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Haertel F, Nuding S, Reisberg D, Peters M, Werdan K, Schulze PC, Ebelt H. The Prognostic Value of a Liver Function Test Using Indocyanine Green (ICG) Clearance in Patients with Multiple Organ Dysfunction Syndrome (MODS). J Clin Med 2024; 13:1039. [PMID: 38398351 PMCID: PMC10888702 DOI: 10.3390/jcm13041039] [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: 11/14/2023] [Revised: 01/22/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) is common in intensive care units (ICUs) and is associated with high mortality. Although there have been multiple investigations into a multitude of organ dysfunctions, little is known about the role of liver dysfunction. In addition, clinical and laboratory findings of liver dysfunction may occur with a significant delay. Therefore, the aim of this study was to investigate whether a liver function test, based on indocyanine green (ICG)-clearance, contains prognostic information for patients in the early phase of MODS. METHODS The data of this analysis were based on the MODIFY study, which included 70 critically ill patients of a tertiary medical ICU in the early phase of MODS (≤24 h after diagnosis by an APACHE II score ≥ 20 and a sinus rhythm ≥ 90 beats per minute, with the following subgroups: cardiogenic (cMODS) and septic MODS (sMODS)) over a period of 18 months. ICG clearance was characterized by plasma disappearance rate = PDR (%/min); it was measured non-invasively by using the LiMON system (PULSION Medical Systems, Feldkirchen, Germany). The PDR was determined on the day of study inclusion (baseline) and after 96 h. The primary endpoint of this analysis was 28-day mortality. RESULTS ICG clearance was measured in 44 patients of the MODIFY trial cohort, of which 9 patients had cMODS (20%) and 35 patients had sMODS (80%). Mean age: 59.7 ± 16.5 years; 31 patients were men; mean APACHE II score: 33.6 ± 6.3; 28-day mortality was 47.7%. Liver function was reduced in the total cohort as measured by a PDR of 13.4 ± 6.3%/min At baseline, there were no relevant differences between survivors and non-survivors regarding ICG clearance (PDR: 14.6 ± 6.1%/min vs. 12.1 ± 6.5%/min; p = 0.21). However, survivors showed better liver function than non-survivors after 96 h (PDR: 21.9 ± 6.3%/min vs. 9.2 ± 6.3%/min, p < 0.05). Consistent with these findings, survivors but not non-survivors show a significant improvement in the PDR (7.3 ± 6.3%/min vs. -2.9 ± 2.6%/min; p < 0.01) within 96 h. In accordance, receiver-operating characteristic curves (ROCs) at 96 h but not at baseline show a link between the PDR and 28-day mortality (PDR at 96 h: AUC: 0.87, 95% CI: 0.76-0.98; p < 0.01. CONCLUSIONS In our study, we found that ICG clearance at baseline did not provide prognostic information in patients in the early stages of MODS despite being reduced in the total cohort. However, improvement of ICG clearance 96 h after ICU admission is associated with reduced 28-day mortality.
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Affiliation(s)
- Franz Haertel
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Sebastian Nuding
- Department of Internal Medicine III, Cardiology University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle, Germany
- Department of Internal Medicine II, Cardiology, Hospital St. Elisabeth and St. Barbara Halle (Saale), Mauerstraße 5, 06110 Halle (Saale), Germany
| | - Diana Reisberg
- Department of pediatrics, Ameos Hospital Aschersleben, Eislebener Str. 7A, 06449 Aschersleben, Germany
| | - Martin Peters
- Department of Internal Medicine, Helios Hospital Jerichower Land, August-Bebel-Str. 55a, 39288 Burg, Germany
| | - Karl Werdan
- Department of Internal Medicine III, Cardiology University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle, Germany
| | - P. Christian Schulze
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
| | - Henning Ebelt
- Department of Internal Medicine III, Cardiology University Hospital Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle, Germany
- Department of Internal Medicine II, Cardiology, Catholic Hospital “St. Johann Nepomuk”, Haarbergstr. 72, 99097 Erfurt, Germany
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Supthut W, Nuding S, Wienke A, Müller-Werdan U, Werdan K, Ebelt H. [Relationship between cardiac output, heart rate and microcirculation in patients with multiorgan dysfunction syndrome]. Med Klin Intensivmed Notfmed 2023:10.1007/s00063-023-01086-9. [PMID: 38038767 DOI: 10.1007/s00063-023-01086-9] [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: 06/18/2023] [Revised: 10/15/2023] [Accepted: 10/29/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) is one of the main causes of death in intensive care units. There is evidence that microcirculation in sepsis and coronary shock is regulated separately from hemodynamics. This study investigates the relationship between heart rate (HR), cardiac output (CO) and microcirculation in patients with MODS. METHODS This is a partial analysis of the "MODIFY study" (Reducing Elevated Heart Rate in Patients With Multiple Organ Dysfunction Syndrome [MODS] by Ivabradine). During the period 05/2010-09/2011, the microcirculation of 46 patients with septic and coronary MODS was measured using the sidestream dark field technique on the day of inclusion and 96 h later. Patients were randomized into a control and ivabradine treatment group. RESULTS Overall, there is a relevant improvement in microcirculation over time small perfused vessels, SPV [%] on day 0, d0:56.5 ± 34.2/d4:73.2 ± 22.1 (p = 0.03); perfused vessel density, PVDsmall [1/mm2] d0:7.5 ± 5.0/d4:9.8 ± 3.4 (p = 0.04); proportion of perfused vessels, PPVsmall [%] d0:51.6 ± 31.6/d4:66.7 ± 21.8 (p = 0.04); microcirculatory flow index, MFI d0:1.7 ± 1.0/d4:2.2 ± 0.7 (p = 0.05). Administration of ivabradine shows no effect. In patients with coronary MODS, there is a relevant correlation between microcirculatory parameters and cardiac output (SPV [%]: r = 0.98, p = 0.004). Patients with coronary MODS show better microcirculation values at high heart rates (> 100 bpm), while patients with septic MODS show an opposite relationship. CONCLUSION The results indicate that in critically ill patients, depending on the genesis of the MODS, there are different relationships between HF or CO values, on the one hand, and the parameters of the microcirculation, on the other.
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Affiliation(s)
- Wiebke Supthut
- Klinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland.
| | - Sebastian Nuding
- Medizinische Klinik II, Krankenhaus St. Elisabeth und St. Barbara, Halle (Saale), Deutschland
| | - Andreas Wienke
- Institut für Medizinische Epidemiologie, Biometrie und Informatik, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Ursula Müller-Werdan
- Klinik für Geriatrie und Altersmedizin und EGZB, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Karl Werdan
- Klinik für Innere Medizin III, Universitätsklinikum Halle (Saale), Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland
| | - Henning Ebelt
- Klinik für Innere Medizin II, Katholisches Krankenhaus St. Johann Nepomuk, Erfurt, Deutschland
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Haertel F, Reisberg D, Peters M, Nuding S, Schulze PC, Werdan K, Ebelt H. Predicting the Need for Renal Replacement Therapy Using a Vascular Occlusion Test and Tissue Oxygen Saturation in Patients in the Early Phase of Multiorgan Dysfunction Syndrome. J Clin Med 2022; 11:jcm11051420. [PMID: 35268511 PMCID: PMC8911273 DOI: 10.3390/jcm11051420] [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: 01/11/2022] [Revised: 02/19/2022] [Accepted: 03/02/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Acute kidney injury (AKI) is associated with an increased mortality in critically ill patients, especially in patients with multiorgan dysfunction syndrome (MODS). In daily clinical practice, the grading of AKI follows the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. In most cases, a relevant delay occurs frequently between the onset of AKI and detectable changes in creatinine levels as well as clinical symptoms. The aim of the present study was to examine whether a near infrared spectroscopy (NIRS)-based, non-invasive ischemia–reperfusion test (vascular occlusion test (VOT)) together with unprovoked (under resting conditions) tissue oxygen saturation (StO2) measurements, contain prognostic information in the early stage of MODS regarding the developing need for renal replacement therapy (RRT). Methods: Within a period of 18 months, patients at the medical intensive care unit of a tertiary university hospital with newly developed MODS (≤24 h after diagnosis, APACHE II score ≥20) were included in our study. The VOT occlusion slope (OS) and recovery slope (RS) were recorded in addition to unprovoked StO2. StO2 was determined non-invasively in the area of the thenar muscles using a bedside NIRS device. The VOT was carried out by inflating a blood pressure cuff on the upper arm. AKI stages were determined by the changes in creatinine levels, urinary output, and/or the need for RRT according to KDIGO. Results: 56 patients with MODS were included in the study (aged 62.5 ± 14.4 years, 40 men and 16 women, APACHE II score 34.5 ± 6.4). Incidences of the different AKI stages were: no AKI, 16.1% (n = 9); AKI stage I, 19.6% (n = 11); AKI stage II, 25% (n = 14); AKI stage III, 39.3% (n = 22). Thus, 39.3% of the patients (n = 22) developed the need for renal replacement therapy (AKI stage III). These patients had a significantly higher mortality over 28 days (RRT, 72% (n = 16/22) vs. no RRT, 44% (n = 15/34); p = 0.03). The mean unprovoked StO2 of all patients at baseline was 81.7 ± 11.1%, and did not differ between patients with or without the need for RRT. Patients with RRT showed significantly weaker negative values of the OS (−9.1 ± 3.7 vs. −11.7 ± 4.1%/min, p = 0.01) and lower values for the RS (1.7 ± 0.9 vs. 2.3 ± 1.6%/s, p = 0.02) compared to non-dialysis patients. Consistent with these results, weaker negative values of the OS were found in higher AKI stages (no AKI, −12.7 ± 4.1%/min; AKI stage I, −11.5 ± 3.0%/min; AKI stage II, −11.1 ± 3.3%/min; AKI stage III, −9.1 ± 3.7%/min; p = 0.021). Unprovoked StO2 did not contain prognostic information regarding the AKI stages. Conclusions: The weaker negative values of the VOT parameter OS are associated with an increased risk of developing AKI and RRT, and increased mortality in the early phase of MODS, while unprovoked StO2 does not contain prognostic information in that regard.
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Affiliation(s)
- Franz Haertel
- Klinik für Innere Medizin I, Universitaetsklinikum Jena, Am Klinikum 1, 07747 Jena, Germany;
- Klinik für Innere Medizin III, Universitaetsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany; (D.R.); (M.P.); (S.N.); (K.W.); (H.E.)
- Correspondence: ; Tel.: +49-3641-9324-554
| | - Diana Reisberg
- Klinik für Innere Medizin III, Universitaetsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany; (D.R.); (M.P.); (S.N.); (K.W.); (H.E.)
- Klinik für Pädiatrie, Ameos Klinikum Aschersleben, Eislebener Str. 7A, 06449 Aschersleben, Germany
| | - Martin Peters
- Klinik für Innere Medizin III, Universitaetsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany; (D.R.); (M.P.); (S.N.); (K.W.); (H.E.)
- Klinik für Innere Medizin, Helios Klinikum Jerichower Land, August-Bebel-Str. 55a, 39288 Burg, Germany
| | - Sebastian Nuding
- Klinik für Innere Medizin III, Universitaetsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany; (D.R.); (M.P.); (S.N.); (K.W.); (H.E.)
- Klinik für Innere Medizin II, Krankenhaus “St. Elisabeth”, Mauerstr. 5, 06110 Halle (Saale), Germany
| | - P. Christian Schulze
- Klinik für Innere Medizin I, Universitaetsklinikum Jena, Am Klinikum 1, 07747 Jena, Germany;
| | - Karl Werdan
- Klinik für Innere Medizin III, Universitaetsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany; (D.R.); (M.P.); (S.N.); (K.W.); (H.E.)
| | - Henning Ebelt
- Klinik für Innere Medizin III, Universitaetsklinikum Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany; (D.R.); (M.P.); (S.N.); (K.W.); (H.E.)
- Klinik für Innere Medizin II, Katholisches Krankenhaus “St. Johann Nepomuk”, Haarbergstr. 72, 99097 Erfurt, Germany
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Prognostic Value of Tissue Oxygen Saturation Using a Vascular Occlusion Test in Patients in the Early Phase of Multiorgan Dysfunction Syndrome. Shock 2020; 51:706-712. [PMID: 30052575 DOI: 10.1097/shk.0000000000001225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple organ dysfunction syndrome (MODS) is a common disease pattern in intensive care units which is associated with an increased mortality. The aim of this study was to investigate whether a near-infrared spectroscopy (NIRS)-based noninvasive ischemia-reperfusion test (vascular occlusion test) using the parameter of tissue oxygen saturation (StO2) contains prognostic information for patients in the early phase of MODS. METHODS Within a period of 18 months between 2010 and 2012, 56 patients who newly developed MODS (≤24 h after diagnosis, Acute Physiology and Chronic Health Evaluation [APACHE] II score ≥20, subgroups: cardiogenic MODS [cMODS] and septic MODS [sMODS]) were included into the study. The StO2 was determined non-invasively in the area of the thenar muscles using a bedside NIRS device, InSpectra Tissue Spectrometer Model 650 (Hutchinson Technology Inc., Hutchinson, MN). The VOT was carried out by inflating a blood pressure cuff on the upper arm 30 mmHg above systolic blood pressure for 5 min. The parameters occlusion slope (OS) and recovery slope (RS) were recorded. RESULTS Fifteen patients with cMODS and 41 patients with sMODS were included in the study (age: 62.5 ± 14.4 years, 40 men and 16 women, APACHE II score: 34.6 ± 6.4). Twenty-eight-day-mortality was 55.4% (cMODS: 7 out of 15 patients, sMODS: 24 out of 41 patients). The measurement of StO2 while applying the VOT at baseline showed an OS of -11.7 ± 3.7%/min and an RS of 2.2 ± 1.5%/s. Survivors had significantly better values compared with non-survivors at baseline regarding OS (-12.8 ± 3.5%/min vs. -9.8 ± 3.4%/min; P = 0.016) and RS (2.6 ± 1.7%/s vs. 1.6 ± 1.0%/s; P = 0.022). Receiver-operating characteristic (ROC) curves show that the area under the curve (AUC) for OS was found to be significantly related to 28-day mortality (AUC: 0.7; 95% confidence interval [CI]: 0.56-0.85; P = 0.01). However, using both univariate and multivariate binary logistic regression models, RS was significantly associated with increased 28-day mortality (OR [univariate model]: 1.21 [95% CI: 1.1-1.8]; OR [multivariate model]: 1.23 [95% CI: 1.1-1.3]). CONCLUSIONS Impaired values of the VOT-parameters OS and RS are associated with an increased 28-day mortality in patients in the early phase of MODS.
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Sathyamurthy I, Newale S. Ivabradine: Evidence and current role in cardiovascular diseases and other emerging indications. Indian Heart J 2018; 70 Suppl 3:S435-S441. [PMID: 30595304 PMCID: PMC6309574 DOI: 10.1016/j.ihj.2018.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/31/2018] [Accepted: 08/05/2018] [Indexed: 12/18/2022] Open
Abstract
Increased heart rate (HR) is associated with deleterious effects on several disease conditions. Chronic heart failure (CHF) is one of the cardiovascular diseases with recurrent hospitalization burden and an ongoing drain on health-care expenditure. Despite advancement in medicine, management of CHF remains a challenge to health-care providers. Ivabradine selectively and specifically inhibits the pacemaker I(f) ionic current which reduces the cardiac pacemaker activity. The main effect of ivabradine therapy is the substantial lowering of HR. It does not influence intracardiac conduction, contractility, or ventricular repolarization. As shown in numerous clinical studies, ivabradine improves clinical outcomes and quality of life and reduces the risk of death from heart failure (HF) or other cardiovascular causes. Recently updated HF guidelines recommend ivabradine as a class II indication for reduction of HF hospitalizations. Based on the principle of benefits of reduced HR, the ivabradine in patients with ischemic heart disease, sepsis, and multiple organ dysfunction syndrome has also been studied. It can also be a useful agent for HR reduction in patients with contraindications to use beta-blockers or those who cannot tolerate them. In this review, we provide an overview of efficacy and safety of ivabradine and its combination with currently recommended pharmacological therapy in different conditions.
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Affiliation(s)
- I Sathyamurthy
- Dept of Cardiology, Apollo Hospitals, Chennai, 600006, India.
| | - Sanket Newale
- Dr. Newale Health Centre, Navi Mumbai, 400614, India.
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Wen W, Wang K, Jiang ZM, Zhang ZH, Zhou L. Continuous blood purification ameliorates clinical signs and corrects the plasma phospholipid levels of patients with multiple organ dysfunction syndromes. J Clin Lab Anal 2018; 32:e22411. [PMID: 29457280 DOI: 10.1002/jcla.22411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 01/24/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Multiple organ dysfunction syndromes (MODS) is reported as a leading cause of mortality in intensive care units. Recently, continuous blood purification (CBP) has been mostly applied for MODS treatment. Thus, the purpose of this study was to investigate the effects of CBP on plasma phospholipid level in patients with MODS. METHODS A total of 126 patients with MODS and 120 healthy people were collected. The serum cytokine levels, blood biochemical parameters, and blood gas indexes were detected, and the correlation among phospholipid compounds with serum cytokine levels, blood biochemical parameters, and blood gas indexes was analyzed. RESULTS Before CBP, levels of body temperature, RR, HR, CVP, IL-6, IL-10, TNF-α, BUN, SCr, PaCO2 , SM747, and LPC540 were obviously higher, and pH, HCO3- , PaO2 , SaO2 , PE750, PI885, PC792, PC826, PC830, PC854, PC802, and PG747 were lower in the MODS group than those in the control group. During CBP, the MODS group had gradually declined RR, CVP, levels of IL-6, IL-10 and TNF-α, BUN, SCr, PaCO2 , SM747, and LPC540 and increased HCO3- , PaO2 and SaO2 , PE750, PI885, PC792, PC826, PC830, PC854, PC802, and PG747. Besides, levels of PE750, PI885, PC792, PC826, PC830, PC854, PC802, and PG747 had an obvious negative correlation with levels of TNF-α, IL-10, IL-6, BUN, SCr, and PaCO2 , and a significant positive correlation with levels of HCO3- , PaO2 , and SaO2 . CONCLUSION CBP could effectively ameliorate clinical signs of patients with MODS and correct the plasma phospholipid levels.
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Affiliation(s)
- Wei Wen
- Department of Intensive Care Unit, Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Kun Wang
- Department of Business Management, Shandong Center for Disease Control and Prevention, Jinan, China
| | - Zhi-Ming Jiang
- Department of Intensive Care Unit, Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Zhong-Hui Zhang
- Department of Intensive Care Unit, Shandong Provincial Qianfoshan Hospital, Jinan, China
| | - Lei Zhou
- Department of Intensive Care Unit, Shandong Provincial Qianfoshan Hospital, Jinan, China
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[Prognostic relevance of tissue oxygen saturation in patients in the early stage of multiple organ dysfunction syndrome]. Med Klin Intensivmed Notfmed 2018; 114:146-153. [PMID: 29671035 DOI: 10.1007/s00063-018-0438-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 11/16/2017] [Accepted: 11/22/2017] [Indexed: 10/17/2022]
Abstract
BACKGROUND Patients in circulatory shock exhibit insufficient peripheral perfusion to ensure adequate oxygenation of vital organs such as the heart and brain. Early detection of reduced tissue oxygen saturation (StO2) could be used for rapid therapeutic intervention and thus improve the prognosis of patients in the early stage of multiple organ dysfunction syndrome (MODS). MATERIALS AND METHODS A total of 60 patients in the early stage of MODS (APACHE [Acute Physiology and Chronic Health Evaluation] II score ≥20) were investigated in a monocentric, prospective, randomized phase II study. StO2 was measured using the InSpectraTM StO2 system and compared with known indicators of hypoxia (peripheral oxygen saturation [SpO2], arterial oxygen saturation [SaO2], central venous oxygen saturation [ScvO2], pH, serum lactate). Clinical endpoints of the study were 28-day and 6‑month mortality as well as the need for invasive mechanical ventilation and renal replacement therapy during the hospital stay, respectively. RESULTS An increased 28-day and 6‑month mortality is found for patients with StO2 <75% in contrast to patients with StO2 ≥75%. Correlations of StO2 with SpO2, ScvO2, and serum lactate are confirmed. Patients with reduced StO2 tend to show a higher disease severity as measured by APACHE II score. CONCLUSION StO2 shows prognostic relevance in patients at the early stage of MODS. Thus, the rapid and noninvasive assessment of StO2 could be useful in risk stratification of these patients.
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Reducing Elevated Heart Rates in Patients with Multiple Organ Dysfunction Syndrome with The I f (Funny Channel Current) Inhibitor Ivabradine. Shock 2018; 49:402-411. [DOI: 10.1097/shk.0000000000000992] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Oliva F, Sormani P, Contri R, Campana C, Carubelli V, Cirò A, Morandi F, Di Tano G, Mortara A, Senni M, Metra M, Ammirati E. Heart rate as a prognostic marker and therapeutic target in acute and chronic heart failure. Int J Cardiol 2018; 253:97-104. [DOI: 10.1016/j.ijcard.2017.09.191] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 06/12/2017] [Accepted: 09/22/2017] [Indexed: 12/28/2022]
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If Channel Inhibition With Ivabradine Does Not Improve Cardiac and Vascular Function in Experimental Septic Shock. Shock 2018; 46:297-303. [PMID: 26909707 DOI: 10.1097/shk.0000000000000593] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Previous studies have suggested that lowering heart rate (HR) by selective β1-blockers improves sepsis-induced cardiac and vascular dysfunction primarily by decreasing proinflammatory pathways. However, the impact of isolated heart rate reduction (HRR) on hemodynamics and inflammatory pathways remains unknown. The present study was designed to assess the effects of HRR by ivabradine, an If channel inhibitor, on cardiovascular function and inflammatory pathways in peritonitis-induced septic shock in rats. DESIGN Randomized animal study. SETTING University research laboratory. INTERVENTIONS Four hours after cecal ligation and puncture (CLP), Wistar rats were randomly allocated to the following groups: CLP (n = 8) and CLP + ivabradine (n = 8, administered per os 4 h after the surgery). Another eight Wistar male rats underwent sham operation. All rats received a continuous infusion of saline (10 mL kg h), analgesic (nalbuphine: 0.2 mg kg h), and antibiotics (imipenem and cilastatin sodium: 10 mg kg) 4 h after the surgery. Assessment at 18 h included hemodynamics, in vivo cardiac function by echocardiography, and ex vivo vasoreactivity by myography. Circulating cytokine levels (TNF-α, IL-6, and IL-10) were measured by ELISA, whereas cardiac and vascular protein expressions of NF-κB/IκBα/iNOS and Akt/eNOS were assessed by Western blotting. RESULTS Compared with sham animals, CLP induced tachycardia, hypotension, decreased cardiac output, hyperlactatemia, and vascular hyporesponsiveness to vasopressors. Compared with the CLP group, adjunction of ivabradine decreased the HR without any impact on blood pressure, lactatemia, or vascular responsiveness to vasopressors. Adjunction of ivabradine to CLP rats had no impact on TNF-α, IL-6, and IL-10 cytokines, or on the protein expression levels of phosphorylated forms of NF-κB, Akt, eNOS, and degradation of IκBα in cardiac and vascular tissues. CONCLUSION Isolated HRR by ivabradine in an experimental model of septic shock does not appear to be associated with any effect on the tested parameters of cardiac function or on vascular responsiveness to vasopressors. Moreover, in this setting, ivabradine does not alter the circulating levels of selected pro/anti-inflammatory cytokines or cardiac and vascular NF-κB/IκBα protein expression levels.
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Müller-Werdan U, Stöckl G, Werdan K. Advances in the management of heart failure: the role of ivabradine. Vasc Health Risk Manag 2016; 12:453-470. [PMID: 27895488 PMCID: PMC5118024 DOI: 10.2147/vhrm.s90383] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
A high resting heart rate (≥70–75 b.p.m.) is a risk factor for patients with heart failure (HF) with reduced ejection fraction (EF), probably in the sense of accelerated atherosclerosis, with an increased morbidity and mortality. Beta-blockers not only reduce heart rate but also have negative inotropic and blood pressure-lowering effects, and therefore, in many patients, they cannot be given in the recommended dose. Ivabradine specifically inhibits the pacemaker current (funny current, If) of the sinoatrial node cells, resulting in therapeutic heart rate lowering without any negative inotropic and blood pressure-lowering effect. According to the European Society of Cardiology guidelines, ivabradine should be considered to reduce the risk of HF hospitalization and cardiovascular death in symptomatic patients with a reduced left ventricular EF ≤35% and sinus rhythm ≥70 b.p.m. despite treatment with an evidence-based dose of beta-blocker or a dose below the recommended dose (recommendation class “IIa” = weight of evidence/opinion is in favor of usefulness/efficacy: “should be considered”; level of evidence “B” = data derived from a single randomized clinical trial or large nonrandomized studies). Using a heart rate cutoff of ≥ 75 b.p.m., as licensed by the European Medicines Agency, treatment with ivabradine 5–7.5 mg b.i.d. reduces cardiovascular mortality by 17%, HF mortality by 39% and HF hospitalization rate by 30%. A high resting heart rate is not only a risk factor in HF with reduced EF but also at least a risk marker in HF with preserved EF, in acute HF and also in special forms of HF. In this review, we discuss the proven role of ivabradine in the validated indication “HF with reduced EF” together with interesting preliminary findings, and the potential role of ivabradine in further, specific forms of HF.
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Affiliation(s)
| | - Georg Stöckl
- Department of Medical Affairs, Servier Deutschland GmbH, Munich
| | - Karl Werdan
- Department of Medicine III, University Hospital Halle (Saale), Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
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13
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Ebelt H, Geißler I, Ruccius S, Otto V, Hoffmann S, Korth H, Klöckner U, Zhang Y, Li Y, Grossmann C, Rueckschloss U, Gekle M, Stieber J, Frantz S, Werdan K, Müller-Werdan U, Loppnow H. Direct inhibition, but indirect sensitization of pacemaker activity to sympathetic tone by the interaction of endotoxin with HCN-channels. Clin Exp Pharmacol Physiol 2016; 42:874-80. [PMID: 25933122 DOI: 10.1111/1440-1681.12415] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 04/08/2015] [Accepted: 04/19/2015] [Indexed: 01/09/2023]
Abstract
In critically ill patients regulation of heart-rate is often severely disturbed. Interaction of bacterial endotoxin (lipopolysaccharide, LPS) with hyperpolarization-activated cyclic nucleotide-gated cation-(HCN)-channels may interfere with heart-rate regulation. This study analyzes the effect of LPS, the HCN-channel blocker ivabradine or Ca(2+) -channel blockers (nifedipine, verapamil) on pacemaking in spontaneously beating neonatal rat cardiomyocytes (CM) in vitro. In vivo, the effect of LPS on the heart-rate of adult CD1-mice with and without autonomic blockade is analyzed telemetrically. LPS (100 ng/mL) and ivabradine (5 μg/mL) reduced the beating-rate of CM by 20.1% and 24.6%, respectively. Coincubation of CM with both, LPS and ivabradine, did not further reduce the beating-rate, indicating interaction of both compounds with HCN-channels, while coincubation with Ca(2+) -channel blockers and LPS caused additive beating-rate reduction. In CD1-mice (containing an active autonomic-nervous-system), injection of LPS (0.4 mg/kg) expectedly resulted in increased heart-rate. However, if the autonomic nervous system was blocked by propranolol and atropine, in line with the in vitro data, LPS induced a significant reduction of heart-rate, which was not additive to ivabradine. The in vivo and in vitro results indicate that LPS interacts with HCN-channels of cardiomyocytes. Thus, LPS indirectly sensitizes HCN-channels for sympathetic activation (tachycardic-effect), and in parallel directly inhibits channel activity (bradycardic-effect). Both effects may contribute to the detrimental effects of septic cardiomyopathy and septic autonomic dysfunction.
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Affiliation(s)
- Henning Ebelt
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Isabel Geißler
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Sara Ruccius
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Volker Otto
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Sophie Hoffmann
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Heinrich Korth
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Udo Klöckner
- Julius-Bernstein-Institute of Physiology, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Germany
| | - Ying Zhang
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Yi Li
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Claudia Grossmann
- Julius-Bernstein-Institute of Physiology, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Germany
| | - Uwe Rueckschloss
- Julius-Bernstein-Institute of Physiology, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Germany
| | - Michael Gekle
- Julius-Bernstein-Institute of Physiology, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Germany
| | - Juliane Stieber
- Institute of Experimental and Clinical Pharmacology and Toxicology, University of Erlangen, Erlangen, Germany
| | - Stefan Frantz
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Karl Werdan
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Ursula Müller-Werdan
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.,Chair of Geriatrics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Harald Loppnow
- Department of Internal Medicine III, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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Abstract
Elevated resting heart rate has been linked to poor outcomes in patients with chronic systolic heart failure. Blockade of funny current channel with ivabradine reduces heart rate without inotropic effects. Ivabradine was recently approved by US Food and Drug Administration for patients with stable, symptomatic chronic heart failure (HF) with left ventricular ejection fraction (LVEF) ≤35 %, who are in sinus rhythm with resting heart rate (HR) ≥ 70 bpm and either are on maximally tolerated doses of beta-blockers, or have a contraindication to beta-blockers. This article will review and evaluate the data supporting the use of ivabradine in patients with HF and explore its mechanisms and physiologic effects.
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Affiliation(s)
- Gabriela Orasanu
- Advanced Heart Failure and Transplantation Center, Harrington Heart & Vascular Institute, Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Sadeer G Al-Kindi
- Advanced Heart Failure and Transplantation Center, Harrington Heart & Vascular Institute, Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106, USA
| | - Guilherme H Oliveira
- Advanced Heart Failure and Transplantation Center, Harrington Heart & Vascular Institute, Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH, 44106, USA.
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Chaudhary R, Garg J, Krishnamoorthy P, Shah N, Lanier G, Martinez MW, Freudenberger R. Ivabradine: Heart Failure and Beyond. J Cardiovasc Pharmacol Ther 2015; 21:335-43. [PMID: 26721645 DOI: 10.1177/1074248415624157] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 11/16/2015] [Indexed: 11/16/2022]
Abstract
Heart failure affects over 5 million people in the United States and carries a high rate of mortality. Ivabradine, a new agent has been added to the current medical options for managing heart failure. It is a selective funny current (If) inhibitor in sinoatrial node and slows its firing rate, prolonging diastolic depolarization without a negative inotropic effect. Ivabradine was only recently approved by Food and Drug administration after the results of Systolic Heart Failure Treatment with the If Inhibitor Ivabradine (SHIFT) trial, for a reduction in rehospitalizations from chronic heart failure. This trial assessed patients with stable heart failure with reduced ejection fraction and a heart rate of at least 70 beats per minute at rest on maximally tolerated beta-blocker therapy and demonstrated statistically significant reduction in heart failure hospitalization and deaths. Additionally, ivabradine has been associated with reduced cardiac remodeling, reduced heart rate variability, improvement in exercise tolerance, improved heart failure class of New York Heart Association, and better quality of life. It has also been tried in other conditions, such as inappropriate sinus tachycardia and cardiogenic shock, and is currently in phase II trial for patients with newly diagnosed multiple organ dysfunction syndrome.
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Affiliation(s)
- Rahul Chaudhary
- Department of Medicine, Sinai Hospital of Baltimore, Johns Hopkins University, Baltimore, MD, USA
| | - Jalaj Garg
- Division of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Parasuram Krishnamoorthy
- Department of Medicine, Englewood Hospital and Medical Center, Mount Sinai School of Medicine, Englewood, NJ, USA
| | - Neeraj Shah
- Division of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
| | - Gregg Lanier
- Division of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Mathew W Martinez
- Division of Cardiology, Lehigh Valley Health Network, Allentown, PA, USA
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Bonadei I, Vizzardi E, Sciatti E, Carubelli V, Lombardi CM, D'Aloia A, Metra M. Is there a role for ivabradine beyond its conventional use? Cardiovasc Ther 2015; 32:189-92. [PMID: 24828443 DOI: 10.1111/1755-5922.12080] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Results of recent clinical trials in patients with stable angina and chronic heart failure have successfully demonstrated a beneficial role of use of ivabradine in addition to the conventional therapy. Based on the results of these trials, the aim of our review was to give an overview of the literature about the use of ivabradine in clinical settings outside its usual purpose.
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Affiliation(s)
- Ivano Bonadei
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Study of Brescia, Brescia, Italy
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Böhm M, Reil JC, Deedwania P, Kim JB, Borer JS. Resting heart rate: risk indicator and emerging risk factor in cardiovascular disease. Am J Med 2015; 128:219-28. [PMID: 25447617 DOI: 10.1016/j.amjmed.2014.09.016] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 09/10/2014] [Accepted: 09/17/2014] [Indexed: 12/14/2022]
Abstract
Resting heart rate is central to cardiac output and is influenced by changes occurring in numerous diseases. It predicts longevity and cardiovascular diseases, and current evidence suggests that it is also an important marker of outcome in cardiovascular disease, including heart failure. Beta-blockers improve outcomes in heart failure; however, they have effects outside reducing heart rate. Ivabradine has demonstrated efficacy in reducing rehospitalizations and mortality in heart failure and in improving exercise tolerance and reducing angina attacks in patients with coronary artery disease, whereas selective heart rate reduction may also prove to be beneficial in therapeutic areas outside those in which ivabradine has already demonstrated clinical efficacy. This review provides an update on the associations between heart rate and cardiovascular outcomes in various conditions, the experimental effects of heart rate reduction with ivabradine, and the potential new indications in cardiovascular disease.
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Affiliation(s)
- Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.
| | - Jan-Christian Reil
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
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Vela-Vásquez RS, Grigorov-Tzenkov I, Aguilar JL. Beta-blockers in septic shock: a review. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2015; 62:90-95. [PMID: 25152109 DOI: 10.1016/j.redar.2014.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Revised: 06/21/2014] [Accepted: 07/02/2014] [Indexed: 06/03/2023]
Abstract
In septic shock, high adrenergic stress is associated with cardiovascular and systemic adverse effects, which can negatively affect the results. Beta-adrenergic receptor block has been shown to be effective in controlling the disproportionate increase in heart rate, maintaining a favorable hemodynamic profile and apparently improving the efficiency of the cardiovascular system in order to maintain tissue perfusion. They have also been shown to modulate favorably catecholamine-induced immunosuppression and to decrease insulin resistance, protein catabolism, and proinflammatory cytokine expression associated with cardiovascular dysfunction. Selective beta-1 blockers appear to provide better results than non-selective blockers, even suggesting a positive impact on mortality. Future clinical trials are still needed to confirm these findings and define the scope of their benefits.
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Affiliation(s)
- R S Vela-Vásquez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Son LLatzer, Palma de Mallorca, Islas Baleares, España.
| | - I Grigorov-Tzenkov
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Son LLatzer, Palma de Mallorca, Islas Baleares, España
| | - J L Aguilar
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Son LLatzer, Palma de Mallorca, Islas Baleares, España
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Lattuca B, Roubille F. Ivabradine: A promising drug in cardiogenic shock to prevent the undesirable sinus tachycardia induced by dobutamine? Int J Cardiol 2015; 178:308-10. [DOI: 10.1016/j.ijcard.2014.09.106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 09/20/2014] [Indexed: 10/24/2022]
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Sanfilippo F, Santonocito C, Morelli A, Foex P. Beta-blocker use in severe sepsis and septic shock: a systematic review. Curr Med Res Opin 2015; 31:1817-25. [PMID: 26121122 DOI: 10.1185/03007995.2015.1062357] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Recent growing evidence suggests that beta-blocker treatment could improve cardiovascular dynamics and possibly the outcome of patients admitted to intensive care with severe sepsis or septic shock. DESIGN Systematic review. DATA SOURCES MEDLINE and EMBASE healthcare databases. REVIEW METHODS To investigate this topic, we conducted a systematic review of the above databases up to 31 May 2015. Due to the clinical novelty of the subject, we also included non-randomized clinical studies. We focused on the impact of beta-blocker treatment on mortality, also investigating its effects on cardiovascular, immune and metabolic function. Evidence from experimental studies was reviewed as well. RESULTS From the initial search we selected 10 relevant clinical studies. Five prospective studies (two randomized) assessed the hemodynamic effects of the beta1-blocker esmolol. Heart rate decreased significantly in all, but the impact on other parameters differed. The imbalance between prospective studies' size (10 to 144 patients) and the differences in their design disfavor a meta-analysis. One retrospective study showed improved hemodynamics combining metoprolol and milrinone in septic patients, and another retrospective study found no association between beta-blocker administration and mortality. We also found three case series. Twenty-one experimental studies evaluated the hemodynamic, immune and/or metabolic effects of selective and/or non-selective beta-blockers in animal models of sepsis (dogs, mice, pigs, rats, sheep), yielding conflicting results. CONCLUSIONS Whilst there is not enough prospective data to conduct a meta-analysis, the available clinical data are promising. We discuss the ability of beta blockade to modulate sepsis-induced alterations at cardiovascular, metabolic, immunologic and coagulation levels.
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Affiliation(s)
- Filippo Sanfilippo
- a a Cardiothoracic Intensive Care Unit, Intensive Care Directorate - St George's University Hospitals NHS Foundation Trust , London , United Kingdom
| | - Cristina Santonocito
- b b Cardiothoracic Critical Care Unit, Oxford Heart Centre - John Radcliffe Hospital, Oxford University Hospitals , Oxford , United Kingdom
| | - Andrea Morelli
- c c Department of Cardiovascular , Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, University of Rome , 'La Sapienza' , Rome , Italy
| | - Pierre Foex
- d d Nuffield Division of Anaesthetics, University of Oxford - John Radcliffe Hospital , Oxford , United Kingdom
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Bonadei I, Sciatti E, Vizzardi E, D'Aloia A, Metra M. Ivabradine during cardiogenic shock: a clinical case and review of the literature. Heart Lung 2014; 44:57-8. [PMID: 25240447 DOI: 10.1016/j.hrtlng.2014.08.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 08/06/2014] [Indexed: 11/24/2022]
Abstract
Although the introduction of novel medical and invasive therapies in recent years has led to a significant reduction in mortality from heart failure, the same cannot be said for mortality due to cardiogenic shock. Drug therapy with inotropic agents and catecholamines has the disadvantage of causing increased myocardial oxygen consumption resulting in increased heart rate which may lead to the widening of the ischemic area. A reduction in heart rate with the administration of β-blockers is contraindicated due to negative inotropic and blood pressure lowering effects, typical of this group of drugs. Thus the theoretical possibility of ivabradine administration for an isolated reduction in heart rate, associated with the absence of a negative inotropic effect, could favorably influence hemodynamics in patients with cardiogenic shock. We report a case of cardiogenic shock treated by adding ivabradine to the currently used therapy.
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Affiliation(s)
- Ivano Bonadei
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Study of Brescia, Italy
| | - Edoardo Sciatti
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Study of Brescia, Italy
| | - Enrico Vizzardi
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Study of Brescia, Italy.
| | - Antonio D'Aloia
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Study of Brescia, Italy
| | - Marco Metra
- Section of Cardiovascular Diseases, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Study of Brescia, Italy
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22
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Rozec B. How to slow down septic hearts? J Mol Cell Cardiol 2014; 74:112-4. [DOI: 10.1016/j.yjmcc.2014.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 04/15/2014] [Accepted: 05/07/2014] [Indexed: 01/09/2023]
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Gallet R, Ternacle J, Damy T, Guendouz S, Bremont C, Seemann A, Gueret P, Dubois-Rande JL, Lim P. Hemodynamic effects of Ivabradine in addition to dobutamine in patients with severe systolic dysfunction. Int J Cardiol 2014; 176:450-5. [PMID: 25129291 DOI: 10.1016/j.ijcard.2014.07.093] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 05/23/2014] [Accepted: 07/26/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Dobutamine induced tachycardia increases myocardial oxygen consumption and impairs ventricular filling. We hypothesized that Ivabradine may be efficient to control dobutamine induced tachycardia. METHODS We assessed the effects of Ivabradine in addition to dobutamine in stable heart failure (HF) patients (LVEF < 35%, n = 22, test population) and validated its effects in refractory cardiogenic shock patients (n = 9, validation population) with contraindication to cardiac assistance or transplant. In the test population (62 ± 17 years, LVEF = 24 ± 8%), systolic and diastolic function were assessed at rest and under dobutamine [10 γ/min], before and after Ivabradine [5mg per os]. In the validation population (54 ± 11 years, LVEF = 22 ± 7%), Ivabradine [5mg twice a day] was added to the dobutamine infusion. RESULTS In the test population, Ivabradine decreased heart rate [HR] at rest and during dobutamine echocardiography (-9 ± 8 bpm, P = 0.0004). The decrease in HR was associated with a decrease in cardiac power output and an increase in diastolic duration at rest (+ 74 ± 67 ms, P = 0.0002), and during dobutamine infusion (+ 75 ± 67 ms, P < 0.0001). Change in LVEF during dobutamine was greater after Ivabradine treatment than before (+ 7.2 ± 4.7% vs. + 3.6 ± 4.2%, P = 0.002). In the validation population, Ivabradine decreased HR (-18 ± 11 bpm, P = 0.008) and improved diastolic filling time (+ 67 ± 42 ms, P = 0.012) without decreasing cardiac output. At 24h, Ivabradine improved systolic blood pressure (+ 9 ± 5 mmHg, P = 0.007), daily urine output (+ 0.7 ± 0.5L, P = 0.008), oxygen balance (ΔScv02 = + 13 ± 15%, P = 0.010), and NT-pro BNP (-2270 ± 1912 pg/mL, P = 0.017). Finally, only 2/9 (22%) patients died whereas expected mortality determined from a historical cohort was 78% (P = 0.017). CONCLUSION This pilot study demonstrates the safety and potential benefit of a HR lowering agent in cardiogenic shock.
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Affiliation(s)
- Romain Gallet
- AP-HP - University Hospital Henri Mondor, Cardiovascular Department, INSERM U955 Team 3, Creteil, France.
| | - Julien Ternacle
- AP-HP - University Hospital Henri Mondor, Cardiovascular Department, INSERM U955 Team 3, Creteil, France
| | - Thibaud Damy
- AP-HP - University Hospital Henri Mondor, Cardiovascular Department, INSERM U955 Team 3, Creteil, France
| | - Soulef Guendouz
- AP-HP - University Hospital Henri Mondor, Cardiovascular Department, INSERM U955 Team 3, Creteil, France
| | - Camille Bremont
- AP-HP - University Hospital Henri Mondor, Cardiovascular Department, INSERM U955 Team 3, Creteil, France
| | - Aurélien Seemann
- AP-HP - University Hospital Henri Mondor, Cardiovascular Department, INSERM U955 Team 3, Creteil, France
| | - Pascal Gueret
- AP-HP - University Hospital Henri Mondor, Cardiovascular Department, INSERM U955 Team 3, Creteil, France
| | - Jean-Luc Dubois-Rande
- AP-HP - University Hospital Henri Mondor, Cardiovascular Department, INSERM U955 Team 3, Creteil, France
| | - Pascal Lim
- AP-HP - University Hospital Henri Mondor, Cardiovascular Department, INSERM U955 Team 3, Creteil, France
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De Santis V, Frati G, Greco E, Tritapepe L. Ivabradine: a preliminary observation for a new terapeutic role in patients with multiple organ dysfunction syndrome. Clin Res Cardiol 2014; 103:831-4. [PMID: 24805930 PMCID: PMC4159564 DOI: 10.1007/s00392-014-0722-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 04/24/2014] [Indexed: 12/13/2022]
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I(f) blocking potency of ivabradine is preserved under elevated endotoxin levels in human atrial myocytes. J Mol Cell Cardiol 2014; 72:64-73. [PMID: 24583250 PMCID: PMC4046244 DOI: 10.1016/j.yjmcc.2014.02.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 01/23/2014] [Accepted: 02/14/2014] [Indexed: 11/21/2022]
Abstract
Lower heart rate is associated with better survival in patients with multiple organ dysfunction syndrome (MODS), a disease mostly caused by sepsis. The benefits of heart rate reduction by ivabradine during MODS are currently being investigated in the MODIfY clinical trial. Ivabradine is a selective inhibitor of the pacemaker current If and since If is impaired by lipopolysaccharide (LPS, endotoxin), a trigger of sepsis, we aimed to explore If blocking potency of ivabradine under elevated endotoxin levels in human atrial cardiomyocytes. Treatment of myocytes with S-LPS (containing the lipid A moiety, a core oligosaccharide and an O-polysaccharide chain) but not R595 (an O-chain lacking LPS-form) caused If inhibition under acute and chronic septic conditions. The specific interaction of S-LPS but not R595 to pacemaker channels HCN2 and HCN4 proves the necessity of O-chain for S-LPS–HCN interaction. The efficacy of ivabradine to block If was reduced under septic conditions, an observation that correlated with lower intracellular ivabradine concentrations in S-LPS- but not R595-treated cardiomyocytes. Computational analysis using a sinoatrial pacemaker cell model revealed that despite a reduction of If under septic conditions, ivabradine further decelerated pacemaking activity. This novel finding, i.e. If inhibition by ivabradine under elevated endotoxin levels in vitro, may provide a molecular understanding for the efficacy of this drug on heart rate reduction under septic conditions in vivo, e.g. the MODIfY clinical trial. S-LPS impairs If via interaction of its O-chain to HCN channels. Efficacy of ivabradine for If blockage is reduced under elevated endotoxin levels. S-LPS reduces intracellular ivabradine concentrations. Ivabradine is efficient to decelerate sinoatrial pacemaking activity under septic conditions in silico.
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Correale M, Brunetti ND, Montrone D, Totaro A, Ferraretti A, Ieva R, di Biase M. Functional improvement in pulmonary arterial hypertension patients treated with ivabradine. J Card Fail 2014; 20:373-5. [PMID: 24556029 DOI: 10.1016/j.cardfail.2014.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 02/11/2014] [Accepted: 02/11/2014] [Indexed: 11/29/2022]
Affiliation(s)
| | | | | | - Antonio Totaro
- Department of Cardiology, University of Foggia, Foggia, Italy
| | | | - Riccardo Ieva
- Department of Cardiology, University of Foggia, Foggia, Italy
| | - Matteo di Biase
- Department of Cardiology, University of Foggia, Foggia, Italy
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Roubille F, Lattuca B, Busseuil D, Leclercq F, Davy JM, Rhéaume E, Tardif JC. Is ivabradine suitable to control undesirable tachycardia induced by dobutamine in cardiogenic shock treatment? Med Hypotheses 2013; 81:202-6. [DOI: 10.1016/j.mehy.2013.05.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Accepted: 05/02/2013] [Indexed: 12/26/2022]
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Heart rate before ICU discharge: a simple and readily available predictor of short- and long-term mortality from critical illness. Clin Res Cardiol 2013; 102:599-606. [PMID: 23624998 DOI: 10.1007/s00392-013-0571-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 04/17/2013] [Indexed: 01/06/2023]
Abstract
PURPOSE A heart rate >90 bpm serves as one of four characteristics defining the systemic inflammatory response syndrome and is used in scoring systems to predict in-hospital mortality of intensive care unit (ICU) patients. Despite its central role in critical illness, specific data regarding the relationship between heart rate and outcome are rare. METHODS In this post hoc analysis of a prospectively collected database, we analyzed the value of heart rate averaged from four predefined time points during the last 24 h before ICU discharge as a predictor of post-ICU in-hospital and post-hospital mortality in medical ICU patients. Furthermore, the relationship between heart rate and inflammation, as well as the influence of rate control medications on the association between heart rate and outcome were identified. RESULTS Among the 702 ICU patients discharged from the ICU, 7.1 % died before hospital discharge. At 4 years of follow-up, post-hospital mortality was 14.4 %. Multivariate Cox proportional hazards models revealed heart rate before ICU discharge (HR 5.95; 95 % CI 1.24-28.63; p = 0.03) as an independent predictor of post-ICU in-hospital mortality. Both heart rate (HR 2.56; 95 % CI, 1.05-6.34; p = 0.04) and the C-reactive protein serum concentration before ICU discharge (HR, 1.26; 95 % CI, 1.09-1.46; p = 0.002) were independently associated with post-hospital mortality. Heart rate control therapy reduced the risk of post-ICU in-hospital (HR 0.38; 95 % CI, 0.18-0.81; p = 0.01) and post-hospital (HR, 0.47; 95 % CI, 0.22-1.00; p = 0.05) mortality. CONCLUSION Heart rate evaluated 24 h before ICU discharge was independently associated with post-ICU in-hospital and post-hospital mortality. Pharmacological interventions to control heart rate may beneficially influence post-ICU mortality.
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De Santis V, Vitale D, Santoro A, Magliocca A, Porto AG, Nencini C, Tritapepe L. Ivabradine: potential clinical applications in critically ill patients. Clin Res Cardiol 2013; 102:171-8. [PMID: 23064879 DOI: 10.1007/s00392-012-0516-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2012] [Accepted: 10/04/2012] [Indexed: 12/17/2022]
Abstract
It has been extensively demonstrated that an elevated heart rate is a modifiable, independent risk factor for cardiovascular events. A high heart rate increases myocardial oxygen consumption and reduces diastolic perfusion time. It can also increase ventricular diastolic pressures and induce ventricular arrhythmias. Critical care patients are prone to develop a stress induced cardiac impairment and consequently an increase in sympathetic tone. This in turn increases heart rate. In this setting, however, heart rate lowering might be difficult because the effects of inotropic drugs could be hindered by heart rate reducing drugs like beta-blockers. Ivabradine is a new selective antagonist of funny channels. It lowers heart rate, reducing the diastolic depolarization slope. Moreover, ivabradine is not active on sympathetic pathways, thus avoiding any interference with inotropic amines. We reviewed the literature available regarding heart rate control in critical care patients, focusing our interest on the use of ivabradine to assess the potential benefits of the drug in this particular setting.
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Affiliation(s)
- Vincenzo De Santis
- Department of Anesthesiology and Intensive Care, Azienda USL di Ravenna, Viale Randi 5, 48121, Ravenna, Italy.
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Ivabradine in pulmonary arterial hypertension: can we delay the need for parenteral prostanoid therapy? Clin Res Cardiol 2013; 102:391-3. [DOI: 10.1007/s00392-013-0541-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 01/23/2013] [Indexed: 10/27/2022]
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Papaioannou VE, Verkerk AO, Amin AS, de Bakker JMT. Intracardiac origin of heart rate variability, pacemaker funny current and their possible association with critical illness. Curr Cardiol Rev 2013; 9:82-96. [PMID: 22920474 PMCID: PMC3584310 DOI: 10.2174/157340313805076359] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 07/21/2012] [Accepted: 07/29/2012] [Indexed: 01/23/2023] Open
Abstract
Heart rate variability (HRV) is an indirect estimator of autonomic modulation of heart rate and is considered a risk marker in critical illness, particularly in heart failure and severe sepsis. A reduced HRV has been found in critically ill patients and has been associated with neuro-autonomic uncoupling or decreased baroreflex sensitivity. However, results from human and animal experimental studies indicate that intracardiac mechanisms might also be responsible for interbeat fluctuations. These studies have demonstrated that different membrane channel proteins and especially the so-called 'funny' current (If), an hyperpolarization-activated, inward current that drives diastolic depolarization resulting in spontaneous activity in cardiac pacemaker cells, are altered during critical illness. Furthermore, membrane channels kinetics seem to have significant impact upon HRV, whose early decrease might reflect a cellular metabolic stress. In this review article we present research findings regarding intracardiac origin of HRV, at the cellular level and in both isolated sinoatrial node and whole ex vivo heart preparations. In addition, we will review results from various experimental studies that support the interrelation between If and HRV during endotoxemia. We suggest that reduced HRV during sepsis could also be associated with altered pacemaker cell membrane properties, due to ionic current remodeling.
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Affiliation(s)
- Vasilios E Papaioannou
- Democritus University of Thrace, Alexandroupolis University Hospital, Intensive Care Unit, Alexandroupolis Medical School, Dragana 68100, Greece.
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Correale M, Montrone D, Ieva R, Di Biase M, Brunetti ND. Ivabradine in systemic sclerosis related pulmonary arterial hypertension. Eur J Intern Med 2012; 23:e210-1. [PMID: 23021874 DOI: 10.1016/j.ejim.2012.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 09/05/2012] [Accepted: 09/06/2012] [Indexed: 11/23/2022]
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Riccioni G. Ivabradine: an intelligent drug for the treatment of ischemic heart disease. Molecules 2012; 17:13592-604. [PMID: 23159921 PMCID: PMC6268242 DOI: 10.3390/molecules171113592] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 10/30/2012] [Accepted: 10/30/2012] [Indexed: 12/13/2022] Open
Abstract
Heart rate (HR) is a precisely regulated variable, which plays a critical role in health and disease. Elevated resting HR is a significant predictor of all-cause and cardiovascular mortality in the general population and patients with cardiovascular disease (CVD). β-blocking drugs exert negative effects on regional myocardial blood flow and function when HR reduction is eliminated by atrial pacing; calcium channel antagonists (CCAs) functionally antagonize coronary vasoconstriction mediated through α-adreno-receptors and are thus devoid of this undesired effect, but the compounds are nevertheless negative inotropes. From these observations derives the necessity to find alternative, more selective drugs to reduce HR through inhibition of specific electrical current (I(f)). Ivabradine (IVA) is a novel specific HR-lowering agent that acts in sinus atrial node (SAN) cells by selectively inhibiting the pacemaker I(f) current in a dose-dependent manner by slowing the diastolic depolarization slope of SAN cells, and by reducing HR at rest during exercise in humans. Coronary artery diseases (CAD) represent the most common cause of death in middle-aged and older adults in European Countries. Most ischemic episodes are triggered by an increase in HR, that induces an imbalance between myocardial oxygen delivery and consumption. IVA, a selective and specific inhibitor of the I(f) current which reduced HR without adverse hemodynamic effects, has clearly and unequivocally demonstrated its efficacy in the treatment of chronic stable angina pectoris (CSAP) and myocardial ischemia with optimal tolerability profile due to selective interaction with I(f) channels. The aim of this review is to point out the usefulness of IVA in the treatment of ischemic heart disease.
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Affiliation(s)
- Graziano Riccioni
- Intensive Cardiology Care Unit, San Camillo de Lellis Hospital, Manfredonia, via Isonzo, 71043 Foggia, Italy.
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Simonis G, Steiding K, Schaefer K, Rauwolf T, Strasser RH. A prospective, randomized trial of continuous lateral rotation ("kinetic therapy") in patients with cardiogenic shock. Clin Res Cardiol 2012; 101:955-62. [PMID: 22729756 DOI: 10.1007/s00392-012-0484-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 06/08/2012] [Indexed: 01/07/2023]
Abstract
BACKGROUND Continuous lateral rotation ["Kinetic therapy" (KT)] has been shown to reduce complications and to shorten hospital stay in trauma patients. Data in non-surgical patients is inconclusive. Retrospective data suggest a beneficial effect of KT in patients with cardiogenic shock (CS) requiring ventilator therapy. KT, however, has not been tested prospectively in those patients. METHODS A prospective, randomized, open-label trial was performed to compare KT using oscillating beds (TryaDyne Proventa, KCI) with standard care (SC). Patients with cardiogenic shock requiring ventilator therapy for more than 24 h were included. Primary endpoint was the occurrence of hospital-acquired pneumonia. Secondary endpoints were the occurrence of pressure ulcers during the hospital stay and 1-year all-cause mortality. RESULTS Forty-five patients were randomized to KT, and 44 to SC. All patients required at least one inotropic agent and one vasopressor for circulatory assistance. The groups were comparable in the etiology of heart disease, in the use of revascularization procedures, the use of balloon counterpulsation, and APACHE-II score (33 ± 5 vs. 33 ± 4) and SOFA score (11 ± 1 vs. 11 ± 1) at inclusion; however, more patients in SC were subject to resuscitation before inclusion. Hospital-acquired pneumonia occurred in 10 patients in KT and 28 patients in SC (p < 0.001); pressure ulcers were seen in 10 versus 2 patients (p < 0.001). Hospital mortality tended to be lower in KT, and 1-year all-cause mortality was 41 % in KT and 66 % in SC (p = 0.028). CONCLUSION The use of KT reduces rates of pneumonia and pressure ulcers as compared to SC. Moreover, in this study, patients with KT had a better outcome. The study suggests that KT should be used in patients with cardiogenic shock requiring ventilator therapy for a prolonged time.
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Affiliation(s)
- Gregor Simonis
- Department of Medicine/Cardiology, Heart Center, Dresden University of Technology, Fetscherstr. 76, 01307, Dresden, Germany.
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Zhang R, Bobylev D, Stiefel P, Haverich A, Bara C. Lasting reduction of heart transplant tachycardia with ivabradine is effective and well tolerated: results of 48-month study. Clin Res Cardiol 2012; 101:631-6. [DOI: 10.1007/s00392-012-0436-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 02/24/2012] [Indexed: 11/29/2022]
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Correale M, Montrone D, Biase MD, Brunetti ND. Safe and well-tolerated treatment with ivabradine in systemic sclerosis affected by pulmonary hypertension. Clin Res Cardiol 2012; 101:593-4. [PMID: 22383181 DOI: 10.1007/s00392-012-0437-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 02/24/2012] [Indexed: 11/25/2022]
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Heart rate as an independent risk factor in patients with multiple organ dysfunction: a prospective, observational study. Clin Res Cardiol 2011; 101:139-47. [DOI: 10.1007/s00392-011-0375-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Accepted: 10/21/2011] [Indexed: 02/07/2023]
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