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Fiori E, De Fazio L, Pidone C, Perone F, Tocci G, Battistoni A, Barbato E, Volpe M, Gallo G. Asymptomatic hyperuricemia: to treat or not a threat? A clinical and evidence-based approach to the management of hyperuricemia in the context of cardiovascular diseases. J Hypertens 2024; 42:1665-1680. [PMID: 39051476 DOI: 10.1097/hjh.0000000000003807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Asymptomatic hyperuricemia is defined by serum uric acid levels above 6.2 mg/dl in women and 7 mg/dl in men. In the presence of monosodium urate crystal formation and articular inflammation, hyperuricemia may become symptomatic (namely nephrolithiasis and gout). Uric acid results from purine catabolism and is at the centre of a complex metabolic interplay that involves oxidative stress, inflammation, renin-angiotensin-aldosterone system (RAAS) activation and insulin resistance. Uric acid levels present a continuous relation with conditions like hypertension and chronic kidney disease (CKD) and are reported to have an impact on risk of cardiovascular events. However, whether elevated uric acid is a causal agent and thus a possible therapeutic target is still uncertain and matter of further investigation. Treating symptomatic hyperuricemia involves lowering uric acid drugs and controlling inflammation. Urate-lowering agents are well tolerated but show minimal impact on cardiovascular events in patients with gout. Use of direct-acting urate-lowering agents in asymptomatic hyperuricemia associated with cardiovascular diseases does not warrant a clear benefit, whereas addressing cardiovascular issues with guideline-recommended therapies lowers uric acid and reduces the occurrence of cardiovascular events. Regular assessment of uric acid and clinical symptoms is advised before starting and renewing a urate-lowering treatment.
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Affiliation(s)
- Emiliano Fiori
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome
| | - Ludovica De Fazio
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome
| | - Chiara Pidone
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic "Villa delle Magnolie", Castel Morrone, Caserta
| | - Giuliano Tocci
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome
| | - Allegra Battistoni
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome
| | - Emanuele Barbato
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome
| | | | - Giovanna Gallo
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome
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Yokota T, Kinugawa S, Fukushima A, Okumura T, Murohara T, Tsutsui H. Efficacy and safety of the urate-lowering agent febuxostat in chronic heart failure patients with hyperuricemia: results from the LEAF-CHF study. Heart Vessels 2024:10.1007/s00380-024-02448-9. [PMID: 39158751 DOI: 10.1007/s00380-024-02448-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 08/08/2024] [Indexed: 08/20/2024]
Abstract
Hyperuricemia is an independent predictor of mortality in patients with chronic heart failure (CHF). To determine whether febuxostat, a urate-lowering agent, may improve clinical outcomes in CHF patients, we conducted a multicenter, prospective, randomized, open-label, blinded endpoint study with a treatment period of 24 weeks. We randomly assigned Japanese outpatients diagnosed with both CHF with reduced left ventricular ejection fraction (LVEF < 40%) and asymptomatic hyperuricemia (serum uric acid [UA] levels > 7.0 mg/dl and < 10.0 mg/dl) to either a febuxostat group (n = 51) or a control group (n = 50). The primary efficacy endpoint was the change in log-transformed plasma B-type natriuretic peptide (BNP) levels from baseline to week 24 (or at discontinuation). The secondary efficacy endpoints were the changes in LV systolic or diastolic function evaluated by echocardiography, New York Heart Association (NYHA) class, hemoglobin, and estimated glomerular filtration rate from baseline to week 24, and the change in log-transformed plasma BNP levels or serum UA levels from baseline to weeks 4, 8, 12, 16 and 20 (BNP) or weeks 4, 8, 12, 16, 20 and 24 (serum UA). The primary safety endpoints were occurrence of all-cause death or major cardiovascular events. The mean age of participants was 70 years; 14% were female. The febuxostat group and the control group did not differ with respect to the primary efficacy endpoint (p = 0.13), although the decrease in log-transformed plasma BNP levels from baseline to each of weeks 4, 8, 12, 16 and 20 was greater in the febuxostat group. There were no significant differences between the two groups in the primary safety endpoints or the secondary efficacy endpoints except reduced serum UA levels in the febuxostat group. Febuxostat did not reduce plasma BNP levels at week 24 in patients with CHF, but it appeared safe with no increase in major cardiovascular events and all-cause or cardiovascular mortality.
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Affiliation(s)
- Takashi Yokota
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
- Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Kita-14 Nishi-5, Kita-ku, Sapporo, 060-8648, Japan.
| | - Shintaro Kinugawa
- Department Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
- Division of Cardiovascular Medicine, Faculty of Medical Sciences, Research Institute of Angiocardiology, Kyushu University, Fukuoka, Japan
| | - Arata Fukushima
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroyuki Tsutsui
- School of Medicine and Graduate School, International University of Health and Welfare, Okawa, Japan
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Matsumoto S, Yang M, Shen L, Henderson A, Claggett BL, Desai AS, Lefkowitz M, Rouleau JL, Vardeny O, Zile MR, Jhund PS, Vaduganathan M, Solomon SD, McMurray JJV. Effects of sacubitril/valsartan according to polypharmacy status in PARAGON-HF. Eur J Heart Fail 2024; 26:1125-1138. [PMID: 38587090 DOI: 10.1002/ejhf.3223] [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: 01/15/2024] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024] Open
Abstract
AIMS Patients with heart failure (HF) and preserved ejection fraction (HFpEF) have a particularly high prevalence of comorbidities, often necessitating treatment with many medications. The aim of this study was to evaluate the association between polypharmacy status and outcomes in PARAGON-HF. METHODS AND RESULTS In this post hoc analysis, baseline medication status was available in 4793 of 4796 patients included in the primary analysis of PARAGON-HF. The effects of sacubitril/valsartan, compared with valsartan, were assessed according to the number of medications at baseline: 683 non-polypharmacy (<5 medications); 2750 polypharmacy (5-9 medications), and 1360 hyper-polypharmacy (≥10 medications). The primary outcome was total HF hospitalizations and cardiovascular deaths. Patients with hyper-polypharmacy were older, had more severe limitations due to HF (worse New York Heart Association class and Kansas City Cardiomyopathy Questionnaire scores), and had greater comorbidity. The non-adjusted risk of the primary outcome was significantly higher in patients taking more medications, and similar trends were seen for HF hospitalization and cardiovascular and all-cause death. The effect of sacubitril/valsartan versus valsartan on the primary outcome from the lowest to highest polypharmacy category was (as a rate ratio): 1.19 (0.76-1.85), 0.94 (0.77-1.15), and 0.77 (0.61-0.96) (pinteraction = 0.16). Treatment-related adverse events were more common in patients in the higher polypharmacy categories but not more common with sacubitril/valsartan, versus valsartan, in any polypharmacy category. CONCLUSIONS Polypharmacy is very common in patients with HFpEF, and those with polypharmacy have worse clinical status and a higher rate of non-fatal and fatal outcomes. The benefit of sacubitril/valsartan was not diminished in patients taking a larger number of medications at baseline.
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Affiliation(s)
- Shingo Matsumoto
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mingming Yang
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Li Shen
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Alasdair Henderson
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, MN, USA
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Zuo C, Li X, Guan Y, Fan L, Li J, Tian D, Chen C, Li X, Gu Z, Zhang C, Bian X, Lv Q. Influence of Aging on Outcomes of Sacubitril/Valsartan in Hypertensive Patients with Heart Failure: A Multicenter Retrospective Study. Anatol J Cardiol 2024; 28:194-200. [PMID: 38430112 PMCID: PMC11017677 DOI: 10.14744/anatoljcardiol.2023.3857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 12/26/2023] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND The aim of this study was to investigate the influence of aging on the effectiveness and tolerance of sacubitril/valsartan (sac/val) among hypertensive patients complicated with heart failure in a real-world setting. METHODS This multicenter, retrospective study included patients (≥18 years old) admitted with a diagnosis of hypertension and heart failure, starting sac/val therapy between January 2020 and December 2021 from 3 medical centers. Patients were grouped by the cutoff age of 65 years. Outcomes were collected 31-365 days after the initiation of sac/val and were compared in a matched cohort after 1: 1 propensity score matching (PSM). RESULTS A total of 794 patients were finally analyzed. Blood pressure and cardiac functions improved significantly compared with values at baseline. There were 269 patients in each cohort (<65 years and ≥65 years) after PSM. After PSM, the incidence of hyperuricemia and hypotension in the elderly patients (≥65 years) was significantly higher than in those <65 years of age. Kaplan-Meier estimate suggested that the cumulative incidence of new or recurrent cardiovascular events increased significantly at the age of ≥65 years after the point of 3 months (log-rank P =.00087). CONCLUSION Sac/val benefited patients in both cohorts by improving blood pressure and cardiac function. Elderly patients (≥65 years) were susceptible to hypotension, low diastolic blood pressure, hyperuricemia, and underwent cardiac-related readmissions more frequently.
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Affiliation(s)
- Chengchun Zuo
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yingyun Guan
- Department of Pharmacy, Ruijin Hospital School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Linlin Fan
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dan Tian
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Can Chen
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoyu Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhichun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Chi Zhang
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiaolan Bian
- Department of Pharmacy, Ruijin Hospital School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, China
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Pontremoli R, Ghinatti MC, Barnini C. Asymptomatic hyperuricemia and cardiovascular mortality: A matter of mechanisms? Eur J Intern Med 2024; 121:42-43. [PMID: 38072686 DOI: 10.1016/j.ejim.2023.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 11/30/2023] [Indexed: 03/08/2024]
Affiliation(s)
- Roberto Pontremoli
- Department of Internal Medicine and Medical Specialties, University of Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | | | - Cecilia Barnini
- Department of Internal Medicine and Medical Specialties, University of Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Innsbruck Medical University, Innsbruck, Austria
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Ostrominski JW, Vaduganathan M. Chapter 2: Clinical and Mechanistic Potential of Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors in Heart Failure with Preserved Ejection Fraction. Am J Med 2024; 137:S9-S24. [PMID: 37160196 DOI: 10.1016/j.amjmed.2023.04.035] [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: 04/01/2022] [Accepted: 04/18/2023] [Indexed: 05/11/2023]
Abstract
Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have emerged as an important approach for the treatment of heart failure in patients with or without diabetes. Although the precise mechanisms underpinning their clinical impact remain incompletely resolved, mechanistic studies and insights from major clinical trials have demonstrated the impact of SGLT2 inhibitors on numerous cardio-renal-metabolic pathways of relevance to heart failure with preserved ejection fraction (HFpEF), which, in the contemporary era, constitutes approximately half of all patients with heart failure. Despite rates of morbidity and mortality that are commensurate with those of heart failure with reduced ejection fraction, disease-modifying therapies have comparatively been severely lacking. As such, HFpEF remains among the greatest unmet needs in cardiovascular medicine. Within the past decade, HFpEF has been established as a highly integrated disorder, involving not only the cardiovascular system, but also the lungs, kidneys, skeletal muscle, and adipose tissue. Given their multisystem impact, SGLT2i offer unique promise in addressing the complex pathophysiology of HFpEF, and in recent randomized controlled trials, were shown to significantly reduce heart failure events and cardiovascular death in patients with HFpEF. Herein, we discuss several proposed mechanisms of clinical benefit of SGLT2i in HFpEF.
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Affiliation(s)
- John W Ostrominski
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, Mass.
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7
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Banerjee M, Pal R, Maisnam I, Chowdhury S, Mukhopadhyay S. Serum uric acid lowering and effects of sodium-glucose cotransporter-2 inhibitors on gout: A meta-analysis and meta-regression of randomized controlled trials. Diabetes Obes Metab 2023; 25:2697-2703. [PMID: 37334516 DOI: 10.1111/dom.15157] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/19/2023] [Accepted: 05/20/2023] [Indexed: 06/20/2023]
Abstract
AIMS To pool the effects of sodium-glucose cotransporter-2 (SGLT2) inhibitors on gout and to investigate the association of these effects with baseline serum uric acid (SUA), SUA lowering, and underlying conditions, such as type 2 diabetes mellitus (T2DM)/heart failure (HF). METHODS PubMed, Embase, Web of Science, Cochrane Library and clinical trial registry websites were searched for randomized controlled trials (RCTs) or post hoc analyses (≥1-year duration; PROSPERO:CRD42023418525). The primary outcome was a composite of gouty arthritis/gout flares and commencement of anti-gout drugs (SUA-lowering drugs/colchicine). Hazard ratios (HRs) with 95% confidence interval (CI) were pooled using a generic inverse-variance method with a random-effects model. Mixed-effects model univariate meta-regression analysis was performed. RESULTS Five RCTs involving 29 776 patients (T2DM, n = 23 780) and 1052 gout-related events were identified. Compared to placebo, SGLT2 inhibitor use was significantly associated with reduced risk of composite gout outcomes (HR 0.55, 95% CI 0.45-0.67; I2 = 61%, P < 0.001). Treatment benefits did not differ between trials being conducted exclusively in baseline HF versus those conducted in patients with T2DM (P-interaction = 0.37), but were greater with dapagliflozin 10 mg and canagliflozin 100/300 mg (P < 0.01 for subgroup differences). Sensitivity analysis excluding trials that evaluated the effects of empagliflozin 10/25 mg (HR 0.68, 95% CI 0.57-0.81; I2 = 0%) accentuated the benefits of SGLT2 inhibitors with no between-trial heterogeneity (HR 0.46, 95% CI 0.39-0.55; I2 = 0%). Univariate meta-regression found no impact of baseline SUA, SUA lowering on follow-up, diuretic use, or other variables on their anti-gout effects. CONCLUSION We found that SGLT2 inhibitors significantly reduced the risk of gout in individuals with T2DM/HF. Lack of an association with SUA-lowering effects suggests that metabolic and anti-inflammatory effects of SGLT2 inhibitors may predominantly mediate their anti-gout benefits.
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Affiliation(s)
- Mainak Banerjee
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Rimesh Pal
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Indira Maisnam
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Subhankar Chowdhury
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, India
| | - Satinath Mukhopadhyay
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, India
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Lyu X, Du Y, Liu G, Mai T, Li Y, Zhang Z, Bei C. Prevalence and influencing factors of hyperuricemia in middle-aged and older adults in the Yao minority area of China: a cross-sectional study. Sci Rep 2023; 13:10185. [PMID: 37349536 PMCID: PMC10287663 DOI: 10.1038/s41598-023-37274-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/19/2023] [Indexed: 06/24/2023] Open
Abstract
Hyperuricemia (HUA) endangers human health, and its prevalence has increased rapidly in recent decades. The current study investigated HUA's prevalence and influencing factors in Gongcheng, southern China. A cross-sectional investigation was conducted; 2128 participants aged 30-93 years were included from 2018 to 2019. Univariate and multivariate logistic regression models were used to screen HUA variables. A Bayesian network model was constructed using the PC algorithm to evaluate the association between influencing factors and HUA. The prevalence of HUA was 15.6% (23.2% in men, 10.7% in women). After screening the variables using a logistic regression analysis model, fatty liver disease (FLD), dyslipidemia, abdominal obesity, creatinine (CREA), somatotype, bone mass, drinking, and physical activity level at work were included in the Bayesian network model. The model results showed that dyslipidemia, somatotype, CREA, and drinking were directly related to HUA. Bone mass and FLD were indirectly associated with HUA by affecting the somatotype. The prevalence of HUA in Gongcheng was high in China. The prevalence of HUA was related to somatotype, drinking, bone mass, physical activity level at work, and other metabolic diseases. A good diet and moderate exercise are recommended to maintain a healthy somatotype and reduce the prevalence rate of HUA.
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Affiliation(s)
- Xiao Lyu
- Department of Epidemiology and Health Statistics, School of Public Health, Guilin Medical University, Huan Cheng North 2nd Road 109, Guilin, 541004, Guangxi, China
| | - Yuanxiao Du
- Department of Epidemiology and Health Statistics, School of Public Health, Guilin Medical University, Huan Cheng North 2nd Road 109, Guilin, 541004, Guangxi, China
| | - Guoyu Liu
- Department of Epidemiology and Health Statistics, School of Public Health, Guilin Medical University, Huan Cheng North 2nd Road 109, Guilin, 541004, Guangxi, China
| | - Tingyu Mai
- Department of Environmental and Occupational Health, School of Public Health, Guilin Medical University, Huan Cheng North 2nd Road 109, Guilin, 541004, Guangxi, China
| | - You Li
- Department of Environmental and Occupational Health, School of Public Health, Guilin Medical University, Huan Cheng North 2nd Road 109, Guilin, 541004, Guangxi, China
| | - Zhiyong Zhang
- Department of Environmental and Occupational Health, School of Public Health, Guilin Medical University, Huan Cheng North 2nd Road 109, Guilin, 541004, Guangxi, China.
- Guangxi Key Laboratory of Environmental Exposomics and Entire Lifecycle Heath, Guangxi Health Commission Key Laboratory of Entire Lifecycle Health and Care, School of Public Health, Guilin Medical University, Guilin, China.
| | - Chunhua Bei
- Department of Epidemiology and Health Statistics, School of Public Health, Guilin Medical University, Huan Cheng North 2nd Road 109, Guilin, 541004, Guangxi, China.
- Guangxi Key Laboratory of Environmental Exposomics and Entire Lifecycle Heath, Guangxi Health Commission Key Laboratory of Entire Lifecycle Health and Care, School of Public Health, Guilin Medical University, Guilin, China.
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Otani N, Ouchi M, Mizuta E, Morita A, Fujita T, Anzai N, Hisatome I. Dysuricemia-A New Concept Encompassing Hyperuricemia and Hypouricemia. Biomedicines 2023; 11:biomedicines11051255. [PMID: 37238926 DOI: 10.3390/biomedicines11051255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/28/2023] Open
Abstract
The importance of uric acid, the final metabolite of purines excreted by the kidneys and intestines, was not previously recognized, except for its role in forming crystals in the joints and causing gout. However, recent evidence implies that uric acid is not a biologically inactive substance and may exert a wide range of effects, including antioxidant, neurostimulatory, proinflammatory, and innate immune activities. Notably, uric acid has two contradictory properties: antioxidant and oxidative ones. In this review, we present the concept of "dysuricemia", a condition in which deviation from the appropriate range of uric acid in the living body results in disease. This concept encompasses both hyperuricemia and hypouricemia. This review draws comparisons between the biologically biphasic positive and negative effects of uric acid and discusses the impact of such effects on various diseases.
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Affiliation(s)
- Naoyuki Otani
- Department of Cardiology, Dokkyo Medical University Nikkyo Medical Center, Nikko 321-1298, Tochigi, Japan
| | - Motoshi Ouchi
- Department of Pharmacology and Toxicology, Dokkyo Medical University School of Medicine, Mibu 321-0293, Tochigi, Japan
| | - Einosuke Mizuta
- Department of Cardiology, Sanin Rosai Hospital, Yonago 683-8605, Tottori, Japan
| | - Asuka Morita
- Department of Pharmacology and Toxicology, Dokkyo Medical University School of Medicine, Mibu 321-0293, Tochigi, Japan
| | - Tomoe Fujita
- Department of Pharmacology and Toxicology, Dokkyo Medical University School of Medicine, Mibu 321-0293, Tochigi, Japan
| | - Naohiko Anzai
- Department of Pharmacology and Toxicology, Dokkyo Medical University School of Medicine, Mibu 321-0293, Tochigi, Japan
- Department of Pharmacology, Chiba University Graduate School of Medicine, Chiba 260-8670, Chiba, Japan
| | - Ichiro Hisatome
- Yonago Medical Center, National Hospital Organization, Yonago 683-0006, Tottori, Japan
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Kashiwagi Y, Nagoshi T, Kimura H, Tanaka Y, Oi Y, Inoue Y, Ogawa K, Kawai M, Yoshimura M. Effects of angiotensin receptor-neprilysin inhibitor on insulin resistance in patients with heart failure. ESC Heart Fail 2023; 10:1860-1870. [PMID: 36942494 DOI: 10.1002/ehf2.14352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/20/2023] [Accepted: 02/27/2023] [Indexed: 03/23/2023] Open
Abstract
AIMS Although the haemodynamic effects of angiotensin receptor-neprilysin inhibitor (ARNI) on patients with heart failure have been demonstrated, the effect on glucose metabolism has not been fully elucidated. We retrospectively investigated the effect of ARNI on abnormal glucose metabolism in patients with stable chronic heart failure using an additional structural equation model (SEM) analysis. METHODS We analysed 34 patients who regularly visited to the outpatient department of our institute with heart failure from October 2021 and July 2022 and who were taking angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs). Seventeen patients switched from ACE inhibitors or ARBs to an ARNI (ARNI group), and the other 17 patients continued treatment with ACE inhibitors or ARBs (control group). RESULTS At baseline, although the ARNI group included fewer patients with heart failure with preserved ejection fraction in comparison with the control group (P = 0.004), patients with heart failure with mildly reduced ejection fraction, and heart failure with reduced ejection fraction were mostly biased towards the ARNI group (although not statistically significant). The baseline insulin resistance in the ARNI group was already significantly higher in comparison with the control group [fasting blood insulin, 9.7 (7.4, 11.6) vs. 7.8 (5.2, 9.2) μU/mL, P = 0.033; homoeostasis model assessment of insulin resistance (HOMA-IR), 3.10 (1.95, 4.19) vs. 2.02 (1.56, 2.42), P = 0.014]. Three months later, the fasting blood insulin and the HOMA-IR levels were both found to have decreased in comparison with the baseline values [baseline to 3 months: insulin, 9.7 (7.4, 11.6) to 7.3 (4.6, 9.4) μU/mL, P < 0.001; HOMA-IR, 3.10 (1.95, 4.19) to 1.96 (1.23, 3.09), P < 0.001]. An additional SEM analysis demonstrated that the initiation of ARNI had caused a reduction in the fasting blood insulin and the HOMA-IR levels at 3 months independently of the baseline fasting blood insulin and HOMA-IR levels, respectively. Similarly, the initiation of ARNI resulted in a significant reduction in serum uric acid levels (6.28 ± 0.35 to 5.80 ± 0.30 mg/dL, P = 0.008). CONCLUSIONS In conclusion, even in a short period of only 3 months, the administration of ARNI improved insulin resistance and consequently reduced the serum uric acid levels in patients with stable chronic heart failure. Although the ARNI group already had high insulin resistance at baseline, an additional SEM analysis revealed that the decreased insulin resistance was truly due to the effect of ARNI.
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Affiliation(s)
- Yusuke Kashiwagi
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Tomohisa Nagoshi
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Haruka Kimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshiro Tanaka
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuhei Oi
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yasunori Inoue
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kazuo Ogawa
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Makoto Kawai
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Michihiro Yoshimura
- Division of Cardiology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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11
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Shiina K, Tomiyama H, Tanaka A, Imai T, Hisauchi I, Taguchi I, Sezai A, Toyoda S, Dohi K, Kamiya H, Kida K, Anzai T, Chikamori T, Node K, Ako J, Amano R, Asai M, Eguchi K, Eshima K, Fujiki S, Fujita M, Hikoso S, Hiramitsu S, Hoshide S, Hoshino A, Ikeda Y, Ikehara Y, Inomata T, Inoue T, Ishii K, Ishizaka N, Ito M, Iwahashi N, Iwakura K, Kadokami T, Kanbara T, Kanzaki Y, Kashimura K, Kimura K, Kishi S, Kitada S, Kitakaze M, Kiyosue A, Kodama K, Kojima T, Kondo T, Kubota Y, Kusunose K, Machii N, Matsunaga K, Matsuo Y, Matsuzawa Y, Mikami T, Minamino T, Murohara T, Nagai T, Nagano Y, Nagumo M, Nakamura I, Nakamura K, Nakatani D, Nanasato M, Naruse H, Nishino M, Niwano S, Oguri M, Ohte N, Oikawa M, Okumura T, Okumura M, Onishi K, Oyama JI, Ozaki Y, Saito K, Sakamoto T, Sakata Y, Sakuma M, Sata M, Sekino H, Shimabukuro M, Shimizu W, Suzuki M, Suzuki K, Takahama H, Takahashi N, Takeishi Y, Tamaki S, Tanaka A, Tanimoto S, Teragawa H, Tobushi T, Toita T, Tokuda K, Tsutsui H, Ueda S, Uehara H, Uematsu M, Watada H, Yahagi K, Yamada T, Yamada H, Yoshida T, Yoshihisa A. Canagliflozin independently reduced plasma volume from conventional diuretics in patients with type 2 diabetes and chronic heart failure: a subanalysis of the CANDLE trial. Hypertens Res 2023; 46:495-506. [PMID: 36380202 DOI: 10.1038/s41440-022-01085-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 09/24/2022] [Accepted: 10/03/2022] [Indexed: 11/16/2022]
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2is) reduce the risk of heart failure progression and mortality rates. Moreover, osmotic diuresis induced by SGLT2 inhibition may result in an improved heart failure prognosis. Independent of conventional diuretics in patients with type 2 diabetes (T2D) and chronic heart failure, especially in patients with heart failure with preserved ejection fraction (HFpEF), it is unclear whether SGLT2i chronically reduces estimated plasma volume (ePV). As a subanalysis of the CANDLE trial, which assessed the effect of canagliflozin on N-terminal pro-brain natriuretic peptide (NT-proBNP), we examined the change (%) in ePV over 24 weeks of treatment based on the baseline level associated with diuretic usage. In the CANDLE trial, nearly all patients were clinically stable (NYHA class I-II), with approximately 70% of participants presenting a baseline phenotype of HFpEF. A total of 99 (42.5%) patients were taking diuretics (mostly furosemide) at baseline, while 134 (57.5%) were not. Relative to glimepiride, canagliflozin significantly reduced ePV without worsening renal function in patients in both groups: -4.00% vs. 1.46% (p = 0.020) for the diuretic group and -6.14% vs. 1.28% (p < 0.001) for the nondiuretic group. Furthermore, canagliflozin significantly reduced serum uric acid without causing major electrolyte abnormalities in patients in both subgroups. The long-term beneficial effect of SGLT2i on intravascular congestion could be independent of conventional diuretic therapy without worsening renal function in patients with T2D and HF (HFpEF predominantly). In addition, the beneficial effects of canagliflozin are accompanied by improved hyperuricemia without causing major electrolyte abnormalities.
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Affiliation(s)
- Kazuki Shiina
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan.
| | | | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
| | - Takumi Imai
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Itaru Hisauchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Isao Taguchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Akira Sezai
- The Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Haruo Kamiya
- Department of Cardiology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya, Japan
| | - Keisuke Kida
- Department of Pharmacology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Hokkaido University, Sapporo, Japan
| | | | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, Saga, Japan
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12
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McDowell K, Jhund PS, McMurray JJ. REPLY TO Dapagliflozin reduces uric acidconcentration, an independent predictor of adverse outcomes in DAPA-HF. Eur J Heart Fail 2022; 24:1994. [PMID: 36093864 DOI: 10.1002/ejhf.2686] [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: 09/06/2022] [Accepted: 09/08/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Kirsty McDowell
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - John Jv McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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13
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Doehner W, Anker SD, Butler J, Zannad F, Filippatos G, Ferreira JP, Salsali A, Kaempfer C, Brueckmann M, Pocock SJ, Januzzi JL, Packer M. Uric acid and sodium-glucose cotransporter-2 inhibition with empagliflozin in heart failure with reduced ejection fraction: the EMPEROR-reduced trial. Eur Heart J 2022; 43:3435-3446. [PMID: 35788657 PMCID: PMC9492270 DOI: 10.1093/eurheartj/ehac320] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 05/10/2022] [Accepted: 06/03/2022] [Indexed: 12/13/2022] Open
Abstract
Background The sodium-glucose cotransporter-2 inhibitor empagliflozin decreases the risk of cardiovascular death or hospitalization for heart failure (HF) in patients with HF with reduced ejection fraction. Empagliflozin reduces serum uric acid (SUA), but the relevance of this effect in patients with HF is unclear. This study aimed to investigate the effect of empagliflozin on SUA levels and the therapeutic efficacy of empagliflozin in relation to SUA. Methods The association between SUA and the composite primary outcome of cardiovascular death or hospitalization for worsening HF, its components, and all-cause mortality was investigated in 3676 patients of the EMPEROR-Reduced trial (98.6% of the study cohort). The treatment effect of empagliflozin was studied in relation to SUA as continuous variable, to clinical hyperuricaemia (SUA >5.7 mg/dL for women, >7.0 mg/dL for men) and in subgroups of patients of tertiles of SUA. Results Hyperuricaemia was prevalent in 53% of patients with no sex differences. Elevated SUA (highest tertile, mean SUA 9.38 ± 1.49 mg/dL) was associated with advanced severity of HF and with worst outcome [composite outcome, hazard ratio (HR) 1.64 (95% confidence interval, CI 1.28–2.10); cardiovascular mortality, HR 1.98 (95% CI 1.35–2.91); all-cause mortality, HR 1.8 (95% CI 1.29–2.49), all P < 0.001] in multivariate adjusted analyses, as compared with the lowest tertile. SUA was reduced following treatment with empagliflozin at 4 weeks (vs. placebo: −1.12 ± 0.04 mg/dL, P < 0.0001) and remained lower throughout follow-up, with a similar reduction in all prespecified subgroups. Empagliflozin reduced events of clinically relevant hyperuricaemia (acute gout, gouty arthritis or initiation of anti-gout therapy) by 32% [HR 0.68 (95% CI 0.52–0.89), P = 0.004]. The beneficial effect of empagliflozin on the primary endpoint was independent of baseline SUA [HR 0.76 (95% CI 0.65–0.88), P < 0.001) and of the change in SUA at 4 weeks [HR 0.81 (95% CI 0.69–0.95), P = 0.012]. As a hypothesis-generating finding, an interaction between SUA and treatment effect suggested a benefit of empagliflozin on mortality (cardiovascular and all-cause mortality) in patients in elevated SUA (P for interaction = 0.005 and = 0.011, respectively). Conclusion Hyperuricaemia is common in HF and is an independent predictor of advanced disease severity and increased mortality. Empagliflozin induced a rapid and sustained reduction of SUA levels and of clinical events related to hyperuricaemia. The benefit of empagliflozin on the primary outcome was observed independently of SUA.
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Affiliation(s)
- Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies, and Department of Cardiology (CVK), and German Centre for Cardiovascular Research Partner Site Berlin, and Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Stefan D Anker
- Berlin Institute of Health Center for Regenerative Therapies, and Department of Cardiology (CVK), and German Centre for Cardiovascular Research Partner Site Berlin, and Center for Stroke Research Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Javed Butler
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX 75226 USA.,Department of Medicine, University of Mississippi School of Medicine, Jackson, MS 39216, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy 54500, France
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, 12461, Haidari Athens, Greece
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy 54500, France.,UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, 4200-319 Porto, Portugal
| | - Afshin Salsali
- Heart Failure and Diabetes Global Development, Boehringer Ingelheim Pharmaceuticals, Inc, 900 Ridgebury Rd, Ridgefield, CT 06877, USA.,Faculty of Medicine, Rutgers University, New Brunswick, NJ 07103, USA
| | - Carolyn Kaempfer
- Faculty of Medicine, Rutgers University, New Brunswick, NJ 07103, USA.,mainanalytics GmbH, Sulzbach, Otto-Volger-Str. 3c, 65843 Sulzbach/Taunus, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International, Binger Str. 173, 55218 Ingelheim, Germany.,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Milton Packer
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.,Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas ,TX 75226 USA.,Imperial College, London SW7 2BX, UK
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14
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Carter S, Hendren NS, Grodin JL. Editorial Commentary for "Dapagliflozin reduces uric acid concentration, an independent predictor of adverse outcomes in DAPA-HF" by McDowell, K, et al. Eur J Heart Fail 2022; 24:1077-1079. [PMID: 35485178 DOI: 10.1002/ejhf.2516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/14/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Spencer Carter
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Nicholas S Hendren
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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15
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Leoncini G, Barnini C, Manco L, Nobili G, Dotta D, Penso M, Russo E, Cappadona F, Viazzi F, Pontremoli R. Uric acid lowering for slowing CKD progression after the CKD-FIX trial: a solved question or still a dilemma? Clin Kidney J 2022; 15:1666-1674. [PMID: 36003668 PMCID: PMC9394710 DOI: 10.1093/ckj/sfac075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Indexed: 11/17/2022] Open
Abstract
Hyperuricemia has been associated with several cardiovascular risk factors and is a well-known predictor of kidney disease. In vitro studies as well as animal models highlighted a role for uric acid in the development and progression of haemodynamic and tissue damage at the renal level leading to glomerular and tubulointerstitial abnormalities. Urate-lowering treatment, especially by xanthine oxidase inhibitors, has been proposed in order to improve kidney outcomes. However, recent randomized controlled trials failed to demonstrate a beneficial effect of allopurinol or febuxostat on renal disease, casting doubts on the role of this therapeutical approach to improve nephroprotection. We provide a critical overview of current literature on this topic and offer a possible interpretation of results from recent intervention trials with urate-lowering treatment on renal outcomes.
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Affiliation(s)
- Giovanna Leoncini
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Cecilia Barnini
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Luca Manco
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giulia Nobili
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Daniele Dotta
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Martina Penso
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Elisa Russo
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesca Cappadona
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesca Viazzi
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genova, Italy
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16
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McDowell K, Welsh P, Docherty KF, Morrow DA, Jhund PS, De Boer RA, O'Meara E, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, Hammarstedt A, Langkilde AM, Sjöstrand M, Lindholm D, Solomon SD, Sattar N, Sabatine MS, McMurray JJ. Dapagliflozin reduces uric acid concentration, an independent predictor of adverse outcomes in
DAPA‐HF. Eur J Heart Fail 2022; 24:1066-1076. [PMID: 35064721 PMCID: PMC9540869 DOI: 10.1002/ejhf.2433] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/06/2022] [Accepted: 01/09/2022] [Indexed: 11/08/2022] Open
Abstract
Aims Blood uric acid (UA) levels are frequently elevated in patients with heart failure and reduced ejection fraction (HFrEF), may lead to gout and are associated with worse outcomes. Reduction in UA is desirable in HFrEF and sodium–glucose cotransporter 2 inhibitors may have this effect. We aimed to examine the association between UA and outcomes, the effect of dapagliflozin according to baseline UA level, and the effect of dapagliflozin on UA in patients with HFrEF in the DAPA‐HF trial. Methods and results The association between UA and the primary composite outcome of cardiovascular death or worsening heart failure, its components, and all‐cause mortality was examined using Cox regression analyses among 3119 patients using tertiles of UA, after adjustment for other prognostic variables. Change in UA from baseline over 12 months was also evaluated. Patients in tertile 3 (UA ≥6.8 mg/dl) versus tertile 1 (<5.4 mg/dl) were younger (66.3 ± 10.8 vs. 68 ± 10.2 years), more often male (83.1% vs. 71.5%), had lower estimated glomerular filtration rate (58.2 ± 17.4 vs. 70.6 ± 18.7 ml/min/1.73 m2), and more often treated with diuretics. Higher UA was associated with a greater risk of the primary outcome (adjusted hazard ratio tertile 3 vs. tertile 1: 1.32, 95% confidence interval [CI] 1.06–1.66; p = 0.01). The risk of heart failure hospitalization and cardiovascular death increased by 7% and 6%, respectively per 1 mg/dl unit increase of UA (p = 0.04 and p = 0.07). Spline analysis revealed a linear increase in risk above a cut‐off UA value of 7.09 mg/dl. Compared with placebo, dapagliflozin reduced UA by 0.84 mg/dl (95% CI −0.93 to −0.74) over 12 months (p < 0.001). Dapagliflozin improved outcomes, irrespective of baseline UA concentration. Conclusion Uric acid remains an independent predictor of worse outcomes in a well‐treated contemporary HFrEF population. Compared with placebo, dapagliflozin reduced UA and improved outcomes irrespective of UA concentration.
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Affiliation(s)
- Kirsty McDowell
- BHF Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Paul Welsh
- BHF Cardiovascular Research Centre University of Glasgow Glasgow UK
| | | | - David A Morrow
- Cardiovascular Division, Department of Medicine Brigham and Women's Hospital Boston MA USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Rudolf A De Boer
- Department of Cardiology University Medical Center and University of Groningen Groningen Netherlands
| | - Eileen O'Meara
- Montreal Heart Institute Université de Montréal Montreal Quebec Canada
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Mikhail N. Kosiborod
- Saint Luke's Mid America Heart Institute University of Missouri Kansas City MO USA
- The George Institute for Global Health University of New South Wales Sydney Australisa
| | | | - Piotr Ponikowski
- Centre for Heart Diseases, University Hospital Wroclaw Medical University Wroclaw Poland
| | - Ann Hammarstedt
- Late Stage Development, Cardiovascular, Renal and Metabolism Biopharmaceuticals R&D Astrazeneca Gothenburg Sweden
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism Biopharmaceuticals R&D Astrazeneca Gothenburg Sweden
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism Biopharmaceuticals R&D Astrazeneca Gothenburg Sweden
| | - Daniel Lindholm
- Late Stage Development, Cardiovascular, Renal and Metabolism Biopharmaceuticals R&D Astrazeneca Gothenburg Sweden
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine Brigham and Women's Hospital Boston MA USA
| | - Naveed Sattar
- BHF Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Marc S. Sabatine
- TIMI Study Group, Cardiovascular Division Brigham and Women's Hospital, Harvard Medical School Boston MA USA
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17
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Zhang R, Sun X, Li Y, He W, Zhu H, Liu B, Zhang A. The Efficacy and Safety of Sacubitril/Valsartan in Heart Failure Patients: A Review. J Cardiovasc Pharmacol Ther 2022; 27:10742484211058681. [PMID: 34994233 DOI: 10.1177/10742484211058681] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure (HF) is one of the leading causes of morbidity and mortality worldwide. Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor, has been approved for the treatment of HF. At present, there have been few systematic and detailed reviews discussing the efficacy and safety of sacubitril/valsartan in HF. In this review, we first introduced the pharmacological mechanisms of sacubitril/valsartan, including the reduction in the degradation of natriuretic peptides in the natriuretic peptide system and inhibition of the renin-angiotensin system. Then, we summarized the efficacy of sacubitril/valsartan in HF patients with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF) including the reduction in risks of mortality and hospitalization, reversal of cardiac remodeling, regulation of biomarkers of HF, improvement of the quality of life, antiarrhythmia, improving renal dysfunction and regulation of metabolism. Finally, we discussed the safety and tolerability of sacubitril/valsartan in the treatment of HFrEF or HFpEF. Compared with ACEIs/ARBs or placebo, sacubitril/valsartan showed good safety and tolerability, although the risk of hypotension might be high. In conclusion, the overwhelming majority of studies show that sacubitril/valsartan is effective and safe in the treatment of HFrEF patients but that it has little benefit in HFpEF patients. Sacubitril/valsartan will probably be a promising anti-HF drug in the near future.
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Affiliation(s)
- Rui Zhang
- Department of Cardiology, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China.,Cardiac Care Unit, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China.,Cardiac Rehabilitation Centre, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Xiaotong Sun
- Shandong Provincial Medicine and Health Key Laboratory of Clinical Anesthesia, Department of Anesthesiology, Weifang Medical University, Weifang, China
| | - Ya Li
- Department of Cardiology, Shanghai General Hospital, School of Medicine, 12474Shanghai Jiaotong University, Hongkou District, Shanghai, China
| | - Wenzheng He
- Intensive Care Unit, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Hongguang Zhu
- Dental Department, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Baoshan Liu
- Department of Cardiology, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China.,Cardiac Care Unit, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China.,Cardiac Rehabilitation Centre, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China
| | - Aiyuan Zhang
- Department of Cardiology, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China.,Cardiac Care Unit, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China.,Cardiac Rehabilitation Centre, 117907Weifang People's Hospital, the First Affiliated Hospital of Weifang Medical University, Weifang, China
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18
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Azouz AA, Omar HA, Hersi F, Ali FEM, Hussein Elkelawy AMM. Impact of the ACE2 activator xanthenone on tacrolimus nephrotoxicity: Modulation of uric acid/ERK/p38 MAPK and Nrf2/SOD3/GCLC signaling pathways. Life Sci 2022; 288:120154. [PMID: 34800514 DOI: 10.1016/j.lfs.2021.120154] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 10/30/2021] [Accepted: 11/12/2021] [Indexed: 10/19/2022]
Abstract
AIMS The calcineurin inhibitor tacrolimus is an effective and widely used immunosuppressant after organ transplantation to reduce graft rejection. However, its nephrotoxic effect could compel the patients to treatment discontinuation. The beneficial effects of angiotensin-converting enzyme 2 (ACE2) on the kidney and other organs have been investigated in several studies, but its role in tacrolimus nephrotoxicity still needs to be elucidated. Our study was designed to investigate effects of the ACE2 activator xanthenone on tacrolimus-induced renal injury. MATERIALS AND METHODS Male Wistar rats were administered xanthenone (2 mg/kg) concurrently with tacrolimus (1 mg/kg) for 3 weeks, then blood and kidney tissue samples were collected for biochemical and molecular investigations. KEY FINDINGS Co-administration of xanthenone significantly improved renal functions in tacrolimus-treated rats, where serum creatinine, urea, and uric acid levels were close to those of the normal control. Besides, xanthenone reduced renal angiotensin (ANG) II content, while elevated ANG (1-7). Relative protein expressions of p-ERK/ERK and p-p38 MAPK/p38 MAPK inflammatory signals were downregulated upon xanthenone administration with tacrolimus. In addition, xanthenone reinforced antioxidant defense against tacrolimus by enhancing protein expression of the transcription factor Nrf2 with subsequently increased mRNA expressions of the antioxidants SOD3 and GCLC. SIGNIFICANCE These protective effects of xanthenone could be attributed to ANG II degradation to ANG (1-7) by ACE2 activation resulting in regulated inflammatory and oxidative responses in the kidney. Therefore, administration of xanthenone along with tacrolimus could be a promising therapeutic strategy to reduce the adverse effects and increase the tolerability to tacrolimus immunosuppressive therapy.
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Affiliation(s)
- Amany A Azouz
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62514, Egypt.
| | - Hany A Omar
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62514, Egypt; Sharjah Institute for Medical Research, University of Sharjah, United Arab Emirates
| | - Fatema Hersi
- Sharjah Institute for Medical Research, University of Sharjah, United Arab Emirates
| | - Fares E M Ali
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut 71524, Egypt
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Li TT, Li HY, Cheng J. Changes of serum uric acid and its clinical correlation in children with dilated cardiomyopathy. Transl Pediatr 2021; 10:3211-3217. [PMID: 35070835 PMCID: PMC8753472 DOI: 10.21037/tp-21-537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 12/14/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Dilated cardiomyopathy (DCM) is the most common type of childhood cardiomyopathy and uric acid (UA) is considered closely associated with cardiovascular disease. There are few reports about the relationship between serum UA level and DCM in children, and the present study aimed to analyze the changes and clinical correlation of the two. METHODS The clinical data of 49 children under 16 years old and who were hospitalized with DCM, and 44 healthy children who underwent physical examination in the same period at Tianjin Children's Hospital from June 2015 to November 2019 were analyzed retrospectively. RESULTS The 49 children in the case group included 17 males and 32 females, aged from 2 to 172 months. The case group were divided into New York Heart Association (NYHA) functional class I (n=2), class II (n=17), class III (n=11), and class IV (n=19). The 44 healthy children selected as the control group included 20 males and 24 females aged from 2 to 161 months. The serum UA level was detected, and an ultrasonic cardiogram was conducted in each child. The serum UA level, left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), and left atrial diameter (LAD) of the case group were higher than that of the control group, while the left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS) were lower than that of the control group, and significant statistical differences were seen between the two groups (P<0.01). The serum UA level, LVEDD, LVESD, and LAD of NYHAIII-IV class patients were higher than that of the NYHAI-II class, but LVEF and LVFS were lower than that of the NYHA I-II class, and there were significant statistical differences between the two groups (P<0.01). Statistical correlations were seen between the serum UA level and NYHA functional class, LVEDD, LVESD, LAD, LVEF, and LVFS (rs=0.599, 0.567, 0.579, 0.475, -0.333, -0.341, respectively, P<0.05). CONCLUSIONS Elevated serum UA levels exist in children with DCM and correlate with NYHA functional class and ultrasonic values. Change in serum UA levels may be used as a biomarker reflecting the severity of DCM in children.
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Affiliation(s)
- Ting-Ting Li
- Department of Cardiology, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin, China
| | - Hao-Ying Li
- Department of Cardiology, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin, China
| | - Ji Cheng
- Department of Cardiology, Tianjin Children's Hospital/Tianjin University Children's Hospital, Tianjin, China
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20
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Pascual-Figal D, Bayés-Genis A, Beltrán-Troncoso P, Caravaca-Pérez P, Conde-Martel A, Crespo-Leiro MG, Delgado JF, Díez J, Formiga F, Manito N. Sacubitril-Valsartan, Clinical Benefits and Related Mechanisms of Action in Heart Failure With Reduced Ejection Fraction. A Review. Front Cardiovasc Med 2021; 8:754499. [PMID: 34859070 PMCID: PMC8631913 DOI: 10.3389/fcvm.2021.754499] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/06/2021] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is a clinical syndrome characterized by the presence of dyspnea or limited exertion due to impaired cardiac ventricular filling and/or blood ejection. Because of its high prevalence, it is a major health and economic burden worldwide. Several mechanisms are involved in the pathophysiology of HF. First, the renin-angiotensin-aldosterone system (RAAS) is over-activated, causing vasoconstriction, hypertension, elevated aldosterone levels and sympathetic tone, and eventually cardiac remodeling. Second, an endogenous compensatory mechanism, the natriuretic peptide (NP) system is also activated, albeit insufficiently to counteract the RAAS effects. Since NPs are degraded by the enzyme neprilysin, it was hypothesized that its inhibition could be an important therapeutic target in HF. Sacubitril/valsartan is the first of the class of dual neprilysin and angiotensin receptor inhibitors (ARNI). In patients with HFrEF, treatment with sacubitril/valsartan has demonstrated to significantly reduce mortality and the rates of hospitalization and rehospitalization for HF when compared to enalapril. This communication reviews in detail the demonstrated benefits of sacubitril/valsartan in the treatment of patients with HFrEF, including reduction of mortality and disease progression as well as improvement in cardiac remodeling and quality of life. The hemodynamic and organic effects arising from its dual mechanism of action, including the impact of neprilysin inhibition at the renal level, especially relevant in patients with type 2 diabetes mellitus, are also reviewed. Finally, the evidence on the demonstrated safety and tolerability profile of sacubitril/valsartan in the different subpopulations studied has been compiled. The review of this evidence, together with the recommendations of the latest clinical guidelines, position sacubitril/valsartan as a fundamental pillar in the treatment of patients with HFrEF.
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Affiliation(s)
- Domingo Pascual-Figal
- Cardiology Department, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Antoni Bayés-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Department of Medicine, Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Autonomous University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Carlos III Institute of Health, Madrid, Spain
| | | | - Pedro Caravaca-Pérez
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Carlos III Institute of Health, Madrid, Spain
- Cardiology Service, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | | | - Maria G. Crespo-Leiro
- Advanced Heart Failure and Heart Transplant Unit, Cardiology Department, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
- Institute of Biomedical Research (INIBIC), A Coruña, Spain
| | - Juan F. Delgado
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Carlos III Institute of Health, Madrid, Spain
- Cardiology Service, Hospital Universitario 12 de Octubre, Madrid, Spain
- Faculty of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Javier Díez
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares, Carlos III Institute of Health, Madrid, Spain
- Cardiovascular Diseases Programme, Centre of Applied Medical Research, University of Navarra, Pamplona, Spain
- Departments of Nephrology, Cardiology, and Cardiac Surgery, University of Navarra Clinic, Pamplona, Spain
- Navarra Institute for Health Research, Pamplona, Spain
| | - Francesc Formiga
- Internal Medicine Department, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - Nicolás Manito
- Heart Failure and Heart Transplantation Unit, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
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21
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Angiotensin receptor-neprilysin inhibitors: Comprehensive review and implications in hypertension treatment. Hypertens Res 2021; 44:1239-1250. [PMID: 34290389 DOI: 10.1038/s41440-021-00706-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/16/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Abstract
Angiotensin receptor-neprilysin inhibitors (ARNIs) are a new class of cardiovascular agents characterized by their dual action on the major regulators of the cardiovascular system, including the renin-angiotensin system (RAS) and the natriuretic peptide (NP) system. The apparent clinical benefit of one ARNI, sacubitril/valsartan, as shown in clinical trials, has positioned the drug class as a first-line therapy in patients with heart failure, particularly with reduced ejection fraction. Accumulating evidence also suggests that sacubitril/valsartan is superior to conventional RAS blockers in lowering blood pressure in patients with hypertension. To decide whether to apply an ARNI to treat hypertension clinically, it is important to understand the potential properties of the drug in modulating multiple factors inside and outside the cardiovascular system beyond its effect on reducing peripheral blood pressure. In this context, ARNIs are distinct from preexisting antihypertensive medications in terms of the multiple actions of NPs in various organs and the pharmacological potential of neprilysin inhibitors to modulate multiple cardiac and noncardiac peptides. In particular, analysis of the clinical trials of sacubitril/valsartan implies that ARNIs can provide additional clinical benefits independent of their original purpose, including alleviation of glycemic control and renal impairment in patients with heart failure. Understanding the potential mechanisms of action of ARNIs will help interpret the relevance of their additional benefits beyond lowering blood pressure in hypertension. This review summarizes the comprehensive clinical evidence and relevance of ARNIs by specifically focusing on the potential properties of this new drug class in treating patients with hypertension.
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Abstract
Background Hyperuricemia is a state in which the serum levels of uric acid are elevated. As such it has a pronounced effect on vascular and renal function with their consequences, while also showing some antioxidant effects that show to be beneficial. Summary Hyperuricemia has shown to have a J-shaped relationship with mortality, is frequently associated with development and progression of heart and kidney disease, and is correlated with malnutrition-inflammation-atherosclerosis syndrome, although several Mendelian studies have failed to show an association with morbidity and mortality. Hyperuricemia is usually associated with gout flares and tophi development but can also present as asymptomatic hyperuricemia. It is still uncertain whether asymptomatic hyperuricemia is an independent risk factor for cardiovascular or renal disease and as such its treatment is questionable. Key messages Some possible tools for future decision making are the use of noninvasive techniques such as pulse wave analysis, urinary sediment analysis, and joint ultrasound, which could help identify individuals with asymptomatic hyperuricemia that could benefit from urate lowering therapy most.
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Affiliation(s)
- Tadej Petreski
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Robert Ekart
- Faculty of Medicine, University of Maribor, Maribor, Slovenia.,Department of Dialysis, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia
| | - Radovan Hojs
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Sebastjan Bevc
- Department of Nephrology, Clinic for Internal Medicine, University Medical Centre Maribor, Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
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23
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Gulab A, Torres R, Pelayo J, Lo KB, Shahzad A, Pradhan S, Rangaswami J. Uric acid as a cardiorenal mediator: pathogenesis and mechanistic insights. Expert Rev Cardiovasc Ther 2021; 19:547-556. [PMID: 34112023 DOI: 10.1080/14779072.2021.1941873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Introduction: The role of serum uric acid as a connector in cardiorenal interactions has been long debated and studied extensively in the past decade. Epidemiological, and clinical data suggest that hyperuricemia may be an independent risk factor as well as a strong predictor of morbidity and mortality in cardiovascular diseases (CVD) and renal diseases. New data suggesting that urate lowering therapies may improve outcomes in cardiovascular diseases have generated interest.Areas Covered: This review attempts to summarize the pathophysiological mechanisms by which hyperuricemia causes cardiorenal dysfunction. It also provides a summary of the recent evidence for urate lowering therapies and the possible underlying mechanisms which lead to cardiovascular benefits. This was a narrative review with essential references or cross references obtained via expert opinion.Expert Opinion: Emphasis on newer drugs that address the cardio-renal metabolic axis and the relation to their effects on uric acid may help further elucidate underlying mechanisms responsible for their cardiovascular and renal benefits. Once these benefits are well established, we will be able to come up with guidelines for targeting hyperuricemia. This can potentially lead to a change in clinical practice and can possibly lead to improved cardiovascular and renal outcomes.
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Affiliation(s)
- Asma Gulab
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Ricardo Torres
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Jerald Pelayo
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Kevin Bryan Lo
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Anum Shahzad
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Supriya Pradhan
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA
| | - Janani Rangaswami
- Department of Medicine, Einstein Medical Center, Philadelphia, PA, USA.,Department of Internal Medicine, Sidney Kimmel College of Thomas Jefferson University, Philadelphia, PA, USA
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24
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Verdiani V. Sacubitril/valsartan: from the PARADIGM-HF trial results to heart failure patients in internal medicine. A narrative review. ITALIAN JOURNAL OF MEDICINE 2021. [DOI: 10.4081/itjm.2021.1347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Data regarding the treatment of heart failure (HF) patients derived from randomized, controlled clinical trials, which, with rare exceptions, appear to be distant from the real world of internal medicine. Many trials have been conducted in cardiology departments: however, the characteristics of patients admitted to cardiology wards are largely different from those of patients hospitalized in internal medicine wards. Recently, the PARADIGM-HF study established the efficacy of sacubitril-valsartan – the first drug of the angiotensin II receptor neprilysin inhibitor (ARNI) class - versus enalapril in increasing survival and reducing hospitalizations in a selected population of HF patients with reduced ventricular function. Although practical guidance on the use of ARNI has been published, it is not specific to HF patients admitted to internal medicine wards. In this review, we examine all available data in order to understand if the characteristics of HF patients followed in internal medicine departments hinder or contraindicate the use of sacubitril-valsartan and what indications appear more appropriate in this setting.
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25
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Selvaraj S, Claggett BL, Pfeffer MA, Desai AS, Mc Causland FR, McGrath MM, Anand IS, Veldhuisen DJ, Kober L, Janssens S, Cleland JG, Pieske B, Rouleau JL, Zile MR, Shi VC, Lefkowitz MP, McMurray JJ, Solomon SD. Serum uric acid, influence of sacubitril–valsartan, and cardiovascular outcomes in heart failure with preserved ejection fraction:
PARAGON‐HF. Eur J Heart Fail 2020; 22:2093-2101. [DOI: 10.1002/ejhf.1984] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/06/2020] [Accepted: 08/17/2020] [Indexed: 01/05/2023] Open
Affiliation(s)
- Senthil Selvaraj
- Division of Cardiology, Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA USA
| | - Brian L. Claggett
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital Boston MA USA
| | - Marc A. Pfeffer
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital Boston MA USA
| | - Akshay S. Desai
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital Boston MA USA
| | | | - Martina M. McGrath
- Renal Division Brigham and Women's Hospital, Harvard Medical School Boston MA USA
| | - Inder S. Anand
- Department of Cardiovascular Medicine University of Minnesota Minneapolis MN USA
| | - Dirk J. Veldhuisen
- Department of Cardiology University of Groningen, University Medical Centre Groningen Groningen the Netherlands
| | - Lars Kober
- Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Stefan Janssens
- Department of Cardiology University Hospitals Leuven Belgium
| | - John G.F. Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit University of Glasgow Glasgow UK
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology German Centre for Cardiovascular Research partner site Berlin Berlin Germany
| | - Jean L. Rouleau
- Montreal Institute of Cardiology University of Montreal Montreal QC Canada
| | - Michael R. Zile
- Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center Charleston SC USA
| | | | | | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Scott D. Solomon
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital Boston MA USA
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26
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Packer M. Uric Acid Is a Biomarker of Oxidative Stress in the Failing Heart: Lessons Learned from Trials With Allopurinol and SGLT2 Inhibitors. J Card Fail 2020; 26:977-984. [PMID: 32890737 DOI: 10.1016/j.cardfail.2020.08.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/27/2020] [Accepted: 08/28/2020] [Indexed: 12/14/2022]
Abstract
Hyperuricemia increases the risk of heart failure, and higher levels of serum uric acid are seen in patients who have worse ventricular function, functional capacity, and prognosis. Heart failure is also accompanied by an upregulation of xanthine oxidase, the enzyme that catalyzes the formation of uric acid and a purported source of reactive oxygen species. However, the available evidence does not support the premise that either uric acid or the activation of xanthine oxidase has direct injurious effects on the heart in the clinical setting. Xanthine oxidase inhibitors (allopurinol and oxypurinol) have had little benefit and may exert detrimental effects in patients with chronic heart failure in randomized controlled trials, and the more selective and potent inhibitor febuxostat increases the risk of cardiovascular death more than allopurinol. Instead, the available evidence indicates that changes in xanthine oxidase and uric acid are biomarkers of oxidative stress (particularly in heart failure) and that xanthine oxidase may provide an important source of nitric oxide that quenches the injurious effects of reactive oxygen species. A primary determinant of the cellular redox state is nicotinamide adenine dinucleotide, whose levels drive an inverse relationship between xanthine oxidase and sirtuin-1, a nutrient deprivation sensor that exerts important antioxidant and cardioprotective effects. Interestingly, sodium-glucose cotransporter 2 inhibitors induce a state of nutrient deprivation that includes activation of sirtuin-1, suppression of xanthine oxidase, and lowering of serum uric acid. The intermediary role of sirtuin-1 in both uric acid-lowering and cardioprotection may explain why, in mediation analyses of large-scale cardiovascular trials, the effect of sodium-glucose cotransporter 2 inhibitors to decrease serum uric acid is a major predictor of the ability of these drugs to decrease serious heart failure events.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas and Imperial College, London, UK.
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27
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Mazza A, Townsend DM, Torin G, Schiavon L, Camerotto A, Rigatelli G, Cuppini S, Minuz P, Rubello D. The role of sacubitril/valsartan in the treatment of chronic heart failure with reduced ejection fraction in hypertensive patients with comorbidities: From clinical trials to real-world settings. Biomed Pharmacother 2020; 130:110596. [PMID: 34321170 PMCID: PMC8963534 DOI: 10.1016/j.biopha.2020.110596] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/13/2020] [Accepted: 07/28/2020] [Indexed: 12/20/2022] Open
Abstract
Background: Sacubitril/valsartan, the first agent to be approved in a new class of drugs called angiotensin receptor neprilysin inhibitors (ARNIs), has been shown to reduce cardiovascular mortality and morbidity compared to enalapril in outpatient subjects with chronic heart failure (HF) and reduced left ventricular ejection fraction (HFrEF). However, there is little real-world evidence about the efficacy of ARNIs in elderly hypertensive patients with HFrEF and comorbidities. Methods: In this prospective open-label study, 108 subjects, 54 of them (mean age 78.6 ± 8.2 years, 75.0 % male), with HFrEF (29.8 ± 4.3 %) and New York Heart Association (NYHA) class II-III symptoms were assigned to receive ARNIs twice daily, according to the recommended dosage of 24/26, 49/51, 97/103 mg. Patients were gender- and age-matched with a control arm of patients with HFrEF receiving the optimal standard therapy for HF. The clinic blood pressure (BP), N-terminal pro-B-type natriuretic peptide (NT-proBNP), estimated glomerular filtration rate (eGFR), blood glucose and glycated hemoglobin (HbA1c), uric acid (UA), left ventricular ejection fraction (LVEF) and NYHA class were evaluated at a mean follow-up of 12 months. During the follow-up, the clinical outcomes, including mortality and re-hospitalization for HF, were collected. Results: NYHA class significantly improved in the ARNI arm compared to the control (24.9 vs. 6.4 %, shifting from class III to II, and 55.4 vs. 25.2 %, from class II to I, p < 0.05 for all). A significant improvement in LVEF and eGFR levels was found in the ARNI arm compared to controls (42.4 vs. 34.2 %, 73.8 vs. 61.2 mL/min, respectively; p < 0.001 for all). NT-proBNP, clinic systolic and diastolic BP, blood glucose, HbA1c and UA values were reduced in both treatment arms, but they were lower in the ARNI arm compared controls (3107 vs. 4552 pg/mL, 112.2 vs. 120.4 and 68.8 vs. 75.6 mmHg, 108.4 vs. 112.6 mg/dL, 5.4 vs. 5.9 % and 5.9 vs. 6.4 mg/dL, respectively, p < 0.05). Mortality and re-hospitalization for HF was lower in the ARNI arm than controls (20.1 vs. 33.6 % and 27.7 vs. 46.3 % respectively; p < 0.05 for all). Gender differences were not found in either arm. No patients refused to continue the study, and no side effects to the ARNI treatment were observed. Conclusions: In elderly patients with HFrEF and comorbidities, ARNI treatment seems effective and safe. The improvement in LVEF and cardiac remodeling, BP, eGFR, serum glucose, UA and HbA1c could be the mechanisms by which ARNIs play their beneficial role on clinical outcomes. However, these results need to be confirmed in studies involving a greater number of subjects, and with a longer follow-up.
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Affiliation(s)
- Alberto Mazza
- ESH Excellence Hypertension Centre, Internal Medicine Unit, S. Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy.
| | - Danyelle M Townsend
- Department of Drug Discovery and Biomedical Sciences, Medical University of South Carolina, USA
| | - Gioia Torin
- ESH Excellence Hypertension Centre, Internal Medicine Unit, S. Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy; Unit of Internal Medicine, S. Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy
| | - Laura Schiavon
- ESH Excellence Hypertension Centre, Internal Medicine Unit, S. Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy; Unit of Internal Medicine, S. Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy
| | - Alessandro Camerotto
- Department of Diagnosis and Care, Clinical Laboratory, S. Maria della Misericordia General Hospital, Rovigo, Italy
| | - Gianluca Rigatelli
- Interventional Cardiology Unit, Division of Cardiology, S. Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy
| | - Stefano Cuppini
- Unit of Internal Medicine, S. Maria della Misericordia General Hospital, AULSS 5 Polesana, Rovigo, Italy
| | - Pietro Minuz
- Unit of Internal Medicine C, Department of Medicine, University of Verona, Verona, Italy
| | - Domenico Rubello
- Nuclear Medicine Unit, Santa Maria della Misericordia Hospital, Rovigo, Italy.
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28
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Cuthbert JJ, Pellicori P, Clark AL. Cardiovascular Outcomes with Sacubitril-Valsartan in Heart Failure: Emerging Clinical Data. Ther Clin Risk Manag 2020; 16:715-726. [PMID: 32848403 PMCID: PMC7425097 DOI: 10.2147/tcrm.s234772] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/28/2020] [Indexed: 12/11/2022] Open
Abstract
One of the defining features of heart failure (HF) is neurohormonal activation. The renin-angiotensin-aldosterone-system (RAAS) and sympathetic nervous system (SNS) cause vasoconstriction and fluid retention and, in response, the secretion of natriuretic peptides (NPs) from volume and pressure-overloaded myocardium promotes vasodilation and diuresis. Inhibition of the RAAS with either angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) has been the cornerstone of medical treatment for HF with a reduced ejection fraction (HFrEF) but, until recently, it was unclear how the beneficial effects of NPs may be augmented in patients with HF. Neprilysin, a metalloproteinase widely distributed throughout the body, plays a role in degrading the gross excess of circulating NPs in patients with HF. Early studies of neprilysin inhibition suggested possible physiological benefits. In 2014, the PARADIGM-HF trial found that sacubitril-valsartan, a combination of the ARB valsartan, and the neprilysin inhibitor sacubitril, was superior to enalapril in patients with HFrEF, reducing the relative risk of cardiovascular (CV) death or first hospitalisation with HF by 20%. Almost half of the patients with HF symptoms have a “preserved” ejection fraction (HFpEF); however, the PARAGON-HF study found that sacubitril-valsartan in patients with LVEF ≥45% had no effect on CV death or first and recurrent hospitalisations with HF compared to valsartan. Guidelines across the world have changed to include sacubitril-valsartan for patients with HFrEF yet, nearly 6 years after PARADIGM-HF, there is still uncertainty as to when and in whom sacubitril-valsartan should be started. Furthermore, there may yet be subsets of patients with HFpEF who might benefit from treatment with sacubitril-valsartan. This review will describe the mechanisms behind the outcome benefit of sacubitril-valsartan in patients with HFrEF and to consider its future role in the management of patients with HF.
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Affiliation(s)
- Joseph J Cuthbert
- Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Kingston upon Hull HU16 5JQ, UK
| | - Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Andrew L Clark
- Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Kingston upon Hull HU16 5JQ, UK
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Driggin E, Helmke S, De Los Santos J, Teruya S, Guadalupe S, Goldsmith J, Maurer MS. Markers of nutritional status and inflammation in transthyretin cardiac amyloidosis: association with outcomes and the clinical phenotype. Amyloid 2020; 27:73-80. [PMID: 31825676 DOI: 10.1080/13506129.2019.1698417] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Patients with transthyretin (TTR) cardiac amyloidosis demonstrate cardiac cachexia with progression of their cardiomyopathy, which is characterised by malnutrition and a heightened inflammatory state. How best to measure this condition is less well characterised. We investigated differences in survival among patients with ATTR cardiac amyloidosis by nutritional status as defined by modified BMI (mBMI) and by inflammatory state as defined by serum uric acid.Methods and results: This study was a retrospective analysis of patients diagnosed with ATTR cardiac amyloidosis at a single tertiary medical centre. Baseline characteristics were compared by nutritional status as measured by mBMI and by inflammatory state as measured by serum uric acid. Kaplan-Meier survival analyses were used to compare nutritional status and inflammatory status for the composite outcome of death. Cox proportional hazards modelling was used to assess predictors of death in this cohort. Three hundred patients (mean age 75 ± 11) years, 84.3% male) were included. Those with low mBMI (<1185 kg/m2 g/L) had shorter time to death (5.4 vs. 6.8 years, log rank p = .045) and those with elevated serum uric acid (>8.8 mg/dL) had shorter time to death (4.9 vs. 7.7 years, log rank p < .0001). Those with both low mBMI and elevated serum uric acid had the shortest time to death (4.3 years, log rank p = .005). In this cohort, mBMI was not a univariate predictor of death though there was a trend towards significance (HR 0.92, per 100 kg/m2 g/L, 95% CI 0.828-1.016, p = .099). Serum uric acid was a univariate predictor of death (HR 1.27 per 1 mg/dL, 95% CI 1.114-1.455, p < .001). In multivariate Cox analysis, this association remained significant (HR 1.31 per 1 mg/dL increase, 95% CI 1.096-1.560, p = .003) as well as in a separate stepwise model controlling for potential confounders including daily diuretic use, uric acid lowering therapy, and renal dysfunction.Conclusions: Both nutritional status as measured by mBMI and inflammation as measured by serum uric acid are associated with survival in patients with TTR cardiac amyloidosis however only serum uric acid is an independent predictor of death.
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Affiliation(s)
- Elissa Driggin
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Stephen Helmke
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | | | - Sergio Teruya
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Samantha Guadalupe
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Jeff Goldsmith
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
| | - Mathew S Maurer
- NewYork-Presbyterian Hospital/Columbia University Medical Center, New York, NY, USA
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Kramer F, Voss S, Roessig L, Igl BW, Butler J, Lam CSP, Maggioni AP, Shah SJ, Pieske B. Evaluation of high-sensitivity C-reactive protein and uric acid in vericiguat-treated patients with heart failure with reduced ejection fraction. Eur J Heart Fail 2020; 22:1675-1683. [PMID: 32216011 PMCID: PMC7687153 DOI: 10.1002/ejhf.1787] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 12/11/2022] Open
Abstract
Aims The effects of vericiguat vs. placebo on high‐sensitivity C‐reactive protein (hsCRP) and serum uric acid (SUA) were assessed in patients with heart failure with reduced ejection fraction (HFrEF) in the Phase 2 SOCRATES‐REDUCED study (NCT01951625). Methods and results Changes from baseline hsCRP and SUA values at 12 weeks with placebo and vericiguat (1.25 mg, 2.5 mg, 5.0 mg and 10.0 mg, respectively) were assessed. The probability of achieving an hsCRP value of ≤3.0 mg/L or SUA value of <7.0 mg/dL at week 12 was tested. Median baseline hsCRP and SUA levels were 3.68 mg/L [interquartile range (IQR) 1.41–8.41; n = 335] and 7.80 mg/dL (IQR 6.40–9.33; n = 348), respectively. Baseline‐adjusted mean percentage changes in hsCRP were 0.2%, −19.5%, −24.3%, −25.7% and −31.9% in the placebo and vericiguat 1.25 mg, 2.5 mg, 5.0 mg and 10.0 mg groups, respectively; significance vs. placebo was observed in the vericiguat 10.0 mg group (P = 0.035). Baseline‐adjusted mean percentage changes in SUA were 5.0%, −1.3%, −1.1%, −3.5% and −5.3% in the placebo, and vericiguat 1.25 mg, 2.5 mg, 5.0 mg and 10.0 mg groups, respectively; significance vs. placebo was observed in the 5.0 mg and 10.0 mg groups (P = 0.0202 and P = 0.004, respectively). Estimated probability for an end‐of‐treatment hsCRP value of ≤3.0 mg/L and SUA value of <7.0 mg/dL was higher with vericiguat compared with placebo. The effect was dose‐dependent, with the greatest effect observed in the 10.0 mg group. Conclusions Vericiguat treatment for 12 weeks was associated with reductions in hsCRP and SUA, and a higher likelihood of achieving an hsCRP value of ≤3.0 mg/L and SUA value of <7.0 mg/dL.
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Affiliation(s)
- Frank Kramer
- Medical Devices and eHealth Clinical, Bayer AG, Wuppertal, Germany
| | | | | | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Carolyn S P Lam
- National Heart Centre and Duke University-National University of Singapore, Singapore, Singapore.,University Medical Centre Groningen, Groningen, the Netherlands.,The George Institute for Global Health, Sydney, NSW, Australia
| | - Aldo P Maggioni
- Italian Association of Hospital Cardiologists (ANMCO) Research Centre, Florence, Italy
| | - Sanjiv J Shah
- 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 Universitätsmedizin Berlin, Berlin, Germany.,German Heart Centre Berlin (DHZB), Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany.,German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
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Prognostic Value of Serum Uric Acid in Hospitalized Heart Failure Patients With Preserved Ejection Fraction (from the Japanese Nationwide Multicenter Registry). Am J Cardiol 2020; 125:772-776. [PMID: 31898963 DOI: 10.1016/j.amjcard.2019.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/01/2019] [Accepted: 12/04/2019] [Indexed: 01/09/2023]
Abstract
Elevated serum uric acid (UA) is associated with an increased risk of cardiovascular disease and worse clinical outcome in patients with cardiovascular disease. Nevertheless, the prognostic value of serum UA level in hospitalized heart failure patients with preserved ejection fraction (HFpEF) has not been fully elucidated. The aim of this study was to investigate whether serum UA level on admission could be associated with subsequent mortality in hospitalized patients with HFpEF. We examined 516 consecutive hospitalized HFpEF (left ventricular ejection fraction ≥50%) patients with decompensated heart failure from our HFpEF-specific multicenter registry who had serum UA data on admission. The primary outcome of interest was all-cause death. During a median follow-up period of 749 (interquartile range 540 to 831) days, 90 (17%) patients died. Higher serum UA level was significantly related to increased incidence of all-cause death (p = 0.016). In addition, patients with higher serum UA (≥6.6 mg/dl, median) and plasma B-type natriuretic peptide (≥401.2 pg/ml, median) levels had the highest incidence of all-cause death in the groups (p = 0.002). In multivariable Cox regression analysis, serum UA was an independent determinant of mortality (hazards ratio 1.23, 95% confidence interval 1.10 to 1.39) even after adjustment for prespecified confounders, renal function and the use of diuretics before admission. In conclusions, higher admission serum UA was an independent determinant of mortality in hospitalized HFpEF patients. Our findings indicate the importance of assessing admission serum UA level for further risk stratification in hospitalized patients with HFpEF.
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Hsiao FC, Wang CL, Chang PC, Lu YY, Huang CY, Chu PH. Angiotensin Receptor Neprilysin Inhibitor for Patients With Heart Failure and Reduced Ejection Fraction: Real-World Experience From Taiwan. J Cardiovasc Pharmacol Ther 2019; 25:152-157. [DOI: 10.1177/1074248419872958] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Angiotensin receptor neprilysin inhibitor (ARNI) was recommended by major guidelines as the frontline therapy for heart failure with reduced ejection fraction (HFrEF) since its clinical benefit was proved in the Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure (PARADIGM-HF) trial. However, little is known about its safety and effectiveness in real-world practice, often with sicker and more fragile patients. In addition, East Asia population is underrepresented in PARADIGM-HF trial. Methods: We performed a retrospective analysis of patients who received ARNI in 3 medical institutes located in Northern Taiwan. Patients who received a prescription of at least 30 days of ARNI were enrolled. The date of first prescription was defined as the index date, and a period of 12 months preceding the index date was defined as the baseline period. Results: A total of 452 patients were identified (age: 61.9 ± 15.0, male: 79.4%). Compared to PARADIGM-HF populations, our patients had higher values of baseline serum creatinine (mean: 1.5 vs 1.1 mg/dL) and B-type natriuretic peptide (BNP; median: 554.5 vs 255 pg/mL). After 12 months, 41.6% of the patients received less than half of the standard dose. Overall, all-cause death, cardiovascular death, and heart failure readmission rate were 3.0%, 1.1%, and 6.9% in 12 months, respectively. In those who had both baseline and 12-month data, renal function did not change (1.7-1.8 mg/dL, P = .091), left ventricular ejection fraction improved (30.8%-36.8%, P < .001), BNP decreased (777.0-655.8 pg/mL, P = .032), and uric acid decreased (7.5-7.1 mg/dL, P = .009). Conclusion: In our study, patients with HFrEF had higher BNP and serum creatinine level at baseline and had received lower dose of ARNI than the PARADIGM-HF populations. Angiotensin receptor neprilysin inhibitor appeared to be safe as regard renal function and effective in real-world practice. Left ventricular reverse remodeling was observed 1 year after heart failure medication treatment, including ARNI.
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Affiliation(s)
- Fu-Chih Hsiao
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Chun-Li Wang
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Po-Cheng Chang
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Yu-Ying Lu
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Chien-Ying Huang
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
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Sutton Burke EM, Kelly TC, Shoales LA, Nagel AK. Angiotensin Receptor Blockers Effect on Serum Uric Acid-A Class Effect? J Pharm Pract 2019; 33:874-881. [PMID: 31390929 DOI: 10.1177/0897190019866315] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE To provide a comprehensive review to determine whether there is a class effect among angiotensin receptor blockers (ARBs) in relation to serum uric acid. SUMMARY A literature search was conducted and 8 articles were identified for inclusion in this review. In the studies reviewed, candesartan and valsartan were shown to have either a neutral or negative effect on serum uric acid. Azilsartan was shown to have a negative impact on serum uric acid while eprosartan appeared to have no impact on serum uric acid levels. Irbesartan demonstrated either a neutral or positive effect on serum uric acid while losartan exhibited a positive effect. CONCLUSION The available data indicate that the reduction of serum uric acid is not a class effect of ARBs. Of the available agents, only losartan has clear evidence of its ability to lower serum uric acid. For patients with high blood pressure and elevated serum uric acid, losartan should be considered as a first-line agent with irbesartan as an alternative when appropriate.
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Affiliation(s)
- Elizabeth M Sutton Burke
- Pharmacy Practice and Administration, 242956Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
| | - Tessa C Kelly
- Pharmacy Practice and Administration, 242956Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
| | - Lindsey A Shoales
- Pharmacy Practice and Administration, 242956Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
| | - Angela K Nagel
- Pharmacy Practice and Administration, 242956Wegmans School of Pharmacy, St. John Fisher College, Rochester, NY, USA
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Canepa M, Ameri P, Lucci D, Nicolosi GL, Marchioli R, Porcu M, Tognoni G, Franzosi MG, Latini R, Maseri A, Tavazzi L, Maggioni AP. Modes of death and prognostic outliers in chronic heart failure. Am Heart J 2019; 208:100-109. [PMID: 30580128 DOI: 10.1016/j.ahj.2018.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 11/18/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The impact of incident sudden cardiac death (SCD) on the predictive accuracy of prognostic risk scores for patients with chronic heart failure (HF) has rarely been examined. We assessed the relationship between estimated probability of death and modes of death in this population, as well as the predictors of death and survival in prognostic outliers. METHODS AND RESULTS The MAGGIC 3-year probability of death was estimated in 6,859 participants of the GISSI-HF trial (mean age 67±11 years, 78% men, 91% with ejection fraction <40%, mean follow-up 3.5±1.3 years, observed mortality 28.4%). The incidence of SCD progressively decreased with increased probability of death, and occurred in 52.5% of patients estimated at low-risk (N = 61 with probability <14%) vs. in 23.5% of the high-risk ones (N = 375 with probability >56%, P < .0001). On the contrary, death from worsening HF was significantly more frequent in the latter group (19.7% vs. 46.1%, P < .0001). The overall predictive accuracy of the MAGGIC model improved after excluding deaths from SCD (AUC from 0.731 to 0.760, P = .0034). Among patients estimated at low-risk (N = 61 dead, 743 alive), independent predictors of death were older age, longer history of HF, higher serum uric acid and chronic obstructive pulmonary disease. The only predictor of survival in patients estimated at high-risk (N = 210 alive, 375 dead) was higher systolic blood pressure. CONCLUSIONS The MAGGIC risk score demonstrated its scarce ability to capture SCD, particularly in chronic HF patients estimated at low risk of death. Newer and better prognostic tools in the evolving horizon of HF are needed.
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Affiliation(s)
- Marco Canepa
- Cardiovascular Disease Unit, Policlinic Hospital San Martino IRCCS & Department of Internal Medicine, University of Genova, Genova, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, Policlinic Hospital San Martino IRCCS & Department of Internal Medicine, University of Genova, Genova, Italy
| | - Donata Lucci
- ANMCO Research Centre, Florence, Fondazione per il Tuo cuore - HCF onluse, Florence, Italy
| | - Gian Luigi Nicolosi
- Department of Cardiology, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | | | - Maurizio Porcu
- Dipartimento Cardio-Toraco-Vascolare, Azienda Ospedaliera G. Brotzu-San Michele, Cagliari, Italy
| | - Gianni Tognoni
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Maria Grazia Franzosi
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Roberto Latini
- Department of Cardiovascular Research, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | - Attilio Maseri
- Fondazione per il Tuo cuore - HCF onlus, Florence, Italy
| | - Luigi Tavazzi
- Scientific Direction, Maria Cecilia Hospital, GVM Care and Research, Ettore Sansavini Health Science Foundation, Cotignola, Italy
| | - Aldo Pietro Maggioni
- ANMCO Research Centre, Florence, Fondazione per il Tuo cuore - HCF onluse, Florence, Italy.
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Manolis AS, Manolis TA, Manolis AA, Melita H. Neprilysin Inhibitors: Filling a Gap in Heart Failure Management, Albeit Amidst Controversy and at a Significant Cost. Am J Cardiovasc Drugs 2019; 19:21-36. [PMID: 29926350 DOI: 10.1007/s40256-018-0289-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Dual angiotensin and neprilysin inhibition using the combination drug sacubitril-valsartan has ushered in a new era in the treatment of heart failure (HF). The randomized controlled PARADIGM-HF trial, which randomized 8399 patients with HF to enalapril or sacubitril-valsartan, showed a 20% reduction in mortality and HF hospitalization with the new drug. This has been heralded as a step toward filling a crucial gap in HF management by providing strong evidence that combined inhibition of the angiotensin receptor and neprilysin is superior to inhibition of the renin-angiotensin system alone in stable patients with chronic HF as it negates the deleterious effects of angiotensin while concomitantly augmenting the beneficial effects of the endogenous natriuretic peptide system. This new therapy is costly, and other confirmatory studies have been lacking for over 2 years since its approval by major regulatory authorities. As such, controversy and heated discussions have amassed, as has detailed information from a plethora of secondary analyses of this pivotal trial about the pros and cons of this promising new therapeutic strategy in HF management. The aim of this review was to provide a critical assessment of all these aspects.
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Affiliation(s)
- Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Vas. Sofias 114, 115 27, Athens, Greece.
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Costanzo MR. Uric acid is important, but there is something that matters even more: to deliver sacubitril/valsartan to eligible heart failure patients. Eur J Heart Fail 2018; 20:523-524. [DOI: 10.1002/ejhf.1087] [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: 10/18/2017] [Accepted: 10/29/2017] [Indexed: 11/12/2022] Open
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