Marı́a Angeles Martı́nez

Hyperuricemia, gout and the metabolic syndrome

Purpose of reviewThe metabolic syndrome is defined by the clustering of a number of cardiovascular risk factors and entails an increased risk for cardiovascular disease and mortality from both cardiovascular disease and all causes. In the present paper, we review the most recent evidence on the association between hyperuricemia, metabolic syndrome, and cardiovascular disease. Recent findingsSerum urate is frequently elevated in patients with the metabolic syndrome and increases with the number of components of this condition. Hyperuricemia has been related to decreased renal uric acid excretion, which may be mediated by enhanced proximal tubular sodium reabsorption and hyperinsulinemia. Recent epidemiologic studies have shed some light on the prognosis of hyperuricemia. While hyperuricemia appears to show a benign significance in low cardiovascular risk individuals, it clearly increases cardiovascular mortality in patients at high cardiovascular disease risk. SummaryClinicians should be aware of the presence of metabolic syndrome in patients with hyperuricemia or gout in order to control its components (high blood pressure, obesity, etc.) and hence reduce the risk for cardiovascular disease. Long-term, randomized interventional clinical trials are needed to test the hypothesis that urate-lowering therapy can reduce cardiovascular risk in these patients.

Prevalence of Left ventricular hypertrophy in patients with mild hypertension in primary care: Impact of echocardiography on cardiovascular risk stratification

BACKGROUND Left ventricular hypertrophy (LVH) is an important predictor of cardiovascular risk, and its detection contributes to risk stratification. The aims of the present study were to estimate the prevalence of echocardiographic LVH and to evaluate the influence of echocardiography (ECHO) on cardiovascular risk stratification in hypertensive patients presenting in primary care. METHODS In this cross-sectional study, 250 patients recently diagnosed with mild hypertension underwent clinical evaluation including electrocardiography (ECG), microalbuminuria measurement, 24-h blood pressure monitoring and ECHO. Level of cardiovascular risk was stratified, initially using routine procedures including ECG to assess target organ damage and then again after detection of LVH by ECHO. RESULTS The frequency of echocardiographic LVH was 32%, substantially higher than that detected by ECG (9%). Initial cardiovascular risk stratification yielded the following results: 30% low risk, 49% medium risk, 16% high risk, and 5% very high risk subjects. The detection of LVH by ECHO provoked a significant change in the risk strata distribution, particularly in those patients initially classified as being at medium risk. In this group, 40% of subjects were reclassified as high risk subjects according to ECHO information. The new classification was as follows: 23% low risk, 30% medium risk, 42% high risk, and 5% very high risk subjects. CONCLUSIONS A substantial proportion of mildly hypertensive patients presenting in primary care have LVH determined by ECHO. Our results suggest that this procedure could significantly improve cardiovascular risk stratification in those patients with multiple risk factors, but no evidence of target organ damage by routine investigations.

Relaxation by urocortin of human saphenous veins

Urocortin, an endogenous peptide structurally related to corticotropin‐releasing factor (CRF), has potent cardiovascular effects, suggesting that it may be of significance in cardiovascular regulation. The objective of this study was to analyse the effects of urocortin and its action mechanisms on human blood vessels. To this, 3 mm long segments from human saphenous veins were prepared for isometric tension recording in an organ bath. In the segments at basal resting tone, urocortin did not produce any effect, but in the segments precontracted with endothelin‐1 (1 – 10 nM), urocortin (1 pM – 10 nM) produced concentration‐dependent relaxation. This relaxation was not modified by the inhibitor of nitric oxide synthase NG‐nitro‐L‐arginine methyl ester (L‐NAME, 100 μM), but it was potentiated by the cyclo‐oxygenase inhibitor meclofenamate (10 μM) and it was reduced by the inhibitors of high‐conductance Ca2+‐dependent potassium channels tetraethylammonium (TEA, 10 mM) and charybdotoxin (100 nM). These results indicate that human saphenous veins are very sensitive to urocortin, which produces vascular relaxation by a mechanism independent of nitric oxide and dependent of high‐conductance Ca2+‐dependent potassium channels, and that it may be opposed by the release of vasoconstrictor prostanoids. Therefore, urocortin may be of significance for regulation of the venous circulation in humans.

Time course and prognostic significance of hemostatic changes in sepsis: relation to tumor necrosis factor-alpha.

OBJECTIVES To describe the time course and prognostic significance of tumor necrosis factor-alpha (TNF-alpha) levels and hemostatic abnormalities in clinical sepsis. DESIGN Prospective, observational study with sequential measurements in an inception cohort. SETTING An emergency department in a university teaching hospital. Patients were followed up until they either left the hospital or died. PATIENTS During a 1-yr period, 43 adult patients were selected from all emergency department patients who met the established criteria for sepsis. Excluded were patients with either organ dysfunction or septic shock at the time of admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Blood samples were collected serially (day of admission and on days 3, 5, and 7) to determine TNF-alpha, platelet count, fibrinogen, factor VII, antithrombin III, tissue-type plasminogen activator activity, plasminogen activator inhibitor activity, plasminogen, and alpha2-antiplasmin. Fibrinopeptide A was measured only on the day of admission. Data were analyzed to determine whether admission values or serially obtained values within 7 days were useful in predicting outcome. Thirteen patients died and 30 survived. On admission, assay values indicated that platelet count and antithrombin III were significantly lower than normal (as observed in 50 healthy adults). Fibrinogen, plasminogen activator inhibitor type 1, tissue-type plasminogen activator, fibrinopeptide A, and TNF-alpha were higher than normal, whereas concentrations of factor VII, plasminogen, and alpha2-antiplasmin were in the normal range. No differences were detected in the admission values between survivors and nonsurvivors, except for antithrombin III. However, subsequent values of some variables demonstrated a difference between survivors and nonsurvivors. Survivors showed increasing platelet count and antithrombin III values compared with nonsurvivors, in whom the values remained low, with no significant changes during the study period. High TNF-alpha levels were found in both groups, but only survivors experienced progressive decrease during the observation period. CONCLUSIONS Early clinical sepsis is characterized by high plasma levels of TNF-alpha and by activation of the coagulation and fibrinolysis systems. Longitudinal analysis of some variables (antithrombin III, platelet count, and TNF-ea) showed some differences with time between the survivor and nonsurvivor groups, but we feel that such differences were not large enough to be predictive in individual patients.

Metabolic syndrome: prevalence, associated factors, and C-reactive protein: the MADRIC (MADrid RIesgo Cardiovascular) Study.

The metabolic syndrome (MS) is defined by the clustering of a number of cardiovascular risk factors. The aims of the present study were to estimate the prevalence of MS in Madrid (Spain) by 2 definitions and to investigate its relationship with several sociodemographic factors and C-reactive protein (CRP) levels. This was a cross-sectional population study, and participants were 1344 subjects aged 31 to 70 years. Clinical evaluation included data on sociodemographic and cardiovascular background, physical examination, fasting glucose, triglycerides, and high-density lipoprotein cholesterol. The CRP levels were determined in a subgroup of 843 subjects. The diagnosis of MS was made according to the 2005 Adult Treatment Panel III (ATP III) and International Diabetes Federation (IDF) definitions. The age- and sex-adjusted prevalence of MS was 24.6% (95% confidence interval [CI], 22.3%-26.9%) using the ATP III definition and 30.9% (95% CI, 28.4%-33.3%) using the International Diabetes Federation definition. The overall agreement rate was 91.5% (kappa = 0.80; 95% CI, 0.76-0.83). Prevalence figures by both definitions were higher in men than in women and increased with age. Male sex, older age, low educational level, and physical inactivity were all determinants of ATP III-defined MS. The presence of MS or any of its components was associated with high CRP levels. In a logistic regression analysis, low educational level and waist circumference were the best predictors for high CRP level. The prevalence of MS in the Madrid region is one of the highest in Europe and confirms the strong Spanish regional variability in this syndrome frequency. Some sociodemographic and lifestyle factors, particularly educational level, are predictors for MS and high CRP levels.

Frequency and determinants of microalbuminuria in mild hypertension: a primary-care-based study

Objective To evaluate the frequency of microalbuminuria and its relationship with several risk factors and left ventricular mass in a population of mildly hypertensive subjects attended in a primary-care setting. Design Cross-sectional study. Setting Eight primary-care centres. Patients Two hundred and twenty-three non-diabetic patients recently diagnosed with mild hypertension were included in the study. None of them had clinical evidence of target-organ damage or had received prior antihypertensive treatment. Interventions Subjects included in the study underwent clinical interview, measurement of blood pressure (BP) on three visits, blood analysis, measurement of albumin by immunonephelometry in three overnight urine collections, 24 h BP monitoring and M-mode and Doppler echocardiography. Main outcome measures Tobacco habit, clinic BP, body mass index, serum lipids and uric acid, glycaemia, urinary albumin excretion (UAE), ambulatory BP and left ventricular mass index. Results The frequency of microalbuminuria was 7.2%. Microalbuminuric patients were more likely to be men and to be characterized by higher ambulatory BP, body mass index and uric acid levels. Regression analysis demonstrated that male sex and 24 h systolic BP were determinants of UAE. Patients with white-coat hypertension showed lower UAE than did subjects with sustained hypertension. Although a certain relationship between UAE and left ventricular mass index was found, these variables were not significantly correlated. Conclusions A low proportion of mildly hypertensive patients attended in a primary care setting are microalbuminuric. In this population, UAE is an expression of BP values over 24 h and correlates with several risk factors.

Cerebral vasoconstriction produced by vasopressin in conscious goats: role of vasopressin V1 and V2 receptors and nitric oxide

To examine the role of vasopressin V1 and V2 receptors, nitric oxide and prostanoids in the cerebrovascular effects of arginine vasopressin, cerebral blood flow was electromagnetically measured in awake goats. In 16 animals, vasopressin (0.03 – 1 μg), injected into the cerebral circulation, caused increments of resting cerebrovascular resistance which ranged from 18% (0.03 μg, P<0.01) to 79% (1 μg, P<0.01). Desmopressin (0.03 – 1 μg, four goats) did not affect significantly cerebrovascular resistance. The cerebrovascular resistance increases by vasopressin were reduced significantly by the antagonist for vasopressin V1 receptors d(CH2)5Tyr(Me)‐AVP in a rate depending way (five (six goats) and 15 (four goats) μg min−1), and by the mixed antagonist for vasopressin V1 and V2 receptors desGly‐d(CH2)5‐D‐Tyr(Et)Val‐AVP (5 μg min−1, four goats), and they were not significantly affected by the antagonist for vasopressin V2 receptors d(CH2)5, D‐Ile2, Ile4‐AVP (5 μg min−1, four goats). The inhibitor of nitric oxide synthesis Nw‐nitro‐L‐arginine methyl ester (L‐NAME, 47 mg kg−1 i.v., five goats) augmented cerebrovascular resistance by 130% (P<0.01), and for 24 h after this treatment the cerebrovascular effects of vasopressin were potentiated. The inhibitor of cyclo‐oxygenase meclofenamate (6 mg kg−1 i.v., five goats) did not modify significantly resting haemodynamic variables measured or the cerebrovascular effects of vasopressin. Therefore, the vasopressin‐induced cerebral vasoconstriction may be mediated by vasopressin V1 receptors, without involvement of vasopressin V2 receptors, and may be modulated by nitric oxide but not by prostanoids.

Effects of diabetes on the vascular response to nitric oxide and constrictor prostanoids: gender and regional differences

To analyze the effects of diabetes mellitus on the vascular responsiveness to nitric oxide and thromboxane receptor stimulation, 2 mm long segments of basilar, coronary, renal and tail arteries from male and female, control (normoglycemic) and streptozotocin-induced diabetic rats, were prepared for isometric tension recording. In the segments at basal resting tension, the thromboxane analog U46619 (10(-9)-10(-5) M) produced concentration-dependent contraction, which was similar in arteries from male and female rats, and was reduced by diabetes in coronary arteries from male and in tail arteries from female rats. In the vascular segments precontracted with endothelin-1 (10(-9) M), acetylcholine (10(-9)-3 x 10(-5) M) produced concentration-dependent relaxation which was similar in all arteries from normoglycemic male and female rats, and was increased by diabetes in tail arteries from female, but not in those from male rats. In precontracted segments the nitric oxide donor sodium nitroprusside (10(-10)-10(-5) M) also produced concentration-dependent relaxation, which was higher in basilar arteries from normoglycemic females compared with males, and was increased by diabetes in tail arteries from female but not from male rats. These results suggest that diabetes may increase the relaxation to nitric oxide in tail arteries, and may reduce the contraction to thromboxane receptor activation in coronary and tail arteries in a gender-dependent way. These changes in vascular reactivity may be adaptative to the vascular alterations produced by diabetes.

Impaired potentiation by endothelin-1 and vasopressin of sympathetic contraction in tail artery from hypertensive rats

OBJECTIVE To analyse the effects of endothelin-1 and vasopressin on the sympathetic vasoconstriction during hypertension. METHODS Electrical field stimulation (4 Hz) was applied to isolated, 2 mm segments of the tail artery from spontaneously hypertensive (SHR) and normotensive Wistar-Kyoto (WKY) rats prepared for isometric tension recording. RESULTS The contraction to electrical stimulation was potentiated by endothelin-1 (10(-10)-10(-8) M) in arteries from WKY but not from SHR, and by vasopressin (10(-12)-10(-10) M) more markedly in arteries from WKY than from SHR. The potentiation by endothelin-1 was reduced more markedly by the antagonist of endothelin ETA receptors BQ-123 (10(-5) M) than by the endothelin ETB receptor antagonist BQ-788 (10(-5) M). The potentiation by vasopressin was reduced by the antagonist of vasopressin V1 receptors d(CH2)5Tyr(Me)AVP (10(-7) M), but not by the vasopressin V2 receptor antagonist d(CH2)5D-Ile2, Ile4AVP (10(-7) M). The blocker of L-type calcium channels verapamil (10(-5) M) reduced the potentiation by both endothelin-1 and vasopressin in arteries from WKY rats, and increased the potentiation by vasopressin in arteries from SHR. Noradrenaline (10(-8)-10(-4) M) contraction was not modified by endothelin-1 (3 x 10(-9) M) or vasopressin (3 x 10(-11) M), and contraction to endothelin-1 (10(-9)-10(-7) M) and vasopressin (10(-10)-10(-7) M) was lower in arteries from SHR than from WKY rats. CONCLUSIONS (1) The potentiation by endothelin-1 and vasopressin of the sympathetic vasoconstriction, probably due to increased release of noradrenaline, is impaired during hypertension, and (2) this potentiation is mediated mainly by endothelin ETA receptors, and by vasopressin V1 receptors, in both WKY and SHR, and for both peptides it is mediated by L-type calcium channels in arteries from normotensive but not in those from hypertensive animals.

Coronary effects of vasopressin during partial ischemia and reperfusion in anesthetized goats. Role of nitric oxide and prostanoids.

To examine the coronary effects of arginine-vasopressin and its interaction with nitric oxide and prostanoids during partial ischemia and reperfusion, left circumflex coronary artery flow was electromagnetically measured and partial occlusion of this artery was induced for 60 min, followed by reperfusion in anesthetized goats (seven non-treated, six treated with N(W)-nitro-L-arginine methyl esther (L-NAME) and five with meclofenamate). During partial coronary occlusion, coronary vascular conductance decreased by 20-31% (P<0.01), and the coronary vasodilatation in response to acetylcholine (3-100 ng) and sodium nitroprusside (1-10 microg) was much reduced in every case; the vasoconstriction in response to arginine-vasopressin (0.03-0.3 microg) was attenuated in non-treated animals; this attenuation was reversed by L-NAME and was accentuated by meclofenamate. At 30 min of reperfusion, coronary vascular conductance remained decreased by 11-25% (P<0.05 or P<0.01), and the vasodilatation in response to acetylcholine and sodium nitroprusside as well as the vasoconstriction with arginine-vasopressin was as in the control and comparable in the three groups of animals. These results suggest: (1) that, during ischemia, the coronary vasodilator reserve is greatly reduced and the vasoconstriction with arginine-vasopressin is attenuated, with preservation of the modulatory role of nitric oxide and probable involvement of vasoconstrictor prostanoids in this vasoconstriction; and (2) that, during reperfusion, the coronary vasodilator reserve and the coronary reactivity to acetylcholine and arginine-vasopressin recover, but the modulatory role of nitric oxide in this reactivity may be attenuated.