The results of pathophysiological studies have suggested that in the heart, as well as in the kidney, AT1 receptor blockers act in the early stages of the disease, improving left ventricular dysfunction in hypertensive patients and preventing microalbuminuria in diabetic animals. It seems reliable to suggest that AT1 receptor blockers are to be preferred to ACE-inhibitors for an early prevention of cardiovascular and renal disease. The new inhibitors of renin activity may further amplify our chances, also blocking the negative effects mediated by angiotensin II escape and by stimulation of the prorenin/renin receptors.

[Usefulness of a telematic system and image analysis in the follow-up of high-risk patients: a new health service model]

BACKGROUND

Inadequate blood pressure control in hypertensive patients is in contrast with the evidence from clinical studies of effectiveness of the same antihypertensive compounds used in clinical practice. These results may be due to follow-up management of hypertensive patients and in particular to the interaction between general practitioners (GPs) and hypertension specialists. The aim of this study was to assess the effectiveness of an internet-based digital network, connecting specialists and GPs in the Campania Region, on blood pressure control and major cardiovascular events.

METHODS

A network between the Hypertension Center of "Federico II" University, 14 specialist centers and 60 GPs was done in the Campania Region (Campania Salute Project, CS). Randomized GPs enrolled in CS could update online clinic records of patients (n = 1979). As a control group, we included 2045 patients referred to the specialist centers by GPs from outside the network. All patients completed a 2-year follow-up.

RESULTS

CS determined a significant reduction in systolic and diastolic blood pressure (CS group 144 +/- 18/91 +/- 11 vs 136 +/- 17/86 +/- 10 mmHg; control group 144 +/- 17/90 +/- 10 vs 139 +/- 15/87 +/- 9 mmHg, p < 0.001). Indeed, the CS group showed less frequent fatal and non-fatal major cardiovascular events (2.9 vs 4.3%, chi2 = 5.047, p < 0.02).

CONCLUSIONS

Our results support the hypothesis that telematic connections may contribute to improve blood pressure control and reduce major cardiovascular events.

β2-Adrenergic receptor polymorphisms and treatment-induced regression of left ventricular hypertrophy in hypertension

OBJECTIVES

Although blood pressure is considered the major determinant of left ventricular hypertrophy in hypertension, genetic variability is increasingly being considered among the factors influencing this complication. beta(2)-Adrenergic receptors (beta(2)ARs) are up-regulated in hypertension and largely polymorphic within the human population. Recently, we have shown that the Glu27 beta(2)AR variant is strongly associated with cardiac hypertrophy in hypertension. The objective of this study is to verify whether this polymorphism also affects hypertrophy regression in response to antihypertensive therapy.

METHODS

In a prospective follow-up study we screened 970 hypertensive patients of Caucasian descent for the Gly16Arg, Gln27Glu, and Thr164Ile beta(2)AR polymorphisms and left ventricular echocardiographic hypertrophy and assigned selected patients to enalapril or atenolol to assess left ventricular hypertrophy regression after 2-year follow-up. Results were stratified according to treatment and the Glu27Gln polymorphism of the beta(2)AR. In cells with stable overexpression of the Glu27 or Gln27 variant of beta(2)AR, we also explored the implications of this polymorphism on hypertrophy-related intracellular signal transduction.

RESULTS

Among hypertensive patients, the Gly16 allele was found in 63% of patients and the Glu27 allele was found in 40.6%. Both polymorphisms were in linkage disequilibrium, as expected. Four hundred forty-one hypertrophic hypertensive patients completed the 2-year follow-up. At baseline, patients carrying at least 1 allele of the Glu27 variant presented with a larger cardiac size despite similar blood pressure levels (142.9 +/- 22.5 g/m(2) in Glu27 carriers versus 138.2 +/- 18.4 g/m(2) in Gln27 carriers, P < .02). Blood pressure normalization was achieved by both drugs. At follow-up, compared with the Gln27 patients, the Glu27 patients showed a larger reduction in hypertrophy when treated with enalapril (percent change in left ventricular mass, -6.3% +/- 7.7% in Glu27 carriers versus -2.18% +/- 7.9% in Gln27 carriers; P < .05) but not with atenolol therapy (-2.8% +/- 8.9% in Glu27 carriers versus -2.4% +/- 8.8% in Gln27 carriers, P = not significant). In in vitro studies the activation of p38 and extracellular signal-regulated kinase (ERK-) 1/2 (data not shown) and the activity of the atrial natriuretic factor (ANF) promoter after isoproterenol (INN, isoprenaline) stimulation were larger in Glu27 beta(2)AR overexpressing cells than in Gln27 beta(2)AR overexpressing cells (fold difference compared with unstimulated cells, 9.7 +/- 2.9 for Glu27 beta(2)AR versus 4.2 +/- 0.3 for Gln27 beta(2)AR; P < .05).

CONCLUSIONS

The Glu27 variant of beta(2)AR enhances hypertension-induced left ventricular hypertrophy. In these patients angiotensin-converting enzyme inhibitors are more efficient than beta-blockers in reducing cardiac size.

The use of a telematic connection for the follow-up of hypertensive patients improves the cardiovascular prognosis

BACKGROUND

Inadequate blood pressure (BP) control could be due to incorrect management of hypertensives caused by the lack of interaction between general practitioners (GP) and hypertension specialists.

OBJECTIVES

To test the effectiveness on BP and total cardiovascular risk (TCVR) control of an internet-based digital network connecting specialists and GPs.

METHODS

We created a network among the Hypertension Clinic, Federico II University (Naples, Italy), 23 hospital-based hypertension clinics and 60 GPs from the area (CampaniaSalute Network, CS). Randomized GPs enrolled in CS could update online records of patients (n = 1979). As a control, we included 2045 patients referred to the specialist clinics by GPs from outside the network. All patients completed a 2-year follow-up.

RESULTS

CS provided a larger reduction in BP [systolic/diastolic BP (SBP/DBP): 7.3 +/- 0.4/5.4 +/- 0.3 versus 4.1 +/- 0.4/3.1 +/- 0.26 mmHg, CS versus control; P < 0.001 for both] and percentage of patients with BP < 140/90 mmHg (CS versus control: baseline, 33 versus 34%, NS; end of follow-up, 51 versus 47%, chi = 13.371; P < 0.001). A European Society of Hypertension-European Society of Cardiology (ESH/ESC) TCVR score was calculated [from 1 (average) to 5 (very high TCVR)]. The CS group showed a reduction in the mean TCVR score (CS: from 3.5 +/- 0.02 to 3.2 +/- 0, P < 0.01, ANOVA; control group: 3.5 +/- 0.03 to 3.4 +/- 0.03, NS) and, accordingly, fatal and non-fatal major cardiovascular events (MACE) were less frequent (2.9 versus 4.3%; chi = 5.047, P < 0.02). CS predicts fewer MACE in multiple binary regression analysis (beta:-7.27, P < 0.008) reducing the risk for MACE compared to control [odds ratio (OR): 0.838; 95% confidence interval (CI): 0.73-0.96].

CONCLUSION

Our results support the idea that telemedicine can achieve better control of BP and TCVR.

Benefits of combination therapy in hypertensive patients with associated coronary artery disease: a subgroup with specific demands

Although prevention of coronary artery disease (CAD) is one of the main goals of antihypertensive therapy, when first seen hypertensive patients often have associated CAD. These patients need a therapy that can exert an acute anti-ischemic action, such as ad hoc relief of angina pectoris, and can also reduce the incidence of myocardial infarction (MI) or reinfarction. Reduction in blood pressure (BP) alone does not appear to be adequate because in hypertensive patients CAD is a complex and multifactorial process involving not only hemodynamic, neurohormonal, and metabolic factors but also hypertension-induced myocardial and vascular structural changes, which appear independently to contribute to risk for CAD. In theory, antihypertensive combination therapy, by summing the different effects of various drugs, appears to have a greater capacity for comprehensive management of hypertensive patients with CAD. Simultaneous administration of angiotensin-converting enzyme (ACE) inhibitors and calcium-channel blockers appears to be particularly effective. In several clinical trials with long-term follow-up, ACE inhibitor therapy has been associated with a substantial reduction in the risk for major ischemic events. The antiproliferative action of ACE inhibitors on myocardium and the vascular wall, their hemodynamic effects, antiatherogenic actions, neurohormonal attenuation, and certain genetic issues may account for the ability of this class of drugs to reduce the risk for CAD-related events. Although ACE inhibitors can be expected to increase coronary blood flow when the renin-angiotensin system is activated and to reduce BP, ventricular filling pressure, and sympathetic drive, thus far an acute anti-ischemic action of these drugs has not been demonstrated. Unlike ACE inhibitors, which usually have class-specific effects, there are important differences in the clinical effects of various calcium antagonists. The first generation of dihydropyridine calcium-entry blockers has failed to demonstrate efficacy in secondary prevention of coronary artery events. However, verapamil reduces mortality in patients with normal left ventricular function. The antihypertensive efficacy of verapamil, its antiatherogenic action, and its ability to reverse left ventricular hypertrophy, to improve diastolic function, and to interfere with endothelium-derived contracting factors may also account for the improved survival of patients with CAD treated with this drug. Moreover, verapamil is also effective in the treatment of all types of angina because it reduces myocardial oxygen consumption as a result of its hypotensive effect and its ability to reduce heart rate, and it may also improve oxygen delivery to the myocardium because of its action on coronary vasodilatation. It is also important to consider that ACE inhibitors and calcium antagonists often induce the same beneficial effects through different mechanisms, thus allowing a synergistic action when the two classes of drugs are administered together.

[Submucosal lipomas of the colon (considerations apropos of 3 clinical cases)]

Submucous colonic lipoma is relatively rare and can be the cause of important diagnostic and consequently therapeutic problems. The AA. reexamine the anatomo pathological and clinical features and the diagnostic and therapeutic problems, and refer 3 cases observed one of which was localized in the ileo-cecal valve. The AA. remark that radiological and endoscopic investigations and laparotomy features also can simulate a malignant tumor and address to the surgical technics of the oncologic surgery.