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Díez-Villanueva P, Jimenez-Mendez C, Pérez Á, Esteban-Fernández A, Datino T, Martínez-Sellés M, Ayesta A. Do Elderly Patients with Heart Failure and Reduced Ejection Fraction Benefit from Pharmacological Strategies for Prevention of Arrhythmic Events? Cardiology 2023; 148:195-206. [PMID: 37040727 DOI: 10.1159/000530424] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/20/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Heart failure is associated with aging. It is one of the leading causes of morbidity and mortality in Western countries and constitutes the main cause of hospitalization among elderly patients. The pharmacological therapy of patients with heart failure with reduced ejection fraction (HFrEF) has greatly improved during the last years. However, elderly patients less frequently receive recommended medical treatment. SUMMARY The quadruple therapy (sacubitril/valsartan, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors) is nowadays the cornerstone of medical treatment since it associates lower risk of heart failure hospitalizations and mortality (also of arrhythmic origin). Cardiac arrhythmias, including sudden cardiac death, are common in patients with HFrEF, entailing worse prognosis. Previous studies addressing the role of blocking the renin-angiotensin-aldosterone system and beta-adrenergic receptors in HFrEF have suggested different beneficial effects on arrhythmia mechanisms. Therefore, the lower mortality associated with the use of the four pillars of HFrEF therapy depends, in part, on lower sudden (mostly arrhythmic) cardiac death. KEY MESSAGES In this review, we highlight and assess the role of the four pharmacological groups that constitute the central axis of the medical treatment of patients with HFrEF in clinical prognosis and prevention of arrhythmic events, with special focus on the elderly patient, since evidence supports that most benefits provided are irrespective of age, but elderly patients receive less often guideline-recommended medical treatment.
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Affiliation(s)
| | | | - Ángel Pérez
- Cardiology Department, Hospital Universitario de Burgos, Burgos, Spain
- Facultad de Ciencias de la Salud, Universidad Isabel I, Burgos, Spain
| | | | - Tomás Datino
- Cardiology Department, Hospital Universitario Quirón and Complejo Hospitalario Ruber Juan Bravo, Madrid, Spain
- Universidad Europea de Madrid, Madrid, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
- Universidad Complutense and Universidad Europea, Madrid, Spain
| | - Ana Ayesta
- Cardiology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
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2
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Wei Z, Zhang M, Zhang Q, Gong L, Wang X, Wang Z, Gao M, Zhang Z. A narrative review on sacubitril/valsartan and ventricular arrhythmias. Medicine (Baltimore) 2022; 101:e29456. [PMID: 35801732 PMCID: PMC9259167 DOI: 10.1097/md.0000000000029456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Sacubitril/valsartan, the first angiotensin receptor neprilysin inhibitor approved by the Food and Drug Administration for marketing, has been shown to reduce the risk of cardiovascular death or heart failure hospitalization and improve symptoms in patients with chronic heart failure with a reduced ejection fraction. However, some researchers have also found that sacubitril/valsartan has an antiarrhythmic effect. The mechanism by which sacubitril/valsartan reduces the mortality associated with malignant ventricular arrhythmias is not precise. Many studies have concluded that ventricular arrhythmia is associated with a reduction in myocardial fibrosis. This article reviews the current understanding of the effects of sacubitril/valsartan on the reduction of ventricular arrhythmia and explains its possible mechanisms. The results of this study suggest that sacubitril/valsartan reduces the occurrence of appropriate implantable cardioverter-defibrillator shocks. Meanwhile, sacubitril/valsartan may reduce the occurrence of ventricular arrhythmias by affecting 3 pathways of B-type natriuretic peptide, Angiotensin II, and Bradykinin. The conclusion of this study is that sacubitril/valsartan reduces the number of implantable cardioverter-defibrillator shocks and ventricular arrhythmias in heart failure with reduced ejection fraction patients.
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Affiliation(s)
- Zhaoyang Wei
- Department of Cardiology, the First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Meiwei Zhang
- Department of Cardiology, the First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Qian Zhang
- Department of Cardiology, the First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Linan Gong
- Department of Cardiology, the First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Xiangyu Wang
- Department of Cardiology, the First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Zanzan Wang
- Department of Cardiology, the First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Ming Gao
- Department of Cardiology, the First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Zhiguo Zhang
- Department of Cardiology, the First Hospital of Jilin University, Changchun, Jilin Province, China
- * Correspondence: Zhiguo Zhang, MD, Department of Cardiology, the First Hospital of Jilin University, Changchun, Jilin Province 130021, China (e-mail: )
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Zhou Y, Rui S, Tang S, Ju C. Exploration of Mechanisms of Sacubitril/Valsartan in the Treatment of Cardiac Arrhythmias Using a Network Pharmacology Approach. Front Cardiovasc Med 2022; 9:829484. [PMID: 35498046 PMCID: PMC9043521 DOI: 10.3389/fcvm.2022.829484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/10/2022] [Indexed: 11/23/2022] Open
Abstract
Significant reductions in the incidence of cardiac arrhythmia (CA) and sudden cardiac death (SCD), along with amelioration of heart failure, have been reported for treatment with Sacubitril/valsartan (SV). However, its anti-arrhythmic mechanism remains unclear. The current study aims to explore the anti-arrhythmic molecular mechanism of SV. The direct protein targets (DPT) of SV were extracted from DrugBank. The protein-protein interaction (PPI) network of SV DPTs was constructed using STRING, and the indirect protein targets (IPTs) were also identified. A search for arrhythmia-related genes was conducted using GeneCards and the Comparative Toxicogenomics Database (CTD). The DTPs, ITPs, and arrhythmia-related genes from the two datasets were combined in a Venn diagram, and the overlapping genes were identified as core target genes. The Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses identified the top 20 biological processes and signaling pathways related to disease and the therapeutic effects of SV. The renin-angiotensin system, adrenergic signaling in cardiomyocytes, and gap junction pathways are strongly implicated in the effects of SV on CA. In conclusion, our bioinformatics analyses provided evidence pertaining to the possible antiarrhythmic mechanisms of SV and may contribute to the development of novel drugs for CA.
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Affiliation(s)
- Yu Zhou
- Department of Emergency, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Shibao Rui
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Shengxin Tang
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Changlin Ju
- Department of Cardiology, The First Affiliated Hospital of Wannan Medical College, Wuhu, China
- *Correspondence: Changlin Ju,
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Sacubitril/Valsartan in the Management of Heart Failure Patients with Cardiac Implantable Electronic Devices. Am J Cardiovasc Drugs 2021; 21:383-393. [PMID: 33118151 DOI: 10.1007/s40256-020-00448-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/16/2020] [Indexed: 12/11/2022]
Abstract
For heart failure patients with cardiac implantable electronic devices (CIEDs), especially those who remain symptomatic after implantation, the best management strategy is still unclear. Although there are several concerns regarding the clinical utilization of sacubitril/valsartan, it has improved the prognosis of patients with heart failure compared with the use of renin-angiotensin system inhibitors in recent years. Recent real-world observational studies and post hoc analyses demonstrated that sacubitril/valsartan might have effects in patients with CIEDs. Given its potential underlying mechanisms, sacubitril/valsartan could improve outcomes of mortality and sudden cardiac death incidence, as well as clinical and echocardiographic evaluations. The possible antiarrhythmic effect of sacubitril/valsartan is still debated. Moreover, given that hypotension is the critical limitation of uptitration, the rise in systolic blood pressure attributed to cardiac resynchronization therapy might support the use of sacubitril/valsartan, with improved tolerance. The clinical utility of sacubitril/valsartan in heart failure patients with CIEDs requires further investigation to determine the actual effects, optimal target populations, and underlying mechanisms.
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Eiringhaus J, Wünsche CM, Tirilomis P, Herting J, Bork N, Nikolaev VO, Hasenfuss G, Sossalla S, Fischer TH. Sacubitrilat reduces pro-arrhythmogenic sarcoplasmic reticulum Ca 2+ leak in human ventricular cardiomyocytes of patients with end-stage heart failure. ESC Heart Fail 2020; 7:2992-3002. [PMID: 32710603 PMCID: PMC7586991 DOI: 10.1002/ehf2.12918] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 05/20/2020] [Accepted: 07/13/2020] [Indexed: 12/11/2022] Open
Abstract
Aims Inhibition of neprilysin and angiotensin II receptor by sacubitril/valsartan (Val) (LCZ696) reduces mortality in heart failure (HF) patients compared with sole inhibition of renin–angiotensin system. Beneficial effects of increased natriuretic peptide levels upon neprilysin inhibition have been proposed, whereas direct effects of sacubitrilat (Sac) (LBQ657) on myocardial Ca2+ cycling remain elusive. Methods and results Confocal microscopy (Fluo‐4 AM) was used to investigate pro‐arrhythmogenic sarcoplasmic reticulum (SR) Ca2+ leak in freshly isolated murine and human ventricular cardiomyocytes (CMs) upon Sac (40 μmol/L)/Val (13 μmol/L) treatment. The concentrations of Sac and Val equalled plasma concentrations of LCZ696 treatment used in PARADIGM‐HF trial. Epifluorescence microscopy measurements (Fura‐2 AM) were performed to investigate effects on systolic Ca2+ release, SR Ca2+ load, and Ca2+‐transient kinetics in freshly isolated murine ventricular CMs. The impact of Sac on myocardial contractility was evaluated using in toto‐isolated, isometrically twitching ventricular trabeculae from human hearts with end‐stage HF. Under basal conditions, the combination of Sac/Val did not influence diastolic Ca2+‐spark frequency (CaSpF) nor pro‐arrhythmogenic SR Ca2 leak in isolated murine ventricular CMs (n CMs/hearts = 80/7 vs. 100/7, P = 0.91/0.99). In contrast, Sac/Val treatment reduced CaSpF by 35 ± 9% and SR Ca2+ leak by 45 ± 9% in CMs put under catecholaminergic stress (isoproterenol 30 nmol/L, n = 81/7 vs. 62/7, P < 0.001 each). This could be attributed to Sac, as sole Sac treatment also reduced both parameters by similar degrees (reduction of CaSpF by 57 ± 7% and SR Ca2+ leak by 76 ± 5%; n = 101/4 vs. 108/4, P < 0.01 each), whereas sole Val treatment did not. Systolic Ca2+ release, SR Ca2+ load, and Ca2+‐transient kinetics including SERCA activity (kSERCA) were not compromised by Sac in isolated murine CMs (n = 41/6 vs. 39/6). Importantly, the combination of Sac/Val and Sac alone also reduced diastolic CaSpF and SR Ca2+ leak (reduction by 74 ± 7%) in human left ventricular CMs from patients with end‐stage HF (n = 71/8 vs. 78/8, P < 0.05 each). Myocardial contractility of human ventricular trabeculae was not acutely affected by Sac treatment as the developed force remained unchanged over a time course of 30 min (n trabeculae/hearts = 3/3 vs. 4/3). Conclusion This study demonstrates that neprilysin inhibitor Sac directly improves Ca2+ homeostasis in human end‐stage HF by reducing pro‐arrhythmogenic SR Ca2+ leak without acutely affecting systolic Ca2+ release and inotropy. These effects might contribute to the mortality benefits observed in the PARADIGM‐HF trial.
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Affiliation(s)
- Jörg Eiringhaus
- Abt. Kardiologie und Pneumologie/Herzzentrum, Georg-August-Universität Göttingen, Göttingen, Germany.,Deutsches Zentrum für Herz-Kreislauf Forschung (DZHK), Standort Göttingen, Göttingen, Germany.,Abt. Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hanover, Germany
| | - Christoph M Wünsche
- Abt. Kardiologie und Pneumologie/Herzzentrum, Georg-August-Universität Göttingen, Göttingen, Germany.,Deutsches Zentrum für Herz-Kreislauf Forschung (DZHK), Standort Göttingen, Göttingen, Germany
| | - Petros Tirilomis
- Abt. Kardiologie und Pneumologie/Herzzentrum, Georg-August-Universität Göttingen, Göttingen, Germany.,Deutsches Zentrum für Herz-Kreislauf Forschung (DZHK), Standort Göttingen, Göttingen, Germany
| | - Jonas Herting
- Abt. Kardiologie und Pneumologie/Herzzentrum, Georg-August-Universität Göttingen, Göttingen, Germany.,Deutsches Zentrum für Herz-Kreislauf Forschung (DZHK), Standort Göttingen, Göttingen, Germany
| | - Nadja Bork
- Institut für Experimentelle Herz-Kreislaufforschung, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Viacheslav O Nikolaev
- Institut für Experimentelle Herz-Kreislaufforschung, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Gerd Hasenfuss
- Abt. Kardiologie und Pneumologie/Herzzentrum, Georg-August-Universität Göttingen, Göttingen, Germany.,Deutsches Zentrum für Herz-Kreislauf Forschung (DZHK), Standort Göttingen, Göttingen, Germany
| | - Samuel Sossalla
- Abt. Kardiologie und Pneumologie/Herzzentrum, Georg-August-Universität Göttingen, Göttingen, Germany.,Deutsches Zentrum für Herz-Kreislauf Forschung (DZHK), Standort Göttingen, Göttingen, Germany.,Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Thomas H Fischer
- Abt. Kardiologie und Pneumologie/Herzzentrum, Georg-August-Universität Göttingen, Göttingen, Germany.,Deutsches Zentrum für Herz-Kreislauf Forschung (DZHK), Standort Göttingen, Göttingen, Germany.,Abt. Kardiologie, Medizinische Klinik und Poliklinik I, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, Würzburg, 97080, Germany
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Vicent L, Martínez-Sellés M. Can Sacubitril/Valsartan Have a Proarrhythmic Effect in Some High-Risk Patients? Cardiology 2019; 143:34-35. [PMID: 31330516 DOI: 10.1159/000500193] [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: 03/25/2019] [Accepted: 03/28/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Lourdes Vicent
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBERCV, Madrid, Spain
| | - Manuel Martínez-Sellés
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIBERCV, Madrid, Spain, .,Universidad Complutense, Madrid, Spain, .,Universidad Europea, Madrid, Spain,
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