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Khan MS, Ochani RK, Butler J. Implications of Diuretic Use in Contextualizing Clinical Trial Results in Patients With Heart Failure With Preserved Ejection Fraction. Am J Cardiol 2024; 231:79-81. [PMID: 39243879 DOI: 10.1016/j.amjcard.2024.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2024] [Accepted: 08/22/2024] [Indexed: 09/09/2024]
Affiliation(s)
- Muhammad Shahzeb Khan
- Baylor Scott and White Research Institute, Dallas, Texas; Department of Medicine, Baylor College of Medicine, Temple, Texas; Division of Cardiology, Heart Hospital Plano, Plano, Texas
| | - Rohan Kumar Ochani
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, New York
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas; Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi
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2
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Manyara AM, Davies P, Stewart D, Weir CJ, Young AE, Blazeby J, Butcher NJ, Bujkiewicz S, Chan AW, Dawoud D, Offringa M, Ouwens M, Hróbjartsson A, Amstutz A, Bertolaccini L, Bruno VD, Devane D, Faria CDCM, Gilbert PB, Harris R, Lassere M, Marinelli L, Markham S, Powers JH, Rezaei Y, Richert L, Schwendicke F, Tereshchenko LG, Thoma A, Turan A, Worrall A, Christensen R, Collins GS, Ross JS, Taylor RS, Ciani O. Reporting of surrogate endpoints in randomised controlled trial reports (CONSORT-Surrogate): extension checklist with explanation and elaboration. BMJ 2024; 386:e078524. [PMID: 38981645 PMCID: PMC11231881 DOI: 10.1136/bmj-2023-078524] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 07/11/2024]
Affiliation(s)
- Anthony Muchai Manyara
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Global Health and Ageing Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Philippa Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Amber E Young
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Blazeby
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Nancy J Butcher
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - An-Wen Chan
- Women's College Research Institute, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dalia Dawoud
- Science, Evidence, and Analytics Directorate, Science Policy and Research Programme, National Institute for Health and Care Excellence, London, UK
- Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network, Odense University hospital, Odense, Denmark
| | - Alain Amstutz
- CLEAR Methods Centre, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Luca Bertolaccini
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Vito Domenico Bruno
- IRCCS Galeazzi-Sant'Ambrogio Hospital, Department of Minimally Invasive Cardiac Surgery, Milan, Italy
| | - Declan Devane
- University of Galway, Galway, Ireland
- Health Research Board-Trials Methodology Research Network, University of Galway, Galway, Ireland
| | - Christina D C M Faria
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Marissa Lassere
- St George Hospital and School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - Lucio Marinelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Sarah Markham
- Patient author, UK
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - John H Powers
- George Washington University School of Medicine, Washington, DC, USA
| | - Yousef Rezaei
- Heart Valve Disease Research Centre, Rajaie Cardiovascular Medical and Research Centre, Iran University of Medical Sciences, Tehran, Iran
- Ardabil University of Medical Sciences, Ardabil, Iran
- Behyan Clinic, Pardis New Town, Tehran, Iran
| | - Laura Richert
- University of Bordeaux, Centre d'Investigation Clinique-Epidémiologie Clinique 1401, Research in Clinical Epidemiology and in Public Health and European Clinical Trials Platform & Development/French Clinical Research Infrastructure Network, Institut National de la Santé et de la Recherche Médicale/Institut Bergonié/Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | | | - Larisa G Tereshchenko
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Alparslan Turan
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, OH, USA
| | | | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen and Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Gary S Collins
- UK EQUATOR Centre, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joseph S Ross
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Robertson Centre for Biostatistics, School of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management, Bocconi University, Milan 20136, Italy
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3
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Manyara AM, Davies P, Stewart D, Weir CJ, Young AE, Blazeby J, Butcher NJ, Bujkiewicz S, Chan AW, Dawoud D, Offringa M, Ouwens M, Hróbjartsson A, Amstutz A, Bertolaccini L, Bruno VD, Devane D, Faria CDCM, Gilbert PB, Harris R, Lassere M, Marinelli L, Markham S, Powers JH, Rezaei Y, Richert L, Schwendicke F, Tereshchenko LG, Thoma A, Turan A, Worrall A, Christensen R, Collins GS, Ross JS, Taylor RS, Ciani O. Reporting of surrogate endpoints in randomised controlled trial protocols (SPIRIT-Surrogate): extension checklist with explanation and elaboration. BMJ 2024; 386:e078525. [PMID: 38981624 PMCID: PMC11231880 DOI: 10.1136/bmj-2023-078525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 07/11/2024]
Affiliation(s)
- Anthony Muchai Manyara
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Global Health and Ageing Research Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Philippa Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Amber E Young
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Blazeby
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Bristol NIHR Biomedical Research Centre, Bristol, UK
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Nancy J Butcher
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Sylwia Bujkiewicz
- Biostatistics Research Group, Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - An-Wen Chan
- Women's College Research Institute, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dalia Dawoud
- Science, Evidence, and Analytics Directorate, Science Policy and Research Programme, National Institute for Health and Care Excellence, London, UK
- Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Martin Offringa
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | | | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network, Odense University hospital, Odense, Denmark
| | - Alain Amstutz
- CLEAR Methods Centre, Division of Clinical Epidemiology, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Oslo, Norway
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Luca Bertolaccini
- Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Vito Domenico Bruno
- IRCCS Galeazzi-Sant'Ambrogio Hospital, Department of Minimally Invasive Cardiac Surgery, Milan, Italy
| | - Declan Devane
- University of Galway, Galway, Ireland
- Health Research Board-Trials Methodology Research Network, University of Galway, Galway, Ireland
| | - Christina D C M Faria
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Marissa Lassere
- St George Hospital and School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - Lucio Marinelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Sarah Markham
- Patient author, UK
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - John H Powers
- George Washington University School of Medicine, Washington, DC, USA
| | - Yousef Rezaei
- Heart Valve Disease Research Centre, Rajaie Cardiovascular Medical and Research Centre, Iran University of Medical Sciences, Tehran, Iran
- Ardabil University of Medical Sciences, Ardabil, Iran
- Behyan Clinic, Pardis New Town, Tehran, Iran
| | - Laura Richert
- University of Bordeaux, Centre d'Investigation Clinique-Epidémiologie Clinique 1401, Research in Clinical Epidemiology and in Public Health and European Clinical Trials Platform & Development/French Clinical Research Infrastructure Network, Institut National de la Santé et de la Recherche Médicale/Institut Bergonié/Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | | | - Larisa G Tereshchenko
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Alparslan Turan
- Department of Outcomes Research, Anaesthesiology Institute, Cleveland Clinic, OH, USA
| | | | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, the Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen and Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Gary S Collins
- UK EQUATOR Centre, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Joseph S Ross
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Rod S Taylor
- MRC/CSO Social and Public Health Sciences Unit, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
- Robertson Centre for Biostatistics, School of Health and Well Being, University of Glasgow, Glasgow, UK
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management, Bocconi University, Milan 20136, Italy
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Tanashat M, Manasrah A, Abouzid M. Effects of dapagliflozin and empagliflozin on 6-min walk distance in heart failure with preserved and reduced ejection fraction: A systematic review and meta-analysis of randomized controlled trials involving 2624 patients. Eur J Clin Pharmacol 2024; 80:951-963. [PMID: 38498097 DOI: 10.1007/s00228-024-03660-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/25/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Dapagliflozin and empagliflozin are antidiabetic medications. They are the first two sodium-glucose cotransporter-2 inhibitors (SGLT2i) to receive the US Food and Drug Administration approval to manage heart failure. Emerging new trials have examined changes in the 6-min walk distance as a clinically significant response to dapagliflozin and empagliflozin in patients with heart failure with reduced ejection fraction (HFpEF) and heart failure with preserved ejection fraction (HFrEF). This meta-analysis aims to evaluate the effects of dapagliflozin and empagliflozin on the 6-min walk distance in patients with HFpEF and HFrEF. To our knowledge, no such meta-analysis has been published. METHODS Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched four electronic databases (PubMed, EMBASE, Cochrane Library, and Web of Science) to identify eligible studies reported up to December 16, 2023. Using Review Manager software, we reported outcomes as risk ratios (RRs) or mean difference (MD) and confidence intervals (CIs). A p-value ≤ 0.05 is considered as statistically significant. RESULTS The meta-analysis included a total of 8 studies with 2624 patients. Overall, the results showed insignificant differences in the 6-min walk between the SGLT2i and placebo (MD 24, 95% CI -0.30 to 18.78, p = 0.06). Results became significant after resolving the heterogeneity (MD 6.72, 95% CI 0.13 to 13.31, p = 0.05). Notably, the results of each drug separately were insignificant. More robust observations occurred in the HFpEF group (MD 10.73, 95% CI 1.08 to 20.39, p = 0.03). Compared to placebo, patients on dapagliflozin reported significant improvement in the Kansas City Cardiomyopathy Questionnaire Clinical Summary (KCCQ-CS) and Overall Summary (KCCQ-OS) with values of MD 5.18 (95% CI 2.80 to 7.57, p < 0.0001) and MD 4.06 (95% CI 1.66 to 6.46, p = 0.0009), respectively. The dapagliflozin group and patients with HFpEF had reported a significant reduction in their weight compared with the control group (MD -0.59 CI -1.09 to -0.08, p = 0.02) and (MD -0.80 CI -1.47 to -0.13, p = 0.02), respectively. No significant side effects were observed for dapagliflozin or empagliflozin. CONCLUSION Patients with HFpEF experienced benefits from SGLT2i administration, as evidenced by improved 6-min walk distances and weight reduction. Dapagliflozin demonstrated clinical and overall improvements in KCCQ scores and was more effective in reducing weight than the placebo. Both Dapagliflozin and Empagliflozin were well-tolerated and exhibited favorable safety profiles. Future studies could benefit from a larger patient population, a longer follow-up period, and a broader range of SGLT2i.
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Affiliation(s)
| | | | - Mohamed Abouzid
- Department of Physical Pharmacy and Pharmacokinetics, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3 St, 60-806, Poznan, Poland.
- Doctoral School, Poznan University of Medical Sciences, 60-812, Poznan, Poland.
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5
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Desai DA, Baby A, Ananthamohan K, Green LC, Arif M, Duncan BC, Kumar M, Singh RR, Koch SE, Natesan S, Rubinstein J, Jegga AG, Sadayappan S. Roles of cMyBP-C phosphorylation on cardiac contractile dysfunction in db/db mice. JOURNAL OF MOLECULAR AND CELLULAR CARDIOLOGY PLUS 2024; 8:100075. [PMID: 38957358 PMCID: PMC11218625 DOI: 10.1016/j.jmccpl.2024.100075] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
Type 2 diabetes mellitus (T2DM) is a metabolic disease and comorbidity associated with several conditions, including cardiac dysfunction leading to heart failure with preserved ejection fraction (HFpEF), in turn resulting in T2DM-induced cardiomyopathy (T2DM-CM). However, the molecular mechanisms underlying the development of T2DM-CM are poorly understood. It is hypothesized that molecular alterations in myopathic genes induced by diabetes promote the development of HFpEF, whereas cardiac myosin inhibitors can rescue the resultant T2DM-mediated cardiomyopathy. To test this hypothesis, a Leptin receptor-deficient db/db homozygous (Lepr db/db) mouse model was used to define the pathogenesis of T2DM-CM. Echocardiographic studies at 4 and 6 months revealed that Lepr db/db hearts started developing cardiac dysfunction by four months, and left ventricular hypertrophy with diastolic dysfunction was evident at 6 months. RNA-seq data analysis, followed by functional enrichment, revealed the differential regulation of genes related to cardiac dysfunction in Lepr db/db heart tissues. Strikingly, the level of cardiac myosin binding protein-C phosphorylation was significantly increased in Lepr db/db mouse hearts. Finally, using isolated skinned papillary muscles and freshly isolated cardiomyocytes, CAMZYOS ® (mavacamten, MYK-461), a prescription heart medicine used for symptomatic obstructive hypertrophic cardiomyopathy treatment, was tested for its ability to rescue T2DM-CM. Compared with controls, MYK-461 significantly reduced force generation in papillary muscle fibers and cardiomyocyte contractility in the db/db group. This line of evidence shows that 1) T2DM-CM is associated with hyperphosphorylation of cardiac myosin binding protein-C and 2) MYK-461 significantly lessened disease progression in vitro, suggesting its promise as a treatment for HFpEF.
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Affiliation(s)
- Darshini A. Desai
- Center for Cardiovascular Research, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Akhil Baby
- Center for Cardiovascular Research, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
- Department of Genetic Engineering, School of Biotechnology, Madurai Kamaraj University, Madurai 625021, India
| | - Kalyani Ananthamohan
- Center for Cardiovascular Research, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Lisa C. Green
- Center for Cardiovascular Research, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Mohammed Arif
- Center for Cardiovascular Research, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Brittany C. Duncan
- Center for Cardiovascular Research, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Mohit Kumar
- Center for Cardiovascular Research, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Rohit R. Singh
- Center for Cardiovascular Research, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Sheryl E. Koch
- Center for Cardiovascular Research, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Sankar Natesan
- Department of Genetic Engineering, School of Biotechnology, Madurai Kamaraj University, Madurai 625021, India
| | - Jack Rubinstein
- Center for Cardiovascular Research, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
| | - Anil G. Jegga
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Sakthivel Sadayappan
- Center for Cardiovascular Research, Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Cincinnati, OH 45267, USA
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6
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McMurray JJV, Docherty KF, de Boer RA, Hammarstedt A, Kitzman DW, Kosiborod MN, Maria Langkilde A, Reicher B, Senni M, Shah SJ, Wilderäng U, Verma S, Solomon SD. Effect of Dapagliflozin Versus Placebo on Symptoms and 6-Minute Walk Distance in Patients With Heart Failure: The DETERMINE Randomized Clinical Trials. Circulation 2024; 149:825-838. [PMID: 38059368 DOI: 10.1161/circulationaha.123.065061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 11/02/2023] [Indexed: 12/08/2023]
Abstract
BACKGROUND Sodium-glucose cotransporter 2 inhibitors reduce the risk of worsening heart failure (HF) and cardiovascular death in patients with HF irrespective of left ventricular ejection fraction. It is important to determine whether therapies for HF improve symptoms and functional capacity. METHODS The DETERMINE (Dapagliflozin Effect on Exercise Capacity Using a 6-Minute Walk Test in Patients With Heart Failure) double-blind, placebo-controlled, multicenter trials assessed the efficacy of the sodium-glucose cotransporter 2 inhibitor dapagliflozin on the Total Symptom Score (TSS) and Physical Limitation Scale (PLS) of the Kansas City Cardiomyopathy Questionnaire (KCCQ) and 6-minute walk distance (6MWD) in 313 patients with HF with reduced ejection fraction (DETERMINE-Reduced) and in 504 patients with HF with preserved ejection fraction (DETERMINE-Preserved) with New York Heart Association class II or III symptoms and elevated natriuretic peptide levels. The primary outcomes were changes in the KCCQ-TSS, KCCQ-PLS, and 6MWD after 16 weeks of treatment. RESULTS Among the 313 randomized patients with HF with reduced ejection fraction, the median placebo-corrected difference in KCCQ-TSS from baseline at 16 weeks was 4.2 (95% CI, 1.0, 8.2; P=0.022) in favor of dapagliflozin. The median placebo-corrected difference in KCCQ-PLS was 4.2 (95% CI, 0.0, 8.3; P=0.058). The median placebo-corrected difference in 6MWD from baseline at 16 weeks was 3.2 meters (95% CI, -6.5, 13.0; P=0.69). In the 504 patients with HF with preserved ejection fraction, the median placebo-corrected 16-week difference in KCCQ-TSS and KCCQ-PLS was 3.2 (95% CI, 0.4, 6.0; P=0.079) and 3.1 (-0.1, 5.4; P=0.23), respectively. The median 16-week difference in 6MWD was 1.6 meters (95% CI, -5.9, 9.0; P=0.67). In an exploratory post hoc analysis of both trials combined (DETERMINE-Pooled), the median placebo-corrected difference from baseline at 16 weeks was 3.7 (1.5, 5.9; P=0.005) for KCCQ-TSS, 4.0 (0.3, 4.9; P=0.036) for KCCQ-PLS, and 2.5 meters (-3.5, 8.4; P=0.50) for 6MWD. CONCLUSIONS Dapagliflozin improved the KCCQ-TSS in patients with HF with reduced ejection fraction but did not improve KCCQ-PLS or 6MWD. Dapagliflozin did not improve these outcomes in patients with HF with preserved ejection fraction. In a post hoc analysis including all patients across the full spectrum of ejection fraction, there was a beneficial effect of dapagliflozin on KCCQ-TSS and KCCQ-PLS but not 6MWD. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT03877237 and NCT03877224.
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Affiliation(s)
- John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M., K.F.D.)
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M., K.F.D.)
| | - Rudolf A de Boer
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands (R.A.d.B.)
| | - Ann Hammarstedt
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden (A.H., A.M.L., U.W.)
| | - Dalane W Kitzman
- Sections on Cardiovascular Medicine and Geriatrics/Gerontology, Wake Forest University School of Medicine, Winston-Salem, NC (D.W.K.)
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City (M.N.K.)
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden (A.H., A.M.L., U.W.)
| | - Barry Reicher
- AstraZeneca BioPharmaceuticals Research & Development, Late-Stage Development, Cardiovascular, Renal and Metabolic, Gaithersburg, MD (B.R.)
| | - Michele Senni
- Cardiovascular Department, Papa Giovanni XXIII Hospital Bergamo, Italy (M.S.)
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | - Ulrica Wilderäng
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research & Development, AstraZeneca, Gothenburg, Sweden (A.H., A.M.L., U.W.)
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Ontario, Canada (S.V.)
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.)
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7
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Lin X, Wu G, Wang S, Huang J. The prevalence of coronary microvascular dysfunction (CMD) in heart failure with preserved ejection fraction (HFpEF): a systematic review and meta-analysis. Heart Fail Rev 2024; 29:405-416. [PMID: 37870703 DOI: 10.1007/s10741-023-10362-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
To date, studies on the prevalence of coronary microvascular dysfunction (CMD) in heart failure with preserved ejection fraction (HFpEF) have not been summarized and analyzed as a whole. We conducted this systematic review and meta-analysis to assess the prevalence of CMD in patients with HFpEF. The PubMed, Cochrane, and Embase databases were searched from dates of inception until May 1, 2023. The primary outcome was the prevalence of CMD in patients with HFpEF, and values of CMD prevalence were pooled using a random-effects model. In total, 10 studies involving 1267 patients, including 822 with HFpEF and 445 without HFpEF, were included. The pooled prevalence of CMD in patients with HFpEF was 71% (95% CI, 0.63-0.79). In the subgroup analysis, the prevalence of CMD was 79% (95% CI, 0.71-0.87) by invasive measurement and 66% (95% CI, 0.54-0.77) by noninvasive measurement and 67% (95% CI, 0.52-0.82) with CFR < 2.0 and 75.0% (95% CI, 0.71-0.79) with CFR < 2.5. The prevalence of endothelium-independent CMD and endothelium-dependent CMD was 62% (95% CI, 0.53-0.72) and 50% (95% CI, 0.19-0.81), respectively. The prevalence of CMD was 74% (95% CI = 0.69-0.79) and 66% (95% CI = 0.41-0.90) in prospective and retrospective studies, respectively. Compared with the control group, patients with HFpEF had a significantly lower CFR (MD = - 1.28, 95% CI = - 1.82 to - 0.74, P < 0.01) and a higher prevalence of CMD (RR = 2.21, 95% CI = 1.52 to 3.20, P < 0.01). Qualitative analysis demonstrated that CMD might be associated with poor clinical outcomes in patients with HFpEF. In conclusion, this is the first systematic review and meta-analysis of all studies reporting the prevalence of CMD in patients with HFpEF. Our study demonstrates that CMD is common in patients with HFpEF and might be associated with poor clinical outcomes in these patients. Clinicians should attach importance to CMD in the diagnosis and treatment of HFpEF. The number of studies in this field is relatively small. Therefore, more high-quality studies are needed to explore the diagnostic and prognostic value of CMD and the potential role of CMD as a therapeutic target in patients with HFpEF.
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Affiliation(s)
- Xiaoxiao Lin
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310030, China
| | - Guomin Wu
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310030, China
| | - Shuai Wang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310030, China.
| | - Jinyu Huang
- Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310030, China.
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8
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Meng S, Yu Y, Yu S, Zhu S, Shi M, Xiang M, Ma H. Advances in Metabolic Remodeling and Intervention Strategies in Heart Failure. J Cardiovasc Transl Res 2024; 17:36-55. [PMID: 37843752 DOI: 10.1007/s12265-023-10443-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 09/27/2023] [Indexed: 10/17/2023]
Abstract
The heart is the most energy-demanding organ throughout the whole body. Perturbations or failure in energy metabolism contributes to heart failure (HF), which represents the advanced stage of various heart diseases. The poor prognosis and huge economic burden associated with HF underscore the high unmet need to explore novel therapies targeting metabolic modulators beyond conventional approaches focused on neurohormonal and hemodynamic regulators. Emerging evidence suggests that alterations in metabolic substrate reliance, metabolic pathways, metabolic by-products, and energy production collectively regulate the occurrence and progression of HF. In this review, we provide an overview of cardiac metabolic remodeling, encompassing the utilization of free fatty acids, glucose metabolism, ketone bodies, and branched-chain amino acids both in the physiological condition and heart failure. Most importantly, the latest advances in pharmacological interventions are discussed as a promising therapeutic approach to restore cardiac function, drawing insights from recent basic research, preclinical and clinical studies.
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Affiliation(s)
- Simin Meng
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University; State Key Laboratory of Transvascular Implantation Devices; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, 310009, China
| | - Yi Yu
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University; State Key Laboratory of Transvascular Implantation Devices; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, 310009, China
| | - Shuo Yu
- Department of Anesthesiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, 310009, China
| | - Shiyu Zhu
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University; State Key Laboratory of Transvascular Implantation Devices; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, 310009, China
| | - Mengjia Shi
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University; State Key Laboratory of Transvascular Implantation Devices; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, 310009, China
| | - Meixiang Xiang
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University; State Key Laboratory of Transvascular Implantation Devices; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, 310009, China.
| | - Hong Ma
- Department of Cardiology, The Second Affiliated Hospital, School of Medicine, Zhejiang University; State Key Laboratory of Transvascular Implantation Devices; Cardiovascular Key Laboratory of Zhejiang Province, Hangzhou, Zhejiang, 310009, China.
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9
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Perfilova VN, Muzyko EA, Taran AS, Shevchenko AA, Naumenko LV. Problems and prospects for finding new pharmacological agents among adenosine receptor agonists, antagonists, or their allosteric modulators for the treatment of cardiovascular diseases. BIOMEDITSINSKAIA KHIMIIA 2023; 69:353-370. [PMID: 38153051 DOI: 10.18097/pbmc20236906353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
A1-adenosine receptors (A1AR) are widely distributed in the human body and mediate many different effects. They are abundantly present in the cardiovascular system, where they control angiogenesis, vascular tone, heart rate, and conduction. This makes the cardiovascular system A1AR an attractive target for the treatment of cardiovascular diseases (CVD). The review summarizes the literature data on the structure and functioning of A1AR, and analyzes their involvement in the formation of myocardial hypertrophy, ischemia-reperfusion damage, various types of heart rhythm disorders, chronic heart failure, and arterial hypertension. Special attention is paid to the role of some allosteric regulators of A1AR as potential agents for the CVD treatment.
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Affiliation(s)
- V N Perfilova
- Volgograd State Medical University, Volgograd, Russia; Volgograd Medical Research Center, Volgograd, Russia
| | - E A Muzyko
- Volgograd State Medical University, Volgograd, Russia
| | - A S Taran
- Volgograd State Medical University, Volgograd, Russia
| | | | - L V Naumenko
- Volgograd State Medical University, Volgograd, Russia
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10
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Lewis GD, Gosch K, Cohen LP, Nassif ME, Windsor SL, Borlaug BA, Kitzman DW, Shah SJ, Khumri T, Umpierrez G, Lamba S, Sharma K, Khan SS, Kosiborod MN, Sauer AJ. Effect of Dapagliflozin on 6-Minute Walk Distance in Heart Failure With Preserved Ejection Fraction: PRESERVED-HF. Circ Heart Fail 2023; 16:e010633. [PMID: 37869881 PMCID: PMC10655911 DOI: 10.1161/circheartfailure.123.010633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/08/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Heart failure with preserved ejection fraction is associated with significant functional limitations, yet treatments for improving exercise performance have been elusive. We sought to explore the association between prespecified patient characteristics and changes in 6-minute walk distance that constitute a clinically significant response to dapagliflozin. METHODS We performed a responder analysis to understand patient characteristics associated with clinically meaningful improvement in 6-minute walk test (6MWT) distance ≥15 m among patients randomized to 12 weeks of dapagliflozin versus placebo in the double-blind PRESERVED-HF trial (Effects of Dapagliflozin on Biomarkers, Symptoms and Functional Status in Patients With Preserved Ejection Fraction Heart Failure). RESULTS A total of 289 randomized patients had 6MWT distance completed at baseline and 12 weeks. Patients randomized to dapagliflozin improved walking distance by ≥15 m more frequently than those on placebo (n=64, 44% versus n=48, 34%). After adjusting for baseline covariates, patients randomized to dapagliflozin were more likely to experience a clinically meaningful improvement in 6MWT distance compared with those that received placebo (adjusted odds ratio, 1.66 [95% CI, 1.00-2.75]; P=0.05). Dapagliflozin-treated patients were also less likely to have a ≥15 m reduction in 6MWT distance compared with placebo-treated patients (adjusted odds ratio, 0.56 [95% CI, 0.33-0.94]; P=0.03). These results were consistent across all prespecified subgroups (all P values for interaction were not significant). CONCLUSIONS Compared with those on placebo, patients with heart failure with preserved ejection fraction randomized to dapagliflozin were more likely to experience a clinically meaningful improvement and less likely to experience a deterioration in physical function over 12 weeks as measured by 6MWT distance. Beneficial response to dapagliflozin was consistent across prespecified subgroups. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03030235.
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Affiliation(s)
- Gregory D. Lewis
- Cardiology Division, Massachusetts General Hospital, Boston (G.D.L., L.P.C.)
| | - Kensey Gosch
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (K.G., M.E.N., S.L.W., T.K., M.N.K., A.J.S.)
- University of Missouri-Kansas City School of Medicine (K.G., M.E.N., T.K., M.N.K., A.J.S.)
| | - Laura P. Cohen
- Cardiology Division, Massachusetts General Hospital, Boston (G.D.L., L.P.C.)
| | - Michael E. Nassif
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (K.G., M.E.N., S.L.W., T.K., M.N.K., A.J.S.)
- University of Missouri-Kansas City School of Medicine (K.G., M.E.N., T.K., M.N.K., A.J.S.)
| | - Sheryl L. Windsor
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (K.G., M.E.N., S.L.W., T.K., M.N.K., A.J.S.)
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (B.A.B.)
| | - Dalane W. Kitzman
- Department of Internal Medicine, Sections on Cardiovascular Medicine and Geriatrics, Wake Forest University School of Medicine, Winston-Salem, NC (D.W.K.)
| | - Sanjiv J. Shah
- Department of Medicine and Bluhm Cardiovascular Institute, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., S.S.K.)
| | - Taiyeb Khumri
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (K.G., M.E.N., S.L.W., T.K., M.N.K., A.J.S.)
- University of Missouri-Kansas City School of Medicine (K.G., M.E.N., T.K., M.N.K., A.J.S.)
| | | | - Sumant Lamba
- First Coast Cardiovascular Institute, Jacksonville, FL (S.L.)
| | - Kavita Sharma
- Johns Hopkins University School of Medicine, Baltimore, MD (K.S.)
| | - Sadiya S. Khan
- Department of Medicine and Bluhm Cardiovascular Institute, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S., S.S.K.)
| | - Mikhail N. Kosiborod
- Cardiology Division, Massachusetts General Hospital, Boston (G.D.L., L.P.C.)
- University of Missouri-Kansas City School of Medicine (K.G., M.E.N., T.K., M.N.K., A.J.S.)
| | - Andrew J. Sauer
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (K.G., M.E.N., S.L.W., T.K., M.N.K., A.J.S.)
- University of Missouri-Kansas City School of Medicine (K.G., M.E.N., T.K., M.N.K., A.J.S.)
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11
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Vaz-Salvador P, Adão R, Vasconcelos I, Leite-Moreira AF, Brás-Silva C. Heart Failure with Preserved Ejection Fraction: a Pharmacotherapeutic Update. Cardiovasc Drugs Ther 2023; 37:815-832. [PMID: 35098432 PMCID: PMC8801287 DOI: 10.1007/s10557-021-07306-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/17/2021] [Indexed: 02/06/2023]
Abstract
While guidelines for management of heart failure with reduced ejection fraction (HFrEF) are consensual and have led to improved survival, treatment options for heart failure with preserved ejection fraction (HFpEF) remain limited and aim primarily for symptom relief and improvement of quality of life. Due to the shortage of therapeutic options, several drugs have been investigated in multiple clinical trials. The majority of these trials have reported disappointing results and have suggested that HFpEF might not be as simply described by ejection fraction as previously though. In fact, HFpEF is a complex clinical syndrome with various comorbidities and overlapping distinct phenotypes that could benefit from personalized therapeutic approaches. This review summarizes the results from the most recent phase III clinical trials for HFpEF and the most promising drugs arising from phase II trials as well as the various challenges that are currently holding back the development of new pharmacotherapeutic options for these patients.
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Affiliation(s)
- Pedro Vaz-Salvador
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Rui Adão
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Inês Vasconcelos
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Adelino F. Leite-Moreira
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Carmen Brás-Silva
- Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development Center - UnIC, University of Porto, Alameda Prof. Hernâni Monteiro, 4200-319 Porto, Portugal
- Faculty of Nutrition and Food Sciences, University of Porto, Rua Do Campo Alegre, 823 4150-180 Porto, Portugal
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12
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Nguyen ATN, Tran QL, Baltos JA, McNeill SM, Nguyen DTN, May LT. Small molecule allosteric modulation of the adenosine A 1 receptor. Front Endocrinol (Lausanne) 2023; 14:1184360. [PMID: 37435481 PMCID: PMC10331460 DOI: 10.3389/fendo.2023.1184360] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/23/2023] [Indexed: 07/13/2023] Open
Abstract
G protein-coupled receptors (GPCRs) represent the target for approximately a third of FDA-approved small molecule drugs. The adenosine A1 receptor (A1R), one of four adenosine GPCR subtypes, has important (patho)physiological roles in humans. A1R has well-established roles in the regulation of the cardiovascular and nervous systems, where it has been identified as a potential therapeutic target for a number of conditions, including cardiac ischemia-reperfusion injury, cognition, epilepsy, and neuropathic pain. A1R small molecule drugs, typically orthosteric ligands, have undergone clinical trials. To date, none have progressed into the clinic, predominantly due to dose-limiting unwanted effects. The development of A1R allosteric modulators that target a topographically distinct binding site represent a promising approach to overcome current limitations. Pharmacological parameters of allosteric ligands, including affinity, efficacy and cooperativity, can be optimized to regulate A1R activity with high subtype, spatial and temporal selectivity. This review aims to offer insights into the A1R as a potential therapeutic target and highlight recent advances in the structural understanding of A1R allosteric modulation.
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Affiliation(s)
- Anh T. N. Nguyen
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Quan L. Tran
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Jo-Anne Baltos
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Samantha M. McNeill
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Diep T. N. Nguyen
- Department of Information Technology, Faculty of Engineering and Technology, Vietnam National University, Hanoi, Vietnam
| | - Lauren T. May
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
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13
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Ratitch B, Trigg A, Majumder M, Vlajnic V, Rethemeier N, Nkulikiyinka R. Clinical Validation of Novel Digital Measures: Statistical Methods for Reliability Evaluation. Digit Biomark 2023; 7:74-91. [PMID: 37588480 PMCID: PMC10425717 DOI: 10.1159/000531054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 05/02/2023] [Indexed: 08/18/2023] Open
Abstract
Background Assessment of reliability is one of the key components of the validation process designed to demonstrate that a novel clinical measure assessed by a digital health technology tool is fit-for-purpose in clinical research, care, and decision-making. Reliability assessment contributes to characterization of the signal-to-noise ratio and measurement error and is the first indicator of potential usefulness of the proposed clinical measure. Summary Methodologies for reliability analyses are scattered across literature on validation of PROs, wet biomarkers, etc., yet are equally useful for digital clinical measures. We review a general modeling framework and statistical metrics typically used for reliability assessments as part of the clinical validation. We also present methods for the assessment of agreement and measurement error, alongside modified approaches for categorical measures. We illustrate the discussed techniques using physical activity data from a wearable device with an accelerometer sensor collected in clinical trial participants. Key Messages This paper provides statisticians and data scientists, involved in development and validation of novel digital clinical measures, an overview of the statistical methodologies and analytical tools for reliability assessment.
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Affiliation(s)
- Bohdana Ratitch
- Statistics and Data Insights, Bayer Inc., Mississauga, ON, Canada
| | - Andrew Trigg
- Medical Affairs Statistics, Bayer plc, Reading, UK
| | | | - Vanja Vlajnic
- Statistics and Data Insights, Bayer Corporation, Whippany, NJ, USA
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14
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Aimo A, Senni M, Barison A, Panichella G, Passino C, Bayes-Genis A, Emdin M. Management of heart failure with preserved ejection fraction: from neurohormonal antagonists to empagliflozin. Heart Fail Rev 2023; 28:179-191. [PMID: 35488030 PMCID: PMC9902425 DOI: 10.1007/s10741-022-10228-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2022] [Indexed: 02/07/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a highly prevalent syndrome with multifaceted pathophysiology. All approaches to neurohormonal modulation were shown not to improve survival in HFpEF, despite their well-established efficacy in heart failure with reduced ejection fraction (HFrEF). This might be attributed to suboptimal study design, inadequate diagnostic criteria, or statistical power, but is also likely to reflect a lack of consideration for its clinical heterogeneity. The attention then shifted to the phenotypic heterogeneity of HFpEF, with the ultimate goal of developing therapies tailored to individual patient phenotypes. Recently, the sodium-glucose co-transporter-2 inhibitor (SGLT2i) empagliflozin has been found to reduce the combined risk of cardiovascular death or hospitalization for HF in patients with HFpEF, a result driven by a reduction in HF hospitalizations. This paper recapitulates the journey from the failure of trials on neurohormonal antagonists to the attempts of personalized approaches and the new perspectives of SGLT2i therapy for HFpEF.
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Affiliation(s)
- Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Senni
- Cardiovascular Department & Cardiology Unit, ASST Papa Giovanni XXIII - Bergamo, Bergamo, Italy
| | - Andrea Barison
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Antoni Bayes-Genis
- ICREC (Heart Failure and Cardiac Regeneration) Research Programme, Health Sciences Research Institute Germans Trias I Pujol (IGTP), Badalona, Spain
- Hospital Universitari Germans Trias I Pujol, Badalona (Barcelona), Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology and Cardiovascular Medicine Department, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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15
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Nayeem MA, Geldenhuys WJ, Hanif A. Role of cytochrome P450-epoxygenase and soluble epoxide hydrolase in the regulation of vascular response. ADVANCES IN PHARMACOLOGY 2023; 97:37-131. [DOI: 10.1016/bs.apha.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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16
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Md MA, Parrott CF, Ph D MJH, Ph D PHB, Md FY, Md BU. Skeletal muscle abnormalities in heart failure with preserved ejection fraction. Heart Fail Rev 2023; 28:157-168. [PMID: 35353269 DOI: 10.1007/s10741-022-10219-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 02/07/2023]
Abstract
Almost half of all heart failure (HF) disease burden is due to HF with preserved ejection fraction (HFpEF). The primary symptom in patients with HFpEF, even when well compensated, is severe exercise intolerance and is associated with their reduced quality of life. Recently, studies showed that HFpEF patients have multiple skeletal muscle (SM) abnormalities, and these are associated with decreased exercise intolerance. The SM abnormalities are likely intrinsic to the HFpEF syndrome, not a secondary consequence of an epiphenomenon. These abnormalities are decreased muscle mass, reduced type I (oxidative) muscle fibers, and reduced type I-to-type II fiber ratio as well as a reduced capillary-to-fiber ratio, abnormal fat infiltration into the thigh SM, increased levels of atrophy genes and proteins, reduction in mitochondrial content, and rapid depletion of high-energy phosphate during exercise with markedly delayed repletion of high-energy phosphate during recovery in mitochondria. In addition, patients with HFpEF have impaired nitric oxide bioavailability, particularly in the microvasculature. These SM abnormalities may be responsible for impaired diffusive oxygen transport and/or impaired SM oxygen extraction. To date, exercise training (ET) and caloric restriction are some of the interventions shown to improve outcomes in HFpEF patients. Improvements in exercise tolerance following aerobic ET are largely mediated through peripheral SM adaptations with minimal change in central hemodynamics and highlight the importance of targeting SM to improve exercise intolerance in HFpEF. Focusing on the abnormalities mentioned above may improve the clinical condition of patients with HFpEF.
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Affiliation(s)
- Matthew Anderson Md
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1045, USA
| | - Clifton Forrest Parrott
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1045, USA
| | - Mark J Haykowsky Ph D
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, AB, Canada
| | - Peter H Brubaker Ph D
- Department of Health and Exercise Science, Wake Forest School of Medicine, Winston-Salem, USA
| | - Fan Ye Md
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1045, USA
| | - Bharathi Upadhya Md
- Cardiovascular Medicine Section, Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157-1045, USA.
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17
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Parra-Lucares A, Romero-Hernández E, Villa E, Weitz-Muñoz S, Vizcarra G, Reyes M, Vergara D, Bustamante S, Llancaqueo M, Toro L. New Opportunities in Heart Failure with Preserved Ejection Fraction: From Bench to Bedside… and Back. Biomedicines 2022; 11:70. [PMID: 36672578 PMCID: PMC9856156 DOI: 10.3390/biomedicines11010070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/07/2022] [Accepted: 12/13/2022] [Indexed: 12/29/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a growing public health problem in nearly 50% of patients with heart failure. Therefore, research on new strategies for its diagnosis and management has become imperative in recent years. Few drugs have successfully improved clinical outcomes in this population. Therefore, numerous attempts are being made to find new pharmacological interventions that target the main mechanisms responsible for this disease. In recent years, pathological mechanisms such as cardiac fibrosis and inflammation, alterations in calcium handling, NO pathway disturbance, and neurohumoral or mechanic impairment have been evaluated as new pharmacological targets showing promising results in preliminary studies. This review aims to analyze the new strategies and mechanical devices, along with their initial results in pre-clinical and different phases of ongoing clinical trials for HFpEF patients. Understanding new mechanisms to generate interventions will allow us to create methods to prevent the adverse outcomes of this silent pandemic.
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Affiliation(s)
- Alfredo Parra-Lucares
- Critical Care Unit, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
- MD PhD Program, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | - Esteban Romero-Hernández
- MD PhD Program, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
- Division of Internal Medicine, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Eduardo Villa
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | - Sebastián Weitz-Muñoz
- Division of Internal Medicine, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Geovana Vizcarra
- Division of Internal Medicine, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Martín Reyes
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | - Diego Vergara
- School of Medicine, Faculty of Medicine, Universidad de Chile, Santiago 8380420, Chile
| | - Sergio Bustamante
- Coronary Care Unit, Cardiovascular Department, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Marcelo Llancaqueo
- Coronary Care Unit, Cardiovascular Department, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
| | - Luis Toro
- Division of Nephrology, Department of Medicine, Hospital Clínico Universidad de Chile, Santiago 8380420, Chile
- Centro de Investigación Clínica Avanzada, Hospital Clínico, Universidad de Chile, Santiago 8380420, Chile
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18
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Nayeem MA, Hanif A, Geldenhuys WJ, Agba S. Crosstalk between adenosine receptors and CYP450-derived oxylipins in the modulation of cardiovascular, including coronary reactive hyperemic response. Pharmacol Ther 2022; 240:108213. [PMID: 35597366 DOI: 10.1016/j.pharmthera.2022.108213] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 12/14/2022]
Abstract
Adenosine is a ubiquitous endogenous nucleoside or autacoid that affects the cardiovascular system through the activation of four G-protein coupled receptors: adenosine A1 receptor (A1AR), adenosine A2A receptor (A2AAR), adenosine A2B receptor (A2BAR), and adenosine A3 receptor (A3AR). With the rapid generation of this nucleoside from cellular metabolism and the widespread distribution of its four G-protein coupled receptors in almost all organs and tissues of the body, this autacoid induces multiple physiological as well as pathological effects, not only regulating the cardiovascular system but also the central nervous system, peripheral vascular system, and immune system. Mounting evidence shows the role of CYP450-enzymes in cardiovascular physiology and pathology, and the genetic polymorphisms in CYP450s can increase susceptibility to cardiovascular diseases (CVDs). One of the most important physiological roles of CYP450-epoxygenases (CYP450-2C & CYP2J2) is the metabolism of arachidonic acid (AA) and linoleic acid (LA) into epoxyeicosatrienoic acids (EETs) and epoxyoctadecaenoic acid (EpOMEs) which generally involve in vasodilation. Like an increase in coronary reactive hyperemia (CRH), an increase in anti-inflammation, and cardioprotective effects. Moreover, the genetic polymorphisms in CYP450-epoxygenases will change the beneficial cardiovascular effects of metabolites or oxylipins into detrimental effects. The soluble epoxide hydrolase (sEH) is another crucial enzyme ubiquitously expressed in all living organisms and almost all organs and tissues. However, in contrast to CYP450-epoxygenases, sEH converts EETs into dihydroxyeicosatrienoic acid (DHETs), EpOMEs into dihydroxyoctadecaenoic acid (DiHOMEs), and others and reverses the beneficial effects of epoxy-fatty acids leading to vasoconstriction, reducing CRH, increase in pro-inflammation, increase in pro-thrombotic and become less cardioprotective. Therefore, polymorphisms in the sEH gene (Ephx2) cause the enzyme to become overactive, making it more vulnerable to CVDs, including hypertension. Besides the sEH, ω-hydroxylases (CYP450-4A11 & CYP450-4F2) derived metabolites from AA, ω terminal-hydroxyeicosatetraenoic acids (19-, 20-HETE), lipoxygenase-derived mid-chain hydroxyeicosatetraenoic acids (5-, 11-, 12-, 15-HETEs), and the cyclooxygenase-derived prostanoids (prostaglandins: PGD2, PGF2α; thromboxane: Txs, oxylipins) are involved in vasoconstriction, hypertension, reduction in CRH, pro-inflammation and cardiac toxicity. Interestingly, the interactions of adenosine receptors (A2AAR, A1AR) with CYP450-epoxygenases, ω-hydroxylases, sEH, and their derived metabolites or oxygenated polyunsaturated fatty acids (PUFAs or oxylipins) is shown in the regulation of the cardiovascular functions. In addition, much evidence demonstrates polymorphisms in CYP450-epoxygenases, ω-hydroxylases, and sEH genes (Ephx2) and adenosine receptor genes (ADORA1 & ADORA2) in the human population with the susceptibility to CVDs, including hypertension. CVDs are the number one cause of death globally, coronary artery disease (CAD) was the leading cause of death in the US in 2019, and hypertension is one of the most potent causes of CVDs. This review summarizes the articles related to the crosstalk between adenosine receptors and CYP450-derived oxylipins in vascular, including the CRH response in regular salt-diet fed and high salt-diet fed mice with the correlation of heart perfusate/plasma oxylipins. By using A2AAR-/-, A1AR-/-, eNOS-/-, sEH-/- or Ephx2-/-, vascular sEH-overexpressed (Tie2-sEH Tr), vascular CYP2J2-overexpressed (Tie2-CYP2J2 Tr), and wild-type (WT) mice. This review article also summarizes the role of pro-and anti-inflammatory oxylipins in cardiovascular function/dysfunction in mice and humans. Therefore, more studies are needed better to understand the crosstalk between the adenosine receptors and eicosanoids to develop diagnostic and therapeutic tools by using plasma oxylipins profiles in CVDs, including hypertensive cases in the future.
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Affiliation(s)
- Mohammed A Nayeem
- Faculties of the Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV, USA.
| | - Ahmad Hanif
- Faculties of the Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV, USA
| | - Werner J Geldenhuys
- Faculties of the Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV, USA
| | - Stephanie Agba
- Graduate student, Department of Pharmaceutical Sciences, School of Pharmacy, West Virginia University, Morgantown, WV, USA
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19
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Lin X, Wu G, Gao B, Wang S, Huang J. Bibliometric and visual analysis of coronary microvascular dysfunction. Front Cardiovasc Med 2022; 9:1021346. [PMID: 36457808 PMCID: PMC9705352 DOI: 10.3389/fcvm.2022.1021346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/31/2022] [Indexed: 11/05/2023] Open
Abstract
Background Coronary microvascular dysfunction (CMD) may play an important role in various cardiovascular diseases, including HFpEF and both obstructive and non-obstructive coronary artery disease (CAD). To date, there has been no bibliometric analysis to summarize this field. Here, we aim to conduct a bibliometric analysis of CMD to determine the current status and frontiers in this field. Materials and methods Publications about CMD were taken from the Web of Science Core Collection database (WOSCC). WOSCC's literature analysis wire, the VOSviewer 1.6.16, and CiteSpace 5.1.3 were used to conduct the analysis. Results A total of 785 publications containing 206 reviews and 579 articles are included in the sample. The leading authors are Iacopo Olivotto, Paolo G. Camici, and Carl J. Pepine. The most productive institutions are the University of Florence, Cedars Sinai Medical Center, and Harvard University. The most productive countries are the USA, Italy, and England. There are a total of 237 journals that contribute to this field, and the leading journals in our study were the International Journal of Cardiology, the European Heart Journal and the JACC. From 2012 to 2021, the top three most-cited articles focused on the association between HFpEF and CMD. The important keywords are heart failure, hypertrophic cardiomyopathy, chest pain, women, coronary flow reserve (CFR), endothelial dysfunction and prognostic value. "Positron emission tomography" shows the strongest burst strength, followed by "blow flow" and "artery." The keywords that started to burst from 2015 are particularly emphasized, including "heart failure," "coronary flow reserve," and "management." Conclusion Studies about CMD are relatively limited, and the largest contribution comes from the USA, Italy and England. More studies are needed, and publications from other countries should be enhanced. The main research hotspots in the CMD field include CMD in patients with HFpEF, sex differences, the new methods of diagnosis for CMD, and the effective treatment of CMD. Attention should be given to CMD in patients with HFpEF, and untangling the association between CMD and HFpEF could be helpful in the development of physiology-stratified treatment for patients with CMD and HFpEF.
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Affiliation(s)
- Xiaoxiao Lin
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Guomin Wu
- Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Beibei Gao
- Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shuai Wang
- Department of Translation Medicine Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinyu Huang
- Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
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20
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Zhou H, Zhan R, Chen X, Lin Y, Zhang S, Zheng H, Wang X, Huang M, Xu C, Liao X, Tian T, Zhuang X. Targeting efficacy of spironolactone in patients with heart failure with preserved ejection fraction: the TOPCAT study. ESC Heart Fail 2022; 10:322-333. [PMID: 36221795 PMCID: PMC9871668 DOI: 10.1002/ehf2.14068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/29/2022] [Accepted: 06/27/2022] [Indexed: 01/27/2023] Open
Abstract
AIMS We aimed to explore the heterogeneous treatment effects (HTEs) for spironolactone treatment in patients with Heart failure with preserved ejection fraction (HFpEF) and examine the efficacy and safety of spironolactone medication, ensuring a better individualized therapy. METHODS AND RESULTS We used the causal forest algorithm to discover the heterogeneous treatment effects (HTEs) from patients in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial. Cox regressions were performed to assess the hazard ratios (HRs) of spironolactone medication for cardiovascular death and drug discontinuation in each group. The causal forest model revealed three representative covariates and participants were partitioned into four subgroups which were Group 1 (baseline BMI ≤ 31.71 kg/m2 and baseline ALP ≤ 80 U/L, n = 759); Group 2 (BMI ≤ 31.71 kg/m2 and ALP > 80 U/L, n = 1088); Group 3 (BMI > 31.71 kg/m2 , and WBC ≤ 6.6 cells/μL, n = 633); Group 4 (BMI > 31.71 kg/m2 and WBC > 6.6 cells/μL, n = 832), respectively. In the four subgroups, spironolactone therapy reduced the risk of cardiovascular death in high-risk group (Group 4) with both high BMI and WBC count (HR: 0.76; 95% CI 0.58 to 0.99; P = 0.045) but increased the risk in low-risk group (Group 1) with both low BMI and ALP (HR: 1.45; 95% CI 1.02 to 2.07; P = 0.041; P for interaction = 0.020) but showed similar risk of drug discontinuation (P for interaction = 0.498). CONCLUSION Our study manifested the HTEs of spironolactone in patients with HFpEF. Spironolactone treatment in HFpEF patients is feasible and effective in patients with high BMI and WBC while harmful in patients with low BMI and ALP. Machine learning model could be meaningful for improved categorization of patients with HFpEF, ensuring a better individualized therapy in the clinical setting.
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Affiliation(s)
- Hui‐min Zhou
- Cardiology DepartmentThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina,NHC Key Laboratory of Assisted Circulation (Sun Yat‐Sen University)GuangzhouChina
| | - Rong‐jian Zhan
- Zhongshan School of MedicineSun Yat‐sen UniversityGuangzhouChina
| | - Xuanyu Chen
- School of MathematicsSun Yat‐sen UniversityGuangzhouChina
| | - Yi‐fen Lin
- Cardiology DepartmentThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina,NHC Key Laboratory of Assisted Circulation (Sun Yat‐Sen University)GuangzhouChina
| | - Shao‐zhao Zhang
- Cardiology DepartmentThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina,NHC Key Laboratory of Assisted Circulation (Sun Yat‐Sen University)GuangzhouChina
| | - Huigan Zheng
- School of MathematicsSun Yat‐sen UniversityGuangzhouChina
| | - Xueqin Wang
- School of ManagementUniversity of Science and Technology of ChinaHefeiChina
| | - Meng‐ting Huang
- Cardiology DepartmentThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina,NHC Key Laboratory of Assisted Circulation (Sun Yat‐Sen University)GuangzhouChina
| | - Chao‐guang Xu
- Cardiology DepartmentThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina,NHC Key Laboratory of Assisted Circulation (Sun Yat‐Sen University)GuangzhouChina
| | - Xin‐xue Liao
- Cardiology DepartmentThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina,NHC Key Laboratory of Assisted Circulation (Sun Yat‐Sen University)GuangzhouChina
| | - Ting Tian
- School of MathematicsSun Yat‐sen UniversityGuangzhouChina
| | - Xiao‐dong Zhuang
- Cardiology DepartmentThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina,NHC Key Laboratory of Assisted Circulation (Sun Yat‐Sen University)GuangzhouChina
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21
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Ruan W, Ma X, Bang IH, Liang Y, Muehlschlegel JD, Tsai KL, Mills TW, Yuan X, Eltzschig HK. The Hypoxia-Adenosine Link during Myocardial Ischemia-Reperfusion Injury. Biomedicines 2022; 10:1939. [PMID: 36009485 PMCID: PMC9405579 DOI: 10.3390/biomedicines10081939] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022] Open
Abstract
Despite increasing availability and more successful interventional approaches to restore coronary reperfusion, myocardial ischemia-reperfusion injury is a substantial cause of morbidity and mortality worldwide. During myocardial ischemia, the myocardium becomes profoundly hypoxic, thus causing stabilization of hypoxia-inducible transcription factors (HIF). Stabilization of HIF leads to a transcriptional program that promotes adaptation to hypoxia and cellular survival. Transcriptional consequences of HIF stabilization include increases in extracellular production and signaling effects of adenosine. Extracellular adenosine functions as a signaling molecule via the activation of adenosine receptors. Several studies implicated adenosine signaling in cardioprotection, particularly through the activation of the Adora2a and Adora2b receptors. Adenosine receptor activation can lead to metabolic adaptation to enhance ischemia tolerance or dampen myocardial reperfusion injury via signaling events on immune cells. Many studies highlight that clinical strategies to target the hypoxia-adenosine link could be considered for clinical trials. This could be achieved by using pharmacologic HIF activators or by directly enhancing extracellular adenosine production or signaling as a therapy for patients with acute myocardial infarction, or undergoing cardiac surgery.
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Affiliation(s)
- Wei Ruan
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
- Department of Anesthesiology, Second Xiangya Hospital, Central South University, Changsha 410011, China
| | - Xinxin Ma
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - In Hyuk Bang
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Yafen Liang
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Jochen Daniel Muehlschlegel
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Kuang-Lei Tsai
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Tingting W. Mills
- Department of Biochemistry and Molecular Biology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Xiaoyi Yuan
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Holger K. Eltzschig
- Department of Anesthesiology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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22
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Jiang Y, Lin J, Zheng H, Zhu P. The Role of Purinergic Signaling in Heart Transplantation. Front Immunol 2022; 13:826943. [PMID: 35529844 PMCID: PMC9069525 DOI: 10.3389/fimmu.2022.826943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/22/2022] [Indexed: 11/13/2022] Open
Abstract
Heart transplantation remains the optimal treatment option for patients with end-stage heart disease. Growing evidence demonstrates that purinergic signals mediated by purine nucleotides and nucleosides play vital roles in heart transplantation, especially in the era of ischemia-reperfusion injury (IRI) and allograft rejection. Purinergic signaling consists of extracellular nucleotides and nucleosides, ecto-enzymes, and cell surface receptors; it participates in the regulation of many physiological and pathological processes. During transplantation, excess adenosine triphosphate (ATP) levels are released from damaged cells, and driver detrimental inflammatory responses largely via purinergic P2 receptors. Ecto-nucleosidases sequentially dephosphorylate extracellular ATP to ADP, AMP, and finally adenosine. Adenosine exerts a cardioprotective effect by its anti-inflammatory, antiplatelet, and vasodilation properties. This review focused on the role of purinergic signaling in IRI and rejection after heart transplantation, as well as the clinical applications and prospects of purinergic signaling.
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Affiliation(s)
| | | | | | - Ping Zhu
- Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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23
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Aronow WS, Lloji A, Sreenivasan J, Novograd J, Pan S, Lanier GM. Heart failure with preserved ejection fraction: key stumbling blocks for experimental drugs in clinical trials. Expert Opin Investig Drugs 2022; 31:463-474. [PMID: 35443138 DOI: 10.1080/13543784.2022.2069009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Heart failure with preserved ejection fraction (HFpEF) is a disease process with a high prevalence. Accounting for more than 50% of all heart failure cases, it carries a significant mortality. So far, there has been a lack of therapeutic options that truly show improvement in morbidity and mortality. Certain novel therapies have shown a decrease in heart failure hospitalizations, however, this beneficial effect was more pronounced for heart failure patients with mildly reduced ejection fraction (EF). AREAS COVERED This review summarizes the pathophysiology of the disease to help elucidate the differences between heart failure with reduced ejection fraction (HFrEF), and HFpEF, which could explain why therapies are successful in one (rather than the other). At the focus of this review are non-standardized nomenclature across major trials, the challenges of finding a therapeutic agent for such a heterogeneous population, and identification of specific phenotypes that have different outcomes and could be a target for future therapies. EXPERT OPINION Lack of standardized diagnostic criteria, associated with population heterogeneity, might explain why trials have failed to improve outcomes for patients with HFpEF. Standardizing phenotypes and recapitulating these phenotypes in animal models, as well as understanding the mechanisms of the disease at the molecular level could be the first steps in identifying promising therapeutic options.
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Affiliation(s)
- Wilbert S Aronow
- Westchester Medical Center, New York Medical College,New York, USA
| | - Amanda Lloji
- Westchester Medical Center, New York Medical College,New York, USA
| | | | - Joel Novograd
- Westchester Medical Center, New York Medical College,New York, USA
| | - Stephen Pan
- Westchester Medical Center, New York Medical College,New York, USA
| | - Gregg M Lanier
- Westchester Medical Center, New York Medical College,New York, USA
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24
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IJzerman AP, Jacobson KA, Müller CE, Cronstein BN, Cunha RA. International Union of Basic and Clinical Pharmacology. CXII: Adenosine Receptors: A Further Update. Pharmacol Rev 2022; 74:340-372. [PMID: 35302044 PMCID: PMC8973513 DOI: 10.1124/pharmrev.121.000445] [Citation(s) in RCA: 70] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Our previous International Union of Basic and Clinical Pharmacology report on the nomenclature and classification of adenosine receptors (2011) contained a number of emerging developments with respect to this G protein-coupled receptor subfamily, including protein structure, protein oligomerization, protein diversity, and allosteric modulation by small molecules. Since then, a wealth of new data and results has been added, allowing us to explore novel concepts such as target binding kinetics and biased signaling of adenosine receptors, to examine a multitude of receptor structures and novel ligands, to gauge new pharmacology, and to evaluate clinical trials with adenosine receptor ligands. This review should therefore be considered a further update of our previous reports from 2001 and 2011. SIGNIFICANCE STATEMENT: Adenosine receptors (ARs) are of continuing interest for future treatment of chronic and acute disease conditions, including inflammatory diseases, neurodegenerative afflictions, and cancer. The design of AR agonists ("biased" or not) and antagonists is largely structure based now, thanks to the tremendous progress in AR structural biology. The A2A- and A2BAR appear to modulate the immune response in tumor biology. Many clinical trials for this indication are ongoing, whereas an A2AAR antagonist (istradefylline) has been approved as an anti-Parkinson agent.
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Affiliation(s)
- Adriaan P IJzerman
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands (A.P.IJ.); National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Molecular Recognition Section, Bethesda, Maryland (K.A.J.); Universität Bonn, Bonn, Germany (C.E.M.); New York University School of Medicine, New York, New York (B.N.C.); and Center for Neurosciences and Cell Biology and Faculty of Medicine, University of Coimbra, Coimbra, Portugal (R.A.C.)
| | - Kenneth A Jacobson
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands (A.P.IJ.); National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Molecular Recognition Section, Bethesda, Maryland (K.A.J.); Universität Bonn, Bonn, Germany (C.E.M.); New York University School of Medicine, New York, New York (B.N.C.); and Center for Neurosciences and Cell Biology and Faculty of Medicine, University of Coimbra, Coimbra, Portugal (R.A.C.)
| | - Christa E Müller
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands (A.P.IJ.); National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Molecular Recognition Section, Bethesda, Maryland (K.A.J.); Universität Bonn, Bonn, Germany (C.E.M.); New York University School of Medicine, New York, New York (B.N.C.); and Center for Neurosciences and Cell Biology and Faculty of Medicine, University of Coimbra, Coimbra, Portugal (R.A.C.)
| | - Bruce N Cronstein
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands (A.P.IJ.); National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Molecular Recognition Section, Bethesda, Maryland (K.A.J.); Universität Bonn, Bonn, Germany (C.E.M.); New York University School of Medicine, New York, New York (B.N.C.); and Center for Neurosciences and Cell Biology and Faculty of Medicine, University of Coimbra, Coimbra, Portugal (R.A.C.)
| | - Rodrigo A Cunha
- Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands (A.P.IJ.); National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Molecular Recognition Section, Bethesda, Maryland (K.A.J.); Universität Bonn, Bonn, Germany (C.E.M.); New York University School of Medicine, New York, New York (B.N.C.); and Center for Neurosciences and Cell Biology and Faculty of Medicine, University of Coimbra, Coimbra, Portugal (R.A.C.)
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25
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Fopiano KA, Jalnapurkar S, Davila AC, Arora V, Bagi Z. Coronary Microvascular Dysfunction and Heart Failure with Preserved Ejection Fraction - implications for Chronic Inflammatory Mechanisms. Curr Cardiol Rev 2022; 18:e310821195986. [PMID: 34488616 PMCID: PMC9413735 DOI: 10.2174/1573403x17666210831144651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/01/2021] [Accepted: 06/14/2021] [Indexed: 11/22/2022] Open
Abstract
Coronary Microvascular Dysfunction (CMD) is now considered one of the key underlying pathologies responsible for the development of both acute and chronic cardiac complications. It has been long recognized that CMD contributes to coronary no-reflow, which occurs as an acute complication during percutaneous coronary interventions. More recently, CMD was proposed to play a mechanistic role in the development of left ventricle diastolic dysfunction in heart failure with preserved ejection fraction (HFpEF). Emerging evidence indicates that a chronic low-grade pro-inflammatory activation predisposes patients to both acute and chronic cardiovascular complications raising the possibility that pro-inflammatory mediators serve as a mechanistic link in HFpEF. Few recent studies have evaluated the role of the hyaluronan-CD44 axis in inflammation-related cardiovascular pathologies, thus warranting further investigations. This review article summarizes current evidence for the role of CMD in the development of HFpEF, focusing on molecular mediators of chronic proinflammatory as well as oxidative stress mechanisms and possible therapeutic approaches to consider for treatment and prevention.
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Affiliation(s)
- Katie Anne Fopiano
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Sawan Jalnapurkar
- Division of Cardiology, Department of Medicine, Medical College of Georgia, Augusta University Augusta, GA 30912, USA
| | - Alec C Davila
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Vishal Arora
- Division of Cardiology, Department of Medicine, Medical College of Georgia, Augusta University Augusta, GA 30912, USA
| | - Zsolt Bagi
- Department of Physiology, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
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Pieske B, Wachter R, Shah SJ, Baldridge A, Szeczoedy P, Ibram G, Shi V, Zhao Z, Cowie MR. Effect of Sacubitril/Valsartan vs Standard Medical Therapies on Plasma NT-proBNP Concentration and Submaximal Exercise Capacity in Patients With Heart Failure and Preserved Ejection Fraction: The PARALLAX Randomized Clinical Trial. JAMA 2021; 326:1919-1929. [PMID: 34783839 PMCID: PMC8596197 DOI: 10.1001/jama.2021.18463] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE There is limited evidence on the benefits of sacubitril/valsartan vs broader renin angiotensin system inhibitor background therapy on surrogate outcome markers, 6-minute walk distance, and quality of life in patients with heart failure and mildly reduced or preserved left ventricular ejection fraction (LVEF >40%). OBJECTIVE To evaluate the effect of sacubitril/valsartan on N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, 6-minute walk distance, and quality of life vs background medication-based individualized comparators in patients with chronic heart failure and LVEF of more than 40%. DESIGN, SETTING, AND PARTICIPANTS A 24-week, randomized, double-blind, parallel group clinical trial (August 2017-October 2019). Of 4632 patients screened at 396 centers in 32 countries, 2572 patients with heart failure, LVEF of more than 40%, elevated NT-proBNP levels, structural heart disease, and reduced quality of life were enrolled (last follow-up, October 28, 2019). INTERVENTIONS Patients were randomized 1:1 either to sacubitril/valsartan (n = 1286) or to background medication-based individualized comparator (n = 1286), ie, enalapril, valsartan, or placebo stratified by prior use of a renin angiotensin system inhibitor. MAIN OUTCOMES AND MEASURES Primary end points were change from baseline in plasma NT-proBNP level at week 12 and in the 6-minute walk distance at week 24. Secondary end points were change from baseline in quality of life measures and New York Heart Association (NYHA) class at 24 weeks. RESULTS Among 2572 randomized patients (mean age, 72.6 years [SD, 8.5 years]; 1301 women [50.7%]), 2240 (87.1%) completed the trial. At baseline, the median NT-proBNP levels were 786 pg/mL in the sacubitril/valsartan group and 760 pg/mL in the comparator group. After 12 weeks, patients in the sacubitril/valsartan group (adjusted geometric mean ratio to baseline, 0.82 pg/mL) had a significantly greater reduction in NT-proBNP levels than did those in the comparator group (adjusted geometric mean ratio to baseline, 0.98 pg/mL) with an adjusted geometric mean ratio of 0.84 (95% CI, 0.80 to 0.88; P < .001). At week 24, there was no significant between-group difference in median change from baseline in the 6-minute walk distance with an increase of 9.7 m vs 12.2 m (adjusted mean difference, -2.5 m; 95% CI, -8.5 to 3.5; P = .42). There was no significant between-group difference in the mean change in the Kansas City Cardiomyopathy Questionnaire clinical summary score (12.3 vs 11.8; mean difference, 0.52; 95% CI, -0.93 to 1.97) or improvement in NYHA class (23.6% vs 24.0% of patients; adjusted odds ratio, 0.98; 95% CI, 0.81 to 1.18). The most frequent adverse events in the sacubitril/valsartan group vs the comparator group were hypotension (14.1% vs 5.5%), albuminuria (12.3% vs 7.6%), and hyperkalemia (11.6% vs 10.9%). CONCLUSIONS AND RELEVANCE Among patients with heart failure and left ventricular ejection factor of higher than 40%, sacubitril/valsartan treatment compared with standard renin angiotensin system inhibitor treatment or placebo resulted in a significantly greater decrease in plasma N-terminal pro-brain natriuretic peptide levels at 12 weeks but did not significantly improve 6-minute walk distance at 24 weeks. Further research is warranted to evaluate potential clinical benefits of sacubitril/valsartan in these patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03066804.
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Affiliation(s)
- Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow Klinikum, Berlin, Germany
- Department of Internal Medicine and Cardiology, German Heart Center, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH), Berlin, Germany
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), partner site Göttingen, Göttingen, Germany
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Abigail Baldridge
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Peter Szeczoedy
- Novartis Pharma AG, Basel, Switzerland
- Now with Vifor Pharma Management Ltd, Glattbrugg, Switzerland
| | | | - Victor Shi
- Novartis Pharmaceuticals, East Hanover, New Jersey
| | | | - Martin R. Cowie
- Royal Brompton Hospital, London, United Kingdom
- School of Cardiovascular Medicine & Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, United Kingdom
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27
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Campos-Martins A, Bragança B, Correia-de-Sá P, Fontes-Sousa AP. Pharmacological Tuning of Adenosine Signal Nuances Underlying Heart Failure With Preserved Ejection Fraction. Front Pharmacol 2021; 12:724320. [PMID: 34489711 PMCID: PMC8417789 DOI: 10.3389/fphar.2021.724320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/04/2021] [Indexed: 12/30/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) roughly represents half of the cardiac failure events in developed countries. The proposed 'systemic microvascular paradigm' has been used to explain HFpHF presentation heterogeneity. The lack of effective treatments with few evidence-based therapeutic recommendations makes HFpEF one of the greatest unmet clinical necessities worldwide. The endogenous levels of the purine nucleoside, adenosine, increase significantly following cardiovascular events. Adenosine exerts cardioprotective, neuromodulatory, and immunosuppressive effects by activating plasma membrane-bound P1 receptors that are widely expressed in the cardiovascular system. Its proven benefits have been demonstrated in preclinical animal tests. Here, we provide a comprehensive and up-to-date critical review about the main therapeutic advantages of tuning adenosine signalling pathways in HFpEF, without discounting their side effects and how these can be seized.
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Affiliation(s)
- Alexandrina Campos-Martins
- Laboratório de Farmacologia e Neurobiologia, Centro de Investigação Farmacológica e Inovação Medicamentosa (MedInUP), Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto (ICBAS-UP), Porto, Portugal
| | - Bruno Bragança
- Laboratório de Farmacologia e Neurobiologia, Centro de Investigação Farmacológica e Inovação Medicamentosa (MedInUP), Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto (ICBAS-UP), Porto, Portugal.,Department of Cardiology, Centro Hospitalar Tâmega e Sousa, Penafiel, Portugal
| | - Paulo Correia-de-Sá
- Laboratório de Farmacologia e Neurobiologia, Centro de Investigação Farmacológica e Inovação Medicamentosa (MedInUP), Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto (ICBAS-UP), Porto, Portugal
| | - Ana Patrícia Fontes-Sousa
- Laboratório de Farmacologia e Neurobiologia, Centro de Investigação Farmacológica e Inovação Medicamentosa (MedInUP), Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto (ICBAS-UP), Porto, Portugal
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28
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Shah SJ, Cowie MR, Wachter R, Szecsödy P, Shi V, Ibram G, Hu M, Zhao Z, Gong J, Pieske B. Baseline characteristics of patients in the PARALLAX trial: insights into quality of life and exercise capacity in heart failure with preserved ejection fraction. Eur J Heart Fail 2021; 23:1541-1551. [PMID: 34170062 DOI: 10.1002/ejhf.2277] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 04/29/2021] [Accepted: 05/01/2021] [Indexed: 11/06/2022] Open
Abstract
AIMS We sought to describe the baseline characteristics of PARALLAX [a randomized controlled trial of sacubitril/valsartan vs. individualized medical therapy in heart failure (HF) with mildly reduced and preserved ejection fraction (HFpEF)]; compare PARALLAX to recent HFpEF trials; and examine the clinical characteristics associated with quality of life (QOL) and 6-min walk test distance (6MWD). METHODS AND RESULTS A total of 2566 patients with HF and left ventricular ejection fraction (LVEF) >40% were randomized, of whom 96% had an LVEF ≥45%. Multivariable linear regression was used to determine characteristics associated with Kansas City Cardiomyopathy Questionnaire clinical summary score (KCCQ-CSS) and 6MWD. Mean age was 73 ± 8 years, 51% were female, and comorbidities were common. Of the QOL measures tested in PARALLAX, the Short Form Health Survey-36 physical functioning score was most closely correlated with 6MWD (R = 0.41, P < 0.001), and outperformed the KCCQ physical limitation score (R = 0.33) and KCCQ-CSS (R = 0.31) on multivariable analyses. Female sex, higher body mass index, history of coronary artery disease, lower LVEF, and higher N-terminal pro-B-type natriuretic peptide (NT-proBNP) were associated with worse (lower) KCCQ-CSS; older age, female sex, higher body mass index, diabetes, coronary artery disease, chronic obstructive pulmonary disease, prior HF hospitalization, lower LVEF, and higher NT-proBNP were associated with shorter 6MWD (P < 0.05 for all associations). CONCLUSIONS PARALLAX is the largest HFpEF study to date to examine 6MWD together with QOL. The KCCQ-CSS and 6MWD were modestly correlated, and several factors were associated with worse values of both. These results provide insight into the association between QOL and exercise capacity in HFpEF.
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Affiliation(s)
- Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Martin R Cowie
- School of Cardiovascular Medicine & Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany.,Clinic for Cardiology and Pneumology, University Medicine Göttingen and DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | | | | | | | - Mo Hu
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité University Medicine, Berlin, Germany.,Department of Internal Medicine and Cardiology, German Heart Center; DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
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29
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Shah RV, Schoenike MW, Armengol de la Hoz MÁ, Cunningham TF, Blodgett JB, Tanguay M, Sbarbaro JA, Nayor M, Rouvina J, Kowal A, Houstis N, Baggish AL, Ho JE, Hardin C, Malhotra R, Larson MG, Vasan RS, Lewis GD. Metabolic Cost of Exercise Initiation in Patients With Heart Failure With Preserved Ejection Fraction vs Community-Dwelling Adults. JAMA Cardiol 2021; 6:653-660. [PMID: 33729454 DOI: 10.1001/jamacardio.2021.0292] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Heart failure with preserved ejection fraction (HFpEF) is a joint metabolic and cardiovascular disorder with significant noncardiac contributions. Objective To define and quantify the metabolic cost of initiating exercise in individuals with and without HFpEF and its functional consequences. Design, Setting, and Participants This prospective cohort study included individuals with hemodynamically confirmed HFpEF from the Massachusetts General Hospital Exercise Study (MGH-ExS) and community-dwelling participants from the Framingham Heart Study (FHS). Analysis began April 2016 and ended November 2020. Exposures Internal work (IW), a measure of work equivalents required to initiate movement. Main Outcomes and Measures Using breath-by-breath oxygen uptake (V̇o2) measurements and V̇o2-work rate associations, cost of initiating exercise (IW) in patients with HFpEF (MGH-ExS) and in community-dwelling individuals (FHS) was quantified. Linear regression was used to estimate associations between IW and clinical/hemodynamic measures. Results Of 3231 patients, 184 (5.7%) had HFpEF and were from MGH-ExS, and 3047 (94.3%) were community-dwelling individuals from FHS. In the MGH-ExS cohort, 86 (47%) were women, the median (interquartile range) age was 63 (53-72) years, and the median (interquartile range) peak V̇o2 level was 13.33 (11.77-15.62) mL/kg/min. In the FHS cohort, 1620 (53%) were women, the median (interquartile range) age was 54 (48-60) years, and the median (interquartile range) peak V̇o2 level was 22.2 (17.85-27.35) mL/kg/min. IW was higher in patients with HFpEF and accounted for 27% (interquartile range, 21%-39%) of the total work (IW + measured external workload on the cycle), compared with 15% (interquartile range, 12%-20%) of that in FHS participants. Body mass index accounted for greatest explained variance in patients with HFpEF from MGH-ExS and FHS participants (22% and 18%, respectively), while resting cardiac output and biventricular filling pressures were not significantly associated with variance in IW in patients with HFpEF. A higher IW in patients with HFpEF was associated with a greater increase in left- and right-sided cardiac filing pressure during unloaded exercise, despite similar resting hemodynamic measures across IW. Conclusions and Relevance This study found that internal work, a new body mass index-related measure reflecting the metabolic cost of initiating movement, is higher in individuals with HFpEF compared with middle-aged adults in the community and is associated with steep, early increases in cardiac filling pressures. These findings highlight the importance of quantifying heterogeneous responses to exercise initiation when evaluating functional intolerance in individuals at risk for or with HFpEF.
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Affiliation(s)
- Ravi V Shah
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Mark W Schoenike
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Miguel Á Armengol de la Hoz
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston.,MIT Critical Data, Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge.,Biomedical Engineering and Telemedicine Group, Biomedical Technology Centre CTB, ETSI Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Thomas F Cunningham
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jasmine B Blodgett
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Melissa Tanguay
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - John A Sbarbaro
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Matthew Nayor
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jennifer Rouvina
- Pulmonary Critical Care Unit, Massachusetts General Hospital, Boston
| | - Alyssa Kowal
- Pulmonary Critical Care Unit, Massachusetts General Hospital, Boston
| | - Nicholas Houstis
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Aaron L Baggish
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jennifer E Ho
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Corey Hardin
- Pulmonary Critical Care Unit, Massachusetts General Hospital, Boston
| | - Rajeev Malhotra
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Martin G Larson
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Ramachandran S Vasan
- Section of Preventive Medicine and Epidemiology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts.,Division of Cardiology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Gregory D Lewis
- Simches Cardiovascular Research Center, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston.,Pulmonary Critical Care Unit, Massachusetts General Hospital, Boston
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30
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Correale M, Tricarico L, Fortunato M, Mazzeo P, Nodari S, Di Biase M, Brunetti ND. New Targets in Heart Failure Drug Therapy. Front Cardiovasc Med 2021; 8:665797. [PMID: 34026873 PMCID: PMC8131549 DOI: 10.3389/fcvm.2021.665797] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/19/2021] [Indexed: 12/16/2022] Open
Abstract
Despite recent advances in chronic heart failure management (either pharmacological or non-pharmacological), the prognosis of heart failure (HF) patients remains poor. This poor prognosis emphasizes the need for developing novel pathways for testing new HF drugs, beyond neurohumoral and hemodynamic modulation approaches. The development of new drugs for HF therapy must thus necessarily focus on novel approaches such as the direct effect on cardiomyocytes, coronary microcirculation, and myocardial interstitium. This review summarizes principal evidence on new possible pharmacological targets for the treatment of HF patients, mainly focusing on microcirculation, cardiomyocyte, and anti-inflammatory therapy.
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Affiliation(s)
- Michele Correale
- Department of Cardiology, Policlinico Riuniti University Hospital, Foggia, Italy
| | - Lucia Tricarico
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Martino Fortunato
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Pietro Mazzeo
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Savina Nodari
- Cardiology Section, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Di Biase
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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31
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Graziani F, Lillo R, Crea F. Rationale for the Use of Pirfenidone in Heart Failure With Preserved Ejection Fraction. Front Cardiovasc Med 2021; 8:678530. [PMID: 33969025 PMCID: PMC8100203 DOI: 10.3389/fcvm.2021.678530] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/29/2021] [Indexed: 12/28/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a major public health problem with growing prevalence and poor outcomes, mainly due to the lack of an effective treatment. HFpEF pathophysiology is heterogeneous and complex. Recently a “new paradigm” has been proposed, suggesting that cardiovascular and non-cardiovascular coexisting comorbidities lead to a systemic inflammatory state, perturbing the physiology of the endothelium and the perivascular environment and engaging molecular pathways that ultimately converge to myocardial fibrosis. If inflammation and fibrosis are the “fil rouge” in the heterogeneous spectrum of HFpEF, anti-fibrotic and anti-inflammatory drugs may have a role in its treatment. Pirfenidone is an orally bioavailable drug with antifibrotic and anti-inflammatory properties already approved for the treatment of idiopathic pulmonary fibrosis. Pirfenidone has been recently tested in animal models of myocardial fibrosis with promising results. Here we will review the rationale underlying the potential therapeutic effect of Pirfenidone in HFpEF.
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Affiliation(s)
- Francesca Graziani
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Rosa Lillo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Catholic University of the Sacred Heart, Rome, Italy
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32
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Vaikunth SS, Lui GK. Heart failure with reduced and preserved ejection fraction in adult congenital heart disease. Heart Fail Rev 2021; 25:569-581. [PMID: 31873841 DOI: 10.1007/s10741-019-09904-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is common in patients with adult congenital heart disease. Many of the most common congenital defects have a high prevalence of HFrEF, including left-sided obstructive lesions (aortic stenosis, coarctation of the aorta, Shone complex), tetralogy of Fallot, Ebstein anomaly, lesions in which there is a systemic right ventricle, and lesions palliated with a Fontan circulation. However, heart failure with preserved ejection fraction (HFpEF) is also prevalent in all these lesions. Comprehensive evaluation includes physical exam, biomarkers, echocardiography and advanced imaging, exercise stress testing, and, in some cases, invasive hemodynamics. Guideline-directed medical therapy for HFrEF can be applied to left-sided lesions and may be considered on an individual basis for systemic right ventricle and single-ventricle patients. Medical therapy is limited for HFpEF. However, in both HFrEF and HFpEF, ventricular dyssynchrony and arrhythmias play an important role, and medications for rhythm control, ablation, and cardiac resynchronization therapy should be considered. Finally, aggressive management of cardiovascular risk factors and comorbidities, including, but not limited to, hypertension, obesity, diabetes, dyslipidemia, and obstructive sleep apnea, cannot be overemphasized.
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Affiliation(s)
- Sumeet S Vaikunth
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - George K Lui
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Palo Alto, CA, USA
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33
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Amelia T, van Veldhoven JPD, Falsini M, Liu R, Heitman LH, van Westen GJP, Segala E, Verdon G, Cheng RKY, Cooke RM, van der Es D, IJzerman AP. Crystal Structure and Subsequent Ligand Design of a Nonriboside Partial Agonist Bound to the Adenosine A 2A Receptor. J Med Chem 2021; 64:3827-3842. [PMID: 33764785 PMCID: PMC8154574 DOI: 10.1021/acs.jmedchem.0c01856] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
![]()
In this study, we
determined the crystal structure of an engineered
human adenosine A2A receptor bound to a partial agonist
and compared it to structures cocrystallized with either a full agonist
or an antagonist/inverse agonist. The interaction between the partial
agonist, belonging to a class of dicyanopyridines, and amino acids
in the ligand binding pocket inspired us to develop a small library
of derivatives and assess their affinity in radioligand binding studies
and potency and intrinsic activity in a functional, label-free, intact
cell assay. It appeared that some of the derivatives retained the
partial agonist profile, whereas other ligands turned into inverse
agonists. We rationalized this remarkable behavior with additional
computational docking studies.
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Affiliation(s)
- Tasia Amelia
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC Leiden, The Netherlands.,School of Pharmacy, Bandung Institute of Technology, Jalan Ganesha 10, 40132 Bandung, Indonesia
| | - Jacobus P D van Veldhoven
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC Leiden, The Netherlands
| | - Matteo Falsini
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC Leiden, The Netherlands
| | - Rongfang Liu
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC Leiden, The Netherlands
| | - Laura H Heitman
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC Leiden, The Netherlands
| | - Gerard J P van Westen
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC Leiden, The Netherlands
| | - Elena Segala
- Sosei Heptares, Steinmetz Building, Granta Park, Cambridge CB21 6DG, United Kingdom
| | - Grégory Verdon
- Sosei Heptares, Steinmetz Building, Granta Park, Cambridge CB21 6DG, United Kingdom
| | - Robert K Y Cheng
- Sosei Heptares, Steinmetz Building, Granta Park, Cambridge CB21 6DG, United Kingdom
| | - Robert M Cooke
- Sosei Heptares, Steinmetz Building, Granta Park, Cambridge CB21 6DG, United Kingdom
| | - Daan van der Es
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC Leiden, The Netherlands
| | - Adriaan P IJzerman
- Division of Drug Discovery and Safety, Leiden Academic Centre for Drug Research, Leiden University, Einsteinweg 55, 2333 CC Leiden, The Netherlands
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34
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Rueda P, Merlin J, Chimenti S, Feletou M, Paysant J, White PJ, Christopoulos A, Sexton PM, Summers RJ, Charman WN, May LT, Langmead CJ. Pharmacological Insights Into Safety and Efficacy Determinants for the Development of Adenosine Receptor Biased Agonists in the Treatment of Heart Failure. Front Pharmacol 2021; 12:628060. [PMID: 33776771 PMCID: PMC7991592 DOI: 10.3389/fphar.2021.628060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/26/2021] [Indexed: 11/13/2022] Open
Abstract
Adenosine A1 receptors (A1R) are a potential target for cardiac injury treatment due to their cardioprotective/antihypertrophic actions, but drug development has been hampered by on-target side effects such as bradycardia and altered renal hemodynamics. Biased agonism has emerged as an attractive mechanism for A1R-mediated cardioprotection that is haemodynamically safe. Here we investigate the pre-clinical pharmacology, efficacy and side-effect profile of the A1R agonist neladenoson, shown to be safe but ineffective in phase IIb trials for the treatment of heart failure. We compare this agent with the well-characterized, pan-adenosine receptor (AR) agonist NECA, capadenoson, and the A1R biased agonist VCP746, previously shown to be safe and cardioprotective in pre-clinical models of heart failure. We show that like VCP746, neladenoson is biased away from Ca2+ influx relative to NECA and the cAMP pathway at the A1R, a profile predictive of a lack of adenosine-like side effects. Additionally, neladenoson was also biased away from the MAPK pathway at the A1R. In contrast to VCP746, which displays more 'adenosine-like' signaling at the A2BR, neladenoson was a highly selective A1R agonist, with biased, weak agonism at the A2BR. Together these results show that unwanted hemodynamic effects of A1R agonists can be avoided by compounds biased away from Ca2+ influx relative to cAMP, relative to NECA. The failure of neladenoson to reach primary endpoints in clinical trials suggests that A1R-mediated cAMP inhibition may be a poor indicator of effectiveness in chronic heart failure. This study provides additional information that can aid future screening and/or design of improved AR agonists that are safe and efficacious in treating heart failure in patients.
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Affiliation(s)
- Patricia Rueda
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Jon Merlin
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Stefano Chimenti
- Cardiovascular Discovery Research Unit, Institut de Recherches Servier, Suresnes, France
| | - Michel Feletou
- Cardiovascular Discovery Research Unit, Institut de Recherches Servier, Suresnes, France
| | - Jerome Paysant
- Cardiovascular Discovery Research Unit, Institut de Recherches Servier, Suresnes, France
| | - Paul J. White
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Arthur Christopoulos
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Patrick M. Sexton
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Roger J. Summers
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - William N. Charman
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Lauren T. May
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
| | - Christopher J. Langmead
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
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McNeill SM, Baltos JA, White PJ, May LT. Biased agonism at adenosine receptors. Cell Signal 2021; 82:109954. [PMID: 33610717 DOI: 10.1016/j.cellsig.2021.109954] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/11/2021] [Accepted: 02/13/2021] [Indexed: 01/14/2023]
Abstract
Adenosine modulates many aspects of human physiology and pathophysiology through binding to the adenosine family of G protein-coupled receptors, which are comprised of four subtypes, the A1R, A2AR, A2BR and A3R. Modulation of adenosine receptor function by exogenous agonists, antagonists and allosteric modulators can be beneficial for a number of conditions including cardiovascular disease, Parkinson's disease, and cancer. Unfortunately, many preclinical drug candidates targeting adenosine receptors have failed in clinical trials due to limited efficacy and/or severe on-target undesired effects. To overcome the key barriers typically encountered when transitioning adenosine receptor ligands into the clinic, research efforts have focussed on exploiting the phenomenon of biased agonism. Biased agonism provides the opportunity to develop ligands that favour therapeutic signalling pathways, whilst avoiding signalling associated with on-target undesired effects. Recent studies have begun to define the structure-function relationships that underpin adenosine receptor biased agonism and establish how this phenomenon can be harnessed therapeutically. In this review we describe the recent advancements made towards achieving therapeutically relevant biased agonism at adenosine receptors.
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Affiliation(s)
- Samantha M McNeill
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Jo-Anne Baltos
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia; Department of Pharmacology, Monash University, Melbourne, VIC, Australia.
| | - Paul J White
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia
| | - Lauren T May
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Melbourne, VIC, Australia; Department of Pharmacology, Monash University, Melbourne, VIC, Australia.
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Azhar G, Wei JY, Schutzler SE, Coker K, Gibson RV, Kirby MF, Ferrando AA, Wolfe RR. Daily Consumption of a Specially Formulated Essential Amino Acid-Based Dietary Supplement Improves Physical Performance in Older Adults With Low Physical Functioning. J Gerontol A Biol Sci Med Sci 2021; 76:1184-1191. [PMID: 33475727 DOI: 10.1093/gerona/glab019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Indexed: 02/07/2023] Open
Abstract
We have investigated the hypothesis that nutritional supplementation of the diet in low-physical-functioning older individuals with a specially formulated composition based on essential amino acids (EAAs) would improve physical function as compared to supplementation with the same amount of whey protein. A third group of comparable volunteers were given nutrition education but no supplementation of the diet. After 6 weeks of whey protein supplementation (n = 32), there was no effect on the distance walked in 6 minutes, but the distance walked improved significantly from the pre-value after 12 weeks of whey supplementation. EAA consumption (n = 28) significantly improved walking distance at both 6 and 12 weeks. The distance walked at 12 weeks (419.0 ± 25.0 m) was 35.4 m greater than the pre-value of 384.0 ± 23.0 m (p < .001). The increase in distance walked by the EAA group was also significantly greater than that in the whey group at both 6 and 12 weeks (p < .01). In contrast, a decrease in distance walked was observed in the control group (n = 32) (not statistically significant, NS). EAA supplementation also improved grip strength and leg strength, and decreased body weight and fat mass. Plasma low-density lipoprotein concentration was significantly reduced in the EAA group, as well as the concentration of macrophage migration inhibitory factor. There were no adverse responses in any groups, and compliance was greater than 95% in all individuals consuming supplements. We conclude that dietary supplementation with an EAA-based composition may be a beneficial therapy in older individuals with low physical functional capacity. Clinical Trials Registration Number: This study was registered with ClinicalTrials.gov: NCT03424265-"Nutritional interventions in heart failure."
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Affiliation(s)
- Gohar Azhar
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Jeanne Y Wei
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Scott E Schutzler
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Karen Coker
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Regina V Gibson
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Mitchell F Kirby
- Department of Dietetics and Nutrition, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Arny A Ferrando
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Robert R Wolfe
- Department of Geriatrics, Donald W. Reynolds Institute on Aging, University of Arkansas for Medical Sciences, Little Rock, USA
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Bisaccia G, Ricci F, Gallina S, Di Baldassarre A, Ghinassi B. Mitochondrial Dysfunction and Heart Disease: Critical Appraisal of an Overlooked Association. Int J Mol Sci 2021; 22:ijms22020614. [PMID: 33435429 PMCID: PMC7827742 DOI: 10.3390/ijms22020614] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/03/2021] [Accepted: 01/07/2021] [Indexed: 12/11/2022] Open
Abstract
The myocardium is among the most energy-consuming tissues in the body, burning from 6 to 30 kg of ATP per day within the mitochondria, the so-called powerhouse of the cardiomyocyte. Although mitochondrial genetic disorders account for a small portion of cardiomyopathies, mitochondrial dysfunction is commonly involved in a broad spectrum of heart diseases, and it has been implicated in the development of heart failure via maladaptive circuits producing and perpetuating mitochondrial stress and energy starvation. In this bench-to-bedside review, we aimed to (i) describe the key functions of the mitochondria within the myocardium, including their role in ischemia/reperfusion injury and intracellular calcium homeostasis; (ii) examine the contribution of mitochondrial dysfunction to multiple cardiac disease phenotypes and their transition to heart failure; and (iii) discuss the rationale and current evidence for targeting mitochondrial function for the treatment of heart failure, including via sodium-glucose cotransporter 2 inhibitors.
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Affiliation(s)
- Giandomenico Bisaccia
- MIUR Department of Excellence, Department of Neuroscience, Imaging and Clinical Sciences, University “G.d’Annunzio” of Chieti-Pescara, Via Luigi Polacchi, 11-66100 Chieti, Italy; (G.B.); (S.G.)
| | - Fabrizio Ricci
- MIUR Department of Excellence, Department of Neuroscience, Imaging and Clinical Sciences, University “G.d’Annunzio” of Chieti-Pescara, Via Luigi Polacchi, 11-66100 Chieti, Italy; (G.B.); (S.G.)
- Department of Clinical Sciences, Lund University, E-205 02 Malmö, Sweden
- Casa di Cura Villa Serena, Città Sant’Angelo, 65013 Pescara, Italy
- Correspondence: ; Tel./Fax: +39-871-355-6922
| | - Sabina Gallina
- MIUR Department of Excellence, Department of Neuroscience, Imaging and Clinical Sciences, University “G.d’Annunzio” of Chieti-Pescara, Via Luigi Polacchi, 11-66100 Chieti, Italy; (G.B.); (S.G.)
| | - Angela Di Baldassarre
- Department of Medicine and Aging Sciences, University “G.d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (A.D.B.); (B.G.)
| | - Barbara Ghinassi
- Department of Medicine and Aging Sciences, University “G.d’Annunzio” of Chieti-Pescara, 66100 Chieti, Italy; (A.D.B.); (B.G.)
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Vincenzi F, Pasquini S, Battistello E, Merighi S, Gessi S, Borea PA, Varani K. A 1 Adenosine Receptor Partial Agonists and Allosteric Modulators: Advancing Toward the Clinic? Front Pharmacol 2020; 11:625134. [PMID: 33362567 PMCID: PMC7756085 DOI: 10.3389/fphar.2020.625134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 11/17/2020] [Indexed: 11/21/2022] Open
Affiliation(s)
- Fabrizio Vincenzi
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Silvia Pasquini
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Enrica Battistello
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Stefania Merighi
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Stefania Gessi
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | | | - Katia Varani
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
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Del Buono MG, Iannaccone G, Scacciavillani R, Carbone S, Camilli M, Niccoli G, Borlaug BA, Lavie CJ, Arena R, Crea F, Abbate A. Heart failure with preserved ejection fraction diagnosis and treatment: An updated review of the evidence. Prog Cardiovasc Dis 2020; 63:570-584. [DOI: 10.1016/j.pcad.2020.04.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 04/19/2020] [Indexed: 12/20/2022]
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Pagel PS, Tawil JN, Boettcher BT, Izquierdo DA, Lazicki TJ, Crystal GJ, Freed JK. Heart Failure With Preserved Ejection Fraction: A Comprehensive Review and Update of Diagnosis, Pathophysiology, Treatment, and Perioperative Implications. J Cardiothorac Vasc Anesth 2020; 35:1839-1859. [PMID: 32747202 DOI: 10.1053/j.jvca.2020.07.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/15/2020] [Accepted: 07/02/2020] [Indexed: 02/07/2023]
Abstract
Almost three-quarters of all heart failure patients who are older than 65 have heart failure with preserved ejection fraction (HFpEF). The proportion and hospitalization rate of patients with HFpEF are increasing steadily relative to patients in whom heart failure occurs as result of reduced ejection fraction. The predominance of the HFpEF phenotype most likely is explained by the prevalence of medical conditions associated with an aging population. A multitude of age-related, medical, and lifestyle risk factors for HFpEF have been identified as potential causes for the sustained low-grade proinflammatory state that accelerates disease progression. Profound left ventricular (LV) systolic and diastolic stiffening, elevated LV filling pressures, reduced arterial compliance, left atrial hypertension, pulmonary venous congestion, and microvascular dysfunction characterize HFpEF, but pulmonary arterial hypertension, right ventricular dilation and dysfunction, and atrial fibrillation also frequently occur. These cardiovascular features make patients with HFpEF exquisitely sensitive to the development of hypotension in response to acute declines in LV preload or afterload that may occur during or after surgery. With the exception of symptom mitigation, lifestyle modifications, and rigorous control of comorbid conditions, few long-term treatment options exist for these unfortunate individuals. Patients with HFpEF present for surgery on a regular basis, and anesthesiologists need to be familiar with this heterogeneous and complex clinical syndrome to provide successful care. In this article, the authors review the diagnosis, pathophysiology, and treatment of HFpEF and also discuss its perioperative implications.
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Affiliation(s)
- Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
| | - Justin N Tawil
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Brent T Boettcher
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - David A Izquierdo
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Timothy J Lazicki
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - George J Crystal
- Department of Anesthesiology, University of Illinois College of Medicine, Chicago, IL
| | - Julie K Freed
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
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41
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Kokhan EV, Kiyakbaev GK, Kobalava ZD. [Frequency of use and Indications for Beta-Blockers in Heart Failure with Preserved Ejection Fraction]. KARDIOLOGIIA 2020; 60:30-40. [PMID: 32720613 DOI: 10.18087/cardio.2020.6.n1062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/20/2020] [Indexed: 06/11/2023]
Abstract
Aim To evaluate trends in beta-blocker prescribing and incidence of possible reasons for beta-blocker administration, including arterial hypertension (AH), atrial fibrillation (AF), ischemic heart disease (IHD), and myocardial infarction, in participants of clinical studies enrolling patients with chronic heart failure with preserved ejection fraction (CHF-PEF).Material and methods A systematic literature search was performed in the PubMed and EMBASE databases. The study included RCSs of pharmacological therapies for patients with CHF-PEF conducted from 1993 through 2019. Studies of beta-blocker efficacy or those including a specific population (CHF-PEF+IHD or CHF-PEF+AH, etc.) were excluded from the analysis. Baseline characteristics of patients, incidence rate of beta-blocker prescribing, and prevalence of AH, AF, IHD, and MI were recorded. Trends in prevalence of concomitant diseases and the proportion of patients using beta-blockers by the year of enrollment to the study were analyzed with the Mann-Kendall test.Results 14 RCSs of 718 selected publications completely met the inclusion and exclusion criteria. Beta-blocker prescribing significantly increased between 1993 and 2019 (tau=0.51; p=0.014) and reached 80 % in recent studies. Furthermore, prevalence of IHD, MI, AH, and AF did not significantly change among the RCS participants (p>0.05 for all). However, while for AH and AF, a tendency toward an increasing prevalence (tau=0.4; p=0.055 and tau=0.043; p=0.063, respectively) could be considered and became statistically significant for AF when the ALDO-DHF study was excluded from the analysis (tau=0.5; p=0.042), the MI prevalence tended to decrease (tau= -0.73; p=0.06).Conclusion Beta-blocker prescribing to patients upon inclusion into RCSs for CHF-PEF has significantly increased for the recent 20 years while the incidence of formal reasons for beta-blocker administration (AF, AH, MI, IHD) did not significantly change.
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Affiliation(s)
- E V Kokhan
- Peoples' Friendship University of Russia (RUDN University), Russia, Moscow
| | - G K Kiyakbaev
- Peoples' Friendship University of Russia (RUDN University), Russia, Moscow
| | - Zh D Kobalava
- Peoples' Friendship University of Russia (RUDN University), Russia, Moscow
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Wachter R, Shah SJ, Cowie MR, Szecsödy P, Shi V, Ibram G, Zhao Z, Gong J, Klebs S, Pieske B. Angiotensin receptor neprilysin inhibition versus individualized RAAS blockade: design and rationale of the PARALLAX trial. ESC Heart Fail 2020; 7:856-864. [PMID: 32297449 PMCID: PMC7261527 DOI: 10.1002/ehf2.12694] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/09/2020] [Accepted: 03/12/2020] [Indexed: 12/11/2022] Open
Abstract
Aims Although the effect of the angiotensin receptor blocker neprilysin inhibitor (ARNI) sacubitril/valsartan on heart failure (HF) hospitalizations and cardiovascular death has been evaluated, its effects on functional capacity in patients with HF and ejection fraction (EF) >40% has yet to be determined. In addition, no prior studies have compared sacubitril/valsartan with angiotensin‐converting enzyme inhibitor therapy. We sought to compare the effect of ARNI to background‐medication‐based individualized comparators (BMICs) on N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP), functional capacity [6 min walk distance (6MWD)], symptoms, and quality of life [Kansas City Cardiomyopathy Questionnaire (KCCQ)] in patients with HF and EF >40% in a randomized clinical trial. Methods PARALLAX is a prospective, randomized, controlled, double‐blind multicentre clinical trial in patients with chronic symptomatic HF with EF >40%, New York Heart Association (NYHA) class II–IV symptoms, elevated natriuretic peptides, and evidence of structural heart disease. Eligible patients are randomized to sacubitril/valsartan vs. BMIC for cardiovascular and related co‐morbidities. BMIC includes (i) enalapril, (ii) valsartan, and (iii) placebo depending on the type of medical therapy prior to enrolment. The primary endpoints are the change in plasma NT‐proBNP concentration from baseline to 12 weeks and the change from baseline in 6MWD distance at 24 weeks. The secondary endpoints assess quality of life and symptom burden. Conclusions PARALLAX will determine if sacubitril/valsartan compared with standard medical therapy for co‐morbidities improves NT‐proBNP levels, exercise capacity, quality of life, and symptom burden in HF patients with EF >40%.
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Affiliation(s)
- Rolf Wachter
- Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany.,Clinic for Cardiology and Pneumology, University Medical Center Göttingen and DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Martin R Cowie
- Faculty of Medicine, National Heart & Lung Institute, Imperial College, London, UK
| | | | - Victor Shi
- Novartis, East Hanover EastHanover NJ, USA
| | | | | | | | - Sven Klebs
- Novartis Pharma GmbH, Nuremberg, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité University Medicine Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, German Heart Center, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany.,Clinical Research Unit Cardiology, Berlin Institute of Health, Berlin, Germany
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43
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Borlaug BA. Evaluation and management of heart failure with preserved ejection fraction. Nat Rev Cardiol 2020; 17:559-573. [DOI: 10.1038/s41569-020-0363-2] [Citation(s) in RCA: 168] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/02/2020] [Indexed: 01/19/2023]
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Dal Ben D, Lambertucci C, Buccioni M, Martí Navia A, Marucci G, Spinaci A, Volpini R. Non-Nucleoside Agonists of the Adenosine Receptors: An Overview. Pharmaceuticals (Basel) 2019; 12:E150. [PMID: 31597388 PMCID: PMC6958362 DOI: 10.3390/ph12040150] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/03/2019] [Accepted: 10/05/2019] [Indexed: 12/17/2022] Open
Abstract
Potent and selective adenosine receptor (AR) agonists are of pharmacological interest for the treatment of a wide range of diseases and conditions. Among these derivatives, nucleoside-based agonists represent the great majority of molecules developed and reported to date. However, the limited availability of compounds selective for a specific AR subtype (i.e., A2BAR) and a generally long and complex synthetic route for largely substituted nucleosides are the main drawbacks of this category of molecules. Non-nucleoside agonists represent an alternative set of compounds able to stimulate the AR function and based on simplified structures. This review provides an updated overview on the structural classes of non-nucleoside AR agonists and their biological activities, with emphasis on the main derivatives reported in the literature. A focus is also given to the synthetic routes employed to develop these derivatives and on molecular modeling studies simulating their interaction with ARs.
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Affiliation(s)
- Diego Dal Ben
- School of Pharmacy, Medicinal Chemistry Unit, University of Camerino, 62032 Camerino (MC), Italy.
| | - Catia Lambertucci
- School of Pharmacy, Medicinal Chemistry Unit, University of Camerino, 62032 Camerino (MC), Italy.
| | - Michela Buccioni
- School of Pharmacy, Medicinal Chemistry Unit, University of Camerino, 62032 Camerino (MC), Italy.
| | - Aleix Martí Navia
- School of Pharmacy, Medicinal Chemistry Unit, University of Camerino, 62032 Camerino (MC), Italy.
| | - Gabriella Marucci
- School of Pharmacy, Medicinal Chemistry Unit, University of Camerino, 62032 Camerino (MC), Italy.
| | - Andrea Spinaci
- School of Pharmacy, Medicinal Chemistry Unit, University of Camerino, 62032 Camerino (MC), Italy.
| | - Rosaria Volpini
- School of Pharmacy, Medicinal Chemistry Unit, University of Camerino, 62032 Camerino (MC), Italy.
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Davila A, Tian Y, Czikora I, Li J, Su H, Huo Y, Patel V, Robinson V, Kapuku G, Weintraub N, Bagi Z. Adenosine Kinase Inhibition Augments Conducted Vasodilation and Prevents Left Ventricle Diastolic Dysfunction in Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2019; 12:e005762. [PMID: 31525084 DOI: 10.1161/circheartfailure.118.005762] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is often manifested as impaired cardiovascular reserve. We sought to determine if conducted vasodilation, which coordinates microvascular resistance longitudinally to match tissue metabolic demand, becomes compromised in HFpEF. We hypothesized that the metabolic vasodilator adenosine facilitates and that inhibition of ADK (adenosine kinase) augments conducted vasodilation for a more efficient myocardial perfusion and improved left ventricle (LV) diastolic function in HFpEF. METHODS AND RESULTS We assessed conducted vasodilation in obese ZSF1 rats that develop LV diastolic dysfunction and is used to model human HFpEF. Additionally, conducted vasodilation was measured in arterioles isolated from the right atrial appendages of patients with HFpEF. We found a markedly reduced conducted vasodilation both in obese ZSF1 rats and in patients with HFpEF. Impaired conducted vasodilation was accompanied by increased vascular ADK expression. Isolated rat and human arterioles incubated with adenosine (10 nmol/L) or ADK inhibitor ABT-702 (0.1 µmol/L) both displayed augmented conducted vasodilation. Treatment of obese ZSF1 rats with ABT-702 (1.5 mg/kg, IP for 8 weeks) prevented LV diastolic dysfunction, and in a crossover design augmented conducted vasodilation and improved LV diastolic function. ABT-702 treated obese ZSF1 rats exhibited reduced expression of myocardial carbonic anhydrase 9 and collagen, surrogate markers of myocardial hypoxia. CONCLUSIONS Upregulation of vascular ADK mitigates adenosine-facilitated conducted vasodilation in obese ZSF1 rats and in patients with HFpEF. We propose that pharmacological inhibition of ADK could be beneficial for therapeutic augmentation of conducted vasodilation, thereby improving tissue perfusion and LV diastolic function in HFpEF.
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Affiliation(s)
- Alec Davila
- Department of Physiology (A.D., Y.T., I.C., Z.B.), Medical College of Georgia, Augusta University
| | - Yanna Tian
- Department of Physiology (A.D., Y.T., I.C., Z.B.), Medical College of Georgia, Augusta University
| | - Istvan Czikora
- Department of Physiology (A.D., Y.T., I.C., Z.B.), Medical College of Georgia, Augusta University
| | - Jie Li
- Vascular Biology Center (J.L., H.S., Y.H., N.W.), Medical College of Georgia, Augusta University
| | - Huabo Su
- Vascular Biology Center (J.L., H.S., Y.H., N.W.), Medical College of Georgia, Augusta University
| | - Yuqing Huo
- Vascular Biology Center (J.L., H.S., Y.H., N.W.), Medical College of Georgia, Augusta University
| | - Vijay Patel
- Department of Surgery (V.P.), Medical College of Georgia, Augusta University
| | - Vincent Robinson
- Division of Cardiology (V.R., N.W.), Medical College of Georgia, Augusta University
| | - Gaston Kapuku
- Department of Medicine, Georgia Prevention Institute, Department of Population Health Sciences (G.K.), Medical College of Georgia, Augusta University
| | - Neal Weintraub
- Vascular Biology Center (J.L., H.S., Y.H., N.W.), Medical College of Georgia, Augusta University.,Division of Cardiology (V.R., N.W.), Medical College of Georgia, Augusta University
| | - Zsolt Bagi
- Department of Physiology (A.D., Y.T., I.C., Z.B.), Medical College of Georgia, Augusta University
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