Outcome of angiotensin receptor-neprilysin inhibitor on anxiety and depression in heart failure with reduced ejection fraction vs. heart failure with preserved ejection fraction

Associations of Depression, Antidepressants with Atrial Fibrillation Risk in HFpEF Patients

Background

Studies dedicated to exploring the incidence of atrial fibrillation (AF) in patients with concurrent depression and heart failure with preserved ejection fraction (HFpEF) are scarce. The impact of antidepressant therapy on AF risk within this population remains unclear. Our current study aimed to investigate the link between depression and AF risk in HFpEF patients and to assess the influence of antidepressant medication on the development of AF.

Methods

We utilized Kaplan-Meier estimates to determine the event-free status for AF and applied the Log-rank test for comparative analysis between groups. The associations were quantified using univariate and multivariate Cox proportional hazards regression models, with results expressed as hazard ratios (HR) and 95% confidence intervals (CI).

Results

Among the 784 patients in the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, 29.1% (228) were identified with major depression. After adjusting for significant confounders, compared with mild depression, major depression at baseline was not linked to the incidence of AF (adjusted HR = 0.82, 95% CI: 0.46-1.49). Additionally, compared with controls, antidepressant use at baseline did not significantly influence the risk of incident AF in patients with HFpEF and major depression (adjusted HR = 0.41, 95% CI: 0.08-2.10).

Conclusions

The presence of major depression at baseline did not elevate the risk of incident AF among individuals with HFpEF. Additionally, the use of antidepressants showed no correlation with an increased rate of AF among HFpEF patients with comorbid major depression.

Clinical Trial Registration

URL: https://clinicaltrials.gov/study/NCT00094302. Unique identifier: NCT00094302.

Menopause-Associated Depression: Impact of Oxidative Stress and Neuroinflammation on the Central Nervous System-A Review

Perimenopausal depression, occurring shortly before or after menopause, is characterized by symptoms such as emotional depression, anxiety, and stress, often accompanied by endocrine dysfunction, particularly hypogonadism and senescence. Current treatments for perimenopausal depression primarily provide symptomatic relief but often come with undesirable side effects. The development of agents targeting the specific pathologies of perimenopausal depression has been relatively slow. The erratic fluctuations in estrogen and progesterone levels during the perimenopausal stage expose women to the risk of developing perimenopausal-associated depression. These hormonal changes trigger the production of proinflammatory mediators and induce oxidative stress, leading to progressive neuronal damage. This review serves as a comprehensive overview of the underlying mechanisms contributing to perimenopausal depression. It aims to shed light on the complex relationship between perimenopausal hormones, neurotransmitters, brain-derived neurotrophic factors, chronic inflammation, oxidative stress, and perimenopausal depression. By summarizing the intricate interplay between hormonal fluctuations, neurotransmitter activity, brain-derived neurotrophic factors, chronic inflammation, oxidative stress, and perimenopausal depression, this review aims to stimulate further research in this field. The hope is that an increased understanding of these mechanisms will pave the way for the development of more effective therapeutic targets, ultimately reducing the risk of depression during the menopausal stage for the betterment of psychological wellbeing.

Advances in Heart Failure with Preserved Ejection Fraction Management - The Role of Sacubitril-Valsartan, Pirfenidone, Spironolactone and Empagliflozin: Is Success a Series of Small Victories?

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a syndrome characterized by marked heterogeneity in comorbidities and etiopathology substrates, leading to a diverse range of clinical manifestations and courses. Treatment options have been extremely limited and up to this day, there are virtually no pharmaceutical agents proven to reduce mortality in these patients.

OBJECTIVE

The primary objective of this narrative review is to critically summarize existing evidence regarding the use of Angiotensin Receptor-Neprilysin Inhibitor (ARNI), spironolactone, pirfenidone and empagliflozin in HFpEF.

METHODS

Medline (via PubMed) and Scopus were searched - from inception up to May 2022- using adequately selected keywords. Additional hand-search was also performed using the references of the articles identified as relevant (snowball strategy).

RESULTS

Angiotensin Receptor-Neprilysin Inhibitor (ARNI) and spironolactone, despite being very successful in HFrEF, did not do well in clinical trials of HFpEF, although there appear to be certain subsets of patients who may derive benefit. Data regarding pirfenidone are limited and come from small trials; as a result, it would be premature to draw firm conclusions, although it seems improbable that this agent will ever become a mainstay in the general population of HPpEF patients, while there may be a niche for the drug in individuals with comorbidities associated with an intense fibrotic activity. Finally, empagliflozin, largely welcomed as the first agent to have a "positive" randomized clinical trial in HFpEF, does not seem to evade the general pattern of reduced hospitalizations for HF with no substantial effect on mortality, seen in ARNI and spironolactone HFpEF trials.

CONCLUSION

Recent research in drug treatment for HFpEF has resulted in an overall mixed picture, with trials showing potential benefits from certain classes of drugs, such as sodium-glucose co-transporter 2 inhibitors, and no benefit from other drugs, which have shown to be effective in patient with reduced ejection fraction. However, small steps may be the way to go in HFpEF, and success is sometimes just a series of small victories.