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Qu Y, Henderson KA, Harper TA, Vargas HM. Scientific Review of the Proarrhythmic Risks of Oligonucleotide Therapeutics: Are Dedicated ICH S7B/E14 Studies Needed for Low-Risk Modalities? Clin Pharmacol Ther 2024. [PMID: 38362953 DOI: 10.1002/cpt.3204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/25/2024] [Indexed: 02/17/2024]
Abstract
Oligonucleotide therapeutics (ONTs) represent a new modality with unique pharmacological and chemical properties that modulate gene expression with a high degree of target specificity mediated by complementary Watson-Crick base pair hybridization. To date, the proarrhythmic assessment of ONTs has been influenced by International Conference on Harmonization (ICH) E14 and S7B guidance. To document current hERG/QTc evaluation practices, we reviewed US Food and Drug Administration (FDA) and the European Medicines Agency (EMA) Approval Packages (source: PharmaPendium.com) and collated preclinical and clinical studies for 17 marketed ONTs. In addition, clinical QTc data from 12 investigational ONTs were obtained from the literature. Of the marketed ONTs, eight were tested in the hERG assay with no inhibitory effect identified at the top concentration (range: 34-3,000 μM) tested. Fourteen of the ONTs were evaluated in nonhuman primate cardiovascular studies with 11 of them in dedicated telemetry studies. No effect on QTc intervals were observed (at high exposure multiples) in all studies. Clinically, four ONTs were evaluated in TQT studies; an additional six ONTs were assessed by concentration-QTc interval analysis, and six by routine safety electrocardiogram monitoring. None of the clinical studies identified a QTc prolongation risk; the same was true for the 12 investigational ONTs. A search of the FDA Adverse Event Database indicated no association between approved ONTs and proarrhythmias. Overall, the collective weight of evidence from 29 ONTs demonstrate no clinical proarrhythmic risk based on data obtained from ICH S7B/E14 studies. Thus, new ONTs may benefit from reduced testing strategies because they have no proarrhythmic risk, a similar cardiac safety profile as monoclonal antibodies, proteins, and peptides.
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Affiliation(s)
- Yusheng Qu
- Amgen Research, Translational Safety & Bioanalytical Sciences, Amgen Inc., Thousand Oaks, California, USA
| | - Kim A Henderson
- Amgen Research, Translational Safety & Bioanalytical Sciences, Amgen Inc., Thousand Oaks, California, USA
| | - Tod A Harper
- Amgen Research, Translational Safety & Bioanalytical Sciences, Amgen Inc., Thousand Oaks, California, USA
| | - Hugo M Vargas
- Amgen Research, Translational Safety & Bioanalytical Sciences, Amgen Inc., Thousand Oaks, California, USA
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Wu WW, Choe M, Johannesen L, Vicente J, Bende G, Stockbridge NL, Strauss DG, Garnett C. ICH S7B In Vitro Assays Do Not Address Mechanisms of QT C Prolongation for Peptides and Proteins - Data in Support of Not Needing Dedicated QT C Studies. Clin Pharmacol Ther 2023; 114:1332-1341. [PMID: 37702218 DOI: 10.1002/cpt.3047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/29/2023] [Indexed: 09/14/2023]
Abstract
Current cardiac safety testing focuses on detecting drug-induced QTC prolongation as a surrogate for risk of Torsade de Pointes. The nonclinical strategy, described in International Conference on Harmonization (ICH) S7B, includes in vitro assessment of hERG block or ventricular repolarization delay and in vivo QT prolongation. Several studies have reported predictive values of ICH S7B results for clinical QTC outcomes for small molecules; none has examined peptides and proteins other than monoclonal antibodies. To address this knowledge gap, information for peptides and proteins submitted to the US Food and Drug Administration (FDA) was collected. Results of hERG assays, ventricular repolarization assays, and in vivo QT assessment were compared with clinical QTC study outcomes. The results show that 14% clinical QTC studies for approved and investigational products failed to exclude 10-ms QTC prolongation. Clinical QTC prolongation for these molecules lacked concentration-dependence which is expected for hERG block-mediated mechanism or QTC prolongation could not be excluded due to characterization in the clinical study. The hERG and ventricular repolarization assays do not identify clinical QTC prolongation potential for peptides and proteins. Lack of alignment between hERG and ventricular repolarization assay results and clinical QTC outcomes suggests that the mechanisms of QTC prolongation by some peptides and proteins are unrelated to direct cardiac ion channel block. Similar to large targeted proteins and monoclonal antibodies, peptides and proteins regardless of size have a low likelihood of direct cardiac ion channel interactions. This characteristic supports waiving the requirement for thorough QT assessment for products comprised of naturally occurring amino acids unless proarrhythmia potential is suggested by nonclinical or clinical data.
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Affiliation(s)
- Wendy W Wu
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Moran Choe
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
- Division of Hematology, Oncology, Toxicology, Office of Oncologic Diseases, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Lars Johannesen
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jose Vicente
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Girish Bende
- Division of Cardiometabolic and Endocrine Pharmacology, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
- Takeda Pharmaceutical Company Limited, Cambridge, Massachusetts, USA
| | - Norman L Stockbridge
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - David G Strauss
- Division of Applied Regulatory Science, Office of Clinical Pharmacology, Office of Translational Science, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christine Garnett
- Division of Cardiology and Nephrology, Office of Cardiology, Hematology, Endocrinology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
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Dev P, Deb P, Das R, Bhattacharyya P, Sharma N, Majumdar T. An Observational Study on Arrhythmia During Cesarean Section Under Spinal Anesthesia: Incidence, Risk Factors, and Effects on Immediate Post-delivery Neonatal Outcome. Cureus 2021; 13:e16898. [PMID: 34513471 PMCID: PMC8415343 DOI: 10.7759/cureus.16898] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2021] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Various types of arrhythmia have been reported during cesarean section under spinal anesthesia. But the possible causative factors and the effects of arrhythmia on immediate post-delivery neonatal outcome are not well established. METHODS This prospective observational study was conducted over a period of one year in a tertiary care hospital on women undergoing cesarean section under spinal anesthesia. The objectives of the study were to determine the incidence of arrhythmia, its types, the possible factors influencing arrhythmia, and the immediate post-delivery neonatal outcome. Data collected were analyzed using Statistical Package for the Social Sciences (SPSS) software version 21 (IBM Corp. Armonk, NY). RESULTS In our study, the incidence of arrhythmia was 31.9% during cesarean section under spinal anesthesia; and sinus bradycardia was the most common type. Arrhythmia occurred more in women with hypotension, when maximum block height was above T4 level and dose of intrathecal hyperbaric bupivacaine was more than 2.2 mL (P value <0.05). Also, uterine manipulation led to sudden bradycardia and transient cardiac asystole in two patients which was preceded by subjective symptoms of pain and discomfort. None of the neonates required cardiopulmonary resuscitation or neonatal intensive care unit admission within an hour of birth. APGAR (Appearance (skin color), Pulse (heart rate), Grimace (reflex irritability), Activity (muscle tone), and Respiration) scores at 1 and 5 minutes were similar in all the newborns born to mothers with or without arrhythmia. CONCLUSION The occurrence of arrhythmia during cesarean section under spinal anesthesia, though very common, is rarely life-threatening. Keeping maximum level of block height between T4 and T6, using lower possible drug dose to provide adequate level of sensory block, prompt management of hypotension, and strict monitoring during uterine manipulation may reduce the overall incidence of arrhythmia. Intraoperative arrhythmia, however, does not adversely affect the immediate post-delivery neonatal outcome.
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Affiliation(s)
- Priyanka Dev
- Anesthesiology and Critical Care, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, IND
| | - Prakash Deb
- Anesthesiology and Critical Care, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, IND
| | - Rituparna Das
- Obstetrics and Gynaecology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, IND
| | - Prithwis Bhattacharyya
- Anesthesiology and Critical Care, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, IND
| | - Nalini Sharma
- Obstetrics and Gynaecology, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, IND
| | - Tushar Majumdar
- Anesthesiology and Critical Care, North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences, Shillong, IND
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Validation of using cardioplegic solutions for preserving cardiac function in isolated rabbit heart assays. J Pharmacol Toxicol Methods 2021; 111:107082. [PMID: 34082139 DOI: 10.1016/j.vascn.2021.107082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/29/2021] [Accepted: 05/23/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Cardioplegic solutions were first developed to preserve heart function during cardiac surgeries and heart transplants but have application in the nonclinical setting. Due to lack of lab space in the vivarium, cardioplegic solution was used to conserve cardiac function for ex-vivo studies performed in a separate building. All studies in this report were conducted with isolated female rabbit hearts (IRHs) via retrograde perfusion using the Langendorff apparatus to investigate if cardioplegia usage affects cardiac function. METHODS Cardioplegia was achieved with a hyperkalemia (27 mM KCL) solution kept at 4 °C. Cardiac function was assessed by measuring ECG parameters, left ventricular contractility, and coronary flow under constant perfusion pressure. IRHs were cannulated with Krebs Henseleit buffer (KH) either fresh or after cardioplegic solution storage (C-IRH). Three comparisons were performed with and without cardioplegia; (i) direct side-by side studies of cardiac function; (ii) pharmacological responses to typical ion channels blockers, dofetilide, flecainide, and diltiazem; (iii) retrospective evaluation of cardiac functions in a large sample of hearts. RESULTS In the side-by-side comparisons, cardioplegia-stored IRHs (C-IRH; storage time 90 min) had similar electrocardiographic (ECG) and hemodynamic parameters to fresh-cannulated hearts with KH buffer (KH-IRH). In addition, responses to dofetilide, flecainide, and diltiazem, were similar for C-IRH and KH-IRH hearts. Over the years (2006-2011), baseline data was collected from 79 hearts without cardioplegia and 100 hearts with cardioplegia (C-IRH; storage time 15 min), which showed no meaningful differences in a retrospective analysis. DISCUSSION Cardiac function was preserved after cardioplegic treatment, however, coronary flow rates were decreased (-19.3%) in C-IRH hearts which indicated an altered coronary vascular tone. In conclusion, storage in cardioplegic solution preserves rabbit cardiac function, a practice that enables heart tissues to be collected at one site (e.g., vivarium) and transported to a laboratory in a separate location.
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Arrhythmic risk during pregnancy and postpartum in patients with long QT syndrome. Herzschrittmacherther Elektrophysiol 2021; 32:180-185. [PMID: 33782754 PMCID: PMC8166676 DOI: 10.1007/s00399-021-00757-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/16/2021] [Indexed: 12/13/2022]
Abstract
Congenital long QT syndrome (LQTS) is a genetic disorder characterized by a prolonged QT interval in the surface electrocardiogram (ECG) that predisposes affected individuals to arrhythmic syncope, ventricular torsades-de-pointes, and sudden cardiac death at a young age. Investigations of large patient cohorts revealed sex-related differences in the LQTS phenotype. Adult women with LQTS are at higher risk for cardiac arrhythmias than are adult men with LQTS. Sex hormones are thought to play the primary role for these gender differences. Clinical experience and translational studies indicated that females with LQTS have a lower risk for cardiac arrhythmias during pregnancy and elevated risk in the postpartum period due to contrasting effects of estradiol and progesterone, as well as postpartum hormones on the action potential and arrhythmia substrate. However, this pro- or anti-arrhythmic potential of hormones varies depending on the underlying genotype, partly since sex hormones have distinct effects on different (affected) cardiac ion channels. Thus, a comprehensive evaluation of women with LQTS prior to and during pregnancy, during labor, and in the postpartum period with consideration of the patient’s disease- and gene-specific risk factors is essential to providing precision management in this patient group. This review discusses the current understanding of hormonal influences in LQTS and provides practical guidance for the optimal management of LQTS patients during pregnancy, delivery, and the postpartum period.
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The Effect of Carbetocin Dose on Transmural Dispersion of Myocardial Repolarization in Healthy Parturients Scheduled for Elective Cesarean Delivery Under Spinal Anesthesia: A Prospective, Randomized Clinical Trial. Anesth Analg 2021; 132:485-492. [PMID: 32149759 DOI: 10.1213/ane.0000000000004712] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND QT interval prolongation is associated with torsade de pointes but remains a poor predictor of drug torsadogenicity. Increased transmural dispersion of myocardial repolarization (TDR), measured as the time interval between the peak and end of the T wave (Tp-e), is a more reliable predictor. Carbetocin is recommended as an uterotonic in patients undergoing cesarean delivery (CD), but its effect on Tp-e is unknown. We evaluated the effect of carbetocin dose on Tp-e and Bazett-corrected QT intervals (QTc) during elective CD under spinal anesthesia. METHODS On patient consent, 50 healthy parturients undergoing elective CD with a standardized spinal anesthetic and phenylephrine infusion were randomized to receive an intravenous (IV) bolus of carbetocin 50 µg (C50) or 100 µg (C100) via an infusion pump over 1 minute. A 12-lead electrocardiogram (ECG) was obtained at baseline, 5 minutes after spinal anesthesia, then 5 and 10 minutes after carbetocin administration. A cardiologist blinded to group and timing of ECGs measured QTc and Tp-e using Emori's criteria. Primary outcome was the change in Tp-e at 5 minutes after carbetocin administration between the C50 and C100 groups and within each group compared to baseline values. Secondary outcomes included occurrence of arrhythmias, changes in QTc at 5 and 10 minutes after carbetocin, changes in both QTc and Tp-e after spinal anesthesia compared to baseline between and within groups. RESULTS Data from 41 parturients with a mean (standard deviation [SD]) age of 39.0 (0.7) years and weight of 75.0 (12.0) kg were analyzed. Between groups, at 5 minutes after carbetocin administration, Tp-e in C100 was 4.1 milliseconds longer compared to C50 (95% confidence interval [CI], 0.8-7.5; P = .01). Within groups, at 5 minutes after carbetocin administration, C50 did not significantly increase Tp-e compared to baseline (mean difference [MD] 1.9 milliseconds; 95% CI, -0.95 to 4.81 milliseconds; P = .42) but C100 did (MD 5.1 milliseconds; 95% CI, 2.1-8.1; P = .003). QTc increased significantly within C50 and C100 groups at 5 and 10 minutes after carbetocin administration (all P < .001), with no between-group differences. There were no arrhythmias. CONCLUSIONS Tp-e was unaffected by C50 IV given after CD in healthy parturients under spinal anesthesia, but minimally prolonged by C100. The increase in QTc after carbetocin administration was statistically significant, but with no apparent dose-dependent effect. The minimal Tp-e prolongation at the higher dose is unlikely to have any clinically significant impact on TDR and therefore the risk of inducing torsade de pointes is low.
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Bodi I, Wuelfers EM, Castiglione A, Perez-Feliz S, Zehender M, Brunner M, Bode C, Seemann G, Odening KE. Comment: postpartum hormones oxytocin and prolactin cause pro-arrhythmic prolongation of cardiac repolarization in long QT syndrome type 2—Authors’ reply. Europace 2019; 21:1141-1142. [DOI: 10.1093/europace/euz182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ilona Bodi
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Experimental Cardiovascular Medicine, Heart Center University of Freiburg, Freiburg, Germany
| | - Eike M Wuelfers
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Experimental Cardiovascular Medicine, Heart Center University of Freiburg, Freiburg, Germany
| | - Alessandro Castiglione
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Experimental Cardiovascular Medicine, Heart Center University of Freiburg, Freiburg, Germany
| | - Stefanie Perez-Feliz
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Experimental Cardiovascular Medicine, Heart Center University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Brunner
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Medical Intensive Care, St. Josefskrankenhaus, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gunnar Seemann
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Experimental Cardiovascular Medicine, Heart Center University of Freiburg, Freiburg, Germany
| | - Katja E Odening
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute of Experimental Cardiovascular Medicine, Heart Center University of Freiburg, Freiburg, Germany
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Bodi I, Sorge J, Castiglione A, Glatz SM, Wuelfers EM, Franke G, Perez-Feliz S, Koren G, Zehender M, Bugger H, Seemann G, Brunner M, Bode C, Odening KE. Postpartum hormones oxytocin and prolactin cause pro-arrhythmic prolongation of cardiac repolarization in long QT syndrome type 2. Europace 2019; 21:1126-1138. [DOI: 10.1093/europace/euz037] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/21/2019] [Indexed: 12/16/2022] Open
Abstract
Aims
Women with long QT syndrome 2 (LQT2) have a particularly high postpartal risk for lethal arrhythmias. We aimed at investigating whether oxytocin and prolactin contribute to this risk by affecting repolarization.
Methods and results
In female transgenic LQT2 rabbits (HERG-G628S, loss of IKr), hormone effects on QT/action potential duration (APD) were assessed (0.2–200 ng/L). Hormone effects (200 ng/L) on ion currents and cellular APD were determined in transfected cells and LQT2 cardiomyocytes. Hormone effects on ion channels were assessed with qPCR and western blot. Experimental data were incorporated into in silico models to determine the pro-arrhythmic potential. Oxytocin prolonged QTc and steepened QT/RR-slope in vivo and prolonged ex vivo APD75 in LQT2 hearts. Prolactin prolonged APD75 at high concentrations. As underlying mechanisms, we identified an oxytocin- and prolactin-induced acute reduction of IKs-tail and IKs-steady (−25.5%, oxytocin; −13.3%, prolactin, P < 0.05) in CHO-cells and LQT2-cardiomyocytes. IKr currents were not altered. This oxytocin-/prolactin-induced IKs reduction caused APD90 prolongation (+11.9%/+13%, P < 0.05) in the context of reduced/absent IKr in LQT2 cardiomyocytes. Hormones had no effect on IK1 and ICa,L in cardiomyocytes. Protein and mRNA levels of CACNA1C/Cav1.2 and RyR2 were enhanced by oxytocin and prolactin. Incorporating these hormone effects into computational models resulted in reduced repolarization reserve and increased propensity to pro-arrhythmic permanent depolarization, lack of capture and early afterdepolarizations formation.
Conclusions
Postpartum hormones oxytocin and prolactin prolong QT/APD in LQT2 by reducing IKs and by increasing Cav1.2 and RyR2 expression/transcription, thereby contributing to the increased postpartal arrhythmic risk in LQT2.
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Affiliation(s)
- Ilona Bodi
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg - Bad Krozingen and Medical Center – University of Freiburg, Freiburg, Germany
| | - Jonathan Sorge
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alessandro Castiglione
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg - Bad Krozingen and Medical Center – University of Freiburg, Freiburg, Germany
| | - Sylva M Glatz
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Eike M Wuelfers
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg - Bad Krozingen and Medical Center – University of Freiburg, Freiburg, Germany
| | - Gerlind Franke
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefanie Perez-Feliz
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg - Bad Krozingen and Medical Center – University of Freiburg, Freiburg, Germany
| | - Gideon Koren
- Division of Cardiology, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Manfred Zehender
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Heiko Bugger
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gunnar Seemann
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg - Bad Krozingen and Medical Center – University of Freiburg, Freiburg, Germany
| | - Michael Brunner
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Cardiology and Medical Intensive Care, St. Josefskrankenhaus, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katja E Odening
- Department of Cardiology and Angiology I, Heart Center University of Freiburg, Hugstetter Str. 55, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg - Bad Krozingen and Medical Center – University of Freiburg, Freiburg, Germany
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Birch S, Lu C. Ergometrine-induced atrial fibrillation at caesarean section. BMJ Case Rep 2019; 12:12/2/e226747. [PMID: 30765440 DOI: 10.1136/bcr-2018-226747] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 36-year-old woman with a history of one previous caesarean section presented to the birthing suite of a regional hospital with spontaneous rupture of membranes at 39+2/40 weeks. Syntocinon was administered to initiate uterine contractions in the absence of labour, as the patient desired vaginal birth. A caesarean section was subsequently indicated and ergometrine was administered for uterine atony. The patient immediately developed atrial fibrillation (AF). AF is the most common sustained arrhythmia in the general population, but is rare in the obstetric population. AF occurring in an intrapartum setting following the administration of syntocinon and ergometrine, is not documented in the literature. We suggest the initiation of paroxysmal AF was precipitated by an abrupt alteration in autonomic tone caused by administration of syntocinon followed by ergometrine.
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Affiliation(s)
- Samuel Birch
- Cardiology department, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Corrine Lu
- Department of Obstetrics and Gynaecology, Centenary Hospital for Women and Children, Canberra Hospital, Garran, Australian Capital Territory, Australia
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Probucol prevents atrial ion channel remodeling in an alloxan-induced diabetes rabbit model. Oncotarget 2018; 7:83850-83858. [PMID: 27863381 PMCID: PMC5356629 DOI: 10.18632/oncotarget.13339] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 11/09/2016] [Indexed: 12/21/2022] Open
Abstract
Diabetes mellitus (DM) increases the risk of developing atrial fibrillation (AF), but the molecular mechanisms of diabetes-induced atrial remodeling processes have not been fully characterized. The aim of this study was to examine the mechanisms underlying atrial ion channel remodeling in alloxan-induced diabetes model in rabbits. A total of 40 Japanese rabbits were randomly assigned to a control group (C), alloxan-induced diabetic group (DM), probucol-treated control group (Control-P), and probucol-treated diabetic group (DM-P). Using whole-cell voltage-clamp techniques, ICa,L, INa and action potential durations (APDs) were measured in cardiomyocytes isolated from the left atria in the four groups, respectively. In the DM group, increased Ica,L and decreased INa currents were reflected in prolonged APD90 and APD50 values. These changes were reversed in the DM-P group. In conclusion, probucol cured AF by alleviating the ion channel remodeling of atrial myocytes in the setting of diabetes and the promising therapeutic potential of anti-oxidative compounds in the treatment of AF warrants further study.
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Nakanishi M, Masumo K, Oota T, Kato T, Imanishi T. Ventricular tachycardia observed during cesarean section in a patient without structural cardiac disease. JA Clin Rep 2015; 1:23. [PMID: 29497655 PMCID: PMC5818695 DOI: 10.1186/s40981-015-0019-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 09/23/2015] [Indexed: 12/04/2022] Open
Abstract
A 32-year-old gravida 2, para 1 woman without structural cardiac disease was scheduled for her second cesarean section under combined spinal and epidural anesthesia (CSEA). She had stable hemodynamics after delivery; however, 16 min after the application of uterotonics, ventricular tachycardia (VT) with a heart rate (HR) of 150 bpm appeared. VT lasted for <30 s, and her hemodynamics remained stable. Ventricular arrhythmia frequently appeared for 3 min, and the HR at sinus rhythm was approximately 90 bpm. After the discontinuation of oxytocin, VT did not reappear. A postoperative 12-lead electrocardiogram showed first-degree atrioventricular block, but echocardiography performed 2 days later did not reveal any structural abnormalities. Autonomic nervous imbalance induced by CSEA, ephedrine, and oxytocin, as well as ergometrine may cause intraoperative VT during cesarean section in patients without structural cardiac disease.
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Affiliation(s)
- Mika Nakanishi
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
| | - Kaoru Masumo
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
| | - Takako Oota
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
| | - Takeshi Kato
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
| | - Toshihiro Imanishi
- Department of Anesthesia, Osakafu Saiseikai Noe Hospital, Fruichi 1-3-25, Joto-ku, Osaka City, Osaka Japan
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Amouzadeh HR, Engwall MJ, Vargas HM. Safety Pharmacology Evaluation of Biopharmaceuticals. Handb Exp Pharmacol 2015; 229:385-404. [PMID: 26091648 DOI: 10.1007/978-3-662-46943-9_15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Biotechnology-derived pharmaceuticals or biopharmaceuticals (BPs) are molecules such as monoclonal antibodies, soluble/decoy receptors, hormones, enzymes, cytokines, and growth factors that are produced in various biological expression systems and are used to diagnose, treat, or prevent various diseases. Safety pharmacology (SP) assessment of BPs has evolved since the approval of the first BP (recombinant human insulin) in 1982. This evolution is ongoing and is informed by various international harmonization guidelines. Based on these guidelines, the potential undesirable effect of every drug candidate (small molecule or BP) on the cardiovascular, central nervous, and respiratory systems, referred to as the "core battery," should be assessed prior to first-in-human administration. However, SP assessment of BPs poses unique challenges such as choice of test species and integration of SP parameters into repeat-dose toxicity studies. This chapter reviews the evolution of SP assessment of BPs using the approval packages of marketed BPs and discusses the past, current, and new and upcoming approach and methods that can be used to generate high-quality data for the assessment of SP of BPs.
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Affiliation(s)
- Hamid R Amouzadeh
- Global Patient Safety, Global Regulatory Affairs & Safety, Amgen Inc, Thousand Oaks, CA, USA
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