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Akhtar KH, Khan MS, Baron SJ, Zieroth S, Estep J, Burkhoff D, Butler J, Fudim M. The spectrum of post-myocardial infarction care: From acute ischemia to heart failure. Prog Cardiovasc Dis 2024; 82:15-25. [PMID: 38242191 DOI: 10.1016/j.pcad.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 01/21/2024]
Abstract
Heart failure (HF) is the leading cause of mortality in patients with acute myocardial infarction (AMI), with incidence ranging from 14% to 36% in patients admitted due to AMI. HF post-MI develops due to complex inter-play between macrovascular obstruction, microvascular dysfunction, myocardial stunning and remodeling, inflammation, and neuro-hormonal activation. Cardiogenic shock is an extreme presentation of HF post-MI and is associated with a high mortality. Early revascularization is the only therapy shown to improve survival in patients with cardiogenic shock. Treatment of HF post-MI requires prompt recognition and timely introduction of guideline-directed therapies to improve mortality and morbidity. This article aims to provide an up-to-date review on the incidence and pathogenesis of HF post-MI, current strategies to prevent and treat onset of HF post-MI, promising therapeutic strategies, and knowledge gaps in the field.
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Affiliation(s)
- Khawaja Hassan Akhtar
- Department of Medicine, Section of Cardiovascular Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Suzanne J Baron
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jerry Estep
- Section of Heart Failure & Transplantation, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, Columbia University Medical Center, New York City, NY, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA; Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.
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Lorente-Ros M, Aguilar-Gallardo JS, Shah A, Narasimhan B, Aronow WS. An overview of mineralocorticoid receptor antagonists as a treatment option for patients with heart failure: the current state-of-the-art and future outlook. Expert Opin Pharmacother 2022; 23:1737-1751. [PMID: 36262014 DOI: 10.1080/14656566.2022.2138744] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Mineralocorticoid receptor antagonists (MRAs) improve cardiovascular outcomes in patients with heart failure. These benefits of MRAs vary in different heart failure populations based on left ventricular ejection fraction and associated comorbidities. AREAS COVERED We define the pharmacologic properties of MRAs and the pathophysiological rationale for their utility in heart failure. We outline the current literature on the use of MRAs in different heart failure populations, including reduced and preserved ejection fraction (HFrEF/ HFpEF), and acute heart failure decompensation. Finally, we describe the limitations of currently available data and propose future directions of study. EXPERT OPINION While there is strong evidence supporting the use of MRAs in HFrEF, evidence in patients with HFpEF or acute heart failure is less definitive. Comorbidities such as obesity or atrial fibrillation could be clinical modifiers of the response to MRAs and potentially alter the risk/benefit ratio in these subpopulations. Emerging evidence for new non-steroidal MRAs reveal promising preliminary results that, if confirmed in large randomized clinical trials, could favor a change in clinical practice.
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Affiliation(s)
- Marta Lorente-Ros
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside-West, 1111 Amsterdam Avenue, New York, NY 10019, USA
| | - Jose S Aguilar-Gallardo
- Department of Medicine, The Icahn School of Medicine at Mount Sinai, Mount Sinai Morningside-West, 1111 Amsterdam Avenue, New York, NY 10019, USA
| | - Aayush Shah
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, 6565 Fannin St, Houston, TX 77030, USA
| | - Bharat Narasimhan
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, 6565 Fannin St, Houston, TX 77030, USA
| | - Wilbert S Aronow
- Department of Cardiology, New York Medical College, Westchester Medical Center, 100 Woods Rd, Valhalla, NY 10901, USA
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3
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Chen Y, Wu J, Tang Y, Li Z, Wen Q, Sun X, Yuan H, Lu Y, Cai J. Multimorbidity and combined interventions for patients with coronary heart disease in Chinese population: Latent class analysis of a multi-center study. Int J Cardiol 2022; 368:17-26. [PMID: 35963444 DOI: 10.1016/j.ijcard.2022.08.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/08/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS This study aimed to explore the profile of multimorbidity phenotype clusters and their discrepancy in mortality and the efficiency of combined interventions on blood pressure, glucose and lipid in each cluster. METHODS Fine and Gray competing risk regression models and Kaplan-Meier curves were used to assess the association between multimorbidity and mortality and rehospitalization. Fine and Gray competing risk regression models and subgroup analyses were used to estimate the relations between combined interventions and mortality. RESULTS Three distinct multimorbidity clusters were observed: Class 1 named severe class, Class 2 termed moderate class, and Class 3 named mild class. Competing risk regression models revealed that patients in Class 1 have the greatest burden of mortality and rehospitalization compared to Class 3 after confounder adjustment, with HRs 1.43 (95% CI 1.30-1.56, P < 0.001) and 2.97 (95% CI 2.74-3.21, P < 0.001), respectively. The patients in Class 2 have moderate risk of mortality and rehospitalization compared to Class 3 after confounder adjustment, with HRs 1.41 (95% CI 1.30-1.52, P < 0.001) and 2.39 (95% CI 2.23-2.56, P < 0.001), respectively. Furthermore, we found that combined interventions on blood pressure, glucose and lipid simultaneously could further benefit on survival compared to each individual intervention or two in combine. CONCLUSIONS This study found that multimorbidity among patients with CHD was common and increased the risks of death and rehospitalization. Three multimorbidity clusters that were significantly associated with death and rehospitalization were identified. Simultaneous intervention on blood pressure, glucose and lipid level may further benefit CHD patient in survival.
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Affiliation(s)
- Yuanyuan Chen
- Department of Cardiology, The Third Xiangtan Hospital, Central South University, Changsha 410013, China
| | - Junru Wu
- Department of Cardiology, The Third Xiangtan Hospital, Central South University, Changsha 410013, China
| | - Yan Tang
- Department of Cardiology, The Third Xiangtan Hospital, Central South University, Changsha 410013, China
| | - Zhengxin Li
- Department of Cardiology, The Third Xiangtan Hospital, Central South University, Changsha 410013, China
| | - Qing Wen
- Department of Cardiology, The Third Xiangtan Hospital, Central South University, Changsha 410013, China
| | - Xuejing Sun
- Department of Cardiology, The Third Xiangtan Hospital, Central South University, Changsha 410013, China
| | - Hong Yuan
- Department of Cardiology, The Third Xiangtan Hospital, Central South University, Changsha 410013, China; The Center of Clinical Pharmacology, The Third Xiangtan Hospital, Central South University, Changsha 410013, China
| | - Yao Lu
- The Center of Clinical Pharmacology, The Third Xiangtan Hospital, Central South University, Changsha 410013, China.
| | - Jingjing Cai
- Department of Cardiology, The Third Xiangtan Hospital, Central South University, Changsha 410013, China; The Center of Clinical Pharmacology, The Third Xiangtan Hospital, Central South University, Changsha 410013, China.
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4
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Heart Failure After ST-Elevation Myocardial Infarction: Beyond Left Ventricular Adverse Remodeling. Curr Probl Cardiol 2022:101215. [PMID: 35460680 DOI: 10.1016/j.cpcardiol.2022.101215] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/13/2022] [Indexed: 12/11/2022]
Abstract
ST-segment elevation myocardial infarction (STEMI) remains a significant source of morbidity and mortality worldwide. Despite advances in treatment leading to a significant reduction in the early complications and in-hospital mortality, a significant proportion of STEMI survivors develop heart failure (HF) at follow-up. The classic paradigm of HF after STEMI is one characterized by left ventricular adverse remodeling (LVAR) and encompasses the process of regional and global structural and functional changes that occur in the heart as a consequence of loss of viable myocardium, increased wall stress and neurohormonal activation, and results in HF with reduced ejection fraction (HFrEF). More recently, however, with further improvements in the treatment of STEMI the incidence and entity of LVAR appear to be largely reduced, yet the risk for HF following STEMI is not abolished and remains substantial, identifying a new paradigm by which patients with STEMI present with HF and preserved EF (HFpEF) characterized by reduction of diastolic or systolic reserve independent of LVAR.
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Aldosterone Blockade in Acute Myocardial Infarction: A Systematic Review and Meta-Analysis. Cardiovasc Ther 2021; 2021:1710731. [PMID: 34786023 PMCID: PMC8560277 DOI: 10.1155/2021/1710731] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/02/2021] [Accepted: 09/18/2021] [Indexed: 12/12/2022] Open
Abstract
Background A comprehensive evaluation of the benefits of mineralocorticoid receptor antagonists (MRA) in acute myocardial infarction (AMI) patients is lacking. Objective To summarize the evidence on the efficacy and safety of MRA in patients admitted for AMI. Methods Articles were identified through PubMed, Embase, Cochrane Library, Ovid (Medline1946-2021), and ClinicalTrials.gov databases from their inception to December 31, 2020. Results 15 articles with a total of 11,861 patients were included. MRA reduced the risk of all-cause mortality by 16% (relative ratio (RR): 0.84; 95% confidence interval (CI) (0.76, 0.94); P = 0.002) and the incidence of cardiovascular adverse events by 12% (RR: 0.88, 95% CI (0.83, 0.93), P < 0.00001) in post-AMI patients, and further analysis demonstrated that early administration of MRA within 7 days after AMI resulted in a greater reduction in all-cause mortality (RR: 0.72, 95% CI (0.61, 0.85), P < 0.0001). Subgroup analyses showed that post-STEMI patients without left ventricular systolic dysfunction (LVSD) treated with MRA had a 36% reduction in all-cause mortality (RR: 0.64, 95% CI (0.46, 0.89), P = 0.007) and a 22% reduction in cardiovascular adverse events (RR: 0.78, 95% CI (0.67, 0.91), P = 0.002). Meanwhile, post-STEMI patients without LVSD treated with MRA get significant improvements in left ventricular ejection fraction (mean difference (MD): 2.69, 95% CI (2.44, 2.93), P < 0.00001), left ventricular end-systolic index (MD: -4.52 ml/m2, 95% CI (-8.21, -0.83), P = 0.02), and left ventricular end-diastolic diameter (MD: -0.11 cm, 95% CI (-0.22, 0.00), P = 0.05). The corresponding RR were 1.72 (95% CI (1.43, 2.07), P < 0.00001) for considered common adverse events (hyperkalemia, gynecomastia, and renal dysfunction). Conclusions Our findings suggest that MRA treatment reduces all-cause mortality and cardiovascular adverse events in post-AMI patients, which is more significant in patients after STEMI without LVSD. In addition, MRA treatment may exert beneficial effects on the reversal of cardiac remodeling in patients after STEMI without LVSD.
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Wong EC, Fordyce CB, Wong G, Lee T, Perry‐Arnesen M, Mackay M, Singer J, Cairns JA, Turgeon RD. Predictors of the Use of Mineralocorticoid Receptor Antagonists in Patients With Left Ventricular Dysfunction Post-ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2021; 10:e019167. [PMID: 34227405 PMCID: PMC8483484 DOI: 10.1161/jaha.120.019167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/22/2021] [Indexed: 01/14/2023]
Abstract
Background Guidelines recommend mineralocorticoid receptor antagonist (MRA) use in patients with left ventricular ejection fraction ≤40% following a myocardial infarction plus heart failure or diabetes mellitus, based on mortality benefit in the EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study) trial. The objective of this study was to evaluate the real-world utilization of MRAs for patients with ST-segment-elevation myocardial infarction (STEMI) with left ventricular dysfunction. Methods and Results The prospective, population-based, Vancouver Coastal Health Authority STEMI database was linked with local outpatient cardiology records from 2007 to 2018. EPHESUS criteria were used to define post-STEMI MRA eligibility (left ventricular ejection fraction ≤40% plus clinical heart failure or diabetes mellitus, and no dialysis-dependent renal dysfunction). The primary outcome was MRA prescription among eligible patients at discharge and the secondary outcome was MRA prescription within 3 months postdischarge. Of 2691 patients with STEMI, 317 (12%) were MRA eligible, and 70 (22%) eligible patients were prescribed an MRA at discharge. Among eligible patients with no MRA at discharge, 12/126 (9.5%) with documented postdischarge follow-up were prescribed an MRA within 3 months. In multivariable analysis, left ventricular ejection fraction (odds ratio [OR], 1.55 per 5% left ventricular ejection fraction decrease; 95% CI, 1.26-1.90) and calendar year (OR, 1.23 per year, 95% CI, 1.11-1.37) were associated with MRA prescription at discharge. Other prespecified variables were not associated with MRA prescription. Conclusions In this contemporary STEMI cohort, only 1 in 4 MRA-eligible patients were prescribed an MRA within 3 months following hospitalization despite high-quality evidence for use. Novel decision-support tools are required to optimize pharmacotherapy decisions during hospitalization and follow-up to target this gap in post-STEMI care.
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Affiliation(s)
- Eric C. Wong
- Division of General Internal MedicineDepartment of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Christopher B. Fordyce
- Division of CardiologyDepartment of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Centre for Health Evaluation and Outcome SciencesProvidence Health Care Research InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Vancouver Coastal Health AuthorityVancouverBritish ColumbiaCanada
| | - Graham Wong
- Division of CardiologyDepartment of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Vancouver Coastal Health AuthorityVancouverBritish ColumbiaCanada
| | - Terry Lee
- Centre for Health Evaluation and Outcome SciencesProvidence Health Care Research InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | | | - Martha Mackay
- Centre for Health Evaluation and Outcome SciencesProvidence Health Care Research InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- School of NursingUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- St. Paul's Hospital Heart CentreVancouverBritish ColumbiaCanada
| | - Joel Singer
- Centre for Health Evaluation and Outcome SciencesProvidence Health Care Research InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- School of Population and Public HealthUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - John A. Cairns
- Division of CardiologyDepartment of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Ricky D. Turgeon
- Division of CardiologyDepartment of MedicineUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Centre for Health Evaluation and Outcome SciencesProvidence Health Care Research InstituteUniversity of British ColumbiaVancouverBritish ColumbiaCanada
- Faculty of Pharmaceutical SciencesUniversity of British ColumbiaVancouverBritish ColumbiaCanada
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7
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Schupp T, Akin I, Behnes M. Pharmacological Treatment Following Myocardial Infarction: How Large Is the Gap Between Guideline Recommendations and Routine Clinical Care? J Am Heart Assoc 2021; 10:e021799. [PMID: 34227398 PMCID: PMC8483471 DOI: 10.1161/jaha.121.021799] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- Tobias Schupp
- First Department of Medicine Faculty of Medicine Mannheim University of Heidelberg Mannheim Germany
| | - Ibrahim Akin
- First Department of Medicine Faculty of Medicine Mannheim University of Heidelberg Mannheim Germany
| | - Michael Behnes
- First Department of Medicine Faculty of Medicine Mannheim University of Heidelberg Mannheim Germany
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8
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Zeigler AC, Chandrabhatla AS, Christiansen SL, Nelson AR, Holmes JW, Saucerman JJ. Network model-based screen for FDA-approved drugs affecting cardiac fibrosis. CPT Pharmacometrics Syst Pharmacol 2021; 10:377-388. [PMID: 33571402 PMCID: PMC8099443 DOI: 10.1002/psp4.12599] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/08/2020] [Accepted: 01/14/2021] [Indexed: 12/30/2022] Open
Abstract
Cardiac fibrosis is a significant component of pathological heart remodeling, yet it is not directly targeted by existing drugs. Systems pharmacology approaches have the potential to provide mechanistic frameworks with which to predict and understand how drugs modulate biological systems. Here, we combine network modeling of the fibroblast signaling network with 36 unique drug-target interactions from DrugBank to predict drugs that modulate fibroblast phenotype and fibrosis. Galunisertib was predicted to decrease collagen and α-SMA expression, which we validated in human cardiac fibroblasts. In vivo fibrosis data from the literature validated predictions for 10 drugs. Further, the model was used to identify network mechanisms by which these drugs work. Arsenic trioxide was predicted to induce fibrosis by AP1-driven TGFβ expression and MMP2-driven TGFβ activation. Entresto (valsartan/sacubitril) was predicted to suppress fibrosis by valsartan suppression of ERK signaling and sacubitril enhancement of PKG activity, both of which decreased Smad3 activity. Overall, this study provides a framework for integrating drug-target mechanisms with logic-based network models, which can drive further studies both in cardiac fibrosis and other conditions.
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Affiliation(s)
- Angela C. Zeigler
- Department of Biomedical EngineeringUniversity of VirginiaCharlottesvilleVirginiaUSA
| | | | | | - Anders R. Nelson
- Department of PharmacologyUniversity of VirginiaCharlottesvilleVirginiaUSA
| | - Jeffrey W. Holmes
- Department of Biomedical EngineeringUniversity of VirginiaCharlottesvilleVirginiaUSA
- Division of Cardiovascular MedicineUniversity of VirginiaCharlottesvilleVirginiaUSA
| | - Jeffrey J. Saucerman
- Department of Biomedical EngineeringUniversity of VirginiaCharlottesvilleVirginiaUSA
- Division of Cardiovascular MedicineUniversity of VirginiaCharlottesvilleVirginiaUSA
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9
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Jenča D, Melenovský V, Stehlik J, Staněk V, Kettner J, Kautzner J, Adámková V, Wohlfahrt P. Heart failure after myocardial infarction: incidence and predictors. ESC Heart Fail 2020; 8:222-237. [PMID: 33319509 PMCID: PMC7835562 DOI: 10.1002/ehf2.13144] [Citation(s) in RCA: 250] [Impact Index Per Article: 62.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/14/2020] [Accepted: 11/15/2020] [Indexed: 12/11/2022] Open
Abstract
Aims The aim of the present paper was to provide an up‐to‐date view on epidemiology and risk factors of heart failure (HF) development after myocardial infarction. Methods and results Based on literature review, several clinical risk factors and biochemical, genetic, and imaging biomarkers were identified to predict the risk of HF development after myocardial infarction. Conclusions Heart failure is still a frequent complication of myocardial infarction. Timely identification of subjects at risk for HF development using a multimodality approach, and early initiation of guideline‐directed HF therapy in these patients, can decrease the HF burden.
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Affiliation(s)
- Dominik Jenča
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Vojtěch Melenovský
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Josef Stehlik
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Vladimír Staněk
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jiří Kettner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Faculty of Medicine, Dentistry of the Palacký University, Olomouc, Czech Republic
| | - Věra Adámková
- Department of Preventive Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Peter Wohlfahrt
- Third Faculty of Medicine, Charles University, Prague, Czech Republic.,Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,Department of Preventive Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Centre for Cardiovascular Prevention, First Faculty of Medicine and Thomayer Hospital, Charles University, Videnska 800, Prague 4, 140 59, Czech Republic
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Asakura M, Ito S, Yamada T, Saito Y, Kimura K, Yamashina A, Hirayama A, Kobayashi Y, Hanatani A, Tsujimoto M, Yasuda S, Abe Y, Higashino Y, Tamaki Y, Sugino H, Niinuma H, Okuhara Y, Koitabashi T, Momomura SI, Asai K, Nomura A, Kawai H, Satoh Y, Yoshikawa T, Hirata KI, Yokoi Y, Tanaka J, Shibata Y, Maejima Y, Tamaki S, Kawata H, Iwahashi N, Kobayashi M, Higuchi Y, Kada A, Yamamoto H, Kitakaze M. Efficacy and safety of early initiation of eplerenone treatment in patients with acute heart failure (EARLIER trial): a multicenter, randomized, double-blind, placebo-controlled trial. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2020; 8:108-117. [PMID: 33175088 DOI: 10.1093/ehjcvp/pvaa132] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/16/2020] [Accepted: 11/03/2020] [Indexed: 11/12/2022]
Abstract
AIMS A mineralocorticoid receptor antagonist (MRA) is effective in patients with chronic heart failure; however, the effects of the early initiation of an MRA in patients with acute heart failure (AHF) have not been elucidated. METHODS AND RESULTS In this multicenter, randomized, double-blind, placebo-controlled, parallel-group study, we focused on the safety and effectiveness of the treatment with eplerenone, a selective MRA in 300 patients with AHF, that is, 149 in the eplerenone group and 151 in the placebo group in 27 Japanese institutions. The key inclusion criteria were (1) patients aged 20 years or older and (2) those with left ventricular ejection fraction of ≤ 40%. The primary outcome was a composite of cardiac death or first re-hospitalization due to cardiovascular disease within 6 months. The mean age of the participants was 66.8 years, 27.3% were women, and the median levels of brain natriuretic peptide were 376.0 pg/mL. The incidences of the primary outcome were 19.5% in the eplerenone group and 17.2% in the placebo group (hazard ratio (HR): 1.09, 95% confidence interval (CI): 0.642-1.855). In prespecified secondary outcomes, HR for the composite endpoint, cardiovascular death, or first re-hospitalization due to heart failure (HF) within 6 months was 0.55 (95% CI: 0.213 to 1.434). The safety profile for eplerenone was as expected. CONCLUSION The early initiation of eplerenone in patients with AHF could safely be utilized. The reduction of the incidence of a composite of cardiovascular death or first re-hospitalization for cardiovascular diseases by eplerenone is inconclusive because of inadequate power.
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Affiliation(s)
- Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Hyogo, Japan
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shin Ito
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takahisa Yamada
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Yoshihiko Saito
- Department of Cardiovascular Medicine, Nara Medical University, Nara Medical University Hospital, Nara, Japan
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Akira Yamashina
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Hirayama
- The Division of Cardiology, Department of Medicine, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Youichi Kobayashi
- Division of Cardiology, Department of Medicine, Showa University Hospital, Tokyo, Japan
| | - Akihisa Hanatani
- Department of Cardiovascular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Mitsuru Tsujimoto
- Department of Cardiology, Cardiovascular Center, Veritas Hospital, Hyogo, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Yorihiko Higashino
- Department of Cardiology, Higashi Takarazuka Satoh Hospital, Hyogo, Japan
| | - Yodo Tamaki
- Department of Cardiology, Tenri Hospital, Nara, Tenri, Japan
| | - Hiroshi Sugino
- Department of Cardiac Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Hiroyuki Niinuma
- Department of Cardiology, St. Luke's International Hospital, Tokyo, Japan
| | - Yoshitaka Okuhara
- Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Toshimi Koitabashi
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Tokyo, Japan
| | - Shin-Ichi Momomura
- Cardiovascular Division, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Kuniya Asai
- Department of Cardiovascular Medicine, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Akihiro Nomura
- Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medical Science, Ishikawa, Japan
| | - Hiroya Kawai
- Division of Cardiovascular Medicine, Hyogo Prefectural Himeji Cardiovascular Center, Hyogo Brain and Heart Center, Hyogo, Japan
| | - Yasuhiro Satoh
- Department of Cardiology, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | | | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshiaki Yokoi
- Department of Medicine, Cardiac Arrhythmia Center, Kishiwada Tokushukai Hospital, Kishiwada, Osaka, Japan
| | - Jun Tanaka
- Department of Cardiology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Yoshisato Shibata
- Department of Cardiology, Miyazaki Medical Association Hospital, Miyazaki, Japan
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University Medical Hospital, Tokyo, Japan
| | - Shunsuke Tamaki
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Hiroyuki Kawata
- Department of Cardiovascular Medicine, Nara Medical University, Nara Medical University Hospital, Nara, Japan
| | - Noriaki Iwahashi
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | | | - Yoshiharu Higuchi
- The Division of Cardiology, Department of Medicine, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Akiko Kada
- Department of Clinical Research Management, National Hospital Organization Nagoya Medical Center, Aichi, Japan
| | - Haruko Yamamoto
- Department of Advance Medical Technology Development, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi Suita 564-8565, Osaka, Japan
| | - Masafumi Kitakaze
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
- Hanwa Daini Senboku Hospital, 3176 Fukaikitamachi, Naka-ku Sakai City, Osaka 599-8271, Japan
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11
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Kalogeropoulos AP, Simitsis P, Skopicki HA. Secrets of spironolactone: continuing insights from TOPCAT Americas. Eur J Heart Fail 2020; 22:1625-1627. [PMID: 32628354 DOI: 10.1002/ejhf.1959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/02/2020] [Indexed: 11/08/2022] Open
Affiliation(s)
| | - Panagiotis Simitsis
- Heart Failure Unit, Departments of Cardiology & Critical Care Medicine, Attikon University Hospital, University of Athens Medical School, Athens, Greece
| | - Hal A Skopicki
- Division of Cardiology, Department of Medicine, Stony Brook University, Stony Brook, NY, USA
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12
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Mineralocorticoid receptor antagonists lead to increased adenosine bioavailability and modulate contractile cardiac parameters. Heart Vessels 2019; 35:719-730. [PMID: 31820090 DOI: 10.1007/s00380-019-01542-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 11/29/2019] [Indexed: 10/25/2022]
Abstract
Activation of mineralocorticoid receptor antagonists (MRAs) is cardioprotective; however, this property is lost upon blockade or inactivation of adenosine (ADO) receptor A2b. In this study, we investigated whether the effects of MRAs are mediated by an interaction between cardioprotective ADO receptors A1 and A3. Spironolactone (SPI) or eplerenone (EPL) increased ADO levels in the plasma of treated animals compared to control animals. SPI or EPL increased the protein and activity levels of ecto-5'-nucleotidase (NT5E), an enzyme that synthesizes ADO, compared to control. The levels of ADO deaminase (ADA), which degrades ADO, were not affected by SPI or EPL; however, the activity of ADA was reduced in SPI-treated rats compared to control. Using an isolated cardiomyocyte model, we found inotropic and chronotropic effects, and increased calcium transient [Ca2+]i in cells treated with ADO receptor A1 or A3 antagonists compared to control groups. Upon co-treatment with MRAs, EPL and SPI fully and partially reverted the effects of receptor A1 or A3 antagonism, respectively. Collectively, MRAs in vivo lead to increased ADO bioavailability. In vitro, the rapid effects of SPI and EPL are mediated by an interaction between ADO receptors A1 and A3.
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13
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Post-Myocardial Infarction Heart Failure. JACC-HEART FAILURE 2019; 6:179-186. [PMID: 29496021 DOI: 10.1016/j.jchf.2017.09.015] [Citation(s) in RCA: 218] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 09/05/2017] [Accepted: 09/10/2017] [Indexed: 12/22/2022]
Abstract
Heart failure (HF) complicating myocardial infarction (MI) is common and may be present at admission or develop during the hospitalization. Among patients with MI, there is a strong relationship between degree of HF and mortality. The optimal management of the patient with HF complicating MI varies according to time since the onset of infarction. Medical therapy for HF after MI includes early (within 24 h) initiation of angiotensin-converting enzyme inhibitors and early (within 7 days) use of aldosterone antagonists. Alternatively, in patients with MI and ongoing HF, early use (<24 h) of beta-blockers is associated with an increased risk of cardiogenic shock and death. Long-term beta-blocker use after MI is associated with a reduced risk of reinfarction and death. Thus, it is critical to frequently re-evaluate beta-blocker eligibility among patients after MI with HF. Cardiogenic shock is an extreme presentation of HF after MI and is a leading cause of death in the MI setting. The only therapy proven to reduce mortality for patients with cardiogenic shock is early revascularization. Several studies are examining new approaches to mitigate the occurrence and adverse impact of post-MI HF. These studies are testing drugs for HF and diabetes and are evaluating mechanical support devices to bridge patients to recovery or transplantation.
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14
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Considerations for Clinical Trials Targeting the Myocardial Interstitium. JACC Cardiovasc Imaging 2019; 12:2319-2331. [DOI: 10.1016/j.jcmg.2019.03.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/26/2019] [Accepted: 03/07/2019] [Indexed: 01/23/2023]
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15
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Abstract
Inflammation plays a central role in the development of heart failure, especially in heart failure with preserved ejection fraction (HFpEF). Furthermore, the inflammatory response enables the induction of regenerative processes following acute myocardial injury. Recent studies in humans and animals have greatly advanced our understanding of the underlying mechanisms behind these adaptations. Importantly, inflammation can have both beneficial and detrimental effects, dependent on its extent, localization, and duration. Therefore, modulation of cardiac inflammation has been suggested as an attractive target for the treatment of heart failure, which has been investigated in numerous clinical trials. This review discusses key inflammatory mechanisms contributing to the pathogenesis of heart failure and their potential impact as therapeutic targets.
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Affiliation(s)
- C Riehle
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - J Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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Gronda E, Sacchi S, Benincasa G, Vanoli E, Napoli C. Unresolved issues in left ventricular postischemic remodeling and progression to heart failure. J Cardiovasc Med (Hagerstown) 2019; 20:640-649. [DOI: 10.2459/jcm.0000000000000834] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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17
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Stienen S, Rossignol P, Barros A, Girerd N, Pitt B, Zannad F, Ferreira JP. Determinants of anti-fibrotic response to mineralocorticoid receptor antagonist therapy: insights from the Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) and Early Eplerenone Treatment in Patients with Acute ST-elevation Myocardial Infarction without Heart Failure (REMINDER) trials. Clin Res Cardiol 2019; 109:194-204. [DOI: 10.1007/s00392-019-01500-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 06/03/2019] [Indexed: 12/15/2022]
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18
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Papademetriou V, Toumpourleka M, Imprialos KP, Alataki S, Manafis A, Stavropoulos K. The Role of Mineralocorticoid Receptor Antagonists in Heart Failure with Reduced Ejection Fraction. Curr Pharm Des 2019; 24:5517-5524. [DOI: 10.2174/1381612825666190219141326] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 02/13/2019] [Indexed: 12/20/2022]
Abstract
Background:
Heart failure (HF) is a worldwide modern epidemic, associated with significant morbidity
and mortality. Several causes have been identified for the syndrome, most of which share common pathophysiologic
pathways, including neurohormonal activation. Central to the latter lies activation of the reninangiotensin-
aldosterone system, and its effects on cardiovascular disease progression.
Objectives:
The aim of this review is to summarize the pathophysiology of aldosterone and the effects of its
blockage in the failing heart, as well as to provide state-of-the-art evidence, and address future perspectives regarding
the use of mineralocorticoid receptor antagonists in heart failure with reduced ejection fraction.
Method:
Literature was reviewed for studies that assess the pathophysiology of aldosterone in HF with reduced
ejection fraction (HFrEF), and the effects of mineralocorticoid receptor antagonists (MRAs) in this condition.
Results:
Several major society guidelines have synthesized the available evidence on HFrEF management, and
drugs that block the renin-angiotensin-aldosterone system at different levels continue to form the key component
of standard of care for these patients. Mineralocorticoid receptor antagonists are an important part of HFrEF
pharmacologic treatment, and their use is supported by a high level of evidence studies. This class of drugs demonstrated
significant benefits for morbidity and mortality, across the spectrum oh HFrEF, including patients after
acute myocardial infarction.
Conclusion:
Current evidence supports the central role of aldosterone in HFrEF progression, and the significant
benefits on outcomes with the use of MRAs.
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Affiliation(s)
| | - Maria Toumpourleka
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos P. Imprialos
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sofia Alataki
- Medical Clinic IV-Department of Cardiology, Manicipal Hospital Karlsruhe, Academic Teaching Hospital, University of Freiburg, Karlsruhe, Germany
| | - Alexandros Manafis
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Stavropoulos
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Interactions between the Cyclooxygenase Metabolic Pathway and the Renin-Angiotensin-Aldosterone Systems: Their Effect on Cardiovascular Risk, from Theory to the Clinical Practice. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7902081. [PMID: 30386795 PMCID: PMC6189683 DOI: 10.1155/2018/7902081] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 09/10/2018] [Indexed: 02/07/2023]
Abstract
Coronary artery disease (CAD) and stroke are the most common and serious long-term complications of hypertension. Acetylsalicylic acid (ASA) significantly reduces their incidence and cardiovascular mortality. The RAAS activation plays an important role in pathogenesis of CVD, resulting in increased vascular resistance, proliferation of vascular-smooth-muscle-cells, and cardiac hypertrophy. Drugs acting on the renin-angiotensin-aldosterone system (RAAS) are demonstrated to reduce cardiovascular events in population with cardiovascular disease (CVD). The cyclooxygenase inhibitors limit the beneficial effect of RAAS-inhibitors, which in turn may be important in subjects with hypertension, CAD, and congestive heart failure. These observations apply to most of nonsteroidal anti-inflammatory drugs and ASA at high doses. Nevertheless, there is no strong evidence confirming presence of similar effects of cardioprotective ASA doses. The benefit of combined therapy with low-doses of ASA is-in some cases-significantly higher than that of monotherapy. So far, the significance of ASA in optimizing the pharmacotherapy remains not fully established. A better understanding of its influence on the particular CVD should contribute to more precise identification of patients in whom benefits of ASA outweigh the complication risk. This brief review summarizes the data regarding usefulness and safety of the ASA combination with drugs acting directly on the RAAS.
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20
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Docherty KF, Jhund PS. Early use of mineralocorticoid receptor antagonists in ST-elevation myocardial infarction: is it ever too early? Heart 2018; 104:1812-1813. [PMID: 29760244 DOI: 10.1136/heartjnl-2018-313371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Kieran F Docherty
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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21
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Beygui F, Van Belle E, Ecollan P, Machecourt J, Hamm CW, Lopez De Sa E, Flather M, Verheugt FWA, Vicaut E, Zannad F, Pitt B, Montalescot G. Individual participant data analysis of two trials on aldosterone blockade in myocardial infarction. Heart 2018; 104:1843-1849. [PMID: 29695512 DOI: 10.1136/heartjnl-2018-312950] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 03/26/2018] [Accepted: 03/28/2018] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Two recent randomised trials studied the benefit of mineralocorticoid receptor antagonists (MRAs) in ST-segment elevation myocardial infarction (STEMI) irrespective or in absence of heart failure. The studies were both undersized to assess hard clinical endpoints. A pooled analysis was preplanned by the steering committees. METHODS We conducted a prespecified meta-analysis of patient-level data of patients with STEMI recruited in two multicentre superiority trials, randomised within 72 hours after symptom onset. Patients were allocated (1:1) to two MRA regimens: (1) an intravenous bolus of potassium canrenoate (200 mg) followed by oral spironolactone (25 mg once daily) versus standard therapy or (2) oral eplerenone (25-50 mg) versus placebo. The primary and key secondary outcomes, all-cause death and the composite of all-cause death or resuscitated sudden death, respectively, were assessed in the intention-to-treat population using a Cox model stratified on the study identifier. RESULTS Patients were randomly assigned to receive (n=1118) or not the MRA regimen (n=1123). After a median follow-up time of 188 days, the primary and secondary outcomes occurred in 5 (0.4%) and 17 (1.5%) patients (adjusted HR (adjHR) 0.31, 95% CI 0.11 to 0.86, p=0.03) and 6 (0.5%) and 22 (2%) patients (adjHR 0.26, 95% CI 0.10 to 0.65, p=0.004) in the MRA and control groups, respectively. There were also trends towards lower rates of cardiovascular death (p=0.06) and ventricular fibrillation (p=0.08) in the MRA group. CONCLUSION Our analysis suggests that compared with standard therapy, MRA regimens are associated with a reduction of death and death or resuscitated sudden death in STEMI.
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Affiliation(s)
- Farzin Beygui
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Caen, EA4650 Normandie Université, Caen, Basse-Normandie, France
| | - Eric Van Belle
- INSERM U1011 and Cardiology, Institut Coeur Poumon, CHRU de Lille, Lille, France
| | - Patrick Ecollan
- SAMU, ACTION Study Group, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
| | - Jacques Machecourt
- Service de Cardiologie, Centre Hospitalier Universitaire de Grenoble, Grenoble, Rhône-Alpes, France
| | | | | | - Marcus Flather
- Cardiology, University of East Anglia and Norfolk and Norwich University Hospital, Norwich, UK
| | | | - Eric Vicaut
- ACTION Study Group, Unite de Recherche Clinique, Hôpital Lariboisière, Paris, France
| | - Faiez Zannad
- Inserm CIC 1433 and Cardiology, Centre Hospitalier Universitaire de Nancy, Vandœuvre-lès-Nancy, France
| | - Bertram Pitt
- University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Gilles Montalescot
- Cardiology, Sorbonne Université-Paris 6, ACTION Study Group, Institut de Cardiologie (AP-HP), Centre Hospitalier Universitaire Pitié-Salpêtriėre, INSERM UMRS 1166, Paris, France
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22
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Hermidorff MM, de Assis LVM, Isoldi MC. Genomic and rapid effects of aldosterone: what we know and do not know thus far. Heart Fail Rev 2018; 22:65-89. [PMID: 27942913 DOI: 10.1007/s10741-016-9591-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Aldosterone is the most known mineralocorticoid hormone synthesized by the adrenal cortex. The genomic pathway displayed by aldosterone is attributed to the mineralocorticoid receptor (MR) signaling. Even though the rapid effects displayed by aldosterone are long known, our knowledge regarding the receptor responsible for such event is still poor. It is intense that the debate whether the MR or another receptor-the "unknown receptor"-is the receptor responsible for the rapid effects of aldosterone. Recently, G protein-coupled estrogen receptor-1 (GPER-1) was elegantly shown to mediate some aldosterone-induced rapid effects in several tissues, a fact that strongly places GPER-1 as the unknown receptor. It has also been suggested that angiotensin receptor type 1 (AT1) also participates in the aldosterone-induced rapid effects. Despite this open question, the relevance of the beneficial effects of aldosterone is clear in the kidneys, colon, and CNS as aldosterone controls the important water reabsorption process; on the other hand, detrimental effects displayed by aldosterone have been reported in the cardiovascular system and in the kidneys. In this line, the MR antagonists are well-known drugs that display beneficial effects in patients with heart failure and hypertension; it has been proposed that MR antagonists could also play an important role in vascular disease, obesity, obesity-related hypertension, and metabolic syndrome. Taken altogether, our goal here was to (1) bring a historical perspective of both genomic and rapid effects of aldosterone in several tissues, and the receptors and signaling pathways involved in such processes; and (2) critically address the controversial points within the literature as regarding which receptor participates in the rapid pathway display by aldosterone.
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Affiliation(s)
- Milla Marques Hermidorff
- Laboratory of Hypertension, Research Center in Biological Science, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Campus Morro do Cruzeiro, Ouro Preto, MG, 35400-000, Brazil
| | - Leonardo Vinícius Monteiro de Assis
- Laboratory of Comparative Physiology of Pigmentation, Department of Physiology, Institute of Biosciences, University of São Paulo, São Paulo, Brazil
| | - Mauro César Isoldi
- Laboratory of Hypertension, Research Center in Biological Science, Institute of Exact and Biological Sciences, Federal University of Ouro Preto, Campus Morro do Cruzeiro, Ouro Preto, MG, 35400-000, Brazil.
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23
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Association of mineralocorticoid receptor antagonist use and in-hospital outcomes in patients with acute heart failure. Clin Res Cardiol 2017; 107:76-86. [DOI: 10.1007/s00392-017-1161-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 09/13/2017] [Indexed: 12/12/2022]
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24
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Wang GG, Wang SJ, Qin J, Li CS, Yu XZ, Shen H, Yang LP, Fu Y, Zheng YA, Zhao B, Yu DM, Qin FJ, Zhou DG, Li Y, Liu FJ, Li W, Zhao W, Gao X, Wang Z, Jin M, Zeng H, Li Y, Wang GX, Zhou H, Sun XL, Wang PB, Woo KS. Characteristics, Management, and Outcomes of Acute Heart Failure in the Emergency Department: A Multicenter Registry Study with 1-year Follow-up in a Chinese Cohort in Beijing. Chin Med J (Engl) 2017; 130:1894-1901. [PMID: 28776539 PMCID: PMC5555121 DOI: 10.4103/0366-6999.211880] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The emergency department (ED) has a pivotal influence on the management of acute heart failure (AHF), but data concerning current ED management are scarce. This Beijing AHF Registry Study investigated the characteristics, ED management, and short- and long-term clinical outcomes of AHF. METHODS This prospective, multicenter, observational study consecutively enrolled 3335 AHF patients who visited 14 EDs in Beijing from January 1, 2011, to September 23, 2012. Baseline data on characteristics and management were collected in the EDs. Follow-up data on death and readmissions were collected until November 31, 2013, with a response rate of 92.80%. The data were reported as median (interquartile range) for the continuous variables, or as number (percentage) for the categorical variables. RESULTS The median age of the enrolled patients was 71 (58-79) years, and 46.84% were women. In patients with AHF, coronary heart disease (43.27%) was the most common etiology, and myocardium ischemia (30.22%) was the main precipitant. Most of the patients in the ED received intravenous treatments, including diuretics (79.28%) and vasodilators (74.90%). Fewer patients in the ED received neurohormonal antagonists, and 25.94%, 31.12%, and 33.73% of patients received angiotensin converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and spironolactone, respectively. The proportions of patients who were admitted, discharged, left against medical advice, and died were 55.53%, 33.58%, 7.08%, and 3.81%, respectively. All-cause mortalities at 30 days and 1 year were 15.30% and 32.27%, respectively. CONCLUSIONS Substantial details on characteristics and ED management of AHF were investigated. The clinical outcomes of AHF patients were dismal. Thus, further investigations of ED-based therapeutic approaches for AHF are needed.
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Affiliation(s)
- Guo-Gan Wang
- Emergency and Critical Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Si-Jia Wang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Jian Qin
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Chun-Sheng Li
- Department of Emergency, Beijing Chao Yang Hospital, Beijing 100020, China
| | - Xue-Zhong Yu
- Department of Emergency, Peking Union Medical College Hospital, Beijing 100032, China
| | - Hong Shen
- Department of Emergency, The General Hospital of Chinese People's Liberation Army, Beijing 100853, China
| | - Li-Pei Yang
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Yan Fu
- Department of Emergency, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Ya-An Zheng
- Department of Emergency, Peking University Third Hospital, Beijing 100083, China
| | - Bin Zhao
- Department of Emergency, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Dong-Min Yu
- Department of Emergency, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Fu-Jun Qin
- Department of Emergency, Fangshan District Liangxiang Hospital, Beijing 102400, China
| | - De-Gui Zhou
- Department of Emergency, The Hospital of Shunyi District, Beijing 101300, China
| | - Ying Li
- Department of Emergency, People's Hospital of Beijing Daxing District, Beijing 102600, China
| | - Fu-Jun Liu
- Department of Emergency, The Luhe Teaching Hospital of the Capital Medical University, Beijing 101100, China
| | - Wei Li
- Medical Research and Biometrics Centre, National Centre for Cardiovascular Diseases, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences, Xishan Institute of Fuwai Hospital, Beijing 102300, China
| | - Wei Zhao
- Information Technology Centre, Fuwai Hospital, Beijing 100037, China
| | - Xin Gao
- Emergency and Critical Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zheng Wang
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing 100053, China
| | - Ming Jin
- Department of Emergency, Beijing Chao Yang Hospital, Beijing 100020, China
| | - Hong Zeng
- Department of Emergency, Beijing Chao Yang Hospital, Beijing 100020, China
| | - Yi Li
- Department of Emergency, Peking Union Medical College Hospital, Beijing 100032, China
| | - Guo-Xing Wang
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
| | - Hong Zhou
- Department of Emergency, Beijing Tongren Hospital, Capital Medical University, Beijing 100730, China
| | - Xiao-Lu Sun
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Peng-Bo Wang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Heart Center, First Hospital of Tsinghua University, Beijing 100016, China
| | - Kam-Sang Woo
- Department of Medicine and Therapeutics, School of Life Sciences, The Chinese University of Hong Kong, Hong Kong 999077, China
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Ferreira JP, Mentz RJ, Pizard A, Pitt B, Zannad F. Tailoring mineralocorticoid receptor antagonist therapy in heart failure patients: are we moving towards a personalized approach? Eur J Heart Fail 2017; 19:974-986. [DOI: 10.1002/ejhf.814] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/30/2016] [Accepted: 02/21/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- João Pedro Ferreira
- Centre d'Investigation Clinique Plurithématique 1433, INSERM U1116; University of Lorraine; Nancy France
- Department of Physiology and Cardiothoracic Surgery; Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto; Porto Portugal
| | - Robert J. Mentz
- Duke Clinical Research Institute and Division of Cardiology, Department of Medicine; Duke University Medical Center; Durham NC USA
| | - Anne Pizard
- Centre d'Investigation Clinique Plurithématique 1433, INSERM U1116; University of Lorraine; Nancy France
| | - Bertram Pitt
- Department of Cardiology; University of Michigan School of Medicine; Ann Arbor MI USA
| | - Faiez Zannad
- Centre d'Investigation Clinique Plurithématique 1433, INSERM U1116; University of Lorraine; Nancy France
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26
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Optimizing Cardiovascular Care With Mineralocorticoid Receptor Antagonists. J Nurse Pract 2017. [DOI: 10.1016/j.nurpra.2016.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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27
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Beygui F, Cayla G, Roule V, Roubille F, Delarche N, Silvain J, Van Belle E, Belle L, Galinier M, Motreff P, Cornillet L, Collet JP, Furber A, Goldstein P, Ecollan P, Legallois D, Lebon A, Rousseau H, Machecourt J, Zannad F, Vicaut E, Montalescot G. Early Aldosterone Blockade in Acute Myocardial Infarction: The ALBATROSS Randomized Clinical Trial. J Am Coll Cardiol 2016; 67:1917-27. [PMID: 27102506 DOI: 10.1016/j.jacc.2016.02.033] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mineralocorticoid receptor antagonists (MRA) improve outcome in the setting of post-myocardial infarction (MI) heart failure (HF). OBJECTIVES The study sought to assess the benefit of an early MRA regimen in acute MI irrespective of the presence of HF or left ventricular (LV) dysfunction. METHODS We randomized 1,603 patients to receive an MRA regimen with a single intravenous bolus of potassium canrenoate (200 mg) followed by oral spironolactone (25 mg once daily) for 6 months in addition to standard therapy or standard therapy alone. The primary outcome of the study was the composite of death, resuscitated cardiac arrest, significant ventricular arrhythmia, indication for implantable defibrillator, or new or worsening HF at 6-month follow-up. Key secondary/safety outcomes included death and other individual components of the primary outcome and rates of hyperkalemia at 6 months. RESULTS The primary outcome occurred in 95 (11.8%) and 98 (12.2%) patients in the treatment and control groups, respectively (hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.73 to 1.28). Death occurred in 11 (1.4%) and 17 (2.1%) patients in the treatment and control groups, respectively (HR: 0.65; 95% CI: 0.30 to 1.38). In a non-pre-specified exploratory analysis, the odds of death were reduced in the treatment group (3 [0.5%] vs. 15 [2.4%]; HR: 0.20; 95% CI: 0.06 to 0.70) in the subgroup of ST-segment elevation MI (n = 1,229), but not in non-ST-segment elevation MI (p for interaction = 0.01). Hyperkalemia >5.5 mmol/l(-1) occurred in 3% and 0.2% of patients in the treatment and standard therapy groups, respectively (p < 0.0001). CONCLUSIONS The study failed to show the benefit of early MRA use in addition to standard therapy in patients admitted for MI. (Aldosterone Lethal effects Blockade in Acute myocardial infarction Treated with or without Reperfusion to improve Outcome and Survival at Six months follow-up; NCT01059136).
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Affiliation(s)
- Farzin Beygui
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Guillaume Cayla
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Nimes, Nîmes, France
| | - Vincent Roule
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Caen, Caen, France
| | - François Roubille
- Service de Cardiologie, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | | | - Johanne Silvain
- ACTION Study Group, Institut de Cardiologie (AP-HP), Centre Hospitalier Universitaire Pitié-Salpêtriėre, Paris, France
| | - Eric Van Belle
- Service de Cardiologie, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Loic Belle
- Service de Cardiologie, Centre Hospitalier d'Annecy, Annecy, France
| | - Michel Galinier
- Service de Cardiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Pascal Motreff
- Service de Cardiologie, Centre Hospitalier Universitaire de Clermont Ferrand, Clermont Ferrand, France
| | - Luc Cornillet
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Nimes, Nîmes, France
| | - Jean-Philippe Collet
- ACTION Study Group, Institut de Cardiologie (AP-HP), Centre Hospitalier Universitaire Pitié-Salpêtriėre, Paris, France
| | - Alain Furber
- Service de Cardiologie, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Patrick Goldstein
- Service d'Accueil des Urgences et SAMU, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Patrick Ecollan
- ACTION Study Group, SAMU, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
| | - Damien Legallois
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Alain Lebon
- ACTION Study Group, Service de Cardiologie, Centre Hospitalier Universitaire de Caen, Caen, France
| | - Hélène Rousseau
- ACTION Study Group, Unite de Recherche Clinique, Hôpital Lariboisière, Paris, France
| | - Jacques Machecourt
- Service de Cardiologie, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Faiez Zannad
- INSERM, CIC 1433 et Pôle de Cardiologie, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Eric Vicaut
- ACTION Study Group, Unite de Recherche Clinique, Hôpital Lariboisière, Paris, France
| | - Gilles Montalescot
- ACTION Study Group, Institut de Cardiologie (AP-HP), Centre Hospitalier Universitaire Pitié-Salpêtriėre, Paris, France.
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Pitt B, Pedro Ferreira J, Zannad F. Mineralocorticoid receptor antagonists in patients with heart failure: current experience and future perspectives. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2016; 3:48-57. [DOI: 10.1093/ehjcvp/pvw016] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 01/14/2023]
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Pitt B. MRAs in Patients With AMI Without Early Evidence of Heart Failure. J Am Coll Cardiol 2016; 67:1928-30. [DOI: 10.1016/j.jacc.2016.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 02/16/2016] [Indexed: 10/21/2022]
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Fraccarollo D, Galuppo P, Sieweke J, Napp LC, Grobbecker P, Bauersachs J. Efficacy of mineralocorticoid receptor antagonism in the acute myocardial infarction phase: eplerenone versus spironolactone. ESC Heart Fail 2015; 2:150-158. [PMID: 28834677 PMCID: PMC6410542 DOI: 10.1002/ehf2.12053] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 06/06/2015] [Accepted: 06/13/2015] [Indexed: 12/30/2022] Open
Abstract
AIMS The selective mineralocorticoid receptor (MR) antagonist eplerenone given early in patients with acute myocardial infarction (MI) improves clinical outcome, whereas little is known about the effectiveness of early spironolactone therapy. We aimed to compare the ability of eplerenone and spironolactone to promote cardiac repair after experimental MI. METHODS AND RESULTS Starting immediately after coronary artery ligation, C57BL/6J mice were treated with placebo, eplerenone, or spironolactone. At 7 days, treatment with eplerenone or spironolactone reduced thinning and expansion of healing infarct and improved early left ventricular chamber enlargement. Remarkably, eplerenone therapy resulted in significantly greater improvement than spironolactone of left ventricular contractile function and relaxation, associated with a more considerable leftward and downward shift of the pressure volume curve. Seven-day survival rate was significantly increased only in eplerenone treated mice. Moreover, eplerenone was superior to spironolactone in ameliorating neovessel formation in the injured myocardium. Optimized flow cytometry analysis of the monocyte differentiation marker Ly6C revealed predominant accumulation of Ly6Chigh monocytes/macrophages at the site of ischemic injury during the early inflammatory phase in placebo-treated mice. In contrast, MR antagonism, especially by eplerenone, led to a skewing of the monocyte/macrophage population toward a higher frequency of healing promoting Ly6Clow cells. CONCLUSION The MR antagonist eplerenone versus spironolactone showed superior efficacy during the acute MI phase with more beneficial effects on survival, early cardiac dilation, and functional decline. Modulation of monocyte maturation and enhanced infarct neovessel formation appears to play a pivotal role.
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Affiliation(s)
- Daniela Fraccarollo
- Klinik fuer Kardiologie und AngiologieMedizinische Hochschule HannoverHannoverGermany
| | - Paolo Galuppo
- Klinik fuer Kardiologie und AngiologieMedizinische Hochschule HannoverHannoverGermany
| | - Jan‐Thorben Sieweke
- Klinik fuer Kardiologie und AngiologieMedizinische Hochschule HannoverHannoverGermany
| | - L. Christian Napp
- Klinik fuer Kardiologie und AngiologieMedizinische Hochschule HannoverHannoverGermany
| | | | - Johann Bauersachs
- Klinik fuer Kardiologie und AngiologieMedizinische Hochschule HannoverHannoverGermany
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Brown K, Chee J, Kyung S, Vettichira B, Papadimitriou L, Butler J. Mineralocorticoid Receptor Antagonism in Acute Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015. [PMID: 26199117 DOI: 10.1007/s11936-015-0402-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OPINION STATEMENT Heart failure (HF) remains a tremendous burden to health care systems and patients worldwide. The cornerstone neurohormonal disruption that leads to the debilitating sequelae in HF patients revolves primarily around aldosterone and the renin-angiotensin-aldosterone system (RAAS). Aldosterone plays a detrimental role in tissue remodeling by inducing inflammation and fibrosis within the cardiovascular and renal systems, leaving mineralocorticoid receptor antagonists (MRAs) as key pharmacological tools to slow pathogenesis and improve patient outcomes. The role of MRA in improving morbidity and mortality in outpatients with chronic HF and low ejection fraction is well established and supported by large randomized controlled trials. However, evidence-based data relating to the use of MRA in acute HF (AHF) remain somewhat limited, and therefore, the use of MRA is not ubiquitously considered in the acute setting. Current studies for the use of MRA in AHF are limited by small sample size as well as safety concerns relating to the dose-dependent effects on electrolyte homeostasis and renal function. Here, we discuss the imperative need for additional trials elucidating the potential benefits of MRA in AHF as an adjunct diuretic therapy. We not only discuss the role of MRA in neurohormonal regulation of aldosterone but also highlight a potential dose-dependent role for MRA in natriuresis. Furthermore, we showcase existing and recent evidence-based data demonstrating the effectiveness of MRA in AHF and on long-term outcomes. Finally, we look at several treatment strategies and safety concerns as they relate to MRA use so as to aid in avoidance of MRA-related complications while facilitating achievement of treatment goals.
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Affiliation(s)
- Kemar Brown
- Division of Cardiology, Health Sciences Center, Stony Brook University, T-16, Room 080, Stony Brook, NY, 11794, USA
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Khalili H, Edwards A, Jones J, de Lemos JA, Das SR. Rates of aldosterone antagonist use after myocardial infarction remain poor over time among guideline eligible patients. Int J Cardiol 2014; 176:1334-5. [DOI: 10.1016/j.ijcard.2014.07.146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 07/27/2014] [Indexed: 10/24/2022]
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Huang G, Clavijo L. Mortality in acute coronary syndromes: many small steps in the right direction. Interv Cardiol 2014. [DOI: 10.2217/ica.14.18] [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] Open
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Montalescot G, Pitt B, Lopez de Sa E, Hamm CW, Flather M, Verheugt F, Shi H, Turgonyi E, Orri M, Vincent J, Zannad F. Early eplerenone treatment in patients with acute ST-elevation myocardial infarction without heart failure: the Randomized Double-Blind Reminder Study. Eur Heart J 2014; 35:2295-302. [PMID: 24780614 DOI: 10.1093/eurheartj/ehu164] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS We aimed to assess the impact of eplerenone on cardiovascular (CV) outcomes in STEMI without known heart failure, when initiated within 24 h of symptom onset. METHODS AND RESULTS In this randomized, placebo-controlled, double-blind trial, we assigned 1012 patients with acute STEMI and without a history of heart failure to receive either eplerenone (25-50 mg once daily) or placebo in addition to standard therapy. The primary endpoint was the composite of CV mortality, re-hospitalization, or, extended initial hospital stay, due to diagnosis of HF, sustained ventricular tachycardia or fibrillation, ejection fraction ≤40%, or elevated BNP/NT-proBNP at 1 month or more after randomization. BNP elevation was defined as BNP levels or values above 200 pg/mL or NT-proBNP values above 450 pg/mL (in patients aged below 50); above 900 pg/mL (age 50-75 years) or above 1800 pg/mL (patients older than 75). After a mean follow-up of 10.5 months, the primary endpoint occurred in 92 patients (18.2%) in the eplerenone group and in 149 patients (29.4%) in the placebo group [adjusted hazard ratio (HR), 0.58; 95% confidence interval (CI), 0.45-0.76; P < 0.0001]. The primary endpoint was driven by a high BNP/NT-proBNP level (adjusted HR, 0.60; 95% CI, 0.45-0.79; P < 0.0003). Adverse event rates were similar in both groups. Serum potassium levels exceeded 5.5 mmol/L in 5.6 vs. 3.2% (P = 0.09) and were below 3.5 mmol/L in 1.4 vs. 5.6% of patients (P = 0.0002), in the eplerenone and placebo groups, respectively. CONCLUSION The addition of eplerenone during the acute phase of STEMI was safe and well tolerated. It reduced the primary endpoint over a mean 13 months follow-up mostly because of significantly lower BNP/NT-proBNP levels. Additional studies are needed to clarify the role of early use of MRAs in STEMI patients without heart failure. CLINICAL TRIAL REGISTRATION NCT01176968.
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Affiliation(s)
- Gilles Montalescot
- Institut de Cardiologie, Centre Hospitalier Pitié-Salpêtrière (AP-HP, ACTION Group, University Paris 6), 47 boulevard de l'Hôpital, 75013 Paris, France
| | - Bertram Pitt
- Division of Cardiology, University of Michigan School of Medicine, Ann Arbor, USA
| | | | | | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Freek Verheugt
- Onze Lieve Vrouwe Gasthuis (OLVG), Amsterdam, The Netherlands
| | | | | | | | | | - Faiez Zannad
- Centre d'Investigation Clinique INSERM, Université de Lorraine and CHU, Nancy, France
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Weir RA, Tsorlalis IK, Steedman T, Dargie HJ, Fraser R, McMurray JJ, Connell JM. Aldosterone and cortisol predict medium-term left ventricular remodelling following myocardial infarction. Eur J Heart Fail 2014; 13:1305-13. [DOI: 10.1093/eurjhf/hfr129] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Robin A.P. Weir
- Cardiology Department; Western Infirmary; Glasgow G11 6NT UK
| | | | - Tracey Steedman
- Cardiology Department; Western Infirmary; Glasgow G11 6NT UK
| | - Henry J. Dargie
- Cardiology Department; Western Infirmary; Glasgow G11 6NT UK
| | - Robert Fraser
- BHF Cardiovascular Research Centre; University of Glasgow; UK
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Cleland JG, Coletta AP, Torabi A, Ahmed D, Clark AL. Clinical trials update from the European Society of Cardiology Meeting 2010: SHIFT, PEARL-HF, STAR-heart, and HEBE-III. Eur J Heart Fail 2014; 12:1261-4. [DOI: 10.1093/eurjhf/hfq186] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- John G.F. Cleland
- Department of Cardiology, Hull York Medical School; University of Hull, Daisy Building, Castle Hill Hospital; Cottingham Kingston-upon-Hull HU16 5JQ UK
| | - Alison P. Coletta
- Department of Cardiology, Hull York Medical School; University of Hull, Daisy Building, Castle Hill Hospital; Cottingham Kingston-upon-Hull HU16 5JQ UK
| | - Azam Torabi
- Department of Cardiology, Hull York Medical School; University of Hull, Daisy Building, Castle Hill Hospital; Cottingham Kingston-upon-Hull HU16 5JQ UK
| | - Daniyal Ahmed
- Department of Cardiology, Hull York Medical School; University of Hull, Daisy Building, Castle Hill Hospital; Cottingham Kingston-upon-Hull HU16 5JQ UK
| | - Andrew L. Clark
- Department of Cardiology, Hull York Medical School; University of Hull, Daisy Building, Castle Hill Hospital; Cottingham Kingston-upon-Hull HU16 5JQ UK
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Abstract
Diuretics have been recommended as first-line treatment of hypertension and are also valuable in the management of hypervolemia and electrolyte disorders. This review summarizes the key features of the most commonly used diuretics. We then provide an update of clinical trials for diuretics during the past 5 years. Compared to other classes of medications, thiazide diuretics are at least as effective in reducing cardiovascular events (CVEs) in patients with hypertension and are more effective than β-blockers and angiotensin-converting enzyme inhibitors in reducing stroke. Observational cohort data and a network analysis have shown that CVEs are lowered by one-fifth from chlorthalidone when compared to the commonly used thiazide, hydrochlorothiazide. Relative to placebo, chlorthalidone increases life expectancy. In those aged 80 years and older, the diuretic, indapamide, lowers CVEs relative to placebo. The aldosterone antagonist, eplerenone, lowers total mortality in early congestive heart failure. The benefit of eplerenone following acute myocardial infarction (MI) is limited to administration within 3 to 6 days post-MI. Aldosterone antagonists have been shown to lower the incidence of sudden cardiac death and to reduce proteinuria. In the setting of heart failure, long acting loop diuretics azosemide and torasemide are more effective in improving heart failure outcomes than the far more commonly used short acting furosemide. Evening dosing of diuretics appears to lower CVEs relative to morning dosing. In conclusion, diuretics are a diverse class of drugs that remain extremely important in the management of hypertension and hypervolemic states.
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Affiliation(s)
- George C Roush
- 1UCONN School of Medicine and St Vincent's Medical Center, Bridgeport, CT, USA
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Rao KK, Enriquez JR, de Lemos JA, Alexander KP, Chen AY, McGuire DK, Fonarow GC, Das SR. Use of aldosterone antagonists at discharge after myocardial infarction: results from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get with the Guidelines (GWTG). Am Heart J 2013; 166:709-15. [PMID: 24093851 DOI: 10.1016/j.ahj.2013.06.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 06/24/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aldosterone antagonists (AldA) improve survival after myocardial infarction (MI) in patients with left ventricular systolic dysfunction (ejection fraction [EF] <40%) concomitant with either clinical heart failure (HF) or diabetes mellitus (DM). Although current American College of Cardiology/American Heart Association guidelines provide a class I recommendation for AldA therapy in such patients, how US practice reflects these recommendations is unclear. METHODS Using data from the National Cardiovascular Data Registry ACTION Registry-GWTG, we describe contemporary discharge AldA prescription patterns among 202,213 patients discharged after acute MI from 526 US sites participating in ACTION Registry-GWTG between January 2007 and March 2011. RESULTS Overall, 10.0% of patients were eligible for AldA without documented contraindication, with only 14.5% of eligible patients receiving AldA at discharge. Among the subset of AldA-eligible patients discharged on otherwise optimal medical therapy (68.9%), AldAs were prescribed to 16.1%. Aldosterone antagonist use was higher in patients with EF <40% and clinical HF with or without DM (17.7% and 16.6%, respectively), compared with patients with EF <40% and DM without clinical HF (7.8%, P < .001 for each). Fewer than 2% of participating centers used AldA in ≥50% of eligible patients. CONCLUSIONS Despite clinical outcome evidence and class I guideline recommendations, AldAs are underused in the United States, with only 1 in 7 eligible patients prescribed AldA at discharge after MI. This contrasts with high use of other evidence-based post-MI medications and identifies a specific gap in translation of evidence into clinical practice.
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Affiliation(s)
- Krishnasree K Rao
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
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Koifman E, Kopel E, Maor E, Fefer P, Matezky S, Tofler G, Hamdan A, Grossman E, Goldenberg I, Klempfner R. Mineralocorticoid receptor antagonist use in eligible patients following acute myocardial infarction: Real world data from the Acute Coronary Syndrome Israeli Surveys: 2004–2010. Int J Cardiol 2013; 168:3971-6. [DOI: 10.1016/j.ijcard.2013.06.091] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Revised: 05/21/2013] [Accepted: 06/30/2013] [Indexed: 10/26/2022]
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Hu LJ, Chen YQ, Deng SB, Du JL, She Q. Additional use of an aldosterone antagonist in patients with mild to moderate chronic heart failure: a systematic review and meta-analysis. Br J Clin Pharmacol 2013; 75:1202-12. [PMID: 23088367 DOI: 10.1111/bcp.12012] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 10/16/2012] [Indexed: 12/01/2022] Open
Abstract
AIMS Aldosterone antagonists (AldoAs) have been used to treat severe chronic heart failure (CHF). There is uncertainty regarding the efficacy of using AldoAs in mild to moderate CHF with New York Heart Association (NYHA) classifications of I to II. This study summarizes the evidence for the efficacy of spironolactone (SP), eplerenone (EP) and canrenone in mild to moderate CHF patients. METHODS PubMed, MEDLINE, EMBASE and OVID databases were searched before June 2012 for randomized and quasi-randomized controlled trials assessing AldoA treatment in CHF patients with NYHA classes I to II. Data concerning the study's design, patients' characteristics and outcomes were extracted. Risk ratio (RR) and weighted mean differences (WMD) or standardized mean difference were calculated using either fixed or random effects models. RESULTS Eight trials involving 3929 CHF patients were included. AldoAs were superior to the control in all cause mortality (RR 0.79, 95% CI 0.66, 0.95) and in re-hospitalization for cardiac causes (RR 0.62, 95% CI 0.52, 0.74), the left ventricular ejection fraction was improved by AldoA treatment (WMD 2.94%, P = 0.52). Moreover, AldoA therapy decreased the left ventricular end-diastolic volume (WMD -14.04 ml, P < 0.00001), the left ventricular end-systolic volume (WMD -14.09 ml, P < 0.00001). A stratified analysis showed a statistical superiority in the benefits of SP over EP in reducing LVEDV and LVESV. AldoAs reduced B-type natriuretic peptide concentrations (WMD -37.76 pg ml(-1), P < 0.00001), increased serum creatinine (WMD 8.69 μmol l(-1), P = 0.0003) and occurrence of hyperkalaemia (RR 1.78, 95% CI 1.43, 2.23). CONCLUSIONS Additional use of AldoAs in CHF patients may decrease mortality and re-hospitalization for cardiac reasons, improve cardiac function and simultaneously ameliorate LV reverse remodelling.
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Affiliation(s)
- Li-jun Hu
- Department of cardiology, Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Girerd N, Pang PS, Swedberg K, Fought A, Kwasny MJ, Subacius H, Konstam MA, Maggioni A, Gheorghiade M, Zannad F. Serum aldosterone is associated with mortality and re-hospitalization in patients with reduced ejection fraction hospitalized for acute heart failure: analysis from the EVEREST trial. Eur J Heart Fail 2013; 15:1228-35. [PMID: 23787720 DOI: 10.1093/eurjhf/hft100] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Post-discharge morbidity and mortality for acute heart failure (AHF) patients remains high. Although the adverse effects of neurohormonal activation are well known in chronic HF, the prognostic significance of serum aldosterone in patients hospitalized for AHF has not been well studied. METHODS AND RESULTS A secondary analysis was carried out of the placebo arm (n = 1850) from the EVEREST trial which had aldosterone measured at baseline. All patients were hospitalized for worsening HF and had an LVEF <40%. The median follow-up was 9.9 months. The association between serum aldosterone levels at baseline and the independently adjudicated outcomes [all-cause mortality (ACM) and the combined outcome of cardiovascular mortality (CVM) and HF re-hospitalization] were explored with multivariable Cox models. Median aldosterone levels increased during the hospital stay from 11 ng/dL at baseline to 15 ng/dL at discharge (P < 0.001) and remained increased after discharge (16 ng/dL at 24 weeks, P < 0.001). After adjusting for potential confounders, higher baseline aldosterone levels were associated with an increased risk for ACM and CVM or HF re-hospitalization [hazard ratio (HR) 1.49, 95% confidence intrerval (CI) 1.11-1.99; and HR 1.40, 95% CI 1.11-1.78, respectively, in the highest quartile when compared with the lowest]. CONCLUSION In patients with LVEF <40% hospitalized for AHF and receiving standard therapy, serum aldosterone levels correlated with worse post-discharge outcomes. Aldosterone levels increase during AHF hospitalization and remain increased long after discharge. These results suggest that further modulation of the renin-angiotensin-aldosterone system in patients admitted with worsening HF might favourably improve post-discharge outcomes.
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Affiliation(s)
- Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques 9501, Université de Lorraine, CHU de Nancy, Institut Lorrain du cœur et des vaisseaux, Nancy, France
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Zwadlo C, Bauersachs J. Mineralocorticoid receptor antagonists for therapy of coronary artery disease and related complications. Curr Opin Pharmacol 2013; 13:280-6. [DOI: 10.1016/j.coph.2012.12.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 12/09/2012] [Accepted: 12/28/2012] [Indexed: 01/05/2023]
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Rossi R, Crupi N, Coppi F, Monopoli D, Sgura F. Importance of the time of initiation of mineralocorticoid receptor antagonists on risk of mortality in patients with heart failure. J Renin Angiotensin Aldosterone Syst 2013; 16:119-25. [PMID: 23539659 DOI: 10.1177/1470320313482603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 02/14/2013] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Several studies have definitively shown the benefit of mineralocorticoid receptor antagonists (MRAs) in patients with heart failure (HF). However, very few prior studies examined the relationship between the timing of initiation of MRAs and prognosis. In addition, on this topic, there is no information regarding the specific population of patients suffering a first episode of decompensated congestive HF. METHODS We studied a homogenous cohort of patients discharged alive from our hospital after a first episode of decompensated congestive HF, in order to clarify the association between time of aldosterone receptor antagonist (ARA) initiation (within the first 90 days after hospital discharge) and mortality. Our population was composed of a series of consecutive patients. All-cause mortality was compared between patients who initiated MRAs at discharge (early group) and those who initiated MRAs one month later and up to 90 days after discharge (delayed group). We used prescription time distribution matching to control for survival difference between groups. RESULTS The early and delayed groups consisted of 365 and 320 patients, respectively. During the one-year follow-up, a significant difference in mortality was demonstrated between groups. Adjusted hazard ratios (HRs) for early versus delayed initiation were 1.72 (95% confidence interval (CI) 0.96 to 2.84) at six months, and 1.93 (95% CI 1.18 to 3.14) at one year. CONCLUSIONS Delay of MRA initiation up to 30 to 90 days after discharge implies a significant increase in mortality compared with MRA initiation at discharge, after a first episode of decompensate congestive HF.
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Affiliation(s)
- Rosario Rossi
- Institute of Cardiology, Policlinico Hospital, University of Modena and Reggio Emilia, Italy
| | - Nicola Crupi
- Institute of Cardiology, Policlinico Hospital, University of Modena and Reggio Emilia, Italy
| | - Francesca Coppi
- Institute of Cardiology, Policlinico Hospital, University of Modena and Reggio Emilia, Italy
| | - Daniel Monopoli
- Institute of Cardiology, Policlinico Hospital, University of Modena and Reggio Emilia, Italy
| | - Fabio Sgura
- Institute of Cardiology, Policlinico Hospital, University of Modena and Reggio Emilia, Italy
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012; 127:e362-425. [PMID: 23247304 DOI: 10.1161/cir.0b013e3182742cf6] [Citation(s) in RCA: 1071] [Impact Index Per Article: 89.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2012; 61:e78-e140. [PMID: 23256914 DOI: 10.1016/j.jacc.2012.11.019] [Citation(s) in RCA: 2191] [Impact Index Per Article: 182.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
The field of heart transplantation has seen significant progress in the past 40 years. However, the breakthroughs in long-term outcome have seen stagnation in the past decade. Through advances in genomics and transcriptomics, there is hope that an era of personalized transplant therapy lies in the future. To see where heart transplantation truly fits into the long term, searching for and understanding the alternative approaches for heart failure therapy is both important and inevitable. The application of mechanical circulatory support has contributed to the largest advancement in treatment of end stage heart failure. It has already been approved for destination therapy of heart failure, and greater portability and ease of use of the device will be the future trend. Although it is still not prime time for stem cell therapy, clinical experiences have already suggested its potential therapeutic effects. And finally, whole organ engineering is on the horizon as new techniques have opened the way for this to proceed. In the end, progress on alternative therapies largely depends on our deeper understanding of the mechanisms of heart failure and how to prevent it.
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Kampourides N, Tziakas D, Chalikias G, Papazoglou D, Maltezos E, Symeonides D, Konstantinides S. Usefulness of matrix metalloproteinase-9 plasma levels to identify patients with preserved left ventricular systolic function after acute myocardial infarction who could benefit from eplerenone. Am J Cardiol 2012; 110:1085-91. [PMID: 22742718 DOI: 10.1016/j.amjcard.2012.05.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Revised: 05/24/2012] [Accepted: 05/24/2012] [Indexed: 10/28/2022]
Abstract
We sought to assess possible interactions between eplerenone use and a plasma marker of collagen turnover on prognosis in patients after acute myocardial infarction (AMI) and preserved left ventricular (LV) ejection fraction (≥40%). Three hundred three patients with AMI (58 ± 11 years old, 249 men) and preserved systolic LV function were studied prospectively for 24 months. Plasma levels of matrix metalloproteinase-9 (MMP-9) were assessed on day 7 after AMI. Patients were categorized according to whether (n = 201) or not (n = 102) they received eplerenone (25 mg/day) and their baseline MMP-9 levels using the cut-off level suggested by receiver operating characteristics analysis (12.7 ng/ml). Death from cardiovascular causes, nonfatal reinfarction, hospitalization for unstable angina, and development of heart failure symptoms were considered study end points. Eplerenone use was not associated with better prognosis in the entire study group (p = 0.132). However, a significant beneficial eplerenone effect on outcome was observed in patients with low baseline levels of MMP-9 (event-free survival for eplerenone vs noneplerenone arm 65% vs 35%, p = 0.005). Eplerenone had no effect (p = 0.741) in the subgroup of patients with high baseline MMP-9 levels. In conclusion, in patients after AMI with preserved LV systolic function, low baseline levels of MMP-9 identify a subgroup of patients in whom eplerenone use is associated with a survival benefit.
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Galuppo P, Bauersachs J. Mineralocorticoid receptor activation in myocardial infarction and failure: recent advances. Eur J Clin Invest 2012; 42:1112-20. [PMID: 22536780 DOI: 10.1111/j.1365-2362.2012.02676.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The classical view of aldosterone actions via the mineralocorticoid receptor (MR) limited to control of fluid balance and blood pressure homoeostasis has been progressively overcome by clinical and experimental evidence emphasizing the pleiotropic role of MR activation in the pathogenesis of cardiovascular disease. Clinical studies have shown the benefit of MR blockade in patients with left ventricular dysfunction and heart failure after myocardial infarction (MI), hypertension or diabetic nephropathy. Deleterious effects of MR activation include cardiac structural and electrical remodelling, cardiovascular fibrosis, inflammation and oxidative stress. Complexity of pathophysiological role of MR derives from the presence of circulating glucocorticoids at higher concentrations than aldosterone and the equal affinity of the MR for aldosterone, cortisol and corticosterone. Recent experimental studies using different animal models and genetic tools have deeply explored the cell-specific functional role of MR in cardiovascular pathology. This review addresses emerging preclinical studies as well as ongoing clinical trials regarding MR activation in MI and failure.
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Affiliation(s)
- Paolo Galuppo
- Klinik fuer Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany
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Loan Le TY, Mardini M, Howell VM, Funder JW, Ashton AW, Mihailidou AS. Low-Dose Spironolactone Prevents Apoptosis Repressor With Caspase Recruitment Domain Degradation During Myocardial Infarction. Hypertension 2012; 59:1164-9. [DOI: 10.1161/hypertensionaha.111.190488] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Low-dose mineralocorticoid receptor antagonists reduce morbidity and mortality in patients with heart failure and myocardial infarction, despite normal plasma aldosterone levels. Since apoptosis plays an important role in heart failure and postinfarction left ventricular remodeling, we examined whether low-dose mineralocorticoid receptor antagonists modulate cardiomyocyte death by regulating the apoptosis repressor protein apoptosis repressor with caspase recruitment domain to lessen the extent of apoptosis. Hearts from adult male Sprague-Dawley rats were subjected to regional ischemia followed by reperfusion ex vivo, with mineralocorticoid receptor antagonists added to perfusates before ischemia. Low-dose spironolactone (10 nmol/L) or eplerenone (100 nmol/L) significantly reduced infarct size. Spironolactone also prevented cleavage of the apoptotic chromatin condensation inducer in the nucleus and of the inhibitor of caspase-activated DNAse induced by ischemia-reperfusion, thereby abolishing chromatin condensation and internucleosomal cleavage. Ischemia-reperfusion–induced activation of caspases 2, 3, and 9, but not caspase 8, was prevented by spironolactone, suggesting targeted regulation of the intrinsic pathway. Low-dose spironolactone and eplerenone prevented loss of the apoptosis repressor with the caspase recruitment domain and reduced myocyte death. In H9c2 cells, mineralocorticoid receptor activation by aldosterone resulted in apoptosis repressor with caspase recruitment domain degradation and enhanced apoptosis; these actions were prevented by coadministration of spironolactone. Using a triple lysine mutant we identified that aldosterone enhances posttranscriptional degradation of the apoptosis repressor with a caspase recruitment domain via the ubiquitin-proteasomal pathway. Our data demonstrate that low-dose mineralocorticoid receptor antagonists reduce infarct size and apoptosis in the reperfused myocardium by preventing the apoptosis repressor with caspase recruitment domain degradation.
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Affiliation(s)
- Thi Yen Loan Le
- From the Department of Cardiology (T.Y.L.L., M.M., A.S.M.), Royal North Shore Hospital, Sydney, New South Wales, Australia; Cardiovascular and Hormonal Research Laboratory, Cardiology Division (T.Y.L.L., M.M., A.S.M.), Hormone and Cancer Division (V.M.H.), and Division of Perinatal Research (A.W.A.), Kolling Institute of Medical Research, Royal North Shore Hospital and the University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology (M.M.), Westmead Hospital, Sydney, New South
| | - Mahidi Mardini
- From the Department of Cardiology (T.Y.L.L., M.M., A.S.M.), Royal North Shore Hospital, Sydney, New South Wales, Australia; Cardiovascular and Hormonal Research Laboratory, Cardiology Division (T.Y.L.L., M.M., A.S.M.), Hormone and Cancer Division (V.M.H.), and Division of Perinatal Research (A.W.A.), Kolling Institute of Medical Research, Royal North Shore Hospital and the University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology (M.M.), Westmead Hospital, Sydney, New South
| | - Viive M. Howell
- From the Department of Cardiology (T.Y.L.L., M.M., A.S.M.), Royal North Shore Hospital, Sydney, New South Wales, Australia; Cardiovascular and Hormonal Research Laboratory, Cardiology Division (T.Y.L.L., M.M., A.S.M.), Hormone and Cancer Division (V.M.H.), and Division of Perinatal Research (A.W.A.), Kolling Institute of Medical Research, Royal North Shore Hospital and the University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology (M.M.), Westmead Hospital, Sydney, New South
| | - John W. Funder
- From the Department of Cardiology (T.Y.L.L., M.M., A.S.M.), Royal North Shore Hospital, Sydney, New South Wales, Australia; Cardiovascular and Hormonal Research Laboratory, Cardiology Division (T.Y.L.L., M.M., A.S.M.), Hormone and Cancer Division (V.M.H.), and Division of Perinatal Research (A.W.A.), Kolling Institute of Medical Research, Royal North Shore Hospital and the University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology (M.M.), Westmead Hospital, Sydney, New South
| | - Anthony W. Ashton
- From the Department of Cardiology (T.Y.L.L., M.M., A.S.M.), Royal North Shore Hospital, Sydney, New South Wales, Australia; Cardiovascular and Hormonal Research Laboratory, Cardiology Division (T.Y.L.L., M.M., A.S.M.), Hormone and Cancer Division (V.M.H.), and Division of Perinatal Research (A.W.A.), Kolling Institute of Medical Research, Royal North Shore Hospital and the University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology (M.M.), Westmead Hospital, Sydney, New South
| | - Anastasia S. Mihailidou
- From the Department of Cardiology (T.Y.L.L., M.M., A.S.M.), Royal North Shore Hospital, Sydney, New South Wales, Australia; Cardiovascular and Hormonal Research Laboratory, Cardiology Division (T.Y.L.L., M.M., A.S.M.), Hormone and Cancer Division (V.M.H.), and Division of Perinatal Research (A.W.A.), Kolling Institute of Medical Research, Royal North Shore Hospital and the University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology (M.M.), Westmead Hospital, Sydney, New South
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Fraccarollo D, Galuppo P, Bauersachs J. Novel therapeutic approaches to post-infarction remodelling. Cardiovasc Res 2012; 94:293-303. [PMID: 22387461 DOI: 10.1093/cvr/cvs109] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Adverse cardiac remodelling is a major cause of morbidity and mortality following acute myocardial infarction (MI). Mechanical and neurohumoral factors involved in structural and molecular post-infarction remodelling were important targets in research and treatment for years. More recently, therapeutic strategies that address myocardial regeneration and pathophysiological mechanisms of infarct wound healing appear to be useful novel tools to prevent progressive ventricular dilation, functional deterioration, life-threatening arrhythmia, and heart failure. This review provides an overview of future and emerging therapies for cardiac wound healing and remodelling after MI.
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Affiliation(s)
- Daniela Fraccarollo
- Klinik fuer Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany
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