Evaluation of benazepril in cats with heart disease in a prospective, randomized, blinded, placebo-controlled clinical trial

Clinical-Diagnostic and Therapeutic Advances in Feline Hypertrophic Cardiomyopathy

A comprehensive literature review was conducted to summarise existing evidence and the latest therapeutic advancements in feline HCM. The disease phenotype is characterised by the development of concentric hypertrophy, which is variable but often asymmetric, primarily affecting the left ventricle. The HCM is marked by diastolic dysfunction, resulting in a reduced intracavitary internal diameter due to the disordered alignment of cardiomyocytes and excessive collagen deposition, which thickens the myocardial tissue and impairs relaxation. There is strong evidence supporting the role of genetic mutations in sarcomeric genes in the development of HCM. Clinical signs vary but are frequently associated with congestive heart failure (CHF) and ATE. Diagnosis is based on a combination of clinical evaluation, laboratory tests, and imaging studies, although certain aspects of the disease remain insufficiently understood and require further research. Therapeutic management focuses on controlling clinical signs, slowing disease progression, and improving both quality of life and life expectancy. However, ongoing studies are essential to refine diagnostic strategies and explore novel treatment options for better disease management.

Frequency and progression of azotemia during acute and chronic treatment of congestive heart failure in cats

BACKGROUND

Azotemia is common in cats with congestive heart failure (CHF) and might be exacerbated by diuretic therapy.

HYPOTHESIS/OBJECTIVES

Determine frequency, risk factors, and survival impact of progressive azotemia in cats treated for CHF.

ANIMALS

One hundred and sixteen client-owned cats with kidney function testing performed at least twice during acute or chronic CHF treatment.

METHODS

Serum creatinine (sCr) and electrolyte concentrations were determined at multiple clinical timepoints to detect azotemia and kidney injury (KI; sCr increase ≥0.3 mg/dL). Furosemide dosage between timepoints was calculated. Multivariable modeling was performed to identify predictors of KI, change in serum biochemistry results, and survival.

RESULTS

Azotemia was common at all timepoints, including initial CHF diagnosis (44%). Kidney injury was documented in 66% of cats. Use of a furosemide continuous rate infusion was associated with increased risk of KI during hospitalization (odds ratio, 141.6; 95% confidence interval [CI], 12.1-6233; P = .01). Higher furosemide dosage was associated with increase in sCr during hospitalization (P = .03) and at first reevaluation (P = .01). Treatment with an angiotensin converting enzyme inhibitor was associated with fewer lifetime KI events (P = .02). Age in years was the only variable associated with shorter survival (hazard ratio, 1.1; 95% CI, 1.0-1.1; P = .03). Neither sCr nor KI were associated with long-term outcome.

CONCLUSIONS AND CLINICAL IMPORTANCE

Azotemia and KI were common in cats during CHF treatment but did not impact survival.

Synergistic integration of deep learning with protein docking in cardiovascular disease treatment strategies

This research delves into the exploration of the potential of tocopherol-based nanoemulsion as a therapeutic agent for cardiovascular diseases (CVD) through an in-depth molecular docking analysis. The study focuses on elucidating the molecular interactions between tocopherol and seven key proteins (1O8a, 4YAY, 4DLI, 1HW9, 2YCW, 1BO9 and 1CX2) that play pivotal roles in CVD development. Through rigorous in silico docking investigations, assessment was conducted on the binding affinities, inhibitory potentials and interaction patterns of tocopherol with these target proteins. The findings revealed significant interactions, particularly with 4YAY, displaying a robust binding energy of -6.39 kcal/mol and a promising Ki value of 20.84 μM. Notable interactions were also observed with 1HW9, 4DLI, 2YCW and 1CX2, further indicating tocopherol's potential therapeutic relevance. In contrast, no interaction was observed with 1BO9. Furthermore, an examination of the common residues of 4YAY bound to tocopherol was carried out, highlighting key intermolecular hydrophobic bonds that contribute to the interaction's stability. Tocopherol complies with pharmacokinetics (Lipinski's and Veber's) rules for oral bioavailability and proves safety non-toxic and non-carcinogenic. Thus, deep learning-based protein language models ESM1-b and ProtT5 were leveraged for input encodings to predict interaction sites between the 4YAY protein and tocopherol. Hence, highly accurate predictions of these critical protein-ligand interactions were achieved. This study not only advances the understanding of these interactions but also highlights deep learning's immense potential in molecular biology and drug discovery. It underscores tocopherol's promise as a cardiovascular disease management candidate, shedding light on its molecular interactions and compatibility with biomolecule-like characteristics.

Advancing Treatments for Feline Hypertrophic Cardiomyopathy: The Role of Animal Models and Targeted Therapeutics

Feline HCM is the most common cardiovascular disease in cats, leading to devastating outcomes, including congestive heart failure (CHF), arterial thromboembolism (ATE), and sudden death. Evidence demonstrating long-term survival benefit with currently available therapies is lacking. Therefore, it is imperative to explore intricate genetic and molecular pathways that drive HCM pathophysiology to inspire the development of novel therapeutics. Several clinical trials exploring new drug therapies are currently underway, including those investigating small molecule inhibitors and rapamycin. This article outlines the key work performed using cellular and animal models that has led to and continues to guide the development of new innovative therapeutic strategies.

Beyond Angiotensin-Converting Enzyme Inhibitors: Modulation of the Renin-Angiotensin-Aldosterone System to Delay or Manage Congestive Heart Failure

The renin-angiotensin-aldosterone system (RAAS) consists of bioactive angiotensin peptides, enzymatic pathways, receptors, and the steroid hormone aldosterone. The RAAS regulates blood pressure, sodium, and electrolyte homeostasis and mediates pathologic disease processes. Within this system is an alternative arm that counterbalances the vasoconstrictive, sodium and water retentive, and pro-fibrotic and inflammatory effects of the classical arm. Improved biochemical methodologies in RAAS quantification are elucidating how this complex system changes in health and disease. Future treatments for cardiovascular and kidney disease will likely involve a more nuanced manipulation of this system rather than simple blockade.

The standards of reporting trials in pets (PetSORT): Explanation and elaboration

Well-designed randomized controlled trials (RCTs) provide the best evidence of the primary research designs for evaluating the effectiveness of interventions. However, if RCTs are incompletely reported, the methodological rigor with which they were conducted cannot be reliably evaluated and it may not be possible to replicate the intervention. Missing information also may limit the reader's ability to evaluate the external validity of a trial. Reporting guidelines are available for clinical trials in human healthcare (CONSORT), livestock populations (REFLECT), and preclinical experimental research involving animals (ARRIVE 2.0). The PetSORT guidelines complement these existing guidelines, providing recommendations for reporting controlled trials in pet dogs and cats. The rationale and scientific background are explained for each of the 25 items in the PetSORT reporting recommendations checklist, with examples from well-reported trials.

Effects of moxibustion at bilateral Feishu (BL13) and Xinshu (BL15) combined with benazepril on myocardial cells apoptosis index and apoptosis-related proteins cytochrome c and apoptosis-inducing factor in rats with chronic heart failure

OBJECTIVE

To observe the effects of moxibustion at bilateral Feishu (BL13) and Xinshu (BL15) combined with benazepril on myocardial cells apoptosis index, the expression levels of apoptosis-related proteins cytochrome c (Cyt-C) and apoptosis-inducing factor (AIF) in chronic heart failure (CHF) rats.

METHODS

Sixty-five rats were randomly divided into normal group () and model-I group (). After modeling, CHF rats in model-I group were divided into model group, moxibustion group, benazepril group, moxibustion plus benazepril group (abbreviated as aibei group, the same below), 10 rats in each group. Echocardiogram index was examined by echocardiography. Hemodynamic indices were measured by rat cardiac function meter. Serum B-type brain natriuretic peptide (BNP) was detected by enzyme-linked immunosorbent assay. Myocardial cells apoptosis index was detected by terminal-deoxynucleoitidyl transferase mediated nick end labeling staining. Pathological changes of myocardial tissues were observed by hematoxylin and eosin staining. The expression levels of Cyt-C and AIF in myocardial tissues were detected by Western blot.

RESULTS

Compared with normal group, ejection fraction and left ventricular diameter shortening rate in model-Ⅰ group were significantly reduced, myocardial cells of rats in model group exhibited unclear transverse striations, cells swellings and vacuoles, cardiac functions were deteriorated, serum BNP level, myocardial cells apoptosis index, and the expression levels of Cyt-C and AIF were significantly increased. Compared with model group, myocardial cells of rats in moxibustion group, benazepril group, and aibei group were dyed more evenly, muscle fibers were arranged relatively neatly, cardiac functions were improved, serum BNP level, myocardial cells apoptosis index, and the expression levels of Cyt-C and AIF were significantly decreased. Compared with aibei group, cardiac functions were worsened, myocardial cells apoptosis index, and the expression levels of Cyt-C and AIF were increased.

CONCLUSION

Moxibustion at bilateral Feishu (BL13) and Xinshu (BL15) combined with benazepril could improve CHF better than moxibustion at bilateral Feishu (BL13) and Xinshu (BL15) or benazepril alone. The mechanisms might be that they can inhibit the expressions of Cyt-C and AIF, and inhibit the apoptosis of cardiomyocytes.

The Feline Cardiomyopathies: 2. Hypertrophic cardiomyopathy

Practical relevance:

Hypertrophic cardiomyopathy (HCM) is the most common form of feline cardiomyopathy observed clinically and may affect up to approximately 15% of the domestic cat population, primarily as a subclinical disease. Fortunately, severe HCM, leading to heart failure or arterial thromboembolism (ATE), only occurs in a small proportion of these cats.

Patient group:

Domestic cats of any age from 3 months upward, of either sex and of any breed, can be affected. A higher prevalence in male and domestic shorthair cats has been reported.

Diagnostics:

Subclinical feline HCM may or may not produce a heart murmur or gallop sound. Substantial left atrial enlargement can often be identified radiographically in cats with severe HCM. Biomarkers should not be relied on solely to diagnose the disease. While severe feline HCM can usually be diagnosed via echocardiography alone, feline HCM with mild to moderate left ventricular (LV) wall thickening is a diagnosis of exclusion, which means there is no definitive test for HCM in these cats and so other disorders that can cause mild to moderate LV wall thickening (eg, hyperthyroidism, systemic hypertension, acromegaly, dehydration) need to be ruled out.

Key findings:

While a genetic cause of HCM has been identified in two breeds and is suspected in another, for most cats the cause is unknown. Systolic anterior motion of the mitral valve (SAM) is the most common cause of dynamic left ventricular outflow tract obstruction (DLVOTO) and, in turn, the most common cause of a heart murmur with feline HCM. While severe DLVOTO is probably clinically significant and so should be treated, lesser degrees probably are not. Furthermore, since SAM can likely be induced in most cats with HCM, the distinction between HCM without obstruction and HCM with obstruction (HOCM) is of limited importance in cats. Diastolic dysfunction, and its consequences of abnormally increased atrial pressure leading to signs of heart failure, and sluggish atrial blood flow leading to ATE, is the primary abnormality that causes clinical signs and death in affected cats. Treatment (eg, loop diuretics) is aimed at controlling heart failure. Preventive treatment (eg, antithrombotic drugs) is aimed at reducing the risk of complications (eg, ATE).

Conclusions:

Most cats with HCM show no overt clinical signs and live a normal or near-normal life despite this disease. However, a substantial minority of cats develop overt clinical signs referable to heart failure or ATE that require treatment. For most cats with clinical signs caused by HCM, the long-term prognosis is poor to grave despite therapy.

Areas of uncertainty:

Genetic mutations (variants) that cause HCM have been identified in a few breeds, but, despite valiant efforts, the cause of HCM in the vast majority of cats remains unknown. No treatment currently exists that reverses or even slows the cardiomyopathic process in HCM, again despite valiant efforts. The search goes on.

Effect of angiotensin receptor blockers and angiotensin-converting enzyme 2 on plasma equilibrium angiotensin peptide concentrations in cats with heart disease

Background

Little is known about the effect of renin angiotensin aldosterone system‐inhibiting (RAASi) drugs on alternative angiotensin peptides (APs) such as angiotensin 1‐7 (Ang1‐7), which are mediated by angiotensin‐converting enzyme 2 (ACE2).

Hypothesis/Objectives

Angiotensin receptor blockers (ARBs) would alter balance of APs and differences would be magnified in vitro by incubation of plasma samples with recombinant human ACE2 (rhACE2).

Animals

Six cats with cardiomyopathy (CM), 8 healthy cats.

Methods

Prospective open label trial. Plasma equilibrium concentrations of APs were measured in healthy cats as well as in CM cats that first received no RAASi drugs (CM_noRAASi) and then after 14 days of PO telmisartan (CM_ARB). Plasma APs also were measured after in vitro incubation with rhACE2.

Results

No significant differences were found between healthy and CM_noRAASi groups. Concentrations of several APs, including angiotensin I (AT1) and angiotensin II (AT2) were significantly different between CM_noRAASi and CM_ARB groups. Incubation with rhACE2 decreased AT1 and AT2 in both groups. The geometric mean concentration of Ang1‐7 was significantly higher in CM_ARB (4.9 pg/mL; 95% confidence interval [CI], 3.7‐6.4 pg/mL) vs CM_noRAASi (3.2 pg/mL; 95% CI, 2.2‐4.7 pg/mL; P = .01) and in CM_ARB + ACE2 (5.0 pg/mL; 95% CI, 3.9‐6.4 pg/mL) vs CM_noRAASi + ACE2 (3.0 pg/mL; 95% CI, 1.7‐5.5 pg/mL; P = .01). The most favorable theoretical AP profile that maximized Ang1‐7 and other alternative APs was CM_ARB + ACE2.

Conclusions and Clinical Importance

Balance between traditional and alternative APs can be favorably shifted using ARBs and in vitro incubation with rhACE2. These data shed light on new AP‐targeting strategies in cats with CM.

ACVIM consensus statement guidelines for the classification, diagnosis, and management of cardiomyopathies in cats

Cardiomyopathies are a heterogeneous group of myocardial disorders of mostly unknown etiology, and they occur commonly in cats. In some cats, they are well‐tolerated and are associated with normal life expectancy, but in other cats they can result in congestive heart failure, arterial thromboembolism or sudden death. Cardiomyopathy classification in cats can be challenging, and in this consensus statement we outline a classification system based on cardiac structure and function (phenotype). We also introduce a staging system for cardiomyopathy that includes subdivision of cats with subclinical cardiomyopathy into those at low risk of life‐threatening complications and those at higher risk. Based on the available literature, we offer recommendations for the approach to diagnosis and staging of cardiomyopathies, as well as for management at each stage.

Evaluation of benazepril in cats with heart disease in a prospective, randomized, blinded, placebo-controlled clinical trial

Background

Heart disease is an important cause of morbidity and mortality in cats, but there is limited evidence of the benefit of any medication.

Hypothesis

The angiotensin‐converting enzyme inhibitor benazepril would delay the time to treatment failure in cats with heart disease of various etiologies.

Animals

One hundred fifty‐one client‐owned cats.

Methods

Cats with heart disease, confirmed by echocardiography, with or without clinical signs of congestive heart failure, were recruited between 2002 and 2005 and randomized to benazepril or placebo in a prospective, multicenter, parallel‐group, blinded clinical trial. Benazepril (0.5‐1.0 mg/kg) or placebo was administered PO once daily for up to 2 years. The primary endpoint was treatment failure. Analyses were conducted separately for all‐cause treatment failure (main analysis) and heart disease‐related treatment failure (supportive analysis).

Results

No benefit of benazepril versus placebo was detected for time to all‐cause treatment failure (P = .42) or time to treatment failure related to heart disease (P = .21). Hazard ratios (95% confidence interval [CI]) from multivariate analysis for benazepril compared with placebo were 1.00 (0.57‐1.74) for all‐cause failure, and 0.99 (0.50‐1.94) for forward selection and 0.93 (0.48‐1.81) for bidirectional selection models for heart disease‐related failure. There were no significant differences between groups over time after administration of the test articles in left atrium diameter, left ventricle wall thickness, quality of life scores, adverse events, or plasma biochemistry or hematology variables.

Conclusions and Clinical Relevance

Benazepril was tolerated well in cats with heart disease, but no evidence of benefit was detected.