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Pharmacological reasons that may explain why randomized clinical trials have failed in acute heart failure syndromes. Int J Cardiol 2016; 233:1-11. [PMID: 28161130 DOI: 10.1016/j.ijcard.2016.11.124] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 11/04/2016] [Accepted: 11/06/2016] [Indexed: 12/27/2022]
Abstract
Acute heart failure (AHF) represents a clinical challenge as it encloses a heterogeneous group of syndromes (AHFS) with different pathophysiology, clinical presentations, prognosis and response to therapy. In the last 25years multiple therapeutic targets have been identified and numerous new drugs were evaluated but, up to now, all failed to demonstrate a consistent benefit on clinical outcomes. Moreover, a repeated finding has been the poor correlation between the encouraging results of preclinical and early clinical trials and the lack of effect on outcomes observed in phase III trials. We review several possible pharmacological reasons that may explain the lack of success to develop new drugs and the pharmacological challenges to overcome in the future to develop new more effective and safer drugs for the treatment of AHFS.
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Cook JC, Tran RH, Patterson JH, Rodgers JE. Evolving therapies for the management of chronic and acute decompensated heart failure. Am J Health Syst Pharm 2016; 73:1745-1754. [PMID: 27769970 DOI: 10.2146/ajhp150635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE The pharmacology, clinical efficacy, and safety profiles of evolving therapies for the management of chronic heart failure (HF) and acute decompensated heart failure (ADHF) are described. SUMMARY HF confers a significant financial burden despite the widespread use of traditional guideline-directed medical therapies such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and aldosterone receptor antagonists, and the rates of HF-related mortality and hospitalization have remained unacceptably high. In response to a demand for novel pharmacologic agents, several therapeutic compounds have recently gained approval or are currently under review by the Food and Drug Administration. Sacubitril-valsartan has demonstrated benefit in reducing cardiovascular mortality and HF-related hospitalizations in clinical trials, while ivabradine and ferric carboxymaltose have proven efficacious in reducing HF-related hospitalizations. Lastly, the role of serelaxin in ADHF is currently under investigation in an ongoing Phase III study. While large, outcome-driven clinical trials are fundamental in informing the clinical application of these therapeutic agents, careful patient selection is imperative to ensuring similar outcomes postmarketing. In addition, optimization of current guideline-directed medical therapy remains essential as new therapies emerge and are incorporated into guideline recommendations. Additional therapeutic agents currently undergoing investigation include bucindolol hydrochloride, cimaglermin alfa, nitroxyl, omecamtiv mecarbil, TRV027, and ularitide. Clinical practitioners should remain abreast of emerging literature so that new therapeutic entities are optimally applied and positive patient outcomes are achieved. CONCLUSION Recently introduced agents for the treatment of patients with HF include sacubitril-valsartan, ivabradine, and ferric carboxymaltose. Additional agents worthy of attention include serelaxin and other therapies currently under investigation.
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Affiliation(s)
- Jennifer C Cook
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Richard H Tran
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - J Herbert Patterson
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC
| | - Jo E Rodgers
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC.
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Teerlink JR, Felker GM, McMurray JJV, Ponikowski P, Metra M, Filippatos GS, Ezekowitz JA, Dickstein K, Cleland JGF, Kim JB, Lei L, Knusel B, Wolff AA, Malik FI, Wasserman SM. Acute Treatment With Omecamtiv Mecarbil to Increase Contractility in Acute Heart Failure: The ATOMIC-AHF Study. J Am Coll Cardiol 2016; 67:1444-1455. [PMID: 27012405 DOI: 10.1016/j.jacc.2016.01.031] [Citation(s) in RCA: 167] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/04/2016] [Accepted: 01/05/2016] [Indexed: 01/10/2023]
Abstract
BACKGROUND Omecamtiv mecarbil (OM) is a selective cardiac myosin activator that increases myocardial function in healthy volunteers and in patients with chronic heart failure. OBJECTIVES This study evaluated the pharmacokinetics, pharmacodynamics, tolerability, safety, and efficacy of OM in patients with acute heart failure (AHF). METHODS Patients admitted for AHF with left ventricular ejection fraction ≤40%, dyspnea, and elevated plasma concentrations of natriuretic peptides were randomized to receive a double-blind, 48-h intravenous infusion of placebo or OM in 3 sequential, escalating-dose cohorts. RESULTS In 606 patients, OM did not improve the primary endpoint of dyspnea relief (3 OM dose groups and pooled placebo: placebo, 41%; OM cohort 1, 42%; cohort 2, 47%; cohort 3, 51%; p = 0.33) or any of the secondary outcomes studied. In supplemental, pre-specified analyses, OM resulted in greater dyspnea relief at 48 h (placebo, 37% vs. OM, 51%; p = 0.034) and through 5 days (p = 0.038) in the high-dose cohort. OM exerted plasma concentration-related increases in left ventricular systolic ejection time (p < 0.0001) and decreases in end-systolic dimension (p < 0.05). The adverse event profile and tolerability of OM were similar to those of placebo, without increases in ventricular or supraventricular tachyarrhythmias. Plasma troponin concentrations were higher in OM-treated patients compared with placebo (median difference at 48 h, 0.004 ng/ml), but with no obvious relationship with OM concentration (p = 0.95). CONCLUSIONS In patients with AHF, intravenous OM did not meet the primary endpoint of dyspnea improvement, but it was generally well tolerated, it increased systolic ejection time, and it may have improved dyspnea in the high-dose group. (Acute Treatment with Omecamtiv Mecarbil to Increase Contractility in Acute Heart Failure [ATOMIC-AHF]; NCT01300013).
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Affiliation(s)
- John R Teerlink
- School of Medicine, University of California San Francisco, San Francisco, California; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California.
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Clinical Military Hospital, Wroclaw, Poland
| | - Marco Metra
- Division of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | | | - Kenneth Dickstein
- Cardiology Division, University of Bergen, Bergen, Norway; Cardiology Division, Stavanger University Hospital, Stavanger, Norway
| | - John G F Cleland
- National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom
| | - Jae B Kim
- Amgen, Inc., Thousand Oaks, California
| | - Lei Lei
- Amgen, Inc., Thousand Oaks, California
| | | | | | - Fady I Malik
- Cytokinetics, Inc., South San Francisco, California
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Weiss G, Teichman S, Stewart D, Nader D, Wood S, Breining P, Unemori E. Recombinant human relaxin versus placebo for cervical ripening: a double-blind randomised trial in pregnant women scheduled for induction of labour. BMC Pregnancy Childbirth 2016; 16:260. [PMID: 27596360 PMCID: PMC5011832 DOI: 10.1186/s12884-016-1046-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 07/08/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Nonclinical studies indicate that the hormone relaxin is a good candidate for a safe cervical ripening agent that does not cause uterine contractions. METHODS This Phase II study (conducted November 2, 2005-October 20, 2006) was a randomised, double blind, placebo controlled trial testing 24-h intravenous infusion of serelaxin (recombinant human relaxin) or placebo for cervical ripening in 72 healthy, primiparous women. Eligible subjects had a singleton pregnancy ≥40 weeks, were planned for elective induction, had vertex presentation of the fetus, intact membranes and a Bishop score at screening ≤4. In Part A of the study, safety evaluation of three escalating doses of serelaxin (7.5, 25 or 75 μg/kg/day) or placebo was performed in 22 subjects admitted to the hospital 24 h prior to scheduled induction (n = 7, 4, 4, and 7 subjects, respectively). The highest safe dose from Part A and placebo were then tested in Part B for safety and cervical ripening (n = 25 subjects/arm). Planned randomisation ratio was of 4:2 (serelaxin:placebo) for each dose group in Part A and 1:1 for Part B. For analysis, subjects in Part B were pooled with those receiving the same dose in Part A and all subjects receiving placebo were pooled. The primary efficacy endpoint was change from baseline in Bishop score at 6, 12 and 24 h or end of study drug administration. Maternal safety evaluations included adverse events and vital signs through 4 weeks. Fetal assessments included serial heart rate monitoring and nonstress testing. Neonatal assessments included Apgar scores, NICU admissions, and adverse events through 4 weeks. RESULTS Overall, 74 subjects were randomized and 72 were treated. There were no significant differences between the groups receiving the highest safe dose of serelaxin (75 μg/kg/day) and placebo in the primary or secondary efficacy endpoints. Changes from baseline in Bishop score at 24 h were 4.19 ± 1.9 and 3.26 ± 2.26 in the pooled placebo and serelaxin groups, respectively (p = 0.2507). Serelaxin was well tolerated and no anti-serelaxin antibodies were detected in either subjects or neonates. CONCLUSION Serelaxin infusion at the end of pregnancy was well tolerated but did not advance cervical ripening. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT00259103 (15 November 2005).
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Affiliation(s)
- Gerson Weiss
- Department of Obstetrics, Gynecology and Women's Health, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, 07101, USA.
| | - Sam Teichman
- At the time of study conduct, an employee of Corthera, Inc. (formerly BAS Medical), 1660 South Amphlett Blvd., San Mateo, CA, 94402, USA
| | - Dennis Stewart
- At the time of study conduct, an employee of Corthera, Inc. (formerly BAS Medical), 1660 South Amphlett Blvd., San Mateo, CA, 94402, USA
| | - David Nader
- At the time of study conduct, an employee of Corthera, Inc. (formerly BAS Medical), 1660 South Amphlett Blvd., San Mateo, CA, 94402, USA
| | - Susan Wood
- At the time of study conduct, an employee of Corthera, Inc. (formerly BAS Medical), 1660 South Amphlett Blvd., San Mateo, CA, 94402, USA
| | - Peter Breining
- At the time of study conduct, an employee of Corthera, Inc. (formerly BAS Medical), 1660 South Amphlett Blvd., San Mateo, CA, 94402, USA
| | - Elaine Unemori
- At the time of study conduct, an employee of Corthera, Inc. (formerly BAS Medical), 1660 South Amphlett Blvd., San Mateo, CA, 94402, USA
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Abstract
Despite advances in therapy, patients with heart failure (HF) continue to experience unacceptably high rates of hospitalization and death, as well as poor quality of life. As a consequence, there is an urgent need for new treatments that can improve the clinical course of the growing worldwide population of HF patients. Serelaxin and ularatide, both based on naturally occurring peptides, have potent vasodilatory as well as other effects on the heart and kidneys. For both agents, phase 3 studies that are designed to determine whether they improve outcomes in patients with acute HF have completed enrollment. TRV027, a biased ligand for the type 1 angiotensin receptor with effects that extend beyond traditional angiotensin-receptor blockers is also being studied in the acute HF population. Omecamtiv mecarbil, an inotropic agent that improves myocardial contractility by a novel mechanism, and vericiguat, a drug that stimulates soluble guanylate cyclase, are both being developed to treat patients with chronic HF. Finally, despite the negative results of the CUPID study, gene transfer therapy continues to be explored as a means of improving the function of the failing heart. The basis for the use of these drugs and their current status in clinical trials are discussed. (Circ J 2016; 80: 1882-1891).
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Collins SP, Levy PD, Martindale JL, Dunlap ME, Storrow AB, Pang PS, Albert NM, Felker GM, Fermann GJ, Fonarow GC, Givertz MM, Hollander JE, Lanfear DJ, Lenihan DJ, Lindenfeld JM, Peacock WF, Sawyer DB, Teerlink JR, Butler J. Clinical and Research Considerations for Patients With Hypertensive Acute Heart Failure: A Consensus Statement from the Society of Academic Emergency Medicine and the Heart Failure Society of America Acute Heart Failure Working Group. J Card Fail 2016; 22:618-27. [DOI: 10.1016/j.cardfail.2016.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 04/14/2016] [Accepted: 04/18/2016] [Indexed: 12/20/2022]
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Collins SP, Levy PD, Martindale JL, Dunlap ME, Storrow AB, Pang PS, Albert NM, Felker GM, Fermann GJ, Fonarow GC, Givertz MM, Hollander JE, Lanfear DE, Lenihan DJ, Lindenfeld JM, Peacock WF, Sawyer DB, Teerlink JR, Butler J. Clinical and Research Considerations for Patients With Hypertensive Acute Heart Failure: A Consensus Statement from the Society for Academic Emergency Medicine and the Heart Failure Society of America Acute Heart Failure Working Group. Acad Emerg Med 2016; 23:922-31. [PMID: 27286136 DOI: 10.1111/acem.13025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 04/19/2016] [Accepted: 04/19/2016] [Indexed: 01/04/2023]
Abstract
Management approaches for patients in the emergency department (ED) who present with acute heart failure (AHF) have largely focused on intravenous diuretics. Yet, the primary pathophysiologic derangement underlying AHF in many patients is not solely volume overload. Patients with hypertensive AHF (H-AHF) represent a clinical phenotype with distinct pathophysiologic mechanisms that result in elevated ventricular filling pressures. To optimize treatment response and minimize adverse events in this subgroup, we propose that clinical management be tailored to a conceptual model of disease that is based on these mechanisms. This consensus statement reviews the relevant pathophysiology, clinical characteristics, approach to therapy, and considerations for clinical trials in ED patients with H-AHF.
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Affiliation(s)
- Sean P. Collins
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
| | - Phillip D. Levy
- Department of Emergency Medicine; Wayne State University; Detroit MI
| | | | - Mark E. Dunlap
- Department of Medicine; Case Western University; Cleveland OH
| | - Alan B. Storrow
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
| | - Peter S. Pang
- Department of Emergency Medicine; Indiana University; Indianapolis IN
| | | | | | - Gregory J. Fermann
- Department of Emergency Medicine; University of Cincinnati; Cincinnati OH
| | - Gregg C. Fonarow
- Department of Medicine; University of California at Los Angeles; Los Angeles CA
| | | | - Judd E. Hollander
- Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | | | | | | | - W. Frank Peacock
- Department of Emergency Medicine; Baylor College of Medicine; Houston TX
| | | | - John R. Teerlink
- Department of Medicine; San Francisco VA Medical Center; San Francisco CA
| | - Javed Butler
- Department of Medicine; Stony Brook University; Stony Brook NY
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Sarwar M, Du XJ, Dschietzig TB, Summers RJ. The actions of relaxin on the human cardiovascular system. Br J Pharmacol 2016; 174:933-949. [PMID: 27239943 DOI: 10.1111/bph.13523] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 04/01/2016] [Accepted: 04/26/2016] [Indexed: 12/14/2022] Open
Abstract
The insulin-like peptide relaxin, originally identified as a hormone of pregnancy, is now known to exert a range of pleiotropic effects including vasodilatory, anti-fibrotic, angiogenic, anti-apoptotic and anti-inflammatory effects in both males and females. Relaxin produces these effects by binding to a cognate receptor RXFP1 and activating a variety of signalling pathways including cAMP, cGMP and MAPKs as well as by altering gene expression of TGF-β, MMPs, angiogenic growth factors and endothelin receptors. The peptide has been shown to be effective in halting or reversing many of the adverse effects including fibrosis in animal models of cardiovascular disease including ischaemia/reperfusion injury, myocardial infarction, hypertensive heart disease and cardiomyopathy. Relaxin given to humans is safe and produces favourable haemodynamic changes. Serelaxin, the recombinant form of relaxin, is now in extended phase III clinical trials for the treatment of acute heart failure. Previous clinical studies indicated that a 48 h infusion of relaxin improved 180 day mortality, yet the mechanism underlying this effect is not clear. This article provides an overview of the cellular mechanism of effects of relaxin and summarizes its beneficial actions in animal models and in the clinic. We also hypothesize potential mechanisms for the clinical efficacy of relaxin, identify current knowledge gaps and suggest new ways in which relaxin could be useful therapeutically. LINKED ARTICLES This article is part of a themed section on Recent Progress in the Understanding of Relaxin Family Peptides and their Receptors. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.10/issuetoc.
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Affiliation(s)
- Mohsin Sarwar
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Australia
| | - Xiao-Jun Du
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Thomas B Dschietzig
- Immundiagnostik AG, Bensheim, Germany.,Campus Mitte, Medical Clinic for Cardiology and Angiology, Charité-University Medicine Berlin, Berlin, Germany.,Relaxera Pharmazeutische Gesellschaft mbH & Co. KG, Bensheim, Germany
| | - Roger J Summers
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Australia
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Conrad KP. G-Protein-coupled receptors as potential drug candidates in preeclampsia: targeting the relaxin/insulin-like family peptide receptor 1 for treatment and prevention. Hum Reprod Update 2016; 22:647-64. [PMID: 27385360 DOI: 10.1093/humupd/dmw021] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 05/16/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Important roles for G-protein-coupled receptors (GPCRs) have been identified in the maternal physiological adaptations to pregnancy and in the pathogenesis of preeclampsia. On this basis, GPCRs are potential therapeutic targets for preeclampsia. OBJECTIVES AND RATIONALE In this review, vasopressin and apelin are initially considered in this context before the focus on the hormone relaxin and its cognate receptor, the relaxin/insulin-like family peptide receptor 1 (RXFP1). Based on both compelling scientific rationale and a promising safety profile, the relaxin ligand-receptor system is comprehensively evaluated as a potential therapeutic endpoint in preeclampsia. SEARCH METHODS The published literature relating to the topic was searched through January 2016 using PubMed. OUTCOMES Relaxin is a peptide hormone secreted by the corpus luteum; it circulates in the luteal phase and during pregnancy. Activation of RXFP1 is vasodilatory; thus, relaxin supplementation is expected to at least partly restore the fundamental vasodilatory changes of normal pregnancy, thereby alleviating maternal organ hypoperfusion, which is a major pathogenic manifestation of severe preeclampsia. Specifically, by exploiting its pleiotropic hemodynamic attributes in preeclampsia, relaxin administration is predicted to (i) reverse robust arterial myogenic constriction; (ii) blunt systemic and renal vasoconstriction in response to activation of the angiotensin II receptor, type 1; (iii) mollify the action of endogenous vasoconstrictors on uterine spiral arteries with failed remodeling and retained smooth muscle; (iv) increase arterial compliance; (v) enhance insulin-mediated glucose disposal by promoting skeletal muscle vasodilation and (vi) mobilize and activate bone marrow-derived angiogenic progenitor cells, thereby repairing injured endothelium and improving maternal vascularity in organs such as breast, uterus, pancreas, skin and fat. By exploiting its pleiotropic molecular attributes in preeclampsia, relaxin supplementation is expected to (i) enhance endothelial nitric oxide synthesis and bioactivity, as well as directly reduce vascular smooth muscle cytosolic calcium, thus promoting vasodilation; (ii) improve the local angiogenic balance by augmenting arterial vascular endothelial and placental growth factor (VEGF and PLGF) activities; (iii) ameliorate vascular inflammation; (iv) enhance placental peroxisome proliferator-activated receptor gamma, coactivator 1 alpha (PCG1α) expression, and hence, peroxisome proliferator-activated receptor gamma (PPAR-γ) activity and (v) confer cytotrophoblast and endothelial cytoprotection. Insofar as impaired endometrial maturation (decidualization) predisposes to the development of preeclampsia, relaxin administration in the late secretory phase and during early pregnancy would be anticipated to improve decidualization, and hence trophoblast invasion and spiral artery remodeling, thereby reducing the risk of preeclampsia. Relaxin has a favorable safety profile both in the non-pregnant condition and during pregnancy. WIDER IMPLICATIONS There is a strong scientific rationale for RXFP1 activation in severe preeclampsia by administration of relaxin, relaxin analogs or small molecule mimetics, in order to mollify the disease pathogenesis for safe prolongation of pregnancy, thus allowing time for more complete fetal maturation, which is a primary therapeutic endpoint in treating the disease. In light of recent data implicating deficient or defective decidualization as a potential etiological factor in preeclampsia and the capacity of relaxin to promote endometrial maturation, the prophylactic application of relaxin to reduce the risk of preeclampsia is a plausible therapeutic approach to consider. Finally, given its pleiotropic and beneficial attributes particularly in the cardiovascular system, relaxin, although traditionally considered as a 'pregnancy' hormone, is likely to prove salutary for several disease indications in the non-pregnant population.
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Affiliation(s)
- Kirk P Conrad
- Department of Physiology and Functional Genomics and Department of Obstetrics and Gynecology, D.H. Barron Reproductive and Perinatal Biology Research Program, University of Florida, 1600 SW Archer Road, PO Box 100274 M522, Gainesville, FL 32610, USA
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111
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Relaxing the artery: A new strategy to limit atherogenesis. Atherosclerosis 2016; 251:510-511. [PMID: 27318867 DOI: 10.1016/j.atherosclerosis.2016.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 06/08/2016] [Indexed: 11/22/2022]
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112
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Antifibrotic Actions of Serelaxin – New Roles for an Old Player. Trends Pharmacol Sci 2016; 37:485-497. [DOI: 10.1016/j.tips.2016.02.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/16/2016] [Accepted: 02/19/2016] [Indexed: 12/25/2022]
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Tran HA, Lin F, Greenberg BH. Potential new drug treatments for congestive heart failure. Expert Opin Investig Drugs 2016; 25:811-26. [DOI: 10.1080/13543784.2016.1181749] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Shuai XX, Meng YD, Lu YX, Su GH, Tao XF, Han J, Xu SD, Luo P. Relaxin-2 improves diastolic function of pressure-overloaded rats via phospholamban by activating Akt. Int J Cardiol 2016; 218:305-311. [PMID: 27240156 DOI: 10.1016/j.ijcard.2016.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 04/18/2016] [Accepted: 05/12/2016] [Indexed: 02/05/2023]
Abstract
BACKGROUND Relaxin is a peptide hormone which has been demonstrated to be safe and has a therapeutic effect on acute heart failure in clinic trials. However, its effect on diastolic function is still unknown. The aims of the study were to determine whether relaxin could improve the diastolic function in pressure-overloaded rat model and to analyze potential mechanisms. METHODS AND RESULTS In the present study, a pressure-overloaded rat model induced by transaortic constriction (TAC) was established. Four weeks after TAC, echocardiography was performed and then all the rat models were randomly divided into 3 groups: models without intramyocardial injection (TAC), with intramyocardial injection of empty adenoviral vector (TAC+GFP) and adenoviral vector overexpression relaxin-2 gene (TAC+RLN2). A sham group was also included. Twelve days after intramyocardial injection, echocardiography and hemodynamics were carried out to evaluate diastolic function in sham, TAC, TAC+GFP and TAC+RLN2 groups. Then hearts were harvested for subsequent examinations. The results indicated that relaxin-2 had ameliorated diastolic function in the pressure-overloaded rats. Compared with the TAC and TAC+GFP groups, the relaxin-2 gene transfer increased phosphorylation of Akt at both the Ser473 and Thr308 sites. Meanwhile, it increased the Ser16 and Thr17- phosphorylation levels of phospholamban (PLB). Furthermore, SERCA2 activity was enhanced in the TAC+RLN2 group more than in the TAC and TAC+GFP groups. CONCLUSIONS These results demonstrated that relaxin-2 gene therapy improved diastolic function in pressure-overloaded rats. The potential mechanism may be that relaxin-2 gene transfer enhances SERCA2 activity in hearts by increasing phospholamban phosphorylation through nuclear-targeted Akt phosphorylation.
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Affiliation(s)
- Xin-Xin Shuai
- Department of Cardiology, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yi-di Meng
- Department of Cardiology, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yong-Xin Lu
- Department of Cardiology, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430022, China.
| | - Guan-Hua Su
- Department of Cardiology, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xiao-Fang Tao
- Department of Cardiology, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430022, China
| | - Jun Han
- Department of Cardiology, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430022, China
| | - Su-Dan Xu
- Department of Cardiology, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430022, China
| | - Ping Luo
- Department of Cardiology, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan 430022, China
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Favreau-Lessard AJ, Ryzhov S, Sawyer DB. Novel Biological Therapies Targeting Heart Failure: Myocardial Rejuvenation. Heart Fail Clin 2016; 12:461-71. [PMID: 27371521 DOI: 10.1016/j.hfc.2016.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Recovery of ventricular function occurs in a subset of patients with advanced heart failure treated with medical and/or mechanical therapy. Finding strategies that induce ventricular recovery through induction of repair, regeneration, or "rejuvenation" is a long-sought goal of research programs. Cell-based strategies, use of recombinant growth and survival factors, and gene delivery are under investigation. In this brief article we highlight a few of the biological approaches in development to treat heart failure.
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Affiliation(s)
- Amanda J Favreau-Lessard
- Center for Molecular Medicine, Maine Medical Center Research Institute, Maine Medical Center, 81 Research Drive, Scarborough, ME 04074, USA
| | - Sergey Ryzhov
- Center for Molecular Medicine, Maine Medical Center Research Institute, Maine Medical Center, 81 Research Drive, Scarborough, ME 04074, USA
| | - Douglas B Sawyer
- Center for Molecular Medicine, Maine Medical Center Research Institute, Maine Medical Center, 81 Research Drive, Scarborough, ME 04074, USA.
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Vaduganathan M, Butler J, Roessig L, Fonarow GC, Greene SJ, Metra M, Cotter G, Kupfer S, Zalewski A, Sato N, Filippatos G, Gheorghiade M. Clinical trials in hospitalized heart failure patients: targeting interventions to optimal phenotypic subpopulations. Heart Fail Rev 2016; 20:393-400. [PMID: 25894076 DOI: 10.1007/s10741-015-9485-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
With one possible exception, the last decade of clinical trials in hospitalized heart failure (HHF) patients has failed to demonstrate improvement in long-term clinical outcomes. This trend necessitates a need to evaluate optimal drug development strategies and standards of trial conduct. It has become increasingly important to recognize the heterogeneity among HHF patients and the differential characterization of novel drug candidates. Targeting these agents to specific subpopulations may afford optimal net response related to the particular mode of action of the drug. Analyses of previous trials demonstrate profound differences in the baseline characteristics of patients enrolled across global regions and participating sites. Such differences may influence risks for events and interpretation of results. Therefore, the actual execution of trials and the epidemiology of HHF populations at the investigative sites must be taken into consideration. Collaboration among participating sites including the provision of registry data tailored to the planned development program will optimize trial conduct. Observational data prior to study initiation may enable sites to feedback and engage in protocol development to allow for feasible and valid clinical trial conduct. This site-centered, epidemiology-based network environment may facilitate studies in specific patient populations and promote optimal data collection and clear interpretation of drug safety and efficacy. This review summarizes the roundtable discussion held by a multidisciplinary team of representatives from academia, National Institutes of Health, industry, regulatory agencies, payers, and contract and academic research organizations to answer the question: Who should be targeted for novel therapies in HHF?
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Affiliation(s)
- Muthiah Vaduganathan
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
Outcomes for patients with acute heart failure remain suboptimal and treatments principally target improvement of symptoms. To date there has been no therapy approved for acute heart failure shown to improve mortality or readmission risk post-discharge. Serelaxin, a recombinant form of the naturally occurring polypeptide hormone relaxin, has demonstrated promise in preclinical and early clinical trials as a potentially novel therapy for acute heart failure. It is postulated through its anti-fibrotic and vasodilatory effects that this agent can improve outcomes in both the short and long term in these patients. Randomized clinical data has suggested that the medication is safe and well tolerated. However, definitive outcomes data is currently being assessed in a large multi-center trial.
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Affiliation(s)
- Danyaal S Moin
- a Division of Cardiology , Stony Brook University School of Medicine , Stony Brook , NY , USA
| | - Michelle W Bloom
- a Division of Cardiology , Stony Brook University School of Medicine , Stony Brook , NY , USA
| | - Lampros Papadimitriou
- a Division of Cardiology , Stony Brook University School of Medicine , Stony Brook , NY , USA
| | - Javed Butler
- a Division of Cardiology , Stony Brook University School of Medicine , Stony Brook , NY , USA
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118
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AlFaleh H, Elasfar AA, Ullah A, AlHabib KF, Hersi A, Mimish L, Almasood A, Al Ghamdi S, Ghabashi A, Malik A, Hussein GA, Al-Murayeh M, Abuosa A, Al Habeeb W, Kashour T. Worsening heart failure in ‘real-world’ clinical practice: predictors and prognostic impact. Eur J Heart Fail 2016; 19:987-995. [DOI: 10.1002/ejhf.515] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/21/2015] [Accepted: 01/01/2016] [Indexed: 12/21/2022] Open
Affiliation(s)
- Hussam AlFaleh
- Department of Cardiac Sciences, College of Medicine; King Saud University; Riyadh Saudi Arabia
| | - Abdelfatah A. Elasfar
- King Salman Heart Center; King Fahd Medical City; Riyadh Saudi Arabia
- Cardiology Department Tanta University; Egypt
| | - Anhar Ullah
- Department of Cardiac Sciences, College of Medicine; King Saud University; Riyadh Saudi Arabia
| | - Khalid F. AlHabib
- Department of Cardiac Sciences, College of Medicine; King Saud University; Riyadh Saudi Arabia
| | - Ahmad Hersi
- Department of Cardiac Sciences, College of Medicine; King Saud University; Riyadh Saudi Arabia
| | - Layth Mimish
- King Abdulaziz University Hospital; King Abdulaziz University; Jeddah Saudi Arabia
| | - Ali Almasood
- Prince Sultan Cardiac Center; Riyadh Saudi Arabia
| | | | | | - Asif Malik
- King Fahad General Hospital; Jeddah Saudi Arabia
| | | | | | | | - Waleed Al Habeeb
- Department of Cardiac Sciences, College of Medicine; King Saud University; Riyadh Saudi Arabia
| | - Tarek Kashour
- Department of Cardiac Sciences, College of Medicine; King Saud University; Riyadh Saudi Arabia
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119
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Mohan M, Hawkey S, Baig F, Choy AM, Lang CC. Underutilization of IV nitrates in the treatment of acute heart failure. Cardiovasc Ther 2016; 33:247-52. [PMID: 25981786 DOI: 10.1111/1755-5922.12135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Acute heart failure (AHF) is a growing public health concern with high inhospital mortality and costs. Clinical practice guidelines, underpinned by positive randomized controlled trials, recommend the early use of intravenous (IV) nitrates in the treatment of AHF. However, the "real-world" usage of IV nitrates has not been clearly defined. The objective of this study was to examine the use of IV nitrates in the treatment of AHF as recommended by clinical practice guidelines. A case-record analysis was conducted of all admissions with AHF at a large teaching hospital. Of the 81 AHF patients (mean age 77 ± 11, mean SBP 130 ± 27 mmHg) enrolled for this analysis, only 5 (6%) received IV nitrates at the time of AHF admission. Forty (49%, mean age 77 ± 11, mean SBP 131 ± 27 mmHg) of these 81 patients met the guideline criteria for suitability for IV nitrates and only 5 (12%) of these received them during this admission. Patients who received IV nitrates were more likely to have higher blood pressure and all had myocardial ischemia as a precipitant. Seventy-five (93%) of the total population received loop diuretics on admission. Overall, this study shows that loop diuretics remain the first-line therapy in AHF with little use of IV nitrates, despite recommendations from clinical practice guidelines.
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Affiliation(s)
- Mohapradeep Mohan
- Division of Cardiovascular & Diabetes Medicine, Ninewells Hospital & Medical School, Dundee, Angus, UK
| | - Sean Hawkey
- Division of Cardiovascular & Diabetes Medicine, Ninewells Hospital & Medical School, Dundee, Angus, UK
| | - Fatima Baig
- Division of Cardiovascular & Diabetes Medicine, Ninewells Hospital & Medical School, Dundee, Angus, UK
| | - Anna Maria Choy
- Division of Cardiovascular & Diabetes Medicine, Ninewells Hospital & Medical School, Dundee, Angus, UK
| | - Chim C Lang
- Division of Cardiovascular & Diabetes Medicine, Ninewells Hospital & Medical School, Dundee, Angus, UK
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120
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Castrini AI, Carubelli V, Lazzarini V, Bonadei I, Lombardi C, Metra M. Serelaxin a novel treatment for acute heart failure. Expert Rev Clin Pharmacol 2016; 8:549-57. [PMID: 26294074 DOI: 10.1586/17512433.2015.1073587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Acute heart failure (AHF) represents a major healthcare burden with a high risk of in-hospital and post-discharge mortality, which remained almost unchanged in the last few decades, underscoring the need of new treatments. Relaxin is a naturally occurring human peptide initially identified as a reproductive hormone and has been shown to play a key role in the maternal hemodynamic and renal adjustments that accommodate pregnancy. Recently, the new molecule serelaxin, a recombinant form of the naturally occurring hormone relaxin has been studied in patients hospitalized for AHF. In addition to vasodilation, serelaxin has anti-oxidative, anti-inflammatory and connective tissue regulating properties. In preclinical studies, it reduced both systemic and renal vascular resistance and, in the clinical trials Pre-RELAX-AHF and RELAX-AHF, it improved dyspnea and signs of congestion. In addition, serelaxin was associated with a reduction of 180-day mortality. The aim of this review is to summarize the pharmacological properties of serelaxin and the results of the preclinical and clinical studies.
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Affiliation(s)
- Anna Isotta Castrini
- a Department of Medical and Surgical Specialties, Cardiology, Radiological Sciences, and Public Health, University and Civil Hospital of Brescia, Brescia, Italy
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121
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Mita M, Katayama H. A relaxin-like gonad-stimulating peptide from the starfish Aphelasterias japonica. Gen Comp Endocrinol 2016; 229:56-61. [PMID: 26944483 DOI: 10.1016/j.ygcen.2016.02.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/19/2016] [Accepted: 02/29/2016] [Indexed: 11/21/2022]
Abstract
Relaxin-like gonad-stimulating peptide (RGP) in starfish is the first identified invertebrate gonadotropin responsible for final gamete maturation. In this study, a new ortholog RGP was identified from Aphelasterias japonica. The DNA sequence encoding A. japonica RGP (AjaRGP) consists of 342 base pairs with an open reading frame encoding a peptide of 113 amino acids (aa), including a signal peptide (26aa), B-chain (20aa), C-peptide (42aa), and A-chain (25aa). AjaRGP is a heterodimeric peptide with disulfide cross-linkages. Comparing with Asterias amurensis RGP (AamRGP) and Patiria (=Asterina) pectinifera RGP (PpeRGP), the amino acid identity levels of AjaRGP with respect to AamRGP and PpeRGP are 84% and 58% for the A-chain and 90% and 68% for the B-chain, respectively. This suggests that AjaRGP is closer to AmaRGP rather than PpeRGP. Although chemical synthetic AjaRGP can induce gamete spawning and oocyte maturation in ovarian fragments of A. japonica, the ovary of P. pectinifera fails to respond to AjaRGP. This suggests that AjaRGP acts species-specifically.
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Affiliation(s)
- Masatoshi Mita
- Department of Biology, Faculty of Education, Tokyo Gakugei University, Nukuikita-machi 4-1-1, Koganei-shi, Tokyo 184-8501, Japan.
| | - Hidekazu Katayama
- Department of Applied Biochemistry, School of Engineering, Tokai University, 4-1-1, Kitakaname, Hiratuska, Kanagawa 259-1292, Japan
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122
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Organ protection possibilities in acute heart failure. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2016.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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123
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Frati A, Ricci B, Pierucci F, Nistri S, Bani D, Meacci E. Role of sphingosine kinase/S1P axis in ECM remodeling of cardiac cells elicited by relaxin. Mol Endocrinol 2016; 29:53-67. [PMID: 25415609 DOI: 10.1210/me.2014-1201] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The initiation and progression of heart failure is linked to adverse cardiac remodeling of the extracellular matrix (ECM) during disease mainly through the deregulation of myocardial metalloproteinases (MMPs). Relaxin (RLX), a peptide hormone acting as a physiological cardiac effector, is a key regulator of ECM remodeling in reproductive and nonreproductive tissues. Studying primary cultures of mouse cardiac muscle cells and rat H9c2 cardiomyoblasts, we have obtained evidence for a new signaling pathway activated by RLX to induce ECM remodeling that involves the bioactive sphingolipids sphingosine-1-phosphate (S1P) and ceramide. In both cell populations, recombinant human RLX increased sphingosine kinase activity and S1P formation, whereas sphingomyelin and ceramide content were decreased in [(3)H]serine-labeled cells. According to the literature, RLX promoted MMP-2 and MMP-9 expression/release. Pharmacological inhibition of sphingolipid metabolism and silencing of sphingosine kinase 1, the enzyme responsible for S1P formation, were able to prevent MMP expression/release elicited by the hormone and induce the expression of tissue inhibitor of MMPs. In addition, we found that sphingolipid signaling is required for the regulation of connective tissue growth factor, a member of the CCN 1-3 family of genes that are involved in cell proliferation and differentiation. Finally, the induction of cardiomyoblast maturation induced by RLX was also found to be counteracted by inhibition of S1P formation. In conclusion, these findings provide a novel mechanism by which RLX acts on cardiac ECM remodeling and cardiac cell differentiation and offer interesting therapeutic options to prevent heart fibrosis and to favor myocardial regeneration.
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Affiliation(s)
- Alessia Frati
- Department of Biomedical, Experimental, and Clinical Sciences (A.F., B.R., F.P., E.M.), Research Unit of Biochemistry, and Department of Experimental and Clinical Medicine (S.N., D.B.), Research Unit of Histology and Embryology, University of Florence, 50134 Florence, Italy
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124
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Lemm H, Dietz S, Janusch M, Buerke M. [Modern drug therapy in cardiovascular intensive care medicine]. Internist (Berl) 2016; 56:702, 704-8, 710-2. [PMID: 26054838 DOI: 10.1007/s00108-015-3717-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Vasoactive drugs and inotropes are important in the hemodynamic management of patients with cardiogenic shock despite modest volume administration. Currently, the concept of cardiac relief is pursued in the treatment of acute heart failure. In this article we present the use of different drugs in the intensive care unit for acute heart failure and cardiogenic shock. In acute heart failure catecholamines are only used during the transition from heart failure to cardiogenic shock. Here, the therapeutic concept of ventricular unloading is more sought after. This can be achieved by the use of diuretics, nitrates, levosimendan (inodilatator), or in the future serelaxin. The hemodynamic management in cardiogenic shock occurs after moderate volume administration with dobutamine to increase inotropy. If no adequate perfusion pressures are achieved, norepinephrine can be administered as a vasopressor. If there is still no sufficient increase in cardiac output, the inodilatator levosimendan can be used. Levosimendan instead of phosphodiesterase inhibitors in this case is preferable. The maxim of hemodynamic management in cardiogenic shock is the transient use of inotropes and vasopressors in the lowest dose possible and only for as long as necessary. This means that one should continuously check whether the dose can be reduced. There are no mortality data demonstrating the utility of hemodynamic monitoring based on objective criteria—but it makes sense to use inotropes and vasopressors sparingly.
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Affiliation(s)
- H Lemm
- Medizinische Klinik II - Kardiologie, Angiologie, Internistische Intensivmedizin, St. Marienkrankenhaus Siegen, Kampenstr. 51, 57072, Siegen, Deutschland
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125
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Capítulo 13. Novedades en el tratamiento de la falla cardiaca. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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126
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Yang J, Fan Z, Yang J, Yang C, Wang H. Relaxin: A novel therapy for acute heart failure. Int J Cardiol 2016; 206:167-8. [PMID: 26541698 DOI: 10.1016/j.ijcard.2015.10.196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 10/25/2015] [Indexed: 11/20/2022]
Affiliation(s)
- Jian Yang
- Department of Cardiology, The First College of Clinical Medical Sciences, China, Three Gorges University, Yichang 443000, Hubei Province, China.
| | - Zhixing Fan
- Department of Cardiology, The First College of Clinical Medical Sciences, China, Three Gorges University, Yichang 443000, Hubei Province, China
| | - Jun Yang
- Department of Cardiology, The First College of Clinical Medical Sciences, China, Three Gorges University, Yichang 443000, Hubei Province, China
| | - Chaojun Yang
- Department of Cardiology, The First College of Clinical Medical Sciences, China, Three Gorges University, Yichang 443000, Hubei Province, China
| | - Huibo Wang
- Department of Cardiology, The First College of Clinical Medical Sciences, China, Three Gorges University, Yichang 443000, Hubei Province, China
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127
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Wang G, Wang P, Li Y, Liu W, Bai S, Zhen Y, Li D, Yang P, Chen Y, Hong L, Sun J, Chen J, Wang X, Zhu J, Hu D, Li H, Wu T, Huang J, Tan H, Zhang J, Liao Z, Yu L, Mao Y, Ye S, Feng L, Hua Y, Ni X, Zhang Y, Wang Y, Li W, Luan X, Sun X, Wang S. Efficacy and Safety of 1-Hour Infusion of Recombinant Human Atrial Natriuretic Peptide in Patients With Acute Decompensated Heart Failure: A Phase III, Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial. Medicine (Baltimore) 2016; 95:e2947. [PMID: 26945407 PMCID: PMC4782891 DOI: 10.1097/md.0000000000002947] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 01/11/2016] [Accepted: 02/08/2016] [Indexed: 11/29/2022] Open
Abstract
The aim of the study was to evaluate the efficacy and safety of 1-h infusion of recombinant human atrial natriuretic peptide (rhANP) in combination with standard therapy in patients with acute decompensated heart failure (ADHF). This was a phase III, randomized, double-blind, placebo-controlled, multicenter trial. Eligible patients with ADHF were randomized to receive a 1-h infusion of either rhANP or placebo at a ratio of 3:1 in combination with standard therapy. The primary endpoint was dyspnea improvement (a decrease of at least 2 grades of dyspnea severity at 12 h from baseline). Reduction in pulmonary capillary wedge pressure (PCWP) 1 h after infusion was the co-primary endpoint for catheterized patients. Overall, 477 patients were randomized: 358 (93 catheterized) patients received rhANP and 118 (28 catheterized) received placebo. The percentage of patients with dyspnea improvement at 12 h was higher, although not statistically significant, in the rhANP group than in the placebo group (32.0% vs 25.4%, odds ratio=1.382, 95% confidence interval [CI]: 0.863-2.212, P = 0.17). Reduction in PCWP at 1 h was significantly greater in patients treated with rhANP than in patients treated with placebo (-7.74 ± 5.95 vs -1.82 ± 4.47 mm Hg, P < 0.001). The frequencies of adverse events and renal impairment within 3 days of treatment were similar between the 2 groups. Mortality at 1 month was 3.1% in the rhANP group vs 2.5% in the placebo group (hazard ratio = 1.21, 95% CI: 0.34-4.26; P > 0.99). 1-h rhANP infusion appears to result in prompt, transient hemodynamic improvement with a small, nonsignificant, effect on dyspnea in ADHF patients receiving standard therapy. The safety of 1-h infusion of rhANP seems to be acceptable. (WHO International Clinical Trials Registry Platform [ICTRP] number, ChiCTR-IPR-14005719.).
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Affiliation(s)
- Guogan Wang
- From the Department of Cardiology (G. Wang, P. Wang, J. Huang, H. Tan, J. Zhang, Z. Liao, L. Yu, Y. Mao, S. Ye, L. Feng, Y. Hua, X. Ni, Y. Zhang, X. Luan, X. Sun, S. Wang), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Heart Center (P. Wang), First Hospital of Tsinghua University; Key Laboratory of Cardiovascular Drugs of Ministry of Health (Y. Li), Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; Department of Cardiology (W. Liu, S. Bai), Beijing Anzhen Hospital, The Capital University Medical Sciences, Beijing; Department of Cardiology (Y. Zhen), The First Hospital of Jilin University, Changchun; Department of Cardiology (D. Li), The Affiliated Hospital of Xuzhou Medical College, Xuzhou; Department of Cardiology (P. Yang, Y. Chen), China-Japan Friendship Hospital, Jilin University, Changchun; Department of Cardiology (LH), Jiangxi Provincial People's Hospital, Nanchang; Department of Cardiology (J. Sun), The First People's Hospital of Changzhou, Changzhou; Department of Cardiology (J. Chen), First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou; Department of Cardiology (X. Wang), Beijing Military General Hospital; Department of Cardiology (J. Zhu, D. Hu), Peking University People's Hospital, Beijing; Department of Cardiology (H. Li), The 254 Hospital of People's Liberation Army, Tianjin; Department of Cardiology (T. Wu), Guangzhou Red Cross Hospital, Guangzhou; and Medical Research & Biometrics Center (Y. Wang, W. Li), National Center for Cardiovascular Diseases, Beijing, China
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128
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Tolppanen H, Logeart D. Nouveaux médicaments dans l’insuffisance cardiaque aiguë. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-015-1167-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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129
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Delorme P, de Micheaux PL, Liquet B, Riou J. Type-II generalized family-wise error rate formulas with application to sample size determination. Stat Med 2016; 35:2687-714. [PMID: 26914402 DOI: 10.1002/sim.6909] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 01/13/2016] [Accepted: 01/16/2016] [Indexed: 11/12/2022]
Abstract
Multiple endpoints are increasingly used in clinical trials. The significance of some of these clinical trials is established if at least r null hypotheses are rejected among m that are simultaneously tested. The usual approach in multiple hypothesis testing is to control the family-wise error rate, which is defined as the probability that at least one type-I error is made. More recently, the q-generalized family-wise error rate has been introduced to control the probability of making at least q false rejections. For procedures controlling this global type-I error rate, we define a type-II r-generalized family-wise error rate, which is directly related to the r-power defined as the probability of rejecting at least r false null hypotheses. We obtain very general power formulas that can be used to compute the sample size for single-step and step-wise procedures. These are implemented in our R package rPowerSampleSize available on the CRAN, making them directly available to end users. Complexities of the formulas are presented to gain insight into computation time issues. Comparison with Monte Carlo strategy is also presented. We compute sample sizes for two clinical trials involving multiple endpoints: one designed to investigate the effectiveness of a drug against acute heart failure and the other for the immunogenicity of a vaccine strategy against pneumococcus. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Phillipe Delorme
- Département de Mathématiques et de Statistique, Université de Montreal, 2920 Chemin de la Tour, Montréal, H3T 1J4, Québec, Canada
| | - Pierre Lafaye de Micheaux
- Département de Mathématiques et de Statistique, Université de Montreal, 2920 Chemin de la Tour, Montréal, H3T 1J4, Québec, Canada.,CREST-ENSAI, Campus de Ker-Lann, Rue Blaise Pascal, BP 37203, Bruz Cedex, 35172, France
| | - Benoit Liquet
- Laboratoire de Mathématiques et de leurs Applications, Université de Pau et des Pays de l'Adour, UMR CNRS, Pau, 5142, France.,ARC Centre of Excellence for Mathematical and Statistical Frontiers, Queensland University of Technology (QUT), Brisbane, Australia
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130
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Kobalava Z, Villevalde S, Kotovskaya Y, Hinrichsen H, Petersen-Sylla M, Zaehringer A, Pang Y, Rajman I, Canadi J, Dahlke M, Lloyd P, Halabi A. Pharmacokinetics of serelaxin in patients with hepatic impairment: a single-dose, open-label, parallel group study. Br J Clin Pharmacol 2016; 79:937-45. [PMID: 25511105 DOI: 10.1111/bcp.12572] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/09/2014] [Indexed: 12/28/2022] Open
Abstract
AIMS Serelaxin is a recombinant form of human relaxin-2 in development for treatment of acute heart failure. This study aimed to evaluate the pharmacokinetics (PK) of serelaxin in patients with hepatic impairment. Secondary objectives included evaluation of immunogenicity, safety and tolerability of serelaxin. METHODS This was an open-label, parallel group study (NCT01433458) comparing the PK of serelaxin following a single 24 h intravenous (i.v.) infusion (30 μg kg(-1) day(-1) ) between patients with mild, moderate or severe hepatic impairment (Child-Pugh class A, B, C) and healthy matched controls. Blood sampling and standard safety assessments were conducted. Primary non-compartmental PK parameters [including area under the serum concentration-time curve AUC(0-48 h) and AUC(0-∞) and serum concentration at 24 h post-dose (C24h )] were compared between each hepatic impairment group and healthy controls. RESULTS A total of 49 subjects (including 25 patients with hepatic impairment) were enrolled, of which 48 subjects completed the study. In all groups, the serum concentration of serelaxin increased over the first few hours of infusion, reached steady-state at 12-24 h and then declined following completion of infusion, with a mean terminal half-life of 7-8 h. All PK parameter estimates were comparable between each group of patients with hepatic impairment and healthy controls. No serious adverse events, discontinuations due to adverse events or deaths were reported. No serelaxin treatment-related antibodies developed during this study. CONCLUSIONS The PK and safety profile of serelaxin were not affected by hepatic impairment. No dose adjustment is needed for serelaxin treatment of 48 h i.v. infusion in patients with hepatic impairment.
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Affiliation(s)
| | | | | | | | | | | | - Yinuo Pang
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
| | - Iris Rajman
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Jasna Canadi
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Marion Dahlke
- Novartis Institutes for BioMedical Research, Basel, Switzerland
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131
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Montero-Pérez-Barquero M, Morales-Rull JL. Organ protection possibilities in acute heart failure. Rev Clin Esp 2016; 216:157-64. [PMID: 26896381 DOI: 10.1016/j.rce.2016.01.003] [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: 11/17/2015] [Accepted: 01/11/2016] [Indexed: 10/22/2022]
Abstract
Unlike chronic heart failure (HF), the treatment for acute HF has not changed over the last decade. The drugs employed have shown their ability to control symptoms but have not achieved organ protection or managed to reduce medium to long-term morbidity and mortality. Advances in our understanding of the pathophysiology of acute HF suggest that treatment should be directed not only towards correcting the haemodynamic disorders and achieving symptomatic relief but also towards preventing organ damage, thereby counteracting myocardial remodelling and cardiac and extracardiac disorders. Compounds that exert vasodilatory and anti-inflammatory action in the acute phase of HF and can stop cell death, thereby boosting repair mechanisms, could have an essential role in organ protection.
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Affiliation(s)
- M Montero-Pérez-Barquero
- Servicio de Medicina Interna, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC)/Hospital Reina Sofía, Universidad de Córdoba, Córdoba, España.
| | - J L Morales-Rull
- Unidad de Insuficiencia Cardiaca, Servicio de Medicina Interna, Hospital Universitario Arnau de Vilanova, Región Sanitaria de Lleida, Lleida, España
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Harada K, Yamamoto T, Okumura T, Shigekiyo M, Terada N, Okada A, Kawata A, Iima T, Harada T, Fujisawa K, Kageyama N, Saito A, Yamamoto H, Fujinaga H. Intravenous nicorandil for treatment of the urgent phase acute heart failure syndromes: A randomized, controlled trial. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:329-338. [PMID: 26884620 DOI: 10.1177/2048872616633837] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Vasodilators, such as nitroglycerin, have long been first-line treatments for acute heart failure syndromes (AHFS). Nicorandil is a vasodilator with dual potassium channel opening and nitrate properties. However, there are no randomized controlled studies of intravenous nicorandil safety and efficacy in the urgent phase AHFS. We examined the symptomatic, hemodynamic, and echocardiographic effects and safety, and 60-day clinical outcomes of intravenous nicorandil, in addition to standard therapy, in patients with AHFS in the urgent phase. METHODS In this prospective, randomized controlled trial, 106 AHFS patients were randomized within one hour of arrival to receive either standard therapy (control group, n=56) or standard therapy plus simultaneous intravenous nicorandil (0.2 mg/kg bolus followed by 0.2 mg/kg/h for 24 h; nicorandil group, n=50). Outcomes were assessed at 60 days. RESULTS Patients in the nicorandil group exhibited greater improvement of dyspnea as measured by change in a five-point Likert scale compared to those in the control group (after 1 h infusion: p=0.006, 6 h; p<0.001). The nicorandil group also showed significantly improved E/e', an estimate of left ventricular filling pressure, at 1 and 24 h ( p=0.001 and p=0.004, respectively). In addition, intravenous nicorandil therapy was safe and did not cause side effects such as excessive hypotension or reflex tachycardia. However, it did not reduce all-cause mortality and readmission rates at 60 days. CONCLUSIONS Addition of intravenous nicorandil to standard therapy for urgent phase AHFS improved dyspnea and left ventricular diastolic function but not 60-day outcome.
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Affiliation(s)
- Kenji Harada
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Takashi Yamamoto
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Takanobu Okumura
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Masahito Shigekiyo
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Naho Terada
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Ayumi Okada
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Atsushi Kawata
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Tsutomu Iima
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Takafumi Harada
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Kazutoshi Fujisawa
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Norihito Kageyama
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Akihiro Saito
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Hirofumi Yamamoto
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
| | - Hiroyuki Fujinaga
- Department of Cardiovascular Medicine, Tokushima Prefectural Central Hospital, Tokushima, Japan
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133
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Davison BA, Metra M, Cotter G, Massie BM, Cleland JGF, Dittrich HC, Edwards C, Filippatos G, Givertz MM, Greenberg B, Ponikowski P, Voors AA, O'Connor CM, Teerlink JR. Worsening Heart Failure Following Admission for Acute Heart Failure: A Pooled Analysis of the PROTECT and RELAX-AHF Studies. JACC-HEART FAILURE 2016; 3:395-403. [PMID: 25951761 DOI: 10.1016/j.jchf.2015.01.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 01/06/2015] [Accepted: 01/07/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVES These studies conducted analyses to examine patient characteristics and outcomes associated with worsening heart failure (WHF). BACKGROUND WHF during an admission for acute heart failure (AHF) represents treatment failure and is a potential therapeutic target for clinical trials of AHF. METHODS Individual patient data from the PROTECT (Placebo-Controlled Randomized Study of the Selective A1 Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized with Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function) and RELAX-AHF (Relaxin in Acute Heart Failure) phase II and III studies were pooled for analysis. RESULTS Of 3,691 patients, death or WHF through day 5 occurred in 12.4%, ranging from 9.5% to 14.5% among studies. A multivariable model provided modest discrimination between patients who did or did not develop WHF (C-index = 0.68). After multivariable adjustment, WHF was associated with a mean increase in length of stay of 5.2 days (95% confidence interval [CI]: 4.6 to 5.8 days) and increased risks of 60-day HF or renal failure readmission or cardiovascular death (hazard ratio [HR]: 1.64, 95% CI: 1.34 to 2.01) and 180-day mortality (HR: 1.93, 95% CI: 1.55 to 2.41) (all p < 0.001). The risk of mortality was higher in patients whose WHF required intravenous inotropes or mechanical therapy (HR: 3.03, 95% CI: 2.11 to 4.36) compared with patients whose WHF was treated with intravenous loop diuretic alone (HR: 1.80, 95% CI: 1.36 to 2.36) (both p < 0.001). WHF was associated with larger increases in markers of renal and hepatic dysfunction during the first days of admission, but remained significantly associated with adverse outcomes after adjustment for these changes. CONCLUSIONS WHF during the first 5 days of admission for AHF occurred in approximately 10% to 15% of patients and was associated with longer length of stay and higher risk for readmission and death.
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Affiliation(s)
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gad Cotter
- Momentum Research Inc., Durham, North Carolina
| | - Barry M Massie
- Division of Cardiology, School of Medicine, University of California-San Francisco, San Francisco, California
| | - John G F Cleland
- Department of Cardiology, University of Hull, Kingston upon Hull, United Kingdom; National Heart and Lung Institute, Royal Brompton and Harefield Hospitals National Health Service Trust, Imperial College, London, United Kingdom
| | | | | | | | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Barry Greenberg
- Division of Cardiology, University of California at San Diego, San Diego, California
| | - Piotr Ponikowski
- Department of Cardiology, Medical University, Clinical Military Hospital, Wroclaw, Poland
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, Groningen, the Netherlands
| | | | - John R Teerlink
- Division of Cardiology, School of Medicine, University of California-San Francisco, San Francisco, California; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California
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134
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Fabbri A, Marchesini G, Carbone G, Cosentini R, Ferrari A, Chiesa M, Bertini A, Rea F. Acute heart failure in the emergency department: a follow-up study. Intern Emerg Med 2016; 11:115-22. [PMID: 26506831 DOI: 10.1007/s11739-015-1336-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/30/2015] [Indexed: 12/13/2022]
Abstract
Acute heart failure (AHF) is a major public health issue due to high incidence and poor prognosis. Only a few studies are available on the long-term prognosis and on outcome predictors in the unselected population attending the emergency department (ED) for AHF. We carried out a 1-year follow-up analysis of 1234 consecutive patients from selected Italian EDs from January 2011 to June 2012 for an episode of AHF. Their prognosis and outcome-associated factors were tested by Cox proportional hazard model. Patients' mean age was 84, with 66.0% over 80 years and 56.2% females. Comorbidities were present in over 50% of cases, principally a history of acute coronary syndrome, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, valvular heart disease. Death occurred within 6 h in 24 cases (1.9%). At 30-day follow-up, death was registered in 123 cases (10.0%): 110 cases (89.4%) died of cardiovascular events and 13 (10.6%) of non-cardiovascular causes (cancer, gastrointestinal hemorrhages, sepsis, trauma). At 1-year follow-up, all-cause death was recorded in 50.1% (over 3 out of 4 cases for cardiovascular origin). Six variables (older age, diabetes, systolic arterial pressure <110 mm/Hg, high NT pro-BNP, high troponin levels and impaired cognitive status) were selected as outcome predictors, but with limited discriminant capacity (AUC = 0.649; SE 0.015). Recurrence of AHF was registered in 31.0%. The study identifies a cluster of variables associated with 1-year mortality in AHF, but their predictive capacity is low. Old age and the presence of comorbidities, in particular diabetes are likely to play a major role in dictating the prognosis.
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Affiliation(s)
- Andrea Fabbri
- Department of Emergency Medicine, Presidio Ospedaliero Morgagni-Pierantonio, AUSL della Romagna - Forlì, Via Forlanini 34, 47121, Forlì, Italy.
| | - Giulio Marchesini
- Department of Medical and Surgical Sciences, Clinical Dietetics, University of Bologna, S. Orsola-Malpighi Hospital, via Massarenti 9, 40138, Bologna, Italy
| | - Giorgio Carbone
- Department of Emergency Medicine, Gradenigo Hospital, Corso Regina Margherita 8/10, 10100, Torino, Italy
| | - Roberto Cosentini
- Department of Emergency Medicine, Osp. Maggiore Policlinico, fondazione Cà Granda, via F. Sforza 35, 20122, Milan, Italy
| | - Annamaria Ferrari
- Department of Emergency Medicine, Ospedale S. Maria Nuova, via Risorgimento 80, 4100, Reggio Emilia, Italy
| | - Mauro Chiesa
- Department of Emergency Medicine, Ospedale S. Antonio, Azienda Ospedaliera, via Facciolati 71, 36124, Padua, Italy
| | - Alessio Bertini
- Department of Emergency Medicine, Azienda Ospedaliera Universitaria Pisana, via Roma 67, 56126, Pisa, Italy
| | - Federico Rea
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, via Bicocca degli Arcimboldi 8, 20126, Milan, Italy
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135
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Abstract
Although the period from 1953 to 2001 resulted in the approval of more than 30 medications currently used to treat heart failure (HF), few novel drugs have been approved in the last decade. However, the investigational pipeline for HF medications once again appears promising. In patients with chronic heart failure with reduced ejection fraction (HFrEF), ivabradine and valsartan/sucubitril (LCZ696) were recently approved by the US Food and Drug Administration. Both agents have been shown to reduce the risk of cardiovascular death and HF hospitalization. In the treatment of acute HF, serelaxin and ularitide are the farthest along in development. Both agents have demonstrated favorable effects on surrogate end points and preliminary data suggest a possible mortality benefit with serelaxin. Consequently, phase 3 trials are ongoing to evaluate the effect of serelaxin and ularitide on clinical outcomes. Given the poor history of recent investigational acute HF drugs that have advanced to phase 3/4 studies, enthusiasm for both serelaxin and ularitide must be tempered until these trials are completed.
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Affiliation(s)
- Sarah Hanigan
- Department of Pharmacy, University of Michigan Health System, Ann Arbor, MI, USA
| | - Robert J. DiDomenico
- Department of Pharmacy Practice, Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
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136
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Lühmann T, Mong SK, Simon MD, Meinel L, Pentelute BL. A perfluoroaromatic abiotic analog of H2 relaxin enabled by rapid flow-based peptide synthesis. Org Biomol Chem 2016; 14:3345-9. [DOI: 10.1039/c6ob00208k] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We report on the rapid-flow based synthesis and functional characterization of a H2 relaxin analog that takes advantage of perfluoroarylation-cysteine SNAr chemistry for a disulfide replacement strategy.
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Affiliation(s)
- Tessa Lühmann
- Department of Chemistry
- Massachusetts Institute of Technology
- Cambridge
- USA
- Institute of Pharmacy and Food Chemistry
| | - Surin K. Mong
- Department of Chemistry
- Massachusetts Institute of Technology
- Cambridge
- USA
| | - Mark D. Simon
- Department of Chemistry
- Massachusetts Institute of Technology
- Cambridge
- USA
| | - Lorenz Meinel
- Institute of Pharmacy and Food Chemistry
- University of Wurzburg
- Wurzburg
- Germany
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137
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Contemporary Treatment of Acute Heart Failure. Prog Cardiovasc Dis 2016; 58:367-78. [DOI: 10.1016/j.pcad.2015.12.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 12/29/2015] [Indexed: 01/09/2023]
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138
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Cannon JA, McKean AR, Jhund PS, McMurray JJV. What can we learn from RELAX-AHF compared to previous AHF trials and what does the future hold? Open Heart 2015; 2:e000283. [PMID: 26719808 PMCID: PMC4692046 DOI: 10.1136/openhrt-2015-000283] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 09/06/2015] [Accepted: 10/13/2015] [Indexed: 01/08/2023] Open
Abstract
Each year in the USA there are over 1 million hospital admissions directly related to heart failure (HF). With similar rates across Europe, this places a huge economic burden on healthcare systems globally. Hospitalisation for HF is associated with poor clinical outcomes with 25% of patients being readmitted with signs and symptoms of HF within 1 month of discharge and 10-20% dying in the 6 months after discharge. Although hospital admission could be a sign of disease progression, it is also possible that some of the treatments given acutely for example, inotropic therapy, may result in neurohormonal, haemodynamic and other effects accelerating end-organ damage and contributing to these poor outcomes after discharge. In contrast to the treatment of chronic heart failure (CHF), clinical trials conducted over the past decade in patients with acute HF (AHF) have failed to show significant reductions in morbidity or mortality despite some agents causing beneficial changes in symptoms. As such, the current treatment of patients hospitalised with HF is mainly based on consensus rather than clinical evidence and has changed little over time. We review RELAX-AHF in the context of the other key, large-scale AHF trials conducted over the past 15 years and compare and contrast study design and outcomes in an attempt to determine which factors might be associated with a successful trial in the future.
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Affiliation(s)
- Jane A Cannon
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow , Glasgow , UK
| | - Andrew R McKean
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow , Glasgow , UK
| | - Pardeep S Jhund
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow , Glasgow , UK
| | - John J V McMurray
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow , Glasgow , UK
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139
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Abstract
With the total cases and economic burden of heart failure continuing to rise, there is an overwhelming need for novel therapies. Several drugs for heart failure have succeeded in preclinical and early-phase clinical trials, but most of them failed to show the real benefit in pivotal clinical trials. Meanwhile, the US Food and Drug Administration recently approved two promising new drugs to treat heart failure: ivabradine and sacubitril/valsartan. Furthermore, some of the newer agents in testing offer the potential for significant progress in addition to these drugs. Patiromer and zirconium cyclosilicate are attractive agents that are expected to prevent hyperkalemia during renin-angiotensin-aldosterone system inhibition, and serelaxin and urodilatin are promising drugs in the treatment of acute heart failure. Future clinical trials with more appropriate study designs, optimal clinical endpoints, and proper patient selection are mandatory to assess the true efficacy of these attractive compounds in clinical practice.
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Affiliation(s)
- Takeshi Kitai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Wh Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA; Center for Clinical Genomics, Cleveland Clinic, Cleveland, OH, USA
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140
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Iwaz JA, Lee E, Aramin H, Romero D, Iqbal N, Kawahara M, Khusro F, Knight B, Patel MV, Sharma S, Maisel AS. New Targets in the Drug Treatment of Heart Failure. Drugs 2015; 76:187-201. [DOI: 10.1007/s40265-015-0498-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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141
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Afsar B, Ortiz A, Covic A, Solak Y, Goldsmith D, Kanbay M. Focus on renal congestion in heart failure. Clin Kidney J 2015; 9:39-47. [PMID: 26798459 PMCID: PMC4720202 DOI: 10.1093/ckj/sfv124] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 10/27/2015] [Indexed: 12/11/2022] Open
Abstract
Hospitalizations due to heart failure are increasing steadily despite advances in medicine. Patients hospitalized for worsening heart failure have high mortality in hospital and within the months following discharge. Kidney dysfunction is associated with adverse outcomes in heart failure patients. Recent evidence suggests that both deterioration in kidney function and renal congestion are important prognostic factors in heart failure. Kidney congestion in heart failure results from low cardiac output (forward failure), tubuloglomerular feedback, increased intra-abdominal pressure or increased venous pressure. Regardless of the cause, renal congestion is associated with increased morbidity and mortality in heart failure. The impact on outcomes of renal decongestion strategies that do not compromise renal function should be explored in heart failure. These studies require novel diagnostic markers that identify early renal damage and renal congestion and allow monitoring of treatment responses in order to avoid severe worsening of renal function. In addition, there is an unmet need regarding evidence-based therapeutic management of renal congestion and worsening renal function. In the present review, we summarize the mechanisms, diagnosis, outcomes, prognostic markers and treatment options of renal congestion in heart failure.
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Affiliation(s)
- Baris Afsar
- Department of Medicine, Division of Nephrology , Konya Numune State Hospital , Konya , Turkey
| | - Alberto Ortiz
- Nephrology and Hypertension Department , IIS-Fundacion Jimenez Diaz and School of Medicine , Madrid , Spain
| | - Adrian Covic
- Nephrology Clinic, Dialysis and Renal Transplant Center , 'C.I. PARHON' University Hospital, and 'Grigore T. Popa' University of Medicine , Iasi , Romania
| | - Yalcin Solak
- Department of Nephrology , Sakarya Training and Research Hospital , Sakarya , Turkey
| | - David Goldsmith
- Renal and Transplantation Department , Guy's and St Thomas' Hospitals , London , UK
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology , Koc University School of Medicine , Istanbul , Turkey
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142
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Díez J, Ruilope LM. Serelaxin for the treatment of acute heart failure: a review with a focus on end-organ protection. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2015; 2:119-30. [PMID: 27418970 PMCID: PMC4853824 DOI: 10.1093/ehjcvp/pvv046] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 10/26/2015] [Indexed: 12/15/2022]
Abstract
Acute heart failure (AHF) is a complex clinical syndrome characterized by fluid overload and haemodynamic abnormalities (short-term clinical consequences) and the development of end-organ damage (long-term consequences). Current therapies for the treatment of AHF, such as loop diuretics and vasodilators, help to relieve haemodynamic imbalance and congestion, but have not been shown to prevent (and may even contribute to) end-organ damage, or to provide long-term clinical benefit. Serelaxin is the recombinant form of human relaxin-2, a naturally occurring hormone involved in mediating haemodynamic changes during pregnancy. Preclinical and clinical studies have investigated the effects mediated by serelaxin and the suitability of this agent for the treatment of patients with AHF. Data suggest that serelaxin acts via multiple pathways to improve haemodynamics at the vascular, cardiac, and renal level and provide effective congestion relief. In addition, this novel agent may protect the heart, kidneys, and liver from damage by inhibiting inflammation, oxidative stress, cell death, and tissue fibrosis, and stimulating angiogenesis. Serelaxin may therefore improve both short- and long-term outcomes in patients with AHF. In this review, we examine the unique mechanisms underlying the potential benefits of serelaxin for the treatment of AHF, in particular, those involved in mediating end-organ protection.
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Affiliation(s)
- Javier Díez
- Program of Cardiovascular Diseases, Centre for Applied Medical Research and Department of Cardiology and Cardiac Surgery, University of Navarra Clinic, University of Navarra, Av. Pío XII 55, Pamplona 31008, Spain
| | - Luis M Ruilope
- Research Institute, Hypertension Unit, Hospital 12 de Octubre and Department of Public Health and Preventive Medicine, University Autónoma, Madrid, Spain
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143
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Tietjens J, Teerlink JR. Serelaxin and acute heart failure. Heart 2015; 102:95-9. [DOI: 10.1136/heartjnl-2014-306786] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 10/02/2015] [Indexed: 01/11/2023] Open
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144
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Raleigh JMV, Toldo S, Das A, Abbate A, Salloum FN. Relaxin' the Heart: A Novel Therapeutic Modality. J Cardiovasc Pharmacol Ther 2015; 21:353-62. [PMID: 26589290 DOI: 10.1177/1074248415617851] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 10/22/2015] [Indexed: 12/20/2022]
Abstract
The peptide hormone relaxin has traditionally been linked to the maternal adaptation of the cardiovascular system during the first trimester of pregnancy. By promoting nitric oxide formation through different molecular signaling events, relaxin has been proposed as a pleiotropic and cardioprotective hormone in the setting of many cardiovascular diseases. In fact, preclinical studies were able to demonstrate that relaxin promotes vasodilatation and angiogenesis, ameliorates ischemia/reperfusion injury, and regulates extracellular matrix turnover and remodeling. In the RELAX-AHF phase 3 clinical trial, serelaxin (recombinant human relaxin) was shown to be safe, and it exerted survival benefits in patients with acute heart failure. RELAX-AHF-2 is currently ongoing, and it aims to address a larger population and evaluate harder clinical outcomes. Besides heart failure, acute myocardial infarction, peripheral arterial disease, and stable coronary disease could be target diseases for treatment with serelaxin in future clinical trials.
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Affiliation(s)
- Juan M Valle Raleigh
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Stefano Toldo
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Anindita Das
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Antonio Abbate
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Fadi N Salloum
- Division of Cardiology, Department of Internal Medicine, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
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145
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Dahlke M, Halabi A, Canadi J, Tsubouchi C, Machineni S, Pang Y. Pharmacokinetics of serelaxin in patients with severe renal impairment or end-stage renal disease requiring hemodialysis: A single-dose, open-label, parallel-group study. J Clin Pharmacol 2015; 56:474-83. [PMID: 26239266 PMCID: PMC5063144 DOI: 10.1002/jcph.607] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/31/2015] [Indexed: 11/08/2022]
Abstract
Serelaxin, a recombinant human relaxin-2 hormone, is in clinical development for treating acute heart failure. This open-label, parallel-group study investigated serelaxin pharmacokinetics (PK) after a single 4-hour intravenous infusion (10 µg/kg) in patients with severe renal impairment (n = 6) or end-stage renal disease (ESRD) requiring hemodialysis (PK on the day of dialysis [n = 6] or during dialysis-free interval [n = 6]), compared with matched healthy subjects (n = 18). In all participants, serum serelaxin concentration peaked at the end of infusion and subsequently declined with mean terminal elimination half-life of 6.5-8.8 hours. Compared with healthy subjects, a moderate decrease in serelaxin systemic clearance (37%-52%) and increase in its exposure (30%-115%) were observed in all patients. During the 4-hour hemodialysis in ESRD patients, 30% serelaxin was removed, with hemodialysis clearance constituting approximately 52% of total systemic clearance. Serelaxin was well tolerated with no deaths, serious adverse events (AE), or AE-related discontinuations. Antiserelaxin antibodies were not detected in any participant. Given the shallow dose-response relationship observed with serelaxin in clinical studies and its wide therapeutic window, the observed PK differences in patients with severe renal impairment compared with healthy subjects are unlikely to pose a safety risk and do not warrant a predefined dosage adjustment in such patients.
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Affiliation(s)
| | - Atef Halabi
- Clinical Research Services GmbH, Kiel, Germany
| | | | | | | | - Yinuo Pang
- Novartis Institutes for BioMedical Research, Cambridge, MA, USA
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146
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Ural D, Çavuşoğlu Y, Eren M, Karaüzüm K, Temizhan A, Yılmaz MB, Zoghi M, Ramassubu K, Bozkurt B. Diagnosis and management of acute heart failure. Anatol J Cardiol 2015; 15:860-89. [PMID: 26574757 PMCID: PMC5336936 DOI: 10.5152/anatoljcardiol.2015.6567] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Acute heart failure (AHF) is a life threatening clinical syndrome with a progressively increasing incidence in general population. Turkey is a country with a high cardiovascular mortality and recent national statistics show that the population structure has turned to an 'aged' population.As a consequence, AHF has become one of the main reasons of admission to cardiology clinics. This consensus report summarizes clinical and prognostic classification of AHF, its worldwide and national epidemiology, diagnostic work-up, principles of approach in emergency department,intensive care unit and ward, treatment in different clinical scenarios and approach in special conditions and how to plan hospital discharge.
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Affiliation(s)
- Dilek Ural
- Department of Cardiology, Medical Faculty of Kocaeli University; Kocaeli-Turkey.
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147
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Halls ML, Bathgate RAD, Sutton SW, Dschietzig TB, Summers RJ. International Union of Basic and Clinical Pharmacology. XCV. Recent advances in the understanding of the pharmacology and biological roles of relaxin family peptide receptors 1-4, the receptors for relaxin family peptides. Pharmacol Rev 2015; 67:389-440. [PMID: 25761609 DOI: 10.1124/pr.114.009472] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Relaxin, insulin-like peptide 3 (INSL3), relaxin-3, and INSL5 are the cognate ligands for the relaxin family peptide (RXFP) receptors 1-4, respectively. RXFP1 activates pleiotropic signaling pathways including the signalosome protein complex that facilitates high-sensitivity signaling; coupling to Gα(s), Gα(i), and Gα(o) proteins; interaction with glucocorticoid receptors; and the formation of hetero-oligomers with distinctive pharmacological properties. In addition to relaxin-related ligands, RXFP1 is activated by Clq-tumor necrosis factor-related protein 8 and by small-molecular-weight agonists, such as ML290 [2-isopropoxy-N-(2-(3-(trifluoromethylsulfonyl)phenylcarbamoyl)phenyl)benzamide], that act allosterically. RXFP2 activates only the Gα(s)- and Gα(o)-coupled pathways. Relaxin-3 is primarily a neuropeptide, and its cognate receptor RXFP3 is a target for the treatment of depression, anxiety, and autism. A variety of peptide agonists, antagonists, biased agonists, and an allosteric modulator target RXFP3. Both RXFP3 and the related RXFP4 couple to Gα(i)/Gα(o) proteins. INSL5 has the properties of an incretin; it is secreted from the gut and is orexigenic. The expression of RXFP4 in gut, adipose tissue, and β-islets together with compromised glucose tolerance in INSL5 or RXFP4 knockout mice suggests a metabolic role. This review focuses on the many advances in our understanding of RXFP receptors in the last 5 years, their signal transduction mechanisms, the development of novel compounds that target RXFP1-4, the challenges facing the field, and current prospects for new therapeutics.
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Affiliation(s)
- Michelle L Halls
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia (M.L.H., R.J.S.); Neuropeptides Division, Florey Institute of Neuroscience and Mental Health and Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, Victoria, Australia (R.A.D.B.); Neuroscience Drug Discovery, Janssen Research & Development, LLC, San Diego, California (S.W.S.); Immundiagnostik AG, Bensheim, Germany (T.B.D.); and Charité-University Medicine Berlin, Campus Mitte, Medical Clinic for Cardiology and Angiology, Berlin, Germany (T.B.D.)
| | - Ross A D Bathgate
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia (M.L.H., R.J.S.); Neuropeptides Division, Florey Institute of Neuroscience and Mental Health and Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, Victoria, Australia (R.A.D.B.); Neuroscience Drug Discovery, Janssen Research & Development, LLC, San Diego, California (S.W.S.); Immundiagnostik AG, Bensheim, Germany (T.B.D.); and Charité-University Medicine Berlin, Campus Mitte, Medical Clinic for Cardiology and Angiology, Berlin, Germany (T.B.D.)
| | - Steve W Sutton
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia (M.L.H., R.J.S.); Neuropeptides Division, Florey Institute of Neuroscience and Mental Health and Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, Victoria, Australia (R.A.D.B.); Neuroscience Drug Discovery, Janssen Research & Development, LLC, San Diego, California (S.W.S.); Immundiagnostik AG, Bensheim, Germany (T.B.D.); and Charité-University Medicine Berlin, Campus Mitte, Medical Clinic for Cardiology and Angiology, Berlin, Germany (T.B.D.)
| | - Thomas B Dschietzig
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia (M.L.H., R.J.S.); Neuropeptides Division, Florey Institute of Neuroscience and Mental Health and Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, Victoria, Australia (R.A.D.B.); Neuroscience Drug Discovery, Janssen Research & Development, LLC, San Diego, California (S.W.S.); Immundiagnostik AG, Bensheim, Germany (T.B.D.); and Charité-University Medicine Berlin, Campus Mitte, Medical Clinic for Cardiology and Angiology, Berlin, Germany (T.B.D.)
| | - Roger J Summers
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Parkville, Victoria, Australia (M.L.H., R.J.S.); Neuropeptides Division, Florey Institute of Neuroscience and Mental Health and Department of Biochemistry and Molecular Biology, University of Melbourne, Parkville, Victoria, Australia (R.A.D.B.); Neuroscience Drug Discovery, Janssen Research & Development, LLC, San Diego, California (S.W.S.); Immundiagnostik AG, Bensheim, Germany (T.B.D.); and Charité-University Medicine Berlin, Campus Mitte, Medical Clinic for Cardiology and Angiology, Berlin, Germany (T.B.D.)
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148
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Abstract
Heart failure (HF) can rightfully be called the epidemic of the 21(st) century. Historically, the only available medical treatment options for HF have been diuretics and digoxin, but the capacity of these agents to alter outcomes has been brought into question by the scrutiny of modern clinical trials. In the past 4 decades, neurohormonal blockers have been introduced into clinical practice, leading to marked reductions in morbidity and mortality in chronic HF with reduced left ventricular ejection fraction (LVEF). Despite these major advances in pharmacotherapy, our understanding of the underlying disease mechanisms of HF from epidemiological, clinical, pathophysiological, molecular, and genetic standpoints remains incomplete. This knowledge gap is particularly evident with respect to acute decompensated HF and HF with normal (preserved) LVEF. For these clinical phenotypes, no drug has been shown to reduce long-term clinical event rates substantially. Ongoing developments in the pharmacotherapy of HF are likely to challenge our current best-practice algorithms. Novel agents for HF therapy include dual-acting neurohormonal modulators, contractility-enhancing agents, vasoactive and anti-inflammatory peptides, and myocardial protectants. These novel compounds have the potential to enhance our armamentarium of HF therapeutics.
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Affiliation(s)
- Thomas G von Lueder
- Department of Cardiology, Oslo University Hospital Ullevål, 0407 Oslo, Norway
| | - Henry Krum
- Monash Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, VIC 3004, Australia
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149
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Hossain MA, Haugaard-Kedström LM, Rosengren KJ, Bathgate RAD, Wade JD. Chemically synthesized dicarba H2 relaxin analogues retain strong RXFP1 receptor activity but show an unexpected loss of in vitro serum stability. Org Biomol Chem 2015; 13:10895-903. [PMID: 26368576 DOI: 10.1039/c5ob01539a] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Peptides and proteins are now acknowledged as viable alternatives to small molecules as potential therapeutic agents. A primary limitation to their more widespread acceptance is their generally short in vivo half-lives due to serum enzyme susceptibility and rapid renal clearance. Numerous chemical approaches to address this concern have been undertaken in recent years. The replacement of disulfide bonds with non-reducible elements has been demonstrated to be one effective means by eliminating the deleterious effect of serum reductases. In particular, substitution with dicarba bonds via ring closure metathesis has been increasingly applied to many bioactive cystine-rich peptides. We used this approach for the replacement of the A-chain intramolecular disulfide bond of human relaxin 2 (H2 relaxin), an insulin-like peptide that has important regulatory roles in cardiovascular and connective tissue homeostasis that has led to successful Phase IIIa clinical trials for the treatment of acute heart failure. Use of efficient solid phase synthesis of the two peptide chains was followed by on-resin ring closure metathesis and formation of the dicarba bond within the A-chain and then by off-resin combination with the B-chain via sequential directed inter-chain disulfide bond formation. After purification and comprehensive chemical characterization, the two isomeric synthetic H2 relaxin analogues were shown to retain near-equipotent RXFP1 receptor binding and activation propensity. Unexpectedly, the in vitro serum stability of the analogues was greatly reduced compared with the native peptide. Circular dichroism spectroscopy studies showed subtle differences in the secondary structures between dicarba analogues and H2 relaxin suggesting that, although the overall fold is retained, it may be destabilized which could account for rapid degradation of dicarba analogues in serum. Caution is therefore recommended when using ring closure metathesis as a general approach to enhance peptide stability.
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Affiliation(s)
- Mohammed Akhter Hossain
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Victoria 3010, Australia.
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150
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Vaduganathan M, Kumar V, Voors AA, Butler J. Unsolved challenges in diuretic therapy for acute heart failure: a focus on diuretic response. Expert Rev Cardiovasc Ther 2015; 13:1075-8. [PMID: 26357970 DOI: 10.1586/14779072.2015.1087313] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Loop diuretics represent the mainstay of management of patients hospitalized for heart failure (HF). Diuretic resistance is commonly encountered in clinical practice, but limited evidence-based approaches are available to address it. Recent clinical investigations have proposed common definitions of diuretic response: a change in body weight, net fluid loss or total urinary output to 40 mg of furosemide dose equivalents. Poor diuretic response is characterized by features of advanced HF and atherosclerosis and is independently associated with poor in-hospital and post-discharge outcomes. A number of adjunctive or combination decongestion therapies are available to overcome diuretic resistance, but high-quality prospective data supporting these approaches are lacking. Once a definition has been standardized and accepted, diuretic response may represent an important inclusion criteria and end point in upcoming clinical trials in hospitalized HF to help define an optimal, tailored approach to this challenging clinical entity.
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Affiliation(s)
- Muthiah Vaduganathan
- a 1 Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Varun Kumar
- b 2 Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Adriaan A Voors
- c 3 University Medical Center Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - Javed Butler
- d 4 Division of Cardiology, Stony Brook University, Stony Brook, NY, USA
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