Carotid Baroreceptor Magnetic Activation and Beat-to-Beat Blood Pressure Variability, Implications to Treat Abrupt Blood Pressure Elevation in Labile Hypertension.

Mounting evidence suggests enhanced blood pressure (BP) variability (BPV) independent role in cardiovascular (CV) damage. The goal was to estimate the effect of the carotid baroreceptor (CB) magnetic stimulation on sudden high BP elevation. Mean femoral arterial BP (MAP), heart rate (HR), baroreflex sensitivity (BRS), and ear lobe skin microcirculatory blood flow, by microphotoelectric plethysmography (MPPG), were simultaneously recorded in conscious rabbits sedated by pentobarbital intravenous (i.v.) infusion (5 mg/kg/h) after 40 min CB exposure to 350 mT static magnetic field (SMF), by Nd2 -Fe14 -B magnets (n = 14), or sham magnets exposure (n = 14). BRS was assessed from HR and MAP responses to abrupt hypotension induced by i.v. bolus injections of nitroprusside (Ni) and abrupt MAP elevation (MAPAE ) by i.v. bolus of phenylephrine (Ph). Beat-to-beat BPV was estimated by MAP standard deviation. SMF CB exposure significantly increased BRSNi (74.5 ± 17.8%, P < 0.001) and microcirculation (23.8% ± 11.0%, P = 0.039); decreased MAP (-5.7 ± 1.7%, P < 0.014) and phenylephrine-induced MAPAE (-19.1%, P = 0.043). MAPAE positively correlated with resting MAP (r = 0.342, P = 0.0383) and MAP SD (r = 0.383, P = 0.0194), and inversely with BRSPh (r = -0.47, P = 0.0156). SMF CB exposure enhanced the nitroprusside, which acts by releasing nitric oxide (NO), vasodilatory effect. This indicates arterial baroreflex to improve vessel sensitivity to NO, which is a new physiology with BP buffering effect. A positive correlation of MAP SD to phenylephrine BP ramps suggests a causal relationship and BPV prognostic significance to forecast abrupt BP elevation. Mechano/baroreceptor magneto-sensing property proposed to be the basic physiology by which SMFs boost CV autonomic regulation with potential implementation in high CV risk labile arterial hypertensive disease. © 2022 Bioelectromagnetics Society.

Tonic aortic depressor nerve stimulation does not impede baroreflex dynamic characteristics concomitantly mediated by the stimulated nerve.

Although electrical activation of the carotid sinus baroreflex (baroreflex activation therapy) is being explored as a device therapy for resistant hypertension, possible effects on baroreflex dynamic characteristics of interaction between electrical stimulation and pressure inputs are not fully elucidated. To examine whether the electrical stimulation of the baroreceptor afferent nerve impedes normal short-term arterial pressure (AP) regulation mediated by the stimulated nerve, we electrically stimulated the right aortic depressor nerve (ADN) while estimating the baroreflex dynamic characteristics by imposing pressure inputs to the isolated baroreceptor region of the right ADN in nine anesthetized rats. A Gaussian white noise signal with a mean of 120 mmHg and standard deviation of 20 mmHg was used for the pressure perturbation. A tonic ADN stimulation (2 or 5 Hz, 10 V, 0.1-ms pulse width) decreased mean sympathetic nerve activity (367.0 ± 70.9 vs. 247.3 ± 47.2 arbitrary units, P < 0.01) and mean AP (98.4 ± 7.8 vs. 89.2 ± 4.5 mmHg, P < 0.01) during dynamic pressure perturbation. The ADN stimulation did not affect the slope of dynamic gain in the neural arc transfer function from pressure perturbation to sympathetic nerve activity (16.9 ± 1.0 vs. 14.7 ± 1.6 dB/decade, not significant). These results indicate that electrical stimulation of the baroreceptor afferent nerve does not significantly impede the dynamic characteristics of the arterial baroreflex concomitantly mediated by the stimulated nerve. Short-term AP regulation by the arterial baroreflex may be preserved during the baroreflex activation therapy.

Baroreflex Activation Therapy in Heart Failure With Reduced Ejection Fraction: Available Data and Future Perspective.

Progression of heart failure with reduced ejection fraction (HFrEF) is promoted by sympathovagal imbalance. Baroreflex activation therapy, i.e., electrical stimulation of baroreceptors at the carotid sinus, can restore sympathovagal balance. Large animal studies of baroreflex activation therapy revealed improvements in cardiac function, susceptibility to ventricular arrhythmias, and a survival benefit as compared to untreated controls. Recently, the first randomized and controlled trial of optimal medical and device therapy alone or plus baroreflex activation therapy in patients suffering from HFrEF was published. It demonstrated a reasonable safety profile in this severely ill patient population. Moreover, the study found significant improvements in New York Heart Association class, quality of life, 6-min walk distance, and NT-proBNP levels. This review provides an overview on baroreflex activation therapy for the treatment of HFrEF-from the concept and preclinical findings to most recent clinical data and upcoming trials.

Novel Interventional Therapies to Modulate the Autonomic Tone in Heart Failure.

Heart failure (HF) represents a significant and expanding public health burden associated with increasing prevalence and exponential growth in related health care costs. Contemporary advances in both pharmacological and nonpharmacological therapies have often been restricted in application and benefit. Given the critical role of the autonomic nervous system (ANS) in maintaining cardiovascular homeostasis in the failing heart, there has been increasing interest in the role of ANS modulation as a therapeutic modality in HF. In this review, we highlight the anatomy of the ANS and its role in the pathophysiology of HF, as well as metrics of its assessment. Given the limitations associated with pharmacological ANS modulation, including lack of specificity and medication intolerance, we focus in this review on contemporary nonpharmacological ANS modulation therapies. For each therapy-vagal nerve stimulation, carotid baroreceptor stimulation, spinal cord stimulation, and renal denervation-we review the rationale for modulation, pre-clinical and clinical assessments, as well as procedural considerations and limitations. We conclude by commenting on novel technologies and strategies for ANS modulation on the horizon.

[Resistant hypertension and carotid baroreceptors stimulation]. / HTA résistante et barostimulation carotidienne.

Resistant hypertension remains a frequent and difficult situation; its management has been recently clarified by guidelines from the French Society of Hypertension. Baroreceptor stimulation (BAROSTIM) is an emerging technique aimed at decreasing blood pressure in resistant hypertension. BAROSTIM interferes with baroreflex loop by stimulating baroreceptors and afferences of the baroreflex. There is only one randomized control trial with this technique which showed a modest but apparently durable blood pressure reduction. More evidences are required to refine the place of BAROSTIM, particularly with new devices. Together with renal denervation, BAROSTIM belongs to a new family of interventional techniques which should be considered as potential add-on therapies while optimal medical therapy remains the cornerstone of hypertension management.

New approaches in the treatment of hypertension.

Hypertension is the most common modifiable risk factor for cardiovascular disease and death, and lowering blood pressure with antihypertensive drugs reduces target organ damage and prevents cardiovascular disease outcomes. Despite a plethora of available treatment options, a substantial portion of the hypertensive population has uncontrolled blood pressure. The unmet need of controlling blood pressure in this population may be addressed, in part, by developing new drugs and devices/procedures to treat hypertension and its comorbidities. In this Compendium Review, we discuss new drugs and interventional treatments that are undergoing preclinical or clinical testing for hypertension treatment. New drug classes, eg, inhibitors of vasopeptidases, aldosterone synthase and soluble epoxide hydrolase, agonists of natriuretic peptide A and vasoactive intestinal peptide receptor 2, and a novel mineralocorticoid receptor antagonist are in phase II/III of development, while inhibitors of aminopeptidase A, dopamine ß-hydroxylase, and the intestinal Na(+)/H(+) exchanger 3, agonists of components of the angiotensin-converting enzyme 2/angiotensin(1-7)/Mas receptor axis and vaccines directed toward angiotensin II and its type 1 receptor are in phase I or preclinical development. The two main interventional approaches, transcatheter renal denervation and baroreflex activation therapy, are used in clinical practice for severe treatment resistant hypertension in some countries. Renal denervation is also being evaluated for treatment of various comorbidities, eg, chronic heart failure, cardiac arrhythmias and chronic renal failure. Novel interventional approaches in early development include carotid body ablation and arteriovenous fistula placement. Importantly, none of these novel drug or device treatments has been shown to prevent cardiovascular disease outcomes or death in hypertensive patients.

Carotid Baroreceptor Stimulation in Resistant Hypertension and Heart Failure.

A significant number of hypertensive subjects fail to achieve adequate blood pressure control despite adherence to maximal doses of several antihypertensive drugs. In the same way although medical and device therapies continue to improve the clinical course of heart failure patients, morbidity, mortality and healthcare costs remain high. Electrical stimulation of the carotid sinus is a new interesting approach for the treatment of resistant hypertension and heart failure. The purpose of this paper is to overview the argument starting from physiological background and evaluating the clinical results obtained with this approach in these pathophysiological conditions.

Bilateral or unilateral stimulation for baroreflex activation therapy.

UNLABELLED: Previous trials have shown that in patients with resistant hypertension device-based baroreflex activation therapy (BAT) can substantially reduce blood pressure. However, the fact that electrodes had to be implanted bilaterally may be a drawback for further development of the technique. In this study, we explored whether unilateral stimulation would produce comparable results as bilateral stimulation. In the Pivotal trial, treatment-resistant hypertensive patients were randomized to receive either immediate BAT or deferred BAT, that is, 6 months after implantation. We adjusted stimulation parameters individually so as to provide optimal baroreflex activation. Unilateral stimulation was applied unless bilateral stimulation resulted in a greater blood pressure reduction. When we pooled the 6-month data for the group with immediate BAT and the 12-month data for the group with deferred BAT, a total of 215 patients had been stimulated on one side only (127 at the right side and 88 at the left side), whereas 80 patients had been stimulated bilaterally. Although blood pressure and heart rate did not differ between the 2 groups at baseline, all these variables were significantly lower in the unilateral than in the bilateral group after the 6-month period. When we compared the effect of right-sided stimulation with those of either left-sided or bilateral stimulation, we found right-sided stimulation to be the most effective. We conclude that unilateral and in particular right-sided BAT has a more profound effect on blood pressure than bilateral or left-sided BAT. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00442286.

[New invasive therapies for management of resistant hypertension]. / Nouveaux traitements invasifs de l'hypertension artérielle résistante.

The failure of pharmacological approaches to treat resistant hypertension has stimulated interest in invasive device-based treatments. New catheter systems using radiofrequency or ultrasound energy have been developed, allowing a percutaneous endovascular approach to renal denervation for patients with resistant hypertension. To date, this technique has been evaluated only in a few open-label trials including small numbers and the available evidence suggests a favorable blood pressure-lowering effect in the short-term and a low incidence of immediate complications. All studies published to date have several limitations due to their open-label design. Carotid baroreceptor stimulation requires surgical implantation of electrodes connected to a stimulator. Preliminary results show a positive effect on blood pressure with a complication rate similar to the implantation of a pacemaker. In this context, there are arguments against an uncontrolled use of these procedures in routine practice: an unknown benefit/risk ratio, a variable blood pressure response, absence of cost-effectiveness evaluation. The indications of these procedures should follow the 2013 European Society of Hypertension guidelines. A strict follow-up of patients remains necessary at best by including them in clinical trials or international registries.

Changes in spasticity, widespread pressure pain sensitivity, and baropodometry after the application of dry needling in patients who have had a stroke: a randomized controlled trial.

OBJECTIVE: The purpose of this study was to determine the effects of deep dry needling (DDN) on spasticity, pressure sensitivity, and plantar pressure in patients who have had stroke. METHODS: A randomized controlled trial was conducted. Thirty-four patients who previously had a stroke were randomly assigned either an experimental group that received a single session of DDN over the gastrocnemius and tibialis anterior muscles on the spastic leg or a control group that received no intervention. Spasticity (evaluated with the Ashworth Scale); pressure pain thresholds over the deltoid muscle, second metacarpal, and tibialis anterior muscle; and plantar pressure (baropodometry) were collected by a blinded assessor before and 10 minutes after intervention. RESULTS: A greater number of individuals receiving DDN exhibited decreased spasticity after the intervention (P < .001). The analysis of covariance showed that pressure pain thresholds increased bilaterally in patients receiving DDN compared with those who did not receive the intervention (P < .001). The analysis of covariance also found that patients receiving DDN experienced bilateral increases of support surface in the forefoot, unilateral increase of the support surface in the rear foot of the treated (affected) side, and bilateral decreases in mean pressure (all, P < .02) as compared with those who did not receive DDN. CONCLUSIONS: Our results suggest that a single session of DDN decreases spasticity and widespread pressure sensitivity in individuals with poststroke spasticity. Deep dry needling also induced changes in plantar pressure by increasing the support surface and decreasing the mean pressure.

Baroreceptor afferents modulate brain excitation and influence susceptibility to toxic effects of hyperbaric oxygen.

Unexplained adjustments in baroreflex sensitivity occur in conjunction with exposures to potentially toxic levels of hyperbaric oxygen. To investigate this, we monitored central nervous system, autonomic and cardiovascular responses in conscious and anesthetized rats exposed to hyperbaric oxygen at 5 and 6 atmospheres absolute, respectively. We observed two contrasting phases associated with time-dependent alterations in the functional state of the arterial baroreflex. The first phase, which conferred protection against potentially neurotoxic doses of oxygen, was concurrent with an increase in baroreflex sensitivity and included decreases in cerebral blood flow, heart rate, cardiac output, and sympathetic drive. The second phase was characterized by baroreflex impairment, cerebral hyperemia, spiking on the electroencephalogram, increased sympathetic drive, parasympatholysis, and pulmonary injury. Complete arterial baroreceptor deafferentation abolished the initial protective response, whereas electrical stimulation of intact arterial baroreceptor afferents prolonged it. We concluded that increased afferent traffic attributable to arterial baroreflex activation delays the development of excessive central excitation and seizures. Baroreflex inactivation or impairment removes this protection, and seizures may follow. Finally, electrical stimulation of intact baroreceptor afferents extends the normal delay in seizure development. These findings reveal that the autonomic nervous system is a powerful determinant of susceptibility to sympathetic hyperactivation and seizures in hyperbaric oxygen and the ensuing neurogenic pulmonary injury.

Similarities and differences between renal sympathetic denervation and carotid baroreceptor stimulation.

The two novel approaches recently introduced for the treatment of resistant hypertension, i.e. carotid baroreceptor stimulation and renal denervation, share a number of similarities but are also characterized by important differences. The similarities include the evidence that both interventions have as common pathophysiological background the state of sympathetic overdrive characterizing essential hypertension. In addition both procedures 1) are invasive, 2) exert in the short-term period clearcut blood pressure lowering effects and 3) still face a number of open questions, particularly related to the long-term blood pressure lowering effects, impact on end-organ damage and on cardiovascular events. The differences include the fact that two procedures act on distinct targets that trigger sympathetic activation and consequently blood pressure increase. In addition, only in the case of carotid baroreceptor stimulation the blood pressure effects can be easily assessed immediately following the implantation. Finally, the economic costs, metabolic effects and impact on vagal modulation of heart rate are different between the two interventions. This paper will provide a comparison of the background, effects and outcome of renal denervation and carotid baroreceptor stimulation, stressing whenever possible the clinical implications of the main features of the two interventions.

The pathophysiological basis of carotid baroreceptor stimulation for the treatment of resistant hypertension.

The prevalence of resistant hypertension and existing limitations in antihypertensive drug therapy renders the interventional management of hypertension an attractive alternative. Carotid baroreceptors have been traditionally thought to be implicated only in short-term blood pressure regulation; however recent evidence suggests that the baroreceptors might play an important role even in the long-term blood pressure regulation. Electrical baroreflex stimulation appears safe and effective and might represent a useful adjunct to medical therapy in patients with resistant hypertension. This review endeavors to summarize the complex pathophysiology of blood pressure regulation, to describe the baroreflex circuit, its anatomy and physiology, to present previous data refuting a role for the baroreceptors in the long-term control of blood pressure and recent animal and human data suggesting an effective role of carotid baroreceptor activation in long-lasting blood pressure reduction. In this paper we attempt to critically evaluate existing information in this area and provide the scientific basis for carotid baroreceptor stimulation in the management of resistant hypertension.

Carotid baroreceptor stimulation: a promising approach for the management of resistant hypertension and heart failure.

Many difficult-to-treat clinical entities in the cardiovascular field are characterized by pronounced sympathetic overactivity, including resistant hypertension and heart failure, underlining the need to explore therapeutic options beyond pharmacotherapy. Autonomic modulation via carotid baroreceptor activation has already been evaluated in clinical trials for resistant hypertension, and relevant outcomes with regard to safety and efficacy of the technique are critically presented. The pathophysiological background of heart failure renders carotid baroreceptor stimulation a potential treatment candidate for the disease. Available data from animal models with heart failure point towards significant cardioprotective benefits of this innovative technique. Accordingly, the effects of baroreceptor activation treatment (BAT) on cardiac parameters of hypertensive patients are well-promising, setting the basis for upcoming clinical trials with baroreflex activation on patients with heart failure. However, as the potential therapeutic of BAT unfolds and new perspectives are highlighted, several concerns are raised that should be meticulously addressed before the wide application of this invasive procedure is set in the limelight.

Non-pharmacological modulation of the autonomic tone to treat heart failure.

The autonomic nervous system has a significant role in the pathophysiology and progression of heart failure. The absence of any recent breakthrough advances in the medical therapy of heart failure has led to the evolution of innovative non-pharmacological interventions that can favourably modulate the cardiac autonomic tone. Several new therapeutic modalities that may act at different levels of the autonomic nervous system are being investigated for their role in the treatment of heart failure. The current review examines the role of renal denervation, vagal nerve stimulators, carotid baroreceptors, and spinal cord stimulators in the treatment of heart failure.

The future of interventional management of hypertension: threats and opportunities.

In about 48% hypertensive patients in the United States, blood pressure remains higher than accepted treatment targets despite broad availability of effective pharmaceutical agents. Of these 48%, recent estimates define about 10-11% have treatment-resistant hypertension (TR-HTN). Compensatory changes in sympathetic nervous system function are an important component of HTN. Recent technical advances targeting the sympathetic activity of the carotid sinuses (Baroreflex Activation Therapy-BAT) and the renal sympathetic nerves (Renal Denervation Therapy-RDT) have renewed interest in invasive therapy for the treatment of drug-resistant hypertension. Encouraging results from the recent Rheos Pivotal and Symplicity HTN-2 trials on the safety and efficacy of BAT and RDT respectively, indicate that invasive approaches can safely reduce blood pressure in patients with resistant hypertension. The main goal of this article is to review the results of preclinical and clinical studies on the electric stimulation of the carotid sinus and the catheter-based renal denervation.

Resistant hypertension: baroreflex stimulation as a new tool.

Uncontrolled hypertension remains a significant public health challenge. In recent years, a new baroreflex stimulator has been used to treat these patients. Initial observations suggest that the electrical field stimulation of carotid baroreceptors acutely attenuates sympathetic activation of the vasculature, heart and kidney while augmenting cardiac vagal regulation. During the long-term treatment an average blood pressure (BP) drop of 30-40/15-25 mmHg was observed with a responder rate (>10 mmHg reduction in BP) of up to 80% after 1 year of treatment. Some of this effect can be explained by a 'placebo' effect as suggested by the double-blind Pivotal Trial. The complication rate with the first generation device was 20-30%. With a second generation device, these problems have been reduced to <10%. Even though additional data from controlled clinical trials will be required before more widespread use can be recommended, this treatment option is now approved in Europe for the treatment of severe resistant hypertension and is performed in selected centres with experienced vascular surgeons and hypertension specialists.

Bionic baroreceptor corrects postural hypotension in rats with impaired baroreceptor.

BACKGROUND: Impairment of the arterial baroreflex causes orthostatic hypotension. Arterial baroreceptor sensitivity degrades with age. Thus, an impaired baroreceptor plays a pivotal role in orthostatic hypotension in most elderly patients. There is no effective treatment for orthostatic hypotension. The aims of this investigation were to develop a bionic baroreceptor (BBR) and to verify whether it corrects postural hypotension. METHODS AND RESULTS: The BBR consists of a pressure sensor, a regulator, and a neurostimulator. In 35 Sprague-Dawley rats, we vascularly and neurally isolated the baroreceptor regions and attached electrodes to the aortic depressor nerve for stimulation. To mimic impaired baroreceptors, we maintained intracarotid sinus pressure at 60 mm Hg during activation of the BBR. Native baroreflex was reproduced by matching intracarotid sinus pressure to the instantaneous pulsatile aortic pressure. The encoding rule for translating intracarotid sinus pressure into stimulation of the aortic depressor nerve was identified by a white noise technique and applied to the regulator. The open-loop arterial pressure response to intracarotid sinus pressure (n=7) and upright tilt-induced changes in arterial pressure (n=7) were compared between native baroreceptor and BBR conditions. The intracarotid sinus pressure-arterial pressure relationships were comparable. Compared with the absence of baroreflex, the BBR corrected tilt-induced hypotension as effectively as under native baroreceptor conditions (native, -39±5 mm Hg; BBR, -41±5 mm Hg; absence, -63±5 mm Hg; P<0.05). CONCLUSIONS: The BBR restores the pressure buffering function. Although this research demonstrated feasibility of the BBR, further research is needed to verify its long-term effect and safety in larger animal models and humans.

Electrical stimulation of deep peroneal nerve mimicking acupuncture inhibits the pressor response via capsaicin-insensitive afferents in anesthetized rats.

OBJECTIVE: To assess the inhibitory modulation of blood pressure by stimulation of the deep peroneal nerve (DPN) and to determine the involvement of nociceptive fibers in the modulation. METHODS: All the animals were divided into six groups (A-F). The rats in groups A and B received no pretreatment. The rats in groups C and D received subcutaneous injection of capsaicin or control vehicle, respectively, near the DPN for 2 days. Those in groups E and F had the DPN exposed to capsaicin or control vehicle, respectively, for 20 min. Subsequently, pressor responses were induced by stimulation of paraventricular nucleus (PVN) either electrically (groups A and C C-F) or chemically via injection of glutamate (group B). After two stable pressor responses (baseline), all groups were subject to 5-min DPN stimulation followed by PVN stimulation for 10 s. Arterial blood pressure, heart rate, and electrocardiogram were recorded. The pressor response was calculated as the difference in the mean arterial pressure (MAP) before and after PVN stimulation, and changes from baseline in pressor response after DPN stimulation were compared between the groups. RESULTS: Increases of MAP of 22.88±2.18 mm Hg and 20.32±5.25 mm Hg were induced by electrical (group A) or chemical (group B) stimulation of the PVN, respectively. These pressor responses were inhibited by stimulation of the DPN, and the MAP was reduced to 12.00±2.10 mm Hg in group A (n=6, P<0.01) and 7.00±2.85 mm Hg in group B (n=6, P<0.01). Subcutaneous injection of capsaicin (125 mg/kg) near the DPN in group C (n=7) had no effect on the inhibitory effect of DPN stimulation compared with the group D (n=9), and neither did blockade of nociceptive fibers with capsaicin in group E (n=6) compared with group F (n=8). CONCLUSION: Stimulation of the DPN mimicking acupuncture has an inhibitory effect on the pressor response, and the effect is mediated by capsaicin-insensitive afferent fibers in the DPN.

Increased heart rate variability during nondirective meditation.

PURPOSE: Meditation practices are in use for relaxation and stress reduction. Some studies indicate beneficial cardiovascular health effects of meditation. The effects on the autonomous nervous system seem to vary among techniques. The purpose of the present study was to identify autonomic nerve activity changes during nondirective meditation. MATERIALS AND METHODS: Heart rate variability (HRV), blood pressure variability (BPV), and baroreflex sensitivity (BRS) were monitored in 27 middle-aged healthy participants of both genders, first during 20 min regular rest with eyes closed, thereafter practising Acem meditation for 20 min. Haemodynamic and autonomic data were collected continuously (beat-to-beat) and non-invasively. HRV and BPV parameters were estimated by power spectral analyses, computed by an autoregressive model. Spontaneous activity of baroreceptors were determined by the sequence method. Primary outcomes were changes in HRV, BPV, and BRS between rest and meditation. RESULTS: HRV increased in the low-frequency (LF) and high-frequency (HF) bands during meditation, compared with rest (p = 0.014, 0.013, respectively). Power spectral density of the RR-intervals increased as well (p = 0.012). LF/HF ratio decreased non-significantly, and a reduction of LF-BPV power was observed during meditation (p < 0.001). There was no significant difference in BRS. Respiration and heart rates remained unchanged. Blood pressure increased slightly during meditation. CONCLUSION: There is an increased parasympathetic and reduced sympathetic nerve activity and increased overall HRV, while practising the technique. Hence, nondirective meditation by the middle aged may contribute towards a reduction of cardiovascular risk.