Changes in biomarkers and 24 hours blood pressure in hypertensive African Americans with the metabolic syndrome: comparison of amlodipine/olmesartan versus hydrochlorothiazide/losartan.

We evaluated the efficacy of amlodipine and olmesartan (A/O; Azor) versus losartan and hydrochlorothiazide (L/H; Hyzaar), on changes in serum and urine biomarkers of inflammation and oxidation, neutrophil reactive oxygen species generation, and changes in systolic blood pressure (BP), diastolic BP, and heart rate as measured with 24 hours ambulatory BP monitoring in a high-risk, hypertensive African-American population with the metabolic syndrome. Sixty-six African-American subjects with Stage 1 and 2 hypertension and characteristics of the metabolic syndrome were treated in open-label, active comparator fashion for 20 weeks. After 14 weeks of therapy, treatment with A/O had a significant effect on reducing the production of reactive oxygen series, plasminogen activator inhibitor-1, F2 isoprostane, myeloperoxidase, and homeostasis model assessment for insulin resistance while L/H treatment only significantly lowered levels of plasminogen activator inhibitor-1 and homeostasis model assessment for insulin resistance. Treatment with A/O showed a trend of a more immediate and sustained systolic and diastolic BP-lowering, as well as night time BP reduction. In addition to a trend toward lower blood pressure, treatment with A/O in comparison with L/H has superior efficacy in reducing reactive oxygen species generation and production of inflammatory and oxidative biomarkers in a hypertensive African-American population with features of the metabolic syndrome.

Changes in Central Aortic Pressure, Endothelial Function and Biomarkers in Hypertensive African-Americans with the Cardiometabolic Syndrome: Comparison of Amlodipine/Olmesartan versus Hydrochlorothiazide/Losartan.

Sixty-six self-identified African-American subjects with stage 1 and 2 hypertension and characteristics of the cardiometabolic syndrome were treated with amlodipine/olmesartan (A/O) versus losartan/hydrochlorothiazide (L/H) for 20 weeks in an open-label, active comparator fashion. Subjects not meeting a blood pressure (BP) value of <125/75 mm Hg on either regimen at week 14 were placed on additional or alternative therapy. After 20 weeks of therapy, systolic BP was reduced by 34.6 ± 4.2 mm Hg in the A/O group and by 27.0 ± 4.1 mm Hg in the L/H group (p = 0.012 A/O vs. L/H). Diastolic BP was reduced by 16.9 ± 2.0 mm Hg in the A/O group and by 12.3 ± 2.0 mm Hg in the L/H group (p = 0.022 A/O vs. L/H). There was a substantial increase in endothelial function of 44 and 103% in the L/H and A/O groups, respectively (p < 0.005 A/O vs. L/H). Central aorta augmentation pressure was significantly reduced by 42% with the A/O treatment, and a smaller, significant reduction of 28% was observed with the L/H treatment (p = 0.034 A/O vs. L/H). There was a reduction in sIL-6 levels of 20 and 33%, a reduction in serum leptin levels of 22 and 40%, and an increase in serum adiponectin of 19 and 46% in the L/H and A/O groups, respectively (p < 0.005 A/O vs. L/H for each biomarker). Treatment with A/O after 14 weeks reduced pulse wave velocity by 22% (p = 0.011 time comparison), whereas L/H treatment had no significant effect. Our findings suggest that, in addition to effective BP reduction, A/O differentially regulates markers of inflammation and obesity, thereby potentially providing greater vascular protection.

Vascular effects of nebivolol added to hydrochlorothiazide in African Americans with hypertension and echocardiographic evidence of diastolic dysfunction: the NASAA study.

BACKGROUND: African Americans have greater risk of cardiovascular events than comparator populations of white European origin. A potential reason for this is reduced nitric oxide bioavailability in African Americans, resulting in increased prevalence of factors that contribute to ventricular dysfunction. We investigated the effects of nebivolol with the diuretic hydrochlorothiazide (HCTZ) in hypertensive African Americans with echocardiographic evidence of diastolic dysfunction. METHODS: A total of 42 African American patients were assigned to nebivolol and HCTZ in an open-label fashion for a 24-week period. Changes in blood pressure (BP), echocardiographic parameters, and success in attaining target BP were determined. As an indirect determinant of endothelial function, serum total nitric oxide (NOx) levels and asymmetric dimethyl arginine (ADMA) levels were performed at baseline and after the treatment period. RESULTS: The systolic BP decreased from 150 ± 13 to 136 ± 16 mm Hg (P < .005). Diastolic BP decreased from 94 ± 13 to 84 ± 9 mm Hg (P = .008). Of the patients that completed the study, 77% achieved a combined target BP of systolic BP <140 mm Hg and a diastolic BP <90 mm Hg. Serum NOx increased by 41% and 39% in patients that were treated with 10 mg and 20 mg daily nebivolol, respectively. The ADMA levels decreased by 44% following treatment. The change in systolic BP was strongly correlated to the change in ADMA (r = .54; P = .024). Furthermore, in comparison to a group of age-matched patients controlled with diuretic therapy only, the ADMA levels were significantly lower in the nebivolol posttreatment group (controlled BP with diuretic: 0.32 ± 0.07µmol/L; nebivolol posttreatment: 0.24 ± 0.06 µmol/L; P < .05). CONCLUSION: Reduced BP with nebivolol in hypertensive African Americans and echocardiographic evidence of diastolic dysfunction correlates with improved endothelial function. Furthermore, improvement in endothelial function and increased nitric oxide bioavailability suggests a potential mechanism of efficacy of nebivolol in these patients.

The impact of lipoic acid on endothelial function and proteinuria in quinapril-treated diabetic patients with stage I hypertension: results from the QUALITY study.

BACKGROUND: We sought to determine whether a combination of angiotensin-converting enzyme inhibitors (ACEIs) and the nutraceutical α-lipoic acid (ALA) regulates blood pressure, endothelial function, and proteinuria in diabetic patients with Stage I hypertension. METHODS: A total of 40 diabetic patients with Stage I hypertension were treated in a crossover double-blinded manner. Patients were administered quinapril ([QUI] 40 mg/d) for 8 weeks or QUI + ALA (600 mg/d) for 8 weeks. Measurements included blood pressure, 24-hour collection of urinary albumin, and endothelial-dependent flow-mediated dilation (FMD). RESULTS: There was a change of metabolic parameters in both study groups after 8 weeks of therapy. In comparison to baseline, the 24-hour urinary albumin significantly decreased by 30% in the QUI group (P = .018, time comparison) and 53% in QUI + ALA group (P < .005, time and group comparison). Also, when compared with baseline, FMD significantly increased by 58% in QUI group (P < .005, time comparison) and by 116% in QUI + ALA group (P < .005, time and group comparison). Systolic and diastolic blood pressure reduced significantly by 10% with QUI treatment. There was no further blood pressure reduction when patients were administered both QUI and ALA. CONCLUSIONS: In diabetic patients with hypertension, QUI reduces blood pressure, proteinuria, and improves endothelial function. Moreover, this effect is strongly potentiated with a combination of QUI and ALA. These results may attenuate the progression of vascular pathophysiology seen in patients with a combination of diabetes and hypertension.

Modulation of leptin levels by oxidized linoleic acid: a connection to atherosclerosis?

The objective of the study was to determine the effects of oxidized linoleic acid (Ox-LA) on plasma leptin and to determine the relationship between plasma leptin levels and atherosclerosis in animals treated with Ox-LA. Low-density lipoprotein (LDL) receptor knockout (LDL r(-/-)) mice were fed a high fat diet with or without Ox-LA for 11 weeks. Plasma leptin levels in the high fat group consuming Ox-LA were significantly higher (14,052 ± 601 pg/mL vs. 10,950 ± 541 pg/mL; P < .01) compared to the group receiving the high fat diet alone. There was a highly significant correlation between the plasma leptin levels and aortic atherosclerotic lesions. From this we conclude that chronic exposure to dietary Ox-LA increases the plasma levels of leptin in LDL r(-/-) mice on a high fat diet. Considering our previous finding that dietary Ox-LA increased atherosclerosis, the current findings emphasize the need to reduce dietary intake of oxidized fat.

Raising HDL cholesterol in women.

High-density lipoprotein cholesterol (HDL-C) concentration is essential in the determination of coronary heart disease (CHD) risk in women. This is especially true in the postmenopausal state, where lipid profiles and CHD risk mimic that of age-matched men. Thus, interventions designed to reduce CHD risk by raising HDL-C levels may have particular significance during the transition to menopause. This review discusses HDL-C-raising therapies and the role of HDL in the primary prevention of CHD in women. Lifestyle-based interventions such as dietary change, aerobic exercise regimens, and smoking cessation are initial steps that are effective in raising HDL-C, and available data suggest women respond similarly to men with these interventions. When combined with pharmacotherapy, the effects of these lifestyle alterations are further amplified. Though studies demonstrating gender-specific differences in therapy are limited, niacin continues to be the most effective agent in raising HDL-C levels, especially when used in combination with fibrate or statin therapy. Emerging treatments such as HDL mimetic therapy show much promise in further raising HDL-C levels and improving cardiovascular outcomes.

Nebivolol in high-risk, obese African Americans with stage 1 hypertension: effects on blood pressure, vascular compliance, and endothelial function.

The authors sought to determine whether nebivolol treatment results in changes in blood pressure (BP), nitric oxide bioavailability, and vascular function in obese African Americans with recently diagnosed stage 1 hypertension. Forty-three obese, hypertensive African Americans (mean BP: systolic, 148.8+/-14.3 mm Hg; diastolic, 90.4+/-8.2 mm Hg) were treated with nebivolol (5-10 mg/d) for 8 weeks. Primary outcomes were change in systolic and diastolic BP and efficacy in reaching normotensive BP. Mean systolic BP decreased by 9.2+/-14 mm Hg (P<.005) and diastolic BP decreased 6.8+/-9 mm Hg (P<.005) with 8 weeks of therapy. Significant improvements were seen in arterial compliance with nebivolol treatment as measured by aortic augmentation index (P<.005) and time to wave reflection (P=.013). Nebivolol treatment improved endothelial function as measured by flow-mediated dilation (P<.005). Levels of erythrocyte cellular superoxide dismutase increased with nebivolol, indirectly suggesting increased bioavailability of nitric oxide (P<.005). Monotherapy with nebivolol in obese, hypertensive African Americans results in significant systolic and diastolic BP reduction by mechanisms that include improved vascular function and compliance.

Metabolic syndrome and cardiovascular disease in South Asians.

This review discusses the prevalence of metabolic syndrome and cardiovascular disease in the South Asian population, evaluates conventional and emerging risk factors, and reinforces the need for ethnic-specific redefinition of guidelines used to diagnose metabolic syndrome. We reviewed recent and past literature using Ovid Medline and PubMed databases. South Asians represent one of the largest and fastest growing ethnic groups in the world. With this growth, a dramatic rise in the rates of acute myocardial infarction and diabetes is being seen in this population. Potential etiologies for this phenomenon include dietary westernization, poor lifestyle measures, adverse body fat patterning, and genetics. While traditional risk factors for diabetes and cardiovascular disease should not be overlooked, early metabolic syndrome has now been shown in the South Asian pediatric population, suggesting that "metabolic programming" and perinatal influences may likely play a substantial role. Health care practitioners must be aware that current guidelines used to identify individuals with metabolic syndrome are underestimating South Asian individuals at risk. New ethnic-specific guidelines and prevention strategies are discussed in this review and should be applied by clinicians to their South Asian patients.

Usefulness of elevations in serum choline and free F2)-isoprostane to predict 30-day cardiovascular outcomes in patients with acute coronary syndrome.

Our objectives were to evaluate the prognostic value of several biomarkers in patients with acute coronary syndrome (ACS) through an evaluation of the 30-day clinical outcomes. Multiple biomarkers have emerged as potentially useful in risk stratification of ACS. Specifically, markers of vascular inflammation and oxidative stress might be helpful in the determination of clinical outcomes. We evaluated patients presenting with chest pain. ACS was defined by symptoms of cardiac ischemia plus electrocardiographic changes or positive troponin I. Levels of serum troponin I, high sensitivity C-reactive protein, serum choline, and free F(2)-isoprostane were obtained. Patients were followed up for 30 days (n = 108) with determination of nonfatal myocardial infarction, congestive heart failure, need for revascularization, and death. Of the 108 patients, 26 had a cardiac event. Free F(2)-isoprostane and choline levels (but not high-sensitivity C-reactive protein levels) predicted 30-day cardiac events. To determine the value of choline and F(2)-isoprostane levels in predicting 30-day cardiac events, receiver operating curves were generated. The optimal cutoff point of these markers was a serum F(2)-isoprostane level of 124.5 pg/ml (r = 0.82) and a serum choline level of 30.5 mumol/L (r = 0.76). F(2)-isoprostane and choline had a positive predictive value of 57% and 44% and a negative predictive value of 90% and 89%, respectively. In conclusion, serum choline and free F(2)-isoprostane are predictors of cardiac events in ACS. A model that includes an array of biomarkers, including troponin, choline, and free F(2)-isoprostane, might be useful in predicting patients at greater risk of future events in ACS.

The role of quinapril in the presence of a weight loss regimen: endothelial function and markers of obesity in patients with the metabolic syndrome.

Forty-four patients with the metabolic syndrome were placed on a reduced-calorie and reduced-fat regimen to lose weight throughout a 56-week period. The patients were treated in a crossover fashion with placebo and the angiotensin-converting enzyme inhibitor quinapril for 24 weeks each. The study measured endothelial-dependent flow-mediated dilation plus serum obesity markers of adiponectin and leptin. Metabolic parameters improved after 56 weeks. Serum adiponectin level increased by 18% (P<.05 vs baseline) and serum leptin level decreased by 16% with placebo (P<.05 vs baseline). These findings were potentiated further in the quinapril group. In comparison with baseline, flow-mediated dilation was increased by 13% in the placebo group (P=.055 vs baseline) and by 43% in the quinapril group (P<.001 vs baseline and placebo). These findings suggest that weight loss therapy improves endothelial function and markers of obesity. These results are potentiated with quinapril and are independent of changes in metabolic parameters.

Irbesartan and lipoic acid improve endothelial function and reduce markers of inflammation in the metabolic syndrome: results of the Irbesartan and Lipoic Acid in Endothelial Dysfunction (ISLAND) study.

BACKGROUND: The metabolic syndrome is associated with increased angiotensin II activity, induction of a proinflammatory and oxidative state, and endothelial dysfunction. We evaluated the ability of irbesartan, an angiotensin receptor blocker, and lipoic acid, an antioxidant, to affect endothelial function and inflammation in patients with the metabolic syndrome. METHODS AND RESULTS: We randomized 58 subjects with the metabolic syndrome in a double-blinded manner to irbesartan 150 mg/d (n=14), lipoic acid 300 mg/d (n=15), both irbesartan and lipoic acid (n=15), or matching placebo (n=14) for 4 weeks. Endothelium-dependent and -independent flow-mediated vasodilation was determined under standard conditions. Plasma levels of interleukin-6, plasminogen activator-1, and 8-isoprostane were measured. After 4 weeks of therapy, endothelium-dependent flow-mediated vasodilation of the brachial artery was increased by 67%, 44%, and 75% in the irbesartan, lipoic acid, and irbesartan plus lipoic acid groups, respectively, compared with the placebo group. Treatment with irbesartan and/or lipoic acid was associated with statistically significant reductions in plasma levels of interleukin-6 and plasminogen activator-1. In addition, treatment with irbesartan or irbesartan plus lipoic acid decreased 8-isoprostane levels. No significant changes in blood pressure were noted in any of the study groups. CONCLUSIONS: Administration of irbesartan and/or lipoic acid to patients with the metabolic syndrome improves endothelial function and reduces proinflammatory markers, factors that are implicated in the pathogenesis of atherosclerosis.

Exercise reduces preexisting atherosclerotic lesions in LDL receptor knock out mice.

Exercise is recommended both as a prophylactic and also as a therapeutic approach for patients with established coronary artery disease. In this study, we investigated the effect of a normal chow diet, with or without exercise in LDL r-/- mice with preexisting atherosclerotic lesions. A total of 28 LDL r-/- mice (LDL receptor knock out mice, 4-6 weeks old) were fed a high fat, high cholesterol diet (inductive phase). At the end of the 3 months, eight mice were sacrificed, and plasma autoantibodies to oxidatively modified proteins, cholesterol levels, and surface area of the lesions in the aorta were determined. The remaining mice were divided into two groups, and placed on a normal chow diet alone, or normal chow and exercise for three more months (regressive phase). Plasma autoantibodies to oxidatively modified proteins and cholesterol were measured along with the lesion size. Compared to the group of animals at the end of the inductive phase, both the groups of animals in the regressive phase had very low levels of plasma cholesterol and autoantibodies, and almost a 50% reduction in the aortic lesion area. The group that was exercised had the lowest levels of autoantibodies and aortic lesions as compared to the group without the exercise. However, the plasma cholesterol levels were comparable in both groups. This study demonstrates that reduction of preexisting atherosclerotic lesions is accelerated dramatically by exercise in LDL r-/- mice.

Oxidized fatty acids promote atherosclerosis only in the presence of dietary cholesterol in low-density lipoprotein receptor knockout mice.

Studies suggest that heated oils contribute to the presence of oxidized components in the circulating lipoproteins and to the development of atherosclerosis in animals. We evaluated the effects of 11-13 wk of consumption of a well defined dietary oxidized fatty acid, 13-hydroxylinoleic acid (13-HODE) (8 mg), on atherosclerotic lesion development and plasma cholesterol concentrations in mice fed diets varying in fat and cholesterol contents. LDL receptor knockout mice were used in two feeding studies. In study 1, oxidized fatty acid consumption in association with a high fat diet increased aortic lesion areas by >100% (P < 0.05). Surprisingly, oxidized fatty acid intake also tended to increase plasma total cholesterol (P = 0.12) and LDL cholesterol (P < 0.05) as well as oxidative stress as measured by higher levels of autoantibodies to oxidatively modified proteins (P = 0.008). However, in mice fed a nonpurified diet, oxidized fatty acids were not atherogenic and may even have been beneficial, as indicated by a lower plasma triglyceride (TG) concentration (P < 0.05). In study 2, mice were fed either a high fat, medium fat or low fat diet to evaluate whether the increase in aortic lesions due to oxidized fatty acid consumption in study 1 was a result of the associated higher plasma total and LDL cholesterol concentrations. In study 2, 13-HODE-treated mice in the medium and low fat diet groups but not those fed the high fat diet had larger atherosclerotic lesions (P < 0.05). Additionally, plasma total and LDL cholesterol as well as TG were not affected by HODE treatment. However, the total cholesterol:HDL cholesterol ratio was higher in treated mice (P < 0.05) and HDL cholesterol was lower in HODE-treated mice that were fed the low fat diet (P < 0.05). Our results suggest that, in mice fed cholesterol, oxidized fatty acids may be atherogenic, both in terms of increased oxidative stress (as seen in study 1) and by increasing the atherogenicity of the plasma cholesterol profile.

Enhanced solubilization and intestinal absorption of cholesterol by oxidized linoleic acid.

Solubilization of cholesterol in the intestinal lumen by bile acids and the subsequent formation of mixed micelles is an important step in the absorption of cholesterol. We propose that oxidized fatty acids (ox-FA) may mimic bile acids and form mixed micelles with cholesterol much more efficiently, as compared with unoxidized fatty acids, thereby increasing there absorption. In an in vitro assay at concentrations of 1, 5, and 10 mM, oxidized linoleic acid (ox-18:2) increased the solubilization of cholesterol (3.06, 8.16, and 15.46 nmol/ml) in a dose dependent manner compared with a 10 mM unoxidized linoleic acid (unox-18:2 at 0.97 nmol/ml). The uptake of cholesterol solubilized in the presence of ox-18:2 by Caco-2 cells and everted rat intestinal sacs was greater (1.78 and 1.95 nmol/ml respectively) as compared with the cholesterol solubilized in the presence of unox-18:2 (0.29 and 0.61 nmol/ml; P = 0.05). In addition, when LDL receptor deficient mice were fed a high fat diet along with ox-18:2 their plasma cholesterol levels were greater than animals fed the high fat diet alone (1290 mg/dl vs. 1549 mg/dl, P = 0.013). From these results, we suggest that ox-FA, by enhancing the solubilization of luminal cholesterol, increases the uptake of cholesterol that might lead to hypercholesterolemia and atherosclerosis.