Effectiveness and Safety of Enteric-Coated vs Uncoated Aspirin in Patients With Cardiovascular Disease: A Secondary Analysis of the ADAPTABLE Randomized Clinical Trial

Importance

Clinicians recommend enteric-coated aspirin to decrease gastrointestinal bleeding in secondary prevention of coronary artery disease even though studies suggest platelet inhibition is decreased with enteric-coated vs uncoated aspirin formulations.

Objective

To assess whether receipt of enteric-coated vs uncoated aspirin is associated with effectiveness or safety outcomes.

Design, Setting, and Participants

This is a post hoc secondary analysis of ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness), a pragmatic study of 15 076 patients with atherosclerotic cardiovascular disease having data in the National Patient-Centered Clinical Research Network. Patients were enrolled from April 19, 2016, through June 30, 2020, and randomly assigned to receive high (325 mg) vs low (81 mg) doses of daily aspirin. The present analysis assessed the effectiveness and safety of enteric-coated vs uncoated aspirin among those participants who reported aspirin formulation at baseline. Data were analyzed from November 11, 2019, to July 3, 2023.

Intervention

ADAPTABLE participants were regrouped according to aspirin formulation self-reported at baseline, with a median (IQR) follow-up of 26.2 (19.8-35.4) months.

Main Outcomes and Measures

The primary effectiveness end point was the cumulative incidence of the composite of myocardial infarction, stroke, or death from any cause, and the primary safety end point was major bleeding events (hospitalization for a bleeding event with use of a blood product or intracranial hemorrhage). Cumulative incidence at median follow-up for primary effectiveness and primary safety end points was compared between participants taking enteric-coated or uncoated aspirin using unadjusted and multivariable Cox proportional hazards models. All analyses were conducted for the intention-to-treat population.

Results

Baseline aspirin formulation used in ADAPTABLE was self-reported for 10 678 participants (median [IQR] age, 68.0 [61.3-73.7] years; 7285 men [68.2%]), of whom 7366 (69.0%) took enteric-coated aspirin and 3312 (31.0%) took uncoated aspirin. No significant difference in effectiveness (adjusted hazard ratio [AHR], 0.94; 95% CI, 0.80-1.09; P = .40) or safety (AHR, 0.82; 95% CI, 0.49-1.37; P = .46) outcomes between the enteric-coated aspirin and uncoated aspirin cohorts was found. Within enteric-coated aspirin and uncoated aspirin, aspirin dose had no association with effectiveness (enteric-coated aspirin AHR, 1.13; 95% CI, 0.88-1.45 and uncoated aspirin AHR, 0.99; 95% CI, 0.83-1.18; interaction P = .41) or safety (enteric-coated aspirin AHR, 2.37; 95% CI, 1.02-5.50 and uncoated aspirin AHR, 0.89; 95% CI, 0.49-1.64; interaction P = .07).

Conclusions and Relevance

In this post hoc secondary analysis of the ADAPTABLE randomized clinical trial, enteric-coated aspirin was not associated with significantly higher risk of myocardial infarction, stroke, or death or with lower bleeding risk compared with uncoated aspirin, regardless of dose, although a reduction in bleeding with enteric-coated aspirin cannot be excluded. More research is needed to confirm whether enteric-coated aspirin formulations or newer formulations will improve outcomes in this population.

Trial Registration

ClinicalTrials.gov Identifier: NCT02697916.

Comparative Effectiveness of Aspirin Dosing in Cardiovascular Disease

BACKGROUND

The appropriate dose of aspirin to lower the risk of death, myocardial infarction, and stroke and to minimize major bleeding in patients with established atherosclerotic cardiovascular disease is a subject of controversy.

METHODS

Using an open-label, pragmatic design, we randomly assigned patients with established atherosclerotic cardiovascular disease to a strategy of 81 mg or 325 mg of aspirin per day. The primary effectiveness outcome was a composite of death from any cause, hospitalization for myocardial infarction, or hospitalization for stroke, assessed in a time-to-event analysis. The primary safety outcome was hospitalization for major bleeding, also assessed in a time-to-event analysis.

RESULTS

A total of 15,076 patients were followed for a median of 26.2 months (interquartile range [IQR], 19.0 to 34.9). Before randomization, 13,537 (96.0% of those with available information on previous aspirin use) were already taking aspirin, and 85.3% of these patients were previously taking 81 mg of daily aspirin. Death, hospitalization for myocardial infarction, or hospitalization for stroke occurred in 590 patients (estimated percentage, 7.28%) in the 81-mg group and 569 patients (estimated percentage, 7.51%) in the 325-mg group (hazard ratio, 1.02; 95% confidence interval [CI], 0.91 to 1.14). Hospitalization for major bleeding occurred in 53 patients (estimated percentage, 0.63%) in the 81-mg group and 44 patients (estimated percentage, 0.60%) in the 325-mg group (hazard ratio, 1.18; 95% CI, 0.79 to 1.77). Patients assigned to 325 mg had a higher incidence of dose switching than those assigned to 81 mg (41.6% vs. 7.1%) and fewer median days of exposure to the assigned dose (434 days [IQR, 139 to 737] vs. 650 days [IQR, 415 to 922]).

CONCLUSIONS

In this pragmatic trial involving patients with established cardiovascular disease, there was substantial dose switching to 81 mg of daily aspirin and no significant differences in cardiovascular events or major bleeding between patients assigned to 81 mg and those assigned to 325 mg of aspirin daily. (Funded by the Patient-Centered Outcomes Research Institute; ADAPTABLE ClinicalTrials.gov number, NCT02697916.).

Rationale and Design of the Aspirin Dosing-A Patient-Centric Trial Assessing Benefits and Long-term Effectiveness (ADAPTABLE) Trial

Importance

Determining the right dosage of aspirin for the secondary prevention treatment of atherosclerotic cardiovascular disease (ASCVD) remains an unanswered and critical question.

Objective

To report the rationale and design for a randomized clinical trial to determine the optimal dosage of aspirin to be used for secondary prevention of ASCVD, using an innovative research method.

Design, Setting, and Participants

This pragmatic, open-label, patient-centered, randomized clinical trial is being conducted in 15 000 patients within the National Patient-Centered Clinical Research Network (PCORnet), a distributed research network of partners including clinical research networks, health plan research networks, and patient-powered research networks across the United States. Patients with established ASCVD treated in routine clinical practice within the network are eligible. Patient recruitment began in April 2016. Enrollment was completed in June 2019. Final follow-up is expected to be completed by June 2020.

Interventions

Participants are randomized on a web platform in a 1:1 fashion to either 81 mg or 325 mg of aspirin daily.

Main Outcomes and Measures

The primary efficacy end point is the composite of all-cause mortality, hospitalization for nonfatal myocardial infarction, or hospitalization for a nonfatal stroke. The primary safety end point is hospitalization for major bleeding associated with a blood-product transfusion. End points are captured through regular queries of the health systems' common data model within the structure of PCORnet's distributed data environment.

Conclusions and Relevance

As a pragmatic study and the first interventional trial conducted within the PCORnet electronic data infrastructure, this trial is testing several unique and innovative operational approaches that have the potential to disrupt and transform the conduct of future patient-centered randomized clinical trials by evaluating treatments integrated in clinical practice while at the same time determining the optimal dosage of aspirin for secondary prevention of ASCVD.

Trial Registration

ClinicalTrials.gov Identifier: NCT02697916.

Association of Post-Traumatic Stress Disorder Symptoms Following Hurricane Katrina With Incident Cardiovascular Disease Events Among Older Adults With Hypertension

OBJECTIVE

To determine the association of post-traumatic stress disorder (PTSD) symptoms following Hurricane Katrina with incident cardiovascular disease (CVD) events in older, hypertensive, community-dwelling adults both overall and stratified by age, sex, and race.

METHODS

This was a prospective cohort study performed in Southeastern Louisiana 12-24 months following Hurricane Katrina through February 2011. Participants were community-dwelling older adults (n = 2,073) enrolled in the Cohort Study of Medication Adherence Among Older Adults with no known history of CVD events. PTSD symptoms were assessed via telephone interview 12-24 months following Hurricane Katrina using the PTSD CheckList-Specific Version. The presence of PTSD symptoms was defined by scores greater than or equal to 37. Incident CVD events (stroke, myocardial infarction, hospitalization for congestive heart failure, or CVD death) were identified and adjudicated over a median 3.8-year follow-up period.

RESULTS

Overall, 8.6% of participants screened positive for PTSD symptoms, and 11.6% had an incident CVD event during follow-up. PTSD symptoms were associated with an adjusted hazard ratio (aHR) for CVD events of 1.7 (95% confidence interval [CI], 1.1, 2.6). The association was present among blacks (aHR, 3.3, 95% CI, 1.7, 6.3) but not whites (aHR, 0.9, 95% CI, 0.4, 1.9); the interaction of PTSD symptoms and race on CVD events was statistically significant.

CONCLUSION

PTSD symptoms following Hurricane Katrina were associated with a higher risk of incident CVD in older adults with hypertension, with a stronger association in blacks compared with whites.

Role of intracellular angiotensin II

It has become clear that the vasoactive peptide angiotensin II, like other so-called intracrines, can act in the intracellular space. Evidence has accumulated indicating that such angiotensin II activity can be upregulated in disease states and cause pathology. Indeed, other intracrines appear to be involved in disease pathogenesis as well. At the same time, nitric oxide, potentially a cell protective factor, has been shown to be upregulated by intracellular angiotensin II. Recently data have been developed indicating that other potentially protective factors are directly upregulated at neuronal nuclei by angiotensin II. This led to the suggestion that intracellular angiotensin II is cell protective and not pathological. Here, the data on both sides of this issue and a possible resolution are discussed. In summary, there is evidence for both protective and pathological actions of intracellular angiotensin, just as there is abundant evidence derived from whole animal physiology to indicate that angiotensin-driven signaling cascades, including angiotensin II type 2 receptor- and Mas receptor-mediated events, can mitigate the effects of the angiotensin II/angiotensin II type 1 receptor axis (25). This mitigation does not negate the physiological and pathological importance of angiotensin II/angiotensin II type 1 receptor action but does expand our understanding of the workings of both intracellular and extracellular angiotensin II.

A Reassessment of the Pathophysiology of Progressive Cardiorenal Disorders

Heart failure and chronic renal diseases are usually progressive and only partially amenable to therapy. These disorders can be the sequelae of hypertension or worsened by hypertension. They are associated with the tissue up-regulation of multiple peptides, many of which are capable of acting within the cell interior. This article proposes that these peptides, intracrines, can form self-sustaining regulatory loops that can spread through heart or kidney, producing progressive disease. Moreover, mineralocorticoid activation seems capable of amplifying some of these peptide networks. This view suggests an expanded explanation of the pathogenesis of progressive cardiorenal disease and suggests new approaches to treatment.

Age-Related Macular Degeneration and Intracrine Biology: An Hypothesis

This laboratory has studied the intracellular actions of angiotensin II and other signaling proteins that can act in the intracellular space-peptides/proteins we have called intracrines. Moreover, we have suggested that general principles of intracrine action exist and can help explain the progression of some chronic degenerative diseases such as diabetic nephropathy and congestive heart failure. Here, a similar analysis is carried out in the case of age-related macular degeneration. We propose that intracrine mechanisms are operative in this disorder. In particular, we hypothesize that intracrine loops involving renin, angiotensin II, transforming growth factor-beta, vascular endothelial growth factor, bone morphogenetic protein-4, and p53, among other factors, are involved. If this analysis is correct, it suggests a commonality of mechanism linking chronic progressive renal diseases, congestive heart failure, and macular degeneration.

Studies of intracellular angiotensin II

Many extracellular signaling proteins act within their cells of synthesis and/or in target cells after internalization. This type of action is called intracrine and it plays a role in diverse biological processes. The mechanisms of intracrine intracellular action are becoming clear thanks to the application of modern techniques of molecular biology. Here, progress in this area is reviewed. In particular the intracrine biology of angiotensin II is discussed.

Thirty years of intracrinology

BACKGROUND

Intracrinology is the study of the intracellular actions, regulation, trafficking, and interactions of extracellular signaling peptides/proteins.

METHODS

We describe the development of intracrine biology since the term was defined in 1984.

RESULTS

Intracrine biology plays a role in many normal and pathological processes and represents a fertile field for the development of novel therapeutics.

CONCLUSION

Although 30 years old, the field of intracrinology is only now becoming widely accepted. Intracrine principles can be applied to the investigation of physiological processes and to the development of new therapies.

Intracellular Enhanced Cyan Fluorescent Protein/Angiotensin II Does Not Modify Angiotensinogen Accumulation in Transgenic Mice

BACKGROUND

Several studies suggest that extracellular angiotensin can upregulate renin and angiotensinogen (AGT). We have shown that enhanced cyan fluorescent protein/angiotensin II (ECFP/AngII) transgenic mice, in which AngII is fused downstream of ECFP and regulated by the mouse metallothionein housekeeping gene, possess elevated blood pressure and kidney thrombotic microangiopathy. The present study evaluated the effect of intracellular AngII on AGT messenger RNA (mRNA) and protein levels in ECFP/AngII transgenic mice.

METHODS

The traditional guanidinium thiocyanate method was used to extract total mRNA. Proteins were extracted by homogenization in a tissue extraction reagent buffer. Northern blots for AGT mRNA and an 18S ribosomal RNA control were performed. Immunoblots for AGT protein levels with actin and tubulin controls were evaluated.

RESULTS

Northern blot densitometry showed liver mRNA levels an average of 12-fold greater than levels in the brain or kidney in both Lines A and D (different copies of the transgene) with no quantifiable differences between wild-type (WT) and homozygous (HO) transgenic mice. Immunoblots showed liver AGT protein levels 3.2-fold greater than levels in the brain or kidney, with no differences observed between WT and HO transgenic mice.

CONCLUSION

ECFP/AngII transgene expression does not alter AGT mRNA or protein levels in major organs (kidney, liver, and brain) of transgenic mice. The altered blood pressure and kidney thrombosis observed in these transgenic mouse lines are not the result of increased intracellular AGT synthesis and resultant increases in free extracellular AngII. This finding is consistent with our published studies that indicate no increase in circulating AngII by radioimmunoassay.

Reduction of Blood Pressure by AT1 Receptor Decoy Peptides

BACKGROUND

We previously identified the binding of the chaperone protein gamma-aminobutyric acid receptor-associated protein (GABARAP) to a sequence on the carboxy-terminus of the angiotensin II AT1 receptor (AT1R) and showed that this binding enhances AT1R trafficking to the cell surface as well as angiotensin signaling.

METHODS

In this study, we treated sodium-depleted mice with decoy peptides consisting either of a fusion of the cell-penetrating peptide penetratin and the GABARAP/AT1R binding sequence or penetratin fused to a mutated AT1R sequence. We used telemetry to measure blood pressure.

RESULTS

Systolic and diastolic pressure fell during the 24 hours following decoy peptide injection but not after control peptide injection. Active cell-penetrating decoy peptide decreased 24-hour average systolic blood pressure from 129.8 ± 4.7 mmHg to 125.0 ± 6.0 mmHg (mean ± standard deviation). Diastolic blood pressure fell from 99.0 ± 7.1 mmHg to 95.0 ± 9.2 mmHg (n=5). Administration of the control peptide raised systolic blood pressure from 128.7 ± 1.3 mmHg to 131.7 ± 2.9 mmHg and diastolic pressure from 93.9 ± 4.5 mmHg to 95.9 ± 4.2 mmHg (n=5). The decreases in both systolic and diastolic blood pressure after active peptide administration were statistically significant compared to control peptide administration (P<0.05, two-tailed Wilcoxon rank-sum test).

CONCLUSION

These results indicate the physiological and potentially therapeutic relevance of inhibitors of GABARAP/AT1R binding.

Lessons from in vitro studies and a related intracellular angiotensin II transgenic mouse model

In the classical renin-angiotensin system, circulating ANG II mediates growth stimulatory and hemodynamic effects through the plasma membrane ANG II type I receptor, AT1. ANG II also exists in the intracellular space in some native cells, and tissues and can be upregulated in diseases, including hypertension and diabetes. Moreover, intracellular AT1 receptors can be found associated with endosomes, nuclei, and mitochondria. Intracellular ANG II can function in a canonical fashion through the native receptor and also in a noncanonical fashion through interaction with alternative proteins. Likewise, the receptor and proteolytic fragments of the receptor can function independently of ANG II. Participation of the receptor and ligand in alternative intracellular pathways may serve to amplify events that are initiated at the plasma membrane. We review historical and current literature relevant to ANG II, compared with other intracrines, in tissue culture and transgenic models. In particular, we describe a new transgenic mouse model, which demonstrates that intracellular ANG II is linked to high blood pressure. Appreciation of the diverse, pleiotropic intracellular effects of components of the renin-angiotensin system should lead to alternative disease treatment targets and new therapies.

Predictors of decline in medication adherence: results from the cohort study of medication adherence among older adults

Few data are available on the predictors of decline in antihypertensive medication adherence and the association of decline in adherence with subsequent blood pressure (BP) control. The current analysis included 1965 adults from the Cohort Study of Medication Adherence Among Older Adults recruited between August 2006 and September 2007. Decline in antihypertensive medication adherence was defined as a ≥2-point decrease on the 8-item Morisky Medication Adherence Scale assessed during telephone surveys 1 and 2 years after baseline. Risk factors for decline in adherence were collected using telephone surveys and administrative databases. BP was abstracted from outpatient records. The annual rate for a decline in adherence was 4.3% (159 participants experienced a decline). After multivariable adjustment, a decline in adherence was associated with an odds ratio (OR) for uncontrolled BP (≥140/90 mm Hg) at follow-up of 1.68 (95% CI: 1.01-2.80). Depressive symptoms (OR: 1.84 [95% CI: 1.20-2.82]) and a high stressful life events score (OR: 1.68 [95% CI: 1.19-2.38]) were associated with higher ORs for a decline in adherence. Female sex (OR: 0.61 [95% CI: 0.42-0.88]), being married (OR: 0.68 [95% CI: 0.47-0.98]), and calcium channel blocker use (OR: 0.68 [95% CI: 0.48-0.97]) were associated with lower ORs for decline. In summary, a decline in antihypertensive medication adherence was associated with uncontrolled BP. Modifiable factors associated with decline were identified. Further research is warranted to determine whether interventions can prevent the decline in antihypertensive medication adherence and improve BP control.

Expression of a naturally occurring angiotensin AT(1) receptor cleavage fragment elicits caspase-activation and apoptosis

Several transmembrane receptors are documented to accumulate in nuclei, some as holoreceptors and others as cleaved receptor products. Our prior studies indicate that a population of the 7-transmembrane angiotensin type-1 receptor (AT(1)R) is cleaved in a ligand-augmented manner after which the cytoplasmic, carboxy-terminal cleavage fragment (CF) traffics to the nucleus. In the present report, we determine the precise cleavage site within the AT(1)R by mass spectrometry and Edman sequencing. Cleavage occurs between Leu(305) and Gly(306) at the junction of the seventh transmembrane domain and the intracellular cytoplasmic carboxy-terminal domain. To evaluate the function of the CF distinct from the holoreceptor, we generated a construct encoding the CF as an in-frame yellow fluorescent protein fusion. The CF accumulates in nuclei and induces apoptosis in CHO-K1 cells, rat aortic smooth muscle cells (RASMCs), MCF-7 human breast adenocarcinoma cells, and H9c2 rat cardiomyoblasts. All cell types show nuclear fragmentation and disintegration, as well as evidence for phosphotidylserine displacement in the plasma membrane and activated caspases. RASMCs specifically showed a 5.2-fold increase (P < 0.001) in CF-induced active caspases compared with control and a 7.2-fold increase (P < 0.001) in cleaved caspase-3 (Asp174). Poly(ADP-ribose)polymerase was upregulated 4.8-fold (P < 0.001) in CF expressing cardiomyoblasts and colocalized with terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL). CF expression also induces DNA laddering, the gold-standard for apoptosis in all cell types studied. CF-induced apoptosis, therefore, appears to be a general phenomenon as it is observed in multiple cell types including smooth muscle cells and cardiomyoblasts.

Quality of life in hypertensive clinic patients following hurricane katrina

BACKGROUND

The purpose of this study was to assess quality of life among hypertensive patients in the year following Hurricane Katrina.

METHODS

Hypertensive patients (n  =  211) in a multispecialty group practice in New Orleans completed validated surveys during the year after Hurricane Katrina. We assessed patients' demographics, quality of life (Medical Outcomes Study 36), hurricane coping self-efficacy, property damage, stress, and changes in distance from and visits with family and friends.

RESULTS

The mean age of participants was 63.5 years, 45.0% were men, 70.6% were white, 89.5% had graduated from high school, and 68.3% were married. Mean quality of life scores (standard deviation) were physical functioning 64.6 (30.0), role physical 60.0 (42.8), bodily pain 59.9 (24.3), general health 60.4 (20.5), vitality 53.6 (26.5), social functioning 74.5 (28.1), role emotional 67.8 (41.1), and mental 72.3 (22.0). After adjustment for age, gender, and race, lower coping self-efficacy, more damage to their residence, higher levels of stress after the storm, increased distance from family and friends, and decreased visits with family and friends were associated with lower quality of life. Personal and financial losses were identified as the most common cause of postdisaster stress, reported by 29.6% of participants.

CONCLUSIONS

Storm-related factors were associated with lower quality of life in adult patients with hypertension after Hurricane Katrina. Providers managing hypertensive patients in disaster-prone areas may want to consider these factors in identifying patients at risk for lower quality of life following catastrophes.

A regulatory approach to health care reform

Although the technical prowess of American medicine is widely appreciated, considerable concern centers on the delivery and financing of health care, and, in particular, on issues of cost and access. Progress in addressing these concerns has been slow in coming with standard approaches to reform failing to win wide approval. It is here suggested that a series of relatively straightforward regulatory reforms could redirect the medical delivery enterprise and reduce many of the distortions that plague it today. These regulatory reforms center on insurance portability, the elimination of discounting, insurance reform, the provision of provider-specific outcomes data, and technology assessment. These regulatory changes offer the prospect of making the system more rational and efficient, while minimizing rationing and avoiding major institutional change. They also may stimulate additional novel suggestions for reform.

The mitochondrial component of intracrine action

In recent years the actions of intracellular-acting, extracellular signaling proteins/peptides (intracrines) have become increasingly defined. General principles of intracrine action have been proposed. Mitochondria represent one locus of intracrine action, and thus far, angiotensin II, transforming growth factor-beta, growth hormone, atrial natriuretic peptide, Wnt 13, stanniocalcin, other renin-angiotensin system components, and vascular endothelial-derived growth factor, among others, have been shown to be mitochondria-localizing intracrines. The implications of this mitochondrial intracrine biology are discussed.

C-terminal processing of GABARAP is not required for trafficking of the angiotensin II type 1A receptor

OBJECTIVE

GABARAP, a small (117 aa) trafficking protein, binds to the C-terminal, cytoplasmic domain of rat angiotensin type-1A receptor (AT(1)R), the predominant effector of the octapeptide angiotensin II (Ang II) (Cook et al., Circ. Res. 2008;102:1539-47). The objectives of this study were to map the interaction domains of GABARAP and AT(1)R, to determine the effect of GABARAP association on AT(1)R signaling activity, and to determine the importance of post-translational processing of GABARAP on accumulation of AT(1)R on the plasma membrane and its signaling function.

RESULTS

Deletion analysis identified two regions within GABARAP necessary for interaction with AT(1)R in yeast two-hybrid assays: 1) a domain comprised of residues 32-51 that is nearly identical to that involved in binding and intracellular trafficking of the GABA(A) receptor and 2) a domain encompassing the C-terminal 21 aa. The GABARAP interaction domain of AT(1)R was delimited to the 15 aa immediately downstream of the last membrane spanning region. Overexpression of GABARAP in rat adrenal pheochromocytoma PC-12 cells increased the cell-surface expression of AT(1)R and Ang II-dependent activation of the cAMP signaling pathway. Residues within AT(1)R necessary for these responses were identified by mutational analysis. In PC-12 cells, GABARAP was constitutively and quantitatively cleaved at the C-terminus peptide bond and this cleavage was prevented by mutation of Gly(116). Wild-type GABARAP and the G116A mutant were, however, equally effective in stimulating AT(1)R surface expression and signaling activity.

CONCLUSIONS

GABARAP and AT(1)R interact through discrete domains and this association regulates the cell-surface accumulation and, consequently, ligand-induced function of the receptor. Unlike that observed with the GABA(A) receptor, this regulation is not dependent on C-terminal processing and modification of GABARAP.

Senescence, apoptosis, and stem cell biology: the rationale for an expanded view of intracrine action

Some extracellular-signaling peptides also at times function within the intracellular space. We have termed these peptides intracrines and have argued that intracrine function is associated with a wide variety of peptides/proteins including hormones, growth factors, cytokines, enzymes, and DNA-binding proteins among others. Here we consider the possibility that intracrines participate in the related phenomena of senescence, apoptosis, and stem cell regulation of tissue biology. Based on this analysis, we also suggest that the concept of intracrine action be expanded to include possible regulatory peptide transfer via exosomes/microvesicles and possibly by nanotubes. Moreover, the process of microvesicular and nanotube transfer of peptides and other biologically relevant molecules, which we inclusively term laterality, is explored. These notions have potentially important therapeutic implications, including implications for the therapy of cardiovascular disease.

New insights into target organ involvement in hypertension

Hypertension and its sequelae are complex processes. Optimization of the care of the hypertensive patient requires not only attention to the regulation of arterial pressure but also attention to blunting the hypertension-related processes that lead to vascular disease. It is clear that the regulation of these processes is much more complex than previously understood. Here several new insights into the pathogenesis of hypertension-related vascular disease have been explored. While this review is not exhaustive, it does serve to point out the varied nature of the biologic processes that must be taken into account and it points to new avenues for the development of therapeutic agents.

New medication adherence scale versus pharmacy fill rates in seniors with hypertension

OBJECTIVE

To evaluate the association and concordance of the new 8-item self-report Morisky Medication Adherence Scale (MMAS) with pharmacy fill data in a sample of community-dwelling seniors with hypertension.

STUDY DESIGN

Cross-sectional study.

METHODS

Pharmacy records for antihypertensive medications were abstracted for 87 managed care adult patients with hypertension 65 years and older who completed a survey that included the MMAS. Continuous single-interval medication availability (CSA), medication possession ratio (MPR), and continuous multiple-interval medication gaps (CMG) were calculated using pharmacy data. The MMAS adherence was categorized as high, medium, and low (MMAS scores of 8, 6 to <8, and <6, respectively); pharmacy fill nonpersistence was defined as less than 0.8 for CSA and MPR and as greater than 0.2 for CMG.

RESULTS

Overall, 58%, 33%, and 9% of participants had high, medium, and low medication adherence, respectively, by the MMAS. After adjustment for demographics and in comparison to high adherers on the MMAS, patients with low MMAS adherence were 6.89 (95% confidence interval [CI], 2.48-19.10) times more likely to have nonpersistent pharmacy fill adherence by CSA and were 5.22 (95% CI, 1.88-14.50) times more likely to have nonpersistent pharmacy fill adherence by MPR. Concordance between the MMAS and CSA, MPR, and CMG was 75% or higher.

CONCLUSIONS

The MMAS is significantly associated with antihypertensive drug pharmacy refill adherence. Although further validation of the MMAS is needed, it may be useful in identifying low medication adherers in clinical settings.

Newer Insights into the Biochemical Physiology of the Renin–Angiotensin System: Role of Angiotensin-(1-7), Angiotensin Converting Enzyme 2, and Angiotensin-(1-12)

Knowledge of the mechanisms by which the rennin–angiotensin system contributes to cardiovascular pathology continues to advance at a rapid pace as newer methods and therapies uncover the nature of this complex system and its fundamental role in the regulation of blood pressure and tissue function. The characterization of the biochemical pathways and functions mediated by angiotensin-(1-7) [Ang-(1-7)], angiotensin converting enzyme 2 (ACE2), and the mas receptor has revealed a vasodepressor and antiproliferative axis that within the rennin–angiotensin system opposes the biological actions of angiotensin II (Ang II). In addition, new research expands on this knowledge by demonstrating additional mechanisms for the formation of Ang II and Ang-(1-7) through the existence of an alternate form of the angiotensinogen substrate [angiotensin-(1-12)] which generates Ang II and even Ang-(1-7) through a non-renin dependent action. Altogether, this research paves the way for a better understanding of the intracellular mechanisms involved in the synthesis of angiotensin peptides and its consequences in terms of cell function in both physiology and pathology.

Obesity-related hypertension

Obesity-associated arterial hypertension is characterized by activation of the sympathetic nervous system, activation of the renin-angiotensin system, and sodium retention, among other abnormalities. In this review, the following 3 facets of the obesity/hypertension nexus will be discussed: the potential mechanisms by which obesity can lead to elevated arterial pressure, the interaction of obesity with the sequelae of hypertension, and the therapies that are believed to optimally treat obesity-related hypertension.

Medication adherence in older clinic patients with hypertension after Hurricane Katrina: implications for clinical practice and disaster management

BACKGROUND

In post-disaster situations, additional barriers may reduce antihypertensive medication adherence.

METHODS

Between November 2005 and August 2006, 210 hypertensive patients receiving care at a multispecialty group practice in New Orleans completed a structured questionnaire. Antihypertensive medication adherence was measured with the Hill-Bone medication compliance subscale. In a subset of patients, data on difficulties patients encountered with blood pressure medications in the aftermath of Hurricane Katrina were collected.

RESULTS

: Seventy-six percent of patients reported damage to their residence and 46% of patients had less-than-perfect medication adherence. After multivariate adjustment, less than perfect medication adherence postdisaster was more common among people aged <65 years (prevalence ratio = 1.37; 95% confidence interval: 1.03-1.82) and non-whites (1.32; 95% confidence interval: 1.02-1.71). Uncontrolled blood pressure (systolic/diastolic > or =140/> or =90 mm Hg) was more common in those with less-than-perfect adherence than their counterparts with perfect adherence (51% versus 42%, respectively). In addition, 7% of patients reported not bringing their blood pressure medications when they evacuated, 28% ran out of blood pressure medications, 16% reported difficulties getting medications filled, and 28% reported a blood pressure medication change postdisaster.

CONCLUSIONS

Opportunities exist to improve disaster planning and prescription refill processes and increase medication adherence and hypertension control postdisasters.

The physiological basis of intracrine stem cell regulation

Intracrine peptides and proteins participate in the regulation of adult and pleuripotential embryonic-like stem cells. Included among these factors are VEGF, dynorphin, the readthrough form of acetylcholinesterase, Oct3/4, Pdx-1, Pax-6, and high-mobility group protein B1, among others. In some cases, the establishment of intracrine feedback loops can be shown to be relevant to this regulation, consistent with previously proposed principles of intracrine action. Here the role of intracrines in stem cell regulation is reviewed, with particular attention to the intracrine regulation of cardiac stem cells. The reprogramming of cells to restore the pleuripotent phenotype and the possible role of stem/progenitor cells in neoplasia are also discussed.

The trafficking protein GABARAP binds to and enhances plasma membrane expression and function of the angiotensin II type 1 receptor

Proteins that bind to the intracellular expanses, particularly cytoplasmic tail regions, of heptahelical integral membrane receptors are of particular interest in that they can mediate or modulate trafficking or intracellular signaling. In an effort to distinguish new proteins that might promote angiotensin II type 1 (AT(1)) receptor intracellular events, we screened a yeast 2-hybrid mouse brain library with the rat AT(1A) receptor (AT(1)R) carboxyl terminus and identified GABARAP, a protein involved in intracellular trafficking of the GABA(A) receptor, as a binding partner for the AT(1)R. Interaction of GABARAP with the AT(1)R carboxyl terminus was further substantiated using GST pull-down assays, and binding of the full-length tagged AT(1)R to GABARAP was verified using coimmunoprecipitation. Bioluminescence resonance energy transfer assays further confirmed specific interaction of GABARAP with AT(1)R. Moreover, GABARAP clearly increased the steady-state level of plasma membrane-associated AT(1)R in PC-12 cells. Cotransfection of GABARAP with an AT(1)R fluorescent fusion protein increased PC-12 cell surface expression of the AT(1)R more than 6-fold when standardized to the level of intracellular expression. Furthermore, GABARAP overexpression in CHO-K1 cells engineered to express AT(1)R increased angiotensin II binding sites 3.7-fold and angiotensin II-induced phospho-extracellular signal-regulated kinase 1/2 and cellular proliferation significantly over levels obtained with AT(1)R overexpression alone. In addition, small interfering RNA-mediated knockdown of GABARAP reduced the steady-state levels of the AT(1)R fluorescent fusion protein by 43% and its cell surface expression by 84%. Immunoblot analyses confirmed the quantitative image data. We conclude that GABARAP binds to and promotes trafficking of the AT(1)R to the plasma membrane.

The basis of an intracrine pharmacology

Intracrines are extracellular signaling peptide factors that can act in the intracellular space after either internalization or retention in the cells that synthesize them. They are structurally diverse and include hormones, growth factors, enzymes, DNA-binding proteins, and other peptide moieties. We have suggested principles of intracrine action and have applied those principles to forms of cellular and tissue differentiation, hormonal responsiveness, and memory. Moreover, recent findings make clear that some currently available pharmaceuticals act via the alteration of intracrine function. Thus, the beginnings of an intracrine pharmacology are at hand and we here review principles applicable to the design of such agents. The intracrine pharmacology of the renin-angiotensin system, angiogenesis, and stem cell development is discussed.

Mechanisms of Disease: intracrine physiology in the cardiovascular system

The field of intracrine physiology attempts to codify the biological actions of intracrines--extracellular signaling proteins or peptides that also operate in the intracellular space, either because they are retained in their cells of synthesis or because they have been internalized by a target cell. Intracrines are structurally diverse; hormones, growth factors, DNA-binding proteins and enzymes can all display intracrine functionality. Here, we review the role of intracrines in the heart and vasculature, including the intracrine actions of renin-angiotensin-system components in cardiac pathology, dynorphin B in cardiac development, and a variety of factors in pathologic and therapeutic angiogenesis. We argue that principles of intracrine physiology can inform our understanding of important pathologic processes such as left ventricular hypertrophy, diabetic cardiomyopathy and arrythmogenesis, and can aid the development of more-effective therapeutic interventions in cardiovascular disease.

Inhibition of Erythroleukemia Cell Growth by Triplex-forming RNAs

OBJECTIVE

We have previously reported that oligodeoxyribonucleotides, designed to bind in a triplex fashion to a specific p53 binding site homology, inhibit the proliferation of colon cancer cells in vitro and in vivo. The present study was designed to extend these observations and to determine whether ribonucleic acid (RNA) generated from a retroviral vector (RVV) and possessing a corresponding triplex forming site can, in a similar fashion, inhibit proliferation of p53-null K-562 leukemia cells. Viral vectors may offer advantages over oligonucleotides for tumor treatment. RVVs have the potential to be taken up more efficiently than oligonucleotides and to be expressed continuously and long-term, circumventing the need for repeated and frequent oligomer administration.

EXPERIMENTAL DESIGN

The p53-null human erythroleukemia cell line, K-562, was stably transfected with a tetracycline-repressible p53 expression construct (p53/pUHD10-3). p53 protein in these cells is expressed in the absence of tetracycline but down-regulated upon tetracycline treatment. Triplex-forming oligonucleotides [Hoog 1 (experimental) and Hoog 3 (control)] were cloned into RVVs in order to generate triplex-forming fusion mRNAs. Naive K-562 cells and p53/pUHD10-3-transfected K-562 cells (with and without tetracycline treatment) were infected with viruses that express the triplex-forming RNAs. Cell growth was measured by BrdU incorporation into DNA.

RESULTS

RVVs encoding Hoog 1, in both orientations, inhibit the growth of naive K-562 cells and p53-transfected, tet-repressed K-562 cells. p53 expression in K-562 cells decreases growth to the same extent as Hoog 1 RVV treatment. However, Hoog 1-RVV does not further inhibit growth of p53-expressing K-562 cells. Treatment with an RVV encoding the control, Hoog 3, has no growth inhibitory effect.

CONCLUSION

Triple helix-forming RNAs directed to a p53 consensus sequence homology reduce leukemia cell proliferation, suggesting a novel method of treatment.

Cleavage of the angiotensin II type 1 receptor and nuclear accumulation of the cytoplasmic carboxy-terminal fragment

Our published studies show that the distribution of the ANG II type 1 (AT(1)) receptor (AT(1)R), expressed as a enhanced yellow fluorescent fusion (YFP) protein (AT(1)R/EYFP), is altered upon cellular treatment with ANG II or coexpression with intracellular ANG II. AT(1)R accumulates in nuclei of cells only in the presence of ANG II. Several transmembrane receptors are known to accumulate in nuclei, some as holoreceptors and others as cleaved receptor products. The present study was designed to determine whether the AT(1)R is cleaved before nuclear transport. A plasmid encoding a rat AT(1)R labeled at the amino terminus with enhanced cyan fluorescent protein (CFP) and at the carboxy terminus with EYFP was employed. Image analyses of this protein in COS-7 cells, CCF-STTG1 glial cells, and A10 vascular smooth muscle cells show the two fluorescent moieties to be largely spatially colocalized in untreated cells. ANG II treatment, however, leads to a separation of the fluorescent moieties with yellow fluorescence accumulating in more than 30% of cellular nuclei. Immunoblot analyses of extracts and conditioned media from transfected cells indicate that the CFP domain fused to the extracellular amino-terminal AT(1)R domain is cleaved from the membrane and that the YFP domain, together with the intracellular cytoplasmic carboxy terminus of the AT(1)R, is also cleaved from the membrane-bound receptor. The carboxy terminus of the AT(1)R is essential for cleavage; cleavage does not occur in protein deleted with respect to this region. Overexpressed native AT(1)R (nonfusion) is also cleaved; the intracellular 6-kDa cytoplasmic domain product accumulates to a significantly higher level with ANG II treatment.

An intracrine view of angiogenesis

Angiogenesis, the generation of new blood vessels from pre-existing vessels, is an integral component of wound healing, responses to inflammation and other physiologic processes. It is also an essential part of tumor growth; in the absence of new vessel formation, tumors cannot expand beyond a small volume. Although much is known about angiogenesis and its regulation, there is no overall theory that describes or explains this process. It is here suggested that the intracrine hypothesis, which ascribes to certain extracellular signaling peptides (whether hormones, growth factors, DNA-binding proteins or enzymes) a role in both intracellular biology and extracellular signaling, can contribute to a more general understanding of angiogenesis. Intracrine factors participate in angiogenesis in the following ways: (1) they can act within the cells that synthesized them (type I intracrine action), (2) they can be secreted and then taken up by their cell of synthesis to act intracellularly (type II intracrine action ), or (3) they can be secreted and internalized by a distant target cell (type III intracrine action). The parallels between the intracrine growth factor mechanisms cancer cells employ in stimulating their own growth and the mechanisms operative in endothelial cell proliferation during angiogenesis ("intracrine reciprocity") are discussed. Collectively, these explorations lead to testable hypotheses regarding the regulation of normal and pathological angiogenesis, and point to similarities between tumor-induced angiogenesis and tissue differentiation.

Nuclear accumulation of the AT1 receptor in a rat vascular smooth muscle cell line: effects upon signal transduction and cellular proliferation

The objective of the study was to identify the functional outcome of intracellular versus extracellular angiotensin II-AT(1) receptor interactions in vascular cells. Rat vascular smooth muscle cell line A10 was transfected, independently and concurrently, with plasmids encoding fluorescent fusion proteins of rat angiotensin II (pECFP/AII, encodes AII fused downstream of enhanced cyan fluorescent protein) and the rat AT(1a) receptor (pAT(1)R/EYFP, encodes the rat AT(1a) receptor fused upstream of enhanced yellow fluorescent protein). The AII fluorescent fusion protein possesses no secretory signal peptide and deconvolution microscopy established that is maintained within these cells predominantly in the nucleus. AT(1)R/EYFP was absent from the nucleus when expressed exclusively or in untreated cells but accumulated in the nucleus following exogenous AII treatment or when co-expressed with ECFP/AII. Furthermore, expression of ECFP/AII stimulated proliferation of A10 vascular smooth muscle cells (VSMCs) 1.6-fold (P < 0.05). Transfection of a control, pECFP/AII(C) (which encodes a scrambled AII peptide fused to ECFP) had no growth effect. In light of the intracellular growth effects of ECFP/AII, we sought to elucidate the underlying signaling pathways. We found that extracellular AII treatment of A10 cells activated cAMP response element-binding protein (CREB) as determined by one-hybrid assays and immunoblots. Expression of intracellular ECFP/AII similarly activated CREB. However, intracellular and extracellular AII activated CREB through different phosphorylation pathways. Exogenous AII treatment of A10 cells activated p38MAPK and ERK1/2 phosphorylation as determined by Western blot analyses and one-hybrid assays. The p38MAPK inhibitor, SB203580, and the ERK kinase inhibitor, PD98059 each partially inhibited exogenous AII-conferred CREB activation confirming that p38MAPK and ERK1/2 mediate CREB phosphorylation in this system. In contrast, expression of ECFP/AII (intracellular AII) in A10 VSMCs activated p38MAPK but not ERK1/2; inhibition of p38MAPK by SB203580 inhibited intracellular AII-induced CREB phosphorylation. In summary, extracellular AII stimulates at least one pathway common to intracellular AII. This common pathway, in the case of exogenous AII, likely reflects intracellular signaling following internalization of receptor-ligand complex. Extracellular AII also stimulates a unique pathway, apparently reflecting interaction with plasma membrane-associated AT(1)R.

The role of research in the modern medical center: the ochsner clinic foundation perspective

American research universities and medical centers have made dramatic contributions to the care of the sick and to our understanding of disease. Their research is the cornerstone upon which modern medicine has been built. Today, changes in the societal context in which research is conducted are placing great strains on academic medical centers while advances in science present them with great opportunities. Here these issues are explored using the experience of the Ochsner Clinic Foundation as a point of reference.