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Liang Y, Ruan W, Jiang Y, Smalling R, Yuan X, Eltzschig HK. Interplay of hypoxia-inducible factors and oxygen therapy in cardiovascular medicine. Nat Rev Cardiol 2023; 20:723-737. [PMID: 37308571 PMCID: PMC11014460 DOI: 10.1038/s41569-023-00886-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 06/14/2023]
Abstract
Mammals have evolved to adapt to differences in oxygen availability. Although systemic oxygen homeostasis relies on respiratory and circulatory responses, cellular adaptation to hypoxia involves the transcription factor hypoxia-inducible factor (HIF). Given that many cardiovascular diseases involve some degree of systemic or local tissue hypoxia, oxygen therapy has been used liberally over many decades for the treatment of cardiovascular disorders. However, preclinical research has revealed the detrimental effects of excessive use of oxygen therapy, including the generation of toxic oxygen radicals or attenuation of endogenous protection by HIFs. In addition, investigators in clinical trials conducted in the past decade have questioned the excessive use of oxygen therapy and have identified specific cardiovascular diseases in which a more conservative approach to oxygen therapy could be beneficial compared with a more liberal approach. In this Review, we provide numerous perspectives on systemic and molecular oxygen homeostasis and the pathophysiological consequences of excessive oxygen use. In addition, we provide an overview of findings from clinical studies on oxygen therapy for myocardial ischaemia, cardiac arrest, heart failure and cardiac surgery. These clinical studies have prompted a shift from liberal oxygen supplementation to a more conservative and vigilant approach to oxygen therapy. Furthermore, we discuss the alternative therapeutic strategies that target oxygen-sensing pathways, including various preconditioning approaches and pharmacological HIF activators, that can be used regardless of the level of oxygen therapy that a patient is already receiving.
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Affiliation(s)
- Yafen Liang
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Wei Ruan
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Yandong Jiang
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Richard Smalling
- Department of Cardiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Xiaoyi Yuan
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Holger K Eltzschig
- Department of Anaesthesiology, Critical Care and Pain Medicine, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
- Outcomes Research Consortium, Cleveland, OH, USA
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Hofmann R, Befekadu Abebe T, Herlitz J, James SK, Erlinge D, Yndigegn T, Alfredsson J, Kellerth T, Ravn-Fischer A, Völz S, Lauermann J, Jernberg T, Lindahl B, Langenskiöld S. Routine Oxygen Therapy Does Not Improve Health-Related Quality of Life in Patients With Acute Myocardial Infarction-Insights From the Randomized DETO2X-AMI Trial. Front Cardiovasc Med 2021; 8:638829. [PMID: 33791349 PMCID: PMC8006541 DOI: 10.3389/fcvm.2021.638829] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/01/2021] [Indexed: 12/18/2022] Open
Abstract
Background: After decades of ubiquitous oxygen therapy in all patients with acute myocardial infarction (MI), recent guidelines are more restrictive based on lack of efficacy in contemporary trials evaluating hard clinical outcomes in patients without hypoxemia at baseline. However, no evidence regarding treatment effects on health-related quality of life (HRQoL) exists. In this study, we investigated the impact of routine oxygen supplementation on HRQoL 6–8 weeks after hospitalization with acute MI. Secondary objectives included analyses of MI subtypes, further adjustment for infarct size, and oxygen saturation at baseline and 1-year follow-up. Methods: In the DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial, 6,629 normoxemic patients with suspected MI were randomized to oxygen at 6 L/min for 6–12 h or ambient air. In this prespecified analysis, patients younger than 75 years of age with confirmed MI who had available HRQoL data by European Quality of Life Five Dimensions questionnaire (EQ-5D) in the national registry were included. Primary endpoint was the EQ-5D index assessed by multivariate linear regression at 6–10 weeks after MI occurrence. Results: A total of 3,086 patients (median age 64, 22% female) were eligible, 1,518 allocated to oxygen and 1,568 to ambient air. We found no statistically significant effect of oxygen therapy on EQ-5D index (−0.01; 95% CI: −0.03–0.01; p = 0.23) or EQ-VAS score (−0.57; 95% CI: −1.88–0.75; p = 0.40) compared to ambient air after 6–10 weeks. Furthermore, no significant difference was observed between the treatment groups in EQ-5D dimensions. Results remained consistent across MI subtypes and at 1-year follow-up, including further adjustment for infarct size or oxygen saturation at baseline. Conclusions: Routine oxygen therapy provided to normoxemic patients with acute MI did not improve HRQoL up to 1 year after MI occurrence. Clinical Trial Registration:ClinicalTrials.gov number, NCT01787110.
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Affiliation(s)
- Robin Hofmann
- Division of Cardiology, Department of Clinical Science and Education, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | | | - Johan Herlitz
- Department of Health Sciences, University of Borås, Borås, Sweden
| | - Stefan K James
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - David Erlinge
- Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - Troels Yndigegn
- Department of Clinical Sciences, Cardiology, Lund University, Lund, Sweden
| | - Joakim Alfredsson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Cardiology, Linköping University Hospital, Linköping, Sweden
| | - Thomas Kellerth
- Department of Cardiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Annica Ravn-Fischer
- Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Cardiology, University of Gothenburg, Gothenburg, Sweden
| | - Sebastian Völz
- Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Cardiology, University of Gothenburg, Gothenburg, Sweden
| | - Jörg Lauermann
- Department of Cardiology, Ryhov Hospital, Jönköping, Sweden.,Department of Health, Medicine and Caring, Linköping University, Linköping, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
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