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Clinical and echocardiographic benefit of Sacubitril/Valsartan in a real-world population with HF with reduced ejection fraction. Sci Rep 2020; 10:6665. [PMID: 32313194 PMCID: PMC7170843 DOI: 10.1038/s41598-020-63801-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/03/2020] [Indexed: 11/24/2022] Open
Abstract
The aim of this study was to evaluate the effects of Sacubitril/Valsartan (S/V) on clinical, laboratory and echocardiographic parameters and outcomes in a real-world population with heart failure with reduced ejection fraction (HFrEF). This was a prospective observational study enrolling patients with HFrEF undergoing treatment with S/V. The primary outcome was the composite of cardiac death and HF rehospitalization at 12 months follow-up; secondary outcomes were all-cause death, cardiac death and the occurrence of rehospitalization for worsening HF. The clinical outcome was compared with a retrospective cohort of 90 HFrEF patients treated with standard medical therapy. The study included 90 patients (66.1 ± 11.7 years) treated with S/V. The adjusted regression analysis showed a significantly lower risk for the primary outcome (HR:0.31; 95%CI, 0.11–0.83; p = 0.019) and for HF rehospitalization (HR:0.27; 95%CI, 0.08–0.94; p = 0.039) in S/V patients as compared to the control group. A significant improvement in NYHA class, left ventricular ejection fraction, left ventricular end systolic volume and systolic pulmonary arterial pressure was observed up to 6 months. S/V did not affect negatively renal function and was associated with a significantly lower dose of furosemide dose prescribed at 6- and 12-month follow-up. In this study, S/V reduced the risk of HF rehospitalization and cardiac death at 1 year in patients with HFrEF. S/V improved NYHA class, echocardiographic parameters and need of furosemide, and preserved renal function.
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152
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Golforoush P, Schneider MD. Intensive care for human hearts in pluripotent stem cell models. NPJ Regen Med 2020; 5:4. [PMID: 32194989 PMCID: PMC7060343 DOI: 10.1038/s41536-020-0090-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 02/06/2020] [Indexed: 12/12/2022] Open
Abstract
Successful drug discovery is ultimately contingent on the availability of workable, relevant, predictive model systems. Conversely, for cardiac muscle, the lack of human preclinical models to inform target validation and compound development has likely contributed to the perennial problem of clinical trial failures, despite encouraging non-human results. By contrast, human cardiomyocytes produced from pluripotent stem cell models have recently been applied to safety pharmacology, phenotypic screening, target validation and high-throughput assays, facilitating cardiac drug discovery. Here, we review the impact of human pluripotent stem cell models in cardiac drug discovery, discussing the range of applications, readouts, and disease models employed, along with the challenges and prospects to advance this fruitful mode of research further.
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Affiliation(s)
- Pelin Golforoush
- National Heart and Lung Institute, Imperial College London, London, W12 0NN UK
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153
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Fonseca C, Brito D, Ferreira J, Franco F, Morais J, Silva Cardoso J. Response to the Letter to the Editor “When sacubitril/valsartan met neprilysin and B-type natriuretic peptide in the labyrinth of biochemistry”. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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154
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Fonseca C, Brito D, Ferreira J, Franco F, Morais J, Silva Cardoso J. Response to the Letter to the Editor “When sacubitril/valsartan met neprilysin and B-type natriuretic peptide in the labyrinth of biochemistry”. Rev Port Cardiol 2020; 39:179-180. [DOI: 10.1016/j.repc.2020.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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155
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Ibrahim NE, McCarthy CP, Shrestha S, Gaggin HK, Mukai R, Szymonifka J, Apple FS, Burnett JC, Iyer S, Januzzi JL. Effect of Neprilysin Inhibition on Various Natriuretic Peptide Assays. J Am Coll Cardiol 2020; 73:1273-1284. [PMID: 30898202 DOI: 10.1016/j.jacc.2018.12.063] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/27/2018] [Accepted: 12/05/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND With sacubitril/valsartan treatment, B-type natriuretic peptide (BNP) concentrations increase; it remains unclear whether change in BNP concentrations is similar across all assays for its measurement. Effects of sacubitril/valsartan on atrial natriuretic peptide (ANP) concentrations in patients are unknown. Lastly, the impact of neprilysin inhibition on mid-regional pro-ANP (MR-proANP), N-terminal pro-BNP (NT-proBNP), proBNP1-108, or C-type natriuretic peptide (CNP) is not well understood. OBJECTIVES This study sought to examine the effects of sacubitril/valsartan on results from different natriuretic peptide assays. METHODS Twenty-three consecutive stable patients with heart failure and reduced ejection fraction were initiated and titrated on sacubitril/valsartan. Change in ANP, MR-proANP, BNP (using 5 assays), NT-proBNP (3 assays), proBNP1-108, and CNP were measured over 3 visits. RESULTS Average time to 3 follow-up visits was 22, 46, and 84 days. ANP rapidly and substantially increased with initiation and titration of sacubitril/valsartan, more than doubling by the first follow-up visit (+105.8%). Magnitude of ANP increase was greatest in those with concentrations above the median at baseline (+188%) compared with those with lower baseline concentrations (+44%); ANP increases were sustained. Treatment with sacubitril/valsartan led to inconsistent changes in BNP, which varied across methods assessed. Concentrations of MR-proANP, NT-proBNP, and proBNP1-108 variably declined after treatment; whereas CNP concentrations showed no consistent change. CONCLUSIONS Initiation and titration of sacubitril/valsartan led to variable changes in concentrations of multiple natriuretic peptides. These results provide important insights into the effects of sacubitril/valsartan treatment on individual patient results, and further suggest the benefit of neprilysin inhibition may be partially mediated by increased ANP concentrations.
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Affiliation(s)
- Nasrien E Ibrahim
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Cian P McCarthy
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Shreya Shrestha
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | - Hanna K Gaggin
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Renata Mukai
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Fred S Apple
- Laboratory Medicine & Pathology, Hennepin County Medical Center & University of Minnesota, Minneapolis, Minnesota
| | | | | | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Baim Institute for Clinical Research, Boston, Massachusetts.
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156
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GF, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
| | - Marinella Ruospo
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
| | - Patrizia Natale
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
| | - Robert R Quinn
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| | - Paul E Ronksley
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical Center, Department of Medicine, 3459 Fifth Avenue, Pittsburgh, PA, USA, 15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of Otago, Department of Medicine, Nephrologist, Christchurch, New Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| | - Giovanni Fm Strippoli
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
- The Children's Hospital at Westmead, Cochrane Kidney and Transplant, Centre for Kidney Research, Westmead, NSW, Australia, 2145
| | - Pietro Ravani
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
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157
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Gupta DK, Walford GA, Ma Y, Jarolim P, Wang TJ. Racial/ethnic differences in circulating natriuretic peptide levels: The Diabetes Prevention Program. PLoS One 2020; 15:e0229280. [PMID: 32084251 PMCID: PMC7034896 DOI: 10.1371/journal.pone.0229280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/03/2020] [Indexed: 12/11/2022] Open
Abstract
Natriuretic peptides are cardiac-derived hormones that enhance insulin sensitivity and reduce fat accumulation. Low natriuretic peptide levels are associated with increased risk of type 2 diabetes mellitus (DM2); a condition with variable prevalence across racial/ethnic groups. Few studies have examined whether circulating natriuretic peptide levels and their response to preventive interventions for DM2 differ by race/ethnicity. The Diabetes Prevention Program (DPP) is a clinical trial (July 31, 1996- July 31, 2001) that randomized participants to preventive interventions for DM2. Using stored serum samples, we examined N-terminus pro-B-type natriuretic peptide (NT-proBNP) levels in 3,220 individuals (56% white; 19% African-American; 15% Hispanic; 5% American-Indian; 5% Asian). The influence of race/ethnicity on NT-proBNP concentrations at baseline and after two years of treatment with placebo, lifestyle, or metformin was examined with multivariable-adjusted regression. At baseline, NT-proBNP differed significantly by race (P < .001), with the lowest values in African-American individuals. Hispanic individuals also had lower baseline NT-proBNP levels compared with whites (P< .001), while NT-proBNP levels were similar between white, American-Indian, and Asian individuals. At two years of follow-up, NT-proBNP levels decreased in African-Americans in each of the DPP study arms, whereas they were stable or increased in the other racial/ethnic groups. In the DPP, African-American individuals had lower circulating NT-proBNP levels compared with individuals in other racial/ethnic groups at baseline and after two years of preventive interventions. Further studies should examine the cardio-metabolic implications of lower natriuretic peptide levels in African-Americans. Trial Registration: ClinicalTrials.gov NCT00004992
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Affiliation(s)
- Deepak K. Gupta
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- * E-mail:
| | - Geoffrey A. Walford
- Diabetes Research Center (Diabetes Unit), Massachusetts General Hospital, Boston, MA, United States of America
- Department of Medicine, Harvard Medical School, Boston, MA, United States of America
- Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA, United States of America
| | - Yong Ma
- Diabetes Prevention Program Data Coordinating Center, The Biostatistics Center, George Washington University, Rockville, MD, United States of America
| | - Petr Jarolim
- Biomarker Research Laboratory/TIMI Clinical Trial Laboratory, Department of Pathology, Brigham and Women’s Hospital, Boston, MA, United States of America
- Department of Pathology, Harvard Medical School, Boston, MA, United States of America
| | - Thomas J. Wang
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Vanderbilt University School of Medicine, Nashville, TN, United States of America
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, TN, United States of America
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158
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Polónia J, Gonçalves FR. The historical evolution of knowledge of the involvement of neurohormonal systems in the pathophysiology and treatment of heart failure. Rev Port Cardiol 2020; 38:883-895. [PMID: 32063405 DOI: 10.1016/j.repc.2019.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/22/2019] [Accepted: 05/26/2019] [Indexed: 01/29/2023] Open
Abstract
Our knowledge of the pathophysiology of heart failure (HF) underwent profound changes during the 1980s. Once thought to be of exclusively structural origin, HF began to be seen as the consequence of hormonal imbalance. A number of seminal studies were published in that decade focusing on the impact of neurohormonal activation in HF. Presently, eight neurohormonal systems are known to have a key role in HF development: four stimulate vasoconstriction and sodium/water retention (the sympathetic nervous system, the renin-angiotensin-aldosterone system [RAAS], endothelin, and the vasopressin-arginine system), while the other four stimulate vasodilation and natriuresis (the prostaglandin system, nitric oxide, the dopaminergic system, and the natriuretic peptide system [NPS]). These systems are strongly interconnected and are subject to intricate regulation, functioning together in a delicate homeostasis. Disruption of this homeostasis is characteristic of HF. This review explores the historical development of knowledge on the impact of the neurohormonal systems on HF pathophysiology, from the first studies to current understanding. In addition, the therapeutic potential of each of these systems is discussed, and currently used neurohormonal antagonists are characterized. Special emphasis is given to the latest drug approved for use in HF with reduced ejection fraction, sacubitril/valsartan. This drug combines two different molecules, acting on two different systems (RAAS and NPS) simultaneously.
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Affiliation(s)
- Jorge Polónia
- Departamento de Medicina da Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
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159
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Revuelta-López E, Núñez J, Gastelurrutia P, Cediel G, Januzzi JL, Ibrahim NE, Emdin M, VanKimmenade R, Pascual-Figal D, Núñez E, Gommans F, Lupón J, Bayés-Genís A. Neprilysin inhibition, endorphin dynamics, and early symptomatic improvement in heart failure: a pilot study. ESC Heart Fail 2020; 7:559-566. [PMID: 32045114 PMCID: PMC7160502 DOI: 10.1002/ehf2.12607] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 11/26/2019] [Accepted: 12/09/2019] [Indexed: 12/11/2022] Open
Abstract
Aim Sacubitril/valsartan is a first‐in‐class angiotensin receptor‐neprilysin inhibitor developed for the treatment of heart failure with reduced ejection fraction. Its benefits are achieved through the inhibition of neprilysin (NEP) and the specific blockade of the angiotensin receptor AT1. The many peptides metabolized by NEP suggest multifaceted potential consequences of its inhibition. We sought to evaluate the short‐term changes in serum endorphin (EP) values and their relation with patients' physical functioning after initiation of sacubitril/valsartan treatment. Methods and results A total of 105 patients with heart failure with reduced ejection fraction, who were candidates for sacubitril/valsartan treatment, were included in this prospective, observational, multicentre, and international study. In a first visit, and in agreement with current guidelines, treatment with angiotensin‐converting enzyme inhibitors or angiotensin receptor blocker was replaced by sacubitril/valsartan because of clinical indication by the responsible physician. By protocol, patients were reevaluated at 30 days after the start of sacubitril/valsartan. Serum levels of α‐ (α‐EP), γ‐Endorphin (γ‐EP), and soluble NEP (sNEP) were measured using enzyme‐linked immunoassays. New York Heart Association (NYHA) functional class was used as an indicator of patient's functional status. Baseline median levels of circulating α‐EP, γ‐EP, and sNEP were 582 (160–772), 101 (37–287), and 222 pg/mL (124–820), respectively. There was not a significant increase in α‐EP nor γ‐EP serum values after sacubitril/valsartan treatment (P value = 0.194 and 0.102, respectively). There were no significant differences in sNEP values between 30 days and baseline (P value = 0.103). Medians (IQR) of Δα‐EP, Δγ‐EP, and ΔsNEP between 30 days and baseline were 9.3 (−34 − 44), −3.0 (−46.0 − 18.9), and 0 units (−16.4 − 157.0), respectively. In a pre–post sacubitril/valsartan treatment comparison, there was a significant improvement in NYHA class, with 36 (34.3%) patients experiencing improvement by at least one NYHA class category. Δα‐EP and ΔsNEP showed to be significantly associated with NYHA class after 30 days of treatment (P = 0.014 and P < 0.001, respectively). Δα‐EP was linear and significantly associated with NYHA class improvement after 30 days of sacubitril/valsartan treatment. Conclusions These preliminary data suggest that beyond the haemodynamic benefits achieved with sacubitril/valsartan, the altered cleavage of endorphin peptides by NEP inhibition may participate in patients' symptoms improvement.
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Affiliation(s)
- Elena Revuelta-López
- Heart Failure and Cardiac Regeneration (ICREC) Research Program, Health Science Research Institute Germans Trias i Pujol (IGTP), Badalona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, (CIBERCV,), Madrid, Spain
| | - Julio Núñez
- Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, (CIBERCV,), Madrid, Spain.,Cardiology Department, Hospital Clínico Universitario, Universitat de València, INCLIVA, Valencia, Spain; INCLIVA; Universitat de València, Valencia, Spain
| | - Paloma Gastelurrutia
- Heart Failure and Cardiac Regeneration (ICREC) Research Program, Health Science Research Institute Germans Trias i Pujol (IGTP), Badalona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, (CIBERCV,), Madrid, Spain
| | - Germán Cediel
- Cardiology Service and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital and Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Massachusetts, MA, USA
| | - Nasrien E Ibrahim
- Division of Cardiology, Massachusetts General Hospital and Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Massachusetts, MA, USA
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Roland VanKimmenade
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Domingo Pascual-Figal
- Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, (CIBERCV,), Madrid, Spain.,Cardiology Department, Hospital Virgen de la Arrixaca, Universidad de Murcia, Murcia, Spain
| | - Eduardo Núñez
- Cardiology Department, Hospital Clínico Universitario, Universitat de València, INCLIVA, Valencia, Spain; INCLIVA; Universitat de València, Valencia, Spain
| | - Frank Gommans
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Josep Lupón
- Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, (CIBERCV,), Madrid, Spain.,Cardiology Service and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Antoni Bayés-Genís
- Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, (CIBERCV,), Madrid, Spain.,Cardiology Service and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
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160
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Abstract
New therapeutic strategies aimed to tackle the rising socio-economic burden of heart failure (HF) have become an impelling priority. The new pharmacological class of angiotensin (Ang) receptor-neprilysin inhibitors (ARNI) prompted a real conceptual change in the treatment of HF moving from only the inhibition of the renin-Ang-aldosterone system and sympathetic nervous system to a strategy based on the concomitant pharmacological enhancement of endogenous natriuretic peptides. Sacubitril/valsartan, a first-in-class ARNI, has reduced the primary composite endpoint of cardiovascular death or HF hospitalisation, sudden cardiac death, disease progression and improved quality of life, compared with enalapril, in patients on evidence-based contemporary medical therapy. Our review underlines the increasing body of evidence supporting the efficacy of sacubitril/valsartan, which may be considered a new disease-modifying therapy and, after about 30 years of research, a real step forward in HF pharmacological therapy.
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161
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Gao Y, Xing C, Hao W, Zhao H, Wang L, Luan B, Hou A. The Impact of Sacrubitril/Valsartan on Clinical Treatment and hs-cTnT and NT-ProBNP Serum Levels and the Left Ventricular Function in Patients with Chronic Heart Failure. Int Heart J 2020; 61:1-6. [DOI: 10.1536/ihj.19-231] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yang Gao
- Department of Cardiology, The People's Hospital of Liaoning Province
| | - Changtai Xing
- Department of Cardiology, The Center Hospital Affiliated to Shenyang Medical College
| | - Wenjun Hao
- Department of Cardiology, The People's Hospital of Liaoning Province
| | - Hongwei Zhao
- Department of Cardiology, The People's Hospital of Liaoning Province
| | - Lili Wang
- Department of Cardiology, The People's Hospital of Liaoning Province
| | - Bo Luan
- Department of Cardiology, The People's Hospital of Liaoning Province
| | - Aijie Hou
- Department of Cardiology, The People's Hospital of Liaoning Province
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162
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Tsutamoto T, Sakai H, Yamamoto T, Nakagawa Y. Heart is the Target Organ of Endogenous Cardiac Natriuretic Peptides. Int Heart J 2020; 61:77-82. [PMID: 31956150 DOI: 10.1536/ihj.19-379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study aimed to evaluate whether the heart is the target organ of endogenous atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) in patients with heart failure (HF) with reduced ejection fraction (HFrEF).We measured the plasma levels of cyclic guanosine monophosphate (cGMP), which is a second messenger of ANP and BNP, in the aortic root (AO) and coronary sinus (CS) in 237 patients with HFrEF. Plasma levels of cGMP were significantly higher in the CS than those in the AO in 237 patients with HFrEF (10.0 ± 4.5 versus 10.5 ± 4.3 pmoL/mL, P < 0.0001) and were significantly higher in the CS than those in the AO (8.0 ± 3.6 versus 8.9 ± 3.8 pmoL/mL, P < 0.0001) in mild HF patients (New York Heart Association (NYHA) II, n = 114), but there was no difference in plasma cGMP between the AO and the CS (11.9 ± 4.4 versus 11.9 ± 4.3 pmoL/mL, NS) in severe HF patients (NYHA III-IV, n = 123). In mild HF patients, log (ANP + BNP) in the AO was an independent predictor of (CS-AO) cGMP among hemodynamics and nitrate therapy. There was a significant correlation between log [(CS-AO) ANP + (CS-AO) BNP] and (CS-AO) cGMP (r = 0.455, P < 0.0001) in mild HF patients.These findings indicate that cGMP is produced from the failing heart and that the heart is the target organ of endogenous ANP and BNP in patients with HFrEF. In severe HF patients, cGMP production may be attenuated because of the downregulation of biological receptors and/or increased cGMP degradation in the failing heart.
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Affiliation(s)
| | - Hiroshi Sakai
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Takashi Yamamoto
- Department of Cardiovascular Medicine, Shiga University of Medical Science
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science
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163
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Sokos GG, Raina A. Understanding the early mortality benefit observed in the PARADIGM-HF trial: considerations for the management of heart failure with sacubitril/valsartan. Vasc Health Risk Manag 2020; 16:41-51. [PMID: 32021227 PMCID: PMC6972579 DOI: 10.2147/vhrm.s197291] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 08/02/2019] [Indexed: 12/11/2022] Open
Abstract
This review aims to elucidate the optimal dosing of angiotensin receptor-neprilysin inhibitor (ARNI) therapy in the heart failure (HF) treatment paradigm through examination of the trial population characteristics and the mortality benefit observed in the Prospective Comparison of ARNI with angiotensin-converting enzyme inhibitor (ACEI) to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF; NCT01035255) trial. Considerations regarding the initiation and titration of sacubitril/valsartan, a first-in-class ARNI, will also be addressed. The approval of sacubitril/valsartan heralded the first novel pharmacological class in over a decade for the treatment of heart failure with reduced ejection fraction (HFrEF). The PARADIGM-HF trial showed that treatment with valsartan/valsartan reduced the risk of first occurrence of either cardiovascular death or HF-related hospitalization (composite primary endpoint) by 20% compared with enalapril in patients with HFrEF. The incremental benefits of treatment with valsartan/valsartan over enalapril demonstrated in the PARADIGM-HF trial led to strong recommendations for its use over ACEIs or angiotensin receptor blockers to further reduce morbidity and mortality in the 2016 and 2017 American College of Cardiology/American Heart Association/Heart Failure Society of America updates to the guidelines for the management of HF. Although the optimal timing for the initiation of valsartan/valsartan has yet to be determined, its early use is likely to have a positive impact on patient outcomes.
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Affiliation(s)
- George G Sokos
- Department of Medicine, Division of Cardiology, West Virginia School of Medicine, Morgantown, WV, USA
| | - Amresh Raina
- Pulmonary Hypertension Program, Section of Heart Failure/Transplant/MCS & Pulmonary Hypertension, Allegheny General Hospital, AGH McGinnis Cardiovascular Institute, Pittsburgh, PA, USA
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164
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Díez-Villanueva P, Vicent L, de la Cuerda F, Esteban-Fernández A, Gómez-Bueno M, de Juan-Bagudá J, Iniesta ÁM, Ayesta A, Rojas-González A, Bover-Freire R, Iglesias D, García-Aguado M, Perea-Egido JÁ, Salamanca J, Martínez-Sellés M. Left Ventricular Ejection Fraction Recovery in Patients with Heart Failure and Reduced Ejection Fraction Treated with Sacubitril/Valsartan. Cardiology 2020; 145:275-282. [PMID: 31940620 DOI: 10.1159/000505148] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/01/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND A significant number of heart failure (HF) patients with reduced left ventricular ejection fraction (LVEF) experience ventricular function recovery during follow-up. We studied the variables associated with LVEF recovery in patients treated with sacubitril/valsartan (SV) in clinical practice. METHODS We analyzed data from a prospective and multicenter registry including 249 HF outpatients with reduced LVEF who started SV between October 2016 and March 2017. The patients were classified into 2 groups according to LVEF at the end of follow-up (>35%: group R, or ≤35%: group NR). RESULTS After a mean follow-up of 7 ± 0.1 months, 62 patients (24.8%) had LVEF >35%. They were older (71.3 ± 10.8 vs. 67.5 ± 12.1 years, p = 0.025), and suffered more often from hypertension (83.9 vs. 73.8%, p = 0.096) and higher blood pressure before and after SV (both, p < 0.01). They took more often high doses of beta-blockers (30.6 vs. 27.8%, p = 0.002), with a smaller proportion undergoing cardiac resynchronization therapy (14.8 vs. 29.0%, p = 0.028) and fewer implanted cardioverter defibrillators (ICD; 32.8 vs. 67.9%, p < 0.001), this being the only predictive variable of NR in the multivariate analysis (OR 0.26, 95% CI 0.13-0.47, p < 0.0001). At the end of follow-up, the mean LVEF in group R was 41.9 ± 8.1% (vs. 26.3 ± 4.7% in group NR, p < 0.001), with an improvement compared with the initial LVEF of 14.6 ± 10.8% (vs. 0.8 ± 4.5% in group NR, p < 0.0001). Functional class improved in both groups, mainly in group R (p = 0.035), with fewer visits to the emergency department (11.5 vs. 21.6%, p = 0.07). CONCLUSIONS In patients with LVEF ≤35% treated with SV, not carrying an ICD was independently associated with LVEF recovery, which was related to greater improvement in functional class.
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Affiliation(s)
| | - Lourdes Vicent
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Manuel Gómez-Bueno
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | | | | | - Ana Ayesta
- Servicio de Cardiología, Hospital del Sureste, Arganda del Rey, Madrid, Spain
| | | | - Ramón Bover-Freire
- Servicio de Cardiología, Hospital Universitario Clínico de San Carlos, Madrid, Spain
| | - Diego Iglesias
- Servicio de Cardiología, Hospital Infanta Sofía, Madrid, Spain
| | | | | | - Jorge Salamanca
- Servicio de Cardiología, Hospital Universitario La Princesa, Madrid, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, Madrid, Spain.,Universidad Complutense, Universidad Europea, Madrid, Spain
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165
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Zhao D, Guallar E, Vaidya D, Ndumele CE, Ouyang P, Post WS, Lima JA, Ying W, Kass DA, Hoogeveen RC, Shah SJ, Subramanya V, Michos ED. Cyclic Guanosine Monophosphate and Risk of Incident Heart Failure and Other Cardiovascular Events: the ARIC Study. J Am Heart Assoc 2020; 9:e013966. [PMID: 31928156 PMCID: PMC7033823 DOI: 10.1161/jaha.119.013966] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Cyclic guanosine monophosphate (cGMP) is a second messenger regulated through natriuretic peptide and nitric oxide pathways. Stimulation of cGMP signaling is a potential therapeutic strategy for heart failure with preserved ejection fraction (HFpEF) and atherosclerotic cardiovascular disease (ASCVD). We hypothesized that plasma cGMP levels would be associated with lower risk for incident HFpEF, any HF, ASCVD, and coronary heart disease (CHD). Methods and Results We conducted a case–cohort analysis nested in the ARIC (Atherosclerosis Risk in Communities) study. Plasma cGMP was measured in 875 participants at visit 4 (1996–1998), with oversampling of incident HFpEF cases. We used Cox proportional hazard models to assess associations of cGMP with incident HFpEF, HF, ASCVD (CHD+stroke), and CHD. The mean (SD) age was 62.4 (5.6) years and median (interquartile interval) cGMP was 3.4 pmol/mL (2.4–4.6). During a median follow‐up of 9.9 years, there were 283 incident cases of HFpEF, 329 any HF, 151 ASCVD, and 125 CHD. In models adjusted for CVD risk factors, the hazard ratios (95% CI) associated with the highest cGMP tertile compared with lowest for HFpEF, HF, ASCVD, and CHD were 1.88 (1.17–3.02), 2.18 (1.18–4.06), 2.84 (1.44–5.60), and 2.43 (1.19–5.00), respectively. In models further adjusted for N‐terminal‐proB‐type natriuretic peptide, associations were attenuated for HFpEF and HF but remained statistically significant for ASCVD (2.56 [1.26–5.20]) and CHD (2.25 [1.07–4.71]). Conclusions Contrary to our hypothesis, higher cGMP levels were associated with incident CVD in a community‐based cohort. The associations of cGMP with HF or HFpEF may be explained by N‐terminal‐proB‐type natriuretic peptide, but not for ASCVD and CHD.
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Affiliation(s)
- Di Zhao
- Department of Epidemiology Johns Hopkins University Bloomberg School of Public Health Baltimore MD
| | - Eliseo Guallar
- Department of Epidemiology Johns Hopkins University Bloomberg School of Public Health Baltimore MD
| | - Dhananjay Vaidya
- Department of Epidemiology Johns Hopkins University Bloomberg School of Public Health Baltimore MD.,Division of General Internal Medicine Department of Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Chiadi E Ndumele
- Department of Epidemiology Johns Hopkins University Bloomberg School of Public Health Baltimore MD.,Division of Cardiology Department of Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Pamela Ouyang
- Division of Cardiology Department of Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Wendy S Post
- Department of Epidemiology Johns Hopkins University Bloomberg School of Public Health Baltimore MD.,Division of Cardiology Department of Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Joao A Lima
- Division of Cardiology Department of Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Wendy Ying
- Division of Cardiology Department of Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - David A Kass
- Division of Cardiology Department of Medicine Johns Hopkins University School of Medicine Baltimore MD
| | - Ron C Hoogeveen
- Division of Cardiovascular Research Department of Medicine Baylor College of Medicine Houston TX
| | - Sanjiv J Shah
- Division of Cardiology Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Vinita Subramanya
- Department of Epidemiology Emory University Rollins School of Public Health Atlanta GA
| | - Erin D Michos
- Department of Epidemiology Johns Hopkins University Bloomberg School of Public Health Baltimore MD.,Division of Cardiology Department of Medicine Johns Hopkins University School of Medicine Baltimore MD
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Li H, Duan Y, Chen B, Zhao Y, Su W, Wang S, Wu J, Lu L. New pharmacological treatments for heart failure with reduced ejection fraction (HFrEF): A Bayesian network meta-analysis. Medicine (Baltimore) 2020; 99:e18341. [PMID: 32000355 PMCID: PMC7004768 DOI: 10.1097/md.0000000000018341] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Heart failure with reduced ejection fraction (HFrEF) has contributed to an increasing number of deaths and readmissions over the past few decades. Despite the appearance of standard treatments, including diuretics, β-receptor blockers and angiotensin-converting enzyme inhibitor (ACEI), there are still a large number of patients who have progressive deterioration of heart function and, inevitably, end-stage heart failure. In recent years, new medications for treating chronic heart failure have been clinically applied, but there is controversy surrounding drug selection and whether patients with HFrEF benefit from these medications. Therefore, we aimed to compare and rank different new pharmacological treatments in patients with HFrEF. METHODS We performed a network meta-analysis to identify both direct and indirect evidence from relevant studies. We searched MEDLINE, EMBASE, and PsycINFO through the OVID database and CENTRAL through the Cochrane Library for clinical randomized controlled trials investigating new pharmacological treatments in patients with HFrEF published up to September 30, 2018. We included trials of ivabradine, levosimendan, omega-3, tolvaptan, recombinant human B-type natriuretic peptide (rhBNP), isosorbide dinitrate and hydralazine (ISDN/HYD) and angiotensin-neprilysin inhibition (LCZ696). We extracted the relevant information from these trials with a predefined data extraction sheet and assessed the risk of bias with the Cochrane risk of bias tool. Based on these items, more than half of the entries were judged as having an overall low to moderate risk of bias; the remaining studies had a high or unclear risk of bias. The outcomes investigated were left ventricle ejection fraction (LVEF %), heart rate (HR) and serum level of B-type natriuretic peptide (BNP). We performed a random-effects network meta-analysis within a Bayesian framework. RESULTS We deemed 32 trials to be eligible that included 3810 patients and 32 treatments. Overall, 32 (94.1%) trials had a low to moderate risk of bias, while 2 (5.9%) trials had a high risk of bias. The quality of the included studies was rated as low in regard to allocation concealment and blinding and high in regard to other domains according to the Cochrane tools. As for increasing LVEF%, levosimendan was better than placebo (-3.77 (-4.96, -2.43)) and was the best intervention for improving ventricle contraction. As for controlling HR, n3-PUFA was better than placebo (4.01 (-0.44, 8.48)) and was the best choice for regulating HR. As for decreasing BNP, omega-3 was better than placebo (941.99 (-47.48, 1952.89) and was the best therapy for improving ventricle wall tension. CONCLUSIONS Our study confirmed the effectiveness of the included new pharmacological treatments for optimizing the structural performance and improving the cardiac function in the management of patients with HFrEF and recommended several interventions for clinical practice.
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Affiliation(s)
- Heng Li
- Cardiology Department of Tung Wah, Affiliated Hospital of Sun-Yat-Sen University
| | - Yuting Duan
- Clinical Research Center, South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine
| | - Benfa Chen
- Cardiology Department of Tung Wah, Affiliated Hospital of Sun-Yat-Sen University
| | - Yu Zhao
- Cardiology Department of Tung Wah, Affiliated Hospital of Sun-Yat-Sen University
| | - Weiping Su
- Cardiology Department of Tung Wah, Affiliated Hospital of Sun-Yat-Sen University
| | - Shanhua Wang
- Cardiology Department of Tung Wah, Affiliated Hospital of Sun-Yat-Sen University
| | - Jiaming Wu
- Zhongshan Affiliated Hospital, Guangzhou University of Chinese Medicine, China
| | - Liming Lu
- Clinical Research Center, South China Research Center for Acupuncture and Moxibustion, Medical College of Acu-Moxi and Rehabilitation, Guangzhou University of Chinese Medicine
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167
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Lin X, Fang L. Pharmaceutical Treatment for Heart Failure. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1177:269-295. [PMID: 32246448 DOI: 10.1007/978-981-15-2517-9_7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure (HF) is defined as a clinical syndrome resulting from structural or functional impairment of ventricular fillings or ejections of blood. Currently, HF is divided into three groups which include HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF) and HF with midrange EF (HFmrEF). Even though major advances have been made in treating HFrEF during the past decades, heart failure is a fatal disease. In this review, we briefly summarize the current advances in pharmaceutical managements for heart failure, which includes drugs used in acute heart failure as well as those that prevent heart failure progression, in each category major clinical trials are also described. In addition, information about some of potential new drugs are also mentioned. Traditional Chinese medicine also shows its potential in treating HF, and we are still lack of medicine to treat HFpEF.
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Affiliation(s)
- Xue Lin
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ligang Fang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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168
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Kozhuharov N, Goudev A, Flores D, Maeder MT, Walter J, Shrestha S, Gualandro DM, de Oliveira Junior MT, Sabti Z, Müller B, Noveanu M, Socrates T, Ziller R, Bayés-Genís A, Sionis A, Simon P, Michou E, Gujer S, Gori T, Wenzel P, Pfister O, Conen D, Kapos I, Kobza R, Rickli H, Breidthardt T, Münzel T, Erne P, Mueller C. Effect of a Strategy of Comprehensive Vasodilation vs Usual Care on Mortality and Heart Failure Rehospitalization Among Patients With Acute Heart Failure: The GALACTIC Randomized Clinical Trial. JAMA 2019; 322:2292-2302. [PMID: 31846016 PMCID: PMC6990838 DOI: 10.1001/jama.2019.18598] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Short-term infusions of single vasodilators, usually given in a fixed dose, have not improved outcomes in patients with acute heart failure (AHF). OBJECTIVE To evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation using individualized up-titrated doses of established vasodilators in patients with AHF. DESIGN, SETTING, AND PARTICIPANTS Randomized, open-label blinded-end-point trial enrolling 788 patients hospitalized for AHF with dyspnea, increased plasma concentrations of natriuretic peptides, systolic blood pressure of at least 100 mm Hg, and plan for treatment in a general ward in 10 tertiary and secondary hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Enrollment began in December 2007 and follow-up was completed in February 2019. INTERVENTIONS Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization (n = 386) or usual care (n = 402). Early intensive and sustained vasodilation was a comprehensive pragmatic approach of maximal and sustained vasodilation combining individualized doses of sublingual and transdermal nitrates, low-dose oral hydralazine for 48 hours, and rapid up-titration of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or sacubitril-valsartan. MAIN OUTCOMES AND MEASURES The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days. RESULTS Among 788 patients randomized, 781 (99.1%; median age, 78 years; 36.9% women) completed the trial and were eligible for primary end point analysis. Follow-up at 180 days was completed for 779 patients (99.7%). The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 117 patients (30.6%) in the intervention group (including 55 deaths [14.4%]) and in 111 patients (27.8%) in the usual care group (including 61 deaths [15.3%]) (absolute difference for the primary end point, 2.8% [95% CI, -3.7% to 9.3%]; adjusted hazard ratio, 1.07 [95% CI, 0.83-1.39]; P = .59). The most common clinically significant adverse events with early intensive and sustained vasodilation vs usual care were hypokalemia (23% vs 25%), worsening renal function (21% vs 20%), headache (26% vs 10%), dizziness (15% vs 10%), and hypotension (8% vs 2%). CONCLUSIONS AND RELEVANCE Among patients with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, did not significantly improve a composite outcome of all-cause mortality and AHF rehospitalization at 180 days. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00512759.
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Affiliation(s)
- Nikola Kozhuharov
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Assen Goudev
- Queen Ioanna University Hospital Sofia, Department of Cardiology, Medical University of Sofia, Sofia, Bulgaria
| | - Dayana Flores
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Micha T. Maeder
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Joan Walter
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Samyut Shrestha
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Danielle Menosi Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Heart Institute (INCOR), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | - Zaid Sabti
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Beat Müller
- Department of General Internal and Emergency Medicine, Medical University Clinic of the University of Basel, Kantonsspital Aarau, Aarau, Switzerland
| | - Markus Noveanu
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Thenral Socrates
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Medical Outpatient Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ronny Ziller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Antoni Bayés-Genís
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Patrick Simon
- Clinical Trial Unit, University Hospital Basel, Basel, Switzerland
| | - Eleni Michou
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Samuel Gujer
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Internal Medicine, Kantonsspital Obwalden, Sarnen, Switzerland
| | - Tommaso Gori
- University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Philip Wenzel
- University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Otmar Pfister
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - David Conen
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Ioannis Kapos
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Richard Kobza
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Hans Rickli
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Tobias Breidthardt
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Münzel
- University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Paul Erne
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
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169
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Senni M, Wachter R, Witte KK, Straburzynska-Migaj E, Belohlavek J, Fonseca C, Mueller C, Lonn E, Chakrabarti A, Bao W, Noe A, Schwende H, Butylin D, Pascual-Figal D. Initiation of sacubitril/valsartan shortly after hospitalisation for acutely decompensated heart failure in patients with newly diagnosed (de novo) heart failure: a subgroup analysis of the TRANSITION study. Eur J Heart Fail 2019; 22:303-312. [PMID: 31820537 DOI: 10.1002/ejhf.1670] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/01/2019] [Accepted: 10/11/2019] [Indexed: 12/28/2022] Open
Abstract
AIMS Sacubitril/valsartan has shown efficacy and tolerability in patients with heart failure (HF) and reduced ejection fraction (HFrEF) in the ambulatory setting (PARADIGM-HF), and following stabilisation of acutely decompensated HF (ADHF) (PIONEER-HF and TRANSITION). However, data are lacking for the initiation of sacubitril/valsartan in newly diagnosed (de novo) HFrEF. Here, we assess the tolerability of initiating sacubitril/valsartan following ADHF in TRANSITION subgroups of patients with a de novo vs. prior diagnosis of HFrEF. METHODS AND RESULTS TRANSITION randomised 1002 patients to pre- and post-discharge initiation of sacubitril/valsartan (analysis set n = 991, following exclusions for mis-randomisation). In this post-hoc analysis, tolerability to sacubitril/valsartan [proportion of patients achieving target dose (97/103 mg b.i.d.) at 10 weeks post-randomisation], adverse events (AEs) and serious AEs (SAEs) were compared in de novo (n = 286) and prior HFrEF (n = 705) subgroups. More de novo than prior HFrEF patients achieved target dose at Week 10 (56% vs. 45%; relative risk ratio 1.30, 95% confidence interval 1.12-1.52, P < 0.001), and fewer had SAEs and permanent treatment discontinuations. Initiation of sacubitril/valsartan did not prevent the concomitant initiation and up-titration of guideline-directed HF therapies. De novo patients showed faster and greater decreases in N-terminal pro-B-type natriuretic peptide and high-sensitivity troponin-T, and lower rates of HF and all-cause rehospitalisation vs. prior HFrEF. CONCLUSIONS After ADHF, first-line initiation of sacubitril/valsartan in de novo HFrEF, alongside the initiation of other guideline-directed therapies, is feasible and is associated with a better risk-benefit profile than in patients with prior HFrEF. Early intervention with sacubitril/valsartan may be considered to delay disease progression in patients with de novo HFrEF. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02661217.
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Affiliation(s)
- Michele Senni
- Cardiology Division, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany.,Clinic for Cardiology and Pneumology, University Medicine Göttingen, Germany and German Cardiovascular Research Center, partner site Göttingen, Göttingen, Germany
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | - Jan Belohlavek
- General Teaching Hospital, Charles University in Prague, Prague, Czech Republic
| | - Candida Fonseca
- Heart Failure Unit, Internal Medicine Department, Hospital de São Francisco Xavier, CHLO, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | | | - Eva Lonn
- McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | | | - Weibin Bao
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Adele Noe
- Novartis Pharma AG, Basel, Switzerland
| | | | | | - Domingo Pascual-Figal
- Cardiology Department, Hospital Universitario Virgen de la Arrixaca, Universidad de Murcia, Murcia, Spain
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170
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The historical evolution of knowledge of the involvement of neurohormonal systems in the pathophysiology and treatment of heart failure. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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171
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Fu S, Chang Z, Luo L, Deng J. Therapeutic Progress and Knowledge Basis on the Natriuretic Peptide System in Heart Failure. Curr Top Med Chem 2019; 19:1850-1866. [PMID: 31448711 DOI: 10.2174/1568026619666190826163536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/25/2019] [Accepted: 07/25/2019] [Indexed: 01/26/2023]
Abstract
Notwithstanding substantial improvements in diagnosis and treatment, Heart Failure (HF) remains a major disease burden with high prevalence and poor outcomes worldwide. Natriuretic Peptides (NPs) modulate whole cardiovascular system and exhibit multiple cardio-protective effects, including the counteraction of the Renin-Angiotensin-Aldosterone System (RAAS) and Sympathetic Nervous System (SNS), promotion of vasodilatation and natriuresis, and inhibition of hypertrophy and fibrosis. Novel pharmacological therapies based on NPs may achieve a valuable shift in managing patients with HF from inhibiting RAAS and SNS to a reversal of neurohormonal imbalance. Enhancing NP bioavailability through exogenous NP administration and inhibiting Neutral Endopeptidase (NEP) denotes valuable therapeutic strategies for HF. On the one hand, NEP-resistant NPs may be more specific as therapeutic choices in patients with HF. On the other hand, NEP Inhibitors (NEPIs) combined with RAAS inhibitors have proved to exert beneficial effects and reduce adverse events in patients with HF. Highly effective and potentially safe Angiotensin Receptor Blocker Neprilysin Inhibitors (ARNIs) have been developed after the failure of NEPIs and Vasopeptidase Inhibitors (VPIs) due to lacking efficacy and safety. Therapeutic progress and knowledge basis on the NP system in HF are summarized in the current review.
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Affiliation(s)
- Shihui Fu
- Department of Geriatric Cardiology, National Clinical Research Center of Geriatrics Disease, Beijing Key Laboratory of Precision Medicine for Chronic Heart Failure, Chinese People's Liberation Army General Hospital, Beijing, China.,Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhenyu Chang
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Leiming Luo
- Department of Geriatric Cardiology, National Clinical Research Center of Geriatrics Disease, Beijing Key Laboratory of Precision Medicine for Chronic Heart Failure, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Juelin Deng
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Beijing, China
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172
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Discovery of Novel Multi-target Inhibitor of angiotensin type 1 receptor and neprilysin inhibitors from Traditional Chinese Medicine. Sci Rep 2019; 9:16205. [PMID: 31700033 PMCID: PMC6838339 DOI: 10.1038/s41598-019-52309-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/14/2019] [Indexed: 12/11/2022] Open
Abstract
Angiotensin II type-1 receptor–neprilysin inhibitor (ARNi) is consisted of Angiotensin II type-1 receptor (AT1) antagonist and neprilysin (NEP) inhibitor, which could simultaneously increase the vasodilators of the natriuretic peptides and antagonize vasoconstrictors of Ang II. ARNi has been proved a superior effect and lower risks of death on chronic heart failure (CHF) and hypertension. In this paper, ARNi from Traditional Chinese Medicines (TCM) was discovered based on target combination of AT1 and NEP by virtual screening, biological assay and molecular dynamics (MD) simulations. Two customized strategies of combinatorial virtual screening were implemented to discover AT1 antagonist and NEP inhibitor based on pharmacophore modeling and docking computation respectively. Gyrophoric acid (PubChem CID: 135728) from Parmelia saxatilis was selected as AT1 antagonist and assayed with IC50 of 29.76 μM by calcium influx assay. And 3,5,3′-triiodothyronine (PubChem CID: 861) from Bos taurus domesticus was screened as NEP inhibitor and has a dose dependent inhibitory activity by biochemistry fluorescence assay. Combined with MD simulations, these compounds can generate interaction with the target, key interactive residues of ARG167, TRP84, and VAL108 in AT1, and HIS711 in NEP were also identified respectively. This study designs the combinatorial strategy to discover novel frames of ARNi from TCM, and gyrophoric acid and 3,5,3′-triiodothyronine could provide the clues and revelations of drug design and therapeutic method of CHF and hypertension for TCM clinical applications.
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173
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Spoto S, Valeriani E, Locorriere L, Anguissola GB, Pantano AL, Terracciani F, Bono MC, Costantino S, Ciccozzi M, Angeletti S. Use of sacubitril/valsartan in Marfan syndrome-related cardiomyopathy: The first case report. Medicine (Baltimore) 2019; 98:e17978. [PMID: 31764806 PMCID: PMC6882602 DOI: 10.1097/md.0000000000017978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Marfan syndrome is a rare cause of heart failure due to primary or secondary cardiomyopathy. Recently, sacubitril/valsartan-an angiotensin receptor blocker-neprilysin inhibitor-has been added in clinical practice as a standard therapy for heart failure. To our knowledge, there are no data on sacubitril/valsartan's effects on cardiovascular outcomes in patients with Marfan syndrome. PATIENT CONCERNS A 24-year-old man was admitted to our Internal Medicine Department due to dyspnea, ascites, and leg swelling. Arterial blood gas analysis revealed severe hypoxemia with respiratory and metabolic alkalosis. Hilar congestion was highlighted on chest x-ray. DIAGNOSES Recurrent acute decompensated heart failure with reduced ejection fraction despite optimal medical therapy in Marfan-related cardiomyopathy. INTERVENTIONS AND OUTCOMES Sacubitril/valsartan was added to optimal medical therapy after hemodynamic stabilization allowing progressive clinical, laboratoristic, and echocardiographic improvement. Patient maintained a free survival from heart failure and a good quality of life until 9-month follow-up. LESSONS Sacubitril/valsartan should be effective on pathophysiologic mechanisms and cardiovascular outcomes of Marfan syndrome-related cardiovascular complications.
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Affiliation(s)
- Silvia Spoto
- Internal Medicine Department, University Campus Bio-Medico of Rome, Rome
| | | | - Luciana Locorriere
- Internal Medicine Department, University Campus Bio-Medico of Rome, Rome
| | | | | | | | | | | | | | - Silvia Angeletti
- Unit of Clinical Laboratory Science, University Campus Bio-Medico of Rome, Rome, Italy
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174
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Mohanty AF, Levitan EB, Dodson JA, Vardeny O, King JB, LaFleur J, He T, Patterson OV, Alba PR, Russo PA, Choi ME, Bress AP. Characteristics and Healthcare Utilization Among Veterans Treated for Heart Failure With Reduced Ejection Fraction Who Switched to Sacubitril/Valsartan. Circ Heart Fail 2019; 12:e005691. [DOI: 10.1161/circheartfailure.118.005691] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background:
US guidelines recommend that patients with heart failure with reduced ejection fraction (HFrEF), who tolerate an ACEI (angiotensin-converting enzyme inhibitor) or ARB (angiotensin II receptor blocker), be switched to sacubitril/valsartan to reduce morbidity and mortality. We compared characteristics and healthcare utilization between Veterans with HFrEF who were switched to sacubitril/valsartan versus maintained on an ACEI or ARB.
Methods:
retrospective cohort study of treated HFrEF (July 2015–June 2017) using Veterans Affairs data. The index date was the first fill for sacubitril/valsartan and if none, for an ACEI or ARB. Treated HFrEF was defined by (1) left ventricular ejection fraction ≤40%, (2) ≥1 in/outpatient HF encounter, and (3) ≥1 ACEI or ARB fill, all within 1-year preindex. Poisson regression models were used to compare baseline characteristics and 1:1 propensity score-matched adjusted 4-month follow-up healthcare utilization between sacubitril/valsartan switchers and ACEI or ARB maintainers.
Results:
Switchers (1612; 4.2%) were less likely than maintainers (37 065; 95.8%) to have a history of myocardial infarction or hypertension, and more likely to be black, have a lower left ventricular ejection fraction, and higher preindex healthcare utilization. Switchers were less likely to experience follow-up all-cause hospitalizations (11.2% versus 14.0%; risk ratio 0.80 [95% CI, 0.65–0.98],
P
value 0.035).
Conclusions:
Few Veterans with treated HFrEF were switched to sacubitril/valsartan within the first 2 years of Food and Drug Administration approval. Sacubitril/valsartan use was associated with a lower risk for all-cause hospitalizations at 4 months follow-up. Reasons for lack of guideline-recommended sacubitril/valsartan initiation warrant investigation and may reveal opportunities for HFrEF care optimization.
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Affiliation(s)
- April F. Mohanty
- Department of Internal Medicine, Division of Epidemiology (A.F.M., T.H., O.V.P., P.R.A.), University of Utah School of Medicine, Salt Lake City, UT
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama. (E.B.L.)
| | - John A. Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY (J.A.D.)
| | - Orly Vardeny
- University of Minnesota Medical School and Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota (O.V.)
| | - Jordan B. King
- Department of Population Health Sciences (J.B.K., A.P.B.), University of Utah School of Medicine, Salt Lake City, UT
| | - Joanne LaFleur
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
- Department of Pharmacotherapy, University of UT College of Pharmacy, Salt Lake City, UT (J.L.)
| | - Tao He
- Department of Internal Medicine, Division of Epidemiology (A.F.M., T.H., O.V.P., P.R.A.), University of Utah School of Medicine, Salt Lake City, UT
| | - Olga V. Patterson
- Department of Internal Medicine, Division of Epidemiology (A.F.M., T.H., O.V.P., P.R.A.), University of Utah School of Medicine, Salt Lake City, UT
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
| | - Patrick R. Alba
- Department of Internal Medicine, Division of Epidemiology (A.F.M., T.H., O.V.P., P.R.A.), University of Utah School of Medicine, Salt Lake City, UT
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
| | - Patricia A. Russo
- US Health Economics & Outcomes Research, Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.A.R.)
| | | | - Adam P. Bress
- Department of Population Health Sciences (J.B.K., A.P.B.), University of Utah School of Medicine, Salt Lake City, UT
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
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175
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Perera K, Ademi Z, Liew D, Zomer E. Sacubitril-valsartan versus enalapril for acute decompensated heart failure: a cost-effectiveness analysis. Eur J Prev Cardiol 2019; 28:966-972. [DOI: 10.1177/2047487319878953] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 09/08/2019] [Indexed: 11/16/2022]
Abstract
Abstract
Background
The Comparison of Sacubitril–Valsartan versus Enalapril on Effect on NT-proBNP in Patients Stabilised from an Acute Heart Failure Episode (PIONEER-HF) trial demonstrated significant reductions in N-terminal pro-B-type natriuretic peptide. Our study explored the cost-effectiveness of the use of sacubitril-valsartan versus enalapril in acute decompensated heart failure from the Australian healthcare perspective.
Methods
A Markov model was designed using data from the PIONEER-HF trial to model the clinical progress and costs of patients over a lifetime time horizon. The model consisted of three health states: ‘alive and event-free’, ‘alive after non-fatal hospitalisation for acute decompensated heart failure’ or ‘dead’. Costs and utilities were estimated from published sources. The cost of sacubitril-valsartan (per the Australian pharmaceutical benefits schedule) was AU$7.08/day. Outcomes of interest were the incremental cost-effectiveness ratios in terms of cost per quality-adjusted life year gained and cost per year of life saved. Cost and benefits were discounted at 5.0% per annum.
Results
Compared to enalapril, sacubitril-valsartan was estimated to cost an additional AU$7464 (discounted) per person, but lead to 0.127 years of life saved (discounted) and 0.096 quality-adjusted life years gained (discounted) over a lifetime analysis. These equated to incremental cost-effectiveness ratios of AU$58,629/year of life saved (US$41,795, EU€58,629, GBP£32,001) and AU$77,889/quality-adjusted life year gained (US$55,526, EU€49,202, GBP£42,504). We have assumed a threshold of AU$50,000/quality-adjusted life year gained to suggest cost-effectiveness.
Conclusions
At its current acquisition price, sacubitril-valsartan in comparison to enalapril is not likely to be cost-effective in the management of acute decompensated heart failure in Australia. A price reduction of more than 25% would confer cost-effectiveness.
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Affiliation(s)
- Kanila Perera
- School of Public Health and Preventive Medicine, Monash University, Australia
| | - Zanfina Ademi
- School of Public Health and Preventive Medicine, Monash University, Australia
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Australia
| | - Ella Zomer
- School of Public Health and Preventive Medicine, Monash University, Australia
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176
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Kim JJ, Youn JC. Eligibility and Usage of Sacubitril/Valsartan in Korea. INTERNATIONAL JOURNAL OF HEART FAILURE 2019; 1:69-71. [PMID: 36262742 PMCID: PMC9536666 DOI: 10.36628/ijhf.2019.0008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Jin-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Chan Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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177
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Sciatti E, Dallapellegrina L, Metra M, Lombardi CM. New drugs for the treatment of chronic heart failure with a reduced ejection fraction. J Cardiovasc Med (Hagerstown) 2019; 20:650-659. [DOI: 10.2459/jcm.0000000000000850] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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178
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Chandra A, Lewis EF, Claggett BL, Desai AS, Packer M, Zile MR, Swedberg K, Rouleau JL, Shi VC, Lefkowitz MP, Katova T, McMurray JJV, Solomon SD. Effects of Sacubitril/Valsartan on Physical and Social Activity Limitations in Patients With Heart Failure: A Secondary Analysis of the PARADIGM-HF Trial. JAMA Cardiol 2019; 3:498-505. [PMID: 29617523 DOI: 10.1001/jamacardio.2018.0398] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Health-related quality of life (HRQL) of patients with heart failure is markedly reduced compared with that in patients with other chronic diseases, demonstrating substantial limitations in physical and social activities. In the Prospective Comparison of ARNI With an ACE-Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial, sacubitril/valsartan improved overall HRQL compared with enalapril, as determined by the Kansas City Cardiomyopathy Questionnaire (KCCQ). Objective To examine the effects of sacubitril/valsartan on physical and social activities. Design, Setting, and Participants The PARADIGM-HF trial was a randomized, double-blind, active treatment-controlled clinical trial performed from December 8, 2009, to March 31, 2014, in 8399 patients with New York Heart Association class II to IV disease and a left ventricular ejection fraction of 40% or less at 1043 centers in 38 countries. Data analysis was performed from August 1, 2017, to December 25, 2017. Interventions Sacubitril/valsartan, 200 mg twice daily, or enalapril, 10 mg twice daily. Main Outcomes and Measures Patients completed HRQL assessments using the KCCQ at randomization, 4-month, 8-month, and annual visits. The effect of sacubitril/valsartan on components of the physical and social limitation sections of the KCCQ at 8 months and longitudinally and related biomarkers and clinical outcomes were studied. Results At baseline, 7618 of 8399 patients (90.7%) (mean [SD] age, 64 [11] years; 5987 [78.6%] male and 1631 [21.4%] female) completed the initial KCCQ assessment. Patients reported the greatest limitations at baseline in jogging and sexual relationships. Patients receiving sacubitril/valsartan had significantly better adjusted change scores in most physical and social activities at 8 months and during 36 months compared with those receiving enalapril. The largest improvement over enalapril was in household chores (adjusted change score difference, 2.35; 95% CI, 1.19-3.50; P < .001) and sexual relationships (adjusted change score difference, 2.72; 95% CI, 0.97-4.46; P = .002); both persisted through 36 months (overall change score difference, 1.69 [95% CI, 0.78-2.60], P < .001; and 2.36 [95% CI, 1.01-3.71], P = .001, respectively). Conclusions and Relevance In patients with heart failure with reduced ejection fraction, sacubitril/valsartan significantly improved nearly all KCCQ physical and social activities compared with enalapril, with the largest responses in household chores and sexual relationships. In addition to reduced likelihood of cardiovascular death, all-cause mortality, and heart failure hospitalization, sacubitril/valsartan may improve limitations in common activities in these patients. Trial Registration clinicaltrials.gov Identifier: NCT01035255.
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Affiliation(s)
| | | | | | | | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.,National Heart and Lung Institute, Imperial College, London, England
| | - Jean L Rouleau
- National Heart and Lung Institute, Imperial College, London, England.,Institut Cardiologie de Montreal, Université de Montreal, Montreal, Quebec, Canada
| | | | | | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland
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179
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van der Pol S, de Jong LA, Vemer P, Jansen DEMC, Postma MJ. Cost-Effectiveness of Sacubitril/Valsartan in Germany: An Application of the Efficiency Frontier. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1119-1127. [PMID: 31563254 DOI: 10.1016/j.jval.2019.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 04/07/2019] [Accepted: 06/19/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND To assess the cost-effectiveness of new treatments in Germany, the efficiency frontier (EF) method has been developed. We compared the cost-effectiveness analysis using international standards and the German methodology, using the heart failure drug sacubitril/valsartan as an example. METHODS A previously developed Markov model was adapted to include 4 treatment options: no treatment, enalapril, candesartan, and sacubitril/valsartan. The internationally used incremental cost-effectiveness ratio (ICER) was calculated, as well as cost-effectiveness acceptability curves. Additionally, EFs, net monetary benefits (NMBs), and price-acceptability curves were created according to German guidelines. All analyses were performed from the perspective of the German Statutory Health Insurance. RESULTS The base-case ICER for sacubitril/valsartan compared to enalapril is €19 300/quality-adjusted life-year. On the cost-effectiveness acceptability curve, sacubitril/valsartan is most likely to be cost-effective, out of all included comparators, from a hypothetical willingness-to-pay threshold of €18 250/quality-adjusted life-year onward. No EF could be constructed for the base case. Taking the uncertainty of the input parameters into account for the probabilistic sensitivity analysis, a NMB of around -€14 000 was calculated, depending on the outcome considered, with the NMB being zero at a daily price for sacubitril/valsartan ranging from €1.52 to €1.67. CONCLUSION We calculated an ICER for Germany, comparable to previously published cost-effectiveness analyses for Europe, which widely concluded sacubitril/valsartan to be cost-effective. Using the German EF approach, a considerable discount needs to be applied before sacubitril/valsartan can be considered cost-effective.
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Affiliation(s)
- Simon van der Pol
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Lisa A de Jong
- Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Pepijn Vemer
- Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands; Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Danielle E M C Jansen
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Department of Sociology, Interuniversity Center for Social Science Theory and Methodology (ICS), University of Groningen, Groningen, The Netherlands
| | - Maarten J Postma
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Groningen Research Institute of Pharmacy, University of Groningen, Groningen, The Netherlands; Institute of Science in Healthy Aging and Healthcare (SHARE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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180
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Castro RRT, Joyce E, Lakdawala NK, Stewart G, Nohria A, Givertz MM, Desai A, Lewis EF, Stevenson LW. Patients report more severe daily limitations than recognized by their physicians. Clin Cardiol 2019; 42:1181-1188. [PMID: 31571248 PMCID: PMC6906987 DOI: 10.1002/clc.23269] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/06/2019] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Patient limitations guide selection of heart failure therapies, for which indications often specify New York Heart Association Class. OBJECTIVES To determine the extent of patient-reported limitations during daily activities and compare to New York Heart Association class assigned by providers during the same visit, and to left ventricular ejection fraction (LVEF) group. METHODS AND RESULTS While waiting for their appointment, 948 patients on return visits to an ambulatory HF clinic completed a written questionnaire assessing specific activity limitations, which were compared to physician-assigned NYHA class during the same visit. Patient-reported limitation to perform daily activity ranged from 25% for bathing to 61% for yardwork or housework and 71% for jogging or hurrying. Most patients who did not report limitations to perform daily life activities were correctly classified as NYHA I by the physicians (76%), but 12% of the 376 patients classified as NYHA I reported limitations to showering or bathing and 73% reported limitations while doing yardwork or house work. Limitation to walking was reported by 172 patients (50%) classified as class II. Limitations to walking one block were most common in patients with LVEF ≥40% compared to patients with LVEF <40%, and least commonly, in HF with better EF (improved from 31 ± 13 to 52 ± 7). CONCLUSIONS Activity limitations are commonly reported by ambulatory HF patients, but underestimated by physicians. It is not clear how this should guide therapy validated for NYHA class but focused activity questions may merit wider use to track limitations and improvement in ambulatory HF.
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Affiliation(s)
- Renata R T Castro
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Hospital Naval Marcilio Dias, Rio de Janeiro, Brazil.,School of Medicine, Universidade Iguaçu, Rio de Janeiro, Brazil
| | - Emer Joyce
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Neal K Lakdawala
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Garrick Stewart
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anju Nohria
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael M Givertz
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Akshay Desai
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eldrin F Lewis
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lynne W Stevenson
- Cardiomyopathy & Advanced Heart Disease Training, Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
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181
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Abstract
Heart failure (HF) is a complex syndrome with an enormous societal burden in terms of cost, morbidity, and mortality. Natriuretic peptide testing is now widely used to support diagnosis, prognostication, and management of patients with HF and are incorporated into HF clinical practice guidelines. Beyond the natriuretic peptides, novel biomarkers may supplement traditional clinical and laboratory testing to improve understanding of the complex disease process of HF and possibly to personalize care for those affected through better individual phenotyping. In this review, we will discuss natriuretic peptides and the more novel biomarkers by dividing them into categories based on the major pathophysiologic pathways they represent. Given the complex physiology in HF, it is reasonable to expect that the future of biomarker testing lies in the application of multimarker testing panels, precision medicine to improve HF care delivery, and the use of biomarkers in proteomics and metabolomics to further improve HF care.
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Affiliation(s)
- Nasrien E Ibrahim
- From the Cardiology Division, Massachusetts General Hospital, Boston (N.E.I., J.L.J.).,Harvard Medical School, Boston, MA (N.E.I., J.L.J.)
| | - James L Januzzi
- From the Cardiology Division, Massachusetts General Hospital, Boston (N.E.I., J.L.J.).,Harvard Medical School, Boston, MA (N.E.I., J.L.J.).,Baim Institute for Clinical Research, Boston, MA (J.L.J.)
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182
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Haynes R, Judge PK, Staplin N, Herrington WG, Storey BC, Bethel A, Bowman L, Brunskill N, Cockwell P, Hill M, Kalra PA, McMurray JJV, Taal M, Wheeler DC, Landray MJ, Baigent C. Effects of Sacubitril/Valsartan Versus Irbesartan in Patients With Chronic Kidney Disease. Circulation 2019; 138:1505-1514. [PMID: 30002098 DOI: 10.1161/circulationaha.118.034818] [Citation(s) in RCA: 137] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Sacubitril/valsartan reduces the risk of cardiovascular mortality among patients with heart failure with reduced ejection fraction, but its effects on kidney function and cardiac biomarkers in people with moderate to severe chronic kidney disease are unknown. METHODS The UK HARP-III trial (United Kingdom Heart and Renal Protection-III), a randomized double-blind trial, included 414 participants with an estimated glomerular filtration rate (GFR) 20 to 60 mL/min/1.73 m2 who were randomly assigned to sacubitril/valsartan 97/103 mg twice daily versus irbesartan 300 mg once daily. The primary outcome was measured GFR at 12 months using ANCOVA with adjustment for each individual's baseline measured GFR. All analyses were by intention to treat. RESULTS In total, 207 participants were assigned to sacubitril/valsartan and 207 to irbesartan. Baseline measured GFR was 34.0 (SE, 0.8) and 34.7 (SE, 0.8) mL/min/1.73 m2, respectively. At 12 months, there was no difference in measured GFR: 29.8 (SE 0.5) among those assigned sacubitril/valsartan versus 29.9 (SE, 0.5) mL/min/1.73 m2 among those assigned irbesartan; difference, -0.1 (0.7) mL/min/1.73 m2. Effects were similar in all prespecified subgroups. There was also no significant difference in estimated GFR at 3, 6, 9, or 12 months and no clear difference in urinary albumin:creatinine ratio between treatment arms (study average difference, -9%; 95% CI, -18 to 1). However, compared with irbesartan, allocation to sacubitril/valsartan reduced study average systolic and diastolic blood pressure by 5.4 (95% CI, 3.4-7.4) and 2.1 (95% CI, 1.0-3.3) mm Hg and levels of troponin I and N terminal of prohormone brain natriuretic peptide (tertiary end points) by 16% (95% CI, 8-23) and 18% (95% CI, 11-25), respectively. The incidence of serious adverse events (29.5% versus 28.5%; rate ratio, 1.07; 95% CI, 0.75-1.53), nonserious adverse reactions (36.7% versus 28.0%; rate ratio, 1.35; 95% CI, 0.96-1.90), and potassium ≥5.5 mmol/L (32% versus 24%, P=0.10) was not significantly different between randomized groups. CONCLUSIONS Over 12 months, sacubitril/valsartan has similar effects on kidney function and albuminuria to irbesartan, but it has the additional effect of lowering blood pressure and cardiac biomarkers in people with chronic kidney disease. CLINICAL TRIAL REGISTRATION URL: http://www.isrctn.com . Unique identifier: ISRCTN11958993.
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Affiliation(s)
- Richard Haynes
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Parminder K Judge
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Natalie Staplin
- Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - William G Herrington
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Benjamin C Storey
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Angelyn Bethel
- Nuffield Department of Population Health, and Diabetes Trials Unit, Radcliffe Department of Medicine (A.B.), University of Oxford, UK
| | - Louise Bowman
- Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Nigel Brunskill
- Department of Infection, Immunity and Inflammation, University of Leicester, UK (N.B.)
| | - Paul Cockwell
- Department of Nephrology, University Hospitals Birmingham, UK (P.C.)
| | - Michael Hill
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Philip A Kalra
- Department of Nephrology, Salford Royal Hospital NHS Foundation Trust, UK (P.A.K.)
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK (J.J.V.M.)
| | - Maarten Taal
- Faculty of Medicine and Health Sciences, University of Nottingham, UK (M.T.)
| | - David C Wheeler
- Centre for Nephrology, University College London, UK (D.C.W.)
| | - Martin J Landray
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
| | - Colin Baigent
- Medical Research Council Population Health Research Unit (R.H., P.K.J., W.G.H., B.C.S., M.H., M.J.L., C.B.), University of Oxford, UK.,Clinical Trial Service Unit (R.H., P.K.J., N.S., W.G.H., B.C.S., L.B., M.H., M.J.L., C.B.), University of Oxford, UK
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183
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Jorsal A, Pryds K, McMurray JJV, Wiggers H, Sommer A, Nielsen JC, Nielsen RR. Optimizing heart failure treatment following cardiac resynchronization therapy. Clin Res Cardiol 2019; 109:638-645. [DOI: 10.1007/s00392-019-01553-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 09/13/2019] [Indexed: 12/28/2022]
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184
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ARNIs: balancing “the good and the bad” of neuroendocrine response to HF. Clin Res Cardiol 2019; 109:599-610. [DOI: 10.1007/s00392-019-01547-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 09/10/2019] [Indexed: 10/26/2022]
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185
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Desai AS, Solomon SD, Shah AM, Claggett BL, Fang JC, Izzo J, McCague K, Abbas CA, Rocha R, Mitchell GF. Effect of Sacubitril-Valsartan vs Enalapril on Aortic Stiffness in Patients With Heart Failure and Reduced Ejection Fraction: A Randomized Clinical Trial. JAMA 2019; 322:1077-1084. [PMID: 31475296 PMCID: PMC6749534 DOI: 10.1001/jama.2019.12843] [Citation(s) in RCA: 200] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Compared with enalapril, sacubitril-valsartan reduces cardiovascular mortality and heart failure hospitalization in patients with heart failure and reduced ejection fraction (HFrEF). These benefits may be related to effects on hemodynamics and cardiac remodeling. OBJECTIVE To determine whether treatment of HFrEF with sacubitril-valsartan improves central aortic stiffness and cardiac remodeling compared with enalapril. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind clinical trial of 464 participants with heart failure and ejection fraction of 40% or less enrolled across 85 US sites between August 17, 2016, and June 28, 2018. Follow-up was completed on January 26, 2019. INTERVENTIONS Randomization (1:1) to sacubitril-valsartan (n = 231; target dosage, 97/103 mg twice daily) vs enalapril (n = 233; target dosage, 10 mg twice daily) for 12 weeks. MAIN OUTCOMES AND MEASURES The primary outcome was change from baseline to week 12 in aortic characteristic impedance (Zc), a measure of central aortic stiffness. Prespecified secondary outcomes included change from baseline to week 12 in N-terminal pro-B-type natriuretic peptide, ejection fraction, global longitudinal strain, mitral annular relaxation velocity, mitral E/e' ratio, left ventricular end-systolic and end-diastolic volume indexes (LVESVI and LVEDVI), left atrial volume index, and ventricular-vascular coupling ratio. RESULTS Of 464 validly randomized participants (mean age, 67.3 [SD, 9.1] years; 23.5% women), 427 completed the study. At 12 weeks, Zc decreased from 223.8 to 218.9 dyne × s/cm5 in the sacubitril-valsartan group and increased from 213.2 to 214.4 dyne × s/cm5 in the enalapril group (treatment difference, -2.2 [95% CI, -17.6 to 13.2] dyne × s/cm5; P = .78). Of 9 prespecified secondary end points, no significant between-group difference in change from baseline was seen in 4, including left ventricular ejection fraction (34%-36% with sacubitril-valsartan vs 33 to 35% with enalapril; treatment difference, 0.6% [95% CI, -0.4% to 1.7%]; P = .24). However, greater reductions from baseline were seen with sacubitril-valsartan than with enalapril in all others, including left atrial volume (from 30.4 mL/m2 to 28.2 mL/m2 vs from 29.8 mL/m2 to 30.5 mL/m2; treatment difference, -2.8 mL/m2 [95% CI, -4.0 to -1.6 mL/m2]; P < .001), LVEDVI (from 75.1 mL/m2 to 70.3 mL/m2 vs from 79.1 mL/m2 to 75.6 mL/m2; treatment difference, -2.0 mL/m2 [95% CI, -3.7 to 0.3 mL/m2]; P = .02), LVESVI (from 50.8 mL/m2 to 46.3 mL/m2 vs from 54.1 to 50.6 mL/m2; treatment difference, -1.6 mL/m2 [95% CI, -3.1 to -0.03 mL/m2]; P = .045), and mitral E/e' ratio (from 13.8 to 12.3 vs from 13.4 to 13.8; treatment difference, -1.8 [95% CI, -2.8 to -0.8]; P = .001). Rates of adverse events including hypotension (1.7% vs 3.9%) were similar in both groups. CONCLUSIONS AND RELEVANCE Treatment of HFrEF with sacubitril-valsartan, compared with enalapril, did not significantly reduce central aortic stiffness. The study findings may provide insight into mechanisms underlying the effects of sacubitril-valsartan in HFrEF. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02874794.
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Affiliation(s)
- Akshay S. Desai
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Amil M. Shah
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Brian L. Claggett
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts
| | - James C. Fang
- Cardiovascular Medicine, University of Utah, Salt Lake City
| | - Joseph Izzo
- Department of Medicine, State University of New York at Buffalo, Buffalo
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186
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Torrado J, Cain C, Mauro AG, Romeo F, Ockaili R, Chau VQ, Nestler JA, Devarakonda T, Ghosh S, Das A, Salloum FN. Sacubitril/Valsartan Averts Adverse Post-Infarction Ventricular Remodeling and Preserves Systolic Function in Rabbits. J Am Coll Cardiol 2019; 72:2342-2356. [PMID: 30384891 DOI: 10.1016/j.jacc.2018.07.102] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/23/2018] [Accepted: 07/30/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sacubitril/valsartan (SAC/VAL) is approved by the U.S. Food and Drug Administration for heart failure with reduced ejection fraction (HFrEF). OBJECTIVES This study investigated the effects of SAC/VAL on acute myocardial infarction (MI) and cardiac remodeling in a translational rabbit model of MI. METHODS New Zealand White rabbits were sedated and underwent conscious MI (45-min ischemia) by balloon inflation (previously implanted surgically) followed by 72 h (acute protocol) or 10 weeks (chronic protocols) of reperfusion. "Infarct-sparing" protocol: SAC/VAL, VAL, or placebo were randomly allocated and administered at reperfusion. "HFrEF-treatment" protocol: rabbits were randomized, and treatment commenced after echocardiography-confirmed left ventricular ejection fraction (LVEF) ≤40%. "HFrEF-prevention" protocol: treatment started at reperfusion and continued daily throughout the study. RESULTS Compared with placebo, SAC/VAL and VAL significantly reduced infarct size (TTC staining) and plasma troponin levels; however, only SAC/VAL preserved LVEF at 72 h post-MI. In the HFrEF-treatment protocol, LVEF improvement was observed with SAC/VAL compared with both placebo and VAL starting 2 weeks post-treatment, a benefit that persisted throughout study duration. In the HFrEF-prevention protocol, SAC/VAL and VAL attenuated the decline in LVEF post-MI, although SAC/VAL offered better functional protection. The functional improvement observed in both treatment protocols was paralleled by significant reduction in left ventricular (LV) scar size (Picrosirius red staining) in the SAC/VAL groups. CONCLUSIONS Reperfusion therapy with SAC/VAL or VAL offers robust acute infarct-sparing benefits; however, SAC/VAL treatment offered superior short-term and long-term benefits in preventing MI-induced LV dysfunction compared with VAL. SAC/VAL also significantly attenuated LV scar size following MI compared with placebo, whereas VAL did not reach statistical significance in scar reduction.
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Affiliation(s)
- Juan Torrado
- Pauley Heart Center, Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia; Department of Cardiology, Clinic Hospital, School of Medicine, Republic University, Montevideo, Uruguay
| | - Chad Cain
- Pauley Heart Center, Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Adolfo G Mauro
- Pauley Heart Center, Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Francisco Romeo
- Pauley Heart Center, Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia; Department of Cardiology, Hospital Italiano, Buenos Aires, Argentina
| | - Ramzi Ockaili
- Pauley Heart Center, Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Vinh Q Chau
- Pauley Heart Center, Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - John A Nestler
- Pauley Heart Center, Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Teja Devarakonda
- Pauley Heart Center, Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Siddhartha Ghosh
- Pauley Heart Center, Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Anindita Das
- Pauley Heart Center, Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Fadi N Salloum
- Pauley Heart Center, Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia.
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187
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Differential Regulation of ANP and BNP in Acute Decompensated Heart Failure: Deficiency of ANP. JACC-HEART FAILURE 2019; 7:891-898. [PMID: 31521687 DOI: 10.1016/j.jchf.2019.05.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study investigated the differential regulation of circulating atrial natriuretic peptide (ANP) and B-type natriuretic peptide (BNP) in patients with acute decompensated heart failure (ADHF) and tested the hypothesis that a relative deficiency of ANP exists in a subgroup of patients with ADHF. BACKGROUND The endocrine heart releases the cardiac hormones ANP and BNP, which play a key role in cardiovascular (CV), renal, and metabolic homeostasis. In heart failure (HF), both plasma ANP and BNP are increased as a compensatory homeostatic response to myocardial overload. METHODS ANP and BNP concentrations were measured in a small group of patients with ADHF (n = 112). To support this study's goal, a total of 129 healthy subjects were prospectively recruited to establish contemporary normal values for ANP and BNP. Plasma 3',5'cyclic guanosine monophosphate (cGMP), ejection fraction (EF), and body mass index (BMI) were measured in these subjects. RESULTS In cases of ADHF, 74% of patients showed elevated ANP and BNP. Importantly, 26% of patients were characterized as having normal ANP (21% of this subgroup had normal ANP and elevated BNP). Cyclic GMP was lowest in the ADHF group with normal levels of ANP (p < 0.001), whereas BMI and EF were inversely related to ANP levels (p = 0.003). CONCLUSIONS Among a subgroup of patients hospitalized with ADHF, the presence of an ANP deficiency is consistent with a differential regulation of ANP and BNP and suggests the existence of a potentially compromised compensatory cardiac endocrine response. These findings have implications for the pathophysiology, diagnostics, and therapeutics of human HF.
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188
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Packer M. Neurohormonal Antagonists Are Preferred to an Implantable Cardioverter-Defibrillator in Preventing Sudden Death in Heart Failure. JACC-HEART FAILURE 2019; 7:902-906. [PMID: 31521684 DOI: 10.1016/j.jchf.2019.05.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 05/24/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas; Imperial College, London, United Kingdom.
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189
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Adamson PD, Anderson JA, Brook RD, Calverley PMA, Celli BR, Cowans NJ, Crim C, Dixon IJ, Martinez FJ, Newby DE, Vestbo J, Yates JC, Mills NL. Cardiac Troponin I and Cardiovascular Risk in Patients With Chronic Obstructive Pulmonary Disease. J Am Coll Cardiol 2019; 72:1126-1137. [PMID: 30165984 PMCID: PMC6119211 DOI: 10.1016/j.jacc.2018.06.051] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 05/24/2018] [Accepted: 06/15/2018] [Indexed: 11/25/2022]
Abstract
Background Patients with chronic obstructive pulmonary disease (COPD) have increased risk of cardiovascular events. Objectives This study evaluated the association between high-sensitivity cardiac troponin I concentration and cardiovascular events in patients with COPD and heightened cardiovascular risk. Methods In a double-blind randomized controlled trial, 16,485 patients with COPD and cardiovascular disease or risk factors were randomized to once daily inhaled placebo, fluticasone furoate (100 μg), vilanterol (25 μg), or their combination. Plasma high-sensitivity cardiac troponin I concentrations were measured in a subgroup of 1,599 patients. Outcomes were on-treatment cardiovascular events and COPD exacerbations over a median of 18 months, and cardiovascular death over a median of 27 months. Results Baseline plasma cardiac troponin I concentrations were above the limit of detection (1.2 ng/l) in 1,542 (96%) patients. Concentrations were unaffected by inhaled therapies at 3 months (p > 0.05). Compared with the lowest quintile (cardiac troponin <2.3 ng/l), patients in the highest quintile (≥7.7 ng/l) were at greater risk of cardiovascular events (hazard ratio [HR] 3.7; 95% confidence interval [CI]: 1.3 to 10.1; p = 0.012) and cardiovascular death (HR: 20.1; 95% CI: 2.4 to 165.2; p = 0.005) after adjustment for risk factors. By contrast, there were no differences in exacerbations between quintiles (HR: 1.1; 95% CI: 0.8 to 1.5; p = 0.548). Conclusions In patients with COPD and heightened cardiovascular risk, plasma cardiac troponin I concentrations are a specific and major indicator of future cardiovascular events and cardiovascular death. Inhaled therapies did not affect cardiac troponin I concentrations consistent with their neutral effect on mortality and cardiovascular outcomes. (Study to Evaluate the Effect of Fluticasone Furoate/Vilanterol on Survival in Subjects With Chronic Obstructive Pulmonary Disease [SUMMIT]; NCT01313676)
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Affiliation(s)
- Philip D Adamson
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Julie A Anderson
- Research & Development, GSK, Stockley Park, Middlesex, United Kingdom
| | - Robert D Brook
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan
| | - Peter M A Calverley
- Department of Medicine, Clinical Sciences Centre, University of Liverpool, University Hospital Aintree, Liverpool, United Kingdom
| | - Bartolome R Celli
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Courtney Crim
- Research & Development, GSK, Research Triangle Park, North Carolina
| | - Ian J Dixon
- Statistics and Programming, Veramed, Twickenham, United Kingdom
| | - Fernando J Martinez
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, New York
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Jørgen Vestbo
- Division of Infection, Immunity and Centre for Respiratory Medicine and Allergy, Manchester Academic Health Science Centre, The University of Manchester and Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Julie C Yates
- Research & Development, GSK, Research Triangle Park, North Carolina
| | - Nicholas L Mills
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
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Tiepolo A, Nougué H, Damoisel C, Launay JM, Vodovar N, Mebazaa A. Evolution of B-type natriuretic peptide and N-terminal pro-brain natriuretic peptide during acute decompensated heart failure in a chronic heart failure patient with reduced ejection fraction treated with Sacubitril/Valsartan: a case report. Eur Heart J Case Rep 2019; 3:ytz108. [PMID: 31660484 PMCID: PMC6764567 DOI: 10.1093/ehjcr/ytz108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/20/2019] [Accepted: 06/17/2019] [Indexed: 11/16/2022]
Abstract
Background B-type natriuretic peptide (BNP) and the N-terminal proBNP (NT-proBNP) exhibit different evolution in chronic heart failure patients with reduced ejection fraction treated with Sacubitril/Valsartan; BNP increasing or remaining stable, while NT-proBNP decreases. However, how this difference translates upon acute decompensation is unknown. Case summary Herein, we described in a 78-year-old woman with chronic heart failure with reduced ejection fraction treated with Sacubitril/Valsartan who had acute decompensated heart failure (ADHF). BNP and NT-proBNP were markedly high during ADHF and showed parallel return to baseline level after clinical improvement. Discussion BNP and NT-proBNP retained similar value for the diagnosis of ADHF in patient treated with Sacubitril/Valsartan. These findings strongly suggest that either BNP or NT-proBNP can be used indifferently in this context, while their relative use is debated in chronic heart failure.
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Affiliation(s)
- Ambre Tiepolo
- Inserm UMR-S 942, 41 boulevard de la Chapelle, Paris Cedex 10, France
- Department of Anaesthesiology and Intensive Care, Saint-Louis and Lariboisière Hospital, 2 rue Ambroise Paré, Paris, France
| | - Hélène Nougué
- Inserm UMR-S 942, 41 boulevard de la Chapelle, Paris Cedex 10, France
- Department of Anaesthesiology and Intensive Care, Saint-Louis and Lariboisière Hospital, 2 rue Ambroise Paré, Paris, France
| | - Charles Damoisel
- Department of Anaesthesiology and Intensive Care, Saint-Louis and Lariboisière Hospital, 2 rue Ambroise Paré, Paris, France
| | - Jean-Marie Launay
- Inserm UMR-S 942, 41 boulevard de la Chapelle, Paris Cedex 10, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Centre for Biological Resources BB-0033-00064, Lariboisière Hospital, 2 rue Ambroise Paré, Paris, France
| | - Nicolas Vodovar
- Inserm UMR-S 942, 41 boulevard de la Chapelle, Paris Cedex 10, France
| | - Alexandre Mebazaa
- Inserm UMR-S 942, 41 boulevard de la Chapelle, Paris Cedex 10, France
- Department of Anaesthesiology and Intensive Care, Saint-Louis and Lariboisière Hospital, 2 rue Ambroise Paré, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
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191
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Abellas‐Sequeiros M, Prado Díaz S, Rey JM, Alonso‐Salinas GL, Zamorano JL. Sacubitril/valsartan and B‐type natriuretic peptide value: recalculating route. Eur J Heart Fail 2019; 22:162-163. [DOI: 10.1002/ejhf.1589] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/02/2019] [Accepted: 07/22/2019] [Indexed: 11/07/2022] Open
Affiliation(s)
| | | | - Jose Manuel Rey
- Department of Clinical AnalysisHospital Ramon y Cajal Madrid Spain
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Forte M, Madonna M, Schiavon S, Valenti V, Versaci F, Zoccai GB, Frati G, Sciarretta S. Cardiovascular Pleiotropic Effects of Natriuretic Peptides. Int J Mol Sci 2019; 20:ijms20163874. [PMID: 31398927 PMCID: PMC6719167 DOI: 10.3390/ijms20163874] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/03/2019] [Accepted: 08/07/2019] [Indexed: 02/07/2023] Open
Abstract
Atrial natriuretic peptide (ANP) is a cardiac hormone belonging to the family of natriuretic peptides (NPs). ANP exerts diuretic, natriuretic, and vasodilatory effects that contribute to maintain water–salt balance and regulate blood pressure. Besides these systemic properties, ANP displays important pleiotropic effects in the heart and in the vascular system that are independent of blood pressure regulation. These functions occur through autocrine and paracrine mechanisms. Previous works examining the cardiac phenotype of loss-of-function mouse models of ANP signaling showed that both mice with gene deletion of ANP or its receptor natriuretic peptide receptor A (NPR-A) developed cardiac hypertrophy and dysfunction in response to pressure overload and chronic ischemic remodeling. Conversely, ANP administration has been shown to improve cardiac function in response to remodeling and reduces ischemia-reperfusion (I/R) injury. ANP also acts as a pro-angiogenetic, anti-inflammatory, and anti-atherosclerotic factor in the vascular system. Pleiotropic effects regarding brain natriuretic peptide (BNP) and C-type natriuretic peptide (CNP) were also reported. In this review, we discuss the current evidence underlying the pleiotropic effects of NPs, underlying their importance in cardiovascular homeostasis.
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Affiliation(s)
| | | | - Sonia Schiavon
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy
| | - Valentina Valenti
- Department of Cardiology, Santa Maria Goretti Hospital, 04100 Latina, Italy
| | - Francesco Versaci
- Department of Cardiology, Santa Maria Goretti Hospital, 04100 Latina, Italy
| | - Giuseppe Biondi Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy
- Mediterranea Cardiocentro, 80122 Napoli, Italy
| | - Giacomo Frati
- IRCCS NEUROMED, 86077 Pozzilli, Italy
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy
| | - Sebastiano Sciarretta
- IRCCS NEUROMED, 86077 Pozzilli, Italy.
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy.
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193
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Tsutamoto T, Sakai H, Yamamoto T, Nakagawa Y. Renal Clearance of N-Terminal pro-Brain Natriuretic Peptide Is Markedly Decreased in Chronic Kidney Disease. Circ Rep 2019; 1:326-332. [PMID: 33693158 PMCID: PMC7892492 DOI: 10.1253/circrep.cr-19-0063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 12/11/2022] Open
Abstract
Background: The ratio of N-terminal pro-brain natriuretic peptide (NT-proBNP) secretion from the heart to peripheral NT-proBNP remains unknown in patients with chronic kidney disease (CKD). Methods and Results: We measured plasma NT-proBNP in the aortic root (AO; NT-proBNPAO) and in the coronary sinus (CS; NT-proBNPCS) in 544 patients. Patients were classified into 6 categories based on estimated glomerular filtration rate (eGFR): G1, n=44, eGFR ≥90 mL/min/1.73 m2; G2, n=221, 60≤eGFR<90 mL/min/1.73 m2; G3a, n=132, 45≤eGFR<60 mL/min/1.73 m2; G3b, n=77, 30≤eGFR<45 mL/min/1.73 m2; G4, n=34, 15≤eGFR<30 mL/min/1.73 m2; and G5, n=36, eGFR <15 mL/min/1.73 m2. In non-CKD patients, hemodynamics but not eGFR were independent predictors of log NT-proBNP. In CKD patients, eGFR and hemodynamics were independent predictors of log NT-proBNP. The ratio of NT-proBNP secretion from the heart to NT-proBNPAO significantly decreased with decreasing eGFR in 6 groups (P<0.0001): G1, 67±38%; G2, 50±24%; G3a, 40±21%; G3b, 30±16%; G4, 14.8±7.9%; and G5, 3.5±2.4%, respectively. Conclusions: eGFR contributes to the value of NT-proBNP for prediction of hemodynamic overload in CKD patients but not in non-CKD patients, and the ratio of NT-proBNP secretion from the heart to peripheral NT-proBNP is markedly decreased in CKD patients, especially those with eGFR <30 mL/min/1.73 m2.
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Affiliation(s)
- Takayoshi Tsutamoto
- Department of Cardiovascular Medicine, Shiga University of Medical Science Otsu Japan
| | - Hiroshi Sakai
- Department of Cardiovascular Medicine, Shiga University of Medical Science Otsu Japan
| | - Takashi Yamamoto
- Department of Cardiovascular Medicine, Shiga University of Medical Science Otsu Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science Otsu Japan
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194
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Abstract
Heart failure (HF) prevalence continues to rise and remains a significant burden to patients, caregivers, providers, and the healthcare system. Guideline-directed medical therapy with standard neurohormonal blockade has been the cornerstone of medical management for many years. Despite aggressive utilization of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and aldosterone antagonists, HF hospitalizations and readmissions are common and residual mortality remains high. With the development of two novel medical therapies (sacubitril/valsartan and ivabradine), the American College of Cardiology, American Heart Association, and Heart Failure Society of America released a pharmacologic update to provide guidelines for incorporation of these agents into clinical practice. Although effective via different mechanisms of action, both agents now have a prominent role in risk reduction. HF medical regimens often become quite complex, especially when associated with comorbid conditions, and require frequent follow-up. Providers must be proficient in patient monitoring, medication dose titration, and therapy optimization. Individualized patient care strategies such as guideline-directed therapy can promote long-term adherence and quality of life.
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195
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Reddy YNV, Iyer SR, Scott CG, Rodeheffer RJ, Bailey K, Jenkins G, Batzler A, Redfield MM, Burnett JC, Pereira NL. Soluble Neprilysin in the General Population: Clinical Determinants and Its Relationship to Cardiovascular Disease. J Am Heart Assoc 2019; 8:e012943. [PMID: 31345101 PMCID: PMC6761669 DOI: 10.1161/jaha.119.012943] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Neprilysin is a metalloprotease involved in proteolysis of numerous peptides, including natriuretic peptides, and is of prognostic and therapeutic importance in heart failure with reduced ejection fraction. No studies have investigated circulating neprilysin in the community, its clinical correlates, or its relationship to cardiovascular disease in the general population. Methods and Results Plasma neprilysin was measured in 1536 participants from Olmsted County, Minnesota, using a commercially available sandwich ELISA assay. Clinical and echocardiographic correlates and subsequent outcomes were determined. Soluble neprilysin is non‐normally distributed in the community (median: 3.9 ng/mL; interquartile range: 1.0–43.0 ng/mL). There was no relationship between plasma neprilysin and age (Spearman correlation: −0.04, P=0.16); body mass index (Spearman correlation: −0.04, P=0.16); glomerular filtration rate (Spearman correlation: −0.007, P=0.8); or A‐, B‐, or C‐type natriuretic peptides (Spearman correlation: 0.03, P=0.22; −0.001, P=0.96; 0.01, P=0.67, respectively). Among tertiles of neprilysin, the lowest tertile group had the highest prevalence of smokers (P<0.001), hypertension (P=0.04), dyslipidemia (P=0.03), and diastolic dysfunction (P=0.02). Soluble neprilysin was not prospectively associated with death or heart failure over a median of 10.7 years. Conclusions In a large community‐based cohort, for the first time, we described the distribution of circulating neprilysin in the general community. We observed that neprilysin does not correlate with natriuretic peptide levels and is not independently associated with adverse outcomes. The novel associations observed between low soluble neprilysin levels and an adverse cardiometabolic and smoking profile requires further investigation.
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Affiliation(s)
- Yogesh N V Reddy
- The Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | | | | | | | - Kent Bailey
- Division of Biomedical Statistics and Informatics Mayo Clinic Rochester MN
| | - Gregory Jenkins
- Division of Biomedical Statistics and Informatics Mayo Clinic Rochester MN
| | - Anthony Batzler
- Division of Biomedical Statistics and Informatics Mayo Clinic Rochester MN
| | | | - John C Burnett
- The Department of Cardiovascular Medicine Mayo Clinic Rochester MN
| | - Naveen L Pereira
- The Department of Cardiovascular Medicine Mayo Clinic Rochester MN.,Department of Molecular Pharmacology and Experimental Therapeutics Mayo Clinic Rochester MN
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196
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Okamoto R, Ali Y, Hashizume R, Suzuki N, Ito M. BNP as a Major Player in the Heart-Kidney Connection. Int J Mol Sci 2019; 20:ijms20143581. [PMID: 31336656 PMCID: PMC6678680 DOI: 10.3390/ijms20143581] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 07/15/2019] [Accepted: 07/17/2019] [Indexed: 02/07/2023] Open
Abstract
Brain natriuretic peptide (BNP) is an important biomarker for patients with heart failure, hypertension and cardiac hypertrophy. Although it is known that BNP levels are relatively higher in patients with chronic kidney disease and no heart disease, the mechanism remains unknown. Here, we review the functions and the roles of BNP in the heart-kidney interaction. In addition, we discuss the relevant molecular mechanisms that suggest BNP is protective against chronic kidney diseases and heart failure, especially in terms of the counterparts of the renin-angiotensin-aldosterone system (RAAS). The renal medulla has been reported to express depressor substances. The extract of the papillary tips from kidneys may induce the expression and secretion of BNP from cardiomyocytes. A better understanding of these processes will help accelerate pharmacological treatments for heart-kidney disease.
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Affiliation(s)
- Ryuji Okamoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan.
| | - Yusuf Ali
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Ryotaro Hashizume
- Department of Pathology and Matrix Biology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Noboru Suzuki
- Department of Animal Genomics, Functional Genomics Institute, Mie University Life Science Research Center, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
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197
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O'Meara E, Prescott MF, Claggett B, Rouleau JL, Chiang LM, Solomon SD, Packer M, McMurray JJV, Zile MR. Independent Prognostic Value of Serum Soluble ST2 Measurements in Patients With Heart Failure and a Reduced Ejection Fraction in the PARADIGM-HF Trial (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure). Circ Heart Fail 2019; 11:e004446. [PMID: 29748349 DOI: 10.1161/circheartfailure.117.004446] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 04/06/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Soluble ST2 (sST2) is associated with cardiac remodeling and fibrosis. In chronic heart failure, the predictive value of sST2 has not been evaluated in a model that includes both NT-proBNP (N-terminal pro-B-type natriuretic peptide) and hs-TnT (high-sensitivity cardiac troponin T), in a trial in which treatment had a major impact. Therefore, the effects of treatment on sST2 levels in PARADIGM-HF trial (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure), the relationships between sST2 and outcomes, and the prognostic utility of various sST2 partition values were examined. METHODS AND RESULTS Baseline (n=2002), 1-month (n=1936), and 8-month postrandomization (n=1758) sST2 levels were compared between treatment groups (sacubitril/valsartan versus enalapril). Relationships between baseline sST2 and (1) heart failure hospitalization, (2) cardiovascular death, and (3) combined heart failure hospitalization and cardiovascular death were assessed using restricted cubic spline models. Adjusted Cox proportional hazards models were used to examine the impact of sST2 change from baseline to 1 month on the hazard of experiencing each outcome. Sacubitril/valsartan led to more reductions and fewer increases in sST2 levels versus enalapril. After adjusting for other predictors, including NT-proBNP and hs-TnT, baseline sST2 remained an independent predictor of outcomes. Associations between baseline sST2 and outcomes were linear. sST2 increases at 1 month were associated with worse subsequent outcomes and decreased with better outcomes (P=0.001, 0.012, and 0.009 for the 3 outcomes, respectively). CONCLUSIONS Sacubitril/valsartan resulted in greater reductions and less increases in sST2 levels than enalapril. No specific threshold was associated with risk, as linear relationships between baseline sST2 and outcomes were observed. Changes in sST2 from baseline to 1 month were independently associated with the risk of outcomes. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT01035255.
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Affiliation(s)
- Eileen O'Meara
- Montreal Heart Institute Department of Medicine (Cardiology) and Research Centre, and Université de Montréal, QC, Canada (E.O., J.L.R.).
| | | | - Brian Claggett
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.C., S.D.S.)
| | - Jean L Rouleau
- Montreal Heart Institute Department of Medicine (Cardiology) and Research Centre, and Université de Montréal, QC, Canada (E.O., J.L.R.)
| | - Lu-May Chiang
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (M.F.P., L.-M.C.)
| | - Scott D Solomon
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (B.C., S.D.S.)
| | - Milton Packer
- Baylor Heart and Vascular Hospital, Baylor University Medical Center, Dallas, TX (M.P.)
| | - John J V McMurray
- Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.)
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston (M.R.Z.)
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198
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Rydén L, Roos A, Holzmann MJ. Chronic Myocardial Injury and Risk for Stroke. Am J Med 2019; 132:833-839. [PMID: 30716296 DOI: 10.1016/j.amjmed.2019.01.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 01/20/2019] [Accepted: 01/22/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Chronic myocardial injury, defined as persistent troponin levels >99th percentile values when measured with high-sensitivity assays (hs-cTn), is common. The association between chronic myocardial injury and stroke is unknown. This study aimed to investigate the association between chronic myocardial injury and stroke. METHODS From 2011 to 2014, we included patients with chest pain and high-sensitivity cardiac troponin T levels measured concurrently but without acute conditions associated with elevated high-sensitivity cardiac troponin T levels. Cox regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) for stroke in patients with stable high-sensitivity cardiac troponin T levels of 5-9, 10-14, 15-29, 30-49, and ≥50 ng/L, using <5 ng/L as reference group. Categories >14 ng/L were defined as chronic myocardial injury. RESULTS A total of 19,460 patients were included, among whom 1528 (7.9%) had chronic myocardial injury. During a mean follow-up of 2.1 years, there were 244 (1.2%) strokes. With increasing high-sensitivity cardiac troponin T levels yearly stroke rates increased from 0.24% to 4.0%. Adjusted hazard ratios with 95% confidence intervals for stroke were 1.83 (1.27-2.64) in patients with high-sensitivity cardiac troponin T levels of 5-9 ng/L, increasing to 1.95 (1.21-3.14), 3.38 (1.80-6.35), and 4.32 (1.89-9.91) in patients with high-sensitivity cardiac troponin T levels of 15-29, 30-49, and ≥50 ng/L, respectively. CONCLUSIONS Patients with chronic myocardial injury have up to a 4-fold increased risk of stroke compared with patients with high-sensitivity cardiac troponin T levels <5 ng/L. Our findings indicate that patients with any detectable high-sensitivity cardiac troponin T level, in particular those with chronic myocardial injury, have an increased risk of stroke and require further attention.
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Affiliation(s)
- Linda Rydén
- Karolinska Institutet, Stockholm, Sweden; Karolinska University Hospital, Stockholm, Sweden
| | - Andreas Roos
- Karolinska Institutet, Stockholm, Sweden; Karolinska University Hospital, Stockholm, Sweden
| | - Martin J Holzmann
- Karolinska Institutet, Stockholm, Sweden; Karolinska University Hospital, Stockholm, Sweden.
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199
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Mueller C, McDonald K, de Boer RA, Maisel A, Cleland JG, Kozhuharov N, Coats AJ, Metra M, Mebazaa A, Ruschitzka F, Lainscak M, Filippatos G, Seferovic PM, Meijers WC, Bayes‐Genis A, Mueller T, Richards M, Januzzi JL. Heart Failure Association of the European Society of Cardiology practical guidance on the use of natriuretic peptide concentrations. Eur J Heart Fail 2019; 21:715-731. [DOI: 10.1002/ejhf.1494] [Citation(s) in RCA: 250] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/04/2019] [Accepted: 04/23/2019] [Indexed: 12/11/2022] Open
Affiliation(s)
- Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital Basel, University of Basel Basel Switzerland
| | - Kenneth McDonald
- Department of CardiologySt. Vincent's University Hospital Dublin Ireland
| | - Rudolf A. de Boer
- University of Groningen, University Medical CenterGroningen, Department of Cardiology The Netherlands
| | | | - John G.F. Cleland
- Robertson Institute of Biostatistics and Clinical Trials UnitUniversity of Glasgow Glasgow UK
| | - Nikola Kozhuharov
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB)University Hospital Basel, University of Basel Basel Switzerland
| | - Andrew J.S. Coats
- University of Warwick Coventry UK
- Monash University Melbourne Australia
- Pharmacology, Centre of Clinical and Experimental Medicine, San Raffaele Pisana Scientific Institute Rome Italy
| | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of Brescia Brescia Italy
| | - Alexandre Mebazaa
- Université de Paris, APHP Département d'Anethésie‐Réanimation Hôpitaux Universitaires Saint Louis Lariboisière Paris France
| | - Frank Ruschitzka
- Department of Cardiology, University Heart CentreUniversity Hospital Zurich Zurich Switzerland
| | - Mitja Lainscak
- Department of Internal MedicineGeneral Hospital Murska Sobota Murska Sobota Slovenia
- Faculty of MedicineUniversity of Ljubljana Slovenia
| | - Gerasimos Filippatos
- Department of Cardiology, Athens University Hospital AttikonUniversity of Athens Greece
- University of CyprusMedical School Nicosia Cyprus
| | | | - Wouter C. Meijers
- University of Groningen, University Medical CenterGroningen, Department of Cardiology The Netherlands
| | - Antoni Bayes‐Genis
- Heart InstituteHospital Universitari Germans Trias i Pujol, CIBERCV Barcelona Spain
- Department of MedicineAutonomous University of Barcelona Barcelona Spain
| | - Thomas Mueller
- Department of Clinical PathologyHospital of Bolzano Bolzano Italy
| | - Mark Richards
- Christchurch Heart InstituteUinversity of Otago New Zealand
- Cardiovascular Research InstituteNational University of Singapore Singapore
| | - James L. Januzzi
- Cardiology Division of the Department of MedicineMassachusetts General Hospital, Harvard Medical School Boston MA USA
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200
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Abstract
Objective, noninvasive, clinical assessment of patients with heart failure can be made using biomarker measurements, including natriuretic peptides, cardiac troponins, soluble suppression of tumorigenicity 2, and galectin-3. The aim of this review is to provide clinicians with guidance on the use of heart failure biomarkers in clinical practice. The authors provide a didactic narrative based on current literature, an exemplary case study, and their clinical experience.
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