Clinical trial NCT03371823: Vascular Dysfunction in Hypertensive Postmenopausal Women
Official title: Losartan and ET-1 Mediated Constriction in Postmenopausal Women With High Blood Pressure
Study type: INTERVENTIONAL
Overall status: TERMINATED
Phase: PHASE4
Conditions: Cardiovascular Diseases
Hypertension
Keywords: Hypertension
Endothelin-1 receptor
Lead sponsor: University of Delaware
Sponsor class: OTHER
Collaborators: name: National Institutes of Health (NIH)
First posted: 2017-12-13
Enrollment: 8
Sex: FEMALE
Minimum age (years): 50
Maximum age (years): 70
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: NON_RANDOMIZED
Intervention model: PARALLEL
Primary purpose: OTHER

Brief summary: The purpose of this study is to investigate the role of ET-1 in mediating vasoconstrictor tone in hypertensive postmenopausal women (PMW) alone and in combination with a commonly prescribed Angiotensin II (ANG II) antagonist. The long term goal is to understand the mechanisms contributing to hypertension (HTN) in PMW. This study is the first step in reaching our goal.

Detailed description: Cardiovascular disease (CVD) is the leading cause of death in women, and mortality from CVD is higher in PMW compared to age-matched men. PMW are at a greater risk for developing HTN, a major risk factor for CVD. They are also more likely to have uncontrolled or resistant HTN despite medication.

ANG II is a common therapeutic target for the treatment HTN. ANG II blockade is highly effective in normalizing blood pressure (BP) in hypertensive male rats, but does not reduce BP to the same degree in hypertensive post menopausal female rats. Endothelin-1 (ET-1) receptor antagonists reduce BP in hypertensive postmenopausal female rats, but have no effect on males. Thus the mechanisms contributing to HTN in female rats and likely women, particularly after menopause, are complex, multifactorial and not completely understood.

After menopause, the vasoconstrictor effects of both ANG II and ET-1 are amplified in animal models. As such, these two predominant pathways may contribute to the high incidence of HTN in PMW. ET-1 is a potent vasoconstrictor produced and released by endothelial cells that binds to two receptor subtypes, ET-A and ET-B. While both receptors are located on vascular smooth muscle (VSM) and mediate vasoconstriction, ET-B receptors are also located on the endothelium and mediate vasodilation via nitric oxide.

Importantly, the production of ET-1 and expression of ET-A and B receptors can be modulated by hormones such as estradiol and ANG II. Estradiol attenuates ET-1 production, and reduces ET-1 mediated vasoconstriction via an ET-B receptor mechanism in vitro. Thus, decline in estradiol after menopause may enhance vasoconstrictor tone via ET-1 and lead to HTN. ET-1 also potentiates the vasoconstrictor effects of ANG II since the vasoconstrictor and hypertensive effects of ANG II are ameliorated by ET-1 receptor blockade. Additionally, ANG II stimulates the synthesis of ET-1 and upregulates ET-A and ET-B receptor expression on VSM. The ANG II receptor antagonist Losartan reduces ET-A and ET-B receptor expression and attenuates the constrictor effects of ET-1 in a diabetic rat model. Therefore, ET-1 is an important independent factor contributing to HTN in PMW, but therapeutic agents targeting both ANG II and ET-1 may have greater efficacy given their interactions.

The investigators propose a comprehensive assessment of vascular function by measuring blood flow responses in the cutaneous circulation during perfusion of ET-1 receptor antagonists via microdialysis, combined with measures of intracellular protein and receptor expression of endothelial cells and skin punch biopsies collected from normotensive and hypertensive PMW. Investigators central hypothesis is that hypertensive PMW have greater ET-1 mediated vasoconstrictor tone due to increased ET-1 expression, down-regulation of ET-B receptors on endothelial cells and up-regulation of both ET-A and ET-B receptors on VSM leading to increased vasoconstriction and HTN. Investigators further hypothesize that ANG II exacerbates the increase in ET-1, and ET-A and ET-B receptor expression contributing to exaggerated constriction with HTN in PMW.

Eligibility criteria: Inclusion Criteria: - Women.

* \> 1year post menopausal.
* Age range 50-70 years
* Resting ECG in normal limits
* Standard blood chemistry within normal limits
* Systolic blood pressure: \<130mm Hg for normotensives; \>130mm Hg for hypertensives.
* Diastolic blood pressure: \< 80mm Hg for normotensives; \> 80mm Hg for hypertensives.

Exclusion Criteria:

* History of cardiovascular disease
* Blood clots or stroke
* Cancer
* Diabetes
* Kidney or Liver disease
* Obesity (BMI\>35kg/m2)
* Pregnant/Breast feeding
* Current use of hormone therapy
* Current use of tobacco products
* High cholesterol
* Current use of anti-hypertensive meds

Primary outcomes:
measure: ET-1 Mediated Constriction
timeFrame: Each participant was assessed at baseline and 2 weeks later.
Secondary outcomes:
measure: Endothelin Receptor A and B Expression
timeFrame: Baseline and 2 weeks later
Other outcomes:
Locations:
city: Newark
country: United States
facility: University of Delaware
state: Delaware
Study officials:
affiliation: University of Delaware
name: Megan Wenner, Ph.D
role: PRINCIPAL_INVESTIGATOR
References:
citation: Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, Bravata DM, Dai S, Ford ES, Fox CS, Franco S, Fullerton HJ, Gillespie C, Hailpern SM, Heit JA, Howard VJ, Huffman MD, Kissela BM, Kittner SJ, Lackland DT, Lichtman JH, Lisabeth LD, Magid D, Marcus GM, Marelli A, Matchar DB, McGuire DK, Mohler ER, Moy CS, Mussolino ME, Nichol G, Paynter NP, Schreiner PJ, Sorlie PD, Stein J, Turan TN, Virani SS, Wong ND, Woo D, Turner MB; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Executive summary: heart disease and stroke statistics--2013 update: a report from the American Heart Association. Circulation. 2013 Jan 1;127(1):143-52. doi: 10.1161/CIR.0b013e318282ab8f. No abstract available.
citation: Barton M, Meyer MR. Postmenopausal hypertension: mechanisms and therapy. Hypertension. 2009 Jul;54(1):11-8. doi: 10.1161/HYPERTENSIONAHA.108.120022. Epub 2009 May 26. No abstract available.
citation: Kim JK, Alley D, Seeman T, Karlamangla A, Crimmins E. Recent changes in cardiovascular risk factors among women and men. J Womens Health (Larchmt). 2006 Jul-Aug;15(6):734-46. doi: 10.1089/jwh.2006.15.734.
citation: Yanes LL, Romero DG, Iles JW, Iliescu R, Gomez-Sanchez C, Reckelhoff JF. Sexual dimorphism in the renin-angiotensin system in aging spontaneously hypertensive rats. Am J Physiol Regul Integr Comp Physiol. 2006 Aug;291(2):R383-90. doi: 10.1152/ajpregu.00510.2005. Epub 2006 Mar 30.
citation: Yanes LL, Romero DG, Iliescu R, Zhang H, Davis D, Reckelhoff JF. Postmenopausal hypertension: role of the Renin-Angiotensin system. Hypertension. 2010 Sep;56(3):359-63. doi: 10.1161/HYPERTENSIONAHA.110.152975. Epub 2010 Aug 2.
citation: Reckelhoff JF. Gender differences in the regulation of blood pressure. Hypertension. 2001 May;37(5):1199-208. doi: 10.1161/01.hyp.37.5.1199.
citation: Yanes LL, Reckelhoff JF. Postmenopausal hypertension. Am J Hypertens. 2011 Jul;24(7):740-9. doi: 10.1038/ajh.2011.71. Epub 2011 Apr 21.
citation: Yanes LL, Romero DG, Cucchiarelli VE, Fortepiani LA, Gomez-Sanchez CE, Santacruz F, Reckelhoff JF. Role of endothelin in mediating postmenopausal hypertension in a rat model. Am J Physiol Regul Integr Comp Physiol. 2005 Jan;288(1):R229-33. doi: 10.1152/ajpregu.00697.2003. Epub 2004 Aug 19.
citation: Lima R, Yanes LL, Davis DD, Reckelhoff JF. Roles played by 20-HETE, angiotensin II and endothelin in mediating the hypertension in aging female spontaneously hypertensive rats. Am J Physiol Regul Integr Comp Physiol. 2013 Feb;304(3):R248-51. doi: 10.1152/ajpregu.00380.2012. Epub 2012 Dec 5.
citation: Haynes WG. Endothelins as regulators of vascular tone in man. Clin Sci (Lond). 1995 May;88(5):509-17. doi: 10.1042/cs0880509.
citation: Ishikawa K, Ihara M, Noguchi K, Mase T, Mino N, Saeki T, Fukuroda T, Fukami T, Ozaki S, Nagase T, et al. Biochemical and pharmacological profile of a potent and selective endothelin B-receptor antagonist, BQ-788. Proc Natl Acad Sci U S A. 1994 May 24;91(11):4892-6. doi: 10.1073/pnas.91.11.4892.
citation: Yanagisawa M, Kurihara H, Kimura S, Tomobe Y, Kobayashi M, Mitsui Y, Yazaki Y, Goto K, Masaki T. A novel potent vasoconstrictor peptide produced by vascular endothelial cells. Nature. 1988 Mar 31;332(6163):411-5. doi: 10.1038/332411a0.
citation: Juan SH, Chen JJ, Chen CH, Lin H, Cheng CF, Liu JC, Hsieh MH, Chen YL, Chao HH, Chen TH, Chan P, Cheng TH. 17beta-estradiol inhibits cyclic strain-induced endothelin-1 gene expression within vascular endothelial cells. Am J Physiol Heart Circ Physiol. 2004 Sep;287(3):H1254-61. doi: 10.1152/ajpheart.00723.2003. Epub 2004 May 6.
citation: Pedersen SH, Nielsen LB, Mortensen A, Nilas L, Ottesen B. Progestins oppose the effects of estradiol on the endothelin-1 receptor type B in coronary arteries from ovariectomized hyperlipidemic rabbits. Menopause. 2008 May-Jun;15(3):503-10. doi: 10.1097/gme.0b013e318156f803.
citation: Wenzel RR, Ruthemann J, Bruck H, Schafers RF, Michel MC, Philipp T. Endothelin-A receptor antagonist inhibits angiotensin II and noradrenaline in man. Br J Clin Pharmacol. 2001 Aug;52(2):151-7. doi: 10.1046/j.0306-5251.2001.01422.x.
citation: Gossl M, Mitchell A, Lerman A, Opazo Saez A, Schafers RF, Erbel R, Philipp T, Wenzel RR. Endothelin-B-receptor-selective antagonist inhibits endothelin-1 induced potentiation on the vasoconstriction to noradrenaline and angiotensin II. J Hypertens. 2004 Oct;22(10):1909-16. doi: 10.1097/00004872-200410000-00013.
citation: Ballew JR, Fink GD. Role of ET(A) receptors in experimental ANG II-induced hypertension in rats. Am J Physiol Regul Integr Comp Physiol. 2001 Jul;281(1):R150-4. doi: 10.1152/ajpregu.2001.281.1.R150.
citation: Barton M, Shaw S, d'Uscio LV, Moreau P, Luscher TF. Angiotensin II increases vascular and renal endothelin-1 and functional endothelin converting enzyme activity in vivo: role of ETA receptors for endothelin regulation. Biochem Biophys Res Commun. 1997 Sep 29;238(3):861-5. doi: 10.1006/bbrc.1997.7394.
citation: Dimitrijevic I, Edvinsson ML, Chen Q, Malmsjo M, Kimblad PO, Edvinsson L. Increased expression of vascular endothelin type B and angiotensin type 1 receptors in patients with ischemic heart disease. BMC Cardiovasc Disord. 2009 Aug 25;9:40. doi: 10.1186/1471-2261-9-40.
citation: Kanno K, Hirata Y, Tsujino M, Imai T, Shichiri M, Ito H, Marumo F. Up-regulation of ETB receptor subtype mRNA by angiotensin II in rat cardiomyocytes. Biochem Biophys Res Commun. 1993 Aug 16;194(3):1282-7. doi: 10.1006/bbrc.1993.1962.
citation: Moreau P, d'Uscio LV, Shaw S, Takase H, Barton M, Luscher TF. Angiotensin II increases tissue endothelin and induces vascular hypertrophy: reversal by ET(A)-receptor antagonist. Circulation. 1997 Sep 2;96(5):1593-7. doi: 10.1161/01.cir.96.5.1593.
citation: Kobayashi T, Nogami T, Taguchi K, Matsumoto T, Kamata K. Diabetic state, high plasma insulin and angiotensin II combine to augment endothelin-1-induced vasoconstriction via ETA receptors and ERK. Br J Pharmacol. 2008 Dec;155(7):974-83. doi: 10.1038/bjp.2008.327. Epub 2008 Aug 18.
citation: Hong HJ, Chan P, Liu JC, Juan SH, Huang MT, Lin JG, Cheng TH. Angiotensin II induces endothelin-1 gene expression via extracellular signal-regulated kinase pathway in rat aortic smooth muscle cells. Cardiovasc Res. 2004 Jan 1;61(1):159-68. doi: 10.1016/j.cardiores.2003.10.019.
citation: Kohno M, Horio T, Ikeda M, Yokokawa K, Fukui T, Yasunari K, Kurihara N, Takeda T. Angiotensin II stimulates endothelin-1 secretion in cultured rat mesangial cells. Kidney Int. 1992 Oct;42(4):860-6. doi: 10.1038/ki.1992.361.
citation: Wenner MM, Sebzda KN, Kuczmarski AV, Pohlig RT, Edwards DG. ETB receptor contribution to vascular dysfunction in postmenopausal women. Am J Physiol Regul Integr Comp Physiol. 2017 Jul 1;313(1):R51-R57. doi: 10.1152/ajpregu.00410.2016. Epub 2017 Apr 24.