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With the objectives of clarifying the concepts related to "cardiometabolic risk," "metabolic syndrome" and "risk stratification" and presenting practical strategies to identify and reduce cardiovascular risk in multiethnic patient populations, the Cardiometabolic Working Group presents an executive summary of a detailed analysis and position paper that offers a comprehensive and consolidated approach to the identification and management of cardiometabolic risk. The above concepts overlap and relate to the atherogenic process and development of type 2 diabetes. However, there is confusion about what these terms mean and how they can best be used to improve our understanding of cardiovascular disease treatment and prevention. The concepts related to cardiometabolic risk, pathophysiology, and strategies for identification and management (including health behaviours, pharmacotherapy, and surgery) in the multiethnic Canadian population are presented. "Global cardiometabolic risk" is proposed as an umbrella term for a comprehensive list of existing and emerging factors that predict cardiovascular disease and/or type 2 diabetes. Health behaviour interventions (weight loss, physical activity, diet, smoking cessation) in people identified at high cardiometabolic risk are of critical importance given the emerging crisis of obesity and the consequent epidemic of type 2 diabetes. Vascular protective measures (health behaviours for all patients and pharmacotherapy in appropriate patients) are essential to reduce cardiometabolic risk, and there is growing consensus that a multidisciplinary approach is needed to adequately address cardiometabolic risk factors. Health care professionals must also consider ethnicity-related risk factors in order to appropriately evaluate all individuals in their diverse patient populations., (Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The concepts of "cardiometabolic risk," "metabolic syndrome," and "risk stratification" overlap and relate to the atherogenic process and development of type 2 diabetes. There is confusion about what these terms mean and how they can best be used to improve our understanding of cardiovascular disease treatment and prevention. With the objectives of clarifying these concepts and presenting practical strategies to identify and reduce cardiovascular risk in multiethnic patient populations, the Cardiometabolic Working Group reviewed the evidence related to emerging cardiovascular risk factors and Canadian guideline recommendations in order to present a detailed analysis and consolidated approach to the identification and management of cardiometabolic risk. The concepts related to cardiometabolic risk, pathophysiology, and strategies for identification and management (including health behaviours, pharmacotherapy, and surgery) in the multiethnic Canadian population are presented. "Global cardiometabolic risk" is proposed as an umbrella term for a comprehensive list of existing and emerging factors that predict cardiovascular disease and/or type 2 diabetes. Health behaviour interventions (weight loss, physical activity, diet, smoking cessation) in people identified at high cardiometabolic risk are of critical importance given the emerging crisis of obesity and the consequent epidemic of type 2 diabetes. Vascular protective measures (health behaviours for all patients and pharmacotherapy in appropriate patients) are essential to reduce cardiometabolic risk, and there is growing consensus that a multidisciplinary approach is needed to adequately address cardiometabolic risk factors. Health care professionals must also consider risk factors related to ethnicity in order to appropriately evaluate everyone in their diverse patient populations., (Copyright © 2011 Elsevier Inc. All rights reserved.)

To understand the relationship between putative neurohormonal factors operative in hypertension and coronary artery calcification (CAC), the relevant cellular actions of angiotensin (Ang II) and endothelin-1 (ET-1) are reviewed. There is compelling evidence to implicate ET-1 in CAC. ET-1 increases phosphate transport with a 42 to 73% increase in V(max). Increased cellular phosphate may induce CAC through increased Ca x phosphate product, transformation of vascular smooth muscle cells into a bone-producing phenotype or cell apoptosis that releases procalcific substances. ET-1 is increased in several models of vascular calcification. ET-1 inhibits inhibitors of calcification, matrix Gla and osteoprotegerin, while enhancing pro-calcific factors such as BMP-2 and osteopontin. In contrast, Ang II inhibits phosphate transport decreasing V(max) by 38% and increases matrix Gla. Ang II also stimulates bone resorption. Vascular calcification is reduced by ET-1 A receptor antagonists and to a greater extent than angiotensin receptor blockade although both agents reduce blood pressure.

Objective: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension., Evidence: MEDLINE searches were conducted from November 2008 to October 2009 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed full-text articles only., Recommendations: Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Changes to the recommendations for 2010 relate to automated office blood pressure measurements. Automated office blood pressure measurements can be used in the assessment of office blood pressure. When used under proper conditions, an automated office systolic blood pressure of 135 mmHg or higher or diastolic blood pressure of 85 mmHg or higher should be considered analogous to a mean awake ambulatory systolic blood pressure of 135 mmHg or higher and diastolic blood pressure of 85 mmHg or higher, respectively., Validation: All recommendations were graded according to strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. To be approved, all recommendations were required to be supported by at least 70% of task force members. These guidelines will continue to be updated annually.

Objective: To update the evidence-based recommendations for the prevention and treatment of hypertension in adults for 2010., Options and Outcomes: For lifestyle and pharmacological interventions, randomized trials and systematic reviews of trials were preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the general lack of long-term morbidity and mortality data in this field. Progressive renal impairment was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease., Evidence: A Cochrane Collaboration librarian conducted an independent MEDLINE search from 2008 to August 2009 to update the 2009 recommendations. To identify additional studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence., Recommendations: For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to 1500 mg (65 mmol) per day in adults 50 years of age or younger, to 1300 mg (57 mmol) per day in adults 51 to 70 years of age, and to 1200 mg (52 mmol) per day in adults older than 70 years of age; perform 30 min to 60 min of moderate aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week for men or nine standard drinks per week for women; follow a diet that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources, and that is low in saturated fat and cholesterol; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in patients with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, considerations for initial therapy should include thiazide diuretics, angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. The combination of ACE inhibitors and ARBs should not be used, unless compelling indications are present to suggest consideration of dual therapy. Agents appropriate for first-line therapy for isolated systolic hypertension include thiazide diuretics, long-acting dihydropyridine CCBs or ARBs. In patients with coronary artery disease, ACE inhibitors, ARBs or betablockers are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. In selected high-risk patients in whom combination therapy is being considered, an ACE inhibitor plus a long-acting dihydropyridine CCB is preferable to an ACE inhibitor plus a thiazide diuretic. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian lipid treatment guidelines. Selected patients with hypertension who do not achieve thresholds for statin therapy, but who are otherwise at high risk for cardiovascular events, should nonetheless receive statin therapy. Once blood pressure is controlled, low-dose acetylsalicylic acid therapy should be considered., Validation: All recommendations were graded according to the strength of the evidence and voted on by the 63 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 80% consensus. These guidelines will continue to be updated annually., Sponsors: The Canadian Hypertension Education Program process is sponsored by the Canadian Hypertension Society, Blood Pressure Canada, the Public Health Agency of Canada, the College of Family Physicians of Canada, the Canadian Pharmacists Association, the Canadian Council of Cardiovascular Nurses, and the Heart and Stroke Foundation of Canada.

Background: Despite an increasing body of evidence on the benefit of lowering elevated levels of low-density lipoprotein cholesterol (LDL-C), there is still considerable concern that patients are not achieving target LDL-C levels., Objective: The CANadians Achieve Cholesterol Targets Fast with Atorvastatin Stratified Titration (CanACTFAST) trial tested whether an algorithm-based statin dosing approach would enable patients to achieve LDL-C and total cholesterol/high-density lipoprotein cholesterol (TC/HDL-C) ratio targets quickly., Methods: Subjects requiring statin therapy, but with an LDL-C level of 5.7 mmol/L or lower, and triglycerides of 6.8 mmol/L or lower at screening participated in the 12-week study, which had two open-label, six-week phases: a treatment period during which patients received 10 mg, 20 mg, 40 mg or 80 mg of atorvastatin based on an algorithm incorporating baseline LDL-C value and cardiovascular risk; and patients who achieved both LDL-C and TC/HDL-C ratio targets at six weeks continued on the same atorvastatin dose. Patients who did not achieve both targets received dose uptitration using a single-step titration regimen. The primary efficacy outcome was the proportion of patients achieving target LDL-C levels after 12 weeks., Results: Of 2016 subjects screened at 88 Canadian sites, 1258 were assigned to a study drug (1101 were statin-free and 157 were statin-treated at baseline). The proportion of subjects who achieved LDL-C targets after 12 weeks of treatment was 86% (95% CI 84% to 88%) for statin-free patients and 54% (95% CI 46% to 61%) for statin-treated patients. Overall, 1003 subjects (80%; 95% CI 78% to 82%) achieved both lipid targets., Conclusions: Algorithm-based statin dosing enables patients to achieve LDL-C and TC/HDL-C ratio targets quickly, with either no titration or a single titration.

Aim: The objective of this investigation was to determine whether nitric oxide (NO) and peroxynitrite alter the gene expression of interleukin receptors (IL-R) in cardiomyocytes., Main Methods: Cardiomyocytes, from neonatal mouse heart, in culture were treated with the NO donor 3-morpholinosydnonimine hydrochloride (SIN-1), which releases NO and peroxynitrite. IL-R gene expression was assessed by microarray analysis., Key Findings: Gene expression data show that the IL-2 receptor family showed a highly significant and 1.7-fold increase in the gamma chain component which is common to all members of the IL-2 family receptors. There was a significant and 2-fold increase in IL-21 R and an increase of 1.8-fold in IL-7 Ralpha gene expression. In contrast there was a significant 0.7-fold decrease in IL-9 Ralpha. The IL-1 receptor family showed a significant and 1.4-fold increase in IL-1 R1 compared to control but no change in IL-18 R1 gene expression which was similar to control. The IL-6 family showed a significant increase in oncostatin M receptor gene expression of 1.3-fold but no change in IL-6 R alpha or IL-11 R alpha., Significance: These data suggest that NO/peroxynitrite by increasing gene expression of certain IL-Rs may magnify the effects of specific interleukins in conditions of excess interleukin production.

Background and Aim of the Study: The involvement of p38 MAPK in mediating factors that may produce aortic valve disease is unknown. Angiotensin II (Ang II) has been implicated in the development of aortic stenosis through either the generation of free radicals and/or the modulation of inflammatory responses. A variety of proinflammatory factors utilize Toll-like receptors, and these may also play a role in the development of aortic valve disease., Methods: Valve interstitial cells (VICs) were cultured from porcine aortic valves. Cells were treated with Ang II, 3-morpholinosydnonimine (SIN-1), which liberates NO and superoxide anion generating peroxynitrite, or the lipopetide Toll-like receptor-2 (TLR-2) agonist Pam3CSK4., Results: In response to Ang II (1 microM), MAPK phosphorylation levels were increased by 3.5-fold after 15 min, peaked at 4.6-fold after 60 min, and decreased to 1.9-fold greater than control after 120 min of treatment. In response to SIN-1, phosphorylation levels were increased progressively throughout the 90 min of treatment and were significantly (p < 0.05) twofold (1.9 +/- 0.3) greater than control or native p38 MAPK (2.3 +/- 0.4) after 90 min. SB202190, a relatively selective inhibitor of the p38a MAPK isoform, reduced SIN-1-induced p38 MAPK phosphorylation. In contrast, there was a rapid and marked decline in phosphorylated p38 MAPK, in response to Pam3CSK4 that was evident at 30 min; after 90 min, the p38 MAPK level was 85% lower than baseline., Conclusion: p38 MAPK is present in VICs, and is activated by Ang II. Peroxynitrite similarly increased p38 MAPK phosphorylation, which suggests that these two factors involve similar pathways in their effect on VICs. Alternatively, peroxynitrite may be involved in the pathway by which Ang II activates p38 MAPK. The dramatic reduction in p38 MAPK phosphorylation by TLR-2 stimulation excludes a role for this receptor type in mediating Ang II or peroxynitrite effects, and suggests that inflammatory factors that act through TLR-2 to dephosphorylate p38 MAPK utilize pathways different from Ang II or peroxynitrite, to produce their effect on the aortic valve.

The objective of this study was to examine the potential of stearic acid to induce cardiomyocyte cell death and the hypothesis that the amount of cellular lipid is a determinant of cell death. In cardiomyocytes from embryonic chick heart, stearic acid (SA) produced a significant (P < 0.001) concentration-dependent increase in cell death with an ED(50) of 71 microM. In contrast, capric (C10:0) or oleic acid (OA; C18:1), at < 200 microM, did not alter cell viability. Stearic acid-induced cell death was significantly reduced by OA and to a lesser extent by capric acid. Neither OA nor capric acid altered cell death produced by potassium cyanide and deoxyglucose. Stearic acid (100 microM) induced a significant (P < 0.05) twofold increase in cellular lipid as assessed by Nile blue and Sudan Black staining. A role for cellular lipid in cardiomyocyte death was excluded because OA increased cellular lipid, at concentrations that did not induce cell death; OA did not alter SA-induced cellular fat stores but reduced cell death; and the PPARgamma; agonist troglitazone at concentrations that reduced cellular lipid content did not alter cell death. High concentrations of troglitazone, however, induced cell death. In summary, SA is a potent inducer of cardiac cell death and intracellular lipid accumulation. The amount of intracellular lipid, however, is not a determinant of cardiomyocyte cell death. Troglitazone has potential cardiotoxicity at high doses but, at lower concentrations, does not prevent cardiac lipotoxicity, which can be completely prevented by low concentrations of oleic acid.

1. The aim of the present study was to investigate the role of p38 mitogen-activated protein kinases (MAPK) in mediating the effect of noradrenaline (NA) on cardiomyocyte cell viability. 2. Cardiomyocytes from embryonic chick heart were treated with various concentrations of NA, phenylephrine or isoproterenol and p38 MAPK activation was determined by western blotting. Total cell death was assessed by the 3-(4,5-dimethyl-2 thiazoyl)-2,5-diphenyl-2H-tetrazolium bromide assay. Apoptosis was determined by specific DNA fragmentation. 3. At 100 micromol/L, NA produced a significant increase in cell death that was associated with microscopic changes and DNA fragmentation indicative of apoptosis. The p38 MAPK inhibitor SB202190 (at 1 micromol/L beginning 1 h before NA), reduced NA-induced p38 MAPK activation and significantly accentuated NA-induced cell death. In contrast, the mitogen-activated protein kinase kinase ERK1/2 inhibitor PD98059 (at 1 micromol/L beginning 1 h before NA) did not significantly alter NA-induced cell death. These effects of NA were mediated, in part, through alpha-adrenoceptor because phenylephrine (100 micromol/L), like NA, also induced p38 MAPK activation. However, 100 micromol/L isoproterenol produced a sustained dephosphorylation of p38 MAPK. 4. These data show that NA-induced p38 MAPK activation, through alpha-adrenoceptor, has a protective role in cardiomyocytes to antagonize NA-induced cell death. In contrast, beta-adrenoceptor stimulation produces dephosphorylation of p38 MAPK.

Objective: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension., Options and Outcomes: The diagnosis of hypertension is dependent on appropriate blood pressure measurement, the timely assessment of serially elevated readings, the degree of blood pressure elevation, the method of measurement (office, ambulatory, home) and associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk and determine the urgency, intensity and type of treatment required., Evidence: MEDLINE searches were conducted from November 2007 to October 2008 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed full-text articles only., Recommendations: Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Key messages include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of global risk assessment and the need for ongoing monitoring of hypertensive patients to identify incident type 2 diabetes., Validation: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations were required to be supported by at least 70% of task force members. These guidelines will continue to be updated annually.

Objective: To update the evidence-based recommendations for the prevention and management of hypertension in adults for 2009., Options and Outcomes: For lifestyle and pharmacological interventions, evidence from randomized controlled trials and systematic reviews of trials was preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. Progression of kidney dysfunction was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease., Evidence: A Cochrane collaboration librarian conducted an independent MEDLINE search from 2007 to August 2008 to update the 2008 recommendations. To identify additional published studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence., Recommendations: For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium to less than 2300 mg (100 mmol)/day (and 1500 mg to 2300 mg [65 mmol to 100 mmol]/day in hypertensive patients); perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is reduced in saturated fat and cholesterol, and that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on by the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. Antihypertensive therapy should be considered in all adult patients regardless of age (caution should be exercised in elderly patients who are frail). For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin- converting enzyme (ACE) inhibitors (in patients who are not black), long-acting calcium channel blockers (CCBs), angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered as the initial treatment of hypertension if the systolic blood pressure is 20 mmHg above the target or if the diastolic blood pressure is 10 mmHg above the target. The combination of ACE inhibitors and ARBs should not be used. Other agents appropriate for first-line therapy for isolated systolic hypertension include long- acting dihydropyridine CCBs or ARBs. In patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors or ARBs (if intolerant to ACE inhibitors) are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered., Validation: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

Understanding the mechanism by which chronic high blood pressure induces vascular disease is of fundamental importance for prevention of the adverse consequences of hypertension. Clinical and population studies have consistently found increased circulating levels of interleukin 18 (IL-18) in patients with hypertension. Although obesity, and possibly age, is a determinant of plasma IL-18 levels, the relationship of IL-18 to hypertension seems to be independent of these factors. Experimental evidence indicates that the expression of IL-18 and/or its receptor can be induced by catecholamines or angiotensin, two factors that are involved in the pathophysiology of hypertension. Elevated circulating IL-18 levels are associated with vascular changes in the carotid artery, including increased carotid intima-media thickness, which, in turn, is a predictor of cardiovascular events in patients with established coronary disease. IL-18, either directly or through oxidative stress pathways and matrix metalloproteins, can alter endothelial function or induce vascular smooth muscle cell migration and/or proliferation to produce the vascular changes that occur with hypertension. This Review examines the data on IL-18 and hypertensive vascular disease, and explores the potential cellular and molecular mechanisms that might connect hypertension to vascular disease.

Background and Objectives: Jumonji (jmj) is the prototypical member of the jmj domain-containing protein family. It regulates the expression of several genes, in particular genes involved in cardiac cell growth in the embryonic heart. The function of jmj in the mature or developed heart, however, is unclear., Results: We propose that JMJ domain 2A family may be involved in modulating the development of cardiac hypertrophy through interactions with cell cycle-regulatory proteins, specifically retinoblastoma protein, cyclin D and transcription factor E2F, that lead to cell growth. Because nitric oxide can block the development of cardiac hypertrophy and upregulate both jmj gene and protein expression, we propose that jmj is a novel regulatory factor mediating nitric oxide-induced modulation of cardiac hypertrophy., Conclusion: Jmj may be a critical, previously unrecognized factor that 'counteracts' the development of cardiac hypertrophy. Biotechnology approaches to increase its expression may be a potential therapeutic strategy to mitigate the increased cardiovascular morbidity and mortality associated with cardiac hypertrophy.

The objective of this study was to determine whether the metalloporphyrin, 5,10,15,20-tetrakis(4-sulfonatophenyl) porphyrinato iron (III) chloride (FeTPPS), antagonized the effect of peroxynitrite, oxygen-free radicals, and the combination of the two, on cardiomyocyte cell viability. We further sought to compare the effects of FeTPPS to an inhibitor of the mitochondrial transmembrane permeability transition pores (PTP)-cyclosporin A. Cardiomyocytes from embryonic chick heart were treated with 3-morpholinosydnonimine (SIN-1), which decomposes to liberate NO and superoxide anion (O(2) (-)) which in turn generates peroxynitrite. FeTPPS antagonized cell death induced by either SIN-1 or H(2)O(2). The combination of H(2)O(2) plus SIN-1 further enhanced the amount of cell death over SIN-1 alone. FeTPPS rescued cells from almost complete cell death with the combination of SIN-1 plus H(2)O(2). SIN-1 induced cardiac protein nitration, including mitochondrial proteins as demonstrated by Western blotting with nitrotyrosine-specific antibodies. FeTPPS reduced cellular protein nitration. SIN-1-induced loss of mitochondrial transmembrane permeability transition pores potential was visualized with fluorescent dye staining and was reversed by FeTPPS. In contrast, the mitochondrial PTP blocker cyclosporin A did not alter SIN-1-induced cell death. In summary, these data demonstrate the enhanced cellular lethality of the combination of peroxynitrite and reactive oxygen species from hydrogen peroxide. A mitochondrial death pathway was implicated as nitration of mitochondrial proteins was induced by peroxynitrite that also induced a loss of DeltaPsim that was prevented by FeTPPS. In contrast, cyclosporin did not antagonize the effects of SIN-1. The ability of FeTPPS to reduce reactive nitrogen-induced cell death, and protein nitration suggests that FeTPPS is a useful agent to maintain cell viability and is better than cyclosporin in this situation.

The objective of this study was to determine whether the dual action of nitric oxide (NO) on cardiomyocyte cell viability is mediated through p38 mitogen-activated protein kinase (MAPK)-induced cell death and extracellular signal-regulated kinase (ERK1/2)-mediated cell survival pathways, and whether either of these is mediated through a cGMP-protein kinase G (PKG) pathway. Cell viability of embryonic chick cardiomyocytes was assessed by the MTT assay, which is based on the ability of viable cells to reduce 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide. The NO donor sodium nitroprusside (SNP) produced a significant (P < 0.01) concentration-dependent reduction in cell viability or increase in cell death. Sodium nitroprusside induced ERK1/2 phosphorylation, and the mitogen-activated protein kinase (MEK1/2) inhibitor PD 98059 significantly increased cell death. In contrast, SB202190, a relatively selective inhibitor of p38 MAPK, did not affect SNP-induced cell death. The cardioprotective effect of NO was prbably mediated in part via cGMP because 1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one, a selective inhibitor of NO-sensitive guanylyl cyclase, produced a significant enhancement of SNP-induced cell death. In contrast, the PKG inhibitor KT5823 did not affect cell viability. In summary, these data suggest that NO, via stimulation of soluble guanylyl cyclase, activates MEK1/2 whose product, ERK1/2, protects against cell death. In contrast, SNP-induced p38 MAPK activation does not modulate NO-induced cardiomyocyte cell death. Not all cGMP targets affect NO-induced cell death, since the PKG pathway does not enhance or suppress NO-induced cardiomyocyte cell death. Enhancement of the ERK1/2 responses to NO may permit the beneficial effects of NO to predominate.

Objective: To update the evidence-based recommendations for the prevention and management of hypertension in adults., Options and Outcomes: For lifestyle and pharmacological interventions, evidence was preferentially reviewed from randomized controlled trials and systematic reviews of trials. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. Progression of kidney dysfunction was also accepted as a clinically relevant primary outcome among patients with chronic kidney disease., Evidence: A Cochrane collaboration librarian conducted an independent MEDLINE search from 2006 to August 2007 to update the 2007 recommendations. To identify additional published studies, reference lists were reviewed and experts were contacted. All relevant articles were reviewed and appraised independently by content and methodological experts using prespecified levels of evidence., Recommendations: For lifestyle modifications to prevent and treat hypertension, restrict dietary sodium intake to less than 100 mmol/day (and 65 mmol/day to 100 mmol/day in hypertensive patients); perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (smaller than 102 cm for men and smaller than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a diet that is reduced in saturated fat and cholesterol, and one that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and consider stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should be predicated on by the patient's global atherosclerotic risk, target organ damage and comorbid conditions. Blood pressure should be decreased to lower than 140/90 mmHg in all patients, and to lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients will require more than one agent to achieve these target blood pressures. For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin-converting enzyme (ACE) inhibitors (in nonblack patients), long-acting calcium channel blockers (CCBs), angiotensin receptor antagonists (ARBs) or beta-blockers (in those younger than 60 years of age). A combination of two first-line agents may also be considered for initial treatment of hypertension if systolic blood pressure is 20 mmHg above target or if diastolic blood pressure is 10 mmHg above target. Other agents appropriate for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine CCBs or ARBs. In patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor/diuretic combination is preferred; in patients with proteinuric nondiabetic chronic kidney disease, ACE inhibitors are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension but who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered., Validation: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

Objective: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension., Options and Outcomes: The diagnosis of hypertension is dependent on appropriate blood pressure measurement, the timely assessment of serially elevated readings, degree of blood pressure elevation, method of measurement (office, ambulatory, home) and associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk and determine the urgency, intensity and type of treatment required., Evidence: MEDLINE searches were conducted from November 2006 to October 2007 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed, full-text articles only., Recommendations: Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Key messages in 2008 include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of global risk assessment and the need for ongoing monitoring of hypertensive patients to identify incident type 2 diabetes., Validation: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here received at least 70% consensus. These guidelines will continue to be updated annually.

Peroxynitrite is well-recognized as being capable of inducing damaging cellular effects and has been identified as a mediator of cell damage in numerous disease states, including cardiovascular diseases. Metalloporphyrins are a class of molecule that represents an exciting new pharmacological approach to reducing peroxynitrite levels. These compounds catalyze the conversion of the harmful peroxynitrite molecules into less toxic derivatives and can be considered the reasonable intervention to reduce the toxicity of peroxynitrite. Several compounds have been synthesized and tested with promising results. Differences in the metalloporphyrin structure affect their reactivity. Iron-based metalloporphyrins display the highest rate of peroxynitrite decomposition with the narrowest scope of side reactions, whereas manganese-based metalloporphyrins react slower and with more pronounced secondary reactions, notably functioning as superoxide dismutase mimetics. This review examines the evidence that peroxynitrite is operative in patients with cardiovascular disease focusing on metalloporphyrin peroxynitrite decomposition catalysts and the evidence for their utility in the pharmacological treatment of major cardiovascular diseases. The data suggest that modification of peroxynitrite-induced cardiovascular injury is an intriguing and useful treatment approach.

The objective of this study was to determine the role of palmitate-induced stimulation of nitric oxide synthase (NOS) on palmitate-induced cell death, specifically distinguishing the effects of the subtype NOS2 from NOS3, defining the effect of NO on mitochondria death pathways, and determining whether palmitate induces peroxynitrite formation which may impact cardiomyocyte cell survival. Cardiomyocytes from embryonic chick hearts were treated with palmitate 300-500 microM. Cell death was assessed by the 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide (MTT) assay. The ability of palmitate to induce NO production and its consequences were tested by using the NOS inhibitor 7-nitroindazole (7-N) and the peroxynitrite scavenger (5,10,15,20-tetrakis(4-sulfonatophenyl)porphyrinato iron (III) chloride) (FeTPPS). The effect of palmitate on the mitochondria was assessed by Western blotting for cytochrome c release into the cytosol, and assessment of mitochondrial transmembrane potential (DeltaPsi(m)) by 5,5',6,6'-tetrachloro-1,1',3,3'-tetraethyl-benzimidazolyl-carbocyanine iodide staining and immunocytochemistry. The NOS inhibitor 7-N, which is selective for NOS2 and not for NOS3, significantly (p<0.05) increased palmitate-induced cell death. In contrast, 7-N did not alter cell death produced by the combination of potassium cyanide and deoxyglucose, which, respectively, inhibit glycolysis and oxidative phosphorylation. The mitochondrial actions of palmitate, specifically palmitate-induced translocation of mitochondrial cytochrome c to cytosol and loss of mitochondrial transmembrane potential, were not altered by pretreatment with 7-N. FeTPPS, which isomerizes peroxynitrite to nitrate and thereby reduces the toxic effects of peroxynitrite, produced a significant reduction in palmitate-induced cell death. In summary, these data suggest that palmitate stimulates NO production, which has a dual action to protect against cell death or to induce cell death. Palmitate-induced cell death is mediated, in part, through NO generation, which leads to peroxynitrite formation. The protective effect of NO is operative through stimulation of NOS2 but not NOS3. The actions of NO on palmitate-induced cell death are independent of mitochondrial cell death pathways.

Jumonji (JMJ, Jarid2), a prototypical member of the jumonji domain-containing protein family, plays a major role in embryonic cardiac development, but its role in the developed heart is unclear. Cardiomyocytes from neonatal mouse heart were treated in culture with NO donor SIN-1, 500 microM, for 2, 4, and 20 h. SIN-1 treatment was associated with a significant and 6.9 +/- 2.5 fold increase in jmj gene expression over all time points. The expression of jmj increased markedly and significantly 4.2 +/- 1.1 fold, 16.6 +/- 4.1 fold, and 2.7 +/- 0.3 fold, respectively, at time points 2 h, 4 h, and 20 h after treatment. The ability of the increase in gene expression to translate into an increase in cellular protein expression was ascertained by Western blotting, which showed an increase in the JMJ protein in whole-cell lysates. Because of the relationship of JMJ to Rb and ANP in the heart, gene expression of these proteins was also examined. SIN-1 produced a small but significant increase in Rb2, but not Rb1 or Rb-binding proteins 4, 6, or 7. In contrast, SIN-1 produced a marked and significant reduction in natriuretic peptide precursor type B but not type C to 0.24 +/- 0.09 fold of the control. These data suggest that JMJ may be a critical, previously unrecognized factor that mediates some of the cellular effects of NO, that NO may be able to increase JMJ in diseases associated with reduced JMJ expression.

Aim: The objective of this study was to examine the interaction ofa 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor (statin) with a nitric oxide (NO) donor from the perspective of the impact on cardiomyocyte cell viability., Methods: Embryonic chick cardiomyocytes in culture were treated with a wide range of concentrations of sodium nitroprusside (SNP), which releases NO and also generates toxic reactive nitrogen species. SNP was combined with the HMG-CoA reductase inhibitor lovastatin and cell viability was assessed by the MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide] assay., Results: SNP and lovastatin each produced a significant (p < 0.01) concentration-dependent increase in cell death. Using SNP concentrations at or below the ED50, SNP (0.01, 0.1 or 0.5 mmol/l) increased the amount of cell death when combined with lovastatin (1, 10, 50 and 100 micromol/l). At lovastatin concentrations of 50 micromol/l and less, the amount of cell death was consistently similar to the arithmetic sum of SNP and lovastatin, suggesting that there was an additive and not synergistic relationship between SNP and lovastatin. In combination with lovastatin (100 micromol/l), however, the amount of cell death was consistently lower than the calculated expected value and suggested saturation of a common mechanism. The combination of SNP and lovastatin produced the characteristic microscopic changes of apoptosis. Considering that both SNP and lovastatin can activate caspase-3, cells were treated with the caspase-3 inhibitor Ac-DEVD-CHO. This inhibitor produced a significant (p < 0.05) and consistent 30% reduction in the amount of cell death induced by SNP and lovastatin., Conclusion: These data suggest that the cardiomyocyte toxicity from NO continues to be evident uninterrupted by and not accentuated by the presence of an HMG-CoA inhibitor. The cardiac adverse effect of each of these agents utilizes a common pathway involving caspase-3 so that their cardiotoxicity can be blunted by a caspase-3 inhibitor., (Copyright 2008 S. Karger AG, Basel.)

Unlabelled: The objectives of this study were to determine whether endogenous opioids are operative in modulating the CNS action of angiotensin II (ang II) on blood pressure and to determine whether this is mediated by endogenous mu or kappa opioid receptor agonists. The study design was: unanesthetized Wistar rats, 300-400g, previously instrumented with a cannula in the lateral cerebral ventricle and a catheter in the femoral artery, had ang II, 0.5microg, injected into the lateral cerebral ventricle (ICV). Groups were allocated to receive naloxone, a mu opioid receptor antagonist or MR 2266 a selective kappa opioid receptor antagonist prior to ang II. In other experiments in unanesthetized rats, baroreceptor reflex function was assessed by intravenous injection of phenylephrine or nitroprusside and the interaction of endogenous opioids and ang II ascertained with use of the mu or kappa opioid receptor antagonist ., Results: Ang II significantly (p<0.05) increased systolic and diastolic blood pressure. The kappa opioid antagonist, MR 2266, 25microg/kg ICV, significantly (p<0.05) reduced and MR 2266, 50microg/kg ICV, completely prevented the increase in blood pressure produced by ang II. In contrast, the mu opioid receptor antagonist, naloxone, 50microg/kg, ICV, did not significantly attenuate the blood pressure responses to ang II. Ang II induced alteration in baroreceptor function. The effect of ang II on baroreceptor function was significantly antagonized by the kappa opioid receptor antagonist MR 2266. In conclusion, these data indicate that: (a) endogenous opioids modulate the pressor response to intracerebral ang II, (b) this effect is mediated mainly through endogenous kappa opioid agonists and kappa rather than mu opioid receptors, (c) alteration of baroreceptor sensitivity by ang II is modulated by endogenous kappa opioids.

The objective of this study was to understand the mechanism of action of nitric oxide (NO) in the heart by determining whether nitric oxide (NO) released from sodium nitroprusside (SNP) induces p38 mitogen activated protein kinase (p38 MAPK) phosphorylation and whether this is mediated through a cyclic GMP (cGMP)/protein kinase G (PKG) pathway. p38 MAPK activation was examined by Western blotting of whole cell lysates of embryonic chick cardiomyocytes with antibodies specific to the native or phosphorylated forms of p38 MAPK. SNP, 1 mM, which released significant amounts of NO as determined by Griess reaction, induced p38 MAPK phosphorylation that was apparent within 10 min, was significantly (p<0.05) greater than control at 60 min and remained higher than initial levels up to the 4 h end point of the experiment. This could not be attributed to hydrogen peroxide release from SNP as catalase did not affect SNP-induced p38 MAPK phosphorylation. SB202190, a relatively selective inhibitor of p38 MAPK, mainly p38alpha MAPK, inhibited SNP-induced p38 MAPK phosphorylation. SNP-induced p38 MAPK phosphorylation was not altered by pre-treatment with the PKG inhibitor KT 5823 or by ODQ a potent and selective inhibitor of NO-sensitive guanylyl cyclase. p38 MAPK phosphorylation was not induced by the cell permeable cGMP analogue, 8-Br-cGMP. In summary, considering that new therapeutic strategies aimed at NO and p38 MAPK are being considered for myocardial injury and heart failure, these data demonstrate that SNP induces p38 MAPK phosphorylation through a pathway that is independent of NO-induced activation of cGMP/PKG pathways and suggest that non cGMP/PKG regulatory proteins leading to p38 MAPK phosphorylation merit further investigation to address this therapeutic target.

The role of p53 in mediating nitric oxide (NO)-induced cell death remains uncertain. The exogenous NO donor S-nitrosoglutathione (GSNO) produced a concentration-dependent reduction in cell viability in embryonic chick cardiomyocytes in culture. Western blotting and immunocytochemistry for p53 showed that p53 was increased in whole cell lysates by GSNO: 0.001 mM GSNO led to 1.3 +/- 0.5-fold increase compared to control, and significantly (p < 0.05) increased to 1.6 +/- 0.2-fold after 0.01 mM GSNO. Higher GSNO concentrations did not further increase p53 protein expression despite producing significant increases in cell death. The p53 inhibitor pifithrin did not block GSNO-induced cell death. GSNO induced morphological changes of DNA fragmentation, nuclear condensation, and cell shrinkage. Pifithrin failed to block these morphologic changes, while it antagonized the similar cellular changes induced by adriamycin, which operates in part through p53. NO induced a concentration-dependent DNA damage. When assessed by the comet assay, the damage was 2.1 +/- 0.3-fold and 2.6 +/- 0.5-fold more than the control following 0.01 mM and 1.0 mM GSNO treatments, respectively. The DNA damage was not reduced by treatment with the pifithrin, which markedly reduced DNA damage induced by adriamycin. There was no p53 translocation to mitochondria, any major cytochrome c release from mitochondria, or change in mitochondrial membrane potential. Furthermore, cyclosporin A, which inhibits mitochondrial pore opening and cytochrome c loss, did not alter NO-induced cell death. Translocation of p53 from the cytosol to the nucleus occurred with a maximal increase of 2.9-fold in the nucleus following 1.0 mM GSNO for 24 h. These data indicate that in cardiomyocytes, NO induced marked DNA damage and translocation of p53 to the nucleus, suggesting that p53 is involved in the cellular response to NO, perhaps to modulate the genomic response to NO-induced cellular toxicity. NO-induced cell death, however, operates through p53-independent pathways, including a mitochondrial apoptotic pathway.

There is unequivocal evidence of autophagy in the heart, both in human hearts from patients who experienced heart failure and in experimental models of myocardial ischemia and reperfusion. Whether autophagy is involved in the pathophysiology of these conditions is controversial as studies suggest inhibition of Beclin 1 can increase or decrease cardiomyocyte cell injury. Increased beclin 1 expression, however, has been consistently identified in myocardial ischemia/reperfusion. Because of the role of nitric oxide (NO) in myocardial ischemia/reperfusion as well as in heart failure, we sought to determine whether NO and its byproduct peroxynitrite alter the expression of some genes involved in autophagy in the heart. Neonatal mouse cardiomyocytes were treated with SIN-1 (3-morpholinosydnonimine), which releases NO and accelerates formation of peroxynitrite. Gene expression was evaluated using RNA labeled and hybridized to cDNA microarrays. SIN-1 treatment induced significant changes in five caspases. In contrast, there were no changes in three genes involved in autophagy, namely beclin 1, Atg5l and Atg12l. Several different time periods were examined; a short time period, 2h, to more closely model myocardial ischemia reperfusion and a long time period, 20 h, that more closely represents sustained injury. In summary, evidence to date suggests that NO is not involved in increased beclin 1 expression in ischemia/reperfusion injury in the heart and would be unlikely to account for the signs of autophagy in the hearts of patients with heart failure.

The objective of this study was to determine whether adrenomedullin, a vasodilator peptide, modulates the process of cell death in cardiomyocytes and whether its effect would be enhanced by the endopeptidase inhibitor omapatrilat, which reduces adrenomedullin degradation. Further, we sought to determine whether the effect of adrenomedullin involved an action to preserve mitochondrial transmembrane potential (DeltaPsi(m)). Cardiomyocytes in culture were treated with agents that interrupted the mitochondrial electron transport chain, inhibiting glycolysis and oxidative phosphorylation. Cell death was evaluated by the MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide) assay and DeltaPsi(m) was assessed by fluorescent microscopy. Cytochrome c loss from mitochondria and appearance in cytosol was determined by Western blotting. Potassium cyanide (KCN) plus deoxyglucose or antimycin A, for 24 h, produced significant (p<0.01) concentration-dependent reductions in cell viability or increases in cell death. Adrenomedullin reduced cell death produced in this manner and the effect of adrenomedullin was enhanced by treatment with omapatrilat. In contrast, there was no additional reduction in cell death by lisinopril treatment. Omapatrilat plus adrenomedullin reduced the KCN plus deoxyglucose-induced increase in cytosolic cytochrome c. A likely mechanism centers on the ability of adrenomedullin plus omapatrilat to prevent the decline in mitochondrial DeltaPsi(m) produced by KCN plus deoxyglucose treatment. In summary, adrenomedullin plus omapatrilat limited the decline in mitochondrial DeltaPsi(m) that accompanies interruption of mitochondrial metabolism and limited the extent of cell death in cardiomyocytes treated with KCN plus deoxyglucose or antimycin. Adrenomedullin plus the endopeptidase inhibitor omapatrilat may be a useful strategy to protect cardiomyocytes from cell death, in conditions associated with impairment of mitochondrial function.

Objective: To provide updated, evidence-based recommendations for the prevention and management of hypertension in adults., Options and Outcomes: For lifestyle and pharmacological interventions, evidence was reviewed from randomized controlled trials and systematic reviews of trials. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. However, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity and mortality data in this field. For treatment of patients with kidney disease, the progression of kidney dysfunction was also accepted as a clinically relevant primary outcome., Evidence: A Cochrane collaboration librarian conducted an independent MEDLINE search from 2005 to August 2006 to update the 2006 Canadian Hypertension Education Program recommendations. In addition, reference lists were scanned and experts were contacted to identify additional published studies. All relevant articles were reviewed and appraised independently by both content and methodological experts using prespecified levels of evidence., Recommendations: Dietary lifestyle modifications for prevention of hypertension, in addition to a well-balanced diet, include a dietary sodium intake of less than 100 mmol/day. In hypertensive patients, the dietary sodium intake should be limited to 65 mmol/day to 100 mmol/day. Other lifestyle modifications for both normotensive and hypertensive patients include: performing 30 min to 60 min of aerobic exercise four to seven days per week; maintaining a healthy body weight (body mass index of 18.5 kg/m2 to 24.9 kg/m2) and waist circumference (less than 102 cm in men and less than 88 cm in women); limiting alcohol consumption to no more than 14 units per week in men or nine units per week in women; following a diet reduced in saturated fat and cholesterol, and one that emphasizes fruits, vegetables and low-fat dairy products, dietary and soluble fibre, whole grains and protein from plant sources; and considering stress management in selected individuals with hypertension. For the pharmacological management of hypertension, treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and any comorbid conditions: blood pressure should be lowered to lower than 140/90 mmHg in all patients and lower than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease. Most patients require more than one agent to achieve these blood pressure targets. In adults without compelling indications for other agents, initial therapy should include thiazide diuretics; other agents appropriate for first-line therapy for diastolic and/or systolic hypertension include angiotensin-converting enzyme (ACE) inhibitors (except in black patients), long-acting calcium channel blockers (CCBs), angiotensin receptor blockers (ARBs) or beta-blockers (in those younger than 60 years of age). First-line therapy for isolated systolic hypertension includes long-acting dihydropyridine CCBs or ARBs. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction, or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with cerebrovascular disease, an ACE inhibitor plus diuretic combination is preferred; in patients with nondiabetic chronic kidney disease, ACE inhibitors are recommended; and in patients with diabetes mellitus, ACE inhibitors or ARBs (or, in patients without albuminuria, thiazides or dihydropyridine CCBs) are appropriate first-line therapies. All hypertensive patients with dyslipidemia should be treated using the thresholds, targets and agents outlined in the Canadian Cardiovascular Society position statement (recommendations for the diagnosis and treatment of dyslipidemia and prevention of cardiovascular disease). Selected high-risk patients with hypertension who do not achieve thresholds for statin therapy according to the position paper should nonetheless receive statin therapy. Once blood pressure is controlled, acetylsalicylic acid therapy should be considered., Validation: All recommendations were graded according to strength of the evidence and voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

Objective: To provide updated, evidence-based recommendations for the diagnosis and assessment of adults with hypertension., Options and Outcomes: The diagnosis of hypertension is dependent on the appropriate measurement of blood pressure, the timely assessment of serially elevated readings, the degree of blood pressure elevation, the method of measurement (office, ambulatory, home) and any associated comorbidities. The presence of cardiovascular risk factors and target organ damage should be ascertained to assess global cardiovascular risk, and to determine the urgency, intensity and type of treatment required., Evidence: MEDLINE searches were conducted from November 2005 to October 2006 with the aid of a medical librarian. Reference lists were scanned, experts were contacted, and the personal files of authors and subgroup members were used to identify additional studies. Content and methodological experts assessed studies using prespecified, standardized evidence-based algorithms. Recommendations were based on evidence from peer-reviewed, full-text articles only., Recommendations: Recommendations for blood pressure measurement, criteria for hypertension diagnosis and follow-up, assessment of global cardiovascular risk, diagnostic testing, diagnosis of renovascular and endocrine causes of hypertension, home and ambulatory monitoring, and the use of echocardiography in hypertensive individuals are outlined. Key messages in 2007 include continued emphasis on the expedited, accurate diagnosis of hypertension, the importance of assessing the risk of cerebrovascular events as part of global risk assessment, the need for ongoing reassessment of patients with high normal blood pressure, and reviews of recent studies involving laboratory testing and home monitoring., Validation: All recommendations were graded according to strength of the evidence and were voted on by the 57 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here received at least 70% consensus. These guidelines will continue to be updated annually.

Epicardial fat is a relatively neglected component of the heart. The purpose of this review was to examine the anatomic and biochemical data on epicardial fat; to examine the relationship of epicardial fat to obesity and to explore the potential role of epicardial fat in the relationship of obesity to coronary atherothrombotic disease. Epicardial fat covers 80% of the heart's surface and constitutes 20% of total heart weight. It is present along the distribution of the coronary arteries, over the right ventricle especially along the right border, anterior surface and at the apex. There is three- to fourfold more epicardial fat associated with the right than the left ventricle. Putative physiologic functions of epicardial fat are based on observational data and include: buffering coronary arteries against the torsion induced by the arterial pulse wave and cardiac contraction, facilitating coronary artery remodelling, regulating fatty acid homeostasis in the coronary microcirculation and providing fatty acids to cardiac muscle as a local energy source in times of high demand. A considerable amount of the data on epicardial fat originates from autopsy series that have the inherent problem that conditions leading to death may have altered body composition and adiposity. With this caveat, data indicate that epicardial fat mass increases age until age 20-40 years but thereafter the amount of epicardial fat is not dependent on age. The amount of epicardial fat correlates with heart weight but the presence of myocardial ischemia and hypertrophy does not alter the ratio of epicardial fat to cardiac muscle mass. A number of properties differentiate epicardial fat from other fat depots specifically its smaller adipocytes size; different fatty acid composition, high protein content; high rates of fatty acid incorporation, fatty acid synthesis, insulin-induced lipogenesis or fatty acid breakdown; low rates of glucose utilization, low expression (mRNA) of lipoprotein lipase, stearoyl-CoA desaturase and acetyl-CoA carboxylase-alpha, and slow regression during weight loss. There is a significant direct relationship between the amount of epicardial fat and general body adiposity. Clinical imaging studies have demonstrated a strong direct correlation between epicardial fat and abdominal visceral adiposity. Several lines of evidence support a role for epicardial fat in the pathogenesis of coronary artery disease, namely the close anatomic relationship between epicardial fat and coronary arteries; the positive correlation between the amount of epicardial fat and the presence of coronary atherosclerosis and the ability of adipose tissue to secrete hormones and cytokines that modulate coronary artery atherothrombosis. Thus, epicardial fat maybe an important factor responsible for cardiovascular disease in obesity.

Nitric oxide (NO) is fundamentally important molecule which produces a wide range of cellular effects with the most poorly understood one being alteration in the sensitivity to cell death. The objective of this study was to test the hypothesis that NO would differentially affect caspase or autophagy gene expression in a manner that might account for the disparate actions of NO to either enhance or protect against cell death. Neonatal mouse cardiomyocytes in culture were treated with the NO donor SIN-1 (3-morpholinosydnonimine hydrochloride) for up to 20 h. RNA was collected, after either 2, 4 or 20 h, labeled and hybridized to cDNA microarray slides The concentration of SIN-1 was selected after concentration response studies of SIN-1 on cell viability, assessed by the MTT assay. The cDNA microarrays were used that contained the mouse genome version 2.0 with genes for enzymes crucial to apoptosis, namely caspases-1, -2, -3, -6, -7, -8, -9, -11, -12 and -14, as well as for enzymes crucial to autophagy namely beclin-1, Apg5l and Apg12l. Considering the entire 20 h period, treatment with SIN-1 was associated with significant (p<0.05) changes in five caspases. In contrast, there were no changes in the three separate genes involved in autophagy. Time course experiments showed a consistent increase in caspase-8, -11 and -14, and a consistent decrease in caspase-1 and -6. Notably, caspase-1 showed a persistent and marked reduction so that after 20 h of treatment, caspase-1 was dramatically reduced, almost ten fold, to 0.14+/-0.11 of control. In conclusion, these results suggest that: (i) NO regulates the expression of genes involved in apoptotic but not some involved in autophagic cell death; (ii) the more recently discovered caspase-14 may have a role in the heart; (iii) NO-induced alteration of different caspases may explain the ability of NO to either enhance or protect against cell death depending on whether associated factors involve, respectively caspases-8, -11, and -14 or -1 and -6.

The objective of this study was to determine whether an HMG Co A reductase inhibitor (statin) reduces protein synthesis in cardiomyocytes and whether this action maybe an underlying mechanism for statin-induced cell death. Cardiomyocytes from embryonic chick heart were maintained in culture. Cells exposed to lovastatin for 4 h showed a concentration dependent reduction in protein synthesis as assessed by [3H] leucine incorporation and [35S] methionine incorporation. Compared to control, lovastatin 100 microM, which produced a 25% increase in cell death, induced a three-fold reduction in methionine incorporation. [35S] methionine autoradiography showed little (new) protein synthesis at concentrations of lovastatin of 70 microM or higher; an effect that was not limited to specific proteins. Cardiomyocytes treated with lovastatin showed morphologic changes in the nucleoli consistent with insufficient protein synthesis. These cardiomyocytes manifested cell death under conditions of reduced protein synthesis. Interruption of protein synthesis with cycloheximide, a ribosomal RNA transcription inhibitor or reduction in protein substrate availability by lowering the media concentration of fetal calf serum was associated with a concentration-dependent reductions in cell viability. Importantly, stimulation of protein synthesis by higher concentrations of fetal calf serum limited lovastatin-induced cell death. These data suggest that statin-induced inhibition of protein synthesis is an underlying mechanism for statin-induced cell death.

Objective: To provide updated, evidence-based recommendations for the management of hypertension in adults., Options and Outcomes: For lifestyle and pharmacological interventions, evidence from randomized, controlled trials and systematic reviews of trials was preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. For lifestyle interventions, blood pressure (BP) lowering was accepted as a primary outcome given the lack of long-term morbidity/mortality data in this field. For treatment of patients with kidney disease, the development of proteinuria or worsening of kidney function was also accepted as a clinically relevant primary outcome., Evidence: MEDLINE searches were conducted from November 2004 to October 2005 to update the 2005 recommendations. In addition, reference lists were scanned and experts were contacted to identify additional published studies. All relevant articles were reviewed and appraised independently by content and methodological experts using prespecified levels of evidence., Recommendations: Lifestyle modifications to prevent and/or treat hypertension include the following: perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index of 18.5 kg/m2 to 24.9 kg/m2) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week in men or nine standard drinks per week in women; follow a diet that is reduced in saturated fat and cholesterol and that emphasizes fruits, vegetables and low-fat dairy products; restrict salt intake; and consider stress management in selected individuals. Treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and comorbid conditions. BP should be lowered to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease (regardless of the degree of proteinuria). Most adults with hypertension require more than one agent to achieve these target BPs. For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic hypertension with or without systolic hypertension include beta-blockers (in those younger than 60 years), angiotensin-converting enzyme (ACE) inhibitors (in nonblack patients), long-acting calcium channel blockers or angiotensin receptor antagonists. Other agents for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine calcium channel blockers or angiotensin receptor antagonists. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with diabetes mellitus, ACE inhibitors or angiotensin receptor antagonists (or in patients without albuminuria, thiazides or dihydropyridine calcium channel blockers) are appropriate first-line therapies; and in patients with nondiabetic chronic kidney disease, ACE inhibitors are recommended. All hypertensive patients should have their fasting lipids screened, and those with dyslipidemia should be treated using the thresholds, targets and agents recommended by the Canadian Hypertension Education Program Working Group on the management of dyslipidemia and the prevention of cardiovascular disease. Selected patients with hypertension, but without dyslipidemia, should also receive statin therapy and/or acetylsalicylic acid therapy., Validation: All recommendations were graded according to strength of the evidence and voted on by the 45 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

Background and Aim of the Study: The aortic valve leaflets plus the aorta and sinuses of Valsalva are a functional unit that optimizes distribution of the diastolic pressure load on the aortic valve leaflets. The study aim was to examine the hypothesis that echocardiographically measured parameters of aortic wall stress at the level of the sinuses of Valsalva, namely aortic wall thickness and luminal diameter, are associated with the presence of aortic valve sclerosis (AVS)., Methods: Among 103 patients (age range 60-70 years) referred for echocardiography at a university hospital, 59 with AVS were compared to an age-matched control group (n = 44) with no echocardiographic abnormalities. Subjects with congenital bicuspid aortic valves were excluded from the study. Transthoracic echocardiographically obtained digital loop recordings were reviewed and two-dimensionally guided measurements were made at the level of the aortic annulus and sinus of Valsalva using electronic calipers, from the parasternal long-axis view., Results: There was a significant linear relationship and direct correlation between aortic root diameter at the sinus of Valsalva and body surface area (BSA) (r = 0.488, F = 31.6, p < 0.001) in both the AVS (r = 0.491, F = 18.1, p < 0.001) and control (r = 0.571; F = 20.3; p < 0.001) groups. After adjusting for BSA, aortic wall thickness was significantly (p < 0.05) smaller in AVS patients compared to controls. Luminal diameter was not significantly different between the two groups. The specificity of the relationship with sinus of Valsalva wall thickness was confirmed by an absence of any difference in aortic root thickness at the level of the aortic annulus in AVS compared to controls., Conclusion: AVS is associated with a thinner aortic wall at the level of the sinus of Valsalva. This novel finding suggests that a thinner aortic wall, a reflection of its constituents, likely acting through its contribution to reduced aortic compliance and increased aortic stress, leads to the thickening of aortic valve leaflets characteristic of AVS. Further understanding of this relationship may unravel the pathophysiology of this type of aortic valve disease.

To investigate the effect of chronic amiodarone treatment on tissue phospholipids, a marker of amiodarone-induced toxicity, and to test the hypothesis that tissue phospholipids changes are related to amiodarone-induced effects on thyroid function, male Wistar rats were treated with amiodarone and tissue phospholipid content and fractions were assessed. Twenty-six animals were allocated to 4 groups: (i) group 1 received amiodarone, 20 mg/kg per day, for 3 weeks (n = 6); (ii) group 2 received amiodarone for 5 weeks (n = 6); (iii) group 3 received drug for 6 weeks (n = 6), and (iv) group 4 (control group) received the diluent for 6 weeks (n = 8). Total phospholipid content of lung, kidney and skeletal muscle but not heart was increased after 3 weeks of amiodarone treatment. With longer durations of treatment, the phospholipid content was significantly (p < 0.05) reduced in all four organs. The proportion of phospholipids in different classes was modified by amiodarone treatment with the most consistent changes across different tissues being reductions in phosphatidylethanolamine and increases in phosphatidylserine. Serum thyroxine concentration was significantly (p < 0.05) reduced at 5 weeks of treatment and thereafter. There was a significant correlation between serum thyroxine and total phospholipid concentration in heart (r = 0.555; p < 0.05) and lung (r = 0.502; p < 0.05). For heart, there was a significant correlation between serum thyroxine and the distribution of phospholipid classes, mainly for phosphatidylserine even after considering amiodarone dose. The same was found in the lung. In the kidney and skeletal muscle, there was a significant (p < 0.05) correlation between serum thyroxine and the proportion of phospholipids in phosphatidylcholine and sphingomyelin. In conclusion, this study presents the novel finding of a biphasic tissue phospholipid response to amiodarone characterized by a short term increase in phospholipids in lung, kidney and skeletal muscle but not the heart followed by a long term decline in phospholipids in all four organs that is likely due to a direct action of amiodarone on phospholipid metabolism and potentially the result of amiodarone-induced reduction in thyroid function., (Copyright 2006 S. Karger AG, Basel.)

Because cytoskeletal actin is regulated, in part, by Rho, and because Rho and caspases are involved in apoptosis, we sought to determine whether there was an association between RhoB and caspase-2. A RhoB-caspase-2 association was consistently demonstrated in neonatal mouse cardiomyocytes with Western Blotting, either after immunoprecipitation with RhoB followed by immunoblotting with caspase-2, or in reciprocal experiments after immuno precipitation with caspase-2 and immunoblotting with RhoB (n = 14). Although the RhoB-caspase-2 complex was constitutively present, the link between RhoB and caspase-2 may be operative in apoptosis because the HMG-CoA reductase inhibitor lovastatin increased the RhoB-caspase complex, especially in the nuclear fraction of the cell, with a peak occurrence 2 h after treatment. This association was unaffected by the caspase-2 inhibitor zVDVAD. Lovastatin produced apoptosis that was accompanied by an activation of caspase-2, as demonstrated by its immunohistochemistry and by the fact that the caspase-2 inhibitor zVDVAD reduced lovastatin-induced apoptosis. Lovastatin induced dramatic changes in cell morphology and a reduction in F-actin. Immunoblotting for actin suggests that lovastatin does not induce a degradation of the actin molecule, but rather affects filamentous F-actin. Caspase-2 inhibition with zVDVAD reduced lovastatin-induced alteration in cytoskeletal F-actin. The Rho inhibitor, Clostridium difficile toxin B, blunted the ability of lovastatin to induce apoptosis. In summary, these data show a previously unrecognized association between RhoB and caspase-2 in the cytosolic and nuclear fractions, which has ramifications for processes regulated by RhoB and caspase-2, including apoptosis.

This study examined the impact of ceramide, an intracellular mediator of apoptosis, on the mitochondria to test the hypothesis that ceramide utilized p38 MAPK in the mitochondria to alter mitochondrial potential and induce apoptosis. The capacity of ceramide to adversely affect mitochondria was demonstrated by the significant loss of mitochondrial potential (DeltaPsim), indicated by a J-aggregate fluorescent probe, after embryonic chick cardiomyocytes were treated with the cell permeable ceramide analogue C2-ceramide. p38 MAPK was identified in the mitochondrial fraction of the cell and p38 MAPK phosphorylation in this mitochondrial fraction of the cell occurred with ceramide treatment. In addition, SAPK phosphorylation and a decrease in ERK phosphorylation occurred in whole cell lysates after ceramide treatment. The p38 MAPK inhibitor SB 202190 but not the MEK inhibitor PD 98059 significantly inhibited ceramide-induced apoptosis and loss of DeltaPsim. These data suggest that p38 MAPK is present in the mitochondria and its activation by ceramide indicates local signaling more directly coupled to the mitochondrial pathway in apoptosis.

Objective: To provide updated, evidence-based recommendations for the management of hypertension in adults., Options and Outcomes: For lifestyle and pharmacological interventions, evidence from randomized controlled trials and systematic reviews of trials was preferentially reviewed. While changes in cardiovascular morbidity and mortality were the primary outcomes of interest, for lifestyle interventions, blood pressure lowering was accepted as a primary outcome given the lack of long-term morbidity/mortality data in this field, and for certain comorbid conditions, other relevant outcomes, such as development of proteinuria or worsening of kidney function, were considered., Evidence: MEDLINE searches were conducted from November 2003 to October 2004 to update the 2004 recommendations. Reference lists were scanned, experts were contacted, and the personal files of the subgroup members and authors were used to identify additional published studies. All relevant articles were reviewed and appraised independently, using prespecified levels of evidence, by content and methodology experts. As per previous years, only studies that had been published in the peer-reviewed literature were included; evidence from abstracts, conference presentations and unpublished personal communications was not included., Recommendations: Lifestyle modifications to prevent and/or treat hypertension include the following: perform 30 min to 60 min of aerobic exercise on four to seven days of the week; maintain a healthy body weight (body mass index of 18.5 kg/m2 to 24.9 kg/m2) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 units per week in men or nine units per week in women; follow a reduced fat, low cholesterol diet with an adequate intake of potassium, magnesium and calcium; restrict salt intake; and consider stress management (in selected individuals). Treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and any comorbid conditions. Blood pressure should be lowered to 140/90 mmHg or less in all patients, and to 130/80 mmHg or less in those with diabetes mellitus or chronic kidney disease. Most adults with hypertension require more than one agent to achieve target blood pressures. For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic hypertension with or without systolic hypertension include beta-blockers (in those younger than 60 years), angiotensin-converting enzyme (ACE) inhibitors (except in black patients), long-acting calcium channel blockers and angiotensin receptor antagonists. Other agents appropriate for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine calcium channel blockers and angiotensin receptor antagonists. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with diabetes mellitus, ACE inhibitors or angiotensin receptor antagonists (or thiazides in patients with diabetes mellitus without albuminuria) are appropriate first-line therapies; and in patients with nondiabetic chronic kidney disease, ACE inhibitors are recommended. All hypertensive patients should have their fasting lipids screened, and those with dyslipidemia should be treated using the thresholds, targets and agents recommended by the Canadian Hypertension Education Program Working Group on the management of dyslipidemia and the prevention of cardiovascular disease. Selected patients with hypertension, but without dyslipidemia, should also receive statin therapy and/or acetylsalicylic acid therapy., Validation: All recommendations were graded according to the strength of the evidence and voted on by the 43 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.

Background: Aortic valve sclerosis (AVS), a condition of thickening and calcification of the normal trileaflet aortic valve without the obstruction to left ventricular outflow, is likely the initial stage in the development of aortic stenosis and is associated with an increased incidence of cardiovascular events. The objective of this study is to critically review the data on the association of blood pressure and hypertension with AVS., Methods: A systematic search of MEDLINE and EMBASE (to June 2004) was conducted using the keywords hypertension and aortic valve. All English language papers were examined if they dealt with hypertension and AVS. All studies were included for analysis if they had a control group., Results: Three population-based, cross-sectional studies with a total sample size of 6450 individuals showed a consistent and significant relationship between hypertension and AVS with an odds ratio (OR) ranging from 1.23 to 1.74. Smaller case-control studies with a total sample size of 1609 individuals did not show consistent results but the OR ranged from 1.75 to 2.38. Only one small study (n = 188) showed fewer cases with hypertension and AVS than in the control group. Hypertension was a significant factor remaining in multivariate analysis after consideration of age and other risk factors in several cross-sectional studies. In contrast, other studies with blood pressure measurements consistently showed no increased blood pressures in the presence of AVS. However, these studies did not examine the prevalence of AVS within age-adjusted blood pressure levels., Conclusions: Cross-sectional population-based studies present evidence of an association between hypertension and AVS with an OR between 1.23 and 1.74. The major limitation in establishing a causal relationship is the failure to demonstrate a gradient of risk between increasing blood pressure and increasing incidence of AVS. In addition, the literature is confounded by the wide variety of definitions for AVS as well as hypertension. At this time, further data is required to conclude that there is a causal relationship between AVS and elevated blood pressure.

The objective of this study was to test the hypothesis that a strategy based on alteration of lipid metabolism would moderate the cellular toxicity of the C16:0 saturated fatty acid-palmitate. Cardiomyocytes from neonatal mice and embryonic chicks were treated with palmitate and both oncotic and apoptotic death were observed. Fenofibrate pretreatment, 1 microM, 24 h prior to palmitate, significantly (p < 0.05) reduced palmitate-induced apoptosis. In contrast, fenofibrate had no significant effect on palmitate-induced apoptosis when fenofibrate treatment was concomitant with palmitate. The protective effect of fenofibrate was restricted to the apoptotic population. The more potent and specific PPARalpha agonist WY 14643, 1 microM, also reduced palmitate-induced apoptosis but to a smaller extent than fenofibrate. The long pretreatment time, 24 h, was necessary to show fenofibrate's effect on apoptosis, suggesting an increase in gene transcription and protein expression. Indeed, fenofibrate increased PPARalpha expression that was mainly demonstrated in the nucleus. These data suggest a novel approach to the reduction of cardiac apoptosis by the chronic treatment with the PPARalpha agonist fenofibrate.

The objective of this study was to test the hypothesis that nitric oxide synthase (NOS) is subjected to regulatory control by palmitate, and that nitric oxide (NO) is operative in palmitate-induced cell death. Palmitate induced a significant ( p<0.05 ) concentration-dependent increase in NOS activity measured by the conversion of [(3)H]arginine to [3H]citrulline in embryonic chick cardiomyocytes. Cellular eNOS and iNOS, determined by immunocytochemistry, were increased by palmitate. Western blotting also showed that palmitate, 500 microM for 4h, significantly increased the amount of cellular of eNOS and iNOS by 36.2+/-6.5% ( p<0.001 ) and 38.4+/-14.4% ( p<0.05 ), respectively. The NOS inhibitor L-NAME significantly ( p<0.05 ) accentuated palmitate-induced cell death These data suggest that palmitate has a bifunctional effect on cell viability--in addition to loss of cell viability, palmitate stimulates NOS activity by inducing an increase in cellular eNOS and iNOS with the resultant NO production serving to protect cardiomyocytes from palmitate-induced cell death.

The objective of this study was to test the hypothesis that cytoskeletal actin fragmentation is mediated through caspase-2, specifically examining the ability of a caspase-2 inhibitor to interfere with actin fragmentation, in comparison with a caspase-3 inhibitor. Cardiomyocytes were cultured from embryonic chick heart. The fine structural element of cellular F-actin was visualized by staining cardiomyocytes with NBD-phallacidin. Lovastatin induced a dramatic and concentration-dependent loss of intact F-actin. The selectivity of this effect of lovastatin was demonstrated by the absence of similar changes in F-actin when cardiomyocytes were treated with the apoptotic stimulus palmitate, the metabolism of which produces acetyl CoA, the early substrate of cholesterol synthesis, through the mevalonate pathway. FACS analysis of NBD-phallacidin-stained cells was used to quantify the amount of F-actin loss. Actin fragmentation produced by lovastatin was operative through a caspase-2 pathway, as the caspase-2 inhibitor, z-VDVAD-fmk, significantly blocked lovastatin-induced changes in F-actin, but the caspase-3 inhibitor, Ac-DEVD-CHO, did not. Interruption of the mevalonate pathway was in part responsible for lovastatin's action, as the downstream metabolite mevalonate partially reversed the effect of lovastatin on actin fragmentation. These data indicate a previously unrecognized link between cytoskeletal actin and caspase-2.

The objective of this study was to evaluate the cardiac toxicity of the HMG-CoA reductase inhibitors by testing the hypothesis that lovastatin induces apoptotic and/or oncotic cell death in the myocyte element of the heart and further that cell death is mediated through interruption of the mevalonate pathway and that apoptosis is induced through activation of caspase-2 and caspase-3. Cardiomyocytes were cultured from embryonic chick heart. Lovastatin-induced apoptosis in these cells was demonstrated by three independent techniques, namely (1) FACS analysis of low DNA content by propidium iodide (PI); (2) microscopic assessment for cellular changes of apoptosis; and (3) FACS analysis of cells stained with PI and fluorescein diacetate. Lovastatin produced a concentration-dependent increase in apoptotic cell death and 100 microM lovastatin showed over a 4-fold increase in apoptosis compared to control. Lovastatin also induced oncotic cell death, as there was a 2.5-fold increase in the amount of oncotic cell death compared to control. Lovastatin-induced apoptosis operated, in part, through the mevalonate pathway. The caspase-2 inhibitor z-VDVAD-fmk and the caspase-3 inhibitor Ac-DEVD-CHO reduced the extent of lovastatin-induced cardiac apoptosis. In contrast, lovastatin-induced oncosis was not only insensitive to these caspase-2 or -3 inhibitors but occurred through a mevalonate-independent mechanism of action. In summary, lovastatin-induced cardiotoxicity is complex and represents the sum of two distinct modes of cell death operating in part through the mevalonate pathway with the apoptotic component subject to modification by inhibitors of the initiator caspase, caspase-2, as well as the effector caspase, caspase-3.

The pathophysiology of acute coronary syndromes is related to erosion or rupture of vulnerable plaque leading to intracoronary thrombosis as a result of activation of the coagulation cascade and platelet aggregation. Potential benefit of hypolipidemic 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibition may be related to the pleiotropic effects such as endothelial function improvement, stabilization of the plaque in relation to reduced macrophage activity and smooth muscle cell proliferation, as well as other anti-inflammatory effects that have been demonstrated in animal models. With the publication of the Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) study, early initiation of statin therapy within 24 to 96 h has been recognized as an important addition to the therapeutic armamentarium in the management of patients with acute coronary syndromes.

Objective: Inflammatory markers predict cardiovascular events in a wide range of patients. Two factors, fibrinogen (FIB) and high-sensitivity C reactive protein (CRP), are currently entering clinical practice as cardiovascular risk predictors. In patients with type 2 diabetes mellitus, we sought to examine the relationship between macrovascular disease, urinary albumin/creatinine ratio (ACR), and FIB or CRP, as well as the relationship of FIB and CRP with traditional risk predictors of these complications of diabetes., Methods: In 202 consecutive patients with type 2 diabetes mellitus from a diabetes clinic, clinical and biochemical data were obtained and a cross-sectional analysis was performed., Results: Patients with macrovascular disease had higher FIB (P=.02) but not higher CRP. They were older, more likely to have retinopathy or elevated serum creatinine, had higher ACR and lower HDL cholesterol. They were more likely to be treated with statins, beta-blockers, and ASA. Adjustment for statin therapy did not result in significant differences in CRP levels according to macrovascular disease status. Both FIB (P=.01) and CRP (P=.02) were significantly higher in patients with ACR whose values were in the proteinuria range. In multivariate analysis, both FIB (P=.001) and CRP (P=.03) were positively correlated with ACR, but no association was seen between CRP and ACR when FIB was entered in the model. Other factors positively associated with ACR were age, diastolic blood pressure, retinopathy, and hemoglobin A1c (HbA1c). FIB and CRP were strongly correlated (R=.49, P< or =.001) and this effect was independent of statin therapy. CRP was positively associated with body mass index (BMI), serum triglycerides, and sulfonylurea therapy and negatively associated with metformin therapy. Patients on statin therapy had significantly higher FIB and lower CRP. Women on hormone replacement therapy (HRT) had significantly lower FIB and higher CRP., Conclusions: In patients with diabetes: (1) the two markers, FIB and CRP, are interrelated; (2) FIB is significantly associated with presence of microvascular disease, independent of CRP; (3) CRP is strongly associated with metabolic factors but not with complications of diabetes, independently of FIB; (4) statins and HRT were divergently associated with CRP and FIB as HRT was associated with lower FIB and higher CRP, while statins showed the reverse association; and (5) CRP and FIB provide different information about the characteristics and consequences of diabetes mellitus because of divergent associations with biological indicators and therapeutic agents.

The objective of this study was to evaluate whether ceramide, palmitate, and inhibitors of mitochondrial electron transport chain shared similar effects on the mitochondria of intact cardiomyocytes in order to determine the likelihood that ceramide and palmitate utilize similar mitochondrial mechanisms or pathways to apoptosis. In embryonic chick cardiomyocytes, ceramide, 100 microM for 24h, induced a 42.9+/-5.8% increase in cell death assessed by the MTT assay, and a significant (P<0.01) 3.9+/-0.6-fold increase in apoptosis assessed by propidium iodide staining of permeabilized cells. Mitochondrial potential (delta psi (m)), as demonstrated microscopically and by flow cytometry of cardiomyocytes stained with a J-aggregate dye, was markedly and significantly reduced by ceramide, palmitate, and two different inhibitors of the mitochondrial electron transport chain-rotenone and antimycin A. In contrast, the effect on mitochondria as assessed by CMX-Ros oxidation was dramatically different, as palmitate, rotenone, and antimycin A each produced a reduction, while ceramide increased CMX-Ros fluorescence. Further ceramide-induced cardiomyocyte apoptosis and loss of delta psi (m) operated through a cyclosporine-insensitive pathway similar to rotenone and antimycin A but distinct from palmitate which induced apoptosis though a cyclosporine-sensitive mechanism in these cells. These data suggest that ceramide acts on the mitochondria of intact cells through a cyclosporine-insensitive mechanism likely from a combination of actions including production of mitochondrial oxidants. The discordant findings between ceramide and palmitate suggest that palmitate-induced cell death is not primarily mediated by de novo ceramide synthesis.

The objective of this study was to determine whether nitric oxide (NO)-induced cell death in cardiomyocytes was operative through de novo synthesis of ceramide by determining whether the ceramide synthase inhibitor fumonisin blocked NO-mediated cell death. Neonatal mouse cardiomyocytes in culture were pretreated with fumonisin B1 (FB1). FB1 is a competitive inhibitor of sphinganine N-acyl transferase, also known as ceramide synthase (EC 2.3.1.24). Cell viability was assessed by the (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide (MTT) assay, which is based on the ability of viable cells to reduce MTT. Treatment with the NO donor nitroso-glutathione (NO-GSH) for 24h produced a significant (p<0.05) concentration-dependent reduction in OD(570) or an increase in cell death. Sodium nitroprusside (SNP) treatment for 24h produced a significant (p<0.001) concentration-dependent reduction in OD(570) and an increase in cardiomyocyte cell death but the effects of SNP were greater than those of NO-GSH. FB1 significantly (p<0.05) reduced cell death induced by either SNP or NO-GSH. The SNP (0.1mM) increase in cell death of 36.9+/-2.8% was significantly (p<0.05) reduced to 24.7+/-1.8% by FB1 (10 microM). The effect of FB1 was not mediated through inhibition of the cell death effects of H(2)O(2), which is produced by SNP, as FB1 did not prevent H(2)O(2)-induced cell death. Confirmation of the ability of ceramide to produce cell death was demonstrated by the cell-permeable ceramide analogue, C(2)-ceramide (100 and 200 microM), which induced, respectively, 23.4+/-11.3 and 78.0+/-3.7% increases in cell death. The cell death effects of SNP and NO-GSH are likely independent of cGMP signal transduction pathways, which are activated by either SNP or NO-GSH, as there was no significant concentration-dependent change in cardiomyocyte viability after treatment with the cell-permeable analogue dibutyryl-GMP. These data show that FB1 blunts SNP- and NO-induced cardiomyocyte death and raise the novel possibility of preventing some of SNP- or NO-induced cardiomyocyte cell death by ceramide synthase inhibition.

Fatty acids such as palmitate have been observed to induce apoptosis in cardiomyocytes but the mechanism of this cytotoxicity is unresolved. The present study sought to determine whether an aspect of fatty acid metabolism is responsible for palmitate-induced apoptosis in cardiomyocytes. As palmitate metabolism increases acetyl CoA production via increased beta oxidation within the mitochondria, we hypothesized that increased acetyl CoA entering the cholesterol biosynthesis pathway might produce intermediates or end products that would be toxic to the cell. To test this hypothesis, cardiomyocytes from embryonic chick cardiomyocytes were treated with the 3-hydroxy-3-methylgutaryl CoA (HMG-CoA) reductase inhibitor lovastatin that inhibits the cholesterol biosynthesis pathway downstream of the acetyl CoA trimerization into HMG-CoA. Lovastatin did not inhibit palmitate-induced apoptosis. Rather, lovastatin induced significant apoptosis itself and when combined with palmitate, the level of apoptosis was equal to the sum of palmitate alone and lovastatin alone. This observation suggests that palmitate and lovastatin are inducing apoptosis by two independent mechanisms. A role for mitochondrial metabolism via carnitine palmitoyl transferase (CPT) in palmitate-induced apoptosis was suggested since capric acid, a fatty acid that is metabolized within the mitochondria but does not utilize CPT-1, did not induce apoptosis. Palmitate-induced apoptosis was further related to the metabolism of saturated fatty acids as the unsaturated fatty acid oleic acid did not induce apoptosis. These data suggest that a unique feature about palmitate metabolism independent of its role in cholesterol biosynthesis is responsible for palmitate-induced apoptosis and the effects of palmitate are additive to those of lovastatin to induce cardiac apoptosis.