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Haryani A, Sangwan A. New Pharmacotherapeutic Classes for the Management of Heart Failure: A Narrative Review. Cureus 2024; 16:e57180. [PMID: 38681432 PMCID: PMC11056082 DOI: 10.7759/cureus.57180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2024] [Indexed: 05/01/2024] Open
Abstract
Heart failure (HF) is a syndrome characterized by the heart failing to pump blood to the body at a rate proportional to its needs. HF is a public health burden globally and one of the leading causes of hospitalizations in adults. While many classes of drugs have been introduced for the treatment of HF, not every drug may be well-tolerated by patients. In this narrative review, we describe a few of the newer classes of medications proposed to be efficacious in treating acute and chronic HF. We focus on vericiguat, omecamtiv mecarbil, ularitide, and serelaxin, and thoroughly examine their efficacy and safety profiles while summarizing the clinical trials of the drugs. There is a need for more long-term studies comparing the efficacy of these medications to the conventional ones.
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Rao S, Pena C, Shurmur S, Nugent K. Atrial Natriuretic Peptide: Structure, Function, and Physiological Effects: A Narrative Review. Curr Cardiol Rev 2021; 17:e051121191003. [PMID: 33530911 PMCID: PMC8950497 DOI: 10.2174/1573403x17666210202102210] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/08/2020] [Accepted: 12/21/2020] [Indexed: 12/30/2022] Open
Abstract
Atrial natriuretic peptide (ANP) is a cardiac peptide with multiple physiological effects, including natriuresis, blood pressure regulation, and renin-angiotensin-aldosterone system (RAAS) antagonism. Pre-proANP is synthesized in the atria and must be extensively cleaved by the protease corin to produce the mature 28 amino acid ANP. The downstream signaling pathway of ANP acts through the guanylyl cyclase receptor and the second messenger cGMP. Studies on ANP's physiological effects have demonstrated its activity on channels present in the apical membrane in the renal nephron, potentially inhibiting or decreasing sodium reabsorption. Recent research has also identified several clinical conditions, such as dilated cardiomyopathy, renal failure, and aging, associated with increased and decreased ANP levels. ANP levels could serve as a potential biomarker for the diagnosis of acute stages of heart failure, and ANP infusion could have a role in the management of acute or chronic heart failure.
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Affiliation(s)
- Sanjana Rao
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA
| | - Camilo Pena
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA
| | - Scott Shurmur
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA
| | - Kenneth Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA,Address correspondence to this author at the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas 79430, USA; Tel: 18067436847; E-mail:
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Gidlöf O. Toward a New Paradigm for Targeted Natriuretic Peptide Enhancement in Heart Failure. Front Physiol 2021; 12:650124. [PMID: 34721050 PMCID: PMC8548580 DOI: 10.3389/fphys.2021.650124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 09/21/2021] [Indexed: 12/11/2022] Open
Abstract
The natriuretic peptide system (NPS) plays a fundamental role in maintaining cardiorenal homeostasis, and its potent filling pressure-regulated diuretic and vasodilatory effects constitute a beneficial compensatory mechanism in heart failure (HF). Leveraging the NPS for therapeutic benefit in HF has been the subject of intense investigation during the last three decades and has ultimately reached widespread clinical use in the form of angiotensin receptor-neprilysin inhibition (ARNi). NPS enhancement via ARNi confers beneficial effects on mortality and hospitalization in HF, but inhibition of neprilysin leads to the accumulation of a number of other vasoactive peptides in the circulation, often resulting in hypotension and raising potential concerns over long-term adverse effects. Moreover, ARNi is less effective in the large group of HF patients with preserved ejection fraction. Alternative approaches for therapeutic augmentation of the NPS with increased specificity and efficacy are therefore warranted, and are now becoming feasible particularly with recent development of RNA therapeutics. In this review, the current state-of-the-art in terms of experimental and clinical strategies for NPS augmentation and their implementation will be reviewed and discussed.
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Affiliation(s)
- Olof Gidlöf
- Department of Cardiology, Clinical Sciences, Lund University, Lund, Sweden
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Teneggi V, Sivakumar N, Chen D, Matter A. Drugs’ development in acute heart failure: what went wrong? Heart Fail Rev 2018; 23:667-691. [DOI: 10.1007/s10741-018-9707-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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5
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Ularitide in Acute Heart Failure. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2018. [DOI: 10.1007/s40138-018-0150-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
PURPOSE OF REVIEW In spite of advances in our understanding of acute heart failure (AHF) and its different phenotypic expressions, AHF management is still centered on volume removal with intravenous diuretics. This narrative review describes the pathophysiology underlying hypertensive AHF and appraises therapies targeting these mechanisms. RECENT FINDINGS Vascular redistribution rather than volume overload may be the primary determinant of elevated cardiac filling pressures and subsequent pulmonary congestion in patients with hypertensive AHF; in these patients, vasodilators should be the predominant treatment. Additional therapy with diuretics in hypertensive AHF should be relegated to the treatment of overt volume overload or persistent congestion in spite of optimized hemodynamics. Intravenous nitroglycerin at high doses can rapidly achieve pulmonary decongestion and reduce downstream critical care needs in these patients. The therapeutic role for synthetic peptides with vasodilator properties has yet to be defined. Evidence supporting both old and new vasodilator therapies is limited by a paucity of well-designed studies and failure to demonstrate improvement in long-term outcomes. Targeted study of this phenotype of AHF is needed before vasodilator therapies become incorporated into treatment guidelines.
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Mullens W, Verbrugge FH, Nijst P, Tang WHW. Renal sodium avidity in heart failure: from pathophysiology to treatment strategies. Eur Heart J 2017; 38:1872-1882. [DOI: 10.1093/eurheartj/ehx035] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 01/16/2017] [Indexed: 01/10/2023] Open
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Packer M, Holcomb R, Abraham WT, Anker S, Dickstein K, Filippatos G, Krum H, Maggioni AP, McMurray JJV, Mebazaa A, O'Connor C, Peacock F, Ponikowski P, Ruschitzka F, van Veldhuisen DJ, Holzmeister J. Rationale for and design of the TRUE-AHF trial: the effects of ularitide on the short-term clinical course and long-term mortality of patients with acute heart failure. Eur J Heart Fail 2016; 19:673-681. [PMID: 27862700 DOI: 10.1002/ejhf.698] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 10/21/2016] [Accepted: 10/27/2016] [Indexed: 12/16/2022] Open
Abstract
The TRUE-AHF is a randomized, double-blind, parallel-group, placebo-controlled trial which is evaluating the effects of a 48-h infusion of ularitide (15 ng/kg/min) on the short- and long-term clinical course of patients with acute heart failure. Noteworthy features of the study include the early enrolment of patients following their initial clinical presentation (within 12 h), and entry blood pressure criteria and thresholds for the adjustment of drug infusion rates, which aim to minimize the risk of hypotension. The trial has two primary endpoints: (i) cardiovascular mortality during long-term follow-up; and (ii) the clinical course of patients during their index hospitalization. Cardiovascular mortality is evaluated in this event-driven trial by following all randomized patients for the occurrence of death until the end of the entire study without truncation at an arbitrarily determined early time point. The clinical course during the index hospitalization is evaluated using the hierarchical clinical composite endpoint, which combines information regarding changes in symptoms and the occurrence of in-hospital worsening heart failure events and death into a single ranked metric that captures interval clinical events and minimizes the likelihood of missing data and confounding due to intensification of background therapy. The design of the TRUE-AHF trial capitalizes on lessons learned from earlier trials and aims to evaluate definitively the potential benefit of ularitide in patients with acute heart failure. TRIAL REGISTRATION NCT01661634.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | | | | | - Stefan Anker
- Innovative Clinical Trials, Department of Cardiology & Pneumology, University Medical Center Göttingen (UMG), Göttingen, Germany
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon Athens University Hospital, Department of Cardiology, Athens, Greece
| | - Henry Krum
- Monash University, Centre of Cardiovascular Research & Education in Therapeutics, Melbourne, Australia
| | - Aldo P Maggioni
- Centro Studi ANMCO, Fondazione 'per il Tuo cuore' HCF ONLUS, Firenze, Italy
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Alexandre Mebazaa
- University of Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaire Saint Louis Lariboisière, Paris, France
| | | | | | | | | | | | - Johannes Holzmeister
- Cardiology, University Hospital Zurich, Zurich, Switzerland.,Cardiorentis AG, Zug, Switzerland
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Tran HA, Lin F, Greenberg BH. Potential new drug treatments for congestive heart failure. Expert Opin Investig Drugs 2016; 25:811-26. [DOI: 10.1080/13543784.2016.1181749] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Capítulo 13. Novedades en el tratamiento de la falla cardiaca. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Emani S, Meyer M, Palm D, Holzmeister J, Haas GJ. Ularitide: a natriuretic peptide candidate for the treatment of acutely decompensated heart failure. Future Cardiol 2015; 11:531-46. [PMID: 26278236 DOI: 10.2217/fca.15.53] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Treatment for acutely decompensated heart failure (ADHF) has not changed much in the last two decades. Currently available therapies have variable efficacy and can be associated with adverse outcomes. Natriuretic peptides properties include diuresis, natriuresis, vasorelaxation, inhibition of renin-angiotensin-aldosterone system, and are thus chosen in the treatment of ADHF. Two forms of natriuretic peptides are currently available for the treatment of ADHF. Urodilatin (INN: ularitide) represents another member of the natriuretic peptide family with a unique molecular structure that may provide distinct benefits in the treatment of ADHF. Early clinical exploratory and Phase II studies have demonstrated that ularitide has potential cardiovascular and renal benefits. Ularitide is currently being tested in the Phase III TRUE-AHF clinical study. TRUE-AHF has features that may be different when compared with other recent outcome studies in ADHF. These distinct differences aim to maximize clinical effects and minimize potential adverse events of ularitide. However, whether this rationale translates into a better outcome needs to be awaited.
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Affiliation(s)
- Sitaramesh Emani
- Division of Cardiology, The Ohio State University, 473 W 12th Ave, Suite 200 DHLRI, Columbus, OH 43210, USA
| | - Markus Meyer
- Cardiorentis Ltd, Steinhauserstrasse 74, Zug 6300, Switzerland
| | - Denada Palm
- Department of Internal Medicine, University of Cincinnati, Medical Sciences Building, 231 Albert Sabin Way #6065, Cincinnati, OH 45267, USA
| | | | - Garrie J Haas
- Division of Cardiology, The Ohio State University, 473 W 12th Ave, Suite 200 DHLRI, Columbus, OH 43210, USA
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Anker SD, Ponikowski P, Mitrovic V, Peacock WF, Filippatos G. Ularitide for the treatment of acute decompensated heart failure: from preclinical to clinical studies. Eur Heart J 2015; 36:715-23. [PMID: 25670819 PMCID: PMC4368857 DOI: 10.1093/eurheartj/ehu484] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The short- and long-term morbidity and mortality in acute heart failure is still unacceptably high. There is an unmet need for new therapy options with new drugs with a new mode of action. One of the drugs currently in clinical testing in Phase III is ularitide, which is the chemically synthesized form of the human natriuretic peptide urodilatin. Urodilatin is produced in humans by differential processing of pro-atrial natriuretic peptide in distal renal tubule cells. Physiologically, urodilatin appears to be the natriuretic peptide involved in sodium homeostasis. Ularitide exerts its pharmacological actions such as vasodilation, diuresis, and natriuresis through the natriuretic peptide receptor/particulate guanylate cyclase/cyclic guanosine monophosphate pathway. In animal models of heart failure as well as Phase I and II clinical studies in heart failure patients, ularitide demonstrated beneficial effects such as symptom relief and vasodilation, while still preserving renal function. Subsequently, the pivotal acute decompensated heart failure (ADHF) Phase III study, called TRUE-AHF, was started with the objectives to evaluate the effects of ularitide infusion on the clinical status and cardiovascular mortality of patients with ADHF compared with placebo. This review summarizes preclinical and clinical data supporting the potential use of ularitide in the treatment of ADHF.
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Affiliation(s)
- Stefan D Anker
- Department of Innovative Clinical Trials, University Medical Centre Göttingen, Göttingen, Germany
| | | | - Veselin Mitrovic
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
| | - W Frank Peacock
- Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
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14
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Novel drug mechanisms in development for heart failure. Pflugers Arch 2014; 466:1219-25. [DOI: 10.1007/s00424-014-1528-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 04/23/2014] [Indexed: 01/10/2023]
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15
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Suzuki S, Fukushima R, Yamamoto Y, Ishikawa T, Hamabe L, Kim S, Yoshiyuki R, Fukayama T, Machida N, Tanaka R. Comparative Effect of Carperitide and Furosemide on Left Atrial Pressure in Dogs with Experimentally Induced Mitral Valve Regurgitation. J Vet Intern Med 2013; 27:1097-104. [DOI: 10.1111/jvim.12154] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 05/24/2013] [Accepted: 07/08/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- S. Suzuki
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - R. Fukushima
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - Y. Yamamoto
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - T. Ishikawa
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - L. Hamabe
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - S. Kim
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - R. Yoshiyuki
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - T. Fukayama
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - N. Machida
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
| | - R. Tanaka
- Department of Veterinary Surgery; Faculty of Veterinary Medicine; Tokyo University of Agriculture and Technology; Fuchu-shi, Tokyo Japan
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Carlson MD, Eckman PM. Review of Vasodilators in Acute Decompensated Heart Failure: The Old and the New. J Card Fail 2013; 19:478-93. [DOI: 10.1016/j.cardfail.2013.05.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 05/14/2013] [Accepted: 05/16/2013] [Indexed: 01/08/2023]
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Gassanov N, Biesenbach E, Caglayan E, Nia A, Fuhr U, Er F. Natriuretic peptides in therapy for decompensated heart failure. Eur J Clin Pharmacol 2011; 68:223-30. [PMID: 21901345 DOI: 10.1007/s00228-011-1117-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2011] [Accepted: 08/09/2011] [Indexed: 10/17/2022]
Abstract
Congestive heart failure (CHF) is the most frequent cause of hospitalization for patients >65 years of age and continues to be a major public health burden among the ageing population. Unlike therapy for chronic CHF, there has been only modest progress in medical treatment for acutely decompensated CHF over the past several decades. Moreover, current treatment-consisting generally of diuretic, inotropic, and vasodilatory agents-is associated with many limitations in clinical practice. Natriuretic peptides provide a promising mechanism of action in the pathophysiologic background for CHF treatment based on their vasodilatory and diuretic properties and effective inhibition of the renin-angiotensin-aldosterone system, which is activated early in the course of CHF. Nesiritide (Natrecor® or Noratak®) is a recombinant natriuretic peptide that has the same 32 amino-acid sequence as human B-type natriuretic peptide. Nesiritide has been shown to improve dyspnea and hemodynamic parameters in patients with decompensated heart failure. Ularitide is a synthetic form of urodilatin, a natriuretic peptide hormone secreted by the kidney. Recent clinical studies suggest that ularitide may play a role in managing decompensated heart failure. This review provides an update on natriuretic peptides and their therapeutic potential in advanced CHF.
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Affiliation(s)
- Natig Gassanov
- Department of Internal Medicine III, University of Cologne, Cologne, Germany.
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Link MG, Yan GX, Kowey PR. Evaluation of toxicity for heart failure therapeutics: studying effects on the QT interval. Circ Heart Fail 2010; 3:547-55. [PMID: 20647490 DOI: 10.1161/circheartfailure.109.917781] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Michael G Link
- Main Line Heart Center and Lankenau Institute for Medical Research, Jefferson Medical College, Wynnewood, Pa 19096, USA
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Sedghi Y, Gaddam KK, Ventura HO. Emerging diuretics for the treatment of heart failure. Expert Opin Emerg Drugs 2009; 14:195-204. [DOI: 10.1517/14728210902721230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Yabiz Sedghi
- Department of Cardiology, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, USA ;
| | - Krishna K Gaddam
- Department of Cardiology, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, USA ;
| | - Hector O Ventura
- Department of Cardiology, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, USA ;
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Inaba H, Hayami N, Ajiki K, Sugishita Y, Kunishima T, Yamagishi N, Yamagishi S, Murakawa Y. Human atrial natriuretic peptide suppresses torsades de pointes in rabbits. Circ J 2008; 72:820-4. [PMID: 18441465 DOI: 10.1253/circj.72.820] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The increase in inward current, primarily L-type Ca2+ current, facilitates torsades de pointes (TdP). Because human atrial natriuretic peptide (ANP) moderates the L-type Ca2+ current, in our study it was hypothesized that ANP counteracts TdP. METHODS AND RESULTS We tested the effect of ANP, guanosine 3', 5'-cyclic monophosphate analogue (8-bromo cGMP) and hydralazine on the occurrence of TdP in a rabbit model. In control rabbits, administration of methoxamine and nifekalant almost invariably caused TdP (14/15). In contrast, ANP (10 microg . kg(-1) . min(-1)) markedly abolished TdP (2/15), whereas hydralazine failed to show a comparable anti-arrhythmic action (10/15). TdP occurred only in 1 of 15 rabbits treated with 8-bromo cGMP. Presence of early afterdepolarization-like hump in the ventricular monophasic action potential was associated with the occurrence of TdP. CONCLUSION Results suggest that ANP affects TdP in the rabbit model, and that this anti-arrhythmic effect of ANP is not necessarily shared by other vasodilating agents.
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Affiliation(s)
- Hideko Inaba
- Fourth Department of Internal Medicine, Mizonokuchi Hospital, Teikyo University School of Medicine, Kawasaki, Japan
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Renal effects of ularitide in patients with decompensated heart failure. Am Heart J 2008; 155:1012.e1-8. [PMID: 18513512 DOI: 10.1016/j.ahj.2008.02.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Accepted: 02/14/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND Renal function frequently deteriorates in decompensated heart failure (DHF) patients, and one determinant is reduced renal blood flow. This may, in part, result from low cardiac output (CO), reduced mean arterial pressure (MAP), and venous congestion. The combined impact of both venous congestion (elevated right atrial pressure [RAP]) and low MAP are reflected by a reduced pressure gradient MAP-RAP. This study investigated the renal effects of ularitide, a synthetic version of the renal natriuretic peptide urodilatin in DHF patients. METHODS In SIRIUS II, a double-blind phase II trial, 221 patients hospitalized for DHF (with dyspnea at rest or minimal activity, cardiac index <or=2.5 L/min per square meter, and pulmonary artery wedge pressure >or=18 mm Hg) were randomized to a single 24-hour infusion of ularitide (7.5, 15, or 30 ng/kg per minute) or placebo added to standard therapy. RESULTS Estimated glomerular filtration rate, serum creatinine, creatinine clearance, and blood urea nitrogen (BUN) were not impaired by ularitide throughout infusion and during a 2-day follow-up period. At 24 hours, 15 ng/kg per minute ularitide reduced BUN levels (-4.07 +/- 12.30 vs -0.20 +/- 7.50 for placebo, P < .05). Ularitide at 15 and 30 ng/kg per minute rapidly elevated CO with sustained effects. Although 15 ng/kg per minute ularitide preserved the pressure gradient MAP-RAP, 30 ng/kg per minute ularitide reduced MAP-RAP by -7.8 +/- 10.6 mm Hg vs -2.4 +/- 9.8 mm Hg for placebo (P < .01, at 6 hours). A strong inverse correlation between MAP-RAP and BUN levels (Corr = -0.50579, P = .00015) was observed with 15 ng/kg per minute ularitide. CONCLUSIONS Single 24-hour infusions of ularitide at 15 ng/kg per minute preserved short-term renal function in DHF patients possibly by both elevating CO and maintaining the MAP-RAP pressure gradient.
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De Luca L, Mebazaa A, Filippatos G, Parissis JT, Böhm M, Voors AA, Nieminen M, Zannad F, Rhodes A, El-Banayosy A, Dickstein K, Gheorghiade M. Overview of emerging pharmacologic agents for acute heart failure syndromes. Eur J Heart Fail 2008; 10:201-13. [PMID: 18279775 DOI: 10.1016/j.ejheart.2008.01.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Revised: 11/15/2007] [Accepted: 01/02/2008] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Several therapies commonly used for the treatment of acute heart failure syndromes (AHFS) present some well-known limitations and have been associated with an early increase in the risk of death. There is, therefore, an unmet need for new pharmacologic agents for the early management of AHFS that may improve both short- and long-term outcomes. AIM To review the recent evidence on emerging pharmacologic therapies in AHFS. METHODS A systematic search of peer-reviewed publications was performed on MEDLINE, EMBASE and Clinical Trials.gov from January 1990 to August 2007. The results of unpublished or ongoing trials were obtained from presentations at national and international meetings and pharmaceutical industry releases. Bibliographies from these references were also reviewed, as were additional articles identified by content experts. RESULTS Cumulative data from large studies and randomised trials suggest that therapies with innovative mechanisms of action may safely and effectively reduce pulmonary congestion or improve cardiac performance in AHFS patients. CONCLUSION Some investigational agents for the management of AHFS are able to improve haemodynamics and/or clinical status. In spite of these promising findings, no new agent has demonstrated a clear benefit in terms of long-term clinical outcomes compared to placebo or conventional therapies.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardiovascular Sciences, European Hospital, Rome, Italy
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Sun Z, Lu W, Tang Y, Zhang J, Chen J, Deng H, Li X, Liu JN. Expression, purification and characterization of human urodilatin in E. coli. Protein Expr Purif 2007; 55:312-8. [PMID: 17544295 DOI: 10.1016/j.pep.2007.04.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2007] [Revised: 04/20/2007] [Accepted: 04/21/2007] [Indexed: 11/29/2022]
Abstract
Urodilatin is a 32-amino acid peptide hormone synthesized in kidney to regulate natriuresis and diuresis. It has been shown clinically useful for the treatment of acute decompensated heart failure. A synthetic deoxyoligonucleotide encoding urodilatin was cloned into a pET32a vector immediately after the thioredoxin encoding sequence with a hexa-hisditine tag and an enterokinase recognition site incorporated in between. The fusion protein was overexpressed in Escherichia coli, which constituted 28% of the total cell proteins. More than 85% of Trx-urodilatin was soluble and purified nearly homogenous by Ni-Sepharose affinity chromatography. Urodilatin was then released from the fusion protein by the enterokinase treatment and separated from the fusion partner by the subtractive chromatography using Ni-Sepharose once again. The urodilatin sample was further purified with reverse phase HPLC. Via a biological activity assayed in vitro, it was found that urodilatin had a potent vasodilatory effect on rabbit aortic strips with an EC50 of (2.02+/-0.36)x10(-6)mg/ml, which was similar to that of the synthetic urodilatin standard. The method described here promises to produce about 4.5mg fully active recombinant urodilatin with homogeneity over 97% from one liter shaking flask culture of E. coli.
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Affiliation(s)
- Ziyong Sun
- Institute of Molecular Medicine and State Key Laboratory of Pharmaceutical Biotechnology, Nanjing University, 22 Hankou Road, Nanjing 210093, China
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Shin DD, Brandimarte F, De Luca L, Sabbah HN, Fonarow GC, Filippatos G, Komajda M, Gheorghiade M. Review of current and investigational pharmacologic agents for acute heart failure syndromes. Am J Cardiol 2007; 99:4A-23A. [PMID: 17239703 DOI: 10.1016/j.amjcard.2006.11.025] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Acute heart failure syndromes (AHFS) are a major public health problem and present a therapeutic challenge to clinicians. Commonly used agents in the treatment of AHFS include diuretics, vasodilators (eg, nitroglycerin, nitroprusside, nesiritide), and inotropes (eg, dobutamine, dopamine, milrinone). Patients admitted to hospital with AHFS and low cardiac output state (AHFS/LO) represent a subgroup with very high inhospital and postdischarge mortality rates. Most of these patients require intravenous inotropic therapy. However, the use of current intravenous inotropes has been associated with risk for hypotension, atrial and ventricular arrhythmias, and possibly increased postdischarge mortality, particularly in those with coronary artery disease. Consequently, there is an unmet need for new agents to safely improve cardiac performance (contractility and/or active relaxation) in this patient population. This article reviews a selection of current and investigational agents for the treatment of AHFS, with a main focus on the high-risk patient population with AHFS/LO.
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Affiliation(s)
- David D Shin
- Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA, and Division of Cardiology, European Hospital, Rome, Italy
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deGoma EM, Vagelos RH, Fowler MB, Ashley EA. Emerging therapies for the management of decompensated heart failure: from bench to bedside. J Am Coll Cardiol 2006; 48:2397-409. [PMID: 17174176 DOI: 10.1016/j.jacc.2006.08.039] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 07/06/2006] [Accepted: 07/31/2006] [Indexed: 11/27/2022]
Abstract
While pharmaceutical innovation has been highly successful in reducing mortality in chronic heart failure, this has not been matched by similar success in decompensated heart failure syndromes. Despite outstanding issues over definitions and end points, we argue in this paper that an unprecedented wealth of pharmacologic innovation may soon transform the management of these challenging patients. Agents that target contractility, such as cardiac myosin activators and novel adenosine triphosphate-dependent transmembrane sodium-potassium pump inhibitors, provide inotropic support without arrhythmogenic increases in cytosolic calcium or side effects of more traditional agents. Adenosine receptor blockade may improve glomerular filtration and diuresis by exerting a direct beneficial effect on glomerular blood flow while vasopressin antagonists promote free water excretion without compromising renal function and may simultaneously inhibit myocardial remodeling. Urodilatin, the renally synthesized isoform of atrial natriuretic peptide, may improve pulmonary congestion via vasodilation and enhanced diuresis. Finally, metabolic modulators such as perhexiline may optimize myocardial energy utilization by shifting adenosine triphosphate production from free fatty acids to glucose, a unique and conceptually appealing approach to the management of heart failure. These advances allow optimism not only for the advancement of our understanding and management of decompensated heart failure syndromes but for the translational research effort in heart failure biology in general.
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Affiliation(s)
- Emil M deGoma
- Stanford University, Stanford, California 94305, USA
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Del Ry S, Passino C, Emdin M, Giannessi D. C-type natriuretic peptide and heart failure. Pharmacol Res 2006; 54:326-33. [PMID: 16904335 DOI: 10.1016/j.phrs.2006.06.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2006] [Revised: 06/08/2006] [Accepted: 06/13/2006] [Indexed: 10/24/2022]
Abstract
C-type natriuretic peptide (CNP) is a peptide produced by the vascular endothelium with vasodilative properties. It shares structural and physiological properties with the atrial and brain natriuretic peptides (ANP and BNP), whose central role in the pathophysiology of heart failure (CHF) is firmly established. The role of CNP, first isolated from porcine brain, has not been yet completely determined. The transcription of the gene, that in man is located on chromosome 2, is regulated by factors such as tumor necrosis factor and interleukin-1. Two mature forms of the peptide exist: CNP-53, that predominates in tissues and CNP-22, found mainly in plasma. As recently found, CNP is produced directly in the myocardium and an increase in plasma levels of this peptide and of its precursor was observed in CHF. The aim of this review was to examine the current literature relating to cardiovascular functions of CNP and in particular to its role in CHF. In fact, CNP may represent an important new local autocrine and endocrine mediator in CHF although further evaluations are required to define its full pathophysiological role in this disease.
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Affiliation(s)
- Silvia Del Ry
- CNR Institute of Clinical Physiology, National Research Council Via Giuseppe Moruzzi 1, 56124 Pisa, Italy
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Ng TMH, Singh AK, Dasta JF, Feldman D, Mebazaa A. Contemporary Issues in the Pharmacologic Management of Acute Heart Failure. Crit Care Clin 2006; 22:199-219, v. [PMID: 16677996 DOI: 10.1016/j.ccc.2006.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute heart failure is an evolving syndrome that continues to be defined by ongoing studies and registries. It is associated with significant morbidity and mortality and places a huge economic burden on health care systems. Improved understanding of the underlying pathophysiologic processes has prompted interest into understanding the implications of current and future pharmacologic management strategies beyond hemodynamics. Diuretics, vasodilators, and inotropes remain the mainstays of therapy with several new classes of agents on the horizon. Clinicians should understand the rationale for use and limitations of each therapy to maximize benefit and cost-effectiveness, while minimizing the potential for adverse outcomes.
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Affiliation(s)
- Tien M H Ng
- Department of Pharmacy, University of Southern California, 1985 Zonal Avenue, Los Angeles, CA 90033, USA.
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Mitrovic V, Lüss H, Nitsche K, Forssmann K, Maronde E, Fricke K, Forssmann WG, Meyer M. Effects of the renal natriuretic peptide urodilatin (ularitide) in patients with decompensated chronic heart failure: a double-blind, placebo-controlled, ascending-dose trial. Am Heart J 2005; 150:1239. [PMID: 16338265 DOI: 10.1016/j.ahj.2005.01.022] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2004] [Accepted: 01/13/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Urodilatin (ularitide), a natriuretic peptide, is produced within the kidneys. The aim of this study was to define the role of 24-hour intravenous infusions of urodilatin in the treatment of decompensated chronic heart failure (DHF). METHODS In this randomized, double-blind, ascending-dose safety study, 24 patients with DHF (cardiac index 1.91 +/- 0.34 L/min per square meter, pulmonary capillary wedge pressure 26 +/- 6 mm Hg, right atrial pressure 11 +/- 4 mm Hg) received urodilatin (7.5, 15, or 30 ng/(kg.min)) or placebo infusions over 24 hours. RESULTS Compared with baseline, urodilatin decreased pulmonary capillary wedge pressure by 10 mm Hg in the 15 ng/(kg.min) group (P < .05) and by 15 mm Hg in the 30 ng/(kg.min) group (P < .05) at 6 hours. In the same dose groups, right atrial pressure decreased, and dyspnea as reported by patients tended to improve. At 24 hours, 15 and 30 ng/(kg.min) urodilatin infusions decreased N-terminal-pro-brain natriuretic peptide levels by 40% and 45%, respectively, compared with baseline. Between 1 to 12 hours, plasma cyclic guanosine monophosphate levels at 15 and 30 ng/(kg.min) urodilatin were significantly higher than both placebo and the respective baseline after infusion start (P < .05 and .01). Among the different groups, there was no obvious difference regarding total number of patients with adverse events and total number of adverse events. During infusion, 3 transient asymptomatic hypotensions occurred in the urodilatin groups. CONCLUSIONS Our findings show that urodilatin may be a new agent for the therapy for DHF.
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Schermuly RT, Weissmann N, Enke B, Ghofrani HA, Forssmann WG, Grimminger F, Seeger W, Walmrath D. Urodilatin, a natriuretic peptide stimulating particulate guanylate cyclase, and the phosphodiesterase 5 inhibitor dipyridamole attenuate experimental pulmonary hypertension: synergism upon coapplication. Am J Respir Cell Mol Biol 2001; 25:219-25. [PMID: 11509332 DOI: 10.1165/ajrcmb.25.2.4256] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In a model of acute pulmonary hypertension in intact rabbits, we investigated the vasodilatory potency of intravascularly administered urodilatin, a renal natriuretic peptide type A known to stimulate particulate guanylate cyclase. Urodilatin infusion was performed in the absence and presence of the phosphodiesterase (PDE) type 5 inhibitor dipyridamole. Stable pulmonary hypertension was evoked by continuous infusion of the thromboxane mimetic U46619, resulting in approximate doubling of the pulmonary artery pressure (PAP). When infused as sole agents, both urodilatin and dipyridamole dose-dependently attenuated the pulmonary hypertension, with doses for a 20% decrease in PAP being 30 ng/kg min for urodilatin and 10 microg/kg min for dipyridamole. A corresponding decrease in systemic arterial pressure (SAP) was noted to occur in response to both agents. Sequential intravenous administration of a subthreshold dose of dipyridamole (1 microg/kg min), which per se did not affect pulmonary and systemic hemodynamics, and a standard dose of urodilatin (30 ng/kg min) resulted in a significant amplification of both the PAP and the SAP decrease in response to the natriuretic peptide. At the same time, manifold enhanced plasmatic cyclic guanosine monophosphate (cGMP) levels were detected. Aerosolized dipyridamole also dose-dependently attenuated pulmonary hypertension, with only 1 microg/kg min being sufficient for a 20% decrease in PAP, with no SAP decline. Preceding administration of subthreshold aerosolized dipyridamole (50 ng/kg min) did, however, cause only a minor amplification of the pulmonary vasodilatory response to a subsequently infused standard dose of urodilatin. In conclusion, this is the first study to show that urodilatin does possess vasodilatory potency in the pulmonary circulation, and enhanced plasma levels of cGMP and synergy with the PDE5 inhibitor dipyridamole both strongly suggest that this effect proceeds via guanylate cyclase activation. The effect of infused urodilatin is, however, not selective for the pulmonary vasculature, as the systemic vascular resistance declines in a corresponding fashion.
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Affiliation(s)
- R T Schermuly
- Department of Internal Medicine, Justus-Liebig-University Giessen, Giessen, Germany.
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Kikuchi M, Nakamura M, Suzuki T, Sato M, Takino T, Hiramori K. Usefulness of carperitide for the treatment of refractory heart failure due to severe acute myocardial infarction. JAPANESE HEART JOURNAL 2001; 42:271-80. [PMID: 11605765 DOI: 10.1536/jhj.42.271] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Carperitide (synthetic atrial natriuretic peptide) is a newly developed drug for the treatment of heart failure. Although this drug has been used for various types of heart failure, it remains unknown whether it has additive effects on hemodynamic parameters or renal excretory function during intensive treatment for acute refractory heart failure. We have examined the cardiorenal and hormonal effects of carperitide (0.05-0.10 microg / min / kg) in 9 patients (mean age: 67+/-8 years) with severe heart failure complicated with acute myocardial infarction, in which a range of intensive treatments have already been started. Hemodynamic parameters were determined before and 4, 24 and 48 hours after initiation of carperitide. Pulmonary capillary wedge pressure (mean+/-SD) had decreased dramatically from 21+/-6 to 11+/-5 mmHg (p<0.01) 4 hours after the treatment without significant renal effects. Heart rate and systemic blood pressure were not significantly changed. These beneficial effects were maintained for at least 24 hours. Plasma aldosterone levels fell significantly in response to the drug (from 148+/-68 to 56+/-29 pg / ml; p<0.05). However, mean hourly urine output remained unchanged after carperitide. In conclusion, intravenous infusion of carperitide promptly and persistently reduces left ventricular filling pressure without diuresis, hypotension, reflex tachycardia, or neurohormonal activation in patients with refractory heart failure due to severe acute myocardial infarction.
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Affiliation(s)
- M Kikuchi
- Second Department of Internal Medicine, School of Medicine, Iwate Medical University, Morioka City, Japan
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Garwood S. New pharmacologic options for renal preservation. ANESTHESIOLOGY CLINICS OF NORTH AMERICA 2000; 18:753-71. [PMID: 11094689 DOI: 10.1016/s0889-8537(05)70193-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The understanding of the cause and pathophysiology of renal failure has guided the rational development of pharmacologic renoprotective strategies. Although traditionally anesthesiologists have focused on renal hemodynamic derangements, newer information suggests that cellular interactions amplify and perpetuate the insult. Consequently, the potential renoprotective armamentarium not only encompasses the more traditional vasoactive agents but also therapeutic approaches that may modify the cellular response to injury. Although few of these agents have reached the clinical arena, preliminary work suggests that this new approach to renal injury and protection may be promising.
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Affiliation(s)
- S Garwood
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, USA.
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Kikuchi M, Nakamura M, Suzuki T, Ohira K, Yamaguchi H, Fukami KI, Hiramori K. Marked and prompt hemodynamic improvement by carperitide in refractory congestive heart failure due to dilated cardiomyopathy. JAPANESE HEART JOURNAL 2000; 41:527-33. [PMID: 11041104 DOI: 10.1536/jhj.41.527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A 16-year-old Japanese male diagnosed with congestive heart failure (CHF) due to dilated cardiomyopathy was treated by conventional intensive treatment such as intravenous infusion of diuretics, catecholamines, and phosphodiesterase inhibitors with vasodilators. However, he developed a low output syndrome with appearances of hyponatremia and hypochloremia. As a consequence, intravenous infusion of carperitide (synthetic atrial natriuretic peptide) was added to the therapy. Thereafter his symptoms and hemodynamic parameters promptly and dramatically improved without significant diuresis, and this amelioration persisted for more than 20 days without drug intolerance. This outcome suggests that use of carperitide may be a safe and efficacious means to reduce cardiac preload without hypotension and tachycardia in patients with refractory CHF in whom intensive treatment has already been performed.
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Affiliation(s)
- M Kikuchi
- Second Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan
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Eisenman A, Armali Z, Enat R, Bankir L, Baruch Y. Low-dose vasopressin restores diuresis both in patients with hepatorenal syndrome and in anuric patients with end-stage heart failure. J Intern Med 1999; 246:183-90. [PMID: 10447787 DOI: 10.1046/j.1365-2796.1999.00556.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The purpose of this study was to confirm earlier reports that low-dose vasopressin (LDVP) analogues promote urine output in patients with hepatorenal syndrome (HRS) and to check whether this mode of therapy could also be effective in renal shutdown due to nonhepatic conditions. DESIGN A prospective, open, interventional study. SETTING An intermediate-level (step-down) medical intensive care unit within a general medical ward of a large university-affiliated hospital. SUBJECTS Eighteen successive hospitalized patients with HRS (mean age 65 +/- 13 years) and 11 patients with end-stage congestive heart failure (CHF) (mean age 81 +/- 5 years) who failed to restore urine output with conventional treatment (fluids, dopamine, and diuretics) given for at least 24 h. INTERVENTIONS The patients received LDVP (1 IU h-1) continuously in addition to the conventional treatment. MAIN OUTCOME MEASURES Urine output and creatinine clearance every 24 h. RESULTS In the HRS group, before treatment the urine output was 155 +/- 9 mL 24 -1h (mean +/- SD). After treatment with LDVP for 24, 48, and 72 h, urine output improved to 1067 +/- 87, 1020 +/- 501, and 1311 +/- 988 mL 24 -1h, respectively (P < 0.0001 for all measures; two-tailed paired t-test). In the CHF group, before treatment the urine output was 99 +/- 99 mL 24 -1h. After treatment with LDVP for 24, 48, and 72 h, this improved to 1125 +/- 994 mL 24 -1h (P = 0.0028), 1821 +/- 1300 mL 24 -1h (P = 0.004), and 2920 +/- 2423 mL 24 -1h (P = 0.0012), respectively. The improvement in urine output was not accompanied by a parallel improvement in creatinine clearance. The overall outcome did not change, and all patients except two in each group succumbed to their end-stage disease, due to nonrenal causes. CONCLUSIONS LDVP is effective in restoring urine output both in HRS and in CHF. This suggests that LDVP affects mechanisms not specifically related to liver disease. LDVP may be useful in critical patients with renal shutdown whilst awaiting liver or heart transplantation.
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Affiliation(s)
- A Eisenman
- Liver Unit, Department of Internal Medicine B, Rambam Medical Center, Technion-Israel Institute of Technology, Haifa, Israel.
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Bestle MH, Olsen NV, Christensen P, Jensen BV, Bie P. Cardiovascular, endocrine, and renal effects of urodilatin in normal humans. THE AMERICAN JOURNAL OF PHYSIOLOGY 1999; 276:R684-95. [PMID: 10070128 DOI: 10.1152/ajpregu.1999.276.3.r684] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Effects of urodilatin (5, 10, 20, and 40 ng. kg-1. min-1) infused over 2 h on separate study days were studied in eight normal subjects with use of a randomized, double-blind protocol. All doses decreased renal plasma flow (hippurate clearance, 13-37%) and increased fractional Li+ clearance (7-22%) and urinary Na+ excretion (by 30, 76, 136, and 99% at 5, 10, 20, and 40 ng. kg-1. min-1, respectively). Glomerular filtration rate did not increase significantly with any dose. The two lowest doses decreased cardiac output (7 and 16%) and stroke volume (10 and 20%) without changing mean arterial blood pressure and heart rate. The two highest doses elicited larger decreases in stroke volume (17 and 21%) but also decreased blood pressure (6 and 14%) and increased heart rate (15 and 38%), such that cardiac output remained unchanged. Hematocrit and plasma protein concentration increased with the three highest doses. The renin-angiotensin-aldosterone system was inhibited by the three lowest doses but activated by the hypotensive dose of 40 ng. kg-1. min-1. Plasma vasopressin increased by factors of up to 5 during infusion of the three highest doses. Atrial natriuretic peptide immunoreactivity (including urodilatin) and plasma cGMP increased dose dependently. The urinary excretion rate of albumin was elevated up to 15-fold (37 +/- 17 micrograms/min). Use of a newly developed assay revealed that baseline urinary urodilatin excretion rate was low (<10 pg/min) and that fractional excretion of urodilatin remained below 0.1%. The results indicate that even moderately natriuretic doses of urodilatin exert protracted effects on systemic hemodynamic, endocrine, and renal functions, including decreases in cardiac output and renal blood flow, without changes in arterial pressure or glomerular filtration rate, and that filtered urodilatin is almost completely removed by the renal tubules.
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Affiliation(s)
- M H Bestle
- Department of Medical Physiology, Panum Institute, University of Copenhagen, DK-2200, Denmark
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Lainchbury JG, Richards AM, Nicholls MG, Espiner EA, Yandle TG. Brain natriuretic peptide and neutral endopeptidase inhibition in left ventricular impairment. J Clin Endocrinol Metab 1999; 84:723-9. [PMID: 10022444 DOI: 10.1210/jcem.84.2.5489] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Brain natriuretic peptide (BNP) is increased in left ventricular impairment and neutral endopeptidase (NEP) is involved in its metabolism. In random order, eight patients with left ventricular impairment received placebo, a 4-h infusion of human BNP (3.0 pmol/kg min), a single oral dose of NEP inhibitor (SCH 42495, 300 mg), and combined BNP and SCH 42495. Plasma BNP, cGMP, and cortisol were significantly increased by all three treatments (P < 0.05-P < 0.001). Combined treatment had a synergistic effect on plasma cGMP. The metabolic clearance rate of exogenous BNP was reduced (25%) by NEP inhibition. Endogenous plasma ANP was augmented more than BNP by NEP inhibition. Plasma aldosterone, unchanged during infusions, rose markedly after BNP and after the combined treatment (P < 0.05 for both). Urine sodium excretion, increased by NEP inhibition (P < 0.05) and by BNP (P = 0.05), was unchanged during combined treatment. Urine cGMP excretion was increased, whereas blood pressure was reduced by all active treatments (P < 0.05-0.01 for all). Heart rate increased only with combined treatment (P = 0.007). Plasma renin activity, norepinephrine, and cardiac output were unaffected. BNP infusion and NEP inhibition both induced significant hemodynamic and renal responses. The augmented hypotensive effect of combined treatments, and consequent fall in renal perfusion pressure, may underly the observed blunting of the natriuretic response that occurred despite greater than additive increments in plasma BNP, ANP, and cGMP.
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Affiliation(s)
- J G Lainchbury
- Department of Medicine, Christchurch Hospital, New Zealand
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Murakawa Y, Yamashita T, Kanese Y, Omata M. Effect of atrial natriuretic peptide on electrical defibrillation efficacy. J Cardiovasc Electrophysiol 1998; 9:962-9. [PMID: 9786076 DOI: 10.1111/j.1540-8167.1998.tb00136.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In vitro studies have suggested that human atrial natriuretic peptide (ANP) modulates the electrophysiologic properties of myocardial cells. This study assessed whether ANP could influence defibrillation efficacy. METHODS AND RESULTS In 35 anesthetized dogs, the transcardiac defibrillation threshold (DFT) as well as hemodynamic and electrophysiologic variables were determined before and during treatment with ANP (n = 11), hydralazine (n = 11), or saline (n = 13). ANP (1.5 microg/kg + 0.2 microg/kg per min) increased the plasma concentration of cyclic GMP (a second messenger for ANP) and significantly decreased aortic blood pressure (mean 100+/-11 mmHg to 83+/-15 mmHg). ANP also prolonged ventricular repolarization (effective refractory period 157+/-7 msec to 165+/-11 msec) and markedly reduced DFT (5.4+/-1.2 J to 3.8+/-0.7 J [P < 0.01]) without changing pulmonary artery pressure or sinus cycle length. Neither saline nor hydralazine (1.5 mg/kg) had a significant effect on DFT (saline 4.7+/-2.1 J to 4.6+/-2.4 J; hydralazine 4.3+/-2.0 J to 4.2+/-1.9 J), although hydralazine caused pronounced hypotension (mean aortic pressure 103+/-9 mmHg to 74+/-13 mmHg). CONCLUSION These results suggest that ANP increases defibrillation efficacy, and that this effect is not necessarily shared by other vasodilating agents.
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Affiliation(s)
- Y Murakawa
- Second Department of Internal Medicine, University of Tokyo, Japan.
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Dorner GT, Selenko N, Kral T, Schmetterer L, Eichler HG, Wolzt M. Hemodynamic effects of continuous urodilatin infusion: a dose-finding study. Clin Pharmacol Ther 1998; 64:322-30. [PMID: 9757156 DOI: 10.1016/s0009-9236(98)90181-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the effects of urodilatin (INN, ularitide) on systemic and renal hemodynamic parameters. METHODS Twenty healthy male subjects were included in this double-blind, randomized placebo-controlled trial and assigned to receive either continuous intravenous infusion of different doses of 7.5, 15, or 22.5 ng/kg body weight/min urodilatin or placebo over 300 minutes. Cardiac performance, systolic time intervals, and airway function were measured noninvasively. The effects on renal hemodynamic values were assessed with para-aminohippurate and inulin clearance techniques. RESULTS Urodilatin was well tolerated by all subjects at doses of 7.5 and 15 ng/kg/min. Infusion was stopped prematurely for the group that received 22.5 ng/kg/min urodilatin group because of systemic hypotensive responses with nausea and dizziness. Infusion of 15 ng/kg/min urodilatin significantly increased urine flow by a maximum of 165%, filtration fraction by 46%, renal resistance by 49%, and systemic vascular resistance by 45%. It decreased renal plasma flow by a maximum of 31% from baseline value. No change in cardiac inotropic function was detectable, but cardiac output decreased in all dose groups. Effects on glomerular filtration rate, forced expiratory volume, blood pressure, and pulse were not different from those with placebo. CONCLUSION Continuous infusion of 7.5 ng/kg/min and 15 ng/kg/min urodilatin exerts a significant increase in systemic and renal vascular resistance. Results of our experiments suggested that the therapeutic window for continuous urodilatin infusion is small and that doses higher than approximately 20 ng/kg/min urodilatin carry high risk for adverse drug reactions.
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Affiliation(s)
- G T Dorner
- Department of Clinical Pharmacology, Vienna University, Austria
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AKAMA H, McGRATH BP. The kidney in heart failure: Vasodilator-natriuretic systems. Nephrology (Carlton) 1997. [DOI: 10.1111/j.1440-1797.1997.tb00247.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Meyer M, Flüge T, Kruhøffer M, Forssmann WG. Basic aspects of vasorelaxant and bronchodilating peptides in clinical use: urodilatin (INN: Ularitide), VIP, and PACAP. Ann N Y Acad Sci 1996; 805:443-61; discussion 461-3. [PMID: 8993423 DOI: 10.1111/j.1749-6632.1996.tb17503.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- M Meyer
- Niedersächsisches Institut für Peptid-Forschung (IPF), Hannover, Germany
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Gambaryan S, Häusler C, Markert T, Pöhler D, Jarchau T, Walter U, Haase W, Kurtz A, Lohmann SM. Expression of type II cGMP-dependent protein kinase in rat kidney is regulated by dehydration and correlated with renin gene expression. J Clin Invest 1996; 98:662-70. [PMID: 8698857 PMCID: PMC507475 DOI: 10.1172/jci118837] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
cGMP-based regulatory systems are vital for counteracting the renin-angiotensin system (RAS) which promotes volume expansion and high blood pressure. Natriuretic peptides and nitric oxide acting through their second messenger cGMP normally increase natriuresis and diuresis, and regulate renin release; however, the severe pathological state of cardiac heart failure is characterized by elevated levels of atrial natriuretic peptide that are no longer able to effectively oppose exaggerated RAS effects. There is presently limited information on the intracellular effectors of cGMP actions in the kidney. Recently we reported the cloning of the cDNA for type II cGMP-dependent protein kinase (cGK II), which is highly enriched in intestinal mucosa but was also detected for the first time in kidney. In the present study, cGK II was localized to juxtaglomerular (JG) cells, the ascending thin limb (ATL), and to a lesser extent the brush border of proximal tubules. An activator of renin gene expression, the angiotensin II type I receptor inhibitor, losartan, increased cGK II mRNA and protein three to fourfold in JG cells. In other experiments, water deprivation increased cGK II mRNA and protein three to fourfold in the inner medulla where both cGK II, and a kidney specific CI- channel shown by others to be regulated by dehydration, are localized in the ATL. Whereas additional data suggest that cGK I may primarily mediate cGMP-related changes in renal hemodynamics, cGK II may regulate renin release and ATL ion transport.
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Affiliation(s)
- S Gambaryan
- Medizinische Universitäts-Klinik, Klinische Biochemie and Pathobiochemie, Würzburg, Germany
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