Effect of Eplerenone on Endothelial Function in Metabolic Syndrome — MetSyn  

Metabolic Syndrome Clinical Trial

Official title: Prospective and Open Label Study With Blind End Point Evaluation on the Effect of Mineralocorticoid Receptor Inhibition on Endothelial Function of the Micro- and Macrovasculature in Patients With Metabolic Syndrome

Status Completed

Clinical Trial Summary

Patients with the metabolic syndrome (MetSyn) are at increased risk for cardiovascular mortality and morbidity.This increased cardiovascular risk is attributed to metabolic dysregulations like impaired glucose tolerance or diabetes mellitus and dyslipidemia, abdominal obesity and arterial hypertension, which promote oxidative stress and inflammation with consecutive endothelial dysfunction causing an atherogenic environment.

Aldosterone promoted end organ damage is mainly found in the cardiovascular system and the kidney. Inflammation and activation of different factors promotes fibroblast growth and matrix production resulting in myocardial fibrosis, vascular remodelling and renal fibrosis.

MetSyn and aldosterone are cardiovascular risk factors and it is of crucial importance to note that there is a connection between MetSyn and aldosterone. Other cross sectional studies show a direct correlation of aldosterone levels and impaired glucose metabolism in patients with and without the MetSyn. Taken together, aldosterone influences essential parameters of the MetSyn. Coincidentally parameters of the MetSyn are stimulus for an increased aldosterone synthesis, i.e. visceral adipocytes.

In large scale clinical trials - RALES, EPHESUS, 4E - inhibition of MR has proven to be beneficial in patients with congestive heart failure and post myocardial infarction and this result has been confirmed for diabetic patients, who are known to have an increased cardiovascular risk.

There is only very limited data on the impact of MR inhibition on metabolic, endocrine, and inflammatory parameters in patients with MetSyn, who have not yet suffered from cardiovascular events.

Clinical Trial Description

Patients with the metabolic syndrome (MetSyn) are at increased risk for cardiovascular mortality and morbidity.

This increased cardiovascular risk is attributed to metabolic dysregulations like impaired glucose tolerance or diabetes mellitus and dyslipidemia, abdominal obesity and arterial hypertension, which promote oxidative stress and inflammation and together cause an atherogenic environment. MetSyn is now a well established cardiovascular risk factor and prevalence and incidence of MetSyn in the western world are constantly rising with 19.8 percent prevalence in Germany 4.

Aldosterone is predominantly synthesized in the adrenal glands. In addition, local aldosterone synthesis has been found in the heart and vasculature and aldosterone synthesis in adipocytes is discussed. Aldosterone exerts its effects via the mineralocorticoid receptor (MR). Besides the well described MR in the distal tubule of the kidney MR have also been detected in other organs such as the vasculature and a paracrine mode of action is discussed. Recently it has been described, that MR can be activated independent of aldosterone in hypertensive and obese rats 1. Aldosterone promoted end organ damage is mainly found in the cardiovascular system and the kidney. Inflammation and activation of different factors promotes fibroblast growth and matrix production resulting in myocardial fibrosis, vascular remodelling and renal fibrosis. Aldosterone appears to be involved in all steps of this process by synthesis of reactive oxygen species, induction of inflammation and growth factors like TGF-Beta and connective tissue growth factor. Taken together aldosterone

• as the MetSyn- is an independent cardiovascular risk factor 5.

MetSyn and aldosterone are cardiovascular risk factors and it is of crucial importance to note that there is a connection between MetSyn and aldosterone. In clinical studies it was clearly demonstrated that Renin and Aldosterone in patients with MetSyn are elevated 6. Similar results have been obtained in animal studies where obesity induced arterial hypertension increased renin and aldosterone levels 7-9. In a cross sectional study with 397 participants the impact of aldosterone on the onset of arterial hypertension and MetSyn was analysed. In this study blood pressure was associated with aldosterone levels and aldosterone was correlated with waist circumference, insulin, HOMA index and an unfavourable lipid profile 10.

Other cross sectional studies show a direct correlation of aldosterone levels and impaired glucose metabolism in patients with and without the MetSyn 10;11. Taken together, aldosterone influences essential parameters of the MetSyn. Coincidentally parameters of the MetSyn are stimulus for an increased aldosterone synthesis, i.e. visceral adipocytes 12.

In large scale clinical trials - RALES, EPHESUS, 4E 2;3;13 - inhibition of MR has proven to be beneficial in patients with congestive heart failure and post myocardial infarction and this result has been confirmed for diabetic patients, who are known to have an increased cardiovascular risk. In addition, these diabetic patients had significant less hypoglycaemic episodes, indicating an association of MR inhibition and glucose metabolism. Despite the promising data of MR inhibition on cardiovascular mortality and morbidity there is only very limited data on the impact of MR inhibition on metabolic, endocrine, and inflammatory parameters in patients with MetSyn, who have not yet suffered from cardiovascular events.

1. Nagase M, Fujita T. Mineralocorticoid receptor activation in obesity hypertension. Hypertens Res 2009;

2. Pitt B, Reichek N, Willenbrock R et al. Effects of eplerenone, enalapril, and eplerenone/enalapril in patients with essential hypertension and left ventricular hypertrophy: the 4E-left ventricular hypertrophy study. Circulation 2003; 108: 1831-1838

3. Pitt B, Williams G, Remme W et al. The EPHESUS trial: eplerenone in patients with heart failure due to systolic dysfunction complicating acute myocardial infarction. Eplerenone Post-AMI Heart Failure Efficacy and Survival Study. Cardiovasc Drugs Ther 2001; 15: 79-87

4. Moebus S, Hanisch J, Bramlage P et al. Regional Differences in the Prevalence of the Metabolic Syndrome in Primary Care Practices in Germany. Deutsches Ärzteblatt 12, 208-212. 21-3-2008.

5. Milliez P, Girerd X, Plouin PF, Blacher J, Safar ME, Mourad JJ. Evidence for an increased rate of cardiovascular events in patients with primary aldosteronism. J Am Coll Cardiol 2005; 45: 1243-1248

6. Egan BM, Papademetriou V, Wofford M et al. Metabolic syndrome and insulin resistance in the TROPHY sub-study: contrasting views in patients with high-normal blood pressure. Am J Hypertens 2005; 18: 3-12

7. Carroll JF, King JW, Cohen JS. Hydralazine as antihypertensive therapy in obesity-related hypertension. Int J Obes Relat Metab Disord 2004; 28: 384-390

8. Carroll JF, Dwyer TM, Grady AW et al. Hypertension, cardiac hypertrophy, and neurohumoral activity in a new animal model of obesity. Am J Physiol 1996; 271: H373-H378

9. de Paula RB, da Silva AA, Hall JE. Aldosterone antagonism attenuates obesity-induced hypertension and glomerular hyperfiltration. Hypertension 2004; 43: 41-47

10. Kidambi S, Kotchen JM, Grim CE et al. Association of adrenal steroids with hypertension and the metabolic syndrome in blacks. Hypertension 2007; 49: 704-711

11. Goodfriend TL, Egan B, Stepniakowski K, Ball DL. Relationships among plasma aldosterone, high-density lipoprotein cholesterol, and insulin in humans. Hypertension 1995; 25: 30-36

12. Ehrhart-Bornstein M, Arakelyan K, Krug AW, Scherbaum WA, Bornstein SR. Fat cells may be the obesity-hypertension link: human adipogenic factors stimulate aldosterone secretion from adrenocortical cells. Endocr Res 2004; 30: 865-870

13. Pitt D. ACE inhibitor co-therapy in patients with heart failure: rationale for the Randomized Aldactone Evaluation Study (RALES). Eur Heart J 1995; 16 Suppl N: 107-110

14. Grundy SM, Cleeman JI, Merz CN et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. J Am Coll Cardiol 2004; 44: 720-732

15. Raff U, Schmidt BMW, Schwab J, Achenbach S, Bär I, Schmieder RE. High incidence of aldosterone breakthrough in therapy resistant hypertension. Journal of Hypertension Suppl. 2009.

16. Schmidt BMW, Raff U, Schwab J, Bär I, Schmieder RE. Eplerenone at low dose induces regression of left ventricular hyprtrophy in resistant hypertension. JASN Suppl. 2008.

17. Schmidt BM, Sammer U, Fleischmann I, Schlaich M, Delles C, Schmieder RE. Rapid nongenomic effects of aldosterone on the renal vasculature in humans. Hypertension 2006; 47: 650-655 ;

Study Design

Endpoint Classification: Efficacy Study, Intervention Model: Single Group Assignment, Masking: Open Label, Primary Purpose: Prevention

Related Conditions & MeSH terms

• Endothelial Dysfunction
• Metabolic Syndrome
• Metabolic Syndrome X
• Syndrome

• NCT number: NCT01319344
• Study type: Interventional
• Source: University of Erlangen-Nürnberg Medical School
• Status: Completed
• Phase: Phase 3
• Start date: September 2010
• Completion date: April 2013