Captopril provides sustained hemodynamic benefits in dogs with experimentally induced mitral regurgitation

Dose-response of benazepril on biomarkers of the classical and alternative pathways of the renin-angiotensin-aldosterone system in dogs

Angiotensin-converting enzyme inhibitors (ACEI) such as benazepril are commonly prescribed in both humans and dogs with heart disease to mitigate the renin-angiotensin-aldosterone system (RAAS); however, the dose-dependent effects of benazepril on comprehensive RAAS components remain unknown. In this study, nine purpose-bred healthy dogs received three different dosages of oral benazepril (0.125 mg/kg, 0.25 mg/kg, or 0.5 mg/kg) in a randomized crossover design following induction of RAAS activation by consuming a low-sodium diet. Blood samples were collected at serial time intervals after benazepril dosing to measure plasma benazeprilat (active metabolite of benazepril) and serum RAAS biomarkers. Blood pressure and echocardiogram were performed at baseline and after each benazepril administration. Time-weighted averages for RAAS biomarkers for 12 h post-dose and hemodynamic variables were compared between dosing groups using Wilcoxon rank-sum testing. Compared to the lowest dosage of benazepril (0.125 mg/kg), the highest dosage (0.5 mg/kg) resulted in lower time-weighted average values of angiotensin (Ang) II (- 38%, P = 0.004), Ang1-5 (- 53%, P = 0.001), ACE-S (surrogate for ACE activity; - 59%, P = 0.0002), and ALT-S (surrogate for alternative RAAS activity; - 22%, P = 0.004), and higher values of AngI (+ 78%, P = 0.014) and PRA-S (surrogate for plasma renin activity; + 58%, P = 0.040). There were no relevant differences between dosing groups for blood pressure or echocardiographic variables. Knowledge of dose-dependent alterations in biomarkers of the classical and alternative RAAS pathways could help inform clinical trials for dosage optimization in both dogs and humans.

Management of Chronic Congestive Heart Failure Caused by Myxomatous Mitral Valve Disease in Dogs: A Narrative Review from 1970 to 2020

Simple Summary

Myxomatous mitral valve disease (MMVD) is the most common acquired cardiovascular disease in dogs. The progression of the disease and the increasing severity of valvular regurgitation cause a volume overload of the left heart, leading to left atrial and ventricular remodeling and congestive heart failure (CHF). The treatment of chronic CHF secondary to MMVD in dogs has not always been the same over time. In the last fifty years, the drugs utilized have considerably changed, as well as the therapeutic protocols. Some drugs have also changed their intended use. An analysis of the literature concerning the therapy of chronic heart failure in dogs affected by this widespread degenerative disease is not available; a synthesis of the published literature on this topic and a description of its current state of art are needed. To the authors’ knowledge, a review of this topic has never been published in veterinary medicine; therefore, the aim of this study is to overview the treatments of chronic CHF secondary to MMVD in dogs from 1970 to 2020 using the general framework of narrative reviews.

Abstract

The treatment of chronic congestive heart failure (CHF), secondary to myxomatous mitral valve disease (MMVD) in dogs, has considerably changed in the last fifty years. An analysis of the literature concerning the therapy of chronic CHF in dogs affected by MMVD is not available, and it is needed. Narrative reviews (NRs) are aimed at identifying and summarizing what has been previously published, avoiding duplications, and seeking new study areas that have not yet been addressed. The most accessible open-access databases, PubMed, Embase, and Google Scholar, were chosen, and the searching time frame was set in five decades, from 1970 to 2020. The 384 selected studies were classified into categories depending on the aim of the study, the population target, the pathogenesis of MMVD (natural/induced), and the resulting CHF. Over the years, the types of studies have increased considerably in veterinary medicine. In particular, there have been 43 (24.29%) clinical trials, 41 (23.16%) randomized controlled trials, 10 (5.65%) cross-over trials, 40 (22.60%) reviews, 5 (2.82%) comparative studies, 17 (9.60%) case-control studies, 2 (1.13%) cohort studies, 2 (1.13%) experimental studies, 2 (1.13%) questionnaires, 6 (3.40%) case-reports, 7 (3.95%) retrospective studies, and 2 (1.13%) guidelines. The experimental studies on dogs with an induced form of the disease were less numerous (49–27.68%) than the studies on dogs affected by spontaneous MMVD (128–72.32%). The therapy of chronic CHF in dogs has considerably changed in the last fifty years: in the last century, some of the currently prescribed drugs did not exist yet, while others had different indications.

Testing the Translational Power of the Zebrafish: An Interspecies Analysis of Responses to Cardiovascular Drugs

The zebrafish is rapidly emerging as a promising alternative in vivo model for the detection of drug-induced cardiovascular effects. Despite its increasing popularity, the ability of this model to inform the drug development process is often limited by the uncertainties around the quantitative relevance of zebrafish responses compared with nonclinical mammalian species and ultimately humans. In this test of concept study, we provide a comparative quantitative analysis of the in vivo cardiovascular responses of zebrafish, rat, dog, and human to three model compounds (propranolol, losartan, and captopril), which act as modulators of two key systems (beta-adrenergic and renin–angiotensin systems) involved in the regulation of cardiovascular functions. We used in vivo imaging techniques to generate novel experimental data of drug-mediated cardiovascular effects in zebrafish larvae. These data were combined with a database of interspecies mammalian responses (i.e., heart rate, blood flow, vessel diameter, and stroke volume) extracted from the literature to perform a meta-analysis of effect size and direction across multiple species. In spite of the high heterogeneity of study design parameters, our analysis highlighted that zebrafish and human responses were largely comparable in >80% of drug/endpoint combinations. However, it also revealed a high intraspecies variability, which, in some cases, prevented a conclusive interpretation of the drug-induced effect. Despite the shortcomings of our study, the meta-analysis approach, combined with a suitable data visualization strategy, enabled us to observe patterns of response that would likely remain undetected with more traditional methods of qualitative comparative analysis. We propose that expanding this approach to larger datasets encompassing multiple drugs and modes of action would enable a rigorous and systematic assessment of the applicability domain of the zebrafish from both a mechanistic and phenotypic standpoint. This will increase the confidence in its application for the early detection of adverse drug reactions in any major organ system.

The renin-angiotensin-aldosterone system and its suppression

Chronic activation of the renin-angiotensin-aldosterone system (RAAS) promotes and perpetuates the syndromes of congestive heart failure, systemic hypertension, and chronic kidney disease. Excessive circulating and tissue angiotensin II (AngII) and aldosterone levels lead to a pro-fibrotic, -inflammatory, and -hypertrophic milieu that causes remodeling and dysfunction in cardiovascular and renal tissues. Understanding of the role of the RAAS in this abnormal pathologic remodeling has grown over the past few decades and numerous medical therapies aimed at suppressing the RAAS have been developed. Despite this, morbidity from these diseases remains high. Continued investigation into the complexities of the RAAS should help clinicians modulate (suppress or enhance) components of this system and improve quality of life and survival. This review focuses on updates in our understanding of the RAAS and the pathophysiology of AngII and aldosterone excess, reviewing what is known about its suppression in cardiovascular and renal diseases, especially in the cat and dog.

The effect of benazepril on survival times and clinical signs of dogs with congestive heart failure: Results of a multicenter, prospective, randomized, double-blinded, placebo-controlled, long-term clinical trial

OBJECTIVE

To test the efficacy and tolerability of long-term administration of the angiotensin converting enzyme inhibitor, benazepril, in dogs with heart failure.

METHODS

The study was a prospective, randomized, double-blind, placebo-controlled clinical trial involving 16 centers in France, Italy, Switzerland and UK. A total of 162 dogs with class II and III (ISACHC classification) heart failure caused by chronic valvular disease (CVD) or dilated cardiomyopathy (DCM) were enrolled. Benazepril (minimum dosage, 0.25 mg/kg) or placebo were administered orally once daily for up to 34 months, either alone or as add-on therapy to "standard therapy" i.e. diuretics and/or digoxin and/or anti-arrhythmic drugs.

RESULTS

The mean survival time (to death or withdrawal from the study due to worsening of heart failure) was 2.7 times longer in the benazepril treated group (428 days) as compared with the placebo group (158 days). Differences reached statistical significance (p<0.05 Cox proportional hazards model, 44% reduction in risk). The survival rate after one year was 49% with benazepril and 20% with placebo. Benazepril produced a statistically significant (p<0.05) reduction (by 46%) in the risk of worsening of heart failure (to ISACHC class III) when therapy was initiated early (in ISACHC class II). In sub-group analyses, a statistically significant (p<0.05) benefit of benazepril was reached for both survival and worsening endpoints for dogs with CVD (n=125), but not for the small sample of dogs with DCM (37). Benazepril also improved the exercise tolerance and global clinical condition at day 28 (p<0.05). As compared to the placebo group, dogs treated with benazepril presented with the same frequency of undesirable clinical events and fewer biochemical disturbances (less frequent increases in plasma urea or creatinine and decreases in plasma potassium).

CONCLUSIONS

Benazepril extended the useful life-span of dogs with ISACHC class II and III heart failure (due to CVD) and was well tolerated.

Comparison of the effects of imidapril and enalapril in a prospective, multicentric randomized trial in dogs with naturally acquired heart failure

OBJECTIVE

To compare the efficacy and tolerability of the long-term administration of two different angiotensin-converting enzyme inhibitors, imidapril and enalapril, in a multicentric, prospective, randomized parallel-group scheme clinical trial in dogs with naturally acquired heart disease.

ANIMALS

One hundred twenty eight dogs with clinical signs of heart failure (stage II (64-50%) - III (45-35%) - IV (19-15%) New York Heart Association) caused by chronic valvular disease or dilated cardiomyopathy were selected.

PROCEDURE

Imidapril (minimum dosage 0.25 mg/kg) or enalapril (median dosage 0.5 mg/kg) was administered orally once daily for 12 months, either alone or as an add-on therapy to diuretics and/or digoxin.

RESULTS

The primary outcome measure was the quality of life score after 3 months of therapy. Sixty-one percent of the dogs in the imidapril group (36/59) and 52 % in the enalapril group (30/58) were considered responders. After 12 months, a clear improvement compared to baseline was maintained in each treatment group for most parameters reflecting the quality of life such as fatigue, exercise tolerance, dyspnea, cough and general condition. Quality of life scores and survival times were similar in both groups after 12 months. Both drugs were well tolerated over the one-year follow-up.

CONCLUSIONS

Imidapril proved to be as effective as the reference drug enalapril in the treatment of dogs with NYHA class II-IV heart failure. As with enalapril, imidapril was well tolerated during the long-term treatment period of one year in the dose range used in the study.

Pharmacologic management of myxomatous mitral valve disease in dogs

Myxomatous mitral valve disease (MMVD) causing mitral regurgitation is the most important disease of the heart in small animal cardiovascular medicine. Because MMVD is an example of a chronic disease that progresses from mild to severe over years, treatment strategies change with the stage of the disease. In this review the treatment options are compared and contrasted as they are discussed relative to the recently published ACVIM consensus statement regarding the treatment of MMVD. Results from clinical trials and evidence-based medicine are likely to provide significant improvements in the management of MMVD in the coming decades.

Dose-dependent inhibition of angiotensin converting enzyme by enalapril in cats

Although heart failure in cats is treated with angiotensin converting enzyme (ACE) inhibitors, data on the effects of different doses of enalapril on hemodynamics and the inhibition of ACE activity have not been published. To evaluate the effect of enalapril, 0.25, 0.5, or 1.0 mg/kg was given once (s.i.d., p.o.) or twice (b.i.d., p.o.) a day, and plasma ACE activity, indirect blood pressure, and heart rate were measured. Plasma ACE activity and blood pressure fell dose-dependently. There was a biphasic effect on blood pressure with twice daily administration. Enalapril 0.25 mg/kg b.i.d. inhibited plasma ACE activity by 40% after 24 hr, which was almost the same as the effect of 0.5 and 1.0 mg/kg s.i.d., and 0.5 and 1.0 mg/kg b.i.d., while 0.25 mg/kg s.i.d. inhibited it by 23%. Thus, enalapril with a daily dose exceeding 0.5 mg/kg may provide similar efficacy of ACE inhibition in cats.

Evaluation of collagenase-induced mitral valve regurgitation in dogs

OBJECTIVE

To investigate the hemodynamic changes induced by injecting collagenase into the mitral valve to induce mitral valve regurgitation (MVR) in dogs.

ANIMALS

9 healthy Beagles.

PROCEDURE

Dogs were randomly assigned to 3 groups: control (saline [0.9% NaCl] solution; n = 3), single collagenase injection (C1; 3), and 2 collagenase injections (C2; 3). Open-heart surgery was performed, and saline or collagenase solutions were injected into the mitral valve. Before and weekly for 11 weeks after surgery, radiography, echocardiography, and phonocardiography were performed. Mean pulmonary arterial pressure and mean pulmonary arterial wedge pressure (mPAWP) were measured before and 11 weeks after surgery. Postmortem examinations were performed after dogs were euthanatized.

RESULTS

No changes were detected in the control group during the 11-week follow-up period. A systolic murmur and MVR developed 1 week after surgery in groups C1 and C2. The murmur changed from a protosystolic to a pansystolic murmur, and left atrial diameter and the left atrial-to-aortic root diameter ratio increased with time. Mean pulmonary arterial pressure and mPAWP were greater 11 weeks after surgery in groups C1 and C2, compared with presurgery values. During necropsy, tissue loss was detected in the mitral valve at the site of collagenase injection. Degree of regurgitation corresponded to lesion size.

CONCLUSIONS AND CLINICAL RELEVANCE

Injection of collagenase into the mitral valve of healthy dogs induced MVR, and dogs with MVR developed progressive hemodynamic changes without acute overload. Collagenase-induced MVR may be an appropriate model for evaluation of prognostic markers of idiopathic MVR in dogs.

Short-term hemodynamic evaluation of circumferential mitral annuloplasty for correction of mitral valve regurgitation in dogs

OBJECTIVE

To determine the short-term hemodynamic effects associated with circumferential mitral annuloplasty (CMA) in dogs with mitral regurgitation.

STUDY DESIGN

Prospective experimental study. Animals-Seven healthy adult mongrel dogs.

METHODS

Mitral regurgitation was surgically induced, and annular dilation occurred. Echocardiography and cardiac catheterization were used to determine forward ejection fraction (FEF), regurgitant fraction (RF), pulmonary capillary wedge pressure (PCWP), and annular diameter before and immediately after CMA in five dogs. FEF and RF were also evaluated 7 days after annuloplasty.

RESULTS

Mean annular diameter and PCWP were significantly reduced immediately after CMA. Significant increases in FEF of 19% and 22% were shown immediately and 7 days after CMA. Significant reductions in RF of 19% and 22% were also shown immediately and 7 days after annuloplasty.

CONCLUSIONS

Sustained hemodynamic benefits and a reduction in annular diameter were achieved by CMA in a canine model of mitral regurgitation.

CLINICAL IMPLICATIONS

CMA may be a suitable treatment for heart failure because of mitral regurgitation when early signs of cardiovascular decompensation persist despite appropriate medical management.

Comparison of some pharmacokinetic parameters of 5 angiotensin-converting enzyme inhibitors in normal beagles

This study was designed to determine the degree of inhibition of the angiotensin-converting enzyme (ACE) in 5 normal dogs given single doses of conventionally used ACE inhibitors (ACEis). In addition the time required for that inhibition to return to 50% of the difference between maximum and zero (control values) was measured as an estimate of duration of action. The 5 ACEis (with dosages given in parentheses) were benazapril (0.5 mg/kg), captopril (2.0 mg/kg), enalapril (0.5 mg/kg), lisinopril (0.5 mg/kg), and ramipril (0.25 mg/kg). Blood samples for ACE activities were obtained before dosing and at 1.5, 3.0, 6.0, 12.0, and 24.0 hours after dosing. All ACEis except captopril decreased ACE activities to approximately 25% of control by the 1.5- to 3.0-hour sample, and ACE activities returned to 50% of the difference by the 12-hour sample. The value of AVE activity returned to normal by 24 hours for benazapril, whereas values for ACE activity remained below normal for enalapril, lisinopril, and ramipril at 24 hours. For captopril, however, ACE levels decreased to approximately 80% of control by the 1.5-hour recording, and returned to levels not different from control by the 3-hour recording. Based upon this study performed on normal dogs given a single dose, no pharmacokinetic advantage or disadvantage is apparent for any ACEi except captopril, which, at the dosage used, decreased ACE levels to a much lesser degree and shorter time.

Hemodynamic changes during administration of drugs for mitral regurgitation in dogs

Each of 5 drugs, i.e., 4 different vasodilator drugs (captopril, enalapril, hydralazine and prazosin) and a cardiotonic drug (digoxin), was administered to dogs with mitral regurgitation (MR) for 1-72 days in order to quantitatively evaluate the influence of therapeutic agents on blood flow in heart disease. Hemodynamic changes were assessed before and after administration of each drug by determining mitral regurgitant jet mapping area (MRMA) and aortic forward flow mapping area (AFMA), which were displayed by the color Doppler method, and the ratio of MRMA to AFMA (MRMA/AFMA) as parameters. When the four vasodilator drugs were used appropriately, MRMA and MRMA/AFMA decreased in all cases, compared with the values before the administration. These two parameters showed dose-dependent changes after administration of captopril, enalapril and hydralazine. When the cardiotonic drug was used. MRMA and MRMA/AFMA increased in 4 of 5 cases. The MRMA/AFMA values were slightly more reproducible than the MRMA values, whereas the AFMA values showed no constant tendency when any vasodilator drug or the cardiotonic drug was used. These results suggest that the efficacy of cardiotonic and vasodilator drugs in MR can be quantitatively evaluated by determining MRMA/AFMA in particular, and MRMA.

The acute haemodynamic effects of captopril in dogs with heart failure

The acute effects of three doses of captopril (12.5, 25, and 50 mg [approximately 0.5, 1.0, and 2.0 mg/kg]) on several haemodynamic variables and plasma aldosterone concentration were investigated in four dogs with experimentally produced heart failure (rapid ventricular pacing) and one dog with dilated cardiomyopathy. Haemodynamic variables were measured with a Swan-Ganz thermodilution catheter and an indwelling carotid artery catheter at baseline and 1, 2, and 4 h after drug administration. A statistically significant (P < 0.05) decrease in peripheral vascular resistance was observed 1 and 2 h following the 12.5 mg dose. A significant and large enough decrease in peripheral vascular resistance to produce a significant decrease in mean systemic arterial blood pressure was observed 1 and 2 h after administering 25 and 50 mg of captopril. A mild but significant increase in cardiac output was observed 1 h after each dose. The drug effect on systemic arterial blood pressure lasted less than 4 h. No statistically significant changes were observed for the group in pulmonary capillary wedge pressure, right atrial blood pressure, or plasma aldosterone concentration at any time. We conclude that the acute haemodynamic benefits provided by captopril administration were mild and due primarily to arteriolar dilation. Doses of approximately 1-2 mg/kg produced slightly greater arteriolar dilation than an approximate dose of 0.5 mg/kg. The drug effect was short-lived, lasting less than 4 h.

The power of a statistical test. What does insignificance mean?

In statistical testing of data, the p value is a standard measure for reporting quantitative results. When a significant difference is reported, (e.g., P less than .05), most readers understand that there is less than a 5% chance that the authors have made a type I error (false positive or alpha) with their conclusion. In contrast, when nonsignificant differences between treatments, groups, or parameters of interest are reported (e.g., P greater than .05), many investigators and readers incorrectly interpret the 95% confidence interval for this conclusion as a 95% chance of making the correct decision. In fact, the alpha level of significance (in this example, .05) is only one of the parameters that determines the probability of committing a type II error (false negative or beta) when concluding statistical insignificance. Statistical power is the probability of having made a correct decision when the statistical tests reveal insignificance (P greater than .05) and the null hypothesis is true. The higher the power, the greater the chance that the decision is correct. Power depends on the alpha level of significance, the sample size, the standard deviation of the population or the sample, and the magnitude of the difference the investigators are trying to demonstrate.