1
|
Gottlieb LA, Mahfoud F, Stavrakis S, Jespersen T, Linz D. Autonomic Nervous System: A Therapeutic Target for Cardiac End-Organ Damage in Hypertension. Hypertension 2024; 81:2027-2037. [PMID: 39136127 PMCID: PMC11404762 DOI: 10.1161/hypertensionaha.123.19460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2024]
Abstract
More than 1.5 billion people worldwide have arterial hypertension. Hypertension increases the risks of death and cardiovascular disease, such as atrial fibrillation and heart failure. The autonomic nervous system plays an essential role in hypertension development and disease progression. While lifestyle factors, such as obesity and obstructive sleep apnea, predispose to hypertension by increasing sympathetic activity, hypertension itself maintains the autonomic nervous imbalance, providing the substrate for atrial fibrillation and heart failure. Therefore, autonomic nervous system modulation either by direct targeting or indirect treatment of comorbidities has the potential to treat both hypertension and related atrial and ventricular end-organ damage. We discuss interventions for the modulation of the autonomic nervous system for hypertension and related cardiac end-organ damage, including pharmacological adrenergic beta-receptor blockade, renal denervation, carotid baroreceptor stimulation, low-level vagal stimulation, and ablation of ganglionated plexuses. In summary, the literature suggests that targeting the autonomic nervous system potentially represents a therapeutic approach to prevent atrial and ventricular end-organ damage in patients with hypertension. However, clinical trials specifically designed to test the effect of autonomic modulation on hypertension-mediated cardiac end-organ damage are scarce.
Collapse
Affiliation(s)
- Lisa A Gottlieb
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (L.A.G., T.J., D.L.)
| | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology, and Intensive Care Medicine, Saarland University Hospital, Homburg, Germany (F.M.)
| | - Stavros Stavrakis
- Department of Internal Medicine, Cardiovascular Section, University of Oklahoma Health Sciences Center, Oklahoma City (S.S.)
| | - Thomas Jespersen
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (L.A.G., T.J., D.L.)
| | - Dominik Linz
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (L.A.G., T.J., D.L.)
- Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, the Netherlands (D.L.)
| |
Collapse
|
2
|
Karakasis P, Patoulias D, Popovic DS, Pamporis K, Theofilis P, Nasoufidou A, Stachteas P, Samaras A, Tzikas A, Giannakoulas G, Stavropoulos G, Kassimis G, Karamitsos T, Fragakis N. Effects of mineralocorticoid receptor antagonists on new-onset or recurrent atrial fibrillation: a Bayesian and frequentist network meta-analysis of randomized trials. Curr Probl Cardiol 2024; 49:102742. [PMID: 39002620 DOI: 10.1016/j.cpcardiol.2024.102742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Accepted: 07/10/2024] [Indexed: 07/15/2024]
Abstract
Background Clinical and translational research suggests that mineralocorticoid receptor antagonists (MRAs) may prevent atrial fibrosis and electrical remodeling associated with atrial fibrillation (AF). This study aimed to consolidate existing evidence from randomized controlled trials (RCTs) evaluating the effect of MRAs on incident or recurrent AF. Methods Medline, Cochrane Library and Scopus were searched until February 12, 2024. Triple-independent study selection, data extraction and quality assessment were performed. Evidence was pooled using both pairwise and Bayesian and frequentist network meta-analyses. Results Twenty-three RCTs (13,358 participants) were identified. Based on the pairwise random effects meta-analysis, MRAs were associated with a significant reduction in AF events compared to placebo or usual care (risk ratio {RR}= 0.75; 95% confidence interval {CI}= [0.66, 0.87]; P< 0.001; I2= 3%). This protective effect was robust both for new-onset and recurrent AF episodes (subgroup p-value= 0.69), while the baseline HF status was not a significant effect modifier (subgroup p-value= 0.58). MRAs demonstrated a significantly higher reduction in AF events for patients with chronic renal disease compared to placebo (RR= 0.78; 95% CI= [0.62, 0.98]; P= 0.03; I2= 0%). The network meta-analyses revealed that only spironolactone was associated with a significant reduction in AF events (Bayesian RR= 0.76; 95% CI= [0.65, 0.89]; P< 0.001; level of evidence moderate; SUCRA 0.731), while eplerenone and finerenone showed a neutral effect. Conclusion MRAs confer a significant benefit in terms of reducing incident or recurrent AF episodes, irrespective of HF status. In this context, spironolactone may be preferable compared to eplerenone or finerenone.
Collapse
Affiliation(s)
- Paschalis Karakasis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece.
| | - Dimitrios Patoulias
- Outpatient Department of Cardiometabolic Medicine, Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Djordje S Popovic
- Clinic for Endocrinology, Diabetes and Metabolic Disorders, Clinical Centre of Vojvodina, Medical Faculty, University of Novi Sad, Novi Sad, Serbia
| | - Konstantinos Pamporis
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Panagiotis Theofilis
- First Cardiology Department, General Hospital of Athens "Hippocratio", University of Athens Medical School, Athens, Greece
| | - Athina Nasoufidou
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Panagiotis Stachteas
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Athanasios Samaras
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Apostolos Tzikas
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece; European Interbalkan Medical Center, Department of Cardiology, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, Aristotle University Medical School, Thessaloniki, AHEPA University General Hospital, Greece
| | - George Stavropoulos
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - George Kassimis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| | - Theodoros Karamitsos
- First Department of Cardiology, Aristotle University Medical School, Thessaloniki, AHEPA University General Hospital, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Aristotle University of Thessaloniki, Hippokration General Hospital, Greece
| |
Collapse
|
3
|
Brown JM. Adverse Effects of Aldosterone: Beyond Blood Pressure. J Am Heart Assoc 2024; 13:e030142. [PMID: 38497438 PMCID: PMC11179780 DOI: 10.1161/jaha.123.030142] [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: 03/19/2024]
Abstract
Aldosterone is a steroid hormone that primarily acts through activation of the mineralocorticoid receptor (MR), a nuclear receptor responsible for downstream genomic regulation. Classically, activation of the MR in the renal tubular epithelium is responsible for sodium retention and volume expansion, raising systemic blood pressure. However, activation of the MR across a wide distribution of tissue types has been implicated in multiple adverse consequences for cardiovascular, cerebrovascular, renal, and metabolic disease, independent of blood pressure alone. Primary aldosteronism, heart failure, and chronic kidney disease are states of excessive aldosterone production and MR activity where targeting MR activation has had clinical benefits out of proportion to blood pressure lowering. The growing list of established and emerging therapies that target aldosterone and MR activation may provide new opportunities to improve clinical outcomes and enhance cardiovascular and renal health.
Collapse
Affiliation(s)
- Jenifer M. Brown
- Division of Cardiovascular Medicine, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMAUSA
| |
Collapse
|
4
|
Oraii A, Healey JS, Kowalik K, Pandey AK, Benz AP, Wong JA, Conen D, McIntyre WF. Mineralocorticoid receptor antagonists and atrial fibrillation: a meta-analysis of clinical trials. Eur Heart J 2024; 45:756-774. [PMID: 38195054 DOI: 10.1093/eurheartj/ehad811] [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: 07/14/2023] [Revised: 11/05/2023] [Accepted: 11/28/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND AND AIMS Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in a variety of settings. This study aimed to assess whether cardioprotective effects of MRAs are modified by heart failure (HF) and atrial fibrillation (AF) status and to study their impact on AF events. METHODS MEDLINE, Embase, and Cochrane Central databases were searched to 24 March 2023 for randomized controlled trials evaluating the efficacy of MRAs as compared with placebo or usual care in reducing cardiovascular outcomes and AF events in patients with or at risk for cardiovascular diseases. Random-effects models and interaction analyses were used to test for effect modification. RESULTS Meta-analysis of seven trials (20 741 participants, mean age: 65.6 years, 32% women) showed that the efficacy of MRAs, as compared with placebo, in reducing a composite of cardiovascular death or HF hospitalization remains consistent across patients with HF [risk ratio = 0.81; 95% confidence interval (CI): 0.67-0.98] and without HF (risk ratio = 0.84; 95% CI: 0.75-0.93; interaction P = .77). Among patients with HF, MRAs reduced cardiovascular death or HF hospitalization in patients with AF (hazard ratio = 0.95; 95% CI: 0.54-1.66) to a similar extent as in those without AF (hazard ratio = 0.82; 95% CI: 0.63-1.07; interaction P = .65). Pooled data from 20 trials (21 791 participants, mean age: 65.2 years, 31.3% women) showed that MRAs reduce AF events (risk ratio = 0.76; 95% CI: 0.67-0.87) in both patients with and without prior AF. CONCLUSIONS Mineralocorticoid receptor antagonists are similarly effective in preventing cardiovascular events in patients with and without HF and most likely retain their efficacy regardless of AF status. Mineralocorticoid receptor antagonists may also be moderately effective in preventing incident or recurrent AF events.
Collapse
Affiliation(s)
- Alireza Oraii
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - Krzysztof Kowalik
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Avinash K Pandey
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexander P Benz
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
| | - Jorge A Wong
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - David Conen
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| | - William F McIntyre
- Population Health Research Institute, McMaster University, 237 Barton St East, DBVSRI C3-13A, Hamilton, ON L8L 2X2, Canada
- Division of Cardiology, Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, ON L8N 3Z5, Canada
| |
Collapse
|
5
|
Jia G, Hill MA, Sowers JR. Vascular endothelial mineralocorticoid receptors and epithelial sodium channels in metabolic syndrome and related cardiovascular disease. J Mol Endocrinol 2023; 71:e230066. [PMID: 37610001 PMCID: PMC10502958 DOI: 10.1530/jme-23-0066] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/22/2023] [Indexed: 08/24/2023]
Abstract
Metabolic syndrome is a group of risk factors that increase the risk of developing metabolic and cardiovascular disease (CVD) and include obesity, dyslipidemia, insulin resistance, atherosclerosis, hypertension, coronary artery disease, and heart failure. Recent research indicates that excessive production of aldosterone and associated activation of mineralocorticoid receptors (MR) impair insulin metabolic signaling, promote insulin resistance, and increase the risk of developing metabolic syndrome and CVD. Moreover, activation of specific epithelial sodium channels (ENaC) in endothelial cells (EnNaC), which are downstream targets of endothelial-specific MR (ECMR) signaling, are also believed to play a crucial role in the development of metabolic syndrome and CVD. These adverse effects of ECMR/EnNaC activation are mediated by increased oxidative stress, inflammation, and lipid metabolic disorders. It is worth noting that ECMR/EnNaC activation and the pathophysiology underlying metabolic syndrome and CVD appears to exhibit sexual dimorphism. Targeting ECMR/EnNaC signaling may have a beneficial effect in preventing insulin resistance, diabetes, metabolic syndrome, and related CVD. This review aims to examine our current understanding of the relationship between MR activation and increased metabolic syndrome and CVD, with particular emphasis placed on the role for endothelial-specific ECMR/EnNaC signaling in these pathological processes.
Collapse
Affiliation(s)
- Guanghong Jia
- Department of Medicine-Endocrinology and Metabolism, University of Missouri School of Medicine, Columbia, Missouri, USA
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri, USA
| | - Michael A Hill
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri, USA
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - James R Sowers
- Department of Medicine-Endocrinology and Metabolism, University of Missouri School of Medicine, Columbia, Missouri, USA
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri, USA
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, Missouri, USA
| |
Collapse
|
6
|
Majid A, Hassan FO, Hoque MM, Gbadegoye JO, Lebeche D. Bioactive Compounds and Cardiac Fibrosis: Current Insight and Future Prospect. J Cardiovasc Dev Dis 2023; 10:313. [PMID: 37504569 PMCID: PMC10380727 DOI: 10.3390/jcdd10070313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 07/29/2023] Open
Abstract
Cardiac fibrosis is a pathological condition characterized by excessive deposition of collagen and other extracellular matrix components in the heart. It is recognized as a major contributor to the development and progression of heart failure. Despite significant research efforts in characterizing and identifying key molecular mechanisms associated with myocardial fibrosis, effective treatment for this condition is still out of sight. In this regard, bioactive compounds have emerged as potential therapeutic antifibrotic agents due to their anti-inflammatory and antioxidant properties. These compounds exhibit the ability to modulate fibrogenic processes by inhibiting the production of extracellular matrix proteins involved in fibroblast to myofibroblast differentiation, or by promoting their breakdown. Extensive investigation of these bioactive compounds offers new possibilities for preventing or reducing cardiac fibrosis and its detrimental consequences. This comprehensive review aims to provide a thorough overview of the mechanisms underlying cardiac fibrosis, address the limitations of current treatment strategies, and specifically explore the potential of bioactive compounds as therapeutic interventions for the treatment and/or prevention of cardiac fibrosis.
Collapse
Affiliation(s)
- Abdul Majid
- Department of Physiology, College of Medicine, The University of Tennessee Health Science Center, Translational Research Building, Room 318H, 71 S. Manassas, Memphis, TN 38163, USA
- College of Graduate Health Sciences, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Fasilat Oluwakemi Hassan
- Department of Physiology, College of Medicine, The University of Tennessee Health Science Center, Translational Research Building, Room 318H, 71 S. Manassas, Memphis, TN 38163, USA
- College of Graduate Health Sciences, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Md Monirul Hoque
- Department of Physiology, College of Medicine, The University of Tennessee Health Science Center, Translational Research Building, Room 318H, 71 S. Manassas, Memphis, TN 38163, USA
- College of Graduate Health Sciences, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Joy Olaoluwa Gbadegoye
- Department of Physiology, College of Medicine, The University of Tennessee Health Science Center, Translational Research Building, Room 318H, 71 S. Manassas, Memphis, TN 38163, USA
- College of Graduate Health Sciences, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Djamel Lebeche
- Department of Physiology, College of Medicine, The University of Tennessee Health Science Center, Translational Research Building, Room 318H, 71 S. Manassas, Memphis, TN 38163, USA
- College of Graduate Health Sciences, The University of Tennessee Health Science Center, Memphis, TN 38163, USA
| |
Collapse
|
7
|
Georgianos PI, Agarwal R. The Nonsteroidal Mineralocorticoid-Receptor-Antagonist Finerenone in Cardiorenal Medicine: A State-of-the-Art Review of the Literature. Am J Hypertens 2023; 36:135-143. [PMID: 36331811 PMCID: PMC9951054 DOI: 10.1093/ajh/hpac124] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 10/25/2022] [Accepted: 11/03/2022] [Indexed: 11/06/2022] Open
Abstract
Steroidal mineralocorticoid-receptor-antagonists (MRAs), such as spironolactone and eplerenone, are guideline-directed therapies in patients with heart failure with reduced ejection fraction or resistant hypertension. However, the associated risk of hyperkalemia and hormonal side effects limit their broad use and downstream cardiorenal protection in high-risk patients with type 2 diabetes mellitus (T2DM) and moderate-to-advanced chronic kidney disease (CKD). The critical unmet need to improve long-term cardiorenal outcomes in such patients with CKD has sparked considerable efforts to the discovery and development of a new class of compounds. Finerenone is a novel, nonsteroidal MRA that has recently received regulatory approval with the indication of cardiorenal protection in patients with CKD associated with T2DM. Two landmark phase 3 clinical trials, FIDELIO-DKD and FIGARO-DKD, demonstrated that among patients with T2DM and a broad spectrum of CKD, finerenone reduced the risk of "hard" cardiovascular and kidney failure outcomes as compared with placebo, with a minimal risk of hyperkalemia. Subgroup analyses of these trials also provided preliminary evidence that the efficacy and safety profile of finerenone was similar and irrespective of background therapy with other guideline-directed therapies, such as sodium-glucose co-transporter type 2 (SGLT-2) inhibitors and glucagone-like peptide 1 receptor agonists. Whether the combination of finerenone with a SGLT-2 inhibitor is more beneficial in patients with T2DM and CKD as compared with either therapy alone is a crucial research question that is currently under investigation in an ongoing clinical trial.
Collapse
Affiliation(s)
- Panagiotis I Georgianos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
| |
Collapse
|
8
|
Aimo A, Senni M, Barison A, Panichella G, Passino C, Bayes-Genis A, Emdin M. Management of heart failure with preserved ejection fraction: from neurohormonal antagonists to empagliflozin. Heart Fail Rev 2023; 28:179-191. [PMID: 35488030 PMCID: PMC9902425 DOI: 10.1007/s10741-022-10228-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 02/07/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a highly prevalent syndrome with multifaceted pathophysiology. All approaches to neurohormonal modulation were shown not to improve survival in HFpEF, despite their well-established efficacy in heart failure with reduced ejection fraction (HFrEF). This might be attributed to suboptimal study design, inadequate diagnostic criteria, or statistical power, but is also likely to reflect a lack of consideration for its clinical heterogeneity. The attention then shifted to the phenotypic heterogeneity of HFpEF, with the ultimate goal of developing therapies tailored to individual patient phenotypes. Recently, the sodium-glucose co-transporter-2 inhibitor (SGLT2i) empagliflozin has been found to reduce the combined risk of cardiovascular death or hospitalization for HF in patients with HFpEF, a result driven by a reduction in HF hospitalizations. This paper recapitulates the journey from the failure of trials on neurohormonal antagonists to the attempts of personalized approaches and the new perspectives of SGLT2i therapy for HFpEF.
Collapse
Affiliation(s)
- Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Senni
- Cardiovascular Department & Cardiology Unit, ASST Papa Giovanni XXIII - Bergamo, Bergamo, Italy
| | - Andrea Barison
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Antoni Bayes-Genis
- ICREC (Heart Failure and Cardiac Regeneration) Research Programme, Health Sciences Research Institute Germans Trias I Pujol (IGTP), Badalona, Spain
- Hospital Universitari Germans Trias I Pujol, Badalona (Barcelona), Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| |
Collapse
|
9
|
Ortega‐Paz L, Cristóbal H, Ortiz‐Perez JT, García de Frutos P, Mendieta G, Sandoval E, Rodriguez JJ, Ortega E, García‐Álvarez A, Brugaletta S, Sabaté M, Dantas AP. Direct actions of dapagliflozin and interactions with LCZ696 and spironolactone on cardiac fibroblasts of patients with heart failure and reduced ejection fraction. ESC Heart Fail 2022; 10:453-464. [PMID: 36303443 PMCID: PMC9871706 DOI: 10.1002/ehf2.14186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 09/12/2022] [Accepted: 09/19/2022] [Indexed: 01/27/2023] Open
Abstract
AIMS Inhibitors of SGLT2 (SGLT2i) have shown a positive impact in patients with chronic heart failure and reduced ejection fraction (HFrEF). Nonetheless, the direct effects of SGLT2i on cardiac cells and how their association with main drugs used for HFrEF affect the behaviour and signalling pathways of myocardial fibroblasts are still unknown. We aimed to determine the effects of dapagliflozin alone and in combination with sacubitril/valsartan (LCZ696) or spironolactone on the function of myocardial fibroblasts of patients with heart failure and reduced ejection fraction (HFrEF). METHODS AND RESULTS Myocardial fibroblasts isolated from HFrEF patients (n = 5) were treated with dapagliflozin alone (1 nM-1 μM) or combined with LCZ696 (100 nM) or spironolactone (100 nM). The migratory rate was determined by wound-healing scratch assay. Expression of heart failure (HF) markers and signalling pathways activation were analysed with multiplexed protein array. Commercially available cardiac fibroblasts from healthy donors were used as Control (n = 4). Fibroblasts from HFrEF show higher migratory rate compared with control (P = 0.0036), and increased expression of HF markers [fold-change (Log2): COL1A1-1.3; IL-1b-1.9; IL-6-1.7; FN1-2.9 (P < 0.05)]. Dapagliflozin slowed the migration rate of HFrEF fibroblasts in a dose-dependent manner and markedly decreased the expression of IL-1β, IL-6, MMP3, MMP9, GAL3, and FN1. SGLT2i had no effect on control fibroblasts. These effects were associated with decreased phosphorylation of AKT/GSK3 and PYK2 kinases and the signal transducer and activator of transcription (STAT). A combination of dapagliflozin + LCZ696 further decreased fibroblast migration, although it did not have a significant effect on the regulation of signalling pathways and the expression of biomarkers induced by SGLT2 inhibition alone. In contrast, the combination of dapagliflozin + spironolactone did not change the migration rate of fibroblast but significantly altered SGLT2i responses on MMP9, GAL3, and IL-1b expression, in association with increased phosphorylation of the kinases AKT/GSK3 and ERK1/2. CONCLUSIONS SGLT2i, LCZ696, and spironolactone modulate the function of isolated myocardial fibroblasts from HFrEF patients through the activation of different signalling pathways. The combination of SGLT2i + LCZ696 shows an additive effect on migration, while spironolactone modifies the signalling pathways activated by SGLT2i and its beneficial effects of biomarkers of heart failure.
Collapse
Affiliation(s)
- Luis Ortega‐Paz
- Institut Clinic Cardiovascular (ICCV)Hospital Clinic i Provincial de Barcelona (HCPB)BarcelonaSpain,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Division of CardiologyUniversity of Florida College of MedicineFloridaUSA
| | - Helena Cristóbal
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Institute for Biomedical Research of Barcelona, IIBB‐CSICBarcelonaSpain
| | - José Tomás Ortiz‐Perez
- Institut Clinic Cardiovascular (ICCV)Hospital Clinic i Provincial de Barcelona (HCPB)BarcelonaSpain,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain
| | - Pablo García de Frutos
- Institut Clinic Cardiovascular (ICCV)Hospital Clinic i Provincial de Barcelona (HCPB)BarcelonaSpain,Institute for Biomedical Research of Barcelona, IIBB‐CSICBarcelonaSpain,CIBER de Enfermedades Cardiovasculares (CIBERCV)Instituto de Salud Carlos IIIMadridSpain
| | - Guiomar Mendieta
- Institut Clinic Cardiovascular (ICCV)Hospital Clinic i Provincial de Barcelona (HCPB)BarcelonaSpain,Institute for Biomedical Research of Barcelona, IIBB‐CSICBarcelonaSpain,CIBER de Enfermedades Cardiovasculares (CIBERCV)Instituto de Salud Carlos IIIMadridSpain
| | - Elena Sandoval
- Institut Clinic Cardiovascular (ICCV)Hospital Clinic i Provincial de Barcelona (HCPB)BarcelonaSpain
| | - Juan José Rodriguez
- Institut Clinic Cardiovascular (ICCV)Hospital Clinic i Provincial de Barcelona (HCPB)BarcelonaSpain
| | - Emilio Ortega
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain
| | - Ana García‐Álvarez
- Institut Clinic Cardiovascular (ICCV)Hospital Clinic i Provincial de Barcelona (HCPB)BarcelonaSpain,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,CIBER de Enfermedades Cardiovasculares (CIBERCV)Instituto de Salud Carlos IIIMadridSpain
| | - Salvatore Brugaletta
- Institut Clinic Cardiovascular (ICCV)Hospital Clinic i Provincial de Barcelona (HCPB)BarcelonaSpain,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain
| | - Manel Sabaté
- Institut Clinic Cardiovascular (ICCV)Hospital Clinic i Provincial de Barcelona (HCPB)BarcelonaSpain,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,CIBER de Enfermedades Cardiovasculares (CIBERCV)Instituto de Salud Carlos IIIMadridSpain
| | - Ana Paula Dantas
- Institut Clinic Cardiovascular (ICCV)Hospital Clinic i Provincial de Barcelona (HCPB)BarcelonaSpain,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)BarcelonaSpain,Department of BiomedicineUniversitat de Barcelona Medical SchoolBarcelonaSpain
| |
Collapse
|
10
|
Lorente-Ros M, Aguilar-Gallardo JS, Shah A, Narasimhan B, Aronow WS. An overview of mineralocorticoid receptor antagonists as a treatment option for patients with heart failure: the current state-of-the-art and future outlook. Expert Opin Pharmacother 2022; 23:1737-1751. [PMID: 36262014 DOI: 10.1080/14656566.2022.2138744] [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] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in patients with heart failure. These benefits of MRAs vary in different heart failure populations based on left ventricular ejection fraction and associated comorbidities. AREAS COVERED We define the pharmacologic properties of MRAs and the pathophysiological rationale for their utility in heart failure. We outline the current literature on the use of MRAs in different heart failure populations, including reduced and preserved ejection fraction (HFrEF/ HFpEF), and acute heart failure decompensation. Finally, we describe the limitations of currently available data and propose future directions of study. EXPERT OPINION While there is strong evidence supporting the use of MRAs in HFrEF, evidence in patients with HFpEF or acute heart failure is less definitive. Comorbidities such as obesity or atrial fibrillation could be clinical modifiers of the response to MRAs and potentially alter the risk/benefit ratio in these subpopulations. Emerging evidence for new non-steroidal MRAs reveal promising preliminary results that, if confirmed in large randomized clinical trials, could favor a change in clinical practice.
Collapse
Affiliation(s)
- Marta Lorente-Ros
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside-West, 1111 Amsterdam Avenue, New York, NY 10019, USA
| | - Jose S Aguilar-Gallardo
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside-West, 1111 Amsterdam Avenue, New York, NY 10019, USA
| | - Aayush Shah
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, 6565 Fannin St, Houston, TX 77030, USA
| | - Bharat Narasimhan
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, 6565 Fannin St, Houston, TX 77030, USA
| | - Wilbert S Aronow
- Department of Cardiology, New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY 10901, USA
| |
Collapse
|
11
|
Dhore-Patil A, Thannoun T, Samson R, Le Jemtel TH. Diabetes Mellitus and Heart Failure With Preserved Ejection Fraction: Role of Obesity. Front Physiol 2022; 12:785879. [PMID: 35242044 PMCID: PMC8886215 DOI: 10.3389/fphys.2021.785879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/03/2021] [Indexed: 12/15/2022] Open
Abstract
Heart failure with preserved ejection fraction is a growing epidemic and accounts for half of all patients with heart failure. Increasing prevalence, morbidity, and clinical inertia have spurred a rethinking of the pathophysiology of heart failure with preserved ejection fraction. Unlike heart failure with reduced ejection fraction, heart failure with preserved ejection fraction has distinct clinical phenotypes. The obese-diabetic phenotype is the most often encountered phenotype in clinical practice and shares the greatest burden of morbidity and mortality. Left ventricular remodeling plays a major role in its pathophysiology. Understanding the interplay of obesity, diabetes mellitus, and inflammation in the pathophysiology of left ventricular remodeling may help in the discovery of new therapeutic targets to improve clinical outcomes in heart failure with preserved ejection fraction. Anti-diabetic agents like glucagon-like-peptide 1 analogs and sodium-glucose co-transporter 2 are promising therapeutic modalities for the obese-diabetic phenotype of heart failure with preserved ejection fraction and aggressive weight loss via lifestyle or bariatric surgery is still key to reverse adverse left ventricular remodeling. This review focuses on the obese-diabetic phenotype of heart failure with preserved ejection fraction highlighting the interaction between obesity, diabetes, and coronary microvascular dysfunction in the development and progression of left ventricular remodeling. Recent therapeutic advances are reviewed.
Collapse
Affiliation(s)
- Aneesh Dhore-Patil
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, New Orleans, LA, United States.,Tulane University Heart and Vascular Institute, New Orleans, LA, United States
| | - Tariq Thannoun
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, New Orleans, LA, United States.,Tulane University Heart and Vascular Institute, New Orleans, LA, United States
| | - Rohan Samson
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, New Orleans, LA, United States.,Tulane University Heart and Vascular Institute, New Orleans, LA, United States
| | - Thierry H Le Jemtel
- Section of Cardiology, Department of Medicine, Tulane University School of Medicine, New Orleans, LA, United States.,Tulane University Heart and Vascular Institute, New Orleans, LA, United States
| |
Collapse
|
12
|
Filippatos G, Pitt B, Agarwal R, Farmakis D, Ruilope LM, Rossing P, Bauersachs J, Mentz RJ, Kolkhof P, Scott C, Joseph A, Bakris GL, Anker SD. Finerenone in patients with CKD and T2D with and without heart failure: A prespecified subgroup analysis of the FIDELIO-DKD trial. Eur J Heart Fail 2022; 24:996-1005. [PMID: 35239204 PMCID: PMC9541504 DOI: 10.1002/ejhf.2469] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/07/2022] [Accepted: 03/01/2022] [Indexed: 11/17/2022] Open
Abstract
Aims This prespecified analysis of the FIDELIO‐DKD trial compared the effects of finerenone, a selective non‐steroidal mineralocorticoid receptor antagonist, on cardiorenal outcomes in patients with chronic kidney disease (CKD) and type 2 diabetes (T2D) by history of heart failure (HF). Methods and results Patients with T2D and CKD (urine albumin‐to‐creatinine ratio ≥30–5000 mg/g and estimated glomerular filtration rate [eGFR] ≥25–<75 ml/min/1.73 m2), without symptomatic HF with reduced ejection fraction (New York Heart Association II–IV) and treated with optimized renin–angiotensin system blockade were randomized to finerenone or placebo. The composite cardiovascular (CV) outcome (CV death, non‐fatal myocardial infarction, non‐fatal stroke, or hospitalization for HF) and composite kidney outcome (kidney failure, sustained ≥40% decrease in eGFR from baseline, or renal death) were analysed by investigator‐reported medical history of HF. Of 5674 patients, 436 (7.7%) had a history of HF. Over a median follow‐up of 2.6 years, the effect of finerenone compared with placebo on the composite CV outcome was consistent in patients with and without a history of HF (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.50–1.06 and HR 0.90, 95% CI 0.77–1.04, respectively; interaction p = 0.33). The effect of finerenone on the composite kidney outcome did not differ by history of HF (HR 0.79, 95% CI 0.52–1.20 and HR 0.83, 95% CI 0.73–0.94, respectively; interaction p = 0.83). Conclusion In FIDELIO‐DKD, finerenone improved cardiorenal outcome in patients with CKD and T2D irrespective of baseline HF history.
Collapse
Affiliation(s)
- Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology, Attikon University Hospital, Athens, Greece
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Rajiv Agarwal
- Richard L. Roudebush VA Medical Center and Indiana University, Indianapolis, Indiana, USA
| | | | - Luis M Ruilope
- Cardiorenal Translational Laboratory and Hypertension Unit, Institute of Research imas12, Madrid, Spain.,CIBER-CV, Hospital Universitario 12 de Octubre, Madrid, Spain.,Faculty of Sport Sciences, European University of Madrid, Madrid, Spain
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Peter Kolkhof
- Research and Development, Preclinical Research Cardiovascular, Bayer AG, Wuppertal, Germany
| | | | - Amer Joseph
- Cardiology and Nephrology Clinical Development, Bayer AG, Berlin, Germany
| | - George L Bakris
- Department of Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité - Universitätsmedizin, Berlin, Germany
| | | |
Collapse
|
13
|
Boulmpou A, Theodorakopoulou MP, Alexandrou ME, Boutou AK, Papadopoulos CE, Pella E, Sarafidis P, Vassilikos V. Meta-analysis addressing the impact of cardiovascular-acting medication on peak oxygen uptake of patients with HFpEF. Heart Fail Rev 2022; 27:609-623. [DOI: 10.1007/s10741-021-10207-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2021] [Indexed: 11/28/2022]
|
14
|
Bauersachs J, López-Andrés N. Mineralocorticoid receptor in cardiovascular diseases-Clinical trials and mechanistic insights. Br J Pharmacol 2021; 179:3119-3134. [PMID: 34643952 DOI: 10.1111/bph.15708] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 09/07/2021] [Accepted: 09/27/2021] [Indexed: 12/19/2022] Open
Abstract
Aldosterone binds to the mineralocorticoid receptor (NR3C2), a transcription factor of the nuclear receptor family, present in the kidney and in various other non-epithelial cells including the heart and the vasculature. Indeed, extra-renal pathophysiological effects of this hormone have been characterized, extending its actions to the cardiovascular system. A growing body of clinical and pre-clinical evidence suggests that mineralocorticoid receptor overactivation plays an important pathophysiological role in cardiovascular remodelling by promoting cardiac hypertrophy, fibrosis, arterial stiffness and in inflammation and oxidative stress. The following review article outlines the role of mineralocorticoid receptor in cardiovascular disease with a focus on myocardial remodelling and heart failure (HF) including clinical trials as well as cellular and animal studies.
Collapse
Affiliation(s)
- Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Natalia López-Andrés
- Cardiovascular Translational Research. Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), Complejo Hospitalario de Navarra (CHN), Universidad Pública de Navarra (UPNA), Pamplona, Spain
| |
Collapse
|
15
|
Abstract
PURPOSE OF REVIEW In this article, we review the most current evidence for initiation and maintenance of various antihypertension (HTN) drug classes, including other misconceptions with respect to common comorbidities in patients with HTN. RECENT FINDINGS Although the currently available anti-HTN agents have broad applicability in treating HTN, additional agents, such as angiotensin receptor-neprilysin inhibitors and novel nonsteroidal mineralocorticoid antagonists, have recently gained clinical significance. In addition, there have been some anecdotal concerns regarding the adverse effects, indications, and risks of COVID-19 infection/mortality when using certain anti-HTN agents. SUMMARY Current guidelines currently address the treatment of primary HTN. However, isolated HTN is uncommon and often involves comorbid diseases that require specific regimentation. Several experimental medications are currently in late-stage trials showing potential superiority over current drugs that are available in the market.
Collapse
Affiliation(s)
- Michael F Mendoza
- Faculty of Medicine and Surgery, University of Santo Tomas, Sampaloc, Manila, Philippines
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School of Medicine, New Orleans, Lousiana
| | - Sergey M Kachur
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School of Medicine, New Orleans, Lousiana
- Department of Medicine, University of Central Florida School of Medicine, Orlando, Florida, USA
| | - Carl J Lavie
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School of Medicine, New Orleans, Lousiana
| |
Collapse
|
16
|
DNA Methylation of the Angiotensinogen Gene, AGT, and the Aldosterone Synthase Gene, CYP11B2 in Cardiovascular Diseases. Int J Mol Sci 2021; 22:ijms22094587. [PMID: 33925539 PMCID: PMC8123855 DOI: 10.3390/ijms22094587] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 12/20/2022] Open
Abstract
Angiotensinogen (AGT) and aldosterone play key roles in the regulation of blood pressure and are implicated in the pathogenesis of cardiovascular diseases. DNA methylation typically acts to repress gene transcription. The aldosterone synthase gene CYP11B2 is regulated by angiotensin II and potassium. DNA methylation negatively regulates AGT and CYP11B2 expression and dynamically changes in response to continuous promoter stimulation of each gene. High salt intake and excess circulating aldosterone cause DNA demethylation around the CCAAT-enhancer-binding-protein (CEBP) sites of the ATG promoter region, thereby converting the phenotype of AGT expression from an inactive to an active state in visceral adipose tissue and heart. A close association exists between low DNA methylation at CEBP-binding sites and increased AGT expression in salt-sensitive hypertensive rats. Salt-dependent hypertension may be partially affected by increased cardiac AGT expression. CpG dinucleotides in the CYP11B2 promoter are hypomethylated in aldosterone-producing adenomas. Methylation of recognition sequences of transcription factors, including CREB1, NGFIB (NR4A1), and NURR1 (NR4A2) diminish their DNA-binding activity. The methylated CpG-binding protein MECP2 interacts directly with the methylated CYP11B2 promoter. Low salt intake and angiotensin II infusion lead to upregulation of CYP11B2 expression and DNA hypomethylation in the adrenal gland. Treatment with the angiotensin II type 1 receptor antagonist decreases CYP11B2 expression and leads to DNA hypermethylation. A close association between low DNA methylation and increased CYP11B2 expression are seen in the hearts of patients with hypertrophic cardiomyopathy. These results indicate that epigenetic regulation of both AGT and CYP11B2 contribute to the pathogenesis of cardiovascular diseases.
Collapse
|
17
|
Peigh G, Shah SJ, Patel RB. Left Atrial Myopathy in Atrial Fibrillation and Heart Failure: Clinical Implications, Mechanisms, and Therapeutic Targets. Curr Heart Fail Rep 2021; 18:85-98. [PMID: 33864224 DOI: 10.1007/s11897-021-00510-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW This review discusses the mechanisms, clinical implications, and treatments of left atrial (LA) myopathy in comorbid atrial fibrillation (AF) and heart failure (HF) across the spectrum of ejection fraction. RECENT FINDINGS AF and HF are highly comorbid conditions. Left atrial (LA) myopathy, characterized by impairments in LA structure, function, or electrical conduction, plays a fundamental role in the development of both AF and HF with preserved ejection fraction (AF-HFpEF) along with AF and HF with reduced ejection fraction (AF-HFrEF). While the nature of LA myopathy in AF-HFpEF is unique from that of AF-HFrEF, LA myopathy also leads to progression of both of these conditions. There may be a vulnerable cohort of AF-HF patients who have a disproportionate degree of LA myopathy compared with left ventricular (LV) dysfunction. Further investigations are required to identify therapies to improve LA function in this cohort.
Collapse
Affiliation(s)
- Graham Peigh
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Sanjiv J Shah
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ravi B Patel
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA. .,Division of Cardiology, Northwestern Memorial Hospital, 676 N St. Clair Suite 600, Chicago, IL, 60611, USA.
| |
Collapse
|
18
|
König P, Mayer O, Bruthans J, Seidlerová J, Mateřánková M, Gelžinský J, Rychecká M, Karnosová P, Wohlfahrt P, Cífková R, Filipovský J. The prognostic importance of subclinical heart failure in stable coronary heart disease patients. Acta Cardiol 2020; 75:329-336. [PMID: 30942129 DOI: 10.1080/00015385.2019.1590958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: In stable coronary heart disease (CHD) patients we aimed to assess the predictive potential of only mild increase of brain natriuretic peptide (BNP) in subjects free from symptoms or diagnostic criteria of heart failure (HF).Methods: We examined 967 patients, at least 6 months after myocardial infarction or coronary revascularization and divided them into three categories: 'overt HF' (NYHA II-IV, objective signs of HF, chronic treatment with furosemide and/or spironolactone or history of hospitalisation for HF), 'subclinical HF (BNP over 150 ng/mL, but no criterion of overt HF)' and 'no HF' (no above mentioned criterion present). Follow-up was done to assess 5-years all-cause mortality.Results: Overt and subclinical HF (by definition) had 38.8% and 9.6% of patients, respectively. In analyses adjusted for classical risk factors and other possible covariates, both overt and subclinical HF were independently associated with increased mortality compared to no HF subjects [hazard risk ratio 1.99 (95%CI:1.02-3.91) and 3.01 (95%CI:1.90-4.78), respectively. The risk of total mortality was similar in overt and subclinical HF patients [HRR 1.30 (95%CI: 0.72-2.36)]. Within overt HF group, those with BNP >150 ng/mL had also higher mortality risk than those with low BNP levels [HRR 2.79 (95%CI: 1.67-4.68)]. The addition of left ventricle ejection fraction into definition of HF groups did not affect main results.Conclusions: Mild increase of BNP in generally stable and asymptomatic CHD patients identifies high individual mortality risk in the same extend that presence of clinically manifest HF.
Collapse
Affiliation(s)
- Petr König
- Faculty of Medicine in Pilsen, Charles University and University Hospital, Pilsen, Czech Republic
| | - Otto Mayer
- Faculty of Medicine in Pilsen, Charles University and University Hospital, Pilsen, Czech Republic
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Jan Bruthans
- Faculty of Medicine in Pilsen, Charles University and University Hospital, Pilsen, Czech Republic
- Centre for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer’s Hospital, Prague, Czech Republic
| | - Jitka Seidlerová
- Faculty of Medicine in Pilsen, Charles University and University Hospital, Pilsen, Czech Republic
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Markéta Mateřánková
- Faculty of Medicine in Pilsen, Charles University and University Hospital, Pilsen, Czech Republic
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Julius Gelžinský
- Faculty of Medicine in Pilsen, Charles University and University Hospital, Pilsen, Czech Republic
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Martina Rychecká
- Faculty of Medicine in Pilsen, Charles University and University Hospital, Pilsen, Czech Republic
| | - Petra Karnosová
- Faculty of Medicine in Pilsen, Charles University and University Hospital, Pilsen, Czech Republic
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - Peter Wohlfahrt
- Centre for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer’s Hospital, Prague, Czech Republic
| | - Renata Cífková
- Centre for Cardiovascular Prevention of the First Faculty of Medicine, Charles University and Thomayer’s Hospital, Prague, Czech Republic
| | - Jan Filipovský
- Faculty of Medicine in Pilsen, Charles University and University Hospital, Pilsen, Czech Republic
- Biomedical Center, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| |
Collapse
|
19
|
Microvascular and lymphatic dysfunction in HFpEF and its associated comorbidities. Basic Res Cardiol 2020; 115:39. [PMID: 32451732 PMCID: PMC7248044 DOI: 10.1007/s00395-020-0798-y] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/13/2020] [Indexed: 02/07/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a complex heterogeneous disease for which our pathophysiological understanding is still limited and specific prevention and treatment strategies are lacking. HFpEF is characterised by diastolic dysfunction and cardiac remodelling (fibrosis, inflammation, and hypertrophy). Recently, microvascular dysfunction and chronic low-grade inflammation have been proposed to participate in HFpEF development. Furthermore, several recent studies demonstrated the occurrence of generalized lymphatic dysfunction in experimental models of risk factors for HFpEF, including obesity, hypercholesterolaemia, type 2 diabetes mellitus (T2DM), hypertension, and aging. Here, we review the evidence for a combined role of coronary (micro)vascular dysfunction and lymphatic vessel alterations in mediating key pathological steps in HFpEF, including reduced cardiac perfusion, chronic low-grade inflammation, and myocardial oedema, and their impact on cardiac metabolic alterations (oxygen and nutrient supply/demand imbalance), fibrosis, and cardiomyocyte stiffness. We focus primarily on HFpEF caused by metabolic risk factors, such as obesity, T2DM, hypertension, and aging.
Collapse
|
20
|
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) represents half of HF patients, who are more likely older, women, and hypertensive. Mortality rates in HFpEF are higher compared with age- and comorbidity-matched non-HF controls and lower than in HF with reduced ejection fraction (HFrEF); the majority (50-70%) are cardiovascular (CV) deaths. Among CV deaths, sudden death (SD) (~ 35%) and HF-death (~ 20%) are the leading cardiac modes of death; however, proportionally, CV deaths, SD, and HF-deaths are lower in HFpEF, while non-CV deaths constitute a higher proportion of deaths in HFpEF (30-40%) than in HFrEF (~ 15%). Importantly, the underlying mechanism of SD has not been clearly elucidated and non-arrhythmic SD may be more prominent in HFpEF than in HFrEF. Furthermore, there is no specific strategy for identifying high-risk patients, probably due to wide heterogeneity in presentation and pathophysiology of HFpEF and a plethora of comorbidities in this population. Thus, the management of HFpEF remains problematic due to paucity of data on the clinical benefits of current therapies, which focus on symptom relief and reduction of HF-hospitalization by controlling fluid retention and managing risk-factors and comorbidities. Matching a specific pathophysiology or mode of death with available and novel therapies may improve outcomes in HFpEF. However, this still remains an elusive target, as we need more information on determinants of SD. Implantable cardioverter-defibrillators (ICDs) have changed the landscape of SD prevention in HFrEF; if ICDs are to be applied to HFpEF, there must be a coordinated effort to identify and select high-risk patients.
Collapse
|
21
|
Effect of mineralocorticoid receptor antagonists on cardiac function in patients with heart failure and preserved ejection fraction: a systematic review and meta-analysis of randomized controlled trials. Heart Fail Rev 2020; 24:367-377. [PMID: 30618017 PMCID: PMC6477010 DOI: 10.1007/s10741-018-9758-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a disease with limited evidence-based treatment options. Mineralocorticoid receptor antagonists (MRA) offer benefit in heart failure with reduced ejection fraction (HFrEF), but their impact in HFpEF remains unclear. We therefore evaluated the effect of MRA on echocardiographic, functional, and systemic parameters in patients with HFpEF by a systematic review and meta-analysis. We searched MEDLINE, EMBASE, clinicaltrials.gov, and Cochrane Clinical Trial Collection to identify randomized controlled trials that (a) compared MRA versus placebo/control in patients with HFpEF and (b) reported echocardiographic, functional, and/or systemic parameters relevant to HFpEF. Studies were excluded if: they enrolled asymptomatic patients; patients with HFrEF; patients after an acute coronary event; compared MRA to another active comparator; or reported a follow-up of less than 6 months. Primary outcomes were changes in echocardiographic parameters. Secondary end-points were changes in functional capacity, quality of life measures, and systemic parameters. Quantitative analysis was performed by generating forest plots and calculating effect sizes by random-effect models. Between-study heterogeneity was assessed through Q and I2 statistics. Nine trials with 1164 patients were included. MRA significantly decreased E/e′ (mean difference − 1.37, 95% confidence interval − 1.72 to − 1.02), E/A (− 0.04, − 0.08 to 0.00), left ventricular end-diastolic diameter (− 0.78 mm, − 1.34 to − 0.22), left atrial volume index (− 1.12 ml/m2, − 1.91 to − 0.33), 6-min walk test distance (− 11.56 m, − 21 to − 2.13), systolic (− 4.75 mmHg, − 8.94 to − 0.56) and diastolic blood pressure (− 2.91 mmHg, − 4.15 to − 1.67), and increased levels of serum potassium (0.23 mmol/L, 0.19 to 0.28) when compared with placebo/control. In patients with HFpEF, MRA treatment significantly improves indices of cardiac structure and function, suggesting a decrease in left ventricular filling pressure and reverse cardiac remodeling. MRA increase serum potassium and decrease blood pressure; however, a small decrease in 6-min-walk distance is also noted. Larger prospective studies are warranted to provide definitive answers on the effect of MRA in patients with HFpEF.
Collapse
|
22
|
Safdar Z, Frost A, Basant A, Deswal A, O'Brian Smith E, Entman M. Spironolactone in pulmonary arterial hypertension: results of a cross-over study. Pulm Circ 2020; 10:2045894019898030. [PMID: 32426108 PMCID: PMC7219009 DOI: 10.1177/2045894019898030] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 12/07/2019] [Indexed: 11/15/2022] Open
Abstract
The renin-angiotensin-aldosterone system is implicated in the pathophysiology of pulmonary arterial hypertension. We undertook this study to determine the effects of spironolactone, a mineralocorticoid receptor blocker, on collagen metabolism in pulmonary arterial hypertension patients. After obtaining institutional review board approval and informed consent, 42 pulmonary arterial hypertension patients were prospectively enrolled and 35 patients completed the 16-week randomized double-blinded crossover clinical trial. Subjects received 50 mg spironolactone or placebo and at the end of week 8, treatment arm was switched. Circulating levels of collagen biomarkers, brain natriuretic peptide, and aldosterone levels were measured, and six-minute walk distance, liver function tests, and echocardiogram data were collected at weeks 0, 8, and 16. Mean age was 45 ± 15 years and 87% were females. At baseline, brain natriuretic peptide and aldosterone levels were 74 ± 95 pg/ml and 7 ± 8 pg/ml, respectively. There was no change in the levels of amino-terminal propeptide of procollagen type III (PIIINP), MMP-9, TIMP-1, and MMP-9/TIMP-1 ratio at weeks 8 and 16 compared to baseline values in placebo arm and treatment arm. The baseline six-min walk distance was 436 ± 115 meters at baseline and no change in walk distance was noted at weeks 8 and 16 (P = 0.372). None of the patients developed hyperkalemia or liver function test abnormalities at weeks 8 and 16 requiring discontinuation of study drug. Our study showed no change in collagen metabolite levels in pulmonary arterial hypertension patients treated with spironolactone. Spironolactone was safe and well tolerated by pulmonary arterial hypertension patients with no increased hyperkalemia or liver function test abnormalities.
Collapse
Affiliation(s)
- Zeenat Safdar
- Division of Pulmonary-Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Adaani Frost
- Division of Pulmonary-Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Arya Basant
- Division of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Anita Deswal
- Division of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - E O'Brian Smith
- Division of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Mark Entman
- Division of Cardiology, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
23
|
Neefs J, van den Berg NWE, Krul SPJ, Boekholdt SM, de Groot JR. Effect of Spironolactone on Atrial Fibrillation in Patients with Heart Failure with Preserved Ejection Fraction: Post-Hoc Analysis of the Randomized, Placebo-Controlled TOPCAT Trial. Am J Cardiovasc Drugs 2020; 20:73-80. [PMID: 31214914 PMCID: PMC6978290 DOI: 10.1007/s40256-019-00353-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Mineralocorticoid receptor antagonists (MRAs) reduce the risk of atrial fibrillation (AF) in patients with heart failure (HF) and a reduced ejection fraction. The efficacy of MRAs for AF prevention in patients with HF and a preserved ejection fraction (HFpEF) is unclear. Objectives We performed a secondary analysis of a randomized placebo-controlled trial to determine the efficacy of spironolactone in reducing new-onset AF and recurrence of AF in 2733 patients with symptomatic HFpEF. Methods Patients with and without prevalent AF at baseline were included, and those with permanent AF were excluded. Patients were randomized 1:1 to spironolactone or placebo. The risk of new-onset AF or the recurrence of AF was quantified using hazard ratios (HRs) with corresponding 95% confidence intervals (CIs). Results At baseline, 2228 (64.7%) patients had no history of AF (spironolactone, n = 1111; placebo, n = 1117), whereas 505 (18.4%) patients had prevalent AF (spironolactone, n = 260; placebo, n = 245). During a median follow-up of 3.1 years (interquartile range [IQR] 2.0–4.9), the incidence of new-onset AF was similar in both treatment arms: spironolactone 5.2% (n = 58) versus placebo 4.4% (n = 49); p = 0.41. The risk of new-onset AF was similar in both treatment arms: HR 1.19; 95% CI 0.81–1.74; p = 0.38. AF recurrence was also similar in both treatment arms during a median follow-up of 3.3 years (IQR 1.9–4.7): spironolactone 11.5% (n = 30) versus placebo 11.8% (n = 29); p = 1.00. The risk of recurrence of AF did not differ per treatment arm: HR 0.94; 95% CI 0.57–1.58; p = 0.83. Conclusion Spironolactone does not reduce the risk of new-onset AF or AF recurrence in patients with HFpEF. This is in contrast to results in cohorts of patients with HF and a reduced ejection fraction. Clinical trial registration ClinicalTrials.gov identifier no. NCT00094302 (TOPCAT). Electronic supplementary material The online version of this article (10.1007/s40256-019-00353-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Jolien Neefs
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Sébastien P J Krul
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | - Joris R de Groot
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands.
- Department of Cardiology, Amsterdam UMC, University van Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| |
Collapse
|
24
|
Moss ME, Carvajal B, Jaffe IZ. The endothelial mineralocorticoid receptor: Contributions to sex differences in cardiovascular disease. Pharmacol Ther 2019; 203:107387. [PMID: 31271793 PMCID: PMC6848769 DOI: 10.1016/j.pharmthera.2019.06.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 06/26/2019] [Indexed: 12/20/2022]
Abstract
Cardiovascular disease remains the leading cause of death for both men and women. The observation that premenopausal women are protected from cardiovascular disease relative to age-matched men, and that this protection is lost with menopause, has led to extensive study of the role of sex steroid hormones in the pathogenesis of cardiovascular disease. However, the molecular basis for sex differences in cardiovascular disease is still not fully understood, limiting the ability to tailor therapies to male and female patients. Therefore, there is a growing need to investigate molecular pathways outside of traditional sex hormone signaling to fully understand sex differences in cardiovascular disease. Emerging evidence points to the mineralocorticoid receptor (MR), a steroid hormone receptor activated by the adrenal hormone aldosterone, as one such mediator of cardiovascular disease risk, potentially serving as a sex-dependent link between cardiovascular risk factors and disease. Enhanced activation of the MR by aldosterone is associated with increased risk of cardiovascular disease. Emerging evidence implicates the MR specifically within the endothelial cells lining the blood vessels in mediating some of the sex differences observed in cardiovascular pathology. This review summarizes the available clinical and preclinical literature concerning the role of the MR in the pathophysiology of endothelial dysfunction, hypertension, atherosclerosis, and heart failure, with a special emphasis on sex differences in the role of endothelial-specific MR in these pathologies. The available data regarding the molecular mechanisms by which endothelial-specific MR may contribute to sex differences in cardiovascular disease is also summarized. A paradigm emerges from synthesis of the literature in which endothelial-specific MR regulates vascular function in a sex-dependent manner in response to cardiovascular risk factors to contribute to disease. Limitations in this field include the relative paucity of women in clinical trials and, until recently, the nearly exclusive use of male animals in preclinical investigations. Enhanced understanding of the sex-specific roles of endothelial MR could lead to novel mechanistic insights underlying sex differences in cardiovascular disease incidence and outcomes and could identify additional therapeutic targets to effectively treat cardiovascular disease in men and women.
Collapse
Affiliation(s)
- M Elizabeth Moss
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA, United States of America; Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, United States of America
| | - Brigett Carvajal
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA, United States of America; Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, United States of America
| | - Iris Z Jaffe
- Molecular Cardiology Research Institute, Tufts Medical Center, Boston, MA, United States of America; Sackler School of Graduate Biomedical Sciences, Tufts University School of Medicine, Boston, MA, United States of America.
| |
Collapse
|
25
|
Nagueh SF, Chang SM, Nabi F, Shah DJ, Estep JD. Cardiac Imaging in Patients With Heart Failure and Preserved Ejection Fraction. Circ Cardiovasc Imaging 2019; 10:CIRCIMAGING.117.006547. [PMID: 28838962 DOI: 10.1161/circimaging.117.006547] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/03/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Sherif F Nagueh
- From the Methodist DeBakey Heart and Vascular Center, Houston, TX; and Cardiovascular Imaging Institute Methodist Hospital, Houston, Texas.
| | - Su Min Chang
- From the Methodist DeBakey Heart and Vascular Center, Houston, TX; and Cardiovascular Imaging Institute Methodist Hospital, Houston, Texas
| | - Faisal Nabi
- From the Methodist DeBakey Heart and Vascular Center, Houston, TX; and Cardiovascular Imaging Institute Methodist Hospital, Houston, Texas
| | - Dipan J Shah
- From the Methodist DeBakey Heart and Vascular Center, Houston, TX; and Cardiovascular Imaging Institute Methodist Hospital, Houston, Texas
| | - Jerry D Estep
- From the Methodist DeBakey Heart and Vascular Center, Houston, TX; and Cardiovascular Imaging Institute Methodist Hospital, Houston, Texas
| |
Collapse
|
26
|
Xiang Y, Shi W, Li Z, Yang Y, Wang SY, Xiang R, Feng P, Wen L, Huang W. Efficacy and safety of spironolactone in the heart failure with mid-range ejection fraction and heart failure with preserved ejection fraction: A meta-analysis of randomized clinical trials. Medicine (Baltimore) 2019; 98:e14967. [PMID: 30921200 PMCID: PMC6456096 DOI: 10.1097/md.0000000000014967] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Recent studies have shown the efficacy for using spironolactone to treat heart failure with reduced ejection fraction (HFrEF), but the efficacy of spironolactone for heart failure with mid-range ejection fraction (HFmrEF) and heart failure with preserved ejection fraction (HFpEF) is unclear. This meta-analysis investigated the efficacy and safety of spironolactone in patients with HFmrEF and HFpEF. METHODS AND RESULTS We searched several databases including PubMed and the Cochrane Collaboration, for randomized controlled trials (RCTs) that assessed spironolactone treatment in HFmrEF and HFpEF. Eleven RCTs including 4539 patients were included. Spironolactone reduced hospitalizations (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.73-0.95; P = .006), improved New York Heart Association functional classifications (NYHA-FC) (OR, 0.35; 95% CI, 0.19-0.66; P = .001), decreased the levels of brain natriuretic peptide (BNP) (mean difference [MD], - 44.80 pg/mL; 95% CI, -73.44--16.17; P = .002), procollagen type I C-terminal propeptide (PICP) (MD, -27.04 ng/mL; 95% CI, -40.77--13.32, P < .001) in HFmrEF and HFpEF. Besides, it improved 6-minute walking distances (6-MWD) (standard weighted mean difference [SMD], 0.45 m; 95% CI, 0.27-0.64; P < .001), decreased amino-terminal peptide of procollagen type-III (PIIINP) (SMD, -0.37 μg/L; 95% CI, -0.59--0.15; P = .001) in HFpEF only. The risks of hyperkalemia (P<.001) and gynecomastia (P<.001) were increased. CONCLUSION Patients with HFmrEF and HFpEF could benefit from spironolactone treatment, with reduced hospitalizations, BNP levels, improved NYHA-FC, alleviated myocardial fibrosis by decreasing serum PICP in HFmrEF and HFpEF, decreased PIIINP levels and increased 6-MWD only in HFpEF. The risks of hyperkalemia and gynecomastia were significantly increased with the spironolactone treatment.
Collapse
Affiliation(s)
- Yajie Xiang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenhai Shi
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhuolin Li
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yunjing Yang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | | | - Rui Xiang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Panpan Feng
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Wen
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
27
|
Young MJ, Adler GK. Aldosterone, the Mineralocorticoid Receptor and Mechanisms of Cardiovascular Disease. VITAMINS AND HORMONES 2019; 109:361-385. [DOI: 10.1016/bs.vh.2018.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
|
28
|
Mineralocorticoid receptor: A hidden culprit for hemodialysis vascular access dysfunction. EBioMedicine 2018; 39:621-627. [PMID: 30527626 PMCID: PMC6354623 DOI: 10.1016/j.ebiom.2018.11.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/25/2018] [Accepted: 11/27/2018] [Indexed: 02/08/2023] Open
Abstract
Hemodialysis vascular access dysfunction is a common and intractable problem in clinical practice with no definitive therapy yet available. As a key mediator of vascular and cardiac maladaptive remodeling, mineralocorticoid receptor (MR) plays a pivotal role in vascular fibrosis and intimal hyperplasia (IH) and is potentiated locally in hemodialysis vascular access following diverse injuries, like barotrauma, cannulation and shear stress. MR-related genomic and non-genomic pathways are responsible for triggering vascular smooth muscle cell activation, proliferation, migration and extracellular matrix overproduction. In endothelial cells, MR signaling diminishes nitric oxide production and its bioavailability, but amplifies reactive oxygen species, leading to an inflammatory state. Moreover, MR favors macrophage polarization towards a pro-inflammatory phenotype. In clinical settings like post-angioplasty or stenting restenosis, the beneficial effect of MR antagonists on vascular fibrosis and IH has been validated. In aggregate, therapeutic targeting of MR may provide a new avenue to prevent hemodialysis vascular access dysfunction. MR signaling is instrumental in both insufficient outward remodeling and exuberant inward remodeling of AVF. The effects of MR in VSMC, endothelial cell, and macrophage act synergistically to promote IH and vascular fibrosis in AVF. Pharmacological targeting of MR represents a novel therapeutic strategy to prevent hemodialysis vascular access dysfunction.
Collapse
|
29
|
Kosmas CE, Silverio D, Sourlas A, Montan PD, Guzman E. Role of spironolactone in the treatment of heart failure with preserved ejection fraction. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:461. [PMID: 30603649 DOI: 10.21037/atm.2018.11.16] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Heart failure (HF) is the leading cause of morbidity and mortality globally. Heart failure with preserved ejection fraction (HFpEF) is currently responsible for about half of the patients affected with HF and is associated with impaired functional capacity, as well as significant morbidity due to frequent hospitalizations. Unfortunately, despite its poor prognosis, the management of HFpEF is very controversial and no therapy has been so far shown to reduce mortality in HFpEF. Spironolactone antagonizes the effect of aldosterone and can lead to a reduction in fibrosis and an improvement in left ventricular (LV) function. Furthermore, spironolactone decreases extracellular matrix turnover and myocardial collagen content and improves endothelial vasomotor dysfunction, mechanisms known to influence the progression of HF. Thus, given the aforementioned beneficial actions of spironolactone, extensive research has been conducted to explore the effects of spironolactone on HFpEF. Our review aims to present and discuss the clinical and scientific data pertaining to the role of spironolactone in the treatment of patients with HFpEF.
Collapse
Affiliation(s)
| | - Delia Silverio
- Cardiology Clinic, Cardiology Unlimited, PC, New York, NY, USA
| | | | - Peter D Montan
- Cardiology Clinic, Cardiology Unlimited, PC, New York, NY, USA
| | - Eliscer Guzman
- Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| |
Collapse
|
30
|
Effects of mineralocorticoid receptor antagonists on left ventricular diastolic function, exercise capacity, and quality of life in heart failure with preserved ejection fraction: a meta-analysis of randomized controlled trials. Heart Vessels 2018; 34:597-606. [DOI: 10.1007/s00380-018-1279-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 10/05/2018] [Indexed: 10/28/2022]
|
31
|
Nazário Leão R, Marques da Silva P, Marques Pocinho R, Alves M, Virella D, Palma dos Reis R. Determinants of left ventricular diastolic dysfunction in hypertensive patients. HIPERTENSION Y RIESGO VASCULAR 2018; 35:160-168. [DOI: 10.1016/j.hipert.2017.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/16/2017] [Accepted: 12/14/2017] [Indexed: 01/08/2023]
|
32
|
Clinical Characteristics and Outcomes in the Very Elderly Patients Hospitalized for Acute Heart Failure: Importance of Pharmacologic Guideline Adherence. Sci Rep 2018; 8:14270. [PMID: 30250052 PMCID: PMC6155282 DOI: 10.1038/s41598-018-32684-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 08/20/2018] [Indexed: 12/18/2022] Open
Abstract
The prognostic factors and pharmacological effects of the very elderly patients (aged ≥80 years) with acute heart failure (AHF) remain unclear. The study, therefore, investigated the prognostic impacts of the guideline-recommended pharmacological therapy in these patients. A cohort of 1297 very elderly patients [85.1 ± 4.0 years, 69.7% male, 32.6% heart failure with reduced left ventricular ejection fraction (LVEF), HFrEF], hospitalized for AHF, was studied. The percentage of the recommended prescription for HFrEF at discharge, including renin-angiotensin system inhibitors, β-blockers, and mineralocorticoid receptor antagonists, was calculated as guideline adherence indicator (GAI). Among the 1233 survivors at discharge, 495 subjects (40.1%) died during a mean follow-up of 27.1 ± 23.9 months. Mean GAIs in HFrEF and HFpEF were 70.6 ± 34.9% and 64.1 ± 35.9%, respectively. A higher GAI was associated with less overall mortality [hazard ratio and 95% confidence interval per-1SD: 0.781, 0.655–0.930] and cardiovascular death (0.718, 0.558–0.925), independent of age, gender, diabetes, hypertension, mean blood pressure, LVEF, eGFR, sodium, and NT-proBNP. A GAI of 100% was associated with a better survival in both HFrEF and HFpEF. A prescription of the three recommended medications for HFrEF to the very elderly AHF patients was associated with a better survival after discharge.
Collapse
|
33
|
Barandiarán Aizpurua A, Schroen B, van Bilsen M, van Empel V. Targeted HFpEF therapy based on matchmaking of human and animal models. Am J Physiol Heart Circ Physiol 2018; 315:H1670-H1683. [PMID: 30239232 DOI: 10.1152/ajpheart.00024.2018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The diversity in clinical phenotypes and poor understanding of the underlying pathophysiology of heart failure with preserved ejection fraction (HFpEF) is the main reason why no effective treatments have been found yet. Targeted, instead of one size fits all, treatment seems the only promising approach for treating HFpEF. To be able to design a targeted, phenotype-specific HFpEF treatment, the matrix relating clinical phenotypes and underlying pathophysiological mechanisms has to be clarified. This review discusses the opportunities for additional evaluation of the underlying pathophysiological processes, e.g., to evaluate biological phenotypes on top of clinical routine, to guide us toward a phenotype-specific HFpEF treatment. Moreover, a translational approach with matchmaking of animal models to biological HFpEF phenotypes will be a valuable step to test the effectiveness of novel, targeted interventions in HFpEF. Listen to this article's corresponding podcast at https://ajpheart.podbean.com/e/personalized-medicine-in-hfpef/ .
Collapse
Affiliation(s)
- Arantxa Barandiarán Aizpurua
- Department of Cardiology, Maastricht University Medical Centre , Maastricht , The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht , The Netherlands
| | - Blanche Schroen
- Department of Cardiology, Maastricht University Medical Centre , Maastricht , The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht , The Netherlands
| | - Marc van Bilsen
- Department of Cardiology, Maastricht University Medical Centre , Maastricht , The Netherlands.,Department of Physiology, Cardiovascular Research Institute Maastricht School for Cardiovascular Diseases, Maastricht University , Maastricht , The Netherlands
| | - Vanessa van Empel
- Department of Cardiology, Maastricht University Medical Centre , Maastricht , The Netherlands.,Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre , Maastricht , The Netherlands
| |
Collapse
|
34
|
Jia G, Aroor AR, Hill MA, Sowers JR. Role of Renin-Angiotensin-Aldosterone System Activation in Promoting Cardiovascular Fibrosis and Stiffness. Hypertension 2018; 72:537-548. [PMID: 29987104 PMCID: PMC6202147 DOI: 10.1161/hypertensionaha.118.11065] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Guanghong Jia
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, MO, 65212, USA
- Research Service, Truman Memorial Veterans Hospital, Columbia, MO, 65201, USA
| | - Annayya R. Aroor
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, MO, 65212, USA
- Research Service, Truman Memorial Veterans Hospital, Columbia, MO, 65201, USA
| | - Michael A. Hill
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, MO, 65212, USA
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO, 65211, USA
| | - James R. Sowers
- Diabetes and Cardiovascular Research Center, University of Missouri School of Medicine, Columbia, MO, 65212, USA
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, MO, 65212, USA
- Dalton Cardiovascular Research Center, University of Missouri, Columbia, MO, 65211, USA
- Research Service, Truman Memorial Veterans Hospital, Columbia, MO, 65201, USA
| |
Collapse
|
35
|
Abstract
More than 50% of patients with clinical heart failure have a preserved ejection fraction. Despite mortality that is similar to or slightly lower than heart failure with reduced ejection fraction, trials to date have not shown a therapy that imparts a mortality benefit in heart failure with preserved ejection fraction (HFpEF). HFpEF represents a heterogeneous disorder with a complex pathophysiologic basis, and this may contribute to the negative results in clinical trials. Geographic variations in both patient selection and adherence to study medications confound the interpretation of the trial results. Mineralocorticoid receptor antagonists may be useful in selected patients.
Collapse
Affiliation(s)
- Ajith Nair
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, 6620 Main Street, 12th Floor, Suite 1225, Houston, TX 77030, USA
| | - Anita Deswal
- Department of Medicine, Section of Cardiology, Baylor College of Medicine and Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030, USA.
| |
Collapse
|
36
|
Frangogiannis NG. Cardiac fibrosis: Cell biological mechanisms, molecular pathways and therapeutic opportunities. Mol Aspects Med 2018; 65:70-99. [PMID: 30056242 DOI: 10.1016/j.mam.2018.07.001] [Citation(s) in RCA: 505] [Impact Index Per Article: 84.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/23/2018] [Indexed: 12/13/2022]
Abstract
Cardiac fibrosis is a common pathophysiologic companion of most myocardial diseases, and is associated with systolic and diastolic dysfunction, arrhythmogenesis, and adverse outcome. Because the adult mammalian heart has negligible regenerative capacity, death of a large number of cardiomyocytes results in reparative fibrosis, a process that is critical for preservation of the structural integrity of the infarcted ventricle. On the other hand, pathophysiologic stimuli, such as pressure overload, volume overload, metabolic dysfunction, and aging may cause interstitial and perivascular fibrosis in the absence of infarction. Activated myofibroblasts are the main effector cells in cardiac fibrosis; their expansion following myocardial injury is primarily driven through activation of resident interstitial cell populations. Several other cell types, including cardiomyocytes, endothelial cells, pericytes, macrophages, lymphocytes and mast cells may contribute to the fibrotic process, by producing proteases that participate in matrix metabolism, by secreting fibrogenic mediators and matricellular proteins, or by exerting contact-dependent actions on fibroblast phenotype. The mechanisms of induction of fibrogenic signals are dependent on the type of primary myocardial injury. Activation of neurohumoral pathways stimulates fibroblasts both directly, and through effects on immune cell populations. Cytokines and growth factors, such as Tumor Necrosis Factor-α, Interleukin (IL)-1, IL-10, chemokines, members of the Transforming Growth Factor-β family, IL-11, and Platelet-Derived Growth Factors are secreted in the cardiac interstitium and play distinct roles in activating specific aspects of the fibrotic response. Secreted fibrogenic mediators and matricellular proteins bind to cell surface receptors in fibroblasts, such as cytokine receptors, integrins, syndecans and CD44, and transduce intracellular signaling cascades that regulate genes involved in synthesis, processing and metabolism of the extracellular matrix. Endogenous pathways involved in negative regulation of fibrosis are critical for cardiac repair and may protect the myocardium from excessive fibrogenic responses. Due to the reparative nature of many forms of cardiac fibrosis, targeting fibrotic remodeling following myocardial injury poses major challenges. Development of effective therapies will require careful dissection of the cell biological mechanisms, study of the functional consequences of fibrotic changes on the myocardium, and identification of heart failure patient subsets with overactive fibrotic responses.
Collapse
Affiliation(s)
- Nikolaos G Frangogiannis
- The Wilf Family Cardiovascular Research Institute, Department of Medicine (Cardiology), Albert Einstein College of Medicine, 1300 Morris Park Avenue, Forchheimer G46B, Bronx, NY, 10461, USA.
| |
Collapse
|
37
|
Li S, Zhang X, Dong M, Gong S, Shang Z, Jia X, Chen W, Yang J, Li J. Effects of spironolactone in heart failure with preserved ejection fraction: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97:e11942. [PMID: 30170387 PMCID: PMC6392615 DOI: 10.1097/md.0000000000011942] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is a common syndrome, accounting for more than one half of all heart failure patients, which is associated with high morbidity and mortality. But there is little evidence-based therapeutic strategies for the management of HFpEF. Previous studies reported the effects of spironolactone on HFpEF; however, the results were inconsistent. In this meta-analysis, we evaluated the effects of spironolactone on HFpEF. METHODS Articles were searched on PubMed, EMBASE, and COCHRANE databases before May, 2017, and were supplemented by hand searches of reference lists of included studies and review articles. Eligible articles were restricted to randomized controlled trials (RCTs). The odds ratios (ORs) of the dichotomous data, mean difference (MD) of continuous data, and 95% confidence intervals (CIs) were calculated to assess the effects of spironolactone in patients with HFpEF. RESULTS A total of 7 studies including 4147 participants were analyzed. There were significant improvements on the E/e' index (MD -1.38; 95% CI, -2.03 to -0.73; P < .0001) and E/A velocity ratio (MD -0.05; 95% CI, -0.10 to -0.00; P = .03) under spironolactone treatment compared with placebo, while there was no effect on the deceleration time (MD 1.04; 95% CI, -8.27 to 10.35; P = .83). Subgroup analyses on the E/A velocity ratio showed that there was obvious benefit from spironolactone therapy in patients with follow-up periods >6 months but not in those with follow-up periods ≤6 months. There was no reduction in all-cause mortality and hospitalization compared with placebo. And no improvement in 6-minute walk distance was seen compared with placebo. CONCLUSION This meta-analysis demonstrates that the use of spironolactone improves left ventricular diastolic function in patients with HFpEF, whereas it has no effect on all-cause mortality and hospitalization, and the 6-minute walk distance. Further larger size, multicenter, RCTs are required to confirm the effects of spironolactone on patients with HFpEF.
Collapse
Affiliation(s)
- Shuai Li
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Department of Cardiology, Qilu Hospital of Shandong University
| | - Xinling Zhang
- The Heart Center, Jining First People's Hospital, Jining, Shandong, China
| | - Mei Dong
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Department of Cardiology, Qilu Hospital of Shandong University
| | - Shu Gong
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Department of Cardiology, Qilu Hospital of Shandong University
| | - Zhi Shang
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Department of Cardiology, Qilu Hospital of Shandong University
| | - Xu Jia
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Department of Cardiology, Qilu Hospital of Shandong University
| | - Wenqiang Chen
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Department of Cardiology, Qilu Hospital of Shandong University
| | - Jianmin Yang
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Department of Cardiology, Qilu Hospital of Shandong University
| | - Jifu Li
- Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education and Chinese Ministry of Health, Department of Cardiology, Qilu Hospital of Shandong University
| |
Collapse
|
38
|
Thomas MC. Perspective Review: Type 2 Diabetes and Readmission for Heart Failure. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2018; 12:1179546818779588. [PMID: 29899670 PMCID: PMC5992798 DOI: 10.1177/1179546818779588] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/30/2018] [Indexed: 12/13/2022]
Abstract
Heart failure is a leading cause for hospitalisation and for readmission, especially in patients over the age of 65. Diabetes is an increasingly common companion to heart failure. The presence of diabetes and its associated comorbidity increases the risk of adverse outcomes and premature mortality in patients with heart failure. In particular, patients with diabetes are more likely to be readmitted to hospital soon after discharge. This may partly reflect the greater severity of heart disease in these patients. In addition, agents that reduce the chances of readmission such as β-blockers, renin-angiotensin-aldosterone system blockers, and mineralocorticoid receptor antagonists are underutilised because of the perceived increased risks of adverse drug reactions and other limitations. In some cases, readmission to hospital is precipitated by acute decompensation of heart failure (re-exacerbation) leading to pulmonary congestion and/or refractory oedema. However, it appears that for most of the patients admitted and then discharged with a primary diagnosis of heart failure, most readmissions are not due to heart failure, but rather due to comorbidity including arrhythmia, infection, adverse drug reactions, and renal impairment/reduced hydration. All of these are more common in patients who also have diabetes, and all may be partly preventable. The many different reasons for readmission underline the critical value of multidisciplinary comprehensive care in patients admitted with heart failure, especially those with diabetes. A number of new strategies are also being developed to address this area of need, including the use of SGLT2 inhibitors, novel nonsteroidal mineralocorticoid antagonists, and neprilysin inhibitors.
Collapse
Affiliation(s)
- Merlin C Thomas
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| |
Collapse
|
39
|
Collagen Type III Metabolism Evaluation in Patients with Malignant Head and Neck Cancer Treated with Radiotherapy. BIOMED RESEARCH INTERNATIONAL 2018; 2018:8702605. [PMID: 29780832 PMCID: PMC5892257 DOI: 10.1155/2018/8702605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 02/01/2018] [Accepted: 02/18/2018] [Indexed: 11/18/2022]
Abstract
Ionizing radiation affects the metabolism of key proteins of extracellular matrix including type III collagen, an important component of human skin. The aim of the work is an analysis of the impact of radical and palliative radiotherapy on collagen type III synthesis in patients with head and neck cancer. The test group consisted of 56 males with histopathologically confirmed head and neck cancer, for whom radiotherapy was applied as a form of radical or palliative treatment. The level of procollagen III aminoterminal propeptide (PIIINP), which is a marker of collagen type III synthesis, was determined in blood serum before radiotherapy, immediately following radiotherapy, and 3 months after it was finished. As a result of radical radiotherapy a statistically significant decrease of PIIINP levels in serum (p < 0.0001) was observed, both immediately after the radiotherapy and 3 months after the end of the treatment. Also the palliative radiotherapy caused a significant decrease of PIIINP right after the treatment (p = 0.0052), as well as during the examination performed 3 months later (p = 0.0004). The achieved results suggest that PIIINP can be used as a marker helpful in assessing radiation damage to connective tissue.
Collapse
|
40
|
Ravassa S, Trippel T, Bach D, Bachran D, González A, López B, Wachter R, Hasenfuss G, Delles C, Dominiczak AF, Pieske B, Díez J, Edelmann F. Biomarker-based phenotyping of myocardial fibrosis identifies patients with heart failure with preserved ejection fraction resistant to the beneficial effects of spironolactone: results from the Aldo-DHF trial. Eur J Heart Fail 2018; 20:1290-1299. [PMID: 29709099 DOI: 10.1002/ejhf.1194] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 02/19/2018] [Accepted: 03/12/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Myocardial fibrosis is characterized by excessive cross-linking and deposition of collagen type I and is involved in left ventricular stiffening and left ventricular diastolic dysfunction (LVDD). We investigated whether the effect of spironolactone on LVDD in patients with heart failure with preserved ejection fraction (HFpEF) depends on its effects on collagen cross-linking and/or deposition. METHODS AND RESULTS We investigated 381 HFpEF patients from the multicentre, randomized, placebo-controlled Aldo-DHF trial with measures of the E:e' ratio. The ratio of serum carboxy-terminal telopeptide of collagen type I to serum matrix metalloproteinase-1 (CITP:MMP-1, an inverse index of myocardial collagen cross-linking) and serum carboxy-terminal propeptide of procollagen type I (PICP, a direct index of myocardial collagen deposition) were determined at baseline and after 1-year treatment with spironolactone 25 mg once daily or placebo. Patients were classified by CITP:MMP-1 and PICP tertiles at baseline. While CITP:MMP-1 tertiles at baseline interacted (P < 0.05) with spironolactone effect on E:e', PICP tertiles did not. In fact, while spironolactone treatment did not modify E:e' in patients with lower CITP:MMP-1 levels, this ratio was significantly reduced in the remaining spironolactone-treated patients. In addition, PICP was unchanged in patients with lower CITP:MMP-1 levels but was reduced in the remaining spironolactone-treated patients. CONCLUSIONS A biochemical phenotype of high collagen cross-linking identifies HFpEF patients resistant to the beneficial effects of spironolactone on LVDD. It is suggested that excessive collagen cross-linking, which stabilizes collagen type I fibres, diminishes the ability of spironolactone to reduce collagen deposition in these patients.
Collapse
Affiliation(s)
- Susana Ravassa
- University of Navarra, CIMA, Program of Cardiovascular Diseases, IdiSNA, Navarra Institute for Health Research, Pamplona, Spain, CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Tobias Trippel
- Institute for Internal Medicine and Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Doris Bach
- Institute for Internal Medicine and Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Diana Bachran
- Institute for Internal Medicine and Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Arantxa González
- University of Navarra, CIMA, Program of Cardiovascular Diseases, IdiSNA, Navarra Institute for Health Research, Pamplona, Spain, CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Begoña López
- University of Navarra, CIMA, Program of Cardiovascular Diseases, IdiSNA, Navarra Institute for Health Research, Pamplona, Spain, CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Rolf Wachter
- Department of Cardiology and Pneumology, University of Göttingen Medical Centre Göttingen, Göttingen, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Gerd Hasenfuss
- Department of Cardiology and Pneumology, University of Göttingen Medical Centre Göttingen, Göttingen, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany
| | - Christian Delles
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Anna F Dominiczak
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Burkert Pieske
- Institute for Internal Medicine and Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,Deutsches Herzzentrum Berlin (DHZB), Department of Cardiology, Berlin, Germany
| | - Javier Díez
- University of Navarra, CIMA, Program of Cardiovascular Diseases, IdiSNA, Navarra Institute for Health Research, Pamplona, Spain, CIBERCV, Carlos III Institute of Health, Madrid, Spain.,University of Navarra Clinic, Departments of Cardiology and Cardiac Surgery, and Nephrology, Pamplona, Spain
| | - Frank Edelmann
- Institute for Internal Medicine and Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiology and Pneumology, University of Göttingen Medical Centre Göttingen, Göttingen, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Göttingen, Göttingen, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| |
Collapse
|
41
|
Krittanawong C, Kukin ML. Current Management and Future Directions of Heart Failure With Preserved Ejection Fraction: a Contemporary Review. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:28. [PMID: 29557071 DOI: 10.1007/s11936-018-0623-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF), a complex and debilitating syndrome, is commonly seen in elderly populations. Exacerbation of HFpEF is among the most common reasons for hospital admission in the USA. The high rate of morbidity and mortality from this condition underscores the fact that HFpEF is heterogeneous, complex, and poorly characterized. Randomized, controlled trials have been very successful at identifying treatments for HF with reduced ejection fraction (HFrEF), but effective treatment options for HFpEF are lacking. Here, we discuss (1) the pathophysiology of HFpEF, (2) a standardized diagnostic and therapeutic approach, (3) a comparison of the management of recent guidelines, and (4) challenges and future directions for HFpEF management. The authors believe that it is important to identify new subtypes of HFpEF to better classify genotypes and phenotypes of HFpEF and to develop novel targeted therapies. It is our hypothesis that big data analytics will shine new light on unique HFpEF phenotypes that better respond to treatment modalities.
Collapse
Affiliation(s)
- Chayakrit Krittanawong
- Division of Cardiovascular Diseases, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's Hospital, Mount Sinai Heart, 1000 10th Ave, New York, NY, 10019, USA.
| | - Marrick L Kukin
- Division of Cardiovascular Diseases, Icahn School of Medicine at Mount Sinai, Mount Sinai St. Luke's Hospital, Mount Sinai Heart, 1000 10th Ave, New York, NY, 10019, USA
| |
Collapse
|
42
|
Guasti L, Gaudio G, Lupi A, D'Avino M, Sala C, Mugellini A, Vulpis V, Felis S, Sarzani R, Vanasia M, Maffioli P, Derosa G. Ambulatory blood pressure parameters after canrenone addition to existing treatment regimens with maximum tolerated dose of angiotensin-converting enzyme inhibitors/angiotensin II type 1 receptor blockers plus hydrochlorothiazide in uncontrolled hypertensive patients. DRUG DESIGN DEVELOPMENT AND THERAPY 2017; 11:2293-2300. [PMID: 28831241 PMCID: PMC5552154 DOI: 10.2147/dddt.s134826] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Blockade of the renin-angiotensin-aldosterone system is a cornerstone in cardiovascular disease prevention and hypertension treatment. The relevance of ambulatory blood pressure monitoring (ABPM) has been widely confirmed for both increasing the accuracy of blood pressure (BP) measurements, particularly in pharmacological trials, and focusing on 24 h BP prognostic parameters. The aim of this study was to assess the effects of canrenone addition on ambulatory BP in uncontrolled hypertensive patients already treated with the highest tolerated dose of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II type 1 receptor (AT1R) antagonists plus hydrochlorothiazide (HCT). METHODS ABPM was performed at baseline and after 3 months of combination therapy in 158 outpatients with stage 1 or 2 hypertension who were randomized to add canrenone (50 or 100 mg) to the pre-existing therapy with ACE inhibitors or AT1R antagonists plus HCT. Twenty-four-hour systolic and diastolic BPs were considered normalized when the values were <130 and <80 mmHg, respectively. RESULTS The addition of canrenone was associated with a reduction in systolic and diastolic BPs (24 h and daytime and nighttime; P<0.001), mean arterial pressures (P<0.001), and pulse pressures (P<0.01). The Δ 24 h systolic/diastolic BPs were -13.5±11.2/-8±8 mmHg and -16.1±13.5/-11.2±8.3 mmHg (50 and 100 mg/day, respectively). In the 50 mg arm, the 24 h systolic and diastolic BPs were normalized in 67.5% and 74% of the patients, respectively, and in 61.6% and 68.5% of the patients in the 100 mg arm, respectively (P<0.05; P= not significant for 50 vs 100 mg). The percentage of patients whose nocturnal decrease was >10% with respect to diurnal values did not change during combination therapy. CONCLUSION Canrenone addition to ACE inhibitors or AT1R antagonists plus HCT was associated with a significant reduction of 24 h BP and to an increased number of patients meeting 24 h ABPM targets in a clinical setting of uncontrolled stage 1 or 2 hypertension.
Collapse
Affiliation(s)
- Luigina Guasti
- Research Center on Dyslipidemia, Internal Medicine 1, University of Insubria, Varese, Italy
| | - Giovanni Gaudio
- Internal Medicine Division, Ospedale Angelo Bellini, ASST Valle Olona Somma, Varese, Italy
| | - Alessandro Lupi
- Cardiology Unit, ASL VCO Verbania-Domodossola, Verbania, Italy
| | - Marinella D'Avino
- Unit for the Treatment of Arterial Hypertension, Ospedale Cardarelli, Napoli, Italy
| | - Carla Sala
- Department of Clinical Sciences and Community Health, University of Milan, Milano, Italy.,Cardiovascular Unit, Fondazione IRCCSS Policlinico, Milano, Italy
| | - Amedeo Mugellini
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Vito Vulpis
- Unit for the Diagnosis and Treatment of Arterial Hypertension, Department of Internal Medicine, Policlinico di Bari, Bari, Italy
| | | | - Riccardo Sarzani
- ESH Center of Hypertension, Internal Medicine and Geriatrics, University Politecnica delle Marche, Ancona, Italy.,IRCCS-INRCA, Ancona, Italy
| | | | - Pamela Maffioli
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Giuseppe Derosa
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| |
Collapse
|
43
|
Designing Future Clinical Trials in Heart Failure With Preserved Ejection Fraction: Lessons From TOPCAT. Curr Heart Fail Rep 2017. [DOI: 10.1007/s11897-017-0336-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
|
44
|
Hegde SM, Claggett B, Shah AM, Lewis EF, Anand I, Shah SJ, Sweitzer NK, Fang JC, Pitt B, Pfeffer MA, Solomon SD. Physical Activity and Prognosis in the TOPCAT Trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist). Circulation 2017. [PMID: 28637881 DOI: 10.1161/circulationaha.117.028002] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Physical activity (PA) is inversely associated with adverse cardiovascular outcomes in healthy populations, but the impact of physical activity in patients with heart failure (HF) with preserved ejection fraction is less well characterized. METHODS The baseline self-reported PA of 1751 subjects enrolled in the Americas region of the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) was categorized as poor, intermediate, or ideal PA with American Heart Association criteria. PA was related to the primary composite outcome (HF hospitalization, cardiovascular mortality, or aborted cardiac arrest), its components, and all-cause mortality with the use of multivariable Cox models. RESULTS The mean age at enrollment was 68.6±9.6 years. Few patients met American Heart Association criteria for ideal activity (11% ideal, 14% intermediate, 75% poor). Over a median follow-up of 2.4 years, the primary composite outcome occurred in 519 patients (397 HF hospitalizations, 222 cardiovascular deaths, and 6 aborted cardiac arrests). Compared with those with ideal baseline PA, poor and intermediate baseline PA was associated with a greater risk of the primary outcome (hazard ratio [HR], 2.05; 95% confidence interval [CI], 1.28-3.28; HR, 1.95; 95% CI, 1.15-3.33, respectively), HF hospitalization (HR, 1.93; 95% CI, 1.16-3.22; HR, 1.84; 95% CI, 1.02-3.31), cardiovascular mortality (HR, 4.36; 95% CI, 1.37-13.83; HR, 4.05; 95% CI, 1.17-14.04), and all-cause mortality (HR, 2.95; 95% CI, 1.44-6.02; HR, 2.05; 95% CI, 0.90-4.67) after multivariable adjustment for potential confounders. CONCLUSIONS In patients with HF with preserved ejection fraction, both poor and intermediate self-reported PA were associated with higher risk of HF hospitalization and mortality. CLINICAL TRIAL REGISTRATION URL: https://clinicaltrials.gov. Unique identifier: NCT00094302.
Collapse
Affiliation(s)
- Sheila M Hegde
- From Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.M.H., B.C., A.M.S., E.F.L., M.A.P., S.D.S.); Department of Cardiology, VA Medical Center and Division of Cardiovascular Medicine, University of Minnesota, Minneapolis (I.A.); Cardiology Division, Northwestern University, Chicago, IL (S.J.S.); Division of Cardiology, University of Arizona, Tucson (N.K.S.); Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.D.F.); and Cardiovascular Medicine Division, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Brian Claggett
- From Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.M.H., B.C., A.M.S., E.F.L., M.A.P., S.D.S.); Department of Cardiology, VA Medical Center and Division of Cardiovascular Medicine, University of Minnesota, Minneapolis (I.A.); Cardiology Division, Northwestern University, Chicago, IL (S.J.S.); Division of Cardiology, University of Arizona, Tucson (N.K.S.); Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.D.F.); and Cardiovascular Medicine Division, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Amil M Shah
- From Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.M.H., B.C., A.M.S., E.F.L., M.A.P., S.D.S.); Department of Cardiology, VA Medical Center and Division of Cardiovascular Medicine, University of Minnesota, Minneapolis (I.A.); Cardiology Division, Northwestern University, Chicago, IL (S.J.S.); Division of Cardiology, University of Arizona, Tucson (N.K.S.); Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.D.F.); and Cardiovascular Medicine Division, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Eldrin F Lewis
- From Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.M.H., B.C., A.M.S., E.F.L., M.A.P., S.D.S.); Department of Cardiology, VA Medical Center and Division of Cardiovascular Medicine, University of Minnesota, Minneapolis (I.A.); Cardiology Division, Northwestern University, Chicago, IL (S.J.S.); Division of Cardiology, University of Arizona, Tucson (N.K.S.); Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.D.F.); and Cardiovascular Medicine Division, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Inder Anand
- From Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.M.H., B.C., A.M.S., E.F.L., M.A.P., S.D.S.); Department of Cardiology, VA Medical Center and Division of Cardiovascular Medicine, University of Minnesota, Minneapolis (I.A.); Cardiology Division, Northwestern University, Chicago, IL (S.J.S.); Division of Cardiology, University of Arizona, Tucson (N.K.S.); Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.D.F.); and Cardiovascular Medicine Division, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Sanjiv J Shah
- From Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.M.H., B.C., A.M.S., E.F.L., M.A.P., S.D.S.); Department of Cardiology, VA Medical Center and Division of Cardiovascular Medicine, University of Minnesota, Minneapolis (I.A.); Cardiology Division, Northwestern University, Chicago, IL (S.J.S.); Division of Cardiology, University of Arizona, Tucson (N.K.S.); Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.D.F.); and Cardiovascular Medicine Division, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Nancy K Sweitzer
- From Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.M.H., B.C., A.M.S., E.F.L., M.A.P., S.D.S.); Department of Cardiology, VA Medical Center and Division of Cardiovascular Medicine, University of Minnesota, Minneapolis (I.A.); Cardiology Division, Northwestern University, Chicago, IL (S.J.S.); Division of Cardiology, University of Arizona, Tucson (N.K.S.); Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.D.F.); and Cardiovascular Medicine Division, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - James C Fang
- From Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.M.H., B.C., A.M.S., E.F.L., M.A.P., S.D.S.); Department of Cardiology, VA Medical Center and Division of Cardiovascular Medicine, University of Minnesota, Minneapolis (I.A.); Cardiology Division, Northwestern University, Chicago, IL (S.J.S.); Division of Cardiology, University of Arizona, Tucson (N.K.S.); Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.D.F.); and Cardiovascular Medicine Division, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Bertram Pitt
- From Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.M.H., B.C., A.M.S., E.F.L., M.A.P., S.D.S.); Department of Cardiology, VA Medical Center and Division of Cardiovascular Medicine, University of Minnesota, Minneapolis (I.A.); Cardiology Division, Northwestern University, Chicago, IL (S.J.S.); Division of Cardiology, University of Arizona, Tucson (N.K.S.); Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.D.F.); and Cardiovascular Medicine Division, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Marc A Pfeffer
- From Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.M.H., B.C., A.M.S., E.F.L., M.A.P., S.D.S.); Department of Cardiology, VA Medical Center and Division of Cardiovascular Medicine, University of Minnesota, Minneapolis (I.A.); Cardiology Division, Northwestern University, Chicago, IL (S.J.S.); Division of Cardiology, University of Arizona, Tucson (N.K.S.); Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.D.F.); and Cardiovascular Medicine Division, University of Michigan School of Medicine, Ann Arbor (B.P.)
| | - Scott D Solomon
- From Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.M.H., B.C., A.M.S., E.F.L., M.A.P., S.D.S.); Department of Cardiology, VA Medical Center and Division of Cardiovascular Medicine, University of Minnesota, Minneapolis (I.A.); Cardiology Division, Northwestern University, Chicago, IL (S.J.S.); Division of Cardiology, University of Arizona, Tucson (N.K.S.); Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.D.F.); and Cardiovascular Medicine Division, University of Michigan School of Medicine, Ann Arbor (B.P.).
| |
Collapse
|
45
|
Pandey A, Berry JD. Invited Commentary: Searching for the Perfect Measure of Diastolic Dysfunction-A Futile Exercise? Am J Epidemiol 2017; 185:1228-1230. [PMID: 28453609 DOI: 10.1093/aje/kww215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 10/28/2016] [Indexed: 01/01/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is common, recalcitrant to treatment, and associated with poor outcomes. Diastolic dysfunction (DD) is an independent predictor of HFpEF risk, associated clinical manifestations, and long-term outcomes. However, the usefulness of diastolic function assessment is limited by the heterogeneity in the existing definitions of DD. In this issue of the Journal, Rasmussen-Torvik et al. (Am J Epidemiol. 2017;185(12):1221-1227) have highlighted this problem by evaluating the prevalence and concordance of 4 established definitions of DD in the Coronary Artery Risk Development in Young Adults (CARDIA) cohort. The authors demonstrate significant variability in prevalence of DD and its association with established risk factors across the different definitions. These findings suggest that the current 1-dimensional approach to HFpEF risk prediction based on noninvasive measures of diastolic function may not be optimal. Perhaps the future of HFpEF risk assessment lies in a multimodality approach that combines the relevant echocardiographic measures of diastolic function with blood-based biomarkers (such as N-terminal prohormone of brain natriuretic peptide (NT-proBNP)) and a measure of functional status (such as exercise capacity).
Collapse
Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jarett D. Berry
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
46
|
Ferreira JP, Mentz RJ, Pizard A, Pitt B, Zannad F. Tailoring mineralocorticoid receptor antagonist therapy in heart failure patients: are we moving towards a personalized approach? Eur J Heart Fail 2017; 19:974-986. [DOI: 10.1002/ejhf.814] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/30/2016] [Accepted: 02/21/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- João Pedro Ferreira
- Centre d'Investigation Clinique Plurithématique 1433, INSERM U1116; University of Lorraine; Nancy France
- Department of Physiology and Cardiothoracic Surgery; Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto; Porto Portugal
| | - Robert J. Mentz
- Duke Clinical Research Institute and Division of Cardiology, Department of Medicine; Duke University Medical Center; Durham NC USA
| | - Anne Pizard
- Centre d'Investigation Clinique Plurithématique 1433, INSERM U1116; University of Lorraine; Nancy France
| | - Bertram Pitt
- Department of Cardiology; University of Michigan School of Medicine; Ann Arbor MI USA
| | - Faiez Zannad
- Centre d'Investigation Clinique Plurithématique 1433, INSERM U1116; University of Lorraine; Nancy France
| |
Collapse
|
47
|
Nazário Leão R, Marques da Silva P. Diastolic dysfunction in hypertension. HIPERTENSION Y RIESGO VASCULAR 2017; 34:128-139. [PMID: 28268171 DOI: 10.1016/j.hipert.2017.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 01/26/2017] [Indexed: 12/21/2022]
Abstract
Hypertension and coronary heart disease, often coexisting, are the most common risk factors for heart failure. The progression of hypertensive heart disease involves myocardial fibrosis and alterations in the left ventricular geometry that precede the functional change, initially asymptomatic. The left ventricular diastolic dysfunction is part of this continuum being defined by the presence of left ventricular diastolic dysfunction without signs or symptoms of heart failure or poor left ventricular systolic function. It is highly prevalent in hypertensive patients and is associated with increased cardiovascular morbidity and mortality. Despite its growing importance in clinical practice it remains poorly understood. This review aims to present the epidemiological fundamentals and the latest developments in the pathophysiology, diagnosis and treatment of left ventricular diastolic dysfunction.
Collapse
Affiliation(s)
- R Nazário Leão
- Unidade Funcional Medicina 2, Hospital São José, Centro Hospitalar Lisboa Central - EPE, Lisboa, Portugal; Nova Medical School, Lisboa, Portugal.
| | - P Marques da Silva
- Nova Medical School, Lisboa, Portugal; Núcleo de Investigação Arterial, Unidade Funcional Medicina 4, Hospital Santa Marta, Centro Hospitalar Lisboa Central - EPE, Lisboa, Portugal
| |
Collapse
|
48
|
Role of mineralocorticoid receptor activation in cardiac diastolic dysfunction. Biochim Biophys Acta Mol Basis Dis 2016; 1863:2012-2018. [PMID: 27989961 DOI: 10.1016/j.bbadis.2016.10.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 09/29/2016] [Accepted: 10/26/2016] [Indexed: 02/07/2023]
Abstract
The prevalence of cardiac diastolic dysfunction and heart failure with preserved ejection, a major cause of morbidity and mortality in the western world, is increasing due, in part, to increases in obesity and type 2 diabetes. Characteristics of cardiac diastolic dysfunction include increased myocardial stiffness and impaired left ventricular (LV) relaxation that is characterized by prolonged isovolumic LV relaxation and slow LV filling. Obesity, insulin resistance and type 2 diabetes, especially in females promote activation of mineralocorticoid receptor (MR) signaling with resultant increases in oxidative stress, maladaptive immune responses, inflammation, and impairment of coronary blood flow and cardiac interstitial fibrosis. This review highlights findings from the recent surge in cardiac diastolic dysfunction research. To this end it highlights our contemporary understanding of molecular mechanisms of MR regulation by genetic, epigenetic and posttranslational modifications and resultant cardiac diastolic dysfunction associated with insulin resistance, obesity and type 2 diabetes. This review also explores potential preventative and therapeutic strategies directed in the prevention of cardiac diastolic dysfunction and heart failure with preserved ejection. This article is part of a Special Issue entitled: Genetic and epigenetic control of heart failure edited by Dr. Jun Ren & Yingmei Zhang.
Collapse
|
49
|
Zheng SL, Chan FT, Maclean E, Jayakumar S, Nabeebaccus AA. Reporting trends of randomised controlled trials in heart failure with preserved ejection fraction: a systematic review. Open Heart 2016; 3:e000449. [PMID: 27547434 PMCID: PMC4975871 DOI: 10.1136/openhrt-2016-000449] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 06/14/2016] [Accepted: 06/22/2016] [Indexed: 12/31/2022] Open
Abstract
Background Heart failure with preserved ejection fraction (HFpEF) causes significant cardiovascular morbidity and mortality. Current consensus guidelines reflect the neutral results from randomised controlled trials (RCTs). Adequate trial reporting is a fundamental requirement before concluding on RCT intervention efficacy and is necessary for accurate meta-analysis and to provide insight into future trial design. The Consolidated Standards of Reporting Trials (CONSORT) 2010 statement provides a framework for complete trial reporting. Reporting quality of HFpEF RCTs has not been previously assessed, and this represents an important validation of reporting qualities to date. Objectives The aim was to systematically identify RCTs investigating the efficacy of pharmacological therapies in HFpEF and to assess the quality of reporting using the CONSORT 2010 statement. Methods MEDLINE, EMBASE and CENTRAL databases were searched from January 1996 to November 2015, with RCTs assessing pharmacological therapies on clinical outcomes in HFpEF patients included. The quality of reporting was assessed against the CONSORT 2010 checklist. Results A total of 33 RCTs were included. The mean CONSORT score was 55.4% (SD 17.2%). The CONSORT score was strongly correlated with journal impact factor (r=0.53, p=0.003) and publication year (r=0.50, p=0.003). Articles published after the introduction of CONSORT 2010 statement had a significantly higher mean score compared with those published before (64% vs 50%, p=0.02). Conclusions Although the CONSORT score has increased with time, a significant proportion of HFpEF RCTs showed inadequate reporting standards. The level of adherence to CONSORT criteria could have an impact on the validity of trials and hence the interpretation of intervention efficacy. We recommend improving compliance with the CONSORT statement for future RCTs.
Collapse
Affiliation(s)
- Sean L Zheng
- Department of Cardiology , King's College Hospital , London , UK
| | - Fiona T Chan
- East Sussex Healthcare NHS Trust , East Sussex , UK
| | | | - Shruti Jayakumar
- King's College London GKT School of Medical Education , London , UK
| | | |
Collapse
|
50
|
Lother A, Hein L. Pharmacology of heart failure: From basic science to novel therapies. Pharmacol Ther 2016; 166:136-49. [PMID: 27456554 DOI: 10.1016/j.pharmthera.2016.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Accepted: 07/08/2016] [Indexed: 01/10/2023]
Abstract
Chronic heart failure is one of the leading causes for hospitalization in the United States and Europe, and is accompanied by high mortality. Current pharmacological therapy of chronic heart failure with reduced ejection fraction is largely based on compounds that inhibit the detrimental action of the adrenergic and the renin-angiotensin-aldosterone systems on the heart. More than one decade after spironolactone, two novel therapeutic principles have been added to the very recently released guidelines on heart failure therapy: the HCN-channel inhibitor ivabradine and the combined angiotensin and neprilysin inhibitor valsartan/sacubitril. New compounds that are in phase II or III clinical evaluation include novel non-steroidal mineralocorticoid receptor antagonists, guanylate cyclase activators or myosine activators. A variety of novel candidate targets have been identified and the availability of gene transfer has just begun to accelerate translation from basic science to clinical application. This review provides an overview of current pharmacology and pharmacotherapy in chronic heart failure at three stages: the updated clinical guidelines of the American Heart Association and the European Society of Cardiology, new drugs which are in clinical development, and finally innovative drug targets and their mechanisms in heart failure which are emerging from preclinical studies will be discussed.
Collapse
Affiliation(s)
- Achim Lother
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Heart Center, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Lutz Hein
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany; BIOSS Centre for Biological Signaling Studies, University of Freiburg, Freiburg, Germany.
| |
Collapse
|