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Efentakis P, Varela A, Chavdoula E, Sigala F, Sanoudou D, Tenta R, Gioti K, Kostomitsopoulos N, Papapetropoulos A, Tasouli A, Farmakis D, Davos CH, Klinakis A, Suter T, Cokkinos DV, Iliodromitis EK, Wenzel P, Andreadou I. Levosimendan prevents doxorubicin-induced cardiotoxicity in time- and dose-dependent manner: implications for inotropy. Cardiovasc Res 2020; 116:576-591. [PMID: 31228183 DOI: 10.1093/cvr/cvz163] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 05/22/2019] [Accepted: 06/18/2019] [Indexed: 12/27/2022] Open
Abstract
AIMS Levosimendan (LEVO) a clinically-used inodilator, exerts multifaceted cardioprotective effects. Case-studies indicate protection against doxorubicin (DXR)-induced cardiotoxicity, but this effect remains obscure. We investigated the effect and mechanism of different regimens of levosimendan on sub-chronic and chronic doxorubicin cardiotoxicity. METHODS AND RESULTS Based on preliminary in vivo experiments, rats serving as a sub-chronic model of doxorubicin-cardiotoxicity and were divided into: Control (N/S-0.9%), DXR (18 mg/kg-cumulative), DXR+LEVO (LEVO, 24 μg/kg-cumulative), and DXR+LEVO (acute) (LEVO, 24 μg/kg-bolus) for 14 days. Protein kinase-B (Akt), endothelial nitric oxide synthase (eNOS), and protein kinase-A and G (PKA/PKG) pathways emerged as contributors to the cardioprotection, converging onto phospholamban (PLN). To verify the contribution of PLN, phospholamban knockout (PLN-/-) mice were assigned to PLN-/-/Control (N/S-0.9%), PLN-/-/DXR (18 mg/kg), and PLN-/-/DXR+LEVO (ac) for 14 days. Furthermore, female breast cancer-bearing (BC) mice were divided into: Control (normal saline 0.9%, N/S 0.9%), DXR (18 mg/kg), LEVO, and DXR+LEVO (LEVO, 24 μg/kg-bolus) for 28 days. Echocardiography was performed in all protocols. To elucidate levosimendan's cardioprotective mechanism, primary cardiomyocytes were treated with doxorubicin or/and levosimendan and with N omega-nitro-L-arginine methyl ester (L-NAME), DT-2, and H-89 (eNOS, PKG, and PKA inhibitors, respectively); cardiomyocyte-toxicity was assessed. Single bolus administration of levosimendan abrogated DXR-induced cardiotoxicity and activated Akt/eNOS and cAMP-PKA/cGMP-PKG/PLN pathways but failed to exert cardioprotection in PLN-/- mice. Levosimendan's cardioprotection was also evident in the BC model. Finally, in vitro PKA inhibition abrogated levosimendan-mediated cardioprotection, indicating that its cardioprotection is cAMP-PKA dependent, while levosimendan preponderated over milrinone and dobutamine, by ameliorating calcium overload. CONCLUSION Single dose levosimendan prevented doxorubicin cardiotoxicity through a cAMP-PKA-PLN pathway, highlighting the role of inotropy in doxorubicin cardiotoxicity.
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Affiliation(s)
- Panagiotis Efentakis
- National and Kapodistrian University of Athens, Laboratory of Pharmacology, Faculty of Pharmacy, Panepistimiopolis, Zografou, Athens 15771, Greece.,Center of Cardiology, Cardiology 2, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany.,Center of Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Aimilia Varela
- Biomedical Research Foundation, Academy of Athens, Clinical, Experimental Surgery & Translational Research Center, Athens, Greece
| | - Evangelia Chavdoula
- Biomedical Research Foundation, Academy of Athens, Clinical, Experimental Surgery & Translational Research Center, Athens, Greece
| | - Fragiska Sigala
- First Department of Surgery, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Despina Sanoudou
- 4th Department of Internal Medicine, Clinical Genomics and Pharmacogenomics Unit, "Attikon" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Roxane Tenta
- School of Health Sciences and Education, Department of Nutrition and Dietetics, Harokopio University, Athens, Greece
| | - Katerina Gioti
- School of Health Sciences and Education, Department of Nutrition and Dietetics, Harokopio University, Athens, Greece
| | - Nikolaos Kostomitsopoulos
- Biomedical Research Foundation, Academy of Athens, Clinical, Experimental Surgery & Translational Research Center, Athens, Greece
| | - Andreas Papapetropoulos
- National and Kapodistrian University of Athens, Laboratory of Pharmacology, Faculty of Pharmacy, Panepistimiopolis, Zografou, Athens 15771, Greece.,Biomedical Research Foundation, Academy of Athens, Clinical, Experimental Surgery & Translational Research Center, Athens, Greece
| | | | - Dimitrios Farmakis
- Second Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Athens University Hospital "Attikon", Athens, Greece.,School of Medicine, European University of Cyprus, Nicosia, Cyprus
| | - Costantinos H Davos
- Biomedical Research Foundation, Academy of Athens, Clinical, Experimental Surgery & Translational Research Center, Athens, Greece
| | - Apostolos Klinakis
- Biomedical Research Foundation, Academy of Athens, Clinical, Experimental Surgery & Translational Research Center, Athens, Greece
| | - Thomas Suter
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Dennis V Cokkinos
- Biomedical Research Foundation, Academy of Athens, Clinical, Experimental Surgery & Translational Research Center, Athens, Greece
| | - Efstathios K Iliodromitis
- Second Department of Cardiology, National and Kapodistrian University of Athens, Medical School, Athens University Hospital "Attikon", Athens, Greece
| | - Philip Wenzel
- Center of Cardiology, Cardiology 2, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany.,Center of Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg-University Mainz, 55131 Mainz, Germany
| | - Ioanna Andreadou
- National and Kapodistrian University of Athens, Laboratory of Pharmacology, Faculty of Pharmacy, Panepistimiopolis, Zografou, Athens 15771, Greece
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Cheuk DKL, Sieswerda E, van Dalen EC, Postma A, Kremer LCM. Medical interventions for treating anthracycline-induced symptomatic and asymptomatic cardiotoxicity during and after treatment for childhood cancer. Cochrane Database Syst Rev 2016; 2016:CD008011. [PMID: 27552363 PMCID: PMC8626738 DOI: 10.1002/14651858.cd008011.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Anthracyclines are frequently used chemotherapeutic agents for childhood cancer that can cause cardiotoxicity during and after treatment. Although several medical interventions in adults with symptomatic or asymptomatic cardiac dysfunction due to other causes are beneficial, it is not known if the same treatments are effective for childhood cancer patients and survivors with anthracycline-induced cardiotoxicity. This review is an update of a previously published Cochrane review. OBJECTIVES To compare the effect of medical interventions on anthracycline-induced cardiotoxicity in childhood cancer patients or survivors with the effect of placebo, other medical interventions, or no treatment. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 8), MEDLINE/PubMed (1949 to September 2015), and EMBASE/Ovid (1980 to September 2015) for potentially relevant articles. In addition, we searched reference lists of relevant articles, conference proceedings of the International Society for Paediatric Oncology (SIOP), the American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH), the International Conference on Long-Term Complications of Treatment of Children & Adolescents for Cancer, and the European Symposium on Late Complications from Childhood Cancer (from 2005 to 2015), and ongoing trial databases (the ISRCTN Register, the National Institutes of Health (NIH) Register, and the trials register of the World Health Organization (WHO); all searched in September 2015). SELECTION CRITERIA Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing the effectiveness of medical interventions to treat anthracycline-induced cardiotoxicity with either placebo, other medical interventions, or no treatment. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessments, which another review author checked. We performed analyses according to the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS In the original version of the review we identified two RCTs; in this update we identified no additional studies. One trial (135 participants) compared enalapril with placebo in childhood cancer survivors with asymptomatic anthracycline-induced cardiac dysfunction. The other trial (68 participants) compared a two-week treatment of phosphocreatine with a control treatment (vitamin C, adenosine triphosphate, vitamin E, oral coenzyme Q10) in leukaemia patients with anthracycline-induced cardiotoxicity. Both studies had methodological limitations.The RCT on enalapril showed no statistically significant differences in overall survival, mortality due to heart failure, development of clinical heart failure, and quality of life between treatment and control groups. A post-hoc analysis showed a decrease (that is improvement) in one measure of cardiac function (left ventricular end-systolic wall stress (LVESWS): -8.62% change) compared with placebo (+1.66% change) in the first year of treatment (P = 0.036), but not afterwards. Participants treated with enalapril had a higher risk of dizziness or hypotension (risk ratio 7.17, 95% confidence interval 1.71 to 30.17) and fatigue (Fisher's exact test, P = 0.013).The RCT on phosphocreatine found no differences in overall survival, mortality due to heart failure, echocardiographic cardiac function, and adverse events between treatment and control groups. AUTHORS' CONCLUSIONS Only one trial evaluated the effect of enalapril in childhood cancer survivors with asymptomatic cardiac dysfunction. Although there is some evidence that enalapril temporarily improves one parameter of cardiac function (LVESWS), it is unclear whether it improves clinical outcomes. Enalapril was associated with a higher risk of dizziness or hypotension and fatigue. Clinicians should weigh the possible benefits with the known side effects of enalapril in childhood cancer survivors with asymptomatic anthracycline-induced cardiotoxicity.Only one trial evaluated the effect of phosphocreatine in childhood cancer patients with anthracycline-induced cardiotoxicity. Limited data with a high risk of bias showed no significant difference between phosphocreatine and control treatments on echocardiographic function and clinical outcomes.We did not identify any RCTs or CCTs studying other medical interventions for symptomatic or asymptomatic cardiotoxicity in childhood cancer patients or survivors.High-quality studies should be performed.
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Affiliation(s)
- Daniel KL Cheuk
- The University of Hong Kong, Queen Mary HospitalDepartment of Pediatrics and Adolescent MedicinePokfulam RoadHong KongChina
| | - Elske Sieswerda
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyPO Box 22660AmsterdamNetherlands1100 DD
| | - Elvira C van Dalen
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyPO Box 22660AmsterdamNetherlands1100 DD
| | - Aleida Postma
- University Medical Center Groningen and University of Groningen, Beatrix Children's HospitalDepartment of Paediatric OncologyPostbus 30.000GroningenNetherlands9700 RB
| | - Leontien CM Kremer
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyPO Box 22660AmsterdamNetherlands1100 DD
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Ercan S, Davutoglu V, Cakici M, Kus E, Alici H, Sari I. Rapid recovery from acute myocarditis under levosimendan treatment: report of two cases. J Clin Pharm Ther 2013; 38:179-80. [PMID: 23442057 DOI: 10.1111/jcpt.12038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 12/05/2012] [Indexed: 11/26/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Acute viral myocarditis (AVM) is an inflammatory heart disease that may lead to acute heart failure caused by cardiomyocyte loss. AVM may result in fatal outcome due to hemodynamic compromise. There is no specific treatment for AVM. Treatment is generally same as the treatment of conventional heart failure. Levosimendan is a new molecule with inotropic and vasodilator effect and is widely used for acute decompensated heart failure. DETAILS OF THE CASES Case 1: A 48-years-old, previously healthy male patient admitted to our clinic with complaints of acute onset of rest dyspnea and orthopnea, started the day before. Cardiac chambers were enlarged on echocardiography with global hypokinesia and ejection fraction (EF) was 25%. The patient was diagnosed as AVM complicated with decompensated heart failure. Continuous infusion of 0·2 μg/kg/min levosimendan for 24 h with treatment of conventional heart failure. Echocardiographic follow-up revealed a rapid improvement in left ventricular EF (50%) after 24 h. Case 2: A 33-years-old male patient admitted to our clinic with new onset shortness of breath and palpitation complaints. Echocardiography revealed enlarged left heart cavities with global hypocinesia (EF was 25%). The patient was diagnosed as AVM complicated with decompensated heart failure. Continuous infusion of 0·2 μg/kg/min levosimendan for 24 h with treatment of conventional heart failure. Echocardiography revealed dramatic improvement of left ventricular systolic function (EF = 55%) 24 h later. WHAT IS NEW AND CONCLUSION To our knowledge, there is no report or study on levosimendan therapy for AVM in humans to date. Herein, we share two cases that revealed dramatic improvement in the myocardial function with levosimendan usage during the early phase of AVM.
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Affiliation(s)
- Suleyman Ercan
- Cardiology Department, School of Medicine, Gaziantep University, Gaziantep, Turkey.
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Sieswerda E, van Dalen EC, Postma A, Cheuk DK, Caron HN, Kremer LC. Medical interventions for treating anthracycline-induced symptomatic and asymptomatic cardiotoxicity during and after treatment for childhood cancer. Cochrane Database Syst Rev 2011:CD008011. [PMID: 21901716 DOI: 10.1002/14651858.cd008011.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Anthracyclines are frequently used chemotherapeutic agents for childhood cancer that can cause cardiotoxicity during and after treatment. Although several medical interventions in adults with symptomatic or asymptomatic cardiac dysfunction due to other causes are beneficial, it is not known if the same treatments are effective for childhood cancer patients and survivors with anthracycline-induced cardiotoxicity. OBJECTIVES To compare the effect of medical interventions on anthracycline-induced cardiotoxicity in childhood cancer patients or survivors with the effect of placebo, other medical interventions or no treatment. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2011, issue 1), MEDLINE/PubMed (1949 to May 2011) and EMBASE/Ovid (1980 to May 2011) for potentially relevant articles. We additionally searched reference lists of relevant articles, conference proceedings and ongoing trial databases. SELECTION CRITERIA Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing the effectiveness of medical interventions to treat anthracycline-induced cardiotoxicity with either placebo, other medical interventions or no treatment. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessments which were checked by another review author. MAIN RESULTS We identified two RCTs. One trial (135 patients) compared enalapril with placebo in childhood cancer survivors with asymptomatic anthracycline induced cardiac dysfunction. The other trial (68 patients) compared a two-week treatment of phosphocreatine with a control treatment (vitamin C, ATP, vitamin E, oral coenzyme Q10) in leukaemia patients with anthracycline-induced cardiotoxicity. Both studies had methodological limitations.The RCT on enalapril showed no (statistically) significant differences in overall survival, mortality due to heart failure, development of clinical heart failure and quality of life between treatment and control group. A post-hoc analysis showed a decrease (i.e. improvement) in one measure of cardiac function (left ventricular end systolic wall stress (LVESWS): -8.62% change) compared with placebo (+1.66% change) in the first year of treatment (P = 0.036), but not afterwards. Patients treated with enalapril had a higher risk of dizziness or hypotension (RR 7.17, 95% CI 1.71 to 30.17) and fatigue (Fisher's exact test, P = 0.013).The RCT on phosphocreatine found no differences in overall survival, mortality due to heart failure, echocardiographic cardiac function and adverse events between treatment and control group. AUTHORS' CONCLUSIONS For the effect of enalapril in childhood cancer survivors with asymptomatic cardiac dysfunction, only one RCT is available. Although there is some evidence that enalapril temporarily improves one parameter of cardiac function (LVESWS), it is unclear whether it improves clinical outcomes. Enalapril was associated with a higher risk of dizziness or hypotension and fatigue. Clinicians should weigh the possible benefits with the known side-effects of enalapril in childhood cancer survivors with asymptomatic anthracycline-induced cardiotoxicity.For the effect of phosphocreatine in childhood cancer patients with anthracycline-induced cardiotoxicity, only one RCT is available. Limited data with a high risk of bias showed no significant difference between phosphocreatine and control treatment on echocardiographic function and clinical outcomes.We did not identify any RCTs or CCTs studying other medical interventions for symptomatic or asymptomatic cardiotoxicity in childhood cancer patients or survivors.High-quality studies should be performed.
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Affiliation(s)
- Elske Sieswerda
- Department of Paediatric Oncology, Emma Children's Hospital / Academic Medical Center, PO Box 22660 (room A3-246), Amsterdam, Netherlands, 1100 DD
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Injac R, Strukelj B. Recent advances in protection against doxorubicin-induced toxicity. Technol Cancer Res Treat 2009; 7:497-516. [PMID: 19044329 DOI: 10.1177/153303460800700611] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Anthracycline antibiotics are among the most effective and commonly used anticancer drugs. Unfortunately, their clinical use is restricted by dose-dependent toxicity. Doxorubicin is an anthracycline antibiotic and cytotoxic (antineoplastic) agent. It is commonly used against ovarian, breast, lung, uterine and cervical cancers, Hodgkin's disease, soft tissue and primary bone sarcomas, as well against in several other cancer types. It has been shown that free radicals are involved in doxorubicin-induced toxicity. Doxorubicin causes the generation of free radicals and the induction of oxidative stress, associated with cellular injury. This review illustrates recent applications of different natural products, drugs, drug delivery systems, and approaches for protection against doxorubicin-induced toxicity (2006-present).
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Affiliation(s)
- R Injac
- University of Ljubljana, Askerceva 7, 1000 Ljubljana, Slovenia.
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