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Pinheiro FO, Martins Carvalho M, Madureira P, Seabra Rato M, Macedo F, Costa L. Possible relationship between hydroxychloroquine and electrocardiographic and echocardiographic abnormalities in patients with inflammatory rheumatic diseases--a monocentric study. Lupus 2023; 32:388-393. [PMID: 36598483 DOI: 10.1177/09612033221149875] [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: 01/05/2023]
Abstract
OBJECTIVE Hydroxychloroquine (HCQ) is used in the treatment of inflammatory rheumatic diseases and is considered a safe drug. The role of HCQ in the COVID-19 pandemic highlighted some deleterious cardiac effects of HCQ. We aim to evaluate the prevalence and development of cardiac-adverse events in HCQ-treated patients with inflammatory rheumatic diseases. METHODS We performed a cross-sectional study where patients aged ≥18 years with a diagnosis of inflammatory rheumatic disease currently exposed or not to hydroxychloroquine underwent electrocardiogram (ECG) and echocardiogram. Comparisons between groups were evaluated using chi-square, t test, and Mann-Whitney U test. Logistic regression was performed to determine predictors of changes in ECG and echocardiography. RESULTS Eighty patients were included, 75 (93.8%) female, aged 52 ± 13 years. ECG changes were seen in higher proportion in patients with hypertension (40.6% vs 12.5%, p = .004) and higher median potassium levels-4.5 (4.1-4.8) versus 4.2 (4.0-4.4), p = .023. Echocardiography changes were seen in older patients (59 ± 11 vs 50 ± 13 years, p = .003) and in patients with higher cumulative dose-1752 (785-2190) versus 438 (328-1022) g, p = 0.008 - and time of exposure to HCQ - 12 (6-15) versus 4 (2-9) years, p = 0.028. HCQ cumulative dose (OR 1.001, CI95% 1.000-1.002, p = .033) and exposure time (OR 1.136, CI95% 1.000-1.289, p = .049) were predictors of echocardiography changes, but when adjusted for age, neither HCQ cumulative dose nor exposure time were predictors of echocardiography changes. CONCLUSION No association was found between changes in ECG and echocardiogram in patients under HCQ, which remains a safe drug in patients with inflammatory rheumatic diseases.
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Affiliation(s)
- Filipe Oliveira Pinheiro
- Rheumatology Department, 285211Centro Hospitalar Universitário de São João, Porto, Portugal.,Medicine Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Miguel Martins Carvalho
- Medicine Department, Faculty of Medicine, University of Porto, Porto, Portugal.,Cardiology Department, 285211Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Pedro Madureira
- Rheumatology Department, 285211Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Maria Seabra Rato
- Rheumatology Department, 285211Centro Hospitalar Universitário de São João, Porto, Portugal.,Medicine Department, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Filipe Macedo
- Cardiology Department, 285211Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Lúcia Costa
- Rheumatology Department, 285211Centro Hospitalar Universitário de São João, Porto, Portugal
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2
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Liu L, Jing H, Wu X, Xiang M, Novakovic VA, Wang S, Shi J. The cross-talk of lung and heart complications in COVID-19: Endothelial cells dysfunction, thrombosis, and treatment. Front Cardiovasc Med 2022; 9:957006. [PMID: 35990983 PMCID: PMC9390946 DOI: 10.3389/fcvm.2022.957006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/11/2022] [Indexed: 01/08/2023] Open
Abstract
The pandemic respiratory illness SARS-CoV-2 has increasingly been shown to be a systemic disease that can also have profound impacts on the cardiovascular system. Although associated cardiopulmonary sequelae can persist after infection, the link between viral infection and these complications remains unclear. There is now a recognized link between endothelial cell dysfunction and thrombosis. Its role in stimulating platelet activation and thrombotic inflammation has been widely reported. However, the procoagulant role of microparticles (MPs) in COVID-19 seems to have been neglected. As membrane vesicles released after cell injury or apoptosis, MPs exert procoagulant activity mainly by exposing phosphatidylserine (PS) on their lipid membranes. It can provide a catalytic surface for the assembly of the prothrombinase complex. Therefore, inhibiting PS externalization is a potential therapeutic strategy. In this paper, we describe the pathophysiological mechanism by which SARS-CoV-2 induces lung and heart complications through injury of endothelial cells, emphasizing the procoagulant effect of MPs and PS, and demonstrate the importance of early antithrombotic therapy. In addition, we will detail the mechanisms underlying hypoxia, another serious pulmonary complication related to SARS-CoV-2-induced endothelial cells injury and discuss the use of oxygen therapy. In the case of SARS-CoV-2 infection, virus invades endothelial cells through direct infection, hypoxia, imbalance of the RAAS, and cytokine storm. These factors cause endothelial cells to release MPs, form MPs storm, and eventually lead to thrombosis. This, in turn, accelerates hypoxia and cytokine storms, forming a positive feedback loop. Given the important role of thrombosis in the disease, early antithrombotic therapy is an important tool for COVID-19. It may maintain normal blood circulation, accelerating the clearance of viruses, waning the formation of MPs storm, and avoiding disease progression.
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Affiliation(s)
- Langjiao Liu
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Haijiao Jing
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Xiaoming Wu
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Mengqi Xiang
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
| | - Valerie A. Novakovic
- Department of Research, VA Boston Healthcare System, Harvard Medical School, Boston, MA, United States
| | - Shuye Wang
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
- Shuye Wang
| | - Jialan Shi
- Department of Hematology, First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, China
- Department of Research, VA Boston Healthcare System, Harvard Medical School, Boston, MA, United States
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, United States
- *Correspondence: Jialan Shi ;
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Safety of Short-Term Treatments with Oral Chloroquine and Hydroxychloroquine in Patients with and without COVID-19: A Systematic Review. Pharmaceuticals (Basel) 2022; 15:ph15050634. [PMID: 35631460 PMCID: PMC9144263 DOI: 10.3390/ph15050634] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/27/2022] [Accepted: 05/13/2022] [Indexed: 01/09/2023] Open
Abstract
Chloroquine (CQ) and hydroxychloroquine (HCQ) have recently become the focus of global attention as possible treatments for Coronavirus Disease 2019 (COVID-19). The current systematic review aims to assess their safety in short treatments (≤14 days), whether used alone or in combination with other drugs. Following the PRISMA and SWiM recommendations, a search was conducted using four health databases for all relevant English-, Chinese-, and Spanish-language studies from inception through 30 July 2021. Patients treated for any condition and with any comparator were included. The outcomes of interest were early drug adverse effects and their frequency. A total of 254 articles met the inclusion criteria, including case and case-control reports as well as cross-sectional, cohort, and randomised studies. The results were summarised either qualitatively in table or narrative form or, when possible (99 studies), quantitatively in terms of adverse event frequencies. Quality evaluation was conducted using the CARE, STROBE, and JADAD tools. This systematic review showed that safety depended on drug indication. In COVID-19 patients, cardiac adverse effects, such as corrected QT interval prolongation, were relatively frequent (0–27.3% and up to 33% if combined with azithromycin), though the risk of torsade de pointes was low. Compared to non-COVID-19 patients, COVID-19 patients experienced a higher frequency of cardiac adverse effects regardless of the regimen used. Dermatological adverse effects affected 0–10% of patients with autoimmune diseases and COVID-19. A broad spectrum of neuropsychiatric adverse effects affected patients treated with CQ for malaria with variable frequencies and some cases were reported in COVID-19 patients. Gastrointestinal adverse effects occurred regardless of drug indication affecting 0–50% of patients. In conclusion, CQ and HCQ are two safe drugs widely used in the treatment of malaria and autoimmune diseases. However, recent findings on their cardiac and neuropsychiatric adverse effects should be considered if these drugs were to be proposed as antivirals again.
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4
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Ballet V, Bohme GA, Brohan E, Boukaiba R, Chambard JM, Angouillant-Boniface O, Carriot T, Chantoiseau C, Fouconnier S, Houtmann S, Prévost C, Schombert B, Schio L, Partiseti M. In vitro ion channel profile and ex vivo cardiac electrophysiology properties of the R(-) and S(+) enantiomers of hydroxychloroquine. Eur J Pharmacol 2022; 915:174670. [PMID: 34863995 DOI: 10.1016/j.ejphar.2021.174670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/01/2021] [Accepted: 12/01/2021] [Indexed: 11/03/2022]
Abstract
Hydroxychloroquine (HCQ) is a derivative of the antimalaria drug chloroquine primarily prescribed for autoimmune diseases. Recent attempts to repurpose HCQ in the treatment of corona virus disease 2019 has raised concerns because of its propensity to prolong the QT-segment on the electrocardiogram, an effect associated with increased pro-arrhythmic risk. Since chirality can affect drug pharmacological properties, we have evaluated the functional effects of the R(-) and S(+) enantiomers of HCQ on six ion channels contributing to the cardiac action potential and on electrophysiological parameters of isolated Purkinje fibers. We found that R(-)HCQ and S(+)HCQ block human Kir2.1 and hERG potassium channels in the 1 μM-100 μM range with a 2-4 fold enantiomeric separation. NaV1.5 sodium currents and CaV1.2 calcium currents, as well as KV4.3 and KV7.1 potassium currents remained unaffected at up to 90 μM. In rabbit Purkinje fibers, R(-)HCQ prominently depolarized the membrane resting potential, inducing autogenic activity at 10 μM and 30 μM, while S(+)HCQ primarily increased the action potential duration, inducing occasional early afterdepolarization at these concentrations. These data suggest that both enantiomers of HCQ can alter cardiac tissue electrophysiology at concentrations above their plasmatic levels at therapeutic doses, and that chirality does not substantially influence their arrhythmogenic potential in vitro.
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Affiliation(s)
- Véronique Ballet
- Preclinical Safety Investigative Toxicology, Sanofi-Aventis R&D, Chilly-Mazarin, France
| | - G Andrees Bohme
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, Vitry-sur-Seine, France.
| | - Eric Brohan
- Early Development, Advanced Preparative Chromatography, Sanofi-Aventis R&D, Vitry-sur-Seine, France
| | - Rachid Boukaiba
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, Vitry-sur-Seine, France
| | - Jean-Marie Chambard
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, Vitry-sur-Seine, France
| | | | - Thierry Carriot
- Preclinical Safety Investigative Toxicology, Sanofi-Aventis R&D, Chilly-Mazarin, France
| | - Céline Chantoiseau
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, Vitry-sur-Seine, France
| | - Sophie Fouconnier
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, Vitry-sur-Seine, France
| | - Sylvie Houtmann
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, Vitry-sur-Seine, France
| | - Céline Prévost
- Early Development, Advanced Preparative Chromatography, Sanofi-Aventis R&D, Vitry-sur-Seine, France
| | - Brigitte Schombert
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, Vitry-sur-Seine, France
| | - Laurent Schio
- Integrated Drug Discovery, Sanofi-Aventis R&D, Vitry-sur-Seine, France
| | - Michel Partiseti
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, Vitry-sur-Seine, France
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5
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Pandat S, Zhu Z, Fuentes-Rojas S, Schurmann P. Arrhythmias in COVID-19. Methodist Debakey Cardiovasc J 2021; 17:73-82. [PMID: 34992725 PMCID: PMC8679991 DOI: 10.14797/mdcvj.1039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 09/17/2021] [Indexed: 12/15/2022] Open
Abstract
The coronavirus pandemic remains a major public health burden with multisystem disease manifestations. There has been an ongoing global effort to better understand the unique cardiovascular manifestations of this disease and its associated arrhythmias. In this review, we summarize the current data on incidence and outcomes of arrhythmias in the acute and convalescent period, possible pathophysiologic mechanisms, and medical management. Sinus bradycardia-reported in multiple observational studies in the acute infectious period-stands out as an unexpected inflammatory response. Atrial fibrillation has been noted as the most common pathologic arrhythmia and has been shown to be a poor prognostic marker in multiple cohorts. In the convalescent period, long-term complications such as postural orthostatic tachycardia syndrome and inappropriate sinus tachycardia have been described.
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Affiliation(s)
- Summit Pandat
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Zhihao Zhu
- Houston Methodist Hospital, Houston, Texas, US
| | - Stephanie Fuentes-Rojas
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Paul Schurmann
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
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6
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Schiavone M, Gasperetti A, Gherbesi E, Bergamaschi L, Arosio R, Mitacchione G, Viecca M, Forleo GB. Arrhythmogenic Risk and Mechanisms of QT-Prolonging Drugs to Treat COVID-19. Card Electrophysiol Clin 2021; 14:95-104. [PMID: 35221089 PMCID: PMC8556572 DOI: 10.1016/j.ccep.2021.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Marco Schiavone
- Cardiology Unit, Luigi Sacco University Hospital, Milan, Italy.
| | - Alessio Gasperetti
- Cardiology Unit, Luigi Sacco University Hospital, Milan, Italy; Division of Cardiology, Johns Hopkins University, Baltimore, MD, USA
| | - Elisa Gherbesi
- Cardiology Unit, Luigi Sacco University Hospital, Milan, Italy
| | | | - Roberto Arosio
- Cardiology Unit, Luigi Sacco University Hospital, Milan, Italy
| | | | - Maurizio Viecca
- Cardiology Unit, Luigi Sacco University Hospital, Milan, Italy
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7
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Sacilotto L, Olivetti NQS, Pisani CF, Wu TC, Hajjar LA, Melo SLD, Bueno SCP, Rivarola EWR, Chokr MO, Hardy CA, Hachul DT, Darrieux FCDC, Scanavacca MI. Peculiar Aspects of Patients with Inherited Arrhythmias during the COVID-19 Pandemic. Arq Bras Cardiol 2021; 117:394-403. [PMID: 34495239 PMCID: PMC8395786 DOI: 10.36660/abc.20200391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 11/25/2020] [Indexed: 11/22/2022] Open
Abstract
Desde dezembro de 2019, observamos o rápido avanço da síndrome respiratória aguda grave causada pelo coronavírus 2019 (SARS-CoV-2). O impacto da evolução clínica de uma infecção respiratória é pouco conhecido em pacientes portadores de arritmias hereditárias, devido à baixa prevalência dessas doenças. Os pacientes que apresentam quadros infecciosos podem exacerbar arritmias primárias ocultas ou bem controladas, por diversos fatores, tais como febre, distúrbios eletrolíticos, interações medicamentosas, estresse adrenérgico e, eventualmente, o próprio dano miocárdico do paciente séptico. O objetivo desta revisão é destacar os principais desafios que podemos encontrar durante a pandemia pela Covid 19, especificamente nos pacientes com arritmias hereditárias, com destaque para a síndrome do QT longo congênito (SQTL), a síndrome de Brugada (SBr), a taquicardia ventricular polimórfica catecolaminérgica (TVPC) e a cardiomiopatia arritmogênica do ventrículo direito.
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Affiliation(s)
- Luciana Sacilotto
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Cristiano Faria Pisani
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Tan Chen Wu
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Ludhmila Abrahão Hajjar
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Sissy Lara de Melo
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Sávia Christina Pereira Bueno
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Muhieddine Omar Chokr
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Carina Abigail Hardy
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | - Denise Tessariol Hachul
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
| | | | - Mauricio Ibrahim Scanavacca
- Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP - Brasil
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8
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Thakore A, Nguyen J, Pollack S, Muehlbauer S, Chi B, Knight D, Mehrotra B, Stern J, Cao JJ, Lucore C, Levine J. Electrocardiographic manifestations of COVID-19: Effect on cardiac activation and repolarization. EClinicalMedicine 2021; 39:101057. [PMID: 34377967 PMCID: PMC8343356 DOI: 10.1016/j.eclinm.2021.101057] [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: 02/28/2021] [Revised: 07/12/2021] [Accepted: 07/15/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Prolonged QT intervals are reported in patients with COVID-19. Additionally, virus particles in heart tissue and abnormal troponin levels have been reported. Consequently, we hypothesize that cardiac electrophysiologic abnormalities may be associated with COVID-19. METHODS This is a retrospective study between March 15th, 2020 and May 30th, 2020 of 828 patients with COVID-19 and baseline ECG. Corrected QT (QTc) and QRS intervals were measured from ECGs performed prior to intervention or administration of QT prolonging drugs. QTc and QRS intervals were evaluated as a function of disease severity (patients admitted versus discharged; inpatients admitted to medical unit vs ICU) and cardiac involvement (troponin elevation >0.03 ng/ml, elevated B-natriuretic peptide (BNP) or NT pro-BNP >500 pg/ml). Multivariable analysis was used to test for significance. Odds ratios for predictors of disease severity and mortality were generated. FINDINGS Baseline QTc of inpatients was prolonged compared to patients discharged (450.1±30.2 versus 423.4±21.7 msec, p<0.0001) and relative to a control group of patients with influenza (p=0.006). Inpatients with abnormal cardiac biomarkers had prolonged QTc and QRS compared to those with normal levels (troponin - QTc: 460.9±34.6 versus 445.3±26.6 msec, p<0.0001, QRS: 98.7±24.6 vs 90.5±16.9 msec, p<0.0001; BNP - QTc: 465.9±33.0 versus 446.0±26.2 msec, p<0.0001, QRS: 103.6±25.3 versus 90.6±17.6 msec, p<0.0001). Findings were confirmed with multivariable analysis (all p<0.05). QTc prolongation independently predicted mortality (8.3% increase in mortality for every 10 msec increase in QTc; OR 1.083, CI [1.002, 1.171], p=0.04). INTERPRETATION QRS and QTc intervals are early markers for COVID-19 disease progression and mortality. ECG, a readily accessible tool, identifies cardiac involvement and may be used to predict disease course. FUNDING St. Francis Foundation.
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Affiliation(s)
- Avni Thakore
- Department of Cardiology and Research, St. Francis Hospital, The Heart Center – 100 Port Washington Blvd, Roslyn, New York 11576, United States
- Corresponding author.
| | - James Nguyen
- Department of Cardiology and Research, St. Francis Hospital, The Heart Center – 100 Port Washington Blvd, Roslyn, New York 11576, United States
| | - Simcha Pollack
- Department of Cardiology and Research, St. Francis Hospital, The Heart Center – 100 Port Washington Blvd, Roslyn, New York 11576, United States
| | - Stefan Muehlbauer
- Department of Emergency Medicine, St. Francis Hospital, The Heart Center –100 Port Washington Blvd, Roslyn, New York 11576, United States
| | - Benjamin Chi
- Department of Cardiology and Research, St. Francis Hospital, The Heart Center – 100 Port Washington Blvd, Roslyn, New York 11576, United States
| | - Derek Knight
- Department of Cardiology and Research, St. Francis Hospital, The Heart Center – 100 Port Washington Blvd, Roslyn, New York 11576, United States
| | - Bhoomi Mehrotra
- Department of Hematology and Oncology, St. Francis Hospital, The Heart Center – 100 Port Washington Blvd, Roslyn , New York 11576, United States
| | - Joshua Stern
- Department of Cardiology and Research, St. Francis Hospital, The Heart Center – 100 Port Washington Blvd, Roslyn, New York 11576, United States
| | - J. Jane Cao
- Department of Cardiology and Research, St. Francis Hospital, The Heart Center – 100 Port Washington Blvd, Roslyn, New York 11576, United States
| | - Charles Lucore
- Department of Cardiology and Research, St. Francis Hospital, The Heart Center – 100 Port Washington Blvd, Roslyn, New York 11576, United States
| | - Joseph Levine
- Department of Cardiology and Research, St. Francis Hospital, The Heart Center – 100 Port Washington Blvd, Roslyn, New York 11576, United States
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9
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Gulletta S, Della Bella P, Pannone L, Falasconi G, Cianfanelli L, Altizio S, Cinel E, Da Prat V, Napolano A, D'Angelo G, Brugliera L, Agricola E, Landoni G, Tresoldi M, Rovere PQ, Ciceri F, Zangrillo A, Vergara P. QTc interval prolongation, inflammation, and mortality in patients with COVID-19. J Interv Card Electrophysiol 2021; 63:441-448. [PMID: 34291390 PMCID: PMC8295006 DOI: 10.1007/s10840-021-01033-8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/05/2021] [Indexed: 01/08/2023]
Abstract
Purpose Systemic inflammation has been associated with corrected QT (QTc) interval prolongation. The role of inflammation on QTc prolongation in COVID-19 patients was investigated. Methods Patients with a laboratory-confirmed SARS-CoV-2 infection admitted to IRCCS San Raffaele Scientific Institute (Milan, Italy) between March 14, 2020, and March 30, 2020 were included. QTc-I was defined as the QTc interval by Bazett formula in the first ECG performed during the hospitalization, before any new drug treatment; QTc-II was the QTc in the ECG performed after the initiation of hydroxychloroquine drug treatment. Results QTc-I was long in 45 patients (45%) and normal in 55 patients (55%). Patients with long QTc-I were older and more frequently males. C-Reactive protein (CRP) and white blood cell (WBC) count at hospitalization were higher in patients with long QTc-I and long QTc-II. QTc-I was significantly correlated with CRP levels at hospitalization. After a median follow-up of 83 days, 14 patients (14%) died. There were no deaths attributed to ventricular arrhythmias. Patients with long QTc-I and long QTc-II had a shorter survival, compared with normal QTc-I and QTc-II patients, respectively. In Cox multivariate analysis, independent predictors of mortality were age (HR = 1.1, CI 95% 1.04–1.18, p = 0.002) and CRP at ECG II (HR 1.1, CI 95% 1.0–1.1, p = 0.02). Conclusions QTc at hospitalization is a simple risk marker of mortality risk in COVID-19 patients and reflects the myocardial inflammatory status.
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Affiliation(s)
- Simone Gulletta
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della Bella
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Pannone
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giulio Falasconi
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Lorenzo Cianfanelli
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Savino Altizio
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Elena Cinel
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Valentina Da Prat
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Napolano
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy
| | - Giuseppe D'Angelo
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigia Brugliera
- Department of Rehabilitation and Functional Recovery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.,Cardiac Imaging Unit, Cardio-Thoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.,Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Moreno Tresoldi
- Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrizia Querini Rovere
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.,Division of Immunology, Transplantation and Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.,Department of Hematology and Stem Cell Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- IRCCS San Raffaele Scientific Institute, Vita-Salute University, Milan, Italy.,Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pasquale Vergara
- Arrhythmia Unit and Electrophysiology Laboratories, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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10
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Montnach J, Baró I, Charpentier F, De Waard M, Loussouarn G. Modelling sudden cardiac death risks factors in patients with coronavirus disease of 2019: the hydroxychloroquine and azithromycin case. Europace 2021; 23:1124-1133. [PMID: 34009333 PMCID: PMC8135857 DOI: 10.1093/europace/euab043] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 02/16/2021] [Indexed: 12/23/2022] Open
Abstract
AIMS Coronavirus disease of 2019 (COVID-19) has rapidly become a worldwide pandemic. Many clinical trials have been initiated to fight the disease. Among those, hydroxychloroquine and azithromycin had initially been suggested to improve clinical outcomes. Despite any demonstrated beneficial effects, they are still in use in some countries but have been reported to prolong the QT interval and induce life-threatening arrhythmia. Since a significant proportion of the world population may be treated with such COVID-19 therapies, evaluation of the arrhythmogenic risk of any candidate drug is needed. METHODS AND RESULTS Using the O'Hara-Rudy computer model of human ventricular wedge, we evaluate the arrhythmogenic potential of clinical factors that can further alter repolarization in COVID-19 patients in addition to hydroxychloroquine (HCQ) and azithromycin (AZM) such as tachycardia, hypokalaemia, and subclinical to mild long QT syndrome. Hydroxychloroquine and AZM drugs have little impact on QT duration and do not induce any substrate prone to arrhythmia in COVID-19 patients with normal cardiac repolarization reserve. Nevertheless, in every tested condition in which this reserve is reduced, the model predicts larger electrocardiogram impairments, as with dofetilide. In subclinical conditions, the model suggests that mexiletine limits the deleterious effects of AZM and HCQ. CONCLUSION By studying the HCQ and AZM co-administration case, we show that the easy-to-use O'Hara-Rudy model can be applied to assess the QT-prolongation potential of off-label drugs, beyond HCQ and AZM, in different conditions representative of COVID-19 patients and to evaluate the potential impact of additional drug used to limit the arrhythmogenic risk.
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Affiliation(s)
- Jérôme Montnach
- Université de Nantes, CNRS, INSERM, l’institut du thorax, Nantes F-44000, France
| | - Isabelle Baró
- Université de Nantes, CNRS, INSERM, l’institut du thorax, Nantes F-44000, France
| | - Flavien Charpentier
- Université de Nantes, CNRS, INSERM, l’institut du thorax, Nantes F-44000, France
| | - Michel De Waard
- Université de Nantes, CNRS, INSERM, l’institut du thorax, Nantes F-44000, France
- Laboratory of Excellence, Ion Channels, Science & Therapeutics, Valbonne F-06560, France
| | - Gildas Loussouarn
- Université de Nantes, CNRS, INSERM, l’institut du thorax, Nantes F-44000, France
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11
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Negri S, Faris P, Moccia F. Endolysosomal Ca 2+ signaling in cardiovascular health and disease. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2021; 363:203-269. [PMID: 34392930 DOI: 10.1016/bs.ircmb.2021.03.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
An increase in intracellular Ca2+ concentration ([Ca2+]i) regulates a plethora of functions in the cardiovascular (CV) system, including contraction in cardiomyocytes and vascular smooth muscle cells (VSMCs), and angiogenesis in vascular endothelial cells and endothelial colony forming cells. The sarco/endoplasmic reticulum (SR/ER) represents the largest endogenous Ca2+ store, which releases Ca2+ through ryanodine receptors (RyRs) and/or inositol-1,4,5-trisphosphate receptors (InsP3Rs) upon extracellular stimulation. The acidic vesicles of the endolysosomal (EL) compartment represent an additional endogenous Ca2+ store, which is targeted by several second messengers, including nicotinic acid adenine dinucleotide phosphate (NAADP) and phosphatidylinositol 3,5-bisphosphate [PI(3,5)P2], and may release intraluminal Ca2+ through multiple Ca2+ permeable channels, including two-pore channels 1 and 2 (TPC1-2) and Transient Receptor Potential Mucolipin 1 (TRPML1). Herein, we discuss the emerging, pathophysiological role of EL Ca2+ signaling in the CV system. We describe the role of cardiac TPCs in β-adrenoceptor stimulation, arrhythmia, hypertrophy, and ischemia-reperfusion injury. We then illustrate the role of EL Ca2+ signaling in VSMCs, where TPCs promote vasoconstriction and contribute to pulmonary artery hypertension and atherosclerosis, whereas TRPML1 sustains vasodilation and is also involved in atherosclerosis. Subsequently, we describe the mechanisms whereby endothelial TPCs promote vasodilation, contribute to neurovascular coupling in the brain and stimulate angiogenesis and vasculogenesis. Finally, we discuss about the possibility to target TPCs, which are likely to mediate CV cell infection by the Severe Acute Respiratory Disease-Coronavirus-2, with Food and Drug Administration-approved drugs to alleviate the detrimental effects of Coronavirus Disease-19 on the CV system.
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Affiliation(s)
- Sharon Negri
- Laboratory of Physiology, Department of Biology and Biotechnology "Lazzaro Spallanzani", University of Pavia, Pavia, Italy
| | - Pawan Faris
- Laboratory of Physiology, Department of Biology and Biotechnology "Lazzaro Spallanzani", University of Pavia, Pavia, Italy
| | - Francesco Moccia
- Laboratory of Physiology, Department of Biology and Biotechnology "Lazzaro Spallanzani", University of Pavia, Pavia, Italy.
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12
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Diaz-Arocutipa C, Brañez-Condorena A, Hernandez AV. QTc prolongation in COVID-19 patients treated with hydroxychloroquine, chloroquine, azithromycin, or lopinavir/ritonavir: A systematic review and meta-analysis. Pharmacoepidemiol Drug Saf 2021; 30:694-706. [PMID: 33772933 PMCID: PMC8251490 DOI: 10.1002/pds.5234] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 02/06/2023]
Abstract
Purpose Hydroxychloroquine, chloroquine, azithromycin, and lopinavir/ritonavir are drugs that were used for the treatment of coronavirus disease 2019 (COVID‐19) during the early pandemic period. It is well‐known that these agents can prolong the QTc interval and potentially induce Torsades de Pointes (TdP). We aim to assess the prevalence and risk of QTc prolongation and arrhythmic events in COVID‐19 patients treated with these drugs. Methods We searched electronic databases from inception to September 30, 2020 for studies reporting peak QTc ≥500 ms, peak QTc change ≥60 ms, peak QTc interval, peak change of QTc interval, ventricular arrhythmias, TdP, sudden cardiac death, or atrioventricular block (AVB). All meta‐analyses were conducted using a random‐effects model. Results Forty‐seven studies (three case series, 35 cohorts, and nine randomized controlled trials [RCTs]) involving 13 087 patients were included. The pooled prevalence of peak QTc ≥500 ms was 9% (95% confidence interval [95%CI], 3%–18%) and 8% (95%CI, 3%–14%) in patients who received hydroxychloroquine/chloroquine alone or in combination with azithromycin, respectively. Likewise, the use of hydroxychloroquine (risk ratio [RR], 2.68; 95%CI, 1.56–4.60) and hydroxychloroquine + azithromycin (RR, 3.28; 95%CI, 1.16–9.30) was associated with an increased risk of QTc prolongation compared to no treatment. Ventricular arrhythmias, TdP, sudden cardiac death, and AVB were reported in <1% of patients across treatment groups. The only two studies that reported individual data of lopinavir/ritonavir found no cases of QTc prolongation. Conclusions COVID‐19 patients treated with hydroxychloroquine/chloroquine with or without azithromycin had a relatively high prevalence and risk of QTc prolongation. However, the prevalence of arrhythmic events was very low, probably due to underreporting. The limited information about lopinavir/ritonavir showed that it does not prolong the QTc interval.
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Affiliation(s)
- Carlos Diaz-Arocutipa
- Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Peru.,Programa de Atención Domiciliaria - EsSalud, Lima, Peru.,Asociación para el Desarrollo de la Investigación Estudiantil en Ciencias de la Salud (ADIECS), Lima, Peru
| | - Ana Brañez-Condorena
- Asociación para el Desarrollo de la Investigación Estudiantil en Ciencias de la Salud (ADIECS), Lima, Peru.,Facultad de Medicina de San Fernando, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Adrian V Hernandez
- Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Peru.,Health Outcomes, Policy, and Evidence Synthesis (HOPES) Group, University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
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13
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Umbrajkar S, Stankowski RV, Rezkalla S, Kloner RA. Cardiovascular Health and Disease in the Context of COVID-19. Cardiol Res 2021; 12:67-79. [PMID: 33738009 PMCID: PMC7935632 DOI: 10.14740/cr1199] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 12/17/2020] [Indexed: 02/06/2023] Open
Abstract
First documented in China in early December 2019, the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spread rapidly and continues to test the strength of healthcare systems and public health programs all over the world. Underlying cardiovascular disease has been recognized as a risk factor for coronavirus disease 2019 (COVID-19)-related morbidity and mortality since the early days of the pandemic. In addition, evidence demonstrates cardiac and endothelial damage in somewhere between one-third and three-quarters of individuals with COVID-19, regardless of symptom severity. This damage is thought to be mediated by direct viral infection, immunopathology and hypoxemia with the additional possibility of exacerbation via medication-induced cardiotoxicity. Clinically, the cardiovascular consequences of COVID-19 may present as myocarditis with or without arrhythmia, endothelial dysfunction and thrombosis, acute coronary syndromes and heart failure. Presentation can vary widely and may or may not be typical of the condition in an individual without COVID-19. There is evidence to support the prognostic utility of cardiac biomarkers (e.g., cardiac troponin) and imaging studies (e.g., echocardiography, cardiac magnetic resonance imaging) in the context of COVID-19 and building evidence suggests that cardiovascular screening may be warranted even among those with asymptomatic or mild infection and those without traditional cardiovascular risk factors. In addition, evidence suggests the potential for long-term cardiovascular consequences for those who recover from COVID-19 with implications for the field of cardiology long into the future. Even among those without COVID-19, disruption of infrastructure and changes in human behavior as a result of the pandemic also have an upstream role in cardiovascular outcomes, which have already been documented in multiple locations. This review summarizes what is currently known regarding the pathogenic mechanisms of COVID-19-related cardiovascular injury and describes clinical cardiovascular presentations, prognostic indicators, recommendations for screening and treatment, and long-term cardiovascular consequences of infection. Ultimately, medical personnel must be vigilant in their attention to possible cardiovascular symptoms, take appropriate steps for clinical diagnosis and be prepared for long-term ramifications of myocardial injury sustained as a result of COVID-19.
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Affiliation(s)
- Sidhant Umbrajkar
- University of California, Los Angeles (UCLA), 10833 Le Conte Ave., Los Angeles, CA 90095, USA.,Huntington Medical Research Institutes, 686 South Fair Oaks Ave., Pasadena, CA 91105, USA
| | - Rachel V Stankowski
- Family Health Center of Marshfield, Inc., Marshfield Clinic Health System, 1000 N Oak Ave., Marshfield, WI 54449, USA
| | - Shereif Rezkalla
- Department of Cardiology, Marshfield Medical Center, 1000 N Oak Ave., Marshfield, WI 54449, USA
| | - Robert A Kloner
- Huntington Medical Research Institutes, 686 South Fair Oaks Ave., Pasadena, CA 91105, USA.,Keck School of Medicine of the University of Southern California, 1975 Zonal Ave., Los Angeles, CA 90033, USA
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14
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Moccia F, Negri S, Faris P, Perna A, De Luca A, Soda T, Berra-Romani R, Guerra G. Targeting Endolysosomal Two-Pore Channels to Treat Cardiovascular Disorders in the Novel COronaVIrus Disease 2019. Front Physiol 2021; 12:629119. [PMID: 33574769 PMCID: PMC7870486 DOI: 10.3389/fphys.2021.629119] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/07/2021] [Indexed: 12/15/2022] Open
Abstract
Emerging evidence hints in favor of a life-threatening link between severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) and the cardiovascular system. SARS-CoV-2 may result in dramatic cardiovascular complications, whereas the severity of COronaVIrus Disease 2019 (COVID-19) and the incidence of fatalities tend to increase in patients with pre-existing cardiovascular complications. SARS-CoV-2 is internalized into the host cells by endocytosis and may then escape the endolysosomal system via endosomes. Two-pore channels drive endolysosomal trafficking through the release of endolysosomal Ca2+. Recent evidence suggested that the pharmacological inhibition of TPCs prevents Ebola virus and Middle East Respiratory Syndrome COronaVirus (MERS-CoV) entry into host cells. In this perspective, we briefly summarize the biophysical and pharmacological features of TPCs, illustrate their emerging role in the cardiovascular system, and finally present them as a reliable target to treat cardiovascular complications in COVID-19 patients.
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Affiliation(s)
- Francesco Moccia
- Laboratory of General Physiology, Department of Biology and Biotechnology “L. Spallanzani”, University of Pavia, Pavia, Italy
| | - Sharon Negri
- Laboratory of General Physiology, Department of Biology and Biotechnology “L. Spallanzani”, University of Pavia, Pavia, Italy
| | - Pawan Faris
- Laboratory of General Physiology, Department of Biology and Biotechnology “L. Spallanzani”, University of Pavia, Pavia, Italy
| | - Angelica Perna
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, Campobasso, Italy
| | - Antonio De Luca
- Section of Human Anatomy, Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Teresa Soda
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Roberto Berra-Romani
- School of Medicine, Department of Biomedicine, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
| | - Germano Guerra
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, Campobasso, Italy
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15
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Abstract
The first cases of coronavirus disease 2019 (COVID-19) in Iran were detected on February 19, 2020. Soon the entire country was hit with the virus. Although dermatologists were not immediately the frontline health care workers, all aspects of their practice were drastically affected. Adapting to this unprecedented crisis required urgent appropriate responses. With preventive measures and conserving health care resources being the most essential priorities, dermatologists, as an integral part of the health system, needed to adapt their practices according to the latest guidelines. The spectrum of the challenges encompassed education, teledermatology, lasers, and other dermatologic procedures, as well as management of patients who were immunosuppressed or developed drug reactions and, most importantly, the newly revealed cutaneous signs of COVID-19. These challenges have paved the way for new horizons in dermatology.
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Affiliation(s)
- Maryam Daneshpazhooh
- Department of Dermatology, Tehran University of Medical Sciences, Tehran, Iran; Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - HamidReza Mahmoudi
- Department of Dermatology, Tehran University of Medical Sciences, Tehran, Iran; Autoimmune Bullous Diseases Research Center, Razi Hospital, Tehran University of Medical Sciences, Tehran, Iran
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16
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Rezkalla SH, Kloner RA. Viral myocarditis: 1917-2020: From the Influenza A to the COVID-19 pandemics. Trends Cardiovasc Med 2020; 31:163-169. [PMID: 33383171 PMCID: PMC7965406 DOI: 10.1016/j.tcm.2020.12.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/03/2020] [Accepted: 12/21/2020] [Indexed: 12/12/2022]
Abstract
Myocarditis is common during viral infection with cases described as early as the influenza pandemic of 1917, and the current COVID-19 pandemic is no exception. The hallmark is elevated troponin, which occurs in 36% of COVID patients, with electrocardiogram, echocardiogram, and cardiac magnetic resonance being valuable tools to assist in diagnosis. Cardiac inflammation may occur secondary to direct cardiac invasion with the virus, or to intense cytokine storm, often encountered during the course of the disease. Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and judicious use of beta-blockers are beneficial in management of myocarditis. Corticosteroids may be avoided during the very early phase of viral replication, but can be of clear benefit in hospitalized, critically ill patients. Statins are beneficial to shorten the course of the disease and may decrease mortality.
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Affiliation(s)
- Shereif H Rezkalla
- Department of Cardiology & Cardiovascular Research, Marshfield Clinic Health System, 1000 North Oak Avenue, Marshfield, WI 54449 USA; Adjunct Professor, University of Wisconsin, School of Medicine USA.
| | - Robert A Kloner
- Chief Science Officer, Scientific Director of Cardiovascular Research Institute, Huntington Medical Research Institutes, Pasadena, CA USA; Professor of Medicine (Clinical Scholar), Cardiovascular Division, Dept. of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA USA.
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17
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Çap M, Bilge Ö, Işık F, Burak C, Karagöz A, İnci Ü, Akyüz A, Aslan B, Altıntaş B, Altındağ R, Kaya İ, Adıyaman MŞ, Süleymanoğlu M, Kaya Ş, Baysal E. The effect of favipiravir on QTc interval in patients hospitalized with coronavirus disease 2019. J Electrocardiol 2020; 63:115-119. [PMID: 33181454 PMCID: PMC7647409 DOI: 10.1016/j.jelectrocard.2020.10.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 12/14/2022]
Abstract
Background The effect of favipiravir on the QTc interval during the treatment of Coronavirus Disease 2019 (COVID-19) patients is unclear. Thus, the current study objective was to evaluate any change in the QTc interval in patients who were hospitalized due to COVID-19 receiving favipiravir treatment. Method Patients hospitalized with COVID-19 were assessed in this single-center retrospective study. 189 patients, whose diagnosis was confirmed using real-time PCR, were included in the study. The patients were divided into three groups: those using hydroxychloroquine (Group 1, n = 66), hydroxychloroquine plus favipiravir (Group 2, n = 66), and favipiravir only (Group 3, n = 57). The QTc interval was measured before treatment (QTc-B) and 48 h after (i.e., the median) starting treatment (QTc-AT). Results The median age was 53 (39–66 IQR) and 97 (51%) of patients were female. The median QTc(Bazett)-change was 7 ms (p = 0.028) and 12 ms (p < 0.001) and in Group 1 and 2, respectively. In Group 3, the median QTc(Bazett)-change was observed as −3 ms and was not statistically significant (p = 0.247). In multivariable analysis, while there was a significant relationship between QTc-AT(Bazett) and hydroxychloroquine (β coefficient = 2687, 95%CI 2599–16,976, p = 0,008), there was no significant relationship with favipiravir (β coefficient = 0,180, 95% CI -6435-7724, p = 0,858). Similarly, there was a significant relationship between the QTc-AT interval calculated using the Fredericia formula and hydroxychloroquine (β coefficient = 2120, 95% CI 0,514–14,398, p = 0,035), but not with favipiravir (β coefficient = 0,111, 95% CI -6450- 7221, p = 0,911). Conclusion In the ECG recordings received in the following days after the treatment was started in COVID-19 patients, there was a significant prolongation in the QTc interval with hydroxychloroquine, but there was no significant change with favipiravir.
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Affiliation(s)
- Murat Çap
- Department of Cardiology, SBU Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey.
| | - Önder Bilge
- Department of Cardiology, SBU Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
| | - Ferhat Işık
- Department of Cardiology, SBU Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
| | - Cengiz Burak
- Department of Cardiology, Kafkas University, Kars, Turkey
| | - Ali Karagöz
- Department of Cardiology, SBU Kartal Kosuyolu Education and Research Hospital, İstanbul, Turkey
| | - Ümit İnci
- Department of Cardiology, SBU Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
| | - Abdurrahman Akyüz
- Department of Cardiology, SBU Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
| | - Burhan Aslan
- Department of Cardiology, SBU Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
| | - Bernas Altıntaş
- Department of Cardiology, SBU Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
| | - Rojhat Altındağ
- Department of Cardiology, SBU Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
| | - İlyas Kaya
- Department of Cardiology, SBU Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
| | - Mehmet Şahin Adıyaman
- Department of Cardiology, SBU Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
| | | | - Şafak Kaya
- Department of İnfectious Disease, SBU Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
| | - Erkan Baysal
- Department of Cardiology, SBU Diyarbakır Gazi Yaşargil Education and Research Hospital, Diyarbakır, Turkey
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18
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Oscanoa TJ, Vidal X, Kanters JK, Romero-Ortuno R. Frequency of Long QT in Patients with SARS-CoV-2 Infection Treated with Hydroxychloroquine: A Meta-analysis. Int J Antimicrob Agents 2020; 56:106212. [PMID: 33164789 PMCID: PMC7584880 DOI: 10.1016/j.ijantimicag.2020.106212] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/28/2020] [Accepted: 10/17/2020] [Indexed: 02/07/2023]
Abstract
Introduction Hydroxychloroquine (HCQ) has been proposed as a SARS-CoV-2 treatment but the frequency of long QT (LQT) during use is unknown. Objective To conduct a meta-analysis of the frequency of LQT in patients with SARS-CoV-2 infection treated with HCQ. Data Sources PubMed, EMBASE, Google Scholar, the Cochrane Database of Systematic Reviews and preprint servers (medRxiv, Research Square) were searched for studies published between December 2019 and June 30, 2020. Methods Effect statistics were pooled using random effects. The quality of observational studies and randomized controlled trials was appraised with STROBE and the Cochrane Risk of Bias Assessment tools, respectively. Outcomes Critical LQT was defined as: (1) maximum QT corrected (QTc)≥500 ms (if QRS<120 ms) or QTc≥550 ms (if QRS≥120 ms), and (2) QTc increase ≥60 ms. Results In the 28 studies included (n=9124), the frequency of LQT during HCQ treatment was 6.7% (95% confidence interval [CI]: 3.7-10.2). In 20 studies (n=7825), patients were also taking other QT-prolonging drugs. The frequency of LQT in the other 8 studies (n=1299) was 1.7% (95% CI: 0.3-3.9). Twenty studies (n=6869) reported HCQ discontinuation due to LQT, with a frequency of 3.7% (95% CI: 1.5-6.6). The frequency of ventricular arrhythmias during HCQ treatment was 1.68% (127/7539) and that of arrhythmogenic death was 0.69% (39/5648). Torsades de Pointes occurred in 0.06% (3/5066). Patients aged >60 years were at highest risk of HCQ-associated LQT (P<0.001). Conclusions HCQ-associated cardiotoxicity in SARS-CoV-2 patients is uncommon but requires ECG monitoring, particularly in those aged >60 years and/or taking other QT-prolonging drugs.
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Affiliation(s)
- Teodoro J Oscanoa
- Facultad de Medicina, Universidad Nacional Mayor de San Marcos. Drug Safety Research Center, Facultad de Medicina Humana, Universidad de San Martín de Porres. Hospital Almenara, ESSALUD, Lima, Perú.
| | - Xavier Vidal
- Clinical Pharmacology Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Jørgen K Kanters
- Laboratory of Experimental Cardiology, Department of Biomedical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology, Mercer's Institute for Successful Ageing, St James's Hospital, Dublin, Ireland; Global Brain Health Institute, Trinity College Dublin, Ireland
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19
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Cortegiani A, Ippolito M, Ingoglia G, Iozzo P, Giarratano A, Einav S. Update I. A systematic review on the efficacy and safety of chloroquine/hydroxychloroquine for COVID-19. J Crit Care 2020; 59:176-190. [PMID: 32683212 PMCID: PMC7351664 DOI: 10.1016/j.jcrc.2020.06.019] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/15/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE To assess efficacy and safety of chloroquine (CQ)/hydroxychloroquine (HCQ) for treatment or prophylaxis of COVID-19 in adult humans. MATERIALS AND METHODS MEDLINE, PubMed, EMBASE and two pre-print repositories (bioRxiv, medRxiv) were searched from inception to 8th June 2020 for RCTs and nonrandomized studies (retrospective and prospective, including single-arm, studies) addressing the use of CQ/HCQ in any dose or combination for COVID-19. RESULTS Thirty-two studies were included (6 RCTs, 26 nonrandomized, 29,192 participants). Two RCTs had high risk, two 'some concerns' and two low risk of bias (Rob2). Among nonrandomized studies with comparators, nine had high risk and five moderate risk of bias (ROBINS-I). Data synthesis was not possible. Low and moderate risk of bias studies suggest that treatment of hospitalized COVID-19 with CQ/HCQ may not reduce risk of death, compared to standard care. High dose regimens or combination with macrolides may be associated with harm. Postexposure prophylaxis may not reduce the rate of infection but the quality of the evidence is low. CONCLUSIONS Patients with COVID-19 should be treated with CQ/HCQ only if monitored and within the context of high quality RCTs. High quality data about efficacy/safety are urgently needed.
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Affiliation(s)
- Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy.
| | - Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy
| | - Giulia Ingoglia
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy
| | - Pasquale Iozzo
- Department of Anesthesia and Intensive Care, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Italy
| | - Sharon Einav
- Intensive Care Unit of the Shaare Zedek Medical Medical Centre and Hebrew University Faculty of Medicine, Jerusalem, Israel
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Cadegiani FA. Repurposing existing drugs for COVID-19: an endocrinology perspective. BMC Endocr Disord 2020; 20:149. [PMID: 32993622 PMCID: PMC7523486 DOI: 10.1186/s12902-020-00626-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Coronavirus Disease 2019 (COVID-19) is a multi-systemic infection caused by the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), that has become a pandemic. Although its prevailing symptoms include anosmia, ageusia, dry couch, fever, shortness of brief, arthralgia, myalgia, and fatigue, regional and methodological assessments vary, leading to heterogeneous clinical descriptions of COVID-19. Aging, uncontrolled diabetes, hypertension, obesity, and exposure to androgens have been correlated with worse prognosis in COVID-19. Abnormalities in the renin-angiotensin-aldosterone system (RAAS), angiotensin-converting enzyme-2 (ACE2) and the androgen-driven transmembrane serine protease 2 (TMPRSS2) have been elicited as key modulators of SARS-CoV-2. MAIN TEXT While safe and effective therapies for COVID-19 lack, the current moment of pandemic urges for therapeutic options. Existing drugs should be preferred over novel ones for clinical testing due to four inherent characteristics: 1. Well-established long-term safety profile, known risks and contraindications; 2. More accurate predictions of clinical effects; 3. Familiarity of clinical management; and 4. Affordable costs for public health systems. In the context of the key modulators of SARS-CoV-2 infectivity, endocrine targets have become central as candidates for COVID-19. The only endocrine or endocrine-related drug class with already existing emerging evidence for COVID-19 is the glucocorticoids, particularly for the use of dexamethasone for severely affected patients. Other drugs that are more likely to present clinical effects despite the lack of specific evidence for COVID-19 include anti-androgens (spironolactone, eplerenone, finasteride and dutasteride), statins, N-acetyl cysteine (NAC), ACE inhibitors (ACEi), angiotensin receptor blockers (ARB), and direct TMPRSS-2 inhibitors (nafamostat and camostat). Several other candidates show less consistent plausibility. In common, except for dexamethasone, all candidates have no evidence for COVID-19, and clinical trials are needed. CONCLUSION While dexamethasone may reduce mortality in severely ill patients with COVID-19, in the absence of evidence of any specific drug for mild-to-moderate COVID-19, researchers should consider testing existing drugs due to their favorable safety, familiarity, and cost profile. However, except for dexamethasone in severe COVID-19, drug treatments for COVID-19 patients must be restricted to clinical research studies until efficacy has been extensively proven, with favorable outcomes in terms of reduction in hospitalization, mechanical ventilation, and death.
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Affiliation(s)
- Flavio A Cadegiani
- Adrenal and Hypertension Unit, Division of Endocrinology and Metabolism, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM/UNIFESP), Rua Pedro de Toledo 781 - 13th floor, São Paulo, SP, 04039-032, Brazil.
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Doyno C, Sobieraj DM, Baker WL. Toxicity of chloroquine and hydroxychloroquine following therapeutic use or overdose. Clin Toxicol (Phila) 2020; 59:12-23. [DOI: 10.1080/15563650.2020.1817479] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Cassandra Doyno
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Diana M. Sobieraj
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - William L. Baker
- Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT, USA
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Goldman A, Bomze D, Dankner R, Hod H, Meirson T, Boursi B, Maor E. Cardiovascular adverse events associated with hydroxychloroquine and chloroquine: A comprehensive pharmacovigilance analysis of pre-COVID-19 reports. Br J Clin Pharmacol 2020; 87:1432-1442. [PMID: 32964535 DOI: 10.1111/bcp.14546] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/11/2020] [Accepted: 08/21/2020] [Indexed: 12/27/2022] Open
Abstract
AIM There is a clinical need for safety data regarding hydroxychloroquine (HCQ) and chloroquine (CQ) during the coronavirus (COVID-19) pandemic. We analysed real-world data using the U.S. Food and Drug Administration Adverse Events Reporting System (FAERS) database to assess HCQ/CQ-associated cardiovascular adverse events (CVAEs) in pre-COVID-19 reports. METHODS We conducted disproportionality analysis of HCQ/CQ in the FAERS database (07/2014-9/2019), using reporting odds ratio (ROR) and the lower bound of the information component 95% credibility interval (IC025 ). RESULTS The full database contained 6 677 225 reports with a mean (±SD) age of 53 (±17) years and 74% females. We identified 4895 reports of HCQ/CQ related adverse events, of which 696 (14.2%) were CVAEs. Compared with the full database, HCQ/CQ use was associated with a higher reporting rate of major CVAEs, including cardiomyopathy (n = 86 [1.8%], ROR = 29.0 [23.3-35.9]), QT prolongation (n = 43 [0.9%], ROR = 4.5 [3.3-6.1]), cardiac arrhythmias (n = 117 [2.4%], ROR = 2.2 [1.8-2.7]) and heart failure (n = 136 [2.8%], ROR = 2.2 [1.9-2.7], all IC₀₂₅ > 0). No statistically significant differences were observed between sex and age groups. CVAEs were reported more often in patients with systemic lupus erythematosus and Sjogren's syndrome. HCQ/CQ-associated CVAEs demonstrated subsequent hospitalization and mortality rates of 39% and 8%, respectively. Overdose reports demonstrated an increased frequency of QT prolongation and ventricular arrhythmias (35% and 25%, respectively). CONCLUSION In a real-world setting, HCQ/CQ treatment is associated with higher reporting rates of various CVAEs, particularly cardiomyopathy, QT prolongation, cardiac arrhythmias and heart failure. HCQ/CQ-associated CVAEs result in high rates of severe outcomes and should be carefully considered as an off-label indication, especially for patients with cardiac disorders.
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Affiliation(s)
- Adam Goldman
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler School of Medicine, Tel Aviv University, Israel.,School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - David Bomze
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler School of Medicine, Tel Aviv University, Israel.,School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Israel.,Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland
| | - Rachel Dankner
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler School of Medicine, Tel Aviv University, Israel.,Unit for Cardiovascular Epidemiology, The Gertner Institute for Epidemiology and Health Policy Research, Ramat Gan, Israel
| | - Hanoch Hod
- School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Israel.,Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Tomer Meirson
- Azrieli Faculty of Medicine, Bar-Ilan University, Israel
| | - Ben Boursi
- School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Israel.,Department of Oncology, Sheba Medical Center, Tel HaShomer, Israel.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA
| | - Elad Maor
- School of Medicine, Sackler Faculty of Medicine, Tel-Aviv University, Israel.,Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel
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Beck TC, Beck KR, Holloway CB, Hemings RA, Dix TA, Norris RA. The C-C Chemokine Receptor Type 4 Is an Immunomodulatory Target of Hydroxychloroquine. Front Pharmacol 2020; 11:1253. [PMID: 32973504 PMCID: PMC7482581 DOI: 10.3389/fphar.2020.01253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/30/2020] [Indexed: 12/15/2022] Open
Abstract
The emergence of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; COVID-19) in China, reported to the World Health Organization on December 31, 2019, has led to a large global pandemic and is a major public health issue. As a result, there are more than 200 clinical trials of COVID-19 treatments or vaccines that are either ongoing or recruiting patients. One potential therapy that has garnered international attention is hydroxychloroquine; a potent immunomodulatory agent FDA-approved for the treatment of numerous inflammatory and autoimmune conditions, including malaria, lupus, and rheumatoid arthritis. Hydroxychloroquine has demonstrated promise in vitro and is currently under investigation in clinical trials for the treatment of COVID-19. Despite an abundance of empirical data, the mechanism(s) involved in the immunomodulatory activity of hydroxychloroquine have not been characterized. Using the unbiased chemical similarity ensemble approach (SEA), we identified C-C chemokine receptor type 4 (CCR4) as an immunomodulatory target of hydroxychloroquine. The crystal structure of CCR4 was selected for molecular docking studies using the SwissDock modeling software. In silico, hydroxychloroquine interacts with Thr-189 within the CCR4 active site, presumably blocking endogenous ligand binding. However, the CCR4 antagonists compound 18a and K777 outperformed hydroxychloroquine in silico, demonstrating energetically favorable binding characteristics. Hydroxychloroquine may subject COVID-19 patients to QT-prolongation, increasing the risk of sudden cardiac death. The FDA-approved CCR4 antagonist mogalizumab is not known to increase the risk of QT prolongation and may serve as a viable alternative to hydroxychloroquine. Results from this report introduce additional FDA-approved drugs that warrant investigation for therapeutic use in the treatment of COVID-19.
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Affiliation(s)
- Tyler C. Beck
- Dix Laboratory, Department of Drug Discovery & Biomedical Sciences, Medical University of South Carolina, Charleston, SC, United States,Norris Laboratory, Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, United States,College of Medicine, Medical University of South Carolina, Charleston, SC, United States,*Correspondence: Tyler C. Beck, ; Russell A. Norris,
| | - Kyle R. Beck
- College of Pharmacy, The Ohio State University, Columbus, OH, United States
| | - Calvin B. Holloway
- Pritzker School of Medicine, The University of Chicago, Chicago, IL, United States
| | - Richard A. Hemings
- College of Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Thomas A. Dix
- Dix Laboratory, Department of Drug Discovery & Biomedical Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Russell A. Norris
- Norris Laboratory, Department of Regenerative Medicine and Cell Biology, Medical University of South Carolina, Charleston, SC, United States,*Correspondence: Tyler C. Beck, ; Russell A. Norris,
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