Novel drug targets in clinical development for heart failure

The recent advance and prospect of natural source compounds for the treatment of heart failure

Heart failure is a continuously developing syndrome of cardiac insufficiency caused by diseases, which becomes a major disease endangering human health as well as one of the main causes of death in patients with cardiovascular diseases. The occurrence of heart failure is related to hemodynamic abnormalities, neuroendocrine hormones, myocardial damage, myocardial remodeling etc, lead to the clinical manifestations including dyspnea, fatigue and fluid retention with complex pathophysiological mechanisms. Currently available drugs such as cardiac glycoside, diuretic, angiotensin-converting enzyme inhibitor, vasodilator and β receptor blocker etc are widely used for the treatment of heart failure. In particular, natural products and related active ingredients have the characteristics of mild efficacy, low toxicity, multi-target comprehensive efficacy, and have obvious advantages in restoring cardiac function, reducing energy disorder and improving quality of life. In this review, we mainly focus on the recent advance including mechanisms and active ingredients of natural products for the treatment of heart failure, which will provide the inspiration for the development of more potent clinical drugs against heart failure.

Novelties in the pharmacological approaches for chronic heart failure: new drugs and cardiovascular targets

Despite recent advances in chronic heart failure (HF) management, the prognosis of HF patients is poor. This highlights the need for researching new drugs targeting, beyond neurohumoral and hemodynamic modulation approach, such as cardiomyocyte metabolism, myocardial interstitium, intracellular regulation and NO-sGC pathway. In this review we report main novelties on new possible pharmacological targets for HF therapy, mainly on new drugs acting on cardiac metabolism, GCs-cGMP pathway, mitochondrial function and intracellular calcium dysregulation.

A transitive perspective on the relief of psychosomatic symptoms

A key element of successful psychotherapy for the treatment of psychosomatic disorders is that patients recognize and change the meaning of their experiences. Such changes are brought about by appropriate verbal referencing of symptoms currently experienced within a given narrative. The present theoretical paper argues that changes are not based on better, more adaptive narratives per se, but on the transition (or linkage) process itself that is experienced between different narratives. This view is theoretically justified in various ways: first, it is accounted for through contemporary spatiotemporal neuroscience, which aims to connect mental and structural aspects via a common dynamic property or, according to Northoff, the "common currency" of a brain's orientation along its embeddedness in its contextual world, i.e., body and environment. Second, it is justified through the physics concept of "spontaneous symmetry breaking," which is used analogously to "suffering from symptoms." If the sufferer is willing to experience a process of "going back," that is, moving away from the previous narrative (or aspect) by verbally relating to the felt aspects of the symptom in question (i.e., approaching its meaning), they are moving toward symmetry or an underlying dynamic alignment with their world context. Clinical predictions are derived from the theoretical arguments.

Development and validation of a clinical predictive model for 1-year prognosis in coronary heart disease patients combine with acute heart failure

Background

The risk factors for acute heart failure (AHF) vary, reducing the accuracy and convenience of AHF prediction. The most common causes of AHF are coronary heart disease (CHD). A short-term clinical predictive model is needed to predict the outcome of AHF, which can help guide early therapeutic intervention. This study aimed to develop a clinical predictive model for 1-year prognosis in CHD patients combined with AHF.

Materials and methods

A retrospective analysis was performed on data of 692 patients CHD combined with AHF admitted between January 2020 and December 2020 at a single center. After systemic treatment, patients were discharged and followed up for 1-year for major adverse cardiovascular events (MACE). The clinical characteristics of all patients were collected. Patients were randomly divided into the training (n = 484) and validation cohort (n = 208). Step-wise regression using the Akaike information criterion was performed to select predictors associated with 1-year MACE prognosis. A clinical predictive model was constructed based on the selected predictors. The predictive performance and discriminative ability of the predictive model were determined using the area under the curve, calibration curve, and clinical usefulness.

Results

On step-wise regression analysis of the training cohort, predictors for MACE of CHD patients combined with AHF were diabetes, NYHA ≥ 3, HF history, Hcy, Lp-PLA2, and NT-proBNP, which were incorporated into the predictive model. The AUC of the predictive model was 0.847 [95% confidence interval (CI): 0.811–0.882] in the training cohort and 0.839 (95% CI: 0.780–0.893) in the validation cohort. The calibration curve indicated good agreement between prediction by nomogram and actual observation. Decision curve analysis showed that the nomogram was clinically useful.

Conclusion

The proposed clinical prediction model we have established is effective, which can accurately predict the occurrence of early MACE in CHD patients combined with AHF.

Cross-Talk between Mechanosensitive Ion Channels and Calcium Regulatory Proteins in Cardiovascular Health and Disease

Mechanosensitive ion channels are widely expressed in the cardiovascular system. They translate mechanical forces including shear stress and stretch into biological signals. The most prominent biological signal through which the cardiovascular physiological activity is initiated or maintained are intracellular calcium ions (Ca²⁺). Growing evidence show that the Ca²⁺ entry mediated by mechanosensitive ion channels is also precisely regulated by a variety of key proteins which are distributed in the cell membrane or endoplasmic reticulum. Recent studies have revealed that mechanosensitive ion channels can even physically interact with Ca²⁺ regulatory proteins and these interactions have wide implications for physiology and pathophysiology. Therefore, this paper reviews the cross-talk between mechanosensitive ion channels and some key Ca²⁺ regulatory proteins in the maintenance of calcium homeostasis and its relevance to cardiovascular health and disease.

Discovery of Novel Multi-target Inhibitor of angiotensin type 1 receptor and neprilysin inhibitors from Traditional Chinese Medicine

Angiotensin II type-1 receptor–neprilysin inhibitor (ARNi) is consisted of Angiotensin II type-1 receptor (AT1) antagonist and neprilysin (NEP) inhibitor, which could simultaneously increase the vasodilators of the natriuretic peptides and antagonize vasoconstrictors of Ang II. ARNi has been proved a superior effect and lower risks of death on chronic heart failure (CHF) and hypertension. In this paper, ARNi from Traditional Chinese Medicines (TCM) was discovered based on target combination of AT1 and NEP by virtual screening, biological assay and molecular dynamics (MD) simulations. Two customized strategies of combinatorial virtual screening were implemented to discover AT1 antagonist and NEP inhibitor based on pharmacophore modeling and docking computation respectively. Gyrophoric acid (PubChem CID: 135728) from Parmelia saxatilis was selected as AT1 antagonist and assayed with IC₅₀ of 29.76 μM by calcium influx assay. And 3,5,3′-triiodothyronine (PubChem CID: 861) from Bos taurus domesticus was screened as NEP inhibitor and has a dose dependent inhibitory activity by biochemistry fluorescence assay. Combined with MD simulations, these compounds can generate interaction with the target, key interactive residues of ARG167, TRP84, and VAL108 in AT1, and HIS711 in NEP were also identified respectively. This study designs the combinatorial strategy to discover novel frames of ARNi from TCM, and gyrophoric acid and 3,5,3′-triiodothyronine could provide the clues and revelations of drug design and therapeutic method of CHF and hypertension for TCM clinical applications.

Impact of Event Severity on Hospital Rankings Based on Heart Failure Readmission Rates

The Medicare Readmissions Reduction Program penalizes hospitals with higher than expected readmission rates after discharge for congestive heart failure (CHF). This exploratory study analyzed whether categorizing readmissions by event severity might have implications for the program. The authors used the 5% MedPAR (Medicare Provider and Analysis Review) data for 2008 to 2014 and ranked 1820 hospitals based on all readmissions, readmissions for CHF, short-stay CHF readmissions, and readmissions for severe CHF with evidence of cardiogenic shock. Ranking hospitals based on severe CHF readmissions changes their relative rank order significantly compared to counting all readmissions. If confirmed in the full Medicare data, the finding could inform the design of the Readmission Reduction Program.

The involvement of Nox4 in fine particulate matter exposure-induced cardiac injury in mice

Epidemiological studies have confirmed that ambient fine particulate matter (PM_2.5) exposure is associated with cardiovascular disease (CVD). However, the underlying mechanisms in PM_2.5 exposure-induced heart injury are largely unknown. It has been acknowledged that NADPH oxidase (Nox) 4 plays a critical role in CVD development. To investigate the acute effects of PM_2.5 on the mouse heart and the role of Nox4 in PM_2.5 exposure-induced cardiac injury, C57BL/6J mice were instilled with saline or 1.5, 3.0, 6.0 mg/kg BW PM_2.5 suspension for two weeks (five days per week). The levels of malondialdehyde (MDA), super oxide dismutase (SOD), inducible nitric oxide synthase (iNOS), tumor necrosis factor-α (TNF-α) and interleukin (IL)-1β in heart supernatants were determined using related kits. The expression of Nox4, p67^phox, p47^phox and p22^phox in heart tissue was evaluated by immunofluorescence staining or Western blotting, respectively. Protein levels of p53, Bax, Bcl-2 and Caspase-3 in the heart were examined using immunohistochemical staining and Western blotting. TUNEL assay was used to measure myocardial apoptosis. PM_2.5 exposure leads to obvious cardiac injury. PM_2.5 exposure increases MDA level and iNOS activity, and decreases activity of SOD in heart supernatants of mice. High levels of TNF-α and IL-1β in heart supernatants of mice with PM_2.5 instillation were determined. Nox4 and Nox-associated subunits such as p67^phox, p47^phox and p22^phox expression levels were increased in heart tissue of mice after PM_2.5 exposure. Additionally, PM_2.5 exposure causes myocardial apoptosis in the mouse heart. This study suggested that Nox4 is involved in PM_2.5 exposure-induced cardiac injury in mice.

Developing Drugs for Heart Failure With Reduced Ejection Fraction: What Have We Learned From Clinical Trials?

There remains a large unmet need for new therapies in the treatment of heart failure with reduced ejection fraction (HFrEF). In the early drug development phase, the therapeutic potential of a drug is not yet fully understood and trial endpoints other than mortality are needed to guide drug development decisions. While a true surrogate marker for mortality in heart failure (HF) remains elusive, the successes and failures of previous trials can reveal markers that support clinical Go/NoGo decisions.

Atrial natriuretic peptide: A novel mediator for TGF-β1-induced epithelial-mesenchymal transition in 16HBE-14o and A549 cells

Atrial natriuretic peptide (ANP) is increasingly expressed on airway and inhibits pulmonary arterial remodeling. However, the role of ANP in remodeling of respiratory system is still unclear. The role of ANP on airway remodeling and the possible mechanism was explored in this study. Both human bronchial epithelial 16HBE-14o cells and alveolar epithelial A549 cells were stimulated by TGF-β1, ANP, cGMP inhibitor, PKG inhibitor, and cGMP analogue. The expressions of epithelial markers, mesenchymal markers, and Smad3 were assessed by quantitative real-time PCR and western blotting. Immunohistochemical staining was employed to assess Smad3 expression once it was silenced by siRNA in 16HBE-14o or A549 cells. Our results showed that the mRNA and protein expressions of E-Cadherin were decreased, whereas α-SMA expressions were increased after induction by TGF-β1 in 16HBE-14o and A549 cells. The E-Cadherin expressions were increased and α-SMA expressions were decreased after ANP stimulation. Inhibition of cGMP or PKG decreased E-Cadherin expression but increased α-SMA expression, which could be reversed by cGMP analogue. Moreover, the phosphorylated Smad3 expression was consistent with α-SMA expression. After smad3 was silenced, Smad3 was mostly expressed in cytoplasm instead of nucleus as non-silenced cells during epithelial-mesenchymal transition (EMT). In conclusion, ANP inhibits TGF-β1-induced EMT in 16HBE-14o and A549 cells through cGMP/PKG signaling, by which it targets TGF-β1/Smad3 via attenuating phosphorylation of Smad3. These findings suggest the potential of ANP in the treatment on pulmonary diseases with airway remodeling.

Efficacy and Safety of 1-Hour Infusion of Recombinant Human Atrial Natriuretic Peptide in Patients With Acute Decompensated Heart Failure: A Phase III, Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial

The aim of the study was to evaluate the efficacy and safety of 1-h infusion of recombinant human atrial natriuretic peptide (rhANP) in combination with standard therapy in patients with acute decompensated heart failure (ADHF). This was a phase III, randomized, double-blind, placebo-controlled, multicenter trial. Eligible patients with ADHF were randomized to receive a 1-h infusion of either rhANP or placebo at a ratio of 3:1 in combination with standard therapy. The primary endpoint was dyspnea improvement (a decrease of at least 2 grades of dyspnea severity at 12 h from baseline). Reduction in pulmonary capillary wedge pressure (PCWP) 1 h after infusion was the co-primary endpoint for catheterized patients. Overall, 477 patients were randomized: 358 (93 catheterized) patients received rhANP and 118 (28 catheterized) received placebo. The percentage of patients with dyspnea improvement at 12 h was higher, although not statistically significant, in the rhANP group than in the placebo group (32.0% vs 25.4%, odds ratio=1.382, 95% confidence interval [CI]: 0.863-2.212, P = 0.17). Reduction in PCWP at 1 h was significantly greater in patients treated with rhANP than in patients treated with placebo (-7.74 ± 5.95 vs -1.82 ± 4.47 mm Hg, P < 0.001). The frequencies of adverse events and renal impairment within 3 days of treatment were similar between the 2 groups. Mortality at 1 month was 3.1% in the rhANP group vs 2.5% in the placebo group (hazard ratio = 1.21, 95% CI: 0.34-4.26; P > 0.99). 1-h rhANP infusion appears to result in prompt, transient hemodynamic improvement with a small, nonsignificant, effect on dyspnea in ADHF patients receiving standard therapy. The safety of 1-h infusion of rhANP seems to be acceptable. (WHO International Clinical Trials Registry Platform [ICTRP] number, ChiCTR-IPR-14005719.).

From canonical to non-canonical cyclic nucleotides as second messengers: pharmacological implications

This review summarizes our knowledge on the non-canonical cyclic nucleotides cCMP, cUMP, cIMP, cXMP and cTMP. We place the field into a historic context and discuss unresolved questions and future directions of research. We discuss the implications of non-canonical cyclic nucleotides for experimental and clinical pharmacology, focusing on bacterial infections, cardiovascular and neuropsychiatric disorders and reproduction medicine. The canonical cyclic purine nucleotides cAMP and cGMP fulfill the criteria of second messengers. (i) cAMP and cGMP are synthesized by specific generators, i.e. adenylyl and guanylyl cyclases, respectively. (ii) cAMP and cGMP activate specific effector proteins, e.g. protein kinases. (iii) cAMP and cGMP exert specific biological effects. (iv) The biological effects of cAMP and cGMP are terminated by phosphodiesterases and export. The effects of cAMP and cGMP are mimicked by (v) membrane-permeable cyclic nucleotide analogs and (vi) bacterial toxins. For decades, the existence and relevance of cCMP and cUMP have been controversial. Modern mass-spectrometric methods have unequivocally demonstrated the existence of cCMP and cUMP in mammalian cells. For both, cCMP and cUMP, the criteria for second messenger molecules are now fulfilled as well. There are specific patterns by which nucleotidyl cyclases generate cNMPs and how they are degraded and exported, resulting in unique cNMP signatures in biological systems. cNMP signaling systems, specifically at the level of soluble guanylyl cyclase, soluble adenylyl cyclase and ExoY from Pseudomonas aeruginosa are more promiscuous than previously appreciated. cUMP and cCMP are evolutionary new molecules, probably reflecting an adaption to signaling requirements in higher organisms.