Soluble vascular endothelial growth factor receptor-1 is reduced in patients with resistant hypertension after renal denervation.

Renal denervation (RDN) has been shown in several studies to reduce blood pressure (BP) in patients with resistant hypertension (RH). Data on potential biomarkers associated with BP changes remain scarce. We evaluated whether soluble vascular endothelial growth factor receptor (sVEGFR-1) is affected by the procedure. A total of 57 patients with RH participated in this study. BP and heart rate were recorded at baseline and at 3 months follow-up, at which time blood samples were collected to determine the levels of sVEGFR-1, VEGF-A, VEGF-C, nitric oxide (NO), soluble vascular adhesion molecule 1 and soluble intracellular adhesion molecule 1. None of the biomarkers had a predictive value that could identify responders vs non-responders to RDN. However, sVEGFR-1 concentration was dramatically reduced after RDN (5913±385 vs 280±57 pg ml-1, P<0.001). At the same time VEGF-A levels were significantly increased (10.0±3.0 vs 55.5±7.9 pg ml-1, P<0.001), without significant changes in VEGF-C. NO levels were significantly increased after RDN in the whole group (82.6±6.2 vs 106.9±7.8 µM, P=0.021). Interestingly, the elevation in NO levels at 3 months was only seen in patients who demonstrated a reduction in systolic BP of ⩾10 mm Hg (78.9±8.3 vs 111.6±11.7 µM, P=0.018). We report a significant reduction in sVEGFR-1 levels after RDN procedure, which was accompanied by a significant increase in VEGF-A concentration as well as NO. Changes in plasma cytokines were not quantitatively linked to magnitude of BP reduction. An RDN-induced reduction in sVEGFR-1 plasma levels and increase in VEGF-A would raise the VEGF-A/sVEGFR-1 ratio, thereby increasing VEGF-A bioavailability to act on its full-length receptor and may contribute to the BP-lowering effect potentially via NO-mediated pathways.

Diuretic use in heart failure and outcomes.

Diuretics are frequently administered to relieve congestive symptoms in patients with heart failure (HF). Despite their widespread use, prospective data on the potential of diuretics to modulate HF-related morbidity and mortality are scarce. Diuretic efficacy may be limited by adverse neurohormonal activation and by "congestion-like" symptoms that may occur in the absence of fluid overload. Herein, we review the current knowledge on diuretic use and outcomes in HF.

Barriers to achieving blood pressure treatment targets in elderly hypertensive individuals.

High blood pressure (BP) is highly prevalent among the elderly, and even with pharmacological therapy BP is difficult to control to guideline recommended levels. Although poor compliance to therapy is associated with less BP control, little is known regarding other barriers to attaining on-treatment target BP. This study examined factors associated with achieving on-treatment target BP in 6010 hypertensive participants aged 65-84 years from the Second Australian National Blood Pressure study. Participants were followed for a median of 4.1 years, with BP monitored every 6 months. 'Target BP' was defined as a reduction of systolic/diastolic BP of at least 20/10 mm Hg and BP <160/90 mm Hg from randomization in two consecutive follow-up visits. Cox regression was used to identify factors associated with achieving target BP from a number of baseline and in-study factors. Mean BP at randomization was 168/91 mm Hg and patients had a median of 9 (range: 2-20) study visits. Target BP was achieved in 50% of patients. Demographic factors associated with achieving target BP were male gender, living in a regional area; and clinical factors included history of antihypertensive therapy, increased plasma creatinine, lower pretreatment pulse pressure and in-study use of multiple BP-lowering drugs. Those aged >80 years and seeking care from multiple doctors (hazard ratio 0.40, 95% confidence interval 0.36-0.45, P<0.001) were less likely to achieve target BP. These findings identify clinical markers that can be targeted for intervention, but also demographic factors related to service delivery, which may provide further opportunity for achieving better BP control in hypertensive elderly.

Most individuals with treated blood pressures above target receive only one or two antihypertensive drug classes.

BACKGROUND: A significant proportion of individuals taking antihypertensive therapies fail to achieve blood pressures <140/90 mmHg. In order to develop strategies for improved treatment of blood pressure, we examined the association of blood pressure control with antihypertensive therapies and clinical and lifestyle factors in a cohort of adults at increased cardiovascular risk. METHODS: A cross-sectional study of 3994 adults from Melbourne and Shepparton, Australia enrolled in the SCReening Evaluation of the Evolution of New Heart Failure (SCREEN-HF) study. Inclusion criteria were age ≥60 years with one or more of self-reported ischaemic or other heart disease, atrial fibrillation, cerebrovascular disease, renal impairment or treatment for hypertension or diabetes for ≥2 years. Exclusion criteria were known heart failure or cardiac abnormality on echocardiography or other imaging. The main outcome measures were the proportion of participants receiving antihypertensive therapy with blood pressures ≥140/90 mmHg and the association of blood pressure control with antihypertensive therapies and clinical and lifestyle factors. RESULTS: Of 3623 participants (1975 men and 1648 women) receiving antihypertensive therapy, 1867 (52%) had blood pressures ≥140/90 mmHg. Of these 1867 participants, 1483 (79%) were receiving only one or two antihypertensive drug classes. Blood pressures ≥140/90 mmHg were associated with increased age, male sex, waist circumference and log amino-terminal-pro-B-type natriuretic peptide levels. CONCLUSIONS: Most individuals with treated blood pressures above target receive only one or two antihypertensive drug classes. Prescribing additional antihypertensive drug classes and lifestyle modification may improve blood pressure control in this population of individuals at increased cardiovascular risk.

Early identification of asymptomatic subjects at increased risk of heart failure and cardiovascular events: progress and future directions.

Increasing evidence for a latent, preclinical phase of cardiac pathology prior to the development of symptomatic heart failure has fuelled interest in the potential of developing a screening program for early disease detection and intervention. Cardiac biomarkers have shown promise in identifying subjects with significant left ventricular dysfunction and more recently to assist in cardiovascular risk stratification. However, a number of questions remain regarding the use of these biomarkers for screening purposes. In particular, appropriate cut-off levels and adjustment for individual patient characteristics still need to be established and further cost-effectiveness studies are required before screening programs can be undertaken. Given the enormous and increasing burden of cardiac failure worldwide, the potential of these biomarkers to identify those at greatest risk of the condition, either alone or as part of a hybrid screening strategy is of great interest to the cardiology community. The aim of this review is to outline evidence behind the argument for screening, discuss the remaining barriers to its development and implementation and highlight potential areas for future research.

Combination angiotensin converting enzyme and direct renin inhibition in heart failure following experimental myocardial infarction.

AIMS: Diminishing the activity of the renin-angiotensin system (RAS) plays a pivotal role in the treatment of heart failure. In addition to angiotensin converting enzyme (ACE) inhibitors and angiotensin-receptor blockers, direct renin inhibition has emerged as a potential adjunctive treatment to conventional RAS blockade. We sought to determine the effectiveness of this strategy after myocardial infarction (MI) in the setting of preexisting hypertension, a common premorbid condition in patients with ischemic heart disease. METHODS AND RESULTS: Ten-week-old female heterozygous hypertensive (mRen-2)27 transgenic rats (Ren-2), were randomized to one of five groups (n = 8 per group); sham, MI, MI + aliskiren, MI + lisinopril and MI + combination lisinopril and aliskiren. Cardiac function was assessed by echocardiography and in vivo cardiac catheterization. Untreated MI animals developed heart failure with hypotension, dilation, reduced ejection fraction (EF), and raised left ventricular end-diastolic pressure (LVEDP). Treatment with single agent treatment had only modest effect on cardiac function though combination therapy was associated with significant improvements in EF and LVEDP when compared to untreated MI animals (P < 0.05). Histologic analysis demonstrated increase extracellular matrix deposition and cardiomyocyte hypertrophy in the noninfarct region of all MI groups when compared with sham operated animals (P < 0.05) that was reduced by ACE inhibitor monotherapy and combination treatment but not by aliskiren alone. CONCLUSION: In a hypertensive rat model that underwent experimental MI, EF, and LVEDP, key functional indices of heart failure, were improved by treatment with combination ACE and direct renin inhibition when compared with either agent used alone.

Cardio-renal syndrome: new perspective in diagnostics.

Chronic heart failure and chronic renal failure are at epidemic proportions. These patients have significantly altered cardiac, renal, and all-cause outcomes. Much of the current research has focused on treating these individual organs in isolation. Although there are positive data on outcomes with neurohormonal modulation, they, however, remain underused. At present, data lacks for novel treatment options, while evidence continues to point at significantly worsened prognosis. Current diagnostic tools that detect acute changes in renal function or renal injury appear retrospective, which often hinder meaningful diagnostic and therapeutic decisions. This review is aimed at exploring the importance of accurate assessment of renal function for the heart failure patient by providing a synopsis on cardio-renal physiology and establishing the possibility of novel approaches in bridging the divide.

Five-minute heart rate variability can predict obstructive angiographic coronary disease.

OBJECTIVE: Obstructive coronary artery disease (CAD) is evident in only half of patients referred for diagnostic angiography. Five-minute heart rate variability (HRV) is a non-invasive marker for autonomic control of the vasculature, which this study hypothesised could risk-stratify cardiac patients and reduce unnecessary angiograms. DESIGN: A prospective observational study (the Alternative Risk Markers in Coronary Artery Disease (ARM-CAD) study). SETTING: Three cardiac centres in Melbourne, Australia. PATIENTS: 470 consecutive patients undergoing elective angiography (with predominantly normal cardiac rhythm), regardless of co-morbidity. MAIN OUTCOME MEASURES: The presence of obstructive CAD (≥50% stenosis) on angiography. RESULTS: Patients with obstructive CAD had significantly reduced HRV, particularly in the low frequency (LF) range (median 180 vs 267 ms(2) without CAD; p<0.001). There was a linear trend with the severity of CAD; median LF power (IQR) in patients with normal coronaries was 275 (612), with minor coronary irregularities 255 (400), single-vessel CAD 212 (396) and more severe disease 170 (327) ms(2); p value for trend 0.003. There was a similar reduction in LF power regardless of the anatomical location of coronary stenoses. Comparing patients with LF less than 250 and 250 ms(2) or greater, the adjusted OR for obstructive CAD using multivariate regression was 2.42, 95% CI 1.33 to 4.38 (p=0.004). No interactions were noted in subgroup analysis and HRV added to risk prediction irrespective of the baseline Framingham risk (p<0.0001). CONCLUSION: Low HRV is strongly predictive of angiographic coronary disease regardless of other co-morbidities and is clinically useful as a risk predictor in patients with sinus rhythm. CLINICAL TRIAL REGISTRATION INFORMATION: http://clinicaltrials.gov/ct2/show/NCT00403351 www.armcad.com.

Effect of nesiritide in patients with acute decompensated heart failure.

BACKGROUND: Nesiritide is approved in the United States for early relief of dyspnea in patients with acute heart failure. Previous meta-analyses have raised questions regarding renal toxicity and the mortality associated with this agent. METHODS: We randomly assigned 7141 patients who were hospitalized with acute heart failure to receive either nesiritide or placebo for 24 to 168 hours in addition to standard care. Coprimary end points were the change in dyspnea at 6 and 24 hours, as measured on a 7-point Likert scale, and the composite end point of rehospitalization for heart failure or death within 30 days. RESULTS: Patients randomly assigned to nesiritide, as compared with those assigned to placebo, more frequently reported markedly or moderately improved dyspnea at 6 hours (44.5% vs. 42.1%, P=0.03) and 24 hours (68.2% vs. 66.1%, P=0.007), but the prespecified level for significance (P≤0.005 for both assessments or P≤0.0025 for either) was not met. The rate of rehospitalization for heart failure or death from any cause within 30 days was 9.4% in the nesiritide group versus 10.1% in the placebo group (absolute difference, -0.7 percentage points; 95% confidence interval [CI], -2.1 to 0.7; P=0.31). There were no significant differences in rates of death from any cause at 30 days (3.6% with nesiritide vs. 4.0% with placebo; absolute difference, -0.4 percentage points; 95% CI, -1.3 to 0.5) or rates of worsening renal function, defined by more than a 25% decrease in the estimated glomerular filtration rate (31.4% vs. 29.5%; odds ratio, 1.09; 95% CI, 0.98 to 1.21; P=0.11). CONCLUSIONS: Nesiritide was not associated with an increase or a decrease in the rate of death and rehospitalization and had a small, nonsignificant effect on dyspnea when used in combination with other therapies. It was not associated with a worsening of renal function, but it was associated with an increase in rates of hypotension. On the basis of these results, nesiritide cannot be recommended for routine use in the broad population of patients with acute heart failure. (Funded by Scios; ClinicalTrials.gov number, NCT00475852.).

Is addition of angiotensin receptor blockade superior to increasing ACE inhibitor dose in patients with heart failure?

We conducted a prospective, randomised, open-label, blinded end point (PROBE) study examining the relative efficacy of irbesartan 300 mg/day versus maximising dose of ACE inhibitor, additional to background conventional heart failure therapy. Patients with CHF, NYHA Class II-III and a left ventricular ejection fraction <40% were randomised to one of two treatment arms. All patients were receiving ≤ half target dose of ACE inhibitor as background therapy. 44 patients received an increase in their background ACE inhibitor while 45 patients were given irbesartan (target dose 300 mg/day) in addition to their background ACE inhibitor. The primary end-point was change in brain natriuretic peptide (BNP) from baseline to 6 months. Change in hs-CRP level, 6 min walk distance, and Minnesota living with heart failure quality of life questionnaire (MLWHF) from baseline to 6 months were also evaluated. Patients were well matched at baseline for all end-point parameters as well as for age, gender and baseline systolic ventricular function. There was general improvement in clinical status for all patients but no significant difference between increased ACE inhibitor vs added ARB for change in BNP, hs-CRP, NYHA, 6 min walk or MLWHF (all P>0.05). This PROBE study has demonstrated similar clinical responses with increased dose of ACE inhibitor compared to addition of ARB in patients with systolic CHF. These findings suggest that either approach to increasing renin-angiotensin blockade in patients taking low doses of background ACE inhibitor results in similar clinical outcomes.

Comparison of a supra-sternal cardiac output monitor (USCOM) with the pulmonary artery catheter.

BACKGROUND: Cardiac output (CO) cannot reliably be estimated by clinical examination. We aimed to measure the agreement between CO measurements using a supra-sternal Doppler monitor (USCOM, Coffs Harbour, Australia) and the pulmonary artery catheter (PAC). METHODS: The study was conducted in the intensive care unit of a tertiary teaching hospital. All patients with PAC in situ were eligible. Simultaneous CO readings were taken when clinically indicated. Investigators and clinicians were blinded to each other's results. The CO values used were the mean of three consecutive supra-sternal Doppler readings for patients with a sinus rhythm and seven for atrial fibrillation, and the mean of three thermodilution curves with acceptable form and values within 10% of each other for the PAC. Agreement was measured using both the paired t-test to calculate bias and limits of agreement and the intraclass correlation (ICC) coefficient. RESULTS: Ninety-four subjects were enrolled. From 89 subjects, 250 paired comparisons were obtained. USCOM monitor readings were unobtainable in five patients. Mean supra-sternal Doppler CO was 5.5 litre min(-1). Bias was -0.09 litre min(-1) and levels of agreement were +/- 2.92 litre min(-1) when compared with PAC. ICC was 0.46 (95% CI 0.36-0.56), and mean percentage difference was 19 (IQR 6-31)%. CONCLUSIONS: In our subjects, there was poor agreement between CO measurements done with the supra-sternal Doppler monitor and PAC.

Effect of urotensin II on skin microvessel tone in diabetic patients without heart failure or essential hypertension.

Urotensin II (UII) is a potent vasoconstrictor peptide. Increased plasma levels and kidney expression of UII and its receptor have been observed in diabetes mellitus (DM). The aim of the present study was to evaluate the direct effect of exogenous UII on microvascular tone in DM patients compared with healthy controls. Vasoactive effect of UII (10(-12), 10(-9) and 10(-7) mol/L) on skin microvascular tone was evaluated in 12 controls and 12 DM patients (Type 1 or Type 2) without concomitant heart failure or essential hypertension using the non-invasive technique of iontophoresis and laser Doppler velocimetry. In addition, responses to acetylcholine (ACh) and sodium nitroprusside (SNP) were evaluated. Urotensin II dose-dependently dilated skin microvasculature in control subjects (-51.8 +/- 59.4, 138.6 +/- 101.5, 204.2 +/- 115.7 and 207.5 +/- 81.6 arbitrary flux units (AFUs) for MilliQ and 10(-12), 10(-9) and 10(-7) mol/L UII, respectively) and dose-dependently vasoconstricted the microvasculature in DM patients (100.8 +/- 81.2, 46.2 +/- 85.1, 35.4 +/- 81.4 and 26.6 +/- 79.6 AFUs for MilliQ and 10(-12), 10(-9) and 10(-7) mol/L UII, respectively). Blood flow in control subjects and DM patients was differed significantly, with pair-wise comparisons indicating differences for 10(-9) and 10(-7) mol/L UII (P = 0.04 and P = 0.003). Results of blood flow in diet-controlled DM patients (204.7 +/- 193.6, 261.2 +/- 212.8, 256.1 +/- 202.9 and 233.7 +/- 115.9 AFUs for MilliQ and 10(-12), 10(-9) and 10(-7) mol/L UII, respectively) were similar to those in control subjects compared with results for DM patients receiving antidiabetic medication (48.8 + 80.0, -61.4 +/- 49.1, -75.0 +/- 40.0, -91.7 +/- 80.0 AFUs for MilliQ and 10(-12), 10(-9) and 10(-7) mol/L UII, respectively). Between-group significance remained after adjustment for baseline blood pressure values. Acetylcholine vasodilator responses were attenuated in DM patients compared with those in control subjects (1309.5 +/- 488.6 vs 3498.0 +/- 912.5 AFUs, respectively), whereas SNP responses were similar in the two groups (1467.9 +/- 411.3 vs 1984.4 +/- 410.7 AFUs, respectively). In conclusion, UII causes net vasoconstriction in DM. The UII-induced increases in peripheral vascular tone may contribute to DM-related cardiovascular complications.

Do patients with heart failure appropriately undergo invasive procedures post-myocardial infarction? Results from a prospective multicentre study.

BACKGROUND: The degree of adherence to guideline recommendations that patients following myocardial infarction (MI) with congestive heart failure (CHF) undergo early angiography, and angioplasty if indicated, is unknown. METHODS: We prospectively evaluated the use of invasive procedures in patients with segment-elevation myocardial infarction (STEMI), non-STEMI and CHF, admitted in 1 month to 16 Australian hospitals. RESULTS: Of 475 post-MI patients (248 (52.2%) with STEMI), 112 (23.6%) had CHF, (57 (23.0%) with STEMI). Patients with CHF, compared with those without CHF, were older (67.8 vs 63.2 years; P = 0.002) and were more often women (34 vs 24%, P = 0.03), but had similar rates of other risk factors. Compared with post-MI patients without CHF, patients with CHF had fewer invasive procedures: angiography 72.3% versus 85.1% (P = 0.002) and angioplasty 33.9% versus 52.9% (P < 0.001) (12 (2.5%) patients underwent coronary surgery in-hospital); and among STEMI patients (angiography 72.3% CHF vs 89.5% no CHF [P < 0.001]; angioplasty 50.9% CHF vs 69.1% no CHF [P = 0.011]); these differences remained significant after adjustment for clinical covariates. Of the 121 (25.5%) post-MI patients aged > or =75 years, compared with those <75 years, the frequencies of angiography and angioplasty procedures were 66.1% versus 87.6% (P < 0.001) and 33.9% versus 53.4% (P < 0.001), respectively; 66% of the elderly with, and without, CHF had angiography. CONCLUSION: The presence of CHF post-MI resulted in lower rates of use of angiography and angioplasty, which was not explained by lower procedure rates in the elderly. As these guideline-recommended procedures may improve survival in patients with CHF post-MI, future strategies should aim to enhance their use.

Long-term but not short-term p38 mitogen-activated protein kinase inhibition improves cardiac function and reduces cardiac remodeling post-myocardial infarction.

p38 mitogen-activated protein kinase (p38 MAPK) inhibition exerts beneficial effects on left ventricular (LV) remodeling and dysfunction. p38 MAPK activity is transiently increased soon after myocardial infarction (MI), suggesting brief inhibition may afford the same benefit as long-term inhibition. We examined chronic 12-week p38 MAPK inhibition compared with short-term (7-day) inhibition, and then we discontinued inhibition after MI. Post-MI rats at day 7 received either vehicle, 4-[4-(4-fluorophenyl)-1-(3-phenylpropyl)-5-(4-pyridinyl)-1H-imidazol-2-yl]-3-butyn-1-ol (RWJ67657; RWJ) for 12 weeks (long term; LT-RWJ), RWJ for 1 week and discontinued for 11 weeks (1-week RWJ), or continuous ramipril for 12 weeks. In separate groups of animals, 24 h after MI, vehicle or RWJ was administered for 7 days. Cardiac function was assessed by echocardiography and hemodynamic measurements. Percentage of fractional shortening improved after LT-RWJ and ramipril, but not after 1-week RWJ treatment. Likewise, LV contractility and maximal first derivative of left ventricular pressure (dP/dt(max)) was improved (12.5 and 14.4%) and LV end diastolic pressure (LVEDP) was reduced (49.4 and 54.6%) with both treatments. Functional outcomes were accompanied by regression of interstitial collagen I and alpha-smooth muscle actin expression in LV noninfarct, border, and infarct regions with LT-RWJ and ramipril treatment. Hypertrophy was reduced in noninfarct (18.3 and 12.2%) and border regions (16.3 and 12.0%) with both treatments, respectively. Animals receiving RWJ 24 h after MI for 7 days showed similar improvements in fractional shortening, dP/dt(max), LVEDP, including reduced fibrosis and hypertrophy. In vitro experiments confirmed a dose-dependent reduction in hypertrophy, with RWJ following tumor necrosis factor-alpha stimulation. Continuous but not short-term p38 MAPK blockade attenuates post-MI remodeling, which is associated with functional benefits on the myocardium.