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Abstract
OPINION STATEMENT Despite major advances that have led to effective therapeutic modalities for the treatment of heart failure (HF), this syndrome has continued to be a staggering health problem associated with significant mortality and morbidity. The increasing number of hospital admissions and readmissions related to acute HF continues to pose a fiscal challenge leading to constant interest in development of novel approaches. These point to multiple areas of unmet needs especially in acute HF, thus, necessitating further efforts to develop novel strategies for prevention and treatment of acute HF. One area of continuing focus is targeting the role of autonomic imbalance associated with the development of HF. Autonomic dysregulation, manifested by increased sympathetic drive and reduced parasympathetic activity, has been recognized as a mediator of increased mortality and morbidity in HF and myocardial infarction. Furthermore, vagal withdrawal has been shown to precede acute decompensation, though whether this represents cause or effect is unknown. This review discusses the potential role of autonomic dysregulation as a therapeutic modality for patients with acute decompensated HF.
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152
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Cooper LB, DeVore AD, Michael Felker G. The Impact of Worsening Heart Failure in the United States. Heart Fail Clin 2015; 11:603-14. [PMID: 26462100 DOI: 10.1016/j.hfc.2015.07.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
In-hospital worsening heart failure represents a clinical scenario wherein a patient hospitalized for acute heart failure experiences a worsening of their condition, requiring escalation of therapy. Worsening heart failure is associated with worse in-hospital and postdischarge outcomes. Worsening heart failure is increasingly being used as an endpoint or combined endpoint in clinical trials, as it is unique to episodes of acute heart failure and captures an important event during the inpatient course. While prediction models have been developed to identify worsening heart failure, there are no known FDA-approved medications associated with decreased worsening heart failure. Continued study is warranted.
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Affiliation(s)
- Lauren B Cooper
- Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA.
| | - Adam D DeVore
- Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA
| | - G Michael Felker
- Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715, USA
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153
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Butler J, Gheorghiade M, Kelkar A, Fonarow GC, Anker S, Greene SJ, Papadimitriou L, Collins S, Ruschitzka F, Yancy CW, Teerlink JR, Adams K, Cotter G, Ponikowski P, Felker GM, Metra M, Filippatos G. In-hospital worsening heart failure. Eur J Heart Fail 2015; 17:1104-13. [DOI: 10.1002/ejhf.333] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 06/28/2015] [Accepted: 07/02/2015] [Indexed: 01/08/2023] Open
Affiliation(s)
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - Anita Kelkar
- Cardiology Division; Emory University; Atlanta GA USA
| | - Gregg C. Fonarow
- Cardiology Division; University of California Los Angeles; Los Angeles CA USA
| | - Stefan Anker
- Department of Cardiology; Charite Campus Virchow-Klinikum; Berlin Germany
| | - Stephen J. Greene
- Center for Cardiovascular Innovation; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | | | - Sean Collins
- Department of Emergency Medicine; Vanderbilt University; Nashville TN USA
| | | | - Clyde W. Yancy
- Center for Cardiovascular Innovation; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - John R. Teerlink
- Cardiology Division; University of California San Francisco; San Francisco CA USA
| | - Kirkwood Adams
- Cardiology Division; University of North Carolina; Chapel Hill NC USA
| | | | | | - G. Michael Felker
- Duke Clinical Research Institute; Duke University Medical Center; Durham NC USA
| | - Marco Metra
- Cardiology Division; University of Brescia; Brescia Italy
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154
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155
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Platz E, Jhund PS, Campbell RT, McMurray JJ. Assessment and prevalence of pulmonary oedema in contemporary acute heart failure trials: a systematic review. Eur J Heart Fail 2015; 17:906-16. [PMID: 26230356 DOI: 10.1002/ejhf.321] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 06/06/2015] [Accepted: 06/12/2015] [Indexed: 01/01/2023] Open
Abstract
AIMS Pulmonary oedema is a common and important finding in acute heart failure (AHF). We conducted a systematic review to describe the methods used to assess pulmonary oedema in recent randomized AHF trials and report its prevalence in these trials. METHODS AND RESULTS Of 23 AHF trials published between 2002 and 2013, six were excluded because they were very small or not randomized, or missing full-length publications. Of the remaining 17 (n = 200-7141) trials, six enrolled patients with HF and reduced ejection fraction (HF-REF) and 11, patients with both HF-REF and HF with preserved ejection fraction (HF-PEF). Pulmonary oedema was an essential inclusion criterion, in most trials, based upon findings on physical examination ('rales'), radiographic criteria ('signs of congestion'), or both. The prevalence of pulmonary oedema in HF-REF trials ranged from 75% to 83% and in combined HF-REF and HF-PEF trials from 51% to 100%. Five trials did not report the prevalence or extent of pulmonary oedema assessed by either clinical examination or chest x-ray. Improvement of pulmonary congestion with treatment was inconsistently reported and commonly grouped with other signs of congestion into a score. One trial suggested that patients with rales over >2/3 of the lung fields on admission were at higher risk of adverse outcomes than those without. CONCLUSION Although pulmonary oedema is a common finding in AHF, represents a therapeutic target, and may be of prognostic importance, recent trials used inconsistent criteria to define it, and did not consistently report its severity at baseline or its response to treatment. Consistent and ideally quantitative, methods for the assessment of pulmonary oedema in AHF trials are needed.
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Affiliation(s)
- Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ross T Campbell
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - John J McMurray
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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156
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Di Somma S, Magrini L. Drug Therapy for Acute Heart Failure. ACTA ACUST UNITED AC 2015; 68:706-13. [PMID: 26088867 DOI: 10.1016/j.rec.2015.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 02/10/2015] [Indexed: 01/11/2023]
Abstract
Acute heart failure is globally one of most frequent reasons for hospitalization and still represents a challenge for the choice of the best treatment to improve patient outcome. According to current international guidelines, as soon as patients with acute heart failure arrive at the emergency department, the common therapeutic approach aims to improve their signs and symptoms, correct volume overload, and ameliorate cardiac hemodynamics by increasing vital organ perfusion. Recommended treatment for the early management of acute heart failure is characterized by the use of intravenous diuretics, oxygen, and vasodilators. Although these measures ameliorate the patient's symptoms, they do not favorably impact on short- and long-term mortality. Consequently, there is a pressing need for novel agents in acute heart failure treatment with the result that research in this field is increasing worldwide.
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Affiliation(s)
- Salvatore Di Somma
- Emergency Department Sant'Andrea Hospital, Medical-Surgery Sciences and Translational Medicine, University La Sapienza, Rome, Italy.
| | - Laura Magrini
- Emergency Department Sant'Andrea Hospital, Medical-Surgery Sciences and Translational Medicine, University La Sapienza, Rome, Italy
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157
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Varr BC, Maurer MS. Emerging role of serelaxin in the therapeutic armamentarium for heart failure. Curr Atheroscler Rep 2015; 16:447. [PMID: 25108571 DOI: 10.1007/s11883-014-0447-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute heart failure (AHF) remains a major cause of morbidity and mortality, with an increasing prevalence anticipated over the next few decades as the population ages, heightening already significant health and economic burdens to society. New therapies for AHF have stalled over the past decade for a multitude of reasons, principal among them the heterogeneous population of patients affected with potentially multiple operative pathophysiologic mechanisms making a single targeted therapy a challenge. Serelaxin, a recombinant form of human relaxin-2, mediates adaptive cardiovascular effects during pregnancy that could be beneficial in the AHF population, primarily through nitric oxide-mediated vasodilation. Serelaxin is a novel therapeutic agent that has shown promise in the treatment of AHF in predefined subpopulations, though studies powered for "hard" outcomes are still pending. In this review, we examine the clinical investigations to date involving serelaxin in patients with heart failure and its possible emerging role in the future therapy of AHF.
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Affiliation(s)
- Brandon C Varr
- Division of Cardiology, Columbia University Medical Center, New York, NY, USA,
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158
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Nieminen MS, Dickstein K, Fonseca C, Serrano JM, Parissis J, Fedele F, Wikström G, Agostoni P, Atar S, Baholli L, Brito D, Colet JC, Édes I, Gómez Mesa JE, Gorjup V, Garza EH, González Juanatey JR, Karanovic N, Karavidas A, Katsytadze I, Kivikko M, Matskeplishvili S, Merkely B, Morandi F, Novoa A, Oliva F, Ostadal P, Pereira-Barretto A, Pollesello P, Rudiger A, Schwinger RHG, Wieser M, Yavelov I, Zymliński R. The patient perspective: Quality of life in advanced heart failure with frequent hospitalisations. Int J Cardiol 2015; 191:256-64. [PMID: 25981363 DOI: 10.1016/j.ijcard.2015.04.235] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/30/2015] [Indexed: 12/27/2022]
Abstract
End of life is an unfortunate but inevitable phase of the heart failure patients' journey. It is often preceded by a stage in the progression of heart failure defined as advanced heart failure, and characterised by poor quality of life and frequent hospitalisations. In clinical practice, the efficacy of treatments for advanced heart failure is often assessed by parameters such as clinical status, haemodynamics, neurohormonal status, and echo/MRI indices. From the patients' perspective, however, quality-of-life-related parameters, such as functional capacity, exercise performance, psychological status, and frequency of re-hospitalisations, are more significant. The effects of therapies and interventions on these parameters are, however, underrepresented in clinical trials targeted to assess advanced heart failure treatment efficacy, and data are overall scarce. This is possibly due to a non-universal definition of the quality-of-life-related endpoints, and to the difficult standardisation of the data collection. These uncertainties also lead to difficulties in handling trade-off decisions between quality of life and survival by patients, families and healthcare providers. A panel of 34 experts in the field of cardiology and intensive cardiac care from 21 countries around the world convened for reviewing the existing data on quality-of-life in patients with advanced heart failure, discussing and reaching a consensus on the validity and significance of quality-of-life assessment methods. Gaps in routine care and research, which should be addressed, were identified. Finally, published data on the effects of current i.v. vasoactive therapies such as inotropes, inodilators, and vasodilators on quality-of-life in advanced heart failure patients were analysed.
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Affiliation(s)
| | | | - Cândida Fonseca
- S. Francisco Xavier Hospital, CHLO, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal
| | - Jose Magaña Serrano
- División de Educación en Salud, UMAE Hospital de Cardiología Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico
| | - John Parissis
- Second University Cardiology Clinic, Attiko Teaching Hospital, Athens, Greece
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology and Geriatric Science, University of Rome, Italy
| | | | | | - Shaul Atar
- Department of Cardiology, Galilee Medical Center, Nahariya, Israel
| | - Loant Baholli
- Department of Intensive Care, Klinikum Dortmund, Germany
| | - Dulce Brito
- Cardiology Department, Hospital Universitario de Santa Maria, Lisbon, Portugal
| | | | - István Édes
- Department of Cardiology, University of Debrecen, Hungary
| | | | - Vojka Gorjup
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Slovenia
| | - Eduardo Herrera Garza
- Heart Failure, Heart Transplant Department, Centro Médico Zambrano Hellion, Heart Failure Clinic Unidad Médica de Alta Especialidad, Hospital de Cardiología No. 34, IMSS Monterrey Nuevo León, Mexico
| | | | - Nenad Karanovic
- Clinical Department of Anaesthesiology and Intensive Care, University Hospital of Split, Croatia
| | - Apostolos Karavidas
- Heart Failure Clinic & Echo Lab, Gennimatas General Hospital of Athens, Greece
| | - Igor Katsytadze
- Cardiology Intensive Care Unit, O. Bogomolets National Medical University, Kiev, Ukraine
| | | | | | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Fabrizio Morandi
- Department of Cardiovascular Science, University of Insubria, Circolo Hospital and Macchi Foundation, Varese, Italy
| | | | - Fabrizio Oliva
- Department of Cardiology, Niguarda Ca'Granda Hospital, Milan, Italy
| | - Petr Ostadal
- Department of Cardiology, Cardiovascular Center, Na Homolce Hospital, Prague, Czech Republic
| | | | | | - Alain Rudiger
- Institute of Anaesthesiology, University Hospital Zurich, Switzerland
| | - Robert H G Schwinger
- Department of Internal Medicine, Kliniken Nordoberpfalz, Weiden, Germany; Teaching Hospital of the University of Regensburg, Germany
| | - Manfred Wieser
- Department of Internal Medicine 1, University Hospital Krems, Karl Landsteiner University of Health Sciences, Austria
| | - Igor Yavelov
- Scientific Research Institute of Physico-Chemical Medicine of the Federal Medico-Biological Agency of the Russian Federation, Moscow, Russia
| | - Robert Zymliński
- Department of Cardiology, Cardiology Intensive Care Unit, The 4th Military Hospital, Wroclaw, Poland
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159
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Kumar VA, Viau D, Levy P. New Drugs You Are Going to Read About: Serelaxin, Ularitide, TRV027. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2015; 3:66-73. [PMID: 26236569 DOI: 10.1007/s40138-015-0068-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Nitrovasodilators have long been used as first-line treatment for hypertensive acute heart failure (AHF). Although effective for BP control and symptom alleviation, this class of agents has never been shown to improve mortality or prevent hospital readmissions. Consequently, there has been tremendous interest in development of newer vasodilators with more beneficial therapeutic profiles. In this review, we focus on three of the most promising agents currently being studied: serelaxin, ularitide, and TRV027. While regulatory approval has yet to be obtained, should they prove beneficial in on-going trials, we are looking at a new era of drug therapy that could supplant more conventional treatments and broaden the horizon for management of patients with AHF.
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Affiliation(s)
- Vijaya Arun Kumar
- Department of Emergency medicine, School of Medicine, Wayne State University, 540 East Canfield Street, Detroit, MI 48201, USA, Tel: (313) 577-1335,
| | - David Viau
- Department of Physiology, School of Medicine, Wayne State University, 540 East Canfield Street, Detroit, MI 48201, USA, Tel: (313) 577-1335,
| | - Phillip Levy
- Department of Emergency medicine, School of Medicine, Wayne State University, 540 East Canfield Street, Detroit, MI 48201, USA, Tel: (313) 577-1335,
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160
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Sato N, Takahashi W, Hirayama A, Ajioka M, Takahashi N, Okishige K, Wang X, Maki A, Maruyama H, Ebinger U, Yamaguchi M, Pang Y, Matsumoto H, Kawana M. Multicenter, Randomized, Double-Blinded, Placebo-Controlled Phase II Study of Serelaxin in Japanese Patients With Acute Heart Failure. Circ J 2015; 79:1237-47. [PMID: 25912697 DOI: 10.1253/circj.cj-15-0227] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Serelaxin, a recombinant form of human relaxin-2, is in development for treating acute heart failure (AHF) and a Phase II study in Japanese AHF patients was conducted. METHODS AND RESULTS A randomized, double-blind, placebo-controlled study of serelaxin at 10 and 30 µg·kg(-1)·day(-1)continuous intravenous infusion for up to 48 h, added to standard care for Japanese AHF patients. Primary endpoints were adverse events (AEs) through Day 5, serious AEs (SAEs) through Day 14, and serelaxin pharmacokinetics. Secondary endpoints included changes in systolic blood pressure (SBP) and cardiorenal biomarkers. A total of 46 patients received the study drug and were followed for 60 days. The observed AE profile was comparable between the groups, with no AEs of concern. Dose-dependent increase in the serum concentration of serelaxin was observed across the 2 dose rates of serelaxin. A greater reduction in SBP was observed with serelaxin 30 µg·kg(-1)·day(-1)vs. placebo (-7.7 [-16.4, 1.0] mmHg). A greater reduction in NT-proBNP was noted with serelaxin (-50.8% and -54.9% for 10 and 30 µg·kg(-1)·day(-1), respectively at Day 2). CONCLUSIONS Serelaxin was well tolerated in this study with Japanese AHF patients, with no AEs of concern and favorable beneficial trends on efficacy. These findings support further evaluation of serelaxin 30 µg·kg(-1)·day(-1)in this patient population.
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Affiliation(s)
- Naoki Sato
- Cardiology and Intensive Care Unit, Nippon Medical School Musashi-Kosugi Hospital
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161
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Patel C, Deoghare S. Heart failure: novel therapeutic approaches. J Postgrad Med 2015; 61:101-8. [PMID: 25766342 PMCID: PMC4943440 DOI: 10.4103/0022-3859.153104] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 07/12/2013] [Accepted: 08/27/2013] [Indexed: 11/21/2022] Open
Abstract
Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorders that impairs the ability of the ventricle to fill with or eject blood. Despite effective medical interventions, mortality and morbidity remain substantial. There have been significant advances in the therapy of HF in recent decades, such as the introduction of beta-blockers and antagonists of the renin-angiotensin system but still there is a major unmet need for better therapies for HF. In the present era, pathophysiology of HF has been explored. Various novel pathways, molecular sites have been identified, which contribute to the progression of the disease. By targeting these sites, newer pharmacological agents have been developed, which can play a promising role in the treatment of HF. This article focuses on recent advancements in pharmacotherapy of HF, which include agents targeting myocardial contractility, cytokines and inflammation, fibrosis and remodeling, myocardial metabolism, oxidative stress, and other newly defined pathways.
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Affiliation(s)
- C Patel
- Department of Pharmacology, Government Medical College, Surat, Gujarat, India
| | - S Deoghare
- Department of Pharmacology, Government Medical College, Surat, Gujarat, India
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162
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Wilson SS, Ayaz SI, Levy PD. Relaxin: A Novel Agent for the Treatment of Acute Heart Failure. Pharmacotherapy 2015; 35:315-27. [DOI: 10.1002/phar.1548] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Suprat S. Wilson
- Department of Pharmacy; Detroit Receiving Hospital; Detroit Michigan
| | - Syed I. Ayaz
- Department of Emergency Medicine; Wayne State University School of Medicine; Detroit Michigan
| | - Phillip D. Levy
- Department of Emergency Medicine; Cardiovascular Research Institute; Wayne State University School of Medicine; Detroit Michigan
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163
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Novel markers and therapies for patients with acute heart failure and renal dysfunction. Am J Med 2015; 128:312.e1-22. [PMID: 25446297 DOI: 10.1016/j.amjmed.2014.10.035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 10/07/2014] [Accepted: 10/07/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute kidney injury complicates decompensated heart failure in ∼33% of cases and is associated with morbidity and mortality; thus, we sought to systematically review this topic in order to summarize novel diagnostic and therapeutic approaches. METHODS Structured PubMed searches on these topics were conducted in February 2014 and relevant literature was identified. The PubMed search identified a total of 192 articles that were individually screened for inclusion in this analysis, and 58 were included. RESULTS Acute kidney injury, defined by substantial increases in serum creatinine, is associated consistently with prolonged length of stay, rehospitalization, and mortality. Biomarker studies suggested that natriuretic peptides are prognostic for shorter- and longer-term mortality. Novel proteins indicating kidney damage and albumin in the urine are associated with acute kidney injury. The most promising acute pharmacologic treatment appears to be serelaxin, which has been shown to improve acute heart failure symptoms, hemodynamic parameters, and renal function. CONCLUSIONS The presence of acute kidney injury results in worse clinical outcomes for patients with acute heart failure. Novel biomarkers and therapies hold the promise of improving both cardiac and renal outcomes in these patients.
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164
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Dahlke M, Ng D, Yamaguchi M, Machineni S, Berger S, Canadi J, Rajman I, Lloyd P, Pang Y. Safety and tolerability of serelaxin, a recombinant human relaxin-2 in development for the treatment of acute heart failure, in healthy Japanese volunteers and a comparison of pharmacokinetics and pharmacodynamics in healthy Japanese and Caucasian populations. J Clin Pharmacol 2015; 55:415-22. [PMID: 25408331 DOI: 10.1002/jcph.433] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Revised: 11/13/2014] [Accepted: 11/14/2014] [Indexed: 11/09/2022]
Abstract
Serelaxin, a recombinant form of the human relaxin-2 hormone, is currently under clinical investigation for treatment of acute heart failure. This double-blind, placebo-controlled, dose-ranging study investigated the effect of Japanese ethnicity on the pharmacokinetics (PK), pharmacodynamics (PD), and safety and tolerability of serelaxin. Japanese healthy subjects (n = 32) received 10, 30, or 100 µg/kg/day of serelaxin, or placebo, administered as a 48-hour intravenous infusion. A Caucasian cohort (n = 8) receiving 30 µg/kg/day open-label serelaxin was included for comparison. In all subjects, serum serelaxin concentrations increased rapidly after the start of infusion, approached steady state as early as 4 hours, and declined rapidly upon treatment cessation. Serum exposure to serelaxin increased with increasing doses. Statistical dose proportionality was shown for AUC(inf) over the entire dose range. A significant increase in estimated glomerular filtration rate from baseline to Day 2 (30 and 100 µg/kg/day) and to Day 3 (10 and 100 µg/kg/day) was observed compared with placebo. Serelaxin was well tolerated by all subjects. In conclusion, PK, PD, and safety profiles of serelaxin were generally comparable between Japanese and Caucasian subjects, suggesting that no dose adjustment will be required in Japanese subjects during routine clinical use of this agent.
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165
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Pharmacologic Strategies to Preserve Renal Function in Acute Decompensated Heart Failure. Curr Heart Fail Rep 2015; 12:1-6. [DOI: 10.1007/s11897-014-0239-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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166
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Alexander P, Alkhawam L, Curry J, Levy P, Pang PS, Storrow AB, Collins SP. Lack of evidence for intravenous vasodilators in ED patients with acute heart failure: a systematic review. Am J Emerg Med 2015; 33:133-41. [PMID: 25530194 PMCID: PMC4344879 DOI: 10.1016/j.ajem.2014.09.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 09/02/2014] [Accepted: 09/02/2014] [Indexed: 01/01/2023] Open
Abstract
There are nearly 700,000 annual US emergency department (ED) visits for acute heart failure (AHF). Although blood pressure is elevated on most of these visits, acute therapy remains focused on preload and not afterload reduction. Data from recent prospective studies suggest that patients with AHF with concomitant acute hypertension benefit from intravenous (IV) vasodilators. To better understand the use of vasodilators for such patients, we conducted a systematic review of (1) currently available intravenous vasodilators for ED patients with AHF, or (2) intravenous vasodilators that are not yet available, but have completed phase III clinical trials in AHF, and may be available for ED use in the future. We used multiterm search queries to retrieve research involving nitroglycerin, nitroprusside, enalaprilat, hydralazine, relaxin, and nesiritide. A total of 2001 unique citations were identified from 3 databases: PubMed, EMBASE, and CINAHL. Of these, 1966 were excluded on the basis of established review criteria, leaving 35 published articles for inclusion. Our primary finding was that intravenous nitrovasodilators, when used in the treatment of AHF in ED and ED-like settings, do improve short-term symptoms and appear safe to administer. There are no data suggesting that they impact mortality. Other commonly used vasodilators such as hydralazine and enalaprilat have very little published data about their safety and efficacy. Of note, few studies enrolled patients early in their course of treatment. Thus, to assess the specific impact of vasodilator therapy on both short- and long-term outcomes, future research efforts should focus on patient recruitment in the ED setting.
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Affiliation(s)
- Pauline Alexander
- Department of Emergency Medicine, Vanderbilt University, 1313 21st Ave S, Nashville, TN 37232, United States.
| | - Lora Alkhawam
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 303 E Chicago Ave, Chicago, IL 60611, United States
| | - Jason Curry
- Department of Emergency Medicine, Vanderbilt University, 1313 21st Ave S, Nashville, TN 37232, United States
| | - Phillip Levy
- Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State University, 540 E Canfield St, Detroit, MI 48201, United States
| | - Peter S Pang
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 303 E Chicago Ave, Chicago, IL 60611, United States
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University, 1313 21st Ave S, Nashville, TN 37232, United States
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, 1313 21st Ave S, Nashville, TN 37232, United States
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167
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Synthetic covalently linked dimeric form of H2 relaxin retains native RXFP1 activity and has improved in vitro serum stability. BIOMED RESEARCH INTERNATIONAL 2015; 2015:731852. [PMID: 25685807 PMCID: PMC4317577 DOI: 10.1155/2015/731852] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 10/11/2014] [Indexed: 11/18/2022]
Abstract
Human (H2) relaxin is a two-chain peptide member of the insulin superfamily and possesses potent pleiotropic roles including regulation of connective tissue remodeling and systemic and renal vasodilation. These effects are mediated through interaction with its cognate G-protein-coupled receptor, RXFP1. H2 relaxin recently passed Phase III clinical trials for the treatment of congestive heart failure. However, its in vivo half-life is short due to its susceptibility to proteolytic degradation and renal clearance. To increase its residence time, a covalent dimer of H2 relaxin was designed and assembled through solid phase synthesis of the two chains, including a judiciously monoalkyne sited B-chain, followed by their combination through regioselective disulfide bond formation. Use of a bisazido PEG7 linker and "click" chemistry afforded a dimeric H2 relaxin with its active site structurally unhindered. The resulting peptide possessed a similar secondary structure to the native monomeric H2 relaxin and bound to and activated RXFP1 equally well. It had fewer propensities to activate RXFP2, the receptor for the related insulin-like peptide 3. In human serum, the dimer had a modestly increased half-life compared to the monomeric H2 relaxin suggesting that additional oligomerization may be a viable strategy for producing longer acting variants of H2 relaxin.
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Abstract
Pulmonary oedema (PO) is a common manifestation of acute heart failure (AHF) and is associated with a high-acuity presentation and with poor in-hospital outcomes. The clinical picture of PO is dominated by signs of pulmonary congestion, and its pathogenesis has been attributed predominantly to an imbalance in Starling forces across the alveolar-capillary barrier. However, recent studies have demonstrated that PO formation and resolution is critically regulated by active endothelial and alveolar signalling. PO represents a medical emergency and treatment should be individually tailored to the urgency of the presentation and acute haemodynamic characteristics. Although, the majority of patients admitted with PO rapidly improve as result of conventional intravenous (IV) therapies, treatment of PO remains largely opinion based as there is a general lack of good evidence to guide therapy. Furthermore, none of these therapies showed simultaneous benefit for symptomatic relief, haemodynamic improvement, increased survival and end-organ protection. Future research is required to develop innovative pharmacotherapies capable of relieving congestion while simultaneously preventing end-organ damage.
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Affiliation(s)
- Ovidiu Chioncel
- Institute of Emergency for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee, US
| | | | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois, US
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Collins S, Storrow AB, Albert NM, Butler J, Ezekowitz J, Felker GM, Fermann GJ, Fonarow GC, Givertz MM, Hiestand B, Hollander JE, Lanfear DE, Levy PD, Pang PS, Peacock WF, Sawyer DB, Teerlink JR, Lenihan DJ. Early management of patients with acute heart failure: state of the art and future directions. A consensus document from the society for academic emergency medicine/heart failure society of America acute heart failure working group. J Card Fail 2015; 21:27-43. [PMID: 25042620 PMCID: PMC4276508 DOI: 10.1016/j.cardfail.2014.07.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 06/28/2014] [Accepted: 07/10/2014] [Indexed: 12/18/2022]
Abstract
Heart failure (HF) afflicts nearly 6 million Americans, resulting in one million emergency department (ED) visits and over one million annual hospital discharges. An aging population and improved survival from cardiovascular diseases is expected to further increase HF prevalence. Emergency providers play a significant role in the management of patients with acute heart failure (AHF). It is crucial that emergency physicians and other providers involved in early management understand the latest developments in diagnostic testing, therapeutics and alternatives to hospitalization. Further, clinical trials must be conducted in the ED in order to improve the evidence base and drive optimal initial therapy for AHF. Should ongoing and future studies suggest early phenotype-driven therapy improves in-hospital and post-discharge outcomes, ED treatment decisions will need to evolve accordingly. The potential impact of future studies which incorporate risk-stratification into ED disposition decisions cannot be underestimated. Predictive instruments that identify a cohort of patients safe for ED discharge, while simultaneously addressing barriers to successful outpatient management, have the potential to significantly impact quality of life and resource expenditures.
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Affiliation(s)
- Sean Collins
- Nashville Veterans Affairs Medical Center and Vanderbilt University, Nashville, Tennessee.
| | | | | | | | | | | | | | | | | | | | | | | | | | - Peter S Pang
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - John R Teerlink
- San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California
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170
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Collins SP, Storrow AB, Levy PD, Albert N, Butler J, Ezekowitz JA, Michael Felker G, Fermann GJ, Fonarow GC, Givertz MM, Hiestand B, Hollander JE, Lanfear DE, Pang PS, Frank Peacock W, Sawyer DB, Teerlink JR, Lenihan DJ. Early management of patients with acute heart failure: state of the art and future directions--a consensus document from the SAEM/HFSA acute heart failure working group. Acad Emerg Med 2015; 22:94-112. [PMID: 25423908 DOI: 10.1111/acem.12538] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 08/24/2014] [Indexed: 12/20/2022]
Abstract
Heart failure (HF) afflicts nearly 6 million Americans, resulting in 1 million emergency department (ED) visits and over 1 million annual hospital discharges. The majority of inpatient admissions originate in the ED; thus, it is crucial that emergency physicians and other providers involved in early management understand the latest developments in diagnostic testing, therapeutics, and alternatives to hospitalization. This article discusses contemporary ED management as well as the necessary next steps for ED-based acute HF research.
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Affiliation(s)
- Sean P. Collins
- The Department of Emergency Medicine; Vanderbilt University; Nashville Veterans Affairs Medical Center; Nashville TN
| | - Alan B. Storrow
- The Department of Emergency Medicine; Vanderbilt University; Nashville Veterans Affairs Medical Center; Nashville TN
| | - Phillip D. Levy
- The Department of Emergency Medicine; Wayne State University; Detroit MI
| | - Nancy Albert
- The Division of Cardiology; Cleveland Clinic; Cleveland OH
| | - Javed Butler
- The Division of Cardiology; Emory University; Atlanta GA
| | | | | | - Gregory J. Fermann
- The Department of Emergency Medicine; University of Cincinnati; Cincinnati OH
| | - Gregg C. Fonarow
- The Division of Cardiology; Ronald Reagan-UCLA Medical Center; Los Angeles CA
| | | | - Brian Hiestand
- The Department of Emergency Medicine; Wake Forest University; Winston-Salem NC
| | - Judd E. Hollander
- The Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | | | - Peter S. Pang
- The Department of Emergency Medicine; Northwestern University; Chicago IL
| | - W. Frank Peacock
- The Department of Emergency Medicine; Baylor University; Houston TX
| | - Douglas B. Sawyer
- The Department of Emergency Medicine; Vanderbilt University; Nashville Veterans Affairs Medical Center; Nashville TN
| | - John R. Teerlink
- The Division of Cardiology; San Francisco Veterans Affairs Medical Center; University of California at San Francisco; San Francisco CA
| | - Daniel J. Lenihan
- The Division of Cardiology; Vanderbilt University; Nashville Veterans Affairs Medical Center; Nashville TN
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171
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Kaldara E, Sanoudou D, Adamopoulos S, Nanas JN. Outpatient management of chronic heart failure. Expert Opin Pharmacother 2014; 16:17-41. [PMID: 25480690 DOI: 10.1517/14656566.2015.978286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Heart failure (HF) treatment attracts a share of intensive research because of its poor HF prognosis. In the past decades, the prognosis of HF has improved considerably, mainly as a consequence of the progress that has been made in the pharmacological management of HF. AREAS COVERED This article reviews the outpatient pharmacological management of chronic HF due to left ventricular systolic dysfunction and offers recommendations on the use of various drugs. In addition, the present article attempts to provide practical therapeutic algorithms based on current clinical strategies. EXPERT OPINION Continued research directed toward identifying factors associated with high pharmacotherapy guideline adherence and understanding of variants that influence response to drugs will hopefully halt or reverse the major pathophysiological mechanisms involved in this syndrome.
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Affiliation(s)
- Elisabeth Kaldara
- University of Athens, Medical School, 3rd Cardiology Department , Mikras Asias 67, 11527 Attiki, Athens , Greece +30 2108236877 ; +30 2107789901 ;
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172
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Sarwar M, Samuel CS, Bathgate RA, Stewart DR, Summers RJ. Serelaxin-mediated signal transduction in human vascular cells: bell-shaped concentration-response curves reflect differential coupling to G proteins. Br J Pharmacol 2014; 172:1005-19. [PMID: 25297987 DOI: 10.1111/bph.12964] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 09/16/2014] [Accepted: 09/24/2014] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND AND PURPOSE In a recently conducted phase III clinical trial, RELAX-AHF, serelaxin infusion over 48 h improved short- and long-term clinical outcomes in patients with acute heart failure. In this study we used human primary cells from the umbilical vasculature to better understand the signalling mechanisms activated by serelaxin. EXPERIMENTAL APPROACH We examined the acute effects of serelaxin on signal transduction mechanisms in primary human umbilical vascular cells and its chronic actions on markers of cardiovascular function and disease. KEY RESULTS The RXFP1 receptor, the cognate serelaxin receptor, was expressed at the cell surface in HUVECs and human umbilical vein smooth muscle cells (HUVSMCs), human umbilical artery smooth muscle cells (HUASMCs) and human cardiac fibroblasts (HCFs), but not human umbilical artery endothelial cells. In HUVECs and HUVSMCs, serelaxin increased cAMP, cGMP accumulation and pERK1/2, and the concentration-response curves (CRCs) were bell-shaped. Similar bell-shaped CRCs for cGMP and pERK1/2 were observed in HCFs, whereas in HUASMCs, serelaxin increased cAMP, cGMP and pERK1/2 with sigmoidal CRCs. Gαi/o and lipid raft disruption, but not Gαs inhibition, altered the serelaxin CRC for cAMP and cGMP accumulation in HUVSMC but not HUASMC. Longer term serelaxin exposure increased the expression of neuronal NOS, VEGF, ETβ receptors and MMPs (gelatinases) in RXFP1 receptor-expressing cells. CONCLUSIONS AND IMPLICATIONS Serelaxin caused acute and chronic changes in human umbilical vascular cells that were cell background dependent. Bell-shaped CRCs that were observed only in venous cells and fibroblasts involved Gαi/o located within membrane lipid rafts.
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Affiliation(s)
- M Sarwar
- Drug Discovery Biology, Monash Institute of Pharmacology, Monash University, Melbourne, Vic., Australia
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173
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Abstract
Three innovative pharmaceuticals which might play an important role in the field of cardiology in the near future were recently tested in large clinical studies. Serelaxin, a vasoactive hormone peptide that is produced during pregnancy, reduces vessel resistance, increases cardiac output, and improves renal function. Lately, it was demonstrated that serelaxin significantly reduces congestion symptoms in patients with acute heart failure. As a secondary endpoint the mortality at day 180 was reduced. Therefore, serelaxin seems to be a promising new drug for the treatment of acute heart failure which might have a prognostic impact. Edoxaban is a selective factor Xa inhibitor, which inhibits thrombin production and thrombus formation. Two recently published studies reported that edoxaban is at least as effective as the vitamin K antagonist warfarin in prevention and treatment of venous thromboembolism and in the prevention of stroke and systemic embolism due to nonvalvular atrial fibrillation. Compared to warfarin, edoxaban significantly exhibited less frequent severe bleeding complications. Edoxaban will probably soon be the fourth new oral anticoagulant available for patients. The serine protease proprotein convertase subtilisin/kexin 9 (PCSK9) reduces the ability of the liver to bind low-density lipoprotein cholesterol (LDL-C) and to remove it from the circulation. Recently, a monoclonal antibody for PCSK9 was developed which induces a LDL-C plasma level reduction up to 73 % and also decreases lipoprotein(a) and apolipoprotein B. PCSK9 inhibition is a promising new mechanism for LDL-C reduction and the corresponding drug will be presumably approved soon by the regulatory authorities.
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174
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Huuskes BM, Wise AF, Cox AJ, Lim EX, Payne NL, Kelly DJ, Samuel CS, Ricardo SD. Combination therapy of mesenchymal stem cells and serelaxin effectively attenuates renal fibrosis in obstructive nephropathy. FASEB J 2014; 29:540-53. [PMID: 25395452 DOI: 10.1096/fj.14-254789] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Chronic kidney disease (CKD) results from the development of fibrosis, ultimately leading to end-stage renal disease (ESRD). Although human bone marrow-derived mesenchymal stem cells (MSCs) can accelerate renal repair following acute injury, the establishment of fibrosis during CKD may affect their potential to influence regeneration capacity. Here we tested the novel combination of MSCs with the antifibrotic serelaxin to repair and protect the kidney 7 d post-unilateral ureteral obstruction (UUO), when fibrosis is established. Male C57BL6 mice were sham-operated or UUO-inured (n = 4-6) and received vehicle, MSCs (1 × 10(6)), serelaxin (0.5 mg/kg per d), or the combination of both. In vivo tracing studies with luciferin/enhanced green fluorescent protein (eGFP)-tagged MSCs showed specific localization in the obstructed kidney where they remained for 36 h. Combination therapy conferred significant protection from UUO-induced fibrosis, as indicated by hydroxyproline analysis (P < 0.001 vs. vehicle, P < 0.05 vs. MSC or serelaxin alone). This was accompanied by preserved structural architecture, decreased tubular epithelial injury (P < 0.01 vs. MSCs alone), macrophage infiltration, and myofibroblast localization in the kidney (both P < 0.01 vs. vehicle). Combination therapy also stimulated matrix metalloproteinase (MMP)-2 activity over either treatment alone (P < 0.05 vs. either treatment alone). These results suggest that the presence of an antifibrotic in conjunction with MSCs ameliorates established kidney fibrosis and augments tissue repair to a greater extent than either treatment alone.
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Affiliation(s)
- Brooke M Huuskes
- *Department of Anatomy and Developmental Biology and Department of Pharmacology, Monash University, Clayton, Victoria, Australia; Department of Medicine, University of Melbourne, St. Vincent's Hospital, Melbourne, Australia; and Australia Regenerative Medicine Institute (ARMI) and Monash University, Clayton, Victoria, Australia
| | - Andrea F Wise
- *Department of Anatomy and Developmental Biology and Department of Pharmacology, Monash University, Clayton, Victoria, Australia; Department of Medicine, University of Melbourne, St. Vincent's Hospital, Melbourne, Australia; and Australia Regenerative Medicine Institute (ARMI) and Monash University, Clayton, Victoria, Australia
| | - Alison J Cox
- *Department of Anatomy and Developmental Biology and Department of Pharmacology, Monash University, Clayton, Victoria, Australia; Department of Medicine, University of Melbourne, St. Vincent's Hospital, Melbourne, Australia; and Australia Regenerative Medicine Institute (ARMI) and Monash University, Clayton, Victoria, Australia
| | - Ee X Lim
- *Department of Anatomy and Developmental Biology and Department of Pharmacology, Monash University, Clayton, Victoria, Australia; Department of Medicine, University of Melbourne, St. Vincent's Hospital, Melbourne, Australia; and Australia Regenerative Medicine Institute (ARMI) and Monash University, Clayton, Victoria, Australia
| | - Natalie L Payne
- *Department of Anatomy and Developmental Biology and Department of Pharmacology, Monash University, Clayton, Victoria, Australia; Department of Medicine, University of Melbourne, St. Vincent's Hospital, Melbourne, Australia; and Australia Regenerative Medicine Institute (ARMI) and Monash University, Clayton, Victoria, Australia
| | - Darren J Kelly
- *Department of Anatomy and Developmental Biology and Department of Pharmacology, Monash University, Clayton, Victoria, Australia; Department of Medicine, University of Melbourne, St. Vincent's Hospital, Melbourne, Australia; and Australia Regenerative Medicine Institute (ARMI) and Monash University, Clayton, Victoria, Australia
| | - Chrishan S Samuel
- *Department of Anatomy and Developmental Biology and Department of Pharmacology, Monash University, Clayton, Victoria, Australia; Department of Medicine, University of Melbourne, St. Vincent's Hospital, Melbourne, Australia; and Australia Regenerative Medicine Institute (ARMI) and Monash University, Clayton, Victoria, Australia
| | - Sharon D Ricardo
- *Department of Anatomy and Developmental Biology and Department of Pharmacology, Monash University, Clayton, Victoria, Australia; Department of Medicine, University of Melbourne, St. Vincent's Hospital, Melbourne, Australia; and Australia Regenerative Medicine Institute (ARMI) and Monash University, Clayton, Victoria, Australia
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175
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Increased mortality after an acute heart failure episode: new pathophysiological insights from the RELAX-AHF study and beyond. Curr Heart Fail Rep 2014; 11:19-30. [PMID: 24363020 DOI: 10.1007/s11897-013-0180-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Acute heart failure (AHF) is one of the most common causes of hospital admission. Despite the very high short-term morbidity and mortality and high costs associated with the condition, little progress has been made toward an understanding of the complex mechanisms of AHF, and particularly the spike in mortality after AHF admission. This manuscript addresses certain hypotheses for the pathophysiology of increased mortality after an AHF episode, specifically exploring the role of neurohormonal and inflammatory activation, congestion, and end-organ damage occurring during the first hours and days of an AHF episode. The results of the recently published RELAX-AHF (Relaxin in Acute Heart Failure) study may hold the key to understanding these intricate mechanisms. In the study, congestion and end-organ damage, which were strongly associated with increased 180-day mortality, were relieved by early administration of serelaxin, which was also associated with reduction in 180-day mortality. Hence, it is possible that early treatment of AHF, including decongestion and prevention of damage to end organs, including kidneys, heart, and liver, is critical to preventing mortality in AHF. This may require a change in our strategic approach to the management of patients admitted with AHF, setting them apart from patients with chronic heart failure (HF), and developing specific treatment strategies for AHF patients beyond simply implementing therapies proven to be effective in chronic HF.
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176
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Voors AA, Dahlke M, Meyer S, Stepinska J, Gottlieb SS, Jones A, Zhang Y, Laurent D, Slart RHJA, Navis GJ. Renal hemodynamic effects of serelaxin in patients with chronic heart failure: a randomized, placebo-controlled study. Circ Heart Fail 2014; 7:994-1002. [PMID: 25286914 DOI: 10.1161/circheartfailure.114.001536] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Serelaxin is a promising therapy for acute heart failure. The renal hemodynamic effects of serelaxin in patients with chronic heart failure are unknown. METHODS AND RESULTS In this double-blind, randomized, placebo-controlled, multicenter study, patients with New York Heart Association Class II to III chronic heart failure, left ventricular ejection fraction ≤45%, and estimated glomerular filtration rate (GFR) 30 to 89 mL/min per 1.73 m(2) received intravenous serelaxin 30 μg/kg per day or placebo for 24 hours. Primarily, we assessed the difference between serelaxin and placebo on renal plasma flow (para-aminohippuric acid clearance) and GFR (iothalamate clearance) over 8 to 24 hours. All 22 patients from 1 clinical site were excluded from primary analyses before unblinding because of implausible measurements. The primary analysis comprised 65 patients, mean age was 68 (±10) years, 89% were male, mean estimated GFR was 64 (±19) mL/min per 1.73 m(2), and 34% had New York Heart Association Class III symptoms. Renal plasma flow increased by 29% with serelaxin and 14% with placebo (13% relative increase with serelaxin; P=0.0386), whereas GFR changes did not differ significantly during 8 to 24 hours. Filtration fraction increased by 36% with serelaxin and 62% with placebo (16% relative decrease with serelaxin; P=0.0019) during 8 to 24 hours. Changes in systolic blood pressure were largely similar, and creatinine clearance did not differ between groups. Adverse event rates were similar with serelaxin (20.5%) and placebo (25.0%). CONCLUSIONS In patients with chronic heart failure, serelaxin increased renal plasma flow and reduced the increase in filtration fraction compared with placebo, but did not affect GFR. These results suggest beneficial renal hemodynamic effects in patients with chronic heart failure. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT01546532.
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Affiliation(s)
- Adriaan A Voors
- From the University of Groningen, University Medical Center Groningen, The Netherlands (A.A.V., S.M., R.H.J.A.S., G.J.N.); Novartis Pharma AG, Basel, Switzerland (M.D., A.J., D.L.); Institute of Cardiology, Warsaw, Poland (J.S.); University of Maryland, Baltimore (S.S.G.); and Novartis Pharmaceuticals, East Hanover, NJ (Y.Z.).
| | - Marion Dahlke
- From the University of Groningen, University Medical Center Groningen, The Netherlands (A.A.V., S.M., R.H.J.A.S., G.J.N.); Novartis Pharma AG, Basel, Switzerland (M.D., A.J., D.L.); Institute of Cardiology, Warsaw, Poland (J.S.); University of Maryland, Baltimore (S.S.G.); and Novartis Pharmaceuticals, East Hanover, NJ (Y.Z.)
| | - Sven Meyer
- From the University of Groningen, University Medical Center Groningen, The Netherlands (A.A.V., S.M., R.H.J.A.S., G.J.N.); Novartis Pharma AG, Basel, Switzerland (M.D., A.J., D.L.); Institute of Cardiology, Warsaw, Poland (J.S.); University of Maryland, Baltimore (S.S.G.); and Novartis Pharmaceuticals, East Hanover, NJ (Y.Z.)
| | - Janina Stepinska
- From the University of Groningen, University Medical Center Groningen, The Netherlands (A.A.V., S.M., R.H.J.A.S., G.J.N.); Novartis Pharma AG, Basel, Switzerland (M.D., A.J., D.L.); Institute of Cardiology, Warsaw, Poland (J.S.); University of Maryland, Baltimore (S.S.G.); and Novartis Pharmaceuticals, East Hanover, NJ (Y.Z.)
| | - Stephen S Gottlieb
- From the University of Groningen, University Medical Center Groningen, The Netherlands (A.A.V., S.M., R.H.J.A.S., G.J.N.); Novartis Pharma AG, Basel, Switzerland (M.D., A.J., D.L.); Institute of Cardiology, Warsaw, Poland (J.S.); University of Maryland, Baltimore (S.S.G.); and Novartis Pharmaceuticals, East Hanover, NJ (Y.Z.)
| | - Andrew Jones
- From the University of Groningen, University Medical Center Groningen, The Netherlands (A.A.V., S.M., R.H.J.A.S., G.J.N.); Novartis Pharma AG, Basel, Switzerland (M.D., A.J., D.L.); Institute of Cardiology, Warsaw, Poland (J.S.); University of Maryland, Baltimore (S.S.G.); and Novartis Pharmaceuticals, East Hanover, NJ (Y.Z.)
| | - Yiming Zhang
- From the University of Groningen, University Medical Center Groningen, The Netherlands (A.A.V., S.M., R.H.J.A.S., G.J.N.); Novartis Pharma AG, Basel, Switzerland (M.D., A.J., D.L.); Institute of Cardiology, Warsaw, Poland (J.S.); University of Maryland, Baltimore (S.S.G.); and Novartis Pharmaceuticals, East Hanover, NJ (Y.Z.)
| | - Didier Laurent
- From the University of Groningen, University Medical Center Groningen, The Netherlands (A.A.V., S.M., R.H.J.A.S., G.J.N.); Novartis Pharma AG, Basel, Switzerland (M.D., A.J., D.L.); Institute of Cardiology, Warsaw, Poland (J.S.); University of Maryland, Baltimore (S.S.G.); and Novartis Pharmaceuticals, East Hanover, NJ (Y.Z.)
| | - Riemer H J A Slart
- From the University of Groningen, University Medical Center Groningen, The Netherlands (A.A.V., S.M., R.H.J.A.S., G.J.N.); Novartis Pharma AG, Basel, Switzerland (M.D., A.J., D.L.); Institute of Cardiology, Warsaw, Poland (J.S.); University of Maryland, Baltimore (S.S.G.); and Novartis Pharmaceuticals, East Hanover, NJ (Y.Z.)
| | - Gerjan J Navis
- From the University of Groningen, University Medical Center Groningen, The Netherlands (A.A.V., S.M., R.H.J.A.S., G.J.N.); Novartis Pharma AG, Basel, Switzerland (M.D., A.J., D.L.); Institute of Cardiology, Warsaw, Poland (J.S.); University of Maryland, Baltimore (S.S.G.); and Novartis Pharmaceuticals, East Hanover, NJ (Y.Z.)
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177
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Dschietzig TB. Recombinant human relaxin-2: (how) can a pregnancy hormone save lives in acute heart failure? Am J Cardiovasc Drugs 2014; 14:343-55. [PMID: 24934696 DOI: 10.1007/s40256-014-0078-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Acute heart failure (AHF) syndrome, characterized by pulmonary and/or venous congestion owing to increased cardiac filling pressures with or without diminished cardiac output, is still associated with high post-discharge mortality and hospitalization rates. Many novel and promising therapeutic approaches, among them endothelin-1, vasopressin and adenosine antagonists, calcium sensitization, and recombinant B-type natriuretic hormone, have failed in large studies. Likewise, the classic drugs, vasodilators, diuretics, and inotropes, have never been shown to lower mortality.The phase III trial RELAX-AHF tested recombinant human relaxin-2 (rhRlx) and found it to improve clinical symptoms moderately, to be neutral regarding the combination of death and hospitalization at day 60, to be safe, and to lower mortality at day 180. This review focuses on basic research and pre-clinical findings that may account for the benefit of rhRlx in AHF. The drug combines short-term hemodynamic advantages, such as moderate blood pressure decline and functional endothelin-1 antagonism, with a wealth of protective effects harboring long-term benefits, such as anti-inflammatory, anti-fibrotic, and anti-oxidative actions. These pleiotropic effects are exerted through a complex and intricate signaling cascade involving the relaxin-family peptide receptor-1, the glucocorticoid receptor, nitric oxide, and a cell type-dependent variety of kinases and transcription factors.
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178
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Abstract
In June 2012, the New Guidelines for the Treatment of Acute and Chronic Heart Failure of the European Society of Cardiology were published. According to the EMPHASIS-HF trial, mineralocorticoid receptor antagonists are indicated in all stages of symptomatic chronic heart failure under treatment with β-blockers and ACE inhibitors. Based on the SHIFT trial, patients with class NYHA II-IV heart failure, an ejection fraction <35%, and sinus rhythm with a heart rate of >70/min despite pharmacological treatment including β-blockers at the maximum tolerated dose should be treated with ivabradin. The RAFT trial justified the extended indication for CRT systems. In acute heart failure, the RELAX-AHF trial showed promising results with serelaxin. This manuscript summarizes the innovations of the new guidelines and the underlying clinical trials.
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Affiliation(s)
- J Pöss
- Klinik für Innere Medizin III, Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrbergerstr., 66421, Homburg/Saar, Deutschland,
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179
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Abstract
Acute heart failure (AHF) is characterized by high morbidity and mortality and high costs. Although the treatment of AHF has not changed substantially in recent decades, it is becoming clear that treatment strategies for AHF need to address both the immediate hemodynamic abnormalities giving rise to congestion as well as prevent organ damage that can influence long-term prognosis. Serelaxin, the recombinant form of human relaxin-2, a naturally occurring peptide hormone, has been found to significantly improve symptoms and signs of AHF, prevent in-hospital worsening heart failure, as well as significantly improve 180-day cardiovascular and all-cause mortality after a 48-h infusion commenced within 16 h of presentation (RELAX-AHF study). Available data suggest that the clinical benefits may be attributable to a potential combination of multiple actions of serelaxin, including improving systemic, cardiac, and renal hemodynamics, and protecting cells and organs from damage via anti-inflammatory, anti-cell death, anti-fibrotic, anti-hypertrophic, and pro-angiogenic effects. This manuscript describes the short- and long-term effects of serelaxin in AHF patients, analyzing how these effects can be explained by taking into account the range of hemodynamic and non-hemodynamic actions of serelaxin. In addition, this paper also addresses several aspects related to the role of serelaxin in the therapy of AHF that remain to be clarified and warrant further investigation.
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180
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Núñez J, Garcia S, Núñez E, Bonanad C, Bodí V, Miñana G, Santas E, Escribano D, Bayes-Genis A, Pascual-Figal D, Chorro FJ, Sanchis J. Early serum creatinine changes and outcomes in patients admitted for acute heart failure: the cardio-renal syndrome revisited. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 6:430-440. [PMID: 25080512 DOI: 10.1177/2048872614540094] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The changes in renal function that occurred in patients with acute decompensated heart failure (ADHF) are prevalent, and have multifactorial etiology and dissimilar prognosis. To what extent the prognostic role of such changes may vary according to the presence of renal insufficiency at admission is not clear. Accordingly, we sought to determine whether early creatinine changes (ΔCr) (admission to 48-72 hours) had an effect on 1-year mortality relative to the presence of renal insufficiency at admission. METHODS We included 705 consecutive patients admitted with the diagnosis of ADHF. Admission renal insufficiency was defined as serum creatinine ≥1.4mg/dl (A-RIcr) or estimated glomerular filtration rate <60ml/min/1.73m2 (A-RIGFR). Appropriate survival regression techniques were used. RESULTS The mean age was 72.9±11.4 years and 51.2% were males. Patients with admission renal insufficiency (24.7% and 42.8% for A-RIcr and A-RIGFR, respectively) had higher prevalence of extreme values in ΔCr in either direction (increasing/decreasing). At 1-year follow-up, 114 (16.2%) deaths were registered. The multivariable analysis showed a significant interaction between admission renal insufficiency and ΔCr ( p=0.004 and p=0.019 for A-RIcr and A-RIGFR, respectively). In the presence of renal insufficiency, the continuum of ΔCr followed a positive and almost linear relationship with mortality risk. Conversely, in patients without renal insufficiency, those changes adopted a 'J-shape' trajectory with increased mortality at both ends of the curve distribution. CONCLUSIONS In patients with ADHF the effect of ΔCr on 1-year mortality varied according to its magnitude and the presence of admission renal insufficiency. There was a graded-association with mortality when renal insufficiency was present on admission.
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Affiliation(s)
- Julio Núñez
- 1 Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Spain
| | - Sergio Garcia
- 1 Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Spain
| | - Eduardo Núñez
- 1 Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Spain
| | - Clara Bonanad
- 1 Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Spain
| | - Vicent Bodí
- 1 Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Spain
| | - Gema Miñana
- 2 Servicio de Cardiología, Hospital de Manises, Valencia, Spain
| | - Enrique Santas
- 1 Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Spain
| | - David Escribano
- 1 Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Spain
| | - Antonio Bayes-Genis
- 3 Servicio de Cardiología, Hospital Universitari Germas Trias i Pujol, Badalona, Spain
| | - Domingo Pascual-Figal
- 4 Servicio de Cardiología, Hospital Virgen de la Arrixaca, Universidad de Murcia, Murcia, Spain
| | - Francisco J Chorro
- 1 Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Spain
| | - Juan Sanchis
- 1 Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Spain
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Orso F, Fabbri G, Baldasseroni S, Maggioni AP. Newest additions to heart failure treatment. Expert Opin Pharmacother 2014; 15:1849-61. [PMID: 24989872 DOI: 10.1517/14656566.2014.934812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Despite the improvement in heart failure (HF) therapy in the last 30 years, this condition remains a major public health concern with high hospitalization and mortality rates, and related costs. Recently, new pharmacological approaches are under evaluation. AREAS COVERED For chronic HF with reduced ejection fraction (EF) direct renin inhibitors, neprilysin-angiotensin II receptor inhibitors and aldosterone synthase inhibitors have been tested. For HF with preserved EF, no therapy has been demonstrated up to now to be able to improve patients' outcomes and it remains a substantial unmet need. In acute HF (AHF) new inotropes and vasodilators have been developed and are currently investigated in trials. In this review, mechanism of action and clinical efficacy of new pharmacological approaches on acute and chronic HF will be discussed. EXPERT OPINION In patients with HF, some unmet needs remain to be challenged in the near future. For patients with chronic HF, the management of comorbidities, a better definition and treatment of patients with preserved EF are the major issues to be solved. The treatment of patients admitted for AHF is even more compelling. Several hypotheses of research focused on these issues are tested in ongoing trials.
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Affiliation(s)
- Francesco Orso
- Azienda Ospedaliero-Universitaria Careggi, Department of Heart and Vessel, Section of Geriatric Medicine and Cardiology , Florence , Italy
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182
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Regalbuto R, Maurer MS, Chapel D, Mendez J, Shaffer JA. Joint Commission requirements for discharge instructions in patients with heart failure: is understanding important for preventing readmissions? J Card Fail 2014; 20:641-9. [PMID: 24996200 DOI: 10.1016/j.cardfail.2014.06.358] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 06/24/2014] [Accepted: 06/25/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Many approaches have been considered to reduce heart failure (HF) readmissions. The Joint Commission on Accreditation of Health Care Organizations (JC) requires hospitals to provide patients admitted for HF with discharge instructions that address 6 topics related to HF management: diet, exercise, weight monitoring, worsening symptoms, medications, and follow-up appointments. These guidelines were developed based on expert opinion, but no one has tested whether patients' understanding of these instructions affects 30-day readmission rates. METHODS AND RESULTS We conducted a prospective cohort study of patients admitted for decompensated HF. Patients completed an understanding survey immediately after their nurse read their discharge papers. The survey contained 1 question for each of the 6 JC topics. Of the 145 patients in the study, only 14 (10%) understood all 6 discharge instructions. Patients with complete comprehension of their discharge instructions were significantly less likely to be readmitted within 30 days than those with nonperfect understanding (P = .044), but this association was no longer significant after controlling for level of education and use of English as a primary language. CONCLUSIONS HF patients' comprehension of discharge instructions is inadequate. Patients with limited education and those that do not speak English as a primary language are more likely to have poorer discharge understanding and higher rates of 30-day readmissions.
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Affiliation(s)
- Ricky Regalbuto
- Columbia University Medical Center, NewYork Presbyterian Hospital, New York, New York.
| | - Mathew S Maurer
- Columbia University Medical Center, NewYork Presbyterian Hospital, New York, New York
| | - David Chapel
- Columbia University Medical Center, NewYork Presbyterian Hospital, New York, New York
| | - Jenniliz Mendez
- Columbia University Medical Center, NewYork Presbyterian Hospital, New York, New York
| | - Jonathan A Shaffer
- Columbia University Medical Center, NewYork Presbyterian Hospital, New York, New York
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183
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Karas JA, Scanlon DB, Forbes BE, Vetter I, Lewis RJ, Gardiner J, Separovic F, Wade JD, Hossain MA. 2-Nitroveratryl as a Photocleavable Thiol-Protecting Group for Directed Disulfide Bond Formation in the Chemical Synthesis of Insulin. Chemistry 2014; 20:9549-52. [DOI: 10.1002/chem.201403574] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Indexed: 12/20/2022]
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184
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Novel drug mechanisms in development for heart failure. Pflugers Arch 2014; 466:1219-25. [DOI: 10.1007/s00424-014-1528-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 04/23/2014] [Indexed: 01/10/2023]
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185
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Neverova N, Teerlink JR. Serelaxin: a potential new drug for the treatment of acute heart failure. Expert Opin Investig Drugs 2014; 23:1017-26. [DOI: 10.1517/13543784.2014.924504] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Natalia Neverova
- University of California San Francisco, Department of Medicine,
San Francisco, CA, USA
| | - John R Teerlink
- University of California San Francisco, Department of Medicine,
San Francisco, CA, USA
- San Francisco Veterans Affairs Medical Center, Section of Cardiology,
4150 Clement Street, San Francisco, CA 94131, USA
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186
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Novel drug targets in clinical development for heart failure. Eur J Clin Pharmacol 2014; 70:765-74. [DOI: 10.1007/s00228-014-1671-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 03/19/2014] [Indexed: 01/24/2023]
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Haase N, Rugor J, Przybyl L, Qadri F, Müller DN, Dechend R. Relaxin does not improve Angiotensin II-induced target-organ damage. PLoS One 2014; 9:e93743. [PMID: 24710077 PMCID: PMC3977876 DOI: 10.1371/journal.pone.0093743] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 03/06/2014] [Indexed: 11/23/2022] Open
Abstract
Relaxin is a corpus-luteum produced protein hormone with vasodilatatory, anti-fibrotic, and angiogenic properties that are opposite to angiotensin (Ang) II. We investigated whether or not relaxin ameliorates Ang II-induced target-organ damage. We used double transgenic rats harboring both human renin and angiotensinogen genes (dTGR) that develop severe hypertension, target-organ damage, and die untreated within 7–8 weeks. Recombinant relaxin at a low (26 μg/kg/d) and a high dose (240 μg/kg/d) was given to 4 week-old dTGR and age-matched Sprague-Dawley rats (SD). Systolic blood pressure increased progressively in untreated dTGRs from 162±3 mmHg at week 5 to 225±5 mmHg at week 7. Relaxin had no effect on blood pressure whereas SD rats were normotensive (106±1 mmHg). Untreated and relaxin-treated dTGR had similarly severe cardiac hypertrophy indices. Relaxin did not ameliorate albuminuria and did not prevent matrix-protein deposition in the heart and kidney in dTGR. Finally, relaxin treatment did not reduce mortality. These data suggest that pharmacological doses of relaxin do not reverse severe effects of Ang II.
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Affiliation(s)
- Nadine Haase
- Experimental and Clinical Research Center, a joint cooperation between the Max-Delbrueck Center for Molecular Medicine and the Charité Medical Faculty, Berlin, Germany
| | - Julianna Rugor
- Experimental and Clinical Research Center, a joint cooperation between the Max-Delbrueck Center for Molecular Medicine and the Charité Medical Faculty, Berlin, Germany
| | - Lukasz Przybyl
- Experimental and Clinical Research Center, a joint cooperation between the Max-Delbrueck Center for Molecular Medicine and the Charité Medical Faculty, Berlin, Germany
| | - Fatimunnisa Qadri
- Experimental and Clinical Research Center, a joint cooperation between the Max-Delbrueck Center for Molecular Medicine and the Charité Medical Faculty, Berlin, Germany
| | - Dominik N. Müller
- Experimental and Clinical Research Center, a joint cooperation between the Max-Delbrueck Center for Molecular Medicine and the Charité Medical Faculty, Berlin, Germany
| | - Ralf Dechend
- Experimental and Clinical Research Center, a joint cooperation between the Max-Delbrueck Center for Molecular Medicine and the Charité Medical Faculty, Berlin, Germany
- Department of Cardiology and Nephrology, HELIOS-Klinikum Berlin, Berlin, Germany
- * E-mail:
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van Deursen VM, Edwards C, Cotter G, Davison BA, Damman K, Teerlink JR, Metra M, Felker GM, Ponikowski P, Unemori E, Severin T, Voors AA. Liver function, in-hospital, and post-discharge clinical outcome in patients with acute heart failure-results from the relaxin for the treatment of patients with acute heart failure study. J Card Fail 2014; 20:407-13. [PMID: 24642379 DOI: 10.1016/j.cardfail.2014.03.003] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 01/22/2014] [Accepted: 03/11/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Elevated plasma concentrations of liver function tests are prevalent in patients with chronic heart failure (HF). Little is known about liver function in patients with acute HF. We aimed to assess the prevalence and prognostic value of serial measurements of liver function tests in patients admitted with acute decompensated HF. METHODS We investigated liver function tests from all 234 patients from the Relaxin for the Treatment of Patients With Acute Heart Failure study at baseline and during hospitalization. The end points were worsening HF through day 5, 60-day mortality or rehospitalization, and 180-day mortality. RESULTS Mean age was 70 ± 10 years, 56% were male, and most patients were in New York Heart Association functional class III/IV (73%). Abnormal liver function tests were frequently found for alanine transaminase (ALT; 12%), aspartate transaminase (AST; 21%), alkaline phosphatase (12%), and total bilirubin (19%), and serum albumin (25%) and total protein (9%) were decreased. In-hospital changes were very small. On a continuous scale, baseline ALT and AST were associated with 180-day mortality (hazard ratios [HRs; per doubling] 1.52 [P = .030] and 1.97 [P = .013], respectively) and worsening HF through day 5 (HRs [per doubling] 1.72 [P = .005] and 1.95 [P = .008], respectively). Albumin was associated with 180-day mortality (HR 0.86; P = .001) but not with worsening HF (HR 0.95; P = .248). Total protein was associated with only worsening HF (HR 0.91; P = .004). CONCLUSIONS Abnormal liver function tests are often present in patients with acute HF and are associated with an increased risk for mortality, rehospitalization, and in-hospital worsening HF.
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Affiliation(s)
- Vincent M van Deursen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Gad Cotter
- Momentum Research, Durham, North Carolina
| | | | - Kevin Damman
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California
| | - Marco Metra
- Section of Cardiovascular Diseases, Department of Experimental and Applied Sciences, University of Brescia, Brescia, Italy
| | - G Michael Felker
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Piotr Ponikowski
- Cardiology Department, Military Hospital, Department of Health Sciences, Medical University, Wroclaw, Poland
| | | | | | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Wang TS, Hellkamp AS, Patel CB, Ezekowitz JA, Fonarow GC, Hernandez AF. Representativeness of RELAX-AHF Clinical Trial Population in Acute Heart Failure. Circ Cardiovasc Qual Outcomes 2014; 7:259-68. [DOI: 10.1161/circoutcomes.113.000418] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Teresa S. Wang
- From the Duke Clinical Research Institute (T.S.W., C.B.P., A.F.H.) and Department of Medicine (T.S.W., A.S.H., C.B.P., J.A.E., A.F.H.), Duke University Medical Center, Durham, NC; Division of Cardiology, Manankowski Alberta Heart Institute, Alberta, Canada (J.A.E.); and UCLA Division of Cardiology, University of California at Los Angeles Medical Center, (G.C.F.)
| | - Anne S. Hellkamp
- From the Duke Clinical Research Institute (T.S.W., C.B.P., A.F.H.) and Department of Medicine (T.S.W., A.S.H., C.B.P., J.A.E., A.F.H.), Duke University Medical Center, Durham, NC; Division of Cardiology, Manankowski Alberta Heart Institute, Alberta, Canada (J.A.E.); and UCLA Division of Cardiology, University of California at Los Angeles Medical Center, (G.C.F.)
| | - Chetan B. Patel
- From the Duke Clinical Research Institute (T.S.W., C.B.P., A.F.H.) and Department of Medicine (T.S.W., A.S.H., C.B.P., J.A.E., A.F.H.), Duke University Medical Center, Durham, NC; Division of Cardiology, Manankowski Alberta Heart Institute, Alberta, Canada (J.A.E.); and UCLA Division of Cardiology, University of California at Los Angeles Medical Center, (G.C.F.)
| | - Justin A. Ezekowitz
- From the Duke Clinical Research Institute (T.S.W., C.B.P., A.F.H.) and Department of Medicine (T.S.W., A.S.H., C.B.P., J.A.E., A.F.H.), Duke University Medical Center, Durham, NC; Division of Cardiology, Manankowski Alberta Heart Institute, Alberta, Canada (J.A.E.); and UCLA Division of Cardiology, University of California at Los Angeles Medical Center, (G.C.F.)
| | - Gregg C. Fonarow
- From the Duke Clinical Research Institute (T.S.W., C.B.P., A.F.H.) and Department of Medicine (T.S.W., A.S.H., C.B.P., J.A.E., A.F.H.), Duke University Medical Center, Durham, NC; Division of Cardiology, Manankowski Alberta Heart Institute, Alberta, Canada (J.A.E.); and UCLA Division of Cardiology, University of California at Los Angeles Medical Center, (G.C.F.)
| | - Adrian F. Hernandez
- From the Duke Clinical Research Institute (T.S.W., C.B.P., A.F.H.) and Department of Medicine (T.S.W., A.S.H., C.B.P., J.A.E., A.F.H.), Duke University Medical Center, Durham, NC; Division of Cardiology, Manankowski Alberta Heart Institute, Alberta, Canada (J.A.E.); and UCLA Division of Cardiology, University of California at Los Angeles Medical Center, (G.C.F.)
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190
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Vasodilators in Acute Heart Failure: Review of the Latest Studies. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2014; 2:126-132. [PMID: 24855585 DOI: 10.1007/s40138-014-0040-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Vasodilators play an important role in the management of acute heart failure, particularly when increased afterload is the precipitating cause of decompensation. The time-honored approach to afterload reduction has been largely focused on use of intravenous nitrovasodilators and, when properly dosed, this class of agents does provide substantial symptom relief for patients with acute hypertensive heart failure. Despite this, nitrovasodilators have never been shown to diminish mortality or provide any post-discharge outcome benefit leading to an on-going search for viable and more effective alternatives. While no new vasodilators have been approved for use in acute heart failure since nesiritide more than a decade ago, a number of novel agents have been developed, with some showing significant promise in recent clinical trials. In this review, we summarize the latest study data as it relates to vasodilator therapy and provide a glimpse into the not too distant future state of acute heart failure care.
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191
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McDonagh TA, Komajda M, Maggioni AP, Zannad F, Gheorghiade M, Metra M, Dargie HJ. Clinical trials in acute heart failure: simpler solutions to complex problems. Consensus document arising from a European Society of Cardiology cardiovascular round-table think tank on acute heart failure, 12 May 2009. Eur J Heart Fail 2014; 13:1253-60. [DOI: 10.1093/eurjhf/hfr126] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Theresa A. McDonagh
- Cardiology Department; King's College Hospital; Denmark Hill London SE5 9RS UK
| | - Michel Komajda
- CHU Pitié-Salpêtrière; Institut de Cardiologie; Paris France
| | | | - Faiez Zannad
- Department of Cardiology; Nancy University; Nancy France
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation; Northwestern University; Chicago IL USA
| | - Marco Metra
- Section of Cardiovascular Diseases; University of Brescia; Italy
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Voors AA, Davison BA, Felker GM, Ponikowski P, Unemori E, Cotter G, Teerlink JR, Greenberg BH, Filippatos G, Teichman SL, Metra M. Early drop in systolic blood pressure and worsening renal function in acute heart failure: renal results of Pre-RELAX-AHF. Eur J Heart Fail 2014; 13:961-7. [DOI: 10.1093/eurjhf/hfr060] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Adriaan A. Voors
- Department of Cardiology; University Medical Center Groningen; Hanzeplein 1 9713 GZ Groningen The Netherlands
| | | | | | - Piotr Ponikowski
- Heart Disease Center; 4th Military Clinical Hospital; Wroclaw Poland
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Valentova M, von Haehling S. An overview of recent developments in the treatment of heart failure: update from the ESC Congress 2013. Expert Opin Investig Drugs 2014; 23:573-8. [DOI: 10.1517/13543784.2014.881799] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
Over the past few decades, research on the peptide hormone, relaxin, has significantly improved our understanding of its biological actions under physiological and diseased conditions. This has facilitated the conducting of clinical trials to explore the use of serelaxin (human recombinant relaxin). Acute heart failure (AHF) is a very difficult to treat clinical entity, with limited success so far in developing new drugs to combat it. A recent phase-III RELAX-AHF trial using serelaxin therapy given during hospitalization revealed acute (ameliorated dyspnea) and chronic (improved 180-day survival) effects. Although these findings support a substantial improvement by serelaxin therapy over currently available therapies for AHF, they also raise key questions and stimulate new hypotheses. To facilitate the development of serelaxin as a new drug for heart disease, joint efforts of clinicians, research scientists and pharmacological industries are necessary to study these questions and hypotheses. In this review, after providing a brief summary of clinical findings and the pathophysiology of AHF, we present a working hypothesis of the mechanisms responsible for the observed efficacy of serelaxin in AHF patients. The existing clinical and preclinical data supporting our hypotheses are summarized and discussed. The development of serelaxin as a drug provides an excellent example of the bilateral nature of translational research.
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Affiliation(s)
- Xiao-Jun Du
- Baker IDI Heart and Diabetes Institute, Monash University
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195
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Hernandez AV. Serelaxin: insights into its haemodynamic, biochemical, and clinical effects in acute heart failure. Eur Heart J 2013; 35:410-2. [DOI: 10.1093/eurheartj/eht477] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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196
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Ponikowski P, Mitrovic V, Ruda M, Fernandez A, Voors AA, Vishnevsky A, Cotter G, Milo O, Laessing U, Zhang Y, Dahlke M, Zymlinski R, Metra M. A randomized, double-blind, placebo-controlled, multicentre study to assess haemodynamic effects of serelaxin in patients with acute heart failure. Eur Heart J 2013; 35:431-41. [PMID: 24255129 PMCID: PMC3924183 DOI: 10.1093/eurheartj/eht459] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Aims The aim of this study was to evaluate the haemodynamic effects of serelaxin (30 µg/kg/day 20-h infusion and 4-h post-infusion period) in patients with acute heart failure (AHF). Methods and results This double-blind, multicentre study randomized 71 AHF patients with pulmonary capillary wedge pressure (PCWP) ≥18 mmHg, systolic blood pressure (BP) ≥115 mmHg, and estimated glomerular filtration rate ≥30 mL/min/1.73 m2 to serelaxin (n = 34) or placebo (n = 37) within 48 h of hospitalization. Co-primary endpoints were peak change from baseline in PCWP and cardiac index (CI) during the first 8 h of infusion. Among 63 patients eligible for haemodynamic analysis (serelaxin, n = 32; placebo, n = 31), those treated with serelaxin had a significantly higher decrease in peak PCWP during the first 8 h of infusion (difference vs. placebo: −2.44 mmHg, P = 0.004). Serelaxin showed no significant effect on the peak change in CI vs. placebo. Among secondary haemodynamic endpoints, a highly significant reduction in pulmonary artery pressure (PAP) was observed throughout the serelaxin infusion (largest difference in mean PAP vs. placebo: −5.17 mmHg at 4 h, P < 0.0001). Right atrial pressure, systemic/pulmonary vascular resistance, and systolic/diastolic BP decreased from baseline with serelaxin vs. placebo and treatment differences reached statistical significance at some time points. Serelaxin administration improved renal function and decreased N-terminal pro-brain natriuretic peptide levels vs. placebo. Treatment with serelaxin was well tolerated with no apparent safety concerns. Conclusion The haemodynamic effects of serelaxin observed in the present study provide plausible mechanistic support for improvement in signs and symptoms of congestion observed with this agent in AHF patients. ClinicalTrials.gov identifier NCT01543854.
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Affiliation(s)
- Piotr Ponikowski
- Department of Heart Diseases, Medical University, Military Hospital, Weigla 5, 50-981 Wroclaw, Poland
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Pöss J, Link A, Böhm M. Pharmacological treatment of acute heart failure: current treatment and new targets. Clin Pharmacol Ther 2013; 94:499-508. [PMID: 23863875 DOI: 10.1038/clpt.2013.136] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2013] [Accepted: 07/07/2013] [Indexed: 01/11/2023]
Abstract
Acute heart failure (AHF) is defined as the rapid onset of, or changes in, the symptoms and signs of heart failure (HF). It is a life-threatening situation in which diagnosis and initiation of therapy are crucial. The treatment aims are to stabilize the patient, improve clinical symptoms, and increase long-term survival rates. Few treatments have been investigated in clinical trials. This review summarizes the principles of pharmacologic treatment, the underlying clinical trials, and new pharmacologic targets.
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Affiliation(s)
- J Pöss
- Universitätsklinikum des Saarlandes, Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Homburg/Saar, Germany
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Givertz MM, Teerlink JR, Albert NM, Westlake Canary CA, Collins SP, Colvin-Adams M, Ezekowitz JA, Fang JC, Hernandez AF, Katz SD, Krishnamani R, Stough WG, Walsh MN, Butler J, Carson PE, Dimarco JP, Hershberger RE, Rogers JG, Spertus JA, Stevenson WG, Sweitzer NK, Tang WHW, Starling RC. Acute decompensated heart failure: update on new and emerging evidence and directions for future research. J Card Fail 2013; 19:371-89. [PMID: 23743486 DOI: 10.1016/j.cardfail.2013.04.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 04/17/2013] [Indexed: 01/10/2023]
Abstract
Acute decompensated heart failure (ADHF) is a complex clinical event associated with excess morbidity and mortality. Managing ADHF patients is challenging because of the lack of effective treatments that both reduce symptoms and improve clinical outcomes. Existing guideline recommendations are largely based on expert opinion, but several recently published trials have yielded important data to inform both current clinical practice and future research directions. New insight has been gained regarding volume management, including dosing strategies for intravenous loop diuretics and the role of ultrafiltration in patients with heart failure and renal dysfunction. Although the largest ADHF trial to date (ASCEND-HF, using nesiritide) was neutral, promising results with other investigational agents have been reported. If these findings are confirmed in phase III trials, novel compounds, such as relaxin, omecamtiv mecarbil, and ularitide, among others, may become therapeutic options. Translation of research findings into quality clinical care can not be overemphasized. Although many gaps in knowledge exist, ongoing studies will address issues around delivery of evidence-based care to achieve the goal of improving the health status and clinical outcomes of patients with ADHF.
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Affiliation(s)
- Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Total chemical synthesis of a heterodimeric interchain bis-lactam-linked Peptide: application to an analogue of human insulin-like Peptide 3. INTERNATIONAL JOURNAL OF PEPTIDES 2013; 2013:504260. [PMID: 24288548 PMCID: PMC3830869 DOI: 10.1155/2013/504260] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 08/31/2013] [Accepted: 09/02/2013] [Indexed: 01/06/2023]
Abstract
Nonreducible cystine isosteres represent important peptide design elements in that they can maintain a near-native tertiary conformation of the peptide while simultaneously extending the in vitro and in vivo half-life of the biomolecule. Examples of these cystine mimics include dicarba, diselenide, thioether, triazole, and lactam bridges. Each has unique physicochemical properties that impact upon the resulting peptide conformation. Each also requires specific conditions for its formation via chemical peptide synthesis protocols. While the preparation of peptides containing two lactam bonds within a peptide is technically possible and reported by others, to date there has been no report of the chemical synthesis of a heterodimeric peptide linked by two lactam bonds. To examine the feasibility of such an assembly, judicious use of a complementary combination of amine and acid protecting groups together with nonfragment-based, total stepwise solid phase peptide synthesis led to the successful preparation of an analogue of the model peptide, insulin-like peptide 3 (INSL3), in which both of the interchain disulfide bonds were replaced with a lactam bond. An analogue containing a single disulfide-substituted interchain lactam bond was also prepared. Both INSL3 analogues retained significant cognate RXFP2 receptor binding affinity.
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Relaxin improves multiple markers of wound healing and ameliorates the disturbed healing pattern of genetically diabetic mice. Clin Sci (Lond) 2013; 125:575-85. [PMID: 23742173 PMCID: PMC3906928 DOI: 10.1042/cs20130105] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Diabetic mice are characterized by a disrupted expression pattern of VEGF (vascular endothelial growth factor), and impaired vasculogenesis during healing. Experimental evidence suggests that RLX (relaxin) can improve several parameters associated with wound healing. Therefore we investigated the effects of porcine-derived RLX in diabetes-related wound-healing defects in genetically diabetic mice. An incisional wound model was produced on the back of female diabetic C57BL/KsJ-m+/+Leptdb (db+/db+) mice and their normal littermates (db+/+m). Animals were treated daily with porcine RLX (25 μg/mouse per day, subcutaneously) or its vehicle. Mice were killed on 3, 6 and 12 days after skin injury for measurements of VEGF mRNA and protein synthesis, SDF-1α (stromal cell-derived factor-1α) mRNA and eNOS (endothelial NO synthase) expression. Furthermore, we evaluated wound-breaking strength, histological changes, angiogenesis and vasculogenesis at day 12. Diabetic animals showed a reduced expression of VEGF, eNOS and SDF-1α compared with non-diabetic animals. At day 6, RLX administration resulted in an increase in VEGF mRNA expression and protein wound content, in eNOS expression and in SDF-1α mRNA. Furthermore, the histological evaluation indicated that RLX improved the impaired wound healing, enhanced the staining of MMP-11 (matrix metalloproteinase-11) and increased wound-breaking strength at day 12 in diabetic mice. Immunohistochemistry showed that RLX in diabetic animals augmented new vessel formation by stimulating both angiogenesis and vasculogenesis. RLX significantly reduced the time to complete skin normalization and this effect was abrogated by a concomitant treatment with antibodies against VEGF and CXCR4 (CXC chemokine receptor 4), the SDF-1α receptor. These data strongly suggest that RLX may have a potential application in diabetes-related wound disorders.
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