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Brown JM. Adverse Effects of Aldosterone: Beyond Blood Pressure. J Am Heart Assoc 2024; 13:e030142. [PMID: 38497438 PMCID: PMC11179780 DOI: 10.1161/jaha.123.030142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Aldosterone is a steroid hormone that primarily acts through activation of the mineralocorticoid receptor (MR), a nuclear receptor responsible for downstream genomic regulation. Classically, activation of the MR in the renal tubular epithelium is responsible for sodium retention and volume expansion, raising systemic blood pressure. However, activation of the MR across a wide distribution of tissue types has been implicated in multiple adverse consequences for cardiovascular, cerebrovascular, renal, and metabolic disease, independent of blood pressure alone. Primary aldosteronism, heart failure, and chronic kidney disease are states of excessive aldosterone production and MR activity where targeting MR activation has had clinical benefits out of proportion to blood pressure lowering. The growing list of established and emerging therapies that target aldosterone and MR activation may provide new opportunities to improve clinical outcomes and enhance cardiovascular and renal health.
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Affiliation(s)
- Jenifer M. Brown
- Division of Cardiovascular Medicine, Department of MedicineBrigham and Women’s Hospital, Harvard Medical SchoolBostonMAUSA
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Logeart D, Taille Y, Derumeaux G, Gellen B, Sirol M, Galinier M, Roubille F, Georges JL, Trochu JN, Launay JM, Vodovar N, Bauters C, Vicaut E, Mercadier JJ. Patterns of left ventricular remodeling post-myocardial infarction, determinants, and outcome. Clin Res Cardiol 2024:10.1007/s00392-023-02331-z. [PMID: 38261025 DOI: 10.1007/s00392-023-02331-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 10/20/2023] [Indexed: 01/24/2024]
Abstract
AIM Left ventricular remodeling (LVR) after myocardial infarction (MI) can lead to heart failure, arrhythmia, and death. We aim to describe adverse LVR patterns at 6 months post-MI and their relationships with subsequent outcomes and to determine baseline. METHODS AND RESULTS A multicenter cohort of 410 patients (median age 57 years, 87% male) with reperfused MI and at least 3 akinetic LV segments on admission was analyzed. All patients had transthoracic echocardiography performed 4 days and 6 months post-MI, and 214 also had cardiac magnetic resonance imaging performed on day 4. To predict LVR, machine learning methods were employed in order to handle many variables, some of which may have complex interactions. Six months post-MI, echocardiographic increases in LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), and LV ejection fraction (LVEF) were 14.1% [interquartile range 0.0, 32.0], 5.0% [- 14.0, 25.8], and 8.7% [0.0, 19.4], respectively. At 6 months, ≥ 15% or 20% increases in LVEDV were observed in 49% and 42% of patients, respectively, and 37% had an LVEF < 50%. The rate of death or new-onset HF at the end of 5-year follow-up was 8.8%. Baseline variables associated with adverse LVR were determined best by random forest analysis and included stroke volume, stroke work, necrosis size, LVEDV, LVEF, and LV afterload, the latter assessed by Ea or Ea/Ees. In contrast, baseline clinical and biological characteristics were poorly predictive of LVR. After adjustment for predictive baseline variables, LV dilation > 20% and 6-month LVEF < 50% were significantly associated with the risk of death and/or heart failure: hazard ratio (HR) 2.12 (95% confidence interval (CI) 1.05-4.43; p = 0.04) and HR 2.68 (95% CI 1.20-6.00; p = 0.016) respectively. CONCLUSION Despite early reperfusion and cardioprotective therapy, adverse LVR remains frequent after acute MI and is associated with a risk of death and HF. A machine learning approach identified and prioritized early variables that are associated with adverse LVR and which were mainly hemodynamic, combining LV volumes, estimates of systolic function, and afterload.
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Affiliation(s)
- Damien Logeart
- UMR-S 942 MASCOT, Université Paris Cité and Inserm, Paris, France.
- Assistance Publique Hôpitaux de Paris, Hôpital Lariboisière-Fernand Widal, 75010, Paris, France.
- Université Paris Cité, Paris, France.
| | - Yoann Taille
- Assistance Publique Hôpitaux de Paris, Hôpital Lariboisière-Fernand Widal, 75010, Paris, France
| | - Geneviève Derumeaux
- Assistance Publique Hôpitaux de Paris, Hôpital Henri-Mondor, Créteil, France
| | | | - Marc Sirol
- American Hospital, Neuilly-Sur-Seine, France
| | | | | | | | | | | | - Nicolas Vodovar
- UMR-S 942 MASCOT, Université Paris Cité and Inserm, Paris, France
| | | | - Eric Vicaut
- UMR-S 942 MASCOT, Université Paris Cité and Inserm, Paris, France
- Assistance Publique Hôpitaux de Paris, Hôpital Lariboisière-Fernand Widal, 75010, Paris, France
- Université Paris Cité, Paris, France
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Parksook WW, Williams GH. Aldosterone and cardiovascular diseases. Cardiovasc Res 2023; 119:28-44. [PMID: 35388416 DOI: 10.1093/cvr/cvac027] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/07/2021] [Accepted: 12/28/2021] [Indexed: 11/12/2022] Open
Abstract
Aldosterone's role in the kidney and its pathophysiologic actions in hypertension are well known. However, its role or that of its receptor [minieralocorticoid receptor (MR)] in other cardiovascular (CV) disease are less well described. To identify their potential roles in six CV conditions (heart failure, myocardial infarction, atrial fibrillation, stroke, atherosclerosis, and thrombosis), we assessed these associations in the following four areas: (i) mechanistic studies in rodents and humans; (ii) pre-clinical studies of MR antagonists; (iii) clinical trials of MR antagonists; and (iv) genetics. The data were acquired from an online search of the National Library of Medicine using the PubMed search engine from January 2011 through June 2021. There were 3702 publications identified with 200 publications meeting our inclusion and exclusion criteria. Data strongly supported an association between heart failure and dysregulated aldosterone/MR. This association is not surprising given aldosterone/MR's prominent role in regulating sodium/volume homeostasis. Atrial fibrillation and myocardial infarction are also associated with dysregulated aldosterone/MR, but less strongly. For the most part, the data were insufficient to determine whether there was a relationship between atherosclerosis, stroke, or thrombosis and aldosterone/MR dysregulation. This review clearly documented an expanding role for aldosterone/MR's dysregulation in CV diseases beyond hypertension. How expansive it might be is limited by the currently available data. It is anticipated that with an increased focus on aldosterone/MR's potential roles in these diseases, additional clinical and pre-clinical data will clarify these relationships, thereby, opening approaches to use modulators of aldosterone/MR's action to more precisely treat these CV conditions.
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Affiliation(s)
- Wasita W Parksook
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Endocrinology and Metabolism, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Division of General Internal Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Gordon H Williams
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Lorente-Ros M, Aguilar-Gallardo JS, Shah A, Narasimhan B, Aronow WS. An overview of mineralocorticoid receptor antagonists as a treatment option for patients with heart failure: the current state-of-the-art and future outlook. Expert Opin Pharmacother 2022; 23:1737-1751. [PMID: 36262014 DOI: 10.1080/14656566.2022.2138744] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in patients with heart failure. These benefits of MRAs vary in different heart failure populations based on left ventricular ejection fraction and associated comorbidities. AREAS COVERED We define the pharmacologic properties of MRAs and the pathophysiological rationale for their utility in heart failure. We outline the current literature on the use of MRAs in different heart failure populations, including reduced and preserved ejection fraction (HFrEF/ HFpEF), and acute heart failure decompensation. Finally, we describe the limitations of currently available data and propose future directions of study. EXPERT OPINION While there is strong evidence supporting the use of MRAs in HFrEF, evidence in patients with HFpEF or acute heart failure is less definitive. Comorbidities such as obesity or atrial fibrillation could be clinical modifiers of the response to MRAs and potentially alter the risk/benefit ratio in these subpopulations. Emerging evidence for new non-steroidal MRAs reveal promising preliminary results that, if confirmed in large randomized clinical trials, could favor a change in clinical practice.
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Affiliation(s)
- Marta Lorente-Ros
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside-West, 1111 Amsterdam Avenue, New York, NY 10019, USA
| | - Jose S Aguilar-Gallardo
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside-West, 1111 Amsterdam Avenue, New York, NY 10019, USA
| | - Aayush Shah
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, 6565 Fannin St, Houston, TX 77030, USA
| | - Bharat Narasimhan
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, 6565 Fannin St, Houston, TX 77030, USA
| | - Wilbert S Aronow
- Department of Cardiology, New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY 10901, USA
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Leancă SA, Crișu D, Petriș AO, Afrăsânie I, Genes A, Costache AD, Tesloianu DN, Costache II. Left Ventricular Remodeling after Myocardial Infarction: From Physiopathology to Treatment. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081111. [PMID: 35892913 PMCID: PMC9332014 DOI: 10.3390/life12081111] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/19/2022] [Accepted: 07/21/2022] [Indexed: 12/11/2022]
Abstract
Myocardial infarction (MI) is the leading cause of death and morbidity worldwide, with an incidence relatively high in developed countries and rapidly growing in developing countries. The most common cause of MI is the rupture of an atherosclerotic plaque with subsequent thrombotic occlusion in the coronary circulation. This causes cardiomyocyte death and myocardial necrosis, with subsequent inflammation and fibrosis. Current therapies aim to restore coronary flow by thrombus dissolution with pharmaceutical treatment and/or intravascular stent implantation and to counteract neurohormonal activation. Despite these therapies, the injury caused by myocardial ischemia leads to left ventricular remodeling; this process involves changes in cardiac geometry, dimension and function and eventually progression to heart failure (HF). This review describes the pathophysiological mechanism that leads to cardiac remodeling and the therapeutic strategies with a role in slowing the progression of remodeling and improving cardiac structure and function.
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Affiliation(s)
- Sabina Andreea Leancă
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independentei nr. 1, 700111 Iasi, Romania; (S.A.L.); (A.O.P.); (I.A.); (A.G.); (D.N.T.); (I.I.C.)
| | - Daniela Crișu
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independentei nr. 1, 700111 Iasi, Romania; (S.A.L.); (A.O.P.); (I.A.); (A.G.); (D.N.T.); (I.I.C.)
- Correspondence: ; Tel.: +40-745-264-550
| | - Antoniu Octavian Petriș
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independentei nr. 1, 700111 Iasi, Romania; (S.A.L.); (A.O.P.); (I.A.); (A.G.); (D.N.T.); (I.I.C.)
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Str. University nr. 16, 700083 Iasi, Romania;
| | - Irina Afrăsânie
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independentei nr. 1, 700111 Iasi, Romania; (S.A.L.); (A.O.P.); (I.A.); (A.G.); (D.N.T.); (I.I.C.)
| | - Antonia Genes
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independentei nr. 1, 700111 Iasi, Romania; (S.A.L.); (A.O.P.); (I.A.); (A.G.); (D.N.T.); (I.I.C.)
| | - Alexandru Dan Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Str. University nr. 16, 700083 Iasi, Romania;
- Department of Cardiovascular Rehabilitation, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Dan Nicolae Tesloianu
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independentei nr. 1, 700111 Iasi, Romania; (S.A.L.); (A.O.P.); (I.A.); (A.G.); (D.N.T.); (I.I.C.)
| | - Irina Iuliana Costache
- Department of Cardiology, Emergency Clinical Hospital “Sf. Spiridon”, Bd. Independentei nr. 1, 700111 Iasi, Romania; (S.A.L.); (A.O.P.); (I.A.); (A.G.); (D.N.T.); (I.I.C.)
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, Str. University nr. 16, 700083 Iasi, Romania;
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Mechanisms of cinnamic aldehyde against myocardial ischemia/hypoxia injury in vivo and in vitro: Involvement of regulating PI3K/AKT signaling pathway. Biomed Pharmacother 2022; 147:112674. [DOI: 10.1016/j.biopha.2022.112674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/23/2022] [Accepted: 01/25/2022] [Indexed: 12/27/2022] Open
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Qu X, Yao H, Chen C, Kong S, Sun L, Du L, Liang S, Gao Z, Zheng G, Zheng M, Zhao C, Feng X, Wu G, Zhou H. Spironolactone Improves the All-Cause Mortality and Re-Hospitalization Rates in Acute Myocardial Infarction with Chronic Kidney Disease Patients. Front Pharmacol 2021; 12:632978. [PMID: 34135751 PMCID: PMC8201517 DOI: 10.3389/fphar.2021.632978] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 05/07/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Mineralocorticoid receptor antagonists (MRA) improve outcomes in chronic kidney disease (CKD) and acute myocardial infarction (AMI) patients. However, the lack of evidence regarding long-term clinical outcomes in the use of MRA, including spironolactone, in patients with AMI combined with CKD. Objectives: This study aimed to investigate whether spironolactone could significantly reduce the risk of all-cause mortality and re-admission in patients with AMI and CKD. Methods: In this single center, observational, retrospective, registry based clinical study, a total of 2,465 AMI patients were initially screened; after excluding patients with estimated glomerular filtration rate more than 60 ml/min/1.73 m2, 360 patients in the standard treatment group and 200 patients in the spironolactone group met the criteria. All enrolled patients follow-up for 30 months. The primary outcomes were all-cause mortality and re-admission. The key safety outcome was hyperkalemia rates during the 30 months follow-up period. Results: 160 (44.4%) and 41 (20.5%) patients in the standard treatment and spironolactone groups died, respectively [hazard ratio (HR): 0.389; 95% confidence interval (CI): 0.276–0.548; p < 0.001]. Re-admission occurred in 217 (60.3%) and 95 (47.5%) patients in the standard treatment and spironolactone groups, respectively (HR: 0.664; 95% CI: 0.522–0.846; p = 0.004). The spironolactone group was divided into two based on the daily dose, low dose group (no more than 40 mg) and high dose group (more than 40 mg); the differences in the mortality rate between low dose group (16.7%) and the standard treatment group (44.4%) (HR: 0.309; 95% CI: 0.228–0.418; p < 0.001) and high dose group (34.1%) (HR: 0.429; 95% CI: 0.199–0.925; p = 0.007) were significant. The differences in re-hospitalization rate between low dose group (43.6%) and the standard treatment group (60.3%) (HR: 0.583; 95% CI: 0.457–0.744; p < 0.001) and high dose group (61.4%) (HR: 0.551; 95% CI: 0.326–0.930; p = 0.007) was significant. Hyperkalemia occurred in 18 (9.0%) and 18 (5.0%) patients in the spironolactone group and standard treatment group, respectively (HR: 1.879; 95% CI: 0.954–3.700; p = 0.068). Whereas, Hyperkalemia occurred in high dose group (20.5%) significantly more often than in the standard treatment group (p < 0.001) and low dose group (5.8%) (p = 0.003). Conclusion: Using MRA, such as spironolactone, may substantially reduce the risk of both all-cause mortality and re-admission in patients with AMI and CKD; the use of low-dose spironolactone has the best efficacy and safety. However, this was a relatively small sample size, single center, observational, retrospective, registry based clinical study and further prospective evaluation in adequately powered randomized trials were needed before further use of spironolactone in AMI with CKD population.
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Affiliation(s)
- Xiang Qu
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Hui Yao
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Changxi Chen
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Shuting Kong
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Lingyue Sun
- Department of Cardiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Leilei Du
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Siqi Liang
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Zhan Gao
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Gaoshu Zheng
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Minghua Zheng
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Chuhuan Zhao
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Xiafei Feng
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Gaojun Wu
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Hao Zhou
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
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de Miranda DC, de Oliveira Faria G, Hermidorff MM, Dos Santos Silva FC, de Assis LVM, Isoldi MC. Pre- and Post-Conditioning of the Heart: An Overview of Cardioprotective Signaling Pathways. Curr Vasc Pharmacol 2020; 19:499-524. [PMID: 33222675 DOI: 10.2174/1570161119666201120160619] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 11/22/2022]
Abstract
Since the discovery of ischemic pre- and post-conditioning, more than 30 years ago, the knowledge about the mechanisms and signaling pathways involved in these processes has significantly increased. In clinical practice, on the other hand, such advancement has yet to be seen. This article provides an overview of ischemic pre-, post-, remote, and pharmacological conditioning related to the heart. In addition, we reviewed the cardioprotective signaling pathways and therapeutic agents involved in the above-mentioned processes, aiming to provide a comprehensive evaluation of the advancements in the field. The advancements made over the last decades cannot be ignored and with the exponential growth in techniques and applications. The future of pre- and post-conditioning is promising.
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Affiliation(s)
- Denise Coutinho de Miranda
- Laboratory of Cell Signaling, Research Center in Biological Science, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Brazil
| | - Gabriela de Oliveira Faria
- Laboratory of Cell Signaling, Research Center in Biological Science, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Brazil
| | - Milla Marques Hermidorff
- Laboratory of Cell Signaling, Research Center in Biological Science, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Brazil
| | - Fernanda Cacilda Dos Santos Silva
- Laboratory of Cardiovascular Physiology, Department of Biological Science, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Brazil
| | - Leonardo Vinícius Monteiro de Assis
- Laboratory of Comparative Physiology of Pigmentation, Department of Physiology, Institute of Biosciences, University of Sao Paulo, Sao Paulo, Brazil
| | - Mauro César Isoldi
- Laboratory of Cell Signaling, Research Center in Biological Science, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Ouro Preto, Brazil
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Bulluck H, Fröhlich GM, Nicholas JM, Mohdnazri S, Gamma R, Davies J, Sirker A, Mathur A, Blackman D, Garg P, Moon JC, Greenwood JP, Hausenloy DJ. Mineralocorticoid receptor antagonist pre-treatment and early post-treatment to minimize reperfusion injury after ST-elevation myocardial infarction: The MINIMIZE STEMI trial. Am Heart J 2019; 211:60-67. [PMID: 30893577 PMCID: PMC6483973 DOI: 10.1016/j.ahj.2019.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 02/11/2019] [Indexed: 01/28/2023]
Abstract
Background Mineralocorticoid receptor antagonist (MRA) therapy has been shown to prevent adverse left ventricular (LV) remodeling in ST-segment elevation myocardial infarction (STEMI) patients with heart failure. Whether initiating MRA therapy prior to primary percutaneous coronary intervention (PPCI) accrues additional benefit of reducing myocardial infarct size and preventing adverse LV remodeling is not known. We aimed to investigate whether MRA therapy initiated prior to reperfusion reduces myocardial infarct (MI) size and prevents adverse LV remodeling in STEMI patients. Methods STEMI patients presenting within 12 hours and with a proximal coronary artery occlusion with Thrombolysis In Myocardial Infarction flow grade 0 were consented and randomized to either an intravenous bolus of potassium canrenoate, followed by oral spironolactone for 3 months or matching placebo. The primary endpoint was MI size by cardiovascular magnetic resonance at 3 months. Results Sixty-seven patients completed the study. There was no significant difference in the final MI size at 3 months between the 2 groups (placebo: 17 ± 11%, MRA: 16 ± 10%, P = .574). There was also no difference in acute MI size (26 ± 16% versus 23 ± 14%, P = .425) or myocardial salvage (26 ± 12% versus 24 ± 8%, P = .456). At follow-up, there was a trend towards an improvement in LVEF (placebo: 49 ± 8%, MRA: 54 ± 11%, P = .053), and the MRA group had significantly greater percentage decrease in LVEDV (mean difference: −12.2 (95% CI −20.3 to −4.4)%, P = .003) and LVESV (mean difference: −18.2 (95% CI −30.1 to −6.3)%, P = .003). Conclusion This pilot study showed no benefit of MRA therapy in reducing MI size in STEMI patients when initiated prior to reperfusion, but there was an improvement in LV remodeling at 3 months. Adequately powered studies are warranted to confirm these findings.
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Aldosterone Antagonists Reduce the Risk of Cardiovascular Mortality in Dialysis Patients: A Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 2019:1925243. [PMID: 30941188 PMCID: PMC6421009 DOI: 10.1155/2019/1925243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/24/2019] [Indexed: 12/15/2022]
Abstract
Background and Purpose. Cardiovascular disease is the major cause of death in dialysis patients. Although aldosterone antagonists were considered a treatment for severe heart failure patients to reduce cardiac mortality, whether treating patients undergoing maintenance dialysis with aldosterone antagonists could reduce the risk of cardiocerebrovascular (CCV) remains unclear. We aim to systematically assess the efficacy and tolerability of the addition of aldosterone antagonists to conventional therapy in patients undergoing maintenance dialysis. Materials and Methods. We searched PubMed, EMBASE, the Cochrane Library, the Chinese Biomedical Literature Database (CBM), and the China National Knowledge Infrastructure (CNKI) for relevant articles. The primary endpoint of interest was CCV mortality. The secondary endpoints were all-cause mortality, left ventricular mass index (LVMI), and left ventricular ejection fraction (LVEF). Publication bias was evaluated using funnel plots and Egger's test. The meta-analysis was performed using Review Manager software version 5.3. Results. This analysis included 10 randomized controlled trials (RCTs) with 1172 total chronic dialysis patients. The use of aldosterone antagonists in the dialysis population resulted in a marked reduction in CCV mortality (RR 0.42, 95% CI 0.26-0.65, P=0.0002) and all-cause mortality (RR0.46, 95%CI 0.32-0.66, P<0.0001). The LVEF was improved by treatment with aldosterone antagonists (WMD 6.35%, P<0.00001). Moreover, aldosterone antagonists decreased the LVMI (WMD -8.69 g/m2, P=0.0006), whereas aldosterone antagonists increased the occurrence of hyperkalemia (RR1.70, 95%CI 1-2.88, P=0.05) and gynecomastia (RR 8.01, 95% CI 2.44- 26.27, P=0.0006). Conclusions. Addition of aldosterone antagonists to conventional treatment in chronic dialysis patients may reduce CCV mortality, improve cardiac function, and simultaneously decrease LVMI.
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Han X, Li M, Zhao Z, Zhang Y, Zhang J, Zhang X, Zhang Y, Guan S, Chu L. Mechanisms underlying the cardio-protection of total ginsenosides against myocardial ischemia in rats in vivo and in vitro: Possible involvement of L-type Ca 2+ channels, contractility and Ca 2+ homeostasis. J Pharmacol Sci 2019; 139:240-248. [PMID: 30826245 DOI: 10.1016/j.jphs.2019.02.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 02/01/2019] [Accepted: 02/05/2019] [Indexed: 11/17/2022] Open
Abstract
Here we aimed to observe the effects of total ginsenosides (TG) against isoproterenol (ISO) induced myocardial ischemia (MI) and to explore its underlying mechanisms based on L-type Ca2+ current (ICa-L), intracellular Ca2+ ([Ca2+]i) and contraction in isolated rat myocytes. Rat model of MI was induced by subcutaneously injection of ISO (85 mg/kg) for 2 consecutive days. J-point elevation, heart rate, serum levels of creatine kinase (CK) and lactated dehydrogenase (LDH), and heart morphology changes were observed. Influences of TG on ICa-L, [Ca2+]i and contraction in isolated rat myocytes were observed by the patch-clamp technique and IonOptix detection system. TG significantly reduced J-point elevation, heart rate, serum levels of CK and LDH, and improved heart pathologic morphology. TG decreased ICa-L in concentration-dependent manner with a half-maximal inhibitory concentration (IC50) of 31.65 μg/mL. TG (300 μg/mL) decreased ICa-L of normal and ischemic ventricular myocytes by 64.33 ± 1.28% and 61.29 ± 1.38% respectively. At 30 μg/mL, TG reduced Ca2+ transient by 21.67 ± 0.94% and cell shortening by 38.43 ± 6.49%. This study showed that TG displayed cardioprotective effects on ISO-induced MI rats and the underlying mechanisms may be related to inhibition of ICa-L, damping of [Ca2+]i and decrease of contractility.
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Affiliation(s)
- Xue Han
- School of Pharmacy, Hebei University of Chinese Medicine, Shijiazhuang 050200, Hebei, China
| | - Mengying Li
- School of Pharmacy, Hebei University of Chinese Medicine, Shijiazhuang 050200, Hebei, China
| | - Zhifeng Zhao
- School of Pharmacy, Hebei University of Chinese Medicine, Shijiazhuang 050200, Hebei, China
| | - Yuanyuan Zhang
- School of Pharmacy, Hebei University of Chinese Medicine, Shijiazhuang 050200, Hebei, China
| | - Jianping Zhang
- School of Basic Medicine, Hebei University of Chinese Medicine, Shijiazhuang 050200, Hebei, China
| | - Xuan Zhang
- School of Basic Medicine, Hebei University of Chinese Medicine, Shijiazhuang 050200, Hebei, China
| | - Ying Zhang
- School of Basic Medicine, Hebei University of Chinese Medicine, Shijiazhuang 050200, Hebei, China
| | - Shengjiang Guan
- School of Pharmacy, Hebei University of Chinese Medicine, Shijiazhuang 050200, Hebei, China
| | - Li Chu
- School of Pharmacy, Hebei University of Chinese Medicine, Shijiazhuang 050200, Hebei, China; Hebei Key Laboratory of Integrative Medicine on Liver-Kidney Patterns, Shijiazhuang 050200, Hebei, China.
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Xu Y, Qiu Z, Yang R, Wu Y, Cheng X. Efficacy of mineralocorticoid receptor antagonists in postmyocardial infarction patients with or without left ventricular dysfunction: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97:e13690. [PMID: 30572494 PMCID: PMC6319977 DOI: 10.1097/md.0000000000013690] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND There is heated debate about the benefits of using mineralocorticoid receptor antagonists (MRAs) in addition to standard therapy in patients admitted for myocardial infarction (MI) with or without left ventricular dysfunction (LVD). METHODS Randomized controlled trials (RCTs) were scanned by a formal search of electronic databases (PubMed, EMBASE, Cochrane Library, Ovid, and clinical trials) from their inception to April 2018. A meta-analysis was conducted using Review Manager 5.3 to identify studies reporting the efficacy of MRAs use in post-MI patients with or without LVD. RESULTS Thirteen RCTs involving 11,365 individuals were eligible for this study. MRAs treatment reduced all-cause mortality by 16%, cardiovascular death by 16%, and death from heart failure (HF) by 22% in post-MI patients. MRAs use reduced all-cause mortality by 13% and cardiovascular death by 15% in post-MI patients with LVD, but there was no significant difference in all-cause mortality and cardiovascular death in post-MI patients without LVD (relative ratios [RR] 0.83, 95% confidence interval [CI] 0.26-2.69, P = .76, I = 0%; RR 1.01, 95% CI 0.33-3.09, P = .99, I = 0%). In 6 RCTs involving post-MI patients, MRAs treatment had a significant effect on improving left ventricular ejection fraction (LVEF) (mean difference 3.33, 95% CI 0.91-5.75, P = .007, I = 94%). Patients treated with MRAs did not show a decrease in recurrent MI or repeat revascularization compared with patients treated without MRAs (RR 0.95, 95% CI [0.80-1.12], P = .54, I = 0%; RR 1.09, 95% CI [0.79-1.50], P = .61, I = 0%). However, MRAs treatment significantly increased the incidence of hyperkalemia compared with patients treated without MRAs (RR 2.05, 95% CI [1.60, 2.61], P < .00001, I = 49%). CONCLUSION MRAs treatment reduced all-cause mortality, cardiovascular death, and death from HF in post-MI patients. MRAs treatment also demonstrated a significant improvement in LVEF. MRAs reduced cardiovascular death and all-cause mortality in patients with LVD. Eplerenone significantly reduced all-cause mortality and cardiovascular death in post-MI patients. However, MRAs failed to show any cardiovascular benefit in post-MI patients without LVD.
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Affiliation(s)
- Yan Xu
- Department of Cardiovascular, Institute of Cardiovascular Disease
| | - Zhiqiang Qiu
- Department of Orthopedics, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Renqiang Yang
- Department of Cardiovascular, Institute of Cardiovascular Disease
| | - Yanqing Wu
- Department of Cardiovascular, Institute of Cardiovascular Disease
| | - Xiaoshu Cheng
- Department of Cardiovascular, Institute of Cardiovascular Disease
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13
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Rossello X, Ariti C, Pocock SJ, Ferreira JP, Girerd N, McMurray JJV, Van Veldhuisen DJ, Pitt B, Zannad F. Impact of mineralocorticoid receptor antagonists on the risk of sudden cardiac death in patients with heart failure and left-ventricular systolic dysfunction: an individual patient-level meta-analysis of three randomized-controlled trials. Clin Res Cardiol 2018; 108:477-486. [DOI: 10.1007/s00392-018-1378-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 09/24/2018] [Indexed: 12/15/2022]
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14
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Agra-Bermejo R, Cordero A, Rodríguez-Mañero M, García Acuña JM, Álvarez Álvarez B, Martínez Á, Álvarez Rodríguez L, Abou-Jokh C, Cid Álvarez B, González-Juanatey JR. Clinical impact of mineralocorticoid receptor antagonists treatment after acute coronary syndrome in the real world: A propensity score matching analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2018; 8:652-659. [PMID: 30117745 DOI: 10.1177/2048872618795422] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Recent studies suggest that the benefit of mineralocorticoid receptor antagonists in the acute coronary syndrome setting is controversial. The aim of this study was to examine the current long-term prognostic benefit of mineralocorticoid receptor antagonists in patients with acute coronary syndrome. MATERIAL AND METHODS We conducted a retrospective cohort study of 8318 consecutive acute coronary syndrome patients. Baseline patient characteristics were examined and a follow-up period was established for registry of death, major cardiovascular adverse events and heart failure re-hospitalization. We performed a propensity-matching analysis to draw up two groups of patients paired according to whether or not they had been treated with mineralocorticoid receptor antagonists. The prognostic value of mineralocorticoid receptor antagonists to predict events during follow-up was analysed using Cox regression. RESULTS Among the study participants, only 524 patients (6.3%) were discharged on mineralocorticoid receptor antagonists. Patients on mineralocorticoid receptor antagonists had a different clinical and pharmacological profile. These differences disappeared after the propensity score analysis. The median follow-up was 40.7 months. After the propensity score analysis, the cardiovascular mortality and heart failure readmission rates were similar between patients who were discharged on mineralocorticoid receptor antagonists and those whose not. The use of mineralocorticoid receptor antagonists was only associated with a reduction in major cardiovascular adverse events (hazard ratio=0.83, 95% confidence interval 0.69-0.97, p=0.001). CONCLUSIONS Our results do not corroborate the long-term benefit of mineralocorticoid receptor antagonists to improve survival after acute coronary syndrome in a large cohort of patients with heart failure or reduced left ventricular ejection fraction and diabetes. Their prescription was associated with a significantly lower incidence of major cardiovascular adverse events during the long-term follow-up without effect on heart failure development.
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Affiliation(s)
- Rosa Agra-Bermejo
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Alberto Cordero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.,Cardiology Department, Hospital Universitario de San Juan, Spain
| | - Moisés Rodríguez-Mañero
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Jose M García Acuña
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Belén Álvarez Álvarez
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Álvaro Martínez
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain
| | | | - Charigan Abou-Jokh
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain
| | - Belén Cid Álvarez
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Jose Ramón González-Juanatey
- Cardiology Department, Complejo Hospitalario Universitario de Santiago, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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15
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Docherty KF, Jhund PS. Early use of mineralocorticoid receptor antagonists in ST-elevation myocardial infarction: is it ever too early? Heart 2018; 104:1812-1813. [PMID: 29760244 DOI: 10.1136/heartjnl-2018-313371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Kieran F Docherty
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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16
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Hinton J, Mahmoudi M, Myat A, Curzen N. The role of mineralocorticoid receptor antagonists in patients with acute myocardial infarction: Is the evidence reflective of modern clinical practice? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 19:452-456. [PMID: 29730238 DOI: 10.1016/j.carrev.2018.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/14/2018] [Accepted: 04/10/2018] [Indexed: 11/20/2022]
Affiliation(s)
- Jonathan Hinton
- Coronary Research Group, Department of Cardiology, University Hospital Southampton, Southampton SO16 6YD, UK
| | - Michael Mahmoudi
- Coronary Research Group, Department of Cardiology, University Hospital Southampton, Southampton SO16 6YD, UK; Faculty of Medicine, University of Southampton, UK
| | - Aung Myat
- University of Brighton and Brighton and Sussex Medical School, UK
| | - Nick Curzen
- Coronary Research Group, Department of Cardiology, University Hospital Southampton, Southampton SO16 6YD, UK; Faculty of Medicine, University of Southampton, UK.
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17
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Beygui F, Van Belle E, Ecollan P, Machecourt J, Hamm CW, Lopez De Sa E, Flather M, Verheugt FWA, Vicaut E, Zannad F, Pitt B, Montalescot G. Individual participant data analysis of two trials on aldosterone blockade in myocardial infarction. Heart 2018; 104:1843-1849. [PMID: 29695512 DOI: 10.1136/heartjnl-2018-312950] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/26/2018] [Accepted: 03/28/2018] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Two recent randomised trials studied the benefit of mineralocorticoid receptor antagonists (MRAs) in ST-segment elevation myocardial infarction (STEMI) irrespective or in absence of heart failure. The studies were both undersized to assess hard clinical endpoints. A pooled analysis was preplanned by the steering committees. METHODS We conducted a prespecified meta-analysis of patient-level data of patients with STEMI recruited in two multicentre superiority trials, randomised within 72 hours after symptom onset. Patients were allocated (1:1) to two MRA regimens: (1) an intravenous bolus of potassium canrenoate (200 mg) followed by oral spironolactone (25 mg once daily) versus standard therapy or (2) oral eplerenone (25-50 mg) versus placebo. The primary and key secondary outcomes, all-cause death and the composite of all-cause death or resuscitated sudden death, respectively, were assessed in the intention-to-treat population using a Cox model stratified on the study identifier. RESULTS Patients were randomly assigned to receive (n=1118) or not the MRA regimen (n=1123). After a median follow-up time of 188 days, the primary and secondary outcomes occurred in 5 (0.4%) and 17 (1.5%) patients (adjusted HR (adjHR) 0.31, 95% CI 0.11 to 0.86, p=0.03) and 6 (0.5%) and 22 (2%) patients (adjHR 0.26, 95% CI 0.10 to 0.65, p=0.004) in the MRA and control groups, respectively. There were also trends towards lower rates of cardiovascular death (p=0.06) and ventricular fibrillation (p=0.08) in the MRA group. CONCLUSION Our analysis suggests that compared with standard therapy, MRA regimens are associated with a reduction of death and death or resuscitated sudden death in STEMI.
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Affiliation(s)
- Farzin Beygui
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Caen, EA4650 Normandie Université, Caen, Basse-Normandie, France
| | - Eric Van Belle
- INSERM U1011 and Cardiology, Institut Coeur Poumon, CHRU de Lille, Lille, France
| | - Patrick Ecollan
- SAMU, ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
| | - Jacques Machecourt
- Service de Cardiologie, Centre Hospitalier Universitaire de Grenoble, Grenoble, Rhône-Alpes, France
| | | | | | - Marcus Flather
- Cardiology, University of East Anglia and Norfolk and Norwich University Hospital, Norwich, UK
| | | | - Eric Vicaut
- ACTION Study Group, Unite de Recherche Clinique, Hôpital Lariboisière, Paris, France
| | - Faiez Zannad
- Inserm CIC 1433 and Cardiology, Centre Hospitalier Universitaire de Nancy, Vandœuvre-lès-Nancy, France
| | - Bertram Pitt
- University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Gilles Montalescot
- Cardiology, Sorbonne Université-Paris 6, ACTION Study Group, Institut de Cardiologie (AP-HP), Centre Hospitalier Universitaire Pitié-Salpêtriėre, INSERM UMRS 1166, Paris, France
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