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Published on: September 26, 2018
Rational Medical Therapy Is the Key to Effective Cardiovascular Disease Prevention
1Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada.
Insights
Personalized medicine can be improved by using phenotyping to guide existing therapies for hypertension and stroke prevention. Tailoring treatments based on physiological markers like renin and aldosterone offers better outcomes than relying solely on genetic data.
Area of Science:
- Cardiology
- Pharmacology
- Genetics
Background:
- Worldwide blood pressure control is suboptimal, representing a missed opportunity for cardiovascular risk reduction.
- While genetic variants influence blood pressure, targeted therapies are lacking for most.
- Personalized medicine is advancing, but optimizing current treatments through phenotyping is crucial.
Purpose of the Study:
- To highlight the potential of phenotyping-guided therapy to improve cardiovascular risk management.
- To demonstrate how existing treatments can be optimized for hypertension and stroke prevention.
- To compare the impact of phenotyping-based medicine versus genotype-based personalized medicine.
Main Methods:
- Individualized hypertension therapy based on plasma renin and aldosterone levels.
- Pharmacological interventions for specific hypertension phenotypes (e.g., angiotensin receptor blockers, aldosterone antagonists, amiloride).
- Assessment of carotid plaque burden and its management with intensive lipid-lowering therapy.
- Consideration of B vitamins for homocysteine reduction in stroke prevention.
Main Results:
- Specific phenotypes (high renin/high aldosterone, primary aldosteronism, Liddle phenotype) guide targeted hypertension treatments.
- Effective antiplatelet and anticoagulant therapies, including novel oral anticoagulants, reduce stroke risk.
- Intensive lipid-lowering therapy for carotid plaque burden significantly reduces stroke and myocardial infarction risk (>80%).
- Metabolic B12 deficiency and elevated homocysteine are common, treatable factors for stroke risk.
Conclusions:
- Optimizing current therapies using clinical pharmacology and patient phenotyping can yield substantial improvements in cardiovascular health.
- Phenotyping-based approaches offer a more immediate and impactful strategy for improving patient outcomes compared to emerging genome-based personalized medicine.
- Rational application of available treatments guided by physiological markers is key to enhancing blood pressure control and preventing cardiovascular events.
Abstract:
In an era in which medicine personalized on the basis of genotyping is being proposed, it is timely to recognize that existing therapies could be markedly improved if they were on the basis of more effective application of principles on the basis of available phenotyping. Blood pressure control, which is poor on a worldwide basis, is a major opportunity to reduce cardiovascular risk. There are many genetic variants that have a small effect on blood pressure, but specific therapies are not available for most of them. Individualized therapy for hypertension using plasma renin and aldosterone to identify the physiological drivers of hypertension might markedly improve blood pressure control. For patients with a high renin/high aldosterone phenotype, angiotensin receptor blockers are indicated. For those with a high aldosterone/low renin (primary aldosteronism) phenotype, aldosterone antagonists are best; for those with low renin/low aldosterone (a Liddle phenotype), amiloride is best. Effective antiplatelet therapy and anticoagulation, particularly with the new oral anticoagulants, can markedly reduce the risk of stroke. Metabolic B12 deficiency is very common, usually missed, and easily treated; B vitamins to lower homocysteine levels might be able to reduce the risk of stroke, particularly among elderly patients with atrial fibrillation. A particularly useful phenotype is carotid plaque burden. In high-risk patients, intensive lipid-lowering therapy aimed to prevent progression of carotid plaque can reduce the risk of stroke or myocardial infarction by > 80%. Available therapies, used more rationally on the basis of clinical pharmacology and phenotyping of our patients, could have a bigger effect than genome-based personalized medicine.
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