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Pavsic N, Zbacnik R, Berden P, Kacar P, Dolenc J, Stalc M, Salobir BG, Prokselj K. The association between myocardial ischemia and myocardial dysfunction in adult patients with systemic right ventricle - A single centre multimodality study. Int J Cardiol 2023:S0167-5273(23)00574-0. [PMID: 37087053 DOI: 10.1016/j.ijcard.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 03/10/2023] [Accepted: 04/14/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND The exact interaction of factors leading to myocardial dysfunction and fibrosis of the systemic right ventricle (SRV) is not completely understood. Myocardial ischemia and injury associated with a supply-demand mismatch of the pressure overloaded SRV are thought to play an important role, however studies confirming this are lacking. METHODS Adult SRV patients were included in this single centre cohort study. All patients underwent a comprehensive diagnostic and imaging workup. A two-day stress-rest SPECT was performed to assess myocardial perfusion. SRV ischemia was defined as decreased segmental tracer uptake during exercise with significant improvement at rest. Contrast enhanced cardiac magnetic resonance imaging (CMR) was also performed in a subgroup of patients without contraindication, to assess focal myocardial fibrosis. Differences between patients with and without SRV ischemia were assessed. RESULTS Twenty-three SRV patients (15 with transposition of the great arteries after atrial switch procedure and 8 with congenitally corrected transposition of the great arteries; 5 (22%) females; mean age 38 ± 11 years) were included. Seven (30%) patients had SRV ischemia on SPECT. Late gadolinium enhancement on CMR was more common in patients with SRV ischemia (p = 0.002). However, there was no association between SRV ischemia and different echocardiographic or CMR parameters of SRV systolic function, laboratory markers (high-sensitivity troponin I and NT-proBNP) and exercise capacity. CONCLUSIONS Our multimodality study showed that SRV ischemia in adult SRV patients was associated with more focal myocardial fibrosis, but not with functional or imaging markers of SRV function.
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Affiliation(s)
- Nejc Pavsic
- Department of Cardiology, University Medical Center Ljubljana, Zaloska cesta 7, 1525 Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia.
| | - Rok Zbacnik
- Institute of Radiology, University Medical Centre Ljubljana, Zaloska 7, 1525 Ljubljana, Slovenia
| | - Pavel Berden
- Institute of Radiology, University Medical Centre Ljubljana, Zaloska 7, 1525 Ljubljana, Slovenia
| | - Polona Kacar
- Department of Cardiology, University Medical Center Ljubljana, Zaloska cesta 7, 1525 Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Jure Dolenc
- Department of Cardiology, University Medical Center Ljubljana, Zaloska cesta 7, 1525 Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
| | - Monika Stalc
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia; Department of Nuclear Medicine, University Medical Centre Ljubljana, Zaloska 7, 1525 Ljubljana, Slovenia
| | - Barbara Guzic Salobir
- Department of Nuclear Medicine, University Medical Centre Ljubljana, Zaloska 7, 1525 Ljubljana, Slovenia
| | - Katja Prokselj
- Department of Cardiology, University Medical Center Ljubljana, Zaloska cesta 7, 1525 Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia
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2
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Minotti G, Menna P, Camilli M, Salvatorelli E, Levi R. Beyond hypertension: Diastolic dysfunction associated with cancer treatment in the era of cardio-oncology. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2022; 94:365-409. [PMID: 35659376 DOI: 10.1016/bs.apha.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Cancer patients are at an increased risk of cardiovascular events. Both old-generation cytostatics/cytotoxics and new-generation "targeted" drugs can in fact damage cardiomyocytes, endothelial cells of veins and arteries, specialized cells of the conduction system, pericardium, and valves. A new discipline, cardio-oncology, has therefore developed with the aim of protecting cancer patients from cardiovascular events, while also providing them with the best possible oncologic treatment. Anthracyclines have long been known to elicit cardiotoxicity that, depending on treatment- or patient-related factors, may progress with a variable velocity toward cardiomyopathy and systolic heart failure. However, early compromise of diastolic function may precede systolic dysfunction, and a progression of early diastolic dysfunction to diastolic rather than systolic heart failure has been documented in long-term cancer survivors. This chapter first describes general notions about hypertension in the cancer patient and then moves on reviewing the pathophysiology and clinical trajectories of diastolic dysfunction, and the molecular mechanisms of anthracycline-induced diastolic dysfunction. Diastolic dysfunction can in fact be caused and/or aggravated by hypertension. Pharmacologic foundations and therapeutic opportunities to prevent or treat diastolic dysfunction before it progresses toward heart failure are also reviewed, with a special emphasis on the mechanisms of action of drugs that raised hopes to treat diastolic dysfunction in the general population (sacubitril/valsartan, guanylyl cyclase activators, phosphodiesterase inhibitors, ranolazine, inhibitors of type-2 sodium-glucose-inked transporter). Cardio-oncologists will be confronted with the risk:benefit ratio of using these drugs in the cancer patient.
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Affiliation(s)
- Giorgio Minotti
- Department of Medicine, Campus Bio-Medico University and Fondazione Policlinico, Rome, Italy.
| | - Pierantonio Menna
- Department of Health Sciences, Campus Bio-Medico University and Fondazione Policlinico, Rome, Italy
| | - Massimiliano Camilli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome
| | - Emanuela Salvatorelli
- Department of Medicine, Campus Bio-Medico University and Fondazione Policlinico, Rome, Italy
| | - Roberto Levi
- Department of Pharmacology, Weill Cornell Medicine, New York, NY, United States
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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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Abouelnour A, Gori T. Vasomotor Dysfunction in Patients with Ischemia and Non-Obstructive Coronary Artery Disease: Current Diagnostic and Therapeutic Strategies. Biomedicines 2021; 9:biomedicines9121774. [PMID: 34944590 PMCID: PMC8698648 DOI: 10.3390/biomedicines9121774] [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] [Received: 10/14/2021] [Revised: 11/15/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022] Open
Abstract
Many patients who present with symptoms or objective evidence of ischemia have no or non-physiologically-significant disease on invasive coronary angiography. The diagnosis of ischemic heart disease is thus often dismissed, and patients receive false reassurance or other diagnoses are pursued. We now know that a significant proportion of these patients have coronary microvascular dysfunction and/or vasospastic disease as the underlying pathophysiology of their clinical presentation. Making the correct diagnosis of such abnormalities is important not only because they impact the quality of life, with recurring symptoms and unnecessary repeated testing, but also because they increase the risk for adverse cardiovascular events. The mainstay of diagnosis remains an invasive comprehensive physiologic assessment, which further allows stratifying these patients into appropriate “endotypes”. It has been shown that tailoring treatment to the patient’s assigned endotype improves symptoms and quality of life. In addition to the conventional drugs used in chronic stable angina, multiple newer agents are being investigated. Moreover, innovative non-pharmacologic and interventional therapies are emerging to provide a bail-out in refractory cases. Many of these novel therapies fail to show consistent benefits, but others show quite promising results.
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Affiliation(s)
- Amr Abouelnour
- Zentrum für Kardiologie, Kardiologie I, und Deutsches Zentrum für Herz und Kreislauf Forschung, University Medical Center Mainz, 55131 Standort Rhein-Main, Germany;
- Cardiovascular Institute, Assiut University, Assiut 71515, Egypt
| | - Tommaso Gori
- Zentrum für Kardiologie, Kardiologie I, und Deutsches Zentrum für Herz und Kreislauf Forschung, University Medical Center Mainz, 55131 Standort Rhein-Main, Germany;
- Correspondence:
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Abstract
BACKGROUND Ranolazine is approved in the United States and Europe for chronic stable angina. Microvascular angina (MVA) is defined as angina with no obstructive coronary artery disease. STUDY QUESTION Our objective was to assess the effectiveness of ranolazine at improving angina scores and quality of life in a Canadian cohort with severe refractory angina due to MVA. STUDY DESIGN We administered questionnaires to 31 patients at baseline and after at least 6 weeks of ranolazine treatment. MEASURES AND OUTCOMES Validated, clinically significant changes for each Seattle Angina Questionnaire domain and the Quality of Life Enjoyment and Satisfaction Questionnaire Short Form were obtained from the literature. Score changes between baseline and postranolazine use were analyzed using sign test. RESULTS Patients were mostly female (27 of 31 patients) with a median age of 57 years. After initiation of ranolazine treatment, patients experienced improvements in Quality of Life Enjoyment and Satisfaction Questionnaire Short Form scores (80.6%; P < 0.01) and in 3 of the 4 domains of the Seattle Angina Questionnaire (physical limitation: 73.3%; P = 0.02; treatment satisfaction: 80.6%; P < 0.01; and disease perception: 77.4%; P < 0.01). Patients were less likely to have interactions with the health care system after ranolazine treatment as compared with before (35.5% vs. 93.5%; P < 0.01). CONCLUSIONS Ranolazine significantly improves symptom control and quality of life in patients with MVA and severe refractory angina and reduces their interaction with the health care system. Given the potentially debilitating effect of chronic angina in MVA, ranolazine may be an effective treatment option.
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Minotti G, Menna P, Calabrese V, Greco C, Armento G, Annibali O, Marchesi F, Salvatorelli E, Reggiardo G. Pharmacology of Ranolazine versus Common Cardiovascular Drugs in Patients with Early Diastolic Dysfunction Induced by Anthracyclines or Nonanthracycline Chemotherapeutics: A Phase 2b Minitrial. J Pharmacol Exp Ther 2019; 370:197-205. [PMID: 31101682 DOI: 10.1124/jpet.119.258178] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/15/2019] [Indexed: 12/12/2022] Open
Abstract
We have reported that anthracyclines and nonanthracycline chemotherapeutics caused diastolic dysfunction in cancer patients without cardiovascular risk factors. Diastolic dysfunction occurred as early as 1 week after the last chemotherapy cycle and manifested as impaired myocardial relaxation at echocardiography or persistent elevations of B-type natriuretic peptide (BNP) or troponin. The antianginal drug ranolazine shows cardiac relaxant effects that we considered of value to treat early diastolic dysfunction induced by cancer drugs; therefore, 24 low-risk patients with post-chemotherapy diastolic dysfunction were randomized (1:1) to ranolazine or the investigator's choice of common cardiovascular drugs, such as β-blockers and/or angiotensin-converting enzyme inhibitors or loop diuretics (best standard therapy, BST). After 5 weeks, 12 of 12 patients on ranolazine recovered from diastolic dysfunction, whereas 3 of 12 patients on BST did not improve; however, adverse events (not serious) were apparently more frequent for ranolazine than for BST (4/12 vs. 1/12). Ranolazine did not lower blood pressure, whereas BST reduced systolic pressure and caused a trend toward a reduced diastolic pressure. Most patients at randomization showed tachycardia resulting from chemotherapy-related anemia. Hemoglobin recovery contributed to normalizing heart rate in these patients; however, some patients in the ranolazine arm developed tachycardia through chronotropic effects of high BNP levels and returned to a normal heart rate through the effects of ranolazine on decreasing BNP levels. This minitrial describes the potential effects of ranolazine on relieving chemotherapy-related diastolic dysfunction; however, clinical implications of these findings need to be characterized by studies with an adequate sample size. SIGNIFICANCE STATEMENT: The antianginal drug ranolazine causes cardiac relaxant effects that might relieve diastolic dysfunction. In a clinical pharmacology study, 24 patients were randomized (1:1) to receive ranolazine or common cardiovascular drugs to treat early diastolic dysfunction induced by anthracycline-based or nonanthracycline chemotherapy. Ranolazine relieved diastolic dysfunction in these patients. The safety profile of ranolazine in cancer patients is similar to that of the general population. Compared with common cardiovascular drugs, ranolazine relieved diastolic dysfunction without lowering blood pressure. The sample size of this study was nonetheless too small to permit considerations about the potential clinical value of ranolazine for oncologic patients with early diastolic dysfunction induced by anthracyclines or nonanthracycline chemotherapeutics. This information should be obtained by studies with an adequate sample size.
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Affiliation(s)
- Giorgio Minotti
- Clinical Pharmacology Unit (G.M., P.M.) and Cardio Center (V.C.), Campus Bio-Medico University Hospital, Rome; Units of Drug Sciences (G.M., E.S.), Radiation Oncology (C.G.), Oncology (G.A.), and Hematology (O.A.), Department of Medicine and Center for Integrated Research, University Campus Bio-Medico, Rome; Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome (F.M.); and Mediservice S.r.l., Agrate Brianza (Monza) (G.R.), Italy
| | - Pierantonio Menna
- Clinical Pharmacology Unit (G.M., P.M.) and Cardio Center (V.C.), Campus Bio-Medico University Hospital, Rome; Units of Drug Sciences (G.M., E.S.), Radiation Oncology (C.G.), Oncology (G.A.), and Hematology (O.A.), Department of Medicine and Center for Integrated Research, University Campus Bio-Medico, Rome; Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome (F.M.); and Mediservice S.r.l., Agrate Brianza (Monza) (G.R.), Italy
| | - Vito Calabrese
- Clinical Pharmacology Unit (G.M., P.M.) and Cardio Center (V.C.), Campus Bio-Medico University Hospital, Rome; Units of Drug Sciences (G.M., E.S.), Radiation Oncology (C.G.), Oncology (G.A.), and Hematology (O.A.), Department of Medicine and Center for Integrated Research, University Campus Bio-Medico, Rome; Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome (F.M.); and Mediservice S.r.l., Agrate Brianza (Monza) (G.R.), Italy
| | - Carlo Greco
- Clinical Pharmacology Unit (G.M., P.M.) and Cardio Center (V.C.), Campus Bio-Medico University Hospital, Rome; Units of Drug Sciences (G.M., E.S.), Radiation Oncology (C.G.), Oncology (G.A.), and Hematology (O.A.), Department of Medicine and Center for Integrated Research, University Campus Bio-Medico, Rome; Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome (F.M.); and Mediservice S.r.l., Agrate Brianza (Monza) (G.R.), Italy
| | - Grazia Armento
- Clinical Pharmacology Unit (G.M., P.M.) and Cardio Center (V.C.), Campus Bio-Medico University Hospital, Rome; Units of Drug Sciences (G.M., E.S.), Radiation Oncology (C.G.), Oncology (G.A.), and Hematology (O.A.), Department of Medicine and Center for Integrated Research, University Campus Bio-Medico, Rome; Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome (F.M.); and Mediservice S.r.l., Agrate Brianza (Monza) (G.R.), Italy
| | - Ombretta Annibali
- Clinical Pharmacology Unit (G.M., P.M.) and Cardio Center (V.C.), Campus Bio-Medico University Hospital, Rome; Units of Drug Sciences (G.M., E.S.), Radiation Oncology (C.G.), Oncology (G.A.), and Hematology (O.A.), Department of Medicine and Center for Integrated Research, University Campus Bio-Medico, Rome; Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome (F.M.); and Mediservice S.r.l., Agrate Brianza (Monza) (G.R.), Italy
| | - Francesco Marchesi
- Clinical Pharmacology Unit (G.M., P.M.) and Cardio Center (V.C.), Campus Bio-Medico University Hospital, Rome; Units of Drug Sciences (G.M., E.S.), Radiation Oncology (C.G.), Oncology (G.A.), and Hematology (O.A.), Department of Medicine and Center for Integrated Research, University Campus Bio-Medico, Rome; Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome (F.M.); and Mediservice S.r.l., Agrate Brianza (Monza) (G.R.), Italy
| | - Emanuela Salvatorelli
- Clinical Pharmacology Unit (G.M., P.M.) and Cardio Center (V.C.), Campus Bio-Medico University Hospital, Rome; Units of Drug Sciences (G.M., E.S.), Radiation Oncology (C.G.), Oncology (G.A.), and Hematology (O.A.), Department of Medicine and Center for Integrated Research, University Campus Bio-Medico, Rome; Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome (F.M.); and Mediservice S.r.l., Agrate Brianza (Monza) (G.R.), Italy
| | - Giorgio Reggiardo
- Clinical Pharmacology Unit (G.M., P.M.) and Cardio Center (V.C.), Campus Bio-Medico University Hospital, Rome; Units of Drug Sciences (G.M., E.S.), Radiation Oncology (C.G.), Oncology (G.A.), and Hematology (O.A.), Department of Medicine and Center for Integrated Research, University Campus Bio-Medico, Rome; Hematology and Stem Cell Transplant Unit, IRCCS Regina Elena National Cancer Institute, Rome (F.M.); and Mediservice S.r.l., Agrate Brianza (Monza) (G.R.), Italy
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Schwemer TF, Deutscher N, Diermann N, Böger R, Schwedhelm E, Blankenberg S, Friedrich FW. Effect of ranolazine on plasma arginine derivatives and urinary isoprostane 8-iso-PGF 2α in patients with myocardial infarction in the randomized RIMINI-Trial. Sci Rep 2019; 9:5708. [PMID: 30952941 PMCID: PMC6450888 DOI: 10.1038/s41598-019-42239-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 03/13/2019] [Indexed: 12/20/2022] Open
Abstract
The purpose of the present study was to assess whether 6-week ranolazine application on top of guideline-based treatment impacts on the arginine/NO pathway and urinary isoprostane 8-iso-PGF2α as marker of oxidative stress in patients directly after a myocardial infarction. 20 patients with unstable angina pectoris and proof of acute cardiac ischemia entered the study. 10 subjects received the study drug ranolazine in addition to standard treatment, the others received only standard treatment. Urine and venous blood were collected before and after treatment. At the end of the study and compared to baseline, homoarginine levels had increased in the control group. This was not the case in ranolazine-patients. Interestingly, in ranolazine-treated-patients arginine plasma levels were significantly higher at the end of the study than at baseline (difference +26 µmol/L, 95% CI 8.6 to 44 µmol/L). ADMA and SDMA levels were not different. Urine levels of the oxidative stress marker 8-iso-PGF2α tended to be lower in ranolazine-treated patients (−144 pmol/mg creatinine). Findings of this hypothesis-driven study give evidence that ranolazine treatment enhances arginine plasma levels and lowers oxidative stress.
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Affiliation(s)
| | | | | | - Rainer Böger
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Edzard Schwedhelm
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,Institute of Clinical Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.,University Heart Center Hamburg, Hamburg, Germany
| | - Felix W Friedrich
- Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. .,Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. .,DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Hamburg, Germany.
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Schwemer TF, Radziwolek L, Deutscher N, Diermann N, Sehner S, Blankenberg S, Friedrich FW. Effect of Ranolazine on Ischemic Myocardium IN Patients With Acute Cardiac Ischemia (RIMINI-Trial): A Randomized Controlled Pilot Trial. J Cardiovasc Pharmacol Ther 2018; 24:62-69. [PMID: 29938533 DOI: 10.1177/1074248418784290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Coronary artery disease is the most prevalent manifestation among cardiovascular diseases. Despite modern treatment, risk of ischemic complications in patients with acute coronary syndrome (ACS) remains important. The late Na+ current blocker ranolazine has shown to reduce the risk of recurrent ischemia and worsening of angina in patients with non-ST-segment elevation ACS by possibly improving myocardial perfusion, but up to now no trial has addressed whether this enhanced perfusion also leads to a decrease in ischemic myocardium of patients with ACS. We designed a pilot trial (Reduction of Ischemic Myocardium with Ranolazine-Treatment IN patients with acute myocardial Infarction, ClinicalTrials.gov Identifier: NCT01797484) for feasibility and proof of concept that a 6-week ranolazine add-on therapy would reduce the area of ischemic myocardium in patients with ACS. METHODS AND RESULTS The trial was designed in a 2-armed, controlled and randomized way. Twenty participants with unstable angina, proof of acute cardiac ischemia, and myocardial dyskinesia by speckle-tracking echocardiography were included. Ten participants received the study drug ranolazine additionally to standard treatment. The control group received standard treatment without additional study medication. Speckle-tracking echocardiography was performed before coronary intervention, before the first dose of ranolazine, and after 6 weeks of ranolazine treatment. Ranolazine was administered safely during acute myocardial infarction. Speckle-tracking echocardiography proved to be suitable for evaluation of myocardial dyskinesia. Patients receiving ranolazine showed a trend to higher normal fraction of the cumulative global strain than patients in the standard treatment group (15% vs 11%). No major complications relating study medication were observed. CONCLUSION In conclusion, in this preliminary hypothesis-driven study, 6-week ranolazine therapy was shown to decrease the area of dyskinetic myocardium in patients with ACS by trend. Global strain rate measurement using speckle-tracking echocardiography can be applied measuring those effects and is, compared to other techniques, safe and harmless. Our data provide a sound basis for a follow-up trial.
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Affiliation(s)
- Tjark F Schwemer
- 1 Department for General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Lukas Radziwolek
- 1 Department for General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Navina Deutscher
- 1 Department for General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Nadine Diermann
- 1 Department for General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Susanne Sehner
- 2 Department of Medical Biometry and Epidemiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- 1 Department for General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany.,3 Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,4 DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Felix W Friedrich
- 3 Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,4 DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany.,5 Institute of Experimental Pharmacology and Toxicology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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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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Ferrari R, Camici PG, Crea F, Danchin N, Fox K, Maggioni AP, Manolis AJ, Marzilli M, Rosano GMC, Lopez-Sendon JL. A 'diamond' approach to personalized treatment of angina. Nat Rev Cardiol 2017; 15:120-132. [DOI: 10.1038/nrcardio.2017.131] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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11
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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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12
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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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13
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Affiliation(s)
| | - Tara Sedlak
- University of British Columbia, Vancouver, British Columbia, Canada
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14
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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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15
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Singh A, Steadman CD, Khan JN, Reggiardo G, McCann GP. Effect of late sodium current inhibition on MRI measured diastolic dysfunction in aortic stenosis: a pilot study. BMC Res Notes 2016; 9:64. [PMID: 26847571 PMCID: PMC4743087 DOI: 10.1186/s13104-016-1874-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Accepted: 01/19/2016] [Indexed: 12/19/2022] Open
Abstract
Background Ranolazine is a new anti-anginal drug that acts via late sodium current inhibition, and has been shown to improve diastolic dysfunction in isolated myocytes.
Diastolic dysfuntion is common in patients with aortic stenosis (AS), and precedes symptom development and systolic dysfunction. The purpose of this study was to assess the effects of ranolazine on peak early diastolic strain rate (PEDSR) and exercise capacity in patients with AS. Methods Patients with asymptomatic moderate to severe AS and diastolic dysfunction underwent trans-thoracic echocardiography, exercise testing and cardiac magnetic resonance (CMR) imaging at baseline, 6 weeks after commencing ranolazine and at 10 weeks (4 weeks after discontinuation). Diastolic function was assessed using PEDSR measured on tagged CMR images. Results Fifteen patients (peak pressure gradient 48.8 ± 12.4 mmHg, mean pressure gradient 27.1 ± 7.5 mmHg, aortic valve area 1.26 ± 0.31 cm2) completed the week-6 visit and 13 completed the final visit. Global PEDSR did not significantly increase from baseline (0.79 ± 0.15) to week-6 (0.86 ± 0.18, p = 0.198). There was a borderline significant increase in total exercise duration from 10.47 ± 3.68 min to 11.60 ± 3.25 min (p = 0.06). Conclusion This small pilot study did not show a significant improvement in diastolic function with the use of ranolazine in asymptomatic patients with moderate-severe AS. Further studies with a larger population may be indicated. EduraCT number 2011-000111-26 Electronic supplementary material The online version of this article (doi:10.1186/s13104-016-1874-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anvesha Singh
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK.
| | | | - Jamal N Khan
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK.
| | | | - Gerry P McCann
- Department of Cardiovascular Sciences, University of Leicester and NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK.
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El-Hajj S, AlJaroudi WA, Farag A, Bleich S, Manaoragada P, Iskandrian AE, Hage FG. Effect of changes in perfusion defect size during serial regadenoson myocardial perfusion imaging on cardiovascular outcomes in high-risk patients. J Nucl Cardiol 2016; 23:101-12. [PMID: 26017713 DOI: 10.1007/s12350-015-0174-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 04/30/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND The prognostic value of single-photon emission computed tomography myocardial perfusion imaging (MPI) is well established. There is a paucity of data on the prognostic value of changes in perfusion defect size (PDS) on serial MPIs. METHODS From the MPI database at the University of Alabama at Birmingham, consecutive patients who underwent two regadenoson stress MPIs between July 2008 and March 2013 were identified. The MPIs were analyzed side-by-side using an automated software program for presence and change in PDS. Improvement in PDS was defined as a reduction ≥5% of left ventricle. A drop in left ventricular ejection fraction (LVEF) was defined as a decrease ≥5%. The primary outcome was a composite of death, myocardial infarction (MI), and coronary revascularization (CR). RESULTS There were 698 patients (61 ± 11 years, 53% male, 48% diabetes, 25% prior MI, 49% prior CR) who underwent two regadenoson MPIs within 16 ± 9 months for clinical indications. The primary outcome occurred in 167 (24%) patients (8% death, 9% MI, 15% CR) during 24 ± 16 months of follow-up after the second MPI. The MPIs were normal in both studies in 399 (57%, Group 1), showed improvement in 94 (14%, Group 2, PDS 15% ± 16% vs 28% ± 18%, P < .001) and no change or worsening in 205 patients (29%, Group 3, 28% ± 17% vs 20% ± 17%, P < .001). The best outcomes were seen in Group 1 and the worst in Group 3 (log-rank P < .001). Similar trends were seen for the components of the primary outcome (P = .04 for death, P < .001 for MI, P < .001 for CR). In a Cox-regression model that adjusted for baseline factors including PDS and LVEF on initial MPI, the hazard ratios for primary outcome were 2.0 (P = .02) and 3.9 (P < .001) for Groups 2 and 3 compared to Group 1, respectively. In addition, an LVEF drop ≥5% was independently associated with the primary outcome (HR 1.5, P = .01). CONCLUSION Changes in PDS and LVEF on serial MPIs provide incremental prognostic information to initial and follow-up MPI findings. Lack of improvement or an increase in PDS and a drop in LVEF identify high-risk patients.
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Affiliation(s)
- Stephanie El-Hajj
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Wael A AlJaroudi
- Division of Cardiovascular Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ayman Farag
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Steven Bleich
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Padma Manaoragada
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Ami E Iskandrian
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA
| | - Fadi G Hage
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Lyons Harrison Research Building 314, 1900 University BLVD, Birmingham, AL, 35294, USA.
- Section of Cardiology, Birmingham Veterans Administration Medical Center, Birmingham, AL, USA.
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Gomberg-Maitland M, Schilz R, Mediratta A, Addetia K, Coslet S, Thomeas V, Gillies H, Oudiz RJ. Phase I safety study of ranolazine in pulmonary arterial hypertension. Pulm Circ 2015; 5:691-700. [PMID: 26697176 DOI: 10.1086/683813] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
UNLABELLED Pulmonary arterial hypertension (PAH) causes right ventricular ischemia, dysfunction, and failure. PAH patients may benefit from antianginal agents based on a shared pathophysiology with left ventricular ischemia. A single-center, randomized, placebo-controlled trial (1∶1) to assess the acute vasoreactivity and safety of ranolazine in PAH was conducted. Plasma samples for pharmacokinetic (PK) studies were drawn during hemodynamic measurements at 0, 60, 90, 120, 240, and 360 minutes from a Swan-Ganz catheter. All patients received 500-mg doses, uptitrated to 1,000 mg at week 4, monthly evaluations, and a complete objective assessment after 12 weeks, followed by an open-label extension. Thirteen patients were randomized and 12 enrolled (6 ranolazine, 6 placebo). All patients completed the acute phase; 10 completed the 12-week study. There were no acute changes in invasive hemodynamics. At 12 weeks ranolazine was well tolerated. Only 1 of the 5 patients on ranolazine had a serum concentration considered to be in the therapeutic range. Two serious adverse events required early withdrawal (both in the ranolazine group); gastrointestinal complaints were the most common adverse event. Efficacy measures did not demonstrate any differences between treatment groups. During the open-label trial, 2 additional patients reached a therapeutic concentration. Ranolazine in PAH appears safe, without acute hemodynamic effects after a 500-mg dose. Ranolazine administrated to PAH patients receiving background PAH therapies did not consistently reach therapeutic levels. Future studies should first perform PK analysis in PAH patients receiving PAH therapies and explore the safety and tolerability of the higher doses perhaps necessary to achieve therapeutic levels in PAH patients. ( TRIAL REGISTRATION Clinicaltrials.gov identifier NCT01757808.).
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Affiliation(s)
- Mardi Gomberg-Maitland
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA ; Committee on Clinical Pharmacology and Pharmacogenomics, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Robert Schilz
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, School of Medicine, Case Western University, Cleveland, Ohio, USA
| | - Anuj Mediratta
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Karima Addetia
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Sandra Coslet
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Vasiliki Thomeas
- Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois, USA ; Committee on Clinical Pharmacology and Pharmacogenomics, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | | | - Ronald J Oudiz
- Division of Cardiology, Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA
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Antagonism of Nav channels and α1-adrenergic receptors contributes to vascular smooth muscle effects of ranolazine. Sci Rep 2015; 5:17969. [PMID: 26655634 PMCID: PMC4674695 DOI: 10.1038/srep17969] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 11/10/2015] [Indexed: 12/19/2022] Open
Abstract
Ranolazine is a recently developed drug used for the treatment of patients with chronic stable angina. It is a selective inhibitor of the persistent cardiac Na+ current (INa), and is known to reduce the Na+-dependent Ca2+ overload that occurs in cardiomyocytes during ischemia. Vascular effects of ranolazine, such as vasorelaxation,have been reported and may involve multiple pathways. As voltage-gated Na+ channels (Nav) present in arteries play a role in contraction, we hypothesized that ranolazine could target these channels. We studied the effects of ranolazine in vitro on cultured aortic smooth muscle cells (SMC) and ex vivo on rat aortas in conditions known to specifically activate or promote INa. We observed that in the presence of the Nav channel agonist veratridine, ranolazine inhibited INa and intracellular Ca2+ calcium increase in SMC, and arterial vasoconstriction. In arterial SMC, ranolazine inhibited the activity of tetrodotoxin-sensitive voltage-gated Nav channels and thus antagonized contraction promoted by low KCl depolarization. Furthermore, the vasorelaxant effects of ranolazine, also observed in human arteries and independent of the endothelium, involved antagonization of the α1-adrenergic receptor. Combined α1-adrenergic antagonization and inhibition of SMCs Nav channels could be involved in the vascular effects of ranolazine.
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Lo YC, Tseng YT, Liu CM, Wu BN, Wu SN. Actions of KMUP-1, a xanthine and piperazine derivative, on voltage-gated Na(+) and Ca(2+) -activated K(+) currents in GH3 pituitary tumour cells. Br J Pharmacol 2015; 172:5110-22. [PMID: 26276211 DOI: 10.1111/bph.13276] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/06/2015] [Accepted: 08/07/2015] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND PURPOSE 7-[2-[4-(2-Chlorophenyl)piperazinyl]ethyl]-1,3-dimethylxanthine (KMUP-1) is a xanthine-based derivative. It has soluble GC activation and K(+) -channel opening activity. Effects of this compound on ion currents in pituitary GH3 cells were investigated in this study. EXPERIMENTAL APPROACH The aim of this study was to evaluate effects of KMUP-1 on the amplitude and gating of voltage-gated Na(+) current (INa ) in pituitary GH3 cells and in HEKT293T cells expressing SCN5A. Both the amplitude of Ca(2+) -activated K(+) current and the activity of large-conductance Ca(2+) -activated K(+) (BKCa ) channels were also studied. KEY RESULTS KMUP-1 depressed the transient and late components of INa with different potencies. The IC50 values required for its inhibitory effect on transient and late INa were 22.5 and 1.8 μM respectively. KMUP-1 (3 μM) shifted the steady-state inactivation of INa to a hyperpolarized potential by -10 mV, despite inability to alter the recovery of INa from inactivation. In cell-attached configuration, KMUP-1 applied to bath increased BKCa -channel activity; however, in inside-out patches, this compound applied to the intracellular surface had no effect on it. It prolonged the latency in the generation of action currents elicited by triangular voltage ramps. Additionally, KMUP-1 decreased the peak INa with a concomitant increase of current inactivation in HEKT293T cells expressing SCN5A. CONCLUSIONS AND IMPLICATIONS Apart from activating BKCa channels, KMUP-1 preferentially suppresses late INa . The effects of KUMP-1 on ion currents presented here constitute an underlying ionic mechanism of its actions.
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Affiliation(s)
- Yi-Ching Lo
- Department of Pharmacology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Natural Products, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yu-Ting Tseng
- Department of Pharmacology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Graduate Institute of Natural Products, College of Pharmacy, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chi-Ming Liu
- Department of Nursing, Tzu Hui Institute of Technology, Pingtung, Taiwan
| | - Bin-Nan Wu
- Department of Pharmacology, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Sheng-Nan Wu
- Department of Physiology, National Cheng Kung University Medical College, Tainan, Taiwan.,Institute of Basic Medical Sciences, National Cheng Kung University Medical College, Tainan, Taiwan
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20
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Shockwave therapy for refractory angina: promising but not definitive. Coron Artery Dis 2015; 26:189-91. [PMID: 25837648 DOI: 10.1097/mca.0000000000000228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Serial myocardial perfusion imaging: defining a significant change and targeting management decisions. JACC Cardiovasc Imaging 2015; 7:79-96. [PMID: 24433711 DOI: 10.1016/j.jcmg.2013.05.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 05/20/2013] [Accepted: 05/30/2013] [Indexed: 12/22/2022]
Abstract
Myocardial perfusion imaging (MPI) with gated single-photon emission tomography provides important information on the extent and severity of myocardial perfusion abnormalities, including myocardial ischemia. The availability of software for automated quantitative assessment of myocardial perfusion in an objective and more reproducible manner than visual assessment has allowed MPI to be particularly effective in serial evaluation. Serial testing using MPI is widely used in guiding patient care despite the lack of well-defined appropriateness use criteria. This should not be surprising because ischemic heart disease is a life-long malady subject to dynamic changes throughout its natural course and particularly following man-made interventions that may improve or worsen the disease process, such as medical therapy and coronary revascularization. Serial MPI has filled an important clinical gap by providing crucial information for managing patients with changes in clinical presentations or in anticipation of such changes in patients with stable symptoms. In the research arena, serial MPI has been widely applied in randomized controlled trials to study the impact of various medical and interventional therapies on myocardial perfusion, as well as the relative merits of new imaging procedures (hardware and/or software), radiotracers, and stressor agents. Serial testing, however, unlike initial or 1-time testing, has more stringent requirements and is subject to variability because of technical, procedural, interpretational, and biological factors. The intrinsic variability of MPI becomes important in interpreting serial tests in order to define a true change in a given patient and to guide clinical decision making. The purpose of this first comprehensive review on this subject is to illustrate where serial MPI may be useful clinically and in research studies, and to highlight strategies for addressing the various issues that are unique to serial testing in order to derive more valid and robust data from the serial scans.
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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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Guarini G, Huqi A, Morrone D, Capozza P, Todiere G, Marzilli M. Pharmacological approaches to coronary microvascular dysfunction. Pharmacol Ther 2014; 144:283-302. [DOI: 10.1016/j.pharmthera.2014.06.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 05/16/2014] [Indexed: 02/07/2023]
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Horvath B, Bers DM. The late sodium current in heart failure: pathophysiology and clinical relevance. ESC Heart Fail 2014; 1:26-40. [PMID: 28834665 DOI: 10.1002/ehf2.12003] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 07/13/2014] [Accepted: 07/14/2014] [Indexed: 12/19/2022] Open
Abstract
Large and growing body of data suggest that an increased late sodium current (INa,late ) can have a significant pathophysiological role in heart failure and other heart diseases. The first goal of this article is to describe how INa,late functions under physiological circumstances. The second goal is to show the wide range of cellular mechanisms that can increase INa,late in cardiac disease, and also to describe how the up-regulated INa,late contributes to the pathophysiology of heart failure. The final section of the article discusses the possible use of INa,late -modifying drugs in heart failure, on the basis of experimental and preclinical data.
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Affiliation(s)
- Balazs Horvath
- Department of Physiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
- Faculty of Pharmacy, University of Debrecen, Debrecen, Hungary
| | - Donald M Bers
- Department of Pharmacology, School of Medicine, University of California, Davis, CA, USA
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25
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Mieres JH, Gulati M, Bairey Merz N, Berman DS, Gerber TC, Hayes SN, Kramer CM, Min JK, Newby LK, Nixon JVI, Srichai MB, Pellikka PA, Redberg RF, Wenger NK, Shaw LJ. Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation 2014; 130:350-79. [PMID: 25047587 DOI: 10.1161/cir.0000000000000061] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Sadat K, Ather S, Aljaroudi W, Heo J, Iskandrian AE, Hage FG. The effect of bone marrow mononuclear stem cell therapy on left ventricular function and myocardial perfusion. J Nucl Cardiol 2014; 21:351-67. [PMID: 24379128 DOI: 10.1007/s12350-013-9846-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 12/08/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Bone marrow stem cell (BMC) transfer is an emerging therapy with potential to salvage cardiomyocytes during acute myocardial infarction and promote regeneration and endogenous repair of damaged myocardium in patients with left ventricular (LV) dysfunction. We performed a meta-analysis to examine the association between administration of BMC and LV functional recovery as assessed by imaging. METHODS AND RESULTS Our meta-analysis included data from 32 trials comprising information on 1,300 patients in the treatment arm and 1,006 patients in the control arm. Overall, BMC therapy was associated with a significant increase in LV ejection fraction by 4.6% ± 0.7% (P < .001) (control-adjusted increase of 2.8% ± 0.9%, P = .001), and a significant decrease in perfusion defect size by 9.5% ± 1.4% (P < .001) (control-adjusted decrease of 3.8% ± 1.2%, P = .002). The effect of BMC therapy was similar whether the cells were administered via intra-coronary or intra-myocardial routes and was not influenced by baseline ejection fraction or perfusion defect size. CONCLUSIONS BMC transfer appears to have a positive impact on LV recovery in patients with acute coronary syndrome and those with stable coronary disease with or without heart failure. Most studies were small and a minority used a core laboratory for image analysis.
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Affiliation(s)
- Kamel Sadat
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Lyons-Harrison Research Building 314, 1900 University Blvd, Birmingham, AL, 35294, USA,
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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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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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Affiliation(s)
- Antonio Zaza
- Dipartimento di Biotecnologie e Bioscienze, Università degli Studi Milano-Bicocca, Milano, Italy,
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Fu Z, Zhao L, Chai W, Dong Z, Cao W, Liu Z. Ranolazine recruits muscle microvasculature and enhances insulin action in rats. J Physiol 2013; 591:5235-49. [PMID: 23798495 DOI: 10.1113/jphysiol.2013.257246] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Ranolazine, an anti-anginal compound, has been shown to significantly improve glycaemic control in large-scale clinical trials, and short-term ranolazine treatment is associated with an improvement in myocardial blood flow. As microvascular perfusion plays critical roles in insulin delivery and action, we aimed to determine if ranolazine could improve muscle microvascular blood flow, thereby increasing muscle insulin delivery and glucose use. Overnight-fasted, anaesthetized Sprague-Dawley rats were used to determine the effects of ranolazine on microvascular recruitment using contrast-enhanced ultrasound, insulin action with euglycaemic hyperinsulinaemic clamp, and muscle insulin uptake using (125)I-insulin. Ranolazine's effects on endothelial nitric oxide synthase (eNOS) phosphorylation, cAMP generation and endothelial insulin uptake were determined in cultured endothelial cells. Ranolazine-induced myographical changes in tension were determined in isolated distal saphenous artery. Ranolazine at therapeutically effective dose significantly recruited muscle microvasculature by increasing muscle microvascular blood volume (∼2-fold, P < 0.05) and increased insulin-mediated whole body glucose disposal (∼30%, P = 0.02). These were associated with an increased insulin delivery into the muscle (P < 0.04). In cultured endothelial cells, ranolazine increased eNOS phosphorylation and cAMP production without affecting endothelial insulin uptake. In ex vivo studies, ranolazine exerted a potent vasodilatatory effect on phenylephrine pre-constricted arterial rings, which was partially abolished by endothelium denudement. In conclusion, ranolazine treatment vasodilatates pre-capillary arterioles and increases microvascular perfusion, which are partially mediated by endothelium, leading to expanded microvascular endothelial surface area available for nutrient and hormone exchanges and resulting in increased muscle delivery and action of insulin. Whether these actions contribute to improved glycaemic control in patients with insulin resistance warrants further investigation.
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Affiliation(s)
- Zhuo Fu
- Z. Liu: Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, PO Box 801410, Charlottesville, VA 22908, USA.
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Maier LS, Sossalla S. The late Na current as a therapeutic target: where are we? J Mol Cell Cardiol 2013; 61:44-50. [PMID: 23500390 DOI: 10.1016/j.yjmcc.2013.03.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 02/26/2013] [Accepted: 03/04/2013] [Indexed: 12/19/2022]
Abstract
In this article we review the late Na current which functionally can be measured using patch-clamp electrophysiology (INa,late). This current is largely enhanced under pathological myocardial conditions such as ischemia and heart failure. In addition, INa,late can cause systolic and diastolic contractile dysfunction via a Na-dependent Ca-overload of the myocyte. Moreover, INa,late plays a crucial role as ventricular and atrial proarrhythmic substrate in myocardial pathology by changing cellular electrophysiology. We summarize recent experimental and clinical studies that investigate therapeutic inhibition of this current and discuss the significance of the available data and try to answer not only the question, where we currently are but also where we may go in the near future. This article is part of a Special Issue entitled "Na(+) Regulation in Cardiac Myocytes".
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Affiliation(s)
- Lars S Maier
- Abt. Kardiologie und Pneumologie/Herzzentrum, Deutsches Zentrum für Herzkreislaufforschung, Georg-August-Universität, Göttingen, Germany.
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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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Exercise training early after acute myocardial infarction reduces stress-induced hypoperfusion and improves left ventricular function. Eur J Nucl Med Mol Imaging 2012; 40:315-24. [PMID: 23224706 DOI: 10.1007/s00259-012-2302-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 11/07/2012] [Indexed: 12/18/2022]
Abstract
PURPOSE Exercise training might exert its beneficial effects on myocardial perfusion by inducing coronary vascular adaptations or enhancing collateralization. We evaluated whether long-term exercise-based cardiac rehabilitation started early after ST-elevation acute myocardial infarction (STEMI) improves myocardial perfusion and left ventricular (LV) function. METHODS Forty-six patients with recent STEMI and residual inducible hypoperfusion were randomized into two groups: 25 enrolled in a 6-month outpatient exercise-based cardiac rehabilitation programme (group T) and 21 discharged with generic instructions for maintaining physical activity and correct lifestyle (group C). All patients underwent cardiopulmonary exercise test and dipyridamole rest gated myocardial perfusion single photon emission computed tomography within 1 week after STEMI and at 6-month follow-up. RESULTS At follow-up, group T showed an improvement in peak oxygen consumption, oxygen pulse and in the slope of increase in ventilation over carbon dioxide output (all p < 0.01) associated with a reduction of stress-induced hypoperfusion (p < 0.01) and an improvement in resting and post-stress wall motion score indexes (both p < 0.01), resting and post-stress wall thickening score indexes (both p < 0.05) and resting and post-stress LV ejection fraction (both p < 0.05). On the contrary, no changes in cardiopulmonary indexes, myocardial perfusion and LV function parameters were observed in group C at follow-up. CONCLUSION Exercise training started early after STEMI reduces stress-induced hypoperfusion and improves LV function and contractility. Exercise-induced changes in myocardial perfusion and function were associated with the absence of unfavourable LV remodelling and with an improvement of cardiovascular functional capacity.
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Venkataraman R, Chen J, Garcia EV, Belardinelli L, Hage FG, Heo J, Iskandrian AE. Effect of ranolazine on left ventricular dyssynchrony in patients with coronary artery disease. Am J Cardiol 2012; 110:1440-5. [PMID: 22884560 DOI: 10.1016/j.amjcard.2012.06.055] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 06/25/2012] [Accepted: 06/25/2012] [Indexed: 12/19/2022]
Abstract
We previously reported that ranolazine improves exercise myocardial perfusion. Ranolazine ameliorates myocardial ischemia by augmenting myocardial blood flow; likely by a reduction in the extravascular compression of small vessels. We hypothesized that ranolazine could improve left ventricular (LV) dyssynchrony as assessed by phase analysis of gated single photon emission computed tomographic myocardial perfusion imaging. Patients (n = 32) with known or suspected coronary artery disease and reversible perfusion defects on a clinically indicated stress myocardial perfusion imaging were restudied 4 weeks after ranolazine (500 to 1,000 mg orally twice daily) was added to their conventional treatment in an open-label trial (data previously reported). The LV systolic and diastolic dyssynchrony indexes were obtained using automated phase analysis before and after ranolazine. No significant changes were found in the heart rate or blood pressure (at rest or during stress) after treatment. The perfusion pattern improved in 13 of 18 patients who had undergone exercise testing, but in only 3 of 14 patients who had undergone vasodilator stress testing. No significant changes were seen in the LV ejection fraction or volume after treatment. The systolic and diastolic LV dyssynchrony improved after ranolazine therapy; there was a significant decrease in the systolic phase SD (21 ± 17 vs 18 ± 13, p = 0.04), systolic bandwidth (69 ± 60 vs 53 ± 38, p = 0.03), diastolic SD (29 ± 18 vs 24 ± 15, p = 0.047) and diastolic bandwidth (91 ± 61 vs 72 ± 45, p = 0.02). In conclusion, the present study is the first to show improvements in diastolic and systolic LV synchrony with ranolazine as measured by automated phase analysis of gated single photon emission computed tomographic myocardial perfusion imaging.
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Murthy VL, Di Carli MF. Non-invasive quantification of coronary vascular dysfunction for diagnosis and management of coronary artery disease. J Nucl Cardiol 2012; 19:1060-72; quiz 1075. [PMID: 22714648 PMCID: PMC6526508 DOI: 10.1007/s12350-012-9590-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Venkatesh L. Murthy
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Marcelo F. Di Carli
- Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Boston, MA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Boston, MA
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Animal models as tools to investigate antidiabetic and anti-inflammatory plants. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2012; 2012:142087. [PMID: 22899950 PMCID: PMC3414199 DOI: 10.1155/2012/142087] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 05/30/2012] [Indexed: 01/12/2023]
Abstract
Plants have been historically used for diabetes treatment and related anti-inflammatory activity throughout the world; few of them have been validated by scientific criteria. Recently, a large diversity of animal models has been developed for better understanding the pathogenesis of diabetes mellitus and its underlying inflammatory mechanism and new drugs have been introduced in the market to treat this disease. The aim of this work is to review the available animal models of diabetes and anti-inflammatory activity along with some in vitro models which have been used as tools to investigate the mechanism of action of drugs with potential antidiabetic properties and related anti-inflammatory mechanism. At present, the rigorous procedures for evaluation of conventional antidiabetic medicines have rarely been applied to test raw plant materials used as traditional treatments for diabetes; and natural products, mainly derived from plants, have been tested in chemically induced diabetes model. This paper contributes to design new strategies for the development of novel antidiabetic drugs and its related inflammatory activity in order to treat this serious condition which represents a global public health problem.
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Purcell H, De Silva R. Treating stable angina - is there a NICE way towards an international consensus? Int J Clin Pract 2012; 66:614-8. [PMID: 22698411 DOI: 10.1111/j.1742-1241.2012.02941.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Sossalla S, Maier LS. Role of ranolazine in angina, heart failure, arrhythmias, and diabetes. Pharmacol Ther 2011; 133:311-23. [PMID: 22133843 DOI: 10.1016/j.pharmthera.2011.11.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 11/14/2011] [Indexed: 02/07/2023]
Abstract
Ranolazine which is currently approved as an antianginal agent reduces the Na-dependent Ca overload via inhibition of the late sodium current (late I(Na)) and thus improves diastolic tone and oxygen handling during myocardial ischemia. According to accumulating evidence ranolazine also exerts beneficial effects on diastolic and systolic heart failure where late I(Na) was also found to be elevated. Moreover, late I(Na) plays a crucial role as an arrhythmic substrate. Ranolazine has been described to have antiarrhythmic effects on ventricular as well as atrial arrhythmias without any proarrythmia or severe organ toxicity as it is common for several antiarrhythmic drugs. In patients with diabetes, treatment with ranolazine led to a significant improvement of glycemic control. In this article possible new clinical indications of the late I(Na)-inhibitor ranolazine are reviewed. We summarize novel experimental and clinical studies and discuss the significance of the available data.
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Affiliation(s)
- Samuel Sossalla
- Department of Cardiology & Pneumology, Georg-August-University Göttingen, Germany.
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Giallauria F, Acampa W, Ricci F, Vitelli A, Maresca L, Mancini M, Grieco A, Gallicchio R, Xhoxhi E, Spinelli L, Cuocolo A, Vigorito C. Effects of exercise training started within 2 weeks after acute myocardial infarction on myocardial perfusion and left ventricular function: a gated SPECT imaging study. Eur J Prev Cardiol 2011; 19:1410-9. [PMID: 21965517 DOI: 10.1177/1741826711425427] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Several studies suggested that exercise training might improve myocardial perfusion by inducing coronary vascular adaptations or enhancing collateralization. However, these findings were obtained in patients with chronic coronary artery disease using thallium-201 myocardial perfusion scintigraphy. We evaluated whether a long-term exercise-based cardiac rehabilitation (CR) started early (9 ± 3 days) after ST elevation acute myocardial infarction (STEMI) improves myocardial perfusion and left ventricular (LV) function, evaluated by gated single-photon emission computed tomography (SPECT) imaging. DESIGN Randomized controlled study. METHODS Fifty patients with recent STEMI were randomized into two groups: 24 enrolled in a 6-month exercise-based CR programme (group T) and 26 discharged with generic instructions for maintaining physical activity and correct lifestyle (group C). All patients underwent cardiopulmonary exercise test and gated SPECT within 3 weeks after STEMI and at 6-month follow up. RESULTS At follow up, group T showed a significant reduction of stress-induced ischaemia (p < 0.01) and an improvement in resting and post-stress wall motion (both p < 0.005) and resting (p < 0.05) and post-stress wall thickness (p < 0.005) score indexes. At follow up, group T showed an improvement in peak oxygen consumption (p < 0.0001), O(2) pulse (p < 0.05), and in the slope of increase in ventilation over carbon dioxide output (p < 0.001). No changes in myocardial perfusion parameters, LV function, and cardiopulmonary indexes were observed in group C at follow up. CONCLUSIONS Six months of exercise training early after STEMI reduces stress-induced ischaemia and improves LV wall motion and thickness. Exercise-induced changes in myocardial perfusion and function were associated with the absence of unfavourable LV remodelling and with the improvement of cardiovascular functional capacity.
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Affiliation(s)
- Francesco Giallauria
- Department of Clinical Medicine, Cardiovascular and Immunological Sciences. Cardiac Rehabilitation Unit, University of Naples Federico II, via S. Pansini 5, Naples, Italy.
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Abstract
Advances in pharmacotherapy for stable angina have produced a wide choice of drugs with various mechanisms of action, potentially enabling individualized, patient-specific treatment strategies to be developed. In this Review, the various treatment options for patients with stable angina are discussed. Data from randomized, clinical trials of established and novel drugs are reviewed, with particular emphasis on the proposed mechanisms of action, benefits of therapy, and adverse-effect profiles. The role of coronary revascularization in conjunction with optimal medical therapy as a treatment strategy is discussed, although drug therapy might reduce the need for prompt revascularization if the procedure is being considered solely for the purpose of alleviating angina. Finally, trials to investigate stimulation of angiogenesis using growth-factor, gene, and cell therapy are used to illustrate the challenges of chemically inducing the growth of adequate, durable blood vessels.
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Affiliation(s)
- Bernard R Chaitman
- Department of Medicine, Division of Cardiology, Saint Louis University School of Medicine, 1034 South Brentwood Boulevard, Suite 1550, St Louis, MO 63117, USA.
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Mehta PK, Goykhman P, Thomson LEJ, Shufelt C, Wei J, Yang Y, Gill E, Minissian M, Shaw LJ, Slomka PJ, Slivka M, Berman DS, Bairey Merz CN. Ranolazine improves angina in women with evidence of myocardial ischemia but no obstructive coronary artery disease. JACC Cardiovasc Imaging 2011; 4:514-22. [PMID: 21565740 PMCID: PMC6364688 DOI: 10.1016/j.jcmg.2011.03.007] [Citation(s) in RCA: 138] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2010] [Revised: 03/02/2011] [Accepted: 03/04/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We conducted a pilot study for a large definitive clinical trial evaluating the impact of ranolazine in women with angina, evidence of myocardial ischemia, and no obstructive coronary artery disease (CAD). BACKGROUND Women with angina, evidence of myocardial ischemia, but no obstructive CAD frequently have microvascular coronary dysfunction. The impact of ranolazine in this patient group is unknown. METHODS A pilot randomized, double-blind, placebo-controlled, crossover trial was conducted in 20 women with angina, no obstructive CAD, and ≥ 10% ischemic myocardium on adenosine stress cardiac magnetic resonance (CMR) imaging. Participants were assigned to ranolazine or placebo for 4 weeks separated by a 2-week washout. The Seattle Angina Questionnaire and CMR were evaluated after each treatment. Invasive coronary flow reserve (CFR) was available in patients who underwent clinically indicated coronary reactivity testing. CMR data analysis included the percentage of ischemic myocardium and quantitative myocardial perfusion reserve index (MPRI). RESULTS The mean age of subjects was 57 ± 11 years. Compared with placebo, patients on ranolazine had significantly higher (better) Seattle Angina Questionnaire scores, including physical functioning (p = 0.046), angina stability (p = 0.008), and quality of life (p = 0.021). There was a trend toward a higher (better) CMR mid-ventricular MPRI (2.4 [2.0 minimum, 2.8 maximum] vs. 2.1 [1.7 minimum, 2.5 maximum], p = 0.074) on ranolazine. Among women with coronary reactivity testing (n = 13), those with CFR ≤ 3.0 had a significantly improved MPRI on ranolazine versus placebo compared to women with CFR > 3.0 (Δ in MPRI 0.48 vs. -0.82, p = 0.04). CONCLUSIONS In women with angina, evidence of ischemia, and no obstructive CAD, this pilot randomized, controlled trial revealed that ranolazine improves angina. Myocardial ischemia may also improve, particularly among women with low CFR. These data document approach feasibility and provide outcome variability estimates for planning a definitive large clinical trial to evaluate the role of ranolazine in women with microvascular coronary dysfunction. (Microvascular Coronary Disease In Women: Impact Of Ranolazine; NCT00570089).
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Affiliation(s)
- Puja K. Mehta
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Pavel Goykhman
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Louise E. J. Thomson
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Chrisandra Shufelt
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Janet Wei
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - YuChing Yang
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Edward Gill
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Margo Minissian
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Leslee J. Shaw
- Program in Cardiovascular Outcomes Research and Epidemiology, Emory University, Atlanta, Georgia
| | - Piotr J. Slomka
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Melissa Slivka
- Women’s Heart Center, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Daniel S. Berman
- S. Mark Taper Foundation Imaging Center, Cedars-Sinai Medical Center, Los Angeles, California
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Venkataraman R, Aljaroudi W, Belardinelli L, Heo J, Iskandrian AE. The effect of ranolazine on the vasodilator-induced myocardial perfusion abnormality. J Nucl Cardiol 2011; 18:456-62. [PMID: 21432000 DOI: 10.1007/s12350-011-9364-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 02/20/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND We previously reported that ranolazine improved myocardial ischemia during exercise myocardial perfusion imaging (MPI). Since the mechanism of reversible perfusion defects is different in exercise than vasodilator MPI, and based on the mechanism of action of ranolazine, we hypothesized that vasodilator stress MPI may fail to show improvement in myocardial perfusion pattern. METHODS Patients (n = 18) with known coronary artery disease and with reversible perfusion defects on a clinically indicated vasodilator stress MPI were re-studied 4 weeks after ranolazine (500-1000 mg PO BID) was added to their conventional treatment in an open-label trial. Perfusion pattern was assessed using automated methods. RESULTS The baseline left ventricular ejection fraction was 59% ± 14%. The total perfusion defect (measured by polar maps) was 22% ± 13% before and 21% ± 16% of LV myocardium after treatment (P = NS). The reversible defect size was 14% ± 10% before and 14% ± 11% of LV myocardium after treatment (P = NS). The automated-derived summed stress score was 12 ± 8 before and 12 ± 10 after treatment (P = NS) and the automated-derived summed difference score was 6 ± 5 before and 6 ± 5 after treatment (P = NS). Only 3 patients showed a decrease in reversible perfusion defect size with treatment. CONCLUSION Vasodilator stress MPI failed to show improvement in perfusion pattern after ranolazine treatment in most patients with baseline reversible defects. This is consistent with the unique anti-ischemic mechanism of ranolazine, which acts on the late I Na channel.
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Affiliation(s)
- Rajesh Venkataraman
- Division of Cardiovascular Disease, University of Alabama at Birmingham, 314 LHRB, 1900 University BLVD, Birmingham, AL 35294-0007, USA.
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Abstract
Chronic stable angina is an exceedingly prevalent condition with tremendous clinical, social, and financial implications. Traditional medical therapy for angina consists of beta-blockers, calcium channel blockers, and nitrates. These agents decrease myocardial oxygen demand and ischemia by reducing heart rate, lowering blood pressure, and/or optimizing ventricular loading characteristics. Unique in its mechanism of action, ranolazine is the first new antianginal agent approved for use in the US for chronic angina in over 25 years. By inhibiting the late inward sodium current (I(Na)), ranolazine prevents pathologic intracellular calcium accumulation that leads to ischemia, myocardial dysfunction, and electrical instability. Ranolazine has been proven in multiple clinical trials to reduce the symptoms of angina safely and effectively and to improve exercise tolerance in patients with symptomatic coronary heart disease. These benefits occur without reduction in heart rate and blood pressure or increased mortality. Although ranolazine prolongs the QT(c), experimental data indicate that ranolazine may actually be antiarrhythmic. In a large acute coronary syndrome clinical trial, ranolazine reduced the incidence of supraventricular tachycardia, ventricular tachycardia, new-onset atrial fibrillation, and bradycardic events. Additional benefits of ranolazine under investigation include reductions in glycosylated hemoglobin levels and improved left ventricular function. Ranolazine is a proven antianginal medication in patients with symptomatic coronary heart disease, and should be considered as an initial antianginal agent for those with hypotension or bradycardia.
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Affiliation(s)
- David S Vadnais
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
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Boden WE. Ranolazine and Its Anti-Ischemic Effects. J Am Coll Cardiol 2010; 56:943-5. [DOI: 10.1016/j.jacc.2010.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 07/29/2010] [Indexed: 12/19/2022]
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Stone PH, Chaitman BR, Stocke K, Sano J, DeVault A, Koch GG. The Anti-Ischemic Mechanism of Action of Ranolazine in Stable Ischemic Heart Disease. J Am Coll Cardiol 2010; 56:934-42. [DOI: 10.1016/j.jacc.2010.04.042] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Revised: 03/12/2010] [Accepted: 04/01/2010] [Indexed: 12/19/2022]
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Klocke FJ. Ranolazine and the Myocardial Demand–Supply Balance. JACC Cardiovasc Imaging 2009; 2:1310-2. [DOI: 10.1016/j.jcmg.2009.09.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Accepted: 09/22/2009] [Indexed: 11/25/2022]
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