1. Pharmacogenomic Evaluation of Antihypertensive Responses (PEAR) KEY INVESTIGATORS University of Florida Emory University Mayo Clinic Julie Johnson (PI) Rhonda Cooper- DeHoff Reggie Frye Yan Gong Arlene Chapman (Site PI) Eric Boerwinkle (Site PI) John Gums Amber Beitelshees (Site PI) Wolfgang Sadee, (Site PI) University of Texas at Houston University of Maryland Ohio State University Kent Bailey BACKGROUND  Hypertension (HTN) places over 70 million Americans (1 billion individuals worldwide) at risk for stroke, coronary heart disease, renal failure, and heart failure, and is the most common chronic disease for which medications are prescribed.  Antihypertensive medications are monitored and adjusted based on their effects on blood pressure and certain metabolic parameters, and are utilized to prevent the long-term complications of HTN. Genetic variability plays an important role in the effects of antihypertensive drugs, including their BP lowering, and adverse metabolic effects, and their influence on clinical outcomes. OVERARCHING HYPOTHESIS Discover, replicate and delineate the mechanistic basis for genetic determinants of the BP lowering and adverse metabolic responses to two commonly prescribed classes of antihypertensive drugs, thiazide diuretics and beta-blockers, and the genetic determinants of clinical outcomes associated with these treatments. Our approach will also provide insight into the drug class effect of the genetic associations we study. OVERARCHING AIMS Abbreviations: AME – adverse metabolic effects; BP – blood pressure, CV – cardiovascular HCTZ - hydrochlorothiazide SPECIFIC AIMS Aim 1. Antihypertensive response pharmacogenomics. (Led by Julie Johnson, Stephen Turner, Arlene Chapman, Kent Bailey).  Aim 1 Replication efforts.  HCTZ replication analyses will be conducted on four cohorts, from the US, Italy and Finland, that collectively provide 1,479 participants treated with HCTZ.  Replication of the β-blocker associations will also arise from four different cohorts, also from the US, Italy and Finland, totaling 825 β1-blocker treated individuals (mostly whites).  To provide much needed replication data in blacks, extend the replication data in whites, and enhance the clinical value of the data, we will conduct a 400 subject clinical study, testing different drugs in the same drug classes, namely metoprolol and chlorthalidone. The flow diagram for the study is shown at the right Aim 2. Pharmacogenomics of adverse metabolic responses to antihypertensives. (Led by Eric Boerwinkle, Amber Beitelshees, Rhonda Cooper-DeHoff).  Adverse metabolic effects of thiazides and β1-blockers are of increasing concern clinically.  Test genetic associations with changes in glucose, triglycerides and uric acid in PEAR.  Replication efforts  HCTZ replication analyses will be conducted in one US and two Italian cohorts, providing data on 840 whites and 291 blacks.  β-blocker replication analyses will arise from two Italian cohorts for a total of 430 whites.  There are essentially no data available for replication of β-blocker AMEs in blacks, making the proposed clinical study particularly important to this aim. Aims 3 and 4. Pharmacogenomics of protection against adverse cardiovascular (CV) outcomes and new onset diabetes. (Led by Julie Johnson, Rhonda Cooper-DeHoff, Amber Beitelshees, Eric Boerwinkle).  Primary analyses in Aims 3 and 4 arise from data from the International Verapamil SR-Trandolapril Study Genetic Substudy (INVEST-GENES), for which approximately 6,000 genetic samples are available. INVEST randomized hypertensives with coronary artery disease to treatment with a β- blocker (+ HCTZ) or calcium channel blocker (+ ACE inhibitor) treatment strategy.  Aim 3 will focus on genetic associations with adverse outcomes in hypertension, including death, myocardial infarction (MI) and stroke (INVEST primary outcome).  Aim 4 will determine genetic associations with drug-associated new onset diabetes (INVEST secondary outcome). Genetic associations will be conducted on the Illumina Human50K CVD Bead Chip data.  Replication efforts. Findings from INVEST-GENES will be replicated in the Anglo-Scandinavian Cardiac Outcomes Trial (ASCOT), which included 19,257 high risk hypertensive participants, also randomized to a beta-blocker + thiazide or a CCB + ACE inhibitor treatment strategy. Primary and secondary outcomes were similar to INVEST. Aim 5. Resequencing and molecular functional mechanisms in antihypertensive drug pharmacogenomics. (Led by Wolfgang Sadee, Eric Boerwinkle, Taimour Langaee).  Replicated genetic associations arising from Aims 1-4 will be further investigated to identify the functional polymorphism(s) and define the mechanistic basis for their effects.  Using next-generation sequencing approaches, we will sequence the genomic region of interest in individuals sampled from the extremes of clinical response.  We will also carry out intensive molecular studies focused on potential sources of functional effects, including nonsynonymous variation and differential expression. POPULATIONS BEING STUDIED AND RESOURCES AVAILABLE  Uncomplicated hypertensives (no cardiovascular, renal, liver disease or diabetes) studied for BP and adverse metabolic responses  Ethnically diverse population, approximately 45% minority (42% black)  Phenotype data include: home BP, 24 hour ambulatory BP, office BP, numerous metabolic phenotypes, including glucose, insulin, complete lipid panel, uric acid, plasma renin activity, extensive medical history and clinical/demographic data I including smoking and alcohol history  Biological resources include: DNA, plasma, serum and urine from multiple study time points; lymphocyte RNA from multiple study time points, lymphoblastoid cell lines  High risk hypertensives from large clinical trial  >50 years old, with hypertension + documented coronary artery disease  Extensive medical/demographic information  Ethnically diverse population, approximately 47% white, 42% Hispanic, 11% black Taimour Langaee SPECIFIC AIMS  Test genetic associations of BP response to two antihypertensive drug classes, the thiazide diuretics and β1-selective adrenergic receptor blockers, utilizing PEAR data which includes 50K Illumina Cardiovascular Gene Chip data and Illumina 1M Quad GWA data. Stephen Turner (Site PI) Clorthalidone 15 mg daily Metoprolol IR 50 mg bid HBP, OBP, blood & urine samples for labs, DNA, RNA HBP, OBP, blood & urine samples for labs, DNA, RNA 6 weeks++ 2 weeks Clorthalidone 25 mg daily Metoprolol IR 100 mg bid Washout if treated: Minimum 3 weeks; 4 weeks recommended Eligibility determination Metoprolol baseline studies: HBP, OBP, blood & urine samples for labs, DNA, RNA Chlorthalidone Baseline Studies HBP, OBP, blood & urine samples for labs, DNA, RNA ++Patients will have dose up-titrated if BP > 120/70; otherwise continue initial dose 4 more weeks Min 3 week washout 4 weeks recommended 2 weeks 6 weeks++ Study entry, screening Clinical study diagram