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Felker GM, North R, Mulder H, Jones WS, Anstrom KJ, Patel MJ, Butler J, Ezekowitz JA, Lam CSP, O'Connor CM, Roessig L, Hernandez AF, Armstrong PW. Classification of Heart Failure Events by Severity: Insights From the VICTORIA Trial. J Card Fail 2023; 29:1113-1120. [PMID: 37331690 PMCID: PMC10697691 DOI: 10.1016/j.cardfail.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/19/2023] [Accepted: 04/26/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Hospitalization due to heart failure (HFH) is a major source of morbidity, consumes significant economic resources and is a key endpoint in HF clinical trials. HFH events vary in severity and implications, but they are typically considered equivalent when analyzing clinical trial outcomes. OBJECTIVES We aimed to evaluate the frequency and severity of HF events, assess treatment effects and describe differences in outcomes by type of HF event in VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction). METHODS VICTORIA compared vericiguat with placebo in patients with HF with reduced ejection fraction (< 45%) and a recent worsening HF event. All HFHs were prospectively adjudicated by an independent clinical events committee (CEC) whose members were blinded to treatment assignment. We evaluated the frequency and clinical impact of HF events by severity, categorized by highest intensity of HF treatment (urgent outpatient visit or hospitalization treated with oral diuretics, intravenous diuretics, intravenous vasodilators, intravenous inotropes, or mechanical support) and treatment effect by event categories. RESULTS In VICTORIA, 2948 HF events occurred in 5050 enrolled patients. Overall total CEC HF events for vericiguat vs placebo were 43.9 vs 49.1 events/100 patient-years (P = 0.01). Hospitalization for intravenous diuretics was the most common type of HFH event (54%). HF event types differed markedly in their clinical implications for both in-hospital and post-discharge events. We observed no difference in the distribution of HF events between randomized treatment groups (P = 0.78). CONCLUSION HF events in large global trials vary significantly in severity and clinical implications, which may have implications for more nuanced trial design and interpretation. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT02861534).
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Affiliation(s)
- G Michael Felker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
| | - Rebecca North
- Duke Aging Center, Duke University School of Medicine, Durham, NC, USA
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - W Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Javed Butler
- Baylor University Medical Center, Dallas, TX, USA
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | | | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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Maeda D, Matsue Y, Dotare T, Sunayama T, Iso T, Yatsu S, Ishiwata S, Nakamura Y, Akama Y, Tsujimura Y, Suda S, Kato T, Hiki M, Kasai T, Minamino T. Clinical and prognostic implications of hyaluronic acid in hospitalized patients with heart failure. Heart Vessels 2023:10.1007/s00380-023-02269-2. [PMID: 37079067 DOI: 10.1007/s00380-023-02269-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/12/2023] [Indexed: 04/21/2023]
Abstract
We investigated the clinical and prognostic implications of hyaluronic acid, a liver fibrosis marker, in patients with heart failure. We measured hyaluronic acid levels on admission in 655 hospitalized patients with heart failure between January 2015 and December 2019. Patients were stratified into three groups according to hyaluronic acid level: low (< 84.3 ng/mL, n = 219), middle (84.3-188.2 ng/mL, n = 218), and high (≥ 188.2 ng/mL, n = 218). The primary endpoint was all-cause death. The high hyaluronic acid group had higher N-terminal pro-brain-type natriuretic peptide levels, larger inferior vena cava, and shorter tricuspid annular plane systolic excursion than the other two groups. During the follow-up period (median 485 days), 132 all-cause deaths were observed: 27 (12.3%) in the low, 37 (17.0%) in the middle, and 68 (31.2%) in the high hyaluronic acid (P < 0.001) groups. Cox proportional hazards analysis revealed that higher log-transformed hyaluronic acid levels were significantly associated with all-cause death (hazard ratio, 1.38; 95% confidence interval, 1.15-1.66; P < 0.001). No significant interaction was observed between hyaluronic acid level and reduced/preserved left ventricular ejection fraction on all-cause death (P = 0.409). Hyaluronic acid provided additional prognostic predictability to pre-existing prognostic factors, including the fibrosis-4 index (continuous net reclassification improvement, 0.232; 95% confidence interval, 0.022-0.441; P = 0.030). In hospitalized patients with heart failure, hyaluronic acid was associated with right ventricular dysfunction and congestion and was independently associated with prognosis regardless of left ventricular ejection fraction.
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Affiliation(s)
- Daichi Maeda
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan.
| | - Taishi Dotare
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Tsutomu Sunayama
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Takashi Iso
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Shoichiro Yatsu
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Sayaki Ishiwata
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yutaka Nakamura
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yuka Akama
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Yuichiro Tsujimura
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Shoko Suda
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Takao Kato
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Masaru Hiki
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
| | - Takatoshi Kasai
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
- Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-Ku, Tokyo, 113-8421, Japan
- Japan Agency for Medical Research and Development-Core Research for Evolutionary Medical Science and Technology (AMED-CREST), Japan Agency for Medical Research and Development, Tokyo, Japan
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3
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van Essen BJ, Tromp J, Ter Maaten JM, Greenberg BH, Gimpelewicz C, Felker GM, Davison BA, Severin T, Pang PS, Cotter G, Teerlink JR, Metra M, Voors AA. Characteristics and clinical outcomes of patients with acute heart failure with a supranormal left ventricular ejection fraction. Eur J Heart Fail 2023; 25:35-42. [PMID: 36114655 PMCID: PMC10092799 DOI: 10.1002/ejhf.2695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/14/2022] [Accepted: 09/16/2022] [Indexed: 02/03/2023] Open
Abstract
AIM Recent data suggest that guideline-directed medical therapy of patients with heart failure (HF) with reduced ejection fraction (HFrEF) might improve clinical outcomes in patients with HF up to a left ventricular ejection fraction (LVEF) of 55-65%, whereas patients with higher LVEF do not seem to benefit. Recent data have shown that LVEF may have a U-shaped relation with outcome, with poorer outcome also in patients with supranormal values. This suggests that patients with supranormal LVEF may be a distinctive group of patients. METHODS AND RESULTS RELAX-AHF-2 was a multicentre, placebo-controlled trial on the effects of serelaxin on 180-day cardiovascular (CV) mortality and worsening HF at day 5 in patients with acute HF. Echocardiograms were performed at hospital admission in 6128 patients: 155 (2.5%) patients were classified as HF with supranormal ejection fraction (HFsnEF; LVEF >65%), 1440 (23.5%) as HF with preserved ejection fraction (HFpEF; LVEF 50-65%), 1353 (22.1%) as HF with mildly reduced ejection fraction (HFmrEF; LVEF 41-49%) and 3180 (51.9%) as HFrEF (LVEF <40%). Patients with HFsnEF compared to HFpEF were more often women, had higher prevalence of non-ischaemic HF, had lower levels of natriuretic peptides, were less likely to be treated with beta-blockers and had higher blood urea nitrogen plasma levels. All-cause mortality was not statistically different between groups, although patients with HFsnEF had the highest numerical rate. A declining trend was seen in the proportion of 180-day deaths due to CV causes from HFrEF (290/359, 80.8%) to HFsnEF (14/24, 58.3%). The reverse was observed with death from non-CV causes. No treatment effect of serelaxin was observed in any of the subgroups. CONCLUSIONS In this study, only 2.5% of patients were classified as HFsnEF. HFsnEF was primarily characterized by female sex, lower natriuretic peptides and a higher risk of non-CV death.
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Affiliation(s)
- Bart J van Essen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jasper Tromp
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Saw Swee Hock School of Public Health, National University of Singapore & the National University Health System, Singapore.,Duke-NUS Medical School, Singapore
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Beth A Davison
- Momentum Research Inc., Chapel Hill, NC, USA.,Inserm U 942 (MASCOT), Hopital Lariboisière, Paris, France
| | | | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Gad Cotter
- Momentum Research Inc., Chapel Hill, NC, USA.,Inserm U 942 (MASCOT), Hopital Lariboisière, Paris, France
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, CA, USA
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiologic Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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4
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Dotare T, Ishiwata S, Matsue Y, Nakamura Y, Sunayama T, Maeda D, Yatsu S, Suda S, Kato T, Hiki M, Kasai T, Minamino T. Prevalence and Prognostic Relevance of Isolated Tubular Dysfunction in Patients With Acute Heart Failure. Circ J 2021; 86:709-714. [PMID: 34955476 DOI: 10.1253/circj.cj-21-0759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Renal dysfunction includes glomerular dysfunction (GD) and tubular dysfunction (TD); however, there is limited information regarding the prevalence, coexistence, and prognostic relevance of TD and GD among patients with acute heart failure (AHF).Methods and Results:This study reviewed 489 patients with AHF who had undergone testing at the time of their admission to identify GD (estimated glomerular filtration rate <60 mL/min/1.73 m2) and TD (urinary β-2-microglobulin ≥300 µg/gCr). Patients were grouped according to the presence/absence of GD and TD as having neither condition (n=116), isolated TD (n=101), isolated GD (n=83), or coexisting GD plus TD (n=189). During a median follow up of 466 days (interquartile range: 170-871 days), 107 deaths were observed. Kaplan-Meier curve analysis revealed that, relative to the absence of a GD and TD group, higher mortality rates were observed in the groups with isolated TD, isolated GD, and coexisting GD plus TD (log-rank P<0.001). Similarly, the adjusted Cox regression analyses revealed that significantly higher risks of mortality were associated with isolated TD, isolated GD, and coexisting GD plus TD. Moreover, isolated GD and isolated TD were both independently associated with increased risks of all-cause mortality. CONCLUSIONS As a significant proportion of patients with AHF had isolated TD and an increased risk of mortality, patients with AHF should be screened for TD even if they do not have GD.
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Affiliation(s)
- Taishi Dotare
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Sayaki Ishiwata
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine.,Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine
| | - Yutaka Nakamura
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Tsutomu Sunayama
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Daichi Maeda
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine.,Department of Cardiology, Osaka Medical and Pharmaceutical University
| | - Shoichiro Yatsu
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Shoko Suda
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Takao Kato
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Masaru Hiki
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Takatoshi Kasai
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine.,Sleep and Sleep-Disordered Breathing Center, Juntendo University Hospital
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine.,Japan Agency for Medical Research and Development-Core Research for Evolutionary Medical Science and Technology (AMED-CREST), Japan Agency for Medical Research and Development
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5
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Sex-Differences in Cause of Death for Patients Hospitalized for Heart Failure With Reduced Versus Preserved Ejection Fraction (from the ASCEND-HF Trial). Am J Cardiol 2021; 154:123-126. [PMID: 34284862 DOI: 10.1016/j.amjcard.2021.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/15/2021] [Indexed: 11/21/2022]
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6
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Hayasaka K, Matsue Y, Kitai T, Okumura T, Kida K, Oishi S, Akiyama E, Suzuki S, Yamamoto M, Mizukami A, Yoshioka K, Kuroda S, Kagiyama N, Yamaguchi T, Sasano T. Tricuspid regurgitation pressure gradient identifies prognostically relevant worsening renal function in acute heart failure. Eur Heart J Cardiovasc Imaging 2021; 22:203-209. [PMID: 32157273 DOI: 10.1093/ehjci/jeaa035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 12/31/2019] [Accepted: 02/11/2020] [Indexed: 12/28/2022] Open
Abstract
AIMS Not all worsening renal function (WRF) during heart failure treatment is associated with a poor prognosis. However, a metric capable providing a prognosis of relevant WRF has not been developed. Our aim was to evaluate if a change in tricuspid regurgitation pressure gradient (TRPG) could discriminate prognostically relevant and not relevant WRF in patients with acute heart failure (AHF). METHODS AND RESULTS We examined 809 consecutive hospitalized patients with heart failure (78 ± 12 years, 54% male). WRF was defined as an increase in creatinine >0.3 mg and ≥25% from admission to discharge. TRPG was measured at admission and before discharge using echocardiography. The primary outcome was all-cause death within 1-year after discharge. Patients were classified as follows for analysis: no WRF and no TRPG increase (n = 523); no WRF and TRPG increase (no WRF with iTRPG, n = 170); WRF and no TRPG increase (WRF without iTRPG, n = 90); and WRF and TRPG increase (WRF with iTRPG, n = 26). A change in TRPG weakly but significantly correlated to a change in haemoglobin and haematocrit, a percent decrease in brain natriuretic peptide, and body weight reduction during the index period of hospitalization. All-cause mortality within 1 year was higher in patients with WRF and iTRPG, compared to the other three groups (P = 0.026). On Cox regression analysis, only WRF with iTRPG was associated with higher mortality (hazard ratio 4.24, P = 0.001), even after adjustment for other confounders. CONCLUSION An increase in TRPG may provide a marker to identify prognostically relevant WRF in patients with AHF.
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Affiliation(s)
- Kazuto Hayasaka
- Department of Cardiology, Kameda Medical Center, 929 Higashi-cho, Kamogawa city, Chiba 296-0041, Japan.,Department of Cardiology, National Hospital Organization Disaster Medical Center, 3256 Midori-cho, Tachikawa, Tokyo 190-0014, Japan.,Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
| | - Yuya Matsue
- Cardiovascular Respiratory Sleep Medicine, Juntendo University Graduate School of Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan.,Department of Cardiovascular Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku, Kobe 650-0047, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, Aichi 466-8560, Japan
| | - Keisuke Kida
- Department of Pharmacology, St. Marianna University School of Medicine, 2-16-1 Sugao Miyamae, Kawasaki 216-8511, Japan
| | - Shogo Oishi
- Department of Cardiology, Himeji Cardiovascular Center, 520, Saisho-ko, Himeji, Hyogo 670-0981, Japan
| | - Eiichi Akiyama
- Division of Cardiology, Yokohama City University Medical Center, 4-57, Urafunecho, Minami-ku, Yokohama 232-0024, Japan
| | - Satoshi Suzuki
- Department of Cardiovascular Medicine, Fukushima Medical University, 1 Hikarigaoka, Fukushima 960-1295, Japan
| | - Masayoshi Yamamoto
- Cardiovascular Division, Institute of Clinical Medicine, Graduate School of Comprehensive Human Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Japan
| | - Akira Mizukami
- Department of Cardiology, Kameda Medical Center, 929 Higashi-cho, Kamogawa city, Chiba 296-0041, Japan
| | - Kenji Yoshioka
- Department of Cardiology, Kameda Medical Center, 929 Higashi-cho, Kamogawa city, Chiba 296-0041, Japan
| | - Shunsuke Kuroda
- Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Nobuyuki Kagiyama
- Department of Cardiology, The Sakakibara Heart Institute of Okayama, 2-5-1 Nakai-Cho, Kita-ku, Okayama 700-0804, Japan
| | - Tetsuo Yamaguchi
- Department of Cardiology, Cardiovascular Center, Toranomon Hospital, 2-2-2, Toranomon, Minato-ku, Tokyo 105-8470, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan
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Martins RC, Pintalhão M, Leite-Moreira A, Castro-Chaves P. Relaxin and the Cardiovascular System: from Basic Science to Clinical Practice. Curr Mol Med 2021; 20:167-184. [PMID: 31642776 DOI: 10.2174/1566524019666191023121607] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 08/07/2019] [Accepted: 10/07/2019] [Indexed: 12/16/2022]
Abstract
The peptide hormone relaxin was originally linked to reproductive physiology, where it is believed to mediate systemic and renal hemodynamic adjustments to pregnancy. Recently, its broad range of effects in the cardiovascular system has been the focus of intensive research regarding its implications under pathological conditions and potential therapeutic potential. An understanding of the multitude of cardioprotective actions prompted the study of serelaxin, recombinant human relaxin-2, for the treatment of acute heart failure. Despite early promising results from phase II studies, recently revealed RELAX-AHF-2 outcomes were rather disappointing and the treatment for acute heart failure remains an unmet medical need. This article reviews the physiologic actions of relaxin on the cardiovascular system and its relevance in the pathophysiology of cardiovascular disease. We summarize the most updated clinical data and discuss future directions of serelaxin for the treatment of acute heart failure. This should encourage additional work to determine how can relaxin's beneficial effects be exploited for the treatment of cardiovascular disease.
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Affiliation(s)
- Rafael Clara Martins
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.,Cardiovascular Research Centre, Porto, Portugal.,Internal Medicine Department, São João Hospital Centre, Porto, Portugal
| | - Mariana Pintalhão
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.,Cardiovascular Research Centre, Porto, Portugal.,Internal Medicine Department, São João Hospital Centre, Porto, Portugal
| | - Adelino Leite-Moreira
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.,Cardiovascular Research Centre, Porto, Portugal.,Cardiothoracic Surgery Department, São João Hospital Centre, Porto, Portugal
| | - Paulo Castro-Chaves
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.,Cardiovascular Research Centre, Porto, Portugal.,Internal Medicine Department, São João Hospital Centre, Porto, Portugal
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Loungani RS, Teerlink JR, Metra M, Allen LA, Butler J, Carson PE, Chen CW, Cotter G, Davison BA, Eapen ZJ, Filippatos GS, Gimpelewicz C, Greenberg B, Holbro T, Januzzi JL, Lanfear DE, Pang PS, Piña IL, Ponikowski P, Miller AB, Voors AA, Felker GM. Cause of Death in Patients With Acute Heart Failure: Insights From RELAX-AHF-2. JACC-HEART FAILURE 2020; 8:999-1008. [PMID: 33189635 DOI: 10.1016/j.jchf.2020.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/27/2020] [Accepted: 09/15/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study sought to better understand the discrepant results of 2 trials of serelaxin on acute heart failure (AHF) and short-term mortality after AHF by analyzing causes of death of patients in the RELAX-AHF-2 (Efficacy, Safety and Tolerability of Serelaxin When Added to Standard Therapy in AHF-2) trial. BACKGROUND Patients with AHF continue to suffer significant short-term mortality, but limited systematic analyses of causes of death in this patient population are available. METHODS Adjudicated cause of death of patients in RELAX-AHF-2, a randomized, double-blind, placebo-controlled trial of serelaxin in patients with AHF across the spectrum of ejection fraction (EF), was analyzed. RESULTS By 180 days of follow-up, 11.5% of patients in RELAX-AHF-2 died, primarily due to heart failure (HF) (38% of all deaths). Unlike RELAX-AHF, there was no apparent effect of treatment with serelaxin on any category of cause of death. Older patients (≥75 years) had higher rates of mortality (14.2% vs. 8.8%) and noncardiovascular (CV) death (27% vs. 19%) compared to younger patients. Patients with preserved EF (≥50%) had lower rates of HF-related mortality (30% vs. 40%) but higher non-CV mortality (36% vs. 20%) compared to patients with reduced EF. CONCLUSIONS Despite previous data suggesting benefit of serelaxin in AHF, treatment with serelaxin was not found to improve overall mortality or have an effect on any category of cause of death in RELAX-AHF-2. Careful adjudication of events in the serelaxin trials showed that older patients and those with preserved EF had fewer deaths from HF or sudden death and more deaths from other CV causes and from noncardiac causes. (Efficacy, Safety and Tolerability of Serelaxin When Added to Standard Therapy in AHF [RELAX-AHF-2]; NCT01870778).
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Affiliation(s)
- Rahul S Loungani
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, California, USA
| | - Marco Metra
- Cardiology, ASST Civil Hospitals, and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Peter E Carson
- Department of Cardiology, Washington VA Medical Center, Washington, DC, USA
| | - Chien-Wei Chen
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Gad Cotter
- Momentum Research, Durham, North Carolina, USA
| | | | | | - Gerasimos S Filippatos
- School of Medicine, University of Cyprus, Nicosia, Cyprus, Greece; Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Barry Greenberg
- University of California San Diego Health, Cardiovascular Institute, La Jolla, California, USA
| | | | - James L Januzzi
- Division of Cardiology, Department of Medicine, Harvard Medical School, and Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - David E Lanfear
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ileana L Piña
- Division of Cardiology, Wayne State University, Detroit, Michigan, USA
| | - Piotr Ponikowski
- Department of Cardiology, Wroclaw Medical University, Wroclaw, Poland
| | - Alan B Miller
- Department of Cardiology, University of Florida, Jacksonville, Florida, USA
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - G Michael Felker
- Division of Cardiology and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.
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Kitai T, Miyakoshi C, Morimoto T, Yaku H, Murai R, Kaji S, Furukawa Y, Inuzuka Y, Nagao K, Tamaki Y, Yamamoto E, Ozasa N, Tang WHW, Kato T, Kimura T. Mode of Death Among Japanese Adults With Heart Failure With Preserved, Midrange, and Reduced Ejection Fraction. JAMA Netw Open 2020; 3:e204296. [PMID: 32379331 PMCID: PMC7206504 DOI: 10.1001/jamanetworkopen.2020.4296] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Despite intensive treatment, hospitalized patients with acute decompensated heart failure (ADHF) have a substantial risk of postdischarge mortality. Limited data are available on the possible differences in the incidence and mechanisms of death among patients with heart failure with reduced ejection fraction (HFrEF), heart failure with midrange ejection fraction (HFmrEF), and heart failure with preserved ejection fraction (HFpEF). OBJECTIVES To examine the incidences and mode of postdischarge mortality among patients with ADHF and to compare the risk profile among patients with HFrEF, HFmrEF, and HFpEF. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study of 4056 patients hospitalized for ADHF analyzed data from 3717 patients who were discharged from October 1, 2014, to March 31, 2016. Data analysis was performed from April 1 to August 31, 2019. EXPOSURES Death among patients with ADHF after hospital discharge. MAIN OUTCOMES AND MEASURES All-cause death and cause of postdischarge mortality after the index hospitalization by left ventricular ejection fraction (LVEF) subgroup. RESULTS A total of 3717 patients (mean [SD] age, 77.7 [12.0] years; 2049 [55.1%] male) were included in the study. The mean (SD) LVEF at baseline was 46.4% (16.2%). Among 3717 enrolled patients, 1383 (37.2%) were categorized as having HFrEF (LVEF, <40%), 703 (18.9%) as having HFmrEF (LVEF, 40%-49%), and 1631 (43.9%) as having HFpEF (LVEF, ≥50%). The incidence and causes of death were evaluated after discharge from the index hospitalization. The median follow-up period was 470 days (interquartile range, 357-649 days), and the 1-year follow-up rate was 96%. During follow-up, all-cause death occurred in 848 patients (22.8%; HFrEF group: 298 [21.5%; 95% CI, 19.5%-23.8%]; HFmrEF group: 158 [22.5%; 95% CI, 19.5%-25.7%]; and HRpEF group: 392 [24.0%; 95% CI, 22.0%-26.2%]; P = .26), cardiovascular deaths occurred in 523 patients (14.1%; HFrEF group: 203 [14.7%; 95% CI, 12.9%-16.6%]; HFmrEF group: 97 [13.8%; 95% CI, 11.4%-16.5%]; and HFpEF group: 223 [13.7%; 95% CI, 12.1%-15.4%]; P = .71), and sudden cardiac death occurred in 98 patients (2.6%; HFrEF group: 44 [3.2%; 95% CI, 2.4%-4.2%]; HFmrEF group: 14 [2.0%; 95% CI, 1.2%-3.3%]; and HFpEF group: 40 [2.5%; 95% CI, 1.8%-3.3%]; P = .23). The risks of causes of death were similar among the subtypes. CONCLUSIONS AND RELEVANCE The mode of death was similar among the heart failure subtypes. Given the nonnegligible incidence of sudden cardiac death in patients with HFpEF found in this study, further studies appear to be warranted to identify a high-risk subset in this population.
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Affiliation(s)
- Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
- Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Chisato Miyakoshi
- Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hidenori Yaku
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryosuke Murai
- Department of Cardiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
- Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yasutaka Inuzuka
- Department of Cardiology, Shiga General Hospital, Moriyama, Japan
| | - Kazuya Nagao
- Division of Cardiology, Osaka Red Cross Hospital, Osaka, Japan
| | - Yodo Tamaki
- Division of Cardiology, Tenri Hospital, Tenri, Japan
| | - Erika Yamamoto
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Neiko Ozasa
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - W. H. Wilson Tang
- Kaufman Center for Heart Failure, Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Takao Kato
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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10
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Martin B, Romero G, Salama G. Cardioprotective actions of relaxin. Mol Cell Endocrinol 2019; 487:45-53. [PMID: 30625345 DOI: 10.1016/j.mce.2018.12.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/20/2018] [Accepted: 12/22/2018] [Indexed: 01/19/2023]
Abstract
Relaxin is a hormone of pregnancy first discovered for its ability to induce ligament relaxation in nonpregnant guinea pig and is important for softening of the birth canal during parturition, decidualization, implantation, nipple development and increased maternal renal perfusion, glomerular filtration, and cardiac output. Subsequently, relaxin has been shown to exert multiple beneficial cardiovascular effects during pathological events such as hypertension, atrial fibrillation, heart failure and myocardial infarction, including suppression of arrhythmia and inflammation, and reversal of fibrosis. Despite extensive studies, the mechanisms underlying relaxin's effects are not well understood. Relaxin signals primarily through its G protein coupled receptor, the relaxin family peptide receptor-1, to activate multiple signaling pathways and this review summarizes our understanding of these pathways as they relate to the cardioprotective actions of relaxin, focusing on relaxin's anti-fibrotic, anti-arrhythmic and anti-inflammatory properties. Further, this review includes a brief overview of relaxin in clinical trials for heart failure and progress in the development of relaxin mimetics.
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Affiliation(s)
- Brian Martin
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, 15261, USA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Guillermo Romero
- Department of Pharmacology & Chemical Biology, University of Pittsburgh, Pittsburgh, PA, 15261, USA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, 15261, USA
| | - Guy Salama
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, 15261, USA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, 15261, USA.
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11
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Sinnenberg L, Givertz MM. Acute heart failure. Trends Cardiovasc Med 2019; 30:104-112. [PMID: 31006522 DOI: 10.1016/j.tcm.2019.03.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 03/23/2019] [Accepted: 03/25/2019] [Indexed: 12/21/2022]
Abstract
Acute heart failure (AHF) is one of the most common causes for hospital admission and is associated with a high risk of mortality. Compared to chronic heart failure, there is less robust evidence to guide diagnosis, risk stratification and management of AHF. This state-of-the art review aims to summarize new developments in this field. We also highlight areas of ongoing work including novel vasoactive agents, alternative models to traditional hospital admission and strategies to improve patient engagement.
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Affiliation(s)
- Lauren Sinnenberg
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
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12
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Lee JH, Kim MS, Yoo BS, Park SJ, Park JJ, Shin MS, Youn JC, Lee SE, Jang SY, Choi S, Cho HJ, Kang SM, Choi DJ. KSHF Guidelines for the Management of Acute Heart Failure: Part II. Treatment of Acute Heart Failure. Korean Circ J 2019; 49:22-45. [PMID: 30637994 PMCID: PMC6331324 DOI: 10.4070/kcj.2018.0349] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 10/14/2018] [Accepted: 12/18/2018] [Indexed: 12/11/2022] Open
Abstract
The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic HF were introduced in March 2016. However, chronic and acute HF represent distinct disease entities. Here, we introduce the Korean guidelines for the management of acute HF with reduced or preserved ejection fraction. Part II of this guideline covers the treatment of acute HF.
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Affiliation(s)
- Ju Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Min Seok Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung Su Yoo
- Division of Cardiology, Department of Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea.
| | - Sung Ji Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Joo Park
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Mi Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jong Chan Youn
- Division of Cardiology, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Sang Eun Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Se Yong Jang
- Division of Cardiology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Seonghoon Choi
- Division of Cardiology, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Hyun Jai Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seok Min Kang
- Division of Cardiology, Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ju Choi
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
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13
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Warbrick I, Rabkin SW. Effect of the peptides Relaxin, Neuregulin, Ghrelin and Glucagon-like peptide-1, on cardiomyocyte factors involved in the molecular mechanisms leading to diastolic dysfunction and/or heart failure with preserved ejection fraction. Peptides 2019; 111:33-41. [PMID: 29807087 DOI: 10.1016/j.peptides.2018.05.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 05/19/2018] [Accepted: 05/22/2018] [Indexed: 02/08/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) represents an important cardiac condition because of its increasing prevalence, resistance to treatment and high associated morbidity and mortality. Two of the major mechanisms responsible for HFpEF are impaired cardiomyocyte sarcoplasmic reticulum (SR) Ca2+ ATPase (SERCA2a), which is responsible for calcium reuptake into the SR, and cardiac fibroblasts/myofibroblasts that produce collagen or myocardial fibrosis. Phospholamban (PLB), in the SR and endoplasmic reticulum, is the primary regulator of SERCA2a in the heart and acts as a reversible inhibitor of SERCA2a. Glucagon-like peptide-1, a 30 amino acid peptide, improves diastolic function through increasing SERCA2a expression and activity as well as by decreasing phosphorylation of Ryanodine receptors. It also enhances collagen production through enhanced procollagen IalphaI/IIIalphaI, connective tissue growth factor, fibronectin, TGF-β3 as well as Interleukin -10, -1beta, and -6 gene expression. Relaxin-2, a two chain, 53 amino acid peptide, increases Ser16- and Thr17-phosphorylation levels of PLB, thereby relieving SERCA2a of its inhibition. H3 Relaxin inhibits TGF-β1-stimulated collagen deposition through H3 relaxin-induced increases in pSmad2. Neuregulin-1, an epidermal growth factor, induces nitric oxide and PI-3 kinase activation that enhance SERCA2 activity. Neuregulin-1 was associated with less myocardial macrophage infiltration and cytokine expression reducing collagen deposition. Ghrelin, a 28 amino acid peptide, improves SERCA2a function by inducing PLB phosphorylation. Ghrelin also reduces cardiac fibrosis. In summary, Glucagon-like peptide-1, Relaxin-2, Neuregulin-1, and Ghrelin each modify calcium dynamics, collagen expression, and myocardial fibrosis through attenuation of deleterious signaling cascades, and induction of adaptive pathways, representing potential therapeutic targets for HFpEF.
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Affiliation(s)
| | - Simon W Rabkin
- University of British Columbia, Canada; Department of Medicine (Cardiology), Canada.
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14
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Ambrosy AP, Parzynski CS, Friedman DJ, Fudim M, Hernandez AF, Fonarow GC, Masoudi FA, Al-Khatib SM. Is Time From Last Hospitalization for Heart Failure to Placement of a Primary Prevention Implantable Cardioverter-Defibrillator Associated With Patient Outcomes? Circulation 2018; 138:2787-2797. [PMID: 30565983 DOI: 10.1161/circulationaha.118.035627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Landmark studies have demonstrated the safety and efficacy of implantable cardioverter-defibrillators (ICDs) in selected stable ambulatory patients with heart failure (HF) with a reduced ejection fraction receiving optimal medical therapy. It is not known whether a recent hospitalization for HF before ICD placement is associated with subsequent outcomes. METHODS A post hoc analysis was performed of Medicare beneficiaries enrolled in the National Cardiovascular Data Registry's ICD Registry with a known diagnosis of HF and an ejection fraction ≤35% underdoing a new ICD placement for primary prevention. Patients were grouped based on the timing of ICD placement from the last hospitalization for HF. The association between timing of ICD placement and outcomes was assessed by using multivariable logistic regression models. RESULTS The final analytic cohort included 81 180 patients undergoing initial ICD placement for primary prevention who were currently hospitalized for HF (n=11 563, 14%), hospitalized for HF within 3 months (n=6252, 8%), or hospitalized for HF >3 months previously or had no previous hospitalizations for HF (n=63 365, 78%). Patients currently or recently hospitalized for HF had a higher unadjusted composite periprocedural complication rate (2.60% versus 1.71% versus 1.25%, P<0.001). After adjusting for potential confounders, patients currently hospitalized for HF were at higher risk for death (odds ratio, 2.25; 95% CI, 2.02-2.52; P <0.001) and all-cause readmission (odds ratio, 1.89; 95% CI, 1.79-1.99; P <0.001) at 90 days. CONCLUSION Older patients currently or recently hospitalized for HF undergoing initial ICD placement for primary prevention experienced a higher rate of periprocedural complications and were at increased risk of death in comparison with those receiving an ICD without recent HF hospitalization. Additional prospective, real-world, pragmatic, comparative effectiveness studies should be conducted to define the optimal timing of ICD placement.
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Affiliation(s)
- Andrew P Ambrosy
- Division of Cardiology, The Permanente Medical Group, San Francisco, CA (A.P.A.).,Division of Research, Kaiser Permanente Northern California, Oakland (A.P.A.)
| | - Craig S Parzynski
- Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, CT (C.S.P.)
| | - Daniel J Friedman
- Division of Cardiology, Duke University Medical Center, Durham, NC (D.J.F., M.F., A.F.H., S.M.A.-K.).,Duke Clinical Research Institute, Durham, NC (D.J.F., M.F., A.F.H., S.M.A.-K.)
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC (D.J.F., M.F., A.F.H., S.M.A.-K.).,Duke Clinical Research Institute, Durham, NC (D.J.F., M.F., A.F.H., S.M.A.-K.)
| | - Adrian F Hernandez
- Division of Cardiology, Duke University Medical Center, Durham, NC (D.J.F., M.F., A.F.H., S.M.A.-K.).,Duke Clinical Research Institute, Durham, NC (D.J.F., M.F., A.F.H., S.M.A.-K.)
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, University of California (G.C.F.)
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora (F.A.M.)
| | - Sana M Al-Khatib
- Division of Cardiology, Duke University Medical Center, Durham, NC (D.J.F., M.F., A.F.H., S.M.A.-K.).,Duke Clinical Research Institute, Durham, NC (D.J.F., M.F., A.F.H., S.M.A.-K.)
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15
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Vaduganathan M, Patel RB, Mentz RJ, Subacius H, Chatterjee NA, Greene SJ, Ambrosy AP, Maggioni AP, Udelson JE, Swedberg K, Konstam MA, O'Connor CM, Butler J, Gheorghiade M, Zannad F. Sudden Death After Hospitalization for Heart Failure With Reduced Ejection Fraction (from the EVEREST Trial). Am J Cardiol 2018; 122:255-260. [PMID: 29731121 PMCID: PMC6028287 DOI: 10.1016/j.amjcard.2018.03.362] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/23/2018] [Accepted: 03/29/2018] [Indexed: 01/17/2023]
Abstract
Patients with chronic heart failure with reduced ejection fraction (HFrEF) benefit from medical and device therapies targeting sudden cardiac death (SCD). Contemporary estimates of SCD risk after hospitalization for heart failure are limited. We describe the incidence, timing, and clinical predictors of SCD after hospitalization for HFrEF (≤40%) in the EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan) trial. Multiple logistic regression analyses tested >30 baseline covariates (including treatment randomization, demographics, comorbid conditions, natriuretic peptides, ejection fraction, and medical and device therapies) to identify predictors of 1-year SCD. Of the 4,024 trial patients discharged alive (97%), there were 268 who experienced SCD (7%) and 703 who experienced non-SCD (17%) during median follow-up of 9.9 months. Implantable cardioverter defibrillator use at baseline was 14.5%. Estimates of SCD at 1, 3, 6, and 12 months were 0.8%, 2.3%, 4.1%, and 7.4%, respectively. Most patients were readmitted before SCD (n = 147, 55%). Male gender, black race, diabetes mellitus, and angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker use were potential predictors of 1-year SCD after hospitalization for HFrEF (all p <0.10); however, this final model demonstrated poor discrimination (C-statistic 0.57). In conclusion, in the EVEREST trial, patients hospitalized for HFrEF faced risks of 1-year postdischarge SCD of 7%, which accrued gradually over time, and were balanced with high competing risks of nonsudden death (17%). Traditional clinical characteristics fail to adequately predict SCD risk. Further data are needed to identify patients at greatest relative risk for SCD (compared with non-SCD) after hospitalization for HFrEF.
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16
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You X, Guo ZF, Cheng F, Yi B, Yang F, Liu X, Zhu N, Zhao X, Yan G, Ma XL, Sun J. Transcriptional up-regulation of relaxin-3 by Nur77 attenuates β-adrenergic agonist-induced apoptosis in cardiomyocytes. J Biol Chem 2018; 293:14001-14011. [PMID: 30006349 DOI: 10.1074/jbc.ra118.003099] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 07/12/2018] [Indexed: 12/28/2022] Open
Abstract
The relaxin family peptides have been shown to exert several beneficial effects on the heart, including anti-apoptosis, anti-fibrosis, and anti-hypertrophy activity. Understanding their regulation might provide new opportunities for therapeutic interventions, but the molecular mechanism(s) coordinating relaxin expression in the heart remain largely obscured. Previous work demonstrated a role for the orphan nuclear receptor Nur77 in regulating cardiomyocyte apoptosis. We therefore investigated Nur77 in the hopes of identifying novel relaxin regulators. Quantitative real-time PCR (qRT-PCR) and enzyme-linked immunosorbent assay (ELISA) data indicated that ectopic expression of orphan nuclear receptor Nur77 markedly increased the expression of latexin-3 (RLN3), but not relaxin-1 (RLN1), in neonatal rat ventricular cardiomyocytes (NRVMs). Furthermore, we found that the β-adrenergic agonist isoproterenol (ISO) markedly stimulated RLN3 expression, and this stimulation was significantly attenuated in Nur77 knockdown cardiomyocytes and Nur77 knockout hearts. We showed that Nur77 significantly increased RLN3 promoter activity via specific binding to the RLN3 promoter, as demonstrated by electrophoretic mobility shift assay (EMSA) and chromatin immunoprecipitation (ChIP) assays. Furthermore, we found that Nur77 overexpression potently inhibited ISO-induced cardiomyocyte apoptosis, whereas this protective effect was significantly attenuated in RLN3 knockdown cardiomyocytes, suggesting that Nur77-induced RLN3 expression is an important mediator for the suppression of cardiomyocyte apoptosis. These findings show that Nur77 regulates RLN3 expression, therefore suppressing apoptosis in the heart, and suggest that activation of Nur77 may represent a useful therapeutic strategy for inhibition of cardiac fibrosis and heart failure.
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Affiliation(s)
- Xiaohua You
- From the Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China.,the Center for Translational Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, and
| | - Zhi-Fu Guo
- From the Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China.,the Center for Translational Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, and
| | - Fang Cheng
- the Center for Translational Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, and
| | - Bing Yi
- the Center for Translational Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, and
| | - Fan Yang
- the Center for Translational Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, and
| | - Xinzhu Liu
- the Center for Translational Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, and
| | - Ni Zhu
- From the Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Xianxian Zhao
- From the Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Guijun Yan
- the Reproductive Medicine Center, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 211166, China
| | - Xin-Liang Ma
- the Center for Translational Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, and
| | - Jianxin Sun
- From the Department of Cardiology, Changhai Hospital, Second Military Medical University, Shanghai 200433, China, .,the Center for Translational Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, and
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17
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Yamaguchi T, Kitai T, Miyamoto T, Kagiyama N, Okumura T, Kida K, Oishi S, Akiyama E, Suzuki S, Yamamoto M, Yamaguchi J, Iwai T, Hijikata S, Masuda R, Miyazaki R, Hara N, Nagata Y, Nozato T, Matsue Y. Effect of Optimizing Guideline-Directed Medical Therapy Before Discharge on Mortality and Heart Failure Readmission in Patients Hospitalized With Heart Failure With Reduced Ejection Fraction. Am J Cardiol 2018; 121:969-974. [PMID: 29477488 DOI: 10.1016/j.amjcard.2018.01.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 12/21/2017] [Accepted: 01/02/2018] [Indexed: 12/19/2022]
Abstract
Guideline-directed medical therapy (GDMT) is recommended for patients with heart failure with reduced ejection fraction (HFrEF). However, the prognostic impact of medication optimization at the time of discharge in patients hospitalized with heart failure (HF) is unclear. We analyzed 534 patients (73 ± 13 years old) with HFrEF. The status of GDMT at the time of discharge (prescription of angiotensin converting enzyme inhibitor [ACE-I]/angiotensin receptor blocker [ARB] and β blocker [BB]) and its association with 1-year all-cause mortality and HF readmission were investigated. Patients were divided into 3 groups: those treated with both ACE-I/ARB and BB (Both group: n = 332, 62%), either ACE-I/ARB or BB (Either group: n = 169, 32%), and neither ACE-I/ARB nor BB (None group: n = 33, 6%), respectively. One-year mortality, but not 1-year HF readmission rate, was significantly different in the 3 groups, in favor of the Either and Both groups. A favorable impact of being on GDMT at the time of discharge on 1-year mortality was retained even after adjustment for covariates (Either group: hazard ratio [HR] 0.44, 95% confidence interval [CI] 0.21 to 0.90, p = 0.025 and Both group: HR 0.29, 95% CI 0.13-0.65, p = 0.002, vs None group). For 1-year HF readmission, no such association was found. In conclusion, optimization of GDMT before the time of discharge was associated with a lower 1-year mortality, but not with HF readmission rate, in patients hospitalized with HFrEF.
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18
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Ferrari R, Bueno H, Chioncel O, Cleland JG, Stough WG, Lettino M, Metra M, Parissis JT, Pinto F, Ponikowski P, Ruschitzka F, Tavazzi L. Acute heart failure: lessons learned, roads ahead. Eur J Heart Fail 2018. [DOI: 10.1002/ejhf.1169] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Roberto Ferrari
- Department of Cardiology and LTTA Centre; University Hospital of Ferrara; Ferrara Italy
- Maria Cecilia Hospital, GVM Care & Research; E.S. Health Science Foundation; Cotignola Italy
| | - Héctor Bueno
- Department of Cardiology; Hospital 12 de Octubre; Madrid Spain
| | - Ovidiu Chioncel
- University of Medicine Carol Davila Bucuresti; Institutul de Urgente Boli Cardiovasculare CC; Iliescu Romania
| | - John G. Cleland
- National Heart & Lung Institute; Harefield Hospital, Imperial College; London UK
| | - Wendy Gattis Stough
- Departments of Pharmacy Practice and Clinical Research; Campbell University College of Pharmacy and Health Sciences; Cary NC USA
| | | | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health; University of Brescia; Brescia Italy
| | | | - Fausto Pinto
- Departamento de Cardiologia, CCUL, CAML, Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
| | - Piotr Ponikowski
- Medical University, Centre for Heart Disease; Clinical Military Hospital; Wroclaw Poland
| | - Frank Ruschitzka
- Department of Cardiology; University Heart Center; Zürich Switzerland
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care & Research; E.S. Health Science Foundation; Cotignola Italy
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19
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Martin B, Gabris-Weber BA, Reddy R, Romero G, Chattopadhyay A, Salama G. Relaxin reverses inflammatory and immune signals in aged hearts. PLoS One 2018; 13:e0190935. [PMID: 29346407 PMCID: PMC5773192 DOI: 10.1371/journal.pone.0190935] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 12/22/2017] [Indexed: 02/06/2023] Open
Abstract
Background ‘Healthy’ aging drives structural and functional changes in the heart including maladaptive electrical remodeling, fibrosis and inflammation, which lower the threshold for cardiovascular diseases such as heart failure (HF) and atrial fibrillation (AF). Despite mixed results in recent clinical trials, Relaxin-therapy for 2-days could reduce mortality by 37% at 180-days post-treatment, in patients with acute decompensated HF. Relaxin’s short life-span (hours) but long-lasting protective actions led us to test the hypothesis that relaxin acts at a genomic level to reverse maladaptive remodeling in aging and HF. Methods and results Young (9-month) and aged (24-month), male and female F-344/Brown Norway rats were treated with relaxin (0.4 mg/kg/day) for 2-weeks delivered by subcutaneous osmotic mini-pumps or with sodium acetate (controls). The genomic effects of aging and relaxin were evaluated by extracting RNA from the left ventricles and analyzing genomic changes by RNA-sequencing, Ingenuity Pathway Analysis, MetaCore and tissue immunohistochemistry. We found that aging promotes a native inflammatory response with distinct sex-differences and relaxin suppresses transcription of multiple genes and signaling pathways associated with inflammation and HF in both genders. In addition, aging significantly increased: macrophage infiltration and atrial natriuretic peptide levels in female ventricles, and activation of the complement cascade, whereas relaxin reversed these age-related effects. Conclusion These data support the hypothesis that relaxin alters gene transcription and suppresses inflammatory pathways and genes associated with HF and aging. Relaxin’s suppression of inflammation and fibrosis supports its potential as a therapy for cardiovascular and inflammation-related diseases, such as HF, AF and diabetes.
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Affiliation(s)
- Brian Martin
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America
- School of Medicine, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Beth Ann Gabris-Weber
- School of Medicine, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Rajiv Reddy
- School of Medicine, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Guillermo Romero
- Department of Pharmacology & Chemical Biology, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Ansuman Chattopadhyay
- Molecular Biology Information Service, Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Guy Salama
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America
- School of Medicine, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, United States of America
- * E-mail:
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20
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Wakabayashi K, Ikeda N, Kajimoto K, Minami Y, Keida T, Asai K, Munakata R, Murai K, Sakata Y, Suzuki H, Takano T, Sato N. Trends and predictors of non-cardiovascular death in patients hospitalized for acute heart failure. Int J Cardiol 2018; 250:164-170. [DOI: 10.1016/j.ijcard.2017.09.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 07/17/2017] [Accepted: 09/06/2017] [Indexed: 11/25/2022]
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DeFilippis EM, Butler J, Vaduganathan M. Waiting Period Before Implantable Cardioverter-Defibrillator Implantation in Newly Diagnosed Heart Failure With Reduced Ejection Fraction: A Window of Opportunity. Circ Heart Fail 2017; 10:e004478. [PMID: 29138249 PMCID: PMC5777623 DOI: 10.1161/circheartfailure.117.004478] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Ersilia M DeFilippis
- From the Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (E.M.D., M.V.); and Division of Cardiology, Stony Brook University, NY (J.B.)
| | - Javed Butler
- From the Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (E.M.D., M.V.); and Division of Cardiology, Stony Brook University, NY (J.B.)
| | - Muthiah Vaduganathan
- From the Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA (E.M.D., M.V.); and Division of Cardiology, Stony Brook University, NY (J.B.).
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22
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The evolution of heart failure with reduced ejection fraction pharmacotherapy: What do we have and where are we going? Pharmacol Ther 2017; 178:67-82. [DOI: 10.1016/j.pharmthera.2017.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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23
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Beiert T, Tiyerili V, Knappe V, Effelsberg V, Linhart M, Stöckigt F, Klein S, Schierwagen R, Trebicka J, Nickenig G, Schrickel JW, Andrié RP. Relaxin reduces susceptibility to post-infarct atrial fibrillation in mice due to anti-fibrotic and anti-inflammatory properties. Biochem Biophys Res Commun 2017. [DOI: 10.1016/j.bbrc.2017.06.091] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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24
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Yamamoto E, Kato T, Ozasa N, Yaku H, Inuzuka Y, Tamaki Y, Kitai T, Morimoto T, Taniguchi R, Iguchi M, Kato M, Takahashi M, Jinnai T, Ikeda T, Nagao K, Kawai T, Komasa A, Nishikawa R, Kawase Y, Morinaga T, Kawashima T, Motohashi Y, Kawato M, Toyofuku M, Sato Y, Kuwahara K, Shioi T, Kimura T. Kyoto Congestive Heart Failure (KCHF) study: rationale and design. ESC Heart Fail 2017; 4:216-223. [PMID: 28772047 PMCID: PMC5542729 DOI: 10.1002/ehf2.12138] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 12/04/2016] [Accepted: 12/28/2016] [Indexed: 12/11/2022] Open
Abstract
AIMS Over the last decade, major developments in medicine have led to significant changes in the clinical management of heart failure patients. This study was designed to evaluate the recent trends in clinical characteristics, management, and short-term and long-term prognosis of patients with acute decompensated heart failure (ADHF) in Japan. METHODS AND RESULTS The Kyoto Congestive Heart Failure study is a prospective, observational, multicentre cohort study, enrolling consecutive ADHF patients from 19 participating hospitals in Japan from November 2014 to March 2016. A total of 4000 patients will be enrolled into the study and patients' anthropometric, socio-economic, and clinical data from hospital admission to discharge will be collected. In addition, in a pre-determined subgroup of patients (n=1500), a longitudinal follow-up for 2 years is scheduled. CONCLUSIONS The Kyoto Congestive Heart Failure study will provide valuable information regarding patients with ADHF in the real-world clinical practice of Japan and will be indispensable for future clinical and policy decision-making with respect to heart failure.
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Affiliation(s)
- Erika Yamamoto
- Department of Cardiovascular MedicineGraduate School of Medicine Kyoto UniversityKyotoJapan
| | - Takao Kato
- Department of Cardiovascular MedicineGraduate School of Medicine Kyoto UniversityKyotoJapan
| | - Neiko Ozasa
- Department of Cardiovascular MedicineGraduate School of Medicine Kyoto UniversityKyotoJapan
| | - Hidenori Yaku
- Department of Cardiovascular MedicineGraduate School of Medicine Kyoto UniversityKyotoJapan
| | - Yasutaka Inuzuka
- Department of Cardiovascular MedicineShiga Medical Center for AdultMoriyamaShigaJapan
| | - Yodo Tamaki
- Division of CardiologyTenri HospitalNaraJapan
| | - Takeshi Kitai
- Department of CardiologyKobe City Medical Center General HospitalKobeHyogoJapan
| | - Takeshi Morimoto
- Department of Clinical EpidemiologyHyogo College of MedicineKobeHyogoJapan
| | - Ryoji Taniguchi
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiHyogoJapan
| | - Moritake Iguchi
- National Hospital Organization Kyoto Medical CenterKyotoJapan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Yukihito Sato
- Department of CardiologyHyogo Prefectural Amagasaki General Medical CenterAmagasakiHyogoJapan
| | - Koichiro Kuwahara
- Department of Cardiovascular MedicineGraduate School of Medicine Kyoto UniversityKyotoJapan
| | - Tetsuo Shioi
- Department of Cardiovascular MedicineGraduate School of Medicine Kyoto UniversityKyotoJapan
| | - Takeshi Kimura
- Department of Cardiovascular MedicineGraduate School of Medicine Kyoto UniversityKyotoJapan
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Selim A, Zolty R, Chatzizisis YS. New heart failure pharmacotherapy in clinical trials: a hope in progress. Expert Rev Cardiovasc Ther 2017; 15:649-651. [PMID: 28724329 DOI: 10.1080/14779072.2017.1358614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Ahmed Selim
- a Division of Cardiovascular Medicine , University of Nebraska Medical Center , Omaha , NE , USA
| | - Ronald Zolty
- a Division of Cardiovascular Medicine , University of Nebraska Medical Center , Omaha , NE , USA
| | - Yiannis S Chatzizisis
- a Division of Cardiovascular Medicine , University of Nebraska Medical Center , Omaha , NE , USA
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Abstract
Myocardial injury, mechanical stress, neurohormonal activation, inflammation, and/or aging all lead to cardiac remodeling, which is responsible for cardiac dysfunction and arrhythmogenesis. Of the key histological components of cardiac remodeling, fibrosis either in the form of interstitial, patchy, or dense scars, constitutes a key histological substrate of arrhythmias. Here we discuss current research findings focusing on the role of fibrosis, in arrhythmogenesis. Numerous studies have convincingly shown that patchy or interstitial fibrosis interferes with myocardial electrophysiology by slowing down action potential propagation, initiating reentry, promoting after-depolarizations, and increasing ectopic automaticity. Meanwhile, there has been increasing appreciation of direct involvement of myofibroblasts, the activated form of fibroblasts, in arrhythmogenesis. Myofibroblasts undergo phenotypic changes with expression of gap-junctions and ion channels thereby forming direct electrical coupling with cardiomyocytes, which potentially results in profound disturbances of electrophysiology. There is strong evidence that systemic and regional inflammatory processes contribute to fibrogenesis (i.e., structural remodeling) and dysfunction of ion channels and Ca2+ homeostasis (i.e., electrical remodeling). Recognizing the pivotal role of fibrosis in the arrhythmogenesis has promoted clinical research on characterizing fibrosis by means of cardiac imaging or fibrosis biomarkers for clinical stratification of patients at higher risk of lethal arrhythmia, as well as preclinical research on the development of antifibrotic therapies. At the end of this review, we discuss remaining key questions in this area and propose new research approaches. © 2017 American Physiological Society. Compr Physiol 7:1009-1049, 2017.
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Affiliation(s)
- My-Nhan Nguyen
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Helen Kiriazis
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Xiao-Ming Gao
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Xiao-Jun Du
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
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27
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End points in heart failure-are we doing it right? Eur J Clin Pharmacol 2017; 73:651-659. [PMID: 28280889 DOI: 10.1007/s00228-017-2228-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/27/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Heart Failure (HF) continues to be associated with high mortality and morbidity. We attempted to identify the most common end points used in phase 3 clinical trials of heart failure and discuss their merits and demerits. METHODS Literature evaluation was done using the databases PubMed and Clinicaltrials.gov from January 2010 to December 2016 to identify randomised clinical trials (RCTs) evaluating the effect of therapeutic drugs on heart failure. Following the literature search, the data on the primary end points were extracted from each of the selected trials. The most recurrent and important end points of Phase III clinical trials for HF over the last six years were identified for further discussion. RESULTS From our search, it was observed that the most common end points used in trials with acute heart failure (AHF) were composite end point, dyspnea, CV death and most common end points used in trials with chronic heart failure (CHF) were composite end point, 6 minute walk test (6MWT), CV death or HFH, Vo2 max, all cause mortality, left ventricular ejection fraction (LVEF), and dyspnea. CONCLUSION Choosing the appropriate end points is a critical step in the study design that could turn the tide in the beleaguered drug development pipeline of HF, resulting in the right molecule reaching the HF community.
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28
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Filippatos G, Farmakis D, Metra M, Cotter G, Davison BA, Felker GM, Greenberg BH, Hua TA, Pang PS, Ponikowski P, Qian M, Severin TA, Voors AA, Teerlink JR. Serelaxin in acute heart failure patients with and without atrial fibrillation: a secondary analysis of the RELAX-AHF trial. Clin Res Cardiol 2017; 106:444-456. [PMID: 28150186 PMCID: PMC5511317 DOI: 10.1007/s00392-016-1074-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 12/27/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Atrial fibrillation (AFib) is a common comorbidity in HF and affects patients' outcome. We sought to assess the effects of serelaxin in patients with and without AFib. METHODS In a post hoc analysis of the RELAX-AHF trial, we compared the effects of serelaxin on efficacy end points, safety end points and biomarkers in 1161 patients with and without AFib on admission electrocardiogram. RESULTS AFib was present in 41.3% of patients. Serelaxin had a similar effect in patients with and without AFib, including dyspnea relief by visual analog scale through day 5 [mean change in area under the curve, 541.11 (33.79, 1048.44), p = 0.0366 in AFib versus 361.80 (-63.30, 786.90), p = 0.0953 in non-AFib, interaction p = 0.5954] and all-cause death through day 180 [HR = 0.42 (0.23, 0.77), p = 0.0051 in AFib versus 0.90 (0.53, 1.52), p = 0.6888 in non-AFib, interaction p = 0.0643]. Serelaxin was similarly safe in the two groups and induced similar reductions in biomarkers of cardiac, renal and hepatic damage. Stroke occurred more frequently in AFib patients (2.8 vs. 0.8%, p = 0.0116) and there was a trend for lower stroke incidence in the serelaxin arm in AFib patients (odds ratios, 0.31, p = 0.0759 versus 3.88, p = 0.2255 in non-AFib, interaction p = 0.0518). CONCLUSIONS Serelaxin was similarly safe and efficacious in improving short- and long-term outcomes and inducing organ protection in acute HF patients with and without AFib.
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Affiliation(s)
- Gerasimos Filippatos
- National and Kapodistrian University of Athens, Medical School, Athens, Greece. .,Heart Failure Unit, Department of Cardiology, Athens University Hospital Attikon, 1 Rimini St, 12462, Athens, Greece.
| | - Dimitrios Farmakis
- National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | | | | | | | | | | | - Tsushung A Hua
- Novartis Pharmaceuticals Corporation, New Hanover, NJ, USA
| | - Peter S Pang
- Indiana University School of Medicine and Regenstrief Institute, Indianapolis, IN, USA
| | | | - Min Qian
- Columbia University, New York, NY, USA
| | | | | | - John R Teerlink
- University of California-San Francisco and San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
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29
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Unemori E. Serelaxin in clinical development: past, present and future. Br J Pharmacol 2017; 174:921-932. [PMID: 28009437 DOI: 10.1111/bph.13695] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 11/18/2016] [Accepted: 12/05/2016] [Indexed: 12/15/2022] Open
Abstract
The availability of highly purified recombinant human relaxin, serelaxin, has allowed clinical trials to be conducted in several indications and the elucidation of its pharmacology in human subjects. These studies have demonstrated that serelaxin has unique haemodynamic properties that are likely to contribute to organ protection and long-term outcome benefits in acute heart failure. Clinical observations support its consideration for therapeutic use in other patient populations, including those with chronic heart failure, coronary artery disease, portal hypertension and acute renal failure. LINKED ARTICLES This article is part of a themed section on Recent Progress in the Understanding of Relaxin Family Peptides and their Receptors. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.10/issuetoc.
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30
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Ghosh RK, Banerjee K, Tummala R, Ball S, Ravakhah K, Gupta A. Serelaxin in acute heart failure: Most recent update on clinical and preclinical evidence. Cardiovasc Ther 2016; 35:55-63. [DOI: 10.1111/1755-5922.12231] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Raktim Kumar Ghosh
- Department of Cardiovascular Medicine; St. Vincent Charity Medical Center; A Teaching Hospital affiliated to Case Western Reserve University; Cleveland OH USA
| | | | - Ramyashree Tummala
- Department of Internal Medicine; St. Vincent Charity Medical Center; A Teaching Hospital affiliated to Case Western Reserve University; Cleveland OH USA
| | - Somedeb Ball
- Department of Internal Medicine; St Francis Hospital and Medical Center; Hartford CT USA
| | - Keyvan Ravakhah
- Department of Internal Medicine; St. Vincent Charity Medical Center; A Teaching Hospital affiliated to Case Western Reserve University; Cleveland OH USA
| | - Anjan Gupta
- Department of Cardiovascular Medicine; St. Vincent Charity Medical Center; A Teaching Hospital affiliated to Case Western Reserve University; Cleveland OH USA
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32
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Sarwar M, Du XJ, Dschietzig TB, Summers RJ. The actions of relaxin on the human cardiovascular system. Br J Pharmacol 2016; 174:933-949. [PMID: 27239943 DOI: 10.1111/bph.13523] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/01/2016] [Accepted: 04/26/2016] [Indexed: 12/14/2022] Open
Abstract
The insulin-like peptide relaxin, originally identified as a hormone of pregnancy, is now known to exert a range of pleiotropic effects including vasodilatory, anti-fibrotic, angiogenic, anti-apoptotic and anti-inflammatory effects in both males and females. Relaxin produces these effects by binding to a cognate receptor RXFP1 and activating a variety of signalling pathways including cAMP, cGMP and MAPKs as well as by altering gene expression of TGF-β, MMPs, angiogenic growth factors and endothelin receptors. The peptide has been shown to be effective in halting or reversing many of the adverse effects including fibrosis in animal models of cardiovascular disease including ischaemia/reperfusion injury, myocardial infarction, hypertensive heart disease and cardiomyopathy. Relaxin given to humans is safe and produces favourable haemodynamic changes. Serelaxin, the recombinant form of relaxin, is now in extended phase III clinical trials for the treatment of acute heart failure. Previous clinical studies indicated that a 48 h infusion of relaxin improved 180 day mortality, yet the mechanism underlying this effect is not clear. This article provides an overview of the cellular mechanism of effects of relaxin and summarizes its beneficial actions in animal models and in the clinic. We also hypothesize potential mechanisms for the clinical efficacy of relaxin, identify current knowledge gaps and suggest new ways in which relaxin could be useful therapeutically. LINKED ARTICLES This article is part of a themed section on Recent Progress in the Understanding of Relaxin Family Peptides and their Receptors. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.10/issuetoc.
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Affiliation(s)
- Mohsin Sarwar
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Australia
| | - Xiao-Jun Du
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Thomas B Dschietzig
- Immundiagnostik AG, Bensheim, Germany.,Campus Mitte, Medical Clinic for Cardiology and Angiology, Charité-University Medicine Berlin, Berlin, Germany.,Relaxera Pharmazeutische Gesellschaft mbH & Co. KG, Bensheim, Germany
| | - Roger J Summers
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Australia
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33
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Inamdar AA, Inamdar AC. Heart Failure: Diagnosis, Management and Utilization. J Clin Med 2016; 5:E62. [PMID: 27367736 PMCID: PMC4961993 DOI: 10.3390/jcm5070062] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/28/2016] [Accepted: 06/13/2016] [Indexed: 12/11/2022] Open
Abstract
Despite the advancement in medicine, management of heart failure (HF), which usually presents as a disease syndrome, has been a challenge to healthcare providers. This is reflected by the relatively higher rate of readmissions along with increased mortality and morbidity associated with HF. In this review article, we first provide a general overview of types of HF pathogenesis and diagnostic features of HF including the crucial role of exercise in determining the severity of heart failure, the efficacy of therapeutic strategies and the morbidity/mortality of HF. We then discuss the quality control measures to prevent the growing readmission rates for HF. We also attempt to elucidate published and ongoing clinical trials for HF in an effort to evaluate the standard and novel therapeutic approaches, including stem cell and gene therapies, to reduce the morbidity and mortality. Finally, we discuss the appropriate utilization/documentation and medical coding based on the severity of the HF alone and with minor and major co-morbidities. We consider that this review provides an extensive overview of the HF in terms of disease pathophysiology, management and documentation for the general readers, as well as for the clinicians/physicians/hospitalists.
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Affiliation(s)
- Arati A Inamdar
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ 07601, USA.
- Ansicht Scidel Inc., Edison, NJ 08837, USA.
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Vaduganathan M, Butler J, Roessig L, Fonarow GC, Greene SJ, Metra M, Cotter G, Kupfer S, Zalewski A, Sato N, Filippatos G, Gheorghiade M. Clinical trials in hospitalized heart failure patients: targeting interventions to optimal phenotypic subpopulations. Heart Fail Rev 2016; 20:393-400. [PMID: 25894076 DOI: 10.1007/s10741-015-9485-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
With one possible exception, the last decade of clinical trials in hospitalized heart failure (HHF) patients has failed to demonstrate improvement in long-term clinical outcomes. This trend necessitates a need to evaluate optimal drug development strategies and standards of trial conduct. It has become increasingly important to recognize the heterogeneity among HHF patients and the differential characterization of novel drug candidates. Targeting these agents to specific subpopulations may afford optimal net response related to the particular mode of action of the drug. Analyses of previous trials demonstrate profound differences in the baseline characteristics of patients enrolled across global regions and participating sites. Such differences may influence risks for events and interpretation of results. Therefore, the actual execution of trials and the epidemiology of HHF populations at the investigative sites must be taken into consideration. Collaboration among participating sites including the provision of registry data tailored to the planned development program will optimize trial conduct. Observational data prior to study initiation may enable sites to feedback and engage in protocol development to allow for feasible and valid clinical trial conduct. This site-centered, epidemiology-based network environment may facilitate studies in specific patient populations and promote optimal data collection and clear interpretation of drug safety and efficacy. This review summarizes the roundtable discussion held by a multidisciplinary team of representatives from academia, National Institutes of Health, industry, regulatory agencies, payers, and contract and academic research organizations to answer the question: Who should be targeted for novel therapies in HHF?
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Affiliation(s)
- Muthiah Vaduganathan
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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35
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Abstract
Outcomes for patients with acute heart failure remain suboptimal and treatments principally target improvement of symptoms. To date there has been no therapy approved for acute heart failure shown to improve mortality or readmission risk post-discharge. Serelaxin, a recombinant form of the naturally occurring polypeptide hormone relaxin, has demonstrated promise in preclinical and early clinical trials as a potentially novel therapy for acute heart failure. It is postulated through its anti-fibrotic and vasodilatory effects that this agent can improve outcomes in both the short and long term in these patients. Randomized clinical data has suggested that the medication is safe and well tolerated. However, definitive outcomes data is currently being assessed in a large multi-center trial.
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Affiliation(s)
- Danyaal S Moin
- a Division of Cardiology , Stony Brook University School of Medicine , Stony Brook , NY , USA
| | - Michelle W Bloom
- a Division of Cardiology , Stony Brook University School of Medicine , Stony Brook , NY , USA
| | - Lampros Papadimitriou
- a Division of Cardiology , Stony Brook University School of Medicine , Stony Brook , NY , USA
| | - Javed Butler
- a Division of Cardiology , Stony Brook University School of Medicine , Stony Brook , NY , USA
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36
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Henry BL, Gabris B, Li Q, Martin B, Giannini M, Parikh A, Patel D, Haney J, Schwartzman DS, Shroff SG, Salama G. Relaxin suppresses atrial fibrillation in aged rats by reversing fibrosis and upregulating Na+ channels. Heart Rhythm 2016; 13:983-91. [PMID: 26711798 PMCID: PMC4801709 DOI: 10.1016/j.hrthm.2015.12.030] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) contributes significantly to morbidity and mortality in elderly patients and has been correlated with enhanced age-dependent atrial fibrosis. Reversal of atrial fibrosis has been proposed as therapeutic strategy to suppress AF. OBJECTIVE To test the ability of relaxin to reverse age-dependent atrial fibrosis and suppress AF. METHODS Aged F-344 rats (24 months old) were treated with subcutaneous infusion of vehicle or relaxin (0.4 mg/kg/day) for 2 weeks. Rat hearts were excised, perfused on a Langendorff apparatus, and stained with voltage and Ca(2+) indicator dyes. Optical mapping and programmed electrical stimulation was used to test arrhythmia vulnerability and changes in electrophysiological characteristics. Changes in protein expression and Na(+) current density (INa) were measured by tissue immunofluorescence and whole-cell patch clamp technique. RESULTS In aged rats, sustained AF was readily induced with a premature pulse (n = 7/8) and relaxin treatment suppressed sustained AF by a premature impulse or burst pacing (n = 1/6) (P < .01). Relaxin significantly increased atrial action potential conduction velocity and decreased atrial fibrosis. Relaxin treatment increased Nav1.5 expression (n = 6; 36% ± 10%) and decreased total collagen and collagen I (n = 5-6; 55%-66% ± 15%) in aged atria (P < .05) and decreased collagen I and III and TGF-β1 mRNA (P < .05). Voltage-clamp experiments demonstrated that relaxin treatment (100 nM for 2 days) increased atrial INa by 46% ± 4% (n = 12-13/group, P < .02). CONCLUSION Relaxin suppresses AF through an increase in atrial conduction velocity by decreasing atrial fibrosis and increasing INa. These data provide compelling evidence that relaxin may serve as an effective therapy to manage AF in geriatric patients by reversing fibrosis and modulating cardiac ionic currents.
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Affiliation(s)
- Brian L Henry
- University of Pittsburgh School of Medicine, Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Beth Gabris
- University of Pittsburgh School of Medicine, Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Qiao Li
- University of Pittsburgh School of Medicine, Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Brian Martin
- University of Pittsburgh Department of Bioengineering, and the McGowan Institute for Regenerative Medicine, Pittsburgh, Pennsylvania
| | - Marianna Giannini
- University of Pittsburgh School of Medicine, Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Ashish Parikh
- University of Pittsburgh Department of Bioengineering, and the McGowan Institute for Regenerative Medicine, Pittsburgh, Pennsylvania
| | - Divyang Patel
- University of Pittsburgh School of Medicine, Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Jamie Haney
- University of Pittsburgh Department of Bioengineering, and the McGowan Institute for Regenerative Medicine, Pittsburgh, Pennsylvania
| | - David S Schwartzman
- University of Pittsburgh School of Medicine, Heart and Vascular Institute, Pittsburgh, Pennsylvania
| | - Sanjeev G Shroff
- University of Pittsburgh Department of Bioengineering, and the McGowan Institute for Regenerative Medicine, Pittsburgh, Pennsylvania
| | - Guy Salama
- University of Pittsburgh School of Medicine, Heart and Vascular Institute, Pittsburgh, Pennsylvania,; University of Pittsburgh Department of Bioengineering, and the McGowan Institute for Regenerative Medicine, Pittsburgh, Pennsylvania.
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Organ protection possibilities in acute heart failure. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2016.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Liu LCY, Voors AA, Teerlink JR, Cotter G, Davison BA, Felker GM, Filippatos G, Chen Y, Greenberg BH, Ponikowski P, Pang PS, Prescott MF, Hua TA, Severin TM, Metra M. Effects of serelaxin in acute heart failure patients with renal impairment: results from RELAX-AHF. Clin Res Cardiol 2016; 105:727-37. [PMID: 27017514 PMCID: PMC4988995 DOI: 10.1007/s00392-016-0979-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 03/14/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Serelaxin showed beneficial effects on clinical outcome and trajectories of renal markers in patients with acute heart failure. We aimed to study the interaction between renal function and the treatment effect of serelaxin. METHODS In the current post hoc analysis of the RELAX-AHF trial, we included all patients with available estimated glomerular filtration rate (eGFR) at baseline (n = 1132). Renal impairment was defined as an eGFR <60 ml/min/1.73 m(2) estimated by creatinine. RESULTS 817 (72.2 %) patients had a baseline eGFR <60 ml/min/1.73 m(2). In placebo-treated patients, baseline renal impairment was related to a higher 180 day cardiovascular (HR 3.12, 95 % CI 1.33-7.30) and all-cause mortality (HR 2.81, 95 % CI 1.34-5.89). However, in serelaxin-treated patients, the risk of cardiovascular and all-cause mortality was less pronounced (HR 1.19, 95 % CI 0.54 -2.64; p for interaction = 0.106, and HR 1.15 95 % CI 0.56-2.34 respectively; p for interaction = 0.088). In patients with renal impairment, treatment with serelaxin resulted in a more pronounced all-cause mortality reduction (HR 0.53, 95 % CI 0.34-0.83), compared with patients without renal impairment (HR 1.30, 95 % CI 0.51-3.29). CONCLUSION Renal dysfunction was associated with higher cardiovascular and all-cause mortality in placebo-treated patients, but not in serelaxin-treated patients. The observed reduction in (cardiovascular) mortality in RELAX-AHF was more pronounced in patients with renal dysfunction. These observations need to be confirmed in the ongoing RELAX-AHF-2 trial.
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Affiliation(s)
- Licette C Y Liu
- Department of Cardiology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - John R Teerlink
- San Francisco Veterans Affairs Medical Center, University of California, San Francisco, CA, USA
| | | | | | - G Michael Felker
- Duke University School of Medicine, Duke Heart Center, Durham, NC, USA
| | - Gerasimos Filippatos
- School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Yakuan Chen
- Columbia University Medical Center, New York, NY, USA
| | | | | | - Peter S Pang
- Indiana University School of Medicine, Indianapolis, IN, USA
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Montero-Pérez-Barquero M, Morales-Rull JL. Organ protection possibilities in acute heart failure. Rev Clin Esp 2016; 216:157-64. [PMID: 26896381 DOI: 10.1016/j.rce.2016.01.003] [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: 11/17/2015] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
Abstract
Unlike chronic heart failure (HF), the treatment for acute HF has not changed over the last decade. The drugs employed have shown their ability to control symptoms but have not achieved organ protection or managed to reduce medium to long-term morbidity and mortality. Advances in our understanding of the pathophysiology of acute HF suggest that treatment should be directed not only towards correcting the haemodynamic disorders and achieving symptomatic relief but also towards preventing organ damage, thereby counteracting myocardial remodelling and cardiac and extracardiac disorders. Compounds that exert vasodilatory and anti-inflammatory action in the acute phase of HF and can stop cell death, thereby boosting repair mechanisms, could have an essential role in organ protection.
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Affiliation(s)
- M Montero-Pérez-Barquero
- Servicio de Medicina Interna, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Reina Sofía, Universidad de Córdoba, Córdoba, España.
| | - J L Morales-Rull
- Unidad de Insuficiencia Cardiaca, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Región Sanitaria de Lleida, Lleida, España
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Abstract
Although the period from 1953 to 2001 resulted in the approval of more than 30 medications currently used to treat heart failure (HF), few novel drugs have been approved in the last decade. However, the investigational pipeline for HF medications once again appears promising. In patients with chronic heart failure with reduced ejection fraction (HFrEF), ivabradine and valsartan/sucubitril (LCZ696) were recently approved by the US Food and Drug Administration. Both agents have been shown to reduce the risk of cardiovascular death and HF hospitalization. In the treatment of acute HF, serelaxin and ularitide are the farthest along in development. Both agents have demonstrated favorable effects on surrogate end points and preliminary data suggest a possible mortality benefit with serelaxin. Consequently, phase 3 trials are ongoing to evaluate the effect of serelaxin and ularitide on clinical outcomes. Given the poor history of recent investigational acute HF drugs that have advanced to phase 3/4 studies, enthusiasm for both serelaxin and ularitide must be tempered until these trials are completed.
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Affiliation(s)
- Sarah Hanigan
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI, USA
| | - Robert J. DiDomenico
- Department of Pharmacy Practice, Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
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Afsar B, Ortiz A, Covic A, Solak Y, Goldsmith D, Kanbay M. Focus on renal congestion in heart failure. Clin Kidney J 2015; 9:39-47. [PMID: 26798459 PMCID: PMC4720202 DOI: 10.1093/ckj/sfv124] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 10/27/2015] [Indexed: 12/11/2022] Open
Abstract
Hospitalizations due to heart failure are increasing steadily despite advances in medicine. Patients hospitalized for worsening heart failure have high mortality in hospital and within the months following discharge. Kidney dysfunction is associated with adverse outcomes in heart failure patients. Recent evidence suggests that both deterioration in kidney function and renal congestion are important prognostic factors in heart failure. Kidney congestion in heart failure results from low cardiac output (forward failure), tubuloglomerular feedback, increased intra-abdominal pressure or increased venous pressure. Regardless of the cause, renal congestion is associated with increased morbidity and mortality in heart failure. The impact on outcomes of renal decongestion strategies that do not compromise renal function should be explored in heart failure. These studies require novel diagnostic markers that identify early renal damage and renal congestion and allow monitoring of treatment responses in order to avoid severe worsening of renal function. In addition, there is an unmet need regarding evidence-based therapeutic management of renal congestion and worsening renal function. In the present review, we summarize the mechanisms, diagnosis, outcomes, prognostic markers and treatment options of renal congestion in heart failure.
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Affiliation(s)
- Baris Afsar
- Department of Medicine, Division of Nephrology , Konya Numune State Hospital , Konya , Turkey
| | - Alberto Ortiz
- Nephrology and Hypertension Department , IIS-Fundacion Jimenez Diaz and School of Medicine , Madrid , Spain
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center , 'C.I. PARHON' University Hospital, and 'Grigore T. Popa' University of Medicine , Iasi , Romania
| | - Yalcin Solak
- Department of Nephrology , Sakarya Training and Research Hospital , Sakarya , Turkey
| | - David Goldsmith
- Renal and Transplantation Department , Guy's and St Thomas' Hospitals , London , UK
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology , Koc University School of Medicine , Istanbul , Turkey
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42
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Díez J, Ruilope LM. Serelaxin for the treatment of acute heart failure: a review with a focus on end-organ protection. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 2:119-30. [PMID: 27418970 PMCID: PMC4853824 DOI: 10.1093/ehjcvp/pvv046] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/26/2015] [Indexed: 12/15/2022]
Abstract
Acute heart failure (AHF) is a complex clinical syndrome characterized by fluid overload and haemodynamic abnormalities (short-term clinical consequences) and the development of end-organ damage (long-term consequences). Current therapies for the treatment of AHF, such as loop diuretics and vasodilators, help to relieve haemodynamic imbalance and congestion, but have not been shown to prevent (and may even contribute to) end-organ damage, or to provide long-term clinical benefit. Serelaxin is the recombinant form of human relaxin-2, a naturally occurring hormone involved in mediating haemodynamic changes during pregnancy. Preclinical and clinical studies have investigated the effects mediated by serelaxin and the suitability of this agent for the treatment of patients with AHF. Data suggest that serelaxin acts via multiple pathways to improve haemodynamics at the vascular, cardiac, and renal level and provide effective congestion relief. In addition, this novel agent may protect the heart, kidneys, and liver from damage by inhibiting inflammation, oxidative stress, cell death, and tissue fibrosis, and stimulating angiogenesis. Serelaxin may therefore improve both short- and long-term outcomes in patients with AHF. In this review, we examine the unique mechanisms underlying the potential benefits of serelaxin for the treatment of AHF, in particular, those involved in mediating end-organ protection.
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Affiliation(s)
- Javier Díez
- Program of Cardiovascular Diseases, Centre for Applied Medical Research and Department of Cardiology and Cardiac Surgery, University of Navarra Clinic, University of Navarra, Av. Pío XII 55, Pamplona 31008, Spain
| | - Luis M Ruilope
- Research Institute, Hypertension Unit, Hospital 12 de Octubre and Department of Public Health and Preventive Medicine, University Autónoma, Madrid, Spain
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43
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Tietjens J, Teerlink JR. Serelaxin and acute heart failure. Heart 2015; 102:95-9. [DOI: 10.1136/heartjnl-2014-306786] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 10/02/2015] [Indexed: 01/11/2023] Open
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Raleigh JMV, Toldo S, Das A, Abbate A, Salloum FN. Relaxin' the Heart: A Novel Therapeutic Modality. J Cardiovasc Pharmacol Ther 2015; 21:353-62. [PMID: 26589290 DOI: 10.1177/1074248415617851] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/22/2015] [Indexed: 12/20/2022]
Abstract
The peptide hormone relaxin has traditionally been linked to the maternal adaptation of the cardiovascular system during the first trimester of pregnancy. By promoting nitric oxide formation through different molecular signaling events, relaxin has been proposed as a pleiotropic and cardioprotective hormone in the setting of many cardiovascular diseases. In fact, preclinical studies were able to demonstrate that relaxin promotes vasodilatation and angiogenesis, ameliorates ischemia/reperfusion injury, and regulates extracellular matrix turnover and remodeling. In the RELAX-AHF phase 3 clinical trial, serelaxin (recombinant human relaxin) was shown to be safe, and it exerted survival benefits in patients with acute heart failure. RELAX-AHF-2 is currently ongoing, and it aims to address a larger population and evaluate harder clinical outcomes. Besides heart failure, acute myocardial infarction, peripheral arterial disease, and stable coronary disease could be target diseases for treatment with serelaxin in future clinical trials.
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Affiliation(s)
- Juan M Valle Raleigh
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Stefano Toldo
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Anindita Das
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Antonio Abbate
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Fadi N Salloum
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
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45
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Parikh KS, Felker GM, Metra M. Mode of Death After Acute Heart Failure Hospitalization - A Clue to Possible Mechanisms. Circ J 2015; 80:17-23. [PMID: 26511229 DOI: 10.1253/circj.cj-15-1006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Heart failure continues to be a leading cause of hospitalization worldwide, and acute heart failure (AHF) carries significant risk for short-term morbidity and mortality. Despite many trials of potential new therapies for AHF, there have been very few advances over the recent decades. In this review, we will examine mortality during and after AHF hospitalization, with an emphasis on available data on mode of death (MOD). We will also review data on the timing of different MOD after AHF and the effect of specific therapies, as well as what is known about the contribution of specific pathophysiological mechanisms. Finally, we discuss the potential utility of further study of MOD data for AHF and its application to drug development, risk stratification, and therapeutic tailoring to improve short- and long-term outcomes in AHF.
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46
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Henry BL, Schwartzman DS, Salama G. Mode of Death Prevention by Serelaxin. J Am Coll Cardiol 2015; 66:98-9. [PMID: 26139068 DOI: 10.1016/j.jacc.2014.12.079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 12/01/2014] [Indexed: 11/25/2022]
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47
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Felker GM, Mentz RJ, Teerlink JR, Voors AA, Pang PS, Ponikowski P, Greenberg BH, Filippatos G, Davison BA, Cotter G, Prescott MF, Hua TA, Lopez-Pintado S, Severin T, Metra M. Serial high sensitivity cardiac troponin T measurement in acute heart failure: insights from the RELAX-AHF study. Eur J Heart Fail 2015; 17:1262-70. [DOI: 10.1002/ejhf.341] [Citation(s) in RCA: 91] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 06/30/2015] [Accepted: 07/02/2015] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Robert J. Mentz
- Duke Clinical Research Institute; DUMC Box 3850 Durham NC 27710 USA
| | - John R. Teerlink
- University of California-San Francisco and San Francisco Veterans Affairs Medical Center; San Francisco CA USA
| | | | - Peter S. Pang
- Indiana University School of Medicine; Indianapolis IN USA
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Felker GM, Metra M, Teerlink JR. Reply. J Am Coll Cardiol 2015; 66:99. [DOI: 10.1016/j.jacc.2014.12.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 12/16/2014] [Indexed: 11/30/2022]
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49
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Mebazaa A, Longrois D, Metra M, Mueller C, Richards AM, Roessig L, Seronde MF, Sato N, Stockbridge NL, Gattis Stough W, Alonso A, Cody RJ, Cook Bruns N, Gheorghiade M, Holzmeister J, Laribi S, Zannad F. Agents with vasodilator properties in acute heart failure: how to design successful trials. Eur J Heart Fail 2015; 17:652-64. [PMID: 26040488 DOI: 10.1002/ejhf.294] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 04/17/2015] [Accepted: 04/22/2015] [Indexed: 01/08/2023] Open
Abstract
Agents with vasodilator properties (AVDs) are frequently used in the treatment of acute heart failure (AHF). AVDs rapidly reduce preload and afterload, improve left ventricle to aorta and right ventricle to pulmonary artery coupling, and may improve symptoms. Early biomarker changes after AVD administration have suggested potentially beneficial effects on cardiac stretch, vascular tone, and renal function. AVDs that reduce haemodynamic congestion without causing hypoperfusion might be effective in preventing worsening organ dysfunction. Existing AVDs have been associated with different results on outcomes in randomized clinical trials, and observational studies have suggested that AVDs may be associated with a clinical outcome benefit. Lessons have been learned from past AVD trials in AHF regarding preventing hypotension, selecting the optimal endpoint, refining dyspnoea measurements, and achieving early randomization and treatment initiation. These lessons have been applied to the design of ongoing pivotal clinical trials, which aim to ascertain if AVDs improve clinical outcomes. The developing body of evidence suggests that AVDs may be a clinically effective therapy to reduce symptoms, but more importantly to prevent end-organ damage and improve clinical outcomes for specific patients with AHF. The results of ongoing trials will provide more clarity on the role of AVDs in the treatment of AHF.
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Affiliation(s)
- Alexandre Mebazaa
- University Paris Diderot, Sorbonne Paris Cité, Paris, France.,U942 INSERM, AP-HP, Paris, France.,APHP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Dan Longrois
- Département d'Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, University Paris Diderot, Sorbonne Paris Cité, Paris, U1148 INSERM, Paris, France
| | - Marco Metra
- Cardiology, University of Brescia, Brescia, Italy
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Arthur Mark Richards
- Cardiovascular Research Institute, National University of Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lothar Roessig
- Global Clinical Development, Bayer Pharma AG, Berlin, Germany
| | - Marie France Seronde
- Department of Cardiology, University Hospital of Besançon, U942 INSERM, Besançon, France
| | - Naoki Sato
- Internal Medicine, Cardiology, and Intensive Care Medicine, Nippon Medical School Musashi-Kosugi Hospital, Kanagawa, Japan
| | - Norman L Stockbridge
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | | | - Angeles Alonso
- Scientific Advice Working Party European Medicines Agency, Madrid, Spain
| | | | | | - Mihai Gheorghiade
- Department of Medicine, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Said Laribi
- APHP, Department of Emergency Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, INSERM U942, Paris, France
| | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Université de Lorraine, Nancy, France
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50
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Villalba González JC. Breves de la academia. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rca.2015.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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