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Mayuga KA, Fedorowski A, Ricci F, Gopinathannair R, Dukes JW, Gibbons C, Hanna P, Sorajja D, Chung M, Benditt D, Sheldon R, Ayache MB, AbouAssi H, Shivkumar K, Grubb BP, Hamdan MH, Stavrakis S, Singh T, Goldberger JJ, Muldowney JAS, Belham M, Kem DC, Akin C, Bruce BK, Zahka NE, Fu Q, Van Iterson EH, Raj SR, Fouad-Tarazi F, Goldstein DS, Stewart J, Olshansky B. Sinus Tachycardia: a Multidisciplinary Expert Focused Review. Circ Arrhythm Electrophysiol 2022; 15:e007960. [PMID: 36074973 PMCID: PMC9523592 DOI: 10.1161/circep.121.007960] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.
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Affiliation(s)
- Kenneth A. Mayuga
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Artur Fedorowski
- Karolinska Institutet & Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G.d’Annunzio” University of Chieti-Pescara, Chieti Scalo, Italy
| | | | | | | | | | | | - Mina Chung
- Section of Cardiac Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Phoenix, AZ
| | - David Benditt
- University of Minnesota Medical School, Minneapolis, MN
| | | | - Mirna B. Ayache
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Hiba AbouAssi
- Division of Endocrinology, Metabolism, and Nutrition, Duke University Medical Center, Durham, NC
| | | | | | | | | | - Tamanna Singh
- Department of Cardiovascular Medicine, Cleveland Clinic, OH
| | | | - James A. S. Muldowney
- Vanderbilt University Medical Center &Tennessee Valley Healthcare System, Nashville Campus, Department of Veterans Affairs, Nashville, TN
| | - Mark Belham
- Cambridge University Hospitals NHS FT, Cambridge, UK
| | - David C. Kem
- University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Cem Akin
- University of Michigan, Ann Arbor, MI
| | | | - Nicole E. Zahka
- Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Qi Fu
- Institute for Exercise and Environmental Medicine at Texas Health Presbyterian Hospital Dallas & University of Texas Southwestern Medical Center, Dallas, TX
| | - Erik H. Van Iterson
- Section of Preventive Cardiology & Rehabilitation, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic Cleveland, OH
| | - Satish R Raj
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Fedorowski A, Ricci F, Hamrefors V, Sandau KE, Chung TH, Muldowney JAS, Gopinathannair R, Olshansky B. Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem. Circ Arrhythm Electrophysiol 2022; 15:e010573. [PMID: 35212554 PMCID: PMC9049902 DOI: 10.1161/circep.121.010573] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.
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Affiliation(s)
- Artur Fedorowski
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Neuroscience, Imaging & Clinical Sciences, “G.d’Annunzio” University, Chieti-Pescara
- Casa di Cura Villa Serena, Città Sant’Angelo, Italy
| | - Viktor Hamrefors
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Tae Hwan Chung
- Dept of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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Wahba A, Shibao CA, Muldowney JAS, Peltier A, Habermann R, Biaggioni I. Management of Orthostatic Hypotension in the Hospitalized Patient: A Narrative Review. Am J Med 2022; 135:24-31. [PMID: 34416163 PMCID: PMC8688312 DOI: 10.1016/j.amjmed.2021.07.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/22/2021] [Accepted: 07/22/2021] [Indexed: 01/03/2023]
Abstract
Orthostatic hypotension is a frequent cause of falls and syncope, impairing quality of life. It is an independent risk factor of mortality and a common cause of hospitalizations, which exponentially increases in the geriatric population. We present a management plan based on a systematic literature review and understanding of the underlying pathophysiology and relevant clinical pharmacology. Initial treatment measures include removing offending medications and avoiding large meals. Clinical assessment of the patients' residual sympathetic tone can aid in the selection of initial therapy between norepinephrine "enhancers" or "replacers." Role of splanchnic venous pooling is overlooked, and applying abdominal binders to improve venous return may be effective. The treatment goal is not normalizing upright blood pressure but increasing it above the cerebral autoregulation threshold required to improve symptoms. Hypertension is the most common associated comorbidity, and confining patients to bed while using pressor agents only increases supine blood pressure, leading to worsening pressure diuresis and orthostatic hypotension. Avoiding bedrest deconditioning and using pressors as part of an orthostatic rehab program are crucial in reducing hospital stay.
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Affiliation(s)
- Amr Wahba
- Department of Medicine; Division of Clinical Pharmacology
| | | | | | | | - Ralf Habermann
- Department of Medicine; Geriatric Medicine, Vanderbilt University Medical Center, Nashville, Tenn
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Benge C, Pouliot J, Muldowney JAS. Evaluation of a Clinical Pharmacist Specialist Transition of Care Pathway to Manage Heart Failure Readmissions During a Provider Shortage. J Pharm Pract 2021; 35:929-939. [PMID: 34060365 DOI: 10.1177/08971900211017484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence supports scheduling early follow-up after heart failure (HF) hospitalization with a provider capable of managing hypervolemia. Often this service is provided by cardiologists or specialty nurse practitioners. Continuity or "familiar" providers may be better positioned to identify decompensating HF in patients who have advanced HF and/or multiple complicating medical problems. The objective of this study was to evaluate whether a clinical pharmacy specialist (CPS) service, covering the role of a "familiar" provider in an advanced HF specialty clinic (AHFC) during a staffing shortage, may prevent readmission metrics from worsening. METHODS We evaluated the entire, eligible concurrent cohorts, representing 175 AHFC-CPS and 273 control patient-admissions, respectively. Study- and disease-specific predictors for readmission were assessed. A matched cohort of 202 patient-admissions (101 AHFC-CPS:101 NO-CPS) were evaluated. RESULTS Subjects were predominantly white, elderly males. While overall "clinic [performance] profiling" outcomes for readmissions (p = 0.43) and mortality (p = 0.66) did not statistically differ between the AHFC-CPS and NO-CPS groups, an imbalance in severity of illness persisted. A survival curve and analysis were constructed, and the hazard ratio for all-cause mortality was 0.69 (p = 0.033). CONCLUSIONS This retrospective project supports the premise that AHFC-CPS intervention may be a suitable alternative to maintain the volume status for AHFC patients during a staffing short-fall. More work needs to be done to determine intervention effect size, predictors for readmission, specifically in advanced cardiovascular disease, and to evaluate CPS opportunities in the provision of independent HF care, particularly for patients with advanced HF.
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Affiliation(s)
- Cassandra Benge
- 20106VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Jonathon Pouliot
- 5707Lipscomb University College of Pharmacy and Health Sciences, Nashville, TN, USA
| | - James A S Muldowney
- 20106VA Tennessee Valley Healthcare System, Nashville, TN, USA.,Vanderbilt University Medical Center, Nashville, TN, USA
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Okamoto LE, Celedonio JE, Smith EC, Gamboa A, Shibao CA, Diedrich A, Paranjape SY, Black BK, Muldowney JAS, Peltier AC, Habermann R, Crandall CG, Biaggioni I. Local Passive Heat for the Treatment of Hypertension in Autonomic Failure. J Am Heart Assoc 2021; 10:e018979. [PMID: 33739123 PMCID: PMC8174330 DOI: 10.1161/jaha.120.018979] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Supine hypertension affects a majority of patients with autonomic failure; it is associated with end‐organ damage and can worsen daytime orthostatic hypotension by inducing pressure diuresis and volume loss during the night. Because sympathetic activation prevents blood pressure (BP) from falling in healthy subjects exposed to heat, we hypothesized that passive heat had a BP‐lowering effect in patients with autonomic failure and could be used to treat their supine hypertension. Methods and Results In Protocol 1 (n=22), the acute effects of local heat (40–42°C applied with a heating pad placed over the abdomen for 2 hours) versus sham control were assessed in a randomized crossover fashion. Heat acutely decreased systolic BP by −19±4 mm Hg (versus 3±4 with sham, P<0.001) owing to decreases in stroke volume (−18±5% versus −4±4%, P=0.013 ) and cardiac output (−15±5% versus −2±4%, P=0.013). In Protocol 2 (proof‐of‐concept overnight study; n=12), we compared the effects of local heat (38°C applied with a water‐perfused heating pad placed under the torso from 10 pm to 6 am) versus placebo pill. Heat decreased nighttime systolic BP (maximal change −28±6 versus −2±6 mm Hg, P<0.001). BP returned to baseline by 8 am. The nocturnal systolic BP decrease correlated with a decrease in urinary volume (r=0.57, P=0.072) and an improvement in the morning upright systolic BP (r=−0.76, P=0.007). Conclusions Local heat therapy effectively lowered overnight BP in patients with autonomic failure and supine hypertension and offers a novel approach to treat this condition. Future studies are needed to assess the long‐term safety and efficacy in improving nighttime fluid loss and daytime orthostatic hypotension. Registration URL: https://www.clinicaltrials.gov; Unique identifiers: NCT02417415 and NCT03042988.
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Affiliation(s)
- Luis E Okamoto
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Jorge E Celedonio
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Emily C Smith
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Alfredo Gamboa
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Cyndya A Shibao
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - André Diedrich
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN.,Department of Biomedical Engineering Vanderbilt University Medical Center Nashville TN
| | - Sachin Y Paranjape
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Bonnie K Black
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - James A S Muldowney
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Division of Cardiology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Amanda C Peltier
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Neurology Vanderbilt University Medical Center Nashville TN
| | - Ralf Habermann
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Division of Geriatrics Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN
| | - Craig G Crandall
- Institute for Exercise and Environmental Medicine Texas Health Presbyterian Hospital and UT Southwestern Medical Center Dallas TX
| | - Italo Biaggioni
- Vanderbilt Autonomic Dysfunction Center Vanderbilt University Medical Center Nashville TN.,Division of Clinical Pharmacology Vanderbilt University Medical Center Nashville TN.,Department of Medicine Vanderbilt University Medical Center Nashville TN.,Department of Pharmacology Vanderbilt University Medical Center Nashville TN
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Dixon DD, Muldowney JAS. Management of neurogenic orthostatic hypotension in the heart failure patient. Auton Neurosci 2020; 227:102691. [PMID: 32559655 DOI: 10.1016/j.autneu.2020.102691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 03/25/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022]
Abstract
Neurogenic orthostatic hypotension (nOH) is a common comorbidity in patients with neurodegenerative diseases. It is associated with an increased risk of falls, incident cardiovascular disease, and all-cause mortality. There are over 5 million individuals in the U.S. with heart failure (HF) with an associated 50% mortality rate at 5 years. The prevalence of nOH and HF increase with age and, as the population continues to age, will be increasingly common comorbid conditions. Thus, the effective management of these conditions has important implications for public health. The management of orthostatic hypotension in the context of congestive heart failure is challenging due to the fact that the fundamental principles of management of these disease states are in opposition to each other. In this review, we will discuss the principles of management of nOH and HF and outline strategies for the effective treatment of these comorbid conditions.
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Affiliation(s)
- Debra D Dixon
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - James A S Muldowney
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America.
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7
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Biaggioni I, Shibao CA, Diedrich A, Muldowney JAS, Laffer CL, Jordan J. Blood Pressure Management in Afferent Baroreflex Failure: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 74:2939-2947. [PMID: 31806138 DOI: 10.1016/j.jacc.2019.10.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 12/14/2022]
Abstract
Afferent baroreflex failure is most often due to damage of the carotid sinus nerve because of neck surgery or radiation. The clinical picture is characterized by extreme blood pressure lability with severe hypertensive crises, hypotensive episodes, and orthostatic hypotension, making it the most difficult form of hypertension to manage. There is little evidence-based data to guide treatment. Recommendations rely on understanding the underlying pathophysiology, relevant clinical pharmacology, and anecdotal experience. The goal of treatment should be improving quality of life rather than normalization of blood pressure, which is rarely achievable. Long-acting central sympatholytic drugs are the mainstay of treatment, used at the lowest doses that prevent the largest hypertensive surges. Short-acting clonidine should be avoided because of rebound hypertension, but can be added to control residual hypertensive episodes, often triggered by mental stress or exertion. Hypotensive episodes can be managed with countermeasures and short-acting pressor agents if necessary.
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Affiliation(s)
- Italo Biaggioni
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Autonomic Dysfunction Center, Nashville, Tennessee.
| | - Cyndya A Shibao
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Autonomic Dysfunction Center, Nashville, Tennessee
| | - André Diedrich
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Autonomic Dysfunction Center, Nashville, Tennessee
| | - James A S Muldowney
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Vanderbilt Autonomic Dysfunction Center, Nashville, Tennessee; Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Cheryl L Laffer
- Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jens Jordan
- Institute of Aerospace Medicine, German Aerospace Center, Cologne, Germany; Aerospace Medicine, University of Cologne, Cologne, Germany
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McDonell KE, Preheim BA, Diedrich A, Muldowney JAS, Peltier AC, Robertson D, Biaggioni I, Shibao CA. Initiation of droxidopa during hospital admission for management of refractory neurogenic orthostatic hypotension in severely ill patients. J Clin Hypertens (Greenwich) 2019; 21:1308-1314. [PMID: 31368635 DOI: 10.1111/jch.13619] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 04/08/2019] [Accepted: 04/26/2019] [Indexed: 11/30/2022]
Abstract
Orthostatic hypotension (OH) is a common cause of hospitalization, particularly in the elderly. Hospitalized patients with OH are often severely ill, with complex medical comorbidities and high rates of disability. Droxidopa is a norepinephrine precursor approved for the treatment of neurogenic OH (nOH) associated with autonomic failure that is commonly used in the outpatient setting, but there are currently no data regarding the safety and efficacy of droxidopa initiation in medically complex patients. We performed a retrospective review of patients started on droxidopa for refractory nOH while hospitalized at Vanderbilt University Medical Center between October 2014 and May 2017. Primary outcome measures were safety, change in physician global impression of illness severity from admission to discharge, and persistence on medication after 180-day follow-up. A total of 20 patients were identified through chart review. Patients were medically complex with high rates of cardiovascular comorbidities and a diverse array of underlying autonomic diagnoses. Rapid titration of droxidopa was safe and well tolerated in this cohort, with no cardiovascular events or new onset arrhythmias. Supine hypertension requiring treatment occurred in four patients. One death occurred during hospital admission due to organ failure associated with end-stage amyloidosis. Treating physicians noted improvements in presyncopal symptoms in 80% of patients. After 6 months, 13 patients (65%) continued on droxidopa therapy. In a retrospective cohort of hospitalized, severely ill patients with refractory nOH, supervised rapid titration of droxidopa was safe and effective. Treatment persistence was high, suggesting that symptomatic benefit extended beyond acute intervention.
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Affiliation(s)
- Katherine E McDonell
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brock A Preheim
- Department of Medicine, Division of Clinical Pharmacology, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Andre' Diedrich
- Department of Medicine, Division of Clinical Pharmacology, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - James A S Muldowney
- Department of Medicine, Division of Cardiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Amanda C Peltier
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Robertson
- Department of Medicine, Division of Clinical Pharmacology, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Italo Biaggioni
- Department of Medicine, Division of Clinical Pharmacology, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Cyndya A Shibao
- Department of Medicine, Division of Clinical Pharmacology, School of Medicine, Vanderbilt University, Nashville, Tennessee
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Kasner SE, Wang L, French B, Messe SR, Horenstein R, Mohler ER, Muldowney JAS, Ellenberg J, Kimmel SE. The Impact of Inpatient Versus Outpatient Initiation on Early Warfarin Dosing. Am J Cardiovasc Drugs 2015; 15:267-74. [PMID: 26037731 DOI: 10.1007/s40256-015-0126-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Dosing algorithms for warfarin incorporate clinical and genetic factors but may not account for the numerous comorbidities affecting patients who start warfarin while hospitalized. We aimed to determine whether these algorithms perform differently when warfarin is initiated for inpatients compared with outpatients. PATIENTS AND METHODS We analyzed a prospective cohort of 1015 participants from the Clarification of Optimal Anticoagulation through Genetics (COAG) trial who were randomized to either pharmacogenetically or clinically guided warfarin dosing algorithms. Clinicians and participants were blinded to dose during the first 28 days. We compared groups, based on location at the time of the first warfarin dose request, in relation to the following outcomes: percentage of time in the therapeutic international normalized ratio (INR) range (PTTR) during the first 4 weeks, time to first therapeutic INR, time to maintenance dose, and the difference between predicted and observed maintenance doses. RESULTS A total of 527 participants started warfarin as inpatients and 488 as outpatients. There was no difference in PTTR based on location: 43.2 % for inpatient versus 47.4 % for outpatient initiation [mean adjusted difference -2.2 %; 95 % confidence interval (CI) -5.9 to 1.6]. Similarly, there were no differences in time to first therapeutic INR [hazard ratio (HR) 1.06; 95 % CI 0.91-1.24] or to maintenance dose (HR 0.96; 95 % CI 0.81-1.14). There was no evidence of interaction between study intervention (pharmacogenetically vs. clinically guided therapy) and location of initiation for these main outcomes. The difference between predicted and observed maintenance doses was similar for both locations. CONCLUSION The warfarin dosing algorithms performed similarly for subjects who initiated warfarin as inpatients and outpatients, regardless of whether dosing was pharmacogenetically or clinically guided.
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Affiliation(s)
- Scott E Kasner
- Department of Neurology, University of Pennsylvania Medical Center, 3W Gates Bldg, 3400 Spruce Street, Philadelphia, PA, 19104, USA,
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10
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Bagai K, Muldowney JAS, Song Y, Wang L, Bagai J, Artibee KJ, Vaughan DE, Malow BA. Circadian variability of fibrinolytic markers and endothelial function in patients with obstructive sleep apnea. Sleep 2014; 37:359-67. [PMID: 24497664 DOI: 10.5665/sleep.3414] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is strongly associated with cardiovascular disease, including stroke and acute coronary syndromes. Plasminogen activator inhibitor-1 (PAI-1), the principal inhibitor of tissue-type plasminogen activator (t-PA), has a pronounced circadian rhythm and is elevated in both OSA and cardiovascular disease and may be an important link between the two conditions. Endothelial dysfunction is one of the underlying pathophysiological mechanisms of cardiovascular disease, and may be altered in OSA. Our primary aim was to compare circadian variability of PAI-1 and t-PA in patients with OSA and normal controls by determining the amplitude (peak level) and mesor (rhythm adjusted mean) of PAI-1 and t-PA in serial blood samples over a 24-h period. The secondary aim was to measure markers of endothelial function (brachial and radial artery flow) in patients with OSA compared with normal controls. SETTING Cross-sectional cohort study. PATIENTS OR PARTICIPANTS Subjects age 18 y or older, with a body mass index of 25-45 kg/m(2), with or without evidence of untreated OSA. INTERVENTIONS Plasma samples were collected every 2 h, in OSA patients and matched controls, over a 24-h period. PAI-1 and t-PA antigen and activity were measured. The presence or absence of OSA (apnea-hypopnea index of 5 or greater) was confirmed by overnight polysomnography. Endothelial function was measured via brachial artery flow mediated vasodilatation and computerized arterial pulse waveform analysis. MEASUREMENTS AND RESULTS The rhythm-adjusted mean levels of PAI-1 antigen levels in the OSA group (21.8 ng/mL, 95% confidence level [CI], 18 to 25.7) were significantly higher as compared to the non-OSA group (16 ng/mL, 95% CI, 12.2 to 19.8; P = 0.03). The rhythm-adjusted mean levels of PAI-1 activity levels in the OSA group (23.9 IU/mL, 95% CI, 21.4 to 26.5) were also significantly higher than in the non-OSA group (17.2 IU/ mL, 95% CI, 14.6 to 19.9; P < 0.001).There were strong correlations between amplitude of PAI-1 activity and severity of OSA as measured by AHI (P = 0.02), and minimum oxygen levels during sleep (P = 0.04). Endothelial function parameters did not differ significantly between the two groups. CONCLUSION The presence of obstructive sleep apnea adversely affects circadian fibrinolytic balance with higher mean plasminogen activator inhibitor-1 activity and antigen, and significantly lower mean tissue-type plasminogen activator activity compared with controls. This perturbation may be an important mechanism for increased cardiovascular events in patients with obstructive sleep apnea. Intermittent hypoxia and changes in circadian clock gene activity in obstructive sleep apnea may be responsible for these findings and warrant further study. Favorable changes in fibrinolytic balance may underlie the reduction in cardiovascular events observed with the treatment of obstructive sleep apnea.
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Affiliation(s)
- Kanika Bagai
- Department of Neurology, Vanderbilt University, Nashville, TN
| | | | - Yanna Song
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Lily Wang
- Department of Biostatistics, Vanderbilt University, Nashville, TN
| | - Jayant Bagai
- Department of Medicine, Vanderbilt University, Nashville, TN
| | - Kay J Artibee
- Department of Neurology, Vanderbilt University, Nashville, TN
| | - Douglas E Vaughan
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Beth A Malow
- Department of Neurology, Vanderbilt University, Nashville, TN
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11
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Kimmel SE, French B, Kasner SE, Johnson JA, Anderson JL, Gage BF, Rosenberg YD, Eby CS, Madigan RA, McBane RB, Abdel-Rahman SZ, Stevens SM, Yale S, Mohler ER, Fang MC, Shah V, Horenstein RB, Limdi NA, Muldowney JAS, Gujral J, Delafontaine P, Desnick RJ, Ortel TL, Billett HH, Pendleton RC, Geller NL, Halperin JL, Goldhaber SZ, Caldwell MD, Califf RM, Ellenberg JH. A pharmacogenetic versus a clinical algorithm for warfarin dosing. N Engl J Med 2013; 369:2283-93. [PMID: 24251361 PMCID: PMC3942158 DOI: 10.1056/nejmoa1310669] [Citation(s) in RCA: 552] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND The clinical utility of genotype-guided (pharmacogenetically based) dosing of warfarin has been tested only in small clinical trials or observational studies, with equivocal results. METHODS We randomly assigned 1015 patients to receive doses of warfarin during the first 5 days of therapy that were determined according to a dosing algorithm that included both clinical variables and genotype data or to one that included clinical variables only. All patients and clinicians were unaware of the dose of warfarin during the first 4 weeks of therapy. The primary outcome was the percentage of time that the international normalized ratio (INR) was in the therapeutic range from day 4 or 5 through day 28 of therapy. RESULTS At 4 weeks, the mean percentage of time in the therapeutic range was 45.2% in the genotype-guided group and 45.4% in the clinically guided group (adjusted mean difference, [genotype-guided group minus clinically guided group], -0.2; 95% confidence interval, -3.4 to 3.1; P=0.91). There also was no significant between-group difference among patients with a predicted dose difference between the two algorithms of 1 mg per day or more. There was, however, a significant interaction between dosing strategy and race (P=0.003). Among black patients, the mean percentage of time in the therapeutic range was less in the genotype-guided group than in the clinically guided group. The rates of the combined outcome of any INR of 4 or more, major bleeding, or thromboembolism did not differ significantly according to dosing strategy. CONCLUSIONS Genotype-guided dosing of warfarin did not improve anticoagulation control during the first 4 weeks of therapy. (Funded by the National Heart, Lung, and Blood Institute and others; COAG ClinicalTrials.gov number, NCT00839657.).
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12
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Benge CD, Muldowney JAS. The pharmacokinetics and pharmacodynamics of valsartan in the post-myocardial infarction population. Expert Opin Drug Metab Toxicol 2012; 8:1469-82. [PMID: 22998368 DOI: 10.1517/17425255.2012.725721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The most common risk factors for heart failure are hypertension and myocardial infarction. Angiotensin receptor blockers (ARBs) attenuate the deleterious effects of angiotensin II. Valsartan is a once or twice daily ARB that is FDA-approved for hypertension, LV dysfunction post-myocardial infarction and congestive heart failure as both an adjunct in ACE-inhibitor tolerant, and alternative in ACE-I intolerant patients. AREAS COVERED This article presents a comprehensive review of the literature regarding the pharmacokinetics and pharmacodynamics of valsartan, with particular attention paid to the post-myocardial infarction population. EXPERT OPINION Valsartan is a safe, well-tolerated and readily titratable ARB. In addition to its vasodilatory effects there are pleotropic effects associated with the ARB such as modulation of a number of neurohormonal regulators, cytokines and small molecules. Given the clear evidence-based benefits above and beyond its hypertensive properties, it has the potential, if priced appropriately, to grow in its impact as a pharmacotherapeutic long after its patent expires.
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Affiliation(s)
- Cassandra D Benge
- Nashville Veterans Affairs Medical Center, Cardiology Section, 1310 24th Avenue South, Nashville, TN 37212-263, USA
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13
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Muldowney JAS, Chen Q, Blakemore DL, Vaughan DE. Pentoxifylline Lowers Plasminogen Activator Inhibitor 1 Levels in Obese Individuals: A Pilot Study. Angiology 2012; 63:429-34. [DOI: 10.1177/0003319712436755] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Plasminogen activator inhibitor 1 (PAI-1), the primary inhibitor of fibrinolysis and C-reactive protein (CRP), is a predictor of myocardial infarction. Both are upregulated by tumor necrosis factor-alpha (TNF-α) within the obese population. This pilot study tested the hypothesis that TNF-α blockade with pentoxifylline lowers PAI-1 and high-sensitivity CRP (hsCRP) in obese individuals. Twenty participants were treated with pentoxifylline for 8 weeks. A proportional odds model was used to compare the change in PAI-1 and CRP in the pentoxifylline and placebo groups. Plasminogen activator inhibitor 1, but not hsCRP levels, decreased over the 8-week period of the study ( P = .025 and P = NS). There was significant dropout of participants due to drug tolerability. These findings suggest that these markers of cardiovascular risk are differentially regulated in obesity and that PAI-1 levels can be reduced by pentoxifylline in this population.
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Affiliation(s)
- James A. S. Muldowney
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Qingxia Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dana L. Blakemore
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Douglas E. Vaughan
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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14
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15
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Pecot CV, Fuller M, Muldowney JAS, Misra S. A very late stent thrombosis in a patient with diabetes: a call for lifelong dual anti-platelet therapy. Tenn Med 2009; 102:37-39. [PMID: 19456028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Chad V Pecot
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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16
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Schoenhard JA, Muldowney JAS, Emens JS, Lewy AJ, Vaughan DE. Plasminogen activator inhibitor-1 has a circadian rhythm in blind individuals. Thromb Haemost 2007; 98:479-81. [PMID: 17721638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
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17
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Muldowney JAS, Stringham JR, Levy SE, Gleaves LA, Eren M, Piana RN, Vaughan DE. Antiproliferative Agents Alter Vascular Plasminogen Activator Inhibitor-1 Expression. Arterioscler Thromb Vasc Biol 2007; 27:400-6. [PMID: 17158352 DOI: 10.1161/01.atv.0000254677.12861.b8] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Drug eluting stents (DES) reduce the incidence of restenosis after coronary angioplasty. Enthusiasm has been tempered by a possible increased risk of in-stent thrombosis. We examined the effects of paclitaxel and rapamycin on the endothelial transcriptome to identify alterations in gene expression associated with thrombosis. METHODS AND RESULTS Gene expression profiling was performed on human coronary artery endothelial cells treated with rapamycin or paclitaxel. Plasminogen activator inhibitor-1 (PAI-1) was the most consistently induced transcript in rapamycin-treated human coronary artery endothelial cells. RT-PCR and ELISA were performed to confirm positive findings. Transgenic mice engineered to express enhanced green fluorescent protein under control of the human PAI-1 promoter were also treated. Rapamycin and paclitaxel treated endothelial cells produced dose-dependent increases in PAI-1. There was a variable effect on endothelial tissue-type plasminogen activator (t-PA) expression. Enhanced expression of PAI-1 and enhanced green fluorescent protein were detected in coronary arteries, the aorta, and kidney of the mice. CONCLUSIONS Antiproliferative agents stimulate the expression of prothrombotic genes. PAI-1 expression may also play a role in the prevention of restenosis through an antimigratory mechanism. The effects of antiproliferatives on vascular gene expression deserve further scrutiny in view of the increasing utilization of drug-eluting stents.
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MESH Headings
- Animals
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/pharmacology
- Cell Proliferation/drug effects
- Cells, Cultured
- Coronary Restenosis/prevention & control
- Coronary Thrombosis/etiology
- Coronary Thrombosis/genetics
- Coronary Thrombosis/metabolism
- Coronary Thrombosis/physiopathology
- Dose-Response Relationship, Drug
- Drug Delivery Systems
- Endothelium, Vascular/cytology
- Endothelium, Vascular/drug effects
- Endothelium, Vascular/metabolism
- Gene Expression Profiling
- Green Fluorescent Proteins/metabolism
- Humans
- Mice
- Mice, Transgenic
- Muscle, Smooth, Vascular/cytology
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/metabolism
- Paclitaxel/administration & dosage
- Paclitaxel/pharmacology
- Plasminogen Activator Inhibitor 1/genetics
- Plasminogen Activator Inhibitor 1/metabolism
- RNA, Messenger/genetics
- RNA, Messenger/metabolism
- Risk Factors
- Sirolimus/administration & dosage
- Sirolimus/pharmacology
- Stents/adverse effects
- Tissue Plasminogen Activator/genetics
- Tissue Plasminogen Activator/metabolism
- Up-Regulation/drug effects
- Up-Regulation/genetics
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Affiliation(s)
- James A S Muldowney
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee 37232-6300, USA
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18
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Muldowney JAS, Painter CA, Sanders-Bush E, Brown NJ, Vaughan DE. Acute tissue-type plasminogen activator release in human microvascular endothelial cells: the roles of Galphaq, PLC-beta, IP3 and 5,6-epoxyeicosatrienoic acid. Thromb Haemost 2007; 97:263-71. [PMID: 17264956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
The acute physiologic release of tissue-type plasminogen activator (t-PA) from the endothelium is critical for vascular homeostasis. This process is prostacyclin- and nitric oxide (NO)-independent in humans. It has been suggested that calcium signaling and endothelial-derived hyperpolarizing factors (EDHF) may play a role in t-PA release. G-protein-coupled receptor-dependent calcium signaling is typically Galphaq-dependent. EDHFs have been functionally defined and in various tissues are believed to be various regioisomers of the epoxyeicosatrienoic acids (EETs). We tested the hypothesis in vitro that thrombin-stimulated t-PA release from human microvascular endothelial cells (HMECs) is both Galphaq- and EDHF-dependent. Conditioned media was harvested following thrombin stimulation, and t-PA antigen was measured by ELISA. Thrombin-induced t-PA release was limited by a membrane-permeable Galphaq inhibitory peptide, the PLC-beta antagonist U73122, and the IP3 receptor antagonist 2-aminoethoxyphenylborane, while the Galphaq agonist Pasteurella toxin modestly induced t-PA release. The cytochrome P450 (CYP450) inhibitor, miconazole, and the arachidonic acid epoxygenase inhibitor MS-PPOH inhibited thrombin-stimulated t-PA release, while 5,6-EET-methyl ester stimulated t-PA release. The 5,6- and 14,15-EET antagonist, 14,15-epoxyeicosa-5(Z)-enoic acid, inhibited t-PA release at the 100 microM concentration. However, thrombin-stimulated t-PA release was unaffected by the prostacyclin and NO inhibitors ASA and L-NAME, as well as the potassium channel inhibitors TEA, apamin and charybdotoxin. These studies suggest that thrombin-stimulated t-PA release is Galphaq-, PLC-beta-, IP3-, and 5,6-EET-dependent while being prostacyclin-, NO- and K+ channel-independent in HMECs.
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Affiliation(s)
- James A S Muldowney
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-6300, USA
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19
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Abstract
To test the hypothesis that NO contributes to effects of angiotensin-converting enzyme inhibitors on fibrinolysis, fibrinolytic balance was assessed in 17 normal subjects during placebo and after randomized, double-blind 4-week treatment with the NO precursor L-arginine (3 g TID), ramipril (10 mg QD), or L-arginine+ramipril. Neither L-arginine nor ramipril alone affected basal plasminogen activator inhibitor-1 or tissue-type plasminogen activator (t-PA) antigen in these salt-replete subjects in whom plasma renin activity was suppressed (mean+/-SD 0.7+/-0.5 ng angiotensin I/mL per hour). In contrast, L-arginine+ramipril reduced morning plasminogen activator inhibitor-1 antigen (10.8+/-9.5 ng/mL) and the molar ratio of plasminogen activator inhibitor-1:t-PA (2.3+/-1.6) compared with placebo (13.5+/-10.8 ng/mL, P=0.006; ratio 2.9+/-2.1, P=0.015) or ramipril alone (15.2+/-13.2 ng/mL, P=0.009; ratio 3.7+/-3.3, P=0.005). L-arginine and ramipril synergistically increased d-dimers (23.1+/-31.5, 29.7+/-50.0, 35.1+/-50.0, and 57.1+/-144.8 ng/mL during placebo, L-arginine, ramipril, and L-arginine+ramipril, respectively; P<0.05 for L-arginine+ramipril versus any other group). During ramipril, the NO synthase inhibitor L-NG-nitro-arginine-methyl-ester (2 mg/kg) significantly increased plasminogen activator inhibitor-antigen after 2 hours (from 9.4+/-8.6 ng/mL during vehicle to 13.5+/-11.0 ng/mL during L-NG-nitro-arginine-methyl-ester; P=0.020), consistent with an effect on expression but rapidly increased t-PA activity (from 0.4+/-0.3 to 0.5+/-0.4 IU/mL; P=0.031), consistent with an effect on release. Both effects of L-NG-nitro-arginine-methyl-ester were reversed by L-arginine. During angiotensin-converting enzyme inhibition, endogenous NO decreases plasminogen activator inhibitor-1 antigen and improves fibrinolytic balance in normotensive salt-replete subjects.
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Affiliation(s)
- Nancy J Brown
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
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20
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McLaughlin JN, Mazzoni MR, Cleator JH, Earls L, Perdigoto AL, Brooks JD, Muldowney JAS, Vaughan DE, Hamm HE. Thrombin modulates the expression of a set of genes including thrombospondin-1 in human microvascular endothelial cells. J Biol Chem 2005; 280:22172-80. [PMID: 15817447 DOI: 10.1074/jbc.m500721200] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Thrombospondin-1 (THBS1) is a large extracellular matrix glycoprotein that affects vasculature systems such as platelet activation, angiogenesis, and wound healing. Increases in THBS1 expression have been liked to disease states including tumor progression, atherosclerosis, and arthritis. The present study focuses on the effects of thrombin activation of the G-protein-coupled, protease-activated receptor-1 (PAR-1) on THBS1 gene expression in the microvascular endothelium. Thrombin-induced changes in gene expression were characterized by microarray analysis of approximately 11,000 different human genes in human microvascular endothelial cells (HMEC-1). Thrombin induced the expression of a set of at least 65 genes including THBS1. Changes in THBS1 mRNA correlated with an increase in the extracellular THBS1 protein concentration. The PAR-1-specific agonist peptide (TFLLRNK-PDK) mimicked thrombin stimulation of THBS1 expression, suggesting that thrombin signaling is through PAR-1. Further studies showed THBS1 expression was sensitive to pertussis toxin and protein kinase C inhibition indicating G(i/o)- and G(q)-mediated pathways. THBS1 up-regulation was also confirmed in human umbilical vein endothelial cells stimulated with thrombin. Analysis of the promoter region of THBS1 and other genes of similar expression profile identified from the microarray predicted an EBOX/EGRF transcription model. Expression of members of each family, MYC and EGR1, respectively, correlated with THBS1 expression. These results suggest thrombin formed at sites of vascular injury increases THBS1 expression into the extracellular matrix via activation of a PAR-1, G(i/o), G(q), EBOX/EGRF-signaling cascade, elucidating regulatory points that may play a role in increased THBS1 expression in disease states.
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MESH Headings
- Adenosine Diphosphate/chemistry
- Algorithms
- Amides/pharmacology
- Apoptosis
- Cells, Cultured
- Cluster Analysis
- Culture Media
- DNA Primers/chemistry
- DNA, Complementary/metabolism
- Dose-Response Relationship, Drug
- Electric Impedance
- Endothelium, Vascular/cytology
- Endothelium, Vascular/metabolism
- Enzyme-Linked Immunosorbent Assay
- Extracellular Matrix/metabolism
- GTP-Binding Protein alpha Subunits, Gi-Go/metabolism
- GTP-Binding Protein alpha Subunits, Gq-G11/metabolism
- Gene Expression Regulation
- Humans
- Indoles/pharmacology
- Maleimides/pharmacology
- Microcirculation/metabolism
- Models, Biological
- Nucleic Acid Hybridization
- Oligonucleotide Array Sequence Analysis
- Peptides/chemistry
- Pertussis Toxin/pharmacology
- Promoter Regions, Genetic
- Protein Binding
- Pyridines/pharmacology
- RNA/metabolism
- Receptor, PAR-1/metabolism
- Reverse Transcriptase Polymerase Chain Reaction
- Signal Transduction
- Thrombin/chemistry
- Thrombin/metabolism
- Thrombospondin 1/biosynthesis
- Time Factors
- Umbilical Veins/cytology
- Up-Regulation
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Affiliation(s)
- Joseph N McLaughlin
- Department of Pharmacology, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, 444 Robinson Research Building, 23rd Avenue South at Pierce, Nashville, TN 37232 , USA.
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21
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Shaklee JF, Talbot TR, Muldowney JAS, Vaughan DE, Butler J, House F, Crowe JE, Smith LH, Edwards KM. Smallpox vaccination does not elevate systemic levels of prothrombotic proteins associated with ischemic cardiac events. J Infect Dis 2005; 191:724-30. [PMID: 15688286 DOI: 10.1086/427831] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2004] [Accepted: 10/05/2004] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND During the recent smallpox vaccination campaigns, ischemic cardiac complications were observed after vaccination. To examine a possible association between the smallpox vaccine and postvaccination ischemic events, we investigated alterations in levels of prothrombotic proteins (plasminogen activator inhibitor type 1 [PAI-1] and soluble CD40 ligand [sCD40L]) in recently vaccinated individuals. METHODS Vaccinia-naive (cohort N; aged 18-32 years) and vaccinia-experienced (cohort E; aged 33-49 years) healthy adults were vaccinated with a 1 : 5 dilution of the Aventis Pasteur smallpox vaccine. Plasma levels of PAI-1 and sCD40L were measured in 30 subjects (cohort N, n=15; cohort E, n=15) at baseline and twice after vaccination (between days 7 and 9 and between days 26 and 30). RESULTS Baseline mean PAI-1 levels significantly differed between cohorts N and E (P=.04). Within each exposure cohort, mean PAI-1 levels did not significantly change after vaccination. Baseline sCD40L levels did not differ between cohorts N and E. In cohort N, sCD40L levels significantly decreased after vaccination but returned to baseline levels within 1 month. Vaccination did not significantly alter levels of sCD40L in cohort E. CONCLUSIONS Levels of PAI-1 and sCD40L did not significantly increase after smallpox vaccination. Vaccine-induced alterations in levels of these prothrombotic proteins do not appear to play a role in ischemic events observed after smallpox vaccination.
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Affiliation(s)
- Julia F Shaklee
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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22
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Abstract
To test the hypothesis that NO influences aldosterone production in humans, we examined the effect of
N
G
-nitro-
l
-arginine methyl ester (
l
-NAME) on aldosterone concentrations in the presence and absence of the NO precursor
l
-arginine (3 g TID) and the angiotensin-converting enzyme inhibitor ramipril (10 mg QD). Ten normal subjects were given
l
-NAME (66 μg/kg per min for 30 minutes) or vehicle in random order on separate days during placebo and after randomized, double-blind treatment with
l
-arginine, ramipril, or
l
-arginine plus ramipril. Infusion of
l
-NAME significantly increased systolic blood pressure (all
P
<0.05) and decreased heart rate (all
P
≤0.02) during all 4 treatment arms. After placebo pretreatment, serum aldosterone was significantly higher during
l
-NAME infusion than during vehicle (6.6±1.7 versus 3.3±0.5 ng/dL;
P
=0.045). Combined treatment with
l
-arginine plus ramipril abolished this effect. There was no effect of
l
-NAME on plasma renin activity (PRA;
P
=0.297) or angiotensin II concentrations (
P
=0.537). However, there was a significant interactive effect of
l
-NAME and time on serum potassium (
P
=0.039). There was a significant linear relationship between PRA and aldosterone concentration after vehicle infusion ([aldosterone]=3.9·PRA+1.9;
r
2
=0.476;
P
=0.027) and
l
-NAME infusion ([aldosterone]=7.2·PRA+3.1;
r
2
=0.457;
P
=0.032), and the intercepts of these lines were different (
P
=0.029). There was a significant linear relationship between serum potassium and aldosterone during
l
-NAME ([aldosterone]=8.2 · [potassium]−28.9;
r
2
=0.609;
P
=0.008) but not during vehicle (
P
=0.313). These data suggest that endogenous NO modulates aldosterone synthesis in humans.
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Affiliation(s)
- James A S Muldowney
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-6602, USA
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23
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