Molecular and Vascular Evidence in Managing Hypertension and Hyperlipidemia

Hananto Andriantoro
Divisi vascular, Department Cardiology and vascular Medicine Faculty Medicine University of Indonesia

Endothelial dysfunction
Normal vascular endothelial cells support cardiovascular function by promoting vasodilatation and by inhibiting platelet aggregation, white blood cell adhesion, and smooth muscle cell proliferation. In contrast, dysfunctional endothelium promotes vasoconstriction, favors platelet aggregation, white blood cell adhesion, and smooth muscle cell proliferation. Hypercholesterolemia, hyperglycemia, hypertension, and smoking are the most common risks associated with endothelial dysfunction.

Integrated Perspective on CV Risk Factors and Vascular Disease

Endothelial Dysfunction Oxidative Stress & Inflammation

CV Disease
Ross. N Engl J Med. 1999;340:1151999;340:115-126.

Ross. N Engl J Med. 1999;340:1151999;340:115-126.

Ross. N Engl J Med. 1999;340:115-126.

Cardiovascular death
Cause of death of cardiovascular disease
Myocardial infarction Heart failure Cerebro Vascular Desease Aorta disease Pheriperal Vascular disease End Stage Renal Disease

Endothelial Function in

Hyperlipidemia

Cholesterol and CHD

Multiple Risk Factor Intervention trial( MRFIT)
360.000 men, aged 35-57 CHD mortality rate

150

200

250

300

350

Mg/dl

LDL-C Oxidation Promotes the Development of Atherosclerotic Lesions

Native LDLLDL-C

Modified LDLLDL-C

Atherogenic effects

Oxidative stress

Foam-cell formation Monocyte mobility Chemoattraction Endothelial adhesion Free-radical production

Meagher EA, FitzGerald GA. Free Rad Biol Med. 2000;28:17452000;28:1745-1750; Chisolm GM, Steinberg D. Free Rad Biol Med. 2000;28:18152000;28:1815-1826; Heinecke JW. Am J Cardiol. Cardiol. 2003;91(suppl):12A2003;91(suppl):12A-16A.

Acute Elevations of Plasma Asymmetric Dimethylarginine and Impaired Endothelial Function in Response to a High-Fat Meal in Patients With Type 2 Diabetes

Percentage of flow-induced dilation of the brachial artery (A; n550, *P,0.0001) and plasma level of ADMA (B; n550, **P,0.0005) before (PRE-) and 5 hours after (POST-) ingestion of the high-fat meal.
(Arterioscler Thromb Vasc Biol. 2000;20:20392000;20:2039-2044.)

LDL Cholesterol Upregulates Synthesis of Asymmetrical Dimethylarginine in Human Endothelial Cells

(Circ Res. 2000;87:99-105.)

This increase in ADMA production was significantly inhibited by the intracellular antioxidant pyrrollidine dithiocarbamate (PDTC) Tanah lot 2008

ADMA endogenous inhibitors of NOS

Heart 2001;85:342350

Asymmetric dimethylarginine (ADMA) is synthesised from L-arginine by protein methylase I and subsequently metabolized by dimethylarginine dimethylaminohydrolase (DDAH) yielding citrulline. ADMA acts as an endogenous inhibitor of nitric oxide (NO) synthesis and its concentration is increased in certain disease states, possibly as a result of decreased DDAH actions

Tetrahydrobiopterin (BH 4)
Am J Physiol Heart Circ Physiol , 2001 ;280: H2484H2488.

Effects of Tetrahydrobiopterin on Endothelial Dysfunction

J Am Soc Nephrol 11: 301309, 2000

Renal Perfusion Pressure : RPP

Caveolin
The principal protein component of caveolae is caveolin Interacts with various signaling, including G proteins and calcium regulating protein. Caveolin is also inhibitor of endothelial nitric oxide synthase (eNOS)
Razani, Undergraduate research,2002;1:44-50 Razani, pharmacol Rev.2002;54:431-467

Caveolae

Pharmacol Rev , 2002 54:431467

Lipid Rafts

Caveolae
Caveolin Phospholipid Spingolipid Cholesterol

Pharmacol Rev , 2002 54:431467

Pharmacol Rev , 2002 54:431467

Endothelial Function in

Hypertension

Endothelial Dysfunction and Hypertension

the defect in the endothelium-derived NO system in hypertensive vessels is likely not due to decreased availability of its precursor, L-arginine Muscarinic receptor defect with abnormal responses to acetylcholine the cause of endothelial dysfunction in patients with hypertension is not limited to a defect at the muscarinic receptor level, but is related to a broader abnormality of endothelial cells.
Clin. Cardiol. 1997; 20 (Suppl. II), II-26II-33

Endothelial dysfunction in hypertension

Clin Cardiol 1997;20:suppl II, II26-II33

Endothelial dysfunction in hypertension

Clin Cardiol 1997;20:suppl II, II26-II33

NEW TREATMENT APPROACH Hypertension / hyperlipidemia

Vascular and cardiac biology altered Treat the Endothelium Therapeutic options

ACE Inhibitors

Ca Channel blockers

Statin
Han 2005

* Minimal evidence of effects on endothelial function

Atorvastatin and
endothelial nitric oxide synthetase

Caveolin and hypercholesterol

The expression of caveolin is markedly elevated under conditions of hypercholesterolemia Caveolin-1 Inhibits NO Synthase Activity Atherosclerosis , lipid rafts have been shown to play an important role in other disease processes, including hypertension

J Clin Invest.2002;110:597-603 Circulation.2003;107:2270-2273

CARDS
Collaboration Atorvastatin Diabetes Study
Atorvastatin provided impressive benefits in patients with type 2 diabetes with no history of CVD and with normal to mildly mildlyelevated cholesterol levels 37% reduction in major CVD events (P = .001)

48% reduction in stroke (P = .016)

27% reduction in all -cause mortality (P = .059) all-cause Consistent effect regardless of baseline lipids, gender, or age Safety profile of atorvastatin 10 mg was excellent and comparable to placebo CARDS became the second atorvastatin trial to end early because of observed treatment benefit
Colhoun HM, Betteridge DJ, Durrington PN, et al. Lancet. 2004;364:685-696.

Cumulative incidence for primary end point of non fatal myocardial infarction and fatal coronary artery disease

Cumulative incidence for primary end point of non fatal and fatal stroke (ASCOT-LLA)

Amlodipine besylate and

endothelial nitric oxide synthetase

Nitric Oxide Release

Postulated Effects of Different Agents on Endothelial Cell NO Production

CCB CCB Kinins

BK2

eNOS eNOS mRNA

L-Arginine BH4 Endothelial Cell

NO + L-Citrulline

Loke et al. Hypertension. 1999;34:563-567; Loke. Circulation. 1999;100:1291-1297 Laufs et al. Circulation. 1998;97:1129-1135.

Amlodipin Releases Nitric Oxide From Canine Coronary Microvessels

An Unexpextected Mechanism of action of Calcium Chanel-Blocking Agent
Circulation 1998;97:576-580

80 Change in Nitrite (pmol/mg) 70 60 50 40 30 20 10 0 -10M

Amlodipine

Ramipril

Diltiazem

-9M

-8M

-7M

-6M

-5M ( log )

Amlodipin Releases Nitric Oxide From Canine Coronary Microvessels

An Unexpextected Mechanism of action of Calcium Chanel-Blocking Agent
Circulation 1998;97:576-580

Change in Nitrite (pmol/mg)

140 120 100 80 60 40 20 0 -20

-10M -9M -8M -7M -6M -5M

Amlodipine

Enalapril

Nifedipine

(Log)

Amlodipin Releases Nitric Oxide From Canine Coronary Microvessels

An Unexpextected Mechanism of action of Calcium Chanel-Blocking Agent
Circulation 1998;97:576-580

60 Change in nitrite (pm ol/m g) 50 40 30 20 10 0 -10 -10M -9M -8M -7M -6M -5M ( log )
Microvessels Large Coronary Artery Aorta

Amlodipin Promotes Kinin-Mediated Nitric oxide Production in Coronary Microvessels of Failing Human Hearts
Am J Cardiol 1999;84:27L-33L
70

change in Nitrite (pmol/mg)

60 50 40 30 20 10 0

Amlodipine Ramiprilat Bradykinin

-10mol/L

-9 mol/L

-8mol/L

-7mol/L

-6mol/L

-5mol/L

( Log )

Antioxidant effects

Membrane Antioxidant Activity of Amlodipine

700 700 600 600 500 500 LOOH LOOH ( ( M) M) inhibited inhibited 400 400 300 300 200 200 100 100 0 0 LOOH LOOH = = lipid lipid peroxide. peroxide. * *p p<0.001 <0.001 versus versus control. control. 0.01 0.01 0.1 0.1 1.0 10.0 1.0 10.0 Amlodipine Amlodipine ( ( M) M) 100.0 100.0

* * * * *

Mason -281, 1999 Mason RP RP et et al. al. J J Mol Mol Cell Cell Cardiol Cardiol 31, 31, 275 275-281, 1999

Antioxidant Properties of Calcium Antagonists Related to Membrane Biophysical Interactions

90 Inhibition of MDA Formation (%) 80 70 60 50 40 30 20 10 0

Am J Cardiol 1999;84:16L-22L
Amlodipine
Verapamil

Ditiazem

20

60 Drug Concentration (micro mol/L)

200

CCB Inhibition of Lipid Peroxidation In Vitro * 40

% Inhibition of Lipid Peroxide Formation by Drug (1.0 M) 30 20

10

0
Amlodipine Besylate

Felodipine Verapamil Diltiazem

*P<.001 vs control. Mason et al. J Mol Cell Cardiol. 1999;31:275-281.

Amlodipine Besylate

NO
Vasodilating
Antiproliferative

Antithrombotic

Antiartherosclerotic
Calcium Antagonist-induced NO release may contribute to the pharmacologic profile of this class of drugs (Klaus W et al,
1997)

Fatal and non-fatal stroke

%
5.0 4.0

Atenolol thiazide (No. of events 422)

23%

3.0

2.0

Amlodipine perindopril (No. of events 327) HR = 0.77 (0.66-0.89) p = 0.0003

0.0
9639 9618

1.0

0.0
Number at risk Amlodipine perindopril Atenolol thiazide

1.0
9483 9461

2.0
9331 9274

3.0
9156 9059

4.0
8972 8843

5.0
7863 7720

Years

Unstable angina
%
1.2 1.0 0.8 0.6 0.4 0.2 0.0 0.0
Number at risk Amlodipine perindopril Atenolol thiazide 9639 9618

Atenolol thiazide (No. of events 106)

32%

Amlodipine perindopril (No. of events 73) HR = 0.68 (0.51-0.92) p = 0.0115

1.0
9536 9510

2.0
9416 9374

3.0
9285 9198

4.0
9123 9007

5.0
8021 7888

Years

Peripheral arterial disease

%
2.5 2.0

Atenolol thiazide (No. of events = 202)

35%

1.5 1.0 0.5 0.0

Number at risk Amlodipine perindopril Atenolol thiazide

Amlodipine perindopril (No. of events = 133)

HR = 0.65 (0.52-0.81) p = 0.0001

0.0
9639 9618

1.0
9523 9495

2.0
9382 9348

3.0
9237 9163

4.0
9070 8958

5.0
7958 7828

Years

Cardiovascular Mortality
%
3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0
0.0
Number at risk Amlodipine perindopril Atenolol thiazide 9639 9618

Atenolol thiazide (No. of events 342)

24%

Amlodipine perindopril (No. of events 263) HR = 0.76 (0.65-0.90) p = 0.0010

1.0
9544 9532

2.0
9441 9415

3.0
9322 9261

4.0
9167 9085

5.0
8078 7975

Years

Amlodipine and Atorvastatin Combination

Multiple CV Risk Management Results in Dramatic Reductions in CVD

10% Reduction in BP

10% Reduction in TC

45% Reduction in CVD

Attention should be moved from knowing ones BP and cholesterol concentrations to knowing ones absolute CV risk and its determinants.
J. Emberson et al and Jackson et al
Emberson J et al. Eur Heart J. 2004;25:484-491. Jackson R et al. Lancet. 2005;365:434-441.

GEMINI: Real -World Experience with the Utility of Real-World (amlodipine besylate/atorvastatin calcium) CADUET
Evaluated the real-world utility of single-pill CADUET Uncontrolled, 14-week, office-based, prospective, open-label study of 1220
patients Broad range of severity of concomitant hypertension and dyslipidaemia No washout period CADUET was used in a variety of treatment situations
Added to existing treatment Substituted for amlodipine and atorvastatin Initial drug therapy with diet and exercise

Dosing and titration were at the discretion of the investigator Primary objective: assess percentage of patients at BP and lipid goals at 14
weeks
GEMINI was an openopen-label, uncontrolled clinical study; no conclusions about efficacy efficacy or safety can be made Blank R et al. J Clin Hypertens. 2005;7:2642005;7:264-273.

GEMINI: Baseline LDL -C and BP Levels LDL-C

LDL-C and BP Levels at Baseline, by CV Risk Group
Group I
300
LDL-C (mg/dL)

Group II
300 250 200 150 100 50 300 250 200 150 100 50 100120140160180200
SBP (mm Hg) Patients at increasing CV risk

Group III

250 200 150 100 50 100120140160180200

100120140160180200

CV Risk Group 1: Patients with HTN, DYS, and no additional CV risk factors

CV Risk Group 2: Patients with HTN, DYS, and 1 additional CV risk factor (not DM or CHD)

CV Risk Group 3: Patients with HTN, DYS, and CHD or CHD risk equivalent

Shaded quadrant represents joint BP and LDL-C goal attainment for each CV risk group. DYS=dyslipidaemia; DM=diabetes mellitus. Blank R et al. J Clin Hypertens. 2005;7:264-273.

GEMINI: Number of Patients Reaching BP and LDL-C Goals at End Point Increased from Baseline
LDL-C and BP Levels for all CV Risk Groups at Baseline (in Yellow) and at End Point (in Blue)

Group I
300
LDL-C (mg/dL)

Group II
300 250 200 150 100 50 300 250 200 150 100 50 100120140160180200
SBP (mm Hg) Patients at increasing CV risk

Group III

250 200 150 100 50 100120140160180200

100120140160180200

CV Risk Group 1: Patients with HTN, DYS, and no additional CV risk factors

CV Risk Group 2: Patients with HTN, DYS, and 1 additional CV risk factor (not DM or CHD)

CV Risk Group 3: Patients with HTN, DYS, and CHD or CHD risk equivalent

Shaded quadrant represents joint BP and LDL-C goal attainment for each CV risk group.

Blank R et al. J Clin Hypertens. 2005;7:264-273.

Evidence Based Medicine

Clinical end-points can be divided into two groups. Soft end-points include indices
of atherosclerosis such as a change in the thickness of the arterial wall or in the volume of atherosclerotic tissue within the arteries.

Hard end-points are the number

of cardiovascular events such as myocardial infarction or stroke, or the hardest end-point of all - the mortality rate from cardiovascular disease.
Preston Mason, P Libby, Gerd Assmann, International Task Force for the Prevention of Coronary Heart Disease, March 2004

Cumulative incidence for non-fatal myocardial infarction and fatal coronary heart disease.

Cumulative incidence for total cardiovascular events and procedures in the two blood pressure treatment groups

 (amlodipine CARPE: CADUET (amlodipine besylate/atorvastatin besylate/atorvastatin calcium) calcium) Therapy Results in More Patients Achieving Adherence Compared to Concomitant CCB and Statin Therapies
100%

Unadjusted Proportion of Patients Achieving Adherence

Percentage of Patients with PDC 80%

90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

CADUET Atorvastatin + Amlodipine Amlodipine + Other Statin Other CCB + Atorvastatin Other CCB + Other Statin

67,7% 49,9% 40,4% 46,9% 37,4%

All comparison cohorts significantly lower than CADUET, P <.0001 (PDC : Proportion Days Covered)
CARPE Research Investigators. Presented at 2006 American Society of Hypertension, May 19, 2006. New York, NY.

Conclusion
The results of this presentation indicate that amlodipine and atorvastatin produced a synergistic effect on endothelial dependent mechanisms of NO biosynthesis. The basis for this cellular activity is attributed to changes in eNOS expression, increased coupling efficiency of eNOS and a decrease in cytotoxic ONOO.

Take Home Message

Endothelial dysfunction in hypertension and hyperlipidemia may lead to the development of novel therapeutic strategies to reduce the vascular complications associated with the hypertensive and hyperlipidemia process.