Pharmacological treatments of cardiovascular diseases: Evidence from real-life studies

Monoterpenes and their derivatives as agents for cardiovascular disease management: A systematic review and meta-analysis

BACKGROUND

Monoterpenes are one of the most studied plant's secondary metabolites, they are found abundantly in essential oils of aromatic plants. They also have a great range of pharmacological properties, such as antihypertensive, bradycardic, antiarrhythmic and hypotensive. In the face of the burden caused by cardiovascular disease (CVDs) worldwide, studies using monoterpenes to assess their cardiovascular effects have increased over the years.

PURPOSE

This systematic review aimed to summarize the use of monoterpenes in animal models of any CVDs.

METHODS

PubMed, SCOPUS, LILACS and Web of Science databases were used to search for articles that used monoterpenes, in any type of administration, to treat or prevent CVDs in animal models. The PRISMA guidelines were followed. Two independent researchers extracted main characteristics of studies, methods and outcomes. Data obtained were analyzed qualitatively and quantitatively.

RESULTS

At the ending of the search process, 33 articles were selected for the systematic review. Of these, 17 articles were included in the meta-analysis. A total of 16 different monoterpenes were found for the treatment of hypertension, myocardial infarction, pulmonary hypertension, cardiac hypertrophy and arrhythmia. The main actions include hypotension, bradycardia, vasodilatation, antiarrhythmic, and antioxidant and antiapoptotic properties. From our data, it can be suggested that monoterpenes may be a significant source for new drug development. However, there is still a need to apply these knowledge into clinical research and a long path to pursue before putting them in the market.

CONCLUSION

The variability of cardiovascular effects demonstrated by the monoterpenes highlighted them as a promising candidates for treatment or prevention of CVDs. Nevertheless, studies that investigate their biological sites of action needs to be further encouraged.

Coumarin's Anti-Quorum Sensing Activity Can Be Enhanced When Combined with Other Plant-Derived Small Molecules

Coumarins are class of natural aromatic compounds based on benzopyrones (2H-1-benzopyran-2-ones). They are identified as secondary metabolites in about 150 different plant species. The ability of coumarins to inhibit cell-to-cell communication in bacterial communities (quorum sensing; QS) has been previously described. Coumarin and its derivatives in plant extracts are often found together with other small molecules that show anti-QS properties too. The aim of this study was to find the most effective combinations of coumarins and small plant-derived molecules identified in various plants extracts that inhibit QS in Chromobacterium violaceum ATCC 31532 violacein production bioassay. The coumarin and its derivatives: 7-hydroxycoumarin, 7.8-dihydroxy-4-methylcoumarin, were included in the study. Combinations of coumarins with gamma-octalactone, 4-hexyl-1.3-benzenediol, 3.4.5-trimethoxyphenol and vanillin, previously identified in oak bark (Quercus cortex), and eucalyptus leaves (Eucalyptus viminalis) extracts, were analyzed in a bioassay. When testing two-component compositions, it was shown that 7.8-dihydroxy-4-methylcoumarin, 4-hexyl-1.3-benzendiol, and gamma-octalactone showed a supra-additive anti-QS effect. Combinations of all three molecules resulted in a three- to five-fold reduction in the concentration of each compound needed to achieve EC50 (half maximal effective concentration) against QS in C. violaceum ATCC 31532.

Antioxidants and antioxidant methods: an updated overview

Antioxidants had a growing interest owing to their protective roles in food and pharmaceutical products against oxidative deterioration and in the body and against oxidative stress-mediated pathological processes. Screening of antioxidant properties of plants and plant-derived compounds requires appropriate methods, which address the mechanism of antioxidant activity and focus on the kinetics of the reactions including the antioxidants. Many studies evaluating the antioxidant activity of various samples of research interest using different methods in food and human health have been conducted. These methods are classified, described, and discussed in this review. Methods based on inhibited autoxidation are the most suited for termination-enhancing antioxidants and for chain-breaking antioxidants, while different specific studies are needed for preventive antioxidants. For this purpose, the most common methods used in vitro determination of antioxidant capacity of food constituents were examined. Also, a selection of chemical testing methods was critically reviewed and highlighted. In addition, their advantages, disadvantages, limitations and usefulness were discussed and investigated for pure molecules and raw extracts. The effect and influence of the reaction medium on the performance of antioxidants are also addressed. Hence, this overview provides a basis and rationale for developing standardized antioxidant methods for the food, nutraceuticals, and dietary supplement industries. In addition, the most important advantages and shortcomings of each method were detected and highlighted. The chemical principles of these methods are outlined and critically discussed. The chemical principles of methods of 2,2'-azinobis-(3-ethylbenzothiazoline-6-sulphonate) radical (ABTS^·+) scavenging, 1,1-diphenyl-2-picrylhydrazyl (DPPH·) radical scavenging, Fe³⁺-Fe²⁺ transformation assay, ferric reducing antioxidant power (FRAP) assay, cupric ions (Cu²⁺) reducing power assay (Cuprac), Folin-Ciocalteu reducing capacity (FCR assay), peroxyl radical (ROO·), superoxide radical anion (O₂^·-), hydrogen peroxide (H₂O₂) scavenging assay, hydroxyl radical (OH·) scavenging assay, singlet oxygen (¹O₂) quenching assay, nitric oxide radical (NO·) scavenging assay and chemiluminescence assay are outlined and critically discussed. Also, the general antioxidant aspects of main food components were discussed by a number of methods, which are currently used for the detection of antioxidant properties of food components. This review consists of two main sections. The first section is devoted to the main components in the food and pharmaceutical applications. The second general section comprises some definitions of the main antioxidant methods commonly used for the determination of the antioxidant activity of components. In addition, some chemical, mechanistic and kinetic basis, and technical details of the used methods are given.

Coumarin-piperazine derivatives as biologically active compounds

A number of psychiatric disorders, including anxiety, schizophrenia, Parkinson's disease, depression and others CNS diseases are known to induce defects in the function of neural pathways sustained by the neurotransmitters, like dopamine and serotonin. N-arylpiperazine moiety is important for CNS-activity, particularly for serotonergic and dopaminergic activity. In the scientific literature there are many examples of coumarin-piperazine derivatives, particularly with arylpiperazines linked to a coumarin system via an alkyl liner, which can modulate serotonin, dopamine and adrenergic receptors. Numerous studies have revealed that the inclusion of a piperazine moiety could occasionally provide unexpected improvements in the bioactivity of various biologically active compounds. The piperazine analogs have been shown to have a potent antimicrobial activity and they can also act as BACE-1 inhibitors. On the other hand, arylpiperazines linked to coumarin derivatives have been shown to have antiproliferative activity against leukemia, lung, colon, breast, and prostate tumors. Recently, it has been reported that coumarin-piperazine derivatives exhibit a Fneuroprotective effect by their antioxidant and anti-inflammatory activities and they also show activity as acetylcholinesterase inhibitors and antifilarial activity. In this work we provide a summary of the latest advances in coumarin-related chemistry relevant for biological activity.

In Vitro Antithrombotic and Hypocholesterolemic Activities of Milk Fermented with Specific Strains of Lactococcus lactis

Milk fermented with specific lactic acid bacteria (LAB) was reported to be a rich source of metabolites, such as peptides with different biological activities that may have a positive effect on cardiovascular health. Thus, in this study, the antithrombotic and hypocholesterolemic activities of fermented milk with specific strains of Lactococcus lactis were investigated before and after exposure to a simulated gastrointestinal digestion (SGD) model. The inhibition of thrombin-induced fibrin polymerization (IC₅₀ peptide concentration necessary to inhibit thrombin activity by 50%), anticoagulant activity, inhibition of micellar solubility of cholesterol and bile acid binding capacity of water soluble fractions (WSF) <3 kDa from fermented milk were evaluated. Results indicated that the WSF from fermented milk with Lc-572 showed antithrombotic (IC₅₀ = 0.049 mg/mL) and hypocholesterolemic (55% inhibition of micellar solubility of cholesterol and 27% bile acid binding capacity) activities. Meanwhile, fermented milk with Lc-571 showed mainly antithrombotic activity (IC₅₀ = 0.045 mg/mL). On the other hand, fermented milk with Lc-600 presented mainly hypocholesterolemic activity (31.4% inhibition of micellar solubility of and 70% bile acid binding capacity). Moreover, biological activities were not lost after simulated gastrointestinal digestion conditions. Thus, fermented milk with these specific L. lactis strains show potential for the development of functional foods.

Real-Life Benefits of Statins for Cardiovascular Prevention in Elderly Subjects: A Population-Based Cohort Study

OBJECTIVES

The benefits of initiating statins in the elderly remains debated. We evaluated the effects of initiating statins in the elderly, according to cardiovascular risk.

METHODS

This population-based cohort study used data of the representative sample of the French health care system database for the 2008-2015 period. New users of statins, aged 75 years and older, were dynamically included in the cohort and matched 1:1 to statin nonusers on age, sex, numbers of different drugs dispensed and medical consultations, and cardiovascular history. Patients were classified into 3 cardiovascular risk groups: secondary prevention (history of coronary heart disease), primary prevention with modifiable risk factors (diabetes or cardiovascular medications), and primary prevention without modifiable risk factors (none of the above). Effect of cumulative use of statins on occurrence of acute coronary syndrome or all-cause death was analyzed by using multivariable time-dependent Cox models stratified on cardiovascular risk at inclusion.

RESULTS

Among the 7284 patients included, median follow-up was 4.7 years. Cumulative use of statins was associated with a lower risk of outcomes in the primary prevention with modifiable risk factors group (adjusted hazard ratio 0.93 per year of use; 95% confidence interval, 0.89-0.96; P < .01) and in the secondary prevention group (0.75; 0.63-0.90; P < .01), but not in the primary prevention without modifiable risk factors group (1.01; 0.86-1.18; P = .92).

CONCLUSIONS

Statin treatment was not associated with a reduction in acute coronary syndrome or all-cause death in elderly without modifiable cardiovascular risk factor treated in primary prevention.

Pharmacoepidemiology of statins

The evaluation of the real-life benefits and risks of statins in population is a major pharmacoepidemiological issue, given their widespread use for cardiovascular prevention. The purpose of this review was not to be exhaustive but to show the contributions of pharmacoepidemiology for various aspects of the evaluation of statins such as real-life drug use, effectiveness and risk. Statins are among the most used drugs in the world, but recent data show a slight decrease in use. Actual statin users are older, and have more comorbidities than those studied in clinical trials, but this does not seem to compromise their effectiveness, unlike the compliance issues that are common with these drugs. Beyond the known adverse reactions of statins from the clinical trials, risks of statins can be varied and sometimes difficult to evaluate, considering the ubiquity of cholesterol throughout the body, from drug or endogenous molecule metabolism to the construction of cell membranes or cell activities.

Pharmacokinetic drug interactions of the non-vitamin K antagonist oral anticoagulants (NOACs)

The use of warfarin, the most commonly prescribed oral anticoagulant, is being questioned by clinicians worldwide due to warfarin several limitations (a limited therapeutic window and significant variability in dose-response among individuals, in addition to a potential for drug-drug interactions). Therefore, the need for non-vitamin K antagonist oral anticoagulants (NOACs) with a rapid onset of antithrombotic effects and a predictable pharmacokinetic (PK) and pharmacodynamic (PD) profile led to the approval of five new drugs: the direct factor Xa (F-Xa) inhibitors rivaroxaban, apixaban, edoxaban and betrixaban (newly approved by FDA) and the direct thrombin (factor-IIa) inhibitor dabigatran etexilate. The advantages of NOACs over warfarin are a fixed-dosage, the absence of the need for drug monitoring for changes in anti-coagulation and fewer clinically significant PK and PD drug-drug interactions. NOACs exposure will likely be increased by the administration of strong P-glycoprotein (P-gp) and cytochrome P450 (CYP) 3A4-inhibitors and may increase the risk of bleeds. On the contrary, P-gp inducers could significantly decrease the NOACs plasma concentration with an associated reduction in their anticoagulant effects. This manuscript gives an overview of NOACs PK profiles and their drug-drug interactions potential. This is meant to be of help to physicians in choosing the best therapeutic approach for their patients.

Relaxant and vasoprotective effects of ginger extracts on porcine coronary arteries

Ginger (Zingiber officinale Roscoe) is a popular Chinese herbal medicine, which is considered to warm the stomach and dispel cold in traditional Chinese medicine. Ginger is widely used to treat stomach disorders, and it has been reported to exhibit antithrombotic activity via the inhibition of platelet aggregation and thromboxane B2 production in vitro. Cardiovascular disease is associated with the aberrant functioning of the heart and circulatory system; the relatively narrow vessels of the circulation are commonly affected and blocked by atherosclerosis, which may result in angina or heart attack. Numerous drugs and medicines are used to treat myocardial infarction; however, they are often associated with numerous side effects. Therefore, it is important to identify substitutive drugs with no unbearable side effects. In the present study, the relaxant effects of ginger crude extract (GCE) were determined on porcine coronary arteries. The DPPH radical scavenging assay, lucigenin‑enhanced chemiluminescence assay and western blot analysis were used to individually detect antioxidant assay of ginger extraction or superoxide anion produced by endothelial cells and molecular signaling. The results indicated that GCE induced relaxation of porcine coronary arteries in an endothelium‑dependent manner. GCE increased vasoprotection via the suppression of nitric oxide synthase and cyclooxygenase. In addition, GCE possessed antioxidant ability, as determined using 1,1‑diphenyl‑2‑picrylhydrazyl and lucigenin‑enhanced chemiluminescence assays. Taken together, the present study demonstrated that GCE exerts marked vasoprotective effects and free radical‑scavenging activities in porcine coronary arteries.

Emerging therapeutic uses of direct-acting oral anticoagulants: An evidence-based perspective

Direct-acting oral anticoagulants (DOACs) were claimed to cause a potential paradigm shift in the therapeutic scenario of patients requiring short- and long-term anticoagulation, by virtue of their pharmacological properties, perceived as innovative. The evidence gathered so far (from pre-approval pivotal trials to real-world post-marketing observational data) consistently confirmed that DOACs are overall comparable to vitamin-K antagonists (VKAs) in terms of safety, efficacy and effectiveness and unequivocally documented a consistent and clinically relevant reduced risk of intracranial bleeding in the settings of non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE). Interestingly, two parallel paths can be identified in the current research scenario: A) in the aforementioned consolidated therapeutic indications, an innovative approach is directed towards tailored treatment strategies, to identify patients most likely to benefit from one of the different anticoagulant drugs, in particular subpopulations at increased risk of adverse events (e.g., bleeding); B) in unconventional settings, DOACs are gaining interest for potential use in emerging diseases characterized by arterial and venous thromboembolic risk. In these scenarios, the risk-benefit profile of DOACs, as compared to VKAs or heparins, is less defined. The aim of this review is to critically assess the body of evidence underlying emerging therapeutic uses of DOACs (e.g., heparin-induced thrombocytopenia, anti-phospholipid antibody syndrome), including evolving issues in special populations (e.g., patients with VTE and cancer or cirrhosis). This will be achieved by analyzing the strength (i.e., systematic reviews, randomized clinical trials, observational studies, case report/series) and consistency (i.e., concordance) of both published and unpublished evidence registered in major public repositories.