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Pereira NL, Cresci S, Angiolillo DJ, Batchelor W, Capers Q, Cavallari LH, Leifer D, Luzum JA, Roden DM, Stellos K, Turrise SL, Tuteja S. CYP2C19 Genetic Testing for Oral P2Y12 Inhibitor Therapy: A Scientific Statement From the American Heart Association. Circulation 2024; 150:e129-e150. [PMID: 38899464 PMCID: PMC11300169 DOI: 10.1161/cir.0000000000001257] [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] [Indexed: 06/21/2024]
Abstract
There is significant variability in the efficacy and safety of oral P2Y12 inhibitors, which are used to prevent ischemic outcomes in common diseases such as coronary and peripheral arterial disease and stroke. Clopidogrel, a prodrug, is the most used oral P2Y12 inhibitor and is activated primarily after being metabolized by a highly polymorphic hepatic cytochrome CYP2C219 enzyme. Loss-of-function genetic variants in CYP2C219 are common, can result in decreased active metabolite levels and increased on-treatment platelet aggregation, and are associated with increased ischemic events on clopidogrel therapy. Such patients can be identified by CYP2C19 genetic testing and can be treated with alternative therapy. Conversely, universal use of potent oral P2Y12 inhibitors such as ticagrelor or prasugrel, which are not dependent on CYP2C19 for activation, has been recommended but can result in increased bleeding. Recent clinical trials and meta-analyses have demonstrated that a precision medicine approach in which loss-of-function carriers are prescribed ticagrelor or prasugrel and noncarriers are prescribed clopidogrel results in reducing ischemic events without increasing bleeding risk. The evidence to date supports CYP2C19 genetic testing before oral P2Y12 inhibitors are prescribed in patients with acute coronary syndromes or percutaneous coronary intervention. Clinical implementation of such genetic testing will depend on among multiple factors: rapid availability of results or adoption of the concept of performing preemptive genetic testing, provision of easy-to-understand results with therapeutic recommendations, and seamless integration in the electronic health record.
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Coons JC, Empey PE. Pharmacogenomics in the Management of Pulmonary Arterial Hypertension: Current Perspectives. Pharmgenomics Pers Med 2023; 16:729-737. [PMID: 37457231 PMCID: PMC10349598 DOI: 10.2147/pgpm.s361222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is a rare disease with heterogeneous causes that can lead to right ventricular (RV) failure and death if left untreated. There are currently 10 medications representative of five unique pharmacologic classes that are approved for treatment. These have led to significant improvements in overall clinical outcome. However, substantial variability in dosing requirements and treatment response is evident, leading to suboptimal outcome for many patients. Furthermore, dosing is empiric and iterative and can lead to delays in meeting treatment goals and burdensome adverse effects. Pharmacogenomic (PGx) associations have been reported with certain PAH medications, such as treprostinil and bosentan, and can explain some of the variability in response. Relevant genes associated with treprostinil include CYP2C8, CYP2C9, CAMK2D, and PFAS. CYP2C8 and CYP2C9 are the genes encoding the major metabolizing liver enzymes for treprostinil, and reduced function variants (*2, *3) with CYP2C9 were associated with lower treatment persistence. Additionally, a higher CYP2C9 activity score was associated with a significantly less risk of treatment discontinuation. Other genes of interest that have been explored with treprostinil include CAMK2D, which is associated with right ventricular dysfunction and significantly higher dose requirements. Similarly, PFAS is associated with lower concentrations of cyclic adenosine monophosphate and significantly higher dose requirements. Genes of interest with the endothelin receptor antagonist (ERA) class include GNG2 and CYP2C9. A genetic variant in GNG2 (rs11157866) was linked to a significantly increased rate of clinical improvement with ERAs. The *2 variant with CYP2C9 (encoding for the major metabolizing enzyme for bosentan) was significantly associated with a higher risk for elevations in hepatic aminotransferases and liver injury. In summary, this article reviews the relevant pharmacogenes that have been associated to date with dosing and outcome among patients who received PAH medications.
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Affiliation(s)
- James C Coons
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
- Department of Pharmacy, UPMC Presbyterian-Shadyside Hospital, Pittsburgh, PA, USA
| | - Philip E Empey
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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Mijiti M, Maimaiti A, Chen X, Tuersun M, Dilixiati M, Dilixiati Y, Zhu G, Wu H, Li Y, Turhon M, Abulaiti A, Maimaitiaili N, Yiming N, Kasimu M, Wang Y. CRISPR-cas9 screening identified lethal genes enriched in Hippo kinase pathway and of predictive significance in primary low-grade glioma. Mol Med 2023; 29:64. [PMID: 37183261 PMCID: PMC10183247 DOI: 10.1186/s10020-023-00652-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 04/14/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Low-grade gliomas (LGG) are a type of brain tumor that can be lethal, and it is essential to identify genes that are correlated with patient prognosis. In this study, we aimed to use CRISPR-cas9 screening data to identify key signaling pathways and develop a genetic signature associated with high-risk, low-grade glioma patients. METHODS The study used CRISPR-cas9 screening data to identify essential genes correlated with cell survival in LGG. We used RNA-seq data to identify differentially expressed genes (DEGs) related to cell viability. Moreover, we used the least absolute shrinkage and selection operator (LASSO) method to construct a genetic signature for predicting overall survival in patients. We performed enrichment analysis to identify pathways mediated by DEGs, overlapping genes, and genes shared in the Weighted correlation network analysis (WGCNA). Finally, the study used western blot, qRT-PCR, and IHC to detect the expression of hub genes from signature in clinical samples. RESULTS The study identified 145 overexpressed oncogenes in low-grade gliomas using the TCGA database. These genes were intersected with lethal genes identified in the CRISPR-cas9 screening data from Depmap database, which are enriched in Hippo pathways. A total of 19 genes were used to construct a genetic signature, and the Hippo signaling pathway was found to be the predominantly enriched pathway. The signature effectively distinguished between low- and high-risk patients, with high-risk patients showing a shorter overall survival duration. Differences in hub gene expression were found in different clinical samples, with the protein and mRNA expression of REP65 being significantly up-regulated in tumor cells. The study suggests that the Hippo signaling pathway may be a critical regulator of viability and tumor proliferation and therefore is an innovative new target for treating cancerous brain tumors, including low-grade gliomas. CONCLUSION Our study identified a novel genetic signature associated with high-risk, LGG patients. We found that the Hippo signaling pathway was significantly enriched in this signature, indicating that it may be a critical regulator of tumor viability and proliferation in LGG. Targeting the Hippo pathway could be an innovative new strategy for treating LGG.
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Affiliation(s)
- Maimaitili Mijiti
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, 830054, Urumqi, China
| | - Aierpati Maimaiti
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, 830054, Urumqi, China
| | - Xiaoqing Chen
- The First Affiliated Hospital of Xinjiang Medical University, Urumqi, 830054, Xinjiang, China
| | - Maidina Tuersun
- Xinjiang Medical University, Urumqi, 830011, Xinjiang, China
| | | | | | - Guohua Zhu
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, 830054, Urumqi, China
| | - Hao Wu
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, 830054, Urumqi, China
| | - Yandong Li
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, 830054, Urumqi, China
| | - Mirzat Turhon
- Department of Neurointerventional Surgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing, 100070, China
- Department of Neurointerventional Surgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
| | - Aimitaji Abulaiti
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, 830054, Urumqi, China
| | | | - Nadire Yiming
- Xinjiang Medical University, Urumqi, 830011, Xinjiang, China
| | - Maimaitijiang Kasimu
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, 830054, Urumqi, China.
| | - Yongxin Wang
- Department of Neurosurgery, Neurosurgery Centre, The First Affiliated Hospital of Xinjiang Medical University, Xinjiang, 830054, Urumqi, China.
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Lee SH, Jeong YH, Hong D, Choi KH, Lee JM, Park TK, Yang JH, Hahn JY, Choi SH, Gwon HC, Jeong MH, Kim BK, Joo HJ, Chang K, Park Y, Ahn SG, Suh JW, Lee SY, Cho JR, Her AY, Kim HS, Kim MH, Lim DS, Shin ES, Song YB. Clinical Impact of CYP2C19 Genotype on Clopidogrel-Based Antiplatelet Therapy After Percutaneous Coronary Intervention. JACC Cardiovasc Interv 2023; 16:829-843. [PMID: 37045504 DOI: 10.1016/j.jcin.2023.01.363] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/19/2023] [Accepted: 01/24/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Although there is a growing body of evidence that CYP2C19 genotyping can be beneficial when considering treatment with clopidogrel after percutaneous coronary intervention (PCI), whether a genotype-guided strategy can be generally adopted in routine practice remains unclear among East Asians. OBJECTIVES This study sought to investigate long-term outcomes of patients undergoing clopidogrel-based antiplatelet therapy after drug-eluting stent (DES) implantation according to CYP2C19 genotypes. METHODS From the nationwide multicenter PTRG-DES (Platelet function and genoType-Related long-term proGnosis in DES-treated patients) consortium, patients who underwent CYP2C19 genotyping were selected and classified according to CYP2C19 loss-of-function allele: rapid metabolizers (RMs) or normal metabolizers (NMs) vs intermediate metabolizers (IMs) or poor metabolizers (PMs). The primary outcome was a composite of cardiac death, myocardial infarction, and stent thrombosis at 5 years after the index procedure. RESULTS Of 8,163 patients with CYP2C19 genotyping, 56.7% presented with acute coronary syndrome. There were 3,098 (37.9%) in the RM or NM group, 3,906 (47.9%) in the IM group, and 1,159 (14.2%) in the PM group. IMs or PMs were associated with an increased risk of 5-year primary outcome compared with RMs or NMs (HRadj: 1.42; 95% CI: 1.01-1.98; P = 0.041), and the effect was more pronounced in the first year (HRadj: 1.67; 95% CI: 1.10-2.55; P = 0.016). The prognostic implication of being an IM and PM was significant in acute coronary syndrome patients (HRadj: 1.88; 95% CI: 1.20-2.93; P = 0.005) but not in those with stable angina (HRadj: 0.92; 95% CI: 0.54-1.55; P = 0.751) (interaction P = 0.028). CONCLUSIONS Among East Asians with clopidogrel-based antiplatelet therapy after DES implantation, CYP2C19 genotyping could stratify patients who were likely to have an increased risk of atherothrombotic events. (Platelet Function and genoType-Related Long-term progGosis in DES-treated Patients: A Consortium From Multi-centered Registries [PTRG-DES]; NCT04734028).
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Li MY, Peng LM, Chen XP. Pharmacogenomics in drug-induced cardiotoxicity: Current status and the future. Front Cardiovasc Med 2022; 9:966261. [PMID: 36312261 PMCID: PMC9606405 DOI: 10.3389/fcvm.2022.966261] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/05/2022] [Indexed: 11/15/2022] Open
Abstract
Drug-induced cardiotoxicity (DICT) is an important concern of drug safety in both drug development and clinical application. The clinical manifestations of DICT include cardiomyopathy, arrhythmia, myocardial ischemia, heart failure, and a series of cardiac structural and functional changes. The occurrence of DICT has negative impacts on the life quality of the patients, brings additional social and economic burden. It is important to identify the potential factors and explore the mechanisms of DICT. Traditional cardiovascular risk factors can only partially explain the risk of DICT. Pharmacogenomic studies show accumulated evidence of genetics in DICT and suggest the potential to guide precision therapy to reduce risk of cardiotoxicity. The comprehensive application of technologies such as third-generation sequencing, human induced pluripotent stem (iPS) cells and genome editing has promoted the in-depth understanding of the functional role of susceptible genes in DICT. This paper reviewed drugs that cause DICT, the clinical manifestations and laboratory tests, as well as the related content of genetic variations associated with the risk of DICT, and further discussed the implication of new technologies in pharmacogenomics of DICT.
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Affiliation(s)
- Mo-Yun Li
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China,Hunan Key Laboratory of Pharmacogenetics, Institute of Clinical Pharmacology, Central South University, Changsha, China
| | - Li-Ming Peng
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China,Hunan Key Laboratory of Pharmacogenetics, Institute of Clinical Pharmacology, Central South University, Changsha, China,Department of Cardiology, Xiangya Hospital, Central South University, Changsha, China,*Correspondence: Li-Ming Peng
| | - Xiao-Ping Chen
- Department of Clinical Pharmacology, Xiangya Hospital, Central South University, Changsha, China,Hunan Key Laboratory of Pharmacogenetics, Institute of Clinical Pharmacology, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China,Xiao-Ping Chen
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Abdelazeem B, Shehata J, Abbas KS, El-Shahat NA, Baral N, Adhikari G, Khan H, Hassan M. De-escalation from Prasugrel or Ticagrelor to Clopidogrel in Patients with Acute Coronary Syndrome Managed with Percutaneous Coronary Intervention: An Updated Meta-analysis of Randomized Clinical Trials. Am J Cardiovasc Drugs 2022; 22:287-298. [PMID: 34651261 DOI: 10.1007/s40256-021-00504-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2021] [Indexed: 01/29/2023]
Abstract
INTRODUCTION We aimed to evaluate the clinical benefits of a de-escalation strategy from prasugrel or ticagrelor to clopidogrel versus continuation of prasugrel or ticagrelor along with aspirin in both strategies for patients presenting with acute coronary syndrome (ACS) and treated with percutaneous coronary intervention (PCI), and to analyze the effect of the recently published randomized clinical trial (RCT) by Park et al., which included the largest sample size ever and the largest switched number of patients, on current guidelines and practices. DATA SOURCES The PubMed, EMBASE, Scopus, Web of Science, Cochrane Central, and Google Scholar databases were searched systematically from inception to May 2021 by using the search terms ('de-escalation' OR 'switching') AND ('antiplatelet' OR 'clopidogrel' OR 'ticagrelor' OR 'prasugrel') AND ('percutaneous coronary intervention' OR 'PCI'' OR 'Acute coronary syndrome' OR 'ACS'). STUDY SELECTION AND DATA EXTRACTION We included RCTs that reported the primary outcomes, i.e. net clinical benefits and Bleeding Academic Research Consortium (BARC) type 2 or higher bleeding. A combination of both ischemic and bleeding events was defined as a net clinical benefit. DATA SYNTHESIS A total of four RCTs were included, with 5952 patients. A random-effects meta-analysis revealed that a de-escalation strategy was associated with lower ischemic and bleeding events (net clinical benefits; risk ratio [RR] 0.63, 95% confidence interval [CI] 0.47-0.85; p = 0.003), and lower BARC type 2 or higher bleeding (RR 0.51, 95% CI 0.29-0.91; p = 0.02) when compared with a continuation strategy. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The current guidelines recommend potent P2Y12 prasugrel or ticagrelor for 12 months despite their association with a high risk of bleeding. Our meta-analysis updates cardiologists, providing them with the best available evidence in managing patients with ACS who underwent PCI. CONCLUSION Among patients with ACS treated with PCI, a de-escalation strategy (prasugrel or ticagrelor to clopidogrel) is associated with lower ischemic and bleeding events (net clinical benefits) and lower BARC type 2 or higher bleeding; however, due to the limited number of included studies, further high-quality studies are needed to establish the clinical efficacy of the de-escalation strategy.
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Affiliation(s)
- Basel Abdelazeem
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA.
| | | | | | | | - Nischit Baral
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA
| | - Govinda Adhikari
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA
| | - Hafiz Khan
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA
| | - Mustafa Hassan
- Department of Internal Medicine, McLaren Health Care, Flint/Michigan State University, 401 S Ballenger Hwy, Flint, MI, 48532, USA
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Malik AH, Gupta R, Chakraborty S, Mahajan P, Bandyopadhyay D, Yandrapalli S, Zaid S, Sreenivasan J, Chaturvedi A, Mehta SS, Vyas AV, Patel NC, Combs WG, Ahmad H. Effect of genotype guided oral P2Y12 inhibitor selection after percutaneous coronary intervention: A systematic review and meta-analysis of randomized clinical trials. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 41:115-121. [DOI: 10.1016/j.carrev.2022.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 12/11/2021] [Accepted: 01/06/2022] [Indexed: 11/25/2022]
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Parcha V, Heindl BF, Li P, Kalra R, Limdi NA, Pereira NL, Arora G, Arora P. Genotype-Guided P2Y
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Inhibitor Therapy After Percutaneous Coronary Intervention: A Bayesian Analysis. Circ Genom Precis Med 2021; 14:e003353. [DOI: 10.1161/circgen.121.003353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Among patients receiving percutaneous coronary intervention (PCI), the role of a genotype-guided approach for antiplatelet therapy compared with usual care is unclear. We conducted a Bayesian analysis of the entire TAILOR-PCI (Tailored Antiplatelet Initiation to Lessen Outcomes Due to Decreased Clopidogrel Response After Percutaneous Coronary Intervention) randomized clinical trial population to evaluate the effect of the genotype-guided antiplatelet therapy post-PCI compared with the usual care on the risk of major adverse cardiovascular events (MACE).
Methods:
The primary outcome for our study was the composite of MACE (myocardial infarction, stroke, and cardiovascular death). Secondary outcomes included cardiovascular death, stroke, myocardial infarction, stent thrombosis, and major/minor bleeding. Bayesian modeling was used to estimate the probability of clinical benefit of genotype-guided therapy using (1) noninformative priors (ie, analyzing the TAILOR-PCI trial) and (2) informative priors derived from the ADAPT, POPular Genetics, IAC-PCI, and PHARMCLO trials (ie, analyzing TAILOR-PCI trial in the context of prior evidence). Risk ratio (RR: ratio of cumulative outcome incidence between genotype-guided and conventional therapy group) and 95% credible interval (CrI) were estimated for the study outcomes, and probability estimates for RR <1 were computed.
Results:
Using noninformative priors, in TAILOR-PCI the RR for MACE was 0.78 (95% CrI, 0.55–1.07) in genotype-guided therapy after PCI, and the probability of RR <1 was 94%. Using noninformative priors, the probability of RR <1 for cardiovascular death (RR, 0.95 [95% CrI, 0.52–1.74]), stroke (RR, 0.68 [95% CrI, 0.44–1.06]), myocardial infarction (RR, 0.84 [95% CrI, 0.37–1.89]), stent thrombosis (RR, 0.75 [95% CrI, 0.37–1.45]), and major or minor bleeding (RR, 1.22 [95% CrI, 0.84–1.77]) were 57%, 96%, 67%, 81%, and 15%, respectively. Using informative priors, the posterior probability of RR <1 for MACE, from genotype-guided therapy, was 99% (RR, 0.69 [95% CrI, 0.57–0.84]). Using informative priors, the posterior probability of RR <1 for cardiovascular death (RR, 0.86 [95% CrI, 0.61–1.19]), stroke (RR, 0.69 [95% CrI, 0.48–0.99]), myocardial infarction (RR:0.56 [95% CrI, 0.40–0.78]), stent thrombosis (RR, 0.59 [95% CrI, 0.38–0.94]), and major or minor bleeding (RR, 0.84 [95% CrI, 0.70–0.99]) were 81%, 99%, 99%, 99%, and 99%, respectively.
Conclusions:
Bayesian analysis of the TAILOR-PCI trial provides clinically meaningful data on the posterior probability of reducing MACE using genotype-guided P2Y
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inhibitor therapy after PCI.
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Affiliation(s)
- Vibhu Parcha
- Division of Cardiovascular Disease (V.P., B.F.H., G.A., P.A.), University of Alabama at Birmingham. Cardiology Division, University of Minnesota, MN
| | - Brittain F. Heindl
- Division of Cardiovascular Disease (V.P., B.F.H., G.A., P.A.), University of Alabama at Birmingham. Cardiology Division, University of Minnesota, MN
| | - Peng Li
- School of Nursing (P.L.), University of Alabama at Birmingham
| | - Rajat Kalra
- Cardiology Division, University of Minnesota, MN (R.K.)
| | - Nita A. Limdi
- Department of Neurology (N.A.L.), University of Alabama at Birmingham
- Department of Epidemiology (N.A.L.), University of Alabama at Birmingham
| | - Naveen L. Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (N.L.P.)
- William J. von Liebig Center for Transplantation and Clinical Regeneration (N.L.P.), Mayo Clinic, Rochester, MN
- Department of Molecular Pharmacology and Experimental Therapeutics (N.L.P), Mayo Clinic, Rochester, MN
| | - Garima Arora
- Division of Cardiovascular Disease (V.P., B.F.H., G.A., P.A.), University of Alabama at Birmingham. Cardiology Division, University of Minnesota, MN
| | - Pankaj Arora
- Division of Cardiovascular Disease (V.P., B.F.H., G.A., P.A.), University of Alabama at Birmingham. Cardiology Division, University of Minnesota, MN
- Section of Cardiology, Birmingham Veterans Affairs Medical Center, AL (P.A.)
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Li S, Xu Z, Guo M, Li M, Wen Z. Drug-induced QT Prolongation Atlas (DIQTA) for enhancing cardiotoxicity management. Drug Discov Today 2021; 27:831-837. [PMID: 34718206 DOI: 10.1016/j.drudis.2021.10.009] [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] [Received: 05/26/2021] [Revised: 08/26/2021] [Accepted: 10/20/2021] [Indexed: 11/03/2022]
Abstract
Drug-induced prolongation of the QT interval is common in a variety of pharmaceutical treatments and can lead to serious clinical outcomes. Although substantial efforts have been made to prevent drug-induced QT interval prolongation, the lack of a centralized data source remains the main obstacle to further study of the underlying mechanism and the development of effective prediction strategies. To fill this gap, we propose a schema for stratifying the risk of marketed QT prolonging drugs based on US Food and Drug Administration (FDA)-approved drug labeling and developed a Drug-Induced QT Prolongation Atlas (DIQTA). Potential application of DIQTA was shown by precision dosing in off-label use and therapeutic strategy optimization, as well as the facilitation of artificial intelligence (AI)-based modeling in predictive toxicity.
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Affiliation(s)
- Shihai Li
- College of Chemistry, Sichuan University, Chengdu, Sichuan 610064, China
| | - Zili Xu
- College of Chemistry, Sichuan University, Chengdu, Sichuan 610064, China
| | - Mingkun Guo
- College of Chemistry, Sichuan University, Chengdu, Sichuan 610064, China
| | - Menglong Li
- College of Chemistry, Sichuan University, Chengdu, Sichuan 610064, China
| | - Zhining Wen
- College of Chemistry, Sichuan University, Chengdu, Sichuan 610064, China; Medical Big Data Center, Sichuan University, Chengdu, Sichuan 610064, China.
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Huang MF, Pang LK, Chen YH, Zhao R, Lee DF. Cardiotoxicity of Antineoplastic Therapies and Applications of Induced Pluripotent Stem Cell-Derived Cardiomyocytes. Cells 2021; 10:2823. [PMID: 34831045 PMCID: PMC8616116 DOI: 10.3390/cells10112823] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/05/2021] [Accepted: 10/15/2021] [Indexed: 01/04/2023] Open
Abstract
The therapeutic landscape for the treatment of cancer has evolved significantly in recent decades, aided by the development of effective oncology drugs. However, many cancer drugs are often poorly tolerated by the body and in particular the cardiovascular system, causing adverse and sometimes fatal side effects that negate the chemotherapeutic benefits. The prevalence and severity of chemotherapy-induced cardiotoxicity warrants a deeper investigation of the mechanisms and implicating factors in this phenomenon, and a consolidation of scientific efforts to develop mitigating strategies. Aiding these efforts is the emergence of induced pluripotent stem cells (iPSCs) in recent years, which has allowed for the generation of iPSC-derived cardiomyocytes (iPSC-CMs): a human-based, patient-derived, and genetically variable platform that can be applied to the study of chemotherapy-induced cardiotoxicity and beyond. After surveying chemotherapy-induced cardiotoxicity and the associated chemotherapeutic agents, we discuss the use of iPSC-CMs in cardiotoxicity modeling, drug screening, and other potential applications. Improvements to the iPSC-CM platform, such as the development of more adult-like cardiomyocytes and ongoing advances in biotechnology, will only enhance the utility of iPSC-CMs in both basic science and clinical applications.
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Affiliation(s)
- Mo-Fan Huang
- Department of Integrative Biology and Pharmacology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (M.-F.H.); (L.K.P.)
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX 77030, USA
| | - Lon Kai Pang
- Department of Integrative Biology and Pharmacology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (M.-F.H.); (L.K.P.)
- Department of Neuroscience, Baylor College of Medicine, Houston, TX 77030, USA
| | - Yi-Hung Chen
- Department and Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei 112, Taiwan;
| | - Ruiying Zhao
- Department of Integrative Biology and Pharmacology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (M.-F.H.); (L.K.P.)
| | - Dung-Fang Lee
- Department of Integrative Biology and Pharmacology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA; (M.-F.H.); (L.K.P.)
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, TX 77030, USA
- Center for Stem Cell and Regenerative Medicine, The Brown Foundation Institute of Molecular Medicine for the Prevention of Human Diseases, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
- Center for Precision Health, School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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Zhang Y, Zhang Y, Shi X, Lin B, Han J, Wang Y, Yan J, Peng W, Li W, Zheng Z, Lin Y. Clopidogrel versus Ticagrelor in CYP2C19 Loss-of-Function Allele Noncarriers: A Real-World Study in China. Thromb Haemost 2021; 122:842-852. [PMID: 34428831 DOI: 10.1055/s-0041-1735193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This article compares the clinical outcomes of clopidogrel and ticagrelor in patients with acute coronary syndrome (ACS) without cytochrome P450 (CYP)2C19 loss-of-function (LOF) alleles and investigates whether clopidogrel could be an alternative P2Y12 inhibitor without increasing the risk of ischemic events. METHODS Patients were divided into the clopidogrel-treated group and the ticagrelor-treated group. Inverse probability of treatment weighting (IPTW) calculated by propensity scores was used to adjust confounding covariates. The primary outcome was major adverse cardiovascular or cerebrovascular events (MACCEs) within 12 months. The secondary outcomes were MACCEs plus unstable angina, and clinically significant bleeding events. RESULTS Finally, 2,199 patients were included. Of them, 1,606 were treated with clopidogrel, and 593 were treated with ticagrelor. The mean age of the original cohort was 59.92 ± 9.81 years. During the 12-month follow-up period, MACCEs occurred in 89 patients (4.0%). No significant differences were observed in MACCEs (IPTW-adjusted hazard ratio [HR], 0.87; 95% confidence interval [CI], 0.65-1.18), MACCEs plus unstable angina (IPTW-adjusted HR, 1.20; 95% CI, 0.91-1.59), or clinically significant bleeding events (IPTW-adjusted HR, 0.81; 95% CI, 0.53-1.23) between the clopidogrel- and ticagrelor-treated groups. CONCLUSION In patients with ACS without CYP2C19 LOF alleles, clopidogrel was not associated with a higher risk of MACCEs when compared with ticagrelor. The main findings of this study support use of clopidogrel in CYP2C19 LOF noncarriers as an alternative P2Y12 inhibitor, which may reduce medical expenses and adverse reactions caused by more potent P2Y12 inhibitors in these patients.
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Affiliation(s)
- Yunnan Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Yi Zhang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Xiujin Shi
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Baidi Lin
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Jialun Han
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Yifan Wang
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Jialin Yan
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
| | - Wenxing Peng
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wenzheng Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ze Zheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yang Lin
- Department of Pharmacy, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,School of Pharmaceutical Sciences, Capital Medical University, Beijing, China
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12
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Gimbel ME, Ten Berg JM. Safety considerations with the use of platelet inhibitors for elderly patients with non-ST- elevation acute coronary syndrome. Expert Opin Drug Saf 2021; 20:1545-1552. [PMID: 34106029 DOI: 10.1080/14740338.2021.1936498] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Dual antiplatelet therapy (DAPT) is standard treatment for patients with acute coronary syndrome (ACS). This includes lifelong aspirin combined with a P2Y12 inhibitor for 1 year. The indication for one of the P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) is dependent on the treatment strategy; whether patients undergo coronary angiography or are treated medically only. Tailoring antiplatelet therapy to the risk profile of the individual patient is of specific importance to the older patient.Areas covered: In this review, we discuss dual antiplatelet therapy in elderly patients with ACS. We present the options to tailor antiplatelet therapy based on platelet function testing, CYP2C19 genotyping and patients' thrombotic and bleeding risk. Finally, we discuss alternatives for dual antiplatelet therapy.Expert opinion: DAPT in elderly patients with ACS should consist of aspirin with clopidogrel or ticagrelor. Weighing patients' thrombotic and bleeding risk, based on clinical judgment or with use of specific risk scores, is probably the most convenient method to individualize antiplatelet therapy; however, CYP2C19 genotyping can also be used. In elderly patients with an increased bleeding risk, clopidogrel is a safe and effective alternative to ticagrelor. An alternative to 12 months DAPT could be ticagrelor monotherapy after a short period of DAPT.
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Affiliation(s)
- M E Gimbel
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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13
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Pereira NL, Rihal C, Lennon R, Marcus G, Shrivastava S, Bell MR, So D, Geller N, Goodman SG, Hasan A, Lerman A, Rosenberg Y, Bailey K, Murad MH, Farkouh ME. Effect of CYP2C19 Genotype on Ischemic Outcomes During Oral P2Y 12 Inhibitor Therapy: A Meta-Analysis. JACC Cardiovasc Interv 2021; 14:739-750. [PMID: 33744207 PMCID: PMC9853943 DOI: 10.1016/j.jcin.2021.01.024] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 01/24/2023]
Abstract
OBJECTIVES The aim of this study was to examine the effect of CYP2C19 genotype on clinical outcomes in patients with coronary artery disease (CAD) who predominantly underwent percutaneous coronary intervention (PCI), comparing those treated with ticagrelor or prasugrel versus clopidogrel. BACKGROUND The effect of CYP2C19 genotype on treatment outcomes with ticagrelor or prasugrel compared with clopidogrel is unclear. METHODS Databases through February 19, 2020, were searched for studies reporting the effect of CYP2C19 genotype on ischemic outcomes during ticagrelor or prasugrel versus clopidogrel treatment. Study eligibility required outcomes reported for CYP2C19 genotype status and clopidogrel and alternative P2Y12 inhibitors in patients with CAD with at least 50% undergoing PCI. The primary analysis consisted of randomized controlled trials (RCTs). A secondary analysis was conducted by adding non-RCTs to the primary analysis. The primary outcome was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia. Meta-analysis was conducted to compare the 2 drug regimens and test interaction with CYP2C19 genotype. RESULTS Of 1,335 studies identified, 7 RCTs were included (15,949 patients, mean age 62 years; 77% had PCI, 98% had acute coronary syndromes). Statistical heterogeneity was minimal, and risk for bias was low. Ticagrelor and prasugrel compared with clopidogrel resulted in a significant reduction in ischemic events (relative risk: 0.70; 95% confidence interval: 0.59 to 0.83) in CYP2C19 loss-of-function carriers but not in noncarriers (relative risk: 1.0; 95% confidence interval: 0.80 to 1.25). The test of interaction on the basis of CYP2C19 genotype status was statistically significant (p = 0.013), suggesting that CYP2C19 genotype modified the effect. An additional 4 observational studies were found, and adding them to the analysis provided the same conclusions (p value of the test of interaction <0.001). CONCLUSIONS The effect of ticagrelor or prasugrel compared with clopidogrel in reducing ischemic events in patients with CAD who predominantly undergo PCI is based primarily on the presence of CYP2C19 loss-of-function carrier status. These results support genetic testing prior to prescribing P2Y12 inhibitor therapy.
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Affiliation(s)
- Naveen L Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Charanjit Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan Lennon
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Gil Marcus
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Malcolm R Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Nancy Geller
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Shaun G Goodman
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Ahmed Hasan
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Kent Bailey
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
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14
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Alkhatib N, Sweitzer NK, Lee CS, Erstad B, Slack M, Gharaibeh M, Karnes J, Klimecki W, Ramos K, Abraham I. Ex Ante Economic Evaluation of Arg389 Genetically Targeted Treatment with Bucindolol versus Empirical Treatment with Carvedilol in NYHA III/IV Heart Failure. Am J Cardiovasc Drugs 2021; 21:205-217. [PMID: 32710439 DOI: 10.1007/s40256-020-00425-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The Beta-Blocker Evaluation Survival Trial showed no survival benefit for bucindolol in New York Heart Association (NYHA) class III/IV heart failure (HF) with reduced ejection fraction, but subanalyses suggested survival benefits for non-Black subjects and Arg389 homozygotes. We conducted an ex ante economic evaluation of Arg389 targeted treatment with bucindolol versus carvidolol, complementing a previous ex ante economic evaluation of bucindolol preceded by genetic testing for the Arg389 polymorphism, in which genetic testing prevailed economically over no testing. METHODS A decision tree analysis with an 18-month time horizon was performed to estimate the cost effectiveness/cost utility of trajectories of 100%, 50%, and 0% of patients genetically tested for Arg389 and comparing bucindolol with empirical carvedilol treatment as per prior BEST subanalyses. Incremental cost-effectiveness/cost-utility ratios (ICERs/ICURs) were estimated. RESULTS Race-based analyses for non-White subjects at 100% testing showed a loss of (0.04) life-years and (0.03) quality-adjusted life-years (QALYs) at an incremental cost of $2185, yielding a negative ICER of ($54,625)/life-year and ICUR of ($72,833)/QALY lost; at 50%, the analyses showed a loss of (0.27) life-years and (0.16) QALYs at an incremental cost of $1843, yielding a negative ICER of ($6826)/life-year and ICUR of ($11,519)/QALY lost; at 0%, the analyses showed a loss of (0.33) life-years and (0.30) QALYs at an incremental cost of $1459, yielding a negative ICER of ($4421)/life-year and ICUR of ($4863)/QALY lost. Arg389 homozygote analyses at 100% testing showed incremental gains of 0.02 life-years and 0.02 QALYs at an incremental cost of $378, yielding an ICER of 18,900/life-year and ICUR of $18,900/QALY gained; at 50%, the analyses showed a loss of (0.24) life-years and (0.09) QALYs at an incremental cost of $1039, yielding a negative ICER of ($4329)/life-year and ICUR of ($9336)/QALY lost; at 0%, the analyses showed a loss of (0.33) life-years and (0.30) QALYs at an incremental cost of $1459, yielding a negative ICER of ($4421)/life-year and ICUR of ($4863)/QALY lost. CONCLUSION This independent ex ante economic evaluation suggests that genetically targeted treatment with bucindolol is unlikely to yield clinicoeconomic benefits over empirical treatment with carvedilol in NYHA III/IV HF.
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15
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Izquierdo M, Merchant RA, Morley JE, Anker SD, Aprahamian I, Arai H, Aubertin-Leheudre M, Bernabei R, Cadore EL, Cesari M, Chen LK, de Souto Barreto P, Duque G, Ferrucci L, Fielding RA, García-Hermoso A, Gutiérrez-Robledo LM, Harridge SDR, Kirk B, Kritchevsky S, Landi F, Lazarus N, Martin FC, Marzetti E, Pahor M, Ramírez-Vélez R, Rodriguez-Mañas L, Rolland Y, Ruiz JG, Theou O, Villareal DT, Waters DL, Won Won C, Woo J, Vellas B, Fiatarone Singh M. International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines. J Nutr Health Aging 2021; 25:824-853. [PMID: 34409961 DOI: 10.1007/s12603-021-1665-8] [Citation(s) in RCA: 375] [Impact Index Per Article: 125.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The human ageing process is universal, ubiquitous and inevitable. Every physiological function is being continuously diminished. There is a range between two distinct phenotypes of ageing, shaped by patterns of living - experiences and behaviours, and in particular by the presence or absence of physical activity (PA) and structured exercise (i.e., a sedentary lifestyle). Ageing and a sedentary lifestyle are associated with declines in muscle function and cardiorespiratory fitness, resulting in an impaired capacity to perform daily activities and maintain independent functioning. However, in the presence of adequate exercise/PA these changes in muscular and aerobic capacity with age are substantially attenuated. Additionally, both structured exercise and overall PA play important roles as preventive strategies for many chronic diseases, including cardiovascular disease, stroke, diabetes, osteoporosis, and obesity; improvement of mobility, mental health, and quality of life; and reduction in mortality, among other benefits. Notably, exercise intervention programmes improve the hallmarks of frailty (low body mass, strength, mobility, PA level, energy) and cognition, thus optimising functional capacity during ageing. In these pathological conditions exercise is used as a therapeutic agent and follows the precepts of identifying the cause of a disease and then using an agent in an evidence-based dose to eliminate or moderate the disease. Prescription of PA/structured exercise should therefore be based on the intended outcome (e.g., primary prevention, improvement in fitness or functional status or disease treatment), and individualised, adjusted and controlled like any other medical treatment. In addition, in line with other therapeutic agents, exercise shows a dose-response effect and can be individualised using different modalities, volumes and/or intensities as appropriate to the health state or medical condition. Importantly, exercise therapy is often directed at several physiological systems simultaneously, rather than targeted to a single outcome as is generally the case with pharmacological approaches to disease management. There are diseases for which exercise is an alternative to pharmacological treatment (such as depression), thus contributing to the goal of deprescribing of potentially inappropriate medications (PIMS). There are other conditions where no effective drug therapy is currently available (such as sarcopenia or dementia), where it may serve a primary role in prevention and treatment. Therefore, this consensus statement provides an evidence-based rationale for using exercise and PA for health promotion and disease prevention and treatment in older adults. Exercise prescription is discussed in terms of the specific modalities and doses that have been studied in randomised controlled trials for their effectiveness in attenuating physiological changes of ageing, disease prevention, and/or improvement of older adults with chronic disease and disability. Recommendations are proposed to bridge gaps in the current literature and to optimise the use of exercise/PA both as a preventative medicine and as a therapeutic agent.
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Affiliation(s)
- M Izquierdo
- Mikel Izquierdo, PhD, Department of Health Sciences, Public University of Navarra, Av. De Barañain s/n 31008 Pamplona (Navarra) Spain, Tel + 34 948 417876
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16
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Coons JC, Crisamore K, Adams S, Modany A, Simon MA, Zhao W, Shaik IH, Venkataramanan R, Empey PE. A pilot study of oral treprostinil pharmacogenomics and treatment persistence in patients with pulmonary arterial hypertension. Ther Adv Respir Dis 2021; 15:17534666211013688. [PMID: 33929912 PMCID: PMC8111525 DOI: 10.1177/17534666211013688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 04/01/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND AIMS Treprostinil is a prostacyclin analog used to treat pulmonary arterial hypertension. Dosing is empiric and based on tolerability. Adverse effects are common and can affect treatment persistence. Pharmacogenomic variants that may affect treprostinil metabolism and transport have not been well-characterized. We aimed to investigate the pharmacogenomic sources of variability in treatment persistence and dosing. METHODS Patients were prospectively recruited from an IRB approved biobank registry at a single pulmonary hypertension center. A cohort of patients who received oral treprostinil were screened for participation. Pharmacogenomic analysis was for variants in CYP2C8, CYP2C9, and ABCC4. A retrospective review was conducted for demographics, clinical status, dosing, and response. Fisher's exact test was used for categorical data and Kruskal-Wallis test or Wilcoxon rank sum were used for continuous data. RESULTS A total of 15 patients received oral treprostinil and were consented. Their median age was 53 years, 73% were female, and 93% were White. The median total daily dose was 22.5 mg (13.5, 41) at last clinical observation. 40% of patients discontinued treatment with a majority due to adverse effects. Approximately 27% of patients had a loss-of-function variant in CYP2C8 (*1/*3 or *1/*4), whereas 47% of patients had a loss-of-function variant in CYP2C9 (*1/*2, *1/*3, or *2/*2). Minor allele frequencies for ABCC4 (rs1751034 and rs3742106) were 0.17 and 0.43, respectively. Survival analysis showed that increased CYP2C9 activity score was associated with decreased risk for treatment discontinuation [hazard ratio (HR): 0.13; 95% confidence interval (CI): 0.02, 0.91; p = 0.04]. Genetic variants were not significantly associated with dosing. CONCLUSION Genetic variants responsible for the metabolism and transport of oral treprostinil were common. Increased CYP2C9 activity score was associated with decreased risk for treatment discontinuation. However, dosing was not associated with genetic variants in metabolizing enzymes for treprostinil. Our findings suggest significant variability in treatment persistence to oral treprostinil, with pharmacogenomics being a potentially important contributor.The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- James C. Coons
- University of Pittsburgh School of Pharmacy, Clinical Pharmacist, Cardiology, UPMC Presbyterian Hospital, Salk Hall, Room 727, 3501 Terrace Street, Pittsburgh, PA 15261, USA
| | - Karryn Crisamore
- Department of Pharmaceutical Sciences, Center for Clinical Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | | | | | - Marc A. Simon
- Bioengineering, and Clinical Translational Science, Department of Medicine/Division of Cardiology, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, USA
- Heart and Vascular Institute, Heart Failure Research, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Wenchen Zhao
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Imam H. Shaik
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Raman Venkataramanan
- Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Philip E. Empey
- Pharmacogenomics Center of Excellence, Institute for Personalized Medicine, Department of Pharmacy and Therapeutics, Center for Clinical Pharmaceutical Sciences and the Clinical and Translational Science Institute, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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Pereira NL, Farkouh ME, So D, Lennon R, Geller N, Mathew V, Bell M, Bae JH, Jeong MH, Chavez I, Gordon P, Abbott JD, Cagin C, Baudhuin L, Fu YP, Goodman SG, Hasan A, Iturriaga E, Lerman A, Sidhu M, Tanguay JF, Wang L, Weinshilboum R, Welsh R, Rosenberg Y, Bailey K, Rihal C. Effect of Genotype-Guided Oral P2Y12 Inhibitor Selection vs Conventional Clopidogrel Therapy on Ischemic Outcomes After Percutaneous Coronary Intervention: The TAILOR-PCI Randomized Clinical Trial. JAMA 2020; 324:761-771. [PMID: 32840598 PMCID: PMC7448831 DOI: 10.1001/jama.2020.12443] [Citation(s) in RCA: 242] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE After percutaneous coronary intervention (PCI), patients with CYP2C19*2 or *3 loss-of-function (LOF) variants treated with clopidogrel have increased risk of ischemic events. Whether genotype-guided selection of oral P2Y12 inhibitor therapy improves ischemic outcomes is unknown. OBJECTIVE To determine the effect of a genotype-guided oral P2Y12 inhibitor strategy on ischemic outcomes in CYP2C19 LOF carriers after PCI. DESIGN, SETTING, AND PARTICIPANTS Open-label randomized clinical trial of 5302 patients undergoing PCI for acute coronary syndromes (ACS) or stable coronary artery disease (CAD). Patients were enrolled at 40 centers in the US, Canada, South Korea, and Mexico from May 2013 through October 2018; final date of follow-up was October 2019. INTERVENTIONS Patients randomized to the genotype-guided group (n = 2652) underwent point-of-care genotyping. CYP2C19 LOF carriers were prescribed ticagrelor and noncarriers clopidogrel. Patients randomized to the conventional group (n = 2650) were prescribed clopidogrel and underwent genotyping after 12 months. MAIN OUTCOMES AND MEASURES The primary end point was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia at 12 months. A secondary end point was major or minor bleeding at 12 months. The primary analysis was in patients with CYP2C19 LOF variants, and secondary analysis included all randomized patients. The trial had 85% power to detect a minimum hazard ratio of 0.50. RESULTS Among 5302 patients randomized (median age, 62 years; 25% women), 82% had ACS and 18% had stable CAD; 94% completed the trial. Of 1849 with CYP2C19 LOF variants, 764 of 903 (85%) assigned to genotype-guided therapy received ticagrelor, and 932 of 946 (99%) assigned to conventional therapy received clopidogrel. The primary end point occurred in 35 of 903 CYP2C19 LOF carriers (4.0%) in the genotype-guided therapy group and 54 of 946 (5.9%) in the conventional therapy group at 12 months (hazard ratio [HR], 0.66 [95% CI, 0.43-1.02]; P = .06). None of the 11 prespecified secondary end points showed significant differences, including major or minor bleeding in CYP2C19 LOF carriers in the genotype-guided group (1.9%) vs the conventional therapy group (1.6%) at 12 months (HR, 1.22 [95% CI, 0.60-2.51]; P = .58). Among all randomized patients, the primary end point occurred in 113 of 2641 (4.4%) in the genotype-guided group and 135 of 2635 (5.3%) in the conventional group (HR, 0.84 [95% CI, 0.65-1.07]; P = .16). CONCLUSIONS AND RELEVANCE Among CYP2C19 LOF carriers with ACS and stable CAD undergoing PCI, genotype-guided selection of an oral P2Y12 inhibitor, compared with conventional clopidogrel therapy without point-of-care genotyping, resulted in no statistically significant difference in a composite end point of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia based on the prespecified analysis plan and the treatment effect that the study was powered to detect at 12 months. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01742117.
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Affiliation(s)
- Naveen L. Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Michael E. Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada
| | - Derek So
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ryan Lennon
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Nancy Geller
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Verghese Mathew
- Department of Medicine, Loyola University, Maywood, Illinois
| | - Malcolm Bell
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jang-Ho Bae
- Department of Internal Medicine, Division of Cardiology, Konyang University, Seo-gu, Taejon, South Korea
| | - Myung Ho Jeong
- Heart Research Center, Chonnam National University, Gwangju, South Korea
| | - Ivan Chavez
- Department of Cardiology, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Paul Gordon
- Division of Cardiology, The Miriam Hospital, Providence, Rhode Island
| | - J. Dawn Abbott
- Division of Cardiology, Rhode Island Hospital, Providence, Rhode Island
| | - Charles Cagin
- Mayo Clinic Health System—La Crosse, La Crosse, Wisconsin
| | - Linnea Baudhuin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Yi-Ping Fu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Shaun G. Goodman
- St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta
| | - Ahmed Hasan
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Erin Iturriaga
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mandeep Sidhu
- Division of Cardiology, Department of Medicine, Albany Medical Center and Albany Medical College, Albany, New York
| | | | - Liewei Wang
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Richard Weinshilboum
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Robert Welsh
- Department of Medicine, Mazankowski Alberta Heart Institute and University of Alberta, Edmonton, Alberta, Canada
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Kent Bailey
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Charanjit Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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18
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Pereira NL, Rihal CS, So DYF, Rosenberg Y, Lennon RJ, Mathew V, Goodman SG, Weinshilboum RM, Wang L, Baudhuin LM, Lerman A, Hasan A, Iturriaga E, Fu YP, Geller N, Bailey K, Farkouh ME. Clopidogrel Pharmacogenetics. Circ Cardiovasc Interv 2020; 12:e007811. [PMID: 30998396 DOI: 10.1161/circinterventions.119.007811] [Citation(s) in RCA: 127] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Common genetic variation in CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) *2 and *3 alleles leads to a loss of functional protein, and carriers of these loss-of-function alleles when treated with clopidogrel have significantly reduced clopidogrel active metabolite levels and high on-treatment platelet reactivity resulting in increased risk of major adverse cardiovascular events, especially after percutaneous coronary intervention. The Food and Drug Administration has issued a black box warning advising practitioners to consider alternative treatment in CYP2C19 poor metabolizers who might receive clopidogrel and to identify such patients by genotyping. However, routine clinical use of genotyping for CYP2C19 loss-of-function alleles in patients undergoing percutaneous coronary intervention is not recommended by clinical guidelines because of lack of prospective evidence. To address this critical gap, TAILOR-PCI (Tailored Antiplatelet Initiation to Lessen Outcomes due to Decreased Clopidogrel Response After Percutaneous Coronary Intervention) is a large, pragmatic, randomized trial comparing point-of-care genotype-guided antiplatelet therapy with routine care to determine whether identifying CYP2C19 loss-of-function allele patients prospectively and prescribing alternative antiplatelet therapy is beneficial.
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Affiliation(s)
- Naveen L Pereira
- Department of Cardiovascular Medicine (N.L.P., C.S.R., A.L.), Mayo Clinic, Rochester, MN.,Department of Molecular Pharmacology and Experimental Therapeutics (N.L.P., R.M.W., L.W.), Mayo Clinic, Rochester, MN
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine (N.L.P., C.S.R., A.L.), Mayo Clinic, Rochester, MN
| | - Derek Y F So
- University of Ottawa Heart Institute, Ontario, Canada (D.Y.F.S.)
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, Bethesda, MD (Y.R., A.H., E.I., Y.-P.F., N.G.)
| | - Ryan J Lennon
- Department of Health Sciences Research (R.J.L., K.B.), Mayo Clinic, Rochester, MN
| | - Verghese Mathew
- Division of Cardiology, Loyola University Health System, Loyola University Chicago Stritch School of Medicine, Maywood, IL (V.M.)
| | - Shaun G Goodman
- St. Michael's Hospital, University of Toronto, Ontario, Canada (S.G.G.)
| | - Richard M Weinshilboum
- Department of Molecular Pharmacology and Experimental Therapeutics (N.L.P., R.M.W., L.W.), Mayo Clinic, Rochester, MN
| | - Liewei Wang
- Department of Molecular Pharmacology and Experimental Therapeutics (N.L.P., R.M.W., L.W.), Mayo Clinic, Rochester, MN
| | - Linnea M Baudhuin
- Department of Laboratory Medicine and Pathology (L.M.B.), Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Department of Cardiovascular Medicine (N.L.P., C.S.R., A.L.), Mayo Clinic, Rochester, MN
| | - Ahmed Hasan
- National Heart, Lung, and Blood Institute, Bethesda, MD (Y.R., A.H., E.I., Y.-P.F., N.G.)
| | - Erin Iturriaga
- National Heart, Lung, and Blood Institute, Bethesda, MD (Y.R., A.H., E.I., Y.-P.F., N.G.)
| | - Yi-Ping Fu
- National Heart, Lung, and Blood Institute, Bethesda, MD (Y.R., A.H., E.I., Y.-P.F., N.G.)
| | - Nancy Geller
- National Heart, Lung, and Blood Institute, Bethesda, MD (Y.R., A.H., E.I., Y.-P.F., N.G.)
| | - Kent Bailey
- Department of Health Sciences Research (R.J.L., K.B.), Mayo Clinic, Rochester, MN
| | - Michael E Farkouh
- Peter Munk Cardiac Centre, Heart and Stroke Richard Lewar Centre, University of Toronto, Canada (M.E.F.)
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Rosenbaum AN, Agre KE, Pereira NL. Genetics of dilated cardiomyopathy: practical implications for heart failure management. Nat Rev Cardiol 2019; 17:286-297. [PMID: 31605094 DOI: 10.1038/s41569-019-0284-0] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2019] [Indexed: 12/19/2022]
Abstract
Given the global burden of heart failure, strategies to understand the underlying cause or to provide prognostic information are critical to reducing the morbidity and mortality associated with this highly prevalent disease. Cardiomyopathies often have a genetic cause, and the field of heart failure genetics is progressing rapidly. Through a deliberate investigation, evaluation for a familial component of cardiomyopathy can lead to increased identification of pathogenic genetic variants. Much research has also been focused on identifying markers of risk in patients with cardiomyopathy with the use of genetic testing. Advances in our understanding of genetic variants have been slightly offset by an increased recognition of the heterogeneity of disease expression. Greater breadth of genetic testing can increase the likelihood of identifying a variant of uncertain significance, which is resolved only rarely by cellular functional validation and segregation analysis. To increase the use of genetics in heart failure clinics, increased availability of genetic counsellors and other providers with experience in genetics is necessary. Ultimately, through ongoing research and increased clinical experience in cardiomyopathy genetics, an improved understanding of the disease processes will facilitate better clinical decision-making about the therapies offered, exemplifying the implementation of precision medicine.
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Affiliation(s)
| | - Katherine E Agre
- Department of Clinical Genomics, Mayo Clinic, Rochester, MN, USA
| | - Naveen L Pereira
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA. .,William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA. .,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN, USA.
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20
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Cresci S, Pereira NL, Ahmad F, Byku M, de las Fuentes L, Lanfear DE, Reilly CM, Owens AT, Wolf MJ. Heart Failure in the Era of Precision Medicine: A Scientific Statement From the American Heart Association. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2019; 12:458-485. [DOI: 10.1161/hcg.0000000000000058] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
One of 5 people will develop heart failure over his or her lifetime. Early diagnosis and better understanding of the pathophysiology of this disease are critical to optimal treatment. The “omics”—genomics, pharmacogenomics, epigenomics, proteomics, metabolomics, and microbiomics— of heart failure represent rapidly expanding fields of science that have, to date, not been integrated into a single body of work. The goals of this statement are to provide a comprehensive overview of the current state of these omics as they relate to the development and progression of heart failure and to consider the current and potential future applications of these data for precision medicine with respect to prevention, diagnosis, and therapy.
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21
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Sayed N, Ameen M, Wu JC. Personalized medicine in cardio-oncology: the role of induced pluripotent stem cell. Cardiovasc Res 2019; 115:949-959. [PMID: 30768178 PMCID: PMC6933506 DOI: 10.1093/cvr/cvz024] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/14/2019] [Accepted: 02/06/2019] [Indexed: 12/19/2022] Open
Abstract
Treatment of cancer has evolved in the last decade with the introduction of new therapies. Despite these successes, the lingering cardiotoxic side-effects from chemotherapy remain a major cause of morbidity and mortality in cancer survivors. These effects can develop acutely during treatment, or even years later. Although many risk factors can be identified prior to beginning therapy, unexpected toxicity still occurs, often with lasting consequences. Specifically, cardiotoxicity results in cardiac cell death, eventually leading to cardiomyopathy and heart failure. Certain risk factors may predispose an individual to experiencing adverse cardiovascular effects, and when unexpected cardiotoxicity occurs, it is generally managed with supportive care. Animal models of chemotherapy-induced cardiotoxicity have provided some mechanistic insights, but the precise mechanisms by which these drugs affect the heart remains unknown. Moreover, the genetic rationale as to why some patients are more susceptible to developing cardiotoxicity has yet to be determined. Many genome-wide association studies have identified genomic variants that could be associated with chemotherapy-induced cardiotoxicity, but the lack of validation has made these studies more speculative rather than definitive. With the advent of human induced pluripotent stem cell (iPSC) technology, researchers not only have the opportunity to model human diseases, but also to screen drugs for their efficacy and toxicity using human cell models. Furthermore, it allows us to conduct validation studies to confirm the role of genomic variants in human diseases. In this review, we discuss the role of iPSCs in modelling chemotherapy-induced cardiotoxicity.
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Affiliation(s)
- Nazish Sayed
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Mohamed Ameen
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
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22
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International survey of patients undergoing percutaneous coronary intervention and their attitudes toward pharmacogenetic testing. Pharmacogenet Genomics 2019; 29:76-83. [PMID: 30724853 DOI: 10.1097/fpc.0000000000000368] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate perceptions toward pharmacogenetic testing of patients undergoing percutaneous coronary intervention (PCI) who are prescribed dual antiplatelet therapy (DAPT) and whether geographical differences in these perceptions exist. PARTICIPANTS AND METHODS TAILOR-PCI is the largest genotype-based cardiovascular clinical trial randomizing participants to conventional DAPT or prospective genotyping-guided DAPT. Enrolled patients completed surveys before and 6 months after randomization. RESULTS A total of 1327 patients completed baseline surveys of whom 28, 29, and 43% were from Korea, Canada and the USA, respectively. Most patients (77%) valued identifying pharmacogenetic variants; however, fewer Koreans (44%) as compared with Canadians (91%) and USA (89%) patients identified pharmacogenetics as being important (P<0.001). After adjusting for age, sex, and country, those who were confident in their ability to understand genetic information were significantly more likely to value identifying pharmacogenetic variants (odds ratio: 30.0; 95% confidence interval: 20.5-43.8). Only 21% of Koreans, as opposed to 86 and 77% of patients in Canada and USA, respectively, were confident in their ability to understand genetic information (P<0.001). CONCLUSION Although genetically mediated clopidogrel resistance is more prevalent amongst Asians, Koreans undergoing PCI identified pharmacogenetic variants as less important to their healthcare, likely related to their lack of confidence in their ability to understand genetic information. To enable successful implementation of pharmacogenetic testing on a global scale, the possibility of international population differences in perceptions should be considered.
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23
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Asleh R, Snipelisky D, Hathcock M, Kremers W, Liu D, Batzler A, Jenkins G, Kushwaha S, Pereira NL. Genomewide association study reveals novel genetic loci associated with change in renal function in heart transplant recipients. Clin Transplant 2018; 32:e13395. [PMID: 30160337 DOI: 10.1111/ctr.13395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/13/2018] [Accepted: 08/23/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Renal dysfunction occurs commonly after heart transplantation (HTx) with wide inter-individual variability but whether a genetic predisposition exists in these patients is unknown. Genomewide association studies (GWAS) have not been performed to assess the association of genetic variation with change in renal function after HTx. METHODS Clinical and demographic data of patients who underwent HTx and provided blood samples and consent for genetic analysis were included. Genotyping was performed using Illumina Infinium Human CoreExome v1.0 analysis kit. A GWAS utilizing linear regression models was performed with estimated glomerular filtration rate (eGFR) at 1 year as the phenotype after adjusting for baseline eGFR prior to HTx and conversion from calcineurin inhibitor to sirolimus as primary immunosuppression therapy. RESULTS A total of 251 HTx recipients were genotyped for 314,903 single nucleotide polymorphisms (SNPs). The mean (SD) age was 50 (12.5) years; most patients were of European origin (n = 243, 96.8%) and males (n = 179, 71.3%). After adjustment for potential confounders, two variants, rs17033285 (P = 4.3 × 10-7 ) and rs4917601 (P = 6.46 × 10-7 ), in a long non-coding RNA (lncRNA) gene LINC01121 and a pseudogene BTBD7P2, were identified to have a significant association with change in GFR at 1 year after HTx. CONCLUSIONS Our first of its kind GWAS demonstrates that genetic variation affects renal function after HTx independent of other risk factors. Agnostic genetic approaches such as these may lead to identification of novel biological pathways such as the role of lncRNAs in the development of renal dysfunction post-HTx.
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Affiliation(s)
- Rabea Asleh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - David Snipelisky
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Matthew Hathcock
- Department of Biomedical Statistic and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Walter Kremers
- Department of Biomedical Statistic and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Duan Liu
- Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
| | - Anthony Batzler
- Department of Biomedical Statistic and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Gregory Jenkins
- Department of Biomedical Statistic and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Sudhir Kushwaha
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Naveen L Pereira
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.,Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota
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24
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Sparks LM. Exercise training response heterogeneity: physiological and molecular insights. Diabetologia 2017; 60:2329-2336. [PMID: 29032385 DOI: 10.1007/s00125-017-4461-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 08/18/2017] [Indexed: 12/17/2022]
Abstract
The overall beneficial effects of exercise are well studied, but why some people do not respond favourably to exercise is less understood. The National Institutes of Health Common Fund has recently launched the large-scale discovery project 'Molecular Transducers of Physical Activity in Humans' to examine the physiological and molecular (i.e. genetic, epigenetic, lipidomic, metabolomic, proteomic, etc.) responses to exercise training. A nationwide, multicentre clinical trial such as this one also provides a unique opportunity to robustly investigate the non-response to exercise in thousands of individuals that have undergone supervised aerobic- and resistance-based exercise training interventions. The term 'non-responder' is used here to address the lack of a response (to an exercise intervention) in an outcome specified a priori. Cardiorespiratory fitness ([Formula: see text]) as an exercise response variable was recently reviewed; thus, this review focuses on metabolic aspects of the non-response to exercise training. Integrated -omics platforms are discussed as an approach to disentangle the complicated relationships between endogenous and exogenous factors that drive the lack of a response to exercise in some individuals. Harnessing the power of combined -omics platforms with deep clinical phenotyping of human study participants will advance the field of exercise metabolism and shift the paradigm, allowing exercise interventions to be targeted at those most likely to benefit and identifying novel approaches to treat those who do not.
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Affiliation(s)
- Lauren M Sparks
- Translational Research Institute for Metabolism and Diabetes, Florida Hospital, 301 E Princeton Street, Orlando, FL, 32804, USA.
- Sanford Burnham Prebys Medical Discovery Institute, Orlando, FL, USA.
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25
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Pereira NL. Genetic Risk and Altering Lipids With Lifestyle Changes and Metformin: Is Fate Modifiable? CIRCULATION. CARDIOVASCULAR GENETICS 2016; 9:469-471. [PMID: 27998943 DOI: 10.1161/circgenetics.116.001646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Naveen L Pereira
- From the Department of Cardiology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN.
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26
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Brown SA. Principles for Developing Patient Avatars in Precision and Systems Medicine. Front Genet 2016; 6:365. [PMID: 26779255 PMCID: PMC4705226 DOI: 10.3389/fgene.2015.00365] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/20/2015] [Indexed: 12/17/2022] Open
Affiliation(s)
- Sherry-Ann Brown
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic Rochester, MN, USA
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27
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Mugoša S, Djordjević N, Djukanović N, Protić D, Bukumirić Z, Radosavljević I, Bošković A, Todorović Z. Factors affecting the development of adverse drug reactions to β-blockers in hospitalized cardiac patient population. Patient Prefer Adherence 2016; 10:1461-9. [PMID: 27536078 PMCID: PMC4977081 DOI: 10.2147/ppa.s108579] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The aim of the present study was to undertake a study on the prevalence of cytochrome P450 2D6 (CYP2D6) poor metabolizer alleles (*3, *4, *5, and *6) on a Montenegrin population and its impact on developing adverse drug reactions (ADRs) of β-blockers in a hospitalized cardiac patient population. A prospective study was conducted in the Cardiology Center of the Clinical Center of Montenegro and included 138 patients who had received any β-blocker in their therapy. ADRs were collected using a specially designed questionnaire, based on the symptom list and any signs that could point to eventual ADRs. Data from patients' medical charts, laboratory tests, and other available parameters were observed and combined with the data from the questionnaire. ADRs to β-blockers were observed in 15 (10.9%) patients. There was a statistically significant difference in the frequency of ADRs in relation to genetically determined enzymatic activity (P<0.001), with ADRs' occurrence significantly correlating with slower CYP2D6 metabolism. Our study showed that the adverse reactions to β-blockers could be predicted by the length of hospitalization, CYP2D6 poor metabolizer phenotype, and the concomitant use of other CYP2D6-metabolizing drugs. Therefore, in hospitalized patients with polypharmacy CYP2D6 genotyping might be useful in detecting those at risk of ADRs.
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Affiliation(s)
- Snežana Mugoša
- Department of Pharmacotherapy, Faculty of Pharmacy, University of Montenegro
- Clinical Trial Department, Agency for Medicines and Medical Devices of Montenegro, Podgorica, Montenegro
| | - Nataša Djordjević
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Kragujevac
| | | | - Dragana Protić
- Department of Pharmacology, Clinical Pharmacology and Toxicology
| | - Zoran Bukumirić
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade
| | - Ivan Radosavljević
- Department of Surgery, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Aneta Bošković
- Clinic for Heart Diseases, Clinical Centre of Montenegro, Podgorica, Montenegro
| | - Zoran Todorović
- Department of Pharmacology, Clinical Pharmacology and Toxicology
- Department of Clinical Immunology and Allergy, Medical Center “Bežanijska kosa”, Belgrade, Serbia
- Correspondence: Zoran Todorović, Department of Pharmacology, Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Dr Subotića Starijeg 1, PO Box 38, 11129 Belgrade, Serbia, Tel +381 11 36 43 389, Fax +381 11 36 43 397, Email
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28
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Kamath PS, Mookerjee RP. Individualized care for portal hypertension: Not quite yet. J Hepatol 2015; 63:543-5. [PMID: 26150255 DOI: 10.1016/j.jhep.2015.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 07/01/2015] [Accepted: 07/01/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55905, USA.
| | - Rajeshwar P Mookerjee
- Liver Failure Group, University College London Institute for Liver and Digestive Health, University College London Medical School, Royal Free Hospital, London, United Kingdom
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Abstract
Consensus practice guidelines and the implementation of clinical therapeutic advances are usually based on the results of large, randomized clinical trials (RCTs). However, RCTs generally inform us on an average treatment effect for a presumably homogeneous population, but therapeutic interventions rarely benefit the entire population targeted. Indeed, multiple RCTs have demonstrated that interindividual variability exists both in drug response and in the development of adverse effects. The field of pharmacogenomics promises to deliver the right drug to the right patient. Substantial progress has been made in this field, with advances in technology, statistical and computational methods, and the use of cell and animal model systems. However, clinical implementation of pharmacogenetic principles has been difficult because RCTs demonstrating benefit are lacking. For patients, the potential benefits of performing such trials include the individualization of therapy to maximize efficacy and minimize adverse effects. These trials would also enable investigators to reduce sample size and hence contain costs for trial sponsors. Multiple ethical, legal, and practical issues need to be considered for the conduct of genotype-based RCTs. Whether pre-emptive genotyping embedded in electronic health records will preclude the need for performing genotype-based RCTs remains to be seen.
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Affiliation(s)
- Naveen L Pereira
- Division of Cardiovascular Diseases, Department of Internal Medicine, 200 First Street SW, Rochester, MN 55905, USA
| | - Daniel J Sargent
- Department of Biomedical Statistics and Informatics, Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and Heart and Stroke Richard Lewer Centre, University of Toronto, 585 University Avenue, Toronto, ON M5G 2N2, Canada
| | - Charanjit S Rihal
- Division of Cardiovascular Diseases, Department of Internal Medicine, 200 First Street SW, Rochester, MN 55905, USA
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30
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Shahabi P, Dubé MP. Cardiovascular pharmacogenomics; state of current knowledge and implementation in practice. Int J Cardiol 2015; 184:772-795. [DOI: 10.1016/j.ijcard.2015.02.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 02/17/2015] [Accepted: 02/21/2015] [Indexed: 02/07/2023]
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Abstract
PURPOSE OF REVIEW Novel medical approaches and personalized medicine seek to use genetic information to 'individualize' and improve diagnosis, prevention, and therapy. The personalized management of cardiovascular disease involves a large spectrum of potential applications, from diagnostics of monogenic disorders, to prevention and management strategies based on modifier genes, to pharmacogenetics, in which individual genetic information is used to optimize the pharmacological treatments. RECENT FINDINGS Evidence suggests that the common polymorphic variants of modifier genes could influence drug response in cardiovascular disease in a variety of areas, including heart failure, arrhythmias, dyslipidemia, and hypertension. In heart failure, common genetic variants of β-adrenergic receptors, α-adrenergic receptors, and endothelin receptors (among others) have been associated with variable response to heart failure therapies. The challenge remains to develop strategies to leverage this information in ways that personalize and optimize cardiovascular therapy based on a patient's genetic profile. SUMMARY Although advances in technologies will continue to transition personalized medicine from the research to the clinical setting, healthcare providers will need to reshape the clinical diagnostic paradigms. Ultimately, pharmacogenetics will give providers the options for improving patient management on the basis of pharmacogenetic data.
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Affiliation(s)
- Luisa Mestroni
- University of Colorado Cardiovascular Institute and Adult Medical Genetics Program, Aurora, Colorado, USA
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32
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Ganesh SK, Arnett DK, Assimes TL, Basson CT, Chakravarti A, Ellinor PT, Engler MB, Goldmuntz E, Herrington DM, Hershberger RE, Hong Y, Johnson JA, Kittner SJ, McDermott DA, Meschia JF, Mestroni L, O’Donnell CJ, Psaty BM, Vasan RS, Ruel M, Shen WK, Terzic A, Waldman SA. Genetics and Genomics for the Prevention and Treatment of Cardiovascular Disease: Update. Circulation 2013; 128:2813-51. [DOI: 10.1161/01.cir.0000437913.98912.1d] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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33
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Heart Valve Tissue Engineering. Biomater Sci 2013. [DOI: 10.1016/b978-0-08-087780-8.00116-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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34
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Aslibekyan S, Goodarzi MO, Frazier-Wood AC, Yan X, Irvin MR, Kim E, Tiwari HK, Guo X, Straka RJ, Taylor KD, Tsai MY, Hopkins PN, Korenman SG, Borecki IB, Chen YDI, Ordovas JM, Rotter JI, Arnett DK. Variants identified in a GWAS meta-analysis for blood lipids are associated with the lipid response to fenofibrate. PLoS One 2012; 7:e48663. [PMID: 23119086 PMCID: PMC3485381 DOI: 10.1371/journal.pone.0048663] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 09/28/2012] [Indexed: 12/23/2022] Open
Abstract
A recent large-scale meta-analysis of genome-wide studies has identified 95 loci, 59 of them novel, as statistically significant predictors of blood lipid traits; we tested whether the same loci explain the observed heterogeneity in response to lipid-lowering therapy with fenofibrate. Using data from the Genetics of Lipid Lowering Drugs and Diet Network (GOLDN, n = 861) we fit linear mixed models with the genetic markers as predictors and high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, total cholesterol, and triglyceride concentrations as outcomes. For all four traits, we analyzed both baseline levels and changes in response to treatment with fenofibrate. For the markers that were significantly associated with fenofibrate response, we fit additional models evaluating potential epistatic interactions. All models were adjusted for age, sex, and study center as fixed effects, and pedigree as a random effect. Statistically significant associations were observed between the rs964184 polymorphism near APOA1 (P-value≤0.0001) and fenofibrate response for HDL and triglycerides. The association was replicated in the Pharmacogenetics of Hypertriglyceridemia in Hispanics study (HyperTG, n = 267). Suggestive associations with fenofibrate response were observed for markers in or near PDE3A, MOSC1, FLJ36070, CETP, the APOE-APOC1-APOC4-APOC2, and CILP2. Finally, we present strong evidence for epistasis (P-value for interaction = 0.0006 in GOLDN, 0.05 in HyperTG) between rs10401969 near CILP2 and rs4420638 in the APOE-APOC1-APOC4-APOC2 cluster with total cholesterol response to fenofibrate. In conclusion, we present evidence linking several novel and biologically relevant genetic polymorphisms to lipid lowering drug response, as well as suggesting novel gene-gene interactions in fenofibrate pharmacogenetics.
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Affiliation(s)
- Stella Aslibekyan
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America.
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Stankov K, Sabo A, Mikov M. Pharmacogenetic Biomarkers as Tools for Pharmacoepidemiology of Severe Adverse Drug Reactions. Drug Dev Res 2012. [DOI: 10.1002/ddr.21050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Karmen Stankov
- Clinical Center of Vojvodina; Medical Faculty Novi Sad; University of Novi Sad; 21000; Novi Sad; Serbia
| | - Ana Sabo
- Department of Pharmacology, Toxicology and Clinical Pharmacology; Medical Faculty Novi Sad; University of Novi Sad; 21000; Novi Sad; Serbia
| | - Momir Mikov
- Department of Pharmacology, Toxicology and Clinical Pharmacology; Medical Faculty Novi Sad; University of Novi Sad; 21000; Novi Sad; Serbia
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36
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Kang S, Hong S. Prediction of personalized drugs based on genetic variations provided by DNA sequencing technologies. Genes Genomics 2011. [DOI: 10.1007/s13258-011-0124-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Myburgh R, Hochfeld WE, Dodgen TM, Ker J, Pepper MS. Cardiovascular pharmacogenetics. Pharmacol Ther 2011; 133:280-90. [PMID: 22123178 DOI: 10.1016/j.pharmthera.2011.11.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 11/04/2011] [Indexed: 12/25/2022]
Abstract
Human genetic variation in the form of single nucleotide polymorphisms as well as more complex structural variations such as insertions, deletions and copy number variants, is partially responsible for the clinical variation seen in response to pharmacotherapeutic drugs. This affects the likelihood of experiencing adverse drug reactions and also of achieving therapeutic success. In this paper, we review key studies in cardiovascular pharmacogenetics that reveal genetic variations underlying the outcomes of drug treatment in cardiovascular disease. Examples of genetic associations with drug efficacy and toxicity are described, including the roles of genetic variability in pharmacokinetics (e.g. drug metabolizing enzymes) and pharmacodynamics (e.g. drug targets). These findings have functional implications that could lead to the development of genetic tests aimed at minimizing drug toxicity and optimizing drug efficacy in cardiovascular medicine.
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Affiliation(s)
- Renier Myburgh
- Department of Immunology, Faculty of Health Sciences, University of Pretoria, South Africa
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Holmes DR, Becker JA, Granger CB, Limacher MC, Page RL, Sila C, Drozda JP, Cacchione JG, Erb BD, Harrington RA, Kennett JD, Krumholz HM, Masoudi FA, Peterson ED, Poppas A, Sahn DJ, Sanz ML, Shahian DM, Windle JR, Wyman JF. ACCF/AHA 2011 Health Policy Statement on Therapeutic Interchange and Substitution. J Am Coll Cardiol 2011; 58:1287-307. [DOI: 10.1016/j.jacc.2011.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Holmes DR, Becker JA, Granger CB, Limacher MC, Page RL, Sila C. ACCF/AHA 2011 health policy statement on therapeutic interchange and substitution: a report of the American College of Cardiology Foundation Clinical Quality Committee. Circulation 2011; 124:1290-310. [PMID: 21844072 DOI: 10.1161/cir.0b013e31822d97d5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Joyner MJ, Pedersen BK. Ten questions about systems biology. J Physiol 2011; 589:1017-30. [PMID: 21224238 PMCID: PMC3060582 DOI: 10.1113/jphysiol.2010.201509] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2010] [Accepted: 12/20/2010] [Indexed: 12/16/2022] Open
Abstract
In this paper we raise 'ten questions' broadly related to 'omics', the term systems biology, and why the new biology has failed to deliver major therapeutic advances for many common diseases, especially diabetes and cardiovascular disease. We argue that a fundamentally narrow and reductionist perspective about the contribution of genes and genetic variants to disease is a key reason 'omics' has failed to deliver the anticipated breakthroughs. We then point out the critical utility of key concepts from physiology like homeostasis, regulated systems and redundancy as major intellectual tools to understand how whole animals adapt to the real world. We argue that a lack of fluency in these concepts is a major stumbling block for what has been narrowly defined as 'systems biology' by some of its leading advocates. We also point out that it is a failure of regulation at multiple levels that causes many common diseases. Finally, we attempt to integrate our critique of reductionism into a broader social framework about so-called translational research in specific and the root causes of common diseases in general. Throughout we offer ideas and suggestions that might be incorporated into the current biomedical environment to advance the understanding of disease through the perspective of physiology in conjunction with epidemiology as opposed to bottom-up reductionism alone.
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Affiliation(s)
- Michael J Joyner
- Department of Anesthesiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Heart valve tissue engineering: quo vadis? Curr Opin Biotechnol 2011; 22:698-705. [PMID: 21315575 DOI: 10.1016/j.copbio.2011.01.004] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 01/18/2011] [Indexed: 01/08/2023]
Abstract
Surgical replacement of diseased heart valves by mechanical and tissue valve substitutes is now commonplace and generally enhances survival and quality of life. However, a fundamental problem inherent to the use of existing mechanical and biological prostheses in the pediatric population is their failure to grow, repair, and remodel. A tissue engineered heart valve could, in principle, accommodate these requirements, especially somatic growth. This review provides a brief overview of the field of heart valve tissue engineering, with emphasis on recent studies and evolving concepts, especially those that establish design criteria and key hurdles that must be surmounted before clinical implementation.
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Abstract
Heart failure is an important cause of morbidity and mortality in individuals of all ages. The many-faceted nature of the clinical heart failure syndrome has historically frustrated attempts to develop an overarching explanative theory. However, much useful information has been gained by basic and clinical investigation, even though a comprehensive understanding of heart failure has been elusive. Heart failure is a growing problem, in both adult and pediatric populations, for which standard medical therapy, as of 2010, can have positive effects, but these are usually limited and progressively diminish with time in most patients. If we want curative or near-curative therapy that will return patients to a normal state of health at a feasible cost, much better diagnostic and therapeutic technologies need to be developed. This review addresses the vexing group of heart failure etiologies that include cardiomyopathies and other ventricular dysfunctions of various types, for which current therapy is only modestly effective. Although there are many unique aspects to heart failure in patients with pediatric and congenital heart disease, many of the innovative approaches that are being developed for the care of adults with heart failure will be applicable to heart failure in childhood.
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Affiliation(s)
- Daniel J Penny
- Section of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA
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Erzurum S, Rounds SI, Stevens T, Aldred M, Aliotta J, Archer SL, Asosingh K, Balaban R, Bauer N, Bhattacharya J, Bogaard H, Choudhary G, Dorn GW, Dweik R, Fagan K, Fallon M, Finkel T, Geraci M, Gladwin MT, Hassoun PM, Humbert M, Kaminski N, Kawut SM, Loscalzo J, McDonald D, McMurtry IF, Newman J, Nicolls M, Rabinovitch M, Shizuru J, Oka M, Polgar P, Rodman D, Schumacker P, Stenmark K, Tuder R, Voelkel N, Sullivan E, Weinshilboum R, Yoder MC, Zhao Y, Gail D, Moore TM. Strategic plan for lung vascular research: An NHLBI-ORDR Workshop Report. Am J Respir Crit Care Med 2010; 182:1554-62. [PMID: 20833821 DOI: 10.1164/rccm.201006-0869ws] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The Division of Lung Diseases of the National Heart, Lung, and Blood Institute, with the Office of Rare Diseases Research, held a workshop to identify priority areas and strategic goals to enhance and accelerate research that will result in improved understanding of the lung vasculature, translational research needs, and ultimately the care of patients with pulmonary vascular diseases. Multidisciplinary experts with diverse experience in laboratory, translational, and clinical studies identified seven priority areas and discussed limitations in our current knowledge, technologies, and approaches. The focus for future research efforts include the following: (1) better characterizing vascular genotype-phenotype relationships and incorporating systems biology approaches when appropriate; (2) advancing our understanding of pulmonary vascular metabolic regulatory signaling in health and disease; (3) expanding our knowledge of the biologic relationships between the lung circulation and circulating elements, systemic vascular function, and right heart function and disease; (4) improving translational research for identifying disease-modifying therapies for the pulmonary hypertensive diseases; (5) establishing an appropriate and effective platform for advancing translational findings into clinical studies testing; and (6) developing the specific technologies and tools that will be enabling for these goals, such as question-guided imaging techniques and lung vascular investigator training programs. Recommendations from this workshop will be used within the Lung Vascular Biology and Disease Extramural Research Program for planning and strategic implementation purposes.
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Affiliation(s)
- Serpil Erzurum
- Department of Pathobiology, Cleveland Clinic, Cleveland, Ohio, USA
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Lubitz SA, Ozcan C, Magnani JW, Kääb S, Benjamin EJ, Ellinor PT. Genetics of atrial fibrillation: implications for future research directions and personalized medicine. Circ Arrhythm Electrophysiol 2010; 3:291-9. [PMID: 20551423 DOI: 10.1161/circep.110.942441] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Steven A Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA 02114, USA
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Landau R. Pharmacogenetic influences in obstetric anaesthesia. Best Pract Res Clin Obstet Gynaecol 2010; 24:277-87. [DOI: 10.1016/j.bpobgyn.2009.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Accepted: 11/25/2009] [Indexed: 10/20/2022]
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Azam SM, Jozic J. Variable platelet responsiveness to aspirin and clopidogrel: role of platelet function and genetic polymorphism testing. Transl Res 2009; 154:309-13. [PMID: 19931197 DOI: 10.1016/j.trsl.2009.09.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 09/29/2009] [Accepted: 09/29/2009] [Indexed: 12/19/2022]
Abstract
Dual antiplatelet therapy with aspirin and clopidogrel is the standard treatment for patients with an acute coronary syndrome or percutaneous coronary intervention. However, at standard doses, many patients still experience an adverse cardiovascular event. Numerous studies have demonstrated that a laboratory assessment of platelet resistance to an antiplatelet medication is associated with adverse outcomes. The gold standard in assessing platelet function is light transmittance aggregometry. However, because of the time necessary to complete the test, the need for skilled technicians, and the associated costs, newer point-of-care tests have been developed to assess rapidly an individual's platelet responsiveness. Although numerous studies demonstrate an association with adverse outcomes and platelet resistance, currently no clinical trial results demonstrate a treatment strategy to mitigate the adverse outcomes associated with platelet resistance. Studies currently underway are evaluating treatment options for a laboratory assessment of platelet resistance, such as increasing the clopidogrel maintenance dose. Until such results are available, routine testing of platelet resistance to aspirin or clopidogrel should be used only in a research setting.
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Affiliation(s)
- Salman M Azam
- University Hospitals Case Medical Center, Harrington-McLaughlin Heart and Vascular Institute, Cleveland, Ohio 44106, USA
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