Pharmacologic Management for Heart Failure and Emerging Therapies

Probiotics as potential treatments to reduce myocardial remodelling and heart failure via the gut-heart axis: State-of-the-art review

Probiotics are considered to represent important modulators of gastrointestinal health through increased colonization of beneficial bacteria thus altering the gut microflora. Although these beneficial effects of probiotics are now widely recognized, emerging evidence suggests that alterations in the gut microflora also affect numerous other organ systems including the heart through a process generally referred to as the gut-heart axis. Moreover, cardiac dysfunction such as that seen in heart failure can produce an imbalance in the gut flora, known as dysbiosis, thereby further contributing to cardiac remodelling and dysfunction. The latter occurs by the production of gut-derived pro-inflammatory and pro-remodelling factors which exacerbate cardiac pathology. One of the key contributors to gut-dependent cardiac pathology is trimethylamine N-oxide (TMAO), a choline and carnitine metabolic by-product first synthesized as trimethylamine which is then converted into TMAO by a hepatic flavin-containing monooxygenase. The production of TMAO is particularly evident with regular western diets containing high amounts of both choline and carnitine. Dietary probiotics have been shown to reduce myocardial remodelling and heart failure in animal models although the precise mechanisms for these effects are not completely understood. A large number of probiotics have been shown to possess a reduced capacity to synthesize gut-derived trimethylamine and therefore TMAO thereby suggesting that inhibition of TMAO is a factor mediating the beneficial cardiac effects of probiotics. However, other potential mechanisms may also be important contributing factors. Here, we discuss the potential benefit of probiotics as effective therapeutic tools for attenuating myocardial remodelling and heart failure.

Impact of polyphenols on heart failure and cardiac hypertrophy: clinical effects and molecular mechanisms

Polyphenols are abundant in regular diets and possess antioxidant, anti-inflammatory, anti-cancer, neuroprotective, and cardioprotective effects. Regarding the inadequacy of the current treatments in preventing cardiac remodeling following cardiovascular diseases, attention has been focused on improving cardiac function with potential alternatives such as polyphenols. The following online databases were searched for relevant orginial published from 2000 to 2023: EMBASE, MEDLINE, and Web of Science databases. The search strategy aimed to assess the effects of polyphenols on heart failure and keywords were "heart failure" and "polyphenols" and "cardiac hypertrophy" and "molecular mechanisms". Our results indicated polyphenols are repeatedly indicated to regulate various heart failure-related vital molecules and signaling pathways, such as inactivating fibrotic and hypertrophic factors, preventing mitochondrial dysfunction and free radical production, the underlying causes of apoptosis, and also improving lipid profile and cellular metabolism. In the current study, we aimed to review the most recent literature and investigations on the underlying mechanism of actions of different polyphenols subclasses in cardiac hypertrophy and heart failure to provide deep insight into novel mechanistic treatments and direct future studies in this context. Moreover, due to polyphenols' low bioavailability from conventional oral and intravenous administration routes, in this study, we have also investigated the currently accessible nano-drug delivery methods to optimize the treatment outcomes by providing sufficient drug delivery, targeted therapy, and less off-target effects, as desired by precision medicine standards.

Trial characteristics associated with under-enrolment of females in randomized controlled trials of heart failure with reduced ejection fraction: a systematic review

AIMS

To evaluate temporal trends in the enrolment of females in randomized controlled trials (RCTs) of heart failure with reduced ejection fraction (HFrEF) published in high-impact journals, and assess RCT characteristics associated with under-enrolment.

METHODS AND RESULTS

We searched MEDLINE, EMBASE and CINAHL for studies published from January 2000 to May 2019 in journals with impact factor ≥10. We included RCTs that recruited adults with HFrEF. We used a 20% threshold below the sex distribution of HFrEF to define under-enrolment. We used multivariable logistic regression to assess trial characteristics independently associated with under-enrolment. We included 317 RCTs. Among the 183 097 participants, mean (standard deviation) age was 63.0 (7.0) years and 25.5% were female. Females were under-enrolled in 71.6% [95% confidence interval (CI) 66.6-76.6%] of the RCTs; enrolment did not increase significantly between 2000-2019. Sex-related eligibility criteria [odds ratio (OR) 2.05, 95% CI 1.01-4.16; P = 0.046]; recruitment in ambulatory settings (OR 2.56, 95% CI 1.37-4.81; P = 0.003); trial coordination in North America (OR 4.44, 95% CI 1.09-18.07; P = 0.037), Europe (OR 6.79, 95% CI 1.63-27.39; P = 0.018) and Asia (OR 9.33, 95% CI 1.40-12.40; P = 0.033); drug (OR 1.76, 95% CI 1.96-7.36; P < 0.001) and device/surgical interventions (OR 1.69, 95% CI 1.16-9.43; P = 0.002); and men in first and last authorship position (OR 1.32, 95% CI 1.12-3.54; P = 0.047) were associated with under-enrolment of females.

CONCLUSIONS

Females were under-enrolled relative to disease distribution in a majority of high-impact HFrEF RCTs, with no change in temporal trends between 2000 and 2019. Trial characteristics and gender of trial leaders were associated with under-enrolment.

Resveratrol Improves Heart Function by Moderating Inflammatory Processes in Patients with Systolic Heart Failure

The effects of resveratrol (RES) in heart failure have already been evaluated in animal models; however, in human clinical trials, they have not been confirmed yet. The aim of this study was to assess the effects of resveratrol treatment in systolic heart failure patients (heart failure with reduced ejection fraction or HFrEF). In this human clinical trial, 60 outpatients with NYHA (New York Heart Association) class II-III HFrEF were enrolled and randomized into two groups: receiving either 100-mg resveratrol daily or placebo for three months. At the beginning and at the end of the study echocardiography, a six-minute walk test, spirometry, quality of life questionnaire, lab test and RNA profile analysis were performed. The systolic and diastolic left ventricular function, as well as the global longitudinal strain, were improved significantly in the resveratrol-treated group (RES). Exercise capacity, ventilation parameters and quality of life also improved significantly in the RES group. In parallel, the cardiac biomarker levels (N-terminal prohormone of brain natriuretic peptide (NT-proBNP) and galectin-3) decreased in the treated group. The level of inflammatory cytokines decreased significantly after RES supplementation, as a consequence of the decreased expression level of leucocyte electron transport chain proteins. The main findings of our trial are that RES treatment added to the standard heart failure therapy improved heart function and the clinical condition by moderating the inflammatory processes in patients with HFrEF.

New Analytical Method for Simultaneous Analysis of Losartan and E-3174 by HPLC in Human Plasma: Application in Pharmaceutical Science

Background:

Losartan, one of the most frequently used drugs in Heart Failure (HF) treatment, could be modified for its bioavailability (BA) by generic formulations and other factors. Hence, the importance of therapeutic drug monitoring.

Objective:

Development and validation of a simplified analytical method using HPLC for simultaneous quantification of losartan and E-3174 in human plasma samples. The method was tested for determining the pharmacokinetics parameters of HF patients.

Methods:

Analytical conditions were optimized using a C18 column (4.6 X 50 mm, 3 μm. Thermo Scientific) at 25ºC. Conditions of mobile phase: a phosphate buffer (0.01M), adjusted to pH 2.5 with phosphoric acid (1M) and Acetonitrile (60:40 v/v). The flow rate was maintained at 1.2 mL/min, on a running time of 5 min and a sample injection volume of 50 μL. Absorbance for measurement of losartan and E-3174 was 200 nm. Pharmacokinetics profiles were determined with Phoenix Win- Nonlin 8.1 software in a non-compartmental model.

Results:

Analytical method developed and validated in this work is precise and accurate for simultaneous determination of losartan and E-3174 in human plasma samples in a range of 0.02 -10 μg/mL. In HF subjects, lower Tmax and higher Cmax for losartan and E-3174 patent than generic formulation were observed, which can be translated into less biological effect and more time to present it by the generic drug.

Conclusion:

The pharmacokinetic profile is dependent on the type of formulation studied (generic/ patent) hence the importance of conducting evaluations in our patients to ensure that the expected therapeutic effect is achieved with treatment administered.

Circulating microRNA in Heart Failure - Practical Guidebook to Clinical Application

Heart failure (HF) remains a major cause of death and disability worldwide. Currently, B-type natriuretic peptide and N-terminal pro-brain natriuretic peptide are diagnostic biomarkers used in HF. Although very sensitive, they are not specific enough and do not allow the prediction or early diagnosis of HF. Many ongoing studies focus on determining the underlying cause and understanding the mechanisms of HF on the cellular level. MicroRNAs (miRNAs) are non-coding RNAs which control the majority of cellular processes and therefore are considered to have a potential clinical application in HF. In this review, we aim to provide synthesized information about miRNAs associated with ejection fraction, HF etiology, diagnosis, and prognosis, as well as outline therapeutic application of miRNAs in HF. Further, we discuss methodological challenges associated with the analysis of miRNAs and provide recommendations for defining a study population, collecting blood samples, and selecting detection methods to study miRNAs in a reliable and reproducible way. This review is intended to be an accessible tool for clinicians interested in the field of miRNAs and HF.

Getting site-specific with actomyosin inhibitors

Actin and myosin play important roles in many devastating diseases and thus are attractive targets for small-molecule therapy. In this issue of JBC, Guhathakurta et al. have developed a high-throughput screening assay to find small molecules that interfere with the actomyosin interaction. They utilized time-resolved FRET (TR-FRET) and a unique donor-acceptor pair (filamentous actin and a peptide that binds near the myosin-binding site on actin) to find novel molecules that interfere with the actomyosin ATPase and alter the structure of actin filaments. These findings demonstrate the power and potential of high-throughput TR-FRET in monitoring molecular interactions.

Management of advanced heart failure: a review

INTRODUCTION

Heart failure (HF) has become a global pandemic. Despite recent developments in both medical and device treatments, HF incidences continues to increase. The current definition of HF restricts itself to stages at which clinical symptoms are apparent. In advanced heart failure (AdHF), it is universally accepted that all patients are refractory to traditional therapies. As the number of HF patients increase, so does the need for additional treatments, with an increased proportion of patients requiring advanced therapies. Areas covered: This review discusses extensive evidence for the effect of medical treatment on HF, although the data on the effect on AdHF is scare. Authors review the relevant literature for treating AdHF patients. Furthermore, mechanical circulatory devices (MCD) have emerged as an alternative to heart transplantation and have been shown to enhance quality of life and reduce mortality therefore authors also review the current literature on the different MCD and technologies. Expert commentary: More patients will need advanced therapies, as the access to heart transplantation is limited by the number of available donors. AdHF patients should be identified timely since the window of opportunities for advanced therapy is narrow as their morbidity is progressive and survival is often short.

Sarcomere-based genetic enhancement of systolic cardiac function in a murine model of dilated cardiomyopathy

Diminished cardiac contractile function is a characteristic feature of dilated cardiomyopathy (DCM) and many other heart failure (HF) causing etiologies. We tested the hypothesis that targeting the sarcomere to increase cardiac contractility can effectively prevent the DCM phenotype in muscle-LIM protein knockout (MLP^-/-) mice. The ablation of cardiac myosin binding protein C (MYBPC3^-/-) protected the MLP^-/- mice from developing the DCM phenotype. We examined the in vivo cardiac function and morphology of the resultant mouse model lacking both MLP and MYBPC3 (DKO) by echocardiography and pressure-volume catheterization and found a significant reduction in hypertrophy, as evidenced by normalized wall thickness and chamber dimensions, and improved systolic function, as evidenced by enhanced ejection fraction (~26% increase compared MLP^-/- mice) and rate of pressure development (DKO 7851.0 ± 504.8 vs. MLP^-/- 4496.4 ± 196.8 mmHg/s). To investigate the molecular basis for the improved DKO phenotype we performed mechanical experiments in skinned myocardium isolated from WT and the individual KO mice. Skinned myocardium isolated from DKO mice displayed increased Ca²⁺ sensitivity of force generation, and significantly accelerated rate of cross-bridge detachment (+63% compared to MLP^-/-) and rate of XB recruitment (+58% compared to MLP^-/-) at submaximal Ca²⁺ activations. The in vivo and in vitro functional enhancement of DKO mice demonstrates that enhancing the sarcomeric contractility can be cardioprotective in HF characterized by reduced cardiac output, such as in cases of DCM.