• „ ORIGINAL ARTICLE

Key genetic variants in the renin-angiotensin system and left ventricular mass in a cohort of Polish patients with heart failure

Iwona Gorący1, Małgorzata Peregud-Pogorzelska2, Krzysztof Safranow3, Andrzej Ciechanowicz1

1Department of Clinical and Molecular Biochemistry, Pomeranian Medical University, Szczecin, Poland

2Clinic of Cardiology, Pomeranian Medical University, Szczecin, Poland

3Department of Biochemistry and Medical Chemistry, Pomeranian Medical University, Szczecin, Poland

Editorial

by Palmer,

see p. 728

INTRODUCTION

Heart failure (HF) is a growing global health problem that is also responsible for high mortality. The most common causes of HF are ischemic heart disease (IHD), hypertension (HT), valvular heart disease (VD) or cardiomyopathy [1]. However, it is known that the etiology of HF is complex and researchers are still looking for factors that influence the development and progression of HF.

It is already known that the renin-angiotensin system (RAS) plays an important role in the pathophysiology of left ventricular (LV) dysfunction, left ventricular hypertrophy (LVH), regulation of arterial pressure, cardiovascular diseases, and thus, HF [2]. Angiotensinogen (AGT), angiotensin-converting enzyme (ACE) and angiotensin II receptor type 1 (AGTR1) are key components of RAS. So far, researchers have shown that AGT polymorphisms are mainly associated with the development of HT or IH [3, 4], while the correlations with HF remain inconsistent [5, 6]. However, some studies indicate a correlation between AGT gene polymorphism and increased left ventricular mass (LVM) [7, 8], and LVH is a strong predictor of HF [9].

The insertion/deletion polymorphism (I/D) of the ACE gene is the most extensively studied and has been shown to be correlated with HT, IHD and other cardiovascular intermediate phenotypes [10–15]. Moreover, ACE has been known to have a crucial role in the development of cardiac remodeling by either angiotensin II or aldosterone [16]. There are some reports that suggest that this polymorphism is associated with increased LVM in normotensive and hypertensive patients or in patients with cardiomyopathy [17, 18], although there are studies that do not support this correlation [19, 20]. While the genetic determinants of LVM in patients with HF have not been so extensively studied, the role of the I/D ACE polymorphism in shaping LVM is not fully understood. There is no direct reporting targeting of genetic predisposition to increase LVM in patients with HF, and the role of I/D ACE polymorphism in LVM modulation may be significant, and thus, for HF may be of pivotal importance.

The effect of AGTR1 on the regulation of LVM was also demonstrated, as it was found to influence the regulation of blood volume and stimulate the growth and proliferation of heart cells, which causes the development of HF [21]. However, the results of available studies remain controversial and other studies were not able to detect any influence of RAS gene polymorphisms on LVM [22, 23]. Although the potential role of the RAS system in structure and heart disorders is relatively well understood, these molecular mechanisms involved in LVM in patients with HF continue to be studied. Especially, RAS genetic polymorphisms involved in HF pathophysiology are of particular interest as the plausible candidates may play a role in modifying LVM.

Therefore, the aim of our study was to analyze the association between the G(–6)A AGT (rs5051), I/D ACE (rs4646994) and A1166C AGTR1 (rs5186) genetic variants and both HF and the LVM in a cohort of Polish patients with HF.

METHODS

Patients

This study was conducted in accordance with the Declaration of Helsinki and was approved by the local bioethics committee at the Pomeranian Medical University (PMU) in Szczecin, Poland. Written informed consent was obtained from study participants.

This was a case-control study of patients with a diagnosis of HF from Department of Cardiac Surgery and Cardiology Department of PMU. A total of 401 patients (293 men, 108 women) included in the study had symptomatic HF, defined as New York Heart Association (NYHA) functional class I–IV. The study group with HF included patients with IHD (n = 245; 192 men, 53 women), patients with VD (n = 68; 37 men, 31 women), and patients with combined disease, IHD and VD (n = 88; 64 men, 24 women). Among these HF patients were 195 patients with reduced ejection fraction <50% (HF with reduced ejection fraction [HfrEF] subgroup). Doppler echocardiography was used to examine LV dysfunction.

Demographic data and medical history of patients were collected from their medical chart records. The control group was consisted of 120 volunteers (43 men, 77 women) without history of cardiac disease.

Echocardiography

Transthoracic echocardiography was performed using an Acuson Sequoia 512 unit (Siemens, Munich, Germany) equipped with a 2–4 MHz imaging transducer, according to the recommendations of the American Society of Echocardiography (ASE). Measurements of LV end-diastolic diameter (LVEDD), LV septal wall thickness diameter (IVTd) and posterior wall thickness diameter (PWTd) were obtained in the M-mode parasternal long-axis view. An average of values after three image acquisitions was calculated. In cases with suboptimal M-mode acquisition, measurements in two-dimensional views were obtained instead. LVM was calculated with the ASE-recommended formula [24]: LVM (g) = 0.8 × {1.04 [(LVEDD + PWTd + IVTd)3 – (LVEDD)3]} + 0.6 g. Body surface area was calculated using the Mosteller formula {square root [height (cm) × weight (kg)]/3600} and LVM was indexed to the body surface area. LVH was defined as LV mass index (LVMI) >115 g/m2 in men and >95 g/m2 in women [24].

Genotyping

Genomic DNA was isolated from whole blood collected into ethylenediaminetetraacetic acid tubes using the QIAamp Blood DNA Mini Kit (QIAGEN, Hilden, Germany).

For the analysis, a polymerase chain reaction and polymerase chain reaction/restriction fragments length polymorphism (PCR/RFLP) method were applied. Genotyping of the G(–6)A AGT (rs5051), I/D ACE (rs4646994) and A1166C AGTR1 (rs5186) polymorphisms were carried out as previously described [25].

Statistical analysis

The distributions of all quantitative variables, except age, were significantly different from normal distribution (P <0.05, Shapiro-Wilk’s test). Therefore, quantitative variables were presented as the median with lower quartile and upper quartile, and analyzed using the non-parametric Kruskal-Wallis or the Mann-Whitney U test. Qualitative variables were presented as number with corresponding percentage and compared between groups with the chi-square or the Fisher exact test. Concordance of genotype distribution with Hardy-Weinberg equilibrium was performed with the exact test. Strength of association of qualitative variables with genotypes and alleles was described as odds ratio (OR) with 95% confidence interval (95% CI). Multivariable logistic regression analysis adjusted for age and sex was performed to verify whether the associations of genetic polymorphisms with HF are independent of these demographic factors. P <0.05 was considered statistically significant without correction for multiple tests. Bonferroni-corrected P-value thresholds were calculated as follows: for the study of associations between HF and each of the 3 polymorphisms in 4 models of inheritance (dominant, recessive or additive mode for minor allele as well as comparison of wild-type homozygotes with mutated ones), 3 × 4 = 12 tests were performed, so the corrected P-value threshold was 0.05/12 = 0.0042; for the study of associations between LVMI and each of the 3 polymorphisms in 4 aforementioned models of inheritance in the whole group of HF patients and in the subgroups with arterial hypertension or with HFrEF, 3 × 4 × 3 = 36 tests were performed, so the corrected P-value threshold was 0.05/36 = 0.0014. Calculations were performed with Statistica 13 software (Statistica, Dell Inc. [2016], version 13, software.dell.com).

RESULTS

The baseline characteristics of the HF subjects is shown in Table 1. T

he BMI and age proved to be significantly higher in the HF group, when compared to controls. Similarly, smoking, diabetes, and HT were more common among HF patients than controls. Significant differences in all echocardiographic parameters were noted between HF patients and controls (higher IVT, PWT, LVM, LVMI, LVEDD and lower ejection fraction [EF] values in the HF group) (Table 1).

The G(–6)A AGT, I/D ACE and A1166C AGT1R gene polymorphism genotypes were found to be in Hardy-Weinberg equilibrium both in the HF and control group (P >0.1). We observed a significant association between HF and genotypes of G(–6)A AGT (Table 2).

Analyses revealed that homozygotes AA of AGT are significantly less common in the HF group than in the control group (P = 0.014). The negative association between AA AGT genotype and HF was even stronger in multivariable logistic regression model adjusted for age and sex (OR, 0.427; 95% CI, 0.245–0.742; P = 0.0025), reaching the Bonferroni-corrected P-value threshold (<0.0042). No association was found between I/D ACE or A1166C AGT1R gene polymorphism and HF, both in univariable and multivariable analyses (P >0.3).

The results of association of the G(–6)A AGT, I/D ACE and A1166C AGT1R polymorphisms with LVMI in HF patients are summarized in Table 3.

1. 1. Jackson G, Gibbs CR, Davies MK, et al. ABC of heart failure. Pathophysiology. BMJ. 2000; 320(7228): 167–170, doi: 10.1136/bmj.320.7228.167, indexed in Pubmed: 10634740.
2. 2. Gradman AH, Alfayoumi F. From left ventricular hypertrophy to congestive heart failure: management of hypertensive heart disease. Prog Cardiovasc Dis. 2006; 48(5): 326–341, doi: 10.1016/j.pcad.2006.02.001, indexed in Pubmed: 16627048.
3. 3. Unger T. The role of the renin-angiotensin system in the development of cardiovascular disease. Am J Cardiol. 2002; 89(2A): 3A–9A; discussion 10A, doi: 10.1016/s0002-9149(01)02321-9, indexed in Pubmed: 11835903.
4. 4. Buraczyńska M, Pijanowski Z, Spasiewicz D, et al. Renin-angiotensin system gene polymorphisms: assessment of the risk of coronary heart disease. Kardiol Pol. 2003; 58(1): 1–9, indexed in Pubmed: 14502296.
5. 5. Robinson M, Williams SM. Role of two angiotensinogen polymorphisms in blood pressure variation. J Hum Hypertens. 2004; 18(12): 865–869, doi: 10.1038/sj.jhh.1001768, indexed in Pubmed: 15343353.
6. 6. Pilbrow AP, Palmer BR, Frampton CM, et al. Angiotensinogen M235T and T174M gene polymorphisms in combination doubles the risk of mortality in heart failure. Hypertension. 2007; 49(2): 322–327, doi: 10.1161/01.HYP.0000253061.30170.68, indexed in Pubmed: 17145981.
7. 7. Tiret L, Mallet C, Poirier O, et al. Lack of association between polymorphisms of eight candidate genes and idiopathic dilated cardiomyopathy: the CARDIGENE study. J Am Coll Cardiol. 2000; 35(1): 29–35, doi: 10.1016/s0735-1097(99)00522-7, indexed in Pubmed: 10636255.
8. 8. Kim HS, Lee MM, Oh BH, et al. Synergistic effect of angiotensin-converting enzyme and angiotensinogen gene on cardiac hypertrophy. Int J Cardiol. 2000; 72(2): 151–161, doi: 10.1016/s0167-5273(99)00184-9, indexed in Pubmed: 10646957.
9. 9. Wang AYM, Chan JCN, Wang M, et al. Cardiac hypertrophy and remodeling in relation to ACE and angiotensinogen genes genotypes in Chinese dialysis patients. Kidney Int. 2003; 63(5): 1899–1907, doi: 10.1046/j.1523-1755.2003.00933.x, indexed in Pubmed: 12675870.
10. 10. Yuan Y, Meng L, Zhou Y, et al. Genetic polymorphism of angiotensin-converting enzyme and hypertrophic cardiomyopathy risk: a systematic review and meta-analysis. Medicine (Baltimore). 2017; 96(48): e8639, doi: 10.1097/MD.0000000000008639, indexed in Pubmed: 29310338.
11. 11. Dzida G, Sobstyl J, Puzniak A, et al. Polymorphisms of angiotensin-converting enzyme and angiotensin II receptor type 1 genes in essential hypertension in a Polish population. Med Sci Monit. 2001; 7(6): 1236–1241, indexed in Pubmed: 11687736.
12. 12. Jastrzebska M, Widecka K, Ciechanowicz A, et al. Plasminogen activator inhibitor-1 (PAI-1) 4G/5G and angiotensin converting enzyme (ACE) I/D gene polymorphisms and fibrinolytic activity in patients with essential hypertension and dyslipidemia [article in Polish]. Pol Arch Med Wewn. 2005; 113(1): 7–20, indexed in Pubmed: 16130596.
13. 13. Potaczek DP, Undas A, Iwaniec T, et al. The angiotensin-converting enzyme gene insertion/deletion polymorphism and effects of quinapril and atorvastatin on haemostatic parameters in patients with coronary artery disease. Thromb Haemost. 2005; 94(1): 224–225, indexed in Pubmed: 16116691.
14. 14. Potaczek DP, Undas A, Celinska-Lowenhoff M, et al. The I allele of the angiotensin-converting enzyme gene polymorphism may determine an increase in homocysteine levels in fibrate-treated subjects. Cardiovasc Drugs Ther. 2006; 20(3): 229–232, doi: 10.1007/s10557-006-8374-8, indexed in Pubmed: 16779534.
15. 15. Kryczka KE, Płoski R, Księżycka E, et al. The association between the insertion/deletion polymorphism of the angiotensin-converting enzyme gene and the plasma fibrinogen level in women and men with premature coronary artery atherosclerosis. Pol Arch Intern Med. 2020; 130(9): 748–756, doi: 10.20452/pamw.15461, indexed in Pubmed: 32584014.
16. 16. Masuyer G, Schwager SLU, Sturrock ED, et al. Molecular recognition and regulation of human angiotensin-I converting enzyme (ACE) activity by natural inhibitory peptides. Sci Rep. 2012; 2: 717, doi: 10.1038/srep00717, indexed in Pubmed: 23056909.
17. 17. Linhart A, Sedlácek K, Jáchymová M, et al. Lack of association of angiotensin-converting enzyme and angiotensinogen genes polymorphisms with left ventricular structure in young normotensive men. Blood Press. 2000; 9(1): 47–51, indexed in Pubmed: 10854008.
18. 18. Estacio RO, Jeffers BW, Havranek EP, et al. Deletion polymorphism of the angiotensin converting enzyme gene is associated with an increase in left ventricular mass in men with type 2 diabetes mellitus. Am J Hypertens. 1999; 12(6): 637–642, doi: 10.1016/s0895-7061(99)00013-8, indexed in Pubmed: 10371375.
19. 19. Doolan G, Nguyen L, Chung J, et al. Progression of left ventricular hypertrophy and the angiotensin-converting enzyme gene polymorphism in hypertrophic cardiomyopathy. Int J Cardiol. 2004; 96(2): 157–163, doi: 10.1016/j.ijcard.2004.05.003, indexed in Pubmed: 15314809.
20. 20. Karaali ZE, Agachan B, Yilmaz H, et al. Angiotensin-converting enzyme I/D gene polymorphisms and effects of left ventricular hypertrophy in Turkish myocardial infarction patients. Acta Cardiol. 2004; 59(5): 493–497, doi: 10.2143/AC.59.5.2005221, indexed in Pubmed: 15529552.
21. 21. Oro C, Qian H, Thomas WG. Type 1 angiotensin receptor pharmacology: signaling beyond G proteins. Pharmacol Ther. 2007; 113(1): 210–226, doi: 10.1016/j.pharmthera.2006.10.001, indexed in Pubmed: 17125841.
22. 22. López-Contreras J, Blanco-Vaca F, Borrás X, et al. Usefulness of the I/D angiotensin-converting enzyme genotype for detecting the risk of left ventricular hypertrophy in pharmacologically treated hypertensive men. J Hum Hypertens. 2000; 14(5): 327–331, doi: 10.1038/sj.jhh.1001005, indexed in Pubmed: 10822320.
23. 23. Liu A, Wang S, Zhang C, et al. Role of angiotensin-converting enzyme insertion/deletion polymorphism in sudden cardiac arrest. J Cell Biochem. 2019; 120(3): 3474–3478, doi: 10.1002/jcb.27622, indexed in Pubmed: 30242890.
24. 24. Lang RM, Bierig M, Devereux RB, et al. Chamber Quantification Writing Group, American Society of Echocardiography’s Guidelines and Standards Committee, European Association of Echocardiography. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005; 18(12): 1440–1463, doi: 10.1016/j.echo.2005.10.005, indexed in Pubmed: 16376782.
25. 25. Gorący I, Dawid G, Łoniewska B, et al. Genetics of the renin-angiotensin system with respect to cardiac and blood pressure phenotypes in healthy newborn infants. J Renin Angiotensin Aldosterone Syst. 2013; 14(4): 337–347, doi: 10.1177/1470320312450531, indexed in Pubmed: 22772796.
26. 26. Ames MK, Atkins CE, Pitt B. The renin-angiotensin-aldosterone system and its suppression. J Vet Intern Med. 2019; 33(2): 363–382, doi: 10.1111/jvim.15454, indexed in Pubmed: 30806496.
27. 27. Zakrzewski-Jakubiak M, de Denus S, Dubé MP, et al. Ten renin-angiotensin system-related gene polymorphisms in maximally treated Canadian Caucasian patients with heart failure. Br J Clin Pharmacol. 2008; 65(5): 742–751, doi: 10.1111/j.1365-2125.2007.03091.x, indexed in Pubmed: 18279468.
28. 28. Imen T, Grissa MH, Boubaker H, et al. AGT M235t polymorphism and heart failure in a cohort of Tunisian population: diagnostic and prognostic value. Int J Clin Exp Med. 2015; 8(9): 16346–16351, indexed in Pubmed: 26629155.
29. 29. Vancura V, Hubácek J, Málek I, et al. Does angiotensin-converting enzyme polymorphism influence the clinical manifestation and progression of heart failure in patients with dilated cardiomyopathy? Am J Cardiol. 1999; 83(3): 461–462, A10, doi: 10.1016/s0002-9149(98)00889-3, indexed in Pubmed: 10072245.
30. 30. Inoue I, Nakajima T, Williams CS, et al. A nucleotide substitution in the promoter of human angiotensinogen is associated with essential hypertension and affects basal transcription in vitro. J Clin Invest. 1997; 99(7): 1786–1797, doi: 10.1172/JCI119343, indexed in Pubmed: 9120024.
31. 31. Fajar JK, Pikir BS, Sidarta EP, et al. The gene polymorphism of angiotensin-converting enzyme intron deletion and angiotensin-converting enzyme G2350A in patients with left ventricular hypertrophy: a meta-analysis. Indian Heart J. 2019; 71(3): 199–206, doi: 10.1016/j.ihj.2019.07.002, indexed in Pubmed: 31543192.
32. 32. Bahramali E, Rajabi M, Jamshidi J, et al. Association of ACE gene D polymorphism with left ventricular hypertrophy in patients with diastolic heart failure: a case-control study. BMJ Open. 2016; 6(2): e010282, doi: 10.1136/bmjopen-2015-010282, indexed in Pubmed: 26861937.
33. 33. Favé MJ, Lamaze FC, Soave D, et al. Gene-by-environment interactions in urban populations modulate risk phenotypes. Nat Commun. 2018; 9(1): 827, doi: 10.1038/s41467-018-03202-2, indexed in Pubmed: 29511166.
34. 34. Goracy J, Peregud-Pogorzelska M, Goracy I, et al. Allelic variants of genes: angiotensin I-converting enzyme (ACE), angiotensin-II type 1 receptor (AT1R), methylenetetrahydrofolate reductase and left ventricular mass in patients with myocardial infarction [article in Polish]. Pol Arch Med Wewn. 2006; 115(2): 105–111, indexed in Pubmed: 17274465.
35. 35. Ruggenenti P, Iliev I, Costa GM, et al. Bergamo Nephrologic Diabetes Complications Trial Study Group. Preventing left ventricular hypertrophy by ACE inhibition in hypertensive patients with type 2 diabetes: a prespecified analysis of the Bergamo Nephrologic Diabetes Complications Trial (BENEDICT). Diabetes Care. 2008; 31(8): 1629–1634, doi: 10.2337/dc08-0371, indexed in Pubmed: 18443191.
36. 36. Suzuki H, Kanno Y, Ikeda N, et al. Selection of the dose of angiotensin converting enzyme inhibitor for patients with diabetic nephropathy depends on the presence or absence of left ventricular hypertrophy. Hypertens Res. 2002; 25(6): 865–873, doi: 10.1291/hypres.25.865, indexed in Pubmed: 12484510.
37. 37. Ahmed SN, Jhaj R, Sadasivam B, et al. Regression of the left ventricular hypertrophy in patients with essential hypertension on standard drug therapy. Discoveries (Craiova). 2020; 8(3): e115, doi: 10.15190/d.2020.12, indexed in Pubmed: 33102689.
38. 38. Dawson A, Morris AD, Struthers AD. The epidemiology of left ventricular hypertrophy in type 2 diabetes mellitus. Diabetologia. 2005; 48(10): 1971–1979, doi: 10.1007/s00125-005-1896-y, indexed in Pubmed: 16094529.
39. 39. Nakayama M, Nakano H, Tsuboi N, et al. The effect of angiotensin receptor blockade ARB on the regression of left ventricular hypertrophy in hemodialysis patients: comparison between patients with D allele and non-D allele ACE gene polymorphism. Clin Nephrol. 2005; 64(5): 358–363, doi: 10.5414/cnp64358, indexed in Pubmed: 16312263.