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Schroeder L, Monno P, Unger M, Ackerl J, Shatilova O, Schmitt J, Dresbach T, Mueller A, Kipfmueller F. Heart rate control with landiolol hydrochloride in infants with ventricular dysfunction and pulmonary hypertension. ESC Heart Fail 2022; 10:385-396. [PMID: 36256500 PMCID: PMC9871696 DOI: 10.1002/ehf2.14202] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/30/2022] [Accepted: 10/02/2022] [Indexed: 01/27/2023] Open
Abstract
AIMS Sinus tachycardia potentially leads to a deterioration of cardiac function in critically ill infants. The ultrashort-acting beta-blocker landiolol hydrochloride is a new pharmacological option for a selective heart rate (HR) control in patients with sinus tachycardia and heart failure. METHODS AND RESULTS This study was a monocentric retrospective medical chart review study at the University Children's Hospital Bonn (Germany) from 01 January 2018 until 30 June 2020. This study included a cohort of 62 term and preterm infants with a diagnosis of ventricular dysfunction and/or pulmonary hypertension (PH), in combination with preexisting tachycardia and treatment with landiolol hydrochloride. Infants were allocated to subgroups according to weeks of gestational age (GA): born at <35 weeks of GA (Group A) and born at >35 weeks of GA (Group B). Tachycardia was defined depending on GA (<35 weeks of GA: >170 b.p.m.; ≥ 35 weeks of GA: >150 b.p.m.). The primary endpoint was defined as percentage of patients achieving HR normalization during the first 24 h of landiolol treatment. Twenty-nine infants were allocated to Group A and 33 infants to Group B. The overall median GA of the infants was 35.3 (23.3/41.3), with 53% female infants. The primary endpoint was achieved in 57 patients (91.9%). The median time to reach target HR was 1.8 (0.3-24) h. The median starting dose of landiolol was 8.8 (3.9-25.3) μk/kg/min, with a median dosing during the first 24 h of landiolol treatment of 9.9 (2.8-35.4) μk/kg/min. The median landiolol dose while achieving the target HR was 10 (2.4-44.4) μk/kg/min. The right ventricular dysfunction improved significantly in both groups 24 h after onset of landiolol infusion (P = 0.001 in Group A and P = 0.045 in Group B). The left ventricular and biventricular dysfunction improved significantly 24 h after onset of landiolol infusion in infants of Group B (P = 0.004 and P = 0.006, respectively). The severity of PH improved significantly after 24 h in infants of Group A (P < 0.001). During landiolol treatment, no severe drug-related adverse event was noted. CONCLUSIONS The use of landiolol hydrochloride for HR control of non-arrhythmic tachycardia in critically ill infants is well tolerated. Reduction of HR can be guided quickly and landiolol treatment is associated with an improvement of ventricular dysfunction and PH.
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Affiliation(s)
- Lukas Schroeder
- Department of Neonatology and Pediatric Intensive Care MedicineUniversity Children's Hospital BonnVenusberg‐Campus 1D‐53127BonnGermany
| | - Paulina Monno
- Department of Neonatology and Pediatric Intensive Care MedicineUniversity Children's Hospital BonnVenusberg‐Campus 1D‐53127BonnGermany
| | | | | | | | - Joachim Schmitt
- Department of Neonatology and Pediatric Intensive Care MedicineUniversity Children's Hospital BonnVenusberg‐Campus 1D‐53127BonnGermany
| | - Till Dresbach
- Department of Neonatology and Pediatric Intensive Care MedicineUniversity Children's Hospital BonnVenusberg‐Campus 1D‐53127BonnGermany
| | - Andreas Mueller
- Department of Neonatology and Pediatric Intensive Care MedicineUniversity Children's Hospital BonnVenusberg‐Campus 1D‐53127BonnGermany
| | - Florian Kipfmueller
- Department of Neonatology and Pediatric Intensive Care MedicineUniversity Children's Hospital BonnVenusberg‐Campus 1D‐53127BonnGermany
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Abstract
Patients with advanced heart failure suffer from severe and persistent symptoms, often not responding disease-modifying drugs, a marked limitation of functional capacity and poor quality of life that can ameliorate with inotropic drugs therapy. In small studies, pulsed infusions of classical inotropes (ie, dobutamine and milrinone) are associated with improvement in hemodynamic parameters and quality of life in patients with advanced heart failure. However, because of the adverse effects of these drugs, serious safety issues have been raised. Levosimendan is a calcium-sensitizing inodilators with a triple mechanism of action, whose infusion results in hemodynamic, neurohormonal, and inflammatory cytokine improvements in patients with chronic advanced HF. In addition, levosimendan has important pleiotropic effects, including protection of myocardial, renal, and liver cells from ischemia-reperfusion injury, and anti-inflammatory and antioxidant effects; these properties possibly make levosimendan an "organ protective" inodilator. In clinical trials and real-world evidence, infusion of levosimendan at fixed intervals is safe and effective in patients with advanced HF, alleviating clinical symptoms, reducing hospitalizations, and improving the quality of life. Therefore, the use of repeated doses of levosimendan could represent the therapy of choice as a bridge to transplant/left ventricular assist device implantation or as palliative therapy in patients with advanced heart failure.
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McCrink KA, Maning J, Vu A, Jafferjee M, Marrero C, Brill A, Bathgate-Siryk A, Dabul S, Koch WJ, Lymperopoulos A. β-Arrestin2 Improves Post-Myocardial Infarction Heart Failure via Sarco(endo)plasmic Reticulum Ca 2+-ATPase-Dependent Positive Inotropy in Cardiomyocytes. Hypertension 2017; 70:972-981. [PMID: 28874462 DOI: 10.1161/hypertensionaha.117.09817] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 06/25/2017] [Accepted: 07/14/2017] [Indexed: 12/21/2022]
Abstract
Heart failure is the leading cause of death in the Western world, and new and innovative treatments are needed. The GPCR (G protein-coupled receptor) adapter proteins βarr (β-arrestin)-1 and βarr-2 are functionally distinct in the heart. βarr1 is cardiotoxic, decreasing contractility by opposing β1AR (adrenergic receptor) signaling and promoting apoptosis/inflammation post-myocardial infarction (MI). Conversely, βarr2 inhibits apoptosis/inflammation post-MI but its effects on cardiac function are not well understood. Herein, we sought to investigate whether βarr2 actually increases cardiac contractility. Via proteomic investigations in transgenic mouse hearts and in H9c2 rat cardiomyocytes, we have uncovered that βarr2 directly interacts with SERCA2a (sarco[endo]plasmic reticulum Ca2+-ATPase) in vivo and in vitro in a β1AR-dependent manner. This interaction causes acute SERCA2a SUMO (small ubiquitin-like modifier)-ylation, increasing SERCA2a activity and thus, cardiac contractility. βarr1 lacks this effect. Moreover, βarr2 does not desensitize β1AR cAMP-dependent procontractile signaling in cardiomyocytes, again contrary to βarr1. In vivo, post-MI heart failure mice overexpressing cardiac βarr2 have markedly improved cardiac function, apoptosis, inflammation, and adverse remodeling markers, as well as increased SERCA2a SUMOylation, levels, and activity, compared with control animals. Notably, βarr2 is capable of ameliorating cardiac function and remodeling post-MI despite not increasing cardiac βAR number or cAMP levels in vivo. In conclusion, enhancement of cardiac βarr2 levels/signaling via cardiac-specific gene transfer augments cardiac function safely, that is, while attenuating post-MI remodeling. Thus, cardiac βarr2 gene transfer might be a novel, safe positive inotropic therapy for both acute and chronic post-MI heart failure.
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Affiliation(s)
- Katie A McCrink
- From the Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL (K.A.M., J.M., A.V., M.J., C.M., A.B., A.B.-S., S.D., A.L.); and Department of Pharmacology, Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (W.J.K.)
| | - Jennifer Maning
- From the Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL (K.A.M., J.M., A.V., M.J., C.M., A.B., A.B.-S., S.D., A.L.); and Department of Pharmacology, Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (W.J.K.)
| | - Angela Vu
- From the Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL (K.A.M., J.M., A.V., M.J., C.M., A.B., A.B.-S., S.D., A.L.); and Department of Pharmacology, Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (W.J.K.)
| | - Malika Jafferjee
- From the Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL (K.A.M., J.M., A.V., M.J., C.M., A.B., A.B.-S., S.D., A.L.); and Department of Pharmacology, Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (W.J.K.)
| | - Christine Marrero
- From the Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL (K.A.M., J.M., A.V., M.J., C.M., A.B., A.B.-S., S.D., A.L.); and Department of Pharmacology, Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (W.J.K.)
| | - Ava Brill
- From the Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL (K.A.M., J.M., A.V., M.J., C.M., A.B., A.B.-S., S.D., A.L.); and Department of Pharmacology, Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (W.J.K.)
| | - Ashley Bathgate-Siryk
- From the Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL (K.A.M., J.M., A.V., M.J., C.M., A.B., A.B.-S., S.D., A.L.); and Department of Pharmacology, Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (W.J.K.)
| | - Samalia Dabul
- From the Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL (K.A.M., J.M., A.V., M.J., C.M., A.B., A.B.-S., S.D., A.L.); and Department of Pharmacology, Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (W.J.K.)
| | - Walter J Koch
- From the Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL (K.A.M., J.M., A.V., M.J., C.M., A.B., A.B.-S., S.D., A.L.); and Department of Pharmacology, Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (W.J.K.)
| | - Anastasios Lymperopoulos
- From the Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University College of Pharmacy, Fort Lauderdale, FL (K.A.M., J.M., A.V., M.J., C.M., A.B., A.B.-S., S.D., A.L.); and Department of Pharmacology, Center for Translational Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (W.J.K.).
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Abstract
OBJECTIVES The objectives of this review are to discuss the paradigms used to stage heart failure in children, the classification and physiologic profile of cardiomyopathies, and the acute and chronic pharmacologic management of heart failure. DATA SOURCE MEDLINE, PubMed. CONCLUSION The etiology of chronic heart failure in pediatrics is vast. The paradigm of extrapolating adult clinical trials and technological advancements to treat heart failure in children has become a nonsustainable model. The field of pediatric heart failure continues to advance with more robust guideline-directed care and the imminent creation of a dynamic, contemporary international database. As the field involves a markedly heterogeneous patient population, it is imperative to use pediatric specific descriptors of disease impact. The fields of pediatric heart failure and critical care medicine will continue to evolve together as childhood specific registries, quality improvement guidelines, and research will lead to practice models eliciting optimal therapy for patients with heart failure in the intensive care setting.
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Jaiswal A, Nguyen VQ, Le Jemtel TH, Ferdinand KC. Novel role of phosphodiesterase inhibitors in the management of end-stage heart failure. World J Cardiol 2016; 8:401-412. [PMID: 27468333 PMCID: PMC4958691 DOI: 10.4330/wjc.v8.i7.401] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 04/28/2016] [Accepted: 06/02/2016] [Indexed: 02/06/2023] Open
Abstract
In advanced heart failure (HF), chronic inotropic therapy with intravenous milrinone, a phosphodiesterase III inhibitor, is used as a bridge to advanced management that includes transplantation, ventricular assist device implantation, or palliation. This is especially true when repeated attempts to wean off inotropic support result in symptomatic hypotension, worsened symptoms, and/or progressive organ dysfunction. Unfortunately, patients in this clinical predicament are considered hemodynamically labile and may escape the benefits of guideline-directed HF therapy. In this scenario, chronic milrinone infusion may be beneficial as a bridge to introduction of evidence based HF therapy. However, this strategy is not well studied, and in general, chronic inotropic infusion is discouraged due to potential cardiotoxicity that accelerates disease progression and proarrhythmic effects that increase sudden death. Alternatively, chronic inotropic support with milrinone infusion is a unique opportunity in advanced HF. This review discusses evidence that long-term intravenous milrinone support may allow introduction of beta blocker (BB) therapy. When used together, milrinone does not attenuate the clinical benefits of BB therapy while BB mitigates cardiotoxic effects of milrinone. In addition, BB therapy decreases the risk of adverse arrhythmias associated with milrinone. We propose that advanced HF patients who are intolerant to BB therapy may benefit from a trial of intravenous milrinone as a bridge to BB initiation. The discussed clinical scenarios demonstrate that concomitant treatment with milrinone infusion and BB therapy does not adversely impact standard HF therapy and may improve left ventricular function and morbidity associated with advanced HF.
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6
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End-of-life care in patients with heart failure. J Card Fail 2014; 20:121-34. [PMID: 24556532 DOI: 10.1016/j.cardfail.2013.12.003] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 12/05/2013] [Accepted: 12/06/2013] [Indexed: 01/11/2023]
Abstract
Stage D heart failure (HF) is associated with poor prognosis, yet little consensus exists on the care of patients with HF approaching the end of life. Treatment options for end-stage HF range from continuation of guideline-directed medical therapy to device interventions and cardiac transplantation. However, patients approaching the end of life may elect to forego therapies or procedures perceived as burdensome, or to deactivate devices that were implanted earlier in the disease course. Although discussing end-of-life issues such as advance directives, palliative care, or hospice can be difficult, such conversations are critical to understanding patient and family expectations and to developing mutually agreed-on goals of care. Because patients with HF are at risk for rapid clinical deterioration or sudden cardiac death, end-of-life issues should be discussed early in the course of management. As patients progress to advanced HF, the need for such discussions increases, especially among patients who have declined, failed, or been deemed to be ineligible for advanced HF therapies. Communication to define goals of care for the individual patient and then to design therapy concordant with these goals is fundamental to patient-centered care. The objectives of this white paper are to highlight key end-of-life considerations in patients with HF, to provide direction for clinicians on strategies for addressing end-of-life issues and providing optimal patient care, and to draw attention to the need for more research focusing on end-of-life care for the HF population.
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7
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Beca S, Ahmad F, Shen W, Liu J, Makary S, Polidovitch N, Sun J, Hockman S, Chung YW, Movesian M, Murphy E, Manganiello V, Backx PH. Phosphodiesterase type 3A regulates basal myocardial contractility through interacting with sarcoplasmic reticulum calcium ATPase type 2a signaling complexes in mouse heart. Circ Res 2013; 112:289-97. [PMID: 23168336 PMCID: PMC3579621 DOI: 10.1161/circresaha.111.300003] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Accepted: 11/19/2012] [Indexed: 11/16/2022]
Abstract
RATIONALE cAMP is an important regulator of myocardial function, and regulation of cAMP hydrolysis by cyclic nucleotide phosphodiesterases (PDEs) is a critical determinant of the amplitude, duration, and compartmentation of cAMP-mediated signaling. The role of different PDE isozymes, particularly PDE3A vs PDE3B, in the regulation of heart function remains unclear. OBJECTIVE To determine the relative contribution of PDE3A vs PDE3B isozymes in the regulation of heart function and to dissect the molecular basis for this regulation. METHODS AND RESULTS Compared with wild-type littermates, cardiac contractility and relaxation were enhanced in isolated hearts from PDE3A(-/-), but not PDE3B(-/-), mice. Furthermore, PDE3 inhibition had no effect on PDE3A(-/-) hearts but increased contractility in wild-type (as expected) and PDE3B(-/-) hearts to levels indistinguishable from PDE3A(-/-). The enhanced contractility in PDE3A(-/-) hearts was associated with cAMP-dependent elevations in Ca(2+) transient amplitudes and increased sarcoplasmic reticulum (SR) Ca(2+) content, without changes in L-type Ca(2+) currents of cardiomyocytes, as well as with increased SR Ca(2+)-ATPase type 2a activity, SR Ca(2+) uptake rates, and phospholamban phosphorylation in SR fractions. Consistent with these observations, PDE3 activity was reduced ≈8-fold in SR fractions from PDE3A(-/-) hearts. Coimmunoprecipitation experiments further revealed that PDE3A associates with both SR calcium ATPase type 2a and phospholamban in a complex that also contains A-kinase anchoring protein-18, protein kinase type A-RII, and protein phosphatase type 2A. CONCLUSIONS Our data support the conclusion that PDE3A is the primary PDE3 isozyme modulating basal contractility and SR Ca(2+) content by regulating cAMP in microdomains containing macromolecular complexes of SR calcium ATPase type 2a-phospholamban-PDE3A.
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Affiliation(s)
- Sanja Beca
- Department of Physiology, University of Toronto, Toronto, Ontario
| | - Faiyaz Ahmad
- The Cardiovascular Pulmonary Branch, National Heart, Lung and Blood Institute, NIH, Bethesda
| | - Weixing Shen
- The Cardiovascular Pulmonary Branch, National Heart, Lung and Blood Institute, NIH, Bethesda
| | - Jie Liu
- Department of Physiology, University of Toronto, Toronto, Ontario
| | - Samy Makary
- Department of Physiology, University of Toronto, Toronto, Ontario
- Division of Cardiology, University Health Network, Toronto, Ontario
| | | | - Junhui Sun
- Systems Biology Center, National Heart, Lung and Blood Institute, NIH, Bethesda
| | - Steven Hockman
- The Cardiovascular Pulmonary Branch, National Heart, Lung and Blood Institute, NIH, Bethesda
| | - Youn Wook Chung
- The Cardiovascular Pulmonary Branch, National Heart, Lung and Blood Institute, NIH, Bethesda
| | - Matthew Movesian
- Cardiology Section, VA Salt Lake City Health Care System, Salt Lake City, UT
| | - Elizabeth Murphy
- Systems Biology Center, National Heart, Lung and Blood Institute, NIH, Bethesda
| | - Vincent Manganiello
- The Cardiovascular Pulmonary Branch, National Heart, Lung and Blood Institute, NIH, Bethesda
| | - Peter H. Backx
- Department of Physiology, University of Toronto, Toronto, Ontario
- Department of Medicine, University of Toronto, Toronto, Ontario
- Division of Cardiology, University Health Network, Toronto, Ontario
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8
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Kontinuierliche β-Blockade mit Esmolol in Kombination mit Enoximon-Gabe. Anaesthesist 2008; 57:231-41. [DOI: 10.1007/s00101-008-1313-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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9
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Long KM, Kirby R. An update on cardiovascular adrenergic receptor physiology and potential pharmacological applications in veterinary critical care. J Vet Emerg Crit Care (San Antonio) 2008. [DOI: 10.1111/j.1476-4431.2007.00266.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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Metra M, Nodari S, Bordonali T, Milani P, Fracassi F, Dei Cas L. β-blocker therapy of heart failure: an update. Expert Opin Pharmacother 2007; 8:289-98. [PMID: 17266464 DOI: 10.1517/14656566.8.3.289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The beneficial effects of beta-blocker therapy in patients with heart failure have been consistently shown by multi-center randomised trials. These agents are effective and also relatively well tolerated in the elderly and in patients with diabetes and advanced heart failure--traditionally considered as relative contraindications to their administration. However, the use of beta-blockers in clinical practice remains low. The difficulties in their initiation and up-titration may be overcome by patient and physician education, as well as by their initiation during hospitalisation and/or the involvement of non-physician providers (i.e., a nurse facilitator). Forthcoming advances in the pharmacokinetic and pharmacodynamic characteristics of some beta-blockers, and testing of novel methods for patient and drug selection may be based on genetic testing, and may allow further improvement of beta-blocker therapy in the next future.
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Affiliation(s)
- Marco Metra
- University of Brescia c/o Cardiologia, Section of Cardiovascular Diseases, Department of Experimental and Applied Medicine, Spedali Civili, P.zza Spedali Civili 125123 Brescia, Italy.
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11
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Abstract
Despite the current advances in treatment, acute decompensated heart failure accounts for more than 1 million hospital admissions annually. Many of the patients hospitalized are already receiving long-term treatment with beta-blockers. For patients who receive full dose beta-blocker therapy and suffer acute decompensated heart failure, clinicians face two key questions: what to do, if anything, with the dosage of beta-blocker and what is the best way to integrate inotropic and beta-blocker therapies for patients who require inotropes. This article discusses these issues and reviews the available literature. Because these topics have received little systematic evaluation, we also present our clinical approaches to these problems.
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Affiliation(s)
- Rami Alharethi
- Division of Cardiology, UHN-62, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
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12
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Lowes BD, Shakar SF, Metra M, Feldman AM, Eichhorn E, Freytag JW, Gerber MJ, Liard JF, Hartman C, Gorczynski R, Evans G, Linseman JV, Stewart J, Robertson AD, Roecker EB, Demets DL, Bristow MR. Rationale and design of the enoximone clinical trials program. J Card Fail 2006; 11:659-69. [PMID: 16360960 DOI: 10.1016/j.cardfail.2005.10.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2005] [Revised: 08/29/2005] [Accepted: 10/27/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic heart failure is a disease syndrome characterized in its advanced stages by a poor quality of life, frequent hospitalizations, and a high risk of mortality. In advanced and ultra-advanced chronic heart failure, many treatment options, such as cardiac transplantation and mechanical devices, are severely limited by availability and cost. Short-term Phase II clinical trials suggest that low-dose oral inotropic therapy with enoximone may improve hemodynamics and exercise capacity, without adversely affecting mortality, in selected subjects with advanced chronic heart failure. Based on these data, the ability of enoximone to deliver safe and efficacious palliative treatment of advanced/ultra-advanced chronic heart failure is being evaluated in Phase III clinical trials. METHODS AND RESULTS The Enoximone Clinical Trials Program is a series of 4 clinical trials designed to evaluate the safety and efficacy of oral enoximone in advanced chronic heart failure. ESSENTIAL I and II (The Studies of Oral Enoximone Therapy in Advanced Heart Failure) will investigate the effects of oral enoximone on all-cause mortality and cardiovascular hospitalization, submaximal exercise capacity, and quality of life in subjects with New York Heart Association Class III/IV chronic heart failure. EMOTE (Oral Enoximone in Intravenous Inotrope-Dependent Subjects) will evaluate the potential of oral enoximone to wean subjects with ultra-advanced chronic heart failure from chronic intravenous inotropic therapy to which they have been shown to be dependent. EMPOWER (Enoximone Plus Extended-Release Metoprolol Succinate in Subjects with Advanced Chronic Heart Failure) will explore the potential of enoximone to increase the tolerability of continuous release metoprolol in subjects shown previously to be hemodynamically intolerant to beta-blocker treatment. CONCLUSION These studies are Phase III, multicenter, randomized, double-blinded, placebo-controlled trials designed to test the general hypothesis that chronic oral administration of low doses of enoximone can produce beneficial effects in subjects with advanced or ultra-advanced chronic heart failure.
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Affiliation(s)
- Brian D Lowes
- University of Colorado Health Sciences Center, Denver, Colorado 80262, USA
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13
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Bayram M, De Luca L, Massie MB, Gheorghiade M. Reassessment of dobutamine, dopamine, and milrinone in the management of acute heart failure syndromes. Am J Cardiol 2005; 96:47G-58G. [PMID: 16181823 DOI: 10.1016/j.amjcard.2005.07.021] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The appropriate role of intravenous inodilator therapy (inotropic agents with vasodilator properties) in the management of acute heart failure syndromes (AHFS) has long been a subject of controversy, mainly because of the lack of prospective, placebo-controlled trials and a lack of alternative therapies. The use of intravenous inodilator infusions, however, remains common, but highly variable. As new options emerge for the treatment of AHFS, the available information should be reviewed to determine which approaches are supported by evidence, which are used empirically without evidence, and which should be considered inappropriate. For these purposes, we reviewed data available from randomized controlled trials on short-term, intermittent, and long-term use of intravenous inodilator agents (dobutamine, dopamine, and milrinone) in AHFS. Randomized controlled trials failed to show benefits with current medications and suggested that acute, intermittent, or continuous use of inodilator infusions may increase morbidity and mortality in patients with AHFS. Their use should be restricted to patients who are hypotensive as a result of low cardiac output despite a high left ventricular filling pressure.
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Affiliation(s)
- Melike Bayram
- Department of Medicine Residency Training Program, University of Michigan, Ann Arbor, Michigan, USA
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14
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Abstract
Adverse neurohormonal activation is an essential component in the pathogenesis of acute decompensated congestive heart failure (CHF). Consequently, blunting this activation is an important therapeutic goal. B-type natriuretic peptide (BNP) is a counterregulatory hormone produced by the ventricles in response to pressure and volume load. Endogenous BNP levels are significantly elevated in patients with acute CHF, but these levels are frequently inadequate to overcome the excess neurohormonal activation present in this condition. Infusion of nesiritide, a recombinant form of endogenous human BNP, increases circulating BNP levels by several-fold, augmenting the counterregulatory effects of this hormone. Clinical trials demonstrate that in patients with acute decompensated CHF, nesiritide produces arterial and venous vasodilation, reducing both preload and afterload; blunts adverse neurohormones, including renin, aldosterone, norepinephrine, and endothelin-1; and improves renal hemodynamics and tubular function. As a result, nesiritide quickly reduces clinical symptoms and improves mortality in patients with acute CHF.
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Affiliation(s)
- Andrew J Burger
- Beth Israel Deaconess Medical Center, Noninvasive Cardiology Laboratory, Baker-3, 1 Deaconess Road, Boston, MA 02215, USA.
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15
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Rosenthal D, Chrisant MRK, Edens E, Mahony L, Canter C, Colan S, Dubin A, Lamour J, Ross R, Shaddy R, Addonizio L, Beerman L, Berger S, Bernstein D, Blume E, Boucek M, Checchia P, Dipchand A, Drummond-Webb J, Fricker J, Friedman R, Hallowell S, Jaquiss R, Mital S, Pahl E, Pearce FB, Pearce B, Rhodes L, Rotondo K, Rusconi P, Scheel J, Pal Singh T, Towbin J. International Society for Heart and Lung Transplantation: Practice guidelines for management of heart failure in children. J Heart Lung Transplant 2005; 23:1313-33. [PMID: 15607659 DOI: 10.1016/j.healun.2004.03.018] [Citation(s) in RCA: 178] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- David Rosenthal
- International Society for Heart and Lung Transplantation, Addison, Texas.
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16
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Abraham WT, Cheng ML, Smoluk G. Clinical and Hemodynamic Effects of Nesiritide (B-Type Natriuretic Peptide) in Patients With Decompensated Heart Failure Receiving ? Blockers. ACTA ACUST UNITED AC 2005; 11:59-64. [PMID: 15860969 DOI: 10.1111/j.1527-5299.2005.03792.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The use of beta blockers in congestive heart failure presents a therapeutic challenge for patients with acute episodes of decompensation. Such patients may be less responsive to positive inotropic agents, whereas the beneficial effects of nesiritide, which are not dependent on the beta-adrenergic receptor signal-transduction pathway, may be preserved. This analysis of the Vasodilation in the Management of Acute CHF trial evaluated the safety and efficacy of nesiritide in decompensated congestive heart failure patients receiving beta blockers. The Vasodilation in the Management of Acute CHF trial was a multicenter, randomized, controlled evaluation of nesiritide in 489 hospitalized patients with decompensated congestive heart failure. One hundred twenty-three patients were on chronic beta-blocker therapy at enrollment (31 randomized to placebo, 50 to nesiritide, and 42 to nitroglycerin). Primary end points included pulmonary capillary wedge pressure and dyspnea evaluation at 3 hours. Patients receiving nesiritide, but not IV nitroglycerin, had significantly reduced pulmonary capillary wedge pressure vs. placebo at 3 hours regardless of beta-blocker use. The use of beta blockers did not alter the beneficial effects of nesiritide on systemic blood pressure, heart rate, or dyspnea evaluation. In nesiritide-treated subjects, safety profiles were similar regardless of beta-blocker use. Thus, the clinical and hemodynamic benefits and safety of nesiritide are preserved in decompensated congestive heart failure patients receiving chronic beta blockade.
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Affiliation(s)
- William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH 43210-1252, USA.
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17
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Abstract
Congestive heart failure is a common condition with a poor prognosis. Its high rates of morbidity and mortality produce a huge societal burden. Current pharmacological treatment approaches are based on angiotensin-converting enzyme inhibitors, diuretics and digoxin, but up to 5% of patients may have refractory disease with persistent symptoms at rest. Such patients with advanced-stage disease may be candidates for treatment with the novel agent vesnarinone, a mixed phosphodiesterase inhibitor and ion-channel modifier that has modest, dose-dependent, positive inotropic activity, but minimal negative chronotropic activity. Vesnarinone improves ventricular performance most in patients with the worst degree of heart failure. However, before the initiation of vesnarinone therapy, risk-benefit profiles in individual patients should be considered, because in two large-scale studies [i.e. of the high dosage used in the Vesnarinone Study Group Trial (VSGT), and of both dosages used in the Vesnarinone Trial (VEST)] a dose-dependent increase in mortality was identified for vesnarinone 30-120 mg/day. The two studies also found significant vesnarinone-induced, short-term improvements in quality of life (QOL) in patients with refractory end-stage heart failure. Such patients are the most willing to trade-off a slightly increased risk of mortality for improved QOL. It is thus in these patients with refractory end-stage heart failure that vesnarinone may ultimately establish an important treatment role. However, detailed further investigation of the overall place of vesnarinone in heart failure management, with particular reference to the clinical potential of vesnarinone plus beta-blocker combination therapy, for example, is certainly warranted.
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Affiliation(s)
- Arthur M Feldman
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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18
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Ringe HIG, Varnholt V, Gaedicke G. Cardiac rescue with enoximone in volume and catecholamine refractory septic shock. Pediatr Crit Care Med 2003; 4:471-5. [PMID: 14525645 DOI: 10.1097/01.pcc.0000074275.61913.72] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In December 2000 and February 2001, two children with suspected meningococcal disease were admitted to our pediatric intensive unit. Their Glasgow Meningococcal Septicaemia Prognostic score was 12 points. General treatment including antibiotics, steroids in case of meningitis, and fluid replacement, was performed. Despite appropriate volume replacement, intubation and ventilation, noradrenaline and adrenaline continuous infusions < or =1.0 microg/kg/min, and additional bolus infusions, cardiac output deteriorated within minutes in both children. Calcium and bicarbonate were given without sustained effect. Echocardiography demonstrated no pericardial effusion and shortening fraction was <10%. External cardiac massage had to be performed immediately in one case for electromechanical uncoupling. Both patients received a bolus of enoximone 2 mg/kg and 5 mg/kg body weight, respectively, followed by a continuous infusion of 20-23 microg/kg/min. Thereafter, both children had an adequate blood pressure and their shortening fraction increased to >30%. Within minutes, the catecholamine infusion could be reduced in both patients. The children completely recovered from their life-threatening situations. In patients with severe prolonged catecholamine and volume refractory endotoxin shock in Waterhouse-Friderichsen syndrome, even with electromechanical uncoupling and complete myocardial arrest, enoximone can immediately restore myocardial contractility.
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Affiliation(s)
- Hannelore I G Ringe
- Paediatric Intensive Care Unit, Charité Children's Hospital, Humboldt University Berlin, Berlin, Germany.
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19
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Ghio S, Constantin C, Raineri C, Fontana A, Klersy C, Campana C, Tavazzi L. Enoximone echocardiography: a novel test to evaluate left ventricular contractile reserve in patients with heart failure on chronic beta-blocker therapy. Cardiovasc Ultrasound 2003; 1:13. [PMID: 14596683 PMCID: PMC240109 DOI: 10.1186/1476-7120-1-13] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2003] [Accepted: 09/25/2003] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It has been suggested that an extensive contractile reserve identified recognised by means of dobutamine stress echocardiography may predict a better prognosis in patients with severe left ventricular dysfunction at rest. However, the clinical use of dobutamine stress echocardiography may be limited in patients with chronic heart failure by the substantial proportion of such patients treated with beta-blockers, since the inotropic response to adrenergic stimulation is known to be attenuated in patients receiving beta-adrenoceptor blockers. Enoximone is a positive inotropic agent that inhibits cyclic adenosine monophosphate-specific phosphosdiesterase. We therefore tested the hypothesis that enoximone may be an alternative to dobutamine in evaluating left ventricular contractile reserve in patients with systolic dysfunction on chronic beta-blocker therapy. METHODS We studied 26 patients (21 males and five females) with a mean age of 58 PlusMinus; 10 years: 11 were not receiving beta-blockers (noBB group); 15 were receiving carvedilol at a mean dose of 34 mg/day (BB group). Dobutamine was infused at doses of 5 and 10 micrograms/kg/min, and enoximone at a dose of 1.5 mg/kg. RESULTS The ejection fraction in the noBB group increased by 9% with dobutamine and 8.73% with enoximone (p = 0.86); in the BB group, it increased by 6% with dobutamine and 8.94% with enoximone (p = 0.03). Regional peak systolic velocities were evaluated by means of tissue Doppler imaging in four basal and four medium level segments. In the noBB group, they increased more with dobutamine than with enoximone in three of the eight segments; no significant differences were found in the BB group. Dobutamine induced non-sustained ventricular tachycardia in three patients and supraventricular tachycardia in one, whereas enoximone did not induce any repetitive arrhythmias. CONCLUSIONS Enoximone might be preferable to low-dose dobutamine for evaluating left ventricular contractile reserve in chronically beta-blocked heart failure patients as it is slightly more potent and has a better safety profile.
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Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Istituto di Ricovero e Cura a carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Cristina Constantin
- Division of Cardiology, Istituto di Ricovero e Cura a carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Claudia Raineri
- Division of Cardiology, Istituto di Ricovero e Cura a carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Alessandra Fontana
- Division of Cardiology, Istituto di Ricovero e Cura a carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Catherine Klersy
- Division of Biometry and Clinical Epidemiology, Istituto di Ricovero e Cura a carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Carlo Campana
- Division of Cardiology, Istituto di Ricovero e Cura a carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Luigi Tavazzi
- Division of Cardiology, Istituto di Ricovero e Cura a carattere Scientifico Policlinico San Matteo, Pavia, Italy
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20
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Ventura HO, Kalapura T. Beta-blocker therapy and severe heart failure: myth or reality? CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2003; 9:197-202. [PMID: 12937355 DOI: 10.1111/j.1527-5299.2003.01467.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The medical management of heart failure has undergone remarkable progress in the past 10 years. The paradigm shift is toward long-term reparative strategies that help in altering the biologic properties of the failing heart. Together with angiotensin-converting enzyme inhibitors, beta blockers have emerged as standard therapy for heart failure, especially for patients with mild to moderate heart failure. Since most of the clinical trials demonstrating the benefits of betablockers have been done in patients with mild to moderate heart failure, some controversy exists about the utility of beta-blocking agents in patients with advanced heart failure. This review will summarize the rationale and the use of beta blockers, a very challenging therapeutic strategy, in patients with severe heart failure.
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Affiliation(s)
- Hector O Ventura
- Department of Cardiology, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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21
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Abstract
During the course of treatment of heart failure patients, cardiotonic agents are inevitable for improvement of myocardial dysfunction. Clinically available agents, such as beta-adrenoceptor agonists and selective phosphodiesterase 3 inhibitors, act mainly via cyclic AMP/protein kinase A-mediated facilitation of Ca(2+) mobilisation (upstream mechanism). These agents are associated with the risk of Ca(2+) overload leading to arrhythmias, myocardial cell injury and premature cell death. In addition, they are energetically disadvantageous because of an increase in activation energy and metabolic effects. Cardiac glycosides act also via an upstream mechanism and readily elicit Ca(2+) overload with a narrow safety margin. No currently available agents act primarily via an increase in the myofilament sensitivity to Ca(2+) ions (central and/or downstream mechanisms). Novel Ca(2+) sensitisers under basic research may deserve clinical trials to examine the therapeutic potential to replace currently employed agents in acute and chronic heart failure patients. Molecular mechanisms of action of Ca(2+) sensitisers are divergent. In addition, they show a wide range of discrete pharmacological profiles due to additional actions associated with individual compounds. Therefore, the outcome of clinical trials has to be explained carefully based on these mechanisms of actions.
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Affiliation(s)
- Masao Endoh
- Department of Pharmacology, Yamagata University School of Medicine, 2-2-2 Iida-nishi, Yamagata, 990-9585 Japan.
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22
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Jain P, Massie BM, Gattis WA, Klein L, Gheorghiade M. Current medical treatment for the exacerbation of chronic heart failure resulting in hospitalization. Am Heart J 2003; 145:S3-17. [PMID: 12594447 DOI: 10.1067/mhj.2003.149] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Parag Jain
- Northwestern University, Feinberg School of Medicine, Chicago, Ill 60611, USA
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23
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Abstract
Regulation of myocardial contractility by cardiotonic agents is achieved by an increase in intracellular Ca2+ mobilization (upstream mechanism), an increase in Ca2+ binding affinity to troponin C (central mechanism), or facilitation of the process subsequent to Ca2+ binding to troponin C (downstream mechanism). cAMP mediates the regulation induced by Ca2+ mobilizers such as beta-adrenoceptor agonists and selective phosphodiesterase III inhibitors acting through the upstream mechanism. These agents act likewise on the central mechanism to decrease Ca2+ sensitivity of troponin C in association with the cAMP-mediated phosphorylation of troponin I. In addition to such a well-known action of cAMP, recent experimental findings have revealed that Ca2+ sensitizers, such as levosimendan, OR-1896, and UD-CG 212 Cl, require the cAMP-mediated signaling for induction of Ca2+ sensitizing effect. These agents shift the [Ca2+] -force relationship to the left, but their positive inotropic effect (PIE) is inhibited by carbachol, which suppresses selectively the cAMP-mediated PIE. These findings imply that cAMP may play a crucial role in increasing the myofilament Ca2+ sensitivity by cross-talk with the action of individual cardiotonic agents. No clinically available cardiotonic agents act primarily via Ca2+ sensitization, but the PIE of pimobendan and levosimendan is partly mediated by an increase in myofilament Ca2+ sensitivity. Evidence is accumulating that cardiotonic agents with Ca2+ sensitizing action are more effective than agents that act purely via the upstream mechanism in clinical settings. Further clinical trials are required to establish the effectiveness of Ca2+ sensitizers in long-term therapy for congestive heart failure patients.
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Affiliation(s)
- Masao Endoh
- Department of Pharmacology, Yamagata University School of Medicine, Japan.
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24
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Zaugg M, Schaub MC, Pasch T, Spahn DR. Modulation of beta-adrenergic receptor subtype activities in perioperative medicine: mechanisms and sites of action. Br J Anaesth 2002; 88:101-23. [PMID: 11881864 DOI: 10.1093/bja/88.1.101] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
This review focuses on the mechanisms and sites of action underlying beta-adrenergic antagonism in perioperative medicine. A large body of knowledge has recently emerged from basic and clinical research concerning the mechanisms of the life-saving effects of beta-adrenergic antagonists (beta-AAs) in high-risk cardiac patients. This article re-emphasizes the mechanisms underlying beta-adrenergic antagonism and also illuminates novel rationales behind the use of perioperative beta-AAs from a biological point of view. Particularly, it delineates new concepts of beta-adrenergic signal transduction emerging from transgenic animal models. The role of the different characteristics of various beta-AAs is discussed, and evidence will be presented for the selection of one specific agent over another on the basis of individual drug profiles in defined clinical situations. The salutary effects of beta-AAs on the cardiovascular system will be described at the cellular and molecular levels. Beta-AAs exhibit many effects beyond a reduction in heart rate, which are less known by perioperative physicians but equally desirable in the perioperative care of high-risk cardiac patients. These include effects on core components of an anaesthetic regimen, such as analgesia, hypnosis, and memory function. Despite overwhelming evidence of benefit, beta-AAs are currently under-utilized in the perioperative period because of concerns of potential adverse effects and toxicity. The effects of acute administration of beta-AAs on cardiac function in the compromised patient and strategies to counteract potential adverse effects will be discussed in detail. This may help to overcome barriers to the initiation of perioperative treatment with beta-AAs in a larger number of high-risk cardiac patients undergoing surgery.
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Affiliation(s)
- M Zaugg
- Department of Anesthesiology, University Hospital Zurich, Switzerland
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25
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Engelhardt S, Boknik P, Keller U, Neumann J, Lohse MJ, Hein L. Early impairment of calcium handling and altered expression of junctin in hearts of mice overexpressing the beta1-adrenergic receptor. FASEB J 2001; 15:2718-20. [PMID: 11606476 DOI: 10.1096/fj.01-0107fje] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic stimulation of cardiac beta1-adrenergic receptors contributes to disease progression and mortality in patients and animal models of heart failure. To search for the mechanism of adrenergic impairment of cardiac function in vivo, we studied transgenic mice with cardiac-specific overexpression of beta1-adrenergic receptors. Transgenic mice with cardiac overexpression of beta1-adrenergic receptors showed progressive left ventricular fibrosis starting at 4 months of age. Left ventricular catheterization revealed a modest enhancement of contractility and relaxation at 2 months of age, followed by progressive dysfunction in both parameters and ultimately cardiac failure. When the effects of endogenous catecholamines were blocked by the b-receptor antagonist propranolol, maximal rate of contractility (dp/dtmax) and maximal rate of relaxation (dp/dtmin) were significantly blunted in 2-month-old beta1-receptor transgenic mice. Isolated cardiomyocytes from these animals displayed markedly altered calcium transients with significant prolongation of the intracellular calcium transient compared with nontransgenic littermates. We determined the expression of sarcoplasmic reticulum proteins involved in calcium handling by RNase protection assay and by immunoblotting. Although the expression of calsequestrin, triadin, and phospholamban was not altered, we observed a progressive decrease in junctin abundance in beta1-receptor transgenic mice (Pbeta1-adrenergic receptors.
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MESH Headings
- Animals
- Blood Pressure/physiology
- Blotting, Western
- Calcium/metabolism
- Calcium-Binding Proteins/genetics
- Calcium-Binding Proteins/metabolism
- Calcium-Transporting ATPases/genetics
- Calcium-Transporting ATPases/metabolism
- Carrier Proteins/genetics
- Carrier Proteins/metabolism
- Gene Expression Regulation
- Gene Expression Regulation, Developmental
- Humans
- Hypertrophy, Left Ventricular/genetics
- Hypertrophy, Left Ventricular/metabolism
- Hypertrophy, Left Ventricular/physiopathology
- Membrane Proteins
- Mice
- Mice, Transgenic
- Mixed Function Oxygenases
- Muscle Proteins/genetics
- Muscle Proteins/metabolism
- Myocardial Contraction/physiology
- Myocardium/cytology
- Myocardium/metabolism
- RNA, Messenger/genetics
- RNA, Messenger/metabolism
- Receptors, Adrenergic, beta-1/genetics
- Receptors, Adrenergic, beta-1/physiology
- Sarcoplasmic Reticulum/metabolism
- Sarcoplasmic Reticulum Calcium-Transporting ATPases
- Time Factors
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Affiliation(s)
- S Engelhardt
- Institut für Pharmakologie und Toxikologie, Universität Würzburg, Germany; and, Institut für Pharmakologie und Toxikologie, Universität Münster, Germany
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26
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Abstract
The available evidence suggests that while chronic inotropic support likely exerts a long-term deleterious effect on survival, their use is accompanied by short-term enhancements in symptomatology and decreases in medical resource use, thereby curtailing the overall medical costs. The decision to use chronic parenteral inotropic support should not be made lightly and must be considered only after all evidence based therapeutic options has been investigated thoroughly and tried (Fig. 1). This should include not only hemodynamic monitoring-based drug therapy but [figure: see text] also appropriate consideration for options such as heart transplantation or patient enrollment into large-scale drug trials that seek to answer pertinent issues relating to various aspects of advanced heart failure therapeutics. The use of parenteral inotropic support as a chronic bridge to transplantation is accepted widely but remains controversial in other scenarios. For instance, when refractory congestion or hypoperfusion is exhibited in the absence of any definitive medical or mechanical option, it may be wise to contemplate inotropic support after appropriate informed consent has been obtained from the patient. Lastly, it is of great importance to continually seek ways to transit the patient from this approach to a definitive therapeutic end point, such as with transition to oral beta-blockade, which may be better tolerated in the patient with advanced heart failure using an inotropic umbrella.
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Affiliation(s)
- M R Mehra
- Ochsner Cardiomyopathy and Heart Transplantation Center, Ochsner Clinic, New Orleans, Louisiana, USA.
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27
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Abstract
BACKGROUND Agents that increase cardiac contractility (positive inotropes) have beneficial hemodynamic effects in patients with acute and chronic heart failure but have frequently led to increased mortality when given on a long-term basis. Despite this fact, inotropes remain commonly used in the management of heart failure. METHODS We reviewed the available data on short- and long-term inotrope use in heart failure, emphasizing high-quality evidence on the basis of randomized trials that were powered to address clinical end points. RESULTS Available data suggest that long-term inotropic therapy has a negative impact on survival in patients with heart failure, regardless of the agent used. The data that inotropic therapy improves quality of life are mixed. High-quality randomized evidence is lacking for the use of inotropes for other heart failure indications, such as for acute decompensations or as a "bridge to transplant." CONCLUSIONS On the basis of the available evidence, the routine use of inotropes as heart failure therapy is not indicated in either the acute or chronic setting. Potentially appropriate uses of inotropes include as temporary treatment of diuretic-refractory acute heart failure decompensations or as a bridge to definitive treatment such as revascularization or cardiac transplantation. Inotropes also may be appropriate as a palliative measure in patients with truly end-stage heart failure. A model of heart failure pathophysiologic features that combines an understanding of both hemodynamic and neurohormonal factors will be required to best develop and evaluate novel treatments for advanced heart failure.
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Affiliation(s)
- G M Felker
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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28
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Shakar SF, Bristow MR. Low-level inotropic stimulation with type III phosphodiesterase inhibitors in patients with advanced symptomatic chronic heart failure receiving beta-blocking agents. Curr Cardiol Rep 2001; 3:224-31. [PMID: 11305977 DOI: 10.1007/s11886-001-0027-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
beta-blocking agents are now well established as a cornerstone therapy in mild to moderate heart failure. Patients with more advanced heart failure depend on adrenergic activation to maintain adequate myocardial function. This leads to significant difficulties in using beta-blockers in advanced or severe heart failure. In addition, recent data indicate that adrenergic withdrawal might be detrimental in some of these patients. In higher doses, positive inotropic agents have been shown to increase mortality when used alone in subsets with advanced heart failure. Preliminary data suggest that the combination of low-dose phosphodiesterase inhibitors and a beta-blocker may be better tolerated and does not appear to be associated with the adverse effects of either therapy used alone. We discuss the theoretic underpinning of this approach and the supportive clinical data.
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Affiliation(s)
- S F Shakar
- University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80262, USA
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29
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Abstract
Despite their theoretic appeal, agents that increase cardiac contractility (positive inotropes) have consistently been shown to increase mortality when given chronically to patients with heart failure. The routine use of inotropes as heart failure therapy in either the acute or the chronic setting is not supported by the available data. Some appropriate uses of inotropes are as temporary treatment of diuretic-refractory acute heart failure decompensations, or as a bridge to definitive treatment such as revascularization or cardiac transplantation. Although controversial, the use of inotropes as a palliative measure in the small subset of patients with truly end-stage heart failure may be appropriate. An understanding of the appropriate goals of therapy is important for both patients and physicians if rational decisions about the use of inotropes are to be made.
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Affiliation(s)
- G M Felker
- Division of Cardiology, Department of Medicine, Duke University Medical Center, DUMC Box 3356, Durham, NC 27710, USA
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30
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Burkhoff D, Shemer I, Felzen B, Shimizu J, Mika Y, Dickstein M, Prutchi D, Darvish N, Ben-Haim SA. Electric currents applied during the refractory period can modulate cardiac contractility in vitro and in vivo. Heart Fail Rev 2001; 6:27-34. [PMID: 11248765 DOI: 10.1023/a:1009851107189] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- D Burkhoff
- Divisions of Circulatory Physiology and Cardiology, Cardiac Physiology Laboratory, Department of Medicine, Columbia University, NY, USA.
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