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Nesterov SV, Räty J, Nammas W, Maaniitty T, Galloo X, Stassen J, Laurila S, Vasankari T, Huusko J, Bax JJ, Saraste A, Knuuti J. Short-term effects of sacubitril/valsartan therapy on myocardial oxygen consumption and energetic efficiency of cardiac work in heart failure with reduced ejection fraction: A randomized controlled study. Eur J Heart Fail 2024; 26:117-126. [PMID: 37905338 DOI: 10.1002/ejhf.3072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/19/2023] [Accepted: 10/21/2023] [Indexed: 11/02/2023] Open
Abstract
AIMS We sought to evaluate the mechanism of angiotensin receptor-neprilysin inhibitor (ARNI) sacubitril/valsartan therapy and compare it with a valsartan-only control group in patients with heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS The study was a phase IV, prospective, randomized, double-blind, parallel-group study in patients with New York Heart Association class II-III heart failure and left ventricular ejection fraction (LVEF) ≤35%. During a 6-week run-in period, all patients received valsartan therapy, which was up-titrated to the highest tolerated dose level (80 mg bid or 160 mg bid) and then randomized to either valsartan or sacubitril/valsartan. Myocardial oxygen consumption, energetic efficiency of cardiac work, cardiac and systemic haemodynamics were quantified using echocardiography and 11 C-acetate positron emission tomography before and after 6 weeks of therapy (on stable dose) in 55 patients (ARNI group: n = 27, mean age 63 ± 10 years, LVEF 29.2 ± 10.4%; and valsartan-only control group: n = 28, mean age 64 ± 8 years, LVEF 29.0 ± 7.3%; all p = NS). The energetic efficiency of cardiac work remained unchanged in both treatment arms. However, both diastolic (-4.5 mmHg; p = 0.026) and systolic blood pressure (-9.8 mmHg; p = 0.0007), myocardial perfusion (-0.054 ml/g/min; p = 0.045), and left ventricular mechanical work (-296; p = 0.038) decreased significantly in the ARNI group compared to the control group. Although myocardial oxygen consumption decreased in the ARNI group (-5.4%) compared with the run-in period and remained unchanged in the control group (+0.5%), the between-treatment group difference was not significant (p = 0.088). CONCLUSIONS We found no differences in the energetic efficiency of cardiac work between ARNI and valsartan-only groups in HFrEF patients. However, ARNI appears to have haemodynamic and cardiac mechanical effects over valsartan in heart failure patients.
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Affiliation(s)
- Sergey V Nesterov
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Johanna Räty
- Department of Clinical Physiology, Nuclear Medicine and PET, Turku University Hospital, Turku, Finland
| | - Wail Nammas
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Teemu Maaniitty
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
- Department of Clinical Physiology, Nuclear Medicine and PET, Turku University Hospital, Turku, Finland
| | - Xavier Galloo
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan Stassen
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sanna Laurila
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Tuija Vasankari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | | | - Jeroen J Bax
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Antti Saraste
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Juhani Knuuti
- Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
- Department of Clinical Physiology, Nuclear Medicine and PET, Turku University Hospital, Turku, Finland
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Circulating neprilysin hypothesis: A new opportunity for sacubitril/valsartan in patients with heart failure and preserved ejection fraction? PLoS One 2021; 16:e0249674. [PMID: 33989294 PMCID: PMC8121351 DOI: 10.1371/journal.pone.0249674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/23/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Circulating Neprilysin (sNEP) has emerged as a potential prognostic biomarker in heart failure (HF). In PARAGON-HF benefit of sacubitril/valsartan was only observed in patients with left ventricular ejection fraction (LVEF) ≤57%. We aimed to assess the prognostic value of sNEP in outpatients with HF and LVEF >57%, in comparison with patients with LVEF ≤57%. METHODS Consecutive HF outpatients were included from May-2006 to February-2016. The primary endpoint was the composite of all-cause death or HF hospitalization and the main secondary endpoint was the composite of cardiovascular death or HF hospitalization. For the later competing risk methods were used. RESULTS sNEP was measured in 1428 patients (age 67.7±12.7, 70.3% men, LVEF 35.8% ±14), 144 of which had a LVEF >57%. sNEP levels did not significantly differ between LVEF groups (p = 0.31). During a mean follow-up of 6±3.9 years, the primary endpoint occurred in 979 patients and the secondary composite endpoint in 714 (in 111 and 84 of the 144 patients with LVEF >57%, respectively). sNEP was significantly associated with both composite endpoints. Age- and sex- adjusted Cox regression analyses showed higher hazard ratios for sNEP in patients with LVEF >57%, both for the primary (HR 1.37 [1.16-1.61] vs. 1.04 [0.97-1.11]) and the secondary (HR 1.38 [1.21-1.55] vs. 1.11 [1.04-1.18]) composite endpoints. CONCLUSIONS sNEP prognostic value in patients with HF and LVEF >57% outperforms that observed in patients with lower LVEF. Precision medicine using sNEP may identify HF patients with preserved LVEF that may benefit from treatment with sacubitril/valsartan.
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Salazar J, Rojas-Quintero J, Cano C, Pérez JL, Ramírez P, Carrasquero R, Torres W, Espinoza C, Chacín-González M, Bermúdez V. Neprilysin: A Potential Therapeutic Target of Arterial Hypertension? Curr Cardiol Rev 2020; 16:25-35. [PMID: 31241018 PMCID: PMC7062041 DOI: 10.2174/1573403x15666190625160352] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/13/2019] [Accepted: 06/13/2019] [Indexed: 02/07/2023] Open
Abstract
Arterial hypertension is the most prevalent chronic disease in the adult population of developed countries and it constitutes a significant risk factor in the development of cardiovascular disease, contributing to the emergence of many comorbidities, among which heart failure excels, a clinical syndrome that nowadays represents a major health problem with uncountable hospitalizations and the indolent course of which progressively worsens until quality of life decreases and lastly death occurs prematurely. In the light of this growing menace, each day more efforts are invested in the field of cardiovascular pharmacology, searching for new therapeutic options that allow us to modulate the physiological systems that appear among these pathologies. Therefore, in the later years, the study of natriuretic peptides has become so relevant, which mediate beneficial effects at the cardiovascular level such as diuresis, natriuresis, and decreasing cardiac remodeling; their metabolism is mediated by neprilysin, a metalloproteinase, widely expressed in the human and capable of catalyzing many substrates. The modulation of these functions has been studied by decades, giving room to Sacubitril, the first neprilysin inhibitor, which in conjunction with an angiotensin receptor blocker has provided a high efficacy and tolerability among patients with heart failure, for whom it has already been approved and recommended. Nonetheless, in the matter of arterial hypertension, significant findings have arisen that demonstrate the potential role that it will play among the pharmacological alternatives in the upcoming years.
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Affiliation(s)
- Juan Salazar
- Endocrine and Metabolic Disease Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - Joselyn Rojas-Quintero
- Pulmonary and Critical Care Medicine Department, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Clímaco Cano
- Endocrine and Metabolic Disease Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - José L Pérez
- Endocrine and Metabolic Disease Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - Paola Ramírez
- Endocrine and Metabolic Disease Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - Rubén Carrasquero
- Endocrine and Metabolic Disease Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | - Wheeler Torres
- Endocrine and Metabolic Disease Research Center, School of Medicine, University of Zulia, Maracaibo, Venezuela
| | | | | | - Valmore Bermúdez
- Universidad Simon Bolívar, Facultad de Ciencias de la Salud, Barranquilla, Colombia
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Choi HM, Shin MS. Angiotensin receptor-neprilysin inhibitor for the treatment of heart failure: a review of recent evidence. Korean J Intern Med 2020; 35:498-513. [PMID: 32392658 PMCID: PMC7214374 DOI: 10.3904/kjim.2020.105] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 04/22/2020] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is a growing health concern in aging societies worldwide. Sacubitril/valsartan is changing the real-world treatment in the whole spectrum of HF. The beginning was the PARADIGM-HF trial published in 2014, which demonstrated the beneficial effects of inhibiting natriuretic peptide breakdown in combination with hindering the renin-angiotensin system in HF patients with a reduced ejection fraction. Subsequent large-scale randomized trials have evaluated angiotensin receptor-neprilysin inhibitor in HF patients with acute decompensation or with preserved ejection fraction. The post hoc analyses are being conducted as well. This review summarizes the recent evidence of sacubitril/ valsartan regarding patient-centered outcomes, based on randomized controlled trials and their associated studies.
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Affiliation(s)
- Hong-Mi Choi
- Division of Cardiology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Mi-Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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Revuelta-López E, Núñez J, Gastelurrutia P, Cediel G, Januzzi JL, Ibrahim NE, Emdin M, VanKimmenade R, Pascual-Figal D, Núñez E, Gommans F, Lupón J, Bayés-Genís A. Neprilysin inhibition, endorphin dynamics, and early symptomatic improvement in heart failure: a pilot study. ESC Heart Fail 2020; 7:559-566. [PMID: 32045114 PMCID: PMC7160502 DOI: 10.1002/ehf2.12607] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 11/26/2019] [Accepted: 12/09/2019] [Indexed: 12/11/2022] Open
Abstract
Aim Sacubitril/valsartan is a first‐in‐class angiotensin receptor‐neprilysin inhibitor developed for the treatment of heart failure with reduced ejection fraction. Its benefits are achieved through the inhibition of neprilysin (NEP) and the specific blockade of the angiotensin receptor AT1. The many peptides metabolized by NEP suggest multifaceted potential consequences of its inhibition. We sought to evaluate the short‐term changes in serum endorphin (EP) values and their relation with patients' physical functioning after initiation of sacubitril/valsartan treatment. Methods and results A total of 105 patients with heart failure with reduced ejection fraction, who were candidates for sacubitril/valsartan treatment, were included in this prospective, observational, multicentre, and international study. In a first visit, and in agreement with current guidelines, treatment with angiotensin‐converting enzyme inhibitors or angiotensin receptor blocker was replaced by sacubitril/valsartan because of clinical indication by the responsible physician. By protocol, patients were reevaluated at 30 days after the start of sacubitril/valsartan. Serum levels of α‐ (α‐EP), γ‐Endorphin (γ‐EP), and soluble NEP (sNEP) were measured using enzyme‐linked immunoassays. New York Heart Association (NYHA) functional class was used as an indicator of patient's functional status. Baseline median levels of circulating α‐EP, γ‐EP, and sNEP were 582 (160–772), 101 (37–287), and 222 pg/mL (124–820), respectively. There was not a significant increase in α‐EP nor γ‐EP serum values after sacubitril/valsartan treatment (P value = 0.194 and 0.102, respectively). There were no significant differences in sNEP values between 30 days and baseline (P value = 0.103). Medians (IQR) of Δα‐EP, Δγ‐EP, and ΔsNEP between 30 days and baseline were 9.3 (−34 − 44), −3.0 (−46.0 − 18.9), and 0 units (−16.4 − 157.0), respectively. In a pre–post sacubitril/valsartan treatment comparison, there was a significant improvement in NYHA class, with 36 (34.3%) patients experiencing improvement by at least one NYHA class category. Δα‐EP and ΔsNEP showed to be significantly associated with NYHA class after 30 days of treatment (P = 0.014 and P < 0.001, respectively). Δα‐EP was linear and significantly associated with NYHA class improvement after 30 days of sacubitril/valsartan treatment. Conclusions These preliminary data suggest that beyond the haemodynamic benefits achieved with sacubitril/valsartan, the altered cleavage of endorphin peptides by NEP inhibition may participate in patients' symptoms improvement.
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Affiliation(s)
- Elena Revuelta-López
- Heart Failure and Cardiac Regeneration (ICREC) Research Program, Health Science Research Institute Germans Trias i Pujol (IGTP), Badalona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, (CIBERCV,), Madrid, Spain
| | - Julio Núñez
- Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, (CIBERCV,), Madrid, Spain.,Cardiology Department, Hospital Clínico Universitario, Universitat de València, INCLIVA, Valencia, Spain; INCLIVA; Universitat de València, Valencia, Spain
| | - Paloma Gastelurrutia
- Heart Failure and Cardiac Regeneration (ICREC) Research Program, Health Science Research Institute Germans Trias i Pujol (IGTP), Badalona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, (CIBERCV,), Madrid, Spain
| | - Germán Cediel
- Cardiology Service and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital and Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Massachusetts, MA, USA
| | - Nasrien E Ibrahim
- Division of Cardiology, Massachusetts General Hospital and Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, Massachusetts, MA, USA
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Roland VanKimmenade
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Domingo Pascual-Figal
- Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, (CIBERCV,), Madrid, Spain.,Cardiology Department, Hospital Virgen de la Arrixaca, Universidad de Murcia, Murcia, Spain
| | - Eduardo Núñez
- Cardiology Department, Hospital Clínico Universitario, Universitat de València, INCLIVA, Valencia, Spain; INCLIVA; Universitat de València, Valencia, Spain
| | - Frank Gommans
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Josep Lupón
- Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, (CIBERCV,), Madrid, Spain.,Cardiology Service and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Antoni Bayés-Genís
- Centro de Investigación Biomédica en Red Enfermedades Cardiovaculares, (CIBERCV,), Madrid, Spain.,Cardiology Service and Heart Failure Unit, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
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