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Prognostic significance of endothelial dysfunction in hypertensive patients
Perspective: The findings are intriguing particularly since the results were independent of 24-hour blood pressure measurements at baseline, which was the only other independent predictor of CVD events. We presently treat to targets for blood pressure and serum lipids. Normalization of vascular endothelial function, i.e., brachial artery response to occlusion release, may become a useful and better target for coronary risk reduction in the future. MR
distance and speed on the Walking Impairment Questionnaire and better overall well being by the SF-36. In subgroup analysis, there was no effect of smoking or diabetes, however the patients from Russia had a significantly greater benefit than those from the US. Conclusions: Proprionyl-L-carnitine safely improved treadmill exercise performance and enhanced functional status in claudication. Perspective: While working via different pathways, both p-L carnitine and L-arginine supplements have been shown to help claudication. Unfortunately the design of this small study, leaves many unanswered questions, particularly the impact of smoking, diabetes, and associated neuromuscular disorders and the probability of value. Nevertheless, 2000 mg of p-L-carnitine is a relatively cheap micronutrient and may be worth trying in claudication with the caveat that safety and drug interactions are not established. MR
Effects of an Angry Temperament on Coronary Heart Disease Risk Williams JE, Nieto FJ, Sanford CP, Tyroler HA. Am J Epidemiol 2001;154:230 –5. Study Question: Persons predisposed to anger have a risk of coronary events more than twice those without this trait. This analysis sought to determine which component of an anger-prone personality, anger-temperament vs. anger-reaction, more strongly predicts coronary heart disease (CHD) risk. Methods: The 12,990 healthy middle-aged men and women (black and white) in the population-based prospective study of CVD risk factors (ARIC, Atherosclerosis Risk in Communities Study) were screened for standard risk factors and additionally the Spielberger trait anger-temperament and trait anger-reaction subscales. Follow-up averaged 53 months. An incident CHD event was characterized as acute MI/fatal CHD, revascularization and silent MI. Hard events were restricted to MI/fatal CHD. Results: After multivariate adjustment, among normotensive persons, a strong, angry temperament (tendency to quick, minimally provoked, or unprovoked anger) was associated with relative risk of 2.10 for combined CHD events and 2.28 for hard events. The strength of the risk attributable to anger-temperament was comparable to hypertension, and was not a significant risk factor in hypertensive persons. In contrast there was a minimal and insignificant association between CHD risk and strong angerreaction (anger in response to frustration or mistreatment). Conclusions: A strong, angry temperament rather than anger in reaction to unfair treatment places normotensive middleaged persons at risk for cardiac events, and may confer a risk similar to hypertension. Perspective: Intense volatile anger is associated with activation of the sympathetic adrenal medullary system and can induce endothelial dysfunction, activate platelets and macrophages and increase cardiovascular work. The findings add to a considerable body of evidence that personality traits can influence CHD risk. The results are easy to translate to the clinical setting. Road rage is harmful and non-productive. While the occasional anger in response to criticism or frustration may also not be productive, it does not increase CHD risk. MR
Prognostic Significance of Endothelial Dysfunction in Hypertensive Patients Perticone F, Ceravolo R, Pujia A, et al. Circulation 2001;104: 191– 6. Study Question: Coronary endothelial-dependent vasodilation is an independent predictor of prognosis in coronary disease. This study sought to determine whether forearm endothelial function predicts outcome in essential hypertension Methods: Endothelial-dependent and -independent vasodilation was investigated in 225 previously untreated hypertensive men and women (age 35–54 years) by brachial artery infusion of increasing doses of acetylcholine (Ach) and sodium nitroprusside. Patients received individually tailored treatment with target blood pressure to ⬍140/90 mm Hg with lifestyle changes and drug treatment including diuretics, beta-blockers, ACEi, ANG II antagonists and calcium channel blockers alone or in combinations. Patients were divided into tertiles by percent increase in Ach-stimulated forearm blood flow (FBF) from basal flow. Results: During a mean follow-up of 31.5 months, 29 major CVD events (19 cardiac, 9 cerebrovascular, 1 peripheral vascular) occurred. Event rates per 100 patient years were 8.17, 4.34 and 2.02 in the first, second and third tertiles of peak percent increase in FBF during Ach. The excess relative risk associated with decreased endothelial-dependent vasodilation was 2.08 after controlling for individual risk markers, including basal 24-hour ambulatory blood pressure and after exclusion of soft events. There was no relationship between events and the response to nitroprusside. Conclusions: Forearm endothelial dysfunction is a marker of future cardiovascular events in patients with essential hypertension.
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distance and speed on the Walking Impairment Questionnaire and better overall well being by the SF-36. In subgroup analysis, there was no effect of smoking or diabetes, however the patients from Russia had a significantly greater benefit than those from the US. Conclusions: Proprionyl-L-carnitine safely improved treadmill exercise performance and enhanced functional status in claudication. Perspective: While working via different pathways, both p-L carnitine and L-arginine supplements have been shown to help claudication. Unfortunately the design of this small study, leaves many unanswered questions, particularly the impact of smoking, diabetes, and associated neuromuscular disorders and the probability of value. Nevertheless, 2000 mg of p-L-carnitine is a relatively cheap micronutrient and may be worth trying in claudication with the caveat that safety and drug interactions are not established. MR
Effects of an Angry Temperament on Coronary Heart Disease Risk Williams JE, Nieto FJ, Sanford CP, Tyroler HA. Am J Epidemiol 2001;154:230 –5. Study Question: Persons predisposed to anger have a risk of coronary events more than twice those without this trait. This analysis sought to determine which component of an anger-prone personality, anger-temperament vs. anger-reaction, more strongly predicts coronary heart disease (CHD) risk. Methods: The 12,990 healthy middle-aged men and women (black and white) in the population-based prospective study of CVD risk factors (ARIC, Atherosclerosis Risk in Communities Study) were screened for standard risk factors and additionally the Spielberger trait anger-temperament and trait anger-reaction subscales. Follow-up averaged 53 months. An incident CHD event was characterized as acute MI/fatal CHD, revascularization and silent MI. Hard events were restricted to MI/fatal CHD. Results: After multivariate adjustment, among normotensive persons, a strong, angry temperament (tendency to quick, minimally provoked, or unprovoked anger) was associated with relative risk of 2.10 for combined CHD events and 2.28 for hard events. The strength of the risk attributable to anger-temperament was comparable to hypertension, and was not a significant risk factor in hypertensive persons. In contrast there was a minimal and insignificant association between CHD risk and strong angerreaction (anger in response to frustration or mistreatment). Conclusions: A strong, angry temperament rather than anger in reaction to unfair treatment places normotensive middleaged persons at risk for cardiac events, and may confer a risk similar to hypertension. Perspective: Intense volatile anger is associated with activation of the sympathetic adrenal medullary system and can induce endothelial dysfunction, activate platelets and macrophages and increase cardiovascular work. The findings add to a considerable body of evidence that personality traits can influence CHD risk. The results are easy to translate to the clinical setting. Road rage is harmful and non-productive. While the occasional anger in response to criticism or frustration may also not be productive, it does not increase CHD risk. MR
Prognostic Significance of Endothelial Dysfunction in Hypertensive Patients Perticone F, Ceravolo R, Pujia A, et al. Circulation 2001;104: 191– 6. Study Question: Coronary endothelial-dependent vasodilation is an independent predictor of prognosis in coronary disease. This study sought to determine whether forearm endothelial function predicts outcome in essential hypertension Methods: Endothelial-dependent and -independent vasodilation was investigated in 225 previously untreated hypertensive men and women (age 35–54 years) by brachial artery infusion of increasing doses of acetylcholine (Ach) and sodium nitroprusside. Patients received individually tailored treatment with target blood pressure to ⬍140/90 mm Hg with lifestyle changes and drug treatment including diuretics, beta-blockers, ACEi, ANG II antagonists and calcium channel blockers alone or in combinations. Patients were divided into tertiles by percent increase in Ach-stimulated forearm blood flow (FBF) from basal flow. Results: During a mean follow-up of 31.5 months, 29 major CVD events (19 cardiac, 9 cerebrovascular, 1 peripheral vascular) occurred. Event rates per 100 patient years were 8.17, 4.34 and 2.02 in the first, second and third tertiles of peak percent increase in FBF during Ach. The excess relative risk associated with decreased endothelial-dependent vasodilation was 2.08 after controlling for individual risk markers, including basal 24-hour ambulatory blood pressure and after exclusion of soft events. There was no relationship between events and the response to nitroprusside. Conclusions: Forearm endothelial dysfunction is a marker of future cardiovascular events in patients with essential hypertension.
ACC CURRENT JOURNAL REVIEW Nov/Dec 2001
33