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Calvo D, Filgueiras-Rama D, Jalife J. Mechanisms and Drug Development in Atrial Fibrillation. Pharmacol Rev 2018; 70:505-525. [PMID: 29921647 PMCID: PMC6010660 DOI: 10.1124/pr.117.014183] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Atrial fibrillation is a highly prevalent cardiac arrhythmia and the most important cause of embolic stroke. Although genetic studies have identified an increasing assembly of AF-related genes, the impact of these genetic discoveries is yet to be realized. In addition, despite more than a century of research and speculation, the molecular and cellular mechanisms underlying AF have not been established, and therapy for AF, particularly persistent AF, remains suboptimal. Current antiarrhythmic drugs are associated with a significant rate of adverse events, particularly proarrhythmia, which may explain why many highly symptomatic AF patients are not receiving any rhythm control therapy. This review focuses on recent advances in AF research, including its epidemiology, genetics, and pathophysiological mechanisms. We then discuss the status of antiarrhythmic drug therapy for AF today, reviewing molecular mechanisms, and the possible clinical use of some of the new atrial-selective antifibrillatory agents, as well as drugs that target atrial remodeling, inflammation and fibrosis, which are being tested as upstream therapies to prevent AF perpetuation. Altogether, the objective is to highlight the magnitude and endemic dimension of AF, which requires a significant effort to develop new and effective antiarrhythmic drugs, but also improve AF prevention and treatment of risk factors that are associated with AF complications.
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Affiliation(s)
- David Calvo
- Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain (D.C.); Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (D.F.-R., J.J.); Department of Cardiology, Arrhythmia Unit, Hospital Clínico Universitario San Carlos, Madrid, Spain (D.F.-R.); Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (D.F.-R., J.J.); and Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (J.J.)
| | - David Filgueiras-Rama
- Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain (D.C.); Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (D.F.-R., J.J.); Department of Cardiology, Arrhythmia Unit, Hospital Clínico Universitario San Carlos, Madrid, Spain (D.F.-R.); Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (D.F.-R., J.J.); and Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (J.J.)
| | - José Jalife
- Department of Cardiology, Arrhythmia Unit, Hospital Universitario Central de Asturias and Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain (D.C.); Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain (D.F.-R., J.J.); Department of Cardiology, Arrhythmia Unit, Hospital Clínico Universitario San Carlos, Madrid, Spain (D.F.-R.); Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain (D.F.-R., J.J.); and Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan (J.J.)
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Porta A, Barrabés JA, Candell-Riera J, Agulló L, Aguadé-Bruix S, de León G, Figueras J, Garcia-Dorado D. Plasma B-type natriuretic peptide levels are poorly related to the occurrence of ischemia or ventricular arrhythmias during symptom-limited exercise in low-risk patients. Arch Med Sci 2016; 12:341-8. [PMID: 27186178 PMCID: PMC4848363 DOI: 10.5114/aoms.2016.59258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 02/03/2015] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION The usefulness of B-type natriuretic peptide (BNP) as a marker of ischemia is controversial. BNP levels have predicted arrhythmias in various settings, but it is unknown whether they are related to exercise-induced ischemic ventricular arrhythmias. MATERIAL AND METHODS We analyzed in 63 patients (64 ±14 years, 65% male, 62% with known coronary disease) undergoing exercise stress single-photon emission computed tomography (SPECT) the association between plasma BNP values (before and 15 min after exercise) and the occurrence of ischemia or ventricular arrhythmias during the test. RESULTS Exercise test (8.1 ±2.7 min, 7.4 ±8.1 metabolic equivalents, 82 ±12% of maximal predicted heart rate) induced reversible perfusion defects in 23 (36%) patients. Eight (13%) patients presented significant arrhythmias (≥ 7 ventricular premature complexes/min, couplets, or non-sustained ventricular tachycardia during exercise or in the first minute of recovery). Median baseline BNP levels were 17.5 (12.4-66.4) pg/ml in patients developing scintigraphic ischemia and 45.6 (13.2-107.4) pg/ml in those without ischemia (p = 0.137). The BNP levels increased after exercise (34.4 (15.3-65.4)% increment over baseline, p < 0.001), but the magnitude of this increase was not related to SPECT positivity (35.7 (18.8-65.4)% vs. 27.9 (5.6-64.0)% in patients with and without ischemia, respectively, p = 0.304). No significant association was found between BNP values (at baseline or their change during the test) and ventricular arrhythmias. CONCLUSIONS Plasma BNP values - at baseline or after exercise - were not associated with myocardial ischemia or with ventricular arrhythmia during exercise SPECT. These results highlight the limited usefulness of this biomarker to assess acute ischemia.
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Affiliation(s)
- Andreu Porta
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José A Barrabés
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jaume Candell-Riera
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Agulló
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Santiago Aguadé-Bruix
- Servicio de Medicina Nuclear, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gustavo de León
- Servicio de Medicina Nuclear, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jaume Figueras
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Garcia-Dorado
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, VHIR, Universitat Autònoma de Barcelona, Barcelona, Spain
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Barrabés JA, Inserte J, Agulló L, Rodríguez-Sinovas A, Alburquerque-Béjar JJ, Garcia-Dorado D. Effects of the Selective Stretch-Activated Channel Blocker GsMtx4 on Stretch-Induced Changes in Refractoriness in Isolated Rat Hearts and on Ventricular Premature Beats and Arrhythmias after Coronary Occlusion in Swine. PLoS One 2015; 10:e0125753. [PMID: 25938516 PMCID: PMC4418727 DOI: 10.1371/journal.pone.0125753] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 03/26/2015] [Indexed: 01/19/2023] Open
Abstract
Mechanical factors may contribute to ischemic ventricular arrhythmias. GsMtx4 peptide, a selective stretch-activated channel blocker, inhibits stretch-induced atrial arrhythmias. We aimed to assess whether GsMtx4 protects against ventricular ectopy and arrhythmias following coronary occlusion in swine. First, the effects of 170-nM GsMtx4 on the changes in the effective refractory period (ERP) induced by left ventricular (LV) dilatation were assessed in 8 isolated rat hearts. Then, 44 anesthetized, open-chest pigs subjected to 50-min left anterior descending artery occlusion and 2-h reperfusion were blindly allocated to GsMtx4 (57 μg/kg iv. bolus and 3.8 μg/kg/min infusion, calculated to attain the above concentration in plasma) or saline, starting 5-min before occlusion and continuing until after reflow. In rat hearts, LV distension induced progressive reductions in ERP (35±2, 32±2, and 29±2 ms at 0, 20, and 40 mmHg of LV end-diastolic pressure, respectively, P<0.001) that were prevented by GsMTx4 (33±2, 33±2, and 32±2 ms, respectively, P=0.002 for the interaction with LV end-diastolic pressure). Pigs receiving GsMtx4 had similar number of ventricular premature beats during the ischemic period as control pigs (110±28 vs. 103±21, respectively, P=0.842). There were not significant differences among treated and untreated animals in the incidence of ventricular fibrillation (13.6 vs. 22.7%, respectively, P=0.696) or tachycardia (36.4 vs. 50.0%, P=0.361) or in the number of ventricular tachycardia episodes during the occlusion period (1.8±0.7 vs. 5.5±2.6, P=0.323). Thus, GsMtx4 administered under these conditions does not suppress ventricular ectopy following coronary occlusion in swine. Whether it might protect against malignant arrhythmias should be tested in studies powered for these outcomes.
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Affiliation(s)
- José A. Barrabés
- Servicio de Cardiología, Hospital Universitari Vall d’Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
- * E-mail:
| | - Javier Inserte
- Servicio de Cardiología, Hospital Universitari Vall d’Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Agulló
- Servicio de Cardiología, Hospital Universitari Vall d’Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Rodríguez-Sinovas
- Servicio de Cardiología, Hospital Universitari Vall d’Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan J. Alburquerque-Béjar
- Servicio de Cardiología, Hospital Universitari Vall d’Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - David Garcia-Dorado
- Servicio de Cardiología, Hospital Universitari Vall d’Hebron, Institut de Recerca (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
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