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Lenaeus M, Gamal El-Din TM, Tonggu L, Zheng N, Catterall WA. Structural basis for inhibition of the cardiac sodium channel by the atypical antiarrhythmic drug ranolazine. NATURE CARDIOVASCULAR RESEARCH 2023; 2:587-594. [PMID: 39185478 PMCID: PMC11343317 DOI: 10.1038/s44161-023-00271-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/13/2023] [Indexed: 08/27/2024]
Affiliation(s)
- Michael Lenaeus
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
- Department of Pharmacology, University of Washington, Seattle, WA, USA
| | | | - Lige Tonggu
- Department of Pharmacology, University of Washington, Seattle, WA, USA
| | - Ning Zheng
- Department of Pharmacology, University of Washington, Seattle, WA, USA
- Howard Hughes Medical Institute, University of Washington, Seattle, WA, USA
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2
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Kim C, Lever N, Cooper J. Antiarrhythmic drugs and anaesthesia. Part 2: pharmacotherapy. BJA Educ 2023; 23:52-60. [PMID: 36686887 PMCID: PMC9845544 DOI: 10.1016/j.bjae.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- C.J. Kim
- Auckland City Hospital (Te Toka Tumai), Auckland, New Zealand
| | - N. Lever
- Auckland City Hospital (Te Toka Tumai), Auckland, New Zealand
- University of Auckland, Auckland, New Zealand
| | - J.O. Cooper
- Auckland City Hospital (Te Toka Tumai), Auckland, New Zealand
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3
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Ranolazine: An Old Drug with Emerging Potential; Lessons from Pre-Clinical and Clinical Investigations for Possible Repositioning. Pharmaceuticals (Basel) 2021; 15:ph15010031. [PMID: 35056088 PMCID: PMC8777683 DOI: 10.3390/ph15010031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 02/07/2023] Open
Abstract
Ischemic heart disease is a significant public health problem with high mortality and morbidity. Extensive scientific investigations from basic sciences to clinics revealed multilevel alterations from metabolic imbalance, altered electrophysiology, and defective Ca2+/Na+ homeostasis leading to lethal arrhythmias. Despite the recent identification of numerous molecular targets with potential therapeutic interest, a pragmatic observation on the current pharmacological R&D output confirms the lack of new therapeutic offers to patients. By contrast, from recent trials, molecules initially developed for other fields of application have shown cardiovascular benefits, as illustrated with some anti-diabetic agents, regardless of the presence or absence of diabetes, emphasizing the clear advantage of “old” drug repositioning. Ranolazine is approved as an antianginal agent and has a favorable overall safety profile. This drug, developed initially as a metabolic modulator, was also identified as an inhibitor of the cardiac late Na+ current, although it also blocks other ionic currents, including the hERG/Ikr K+ current. The latter actions have been involved in this drug’s antiarrhythmic effects, both on supraventricular and ventricular arrhythmias (VA). However, despite initial enthusiasm and promising development in the cardiovascular field, ranolazine is only authorized as a second-line treatment in patients with chronic angina pectoris, notwithstanding its antiarrhythmic properties. A plausible reason for this is the apparent difficulty in linking the clinical benefits to the multiple molecular actions of this drug. Here, we review ranolazine’s experimental and clinical knowledge on cardiac metabolism and arrhythmias. We also highlight advances in understanding novel effects on neurons, the vascular system, skeletal muscles, blood sugar control, and cancer, which may open the way to reposition this “old” drug alone or in combination with other medications.
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4
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Tamargo J, Lopez-Sendon J. Ranolazine: a better understanding of pathophysiology and patient profile to guide treatment of chronic stable angina. Future Cardiol 2021; 18:235-251. [PMID: 34841884 DOI: 10.2217/fca-2021-0058] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Chronic stable angina pectoris, the most prevalent symptomatic manifestation of coronary artery disease, greatly impairs quality of life and is associated with an increased risk for adverse cardiovascular outcomes. Better understanding of the pathophysiologic mechanisms of myocardial ischemia permitted new therapeutic strategies to optimize the management of angina patients. Ideally, antianginal drug treatment should be tailored to individual patient's profile and chosen according to the pathophysiology, hemodynamic profile, adverse effects, potential drug interactions and comorbidities. In this respect, and because of its peculiar mechanism of action, ranolazine represents an alternative therapeutic approach in patients with chronic stable angina and may be considered the first choice in presence of comorbidities that difficult the use of traditional therapies.
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Affiliation(s)
- Juan Tamargo
- Department of Pharmacology & Toxicology, School of Medicine, Universidad Complutense, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid 28040, Spain
| | - Jose Lopez-Sendon
- IdiPaz Reseach Institute. Hospital Universitario La Paz. Universidad Autonoma de Madrid, Madrid 28036, Spain
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5
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Kelly MA. Neurological complications of cardiovascular drugs. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:319-344. [PMID: 33632450 DOI: 10.1016/b978-0-12-819814-8.00020-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Cardiovascular drugs are used to treat arterial hypertension, hyperlipidemia, arrhythmias, heart failure, and coronary artery disease. They also include antiplatelet and anticoagulant drugs that are essential for prevention of cardiogenic embolism. Most neurologic complications of the cardiovascular drugs are minor or transient and are far outweighed by the anticipated benefits of treatment. Other neurologic complications are more serious and require early recognition and management. Overtreatment of arterial hypertension may cause lightheadedness or fatigue but often responds readily to dose adjustment or an alternative drug. Other drug complications may be more troublesome as in myalgia associated with statins or headache associated with vasodilators. The recognized bleeding risk of the antithrombotics requires careful calculation of risk/benefit ratios for individual patients. Many neurologic complications of cardiovascular drugs are well documented in clinical trials with known frequency and severity, but others are rare and recognized only in isolated case reports or small case series. This chapter draws on both sources to report the adverse effects on muscle, nerve, and brain associated with commonly used cardiovascular drugs.
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Affiliation(s)
- Michael A Kelly
- Department of Neurology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL, United States.
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6
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Urits I, Patel A, Leider J, Anya A, Franscioni H, Jung JW, Kassem H, Kaye AD, Viswanath O. An evidence-based review of neuromodulation for the treatment and management of refractory angina. Best Pract Res Clin Anaesthesiol 2020; 34:517-528. [PMID: 33004163 DOI: 10.1016/j.bpa.2020.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 08/03/2020] [Indexed: 11/29/2022]
Abstract
Angina pectoris is defined as substernal chest pain that is typically exacerbated by exertion, stress, or other exposures. There are various methods of treatment for angina. Lifestyle modification and pharmacological management are considered as conservative treatments. If these medications do not result in the resolution of pain, more invasive approaches are an option, like coronary revascularization. Refractory angina (RA) is differentiated from acute or chronic angina based on the persistence of symptoms despite conventional therapies. Overall, the prevalence of RA is estimated to be 5%-15% in patients with coronary artery disease, which can account for up to 1,500,000 current cases and 100,000 new cases in the United States per year. Spinal cord stimulation treatment is a viable option for patients who are suffering from RA pain and are either not candidates for revascularization surgery or are currently not being well managed on more traditional treatments. Many studies show a positive result.
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Affiliation(s)
- Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Anjana Patel
- Georgetown University School of Medicine, Washington, DC, USA
| | - Joseph Leider
- Georgetown University School of Medicine, Washington, DC, USA
| | - Anthony Anya
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - Jai Won Jung
- Georgetown University School of Medicine, Washington, DC, USA
| | - Hisham Kassem
- Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL, USA
| | - Alan D Kaye
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA
| | - Omar Viswanath
- Louisiana State University Health Shreveport, Department of Anesthesiology, Shreveport, LA, USA; Valley Pain Consultants - Envision Physician Services, Phoenix, AZ, USA; Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, USA; University of Arizona College of Medicine-Phoenix, Department of Anesthesiology, Phoenix, AZ, USA
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7
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Hemodynamic Effects of Late Sodium Current Inhibitors in a Swine Model of Heart Failure. J Card Fail 2019; 25:828-836. [DOI: 10.1016/j.cardfail.2019.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 08/03/2019] [Accepted: 08/20/2019] [Indexed: 12/19/2022]
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8
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Zhao Z, Li X, El-Battrawy I, Lan H, Zhong R, Xu Q, Huang M, Liao Z, Lang S, Zimmermann WH, Cyganek L, Wieland T, Akin I, Zhou XB, Borggrefe M. Drug Testing in Human-Induced Pluripotent Stem Cell-Derived Cardiomyocytes From a Patient With Short QT Syndrome Type 1. Clin Pharmacol Ther 2019; 106:642-651. [PMID: 30947366 DOI: 10.1002/cpt.1449] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/13/2019] [Indexed: 12/19/2022]
Abstract
Short QT syndrome (SQTS) predisposes afflicted patients to sudden cardiac death. Until now, only one drug-quinidine-has been shown to be effective in patients with SQTS type 1(SQTS1). The objective of this study was to use human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) from a patient with SQTS1 to search for potentially effective drugs for the treatment of SQTS1 patients. Patch clamp and single-cell contraction measurements were employed to assess drug effects. Ivabradine, mexiletine, and ajmaline but not flecainide, ranolazine, or amiodarone prolonged the action potential duration (APD) in hiPSC-CMs from an SQTS1 patient. Ivabradine, ajmaline, and mexiletine inhibited KCNH2 channel currents significantly, which may underlie their APD-prolonging effects. Under proarrhythmic epinephrine stimulation in spontaneously beating SQTS1 hiPSC-CMs, ivabradine, mexiletine, and ajmaline but not flecainide reduced the epinephrine-induced arrhythmic events. The results demonstrate that ivabradine, ajmaline, and mexiletine may be candidate drugs for preventing tachyarrhythmias in SQTS1 patients.
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Affiliation(s)
- Zhihan Zhao
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany.,German Center for Cardiovascular Research, Partner Sites, Heidelberg, Mannheim, Göttingen, Germany.,Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin Li
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ibrahim El-Battrawy
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany.,German Center for Cardiovascular Research, Partner Sites, Heidelberg, Mannheim, Göttingen, Germany
| | - Huan Lan
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany.,German Center for Cardiovascular Research, Partner Sites, Heidelberg, Mannheim, Göttingen, Germany
| | - Rujia Zhong
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Qiang Xu
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Mengying Huang
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Zhenxing Liao
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Siegfried Lang
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany.,German Center for Cardiovascular Research, Partner Sites, Heidelberg, Mannheim, Göttingen, Germany
| | - Wolfram-Hubertus Zimmermann
- German Center for Cardiovascular Research, Partner Sites, Heidelberg, Mannheim, Göttingen, Germany.,Institute of Pharmacology and Toxicology, University of Göttingen, Göttingen, Germany
| | - Lukas Cyganek
- German Center for Cardiovascular Research, Partner Sites, Heidelberg, Mannheim, Göttingen, Germany.,Stem Cell Unit, Clinic for Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany
| | - Thomas Wieland
- German Center for Cardiovascular Research, Partner Sites, Heidelberg, Mannheim, Göttingen, Germany.,Institute of Experimental and Clinical Pharmacology and Toxicology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany.,German Center for Cardiovascular Research, Partner Sites, Heidelberg, Mannheim, Göttingen, Germany
| | - Xiao-Bo Zhou
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany.,German Center for Cardiovascular Research, Partner Sites, Heidelberg, Mannheim, Göttingen, Germany.,Key Laboratory of Medical Electrophysiology of Ministry of Education and Medical Electrophysiological Key Laboratory of Sichuan Province, Institute of Cardiovascular Research, Southwest Medical University, Luzhou, China
| | - Martin Borggrefe
- First Department of Medicine, Medical Faculty Mannheim, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany.,German Center for Cardiovascular Research, Partner Sites, Heidelberg, Mannheim, Göttingen, Germany
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9
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Mezincescu A, Karthikeyan VJ, Nadar SK. Ranolazine: A true pluripotent cardiovascular drug or jack of all trades, master of none? Sultan Qaboos Univ Med J 2018; 18:e13-e23. [PMID: 29666676 DOI: 10.18295/squmj.2018.18.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 12/18/2017] [Accepted: 01/08/2018] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular disease (CVD) is a leading cause of morbidity and mortality worldwide. Although the majority of patients with CVD are treated with interventional procedures, a substantial number require medical therapy in terms of both prognosis and symptomatic relief. However, commonly used agents such as β-blockers and calcium channel blockers reduce blood pressure in patients whose resting pressures are often already low. Ranolazine is a promising agent that does not have significant effects on blood pressure or heart rate. Use of this drug has been documented in various cardiovascular conditions, including ischaemic heart disease, heart failure and arrhythmias. This review article aimed to examine current evidence on the use of ranolazine in various cardiovascular conditions in order to determine whether it is a true pluripotent cardiovascular agent or, on the other hand, a "jack of all trades, master of none."
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Affiliation(s)
- Alice Mezincescu
- Cardiovascular & Diabetes Research Unit, University of Aberdeen, Aberdeen, UK
| | - V J Karthikeyan
- Royal Albert Edward Infirmary, Wrightington Wigan & Leigh NHS Foundation Trust, Wigan, UK
| | - Sunil K Nadar
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
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10
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Guarini G, Huqi A, Morrone D, Capozza PFG, Marzilli M. Trimetazidine and Other Metabolic Modifiers. Eur Cardiol 2018; 13:104-111. [PMID: 30697354 DOI: 10.15420/ecr.2018.15.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Treatment goals for people with chronic angina should focus on the relief of symptoms and improving mortality rates so the patient can feel better and live longer. The traditional haemodynamic approach to ischaemic heart disease was based on the assumption that increasing oxygen supply and decreasing oxygen demand would improve symptoms. However, data from clinical trials, show that about one third of people continue to have angina despite a successful percutaneous coronary intervention and medical therapy. Moreover, several trials on chronic stable angina therapy and revascularisation have failed to show benefits in terms of primary outcome (survival, cardiovascular death, all-cause mortality), symptom relief or echocardiographic parameters. Failure to significantly improve quality of life and prognosis may be attributed in part to a limited understanding of ischaemic heart disease, by neglecting the fact that ischaemia is a metabolic disorder. Shifting cardiac metabolism from free fatty acids towards glucose is a promising approach for the treatment of patients with stable angina, independent of the underlying disease (macrovascular and/or microvascular disease). Cardiac metabolic modulators open the way to a greater understanding of ischaemic heart disease and its common clinical manifestations as an energetic disorder rather than an imbalance between the demand and supply of oxygen and metabolites.
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Affiliation(s)
- Giacinta Guarini
- Cardiovascular Medicine Division, Cardiothoracic and Vascular Department, University of Pisa Italy
| | - Alda Huqi
- Cardiovascular Medicine Division, Ospedale della Versilia, Lido di Camaiore Italy
| | - Doralisa Morrone
- Cardiovascular Medicine Division, Cardiothoracic and Vascular Department, University of Pisa Italy
| | | | - Mario Marzilli
- Cardiovascular Medicine Division, Cardiothoracic and Vascular Department, University of Pisa Italy
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11
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Dalal JJ, Mishra S. Modulation of myocardial energetics: An important category of agents in the multimodal treatment of coronary artery disease and heart failure. Indian Heart J 2017. [PMID: 28648439 PMCID: PMC5485408 DOI: 10.1016/j.ihj.2017.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The combined and relative contribution of glucose and fatty acid oxidation generates myocardial energy, which regulates the cardiac function and efficiency. Any dysregulation in this metabolic homeostasis can adversely affect the function of heart and contribute to cardiac conditions such as angina and heart failure. Metabolic agents ameliorate this internal metabolic anomaly, by shifting the energy production pathway from free fatty acids to glucose, resulting in a better performance of the heart. Metabolic therapy is relatively a new modality, which functions through optimization of cardiac substrate metabolism. Among the metabolic therapies, trimetazidine and ranolazine are the agents presently available in India. In the present review, we would like to present the metabolic perspective of pathophysiology of coronary artery disease and heart failure, and metabolic therapy by using trimetazidine and ranolazine.
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Affiliation(s)
| | - Sundeep Mishra
- Department of Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India
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12
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Salazar CA, Basilio Flores JE, Veramendi Espinoza LE, Mejia Dolores JW, Rey Rodriguez DE, Loza Munárriz C. Ranolazine for stable angina pectoris. Cochrane Database Syst Rev 2017; 2:CD011747. [PMID: 28178363 PMCID: PMC6373632 DOI: 10.1002/14651858.cd011747.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Stable angina pectoris is a chronic medical condition with significant impact on mortality and quality of life; it can be macrovascular or microvascular in origin. Ranolazine is a second-line anti-anginal drug approved for use in people with stable angina. However, the effects of ranolazine for people with angina are considered to be modest, with uncertain clinical relevance. OBJECTIVES To assess the effects of ranolazine on cardiovascular and non-cardiovascular mortality, all-cause mortality, quality of life, acute myocardial infarction incidence, angina episodes frequency and adverse events incidence in stable angina patients, used either as monotherapy or as add-on therapy, and compared to placebo or any other anti-anginal agent. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and the Conference Proceedings Citation Index - Science in February 2016, as well as regional databases and trials registers. We also screened reference lists. SELECTION CRITERIA Randomised controlled trials (RCTs) which directly compared the effects of ranolazine versus placebo or other anti-anginals in people with stable angina pectoris were eligible for inclusion. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, extracted data and assessed risk of bias. Estimates of treatment effects were calculated using risk ratios (RR), mean differences (MD) and standardised mean differences (SMD) with 95% confidence intervals (CI) using a fixed-effect model. Where we found statistically significant heterogeneity (Chi² P < 0.10), we used a random-effects model for pooling estimates. Meta-analysis was not performed where we found considerable heterogeneity (I² ≥ 75%). We used GRADE criteria to assess evidence quality and the GRADE profiler (GRADEpro GDT) to import data from Review Manager 5.3 to create 'Summary of findings' tables. MAIN RESULTS We included 17 RCTs (9975 participants, mean age 63.3 years). We found very limited (or no) data to inform most planned comparisons. Summary data were used to inform comparison of ranolazine versus placebo. Overall, risk of bias was assessed as unclear.For add-on ranolazine compared to placebo, no data were available to estimate cardiovascular and non-cardiovascular mortality. We found uncertainty about the effect of ranolazine on: all-cause mortality (1000 mg twice daily, RR 0.83, 95% CI 0.26 to 2.71; 3 studies, 2053 participants; low quality evidence); quality of life (any dose, SMD 0.25, 95% CI -0.01 to 0.52; 4 studies, 1563 participants; I² = 73%; moderate quality evidence); and incidence of non-fatal acute myocardial infarction (AMI) (1000mg twice daily, RR 0.40, 95% CI 0.08 to 2.07; 2 studies, 1509 participants; low quality evidence). Add-on ranolazine 1000 mg twice daily reduced the fervour of angina episodes (MD -0.66, 95% CI -0.97 to -0.35; 3 studies, 2004 participants; I² = 39%; moderate quality evidence) but increased the risk of non-serious adverse events (RR 1.22, 95% CI 1.06 to 1.40; 3 studies, 2053 participants; moderate quality evidence).For ranolazine as monotherapy compared to placebo, we found uncertain effect on cardiovascular mortality (1000 mg twice daily, RR 1.03, 95% CI 0.56 to 1.88; 1 study, 2604 participants; low quality evidence). No data were available to estimate non-cardiovascular mortality. We also found an uncertain effect on all-cause mortality for ranolazine (1000 mg twice daily, RR 1.00, 95% CI 0.81 to 1.25; 3 studies, 6249 participants; low quality evidence), quality of life (1000 mg twice daily, MD 0.28, 95% CI -1.57 to 2.13; 3 studies, 2254 participants; moderate quality evidence), non-fatal AMI incidence (any dose, RR 0.88, 95% CI 0.69 to 1.12; 3 studies, 2983 participants; I² = 50%; low quality evidence), and frequency of angina episodes (any dose, MD 0.08, 95% CI -0.85 to 1.01; 2 studies, 402 participants; low quality evidence). We found an increased risk for non-serious adverse events associated with ranolazine (any dose, RR 1.50, 95% CI 1.12 to 2.00; 3 studies, 947 participants; very low quality evidence). AUTHORS' CONCLUSIONS We found very low quality evidence showing that people with stable angina who received ranolazine as monotherapy had increased risk of presenting non-serious adverse events compared to those given placebo. We found low quality evidence indicating that people with stable angina who received ranolazine showed uncertain effect on the risk of cardiovascular death (for ranolazine given as monotherapy), all-cause death and non-fatal AMI, and the frequency of angina episodes (for ranolazine given as monotherapy) compared to those given placebo. Moderate quality evidence indicated that people with stable angina who received ranolazine showed uncertain effect on quality of life compared with people who received placebo. Moderate quality evidence also indicated that people with stable angina who received ranolazine as add-on therapy had fewer angina episodes but increased risk of presenting non-serious adverse events compared to those given placebo.
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Affiliation(s)
- Carlos A Salazar
- Universidad Peruana Cayetano HerediaDepartment of MedicineAvenida Honorio Delgado 430San Martin de PorresLimaLimaPeru
| | | | | | - Jhon W Mejia Dolores
- Universidad Nacional Mayor de San MarcosFaculty of MedicineAv. Grau 755LimaLimaPeru
| | | | - César Loza Munárriz
- Universidad Peruana Cayetano HerediaDepartment of NephrologyHospital Cayetano HerediaHonorio Delgado 420LimaPeru31
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Abstract
Chronic stable angina is a significant problem in older adults. The goal of therapy is to provide symptomatic relief, improve patient quality of life, and prevent subsequent angina or myocardial infarction that could lead to sudden death. The efficacy and safety of drugs such as beta-blockers and calcium channel blockers for managing chronic stable angina in older adults has not been rigorously investigated. Drug selection should be based on physiologic alterations, patient comorbidities, adverse reaction profile, and cost.
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Morissette P, Regan C, Fitzgerald K, Gerenser P, Travis J, Wang S, Fanelli P, Sannajust F. Shortening of the electromechanical window in the ketamine/xylazine-anesthetized guinea pig model to assess pro-arrhythmic risk in early drug development. J Pharmacol Toxicol Methods 2016; 81:171-82. [DOI: 10.1016/j.vascn.2016.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/23/2016] [Accepted: 06/04/2016] [Indexed: 11/26/2022]
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15
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Guarini G, Huqi A, Morrone D, Marzilli M. Pharmacological Agents Targeting Myocardial Metabolism for the Management of Chronic Stable Angina : an Update. Cardiovasc Drugs Ther 2016; 30:379-391. [DOI: 10.1007/s10557-016-6677-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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16
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Mason FE, Sossalla S. The Significance of the Late Na+ Current for Arrhythmia Induction and the Therapeutic Antiarrhythmic Potential of Ranolazine. J Cardiovasc Pharmacol Ther 2016; 22:40-50. [DOI: 10.1177/1074248416644989] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The purpose of this article is to review the basis of arrhythmogenesis, the functional and clinical role of the late Na current, and its therapeutic inhibition. Under pathological conditions such as ischemia and heart failure this current is abnormally enhanced and influences cellular electrophysiology as a proarrhythmic substrate in myocardial pathology. Ranolazine the only approved late Na current blocker has been demonstrated to produce antiarrhythmic effects in the atria and the ventricle. We summarize recent experimental and clinical studies of ranolazine and other experimental late Na current blockers and discuss the significance of the available data.
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Affiliation(s)
- Fleur E. Mason
- Department of Cardiology and Pneumology, Georg-August-University Göttingen, Göttingen, Germany
| | - Samuel Sossalla
- Department of Cardiology and Pneumology, Georg-August-University Göttingen, Göttingen, Germany
- Department of Internal Medicine III (Cardiology and Angiology), University Hospital Schleswig-Holstein, Kiel, Germany
- German Centre for Cardiovascular Research (DZHK), Göttingen & Kiel, Germany
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17
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Giannopoulos AA, Giannoglou GD, Chatzizisis YS. Pharmacological approaches of refractory angina. Pharmacol Ther 2016; 163:118-31. [DOI: 10.1016/j.pharmthera.2016.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Affiliation(s)
| | - Tara Sedlak
- University of British Columbia, Vancouver, British Columbia, Canada
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Ambrosio G, Tamargo J, Grant PJ. Non-haemodynamic anti-anginal agents in the management of patients with stable coronary artery disease and diabetes: A review of the evidence. Diab Vasc Dis Res 2016; 13:98-112. [PMID: 26873904 DOI: 10.1177/1479164115609028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Patients with coronary artery disease and concomitant diabetes mellitus tend to have more extensive vessel disease than non-diabetes mellitus coronary artery disease patients, are at high risk of adverse cardiovascular events and suffer from a great anginal burden. Very few trials have specifically addressed the issue of optimal anti-anginal therapy in coronary artery disease patients who also have diabetes mellitus. Among 'classical' anti-anginal agents, recent guidelines do not specifically recommend any molecule over others; however, European Society of Cardiology guidelines acknowledge that favourable data in patients with concomitant diabetes mellitus and coronary artery disease are available for trimetazidine and ranolazine, two anti-anginal agents with a non-haemodynamic mechanism of action. The aim of this article is to review available evidence supporting the anti-anginal efficacy of these two drugs in the difficult-to-treat population of diabetes mellitus patients, including their effects on glycated haemoglobin (HbA1c), a measure of medium-term glycaemic control. Although direct head-to-head comparisons have not been performed, available evidence favours ranolazine as an effective anti-anginal agent over trimetazidine in this population. In addition, ranolazine lowers HbA1c, indicating that it may improve glycaemic control in patients with diabetes mellitus. Conversely, scanty data are available on the metabolic effects of trimetazidine in this cohort of patients. Thus, ranolazine may represent a valuable therapeutic option in stable coronary artery disease patients with diabetes mellitus.
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Affiliation(s)
- Giuseppe Ambrosio
- Division of Cardiology, School of Medicine, University of Perugia, Perugia, Italy
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Peter J Grant
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Coleman CI, Freemantle N, Kohn CG. Ranolazine for the treatment of chronic stable angina: a cost-effectiveness analysis from the UK perspective. BMJ Open 2015; 5:e008861. [PMID: 26546142 PMCID: PMC4636621 DOI: 10.1136/bmjopen-2015-008861] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To estimate the cost-effectiveness of ranolazine when added to standard-of-care (SoC) antianginals compared with SoC alone in patients with stable coronary disease experiencing ≥3 attacks/week. SETTING An economic model utilising a UK health system perspective, a 1-month cycle-length and a 1-year time horizon. PARTICIPANTS Patients with stable coronary disease experiencing ≥3 attacks/week starting in 1 of 4 angina frequency health states based on Seattle Angina Questionnaire Angina Frequency (SAQAF) scores (100=no; 61-99=monthly; 31-60=weekly; 0-30=daily angina). INTERVENTION Ranolazine added to SoC or SoC alone. Patients were allowed to transition between SAQAF states (first cycle only) or death (any cycle) based on probabilities derived from the randomised, controlled Efficacy of Ranolazine in Chronic Angina trial and other studies. Patients not responding to ranolazine in month 1 (not improving ≥1 SAQAF health state) discontinued ranolazine and were assumed to behave like SoC patients. PRIMARY AND SECONDARY OUTCOMES MEASURES Costs (£2014) and quality-adjusted life-years (QALYs) for patients receiving and not receiving ranolazine. RESULTS Ranolazine patients lived a mean of 0.701 QALYs at a cost of £5208. Those not receiving ranolazine lived 0.662 QALYs at a cost of £5318. The addition of ranolazine to SoC was therefore a dominant economic strategy. The incremental cost-effectiveness ratio was sensitive to ranolazine cost; exceeding £20,000/QALY when ranolazine's cost was >£203/month. Ranolazine remained a dominant strategy when indirect costs were included and mortality rates were assumed to increase with worsening severity of SAQAF health states. Monte Carlo simulation found ranolazine to be a dominant strategy in ∼71% of 10,000 iterations. CONCLUSIONS Although UK-specific data on ranolazine's efficacy and safety are lacking, our analysis suggest ranolazine added to SoC in patients with weekly or daily angina is likely cost-effective from a UK health system perspective.
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Affiliation(s)
- Craig I Coleman
- University of Connecticut, School of Pharmacy and Evidence-Based Practice Center, Storrs, Connecticut, USA
| | | | - Christine G Kohn
- University of Saint Joseph, School of Pharmacy, Hartford, Connecticut, USA
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Abstract
Chronic angina is a common manifestation of ischaemic heart disease. Medical treatments are the mainstay approach to reduce the occurrence of angina and improve patients' quality of life. This Series paper focuses on commonly used standard treatments (eg, nitrates, β blockers, and calcium-channel blockers), emerging anti-angina treatments (which are not available in all parts of the world), and experimental treatments. Although many emerging treatments are available, evidence is scarce about their ability to reduce angina and ischaemia.
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Affiliation(s)
- Steen E Husted
- Department of Medicine, Hospital Unit West, Herning, Denmark; Department of Clinical Pharmacology, Institute of Biomedicine, Aarhus University, Aarhus, Denmark
| | - E Magnus Ohman
- The Program for Advanced Coronary Disease, Division of Cardiology, Duke University and Duke Clinical Research Institute, Durham, NC, USA.
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Abstract
: We used the isolated working rat model to evaluate the effect of therapeutic concentrations (5-10 μM) of ranolazine on contractile performance, oxygen consumption, irreversible ischemic injury, and sarcoplasmic reticulum (SR) function. Ischemic injury was induced by 30 minutes of global ischemia followed by 120 minutes of Langendorff reperfusion and evaluated on the basis of triphenyltetrazolium chloride staining. SR function was determined on the basis of [H]-ryanodine binding, the kinetics of calcium-induced calcium release, measured by quick filtration technique, and oxalate-supported calcium uptake. In working hearts, ranolazine significantly reduced oxygen consumption (P = 0.031), in the absence of significant changes in contractile performance, and decreased irreversible ischemic injury (P = 0.011), if administered either before ischemia-reperfusion (25.4% ± 4.7% vs. 42.7% ± 6.0%) or only at the time of reperfusion (20.2% ± 5.2% vs. 43.7% ± 9.9%). In SR experiments, treatment with ranolazine determined a significant reduction in [H]-ryanodine binding (P = 0.029), because of decreased binding site density (369 ± 9 vs. 405 ± 12 fmol/mg), and in the kinetics of SR calcium release (P = 0.011), whose rate constant was decreased, whereas active calcium uptake was not affected. Ranolazine effectiveness at reperfusion and its ability to module SR calcium release suggest that this drug might be particularly useful to induce cardioprotection during coronary revascularization interventions, although the relevance of the effects on calcium homeostasis remains to be determined.
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Gupta T, Khera S, Kolte D, Aronow WS, Iwai S. Antiarrhythmic properties of ranolazine: A review of the current evidence. Int J Cardiol 2015; 187:66-74. [PMID: 25828315 DOI: 10.1016/j.ijcard.2015.03.324] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 03/20/2015] [Indexed: 12/19/2022]
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Rosa GM, Dorighi U, Ferrero S, Brunacci M, Bertero G, Brunelli C. Ranolazine for the treatment of atrial fibrillation. Expert Opin Investig Drugs 2015; 24:825-36. [DOI: 10.1517/13543784.2015.1036984] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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De Ferrari GM, Maier LS, Mont L, Schwartz PJ, Simonis G, Leschke M, Gronda E, Boriani G, Darius H, Guillamón Torán L, Savelieva I, Dusi V, Marchionni N, Quintana Rendón M, Schumacher K, Tonini G, Melani L, Giannelli S, Alberto Maggi C, Camm AJ. Ranolazine in the treatment of atrial fibrillation: Results of the dose-ranging RAFFAELLO (Ranolazine in Atrial Fibrillation Following An ELectricaL CardiOversion) study. Heart Rhythm 2015; 12:872-8. [PMID: 25602175 DOI: 10.1016/j.hrthm.2015.01.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Currently available antiarrhythmic agents for the treatment of atrial fibrillation (AF) have important limitations, leaving an unmet need for safe and effective therapy. Ranolazine is an approved antianginal agent with a favorable safety profile and electrophysiologic properties suggesting a potential role in the treatment of AF. OBJECTIVE The purpose of this study was to assess the safety and efficacy of ranolazine in the prevention of AF recurrence after successful electrical cardioversion and to ascertain the most appropriate dose of this agent. METHODS This prospective, multicenter, randomized, double-blind, placebo-control parallel group phase II dose-ranging trial randomized patients with persistent AF (7 days to 6 months) 2 hours after successful electrical cardioversion to placebo, or ranolazine 375 mg, 500 mg, or 750 mg bid. Patients were monitored daily by transtelephonic ECG. The primary end-point was the time to first AF recurrence. RESULTS Of 241 patients randomized, 238 took at least 1 drug dose. Ranolazine proved to be safe and tolerable. No dose of the drug significantly prolonged time to AF recurrence. AF recurred in 56.4%, 56.9%, 41.7%, and 39.7% of patients in the placebo, ranolazine 375 mg, ranolazine 500 mg, and ranolazine 750 mg groups, respectively. The reduction in overall AF recurrence in the combined 500-mg and 750-mg groups was of borderline significance compared to the placebo group (P = .053) and significant compared to 375-mg group (P = .035). CONCLUSION No dose of ranolazine significantly prolonged time to AF recurrence. However, the 500-mg and 750 mg-groups combined reduced AF recurrences, suggesting a possible role for this agent in the treatment of AF.
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Affiliation(s)
- Gaetano M De Ferrari
- Department of Cardiology and Cardiovascular Clinical Research Center, Fondazione IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Pavia, Italy.
| | - Lars S Maier
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Lluís Mont
- Department of Cardiology, Thorax Institute Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Peter J Schwartz
- Center for Cardiac Arrhythmias of Genetic Origin-IRCCS Istituto Auxologico Italiano, Milan, Italy
| | | | - Matthias Leschke
- Klinikum Esslingen GmbH, Abteilung Kardiologie, Esslingen, Germany
| | | | - Giuseppe Boriani
- Ospedale S. Orsola-Malpighi, Dipartimento di Cardiologia, Bologna, Italy
| | | | | | | | - Veronica Dusi
- Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia and University of Pavia, Italy
| | - Niccolò Marchionni
- Division of Geriatric Cardiology and Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Miguel Quintana Rendón
- The Karolinska Institute at Hospital de Torrevieja, Servicio de Cardiología, Alicante, Spain
| | - Kai Schumacher
- Menarini Research & Business Service GmbH, Berlin, Germany
| | | | - Lorenzo Melani
- Menarini Industrie Farmaceutiche Riunite s.r.l, Florence, Italy
| | | | | | - A John Camm
- St. George's University, London, United Kingdom
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Sandhiya S, Dkhar SA, Pillai AA, George M, Jayaraman B, Chandrasekaran A. Comparison of ranolazine and trimetazidine on glycemic status in diabetic patients with coronary artery disease - a randomized controlled trial. J Clin Diagn Res 2015; 9:OC01-5. [PMID: 25738014 DOI: 10.7860/jcdr/2015/10594.5448] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 10/31/2014] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Cardiovascular diseases have become the leading cause of death around the globe and diabetes mellitus (DM) is considered to be a coronary artery disease (CAD) risk equivalent. Ranolazine, an anti anginal drug has been found to reduce Glycated haemoglobin (HbA1c) in diabetes patients with chronic angina. However the effect of another antianginal drug trimetazidine, on glycemic status is not clear. AIM To compare the effect of ranolazine and trimetazidine on glycemic status in diabetic patients with CAD. SETTINGS AND DESIGN Patients diagnosed with CAD and diabetes mellitus attending Cardiology Out Patient Department (OPD), Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India were recruited for this randomized open label parallel arm trial. MATERIALS AND METHODS The study conducted from January-2012 to April-2013 had 47 eligible patients diagnosed with CAD and diabetes mellitus. They were randomized to receive either ranolazine 500 mg BD or trimetazidine 35 mg BD for 12 weeks. HbA1c levels, fasting blood glucose (FBG), lipid profile, QT and QTc intervals were measured at baseline and after 12 weeks. STATISTICAL ANALYSIS Unpaired t-test was used to compare the baseline characteristics of between the groups while comparison within the groups were done using Paired t-test. Wilcoxon and Mann Whitney U-tests were used for non parametric data. Graph pad instat version-3 was used for statistical analysis. Values were expressed as mean ± SD. A p < 0.05 was considered statistically significant. RESULTS The study could not find any change in HbA1c levels in both ranolazine and trimetazidine groups. The adverse effects reported from patients on ranolazine include angina, constipation, postural hypotension, headache, dizziness, nausea and weakness while patients on trimetazidine complained of constipation, weakness, palpitations, angina, dizziness, nausea, dyspepsia, headache, gastric discomfort, joint pain, etc. CONCLUSION In patients with chronic angina and diabetes mellitus Ranolazine 500mg BD and Trimetazidine 35mg BD did not show any effect on HbA1c and fasting blood glucose lebel.
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Affiliation(s)
- Selvarajan Sandhiya
- Assistant Professor, Department of Clinical Pharmacology, JIPMER , Puducherry, India
| | | | | | - Melvin George
- Assistant Professor, Cardiac Clinical Trials, Department of Cardiology, SRM Medical College Hospital & Research Centre , Kattankulathur, Chennai, India
| | | | - Adithan Chandrasekaran
- Senior Professor & Head, Department of Clinical Pharmacology, JIPMER , Puducherry, India
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Cattaneo M, Porretta AP, Gallino A. Ranolazine: Drug overview and possible role in primary microvascular angina management. Int J Cardiol 2014; 181:376-81. [PMID: 25555283 DOI: 10.1016/j.ijcard.2014.12.055] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 12/21/2014] [Indexed: 12/19/2022]
Abstract
Ranolazine is a novel well-tolerated anti-ischemic drug, which selectively inhibits late sodium current and exerts metabolic properties without any hemodynamic effect. Ranolazine has been approved as a second-line medical treatment for symptomatic stable coronary artery disease. Primary microvascular angina (MVA) is suspected when angina symptoms occur in patients with demonstrated myocardial ischemia, absence of myocardial disease and normal coronary artery angiography. Recent clinical data suggest that MVA represents a complex entity, which has been increasingly recognized as a significant cause of morbidity. High variability and low response to traditional anti-anginal treatment characterize primary MVA. Despite the fact that clinical and preclinical evidence provides information regarding ranolazine usefulness in primary MVA management, only three recent small randomized trials have investigated this issue. By selecting peer-reviewed literature in Pubmed and Cochrane Library, this review provides an overview on ranolazine pharmacology and efficacy, focusing on recent evidence suggesting its usefulness in management of primary MVA.
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Affiliation(s)
- Mattia Cattaneo
- Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli-San Giovanni, Bellinzona, Switzerland.
| | - Alessandra Pia Porretta
- Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli-San Giovanni, Bellinzona, Switzerland
| | - Augusto Gallino
- Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli-San Giovanni, Bellinzona, Switzerland; University of Zürich, Zürich, Switzerland
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Abstract
Mortality rates attributable to coronary heart disease have declined in recent years, possibly related to changes in clinical presentation patterns and use of proven secondary prevention strategies. Chronic stable angina (CSA) remains prevalent, and the goal of treatment is control of symptoms and reduction in cardiovascular events. Ranolazine is a selective inhibitor of the late sodium current in myocytes with anti-ischemic and metabolic properties. It was approved by the US Food and Drug Administration in 2006 for use in patients with CSA. Multiple, randomized, placebo-controlled trials have shown that ranolazine improves functional capacity and decreases anginal episodes in CSA patients, despite a lack of a significant hemodynamic effect. Ranolazine did not improve cardiovascular mortality or affect incidence of myocardial infarction in the MERLIN (Metabolic Efficiency with Ranolazine for Less Ischemia in Non-ST-Elevation Acute Coronary Syndrome)-TIMI (Thrombolysis In Myocardial Infarction) 36 trial, but significantly decreased the incidence of recurrent angina. More recently, ranolazine has been shown to have beneficial and potent antiarrhythmic effects, both on supraventricular and ventricular tachyarrhythmias, largely due to its inhibition of the late sodium current. Randomized controlled trials testing these effects are underway. Lastly, ranolazine appears to be cost-effective due to its ability to decrease angina-related hospitalizations and improve quality of life.
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Affiliation(s)
- J Nicolás Codolosa
- Einstein Center for Heart and Vascular Health, Einstein Medical Center, Philadelphia, PA, USA
| | - Subroto Acharjee
- Einstein Center for Heart and Vascular Health, Einstein Medical Center, Philadelphia, PA, USA
| | - Vincent M Figueredo
- Einstein Center for Heart and Vascular Health, Einstein Medical Center, Philadelphia, PA, USA
- Jefferson Medical College, Philadelphia, PA, USA
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Burashnikov A, Di Diego JM, Barajas-Martínez H, Hu D, Zygmunt AC, Cordeiro JM, Moise NS, Kornreich BG, Belardinelli L, Antzelevitch C. Ranolazine effectively suppresses atrial fibrillation in the setting of heart failure. Circ Heart Fail 2014; 7:627-33. [PMID: 24874201 DOI: 10.1161/circheartfailure.114.001129] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is a critical need for safer and more effective pharmacological management of atrial fibrillation (AF) in the setting of heart failure (HF). METHODS AND RESULTS This study investigates the electrophysiological, antiarrhythmic, and proarrhythmic effects of a clinically relevant concentration of ranolazine (5 μmol/L) in coronary-perfused right atrial and left ventricular preparations isolated from the hearts of HF dogs. HF was induced by ventricular tachypacing (2-6 weeks at 200-240 beats per minute; n=17). Transmembrane action potentials were recorded using standard microelectrode techniques. In atria, ranolazine slightly prolonged action potential duration but significantly depressed sodium channel current-dependent parameters causing a reduction of maximum rate of rise of the action potential upstroke, a prolongation of the effective refractory period secondary to the development of postrepolarization refractoriness, and an increase in diastolic threshold of excitation and atrial conduction time. Ranolazine did not significantly alter these parameters or promote arrhythmias in the ventricles. Ranolazine produced greater inhibition of peak sodium channel current in atrial cells isolated from HF versus normal dogs. A single premature beat reproducibly induced self-terminating AF in 10 of 17 atria. Ranolazine (5 μmol/L) suppressed induction of AF in 7 of 10 (70%) atria. In the remaining 3 atria, ranolazine reduced frequency and duration of AF. CONCLUSIONS Our results demonstrate more potent suppression of AF by ranolazine in the setting of HF than previously demonstrated in nonfailing hearts and absence of ventricular proarrhythmia. The data suggest that ranolazine may be of benefit as an alternative to amiodarone and dofetilide in the management of AF in patients with HF.
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Affiliation(s)
- Alexander Burashnikov
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.).
| | - José M Di Diego
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Hector Barajas-Martínez
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Dan Hu
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Andrew C Zygmunt
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Jonathan M Cordeiro
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - N Sydney Moise
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Bruce G Kornreich
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Luiz Belardinelli
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.)
| | - Charles Antzelevitch
- From the Masonic Medical Research Laboratory, Utica, NY (A.B., J.M.D.D., H.B.-M., D.H., A.C.Z., J.M.C., C.A.); Department of Clinical and Biological Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY (N.S.M., B.G.K.); and Gilead Sciences, Foster City, CA (L.B.).
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Banon D, Filion KB, Budlovsky T, Franck C, Eisenberg MJ. The usefulness of ranolazine for the treatment of refractory chronic stable angina pectoris as determined from a systematic review of randomized controlled trials. Am J Cardiol 2014; 113:1075-82. [PMID: 24462341 DOI: 10.1016/j.amjcard.2013.11.070] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 11/23/2013] [Accepted: 11/23/2013] [Indexed: 10/25/2022]
Abstract
Despite the use of traditional antianginal medications (i.e., β blockers, calcium channel blockers, and nitrates) and revascularization therapies, symptoms of chronic stable angina pectoris (CSAP) persist in ≥25% of patients. The objective of this systematic review was to synthesize the available evidence from randomized controlled trials (RCTs) of ranolazine for the treatment of CSAP. We systematically searched the Cochrane Register of Controlled Trials, EMBASE, and MEDLINE through July 2013 for RCTs comparing ranolazine with placebo or antianginal medications administered as part of usual care for the management of CSAP. End points of interest included exercise stress test performance (duration, time to angina, and time to ST-segment depression), frequency of angina attacks/week, nitroglycerin use/week, and quality of life. We identified 7 RCTs (n = 3,317) of patients with CSAP due to coronary artery disease. Comparators included placebo, amlodipine, and atenolol. All but 1 trial showed a statistically significant improvement in all 3 exercise stress test parameters with ranolazine compared with placebo. Ranolazine also reduced angina frequency and nitroglycerin use compared with placebo. These findings were consistent whether or not patients were also prescribed traditional antianginal pharmacotherapy. In conclusion, ranolazine reduces anginal symptoms among patients with symptomatic CSAP despite their use of traditional antianginal medications.
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Koskinas KC, Fragakis N, Katritsis D, Skeberis V, Vassilikos V. Ranolazine enhances the efficacy of amiodarone for conversion of recent-onset atrial fibrillation. Europace 2014; 16:973-9. [DOI: 10.1093/europace/eut407] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Reffelmann T, Kloner RA. Ranolazine: an anti-anginal drug with further therapeutic potential. Expert Rev Cardiovasc Ther 2014; 8:319-29. [DOI: 10.1586/erc.09.178] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Vaishnav A, Vaishnav A, Lokhandwala Y. Refractory atrial fibrillation effectively treated with ranolazine. Indian Heart J 2014; 66:115-8. [PMID: 24581108 PMCID: PMC3946441 DOI: 10.1016/j.ihj.2013.12.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 08/11/2013] [Accepted: 12/05/2013] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation is the most common sustained cardiac arrhythmia which is often troublesome to manage. Currently, rhythm and rate control medications are the mainstays of therapy. In 2 amiodarone-refractory highly symptomatic patients, an innovative approach using ranolazine, which selectively acts on Na+ channels and delays atrial depolarization, was tried successfully.
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Affiliation(s)
- Aditi Vaishnav
- Medical Student, Dr. D.Y. Patil Medical College, Navi Mumbai, India
| | - Avani Vaishnav
- Medical Student, Dr. D.Y. Patil Medical College, Navi Mumbai, India
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Young JW, Melander S. Evaluating symptoms to improve quality of life in patients with chronic stable angina. Nurs Res Pract 2013; 2013:504915. [PMID: 24455229 PMCID: PMC3884863 DOI: 10.1155/2013/504915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Revised: 08/15/2013] [Accepted: 10/11/2013] [Indexed: 02/05/2023] Open
Abstract
Chronic stable angina (CSA) is a significant problem in the United States that can negatively impact patient quality of life (QoL). An accurate assessment of the severity of a patient's angina, the impact on their functional status, and their risk of cardiovascular complications is key to successful treatment of CSA. Active communication between the patient and their healthcare provider is necessary to ensure that patients receive optimal therapy. Healthcare providers should be aware of atypical symptoms of CSA in their patients, as patients may continue to suffer from angina despite the availability of multiple therapies. Patient questionnaires and symptom checklists can help patients communicate proactively with their healthcare providers. This paper discusses the prevalence of CSA, its impact on QoL, and the tools that healthcare providers can use to assess the severity of their patients' angina and the impact on QoL.
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Affiliation(s)
- Jeffrey W. Young
- UTHSC College of Nursing, 920 Madison Avenue, Memphis, TN 38163, USA
| | - Sheila Melander
- UTHSC College of Nursing, 920 Madison Avenue, Memphis, TN 38163, USA
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Remme CA, Wilde AAM. Targeting sodium channels in cardiac arrhythmia. Curr Opin Pharmacol 2013; 15:53-60. [PMID: 24721654 DOI: 10.1016/j.coph.2013.11.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 11/26/2013] [Accepted: 11/28/2013] [Indexed: 12/15/2022]
Abstract
Cardiac voltage-gated sodium channels are responsible for proper electrical conduction in the heart. During acquired pathological conditions and inherited sodium channelopathies, altered sodium channel function causes conduction disturbances and ventricular arrhythmias. Although the clinical, genetic and biophysical characteristics of cardiac sodium channel disease have been extensively studied, limited progress has been made in the development of treatment strategies targeting sodium channels. Classical non-selective sodium channel blockers have only limited clinical applicability, while more selective inhibitors of the late sodium current constitute a more promising treatment option. Because of our insufficient understanding of their complexity and subcellular diversity, other specific therapeutic targets for modulating sodium channels remain elusive. The current status and future potential of targeting sodium channels in cardiac arrhythmias are discussed.
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Affiliation(s)
- Carol Ann Remme
- Department of Clinical and Experimental Cardiology, Academic Medical Center, University of Amsterdam, The Netherlands.
| | - Arthur A M Wilde
- Department of Clinical and Experimental Cardiology, Academic Medical Center, University of Amsterdam, The Netherlands
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Kloner RA, Hines ME, Geunes-Boyer S. Efficacy and safety of ranolazine in patients with chronic stable angina. Postgrad Med 2013; 125:43-52. [PMID: 24200760 DOI: 10.3810/pgm.2013.11.2711] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Chronic stable angina (CSA) impairs patient quality of life, is associated with increased patient mortality, and is a prominent symptom of coronary artery disease (CAD), the latter being prevalent worldwide in patients. Currently, therapeutic options for patients with CSA include β-blockers, calcium channel blockers, nitrates, and ranolazine. Ranolazine is a first-in-class piperazine derivative that inhibits the late inward sodium current in cardiac cells and is considered an effective and safe option for treating patients with CSA. As with any first-in-class agent, it is important for the practitioner to be familiar with the safety profile of the drug. Therefore, the objective of our article is to review safety data on the use of ranolazine in patients with CSA. Clinical data show that ranolazine is well tolerated: major treatment-associated adverse events include dizziness, nausea, headache, and constipation. Ranolazine treatment is also associated with QTc-interval prolongation; however, QTc-interval prolongation with ranolazine does not appear to have clinical consequences-in fact, several studies suggest that ranolazine therapy may have an antiarrhythmic effect in patients. Notably, ranolazine is hemodynamically neutral in that it exerts its antianginal effect without significantly impacting patient heart rate or blood pressure. In addition, small decreases in glycosylated hemoglobin levels have been seen in patients with type 2 diabetes mellitus. Overall, ranolazine (in doses of 500 mg and 1000 mg, twice daily) is a safe and effective option for monotherapy or add-on therapy to reduce anginal symptoms in patients with CSA.
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Affiliation(s)
- Robert A Kloner
- Director of Research, Heart Institute, Good Samaritan Hospital, Los Angeles, CA; Professor of Medicine, Cardiovascular Division, Keck School of Medicine, University of Southern California, Los Angeles, CA.
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Moreno JD, Yang PC, Bankston JR, Grandi E, Bers DM, Kass RS, Clancy CE. Ranolazine for congenital and acquired late INa-linked arrhythmias: in silico pharmacological screening. Circ Res 2013; 113:e50-e61. [PMID: 23897695 DOI: 10.1161/circresaha.113.301971] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
RATIONALE The antianginal ranolazine blocks the human ether-a-go-go-related gene-based current IKr at therapeutic concentrations and causes QT interval prolongation. Thus, ranolazine is contraindicated for patients with preexisting long-QT and those with repolarization abnormalities. However, with its preferential targeting of late INa (INaL), patients with disease resulting from increased INaL from inherited defects (eg, long-QT syndrome type 3 or disease-induced electric remodeling (eg, ischemic heart failure) might be exactly the ones to benefit most from the presumed antiarrhythmic properties of ranolazine. OBJECTIVE We developed a computational model to predict if therapeutic effects of pharmacological targeting of INaL by ranolazine prevailed over the off-target block of IKr in the setting of inherited long-QT syndrome type 3 and heart failure. METHODS AND RESULTS We developed computational models describing the kinetics and the interaction of ranolazine with cardiac Na(+) channels in the setting of normal physiology, long-QT syndrome type 3-linked ΔKPQ mutation, and heart failure. We then simulated clinically relevant concentrations of ranolazine and predicted the combined effects of Na(+) channel and IKr blockade by both the parent compound ranolazine and its active metabolites, which have shown potent blocking effects in the therapeutically relevant range. Our simulations suggest that ranolazine is effective at normalizing arrhythmia triggers in bradycardia-dependent arrhythmias in long-QT syndrome type 3 as well tachyarrhythmogenic triggers arising from heart failure-induced remodeling. CONCLUSIONS Our model predictions suggest that acute targeting of INaL with ranolazine may be an effective therapeutic strategy in diverse arrhythmia-provoking situations that arise from a common pathway of increased pathological INaL.
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Affiliation(s)
- Jonathan D Moreno
- Tri-Institutional MD-PhD Program, Weill Cornell Medical College/The Rockefeller University/Sloan-Kettering Cancer Institute, New York, New York, USA, 10021
| | - Pei-Chi Yang
- Department of Pharmacology, University of California, Davis, Genome Building Rm 3503, Davis, CA 95616-8636
| | - John R Bankston
- Department of Pharmacology Columbia University College of Physicians and Surgeons 630 W. 168th St. New York, NY 10032, USA
| | - Eleonora Grandi
- Department of Pharmacology, University of California, Davis, Genome Building Rm 3503, Davis, CA 95616-8636
| | - Donald M Bers
- Department of Pharmacology, University of California, Davis, Genome Building Rm 3503, Davis, CA 95616-8636
| | - Robert S Kass
- Department of Pharmacology Columbia University College of Physicians and Surgeons 630 W. 168th St. New York, NY 10032, USA
| | - Colleen E Clancy
- Department of Pharmacology, University of California, Davis, Genome Building Rm 3503, Davis, CA 95616-8636
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Late sodium current inhibition in acquired and inherited ventricular (dys)function and arrhythmias. Cardiovasc Drugs Ther 2013; 27:91-101. [PMID: 23292167 DOI: 10.1007/s10557-012-6433-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The late sodium current has been increasingly recognized for its mechanistic role in various cardiovascular pathologies, including angina pectoris, myocardial ischemia, atrial fibrillation, heart failure and congenital long QT syndrome. Although relatively small in magnitude, the late sodium current (I(NaL)) represents a functionally relevant contributor to cardiomyocyte (electro)physiology. Many aspects of I(NaL) itself are as yet still unresolved, including its distribution and function in different cell types throughout the heart, and its regulation by sodium channel accessory proteins and intracellular signalling pathways. Its complexity is further increased by a close interrelationship with the peak sodium current and other ion currents, hindering the development of inhibitors with selective and specific properties. Thus, increased knowledge of the intricacies of the complex nature of I(NaL) during distinct cardiovascular conditions and its potential as a pharmacological target is essential. Here, we provide an overview of the functional and electrophysiological effects of late sodium current inhibition on the level of the ventricular myocyte, and its potential cardioprotective and anti-arrhythmic efficacy in the setting of acquired and inherited ventricular dysfunction and arrhythmias.
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A rare neurological complication of ranolazine. Case Rep Neurol Med 2013; 2013:451206. [PMID: 23936696 PMCID: PMC3713362 DOI: 10.1155/2013/451206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 06/19/2013] [Indexed: 12/19/2022] Open
Abstract
Myoclonus is not a known side effect of ranolazine. We report a case of myoclonus in a 72-year-old female who underwent cardiac catheterization for angina and was started on ranolazine after the procedure. Two days after ranolazine therapy on 1000 mg per day in divided doses, myoclonus developed, which severely impaired her normal activity. Her symptoms resolved 2 days after discontinuation of ranolazine. Ranolazine was resumed after discharge from hospital with recurrent myoclonus after two days of therapy. The causal relationship between ranolazine and myoclonus was suggested by cessation of myoclonus after ranolazine was discontinued.
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Abstract
Ranolazine is currently approved for use in chronic angina. The basis for this use is likely related to inhibition of late sodium channels with resultant beneficial downstream effects. Randomized clinical trials have demonstrated an improvement in exercise capacity and reduction in angina episodes with ranolazine. This therapeutic benefit occurs without the hemodynamic effects seen with the conventional antianginal agents. The inhibition of late sodium channels as well as other ion currents has a central role in the potential use of ranolazine in ischemic heart disease, arrhythmias, and heart failure. Despite its QTc-prolonging action, albeit minimal, clinical data have not shown a predisposition to torsades de pointes, and the medication has shown a reasonable safety profile even in those with structural heart disease. In this article we present the experimental and clinical data that support its current therapeutic role, and provide insight into potential future clinical applications.
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Affiliation(s)
- Nael Hawwa
- Internal Medicine Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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42
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Zuchi C, Tritto I, Ambrosio G. Angina pectoris in women: Focus on microvascular disease. Int J Cardiol 2013; 163:132-40. [DOI: 10.1016/j.ijcard.2012.07.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 07/07/2012] [Accepted: 07/07/2012] [Indexed: 12/19/2022]
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Frommeyer G, Rajamani S, Grundmann F, Stypmann J, Osada N, Breithardt G, Belardinelli L, Eckardt L, Milberg P. New Insights into the Beneficial Electrophysiologic Profile of Ranolazine in Heart Failure: Prevention of Ventricular Fibrillation With Increased Postrepolarization Refractoriness and Without Drug-Induced Proarrhythmia. J Card Fail 2012. [DOI: 10.1016/j.cardfail.2012.10.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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45
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Fragakis N, Koskinas KC, Katritsis DG, Pagourelias ED, Zografos T, Geleris P. Comparison of effectiveness of ranolazine plus amiodarone versus amiodarone alone for conversion of recent-onset atrial fibrillation. Am J Cardiol 2012; 110:673-7. [PMID: 22621799 DOI: 10.1016/j.amjcard.2012.04.044] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 04/26/2012] [Accepted: 04/26/2012] [Indexed: 12/19/2022]
Abstract
Ranolazine, an antianginal agent with antiarrhythmic properties, prevents atrial fibrillation (AF) in patients with acute coronary syndrome. In experimental models, the combination of ranolazine and amiodarone has marked synergistic effects that potently suppress AF. Currently, the clinical effect of the ranolazine-amiodarone combination for the conversion of AF is unknown. This prospective randomized pilot study compared the safety and efficacy of ranolazine plus amiodarone versus amiodarone alone for the conversion of recent-onset AF. We enrolled 51 consecutive patients with AF (<48-hour duration) eligible for pharmacologic cardioversion. Patients (33 men, 63 ± 8 years of age) were randomized to intravenous amiodarone for 24 hours (group A, n = 26) or to intravenous amiodarone plus oral ranolazine 1,500 mg at time of randomization (group A + R, n = 25). The 2 groups were well balanced with respect to clinical characteristics and left atrial diameter. Conversion within 24 hours (primary end point) was achieved in 22 patients (88%) in group A + R versus 17 patients (65%) in group A (p = 0.056). Time to conversion was shorter in group A + R than in group A (9.8 ± 4.1 vs 14.6 ± 5.3 hours, p = 0.002). According to Cox regression analysis, left atrial diameter and A + R treatment were the only independent predictors of time to conversion (hazard ratio 5.35, 95% confidence interval 2.37 to 12.11, p <0.001; hazard ratio 0.81, 95% confidence interval 0.74 to 0.88, p <0.001, respectively). There were no proarrhythmic events in either group. In conclusion, addition of ranolazine to standard amiodarone therapy is equally safe and appears to be more effective compared to amiodarone alone for conversion of recent-onset AF.
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Affiliation(s)
- Nikolaos Fragakis
- 3rd Cardiology Department, Hippokrateion Hospital, Aristotle University Medical School, Thessaloniki, Greece
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Frommeyer G, Kaiser D, Uphaus T, Kaese S, Osada N, Rajamani S, Belardinelli L, Breithardt G, Eckardt L, Milberg P. Effect of ranolazine on ventricular repolarization in class III antiarrhythmic drug-treated rabbits. Heart Rhythm 2012; 9:2051-8. [PMID: 23044390 DOI: 10.1016/j.hrthm.2012.08.029] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ranolazine exhibits a synergistic effect in combination with class III drugs to suppress atrial fibrillation. OBJECTIVE To investigate whether a combination therapy affects repolarization and provokes ventricular tachyarrhythmias (VT) in a sensitive model of proarrhythmia. METHODS Thirty-seven rabbits were assigned to 3 groups and fed with amiodarone (50 mg/kg/d; n = 10) or dronedarone (50 mg/kg/d; n = 10) over a period of 6 weeks. A third group was used as control (n = 17). After obtaining baseline data in Langendorff-perfused control hearts, sotalol (100 μM) was administered in this group. Thereafter, ranolazine (10 μM) was additionally infused on top of amiodarone, dronedarone, or sotalol. RESULTS Chronic treatment with amiodarone or dronedarone as well as sotalol significantly increased action potential duration at 90% repolarization (APD(90)). Additional treatment with ranolazine further increased APD(90) in amiodarone- and dronedarone-pretreated hearts but not in sotalol-treated hearts. Ranolazine increased postrepolarization refractoriness as compared with amiodarone or dronedarone alone owing to a marked effect on the refractory period. In contrast to amiodarone and dronedarone, acute application of sotalol increased dispersion of repolarization (P < .05). Additional treatment with ranolazine did not further increase spatial or temporal dispersion. After lowering extracellular [K(+)] in bradycardic hearts, no proarrhythmia occurred in amiodarone- or dronedarone-treated hearts whereas 11 of 17 sotalol-treated hearts showed early afterdepolarizations and subsequent polymorphic VT. Additional treatment with ranolazine reduced the number of VT episodes in sotalol-treated hearts and did not cause proarrhythmia in combination with amiodarone or dronedarone. CONCLUSIONS Application of ranolazine on top of class III drugs does not cause proarrhythmia despite a marked effect on ventricular repolarization. The effect of ranolazine on the repolarization reserve is associated with the lack of effect on early afterdepolarizations and dispersion of repolarization.
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Affiliation(s)
- Gerrit Frommeyer
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
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Tzeis S, Andrikopoulos G. Antiarrhythmic properties of ranolazine – from bench to bedside. Expert Opin Investig Drugs 2012; 21:1733-41. [DOI: 10.1517/13543784.2012.716826] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Long-term nerve excitability changes by persistent Na+ current blocker ranolazine. Neurosci Lett 2012; 524:101-6. [PMID: 22824305 DOI: 10.1016/j.neulet.2012.07.010] [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] [Revised: 07/04/2012] [Accepted: 07/08/2012] [Indexed: 01/23/2023]
Abstract
The persistent Na(+) current (Na(p)) in peripheral axons plays an important functional role in controlling the axonal excitability. Abnormal Na(p) is believed to contribute to neurodegeneration and neuropathic pain, and thus it is an attractive therapeutic target. To assess the chronic behavior of selective Na(p) blockade, axonal excitability testing was performed in vivo in normal male mice exposed to ranolazine by recording the tail sensory nerve action potentials (SNAPs). Seven days after administering ranolazine i.p. (50mg/kg) daily for 1 week, nerve excitability testing showed decreased strength-duration time constant in the ranolazine group in comparison to the control (P<0.03). This change is explained by the long-term effects of ranolazine on Na(p). Importantly, ranolazine showed no effect on other ion channels that influence axonal excitability. Further study is needed to assess the chronic Na(p) blockade as a useful therapy in peripheral nerve diseases associated with abnormal nerve excitability.
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Management of Patients With Refractory Angina: Canadian Cardiovascular Society/Canadian Pain Society Joint Guidelines. Can J Cardiol 2012; 28:S20-41. [DOI: 10.1016/j.cjca.2011.07.007] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 07/21/2011] [Accepted: 07/21/2011] [Indexed: 11/24/2022] Open
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Moreno JD, Clancy CE. Pathophysiology of the cardiac late Na current and its potential as a drug target. J Mol Cell Cardiol 2011; 52:608-19. [PMID: 22198344 DOI: 10.1016/j.yjmcc.2011.12.003] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 11/30/2011] [Accepted: 12/07/2011] [Indexed: 12/19/2022]
Abstract
A pathological increase in the late component of the cardiac Na(+) current, I(NaL), has been linked to disease manifestation in inherited and acquired cardiac diseases including the long QT variant 3 (LQT3) syndrome and heart failure. Disruption in I(NaL) leads to action potential prolongation, disruption of normal cellular repolarization, development of arrhythmia triggers, and propensity to ventricular arrhythmia. Attempts to treat arrhythmogenic sequelae from inherited and acquired syndromes pharmacologically with common Na(+) channel blockers (e.g. flecainide, lidocaine, and amiodarone) have been largely unsuccessful. This is due to drug toxicity and the failure of most current drugs to discriminate between the peak current component, chiefly responsible for single cell excitability and propagation in coupled tissue, and the late component (I(NaL)) of the Na(+) current. Although small in magnitude as compared to the peak Na(+) current (~1-3%), I(NaL) alters action potential properties and increases Na(+) loading in cardiac cells. With the increasing recognition that multiple cardiac pathological conditions share phenotypic manifestations of I(NaL) upregulation, there has been renewed interest in specific pharmacological inhibition of I(Na). The novel antianginal agent ranolazine, which shows a marked selectivity for late versus peak Na(+) current, may represent a novel drug archetype for targeted reduction of I(NaL). This article aims to review common pathophysiological mechanisms leading to enhanced I(NaL) in LQT3 and heart failure as prototypical disease conditions. Also reviewed are promising therapeutic strategies tailored to alter the molecular mechanisms underlying I(Na) mediated arrhythmia triggers.
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Affiliation(s)
- Jonathan D Moreno
- Tri-Institutional MD-PhD Program, Weill Cornell Medical College/The Rockefeller University/Sloan-Kettering Cancer Institute, New York, NY 10021, USA
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