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Madias JE. An Opportune Time to Consider Glucose-Insulin-Potassium Therapy for Takotsubo Syndrome. Am J Cardiovasc Drugs 2023; 23:467-470. [PMID: 37526886 DOI: 10.1007/s40256-023-00597-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/02/2023]
Abstract
This viewpoint takes the position that the management of takotsubo syndrome (TTS) should not wait the elucidation of the pathophysiology of this mysterious malady but should move along the direction currently implemented for acute coronary syndromes (ACS). Accordingly, and since there is a current rekindled interest in the salutary effect of glucose-insulin-potassium (GIK) for the management of acute myocardial infarction, and in general of the broad domain of ACS, it is the opinion of this author that it is an opportune time for the same therapeutic principles, including GIK, applied for the broad domain of suspected ACS (in view of the prospective phase 3 IMMEDIATE-2 trial), to be considered for TTS.
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Affiliation(s)
- John E Madias
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY, 11373, USA.
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SELKER HARRYP, GORMAN SHEEONA, KAITIN KENNETHI. EFFICACY-TO-EFFECTIVENESS CLINICAL TRIALS. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2018; 129:279-300. [PMID: 30166723 PMCID: PMC6116609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Efficacy trials, which assess treatments in optimally selected patients under advantageous conditions for relatively short time periods, are necessary to gain regulatory approval for marketing. In contrast, effectiveness trials, which test treatments across a spectrum of patients in real-world conditions with follow-up periods that match typical treatment regimens, provide critical information on drug effects in those patients who may ultimately receive the treatment. We previously proposed a study design that integrates efficacy and effectiveness trials into a 2-component "efficacy-to-effectiveness (E2E) trial," in which if the initial efficacy trial component is positive, then the trial immediately and seamlessly transitions to the effectiveness trial component. However, we believe that total study duration could be even further shortened by simultaneously addressing efficacy and effectiveness too (EE2). An EE2 trial rigorously demonstrates efficacy, but uses broad inclusion characteristics of effectiveness trials. An example of a study using EE2 design, the IMMEDIATE (Immediate Myocardial Metabolic enhancement During Initial Assessment and Treatment in Emergency Care) trial, is provided.
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Affiliation(s)
- HARRY P. SELKER
- Correspondence and reprint requests: Harry P. Selker, MD, MSPH, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts Clinical and Translational Science Institute,
Tufts University, 800 Washington St., Boston, Massachusetts 02111617-636-5009617-636-8023
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Niederberger P, Farine E, Arnold M, Wyss RK, Sanz MN, Méndez-Carmona N, Gahl B, Fiedler GM, Carrel TP, Tevaearai Stahel HT, Longnus SL. High pre-ischemic fatty acid levels decrease cardiac recovery in an isolated rat heart model of donation after circulatory death. Metabolism 2017; 71:107-117. [PMID: 28521863 DOI: 10.1016/j.metabol.2017.03.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 03/07/2017] [Accepted: 03/08/2017] [Indexed: 01/07/2023]
Abstract
RATIONALE Donation after circulatory death (DCD) could improve cardiac graft availability. However, strategies to optimize cardiac graft recovery remain to be established in DCD; these hearts would be expected to be exposed to high levels of circulatory fat immediately prior to the inevitable period of ischemia prior to procurement. OBJECTIVE We investigated whether acute exposure to high fat prior to warm, global ischemia affects subsequent hemodynamic and metabolic recovery in an isolated rat heart model of DCD. METHODS AND RESULTS Hearts of male Wistar rats underwent 20min baseline perfusion with glucose (11mM) and either high fat (1.2mM palmitate; HF) or no fat (NF), 27min global ischemia (37°C), and 60min reperfusion with glucose only (n=7-8 per group). Hemodynamic recovery was 50% lower in HF vs. NF hearts (34±30% vs. 78±8% (60min reperfusion value of peak systolic pressure*heart rate as percentage of mean baseline); p<0.01). During early reperfusion, glycolysis (0.3±0.3 vs. 0.7±0.3μmol*min-1*g dry-1, p<0.05), glucose oxidation (0.1±0.03 vs. 0.4±0.2μmol*min-1*g dry-1, p<0.01) and pyruvate dehydrogenase activity (1.8±0.6 vs. 3.6±0.5U*g protein-1, p<0.01) were significantly reduced in HF vs. NF groups, respectively, while lactate release was significantly greater (1.8±0.9 vs. 0.6±0.2μmol*g wet-1*min-1; p<0.05). CONCLUSIONS Acute, pre-ischemic exposure to high fat significantly lowers post-ischemic cardiac recovery vs. no fat despite identical reperfusion conditions. These findings support the concept that oxidation of residual fatty acids is rapidly restored upon reperfusion and exacerbates ischemia-reperfusion (IR) injury. Strategies to optimize post-ischemic cardiac recovery should take pre-ischemic fat levels into consideration.
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Affiliation(s)
- Petra Niederberger
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Emilie Farine
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Maria Arnold
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Rahel K Wyss
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Maria N Sanz
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Natalia Méndez-Carmona
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Brigitta Gahl
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Georg M Fiedler
- Center of Laboratory Medicine, University Institute of Clinical Chemistry, University Hospital, Inselspital, Bern, Switzerland.
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Hendrik T Tevaearai Stahel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
| | - Sarah L Longnus
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital, University of Bern, Switzerland.
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Ito S, Nagoshi T, Minai K, Kashiwagi Y, Sekiyama H, Yoshii A, Kimura H, Inoue Y, Ogawa K, Tanaka TD, Ogawa T, Kawai M, Yoshimura M. Possible increase in insulin resistance and concealed glucose-coupled potassium-lowering mechanisms during acute coronary syndrome documented by covariance structure analysis. PLoS One 2017; 12:e0176435. [PMID: 28430816 PMCID: PMC5400267 DOI: 10.1371/journal.pone.0176435] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/10/2017] [Indexed: 12/16/2022] Open
Abstract
Objective Although glucose-insulin-potassium (GIK) therapy ought to be beneficial for ischemic heart disease in general, variable outcomes in many clinical trials of GIK in acute coronary syndrome (ACS) had a controversial impact. This study was designed to examine whether “insulin resistance” is involved in ACS and to clarify other potential intrinsic compensatory mechanisms for GIK tolerance through highly statistical procedure. Methods and results We compared the degree of insulin resistance during ACS attack and remission phase after treatment in individual patients (n = 104). During ACS, homeostasis model assessment of insulin resistance (HOMA-IR) values were significantly increased (P<0.001), while serum potassium levels were transiently decreased (degree of which was indicated by ΔK) (P<0.001). This finding provides a renewed paradox, as ΔK, a surrogate marker of intrinsic GIK cascade activation, probably reflects the validated glucose metabolism during ischemic attack. Indeed, multiple regression analysis revealed that plasma glucose level during ACS was positively correlated with ΔK (P = 0.026), whereas HOMA-IR had no impact on ΔK. This positive correlation between ΔK and glucose was confirmed by covariance structure analysis with a strong impact (β: 0.398, P = 0.015). Intriguingly, a higher incidence of myocardial infarction relative to unstable angina pectoris, as well as a longer hospitalization period were observed in patients with larger ΔK, indicating that ΔK also reflects disease severity of ACS. Conclusions Insulin resistance most likely increases during ACS; however, ΔK was positively correlated with plasma glucose level, which overwhelmed insulin resistance condition. The present study with covariance structure analysis suggests that there are potential endogenous glucose-coupled potassium lowering mechanisms, other than insulin, regulating glucose metabolism during ACS.
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Affiliation(s)
- Satoshi Ito
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
| | - Tomohisa Nagoshi
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
- * E-mail:
| | - Kosuke Minai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
| | - Yusuke Kashiwagi
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
| | - Hiroshi Sekiyama
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
| | - Akira Yoshii
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
| | - Haruka Kimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
| | - Yasunori Inoue
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
| | - Kazuo Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
| | - Toshikazu D. Tanaka
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
| | - Takayuki Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
| | - Makoto Kawai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, JAPAN
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