Hypertension is a major risk factors for cardiovascular disease. It [601799]

1
Introduction
Hypertension is a major risk factors for cardiovascular disease. It
affects 30% of adult population and it accelerates the development of
atherosclerosis. Various cardiovascular disease can affect the integrity of
the endothelium and induce endothelial dysfunction 6,7,8. Early
identification of endothelial dysfunction, represents a main target in
primary prevention of cardiovascular disease . Noninvasive assessment
methods of endothelial dysfunction include tests such as: Doppler
echocardiography ( brachial artery ultrasound flow mediated vasodilatation )
and determination of biochemical markers of endothelial dysfunction – such
as asymmetric dimethyl arginine (ADMA) , and of vascular inflammation –
such as high-sensitivity C -reactive protein 2.
A structural marker of subclinical vascular atherosclesis is the
echographic assessed c arotid intima -media thickness (IMT) 15. IMT
represents an i ndependent predictor of major cardiovascular events in the
general population 12. Several studies show that and increased blood
pressure plays has an important role in increasing the IMT 10.
Statins are known not only to reduce plasmatic cholesterol levels, but
also to reduce the inflammation of atherosclerotic lesions and to improve
endothel ial function in hypercholesterolemic patients . One of the most
efficient statins is r osuvastatin 12,13.

2
Our study had as main objective to evaluate whether rosuvastatin
therapy is also efficient in i mprov ing endothelial dysfunction in
normocholesterolemic hypertensive patients .
Material s and Method s
Study design and patients . We performed a prospective study . The
study was conducted during a period of 12 months and included patients
with essential arterial hypertension. The inclusion criteria in the study
were: age ≥ 18 years, mild or moderate essential hypertension (systolic
blood pressure of 140 -179 mmHg, diastolic blood pressure of 90 -119
mmHg), plasmatic cholesterol levels <190 mg without c holesterol -lowering
therapy six months pri or to inclusion. We excluded the hypertensive
patients with documented coronary artery disease, heart failure, diabetes
mellitus, chronic kidney disease, chronic hepatic disease, history of stroke,
bronchial asthma, peripheral arterial disease, acute or c hronic inflammatory
states. The treatment for arterial hypertension included beta blockers ,
diuretics and/or calcium channel blockers.
Before b eing admitted in the study, all patients completed the
informed consent form to participate in the study and to allow the
retrospective evaluation of clinical data. The informed consent form was
approved by the local ethical committee. The patients` participation in the

3
study was completely voluntary, and they were able to withdraw it at any
point.
Procedures . Medical history was checked in all patients . All patients
were physically examined and underwent laboratory investigations,
electrocardiogram (ECG), echocardiography, vascular echography to
evaluat e carotid intima -media thickness (IMT) and brachial artery flow
mediated vasodilatation (FMD) .
Laboratory determinations were done in a fasting state (>12 hours
since the last intake of food) and in a temperature -controlled room. The
venous blood samples were collected after 15 minutes of rest, immediately
placed on ice . The determinations for serum glucose, total cholesterol,
HDL -cholesterol, LDL -cholesterol, triglycerides were performed by
routine laboratory methods, inside the hospital. Total cholesterol ≥ 190
mg/dL and triglyceride levels ≥ 150 mg/dL were considered as
dyslipidemia .
Plasma levels of high -sensitivity C -reactive protein (hs -CRP) were
measured by means of a highly sensitive quantitative immunoturbidimetric
method, using a CRP Ultra kit. The lo west detection limit for ultrasensitive
method was 0. 01 mg / dL.
Plasma ADMA levels were measured in Heidelberg , Germany,
by a simple and fast LC –MS–MS analytical method with fluorescence

4
detection. For this laboratory, the reference value for ADMA was inside the
range of 0. 3 – 0. 8 μmol/L, for both sexes and all age groups over 18 years
of age.
Determination of forearm flow mediated vasodilatation (FMD) was
done using a VIVID S5 (GE Healthcare) equipment, according to the
international guidelines 4.
Carotid intima -media thickness (IMT) of the common carotid artery
was determined at baseline in both common carotid arteries, according to
Mannheim consensus 18, using the 9 MHz linear array transducer . The
intima -media thickness was calculated by built -in software of the
ultrasound system. The mean IMT was calculated for each of the four
measurements sites in each patient.
According to the results of the investigations, the patients were
distributed int o three groups. Group I (n=3 0 patients) had endothelial
dysfunction (FMD ≤10%) with subclinical carotid atherosclerosis
(IMT≥0.9 mm). They received 20 mg rosuvastatin daily. Group II (n=25
patients) had endothelial dysfunction (FMD<10%) with normal carotid
IMT (<0.9 mm). They received treatment with 10 mg rosuvastatin. Group
III (n=4 5 patients) represented the control group (FMD>10%, IMT<0.9).
They received no rosuvastatin therapy.

5
Statistical analysis . Continuous variables were evaluated using t –
test. Pearson correlation coefficient (r) test was used to calculate the
correlation between the analyzed variables. The value of r closer to 1 was
considered to indicate a stronger correlation of the parameters. Simple
linear regression analysis was performed t o assess the relationship between
the ADMA plasma levels, FMD and IMT in hypertensive patients. The
independent relationship between these parameters was evaluated by
backward multiple regression analysis. Parametric data are reported as
mean±1 standard de viation (SD). Significant differences were assumed to
be at p<0.05. Statistical analysis was performed using MedCalc 12.3.0.0
statistical software for Windows.

Results and Discussion
A total of 100 patients were enrolled. Sex distribution in the group
was 51% men and 49% women. Mean age was 5 2±11, with limits between
31-72 years. Baseline characteristics of the patients are presented in t able I .
Table I . Baseline characteristics of the patients.
Clinical
character s Group I
n=30 Group II
n=25 Group III
n=45 P value
I vs II P value
I vs III P value
II vs III
Male sex 13
(43 %) 11
(46%) 27
(60%) >0.05 >0.05 >0.05
Age years 53.27±14 51.43±12 54.74±13 >0.05 >0.05 >0.05
Heart rate
(beats/min) 74.6±8.8 75,8±9.7 73.9±10.2 >0.05 >0.05 >0.05
Systolic BP
(mmHg) 160.74±10.54 158.81±9.43 157.66±9.12 >0.05 >0.05 >0.05

6
Diastolic
BP (mmHg) 99.00±7.21 96.32±5.27 95.46±5.97 >0.05 >0.05 >0.05
Total Cl
(mg/dL) 188±6.5 190±7.6 188±13.1 >0.05 >0.05 >0.05
LDL
(mg/dL) 117±13 115±12 116±8 >0.05 >0.05 >0.05
HDL
(mg/dL) 39±4 41±6 40±8 >0.05 >0.05 >0.05
Triglycerid
es (mg/dL) 138±8 137±10 139±7 >0.05 >0.05 >0.05
Glycaemia
(mg/dL) 98±4 97±5 99±3 >0.05 >0.05 >0.05
Smokers % 15 (63 %) 13 (57 %) 9 (60%) >0.05 >0.05 <0.05
hs-CRP
(mg/L) 342±47 303±37 201±52 0.0061 <0.0001 <0.0001
Plasma
ADMA
(μmol/L) 0.96±0.07 0.67±0.07 0.54±0.07 <0.0001 <0.0001 <0.0001
FMD (%) 6.53±0.76 8.48±0.79 14.67±1.17 <0.0001 <0.0001 <0.0001
IMT (mm) 1.15±0.09 0.82±0.07 0.73±0.08 <0.0001 <0.0001 >0.05
Data are presented as number (%) for categorical variables and as
mean±1 standard deviation for continuous variables. C: cholesterol, hs-
CRP: high -sensitive C reactive protein , ADMA: asymmetric dimethyl
arginine, FMD: Flow -mediated vasodilatation, IMT: Intima -media
thickness BP: blood pressure, SD: standard deviation.

There were no significant differences between the groups with
respect to all demographic and blood pressure parameters (p>0. 05).
In group I patients, with endothelial dysfunction and subclinical
carotid atherosclerosis, % FMD was significant correlated with ADMA
levels (r= -0.83, p<0.0001) and IMT (r= -0.7, p=0.0002). At multiple
regression analysis, independent variables associated w ith % FMD were
again IMT (p<0.001) and ADMA levels ( P<0.01).
In group II, although the ADMA levels were still normal in the
presence of demonstrated impaired flow -mediated vasodilatation, we found

7
significant correlations between % FMD and ADMA levels ( r=-0.93,
p<0.001), systolic BP (r=0.87, p<0.0001), hs -CRP (r=0.79, p<0.0001),
diastolic BP (r=0.77, p<0.0001), cholesterol level (r=0.71, p=0.0001),
smoking (r=0.46, p=0.02)and age (r=0.67, p=0.0002). At backward
multiple regression analysis, only one vari able – ADMA, was independent
associated with FMD (p<0.001).
In the non -interventional group III, %FMD correlated negative with
ADMA levels (r= -0.55, p=0.03), cholesterol levels (r= -0.9, p<0.0001), hs –
CRP (r= -0.96, p<0.0001), systolic BP (r= -0.95, p<0.0001 ), diastolic BP
(r=-0.94, p<0.0001) and smoking (r= -0.7, p<0.003). The multivariable
regression analysis found that independent variables associated with FMD
were ADMA levels (p<0.01), hs -CRP (p<0.01) and systolic BP (p<0. 001).
The association between FMD , ADMA levels and IMT in the three
patient groups, at baseline, as outlined by a linear regression model, is
presented in figure 1.
All procedures and laboratory measurements were done at baseline
and after 6 months. Variations of carotid IMT were used as indicator of
progression or regression of atherosclerosis, while those of % FMD as
indicator of endothelial dysfunction evolution.

8

Figure 1
Association between plasma ADMA levels, FMD, carotid IMT, in the three
groups of hypertensive patients, at baseline. %FMD: percent flow mediated
forearm vasodilatation, IMT: carotid intima -media thickness, ADMA:
asymmetric dimethyl arginine.

Analyzing the evolution of antioxidant ADMA levels in the three
groups, we note that at 6 months a significant reduction occurred under
rosuvastatin therapy (p< 0.001) . The decrease was extremely significant in
group I (p<0.0001). A slight increase, not statistical significant, occurred in
group III patients. The dynamics of these results is shown in fig ure 2.
Concerning the changes at 6 months in endothelium dependent
brachial flow mediated vasodilatation, we noted a highly significant
increase in group I (p<0.001). In group II patients, the increase of % FMD

9

was also significant (p< 0.01). In the control group III, there was a slight ,
not significant inc rease (p>0.05). The dynamic aspects of FMD values are
represented in fig ure 2.
Regarding the changes of carotid IMT, we note d that in group I, with
documented subclinical atheroscler osis, IMT decreased statistical
significant (p<0.001). In group II , IMT decreased not statistical significant ,
while in group III patients, there was a slight increase in IMT (p>0.05). The
dynamics of IMT is presented in fig ure 3.
At 6 months, the associ ation between the biochemical, functional and
structural parameters of endothelial dysfunction in group I remained
significant, but less strong than at baseline ( % FMD with ADMA: r= -0.51,
p<0.02; % FMD with IMT:r=0.51, p<0.02, ADMA with IMT: r= -0.44,
p<0,04) (Figure 5).
6.53 8.48 14.6
7.55 9.1 14.53 % % FMD changes
Baseline 6 monthsp<0.001 p<0.01
Figure 2
Dynamics of ADMA values (µmol /L) and % FMD changes in
hypertensive patients treated with rosuvastatin 20 mg (group I) or 10 mg
(group II), versus no rosuvastatin therapy (group III). ADMA: Asymmetric
dimethyl arginine . FMD: flow -mediated vasodilatation

10
In group II patients, 10 mg rosuvastatin administered daily for 6 months
improved significant % FMD (p<0.01), but did not influence significantly
carotid IMT.

Figure 3
Dynamics of IMT values in hypertensive patients treated with rosuvastatin
20 mg (group I) or 10 mg (group II), versus no rosuvastatin therapy (group
III). IMT: carotid intima -media thickness

Plasma ADMA levels decreased significantly (p<0.0001) and
correlated negative with % FMD (r= -0.51, p<0.02) and positive with
carotid IMT(r=0.54, p<0.006) There was a strong positive association
between %FMD and IMT (r=0.80, p<0.001).
In group III (control group), the changes in the evaluated parameters
were not significant and the associations between %FMD, ADMA levels
and IMT were not statistical significant (Figure 4).
A number of studies have reported ADMA as a new and powerful
risk marker of cardiovascular disease, the predictive power overcoming 1.15
0.82
0.73 1.02
0.8 0.79 mm IMT changes
Baseline
6 monthsp<0.01

11
traditional cardiovascular risk factors 1,3,13,18. Interventions such as
treatment with L -arginine have been shown to improve endothelium –
mediated vasodilatation in people with high ADMA levels 23. One study
has stated that rosuvastatin therapy lowers plasma ADMA levels in patients
with hypercholestero lemia 11.
In our study, hypertensive patients without hypercholesterolemia
were included. Interestingly, the reduction of ADMA levels under
rosuvastatin therapy occurred in all patients with endothelial dysfunction,
even if they had normal ADMA values at b aseline . This is an interesting
finding, not noted in previous studies.
There are no data in the literature on the minimum time interval after
which influence of statins on changes in endothelial function can be
highlighted. In our study, the statin induc ed improvement in endothelium
dependent vasodilatation was significant after six months .
Rosuvastatin effect on reducing IMT was significant after six months
therapy. This result is concordant with the outcomes of other studies 5, 16,
17, 20, 21,22.
Following the dynamics of ADMA, FMD and IMT changes under
rosuvastatin therapy, we observed that FMD and ADMA changes were
dose independent, while IMT cha nged only at the dose of 20 mg.

12

Figure 4
Association between ADMA levels and IMT, respective FMD, in the three
groups of hypertensive patients, at 12 months. %FMD: percent flow
mediated forearm vasodilatation, IMT: carotid intima -media thickness,
ADMA: asymmetric dimethyl a rginine.

Conclusions
Our results suggest that rosuvastatin treatment in hypertensive
patients improves endothelial function and slows down the progression of
subclinical atherosclerotic lesions , the dose of 20 mg daily being more
efficient than the dose of 10 mg daily, administered for at least 6 months .

13
Referen ces

1. Anderssohn M, Schwedhelm E, Lue neburg N. Asymmetric
dimethylarginine as a mediator of vascular dysfunction and a marker
of cardiovascular disease and mortality: an intriguing interaction with
diabetes mellitus. Diab Vasc Dis Res 2010;7(2):105 –18.
2. Andor M, Tomescu M. Endothelial dysfunction – Methods of
assessment and pharmacological approach in cardiovascular disease.
Timisoara Medical Journal 2005;55:58 -63.
3. Arnett DK et al. Hypertension and subclinical carotid artery
atherosclerosis in blacks and whites: The Atherosclerosis Risk in
Communities Study. Arch Intern Med 1996;17:1983 –9.
4. Corretti MC, Anderson TJ, Benjamin EJ et al. Guidelines for the
ultrasound assessment of endothelial -dependent flow -mediated
vasodilation of the brachial artery: a report of the international
brachial artery reactivity task force. JACC 2002;39:257 -65.
5. Feldstein CA. Statins in hypertension: are they a new class of
antihypertensive agents? Am J Ther 2010 May -Jun;17(3):255 -62.
6. Furchgott RF, Zawadzki JV. The obligatory rle of endothelial cells in
the relaxation of arterial smooth muscle by acetylcholine. Nature
1980;288:373 –6.
7. Furchgott RF. The role of the endothelium in the responses of vascular
smooth muscle to drugs. Annu Rev Pharmacol Toxicol 1984;24:175 –
97.
8. Ignarro LJ, Buga GM, Wood KS, Byrns RE, Chaudhuri G.
Endothelium -derived relaxing factor produced and released from
artery and vein is nitric oxide. Proc Natl Acad Sci USA
1987;84:9265 –9.
9. Jones PH, Davidson MH, Stein EA, et al; STELLAR Study Group.
Comparison of the efficacy and safety of rosuvastatin versus
atorvastatin, simvastatin, and pravastatin across doses (STELLAR
Trial). Am J Cardiol 2003;92:152 -60.
10. Lakka TA, Salonen R, Kaplan GA, Salonen JT. Blood pressure and
the progression of carotid atherosclerosis in middle -aged men.
Hypertension 1999;34:51 –56.
11. Lu TM, Ding YA, Leu HB, Yin WH, Sheu WH, Chu KM. Effect of
rosuvastatin on plasma levels of asymmetric dimethylarginine in
patients with hyperchol esterolemia. Am J Cardiol 2004; 94:157-61.
12. Mancini GB, Dahlof B, Diez J. Surrogate markers for cardiovascular
disease: structural markers. Circulation 2004;109:IV22 –IV30.
13. Martinez -Gonzalez J, Badimon L. Influence of statin use on

14
endothelial function: from bench to clinics. Curr Pharm Des
2007;13:1771 -86.
14. Matsuguma K, Ueda S, Yamagishi S, Matsumoto Y, Kaneyuki U,
Shibata R et al. Molecular mechanism for elevation of asymmetric
dimethylarginine and its role for hypertension in chronic kidney
disease. J Am Soc Nephrol 2006;17:2176 –83.
15. O’Leary DH, Polak JF, Kronmal RA, Manolio TA, Burke GL,
Wolfson SK Jr. Carotid -artery intima and media thickness as a risk
factor for myocardial infarction and stroke in older adults.
Cardiovascular He alth Study Collaborative Research Group. N Engl J
Med 1999;340:14 –22.
16. Riccioni G, Bazzano LA, Bucciarelli T, Mancini B, di Ilio E, D'Orazio
N. Rosuvastatin reduces intima -media thickness in hypercholes –
terolemic subjects with asymptomatic carotid artery disease. The
Asymptomatic Carotid Atherosclerotic Disease in Manfredonia
(ACADIM) Study. Expert Opin Pharmacother. 2008 Oct; 9:2403 -8.
17. Rossi R, Nuzzo AAU,Olaru AI, Origliani G, Modena MG. Endothelial
function affects early carotid atheroscle rosis. J Hypertens
2011;29(6):1136 –44.
18. Sibal L, Agarwal SA, D’Home P, Boger RH. The Role of Asymmetric
Dimethyl arginine (ADMA) in endothelial dysfunction and
cardiovascular disease. Curr Cardiol Revue 2010; 6(2): 82 -90.
18. Touboul PJ, Hennerici MG, Meairs S, Adams H, Amarenco P,
Bornstein N et al. Mannheim Carotid Intima -Media Thickness
Consensus (2004 – 2006). An Update on Behalf of the Advisory
Board of the 3rd and 4th Watching the Risk Symposium 13th and 15th
European Stroke Conferences, Mannheim , Germany, 2004, and
Brussels, Belgium, 2006. Cerebrovasc Dis 2006;23:75 -80.
20. Tsiara S, Elisaf M, Mikhailidis DP. Early vascular benefits of statin
therapy. Curr Med Res Opin 2003;19:540 -56.
21. Vladimirova -Kitova LG, Deneva -Koycheva TI. Asymmetric
dimethylarginine –a determinant of the effect of the high dose
Simvastatin. Clin Biochem. 2010 Jul;43(10 -11):843 -50
22. Vladimirova -Kitova LG, Deneva -Koycheva TI. The effect of
simvastatin on asymmetric dimethylarginine and flow -mediated
vasodilation after optimizing the LDL level: a randomized, placebo –
controlled study. Vascul Pharmacol. 2012 Mar -Apr;56(3 -4):122 -30
23. Wang H, Liu J. Plasma asymmetric dimethylarginine and L -arginine
levels in Chinese patients with essentialhypertension witho ut coronary
artery disease. J Cardiovasc Dis Res. 2011 Jul;2(3):177 -80.