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Newman JD, O'Meara E, Böhm M, Savarese G, Kelly PR, Vardeny O, Allen LA, Lancellotti P, Gottlieb SS, Samad Z, Morris AA, Desai NR, Rosano GMC, Teerlink JR, Giraldo CS, Lindenfeld J. Implications of Atrial Fibrillation for Guideline-Directed Therapy in Patients With Heart Failure: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:932-950. [PMID: 38418008 DOI: 10.1016/j.jacc.2023.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/29/2023] [Accepted: 12/18/2023] [Indexed: 03/01/2024]
Abstract
Atrial fibrillation (AF) and heart failure (HF) are common cardiovascular conditions that frequently coexist. Among patients with HF, more than one-half also have AF. Both are associated with significant morbidity and mortality. Moreover, the prevalence of each is increasing globally, and this trend is expected to continue owing to an aging population and increased life expectancy. Diagnosis of AF in a patient with HF is associated with greater symptom burden, more frequent hospitalizations, and a worse prognosis. Guideline-directed medical therapy (GDMT) for HF can affect the incidence of AF. Once present, AF can influence the efficacy of some components of GDMT for HF. In this review, we discuss the effect of GDMT for HF across the spectrum of ejection fraction on prevention of AF as well as the benefit of GDMT in patients with vs without AF.
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Affiliation(s)
| | - Eileen O'Meara
- Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada
| | - Michael Böhm
- University of the Saarland, Homberg/Saar, Germany
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institute, Stockholm, Sweden; Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | | | - Orly Vardeny
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Stephen S Gottlieb
- Division of Cardiovascular Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA; Baltimore Veterans Administration Medical Center, Baltimore, Maryland, USA
| | | | | | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Giuseppe M C Rosano
- Center for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | | | | | - JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Cai X, Li N. Association between Use of Spironolactone and Risk of Stroke in Hypertensive Patients: A Cohort Study. Pharmaceuticals (Basel) 2022; 16:ph16010057. [PMID: 36678555 PMCID: PMC9861555 DOI: 10.3390/ph16010057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/27/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023] Open
Abstract
Objective: to investigate the relationship between the use of spironolactone and the risk of stroke in hypertensive patients. Methods: a total of 2464 spironolactone users and 12,928 non-users were identified (unmatched original cohort), and 1:1 matched pairs of 2461 spironolactone users and 2461 non-users based on propensity scores were created (propensity-score-matched cohort). Results: In the unmatched original cohort, the unadjusted analysis showed that the use of spironolactone was associated with a lower risk of total stroke (HR, 0.71; 95% CI, 0.61−0.84; p < 0.001), which was sustained in the adjusted analysis. According to stroke type, the association was with ischemic strokes (propensity-score-adjusted HR, 0.71; 95% CI, 0.59−0.85; p < 0.001) and hemorrhagic ones (propensity-score-adjusted HR, 0.63; 95% CI, 0.45−0.88; p = 0.008). Similar results were shown in the propensity-score-matched cohort. The results of the subgroup and sensitivity analyses were consistent with those of the primary analysis. The dose−response analysis demonstrated a dose-dependent association of spironolactone with a lower risk of stroke in hypertensive patients. Conclusions: The use of spironolactone was associated with a significantly lower risk of stroke events in hypertensive patients. Further research, including prospective randomized clinical trials, is needed to validate our findings.
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Gupta P, Suppakitjanusant P, Stevenson M, Goodman M, Tangpricha V. Potassium Concentrations in Transgender Women Using Spironolactone: A Retrospective Chart Review. Endocr Pract 2022; 28:1113-1117. [PMID: 35964859 DOI: 10.1016/j.eprac.2022.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 08/04/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To assess the incidence of hyperkalemia in transgender women using spironolactone retrospectively. METHODS This was a retrospective chart review of transgender women who received gender-affirming hormone therapy that included spironolactone from the endocrinology clinic between January 1, 2000 and September 6, 2018. The 44 subjects that had paired potassium levels documented and were on spironolactone were included and analyzed. Study outcomes included incidence of hyperkalemia (serum potassium >5.0 mmol/L), the relationship between duration and degree of hyperkalemia and difference between potassium concentrations at the beginning of spironolactone treatment vs last potassium concentration. RESULTS The median age of the subjects was 36.5 years. The cohort was predominantly of non- Hispanic white (32/44). No potassium level was above 5.5 mmol/ L and all subjects had creatinine < 2 mg/dL. The median duration of treatment was 25 months (range 2- 92 months) and a total of 140 potassium measurements were available. The mean potassium concentration (3.87 mmol/L) before the initiation of spironolactone wwas lower than the mean potassium concentration (4.03 mmol/L) while on spironolactone and the difference was statistically significant but clinically insignificant (mean difference 0.16 mmol/L, p=0.013). The regression beta i.e., average change in potassium concentration per one additional month of treatment duration was -00.1, 95% CI [-00.4, 0.01], p=0.255 which signified no relation between treatment duration and spironolactone use. CONCLUSION No subject had laboratory evidence of hyperkalemia after the initiation of spironolactone. Frequent measurement of potassium levels might be unnecessary in transgender women taking spironolactone, in patients with serum creatinine < 2 mg/dL.
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Affiliation(s)
- Pranav Gupta
- Division of Endocrinology, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Pichatorn Suppakitjanusant
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Mary Stevenson
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Atlanta VA Medical Center, Decatur, GA, USA.
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Kolkhof P, Hartmann E, Freyberger A, Pavkovic M, Mathar I, Sandner P, Droebner K, Joseph A, Hüser J, Eitner F. Effects of Finerenone Combined with Empagliflozin in a Model of Hypertension-Induced End-Organ Damage. Am J Nephrol 2021; 52:642-652. [PMID: 34111864 PMCID: PMC8619789 DOI: 10.1159/000516213] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 03/27/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The nonsteroidal mineralocorticoid receptor (MR) antagonist finerenone and sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated clinical benefits in CKD patients with type 2 diabetes. Clinical data analyzing the potential value of a combination therapy are currently limited. We therefore investigated cardiorenal protection of respective mono- and combination therapy in a preclinical model of hypertension-induced end-organ damage. METHODS Cardiovascular (CV) morbidity and mortality were studied in hypertensive, N(ω)-nitro-L-arginine methyl ester-treated, renin-transgenic (mRen2)27 rats. Rats (10- to 11-week-old females, n = 13-17/group) were treated once daily orally for up to 7 weeks with placebo, finerenone (1 and 3 mg/kg), empagliflozin (3 and 10 mg/kg), or a combination of the respective low doses. Key outcome parameters included mortality, proteinuria, plasma creatinine and uric acid, blood pressure, and cardiac and renal histology. RESULTS Placebo-treated rats demonstrated a 50% survival rate over the course of 7 weeks. Drug treatment resulted in variable degrees of survival benefit, most prominently in the low-dose combination group with a survival benefit of 93%. Monotherapies of finerenone or empagliflozin dose-dependently reduced proteinuria, while low-dose combination revealed an early, sustained, and over-additive reduction in proteinuria. Empagliflozin induced a strong and dose-dependent increase in urinary glucose excretion which was not influenced by finerenone coadministration in the combination arm. Low-dose combination but not respective low-dose monotherapies significantly reduced plasma creatinine and plasma uric acid after 6 weeks. Treatment with finerenone and the low-dose combination significantly decreased systolic blood pressure after 5 weeks. There was a dose-dependent protection from cardiac and kidney fibrosis and vasculopathy with both agents, while low-dose combination therapy was more efficient than the respective monotherapy dosages on most cardiorenal histology parameters. DISCUSSION/CONCLUSIONS Nonsteroidal MR antagonism by finerenone and SGLT2 inhibition by empagliflozin confer CV protection in preclinical hypertension-induced cardiorenal disease. Combination of these 2 independent modes of action at low dosages revealed efficacious reduction in important functional parameters such as proteinuria and blood pressure, plasma markers including creatinine and uric acid, cardiac and renal lesions as determined by histopathology, and mortality indicating a strong potential for combined clinical use in cardiorenal patient populations.
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Affiliation(s)
- Peter Kolkhof
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Elke Hartmann
- Research Pathology, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Alexius Freyberger
- Clinical Pathology, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Mira Pavkovic
- Biomarker Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Ilka Mathar
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Peter Sandner
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Karoline Droebner
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Amer Joseph
- Clinical Development, R&D Pharmaceuticals, Bayer AG, Berlin, Germany
| | - Jörg Hüser
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
| | - Frank Eitner
- Cardiovascular Research, Research and Early Development, R&D Pharmaceuticals, Bayer AG, Wuppertal, Germany
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Tezuka Y, Turcu AF. Mineralocorticoid Receptor Antagonists Decrease the Rates of Positive Screening for Primary Aldosteronism. Endocr Pract 2020; 26:1416-1424. [PMID: 33471733 PMCID: PMC7881525 DOI: 10.4158/ep-2020-0277] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/16/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Mineralocorticoid receptor antagonists (MRAs) are effective in patients with resistant hypertension and/or primary aldosteronism (PA). Screening for PA should ideally be conducted after stopping medications that might interfere with the renin-angiotensin-aldosterone system, but this is challenging in patients with recalcitrant hypertension or hypokalemia. Herein, we aimed to evaluate the impact of MRAs on PA screening in clinical practice. METHODS We conducted a retrospective cohort study of patients with hypertension who had plasma aldosterone and renin measurements before and after MRA use in a tertiary referral center, over 19 years. RESULTS A total of 146 patients, 91 with PA, were included and followed for up to 18 months. Overall, both plasma renin and aldosterone increased after MRA initiation (from median, interquartile range: 0.5 [0.1, 0.8] to 1.2 [0.6, 4.8] ng/mL/hour and from 19.1 [12.9, 27.7] to 26.4 [17.1, 42.3] ng/dL, respectively; P<.0001 for both), while the aldosterone/renin ratio (ARR) decreased from 40.3 (18.5, 102.7) to 23.1 (8.6, 58.7) ng/dL per ng/mL/hour (P<.0001). Similar changes occurred irrespective of the MRA treatment duration and other antihypertensives used. Positive PA screening abrogation after MRA initiation was found in 45/94 (48%) patients. Conversely, 17% of patients had positive PA screening only after MRA treatment, mostly due to correction of hypokalemia. An initially positive screening test was more likely altered by high MRA doses and more likely persistent in patients with confirmed PA or taking beta-blockers. CONCLUSION MRAs commonly reduce ARR and the proportion of positive PA screening results. When PA is suspected, screening should be repeated off MRAs. ABBREVIATIONS ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; ARR = aldosterone/renin ratio; DRC = direct renin concentration; MRA = mineralocorticoid receptor antagonist; PA = primary aldosteronism; PAC = plasma aldosterone concentration; PRA = plasma renin activity; RAAS = renin-angiotensin-aldosterone system.
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Affiliation(s)
- Yuta Tezuka
- From the (1)Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, and; Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Adina F Turcu
- From the (1)Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, and.
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Abstract
While AF most often occurs in the setting of atrial disease, current assessment and treatment of patients with AF does not focus on the extent of the atrial myopathy that serves as the substrate for this arrhythmia. Atrial myopathy, in particular atrial fibrosis, may initiate a vicious cycle in which atrial myopathy leads to AF, which in turn leads to a worsening myopathy. Various techniques, including ECG, plasma biomarkers, electroanatomical voltage mapping, echocardiography, and cardiac MRI, can help to identify and quantify aspects of the atrial myopathy. Current therapies, such as catheter ablation, do not directly address the underlying atrial myopathy. There is emerging research showing that by targeting this myopathy we can help decrease the occurrence and burden of AF.
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Affiliation(s)
- Harold Rivner
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, US
| | - Raul D Mitrani
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, US
| | - Jeffrey J Goldberger
- Cardiovascular Division, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, US
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Ibarrola J, Garaikoetxea M, Garcia-Peña A, Matilla L, Jover E, Bonnard B, Cuesta M, Fernández-Celis A, Jaisser F, López-Andrés N. Beneficial Effects of Mineralocorticoid Receptor Antagonism on Myocardial Fibrosis in an Experimental Model of the Myxomatous Degeneration of the Mitral Valve. Int J Mol Sci 2020; 21:ijms21155372. [PMID: 32731636 PMCID: PMC7432373 DOI: 10.3390/ijms21155372] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/26/2020] [Accepted: 07/27/2020] [Indexed: 12/21/2022] Open
Abstract
Mitral valve prolapse (MVP) patients develop myocardial fibrosis that is not solely explained by volume overload, but the pathophysiology has not been defined. Mineralocorticoid receptor antagonists (MRAs) improve cardiac function by decreasing cardiac fibrosis in other heart diseases. We examined the role of MRA in myocardial fibrosis associated with myxomatous degeneration of the mitral valve. Myocardial fibrosis has been analyzed in a mouse model of mitral valve myxomatous degeneration generated by pharmacological treatment with Nordexfenfluramine (NDF) in the presence of the MRA spironolactone. In vitro, adult human cardiac fibroblasts were treated with NDF and spironolactone. In an experimental mouse, MRA treatment reduced interstitial/perivascular fibrosis and collagen type I deposition. MRA administration blunted NDF-induced cardiac expression of vimentin and the profibrotic molecules galectin-3/cardiotrophin-1. In parallel, MRA blocked the increase in cardiac non-fibrillar proteins such as fibronectin, aggrecan, decorin, lumican and syndecan-4. The following effects are blocked by MRA: in vitro, in adult human cardiac fibroblasts, NDF-treatment-induced myofibroblast activation, collagen type I and proteoglycans secretion. Our findings demonstrate, for the first time, the contribution of the mineralocorticoid receptor (MR) to the development of myocardial fibrosis associated with mitral valve myxomatous degeneration. MRA could be a therapeutic approach to reduce myocardial fibrosis associated with MVP.
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Affiliation(s)
- Jaime Ibarrola
- Cardiovascular Translational Research, Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain; (J.I.); (M.G.); (A.G.-P.); (L.M.); (E.J.); (M.C.); (A.F.-C.)
| | - Mattie Garaikoetxea
- Cardiovascular Translational Research, Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain; (J.I.); (M.G.); (A.G.-P.); (L.M.); (E.J.); (M.C.); (A.F.-C.)
| | - Amaia Garcia-Peña
- Cardiovascular Translational Research, Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain; (J.I.); (M.G.); (A.G.-P.); (L.M.); (E.J.); (M.C.); (A.F.-C.)
| | - Lara Matilla
- Cardiovascular Translational Research, Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain; (J.I.); (M.G.); (A.G.-P.); (L.M.); (E.J.); (M.C.); (A.F.-C.)
| | - Eva Jover
- Cardiovascular Translational Research, Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain; (J.I.); (M.G.); (A.G.-P.); (L.M.); (E.J.); (M.C.); (A.F.-C.)
| | - Benjamin Bonnard
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, 75013 Paris, France; (B.B.); (F.J.)
| | - Maria Cuesta
- Cardiovascular Translational Research, Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain; (J.I.); (M.G.); (A.G.-P.); (L.M.); (E.J.); (M.C.); (A.F.-C.)
| | - Amaya Fernández-Celis
- Cardiovascular Translational Research, Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain; (J.I.); (M.G.); (A.G.-P.); (L.M.); (E.J.); (M.C.); (A.F.-C.)
| | - Frederic Jaisser
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université Paris Descartes, Université Paris Diderot, 75013 Paris, France; (B.B.); (F.J.)
- Université de Lorraine, INSERM, Centre d’Investigations Cliniques-Plurithématique 1433, UMR 1116, CHRU de Nancy, French-Clinical Research Infrastructure Network (F-CRIN) INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Natalia López-Andrés
- Cardiovascular Translational Research, Navarrabiomed (Miguel Servet Foundation), Instituto de Investigación Sanitaria de Navarra (IdiSNA), 31008 Pamplona, Spain; (J.I.); (M.G.); (A.G.-P.); (L.M.); (E.J.); (M.C.); (A.F.-C.)
- Université de Lorraine, INSERM, Centre d’Investigations Cliniques-Plurithématique 1433, UMR 1116, CHRU de Nancy, French-Clinical Research Infrastructure Network (F-CRIN) INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- Correspondence: ; Tel.: +34-848428539; Fax: +34-848422300
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Neefs J, van den Berg NWE, Krul SPJ, Boekholdt SM, de Groot JR. Effect of Spironolactone on Atrial Fibrillation in Patients with Heart Failure with Preserved Ejection Fraction: Post-Hoc Analysis of the Randomized, Placebo-Controlled TOPCAT Trial. Am J Cardiovasc Drugs 2020; 20:73-80. [PMID: 31214914 PMCID: PMC6978290 DOI: 10.1007/s40256-019-00353-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Mineralocorticoid receptor antagonists (MRAs) reduce the risk of atrial fibrillation (AF) in patients with heart failure (HF) and a reduced ejection fraction. The efficacy of MRAs for AF prevention in patients with HF and a preserved ejection fraction (HFpEF) is unclear. Objectives We performed a secondary analysis of a randomized placebo-controlled trial to determine the efficacy of spironolactone in reducing new-onset AF and recurrence of AF in 2733 patients with symptomatic HFpEF. Methods Patients with and without prevalent AF at baseline were included, and those with permanent AF were excluded. Patients were randomized 1:1 to spironolactone or placebo. The risk of new-onset AF or the recurrence of AF was quantified using hazard ratios (HRs) with corresponding 95% confidence intervals (CIs). Results At baseline, 2228 (64.7%) patients had no history of AF (spironolactone, n = 1111; placebo, n = 1117), whereas 505 (18.4%) patients had prevalent AF (spironolactone, n = 260; placebo, n = 245). During a median follow-up of 3.1 years (interquartile range [IQR] 2.0–4.9), the incidence of new-onset AF was similar in both treatment arms: spironolactone 5.2% (n = 58) versus placebo 4.4% (n = 49); p = 0.41. The risk of new-onset AF was similar in both treatment arms: HR 1.19; 95% CI 0.81–1.74; p = 0.38. AF recurrence was also similar in both treatment arms during a median follow-up of 3.3 years (IQR 1.9–4.7): spironolactone 11.5% (n = 30) versus placebo 11.8% (n = 29); p = 1.00. The risk of recurrence of AF did not differ per treatment arm: HR 0.94; 95% CI 0.57–1.58; p = 0.83. Conclusion Spironolactone does not reduce the risk of new-onset AF or AF recurrence in patients with HFpEF. This is in contrast to results in cohorts of patients with HF and a reduced ejection fraction. Clinical trial registration ClinicalTrials.gov identifier no. NCT00094302 (TOPCAT). Electronic supplementary material The online version of this article (10.1007/s40256-019-00353-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jolien Neefs
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Sébastien P J Krul
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | - S Matthijs Boekholdt
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands
| | - Joris R de Groot
- Department of Cardiology, Heart Center, Academic Medical Center, Amsterdam, The Netherlands.
- Department of Cardiology, Amsterdam UMC, University van Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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9
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Pons Fernández N, Moreno F, Morata J, Moriano A, León S, De Mingo C, Zuñiga Á, Calvo F. Familial hyperaldosteronism type III a novel case and review of literature. Rev Endocr Metab Disord 2019; 20:27-36. [PMID: 30569443 DOI: 10.1007/s11154-018-9481-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Less than 15% of hypertension cases in children are secondary to a primary hyperaldosteronism. This is idiopathic in 60% of the cases, secondary to a unilateral adenoma in 30% and 10% remaining by primary adrenal hyperplasia, familial hyperaldosteronism, ectopic aldosterone production or adrenocortical carcinoma.To date, four types of familial hyperaldosteronism (FH I to FH IV) have been reported. FH III is caused by germline mutations in KCNJ5, encoding the potassium channel Kir3.4. The mutations cause the channel to lose its selectivity for potassium, allowing large quantities of sodium to enter the cell. As a consequence, the membrane depolarizes, voltage-gated calcium channels open, calcium enters the cell, initiating the cascade that leads to aldosterone synthesis. Somatic mutations in KCNJ5 has also been described in aldosterone-producing adenomas. The most frequent presentation of FH III is with severe hyperaldosteronism symptoms and resistance to pharmacological therapy which leads to bilateral adrenalectomy. We will review current literature and describe a child with FH III due to a novel de novo deletion in KCNJ5 with wild phenotype as a sign of clinical variability of this disease.
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Affiliation(s)
- Natividad Pons Fernández
- Department of Pediatrics, Hospital Lluís Alcanyís de Xàtiva, Ctra. Xàtiva a Silla km 2, 46800, Xàtiva, Valencia, Spain.
| | - Francisca Moreno
- Hospital Universitario y Politécnico la Fe de Valencia, Valencia, Spain
| | - Julia Morata
- Department of Pediatrics, Hospital Lluís Alcanyís de Xàtiva, Ctra. Xàtiva a Silla km 2, 46800, Xàtiva, Valencia, Spain
| | - Ana Moriano
- Department of Pediatrics, Hospital Lluís Alcanyís de Xàtiva, Ctra. Xàtiva a Silla km 2, 46800, Xàtiva, Valencia, Spain
| | - Sara León
- Hospital Universitario y Politécnico la Fe de Valencia, Valencia, Spain
| | - Carmen De Mingo
- Hospital Universitario y Politécnico la Fe de Valencia, Valencia, Spain
| | - Ángel Zuñiga
- Hospital Universitario y Politécnico la Fe de Valencia, Valencia, Spain
| | - Fernando Calvo
- Department of Pediatrics, Hospital Lluís Alcanyís de Xàtiva, Ctra. Xàtiva a Silla km 2, 46800, Xàtiva, Valencia, Spain
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10
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Abstract
The mineralocorticoid hormone aldosterone is released by the adrenal glands in a homeostatic mechanism to regulate blood volume. Several cues elicit aldosterone release, and the long-term action of the hormone is to restore blood pressure and/or increase the retrieval of sodium from filtered plasma in the kidney. While the signaling cascade that results in aldosterone release is well studied, the impact of this hormone on tissues and cells in various organ systems is pleotropic. Emerging evidence indicates aldosterone may alter non-coding RNAs (ncRNAs) to integrate the hormonal response, and these ncRNAs may contribute to the heterogeneity of signaling outcomes in aldosterone target tissues. The best studied of the ncRNAs in aldosterone action are the small ncRNAs, microRNAs. MicroRNA expression is regulated by aldosterone stimulation, and microRNAs are able to modulate protein expression at all steps in the renin-angiotensin-aldosterone-signaling system. The discovery and synthesis of microRNAs will be briefly covered followed by a discussion of the reciprocal role of aldosterone/microRNA regulation, including misregulation of microRNA signaling in aldosterone-linked disease states.
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Abstract
Spironolactone has been marketed for over half a century as a ‘potassium-sparing diuretic’, used primarily in patients with ascites. With the realization that primary aldosteronism is the most common (5-13%) form of secondary hypertension, it has become widely used as a mineralocorticoid receptor antagonist. More recently, in the wake of the RALES trial, spironolactone in addition to standard therapy has been shown to be very beneficial in heart failure with a reduced ejection fraction. Despite the failure of the TOPCAT trial, spironolactone is being increasingly used in diastolic heart failure (i.e. with a preserved ejection fraction). The third currently accepted role for spironolactone is in hypertension resistant to three conventional antihypertensives including a diuretic, where it has been proven to be effective, in contra-distinction to renal artery denervation. Finally, brief consideration will be given to ‘areas in waiting’ – pulmonary hypertension/fibrosis, cancer – where spironolactone may play very useful roles.
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Affiliation(s)
- John W Funder
- Hudson Institute, Monash Medical Centre and Monash University, 27-31 Wright St Clayton, VIC, 3168, Australia
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12
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Therapeutic Targeting of Cellular Stress to Prevent Cardiovascular Disease: A Review of the Evidence. Am J Cardiovasc Drugs 2017; 17:83-95. [PMID: 27778192 DOI: 10.1007/s40256-016-0199-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The availability of effective drugs targeting the major risk factors of cardiovascular disease (CVD) has reduced morbidity and mortality. Cumulative relative risk of CVD events can be reduced by 75 % with a combination of aspirin, a β-adrenoceptor antagonist (β-blocker), an HMG-CoA reductase inhibitor (statin), and an angiotensin-converting enzyme inhibitor. The principal pharmacodynamics of these drugs cannot explain the entirety of their cardioprotective action, as other drugs with similar pharmacologic targets have not been associated with favorable clinical effects. This raises the possibility that the cardioprotective drugs have a unique pleiotropic activity that contributes to their clinical efficacy. Recent data suggest that reducing cellular stress such as oxidative, inflammatory, and endoplasmic reticulum stress, might be a common denominator of the drugs with proven efficacy in reducing CVD risk. In this communication, the evidence in favor of this hypothesis is discussed, and ongoing trials with therapeutic agents targeting cellular stresses are reviewed.
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13
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Aldosterone Pathway Blockade to Prevent Atrial Fibrillation: A Systematic Review and Meta-Analysis. Int J Cardiol 2017; 231:155-161. [DOI: 10.1016/j.ijcard.2016.12.029] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/25/2016] [Accepted: 12/10/2016] [Indexed: 11/19/2022]
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14
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Akoumianakis I, Tarun A, Antoniades C. Perivascular adipose tissue as a regulator of vascular disease pathogenesis: identifying novel therapeutic targets. Br J Pharmacol 2016; 174:3411-3424. [PMID: 27976387 DOI: 10.1111/bph.13666] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Revised: 10/04/2016] [Accepted: 10/28/2016] [Indexed: 12/23/2022] Open
Abstract
Adipose tissue (AT) is an active endocrine organ with the ability to dynamically secrete a wide range of adipocytokines. Importantly, its secretory profile is altered in various cardiovascular disease states. AT surrounding vessels, or perivascular AT (PVAT), is recognized in particular as an important local regulator of vascular function and dysfunction. Specifically, PVAT has the ability to sense vascular paracrine signals and respond by secreting a variety of vasoactive adipocytokines. Due to the crucial role of PVAT in regulating many aspects of vascular biology, it may constitute a novel therapeutic target for the prevention and treatment of vascular disease pathogenesis. Signalling pathways in PVAT, such as those using adiponectin, H2 S, glucagon-like peptide 1 or pro-inflammatory cytokines, are among the potential novel pharmacological therapeutic targets of PVAT. LINKED ARTICLES This article is part of a themed section on Molecular Mechanisms Regulating Perivascular Adipose Tissue - Potential Pharmacological Targets? To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v174.20/issuetoc.
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Affiliation(s)
- Ioannis Akoumianakis
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford
| | - Akansha Tarun
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford
| | - Charalambos Antoniades
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford
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15
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Hansen T, Galougahi KK, Celermajer D, Rasko N, Tang O, Bubb KJ, Figtree G. Oxidative and nitrosative signalling in pulmonary arterial hypertension — Implications for development of novel therapies. Pharmacol Ther 2016; 165:50-62. [DOI: 10.1016/j.pharmthera.2016.05.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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16
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Gromotowicz-Poplawska A, Szoka P, Kolodziejczyk P, Kramkowski K, Wojewodzka-Zelezniakowicz M, Chabielska E. New agents modulating the renin-angiotensin-aldosterone system-Will there be a new therapeutic option? Exp Biol Med (Maywood) 2016; 241:1888-1899. [PMID: 27439538 DOI: 10.1177/1535370216660211] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/22/2016] [Indexed: 12/19/2022] Open
Abstract
The renin-angiotensin-aldosterone system (RAAS) is more complex than it was originally regarded. According to the current subject knowledge, there are two main axes of the RAAS: (1) angiotensin-converting enzyme (ACE)-angiotensin II-AT1 receptor axis and (2) ACE2-angiotensin-(1-7)-Mas receptor axis. The activation of the first axis leads to deleterious effects, including vasoconstriction, endothelial dysfunction, thrombosis, inflammation, and fibrosis; therefore, blocking the components of this axis is a highly rational and commonly used therapeutic procedure. The ACE2-Ang-(1-7)-Mas receptor axis has a different role, since it often opposes the effects induced by the classical ACE-Ang II-AT1 axis. Once the positive effects of the ACE2-Ang-(1-7)-Mas axis were discovered, the alternative ways of pharmacotherapy activating this axis of RAAS appeared. This article briefly describes new molecules affecting the RAAS, namely: recombinant human ACE2, ACE2 activators, angiotensin-(1-7) peptide and non-peptide analogs, aldosterone synthase inhibitors, and the third and fourth generation of mineralocorticoid receptor antagonists. The results of the experimental and clinical studies are encouraging, which leads us to believe that these new molecules can support the treatment of cardiovascular diseases as well as cardiometabolic disorders.
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Affiliation(s)
| | - Piotr Szoka
- Department of Biopharmacy, Medical University of Bialystok, 15-089 Bialystok, Poland
| | - Patrycjusz Kolodziejczyk
- Department of Pharmaceutical Analysis, Medical University of Bialystok, 15-522 Bialystok, Poland
| | - Karol Kramkowski
- Department of Biopharmacy, Medical University of Bialystok, 15-089 Bialystok, Poland
| | | | - Ewa Chabielska
- Department of Biopharmacy, Medical University of Bialystok, 15-089 Bialystok, Poland
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Eplerenone restores 24-h blood pressure circadian rhythm and reduces advanced glycation end-products in rhesus macaques with spontaneous hypertensive metabolic syndrome. Sci Rep 2016; 6:23957. [PMID: 27032687 PMCID: PMC4817044 DOI: 10.1038/srep23957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 03/17/2016] [Indexed: 12/27/2022] Open
Abstract
Hypertension is often associated with metabolic syndrome (MetS), and serves as a risk factor of MetS and its complications. Blood pressure circadian rhythm in hypertensive patients has been suggested to contribute to cardiovascular consequences and organ damage of hypertension. But circadian changes of BP and their response to drugs have not been clearly investigated in non-human primates (NHPs) of MetS with hypertension. Here, we identified 16 elderly, hypertensive MetS rhesus monkeys from our in-house cohort. With implanted telemetry, we investigate BP changes and its circadian rhythm, together with the effect of antihypertensive drugs on BP and its diurnal fluctuation. MetS hypertensive monkeys displayed higher BP, obesity, glucose intolerance, and dyslipidemia. We also confirmed impaired 24-h BP circadian rhythm in MetS hypertensive monkeys. Importantly, Eplerenone, a mineralocorticoid receptor blocker, exerts multiple beneficial effects in MetS hypertensive monkeys, including BP reduction, 24-h BP circadian rhythm restoration, and decreased plasma concentration of inflammation factors and advanced glycation end-products. In summary, we identified a naturally-developed hypertensive MetS NHP model, which is of great value in the studies on pathogenesis of MetS-associated hypertension and development of novel therapeutic strategies. We also provided multiple novel mechanistic insights of the beneficial effect of Eplerenone on MetS with hypertension.
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18
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Giordano A, Frontini A, Cinti S. Convertible visceral fat as a therapeutic target to curb obesity. Nat Rev Drug Discov 2016; 15:405-24. [PMID: 26965204 DOI: 10.1038/nrd.2016.31] [Citation(s) in RCA: 167] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
New therapeutic and preventative strategies are needed to address the growing obesity epidemic. In animal models, brown adipose tissue activation and the associated heat produced contribute to countering obesity and the accompanying metabolic abnormalities. Adult humans also have functional brown fat. Here, we present and discuss the concepts of murine and human white adipose tissue plasticity and the transdifferentiation of white adipocytes into brown adipocytes. Human visceral adipocytes - which are crucial contributors to the burden of obesity and its complications - are particularly susceptible to such transdifferentiation. Therefore, we propose that this process should be a focus of anti-obesity research. Approved drugs that have browning properties as well as future drugs that target molecular pathways involved in white-to-brown visceral adipocyte transdifferentiation may provide new avenues for obesity therapy.
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Affiliation(s)
- Antonio Giordano
- Department of Experimental and Clinical Medicine, University of Ancona (Università Politecnica delle Marche), Via Tronto, 10/A 60020 Ancona, Italy
| | - Andrea Frontini
- Department of Public Health Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy
| | - Saverio Cinti
- Department of Experimental and Clinical Medicine, University of Ancona (Università Politecnica delle Marche), Via Tronto, 10/A 60020 Ancona, Italy.,Center of Obesity, University of Ancona (Università Politecnica delle Marche)-United Hospitals, 60020 Ancona, Italy
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19
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Chen MD, Dong SS, Cai NY, Fan MD, Gu SP, Zheng JJ, Yin HM, Zhou XH, Wang LX, Li CY, Zheng C. Efficacy and safety of mineralocorticoid receptor antagonists for patients with heart failure and diabetes mellitus: a systematic review and meta-analysis. BMC Cardiovasc Disord 2016; 16:28. [PMID: 26822790 PMCID: PMC4731899 DOI: 10.1186/s12872-016-0198-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 01/22/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The aim of this study was to systematically assess the efficacy and safety of mineralocorticoid receptor antagonists (MRAs) for patients with heart failure (HF) and diabetes mellitus (DM). METHODS We conducted a comprehensive search for controlled studies that evaluated the efficacy and safety of MRAs in patients with DM and HF. Medline, Embase and Cochrane databases were searched. Two reviewers independently identified citations, extracted data and evaluated quality. Risk estimations were abstracted and pooled where appropriate. RESULTS Four observational studies were included. MRAs use was associated with reduced mortality compared with controls (RR = 0.78; 95% CI: 0.69-0.88; I(2) = 0%; P < 0.001). Increased risk of developing hyperkalaemia was observed in those patients taking MRAs (RR = 1.74; 95% CI: 1.27-2.38; I(2) = 0%; P = 0.0005). CONCLUSIONS The current cumulative evidence suggests that MRAs can improve clinical outcomes but increase the risk of hyperkalaemia in patients with DM and HF. TRIAL REGISTRATION PROSPERO CRD42015025690 .
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Affiliation(s)
- Meng-Die Chen
- Diabetes Center and Department of Endocrinology, The Second Affiliated Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, 325027, Wenzhou, Zhejiang, China.
| | - Si-Si Dong
- Diabetes Center and Department of Endocrinology, The Second Affiliated Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, 325027, Wenzhou, Zhejiang, China.
| | - Ning-Yu Cai
- Department of Orthopedics, The Second Affiliated Hospital of Wenzhou Medical University, 325027, Wenzhou, Zhejiang, China.
| | - Meng-Di Fan
- Diabetes Center and Department of Endocrinology, The Second Affiliated Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, 325027, Wenzhou, Zhejiang, China.
| | - Su-Ping Gu
- Diabetes Center and Department of Endocrinology, The Second Affiliated Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, 325027, Wenzhou, Zhejiang, China.
| | - Jin-Jue Zheng
- Diabetes Center and Department of Endocrinology, The Second Affiliated Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, 325027, Wenzhou, Zhejiang, China.
| | - Hai-Min Yin
- Diabetes Center and Department of Endocrinology, The Second Affiliated Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, 325027, Wenzhou, Zhejiang, China.
| | - Xin-He Zhou
- Diabetes Center and Department of Endocrinology, The Second Affiliated Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, 325027, Wenzhou, Zhejiang, China.
| | - Liang-Xue Wang
- Diabetes Center and Department of Endocrinology, The Second Affiliated Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, 325027, Wenzhou, Zhejiang, China.
| | - Chun-Ying Li
- Diabetes Center and Department of Endocrinology, The Second Affiliated Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, 325027, Wenzhou, Zhejiang, China.
| | - Chao Zheng
- Diabetes Center and Department of Endocrinology, The Second Affiliated Hospital of Wenzhou Medical University, No. 109 West Xueyuan Road, 325027, Wenzhou, Zhejiang, China.
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20
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21
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Bienvenu LA, Reichelt ME, Morgan J, Fletcher EK, Bell JR, Rickard AJ, Delbridge LM, Young MJ. Cardiomyocyte Mineralocorticoid Receptor Activation Impairs Acute Cardiac Functional Recovery After Ischemic Insult. Hypertension 2015; 66:970-7. [PMID: 26351032 DOI: 10.1161/hypertensionaha.115.05981] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 08/11/2015] [Indexed: 01/03/2023]
Abstract
Loss of mineralocorticoid receptor signaling selectively in cardiomyocytes can ameliorate cardiac fibrotic and inflammatory responses caused by excess mineralocorticoids. The aim of this study was to characterize the role of cardiomyocyte mineralocorticoid receptor signaling in ischemia-reperfusion injury and recovery and to identify a role of mineralocorticoid receptor modulation of cardiac function. Wild-type and cardiomyocyte mineralocorticoid receptor knockout mice (8 weeks) were uninephrectomized and maintained on (1) high salt (0.9% NaCl, 0.4% KCl) or (2) high salt plus deoxycorticosterone pellet (0.3 mg/d, 0.9% NaCl, 0.4% KCl). After 8 weeks of treatment, hearts were isolated and subjected to 20 minutes of global ischemia plus 45 minutes of reperfusion. Mineralocorticoid excess increased peak contracture during ischemia regardless of genotype. Recovery of left ventricular developed pressure and rates of contraction and relaxation post ischemia-reperfusion were greater in knockout versus wild-type hearts. The incidence of arrhythmic activity during early reperfusion was significantly higher in wild-type than in knockout hearts. Levels of autophosphorylated Ca(2+)/calmodulin protein kinase II (Thr287) were elevated in hearts from wild-type versus knockout mice and associated with increased sodium hydrogen exchanger-1 expression. These findings demonstrate that cardiomyocyte-specific mineralocorticoid receptor-dependent signaling contributes to electromechanical vulnerability in acute ischemia-reperfusion via a mechanism involving Ca(2+)/calmodulin protein kinase II activation in association with upstream alteration in expression regulation of the sodium hydrogen exchanger-1.
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Affiliation(s)
- Laura A Bienvenu
- From the Department of Cardiovascular Endocrinology, Hudson Institute of Medical Research, Clayton, Australia (L.A.B., J.M., E.K.F., A.J.R., M.J.Y.); and Department of Physiology, Melbourne University, Parkville, Australia (L.A.B., M.E.R., J.R.B., L.M.D.)
| | - Melissa E Reichelt
- From the Department of Cardiovascular Endocrinology, Hudson Institute of Medical Research, Clayton, Australia (L.A.B., J.M., E.K.F., A.J.R., M.J.Y.); and Department of Physiology, Melbourne University, Parkville, Australia (L.A.B., M.E.R., J.R.B., L.M.D.)
| | - James Morgan
- From the Department of Cardiovascular Endocrinology, Hudson Institute of Medical Research, Clayton, Australia (L.A.B., J.M., E.K.F., A.J.R., M.J.Y.); and Department of Physiology, Melbourne University, Parkville, Australia (L.A.B., M.E.R., J.R.B., L.M.D.)
| | - Elizabeth K Fletcher
- From the Department of Cardiovascular Endocrinology, Hudson Institute of Medical Research, Clayton, Australia (L.A.B., J.M., E.K.F., A.J.R., M.J.Y.); and Department of Physiology, Melbourne University, Parkville, Australia (L.A.B., M.E.R., J.R.B., L.M.D.)
| | - James R Bell
- From the Department of Cardiovascular Endocrinology, Hudson Institute of Medical Research, Clayton, Australia (L.A.B., J.M., E.K.F., A.J.R., M.J.Y.); and Department of Physiology, Melbourne University, Parkville, Australia (L.A.B., M.E.R., J.R.B., L.M.D.)
| | - Amanda J Rickard
- From the Department of Cardiovascular Endocrinology, Hudson Institute of Medical Research, Clayton, Australia (L.A.B., J.M., E.K.F., A.J.R., M.J.Y.); and Department of Physiology, Melbourne University, Parkville, Australia (L.A.B., M.E.R., J.R.B., L.M.D.)
| | - Lea M Delbridge
- From the Department of Cardiovascular Endocrinology, Hudson Institute of Medical Research, Clayton, Australia (L.A.B., J.M., E.K.F., A.J.R., M.J.Y.); and Department of Physiology, Melbourne University, Parkville, Australia (L.A.B., M.E.R., J.R.B., L.M.D.)
| | - Morag J Young
- From the Department of Cardiovascular Endocrinology, Hudson Institute of Medical Research, Clayton, Australia (L.A.B., J.M., E.K.F., A.J.R., M.J.Y.); and Department of Physiology, Melbourne University, Parkville, Australia (L.A.B., M.E.R., J.R.B., L.M.D.).
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