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Wiedmann F, Schmidt C. Novel drug therapies for atrial fibrillation. Nat Rev Cardiol 2024; 21:275-276. [PMID: 38418746 DOI: 10.1038/s41569-024-01004-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- Felix Wiedmann
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany
- HCR, Heidelberg Center for Heart Rhythm Disorders, University Hospital Heidelberg, Heidelberg, Germany
| | - Constanze Schmidt
- Department of Cardiology, University Hospital Heidelberg, Heidelberg, Germany.
- DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, University of Heidelberg, Heidelberg, Germany.
- HCR, Heidelberg Center for Heart Rhythm Disorders, University Hospital Heidelberg, Heidelberg, Germany.
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Burashnikov A, Di Diego JM, Patocskai B, Echt DS, Belardinelli L, Antzelevitch C. Effect of Flecainide and Ibutilide Alone and in Combination to Terminate and Prevent Recurrence of Atrial Fibrillation. Circ Arrhythm Electrophysiol 2024; 17:e012454. [PMID: 38146652 DOI: 10.1161/circep.123.012454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/30/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND There is a need for improved approaches to rhythm control therapy of atrial fibrillation (AF). METHODS The effectiveness of flecainide (1.5 µmol/L) and ibutilide (20 nmol/L), alone and in combination, to cardiovert and prevent AF recurrence was studied in canine-isolated coronary-perfused right atrioventricular preparations. We also examined the safety of the combination of flecainide (1.5 µmol/L) and ibutilide (50 nmol/L) using canine left ventricular wedge preparations. RESULTS Sustained AF (>1 hour) was inducible in 100%, 60%, 20%, and 0% of atria in the presence of acetylcholine alone, acetylcholine+ibutilide, acetylcholine+flecainide, and acetylcholine+ibutilide+flecainide, respectively. When used alone, flecainide and ibutilide cardioverted sustained AF in 40% and 20% of atria, respectively, but in 100% of atria when used in combination. Ibutilide prolonged atrial and ventricular effective refractory period by 15% and 8%, respectively, at a cycle length of 500 ms (P<0.05 for both). Flecainide increased the effective refractory period in atria by 27% (P<0.01) but by only 2% in the ventricles. The combination of the 2 drugs lengthened the effective refractory period by 42% in atria (P<0.01) but by only 7% (P<0.05) in the ventricles. In left ventricular wedges, ibutilide prolonged QT and Tpeak-Tend intervals by 25 and 55%, respectively (P<0.05 for both; cycle length, 2000 ms). The addition of flecainide (1.5 µmol/L) partially reversed these effects (P<0.05 for both parameters versus ibutilide alone). Torsades de Pointes score was relatively high with ibutilide alone and low with the drug combination. CONCLUSIONS In our experimental model, a combination of flecainide and ibutilide significantly improves cardioversion and prevents the recurrence of AF compared with monotherapies with little to no risk for the development of long-QT-mediated ventricular proarrhythmia.
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Affiliation(s)
- Alexander Burashnikov
- Lankenau Institute for Medical Research, Wynnewood, PA (A.B., J.M.D.D., B.P., C.A.)
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (A.B., C.A.)
| | - José M Di Diego
- Lankenau Institute for Medical Research, Wynnewood, PA (A.B., J.M.D.D., B.P., C.A.)
| | - Bence Patocskai
- Lankenau Institute for Medical Research, Wynnewood, PA (A.B., J.M.D.D., B.P., C.A.)
| | - Debra S Echt
- InCarda Therapeutics, Inc, Newark, CA (D.S.E., L.B.)
| | | | - Charles Antzelevitch
- Lankenau Institute for Medical Research, Wynnewood, PA (A.B., J.M.D.D., B.P., C.A.)
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA (A.B., C.A.)
- Lankenau Heart Institute, Main Line Health System, Wynnewood, PA (C.A.)
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Saljic A, Heijman J, Dobrev D. Recent Advances in Antiarrhythmic Drug Therapy. Drugs 2023; 83:1147-1160. [PMID: 37540446 PMCID: PMC10462572 DOI: 10.1007/s40265-023-01923-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2023] [Indexed: 08/05/2023]
Abstract
Cardiac arrhythmias remain a common cause of death and disability. Antiarrhythmic drugs (AADs) and antiarrhythmic agents remain a cornerstone of current cardiac arrhythmia management, despite moderate efficacy and the potential for significant adverse proarrhythmic effects. Due to conceptual, regulatory and financial considerations, the number of novel antiarrhythmic targets and agents in the development pipeline has decreased substantially during the last few decades. However, several promising candidates remain and there are exciting developments in repurposing and reformulating already existing drugs for indications related to cardiac arrhythmias. This review discusses the key conceptual considerations for the development of new antiarrhythmic agents, summarizes new compounds and formulations currently in clinical development for rhythm control of atrial fibrillation, and highlights the potential for drug repurposing. Finally, future directions in AAD development are discussed. Together with an ever-increasing understanding of the molecular mechanisms underlying cardiac arrhythmias, these components support a cautiously optimistic outlook towards improved pharmacological treatment opportunities for patients suffering from cardiac arrhythmias.
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Affiliation(s)
- Arnela Saljic
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
| | - Jordi Heijman
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Dobromir Dobrev
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
- Montréal Heart Institute and University de Montréal, Medicine and Research Center, Montréal, Canada.
- Department of Molecular Physiology and Biophysics, Baylor College of Medicine, Houston, USA.
- , Hufelandstrasse 55, 45122, Essen, Germany.
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Narasimhan B, Gandhi K, Moras E, Wu L, Da Wariboko A, Aronow W. Experimental drugs for supraventricular tachycardia: an analysis of early phase clinical trials. Expert Opin Investig Drugs 2023; 32:825-838. [PMID: 37728554 DOI: 10.1080/13543784.2023.2259309] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 09/12/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION Supraventricular tachycardias (SVT) are a diverse group of commonly encountered arrhythmias arising at or above the atrioventricular (AV) node. Conventional anti-arrhythmic medications are restricted by extensive side-effect profiles and limited efficacy. Catheter ablation has emerged as a first-line therapy for many arrhythmias but is not a suitable option for all patients. This has prompted the exploration of novel pharmacological approaches targeting specific molecular mechanisms of SVT. AREAS COVERED This review article aims to summarize recent advancements in pharmacological therapeutics for SVT and their clinical implications. The understanding of molecular mechanisms underlying these arrhythmias, particularly atrial fibrillation, has opened up new possibilities for targeted interventions. Beyond the manipulation of ion channels and membrane potentials, pharmacotherapy now focuses on upstream targets such as inflammation, oxidative stress, and structural remodeling. This review strives to provide a comprehensive overview of recent advancements in pharmacological therapeutics directed at the management of SVT. We begin by providing a brief summary of the mechanisms and management of commonly encountered SVT before delving into individual agents, which in turn are stratified based on their molecular treatment targets. EXPERT OPINION The evolving landscape of pharmacologic therapy offers hope for more personalized and tailored interventions in the management of SVT.
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Affiliation(s)
- Bharat Narasimhan
- DeBakey Cardiovascular Institute, Houston Methodist, Houston, TX, USA
| | - Kruti Gandhi
- Department of Internal Medicine, Icahn School of Medicine, Mount Sinai, New York, NY, USA
| | - Errol Moras
- Department of Internal Medicine, Icahn School of Medicine, Mount Sinai, New York, NY, USA
| | - Lingling Wu
- Department of Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Akanibo Da Wariboko
- Department of Internal Medicine, Icahn School of Medicine, Mount Sinai, New York, NY, USA
| | - Wilbert Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, NY, USA
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Hu D, Barajas-Martinez H, Zhang ZH, Duan HY, Zhao QY, Bao MW, Du YM, Burashnikov A, Monasky MM, Pappone C, Huang CX, Antzelevitch C, Jiang H. Advances in basic and translational research in atrial fibrillation. Philos Trans R Soc Lond B Biol Sci 2023; 378:20220174. [PMID: 37122214 PMCID: PMC10150218 DOI: 10.1098/rstb.2022.0174] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 03/08/2023] [Indexed: 05/02/2023] Open
Abstract
Atrial fibrillation (AF) is a very common cardiac arrhythmia with an estimated prevalence of 33.5 million patients globally. It is associated with an increased risk of death, stroke and peripheral embolism. Although genetic studies have identified a growing number of genes associated with AF, the definitive impact of these genetic findings is yet to be established. Several mechanisms, including electrical, structural and neural remodelling of atrial tissue, have been proposed to contribute to the development of AF. Despite over a century of exploration, the molecular and cellular mechanisms underlying AF have not been fully established. Current antiarrhythmic drugs are associated with a significant rate of adverse events and management of AF using ablation is not optimal, especially in cases of persistent AF. This review discusses recent advances in our understanding and management of AF, including new concepts of epidemiology, genetics and pathophysiological mechanisms. We review the current status of antiarrhythmic drug therapy for AF, new potential agents, as well as mechanism-based AF ablation. This article is part of the theme issue 'The heartbeat: its molecular basis and physiological mechanisms'.
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Affiliation(s)
- Dan Hu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Hector Barajas-Martinez
- Lankenau Institute for Medical Research, and Lankenau Heart Institute, Wynnwood, PA 19096, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19104, USA
| | - Zhong-He Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Hong-Yi Duan
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Qing-Yan Zhao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Ming-Wei Bao
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Yi-Mei Du
- Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People's Republic of China
| | - Alexander Burashnikov
- Lankenau Institute for Medical Research, and Lankenau Heart Institute, Wynnwood, PA 19096, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19104, USA
| | - Michelle M. Monasky
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan 20097, Italy
| | - Carlo Pappone
- Arrhythmology Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan 20097, Italy
- Vita-Salute San Raffaele University, Milan 20132, Italy
- Institute of Molecular and Translational Cardiology (IMTC), San Donato Milanese, Milan 20097, Italy
| | - Cong-Xin Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
| | - Charles Antzelevitch
- Lankenau Institute for Medical Research, and Lankenau Heart Institute, Wynnwood, PA 19096, USA
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19104, USA
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, People's Republic of China
- Cardiovascular Research Institute of Wuhan University, Wuhan 430060, People's Republic of China
- Hubei Key Laboratory of Cardiology, Wuhan 430060, People's Republic of China
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Hartmann N, Knierim M, Maurer W, Dybkova N, Hasenfuß G, Sossalla S, Streckfuss-Bömeke K. Molecular and Functional Relevance of Na V1.8-Induced Atrial Arrhythmogenic Triggers in a Human SCN10A Knock-Out Stem Cell Model. Int J Mol Sci 2023; 24:10189. [PMID: 37373335 DOI: 10.3390/ijms241210189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/26/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
In heart failure and atrial fibrillation, a persistent Na+ current (INaL) exerts detrimental effects on cellular electrophysiology and can induce arrhythmias. We have recently shown that NaV1.8 contributes to arrhythmogenesis by inducing a INaL. Genome-wide association studies indicate that mutations in the SCN10A gene (NaV1.8) are associated with increased risk for arrhythmias, Brugada syndrome, and sudden cardiac death. However, the mediation of these NaV1.8-related effects, whether through cardiac ganglia or cardiomyocytes, is still a subject of controversial discussion. We used CRISPR/Cas9 technology to generate homozygous atrial SCN10A-KO-iPSC-CMs. Ruptured-patch whole-cell patch-clamp was used to measure the INaL and action potential duration. Ca2+ measurements (Fluo 4-AM) were performed to analyze proarrhythmogenic diastolic SR Ca2+ leak. The INaL was significantly reduced in atrial SCN10A KO CMs as well as after specific pharmacological inhibition of NaV1.8. No effects on atrial APD90 were detected in any groups. Both SCN10A KO and specific blockers of NaV1.8 led to decreased Ca2+ spark frequency and a significant reduction of arrhythmogenic Ca2+ waves. Our experiments demonstrate that NaV1.8 contributes to INaL formation in human atrial CMs and that NaV1.8 inhibition modulates proarrhythmogenic triggers in human atrial CMs and therefore NaV1.8 could be a new target for antiarrhythmic strategies.
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Affiliation(s)
- Nico Hartmann
- Clinic for Cardiology and Pneumology, University Medical Center, 37075 Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen and Rhein Main, 61231 Bad Nauheim, Germany
| | - Maria Knierim
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen and Rhein Main, 61231 Bad Nauheim, Germany
- Clinic for Cardio-Thoracic and Vascular Surgery, University Medical Center, 37075 Göttingen, Germany
| | - Wiebke Maurer
- Clinic for Cardiology and Pneumology, University Medical Center, 37075 Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen and Rhein Main, 61231 Bad Nauheim, Germany
| | - Nataliya Dybkova
- Clinic for Cardiology and Pneumology, University Medical Center, 37075 Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen and Rhein Main, 61231 Bad Nauheim, Germany
| | - Gerd Hasenfuß
- Clinic for Cardiology and Pneumology, University Medical Center, 37075 Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen and Rhein Main, 61231 Bad Nauheim, Germany
| | - Samuel Sossalla
- Clinic for Cardiology and Pneumology, University Medical Center, 37075 Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen and Rhein Main, 61231 Bad Nauheim, Germany
- Departments of Cardiology at Kerckhoff Heart and Lung Center, Bad Nauheim and University of Giessen, 61231 Bad Nauheim, Germany
| | - Katrin Streckfuss-Bömeke
- Clinic for Cardiology and Pneumology, University Medical Center, 37075 Göttingen, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Göttingen and Rhein Main, 61231 Bad Nauheim, Germany
- Institute of Pharmacology and Toxicology, University of Würzburg, 97078 Würzburg, Germany
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Reiffel JA, Robinson VM, Kowey PR. Perspective on Antiarrhythmic Drug Combinations. Am J Cardiol 2023; 192:116-123. [PMID: 36787682 DOI: 10.1016/j.amjcard.2023.01.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 01/14/2023] [Accepted: 01/16/2023] [Indexed: 02/13/2023]
Abstract
Physicians use multiple drugs in combination to treat hypertension, heart failure, diabetes mellitus, angina, hyperlipidemia, and many other cardiovascular conditions and risk factors. However, administering antiarrhythmic drugs (AAD) in combination is rarely discussed. Yet, the possibility of increasing efficacy and/or tolerance and/or safety of AADs (by adding mechanisms, offsetting adverse mechanisms, and/or using lower doses) exists. Unfortunately, this topic has not been reviewed in any contemporary cardiac literature of which we are aware, although information regarding AAD combinations has been published. In conclusion, and accordingly, this review discusses the possibility of using AAD combinations for both ventricular arrhythmias and atrial fibrillation, in which the rationale for such combinations, considerations for such combinations, and supporting literature are covered.
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Affiliation(s)
- James A Reiffel
- Vagelos College of Physicians & Surgeons, Columbia University, New York City, New York.
| | - Victoria M Robinson
- Lankenau Heart Institute, Wynnewood Pennsylvania, and Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Peter R Kowey
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
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Bray JJH, Warraich M, Whitfield MG, Peter CU, Baral R, Ahmad M, Ahmad S, Abraham GR, Kirresh A, Sahibzada MS, Muzaffar A, Tomson J, Lambiase PD, Captur G, Banerjee A, Providencia R. Oral Class I and III antiarrhythmic drugs for maintaining sinus rhythm after catheter ablation of atrial fibrillation. Cochrane Database Syst Rev 2023; 3:CD013765. [PMID: 36915032 PMCID: PMC10014144 DOI: 10.1002/14651858.cd013765.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND Recurrence of atrial tachyarrhythmias (ATa) following catheter ablation for atrial fibrillation (AF) is a common problem. Antiarrhythmic drugs have been used shortly after ablation in an attempt to maintain sinus rhythm, particularly Class I and III agents. However, it still needs to be established if the use of Class I or III antiarrhythmic medications, or both, reduce the risk of recurrence of ATa. OBJECTIVES To assess the effects of oral Class I and III antiarrhythmic drugs versus control (standard medical therapy without Class I or III antiarrhythmics, or placebo) for maintaining sinus rhythm in people undergoing catheter ablation for AF. SEARCH METHODS We systematically searched CENTRAL, MEDLINE, Embase, Web of Science Core Collection, and two clinical trial registers without restrictions on language or date to 5 August 2022. SELECTION CRITERIA We sought published, unpublished, and ongoing parallel-design, randomised controlled trials (RCTs) involving adult participants undergoing ablation for AF, with subsequent comparison of Class I and/or III antiarrhythmic use versus control (standard medical therapy or non-Class I and/or III antiarrhythmic use). DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane and performed meta-analyses with risk ratios (RR) and Peto odds ratios (Peto OR). Our primary outcomes were recurrence of atrial tachyarrhythmias; adverse events: thromboembolic events; adverse events: myocardial infarction; adverse events: new diagnosis of heart failure; and adverse events: requirement for one or more hospitalisations for atrial tachyarrhythmia. Our secondary outcomes were: all-cause mortality; and requirement for one or more repeat ablations. Where possible, we performed comparison analysis by Class I and/or III antiarrhythmic and divided follow-up periods for our primary outcome. We performed comprehensive assessments of risk of bias and certainty of evidence applying the GRADE methodology. MAIN RESULTS We included nine RCTs involving a total of 3269 participants. Participants were on average 59.3 years old; 71.0% were male; and 72.9% and 27.4% had paroxysmal and persistent AF, respectively. Class I and/or III antiarrhythmics may reduce recurrence of ATa at 0 to 3 months postablation (risk ratio (RR) 0.74, 95% confidence interval (CI) 0.59 to 0.94, 8 trials, 3046 participants, low-certainty evidence) and likely reduce recurrence at > 3 to 6 months, our a priori primary time point (RR 0.85, 95% CI 0.78 to 0.93, 5 trials, 2591 participants, moderate-certainty evidence). Beyond six months the evidence is very uncertain, and the benefit of antiarrhythmics may not persist (RR 1.14, 95% CI 0.84 to 1.55, 4 trials, 2244 participants, very low-certainty evidence). The evidence suggests that Class I and/or III antiarrhythmics may not increase the risk of thromboembolic events, myocardial infarction, all-cause mortality, or requirement for repeat ablation, at 0 to 3, > 3 to 6, and > 6 months (where data were available; low- to very low-certainty evidence). The use of Class I and/or III antiarrhythmics postablation likely reduces hospitalisations for ATa by approximately 57% at 0 to 3 months (RR 0.43, 95% CI 0.28 to 0.64, moderate-certainty evidence). No data were available beyond three months. No data were available on new diagnoses of heart failure. Fewer data were available for Class I and III antiarrhythmics individually. Based on only one and two trials (n = 125 to 309), Class I antiarrhythmics may have little effect on recurrence of ATa at 0 to 3, > 3 to 6, and > 6 months (RR 0.88, 95% CI 0.64 to 1.20, 2 trials, 309 participants; RR 0.54, 95% CI 0.25 to 1.19, 1 trial, 125 participants; RR 0.87, 95% CI 0.57 to 1.32, 1 trial, 125 participants; low-certainty evidence throughout); requirement for hospitalisation for ATa at 0 to 3 months (low-certainty evidence); or requirement for repeat ablation at 0 to 3 months (low-certainty evidence). No data were available for thromboembolic events, myocardial infarction, new diagnosis of heart failure, or all-cause mortality at any time points, or hospitalisation or repeat ablation beyond three months. Class III antiarrhythmics may have little effect on recurrence of ATa at up to 3 months and at > 3 to 6 months (RR 0.76, 95% CI 0.50 to 1.16, 4 trials, 599 participants, low-certainty evidence; RR 0.82, 95% CI 0.62 to 1.09, 2 trials, 318 participants, low-certainty evidence), and beyond 6 months one trial reported a possible increase in recurrence of ATa (RR 1.95, 95% CI 1.29 to 2.94, 1 trial, 112 participants, low-certainty evidence). Class III antiarrhythmics likely reduce hospitalisations for ATa at 0 to 3 months (RR 0.40, 95% CI 0.26 to 0.63, moderate-certainty evidence), and may have little effect on all-cause mortality (low- to very low-certainty evidence). The effect of Class III antiarrhythmics on thromboembolic events and requirement for repeat ablation was uncertain (very low-certainty evidence for both outcomes). No data were available for myocardial infarction or new diagnosis of heart failure at any time point, outcomes other than recurrence beyond 6 months, or for hospitalisation and repeat ablation > 3 to 6 months. We assessed the majority of included trials as at low or unclear risk of bias. One trial reported an error in the randomisation process, raising the potential risk of selection bias; most of the included trials were non-blinded; and two trials were at high risk of attrition bias. AUTHORS' CONCLUSIONS We found evidence to suggest that the use of Class I and/or III antiarrhythmics up to 3 months after ablation is associated with a reduced recurrence of ATa 0 to 6 months after ablation, which may not persist beyond 6 months, and an immediate reduction in hospitalisation for ATa 0 to 3 months after ablation. The evidence suggests there is no difference in rates of all-cause mortality, thromboembolic events, or myocardial infarction between Class I and/or III antiarrhythmics versus control.
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Affiliation(s)
- Jonathan JH Bray
- Oxford Heart Centre, Oxford University Hospitals Trust, John Radcliffe Hospital, Headley Way, Headington, Oxford, UK
| | - Mazhar Warraich
- Department of Cardiology, Walsall Healthcare NHS Trust, Walsall, UK
| | - Michael G Whitfield
- Institute of Health Informatics Research, University College London, London, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Christina Udani Peter
- Department of Cardiology, Addenbrookes Hospital (Cambridge University Hospitals), Cambridge, UK
| | | | - Mahmood Ahmad
- Department of Cardiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Shazaib Ahmad
- Department of Anaesthesia, St Helier Hospital, London, UK
| | | | - Ali Kirresh
- Department of Cardiology, Royal Free Hospital, London, UK
| | | | - Adnan Muzaffar
- Department of Acute Medicine, Scunthrope General Hospital, Scunthorpe, UK
| | - Joseph Tomson
- Department of Cardiology, Royal Free Hospital, London, UK
| | - Pier D Lambiase
- Centre for Cardiology in the Young, The Heart Hospital, University College London Hospitals, London, UK
| | - Gabriella Captur
- Royal Free Hospital, London, UK
- MRC Unit of Lifelong Health and Ageing, University College London, London, UK
| | - Amitava Banerjee
- Institute of Health Informatics Research, University College London, London, UK
| | - Rui Providencia
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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Surma S, Romańczyk M, Filipiak KJ. Ranolazine - could an antianginal drug be used in stroke prevention? INTERNATIONAL JOURNAL OF CARDIOLOGY CARDIOVASCULAR RISK AND PREVENTION 2022; 14:200137. [PMID: 35677351 PMCID: PMC9168496 DOI: 10.1016/j.ijcrp.2022.200137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Stanisław Surma
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
- Club of Young Hypertensiologists, Polish Society of Hypertension, Gdańsk, Poland
| | - Monika Romańczyk
- Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Krzysztof J Filipiak
- Institute of Clinical Sciences, Maria Sklodowska-Curie Medical Academy, Warsaw, Poland
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10
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Mazola Y, Márquez Montesinos JCE, Ramírez D, Zúñiga L, Decher N, Ravens U, Yarov-Yarovoy V, González W. Common Structural Pattern for Flecainide Binding in Atrial-Selective Kv1.5 and Nav1.5 Channels: A Computational Approach. Pharmaceutics 2022; 14:pharmaceutics14071356. [PMID: 35890252 PMCID: PMC9318806 DOI: 10.3390/pharmaceutics14071356] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 02/04/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia. Its treatment includes antiarrhythmic drugs (AADs) to modulate the function of cardiac ion channels. However, AADs have been limited by proarrhythmic effects, non-cardiovascular toxicities as well as often modest antiarrhythmic efficacy. Theoretical models showed that a combined blockade of Nav1.5 (and its current, INa) and Kv1.5 (and its current, IKur) ion channels yield a synergistic anti-arrhythmic effect without alterations in ventricles. We focused on Kv1.5 and Nav1.5 to search for structural similarities in their binding site (BS) for flecainide (a common blocker and widely prescribed AAD) as a first step for prospective rational multi-target directed ligand (MTDL) design strategies. We present a computational workflow for a flecainide BS comparison in a flecainide-Kv1.5 docking model and a solved structure of the flecainide-Nav1.5 complex. The workflow includes docking, molecular dynamics, BS characterization and pattern matching. We identified a common structural pattern in flecainide BS for these channels. The latter belongs to the central cavity and consists of a hydrophobic patch and a polar region, involving residues from the S6 helix and P-loop. Since the rational MTDL design for AF is still incipient, our findings could advance multi-target atrial-selective strategies for AF treatment.
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Affiliation(s)
- Yuliet Mazola
- Center for Bioinformatics, Simulation and Modeling (CBSM), Universidad de Talca, Talca 3460000, Chile; (Y.M.); (J.C.E.M.M.)
| | - José C. E. Márquez Montesinos
- Center for Bioinformatics, Simulation and Modeling (CBSM), Universidad de Talca, Talca 3460000, Chile; (Y.M.); (J.C.E.M.M.)
| | - David Ramírez
- Departamento de Farmacología, Facultad de Ciencias Biológicas, Universidad de Concepción, Concepción 4030000, Chile;
| | - Leandro Zúñiga
- Escuela de Medicina, Centro de Investigaciones Médicas, Universidad de Talca, Talca 3460000, Chile;
| | - Niels Decher
- Institute for Physiology and Pathophysiology, Vegetative Physiology, Philipps-University of Marburg, 35043 Marburg, Germany;
| | - Ursula Ravens
- Institut für Experimentelle Kardiovaskuläre Medizin, Universitäts-Herzzentrum Freiburg Bad Krotzingen, 79110 Freiburg im Breisgau, Germany;
| | - Vladimir Yarov-Yarovoy
- Department of Physiology and Membrane Biology, University of California, Davis, CA 95616, USA;
| | - Wendy González
- Center for Bioinformatics, Simulation and Modeling (CBSM), Universidad de Talca, Talca 3460000, Chile; (Y.M.); (J.C.E.M.M.)
- Millennium Nucleus of Ion Channels-Associated Diseases (MiNICAD), Talca 3530000, Chile
- Correspondence:
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11
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SEA 2022 Standards for Global Control of Cardiovascular Risk. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2022; 34:130-179. [PMID: 35090775 DOI: 10.1016/j.arteri.2021.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 10/27/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023]
Abstract
One of the objectives of the Spanish Society of Arteriosclerosis is to contribute to better knowledge of vascular disease, its prevention and treatment. It is well known that cardiovascular diseases are the leading cause of death in our country and entail a high degree of disability and health care costs. Arteriosclerosis is a multifactorial disease and therefore its prevention requires a global approach that takes into account the different risk factors with which it is associated. Therefore, this document summarizes the current level of knowledge and includes recommendations and procedures to be followed in patients with established cardiovascular disease or at high vascular risk. Specifically, this document reviews the main symptoms and signs to be evaluated during the clinical visit, the laboratory and imaging procedures to be routinely requested or requested for those in special situations. It also includes vascular risk estimation, the diagnostic criteria of the different entities that are cardiovascular risk factors, and makes general and specific recommendations for the treatment of the different cardiovascular risk factors and their final objectives. Finally, the document includes aspects that are not usually referenced in the literature, such as the organization of a vascular risk consultation.
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12
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Emerging Antiarrhythmic Drugs for Atrial Fibrillation. Int J Mol Sci 2022; 23:ijms23084096. [PMID: 35456912 PMCID: PMC9029767 DOI: 10.3390/ijms23084096] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF), the most common cardiac arrhythmia worldwide, is driven by complex mechanisms that differ between subgroups of patients. This complexity is apparent from the different forms in which AF presents itself (post-operative, paroxysmal and persistent), each with heterogeneous patterns and variable progression. Our current understanding of the mechanisms responsible for initiation, maintenance and progression of the different forms of AF has increased significantly in recent years. Nevertheless, antiarrhythmic drugs for the management of AF have not been developed based on the underlying arrhythmia mechanisms and none of the currently used drugs were specifically developed to target AF. With the increased knowledge on the mechanisms underlying different forms of AF, new opportunities for developing more effective and safer AF therapies are emerging. In this review, we provide an overview of potential novel antiarrhythmic approaches based on the underlying mechanisms of AF, focusing both on the development of novel antiarrhythmic agents and on the possibility of repurposing already marketed drugs. In addition, we discuss the opportunity of targeting some of the key players involved in the underlying AF mechanisms, such as ryanodine receptor type-2 (RyR2) channels and atrial-selective K+-currents (IK2P and ISK) for antiarrhythmic therapy. In addition, we highlight the opportunities for targeting components of inflammatory signaling (e.g., the NLRP3-inflammasome) and upstream mechanisms targeting fibroblast function to prevent structural remodeling and progression of AF. Finally, we critically appraise emerging antiarrhythmic drug principles and future directions for antiarrhythmic drug development, as well as their potential for improving AF management.
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13
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Abstract
Purpose of Review We review therapeutic approaches aimed at restoring function of the failing heart by targeting mitochondrial reactive oxygen species (ROS), ion handling, and substrate utilization for adenosine triphosphate (ATP) production. Recent Findings Mitochondria-targeted therapies have been tested in animal models of and humans with heart failure (HF). Cardiac benefits of sodium/glucose cotransporter 2 inhibitors might be partly explained by their effects on ion handling and metabolism of cardiac myocytes. Summary The large energy requirements of the heart are met by oxidative phosphorylation in mitochondria, which is tightly regulated by the turnover of ATP that fuels cardiac contraction and relaxation. In heart failure (HF), this mechano-energetic coupling is disrupted, leading to bioenergetic mismatch and production of ROS that drive the progression of cardiac dysfunction. Furthermore, HF is accompanied by changes in substrate uptake and oxidation that are considered detrimental for mitochondrial oxidative metabolism and negatively affect cardiac efficiency. Mitochondria lie at the crossroads of metabolic and energetic dysfunction in HF and represent ideal therapeutic targets.
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Affiliation(s)
- Julia Schwemmlein
- Department of Translational Research, Comprehensive Heart Failure Center, University Clinic Würzburg, Würzburg, Germany
| | - Christoph Maack
- Department of Translational Research, Comprehensive Heart Failure Center, University Clinic Würzburg, Würzburg, Germany
| | - Edoardo Bertero
- Department of Translational Research, Comprehensive Heart Failure Center, University Clinic Würzburg, Würzburg, Germany. .,Department of Internal Medicine and Specialties (Di.M.I.), University of Genoa, Genoa, Italy.
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14
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Ranolazine: An Old Drug with Emerging Potential; Lessons from Pre-Clinical and Clinical Investigations for Possible Repositioning. Pharmaceuticals (Basel) 2021; 15:ph15010031. [PMID: 35056088 PMCID: PMC8777683 DOI: 10.3390/ph15010031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 02/07/2023] Open
Abstract
Ischemic heart disease is a significant public health problem with high mortality and morbidity. Extensive scientific investigations from basic sciences to clinics revealed multilevel alterations from metabolic imbalance, altered electrophysiology, and defective Ca2+/Na+ homeostasis leading to lethal arrhythmias. Despite the recent identification of numerous molecular targets with potential therapeutic interest, a pragmatic observation on the current pharmacological R&D output confirms the lack of new therapeutic offers to patients. By contrast, from recent trials, molecules initially developed for other fields of application have shown cardiovascular benefits, as illustrated with some anti-diabetic agents, regardless of the presence or absence of diabetes, emphasizing the clear advantage of “old” drug repositioning. Ranolazine is approved as an antianginal agent and has a favorable overall safety profile. This drug, developed initially as a metabolic modulator, was also identified as an inhibitor of the cardiac late Na+ current, although it also blocks other ionic currents, including the hERG/Ikr K+ current. The latter actions have been involved in this drug’s antiarrhythmic effects, both on supraventricular and ventricular arrhythmias (VA). However, despite initial enthusiasm and promising development in the cardiovascular field, ranolazine is only authorized as a second-line treatment in patients with chronic angina pectoris, notwithstanding its antiarrhythmic properties. A plausible reason for this is the apparent difficulty in linking the clinical benefits to the multiple molecular actions of this drug. Here, we review ranolazine’s experimental and clinical knowledge on cardiac metabolism and arrhythmias. We also highlight advances in understanding novel effects on neurons, the vascular system, skeletal muscles, blood sugar control, and cancer, which may open the way to reposition this “old” drug alone or in combination with other medications.
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15
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Kaplan AD, Joca HC, Boyman L, Greiser M. Calcium Signaling Silencing in Atrial Fibrillation: Implications for Atrial Sodium Homeostasis. Int J Mol Sci 2021; 22:10513. [PMID: 34638854 PMCID: PMC8508839 DOI: 10.3390/ijms221910513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 09/14/2021] [Accepted: 09/14/2021] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most common type of cardiac arrhythmia, affecting more than 33 million people worldwide. Despite important advances in therapy, AF's incidence remains high, and treatment often results in recurrence of the arrhythmia. A better understanding of the cellular and molecular changes that (1) trigger AF and (2) occur after the onset of AF will help to identify novel therapeutic targets. Over the past 20 years, a large body of research has shown that intracellular Ca2+ handling is dramatically altered in AF. While some of these changes are arrhythmogenic, other changes counteract cellular arrhythmogenic mechanisms (Calcium Signaling Silencing). The intracellular Na+ concentration ([Na+])i is a key regulator of intracellular Ca2+ handling in cardiac myocytes. Despite its importance in the regulation of intracellular Ca2+ handling, little is known about [Na+]i, its regulation, and how it might be changed in AF. Previous work suggests that there might be increases in the late component of the atrial Na+ current (INa,L) in AF, suggesting that [Na+]i levels might be high in AF. Indeed, a pharmacological blockade of INa,L has been suggested as a treatment for AF. Here, we review calcium signaling silencing and changes in intracellular Na+ homeostasis during AF. We summarize the proposed arrhythmogenic mechanisms associated with increases in INa,L during AF and discuss the evidence from clinical trials that have tested the pharmacological INa,L blocker ranolazine in the treatment of AF.
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Affiliation(s)
- Aaron D. Kaplan
- Center for Biomedical Engineering and Technology, Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (A.D.K.); (H.C.J.); (L.B.)
- Division of Cardiovascular Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| | - Humberto C. Joca
- Center for Biomedical Engineering and Technology, Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (A.D.K.); (H.C.J.); (L.B.)
| | - Liron Boyman
- Center for Biomedical Engineering and Technology, Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (A.D.K.); (H.C.J.); (L.B.)
| | - Maura Greiser
- Center for Biomedical Engineering and Technology, Department of Physiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (A.D.K.); (H.C.J.); (L.B.)
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16
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Antiarrhythmic Agents: a Review and Comment on Relevance in the Current Era—Part 2. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00944-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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17
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Jost N, Christ T, Magyar J. New Strategies for the Treatment of Atrial Fibrillation. Pharmaceuticals (Basel) 2021; 14:ph14090926. [PMID: 34577626 PMCID: PMC8466466 DOI: 10.3390/ph14090926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/07/2021] [Accepted: 09/08/2021] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia in the clinical practice. It significantly contributes to the morbidity and mortality of the elderly population. Over the past 25-30 years intense effort in basic research has advanced the understanding of the relationship between the pathophysiology of AF and atrial remodelling. Nowadays it is clear that the various forms of atrial remodelling (electrical, contractile and structural) play crucial role in initiating and maintaining the persistent and permanent types of AF. Unlike in ventricular fibrillation, in AF rapid ectopic firing originating from pulmonary veins and re-entry mechanism may induce and maintain (due to atrial remodelling) this complex cardiac arrhythmia. The present review presents and discusses in detail the latest knowledge on the role of remodelling in AF. Special attention is paid to novel concepts and pharmacological targets presumably relevant to the drug treatment of atrial fibrillation.
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Affiliation(s)
- Norbert Jost
- Department of Pharmacology and Pharmacotherapy, Faculty of Medicine, University of Szeged, 6725 Szeged, Hungary
- Department of Pharmacology and Pharmacotherapy, Interdisciplinary Excellence Centre, University of Szeged, 6725 Szeged, Hungary
- ELKH-SZTE Research Group for Cardiovascular Pharmacology, Eötvös Loránd Research Network, 6725 Szeged, Hungary
- Correspondence:
| | - Torsten Christ
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, 20246 Hamburg, Germany
| | - János Magyar
- Department of Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary;
- Department of Sport Physiology, Faculty of Medicine, University of Debrecen, 4032 Debrecen, Hungary
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18
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Nabeh OA, Helaly MM, Menshawey R, Menshawey E, Nasser MMM, Diaa El-deen AM. Contemporary approach to understand and manage COVID-19-related arrhythmia. Egypt Heart J 2021; 73:76. [PMID: 34459992 PMCID: PMC8403826 DOI: 10.1186/s43044-021-00201-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/18/2021] [Indexed: 12/15/2022] Open
Abstract
Arrhythmia, one of the most common complications of COVID-19, was reported in nearly one-third of diagnosed COVID-19 patients, with higher prevalence rate among ICU admitted patients. The underlying etiology for arrhythmia in these cases are mostly multifactorial as those patients may suffer from one or more of the following predisposing mechanisms; catecholamine surge, hypoxia, myocarditis, cytokine storm, QTc prolongation, electrolyte disturbance, and pro-arrhythmic drugs usage. Obviously, the risk for arrhythmia and the associated lethal outcome would rise dramatically among patients with preexisting cardiac disease such as myocardial ischemia, heart failure, cardiomyopathy, and hereditary arrhythmias. Considering all of these variables, the management strategy of COVID-19 patients should expand from managing a viral infection and related host immune response to include the prevention of predictable causes for arrhythmia. This may necessitate the need to investigate the role of some drugs that modulate the pathway of arrhythmia generation. Of these drugs, we discuss the potential role of adrenergic antagonists, trimetazidine, ranolazine, and the debatable angiotensin converting enzyme inhibitors drugs. We also recommend monitoring the level of: unbound free fatty acids, serum electrolytes, troponin, and QTc (even in the absence of apparent pro-arrhythmic drug use) as these may be the only indicators for patients at risk for arrhythmic complications.
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Affiliation(s)
- Omnia Azmy Nabeh
- Department of Medical Pharmacology, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maiada Mohamed Helaly
- Department of Medical Pharmacology, Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rahma Menshawey
- Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Esraa Menshawey
- Kasr Alainy Faculty of Medicine, Cairo University, Cairo, Egypt
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19
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Heijman J, Hohnloser SH, Camm AJ. Antiarrhythmic drugs for atrial fibrillation: lessons from the past and opportunities for the future. Europace 2021; 23:ii14-ii22. [PMID: 33837753 DOI: 10.1093/europace/euaa426] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/29/2020] [Indexed: 12/16/2022] Open
Abstract
Atrial fibrillation (AF) remains a highly prevalent and troublesome cardiac arrhythmia, associated with substantial morbidity and mortality. Restoration and maintenance of sinus rhythm (rhythm-control therapy) is an important element of AF management in symptomatic patients. Despite significant advances and increasing importance of catheter ablation, antiarrhythmic drugs (AADs) remain a cornerstone of rhythm-control therapy. During the past 50 years, experimental and clinical research has greatly increased our understanding of AADs. As part of the special issue on paradigm shifts in AF, this review summarizes important milestones in AAD research that have shaped their current role in AF management, including (i) awareness of the proarrhythmic potential of AADs; (ii) increasing understanding of the pleiotropic effects of AADs; (iii) the development of dronedarone; and (iv) the search for AF-specific AADs. Finally, we discuss short- and long-term opportunities for better AF management through advances in AAD therapy, including personalization of AAD therapy based on individual AF mechanisms.
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Affiliation(s)
- Jordi Heijman
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Faculty of Health, Medicine, and Life Sciences, Maastricht University, PO Box 616, Maastricht 6200, The Netherlands
| | - Stefan H Hohnloser
- Department of Cardiology, J. W. Goethe-Universität Frankfurt am Main, Frankfurt/Main, Germany
| | - A John Camm
- Cardiovascular and Cell Sciences Research Institute, Cardiology Clinical Academic Group, St George's, University of London, London, UK
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20
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Piccini JP, Dufton C, Carroll IA, Healey JS, Abraham WT, Khaykin Y, Aleong R, Krueger SK, Sauer WH, Wilton SB, Rienstra M, van Veldhuisen DJ, Anand IS, White M, Camm AJ, Ziegler PD, Marshall D, Bristow MR, Connolly SJ. Bucindolol Decreases Atrial Fibrillation Burden in Patients With Heart Failure and the ADRB1 Arg389Arg Genotype. Circ Arrhythm Electrophysiol 2021; 14:e009591. [PMID: 34270905 DOI: 10.1161/circep.120.009591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Jonathan P Piccini
- Duke Clinical Research Institute & Duke University Medical Center, Durham, NC (J.P.P.)
| | | | - Ian A Carroll
- ARCA biopharma, Inc, Westminster, CO (C.D., I.A.C., D.M., M.R.B.)
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., S.J.C.)
| | | | | | - Ryan Aleong
- University of Colorado, Aurora (R.A., M.R.B.)
| | | | - William H Sauer
- Brigham and Women's Hospital & Harvard Medical School, Boston, MA (W.H.S.)
| | - Stephen B Wilton
- Libin Cardiovascular Institute of Alberta, University of Calgary (S.B.W.)
| | - Michiel Rienstra
- University of Groningen & University Medical Center Groningen, the Netherlands (M.R., D.J.v.V.)
| | - Dirk J van Veldhuisen
- University of Groningen & University Medical Center Groningen, the Netherlands (M.R., D.J.v.V.)
| | | | | | - A John Camm
- St. George's University of London, United Kingdom (A.J.C.)
| | | | - Debra Marshall
- ARCA biopharma, Inc, Westminster, CO (C.D., I.A.C., D.M., M.R.B.)
| | - Michael R Bristow
- ARCA biopharma, Inc, Westminster, CO (C.D., I.A.C., D.M., M.R.B.).,University of Colorado, Aurora (R.A., M.R.B.)
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, ON (J.S.H., S.J.C.)
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21
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Investigational Anti-Atrial Fibrillation Pharmacology and Mechanisms by Which Antiarrhythmics Terminate the Arrhythmia: Where Are We in 2020? J Cardiovasc Pharmacol 2021; 76:492-505. [PMID: 33165131 PMCID: PMC7641178 DOI: 10.1097/fjc.0000000000000892] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Antiarrhythmic drugs remain the mainstay therapy for patients with atrial fibrillation (AF). A major disadvantage of the currently available anti-AF agents is the risk of induction of ventricular proarrhythmias. Aiming to reduce this risk, several atrial-specific or -selective ion channel block approaches have been introduced for AF suppression, but only the atrial-selective inhibition of the sodium channel has been demonstrated to be valid in both experimental and clinical studies. Among the other pharmacological anti-AF approaches, “upstream therapy” has been prominent but largely disappointing, and pulmonary delivery of anti-AF drugs seems to be promising. Major contradictions exist in the literature about the electrophysiological mechanisms of AF (ie, reentry or focal?) and the mechanisms by which anti-AF drugs terminate AF, making the search for novel anti-AF approaches largely empirical. Drug-induced termination of AF may or may not be associated with prolongation of the atrial effective refractory period. Anti-AF drug research has been largely based on the “suppress reentry” ideology; however, results of the AF mapping studies increasingly indicate that nonreentrant mechanism(s) plays an important role in the maintenance of AF. Also, the analysis of anti-AF drug-induced electrophysiological alterations during AF, conducted in the current study, leans toward the focal source as the prime mechanism of AF maintenance. More effort should be placed on the investigation of pharmacological suppression of the focal mechanisms.
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22
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Wiedmann F, Schmidt C. Vorhofflimmern – was wir nicht wissen („gaps in evidence“). AKTUELLE KARDIOLOGIE 2021. [DOI: 10.1055/a-1378-7400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungAuch nach Jahrzehnten intensiver grundlagenwissenschaftlicher und klinischer
Forschungsbemühungen können nicht alle Fragestellungen, die sich bei der Diagnosestellung und
Behandlung von Vorhofflimmern stellen, abschließend beantwortet werden. Das Konzept der
atrialen Kardiomyopathie unterstreicht, dass es sich bei Vorhofflimmern um keine einheitliche
Krankheitsentität handelt, sondern um einen Prozess, dem eine Vielzahl unterschiedlicher
Ursachen und Mechanismen zugrunde liegt. Noch nicht abschließend geklärt bleibt die hieraus
resultierende klinische Konsequenz. Neue Studienergebnisse weisen auf einen ausgeprägten
klinischen Benefit von rhythmuskontrollierenden Therapiestrategien, sowohl bei neu
diagnostiziertem paroxysmalem Vorhofflimmern als auch bei Herzinsuffizienzpatienten mit
Vorhofflimmern, hin und stellen damit erneut die Frage, ob Rhythmuskontrolle Frequenzkontrolle
vorzuziehen ist.
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Affiliation(s)
- Felix Wiedmann
- Cardiology, University Hospital Heidelberg, Heidelberg, Germany
- Deutsches Zentrum für Herzkreislaufforschung (DZHK), Universität Heidelberg, Heidelberg, Germany
- Heidelberg Center for Heart Rhythm Disorders (HCR), UniversitätsKlinikum Heidelberg, Heidelberg, Germany
| | - Constanze Schmidt
- Klinik für Kardiologie, Angiologie, Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
- Deutsches Zentrum für Herzkreislaufforschung (DZHK), Universität Heidelberg, Heidelberg, Germany
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23
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Ton AT, Nguyen W, Sweat K, Miron Y, Hernandez E, Wong T, Geft V, Macias A, Espinoza A, Truong K, Rasoul L, Stafford A, Cotta T, Mai C, Indersmitten T, Page G, Miller PE, Ghetti A, Abi-Gerges N. Arrhythmogenic and antiarrhythmic actions of late sustained sodium current in the adult human heart. Sci Rep 2021; 11:12014. [PMID: 34103608 PMCID: PMC8187365 DOI: 10.1038/s41598-021-91528-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 05/27/2021] [Indexed: 12/19/2022] Open
Abstract
Late sodium current (late INa) inhibition has been proposed to suppress the incidence of arrhythmias generated by pathological states or induced by drugs. However, the role of late INa in the human heart is still poorly understood. We therefore investigated the role of this conductance in arrhythmias using adult primary cardiomyocytes and tissues from donor hearts. Potentiation of late INa with ATX-II (anemonia sulcata toxin II) and E-4031 (selective blocker of the hERG channel) slowed the kinetics of action potential repolarization, impaired Ca2+ homeostasis, increased contractility, and increased the manifestation of arrhythmia markers. These effects could be reversed by late INa inhibitors, ranolazine and GS-967. We also report that atrial tissues from donor hearts affected by atrial fibrillation exhibit arrhythmia markers in the absence of drug treatment and inhibition of late INa with GS-967 leads to a significant reduction in arrhythmic behaviour. These findings reveal a critical role for the late INa in cardiac arrhythmias and suggest that inhibition of this conductance could provide an effective therapeutic strategy. Finally, this study highlights the utility of human ex-vivo heart models for advancing cardiac translational sciences.
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Affiliation(s)
- Anh Tuan Ton
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - William Nguyen
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Katrina Sweat
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Yannick Miron
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Eduardo Hernandez
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Tiara Wong
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Valentyna Geft
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Andrew Macias
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Ana Espinoza
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Ky Truong
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Lana Rasoul
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Alexa Stafford
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Tamara Cotta
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Christina Mai
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Tim Indersmitten
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Guy Page
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Paul E Miller
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Andre Ghetti
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA
| | - Najah Abi-Gerges
- AnaBios Corporation, 3030 Bunker Hill St., Suite 312, San Diego, CA, 92109, USA.
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24
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Burashnikov A. Depolarization of the atrial resting membrane potential as an approach to enhance the anti-atrial fibrillation efficacy of sodium channel blockers. Heart Rhythm 2021; 18:1221-1222. [PMID: 33785461 DOI: 10.1016/j.hrthm.2021.03.039] [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: 03/25/2021] [Accepted: 03/25/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Alexander Burashnikov
- Lankenau Institute for Medical Research, Wynnewood, Pennsylvania, and Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania.
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25
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Nunoi Y, Kambayashi R, Goto A, Hagiwara-Nagasawa M, Chiba K, Izumi-Nakaseko H, Kawai S, Takei Y, Matsumoto A, Watanabe Y, Sugiyama A. In vivo characterization of anti-atrial fibrillatory potential and pharmacological safety profile of I Na,L plus I Kr inhibitor ranolazine using the halothane-anesthetized dogs. Heart Vessels 2021; 36:1088-1097. [PMID: 33763729 DOI: 10.1007/s00380-021-01830-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/05/2021] [Indexed: 11/25/2022]
Abstract
To characterize in vivo anti-atrial fibrillatory potential and pharmacological safety profile of ranolazine having INa,L plus IKr inhibitory actions in comparison with those of clinically available anti-atrial fibrillatory drugs; namely, dronedarone, amiodarone, bepridil and dl-sotalol in our previous studies, ranolazine dihydrochloride in sub-therapeutic (0.3 mg/kg) and supra-therapeutic (3 mg/kg) doses was intravenously infused over 10 min to the halothane-anesthetized dogs (n = 5). The low dose increased the heart rate, cardiac output and atrioventricular conduction velocity possibly via vasodilator action-induced, reflex-mediated increase of adrenergic tone. Meanwhile, the high dose decreased the heart rate, ventricular contraction, cardiac output and mean blood pressure, indicating that drug-induced direct actions may exceed the reflex-mediated compensation. In addition, it prolonged the atrial and ventricular effective refractory periods, of which potency and selectivity for the former were less great compared with those of the clinically-available drugs. Moreover, it did not alter the ventricular early repolarization period in vivo, but prolonged the late repolarization with minimal risk for re-entrant arrhythmias. These in vivo findings of ranolazine suggest that INa,L suppression may attenuate IKr inhibition-associated prolongation of early repolarization in the presence of reflex-mediated increase of adrenergic tone. Thus, ranolazine alone may be less promising as an anti-atrial fibrillatory drug, but its potential risk for inducing torsade de pointes will be small. These information can be used as a guide to predict the utility and adverse effects of anti-atrial fibrillatory drugs having multi-channel modulatory action.
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Affiliation(s)
- Yoshio Nunoi
- Department of Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan.,Division of Cardiovascular Surgery, Department of Surgery, Faculty of Medicine, Toho University, 6-11-1 Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Ryuichi Kambayashi
- Department of Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Ai Goto
- Department of Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Mihoko Hagiwara-Nagasawa
- Department of Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Koki Chiba
- Department of Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Hiroko Izumi-Nakaseko
- Department of Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Shinichi Kawai
- Department of Inflammation and Pain Control Research, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Yoshinori Takei
- Department of Translational Research and Cellular Therapeutics, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Akio Matsumoto
- Department of Aging Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan
| | - Yoshinori Watanabe
- Division of Cardiovascular Surgery, Department of Surgery, Faculty of Medicine, Toho University, 6-11-1 Omori-nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Atsushi Sugiyama
- Department of Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan. .,Department of Inflammation and Pain Control Research, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan. .,Department of Translational Research and Cellular Therapeutics, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan. .,Department of Aging Pharmacology, Faculty of Medicine, Toho University, 5-21-16 Omori-nishi, Ota-ku, Tokyo, 143-8540, Japan.
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26
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Affiliation(s)
- James A. Reiffel
- Electrophysiology Section, Division of Cardiology, Department of Medicine, Columbia University, New York, NY, USA
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27
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Chukwunyere U, Sehirli AO, Abacioglu N. COVID-19-related arrhythmias and the possible effects of ranolazine. Med Hypotheses 2021; 149:110545. [PMID: 33636586 PMCID: PMC7890340 DOI: 10.1016/j.mehy.2021.110545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/03/2021] [Accepted: 02/12/2021] [Indexed: 12/30/2022]
Abstract
The COVID-19 pandemic has become a burden to the global healthcare community. Despite the severity of the complications associated with COVID-19, no antiviral agent is yet available for the treatment of this disease. Several studies have reported arrhythmias as one of the numerous manifestations associated with COVID-19 infection. Clinicians use different therapeutic agents in the management of COVID-19 patients with arrhythmias, apart from ranolazine; however, some of these drugs are administered with caution because of their significant side effects. In this study, we reviewed the potential antiarrhythmic effects of ranolazine in the management of cardiac arrhythmias associated with COVID-19. Ranolazine is a second-line drug approved for the treatment of chronic stable angina pectoris. Previous studies have shown that ranolazine produces its beneficial cardiac effects without any significant impact on the body’s hemodynamics; hence, blood pressure is not altered. Due to its reduced side effects, ranolazine may be more effective than other drugs in producing the desired relief from COVID-19 related arrhythmias, since it produces its antiarrhythmic effect by modulating sodium, potassium and calcium channels, and suppressing cytokine expression.
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Affiliation(s)
- Ugochukwu Chukwunyere
- Department of Pharmacology, Faculty of Pharmacy, Near East University, Nicosia, Cyprus.
| | - Ahmet Ozer Sehirli
- Department of Pharmacology, Faculty of Dentistry, Near East University, Nicosia, Cyprus
| | - Nurettin Abacioglu
- Department of Pharmacology, Faculty of Pharmacy, Near East University, Nicosia, Cyprus; Department of Pharmacology, Faculty of Pharmacy, Kyrenia University, Kyrenia, Cyprus
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28
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Reiffel JA, Capucci A. "Pill in the Pocket" Antiarrhythmic Drugs for Orally Administered Pharmacologic Cardioversion of Atrial Fibrillation. Am J Cardiol 2021; 140:55-61. [PMID: 33144165 DOI: 10.1016/j.amjcard.2020.10.063] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/16/2020] [Accepted: 10/21/2020] [Indexed: 12/19/2022]
Abstract
The therapy of atrial fibrillation often involves the use of a rhythm control strategy, in which 1 or more antiarrhythmic drugs (AAD), ablative procedures, and/or hybrid approaches involving both of these options are utilized in an attempt to restore and maintain sinus rhythm. For chronic therapy, an AAD is taken daily. However, for patients with symptomatic but infrequent, acute, but nondestabilizing episodes, the use of an AAD only at the time of an episode that can quickly restore sinus rhythm, generally as an out-patient, without the burden of a daily drug regimen, may be better. This is called "pill-in-the-pocket" therapy. This manuscript reviews the "pill-in-the-pocket" concept, traces its development from its origins using quinidine, to its expansion using class IC AADs, to the more recent investigation of ranolazine for this purpose. Who should get it, what it involves, its efficacy rates and concerns are all discussed.
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29
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Dewal RS, Greer-Short A, Lane C, Nirengi S, Manzano PA, Hernández-Saavedra D, Wright KR, Nassal D, Baer LA, Mohler PJ, Hund TJ, Stanford KI. Phospho-ablation of cardiac sodium channel Na v1.5 mitigates susceptibility to atrial fibrillation and improves glucose homeostasis under conditions of diet-induced obesity. Int J Obes (Lond) 2021; 45:795-807. [PMID: 33500550 PMCID: PMC8005377 DOI: 10.1038/s41366-021-00742-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 11/19/2020] [Accepted: 01/04/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained arrhythmia, with growing evidence identifying obesity as an important risk factor for the development of AF. Although defective atrial myocyte excitability due to stress-induced remodeling of ion channels is commonly observed in the setting of AF, little is known about the mechanistic link between obesity and AF. Recent studies have identified increased cardiac late sodium current (INa,L) downstream of calmodulin-dependent kinase II (CaMKII) activation as an important driver of AF susceptibility. METHODS Here, we investigated a possible role for CaMKII-dependent INa,L in obesity-induced AF using wild-type (WT) and whole-body knock-in mice that ablates phosphorylation of the Nav1.5 sodium channel and prevents augmentation of the late sodium current (S571A; SA mice). RESULTS A high-fat diet (HFD) increased susceptibility to arrhythmias in WT mice, while SA mice were protected from this effect. Unexpectedly, SA mice had improved glucose homeostasis and decreased body weight compared to WT mice. However, SA mice also had reduced food consumption compared to WT mice. Controlling for food consumption through pair feeding of WT and SA mice abrogated differences in weight gain and AF inducibility, but not atrial fibrosis, premature atrial contractions or metabolic capacity. CONCLUSIONS These data demonstrate a novel role for CaMKII-dependent regulation of Nav1.5 in mediating susceptibility to arrhythmias and whole-body metabolism under conditions of diet-induced obesity.
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Affiliation(s)
- Revati S. Dewal
- grid.412332.50000 0001 1545 0811Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Center for Diabetes and Metabolism Research Center, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Amara Greer-Short
- grid.261331.40000 0001 2285 7943Department of Biomedical Engineering, The Ohio State University, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Cemantha Lane
- grid.261331.40000 0001 2285 7943Department of Biomedical Engineering, The Ohio State University, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Shinsuke Nirengi
- grid.412332.50000 0001 1545 0811Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Center for Diabetes and Metabolism Research Center, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Pedro Acosta Manzano
- grid.412332.50000 0001 1545 0811Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Center for Diabetes and Metabolism Research Center, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Diego Hernández-Saavedra
- grid.412332.50000 0001 1545 0811Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Center for Diabetes and Metabolism Research Center, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Katherine R. Wright
- grid.412332.50000 0001 1545 0811Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Center for Diabetes and Metabolism Research Center, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Drew Nassal
- grid.261331.40000 0001 2285 7943Department of Biomedical Engineering, The Ohio State University, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Lisa A. Baer
- grid.412332.50000 0001 1545 0811Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Center for Diabetes and Metabolism Research Center, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Peter J. Mohler
- grid.412332.50000 0001 1545 0811Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Thomas J. Hund
- grid.261331.40000 0001 2285 7943Department of Biomedical Engineering, The Ohio State University, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Frick Center for Heart Failure and Arrhythmia, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
| | - Kristin I. Stanford
- grid.412332.50000 0001 1545 0811Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Center for Diabetes and Metabolism Research Center, Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH USA ,grid.412332.50000 0001 1545 0811Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH USA
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30
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Boriani G, Blomström-Lundqvist C, Hohnloser SH, Bergfeldt L, Botto GL, Capucci A, Lozano IF, Goette A, Israel CW, Merino JL, Camm AJ. Safety and efficacy of dronedarone from clinical trials to real-world evidence: implications for its use in atrial fibrillation. Europace 2020; 21:1764-1775. [PMID: 31324921 DOI: 10.1093/europace/euz193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 06/20/2019] [Indexed: 12/27/2022] Open
Abstract
Efficacy and safety of dronedarone was shown in the ATHENA trial for paroxysmal or persistent atrial fibrillation (AF) patients. Further trials revealed safety concerns in patients with heart failure and permanent AF. This review summarizes insights from recent real-world studies and meta-analyses, including reports on efficacy, with focus on liver safety, mortality risk in patients with paroxysmal/persistent AF, and interactions of dronedarone with direct oral anticoagulants. Reports of rapidly progressing liver failure in dronedarone-prescribed patients in 2011 led to regulatory cautions about potential liver toxicity. Recent real-world evidence suggests dronedarone liver safety profile is similar to other antiarrhythmics and liver toxicity could be equally common with many Class III antiarrhythmics. Dronedarone safety concerns (increased mortality in patients with permanent AF) were raised based on randomized controlled trials (RCT) (ANDROMEDA and PALLAS), but comedication with digoxin may have increased the mortality rates in PALLAS, considering the dronedarone-digoxin pharmacokinetic (PK) interaction. Real-world data on apixaban-dronedarone interactions and edoxaban RCT observations suggest no significant safety risks for these drug combinations. Median trough plasma concentrations of dabigatran 110 mg during concomitant use with dronedarone are at acceptable levels, while PK data on the rivaroxaban-dronedarone interaction are unavailable. In RCTs and real-world studies, dronedarone significantly reduces AF burden and cardiovascular hospitalizations, and demonstrates a low risk for proarrhythmia in patients with paroxysmal or persistent AF. The concerns on liver safety must be balanced against the significant reduction in hospitalizations in patients with non-permanent AF and low risk for proarrhythmias following dronedarone treatment.
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Affiliation(s)
- Giuseppe Boriani
- Division of Cardiology, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | | | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J W Goethe University, Frankfurt, Germany
| | - Lennart Bergfeldt
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Västra Götaland, Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | | | - Andreas Goette
- Medical Clinic II, Cardiology Department, St Vincenz-Krankenhaus Paderborn, Paderborn, Germany.,Working Group Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Carsten W Israel
- Division of Clinical Electrophysiology, Department of Cardiology, J W Goethe University, Frankfurt, Germany.,Clinic of Internal Medicine, Bethel-Clinic, Bielefeld, Germany
| | - José L Merino
- Arrhythmia & Robotic EP Unit, Hospital Universitario La Paz-IdiPaz, Madrid, Spain
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St George's University of London, Cranmer Terrace, London SW17 0RE, UK
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31
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Electrophysiological effects of ranolazine in a goat model of lone atrial fibrillation. Heart Rhythm 2020; 18:615-622. [PMID: 33232809 DOI: 10.1016/j.hrthm.2020.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 11/14/2020] [Accepted: 11/17/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND There is still an unmet need for pharmacologic treatment of atrial fibrillation (AF) with few effects on ventricular electrophysiology. Ranolazine is an antiarrhythmic drug reported to have strong atrial selectivity. OBJECTIVE The purpose of this study was to investigate the electrophysiological effects of ranolazine in atria with AF-induced electrical remodeling in a model of lone AF in awake goats. METHODS Electrode patches were implanted on the atrial epicardium of 8 Dutch milk goats. Experiments were performed at baseline and after 2 and 14 days of electrically maintained AF. Several electrophysiological parameters and AF episode duration were measured during infusion of vehicle and different doses of ranolazine (target plasma levels 4, 8, and 16 μM, respectively). RESULTS The highest dose of ranolazine significantly prolonged atrial effective refractory period and decreased atrial conduction velocity at baseline and after 2 days of AF. After 2 weeks of AF, ranolazine prolonged the p5 and p50 of AF cycle length distribution in a dose-dependent manner but was not effective in restoring sinus rhythm. No adverse ventricular arrhythmic events (eg, premature ventricular beats or signs of hemodynamic instability) were observed during infusion of ranolazine at any point in the study. CONCLUSION The lowest investigated dose of ranolazine, which is expected to block both late INa and atrial peak INa, had no effect on the investigated electrophysiological parameters. The highest dose affected both atrial and ventricular electrophysiological parameters at different stages of AF-induced remodeling but was not efficacious in cardioverting AF to sinus rhythm in a goat model of lone AF.
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32
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Geng M, Lin A, Nguyen TP. Revisiting Antiarrhythmic Drug Therapy for Atrial Fibrillation: Reviewing Lessons Learned and Redefining Therapeutic Paradigms. Front Pharmacol 2020; 11:581837. [PMID: 33240090 PMCID: PMC7680856 DOI: 10.3389/fphar.2020.581837] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022] Open
Abstract
Since the clinical use of digitalis as the first pharmacological therapy for atrial fibrillation (AF) 235 years ago in 1785, antiarrhythmic drug therapy has advanced considerably and become a cornerstone of AF clinical management. Yet, a preventive or curative panacea for sustained AF does not exist despite the rise of AF global prevalence to epidemiological proportions. While multiple elevated risk factors for AF have been established, the natural history and etiology of AF remain incompletely understood. In the present article, the first section selectively highlights some disappointing shortcomings and current efforts in antiarrhythmic drug therapy to uncover reasons why AF is such a clinical challenge. The second section discusses some modern takes on the natural history of AF as a relentless, progressive fibro-inflammatory "atriomyopathy." The final section emphasizes the need to redefine therapeutic strategies on par with new insights of AF pathophysiology.
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Affiliation(s)
| | | | - Thao P. Nguyen
- Division of Cardiology, Department of Medicine, The Cardiovascular Research Laboratory, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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33
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Antiarrhythmic Effect of Ranolazine in Combination with Selective NCX-Inhibition in an Experimental Model of Atrial Fibrillation. Pharmaceuticals (Basel) 2020; 13:ph13100321. [PMID: 33092020 PMCID: PMC7589655 DOI: 10.3390/ph13100321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 12/19/2022] Open
Abstract
The aim of this study was to investigate the effects of a combination of ranolazine with different selective inhibitors of the Na+/Ca2+-exchanger (NCX) in an established experimental model of atrial fibrillation (AF). Eighteen hearts of New Zealand white rabbits were retrogradely perfused. Atrial catheters were used to record monophasic action potentials (aPRR). Hearts were paced at three different cycle lengths. Thereby, atrial action potential durations (aAPD90), atrial effective refractory periods (aERP) and atrial post-repolarization refractoriness were obtained. Isoproterenol and acetylcholine were employed to increase the occurrence of AF. Thereafter, the hearts were assigned to two groups (n = 9 each group) and additionally perfused with a combination of 10 µM ranolazine and 1 µM of the selective NCX-inhibitor ORM-10103 (group A: Rano-ORM) or 10 µM ranolazine and 1 µM of another NCX-inhibitor, SEA0400 (group B: Rano-SEA). The infusion of Iso/ACh led to a shortening of aAPD90, aERP, aPRR and the occurrence of AF episodes was significantly increased. Additional perfusion with ranolazine and ORM-10103 (group A) significantly prolonged the refractory periods and aPRR and AF episodes were effectively reduced. In group B, Rano-SEA led to a slight decrease in aAPD90 while aERP and aPRR were prolonged. The occurrence of AF episodes was consecutively reduced. To our knowledge, this is the first study investigating the effect of ranolazine combined with different selective NCX-inhibitors in an isolated whole-heart model of AF. Both combinations prolonged aERP and aPRR and thereby suppressed the induction of AF.
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34
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Wong CK, Tse HF. New methodological approaches to atrial fibrillation drug discovery. Expert Opin Drug Discov 2020; 16:319-329. [PMID: 33016154 DOI: 10.1080/17460441.2021.1826432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice and rhythm control using pharmacological agents is required in selected patients. Nonetheless, current medication is only modestly efficacious and associated with significant cardiovascular and systemic side effects. More efficacious and safe drugs are required to restore and maintain sinus rhythm in patients with AF. AREAS COVERED In this review, several potential drug targets are discussed including trans-membrane ion channels, intracellular calcium signaling, gap junction signaling, atrial inflammation and fibrosis, and the autonomic nervous system. New tools and methodologies for AF drug development are also reviewed including gene therapy, genome-guided therapy, stem cell technologies, tissue engineering, and optogenetics. EXPERT OPINION In recent decades, there has been an increased understanding of the underlying pathogenesis of AF. As a result, there is a gradual paradigm shift from focusing only on trans-membrane ion channel inhibition to developing therapeutic agents that target other underlying arrhythmogenic mechanisms. Gene therapy and genome-guided therapy are emerging as novel treatments for AF with some success in proof-of-concept studies. Recent advances in stem cell technology, tissue engineering, and optogenetics may allow more effective in-vitro drug screening than conventional methodologies.
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Affiliation(s)
- Chun-Ka Wong
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, SAR China
| | - Hung-Fat Tse
- Cardiology Division, Department of Medicine, The University of Hong Kong, Hong Kong, SAR China
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35
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Ni H, Fogli Iseppe A, Giles WR, Narayan SM, Zhang H, Edwards AG, Morotti S, Grandi E. Populations of in silico myocytes and tissues reveal synergy of multiatrial-predominant K + -current block in atrial fibrillation. Br J Pharmacol 2020; 177:4497-4515. [PMID: 32667679 DOI: 10.1111/bph.15198] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 06/22/2020] [Accepted: 07/03/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE Pharmacotherapy of atrial fibrillation (AF), the most common cardiac arrhythmia, remains unsatisfactory due to low efficacy and safety concerns. New therapeutic strategies target atrial-predominant ion-channels and involve multichannel block (poly)therapy. As AF is characterized by rapid and irregular atrial activations, compounds displaying potent antiarrhythmic effects at fast and minimal effects at slow rates are desirable. We present a novel systems pharmacology framework to quantitatively evaluate synergistic anti-AF effects of combined block of multiple atrial-predominant K+ currents (ultra-rapid delayed rectifier K+ current, IKur , small conductance Ca2+ -activated K+ current, IKCa , K2P 3.1 2-pore-domain K+ current, IK2P ) in AF. EXPERIMENTAL APPROACH We constructed experimentally calibrated populations of virtual atrial myocyte models in normal sinus rhythm and AF-remodelled conditions using two distinct, well-established atrial models. Sensitivity analyses on our atrial populations was used to investigate the rate dependence of action potential duration (APD) changes due to blocking IKur , IK2P or IKCa and interactions caused by blocking of these currents in modulating APD. Block was simulated in both single myocytes and one-dimensional tissue strands to confirm insights from the sensitivity analyses and examine anti-arrhythmic effects of multi-atrial-predominant K+ current block in single cells and coupled tissue. KEY RESULTS In both virtual atrial myocytes and tissues, multiple atrial-predominant K+ -current block promoted favourable positive rate-dependent APD prolongation and displayed positive rate-dependent synergy, that is, increasing synergistic antiarrhythmic effects at fast pacing versus slow rates. CONCLUSION AND IMPLICATIONS Simultaneous block of multiple atrial-predominant K+ currents may be a valuable antiarrhythmic pharmacotherapeutic strategy for AF.
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Affiliation(s)
- Haibo Ni
- Department of Pharmacology, University of California, Davis, CA, USA
| | - Alex Fogli Iseppe
- Department of Pharmacology, University of California, Davis, CA, USA
| | - Wayne R Giles
- Faculties of Kinesiology and Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sanjiv M Narayan
- Division of Cardiology, Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Henggui Zhang
- Biological Physics Group, School of Physics and Astronomy, The University of Manchester, Manchester, UK
| | - Andrew G Edwards
- Department of Pharmacology, University of California, Davis, CA, USA
| | - Stefano Morotti
- Department of Pharmacology, University of California, Davis, CA, USA
| | - Eleonora Grandi
- Department of Pharmacology, University of California, Davis, CA, USA
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Intracellular calcium leak in heart failure and atrial fibrillation: a unifying mechanism and therapeutic target. Nat Rev Cardiol 2020; 17:732-747. [PMID: 32555383 DOI: 10.1038/s41569-020-0394-8] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2020] [Indexed: 12/14/2022]
Abstract
Ca2+ is a fundamental second messenger in all cell types and is required for numerous essential cellular functions, including cardiac and skeletal muscle contraction. The intracellular concentration of free Ca2+ ([Ca2+]) is regulated primarily by ion channels, pumps (ATPases), exchangers and Ca2+-binding proteins. Defective regulation of [Ca2+] is found in a diverse spectrum of pathological states that affect all the major organs. In the heart, abnormalities in the regulation of cytosolic and mitochondrial [Ca2+] occur in heart failure (HF) and atrial fibrillation (AF), two common forms of heart disease and leading contributors to morbidity and mortality. In this Review, we focus on the mechanisms that regulate ryanodine receptor 2 (RYR2), the major sarcoplasmic reticulum (SR) Ca2+-release channel in the heart, how RYR2 becomes dysfunctional in HF and AF, and its potential as a therapeutic target. Inherited RYR2 mutations and/or stress-induced phosphorylation and oxidation of the protein destabilize the closed state of the channel, resulting in a pathological diastolic Ca2+ leak from the SR that both triggers arrhythmias and impairs contractility. On the basis of our increased understanding of SR Ca2+ leak as a shared Ca2+-dependent pathological mechanism in HF and AF, a new class of drugs developed in our laboratory, known as rycals, which stabilize RYR2 channels and prevent Ca2+ leak from the SR, are undergoing investigation in clinical trials.
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Isaac E, Cooper SM, Jones SA, Loubani M. Do age-associated changes of voltage-gated sodium channel isoforms expressed in the mammalian heart predispose the elderly to atrial fibrillation? World J Cardiol 2020; 12:123-135. [PMID: 32431783 PMCID: PMC7215965 DOI: 10.4330/wjc.v12.i4.123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 01/18/2020] [Accepted: 03/15/2020] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide. The prevalence of the disease increases with age, strongly implying an age-related process underlying the pathology. At a time when people are living longer than ever before, an exponential increase in disease prevalence is predicted worldwide. Hence unraveling the underlying mechanics of the disease is paramount for the development of innovative treatment and prevention strategies. The role of voltage-gated sodium channels is fundamental in cardiac electrophysiology and may provide novel insights into the arrhythmogenesis of AF. Nav1.5 is the predominant cardiac isoform, responsible for the action potential upstroke. Recent studies have demonstrated that Nav1.8 (an isoform predominantly expressed within the peripheral nervous system) is responsible for cellular arrhythmogenesis through the enhancement of pro-arrhythmogenic currents. Animal studies have shown a decline in Nav1.5 leading to a diminished action potential upstroke during phase 0. Furthermore, the study of human tissue demonstrates an inverse expression of sodium channel isoforms; reduction of Nav1.5 and increase of Nav1.8 in both heart failure and ventricular hypertrophy. This strongly suggests that the expression of voltage-gated sodium channels play a crucial role in the development of arrhythmias in the diseased heart. Targeting aberrant sodium currents has led to novel therapeutic approaches in tackling AF and continues to be an area of emerging research. This review will explore how voltage-gated sodium channels may predispose the elderly heart to AF through the examination of laboratory and clinical based evidence.
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Affiliation(s)
- Emmanuel Isaac
- Department of Cardiothoracic Surgery, Hull University Teaching Hospitals, Cottingham HU16 5JQ, United Kingdom
| | - Stephanie M Cooper
- Department of Biomedical Sciences, University of Hull, Hull HU6 7RX, United Kingdom
| | - Sandra A Jones
- Department of Biomedical Sciences, University of Hull, Hull HU6 7RX, United Kingdom
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull University Teaching Hospitals, Cottingham HU16 5JQ, United Kingdom
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38
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Horváth B, Hézső T, Kiss D, Kistamás K, Magyar J, Nánási PP, Bányász T. Late Sodium Current Inhibitors as Potential Antiarrhythmic Agents. Front Pharmacol 2020; 11:413. [PMID: 32372952 PMCID: PMC7184885 DOI: 10.3389/fphar.2020.00413] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 03/18/2020] [Indexed: 12/19/2022] Open
Abstract
Based on recent findings, an increased late sodium current (INa,late) plays an important pathophysiological role in cardiac diseases, including rhythm disorders. The article first describes what is INa,late and how it functions under physiological circumstances. Next, it shows the wide range of cellular mechanisms that can contribute to an increased INa,late in heart diseases, and also discusses how the upregulated INa,late can play a role in the generation of cardiac arrhythmias. The last part of the article is about INa,late inhibiting drugs as potential antiarrhythmic agents, based on experimental and preclinical data as well as in the light of clinical trials.
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Affiliation(s)
- Balázs Horváth
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Tamás Hézső
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Dénes Kiss
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Kornél Kistamás
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - János Magyar
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Division of Sport Physiology, University of Debrecen, Debrecen, Hungary
| | - Péter P. Nánási
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Department of Dental Physiology and Pharmacology, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
| | - Tamás Bányász
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Huang CLH, Wu L, Jeevaratnam K, Lei M. Update on antiarrhythmic drug pharmacology. J Cardiovasc Electrophysiol 2020; 31:579-592. [PMID: 31930579 DOI: 10.1111/jce.14347] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 12/22/2019] [Accepted: 01/03/2020] [Indexed: 12/28/2022]
Abstract
Cardiac arrhythmias constitute a major public health problem. Pharmacological intervention remains mainstay to their clinical management. This, in turn, depends upon systematic drug classification schemes relating their molecular, cellular, and systems effects to clinical indications and therapeutic actions. This approach was first pioneered in the 1960s Vaughan-Williams classification. Subsequent progress in cardiac electrophysiological understanding led to a lag between the fundamental science and its clinical translation, partly addressed by The working group of the European Society of Cardiology (1991), which, however, did not emerge with formal classifications. We here utilize the recent Revised Oxford Classification Scheme to review antiarrhythmic drug pharmacology. We survey drugs and therapeutic targets offered by the more recently characterized ion channels, transporters, receptors, intracellular Ca2+ handling, and cell signaling molecules. These are organized into their strategic roles in cardiac electrophysiological function. Following analysis of the arrhythmic process itself, we consider (a) pharmacological agents directly targeting membrane function, particularly the Na+ and K+ ion channels underlying depolarizing and repolarizing events in the cardiac action potential. (b) We also consider agents that modify autonomic activity that, in turn, affects both the membrane and (c) the Ca2+ homeostatic and excitation-contraction coupling processes linking membrane excitation to contractile activation. Finally, we consider (d) drugs acting on more upstream energetic and structural remodeling processes currently the subject of clinical trials. Such systematic correlations of drug actions and arrhythmic mechanisms at different molecular to systems levels of cardiac function will facilitate current and future antiarrhythmic therapy.
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Affiliation(s)
- Christopher L-H Huang
- Department of Biochemistry and Physiological Laboratory, University of Cambridge, Cambridge, UK.,Key Laboratory of Medical Electrophysiology of Ministry of Education, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
| | - Lin Wu
- Key Laboratory of Medical Electrophysiology of Ministry of Education, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China.,Department of Cardiology, Peking University First Hospital, Beijing, China
| | | | - Ming Lei
- Key Laboratory of Medical Electrophysiology of Ministry of Education, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China.,Department of Pharmacology, University of Oxford, Oxford, UK
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40
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Dybkova N, Ahmad S, Pabel S, Tirilomis P, Hartmann N, Fischer TH, Bengel P, Tirilomis T, Ljubojevic S, Renner A, Gummert J, Ellenberger D, Wagner S, Frey N, Maier LS, Streckfuss-Bömeke K, Hasenfuss G, Sossalla S. Differential regulation of sodium channels as a novel proarrhythmic mechanism in the human failing heart. Cardiovasc Res 2019; 114:1728-1737. [PMID: 29931291 DOI: 10.1093/cvr/cvy152] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 06/15/2018] [Indexed: 12/18/2022] Open
Abstract
Aims In heart failure (HF), enhanced persistent Na+ current (INaL) exerts detrimental effects on cellular electrophysiology and can induce arrhythmias. However, the underlying regulatory mechanisms remain unclear. Our aim was to potentially investigate the regulation and electrophysiological contribution of neuronal sodium channel NaV1.8 in failing human heart and eventually to reveal a novel anti-arrhythmic therapy. Methods and results By western blot, we found that NaV1.8 protein expression is significantly up-regulated, while of the predominant cardiac isoform NaV1.5 is inversely reduced in human HF. Furthermore, to investigate the relation of NaV1.8 regulation with the cellular proarrhythmic events, we performed comprehensive electrophysiology recordings and explore the effect of NaV1.8 on INaL, action potential duration (APD), Ca2+ spark frequency, and arrhythmia induction in human failing cardiomyocytes. NaV1.8 inhibition with the specific blockers A-803467 and PF-01247324 decreased INaL, abbreviated APD and reduced cellular-spontaneous Ca2+-release and proarrhythmic events in human failing cardiomyocytes. Consistently, in mouse cardiomyocytes stressed with isoproterenol, pharmacologic inhibition and genetically knockout of NaV1.8 (SCN10A-/-), were associated with reduced INaL and abbreviated APD. Conclusion We provide first evidence of differential regulation of NaV1.8 and NaV1.5 in the failing human myocardium and their contribution to arrhythmogenesis due to generation of INaL. We propose inhibition of NaV1.8 thus constitutes a promising novel approach for selective anti-arrhythmic therapy in HF.
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Affiliation(s)
- Nataliya Dybkova
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, DZHK (German Centre for Cardiovascular Research), partner site Goettingen, Germany
| | - Shakil Ahmad
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, DZHK (German Centre for Cardiovascular Research), partner site Goettingen, Germany.,Department of Internal Medicine II, University Medical Center Regensburg, Germany
| | - Steffen Pabel
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, DZHK (German Centre for Cardiovascular Research), partner site Goettingen, Germany.,Department of Internal Medicine II, University Medical Center Regensburg, Germany
| | - Petros Tirilomis
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, DZHK (German Centre for Cardiovascular Research), partner site Goettingen, Germany
| | - Nico Hartmann
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, DZHK (German Centre for Cardiovascular Research), partner site Goettingen, Germany
| | - Thomas H Fischer
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, DZHK (German Centre for Cardiovascular Research), partner site Goettingen, Germany
| | - Philipp Bengel
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, DZHK (German Centre for Cardiovascular Research), partner site Goettingen, Germany
| | - Theodoros Tirilomis
- Department of Thoracic, Cardiac and Vascular Surgery, Georg-August University Goettingen, Germany
| | | | - André Renner
- Department of Thoracic, Cardiac and Vascular Surgery (Heart and Diabetes Center), North Rhine Westphalia, Bad Oeynhausen, Germany
| | - Jan Gummert
- Department of Thoracic, Cardiac and Vascular Surgery (Heart and Diabetes Center), North Rhine Westphalia, Bad Oeynhausen, Germany
| | - David Ellenberger
- Department of Medical Statistics, University Medical Center Goettingen, Germany
| | - Stefan Wagner
- Department of Internal Medicine II, University Medical Center Regensburg, Germany
| | - Norbert Frey
- Department of Internal Medicine III, Molecular Cardiology and Angiology, University Medical Center, Campus Kiel, Schleswig-Holstein, Germany
| | - Lars S Maier
- Department of Internal Medicine II, University Medical Center Regensburg, Germany
| | - Katrin Streckfuss-Bömeke
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, DZHK (German Centre for Cardiovascular Research), partner site Goettingen, Germany
| | - Gerd Hasenfuss
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, DZHK (German Centre for Cardiovascular Research), partner site Goettingen, Germany
| | - Samuel Sossalla
- Clinic for Cardiology & Pneumology, Georg-August University Goettingen, DZHK (German Centre for Cardiovascular Research), partner site Goettingen, Germany.,Department of Internal Medicine II, University Medical Center Regensburg, Germany
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41
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Giaccari A. Sodium-glucose co-transporter inhibitors: Medications that mimic fasting for cardiovascular prevention. Diabetes Obes Metab 2019; 21:2211-2218. [PMID: 31209982 DOI: 10.1111/dom.13814] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/11/2019] [Accepted: 06/11/2019] [Indexed: 12/30/2022]
Abstract
Recent evidence that some diabetes drugs can prevent cardiovascular disease (CVD) has profoundly modified the treatment approach to type 2 diabetes mellitus. Sodium-glucose co-transporter-2 (SGLT2) inhibitors and almost all glucagon-like peptide-1 receptor agonists (GLP-1RAs) have been shown, beyond their effect on glucose control, to lead to a significant decrease in the cardiovascular burden of diabetes. Although these results are well known, the mechanisms of action by which they prevent cardiovascular events are still poorly understood. Both GLP-1RAs and SGLT2 inhibitors promote weight loss, although through different mechanisms. SGLT2 inhibitors promote glycosuria, leading to significant caloric deficit and weight loss. Similarly, GLP-1RAs, probably through an anorexic effect on certain brain areas, inhibit calorie intake, with ensuing weight loss. Although it features less prominently in current treatment pathways, pioglitazone has also demonstrated cardiovascular benefits. Pioglitazone profoundly modifies several mechanisms and risk factors responsible for CVD; however, these mechanisms certainly do not include weight loss. Obesity, and consequent insulin resistance, are well known risk factors for CVD, and it would appear logical to attribute the positive cardiovascular effects of these two classes of drugs to weight loss. The direct metabolic effects of these two classes, however, are profoundly different. The present review proposes a unifying hypothesis to explain the reduction in CVD through three different mechanisms of curbing free fatty acid excess, all leading to the common mechanism of cellular caloric restriction. If this hypothesis is correct, the excellent results obtained with SGLT2 inhibitors could be attributed to their close simulation of fasting.
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Affiliation(s)
- Andrea Giaccari
- Centro Malattie Endocrine e Metaboliche, UOC Endocrinologia e Diabetologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto Patologia Speciale Medica e Semeiotica Medica, Universitá Cattolica del Sacro Cuore, Rome, Italy
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42
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Peyronnet R, Ravens U. Atria-selective antiarrhythmic drugs in need of alliance partners. Pharmacol Res 2019; 145:104262. [PMID: 31059791 DOI: 10.1016/j.phrs.2019.104262] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/30/2019] [Accepted: 05/03/2019] [Indexed: 12/15/2022]
Abstract
Atria-selective antiarrhythmic drugs in need of alliance partners. Guideline-based treatment of atrial fibrillation (AF) comprises prevention of thromboembolism and stroke, as well as antiarrhythmic therapy by drugs, electrical rhythm conversion, ablation and surgical procedures. Conventional antiarrhythmic drugs are burdened with unwanted side effects including a propensity of triggering life-threatening ventricular fibrillation. In order to solve this therapeutic dilemma, 'atria-selective' antiarrhythmic drugs have been developed for the treatment of supraventricular arrhythmias. These drugs are designed to aim at atrial targets, taking advantage of differences in atrial and ventricular ion channel expression and function. However it is not clear, whether such drugs are sufficiently antiarrhythmic or whether they are in need of an alliance partner for clinical efficacy. Atria-selective Na+ channel blockers display fast dissociation kinetics and high binding affinity to inactivated channels. Compounds targeting atria-selective K+ channels include blockers of ultra rapid delayed rectifier (Kv1.5) or acetylcholine-activated inward rectifier K+ channels (Kir3.x), inward rectifying K+ channels (Kir2.x), Ca2+-activated K+ channels of small conductance (SK), weakly rectifying two-pore domain K+ channels (K2P), and transient receptor potential channels (TRP). Despite good antiarrhythmic data from in-vitro and animal model experiments, clinical efficacy of atria-selective antiarrhythmic drugs remains to be demonstrated. In the present review we will briefly summarize the novel compounds and their proposed antiarrhythmic action. In addition, we will discuss the evidence for putative improvement of antiarrhythmic efficacy and potency by addressing multiple pathophysiologically relevant targets as possible alliance partners.
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Affiliation(s)
- Rémi Peyronnet
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg Bad Krozingen, Medical Center, University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ursula Ravens
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg Bad Krozingen, Medical Center, University of Freiburg, Freiburg, Germany; Institute of Physiology, Medical Faculty TU Dresden, Dresden, Germany.
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Avula UMR, Abrams J, Katchman A, Zakharov S, Mironov S, Bayne J, Roybal D, Gorti A, Yang L, Iyer V, Waase M, Saluja D, Ciaccio EJ, Garan H, Marks AR, Marx SO, Wan EY. Heterogeneity of the action potential duration is required for sustained atrial fibrillation. JCI Insight 2019; 5:128765. [PMID: 31021331 DOI: 10.1172/jci.insight.128765] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and accounts for substantial morbidity and mortality. Recently, we created a mouse model with spontaneous and sustained AF caused by a mutation in the NaV1.5 channel (F1759A) that enhances persistent Na+ current, thereby enabling the investigation of molecular mechanisms that cause AF and the identification of novel treatment strategies. The mice have regional heterogeneity of action potential duration of the atria similar to observations in patients with AF. In these mice, we found that the initiation and persistence of the rotational reentrant AF arrhythmias, known as spiral waves or rotors, were dependent upon action potential duration heterogeneity. The centers of the rotors were localized to regions of greatest heterogeneity of the action potential duration. Pharmacologically attenuating the action potential duration heterogeneity reduced both spontaneous and pacing-induced AF. Computer-based simulations also demonstrated that the action potential duration heterogeneity is sufficient to generate rotors that manifest as AF. Taken together, these findings suggest that action potential duration heterogeneity in mice and humans is one mechanism by which AF is initiated and that reducing action potential duration heterogeneity can lessen the burden of AF.
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Affiliation(s)
- Uma Mahesh R Avula
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Jeffrey Abrams
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Alexander Katchman
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Sergey Zakharov
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Sergey Mironov
- Center for Arrhythmia Research, Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph Bayne
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Daniel Roybal
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Anirudh Gorti
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Lin Yang
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Vivek Iyer
- Marin General Hospital, Greenbrae, California, USA
| | - Marc Waase
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Deepak Saluja
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Edward J Ciaccio
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Hasan Garan
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Andrew R Marks
- The Wu Center for Molecular Cardiology, Columbia University, New York, New York, USA.,Department of Physiology and Cellular Biophysics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Steven O Marx
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Elaine Y Wan
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
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Ghosh GC, Ghosh RK, Bandyopadhyay D, Chatterjee K, Aneja A. Ranolazine: Multifaceted Role beyond Coronary Artery Disease, a Recent Perspective. Heart Views 2019; 19:88-98. [PMID: 31007857 PMCID: PMC6448470 DOI: 10.4103/heartviews.heartviews_18_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Ranolazine is a piperazine derivative approved as an antianginal. Primarily used as a second-line antianginal in stable coronary artery disease. Ranolazine blocks the late Na + current and prevents the rise of cytosolic calcium. It decreases myocardial wall tension and improves coronary blood flow. Ranolazine is effective in atrial fibrillation (AF) as an adjunct to electrical or pharmacological cardioversion. It can be used in combination with amiodarone or dronedarone. It has also been used in AF arising after coronary artery bypass grafting surgery. Role of ranolazine is also being evaluated in pulmonary arterial hypertension, diastolic dysfunction, and chemotherapy-induced cardiotoxicity. Ranolazine has some anti-glycemic effect and has shown a reduction of hemoglobin A1c in multiple trials. The antianginal effect of ranolazine has also been seen to be more in patients with diabetes compared to those without diabetes. Ranolazine is being evaluated in patients with the peripheral arterial disease with intermittent claudication and hypertrophic cardiomyopathy. Pilot studies have shown that ranolazine may be beneficial in neurological conditions with myotonia. The evidence-base on the use of ranolazine in various conditions is rapidly increasing with results of further trials eagerly awaited. Accumulating evidence may see ranolazine in routine clinical use for many conditions beyond its traditional role as an antianginal.
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Affiliation(s)
- Gopal Chandra Ghosh
- Department of Cardiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Raktim Kumar Ghosh
- MetroHealth Medical Center, Case Western Reserve University, Heart and Vascular Institute, Cleveland, OH, USA
| | | | - Krishnarpan Chatterjee
- Department of Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ashish Aneja
- MetroHealth Medical Center, Case Western Reserve University, Heart and Vascular Institute, Cleveland, OH, USA
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Standards for global cardiovascular risk management arteriosclerosis. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2019; 31 Suppl 1:1-43. [PMID: 30981542 DOI: 10.1016/j.arteri.2019.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
One of the main goals of the Spanish Society of Arteriosclerosis is to contribute to a wider and greater knowledge of vascular disease, its prevention and treatment. Cardiovascular diseases are the leading cause of death in our country and also lead to a high degree of disability and health expenditure. Arteriosclerosis is a multifactorial disease, this is why its prevention requires a global approach that takes into account the different risk factors with which it is associated. Thus, this document summarizes the current level of knowledge and integrates recommendations and procedures to be followed for patients with established cardiovascular disease or high vascular risk. Specifically, this document reviews the main symptoms and signs to be evaluated during the clinical visit, the laboratory and imaging procedures to be routinely requested or those in special situations. It also includes the estimation of vascular risk, the diagnostic criteria of the different entities that are cardiovascular risk factors, and presents general and specific recommendations for the treatment of the different cardiovascular risk factors and their final objectives. Finally, the document includes aspects that are not often mentioned in the literature, such as the organisation of a vascular risk consultation.
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Carstensen H, Hesselkilde EZ, Haugaard MM, Flethøj M, Carlson J, Pehrson S, Jespersen T, Platonov PG, Buhl R. Effects of dofetilide and ranolazine on atrial fibrillatory rate in a horse model of acutely induced atrial fibrillation. J Cardiovasc Electrophysiol 2019; 30:596-606. [PMID: 30661267 PMCID: PMC6849868 DOI: 10.1111/jce.13849] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 12/21/2018] [Accepted: 01/04/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The atrial fibrillatory rate is a potential biomarker in the study of antiarrhythmic drug effects on atrial fibrillation (AF). The purpose of this study was to evaluate whether dose-dependent changes in the atrial fibrillatory rate can be monitored on surface electrocardiography (ECG) following treatment with dofetilide, ranolazine, and a combination of the two in an acute model of AF in horses. METHODS AND RESULTS Eight horses were subjected to pacing-induced AF on 4 separate days. Saline (control), dofetilide, ranolazine, or a combination of dofetilide and ranolazine was administered in four incremental doses. Atrial fibrillatory activity was extracted from surface ECGs using spatiotemporal QRST cancellation. The mean atrial fibrillatory rate before drug infusion was 297 ± 27 fpm. Dofetilide reduced the atrial fibrillatory rate following the infusion of low doses (0.89 µg/kg, P < 0.05) and within 5 minutes preceding cardioversion (P < 0.05). Cardioversion with ranolazine was preceded by a reduction in the atrial fibrillatory rate in the last minute (P < 0.05). The combination of drugs reduced the atrial fibrillatory rate in a similar manner to dofetilide used alone. A trend toward a lower atrial fibrillatory rate before drug infusion was found among horses cardioverting on low doses of the drugs. CONCLUSION The atrial fibrillatory rate derived from surface ECGs showed a difference in the mode of action on AF between dofetilide and ranolazine. Dofetilide reduced the atrial fibrillatory rate, whereas ranolazine displayed a cardioverting mechanism that was distinct from a slowing of the fibrillatory process.
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Affiliation(s)
- Helena Carstensen
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Eva Zander Hesselkilde
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Maria Mathilde Haugaard
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Mette Flethøj
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Jonas Carlson
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
| | - Steen Pehrson
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Taastrup, Denmark
| | - Thomas Jespersen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
| | - Pyotr G Platonov
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden.,Arrhythmia Clinic, Skåne University Hospital, Lund, Sweden
| | - Rikke Buhl
- Department of Veterinary Clinical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Taastrup, Denmark
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Antiarrhythmic Effects of Combining Dofetilide and Ranolazine in a Model of Acutely Induced Atrial Fibrillation in Horses. J Cardiovasc Pharmacol 2019; 71:26-35. [PMID: 29068807 PMCID: PMC5768216 DOI: 10.1097/fjc.0000000000000541] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: Antiarrhythmic compounds against atrial fibrillation (AF) often have reduced efficacy and may display cardiac and/or noncardiac toxicity. Efficacy can be improved by combining 2 compounds with distinct mechanisms, and it may be possible to use lower doses of each compound, thereby reducing the likelihood of adverse side effects. The purpose of this study was to investigate whether the effective doses of dofetilide and ranolazine can be reduced if the drugs are combined. Methods: Dofetilide, ranolazine, and a combination of these were administered in 4 incremental dosing regimens to horses with acutely pacing-induced AF. Time to cardioversion, atrial effective refractory period, and AF vulnerability and duration were assessed. Results: Of 8 horses, 6 cardioverted to sinus rhythm after infusion with a combination of 0.889 μg/kg dofetilide and 0.104 mg/kg ranolazine. Two horses cardioverted with 0.104 mg/kg ranolazine alone, and 3 cardioverted with 0.889 μg/kg dofetilide alone. The combination therapy decreased AF vulnerability (P < 0.05) and AF duration (P < 0.05). No change in atrial effective refractory period was detected with any of the drugs. Conclusions: The combination of dofetilide and ranolazine showed increased antiarrhythmic effects on acutely induced AF in horses, affecting time to cardioversion, AF vulnerability, and AF duration.
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Ellermann C, Wolfes J, Puckhaber D, Bögeholz N, Leitz P, Lange PS, Eckardt L, Frommeyer G. Digitalis Promotes Ventricular Arrhythmias in Flecainide- and Ranolazine-Pretreated Hearts. Cardiovasc Toxicol 2018; 19:237-243. [DOI: 10.1007/s12012-018-9494-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Dan GA, Dobrev D. Antiarrhythmic drugs for atrial fibrillation: Imminent impulses are emerging. IJC HEART & VASCULATURE 2018; 21:11-15. [PMID: 30225340 PMCID: PMC6138883 DOI: 10.1016/j.ijcha.2018.08.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/15/2018] [Accepted: 08/30/2018] [Indexed: 12/19/2022]
Abstract
Rhythm and rate strategies are considered equivalent for the management of atrial fibrillation (AF). Moreover, both strategies are intended for improving symptoms and quality of life. Despite the clinical availability of several antiarrhythmic drugs (AAD) the alternatives for the patient with comorbidities are significantly fewer because of the concern regarding many adverse effects, including proarrhythmias. The impetuous development of AF ablation gave rise to a false impression that AAD are a second line therapy. All these statements reflect, in fact, the weakness of the classical paradigm and classification regarding AAD and the gap between the current knowledge of AF mechanism and determinants and the "classical" AAD non-discriminatory action. A new paradigm in development of effective and safe AAD is based on modern knowledge of vulnerable parameters involved in the genesis and perpetuation of AF. New AAD will target specific triggers of AF and ion currents which are expressed preferentially in fibrillatory atrium. Such targets will include repolarizing currents and channels, as ultrarapid potassium current, two pore potassium current, the acetylcholine-gated potassium current, small-conductance calcium-dependent potassium channels, but, also, molecular targets involved in intracellular calcium kinetics, as Ca2+-calmodulin-dependent protein kinase, ryanodine receptors and non-coding miRNA. New mechanistic discoveries link AF to inflammation and modern anti-cytokine drugs. There is still a long way to win between basic research and clinical practice, but, without any doubt, antiarrhythmic drug therapy will remain and develop as a cornerstone therapy for AF not in conflict, but complementary and alternative to interventional therapy.
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Affiliation(s)
- Gheorghe-Andrei Dan
- Carol Davila Medicine University, Bucharest, Romania
- Colentina University Hospital, Bucharest, Romania
| | - Dobromir Dobrev
- Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany
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Sicouri S, Belardinelli L, Antzelevitch C. Effect of autonomic influences to induce triggered activity in muscular sleeves extending into the coronary sinus of the canine heart and its suppression by ranolazine. J Cardiovasc Electrophysiol 2018; 30:230-238. [PMID: 30302862 DOI: 10.1111/jce.13770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 10/01/2018] [Accepted: 10/05/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Extrasystoles arising from the muscular sleeves associated with the pulmonary veins (PV), superior vena cava (SVC), and coronary sinus (CS) are known to precipitate atrial fibrillation (AF). The late sodium channel current (INa ) inhibitor ranolazine has been reported to exert antiarrhythmic effects in canine PV and SVC sleeves by suppressing late phase 3 early and delayed after depolarization (EAD and DAD)-induced triggered activity induced by parasympathetic and/or sympathetic stimulation. The current study was designed to extend our existing knowledge of the electrophysiological and pharmacologic properties of canine CS preparations and assess their response to inhibition of late INa following autonomic stimulation. METHODS Transmembrane action potentials were recorded from canine superfused CS using standard microelectrode techniques. Acetylcholine (ACh, 1 µM), isoproterenol (Iso, 1 µM), high calcium ([Ca2+ ]o = 5.4 mM), or a combination were used to induce EADs, DADs, and triggered activity. RESULTS Action potentials (AP) recorded from the CS displayed short and long AP durations (APD), with and without phase 4 depolarization (n = 19). Iso induced DAD-mediated triggered activity. The combination of sympathetic and parasympathetic agonists resulted in late phase 3 EAD-induced triggered activity in all CS preparations. Ranolazine (5-10 µM) suppressed late phase 3 EAD- and DAD-induced triggered activity in 8 of 8 preparations. Subthreshold stimulation induced a prominent hyperpolarization that could be suppressed by atropine. CONCLUSIONS Our results suggest the important role of parasympathetic innervation in the activity of the CS. Autonomic influences promote DAD- and late phase-3-EAD-mediated triggered activity in canine CS, thus generating extrasystolic activity capable of initiating atrial arrhythmias. Ranolazine effectively suppresses these triggers.
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Affiliation(s)
- Serge Sicouri
- Department of Experimental Cardiology, Masonic Medical Research Laboratory, Utica, New York.,Cardiovascular Research Program, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania
| | | | - Charles Antzelevitch
- Department of Experimental Cardiology, Masonic Medical Research Laboratory, Utica, New York.,Cardiovascular Research Program, Lankenau Institute for Medical Research, Wynnewood, Pennsylvania.,Lankenau Heart Institute, Wynnewood, Pennsylvania.,Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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