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Davogustto G, Wells QS, Harrell FE, Greene SJ, Roden DM, Stevenson LW. Impact of Insurance Status and Region on Angiotensin Receptor-Neprilysin Inhibitor Prescription During Heart Failure Hospitalizations. JACC Heart Fail 2024:S2213-1779(24)00161-6. [PMID: 38639698 DOI: 10.1016/j.jchf.2024.02.003] [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] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/26/2024] [Accepted: 02/06/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND An angiotensin receptor-neprilysin inhibitor (ARNI) is the preferred renin-angiotensin system (RAS) inhibitor for heart failure with reduced ejection fraction (HFrEF). Among eligible patients, insurance status and prescriber concern regarding out-of-pocket costs may constrain early initiation of ARNI and other new therapies. OBJECTIVES In this study, the authors sought to evaluate the association of insurance and other social determinants of health with ARNI initiation at discharge from HFrEF hospitalization. METHODS The authors analyzed ARNI initiation from January 2017 to June 2020 among patients with HFrEF eligible to receive RAS inhibitor at discharge from hospitals in the Get With The Guidelines-Heart Failure registry. The primary outcome was the proportion of ARNI prescription at discharge among those prescribed RAS inhibitor who were not on ARNI on admission. A logistic regression model was used to determine the association of insurance status, U.S. region, and their interaction, as well as self-reported race, with ARNI initiation at discharge. RESULTS From 42,766 admissions, 24,904 were excluded for absolute or relative contraindications to RAS inhibitors. RAS inhibitors were prescribed for 16,817 (94.2%) of remaining discharges, for which ARNI was prescribed in 1,640 (9.8%). Self-reported Black patients were less likely to be initiated on ARNI compared to self-reported White patients (OR: 0.64; 95% CI: 0.50-0.81). Compared to Medicare beneficiaries, patients with third-party insurance, Medicaid, or no insurance were less likely to be initiated on ARNI (OR: 0.47 [95% CI: 0.31-0.72], OR: 0.41 [95% CI: 0.25-0.67], and OR: 0.20 [95% CI: 0.08-0.47], respectively). ARNI therapy varied by hospital region, with lowest utilization in the Mountain region. An interaction was demonstrated between the impact of insurance disparities and hospital region. CONCLUSIONS Among patients hospitalized between 2017 and 2020 for HFrEF who were prescribed RAS inhibitor therapy at discharge, insurance status, geographic region, and self-reported race were associated with ARNI initiation.
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Affiliation(s)
- Giovanni Davogustto
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt School of Medicine, Nashville, Tennessee, USA.
| | - Quinn S Wells
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Frank E Harrell
- Department of Biostatistics, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Dan M Roden
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt School of Medicine, Nashville, Tennessee, USA
| | - Lynne W Stevenson
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt School of Medicine, Nashville, Tennessee, USA
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Escobar Cervantes C, Esteban Fernández A, Recio Mayoral A, Mirabet S, González Costello J, Rubio Gracia J, Núñez Villota J, González Franco Á, Bonilla Palomas JL. Identifying the patient with heart failure to be treated with vericiguat. Curr Med Res Opin 2023; 39:661-669. [PMID: 36897009 DOI: 10.1080/03007995.2023.2189857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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] [Indexed: 03/11/2023]
Abstract
The pathophysiology of heart failure with reduced ejection fraction (HFrEF) is a complex process in which a number of neurohormonal systems are involved. Targeting only some of these systems, but not all, translates into a partial benefit of HF treatment. The nitric oxide-soluble guanylate cyclase (sGC)-cGMP pathway is impaired in HF, leading to cardiac, vascular and renal disturbances. Vericiguat is a once-daily oral stimulator of sGC that restores this system. No other disease-modifying HF drugs act on this system. Despite guidelines recommendations, a substantial proportion of patients are not taking all recommended drugs or when taking them, they do so at low doses, limiting their potential benefits. In this context, treatment should be optimized considering different parameters, such as blood pressure, heart rate, renal function, or potassium, as they may interfere with their implementation at the recommended doses. The VICTORIA trial showed that adding vericiguat to standard therapy in patients with HFrEF significantly reduced the risk of cardiovascular death or HF hospitalization by 10% (NNT 24). Furthermore, vericiguat does not interfere with heart rate, renal function or potassium, making it particularly useful for improving the prognosis of patients with HFrEF in specific settings and clinical profiles.
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Affiliation(s)
| | | | | | - Sonia Mirabet
- Cardiology Department, Hospital de Sant Pau, Barcelona, Spain
| | - José González Costello
- Department of Cardiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
- BIOHEART-Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat, Barcelona, Spain
- Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Spain
- Ciber Cardiovascular (CIBERCV), Instituto Salud Carlos III, Madrid, Spain
| | - Jorge Rubio Gracia
- Internal Medicine Department, Hospital Clínico Univeristario Lozano Blesa, University of Zaragoza, Spain
| | - Julio Núñez Villota
- Cardiology Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- Universidad de Valencia, INCLIVA, CIBER Cardiovascular, Valencia, Spain
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3
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Kim D, Jang G, Hwang J, Wei X, Kim H, Son J, Rhee SJ, Yun KH, Oh SK, Oh CM, Park R. Combined Therapy of Low-Dose Angiotensin Receptor-Neprilysin Inhibitor and Sodium-Glucose Cotransporter-2 Inhibitor Prevents Doxorubicin-Induced Cardiac Dysfunction in Rodent Model with Minimal Adverse Effects. Pharmaceutics 2022; 14:pharmaceutics14122629. [PMID: 36559124 PMCID: PMC9788442 DOI: 10.3390/pharmaceutics14122629] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/20/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Although cancer-therapy-related cardiac dysfunction (CTRCD) is a critical issue in clinical practice, there is a glaring lack of evidence regarding cardiotoxicity management. To determine an effective and suitable dosage of treatment using angiotensin receptor-neprilysin inhibitors (ARNI) with sodium-glucose cotransporter 2 inhibitors (SGLT2i), we adopted a clinically relevant rodent model with doxorubicin, which would mimic cardiac dysfunction in CTRCD patients. After the oral administration of drugs (vehicle, SGLT2i, ARNI, Low-ARNI/SGLT2i, ARNI/SGLT2i), several physiologic parameters, including hemodynamic change, cardiac function, and histopathology, were evaluated. Bulk RNA-sequencing was performed to obtain insights into the molecular basis of a mouse heart response to Low-ARNI/SGLT2i treatment. For the first time, we report that the addition of low-dose ARNI with SGLT2i resulted in greater benefits than ARNI, SGLT2i alone or ARNI/SGLT2i combination in survival rate, cardiac function, hemodynamic change, and kidney function against doxorubicin-induced cardiotoxicity through peroxisome proliferator-activated receptor signaling pathway. Low-dose ARNI with SGLT2i combination treatment would be practically beneficial for improving cardiac functions against doxorubicin-induced heart failure with minimal adverse effects. Our findings suggest the Low-ARNI/SGLT2i combination as a feasible novel strategy in managing CTRCD patients.
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Affiliation(s)
- Donghyun Kim
- Department of Biomedical Science and Engineering, Gwangju Institute of Science and Technology, Gwangju 61005, Republic of Korea
| | - Gyuho Jang
- Department of Biomedical Science and Engineering, Gwangju Institute of Science and Technology, Gwangju 61005, Republic of Korea
| | - Jaetaek Hwang
- Department of Biomedical Science and Engineering, Gwangju Institute of Science and Technology, Gwangju 61005, Republic of Korea
| | - Xiaofan Wei
- Department of Biomedical Science and Engineering, Gwangju Institute of Science and Technology, Gwangju 61005, Republic of Korea
| | - Hyunsoo Kim
- Department of Biomedical Science and Engineering, Gwangju Institute of Science and Technology, Gwangju 61005, Republic of Korea
| | - Jinbae Son
- CNCure Biotech, Hwasun 58128, Republic of Korea
| | - Sang-Jae Rhee
- Department of Cardiovascular Medicine, Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan 54538, Republic of Korea
| | - Kyeong-Ho Yun
- Department of Cardiovascular Medicine, Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan 54538, Republic of Korea
| | - Seok-Kyu Oh
- Department of Cardiovascular Medicine, Regional Cardiocerebrovascular Center, Wonkwang University Hospital, Iksan 54538, Republic of Korea
| | - Chang-Myung Oh
- Department of Biomedical Science and Engineering, Gwangju Institute of Science and Technology, Gwangju 61005, Republic of Korea
| | - Raekil Park
- Department of Biomedical Science and Engineering, Gwangju Institute of Science and Technology, Gwangju 61005, Republic of Korea
- Correspondence: ; Tel.: +82-62-715-5361; Fax: +82-62-715-3244
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Popa IP, Haba MȘC, Mărănducă MA, Tănase DM, Șerban DN, Șerban LI, Iliescu R, Tudorancea I. Modern Approaches for the Treatment of Heart Failure: Recent Advances and Future Perspectives. Pharmaceutics 2022; 14:pharmaceutics14091964. [PMID: 36145711 PMCID: PMC9503448 DOI: 10.3390/pharmaceutics14091964] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Heart failure (HF) is a progressively deteriorating medical condition that significantly reduces both the patients’ life expectancy and quality of life. Even though real progress was made in the past decades in the discovery of novel pharmacological treatments for HF, the prevention of premature deaths has only been marginally alleviated. Despite the availability of a plethora of pharmaceutical approaches, proper management of HF is still challenging. Thus, a myriad of experimental and clinical studies focusing on the discovery of new and provocative underlying mechanisms of HF physiopathology pave the way for the development of novel HF therapeutic approaches. Furthermore, recent technological advances made possible the development of various interventional techniques and device-based approaches for the treatment of HF. Since many of these modern approaches interfere with various well-known pathological mechanisms in HF, they have a real ability to complement and or increase the efficiency of existing medications and thus improve the prognosis and survival rate of HF patients. Their promising and encouraging results reported to date compel the extension of heart failure treatment beyond the classical view. The aim of this review was to summarize modern approaches, new perspectives, and future directions for the treatment of HF.
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Affiliation(s)
- Irene Paula Popa
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
| | - Mihai Ștefan Cristian Haba
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Minela Aida Mărănducă
- Department of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Daniela Maria Tănase
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
- Internal Medicine Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700115 Iași, Romania
| | - Dragomir N. Șerban
- Department of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Lăcrămioara Ionela Șerban
- Department of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Radu Iliescu
- Department of Pharmacology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Ionuț Tudorancea
- Cardiology Clinic, “St. Spiridon” County Clinical Emergency Hospital, 700111 Iași, Romania
- Department of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
- Correspondence:
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Bozkurt B, Nair AP, Misra A, Scott CZ, Mahar JH, Fedson S. Neprilysin Inhibitors in Heart Failure: The Science, Mechanism of Action, Clinical Studies, and Unanswered Questions. JACC Basic Transl Sci 2022; 8:88-105. [PMID: 36777165 PMCID: PMC9911324 DOI: 10.1016/j.jacbts.2022.05.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/18/2022] [Accepted: 05/18/2022] [Indexed: 11/16/2022]
Abstract
This article provides a contemporary review and a new perspective on the role of neprilysin inhibition in heart failure (HF) in the context of recent clinical trials and addresses potential mechanisms and unanswered questions in certain HF patient populations. Neprilysin is an endopeptidase that cleaves a variety of peptides such as natriuretic peptides, bradykinin, adrenomedullin, substance P, angiotensin I and II, and endothelin. It has a broad role in cardiovascular, renal, pulmonary, gastrointestinal, endocrine, and neurologic functions. The combined angiotensin receptor and neprilysin inhibitor (ARNi) has been developed with an intent to increase vasodilatory natriuretic peptides and prevent counterregulatory activation of the angiotensin system. ARNi therapy is very effective in reducing the risks of death and hospitalization for HF in patients with HF and New York Heart Association functional class II to III symptoms, but studies failed to show any benefits with ARNi when compared with angiotensin-converting enzyme inhibitors or angiotensin receptor blocker in patients with advanced HF with reduced ejection fraction or in patients following myocardial infarction with left ventricular dysfunction but without HF. These raise the questions about whether the enzymatic breakdown of natriuretic peptides may not be a very effective solution in advanced HF patients when there is downstream blunting of the response to natriuretic peptides or among post-myocardial infarction patients in the absence of HF when there may not be a need for increased natriuretic peptide availability. Furthermore, there is a need for additional studies to determine the long-term effects of ARNi on albuminuria, obesity, glycemic control and lipid profile, blood pressure, and cognitive function in patients with HF.
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Key Words
- ACE, angiotensin-converting enzyme
- ANP, atrial natriuretic peptide
- ARB, angiotensin receptor blocker
- ARN, angiotensin receptor–neprilysin
- ARNi
- Aβ, amyloid beta
- BNP, brain natriuretic peptide
- BP, blood pressure
- CSF, cerebrospinal fluid
- EF, ejection fraction
- FDA, U.S. Food and Drug Administration
- GFR, glomerular filtration rate
- HF, heart failure
- HFpEF, heart failure with preserved ejection fraction
- HFrEF, heart failure with reduced ejection fraction
- LV, left ventricular
- LVEF, left ventricular ejection fraction
- MI, myocardial infarction
- NEP inhibitor
- NT-proBNP, N-terminal pro–brain natriuretic peptide
- NYHA, New York Heart Association
- PDE, phosphodiesterase
- RAAS, renin-angiotensin-aldosterone system
- UACR, urinary albumin/creatine ratio
- angiotensin receptor–neprilysin inhibitor
- cGMP, cyclic guanosine monophosphate
- eGFR, estimated glomerular filtration rate
- heart failure
- neprilysin
- neprilysin inhibitor
- sacubitril
- sacubitril/valsartan
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Affiliation(s)
- Biykem Bozkurt
- Winters Center for Heart Failure Research, Cardiovascular Research Institute, Baylor College of Medicine, DeBakey Veterans Affairs Medical Center, Houston Texas, USA
- Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston Texas, USA
- Address for correspondence: Dr Biykem Bozkurt, MEDVAMC, 2002 Holcombe Boulevard, Houston, Texas, 77030, USA.
| | - Ajith P. Nair
- Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Arunima Misra
- Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston Texas, USA
| | - Claire Z. Scott
- Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jamal H. Mahar
- Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Savitri Fedson
- Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston Texas, USA
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6
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Akbar S, Kabra N, Aronow WS. Impact of Sacubitril/Valsartan on Patient Outcomes in Heart Failure: Evidence to Date. Ther Clin Risk Manag 2020; 16:681-688. [PMID: 32801725 PMCID: PMC7405908 DOI: 10.2147/tcrm.s224772] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022] Open
Abstract
With an estimated 6.2 million adults affected in the USA, heart failure remains a leading cause of morbidity, mortality, and health-care costs, despite the use of guideline-based medical therapies. The search for a more efficient therapy was rekindled when findings from the Prospective Comparison of Angiotensin Receptor–Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial demonstrated evidence for cardiovascular and mortality benefit of sacubitril/valsartan, a dual angiotensin receptor blocker and neprilysin inhibitor (ARNI), over enalapril (an angiotensin-converting enzyme inhibitor) in patients with heart failure and reduced rjection fraction (HFrEF). Following the trial’s compelling results, recommendations for the use of sacubitril/valsartan as a replacement for an angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker were incorporated into the 2016 American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Failure Society of America recommended (HFSA) guidelines for the management of heart failure. This review aims to gain insight into the benefits as well as limitations associated with the use of sacubitril/valsartan in the treatment of heart failure (HF) through exploration of various subgroup analyses of the PARADIGM-HF trial, subsequent retrospective analyses, and randomized controlled trials that followed this landmark trial.
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Affiliation(s)
- Sara Akbar
- Department of Cardiology, Westchester Medical Center, Valhalla, NY 10595, USA.,Department of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Nitin Kabra
- Department of Cardiology, Westchester Medical Center, Valhalla, NY 10595, USA.,Department of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, NY 10595, USA.,Department of Medicine, New York Medical College, Valhalla, NY 10595, USA
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Poglajen G, Anžič-Drofenik A, Zemljič G, Frljak S, Cerar A, Okrajšek R, Šebeštjen M, Vrtovec B. Long-Term Effects of Angiotensin Receptor-Neprilysin Inhibitors on Myocardial Function in Chronic Heart Failure Patients with Reduced Ejection Fraction. Diagnostics (Basel) 2020; 10:E522. [PMID: 32731353 DOI: 10.3390/diagnostics10080522] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/08/2020] [Accepted: 07/27/2020] [Indexed: 12/11/2022] Open
Abstract
Background. We sought to evaluate the long-term effects of angiotensin receptor blocker–neprilysin inhibitor (ARNI) therapy on reverse remodeling of the failing myocardium in HFrEF patients. Methods. We performed a prospective non-randomized longitudinal study on 228 HFrEF patients treated with ARNI at our center. Prior to ARNI introduction all patients received stable doses of ACEI/ARB for at least six months. Clinical, biochemical and echocardiography data were obtained at ARNI introduction and 12-month follow-up. Results At follow-up, we found significant improvements in LVEF (29.7% ± 8% vs. 36.5% ± 9%; p < 0.001), LVOT-VTI (14.8 ± 4.2 cm vs. 17.2 ± 4.2 cm; p < 0.001), TAPSE (1.7 ± 0.5 cm vs. 2.1 ± 0.6 cm; p < 0.001) and LV-EDD (6.5 ± 0.8 cm vs. 6.3 ± 0.9 cm; p = 0.001). NT-proBNP serum levels also decreased significantly (1324 (605, 3281) pg/mL vs. 792 (329, 2022) pg/mL; p = 0.001). A total of 102 (45%) of patients responded favorably to ARNI (ΔLVEF < +5%; Group A) and 126 (55%) patients achieved ΔLVEF ≥ +5% (Group B). The two groups differed significantly in age, heart failure etiology, baseline LVEF and baseline NT-proBNP. On multivariable analysis, nonischemic heart failure, LVEF < 30% and NT-proBNP < 1500 pg/mL emerged as independent correlates of favorable response to ARNI therapy. Conclusion. ARNI therapy appears to improve echocardiographic parameters of left and right ventricular function in HFrEF patients above the effect of pre-existing optimal medical management. These effects may be particularly pronounced in patients with nonischemic heart failure, LVEF < 30% and lower degree of neurohumoral activation.
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Affiliation(s)
- Frederik H Verbrugge
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN.,Biomedical Research Institute Faculty of Medicine and Life Sciences Hasselt University Hasselt Belgium
| | - Barry A Borlaug
- Department of Cardiovascular Diseases Mayo Clinic Rochester MN
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Volpe M, Rubattu S, Battistoni A. ARNi: A Novel Approach to Counteract Cardiovascular Diseases. Int J Mol Sci 2019; 20:ijms20092092. [PMID: 31035359 PMCID: PMC6539682 DOI: 10.3390/ijms20092092] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 12/11/2022] Open
Abstract
Cardiovascular diseases (CVDs) still represent the greatest burden on healthcare systems worldwide. Despite the enormous efforts over the last twenty years to limit the spread of cardiovascular risk factors, their prevalence is growing and control is still suboptimal. Therefore, the availability of new therapeutic tools that may interfere with different pathophysiological pathways to slow the establishment of clinical CVDs is important. Previously, the inhibition of neurohormonal systems, namely the renin–angiotensin–aldosterone system (RAAS) and the sympathetic nervous system, has proven to be useful in the treatment of many CVDs. Attempts have recently been made to target an additional hormonal system, that of the natriuretic peptides (NPs), which, when dysregulated, can also play a role in the development CVDs. Indeed, a new class of drug, the angiotensin receptor–neprilysin inhibitors (ARNi), has the ability to counteract the effects of angiotensin II as well as to increase the activity of NPs. ARNi have already been proven to be effective in the treatment of heart failure with reduced ejection fraction. New evidence has suggested that, in the next years, the field of ARNi application will widen to include other CVDs, such as heart failure, with preserved ejection fraction and hypertension.
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Affiliation(s)
- Massimo Volpe
- Department of Clinical and Molecular Medicine; School of Medicine and Psychology, Sapienza University of Rome, 00189 Rome, Italy.
- IRCCS Neuromed, 86077 Pozzilli, Italy.
| | - Speranza Rubattu
- Department of Clinical and Molecular Medicine; School of Medicine and Psychology, Sapienza University of Rome, 00189 Rome, Italy.
- IRCCS Neuromed, 86077 Pozzilli, Italy.
| | - Allegra Battistoni
- Department of Clinical and Molecular Medicine; School of Medicine and Psychology, Sapienza University of Rome, 00189 Rome, Italy.
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Bratsos S. Efficacy of Angiotensin Converting Enzyme Inhibitors and Angiotensin Receptor-Neprilysin Inhibitors in the Treatment of Chronic Heart Failure: A Review of Landmark Trials. Cureus 2019; 11:e3913. [PMID: 30931184 PMCID: PMC6426571 DOI: 10.7759/cureus.3913] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 01/18/2019] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is a multi-faceted clinical condition affecting up to 2% of the population in the developed world and is linked to significant morbidity and mortality, therefore posing a major public health concern. To this date, pharmacotherapy for HF has mainly focused on chronic HF with reduced ejection fraction (HFrEF), with angiotensin converting enzyme inhibitors (ACEi) being at the centre of the management plan, alongside angiotensin-receptor-blockers (ARBs), β-blockers (BB) and mineralocorticoid receptor antagonists (MRAs). A novel and recently approved therapy, however, involving angiotensin receptor-neprilysin inhibitors (ARNI), has shown very promising results and comparable to those of ACEi, which raises the question of whether ACEi should remain the first-line treatment option for HFrEF. In this review, the evidence regarding the clinical efficacy of ACEi and ARNI in the treatment of HFrEF is discussed, with emphasis placed on the major landmark trials.
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