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Khosla AA, Saunders H, Helgeson S, Hikida H, Aslam N, Salem F, Albadri S, Baig H. The Utility of Bronchoscopy in Hydralazine-Induced ANCA-Associated Vasculitis. Case Rep Pulmonol 2023; 2023:1461011. [PMID: 37095760 PMCID: PMC10122576 DOI: 10.1155/2023/1461011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 04/26/2023] Open
Abstract
Hydralazine is a vasodilator used for the management of hypertension, heart failure, and hypertensive emergencies in pregnancy. It has been implicated in the causation of drug-induced lupus erythematosus (DLE) and rarely with ANCA-associated vasculitis (AAV), which may present as a pulmonary-renal syndrome and be rapidly fatal. Herein, we describe a case of hydralazine-associated AAV presenting as acute kidney injury with the use of early bronchoalveolar lavage (BAL) with serial aliquots to aid with diagnosis. Our case highlights how, in the correct clinical setting, BAL can act as a rapid diagnostic test to help guide quicker treatment to allow for better patient outcomes.
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Affiliation(s)
| | | | | | | | - Nabeel Aslam
- Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Fadi Salem
- Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Sam Albadri
- Mayo Clinic Florida, Jacksonville, FL 32224, USA
| | - Hassan Baig
- Mayo Clinic Florida, Jacksonville, FL 32224, USA
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2
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Abel AAI, Clark AL. Long-Term Pharmacological Management of Reduced Ejection Fraction Following Acute Myocardial Infarction: Current Status and Future Prospects. Int J Gen Med 2021; 14:7797-7805. [PMID: 34795500 PMCID: PMC8593493 DOI: 10.2147/ijgm.s294896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/26/2021] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) with reduced ejection fraction is common following acute myocardial infarction (MI), and active medical management can have a profound impact on prognosis. Reviewing relevant clinical trials, we focus on the pharmacological management of left ventricular systolic dysfunction (LVSD) following an acute MI, although there is overlap with the pharmacological management of chronic HF due to reduced ejection fraction. Angiotensin converting enzyme (ACE) inhibitors, beta-blockers, and mineralocorticoid receptor antagonists are the mainstay of medical management in patients with LVSD post MI; there may also be a role for anticoagulation. Sacubitril-valsartan (angiotensin receptor neprilysin inhibitor) has not yet been shown to be superior to an ACE inhibitor in reducing cardiovascular mortality and HF events in patients with LVSD post MI. Large randomised trials evaluating sodium glucose transporter 2 (SGLT-2) inhibitors in LVSD post MI are ongoing.
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Affiliation(s)
- Alexandra A I Abel
- Department of Academic Cardiology, Castle Hill Hospital, Kingston Upon Hull, UK
| | - Andrew L Clark
- Department of Academic Cardiology, Castle Hill Hospital, Kingston Upon Hull, UK
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3
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Reina-Couto M, Pereira-Terra P, Quelhas-Santos J, Silva-Pereira C, Albino-Teixeira A, Sousa T. Inflammation in Human Heart Failure: Major Mediators and Therapeutic Targets. Front Physiol 2021; 12:746494. [PMID: 34707513 PMCID: PMC8543018 DOI: 10.3389/fphys.2021.746494] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/20/2021] [Indexed: 12/28/2022] Open
Abstract
Inflammation has been recognized as a major pathophysiological contributor to the entire spectrum of human heart failure (HF), including HF with reduced ejection fraction, HF with preserved ejection fraction, acute HF and cardiogenic shock. Nevertheless, the results of several trials attempting anti-inflammatory strategies in HF patients have not been consistent or motivating and the clinical implementation of anti-inflammatory treatments for HF still requires larger and longer trials, as well as novel and/or more specific drugs. The present work reviews the different inflammatory mechanisms contributing to each type of HF, the major inflammatory mediators involved, namely tumor necrosis factor alpha, the interleukins 1, 6, 8, 10, 18, and 33, C-reactive protein and the enzymes myeloperoxidase and inducible nitric oxide synthase, and their effects on heart function. Furthermore, several trials targeting these mediators or involving other anti-inflammatory treatments in human HF are also described and analyzed. Future therapeutic advances will likely involve tailored anti-inflammatory treatments according to the patient's inflammatory profile, as well as the development of resolution pharmacology aimed at stimulating resolution of inflammation pathways in HF.
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Affiliation(s)
- Marta Reina-Couto
- Departamento de Biomedicina – Unidade de Farmacologia e Terapêutica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Centro de Investigação Farmacológica e Inovação Medicamentosa, Universidade do Porto (MedInUP), Porto, Portugal
- Departamento de Medicina Intensiva, Centro Hospitalar e Universitário São João, Porto, Portugal
| | - Patrícia Pereira-Terra
- Departamento de Biomedicina – Unidade de Farmacologia e Terapêutica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Janete Quelhas-Santos
- Departamento de Biomedicina – Unidade de Farmacologia e Terapêutica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Carolina Silva-Pereira
- Departamento de Biomedicina – Unidade de Farmacologia e Terapêutica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Centro de Investigação Farmacológica e Inovação Medicamentosa, Universidade do Porto (MedInUP), Porto, Portugal
| | - António Albino-Teixeira
- Departamento de Biomedicina – Unidade de Farmacologia e Terapêutica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Centro de Investigação Farmacológica e Inovação Medicamentosa, Universidade do Porto (MedInUP), Porto, Portugal
| | - Teresa Sousa
- Departamento de Biomedicina – Unidade de Farmacologia e Terapêutica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
- Centro de Investigação Farmacológica e Inovação Medicamentosa, Universidade do Porto (MedInUP), Porto, Portugal
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Dixit NM, Shah S, Ziaeian B, Fonarow GC, Hsu JJ. Optimizing Guideline-directed Medical Therapies for Heart Failure with Reduced Ejection Fraction During Hospitalization. US CARDIOLOGY REVIEW 2021. [DOI: 10.15420/usc.2020.29] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Heart failure remains a huge societal concern despite medical advancement, with an annual direct cost of over $30 billion. While guideline-directed medical therapy (GDMT) is proven to reduce morbidity and mortality, many eligible patients with heart failure with reduced ejection fraction (HFrEF) are not receiving one or more of the recommended medications, often due to suboptimal initiation and titration in the outpatient setting. Hospitalization serves as a key point to initiate and titrate GDMT. Four evidence-based therapies have clinical benefit within 30 days of initiation and form a crucial foundation for HFrEF therapy: renin-angiotensin-aldosterone system inhibitors with or without a neprilysin inhibitor, β-blockers, mineralocorticoid-receptor-antagonists, and sodium-glucose cotransporter-2 inhibitors. The authors present a practical guide for the implementation of these four pillars of GDMT during a hospitalization for acute heart failure.
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Affiliation(s)
- Neal M Dixit
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Shivani Shah
- Department of Pharmacy Services, Olive View-UCLA Medical Center, Los Angeles, CA
| | - Boback Ziaeian
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Gregg C Fonarow
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Jeffrey J Hsu
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA; Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
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5
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Doughem K, Battisha A, Sheikh O, Konduru L, Madoukh B, Al-Sadawi M, Shaikh S. Hydralazine-Induced ANCA Associated Vasculitis (AAV) Presenting with Pulmonary-Renal Syndrome (PRS): A Case Report with Literature Review. Curr Cardiol Rev 2021; 17:182-187. [PMID: 32418528 PMCID: PMC8226194 DOI: 10.2174/1573403x16666200518092814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 02/29/2020] [Accepted: 03/23/2020] [Indexed: 01/26/2023] Open
Abstract
Hydralazine, an arterial vasodilator, is a widely used medication for the management of hypertension and heart failure, especially for patients who cannot tolerate the use of ACEIs or ARBs. It is generally well-tolerated and has a safe profile in pregnancy. However, hydralazine can induce immune-mediated side effects, such as hydralazine-induced lupus and less commonly hydralazine- induced ANCA vasculitis. The latter most commonly affects the kidneys with or without other organ involvement. There are several cases reported in the literature of hydralazine-induced ANCA associated vasculitis (AAV) that have pulmonary manifestations, also known as hydralazine- induced pulmonary-renal syndrome (PRS), a condition with a high risk of mortality. We are reporting a case of Hydralazine-induced ANCA associated glomerulonephritis with severe diffuse alveolar hemorrhage (DAH). In addition, we will review the current literature and discuss the importance of prompt diagnosis and early management to decrease mortality and morbidity associated with this serious condition.
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Affiliation(s)
- Karim Doughem
- Address correspondence to this author at University of Texas Health Science Center at Houston, Houston, TX 77030, United States; E-mail:
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Houck P, Dandapantula H, Wilkinson D. Cost to Save a Life in Heart Failure: Health Disparity Costs Lives. Cureus 2020; 12:e10081. [PMID: 32999794 PMCID: PMC7522045 DOI: 10.7759/cureus.10081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/26/2020] [Indexed: 11/25/2022] Open
Abstract
Objective The purpose of this paper is to assign a dollar value to life-saving medication, surgical procedures, and medical devices. The knowledge of the wide variation in the cost of drugs, surgery, and devices allows providers and patients to choose higher-valued therapies. Cost is a significant barrier to health. The current reimbursement system is complicated, representing a significant barrier to saving lives by promoting health disparity. Background The cost analysis of heart failure therapies is an important tool in the education of physicians, patients, and vendors of the intervention. The analysis demonstrates disparities between heart failure therapies. The cost to save a single life is calculated from annualized absolute mortality risk reduction, trial length, and estimated 10-year costs. The method allows comparisons of drugs, devices, and surgery. Methods The 10-year cost of drugs is 120 months times the cost of a drug/month as listed by the website GoodRX.com. The 10-year cost of surgery or device therapy was determined from a cost analysis found by a Google search of the literature. When wide ranges were reported, the mean value was selected. 1/absolute mortality risk reduction X 100 is the number needed to treat to save a life annualized for the mean length of the study. The cost to save a life can then be computed by the following formula: Cost/life saved = (10-year cost/annualized absolute mortality risk reduction) X (100) Results Beta-blockers and spironolactone had the lowest cost per life saved at $13,333 and $21,818, respectively. Defibrillators are the most expensive at $6,417,856. Valsartan/sacubitril has a cost of $1,127,733. Dapagliflozin, the newest class of heart failure drug, costs $4,853,200. Conclusions Calculating the cost to save a life gives insight into the value of therapies and demonstrates disparities. It is a means of comparing drugs and devices. New drug therapies are costly, not affordable, and serve as a barrier to the successful treatment of heart failure.
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Affiliation(s)
- Philip Houck
- Medicine/Cardiology, Texas A&M Health Sciences Center, Temple, USA
- Medicine/Cardiology, Baylor Scott & White Health, Temple, USA
| | - Hari Dandapantula
- Medicine/Cardiology, Texas A&M Health Sciences Center, Temple, USA
- Medicine/Cardiology, Baylor Scott & White Health, Temple, USA
| | - Donna Wilkinson
- Cardiology/Nursing, Baylor Scott & White Health, Temple, USA
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7
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Long W, Liao H, Liu Q, Ning Y, Wu T, Kang J, Liu J, Xian S, Yang Z. Effect of nitrate treatment on functional capacity and exercise time in patients with heart failure: a systematic review and meta-analysis. J Int Med Res 2020; 48:300060520939742. [PMID: 32762413 PMCID: PMC7557692 DOI: 10.1177/0300060520939742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Objectives Heart failure (HF) is a common and potentially fatal condition. In 2015, HF affected approximately 40 million people globally. Evidence showing that the use of nitrates can improve clinical outcomes in patients with HF is limited. This study aimed to assess the effect of nitrates on functional capacity and exercise time in patients with HF. Methods PubMed, Cochrane Library, and Embase databases were reviewed for articles on the use of nitrates and other treatments for patients with HF. The primary endpoints were the 6-minute walk test distance, exercise time, and quality of life. Secondary endpoints were all-cause mortality, arrhythmia, hospitalization, and worsening HF. The weighted mean difference, risk ratio, and 95% confidence interval were calculated. Results A total of 14 related studies that comprised 26,321 patients were included. No significant differences were found in the 6-minute walk test distance, exercise time, and quality of life between the nitrate and control treatment groups. There were also no differences in all-cause mortality, the incidence of arrhythmia, hospitalization, and worsening HF between these two groups. Conclusion Patients with HF who receive nitrate treatment do not have better quality of life or exercise capacity compared with controls.
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Affiliation(s)
- Wenjie Long
- Department of Geriatrics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Gaungzhou, China.,Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Huili Liao
- Department of Geriatrics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Gaungzhou, China
| | - Qingqing Liu
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yile Ning
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Tingchun Wu
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China.,Department of Cardiology, The Second Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, China
| | - Jinhua Kang
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jianhong Liu
- Department of Geriatrics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Gaungzhou, China
| | - Shaoxiang Xian
- Department of Geriatrics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Gaungzhou, China.,Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhongqi Yang
- Department of Geriatrics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Gaungzhou, China.,Lingnan Medical Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
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8
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Houck P, Dandapantula H, Hardegree E, Massey J. Why We Fail at Heart Failure: Lymphatic Insufficiency Is Disregarded. Cureus 2020; 12:e8930. [PMID: 32760630 PMCID: PMC7392353 DOI: 10.7759/cureus.8930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Is the definition of heart failure too narrow, not allowing research into compensatory mechanisms, comorbidities, right heart function, and lymphatic function? A review of the absolute mortality of heart failure drugs and devices suggests a modest improvement in outcomes. Absolute mortality from common comorbidities, including renal insufficiency, arrhythmia, conduction deficits, pulmonary hypertension, anemia, obstructive sleep apnea, infection, inflammation, edema, ischemic heart disease, and diabetes II, is significant. The lymphatic function is involved in short, intermediate, and long-term compensation for a failing heart and plays a role in most of the comorbidities. A better definition of heart failure is: Heart failure is a complex clinical syndrome that results from any structural or functional impairment of right or left ventricular filling or ejection of blood and failure of peripheral compensatory mechanisms. Lymphatic function from the anatomic, fluid management, immune modification standpoints requires study. New therapies from this analysis will improve patients with congestive heart failure.
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Affiliation(s)
- Philip Houck
- Medicine/Cardiology, Baylor Scott & White Health, Temple, USA.,Medicine/Cardiology, Texas A&M Health Sciences Center, Temple, USA
| | - Hari Dandapantula
- Medicine/Cardiology, Baylor Scott & White Health, Temple, USA.,Medicine/Cardiology, Texas A&M Health Sciences Center, Temple, USA
| | - Evan Hardegree
- Medicine/Cardiology, Baylor Scott & White Health, Temple, USA
| | - Janet Massey
- Family Medicine/Lymphology, Praxis Dr. Jungkunz, Friedberg, DEU
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9
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Al-Abdouh A, Siyal AM, Seid H, Bekele A, Garcia P. Hydralazine-induced antineutrophil cytoplasmic antibody-associated vasculitis with pulmonary-renal syndrome: a case report. J Med Case Rep 2020; 14:47. [PMID: 32290867 PMCID: PMC7158156 DOI: 10.1186/s13256-020-02378-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 03/23/2020] [Indexed: 11/10/2022] Open
Abstract
Background Hydralazine is a common vasodilator which has been used for the treatment of hypertension and heart failure. Hydralazine can induce antineutrophil cytoplasmic antibody-associated vasculitis due to its auto-immunogenic capability and one of the very rare presentations is pulmonary–renal syndrome. Case presentation We report a case of a 64-year-old African American woman, who presented to our emergency room with shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, leg swelling, fatigue, loss of appetite, cough with clear sputum, and lightheadedness. On admission, she developed acute hypoxic respiratory failure requiring intubation and acute renal failure requiring hemodialysis. A serologic workup was positive for antineutrophil cytoplasmic antibody, antinuclear antibody, anti-histone, anti-cardiolipin IgM, and anti-double-stranded DNA antibodies. A renal biopsy was done due to persistent deterioration in kidney function and demonstrated classic crescentic (pauci-immune) glomerulonephritis. Hydralazine was empirically discontinued early in the admission and she was started on corticosteroids and cyclophosphamide following biopsy results. She was clinically stable but remained dependent on hemodialysis after discharge. Conclusion Hydralazine-induced antineutrophil cytoplasmic antibody-associated vasculitis with pulmonary–renal syndrome is a rare occurrence. In the setting of hydralazine use, multiple positive antigens, and multisystem involvement, clinicians should consider this rare condition requiring prompt cessation of offending drug, early evaluation with biopsy, and contemplate empiric immunosuppressive therapy while biopsy confirmation is pending.
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Affiliation(s)
- Ahmad Al-Abdouh
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD, 21229, USA.
| | | | - Hanan Seid
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD, 21229, USA
| | - Ammer Bekele
- Department of Medicine, Saint Agnes Hospital, Baltimore, MD, 21229, USA
| | - Pablo Garcia
- Section of Critical Care, Department of Medicine, Saint Agnes Hospital, Baltimore, MD, USA
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10
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El Hussein MT, Blayney S, Clark N. ABCs of Heart Failure Management: A Guide for Nurse Practitioners. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2019.12.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Coentro JQ, Pugliese E, Hanley G, Raghunath M, Zeugolis DI. Current and upcoming therapies to modulate skin scarring and fibrosis. Adv Drug Deliv Rev 2019; 146:37-59. [PMID: 30172924 DOI: 10.1016/j.addr.2018.08.009] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 07/08/2018] [Accepted: 08/26/2018] [Indexed: 12/12/2022]
Abstract
Skin is the largest organ of the human body. Being the interface between the body and the outer environment, makes it susceptible to physical injury. To maintain life, nature has endowed skin with a fast healing response that invariably ends in the formation of scar at the wounded dermal area. In many cases, skin remodelling may be impaired, leading to local hypertrophic scars or keloids. One should also consider that the scarring process is part of the wound healing response, which always starts with inflammation. Thus, scarring can also be induced in the dermis, in the absence of an actual wound, during chronic inflammatory processes. Considering the significant portion of the population that is subject to abnormal scarring, this review critically discusses the state-of-the-art and upcoming therapies in skin scarring and fibrosis.
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Affiliation(s)
- João Q Coentro
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland
| | - Eugenia Pugliese
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland
| | - Geoffrey Hanley
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland
| | - Michael Raghunath
- Center for Cell Biology and Tissue Engineering, Institute for Chemistry and Biotechnology (ICBT), Zurich University of Applied Sciences (ZHAW), Wädenswil, Switzerland
| | - Dimitrios I Zeugolis
- Regenerative, Modular & Developmental Engineering Laboratory (REMODEL), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland; Science Foundation Ireland (SFI), Centre for Research in Medical Devices (CÚRAM), Biomedical Sciences Building, National University of Ireland Galway (NUI, Galway), Galway, Ireland.
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12
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Al-Mohammad A. Hydralazine and nitrates in the treatment of heart failure with reduced ejection fraction. ESC Heart Fail 2019; 6:878-883. [PMID: 31119890 PMCID: PMC6676279 DOI: 10.1002/ehf2.12459] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 04/21/2019] [Accepted: 04/29/2019] [Indexed: 11/25/2022] Open
Abstract
Hydralazine and nitrate combination was the first treatment that showed improved survival of patients with heart failure with reduced left ventricular ejection fraction (HFREF) in the Vasodilator Heart Failure Trial (V‐HeFT trial) in 1986. This showed a 34% reduction of mortality at 2 years of follow‐up in patients with advanced heart failure (New York Heart Association Class IV). The angiotensin‐converting enzyme inhibitor (ACEi), beta‐blockers, mineralocorticoid receptor antagonists, and most recently sacubitril–valsartan have superseded the combination of hydralazine and nitrates. However, the latter combination does have a place bridging the survival gap of Black patients with HFREF when added to their standard therapy. This was demonstrated in the African‐American Heart Failure Trial (A‐HeFT trial) in 2004 when the risk reduction in the Black patients was 43% compared with that in the placebo. This combination may have a potential use in patients with contraindications to the use of ACEi, angiotensin receptor blockers, and sacubitril–valsartan. This is suggested by both the European Society of Cardiology (ESC) Guidelines and the guidelines of the National Institute for Health and Care Excellence (NICE). In this perspective, the role of the combination of hydralazine and nitrates in the treatment of HFREF is reviewed through a synopsis of the evidence base consisting of three randomized controlled studies, several further analyses of subgroups within those trials, a systemic review, and two large observational studies of registry cohorts. The place of the combination in the treatment cascades proposed by heart failure guidelines of the ESC and NICE is explored. This perspective is to remind us of their appropriate roles, particularly given the findings of underuse of this combination in people of African ancestry in Europe.
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13
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Cai Y, Zhang Q, Huang C, Lu K, Chen B, Liu C. Yixinshu capsule combined with conventional treatment for chronic heart failure: Protocol for a systematic review and trial sequential analysis. Medicine (Baltimore) 2019; 98:e14960. [PMID: 31083149 PMCID: PMC6531180 DOI: 10.1097/md.0000000000014960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Yixinshu Capsule is widely utilized in Asia for the treatment of chronic heart failure (CHF) as a conventional drug, but a comprehensive conclusion is lacking. Here, we will provide a protocol to perform a meta-analysis and trial sequential analysis to evaluate the efficacy of Yixinshu Capsule combined with conventional treatment for chronic heart failure. METHODS We will conduct a thorough search in six databases, PubMed, EMBASE, Cochrane Library Database, Chinese National Knowledge Infrastructure (CNKI), Chinese Science Journal Database (VIP), and Chinese Biomedical and Medical Database (CBM). Inclusion criteria will be randomized control trials (RCTs) with one group receiving Yixinshu Capsule based on conventional treatment and another group receiving conventional treatment alone. Modified Jadad scale and Cochrane's risk of bias assessment will be used to assess methodological quality. Only studies with modified Jadad scale score ≥3 will be included in meta-analysis for efficacy, which will be defined as moderate methodological quality. The total effective rate will be considered as the primary outcome and the secondary outcome will include mortality, rehospitalized rate, left ventricular ejection fraction (LVEF), 6-minute walking distance, E/A, left ventricular end-diastolic diameter (LVEDD), BNP, and NT-proBNP. We will conduct trial sequential analysis to evaluate the reliability of the primary outcome. RESULTS This study will provide a rational synthesis of current evidences for Yixinshu Capsule on chronic heart failure. CONCLUSION The conclusion of this study will provide evidence for judging the efficacy of Yixinshu Capsule on chronic heart failure. REGISTRATION PROS-PERO CRD42019119612.
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Affiliation(s)
- Yinhe Cai
- Guangzhou University of Chinese Medicine, Guangzhou
| | | | - Cihui Huang
- Guangzhou University of Chinese Medicine, Guangzhou
| | - Ke Lu
- Guangzhou University of Chinese Medicine, Guangzhou
| | - Baishu Chen
- Shenzhen Baoan Traditional Chinese Medicine Hospital Group, Shenzhen, China
| | - Cuiling Liu
- Shenzhen Baoan Traditional Chinese Medicine Hospital Group, Shenzhen, China
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14
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Aeddula NR, Pathireddy S, Ansari A, Juran PJ. Hydralazine-associated antineutrophil cytoplasmic antibody vasculitis with pulmonary-renal syndrome. BMJ Case Rep 2018; 2018:bcr-2018-227161. [PMID: 30413463 PMCID: PMC6229221 DOI: 10.1136/bcr-2018-227161] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hydralazine, a vasodilator, is commonly used as an adjunctive treatment for moderate to severe hypertension, heart failure and hypertensive emergencies in pregnancy. Hydralazine-induced lupus was first described in 1953. Clinical presentation ranges from arthralgia, myalgia, petechiae, or rash to single or multiorgan involvement. An occurrence of systemic vasculitis is a rare complication. When presented as the pulmonary-renal syndrome, it could have a rapidly progressive course which can be fatal. Here, we describe a case of hydralazine-associated rapidly progressive glomerulonephritis and pulmonary haemorrhage. We use this case to review the current literature and discuss and highlight the importance of a high degree of clinical acumen, early diagnosis and prompt treatment for better clinical outcomes.
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Affiliation(s)
- Narothama Reddy Aeddula
- Nephrology, Deaconess Health System, Evansville, Indiana, USA.,Medicine, Indiana University School of Medicine, Evansville, Indiana, USA
| | - Samata Pathireddy
- Internal Medicine, Deaconess Health System, Evansville, Indiana, USA.,Medicine, Indiana University School of Medicine, Evansville, Indiana, USA
| | - Asif Ansari
- Nephrology, Permian Basin Kidney Center, Midland, Texas, USA
| | - Peter J Juran
- Nephrology, Deaconess Health System, Evansville, Indiana, USA.,Medicine, Indiana University School of Medicine, Evansville, Indiana, USA
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Kalmanovich E, Audurier Y, Akodad M, Mourad M, Battistella P, Agullo A, Gaudard P, Colson P, Rouviere P, Albat B, Ricci JE, Roubille F. Management of advanced heart failure: a review. Expert Rev Cardiovasc Ther 2018; 16:775-794. [PMID: 30282492 DOI: 10.1080/14779072.2018.1530112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Heart failure (HF) has become a global pandemic. Despite recent developments in both medical and device treatments, HF incidences continues to increase. The current definition of HF restricts itself to stages at which clinical symptoms are apparent. In advanced heart failure (AdHF), it is universally accepted that all patients are refractory to traditional therapies. As the number of HF patients increase, so does the need for additional treatments, with an increased proportion of patients requiring advanced therapies. Areas covered: This review discusses extensive evidence for the effect of medical treatment on HF, although the data on the effect on AdHF is scare. Authors review the relevant literature for treating AdHF patients. Furthermore, mechanical circulatory devices (MCD) have emerged as an alternative to heart transplantation and have been shown to enhance quality of life and reduce mortality therefore authors also review the current literature on the different MCD and technologies. Expert commentary: More patients will need advanced therapies, as the access to heart transplantation is limited by the number of available donors. AdHF patients should be identified timely since the window of opportunities for advanced therapy is narrow as their morbidity is progressive and survival is often short.
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Affiliation(s)
- Eran Kalmanovich
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France
| | - Yohan Audurier
- b Pharmacy Department , University Hospital of Montpellier , Montpellier , France
| | - Mariama Akodad
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France
| | - Marc Mourad
- c Department of Anesthesiology and Critical Care Medicine , Arnaud de Villeneuve Hospital , Montpellier , France.,d PhyMedExp , University of Montpellier , Montpellier , France
| | - Pascal Battistella
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France
| | - Audrey Agullo
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France
| | - Philippe Gaudard
- c Department of Anesthesiology and Critical Care Medicine , Arnaud de Villeneuve Hospital , Montpellier , France.,d PhyMedExp , University of Montpellier , Montpellier , France
| | - Pascal Colson
- c Department of Anesthesiology and Critical Care Medicine , Arnaud de Villeneuve Hospital , Montpellier , France.,d PhyMedExp , University of Montpellier , Montpellier , France
| | - Philippe Rouviere
- e Department of Cardiovascular Surgery , University Hospital of Montpellier, University of Montpellier , Montpellier , France
| | - Bernard Albat
- e Department of Cardiovascular Surgery , University Hospital of Montpellier, University of Montpellier , Montpellier , France
| | - Jean-Etienne Ricci
- f Department of Cardiology , Nîmes University Hospital, University of Montpellier , Nîmes , France
| | - François Roubille
- a Department of Cardiology , Montpellier University Hospital , Montpellier , France.,d PhyMedExp , University of Montpellier , Montpellier , France
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16
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Cui S, Qiu S, Lu R, Pu S. A multi-functional fluorescent sensor for Zn2+ and HSO4− based on a new diarylethene derivative. Tetrahedron Lett 2018. [DOI: 10.1016/j.tetlet.2018.07.057] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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17
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Kumar B, Strouse J, Swee M, Lenert P, Suneja M. Hydralazine-associated vasculitis: Overlapping features of drug-induced lupus and vasculitis. Semin Arthritis Rheum 2018. [PMID: 29519741 DOI: 10.1016/j.semarthrit.2018.01.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Hydralazine is an antihypertensive medication that has been associated with drug-induced lupus erythematosus (DIL) as well as ANCA-associated vasculitis (AAV). Although rare, early diagnosis is critical since drug cessation is the mainstay of therapy. This retrospective study aims to characterize the clinical, laboratory, and histopathologic features of this disease. METHODS Once approval was obtained from the Institutional Review Board at the University of Iowa, all patients carrying a diagnosis of vasculitis (ICD9 code: 447.6 or ICD10 code: I77.6, I80, L95, M30, or M31) and positive ANCA lab results over the past 15 years were identified. Age, gender, comorbid conditions, medications taken over the prior 6 months, laboratory data, including electrolytes, urine studies and serologies, chest x-rays, CT scans, and pathologic biopsy records were abstracted from the electronic medical record. RESULTS 323 cases of AAV were identified, of which 12 were exposed to hydralazine, all at the time of diagnosis. The average duration of hydralazine therapy was 22 months and mean cumulative dose was 146g. Patients were typically older (70.3 years old) with slight female preponderance (7 females). Eleven patients presented with dyspnea, fatigue, and unintentional weight loss. Five had polyarthralgias and 8 had lower extremity petechiae. All 12 patients were both ANA and ANCA positive. ANA titers ranged from 1:160 and 1:2560. Ten were of diffuse pattern while 2 were nucleolar. ANCA titers ranged from 1:320 to 1:2560. Eleven had a pANCA pattern while one had cANCA. All 12 patients were positive for histone and 11 were positive for myeloperoxidase antibodies. Eleven also had dsDNA antibodies, and 4 had anti-cardiolipin IgG or IgM antibodies. Nine patients were also hypocomplementemic (mean C3 level: 88.4mg/dL; mean C4 level: 16.5mg/dL). All patients had variable levels of proteinuria (1+ to 3+) and eleven had active urine sediment. Urine protein:creatinine ratios ranged from 0.2 to 1.7. Of the 6 patients who underwent kidney biopsy, all 6 showed pauci-immune crescentic glomerulonephritis. Seven patients had bilateral pulmonary interstitial infiltrates and four had pleural effusions on CT scan. Four had pericardial effusions as demonstrated by echocardiography. CONCLUSIONS Hydralazine-associated vasculitis is a drug-associated autoimmune syndrome that presents with interstitial lung disease, hypocomplementemia, and pauci-immune glomerulonephritis. Patients have elements of both DIL and DIV, as manifested by high ANA and ANCA titers as well as the presence of histone and MPO antibodies. Further research is needed to understand the etiopathogenesis of this condition.
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Affiliation(s)
- Bharat Kumar
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242.
| | - Jennifer Strouse
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242
| | - Melissa Swee
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242
| | - Petar Lenert
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242
| | - Manish Suneja
- Division of Immunology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242
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18
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Effect of Oral Nitrates on All-Cause Mortality and Hospitalization in Heart Failure Patients with Reduced Ejection Fraction: A Propensity-Matched Analysis. J Card Fail 2017; 23:286-292. [DOI: 10.1016/j.cardfail.2017.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 01/31/2017] [Accepted: 02/08/2017] [Indexed: 12/28/2022]
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19
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Nyolczas N, Dékány M, Muk B, Szabó B. Combination of Hydralazine and Isosorbide-Dinitrate in the Treatment of Patients with Heart Failure with Reduced Ejection Fraction. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1067:31-45. [PMID: 29086392 DOI: 10.1007/5584_2017_112] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The use of direct acting vasodilators (the combination of hydralazine and isosorbide dinitrate -Hy+ISDN-) in heart failure with reduced ejection fraction (HFrEF) is supported by evidence, but rarely used.However, treatment with Hy+ISDN is guideline-recommended for HFrEF patients who cannot receive either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers due to intolerance or contraindication, and in self-identified African-American HFrEF patients who are symptomatic despite optimal neurohumoral therapy.The Hy+ISDN combination has arterial and venous vasodilating properties. It can decrease preload and afterload, decrease left ventricular end-diastolic diameter and the volume of mitral regurgitation, reduce left atrial and left ventricular wall tension, decrease pulmonary artery pressure and pulmonary arterial wedge pressure, increase stroke volume, and improve left ventricular ejection fraction, as well as induce left ventricular reverse remodelling. Furthermore, Hy+ISDN combination has antioxidant property, it affects endothelial dysfunction beneficially and improves NO bioavailability. Because of these benefits, this combination can improve the signs and symptoms of heart failure, exercise capacity and quality of life, and, most importantly, reduce morbidity and mortality in well-defined subgroups of HFrEF patients.Accordingly, this therapeutic option can in many cases play an essential role in the treatment of HFrEF.
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Affiliation(s)
- Noémi Nyolczas
- Department for Cardiology, Hungarian Defence Forces - Medical Centre, Budapest, Hungary.
| | - Miklós Dékány
- Department for Cardiology, Hungarian Defence Forces - Medical Centre, Budapest, Hungary
| | - Balázs Muk
- Department for Cardiology, Hungarian Defence Forces - Medical Centre, Budapest, Hungary
| | - Barna Szabó
- Heart-Lung Clinic, University Hospital Örebro, Örebro, Sweden
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20
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Tampe B, Steinle U, Tampe D, Carstens JL, Korsten P, Zeisberg EM, Müller GA, Kalluri R, Zeisberg M. Low-dose hydralazine prevents fibrosis in a murine model of acute kidney injury-to-chronic kidney disease progression. Kidney Int 2016; 91:157-176. [PMID: 27692563 DOI: 10.1016/j.kint.2016.07.042] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 07/01/2016] [Accepted: 07/28/2016] [Indexed: 11/18/2022]
Abstract
Acute kidney injury (AKI) and progressive chronic kidney disease (CKD) are intrinsically tied syndromes. In this regard, the acutely injured kidney often does not achieve its full regenerative capacity and AKI directly transitions into progressive CKD associated with tubulointerstitial fibrosis. Underlying mechanisms of such AKI-to-CKD progression are still incompletely understood and specific therapeutic interventions are still elusive. Because epigenetic modifications play a role in maintaining tissue fibrosis, we used a murine model of ischemia-reperfusion injury to determine whether aberrant promoter methylation of RASAL1 contributes causally to the switch between physiological regeneration and tubulointerstitial fibrogenesis, a hallmark of AKI-to-CKD progression. It is known that the antihypertensive drug hydralazine has demethylating activity, and that its optimum demethylating activity occurs at concentrations below blood pressure-lowering doses. Administration of low-dose hydralazine effectively induced expression of hydroxylase TET3, which catalyzed RASAL1 hydroxymethylation and subsequent RASAL1 promoter demethylation. Hydralazine-induced CpG promoter demethylation subsequently attenuated renal fibrosis and preserved excretory renal function independent of its blood pressure-lowering effects. In comparison, RASAL1 demethylation and inhibition of tubulointerstitial fibrosis was not detected upon administration of the angiotensin-converting enzyme inhibitor Ramipril in this model. Thus, RASAL1 promoter methylation and subsequent transcriptional RASAL1 suppression plays a causal role in AKI-to-CKD progression.
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Affiliation(s)
- Björn Tampe
- Department of Nephrology and Rheumatology, Göttingen University Medical Center, Georg August University, Göttingen, Germany
| | - Ulrike Steinle
- Department of Nephrology and Rheumatology, Göttingen University Medical Center, Georg August University, Göttingen, Germany
| | - Désirée Tampe
- Department of Nephrology and Rheumatology, Göttingen University Medical Center, Georg August University, Göttingen, Germany
| | - Julienne L Carstens
- Department of Cancer Biology and the Metastasis Research Center, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Peter Korsten
- Department of Nephrology and Rheumatology, Göttingen University Medical Center, Georg August University, Göttingen, Germany
| | - Elisabeth M Zeisberg
- Department of Cardiology and Pneumology, Göttingen University Medical Center, Georg August University, Göttingen, Germany; German Center for Cardiovascular Research, Göttingen, Germany
| | - Gerhard A Müller
- Department of Nephrology and Rheumatology, Göttingen University Medical Center, Georg August University, Göttingen, Germany
| | - Raghu Kalluri
- Department of Cancer Biology and the Metastasis Research Center, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Zeisberg
- Department of Nephrology and Rheumatology, Göttingen University Medical Center, Georg August University, Göttingen, Germany; German Center for Cardiovascular Research, Göttingen, Germany.
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21
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Moreira-Silva S, Urbano J, Nogueira-Silva L, Bettencourt P, Pimenta J. Impact of Chronic Nitrate Therapy in Patients With Ischemic Heart Failure. J Cardiovasc Pharmacol Ther 2016; 21:466-70. [PMID: 26940569 DOI: 10.1177/1074248416634464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 12/14/2015] [Indexed: 11/15/2022]
Abstract
PURPOSE There is a lack of knowledge on the effects of nitrates alone in heart failure (HF). We aimed to assess the impact of nitrates use in the occurrence of ischemic events in patients with ischemic HF attending an HF clinic. METHODS We performed a retrospective analysis of a cohort of 632 patients managed in an HF clinic between January 2000 and December 2011. Patients with ischemic etiology were selected (n = 290). Patients were classified according to chronic nitrates use (n = 83 nitrates users vs n = 194) and followed up for 5 years for the occurrence of fatal or nonfatal myocardial infarction or stroke. RESULTS Nitrates users had more frequently diabetes, dyslipidemia, and higher body mass index but were less frequently treated with statins. Thirty adverse events were recorded (n = 16 in nitrates group). Variables significantly associated with the occurrence of the end point in univariate analysis were arterial hypertension, diabetes, and nitrates use. Male gender, beta-blockers, statin, and clopidogrel use had a protective effect on the occurrence of the end point. In multivariate analysis, nitrates use remained an independent predictor of adverse outcome when adjusted for each of the variables: arterial hypertension, gender, diabetes, beta-blocker, and clopidogrel use; however, when adjusted for statin use, nitrates were no longer associated with the outcome. CONCLUSION Long-term nitrates use in patients with ischemic HF was associated with higher occurrence of ischemic events, defined as fatal or nonfatal myocardial infarction or stroke. Our results, although from a retrospective analysis, do not support a role for chronic nitrate use in HF.
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Affiliation(s)
- Sofia Moreira-Silva
- Department of Internal Medicine, Centro Hospitalar São João, Porto, Portugal
| | - Joana Urbano
- Department of Internal Medicine, Centro Hospitalar São João, Porto, Portugal
| | - Luís Nogueira-Silva
- Department of Internal Medicine, Centro Hospitalar São João, Porto, Portugal Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Paulo Bettencourt
- Department of Internal Medicine, Centro Hospitalar São João, Porto, Portugal Department of Medicine & Unit of Cardiovascular Research & Development, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Joana Pimenta
- Department of Internal Medicine, Centro Hospitalar São João, Porto, Portugal Department of Medicine & Unit of Cardiovascular Research & Development, Faculty of Medicine, University of Porto, Porto, Portugal
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